3
Identifying Emerging Issues and Research Areas in Occupational Hearing Loss Prevention

In addition to evaluating the relevance and impact of the work of the National Institute for Occupational Safety and Health (NIOSH) Hearing Loss Research Program to health and safety in the workplace, the committee was charged with assessing the program’s targeting of new research areas in occupational safety and health most relevant to future improvements in workplace protection and with identifying emerging issues that appear especially important for NIOSH and the program.

This chapter first provides a brief overview of the Hearing Loss Research Program’s process for identifying new or emerging research areas and notes the topics for new research that the program identified in the evidence package (NIOSH, 2005a). The committee’s assessment of this process is followed by its suggestions regarding emerging research areas or issues in occupational hearing loss prevention that warrant the consideration of the Hearing Loss Research Program. The committee notes that an in-depth effort to identify new areas of needed research was beyond what was feasible within the time frame and scope of this study. In keeping with the guidance of the Framework Document, the committee has provided suggestions on the basis of the expertise of individual members rather than as the product of a formal process to explore and synthesize recommendations that could be developed through a comprehensive review of the field.



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Hearing Loss Research at NIOSH: Reviews of Research Programs of the National Institute for Occupational Safety and Health 3 Identifying Emerging Issues and Research Areas in Occupational Hearing Loss Prevention In addition to evaluating the relevance and impact of the work of the National Institute for Occupational Safety and Health (NIOSH) Hearing Loss Research Program to health and safety in the workplace, the committee was charged with assessing the program’s targeting of new research areas in occupational safety and health most relevant to future improvements in workplace protection and with identifying emerging issues that appear especially important for NIOSH and the program. This chapter first provides a brief overview of the Hearing Loss Research Program’s process for identifying new or emerging research areas and notes the topics for new research that the program identified in the evidence package (NIOSH, 2005a). The committee’s assessment of this process is followed by its suggestions regarding emerging research areas or issues in occupational hearing loss prevention that warrant the consideration of the Hearing Loss Research Program. The committee notes that an in-depth effort to identify new areas of needed research was beyond what was feasible within the time frame and scope of this study. In keeping with the guidance of the Framework Document, the committee has provided suggestions on the basis of the expertise of individual members rather than as the product of a formal process to explore and synthesize recommendations that could be developed through a comprehensive review of the field.

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Hearing Loss Research at NIOSH: Reviews of Research Programs of the National Institute for Occupational Safety and Health THE HEARING LOSS RESEARCH PROGRAM’S PROCESS FOR IDENTIFYING EMERGING ISSUES AND RESEARCH AREAS IN OCCUPATIONAL HEARING LOSS PREVENTION In the mid-1990s, the research agenda for the Hearing Loss Research Program emerged primarily from the development of the National Occupational Research Agenda (NORA) and the work done to prepare Criteria for a Recommended Standard: Occupational Noise Exposure (NIOSH, 1998a). This chapter focuses on the program’s more recent efforts to identify research directions. As described to the committee, two activities figured prominently in recent efforts by the Hearing Loss Research Program to identify research needs. One of these was a Futures Workshop held in April 2005, and the other was the development of the Mining Research Plan. The Hearing Loss Research Program also responds to input from other sources, including findings in Health Hazard Evaluations (HHEs), the needs of stakeholders in regulatory agencies and elsewhere, and collaborative opportunities that arise in conjunction with the work of other agencies or researchers. Futures Workshop 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 (NIOSH, 2006a). The meeting included 25 NIOSH staff members, most of whom were from the Hearing Loss Research Program, and 6 outside experts. Participants are listed in Box 3-1. The NIOSH participants included the Hearing Loss Research Program team leaders, who were leading work related to specific research areas, and program audiologists, engineers, and scientists from the Cincinnati and Pittsburgh research laboratories. The committee was informed that as many NIOSH researchers as possible were included to encourage internal discussion of research needs, opportunities, and goals. The six outside experts gave presentations highlighting important issues in hearing loss research in biology and physiology, epidemiology, instrumentation, control technology, personal protective equipment, and speech communication. The workshop was described as including discussions after each of the presentations and a brainstorming session at the end to generate a list of topics for further consideration by NIOSH hearing loss researchers. The research needs identified at the Futures Workshop and the discussion that took place at that meeting provided the basis for the section “Emerging Issues” in the evidence package from the Hearing Loss Research Program (NIOSH, 2005a). These topics are listed in Box 3-2.

