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ARTICLE

Reduction of Frequent Otitis Media and Pressure-


Equalizing Tube Insertions in Children After
Introduction of Pneumococcal Conjugate Vaccine
Katherine A. Poehling, MD, MPHa, Peter G. Szilagyi, MD, MPHb, Carlos G. Grijalva, MD, MPHc, Stacey W. Martin, MSd, Bonnie LaFleur, PhD, MPHe,
Ed Mitchel, MSc, Richard D. Barth, BSb, J. Pekka Nuorti, MD, DScd, Marie R. Griffin, MD, MPHc,f

Departments of aPediatrics, cPreventive Medicine, eBiostatistics, and fMedicine, Vanderbilt University Medical Center, Nashville, Tennessee; bDepartment of Pediatrics and
Strong Childrens Research Center, University of Rochester School of Medicine and Dentistry, Rochester, New York; dNational Center for Immunization and Respiratory
Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia

The authors have indicated they have no nancial relationships related to this article to disclose.

ABSTRACT
OBJECTIVE. Streptococcus pneumoniae is an important cause of otitis media in children.
In this study we estimated the effect of routine childhood immunization with
www.pediatrics.org/cgi/doi/10.1542/
heptavalent pneumococcal conjugate vaccine on frequent otitis media (3 episodes peds.2006-2138
in 6 months or 4 episodes in 1 year) and pressure-equalizing tube insertions. doi:10.1542/peds.2006-2138
PATIENTS AND METHODS. The study population included all children who were enrolled The views in this article are the sole
responsibility of the authors and do not
at birth in TennCare or selected upstate New York commercial insurance plans as necessarily represent the ofcial views of
of July 1998 and continuously followed until 5 years old, loss of health plan the Centers of Disease Control and
enrollment, study outcome, or end of the study. We compared the risk of devel- Prevention.

oping frequent otitis media or having pressure-equalizing tube insertion for 4 birth Dr Poehlings current afliation is
Department of Pediatrics, Wake Forest
cohorts (1998 1999, 1999 2000, 2000 2001, and 20012002) by using Cox University Medical Center, Winston-Salem,
regression analysis. We used data from the National Immunization Survey to NC.
estimate the heptavalent pneumococcal conjugate vaccine uptake for children in Key Words
otitis media, pressure-equalizing tubes,
these 4 birth cohorts in Tennessee and New York. middle ear ventilation tubes,
tympanostomy tubes, epidemiology,
RESULTS. The proportion of children in Tennessee and New York who received at pneumococcal conjugate vaccine
least 3 doses of heptavalent pneumococcal conjugate vaccine by 2 years of age Abbreviations
increased from 1% for the 1998 1999 birth cohort to 75% for the 2000 2001 PCV7 heptavalent pneumococcal
conjugate vaccine
birth cohort. By age 2 years, 29% of Tennessee and New York children born in PETpressure-equalizing tube
2000 2001 had developed frequent otitis media, and 6% of each of these birth ICD-9 International Classication of
cohorts had pressure-equalizing tubes inserted. Comparing the 2000 2001 birth Diseases, Ninth Revision
NISNational Immunization Survey
cohort to the 1998 1999 birth cohort, frequent otitis media declined by 17% and
Accepted for publication Dec 12, 2006
28%, and pressure-equalizing tube insertions declined by 16% and 23% for Address correspondence to Katherine A.
Tennessee and New York children, respectively. For the 2000 2001 to the 2001 Poehling, MD, MPH, Department of Pediatrics,
Wake Forest University Medical Center,
2002 birth cohort, frequent otitis media and pressure-equalizing tubes remained Medical Center Blvd, Winston-Salem, NC
stable in New York but increased in Tennessee. 27157. E-mail: kpoehlin@wfubmc.edu
PEDIATRICS (ISSN Numbers: Print, 0031-4005;
CONCLUSIONS. After heptavalent pneumococcal conjugate vaccine introduction, chil- Online, 1098-4275); published in the public
dren were less likely to develop frequent otitis media or have pressure-equalizing domain by the American Academy of
Pediatrics
tube insertions.

