Journal of Occupational and Environmental Hygiene

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Evaluating the potential impact of ototoxicant

exposure on worker health

Cody Beaver & Jennifer Schneider

To cite this article: Cody Beaver & Jennifer Schneider (2023) Evaluating the potential impact of
ototoxicant exposure on worker health, Journal of Occupational and Environmental Hygiene,
20:11, 520-535, DOI: 10.1080/15459624.2023.2240874

To link to this article: https://doi.org/10.1080/15459624.2023.2240874

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Published online: 05 Sep 2023.

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JOURNAL OF OCCUPATIONAL AND ENVIRONMENTAL HYGIENE
2023, VOL. 20, NO. 11, 520–535
https://doi.org/10.1080/15459624.2023.2240874

Evaluating the potential impact of ototoxicant exposure on worker health

Cody Beaver and Jennifer Schneider
Collaboratory for Resiliency and Recovery, Rochester Institute of Technology, Rochester, New York, USA

ABSTRACT KEYWORDS
Occupational exposure to ototoxicants, substances that can cause hearing loss alone or Hearing loss; ototoxicity;
exacerbate hearing loss when exposure occurs in combination with noise, is a workplace noise; OSHA; ACGIH; NIOSH
hazard that is poorly understood. A review of existing research indicates that some solvents
and heavy metals may be ototoxic, but few studies have attempted to estimate the impact
of ototoxicant exposure on the United States worker population. Researchers examined
trends in workplace exposure to ototoxicants among workers in the United States by com-
paring exposure data collected by the Occupational Safety and Health Administration
against worker hearing loss data provided by the Bureau of Labor Statistics (BLS) for 2012–
2019. The study found that the noise exposure data was strongly correlated to the hearing
loss data using Pearson’s correlation (p < .001), confirming that the exposure data collected
by OSHA is predictive of the risk of occupational illness as reported by BLS. Chi-square ana-
lysis indicates that reported hearing loss was more common among industry subsectors
with exposure to ototoxicants than those without exposure to ototoxicants. These findings
suggest that workers with coexposure to ototoxicants and noise may be at a higher risk of
experiencing hearing loss than those exposed to noise alone, and action should be taken to
minimize this risk.

Introduction cause of OHL, and it is estimated that up to 18% of

Hearing loss continues to be a significant burden on
worker health in the United States. In 2019 alone,
16,900 work-related hearing loss cases were reported
in the United States, representing approximately 10%
of all work-related illnesses (BLS 2020a). Occupational
hearing loss (OHL) is believed to be a substantial
source of hearing loss in the United States.
Researchers suggested in a 2008 study that OHL is
responsible for nearly 24% of hearing loss in the
United States, which currently affects approximately
11.4% of the public (Tak and Calvert 2008). The
potential adverse effects of hearing loss are numerous,
including difficulty communicating with coworkers
and family members and increased potential for injury
resulting from an inability to hear alarms or equip-
ment noises in the workplace. Extended impacts of
hearing loss include reduced job performance in com-
pleting complex tasks, decreased quality of life, and
lower income and higher medical costs (Themann
and Masterson 2019). Workplace exposure to exces-
sive noise is generally considered to be the primary
workers exposed to excessive noise in the United
States will develop hearing loss at some point in their
careers (Tak et al. 2009; Masterson et al. 2013).
The Occupational Safety and Health Administration
(OSHA) has established requirements for general industry
to identify hazardous noise and control hearing loss in
the workplace, found in 29 CFR 1910.95 Occupational
noise exposure. Initially established in 1971, the standard
was formally amended to include the requirement for a
hearing conservation program in 1981, which was final-
ized in 1983 (OSHA 1983; Middendorf 2004). Under the
rule, if any employees are exposed to hazardous levels of
noise in the workplace (defined as the equivalent of 85
dBA or higher for 8 hr), the employer must establish a
baseline audiogram to monitor the employee’s hearing
annually so that changes in the employee’s hearing
thresholds over time can be compared to baseline and
monitored for early identification of hearing loss. OSHA’s
noise standard also requires employers to record cases of
work-related hearing loss as recordable illnesses on the
OSHA 300 Log, to provide training and protective

CONTACT Cody Beaver cb2680@rit.edu Collaboratory for Resiliency and Recovery, Rochester Institute of Technology, Rochester, New York, USA.
ß 2023 The Author(s). Published with license by Taylor & Francis Group, LLC.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/), which permits
unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. The terms on which this article has been published allow the
posting of the Accepted Manuscript in a repository by the author(s) or with their consent.

equipment to employees included in the hearing conser-
vation program, to monitor the workplace for hazardous
noise regularly, and to maintain records collected under
these requirements (OSHA 1983). However, the OSHA
noise standard does not consider other workplace expo-
sures that could contribute to occupational hearing loss,
including exposure to ototoxic substances (Themann and
Masterson 2019). Research has also noted that the defin-
ition of a Standard Threshold Shift (STS – the standard’s
indicator of OHL, which is defined as a hearing threshold
change of 10 dB or more at 2,000, 3,000, and 4,000 hertz
in one or both ears) may not fully capture hearing loss
that occurs due to exposure to ototoxic substances, as the
STS focuses only on specific frequencies and identifies
28–36% fewer cases of occupational hearing loss than
more recent definitions proposed by the National
Institute of Occupational Safety and Health (NIOSH
1998; Masterson et al. 2014; Blair et al. 2022).
Ototoxicants in the workplace
Ototoxic substances, or “ototoxicants,” are chemical
substances that may damage the auditory and vestibu-
lar systems. The list of known or suspected ototoxi-
cants is diverse, spanning certain pharmaceuticals
(including some antibiotics, antineoplastics, and diu-
retics), solvents, asphyxiants, nitriles, and heavy metals
(Campo et al. 2009). Among ototoxicants, solvents
and heavy metals appear to be those most relevant in
an occupational setting (Campo et al. 2013; Rosati
and Jamesdaniel 2020). Workers are most likely to be
exposed to ototoxicants in manufacturing sectors
(including manufacturing of furniture, chemicals, oil/-
gas, paint, plastics, and machinery), as well as the
mining, agriculture, maritime, and construction sec-
tors (which are typically not governed by the OSHA
general industry standards) (OSHA 2018). However,
managing occupational exposure to ototoxicants is dif-
ficult because the level of exposure at which hearing
loss begins is largely unknown. It is also suspected
that coexposure to multiple ototoxicants and to oto-
toxicants and noise together may further increase the
potential for hearing loss (Campo et al. 2009).
Existing research on ototoxicants consists almost
entirely of cross-sectional studies, which may identify
ototoxic effects but cannot establish a dose-response
relationship, and epidemiological studies using animal
data, which can identify an unsafe exposure level but
may not accurately reflect the combination of factors
present in an occupational setting that could augment
the effects of ototoxicant exposure (Campo et al. 2013;
Clerc and Pouyatos 2022).
JOURNAL OF OCCUPATIONAL AND ENVIRONMENTAL HYGIENE 521
While dose-response relationships have not been
established for most individual ototoxicants, several
studies have attempted to classify chemicals as ototox-
icants based on existing research. A report by the
European Agency for Safety and Health at Work
(2009) and a study by Vyskocil et al. (2012) have
applied a Weight of Evidence methodology, which
considers the relative strength of evidence (such as
animal studies vs. human studies) to determine
whether certain substances show evidence of ototox-
icity. Beginning in 2019, the American Conference of
Governmental Industrial Hygienists (ACGIHV), which
R
also uses a Weight of Evidence methodology in devel-
oping threshold limit values (TLVsV), which are occu-
R
pational exposure limits (OELs) for exposure to
chemical substances, identified certain ototoxicants
using the “OTO” designation (ACGIH 2020). A selec-
tion of ototoxicants identified by EU-OSHA, Vyskocil
et al. (2012), and ACGIH (2023) is provided in Table
1. OSHA has published OELs called Permissible
Exposure Limits (PELs) for most substances identified
in Table 1, but these OELs were not established based
on the potential for ototoxicity and, therefore, may
not prevent hearing loss (Masterson et al. 2013).
Solvent use is a common source of workplace
exposure to ototoxicants. In a 2019 study of
Australian workers, researchers found that an esti-
mated 41.9% of the workforce was exposed to ototoxi-
cants, the most common of which were toluene,
xylene, ethylbenzene, n-hexane, and styrene
(Lewkowski et al. 2019). Solvents appear to target
cochlear hair cells in the inner ear, the loss of which
is irreversible, and may also cause damage to the audi-
tory nervous system (Campo et al. 2009). While sev-
eral solvents appear to be ototoxic on their own,
including toluene, styrene, and ethylbenzene, most
research has focused on exposure to solvent mixtures
as workers are most commonly exposed to several sol-
vents at once (Vyskocil et al. 2012; Choi and Kim
2014; Pleban et al. 2017; Fernandes da Silva et al.
2018). A 2017 meta-analysis of studies related to occu-
pational exposure to ototoxicants found that workers
exposed to a mixture of solvents were twice as likely
to develop hearing loss as those exposed to noise
alone and that the risk of hearing loss increased as the
length of exposure, a weighted dose of exposure, and
the number of solvents in a mixture increased
(Hormozi et al. 2017). It has also been suggested that
exposure to ototoxicants at levels below the OELs may
nonetheless result in an increased risk of hearing loss
(Hormozi et al. 2017; Pleban et al. 2017).
522 C. BEAVER AND J. SCHNEIDER

