Original Studies

Otitis Media in Indonesian Urban and Rural School Children

Ratna Anggraeni, MD, MSc, PhD,* Widya W. Hartanto, MD, MSc,* Bulantrisna Djelantik, MD, PhD,*
Abla Ghanie, MD,† Denny S. Utama, MD, MSc,† Eka P. Setiawan, MD,‡ Erica Lukman, MD,§
Chintriany Hardiningsih, MD, MSc,§ Suprihati Asmuni, MD, PhD,¶ Rery Budiarti, MD, MSc,¶
Sutji Pratiwi Rahardjo, MD, PhD,‖ Riskiana Djamin, MD,‖ Tri Mulyani, BSc,** Kuswandewi Mutyara, MD, MSc,**
Phyllis Carosone-Link, MS,†† Cissy B. Kartasasmita, MD, PhD,** and Eric A. F. Simões, MB, BS, DCH, MD††

Background: Although the epidemiology of otitis media is well-known

with recurrent perforation of the tympanic membrane leading to
in industrialized countries, the extent of otitis media in developing Asian
chronic suppurative otitis media (CSOM).1 Hearing impairment
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countries, especially in south East Asia is not well studied.

because of CSOM is a major form of disability in Southeast Asia
Methods: To define the burden of otitis media and its sequelae in children
causing significant social, educational and vocational burdens in
6–15 years of age, we enrolled elementary and junior high school children
these countries.2–12 The sequelae and complications of CSOM can
in 6 areas in rural and urban Indonesia. Randomly selected schools and
be prevented, if detected and treated early.12
classrooms were selected. All children were administered a questionnaire
Studies that indicated high prevalences of OME and CSOM
and had ear examinations, pneumatic otoscopy and screening audiometry.
in Asia were published between 1991 and 1999. The prevalence
Children with any abnormality on examination or with a relevant history
of CSOM was 15/1000 school children in India7 and 5.3/1000 in
underwent diagnostic audiometry and tympanometry, if indicated.
Malaysia3 compared with 0.01–0.03/1000 in the United States.13
Results: Of the 7005 children studied, 116 had chronic suppurative otitis
This estimate was much higher than in Africa from studies pub-
media (CSOM), 30 had acute otitis media and 26 had otitis media with
lished between 1995 and 2004.14–16 The latest data available from
effusion. 2.7% of rural children had CSOM compared with 0.7% of urban
Indonesia was a study conducted by the Indonesian Ministry of
children (P < 0.0001). The rates per 1000 of CSOM in rural Bali and Band-
Health in 7 provinces in Indonesia between 1993 and 1996. In this
ung were significantly higher (75 and 25, respectively) than in the rest of
study of 19,375 children and adults, there was significant ear, nose
Indonesia (P < 0.05). In rural Bali, the rate per 1000 children of inactive
and throat (ENT) morbidity with almost 40% having some morbid-
CSOM was 63 in 6- to 9-year-old children, compared with 37 in children
ity (external ear diseases 13.9%, middle ear disorders 6.7%, CSOM
aged 13–15 years. Concomitantly, the rates of tympanosclerosis were 7 and
3.0%, acute otitis media (AOM) 0.3% and hearing loss 16.8%).17
26/1000, respectively, in these age groups.
With the development of a 10-valent pneumococcal vaccine
Conclusions: In Indonesia, the prevalence of CSOM is relatively high with
(PCV) conjugated to protein D of Hemophilus influenzae, the pro-
most disease occurring in rural areas. The high rates in rural Bali with early
totype of which has been shown to prevent AOM caused by both
progression to tympanosclerosis suggest a significant burden of potentially
Streptococcus pneumoniae and nontypeable H. influenzae,18–20 there
vaccine preventable illness.
is potential for prevention of the sequelae of AOM, namely CSOM
and subsequent hearing impairment. Because there are no recent
Key Words: chronic suppurative otitis media, otitis media with effusion, studies estimating the burden of CSOM and its sequelae in children
acute otitis media, otoscopy, tympanic membrane perforation from South Asia, we conducted this multicenter study in rural and
urban children in Indonesia, with the ultimate goals of identifying
(Pediatr Infect Dis J 2014;33:1010–1015)
areas with high prevalence of CSOM and deriving a population-
based estimate of childhood CSOM and hearing impairment for
Indonesia.

