Summary

ABSTRACT Occupational hearing loss is a serious concern for many workers, although the number affected is uncertain. Using data from the 1980s and 1990s, the National Institute for Occupational Safety and Health (NIOSH) estimated that at least 4 million workers in the United States were exposed to workplace noise levels that put them at risk of hearing loss. Some workers may also be at risk due to exposure to ototoxic chemicals. Occupational hearing loss may impede communication, contribute to safety hazards in the workplace, and adversely affect other aspects of workers’ lives.

In conjunction with planned reviews of up to 15 NIOSH research programs, the Institute of Medicine convened a committee of experts to review the NIOSH Hearing Loss Research Program to evaluate the relevance of its work to improvements in occupational safety and health and the impact of NIOSH research in reducing workplace illnesses and injuries. Relevance was evaluated in terms of the priority of work carried out and its connection to improvements in workplace protection. Impact was evaluated in terms of its contributions to worker health and safety. The committee was also asked to assess the program’s identification and targeting of new research areas, to identify emerging research issues, and to provide advice on ways the program might be strengthened.

Although responsibility for controlling workplace exposures to noise or ototoxins lies with others, the Hearing Loss Research Program can be expected to contribute to efforts to reduce the effects of these workplace hazards through



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Hearing Loss Research at NIOSH: Reviews of Research Programs of the National Institute for Occupational Safety and Health Summary ABSTRACT Occupational hearing loss is a serious concern for many workers, although the number affected is uncertain. Using data from the 1980s and 1990s, the National Institute for Occupational Safety and Health (NIOSH) estimated that at least 4 million workers in the United States were exposed to workplace noise levels that put them at risk of hearing loss. Some workers may also be at risk due to exposure to ototoxic chemicals. Occupational hearing loss may impede communication, contribute to safety hazards in the workplace, and adversely affect other aspects of workers’ lives. In conjunction with planned reviews of up to 15 NIOSH research programs, the Institute of Medicine convened a committee of experts to review the NIOSH Hearing Loss Research Program to evaluate the relevance of its work to improvements in occupational safety and health and the impact of NIOSH research in reducing workplace illnesses and injuries. Relevance was evaluated in terms of the priority of work carried out and its connection to improvements in workplace protection. Impact was evaluated in terms of its contributions to worker health and safety. The committee was also asked to assess the program’s identification and targeting of new research areas, to identify emerging research issues, and to provide advice on ways the program might be strengthened. Although responsibility for controlling workplace exposures to noise or ototoxins lies with others, the Hearing Loss Research Program can be expected to contribute to efforts to reduce the effects of these workplace hazards through

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Hearing Loss Research at NIOSH: Reviews of Research Programs of the National Institute for Occupational Safety and Health its research and information dissemination. Taking into account several important factors beyond the program’s control, the committee found that over the past decade (the period covered by this review), the Hearing Loss Research Program has made meaningful contributions to improving worker health and safety. Using a five-point scoring scale (where 5 is highest), the committee assigned the research program a score of 4 for impact, indicating that the program has made a moderate contribution on the basis of end outcomes (improvements in worker health or safety) or well-accepted intermediate outcomes (use or adoption of work by stakeholders). However, some of the program’s work appears to be too narrowly targeted or directed to activities that are secondary to meeting the needs of protecting the hearing of workers. For this reason the committee assigned a score of 3 for relevance, indicating that often the research focuses on lesser priorities and is loosely or only indirectly connected to workplace protection. To enhance the relevance and impact of its work and fulfill its stated mission of providing national and world leadership to reduce the prevalence of occupational hearing loss through a focused program of research and prevention, the committee recommends that the NIOSH Hearing Loss Research Program foster effective leadership in program planning and implementation; further implement program evaluation efforts; gain access to additional intramural and extramural expertise, especially in epidemiology and noise control engineering; and initiate and sustain efforts to obtain surveillance data for occupational hearing loss and workplace noise exposure. The National Institute for Occupational Safety and Health (NIOSH) has included prevention of occupational hearing loss as part of its research portfolio since its establishment by the Occupational Safety and Health Act of 1970 (P.L. 91-596). Occupational hearing loss is a serious concern, although the number of workers affected is uncertain. Using data from the 1980s and early 1990s (the most recent available), NIOSH estimated that at least 4 million workers in the United States were exposed to workplace noise levels that put them at risk of hearing loss. Some workers may be at risk due to exposure to ototoxic chemicals. Occupational hearing loss may impede communication and contribute to safety hazards in the workplace, and it may adversely affect other aspects of workers’ lives. In conjunction with planned reviews of up to 15 NIOSH research programs, the Institute of Medicine (IOM) convened a committee of experts to review the NIOSH Hearing Loss Research Program to evaluate the relevance of its work to improvements in occupational safety and health and the impact of NIOSH re-

