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Noise and Military Service: Implications for Hearing Loss and Tinnitus (2006)

Chapter: 5 Responding to Noise Risks: Hearing Conservation Programs in the Military

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Suggested Citation:"5 Responding to Noise Risks: Hearing Conservation Programs in the Military." Institute of Medicine. 2006. Noise and Military Service: Implications for Hearing Loss and Tinnitus. Washington, DC: The National Academies Press. doi: 10.17226/11443.
×

5
Responding to Noise Risks: Hearing Conservation Programs in the Military

The committee’s charge to identify when hearing conservation measures were adequate to protect the hearing of service members derives from legislative language. The legislation requested that the committee identify when audiometric measures used by the military became adequate to evaluate individual hearing loss (threshold shift) and when hearing conservation measures to prevent hearing loss were available to service members. The evaluation of hearing conservation programs is not a simple task of either assessing a checklist of necessary components or performing a straightforward analysis of an audiometric database. This chapter describes key aspects of hearing conservation programs and reviews the development and adequacy of programs in the military. Current hearing conservation programs do not include monitoring or prevention of tinnitus. As described in Chapter 4, the relationship between noise exposure and tinnitus is not yet well understood. However, the committee makes the presumption that measures taken to protect against noise-induced hearing loss are likely to help in the prevention of tinnitus. Thus, many of the elements of a hearing conservation program could be applied to prevention of tinnitus as well as hearing loss.

HEARING CONSERVATION PROGRAMS

Overview and Emergence of Key Components

In large part, serious and sustained interest in hearing conservation developed as a result of World War II, when substantial numbers of service

Suggested Citation:"5 Responding to Noise Risks: Hearing Conservation Programs in the Military." Institute of Medicine. 2006. Noise and Military Service: Implications for Hearing Loss and Tinnitus. Washington, DC: The National Academies Press. doi: 10.17226/11443.
×

members returned home with hearing loss (Gasaway, 1985).1 In fact, one of the earliest regulations dealing with hearing conservation was issued in 1948 by the Air Force (Department of the Air Force, 1948). Industrial hearing conservation programs began to appear in the late 1940s and early 1950s, with some of the first reported programs established in the aviation and metals industries (Bolger, 1956; Hatton, 1956; Wilkins, 1956; Haluska, 1964). Government noise regulations followed in the late 1960s (U.S. Department of Labor, 1969) and became more prominent and widely enforced with the enactment of the Occupational Safety and Health Act of 1970 and dissemination of the associated regulation on noise in 1971 (OSHA, 1971). However, the Occupational Safety and Heath Administration (OSHA) regulation of 1971 only hinted at details of an occupational hearing conservation program. In 1972, the National Institute for Occupational Safety and Health (NIOSH) published Criteria for a Recommended Standard: Occupational Exposure to Noise (NIOSH, 1972). This document described the components of an effective hearing conservation program: sound surveys, noise control, hearing protection, education and training, audiometric monitoring, and recordkeeping. These components were subsequently adopted by OSHA when the Hearing Conservation Amendment (29 C.F.R. 1910.95) was developed (OSHA, 1983). In recent years, program evaluation has been included as an additional component as evaluation tools have been developed (Suter, 1986; NIOSH, 1996; Berger et al., 2000). See Gasaway (1985) for a more complete historical overview of occupational hearing conservation programs and Suter (1988, 2000) for a discussion of the development of the related regulations.

HISTORY OF MILITARY HEARING CONSERVATION PROGRAMS

Overview

The military services’ early attention to hearing health focused on rehabilitation. In the 1940s, clinicians in military hospitals and rehabilitation centers noted many patients with severe hearing loss. In anticipation of a large number of hearing-loss casualties from World War II, the Army and Navy established their first aural rehabilitation centers in 1943 and 1944, respectively (Nixon, 1998). The Veterans Administration established similar facilities soon after (Gasaway, 1988). These centers led to the emergence of a cadre of hearing health professionals, including audiologists, who later assumed important roles in prevention-oriented programs in the military

1  

Reports suggest that the service members found to have hearing losses at the conclusion of World War II included many individuals with hearing losses that predated their military service (Nixon, 1998; Bergman, 2002).

Suggested Citation:"5 Responding to Noise Risks: Hearing Conservation Programs in the Military." Institute of Medicine. 2006. Noise and Military Service: Implications for Hearing Loss and Tinnitus. Washington, DC: The National Academies Press. doi: 10.17226/11443.
×

(Gasaway, 1985; Donahue and Ohlin, 1993). Figure 5-1 is a time line of major developments in military hearing conservation programs.

The introduction of the jet engine to the military in the late 1940s and early 1950s raised new concerns about noise hazards and helped motivate the development of military hearing conservation programs (Nixon, 1998). The Air Force, the Navy (which also has responsibility for the Marine Corps hearing conservation program), and the Army issued regulations or guidelines on hearing conservation in 1948, 1955, and 1956, respectively (Department of the Air Force, 1948; Department of the Navy, 1955; Department of the Army, 1956).

Subsequent revisions of the military services’ noise and hearing conservation documents expanded program elements within each of the services. The Air Force was a leader in these efforts, both in timing and in establishing required program elements, while the Army and Navy programs continued to develop but did not institute mandatory measures. The disparities that existed across the services were noted in a 1977 General Accounting Office report that recommended that the Secretary of Defense adopt consistent policies across the defense agencies (GAO, 1977).

In 1978, a Department of Defense (DoD) Instruction was issued to establish a uniform hearing conservation program, with the goals of eliminating all occupational noise-related hearing loss among DoD personnel (military and civilian) and reducing the costs of compensation (DoD, 1978). The instruction described requirements for sound surveys, the posting of hazardous areas with warning signs, noise abatement, personal hearing protection, education, audiometric testing (preplacement, periodic, and termination audiograms for all personnel exposed routinely to hazardous noise), and recordkeeping (each service was to maintain a hearing conservation data registry) (DoD, 1978). In 1979, DoD introduced standard DoD forms for noise surveys (DD Form 2214), reference audiograms (DD Form 2215), hearing conservation data (DD Form 2216), and biological audiometer calibration checks (DD Form 2217). In the following few years, each of the services published major revisions of their hearing conservation program guidelines to comply with changes mandated by the 1978 DoD Instruction (Department of the Navy, 1979; Department of the Army, 1980; Department of the Air Force, 1982).

Soon thereafter, changes at the federal level were reflected in additional developments in DoD programs. In response to the publication of the OSHA final noise standard, DoD updated its hearing conservation program and policy under a new designation, DoD Instruction 6055.12, in 1987 (DoD, 1987). DoD mandated that the uniformed services comply with OSHA regulations, but the standards and criteria of military programs have been more stringent than those of OSHA (Nixon, 1998). The military services have used lower exchange rates than required by OSHA (the services have

Suggested Citation:"5 Responding to Noise Risks: Hearing Conservation Programs in the Military." Institute of Medicine. 2006. Noise and Military Service: Implications for Hearing Loss and Tinnitus. Washington, DC: The National Academies Press. doi: 10.17226/11443.
×

FIGURE 5-1 Time line of major conflicts and milestones in hearing conservation programs.

NOTES: DoD, Department of Defense; DOEHRS-HC, Defense Occupational and Environmental Health Readiness System–Hearing Conservation; HCP, hearing conservation program; OSHA, Occupational Safety and Health Administration; STS, significant threshold shift.

SOURCES: Gasaway (1988); Nixon (1998); Department of Veterans Affairs (2005); Ohlin (2005b).

Suggested Citation:"5 Responding to Noise Risks: Hearing Conservation Programs in the Military." Institute of Medicine. 2006. Noise and Military Service: Implications for Hearing Loss and Tinnitus. Washington, DC: The National Academies Press. doi: 10.17226/11443.
×

used 3 or 4 dB, instead of the 5-dB exchange rate specified by OSHA) and currently do not use age corrections in calculations of significant threshold shifts (STSs). Until 2004, the military services’ definitions of STS were more sensitive than those of OSHA, identifying more people with possible need for intervention than would have been identified under the OSHA definition. Definitions of STS are discussed in more detail later in this chapter.

In the late 1990s, automated hearing conservation data registries developed by the individual services (the Army and Air Force’s Hearing Evaluation Automated Registry Systems and the Navy’s Hearing Examination and Audiometric Reporting System, HEARS) were replaced by the hearing conservation component of a new DoD-wide system called the Defense Occupational and Environmental Health Readiness System–Hearing Conservation (DOEHRS-HC). The system is designed to collect, maintain, compare, and report hearing conservation data in DoD (U.S. Army Center for Health Promotion and Preventive Medicine, 2004a). Aspects of this system are discussed in more detail below.

History of Hearing Conservation Programs in the Military Services

This section briefly reviews the history of the Air Force, Navy, Army, and Coast Guard hearing conservation programs. Table 5-1 provides additional information about each of the services’ current programs and guiding regulations. The committee’s evaluation of these programs is presented separately at the end of the chapter.

Air Force Hearing Conservation Program History

Established as a military service separate from the Army Air Corps in 1947, the Air Force was responsible for the first regulation to protect and conserve hearing in 1948. The brief document required that hearing protection be worn by personnel working in high-level noise, noise measurements be performed to determine degrees of risk, exposure periods be minimized, and audiometric monitoring be performed on people engaged in testing and operating turbojet and rocket engines (Gasaway, 1988). A 1949 update specified noise limits for work areas (85 dB or below in regularly occupied areas) and the availability of protective devices. It required a weekly hearing test for those with high-intensity noise exposures and temporary reassignment if the audiogram indicated a hearing loss of more than 20 dB2 (Department of the Air Force, 1949).