Table 1. Weight-of-evidence summaries for potentially ototoxic substances and respective exposure limits.
Vyskocil et al. Campo et al. ACGIH TLVs Selected OSHA
Chemicala (2012) (2009) (2023) for Study PEL (TWA)b ACGIH TLV-TWAc
3
Arsenic SUS 0.01 mg/m 0.01 mg/m3
Cadmium SUS 0.005 mg/m3 0.01 mg/m3
Carbon disulfide N OTO 20 ppm 1 ppm
Carbon monoxide N OTO 50 ppm 25 ppm
Ethanol N – –
Ethylbenzene SUS OTO OTO X 100 ppm 20 ppm
Germanium dioxide OTO – –
n-Heptane N N 500 ppm 400 ppm
n-Hexane SUS OTO X 500 ppm 50 ppm
Lead/Lead compounds OTO OTO X 0.05 mg/m3 0.05 mg/m3
Mercury compounds N OTO 0.1 mg/m3 0.01 mg/m3
Methylene chloride N 25 ppm 50 ppm
n-Propylbenzene OTO – –
Styrene OTO OTO OTO X 100 ppm 10 ppm
Toluene OTO OTO OTO X 200 ppm 20 ppm
Trichloroethylene OTO OTO X 100 ppm 10 ppm
Trimethyl tin N OTO 0.1 mg/m3 0.1 mg/m3
Xylenes (p-xylene) SUS OTO OTO X 100 ppm 20 ppm
a
Table Legend:

OTO ¼ Designated as Ototoxic.

SUS ¼ Suspected to be Ototoxic.

N ¼ Determined to be not Ototoxic.

Blank ¼ Not listed in study or reference.
b
Permissible Exposure Limit (PEL) as an 8-hr Time-Weighted Average (TWA) provided by the Occupational Safety and Health Administration (OSHA).
c
Threshold Limit Value (TLV) as an 8-hr Time-Weighted Average (TWA) as determined by the American Council of Governmental Industrial Hygienists
(ACGIH).

Other workplace ototoxicants include certain heavy
metals and asphyxiants. Heavy metals appear to cause
hearing loss by damaging the nervous system, disrupt-
ing the brain’s ability to receive and process auditory
signals (Campo et al. 2009). Lead is the heavy metal
with the most evidence of ototoxicity and is also pre-
sent outside of the workplace (e.g., lead in drinking
water from lead pipe contamination, lead-based paint)
(Rosati and Jamesdaniel 2020). Other suspected oto-
toxicants include germanium dioxide, tin and organic
tin compounds, and certain mercury compounds
(Campo et al. 2009). Asphyxiants, such as carbon
monoxide, may cause hearing loss in certain condi-
tions due to the loss of oxygen to cochlear cells
(Campo et al. 2009).
Coexposure to both ototoxicants and noise is of
particular concern. Research has found that many oto-
toxicants interact with noise during coexposure, either
increasing the impact of noise on the ear (potenti-
ation) or causing damage to hearing greater than
expected from each exposure individually (synergism).
One meta-analysis of ototoxicant studies found that
coexposure to solvent mixtures and noise raised the
risk of experiencing hearing loss three-fold (Hormozi
et al. 2017). Another study of Egyptian workers at sev-
eral facilities found that workers co-exposed to oto-
toxicants and noise were more likely to develop
hearing loss than workers exposed only to noise, even
though the average duration of exposure was nearly
eight years less for the co-exposed group than the
noise-only group and the exposures were at or below
the regulatory OELs (Metwally et al. 2012). The
potential for coexposure to be synergistic or potentia-
tive is especially concerning as it could result in
adverse health effects (such as hearing loss) at expo-
sures that otherwise appear to be acceptable. This is
confirmed by several studies conducted on
Department of Defense personnel, which noted that
coexposure to metals and/or solvents with noise
increased the likelihood that hearing loss would occur,
even though the exposures were below the PELs
(Schaal et al. 2017; Schaal et al. 2018).
Controlling occupational exposure to ototoxicants,
especially in the presence of noise, is very difficult due
to the complexity of workplace exposure and the lack
of knowledge of “ototoxic thresholds,” or concentra-
tions at which exposure to a substance begins to cause
hearing loss. As described in the EU-OSHA report by
Campo et al. (2009), it is difficult to draw conclusions
on the dose-response relationship between ototoxi-
cants and hearing loss due to the variation of study
conditions and possible exposures in different work-
places. However, there is evidence that the risk of
hearing loss can be mitigated by minimizing ototoxi-
cant exposure. Sch€aper et al. (2008) found no differ-
ence between exposure to noise only and coexposure
to toluene and noise, concluding that toluene was
controlled to a low enough level to prevent ototoxicity
as the average toluene exposure was below 50 ppm
and the average noise exposure was approximately 82

