Progress towards early detection services for infants with hearing loss in developing countries

Implementation factors of non-communicable disease policies and programmes for children and youth in low-income and middle-income countries: a systematic review

INTRODUCTION

Despite declared life-course principles in non-communicable disease (NCD) prevention and management, worldwide focus has been on older rather than younger populations. However, the burden from childhood NCDs has mounted; particularly in low-income and middle-income countries (LMICs). There is limited knowledge regarding the implementation of paediatric NCD policies and programmes in LMICs, despite their disproportionate burden of morbidity and mortality. We aimed to understand the barriers to and facilitators of paediatric NCD policy and programme implementation in LMICs.

METHODS

We systematically searched medical databases, Web of Science and WHOLIS for studies on paediatric NCD policy and programme implementation in LMICs. Screening and quality assessment were performed independently by researchers, using consensus to resolve differences. Data extraction was conducted within the WHO health system building-blocks framework. Narrative thematic synthesis was conducted.

RESULTS

93 studies (1992-2020) were included, spanning 86 LMICs. Most were of moderate or high quality. 78% reported on paediatric NCDs outside the four major NCD categories contributing to the adult burden. Across the framework, more barriers than facilitators were identified. The most prevalently reported factors were related to health service delivery, with system fragmentation impeding the continuity of age-specific NCD care. A significant facilitator was intersectoral collaborations between health and education actors to deliver care in trusted community settings. Non-health factors were also important to paediatric NCD policies and programmes, such as community stakeholders, sociocultural support to caregivers and school disruptions.

CONCLUSIONS

Multiple barriers prevent the optimal implementation of paediatric NCD policies and programmes in LMIC health systems. The low sociopolitical visibility of paediatric NCDs limits their prioritisation, resulting in fragmented service delivery and constraining the integration of programmes across key sectors impacting children, including health, education and social services. Implementation research is needed to understand specific contextual solutions to improve access to paediatric NCD services in diverse LMIC settings.

Newborn and infant hearing screening for early detection of hearing loss in Nairobi, Kenya

Background

Early detection of hearing loss and subsequent intervention leads to better speech, language and educational outcomes giving way to improved social economic prospects in adult life. This can be achieved through establishing newborn and infant hearing screening programs.

Objective

To determine the prevalence of hearing loss in newborns and infants in Nairobi, Kenya.

Methods

A cross-sectional pilot study was conducted at the National hospital and at a sub county hospital immunization clinic. A total of 9,963 babies aged 0-3 years, were enrolled in the hearing screening program through convenient sampling over a period of nine months. A case history was administered followed by Distortion Product Oto-acoustic emissions (DPOAEs) and automated auditory brainstem response (AABR) hearing screening.

Results

The screening coverage rate was 98.6% (9963/10,104). The referral rate for the initial screen was 3.6% (356/ 9,963), the return rate for follow-up rescreening was 72% (258 babies out of 356) with a lost to follow-up rate of 28% (98/356). The referral rate of the second screen was 10% (26/258). All the 26 babies referred from the second screen returned for diagnostic hearing evaluation and were confirmed with hearing loss, yielding a prevalence of 3/1000.

Conclusions

Establishing universal newborn and infant hearing screening programs is essential for early detection and intervention for hearing loss. Data management and efficient follow-up systems are an integral part of achieving diagnostic confirmation of hearing loss and early intervention.

Use of Virtual Reality-Based Games to Improve Balance and Gait of Children and Adolescents with Sensorineural Hearing Loss: A Systematic Review and Meta-Analysis

BACKGROUND

Children and adolescents with sensorineural hearing loss (SNHL) often experience motor skill disturbances, particularly in balance and gait, due to potential vestibular dysfunctions resulting from inner ear damage. Consequently, several studies have proposed the use of virtual reality-based games as a technological resource for therapeutic purposes, aiming to improve the balance and gait of this population.

OBJECTIVE

The objective of this systematic review is to evaluate the quality of evidence derived from randomized or quasi-randomized controlled trials that employed virtual reality-based games to enhance the balance and/or gait of children and adolescents with SNHL.

METHODS

A comprehensive search was conducted across nine databases, encompassing articles published in any language until 1 July 2023. The following inclusion criteria were applied: randomized or quasi-randomized controlled trials involving volunteers from both groups with a clinical diagnosis of bilateral SNHL, aged 6-19 years, devoid of physical, cognitive, or neurological deficits other than vestibular dysfunction, and utilizing virtual reality-based games as an intervention to improve balance and/or gait outcomes.

RESULTS

Initially, a total of 5984 articles were identified through the searches. Following the removal of duplicates and screening of titles and abstracts, eight studies remained for full reading, out of which three trials met the eligibility criteria for this systematic review. The included trials exhibited a very low quality of evidence concerning the balance outcome, and none of the trials evaluated gait. The meta-analysis did not reveal significant differences in balance improvement between the use of traditional balance exercises and virtual reality-based games for adolescents with SNHL (effect size: -0.48; [CI: -1.54 to 0.57]; p = 0.37; I² = 0%).

CONCLUSION

Virtual reality-based games show promise as a potential technology to be included among the therapeutic options for rehabilitating the balance of children and adolescents with SNHL. However, given the methodological limitations of the trials and the overall low quality of evidence currently available on this topic, caution should be exercised when interpreting the results of the trials analyzed in this systematic review.

Implementation of Newborn Hearing Screening in Albania

Newborn hearing screening (NHS) was implemented in Albania in four maternity hospitals in 2018 and 2019. Implementation outcome, screening outcome, and screening quality measures were evaluated. Infants were first screened by midwives and nurses before discharge from the maternity hospital and returned for follow-up screening. Acceptability, appropriateness, feasibility, adoption, fidelity, coverage, attendance, and stepwise and final-referral rates were assessed by onsite observations, interviews, questionnaires, and a screening database. A post hoc analysis was performed to identify reasons for loss to follow up (LTFU) in a multivariate logistic regression. In total, 22,818 infants were born, of which 96.6% were screened. For the second screening step, 33.6% of infants were LTFU, 40.4% for the third, and 35.8% for diagnostic assessment. Twenty-two (0.1%) were diagnosed with hearing loss of ≥40 dB, six unilateral. NHS was appropriate and feasible: most infants are born in maternity hospitals, hence nurses and midwives could perform screening, and screening rooms and logistic support were supplied. Adoption among screeners was good. Referral rates decreased steadily, reflecting increasing skill. Occasionally, screening was repeated during a screening step, contrary to the protocol. NHS in Albania was implemented successfully, though LTFU was high. It is important to have effective data tracking and supervision throughout the screening.

Early Hearing Detection and Intervention Results in Northeastern of Iran from 2005 to 2019: A Repeated Cross-Sectional Study

Background

Hearing loss is one of the most common congenital disorders. The Early Diagnosis and Intervention Process is designed for the early diagnosis and intervention of hearing loss in infants. The present study aimed to examine the results of Early Hearing Detection and Intervention (EHDI) in northeastern Iran from 2005 to 2019.

