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Deafness: Burden, prevention and control in India

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Abstract

The high burden of deafness globally and in India is largely preventable and avoidable. According to the 2005 estimates of WHO, 278 million people have disabling hearing impairment. The prevalence of deafness in Southeast Asia ranges from 4.6% to 8.8%. In India, 63 million people (6.3%) suffer from significant auditory loss. Nationwide disability surveys have estimated hearing loss to be the second most common cause of disability. A lack of skilled manpower and human resources make this problem a huge challenge. The Government of India has launched the National Programme for Prevention and Control of Deafness. This article highlights the major components of the programme with a focus on manpower development and ear service provision including rehabilitation. Since the programme is also being implemented at the primary healthcare level, it envisages a reduction in the burden of deafness and prevention of future hearing loss in India.
Deafness: Burden, prevention and control in India
SUNEELA GARG, SHELLY CHADHA, SUMIT MALHOTRA, A. K. AGARWAL
Maulana Azad Medical College, Bahadur Shah Zafar Marg,
New Delhi 110002, India
SUNEELA GARG, SHELLY CHADHA, SUMIT MALHOTRA,
A. K. AGARWAL Department of Community Medicine
Correspondence to SUNEELA GARG; gargsuneela@gmail.com
© The National Medical Journal of India 2009
ABSTRACT
The high burden of deafness globally and in India is largely
preventable and avoidable. According to the 2005 estimates of
WHO, 278 million people have disabling hearing impairment.
The prevalence of deafness in Southeast Asia ranges from 4.6%
to 8.8%. In India, 63 million people (6.3%) suffer from
significant auditory loss. Nationwide disability surveys have
estimated hearing loss to be the second most common cause of
disability. A lack of skilled manpower and human resources
make this problem a huge challenge. The Government of India
has launched the National Programme for Prevention and
Control of Deafness. This article highlights the major components
of the programme with a focus on manpower development and
ear service provision including rehabilitation. Since the
programme is also being implemented at the primary healthcare
level, it envisages a reduction in the burden of deafness and
prevention of future hearing loss in India.
Natl Med J India 2009;22:79–81
SITUATION ANALYSIS OF DEAFNESS IN INDIA
In the process of global epidemiological transition, the economic
burden associated with chronic diseases is on the rise, especially
in low- and middle-income (LAMI) countries.1 Deafness—one
neglected chronic condition—is the most prevalent sensory
disability across nations. According to the 2005 estimates of the
WHO, 278 million people worldwide have disabling hearing
impairment, i.e. moderate-to-profound hearing loss in both ears
(i.e. >41 dB hearing loss).2 Hearing loss is the second most
common cause of years lived with disability (YLD) accounting
for 4.7% of the total YLD. The problem of deafness is dispro-
portionately high in the Southeast Asia region with a prevalence
ranging from 4.6% to 8.8%.3
Population-based surveys in 2003 in India using the WHO
protocol4 estimated the prevalence of hearing impairment to be
6.3% or approximately 63 million people suffering from significant
auditory loss.3 The estimated prevalence of adult onset deafness
in India was found to be 7.6% and childhood onset deafness to be
2%. Earlier during 1977–80, a multicentric collaborative study on
the prevalence and aetiology of hearing impairment was done by
the Indian Council of Medical Research (ICMR) at 4 centres:
Calcutta (Kolkata), Delhi, Madras (Chennai) and Trivandrum
(Thiruvananthapuram) on a total of 11 665 persons in rural areas
and 10 935 in urban areas. The prevalence of hearing impairment
was found to be 10.2%. Severe hearing loss accounted for 24.4%
and mild hearing loss for 15.9%. Overall, rural areas showed a
higher prevalence of hearing loss compared with urban areas.5
The National Sample Survey (NSS) 58th round (2002) surveyed
disability both in urban and rural households and found that
hearing disability was the second most common cause of disability
after locomotor disability.6 Hearing loss accounted for 9% of all
disabilities in the urban and 10% in the rural areas. Depending
upon the extent of a person’s inability to hear properly, the degree
of hearing disability was ascertained. It was estimated that the
number of persons with hearing disability per 100 000 persons
was 291; it was higher in rural (310) compared with urban regions
(236). In the same survey, about 32% of people had profound
(person could not hear at all or could hear only loud sounds) and
39% had severe hearing disability (person could hear only shouted
words). The survey results revealed that about 7% of people were
born with a hearing disability. About 56% and 62% reported the
onset of hearing disability at >60 years of age in the rural and
urban areas, respectively. The incidence of hearing disability in
the past 1 year was reported to be 7 per 100 000 population.6
The magnitude of milder degrees of hearing loss and unilateral
hearing loss would be larger than these estimates for bilateral
hearing loss. The major causes of hearing loss and ear disease in
India have been listed by the WHO survey.3 Ear wax (15.9%) was
the most common cause of reversible hearing loss. Non-infectious
causes such as ageing and presbyacusis are the next most common
causes of auditory impairment in India (10.3%). Middle ear
infections such as chronic suppurative otitis media (5.2%) and
serous otitis media (3%) are other leading causes of hearing loss.
