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NIOSH Hearing Loss Research Program Review NIOSH Publications on Noise and Hearing The National Academies - Advisors to the Nation on Science, Engineering, and Medicine

What has the program achieved?

In this section ....

Research Goal 1

Research Goal 2

Research Goal 3

Research Goal 4

Acronym Finder

Outputs and Transfer - Research Goal 4.6:
Prevent hearing loss from exposure to ototoxic chemicals
alone or in combination with noise

“Occupational exposure to organic solvents and noise: effects on hearing” by Morata et al, 1993 was an important manuscript that motivated further studies on the ototoxicity of chemicals. The manuscript has been cited at least 75 times. It was reprinted in the “1995 Mosby Year Book of Occupational and Environmental Medicine.”

HLR program researchers have published 40 manuscripts on chemical-noise interactions between 1989 and 2005, and made 37 presentations at national and international scientific conferences in the last ten years.

A literature search of MedLine using the terms “chemicals, solvents, hearing” returned two articles between 1983-1992 and twenty articles between 1993 and 2003. The number of papers surpasses 100 when specific chemicals are included as search terms.

With the publication of NORA in 1996, NIOSH identified both hearing loss and multiple exposures as research priorities for the occupational safety and health community.6 The NIOSH publications, Preventing Occupational Hearing Loss: A Practical Guide5 and the Criteria for a Recommended Standard-Occupational Exposure to Noise7 argued for broadening the scope of risk assessment and preventive initiatives. These publications recommended that hearing loss prevention programs take chemical exposures into account when monitoring for hazards, assessing hearing, and controlling exposures.

Conference

In 2002, NIOSH and NHCA co-sponsored the “Best Practices Workshop: Combined Effects of Chemicals and Noise on Hearing”with industry, government, labor, professional and trade organizations, and academia. The goals were to review the current knowledge of chemical ototoxicity and to stimulate discussion addressing chemical exposures in hearing loss prevention. Presentations are available: http://www.cdc.gov/niosh/topics/noise/research/noiseandchem/noiseandchem.html. A report was published in the “Journal of Occupational and Environmental Medicine.”[46] Three publications referenced the report:

Web sites

Today, information on the ototoxicity of chemicals can be found in Web sites such as the ones below and in magazines or trade journals.

Intermediate Outcomes

Standards and guidelines

The HLR program contributions to this area influenced a change in international standards. The 2003 European Parliament Directive EC 10 states, under “Obligations of Employers” that when carrying out risk assessments, employers should “…give particular attention to: any effects on workers’ health and safety resulting from interactions between noise and work-related ototoxic substances…” (http://europa.eu.int/eur-lex/pri/en/oj/dat/2003/l_042/l_04220030215en00380044.pdf).

Legislation regarding worker compensation has also changed in Australia and Brazil.

The HLR program helped prepare best practice guidelines by external groups. ACGIH in its Threshold Limited Values and Biological Exposure Indices (TLVs® and BEIs®) include a note in its Noise Section: “In settings where exposure to toluene, lead, manganese, or n-butyl alcohol occurs, periodic audiograms are advised and should be carefully reviewed.”

Since 1998 the U.S. Army has required consideration of ototoxic chemical exposures for inclusion in its hearing conservation program, “particularly when in combination with marginal noise.”

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Publications:

NIOSH Publications
NIOSH [1998]. NIOSH Criteria for a Recommended Standard: Occupational Exposure to Noise. Cincinnati, OH: U.S. Department of Health and Human Services, Public HealthService, Centers for Disease Control and Prevention, National Institute for OccupationalSafety and Health, DHHS (NIOSH) Publication No. 98-126.

NIOSH [1998]. National Occupational Research Agenda. Cincinnati, OH: U.S.Department of Health and Human Services, Public Health Service, Centers for DiseaseControl and Prevention, National Institute for Occupational Safety and Health, DHHS (NIOSH) Publication No. 96-115, 1996.

NIOSH [1996]. Preventing Occupational Hearing Loss- A Practical Guide. Cincinnati,OH: U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health, DHHS (NIOSH) Publication No. 96-110, 1996.

NIOSH [1988]. A proposed national strategy for the prevention of noise-induced hearingLoss. Chapter 8 in Proposed National strategies for the Prevention of Leading Work-Related Diseases and Injuries, Part 2. Cincinnati, OH: U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health.

