Racial and Ethnic Disparities in Otolaryngology Office Visit and Tympanostomy Tube Placement in Children with Otitis Media.

OBJECTIVES: Racial disparities are pervasive in access to pediatric surgery. The goal of this study was to test the hypotheses that, compared with White children, non-White and Hispanic children: (1) were less likely to attend evaluations by otolaryngologists after a diagnosis of otitis media (OM) eligible for surgical referral, and (2) these children were less likely to receive tympanostomy tube (TT) after surgical consultation. METHODS: The OptumLabs Data Warehouse is a de-identified claims database of privately insured enrollees. Guidelines on the management of OMs suggest that children should be evaluated for surgery if they have recurrent acute OM or chronic OM with effusion. A cohort of children who were diagnosed with OM were constructed. For Hypothesis 1, the primary outcome was otolaryngology office visit within 6 months of a diagnosis of recurrent or chronic OM. For Hypothesis 2, the outcome was TT placement within 6 months following the otolaryngology office visit. Cox regression models were used to determine the relationship between race/ethnicity and the primary outcomes. RESULTS: Among 187,776 children with OMs, 72,774 (38.8%) had otolaryngology visits. In a multivariate Cox model, the hazard ratios of attending otolaryngology visit for Black, Hispanic, and Asian children were 0.93 (95% CI,0.90, 0.96), 0.86 (0.83, 0.88), and 0.74 (0.71, 0.77), compared with White children. Among the children evaluated by otolaryngologists, 46,554 (63.97%) received TT. Black, Hispanic, and Asian children with recurrent acute OM had lower likelihood of receiving TT. CONCLUSIONS: Racial disparities in attending otolaryngology office visit contributed to the disparities in receiving TT. QUALITY OF EVIDENCE: Level 3 Laryngoscope, 134:3846-3852, 2024.

Ear and hearing care programs for First Nations children: a scoping review.

BACKGROUND: Ear and hearing care programs are critical to early detection and management of otitis media (or middle ear disease). Otitis media and associated hearing loss disproportionately impacts First Nations children. This affects speech and language development, social and cognitive development and, in turn, education and life outcomes. This scoping review aimed to better understand how ear and hearing care programs for First Nations children in high-income colonial-settler countries aimed to reduce the burden of otitis media and increase equitable access to care. Specifically, the review aimed to chart program strategies, map the focus of each program against 4 parts of a care pathway (prevention, detection, diagnosis/management, rehabilitation), and to identify the factors that indicated the longer-term sustainability and success of programs. METHOD: A database search was conducted in March 2021 using Medline, Embase, Global Health, APA PsycInfo, CINAHL, Web of Science Core Collection, Scopus, and Academic Search Premier. Programs were eligible or inclusion if they had either been developed or run at any time between January 2010 to March 2021. Search terms encompassed terms such as First Nations children, ear and hearing care, and health programs, initiatives, campaigns, and services. RESULTS: Twenty-seven articles met the criteria to be included in the review and described a total of twenty-one ear and hearing care programs. Programs employed strategies to: (i) connect patients to specialist services, (ii) improve cultural safety of services, and (iii) increase access to ear and hearing care services. However, program evaluation measures were limited to outputs or the evaluation of service-level outcome, rather than patient-based outcomes. Factors which contributed to program sustainability included funding and community involvement although these were limited in many cases. CONCLUSION: The result of this study highlighted that programs primarily operate at two points along the care pathway-detection and diagnosis/management, presumably where the greatest need lies. Targeted strategies were used to address these, some which were limited in their approach. The success of many programs are evaluated as outputs, and many programs rely on funding sources which can potentially limit longer-term sustainability. Finally, the involvement of First Nations people and communities typically only occurred during implementation rather than across the development of the program. Future programs should be embedded within a connected system of care and tied to existing policies and funding streams to ensure long term viability. Programs should be governed and evaluated by First Nations communities to further ensure programs are sustainable and are designed to meet community needs.