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Hearing Loss Research at NIOSH: Reviews of Research Programs of the National Institute for Occupational Safety and Health search on reducing workplace illnesses and injuries. Relevance was evaluated in terms of the priority of work carried out and its connection to improvements in workplace protection. Research impact was evaluated in terms of its contributions to worker health and safety. The committee was also asked to assess the program’s identification and targeting of new research areas, to identify emerging research issues, and to provide advice on ways the program might be strengthened. As part of a research agency, the NIOSH Hearing Loss Research Program can engage in such activities as conducting and supporting research; developing surveillance programs; developing and disseminating recommendations and related tools to aid in implementing best practices to reduce hazardous noise exposure; and contributing to the education and training of employers, workers, and occupational health and safety professionals. Although the Hearing Loss Research Program has no authority to establish or enforce regulations on noise hazards and the prevention of occupational hearing loss, the program can be expected to contribute to efforts to reduce the effects of workplace hazards to hearing. Overall, the committee found that over the past decade (the period covered by this review), the Hearing Loss Research Program has made meaningful contributions to improving worker health and safety. However, some of the program’s work appears to be targeted too narrowly or directed to activities that are secondary to the goal of protecting the hearing of workers. To enhance the relevance and impact of the Hearing Loss Research Program’s work and fulfill its stated mission of providing national and world leadership to reduce the prevalence of occupational hearing loss through a focused program of research and prevention, the committee urges several changes. The committee recommends that the NIOSH Hearing Loss Research Program take steps that include fostering effective leadership in program planning and implementation; further implementing program evaluation efforts; gaining access to additional intramural and extramural expertise, especially in epidemiology and noise control engineering; and initiating and sustaining efforts to obtain surveillance data for occupational hearing loss and workplace noise exposure. STUDY PROCESS The committee’s review focused on the work of the NIOSH Hearing Loss Research Program primarily during the period 1996 through 2005.1 The review 1 The Hearing Loss Research Program is one of the first two research programs to be reviewed for NIOSH by National Academies committees. The review was conducted using evaluation guidance (referred to as the Framework Document) that was developed by the National Academies’ Committee for Review of NIOSH Research Programs (the Framework Committee). The Framework Document appears in Appendix A.

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Hearing Loss Research at NIOSH: Reviews of Research Programs of the National Institute for Occupational Safety and Health was based largely on material that NIOSH Hearing Loss Research Program staff provided to the committee in oral presentations, a written evidence package, and written responses to questions from the committee.2 The committee also received input from program stakeholders (see Chapter 1 and Appendix B), including representatives from labor, industry, regulatory agencies, professional organizations, and academia. The committee excluded nonauditory effects of noise from consideration. As directed by its review guidance, the committee’s evaluation included rating the relevance and impact of the Hearing Loss Research Program using five-point scales. In evaluating relevance, the committee assessed the degree to which the program’s research is in high-priority areas and is connected to improvements in workplace protection. To assign a summary rating, the committee decided to weight all of the program’s activities nearly equally. In evaluating impact, the committee assessed the degree to which the program’s research can be shown to have made a contribution to improvements in worker health and safety. To assign a summary rating, the committee decided to consider the extent to which identifiable and worthwhile accomplishments could be shown, without discounting for lesser degrees of impact from some aspects of the program. The committee’s review was constrained by the lack of historical and current data on the nature and extent of occupational hearing loss or workplace noise exposures among U.S. workers. Data from surveillance programs or longitudinal studies of selected populations are needed to identify industrial sectors or workforce populations with the highest levels of occupational hearing loss or noise exposure and to identify improvements in these end outcomes. FACTORS WITH BROAD EFFECTS ON THE HEARING LOSS RESEARCH PROGRAM Several factors beyond the control of the Hearing Loss Research Program may have prevented it from working in an optimal way to achieve impact and relevance. Already noted is the need to rely on others to effect the changes in the workplace that are necessary to minimize hazardous noise environments and ensure worker compliance with hearing conservation programs. Other important factors are the program’s matrix organization and small budget, congressional 2 Some of the materials provided to the committee are available online at the NIOSH website http://www.cdc.gov/niosh/nas/hlr/.

