COVID-19 and Audiology

The novel coronavirus (COVID-19) has had an unprecedented effect on the delivery of health care in the United States. Most states instituted public quarantine mandates from March to June 2020, and many health-care practices closed for weeks and, often, for months, delaying or suspending health-care access. Audiology practices and services also were affected, which sparked a debate on whether audiology services were essential.

COVID-19 and Early Hearing Detection and Intervention Programs

Benchmarks

Congenital hearing loss is considered a neurodevelopmental emergency and concerns about services related to newborn hearing screening (NBHS) and follow up were forefront in discussions regarding essential health-care services.

Moats and Creel (2020) presented readers with guidance and resources related to early hearing detection and intervention (EHDI) during these unprecedented times with assurance that NBHS and follow-up services are indeed essential. The American Academy of Pediatrics (AAP) advised pediatricians to continue to follow federal and state guidelines on newborn screenings, including NBHS and follow up (AAP, 2020).

Unfortunately, early guidance from national audiology professional organizations conflicted with state and local government mandates, leading to confusion on which health-care facilities and services were essential. As a result, most audiology facilities and services ceased operation for weeks or months.

The 2000 Joint Commission on Infant Hearing (JCIH) guidelines (2019) describe and mandate each state’s EHDI program to achieve benchmark goals for children at one month of age, three months of age, and six months of age, or 1-3-6. These goals state that infants should undergo NBHS prior to discharge from the hospital, but no later than one month of age. In addition, if the infant does not pass their NBHS, they should receive an audiologic evaluation to confirm hearing status no later than three months of age and enroll in early intervention (EI) services as soon as possible after identification or no later than six months of age.

The Coronavirus Pandemic

Between March and August 2020, approximately 1.8 million infants were born in the United States (CDC, 2020b). Due to the COVID-19 pandemic, NBHS, diagnostic, and EI services were interrupted for infants born from late 2019 to 2021. While audiologists around the globe adjusted their health-care practices to provide services differently and more safely, front-line hospital personnel had to ensure that nearly two million infants received NBHS.

In the early months of 2020, infants who did not pass their NBHS were referred to audiology for diagnostic evaluations or for a second NBHS, as required by established EHDI protocol. As the pandemic progressed, many infants who did not pass their NBHS did not receive a referral for further evaluation because diagnostic audiology services were not available.

“Our colleagues who focus on pediatrics have difficult decisions, such as timing for re-screening of an infant. There is no question that initial diagnosis and intervention will be delayed at this time,” American Academy of Audiology President Catherine Palmer reported in a president’s message published online in April 2020 (Palmer, 2020).

The Survey

To gain insight into NBHS services and the ability to meet the 1-3-6 EHDI goals during the pandemic, an informal survey was sent to pediatric audiologists and EHDI coordinators throughout the country. Six pediatric audiologists and four EHDI directors responded.

Responses were received to the following questions:

  1. For audiologists not directly involved in the EHDI process, what do you think they need to know about the impact of COVID-19 on the screening, diagnostic evaluations, and early intervention for children born during this time? How might they be affected?  
  2. Specifically, how do you think COVID-19 is affecting the EHDI goals of 1-3-6? This can be your opinion or, if you have data, please share. You may also report here any anecdotal observations.
  3. Do you have any suggestions to provide to audiologists to help reduce the impact of COVID-19 for children going through the 1-3-6 process? 

A summary of the responses follows.

One Month of Age Illustration
By One Month of Age
All infants should undergo hearing screening prior to discharge from the birth hospital and no later than one month of age, using physiologic measures with objective determination of outcome (JCIH, 2019).

The Centers for Disease Control and Prevention (CDC) collects and analyzes state-level EHDI data annually to monitor the goals of 1-3-6 in the United States. In 2018, the CDC (2020d) reported that 97 percent of infants born in the United States received their NBHS by one month of age. Similar results are expected for 2019, but percentages for 2020 may be negatively affected by the COVID-19 pandemic.

