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In the 26th session of the second series of assessments of
Healthy People 2010, Assistant Secretary for Health ADM Joxel Garcia
convened a Progress Review on Vision and Hearing. He was assisted by staff of
the lead Agency for this Healthy People 2010 focus area, the National
Institutes of Health (NIH), whose principal research and outreach efforts
directed at vision and hearing are centered in the National Eye Institute (NEI)
and the National Institute on Deafness and Other Communication Disorders
(NIDCD), respectively. Also participating in the review were representatives
from other agencies and offices within the U.S. Department of Health and Human
Services (HHS) and from the U.S. Department of Education and the U.S.
Department of Veterans Affairs. Drawing on his experience as Deputy Director of
the Pan American Health Organization, ADM Garcia noted the stark contrast
between the general level of eye health in the United States and that
prevailing in Central America, for instance, whose health officials have been
very grateful for our assistance with cataract surgery and other areas of
concern. However, even in relatively wealthy U.S. States, such as Connecticut,
where ADM Garcia served as Commissioner of Public Health, there remain pockets
of poverty with limited access to vision and hearing screening and treatment
services. ADM Garcia stressed that, as much as our scientific achievements in
these fields should be commended, these advances must be harnessed to a greater
degree to their practical application. At this point, ADM Garcia withdrew from
the meeting to keep another appointment, and Principal Deputy Assistant
Secretary for Health Donald Wright assumed the role of Chair of the Progress
Review.
The complete November 2000 text for the Vision and Hearing
focus area of Healthy People 2010 is available online at www.healthypeople.gov/document/html/volume2/28vision.htm.
Revisions to the focus area chapter that were made after the January 2005
Midcourse Review are available at www.healthypeople.gov/data/midcourse/html/focusareas/fa28toc.htm.
For comparison with the current state of the focus area, the report on the
first-round Progress Review (held on October 20, 2004) is archived at
www.healthypeople.gov/data/2010prog/focus28/2004fa28.htm.
The meeting agenda, tabulated data for all focus area objectives, charts, and
other materials used in the Progress Review can be found at a companion site
maintained by the National Center for Health Statistics (NCHS)/Centers for
Disease Control and Prevention: www.cdc.gov/nchs/about/otheract/hpdata2010/focusareas/fa28-vision2.htm.
That site has a link to wonder.cdc.gov/data2010,
which provides access to detailed definitions for the objectives in all 28
Healthy People 2010 focus areas and periodic updates to their
data.
Data Trends
Richard Klein, Chief of the NCHS Health Promotion Statistics
Branch, presented an overview of data that relate to the Vision and Hearing
objectives. He noted that about 21 million adults in the United States are
visually impaired, and about 36 million (17 percent) have some degree of
hearing loss. On average, lifetime costs associated with visual impairment are
$601,000 per person (in 2003 dollars), and with severe to profound hearing
loss, more than $1 million per person. Early diagnosis, treatment, and use of
protective devices are highly effective in preventing vision and hearing loss.
Of the focus area objectives and subobjectives that were retained after the
2005 Healthy People 2010 Midcourse Review, one has surpassed its
target, three are moving toward their targets, two are getting worse, seven
show little or no change, nine have baseline data only, and three lack any
data. Mr. Klein then provided a more detailed examination of objectives the
focus area workgroup selected to highlight at the Progress Review:
(Obj. 28-4): In 2007, the rate of blindness
and visual impairment among children and adolescents aged 17 years and less was
25 per 1,000 population, virtually unchanged since the baseline year and with
little difference evident among racial and ethnic groups and between genders.
The 2007 rate for children and adolescents from families whose income falls
below the Federal poverty level was 40 per 1,000. The 2010 target for all
population groups is 18 per 1,000.
(Obj. 28-2): In 2002, the baseline year and
the most recent year for which data are available, 36 percent of children aged
5 years and less had received vision screening. Among children in that age
group who had a disability, 64 percent had received such screening, compared
with 35 percent of those without a disability. The target for all population
groups is 52 percent.
(Obj. 28-1): In 2002, the baseline year and
the most recent year for which data are available, 55 percent of adults aged 18
years and older (age-adjusted) were receiving dilated eye examinations at
appropriate intervals—that is, every 2 years. The target for all groups is
58 percent, a target met by females in 2002 and surpassed (at 62 percent) by
persons with at least some college. In 2002, 57 percent of adults who had
diabetes had received dilated eye examinations within the previous year,
compared with 37 percent of adults without diabetes. A related objective in the
Diabetes focus area has a target of 76 percent for the proportion of adults who
have diabetes and who have received a dilated eye examination in the preceding
12 months.
