1Dr. Kulrajat Bhasin

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PLAN OF PRESENTATION

• Causes of hearing impairment• Grades of hearing impairment• Impact of hearing impairment• Foundation for NPPCD• Burden statement of hearing impairment in India• Evolution of NPPCD• NPPCD• Situation review of ear and hearing care services in India• The way ahead: Proposals in 12th five year plan• Summary

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FETAL LIFE/EARLY NEONATAL LIFE

1. Rubella

2. Syphilis

3. Intake of Chloroquine during pregnancy

4. Prematurity

5. Neonatal jaundice

CAUSES OF HEARING IMPAIRMENT

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Grade Audiometric ISO value Impairment description(mean of 500, 1000,

2000, 4000 Hz)

a) 0 (no impairment) 25 dBHL or less (better ear) No or very slight problems. Able to hear whispers

b) 1 (Slight impairment) 26-40 dBHL (better ear) Able to hear and repeat words spoken in normal voice at 1 metre

c) 2 (Moderate impairment) 41-60 dBHL (better ear) Able to hear and repeat words using raised voice at 1 metre

d) 3 (severe impairment) 61-80 dBHL (better ear) Able to hear some words when shouted in better ear

e) 4 (Profound impairment) 81 dBHL or greater (better ear) Unable to hear and understand even shouted voice

GRADES OF HEARING IMPAIRMENT

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INDIAN SCENARIO

• “Person with Disability” means a person suffering from not less than 40% of any disability certified by a medical authority.

• “Hearing Impairment” as defined in the Act means loss of 60 dB or more in the better ear in the conventional range of frequencies.

Category Type of impairment dB Level Speech discrimination % of impairment

I Mild 26-40 80-100% <40%

II Moderate 41-55 50-80% 40-50%

III Severe 56-70 40-50% 50-75%

IV a. Total deafness No hearing No discrimination 100%

b. Near Total 91 and above no discrimination 100%

c. Profound 71-90 <40% 75-100%

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• The WHO definition of ‘deafness’ refers to the complete loss of hearing ability in one or two ears. The cases included in this category will be those having hearing loss more than 90 decibels in the better ear (profound impairment) or total loss of hearing in both the ears.

• The WHO definition of ‘hearing impairment’ refers to both complete and partial loss of the ability to hear (grades 2, 3 and 4).

• In India, by RCI Act, 1992, "hearing handicap" is defined as hearing impairment of 70 decibels and above, in better ear or total loss of hearing in both ears.

• A person with hearing levels of 61 to 70 decibels, (although suffering from severe hearing impairment, as per WHO classification), is automatically excluded in the hearing handicapped category.

DEFINITIONS

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• Persons with Disability Act,1995 states that ‘hearing impairment’ is a disability and a "person with disability" means a person suffering from not less than forty per cent of any disability as certified by a medical authority.

• In addition, in its Section 2(l), “hearing disability” has been redefined as – “a hearing disabled person is one who has the hearing loss of 60 decibels or more in the better ear for conversational range of frequencies”.

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1. Cost to the health departments for treatment of ear disease

2. Low levels of education if families with hearing impaired children cannot afford education or are not offered education

3. Loss of income if HI people do not find work

4. Cost of support to families

5. Social isolation and stigmatism of patient

IMPACT OF HEARING IMPAIRMENT AND EAR DISEASE

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• An inter-country consultation on Prevention of Deafness and Hearing Impairment was held in Colombo, Sri Lanka from 17 to 20 Dec 2002.

• 9 countries, 5 INGOs participated in the consultation.

• India, Nepal, Sri Lanka, Thailand, Bangladesh, Indonesia, Bhutan, Maldives and Myanmar

OBJECTIVES

1. To review the situation of Deafness and Hearing Impairment in each member country of the SEA Region;

2. To share experiences on successes and constraints in different countries;

3. To identify key actions relating to prevention of deafness and hearing impairment to formulate strategic responses to the problem in SEA.

FOUNDATION FOR NPPCD

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MAJOR OUTCOMES (Guidelines)

1. A national policy for prevention and control of deafness is needed in all countries. This should take into account the existing situation and available resources.

2. The policy should have special focus on providing services at the primary level in underserved areas, give attention to the secondary (mid) level for referral, and appropriately strengthen tertiary care.

3. Control of ear infection should be the major goal in the initial years, beside early detection, intervention and management of hearing impairment (URTI in children).

