# ![](media/image1.wmf){width="2.3986111111111112in" height="2.2930555555555556in"} {#section .Chapter-#}

# 28 {#section-1 .Chapter-#}

# Vision and Hearing

Lead Agency: National Institutes of Health

### Contents {#contents .Heading-Special}

[Goal Page 28-3](#goal)

[Overview Page 28-3](#overview)

[Vision Page 28-3](#vision)

[Hearing Page 28-7](#hearing)

[Interim Progress Toward Year 2000 Objectives Page
28-10](#interim-progress-toward-year-2000-objectives)

[Healthy People 2010---Summary of Objectives Page
28-11](#healthy-people-2010summary-of-objectives)

[Healthy People 2010 Objectives Page
28-12](#healthy-people-2010-objectives)

[Vision Page 28-12](#vision-1)

[Hearing Page 28-14](#hearing-1)

[Related Objectives From Other Focus Areas Page
28-17](#related-objectives-from-other-focus-areas)

[Terminology Page 28-17](#terminology)

[References Page 28-19](#references)

##  {#section-2 .unnumbered}

## Goal

**Improve the visual and hearing health of the Nation through
prevention, early detection, treatment, and rehabilitation.**

## Overview

Among the five senses, people depend on vision and hearing to provide
the primary cues for conducting the basic activities of daily life. At
the most basic level, vision and hearing permit people to navigate and
to stay oriented within their environment. These senses provide the
portals for language, whether spoken, signed, or read. They are critical
to most work and recreation and allow people to interact more fully. For
these reasons, vision and hearing are defining elements of the quality
of life. Either, or both, of these senses may be diminished or lost
because of heredity, aging, injury, or disease. Such loss may occur
gradually, over the course of a lifetime, or traumatically in an
instant. Conditions of vision or hearing loss that are linked with
chronic and disabling diseases pose additional challenges for patients
and their families. From the public health perspective, the prevention
of either the initial impairment or additional impairment from these
environmentally orienting and socially connecting senses requires
significant resources. Prevention of vision or hearing loss or their
resulting disabling conditions through the development of improved
disease prevention, detection, or treatment methods or more effective
rehabilitative strategies must remain a priority.

### Vision

#### Issues and Trends

Vision is an essential part of everyday life, depended on constantly by
people at all ages. Vision affects development, learning, communicating,
working, health, and quality of life. In the United States, an estimated
80 million people have potentially blinding eye diseases, 3 million have
low vision, 1.1 million people are legally blind, and 200,000 are more
severely visually impaired.[^1]

In 1981, the economic impact of visual disorders and disabilities was
approximately \$14.1 billion per year.[^2] By 1995, this figure was
estimated to have risen to more than \$38.4 billion---\$22.3 billion in
direct costs and another \$16.1 billion in indirect costs each year.[^3]

Estimates of the number of people in the United States with visual
impairment vary with its definition. Legal blindness represents an
artificial distinction and has little value for rehabilitation but is a
significant policy issue, determining eligibility for certain disability
benefits from the Federal Government. Because of their reliance on
narrow definitions of visual impairment, many estimates of the number of
people with low vision are understated. When low vision is more broadly
defined as visual problems that hamper the performance and enjoyment of
everyday activities, almost 14 million persons are estimated to have low
vision. Visual impairment is 1 of the 10 most frequent causes of
disability in the United States.[^4] In children, visual impairment is
associated with developmental delays and the need for special
educational, vocational, and social services, often into adulthood. In
adults, visual impairment may result in loss of personal independence,
decreased quality of life, and difficulty in maintaining employment.
Impairment may lead to the need for disability payment, vocational and
social services, and nursing home or assisted living placement.

The leading causes of visual impairment are diabetic retinopathy,
cataract, glaucoma, and age-related macular degeneration (AMD). People
with diabetes are at risk of developing diabetic retinopathy, a major
cause of blindness. Because early diagnosis and timely treatment have
been shown to prevent vision loss in more than 90 percent of patients,
health care practice guidelines recommend an annual dilated eye
examination for all people with diabetes.[^5]**^,^** [^6] Studies
indicate, however, that many people with diabetes do not get an annual
dilated eye examination. An estimated 50 percent of patients are
diagnosed too late for treatment to be effective. People with diabetes
also are more likely to have cataracts and glaucoma.

