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NHPP21 - National Programme for the Prevention and Control of Deafness

Quadrant – I

Personal details:

Role Name Affiliation Principal Investigator Dr. C.P. Mishra Professor

Department of Community Medicine Banaras Hindu University, Varanasi Uttar Pradesh, India

Paper Coordinator Dr. Davendra Kumar Taneja Director Professor Department of Community Medicine Maulana Azad Medical College New Delhi, India

Content Writer/Author Dr. M. Meghachandra Singh Professor Department of Community Medicine Maulana Azad Medical College New Delhi, India

Content Reviewer Dr. Bratati Banerjee Professor Department of Community Medicine Maulana Azad Medical College New Delhi, India

Description of Module:

Items Description of Module

Subject Name Community Medicine Paper Name National Health Policies and Programmes

Module Name/Title National Programme for the Prevention and Control of Deafness Module Id NHPP21

Pre-requisites Knowledge on hearing problems; knowledge on national programmes in general

Objectives To study about the national programmes for the prevention and control of deafness

Key words National Programme, Deafness, Prevention, Control

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Introduction Hearing loss is considered to be present among those who report that he/she is not able to hear or even among the normal individuals when the hearing threshold is 25 decibels (dB) or more in the better ear. There are grades of hearing loss depending upon the severity viz. mild, moderate, severe or profound. When the hearing loss is greater than 40 dB in the better hearing ear in adults and 30 dB in the better hearing ear in children, it is considered to be disabling hearing loss.

1 Hearing impairment is the inability

to hear and hearing impaired people can be deaf. ‘Deaf’ people usually have profound hearing loss and they use sign language for communication. Hearing loss is associated with functional loss in terms of delayed language development, and economic burden. Deafness results from several factors and around half of all deafness and hearing impairment can be prevented by screening and management at primary health care level.

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Government of India has launched the National Programme for the Prevention and Control of Deafness since July 2006 to June 2008 as a pilot project, which is being extended throughout the country in a phased manner. Various features of the programme are discussed below.

Learning outcomes At the end of the session, the students should be able to:

Understand deafness and its common causes

Tell the magnitude of the problem of hearing loss

Describe the objectives of National Programme for the Prevention and Control of Deafness (NPPCD) in India

Explain the components and activities under NPPCD

List the expected benefits and

Describe organizational structure of the programme

Main Text

1. Deafness and its causes Deafness is defined as a degree of impairment in which a person is unable to understand speech even in the presence of amplification.

3 In profound deafness, even the loudest sounds produced by

an audiometer (an instrument used to measure hearing by producing pure tone sounds through a range of frequencies) may not be detected. In total deafness, no sounds at all, regardless of amplification or method of production, are heard.

Causes of hearing loss Hearing loss can occur due to congenital and acquired causes. Congenital causes include both hereditary and non-hereditary factors. The congenital factors are related to infections during pregnancy such as maternal rubella, syphilis etc. The other extraneous factors include complications of pregnancy and child birth leading to low birth weight, birth asphyxia, use of medications such as aminoglycosides, cytotoxic drugs, antimalarials, diuretics, severe jaundice during neonatal period. In addition, other acquired conditions such as meningitis, measles, mumps, chronic ear infections such as

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otitis media, injury to the ear or head, exposure to excessive noise in occupations, explosions, loud recreational noise from the use of audio devices at home, concerts, night clubs, parties, bars, sporting events and wax contribute to hearing loss. Majority of these conditions are preventable or controllable.

2. Magnitude of the problem World Health Organization estimates that over 5% of the population globally (360 million people- 328 million adults and 32 million children) have disabling hearing loss. Approximately one-third of the geriatric population above 65 years suffers from disabling hearing loss. The problem is more prominent in South Asia, Asia Pacific and sub-Saharan Africa

1. In India, approximately 6.3% of the

population suffers from disabling hearing loss. It is considered to be the most common sensory deficit in humans. The National Sample Survey Organization report of 2001 suggests that there are 291 persons per one lakh population who suffer from severe to profound hearing loss.

4 Suffering children

in the age group 0-14 years results in a severe loss of productivity, both physical and economic.

