Early Hearing Detection And Intervention Research Articles

Low- and middle-income countries (LMICs) continue to experience the highest incidence of hearing loss. 1 With the incidence of hearing loss projected to reach approximately 2.5 billion globally in the next couple of decades 2, LMICs may bear the highest burden of this proportion. Within the South African context, various risk factors, which form part of the quadruple burden of diseases such as the human immunodeficiency virus (HIV) 3,4, diabetes 5, tuberculosis (TB) 6, and hypertension 7 increase the risk of hearing loss, with COVID-19 having potentially added to this challenge. 8 Ntlhakana et al. 9 found that the combined effects of risk factors increase the risk of hearing loss in South African mine workers, with Khoza-Shangase 10 comprehensively discussing these risk factors for this important sector of the South African economy while arguing for their contextualization.www.shutterstock.com. Golden Rules, audiologists, cochlear implants, hearing aids, OTC.Despite the ever-increasing prevalence of hearing loss in LMICs, such as South Africa, established hearing protocols such as hearing screening do not seem to have improved access to ear and hearing health care to a wider population in these regions. Prevalence of hearing loss remains underreported, thus negatively influencing governmental obligation to provide equitable resources and focus to hearing health care programs. 11 Extreme shortages of ear and hearing health practitioners 12–14, and limited healthcare institutions that provide hearing healthcare services, with preventive ear and hearing care measures taking a back seat 13,15, exacerbate the rapid increase of hearing loss in LMICs. Given that approximately 80% of the South African population, for example, access health through the government funded public health sector, patients who experience ear and hearing related symptoms may not have sufficient access to services due to contextual realities including financial challenges such as transportation money to access health care centres, as well as the general population’s limited awareness of the existence of hearing health care practitioners as a profession. 16,17 The shortage of hearing health practitioners seen through capacity versus demand challenges and the general lack of resources form part of the dilapidated health care system, which lacks the capabilities to deal with most health problems. 18 The strained health care system, at the expense of quality of life, tends to prioritize life-threatening conditions, which hearing loss does not fall under. It is therefore not surprising that some preventive audiological programs such as the hearing conservation programs (HCPs) do not seem to yield positive outcomes of zero ear harm due to excessive noise in mines 19, while early hearing detection and intervention (EHDI) and ototoxicity monitoring programs remain at infancy and developmental stages. 20–22 TELEAUDIOLOGY Teleaudiology emerged as a promising vehicle to deliver hearing health care to a larger population, mitigating the capacity versus demand challenges as far as extreme shortage of hearing health care practitioners is concerned. Khoza-Shangase and Moroe 23 strongly encourage the use of teleaudiology within the South African mining context to mitigate the challenges relating to access. Teleaudiological services imply that a hearing health care practitioner can remotely provide audiological care to patients. Because patients do not have to travel long distances to see a professional, this technique seems to address the costs associated with traveling long distances and access problem, and it also opens access to human resources beyond the boundaries of the area where the services are required — thus South African patients, for example could be seen by audiologists outside South Africa as long as trained and regulated patient site facilitators become available. 24 Research has explored and indicated that teleaudiology can be used to provide majority of the audiological services, which include middle ear assessment 25, hearing assessment, hearing aid fitting, programming of cochlear implants, as well as providing aural rehabilitation and counseling. 26 It is clear that teleaudiology has created some hope in improving access to health care. However, on its own, and without strategic application, the teleaudiology model of service delivery may fall short in achieving its goal; particularly within the realities of the South African context. Closer examination of teleaudiology in LMICs indicates that this model follows the same traditional method of providing hearing health care, which functions outside and/or parallel to existing health care programs. 27 Current methods of provision of ear and hearing care in the South African context still primarily comprise of standalone audiology clinics in state hospitals or private practices in private clinics or rooms. Khoza-Shangase has consistently argued, for example, for a programmatic approach to ototoxicity assessment and monitoring within the quadruple burden of disease in South Africa. 21,28,29 This is where, for example, audiology forms part of all HIV/AIDS and TB programmes in the country, such that budgeting falls under the “life threatening conditions” budget; thus, allowing for increased access as well as sustainability of all preventive audiology initiatives. The traditional method of providing hearing health care has, therefore, been less effective due to the burden of disease prioritization budget allocation approach adopted by National governments — where hearing loss is viewed as non-life-threatening, and thus is of less priority to other conditions. In countries such as South Africa, health resources are distributed inequitably, with hearing health receiving a modicum of those resources, and efficacy proven approaches such as universal newborn hearing screening programs not government mandated. The lack of infrastructural development for technological advancements, as well as lack of training and/or availability of patient site facilitators also prohibit teleaudiology to function optimally. 