Journal Articles

Campen L, Morata T, Kardous C, Gwin K, Wallingford W, Dallaire J, Alvarez FJ [2005]. Ototoxic occupational exposures for a stock car racing team: I: noise surveys. Journal of Occupational and Environmental Hygiene 2: 383–390.

Chouanière D, Demange V, Loquet G, Perrin P, Johnson A-C, Planeau V, Baudin V, Toamain J-P, Morata T [2001]. How to explore the otoneurotoxicity of solvents in the framework of epidemiological studies in the work environment (in French). Otorhinolaryngologia Nova, 11:134-140.

Demange V, Chouanière D, Loquet G, Perrin P, Johnson A-C, Morata T [2001].The ototoxic effects of solvents: a review of the literature (in French). Otorhinolaryngologia Nova 11:141-150. 

Demange V, Chouanière D, Loquet G, Perrin P, Johnson A-C, Planeau V, Baudin V, Toamain J-P, Morata T [2001]. How to explore the otoneurotoxicity of solvents in the framework of epidemiological studies in the work environment (in French), Les Notes Scientifiques et Techniques de I.N.R.S. (Institut National de Recherche et de Sécurité), NS 0202: 1-35.

Dunn DE, Morata TC [1997]. Industrial noise and hearing conservation. Current Opinion in Otolaryngology and Head and Neck Surgery, 5(5):330-333.

Franks JR, Morata TC [1996]. Ototoxic effects of chemicals alone or in concert with noise: a review of human studies. In: Axelsson A, Borchgrevink HM, Hamernik RP, Hellström PA, Henderson D, Salvi R eds. Scientific basis of noise-induced hearing loss. Thieme, New York, 472 p 2.

Gwin K, Wallingford K, Morata T, Van Campen L, Dallaire J, Alvarez FJ [2005]. Ototoxic occupational exposures for a stock car racing team: II: chemical surveys. Journal of Occupational and Environmental Hygiene 2: 406–413.

Henderson D, Morata TC, Hamernik R [2001]. Considerations on assessing the risk of work-related hearing loss. Noise and Health, 3(10): 63-75. 

Jacob L, Alvarenga K, Morata, T [2002]. The effects of occupational exposure to lead on the auditory system: a review of the literature (in Portuguese). Revista Brasileira de Otorrinolaringologia 68(4): 564-9.

Johnson AC, Morata T, Andersson IM, Nylén P, Lindh T, Svensson E [1998]. Hearing loss after exposure to styrene and noise: a pilot study. In: Prasher D, Luxon L eds. Advances in Noise Research: Biological Effects of Noise (vol. I), 282-296.Whurr Publishers Ltd, London. 

Lacerda A, Leroux T, Morata TC. Ototoxic effects of the simultaneous exposure to noise and carbon monoxide: A review (in Portuguese). In press. 

Manjabosco CW, Morata TC, Marques J [2004]. Audiometric findings of agricultural workers (in Portuguese). Arquivos de Otorrinolaringologia 8(4):285-295.

Morata TC [1998]. Assessing occupational hearing loss: beyond noise exposure. Scandinavian Audiology, 27:111-116. 

Morata TC [2003]. Chemical exposure as a risk factor for hearing loss. The Journal of Occupational and Environmental Medicine July, 45(7):676-682. (1 known citation)

Morata TC. Environmental and Occupational Contributors to Hearing Disorders in Levy B and Wegman D, Occupational and Environmental Health: Recognizing and Preventing Disease and Injury. 5th Edition. In press.

Morata, TC [2001]. Industrial Chemicals and Tinnitus. Tinnitus Today 26(4): 12.

Morata, TC [2002]. Interaction between Noise and Asphyxiants: A Concern for Toxicology and Occupational Health. Toxicological Sciences, 66:1-3, 2002. (1 known citation)

Morata TC [2004]. Ototoxicity: an issue in hearing loss prevention in the workplace. Council for Accreditation on Occupational Hearing Conservation (CAOHC) Update, 16(2)7-9.

Morata TC. Study of the effects of the simultaneous exposure to noise and carbon disulfide on workers' hearing (1989). Scandinavian Audiology, 18:53-58. (21 known citations)

Morata, TC, Campo P [2001]. Auditory function after single or combined exposure to styrene: a review. In Henderson D; Prasher D; Kopke R, Salvi R, and Hamernik R. Noise-Induced Hearing Loss: Basic Mechanisms, Prevention and Control. NRN Publications, London, 293-304.