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S treptococcus pneumoniae is an important cause of otitis
media, a common childhood illness that has resulted
in an estimated $5.3 billion annually in direct medical
in these administrative databases, data from the National
Immunization Surveys conducted in 20012004 were
used to estimate PCV7 vaccination coverage among chil-
costs across the United States.1,2 The efficacy of 7-valent dren born between February 1998 and May 2003. This
pneumococcal conjugate vaccine (PCV7) in reducing oti- survey is designed to measure vaccination coverage in a
tis media was evaluated in 2 randomized, controlled nationally representative sample of US children aged 19
trials. The Finnish and Kaiser Permanente trials found to 35 months. The National Immunization Survey used
that young children who received PCV7 had a 6% and random-digit dialing to identify households with age-
7.8% overall reduction in the prevalence of otitis media, appropriate children and followed these telephone in-
respectively, but this decline was statistically significant terviews with mailed surveys to the childrens vaccina-
only in the Kaiser study.3,4 The vaccine efficacy for pre- tion providers. Only provider-verified vaccination
vention of pressure-equalizing tube (PET) insertions, the histories are included in the analysis.
most common surgical procedure in children,5 was 23%
by 3.5 years in the Kaiser trial and 39% by 4 to 5 years Study Population
in the Finnish trial.4,6 We identified children born between July 1 and June 30,
Since PCV7 was incorporated into the routine immu- 1998 1999, 1999 2000, 2000 2001, and 20012002,
nization schedule in the United States by mid 2000,7,8 and enrolled within 30 days of birth in TennCare or in
several studies have demonstrated a dramatic decrease commercial insurance plans of upstate New York. These
in invasive pneumococcal disease.9,10 National survey birth cohorts were continuously followed until age 5,
data indicated that otitis media visits have decreased by loss of enrollment, death, study outcome, or end of the
246 per 1000 children, a 20% decline with no compen- surveillance period (June 30, 2004). For each birth co-
satory increase in other respiratory visits.11 Our previous hort, we estimated the cumulative proportion of chil-
evaluation of children enrolled in Tennessee Medicaid dren who developed frequent otitis media or had PETs
and private insurance programs in the Rochester, New inserted.
York, area showed declines in otitis media visits consis- Birth cohorts were defined by using a July to June
tent with these national data.12 To date, there have been year for 2 reasons. Although PCV7 was licensed in the
no evaluations of PCV7 program effectiveness by using United States in February 2000, coverage of PCV7 by
longitudinal data from individual children to measure most health insurance companies did not begin at that
the change in risk of developing frequent otitis media or time. The routine administration of PCV7 began in the
having PETs inserted. summer of 2000, when the American Academy of Pedi-
In this study, we used an ecological analysis to deter- atrics and the Advisory Committee on Immunization
mine the risk of frequent otitis media (3 episodes in 6 Practices published recommendations and the Vaccines
months or 4 episodes in 1 year) and PET insertions for Children Program began to cover PCV7.7,8,13 A survey
among 4 birth cohorts (1998 1999, 1999 2000, 2000 of primary health care providers in Tennessee and up-
2001, and 20012002). We hypothesized that the risk of state New York confirmed that routine administration of
frequent otitis media and PETs would decrease from the PCV7 began after the summer of 2000 in these regions.14
1998 1999 birth cohort, in which few children received Another reason for a July to June year was that each
PCV7 doses, to subsequent birth cohorts who had pro- year includes 1 winter respiratory virus season as com-
gressively increasing PCV7 uptake. pared with a calendar year, which may include 0, 1, or 2
winter respiratory viral seasons.
Institutional review boards of Vanderbilt University,
PATIENTS AND METHODS
the State of Tennessee, University of Rochester, and the
Sources of Data Centers for Disease Control and Prevention approved
TennCare is Tennessees managed care program that this study.
includes the Medicaid population and other low-income
children. Each enrollee selects from 1 of 7 managed care Study Outcomes
organizations. During the study period, it included 50% We identified 2 outcomes in cohort children: develop-
of children born in Tennessee and all state children who ment of frequent otitis media and PET insertions. We
were enrolled in Medicaid, with a high proportion of identified all hospitalizations, emergency department
children from racial and ethnic minority groups and visits, and outpatient visits for otitis media by Interna-
low-income families. The upstate New York database tional Classification of Diseases, Ninth Revision (ICD-9) codes
contains data from 3 commercial insurance managed (ICD-9 381.0 381.4, 382.x). An episode of otitis media
care organizations, which together provided coverage was the first such visit or a visit at least 21 days after a
for nearly 70% of children in the Rochester, New York, previous otitis media visit to distinguish reinfections
region. from relapses or persistent infections.4,15,16 A child devel-
Because of incomplete PCV7 vaccination information oped frequent otitis media on the date of the first of the