Glaucoma is a major public health problem in this country. The disease
causes progressive optic nerve damage that, if left untreated, leads to
blindness. An estimated 3 million people in the United States have the
disease;[^7] of these, as many as 120,000 are blind as a result.[^8]
Furthermore, glaucoma is the number one cause of blindness in African
Americans. Treatments to slow the progression of the disease are
available. However, at least half of the people who have glaucoma are
not receiving treatment because they are unaware of their condition.
Blindness from glaucoma is believed to impose significant costs annually
on the Federal Government in Social Security benefits, lost tax
revenues, and health care expenditures.

While important strides have been made in the prevention and treatment
of eye disease, there is no cure for many causes of vision loss,
particularly AMD. In addition to being a leading cause of blindness in
the United States, AMD is a leading cause of low vision. People with low
vision often cannot perform daily routine activities, such as reading
the newspaper, preparing meals, or recognizing faces of friends. The
inability to see well affects functional capabilities and social
interactions and can lead to a loss of independence.

Myopia, or nearsightedness, is a common condition in which images of
distant objects are focused in front of, instead of on, the retina.
Myopia occurs in approximately 25 percent of the U.S. population.[^9] In
children, myopia is found in 2 percent of those entering first grade and
15 percent of those entering high school.[^10]

Many infants and young children are at high risk for vision problems
because of hereditary, prenatal, or perinatal factors. These individuals
need to be identified and tested early and annually to make sure their
eyes and visual system are functioning normally. Research in the 1980s
and 1990s found that amblyopia, a leading cause of visual impairment in
children, results from visual problems in very early life.[^11] These
problems can be prevented or reversed with early detection and
appropriate
intervention.![](media/image2.wmf){width="4.580555555555556in"
height="5.492361111111111in"}

While nothing medically can be done for patients with low vision, their
quality of life can be greatly improved. Many low vision services and
devices are available to help patients maintain their independence.
Generally, devices fall into two categories: visual and adaptive. Visual
devices use lenses or combinations of lenses to provide magnification.
They include such aids as magnifying spectacles, hand-held magnifiers,
stand magnifiers, computer monitors with large type, and closed-circuit
televisions. Adaptive devices include large-print reading materials
(books, newspapers), check writing guides, and high-contrast watch
dials. Also in this latter category are auditory aids, such as talking
computers.

#### Disparities

More than two-thirds of visually impaired adults are over age 65 years.
Although no gender differences exist in the number of older adults with
vision problems, more women are visually impaired than men are because,
on average, women live longer than men do. By 1999, almost 34 million
persons in the United States were expected to be over age 65 years; that
number is expected to more than double by the year 2030.[^12] As the
population of older adults grows larger, the number of people with
visual impairment and other aging-related disabilities is expected to
increase.

African Americans are twice as likely to be visually impaired as are
whites of comparable socioeconomic status.Error: Reference source not
found Studies conducted in the United States and the West Indies have
shown that primary open-angle glaucoma exists in a substantially higher
proportion of Caribbean blacks and African Americans than in
whites.Error: Reference source not found**^,^** [^13]**^,^** [^14]

Hispanics have three times the risk of developing type 2 diabetes as
whites, and they also have a higher risk of complications.[^15]
Available data suggest that visual impairment may be an important public
health problem in the Mexican-Hispanic population.[^16] There also is a
higher rate of myopia in Asian children.[^17]

Many barriers still need to be overcome in reducing vision disorders.
Among the major prevention strategies are educating health care
professionals and the general population about the benefits of
prevention, improving access to quality health care across socioeconomic
classes to decrease disparities, and gaining cooperation of families in
the screening and treatment of infants and children.

#### Opportunities

Blindness and visual impairment from most eye diseases and disorders can
be reduced with early detection and treatment. Most eye diseases,
however, lack symptoms until vision is lost. Vision that is lost cannot
be restored. Therefore, early intervention through regular vision exams
needs to be emphasized. Health education programs directed at groups at
higher risk for eye diseases and disorders are essential in preventing
blindness and visual impairments. The incorporation of vision into
health education programs can be beneficial to participants and to
agencies seeking to provide quality care to their clients.

The prevention of blindness and visual impairment and the promotion of
eye health often result in improved health status and reduced risk
factors for illness, disability, and death from diseases and injuries
across all age groups. Translation of scientific advances can help
people who are blind and visually impaired maintain their quality of
life and independence.