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Hearing Loss Research at NIOSH: Reviews of Research Programs of the National Institute for Occupational Safety and Health earmarking of much of the program funding, and economic factors that employers may believe to be unfavorable to workplace implementation of noise control approaches to hearing loss prevention. The Hearing Loss Research “Program” operates in a matrix environment, not as an identifiable entity in the NIOSH organization chart. The program comprises a collection of activities taking place principally within five organizationally separate and geographically distributed NIOSH units. Moreover, the Hearing Loss Research Program budget is small. In fiscal year (FY) 2005, the program had $5.2 million in intramural funding and $2.3 million in extramural funding, out of a total NIOSH budget of $286 million. Congressional direction as to the amount of the NIOSH budget to be applied to mining safety and health has significantly shaped the portfolio, staffing, and funding levels within the Hearing Loss Research Program. Funding that supports work related to noise control and prevention of hearing loss in the mining sector cannot be redirected to other Hearing Loss Research Program priorities. In FY 2005, this funding represented 69 percent of the Hearing Loss Research Program’s total spending. Over the course of its review, the committee also saw that the Hearing Loss Research Program is undergoing change as part of NIOSH’s broader organizational changes and as a result of preparation for the IOM review. These changes have included identifying new research goals, naming new leadership, modifying the name of the program, and renaming one of its four research goals. Development of a strategic plan has been deferred until the conclusion of the IOM review. HEARING LOSS RESEARCH PROGRAM MISSION AND GOALS The stated mission of the Hearing Loss Research Program is to provide national and world leadership to reduce the prevalence of occupational hearing loss through a focused program of research and prevention. In 2005, the Hearing Loss Research Program established four research goals: Contribute to the Development, Implementation, and Evaluation of Effective Hearing Loss Prevention Programs Reduce Hearing Loss Through Interventions Targeting Personal Protective Equipment Develop Engineering Controls to Reduce Noise Exposures Improve Understanding of Occupational Hearing Loss Through Surveillance and Investigation of Risk Factors The Hearing Loss Research Program used these four goals to organize the primary evidence package provided to the committee. In turn, the committee used

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Hearing Loss Research at NIOSH: Reviews of Research Programs of the National Institute for Occupational Safety and Health the four goals to organize its detailed examination of the program, while recognizing that these specific research goals were established only at the end of the period covered by the assessment. ASSESSMENT OF RELEVANCE Using the limited surveillance information available and members’ expert judgment, the committee found that the Hearing Loss Research Program mission and four main research goals as stated were highly relevant to the overall aim of reducing occupational hearing loss. However, the committee identified several activities of lesser priority among the work carried out to pursue these goals, leading to considerable variation in relevance across the components of the program. The program’s efforts in development, implementation, and evaluation of effective hearing loss prevention programs (Research Goal 1) have addressed high-priority needs. The program has identified objectives and activities that, if pursued successfully, should prove to be highly relevant to the reduction of occupational hearing loss. However, increased emphasis is needed on evaluation of the components of hearing loss prevention programs, as well as on dissemination of materials to facilitate the development and application of engineering controls in prevention programs. Research efforts on interventions targeting personal protective equipment (Research Goal 2) have focused primarily on two pressing problems: (1) more accurate representation in Noise Reduction Ratings of the workplace effectiveness of hearing protection devices and (2) evaluation of the fit and effectiveness of the devices during the work shift. The committee found this prioritization appropriate and adequately connected to improvements in workplace protection. For engineering controls to reduce noise exposure (Research Goal 3), apportionment of effort within the discretionary budget of the Hearing Loss Program has not reflected their importance in the hierarchy of controls. Research efforts have been concentrated in the mining sector, with some attention to the construction sector. Miners are known to face serious noise hazards but represent a small proportion of the noise-exposed workforce. Although the committee considered the emphasis on mining, reflecting congressional direction, to be disproportionate to the distribution of workers exposed to noise hazards in other industrial sectors, this allocation is outside the control of the Hearing Loss Research Program. However, drawing on additional noise control engineering expertise, the program could and should take more aggressive steps both to apply and transfer technologies developed for the mining industry to other industry sectors and to develop noise control technology for other sectors.

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Hearing Loss Research at NIOSH: Reviews of Research Programs of the National Institute for Occupational Safety and Health The relevance of research efforts to improve understanding of occupational hearing loss through surveillance and investigation of risk factors (Research Goal 4) is mixed. The objective of establishing effective surveillance systems to monitor workers’ noise exposures and incidence of hearing loss is highly relevant and requires increased attention, expertise, and priority from the Hearing Loss Research Program. However, the current and planned portfolio of surveillance activities is not focused on generating valid estimates of the number of individuals with occupational hearing loss, the risk of developing occupational hearing loss, or the distribution of noise exposure among workers. Investigation of the contribution of exposure to ototoxins to occupational hearing loss is appropriate, but the magnitude of the problem should be assessed. The committee judged efforts to elucidate the genetics of hearing loss and the role of the aging process unrelated to noise exposure as a diffusion of mission from worker safety. It would be more appropriate for these basic science questions to be pursued by other researchers outside of NIOSH. The program’s expectations of benefit from audiometry data derived from surveys of the general population did not seem realistic. The assessment of relevance also took into account the input and interests of stakeholders. Stakeholder involvement and input into NIOSH research prioritization were most apparent and laudable in the area of development, implementation, and evaluation of hearing loss prevention programs, at least as manifested in participation in conferences and workshops. With some exceptions noted elsewhere in this report, stakeholders (many of whom have partnered or collaborated with the Hearing Loss Research Program) submitted positive opinions to the committee about the relevance and appropriateness of the program’s research efforts. Overall, the committee found the activities of the Hearing Loss Research Program to include strong, high-priority work, as well as projects that the committee viewed to be of lesser priority. The committee was concerned that the program was not giving sufficient emphasis and priority to surveillance for occupational hearing loss and noise exposure, a fundamental gap in the field, or devoting enough breadth and expertise to its efforts in noise control engineering. In particular, the scope of Research Goal 3 was perceived as much too narrow, focused primarily on underground coal miners who constitute a small fraction of potentially noise-exposed industrial workers in the United States. On the basis of its review, the committee assigned a score of 3 for the relevance of the NIOSH Hearing Loss Research Program. The five-point scale used for the rating of relevance is shown in Box S-1.