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Hearing Loss Research at NIOSH: Reviews of Research Programs of the National Institute for Occupational Safety and Health BOX 3-1 Participants in the NIOSH Hearing Loss Prevention Futures Workshop April 7–8, 2005 Jim Banach, Vice-President, Quest Technologies Elliott Berger, Senior Scientist, E-A-R/Aearo Corporation Scott Brueck, NIOSH, Division of Surveillance, Hazard Evaluations, and Field Studies (DSHEFS) Adrian Davis, MRC Hearing and Communication Group, School of Education; University of Manchester, United Kingdom Rickie Davis, NIOSH, Team Leader, Division of Applied Research and Technology (DART) Clayton Doak, NIOSH, Education and Information Division (EID) Dennis Driscoll, Noise Control Engineering Consultant, Associates in Acoustics, Inc. Scott Earnest, NIOSH, Branch Chief, DART John Franks, NIOSH, DART Pam Graydon, NIOSH, DART Chuck Hayden, NIOSH, DART Don Henderson, Professor, State University of New York, Buffalo DeLon Hull, NIOSH, Director, Office of Research and Technology Transfer David Ingram, NIOSH, Team Leader, Pittsburgh Research Laboratory (PRL) Peter Kovalchik, NIOSH, Team Leader, PRL Greg Lotz, NIOSH, Associate Director for Science, DART R. J. Matetic, NIOSH, Branch Chief, PRL Rich McKinley, U.S. Air Force, Wright-Patterson Air Force Base Leroy Mickelsen, NIOSH, Deputy Division Director (Acting), DART Thais Morata, NIOSH, DART Bill Murphy, NIOSH, Team Leader, DART Bob Randolph, NIOSH, Team Leader, PRL Ray Sinclair, NIOSH, Senior Scientist, Office of the Director Carol Stephenson, NIOSH, Branch Chief, EID Mark Stephenson, NIOSH, DART Christa Themann, NIOSH, DART Randy Tubbs, NIOSH, DSHEFS Rohit Verma, NIOSH, EID Mary Lynn Woebkenberg, NIOSH, Division Director, DART Ed Zechmann, NIOSH, DART SOURCE: NIOSH, 2006a.

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Hearing Loss Research at NIOSH: Reviews of Research Programs of the National Institute for Occupational Safety and Health BOX 3-2 Emerging Research Issues Identified by the Hearing Loss Research Program Short Term Research Goal 1 Conduct economic cost/benefit analysis of hearing conservation programs and noise controls Research Goal 2 Refine fit-check protocol (make as short as possible but still retain accuracy) Research Goal 3 Develop basic guidelines on engineering controls and the maintenance of those controls Provide leadership to encourage noise education in undergraduate engineering programs Publish available noise control solutions (update print and/or web based), with feedback loop Develop engineering controls for small businesses Long Term Research Goal 1 Establish a centralized repository of audiometric data that can be accessed by professionals Collaborate with partners in education to reach young workers with prevention information and skills Strengthen efforts to transfer and disseminate information Research Goal 3 Encourage manufacturers to provide noise labels Research Goal 4 Establish ongoing surveillance programs for occupational hearing loss and noise exposure Repeat large epidemiologic survey of industry (NOES [National Occupational Exposure Survey]) Collect industry- and job task-specific noise exposure data Establish the effectiveness of prophylactic treatments for noise-exposed workers Establish recommended exposure limits for mixed exposure of ototoxic chemicals and noise SOURCE: NIOSH, 2005a, 2006a.