While home births in the United States typically account for less than one percent of births in the nation (ACOG, 2020), this number has been rising and is expected to rise even more as women avoid giving birth in a hospital during the COVID-19 pandemic (Ayres-Brown, 2020; Ries, 2020). Many pregnant women and their families worry that they or their infants will contract COVID-19 in the hospital. Others consider home birth because of hospital restrictions on the number of support people permitted to accompany pregnant women during the birth of a baby.

Although data are limited, most newborns with COVID-19 had mild or no symptoms and recovered (CDC, 2020e). Yet the number of women seeking birth options outside of the traditional hospital setting continues to rise. There is an overwhelming increase in demand for midwives who can deliver infants at home or in facilities that are not part of the traditional health-care system (de Freytas-Tamura, 2020).

There are no statistics documenting home births and births outside of hospitals in this time period, but there has been a marked reduction in the number of babies born in hospitals. It is reasonable to conclude that these infants did not receive their NBHS, or in the best-case scenario, received it later than the recommended one month of age.

Another issue is an increase in the number of infants who did not pass their NBHS, likely due to infant discharge sooner than 24 hours (per parent or birthing facility request) to reduce exposure to COVID-19. Early discharges may result in infants not being able to receive the second confirmatory NBHS with normal results.

Three Months of Age Illustration
By Three Months of Age
All infants whose initial birth-screen and any subsequent rescreening warrant additional testing should have appropriate audiologic evaluation to confirm the infant’s hearing status no later than three months of age (JCIH, 2019).

According to CDC 2018 data, 68 percent of infants who did not pass their NBHS received a diagnostic evaluation by three months of age (CDC, 2020c). Data for most of 2019 are not yet available, but it is reasonable to assume that the percentage will be similar or higher. For infants born in late 2019 or in 2020, a different story emerges.

Since the COVID-19 pandemic began, EHDI programs and pediatric audiologists report a reduction in the number of infants who failed NBHS receiving their diagnostic evaluation by three months of age. This includes infants born in late 2019 and those born within approximately the first six months of 2020.

This issue has been addressed by most state EHDI programs with published online guidance for health-care professionals and parents. The National Center for Hearing Assessment and Management (NCHAM) has many resources for hearing screeners, parents, early interventionists, and audiologists to guide them during these times.

The NBHS training curriculum was modified in the early months of COVID-19 to include more information for parents whose infant did not pass the NBHS. The following language was included: “We just finished screening your infant’s hearing and your infant did not pass. Our hospital knows that hearing screening is a very important part of monitoring the health of every newborn. Due to the current COVID-19 situation and our hospital’s directive, we are unable to schedule an outpatient hearing screening today. Please share this with your infant’s health-care provider…As soon as restrictions have been removed, you will be contacted about scheduling an appointment for follow-up testing” (NCHAM, 2020).

In the spring of 2020, clinic closures, limited providers, and canceled appointments resulted in decreased availability of diagnostic testing for infants who did not pass their NBHS. Survey responses supported these findings, with 70 percent of respondents reporting that diagnostic infant evaluations for babies not passing their NBHS were delayed due to clinic closures, the rescheduling of patients who were originally scheduled before closures, and concern about the virus from parents who did not want to reschedule, no-showed, or cancelled even after being rescheduled.

Six Months of Age Illustration
By Six Months of Age
Early intervention services should be offered through an approach that reflects the family’s preferences and goals for their child and should begin as soon as possible after diagnosis, but no later than six months of age, and require a signed Part C of IDEA (Individuals with Disabilities Education Act, 2004) Individualized Family Service Plan (JCIH, 2019).

In 2018, the CDC reported that 64 percent of infants identified as d/Deaf or hard of hearing were enrolled in EI by six months of age (CDC, 2020d). The 2019 data is not yet available, but we do know that, over the past decade, this number has improved steadily. Speculation on the data for 2020 must take into consideration the delays the COVID-19 pandemic has caused for infants receiving confirmatory audiological identification and, subsequently, the timeliness of EI services.