Burden of respiratory infections and otitis media in the Inuit population of Nunavik, Quebec, Canada.

BACKGROUND: Respiratory infections are a major health problem in the Inuit population of Nunavik, province of Quebec, Canada. OBJECTIVES: A study was undertaken to assess the burden of lower (LRTI) and upper respiratory tract infections (URTI) and otitis media (OM) and to explore some of their determinants including the pneumococcal conjugate vaccine (PCV) status. METHODS: The reference population includes children less than 5 years of age born in 1994-2010 and a sample of 825 children was selected for this study. Outpatient medical records were reviewed. Visits with a diagnosis of LRTI, URTI and OM were extracted. Univariate and multivariate statistical analyses were performed to identify predictors of disease risk. RESULTS: The average number of LRTI, URTI and OM episodes were, respectively, 2.6, 6.2 and 5.9 from birth up to the 5th birthday. Seasonal patterns were similar for URTI and OM, but was different for LRTI. Children who received the recommended 4 PCV doses had a lower LRTI and OM risk than unvaccinated children. There was a trend towards a lower OM risk associated with a mixed PCV10+ PCV13 schedule compared with PCV7. CONCLUSION: Results suggest a lower LRTI and OM risk associated with PCV use in this high-risk population but respiratory disease risk remains high compared with the general population in Quebec.

The impact of hearing impairment on Aboriginal children's school attendance in remote Northern Territory: a data linkage study.

OBJECTIVE: To investigate the association between hearing impairment (HI) and Year 1 school attendance in Aboriginal children in the Northern Territory (NT) of Australia. METHODS: Observational cohort study (n=3,744) by analysing linked individual-level information for Aboriginal children from the NT Government school attendance records, NT Perinatal Register and Remote Hearing Assessment dataset, and community level data for relative remoteness, socioeconomic disadvantage and housing crowdedness. RESULTS: Children with unilateral hearing loss, mild HI and moderate or worse HI had significantly lower Year 1 attendance than those with normal hearing, attending 5.6 (95%CI, -9.10 ∼-2.10), 4.0 (95%CI, -7.17 ∼-0.90) and 6.1 (95%CI, -10.71 ∼-1.49) days fewer, respectively. Other variables that yielded significant association were: male gender, having attended preschool less than 20% of available days, speaking English as second language, twin birth and average household size >5. CONCLUSIONS: Aboriginal children with any level of HI are likely to have lower school attendance rates in Year 1 than their peers with normal hearing. Implications for public health: In this population, where the prevalence of otitis media and accompanying HI remains extremely high, the early detection and management of hearing loss on entry into primary school should be included in the measures to improve school attendance.

The impact of continuity of care on antibiotic prescribing in acute otitis media.

BACKGROUND: The rate of antibiotic prescribing for acute otitis media (AOM) remains high despite efforts to decrease inappropriate use. Studies have aimed to understand the prescribing patterns of providers to increase antibiotic stewardship. Watch and wait (WAW) prescriptions are effective at decreasing the number of antibiotic prescriptions being filled by patients. Additionally, poor continuity of care has been associated with higher cost and lower quality health care. OBJECTIVE: To understand the antibiotic prescribing habits for AOM in a largely Hispanic population. METHODS: A retrospective review was performed from 2016 to 2018 of all patients under 25 years old with a diagnosis of AOM seen at multiple outpatient primary care clinics of a single institution. Charts were reviewed for factors including race, ethnicity, gender, insurance status, presence of fever, primary care physician visit, and treatment choice. Data were collected and analyzed using STATA software with t-tests, ANOVA, and Pearson chi squared analysis. RESULTS: Antibiotics were prescribed 95.6% of the time with 3.8% being WAW prescriptions. There was no significant difference in antibiotic prescribing by race (p = 0.66), ethnicity (p = 0.38), gender (p = 0.34) or insurance status (p = 0.24). There was a difference between physicians, nurse practitioners, and physician's assistants and antibiotic prescribing rate (p < 0.01). Additionally, seen by their primary care provider were less likely to be prescribed antibiotics (85.8% vs 94.4%, p = 0.01). CONCLUSION: While a patient's race, ethnicity, gender, and insurance status did not influence the prescribing rate of physicians, continuity of care may play an important role in decreasing inappropriate antibiotic prescribing.