### Hearing

#### Issues and Trends

An estimated 28 million people in the United States are deaf or hard of
hearing.[^18] Some 1,465,000 individuals aged 3 years or older are deaf
in both ears.[^19] Deafness or hearing impairment may be caused by
genetic factors, noise or trauma, sensitivity to certain drugs or
medications, and viral or bacterial infections.

Language is the set of rules that allow for the sharing of thoughts,
ideas, and emotions. Speaking is one way that language can be expressed.
Language also is expressed in writing or through sign language by some
groups of individuals. In some cases, language can be expressed in
additional ways by people who have neurological disorders. The most
intensive period for development of language, either spoken or signed,
is during the first 3 years of life. This is the period when the brain
is developing and maturing. The skills associated with effective
acquisition of language, either speech or sign, depend on exposure to,
and manipulation of, these communication tools. Early identification of
deafness or hearing loss is a critical factor in preventing or
ameliorating language delay or disorder in children who are deaf or hard
of hearing, allowing appropriate intervention or rehabilitation to begin
while the developing brain is ready. Early identification and
intervention have lifelong implications for the child's understanding
and use of language.

The standard estimate of congenital hearing loss (1 in 1,000 live
births) appears to underestimate actual congenital hearing loss as
reported in data from States with universal newborn screening programs.
Estimates based on emerging data place the number at 2 to 3 per 1,000
live births.[^20] These data do not include children who are born with
normal hearing but have late-onset or progressive hearing loss. Hearing
loss often is sufficient to prevent the spontaneous development of
spoken language.[^21]**^,^** [^22]**^,^** [^23]**^,^** [^24] More than
50 percent of childhood hearing impairments are believed to be of
genetic origin.[^25] Earliest possible identification of infant hearing
loss has been endorsed widely as critical for the developing child.
Minimal hearing loss also is an important factor in school success and
psychosocial development.[^26]

Estimates for the average age of diagnosis of hearing loss in infants
and children range from 14 months[^27] to around 3 years.[^28] This
delay of diagnosis is significant in terms of time lost for
rehabilitation and time lost during unique opportunities provided by
brain development in the infant and young child for language
acquisition, spoken or signed. Nearly 15 percent of children have a
low-frequency or high-frequency hearing loss.[^29] Strategies for
intervention or rehabilitation depend on the kind of hearing loss, age
of onset, services available, and family preferences. Strategies include
hearing aids, augmentative and assistive devices, oral-auditory
instruction, sign language instruction, interpreter services, cued
speech, cochlear implant, or combinations of these devices and
strategies.

More than 300 inherited syndromes involve hearing
impairment.[^30]**^,^** [^31] Hereditary hearing loss can be either
syndromic (accompanied by other characteristics, such as visual
impairment) or nonsyndromic (where hearing loss is the only identifiable
characteristic). Not all hereditary hearing loss is present at birth.
Some hereditary hearing loss may be progressive or may appear later in
childhood or adulthood as late-onset hearing impairment or deafness. One
cause of late-onset hearing loss is otosclerosis. Otosclerosis, an
abnormal growth of bone in the middle ear, results in gradual loss of
hearing and affects 1 out of 100 adults in the U.S. population. Another
form of hearing loss is Meniere's disease,[^32] which causes bilateral,
often fluctuating, hearing loss in 20 to 40 percent of cases, usually in
conjunction with balance disorder and
tinnitus.![](media/image3.wmf){width="4.5993055555555555in"
height="4.3in"}

Otitis media, or middle ear infection, accounts for 24.5 million visits
to doctors' offices[^33] and is the most frequent reason cited for
taking children to the emergency department.[^34] Health care costs for
otitis media in the United States have been reported to be \$3 billion
to \$5 billion per year.[^35] Otitis media often occurs in repeated
bouts, causing periods of hearing loss that can affect children during
the critical time for language and speech acquisition and hamper
children in a variety of learning environments.