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Hearing Loss Research at NIOSH: Reviews of Research Programs of the National Institute for Occupational Safety and Health Noted in the evidence package are plans to use the information from the Futures Workshop in developing a strategic plan for the Hearing Loss Research Program. The program is deferring its work on the strategic plan pending completion of the current Institute of Medicine review (Lotz, 2006c). Mining Research Plan The Mining Research Plan was developed as part of a strategic planning effort for the NIOSH Mining Safety and Health Research Program, which is undergoing a parallel review by a separate National Academies committee. According to the evidence package for the Mining Safety and Health Research Program review, “the plan was developed to focus the research and prevention activities on the areas of greatest need, as articulated by our customers and stakeholders and illustrated by the surveillance data” (NIOSH, 2006b; also see http://www.cdc.gov/niosh/nas/mining/whatis-miningresearchplan.htm). The plan identifies seven strategic goals, each with intermediate goals and performance measures. Strategic Goal 2 is “Reduce noise-induced hearing loss (NIHL) in the mining industry.” The intermediate goals and performance measures for Strategic Goal 2 are shown in Box 3-3. In response to an inquiry from the committee, the Hearing Loss Research Program provided additional information on this portion of the Mining Research Plan. The development of the strategic goal on hearing loss prevention was the responsibility of the Hearing Loss Prevention Branch at the Pittsburgh Research Laboratory. Significant input was provided by important stakeholders through the Noise Partnership Committee, whose members include the United Mine Workers of America, the Bituminous Coal Operators Association, the National Mining Association, and the Mine Safety and Health Administration. These stakeholders contributed surveillance data for consideration in the strategic planning process as well as information on such topics as research barriers to overcome and knowledge gaps related to hearing loss prevention in the mining industry (Lotz, 2006a). Although the Hearing Loss Research Program noted in the evidence package the existence of the Mining Research Plan and its strategic goal regarding hearing loss prevention, it was not clear how the Mining Research Plan factored into the work and planning of the Hearing Loss Research Program as a whole. Other than in a response to an inquiry from the committee, discussion of the Mining Research Plan or reference to this plan and its performance measures was notably absent from information conveyed to the committee by the Hearing Loss Research Program. The committee believes that the Hearing Loss Research Program could benefit from increased exchange and collaboration among all the program’s researchers in the development of research plans and priorities.

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Hearing Loss Research at NIOSH: Reviews of Research Programs of the National Institute for Occupational Safety and Health BOX 3-3 Hearing Loss Prevention Goals in the NIOSH Mining Research Plan Strategic Goal 2: Reduce noise-induced hearing loss (NIHL) in the mining industry Performance Measure: The shorter-term goal of this research will be achieved if the frequency of noise overexposure of miners is reduced by 25 percent in 5 years and 50 percent in 10 years. However, NIHL usually occurs gradually over a career. The ultimate long-term measure of success is the elimination of new cases of NIHL. The overall success of our hearing loss prevention research will only be seen in 20–30 years. Intermediate Goal 2.1: Develop and maintain a noise source/mine worker exposure database for prioritizing noise control technology. Performance Measure: This goal will be achieved through development of a database of noise source/exposure relationships and equipment noise in all mining commodities and its use by the mining industry and the Mine Safety and Health Administration (MSHA) by 2008. Intermediate Goal 2.2: Develop engineering noise control technologies applicable to surface and underground mining equipment. Performance Measure: The goal for existing noise controls will be achieved by disseminating comprehensive procedures for the evaluation and application of suitable noise controls in underground and surface metal, nonmetal, and coal mines within 3, 4, and 5 years, respectively. The goal for noise control development will be achieved if the industry implements effective new noise controls that reduce the noise overexposures of miners by 25 percent (versus the baseline values) by 2009. Intermediate Goal 2.3: Empower workers to acquire and pursue more effective hearing conservation actions. Performance Measure: This goal will be achieved through measures of dissemination and usage of communication, training, and empowerment tools by 2006. A key measure will be the actual noise dose reduction attained through increased prevention behavior and usage of dose monitoring systems. Intermediate Goal 2.4: Improve the reliability of communication in noisy workplaces. Performance Measure: This goal will be achieved to the extent that key stakeholders acquire, accept, and implement the guidelines on alleviating communications issues by 2006. SOURCE: NIOSH, 2006b.