Middle ear abnormalities at age 5 years in relation with early onset otitis media and number of episodes, in the Inuit population of Nunavik, Quebec, Canada.

Otitis media (OM) and their sequelae are a major health issue in the Inuit population of Nunavik, Quebec. Hypotheses of the study were: (i) early onset OM leads to repeated OM; (ii) repeated OM episodes leads to middle ear abnormalities (MEA) at age 5 years, (iii) pneumococcal conjugate vaccines (PCVs) may reduce multiple OM and MEA. Immunisation cards, medical records and audiology screening tests at age 5 years in a sample of 610 children born in 1994-2010 in 3 communities were reviewed. Children were classified into three categories using a score based on audiology screening tests: no abnormality, minor, or major MEA. The average number of OM episodes before age 5 years was 5.0 and 30% had minor and 17% major MEA at age 5 years. Community residency predicted both frequent (≥ 8) OM episodes and MEA. Early onset OM (age <6 months) was a predictor of frequent OM (RR = 1.71; 95%CI: 1.50-1.95) whereas PCV (≥1 dose ≥ age 2 months) has no significant effect. Frequent OM episodes were associated with major MEA (RR = 2.16; 95%CI: 1.20-3.85). Although associations were not statistically significant, there was a trend towards a protective effect of PCV administration on frequent OM and minor MEA, but not major MEA. In conclusion, results support an association between early onset OM, frequent OM and MEA that could represent a causal pathway.

Otitis media and mastoiditis in temporal bones of prehistoric Chilean populations. A paleopathological and paleoepidemiological study.

BACKGROUND: This study evaluates otitis media in prehistoric populations in northern Chile. AIMS/OBJECTIVES: Determining prevalence of otitis media and diagnostic usefulness of temporal-bone X-rays in skulls. MATERIALS AND METHODS: 444 skulls belonging to three groups: prehistoric-coastal (400-1000 AD), prehistoric-highland (400-1000 AD) and Pisagua-Regional Developments (1000-1450 AD). Skulls were evaluated visually and with Schuller's view X-rays. Five skulls diagnosed as having had otitis media, five diagnosed as normal, and one with temporal bone fistula also had a computed tomography (CT). RESULTS: Changes suggestive of otitis media were present in Prehistoric-coastal 53.57%; Pisagua-Regional Developments 70.73%; prehistoric-highlands 47.90%. Diagnostic effectiveness of Schuller's view X-rays for assesing middle ear disease was confirmed by CT studies. The case with temporal bone fistula had changes suggestive of mastoiditis and possible post auricular abscess. CONCLUSIONS: There was a high prevalence of otitis media in prehistoric populations in Chile. The higher prevalence in one group was presumably due to racial factors. Temporal-bone X-rays are effective for massive evaluation of ear disease in skulls. A case of mastoiditis with temporal bone fistula and possible post-auricular abscess is documented. SIGNIFICANCE: Documenting racial factors in otitis media. Validating X-rays for massive evaluation of otitis media in skulls.

Do demographic disparities exist in the diagnosis and surgical management of otitis media?

