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  • Vaccine xxx (xxxx) xxx

    Contents lists available at ScienceDirect


    journal homepage: www.elsevier .com/locate /vacc ine

    Sensorineural hearing loss (SNHL) as an adverse event following immunization (AEFI): Case definition & guidelines for data collection, analysis, and presentation of immunization safety data 0264-410X/� 2020 Published by Elsevier Ltd.

    Abbreviations: AAOHNS, American Academy of Otolaryngology-Head and Neck Surgery; ABR, Auditory brainstem response; AEFI, Adverse event following immu ASHA, American Speech-Language-Hearing Association; AIED, Autoimmune inner ear disease; AISNHL, Autoimmune sensorineural hearing loss; ASSR, Auditory ste response; BAER, Brainstem auditory evoked response; CHL, Conductive hearing loss; CNS, Central nervous system; CMV, Cytomegalovirus; COM, Chronic otitis media Distortion product otoacoustic emissions; dB, Decibel; GBD, Global burden of disease; HL, Hearing loss; Hz, Hertz; ISSNHL, Idiopathic sudden sensorineural hearing lo Joint Committee on Infant Hearing; LMIC, Low- and middle-income countries; MHL, Mixed hearing loss; NIDCD, National Institute of Deafness and Other Commu Disorders; NMDA, N-methyl-D-aspartate receptor; OAE, Otoacoustic emissions; OM, Otitis media; PSHNL, Profound sensorineural hearing loss; ROS, Reactive oxygen SHL, Sudden hearing loss; SNHL, Sensorineural hearing loss; SOSNHL, Sudden onset sensorineural hearing loss; SSNHL, Sudden sensorineural hearing loss; TEOAE, T evoked otoacoustic emissions. ⇑ Corresponding authors: Baylor College of Medicine, Texas Children’s Hospital, Houston, TX, USA.

    E-mail address: (F.M. Munoz). 1 Brighton Collaboration homepage:

    Please cite this article as: Y.-C. Carol Liu, T. Ibekwe, J. M. Kelso et al., Sensorineural hearing loss (SNHL) as an adverse event following immunization Case definition & guidelines for data collection, analysis, and presentation of immunization safety data, Vaccine, vaccine.2020.05.019

    Yi-Chun Carol Liu a,⇑, Titus Ibekwe b, John M. Kelso c, Nicola P. Klein d, Nathan Shehu e, Wendy Steuerwald f, Satinder Aneja g, Matthew Z. Dudley h, Robert Garry i, Flor M. Munoz j,⇑, The Brighton Collaboration SNHL Working Group 1

    aDepartment of Otorhinolaryngology, Baylor College of Medicine and Texas Children’s Hospital, Houston, TX, USA bDepartment of Otorhinolaryngology, University of Abuja, Nigeria cDivision of Allergy, Asthma and Immunology, Scripps Clinic, San Diego, CA, USA dKaiser Permanente Vaccine Study Center, Oakland, CA, USA eDepartment of Pediatric Infectious Diseases, Jos University, Nigeria fDepartment of Audiology, Phoenix Children’s Hospital, Phoenix, AZ, USA gDepartment of Pediatrics, School of Medical Sciences and Research, Sharda University, Gr Noida, India hDepartment of International Health, and Institute for Vaccine Safety, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA i Tulane University, Louisiana, USA jDepartment of Pediatrics, Section of Infectious Diseases, and Department of Molecular Virology and Microbiology, Baylor College of Medicine, Houston, TX, USA

    a r t i c l e i n f o a b s t r a c t

    Article history: Received 30 April 2020 Accepted 6 May 2020 Available online xxxx

    Keywords: Sensorineural hearing loss (SNHL) Hearing loss (HL) Adverse event Adverse event of special interest (AESI) Adverse event following immunization (AEFI) Immunization Vaccines Guidelines Case definition

    This is a Brighton Collaboration case definition of the term ‘‘Sensorineural Hearing Loss” to be utilized in the evaluation of adverse events following immunization. The case definition was developed by a group of experts convened by the Coalition for Epidemic Preparedness Innovations (CEPI) in the context of active development of vaccines for Lassa Fever and other emerging pathogens. The case definition format of the Brighton Collaboration was followed to develop a consensus definition and define levels of diag- nostic certainty, after an exhaustive review of the literature and expert consultation. The document underwent peer review by the Brighton Collaboration Network.

    � 2020 Published by Elsevier Ltd.

    nization; ady state ; DPOAE, ss; JCIH, nication species; ransient

    (AEFI): .1016/j.