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Hearing Loss Research at NIOSH: Reviews of Research Programs of the National Institute for Occupational Safety and Health Health Hazard Evaluations HHEs are another potential means for NIOSH to identify research needs. The Health Hazard Evaluation Program is legislatively mandated to provide assistance to employers or employees in evaluating whether chemical, physical, biological, or other agents are hazardous as used or found in the workplace (NIOSH, 1998b). Since the program’s inception in 1972, more than 8,000 evaluations have been completed. Of the HHEs completed since 1981, at least 154 have some reference to either hearing loss or noise exposure (see http://www.cdc.gov/niosh/hhe/). One instance in which HHEs helped to identify an area of research for the Hearing Loss Research Program was the observation of widespread hearing loss among 25-year-old carpenters (Bureau of National Affairs, 2001; Tubbs, 2002; Lotz, 2006b). The hearing loss observed in audiograms collected at two conventions of carpenters was worse than might have been anticipated based on the sound levels that had been measured at construction sites and the relatively short work duration based on the workers’ ages. The discrepancy between noise level and exposure conditions and observed hearing loss suggested to Hearing Loss Research Program investigators that the impulsive-type noise to which carpenters are exposed may be more damaging than had previously been thought. Following up on these observations, the Hearing Loss Research Program began working with the United Brotherhood of Carpenters to develop a research plan and educational materials to promote awareness of noise hazards and more effective use of hearing protection devices among carpenters, as described in the evidence package for Research Goal 1 (NIOSH, 2005b). A second example of an HHE leading the Hearing Loss Research Program to more extensive work was an evaluation of impulsive noise exposures undertaken at an indoor firing range belonging to the National Firearms Unit of what was then the U.S. Immigration and Naturalization Service (Harney et al., 2005; Lotz, 2006b). Work carried out for this HHE helped NIOSH identify limitations of existing sound instruments and measurement standards for impulsive noise. The program’s research and development efforts to address those limitations are discussed under Research Goal 4 (NIOSH, 2005c). COMMITTEE ASSESSMENT OF THE HEARING LOSS RESEARCH PROGRAM’S IDENTIFICATION OF EMERGING ISSUES AND RESEARCH AREAS IN OCCUPATIONAL HEARING LOSS PREVENTION The Framework Document used by the committee to guide its evaluation notes correctly that identifying new or emerging research needs and developing an active research response are among the most challenging aspects of prevention

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Hearing Loss Research at NIOSH: Reviews of Research Programs of the National Institute for Occupational Safety and Health research (see Appendix A). Acknowledging this, as well as the small scale of the program and other challenges noted in Chapter 2, the committee nonetheless has some concerns about the identification of new or emerging research by the Hearing Loss Research Program. With few exceptions, the list of emerging issues in the evidence package (see Box 3-2) resembles work that the Hearing Loss Research Program described as being under way or among its current research goals. For example, the plans described under “Refine hearing protector fit-testing methods” (NIOSH, 2005a) are difficult to distinguish from efforts described as ongoing in the materials on Research Goal 2. Similarly, “Publish available noise control solutions and updates” reflects ongoing work to update a manual published in 1978, albeit in a way that is web accessible and searchable, with a means for users to contribute additional solutions (NIOSH, 2005a). Although a certain degree of continuity in research effort is necessary and understandable, the committee saw no reference to emerging research topics that reflect areas of research potential over a more distant time horizon or greater imaginative leaps than current projects or their natural follow-ons. The Framework Document directs the committee to examine the process by which the program identifies new research needs. According to the Hearing Loss Research Program, the Futures Workshop (described above) was the means for generating the list of emerging issues. The evidence package states that the workshop “was convened to develop a strategic research agenda for the HLR program based on input from the scientific and occupational safety and health communities” (NIOSH, 2005d). Supplemental material about the Futures Workshop noted an emphasis on stimulating internal discussion of research needs and opportunities (NIOSH, 2006a). In the committee’s view, the limited reach of the emerging research needs identified by the Hearing Loss Research Program may reflect two problems. One problem is what the committee sees as the limited breadth and diversity of the program’s outreach to and input from the communities responsible for occupational hearing loss prevention in the development of the program’s 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 or ototoxic chemicals, separately or in combination. The six outside participants in the Futures Workshop are distinguished experts, but they represent a small pool of expertise for the Hearing Loss Research Program to be drawing from in identifying emerging issues. The committee sees a need for much wider outreach to varied research communities for input and ideas to guide the direction of the program’s future work. As discussed in Chapter 2 and again in Chapter 4, the program could benefit from expanding the breadth of