2  

The regulation is not clear regarding the frequencies at which the 20 dB shift is applied.

Suggested Citation:"5 Responding to Noise Risks: Hearing Conservation Programs in the Military." Institute of Medicine. 2006. Noise and Military Service: Implications for Hearing Loss and Tinnitus. Washington, DC: The National Academies Press. doi: 10.17226/11443.
×

The 1956 version of Air Force Regulation (AFR) 160-3 established the first hearing conservation program in the services. It included provisions for the six key components of a hearing conservation program described by OSHA more than 20 years later: sound surveys, education, noise control, hearing protection, audiometric monitoring, and recordkeeping. The regulation introduced a standard form (AF Form 1490) to record hearing conservation data and established a central repository for these data. It further established the policy that all military and civilian personnel who enter into or terminate service with the Air Force would receive an audiometric examination as part of their routine physical examination. Personnel assigned to duty or training involving exposure to hazardous noise would be given a follow-up audiogram 90 days after beginning that duty and annually thereafter. Audiograms were to record hearing sensitivity at each specified frequency: 500, 1000, 2000, 3000, 4000, and 6000 Hz. The regulation also established a classification system for hearing based on the degree of hearing loss on the audiogram; the definition of an STS differed depending on an individual’s classification. Codes were introduced on audiograms to describe the proximity of work areas to hazardous noise as well as the overall noise level of the area (Department of the Air Force, 1956). The 1956 regulation also established procedures for 15- and 40-hour noise-free follow-up audiograms in response to STSs.

The Air Force revised AFR 160-3 in 1973 with adoption of a criterion for inclusion in the hearing conservation program of an equivalent 8-hour daily exposure of 84 dBA with a 4-dB exchange rate, as well as establishment of detailed exposure criteria for various types of impulse noise (Nixon, 1998). The regulation introduced noise exposure limits specified in terms of the A-weighted level of the noise (dBA) (Nixon, 1998). In late 1974, the Air Force established routine automated handling and storage of audiometric monitoring data to facilitate the use and study of these records (Gasaway, 1988). The next major revision of the Air Force regulation on hazardous noise exposure took place in 1982, updating the regulations to comply with the 1978 DoD Instruction on hearing conservation (DoD, 1978).

The current Air Force hearing conservation program is a decentralized effort, managed at each of the more than 80 Air Force installations around the world, with support provided at the Air Force Institute for Occupational Health at Brooks City-Base, Texas. The Air Force uses the hearing conservation program model of the National Institute for Occupational Safety and Health, with program components such as those listed earlier (Narrigan, 2004). In 2004, more than 156,000 Air Force service members, or 42 percent of the active duty Air Force, and over 14,000 civilian employees, all of whom were considered exposed to hazardous noise, were enrolled in the hearing conservation program (Pluta, 2004; DoD, 2005).

Suggested Citation:"5 Responding to Noise Risks: Hearing Conservation Programs in the Military." Institute of Medicine. 2006. Noise and Military Service: Implications for Hearing Loss and Tinnitus. Washington, DC: The National Academies Press. doi: 10.17226/11443.
×

TABLE 5-1 Criteria for Hearing Conservation Programs

Service

Criteria for Hearing Conservation Program Enrollment a

Exchange Rate (dB)

STS Definition

STS Follow-up

Air Force

≥ 85 dBA TWA, or exposure to > 140 dBP

3

≥ 10 dB average shift at 2, 3, 4 kHz

No age correction

Positive and negative STS require follow-up; for positive STS, f/u 1 and 2 must take place within 30 days of annual audiogram, and f/u 1 must be 14 hours noise free

Navy/Marine Corps

Routinely exposed to > 84 dBA or > 140 dBP (“routinely” defined as TWA > 84 dBA for more than 2 days/month)

4

≥ 10 dB average shift at 2, 3, 4 kHz

Change of ≥ 15 dB in either ear at any test frequency from 1 to 4 kHz considered early warning, requiring verbal counseling and assurance of access to appropriate hearing protection

No age correction

Positive and negative STS require follow-up; for positive STS, f/u 1 and 2 must take place within 30 days of annual audiogram, and f/u 1 must be 14 hours noise free

Army

≥ 85 dBA TWA, or exposure to ≥ 140 dBP

Exposure to known or suspected ototoxins

3

≥ 10 dB average shift at 2, 3, 4 kHz

No age correction

Positive and negative STS require follow-up; for positive STS, f/u 1 and 2 must be 14 hours noise free

Coast Guard

≥ 85 dB TWA for ≥ 30 days per calendar year, or exposure to > 140 dBP; also those with > 35 dB shift in 0.5–3 kHz range

4

≥ 10 dB average shift at 2, 3, 4 kHz

Positive and negative STS require follow-up; for positive STS, f/u with up to two consecutive 14-hour noise-free audiograms

Suggested Citation:"5 Responding to Noise Risks: Hearing Conservation Programs in the Military." Institute of Medicine. 2006. Noise and Military Service: Implications for Hearing Loss and Tinnitus. Washington, DC: The National Academies Press. doi: 10.17226/11443.
×

Reference Audiogram

Requirements for Use of Hearing Protection Devices

Guiding Documents

Shall be received prior to duties in hazardous noise

Within 30 days of entering a hazardous noise-exposed job; must be 15 hours noise free

≥ 85 dBA TWA, or exposure to > 140 dBP

AFI 48-20, Interim Guidance (2000)

AFOSH 161-20 (1991)

AFOSH 48-19 (1994)

Required on entry into naval service

Hearing tests performed at Military Entrance Processing Stations shall not be used as a baseline hearing test

Must be noise free (no noise above 80 dBA) for at least 14 hours

> 84 dBA or > 140 dBP

Double protection at > 104dB

OPNAVINST 5100.19D CH-1 Occupational Safety and Health Program Manual for Forces Afloat (2001)

OPNAVINST 5100.23F Occupational Safety and Health Program Manual for Forces Ashore (2002)

NEHC Technical Manual 6260.51.992 (September 2004)

MCO 6260.1 (2000)

MCO P5100.8 F (1998)

DA PAM 40-501 (10 December 1998)

Required at basic training prior to noise exposure

≥ 85 dBA TWA, or exposure to > 140 dBP

Double protection at ≥ 104 dB

Required prior to Coast Guard occupational noise exposure

≥ 85 dB TWA for ≥ 30 days per calendar year, or exposure to > 140 dBP

Double protection at > 104 dB

Chapter 4, Coast Guard Safety and Environmental Health Manual (COMDTINST M5100.47)

Chapter 12, Coast Guard Medical Manual (COMDTINST M6000.1B)

Suggested Citation:"5 Responding to Noise Risks: Hearing Conservation Programs in the Military." Institute of Medicine. 2006. Noise and Military Service: Implications for Hearing Loss and Tinnitus. Washington, DC: The National Academies Press. doi: 10.17226/11443.
×

Service

Criteria for Hearing Conservation Program Enrollment a

Exchange Rate (dB)

STS Definition

STS Follow-up

OSHA requirements

≥ 85 dBA (action level)

5

≥ 10 dB average shift at 2, 3, 4 kHz, either ear

Retest to rule out spurious STS is optional

NIOSH recommendations

≥ 85 dBLAeg

3

≥ 15 dB shift at 0.5, 1, 2, 3, 4, or 6 kHz, either ear, and the same shift at the same test frequency in the same ear on an immediate retest

Immediate retest; if the same, schedule for 30-day confirmation audiogram

DoD requirements

≥ 85 dBA TWA, or impulse noise > 140 dBP

4

(3 strongly encouraged)

≥ 10 dB average shift at 2, 3, 4 kHz, either ear

No age correction

Positive and negative STS require follow-up; for positive STS f/u 1 and 2 must be 14 hours noise free

 

 

 

15 dB shift at 1, 2, 3, or 4 kHz retained as early warning only

 

aCriteria concerning airborne high-frequency or ultrasonic noise are not noted here.

NOTES: DoD, Department of Defense; NIOSH, National Institute for Occupational Safety and Health; OSHA, Occupational Safety and Health Administration; STS, significant threshold shift; TWA, time-weighted average.

SOURCES: OSHA (1971, 1983); U.S. Coast Guard (1990, 2003); Department of the Air Force (1991, 1994, 2000); Department of the Army (1998); Department of the Navy (1998, 2000, 2001, 2002); NIOSH (1998); Hall (2001); DoD (2004b); Navy Environmental Health Center (2004b).