Setting

Northeastern Iran.

Methods

In most cases, the two-stage protocol (otoacoustic emissions [OAE] and automated auditory brainstem response [AABR]) has been used. Infant assessment methods included the use of OAE, ABR, auditory steady-state response, high-frequency tympanometry, and behavioral audiometry. Interventions included medical interventions, hearing rehabilitation, hearing aids, and cochlear implants.

Results

1,162,821 infants were screened. The screening coverage increased from less than 1% in 2005 to about 99% in 2018. The referral rate has been about 1%. 2.17 out of every 1000 infants are hearing impaired, and the most common cases are bilateral hearing loss and mild to moderate hearing loss.

Conclusions

During 2005 to 2019 the coverage rate reached to more than 95% of live births. To improve the EHDI process in this population, better follow-up of diagnosed neonates and expansion of diagnostic and intervention services are needed.

A Study of JCIH (Joint Commission on Infant Hearing) Risk Factors for Hearing Loss in Babies of NICU and Well Baby Nursery at a Tertiary Care Center

Babies in Neonatal Intensive Care Units (NICU) have an additional risk for hearing loss due to various risk factors like, prematurity, low birth weight, mechanical ventilation, hyperbillirubinemia, ototoxic drugs, low APGAR score etc. as compared to the babies from well baby nursery (WBN) who, poses risk factors mostly family history, syndromic deafness. So the present study was aimed know the risk factors responsible for hearing loss in NICU and WBN babies and to assess the incidence of deafness. A total of 800 babies from NICU (n = 402) and WBN (n = 398) underwent hearing screening from a tertiary care center. Hearing screening was done using two staged screening protocol as per JCIH guidelines with Distortion product Evoked Otoacoustic Emissions (DPOAE) and Automated Auditory Brainstem Responses (A-ABR). According to DPOAE test, 311 from NICU and 383 from WBN passed the test and during second screening, 80 out of 91 from NICU and 11 out of 13 from WBN passed the DPOAE test. Further BERA was done at the 3^rd month of corrected age where 6 out of 11 showed positive responses from NICU and 3 babies from WBN had profound hearing loss. Data analysis revealed that family history of deafness, anemia and hypertension in ANC, TORCH in mother, low Apgar score and hyperbillirubinemia in newborns were a major risk factor for hearing impairment. We conclude that the diagnoses of auditory disorders at early stage due to various risk factors are important since appropriate therapeutic intervention and rehabilitation would help in better development of children.

Barriers to access to ear and hearing care services in low- and middle- income countries: A scoping review

People living in low- and middle- income countries (LMICs) meet significant challenges in accessing ear and hearing care (EHC) services. We conducted a scoping review to identify and summarise such barriers, to recognise gaps in the literature, and to identify potential solutions. Reviewers independently screened titles, abstracts and full-text articles and charted data. We undertook thematic analysis of supply and demand side dimensions of access, and summarised findings mapped against the Levesque framework. Of 3048 articles screened, 62 met inclusion criteria for review. Across the five access dimensions, supply-side constraints were more frequently described, the most common being a shortage of EHC workforce or appropriate facilities, despite high demand. We identified a thin geographical spread of literature on barriers to accessing EHC services in LMICs, reflecting low availability of such services. LMICs face a diverse range of demand and supply side challenges including workforce, equipment and resource shortages, and challenges for the majority of the population to pay for such services. There is a need for many LMICs to develop health policy and programmes in EHC, including integration into primary care, scaling up the EHC workforce through increased training and education, and improving EHC literacy through public health measures.

Repercussions of the Degrees of Hearing Loss and Vestibular Dysfunction on the Static Balance of Children With Sensorineural Hearing Loss

OBJECTIVE

The purpose of this study was to assess the static balance of children with sensorineural hearing loss (SNHL) according to the degrees of SNHL and the function of the vestibular system.

METHODS

This cross-sectional study was conducted in public schools located in Caruaru, Pernambuco state, Brazil, with 130 children (65 with normal hearing and 65 with SNHL as documented by air and bone conduction audiometry) of both sexes between 7 and 11 years old. Static balance was assessed by a stabilometric analysis using a force platform consisting of the circular area of center-of-pressure displacement of the children evaluated in 3 positions: bipedal support with feet together and parallel (PF), tandem feet (TF), and 1 foot (OF), carried out under 2 sensory conditions each, with eyes open and eyes closed. After balance assessments, the children with SNHL received examinations of auditory and vestibular functions-through audiometry and computerized vectoelectronystagmography, respectively-to compose the groups according to degrees of SNHL and vestibular function.

RESULTS

The children with severe and profound SNHL demonstrated more static balance instabilities than the children with normal hearing in 5 positions assessed with eyes open (PF, TF, and OF) and eyes closed (PF and TF). The same phenomenon occurred in children with SNHL and associated vestibular dysfunction in all of the positions assessed with eyes open and eyes closed (PF, TF, and OF).

CONCLUSION

The larger the degree of SNHL, the greater the balance instability of the children. The children with SNHL and associated vestibular dysfunction showed the highest balance instabilities in this study.

IMPACT

Children with larger degrees of SNHL and associated vestibular dysfunction might require prolonged periods to rehabilitate their balance.

Contextually appropriate school entry hearing screening protocol for low- and middle-income countries: A scoping review

BACKGROUND

In low- and middle-income countries (LMICs), where universal newborn hearing screening programmes are often not available, school entry hearing screening programmes serve as a safeguard for early detection and intervention for hearing loss in school learners.

OBJECTIVE

To determine a contextually appropriate school entry hearing screening protocol for LMICs.

METHODS

A scoping review was utilised to comprehensively search for relevant publications in the following electronic databases: Africa-Wide Information, CINAHL, Health Source: Nursing/Academic Edition, Cochrane Library, Pubmed, Scopus, and Web of Science. Studies included those that investigated school-based hearing screening protocols or programmes for LMICs among learners aged five to twelve years. The review was conducted and reported according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews checklist.

RESULTS

The search yielded 1863 studies, and after removing duplicates and ineligible studies, 19 studies were selected for data extraction. Pure tone audiometry screening was the most frequently used age-appropriate hearing screening test in the reviewed studies (n = 17). Conducting pure tone audiometry screening using 1, 2, and 4 kHz frequency combination resulted in referral rates ranging from 3.2% to 21%. In studies that included 0.5 kHz to the screening frequencies, referral rates ranged from 5.8% to 56%. Screening at 25 dB HL intensity level yielded referral rates ranging from 3.2% to 10.3%. Immediate rescreening reduced overall referral rates for learners referred for audiological diagnostic testing by up to 57%. Ambient noise levels were controlled by conducting screening in quiet rooms (n = 14) and utilising screening equipment that allows for monitoring and reducing environmental noise (n = 3).