Approximately 10 million persons in the United States have permanent,
irreversible hearing loss from noise or trauma.[^36] Additionally, 30
million people are estimated to be exposed to injurious levels of noise
each day. Noise-induced hearing loss (NIHL) is the most common
occupational disease and the second most self-reported occupational
illness or injury.[^37] In industry-specific studies, 44 percent of
carpenters and 48 percent of plumbers reported they had a perceived
hearing loss.[^38] Ninety percent of coal miners are estimated to have a
hearing impairment by age 52 years,[^39] and 70 percent of male metal
and nonmetal miners will experience a hearing impairment by age 60
years.[^40] (See Focus Area 20. Occupational Safety and Health.)

Data indicate that people are losing hearing earlier in life and that
men are more frequently affected in the 35- to 60-year-old age
group.[^41] Noise-induced hearing loss can be the result of a traumatic,
sudden level of impulse noise, such as an explosion, that can leave an
individual immediately and permanently deafened; the result of
continuing exposure to high levels of sound in the workplace or in
recreational settings; the consequence of years of exposure causing
subtle, progressive damage; or exacerbated due to individual
vulnerability to noise. Noise-induced hearing loss is related to noise
level, proximity to the harmful sound, time of exposure, and individual
susceptibility. Many of these causes can be controlled by prevention.
Prevention of noise-induced hearing loss is necessary for people both on
and off the job.

#### Disparities 

The work environment of the 21st century will require intense use of
communication and information skills and technologies. The individual
who has a communication disability, disorder, or difference will be at a
disadvantage.

Data show that students with disabilities, including hearing impairment
and deafness, are disproportionately disadvantaged.[^42] The average
reading level for deaf persons aged 18 years is estimated at the fourth
grade.[^43] Early intervention for language acquisition, spoken or
signed, can improve later ability to use language. Hearing impairments
also are a major barrier to health care access and
information.[^44]**^,^** [^45] (See Focus Area 6. Disability and
Secondary Conditions.)

Older people also are a major concern in terms of hearing health
disparity. Presbycusis, the loss of hearing associated with aging,
affects about 30 percent of adults who are aged 65 years and older.[^46]
About half of the population over age 75 years has a significant hearing
loss.[^47] As the population ages and lives longer, these numbers are
increasing. Only about one-fourth of those who could benefit from a
hearing aid actually use one.[^48] More than 8 percent of the population
aged 70 years and older report both hearing and vision impairment.[^49]
With the exception of increased hearing loss in men, there are no
currently available data on these disparities.

#### Opportunities

Two activities have yielded opportunity for early identification and
intervention for infants who are born deaf or with hearing impairments.
As of 1999, 20 States had laws requiring hearing screening in the
newborn nursery. Early identification allows for language acquisition,
either spoken or signed, during the critical time period when the child
is developing communication skills. Research in the field of molecular
genetics has identified genes that contribute to hereditary hearing
impairment. The potential exists for early identification and
intervention for hearing impairment. Identifying individuals who may
experience late-onset or progressive hearing loss provides time to make
the appropriate treatment or rehabilitation options available.

Public education can promote hearing health and behavior to reduce
noise-induced hearing loss, which is a fully preventable condition. An
education effort, WISE EARS!,[^50] has been launched by a coalition of
government agencies headed by the National Institute on Deafness and
Other Communication Disorders at the National Institutes of Health and
the National Institute on Occupational Safety and Health at the Centers
for Disease Control and Prevention. They have joined with State
agencies; some 70 public interest, advocacy, and patient organizations;
businesses; industries; and unions as well as health professional
organizations in a national effort to educate the public about ear
defense. The education effort focuses both on the public, with special
emphasis on children, and on the workforce and has important World Wide
Web-based components.

A further opportunity exists with noise-induced hearing loss prevention.
Tinnitus, a ringing, buzzing, or roaring in the ears, is a symptom that
accompanies many forms of hearing loss and can be debilitating. Data
indicate that tinnitus affects almost 15 percent of adults aged 45 years
and older.[^51] Because tinnitus often is associated with preventable
noise-induced hearing loss, hearing protection is key to reducing one
important cause of tinnitus.

Assistive technologies are providing additional strategies for
individuals with disabilities. For individuals who are deaf or hard of
hearing, improved technologies will facilitate their ability to have an
equal opportunity in the workplace and in society. (See Focus Area 6.
Disability and Secondary Conditions.)

Early identification for improved intervention strategies, prevention of
noise-induced hearing loss through health education, and the development
of innovations in assistive technology could improve significantly the
hearing health of the Nation.