Once identified as d/Deaf or hard of hearing, infants and young children should receive services by professionals who are experienced in working with children who are d/Deaf or hard of hearing and their families.

Traditionally, EI evaluations and ongoing services are conducted in face-to-face appointments in the child’s home. Due to the COVID-19 pandemic, most evaluations and EI services are now delivered remotely via telehealth.

Telehealth is a new type of service provision for many early interventionists and patients (ASHA, 2020). The transition to virtual services will likely have an effect on infants and young children identified as d/Deaf or hard of hearing. Yet we know EI services must continue, even during a pandemic. Family-to-family support and the continuation of EI for children identified as d/Deaf or hard of hearing is critical (Yoshinaga-Itano, 2020).

There are many resources for families, including ways to find support from other families, and telehealth can be very effective. However, as with many other health-care services, such as educational systems, the effects of going virtual and the inability to receive in-person services are yet to be seen.

EI enrollment delays will be a natural result of the diagnostic delays. These delays and lack of in-person therapeutic services for children will likely impact developmental outcomes for children who are d/Deaf or hard of hearing.

The ‘Catch-Up’ Phase

Beginning in June 2020, many audiology services resumed and there has since been a significant “catch-up” phase, with infants who were referred for diagnostic evaluations being seen in large numbers. Many pediatric audiology offices are prioritizing appointments for infants who failed their NBHS and even working overtime to minimize the effects of the COVID-19 pandemic on 1-3-6 results. Unfortunately, however, many infants have not yet been seen, possibly due to continuing fears of the virus.

Eighty percent of the survey respondents recommended two or more suggestions for audiologists, such as: Improve communication with families regarding the importance of follow-up testing; answer questions more completely; if possible, provide telehealth; prioritize appointments for infants/children for initial diagnostic testing or hearing aid fittings; and share the safety precautions of your practice with families to improve their confidence in coming to appointments.

It may be years before we can confirm how the COVID-19 pandemic affected the early identification of children who are d/Deaf or hard-of-hearing. What we do know is that children whose hearing losses are identified earlier demonstrate significantly better language scores than children whose hearing losses are identified later (Yoshinaga-Itano, 1998).

Finally, there will be a significant increase in the number of children considered lost to follow up (LTFU) to EHDI programs due to the pandemic. Infants not receiving their NBHS, infants identified by a professional not familiar with EHDI reporting procedures, infants who never received a diagnostic evaluation, or infants or young children identified early in 2020 but who could not obtain EI will all contribute to the increase in LTFU.

Wherever in the 1-3-6 process a child may have been lost is not as relevant as the inability of EHDI programs to contact families to ensure services are available and received to maximize a child’s development.

Conclusions

Do not assume that children born in 2019 and 2020 received an NBHS.

Infants who did not pass the NBHS may not have received diagnostic audiology testing.

For the next two years, all audiologists should be aware of the potential effect of the COVID-19 pandemic on NBHS and be diligent in asking specific questions about screening, diagnostic testing, and developmental milestones on the children they serve.

If a child did not pass a newborn hearing screening and has not had diagnostic audiology testing, provide that testing or refer to a pediatric audiologist. Refer to the state EI program if speech, language, or hearing delays are reported.

The deleterious effects of late identification and intervention for children who are d/Deaf or hard of hearing are well known. Unfortunately, some children who are d/Deaf or hard of hearing who were born shortly before and during the COVID-19 pandemic may experience the delays of early identification and intervention.

While EHDI programs, audiologists, and birthing hospital health-care providers continue to work to ensure infants receive NBHS and follow-up services, all audiologists have an increased responsibility to be aware of the potential impact the COVID-19 pandemic has had on hearing screening for these children.

Audiologists have a responsibility to educate and provide resources for patients and their families, other health-care providers, and their communities to improve care and minimize the impact the pandemic has had on children born during this time.