correspondence
possibility of admission of patients to an ICU. We are unable to treat children who are saved from death by means of vaccination and oral rehydration therapy when they return as adults with ketoacidosis as well as pneumonia and chronic obstructive pulmonary disease. High-dependency units and ICUs should be incorporated into all considerations of managing the burden of noncommunicable diseases. Gregor Pollach, M.D. University of Malawi Blantyre, Malawi [email protected] No potential conflict of interest relevant to this letter was reported. DOI: 10.1056/NEJMc1313604
noncommunicable diseases should extend from policy measures that have a population-wide impact to clinical services for persons who have these diseases. The Global Action Plan for the Prevention and Control of Noncommunicable Diseases, approved by the World Health Assembly in May 2013, provides a judicious combination of such interventions.4 There is also no dissonance between the priority afforded to communicable diseases and maternal and child health and the call for attention to noncommunicable diseases. A life-course approach to health and adoption of universal health coverage as the vehicle for delivering efficient and equitable health care will ensure that all essential health needs are met at each stage of a person’s life.5 Although some ICUs will be needed and must be provided, they cannot become the overriding priority for a health system that must ensure a wide range of promotive, preventive, diagnostic, therapeutic, palliative, and rehabilitative services. At each level of available national resources, we must prioritize the right mix of these services.
The Authors Reply: Both Dhital and Pollach call for prioritizing the provision of clinical care to persons in whom any noncommunicable disease develops. A comprehensive strategy for the prevention and control of noncommunicable diseases should indeed incorporate cost-effective clinical care. However, it is incorrect to portray K. Srinath Reddy, M.D., D.M. prevention and clinical care as conflicting agenPublic Health Foundation of India das competing for scarce resources. Many policy New Delhi, India interventions that reduce the risk of noncommunicable diseases in the population do not cost David J. Hunter, M.B., B.S., M.P.H. money. Basu et al.1 estimate that tobacco-control Harvard School of Public Health Boston, MA measures would prevent 25% of deaths from Since publication of their article, the authors report no furmyocardial infarction and stroke in India. Higher ther potential conflict of interest. taxes on tobacco and alcohol raise revenue, some Basu S, Glantz S, Bitton A, Millett C. The effect of tobacco of which can be used for providing essential 1. control measures during a period of rising cardiovascular dishealth services. In the Philippines, for example, ease risk in India: a mathematical model of myocardial infarcthe tax on tobacco has been raised to fund uni- tion and stroke. PLoS Med 2013;10(7):e1001480. 2. Philippines attacks ‘vices’ with tobacco, alcohol tax raise. versal health coverage.2,3 Australia Network News. December 20, 2012 (http://www.abc Neglect of prevention and primary health care .net.au/news/2012-12-20/an-phils-raises-tobacco2c-alcohol-taxes/ could result in ever-increasing numbers of per- 4438954). Sin Tax. Official Gazette. 2012 (http://www.gov.ph/sin-tax). sons requiring technology-intensive and costly 3. 4. Global action plan for the prevention and control of nontertiary care. No health system in the world, communicable diseases 2013-2020. Geneva: World Health Orgaespecially those in low- and middle-income coun- nization, 2013 (http://apps.who.int/iris/bitstream/10665/94384/1/ tries, can afford the escalating costs of clinical 9789241506236_eng.pdf). 5. The world health report: health systems financing: the path care for patients with noncommunicable diseases to universal coverage. Geneva: World Health Organization, 2010 if the demand for such services is not contained. (http://whqlibdoc.who.int/whr/2010/9789241564021_eng.pdf). The spectrum of the strategic response to DOI: 10.1056/NEJMc1313604
Cochlear Implants To the Editor: In his Perspective article (Sept. the machinery of human communication.” He 26 issue),1 O’Donoghue states that “[d]eafness highlights cochlear implants as a panacea for impairs quality of life by relentlessly dismantling persons with hearing loss, without discussing n engl j med 369;26 nejm.org december 26, 2013
The New England Journal of Medicine Downloaded from nejm.org at THE UNIVERSITY OF IOWA on August 11, 2015. For personal use only. No other uses without permission. Copyright © 2013 Massachusetts Medical Society. All rights reserved.