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4. The policy should promote production and distribution of low-cost, good quality hearing aids.

5. The policy should encourage creation of awareness among public, physicians, paediatricians, obstetricians, pharmacists, paramedics, and school teachers about ear infections and related risk factors for hearing disorders.

6. Policies should be formulated for conservation of hearing through legislation and enforcement of laws for noise control (industrial noise, entertainment centres).

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7. Programmes for prevention and control of deafness should be built around existing health infrastructure.

8. While developing policies, emphasis should be placed on rapid development of all categories of human resources within the framework of a team approach (hearing and speech personnel and teachers for the deaf).

9. Priorities for diseases control in the Member Countries were identified on the basis of burden of disease, feasibility of implementation and availability of resources.

Priority conditions: Middle ear infections

Congenital deafness

Ear wax

Presbycusis

Ototoxicity

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• In 2003, using WHO protocol, prevalence of hearing impairment in India was estimated to be 6.3% or approximately 63 million people suffering from significant auditory loss.

• The estimated prevalence of adult onset deafness in India was found to be 7.6% and childhood onset deafness to be 2%.

BURDEN STATEMENT OF HEARING IMPAIRMENT IN INDIA

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• 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.

• Hearing loss accounted for 9% of all disabilities in urban and 10% in rural areas. The number of persons with hearing disability per 1,00,000 persons was 291; higher in rural (310) compared with urban regions (236).

• Of these, 32% had profound and 39% had severe hearing disability, 7% were born with hearing disability, and about 56% and 62% reported onset of hearing disability at age >60 years in rural and urban areas, respectively.

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• Common causes (WHO survey): Ear wax (15.9%), presbycusis (10.3%), middle ear infections such as chronic suppurative otitis media (5.2%) and serous otitis media (3%), dry perforation of tympanic membrane (0.5%), and bilateral genetic and congenital deafness (0.2%).

• Common causes (The NSS 58th round): 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.

Hearing loss is the second most common cause of years lived with disability (YLD) accounting for 4.7% of the total YLD.

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A National Committee for Prevention and Control of Deafness was formed under the Chairmanship of the DGHS. It developed the framework for NPPCD.

The various activities of this committee include:

1. Development of detailed programme implementation guidelines

2. Development of suitable awareness material such as posters, flip charts, audio clips, television clips

3. Adaptation of WHO training manuals for purpose of trainings of manpower in India

4. Development, standardization and circulation of training presentations for use under the programme

EVOLUTION OF NPPCD

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5. Development and field testing of protocol for school screening activities

6. Development of guidelines regarding hearing aid fitting under the programme.

7. Development of guidelines regarding community based screening camps under the programme

8. Development of guidelines for infant hearing screening in the country

9. State of art literature review and developing recommendations regarding rubella vaccination in the country

10. Monitoring of the programme

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The Government of India initiated the National Programme for Prevention and Control of Deafness (NPPCD) in August 2006.

• It was initially started as a pilot project and was implemented in 25 districts in 10 states and 1 union territory.

• Assam, Andhra Pradesh, Chandigarh, New Delhi, Gujarat, Karnataka, Manipur, Sikkim, Tamil Nadu, Uttaranchal, Uttar Pradesh.

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• The expansion was proposed in a phased manner, with inclusion of 45 new districts each year, and at the end of the 11th FYP, it was proposed to cover 50% of the districts in all the pilot states (except UP) and 25% of the districts in all the other states/UTs.

• It has been up-scaled to include 203 districts in all states and union territories at the end of the 11th FYP (2007–12).

• The programme has been integrated within the National Rural Health Mission at the state and district levels.

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• 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 on-going basis and to operationalize programme components at the district level through coordination between different agencies and partners - government, non-government and community members.

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LONG TERM OBJECTIVE OF THE PROGRAMME

To prevent and control major causes of hearing impairment and deafness, so as to reduce the total disease burden by 25% of the existing burden by the end of eleventh five year plan.

NATIONAL PROGRAMME FOR PREVENTION AND CONTROL OF DEAFNESS (NPPCD)

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OBJECTIVES OF THE PROGRAMME

1. To prevent the avoidable hearing loss on account of disease or injury.

2. Early identification, diagnosis and treatment of ear problems responsible for hearing loss and deafness.

3. To medically rehabilitate persons of all age groups, suffering with deafness.

4. To strengthen the existing inter-sectorial linkages for continuity of the rehabilitation programme, for persons with deafness.