708 POEHLING et al
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following: the third episode of otitis media within 6 TABLE 1 Demographics of Study Populations From TennCare and
months or the fourth episode within 1 year.3 A child was From Private Insurance of the Rochester, New York,
determined to have PET insertions on the date of the first Region
visit with this procedure code (Current Procedural Ter- Demographics n (%)
minology, Fourth Edition, 69433 or 69436).
Tennessee New York
N 150 122 26 409
Birth cohort
Statistical Analysis
19981999 36 939 (25) 7198 (27)
For each birth cohort, we used the Kaplan-Meier esti- 19992000 37 437 (25) 7037 (27)
mator to determine the cumulative proportion of chil- 20002001 37 905 (25) 6588 (25)
dren who developed frequent otitis media or had PETs 20012002 37 841 (25) 5586 (21)
inserted according to age in days; this method adjusts for Censored or continuously enrolled, ya
1 116 279 (77) 18 408 (59)
children who drop out of the cohorts before experienc- 2 94 290 (63) 13 215 (50)
ing the outcomes of interest. In addition, we used Cox Insurance
regression models to evaluate the association between Public 150 122 (100) 0 (0)
birth cohort (1998 1999, 1999 2000, 2000 2001, and Private 0 (0) 26 409 (100)
a Censored means that the children met criteria for frequent otitis media before this age. Chil-
20012002) and risk of developing frequent otitis media
dren who were censored or were still enrolled are included in the data analysis.
or having PET insertion from birth through 2 years of
age. Birth cohort was analyzed as a categorical variable
using the 1998 1999 cohort as the reference. Of chil-
dren enrolled at birth, 24% of Tennessee children and Frequent Otitis Media
39% of New York children, respectively, dropped out by
Tennessee
2 years of age. Separate analyses of outcomes in the first
The TennCare population included 150 122 children
year of life for children who did and did not drop out
with an average of 37 531 children per birth cohort.
showed similar patterns, suggesting absence of informa-
From the 1998 1999 through the 20012002 birth co-
tive censoring (data not shown). To verify that the cri-
horts, 11 007 (7%) and 38 905 (26%) children lost en-
teria for PET insertions were similar across cohorts, we
rollment during the first and second years of life, respec-
compared the age-specific proportion of children with
tively. Overall, 39 763 (26%) children had frequent
PETs who met the study criteria for frequent otitis media
otitis media by 2 years of age. The cumulative proportion
at the time of surgery.
with frequent otitis media by 2 years old was 33%
We used National Immunization Survey (NIS) data
among children born in 1998 1999 compared with
(20012004) from Tennessee and New York to estimate
29%, 29%, and 31% for the subsequent 3 birth cohorts
PCV7 vaccination coverage by 2 years of age in the 4
(Fig 1A). In comparison to the 1998 1999 birth cohort,
birth cohorts of interest.17 For each birth cohort, we
the decrease in frequent otitis media was 16% for the
combined the NIS survey years that sampled children
1999 2000 cohort, 17% for the 2000 2001 cohort, and
with appropriate birthdays. Because 2 to 3 NIS survey
8% for the 20012002 birth cohort (Table 2 ). Exclusion
years were used for each estimate of PCV7 coverage by 2
of serous otitis codes (ICD-9 381.0 381.4) from the def-
years, each estimate was adjusted by dividing the indi-
inition of otitis media in the Tennessee data resulted in a
vidual weights for the included surveys by the total
3% decrease in frequent otitis media visits for all birth
number of surveys used.18 Coverage estimates and 95%
cohorts and no change in any of the hazard ratios.
confidence intervals were calculated for the subgroup of
children in the birth cohort, accounting for the complex
survey design.19 New York
The New York commercial insurance population in-
cluded 26 409 children with an average of 6602 per
RESULTS birth cohort. In the first 3 birth cohorts, 5457 (26%)
The demographics of the study populations are shown in and 2656 (21%) children lost enrollment during the
Table 1. Each of the 4 birth cohorts from Tennessee first and second years of life, respectively. Overall,
accounted for 25% of the Tennessee population, 6067 (32%) children had frequent otitis media by 2
whereas each birth cohort from New York accounted for years of age. The cumulative proportion with frequent
21% to 27% of the upstate New York population. The otitis media by 2 years old was 38% among children
proportion of children who had either frequent otitis born 1998 1999 compared with 33%, 29%, and 27%
media or were continuously enrolled until 1 and 2 years in the 3 subsequent birth cohorts (Fig 1B). In compar-
of age was 77% and 63% in the TennCare population ison to the 1998 1999 birth cohort, there was a pro-
and 59% and 50% in the upstate New York private gressive decline in frequent otitis media that ranged
insurance population. from 16% to 33% (Table 2).