dBA. Juarez-Perez et al. (2014) found that, while hear-
ing loss was present in the studied population, the
prevalence was much lower than in similar studies,
which was likely because both noise and solvent expo-
sures, on the whole, were below regulatory OELs for
all workers monitored. Indeed, for those substances
that ACGIH has designated as ototoxicants, the TLVs
are generally five to 10 times lower than the respective
PELs regulated by OSHA. While research continues,
ototoxic threshold concentrations for exposure to
individual substances may be unknown, especially for
employees who are also exposed to noise. These
examples suggest that lowering exposure to ototoxi-
cants to the greatest extent possible may be the best
defense against hearing loss. There is also evidence
that controlling exposure to ototoxicants is most
important at noise exposures near or below 90 dBA.
As noise exposures increase, noise becomes the pre-
dominant cause of hearing loss, even in the presence
of ototoxicants (Schaal et al. 2017).
Purpose
This study aims to examine if industries with expos-
ure to ototoxicants have an increased risk of hearing
loss compared to industries without exposure to oto-
toxicants, using chemical exposure data provided by
OSHA and hearing loss data provided by the Bureau
of Labor Statistics.
Methods
Sources of data
The data used in this analysis was sourced from the
United States federal government. Data were sorted
according to the North American Industry
Classification System (NAICS) number throughout
the study. NAICS is an economic classification system
that indicates the industry subsector (ranging from
2–6 digits, based on the desired specificity) where the
exposure occurred. Three-digit NAICS codes were
selected for this analysis, corresponding to the indus-
try subsector level. Basic employment information
(the number of employees and establishments in
2019) was collected from the Bureau of Labor
Statistics (BLS) website and is provided in Table 2.
Occupational noise and chemical exposure data, as
collected by OSHA during workplace inspections
between 2012 and 2020, were provided by OSHA via
a Freedom of Information Act request (FOIA request
no. 2021-F-08919, filed on May 13, 2021; OSHA
2021). This data included the sampling date, analyte,
JOURNAL OF OCCUPATIONAL AND ENVIRONMENTAL HYGIENE 523
sample number, exposure concentration (measured as
ppm for solvents or mg/m3 for lead), exposure type,
and sample duration. Other information reported for
each sample included the establishment name and
NAICS code, any emphasis campaigns (focused efforts
at the federal or state level to collect samples of spe-
cific exposures, industries, or job functions) that may
be connected to the sample, relevant OEL, and job
title. The years 2012–2019 were selected due to limita-
tions in the availability of OSHA chemical and noise
exposure data related to the transition from the
Integrated Management Information System (IMIS) to
the OSHA Information System (OIS) in 2011. Data
from 2020 were excluded to avoid bias introduced by
changes in working or OSHA inspections and data
collection due to the COVID-19 pandemic.
Data related to work-related cases and incidence of
hearing loss were obtained from the annual Survey of
Occupational Injuries and Illnesses Data published by
BLS (BLS 2013, 2014, 2015, 2016, 2017, 2018, 2019b,
2020b). These reports are published annually, based
on data reported to OSHA on occupational injuries
and illnesses from the previous year. The supplemen-
tal news release Table SNR08 provides rates of hearing
loss (meeting the OSHA definition of a Standard
Threshold Shift) and other occupational illnesses per
10,000 workers categorized by the NAICS code for
each year from 2012–2019. Each year of data was
used individually for this analysis, and the average
rates of hearing loss over this period are provided in
Table 3.
Selection of ototoxicants
The substances shown in Table 1 were selected for
review in this research-based, in part, on a review of
the literature (Campo et al. 2009; Vyskocil et al. 2012
which both used a weight of evidence methodology;
ACGIH 2023) and based on substances for which
exposure monitoring was available from OSHA.
Campo et al. (2009) and Vyskocil et al. (2012)
reviewed existing animal and human research and
classified substances as an ototoxicant, suspected oto-
toxicant, or not an ototoxicant based on the number
and type of studies (animal vs., human) and the rela-
tive strength of the findings. Substances that did not
have strong evidence in any reviewed study to be des-
ignated as an ototoxicant (or as a suspected ototoxi-
cant) were not considered in this research effort. Of
the 18 substances reviewed, 13 were formally desig-
nated as ototoxic by at least one source. Five of the
remaining substances (carbon disulfide, germanium
524 C. BEAVER AND J. SCHNEIDER

Table 2. NAICS information and Summary Table (BLS 2019a).

Number of Establishments Number of Employees
NAICS Code Industry Subsector Description (2019) (2019 Average)
112 Animal Production 26,553 265,193
212 Mining (except Oil and Gas) 7,049 191,206
213 Support Activities for Mining 18,510 342,235
221 Utilities 18,860 548,712
236 Construction of Buildings 225,276 1,660,005
237 Heavy and Civil Engineering Construction 51,912 1,070,287
238 Specialty Trade Contractors (General Industry) 523,432 4,721,184
311 Food Manufacturing 34,708 1,633,572
312 Beverage and Tobacco Product Manufacturing 13,053 287,284
313 Textile Mills 2,671 108,077
314 Textile Product Mills 6,456 112,453
315 Apparel Manufacturing 6,653 108,416
316 Leather and Allied Product Manufacturing 1,381 27,474
321 Wood Product Manufacturing 14,874 405,851
322 Paper Manufacturing 5,369 364,546
323 Printing and Related Support Activities 28,117 423,311
324 Petroleum and Coal Products Manufacturing 2,334 113,076
325 Chemical Manufacturing 19,424 849,032
326 Plastics and Rubber Products Manufacturing 13,260 730,565
327 Nonmetallic Mineral Product Manufacturing 16,637 416,591
331 Primary Metal Manufacturing 5,479 386,363
332 Fabricated Metal Product Manufacturing 58,522 1,480,500
333 Machinery Manufacturing 30,944 1,123,635
334 Computer and Electronic Product Manufacturing 20,769 1,073,336
335 Electrical Equipment, Appliance, and Component Manufacturing 8,334 400,602
336 Transportation Equipment Manufacturing 15,235 1,731,176
337 Furniture and Related Product Manufacturing 17,658 384,825
339 Miscellaneous Manufacturing 33,143 615,473
423 Merchant Wholesalers, Durable Goods 301,252 3,196,542
424 Merchant Wholesalers, Nondurable Goods 168,231 2,157,409
425 Wholesale Electronic Markets and Agents and Brokers 145,851 529,996
441 Motor Vehicle and Parts Dealers 117,640 2,024,832
442 Furniture and Home Furnishings Stores 46,849 470,918
444 Building Material and Garden Equipment and Supplies Dealers 69,017 1,292,446
445 Food and Beverage Stores 146,161 3,059,858
446 Health and Personal Care Stores 111,179 1,044,197
448 Clothing and Clothing Accessories Stores 120,395 1,299,874
451 Sporting Goods, Hobby, Book, and Music Stores 48,753 548,221
452 General Merchandise Stores 64,649 3,027,793
453 Miscellaneous Store Retailers 112,932 843,349
454 Nonstore Retailers 55,327 576,032
481 Air Transportation 5,980 505,340
484 Truck Transportation 141,139 1,528,166
488 Support Activities for Transportation 47,529 743,527
491 Postal Service 938 7,348
493 Warehousing and Storage 18,736 1,249,145
532 Rental and Leasing Services 55,243 579,043
541 Professional, Scientific, and Technical Services 1,265,969 9,542,312
561 Administrative and Support Services 538,734 8,836,614
562 Waste Management and Remediation Services 29,606 447,873
611 Educational Services 127,507 2,937,234
621 Ambulatory Health Care Services 614,776 7,685,316
622 Hospitals 10,904 5,125,766
624 Social Assistance 931,702 4,012,063
711 Performing Arts, Spectator Sports, and Related Industries 60,933 514,461
713 Amusement, Gambling, and Recreation Industries 86,750 1,740,461
722 Food Services and Drinking Places 654,217 11,972,247
811 Repair and Maintenance 231,285 1,343,563
812 Personal and Laundry Services 229,628 1,526,217
N/A Other industry subsectors not included in this analysis 1,960,691 24,284,752
Total 9,777,116 126,227,895
Industry Subsectors Included in this Analysis 7,816,425 101,943,143
Industry Subsectors Included in this Analysis (%) 79.9% 80.8%
 JOURNAL OF OCCUPATIONAL AND ENVIRONMENTAL HYGIENE 525