3. Objectives of the NPPCD The objectives of the programme are: 3.1. To prevent the avoidable hearing loss on account of disease or injury. 3.2. To conduct early identification, diagnosis and treatment of ear problems responsible for hearing loss and deafness. 3.3. To medically rehabilitate persons of all age groups, suffering with deafness. 3.4. To strengthen the existing inter-sectoral linkages for continuity of the rehabilitation programme, for persons with deafness. 3.5. To develop institutional capacity for ear care services by providing support for equipment and material and training personnel. 4. Components of the programme The various components of the programme are: 4.1. Manpower training and development 4.2. Capacity building for the district hospital, CHC and PHC 4.3. Service provision including rehabilitation 4.4. Awareness generation through IEC activities 4.5. Monitoring and evaluation 4.1. Manpower training and development

Manpower training is done involving Medical college level specialists (ENT and Audiology) to grass root

level workers. Training materials are available for all levels of manpower. There is a budgetary allocation

of Rupees ten lakhs for organizing these training programmes at the district. Brief summary of the levels

of training is shown in table 1. The trainings are conducted by the state nodal officers in collaboration

with state health society and Central Coordination Committee.

Table 1: Training programmes under NPPCD

Category of manpower Objectives, duration Resource persons Doctors and Audiologists at the Medical

To sensitize the objectives of the programme and role of the Medical College in the programme,

Central Coordination committee

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College level-2, preferably, the Head of Department of ENT and another ENT Doctor, an Audiologist

Duration: 1 day

District Hospital ENT Doctors and Audiologists

To sensitize about the programme -Definition of their respective roles -Skill reorientation Duration: 3 days for ENT surgeons, 2 days for Audiologists

Co-ordinators at the State Medical College.

Pediatricians and Obstetricians of the Community health Centre and District hospital

To Create awareness amongst Pediatricians and /Obstetricians regarding causes of deafness. To sensitize them about the importance and techniques of early identification of hearing loss amongst newborns and its causes. Duration: 1 day

ENT Specialist and Audiologist at the District hospital

Doctors at the Primary Health Centre and Community Health Centre, in School Health Scheme, in industrial set ups

To sensitize about the National Programme for Prevention and Control of Deafness. To create awareness regarding the preventable causes of hearing loss/deafness. To reorient in early diagnosis and treatment of common ear diseases/community ENT. To introduce training modules for carrying out training of health care workers in the community Duration: 2 days

District level ENT Surgeons/Audiologists

Public Health Nurses, Multi Purpose Workers male and female (ANMs), Anganwadi Supervisors (AWW Supervisor) and Child Development Project Officers (CDPO) in the district

To sensitize the workers regarding the programme and regarding the ear and hearing care. To enable them to identify deafness at an early age. To motivate them for awareness generation in the community. Duration: 1 day

PHC/CHC doctors/RCI Rehabilitation Professionals

Anganwadi workers (AWW), ASHAs, TBAs

To sensitize towards the programme. To orient towards ear and hearing care in order to facilitate primary and secondary prevention Duration: 1 day

ANMs/AWW Supervisors/CDPOs/RCI Rehabilitation Professionals

Primary School teachers (preferably science background) and Parents of Hearing/Speech impaired Children,

To orient towards the preventable causes and ill effects of hearing loss in a young child. To sensitize towards the early identification of such children and the treatment options/facilities available at different levels of health care. To introduce to the proforma/questionnaire to be filled by the students. Duration: Half day

PHC doctors, trained under the programme and locally available Rehabilitative Professionals

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A budgetary provision of Rs.10.00 lakhs per district has been made for above seven level training programmes.

4.2 . Capacity building

The programme envisages upgradation of infrastructure and manpower for the district hospital,

community health centres and primary health centre in respect of ENT/ Audiology. Funds have been

provided for provision of ENT equipments in the district hospital and primary health centres in rural and

dispensaries in urban areas. Moreover, there is a provision of contractual manpower addition viz. one

Audiological assistant and one Instructor for the young hearing impaired for each district hospital. The list

of equipments in the district hospital added under the programme is shown below.

i) At the PHC and CHC level: Equipments: a) Head Lights b) Ear Speculas c) Ear Syringes d) Otoscope e) Jobson Horne Probes f) Tuning forks of 256, 512, 1024 Hz g) Noise Maker In CHC, Pure tone audiometer Medicine kit: Borospirit ear drops, wax dissolving drops and Antibiotic ear drops, including cotton swabs and normal saline solution, for use by the Health care workers. There is a budgetary provision of Rs. 20,000 per kit for PHC and Rs 50,000 per kit for CHC.