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Hearing Loss Research at NIOSH: Reviews of Research Programs of the National Institute for Occupational Safety and Health BOX S-1 Scale for Rating Program Relevance 5 = Research is in highest-priority subject areas and highly relevant to improvements in workplace protection; research results in, and NIOSH is engaged in, transfer activities at a significant level (highest rating). 4 = Research is in high-priority subject area and adequately connected to improvements in workplace protection; research results in, and NIOSH is engaged in, transfer activities. 3 = Research focuses on lesser priorities and is loosely or only indirectly connected to workplace protection; NIOSH is not significantly involved in transfer activities. 2 = Research program is not well integrated or well focused on priorities and is not clearly connected to workplace protection and inadequately connected to transfer activities. 1 = Research in the research program is an ad hoc collection of projects, is not integrated into a program, and is not likely to improve workplace safety or health. ASSESSMENT OF IMPACT End Outcomes In trying to make judgments about the impact of work done by the Hearing Loss Research Program, the general lack of surveillance data on occupational hearing loss and noise exposures for U.S. workers during the past decade, as well as the lack of large, longitudinal intervention studies, meant that the committee was unable to consider evidence that the program has contributed to changes in end outcomes related to occupational hearing loss. Intermediate Outcomes Given the lack of data on changes in the end outcomes of occupational hearing loss and noise exposure, the committee based its assessment of the impact of the NIOSH Hearing Loss Research Program primarily on the evidence that its research products have been put to use beyond NIOSH in ways that have the potential to influence occupational hearing loss in the workplace. Evidence of these intermediate outcomes was available, in varying degrees, for all four research goals. In some instances, the committee also considered the potential for future impact from Hearing Loss Research Program publications and other program outputs that were not yet associated with intermediate outcomes.

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Hearing Loss Research at NIOSH: Reviews of Research Programs of the National Institute for Occupational Safety and Health The committee found that the Hearing Loss Research Program has made meaningful contributions through activities that include publication of intramural and extramural research findings in the peer-reviewed scientific literature, development of noise reduction methods and materials for the mining industry, collection and publication of resource materials for technical and lay audiences, development and delivery of educational programs, provision of technical advice to regulatory agencies, and participation of staff in the development of various national and international voluntary standards concerning noise and hearing loss. The information provided by the Hearing Loss Research Program and comments from many stakeholders offer strong endorsement of the contributions made to efforts to reduce occupational hearing loss through work related to the development, implementation, and evaluation of effective hearing loss prevention programs (Research Goal 1). Many of the program’s work products, including recommendations and training programs, have been adapted or adopted for use by business, labor, and occupational health professionals. However, the program has paid minimal attention to evaluating the effectiveness of these products in reducing the incidence or severity of occupational hearing loss or in achieving important intermediate outcomes such as sustained improvement in the use of hearing protection devices or the management of hearing loss prevention programs. Evaluation based on changes in knowledge, attitudes, or behavioral intentions is appropriate but not sufficient. The committee found that the Hearing Loss Research Program has made important contributions to increasing knowledge about the real-world performance of hearing protection devices, improving the methods and tools for assessing hearing protector attenuation, and encouraging appropriate regulatory agencies and organizations to modify regulations and other guidance concerning hearing protector attenuation (Research Goal 2). The program’s ability to help constituents in the field of hearing protection device regulation reach consensus around a standard method for measuring the real-ear attenuation of hearing protectors (ANSI [American National Standards Institute] S12.6–1997) has been especially noteworthy. Participation by Hearing Loss Research Program staff not only in intramural research but also in collaborations with other agencies and with academic scientists, hearing protector manufacturers, employers, and workers probably adds to the impact of the program in ways that are difficult to document. The Hearing Loss Research Program is engaged in a narrow set of activities on engineering noise controls (Research Goal 3). These activities have had a limited impact and may have limited prospects for future impact. With a large share of this work taking place at the Pittsburgh Research Laboratory, the focus is primarily on engineering noise controls for mining. Mining equipment that incorporates the results of two projects pursued by Hearing Loss Research Program staff and their