OBJECTIVE: Determine if demographic disparities exist between the diagnosis of otitis media (OM) and the provision of myringotomy and tubes in children. STUDY DESIGN: Cross-sectional analysis of a national database. METHODS: The National Ambulatory Medical Care Survey 2010 and the National Hospital Ambulatory Medical Care Survey-Ambulatory Surgery 2010 were abstracted for cases with a diagnosis of OM and myringotomy and tube (MT) procedures in children, respectively. Sex, race, ethnic, and insurance distributions were computed for OM and MT and then compared for healthcare disparities between rates of OM diagnoses and MT procedures. RESULTS: A total of 13.6 million ambulatory pediatric OM diagnoses were identified in 2010 (55.9% male; 82.4% white, 11.3% black, and 6.3% other; 14.3% Hispanic, 85.7% non-Hispanic). A total of 413 thousand ambulatory myringotomy procedures were identified (59.6% male; 86.0% white, 11.0% black, and 3.0% other; 13.0% Hispanic, 87.0% non-Hispanic). There was no statistically significant difference in the provision of MT versus OM diagnosis according to sex (P = 0.400), race (P = 0.313), or ethnicity (P = 0.228). There was also no statistically significant difference in the percentage of Medicaid coverage for OM children (37.0%) versus those undergoing MT (31.1%; P = 0.376). There does, however, appear to be a statistically higher percentage of non-Hispanic children being diagnosed with otitis media than Hispanic children (P = 0.049). CONCLUSION: There were no significant demographic differences in the incidence of children with OM undergoing MT with respect to sex, race, ethnicity, or insurance status. As a specialty, otolaryngology does not appear to exhibit any disparate healthcare access bias in providing MT to children with OM. LEVEL OF EVIDENCE: NA Laryngoscope, 128:2898-2901, 2018.

A program to respond to otitis media in remote Australian Aboriginal communities: a qualitative investigation of parent perspectives.

BACKGROUND: Indigenous infants and children in Australia, especially in remote communities, experience early and chronic otitis media (OM) which is difficult to treat and has lifelong impacts in health and education. The LiTTLe Program (Learning to Talk, Talking to Learn) aimed to increase infants' access to spoken language input, teach parents to manage health and hearing problems, and support children's school readiness. This paper aimed to explore caregivers' views about this inclusive, parent-implemented early childhood program for 0-3 years in an Aboriginal community health context. METHODS: Data from in-depth, semi-structured interviews with 9 caregivers of 12 children who had participated in the program from one remote Aboriginal community in the Northern Territory are presented. Data were analysed thematically. Caregivers provided overall views on the program. In addition, three key areas of focus in the program are also presented here: speech and language, hearing health, and school readiness. RESULTS: Caregivers were positive about the interactive speech and language strategies in the program, except for some strategies which some parents found alien or difficult: such as talking slowly, following along with the child's topic, using parallel talk, or baby talk. Children's hearing was considered by caregivers to be important for understanding people, enjoying music, and detecting environmental sounds including signs of danger. Caregivers provided perspectives on the utility of sign language and its benefits for communicating with infants and young children with hearing loss, and the difficulty of getting young community children to wear a conventional hearing aid. Caregivers were strongly of the opinion that the program had helped prepare children for school through familiarising their child with early literacy activities and resources, as well as school routines. But caregivers differed as to whether they thought the program should have been located at the school itself. CONCLUSIONS: The caregivers generally reported positive views about the LiTTLe Program, and also drew attention to areas for improvement. The perspectives gathered may serve to guide other cross-sector collaborations across health and education to respond to OM among children at risk for OM-related disability in speech and language development.

Microbiology of otitis media in Indigenous Australian children: review.