Suggested Citation:"5 Responding to Noise Risks: Hearing Conservation Programs in the Military." Institute of Medicine. 2006. Noise and Military Service: Implications for Hearing Loss and Tinnitus. Washington, DC: The National Academies Press. doi: 10.17226/11443.
×

Reference Audiogram

Requirements for Use of Hearing Protection Devices

Guiding Documents

Called baseline audiogram and must be established within 12 months of employee’s exposure at or above the action level

Optional for ≥ 85 dBA TWA; mandatory for > 90 dBA TWA, and for ≥ 85 dBA TWA for workers with STS

29 C.F.R., Chapter XVII, Part 1910, Sub-part G, 36 F.R. 10466, May 29, 1971; Amended 48 F.R. 9776–9785, March 8, 1983

Baseline audiogram to be established within 30 days of enrollment in hearing loss prevention program

Mandatory for > 85 dBA TWA with a 3-dB exchange rate

Criteria for a Recommended Standard: Occupational Noise Exposure (NIOSH, 1998)

Required for all military personnel at basic training prior to noise exposure

Mandatory in “hazardous noise areas” when noise sources are operating, and with exposure to gunfire or artillery fire in test or training situations

DoDI 6055.12 (2004)

Suggested Citation:"5 Responding to Noise Risks: Hearing Conservation Programs in the Military." Institute of Medicine. 2006. Noise and Military Service: Implications for Hearing Loss and Tinnitus. Washington, DC: The National Academies Press. doi: 10.17226/11443.
×
Navy and Marine Corps Hearing Conservation History

The Navy is responsible not only for its own hearing conservation program, but also for that of the U.S. Marine Corps. As with the Air Force, concerns about noise from jet aircraft spurred steps toward a hearing conservation program in the Navy. Aircraft carrier crew members must work close to jet aircraft during flight operations and maintenance. A 1952 study of the effects of jet aircraft engine noise on aircraft carrier personnel indicated a likely negative impact on personnel and operations and suggested a larger scope to the jet-engine noise problem than had been understood before (Rosenblith et al., 1952; Nixon, 1998). The study authors recommended that the Navy emulate the hearing protection programs they had observed at several Air Force installations and also make the wearing of hearing protection compulsory in high-noise settings (Rosenblith et al., 1952). They also recommended additional study of the interaction between noise and humans on aircraft carriers. Exposure to high-intensity noise thereafter became a priority concern for the Navy and motivated its role in the formation of the NAS-NRC Committee on Hearing and Bioacoustics (CHABA, as described in Chapter 2).

The first Navy regulation regarding hearing conservation, issued in 1955, formally established the Navy hearing conservation program, but with no requirements for actions (Department of the Navy, 1955). In 1960, the Navy increased civilian staffing for hearing conservation (Nixon, 1998), and in 1970, the Navy issued its first standards, making hearing conservation programs mandatory when noise levels exceeded 90 dBA. It adopted a noise standard of an equivalent 8-hour daily exposure of 90 dBA with a 5-dB exchange rate (Department of the Navy, 1970; Nixon, 1998). In 1976, the Navy Bureau of Medicine and Surgery directed naval activities to discontinue purchasing self-recording audiometers and to limit group testing to four subjects because of problems with the reliability of the hearing tests as well as with program administration and management (Robertson and Williams, 1984).

An important change in the Navy program took place when program responsibility was transferred from the Bureau of Medicine to the Chief of Naval Operations in 1979 (Nixon, 1998), affording the program more visibility. This change coincided with revision of its hearing conservation program requirements to establish exposure limits of 85 dBA for continuous or intermittent noise, and 140 dB peak sound pressure level for impact or impulse noise (Department of the Navy, 1979). For the first time, the Navy acquired 10 military audiologists (Nixon, 1998), and in 1982, an additional 10 positions were added (Page, 2004a, 2005a).

In the early 1980s, the Navy continued to try to improve its ability to collect and store audiometric information. Automated systems were being developed in conjunction with the use of microprocessor-controlled group

Suggested Citation:"5 Responding to Noise Risks: Hearing Conservation Programs in the Military." Institute of Medicine. 2006. Noise and Military Service: Implications for Hearing Loss and Tinnitus. Washington, DC: The National Academies Press. doi: 10.17226/11443.
×

audiometers. However, as reported in 1984, and continuing until the introduction of DOEHRS-HC in 1999, there remained no efficient way to obtain audiometric data for large numbers of naval service members in order to assess the adequacy of the Navy’s hearing conservation programs (Robertson and Williams, 1984; Page et al., 2002). For example, as of 1990, Navy budgetary constraints permitted the storage of no more than 1–2 years of audiometric data at any time (Ridgley and Wilkins, 1991).

The Navy and Marine Corps hearing conservation programs are currently managed by the Navy Occupational and Environmental Health Center in Portsmouth, Virginia, with program oversight the responsibility of the Chief of Naval Operations. The Navy estimates that 285,000 sailors and civilians, and 67,000 members of the U.S. Marine Corps, are currently enrolled in the hearing conservation program (Page, 2005b). Since the mid-1980s the number of Navy audiologists has grown from 37 to 49, with roughly 21 of them military and the remainder civilian (Page, 2005a). The current documents guiding the Navy’s program are listed in Table 5-1.

Army Hearing Conservation History

Army efforts in the area of noise research and protection began in the early 1940s, and for decades thereafter, hearing conservation efforts in the Army primarily emphasized identification of noise hazards (Donahue and Ohlin, 1993). The Army’s first document describing a hearing conservation program was a technical bulletin issued in 1956 and subsequently revised in 1965 and 1972 (Department of the Army, 1956, 1965, 1972). In 1972, the Army adopted a criterion for hazardous noise exposure of an equivalent 8-hour daily exposure of 85 dBA, with a 5-dB exchange rate (Nixon, 1998). Although all the basic elements of a hearing conservation program were required in a preventive medicine regulation, specific hearing conservation program activities were only recommended (Ohlin, 2005a) and were therefore applied inconsistently at different Army installations. In 1980, the Army issued its first requirements to implement an Army-wide hearing conservation program (Department of the Army, 1980), as directed by the 1978 DoD standards for military hearing conservation programs (DoD, 1978). With this new technical bulletin, hearing protection became mandatory in steady noise when levels were at or above 85 dBA, or when impulse noise levels exceeded 140 dBP. If steady noise was above 108 dBA or impulse noise was over 165 dBP, double protection (both earplugs and ear muffs) was required (Department of the Army, 1980). The exchange rate between noise level and allowable daily exposure was lowered from 5 dB to 4 dB.

In the 1960s, the Army commissioned military audiologists, who came to play an important role in advancing the profession within and outside

Suggested Citation:"5 Responding to Noise Risks: Hearing Conservation Programs in the Military." Institute of Medicine. 2006. Noise and Military Service: Implications for Hearing Loss and Tinnitus. Washington, DC: The National Academies Press. doi: 10.17226/11443.
×

the military (Nixon, 1998). By 1970, 58 audiology positions had been established to provide a servicewide effort in education and training (Gasaway, 1988). Studies indicating high-frequency hearing loss in combat arms personnel (Walden et al., 1971, 1975) convinced Army leaders to improve the education of personnel regarding hearing protection. In 1971, the Army carried out a pilot study for an effort to collect hearing conservation data, which eventually led to the establishment of the Army’s hearing conservation data repository (Nixon, 1998). Another important change in the Army’s program was its transition from manual recording of audiometric test results to the Hearing Evaluation Automated Registry System (HEARS) in 1987 (AMSA, 1997).

Technical and administrative guidance for the Army hearing conservation program is provided centrally from the U.S. Army Center for Health Promotion and Preventive Medicine in Aberdeen, Maryland. In 2003, there were 375,186 soldiers, as well as 53,986 civilians employed by the Army, enrolled in the Army’s hearing conservation program (U.S. Army Center for Health Promotion and Preventive Medicine, 2004b), representing 77 percent of the active duty Army (DoD, 2004a). Since 1990, the number of military audiologists in the Army has dropped by more than half, from 71 to 31 in 2005 (Gates, 2005). Some have been replaced by civilian contractors, who fill a different role in the hearing conservation program than military audiologists. While civilian audiologists’ time is dedicated to clinical roles, uniformed audiologists have additional responsibilities for field-work that afford additional opportunities for the education and motivation of service members regarding hearing conservation program goals.

U.S. Coast Guard Hearing Conservation Program History

The U.S. Coast Guard differs from the other four armed services in that it is not ordinarily part of DoD. In times of peace it has operated as part of the Departments of the Treasury (until 1967), Transportation (1967–2003), and Homeland Security (since March 2003), but in times of war or at the direction of the President, it serves under the Navy (U.S. Coast Guard, 1998). By the late 1960s and early 1970s, the Coast Guard hearing conservation program included noise surveys as well as periodic audiometric testing (McConnell, 2004). Regulatory guidance published in 1982 provided hearing conservation recommendations for commercial vessels inspected by the Coast Guard (U.S. Coast Guard, 1982). It described a program similar to that of the other services, but noted the highly mobile nature of the maritime industry and the resultant difficulties in maintaining a program of audiometric testing and recordkeeping.

In the early 1990s, the Coast Guard instituted a program called the Occupational Medical Monitoring Program, intended to facilitate docu-

Suggested Citation:"5 Responding to Noise Risks: Hearing Conservation Programs in the Military." Institute of Medicine. 2006. Noise and Military Service: Implications for Hearing Loss and Tinnitus. Washington, DC: The National Academies Press. doi: 10.17226/11443.
×

mentation and prevention of occupational hazards. Centrally managed from Coast Guard headquarters, it was determined to be unsuccessful (McConnell, 2004). In 1998, the Coast Guard established a new program called the Occupational Medical Surveillance and Evaluation Program, a physical examination program intended to monitor the health of personnel in jobs designated as having high health risk potential as a result of exposure to chemical or physical agents. The Coast Guard hearing conservation program is one of 14 medical examination protocols in the Occupational Medical Surveillance and Evaluation Program, which helps track audiogram appointments for enrollees to facilitate follow-up.

As with the military services described above, the Coast Guard hearing conservation program requires identification of hazardous noise sources, determination of personnel exposed, application of engineering methods to abate noise, hearing protection and education for those exposed to hazardous noise, and employee monitoring through annual audiometric testing. U.S. Public Health Service officers and Coast Guard line officers serve as Safety and Environmental Health Officers at Coast Guard headquarters and in each of the nine Coast Guard districts. They are responsible for carrying out the sound-level surveys and noise dosimetry necessary to determine which vessels and other work sites necessitate enrollment in the hearing conservation program. Audiometry and other medical aspects of the hearing conservation program are carried out by a different group within the directorate (personal communication, W. McConnell, U.S. Coast Guard, February 10, 2005, and February 23, 2005; McConnell, 2004, 2005). Criteria and guiding documents for the Coast Guard hearing conservation program are shown in Table 5-1.

