Universal Newborn Hearing Screening: An Indian Experience of Conceptualizing and Testing a Comprehensive Model

Cost-effectiveness of portable-automated ABR for universal neonatal hearing screening in India

The World Health Organization considers Universal Neonatal Hearing Screening (UNHS) essential to global public health. Rashtriya Bal Swasthya Karyakram has included newborn hearing screening in India since 2013. The program faces human, infrastructure, and equipment shortages. First-line hearing screening with improved diagnostic accuracy is needed. The Portable Automated Auditory Brainstem Responses (P-AABR) can be used in remote areas for UNHS due to its low infrastructure needs and diagnostic accuracy. This study evaluated the cost-effectiveness of P-AABR in UNHS. We employed an analytical model based on decision trees to assess the cost-effectiveness of Otoacoustic Emission (OAE) and P-AABR. The total cost to the health system for P-AABR, regardless of true positive cases, is INR 10,535,915, while OAE costs INR 7,256,198. P-AABR detects 262 cases, whereas OAE detects 26 cases. Portable Automated ABR costs INR 97 per case detection, while OAE costs INR 67. The final ICER was 97407.69. The P-AABR device is cost-effective, safe and feasible for UNHS Rashtriya Bal Swasthya Karyakram (RBSK) programs. Beyond reducing false referrals and parent indirect costs, it detects more hearing-impaired infants. Even in shortages of skilled workers, existing staff can be trained. Thus, this study suggests integrating this device into community and primary health centers to expand UNHS coverage.

Effect of Health Education on Knowledge and Behaviour Towards Consanguineous Marriage and Infantile Hearing Loss

Awareness regarding consanguineous marriage and other risk factors of infantile hearing loss is essential for prevention, early detection and timely intervention which can save deaf children from lifelong consequences of hearing disability. A pre-post study was done among the general population of Puducherry, India to evaluate the effect of health education on knowledge and behaviour towards consanguineous marriage and infantile hearing loss. Individual direct interviews were done using a questionnaire to assess their awareness about consanguineous marriage and other risk factors of infantile hearing loss, its early detection and intervention. The assessment was repeated after a health education given for the same by direct interaction and pamphlets. The study showed that 65% participants were unaware of consanguinity being a risk factor for congenital hearing loss. More than half of them were unaware of other risk factors, neonatal hearing screening and treatment. Only 35.3% were aware that early identification and intervention enables a deaf child to learn optimum speech and language. Prior to health education, 33.7% were in support of consanguineous marriage whereas, after the health education, only 6.7% supported it showing significant improvement in their attitude towards consanguineous marriage. Post health education, there was overwhelming 100% improvement in their knowledge regarding infantile hearing loss. The study shows the poor awareness among the population of Puducherry regarding consanguineous marriage and infantile hearing loss, thus requiring a widespread sensitization about infantile hearing loss which can prevent lifelong consequences of the hearing disability.

Protocol and programme factors associated with referral and loss to follow-up from newborn hearing screening: a systematic review

BACKGROUND

An effective newborn hearing screening programme has low referral rate and low loss to follow-up (LTFU) rate after referral from initial screening. This systematic review identified studies evaluating the effect of protocol and programme factors on these two outcomes, including the screening method used and the infant group.

METHODS

Five databases were searched (latest: April 2021). Included studies reported original data from newborn hearing screening and described the target outcomes against a protocol or programme level factor. Studies were excluded if results were only available for one risk condition, for each ear, or for < 100 infants, or if methodological bias was observed. Included studies were evaluated for quality across three domains: sample, screening and outcome, using modified criteria from the Ottawa-Newcastle and QUADAS-2 scales. Findings from the included studies were synthesised in tables, figures and text.

RESULTS

Fifty-eight studies reported on referral rate, 8 on LTFU rate, and 35 on both. Only 15 studies defined LTFU. Substantial diversity in referral and LTFU rate was observed across studies. Twelve of fourteen studies that evaluated screening method showed lower referral rates with aABR compared to TEOAE for well babies (WB). Rescreening before hospital discharge and screening after 3 days of age reduced referral rates. Studies investigating LTFU reported lower rates for programmes that had audiologist involvement, did not require fees for step 2, were embedded in a larger regional or national programme, and scheduled follow-up in a location accessible to the families. In programmes with low overall LTFU, higher LTFU was observed for infants from the NICU compared to WB.

CONCLUSION

Although poor reporting and exclusion of non-English articles may limit the generalisability from this review, key influential factors for referral and LTFU rates were identified. Including aABR in WB screening can effectively reduce referral rates, but it is not the only solution. The reported referral and LTFU rates vary largely across studies, implying the contribution of several parameters identified in this review and the context in which the programme is performed. Extra attention should be paid to infants with higher risk for hearing impairment to ensure their return to follow-up.