Table 3. Comparison of BLS hearing loss data against OSHA noise exposure data (2012–2019, manufacturing industry
subsectors).
NAICS Code Industry Subsector Description Total Records Average Noise Level (dBA) Average Rate of Hearing Loss
311 Food Manufacturing 464 93.2 17.4
312 Beverage and Tobacco Product Manufacturing 64 90.3 10.6
314 Textile Product Mills 32 88.0 5.0
321 Wood Product Manufacturing 1267 93.8 22.4
322 Paper Manufacturing 98 88.2 13.9
323 Printing and Related Support Activities 87 85.4 5.6
325 Chemical Manufacturing 168 88.6 3.5
326 Plastics and Rubber Products Manufacturing 602 90.1 9.6
327 Nonmetallic Mineral Product Manufacturing 706 89.4 11.7
331 Primary Metal Manufacturing 565 97.7 20.8
332 Fabricated Metal Product Manufacturing 1594 91.0 11.3
333 Machinery Manufacturing 295 90.9 7.7
334 Computer and Electronic Product Manufacturing 39 92.8 1.1
336 Transportation Equipment Manufacturing 342 89.5 11.5
337 Furniture and Related Product Manufacturing 308 86.2 9.8
339 Miscellaneous Manufacturing 79 88.8 4.1

dioxide, mercury compounds, n-propylbenzene, and
trimethyl tin) did not have available exposure moni-
toring from OSHA and were eliminated from the
review. Carbon monoxide was also eliminated because
the majority of the available exposure monitoring
were instantaneous data rather than data from a time-
weighted average (TWA) assessment. The remaining
ototoxicants selected for this study (as indicated in
Table 1) are: ethylbenzene, n-hexane, lead, styrene,
toluene, trichloroethylene, and xylenes.
Data preparation
While the BLS data collected did not need to be pre-
pared for this analysis, the OSHA noise and chemical
exposure data contained some data that was incom-
plete (indicated as “draft” or otherwise not final),
erroneous (e.g., blank exposure results), reported in
incorrect units (such as percent dose, when the units
should be ppm or mg/m3), or not applicable to this
study. Other studies using OSHA noise exposure data,
namely Middendorf (2004) and Sayler et al. (2019),
also excluded or transformed some data. This study
followed a similar approach. All data was maintained
and analyzed using Microsoft Excel for Microsoft 365
MSO (Version 2202 Build 16.0.14931.20128).
Noise exposure data
The noise exposure data obtained from OSHA was
provided in Microsoft Excel in 2-year increments
(2011–2012, 2013–2014, 2015–2016, 2017–2018, and
2019–2020). First, the years 2012 through 2019 were
combined into one sheet, yielding 109,197 rows of
data. Then, the noise exposure data were separated
based on which measurement criteria were used dur-
ing sample collection to interpret data presented as a
dose percentage. The Action Level (AL) criteria, which
determines whether a hearing conservation program
must be established, uses a sound level threshold of
80 dBA and a 100% dose of 85 dBA during measure-
ment. The PEL criteria, by contrast, determines
whether an employee’s exposure exceeds the regula-
tory OEL and uses a sound level threshold of 90 dBA
and a 100% dose of 90 dBA during measurement.
The data set included the substance identification
number (either “8110” for PEL measurements or
“8111” for AL measurements), the Exposure Type
(“Dose,” “AL,” or “PEL”), and the applicable OEL (as
85 dBA or 90 dBA); however, the data was not con-
sistently coded. For example, some items coded as
8110 would have the exposure type noted as “Action
Level” or were compared against an OEL of 85 dBA.
The researchers could not discern which was the cor-
rectly noted field and which was incorrectly noted.
For consistency, it was assumed that the substance
selected (8110 for PEL and 8111 for Action Level
measurements) was the correct identifier if the expos-
ure type or OEL did not match the expected values.
This method is similar to that used by Sayler et al.
(2019), which was built upon the method employed
by Middendorf (2004) to filter out data that was
incomplete or inconsistent with this analysis. This
method removed any records that met any of the fol-
lowing criteria: no dose level provided; average sound
pressure level below 60 dBA or above 120 dBA; sam-
ple duration below 6 h (360 min) or above 16 h
(960 min); area samples and any other non-personal
monitoring; measurement units blank or unrelated to
noise (degree, parts per million, or milligrams per
cubic meter); site NAICS code blank; or any substance
other than noise. Records were also removed if the
sampling sheet status was set as “Draft,” “Invalid,” or
526 C. BEAVER AND J. SCHNEIDER
“Ready for lab.” Saylor et al. (2019) did not mention
the sampling sheet status in the data cleaning method.
The data reported as a dose percentage were con-
verted to a full-shift time-weighted average (TWA)
dose using Equation 1.
 
Dose ð%Þ
TWA ¼ 16:61  log10 þ 90 dBA (1)
100%
An evaluation of the noise sampling dataset also
found data that appeared to be duplicated. A review
of the data found that the duplicate records appeared
to be multiple instantaneous readings taken during
the same dosimetry record, which resulted in dupli-
cate exposure records when reported by OIS.
However, because the number of instantaneous read-
ings differed by exposure record, these duplicates
could have misrepresented the dosimetry data col-
lected and introduced bias into the analysis. To avoid
this, duplicate records with the same exposure record
number were eliminated. This reduced the number of
PEL records from 42,346 to 8,319 (a reduction of
80.3%) and the number of AL records from 47,970 to
969 (a 98% reduction).
Chemical exposure data
The data relating to chemical exposure monitoring per-
formed by OSHA was also reviewed to remove any data
inconsistent with this analysis or incompletely entered.
OSHA originally sent a total of 161,849 records. Records
that met the following criteria were removed: monitoring
type was not "personal"; sample sheet status was not
"Final" or "Ready for Exposure Assessment and E.A.
Completed"; sampling time of 0 or greater than 16 h;
exposure concentration was blank; or the OEL was blank.
This reduced the data set to 131,254 records, of which
12,545 were related to ototoxicant exposure.
Data analysis
Evaluating the Compatibility of OSHA and BLS data
The first step in this analysis was to determine
whether the data obtained from OSHA and BLS were
comparable. This is necessary because the collection
methods for these two data sets were different. The
BLS dataset is a collection of injury and illness data
that must be recorded annually by OSHA and there-
fore represents a population rather than a sample. The
OSHA data, by contrast, are collected during OSHA
inspections. As OSHA does not inspect each employer
annually, this dataset represents a sample.
To determine whether the OSHA chemical exposure
data can be compared to the hearing loss data from BLS,
the OSHA noise exposure data was used as a proxy, as it
shares the same sample collection strategy. According to
the OSHA Field Operations Manual and the OSHA
Technical Manual, both noise and chemical samples are
selected by the compliance officer based on a review of
illness and injury records, hazard assessments, and other
documentation provided by the employer that indicates
potential exposure to a chemical or noise hazard (OSHA
2019, 2021). It is also well-established that a causal rela-
tionship exists between exposure to noise and hearing
loss. Therefore, if the OSHA noise exposure data and the
BLS hearing loss data are correlated, then it can be
inferred that the OSHA sample collection strategy—that
is, allowing the compliance officer to make a professional
judgment of potential exposure risk as described above –
is predictive of the risk of adverse health effects. By
extension, the OSHA data for worker exposure to ototox-
icants can then be reliably compared to BLS hearing loss
data for this analysis.
First, the noise exposure data from OSHA and the
hearing loss data from BLS were stratified according to
the NAICS code corresponding to the inspected site.
The PEL noise exposure measurements were selected
due to the larger dataset size after data preparation
and cleaning were performed. The manufacturing
industry was chosen for this analysis because 82% of
all noise samples and 75.8% of all reported hearing
loss cases were from subsectors in the manufacturing
industry, although the manufacturing industry subsec-
tors are 21 out of 92 three-digit industry subsectors
represented in the NAICS code. The average hearing
loss rate (per 10,000 workers) from 2012 through 2019
was determined (as reported in Table 3), and the mean
noise measurement over the same period for each sub-
sector in the manufacturing industry was calculated.
Subsectors with fewer than 24 total measurements
(fewer than three taken each year, on average) were
removed due to insufficient data. Next, the average
hearing loss rate was plotted against the mean noise
exposure measurement, and a Pearson correlation ana-
lysis was performed to determine whether the OSHA
and BLS datasets were correlated. This analysis was
repeated with the median noise measurement for each
industry subsector to determine if the OSHA sampling
method (which may target “worst case” exposures) was
skewing the data by introducing outliers (Table 4).
Comparing ototoxicant exposure and hearing loss
data
The second step of the analysis was to compare the
OSHA data on ototoxicant exposure to the BLS hear-
ing loss data. First, the data were stratified by the

