HEARING CONSERVATION ON FRONT LINE OF MILITARY AUDIOLOGY INITIATIVES
By Abigail Shoemaker
Current initiatives in military audiology include the growth of infant hearing screening efforts, progress toward implementing an AuD program for government-affiliated clinicians, and the provision of service delivery to remote Alaskan villages.
In addition, military audiologists from the Army, Air Force and Navy are developing new software to enhance the efficacy of hearing conservation programs. The Evaluating Auditory Readiness Application (EAR3-A), using Windows 95/NT from Microsoft, is expected to be up and running next year.
The new software "represents the common practices among the three services for completing hearing testing and management," stated Leeann Domanico, MS, CCC-A, functional manager of the EAR3-A project and a member of the Department of Defense (DoD) Hearing Conservation Working Group at the U.S. Army Center for Health Promotion and Preventive Medicine (USACHPPM), in Aberdeen Proving Ground, MD.
EAR3-A will facilitate the audiological testing of personnel in all three branches. The new software will be used with military hearing conservation programs operated worldwide. Currently more than 3 million audiological records have been collected in the database of the Army Hearing Conservation Program (HCP) since its implementation in the 1980s. The database maintained by the Air Force contains more than 4 million records.
The Navy and Marine Corps currently do not have a consolidated repository for their data, but do collect data to meet reporting requirements. Using the EAR3-A software will allow the creation of a database.
EAR3-A will be installed at approximately 465 new data collection sites for the Army, 300 for the Air Force, and 300 for the Navy.
Users of the EAR3-A software will send collected data to a yet undetermined central repository where it will be analyzed and compared for service-wide and installation-specific management indicators. Depending on the results, audiologists may conduct on-site visits to assist in implementing hearing conservation techniques.
In developing the EAR3-A software, the services have adopted common business practices. For example, the Army and Air Force have modified their criteria for measuring standard threshold shifts (STS) to coincide with those of the Navy. While the Army and Air Force test for a 10 dB average shift at 2000, 3000 and 4000 Hz as defined by the Occupational Safety and Health Administration (OSHA), the Navy uses the OSHA STS criteria plus a change of 15 dB STS at 1000, 2000, 3000 Hz and 4000 Hz.
This combined criteria identifies early cases of noise-induced hearing loss that would be missed under the criteria of OSHA, stated Maj. Theresa Schulz, PhD, CCC-A, U.S. Air Force executive manager for the Joint Service Hearing Conservation program at USACHPPM and a member of the DoD Hearing Conservation Working Group.
In cases where service-specific requirements must be maintained, the EAR3-A software allows the flexibility to account for those differences.
The EAR3-A software and consolidated business practices should result in cost savings by reducing the need for additional training of personnel and duplication of services, Domanico said. "One installation can do testing for all three services."
The effectiveness of the U.S. Army Hearing Conservation Program is evidenced by statistics from the DoD Working Group and the Medical College of Virginia in Richmond that show a reduction in the incidence of severe hearing loss among Army personnel since 1974. Under contract with the DoD, Tilahun Adera, MD, an epidemiologist at the medical college, is analyzing the Army database to determine a way to evaluate program effectiveness.
"Preliminary data have shown improvement," stated Doug Ohlin, PhD, CCC-A, program manager of the U.S. Army Hearing Conservation Program at USACHPPM and chair of the DoD Working Group. "We have found significant improvement in hearing that appears to correlate with a vigorous hearing conservation program with the commission of 75 military audiologists."
Enlisted Army personnel are rated based on profiles that range from little or moderate hearing loss (H-1 and H-2) to a severe hearing loss (H-3 and higher) that interferes with job performance or combat situations.
A soldier with an H-1 profile has fairly normal hearing, with an average level of no more than 25 dB HL in each ear. An H-2 profile signifies a mild loss of no more than 30 dB HL, and any soldier with a severe hearing loss (40 dB HL or greater) faces the possibility of removal from a position.
According to Dr. Ohlin, 24 percent more enlisted soldiers in armor, artillery and infantry branches had H-1 profiles in 1994 than in 1974. These results add up to savings of approximately $500 million in retraining and replacement costs. The 14.8 percent drop in cases of significant hearing loss translates into "10,000 soldiers you don't have to take away from a job or boot out of the Army," he said.
"The main concern in a hearing conservation program is to look at noise-induced hearing loss," stated Dr. Schulz, "but we are remiss if we don't also note other medical problems," such as acoustic tumors.
Air Force research has established test criteria of 25 dB between ears at any two consecutive frequencies to identify individuals with possible acoustic tumors or other medical pathology ("Industrial Hearing Conservation and Cerebellopontine Angle Tumors,"Ear and Hearing, in press). The 25 dB criteria will be included in the EAR3-A software.
Another initiative in military audiology is in the area of infant hearing screening.
Military hospitals with screening programs have reported a screening rate of approximately 50 percent of babies born to families of military personnel. That figure is up from just 4 percent when the programs began in 1993, stated Donna MacNeil, MA, CCC-A, coordinator of the Pediatric Audiology Program at the Army Audiology and Speech Center, Walter Reed Army Medical Center, in Washington, DC.
Nine military hospitals across the country have universal infant hearing screening programs in place. Eight conduct the screenings before the baby is discharged, while the hospital at the Ft. Hood Army Base in Killeen, Texas, assesses infants after discharge through an outpatient program that was implemented this spring. Ft. Hood has the largest birth rate of any military hospital, MacNeil noted, with more than 3,000 births per year.
