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Hear and now: Chinese Health in NZ

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1 Hear and now: Chinese Health in NZ
Michelle Wong ENT Surgeon, ADHB

2 Population statistics
2013 Census: 4.24 Million Kiwis 170,667 Chinese Life Expectancy born today (non-Maori): Males 80 years Females 84 years Life Expectancy of 65 year-old (non-Maori): Males 84 years Females 86.5 years

3 Population by Age 2013 0-25 years 40-55 years

4 Chinese Population by age 2013
Median age chinese: 31 vs 38 of kiwis Huge 20-35 Smaller 45-60 So in next years ( my working life) See a shift in this graph: Huge number baby makers year olds Aging population years olds increase.

5 Chinese HEARING Health in NZ
Population of baby boomers and elderly on the increase Newborn Hearing Screen Increasing Migrant population from China Bilingual: hearing and tonal languages

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7 UNHS around the World United States
Screening > 3.5 million babies per year. United Kingdom Screening 600,000/yr by March 2005 Australia Screening >100,000 babies per year

8 In New Zealand 135- 170 children / year ( 3/1000 births) with PCHI
Identification ( 2003): Average age 3-4 years Maori 80% by 80 months age ( 6.7 years) Others 80% by 60 months age ( 5 years) About 7 Chinese kids

9 Evidence for the importance of early identification of hearing loss
Critical period= first 6 months of life

10 Vocabulary Range at 3 years of age: Normal hearing
700+ words

11 Vocabulary Range at 3 years of age: Identified at birth
350 words

12 Vocabulary Range at 3 years of age: Identified at 6 months
200 words

13 Vocabulary Range at 3 years of age: Identified at 2 years
Begin pre-school with less than 50 words in their vocabulary.

14 Mean language quotient by age of identification
Even when picked up in the first 12mths they don’t do significantly better. It is not until intervention begins in the first 6mths there is a significant improvement. Mean language quotient by age of identification From:Yoshinago-Itano et al (1998)

15 HIEDI 2001 Hearing Impairment, Early Detection and Intervention formed in NZ 2006 government announces national funding for Newborn Screening program NZ 1 July 2007 rolled out over 3 years 20 DHBs Self governance

16 UNHSEIP- aims: 1. Babies to be screened by 1 month age
2. Audiology assessment completed by 3 months age 3. Initiation of appropriate medical and audiological services and Early Intervention education services, by 6 months of age

17 How do you screen for a baby’s hearing?

18 Infant diagnostic test battery
Tympanometry Otoacoustic Emissions (OAE’s) Auditory Brainstem Response ( ABR)

19 (Distortion Product) Otoacoustic emissions ( DPOAE)

20 Otoacoustic Emissions (OAE’s)
Debris in the ear canal. Fluid behind the eardrum. Click stimulus Pass Result Within the cochlear The “emission” from the Outer Hair Cell travels out the ear & is picked up by the probe. Outer Hair Cells OAE testing probe placed in the ear canal Outer hair cells contract in response to the sound. Fluid & debris can block the stimulus getting in AND block the response coming out = Higher Refer rates.

21 DPOAE’s The most prominent emission is “2F1- F2”
If F1=1000Hz.and F2=1200Hz., then 2F1-F2=2(1000)-1200=800Hz.)

22 (Automated) Auditory Brainstem Response, AABR

23 Automated Auditory Brainstem Response (AABR)
BUT This doesn’t occur as much as with OAE because the recording is not being made back through the ear canal. If built up enough fluid & debris can still increase the refer rate because it blocks the sound getting into the ear. Auditory Brainstem Response (ABR) AABR screening tests the response of the hearing nerve & brainstem. AABR tests beyond both the Inner & Outer hair cells.

24 Automated Auditory Brainstem Response (AABR)
PASS result AABR Template built into the screener (statistical rather than an actual waveform) 35dB

25 AABR – What happens with a restless baby?
Refer result The sensors pick up the muscle movement, which are much larger than the ABR response. This distorts the waveform & it can’t match up to the template/black box algorithm. 35dB

26 1. Exclusion criteria – Age range:
<34 weeks or greater than 6mths old. 6 months old: A baby > 6mths old has a more mature brain & faster response, which the template is NOT designed for. < 34 weeks gestation A baby <34 weeks has a less mature Brain and more delayed response which the sample is not designed for. Normal AABR template for 34 weeks to 6mths of age.