## Interim Progress Toward Year 2000 Objectives

Three Healthy People 2000 objectives addressed vision and hearing. Two
of these objectives, to reduce the number of cases of significant
hearing impairment and to reduce the number of cases of significant
visual impairment, have shown progress toward the targets. One
objective, early detection of significant hearing impairment, shows no
change from baseline.

Note: Unless otherwise noted, data are from the Centers for Disease
Control and\
Prevention, National Center for Health Statistics, *Healthy People 2000
Review, 1998--99*.

## Healthy People 2010---Summary of Objectives

### Vision and Hearing {#vision-and-hearing-1 .Heading-Special-Sub}

**Goal:** Improve the visual and hearing health of the Nation through
prevention, early detection, treatment, and rehabilitation.

  ------------- ------------------------------------------------------------
  **Number**    **Objective Short Title**

  **Vision**    

  28-1          Dilated eye examinations

  28-2          Vision screening for children

  28-3          Impairment due to refractive errors

  28-4          Impairment in children and adolescents

  28-5          Impairment due to diabetic retinopathy

  28-6          Impairment due to glaucoma

  28-7          Impairment due to cataract

  28-8          Occupational eye injury

  28-9          Protective eyewear

  28-10         Vision rehabilitation services and devices

  **Hearing**   

  28-11         Newborn hearing screening, evaluation,\
                and intervention

  28-12         Otitis media

  28-13         Rehabilitation for hearing impairment

  28-14         Hearing examination

  28-15         Evaluation and treatment referrals

  28-16         Hearing protection

  28-17         Noise-induced hearing loss in children

  28-18         Noise-induced hearing loss in adults
  ------------- ------------------------------------------------------------

## Healthy People 2010 Objectives

### Vision

28-1. (Developmental) Increase the proportion of persons who have a
dilated eye examination at appropriate intervals.

**Potential data source:** National Health Interview Survey (NHIS), CDC,
NCHS.

Many eye diseases and disorders have no symptoms or early warning signs.
Dilated eye examinations should be performed at appropriate intervals to
detect changes in the retina or optic nerve or both. Eye care
professionals can view the back of the eye for subtle changes and, if
necessary, initiate treatment at the right time.

28-2. (Developmental) Increase the proportion of preschool\
children aged 5 years and under who receive vision screening.

**Potential data source:** National Health Interview Survey (NHIS), CDC,
NCHS.

Many vision problems begin well before children reach school. Every
effort must be made to ensure that, before they reach age 5 years,
children receive a screening examination from their health care
provider. Early recognition of disease results in more effective
treatment that can be sight-saving or even life-saving.

28-3. (Developmental) Reduce uncorrected visual impairment due to
refractive errors.

**Potential data source:** National Health and Nutrition Examination
Survey (NHANES), CDC, NCHS.

28-4. Reduce blindness and visual impairment in children and adolescents
aged 17 years and under.

**Target:** 20 per 1,000 children and adolescents aged 17 years and
under.

**Baseline:** 25 per 1,000 children and adolescents aged 17 years and
under were blind or visually impaired in 1997.

**Target setting method:** Better than the best.

**Data source:** National Health Interview Survey (NHIS), CDC, NCHS.

+----------------------------------------+-----------------------------+
| **Children and Adolescents Aged\       | **Blindness and Visual\     |
| 17 Years and Under, 1997**             | Impairment**                |
+========================================+=============================+
|                                        | Rate per 1,000              |
+----------------------------------------+-----------------------------+
| **TOTAL**                              | 25                          |
+----------------------------------------+-----------------------------+
| **Race and ethnicity**                 |                             |
+----------------------------------------+-----------------------------+
| American Indian or Alaska Native       | DSU                         |
+----------------------------------------+-----------------------------+
| Asian or Pacific Islander              | DSU                         |
+----------------------------------------+-----------------------------+
| Asian                                  | DSU                         |
+----------------------------------------+-----------------------------+
| > Native Hawaiian or other Pacific     | DSU                         |
| > Islander                             |                             |
+----------------------------------------+-----------------------------+
| Black or African American              | 27                          |
+----------------------------------------+-----------------------------+
| White                                  | 24                          |
+----------------------------------------+-----------------------------+
|                                        |                             |
+----------------------------------------+-----------------------------+
| Hispanic or Latino                     | 23                          |
+----------------------------------------+-----------------------------+
| Not Hispanic or Latino                 | 25                          |
+----------------------------------------+-----------------------------+
| > Black or African American            | 27                          |
+----------------------------------------+-----------------------------+
| > White                                | 25                          |
+----------------------------------------+-----------------------------+
| **Gender**                             |                             |
+----------------------------------------+-----------------------------+
| Female                                 | 24                          |
+----------------------------------------+-----------------------------+
| Male                                   | 26                          |
+----------------------------------------+-----------------------------+
| **Family income level**                |                             |
+----------------------------------------+-----------------------------+
| Poor                                   | 39                          |
+----------------------------------------+-----------------------------+
| Near poor                              | 30                          |
+----------------------------------------+-----------------------------+
| Middle/high income                     | 20                          |
+----------------------------------------+-----------------------------+
| **Disability status**                  |                             |
+----------------------------------------+-----------------------------+
| Persons with disabilities              | 92                          |
+----------------------------------------+-----------------------------+
| Persons without disabilities           | 19                          |
+----------------------------------------+-----------------------------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