Morata TC, Campo P [2002]. Ototoxic effects of styrene alone or in concert with other agents: A review. Noise and Health, Jan - Mar 2002, vol. 4, no. 14, pp. 15-24(10).

Morata TC, Dunn DE, Kretschmer LK, Lemasters GK, Keith RW [1993]. Occupational exposure to organic solvents and noise: effects on hearing. Scandinavian Journal of Work, Environment and Health, 19 (4):245-254. (74 known citations)

Morata TC, Dunn DE, Kretschmer LK, Lemasters GK, Keith RW [1995]. Occupational exposure to organic solvents and noise: effects on hearing. In Emmett E et al. eds. Year Book of Occupational and Environmental Medicine. Mosby- Year Book Inc., St. Louis, pp. 114-117.

Morata TC, Dunn DE, Sieber WK [1994]. Occupational exposure to noise and ototoxic organic solvents. Archives of Environmental Health, 49(5):359-365.

Morata TC, Dunn DE, Sieber WK [1997]. Occupational exposure to noise and ototoxic organic solvents (In Portuguese). In: Nudelmann AA, Costa EA, Seligman J, Ibanez RN eds. PAIR-Perda Auditiva Induzida pelo Ruido, pp 189-201. Editora Bagagem, Porto Alegre.

Morata TC, Engel T, Durão A, Costa TRS, Krieg E, Dunn DE, Lozano MA [1997]. Hearing loss from combined exposures among petroleum refinery workers. Scandinavian Audiology, 26:141-149. (16 known citations)

Morata TC, Engel T, Krieg EF, Dunn DE [1999]. Hearing loss among the workers from the Industrial Complex of Barrancabermeja (in Spanish). In: Organización Panamericana de la Salud (OPS), Organización Mundial de la Salud (OMS), La Búsqueda de la Salud Ocupacional en la Industria de Petróleo Colombiana: Informe Técnico-Cientifico del Proyecto SOIP, 129-140. OPS, OMS, División Salud y Ambiente, Santafé de Bogotá, Colombia. 

Morata TC, Fiorini AC, Fischer FM, Colacioppo S, Wallingford KM, Krieg E, Dunn, DE, Gozzoli L, Padrao MA, Cesar C [1997]. Toluene-induced hearing loss among rotogravure printing workers. Scandinavian Journal of Work, Environment and Health, 23:289-298.  (36 known citations)

Morata TC, Franks JR [1997]. Effect of noise and solvents on hearing: Findings from three field studies. Journal of the Acoustical Society of America, 101:3099 Part 2.

Morata TC, Franks JR, Dunn DE [1994]. Unmet needs in occupational hearing conservation. The Lancet, 344 (8920):479. (3 known citations)

Morata TC, Johnson AC, Nylen P,  Svensson EB, Cheng J, Krieg EK, Lindblad AC, Ernstgård L, Franks J [2002]. Audiometric findings in workers exposed to low levels of  styrene and noise. Journal of Occupational and Environmental Medicine, September, 44 (9): 806-814, 2002.

(7 known citations)

Morata TC, Little MB [2002]. Suggested guidelines for studying the combined effects of occupational exposure to noise and chemicals on hearing. Noise and Health, Jan - Mar 2002, vol. 4, no. 14, pp. 73-87(15).

Morata TC, Lemasters GK [1995]. Epidemiologic considerations in the evaluation of occupational hearing loss. In Morata TC, Dunn DE eds. Occupational Hearing Loss, Occupational Medicine: State of the Art Reviews, 10(3):641-656. Hanley and Belfus, Inc., Philadelphia. (3 known citations)

Morata TC, Nylén PR, Johnson A-C, Dunn, DE [1995]. Auditory and vestibular functions after single or combined exposure to toluene: a review. Archives of Toxicology, 69:413-443. (8 known citations)

Murphy WJ, Franks JR, Morata TC [1997]. A review of the effects of exposure to noise in combination with organic solvents and metals. Journal of the Acoustical Society of America, 101:3100 Part 2.