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Hearing Loss Research at NIOSH: Reviews of Research Programs of the National Institute for Occupational Safety and Health collaborators outside NIOSH is being produced and is in use in a small number of underground coal mines. The program has also contributed to efforts by the Mine Safety and Health Administration (MSHA) to identify technologically feasible and promising noise controls for use in mining. The program’s work on engineering noise controls appears to have had little impact in industrial sectors beyond mining. Development of the database on noise emission levels of powered hand tools can contribute information to users of these tools but makes no contribution to the development of engineering noise controls, either in the design of the products or in their use. In addition, the committee is concerned that the noise emission data were not generated using rigorous operational procedures in an accredited facility as would be expected for data collected for reference and decision-making purposes. Finally, although the development of noise control designs for power tools provided an opportunity for students at a few universities to gain experience in product noise control design, the value of this training experience probably does not outweigh the detractions of failing to aggressively pursue other approaches that are needed to promote the development of robust and effective solutions that could attract industry participation and implementation in the marketplace. The work being done to improve understanding of occupational hearing loss through surveillance and investigation of risk factors (Research Goal 4) has been directed in large part to data gathering, epidemiologic studies, and studies using laboratory animals to investigate the causative mechanisms of hearing loss. Over the past decade an increasing proportion of the work has been done by extramural researchers. The impact of this research occurs primarily through its contributions to the knowledge base on occupational hearing loss. The program’s work on ototoxicity is widely cited by other researchers and is reflected in the hearing conservation policies of some organizations. The program’s support for the Occupational Safety and Health Administration’s (OSHA’s) implementation in 2004 of separate reporting of recordable occupational hearing loss has contributed to generating at least a minimal form of surveillance data. Other work conducted in conjunction with this program area is likely to make some contribution to basic knowledge regarding genetic and age-related aspects of hearing loss but will not readily contribute to knowledge regarding noise exposure and hearing loss among workers. For this as well as other research areas, the limited number of peer-reviewed publications and a lack of timeliness in publishing key research findings and important workshop proceedings were of concern to the committee. On the basis of its review, the committee assigned the NIOSH Hearing Loss Research Program a score of 4 for impact, notwithstanding significant shortcomings in some aspects of the program. The five-point scale used for the rating of impact is shown in Box S-2.

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Hearing Loss Research at NIOSH: Reviews of Research Programs of the National Institute for Occupational Safety and Health BOX S-2 Scale for Rating Program Impact 5 = Research program has made a major contribution to worker health and safety on the basis of end outcomes or well-accepted intermediate outcomes. 4 = Research program has made a moderate contribution on the basis of end outcomes or well-accepted intermediate outcomes; research program generated important new knowledge and is engaged in transfer activities, but well-accepted intermediate outcomes or end outcomes have not been documented. 3 = Research program activities or outputs are going on and are likely to produce improvements in worker health and safety (with explanation of why not rated higher). 2 = Research program activities or outputs are going on and may result in new knowledge or technology, but only limited application is expected. 1 = Research activities and outputs are NOT likely to have any application. NA = Impact cannot be assessed; program is not mature enough. IDENTIFYING EMERGING ISSUES AND RESEARCH AREAS In addition to evaluating the relevance and impact of the work of the NIOSH Hearing Loss Research Program to health and safety in the workplace, the committee is charged with assessing the program’s targeting of new research areas and identification of emerging issues in occupational safety and health most relevant to future improvements in workplace protection. The Hearing Loss Research Program’s Identification of Emerging Issues and Research Areas in Occupational Hearing Loss The NIOSH Hearing Loss Research Program identified 12 emerging research issues distributed across its four current research goals. Two activities figured prominently in the program’s recent efforts to identify research needs: a Futures Workshop in April 2005 and the development of the Mining Health and Safety Research Program Plan. The Futures Workshop was planned as a way to develop research goals for the Hearing Loss Research Program for the next 5 to 10 years. Acknowledging the small scale of the Hearing Loss Research Program and other challenges noted earlier, the committee nonetheless has concerns about the program’s identification of new or emerging research. With few exceptions, the emerging issues resemble the work that the program described elsewhere as being under way or among its current research goals. In the committee’s view, the lim-

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Hearing Loss Research at NIOSH: Reviews of Research Programs of the National Institute for Occupational Safety and Health ited nature of the emerging issues identified by the Hearing Loss Research Program may reflect two problems. One is limited outreach to and input from communities responsible for preventing occupational hearing loss regarding the development of a research agenda. The other problem is the challenge of setting research priorities while having only minimal data on the occurrence of work-related hearing loss and workers’ exposure to noise and/or ototoxic chemicals. The committee sees a need for much wider outreach for input and ideas to guide the direction of future work by the Hearing Loss Research Program. Areas of expertise where the committee particularly urges seeking greater outside contact include engineering noise control, low-noise product design, epidemiology, and program evaluation. Similarly, targeting research efforts without having adequate current information about the epidemiology of work-related hearing loss is necessarily limiting. Although establishing surveillance programs for occupational hearing loss and noise exposure and conducting a large epidemiologic survey of industry are listed as long-term research topics, these activities need to be given higher priority because of the fundamental role of the data they will generate in the research planning process. Emerging Research Needs Identified by the Evaluation Committee The committee was asked to identify emerging research needs in occupational hearing loss and noise control. Given the short time frame for this review, the committee identified a limited number of topics and reviewed suggestions from stakeholders (see Chapter 3), but it could not undertake a comprehensive assessment of the field. RECOMMENDATIONS FOR PROGRAM IMPROVEMENT As the only federal research program focused specifically on the challenge of preventing occupational hearing loss, the NIOSH Hearing Loss Research Program should be an undisputed leader and source of expertise in the fields of occupational hearing loss research, including hearing loss prevention programs, hearing protection, noise control engineering for occupational hearing loss prevention, and occupational hearing loss surveillance and risk factors. The committee identified several potential opportunities to improve the relevance of the program’s work and strengthen its impact on reducing occupational hearing loss. A summary of the committee’s recommendations appears in Box S-3. The committee recognizes that some of these recommendations carry resource implications that have not been fully explored. It hopes that NIOSH will place a

