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NIH Health Disparities Strategic Research Plan and Budget Fiscal Years 2009-2013

MISSION/VISION STATEMENT

The mission of the National Institute on Deafness and Other Communication Disorders (NIDCD) is to conduct and support basic and clinical research and research training in the normal and disordered processes of hearing, balance, smell, taste, voice, speech, and language. Basic and clinical research focused on understanding the normal processes and disorders of human communication are motivated both by intrinsic scientific interest and importance to the health of the Nation.

STRATEGY FOR ADDRESSING HEALTH DISPARITIES

The Director, NIH, has requested that each Institute and Center at NIH develop a Strategic Plan for Reducing Health Disparities. Human communication disorders cross all social and ethnic groups. NIDCD is conducting research to determine how communication disorders may impact health disparities. In addition, NIDCD recognizes the underrepresentation of minorities in its research and research training activities and diligently works to increase participation for these minority individuals and groups. To this end, the NIDCD seeks to facilitate participation of these special populations in its activities to further its research mission and ensure that all populations are served in human communication research. In addition, while the Institute strives to increase opportunities in research for minority groups, the organization also acknowledges and values the need to address research opportunities to understand the basis for health disparities within the purview of NIDCD.

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1.0 AREAS OF EMPHASIS IN RESEARCH

1.1 AREA OF EMPHASIS ONE: HEARING AND BALANCE RESEARCH

Hearing impairment, deafness, and balance disorders can impose a heavy social and economic burden on individuals, their families, and their communities. Approximately 36 million American adults report some degree of hearing loss1 and almost eight million adults report a chronic problem with balance2.

1.1.1 Objective One: Support the Hearing Component of the Hispanic Community Health Study /Study of Latinos (HCHS/SOL) to Improve the Health Outcomes of Hispanic Populations

Approximately two to three out of 1,000 babies born in the United States (U.S.) each year have a detectable hearing loss3, which can affect their speech, language, social, and cognitive development. Hearing loss is one of the most common birth disorders in the U.S., is especially prevalent among Hispanic-Americans and those from low-income households4. In addition, Hispanic children who may also have had multiple middle ear infections, or chronic otitis media, without receiving proper hearing health care services, could experience increased rates of conductive hearing loss as adults5. Since very few studies have examined these disparities, as part of the Hispanic Community Health Study/Study of Latinos (HCHS/SOL), a long-term epidemiological study involving seven institutes of the NIH, the NIDCD will evaluate the prevalence of hearing loss (including noise-induced hearing loss) and tinnitus among Hispanics living in the U.S. (http://www.cscc.unc.edu/hchs/).

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1.1.1.1 Action Plan

The HCHS is recruiting as many as 16,000 adults ages 18-74 at four sites: Bronx, Chicago, Miami, and San Diego. The study will randomly recruit approximately 4,000 Cuban-Americans, 4,000 Mexican-Americans, 4,000 Puerto-Ricans, and 4,000 Central/South Americans, illustrating the diversity of the U.S. Hispanic/Latino population. The study is a unique opportunity to attract and train Hispanic researchers in epidemiology and population-based research. The participants are be recruited through four Field Centers affiliated with San Diego State University, Northwestern University in Chicago, Albert Einstein College of Medicine in the Bronx area of New York, and the University of Miami. Seven additional academic centers serve as scientific and logistical support centers (including University of Wisconsin, Wake Forest University, University of Minnesota at Fairview, University of Mississippi Medical Center, University of Minnesota School of Public Health, Columbia University, and Case Western Reserve University).

1.1.1.2 Performance Measures

This study will examine four different Hispanic groups in the U.S., to determine the prevalence of hearing loss (including conductive hearing loss, noise-induced hearing loss) by age and other risk factors that may play a protective or harmful role in various types of hearing loss.

1.1.1.3 Outcome Measures

Gain a better understanding of the prevalence of hearing loss in the U.S. Hispanic population. Following their audiometric evaluation, study participants will have annual follow-up interviews conducted for 2-4 years to determine whether any new hearing health problems or outcomes (e.g., tinnitus) have occurred.

