Hearing Loss in US Adolescents-Study

Hearing Loss in US Adolescents – Study

ORIGINALCONTRIBUTION
Change in Prevalence of Hearing Loss
in US Adolescents
JosefShargorodsky,MD,MPH
SharonG.Curhan,MD,ScM
GaryC.Curhan,MD,ScD
RolandEavey,MD,SM
HEARING LOSS IS A COMMON
sensory disorder, affecting
tens of millions of individu-
als of all ages in the United
States. HEARING LOSS IN
US ADOLESCENTS- STUDY.
1
In school-aged children, even
slight hearing loss (
15-24 dB) can cre-
ate a need for speech therapy, audi-
tory training, and special accommoda-
tions.
2
Mild hearing loss in young
children can impair speech and lan-
guage development and lead to de-
creased educational achievement and
impaired social-emotional develop-
ment.
3,4
The Third National Health and Nu-
trition Examination Survey (NHANES
III), conducted between 1988 and
1994, demonstrated that 14.9% of US
children aged 6 to 19 years had low-
frequency or high-frequency hearing
loss (pure tone average [PTA]
15 dB)
in at least 1 ear,
5
and 12.5% had audio-
metric evidence of noise-induced hear-
ing loss.
6
Although some hearing loss
in children and adolescents can be at-
tributed to identifiable causes such as
infection, genetic syndromes, compli-
cations of prematurity, perinatal com-
plications, ototoxic medications, head
trauma, and hazardous noise expo-
sure,
7
only limited data exist on poten-
tial risk factors for much of the ac-
quired hearing loss in this population.
Adolescent hearing loss in particu-
lar is not well understood, although it
is common
6,8,9
and can have impor-
tant educational and social implica-
tions.
10
Some risk factors, such as loud
sound exposure from music listening,
may be of particular importance to
adolescents as well.
8,11
We examined 2
serial comparable databases to evalu-
ate whether there has been a change in
the prevalence of hearing loss and to
assess characteristics of hearing im-
pairment in the 12- to 19-year-old age
group.
Author Affiliations:
Channing Laboratory (Drs Shar-
gorodsky, S. G. Curhan, and G. C. Curhan) and Re-
nal Division (Dr G. C. Curhan), Department of Medi-
cine, Brigham and Women’s Hospital, Boston,
Massachusetts; Massachusetts Eye and Ear Infir-
mary,Boston(DrShargorodsky);VanderbiltBillWilker-
son Center for Otolaryngology and Communication
Sciences, Vanderbilt University School of Medicine,
Nashville, Tennessee (Dr Eavey); and Department of
Epidemiology, Harvard School of Public Health, Bos-
ton (Dr G. C. Curhan).
CorrespondingAuthor:
JosefShargorodsky,MD,MPH,
Channing Laboratory, 181 Longwood Ave, Boston,
MA 02115 (josef_shargorodsky@meei.harvard.edu).
Context
Hearing loss is common and, in young persons, can compromise social de-
velopment, communication skills, and educational achievement.
Objective
To examine the current prevalence of hearing loss in US adolescents and
determine whether it has changed over time.
Design
Cross-sectional analyses of US representative demographic and audiometric
data from the 1988 through 1994 and 2005 through 2006 time periods.
Setting
The Third National Health and Nutrition Examination Survey (NHANES III),
1988-1994, and NHANES 2005-2006.
Participants
NHANES III examined 2928 participants and NHANES 2005-2006 ex-
amined 1771 participants, aged 12 to 19 years.
Main Outcome Measures
We calculated the prevalence of hearing loss in par-
ticipants aged 12 to 19 years after accounting for the complex survey design. Audio-
metrically determined hearing loss was categorized as either unilateral or bilateral for
low frequency (0.5, 1, and 2 kHz) or high frequency (3, 4, 6, and 8 kHz), and as slight
loss (
15 to
25 dB) or mild or greater loss (
25 dB) according to hearing sensitivity
in the worse ear. The prevalence of hearing loss from NHANES 2005-2006 was com-
pared with the prevalence from NHANES III (1988-1994). We also examined the cross-
sectional relations between several potential risk factors and hearing loss. Logistic re-
gression was used to calculate multivariate adjusted odds ratios (ORs) and 95%
confidence intervals (CIs).
Results
The prevalence of any hearing loss increased significantly from 14.9% (95%
CI, 13.0%-16.9%) in 1988-1994 to 19.5% (95% CI, 15.2%-23.8%) in 2005-2006
(
P
=.02).In2005-2006,hearinglosswasmorecommonlyunilateral(prevalence,14.0%;
95% CI, 10.4%-17.6%, vs 11.1%; 95% CI, 9.5%-12.8% in 1988-1994;
P
=.005)
and involved the high frequencies (prevalence, 16.4%; 95% CI, 13.2%-19.7%, vs
12.8%; 95% CI, 11.1%-14.5% in 1988-1994;
P
=.02). Individuals from families be-
low the federal poverty threshold (prevalence, 23.6%; 95% CI, 18.5%-28.7%) had
significantly higher odds of hearing loss (multivariate adjusted OR, 1.60; 95% CI, 1.10-
2.32) than those above the threshold (prevalence, 18.4%; 95% CI, 13.6%-23.2%).