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FIGURE 1
Cumulative percent with frequent otitis media in TennCare (A) and New York private insurance (B) according to age for each birth cohort. Note that for more recent cohorts, fewer years
of follow-up were available.

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TABLE 2 Hazard Ratios for Developing Frequent Otitis Media and children who received 4 doses of PCV7 by 2 years of age
Having PETs Inserted at 2 Years Compared With the 1998 increased from 0% in both states to 35% in Tennessee
1999 Birth Cohort in Tennessee and New York and 53% in New York.
Birth Cohort Hazard Ratio (95% Condence Interval)
DISCUSSION
Frequent Otitis Media PETs
For the 2000 2001 birth cohort, we found a 17% and
Tennessee
19981999
28% decline, respectively, in frequent otitis media
19992000 0.84 (0.810.86) 0.88 (0.820.93) among Tennessee and New York children since PCV7
20002001 0.83 (0.810.86) 0.84 (0.790.89) was incorporated into the childhood immunization
20012002 0.92 (0.890.94) 0.97 (0.921.03) schedule. Similarly, PET procedures by 2 years of age
New York declined 16% and 23% since PCV7 introduction. This
19981999
19992000 0.84 (0.790.89) 0.87 (0.751.01)
ecologic approach is supported by NIS PCV7 coverage
20002001 0.72 (0.670.77) 0.77 (0.650.90) estimates indicating that few children in the 1998 1999
20012002 0.67 (0.620.72) 0.79 (0.670.94) birth cohort received PCV7 doses whereas progressively
indicates reference group. more children in the subsequent birth cohorts received
PCV7.17 Interestingly, frequent otitis media and PET pro-
cedures progressively decreased for all birth cohorts in
New York and through the 2000 2001 cohort in Ten-
PETs
nessee. For the 20012002 Tennessee birth cohort, fre-
Tennessee quent otitis media was less than the 1998 1999 cohort
PETs were inserted in 8223 children. Corresponding but higher than the 2000 2001 cohort whereas PET
with the decline in frequent otitis media, the proportion procedures were similar to the 1998 1999 cohort. Al-
of children with PETs by 2 years of age declined (Fig 2A) though others have reported efficacy of PCV7, to our
from 7.1% in the 1998 1999 birth cohort to 6.3% and knowledge, this study is the first to evaluate the devel-
6.1% in 2 subsequent birth cohorts then increased back opment of frequent otitis media and PET procedures in
to 7.1% in the 20012002 birth cohort. This change in defined populations after PCV7 was recommended.
PET insertions (Table 2) from the 1998 1999 cohort The reduction in the proportion of children with fre-
represented a 12% and a 16% decline in the 1999 2000 quent otitis media and PET procedures was more
and 2000 2001 birth cohorts but no change for the marked in the New York private insurance population
20012002 birth cohort. than in the TennCare population. Several factors likely
Among the TennCare population, 78% of children at contributed to this difference. According to the NIS data,
1 year of age and 89% at 2 years of age had frequent PCV7 uptake and the proportion fully vaccinated was