CONCLUSION

An ideal school entry hearing screening protocol in LMIC contexts could potentially utilise pure tone audiometry screening at 1, 2, and 4 kHz, using 25 dB HL screening intensity level with an immediate rescreen for learners with a refer result. School entry hearing screening should be conducted in a quiet room, preferably using hearing screening equipment capable of monitoring ambient noise levels to reduce false positive referrals.

Challenges faced by parents when seeking diagnosis for children with sensorineural hearing loss

INTRODUCTION

The Joint Committee of Infant Hearing (JCIH) recommended hearing screening by one month of age, diagnosis of hearing loss by three months of age, and intervention initiated by six months of age. In Malaysia however, the age of diagnosis of hearing loss in children is relatively late. This study aimed to identify the challenges faced by parents in seeking a diagnosis of hearing loss for their children.

METHOD

The study utilized a semi-structured interview with open-ended questions to obtain information about parents' experiences during the diagnosis period and their challenges when going through that process. In this study, a total of 16 parents of children who were diagnosed with moderate to profound sensorineural hearing loss and received intervention within three years at the time of the study participated. Ten of the children were cochlear implant users, and six were hearing aid users.

RESULTS

Thematic analysis was used to analyse themes generated from the data according to the study objective. Four main themes and 17 subthemes were identified from this study. The four main themes were 1) Parents' emotion; 2) Parental knowledge; 3) Others; 4) Profesional services. Challenges that parents faced often include emotional behaviours such as feeling guilty and devastated during the diagnosis, lack of information-sharing from healthcare givers, lack of knowledge on childhood hearing loss among parents, support from families, seek for a second opinion, worry about others' acceptance, longer time for diagnosis to confirm, late referral to other related profesionals and no priority for the appointment.

CONCLUSION

Emotion is identified as the biggest challenge faced by parents in the process of diagnosis for their children with hearing loss. Hence, management of parental emotion needs to be emphasized by health profesionals as it influences the acceptance of parents towards their child's diagnosis.

Factors Affecting Neonatal Hearing Screening Follow-up in Developing Countries: One Insitution Prospective Pilot Study

Objective

To detect factors related with loss to follow-up (LTF) in neonatal hearing screening (NHS) program of one institution in a developing country.

Methods

A prospective study was planned based on the data collected in a pilot study conducted a year before in the same institution. In this pilot study, hearing screening was performed before hospital discharge for every infant (1217 newborns) in six months period. Total referral rate was 19.1% (223/1217). Loss to follow-up (LTF) was 38.1% (85/223). Telephonic interviews were done with 50 parents who had not come with their child to the second hearing test. For these telephonic interviews the questionnaire with four sections (socio-demographic information; information about pregnancy, birth, and present health condition of the child; caregiver knowledge of neonatal hearing screening, and reasons for default on follow-up) was created.

Results

The mothers participated in this study were 29.1 years (±5.2 SD) of age in average. Place of residence was mostly rural (64%; n=32) with 39.4 Km (±24.8 SD) away from from the rescreen referral center. Their knowledge on neonatal hearing screening, hearing impairment incidence or treatment opportunities was at a very low level. Caregivers’ perceptions that follow-up was unnecessary (50%; n=25), was most frequently given reason for follow-up default, followed by newborns bad health condition (12%; n=6) and forgetting about the follow-up visits (8%; n=6).

Conclusion

The main reason for default in follow-up in our study was caregiver’s poor knowledge about this topic.

Assessment of hearing screening programmes across 47 countries or regions II: coverage, referral, follow-up and detection rates from newborn hearing screening

OBJECTIVES

To assess the performance of newborn hearing screening (NHS) programmes, through selected quality measures and their relationship to protocol design.

DESIGN

NHS coverage, referral, follow-up and detection rates were aggregated. Referral rates were compared to age at screening step 1, number of steps, and test method: OAE or aABR.

STUDY SAMPLE

A questionnaire on existing hearing screening was completed by experts from countries in Europe, plus Russia, Malawi, Rwanda, India and China.

RESULTS

Out of 47 countries or regions, NHS coverage rates were reported from 26, referral rates from 23, follow up from 12 and detection rates from 13. Median coverage rate for step 1 was 96%. Referral rate from step 1 was 6-22% where screening may be performed <24 h from birth, 2-15% for >24 h, and 4% for >72 h. Referral rates to diagnostic assessment averaged 2.1% after one to two steps using OAE only, 1.7% after two steps including aABR, and 0.8% after three to four steps including aABR. Median detection rate for bilateral permanent hearing impairment ≥40dB was 1 per 1000 infants.

CONCLUSION

Referral rates were related to age, test method and number of screening steps. Quality measures were not available for many NHS programmes.

Development of a public audiology service in Southern Malawi: profile of patients across two years

OBJECTIVE

To describe the profile of patients attending the Queen Elizabeth Central Hospital (QECH) audiology clinic in Malawi, over a two-year period (2016-2017).

DESIGN

A retrospective patient record review.

STUDY SAMPLE

There were 2299 patients assessed at the QECH audiology department between January 2016 and December 2017. Adult patients' ages ranged from 18 to 94 years (M = 45.8, SD = 19.22). The mean age of children included in this study was 7.7 years (SD= 5.21). Overall, 45.4% of patients were female.

RESULTS

Of the 61.6% of adults and 41.7% of children found to have some degree of hearing loss, 28.3% and 15.4% were fitted with hearing aids, respectively. The number of patients seen in 2017 (n = 1385) was 34% higher than that of 2016 (n = 914).

CONCLUSION

This study found that demand for hearing services is increasing in this public sector Malawian audiology department but uptake of hearing aids for those in need is low. Future evaluation of service provision and treatment outcomes is needed. Results from this study can be used to inform the development of future audiology clinics in low resource settings.

Quality measures of a multicentre universal newborn hearing screening program in Malaysia

OBJECTIVE

To evaluate and discuss the outcomes of the universal newborn hearing screening program conducted at four public hospitals in Malaysia.

METHOD

A retrospective analysis of the universal newborn hearing screening database from each hospital was performed. The database consisted of 28,432 and 30,340 screening results of babies born in 2015 and 2016, respectively. Quality indicators (coverage rate, referral rate, return for follow-up rate, and ages at screening and diagnosis) were calculated.

RESULTS

Overall coverage rate across the four hospitals was 75% in 2015 and 87.4% in 2016. Over the two years, the referral rates for the first screening ranged from 2.7% to 33.93% with only one hospital achieving the recommended benchmark of <4% in both years. The return for follow-up rates for each participating hospital was generally below the recommended benchmark of ≥95%. The mean age at screening was 3.9 ± 1.2 days and 3.3 ± 0.4 days, respectively. The mean age at diagnosis for 70 infants diagnosed with permanent hearing loss was 4.7 ± 0.7 months in 2015 and 3.6 ± 0.9 months in 2016.

CONCLUSIONS

Quality measures for the universal newborn hearing screening program in four public hospitals in Malaysia were lower than the required standards. Nevertheless, some quality indicators showed statistically significant improvements over the two years. Next steps involve identifying and implementing the best practice strategies to improve the outcome measures and thus the quality of the program.

