Noise induced hearing loss risk assessment in truck drivers

Ali Karimi, Saleh Nasiri1, Farshid Khodaparast Kazerooni1, Mohammad Oliaei2

Occupational Health Department, Faculty of Health, Tehran University of Medical Sciences, Tehran, Iran, 1Occupational and
Environmental Health Department, Public Health Center of Shiraz, Shiraz, Iran, 2Occupational Health Department, Faculty of Health,
Shiraz University of Medical Sciences, Shiraz, Iran

Abstract
Hearing sense is one of the key elements which may have impact on the drivers task quality. This cross-sectional
study investigates the hearing status of 500 truck drivers by pure tone audiometry (AC) in one of the cities in Fars
province, Iran. Hearing threshold levels of the subjects were measured in frequencies of 500Hz-8000Hz. Screening and
determination of permanent threshold shift (PTS) was the first aim of this study. Hence tests were done at least 16 hours
after any exposure to noticeable sound. The effect of age as a confounding factor was considered using ISO equation
and subtracted from whole hearing threshold. The threshold of 25 dB HL and above was considered abnormal but the
calculation of hearing was also carried out using 0 dB HL as reference. Subjects were categorized into two groups on
the basis of working experience and the hearing threshold of 25 dB was considered a boundary of normal hearing sense.
The results of Pearson Chi-Square test showed that working experience as an independent variable has significant
contributing effect on hearing thresholds of truck drivers in frequencies of 500, 1000, 2000 and 4000 Hz (p greater than
0.05). Also, it was shown that currently nine and 12.6 % of truck drivers suffer from impaired hearing sense in left
and right respectively (hearing threshold level greater than 25 dB) in mid frequencies (500, 1000, 2000 Hz) and 45%
in high frequencies of both ears (4000 and 8000 Hz). The results indicated that hearing damage of professional drivers
was expected to occur sooner at 4000 and 8000 Hz than lower frequencies. Finally it was deduced that the occupational
conditions of truck drivers may have bilateral, symmetrical harmful effect on hearing threshold sense in all frequencies
mainly in frequency of 4000 Hz, so health surveillance programs such as education and periodic medical examinations
are emphasized for pre-diagnosing and prevention of any possible impairment and an urgent need to take up some
interventions such as better maintenance of roads, automobile industry efforts to reduce the noise level emission of
vehicles and reducing number of working hours per day of drivers are highlighted to improve the harmful working
conditions of truck drivers.
Keywords: Frequency, noise induced hearing loss, threshold level, truck drivers
PubMed ID: ****
DOI: 10.4103/1463-1741.59999

Introduction
The two most common causes of hearing loss in adults are
generally accepted as being:
1. Effects of ageing
2. Noise-induced hearing loss (NIHL, the effects of
excessive noise exposure).[1]
Noise is a cause of poor health. It can damage hearing and
is associated with a number of psychological problems that
can contribute to stress. As noise is usually experienced at
the same time as vibration there is a combined assault on the
lorry and bus driver from both sources. This is particularly
worrying for bus and lorry drivers who already experience
elevated stress levels from the traffic environment and time
pressures of the work.[2]
49

For those who drive trucks and buses there has been
deterioration in work conditions over the last 20 years. This
deterioration is largely the result of traffic congestion and its
associated air and noise pollution along with the pressure of
maintaining a demanding schedule in circumstances which
make the task almost impossible. A truck or bus driver is at
the sharp end of the failure of our transport system. Buses find
it almost impossible to maintain schedules and the pressure
on truck drivers to meet demanding schedules is intense. The
driver, in both circumstances, has to absorb the failures of
the transport system in the form of increased stress levels,
conflict with customers and the intensification of a wide
range of work pressures in a hostile environment.[2]
Traffic noise is a major source of environmental pollution
in developed and developing nations. Professional drivers
are most susceptible to high noise levels for long duration.
Noise
Noise&&Health,
Health,January-March
January-March2010,
2010,12:46,49-55
Volume 12