otitis media before PET procedure, with no significant higher among New York children than among Tennes-
differences in these proportions in the 4 birth cohorts. see children. Recent studies suggest that mucosal anti-
body response rarely develops after the primary series
New York but is often demonstrated at age 13 or 14 months after
PETs were inserted in 1121 children. The cumulative receiving the booster dose, suggesting its importance for
proportion with PET insertions by 2 years of age in each local mucosal immunity and, consequently, protection
birth cohort declined (Fig 2B) from 7.1% in the 1998 against otitis media.20 These children may have different
1999 cohort to 6.3%, 5.5%, and 5.8% in subsequent rates of exposure to known risk factors, such as day care
cohorts. This change in PET insertions represented a attendance and passive smoke exposure, which we did
13% to 23% decline (Table 2). not measure. There may also be geographical differences
Among the New York commercial insurance popula- among physicians as to what criteria they use to diag-
tion, 93% of children at 1 year of age and 95% at 2 years nose otitis media. Previous studies have found that chil-
of age had developed frequent otitis media by the time of dren were more likely to have had PET procedures if
PET procedure, with no trends in these proportions over they were from the South than the Northeast, were in
time. day care, had no gaps in health coverage, or were of
non-Hispanic white race and ethnicity.21 Furthermore, a
PCV7 Vaccination Coverage higher proportion of New York than Tennessee children
According to the NIS data, the proportion of children at each age group met criteria for frequent otitis media at
receiving PCV7 by 2 years of age according to state and the time of PET insertions, suggesting that the criteria for
birth cohort increased over time (Fig 3). The proportion PET insertions may have been more stringent in the New
of children who received 3 doses of PCV7 by 2 years of York population.
age progressively increased for the 1998 1999 to the The increase in frequent otitis media and PET inser-
20012002 cohorts from 0% in both states to 73% in tions in the 20012002 birth cohort in Tennessee as
Tennessee and 82% in New York. The proportion of compared with the 2 previous birth cohorts is a surpris-

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FIGURE 2
Cumulative percent with PETs in TennCare (A) or New York private insurance (B) placed according to age and birth cohort.

ing and potentially important observation because the pneumococcal disease from nonvaccine serotypes from
20012002 cohort represents children with high PCV7 the pre-PCV7 to post-PCV7 era has been reported for
vaccination rates. It may reflect one or a combination of invasive disease and in one study on otitis media.2226
many factors. The increase in laboratory-confirmed Temporal changes in the children who are enrolled and

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FIGURE 3
Proportion of children who had 3 (A) or 4 (B) doses of PCV7 at 24 months
of age by birth cohort and state according to the National Immunization
Survey.