28-5. (Developmental) Reduce visual impairment due to diabetic
retinopathy.

**Potential data source:** National Health Interview Survey (NHIS), CDC,
NCHS.

28-6. (Developmental) Reduce visual impairment due to\
glaucoma.

**Potential data source:** National Health Interview Survey (NHIS), CDC,
NCHS.

28-7. (Developmental) Reduce visual impairment due to cataract.

**Potential data source**: National Health Interview Survey (NHIS), CDC,
NCHS.

28-8. (Developmental) Reduce occupational eye injury.

**Potential data sources:** Annual Survey of Occupational Injuries and
Illnesses (ASOII), U.S. Department of Labor, Bureau of Labor Statistics;
National Electronic Injury Surveillance System (NEISS), CPSC, and NIOSH.

28-9. (Developmental) Increase the use of appropriate personal
protective eyewear in recreational activities and hazardous situations
around the home.

**Potential data source:** National Health Interview Survey (NHIS), CDC,
NCHS.

Almost all eye injuries can be prevented. Many sports and recreation
activities, including baseball, basketball, tennis, racquetball, and
hockey, carry some risk of eye injury. Some injuries may go unnoticed
because only one eye is involved. Activities at home, such as cooking
and yard work, also may present eye injury risk.

28-10. (Developmental) Increase vision rehabilitation.

**28-10a.** Increase the use of rehabilitation services by persons with
visual impairments.

**28-10b.** Increase the use of visual and adaptive devices by persons
with visual impairments.

**Potential data source:** National Health Interview Survey (NHIS), CDC,
NCHS.

### Hearing

28-11. (Developmental) Increase the proportion of newborns who are
screened for hearing loss by age 1 month, have audiologic evaluation by
age 3 months, and are enrolled in appropriate intervention services by
age 6 months.

**Potential data sources:** State-based Early Hearing Detection and
Intervention (EHDI) Program Network, CDC and/or specific State data.

28-12. Reduce otitis media in children and adolescents.

**Target:** 294 visits per 1,000 children and adolescents under age 18
years.

**Baseline:** 344.7 visits per 1,000 children and adolescents under age
18 years were for otitis media in 1997.

**Target setting method:** Better than the best.

**Data sources**: National Ambulatory Medical Care Survey (NAMCS), CDC,
NCHS; National Hospital Ambulatory Medical Care Survey (NHAMCS), CDC,
NCHS.

  -----------------------------------------------------------------------
  **Children and Adolescents Under Age\            **Visits for\
  18 Years, 1997**                                 Otitis Media**
  ------------------------------------------------ ----------------------
                                                   Rate per 1,000

  **TOTAL**                                        344.7

  **Race and ethnicity**                           

  American Indian or Alaska Native                 DSU

  Asian or Pacific Islander                        DSU

  Asian                                            DNC

  Native Hawaiian or other Pacific Islander        DNC

  Black or African American                        294.9

  White                                            369.1

                                                   

  Hispanic or Latino                               DSU

  Not Hispanic or Latino                           DSU

  **Gender**                                       

  Female                                           321.8

  Male                                             366.5

  **Age**                                          

  Under 3 years                                    1,160.4

  3 to 5 years                                     456.6

  6 to 17 years                                    113.8

  **Family income level**                          

  Poor                                             DNC

  Near poor                                        DNC

  Middle/high income                               DNC

  **Disability status**                            

  Persons with activity limitations                DNC

  Persons without activity limitations             DNC
  -----------------------------------------------------------------------

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

28-13. (Developmental) Increase access by persons who have hearing
impairments to hearing rehabilitation services and adaptive devices,
including hearing aids, cochlear implants, or tactile or other assistive
or augmentative devices.