Table 4. Summary of BLS hearing loss data.
Private Industry
Industry Manufacturing
Average Hearing Loss Rate 10.1
(per 10,000 workers)
Average Hearing Loss Case Count 12.5
(thousands)
Percentage of Private Industry Cases 75.8%
Table 5. OSHA Chemical exposure data summary.
Number of Exposure Samples Taken, 2012–2019 131,254
Samples taken under Strategic Programs 46,848
Samples taken under National Emphasis Programs 93,033
Samples taken of Ototoxicants 12,545
Ethylbenzene 485
n-Hexane 76
Lead 7,482
Styrene 1,276
Toluene 2,175
Trichloroethylene 173
Xylene 878
Number of Inspections, 2012–2019 average 9,797
Number of Exposure Samples Taken per Inspection 13.4
NAICS code to determine the number of exposure
samples collected in each industry subsector from
2012 through 2019 and to exclude industry subsectors
without adequate data from further analysis. Industry
subsectors were excluded if fewer than 39 samples, the
equivalent of three average inspections (see Table 5),
were collected over the 8 years. After eliminating
industry subsectors with inadequate data, 59
remained, representing more than 100 million workers
or approximately 81% of the private industry work-
force (see Table 2). The data was then filtered to iden-
tify the 12,545 samples collected for ototoxicant
exposure (see Table 5 for a summary).
Next, the samples were stratified by year, and the
number of total samples, samples over 0, and samples
over the PEL for each selected ototoxicant were
counted and summed for each year. Along with the
BLS hearing loss data for each industry subsector each
year, the ototoxicant data was used to determine
whether each industry subsector identified ototoxicant
exposure and hearing loss for each year of the ana-
lysis. Hearing loss was straightforward—if the hearing
loss rate was greater than 0 for the industry subsector,
it was marked as "Yes" for that year; otherwise, it was
marked as "No." An industry subsector was considered
to have ototoxicant exposure (i.e., marked as "Yes" for
that year) if any samples were over the PEL or if at
least 20% of the samples had measurable exposure
(i.e., a result greater than the limit of detection, LOD).
This criterion was selected because existing research
suggests that coexposure to noise and ototoxicants
below the PEL or TLV may nevertheless result in
JOURNAL OF OCCUPATIONAL AND ENVIRONMENTAL HYGIENE 527
hearing loss. Samples that did not meet these criteria,
including industry subsectors with only 1 sample (lack
(All)
of samples), were marked as "No" for ototoxicant
1.7
exposure in the given year.
16.5 Finally, industry subsectors were subdivided into
100% the following categories: those that had ototoxicant
exposure and reported hearing loss; those that had
ototoxic exposure and did not report hearing loss;
those that did not have ototoxicant exposure but did
– report hearing loss; and those that did not have oto-
35.7%
70.9% toxicant exposure and did not report hearing loss.
9.6% The sum of industry subsectors in each category was
3.9%
0.6% counted for each year and arranged in a matrix for
59.6% Chi-square analysis to be performed. For the analysis,
10.2%
17.3% the null hypothesis was that, for each given year, there
1.4% was no association in hearing loss between the indus-
7.0%
– try subsectors with ototoxicant exposure and those
– without. A p-value of .05 was selected for the analysis.
To ensure that no single ototoxicant was skewing
the results, based on the fact that lead comprised
nearly 60% of the ototoxicant samples collected by
OSHA, the Chi-square analysis described above was
also performed based on exposure results to each
selected ototoxicant individually. As before, the null
hypothesis was that, for each given year, there was no
association in hearing loss between the industry sub-
sectors with exposure to the selected ototoxicant and
those without. A p-value of .1 was chosen for this
analysis because the size of each dataset was smaller.
Qualifying ototoxicant exposure risk by industry
The final step of the analysis was to determine the
risk of ototoxicant exposure by industry qualitatively.
An exposure risk ranking was calculated for each sub-
sector based on three factors calculated from the
OSHA chemical exposure data and the 2019 employ-
ment data provided by BLS: the number of workers
represented per sample of the selected ototoxicants,
the percentage of samples for the selected ototoxicants
which were greater than the limit of detection, and
the percentage of samples for the selected ototoxicants
which were greater than the PEL. Each industry was
ranked in each category from 1 to 59, with 1 repre-
senting the smallest number of employees per sample
or the greatest percentage, respectively. Then, the col-
lective exposure risk ranking was determined by cal-
culating the geometric mean of each risk rank and
ranking the geometric mean values for each industry
from 1 to 59, with 1 being the smallest mean rank
and 59 being the greatest.
Each category was selected to represent one facet of
exposure risk. The number of workers represented by
528 C. BEAVER AND J. SCHNEIDER
each sample collected was chosen to represent the
relative risk from the use of the selected ototoxicants
qualified by the relative size of the industry—a smaller
ratio means that more samples were collected, indicat-
ing a higher risk of exposure (given OSHA’s sample
collection strategy). The percentage of exposures
greater than the LOD represents the risk of overall
exposure to the selected ototoxicants, as a larger per-
centage indicates many of the samples collected iden-
tified exposure. The percentage of exposures greater
than the PEL likewise represents the risk of higher
exposures to the selected ototoxicants. The geometric
mean was selected due to the potential variation
between the rank scores of each category.
Results
Evaluating the Compatibility of OSHA and BLS
data
A chart plotting the average rate of hearing loss
against the mean noise exposure reading is provided
in Figure 1. Sixteen manufacturing industry subsectors
are shown in the chart. The mean noise exposure
ranged from 85.4 in the Printing and Related Support
Activities subsector (NAICS code 323) to 97.7 in the
Primary Metal Manufacturing subsector (NAICS code
331). The rates of hearing loss per 10,000 workers
ranged from 1.0 in the Computer and Electronic
Product Manufacturing subsector (NAICS code 334)
to 21.7 in the Wood Product Manufacturing subsec-
tor. The Pearson correlation test indicated a moderate
positive correlation between the mean noise exposure
and the average rate of hearing loss, r(14) ¼ 0.5959, p
¼ .0149 (see Figure 1). The same analysis performed
using median noise exposure revealed a strong
Figure 1. Comparing average noise exposure (OSHA data) and
average hearing loss for selected industries (BLS data).
positive correlation with the average rate of hearing
loss, r(14) ¼ .8203, p ¼ .0001 (see Figure 2).
Comparing ototoxicant exposure to hearing loss
data
Table 5 provides a summary of the chemical exposure
data provided by OSHA. After applying exclusion cri-
teria, a total of 131,254 samples remained, of which
93,033 (70.9%) were coded under a National
Emphasis Program (NEP) and 12,545 (9.6%) were
samples of the ototoxicants selected for analysis in
this study. Most of the ototoxicant samples collected
were lead (7,482, or 59.6% of the ototoxicant sam-
ples). The next most common sample was toluene,
totaling 2,175 samples. The most sampled industries
included fabricated metal product manufacturing
(31,165 samples collected), primary metal manufactur-
ing (21,603), transportation equipment manufacturing
(12,216), and machinery manufacturing (10,286).
Industries with the broadest ototoxicant sampling
included: printing (24% of all samples were for oto-
toxicants), plastics/rubber manufacturing (23%), furni-
ture manufacturing (21%), and amusement, gambling,
and recreation industries (22%).
For each year, the ratio of industry subsectors with
reported hearing loss to those without reported hear-
ing loss was greater for the group of subsectors with
ototoxicant exposure than the group without ototoxi-
cant exposure. A summary of the Chi-square analyses
for each year of the analysis is provided in Table 6.
The Chi-square analyses for 2014 through 2019
showed that hearing loss was more common among
industries with exposure to ototoxicants than indus-
tries without exposure and were significant at the p <
.05 level. The analyses performed for 2012 and 2013
showed a similar trend to the remaining years, but the
Figure 2. Comparing median noise exposure (OSHA data) and
average hearing loss for selected industries (BLS data).
Table 6. Chi-Square analysis results.a
Year Ethylbenzene n-Hexane Lead Styrene Toluene Trichloroethylene Xylene All Ototoxicants
2012 5 33 v2: 3.0190 2 36 v2: 0.0070 11 27 v2: 0.6991 5 33 v2: 3.0190 9 29 v2: 3.4404 1 37 v2: 0.5622 8 30 v2: 2.7767 15 23 v2: 1.4811
0 21 p: .0823 1 20 p: .9331 4 17 p: .4031 0 21 p: .0823 1 20 p: .0636 0 21 p: .4534 1 20 p: .0956 5 16 p: .2236