C hildren living in developing countries have a high prevalence

of otitis media with effusion (OME) and severe otitis media
Accepted for publication April 10, 2014.
From the *Department of Otorhinolaryngology, Head and Neck Surgery Faculty of
Medicine Padjadjaran University/Hasan Sadikin General Hospital, Bandung,
Bandung, West Java; †Department of Otorhinolaryngology, Head and Neck
Surgery Faculty of Medicine Sriwijaya University/M. Hoesin Hospital, Palem-
bang, South Sumatera; ‡Department of Otorhinolaryngology. Head and Neck
Surgery Faculty of Medicine Udayana University/Sanglah Hospital, Denpasar,
Bali; §Department of Otorhinolaryngology, Head and Neck Surgery Kanujoso
Djatiwibowo Hospital, Balikpapan, East Kalimantan; ¶Department of Oto-
rhinolaryngology, Head and Neck Surgery Faculty of Medicine Diponegoro
University/Kariadi Hospital, Semarang, Central Java; ‖Department of Otorhi-
nolaryngology, Head and Neck Surgery Faculty of Medicine Hasanuddin Uni-
versity/Wahidin Sudirohusodo Hospital, Makasar, South Sulawesi; **Health
Research Unit Faculty of Medicine Padjadjaran University/Hasan Sadikin
General Hospital, Bandung, West Java, Indonesia; and ††Department of Pedi-
atrics, Section of Infectious Diseases, University of Colorado at Denver Health
Sciences Center and The Children’s Hospital, Denver, CO.
The work was supported by a grant from Glaxo Smith Kline. The authors have no
other funding or conflicts of interest
Address for correspondence: Eric A.F. Simões, MD, DCH, Department of Pedi-
atric Infectious Diseases, The Children’s Hospital, 10123 East 16th Avenue,
Box B055, Aurora, CO 80045, E-mail: eric.simoes@ucdenver.edu.
Copyright © 2014 by Lippincott Williams & Wilkins
ISSN: 0891-3668/14/3310-1010
DOI: 10.1097/INF.0000000000000366
MATERIALS AND METHODS
Study Description
We conducted a prospective study between December
2011and September 2012 to obtain the point prevalence of otitis
media and its sequelae in elementary and secondary school stu-
dents, between the ages of 6 and 15 years. In Indonesia, elemen-
tary schools are from grade 1 to 6 (ages 6–13), secondary schools
from grade 7–9 (ages 12–15) and high school from grades 10–12
(ages 15–18). All education in Indonesia up to secondary school is
free. Hence we conducted this study in elementary and secondary
schools at 6 sites on all the major islands of the archipelago, as a
first step to obtaining a population-based estimate of the sequelae
of AOM in Indonesian children aged 6–15 years. Ethical approval
was obtained for the study from Institutional Review Boards at each
of the 6 Study Centers and at the University of Colorado Denver.
Study Site Description
Indonesia is a tropical archipelago stretching almost 5000
km along the equator with about 13,000 islands. The 15 main
islands are divided into 33 provinces, of which Java is the most
populous and crowded. Six study areas were chosen to represent

