Congenital cytomegalovirus (cCMV) is the most common congenital infection worldwide and a major cause of neurodevelopmental impairment in children.1,2 CMV, a member of the human herpes virus family, is typically asymptomatic in immunocompetent individuals. However, nearly 10% of primary infections result in mononucleosis- symptoms such as malaise, persistent fever, myalgia and cervical lymphadenopathy with less common symptoms such as pneumonia and hepatitis.3,4 It is crucial to note that the vast majority of CMV infections in pregnant women are asymptomatic.5
Most cCMV cases present no signs or symptoms at birth. However, asymptomatic infants may develop neurodevelopmental impairments later in life. Research indicates that up to 13.5% of asymptomatic infants may experience late-onset neurodevelopmental impairments or sensorineural hearing loss (SNHL).6,7 In contrast, symptomatic cCMV infections at birth are associated with a higher risk of severe neurodevelopmental sequelae, including intellectual disability, cerebral palsy, and profound SNHL.8,9 Studies suggest that approximately 15%–35% of infants develop SNHL due to cCMV,10 with bilateral hearing loss more common in symptomatic cases and unilateral hearing loss more frequently observed in asymptomatic cases.11–13
Globally, it is estimated that cCMV affects 0.5% to 2% of newborns annually. However, the exact prevalence of cCMV in Saudi Arabia is not publicly documented. Seroprevalence studies indicate CMV seropositivity ranging from 91.2%-100% across all age groups of females tested.14–16 cCMV infection happen due to reactivation or reinfections during pregnancy. With approximately 500,000 births annually in Saudi Arabia,17 assuming a 1% congenital infection rate, an estimated 5,000 infants could be born with cCMV each year. This prevalence suggests a significant public health impact, potentially leading to up to 1750 cases of hearing loss annually attributable to cCMV.
The importance of CMV screening for all newborns, particularly asymptomatic infants, has been underscored in research and clinical practice guidelines.18,19 Screening facilitates early identification of infants at risk for hearing loss and other sequelae, allowing for timely intervention and management. While antiviral therapies such as ganciclovir and valganciclovir may mitigate symptoms and potentially improve outcomes in symptomatic cases, their impact remains under investigation.20
Audiologists and speech-language pathologists (SLPs) play integral roles in multidisciplinary teams caring for children with cCMV.21,22 Audiologists specialize in evaluating and treating individuals with hearing and balance disorders, while SLPs focus on assessment and treatment of speech, language, communication, swallowing, and voice disorders.23 This multidisciplinary approach is crucial given the wide-ranging impact of cCMV on developmental outcomes.21,22
Insufficient awareness and knowledge of cCMV among healthcare professionals, including audiologists and SLPs, can significantly impact patient care quality. Missed diagnoses or delays in intervention for hearing and speech impairments may occur due to an inadequate understanding of cCMV.24 This issue is compounded by variations in educational preparation and clinical training across countries, including in Saudi Arabia, where audiologists and SLPs typically require a bachelor’s degree, emphasizing university-level education.25,26
In Saudi Arabia, audiology and speech-language pathology are relatively new professions, with the first university program launched in 1985. Currently, there are 879 certified SLPs and 252 audiologists.27 Due to the early development of the field and a shortage of professionals, it is expected that knowledge of cCMV may be lacking. This study aims to assess the awareness and knowledge of cCMV among licensed audiologists and SLPs in Saudi Arabia. Identifying their knowledge gaps and perceptions can help improve care strategies and educational initiatives for children affected by cCMV.