The other causes include dry perforation of tympanic membrane
(0.5%) and bilateral genetic and congenital deafness (0.2%).
The NSS 58th round also enquired about probable causes of
hearing loss in India. In about 25% and 30% cases, for rural and
urban India, respectively, the probable cause was old age. Of the
other reasons, ear discharge and other illnesses were identified as
the cause by a comparatively large proportion of persons with
hearing disability. Also, in the same survey, nearly 1% of hearing
disabled persons reported German measles/rubella as the cause of
hearing disability.
It has been noted by WHO3 that half the causes of deafness are
preventable and about 30%, though not preventable, are treatable
or can be managed with assistive devices. Thus, about 80% of all
deafness can be said to be avoidable. It has also been stated by
WHO3 that there is a shortage of human resources to address
the issue of deafness. The estimated number of ENT specialists
and otologists in India are 7000 and 2000, respectively. The
audiometrist:population ratio was found to be 1:500 000 and
the ratio of speech therapists to the deaf population was 1:200.
There is also a maldistribution of personnel with more people
Medicine and Society
THE NATIONAL MEDICAL JOURNAL OF INDIA VOL. 22, NO. 2, 2009 79
80 THE NATIONAL MEDICAL JOURNAL OF INDIA VOL. 22, NO. 2, 2009
located in urban than rural areas. Human resource analysis revealed
that there is a need to enhance the skills and working capacity of
practising doctors and other personnel.
NATIONAL RESPONSE TO PREVENTION AND
CONTROL OF DEAFNESS
Considering the enormous impact of deafness on the social,
economic and productive life in India due to its burden and also
gaps in human resources to meet this health challenge, primary
healthcare remains the strategy of choice for the provision and
implementation of prevention of deafness and hearing loss in
India. The Government of India initiated the National Programme
for Prevention and Control of Deafness (NPPCD) in 2006. It was
initially started as a pilot project and was implemented in
25 districts in 10 states and 1 union territory. It will be upscaled
to include 203 districts in all states and union territories by the end
of the eleventh 5-year plan (2007–12).
The NPPCD was launched with the long term objective of
reducing the total disease burden of hearing impairment and deafness
by 25% at the end of the eleventh 5-year plan. The programme aims
to cover three levels of prevention and care: primary, secondary and
tertiary ear care by provision of an appropriate response at these
levels. It aims at preventing avoidable hearing loss on account of
disease or injury, identifying early and treating major ear problems,
and medically rehabilitating persons with deafness of all age
groups. It envisages strengthening existing intersectoral linkages
and developing institutional capacity for ear care services. For the
prevention of auditory impairments, it promotes outreach activities
and public awareness through innovative and effective information,
education and communication (IEC) strategies.
The programme has been integrated along with the umbrella
health mission of the Government of India—the National Rural
Health Mission (NRHM)—at the state and district levels. Under
the NPPCD, funds for execution of the programme are given to the
state health society and programme committee of NRHM to carry
out various activities through district health societies. The role of
the state committee is to function as a supervisory and monitoring
authority for smooth conduct of the strategies to prevent and
control deafness.
The district health society and programme committee are
expected to prepare a micro-plan on an ongoing basis and to
operationalize programme components at the district level
through coordination between different agencies and partners—
government, non-government and community members.