  • 2 Y.-C. Carol Liu et al. / Vaccine xxx (xxxx) xxx

    1. Preamble

    Need for Developing Case Definitions and Guidelines for Data Collection, Analysis, and Presentation for SNHL as an Adverse Event Following Immunization (AEFI).

    1.1. Introduction

    Sensorineural hearing loss (SNHL) is a specific type of hearing deficit, first described by De Kleyn in 1944 and distinct from con- ductive hearing loss (CHL). SNHL results from damage to the inner ear, the vestibulocochlear nerve, or the central processing centers of the brain. SNHL can be unilateral or bilateral and the degree of the hearing loss is graded as mild to profound. SNHL can be described by location, severity, audiometric configuration and method of onset. The predominant form of SNHL is unilateral, and the main etiology is idiopathic. Most unilateral disease recov- ers spontaneously and therefore is considered benign, whereas bilateral SNHL is usually related to more serious systemic pathol- ogy and is associated with more severe degree of hearing loss and poorer prognosis [1].

    1.2. Existing case definitions of SNHL

    The most commonly used definition of SNHL, as endorsed by the American Academy of Otolaryngology-Head and Neck Surgery (AAOHNS) and the National Institute of Deafness and Other Com- munication Disorders (NIDCD), is hearing loss of at least 30 dB (dB) in three sequential frequencies in the standard pure tone audiogram [2,3]. However, this definition is not universally utilized and variations of the definition and related terms are used in var- ious publications (Table 1).

    Not using a uniform definition of SNHL, particularly in the set- ting of the assessment of SNHL following immunizations, is a missed opportunity, as data comparability across trials or surveil- lance systems would facilitate data interpretation and promote the scientific understanding of SNHL following immunization. This document proposes a case definition of SNHL based on review of the existing literature and expert consensus, for the assessment of SNHL following immunizations.

    1.3. Diagnosis and classification of hearing loss

    The diagnosis of SNHL depends on the demonstration of reduced hearing acuity by auditory testing. Hearing is measured in decibels (dB), with the threshold of 0 dB for each frequency denoting the value at which normal young adults perceive a tone burst of a given intensity and frequency 50% of the time.

    The threshold for normal hearing is �10 to 15 dB in children and adults. Hearing loss is present when hearing acuity drops below 30 dB [21–24]. While various classifications of hearing loss are described, accepted and commonly utilized thresholds for slight, mild, moderate, severe and profound hearing loss are shown in Table 2. A change of more than 10 dB in hearing acuity over time is not likely to occur due to expected testing variability, and is therefore considered significant. Frequency of hearing loss is desig- nated as low (2000 Hz).

    Hearing loss may be unilateral or bilateral, high or low fre- quency, symmetrical or asymmetrical (same vs. different severity and shape of hearing loss in each ear), sudden or progressive, fluc-

    tuating or stable. (


    Please cite this article as: Y.-C. Carol Liu, T. Ibekwe, J. M. Kelso et al., Sensorineu Case definition & guidelines for data collection, analysis, and presenta vaccine.2020.05.019

    1.4. Epidemiology of hearing loss and SNHL

    1.4.1. Incidence, prevalence, and background rates Hearing loss (HL) is the most frequent sensory deficit. The most

    recent Global Burden of Disease (GBD) study estimated that adult onset HL was the fifth leading cause of disability [25]. The specific prevalence of SNHL is not well described. The World Health Orga- nization (WHO) estimates that 6.1% of the world’s population (466 million persons) have disabling hearing loss. Disabling hearing loss refers to hearing loss greater than 40 dB in the better hearing ear in adults (15 years or older) and greater than 30 dB in the better hear-

    ing ear in children (0 to 14 years). (

    ness/hearing_impairment_grades/en/). Of those with HL, 7% (34 million) are children, 93% (432 million) are adults. [26] The WHO estimates that the number of people with disabling hearing loss will grow to up to 630 million by 2030, and to over 900 million by 2050.

    The prevalence of HL varies with age, sex, geographic region, and the definition of HL used. Although childhood onset HL is less common than adult onset, it has serious implications for language acquisition, communication and learning. The prevalence is higher in males as compared to females across all age groups. Age-related HL is a major concern worldwide with increasing life expectancy. Age-related HL begins in the third decade of life and is common after 65 years with estimated incidence of 1 in 3 people over 65 years having disabling HL.

    According to WHO criteria, an overall prevale