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The Pediatric Infectious Disease Journal  •  Volume 33, Number 10, October 2014 Otitis in Indonesia
the archipelago. From Java there were 2 sites, Bandung District in
West Java province (population: 43,053,732), also the base of the
study, and Semarang District in Central Java province (population:
32,382,657). The following districts were chosen from the other
main islands: from Kalimantan, Balikpapan City and the adja-
cent Samarinda District in East Kalimantan province (population:
3,553,143); from Sulawesi, Makasar City and District in South
Sulawesi province (population: 8,034,776); from Sumatra, Palem-
bang City and District in South Sumatra province (population:
7,450,394) and from Bali, Denpasar City and Abang District in Bali
province (population 3,890,757). Training of all the investigators
in the conduct of all study aspects (questionnaires, examinations,
audiologic methods and tympanometry) was done in a standardiza-
tion meeting before the start of the study.
Choosing Schools and Subjects for the Study
Because the ultimate goal is to apply the results of this study
to the Indonesian population, we followed a strict methodology
that would allow this extrapolation at a later stage. After obtaining
approval from the Ministries of Education and Health we obtained,
from the Department of Education, a list of all elementary and sec-
ondary schools and class-wise break down of the number of sub-
jects in all schools in the selected districts. For each district, we
selected schools with sizes of > 400 children per elementary school
and > 300 per secondary school, in an attempt to recruit 300 and
200 students, respectively, from each of the schools. The study team
at Bandung used a random number generator to list all the schools
and then classes in each school for the study. Separate lists were
made for urban and rural schools in each district. We then excluded
schools in the most populous 10% and in the least populous 10%
to remove outlying schools, to generate the final district-wise list of
urban and rural schools eligible for the study.
School Recruitment
In the order of the randomly generated lists of urban and
rural schools in each district, school principals were approached by
the local investigator and respective research team for permission
to perform the study in that school. With their permission, and with
the approval of the Department of Education, a meeting was organ-
ized with all the school teachers and parents of the chosen classes
to disseminate information regarding the study.
Flow of Study
The investigative teams worked 6 days per week such that
each child followed a 3 day involvement. On day 1, we obtained
consent, registered consented children and filled in the question-
naire. On day 2, ENT surgeons examined all children and per-
formed an otoscopic examination and screening audiology. Earwax
was removed with suction, a curette extraction or irrigation with
luke-warm water by the surgeons to enable subsequent examina-
tion. Where wax was impacted, sodium glycerin or sodium docu-
sate eardrops were used before curetting. On day 3, we performed
diagnostic audiometry and tympanometry on children with a his-
tory of hearing impairment, who did not pass the audiology-screen-
ing test, or had any otoscopic abnormality.
Obtaining Informed Consent and Administration
of the Questionnaire
Two or more classes (about 80 students) were approached
each day with the help of the class teachers. Informed consent
was obtained when parents came to pick up their children after
school, when possible. Parents were informed as a group in their
children’s class rooms using verbal and PowerPoint presenta-
tions. Subsequently, parents were given an informed consent. Six
© 2014 Lippincott Williams & Wilkins
to 8 investigators and subinvestigators were present to answer any
questions, for the 30–40 parents. After obtaining signed informed
consent, parents were administered questionnaires that contained
demographic details, history of ear disease or hearing problems and
risk factors. Parents who were not present were approached for con-
sent and questionnaire administration the next day.
Physical Examination Including Otoscopy and
Hearing Screening
On day 2, the ENT surgeons and assistants (ENT resi-
dents) examined all students whose consent forms and question-
naires were completed the previous day. We used a standardized
ear examination and hearing screening form. A Welch Allyn pneu-
matic otoscope was used to visualize and check the movement of
the tympanic membrane and to determine the presence of tympanic
abnormalities, such as hyperemia, dullness, retraction, perforation,
otorrhea, cholesteatoma and tympanosclerosis/scarring of eardrum
from healed CSOM. Because of the excessive ambient noise in
the schools and no availability for adequate soundproof rooms, we
chose a cutoff of 30 dB for hearing screening assessments. A semi
soundproof room was set up at the most quiet area of the school
with an ambient noise level not exceeding 40 dB. Hearing screen-
ing was performed using an Interacoustics Audio Traveller AA222