5. To develop institutional capacity for ear care services by providing support for equipment and material and training personnel.

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COMPONENTS OF THE PROGRAMME

1. Manpower training and development

For prevention, early identification and management of hearing impaired and deafness cases, training would be provided from medical college level specialists (ENT and Audiology) to grass root level workers.

Level 1: State medical college experts (1 Day)

Level 2: District level ENT officers (5 Days) and Audiologists (2 Days)

Level 3: Obstetricians/Gynecologists and Pediatricians at district and CHC level (1 Day)

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Level 4: Medical Officer under CHC/PHC, Medical Officer under school health scheme, and Medical Officers involved in industrial health (2 Days)

Level 5: CDPO, AW supervisors, MPWs, ANM and PHN (1 Day)

Level 6: AWW, ASHA and TBA (4 Hours)

Level 7: Primary school teachers, Panchayat members, Mahila Mandals and parents of HI children.

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2. Capacity building

a) PHCs and CHCs

• ENT kit is provided to all PHC’s/CHC’s in the selected districts for screening of ear morbidity and detection of hearing loss.

• The equipment to be provided:

a) Head light b) Ear specula c) Ear syringe d) Otoscope

e) Jobson horne probe f) Tuning fork g) Noise maker

• Logistics/Medicines:

Borospirit ear drops, wax dissolving drops and antibiotic ear drops, including cotton swabs and normal saline solution for use by the Health Care Workers.

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b) District Hospitals

• The district hospital is an important centre for management of ear problems and deafness cases referred from the health care facilities at various levels.

• The equipment to be provided:

a) Microscope b) Micro drill

c) Micro ear surgery instruments d) Pure tone audiometer

e) Impedance audiometer f) OAE machine

g) Sound room

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3. Service provision including rehabilitation

Screening camps for early detection, management and rehabilitation of hearing and speech impaired cases at different levels of health care delivery system.

Service components include:

a) Early detection

b) Ear screening camps

c) Treatment (medical and surgical)

d) Appropriate referral/rehabilitation of hearing and speech disorders and hearing aid provision.

e) Awareness creation in the community.

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a) EARLY DETECTION

• The detection is by sensitized personnel at grass root level

• House-to-house surveys by AWW and ASHA under supervision of MPW (deafness cases noted in disability column of ANM’s Village register).

• District level pediatricians and gynecologists, ENT doctors/audiologists

• School teachers, School Health doctors, PHC/CHC doctors

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b) EAR SCREENING CAMPS

• Screening camps will be organised at the PHC/CHC and District level for screening the general population in respect of ear problems, hearing impairment and deafness.

• Ear screening camps will be conducted by the PHC/CHC doctors and district level ENT specialists, trained under the programme.

• The screening camps will be facilitated by the NGOs, identified by the District Health camps and experience of work at the community level.

• One screening camp will be organized per month at any PHC or CHC or District hospital by rotation.

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• Public Health Nurses and MPWs would provide treatment of common ear aliments such as ear wax, ASOM under the guidance of the PHC doctor.

• Trained PHC/CHC doctors will provide early diagnosis of ear diseases and treatment of all common ear aliments.

• All persons requiring special diagnostic facilities, complicated cases and those needing surgical intervention will be referred to the District hospital.

• The District level ENT doctors and audiologists will provide comprehensive preventive, promotive, curative and medical rehabilitative services.

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• The District level paediatricians will be responsible for treating ear diseases so that progress to deafness can be prevented.

• Effective linkages would be developed from peripheral level to district level with the help of functionaries and personnel from grass root level (AWW, ASHA and sensitized parents), sub-centre level (MPWs), PHC medical officers, PHNs, school teachers and school health doctors, private practitioners and District level doctors.

• Equipment required:

Head light, Otoscopes, Tuning forks, 2 or more aural probes, and syringe, cannula, saline etc. for wax removal by syringing.