disenrolled from insurance plans may have contributed exclude the possibility that other concurrent factors,
to this discrepancy. Overall medical care utilization may such as the encouragement of the judicious use of anti-
have increased, which may obscure the vaccine effect. biotics, may have influenced physicians diagnostic pat-
An increase in medical care utilization could increase terns for otitis media.30 Furthermore, administrative data
visit rates for otitis media even if disease rates remained claims incompletely capture individual vaccinations and
stable or decreased. the PCV7 status of the study population is not known.
The incidence of PET insertions in our study popula- However, national estimates show an increase in full
tions is comparable to those reported for other popula- PCV7 vaccination by 2 years of age from 20012002 to
tions. In a large, rural Kentucky practice, 2.0% to 2.2% 20032004.17 Because few children in the 1998 1999
of children received PETs by 1 year of age and 4.0 to were vaccinated whereas most were vaccinated in the
5.8% received PETs during the second year of life.27 20012002 cohort, we cannot compare those who did
Similarly, Paradise et al28 reported 1.8% and 4.2% of and did not receive PCV7 within each cohort. Even if
children had PETs placed during the first and second feasible, comparing children who are or are not vacci-
years of life, respectively. Our cumulative frequency of nated is problematic because children who receive vac-
PETs for the 1998 1999 birth cohorts was 2.5% by 1 cinations are more likely to seek care and thus may be
year of age and 7% by 2 years of age. Our 16% and 23% more likely to have otitis media diagnosed. In addition,
reduction in PETs in Tennessee and New York is com- it is possible that unvaccinated children indirectly ben-
parable to the 20% decline reported in the Kaiser Per- efited because of lower pneumococcal carriage rates and
manente trial.29 decreased transmission of vaccine serotypes with imple-
Our results should be interpreted in light of some mentation of PCV7 vaccination in the populations.3133
potential limitations. In this ecologic study, we cannot Study results were limited to the children who qual-

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ified for TennCare and upstate New York commercial community-wide random sample of medical charts in
insurance. Because the eligibility criteria for Medicaid the Rochester, New York area, the same geographic area
vary by state and over time, Tennessee results may not as this study.40
be representative of all Medicaid populations. The mi-
crobiology of otitis media and the proportion attributable CONCLUSIONS
to S pneumoniae cannot be ascertained from this study. The declines in frequent otitis media and PET insertions
However, our results are compatible with findings matched or exceeded the results in randomized, con-
through 2003 that the microbiology of acute otitis media trolled trials, suggesting direct and indirect benefits to
has changed since the introduction of PCV7 with 35% children who were or were not fully vaccinated. These
reduction in the prevalence of S pneumoniae isolates findings are particularly encouraging in light of PCV7
among bacteria causing otitis media and minimal re- shortages. Furthermore, these reductions in frequent
placement with nonvaccine pneumococcal serotype iso- otitis media and PETs are higher than that seen in ran-
lates.34,35 domized, controlled trials and may have important im-
We found a greater decline in frequent otitis media plications on the cost-effectiveness analyses for PCV7.
for the 2000 2001 birth cohort, 17% and 28% in Ten- However, whether these findings continue or wane, as
nessee and New York, than the 9.3% decline in the suggested by the 20012002 birth cohort from New York
Kaiser Permanente trial.29 The cumulative proportion of and Tennessee, respectively, is important and deserves
children with frequent otitis media in the 1998 1999 additional study and monitoring.
birth cohort was slightly higher (33% in Tennessee and
36% in New York) than in previous studies. In the ACKNOWLEDGMENTS
Kaiser trial, 28% of control children had frequent otitis This project was supported by cooperative agreement
media (3 episodes within 6 months) by 3.5 years of age.29 U38/CCU417958 from the Centers for Disease Control
In other populations, 17.3% of Boston children had 3 and Prevention (CDC) and U50/CCU30086, TS-0825
episodes of otitis media in their first year of life,16 and from American Teachers of Preventive Medicine/CDC.
28% to 31% of rural Kentucky children had 4 or more Dr Poehling also received support from K23 AI065805
episodes of otitis media by age 1 year.27 Our definition of (National Institute of Allergy and Infectious Diseases,
otitis media included the code for serous otitis media, National Institutes of Health) and the Robert Wood
which may account for our modestly higher estimates.36 Johnson Generalist Physician Faculty Scholars Program.
In Tennessee, we found that the proportion with fre- Data to conduct the study were obtained from the
quent otitis media decreased by 3% when serous otitis Tennessee Department of Health and the TennCare Bu-
media was excluded and that the hazard ratios were not reau.
impacted. Another possible explanation for the greater
reduction in frequent otitis media than that seen in
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ERRATA Patel JA, Nair S, Revai K, et al. Association of Proinflammatory
Cytokine Gene Polymorphisms With Susceptibility to Otitis Media.
PEDIATRICS 2006;118:22732279.
Errors occurred in the article by Patel et al, titled Association of Proinflam-
matory Cytokine Gene Polymorphisms With Susceptibility to Otitis Media,
published in the December 2006 issue of Pediatrics (doi:10.1542/peds.2006-
0764). In Tables 2 and 3 on pages 2275 and 2276, respectively, the authors
reported the genotypes for TNF-308 and IL-6174 incorrectly. For TNF-
308, footnote c should be assigned to G/G and footnote d should be
assigned to G/A or A/A. For IL-6174, footnote c should be assigned to
G/G and footnote d should be assigned to G/C or C/C. On page 2277,
Discussion section, second paragraph, line 7, IL-6174 GG polymorphism
should be replaced with TNF-308 AA/AG polymorphism.