(Obj. 28-8a): In 2006, the rate of
occupational eye injuries resulting in lost work days was 3.9 per 10,000
full-time workers in private industry, compared with 4.8 per 10,000 in 2002.
The rate per 10,000 for females in 2006 was 1.8, compared with 5.3 for males.
The target is 3.4 for all population groups.
(Objs. 28-9a, b): In 2002, the baseline
year and the most recent year for which data are available, 15 percent of
children aged 6 to 17 years always or most of the time used protective eyewear
at home. The proportion of such use for females was 11 percent, compared with
17 percent for males. The target is 20 percent for all population groups. In
2002, 33 percent of adults aged 18 years and older (age-adjusted) always or
most of the time used protective eyewear at home, with females by a proportion
of 26 percent and males by 36 percent. Percentage of use showed little
variation by educational level. The target is 37 percent.
(Obj. 28-12): Office visits for otitis
media by children and adolescents aged less than 18 years decreased from 344.7
per 1,000 in 1997 to 233.0 per 1,000 in 2006. Both racial groups, black and
white, for whom data were available in 2006, as well as both genders, surpassed
the target of 294 per 1,000. However, children aged less than 3 years are still
far short of the target, with an office visit rate of 840.1 per 1,000 in
2006.
(Objs. 28-14a, b): In the period
2003–2004, 29 percent of adults aged 20 to 69 years (age-adjusted) had
received a hearing examination in the previous 5 years, little changed from the
30 percent who had done so in the period 1999–2002. The proportion of
females who had received the service in 2003–2004 was 21 percent, compared
with 36 percent of males, who surpass the target of 35 percent. In the period
2003–2004, 38 percent of adults aged 70 years and older had received a
hearing examination in the previous 5 years, the same proportion as in
1999–2002. The proportion of females in this age group who had received
the service in 2003–2004 was 36 percent, compared with 42 percent of
males, which surpasses the target of 41 percent. In 2003–2004, 47 percent
of persons aged 80 years and older had received a hearing examination in the
previous 5 years.
(Objs. 28-13a, c): In 2006, preliminary
data indicate that 162.7 per 1,000 adults with hearing loss and aged 20 to 69
years (age-adjusted) used hearing aids. In 2007, preliminary data indicate that
289.1 per 1,000 adults with hearing loss and aged 70 years and more used
hearing aids. The targets for these two subobjectives have not been
determined.
(Obj. 28-18): In the period 2003–2004,
121.4 per 1,000 adults aged 20 to 69 years (age-adjusted) had noise-induced
hearing loss, compared with 119.0 per 1,000 in 1999–2002. Among racial and
ethnic groups for whom data were available, and by gender, the rates per 1,000
for adults who had noise-induced hearing loss in 2003–2004 were as
follows: non-Hispanic blacks, 85.4; non-Hispanic whites, 133.3; Mexican
Americans, 140.9; females, 72.5 (below target rate); and males, 176.2. The
target for all population groups is 88.1 per 1,000.
(Obj. 28-16a): In the period
2003–2004, 483.0 per 1,000 adults aged 20 to 69 years (age-adjusted) who
were exposed to loud noises used ear protective devices. Among females so
exposed, the rate of use was 253.8 per 1,000, compared with a use rate of 597.4
among males, which surpasses the target rate of 514.5 per 1,000. The rates of
use per 1,000 in 2003–2004 by source of the loud sounds were as follows:
at work, 505.1; from firearms outside of work, 600.9; and from other loud
noises outside of work, 328.4.
Key Challenges and Current Strategies
NEI Acting Deputy Director Lore Anne McNicol and NIDCD
Director James Battey made presentations on the principal themes of the
Progress Review. Their statements, the discussion that ensued, and Progress
Review briefing materials prepared by an interagency workgroup identified a
number of barriers to achieving the objectives, as well as activities under way
to meet these challenges, including the following:
Barriers
Vision
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Vision problems in children have been associated with
developmental delays and the need for special educational, vocational, and
social services. Eye conditions with onset in childhood have the potential to
create visual impairment that lasts a lifetime.
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Vision disorders are the fourth most prevalent class of
disability in the United States and the most prevalent cause of handicapping
conditions in childhood. The most common vision disorders are amblyopia,
strabismus, and significant refractive error.