1.1.1.4. Projected Budget

FY2009: $485,000
FY2010 (est.): $250,000
FY2011 (est.): $250,000

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1.1.2 Objective Two: Support the CHIMES (CMV and Hearing Multicenter Screening Study) to Improve Screening for Newborns in the U.S. for Congenital CMV Infection

Congenital cytomegalovirus (CMV) is the most common viral infection passed from a mother to her unborn child. Approximately one percent of newborns, or about 40,000 infants each year, are born infected with CMV. Children born with CMV infection who have symptoms of infection, such as hearing loss, seizures, visual impairment, and cerebral palsy, are usually identified at birth and receive appropriate medical care. However, the majority of CMV-infected children—roughly 90 percent—have no symptoms at birth. These children have what is called a “silent” infection, which often goes unnoticed. In addition, CMV is a leading cause of progressive hearing loss in children in the U.S. Approximately 10 percent to 15 percent of children with congenital CMV infection have some degree of hearing loss that has delayed onset and worsens during childhood. Although few population based studies of the etiology of hearing loss in infants have been performed, when such studies have included assays for congenital CMV infection, they have strongly suggested that congenital CMV infection is a leading cause of sensorineural hearing loss in children. In addition, even though a majority of infants born in the U.S. are already screened for hearing loss, most infants are not tested for CMV unless they already show signs of the disease. Further, newborn hearing screening cannot detect or predict hearing loss that will occur later in childhood. While the causes of childhood hearing loss remain largely unknown, estimates indicate that as much as 20 percent to 30 percent of childhood hearing loss is caused by CMV infection.

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1.1.2.1 Action Plan

Due to the compelling but limited data on congenital CMV infection and hearing loss in infants, in March 2002, the NIH convened a workshop with a panel of experts on congenital CMV infection and newborn hearing and metabolic screening. The panel made several recommendations regarding future research priorities in the area of congenital CMV infection and hearing loss. Based on the workshop recommendations, the NIH published a Request for Proposals (RFP) and, in 2005, funded the University of Alabama School of Medicine, Birmingham, to lead a multicenter study, entitled the CMV and Hearing Multicenter Screening (CHIMES) Study, on the role of congenital CMV in the development of hearing loss in children. Identifying asymptomatic children and following their progress to determine if hearing loss develops is a major focus of this research. The CHIMES study is one of the largest studies of its kind with approximately 100,000 children from diverse backgrounds to be screened at birth for CMV infection. Those who test positive for CMV will undergo follow-up diagnostic hearing testing to determine the onset, severity, and progression of hearing loss. The scientists will analyze the data to better understand the relationship between CMV infection and hearing loss and to determine the extent to which CMV screening together with hearing testing can improve the detection and prediction of permanent hearing loss in children. The CHIMES study will also examine the multicultural aspects of CMV infection and hearing loss in terms of language and cultural differences.

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1.1.2.2 Performance Measures

This study is NIDCD Government Performance and Reporting Act (GPRA) Scientific Research Outcome, or SRO, goal. SRO 9.4 states that “By 2013, develop and evaluate the efficacy of neonatal screening for congenital cytomegalovirus (CMV) infection to permit identification of infants who will develop CMV-induced hearing loss in the first years of life.” The NIH has developed a strategy to implement neonatal screening for CMV infection to permit the identification of infants who will develop CMV-induced hearing loss. Based on the outcome of patient enrollment, the NIH-supported scientists will proceed to the pilot phase of the CHIMES study. If this goal is successfully accomplished, the NIH will move forward with its goal to improve the health of individuals with hearing loss.

1.1.2.3 Outcome Measures

Monitor progress of this objective as directed in the GPRA SRO goal 9.4 matrix and evaluate the results of this study approximately one year after the contract end date of June 2012.

1.1.2.4. Projected Budget

FY2009: $1,897,450
FY2010 (est.): $1,739,776
FY2011 (est.): $1,587,763

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1.2 AREA OF EMPHASIS TWO: SMELL AND TASTE RESEARCH

Each year, more than 200,000 people visit a physician for chemosensory problems such as smell or taste disorders6, however, many more smell or taste disorders go unreported. Smell and taste play important roles in preferences and aversions for aromas, specific foods, and flavors.

1.2.1 Objective One: Support the Smell and Taste Component of the National Health and Nutrition Examination Survey (NHANES) to Gain a Better Perspective on the Prevalences of Smell and Taste Disorders in Different Populations

Research on smell and taste may help increase our understanding of serious health problems in addition to improving our understanding of food preferences. For example, obesity, diabetes, hypertension, malnutrition, Parkinson’s disease, Alzheimer’s disease, and multiple sclerosis are all accompanied or signaled by chemosensory problems. Several ethnic and minority groups also have a greater risk for some of these chronic diseases. For example, cardiovascular disease is the #1 killer of African Americans in the U.S. with about four out of ten African-American adults having some form of cardiovascular disease. These populations may also have a higher risk of smell and taste disorders.