Material and MethodsStudy Design and SettingWe conducted a cross-sectional survey-based study. Audiologists and SLPs who work in Saudi Arabia were invited to participate in an online survey. The survey link, created using Google Forms, was distributed through social media and snowball sampling among SLP and audiologists in Saudi Arabia. Potential participants received invitations to participate in the survey from a friend or encountered it through social media platforms, mainly LinkedIn, Twitter, and WhatsApp. The inclusion criteria were as follows: (1) both SLPs and audiologists needed to be licensed by SCFHS, and (2) their workplace must be located in Saudi Arabia. Those who were not licensed by SCFHS or not working in Saudi Arabia were excluded. The sample size for this study was calculated using Raosoft, Inc. (Seattle, WA, USA) (http://www.raosoft.com/samplesize.html) (accessed on 21 May 2022), with 90% confidence and an error rate of 10%. The suggested minimum recommended size of the survey was 89; however, we included more responses until we reached 107 participants.
Data CollectionThe data were collected from May to June, 2023, using a self-administered 26-item questionnaire. The questionnaire was developed based on previous work examining healthcare professionals’ awareness and knowledge about cCMV.28,29
The questionnaire was divided into seven sections; section one was the participants’ information sheet, and section two was the participant consent. In section three, the following demographic information was addressed; Saudi Commission for Health Specialties (SCFHS) registration and rank, highest degree, job, years of experience, working with children, workplace, frequency of working with patients with HL, hearing screening in the institution they work in, and whether or not they had children. In section four, participants were asked about their familiarity with various pediatric health conditions, and whether or not they had heard of CMV. If their answer was yes, they were transferred to the next section. Section five included six items that measure their knowledge about cCMV. The first item contains check boxes to assess the long-term sequelae of cCMV, followed by two-point Likert scale questions and three multiple choice questions that assess their general knowledge about cCMV, presentation of HL, and audiological management. In section six, participants were asked about their sources of cCMV information. In the last section, participants were asked about their perspectives on how to raise cCMV awareness. A pilot study with five participants was conducted to test the questions’ clarity and the time needed to answer them. However, based on their feedback, no modifications were needed.
Ethical ConsiderationParticipants were aware of the study’s purpose and were asked voluntarily to fill out the survey after informed consent. Responses were completely anonymous and confidential. The study was ethically approved by the Institutional Review Board, KSU (Ref. No. 23/0344/IRB). All data were kept confidential and were available only to the research team.
Statistical AnalysisBased on the Central Limit Theorem, the sample size of 1007 participants is sufficiently large to assume normality of the sampling distribution. However, to rigorously confirm the normality of our data, we performed several normality tests including the Anderson-Darling test, D’Agostino & Pearson test, Shapiro–Wilk test, and Kolmogorov–Smirnov test. These tests were conducted to validate our assumption of normality for the continuous variables (knowledge scores).
For categorical variables, frequencies and percentages were calculated, and the Chi-square test was used to compare familiarity with pediatric health conditions and cCMV awareness between audiologists and SLPs. Means and standard deviations were computed for continuous variables.
The knowledge score for each participant was calculated by assigning a score of 1 for every correct answer and a score of 0 for every incorrect or “I don’t know” response, with a total possible score of 14. We compared the knowledge scores of audiologists and SLPs using the Student’s t-test, given the confirmation of normality. All data analyses were conducted using GraphPad Prism 9.
ResultsDemographics and Work Experience of the RespondentsThe survey was distributed through social media platforms, and 107 responded with a completion rate of 100%, of whom 29% were audiologists and 71% were SLPs. As shown in Table 1, the SLPs had slightly more years of experience than the audiologists (p-value= 0.35). Most of the respondents, in both groups, were ranked as specialists holding a bachelor’s degree. More than half of the audiologists (58%) and 34% of SLPs work in hospitals. The most common workplace for the SLPs in this study was centers/clinics (49%). Regarding hearing screenings, 68% of the audiologists responded that their institutions offer hearing screening while 50% of the SLPs responded that their institution does not offer it. When participants were asked about the frequency they see patients with HL, the highest proportion of audiologists (65%) responded that they “always” see patients with HL. However, the highest proportion of SLPs (43%) responded that they “sometimes” see patients with HL. The majority of the respondents, from both groups, stated that they always work with children but most of them do not have children of their own.