ii) District hospital: The District hospital is to be an important centre for the management of ear problems and deafness cases, which are referred from the health care facilities at various levels. Provision of following equipments and facility has been made:

(a) Microscope (b) 2 sets of Microdrills with 2 handpieces and burrheads (c) 2 sets of micro-ear surgery instruments. (d) Pure Tone Audiometer (e) Impedance Audiomter (f) OAE machine (g) Sound treated room (air conditioned)

There is a budgetary provision of Rs. 20.00 lakh per district hospital for upgradation of facility and equipments. iii) State Medical College

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Medical colleges with existing audiological and ENT set up act as tertiary referral and training centre. There is a provision of the following equipments and facility (a) Surgical operating microscope for ENT use (b) Microdrill system ear surgery instruments: 21. (c) Indigenous digital audiometer (d) Impedance audiometer (e) OAE analyzer (f) Sound proof room: size 8 ft. X 8 ft. air conditioned room

4.3. Service provision including rehabilitation

Under the programme, screening camps are organized for early detection of hearing impairment and

deafness, management of hearing and speech impaired cases and rehabilitation (including provision of

hearing aids), at different levels of health care delivery system. The involvement of different levels of

health care delivery system including the activities is listed below.

I. Primary level- CHCs/PHCs/SCs/Primary School teachers/Health Workers/Panchayat

Focus is on early identification of cases of hearing impairment and their management in collaboration with NHM, RBSK (Rashtriya Bal Swasthya Karyakram), primary ear care, promoting public awareness in respect of prevention of deafness, sensitization training of health workers and provide support to School Ear care programme. II. Secondary level- District Hospital

At this level, the activities include management of cases referred from PHCs/CHCs, organization of Ear care screening camps in collaboration with NHM and Ministry of Social Justice and empowerment (M/o SJ&E), organization of School Ear Care Programme, and training of manpower for PHC doctors, nurses, audiometric assistants, health workers, and school teachers.

III. Tertiary level-State Medical College In each state, one medical college has been identified to act as the Center of Excellence and referral center for the districts covered under the programme in that state. Two ENT surgeons and one Audiologist from the medical college are being trained under the programme. The functions of the tertiary care include training of manpower i.e. sensitisation programmes and surgical training workshops and management of referred cases. Service components

The service components under the programme include: 4.3.1 Early detection 4.3.2 Ear Screening camps 4.3.3 Treatment: medical and surgical 4.3.4 Appropriate referral 4.3.5 Rehabilitation of hearing and speech disorders and hearing aid provision.

4.3.1. Early Detection

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Early detection of ear problems is facilitated by health care functionaries at all levels including family members/ parents, selected school teachers, MPWs at subcentre level, Public Health Nurses and medical officers in PHCs, CHCs and district level. The other activities are house to house surveys conducted by the Anganwadi workers, ASHAs, under the supervision of the male and female MPWs for detection of cases of hearing impairment and deafness. The deafness cases are noted in the disability column of ANM’s village register. The MPWs will maintain records of each family based on a Family performa provided to them. The District level Pediatricians and Gynecologists will refer to the district ENT surgeon any child born of a high risk pregnancy or delivery, as well as other children who are exposed to a high risk factor in infancy and who show features suggestive of hearing impairment. These children will be screened with OAE and then subjected to diagnostic tests. School teachers are involved in screening the children in the school with the help of pre-prepared proformas to identify children with any ear or hearing problem. These children will then be referred to the School Health doctor for evaluation, diagnosis and guidance regarding treatment. 4.3.2. Ear Screening Camps

Screening camps will be organised in collaboration with National Health Mission (NHM), Rashtriya Bal Suraksha Karyakram (RBSK) and Ministry of Social Justice and Empowerment (M/o SJ&E) at the PHC/CHC and District level for screening the general population in respect of ear problems, hearing impairment and deafness. The camps are used for detection and treatment of common ear problems, spreading awareness regarding ear problems, early detection of deafness, and referral of cases to higher level, education of community, especially the parents of young children regarding importance of right feeding practices, various common ear problems, early detection of deafness in young children, education of Panchayat members, members of Mahila Mandals and Youth leaders for early detection of ear and hearing problems.