30 PROGRAMMATIC APPROACH Given that hearing health in LMICs often receives the modicum of resources, with priority given to major burdens of diseases (e.g., quadruple burden of disease in South Africa), this continues to affect ear and hearing health care provision. Therefore, an alternative model of health care, which may capitalize on the already resource allocated health care initiatives that are considered priority can allow for relatively equitable sharing of resources, which might be useful, particularly for hearing health. Current authors, therefore, argue that a programmatic approach towards ear and hearing care, where ear and hearing health forms part of existing health programs may be a useful alternative. Programmatic approach is a model that encourages different health programs to function within the same umbrella and share resources. Given that a programmatic approach to health care may allow different health care programs such as school health program; prevention of mother-to-child transmission (PMTCT) of HIV; child immunization programme, maternal, child and women’s health and nutrition (MCWH&N); HIV awareness programmes; ward-based primary health care outreach etc. that are already budgeted for, have monitoring embedded in them, and are already accepted by various professionals and paraprofessionals, this approach may be a cost-efficient and responsible alternative that improves service delivery. This might be even more productive as it might allow for the use of task shifting, where already existing paraprofessionals can be utilized with audiologists serving as program managers, thus addressing the capacity versus demand challenges. Khoza-Shangase 31 argues that it is imperative that ear and hearing health care practitioners devote attention and resources to health programs that are aimed at burdens of disease, and health programs that garner department of health support, and are therefore better resourced and sustainable, to achieve preventive outcomes as far as ear health and function are concerned. Shapiro and Galowitz 32 believe that a programmatic approach enables a number of programs to operate under the same umbrella. Current authors are of the view that a programmatic approach to hearing health is the best and alternative solution, particularly in resource-constrained environments. This approach may not only be helpful in as far as resources are concerned, but also strengthen the interdisciplinary collaboration, and improve preventive care. Coupled with teleaudiology, this approach would enhance ear and hearing care within these contexts.

The prevalence of congenital hearing loss is 2 to 3 per 1,000 infants. 1 Due to the implementation of universal newborn hearing screening programs, many children who are deaf or hard-of-hearing (D/HH) are being identified in infancy, compared to an average age of 2 to 3 years a generation ago. 2–4 There is now a large body of research demonstrating that children identified and enrolled into early intervention services before 6 months of age exhibit better language and developmental outcomes than children who are not enrolled into services by this age. 5–8 Early research indicating this association led to the establishment of the Early Hearing Detection and Intervention (EHDI) 1-3-6 benchmarks by the Joint Committee on Infant Hearing (JCIH): Screen hearing before 1 month of age, diagnose hearing loss before 3 months of age, and enroll into early intervention services before 6 months of age. 9www.shutterstock.com. Newborn screening, newborn hearing screening, congenital hearing loss, early hearing detection and intervention.Today, there are EHDI programs in all 50 states and seven territories, which has resulted in nearly 98% of infants receiving a hearing screening by 1 month of age. 10 Despite this success, over 25% of infants who do not pass their newborn hearing screening become lost to follow-up before receiving a final diagnosis, and less than half of those not passing their final newborn hearing screening receive a diagnosis before 3 months of age. 11,12 Timely diagnosis is critical for the early intervention benchmark to be met, as the enrollment process and family acceptance of the diagnosis take time. In 2019, only 45% of infants identified as D/HH were enrolled in early intervention services by 6 months of age. 13 Though progress has been made toward accomplishment of EHDI 1-3-6 goals, there is much that still needs to be done to ensure young children who are D/HH receive the supports they need to reach their full potential. WHAT CONTRIBUTES TO LOSS TO FOLLOW-UP? Due to the large number of infants receiving no follow-up after a failed newborn hearing screening, efforts on further reducing the lost to follow-up (LTF) rate would have the largest impact on improving EHDI 1-3-6 goals. Many factors contribute to the LTF rate; perhaps one of the most important factors is the message given to parents at the time of the screening. Results must be delivered to parents both verbally and in writing, and the next steps should be clearly delineated. Interpreters should be provided for families whose primary language is not spoken English. Screeners should not downplay the results of the screening or attribute a failed screening to “fluid,” as this may discourage the family from seeking follow-up testing. All screeners should receive proper training in communicating hearing screening results with families. The National Center for Hearing Assessment and Management (NCHAM) provides an online Newborn Hearing Screening Training Curriculum. 14 Hospitals conducting newborn hearing screenings should schedule a follow-up appointment for infants in need of further testing, preferably before discharge. Families with an outpatient appointment already scheduled for them before they leave the hospital are more likely to complete the testing. 