Table 1 Descriptive Characteristics of Participants in the Survey (N=107)
Familiarity of cCMV Compared to Other ConditionsParticipants were asked to rate their familiarity with several pediatric conditions. When asked about their familiarity with cCMV, 39% of audiologists reported that they are “very familiar” with cCMV. In contrast, 1% of SLPs reported that they are “very familiar” with cCMV (p-value 0.0001). Most of the SLPs in this study were not familiar with most pediatric disorders, except for fetal alcohol syndrome, with which 37% of them were somewhat familiar, greater than the audiologists (p-value 0.437) (Table 2). On the other hand, audiologists were at least “slightly familiar” with all the listed pediatric disorders except for connexin 26 mutation, fetal alcohol syndrome, and toxoplasmosis.
Table 2 Self-Reported Familiarity with Pediatric Health Conditions
Awareness and Knowledge of cCMVAwareness about cCMV was significantly lower among SLPs compared to the au-diologists (Figure 1). Only 5 of the 31 audiologists (16%) said they had never heard of cCMV, which was significantly lower compared to 39 out of 76 (51%) SLPs (X2=17.57; df=2; p-value 0.0002).
Figure 1 Awareness of cCMV among audiologists and speech pathologists. Chi-square descriptive comparative test was used. Participants were asked whether they had previously heard of cCMV. Percentages (%) are used to show how many respondents chose “Yes” or “No” or ‘Maybe’ as their answer.
To measure their knowledge, participants whose answer was a yes or maybe to the question regarding hearing about cCMV were asked a series of factual questions on cCMV infection to evaluate the level of their knowledge about it. Detailed responses are presented in Supplementary Tables S1 and S2. The first question was about the sequelae of cCMV infection. All of the audiologists (100%) and 86% of the SLPs correctly chose HL as one of the sequelae of cCMV infection while 12% of audiologists and 8% of the SLPs incorrectly chose Asthma. Only 12% of audiologists and 14% of SLPs correctly knew that cCMV can lead to vocal cord paralysis. Most audiologist and SLPs agreed that cCMV is a significant contributor to neurodevelopmental delay and childhood hearing loss. When asked about the frequency of hearing evaluation, almost half (49%) of SLPs indicated that they do not know and audiologists gave inconsistent answers. However, more than half of the audiologists (58%) correctly replied that the follow up required for children born with cCMV is a serial audiological evaluation through the early school years and beyond as needed, while only 27% SLPs answered it correctly. Half of the audiologist and 35% of SLPs believed that infants born with asymptomatic congenital cytomegalovirus are at increased risk of HL at birth.
The knowledge score for each item was calculated and audiologists were compared to the SLPs (Table 3). The scores of the knowledge items between audiologists and SLPs were insignificant except for the question “cCMV is a significant contributor to childhood hearing loss”, in which audiologists scored significantly greater than SLPs (p-value=0.033) and the question “What follow-up is required for all children born with congenital cytomegalovirus?”, in which also the audiologists scored significantly greater than SLPs (p-value=0.0138). There was no significant difference between the mean knowledge scores for audiologists (6.8 out of 14, SD=2) and SLPs (5.7 out of 14, SD=2.5) (p-value=0.069).
Table 3 Assessment Scores of cCMV Knowledge Among Audiologists and Speech Pathologists Who Have Heard of cCMV
Source of the InformationWhen the participants were asked where they received their education regarding cCMV, 53% of the audiologists and 45% of SLPs answered during their undergraduate study (Supplementary, Figure S1). Additionally, the majority of audiologists and SLPs stated that their institutions offer neither hearing tests that target early cCMV screening nor universal cCMV screening, or that they were unaware of their availability. There was no significant difference between the responses of the audiologists and SLPs (p-value >0.05) (Figure 2A and B).
Figure 2 Congenital cytomegalovirus (cCMV) screening availability. Chi-square descriptive comparative test was used. (A) Does your institution or hospital offer hearing test targeting early cCMV screening? (B) Does your institution or hospital offer universal cCMV screening?.
