Otitis media in young Aboriginal children from remote communities in Northern and Central Australia: a cross-sectional survey

BACKGROUND

Middle ear disease (otitis media) is common and frequently severe in Australian Aboriginal children. There have not been any recent large-scale surveys using clear definitions and a standardised middle ear assessment. The aim of the study was to determine the prevalence of middle ear disease (otitis media) in a high-risk population of young Aboriginal children from remote communities in Northern and Central Australia.

METHODS

709 Aboriginal children aged 6-30 months living in 29 communities from 4 health regions participated in the study between May and November 2001. Otitis media (OM) and perforation of the tympanic membrane (TM) were diagnosed by tympanometry, pneumatic otoscopy, and video-otoscopy. We used otoscopic criteria (bulging TM or recent perforation) to diagnose acute otitis media.

RESULTS

914 children were eligible to participate in the study and 709 were assessed (78%). Otitis media affected nearly all children (91%, 95%CI 88, 94). Overall prevalence estimates adjusted for clustering by community were: 10% (95%CI 8, 12) for unilateral otitis media with effusion (OME); 31% (95%CI 27, 34) for bilateral OME; 26% (95%CI 23, 30) for acute otitis media without perforation (AOM/woP); 7% (95%CI 4, 9) for AOM with perforation (AOM/wiP); 2% (95%CI 1, 3) for dry perforation; and 15% (95%CI 11, 19) for chronic suppurative otitis media (CSOM). The perforation prevalence ranged from 0-60% between communities and from 19-33% between regions. Perforations of the tympanic membrane affected 40% of children in their first 18 months of life. These were not always persistent.

CONCLUSION

Overall, 1 in every 2 children examined had otoscopic signs consistent with suppurative ear disease and 1 in 4 children had a perforated tympanic membrane. Some of the children with intact tympanic membranes had experienced a perforation that healed before the survey. In this high-risk population, high rates of tympanic perforation were associated with high rates of bulging of the tympanic membrane.

Otitis media in children vaccinated during consecutive 7-valent or 10-valent pneumococcal conjugate vaccination schedules

BACKGROUND

In 2001 when 7-valent pneumococcal conjugate vaccine (PCV7) was introduced, almost all (90%) young Australian Indigenous children living in remote communities had some form of otitis media (OM), including 24% with tympanic membrane perforation (TMP). In late 2009, the Northern Territory childhood vaccination schedule replaced PCV7 with 10-valent pneumococcal Haemophilus influenzae protein D conjugate vaccine (PHiD-CV10).

METHODS

We conducted regular surveillance of all forms of OM in children in remote Indigenous communities between September 2008 and December 2012. This analysis compares children less than 36 months of age who received a primary course of at least two doses of PCV7 or PHiD-CV10, and not more than one dose of another pneumococcal vaccine.

RESULTS

Mean ages of 444 PCV7- and 451 PHiD-CV10-vaccinated children were 20 and 18 months, respectively. Bilaterally normal middle ears were detected in 7% and 9% respectively. OM with effusion was diagnosed in 41% and 51% (Risk Difference 10% [95% Confidence Interval 3 to 17] p = 0.002), any suppurative OM (acute OM or any TMP) in 51% versus 39% (RD -12% [95% CI -19 to -5] p = 0.0004], and TMP in 17% versus 14% (RD -3% [95% CI -8 to 2] p = 0.2), respectively. Multivariate analyses described a similar independent negative association between suppurative OM and PHiD-CV10 compared to PCV7 (Odds Ratio = 0.6 [95% CI 0.4 to 0.8] p = 0.001). Additional children in the household were a risk factor for OM (OR = 2.4 [95% CI 2 to 4] p = 0.001 for the third additional child), and older age and male gender were associated with less disease. Other measured risk factors were non-significant. Similar clinical results were found for children who had received non-mixed PCV schedules.

CONCLUSIONS

Otitis media remains a significant health and social issue for Australian Indigenous children despite PCV vaccination. Around 90% of young children have some form of OM. Children vaccinated in with PHiD-CV10 had less suppurative OM than children vaccinated with PCV7. Ongoing surveillance during the PCV13 era, and trials of early intervention including earlier and mixed vaccine schedules are warranted.

Otitis media in Indigenous Australian children: review of epidemiology and risk factors

BACKGROUND

Otitis media represents a major health concern in Australian Indigenous children ('Indigenous children'), which has persisted, despite public health measures, for over 30 years.

METHODS

Global searches were performed to retrieve peer-reviewed and 'grey' literature investigating the epidemiology of and risk factors for otitis media in Indigenous children, published between 1985 and 2012.

RESULTS

In Indigenous children, the prevalence of otitis media subtypes is 7.1-12.8 per cent for acute otitis media, 10.5-30.3 per cent for active chronic otitis media and 31-50 per cent for tympanic membrane perforation. The initial onset of otitis media in Indigenous children occurs earlier and persists for longer after the first year of life, compared with non-Indigenous children. Indigenous children are colonised by otopathogens more frequently, at younger ages and with a higher bacterial load. Poor community and domestic infrastructure, overcrowding and exposure to tobacco smoke increase the risk of otitis media in Indigenous children; however, the availability of swimming pools plays no role in the prevention or management of otitis media.