15 This is especially important for families who have a limited awareness of the impact of hearing loss on speech and language development, and thus of the importance of receiving follow-up testing as early as possible. The sharing of family contact information (address and phone number) and name of the baby’s primary care provider (PCP) on the part of the hospital facilitates opportunities for conveying this importance. Many state EHDI programs communicate with families and PCPs to encourage follow-up testing and assist with the process. Another factor contributing to the LTF rate is a diagnosis of transient conductive hearing loss. These children are typically referred to an otolaryngologist for medical evaluation, with the instruction that they return after treatment or medical clearance. This scenario is common in infants with middle ear fluid, and treatment may be delayed for several months. Once cleared by the otolaryngologist, families are not always given the message that they need to return to complete audiological testing to verify the treatment successfully restored hearing. Some hearing losses initially thought to be transient are later determined to be permanent hearing losses. 16 Likewise, when diagnostic testing cannot be completed or results are inconclusive, families do not always return to complete testing. Families should be urged to complete all testing until a final diagnosis is obtained. WAYS TO SUPPORT EHDI GOALS As the primary health care professional in the diagnosis and treatment of children who are D/HH, audiologists can support EHDI goals and optimize outcomes for these children in many ways. One of the most impactful actions toward boosting EHDI goals happens to be one of the simplest—reporting to your state EHDI program. Timely reporting of all follow-up visits of young children who do not pass newborn hearing screening aids EHDI staff in communicating with families more effectively. Parents may be confused about what has taken place or what they are to do next, and parental reports are often inaccurate or insufficient. Access to all audiological testing results allows the EHDI program to counsel parents thoroughly and assist with the referral process. This can also benefit fellow audiologists by providing a thorough evaluation history on a child. Consistent reporting enables EHDI programs to analyze all follow-up data to improve the entire screening, diagnostic, and intervention process. Complete data also proves helpful in the accurate evaluation of the incidence of late-onset hearing loss. In addition, reporting of all outpatient visits can prevent duplication of services. This can occur when families complete follow-up testing, but the results were not reported to EHDI. Parents may become confused when they are informed by their state EHDI program of the need for further testing, and they do not understand that this is the same test they already completed. Upon diagnosis of a permanent hearing loss, informing families of early intervention services and its importance can improve receptiveness to these programs, which subsequently may improve timely early intervention enrollment rates. Audiologists should become familiar with the early intervention and family-to-family support services available in their area and be prepared to connect families to these services. In some states, simply reporting the diagnosis to the EHDI program will start the referral process. For children diagnosed with transient conductive hearing loss, or hearing loss of undetermined type, and referred to an otolaryngologist, audiologists should give clear instructions to return for follow-up testing post-treatment to ensure treatment restored hearing sensitivity and rule out an underlying permanent hearing loss. Preferably, a follow-up appointment will be made before the family leaves the clinic. The latest iteration of the JCIH Position Statement reaffirms that amplification and early intervention services should be considered for children with ongoing conductive hearing loss that cannot be resolved by 6 months of age. 17 Offering amplification to infants and children diagnosed with transient conductive hearing loss who cannot be treated for several months will support speech and language acquisition during this critical window of brain development. Audiologists involved in hospital newborn hearing screening programs can improve follow-up rates by collecting pertinent information for babies who do not pass the newborn hearing screening. Useful information for EHDI programs include the family’s address and phone number, the name of the baby’s primary care physician, and the outpatient follow-up appointment information. Ideally, this appointment should be scheduled for the family prior to hospital discharge. In addition, screener training should include consistent messaging of results. TAKE ACTION Despite progress in early hearing detection and intervention, much improvement is still needed. In some states, the COVID-19 pandemic added further challenges due to closure of health care facilities and families canceling appointments to reduce exposure risks. Optimal EHDI programs have been defined as meeting the EHDI 1-3-6 goals. To provide appropriate access to language stimulation and intervention services as soon as possible, EHDI programs meeting current targets might consider setting a new target of 1-2-3 (screening completed by one month of age, audiologic diagnosis completed by two months of age, and early intervention initiated no later than three months of age). 17 Audiologists influence EHDI goals at every step of the process, including through timely state reporting and clear communication with families. These relatively simple actions taken by audiologists help EHDI programs reduce loss to follow-up, facilitate an earlier diagnosis, and increase rates of timely enrollment into early intervention. Taken together, these actions can dramatically improve language and academic outcomes for children who are deaf or hard-of-hearing. Audiologists should contact their state’s EHDI program for mutual collaboration and inquire about their state’s reporting guidelines.

Early Hearing Detection And Intervention Research Articles

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