Their Opinion and PerspectiveParticipants were asked about their opinions and perspectives regarding the importance of cCMV knowledge. The majority of both the audiologists (85%) and SLPs (84%) thought it was important for them to know more about cCMV, mainly because this knowledge is essential to their professional background. Additionally, they thought that cCMV knowledge should be part of their undergraduate studies.
DiscussionRaising awareness levels and knowledge of cCMV among SLPs and audiologists in Saudi Arabia has the potential to improve the care plans and the service quality for their patients. This study represents the first step toward this goal by assessing the awareness, knowledge, and attitude of these professionals towards cCMV. A total of 107 participants (31 audiologists and 76 SLPs) participated in an online survey. The findings highlight that there is a lack of adequate cCMV knowledge among both groups. While audiologists reported a high level of awareness of CMV, 51% of SLPs were not aware of the condition. However, many expressed a willingness to learn more.
In this study, 84% of audiologists and 49% of SLPs reported awareness of cCMV. It is expected that audiologists would have a higher awareness of cCMV compared to SLPs. This aligns with a previous study in the US, where 86% of audiologists were aware of cCMV compared to only 26% of SLPs.29 The gap between audiologists and SLPs in the US study is greater than the current study. One possible reason for this difference could be the variations in qualifications and certifications between Saudi Arabia and the US In this study, nearly half of the participants reported learning about cCMV during their undergraduate studies. In Saudi Arabia, two out of three academic programs follow the same curriculum to earn a bachelor’s degree in speech and hearing science, followed by a one-year internship during which students choose to qualify as a SLP or an audiologist.27 In contrast, students in the US qualify as audiologists or SLPs only after completing a graduate program.
This higher awareness among audiologists is also reflected in their greater familiarity with other pediatric health conditions than SLPs. The only exception, although non-significant, was fetal alcohol syndrome, where SLPs reported being “somewhat familiar”, with their knowledge significantly greater than that of the audiologists. In this study, 58% of the audiologists work in hospital settings, compared to only 34% of SLPs, although it does not apply to fetal alcohol syndrome. This difference could be because fetal alcohol syndrome affects several functions within SLP’s scope of practice, such as attention, memory and cognition.30
Our study revealed that cCMV knowledge among both groups was limited, with scores of 6.8/14 for audiologists and 5.7/14 for SLPs. This finding aligns with previous research, which has also reported limited knowledge among health professionals across different countries.31–34 Some notable differences were observed in individual item scores between audiologists and SLPs. For instance, audiologists scored significantly greater than SLPs in identifying cCMV as “a significant contributor to childhood hearing loss” and in recognizing that “serial audiological evaluation” is required for children born with cCMV. However, the results also highlight knowledge gaps among audiologists who participated in this study. Specifically, 19% of audiologists responded with “I don’t know” regarding the frequency of hearing evaluation, and 42% failed to recognize that “serial audiological evaluation” is required for children born with cCMV, despite this being essential core knowledge for their practice when treating children infected with cCMV.
In Saudi Arabia, the universal newborn hearing screening (UNHS) program, mandated by the Ministry of Health (MOH) since 2016, involves trained nurses conducting hearing tests in all public hospitals. Newborns who fail the screening after three attempts are referred for a full audiological assessment.35 The cost of screening is covered by the government, ensuring wide access. However, CMV testing is not routinely integrated into these hearing screenings, revealing a gap in linking CMV testing with UNHS.36 Addressing this gap could improve audiologists’ understanding of cCMV.