Limitations and drawbacks of the hospital-based universal neonatal hearing screening program: First report from the Arabian Peninsula and insights

OBJECTIVES

To assess the efficacy of the current universal neonatal hearing screening program in a tertiary medical institution in Oman, identify its limitations and drawbacks, and explore their causative factors.

METHODS

A retrospective review was carried out to analyse the hearing screening of 12,743 live babies born between January 2016 and December 2018. Screen coverage, drop outs, follow up rate, and age at completion of screening, diagnosis, and intervention were analysed. The results were compared with the Joint Committee on Infant Hearing (JCIH) performance quality indices. Prospective questionnaire-based telephonic interviews were then conducted with the parents or caregivers of neonates with hearing loss. Finally, the causes of loss to follow up or delays in hearing screenings, diagnosis, and/or early intervention were studied.

RESULTS

The true prevalence of hearing loss was 4.0 in 1000. The coverage of first-stage screening was 90% whereas the compliance with the second stage was 88.04%. 22.8% of the patients eventually obtained final diagnostic confirmation. The overall compliance with amplification was 30.2%. The completion ages of primary screening and final confirmation were 7.98 and 17.3 weeks respectively. The importance of hearing screening is well received by parents, but problems related to communication, delays in the appointment system, and inefficient follow up tracking were identified as the main limitations and drawbacks of the program.

CONCLUSION

The coverage of the neonatal hearing screening program had not yet reached the required goal of 95%. The performance indicators also fell below the international benchmark. There is a need to address the identified causative factors. Effective communication and well-maintained tracking systems need to be implemented.

Age of identification of sensorineural hearing loss and Characteristics of affected children: Findings from two cross-sectional studies in Saudi Arabia

OBJECTIVES

To identify the average age of identification (AOI) and characteristics of Saudi children with sensorineural hearing loss (SNHL).

METHODS

Two cross-sectional studies were undertaken. Study A: the medical records of 1166 children aged 0-10 years old who visited the audiology clinics in four hospitals in Riyadh and Dammam during 2015 were reviewed. Study B: 174 carers of children aged 0-12 years who visited the audiology clinics in four hospitals in Riyadh during a three-month period were surveyed.

RESULTS

The mean AOI with SNHL in children was 3.2 years (SD = 2.5 years) and 3.1 years (SD = 2.6 years) with 14% and 16% not identified until after primary school age for Studies A and B, respectively. The presence of SNHL was positively associated with parental consanguinity, positive family history of SNHL, history of chemotherapy treatment, brain pathology and prior parental concern regarding their child's hearing.

CONCLUSION

AOI of SNHL among Saudi children is deemed high in relation to the likely age of onset, with about 15 in 100 children identified after school age. Childhood hearing screening programmes (at birth and at school entry) should be considered in order to intervene earlier.

Implementation and evaluation of a rural community-based pediatric hearing screening program integrating in-person and tele-diagnostic auditory brainstem response (ABR)

BACKGROUND

In an attempt to reach remote rural areas, this study explores a community-based, pediatric hearing screening program in villages, integrating two models of diagnostic ABR testing; one using a tele-medicine approach and the other a traditional in-person testing at a tertiary care hospital.

METHODS

Village health workers (VHWs) underwent a five day training program on conducting Distortion Product Oto Acoustic Emissions (DPOAE) screening and assisting in tele-ABR. VHWs conducted DPOAE screening in 91 villages and hamlets in two administrative units (blocks) of a district in South India. A two-step DPOAE screening was carried out by VHWs in the homes of infants and children under five years of age in the selected villages. Those with 'refer' results in 2nd screening were recommended for a follow-up diagnostic ABR testing in person (Group A) at the tertiary care hospital or via tele-medicine (Group B). The overall outcome of the community-based hearing screening program was analyzed with respect to coverage, refer rate, follow-up rate for 2nd screenings and diagnostic testing. A comparison of the outcomes of tele-versus in-person diagnostic ABR follow-up was carried out.

RESULTS

Six VHWs who fulfilled the post training evaluation criteria were recruited for the screening program. VHWs screened 1335 children in Group A and 1480 children in Group B. The refer rate for 2nd screening was very low (0.8%); the follow-up rate for 2nd screening was between 80 and 97% across the different age groups. Integration of tele-ABR resulted in 11% improvement in follow-up compared to in-person ABR at a tertiary care hospital.

CONCLUSIONS

Non-availability of audiologists and limited infrastructure in rural areas has prevented the establishment of large scale hearing screening programs. In existing programs, considerable challenges with respect to follow-up for diagnostic testing was reported, due to patients being submitted to traveling long distance to access services and potential wage losses during that time. In this program model, integration of a tele-ABR diagnostic follow-up improved follow-up in comparison to in-person follow-up. VHWs were successfully trained to conduct accurate screenings in rural communities. The very low refer rate, and improved follow-up rate reflect the success of this community-based hearing screening program.

Enhancing Ear and Hearing Health Access for Children With Technology and Connectivity

PURPOSE

Technology and connectivity advances are demonstrating increasing potential to improve access of service delivery to persons with hearing loss. This article demonstrates use cases from community-based hearing screening and automated diagnosis of ear disease.

METHOD

This brief report reviews recent evidence for school- and home-based hearing testing in underserved communities using smartphone technologies paired with calibrated headphones. Another area of potential impact facilitated by technology and connectivity is the use of feature extraction algorithms to facilitate automated diagnosis of most common ear conditions from video-otoscopic images.

RESULTS

Smartphone hearing screening using calibrated headphones demonstrated equivalent sensitivity and specificity for school-based hearing screening. Automating test sequences with a forced-choice response paradigm allowed persons with minimal training to offer screening in underserved communities. The automated image analysis and diagnosis system for ear disease demonstrated an overall accuracy of 80.6%, which is up to par and exceeds accuracy rates previously reported for general practitioners and pediatricians.

CONCLUSION

The emergence of these tools that capitalize on technology and connectivity advances enables affordable and accessible models of service delivery for community-based ear and hearing care.

Universal newborn hearing screening in southwestern Iran

OBJECTIVES

The implementation of Neonatal Hearing Screening (NHS) program is still at the preliminary stage particularly in developing countries despite the burden of permanent congenital and early-onset hearing impairment. The purpose of this study was to report results for universal newborn NHS in a cohort of children born in the southwestern region of Iran, as part of a national screening program set up by the Iranian National Health System.

METHODS

During this cross-sectional study, which took place between March 2013 and April 2016, healthy newborns were screened using transient evoked otoacoustic emissions (TEOAEs) and automated auditory brainstem responses (AABRs) methods at several points in time as early as possible after birth. Screening followed a two-stage strategy and newborns referred after the second-stage screening were scheduled for diagnostic evaluation.