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Only 42 percent of vision-impaired Americans without
health insurance seek medical attention for their eye problems.
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Eye injuries are the leading cause of blindness in
children in the United States. Many are sports-related injuries, which account
for 100,000 physician visits yearly at a cost of $175 million.
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Age-related eye diseases and conditions—such as
macular degeneration, glaucoma, diabetic retinopathy, and cataracts—are
the leading causes of vision impairment and blindness in people over age 65.
Nearly 63 percent of persons aged 60 and older have refractive errors. With
Americans living longer than ever before and the aging of the baby-boomer
generation, the number of people who are blind or have low vision is projected
to increase substantially by the year 2020.
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Each day, more than 2,000 adult workers in the United
States receive medical treatment because of work-related eye injuries. Eye
injuries are common in all industries, but workers in the fields of
construction, mining, agriculture, and manufacturing have the highest rates of
eye injuries on the job.
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The NEI-sponsored Los Angeles Latino Eye Study suggests
that this population has some of the highest rates for visual impairment and
blindness in the United States, with women affected more frequently than
men.
Hearing
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As with vision problems, the number of U.S. adults with
hearing loss is expected to increase significantly as the population ages,
because hearing loss and aging are related to a high degree. Hearing loss is
one of the three most prevalent chronic conditions in older Americans, ranking
just after hypertension and arthritis. More than 90 percent of adult hearing
loss is sensorineural; that is, the sensory cells in the inner ear, called hair
cells, or the auditory nerve cells are permanently damaged.
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Hearing screening studies in newborns have shown that
congenital hearing loss affects between 1 and 3 of every 1,000 babies born in
the United States. About one-half of congenital hearing loss is genetic; the
other half is related to environmental factors.
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Increases in hearing loss prevalence occur earlier in
life among persons who smoke, are exposed to elevated noise levels, or are at
risk for cardiovascular disease. Recently published data also suggest that
hearing impairment may be a largely unrecognized complication of
diabetes.
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The most reliable study suggests that around 4 to 6
percent of youth aged 6 to 19 years have already experienced some type of
hearing deficit due to noise-induced hearing loss (NIHL). Despite its
prevalence, most young people report that they haven't heard, read, or seen
anything related to NIHL. Even many young people who are aware of the risks of
NIHL may not take preventive action.
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Only one in five of the adults in need of a hearing aid
have one. Stigma appears to have a significant effect on the decision of many
individuals not to wear hearing aids. Also, the cost of a state-of-the-art
hearing aid is in the neighborhood of $6,000.
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Members of the U.S. military are at particularly high
risk for noise-induced hearing loss due to the increased intensity and
magnitude of current operations and extended training and tours of duty.
One-third of soldiers and Marines returning from Afghanistan and Iraq in 2004
were referred to audiologists for hearing evaluations due to acute acoustic
blast exposure. Among those referred, hearing loss was identified in 72
percent.
Activities and Outcomes
Vision
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Ninety percent of sports-related eye injuries in
children can be prevented with the use of protective eyewear.
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A variety of vision rehabilitation services are
available to help people cope with vision loss. These services include clinical
assessments, vision rehabilitation therapy, orientation and mobility training,
counseling, and other support services.
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Cheaper vision screening methods have been developed
that compare well with the standard procedures offered by
ophthalmologists.
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NEI's National Eye Health Education Program promotes and
conducts research, synthesizes and disseminates scientific knowledge, and
fosters the adoption and implementation of evidence-based eye health programs,
interventions, and policies among Federal, State, and local service agencies
and professional organizations in the effort to improve the eye health of all
Americans. NEI has a Web site at www.nei.nih.gov.
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The American Academy of Ophthalmology's EyeSmart
public awareness campaign emphasizes the need for Americans to know their
risk factors for eye diseases, infections, and injuries, and how
ophthalmologists can help prevent, diagnose, and treat eye conditions.
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NEI has awarded seed money to 21 community organizations
to develop programs designed to help reduce uncorrected visual impairment due
to refractive error through the Healthy Vision 2010 Community Awards.
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The Lions Clubs International Foundation and Johnson
& Johnson Vision Care have collaborated to develop Sight for Kids,
a program that provides vision screenings and eye health education for
children. More than 6 million children have been screened through the program;
203,930 have been referred to physicians for further evaluation; 41,818 have
received glasses; and 35,374 have been treated for various eye
conditions.