Karimi, et al.: Hearing loss risk assessment of truck drivers

The most common goal for protecting drivers from auditory

effects of occupational noise is the preservation of hearing
for speech discrimination.[3] One study in India has identified
noise levels in bus cabs of 89-106 dB(A) and observed that
89% of the bus drivers had abnormal audiograms i.e. they
had impaired hearing.[4] Mukherjee et al. investigated some
occupational harmful agents (noise, heat, dust and volatile
organic compounds) of bus drivers in Kolkata and indicated
that drivers undertaking three consecutive trips within
Kolkata city traffic routes in a special bus have higher noise
exposure than the recommended standard.[5] Investigations
of Krishan Kumar and Jain on noise in various modes of
transport in Delhi showed that among the various modes of
transport, noise levels are greatest in auto-rickshaws (8196 dBA) followed by trucks (83-90 dBA) and buses (77-92
dBA). Noise levels in cars were appreciably lower (72-80
dBA) when compared to other modes of[6] transport. 65 dB(A)
is normally taken as an acceptable level so levels above 80
dB(A) give serious cause for concern. A loss of hearing is
typically the result of continuous exposure to high noise
levels of 85 dB(A) and above for a number of years. Noise at
Work Regulations (2005) require personal hearing protection
to be provided where noise levels reach 85 dB(A) or more.[7]
Noise protection is not an easy matter for drivers. Drivers
need to be in aural contact with the outside world and need
to be protected from the health damaging consequences of
noise. Resolving this dilemma through cab design and more
fundamental solutions for the general traffic environment
will be a high priority.[2] Hearing sensitivity at 0 dB(HL) is
normalized to represent average normal hearing for young,
otologically normal adults (male and female) between the
ages of 20 to 29.[8] The range of normal hearing is considered
to be between 0 to 25 dB(HL).[3] The four frequencies pure
tone average of hearing levels at 500; 1,000; 2,000; and 3,000
Hz were used for mid-frequency hearing loss. High frequency
range of 3,000; 4,000; 6,000; and 8,000 Hz was used for
hearing impairment. Threshold of 25-dB(HL) and above was
considered abnormal but the calculation of hearing was also
carried out using 0 dB(HL) as reference.[3]
The American Academy of Otolaryngology has established
referral criteria. Briefly, if the initial audiogram shows
a significant loss (i.e. worse than 25 dB) in either ear or
a significant difference between ears (i.e. 15 and 30 dB
for the low and high frequencies, respectively), a referral
should be made to an audiologist or otolaryngologist.
Also, if a confirmation audiogram reveals a 15 or 20 dB
shift in the low or high frequencies, respectively, a referral
should be considered.[9] Noise induced hearing loss usually
commences around the frequency of 4000 Hz and gradually
progresses within this frequency region and spreads into
adjacent frequencies.[10] This dip in hearing is known as a
notch in the audiogram. A four kHz notch is a common
characteristic of noise induced hearing loss.[1] In this context,
the current study attempts to investigate working conditions
Noise & Health, January-March 2010, Volume 12

of truck drivers and possible effect on their auditory systems.

Additionally, the current perspective of hearing status of truck
drivers would be highlighted to emphasize any necessary
interventions to make recommendations for a significant
improvement in the working environment of this neglected
group of professionals.

Materials and Methods

There are several methods to test the hearing sensitivity
of an individual. It is possible, for example, to examine
hearing levels with an audiometer, tuning fork, or a free field
voice test. Audiometric testing is the accepted standard for
measuring hearing levels, but other procedures are often
used by medical personnel to identify persons with hearing
impairments or hearing disorders. Testing for hearing ability
may take the following forms; testing to determine if a person
can hear at a specified hearing level (screening), or testing
for a threshold of hearing sensitivity. Screening involves
testing for the ability to detect a specified level of sound at
various frequencies. An individual either responds or does
not respond to the signal. Thus, they pass or fail depending
upon their ability to hear at this one level. The pure-tone
screening test usually performed by audiometers, and this
test have become the standard method for measuring hearing
ability.[11] If hearing screenings are to be part of a medical
examination, an audiologist can set-up the screening protocol
and train the subject on how to response to the signals in a
physicians office to carry out the test. Screening at discrete
frequencies can be a fast procedure when administered by a
trained individual to a cooperative patient. Numerous drivers
usually refer to occupational medial examination centers to
receive health identification cards. Among them 500 drivers
(male) were considered by random sampling method (in Iran
it is not common for a female to be truck driver so all of the
drivers were male). Pure tone audiometery (AC: stands for
air conduction, means measuring auditory sense of examinee
about sounds that conducted through the external and middle
ears to the cochlea) is a simple screening method for hearing
loss diagnosis in occupational health. The effect of temporary
threshold shift (TTS) was controlled by considering 16 hours
interval between any exposure to noticeable noise and pure
tone audiometery. Before test, the subjects were clearly
instructed about the test procedure and necessary information
[Table 1] was logged by audiometric technician.
Table 1: Basic information of truck drivers in this study