The Army operates 12 other programs that offer screening to high-risk newborns and infants born at neighboring civilian hospitals on an outpatient basis. "We have a good return rate for military personnel coming back for follow-up appointments," the audiologist said.
All of the screening programs utilize otoacoustic emissions (OAE) testing. Some offer distortion product OAE (DPOAE), while most use transient-evoked OAE (TEOAE) testing.
Of the nearly 17,000 infants screened at military hospitals to date, 43 have been identified with permanent hearing loss. While the national average of infants with hearing loss is about three per 1,000 healthy infants and six per 1,000 when at-risk infants are included, the rate among military personnel is only 2.4 per 1,000.
MacNeil attributes this low figure to the overall good health of military personnel and the availability of good prenatal care. Heredity may be a contributing factor, because people with a significant hearing loss are not admitted to the service.
The infant hearing screening programs have been successful to date, but "we are constantly fighting for funding," MacNeil said. "The individual audiologists deserve a lot of credit for the success of program operation within the confines of the budget at each hospital."
Military audiologists must gain support for the program from their commanding officer, who is in charge of petitioning for funding.
A key source for monetary funding and equipment for hearing screening programs is the Army Exceptional Family Member Program, based in Washington, DC, which provides early intervention services to military personnel who have children with disabilities.
"The program helped us by supplying some of the early screening sites with equipment, and they have been supportive of the program," MacNeil observed. "We owe a lot of gratitude to them."
The reach of military audiology extends to Alaska, where audiological services were provided to civilians in the villages of Aniak and Quinhagak, located along the Bering Sea in the southwestern area of the state. A military audiologist visited the region for two weeks earlier this year to provide services and to help itinerant audiologists.
CDR. M. Victor Berrett, PhD, a Navy reservist from Chesapeake, VA, has traveled to Alaskan villages twice over the past two years as part of a tri-service mission with the Army, Navy and Marine Corps and the Alaska Air National Guard. A medical team plans to visit another region next year.
"Eskimos have a high incidence of middle ear disease and eardrum perforation," Dr. Berrett said, "and we see a lot of noise-induced hearing loss from guns, snowmobiles and chainsaws. We see candidates for amplification and often see people who need an otologist or otolaryngologist."
On the first of these missions, he worked in conjunction with an ENT team to offer additional hearing health care and recommendations to itinerant audiologists and otolaryngologists who fly to remote Alaskan villages to provide care.
"It is almost impossible," he said, for itinerant audiologists to provide complete audiological services over such a large area in that harsh environment. Many times the only way in or out of a village is by plane, snowmobile or boat.
Another challenge is overcoming language and cultural barriers to achieve accurate test results. Many patients do not use eye contact and raise their eyebrows for "yes" and wrinkle their nose for "no," Dr. Berrett reported.
Limited equipment also is a hindrance, he said. "Usually we only have what we can take with us."
The missions provide clinicians and reserve medical personnel with good training for conducting audiological tests and treatment in the field.
Brian Walden, PhD, CCC-A, executive director of the Joint Services/Department of Veterans Affairs AuD Steering Committee, said the committee is getting closer to implementing an AuD program for government-affiliated audiologists.
By next June the committee expects to award funds to at least one university to develop an AuD distance learning program. The goal is to fund at least one other program as well.
"We hope that by the spring of 1998 we will be in a position to select one or more universities to develop a distance learning-based AuD program for government audiologists," said Walden, on staff at Walter Reed Army Medical Center. Ideally, the program would begin in September of 1999.
At present the main focus of the committee is to generate enough money to fund more than one university AuD program in order to reach more practicing audiologists. The Henry M. Jackson Foundation for the Advancement of Military Medicine (HMJF), in Rockville, MD, was selected to issue the request for proposals (RFPs) and conduct the fundraising campaign. RFPs were sent to 129 universities with a deadline of Dec. 12.
Federal regulation mandates that the military cannot request program funds from the commercial sector.
HMJF acts as a neutral third party in soliciting funds for medically-related military endeavors, explained Bryce Redington, PhD, special fund project director for HMJF and the AuD initiative. "Our foundation is a facilitator of military medicine."
HMJF has appealed to approximately 30 companies and organizations, including hearing aid manufacturers, in an effort to increase funding options.
The maximum budget for each university proposal is $250,000.
Once the university programs are in place, Dr. Redington said, "The AuD will enhance the stature of government-based audiologists."
For More Information
M. Victor Berrett, 200 Medical Pkwy., Ste. 303, Chesapeake, VA 23320; (757) 547-9714, ext. 325; or e-mail: email@example.com
Leeann S. Domanico; Douglas Ohlin, PhD; Maj. Theresa Schulz, PhD; and LCDF. Anne Shields, PhD, U.S. Army Center for Health Promotion and Preventive Medicine, Attn: MCHB-DC-CHC, 5158 Blackhawk Rd., Aberdeen Proving Ground, MD 21010-5422; (410) 671-3797
Donna MacNeil, Army Audiology and Speech Center, Walter Reed Army Medical Center, Washington, DC 20307-5001; (202) 782-8586
Bryce Redington, PhD, Henry M. Jackson Foundation for the Advancement of Military Medicine, 1401 Rockville Pike, Ste. 600, Rockville, MD; (301) 424-0800; e-mail: firstname.lastname@example.org; Internet: http://www.hjf.org
Brian Walden, PhD, Army Audiology and Speech Center, Walter Reed Army Medical Center, Washington, DC 20307-5001; (202) 782-8601