MAJOR COMPONENTS OF THE PROGRAMME7
Capacity building and manpower development
Human resource development remains a key component of any
national health programme. The NPPCD through the creation of
trained manpower at multiple levels strengthens the workforce for
efficient and effective delivery of ear care at all levels. Designated
state medical colleges will act as centres of excellence for ear care
interventions in selected districts where the programme is
functional. ENT specialists and audiologists from designated
medical college are assigned the responsibility of providing
technical expertise to the programme in the district. ENT
coordinators at the state medical college impart training to district
ENT surgeons for 5 days under which a reinforcement of hands-
on surgical training in micro-ear procedures pertaining to deafness
is provided. Key procedures that can be performed at the district
level are covered under this training and include myringoplasty,
tympanoplasty, stapedectomy and mastoidectomy. District-level
audiologists/audiometricians are provided a 2-day reorientation
in diagnostic and therapeutic skills. In addition, paediatricians
and obstetricians at the district hospital level and community
health centre level are imparted a day’s training to sensitize them
to various factors responsible for loss of hearing in newborns and
children with special emphasis on antenatal and perinatal care.
Primary healthcare physicians are the key players in the delivery
of public health initiatives in the Indian healthcare delivery system.
The NPPCD involves doctors in primary health centres (PHCs),
school health schemes and those working in various industrial
units in the districts for delivering ear care at the primary care level.
A 2-day training programme is conducted to sensitize these personnel
to their involvement in the NPPCD. Doctors are trained to manage
common ear conditions using standardized guidelines. Similarly,
skills in the use of an otoscope are enhanced and they are exposed
to the surgical and rehabilitation services available in their district
so as to refer patients to the appropriate level of care.
The involvement of grassroots workers, supervisors and
community health volunteers is required to create awareness
among the community about the prevention of hearing loss as well
as to emphasize the need for timely care. The NPPCD sensitizes
men and women multipurpose health workers at the subcentre
level, public health nurses at the PHC, child development project
officers, anganwadi workers (AWW) and their supervisors,
Accredited Social Health Activists (ASHAs) and trained birth
attendants. These workers are expected to play an important role
in facilitating early detection and prevention of hearing loss.
The involvement of community stakeholders is vital for the use
of services planned under the NPPCD. The programme apprises
primary school teachers and parents of hearing/speech impaired
children at the village level about ear care interventions. Teachers
are also trained to provide assistance during the execution of
screening camps organized for schoolchildren.
To fill up the lacunae in audiological services at the district
level, the programme has proposed a post of audiometric assistant
at all districts, to carry out various activities related to deafness
prevention and control. For the acquisition of proper linguistic
and communication skills by a young hearing impaired child, the
programme has proposed a teacher to be trained and inducted for
carrying out hearing and speech rehabilitation of children at the
district level. The feasibility of involving interns who have
finished their graduation in auditory, speech and language
pathology at the All India Institute of Speech and Hearing
impairment (AIISH), Mysore and Ali Yavar Jang National Institute
of Hearing Handicapped (AYJNIHH), Mumbai will be explored
during the implementation of the programme.
EAR SERVICE PROVISION INCLUDING REHABILITATION
Ear health promotion and prevention
To create awareness about hearing and speech problems, grassroots
workers and health personnel will deliver IEC on a continuous basis
to community members. Regular meetings with community-based
organizations such as the gram panchayat, village health committee
and mahila mandals will be conducted to sensitize them about the
importance of early detection of ear problems and hearing loss. The
AWWs and auxiliary nurse midwives (ANMs) will be trained about
the correct posture to feed a baby so as to decrease the incidence of
otitis media due to faulty feeding practices. Emphasis will be placed
on timely referral of children born after a difficult labour or those
who suffered birth asphyxia to screen for loss of hearing. Health
workers will also be trained to assess the speech and hearing of
children visiting immunization clinics and outreach activities.
81
GARG et al. :BURDEN, PREVENTION AND CONTROL OF DEAFNESS IN INDIA
Local, culture-specific innovative strategies will be adopted for
sensitizing community members including school teachers.
Early detection of ear problems and management
House-to-house surveys to ascertain hearing problems in all age
groups will be done by the AWWs and ASHAs, under the supervision
of multipurpose workers and a record of people with deafness will
be maintained. Based on an assessment schedule, school health
doctors will carry out school-level screening of students of primary
classes to identify and manage any diseases/problems related to the
ear. Medical personnel at the primary and secondary level will be
trained so as to provide adequate standardized ear care at these
health facilities. The priority conditions for local management
include middle ear infections and impacted wax. All persons
requiring special diagnostic facilities, complicated cases and those
needing surgical interventions will be referred to the district hospital.