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1.2.1.1 Action Plan

NIDCD plans to support incorporating standard measures of taste and smell into the National Health and Nutrition Examination Survey (NHANES), a nationally-representative, population based survey. The NHANES is a program of studies designed to assess the health and nutritional status of adults and children in the U.S. (http://www.cdc.gov/nchs/nhanes.htm).

1.2.1.2 Performance Measures

This project will help determine the prevalence of smell and/or taste impairment in the U.S., as well as to identify risk factors for smell or taste loss and possible associated conditions such as obesity, altered dietary intake, and chronic illnesses (such as asthma, cardiovascular disease, etc.).

1.2.1.3 Outcome Measures

Support research to gain a better understanding of the prevalence of smell and taste disorders in the U.S. population.

1.2.1.4 Proposed Budget

FY2009: $0
FY2010 (est.): $500,000
FY2011 (est.): $500,000

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1.3 AREA OF EMPHASIS THREE: VOICE, SPEECH, AND LANGUAGE RESEARCH

Voice, speech, and language are tools that all individuals use to communicate or share thoughts, ideas, and emotions. However, approximately 7.5 million people in the U.S. have trouble using their voice7. By the first grade, roughly five percent of children have noticeable speech disorders8. Between six and eight million people in the U.S. have some form of language impairment9. Disorders involving voice, speech, or language, as well as swallowing, can have an overwhelming effect on an individual’s health and quality of life; they affect people of all ages with or without hearing impairment, including children with autism and adults with aphasia or dysarthria.

1.3.1 Objective One: Support Research to Better Identify the Health Disparities in Autism

The communication problems of autism spectrum disorders (ASD) vary, depending upon the intellectual and social development of the individual. Some may be unable to speak, whereas others may have rich vocabularies and are able to talk about topics of interest in great depth. However, most have difficulty effectively using language, and many have problems with word and sentence meaning, intonation, and rhythm. Some children benefit from intensive interventional therapies to treat communication deficits in autism. However, these interventions are often more effective the earlier they are initiated.

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1.3.1.1 Action Plan

Significant racial and ethnic minority disparities exist in the early diagnosis of ASD, often delaying minority access to early interventions and services. In order to better identify children at risk of developing autism, the NIDCD supports this research project to identify behavioral markers of normal and atypical development from two different minority populations.

1.3.1.2 Performance Measures

The results of this research will lead to culturally sensitive screening and evaluation methods that may decrease the age at which all children with ASD are diagnosed.

1.3.1.3 Outcome Measures

Develop better diagnostics and risk assessments to diagnose children from diverse backgrounds with autism.

1.3.1.4 Projected Budget

FY2009: $238,233
FY2010 (est.): $226,872
FY2011 (est.): $0

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1.3.2 Objective Two: Support Research to Better Treat Aphasia in Bilingual Individuals

Aphasia is a disorder that results from damage to portions of the brain that are responsible for language. For most people, these are areas on the left side (hemisphere) of the brain. Aphasia usually occurs suddenly, often as the result of a stroke or head injury, but it may also develop slowly, as in the case of a brain tumor, an infection, or dementia. The disorder impairs the expression and understanding of language as well as reading and writing. According to the National Aphasia Association, approximately 80,000 individuals acquire aphasia each year from strokes. About one million people in the U.S. currently have aphasia. Diagnosis and treatment of bilingual aphasia is one area where disparities continue to exist even though this topic is of great importance in an increasingly bilingual world.

1.3.2.1 Action Plan

Aphasia therapy aims to improve a person’s ability to communicate by helping him or her to use remaining language abilities, restores language abilities as much as possible, compensate for language problems, and learn other methods of communicating. Treatment can involve individual or group therapy with a language therapist to help the individual regain language ability. Other treatment approaches involve the use of computers to improve the language abilities of people with aphasia. Various factors contribute to how well a particular strategy works for each individual; this is compounded for bilingual individuals who are bilingual because the rehabilitation method may not be able to address the bilingual language development. The NIDCD supports research to address the important issue of aphasia treatment for bilingual individuals.

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1.3.2.2 Performance Measures

The results from this study will help to determine an optimal rehabilitation strategy for bilingual individuals with aphasia.