27 New Zealand’s testing protocol

28 That’s it – no national data collection – not even city
That’s it – no national data collection – not even city. Each DHB collects their own ….. 1.6/1000

29 The incident July 2012 – ADHB lead screener told by parents of a baby she was about to screen that the baby had already been screened, but was not recorded. One report from UK Jan 2012; screener testing their own ears Looked at that screener’s prior screens and revealed unusual patters Excessive long or too short times screening between the ears Reduced rate of 2nd referral from DPOAE to AABR One ear of the baby screened twice, sometimes the screener’s own ear. Interesting report from UK in Jan 2012. Sparked an investigation in ADHB and other local DHB’s.

30 ADHB Audit of screener: 1 July 2011- 11 July 2012
1044 babies screened by screener 145 babies had screening in one ear twice 183 babies had screening in one ear with one ear of screener 103 babies who had results recorded from the screener recording her own ear results Over 40% babies in the last year had “issues” Escalated up to National Screening unit and Ministry of health. Hutt Valley also identified irregularity in their rountine screening data. August 2 months after first identification – all DHBs to audit their screeners.

31 Hutt Valley, had missed this little baby Addison who was implanted at 12 months.
Ideally 6 months – NZ youngest at just over 5 months

32 Cochlear implants Chinese Kid

33 Some facts about China Universal Newborn Hearing Screening (UNHS) has been implemented in China since 1999. By 2010 UNHS was implemented in 20 of the 32 Chinese provinces. In large cities 95% of babies are screened in hospital-based programs. In more remote areas babies with high-risk factors for hearing loss are referred to screening centres within 1 month of birth and leaflets about identifying deafness are distributed.

34 Some facts about China and CI
Since 1995 more than 10 000 people in China have received cochlear implants (CIs) 85% of these implant recipients have been children under the age of 7 years CI penetration in China is currently less than 5% of potential pediatric candidates, Cochlear implantation is continuing to expand at great speed, and it is hoped that the infrastructure and capacity will continue to grow and develop.

35 Some numbers of interest
1990: 6 million ‘totally deaf people’1 2008: 21 million people with hearing loss 2 2000: WHO estimated prevalence of hearing loss3 Childhood onset: 0.12% (hearing threshold in better ear is dB HL) Childhood onset: 0.1% (hearing threshold in better ear Is >81 dB HL) Adult onset: 1.3% (hearing threshold in better ear is dB HL) Adult onset: 0.3% (hearing threshold in better ear is >81 dB HL) ~24.5 million people with a severe to profound hearing loss in China Here is some statistics on hearing loss in China: Back in 1990, an official survey reported 6 million totally deaf people in China. In 2008, an article on Universal Hearing Health Care in China reported that ‘approximately 21 million have hearing loss although the actual number is probably higher’. Slightly more recently, a report from WHO in 2000 estimated prevalence of hearing loss for China. For childhood onset hearing loss at ages 15-19, where the hearing threshold level in the better ear was dB HL (averaged over 0.5, 1,2, 4kHz – so a severe hearing loss in the better ear), the prevalence was 0.12% - this would equate to over 1.6 million people with a severe loss (in the better ear) for the current population of China. Where the hearing threshold level in the better ear was 81 or more dB HL (averaged over 0.5, 1,2, 4kHz – so a more profound hearing loss), the prevalence was estimated at 0.1% so this would be over 1.3 million people with childhood onset hearing loss with today’s population. This same report also reported estimated adult onset prevalence data for hearing loss with 1.3% prevalence estimated where the hearing threshold level in the better ear was dB HL – this would be in excess of 17.6 million people by today’s population numbers. A prevalence of 0.3% was estimated where hearing threshold levels in the better ear were over 81dB HL so over 4 million people. So that is a total of over 24.5 million people with hearing loss – that is more is than the entire population of Australia or North Korea of people who could benefit from a Cochlear Implant.