Conclusion
The prevalence of hearing loss among a sample of US adolescents aged
12 to 19 years was greater in 2005-2006 compared with 1988-1994.
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METHODS
Study Population
Participants aged 12 to 19 years from
NHANES III, 1988-1994 (n = 3211), and
NHANES 2005-2006 (n = 2288) were
included. NHANES provides nation-
ally representative cross-sectional data
on the health status of the civilian, non-
institutionalized US population. After
selection using a complex survey de-
sign, participants were interviewed and
examined. The design of NHANES has
been described previously.
9,12
Older in-
dividuals and Mexican American and
black individuals were intentionally
oversampled. Therefore, appropriate
sample weights were used to obtain
weighted regression estimates, and the
final results of our analyses are gener-
alizable to the US population.
9
Audiometric Measures
For both of the NHANES cycles, audi-
ometry was conducted in a dedicated
sound-isolating room in the mobile ex-
amination center by trained examin-
ers using a standardized protocol as pro-
vided by the National Center for Health
Statistics.
9,13
The examiners were pro-
fessionally trained by a certified audi-
ologist from the National Institute for
Occupational Safety and Health. The in-
stitute also conducted performance
monitoring of each technician on a
regular basis. Testing was conducted ac-
cording to a modified Hughson West-
lake procedure, a standard method of
measuring pure-tone detection thresh-
olds using a single stimulus of 1 to 2
seconds with the threshold set as the
lowest level at which a listener detects
50% of the stimuli using the auto-
mated testing mode of the audiom-
eter, except in cases where the hear-
ing thresholds were greater than 100 dB,
in which case those frequencies were
tested manually.
9
An audiometer was calibrated with
the same specifications at the start and
end of the testing at each field loca-
tion. Air conduction thresholds were
measured for each ear at 0.5, 1, 2, 3, 4,
6, and 8 kHz across an intensity range
of −10 to 120 dB. The 1-kHz fre-
quency was tested twice in each ear as
a measure of the reliability of the par-
ticipant’s responses and the first test re-
sponse was used in the analyses. Pure-
tone audiograms were not accepted if
there was a 10-dB or greater differ-
ence between the 1-kHz test-retest
thresholds. Participants using hearing
aids who were not able to remove them
for testing, those who had sufficient ear
pain at the time of the examination that
they could not tolerate headphones,
and those with cochlear implants
were excluded from the audiometry
component.
In some instances, if a pure-tone au-
diometric signal is sufficiently loud, it
can “cross over” and be heard by the
opposite ear via bone conduction. For
the NHANES III cycle, if a participant
had air-conduction threshold values at
a given frequency that differed by 40 dB
or more between ears, masking was per-
formed to ensure accuracy in measure-
ment. If present, the masked values
were used for the analyses. For the
2005-2006 NHANES cycle, masking
was not performed, but a crossover re-
testing protocol was performed when-
ever the observed threshold at any given
frequency was poorer in one ear than
the other by 25 dB at 0.5 kHz and 1 kHz,
or by 40 dB at any higher frequency, to
differentiate the true threshold of the
test ear from an artifact of the nontest-
ing ear. Retesting was accomplished
using insert earphones, which are
smaller and have less direct contact with
the head. Thus, a much louder stimu-
lus is required before crossover occurs.
Consistent with previous investiga-
tions of hearing in this age group, the
low-frequency PTA (LPTA) was ob-
tained by the average of air conduction
pure-tone thresholds at 0.5, 1, and 2 kHz
and the high-frequency PTA (HPTA)
was obtained by the average of air con-
duction pure-tone thresholds at 3, 4, 6,
and8kHz.
5
Low-frequency hearing loss
was defined as LPTA greater than 15 dB
in either ear, and high-frequency hear-
ing loss was defined as HPTA greater
than 15 dB in either ear. Any hearing loss
was defined as LPTA or HPTA greater
than 15 dB in either ear. Further, low-
frequency and high-frequency hearing
loss were characterized as either unilat-
eral or bilateral, mutually exclusive cat-
egories. Consistent with previous litera-
ture, measures of hearing loss were more
finely categorized according to the hear-
ing sensitivity in the worse ear and de-
fined as any (LPTA or HPTA
15 dB),
slight (LPTA or HPTA
15 to
25 dB),
and mild or worse (LPTA or HPTA
25
dB). These definitions have been used
previously in studies of NHANES
data.
5,6,14
Noise-Induced Threshold Shift
A noise-induced threshold shift (NITS)
was defined as an audiogram pattern
that met all of the following 3 criteria
for at least 1 ear: threshold values at 0.5
and 1 kHz were 15 dB or lower; the
maximum threshold value at 3, 4, or 6
kHz was at least 15 dB higher than the
highest threshold value for 0.5 and 1
kHz; and the threshold value at 8 kHz
was more than 10 dB lower than the
maximum threshold at a frequency of
3, 4, or 6 kHz.