2013 11 30 v2: 3.4939 1 40 v2: 0.4466 13 28 v2: 0.0911 9 32 v2: 2.3887 14 27 v2: 3.3582 4 37 v2: 1.8838 16 25 v2: 4.5970 20 21 v2: 2.2596
1 17 p: .0616 0 18 p: .5040 5 13 p: .7628 1 17 p: .1222 2 16 p: .0669 0 18 p: .1699 2 16 p: .0320 5 13 p: .1328

2014 8 34 v2: 1.6225 2 40 v2: 0.0315 18 24 v2: 3.3550 4 38 v2: 1.7368 12 30 v2: 1.8888 1 41 v2: 0.4117 14 28 v2: 1.4517 22 20 v2: 4.0870
1 16 p: .2027 1 16 p: .8592 3 14 p: .0670 0 17 p: .1875 2 15 p: .1693 0 17 p: .5211 3 14 p: .2282 4 13 p: .0432

2015 9 29 v2: 3.4404 4 34 v2: 2.3713 19 19 v2: 2.5434 6 32 v2: 1.5729 15 23 v2: 4.0475 1 37 v2: 0.5622 14 24 v2: 7.3415 21 18 v2: 4.4631
1 20 p: .0636 0 21 p: .1236 6 15 p: .1108 1 20 p: .2098 3 18 p: .0442 0 21 p: .4534 1 20 p: .0067 5 15 p: .0346

2016 12 30 v2: 3.6265 4 38 v2: 1.7368 21 21 v2: .0419 7 35 v2: 3.2147 22 20 v2: 11.000 2 40 v2: 0.8379 16 26 v2: 3.9574 30 12 v2: 4.7363
1 16 p: .0569 0 17 p: .1875 8 9 p: .8378 0 17 p: .0730 1 16 p: .0009 0 17 p: .3600 2 15 p: .0467 7 10 p: .0295

2017 10 32 v2: 2.5641 3 39 v2: 0.0304 17 25 v2: 4.5693 8 34 v2: 0.4560 16 26 v2: 2.3176 1 41 v2: 0.4530 17 25 v2: 4.5693 24 18 v2: 7.6057
1 16 p: .1093 1 16 p: .8615 2 15 p: .0326 2 15 p: .4995 3 14 p: .1279 1 16 p: .5009 2 15 p: .0326 3 14 p: .0058

2018 9 28 v2: 6.3146 2 35 v2: 1.2309 17 20 v2: 4.6392 9 28 v2: 6.3146 13 24 v2: 3.2264 1 36 v2: 0.6048 13 24 v2: 7.1332 23 14 v2: 10.752
0 22 p: .0120 0 22 p: .2672 4 18 p: .0312 0 22 p: .0120 3 19 p: .0725 0 22 p: .4367 1 21 p: .0076 4 18 p: .0010

2019 8 29 v2: 1.5390 2 35 v2: 1.2309 18 19 v2: 5.4765 7 30 v2: 2.4319 12 25 v2: 6.2457 3 34 v2: 1.8793 11 26 v2: 3.4209 20 17 v2: 5.5448
2 20 p: .2148 0 22 p: .2672 4 18 p: .0193 1 21 p: .1189 1 21 p: .0124 0 22 p: .1704 2 20 p: .0644 5 17 p: .0185
Legend:
No. Industries with Exposure and HLNo. Industries with
HL and No Exposure v2: Chi-Square Statistic
No. Industries with Exposure and No HLNo. Industries with
No Exposure and No HLp: p-value
a
Statistically significant results are highlighted in gray. p-value is set at .05 for aggregated ototoxicants and .1 for individual ototoxicants.
JOURNAL OF OCCUPATIONAL AND ENVIRONMENTAL HYGIENE
529
530 C. BEAVER AND J. SCHNEIDER

Table 7. Top quartile industries with ototoxicant exposure risk.

Rank Rank Rank (OTO Samples Mean
Rank NAICS Description Employment (% > LOD) (% > PEL) per Worker) Rank
1 335 Elec. Equip., Appl., and Comp. Mfg. 400,602 9 (62%) 4 (22%) 4 (1,122) 5.24
2 331 Primary Metal Mfg. 386,363 35 (35%) 9 (2%) 1 (257) 6.80
3 237 Heavy and Civil Engineering Const. 1,070,287 14 (57%) 1 (34%) 25 (8,845) 7.05
4 713 Amusement, Gambling, and Rec. Ind. 1,740,461 7 (69%) 3 (24%) 20 (5,258) 7.49
5 337 Furniture and Related Product Mfg. 384,825 6 (75%) 32 (0%) 3 (974) 8.32
6 238 Specialty Trade Contractors (Gen. Ind.) 4,721,184 18 (54%) 2 (25%) 24 (8,126) 9.52
7 316 Leather and Allied Product Mfg. 27,474 2 (100%) 28 (0%) 16 (3,434) 9.64
8 326 Plastics and Rubber Products Mfg. 730,565 8 (66%) 23 (2%) 5 (1,129) 9.73
9 454 Nonstore Retailers 576,032 1 (100%) 27 (0%) 38 (64,004) 10.09
10 562 Waste Mgmt. and Remediation Svcs. 447,873 19 (53%) 7 (15%) 9 (1,653) 10.62
11 325 Chemical Manufacturing 849.032 10 (60%) 12 (7%) 12 (2,542) 11.29
12 332 Fabricated Metal Product Mfg. 1,480,500 38 (28%) 22 (1%) 2 (600) 11.87
13 451 Sporting Goods, Hobby, Book Stores 548,221 13 (58%) 6 (15%) 26 (9,137) 12.66
14 322 Paper Mfg. 364,546 5 (83%) 31 (0%) 22 (6,179) 15.05