audiometer with a preset intensity of 30 dBHL through air conduc-
tion only, at 4 frequencies: 500, 1000, 2000 and 4000 kHz. If the
child could not hear the 30 dB HL tone at any 1 or more frequen-
cies, the child was referred for diagnostic audiometry.
Diagnostic Tympanometry, Audiologic Testing and
Referral
On day 2 or 3, trained audiologists performed diagnostic pure
tone audiometry and tympanometry uisng the Interacoustics Audio
Traveller AA222, in soundproof rooms at nearby ENT centers or at the
site as described above. Children with abnormal findings that needed
treatment were given free consultation and medications, or a referral
letter for a nearby ENT clinic at a health center or hospital, if needed.
Definitions
AOM: a visually abnormal tympanic membrane with signs
of acute inflammation on pneumatic otoscopy (in regard to color,
position and/or mobility) with at least 1 of the following signs: ear
pain, ear discharge and hearing loss.13,21 Otitis media with effusion:
a visually abnormal tympanic membrane on pneumatic otoscopy
(no perforation, dullness and no movement, not red, not bulging)
and/or flat tympanometry (no peak).22 A tympanic membrane per-
foration was defined as follows: a small perforation is < 25% of the
tympanic membrane limited to 1 quadrant, a subtotal perforation is
2 or more quadrants, although a total perforation is all 4 quadrants
and attic if it is in the pars flaccida part of the tympanic membrane.
CSOM: chronic inflammation of the middle ear and mastoid cavity,
with otorrhea of at least for 2 weeks duration through a perforated
tympanic membrane. CSOM was considered to be active if there
was otorrhea and inactive if there was a perforation without otor-
rhea and/or the presence of tympanosclerosis.1
Statistical Analysis
Data were double entered into a Microsoft Access database.
Prevalence comparisons and χ2 analyses were used in statistical
evaluations. Confidence intervals for prevalence estimates were
calculated with a normal approximation to the Poisson distribution
(N ≥ 10) and an exact Poisson test (N < 10).23 Prevalence estimates
were statistically compared using a normal approximation to the
binomial distribution when there were a sufficient number of cases,
and an exact binomial test otherwise.23
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Anggraeni et al The Pediatric Infectious Disease Journal  •  Volume 33, Number 10, October 2014
FIGURE 1.  Map of Indonesia and the 6 study areas.
RESULTS
A total of 7005 school children aged 6–15 years were exam-
ined from the 6 different sites on 5 islands (Fig. 1) and comprised
3454 boys (49.4%) and 3551 girls (50.6%). Of these, 3563 (50.86%)
were from urban areas and 3443 (49.14%) lived in rural areas. Each
site had similar numbers of children examined in rural and urban
areas. Most of the children were in the 6–9 year age group (37.4%)
and the least were in the 13–15 year age group (29.7%; see Table,
Supplemental Digital Content 1, http://links.lww.com/INF/B888,
that illustrates demographics of study subjects).
A history of ear discharge in the past was higher in rural
areas compared with urban areas (P < 0.001) driven by results from
Bandung (P < 0.001; see Table, Supplemental Digital Content 2,
http://links.lww.com/INF/B889, that illustrates subject ear history
obtained from parents or caretakers). The age of first ear discharge
in the past shows that 25% occurred before the age of 2 years and
50% before school entry (Fig. 2A). There were regional differ-
ences with 50% occurring by 3 years of age in Bali and Bandung
areas, compared with 5 years in the rest of Indonesia (Fig. 2B). By
FIGURE 2.  Cumulative frequency distributions for age of first ear discharge by region in Indonesia: (A) All of Indonesia, (B)
Bali and Bandung versus the Rest of Indonesia
1012 | www.pidj.com
contrast, histories of earwax (P = 0.02) and tinnitus (P < 0.001)
were found more often in urban than rural areas (See Table, Sup-
plemental Digital Content 2, http://links.lww.com/INF/B889, that
illustrates subject ear history obtained from parents or caretakers).
Otoscopic examination revealed a perforated tympanic
membrane in 95 children, large/subtotal in 63%, small in 35%
and in the attic in 2%. We did not find any cholesteatoma. There
were higher prevalences of all types of perforation in rural areas
(P < 0.004) mostly driven by Bali (P < 0.05) and large perforations
in Bandung (P < 0.05) (see Table, Supplemental Digital Content
3, http://links.lww.com/INF/B890, which illustrates otoscopic find-
ings in 7005 Indonesian children by urban and rural schools and
study district).
Of the 116 children diagnosed with CSOM, most of them
(77%) were found in rural areas, mostly in Bali (33.6%) and Band-
ung (12.9%). There was an opposite trend in Sumatra (See Table,
Supplemental Digital Content 4, http://links.lww.com/INF/B891,
which illustrates final classification of otologic diagnosis in 7005
Indonesian children by urban and rural schools and study district),
© 2014 Lippincott Williams & Wilkins
The Pediatric Infectious Disease Journal  •  Volume 33, Number 10, October 2014 Otitis in Indonesia