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Hearing Loss Research at NIOSH: Reviews of Research Programs of the National Institute for Occupational Safety and Health outside scientific expertise that it draws upon for planning and review of its work. Areas of expertise in which the committee particularly urges the program to seek greater outside contact include noise control engineering and low-noise product design, epidemiology, and management of hearing conservation programs within corporations. 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 made higher priorities in the near term because of the fundamental role that the data they generate should play in the research planning process. As noted by NIOSH, as well as by the committee elsewhere in this report, the small size of the Hearing Loss Research Program means that the program must necessarily consider its research portfolio carefully. To sustain a leadership role in occupational hearing loss prevention research, however, the Hearing Loss Research Program should actively monitor emerging research needs and opportunities in all aspects of occupational hearing loss prevention. With its limited funding and staffing resources, the program cannot and should not be expected to develop plans to pursue every emerging research area. It should, however, be expected to move into new research areas on the basis of well-informed judgments as to crucial national needs or important concerns that might otherwise be neglected. To address emerging issues effectively, it may well be necessary for the program to gain access to expertise and resources beyond those available within its existing intramural framework. Depending on the subject and the need, appropriate responses may include expanding intramural capacity, targeting extramural funding to work in such areas, collaborating with appropriate stakeholders, or combinations of these. When it addresses such topics through extramural research, the program should expect intramural researchers to actively monitor the outside work and build on the results as appropriate. EMERGING ISSUES AND RESEARCH AREAS IN OCCUPATIONAL HEARING LOSS PREVENTION IDENTIFIED BY THE EVALUATION COMMITTEE The committee was asked to include in its report to NIOSH its identification of emerging research needs in occupational hearing loss and noise control. Had this been the central task of the study charge, the committee would have wanted to undertake various activities, which might have included holding a large workshop, or a series of workshops, to draw ideas from many researchers in the several

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Hearing Loss Research at NIOSH: Reviews of Research Programs of the National Institute for Occupational Safety and Health disciplines involved in occupational hearing loss prevention research and to weigh the relative merits of the ideas proposed. Time constraints precluded this approach, and guidance from NIOSH representatives at the initial meeting reinforced the idea that NIOSH would appreciate the results of brainstorming on the part of committee members rather than requiring an in-depth “research needs” assessment. In this vein, the committee suggests several ideas for consideration. Some of these proposals, like those presented by the Hearing Loss Research Program, are most appropriately characterized as existing research needs that the program should be considering now, whereas others are emerging topics that may deserve increasing attention over the next 10 years. The inclusion of suggestions that describe work similar to activities already being planned by the Hearing Loss Research Program should not be interpreted as implying greater support from the committee for that work than has already been described in Chapter 2. Near-Term Needs Supporting and leading the development of technologies, advocacy, and education related to portable audiometric records (e.g., “smart card technology”) for mobile workers. Rationale: A growing segment of the workforce, particularly in construction and other underserved industries, experiences frequent changes in employment while continuing to work in high-noise environments. Developing robust testing methods and appropriate rating metrics for some of the newer hearing protection device (HPD) technologies, including nonlinear ear plugs, electronic ear plugs, and noise cancellation options at the earplug level. Rationale: New HPD technologies are increasingly available and in use; employers and workers need good information on their effectiveness. Pursuing research and advocacy related to the development of consensus standards for noise emissions testing of power tools. Rationale: Existing standards documents contain insufficient guidance for the conduct of noise emissions testing of power tools for purposes of rating and labeling. Robust and comprehensive testing procedures are a prerequisite to the development of standards for labeling power tools, which will provide guidance for industry “buy-quiet” programs, small business, and the construction sector, as well as the general public. Providing leadership in defining occupational hearing loss and exploring improved means of measuring it (e.g., comparing pure-tone averages, otoacoustic emissions, and any other possible approaches; evaluating the appropriateness of “standard threshold shift”). Rationale: Averages of hearing levels for pure tones at various sound frequencies have been used for decades to describe hearing loss, but different combinations of frequencies are used for these averages, and newer tech-