1.3.2.3 Outcome Measures

Establish recommendations on the best approach for treatment/rehabilitation of bilingual individuals with aphasia.

1.3.2.4 Projected Budget

FY2009: $220,720
FY2010 (est.): $182,283
FY2011 (est.): $0

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1.3.3 Objective Three: Support Research to Examine the Health Disparities in Individuals with Specific Language Impairment (SLI)

Specific language impairment (SLI) is a delay in language development in the absence of other developmental delays or neurological symptoms. About eight percent of American children in kindergarten have SLI. These children have difficulty developing and using language. These difficulties may affect not only understanding and speaking, but also reading and writing abilities once these children enter school. A child with SLI typically scores within the normal range for nonverbal intelligence and has no hearing loss. Motor skills, social-emotional development, and the child’s neurological profile are all normal. The only noticeable gap is in language development. Studies have also shown that up to 80 percent of children with language delays at age two will catch up by age seven. However, this also means that for one in five “late-talking” toddlers, language delays persist. Many children in the U.S. speak various languages, e.g., bilingual or speak in a dialect, such as Southern African American English (SAAE). In addition, health disparities exist for children who live in the rural Deep South. The treatment and services needed for these bilingual and dialect-speaking children with SLI may differ from traditional methods.

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1.3.3.1 Action Plan

By supporting research on examining the clinical markers of SLI in bilingual individuals10 and dialect speakers, NIDCD hopes to improve diagnosis and treatment of SLI in bilingual individuals and dialect speakers. NIDCD-supported scientists can use a new reliable and valid language test has been created for bilinguals in these studies.

1.3.3.2 Performance Measures

The results of these studies will help to improve the diagnosis and availability of treatments options for bilingual individuals and dialect speakers with SLI.

1.3.3.3 Outcome Measures

Continue to improve treatment options for bilinguals and dialect speakers with SLI and lay the groundwork for a larger epidemiological investigation in the future.

1.3.3.4 Projected Budget

FY2009: $1,521,367
FY2010 (est.): $1,354,460
FY2011 (est.): $1,030,827

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2.0 AREAS OF EMPHASIS IN RESEARCH CAPACITY BUILDING

2.1 AREA OF EMPHASIS ONE: ENCOURAGE AND SUPPORT NIDCD GRANTEES TO TRAIN STUDENTS FROM DISADVANTAGED BACKGROUNDS AND/OR UNDERREPRESENTED MINORITY GROUPS

2.1.1 Objective One: Support Research Supplements and the Trans‑NIH Jointly Sponsored11 Ruth L. Kirschstein National Research Service Awards for Individual Predoctoral Fellowships (F31) to Promote Diversity in Health-Related Research

2.1.1.1 Action Plan

Attract and encourage students at or approaching the dissertation/doctoral candidacy stage or post-dissertation stage. Conduct the initial peer review of applications for these fellowship programs within NIDCD’s Scientific Review Branch based on an expedited schedule of four months from submission to award.

2.1.1.2 Performance Measures

Encourage individuals from Underrepresented Groups and Specific Populations to participate in these programs and benefit from to the NIDCD’s expedited review process for these training grants

2.1.1.3 Outcome Measures

Maintain the number of qualified research trainees and individuals in career development programs to enable the research community to be in a position to meet the future health needs of individuals with communication disorders.

2.1.1.4 Projected Budget

FY2009: $1,285,872
FY2010 (est.): $1,300,000
FY2011 (est.): $1,350,000

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3.0 AREAS OF EMPHASIS IN COMMUNITY OUTREACH, INFORMATION DISSEMINATION, AND PUBLIC HEALTH EDUCATION

3.1 AREA OF EMPHASIS ONE: ENCOURAGE PUBLIC OUTREACH TO IMPROVE HEALTH OUTCOMES

3.1.1 Objective One: Support the It's a Noisy Planet. Protect Their Hearing Campaign

The NIDCD Office of Health Communication and Public Liaison sponsors, It's a Noisy Planet. Protect Their Hearing, a national public education campaign (http://www.noisyplanet.nidcd.nih.gov/) designed to increase awareness among parents of children ages eight to twelve (“tweens”) about the causes and prevention of noise-induced hearing loss (NIHL). With this information, parents and other adults can encourage children to adopt healthy habits that will help them protect their hearing for life. NIDCD conducted focus group testing in November 2007 to help determine the most effective promotional messages and strategies for reaching a wide range of audiences, including African American and Spanish-speaking parents of tweens. Eight focus groups were conducted; of these, four groups were conducted in Spanish and two groups were conducted with African Americans. Information obtained from these groups was then used to develop culturally relevant educational and promotional materials for the new campaign, which was launched in October 2008. In July 2009, NIDCD conducted a focus group session to test Spanish-language slogans and visuals for the Noisy Planet campaign. Hispanic parents of children ages eight to twelve years old took part in the discussion, representing a range of education, income levels, and countries of origin.