6,15
Demographic and
Hearing-Related Covariates
Age was categorized as 12 to 13, 14 to
15, 16 to 17, and 18 to 19 years. Race/
ethnicity was classified by the partici-
pants based on the options provided in
the survey. Race/ethnicity was grouped
as non-Hispanic black, non-Hispanic
white, or Hispanic American (in-
cluded responses of “Mexican Ameri-
can” or “other Hispanic”). The “other”
race/ethnicity category was too small to
be analyzed separately but was in-
cluded in the overall estimates. Race/
ethnicity was assessed in this study
based on demonstrated associations
with hearing loss in previous studies.
The poverty-income ratio (PIR) was de-
fined as the total family income di-
vided by the poverty threshold, as de-
termined by the US Census Bureau for
the year of the interview. PIR values less
than 1 were below the official poverty
threshold, whereas PIR values of 1 or
greater indicated income at or above the
poverty level.
16
Participants were asked
if they had ever had 3 or more ear in-
fections. In NHANES 2005-2006, they
HEARING LOSS PREVALENCE IN US ADOLESCENTS
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were also asked if they had ever used
firearms for target shooting, hunting,
or any other purposes and if they had
ever been exposed to steady loud noise
or music for 5 or more hours in a week,
either in a job or outside of a job. Re-
sponses were categorized into yes, no,
and missing.
Statistical Analyses
We calculated the population preva-
lence with 95% confidence intervals
(CIs) of the demographic variables for
the NHANES III and NHANES 2005-
2006 cycles. The prevalence of hearing
loss (any, low-frequency, high-
frequency, unilateral, and bilateral hear-
ing loss of slight or mild or greater in-
tensity) was calculated. Multivariate
logistic regression was performed with
age; sex; race/ethnicity; PIR; a history of
3 or more ear infections; and, for
NHANES 2005-2006, a history of fire-
arm use or loud noise exposure as co-
variates, and any, low-frequency, or high-
frequency hearing loss as the outcome.
The
z
statistic for comparison of propor-
tions was used to compare hearing loss
prevalence between the NHANES III and
NHANES 2005-2006 cycles. All
P
val-
ues were 2-sided, and
P
.05 was con-
sidered statistically significant. Data
analysis was performed using SAS ver-
sion 9.2 (SAS Institute, Cary, North
Carolina). The SURVEYMEANS and
SURVEYLOGISTIC procedures in SAS
were used to account for the complex
survey sampling design.
Protocols to recruit and study par-
ticipants of NHANES III and 2005-
2006 were reviewed and approved by
the National Center for Health Statis-
tics institutional review board. Writ-
ten informed consent was obtained
from all study participants. For all par-
ticipants younger than 18 years, con-
sent was obtained from the partici-
pant as well as a parent or guardian for
interview and examination proce-
dures. Results of examinations were
provided to the individual partici-
pants or to the parents of child partici-
pants. In cases of abnormal results, the
results were returned immediately and
a physician referral was made.
RESULTS
Of the 3211 12-to 19-year-old indi-
viduals who were eligible for audio-
metric evaluation in the NHANES III
cycle, 283 were excluded because of an
incomplete examination, missing val-
ues at 1 or more audiometric frequen-
cies, or a 10-dB or greater difference be-
tween the 1-kHz test-retest thresholds;
thus, 2928 participants (91%) were
available for analysis. Of the 2288 12-
to 19-year-old individuals who were eli-
gible for audiometric testing in the
2005-2006 NHANES cycle, 517 were
excluded because of an incomplete ex-
amination, missing frequency values, or
10-dB or greater difference between the
1-kHz test-retest thresholds; thus, 1771
participants (77%) were available for
analysis. In both survey cycles, partici-
pants with incomplete data did not dif-
fer by age, sex, race/ethnicity, or PIR
from participants with complete data.
Characteristics of US adolescents in
NHANES III and NHANES 2005-
2006 are shown in
T
ABLE
1
. No signifi-
cant differences were observed be-
tween the 2 time periods for age, race/
ethnicity, sex, and PIR. A history of 3
or more ear infections was slightly more
common in NHANES III.
The prevalence of hearing loss in US
adolescents based on NHANES III and
2005-2006 is shown in
T
ABLE
2
. The
prevalence of any hearing loss (unilat-
eral or bilateral LPTA or HPTA
15 dB)
among 12- to 19-year olds was 14.9%
(95% CI, 13.0%-16.9%) in 1988-1994
and 19.5% (95% CI, 15.2%-23.8%) (ap-
proximately 6.5 million individuals) in
2005-2006. This represents a 31% in-
Table 1.