trend was not statistically significant. The Chi-square
analysis performed for the selected individual ototoxi-
cants is also provided in Table 6. When analyzed indi-
vidually, ethylbenzene, lead, styrene, toluene, and
xylene show a statistically significant difference
between hearing loss among exposed and non-exposed
industries. Trichloroethylene and n-hexane did not
yield statistically significant results.
Qualifying ototoxicant exposure risk
The upper quartile of industries with higher ototoxicant
exposure risk is provided in Table 7, representing 13.7
million workers. The majority of the upper quartile were
manufacturing industries, eight out of the fourteen indus-
tries. The three manufacturing sectors with the highest
exposure risk were 335 (Electrical Equipment, Appliance,
and Component Manufacturing), 331 (Primary Metal
Manufacturing), and 337 (Furniture and Related Product
Manufacturing). The three non-manufacturing sectors
with the highest exposure risk were 237 (Heavy and Civil
Engineering Construction), 713 (Amusement, Gambling,
and Recreation Industries), and 238 (Specialty Trade
Contractors [General Industry]).
Discussion
This paper assessed data related to hearing loss, noise
exposure, and exposure to ototoxicants among U.S.
workers across various industries, resulting in several
findings. First, the noise exposure samples collected
during OSHA inspections were correlated with cases
of hearing loss reported to the Bureau of Labor
Statistics. This confirms the relationship between noise
exposure and hearing loss. In addition, it also suggests
that the methods used by OSHA to identify individual
exposure assessments (i.e., to select tasks/personnel
for evaluation based on a hazard analysis) is predictive
of the risk of adverse health effects (in this case, noise,
and hearing loss, respectively). This finding is signifi-
cant, because the same collection method is used for
chemical exposure assessments by OSHA, and the
comparison of OSHA inspection data to BLS injury
and illness data is an understudied area. These find-
ings may allow other sources of occupational injury
and illness to be studied to identify trends in worker
exposure and control methods.
OSHA chemical exposure data confirms that many
industries have measurable ototoxicant exposure.
Unsurprisingly, the largest number of samples were
collected in subsectors representing larger numbers of
establishments and employees. However, when factor-
ing in the ratio of ototoxicant samples out of all sam-
ples collected, and the proportions of those samples
over the LOD or PEL, the risk of exposure was evi-
dent. Many of the manufacturing subsectors men-
tioned in OSHA’s 2018 Technical Bulletin regarding
ototoxicants were confirmed to have a higher risk of
ototoxicant exposure, including the manufacture of
electrical equipment and components, metal products,
furniture, leather, plastics and rubber products, chemi-
cals, and paper. In addition, some non-manufacturing
industries were shown to have a high risk of ototoxi-
cant exposure, including amusement, gambling, and
recreation, heavy construction, specialty trade contrac-
tors, and sporting goods and hobby stores.
Ototoxicants are ubiquitous and exposure to ototoxi-
cants extends well beyond the manufacturing indus-
tries. While the OSHA Technical Bulletin mainly
focuses on exposure in a manufacturing setting, this
analysis shows that exposure can also occur in many
non-manufacturing workplaces.
In addition, OSHA inspection data showed that
industry subsectors with exposure to ototoxicants

were more likely to exhibit cases of hearing loss than
those without exposure to ototoxicants. This trend
was observed across ototoxicant data assessed in com-
bination and individually. It was not immediately evi-
dent to the researchers why the analyses for the years
2012 and 2013 were not statistically significant,
though the ratio of hearing loss among exposed
industries was greater than that among unexposed
industries, as observed in the remaining years. These
findings confirm the general consensus among the
existing body of research that ototoxicants play a role
in occupational hearing loss. In addition, the results
suggest that ototoxicant exposure represents a poten-
tial workplace hazard in the U.S. that warrants further
research.
When examined individually, many of the selected
ototoxicants showed a similar trend: industries with
exposure to the selected ototoxicant tended to exhibit
hearing loss more commonly than industries without
exposure to the selected ototoxicant, even though the
number of samples for each ototoxicant varied. Lead,
the most frequently sampled ototoxicant by OSHA
with 60% of the total samples, showed statistically sig-
nificant results for 4 of the 8 years. Ethylbenzene,
toluene, and xylene provided statistically significant
results for 5, 6, and 7 years, respectively.
Trichloroethylene and n-hexane did not yield similar
results, likely due to the much smaller number of
samples. While Campo et al. (2009) and Vyskocil
et al. (2012) considered these chemicals to be ototoxic,
ACGIH has not formally designated either n-hexane
or trichloroethylene as ototoxic but states that these
are “under investigation for ototoxic effects”
(2023, 133).
Of the research in this field, Clerc and Pouyatos
(2022) is the most analogous to this study. Clerc and
Pouyatos attempted to use several public databases of
occupational exposures and disease among the French
workforce to identify whether trends in hearing loss
could be observed in workers exposed to ototoxicants
and noise. Ultimately, Clerc and Pouyatos (2022) were
unable to produce a predictive model and theorized
the results were due to underreporting of occupational
hearing loss and the fact that hearing loss is only con-
sidered work-related due to exposure to noise and not
ototoxicants. This analysis faced similar limitations,
with slightly different analyses, demonstrating that
public databases may produce limited but viable
results.
Choi and Kim (2014) reviewed audiometric reports
and chemical exposure data for 30,000 Korean work-
ers across various industries and identified increased
JOURNAL OF OCCUPATIONAL AND ENVIRONMENTAL HYGIENE 531
hearing loss in individuals co-exposed to selected
heavy metals and organic solvents than unexposed
individuals. Though Choi and Kim’s analysis differed
in scope (Choi and Kim analyzed each individual’s
records and later aggregated at the industry level
whereas this analysis was performed at the industry
level only), their findings are consistent with this
study’s. This study confirms the findings of Vyskocil
et al. (2012), which suggested that several chemicals
exhibit ototoxicity at concentrations found in occupa-
tional settings.
One of the reviewed studies, Sch€aper et al. (2008),
conflicts with the results of this study, finding that
there was no significant difference in hearing loss
between individuals exposed to both toluene and noise
and those who were exposed to noise alone. Sch€aper
et al. suggested that one possible reason for this dis-
crepancy was that the exposure concentration to tolu-
ene was too low to elicit ototoxic effects. By including
all exposures greater than the LOD, this analysis may
be erroneously counting some exposures that are at or
below ototoxic threshold concentrations, and therefore
not likely to result in hearing loss. However, Metwally
et al. (2012) reported differently, finding that hearing
loss occurred earlier in co-exposed individuals than
those with exposure to noise alone, even at exposure
levels similar to those in Sch€aper et al.’s (2008) study.
Schaal et al. (2017) and (2018) also identified hearing
loss in populations exposed to concentrations well
below the applicable exposure limits.
This study yielded two additional unexpected find-
ings. First, an examination of the noise data provided
by OSHA revealed that the vast majority of noise
exposures appeared to be "repeat measurements" due
to the reporting of instantaneous readings taken dur-
ing a single dosimetry measurement as multiple lines
of data. Neither Middendorf (2004) nor Sayler et al.
(2019) noted this in their analysis of data from IMIS,
the sample management system previously used by
OSHA to store exposure monitoring data. Future
researchers should use care when using noise dosim-
etry data collected by OSHA to avoid skewed findings
resulting from duplicate samples. Second, a review of
available literature found that several substances were
suspected or likely to be ototoxic but were not identi-
fied as such by ACGIH, even though several studies
(Campo et al. 2009; Vyskocil et al. 2012) used a
Weight-of-Evidence model similar to that employed
by ACGIH. The Audible Sound section of the ACGIH
TLV book does mention additional substances in an
endnote that may exacerbate hearing loss or are under
investigation for ototoxicity, but there is no respective
532 C. BEAVER AND J. SCHNEIDER
note or designation within the TLV table where other
target organ toxicities are mentioned, including desig-
nated ototoxicants (ACGIH 2023, 133).
Study limitations and assumptions
There were several limitations to this study. First,
NAICS codes, used to stratify the data in this study,
are economic classifications. The risk to all workers in
the same industry subsector is not equal and may
vary from company to company or from occupational
setting to occupational setting within the industry
subsector. Additional research should be performed
along other stratifications, such as setting or specific
work environment, to reduce any potential impact of
other variables not considered in this study.
There are several limitations inherent to the data
provided by OSHA. Primarily, because the noise and
chemical exposure data are anonymized, it is impos-
sible to tie exposure to an individual. As a result, the
analysis cannot directly control for noise, determine
whether coexposure to both ototoxicants and noise is
present for an individual sample, or to tie a specific
exposure assessment to an incidence of disease.
Instead, this analysis examined exposure results as an
aggregate at the industry level, in which the assessed
exposure results are assumed to be representative of
the industry as a whole. The exposure data collected
by OSHA may not represent average worker exposure
(as it is based on a hazard assessment performed by
the compliance officer) and does not include other
information about the exposure risk, such as the per-
sonal protective equipment worn by the assessed
worker. When worn correctly (alongside additional
exposure controls an employer may choose to imple-
ment), PPE reduces the exposure and potentially miti-
gates the adverse effects of exposure to ototoxicants
and noise. This study attempts to ameliorate these
limitations by considering the OSHA data to represent
"worst-case" exposure. This matches the approach
taken by Sayler et al. (2019), who nevertheless consid-
ered "worst-case" evaluations to be crucial to minimiz-
ing adverse health effects because workers exposed to
"worst-case" levels are those most at risk for occupa-
tional illness.
The data provided by BLS also introduces several limi-
tations. First, the rates of hearing loss reported by BLS
may underrepresent the actual rates of OHL. NIOSH and
others have recognized the OSHA definition of a stand-
ard threshold shift may undercount hearing loss by up to
28–36% (Masterson et al. 2014). In addition, other factors
may encourage employers to underreport cases of hearing
loss, such as a desire to avoid regulatory inspections or
fines (Masterson et al. 2015). Blair et al. (2022) noted
that the OSHA definition of a standard threshold shift
may not capture ototoxicant-related hearing loss. A case
of occupational hearing loss occurs only when an
employee is included in a hearing conservation program
(HCP) which includes annual surveillance. Under the
OSHA standard, an employee is only required to be
entered into an HCP when exposed to high noise levels.
This would, by definition, exclude employees exposed to
ototoxicants if workers are not already entered into an
HCP, or to both ototoxicants and noise at a level too low
to trigger inclusion in an HCP. The employee may
experience undetected hearing loss as a result. BLS data
also does not indicate why an employer was monitoring
hearing – the employer may be monitoring the hearing
of employees exposed to lower noise levels, or those
exposed to ototoxicants as recommended by the 2018
OSHA Technical Bulletin. The monitoring may also
occur at the employee’s request. However, because the
data is reported in the aggregate, it is impossible to differ-
entiate these cases from hearing loss reported by compa-
nies strictly following the OSHA standard. To conduct
this analysis, it was assumed that hearing loss was
recorded per the OSHA standard.
The final limitation of this analysis is the presence
of confounding variables. One confounder present in
this analysis is that of noise. As previously noted,
because the chemical and noise exposure data pro-
vided by OSHA is anonymized and the hearing loss
data provided by BLS is aggregated at the industry
level, the relationships shown in the current analysis
may be present due to noise exposure alone.
However, the researchers believe these findings never-
theless support further mitigation of factors contribu-
ting to workplace hearing loss. It is widely agreed that
ototoxicants increase the risk of hearing loss during
co-exposure with noise, and this study confirmed that
ototoxicants are present in many workplaces in the
U.S. This study also showed statistically significant
results that industries with exposures to the selected
ototoxicants, both alone and as a group, were more
likely to exhibit hearing loss than industries without
such exposures. If nothing else, this strongly suggests
that ototoxicants may present an under-controlled
hazard in the workplace and that further research to
address these confounders is warranted.
Conclusions
This study compared occupational ototoxicant expos-
ure data collected by OSHA during workplace