The Coast Guard does not yet formally participate in DOEHRS-HC. DoD forms 2215 and 2216 or similar forms for recording baseline and monitoring audiogram data are filed in an individual’s medical folder.

ASSESSING THE ADEQUACY OF HEARING CONSERVATION PROGRAMS

Criteria for Evaluating Hearing Conservation Program Effectiveness

Although there is general consensus concerning the necessary components of a hearing conservation program (several authors, cited by Royster and Royster, 1990), there is less agreement regarding how to assess the effectiveness of a program. Several approaches have been proposed, among them the use of checklists to assess the presence of important program components and the use of audiometric databases for population and criteria comparisons.

Suggested Citation:"5 Responding to Noise Risks: Hearing Conservation Programs in the Military." Institute of Medicine. 2006. Noise and Military Service: Implications for Hearing Loss and Tinnitus. Washington, DC: The National Academies Press. doi: 10.17226/11443.
×
Checklists

Hearing conservation programs can be audited with checklists to determine whether all the necessary components are present. A variety of checklists have been developed (Royster and Royster, 1990; Suter and Franks, 1990; NIOSH, 1996, 2005), including one distributed for use by Army hearing conservation program managers (U.S. Army Center for Health Promotion and Preventive Medicine, 2005). The major limitation of this approach is that a checklist alone cannot evaluate the quality of the implementation of each component (Royster and Royster, 2000). Measures such as the rate of compliance with requirements for annual audiograms are indicators of program activities that are necessary, but not sufficient, for effective programs. The Army found several hearing conservation programs that rated highly on their checklist but nonetheless had high incidences of STS (Byrne and Monk, 1993), and Navy researchers reported a similar finding (Wolgemuth et al., 1995). For a program to succeed, it is essential that the use of hearing protection devices be strictly enforced. Also considered necessary is a “key individual” who has overall responsibility for the program, takes a sincere personal interest in its success, has the full support of management, and has the dedication to motivate employees to be active program participants (Royster and Royster, 1990). These features are difficult to evaluate from outside a program.

Audiometric Database Evaluations

The availability of databases with audiometric monitoring information on the members of a hearing conservation program facilitates, but does not simplify, the evaluation of the program. Dobie (1995) noted several methodological challenges in studying the effectiveness of hearing conservation programs with audiometric data, including the need to take into account the effects of age, the typically slowing course of noise-induced hearing loss (as noted in Chapter 2, most hearing loss associated with noise exposure is observed in the first 10–15 years), and learning as individuals gain familiarity with audiometric testing procedures (discussed in Royster and Royster, 2000).

An American National Standards Institute (ANSI) working group labored for more than a decade to produce a standard on program evaluation and examined more than a dozen proposals for using audiometric data to evaluate hearing conservation program effectiveness. They published a draft standard, but it obtained support sufficient for publication only as a Technical Report (S12.13 TR-2002) rather than as a full standard (Acoustical Society of America, 2002). The procedures proposed by the ANSI Technical Report use audiometric database analysis (ADBA) to evaluate hearing con-

Suggested Citation:"5 Responding to Noise Risks: Hearing Conservation Programs in the Military." Institute of Medicine. 2006. Noise and Military Service: Implications for Hearing Loss and Tinnitus. Washington, DC: The National Academies Press. doi: 10.17226/11443.
×

servation program effectiveness. With this approach, if the year-to-year and year-to-baseline variability of audiometric data exceed certain criteria, the data are deemed too variable to provide useful information regarding changes in hearing thresholds and, therefore, are indicative of an ineffective hearing conservation program. The approach relies on the analysis of audiometric data for persons who have remained in the hearing conservation program long enough to receive at least two annual audiograms.

A weakness seen in the ADBA approach is that the subsamples used for the analyses are not randomly selected. The resulting selection bias may lead to inaccurate assessment of a hearing conservation program because those at high risk of hearing loss may be systematically excluded (Adera et al., 1993, 1995). However, an alternative perspective is that nonrandom selection of samples may help to target and evaluate suspected “worst-case” exposures. In addition, poor agreement has been observed when different ADBA procedures are applied to the same data (Adera et al., 1995). Concerns have also been expressed over the derivation of the numerical ranges for the criteria (Acoustical Society of America, 2002), the potential for bias against audiometric data collected in 5-dB steps (Simpson et al., 1993), and the inability to take into account preexisting hearing loss in the populations evaluated (Simpson et al., 1998).

In recent years, several alternative methods for using audiometric data to evaluate hearing conservation programs have been proposed. One uses comparison of the rate of hearing loss (e.g., as indicated by incidence of STS) in a hearing conservation program to that in an appropriate reference population (Adera et al., 2000a), although this requires availability of the reference population. Another method for hearing conservation program evaluation is time trend analysis, which examines patterns of hearing loss over time in multiple discrete cohorts within a larger database (Adera et al., 2000b).

Use of the percentage of workers showing STS in a given time period to evaluate the effectiveness of a hearing conservation program without reference to any comparison population has important limitations. Annual STS rates of 3–6 percent (Morrill and Sterrett, 1981) or 5 percent have been proposed (Franks et al., 1989; Simpson et al., 1994) as achievable by effective programs. However, the effects of variables such as age, sex, race, and previous noise exposure history, as well as merely poor audiometry, may play roles in STS rates, and these would not be taken into account (Melnick, 1984; NIOSH, 1996). Another important concern is that the variability inherent in audiometry is itself sufficiently large to make detection of STS in a noise-exposed population very unlikely (Hetu et al., 1990). Because of the shortcomings inherent in each of the approaches proposed, no standard procedure for evaluating hearing conservation program effectiveness has yet been recognized.

Suggested Citation:"5 Responding to Noise Risks: Hearing Conservation Programs in the Military." Institute of Medicine. 2006. Noise and Military Service: Implications for Hearing Loss and Tinnitus. Washington, DC: The National Academies Press. doi: 10.17226/11443.
×

ASSESSING THE ADEQUACY OF HEARING CONSERVATION PROGRAMS IN THE MILITARY

The committee interpreted its charge to “identify when hearing conservation measures were adequate to protect the hearing of service members” as evaluating the effectiveness of these programs over time. This task poses considerable challenges in the absence of a simple or universally accepted means for evaluating hearing conservation programs, as described above. In addition, it requires evaluation of not just a single program at one point in time, but evaluation of several different programs of the military services as they have changed since World War II.

It is important to note that effectiveness or adequacy of the program is not simply a matter of process: implementing a program as required. Instead, it is contingent on outcomes—whether the program is producing the desired results. Royster and Royster (1990, p. 341) provided one definition of effectiveness:

An effective hearing conservation program provides the noise-exposed population protection from on-the-job noise exposures such that changes in its hearing threshold levels over time are not significantly different from those found in a properly matched control population (a nonindustrial noise-exposed population, or NINEP, exhibiting all of the relevant population characteristics and hearing hazards except for on-the job noise exposure).

Chapter 3 presented some of the data available to the committee to examine changes in hearing thresholds in a few samples of different military service populations over decades from the 1970s to the 1990s, albeit with limitations in the availability of appropriate reference populations. It is difficult to determine the extent to which service members have experienced hearing loss, even for the period since audiometric testing has been required.

In this section the committee reviews additional evidence pertaining to aspects of the process, rather than the outcomes, of military hearing conservation programs since World War II. The committee was unable to carry out an audit of the countless sites at which military hearing conservation programs are implemented; instead it relied on information regarding hearing protection and audiometric monitoring from the published literature and from information, such as that from DOEHRS-HC, provided to the committee by the services. The information available to the committee regarding these features is incomplete but, taken together, may provide some indication of the adequacy of the services’ hearing conservation programs over time.

Noise Control

Hazardous noise exposures may occur in various military settings, including industrial-type workplaces (aircraft refurbishing, shipbuilding), as

Suggested Citation:"5 Responding to Noise Risks: Hearing Conservation Programs in the Military." Institute of Medicine. 2006. Noise and Military Service: Implications for Hearing Loss and Tinnitus. Washington, DC: The National Academies Press. doi: 10.17226/11443.
×

well as military-unique environments, such as combat. Although complete control of hazardous noise in combat is clearly impossible, there are many circumstances in which limiting or reducing hazardous noise at its source is possible. Indeed, the Department of Defense Design Criteria Standard (MIL-STD-1474D), first issued in 1973, emphasizes the importance of incorporating noise control considerations into the design and purchase requirements for military materiel (DoD, 1997). However, as noted in Chapter 3, DoD regulations give priority to maintaining combat readiness and permit tradeoffs between noise reduction and weight, speed, cost, or other factors crucial to the effectiveness of the equipment (DoD, 2004b).

Noise control efforts can range from elaborate engineering measures, to routine maintenance, to isolation of noise sources with insulation. In current operations in Iraq, simple barriers such as sandbags are used where possible to muffle noise from generators or other loud equipment (Chandler, 2004).

In the Navy, silencing technology has been applied in the successive redesign of surface combatant vessels and submarines over the years to provide up to 30 dB reductions in noise levels (Yankaskas and Shaw, 1999; Yankaskas, 2004). In contrast, similar improvements possible on aircraft carriers have not yet been carried out. The 30-year-old carrier design permits intermittent high levels of noise in libraries, passageways, and sleeping berths as well as the high levels measured on flight decks (Yankaskas and Shaw, 1999; Yankaskas, 2004).