Demographic Characteristics of NHANES III (1988-1994) and NHANES 2005-2006
Populations of US 12- to 19-Year-Olds
No. (%) [95% CI]
a
NHANES III
(n = 2928)
NHANES 2005-2006
(n = 1771)
Age, y
12-13 777 (25) [22-28] 417 (23) [20-27]
14-15
721 (26) [24-28]
436 (27) [24-29]
16-17
772 (26) [23-28]
466 (27) [24-30]
18-19
658 (23) [20-26]
452 (23) [18-27]
Race/ethnicity
Non-Hispanic white
764 (66) [62-71]
453 (62) [55-69]
Non-Hispanic black
1023 (15) [13-18]
584 (14) [8-20]
Hispanic
1087 (14) [11-17]
581 (12) [9-14]
Other
54 (5) [3-7]
153 (12) [9-15]
Sex
Male
1379 (51) [48-54]
877 (51) [47-54]
Female
1549 (49) [46-52]
894 (49) [46-53]
Poverty income ratio
b
1
1945 (80) [77-83]
1188 (79) [75-83]
1
983 (20) [17-23]
583 (21) [17-25]
History of
3 ear infections
No
2309 (55) [50-59]
1289 (61) [56-66]
Yes
610 (45) [40-49]
466 (38) [33-43]
History of firearm use
No
NA
1466 (71) [66-76]
Yes
NA
303 (29) [24-33]
History of loud noise for
5 h/wk
No
NA
1300 (71) [66-75]
Yes
NA
469 (29) [25-34]
Abbreviations: CI, confidence interval; NA, not available in that cycle; NHANES, National Health and Nutrition Exami-
nation Survey.
a
Numbers are unweighted numbers of participants. Percentages are weighted to be nationally representative of the
US population.
b
Defined as total family income divided by poverty threshold, as determined by the US Census Bureau for the year of
the interview. PIR values
1 were below the official poverty threshold, whereas PIR values
1 indicated income at
or above the poverty level.
HEARING LOSS PREVALENCE IN US ADOLESCENTS
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crease in the prevalence of hearing loss
over this time (
P
= .02). The preva-
lence of any unilateral hearing loss was
11.1% (95% CI, 9.5%-12.8%) in 1988-
1994 and 14.0% (95% CI, 10.4%-
17.6%) in 2005-2006 (
P
= .005), and any
bilateral hearing loss was 3.8% (95% CI,
2.6%-4.9%) in 1988-1994 and 5.5%
(95% CI, 3.9%-7.1%) in 2005-2006
(
P
= .003). Any high-frequency hear-
ing loss (prevalence, 12.8%; 95% CI,
11.1%-14.5% in 1988-1994; preva-
lence, 16.4%; 95% CI, 13.2%-19.7% in
2005-2006) was more common than
any low-frequency hearing loss (preva-
lence, 6.1%; 95% CI, 4.5%-7.6% in
1988-1994; prevalence, 9.0%; 95% CI,
5.6%-12.5% in 2005-2006) in both sur-
vey cycles. The prevalence of high-
frequency hearing loss was signifi-
cantly higher in NHANES 2005-2006
than in NHANES III (
P
= .02), but the
prevalence of low-frequency hearing
loss was not (
P
= .07). Slight hearing loss
occurred in 11.4% (95% CI, 9.7%-
13.1%) in 1988-1994 and 14.2% (95%
CI, 10.6%-17.8%) in 2005-2006, and
mild or worse hearing loss in 3.5% (95%
CI, 2.5%-4.5%) in 1988-1994 and 5.3%
(95% CI, 3.6%-6.9%) in 2005-2006.
The prevalence of mild or worse hear-
ing loss was significantly higher
(
P
.001) in NHANES 2005-2006 than
in the 1988-1994 cycle, representing a
77% increase. There was no change in
the prevalence of NITS (16.2%; 95% CI,
13.9%-18.6% in 1998-1994; 16.4%;
95% CI, 13.1%-20.0% in 2005-2006;
P
= .09).
The multivariate-adjusted preva-
lence odds ratios (ORs) for risk of hear-
ing loss according to participant char-
acteristics are summarized in
T
ABLE
3
.
The prevalence of hearing loss did not
significantly differ by age or race/
ethnicity in either the 1988-1994 or the
2005-2006 time period. Females (preva-
lence, 17.1%; 95% CI, 12.2%-22.1%)
were significantly less likely than males
(prevalence, 21.8%; 95% CI, 17.0%-
26.6%) to demonstrate any hearing loss
(OR, 0.76; 95% CI, 0.59-0.97) in 2005-
2006 and were significantly less likely
(prevalence, 10.1%; 95% CI, 7.4%-
12.9%) than males (prevalence, 15.3%;
95% CI, 12.5%-18.0%) to demon-
strate high-frequency hearing loss in
1988-1994 (OR, 0.61; 95% CI, 0.42-
0.90). A PIR of less than 1 (preva-
lence, 23.6%; 95% CI, 18.5%-28.7%)
was significantly associated with in-
creased odds of any hearing loss as com-
pared with a PIR of 1 or more (preva-
lence, 18.4%; 95% CI, 13.6%-23.2%;
OR, 1.60; 95% CI, 1.10-2.32) in 2005-
2006, but there was no significant as-
sociation between PIR and hearing loss
in 1988-1994. In 1988-1994, a history
of 3 or more ear infections (preva-
lence, 18.9%; 95% CI, 13.3%-24.6%)
was significantly associated with in-
creased odds of any hearing loss (OR,
1.75; 95% CI, 1.09-2.81) as compared
with fewer than 3 ear infections (preva-
lence, 13.3%; 95% CI, 11.2%-15.5%).