Prasher D, Morata TC, Campo P, Fechter L, Johnson AC, Lund SP, Pawlas K, Starck J, Sliwinska Kowalska M, Sulkowski W [2002]. NoiseChem: A European Commission research project on the effects of exposure to noise and industrial chemicals on hearing and balance. International Journal of Occupational Medicine and Environmental Health, vol. 15, no. 1, p 5-11.

Prasher D, Morata TC, Campo P, Fechter L, Johnson AC, Lund SP, Pawlas K, Starck J, Sliwinska Kowalska M, Sulkowski W [2002]. NoiseChem: A European commission research project on the effects of exposure to noise and industrial chemicals on hearing and balance. Noise and Health, Jan - Mar 2002, vol. 4, no. 14, pp. 41-48(8).

Prince MM, Matanoski GM, Breysee PN, Fechter LD, Pena B (1993).  The combined effect of smoking and noise on changes in hearing acuity.  Proceedings of the 6th International Congress on Noise as a Public Health Problem, Volume 2.  Nice, France, 5-9 July, 1993 pp. 291-298.

Teixeira CF, Giraldo da Silva Augusto L, Morata TC [2003]. Hearing health of workers exposed to insecticides and noise (in Portuguese). Rev. Saúde Pública  37(4):417-423. Ago. (1 known citation)

Teixeira CF, Giraldo da Silva Augusto L, Morata TC [2002]. Occupational exposure to insecticides and their effects on the auditory system. Noise and Health, Jan-Mar 2002, Vol. 4, No. 14, pp. 31-39 (9).

Presentations

Conferences

Morata, T. Addressing the Risk for Hearing Loss from Industrial Chemicals. Presentation at the 88th Annual American Occupational Health Conference, Atlanta, Georgia, May 4-8, 2003. Invited Presentation.

Morata, T. Advances from the investigation of hearing loss from noise and industrial chemicals at the Update in Noise Research Course, promoted by the Brazilian Association of Otolaryngologists. Porto Alegre, RS, Brazil. August 6-7, 1999. Invited Presentation.

Morata, T. Assessing occupational hearing loss: beyond noise exposures at the XXIII International Congress of Audiology, Bari, Italy, June, 1996. Invited Presentation.

Morata, T. Chemical Exposure as a Risk Factor for Hearing Loss. Presentation at the Podium on Noise and Hearing Conservation at the American Industrial Hygiene Conference and Exhibition 2004 Noise Symposium, Atlanta, GA, May 9, 2004. Invited Presentation.

Morata, T. Effect of noise and solvents on hearing and its impact on industrial hygiene practices at the American Industrial Hygiene Conference and Exposition 1997, Dallas, TX, U.S.A, May 17-23, 1997. Invited Presentation

Morata, T. Effect of noise and solvents on hearing: findings from field studies Second European Conference: Protection against Noise. London, UK, April 16-19, 1997. Invited Presentation

Morata, T. Effects of combined exposures on the hearing of petrochemical workers at the American Auditory Society Platform Papers at the 8th Annual Convention of the American Academy of Audiology, Salt Lake City, UT, U.S.A, April, 1996.

Morata, T. Epidemiologic strategies in the investigation of hearing loss from noise and industrial chemicals at the 7th International Audiological Symposium and Protection Against Noise (PAN) 99 Conference on Ototoxicity, Noise, Chemicals and Hearing Loss. Zakopane, Poland, March 20-23, 1999. Invited Presentation

Morata, T. Epidemiologic strategies in the investigation of hearing loss from noise and industrial chemicals at the International Symposium on Audiological Medicine. Manchester, United Kindom, July 11-14, 1999. Invited Presentation

Morata, T. Hearing disorders from combined exposures to noise and solvents: a review at the 137th Meeting of the Acoustical Society of America and the 2nd Convention of the European Acoustics Association. Berlin, Germany, March 15-19, 1999. Invited Presentation

Morata, T. Hearing impairment from combined exposure to noise and chemicals: study designs, methods and analysis strategies at the 1995 Hearing Conservation Conference III/XX, Cincinnati, OH, U.S.A, March, 1995. Invited Presentation

Morata, T. Hearing loss from combined exposures at an oil refinery at the European Conference on Combination Toxicology, Veldhoven, The Netherlands, October, 1995.