**Potential data sources:** National Health Interview Survey (NHIS),
CDC, NCHS; National Health and Nutrition Examination Survey (NHANES),
CDC, NCHS.

28-14. (Developmental) Increase the proportion of persons who have had a
hearing examination on schedule.

**Potential data sources:** National Health Interview Survey (NHIS),
CDC, NCHS; National Health and Nutrition Examination Survey (NHANES),
CDC, NCHS.

Audiologic screening serves both primary and secondary prevention
purposes, resulting in prevention and amelioration of the effects of
hearing loss using developmentally appropriate assessment and treatment.
Differing milestones and screening strategies are needed for pediatric
populations depending upon their status for impairment screening,
disorder screening, or disability screening and their age from birth
through 18 years. In the adult population, both impairment and
disability screening should occur every decade after age 18 years until
age 50 years with more frequent monitoring after age 50 years.[^52]

28-15. (Developmental) Increase the number of persons who are referred
by their primary care physician for hearing\
evaluation and treatment.

**Potential data sources:** National Ambulatory Medical Care Survey
(NAMCS), CDC, NCHS; National Health Interview Survey (NHIS), CDC, NCHS.

28-16. (Developmental) Increase the use of appropriate ear\
protection devices, equipment, and practices.

**Potential data source:** National Health Interview Survey (NHIS), CDC,
NCHS.

Noise-induced hearing loss (NIHL) can be caused by one-time exposure to
an impulse noise, such as gunfire or an explosion, or by repeated
exposure to sounds at various levels over an extended period of time
from sources such as combustion engines, electric motors, or woodworking
equipment. The effects of NIHL may be immediate hearing loss that is
permanent---resulting from an impulse sound that severely damages the
structures of the inner ear---and may be accompanied by tinnitus.
Tinnitus is a ringing, buzzing, or roaring in the ears or head. Hearing
loss and tinnitus may be experienced in one or both ears. Tinnitus may
continue constantly or intermittently throughout a lifetime. The damage
that occurs slowly over years of continuous exposure to loud noise is
accompanied by various changes in the structure of the hair cells. It
also results in hearing loss and tinnitus. Both forms of hearing loss
can be prevented. For the worker, hearing conservation involves
engineering controls, noise monitoring and measuring, employee
notification, audiometric testing and evaluation, health education, and
followup that includes hearing protection and fitting and/or
audiologic/otologic evaluation.[^53]**^,^** [^54] For the public,
knowledge of potentially dangerous noise, fitting and use of hearing
protection, careful product selection, and audiologic/otologic
evaluation are all significant factors in prevention of NIHL.

28-17. (Developmental) Reduce noise-induced hearing loss\
in children and adolescents aged 17 years and under.

**Potential data source:** National Health and Nutrition Examination
Survey (NHANES), CDC, NCHS.

28-18. (Developmental) Reduce adult hearing loss in the noise-exposed
public.

**Potential data sources:** National Health Interview Survey (NHIS),
CDC, NCHS; National Health and Nutrition Examination Survey (NHANES),
CDC, NCHS.

## Related Objectives From Other Focus Areas

5\. Diabetes

5-13. Annual dilated eye examinations

6\. Disability and Secondary Conditions

6-11. Assistive devices and technology

20\. Occupational Safety and Health

20-11. Work-related, noise-induced hearing loss

## Terminology

(A listing of abbreviations and acronyms used in this publication
appears in Appendix H.)

**Age-related macular degeneration (AMD):** Deterioration of the macula
that results in a loss of sharp central vision.

**Amblyopia:** Developmental abnormality of the central nervous system
that causes impaired vision in one or both eyes.

**Assistive devices:** Technical tools and devices used to aid
individuals who have communication disorders in performing actions,
tasks, and activities. Examples of assistive devices include alphabet
boards, text telephones (TT/TTY/TDD), and text-to-speech conversion
software. (See Focus Area 6. Disability and Secondary Conditions.)