Hearing Protection

Control of hazardous noise at its source in military settings is frequently not possible, so that hearing protection, either through administrative controls (e.g., limiting the time a person can spend in hazardous noise) or with protective devices, has been of vital importance. However, administrative controls are difficult to implement in the military, especially in training and on the battlefield, where operational time frames do not adhere to typical workdays. As a result, protection from hearing loss in the military has essentially equated to issuing hearing protection devices.

Recognition of the need for hearing protection has evolved considerably over the past 60 years, as has the quality and effectiveness of the available equipment. Although hearing protection devices were available prior to 1940 (Acton, 1987; Moritz and Bruce, 1994), utilization was essentially nonexistent throughout World War II. A substantial research effort to devise a suitable hearing protection device concluded in 1945 with the development of the Ear Warden V-51R (Shaw and Veneklasen, 1945), a design used by the military through the 1990s. Shaw and Veneklasen (1945) observed that a common form of hearing protection in use by the

Suggested Citation:"5 Responding to Noise Risks: Hearing Conservation Programs in the Military." Institute of Medicine. 2006. Noise and Military Service: Implications for Hearing Loss and Tinnitus. Washington, DC: The National Academies Press. doi: 10.17226/11443.
×

military during the 1940s was cotton or cotton waste, as also documented by Walpole (1943). Unfortunately, such air-permeable material was inadequate as a noise attenuator. In fact, according to an early Air Force regulation, even the devices available by 1949 (three-sized V-51R, cotton plugs moistened in petroleum jelly or paraffin, and dental acrylic custom earmolds) were “effective only against minimal exposure” (Department of the Air Force, 1949).

The years since World War II have seen some marked improvements in hearing protection. Resilient materials needed as interfaces with the flesh around the ear or in the ear canal were improved in comfort, durability, and dynamic characteristics. An important advancement in earplug technology was introduced in the 1970s—the roll-down slow-recovery foam earplug, which has become a predominant form of hearing protection for both military and industrial users worldwide. In a one-sized product, it offered increased levels of protection, as well as comfort, for most users (Camp et al., 1972; Bailey and Walker, 1979; Shaw, 1979; Schleifer et al., 1984). Another technological development was the introduction of active noise reduction systems into tanker helmets in the 1980s and into Air Force flight helmets in the 1990s. These systems served to attenuate low-frequency noise and thereby enhanced communications (McKinley and Nixon, 1993; Anderson and Garinther, 1997; Mozo and Murphy, 1997). Other electronic products for communication also appeared, though in some high-noise environments, such as the flight decks of aircraft carriers, the same hearing protection (“cranial earmuffs”) and communication technology that was used in the 1950s is still in use today (personal communication, J. Page, Naval Environmental Health Center, March, 2005). Developments in hearing protection from World War II to the present are broadly summarized in Table 5-2.

Although gains have been made in the potential noise reduction of hearing protection devices in the past 60 years, the achievable attenuation values have not changed substantially since the 1970s. Table 5-3 summarizes the potential noise reduction provided by the hearing protection devices in current use. Ranges of attenuation are provided because, even in a laboratory setting, performance is highly dependent on the use and fit of the devices. The ranges also allow for the variation in performance between different brands of the same type of device. The use of earplugs together with earmuffs, called dual protection, provides maximum protection. For well-fitted devices, the average attenuation for dual-protection systems is as much as 40–50 dB at frequencies up to 1000 Hz and can be even greater at frequencies at and above 2000 Hz. The amounts of protection that can be provided are adequate in all but the most severe military exposures, such as carrier flight decks.

Suggested Citation:"5 Responding to Noise Risks: Hearing Conservation Programs in the Military." Institute of Medicine. 2006. Noise and Military Service: Implications for Hearing Loss and Tinnitus. Washington, DC: The National Academies Press. doi: 10.17226/11443.
×

Regardless of the data measured in the laboratory, it has become clear that the “real-world” performance of devices is quite different as a result of fit and other factors, such as motivation, training, supervision, and enforcement (Berger et al., 1996; Berger, 2000a). A summary chart of noise reduction ratings versus real-world attenuation is presented in Figure 5-2. The data were drawn from 22 field studies, including 1 conducted in a military setting (Smoorenburg et al., 1986).

Even more important than the difference between potential attenuation and the real-world performance of hearing protection devices in the field, however, is the impact of wearing the devices at all. The percentage of time a hearing protection device is used in a noisy environment has a much greater effect on hearing protection than even changes of 5 or 10 dB in the amount of noise reduction the devices provide when assessed in a laboratory. A recent study highlights this issue. Neitzel and Seixas (2005) measured the attenuation of the hearing protection devices in use and also developed verified estimates of actual wearing time. For devices with approximately 20 dB of real-world attenuation, the effective protection, taking into account wearing time, was less than 3 dB. Although the environment they studied was construction, it is likely that many of the same factors apply to the military setting.

In intensive military operations, such as training and combat, the motivation to wear hearing protection may be further limited by concerns that hearing protection devices may jeopardize the wearer’s safety. Safety could be compromised when using hearing protection devices by impairing communication or causing service members to miss vital auditory warning signals (sounds of enemy troops, ordnance, and the environment).

In a 1975 survey of 3,000 enlisted men from U.S. Army infantry, armor, and artillery branches, 64 percent reported that they routinely used hearing protection, while 90 percent reported that hearing protective devices were readily available to them (Walden et al., 1975). Nearly half of the soldiers reported that they disliked wearing hearing protection. A smaller study observed only 14 of 34 (41 percent) Army drill instructors using hearing protection on a given day (Loeb et al., 1973). A study of submariners, submarine force workers, and support personnel in the early 1980s found that more than 50 percent of personnel surveyed who worked in noisy environments reported never using hearing protection, with officers less likely to report use of hearing protection (Gwin and Lacroix, 1985). More recently, a study on the use of hearing protection devices in one of the most hazardous noise environments in any industrial or military setting, the aircraft carrier flight deck (where noise levels routinely exceed 140 dBA), found that 47 percent of those surveyed reported never wearing double hearing protection even though they were working in

Suggested Citation:"5 Responding to Noise Risks: Hearing Conservation Programs in the Military." Institute of Medicine. 2006. Noise and Military Service: Implications for Hearing Loss and Tinnitus. Washington, DC: The National Academies Press. doi: 10.17226/11443.
×

TABLE 5-2 Available Hearing Protection from World War II to the Present

Time Frame

Typical Devices

Comments

World War II

Cotton

Minor amounts of noise reduction

Fingers

Effective but inconvenient; used by artillery crews to some extent

Nothing

The standard of the day

1945–late 1950s

Vaseline-impregnated cotton

Messy, modestly effective, better for water protection than noise protection

V-51R earplug

Initially produced in three sizes; developed just at the end of World War II

Hard custom earmolds

Easily lost seal, not widely used

Early circumaural earmuff designs

Initial designs had inadequate cushions and modest attenuation (around 20 dB or less) up to 1000 Hz

Navy “cranial earmuffs” introduced in mid-1950s and still in use today (circa 2005)

Plastic earmuff cups held in place by fabric head cap with a plastic shell covering the fabric but not enclosing the earmuff cups; inadequate fitting and modest protection

1960s

V-51R earplug

An extra-small and extra-large size added to fit a wider range of ear canals

Triple-flange earplug

Alternative easier-to-fit design introduced as a two-sized version

Canal caps (pods on light-weight band)

Modest protection for intermittent environments

Malleable putty earplug

Not widely used, and ergonomic problems due to required kneading and messiness

Improved earmuffs

Higher attenuating designs introduced with better cushions and headbands

1970s

Conventional plugs and muffs same as 1960s

Technology essentially mature by this time, but some material improvements such as newer three-sized silicone version of triple-flange plug. Also, color-coded sizing introduced.

Roll-down slow-recovery foam earplugs

New-concept earplug that provided better protection and comfort, but limited use in military initially

Tanker helmets and aircraft flight helmets with internal earcups for noise attenuation

Helmets began to provide not only impact protection, but acoustical protection too. Low-frequency attenuation not as good as conventional earmuffs.

Suggested Citation:"5 Responding to Noise Risks: Hearing Conservation Programs in the Military." Institute of Medicine. 2006. Noise and Military Service: Implications for Hearing Loss and Tinnitus. Washington, DC: The National Academies Press. doi: 10.17226/11443.
×

1980s

Conventional plugs and muffs same as 1960s and 1970s

No technology advances

Tanker helmets began to appear with ANR included

ANR in this environment improved communication and protection

1990s

Same as prior decades

Minor technology advancements especially in cosmetics, but performance essentially unchanged

Widespread use of roll-down slow-recovery foam ear plugs

Most commonly used hearing protection device

Communication earplugs

Use of earphone in foam earplugs for use in tanker and helicopter applications for enhanced communication under helmet and increased protection

Widespread use of ANR for tanker helmets and limited application of ANR for aircraft flight helmets

The advantages of ANR began to appear in aircraft applications too

2000–present

Same as prior decades

As before, except that V-51R plug dropped from inventory

Level-dependent “combat arms” earplugs

New technology provides the ability to protect against weapons and blast noise, but still allow communication and signal detection of lower-level sounds when the impacts are not present

NOTE: ANR = active noise reduction.

SOURCES: Shaw and Veneklasen (1945); Department of the Air Force (1949); Blackstock and Von Gierke (1956); Guild (1966); Gardner and Berger (1994); Mozo and Murphy (1998); Ohlin (2005c); Schulz (2005a); Personal communication, D. Gauger, Bose Corporation, April 2005; personal communication, D. Ohlin, USACHPPM, April 2005.

