Aboriginal Children’s Ear Disease – The Silent Epidemic

One of the best measures of the degree of poverty in a country’s Indigenous population is the prevalence of chronic discharging ears (chronic suppurative otitis media). In Australia. in remote Indigenous communities, the prevalence rate of chronic suppurative otitis media may be up to 70-80% of children yet the World Health Organization has indicated that any prevalence rate of this condition greater than 4% is indicative of a massive public health problem requiring urgent attention. The effect of the associated hearing loss, lack of development of communication skills and problems hearing in school lead to a downward spiral of truancy, underperformance, early school leaving and a life long impact on vocational outcomes. Through out their childhood the average Aboriginal child will have middle ear disease and hearing loss for 36 months compared with an average of 3 months for the non-indigenous child. Reports from General Practitioners who have been involved in the Northern Territory initiatives recently indicate that the major conditions identified are ear, eye and skin diseases in addition to under-nutrition.

So why is middle ear disease such a major problem in Australian Aboriginal children? As a disease of poverty, the public health issues of inadequate housing, over crowding, lack of running water, hygiene issues, lack of access to medical care,  and inadequate nutrition all contribute to a situation where children, almost from birth are exposed to large loads of pathogenic bacteria. These bacteria invade the space at the back of the nose (nasopharynx) and by age 3 months almost all of the usual pathogens for middle ear disease are present in large quantities in the naso pharynx near the opening to the Eustachian tube (which communicates with the middle ear). The Indigenous infant’s immune system is unable to mount a strong enough response to eradicate the bacteria and an inflammatory cascade may cause damage to the mucosal lining of the middle ear leading to chronic bacterial infection within the mucosa and the development of a preservation strategy known as bacterial biofilm over the mucosa (bacterial biofilm is possibly the cause of the recalcitrance of chronic suppurative otitis media to conventional treatments). The young children may develop acute middle ear infections with few of the typical signs seen in non-Indigenous children such as fever, and acute pain. Because of this “silent” infection, with few accompanying symptoms, the mothers of Indigenous children may not be aware of the disease process until the tympanic membrane ruptures and there is discharge. If this discharge occurs for a longer than a month or so it is by definition chronic and will impact on the child’s hearing and learning ability significantly. Even in urban
Aboriginal children, although there is a much lower incidence of discharging ears, there is a relatively high number of children even beyond the age of 10 years with middle ear effusions or “glue ear” as seen in non-Indigenous children. The “improvement “ of the chronic discharging ears to a state of middle ear fluid in urban Aboriginal children can be credited to improvement in accommodation, other public health measures, including access to water and easier access to medical treatment.

 What can we do to reduce the impact of this serious disease which affects so many thousands of Aboriginal and Torres Strait Islanders children in Australia? The recently announced initiatives to improve Aboriginal housing is a fundamental necessity - this together with other successful programs such as encouragement of breastfeeding beyond 6 months, education of parents regarding the effects of smoking on middle ear disease, pneumococcal immunization and intensive projects such as the innovative Queensland Deadly Ears Program. Yet much more is needed - especially early management of acute ear disease in young children to prevent progression to chronic ear disease. There have been a number of projects in the past which have shown that intensive efforts to treat ear disease will show improved results and the lynchpin is the Aboriginal health worker who has been trained to detect ear disease, hearing loss and provide basic treatment as well as educate the parents. With the supervision by nursing staff or, even better, ear nurse specialists as in New Zealand, children with ear disease can be managed in a treatment paradigm different from the current pyramidal system with the ear surgeon at the top - in this paradigm the pyramid is upside down with the health workers and ear nurse specialists being the prime resources. The New Zealand program supported by the Variety Club with ear buses visiting schools and centres has been very successful and direct referrals to general practitioners and, via tele-otology, to ear nose and throat surgeons for diagnosis and treatment suggestions is possible. But we need significant resources. We need uniform treatment protocols throughout the country and there must be improved resources for the ear surgeons to enable them to treat those children who require surgical intervention, particularly the insertion of grommet or ventilation tubes or repair of their chronic tympanic membrane perforations. Mobile operating theatres have been advocated where day surgery can be performed in a mobile operating theatre adjacent to a hospital or even, as has occurred in the past, specialized medical army camps.

For over 60 years Australian otolaryngologists, members of the Australian Society of Otolaryngology, Head and Neck Surgery, have been visiting Aboriginal settlements in rural and remote Australia as well as providing services in urban centres. Twenty six Queensland ear surgeons have volunteered to work in the Northern Territory to treat children with ear conditions picked up by the recent initiative, but because of a dispute between the Federal Department of Family and Children’s Services and the Federal Health Department not one specialist has been sent to the Northern Territory.

The recently announced Fred Hollows Hospital in Alice Springs could be integrated with an ear day surgery hospital and medical and research centre. There, semi retired otolaryngologists could supervise graduate fellows in otolaryngology rotating through their otology fellowships. Another critical resource are the para medical group, particularly the audiologists and speech pathologists - there is a dearth of both of these specialties in remote and rural Australia and appropriate incentives to encourage them to participate in these programs is necessary. Essential in this program is training and education in a culturally sensitive way of all the participants in the ear health program. This includes teachers and Aboriginal education workers with the interface of health and education never more closely allied than in the field of hearing disorders. Every new school built, where there are children with hearing loss should have sound field systems built in so that the teacher’s voice can be amplified. The recent appointment of the first Aboriginal surgeon in Australia, Dr Kelvin Kong, an Ear, Nose and Throat Surgeon to Chair the Indigenous Outcomes Sub-Committee in the Prime Minister’s 2020 Strategy is a welcome decision

But what of research? Basic research into the causes of middle ear infections in Indigenous children is being carried out principally at the Menzies School of Health in Darwin and the Telethon Institute for Child Health Research and Princess Margaret Hospital in Perth. Studies varying from the genetics of recurrent otitis media in Indigenous children, through to studies of the bacteriology, immunology and effective vaccination are being carried out at these centres. Translational research such as the swimming pool project in Western Australia, where there was a dramatic reduction in ear disease as well as eye, skin and chest diseases and even truancy with the “no school no pool” rule are making a difference. There is always scope for further research and funds are necessary for both basic and clinical research work. Fortunately companies such as Rio Tinto and charities such as the Variety Club Ear Bus program are making a practical difference in the field.

There is much more to do - we have the personnel, the will and the passion. It only requires the financial and infrastructure support of Government in Australia to reverse this spiral of despair.

Harvey Coates AO

Information Resource
Indigenous EarInfoNet.
A web resource and yarning place about ear health and hearing issues among Aboriginal Australians.  www.earinfonet.org.au

Associate Professor Harvey Coates is Chair of the Indigenous Sub- Committee of the Australian Society of Otolaryngology Head and Neck Surgery.