Morata, T. Hearing Loss in Workers exposed to solvents. Presentation at the 9th Annual Meeting of the International Neurotoxicology Association, Dresden, Germany, June 22-27, 2003. Invited Presentation

Morata, T. Interaction between noise and industrial chemicals at the 36th Navy Occupational Health and Preventive Medicine Workshop, Hampton, VA, U.S.A, March, 1995. Invited Presentation

Morata, TC, “Noise and Industrial Solvents: Epidemiological Studies.” at the Sixth International Symposium on Noise-Induced Hearing Loss. Cambridge, England, July 7-10, 2000. Invited Presentation

Morata, TC, “Noise and industrial chemicals: testing for their effects on the auditory system,” at the 26th International Congress on Occupational Health, ICOH 2000. Singapore, August 27-September 1, 2000.

Morata, TC, “Noise, Toxins, and the Auditory System.” Presentation at the World Health Organization Consultation Initiative on Auditory Effects of Combined Exposures, Bonn, Germany, June 16-18, 2003. Invited Presentation

Morata, TC, “Occupational strategies in the prevention of noise-induced hearing loss at the Informal Consultation on the Prevention of Hearing Loss,” World Health Organization, Geneva, Switzerland, October 28-30, 1997. Invited Presentation

Morata, T. Ototoxic effects of industrial chemicals alone or in concert with noise at the 1995 Military Audiology Short Course, Richardson, TX, U.S.A, April, 1995. Invited Presentation

Morata, TC. “The Ototoxicity of Industrial Chemicals and Their Interaction with Noise”. Presentation at the American Industrial Hygiene Association Noise Committee/American Industrial Hygiene Conference and Exhibition 2004 Noise Symposium, Atlanta, GA, May 9, 2004. Invited Presentation

Morata, TC. “Report on Noise-Induced Hearing Loss form the South American Region at the Informal Consultation on the Prevention of Hearing Loss,” World Health Organization, Geneva, Switzerland, October 28-30, 1997. Invited Presentation

Morata, TC, “Review of Toluene and Auditory Toxicity at the Workshop on the Auditory Toxicity of Toluene,” promoted by the Danish Environmental Protection Agency Copenhagen, Denmark, January 27, 2000. Invited Presentation

Morata, TC, “Review on multiple occupational risks to the Audiovestibular system at the International Conference on Noise and Vestibular System of the Israel Society for Auditory Research (ISAR) and Protection Against Noise (PAN),” Tel-Aviv, Israel, October 19-22, 1998. Invited Presentation

Morata, TC, “Toluene-induced hearing loss among rotogravure printing workers at the Third European Conference: Protection Against Noise,” Nordic Noise, Stockholm, Sweden, March 12-15, 1998.

Morata, TC, “Toluene, Styrene, Carbon Monoxide: Risk Factors for Hearing Loss, Presentation,” at the 2003 Occupational Safety and Health Administration (OSHA) Consultation Conference  held in  Portland, Oregon, April 28-31, 2003. Invited Presentation

Morata, TC, “Toluene, Styrene, Carbon Monoxide: Risk Factors for Hearing Loss.” Presentation at the Professional Development Course on Noise and Vibration, organized by the Michigan Industrial Hygiene Society in Frankenmuth, Michigan, September 16, 2003. Invited Presentation

Morata, TC, “Update of Hearing Loss Prevention at the Work Place at the Course, Promotion of Hearing Health at the Workplace,” promoted by the Institute of Communication and Hearing. Bauru, SP, Brazil. August 3-4, 1999. Invited Presentation

Murphy, WJ, “Hearing Disorders from combined exposures to Noise and Solvents: A Review.” National Hearing Conservation Association, Best Practices Workshop, Houston, TX, Sept. 20, 2001. Invited Presentation

Murphy, WJ, “Noise Exposure in Combination with Ototoxic Agents.” American Industrial Hygiene Conference and Exposition, May 11, 1998 Atlanta, GA. Invited Presentation

Murphy, WJ,  “Workplace Ototoxicity: It’s more than Noise.” Michigan Safety Conference, April 21, 1998, Lansing, MI. Invited Presentation

Murphy, WJ, “Noise Exposure in Combination with Ototoxic Agents.” Navy Environmental Health Conference April 1, 1998 San Diego, CA. Invited Presentation

Murphy, WJ, “Noise Exposure in Combination with Ototoxic Agents.” Military Audiology Short Course, February 23-26, 1998 Albuquerque, NM. Invited Presentation

Murphy, WJ, Franks, JR, and Morata, TC, “A review of the effects of exposure to noise in combination with organic solvents and metals,” Journal Acoustical Society America, 101, No. 5 Pt. 2, 3100, (1997).

