In the 27th in a series of assessments
of Healthy People 2010, Deputy Assistant Secretary
for Health (Disease Prevention and Health Promotion)
Penelope Royall chaired a focus area Progress Review
on Vision and Hearing, in which she was assisted by staff
of the lead agency for this Healthy People 2010
focus area, the National Institutes of Health (NIH).
This leadership role is carried out by two NIH Institutes,
the National Eye Institute (NEI) and the National Institute
on Deafness and Other Communication Disorders (NIDCD).
CAPT Royall complimented those associated with this recently
created focus area on their outstanding performance in
bringing new scientific knowledge to the front lines
of health care and in the monitoring of the quality of
that care. She stressed the importance of early intervention
to protect and conserve the vision and hearing of young
children and to mitigate the severity of vision and hearing
impairments that can heavily degrade the quality of life
of older Americans. Also participating in the review
were representatives of the U.S. Department of Veterans
Affairs and other U.S. Department of Health and Human
Services (HHS) offices and agencies.
The complete text for the Vision and Hearing focus area
of Healthy People 2010 is available at www.healthypeople.gov/2010/document/html/volume2/28vision.htm.
The meeting agenda, tabulated data for all focus area
objectives, charts, and other materials used in the Progress
Review can be found
at www.cdc.gov/nchs/about/
otheract/hpdata2010/focusareas/fa28-vision.htm.
Data Trends
Edward Sondik, Director of the National Center for Health
Statistics/Centers for Disease Control and Prevention
(CDC), provided an overview of the national impact of
vision and hearing disorders. Approximately 85 million
people in the United States have potentially blinding
eye diseases, have low vision, or are legally blind.
The economic burden of visual disorders and disabilities
came to about $38.4 billion in 1995. An estimated 28
million people in the United States are deaf or hard
of hearing. Dr. Sondik then proceeded to report on progress
achieved in meeting the targets of selected Healthy
People 2010 objectives in the Vision and Hearing
focus area.
In 2002, the first year for which data have ever been
available, the age-adjusted rate of visual impairment
due to diabetic retinopathy among persons age 18 and
older with diabetes was 45.9 per 1,000. The age-adjusted
rate for Hispanics in that age group was 73.3 per 1,000,
compared with 41.0 per 1,000 for non-Hispanic whites
age 18 and older. The 2010 target is 40.0 per 1,000 (Obj.
28-5). In 2002, the age-adjusted rate of visual impairment
due to glaucoma in adults age 45 and older was 13.5 per
1,000. Among non-Hispanic blacks with glaucoma in that
age group, the rate of visual impairment was 38.4 per
1,000 (and more than 50 per 1,000 for those who had not
completed high school). For persons age 45 and older
who had both glaucoma and diabetes, the visual impairment
rate was 29.1 per 1,000 in 2002. The target is 10.5 per
1,000 (Obj. 28-6).
Persons with visual impairments age 18 and older made
use of visual rehabilitation services, such as job training,
counseling, or support, at a rate of 14.1 per 1,000 (age
adjusted) in 2002. The target is 14.2 per 1,000 (Obj.
28-10a). In 2002, persons with visual impairments age
18 and older used visual adaptive devices, such as magnifiers,
closed circuit television, white canes, or guide dogs,
at an age-adjusted rate of 22 percent. Among population
groups for which data were available, usage rates did
not vary significantly by race and ethnicity, gender,
or educational attainment. The target is 25 percent (Obj.
28-10b).