OBJECTIVES: To review research addressing the polymicrobial aetiology of otitis media in Indigenous Australian children in order to identify research gaps and inform best practice in effective prevention strategies and therapeutic interventions. METHODS: Literature review. RESULTS: Studies of aspirated middle-ear fluid represented a minor component of the literature reviewed. Most studies relied upon specimens from middle-ear discharge or the nasopharynx. Culture-based middle-ear discharge studies have found that non-typeable Haemophilus influenzae and Streptococcus pneumoniae predominate, with Moraxella catarrhalis, Staphylococcus aureus and Streptococcus pyogenes isolated in a lower proportion of samples. Alloiococcus otitidis was detected in a number of studies; however, its role in otitis media pathogenesis remains controversial. Nasopharyngeal colonisation is a risk factor for otitis media in Indigenous infants, and bacterial load of otopathogens in the nasopharynx can predict the ear state of Indigenous children. CONCLUSION: Most studies have used culture-based methods and specimens from middle-ear discharge or the nasopharynx. Findings from these studies are consistent with international literature, but reliance on culture may incorrectly characterise the microbiology of this condition. Advances in genomic technologies are now providing microbiologists with the ability to analyse the entire mixed bacterial communities ('microbiomes') of samples obtained from Indigenous children with otitis media.

Indicators for continuous quality improvement for otitis media in primary health care for Aboriginal and Torres Strait Islander children.

Otitis media is a common, generally self-limiting childhood illness that can progress to severe disease and have lifelong sequelae, including hearing loss and developmental delays. Severe disease is disproportionately prevalent among Aboriginal and Torres Strait Islander children. Primary health care is at the frontline of appropriate prevention and treatment. Continuous quality improvement in the prevention and management of important causes of morbidity in client populations is accepted best practice in primary health care and now a requirement of Australian Government funding to services providing care for Aboriginal and Torres Strait Islander children. To date, there have been no indicators for continuous quality improvement in the prevention and management of otitis media and its sequelae in primary health care. Through an expert group consensus process, seven evidence-based indicators, potentially extractable from electronic health records, have been developed. The development process and indicators are described.

No evidence for impaired humoral immunity to pneumococcal proteins in Australian Aboriginal children with otitis media.

BACKGROUND: The Australian Aboriginal population experiences disproportionately high rates of otitis media (OM). Streptococcus pneumoniae is one of the main pathogens responsible for OM and currently no vaccine offering cross strain protection exists. Vaccines consisting of conserved antigens to S. pneumoniae may reduce the burden of OM in high-risk populations; however no data exists examining naturally acquired antibody in Aboriginal children with OM. METHODS: Serum and salivary IgA and IgG were measured against the S. pneumoniae antigens PspA1 and 2, CbpA and Ply in a cross sectional study of 183 children, including 36 non-Aboriginal healthy control children and 70 Aboriginal children and 77 non-Aboriginal children undergoing surgery for OM using a multiplex bead assay. RESULTS: Significant differences were observed between the 3 groups for serum anti-PspA1 IgA, anti-CbpA and anti-Ply IgG and for all salivary antibodies assessed. Aboriginal children with a history of OM had significantly higher antibody titres than non-Aboriginal healthy children with no history of OM and non-Aboriginal children with a history of OM for several proteins in serum and saliva. Non-Aboriginal children with a history of OM had significantly higher salivary anti-PspA1 IgG than healthy children, while all other titres were comparable between the groups. CONCLUSIONS: Conserved vaccine candidate proteins from S. pneumoniae induce serum and salivary antibody responses in Aboriginal and non-Aboriginal children with a history of OM. Aboriginal children do not have an impaired antibody response to the antigens measured from S. pneumoniae and they may represent vaccine candidates in Indigenous populations.

General health, otitis media, nasopharyngeal carriage and middle ear microbiology in Northern Territory Aboriginal children vaccinated during consecutive periods of 10-valent or 13-valent pneumococcal conjugate vaccines.