Prince MM, “Interaction of noise and other ototoxic chemicals in the etiology of occupational hearing loss,” University of Cincinnati, November 5, 1992.

Workshops

Morata, TC, “Tutorial: Addressing the potential risk of hearing loss from chemical exposure in the workplace,” at the 2000 National Hearing Conservation Association (NHCA) Annual Conference. Denver, CO, February 17-19, 2000. Invited Presentation

Poster Presentations

Gwin K, Wallingford K, Van Campen LE, Morata TC (2001). An automobile racing team’s occupational exposure to potentially ototoxic chemicals. 2001 American Industrial Hygiene Conference & Exposition, New Orleans, June 2-7, 2001. (Received the Best of Session Award for the Industrial Hygiene General Practice Session).

Johnson AC, Morata TC, Nylen, P, Svensson E. Hearing loss in workers exposed to styrene and/or noise. Description of audiologic test battery and preliminary results. At the 23rd Annual Midwinter Meeting of the Association for Research in Otolaryngology. St. Petersburg, FL, February 20-24, 2000.

Nylén PR, Morata TC, Johnson AC. Establishing a research network on the auditory effects of mixed exposures to noise and chemicals. Second European Conference: Protection Against Noise. London, UK, April 16-19, 1997.

Standards

ACGIH1998-2005, American Conference of Governmental Industrial Hygienists. Threshold Limit Values and Biological Exposure Indices for 1998-1999, ACGIH, Cincinnati.

ACOEM, American College of Occupational and Environmental Medicine Noise-induced Hearing Loss Evidence-Based Statement, JOEM 45(6) June 2003.

Australia-New Zealand AS/NZS 1269:2005 Occupational Noise Management/Informative Appendix on Ototoxic Agents requiring hearing tests for those exposed to ototoxic agents.

U.S. Army Fact Sheet 51-002-0903. Occupational Ototoxins and Hearing Loss.
http://chppm-www.apgea.army.mil/documents/FACT/51-002-0903.pdf).

U.S. Army. Hearing Conservation Guidelines. Dept. of the Army Pamphlet 40-501, 3-3 1998.

Regulations

Australia Workcover Guides for the Evaluation of Hearing Impaired, June 2002

Brazil. Decreto no. 3048/ May 6, 1999

European Parliament Directive 2003/10/EC
http://europa.eu.int/eur-lex/pri/en/oj/dat/2003/l_042/l_04220030215en00380044.pdf. 

NIOSH [1996].  Comments of the National Institute for Occupational Safety and Health on the Occupational Safety and Health Administration Proposed Rule on Occupational Injury and Illness Recording and Reporting Requirements.  July 1, 1996.    OSHA Docket No. R-02.  NIOSH policy statements.  Cincinnati, OH:  U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health. http://mtn.niosh.cdc.gov/eid/rmca/polstmt/PDFDoc/PSZY31T.pdf

NIOSH [2001].  Comments of the National Institute for Occupational Safety and Health on the Occupational Safety and Health Administration Proposed Delay of Effective Date; Request for Comments on  Occupational Injury and Illness Recording and Reporting Requirements.  September 4, 2001.    OSHA Docket No. R-02A.  NIOSH policy statements.  Cincinnati, OH:  U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health.
http://mtn.niosh.cdc.gov/eid/rmca/polstmt/PDFDoc/PSZY42E.pdf

NIOSH [2002].  Comments of the National Institute for Occupational Safety and Health on the Occupational Safety and Health Administration Proposed Delay of Effective Dates; Request for Comment  Occupational Injury and Illness Recording and Reporting Requirements.  August 30, 2002.    OSHA Docket No. R-02B.  NIOSH policy statements.  Cincinnati, OH:  U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health.
http://dockets.osha.gov/vg001/V028A/00/78/04.PDF

_________________

[47] ACOEM Noise and Hearing Conservation Committee. [2003] ACOEM evidence-based statement: noise-induced hearing loss. Journal of Occupational Environmental Medicine 45(6):579-581.

[48] U.S. Army Fact Sheet 51-002-0903. Occupational Ototoxins and Hearing Loss.
http://chppm-www.apgea.army.mil/documents/FACT/51-002-0903.pdf).

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