**Audiologic evaluation:** Tests and procedures that measure the ability
to hear. Identifies type and degree of hearing loss. Included are tests
of conduction, speech perception and speech discrimination, and case
history; can include a central test battery. Evaluation can include
recommendations about appropriate assistive devices.

**Augmentive devices**: Tools that help individuals with limited or
absent speech to communicate, such as communication boards, pictographs
(symbols that look like the things they represent), and ideographs
(symbols representing ideas).

**Cataract:** Cloudiness of the lens that may prevent a clear image from
forming on the retina.

**Cochlear implant:** Medical device that bypasses damaged structures in
the inner ear and directly stimulates the auditory nerve, allowing some
deaf individuals to hear and to maintain or develop speech and language.

**Cued speech:** Method of communication that combines speech reading
with a system of handshapes placed near the mouth to help deaf or
hard-of-hearing individuals differentiate words that look similar on the
lips (for example, "bunch" versus "punch") or understand words when the
lips do not move (for example, "kick").

**Diabetic retinopathy:** Complication of diabetes that damages the
retina.

**Dilate:** Process by which the pupil is temporarily enlarged with
special eyedrops, allowing the eyecare specialist to view the fundus
better.

**Ear infection:** See *Otitis media*.

**Fundus:** Interior posterior lining of the eye that includes the
retina, optic nerve, and macula.

**Hearing aid:** Electronic device that brings amplified sound to the
ear. A hearing aid usually consists of a microphone, amplifier, and
receiver.

**Hereditary hearing loss:** Hearing loss passed down through
generations of a familythat is, with a genetic basis.

**Legal blindness:** Determines eligibility for benefits from the
Federal Government; however, it has little or no value for
rehabilitation purposes.

**Low vision (limited vision):** A visual impairment, not correctable by
standard eyeglasses or contact lenses, medication, or surgery, that
interferes with an individual's ability to perform activities of daily
living.

**Meniere's disease:** Inner ear disorder that can affect both hearing
and balance and can cause episodes of vertigo, hearing loss, tinnitus,
and the sensation of fullness in the ear.

**Myopia:** Nearsightedness, or the ability to see close objects more
clearly than distant objects. Myopia may be compensated for with glasses
or contact lenses.

**Noise-induced hearing loss:** Hearing loss that is caused by either a
one-time exposure to very loud sound(s) or by repeated exposure to
sounds at various loudness levels over an extended period of time.
Hearing loss may be temporary or permanent.

**Nonsyndromic hereditary hearing loss:** Hearing loss or deafness that
is inherited and is not associated with other inherited features.

**Open angle glaucoma:** Disease characterized by increased intraocular
pressure that damages the optic nerve.

**Optic nerve:** Bundle of over 1 million nerve fibers that carry visual
messages from the retina to the brain.

**Oral-auditory instruction:** Techniques used with persons who have
hearing loss to improve their ability to speakfor example,
speechreading, communication management, language and auditory skill
development, and counseling.

**Otitis media:** Commonly called ear infection; an inflammation of the
middle ear caused by viral or bacterial infection.

**Otosclerosis:** An abnormal growth of bone in the middle ear that
results in gradual loss of hearing and affects 1 out of 100 adults in
the U.S. population.

**Presbycusis:** Loss of hearing that gradually occurs because of inner
or middle ear changes in some individuals as they grow older.

**Rehabilitation:** As used in this focus area, addresses the needs in
daily living skills that are directly related to vision or hearing loss.

**Retina:** Light-sensitive layer of tissue that lines the back of the
eyeball. The retina sends visual impulses through the optic nerve to the
brain.

**Sign language:** Hand movements, gestures, and facial expressions that
convey grammatical structure and meaning.

**Syndromic hereditary hearing loss:** Hearing loss or deafness that is
inherited or passed down through generations of a family along with
other features.

**Tactile devices:** Mechanical instruments that make use of touch to
help individuals to communicate who have certain disabilities, such as
deafness and blindness.

**Tinnitus:** Sensation of a ringing, roaring, or buzzing sound in the
ears or head. Tinnitus is often associated with various forms of hearing
impairment.

**Visual aid:** Optical and nonoptical devices that help people with low
vision make use of their remaining sight.

**Visual field:** Entire area that can be seen when the eye is looking
forward, including peripheral vision.

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