April - June 2003: Universal Newborn Hearing Screening in Poland

1.  Introduction

       Hearing screening in newborns and infants was first performed in Poland in the 60's. During these years hearing tests were performed in infants and toddlers, using mainly behavioral techniques and in a few hospitals rather in a broad scale. In the 90's the tests were conducted under the supervision of the Institute of Pathology and Physiology of Hearing within a context of a governmental project. Selected clinics and hospitals participated in that project, using different screening models (high risk groups or universal), different protocols and techniques (OAE-AABR, AABR-AABR). Despite these efforts the implementation of a large-scale hearing screening in newborns was not realistic. There are approximately 380,000 children born a year in Poland nowadays. If we assume a 3:1000 prevalence of binaural sensorineural hearing loss then we can expect to have approximately 1200 hearing impaired newborns each year.

        The possibility of implementing a universal newborn hearing screening in Poland appeared in 2001 with the initiative of "The Great Orchestra of Christmas Charity" Foundation.

       The Foundation was established in 1993 and in 2001 its members, decided to collect money for a newborn hearing screening project. The result was very successful more than 6 million dollars were collected on the 7th of January, 2001.

        A team of experts was put together having as members neonatologists, otolaryngologists, audiologists, speech-therapists and engineers. All the members worked on a voluntary basis. Their task was (1) to elaborate the details and the implementation of a national universal newborn hearing screening program, which would be based on the general guidelines published previously (European Consensus, 1998; Joint Committee on Infants Hearing Position Statement, 2000) and (2) take into account specific, local conditions. International experts such as Dr. Ferdinado Grandori (Italy), and Dr. Karl White (USA) contributed as consultants to the project.

The team of experts set the following program goals

1. Every newborn will be offered a hearing screening test in a neonatology department. The newborns which are not tested (for a variety of reasons) will be offered a hearing test in audiology departments.

2. Every child who will not pass the hearing test will be referred to an audiology department. Full diagnosis will be completed by the end of third month of life.

3. Every infant with confirmed hearing loss will receive appropriate intervention by the sixth month of life.

4. Infants with late on-set, progressive or acquired hearing loss will be diagnosed and receive appropriate intervention as soon as possible.

5. A computerized system that would maintain current information on hearing screening and any eventual follow-ups would be created. In this context, the safety of data could be guarantied.

6. A surveillance and a evaluation system would be created to assure that contact with infants who need intervention could be continuous and the quality of the program could be systematically improved.


Different local conditions were considered in connection to the program's goals, among others:

· The Time of newborns' discharge from the participating hospitals.

· Any previous neonatal staff's experience in hearing screening.

· How the tasks related to screening could affect the work organization in the various neonatology departments

· The Costs of medical equipment required for both neonatology and audiology departments.

· The Costs of the program's implementation and any additional running costs.

        Till 2001, babies were screened in many hospitals by the staff of the audiology depts, therefore only 17 out of 441 neonatology departments declared that their staff performed hearing screening on their own before. Taking this factor into consideration, the group of experts decided that the Polish program would be based on a two-stage OAE screening protocol. In order to avoid missing infants with late on-set hearing loss and auditory neuropathy, which is observed mainly in the high risk neonatal group, every infant with risk factors confirmed, would be referred to further observation despite the outcome of the screening result. The precise period of follow-up depended on the total number and type of risk factors.

         The Foundation bought screening devices for all neonatology departments (EroScan, by Maico), and diagnostic devices, which supplemented actual equipment of the audiology departments. The testing was conducted with computer terminals, which enable data acquisition and transmission to the central server, where all data is stored in the main database.

        A variety of informational printed material was prepared: instructions for the personnel conducting the screening, questionnaires, and brochures for parents. All printing-costs were covered by the Foundation.

        At the end of May 2002 a pilot program in 36 neonatal departments started. The aim of this pilot study was to check the efficiency of the personnel training, the proper data flow and the identification of any problems that might occur during the program. Based on this pilot project, a two stages training program for approximately 2000 nurses and doctors started in the autumn of 2002. By the end of November 2002 all neonatal and audiological departments joined the national UNHS program.


2. Model and protocol


       The UNHS is conducted in public hospitals (441), but a number of private hospitals is expected to join soon.

        In Poland, newborns are typically released after 48 hours. Every child is offered the hearing test before discharge from the neonatology department. Mothers are informed about hearing loss and its consequences. They receive full information about the screening methodology and any additional services. Although there is no obligatory legislation related to newborn hearing screening until now, almost 100% of born babies are screened.

        The hearing screening result is reported in each child's "Health Book". Newborns who do not need follow-up receive a "blue" information, while the referred cases receive the "yellow" information.

        Every parent, regardless of the screening result, receives a brochure that provides general guidelines for the expected baby's reactions to sound and the baby's speech development at various developmental milestones.

         Babies with at least one ear REFERRED and/or with confirmed hearing-loss risk factors are referred to 53 audiological departments.

         Those infants with confirmed hearing loss are referred to one of nine audiological centers, where an early intervention program is introduced. The rehabilitation is carried to the center which is closer to the residential area of the child.

3. Data Tracking and Surveillance System

       All data is registered both electronically and on paper. Due to the lack of common transmission and connection solutions among the participating hospitals and the issue of data security, a unique data transmission system was elaborated. The computer terminals are equipped with GSM (GPRS) modems communicating in a separate, dedicated network. The team of computer scientists monitors the proper system performance and upgrades the software according to newly develop requirements. The medical coordinator in the "The Children's Memorial Health Institute" (in Warsaw) supervises the entire system. A data analysis and reporting system was also created, in order to follow the progress made by each child at any level of the program.

4. Current outcomes

         From the beginning of the program 120,000 newborns were tested, which corresponds to an the average rate of 1500 daily hearing tests country-wise. Due to the positive results of hearing screening, less than 7% of newborns were referred to audiological departments, out of which 60% failed in only one ear. Children with risk factors account for less than 5% of the population, however about 70% of them resulted as PASS. As a result 11% of all newborns were referred to the second level centers. The number of children referred to next level constantly decreases. No important problems, associated with the follow up visits, have occurred so far.


5. Actual problems

         Although the program is not supervised by the government, the screening tests are now free of charge. All the running costs (except for the staff) are covered by the foundation and the personnel of the participating clinics conducts the tests as a part of their daily routine, without getting any additional payment. The audiological diagnosis costs are covered by the state, but unless some law regulations are settled, they might be insufficient for 2003. An emerging problem is the reimbursement for the hearing aid costs. The present system (partial reimbursement from different sources, relatively long time needed for administrative tasks) makes it difficult to obtain hearing aids before turning 6 months of age. So far all the children with confirmed hearing loss were equipped with hearing aids. The Foundation has undertaken certain actions to provide such a possibility to each newborn with detected hearing loss. The newborns' rehabilitation takes place basing on already existing speech therapy centers. Certain actions were undertaken in order to build up new network of centers specializing in newborn rehabilitation, which would be supervised by 16 local coordinators (one per district) and the general coordinator. The first workshops for speech therapists were organized. The work on including rehabilitation centers into the database system have already begun and the team of experts has considered advantageous that these centers should also be equipped with computer terminals running customized software.