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3.1.1.1 Action Plan

The NIDCD will continue to increase public awareness through education and mass media efforts and define strategic partnerships with other national organizations to help disseminate campaign messages and materials.

3.1.1.2 Performance Measures

To assess how well the Noisy Planet web site is meeting the informational needs of its target audiences, a user satisfaction survey was designed and customer satisfaction results will continue to be monitored. The NIDCD’s Noisy Planet education materials have been extremely popular since the program’s launch. Visits to the Noisy Planet Web site also have grown from nearly 2,000 user sessions in October 2008 to highs of nearly 11,000 user sessions each month.

3.1.1.3 Outcome Measures

Continue to evaluate the effectiveness of the Noisy Planet campaign in helping individuals understand the hazards of noise and how they can practice good hearing health in everyday life.

3.1.1.4 Projected Budget

FY2009: $322,753
FY2010 (est.): $330,000
FY2011 (est.): $340,000

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4.0 AREAS OF EMPHASIS IN INTEGRATION OF RESEARCH, RESEARCH CAPACITY BUILDING, AND COMMUNITY OUTREACH, INFORMATION DISSEMINATION AND PUBLIC HEALTH EDUCATION

4.1 AREA OF EMPHASIS ONE: EARLY HEARING DETECTION AND INTERVENTION (EHDI)

Approximately two to three in every 1,000 children are born with some degree of congenital hearing loss. Hearing loss is also one of the most common birth disorders in the U.S., and is especially prevalent among Native Americans, Hispanic-Americans, and those from low-income households.

In 1989, less than five percent of newborns received hearing screening prior to leaving the hospital10 and most children were not identified to have a hearing impairment until the age of two to three.11 This delay during a critical period for language development led to lifelong difficulties in language acquisition and the need for costly special education in schools for the deaf. In 1993, NIH held a Consensus Development Conference that first endorsed the screening of all newborns for hearing loss before the newborn leaves the hospital.12 Follow-up research supported by NIH examined various research objectives related to EDHI programs. Based on such research, in 1997, an NIH-convened expert panel was able to recommend standard screening methods for nationwide EDHI programs – methods still routinely used today. In 1999, Congress passed and President Clinton signed into law the first Newborn and Infant Hearing Screening and Intervention Act which coordinated and funded state EDHI programs. Today, because of these combined efforts, 42 states plus the District of Columbia and Puerto Rico have legislatively mandated EDHI programs and more than 90 percent of infants are screened for hearing impairment within the first month of life, most before leaving the hospital.13 Children now receive confirmed hearing loss diagnoses on average between two and three months of age, and NIH-supported research has demonstrated that infants beginning remediation for their hearing loss prior to six months of age experience emotional and social development parallel with their physical development. EHDI is another excellent example of why prevention and screening programs play a crucial in the improvement of health outcomes for all populations.

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4.1.1 Objective One: Support Prenatal Alcohol and SIDS and Stillbirth (PASS) Network to Improve EHDI for Native American Children

Native Americans are two times more likely to have hearing loss than Caucasians and four times more likely than other races14. Hearing impairment has great cultural significance to Native Americans due to the reliance on oral communication and the transmission of knowledge held by elders. Alcoholism is one of the most significant public health problems for Native Americans. Native Americans also have some of the highest rates of fetal alcohol spectrum disorders (FASD) in the Nation15. These effects can include physical problems and problems with behavior and learning, including birth defects, vision and hearing problems. Because of the health concerns for hearing loss in Native Americans, the NIDCD supports research to establish health communication strategies that are culturally acceptable, feasible, and sustainable for Native American communities and that will ultimately reduce the incidence of hearing loss and related tinnitus. The NIDCD is also supporting research to extend our knowledge in the prevention, screening, and identification of those most at risk for hearing loss in Native American populations.

