Newborn Hearing Programs in Brazil. Models Outside the US reality. PART 2

Monica Jubran Chapchap* and Flavia Martins Ribeiro**

Brazilian Task Force on Universal Newborn Hearing Screening*

Coordinators of NHS program of Hospital Sao Luiz, Sao Paulo, Brazil* **

Note from the editors: Katia de Almeida Ph.D. and Stavros Hatzopulos Ph.D.

The information on the Brazilian NHS status, reflects a very common scenario observed in many countries where there is no universally acceptable state legislation about hearing screening. According to this scenario, the urban centers can offer NHS services of a certain quality, while distant regions of the country have no NHS facilities what so ever . Also, within the urban centers some NHS providers produce excellent screening results (see the update below) while others remain on an average service level. As it is obvious the average status of a country in terms of NHS services and support cannot be characterized by the results of a few NHS providers.

Screening has sense (in terms of social services) only when it covers the needs of a part of the population (ie 90% ) and in this context it is worth asking how to evaluate the importance and contribution of isolated centers of NHS excellence. These are difficult questions to answer because NHS services require numerous human and economical resources. Despite the increasing interest in NHS and EHDI services internationally, there are many countries where large scale programs are impossible to implement. In these cases (as in Brazil), it is highly important that NHS centers of excellence exist despite their limited coverage of the tested population. It is hoped that within some acceptable time-frame these centers will pass / promote their successful know-how to others, expanding their positive results and promoting better health care.
The above objective is the basic assumption behind the expected success of EHDI programs, where we expect that with the diffusion of the screening know-how social services will improve at a wider scale. Unfortunately since these assumptions do not consider the continuous restriction of financial resources to health and education (internationally) it is too early to predict whether the NHS / EHDI programs will ever succeed.

Introduction

Newborn Hearing Screening (NHS) has been addressed in Brazil in the last 15 years and the number of NHS programs has increased significantly the last 3 years. The past decade was of great importance for the development of NHS (see introduction Newborn Hearing Screening Programs in Brazil, part 1, editorial 2002).

Current outcomes

In September 2003 we acknowledged 174 NHS programs in 20 different states, and 68 of them are located in the state of Sao Paulo. Most of the NHS programs in this state use TEOAEs as a first choice (72%) or DPOAEs (15%) and a few programs use OAE and ABR combined specially for the NICU babies (13%). Brazil has 5794 hospitals and from those only a 174 (0.03%) have implemented NHS programs. The distribution of theses programs among the Brazilian states, taken from the Brazilian Task force on Universal Newborn Hearing Screening web site (www.gatanu.org) is shown in Figure 1. The implementation of new programs has increased significantly in the last years as shown in Figure 2.

Figure 1

Figure 2

Actual problems

Besides the progress in the number of NHS programs, we are facing some issues related to our social, cultural and economical situation. Our public health system cannot fully support the UNHS demand and we are developing some approaches to move towards UNHS models, which fit better the present economical resources in Brazil. On September 5-7^th, 2003 the first National Meeting of Newborn Hearing Screening, was coordinated by GATANU and several points were identified about the course of NHS in Brazil :

Most of the NHS programs are involved only with the detection step, using mainly OAEs with automated or conventional equipment based on standardized protocols of pass/fail criteria as mentioned in part 1 of this editorial. The diagnosis is still a difficult step mainly because it is made in different centers usually distant from the screening site. The other concern is the lack of knowledge in the hearing development and the handling of the audiological evaluation of the infant, especially in the area of electrophysiological procedures (ABR) . It is still argued in Brazil by a number of professionals that the diagnosis at this early age ( 40 weeks or less) is not totally reliable due of the immaturity of the auditory system.
The Joint Committee on Infant Hearing (2000) has recommended a complete electrophysiological test battery such as bone conducted and frequency-specific ABR, but only a few centers in Brazil use these procedures. This lack of know-how could delay the identification of the hearing loss and the consequent intervention policies.
The use of data management systems which can track and manage the NHS information and control the quality of data inserted in the NHS databases, needs to be extended to all participating NHS programs because only a minority is using such kind of data management. The Brazilian NHS programs are mostly based on private initiatives coordinated and run by audiologists that have a tertiary part in the program.
There is a goal of concluding a multi center study by 2005 and for this purpose it is mandatory to use a standardized data management system . NCHAM (makers of the HITRACK software system) has been supporting us with no cost for the first 150 NHS programs using the software and GATANU is in charge of the technical and practical support at no charge as well.
To face the financial difficulties related to UNHS implementation, we have designed a new approach called Optional Newborn Hearing Screening (ONHS), testing babies with no risk indicators for hearing loss. In these programs the parents are informed about the importance of NHS and they have to assume the cost of the test. This is a step toward the implementation of a true UNHS program.
The screening equipment are very expensive considering the economical status across the country and the public health system that supports the majority of our population pays only US$ 1,00 per test making the UNHS a difficult challenge.
The legislation varies through the country by city and state policies. There are 1 state (Parana) and 12 counties laws. The implementation of NHS at this point is not related to the law support. In Brazil , the majority of the programs are implemented in cities and states without any hearing screening specific legislation. Brazil has 5561 counties which 74 have NHS and from those only 12 have relative legislation policies.
Professionals related to the infant health care should get involved and cooperate for the early diagnosis of hearing loss.
The Task Force of Brazilian Society of Pediatrics (founded in 2000) has started the first national wide action campaign informing and involving all the pediatricians with the NHS programs.

Models and Screening protocols of a program in Sao Paulo

The NHS program of the private Hospital Sao Luiz in Sao Paulo, was initiated in 1991 and until today has progressed through numerous steps (ie testing populations) as shown in Figure 3.

Figure 3

The model, protocols for screening and diagnosis stages and the NHS program results from 1999 to 2002 are presented in Figures 4-11. It should be noted that the positive outcomes of this successful program are related to numerous resources, which are not readily available outside the Sao Paulo State.

Figure 4

Figure 5

Figure 6

Figure 7

Figure 8

Figure 9

Figure 10

Figure 11