Histories of 3 or more ear infections
(prevalence, 23.7% vs 17.0%; OR, 1.53;
95% CI, 0.87-2.70), firearm use (preva-
lence, 21.6% vs 18.7%; OR, 1.07; 95%
CI, 0.72-1.59), and loud noise expo-
sure for 5 or more hours in a week
(prevalence, 20.8% vs 19.0%; OR, 1.01;
95% CI, 0.64-1.61) were not signifi-
cantly associated with any hearing loss
in 2005-2006.
COMMENT
In the 2005-2006 NHANES, 1 in 5 US
adolescents 12 to 19 years old demon-
strated hearing loss. Compared with re-
sults from the 1988-1994 NHANES III,
this constitutes a one-third increase in
the prevalence of hearing loss. The ma-
jority of the hearing loss was slight. How-
ever, the prevalence of any hearing loss
25 dB or greater increased significantly
from 3.5% to 5.3%, indicating that 1 in
20 children in this age group have mild
or worse hearing loss. High-frequency
hearing loss was more common than
low-frequency loss, and most cases were
unilateral. Although the finding that the
majority of cases of hearing loss were uni-
lateral was consistent with past litera-
ture,
5
the reasons for this are unknown.
Interval factors between surveys, such as
vaccination against
Haemophilus influ-
Table 2.
Hearing Loss Prevalence in US Adolescents Aged 12 to 19 Years, NHANES III
(1988-1994) and NHANES 2005-2006
No. (Prevalence, %) [95% CI] by Hearing Threshold (HL Severity)
a
15 dB
(Slight or Worse)
15 to
25 dB
(Slight)
b
25 dB
(Mild or Worse)
NHANES III
Any HL
c
480 (14.9) [13.0-16.9] 360 (11.4) [9.7-13.1] 120 (3.5) [2.5-4.5]
Any high-frequency HL 423 (12.8) [11.1-14.5] 339 (10.1) [8.5-11.6] 84 (2.7) [1.7-3.7]
Any low-frequency HL 186 (6.1) [4.5-7.6] 151 (5.2) [3.9-6.5] 35 (0.9) [0.1-1.7]
Unilateral HL 335 (11.1) [9.5-12.8] 278 (9.3) [7.9-10.7] 57 (1.8) [0.9-2.8]
Unilateral high-frequency HL 304 (9.6) [8.1-11.2] 245 (7.7) [6.4-9.1] 59 (1.9) [0.9-2.8]
Unilateral low-frequency HL 140 (5.0) [3.4-6.4] 113 (4.3) [3.0-5.5] 27 (0.7) [0.0-1.4]
Bilateral HL 145 (3.8) [2.6-4.9] 120 (2.9) [2.0-3.8] 25 (0.8) [0.3-1.4]
Bilateral high-frequency HL 119 (3.2) [2.2-4.1] 94 (2.3) [1.6-3.0] 25 (0.8) [0.3-1.4]
Bilateral low-frequency HL 46 (1.1) [0.6-1.7] 38 (0.9) [0.4-1.4] 8 (0.2) [0.0-0.5]
NHANES 2005-2006
Any HL
c
333 (19.5) [15.2-23.8] 239 (14.2) [10.6-17.8] 94 (5.3) [3.6-6.9]
Any high-frequency HL 279 (16.4) [13.2-19.7] 219 (11.7) [9.4-14.1] 60 (4.7) [3.3-6.1]
Any low-frequency HL 155 (9.0) [5.6-12.5] 126 (6.5) [3.5-9.4] 29 (2.5) [1.4-3.7]
Unilateral HL 234 (14.0) [10.4-17.6] 191 (11.3) [8.2-14.5] 43 (2.7) [1.4-3.9]
Unilateral high-frequency HL 209 (12.6) [9.9-15.3] 167 (9.8) [7.8-11.8] 42 (2.8) [1.7-3.9]
Unilateral low-frequency HL 113 (6.8) [3.8-9.8] 90 (5.3) [2.7-8.0] 23 (1.5) [0.6-2.3]
Bilateral HL 99 (5.5) [3.9-7.1] 80 (4.7) [3.5-5.8] 19 (0.8) [0.1-1.5]
Bilateral high-frequency HL 70 (3.8) [2.5-5.1] 52 (3.0) [2.1-3.9] 18 (0.8) [0.1-1.5]
Bilateral low-frequency HL 42 (2.2) [1.5-3.0] 36 (2.0) [1.4-2.7] 6 (0.2) [0.0-0.5]
Abbreviations: CI, confidence interval; HL, hearing loss; NHANES, National Health and Nutrition Examination Survey.
a
Numbers are unweighted numbers of participants. All prevalence percentages are weighted to be nationally representa-
tive of the US population.
b
The slight HL values for the bilateral HL rows include individuals with slight HL in one ear and mild HL in the other ear.
c
Includes unilateral or bilateral hearing loss at either low or high frequency.
HEARING LOSS PREVALENCE IN US ADOLESCENTS
©2010 American Medical Association. All rights reserved.
(Reprinted) JAMA,
August 18, 2010—Vol 304, No. 7
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enzae
and
Streptococcus pneumoniae
,as
well as greater awareness of music-
induced hearing loss, may have led to the
expectation of no change or a reduc-
tion in the prevalence of hearing loss, but
this was not observed.
