755 - A Quality Improvement Program for Targeted Screening for Congenital CMV (cCMV) Infection for Infants that Refer on the Newborn Hearing Screen: Will Infants with cCMV-Associated Hearing Loss be Missed?

Poster Number: 755
Publication Number: 755.12

Rebecca Kruc, University of Minnesota Medical School, St Cloud, MN, United States; Jordan Marmet, University of Minnesota Medical School, Minneapolis, MN, United States; Emily Graupmann, University of Minnesota Medical School, Minneapolis, MN, United States; Jeanne Gallmeier, M Health Fairview, Savage, MN, United States; Mark R. Schleiss, University of Minnesota Medical School, Minneapolis, MN, United States

Background: Congenital cytomegalovirus (cCMV) is the most common infectious cause of sensorineural hearing loss (SNHL). Although controversial (doi: 10.1542/peds.2020-0617), a proposed approach for identification of cCMV is “targeted screening”, whereby all infants who “refer” on the newborn hearing screen (NHS) are tested before hospital discharge.

Objective: We implemented targeted cCMV screening in 2018. In this quality improvement assessment, we examined: 1) compliance with the cCMV order set recommendations; 2) prevalence of cCMV identified by targeted screening; and 3) disease classification and hearing outcomes associated with cCMV.

Design/Methods: Urine PCR assay was recommended prior to hospital discharge in order sets for all infants who “referred” on the NHS for seven birthplaces in Fairview Health Systems nurseries in Minnesota. Referrals were tabulated by the Newborn Hearing Screening program at M Health Fairview/Masonic Children's Hospital.

Results: Approximately 55,000 deliveries occurred during the study period (1/1/18 to 12/31/22). 993 newborns (1.8%) were referred on NHS. Of these, 592 (60%) had urine cCMV PCR testing obtained before discharge. Thirteen infants (2.2%) were identified with cCMV. Additional clinical evaluation (doi: 10.1016/S1473-3099(17)30143-3) indicated that 4 had moderate-to-severe disease, 1 mildly symptomatic disease, 5 were asymptomatic with isolated SNHL, and 3 were asymptomatic (Table 1). Two infants had cCMV-defining cranial ultrasound results (Table 2). Audiological follow-up was available for 12 infants, and 9 (75%) have demonstrated SNHL to date (6 unilateral, 3 bilateral; Table 3). Viral loads ranged from < 137 IU/mL to >9,100,000 IU/mL. Challenges to diagnostic PCR for cCMV prior to nursery discharge included difficulty obtaining urine specimens, parental refusal, and declination of testing at the discharging provider's discretion. 

Conclusion(s): Only 60% of NHS "refer" infants underwent cCMV testing, in spite of the nursery discharge order set requirement. Among infants in the NHS refer group, 2.2% had cCMV infection. Most of the infants had proven SNHL on follow-up, allowing for early diagnosis, commencement of antivirals, and screening for evolution of SNHL. Interestingly, some infants that “referred” on NHS had normal audiological evaluation on follow-up but were noted to have cCMV infection. In most infants, the diagnosis of cCMV had not been clinically suspected. Quality improvement approaches are needed to improve compliance. Targeted cCMV screening for NHS referrals after Minnesota begins universal cCMV testing in 2023 will require optimization.