2563
The
n e w e ng l a n d j o u r na l
the value of American Sign Language (ASL). ASL is a recognized, widely taught language that has enabled deaf people to communicate and create a sense of community and culture, thereby defying the stereotypical notion of isolated deaf people. In addition, Bauman and colleagues affirm that the use of vision is as effective as the use of hearing for access to the world.2 Cochlear implants are not a miracle cure for all. To counteract the possibility of limited spoken language development, a fruitful approach not mentioned in the article is that of exposing infants and children to both spoken and signed languages. Leigh presents research on the advantages of exposure to bilingual and bicultural environments, including positive psychological adjustment, for cochlearimplant users.3 Being bilingual enhances their opportunity to succeed in any situation, allows access to diverse deaf and hearing environments, and minimizes the potential for marginalization. James Huang, M.D. Unity Health Care Washington, DC [email protected]
Irene W. Leigh, Ph.D. Lauri Rush, Psy.D.
of
m e dic i n e
The author replies: I am grateful to Huang et al. for their commentary. Rather than presenting cochlear implants as a panacea, my article clearly outlined their limitations. If competence in spoken language is the goal, then exposure to spoken communication in preference to ASL becomes a necessity.1 The plea for a bilingual approach is wholly impractical, because more than 95% of deaf children are born to hearing parents who have no proficiency in sign language — hence, these parents are powerless to transfer fluency in this language. Signed communication may benefit implant recipients who do not have sufficient competence in spoken language and may provide the only viable access to cognitive, social, and language development. The suggestion that the use of vision is as effective as hearing in obtaining access to the world is simply untenable — nature has provided both senses to offer complementary sensory inputs about our world, and to argue the supremacy of one sense over the other seems superfluous. Cochlear implants may be no panacea, but they offer choice and unprecedented opportunity to deaf people. Gerard O’Donoghue, F.R.C.S.
Gallaudet University Washington, DC No potential conflict of interest relevant to this letter was reported. 1. O’Donoghue G. Cochlear implants — science, serendipity,
and success. N Engl J Med 2013;369:1190-3.
2. Bauman H-DL, ed. Open your eyes: deaf studies talking.
Minneapolis: University of Minnesota Press, 2008. 3. Leigh IW. A lens on deaf identities. New York: Oxford University Press, 2009.
Nottingham Hearing Biomedical Research Unit Nottingham, United Kingdom Since publication of his article, the author reports no further potential conflict of interest. 1. Kral A, O’Donoghue GM. Profound deafness in childhood.
N Engl J Med 2010;363:1438-50.
DOI: 10.1056/NEJMc1313728
DOI: 10.1056/NEJMc1313728
A Recombinant Viruslike Particle Influenza A (H7N9) Vaccine To the Editor: Avian-origin influenza A (H7N9) viruses emerged as human pathogens in China in 2013 and have caused 137 cases and 45 deaths to date.1 These viruses have acquired mutations that could facilitate infection in mammals,2 which could pose a pandemic threat if the viruses become readily transmissible in humans. Vaccines are a key defense against pandemics, but candidate vaccines featuring H7 hemagglutinins (HA) have been poorly immunogenic.3 We have previously described the development, manufacture, and efficacy in mice of an 2564
A/Anhui/1/13 (H7N9) viruslike particle (VLP) vaccine produced in insect cells with the use of recombinant baculovirus. This vaccine combines the HA and neuraminidase (NA) of A/Anhui/1/13 with the matrix 1 protein (M1) of A/Indonesia/ 5/05.4,5 We enrolled 284 adults (≥18 years of age) in a randomized, observer-blinded, placebo-controlled clinical trial of this vaccine; all the participants provided written informed consent. The trial was approved by the Bellberry Human Research Ethics Committee in Adelaide, Australia
n engl j med 369;26 nejm.org december 26, 2013
The New England Journal of Medicine Downloaded from nejm.org at THE UNIVERSITY OF IOWA on August 11, 2015. For personal use only. No other uses without permission. Copyright © 2013 Massachusetts Medical Society. All rights reserved.