Suggested Citation:"5 Responding to Noise Risks: Hearing Conservation Programs in the Military." Institute of Medicine. 2006. Noise and Military Service: Implications for Hearing Loss and Tinnitus. Washington, DC: The National Academies Press. doi: 10.17226/11443.
×

TABLE 5-3 Representative Minimum and Maximum Mean Attenuation Values of Well-Fitted Hearing Protectors Under Laboratory Conditions, in dB

Type of Hearing Protector

Octave-Band Center Frequency (Hz)

125

250

500

1000

2000

4000

8000

Inserted Hearing Protectors

Foam earplugs (attenuation varies with depth of insertion)

20–40

20–40

25–45

25–45

30–40

40–45

35–45

Premolded earplugs

20–30

20–30

20–30

20–35

25–35

30–45

30–45

Formable (fiberglass/mineral wool)

20–30

20–30

20–30

25–30

25–30

35–40

35–40

Formable (wax-impregnated cotton or silicone)

20–25

20–25

20–25

25–30

30–35

40–45

40–45

Custom-molded earplugs

15–35

15–35

15–35

20–35

30–40

35–45

30–45

Semi-insert earplugs

15–30

15–30

10–30

15–30

25–35

25–45

30–45

Circumaural, Helmet, and Combined

Earmuffs (with or without communications components)

5–20

10–25

15–40

25–45

30–40

30–40

25–40

Military helmets

0–15

5–15

15–25

15–30

25–40

30–50

20–50

Dual protection (earplugs + earmuffs)

20–40

25–45

25–50

30–50

35–45

40–50

40–50

Active noise reduction (closed-cup systems; identical to conventional muffs above 1 kHz)

15–25

15–30

20–45

25–40

30–40

30–40

25–40

Other Types

Cotton balls

0–5

0–10

5–10

5–10

10–15

10–20

10–20

Motorcycle helmets

0–5

0–5

0–10

0–15

5–20

10–30

15–35

Air-fed shotblasting helmets

0–5

0–5

0–5

0–15

15–25

15–30

15–25

Finger tips in ear canals

25–30

25–30

25–30

25–30

25–30

30–35

30–35

NOTE: Data are intended to account for brand and testing variability; however, not all manufacturers’ reported data or values referenced in the literature will necessarily fall within the ranges cited. All data are from E·A·RCAL Laboratory as reported by Berger (2000a), except for the shotblasting helmets (Price and Whitaker, 1986) and fingers (Holland, 1967).

Suggested Citation:"5 Responding to Noise Risks: Hearing Conservation Programs in the Military." Institute of Medicine. 2006. Noise and Military Service: Implications for Hearing Loss and Tinnitus. Washington, DC: The National Academies Press. doi: 10.17226/11443.
×

FIGURE 5-2 Comparison of Noise Reduction Ratings published in North America (labeled values based on laboratory tests) to real-world attenuation results derived from 22 studies.

SOURCE: Berger (2000b). Reprinted, with permission, from Berger (1993). Copyright 2000 by E•A•R Company.

mandatory dual-protection environments (Bjorn et al., 2004a). A separate study reported that while all flight deck personnel wear headgear (“cranials”) with earmuffs rated at 23 dB, only 1 of the 22 individuals in the study wore dual hearing protection (Rovig et al., 2004).

The evidence, described above, of limited use of hearing protection among personnel in U.S. military units is consistent with findings from studies in other military and industrial work situations. A review of 67 studies published between 1981 and 1999 and providing data on usage of hearing protection devices frequently found that fewer than 50 percent of those who should have been wearing protection reported doing so (Berger, 2000b). Five studies reported on usage of hearing protection in military units from Canada, the United Kingdom, and Israel. From 0 to 42 percent of personnel in these units reported usually wearing hearing protection all the time in combat situations, and from 63 to 89 percent wore it all the time in other settings.

Despite continuing challenges in motivating service members to use hearing protection devices, there is some indication of an emerging willingness among service members to use hearing protectors (Ohlin, 2005d). This is at least in part due to two new and unrelated military initiatives: an

Suggested Citation:"5 Responding to Noise Risks: Hearing Conservation Programs in the Military." Institute of Medicine. 2006. Noise and Military Service: Implications for Hearing Loss and Tinnitus. Washington, DC: The National Academies Press. doi: 10.17226/11443.
×

extensive effort to solve the extreme noise-exposure problem on aircraft carrier flight decks (Bjorn et al., 2004b), and the introduction of a new type of level-dependent earplug, called the Combat-Arms™ earplug. The earplug provides the ability to hear low-level sounds with less distortion or interference from attenuation than with traditional passive hearing protection devices, while affording protection from blasts and weapons fire (Dancer et al., 1999; U.S. Army Center for Health Promotion and Preventive Medicine, 2004d). Despite these developments, in the coming years it remains likely that the effective use of hearing protectors by service members in combat and other intensive operational settings will be less than that in noncombat and support operations.


FINDING: Compliance with requirements for use of hearing protection devices is crucial for an effective hearing conservation program. There is limited or suggestive evidence to conclude that use of hearing protection devices and the level of real-world hearing protection these devices provide have been and remain not adequate in military hearing conservation programs. However, the studies conducted in U.S. military personnel are generally consistent with studies from other settings that provide additional evidence that the use and real-world protection of hearing protection devices are not adequate.

Audiometric Monitoring

Audiometric monitoring provides some of the most useful information about the effectiveness of hearing conservation programs and for making changes as needed to improve hearing protection. This section reviews the chronology of the availability and use of audiometry, the requirements for entrance and termination audiograms among the military services, and the information available from recent audiometric monitoring as reported through HEARS and DOEHRS-HC.

Whispered Voice Test

Some patients at the military aural rehabilitation facilities established in the late 1940s were not combat casualties, but members of the military accepted for military service with undetected hearing loss (Bergman, 2002). Although audiometers were available at the time, this measurement equipment was not used at the induction centers responsible for the initial processing of personnel. Instead, a conversational speech test or the “whispered voice test” was used to evaluate the hearing ability of recruits. These tests measured the distance at which an individual understood speech at levels that could be understood from 15 or 20 feet away by people with

Suggested Citation:"5 Responding to Noise Risks: Hearing Conservation Programs in the Military." Institute of Medicine. 2006. Noise and Military Service: Implications for Hearing Loss and Tinnitus. Washington, DC: The National Academies Press. doi: 10.17226/11443.
×

normal hearing (Nixon, 1998). Normal hearing was thus represented by notations such as “15/15” or “20/20.” Military applicants were required to have hearing, as measured by the whispered voice test, of 8/15 or better in each ear (Department of Veterans Affairs, 2004). Results of whispered voice tests are extremely variable between testers (Lee, 1998), and early testing environments within the military settings were not likely to be controlled (Bergman, 2002). Without accurate measures of hearing thresholds, some people inducted into the military with hearing loss were classified as normal-hearing individuals. Estimates from two of the military aural rehabilitation centers established in the 1940s suggest 40–65 percent of patients seen had hearing losses predating their military service (Bergman, 2002).

Requirements for Audiograms

During the 1950s and 1960s, measurement of pure-tone thresholds using audiometers became more widespread. In 1956, the Air Force mandated audiometric testing as part of its hearing conservation program, as well as to establish hearing thresholds for all individuals entering Air Force service as part of their routine physical examination (Department of the Air Force, 1956). However, the Air Force’s regulations of 1973 and 1982 did not reiterate the requirement for an audiogram immediately upon entrance into service (Department of the Air Force, 1973, 1982). Instead, the 1982 regulation states that the standard procedure in the Air Force is to obtain reference audiograms within 30 days after assignment at the first permanent duty station (Department of the Air Force, 1982). In 1960, the whispered voice test was replaced by pure-tone audiometry at recruit screening centers (Department of Veterans Affairs, 2004). In 1980, the Army published a policy requiring that a reference audiogram be made a part of the preplacement or entrance physical examination (Department of the Army, 1980), and in 1979, the Navy required that all military personnel receive a reference audiogram upon entry into naval service (Department of the Navy, 1979). DoD did not issue a requirement for reference audiograms at basic training prior to noise exposure until 1996 (DoD, 1996).

Despite these requirements, to date, not all service members are administered a reference audiogram upon entrance. In the Army, Fort Sill is the only basic training site conducting universal audiometric examinations during inprocessing (AMSARA, 2002). In the Air Force, baseline audiometric examinations may frequently be administered after basic training, now more than 6 weeks in duration (Pluta, 2004, 2005a). All of the services stipulate that the audiograms used as a screening tool to establish fitness for military service (most collected at the Military Entrance Processing Stations) are not acceptable as reference audiograms (Department of the Air Force, 1982; Department of the Navy, 1979, 1984). This stems from the varying periods

Suggested Citation:"5 Responding to Noise Risks: Hearing Conservation Programs in the Military." Institute of Medicine. 2006. Noise and Military Service: Implications for Hearing Loss and Tinnitus. Washington, DC: The National Academies Press. doi: 10.17226/11443.
×

of time (up to 18 months) between the military entrance processing examinations and accession to the military as well as concerns about the reliability of these evaluations (Chandler et al., 1986; Niebuhr et al., 2000; Department of Veterans Affairs, 2004). Screening audiograms at military entrance processing stations require manual transcription, allow for variable intervals between calibration, and do not require technician certification or a defined quiet period before the examination (Niebuhr, 2003).