Data for 2001 indicate that 66 percent of newborn infants
received hearing screening within 1 month of birth. The
target is 90 percent (Obj. 28-11a). Of those infants
for whom audiologic evaluation was indicated, 56 percent
received this service before they reached 3 months of
age. The target is 70 percent (Obj. 28-11b). Of those
infants who were evaluated, 57 percent were enrolled
in appropriate intervention services before the age of
6 months. The target is 85 percent (Obj. 28-11c). In
2002, children and adolescents age 18 and younger made
physicians’ office visits for otitis media at a
rate of 302.9 per 1,000, compared with 344.7 per 1,000
in 1997. The target is 294 per 1,000 (Obj. 28-12). Among
the age group younger than 3 years, the rate of visits
was 937.5 per 1,000 in 2002, and for children age 3 to
5, the rate of visits was 452.5 per 1,000 in that year.
In 1999, the rate of new cochlear implants was 17 per
10,000 for deaf or very hard-of-hearing persons. Among
all age groups, the highest rate of new cochlear implants
is reported for deaf or very hard-of-hearing children
younger than 6 years of age. The target for the total
population is 100 new implants per 10,000 (Obj. 28-13b).
Key Challenges and Current Strategies
In the presentations that followed the data overview,
the principal themes were introduced by representatives
of the two co-lead agencies—Paul Sieving, Director
of NEI, and James Battey, Jr., Director of NIDCD. These
agency representatives set the stage for discussions
that ensued among participants in the review, identified
a number of barriers to achieving the objectives, and
discussed activities under way to meet these challenges,
including the following:
-
(Vision) Diabetic retinopathy affects
more than 5.3 million people with diabetes age 18
and older.
Prevalence of diabetic retinopathy parallels
the epidemic of type 2 diabetes, which is more prevalent
among American Indians/Alaska Natives than among any
other racial or ethnic group. Hispanics also are disproportionately
affected. The Los Angeles Latino Eye Study found that
participants who had diabetes for 15 years or more were
more than 3 times as likely to have diabetic retinopathy
and more than 23 times as likely to have a severe form
of the disease than those who had been newly diagnosed. Glaucoma is a leading cause of blindness in black
Americans and Hispanics. The disorder has no symptoms,
causes no pain, and does not affect vision until peripheral
vision has disappeared. Of the estimated 2.2 million
Americans who have glaucoma, half are unaware of the
presence of the disease. Through its National Eye Health Education Program
(NEHEP), launched in 1991, NEI provides Federal leadership,
technical expertise, and resources that have enabled
the vision community to work as a united force to reduce
blindness and vision impairment and to reach out to people
who are at highest risk for eye diseases and disorders. In 2000, the HHS Indian Health Service (IHS)
deployed a telemedicine system specialized for the remote
diagnosis of diabetic retinopathy. IHS increased ophthalmologist
staffing at its facilities by 20 percent in 2003–2004. -
NEI has formed two distinct partnerships that advance
progress toward achievement of the Healthy People
2010 objectives for vision. First, the NEHEP
Partnership represents more than 70 national organizations
in the public and private sector that are working
with their chapters, members, and affiliates to support
the objectives. Second, the Healthy Vision Consortium
is made up of professionals and more than 180 local
organizations that have made a commitment to achieving
these objectives. In addition, the American Optometric
Association signed a Healthy People 2010
Memorandum of Understanding with HHS, under which
the association is working with state health departments
to address the objectives.
-
Each May, NEI sponsors Healthy Vision Month to focus
national public attention on eye health. Each year,
a different Healthy People 2010 vision objective
is featured. The May 2004 observance promoted the
importance of having people with diabetes receive
annual comprehensive dilated eye exams. Some components
of this program will remain in use beyond 2004.
Through the new Healthy Vision Community Awards
Program, NEI provides “seed money” to develop
innovative vision-related health education projects that
have the potential for sustainability. From the program’s
beginning in 2002, more than 120 awards of $10,000 each
have been made to collaborative community health education
initiatives that support Healthy Vision 2010 objectives. -
(Hearing) Congenital hearing loss,
at a rate of approximately 3 per 1,000 births, occurs
more frequently than other conditions for which newborns
are routinely screened. At least 50 percent of congenital
hearing loss has a genetic origin.