possibility of admission of patients to an ICU. We are unable to treat children who are saved from death by means of vaccination and oral rehydration therapy when they return as adults with ketoacidosis as well as pneumonia and chronic obstructive pulmonary disease. High-dependency units and ICUs should be incorporated into all considerations of managing the burden of noncommunicable diseases. Gregor Pollach, M.D. University of Malawi Blantyre, Malawi [email protected] No potential conflict of interest relevant to this letter was reported. DOI: 10.1056/NEJMc1313604
noncommunicable diseases should extend from policy measures that have a population-wide impact to clinical services for persons who have these diseases. The Global Action Plan for the Prevention and Control of Noncommunicable Diseases, approved by the World Health Assembly in May 2013, provides a judicious combination of such interventions.4 There is also no dissonance between the priority afforded to communicable diseases and maternal and child health and the call for attention to noncommunicable diseases. A life-course approach to health and adoption of universal health coverage as the vehicle for delivering efficient and equitable health care will ensure that all essential health needs are met at each stage of a person’s life.5 Although some ICUs will be needed and must be provided, they cannot become the overriding priority for a health system that must ensure a wide range of promotive, preventive, diagnostic, therapeutic, palliative, and rehabilitative services. At each level of available national resources, we must prioritize the right mix of these services.
The Authors Reply: Both Dhital and Pollach call for prioritizing the provision of clinical care to persons in whom any noncommunicable disease develops. A comprehensive strategy for the prevention and control of noncommunicable diseases should indeed incorporate cost-effective clinical care. However, it is incorrect to portray K. Srinath Reddy, M.D., D.M. prevention and clinical care as conflicting agenPublic Health Foundation of India das competing for scarce resources. Many policy New Delhi, India interventions that reduce the risk of noncommunicable diseases in the population do not cost David J. Hunter, M.B., B.S., M.P.H. money. Basu et al.1 estimate that tobacco-control Harvard School of Public Health Boston, MA measures would prevent 25% of deaths from Since publication of their article, the authors report no furmyocardial infarction and stroke in India. Higher ther potential conflict of interest. taxes on tobacco and alcohol raise revenue, some Basu S, Glantz S, Bitton A, Millett C. The effect of tobacco of which can be used for providing essential 1. control measures during a period of rising cardiovascular dishealth services. In the Philippines, for example, ease risk in India: a mathematical model of myocardial infarcthe tax on tobacco has been raised to fund uni- tion and stroke. PLoS Med 2013;10(7):e1001480. 2. Philippines attacks ‘vices’ with tobacco, alcohol tax raise. versal health coverage.2,3 Australia Network News. December 20, 2012 (http://www.abc Neglect of prevention and primary health care .net.au/news/2012-12-20/an-phils-raises-tobacco2c-alcohol-taxes/ could result in ever-increasing numbers of per- 4438954). Sin Tax. Official Gazette. 2012 (http://www.gov.ph/sin-tax). sons requiring technology-intensive and costly 3. 4. Global action plan for the prevention and control of nontertiary care. No health system in the world, communicable diseases 2013-2020. Geneva: World Health Orgaespecially those in low- and middle-income coun- nization, 2013 (http://apps.who.int/iris/bitstream/10665/94384/1/ tries, can afford the escalating costs of clinical 9789241506236_eng.pdf). 5. The world health report: health systems financing: the path care for patients with noncommunicable diseases to universal coverage. Geneva: World Health Organization, 2010 if the demand for such services is not contained. (http://whqlibdoc.who.int/whr/2010/9789241564021_eng.pdf). The spectrum of the strategic response to DOI: 10.1056/NEJMc1313604
Cochlear Implants To the Editor: In his Perspective article (Sept. the machinery of human communication.” He 26 issue),1 O’Donoghue states that “[d]eafness highlights cochlear implants as a panacea for impairs quality of life by relentlessly dismantling persons with hearing loss, without discussing n engl j med 369;26 nejm.org december 26, 2013
The New England Journal of Medicine Downloaded from nejm.org at THE UNIVERSITY OF IOWA on August 11, 2015. For personal use only. No other uses without permission. Copyright © 2013 Massachusetts Medical Society. All rights reserved.