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Hearing Loss Research at NIOSH: Reviews of Research Programs of the National Institute for Occupational Safety and Health nologies such as otoacoustic emissions warrant evaluation in occupational settings. The Hearing Loss Research Program should take the lead in considering ways to measure and define occupational hearing loss. Identifying occupations in the modern workplace with high risk of occupational hearing loss from exposure to noise and/or ototoxins. Rationale: With the changes in workplace environments and the emergence of new occupations and industries (e.g., in nanotechnology), there is a need to learn whether occupational hearing loss hazards exist in settings beyond those that are a source of longstanding concern and attention. Longer-Term Needs Exploring the interaction between cochlear implants and high sound levels. Rationale: Workers with cochlear implants represent a small but growing presence in the workplace. Studies are needed to investigate such issues as the limits of safe sound level exposure for these workers, how workers with cochlear implants should be tested as part of a hearing loss prevention program, and how frequently they should be tested. Identifying effective screening methods using new technologies, such as otoacoustic emissions, to improve early identification of high-risk individuals. Rationale: Earlier identification of workers who show signs of damage to their hearing may help in ensuring that workers’ exposure to noise or ototoxic hazards is being controlled effectively. Supporting the development of technologies for hearing-impaired workers that combine amplification and attenuation capabilities for selectable performance. Rationale: As the U.S. workforce ages, the number of hearing-impaired workers who need both hearing protection and amplification will increase. Developing and promoting standards for product noise emissions labeling. Rationale: Work focused on consumer products has been initiated through the Institute of Noise Control Engineering, but the Hearing Loss Research Program could champion a similar effort to advocate for product noise emissions labeling and testing standards for equipment commonly employed in occupational settings. Conducting well-designed longitudinal studies of workers exposed and unexposed to occupational noise to determine the long-term effects, if any, of occupational noise exposure after the exposure stops. Rationale: Some workers who are exposed to a period of occupational noise are concerned that hearing loss that becomes evident long after such noise exposure ended may be a delayed effect of the earlier exposure. A recent report from the Institute of Medicine (IOM, 2006) found that the available evidence was not sufficient to determine whether perma-