ENT doctors and audiologists at the district level will provide
comprehensive ear care services. District and community health
centre (CHC) level paediatricians and obstetricians trained under
the programme will screen and refer any child born of a high risk
pregnancy or delivery, as well as those children who are exposed to
a high risk factor in infancy. By an assessment of speech milestones,
paediatricians can detect hearing impairment early, apart from
treating common ear problems in children. A standard set of
equipment and medicines will be provided at all levels for ear care
under the NPPCD. Proper referral linkages between different levels
of care will be strengthened for effective delivery of services.
Community screening camps
These will be organized at the PHC/CHC/district level to screen the
population for deafness and hearing impairment. These camps will
also provide an opportunity to increase awareness about the
prevention and control of deafness. These camps will be conducted
by trained personnel along with private practitioners, wherever
feasible. One screening camp will be organized every month at any
healthcare level—PHC/CHC/district hospital by rotation, thus 24
camps will be organized in each district over a period of 2 years. The
camps will be organized by involving key community stakeholders,
panchayat members, mahila mandals and youth leaders. Non-
governmental organizations (NGOs) identified by the district health
society will also facilitate the organization of these camps.
Rehabilitation and hearing aid provision
Patients with complications that require tertiary care will be referred
to state medical colleges. Patients whose complications are not
amenable to medical or surgical correction and who require hearing
aids will be fitted with the same at the district level. This will
primarily include children suffering from bilateral sensorineural
deafness. About 200 hearing aids will be made available in each
district to be fitted to suitable persons. Older persons with
presbyacusis will be provided hearing aids in collaboration with the
Ministry of Social Justice and Empowerment, which provides
rehabilitative services for the elderly. Wherever feasible, suitable
linkages will be developed with community rehabilitation centres
and district disability rehabilitation centres (DDRC) in consultation
with the Rehabilitation Council of India.
Monitoring and supervision
Monitoring tools have been devised for all levels. Indicators have
been developed to supervise the performance of the districts in
deafness prevention and control. Monthly reports are to be
generated citing progress and submitted to higher levels. On-site
evaluations will also be done to provide periodic supportive
supervision. Feedback will be regularly sought from allied
organizations.
OTHER ACTIVITIES UNDER THE PROGRAMME
Supportive activities for other causes of deafness such as noise-
induced hearing loss and congenital deafness require additional
programmatic inputs. The prevention and control of these causes
will be explored and introduced based on the feasibility of
available interventions. A uniform policy for rubella vaccination
under the national immunization programme for congenital
deafness prevention will also be explored. Advocacy regarding
legislation relating to noise and implementation of a hearing
conservation programme will be done. To raise awareness and
accord vital importance to deafness, ‘noise-free days’ and
rashtriya shravan shakti diwas’ will be planned at the national
level. The involvement of preschool teachers through NGOs and
public–private partnership will be attempted. Inclusion of deafness
awareness in textbooks at the primary and secondary school level
through collaboration with the National Council of Educational
Research and Training (NCERT) will be explored. Research for
developing cost-effective, high quality hearing aids within the
country will be promoted. Carrying out community-based studies
will fill epidemiological gaps in data regarding hearing impairment
and deafness. Operational research to improve implementation of
the programme will be conducted at periodic intervals.
CONCLUSION
Integration of primary ear care with primary and district health
systems is likely to yield the most cost-effective solutions. The
strategies included in the NPPCD, if implemented with political
will and strong leadership, will decrease the magnitude of ear
problems and prevent avoidable deafness in India. Networking
and partnerships with different organizations, professionals and
personnel remain critical to the success of the programme. In the
supportive environment facilitated by the launch of NPPCD, it is
imperative to take firm and enthusiastic actions to reduce the
burden of deafness in India.
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... Majority children had congenital deafness (218; 22.66%) followed by cleft lip & palate (212, 22.03%). Our study confirms the findings of several other studies which reported that the prevalence of congenital deafness is more in India and 63 million people suffer from significant auditory loss, due to a lack of skilled manpower and human resources for the management of these defects [11]. The second most common defect was cleft lip & palate. ...
... The prevalence of childhood onset deafness is estimated to be 2%. [1] According to the census of India 2011, among the various identified disability in children, 23% of the children have hearing loss. ...
... In India, 63 million people (6.3%) suffer from significant hearing loss [11]. Comparing the prevalence of disability, found in National Sample Surveys which conducted at different points oftime helps to get the idea about the magnitude of the disability. ...
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