albeit not statistically significant, where CSOM in urban areas was
twice as common as in rural areas.
Although there were no significant differences in AOM
and OME in rural and urban areas, the prevalence of CSOM in
our study of 26.4 per 1000 children in rural areas was strikingly
higher than the prevalence of 7 per 1000 children in urban areas
(Table 1). This rural-urban differential was significantly different in
all age groups (P: 0.00000000025–0.003; Table 1). The prevalence
of active CSOM was only about 2.5 times higher in rural than in
urban areas; however, it was 7 times higher for inactive disease. In
rural areas, we detected an increasing prevalence of tympanoscle-
rosis as children got older, ranging from 1.7/1000 in children aged
6–9 years to 10.4 in children 13–15 years of age (P < 0.05; Table 1).
We found that the highest prevalences of CSOM were in Bali
and Bandung. Hence in an attempt to gain insight into the natural history
of CSOM, we categorized prevalence by age and type of CSOM in Bali
and Bandung versus the rest of Indonesia (Table 2). In Bali, there was
no active disease seen in the 13–15 year age group. Concomitantly, the
prevalence of inactive CSOM in rural Bali decreased from 62.9/1000 in
the youngest age group to 36.5/1000 in the oldest group (r = −0.997, P
= 0.049), an opposite trend to what was seen in the rest of Indonesia (r
= 0.999, P = 0.028). At the same time, there were increasing prevalence
estimates of tympanosclerosis in rural Balinese children as they aged.
DISCUSSION
In this large multicenter study from 12 sites in Indonesia,
conducted in 2012, we found a significant burden of otitis media
and its sequelae in school children. The overall prevalences of
AOM, OME and CSOM were 5/1000, 4/1000 and 27/1000 chil-
dren respectively. Although it is not surprising that the prevalences
of AOM and OME were low in this school aged population, the
current burden of CSOM was surprisingly high, comparable with
prevalences in Africa15,16 and Asia3–7 15–20 years ago. The high-
est prevalence of CSOM of 12–46% was found among Inuits in
Alaska,24 Australian aborigines,25 Native Americans,26 between 4%
and 8% in the Maori in New Zealand,27 Nepal,9,11 and Malaysia,3
1.4–2% in Korea,2 India, 4,6–8 Saudi Arabia,28 and <1% in United
States, United Kingdom, Denmark and Finland.13,29
In our study, the prevalence of CSOM in rural areas (27 per
1000 children or 2.7%) was higher than in urban areas (7 per 1000
children or 0.7%) with P < 0.001. In contrast, in a study of 1030 school
children conducted between 1992 and 1993 by Bastos et al15 in Angola,
there were no differences in the prevalence between urban and rural
children with CSOM. However, a study of 696 rural and 270 urban
school children in Nigeria showed a prevalence of CSOM of 6% in
rural children versus none in urban children.30 Zakzouk and Hajjaj31
in Saudi Arabia showed a higher prevalence of CSOM in rural schools
as well, but no statistical inferences were drawn. In another study from
Bangladesh, Biswas et al32 found that the prevalence of CSOM among
school age children was 12.44% in rural areas and 2.22% in urban
areas, and a Tanzania study showed that in rural areas it was 9.44%.33
The Bangladesh study32 however was a very small study of 225 stu-
dents and the latter study had only 21 children with CSOM.33 Neither of
these studies had the power to show statistically significant differences
in this differential. Our study was designed a priori to be able to show
differences in rural and urban settings by the equal distribution in urban
and rural populations and by the large sample size. CSOM is a common
problem affecting especially the lower socioeconomic group of peo-
ple. High prevalences of CSOM have been attributed to overcrowding,
inadequate housing, poor nutrition and inadequate or unavailable health
care.13 These conditions are commonly seen in rural areas in Indonesia
rather than in urban areas and might underlie our observations. Further-
more, in rural health centers in Indonesia, otoscopes are unavailable,
and health practitioners rarely consider AOM in the diagnosis. Hence
AOM and OME go largely untreated. Uniquely, in our study, this condi-
tion was driven by results from Bali and Bandung, but not from Palem-
bang where it was higher in urban areas. This discrepancy might have
been because the distance between rural and urban areas, where the
studies were conducted in Palembang, was not far apart and therefore
children in rural areas might have gone to urban schools.
The age of first ear discharge in the past by parental recall
in this study occurred by almost 50% in the first 3 years of life in
the urban regions Bali and Bandung (Fig. 2B). This compares to 5