Otitis media, an infection or inflammation of
the middle ear, is one of the most common reasons for
physician visits by children and adolescents and costs
the United States from $3 to $5 billion annually. This
illness often occurs in children who have not yet developed
speech and language, thus making it difficult for parents
to know when their child is suffering from an ear infection.
More than half the children in this country have an episode
of acute otitis media before their first birthday, and
90 percent have an episode by age 5. Medicare for older adults and people with disabilities
and Medicaid for economically disadvantaged patients
do not reimburse fully the cost of cochlear implants,
resulting in disparities in access to health care and
utilization. NIDCD published a Request for Applications that
called for research on specific pathogenic mechanisms
that trigger otitis media, genomic approaches to the
development of an otitis media vaccine, and studies of
genomic markers in individuals that might identify a
predisposition to chronic otitis media infections. Several
grants have been funded in response to this announcement. NIDCD has an ongoing activity in which it creates
initiatives for Hispanic individuals through participation
with various Spanish-language and Hispanic interest meetings,
exhibit opportunities, and collaborative efforts with
the NIH Hispanic Communications Workgroup. A new technology using short electrodes promises
to yield greater benefit from cochlear implants by restoring
hearing at high frequencies, while preserving low-frequency,
residual hearing in individuals who have been unsuccessful
in using hearing aids. The CDC Early Hearing Detection and Intervention
(EHDI) program monitors newborn screening implementation
in collaboration with directors of speech and hearing
programs in state health and welfare agencies. EHDI reported
that, in 2001, 73 percent of hospitals or birthing centers
performed universal hearing screening in 52 participating
states/areas. -
Under the leadership of NIDCD and CDC’s National
Institute on Occupational Safety and Health, a national
effort called Wise Ears! was launched by
a coalition of Federal agencies; state agencies;
public interest, advocacy, and patient organizations;
businesses; industries; and unions to educate the
public about hearing protection. The initiative gives
special attention to children and the workforce.
The recent discovery of bacterial biofilms, which
remain in the middle ear space long after acute onset
of otitis media, is providing new insight into the genesis
of chronic otitis media with persistent middle ear effusion.
Eventually, the discovery should lead to new treatment
options.
Approaches for Consideration
Participants in the review made the following suggestions
for steps to enable further progress toward achievement
of the objectives for the Vision and Hearing focus area:
-
(Vision) Exert greater efforts
to raise awareness of the availability of vision
rehabilitation services among people who have visual
impairments.
Pursue studies on the interacting roles of the
environment and genetics in risk factors for retinal
disease. Strive to describe more completely the prevalence,
physiology, and natural history of optic neuropathies
such as glaucoma, as well as the history of intervention
results, over the full course of these diseases and within
racial and ethnic subpopulations. Develop a knowledge base of design requirements
for architectural structures, open spaces, and parks,
and the devices necessary to help people with
visual impairments to get around and perform everyday
tasks. -
(Hearing) Promote training of audiologists
in procedures for fitting hearing assistive devices
for very young children and infants.
Increase research and development to produce
and refine hearing aids capable of selective amplification
of sound, as in the speech of persons directly in front
of the hearing aid wearer whom they are addressing. Intensify followup studies on persons who have
received cochlear implants to determine why some implantees
benefit much more than others. Seek to define more clearly
the benefits and constraints of binaural (dual) cochlear
implantation. Direct additional resources to development of
a vaccine against otitis media and to the identification
and characterization of genes responsible for hereditary
hearing impairment. -
(Vision and Hearing) Step up collaboration
between NEI and NIDCD and other Federal agencies
with a special interest in addressing problems of
vision and hearing among their clientele, such as
the Administration on Aging, IHS, the U.S. Department
of Veterans Affairs, and the U.S. Department of Education.
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Contacts for information about Healthy People
2010 focus area 28 — Vision and Hearing:
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Cristina V. Beato, M.D.
Acting Assistant Secretary for Health
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