The Air Force was the first service with a requirement that all military and civilian personnel receive an audiometric examination as part of their routine physical examination when they end their Air Force service (Department of the Air Force, 1956). The 1973 and 1982 Air Force regulation updates (Department of the Air Force, 1973, 1982) stated that all personnel whose duties caused them to be routinely exposed to hazardous noise must receive a final audiometric examination within 90 days before the last day of active duty, but they did not specify that all personnel were to receive audiograms at separation from service. In 1980, the Army (Department of the Army, 1980) and in 1979 the Navy and Marine Corps (Department of the Navy, 1979) required hearing tests upon termination of service. In the Coast Guard, termination physical exams included audiograms starting in the early 1990s (McConnell, 2005). However, physical exams are not generally required by the services upon separation unless the last exam or medical assessment is no longer considered current (except for retiring Army service members) (GAO, 2004). Service members may waive the hearing test, however, and many do so rather than face delays in returning home.

Compliance with Requirements for Annual Audiograms

The committee reviewed data regarding compliance with the requirement for annual audiograms for those enrolled in hearing conservation programs. Data were available for the Army from the HEARS and DOEHRS-HC databases for 1989–2003. Air Force data were available only from DOEHRS-HC for 2000–2003. As noted earlier, the DOEHRS system is designed to collect, maintain, compare, and report hearing conservation data within all branches of the DoD. Since its introduction in 1999, the system has experienced repeated changes in contractors, as well as considerable turnover in the audiometric technicians who administer audiograms (Ohlin, 2004a) and several other infrastructure and training problems (Frost, 2004).

Data furnished to the committee on compliance for the Army and the Air Force are plotted in Figure 5-3. Clear peaks and valleys in the data from the Army may, in part, reflect administrative changes in the database. In 1991, for example, a change from reporting the numbers of service members enrolled in the hearing conservation program by medical region to

Suggested Citation:"5 Responding to Noise Risks: Hearing Conservation Programs in the Military." Institute of Medicine. 2006. Noise and Military Service: Implications for Hearing Loss and Tinnitus. Washington, DC: The National Academies Press. doi: 10.17226/11443.
×

FIGURE 5-3 Percentage of Army and Air Force service members enrolled in hearing conservation programs who received annual audiograms, according to the Army Hearing Evaluation Automated Registry System (HEARS) (1989–1998) and the Defense Occupational and Environmental Health Readiness System–Hearing Conservation (DOEHRS-HC) (1999–2003) data repositories.

SOURCES: Air Force Hearing Conservation Registry (2004a); U.S. Army Center for Health Promotion and Preventive Medicine (2004b).

reporting by individual sites led to a large increase in the number of records reported. In 1998, the Army transitioned its HEARS system to DOEHRS-HC and some of the HEARS data were not available to the new system (Ohlin, 2004b). The denominators (numbers of personnel reported as noise exposed) are often estimates based on unit strengths at the larger installations. Numerators are based on the hearing tests received at the data repository. Compliance can be higher than the reported figures if data from all hearing tests are not received or can be artificially inflated if personnel are tested who are not reported as noise exposed (Ohlin, 2005a). Although there are fluctuations in the Army data from 1988 through 2003, average compliance is estimated to be 45 percent over this period. Since 2000, compliance for the Air Force is approximately 55 percent. Thus, half of the

Suggested Citation:"5 Responding to Noise Risks: Hearing Conservation Programs in the Military." Institute of Medicine. 2006. Noise and Military Service: Implications for Hearing Loss and Tinnitus. Washington, DC: The National Academies Press. doi: 10.17226/11443.
×

service members who should have annual audiograms are either not being tested or the test results are not being entered into the database. In either case, missing data are serious obstacles to implementing effective hearing conservation programs.

While the Navy participates in DOEHRS-HC, it has not attempted to produce data on compliance with audiometric testing requirements (Page, 2004b). However, Wolgemuth and colleagues (1995) provided some data on compliance for 154 vessels of the U.S. Atlantic Fleet for 1987–1990. A sample of 12,492 audiometric records from the Navy’s hearing conservation program, representing sampling rates from 20 to 100 percent per vessel, indicated an average compliance rate for annual audiograms of 81 percent reported across vessels (range: 40–100 percent). Compliance figures were not reported by ship type, so the percentage of personnel represented was not clear. Compliance data were not available for the Coast Guard.


FINDING: Results of annual audiograms are available for approximately half of military service members in hearing conservation programs reporting compliance with testing requirements during the period 1988–2003. Incomplete reporting, lack of compliance with requirements for annual audiograms, or both, severely limit the usefulness of the centralized database and the conclusions that can be drawn from it regarding hearing conservation program effectiveness.

Variability in Military Audiometric Databases

As noted earlier in the chapter, data from reference, periodic, and termination audiograms constitute audiometric databases that can be used to evaluate hearing conservation programs. Thomas (1995) analyzed the Air Force audiometric database, using the ANSI draft standard ADBA protocol (S12.13 1991) to evaluate hearing conservation program effectiveness on the basis of audiometric variability. Under the proposed ANSI criteria, the Air Force hearing conservation program qualified as “unacceptable to marginal.” The undesirable levels of variability in the Air Force data may result from normal fluctuations in the responsiveness of individuals, inconsistencies in equipment calibration or testing methods, or actual threshold changes resulting from temporary or permanent hearing loss (Thomas, 1995).

Because methods of audiometric database analysis are best suited for analysis of consecutive audiograms in a stable population with a consistent set of audiometers (Royster and Royster, 2000), a military hearing conservation program may rate poorly using this metric. Service members are typically very mobile—moving from assignment to assignment within the military and then leaving the military within about 4 years (GAO, 1998).

Suggested Citation:"5 Responding to Noise Risks: Hearing Conservation Programs in the Military." Institute of Medicine. 2006. Noise and Military Service: Implications for Hearing Loss and Tinnitus. Washington, DC: The National Academies Press. doi: 10.17226/11443.
×

Thus, consecutive annual audiograms are frequently administered in different locations using different audiometers.

Measures of Significant Threshold Shift and Permanent Threshold Shift

Definitions of STS Definitions of STS have changed in the military services over the years, as summarized in Table 5-4. In 2004 (or as the services implemented DOEHRS-HC software distributed in 2004), all services used a definition of STS consistent with that of OSHA (Ohlin, 2005b). OSHA (1983) defines an STS as a change of 10 dB or more in the average pure-tone thresholds at 2000, 3000, and 4000 Hz in either ear compared with the baseline audiogram.

Royster (1992, 1996), Schulz (1994), and Dobie (2005) have analyzed the impact of different definitions of STS on the sensitivity and specificity of the measure. With increasing sensitivity, more hearing conservation program participants are identified as experiencing an STS, and with increasing specificity, fewer participants are unnecessarily designated as warranting follow-up action. Tradeoffs are necessary between the two. Definitions of STS are policy decisions requiring considerations of hearing loss prevention and the costs of follow-up tests, counseling, referrals, and potential job changes.


STS and PTS in Military Hearing Conservation Programs Chapter 3 reviewed the percentages of STS and permanent threshold shift (PTS) in the personnel enrolled in the military services’ hearing conservation programs over recent years. In those data, a PTS is defined as an STS that is either (1) confirmed upon retest following at least 40 hours of quiet or (2) not resolved through follow-up testing. When the threshold shift is designated as a PTS (either through confirmation or lack of follow-up), the newest thresholds should, but may not always, become the baseline audiogram for future comparisons. As a result, PTS percentages may be artificially high from either a lack of follow-up testing or a failure to establish a new baseline following a previous PTS.

As shown in Figure 5-4, at 7–8 percent, the reported annual percentages of Air Force hearing conservation program enrollees with PTS for the period 1989–2004 are the lowest levels reported across the services. Rates for that period for the Army, Navy, and Marine Corps are approximately 15 percent. It is important to note, however, that these figures are based on data representing only about half of the enrollees in the hearing conservation programs. If this were a random sample of enrollees, it would be more than adequate for the evaluation of the programs. This is not the case, however, and the types of bias that might be introduced by unknown selection factors limit the utility of these data for the evaluation of the military’s hearing conservation programs.

Suggested Citation:"5 Responding to Noise Risks: Hearing Conservation Programs in the Military." Institute of Medicine. 2006. Noise and Military Service: Implications for Hearing Loss and Tinnitus. Washington, DC: The National Academies Press. doi: 10.17226/11443.
×

TABLE 5-4 Definitions of Significant Threshold Shift (STS) in the Military Services over Time

Year

DoD

Air Force

Army

Navy/Marine Corps

1956

 

For personnel with “Class A” hearing: ≥ 20 dB at any of 0.5, 1, 2, 3, 4, 6 kHz

For personnel with “Class B” hearing: ≥ 10 dB at 2 kHz, or ≥ 15 dB at 3 kHz, or ≥ 20 dB at 4 kHz, and/or 6 kHz, one or both ears

 

 

1976

 

Same as previously

 

 

1978

≥ 20 dB in either ear, at any test frequency

Test frequencies were 0.5, 1, 2, 3, 4, and 6 kHz

Same as previously

 

 

1979

 

≥ 20 dB at 1, 2, 3, or 4 kHz

≥ 20 dB at 1, 2, 3, or 4 kHz and/or ≥ 10 dB average at 2, 3, and 4 kHz

No age correction

≥ 15dB at any frequency 0.5–6 kHz in either ear

1982

 

≥ 20 dB at 1, 2, 3, or 4 kHz

 

 

1983

 

 

 

≥ 15 dB at1, 2, 3, or 4 kHz and/or an average change of ≥ 10 dB at 2, 3, and 4 kHz