RESULTS

A total of 92,521 newborns were screened in the urban (n = 67,780) and rural (n = 24,741) regions. Hearing impairment was confirmed in 223 (2.41 per 1000) newborns. One hundred forty-one (1.52 per 1000) of these newborns were affected bilaterally. More than 87% of these infants (195/223) showed a sensorineural hearing loss, while the defect was found to be conductive in 12 cases (P < 0.001). Of the 223 cases with hearing loss, 28 (12.5%) infants had auditory neuropathy. The majority of the infants, in both urban and rural regions, showed severe hearing impairment. We did not observe any significant difference among the incidences associated with gender (p = 0.29).

CONCLUSION

Our results demonstrated that universal newborn hearing screening program is an adequate program for southwestern of Iran with high coverage, low referral rate, and good follow-up rate.

Tele-intervention for children with hearing loss: A comparative pilot study

Introduction This pilot study compared tele-intervention to conventional intervention for children with hearing loss in terms of communication performance, parental perceptions and clinician perceptions. Methods A within-subject design was employed, including 10 children with hearing loss and their parents who each received a structurally similar tele-intervention and conventional intervention session in a counterbalanced manner. Quality of communication performance was analysed using a modified Tait video analysis method. Parent and clinician perceptions were collected through rating-scale surveys and thematic analysis of qualitative responses. Results No significant difference ( p > 0.05) was found between tele-intervention and conventional intervention in terms of communication performance of children. Parent perceptions were not significantly different ( p > 0.05) between conventional and tele-intervention in terms of facilitating meaningful communication interaction. Significant differences were evident for parents' comfort level during the session, whether they found it to be a beneficial experience and whether they would like to continue receiving intervention through this method.  Clinician perceptions of conventional and tele-intervention were not significantly different ( p > 0.05) and tele-intervention was deemed a valuable method of service delivery for clients. Discussion This study provides preliminary evidence that tele-intervention is effective for communication intervention and can be a valuable solution to typical barriers such as distance and the shortage of trained interventionists.

Evaluation of universal newborn hearing screening in South African primary care

BACKGROUND

Universal Newborn Hearing Screening (UNHC) is the gold standard toward early hearing detection and intervention, hence the importance of its deliberation within the South African context.

AIM

To determine the feasibility of screening in low-risk neonates, using Otoacoustic Emissions (OAEs), within the Midwife Obstetric Unit (MOU) three-day assessment clinic at a Community Health Centre (CHC), at various test times following birth.

METHOD

Within a quantitative, prospective design, 272 neonates were included. Case history interviews, otoscopic examinations and Distortion Product OAEs (DPOAEs) screening were conducted at two sessions (within six hours and approximately three days after birth). Data were analysed via descriptive statistics.

RESULTS

Based on current staffing profile and practice, efficient and comprehensive screening is not successful within hours of birth, but is more so at the MOU three-day assessment clinic. Significantly higher numbers of infants were screened at session 2, with significantly less false-positive results. At session 1, only 38.1% of the neonates were screened, as opposed to more than 100% at session 2. Session 1 yielded an 82.1% rate of false positive findings, a rate that not only has important implications for the emotional well-being of the parents; but also for resource-stricken environments where expenditure has to be accounted for carefully.

CONCLUSION

Current findings highlight the importance of studying methodologies to ensure effective reach for hearing screening within the South African context. These findings argue for UNHS initiatives to include the MOU three-day assessment to ensure that a higher number of neonates are reached and confounding variables such as vernix have been eliminated.

Cobertura estimada da triagem auditiva neonatal para usuários do Sistema Único de Saúde, Brasil, 2008-2011

Objetivos: estimar e descrever a cobertura da triagem auditiva neonatal (TAN) para os usuários do Sistema Único de Saúde (SUS) no Brasil, entre 2008 e 2011. Métodos: estudo ecológico de séries temporais utilizando-se dados do Sistema de Informação Ambulatorial do SUS (SIA-SUS), Sistema de Informações sobre Nascidos Vivos (SINASC), Rede Interagencial de Informações para a Saúde (RIPSA) e Sistema de Informações de Beneficiários (SIB) da Agência Nacional de Saúde Suplementar (ANS). A cobertura foi estimada considerando-se os procedimentos para TAN autorizados pelo SUS e os nascidos vivos usuários do SUS, para cada ano e Unidade da Federação. Resultados: a cobertura nacional da TAN para usuários do SUS foi estimada em 7,1% em 2008, e alcançou 21,8% em 2011, com evidências de desigualdades inter e intrarregionais. Maiores coberturas foram observadas no Rio Grande do Sul (60,1%) e no Paraná (59,4%), enquanto Rondônia, Espírito Santo e Pernambuco apresentaram cobertura inferior a 5%. Conclusões: no país, mais de dois terços dos neonatos usuários do SUS não foram submetidos à triagem auditiva, mesmo em 2011, ano seguinte à promulgação da lei nacional que estabeleceu a obrigatoriedade do procedimento. Embora o cenário seja de avanço, a meta é a cobertura universal.

Neuroauditory toxicity of artemisinin combination therapies-have safety concerns been addressed?

Although artemisinin-based combination therapies (ACTs) are widely viewed as safe drugs with a wide therapeutic dose range, concerns about neuroauditory safety of artemisinins arose during their development. A decade ago, reviews of human data suggested a potential neuro-ototoxic effect, but the validity of these findings was questioned. With 5–10 years of programmatic use, emerging artemisinin-tolerant falciparum malaria in southeast Asia, and the first calls to consider an increased dose of artemisinins, we review neuroauditory safety data on ACTs to treat uncomplicated falciparum malaria. Fifteen studies reported a neurological or auditory assessment. The large heterogeneity of neuro-ototoxic end points and assessment methodologies and the descriptive nature of assessments hampered a formal meta-analysis and definitive conclusions, but they highlight the persistent lack of data from young children. This subgroup is potentially most vulnerable to any neuroauditory toxicity because of their development stage, increased malaria susceptibility, and repeated ACT exposure in settings lacking robust safety monitoring.

Why parents refuse newborn hearing screening and default on follow-up rescreening--a South African perspective

OBJECTIVES

This study describes screen refusal and follow-up default characteristics together with caregiver reasons for screen refusal and follow-up default in two South African universal newborn hearing screening programs.

METHODS

A retrospective record review of universal newborn hearing screening conducted at two hospitals (Hospital A n = 954 infants; Hospital B n = 2135) over a 31-33 month period. Otoacoustic emission screening was conducted with rescreen recommended within six weeks for a uni- or bilateral refer. Program efficacy was described according to coverage, referral and follow-up rates. A prospective telephonic interview with caregivers who declined the initial screen (n = 25) and who defaulted on follow-up (n = 25) constituted the next study component. Caregivers were randomly selected from the screening programs for a survey related to reasons for newborn hearing screening refusal and follow-up default.