TABLE 1.  Age-specific Prevalence Estimates per 1000 Children of Otitis Media Diagnoses by Age Group and Urban
Rural Residence in Indonesian School Children

Age Group 6–9 Yrs 10–12 Yrs 13–15 Yrs Total

Age-specific population Urban 1426 1137 1000 3563

Rural 1197 1163 1082 3442
AOM Urban 3.5 (1.1,8.2) 5.3 (1.9,11.5) 3 (0.6,8.8) 3.9 (1.9,6)
Rural 5.8 (2.3,12) 5.2 (1.9,11.2) 2.8 (0.6,8.1) 4.6 (2.4,6.9)
P 0.276 0.596 0.618 0.391
Otitis media with effusion Urban 3.5 (1.1,8.2) 6.2 (2.5,12.7) 1 (0,5.6) 3.6 (1.7,5.6)
Rural 4.2 (1.4,9.7) 1.7 (0.2,6.2) 5.5 (2,12.1) 3.8 (1.7,5.8)
P 0.512 0.084 0.076 0.457
Retraction Urban 2.1 (0.4,3.9) 3.5 (1,9) 3 (0.6,8.8) 2.8 (1.1,4.4)
Rural 8.4 (3.2,12) 8.6 (3.3,14.7) 3.7 (1,9.5) 7 (4.2,9.8)
P 0.023 0.097 0.543 0.010
CSOM Active Urban 2.1 (0.4,6.2) 3.5 (1,9) 3 (0.6,8.8) 2.8 (1.1,4.5)
Rural 6.7 (2.9,13.2) 8.6 (3.3,13.9) 3.7 (1,9.5) 6.4 (3.7,9.1)
P 0.066 0.097 0.543 0.021
Inactive Urban 2.8 (0.8,7.2) 0.9 (0,4.9) 2 (0.2,7.2) 2 (0.8,4)
Rural 14.2 (7.5,21) 16.3 (9,23.7) 13.9 (6.8,20.9) 14.8 (10.8,18.9)
P 0.001 2.45E-05 0.002 3.77E-09
Tympano sclerosis Urban 3.5 (1.1,8.2) 0.9 (0,4.9) 2 (0.2,7.2) 2.2 (1,4.4)
Rural 1.7 (0.2,6) 4.3 (1.4,10) 10.2 (4.2,16.2) 5.2 (2.8,7.6)
P 0.304 0.115 0.016 0.032
Total Urban 8.4 (3.7,13.2) 5.3 (1.9,11.5) 7 (2.8,14.4) 7 (4.3,9.8)
Rural 22.6 (14,31.1) 29.2 (19.4,39.1) 27.7 (17.8,37.6) 26.4 (21,31.9)
P 0.003 1.35E-05 3.6E-04 2.5E-10

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Anggraeni et al The Pediatric Infectious Disease Journal  •  Volume 33, Number 10, October 2014

TABLE 2.  Age-specific Prevalence Estimates per 1000 Children of CSOM Diagnoses by Age Group, Urban Rural
Residence and State in Indonesian School Children