OBJECTIVES: This study aims to monitor the prevalence of suppurative otitis media in remote Indigenous communities after introduction of 13-valent pneumococcal conjugate vaccine (PCV13) in October 2011. We previously reported a decline in suppurative OM following replacement of PCV7 by 10-valent pneumococcal Haemophilus influenzae protein D conjugate vaccine (PHiD-CV10) in October 2009. METHODS: We continued regular surveillance in remote Indigenous communities between February 2010 and August 2013. This analysis reports the general health, otitis media (OM), nasopharyngeal (NP) carriage and middle ear microbiology in children less than 36 months of age who received a primary course of at least two doses of PHiD-CV10 or PCV13, and not more than one dose of another pneumococcal vaccine. RESULTS: Mean ages of 511 PHiD-CV10- and 140 PCV13-vaccinated children were 19 and 13 months, respectively. Most children received 3-dose non-mixed PCV schedules. At the time of assessment, general health was poor and prevalence of risk factors was high in both groups: overall, around 14% of children had scabies, 20% had impetigo, 59% had runny nose and 39% had cough. Average household size was 8 persons, and 60% of the mothers smoked. Bilaterally normal middle ears were detected in 10% and 7%, respectively. OM with effusion (OME), almost all bilateral, was diagnosed in 52% and 50%, any suppurative OM (acute OM or any tympanic membrane perforation [TMP]) in 37% and 41%, and TMP in 14% and 12%, respectively. Children in the PCV13 group had significantly less NP carriage of combined Streptococcus pneumoniae (Spn) and non-typeable Haemophilus influenzae (NTHi) (62% versus 51%) but significantly more polymicrobial (Spn and NTHi) middle ear cultures (12% versus 43%), and significantly less Staphylococcus aureus-positive middle ears (40% versus 7%). Although NP carriage of pneumococcal serotype 19A was low in the PCV13 group, serotypes 19F and 23F persist. CONCLUSIONS: The general health, particularly ear health, of little children in remote Australian Indigenous communities remains in crisis. In particular, transition to PCV13 did not show substantial further improvement in ear health. Possible vaccine-related differences in microbiology, including potential beneficial effects of PHiD-CV10 on NTHi infection, need to be further evaluated in randomised trials.

A multi-centre open-label randomised non-inferiority trial comparing watchful waiting to antibiotic treatment for acute otitis media without perforation in low-risk urban Aboriginal and Torres Strait Islander children (the WATCH trial): study protocol for a randomised controlled trial.

BACKGROUND: Treatment guidelines recommend watchful waiting for children older than 2 years with acute otitis media (AOM) without perforation, unless they are at high risk of complications. The high prevalence of chronic suppurative otitis media (CSOM) in remote Aboriginal and Torres Strait Islander communities leads these children to be classified as high risk. Urban Aboriginal and Torres Strait Islander children are at lower risk of complications, but evidence to support the subsequent recommendation for watchful waiting in this population is lacking. METHODS/DESIGN: This non-inferiority multi-centre randomised controlled trial will determine whether watchful waiting is non-inferior to immediate antibiotics for urban Aboriginal and Torres Strait Islander children with AOM without perforation. Children aged 2 - 16 years with AOM who are considered at low risk for complications will be recruited from six participating urban primary health care services across Australia. We will obtain informed consent from each participant or their guardian. The primary outcome is clinical resolution on day 7 (no pain, no fever of at least 38 °C, no bulging eardrum and no complications of AOM such as perforation or mastoiditis) as assessed by general practitioners or nurse practitioners. Participants and outcome assessors will not be blinded to treatment. With a sample size of 198 children in each arm, we have 80 % power to detect a non-inferiority margin of up to 10 % at a significance level of 5 %, assuming clinical improvement of at least 80 % in both groups. Allowing for a 20 % dropout rate, we aim to recruit 495 children. We will analyse both by intention-to-treat and per protocol. We will assess the cost- effectiveness of watchful waiting compared to immediate antibiotic prescription. We will also report on the implementation of the trial from the perspectives of parents/carers, health professionals and researchers. DISCUSSION: The trial will provide evidence for the safety and effectiveness of watchful waiting for the management of AOM in Aboriginal and Torres Strait Islander children living in urban settings who are considered to be at low risk of complications. TRIAL REGISTRATION: The trial is registered with Australia New Zealand Clinical Trials Registry ( ACTRN12613001068752 ). Date of registration: 24 September 2013.