Suggested Citation:"5 Responding to Noise Risks: Hearing Conservation Programs in the Military." Institute of Medicine. 2006. Noise and Military Service: Implications for Hearing Loss and Tinnitus. Washington, DC: The National Academies Press. doi: 10.17226/11443.
×

1987

 

≥ 20 dB at l, 2, 3, or 4 kHz and/or ≥ 10 dB average at 2, 3, and 4 kHz

No age correction

≥ 20 dB at 1, 2, 3, or 4 kHz and/or ≥ 10 dB average at 2, 3, and 4 kHz

With age correction

 

1999 (DOEHRS-HC)

≥ 15 dB at 1, 2, 3, or 4 kHz and/or ≥ 10 dB average at 2, 3, and 4 kHz

No age correction

≥ 15 dB at 1, 2, 3, or 4 kHz and/or ≥ 10 dB average at 2, 3, and 4 kHz

No age correction

≥ 15 dB at 1, 2, 3, or 4 kHz and/or ≥ 10 dB average at 2, 3, and 4 kHz

No age correction

≥ 15 dB at 1, 2, 3, or 4 kHz and/or ≥ 10 dB average at 2, 3, and 4 kHz

No age correction

2004 (DOEHRS-HC)

≥ 10 dB average at 2, 3, and 4 kHz in either ear

No age correction

≥ 10 dB average at 2, 3, and 4 kHz in either ear

No age correction

≥ 10 dB average at 2, 3, and 4 kHz in either ear

No age correction

≥ 10 dB average at 2, 3, and 4 kHz in either ear

No age correction

 

≥ 15 dB in either ear at any test frequency from 1 to 4 kHz considered an early warning of potential future STS

≥ 15 dB in either ear at any test frequency from 1 to 4 kHz considered an early warning of potential future STS

≥ 15 dB in either ear at any test frequency from 1 to 4 kHz considered an early warning of potential future STS

≥ 15 dB in either ear at any test frequency from 1 to 4 kHz considered an early warning of potential future STS

NOTES: “Class A” and “Class B” hearing defined according to Department of the Air Force (1956).

SOURCES: Department of the Air Force (1956, 1976, 1982); Department of the Navy (1979); Schulz (1994, 2005a,b); Ohlin (2005b); Page (2005b).

Suggested Citation:"5 Responding to Noise Risks: Hearing Conservation Programs in the Military." Institute of Medicine. 2006. Noise and Military Service: Implications for Hearing Loss and Tinnitus. Washington, DC: The National Academies Press. doi: 10.17226/11443.
×

FIGURE 5-4 Percentage of personnel receiving audiometric tests who were identified as showing positive significant threshold shifts (STSs) and permanent threshold shifts (PTSs) (worse hearing) as reported by DOEHRS-HC for the Army, Air Force, Navy, and Marine Corps for 1982–2004. During this time the definition of STS changed, as detailed in Table 5-4.

SOURCES: Air Force Hearing Conservation Registry (2004b); Navy Environmental Health Center (2004a); U.S. Army Center for Health Promotion and Preventive Medicine (2004c).

PTS and STS values for each service are of interest, but far more useful for intervention and improvement are STS and PTS values reported by installation or by military occupational code, which permit a more focused assessment of subpopulations at greatest continuing risk. A review of data for 1991 from the Air Force hearing conservation data registry reported PTS rates of 1 percent and STS rates of 4 percent among pilots (Department of the Air Force, 1992). Among aerospace maintenance workers, 2 percent were reported to have a PTS and 4 percent an STS. Cases of PTS and STS were also reported among other personnel, such as those with financial and paralegal occupational specialties. Davis (1994) assessed the risk of PTS in the Air Force by Air Force Skill Code in 1992. The crude overall risk of PTS among those in the hearing conservation program was 2 percent, with risks ranging from 0 percent to 11 percent across skill codes for military and civilian participants combined.

Suggested Citation:"5 Responding to Noise Risks: Hearing Conservation Programs in the Military." Institute of Medicine. 2006. Noise and Military Service: Implications for Hearing Loss and Tinnitus. Washington, DC: The National Academies Press. doi: 10.17226/11443.
×

A series of studies carried out in the mid-1990s assessed hearing thresholds among Navy personnel, as reviewed in Chapter 3. The studies documented continuing STS, not just among engineering and aviation personnel, but also in administrative and supply occupational categories where it would not be anticipated (Wolgemuth et al., 1995; Page et al., 2002).

In sum, the information available from audiometric monitoring carried out by the military services provides a complex picture of their hearing conservation programs. Most prominent, however, is the handicap posed by the poor compliance with requirements for reporting periodic audiometric data to a central repository, limiting the usefulness of the data registry as a surveillance and evaluation tool.

Program Evaluation

No single approach has been taken for program evaluation by the military services’ hearing conservation programs. Except for the Air Force, a variety of ad hoc efforts to evaluate the effectiveness of the hearing conservation programs have been made (as drawn upon in Chapter 3 and above). Air Force regulations require annual reports concerning the overall state of the hearing conservation program (Department of the Air Force, 1991). Such reporting began in the mid-1970s, continued intermittently into the mid-1990s, and has recently resumed (Department of the Air Force, 1974, 1980, 1992, 1993, 1995; Meyer and Wirth, 1993; Pluta, 2003, 2005b).

Army regulations require reporting of effectiveness indicators at the installation level (Department of the Army, 1998). Data on cases of STS were reported for several years during the 1990s, but such data were unavailable from 1998 through late 2002 because of limitations in the reporting capability of DOEHRS-HC. Overall statistics for compliance with monitoring requirements, hearing profiles, and positive and negative STS cases are reported on the Army’s hearing conservation program website, but no periodic servicewide evaluation is currently undertaken (Ohlin 2005c). However, the U.S. Army Center for Health Promotion and Preventive Medicine provides a program evaluation checklist for use throughout the Army (Ohlin, 1999; U.S. Army Center for Health Promotion and Preventive Medicine, 2005). In the Navy regulations, annual program performance evaluations are to be carried out at the local level but are not required or carried out servicewide (Navy Environmental Health Center, 2004b). According to DoD policy, components are to evaluate the effectiveness of their hearing conservation programs annually based on the prevalence of STS and the percentage of compliance with requirements for annual audiograms (DoD, 2004b).

Since the services’ hearing conservation programs were introduced, individuals and groups with a particular commitment to hearing health

Suggested Citation:"5 Responding to Noise Risks: Hearing Conservation Programs in the Military." Institute of Medicine. 2006. Noise and Military Service: Implications for Hearing Loss and Tinnitus. Washington, DC: The National Academies Press. doi: 10.17226/11443.
×

have worked hard to draw attention to problems and challenges and to evaluate and improve the programs. The committee heard presentations from, and reviewed reports by, people who demonstrated a commitment to the assessment and improvement of their service’s hearing conservation program. They are using the tools available to them (e.g., DOEHRS-HC, surveys, specific self-audit software, and epidemiological studies) to assess the effectiveness of their programs. DOEHRS-HC appears to have as yet unrealized potential to improve evaluation of the hearing conservation programs. Reported compliance with requirements for annual audiograms is low, limiting the data available for review and analysis, and reporting functions of the system are limited.

Conclusions About Program Adequacy

The effectiveness of the military hearing conservation programs is difficult to evaluate because of the disjointed and limited information available. The military services must contend with substantial challenges beyond their control, including the mobility and high turnover of their workforce and most significantly, the extreme and frequently unpredictable exposure to hazardous noise in combat.

Several important aspects of the hearing conservation programs, however, are largely within the discretion of DoD and the military services. These include the degree of funding; number of staff; extent of training; command emphasis on the importance of hearing protection; implementation of noise controls; degree of compliance with requirements for entrance, periodic, and termination audiograms; and reporting of audiometric data to a central repository. Although the committee was not able to systematically review each of these categories, the available information, taken together, is sufficient to conclude that the services’ hearing conservation programs have been and remain inadequate to protect the hearing of service members. This does not suggest that there are not strong and effective efforts at local levels within the services, or even in leadership roles, but that the sum of these efforts is not yet sufficient.


FINDING: The evidence reviewed by the committee—including information on the effectiveness of available hearing protection devices and indicators regarding use of hearing protection, the completeness of audiometric monitoring, and compliance with requirements for entrance and separation audiograms—was sufficient to conclude that hearing conservation programs in the military are currently not adequate to protect the hearing of military service members, and have not been adequate for the period since World War II. This has important human health, personnel readiness, and financial implications.

Suggested Citation:"5 Responding to Noise Risks: Hearing Conservation Programs in the Military." Institute of Medicine. 2006. Noise and Military Service: Implications for Hearing Loss and Tinnitus. Washington, DC: The National Academies Press. doi: 10.17226/11443.
×

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×

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×

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×

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The Institute of Medicine carried out a study mandated by Congress and sponsored by the Department of Veterans Affairs to provide an assessment of several issues related to noise-induced hearing loss and tinnitus associated with service in the Armed Forces since World War II. The resulting book, Noise and Military Service: Implications for Hearing Loss and Tinnitus, presents findings on the presence of hazardous noise in military settings, levels of noise exposure necessary to cause hearing loss or tinnitus, risk factors for noise-induced hearing loss and tinnitus, the timing of the effects of noise exposure on hearing, and the adequacy of military hearing conservation programs and audiometric testing. The book stresses the importance of conducting hearing tests (audiograms) at the beginning and end of military service for all military personnel and recommends several steps aimed at improving the military services’ prevention of and surveillance for hearing loss and tinnitus. The book also identifies research needs, emphasizing topics specifically related to military service.

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