Definitions of hearing loss, a con-
tinuous variable, have not been stan-
dardized among all investigators,
17
and
previous studies have employed maxi-
mal threshold levels that range from 15
dB to 25 dB to define normal hear-
ing.
5,14
Moreover, the definitions of low-
and high-frequency ranges have var-
ied, with some controversy as to the
placement of the 2-kHz frequency in the
low- vs high-frequency category. How-
ever, the 2-kHz frequency has been in-
Table 3.
Multivariate Analyses of Potential Risk Factors for Hearing Loss in US 12 to 19-Year-Olds, NHANES III (1988-1994) and 2005-2006
a
Any HL
High-Frequency HL
Low-Frequency HL
No.
b
Prevalence, %
(95% CI)
c
Multivariate
OR (95% CI) No.
b
Prevalence, %
(95% CI)
c
Multivariate
OR (95% CI) No.
b
Prevalence, %
(95% CI)
c
Multivariate
OR (95% CI)
NHANES III
Age, y
12-13 124 16.0 (11.5-20.5) 1 [Reference] 117 14.9 (10.5-19.2) 1 [Reference] 42 7.0 (4.0-10.0) 1 [Reference]
14-15
115 13.7 (9.4-18.0) 0.90 (0.53-1.53) 100 10.5 (6.6-14.4) 0.72 (0.40-1.30) 52 6.2 (3.3-9.2) 0.91 (0.45-1.84)
16-17
120 14.9 (11.5-18.3) 1.12 (0.72-1.75) 103 12.6 (9.5-15.7) 0.99 (0.63-1.57) 46 5.6 (2.7-8.4) 0.97 (0.48-1.97)
18-19
121 15.2 (10.7-19.6) 1.30 (0.78-2.17) 103 13.3 (10.7-17.5) 1.18 (0.69-2.01) 46 5.4 (3.0-7.7) 1.13 (0.59-2.16)
Race/ethnicity
Non-Hispanic white 115 15.1 (12.3-18.1) 1 [Reference] 95 12.6 (10.2-15.0) 1 [Reference] 50 6.6 (4.4-8.8) 1 [Reference]
Non-Hispanic black 147 13.7 (11.5-15.9) 0.95 (0.71-1.27) 130 12.1 (9.8-14.5) 0.98 (0.71-1.35) 51 4.7 (3.3-6.1) 0.77 (0.51-1.18)
Hispanic
212 16.2 (12.0-20.5) 1.12 (0.76-1.65) 192 14.7 (10.9-18.5) 1.19 (0.81-1.73) 83 6.0 (3.5-8.5) 0.94 (0.56-1.58)
Sex
Male
260 16.9 (13.8-19.8) 1 [Reference] 238 15.3 (12.5-18.0) 1 [Reference] 86 5.4 (3.5-7.2) 1 [Reference]
Female
220 12.9 (9.6-16.1) 0.71 (0.49-1.04) 185 10.1 (7.4-12.9) 0.61 (0.42-0.90) 100 6.8 (4.2-9.4) 1.27 (0.74-2.18)
Poverty income ratio
d
1 291 14.6 (12.2-16.9) 1 [Reference] 253 12.2 (10.2-14.3) 1 [Reference] 111 6.0 (4.1-7.8) 1 [Reference]
1 189 16.2 (12.6-19.9) 1.24 (0.88-1.73) 170 15.0 (11.6-18.4) 1.37 (0.97-1.93) 75 6.4 (3.8-9.0) 1.23 (0.73-2.06)
History of
3 ear infections
No 359 13.3 (11.2-15.5) 1 [Reference] 320 11.7 (9.5-13.8) 1 [Reference] 131 4.8 (3.6-6.0) 1 [Reference]
Yes
120 18.9 (13.3-24.6) 1.75 (1.09-2.81) 102 15.7 (10.8-20.5) 1.66 (1.01-2.74) 54 9.2 (5.0-13.4) 2.04 (1.21-3.42)
NHANES 2005-2006
Age, y
12-13
79 16.0 (8.6-23.5) 1 [Reference] 64 12.9 (6.9-18.8) 1 [Reference] 38 7.3 (1.3-13.2) 1 [Reference]
14-15
78 20.1 (12.6-27.5) 1.30 (0.70-2.41) 67 18.2 (11.4-25.1) 1.47 (0.75-2.86) 39 9.9 (4.8-15.0) 1.40 (0.60-3.27)
16-17
93 21.5 (15.1-27.8) 1.45 (0.97-2.17) 81 17.7 (12.9-22.5) 1.42 (0.85-2.36) 34 8.1 (3.3-12.9) 1.16 (0.71-1.91)
18-19
83 20.1 (15.4-24.7) 1.28 (0.86-1.92) 67 16.5 (12.3-20.6) 1.23 (0.91-1.68) 44 10.9 (6.7-15.2) 1.62 (0.76-3.44)
Race/ethnicity
Non-Hispanic white
97 21.2 (15.0-27.4) 1 [Reference] 81 17.6 (13.0-22.3) 1 [Reference] 46 9.9 (4.7-15.1) 1 [Reference]
Non-Hispanic black 122 20.8 (15.1-26.5) 1.00 (0.65-1.55) 101 17.2 (11.6-22.8) 1.04 (0.66-1.64) 56 9.5 (6.0-12.1) 0.91 (0.46-1.29)
Hispanic
98 17.2 (13.8-20.5) 0.78 (0.51-1.20) 84 14.8 (11.1-18.5) 0.85 (0.55-1.29) 45 8.0 (5.3-10.5) 0.77 (0.56-1.29)
Sex
Male
184 21.8 (17.0-26.6) 1 [Reference] 160 19.4 (15.2-23.6) 1 [Reference] 79 8.8 (6.0-11.7) 1 [Reference]
Female
149 17.1 (12.2-22.1) 0.76 (0.59-0.97) 119 13.4 (10.1-16.6) 0.67 (0.52-0.87) 76 9.2 (4.2-14.2) 1.02 (0.60-1.73)
Poverty income ratio
d
1 212 18.4 (13.6-23.2) 1 [Reference] 181 15.7 (11.7-19.8) 1 [Reference] 96 8.5 (4.9-12.1) 1 [Reference]
1 121 23.6 (18.5-28.7) 1.60 (1.10-2.32) 98 19.1 (13.5-24.6) 1.43 (0.87-2.36) 59 11.1 (6.5-15.7) 1.50 (0.94-2.41)