Age Group 6–9 Yrs 10–12 Yrs 13–15 Yrs Total

Active CSOM Urban Bali 0 (0,16) 6.1 (0.2,33.8) 0 (0,27.1) 1.9 (0,10.5)
Urban Bandung 0 (0,14.8) 0 (0,18.5) 0 (0,20.3) 0 (0,5.9)
Urban rest of Indonesia 3.2 (0.7,9.3) 3.9 (0.8,11.3) 4.4 (0.9,12.9) 3.7 (1.7,7.1)
2.1 (0.4,6.2) 3.5 (1,9) 3 (0.6,8.8) 2.8 (1.1,4.5)
Rural Bali 14 (1.7,50.5) 23.5 (7.6,54.8)* 0 (0,19.2) 12.8 (5.1,26.3)†
Rural Bandung 0 (0,17.7) 5.1 (0.1,18.6) 11 (1.3,39.9) 5.1 (1.1,14.9)
Rural rest of Indonesia 7.1 (2.6,15.5) 5.3 (0.8,11.7) 2.8 (0.3,10.2) 5.2 (2.3,8.1)
6.7 (2.9,13.2) 8.6 (3.3,13.9) 3.7 (1,9.5) 6.4 (3.7,9.1)
Inactive CSOM Urban Bali 4.3 (0.1,24.2) 0 (0,22.4) 0 (0,27.1) 1.9 (0,10.5)
Urban Bandung 4 (0.1,22.4) 0 (0,18.5) 5.5 (0.1,30.6) 3.2 (0.4,11.5)
Urban rest of Indonesia 2.1 (0.3,7.6) 1.3 (0,7.2) 1.5 (0,8.2) 1.7 (0.5,4.3)
2.8 (0.8,7.2) 0.9 (0,4.9) 2 (0.2,7.2) 2 (0.8,4)
Rural Bali 62.9 (28.8,119.4)‡ 46.9 (17.8,76)§ 36.5 (14.6,75.1)* 47.4 (29.2,65.7) ‡
Rural Bandung 19.1 (5.2,49) 20.2 (5.5,51.7) 11 (1.3,39.9) 17 (6.5,27.5)
Rural rest of Indonesia 4.7 (1.3,12.1) 6.6 (2.2,15.5) 8.5 (3.1,18.4) 6.5 (3.2,9.8)
14.2 (7.5,21) 16.3 (9,23.7) 13.9 (6.8,20.9) 14.8 (10.8,18.9)
Tympanosclerosis Urban Bali 8.7 (1.1,31.4) 6.1 (0.2,33.8) 7.4 (0.2,41) 7.5 (2.1,19.3)*
Urban Bandung 0 (0,14.8) 0 (0,18.5) 5.5 (0.1,30.6) 1.6 (0,8.8)
Urban rest of Indonesia 3.2 (0.7,9.3) 0 (0,7.2) 0 (0,5.4) 1.2 (0.3,3.7)
3.5 (1.1,8.2) 0.9 (0,4.9) 2 (0.2,7.2) 2.2 (1,4.4)
Rural Bali 7 (0.2,39) 9.4 (1.1,33.9) 26 (8.4,60.8)* 14.6 (6.3,28.8)†
Rural Bandung 0 (0,17.7) 5.1 (0.1,28.1) 5.5 (0.1,30.8) 3.4 (0.4,12.3)
Rural rest of Indonesia 1.2 (0,6.6) 2.7 (0.3,9.6) 7.1 (2.3,16.5) 3.5 (1.5,6.8)
1.7 (0.2,6) 4.3 (1.4,10) 10.2 (4.2,16.2) 5.2 (2.8,7.6)
Total Urban Bali 13 (2.7,38.1) 12.1 (1.5,43.8) 7.4 (0.2,41) 11.3 (4.1,24.6)
Urban Bandung 4 (0.1,22.4) 0 (0,18.5) 11 (1.3,39.7) 4.8 (1,13.9)
Urban rest of Indonesia 8.4 (3.6,16.6) 5.2 (0.3,9.3) 5.9 (1.6,15) 6.7 (3.4,9.9)
8.4 (3.7,13.2) 5.3 (1.9,11.5) 7 (2.8,14.4) 7 (4.3,9.8)
Rural Bali 83.9 (36.4,131.4)‡ 79.8 (41.9,117.8)‡ 62.5 (27.1,97.9)¶ 74.8 (51.9,97.7)‡
Rural Bandung 19.1 (5.2,49) 30.3 (11.1,66) 27.6 (9,64.5) 25.5 (12.6,38.4)
Rural rest of Indonesia 13 (5.3,20.7) 14.6 (6,23.3) 18.3 (8.4,28.3) 15.2 (10.1,20.2)
22.6 (14,31.1) 29.2 (19.4,39.1) 27.7 (17.8,37.6) 26.4 (21,31.9)
P values were computed comparing Bali to the rest of Indonesia, not including Bandung
*P < 0.05.
†P < 0.1.
‡P < 0.0001.
§P < 0.001.
¶P < 0.01.