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Hearing Loss Research at NIOSH: Reviews of Research Programs of the National Institute for Occupational Safety and Health high enough value on the Hearing Loss Research Program to give serious consideration to finding ways to respond to these opportunities for improvement. Program Management in a Matrix Environment The NIOSH Hearing Loss Research Program operates in a matrix environment, which poses challenges for the program’s ability to develop and implement a program plan and to allocate resources in accordance with program priorities. Even the most talented leadership will find it difficult to successfully manage a program distributed across separate organizational units and to catalyze the planning and mobilization of resources necessary for a cohesive program. The small size of the program also demands skill in setting priorities for program activities and use of program resources. The program as a whole and each of the four research program areas require leadership specifically dedicated to championing a better Hearing Loss Research Program. In addition to having excellent management skills, leaders should be well-regarded experts in hearing loss prevention, noise control engineering, or surveillance methods, with experience in implementing hearing loss prevention or noise control engineering practices in the field. Since 1996, the Hearing Loss Research Program has had to respond to significant organizational and leadership challenges. Although the program has persevered admirably during these transitional times, the committee sees a need to foster leadership that can provide coherence to the program, increase collaboration, and serve as an effective advocate within the matrix environment in which it operates. The committee is encouraged to see that NIOSH has recently appointed from within the NIOSH management staff an overall program manager who is expected to monitor the program’s activities and resources. In this role, the program manager will have an advisory and consultative relationship with the organizational units in which the Hearing Loss Research Program’s work is done, but he will not have authority to mandate the allocation of resources to the program as a whole or its components. The program manager did not make a formal presentation to the committee, and even though he is new to this position, it would have been valuable to the committee to hear his views on the program and the IOM review. Foster effective leadership. NIOSH should ensure that the Hearing Loss Research Program and its components have leadership with appropriate technical expertise as well as skills in managing in a complex environment, mobilizing resources, promoting collaboration within the program, and increasing program coherence. All of these leaders must serve as champions of the program within and outside NIOSH

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Hearing Loss Research at NIOSH: Reviews of Research Programs of the National Institute for Occupational Safety and Health and help to garner adequate resources and recruit expertise. The leaders should be respected and involved in the hearing loss prevention community and in their own fields of expertise. NIOSH should provide the overall program leader with sufficient authority to make appropriate program and budgetary decisions. The leaders of the Hearing Loss Research Program must contend with a small budget—about $7.5 million in FY 2005—much of which is reserved for work related to mining or for extramural research. The committee urges NIOSH to consider the need for program resources that are commensurate with a more robust pursuit of the program’s goals and with sustaining the continuity of the most relevant research in specific program areas. Access to Intramural and Extramural Expertise The committee is concerned that the Hearing Loss Research Program has lacked adequate internal technical expertise, especially in the specialized areas of epidemiology and noise control engineering, and has appeared to rely on a fairly narrow group of external experts for input and collaboration. For the program to hold the position of national leadership, it must draw upon outstanding members of the communities responsible for the prevention of occupational hearing loss both within and outside the program. As the Hearing Loss Research Program garners additional internal expertise, it should also broaden and strengthen its ties to sources of external scientific, hearing loss prevention, and noise control engineering expertise, such as other federal agencies, industry, and the military. With additional expertise, the program will be better positioned to have an impact on occupational hearing loss through its current portfolio as well as to move into emerging research areas for the future. Recruit additional expert researchers to the NIOSH Hearing Loss Research Program staff. The Hearing Loss Research Program should recruit and retain experienced professionals with recognized expertise in the fields of epidemiology and noise control engineering who can exercise leadership in planning, conducting, and evaluating the program’s work in these crucial areas. It is essential for the program to make gaining this additional expertise a priority. Expand access to outside expertise. The program should make efforts to draw more broadly from the communities responsible for the prevention of occupational hearing loss as reviewers, conference participants, and collaborators. As part of this effort, the program should