doi:10.1542/peds.2007-1095

Poehling KA, Szilagyi PG, Grijalva CG, et al. Reduction of Frequent


Otitis Media and Pressure-Equalizing Tube Insertions in Children
After Introduction of Pneumococcal Conjugate Vaccine.
PEDIATRICS 2007;119:707715.
An error occurred in the article by Poehling et al, titled Reduction of
Frequent Otitis Media and Pressure-Equalizing Tube Insertions in Children
After Introduction of Pneumococcal Conjugate Vaccine, published in the
April 2007 issue of Pediatrics (doi:10.1542/peds.2006-2138). On page 715,
reference 11 has an error in an authors name. Nuorti PJ should be Nuorti
JP.

doi:10.1542/peds.2007-1030

Claudius I, Keens T. Do All Infants With Apparent Life-


Threatening Events Need to Be Admitted? PEDIATRICS 2007;119:
679 683.
An error occurred in the article by Claudius and Keens, titled Do All Infants
With Apparent Life-Threatening Events Need to Be Admitted? published in
the April 2007 issue of Pediatrics (doi:10.1542/peds.2006-2549). On page
679, in the Results section of the Abstract, on lines 4-6, the authors wrote:
In our study group, the high-risk criteria of age of 1 year and multiple
apparent life-threatening events yielded a negative predictive value of 100%
to identify the need for hospital admission. It should read: In our study
group, the high-risk criteria of age of 1 month and multiple apparent
life-threatening events yielded a negative predictive value of 100% to iden-
tify the need for hospital admission.

doi:10.1542/peds.2007-1123

1270 ERRATA
Reduction of Frequent Otitis Media and Pressure-Equalizing Tube Insertions in
Children After Introduction of Pneumococcal Conjugate Vaccine
Katherine A. Poehling, Peter G. Szilagyi, Carlos G. Grijalva, Stacey W. Martin,
Bonnie LaFleur, Ed Mitchel, Richard D. Barth, J. Pekka Nuorti and Marie R. Griffin
Pediatrics 2007;119;707
DOI: 10.1542/peds.2006-2138

The online version of this article, along with updated information and services, is
located on the World Wide Web at:
/content/119/4/707.full.html

PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly


publication, it has been published continuously since 1948. PEDIATRICS is owned,
published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point
Boulevard, Elk Grove Village, Illinois, 60007. Copyright 2007 by the American Academy
of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

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Reduction of Frequent Otitis Media and Pressure-Equalizing Tube Insertions in
Children After Introduction of Pneumococcal Conjugate Vaccine
Katherine A. Poehling, Peter G. Szilagyi, Carlos G. Grijalva, Stacey W. Martin,
Bonnie LaFleur, Ed Mitchel, Richard D. Barth, J. Pekka Nuorti and Marie R. Griffin
Pediatrics 2007;119;707
DOI: 10.1542/peds.2006-2138
Updated Information & including high resolution figures, can be found at:
Services /content/119/4/707.full.html

References This article cites 34 articles, 15 of which can be accessed free


at:
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PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly


publication, it has been published continuously since 1948. PEDIATRICS is owned, published,
and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk
Grove Village, Illinois, 60007. Copyright 2007 by the American Academy of Pediatrics. All
rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

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