inspections to work-related cases of hearing loss
reported to BLS to determine whether exposure to
ototoxicants increased the risk of OHL. It was deter-
mined that the exposure assessments performed by
OSHA compliance officers are predictive of the risk of
hearing loss as reported by the Bureau of Labor
Statistics. A review of the chemical exposure data also
identified specific industries with a higher risk of
exposure to ototoxicants, which confirmed a 2018
OSHA Technical Bulletin for manufacturing sectors
but also identified non-manufacturing sectors that
may be at risk. A chi-square analysis of data from
2012 through 2019 found that industry subsectors
with exposure to selected ototoxicants individually
and as an aggregate were more likely to have reported
hearing loss than those without exposure to ototoxi-
cants for six years out of the eight years. The individ-
ual ototoxicants that showed a similar trend were
ethylbenzene, lead, toluene, styrene, and xylene. While
individual worker exposures will vary across the
selected industry subsectors, these findings provide
evidence that workers co-exposed to ototoxicants and
noise may be at increased risk of experiencing hearing
loss and that further assessment is needed to better
understand the impact on the workforce.
Recommendations
This study supports several recommendations. First,
employers should consider limiting employee exposure
to ototoxicants for any employees exposed to noise
over the OSHA Action Level (85 dBA). As ototoxic
threshold concentrations have not been identified for
these substances, employers should consider using As
Low As Reasonably Practicable (ALARP) principles to
control ototoxicant exposure in these workplaces.
Employers should also consider including employees
who may be exposed to ototoxicants and noise in a
hearing conservation program, as recommended by
ACGIH. To further support these efforts, ACGIH
should adapt its "OTO" determination to include a
"potential ototoxicant" designation, as many of the
substances identified as a potential ototoxicant in this
study were not formally designated by ACGIH. Other
studies applying a weight of evidence model have uti-
lized a “potential” designation, and ACGIH itself has
identified some substances as “under investigation for
ototoxicity” in the TLV/BEI handbook. The potential
ototoxicity hazard should be identified in the main
TLV table alongside the other hazard definitions to
identify the potential risks of exposure more
prominently.
JOURNAL OF OCCUPATIONAL AND ENVIRONMENTAL HYGIENE 533
It may also be beneficial to consider other applica-
tions of the analysis method used in this study. To
the authors’ knowledge, no other study has compared
OSHA inspection data against BLS injury and illness
data to identify trends. Other researchers (including
NIOSH and other governmental research bodies)
should review available data to determine other trends
that could further minimize worker injury and illness.
Future research should also review different stratifica-
tions, such as occupation, job title, exposure fre-
quency, and exposure quantification or concentration
triggers (e.g., above/below PEL, AL, TLV).
Finally, OSHA should consider updating the
Technical Bulletin (2018) to further emphasize that
ototoxicants exist in many workplaces and that the
research is still evolving. The technical bulletin briefly
mentions hearing conservation programs, but this
should be expanded based on these findings and
others that have reviewed the applicability of pure-
tone audiometry for ototoxicant-driven hearing loss
(OSHA 2018). OSHA should also consider imple-
menting a National Emphasis Program (NEP) regard-
ing occupational exposure to ototoxicants. NEPs can
be particularly successful at driving sample collection
during inspections, and additional data would create a
further understanding of this emerging occupational
health concern.
Disclosure statement
No potential conflict of interest was reported by the
author(s).
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