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Hearing Loss Research at NIOSH: Reviews of Research Programs of the National Institute for Occupational Safety and Health strengthen ties to the National Institute on Deafness and Other Communication Disorders and other components of the National Institutes of Health to benefit from additional interactions with the scientific researchers there. The program should also explore expanding its collaborations with noise control engineers inside and outside the federal government. Program Planning Even as the National Academies’ evaluation of up to 15 different NIOSH research programs is under way, NIOSH as a whole is undergoing changes. NIOSH has reorganized its research portfolio into sector and cross-sector programs and coordinated emphasis areas. It is developing strategic plans for each of its research programs, and new emphasis is being placed on the translation and application of scientific knowledge to the workplace. The committee commends NIOSH for its continued striving for improvement as an organization. The Hearing Loss Research Program has acknowledged that until recently it has managed more by opportunity than by objective. Although it may not be feasible for such a small program to manage entirely by objective, and the group has proven itself adept at leveraging opportunities, the committee urges additional efforts to focus its limited resources on specific goals, with input from surveillance data, evaluation of the effectiveness of its program activities, regulatory agencies, and other stakeholders. Develop a strategic plan. The Hearing Loss Research Program should develop a strategic plan that takes into account the strengths, weaknesses, and external factors identified in this evaluation. It should reflect a focus on the program’s mission and serve to guide decision making about the value of projects and proposed collaborations. It should also reflect coordination with the strategic plans developed by the sector-based NIOSH research programs that may need to address hearing loss as one of several health hazards faced by the workforce. Use surveillance data as well as stakeholder input to identify priorities. The Hearing Loss Research Program should make the rationale for its research prioritization more explicit, using analyses of surveillance data to the extent possible as well as the concerns and interests of stakeholders from a variety of industrial sectors to guide allocations of resources and effort. Use information from evaluation of hearing loss prevention measures to guide program planning. The Hearing Loss Research Pro-

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Hearing Loss Research at NIOSH: Reviews of Research Programs of the National Institute for Occupational Safety and Health gram should use information gained from evaluation of the effectiveness of its program activities to help identify approaches to hearing loss prevention that should be emphasized, revised, or possibly discontinued. Systematize collaboration with regulatory partners. The Hearing Loss Research Program should establish regular means for conferring with OSHA, MSHA, and the Environmental Protection Agency to better anticipate research needs relevant to regulatory decision making. Evaluation of Hearing Loss Prevention Measures Developing and disseminating “best practices” and training methods for hearing loss prevention programs to apply scientific understanding to the workplace has been an important contribution of the Hearing Loss Research Program and is the focus of Research Goal 1. The program noted the need for intervention effectiveness research designed to validate best practices for each of the seven components of hearing loss prevention programs it advocates. The committee underscores the importance of evaluation of the effectiveness of all program activities, including the dissemination of the educational material that the program develops, as a crucial step in ensuring that the Hearing Loss Research Program serves as a leader in producing evidence-based guidance on hearing loss prevention. Place greater emphasis on evaluation of the effectiveness of hearing loss prevention measures on the basis of outcomes that are as closely related as possible to reducing noise exposure and the incidence of occupational hearing loss. The Hearing Loss Research Program should implement consistent and concerted evaluation activities that inform and focus its work on hearing loss prevention. Prospective evaluations of the recommended components of hearing loss prevention programs are needed to determine which features have the most significant impacts on reducing noise exposure levels or hearing loss incidence rates. These evaluations should address actual (not just intended) worker and employer behavior and the end results of exposure levels and hearing loss. Surveillance Activities The Hearing Loss Research Program identified the lack of surveillance data for workers’ noise exposures and the incidence and severity of occupational hearing

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Hearing Loss Research at NIOSH: Reviews of Research Programs of the National Institute for Occupational Safety and Health loss as one of the fundamental knowledge gaps in the field. The committee agrees and underscores the importance of surveillance data and their careful analysis to help guide priority setting for research in occupational health and safety and for evaluation of program activities. Although the Hearing Loss Research Program has participated in several different efforts to address the lack of surveillance data, the program’s current approaches are piecemeal and require expansion of their conceptual framework and measurement methods. To maintain an appropriate scientific leadership role in the field of occupational hearing loss prevention, the Hearing Loss Research Program needs to increase its emphasis on and expertise in surveillance. Doing so will require resources commensurate with the task, as well as the leadership of one or more experienced epidemiologists integrated into the program staff. Relying on ad hoc epidemiologic assistance is not sufficient. With that additional expertise, the Hearing Loss Research Program should plan means to gather and analyze new data on the occurrence of hearing loss and hazardous noise exposure. Initiate national surveillance for occupational hearing loss and hazardous noise. The Hearing Loss Research Program should rally expertise and resources to lead surveillance of the incidence and prevalence of work-related hearing loss and the occurrence of exposure to hazardous noise levels in occupational settings in the United States. Surveillance efforts should be accompanied by plans for appropriate analyses of the data. Noise Control Perspective Following the industrial hygiene tradition of the “hierarchy of controls,” noise control engineering should be the primary approach to prevention of hearing loss. In reality, employers frequently turn first to administrative controls or hearing protection devices to decrease workers’ exposure to hazardous noise. Perhaps as a result, the research emphasis within the Hearing Loss Research Program has also been on aspects of hearing loss prevention other than noise control. Over the past decade, substantially more of the program’s resources have been brought to bear on noise control engineering, but those resources have been directed primarily to the mining industry. Although congressional guidance has resulted in most of this funding being devoted to a single industrial sector, the committee sees it as the mission of the Hearing Loss Research Program to pursue broader applications of its work on noise control engineering. To help identify the potential for broader applications of mining-related work, the committee urges increased collaboration between the Pittsburgh- and Cincinnati-based researchers.