On the other hand, almost half of the SLPs indicated that they “don’t know” the frequency of the hearing evaluations needed for children diagnosed with cCMV. This can be attributed to the fact that conducting hearing evaluations is not within the scope of practice for SLPs, whereas it is a primary role for audiologists.37 However, this question also revealed inconsistent responses among audiologists in this study. Such inconsistencies have been reported in previous research, which has linked them to the lack of consensus in the literature about cCMV hearing evaluation follow-ups.29 Nevertheless, given the relatively low mean knowledge score among audiologists, we cannot establish a strong association. One possible reason for audiologists’ low scores is that the majority of participants hold only a bachelor’s degree in audiology, which may not provide as deep or specialized knowledge as one might be expected from audiologists with postgraduate studies.
Despite these gaps, both audiologists and SLPs emphasized the importance of gaining more knowledge about cCMV. The majority justified this need for their professional background rather than their current caseload. Moreover, they indicated that educational resources and activities about cCMV should be integrated into undergraduate studies and in their workplaces. The findings of this study can help establish targeted educational programs and training workshops to enhance understanding of cCMV and its implications among audiologists and SLPs in Saudi Arabia. This may prompt healthcare policymakers to establish or revise guidelines for screening and managing cCMV, incorporating it into standard newborn hearing screening protocols. Additionally, the study findings could encourage interdisciplinary collaboration among healthcare professionals to improve the management of cCMV cases. Highlighting the knowledge gap could also drive improvements in screening practices, leading to better detection and management of cCMV-related hearing loss in children, ultimately advancing pediatric audiology and SLP practices in Saudi Arabia.
This study has some limitations. Firstly, it relies on self-selection and self-reporting of participants’ familiarity with pediatric conditions, including cCMV. Secondly, the sample size, especially for the audiologists’ group, was relatively low. Lastly, the study did not include gender or age in the data collection process and did not examine the association of sociodemographic characteristics with cCMV awareness and knowledge. A study among women in the general population in Saudi Arabia reported that general knowledge of cCMV was limited. However, working in the healthcare field and having higher education levels were significantly associated with better knowledge of CMV.38 Therefore, to better understand the gap between the audiologists and the SLPs regarding cCMV awareness, future research with a larger sample size that assesses the association of sociodemographic characteristics, particularly gender, with cCMV awareness using multivariable analysis is required. Despite these limitations, this study is the first in Saudi Arabia to highlight the need to increase awareness of cCMV among SLPs and audiologists. The clinical implications of these findings are significant. Enhancing awareness and knowledge of cCMV among SLPs and audiologists could lead to better-informed clinical practices, improved screening protocols, and more effective management of cCMV-related conditions. This could translate into earlier and more accurate diagnoses, tailored interventions, and better overall patient outcomes. Improved awareness among these professionals may also lead to more consistent and effective communication with families regarding the implications of cCMV, ultimately supporting better long-term outcomes for affected children. Our findings highlight the need for increased awareness not only about cCMV but also for broader medical education among audiologists and SLPs. While the study focused on cCMV, it indicates a general need for improved knowledge across various pediatric conditions. Enhancing education on a range of medical issues, with a focus on cCMV, can lead to better clinical practices and overall patient care. This broader approach will ensure that healthcare professionals are better prepared for diverse medical scenarios, ultimately improving patient outcomes.
ConclusionIn conclusion, cCMV-infected children are anticipated to be commonly encountered by audiologists and SLPs as cCMV is a primary environmental cause of pediatric hearing loss. Our study has demonstrated that audiologists and SLPs require further education about cCMV, which can be integrated into their ongoing continuing education programs. Additionally, we recommend that university programs incorporate more material about cCMV in their curricula, as it is crucial for future healthcare professionals who will work closely with children to be knowledgeable about cCMV. Understanding cCMV’s impact on pediatric hearing loss is vital for early diagnosis and intervention. Proper education and awareness among audiologists and SLPs can lead to better management and support for affected children, ultimately improving their communication outcomes and quality of life.
AcknowledgmentsWe extend our appreciation to Researchers Supporting Project (RSPD2024R554), King Saud University, Riyadh, Saudi Arabia for funding this work.
DisclosureThe authors report no conflicts of interest in this work.
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