RESULTS

Screening coverage (89.3% Hospital A; 57.4% Hospital B), initial referral rates (11.6% Hospital A; 21.2% Hospital B) and follow-up return rates (56.1% Hospital A; 35.8% Hospital B) differed significantly between hospitals and were below benchmarks. The most frequent reasons for screen refusal were related to costs (72%), caregiver knowledge of newborn hearing screening (64%) and health care professional knowledge and team collaboration (16%). Almost all caregivers (96%) indicated that if costs had been included in the birthing package or covered by medical insurance they would have agreed to newborn hearing screening. Reasons for follow-up default were most commonly related to caregiver knowledge of newborn hearing screening (32%) and costs (28%). One in four caregivers (24%) defaulted on follow-up because they forgot to bring their infant for a rescreen. Only half of caregivers (48%) who defaulted on follow-up reported being aware of initial screen results while 60% reported being aware of the recommended follow-up rescreen.

CONCLUSION

Caregivers most commonly refused screening due to associated costs and mostly defaulted on follow-up due to an apparent lack of knowledge regarding initial screen outcome and recommendations made for follow-up. Including NHS as a mandated birthing service is essential if coverage is to be increased, while reducing follow-up defaults requires proactive reminders and improved communication with caregivers.

Community-based newborn hearing screening programme for early detection of permanent hearing loss in Iran: An eight-year cross-sectional study from 2005 to 2012

Objectives

We here present the results of the first eight years of the newborn hearing screening programme in Iran, with a view to establishing the prevalence of hearing impairment among infants, and the efficacy of the programme.

Methods

A total of 3,350,995 infants were screened using the series method of transient evoked otoacoustic emissions (TEOAEs)/automated auditory brainstem responses (AABRs), between 2005 and 2012. The infants were first tested for TEOAEs (three times). Based on the results of this test, the positive cases were referred to the next stage, where they were tested for AABRs. If they also tested positive on AABRs, they were referred to the diagnostic and rehabilitation stages.

Results

Results of this study indicated an infant hearing impairment prevalence of 3 per 1000. Although this rate was as high as 5 per 1000 in the early years of the programme, it decreased to 2.6 per 1000 in the last year. The absolute referral rate was 14.5% in the first stage, which decreased to 0.9% and 0.2% in the second and the third stages, respectively. The follow-up rate was 70% in the first stage, which increased up to 73% and 85% in the second and the third stages, respectively.

Conclusion

The study results suggest that the prevalence of hearing impairment in infants in Iran is comparable with that in developed and developing countries, and that the series TEOAEs/AABRs method used in the screening programme in Iran is efficient.

A large-scale newborn hearing screening in rural areas in China

OBJECTIVES

Newborn hearing screening has been successfully implemented in cities of China, but not in rural areas. This study aimed to provide guidance on implementing hearing screening in the rural areas of China.

METHODS

Subjects were 11,568 babies who were born in 5 counties of Hubei Province of China. Hearing screening followed a two-stage strategy with transient evoked otoacoustic emissions (TEOAEs). Infants referred after the second-stage screening were tested by diagnostic auditory brainstem response (ABR).

RESULTS

The subjects screened included 10,665 (92.2%) normal newborns and 903 (7.8%) newborns with high-risk of hearing loss. While 8190 (70.8%) newborns passed the initial screening, 135 newborns failed in the re-screening, and 90 (66.7%) of these 135 newborns received diagnostic assessment. Finally, 58 infants were diagnosed as hearing loss, and the prevalence of congenital hearing loss among newborns in rural areas was 0.5% (58/11,568).

CONCLUSIONS

This large-scale newborn hearing screening in rural areas of Hubei Province of China demonstrated that the screening rate and referral rate for high-risk infants are low. Urgent measures should be taken by the government to promote newborn hearing screening in the rural areas.

The role of maternal socioeconomic factors in the commitment to universal newborn hearing screening in the Northeastern region of Brazil

OBJECTIVE

The implementation of early hearing detection in developing countries remains elusive. The fragile health care system along with insufficient funding for health care services leads to inadequate universal newborn hearing screening programs. There is a high incidence of loss to follow-up, at different stages of the program, in these countries, compromising the effect of early hearing screening programs. Strategies must be developed to improve family commitment to such programs. The objective of the present study was to examine factors that predict loss to second-stage follow-up at a municipal based, universal newborn hearing screening program in the Northeastern region of Brazil.

METHOD

The current cross sectional study includes 577 newborns who underwent hearing screening and failed. The population was divided into two groups: those who returned and those who were lost to second-stage screening. Differences between groups were explored and adjusted odds ratios were derived.

RESULTS

There was a significantly increased risk of non-adherence to the universal newborn hearing screening program in mothers with low income, few prenatal care visits, minimal education and with a multiparous child.

CONCLUSION

Socioeconomic factors may have a significant influence on the effectiveness of hearing screening programs in poorer regions of Brazil and other low-income countries. Improvements in health care politics, tracking system and public awareness is crucial for successful program implementation.

Neonatal hearing screening and intervention in resource-limited settings: an overview

From a developmental perspective, optimal speech and language outcome is indisputably the primary motivation for neonatal hearing screening of infants with congenital or early-onset hearing loss (PCHL). This paper additionally outlines more broadly the potential value of early hearing detection and intervention in resource-poor countries against the backdrop of limitations of primary prevention of PCHL based on a review of literature from low-income and middle-income countries with per capita incomes of approximately US$6000 or less. It establishes the scientific and developmental foundation for priority consideration for neonatal hearing screening and intervention in any global initiatives for effective early childhood development programmes in resource-limited countries. It also highlights approaches to addressing the various challenges to implementing effective early hearing detection and intervention programmes, and concludes with a discussion on the pivotal role of paediatricians in facilitating timely referral for requisite tests and (re)habilitative services especially for infants with established risk factors.

Efficacy of a community-based infant hearing screening program utilizing existing clinic personnel in Western Cape, South Africa

OBJECTIVE

Screening programs at primary health care immunization clinics have been proposed as an alternative to hospital-based programs in South Africa. The objective of this study was to evaluate the first systematic community-based infant hearing screening program in a developing South African community in the Western Cape.

METHODS

A community-based universal infant hearing screening program initiated at eight primary health care clinics in the Cape Metropolitan area was evaluated over a 19-month research period. During this time 6227 infants that were candidates for screening attended their 6, 10 or 14-week immunization visit at the relevant clinic. Clinic nurses were trained as screening personnel. A two-stage distortion product otoacoustic emissions screening protocol was utilized. The target disorder was uni- or bilateral hearing loss and infants referring the first screen were scheduled for a 4-week follow-up visit at the clinic. Diagnostic audiological and medical evaluations were scheduled at referral hospitals when indicated. The study evaluated the efficacy of the program based on coverage, referral and follow-up rates and diagnostic outcomes according to guidelines specified by the Health Professions Council of South Africa 2007 Position Statement.

RESULTS

Overall coverage rate across the eight clinics was 32.4% with 2018 infants (aged 0-14 weeks) screened. The mean age of the sample at first stage screen was 3.9 weeks of age and 13.5 weeks of age for first hospital visit. Overall first stage screen referral rate was 9.5% with 62 subjects (3%) referred for diagnostic services at hospital level after a follow-up screen. The average follow-up rate for rescreens at clinic level was 85.1% and for initial diagnostic assessments at hospital level it was 91.8%. Prevalence rates were 4.5/1000 with significant hearing loss, including sensorineural (1.5/1000) and conductive (3/1000) losses, and 12.9/1000 for subjects with middle ear effusion.