History of
3 ear infections
No 212 17.0 (12.3-21.8) 1 [Reference] 177 14.9 (10.7-19.0) 1 [Reference] 97 7.5 (4.1-9.5) 1 [Reference]
Yes
118 23.7 (15.5-32.0) 1.53 (0.87-2.70) 99 19.2 (12.5-25.8) 1.36 (0.75-2.47) 61 11.5 (5.6-17.4) 1.64 (0.89-3.02)
History of firearm use
No
272 18.7 (14.2-23.2) 1 [Reference] 224 15.1 (12.0-18.2) 1 [Reference] 128 9.3 (5.4-13.2) 1 [Reference]
Yes
60 21.6 (15.0-28.1) 1.07 (0.72-1.59) 54 19.7 (13.9-25.6) 1.17 (0.78-1.76) 26 8.5 (4.1-12.8) 0.85 (0.43-1.69)
History of loud noise
5 h/wk
No
245 19.0 (13.7-24.2) 1 [Reference] 201 15.4 (11.8-18.9) 1 [Reference] 115 9.1 (4.4-13.7) 1 [Reference]
Yes
87 20.8 (14.8-26.7) 1.01 (0.64-1.61) 77 18.9 (13.2-24.6) 1.15 (0.73-1.80) 39 8.9 (5.2-12.6) 0.94 (0.46-1.93)
Abbreviations: CI, confidence interval; HL, hearing loss; NHANES, National Health and Nutrition Examination Survey; OR, odds ratio.
a
Hearing loss includes unilateral or bilateral HL at either low or high frequency. NHANES III data were adjusted for age, race/ethnicity, sex, poverty income ratio, history of
3 ear infec-
tions; NHANES 2005-2006 data were adjusted for age; race/ethnicity; sex; poverty income ratio; and history of
3 ear infections, firearm use, and loud noise for
5 h per week.
b
All numbers represent unweighted numbers of participants.
c
All prevalence values are weighted to be nationally representative of the US population.
d
Defined as total family income divided by poverty threshold, as determined by the US Census Bureau for the year of the interview. Poverty income ratio values
1 were below the official
poverty threshold, whereas values
1 indicated income at or above the poverty level.
HEARING LOSS PREVALENCE IN US ADOLESCENTS
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cluded in the low-frequency category
and the 15-dB threshold has been used
more consistently to define hearing loss
in studies of children and young
adults.
5,6,10
In this study, the signifi-
cant increase in prevalence of hearing
loss defined by thresholds greater than
15 dB and 25 dB or greater between
1988-1994 and 2005-2006, based on
consistent definitions of hearing loss,
demonstrates an overall worsening of
hearing in this age group.
In the 2005-2006 NHANES, fe-
males had significantly lower odds of
having any or high-frequency hearing
loss than males. In addition, partici-
pants reporting a PIR of less than 1 had
significantly increased odds of any hear-
ing loss in NHANES 2005-2006 but not
in NHANES III.
5
The association with
income is consistent with past litera-
ture,
5,14
yet the mechanisms are un-
clear. A study in Peru found that school-
aged children living in poverty were 4
to 7 times more likely to have hearing
loss than children living in higher-
income countries.
18
Although the au-
thors suggested a major risk factor was
untreated middle ear disease in the con-
text of limited access to pediatric health
care, we adjusted for history of mul-
tiple ear infections; thus, this is un-
likely to explain our findings. Because
much hearing loss is genetic, the role
of parental hearing loss leading to pov-
erty is possible, but we do not have data
on the parents.
In younger age groups, even a slight
change in the hearing threshold can im-
pair learning and speech understand-
ing.
19
Hearing loss in school-aged in-
dividuals can affect learning, speech
perception, social skill development,
and self-image.
20
In a study of 1218
third-, sixth-, and ninth-grade stu-
dents, slight or worse hearing loss (de-
fined as
20 dB) was associated with
lower scores on communication tests,
decreased self-esteem, and increased
stress.