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c) SCHOOL LEVEL SCREENING

• Each year, all children attending primary schools in the selected districts should be screened for the presence of ear & hearing problems, such as:

a) Impacted ear Wax b) Secretory Otitis media

c) Suppurative Otitis media d) Otomycosis/otitis externa

• Refer to higher centre for further management wherever indicated,

a) Follow up for medical treatment

b) Surgical treatment

c) Audiological assessment or work up

d) Specialized diagnostic work up (X-rays, CT scan etc.)

e) Guidance and Counselling

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• Those children, who are positive for ear and hearing disease should then be subjected to clinical screening.

a) The clinical screening should be carried out by the School doctor. Wherever, such a person is unavailable, the task may be taken over by the PHC doctor or any other MBBS level doctor trained under the programme or else any ENT doctor.

b) The names & details of all children being screened must be recorded in a register by the teacher coordinator at the time of clinical

examination.

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4. Awareness generation through IEC activities

For early identification of hearing impaired, especially children so that timely management of such cases is possible and to remove the stigma attached to deafness.

• Community level health workers and doctors undertake this activity on a continuous basis.

• Sensitization is done regarding various aspects relating to early detection of hearing loss, and ill effects of hearing loss on the speech, mental and social development of the child.

• Information regarding various treatment modalities as well as techniques of rehabilitation.

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EXPECTED BENEFITS OF THE PROGRAMME

1. Large scale direct benefit of various services like prevention, early identification, treatment, referral, rehabilitation etc. for hearing impairment and deafness, by a decrease in the magnitude of hearing impaired persons.

2. Decrease in the severity/extent of hearing impairment

3. Improved service network for the persons with hearing impairment in the states and districts covered under the project.

4. Awareness creation regarding prevention of hearing loss among the health workers/grass-root level workers through PHC medical officers and district officers.

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5. Larger community participation and creation of a collective responsibility framework in the broad spectrum of the society to prevent hearing loss.

6. Leadership building in PHC medical officers to help create better sensitization in the grassroots level which will ultimately ensure better implementation of the programme.

7. Capacity building at the district hospitals to ensure better care.

8. State of the art department of ENT at the medical colleges in the state/union territory under the project.

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1. Central Coordination Committee (CCC)- It acts as a Coordinating body, in order to oversee, evaluate and monitor the implementation of the Programme.

• Representatives of Directorate General of Health Services/Ministry of Health & Family Welfare (2)

• Representative of WHO (1)

• ENT specialists/experts (2)

• Audiologists and speech therapists (2)

• Public Health expert (1)

• Representative of RCI (1)

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2. State level

1. State Health Society and Programme Committee, under NRHM

2. State Nodal Officer

Preferably an ENT surgeon at the directorate/Secretariat level who will provide technical guidance and expertise to the State Health Society for the purpose of implementation of the programme in the various districts of the state.

Functions

a) Preparation of State plans

b) Monitor and supervise implementation of NPPCD

c) Release and monitor flow of funds to District Health Societies

d) Review & compile the activities by DNOs/District Health Society in the expenditure of funds and activities of the programme.

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3. District level

1. District Health Society and Programme Committee, under NRHM

2. District Nodal Officer

Preferably an ENT surgeon working in the district hospital/district health society level who will provide technical guidance and

programme management expertise to the District Health Society for the purpose of implementation of the programme in the district.

Functions

a) Planning and preparattion of district micro-plan

b) Implementation of the programme through utilization of government facilities, NGOs and community participation

c) Monitoring of programme

d) Social mobilization and public awareness

e) Monitoring and Financial Assistance to NGOs for organizing camps

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3. District Hospital

The ENT Surgeon and the Audiologist at the District hospital will be the key persons for implementation of the programme.

Functions

a) Assistance in providing audiological services

b) Assistance in conduct of screening camps

c) Assistance in training programmes

d) Monitoring and Evaluation of programme

e) Maintenance of Database

4. Teacher for the young Hearing Impaired

It is proposed that a teacher may be inducted on contractual basis, to look after the therapy and training of the young hearing impaired children at the district level.

Functions

a) Training, therapy & early education for the young hearing impaired children.

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SCHEMES FOR VOLUNTARY ORGANIZATIONS

• For the purpose of the schemes, a voluntary organization means:

a) A society registered under the Indian Societies Registration Act, 1860 or a charitable public trust registered under any law for the time being in force.

b) Track record of having experience in providing health/ rehabilitative services preferably related to hearing/speech services over a minimum period of 3 years.

c) Having available well-trained staff, infrastructure and the required managerial expertise to organize and carry out health camps.

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• The NGO scheme will be implemented through the SNO. The SNO will select NGOs in their respective state as per the prescribed criteria.

• The funds for conducting screening camps would be released to state health society.