36 Tonal languages ~ 88 languages in the world have ‘complex’ tone system (more than 3 tones) – shown in red dots Examples include: Mandarin (e.g. China, Taiwan, Singapore) Cantonese (HK) Thai Swedish

37 Six lexical-tones of / wɐi /, Cantonese
威 (smart) Tone 2 委 (appoint) Tone 3 餵 (feed) Fundamental Frequency (F0) Tone 4 圍 (surround) Tone 5 偉 (huge) Tone 6 胃 (stomach) This is a diagram showing the pitch patterns of the 6 lexical-tones of Cantonese used in everyday Cantonese – Cantonese actually has more than 6 tones! X-axis is time Y-axis is the fundamental frequency, which is the no of vocal fold vibrations per second Let’s hear the six tones. These pitch patterns are all within a range of 60Hz Subtle changes in the pitch pattern (F0 and its harmonics) can lead to complete change in meanings Male If you are a native Cantonese-speaker, to be able to discriminate the 6 lexical tones is an easy task. Where are the non-native Cantonese-speakers in the room, can I have a show of hands? Does any of you find this easy? Don’t worry, you are not alone, many hearing-impaired listeners share this same problem. ============= High level, High rising, Mid level, Low falling, Low rising and Low level 威風,委派,餵飯,圍牆,偉大,胃痛 Time

38 Six lexical-tones of / wɐi /, Cantonese
威 (smart) Tone 2 委 (appoint) Tone 3 餵 (feed) Fundamental Frequency (F0) Tone 4 圍 (surround) Tone 5 偉 (huge) Tone 6 胃 (stomach) This is a diagram showing the pitch patterns of the 6 lexical-tones of Cantonese used in everyday Cantonese – Cantonese actually has more than 6 tones! X-axis is time Y-axis is the fundamental frequency, which is the no of vocal fold vibrations per second Let’s hear the six tones. These pitch patterns are all within a range of 60Hz Subtle changes in the pitch pattern (F0 and its harmonics) can lead to complete change in meanings Male If you are a native Cantonese-speaker, to be able to discriminate the 6 lexical tones is an easy task. Where are the non-native Cantonese-speakers in the room, can I have a show of hands? Does any of you find this easy? Don’t worry, you are not alone, many hearing-impaired listeners share this same problem. ============= High level, High rising, Mid level, Low falling, Low rising and Low level 威風,委派,餵飯,圍牆,偉大,胃痛 Time

39 4 lexicial tones /ma/, Mandarin
F mother hemp horse to scold H R L This slide shows a similar representation for the 4 tones used in Mandarin for the word ‘ma’. Xu, Y. (1997). Journal of Phonetics 25,

40 Outcomes with CI Two large scale outcomes studies in China – still ongoing The preliminary data from the studies indicate that the performance of Mandarin-speaking CI children is comparable to that of US children with CIs. Although the results of studies on CI outcomes of Mandarin-speaking children showed variable outcomes, it is evident that the majority of children benefited from CI intervention. It is generally accepted that recipient outcomes are the most important measure of a CI program. However, objective tests that document outcomes remain scarce in China. Without standardized objective tests, the prescription of effective corrective actions cannot be implemented. China is in the early stages of responding to this challenge. The development of assessment tools opens a new dimension on outcomes research for CI children recipients in China, for example the Mandarin Early Speech Perception Test, a pediatric test battery with a structure paralleling the English ESP, and Mandarin Pediatric Lexical Tone and Disyllabic Word Picture Identification Test in Noise. There are currently two large-scale ongoing outcomes studies on CI outcomes in China: A multi-center pediatric longitudinal study. Four CI clinics are investigating the effect of age of implantation on auditory perception and speech recognition performance for Mandarin-speaking CI children. Comparisons are made between the auditory perception and speech recognition performance of CI children and the normal hearing population. A joint study with the House Ear Institute in the USA and West China Hospital in Chengdu, China. This 4-year study will evaluate the development of speech and language abilities in 120 children who received a CI before the age of 5 years. This research will identify key factors in the early development of speech and language abilities of normal hearing children and compare such factors to those observed in profoundly hearing-impaired children who use CIs and/or hearing aids

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42 11 adults ( 21-50 years), normal hearing
Investigation of cortical and subcortical plasticity following short-term unilateral auditory deprivation in normal hearing adults 11 adults ( years), normal hearing Left custom-fitted silicone plug for 7 days ( equivalent to a mild high freq hearing loss) fMRI 3.0T was performed just after plug inserted and 7 days later; stimulus was a noise burst to evoke cortical activity Late 2013 HL about 30dB at 3 and 4kHz

43 Hearing loss in the elderly

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