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In May 2003, NEI established the first annual Healthy
Vision Month Observance. Healthy Vision Month 2008 focused on the importance of
using protective eyewear during sports-related activities among
children.
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The basic requirements for eye protection in the
workplace are set by the U.S. Department of Labor's Occupational Safety and
Health Administration (OSHA). The National Institute for Occupational Safety
and Health (NIOSH)/Centers for Disease Control and Prevention (CDC) provides a
variety of resources on workplace eye safety. The CDC Workplace Health and
Safety Web page at www.cdc.gov/workplace
includes a link to eye safety resources.
Hearing
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Since 1999, NIDCD has led a coalition of Government
agencies and other partnering organizations in the WISE EARS!®
initiative in a national effort to educate the public about ear defense against
NIHL. The effort places a special emphasis on children and persons in the
workforce. NIDCD has a Web site at www.nidcd.nih.gov.
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The prevalence of hearing screening of newborns has
improved, so that about 90 percent of infants born in hospitals now receive
screening.
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CDC's Early Hearing Detection and Intervention
Program has worked cooperatively with the States to track progress in the
implementation of universal newborn hearing screening.
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Hearing clinics now are located in some national
discount chains, a trend which improves access to diagnosis and treatment of
hearing loss.
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OSHA regulations mandate that employers provide hearing
screenings and ear protective devices for employees in workplaces where noise
levels equal or exceed 85 decibels for an 8-hour time-weighted average.
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In October 2008, NIDCD launched It's a Noisy Planet:
Protect Their Hearing, a new public education campaign designed to
increase awareness of parents of children, aged 8 to 12 years, about the causes
and prevention of NIHL. With this information, parents and other adults can
encourage children to adopt healthy hearing habits before and during the time
that they develop listening, leisure, and working habits.
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The Joint Committee on Infant Hearing Screening,
comprising representatives from professional associations and affinity
organizations, has issued practice guidelines to supplement the training of
pediatric audiologists involved in hearing screening, evaluation, and
intervention programs for infants less than 1 year of age.
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Further research conducted or funded by NIDCD promises
to advance the development and refinement of hearing aid microphones that
permit directional amplification. These devices could then be tailored to the
hearing challenges of individuals in their daily communication settings and
thus be better able to approximate normal hearing.
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NIDCD-funded clinical trials will soon be under way, in
which researchers will test the ability of nutrients, such as vitamins and
minerals, to prevent NIHL in military personnel and college students.
What Needs To Be Done
Participants in the Progress Review made the following
suggestions for public health professionals and policymakers to consider as
steps to enable further progress toward achieving the objectives for Vision and
Hearing:
Vision
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Give greater attention to eliminating or reducing
disparities in eye health among population groups; for instance, myopia is
highly prevalent among Chinese Americans.
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Increase efforts to expand screening for visual problems
among preschool children; currently, only 22 percent are screened.
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Take steps to ensure that all vision screening
guidelines for use in schools include examinations for astigmatism, which has
been shown to have a negative effect on school performance.
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Seek new ways to overcome the barriers that low income
and lack of insurance place against receipt of eye examinations and corrective
eyewear.
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Explore alternative means of communicating with seasonal
migrant workers, a group who are at increased risk for eye injuries and
difficult to reach with health protection information.
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Broaden public awareness that standard prescriptive
eyeglasses do not provide adequate eye protection.
Hearing
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Improve tracking and communication associated with
infants referred from newborn hearing screening programs. Only one-half of
referrals are now receiving appropriate follow-up services.
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Establish protocols for a well-defined, scientifically
based approach for the selection and fitting of hearing aids in infants and
young children.
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Strive to address better the reasons for many
individuals' reluctance to wear hearing aids, which are continually being
improved in form and functionality, although at a cost.
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Accelerate the application of new research findings
about the causes of NIHL and the preventive and therapeutic measures that can
be taken against it.
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Seek to enlarge the share of clinical trials that
receive public funding, rather than continue to rely to such a large degree on
funding from parties that have a financial interest in the outcome of the
trials and the application of research results.
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Direct additional research toward precisely defining the
influence of diabetes on age-related hearing loss.
Vision and Hearing
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Contacts for information about Healthy
People 2010 Focus Area 28—Vision and Hearing:
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[Signed December 23, 2008]
Donald Wright, M.D.,
M.P.H.
Principal Deputy Assistant Secretary for Health
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