Conduct of Screening Camps Ear screening camps will be conducted by the PHC/CHC doctors and district level ENT specialists, trained under the programme in collaboration with the NGOs, identified by the M/o SJ&E/ District Health Society. These NGOs will carry out one screening camp per month at any PHC or CHC or District hospital by rotation. Previously, fund of Rs. 10,000 per camp was provisioned nut now under the 12

th

plan, no budgetary provision has been made for screening camps under NPPCD.

4.3.3. Treatment

Treatment of all affected persons would be undertaken at the following levels: (a) Public Health Nurses and MPWs: would provide treatment of common ear ailments such as Wax, Acute Suppurative Otitis Media etc. under the guidance of the PHC doctor. The Public Health Nurses and MPWs will have the capacity to distribute relevant ear drops and medicines under the guidance of the PHC doctor. (b) Trained PHC/CHC doctors will provide early diagnosis of ear diseases and treatment of all common ear ailments. All persons requiring special diagnostic facilities, complicated cases and those needing surgical intervention will be referred to the District hospital. (c) District hospital: The District level ENT doctors and Audiologists will provide comprehensive preventive, promotive and curative and medical rehabilitative services. Wherever feasible, suitable

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linkages would be developed with the Comprehensive Rehabilitation Centres (CRC) and DDRC in coordination with the Ministry of Social Justice & Empowerment, for provision of rehabilitative services. (d) The District level Pediatricians will also be responsible for treating ear diseases such as Acute Otitis media, so that progress to Deafness can be prevented. 4.3.4. Referral services: Under the programme, emphasis is laid for developing effective linkages from peripheral level to district level with the help of functionaries and personnel from grass root level (AWW, ASHA and sensitised parents and Panchyati Raj Institutions), subcentre level (Male and female MPWs), PHC level medical officers, Public health nurses, School teachers and School health doctors, ENT private practitioners and District level officers.

4.3.5. Rehabilitation and Hearing Aid provision: All patients who are identified as having an ear problem that either requires surgery, hearing aid fitting or rehabilitative therapy are referred to the ENT doctor and Audiologist at the district level who will assess and prescribe surgery or hearing aids. Complicated cases that cannot be adequately handled at the District hospital are further referred to the State Medical College for expert treatment. Patients including children suffering with sensorineural hearing loss that is not amenable to medical or surgical correction and which requires hearing aid are fitted at the district level and these hearing aids are provided by Ministry of Social Justice and Empowerment. Earlier, hearing aids were provided free of cost to children belonging to families having income less than Rs. 6500 per month. Three basic types of hearing models are available depending upon the hearing loss as shown below (Table 2).

Table 2: Hearing aid models and fitting range

Sl No. Hearing aid model Fitting range

1 Model A PTA ranging from 41 to 69 dB HL 2 Model B PTA ranging from 70 to 89 dB HL

3 Model C PTA ranging from > 90 dB HL Under the 12

th plan, there is no budgetary allocation kept separately for provision of hearing aids.

4.4. Awareness generation through IEC activities One of the major activities under the programme is creation of awareness among the people through Information, Education and Communication (IEC) activities by community level health workers and doctors on a continuous basis. The IEC activities are incorporated through screening camps, ENT clinics of hospitals and outpatient departments in PHC/CHCs. Audio and video clips are also shown in leading national television channels. This also helps in reducing the stigma attached to deafness. A large number of posters are prepared for dissemination of information regarding prevention and detection of common ear problems and hearing loss in the community. As per 12

th plan, sensitization will be done regarding

various aspects relating to early detection of hearing loss, providing information regarding various treatment modalities as well as techniques of rehabilitation including elderly persons. There is a budgetary provision of Rs 20.00 lakhs at State level and in addition Rs 2.00 lakhs at each district level for IEC activities under NPPCD.

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4.5. Monitoring and evaluation of the programme

The programme is routinely monitored through various reports from schools, primary health centres,

community health centres, district hospitals, covering aspects of number of ear problems detected, treated,

referred, number of screening camps organised, number of hearing aids distributed, IEC activities done

etc. on a monthly basis. Currently, the programme has not yet been evaluated on a larger scale at the

national level both internally and externally.