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Hearing Loss Research at NIOSH: Reviews of Research Programs of the National Institute for Occupational Safety and Health Integrate the noise control engineering perspective into overall program efforts for all sectors. The Hearing Loss Research Program should apply its dissemination expertise to further emphasize the application of “quiet by design,” “buy quiet,” and engineered noise control approaches to industrial settings as part of hearing loss prevention programs. Develop noise control engineering approaches for non-mining sectors. The Hearing Loss Research Program should increase efforts to develop noise control approaches applicable in industrial sectors outside mining where workers are also at risk from hazardous noise. Where possible, “dual-use” applications from work done in mining could help bring noise reduction benefit to both miners and workers from other industrial sectors. Increase the visibility of noise control engineering as a component of the Hearing Loss Research Program. The Hearing Loss Research Program should use means such as periodic workshops on noise control engineering topics to raise the visibility of its noise control engineering projects within the field. Such workshops can facilitate information exchange, can provide specialized technical training, and may attract qualified professionals who can serve as advisers, consultants, collaborators, or recruits to the NIOSH program. Accredit laboratories used to conduct studies for the Hearing Loss Research Program. The Hearing Loss Research Program should work to achieve accreditation of all laboratories that are involved in the acquisition of data that are published or shared externally. To the extent possible, testing on behalf of the NIOSH intramural program should be carried out at facilities owned or controlled by NIOSH. Extramural Research Between FY 1997 and FY 2005, slightly more than $14 million, about 30 percent of the total expenditures of the NIOSH Hearing Loss Program, was directed toward extramural projects related to hearing loss or noise control engineering. With the exception of one Request for Application (RFA) in 2001, the program has relied on investigator-initiated proposals. The extramural research that has resulted includes important contributions to the knowledge base in this field and has facilitated some productive collaborations with Hearing Loss Research Program researchers. In some cases, however, intramural researchers have not made them-

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Hearing Loss Research at NIOSH: Reviews of Research Programs of the National Institute for Occupational Safety and Health selves aware of relevant extramural research, which may have resulted in limited opportunities for effective collaboration. In addition, greater use of RFAs and focused Program Announcements (PAs) has the potential to direct some extramural funding toward high-priority research topics that complement the intramural work. The Hearing Loss Research Program may also want to further pursue efforts to invite outside researchers to work at NIOSH facilities on a temporary basis and at little cost to the program. The committee recommends the following steps to maximize the benefit that extramural funding might bring to realizing the mission of the Hearing Loss Research Program: Target more of the extramural research funding. The Hearing Loss Research Program should increase its use of Requests for Applications and focused Program Announcements to target more of its extramural research funding toward program priority areas. Increase collaboration and mutual awareness of ongoing work among intramural and extramural researchers. For the Hearing Loss Research Program to maximize the benefit of extramural research, it is important for intramural and extramural researchers to each be aware of the work that the others are doing relevant to occupational hearing loss or noise control. Where appropriate, intramural researchers should be building upon extramural work within the Hearing Loss Research Program. Toward this end, after a grant has been awarded, NIOSH should facilitate increased communication between intra- and extramural researchers.

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Hearing Loss Research at NIOSH: Reviews of Research Programs of the National Institute for Occupational Safety and Health BOX S-3 Summary of Recommendations Program Management in a Matrix Environment Foster effective leadership. Access to Intramural and Extramural Expertise Recruit additional expert researchers to the NIOSH Hearing Loss Research Program staff. Expand access to outside expertise. Program Planning Develop a strategic plan. Use surveillance data as well as stakeholder input to identify priorities. Use information from evaluation of hearing loss prevention measures to guide program planning. Systematize collaboration with regulatory partners. Evaluation of Hearing Loss Prevention Measures Place greater emphasis on evaluation of the effectiveness of hearing loss prevention measures on the basis of outcomes that are as closely related as possible to reducing noise exposure and the incidence of occupational hearing loss. Surveillance Activities Initiate national surveillance for occupational hearing loss and hazardous noise. Noise Control Perspective Integrate the noise control engineering perspective into overall program efforts for all sectors. Develop noise control engineering approaches for non-mining sectors. Increase the visibility of noise control engineering as a component of the Hearing Loss Research Program. Accredit laboratories used to conduct studies for the Hearing Loss Research Program. Extramural Research Target more of the extramural research funding. Increase collaboration and mutual awareness of ongoing work among intramural and extramural researchers.