Breastfeeding as a means to prevent infant morbidity and mortality in Aboriginal Canadians: A population prevented fraction analysis.

OBJECTIVES: Canadian Aboriginal infants experience poor health compared with other Canadian infants. Breastfeeding protects against many infant infections that Canadian Aboriginals disproportionately experience. The objective of our research was to estimate the proportion of select infant infection and mortality outcomes that could be prevented if all Canadian Aboriginal infants were breastfed. METHODS: We used Levin's formula to estimate the proportion of three infectious outcomes and one mortality outcome that could be prevented in infancy by breastfeeding. Estimates were calculated for First Nations (both on- and off-reserve), Métis and Inuit as well as all Canadian infants for comparison. We extracted prevalence estimates of breastfeeding practices from national population-based surveys. We extracted relative risk estimates from published meta-analyses. RESULTS: Between 5.1% and 10.6% of otitis media, 24.3% and 41.4% of gastrointestinal infection, 13.8% and 26.1% of hospitalizations from lower respiratory tract infections, and 12.9% and 24.6% of sudden infant death could be prevented in Aboriginal infants if they received any breastfeeding. CONCLUSION: Interventions that promote, protect and support breastfeeding may prevent a substantial proportion of infection and mortality in Canadian Aboriginal infants.

Ethnic differences in acute hospitalisations for otitis media and elective hospitalisations for ventilation tubes in New Zealand children aged 0-14 years.

AIMS: This paper describes ethnic differences in acute hospitalisations for otitis media (OM) and elective hospitalisations for ventilation tube insertion in New Zealand children aged 0-14 years. Ethnic differences in first attendances at Ear Nose and Throat (ENT) outpatient clinics are also described. METHOD: The analysis included all hospital admissions of children aged 0-14 years during 2002-2008 which met the following criteria: Acute admissions with an ICD-10-AM primary diagnosis code of otitis media; and elective admissions with a primary procedure code of ventilation tube insertion. First attendances at ENT outpatient clinics during 2007-2008 were also reviewed. Explanatory variables included ethnicity, gender, age, and NZ Deprivation Index decile. RESULTS: Among 0-4 year olds, Maori and Pacific children were more likely to be admitted acutely for otitis media than European children. In contrast, both Maori and Pacific children had lower rates of elective admissions for ventilation tube insertion, with ethnic differences being most marked for children from the most deprived areas. Maori and Pacific children aged 5-14 years also had higher acute otitis media admission rates than European children. In contrast to their younger counterparts however, they also had higher rates of ventilation tube insertion. Exploration of ENT outpatient data for children 0-4 years revealed similar first appointment rates for European and Maori children, but lower rates for Pacific and Asian children. For the 5-14 age group, first appointment rates were higher for Maori and Pacific children than for European children. However, Maori and Pacific children in both age groups had higher rates of non-attendance at their first ENT appointments than European children. CONCLUSION: This study highlights ethnic differences in access to ventilation tubes amongst New Zealand's 0-4 year olds, with the greatest inequalities being seen for Maori, Pacific and Asian children living in the most deprived areas. For Maori and Pacific children, such differences cannot be attributed to lower rates of AOM or OME compared to European children. The fact that similar patterns are not seen for children aged 5-14 years potentially suggests that routine Well Child hearing screening may be playing a role in identifying unmet need in this older age group. Such disparities also suggest that factors over and above OM prevalence may be influencing access to ventilation tubes. Further research is required to determine why Maori and Pacific children (0-4 years) have similar/lower ENT appointment rates than European children, despite a higher burden of middle ear disease, as well as higher non-attendance rates at outpatient clinics. Given the importance of early detection and treatment of OM for children's ongoing well-being and education, a greater understanding of the reasons for these inequalities is urgently required.

Estimated prevalence of hearing loss and provision of hearing services in Pacific Island nations.

