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



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Noise and Military Service: Implications for Hearing Loss and Tinnitus 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

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Noise and Military Service: Implications for Hearing Loss and Tinnitus 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).

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

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Noise and Military Service: Implications for Hearing Loss and Tinnitus 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).

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Noise and Military Service: Implications for Hearing Loss and Tinnitus 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.

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Noise and Military Service: Implications for Hearing Loss and Tinnitus 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).

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Noise and Military Service: Implications for Hearing Loss and Tinnitus 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

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

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Noise and Military Service: Implications for Hearing Loss and Tinnitus 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).

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

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Noise and Military Service: Implications for Hearing Loss and Tinnitus 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

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Noise and Military Service: Implications for Hearing Loss and Tinnitus 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

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Noise and Military Service: Implications for Hearing Loss and Tinnitus 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.

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