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4.1.1.1 Action Plan

The NIDCD will support a two year pilot study of hearing in newborn Native American infants. This pilot study will be conducted in collaboration with the National Institute on Alcohol Abuse and Alcoholism (NIAAA) and the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) as part of the Prenatal Alcohol and SIDS and Stillbirth (PASS) Network. The PASS Network has comprehensive clinical sites working with Northern Plains Indian communities to help decrease fetal and infant mortality and to improve child health in these communities. The NIDCD is specifically examining whether a large intake of alcohol prenatally increases the risk of hearing impairment at birth or in the first month of life (sometimes the hearing measurement for very sick, premature, or fussy infants is delayed until one month of age). All babies undergoing the current Infant Physiology Protocol at the Northern Plains sites will be eligible for auditory testing as newborns (N=900/year) over the next two years. Auditory tests will be completed at the newborn and/or one-month assessments. Based on the results of these tests, the NIDCD will be looking for subtle differences to suggest compromise of hearing (and/or brain) function that may be extracted from carefully conducted newborn ABR and OAE hearing evaluations.

4.1.1.2 Performance Measures

The PASS study pilot program, funded by NIDCD, will help to identify the risk factors associated with high maternal alcohol intake prenatally that may lead to hearing loss, later disability, or other significant health problems.

4.1.1.3 Outcome Measures

Improve prevention and intervention strategies that can improve the future health or lives of these high-risk newborns in Native populations. Increase the proportion of infants identified by EHDI programs16 and monitor the proportion of Native American infants identified with hearing loss. Increase knowledge about the importance of hearing screening and follow through for under-represented groups to ensure improved communication, occupational, and financial outcomes for these children. Increase knowledge of professionals about the importance of follow through after hearing screening.

4.1.1.4 Projected Budget

FY2009: $867,054
FY2010 (est.): $0
FY2011 (est.): $0

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1. Based on NCHS/NHIS data for 2007.
2. Based on prevalences from the 1994–95 Disability Supplement to the NHIS and current US population estimates.
3. White KR. The scientific basis for newborn hearing screening: Issues and evidence. Invited keynote address to the Early Hearing Detection and Intervention (EHDI) Workshop sponsored by the Centers for Disease Control and Prevention, Atlanta, Georgia, October 1997.
4. Mehra S, Eavey RD, Keamy DG Jr. The epidemiology of hearing impairment in the United States: newborns, children, and adolescents. Otolaryngol Head Neck Surg. 140(4): 461-472, 2009.
5. Based on previous NHANES data, including: Lee DJ, Gomez-Marin O, Lee HM. Prevalence of childhood hearing loss. The Hispanic Health and Nutrition Examination Survey and the National Health and Nutrition Examination Survey II. Am J Epidemiol. 1996 Sep 1; 144(5): 442-449 and Lee DJ, Carlson DL, Lee HM, Ray LA, Markides KS. Hearing loss and hearing aid use in Hispanic adults: results from the Hispanic Health and Nutrition Examination Survey. Am J Public Health. 1991 Nov; 81(11): 1471-1474.
6. http://www.nidcd.nih.gov/health/statistics/smelltaste/stquickstats.htm.
7. http://www.nidcd.nih.gov/health/statistics/pages/vsl.aspx.
8. Shriberg LD, Tomblin JB, McSweeny JL. Prevalence of speech delay in 6-Year-old children and comorbidity with language impairment. J Speech Lang Hear Res 42: 1461-1481, 1999.
9. http://www.nidcd.nih.gov/health/statistics/pages/vsl.aspx.
10. Maternal Child Health Bureau, Health Resources and Services Administration, http://www.mchb.hrsa.gov/programs/specialneeds/unhs.htm.
11. Morton, CC and Nance, WE. Newborn Hearing Screening – A Silent Revolution. NEJM. 2006; 354: 2151-2164.
12. National Institutes of Health (NIH) Consensus Statement. Early Identification of Hearing Impairment in Infants and Young Children, 1993; 11(1): 1-24.
13. National Center for Hearing Assessment and Management, http://www.infanthearing.org/.
14. Healthy People 2010 objective and proposed objective for Healthy People 2020.
15. Fetal Alcohol Spectrum Disorders among Native Americans. Substance Abuse and Mental Health Services Administration, HHS Publication No. (SMA) 06–4245, 2007.
16. Summer 2008 Newsletter. Center for Healthy Communities/Department of Public Health & Preventive Medicine at Oregon Health & Science University, http://www.oregonprc.org/.

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