2563
The
n e w e ng l a n d j o u r na l
the value of American Sign Language (ASL). ASL is a recognized, widely taught language that has enabled deaf people to communicate and create a sense of community and culture, thereby defying the stereotypical notion of isolated deaf people. In addition, Bauman and colleagues affirm that the use of vision is as effective as the use of hearing for access to the world.2 Cochlear implants are not a miracle cure for all. To counteract the possibility of limited spoken language development, a fruitful approach not mentioned in the article is that of exposing infants and children to both spoken and signed languages. Leigh presents research on the advantages of exposure to bilingual and bicultural environments, including positive psychological adjustment, for cochlearimplant users.3 Being bilingual enhances their opportunity to succeed in any situation, allows access to diverse deaf and hearing environments, and minimizes the potential for marginalization. James Huang, M.D. Unity Health Care Washington, DC [email protected]
Irene W. Leigh, Ph.D. Lauri Rush, Psy.D.
of
m e dic i n e
The author replies: I am grateful to Huang et al. for their commentary. Rather than presenting cochlear implants as a panacea, my article clearly outlined their limitations. If competence in spoken language is the goal, then exposure to spoken communication in preference to ASL becomes a necessity.1 The plea for a bilingual approach is wholly impractical, because more than 95% of deaf children are born to hearing parents who have no proficiency in sign language — hence, these parents are powerless to transfer fluency in this language. Signed communication may benefit implant recipients who do not have sufficient competence in spoken language and may provide the only viable access to cognitive, social, and language development. The suggestion that the use of vision is as effective as hearing in obtaining access to the world is simply untenable — nature has provided both senses to offer complementary sensory inputs about our world, and to argue the supremacy of one sense over the other seems superfluous. Cochlear implants may be no panacea, but they offer choice and unprecedented opportunity to deaf people. Gerard O’Donoghue, F.R.C.S.
Gallaudet University Washington, DC No potential conflict of interest relevant to this letter was reported. 1. O’Donoghue G. Cochlear implants — science, serendipity,
and success. N Engl J Med 2013;369:1190-3.
2. Bauman H-DL, ed. Open your eyes: deaf studies talking.
Minneapolis: University of Minnesota Press, 2008. 3. Leigh IW. A lens on deaf identities. New York: Oxford University Press, 2009.
Nottingham Hearing Biomedical Research Unit Nottingham, United Kingdom Since publication of his article, the author reports no further potential conflict of interest. 1. Kral A, O’Donoghue GM. Profound deafness in childhood.
N Engl J Med 2010;363:1438-50.
DOI: 10.1056/NEJMc1313728
DOI: 10.1056/NEJMc1313728
A Recombinant Viruslike Particle Influenza A (H7N9) Vaccine To the Editor: Avian-origin influenza A (H7N9) viruses emerged as human pathogens in China in 2013 and have caused 137 cases and 45 deaths to date.1 These viruses have acquired mutations that could facilitate infection in mammals,2 which could pose a pandemic threat if the viruses become readily transmissible in humans. Vaccines are a key defense against pandemics, but candidate vaccines featuring H7 hemagglutinins (HA) have been poorly immunogenic.3 We have previously described the development, manufacture, and efficacy in mice of an 2564
A/Anhui/1/13 (H7N9) viruslike particle (VLP) vaccine produced in insect cells with the use of recombinant baculovirus. This vaccine combines the HA and neuraminidase (NA) of A/Anhui/1/13 with the matrix 1 protein (M1) of A/Indonesia/ 5/05.4,5 We enrolled 284 adults (≥18 years of age) in a randomized, observer-blinded, placebo-controlled clinical trial of this vaccine; all the participants provided written informed consent. The trial was approved by the Bellberry Human Research Ethics Committee in Adelaide, Australia
n engl j med 369;26 nejm.org december 26, 2013
The New England Journal of Medicine Downloaded from nejm.org at THE UNIVERSITY OF IOWA on August 11, 2015. For personal use only. No other uses without permission. Copyright © 2013 Massachusetts Medical Society. All rights reserved.