5. Expected benefits of the programme

i. Direct benefit of various services like prevention, early identification, treatment, referral, rehabilitation etc. for hearing impairment and deafness.

ii. Decrease in the magnitude of hearing impaired persons. iii. Decrease in the severity/extent of ear morbidity or hearing impairment. iv. Improved service network for the persons with ear morbidity/hearing impairment in the states and

districts covered under the project. v. Awareness creation among the health workers/grassroot level workers through the primary health

centre medical officers and district officers. vi. Larger community participation to prevent hearing loss through panchyati raj institutions, mahila

mandals, village bodies. vii. Leadership building in the primary health centre medical officers to help create better

sensitization in the grassroots level which will ultimately ensure better implementation of the programme.

viii. Capacity building at the PHC, CHC and district hospitals to ensure better care. ix. Presence of state of the art department of ENT at the medical colleges in the state/union territory under the project. Progress of the programme

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The Ministry of Health and Family Welfare, Govt. of India launched the pilot phase of National Program for Prevention and Control of Deafness (from 2006 to 2008) in 10 States and 1 Union Territory. The Programme was a 100% Centrally Sponsored Scheme during 11th Five Year Plan. However, in the 12th Five Year Plan, the Centre and the States will pool in resources in accordance to the financial norms of National Health Mission. The programme was initiated in year 2007 on pilot mode in 25 districts of 11 State/UTs. It 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, covering all the States and Union territories by March, 2017.

6. Organizational structure of the programme

Central Coordination Committee (CCC) A Central Coordination Committee has been constituted at the central level with the following members to provide technical inputs and facilitate implementation of the Programme: - Representatives of Directorate General of Health Services/Ministry of Health & Family

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Welfare (2) - Adviser NPPCD (1) - Representative of WHO (1) - ENT specialists/experts (2) - Audiologists and Speech therapists 2 - Public Health expert (1) - Representative of Rehabilitation Council of India (1)

I. Central Level

Central Cell: A team consisting of two national consultants, one programme assistant and one data entry operator provides necessary support to the Programme Division in the Ministry of Health & Family Welfare. The team maintains an effective Management Information System (MIS) for collection of data for effective supervision and monitoring of the Programme.

II State level

State Cell There is a team to strengthen monitoring of the programme at State level manned by one consultant, one programme assistant and one data entry operator.

State Health Society and Programme Committee State mission under National Health Mission (NHM) looks after the activities at state level. Under the programme, funds are transferred to State Health Society, for carrying out various activities through District Health Society. The activities include:

Preparation of District plans for implementation of National Programme for prevention and control of Deafness.

Monitoring and supervision of implementation of National Programme for Prevention and Control of Deafness in the state in reference to the programme activities related to Training of Medical and non-medical professionals, IEC and Social mobilisation and Manpower development.

Release and monitor flow of funds to District Health Societies.

Review and take appropriate measures in the expenditure of funds by District Health Society.

State Nodal Officer State Nodal Officer preferably an ENT surgeon or programme manager at the directorate/ Secretariat level provides technical guidance and expertise to the State Health Society for the purpose of implementation of the programme in the various districts of the state. III District level

District Health Society and Programme Committee (under NHM) The activities include

Planning: Preparation of District Micro-plan based on magnitude and distribution of deaf/hearing impaired persons and resources available for ear care.

Implementation of the programme through utilisation of government facilities, involvement of NGOs and community participation.

Monitoring of programme: activities and quality control

Financial and Material Management Social mobilisation and public awareness

Orientation of various functionaries of health and other related sectors.

Procurement of equipments and other materials.

Arrangements for screening camps- through identified NGOs, having adequate infrastructure for carrying out activities under the programme.

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Monitoring and Financial Assistance for organising camps.

District Hospital: It is proposed to strengthen the ear care services at district level by providing manpower support such as one ENT Surgeon, one Audiologist, one Audiometric Assistant and one Instructor for hearing impaired at each district on contractual basis. i. ENT Surgeon: The job responsibilities of the Contractual ENT surgeon are to provide ENT Clinical Services at the District Hospital, and conducting training programmes for health functionaries. ii. Audiologist (Audiologist & Speech language Pathologist): The job responsibilities of the Audiologists are: (a) provision of audiological services and prescribing hearing aids, (b) assist in training programmes, (c) monitoring and evaluation of the programme, and maintenance of database. iii. Audiometric Assistant: The audiometric assistant has the following functions (a) to provide support in screening of hearing impaired persons, (b) visit Community Health Centre (CHC) by visiting on fixed day for screening of hearing impaired persons, (c) assist in training, monitoring and evaluation of the Programme and (d) maintain database. iv. Instructor for the Young Hearing Impaired Children: There is a provision of recruiting an Instructor to look after the therapy, training and early education of the young hearing impaired children at the district level.