INTRODUCTION: Hearing impairment (HI) affects an estimated 538 million people worldwide, with 80% of these living in developing countries. Untreated HI in childhood may lead to developmental delay and in adults results in social isolation, inability to find or maintain employment, and dependency. Early intervention and support programmes can significantly reduce the negative effects of HI. AIM: To estimate HI prevalence and identify available hearing services in some Pacific countries - Cook Islands, Fiji, Niue, Samoa, Tokelau, Tonga. METHODS: Data were collected through literature review and correspondence with service providers. Prevalence estimates were based on census data and previously published regional estimates. RESULTS: Estimates indicate 20-23% of the population may have at least a mild HI, with up to 11% having a moderate impairment or worse. Estimated incidence of chronic otitis media in Pacific Island nations is 3-5 times greater than other Australasian countries in children under 10 years old. Permanent HI from otitis media is substantially more likely in children and adults in Pacific Island nations. Several organisations and individuals provide some limited hearing services in a few Pacific Island nations, but the majority of people with HI are largely underserved. DISCUSSION: Although accurate information on HI prevalence is lacking, prevalence estimates of HI and ear disease suggest they are significant health conditions in Pacific Island nations. There is relatively little support for people with HI or ear disease in the Pacific region. An investment in initiatives to both identify and support people with hearing loss in the Pacific is necessary.

Evolution and Otitis Media: A Review, and a Model to Explain High Prevalence in Indigenous Populations.

Otitis media (OM; inflammation of the middle ear) comprises a group of disorders that are among the most common disorders of childhood. OM is also heritable and has effects on fecundity. This means that OM is subject to evolution, yet the evolutionary forces that may determine susceptibility to OM have not been adequately explored. Here I analyze evolutionary forces that may determine susceptibility to middle ear inflammation. These forces include those affecting function of the middle ear, host immunity, or colonization by and pathogenicity of bacteria. I review existing evolutionary models of host-pathogen interaction and coevolution and apply these to better understand the complex evolutionary landscape of middle ear infection and inflammation in humans, including factors determining transition between stable evolutionary strategies for host and bacteria. This understanding is then applied to an analysis of OM in indigenous populations to devise a new theory for OM prevalence in Australian Aborigine, Native American, Inuit, and Maori populations. I suggest that high prevalence in such groups may have resulted from encounters of these previously isolated populations with European immigrants in the 15th and 16th centuries. This exposed them to new strains of bacteria to which their immune system had not evolved immunity, perturbing a previously stable host-pathogen coevolutionary state.

Race, otitis media, and antibiotic selection.

BACKGROUND AND OBJECTIVE: Previous research suggests that physicians may be less likely to diagnose otitis media (OM) and to prescribe broad-spectrum antibiotics for black versus nonblack children. Our objective was to determine whether race is associated with differences in OM diagnosis and antibiotic prescribing nationally. METHODS: We examined OM visit rates during 2008 to 2010 for children ≤14 years old using the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey. We compared OM visits between black and nonblack children, as percentages of all outpatient visits and visit rates per 1000. We compared antibiotic prescribing by race as the percentage of OM visits receiving narrow-spectrum (eg, amoxicillin) versus broader-spectrum antibiotics. We used multivariable logistic regression to examine whether race was independently associated with antibiotic selection for OM. RESULTS: The percentage of all visits resulting in OM diagnosis was 30% lower in black children compared with others (7% vs 10%, P = .004). However, OM visits per 1000 population were not different between black and nonblack children (253 vs 321, P = .12). When diagnosed with OM during visits in which antibiotics were prescribed, black children were less likely to receive broad-spectrum antibiotics than nonblack children (42% vs 52%, P = .01). In multivariable analysis, black race was negatively associated with broad-spectrum antibiotic prescribing (adjusted odds ratio 0.59; 95% confidence interval, 0.40-0.86). CONCLUSIONS: Differences in treatment choice for black children with OM may indicate race-based differences in physician practice patterns and parental preferences for children with OM.