January - April 2005 : NHS in Cyprus




Cyprus is a country with approximately 8,500 births per year. More than 50% of births occur in privately owned gynecology/maternity hospitals and clinics, and the rest in state hospitals. In recent years, efforts to screen hearing loss in newborns were limited to the Νeonatal Intensive Care Unit in the country’s largest hospital, in Nicosia. Universal prenatal and neonatal screening for disease such as hypothyroidism, and PKU has been undertaken since 1989 by the Center for Preventive Pediatrics, a non-profit organization supported by state and charity funds.


The Center for Preventive Pediatrics initiated efforts to realize a Universal Newborn Hearing Screening Program in 2002, with a planning committee. The relatively small number and wide dispersion of births in many different sites precluded screening before discharge from the birthing facility. Therefore the decision was made that babies would be screened in special “screening sites” located in each major city. During the first pediatrician visit parents are provided with information and a leaflet in question/answer form in order to understand the importance and necessity of the screening their baby’s hearing. Scheduling for screening is undertaken by the pediatrician’s office during the baby’s first visit (around the seventh day of life), which results in screening babies before they reach the end of the second week. Technicians who have received extended special training perform the screening. The first site opened in Limassol in July 2004, as a pilot program. The next site is now in the process of opening in Nicosia, planned to start the second week of February 2005. The program will become universal after opening of the Nicosia site, with immediate coverage for the areas of Paphos (adjunct site for the Limassol center), and Larnaka (adjunct site to the Nicosia center).


Clinical protocols

The screening protocol includes Automated Transient Evoked Otoacoustic Emission (ILO288 Echocheck), and Automatic Auditory Brainstem Response (Natus ALGO). Babies receive the ATEOAE screening initially. If they pass, parents are provided with information on normal language development, milestones to verify the child’s progress, as well as the instances of progressive hearing loss of post-natal onset, and are discharged to the pediatrician’s care. If the first outcome is a “refer”, the ATEOAE testing is repeated within the following week. If the outcome of the second ATEOAE screening is a “pass” parents are provided with the information described above, and discharged. If the outcome of the second ATEOAE screening is “refer”, screening AABR is performed during the same session. If the outcome of the AABR screening is “pass”, they are provided with the above information and discharged, if it is “refer”, they are referred for a complete otologic and diagnostic hearing evaluation to specializing otorhinolaryngologists. The following flowchart describes the screening protocol.




Screener Training

The screening technicians are college graduates in fields related to child development and care. There is a psychologist, three preschool educators, and a sociologist. They underwent a three-week training course that included theoretical background on hearing, hearing loss, the basic principles of audiometry, as well as basic information on language development and early intervention. The theoretical training schedule is outlined in table 1. The seminars at the final days were coupled with observation of actual screening, and the program concluded with screening babies. 

Table 1. Screener training program



Day 1

Physics of sound, outer and middle ear anatomy

Day 2

Inner ear anatomy and physiology

Day 3

Principles of pure tone audiometry

Day 4

Conductive Hearing loss

Day 5

Sensorineural hearing loss

Day 6

Otoacoustic emissions

Day 7

Auditory Brainstem Response

Day 8

Infant hearing loss. Screening,Cyprus UNHS program

Day 8

Normal language development, effects of hearing loss

Day 9

Intervention planning, hearing aids, cochlear implants

Day 10

Communicating with parents

Day 11

Infection control, database maintainance,

Day 12

Hands-on training on Cyprus UNHS equipment, observation

Day 13

Observation, hands-on screening

Day 14

Hands-on screening

Day 15

Hands-on screening


Budget details

The Cyprus UNHS is funded currently by the Center for Preventive Paediatrics. Funds originate mainly from charity donations. Table 2 does not include expenditures in the planning phase. Salaries reflect the yearly projection for UNHS director and the five screeners.


Table 2. Budget details









Office expenses


Office Rent




Screening Equipment




              Total in Euro: 194,993.4



Initial results are shown in table 3. There were 6 referrals from the UNHS. Two babies have unilateral hearing loss, one has bilateral severe to profound hearing loss, and the other three are in the process of being evaluated.



Table 3. Initial results from Cyprus UNHS















6 (0.4%)




Problems and Solutions

Other than organizational difficulties, the program has not encountered severe difficulties until now. The main issues are centered around collaborating with physicians for referrals and diagnosis, and organizing intervention. Intervention is the next step to be covered by Cyprus UNHS.