CONCLUSIONS

The community-based infant hearing screening program was valuable in attaining high follow-up return rates but reaching sufficient coverage may require dedicated screening personnel as opposed to existing nursing personnel.

Age of identification of hearing impairment in Mumbai--a trend analysis

Implementation of Universal Newborn Hearing Screening (UNHS) has led to lowering the age of identification of congenital hearing loss in children. In the absence of UNHS in Mumbai (India), it is pertinent to establish a data base on the age of identification of permanent hearing loss in children to facilitate affirmative action.

OBJECTIVE

To study the trend in age of identification (AOI) of hearing impairment in children studying in special schools.

METHODS

This retrospective study was a survey conducted on a convenient sample. The authentic data about date of birth and age of identification (AOI) of 510 children were collected through parental interview, and scrutiny of documents like birth certificates, first audiological report maintained in special schools/institutes/hospitals.

RESULTS

Time series analysis of the data concluded that from 1989 to 2008, AOI has reduced by 9.59 months. AOI has not reached one year even by 2008 and is much below the target of three months of age as per the recommendation of Joint Committee on Infant Hearing (2007).

CONCLUSION

In absence of Universal Newborn Hearing Screening (UNHS) in Mumbai (India) the present efforts do not seem to be enough in lowering the age of identification of hearing loss and policy decision is warranted.

The influence of epidural anesthesia on new-born hearing screening: A pilot study

Objective:

The main aim was to establish if epidural anesthesia had an influence on new-born hearing screening results in newborns born via elective Cesarean section in healthy pregnancies. Specific objectives included determining screening results in a group of newborns born to mothers who had undergone epidural anesthesia during Cesarean section childbirth (experimental group); and comparing the findings with those of a group of newborns born to mothers who had undergone natural delivery without epidural anesthesia (comparison group); while establishing if the time of screening following delivery had any effect on the overall screening results.

Materials and Methods:

The above objectives were achieved through the use of a prospective quasi-experimental repeated measures design with a comparison group, where 40 newborns (20 in the experimental and 20 in the comparison group) were screened at three different times through transient otoacoustic emissions (TEOAEs) and automated auditory brainstem response (AABR) measures. All participants were screened while resting quietly in open bassinets in an empty new-born nursery. For both test measures, the results were recorded as either pass or refer. Data were analyzed through both descriptive and inferential statistics.

Results:

Findings indicated that hearing screening earlier than four hours after birth, for both the experimental and comparison groups yielded more false positive findings than testing conducted after 24 hours. An index of suspicion in relation to the influence of epidural anesthesia on Automated Auditory Brainstem Response (AABR), when conducted less than four hours after birth, was raised, as statistically significant findings (P<0.05) were obtained.

Conclusions:

The findings have implications for timing of screening where universal newborn hearing screening is being implemented.

Making targeted screening for infant hearing loss an effective option in less developed countries

Developing countries account for a disproportionate burden of infant hearing loss globally but the prospects of the more ideal universal newborn hearing screening (UNHS) have been debated. The Joint Committee on Infant Hearing (JCIH) of USA has consistently proposed targeted newborn hearing screening (TNHS) for such countries. This study therefore set out to examine the appropriateness of JCIH risk factors as a basis for TNHS in Sub-Saharan Africa and Southeast Asia. From a review of relevant literature published in PubMed in the last 10 years, evidence on the effectiveness of TNHS based on JCIH or other risk factors is sparse or limited. Consistent with the prevailing epidemiological profile of these countries additional putative risk factors not listed or more prevalent than those listed by JCIH such as maternal hypertensive disorders in pregnancy, lack of skilled attendant at delivery, non-elective cesarean delivery and infant undernutrition have been demonstrated besides consanguinity. While TNHS has intuitive appeal in resource-poor settings, it is likely to be fraught with diverse operational constraints that could significantly curtail its effectiveness in these two regions. Well-conducted pilot UNHS studies to determine context-specific risk factors, screening efficiency and the potential trade-offs are warranted in each country prior to embarking on TNHS where UNHS is not immediately practicable.

The universal newborn hearing screening in Brazil: from identification to intervention

OBJECTIVE

The objective of the study is to investigate the results of the newborn hearing screening program carried out in a Public Hospital in Brazil, in the first 3 years regarding: (1) the prevalence of hearing impairment; (2) the influence of the universal hearing screening program on the age at which the diagnosis of hearing loss is defined; (3) the cost effectiveness of the program; (4) the outcomes, in terms of the age in which the hearing rehabilitation started.

METHODS

A descriptive study of the first 3 years after starting the universal newborn hearing screening in a Public Hospital of Bauru, São Paulo state, Brazil. The screening method consists of a two-stage screening approach with transient otoacoustic emissions (TOAE), conducted by an audiologist. If the outcome in the second-stage screening is REFER, the infant is submitted to diagnostic follow-up testing and intervention at the Audiology and Speech Pathology Clinic at the University of São Paulo, campus of Bauru. The evaluation of the costs of the universal newborn hearing screening program per each screened newborn (around 4000/year) was done based on a proposal by the National Center for Hearing Assessment and Management, of the Utah State University, United States of America.

RESULTS

11,466 newborns were submitted to hearing screening, corresponding to 90.52% of the living newborns. The prevalence of sensorineural hearing loss was 0.96:1000. Of the 11 children with sensorineural hearing loss, eight children received hearing aids and five started the therapeutic process before the age of 1. Currently, four children between the ages of 11 months and 2 years old were submitted to cochlear implant surgery. The cost of hearing screening was US$7.00 and the annual cost of the universal newborn hearing screening program was US$26,940.47.

CONCLUSION

The hospital-based universal newborn hearing screening carried out through the Brazilian National Health System is viable, with promising results. However, in a country such as Brazil, which presents large socio-economic differences, the same type of analyses should be performed in several regions, so as to take into account specific aspects, to implement the newborn hearing screening along with the Public System.

Hearing screening for school children: comparison of low-cost, computer-based and conventional audiometry

BACKGROUND

There is a need to develop affordable but effective audiometric screening equipment, particularly for use in low-income countries. With advances in computer technology, low-cost computer-based audiometer software has been developed. However, the efficacy of computer-based audiometers in hearing screening and diagnostic assessment requires investigation. The purpose of this study was to evaluate the accuracy of a low-cost, computer-based audiometric system in a school-based hearing screening programme.

METHODS

Eighty children were screened using the computer-based audiometer and with a conventional pure tone screening audiometer. Overall refer rates, as well as frequency and age effects on the accuracy of the computer-based audiometer, were considered.

