Early detection is still an uphill struggle in 2018

Hearing loss detection

Mónica Matos Rodeo, audiologist at the Los Andes Paediatric Society and the Child Cardiovascular Hospital in Cundinamarca, Colombia © MBP

Policy makers in Colombia are yet to approve the implementation of a national screening programme for hearing loss; meanwhile, children between 5 and 7 years old are being diagnosed through techniques that lack endorsement as decisive methods.

The country lags behind in new technology applied internationally for hearing loss detection examinations of the newborn. This is the claim of Mónica Matos Rodelo, speech-language specialist in audiology and occupational health, who affirms that the otoacoustic emissions practised in Colombia are not now the go-to test for this type of examination. In their place are automated auditory evoked potentials, recommended by medical societies and hearing sector federations worldwide.

“While evoked potentials have been used for 30 years in other countries, the latest technology now used allows for very high specificity in results and a lowering of false positives. The algorithms employed ensure that the potentials are reliable,” says Matos Rodeo, an audiologist at the Los Andes Paediatric Society and the Child Cardiovascular Hospital in Cundinamarca. These technological advances mean otoacoustic emissions have become complementary. Outside Colombia they are never obligatory because they are not decisive, but in Colombia they are assumed to be so.

The Colombian government recently rejected the implementation of a screening programme on the grounds of the costs being too high. This becomes arguable, however, on factoring in the “margin of error of two to three percent in evoked potentials; while it is at 20 to 30 percent in the case of otoacoustic emissions, involving detection of hearing loss that is not genuine, while ensuing treatments, and all they entail, could be far more costly for the state. In practical terms, otoacoustic emissions detect inner ear disorders even in external hair cells, but from there on in nothing much is identified, and many disorders occur in nerve or inner hair cells, where only auditory evoked potentials can discover them,” points out Irma Carvajalino, audiologist at the Cinda Foundation.

Work on creating awareness of the importance of this type of examination must currently be carried out along two routes: firstly towards government policy makers, who do not seem to understand the full picture despite many requests made to them by professional audiology and ENT groups in Colombia; secondly in the direction of actual hearing care professionals, who are “in important need of training in these tests with advanced technology so that they do not keep ordering traditional testing, which is often authorised by Colombia’s official health-promoting firms under the EPS scheme,” points out Matos in line with her experience as a lecturer and researcher at the Ibero-american University Corporation.

Late detection all the way

The key to minimising hearing loss lies in early diagnosis and intervention, and this should ideally be achieved before the patient is six-months-old. A 2004 study in Colombia by Matos and Gordillo found that detection of hearing pathologies and the identification of hearing problems was taking place at 6 years of age, just as children were starting full-time education.

“Regrettably, by 2017 the panorama has hardly changed, with detection taking place between five and seven years of age in the country’s main cities; the situation is even more serious in intermediate-sized and small towns, where there are no audiology services because, among other reasons, the EPS companies are not allowing hearing tests to be carried out on children, while they remain evasive on early treatment, even with with groups at high risk of hearing loss,” states Mónica Matos.

This situation has brought a reaction from the hearing care sector, now integrated in discussion groups and pushing a process to get universal screening approved, this being the optimum route towards preventing and treating hearing disability consequences in time, which would have a positive impact on rehabilitation costs. “We are currently giving cochlear implants to seven-yearold children presenting with language and speech problems, but these do not match their age,” says Matos.

According to the aformentioned study, some hearing loss cases are related to pre-eclampsia, gestational diabetes, infectious diseases (both viral and bacterial), injuries, trauma cases, ototoxic drugs, meningitis, and knocks, among others.

State policies are not sufficient

A universal screening law has been under proposal in Colombia since 2005, and supposedly there is awareness of the need to bring one in, but in reality ten years have passed and things now seem “even more entangled”.

The state has always left it to the National Institute for the Deaf (INSOR) to be the guiding body on the subject, yet throughout its existence, and even with different adminstrative offices under its control, INSOR does not seem to have given an early detection programme sufficient importance, and its actions have led more to better positioning for sign language over orality. On this basis, there is now an abyss between the state body and the private sector. According to sources close to Audio Infos, members of the Colombian hearing profession have sat round the table on many occasions with government delegates, but no success was achieved in overcoming arguments linked to technology, costs, and Colombia’s lack of readiness for these processes.

The government finally asked for updated statistics regarding children with hearing loss, but these were not forthcoming either, despite some private entities having carried out their own studies. A genetic test was then proposed in order to detect congenital anomalies related to hearing loss. The request was made to the Ministry of Health by neuropaediatricians and geneticists, but the hearing profession did not back this owing to the fact that results among the deaf scarcely appeared through this genetic testing method. “We wanted a real test. We could not deceive people and give them a diagnosis just through a blood test that didn’t offer detection with even 10% validity,” recalls Irma Carvajalino. In the end, this initiative did not meet with government approval either, since blood samples meant a very costly required storage and cold-chain process. Audiologists began to work in parallel with the Ministry of Health on an official Classification of Health Interventions (CUPS), a list to include all the procedures that can be carried out in Colombia. What is not on the list does not exist. The latest CUPS list to be published, dated April 11, 2017, has hearing procedures registered, but screening was not on the list, so this cannot be ordered and billed for by professionals. Why is it not included? The government maintains that it is a promotion and prevention campaign that should not be included in the CUPS classification, but should have a different modus operandi.

To counterbalance the situation, the Ministry of Health put out treatment guides in which newborn-related information suggested hearing studies being carried out. The problem is that these guides are merely suggestions to professionals; they do not involve any obligatory fulfilment.

To all intents and purposes, if screening is desired, this seems to be in the hands of the private sector. In its own procedures, the government does not include either otoacoustic emissions or automated auditory evoked potentials. The parents of newborn babies must pay for these services without government help. With things as they are, how can screening be promoted and implemented nationwide?

Mara Brugés Polo, Audio Infos Latin America