Summary Disabling hearing loss is prevalent in 5% of the population globally. India has implemented the national programme for the prevention and control of deafness in a phased manner throughout the country with 100% central assistance. In the 12

th plan, it is expected to be contributed by both the Central and State

Governments. The components include capacity building of PHC/CHC, district hospital and medical colleges in terms of infrastructure and manpower. Other activities are early detection of ear and hearing problems both by screening camps and in the outpatient departments of health facilities, management and treatment, provision of hearing aids, establishment of referral system, training of manpower and awareness creation among the people.

References

1. WHO. Deafness and hearing loss. Available from http://www.who.int/mediacentre/factsheets/fs300/en/ (accessed on 20.5.2015).

2. WHO. Deafness and hearing loss. Available from http://www.who.int/topics/deafness/en/ (accessed on 20.5.2015).

3. ElzoukiAY, Harfi HA, Nazer HM, Stapleton FB, William OH, Whitley RJ. Textbook of clinical

pediatrics (2 ed.). Berlin: Springer. 2012,p. 602.

4. MOHFW. Other National Health Programmes. Annual Report 2013-14. Available from

http://www.mohfw.nic.in/WriteReadData/l892s/Chapter1115.pdf (accessed on 21.5.2015)

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Quadrant III. Self-Assessment Q1. What are the grades of hearing loss? Q2. What are the common causes of hearing loss in children? Q3. What are the objectives of the National Programme for the Prevention and Control of Deafness in India? Q4. What are the various components of the NPPCD? Q5. What are the expected benefits of the NPPCD programme?

ANSWERS

1. Hearing loss is considered when a person reports that he/she is not able to hear or even among the normal individuals when the hearing thresholds is 25 decibels (dB) or more in the better ear. There are

grades of hearing loss depending upon the severity viz. mild, moderate, severe or profound. When the hearing loss is greater than 40 dB in the better hearing ear in adults and 30 dB in the better hearing ear in children, it is considered to be disabling hearing loss.

2. The common causes of hearing loss in children are: Chronic ear infections such as otitis media, wax, infections such as measles, mumps, injury to the ear or head and exposure to excessive noise etc.

3. The objectives of the NPPCD are: 1. To prevent the avoidable hearing loss on account of disease or injury. 2. To conduct 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-sectoral 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.

4. Various components of the NPPCD are as follows:

1 Manpower training and development 2 Capacity building for the district hospital, CHC and PHC 3 Service provision including rehabilitation

4 Awareness generation through IEC activities 5 Monitoring and evaluation

5. The expected benefits of the NPPCD are:

i. Benefit of various services like prevention, early identification, treatment, referral, rehabilitation etc. for hearing impairment and deafness.

ii. Decrease in the magnitude of hearing impaired persons. iii. Decrease in the severity/ extent of ear morbidity or hearing impairment. iv. Improved service network for the persons with ear morbidity/hearing impairment in the states and

districts covered under the project. v. Awareness among the health workers/grassroot level workers regarding deafness prevention and

control

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vi. Larger community participation to prevent hearing loss through panchayati raj institutions, mahila mandals, village bodies.

vii. Leadership building in the primary health centre medical officers to help create better sensitisation in the grassroots level which will ultimately ensure better implementation of the programme.

viii. Capacity building at the PHC, CHC and district hospitals to ensure better care. ix. Presence of state of the art department of ENT at the medical colleges in the state/union territory under the project.

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Quadrant-IV: Learn more/Web Resources/Supporting Materials/Interesting Facts:

mohfw.nic.in/.../9025258383Operational%20Guidlines%20for%2012th%20Plan.pdf

mohfw.nic.in/index1.php?lang=1&level=2&sublinkid=343&lid=343

www.nhp.gov.in/national-programme-for-prevention-and-control-of-d_pg www.gktoday.in/national-programme-for-prevention-and-control-of-deafness-nppcd/

www.who.int/pbd/deafness/activities/national_programmes/en/