• Periodic monitoring will be carried out by the MOHFW, SNO and DNO in order to ensure proper functioning of the scheme and suggest modifications if necessary.

• The NGO will implement the programme activities by means of organizing of camps at periodic intervals.

• The camps will be held at PHC/CHC/District hospital level in every district twice a month.

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• These NGOs will sensitize the community (IEC activities) prior to the camp regarding the complaints related to the hearing impairment. People with such complaints should be encouraged to attend these camps.

• Appropriate and prompt referral should be ensured for detected cases.

• The NGO may also use suitable innovative measures to improve the effectiveness of the camp.

• Grant-in-aid to NGO for this scheme is Rs 10,000 per camp.

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GUIDELINES TO PRESCRIBE BTE HEARING AIDS UNDER NPPCD

• These guidelines shall be followed by the ENT Surgeons who will be prescribing the hearing aids to the beneficiaries.

General Information

• Family income should be less than Rs.6,500/- per month to obtain the hearing aid free of cost, however, testing for hearing aids prescription for hearing aids shall be provided to all irrespective of income.

• The hearing aids will be provided only to the Hearing Impaired children (up to the age of 14 years).

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• Hearing aids are to be given only after an ENT clearance and not to be given in case there is active ear discharge or any external ear infection.

• A person is a candidate for hearing aid if he has sensory neural hearing loss or hearing loss with a conductive component which cannot be treated medically or surgically.

• Separate guidelines are provided for adults, children who cannot be conditioned to respond, and children who have limited or no speech.

• All the cases who have been prescribed and issued a hearing aid have to be counselled regarding optimum use, care and maintenance of the hearing aid including the ear mould.

• Replacement/re-issue of a hearing aid will be done only after 3 years of usage.

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OBJECTIVES

• To assess the prevalence and nature of deafness in the SEA Region.

• To assess the prevalence and nature of ear diseases in the Region.

• To identify the structure and plan of action at the national level.

• To identify the facilities and activities at the primary, middle and tertiary level of health services.

• To identify weaknesses and strengths, and short and long-term needs.

• To develop a combined profile on infrastructure in the SEA Region.

SITUATION REVIEW AND UPDATE ON DEAFNESS, HEARING LOSS AND INTERVENTION PROGRAMMES

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FINDINGS

1. A National Policy for prevention of deafness and hearing impairment exists in Indonesia, India, Nepal, Thailand and Sri Lanka.

2. No environment noise control legislation exists in Bhutan, Maldives, Sri Lanka and Nepal. Bangladesh, India, Indonesia and Thailand have in place a legislation/law for environment noise control.

3. Primary ear and hearing care (PEHC) is the strategy of choice for the provision and implementation of prevention of deafness and hearing impairment (PDHI). There is a need to develop PEHC programme in Bangladesh, Bhutan, India, Maldives, Myanmar, Nepal and Sri Lanka.

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4. INDIA Scenario: Manpower

a) Total No. of doctors 5,00,000

Ratio of doctors to the population 1 : 2,224.5

b) Number of ENT Specialists 8,000

Ratio to the population 1 : 1,39,028

c) Number of micro-ear surgeons 4,000

Ratio to the population 1 : 2,78,056

d) Audiologists 1,200

Audiologists per total population 1 : 92,16,854

e) Teachers for the deaf 4,039

Sign language translators/interpreters Available

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5. INDIA Scenario: Prevalence of ear diseases that are a potential cause of hearing loss

(All figures are in % of general population affected by the given entity)

Impacted Cerumen 18.7%

CSOM 5.4%

Chr. NSOM 3.8%

Congenital 0.2%

Post traumatic perforation 0.6%

Presbycusis 10.3%

NIHL NA

Ototoxicity NA

Other causes of SNHL 7.0%

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6. INDIA Scenario: Capacity and Services

• 170 medical colleges with attached teaching hospitals offer degree and diploma in ENT.

• Only about 25-30 centres are equipped with temporal bone dissection facilities.

• Annual output of ENT specialists: 400

• There are 16 schools for Audiology, the most prominent being the All-India Institute for Speech and Hearing (AIISH) in Mysore.

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• There are 22,974 PHCs but none of them is devoted to ear and hearing health care.

• Services available at PHCs include ear examination with otoscope, and referral to higher centre.

• Diseases treated at the primary-level centre

ASOM

CSOM

Cerumen/ear wax

Otitis externa

• The district hospitals (600) act as second-level or mid-level facilities for ear and hearing care.