years of age in the rest of Indonesia. This could be related to the
high incidence of CSOM in these Bali and Bandung.
In school based studies in Asia, the prevalence of OME
ranges from 16/1000 children in Thailand5 to 158/1000 in Korea,34
with varying prevalence estimates in other Asian countries.3,5,6,11,35–39
In our study, the prevalence of OME of 3.8 per 1000 rural children
and 3.6 per 1000 urban children is lower. There was no difference
in the prevalence of OME between the age groups studied. It is pos-
sible that the low prevalence of OME compared with CSOM in our
study might be because of (1) the age which we studied children
(OME typically occurs with the highest prevalence in under fives)40;
(2) environmental differences and/or (3) genetic differences: these
findings have also been observed in a study in Malaysian school
children, ethnically similar to Indonesian children.3
The prevalence of tympanosclerosis in our study was more
common in rural areas compared with urban areas and increased
with age in rural areas. However, the study by Bastos et al15 in
Angola found no difference in the prevalence of tympanosclerosis
among rural and urban children.
There are several limitations to our study. Of necessity by design,
we restricted our study to school children and hence we did not recruit
any smaller children (0–4 years of age). We excluded smaller schools
from the study, and this might have created a bias, but it is unlikely that
this would have influenced the result. It is possible that we could have
missed children who were sick, but the number would have been small.
Some rural areas were not truly rural because they were near urban areas
(as in Semarang and Palembang) and in some areas the rural areas were
not poor and had fair economic conditions (Balikpapan). However,
we chose schools by strict randomization and the rural districts were
those deemed as such by the government of Indonesia. Finally, there
might have been differences in the conduct of the study at various sites.
For example, although the tympanometers and audiometers were well-
maintained and calibrated before the study start, they were of different
makes at each of the 6 study sites. To compensate for these differences,
we held a study meeting at the start of the study with site visits by the
investigators from Bali and Bandung (coordinating sites) to ensure that
standardized study procedures and protocols were followed. Further-
more, we used trained ENT surgeons in each of the areas to minimize
bias that might occur in this type of multicenter study. Finally, since the
climate of Indonesia is quite varied and the study was a point prevalence
study, we might have not captured activity of CSOM. Hence, we chose
to include active and inactive CSOM and tympanosclerosis to indicate
the burden of CSOM in the population.
In our study, long-term sequelae of otitis media were
reflected in a higher number of children developing tympanosclero-
sis at older ages. Although we did not see any children with acute or
chronic mastoiditis, these children would typically be hospitalized
and would have been missed in this study in ambulatory school chil-
dren. An initiative to reduce childhood CSOM is needed to decrease
middle ear problems during and after the school years. Furthermore,
otitis media causes significant distress for individual patients and
their caregivers and remains a major contributor to antibiotic use

1014 | www.pidj.com © 2014 Lippincott Williams & Wilkins

The Pediatric Infectious Disease Journal  •  Volume 33, Number 10, October 2014 Otitis in Indonesia
in young children.40,41 Treatment of these diseases is further com-
plicated by antibiotic resistant S. pneumoniae, driven by antibiotic
overuse to treat respiratory infections.42 A German study showed a
significant reduction in otitis media diagnoses among children after
the introduction of PCVs.20 Furthermore, the prevalence of CSOM
has also declined from 20% to 14% (P = 0.057) in Aboriginal Aus-
tralian children after the introduction of PCVs in recent years.43 This
bodes well for future vaccine-based initiatives to reduce otitis media
in Indonesia. On the other hand an earlier study in the same popula-
tion in Aboriginal Australian children showed no reduction in otitis
media rates after PCV 7 vaccination.44 Clearly, the relationship is
complex and concurrent improvements in socioeconomic condi-
tions could influence any potential impact of vaccination.
In conclusion, otitis media was higher in rural than urban areas
in Indonesia, with most of the cases occurring in the first 3 years of
life. These cases may be prevented and, if so, will decrease the seque-
lae. Promising recent findings with vaccines in other countries sug-
gest that pneumococcal vaccines might reduce this significant burden.
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