10
In addition, 37% of children
with hearing loss were reported to have
repeated at least 1 grade.
10
Given that
children living in impoverished neigh-
borhoods have been shown to have
lower school performance,
21
the higher
prevalence of hearing loss in partici-
pants living below the national pov-
erty level observed in 2005-2006 places
a further burden on this already vul-
nerable group.
Our study did not find a difference
in estimated noise exposure between
the 2 time periods or a significant as-
sociation between self-reported noise
exposure and hearing loss in 2005-
2006. However, adolescents and young
adults typically underestimate symp-
toms of loud sound, tinnitus, and tem-
porary hearing impairment during mu-
sic exposure and underreport concern
for these conditions.
8,22
The preva-
lence of NITS, a purported marker of
noise exposure, was 16.4% (95% CI,
13.1%-20.0%) in 2005-2006 NHANES,
similar to that found in the earlier cycle.
In adults, characterization of NITS
using audiometric noise notches de-
fined similarly to this study was poorly
associated with noise exposure.
23
Al-
ternatively, a higher PTA in the high-
frequency range of hearing has been as-
sociated with loud noise exposure
14,24
and may be a more reliable marker of
noise-induced hearing loss. Possibly,
the finding of a significant increase in
high-frequency hearing loss between
the 1988-1994 and 2005-2006 time pe-
riods may indicate an increase in noise-
induced hearing loss. Intriguingly, a re-
cent cross-sectional study of children
with slight to mild hearing loss in Aus-
tralia found that reported use of per-
sonal stereo devices was associated with
a 70% increased risk of hearing loss.
25
The effects of noise exposure on hear-
ing loss in adolescents deserve further
study.
The strengths and limitations of this
study should be considered. Data from
NHANES are comprehensive and na-
tionally representative, drawing from a
large and diverse sample of partici-
pants. The NHANES audiometric as-
sessment of hearing loss is the gold stan-
dard objective measure and has been
shown to be reliable in numerous stud-
ies.
5,14,26
Although the 1988-1994 and
2005-2006 NHANES study periods
sampled 2 distinct groups of individu-
als, consistency was maintained in the
methods of participant selection and
hearing loss assessment. There was a
minor difference in the treatment of
crossover between the 2 surveys. Al-
though masking was performed in
NHANES III and not in NHANES 2005-
2006, the 2005-2006 survey em-
ployed a crossover protocol to ac-
count for interference by the nontesting
ear. The prevalence of hearing loss may
be underestimated because children
whose hearing aids could not be re-
moved, who could not tolerate ear-
phones, or who had cochlear implants
were not tested. Also, due to the cross-
sectional methodology of this study,
causality with respect to risk factors for
hearing loss cannot be examined. In
NHANES III, the children’s ears were
not examined, nor were additional tests
such as bone conduction performed, so
causes of conductive hearing loss, such
as wax or otitis media, cannot be ex-
cluded.
CONCLUSIONS
The prevalence of hearing loss among
a sample of US adolescents aged 12 to
19 years was greater in 2005-2006 com-
pared with 1988-1994. Further stud-
ies are needed to determine reasons for
this increase and to identify potential
modifiable risk factors to prevent the
development of hearing loss.
HEARING LOSS IN US ADOLESCENTS.
Author Contributions:
Dr Shargorodsky had full ac-
cess to all of the data in the study and takes respon-
sibility for the integrity of the data and the accuracy
of the data analysis.
Drs G. C. Curhan and Eavey contributed equally to
this work as senior authors.
Studyconceptanddesign:
Shargorodsky,G.C.Curhan.
Acquisition of data:
Shargorodsky.
Analysis and interpretation of data:
Shargorodsky,
S. G. Curhan, G. C. Curhan, Eavey.
Drafting of the manuscript:
Shargorodsky.
Critical revision of the manuscript for important in-
tellectual content:
Shargorodsky, S. G. Curhan,
G. C. Curhan, Eavey.
Statistical analysis:
Shargorodsky, G. C. Curhan.
Obtained funding:
Eavey.
Study supervision:
G. C. Curhan, Eavey.
Financial Disclosures:
None reported.
Funding/Support:
This work was supported by the
Massachusetts Eye and Ear Infirmary Foundation and
Vanderbilt University School of Medicine Develop-
ment Funds.
Role of the Sponsor:
The funding organizations had
no role in the design and conduct of the study; in the
collection, analysis, and interpretation of the data; or
in the preparation, review, or approval of the manu-
script.
Additional Contributions:
Sowmya R. Rao, PhD, Har-
vard Medical School and Massachusetts General Hos-
HEARING LOSS PREVALENCE IN US ADOLESCENTS
©2010 American Medical Association. All rights reserved.
(Reprinted) JAMA,
August 18, 2010—Vol 304, No. 7
777
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pital Biostatistics Center, provided statistical support
for this study. Gary P. Jacobson, PhD, Department of
Hearing and Speech Sciences, Vanderbilt Bill Wilker-
son Center for Otolaryngology and Communication
Sciences, provided valuable insights as an internal
manuscript reviewer. No financial compensation was
received by Drs Rao or Jacobson for their contribu-
tions to this study.
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