• There are around 350 government-run hospitals in the whole country that provide tertiary facilities. Of these 120 have the availability of diagnostic facilities for early diagnosis and rehabilitation. There are a significant number of private centres offering this facility but most of them are concentrated in the big cities and are not accessible in the interiors.

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7. NGOs working for awareness and rehabilitation of hearing impaired people:

Hearing International – India

Mahavir Viklang Institute, Mumbai

All India Federation of Deaf, Delhi

Delhi Association for Deaf, Delhi

Delhi Association for Deaf Women, Delhi

Mangalam, Lucknow

Sweekar, Hyderabad

Pratibandhi Kalyan Kendra, Kolkata

Bal Vidyalaya, Chennai

Little Flower Convent, Chennai

Shruti School, Mumbai

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• The Programme was a 100% Centrally Sponsored Scheme during 11th Five Year Plan. However, in as per the 12th Five Year Plan, the Centre and the States will have to pool in resources financial norms of NRHM mutas mutandis. The Programme was initiated in year 2007 on pilot mode in 25 districts of 11 State/UTs. The Programme has been expanded to 192 districts of 20 States/UTs. In the 12th Plan, it is proposed to expand the Programme to additional 200 districts in a phased manner probably covering all the States and Union territories by March, 2017 with the following strategy:

a) Prevention through behaviour change communication (BCC)

b) Capacity building (human resource and equipment) at different level of Health care delivery system for early identification,

management and rehabilitation.

c) Monitoring and evaluation

THE WAY AHEAD: PROPOSALS IN 12TH FIVE YEAR PLAN

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c) Monitoring and Supervision

• One of the lacunae of the programme during its implementation in the 11th Five year plan has been the lack of a suitable mechanism for implementation and monitoring of the programme at all levels.

• In order to overcome this shortcoming, there is a strong need for creation of suitably empowered Programme implementation Committees with monitoring cells at the various levels within the health care delivery system.

• Actions proposed include

1. Strengthening Monitoring & Supervision - Creating Monitoring Cell at Central, State and District level.

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a) Monitoring Cell at Central level

Consultants (2)

Programme Assistants (2)

Data Entry Operator (1)

b) Monitoring Cell at State level

Consultant (1)

Programme Assistant (1)

Data Entry Operator (1)

c) Monitoring Cell at District level

Consultant (1)

Data Entry Operator (1)

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2. Advisory Committee:

• Advisory committee will be constituted at central , state and district level to advise, review and monitor the Program Implementation.

• The committee will consist of subject experts, programme officers, administrators etc.

Public Private Partnership

• Public Private Partnership model will be adopted for early identification and management of Hearing impaired children at the district level involving private ENT specialist wherever ENT specialists are not present in the district hospital.

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Research & Evaluation

• Operation Research will be conducted with respect to different aspects of programme and its components to assess its suitability in different areas.

• The recommendations of these will be integrated in the programme strategies for further implementation of the programme.

• The programme will also be evaluated at the end of 3rd and 5th year about its achievements.

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References • Park K. Textbook of preventive and social medicine. 20th ed, Bhanot; 2009. p. 32-42.• J.Kishore , National Health Programmes of India, 6th edition, Pg No.574-8.• WHO report. Global burden of disease, 2000.• Persons with Disabilities (Equal Opportunities, Protection of Rights and Full Participation)

Act, 1995 as well as under the Rehabilitation Council of India Act, 1992.• WHO. International classification of impairment, disabilty and handicap, 2000.• Prevention and Control of Deafness and Hearing Impairment. Report of an Inter-country

Consultation, Colombo, Sri Lanka, 17-20 December 2002. World Health Organization, Regional Office for South-East Asia, New Delhi. March 2003

• State of hearing and ear care in the SEA Region. WHO-SEARO; 2003. SEA/Deaf/9.(http://www.searo.who.int/LinkFiles/Publications_HEARING_&_EAR_CARE.pdf)

• Disabled persons in India, NSS 58th round (July–December 2002) Report no. 485 (58/ 26/1). New Delhi: National Sample Survey Organization, Ministry of Statistics and Programme Implementation, Government of India, 2003.

• Proposed Plans of Action for Prevention and Alleviation of Hearing Impairment in Countries of the South-East Asia Region. Report of WHO SEARO, New Delhi, December 2007

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Thank You…