CONCLUSION

Despite awareness of the epidemiological burden of otitis media and its risk factors in Indigenous children, studies undertaken since 1985 demonstrate that otitis media remains a significant public health concern in this population.

Benefits of swimming pools in two remote Aboriginal communities in Western Australia: intervention study

OBJECTIVE

To determine the health impact of swimming pools built with the aim of improving quality of life and reducing high rates of pyoderma and otitis media.

DESIGN

Intervention study assessing prevalence of ear disease and skin infections before and at six monthly intervals after opening of swimming pools.

SETTING

Two remote Aboriginal communities in Western Australia.

PARTICIPANTS

84 boys and 78 girls aged < 17 years.

MAIN OUTCOME MEASURES

Changes in prevalence and severity of pyoderma and perforation of tympanic membranes with or without otorrhoea over 18 months after opening of pools.

RESULTS

In community A, 61 children were seen before the pool was opened, and 41, 46, and 33 children were seen at the second, third, and fourth surveys. Equivalent figures for community B were 60, 35, 39, and 45. Prevalence of pyoderma declined significantly from 62% to 18% in community A and from 70% to 20% in community B during the 18 months after the pools opened. Over the same period, prevalence of severe pyoderma fell from 30% to 15% in community A and from 48% to 0% in community B. Prevalence of perforations of the tympanic membrane fell from 32% in both communities to 13% in community A and 18% in community B. School attendance improved in community A.

CONCLUSION

Swimming pools in remote communities were associated with reduction in prevalence of pyoderma and tympanic membrane perforations, which could result in long term benefits through reduction in chronic disease burden and improved educational and social outcomes.

An overview of acute otitis media in Australian Aboriginal children living in remote communities

Australian Aboriginal children experience early, persistent and severe middle ear infections. We conducted a review of the medical literature that addressed acute otitis media (AOM) in Australian Aboriginal children. Comparisons were made with the recent guidelines on the diagnosis and management of AOM prepared by the American Academies of Pediatrics and Family Physicians (AAP & AAFP 2004). Otitis media in Aboriginal children living in remote communities begins in the first 3 months of life following early bacterial colonisation. Young children with persistent signs of suppurative disease (bulging of the tympanic membrane or middle ear discharge) are probably most at risk of developing chronic suppurative otitis media.

Complications of otitis media in Indigenous and non-Indigenous children

In Australia, three to five children die each year because of otitis media complications, and 15 children will suffer permanent hearing loss each year as a result of otitis media. Extracranial complications occur most commonly, and include mastoiditis, cholesteatoma and otitis media with perforation. Intracranial complications are less common, and include meningitis, brain abscess and lateral sinus thrombosis. In Australia, approximately 60% of extracranial and intracranial complications of otitis media occur in children. The contrasting rates of childhood otitis media among Indigenous and non-Indigenous children have implications for the frequency and types of complications occurring in both groups. Otitis media with effusion and acute otitis media predominate among non-Indigenous children, whereas chronic suppurative otitis media (CSOM) occurs most commonly among Indigenous children. The incidence of mastoiditis in Australia is low by international standards (2/100,000 children), but cholesteatoma rates among Indigenous children in Australia are higher than previously estimated (up to 10% in CSOM). A high rate of chronic tympanic membrane perforation occurs among Indigenous children, estimated to be as high as 80%. Intracranial complications of otitis media are uncommon, but are potentially life-threatening and are more likely to occur among Indigenous than non-Indigenous children. Reduced access to medical care, lower socioeconomic status and remote living conditions mean that levels of early childhood hearing loss among Indigenous children are likely to be underestimated. This has implications for early childhood speech and language development and education.

Impact of swimming on chronic suppurative otitis media in Aboriginal children: a randomised controlled trial

OBJECTIVES

To measure the impact of 4 weeks of daily swimming on rates of ear discharge among Aboriginal children with a tympanic membrane perforation (TMP) and on the microbiology of the nasopharynx and middle ear.

DESIGN, SETTING AND PARTICIPANTS

A randomised controlled trial involving 89 Aboriginal children (aged 5-12 2013s) with a TMP, conducted in two remote Northern Territory Aboriginal communities from August to December 2009.

INTERVENTION

4 school weeks of daily swimming lessons (45 minutes) in a chlorinated pool.

MAIN OUTCOME MEASURES

Proportions of children with ear discharge and respiratory and opportunistic bacteria in the nasopharynx and middle ear.

RESULTS

Of 89 children randomly assigned to the swimming or non-swimming groups, 58 (26/41 swimmers and 32/48 non-swimmers) had ear discharge at baseline. After 4 weeks, 24 of 41 swimmers had ear discharge compared with 32 of 48 non-swimmers (risk difference, - 8% (95% CI, - 28% to 12%). There were no statistically significant changes in the microbiology of the nasopharynx or middle ear in swimmers or non-swimmers. Streptococcus pneumoniae and non-typeable Haemophilus influenzae were the dominant organisms cultured from the nasopharynx, and H. influenzae, Staphylococcus aureus and Pseudomonas aeruginosa were the dominant organisms in the middle ear.

CONCLUSIONS

Swimming lessons for Aboriginal children in remote communities should be supported, but it is unlikely that they will substantially reduce rates of chronic suppurative otitis media and associated bacteria in the nasopharynx and middle ear. However, swimming was not associated with increased risk of ear discharge and we found no reason to discourage it.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12613000634774.