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Hearing Loss Research at NIOSH: Reviews of Research Programs of the National Institute for Occupational Safety and Health nent noise-induced hearing loss can develop long after the cessation of a given noise exposure. Assessing the impact of varied working conditions, such as extended shifts, on occupational hearing loss. Rationale: Current noise exposure standards and recommendations are generally based on presumptions of exposure for an 8-hour work day. Current practices in some industry sectors may result in workers routinely being exposed to hearing hazards (i.e., noise, ototoxic chemicals, or both) during longer work days of 12 hours or more. CONCLUSION Identification of emerging concerns is an important and challenging aspect of the Hearing Loss Research Program’s stated mission “to provide national and world leadership to reduce the prevalence of occupational hearing loss through a focused program of research and prevention.” The committee noted room for improvement in the program’s recent approach to this task. Although the committee suggested additional areas for consideration, it emphasizes that this important task warrants more extensive expert input and evaluation than the committee could provide in the context of its review. Whether or not the NIOSH Hearing Loss Research Program is able to undertake activities proposed by the committee, the program should aim to be at the forefront of efforts to review and define needs in occupational hearing loss prevention and to promote opportunities to pursue new and innovative to ways to respond to those needs. REFERENCES Bureau of National Affairs. 2001. Hearing loss expected by carpenters, but study finds workers fear tinnitus more. Occupational Safety and Health Reporter 31(April 5): 303–305. [Online]. Available: http://www.cdc.gov/elcosh/docs/d0400/d000452/d000452.html [accessed May 9, 2006]. Harney JM, King BF, Tubbs RL, Hayden CS, Kardous CA, Khan A, Mickelsen RL, Wilson RD. 2005. NIOSH Health Hazard Evaluation Report, HETA 2000-0191-2960: Immigration and Naturalization Service, National Firearms Unit, Altoona, Pennsylvania. Cincinnati, OH: NIOSH. IOM (Institute of Medicine). 2006. Noise and Military Service: Implications for Hearing Loss and Tinnitus. Humes LE, Joellenbeck LM, Durch JS, eds. Washington, DC: The National Academies Press. Lotz WG (NIOSH). 2006a. RE: additional info and document requests. E-mail to L Joellenbeck, Institute of Medicine. January 30. Lotz WG (NIOSH). 2006b. RE: info request. E-mail to L Joellenbeck, Institute of Medicine. May 26. Lotz WG (NIOSH). 2006c. Re: update on timing, and question. E-mail to L Joellenbeck, Institute of Medicine. June 14.

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Hearing Loss Research at NIOSH: Reviews of Research Programs of the National Institute for Occupational Safety and Health NIOSH (National Institute for Occupational Safety and Health). 1998a. Criteria for a Recommended Standard. Occupational Noise Exposure: Revised Criteria 1998. DHHS (NIOSH) Pub. No. 98-126. Cincinnati, OH: NIOSH. NIOSH. 1998b. Health Hazard Evaluations: Noise and Hearing Loss 1986–1997. DHHS (NIOSH) Pub. No. 99-106. Cincinnati, OH: NIOSH. NIOSH. 2005a. Emerging Issues. In: NIOSH Hearing Loss Research Program: Evidence for the National Academies’ Committee to Review the NIOSH Hearing Loss Research Program. Cincinnati, OH: NIOSH. Pp. 157–162. NIOSH. 2005b. Research Goal 1: Contribute to the Development, Implementation, and Evaluation of Effective Hearing Loss Prevention Programs. In: NIOSH Hearing Loss Research Program: Evidence for the National Academies’ Committee to Review the NIOSH Hearing Loss Research Program. Cincinnati, OH: NIOSH. Pp. 43–75. NIOSH. 2005c. Research Goal 4: Contribute to Reductions in Hearing Loss through the Understanding of Causative Mechanisms. In: NIOSH Hearing Loss Research Program: Evidence for the National Academies’ Committee to Review the NIOSH Hearing Loss Research Program. Cincinnati, OH: NIOSH. Pp. 125–155. NIOSH. 2005d. Selected NIOSH Sponsored Workshops and Conferences Related to the HLR Program. In: NIOSH Hearing Loss Research Program: Evidence for the National Academies’ Committee to Review the NIOSH Hearing Loss Research Program. Cincinnati, OH: NIOSH. Pp. 8A-1–8A-8. NIOSH. 2006a. NIOSH Hearing Loss Research Program: 2005 Futures Workshop. Unpublished document provided to the Committee to Review the NIOSH Hearing Loss Research Program. Cincinnati, OH: NIOSH. NIOSH. 2006b. 1.5 Mining Research Plan (Strategic Goals). In: NIOSH Mining Program Briefing Book. Unpublished document prepared for the Committee to Review the NIOSH Mining Safety and Health Research Program. Pittsburgh, PA: NIOSH. Pp. 33–53. Tubbs RL. 2002. Memorandum: Close-out of HETA 95-0249; HETA 96-0007. Unpublished document provided to the Committee to Review the NIOSH Hearing Loss Research Program. Cincinnati, OH: NIOSH.