RESULTS

There was a significant relationship between the low-cost, computer-based audiometer and a conventional pure tone audiometer when a 40 dBHL refer criterion was used in school hearing screening and when test results at 500 Hz were excluded from analysis. However, background noise effects and software limitations in the computer-based system had major adverse effects on screening performance.

CONCLUSIONS

The study results and preliminary practical experience with the system suggest that, with further software and hardware improvements, a low-cost, computer-based system may well be feasible for routine school screening in developing countries.

Place of birth and characteristics of infants with congenital and early-onset hearing loss in a developing country

OBJECTIVE

To determine the characteristics of infants with sensorineural hearing loss (SNHL) and the relationship with place of birth.

METHODS

Subjects were drawn from hospital-based and community-based universal infant hearing screening programs concurrently conducted from May 2005 to April 2008 in Lagos, Nigeria. Maternal and infant characteristics of children born in hospitals and detected with SNHL were compared with those born outside hospitals. Each program consisted of a first-stage screening with transient-evoked otoacoustic emissions (TEOAE) followed by second-stage automated auditory brainstem response (AABR). Hearing status was confirmed by diagnostic auditory brainstem response, tympanometry and visual response audiometry.

RESULTS

A total of 4718 infants were screened under the hospital-based program out of which 12 (0.3%) infants were confirmed with SNHL whereas 71 (1.0%) of the 7179 infants screened under the community-based program were confirmed with SNHL. Of all infants with SNHL 39 (47.0%) were born in hospitals suggesting that 27 (38.0%) of infants under the community-based program were born in hospitals. Prevalence of SNHL ranged from 4.0 per 1000 among infants born in government hospitals to 23 per 1000 among those born in family homes. Mothers of those born outside hospitals were significantly likely to belong to the Yoruba tribe (p<0.001), use herbal medications in pregnancy (p<0.001), deliver vaginally (p=0.004) but without skilled attendants at delivery (p<0.001). There were no significant differences among the infants themselves except that those born outside hospitals were significantly likely to be detected in the first 3 months of life compared to those born in hospitals (p<0.001).

CONCLUSIONS

A significant proportion of infants with SNHL in many developing countries are likely to be born outside hospitals thus underscoring the need for community-oriented UNHS to facilitate early detection and intervention. Conventional risk factors for SNHL are unlikely to discriminate across places of birth. Pediatricians and otolaryngologists should consider a more active role in fostering community-oriented delivery of primary ear care services in this and similar settings in the developing world.

Early hearing detection and intervention in South Africa

Early hearing detection and intervention programs have become the standard of care to ensure optimal outcomes for infants with hearing loss, their families and society at large. The overwhelming majority of infants with congenital or early-onset permanent bilateral hearing loss are however born in developing countries like South Africa where services are scarce and awareness poor. Despite its comparatively well-developed economic and reasonably developed health care infrastructure in sub-Saharan Africa, limited information on infant hearing loss and the status of early hearing detection and intervention has been available for South Africa. Recently however, an increasing number of initiatives and reports have highlighted the extent of infant hearing loss and the status of identification and intervention services offered in the country. This report provides a review of the available evidence on infant hearing loss and the status of current early hearing detection and intervention services in South Africa.

Community-based infant hearing screening for early detection of permanent hearing loss in Lagos, Nigeria: a cross-sectional study

OBJECTIVE

To determine the feasibility and effectiveness of a community-based universal infant hearing screening programme for detecting permanent congenital and early-onset hearing loss (PCEHL) in Lagos, Nigeria.

METHODS

This is a cross-sectional study in which all infants aged 3 months or under attending four bacille Calmette-Guérin (BCG) immunization clinics accounting for over 75% of the BCG coverage in the study location were screened by community health workers between July 2005 and April 2006. Screening followed a two-stage protocol involving transient evoked otoacoustic emissions and automated auditory brainstem responses. The main outcome measures were screening coverage, referral rates, return rates for second-stage screening and evaluation, yield and age at PCEHL diagnosis.

FINDINGS

In total, 2003 (88%) of 2277 eligible infants attending the four BCG clinics were successfully screened between July 2005 and April 2006 at a mean age of 17.7 days, with no parent declining screening. The majority (55.2%) were born outside a hospital and, of such infants, 77% were born in traditional herbal maternity homes. The overall referral rate for diagnostic evaluation was 4.1%. Only 61% (50/82) of those referred returned for evaluation, and 45 of them were confirmed with PCEHL. Additionally, 11 infants who had previously passed the first screening stage were also found to have PCEHL, resulting in a yield of 28 per 1000 (56/2003). The mean age at diagnosis was 51 days. The sensitivity, specificity and positive predictive value of the first screening stage were 80.4%, 99.7% and 90.0%, respectively. The positive likelihood ratio was 268, while the negative likelihood ratio was 0.2.

CONCLUSION

Routine hearing screening of infants attending BCG immunization clinics by community health workers was feasible and effective for the early detection of PCEHL in Lagos, Nigeria. However, an efficient tracking and follow-up system is needed to improve return rates for second-stage screening and diagnostic evaluation.

Follow-up default in a hospital-based universal newborn hearing screening programme in a low-income country

BACKGROUND

Effective early detection of infants with permanent hearing impairment requires parental compliance with various stages of a screening protocol. However, many infants who failed initial screening tests are often not presented for follow-up evaluation, thus compromising prospects for early detection and intervention. This study set out to determine maternal and infant factors associated with loss to follow-up in a hospital-based universal hearing screening programme in a low-income country.

METHODS

A cross-sectional study in which babies in a tertiary maternity hospital were enrolled into a two-stage hearing screening programme with transient-evoked otoacoustic emissions followed by automated auditory brainstem response (AABR) for all transient-evoked otoacoustic emissions referrals before hospital discharge. Diagnostic evaluation was scheduled for AABR referrals on outpatient basis. Correlates of non-compliance were determined through multivariable logistic regression analyses of relevant maternal and infant factors.

RESULTS

Some 1330 babies participated in the first-stage screening and of 551 scheduled for AABR; 56 (10.2%) did not complete. Some 37 (84.1%) of the 44 AABR referrals did not complete the diagnostic evaluation. There were no significant differences between the profile of those who did not complete either the second-stage screening or diagnostic evaluation and those who completed across virtually all socio-demographic factors except that Christian mothers were significantly more likely not to complete the second-stage screening than diagnostic evaluation compared with their Muslim counterparts (odds ratio: 3.01; 95% confidence intervals: 1.17-7.87). The only independent predictors of non-compliance with pre-discharge screening were delivery by spontaneous vertex (odds ratio: 2.76; 95% confidence intervals: 1.47-5.19) and admission into special care baby unit (odds ratio: 5.62; 95% confidence intervals: 2.92-10.84) while no factor was predictive of non-compliance with diagnostic evaluation.

CONCLUSIONS

Mode of delivery or having high-risk baby influences compliance before hospital discharge while factors other than maternal or infant socio-demographic/medical profile such as unfavourable cultural beliefs and stigma may be key determinants of follow-up compliance after discharge.