Mean
Median
Mode
Standard deviation
Range
Minimum
Maximum

Age (year)
n=500
38
37
32
9.8
48
20
68

Work experience(year)
n=500
12.2
11
13
8.6
44
1
45

50

Karimi, et al.: Hearing loss risk assessment of truck drivers

The working hours per day were varying but the declared;
they usually work more than 10 hours per day. All drivers in
this study were selected according to the following criteria:
not had an accidental hearing loss, not had hearing loss due
to medical surgeries, disease, not exposed to accidental
explosions, explosions or heavy weaponry noise during war/
army activities; not used hearing protective equipment.
Exceeding noise usually causes enhancement in hearing
threshold levels.[12] If we suppose that truck drivers were
exposed to noticeable exceeding noise therefore the hearing
threshold must have affected and increased, it means that
there may be a direct correlation between work experience
and hearing threshold level changes. On the other hand, it is
reasonable to assume that aging makes some contribution
to loss of hearing in people exposed to excessive noise, so
that the hearing threshold would increase with age. The
effect of aging on hearing thresholds has been reported
long ago.[12] Adjustment is needed about aging to clearly
determine if work duration as a contributing variable may
have any effect on hearing threshold level. The international
standard organization equation (ISO-7029) was used to carry
out these adjustments.[13]
The most important question that would be posed with any
job would be - Will the working experience (as duration of
occupational noise exposure) as an independent variable
(apart from other confounding variables such as age, disease,
etc) have any noticeable effect on hearing sense?
The aim of this study was to answer to this question for truck
drivers. To examine the recent declaration corrected hearing
threshold levels in different frequencies were categorized
on the basis of working experience (year); so we have two
groups in each frequency: working experience less than 10
years, working experience more than 10 years This pattern
of stratification is similar to research of Majumder et al.[3]
Hearing handicap is usually denoted as an average hearing
threshold level of greater than 25 dB(HL) for both ears at
selected frequencies.[3]
The hearing threshold level of 25dB is considered the cut
point for normal hearing sense in each frequency. Hence the
subjects were stratified into two groups on the basis of their
corrected with age hearing threshold level in each frequency:
group 1: hearing threshold level less than or equal to 25 dB,
group 2: hearing threshold level greater than 25 dB. Several
methods of analysis were examined to reach a meaningful
conclusion. The independent T-test was performed initially
to compare average of hearing threshold levels vs. working
experience categories, in each frequencies, but the results
of the aforementioned test indicated that in this method of
analysis the hearing threshold level of impaired subjects
were masked by hearing threshold levels of normal subjects
and it was not possible to discover impaired drivers, so other
methods were applied as discussed in next sections.
51

Results
Hearing threshold level in the frequencies in question can
be adjusted using the recent ISO equation, to control for
the effect of age on hearing threshold level. For this, the
threshold shift value due to aging calculated from the ISO
equation is subtracted from the whole hearing threshold
level for each frequency. After adjusting the aging effects on
hearing threshold shifts, Pearson Chi-Square test performed
to examine if working condition of truck drivers may cause
noticeable hearing loss in subjects. Tables 2 and 3 show
results of Pearson Chi-Square tests on the basis of working
experience and hearing threshold levels for left and right ears
respectively.
The results in Table 2 exhibit a significant relationship
between working experience and hearing threshold
ascending in frequencies of 500, 1000, 2000 and 4000 Hz (p
less than 0.05). These results indicate that hearing threshold
of 19.8% of subject with working experience more than 10
years, were exceeded 25dB in frequency of 500 Hz (left
ear), while just 11.9% of those with working experience
less than 10 years have shown this threshold shift, and this
difference is statistically significant. A similar conclusion
can be achieved generally, except for frequencies of 8000
Hz in left ear and 500 and 8000 Hz in right ear. There are
however, some differences in the number of cases in each
aforementioned category [Table 3]. Results indicate that the
longer the time employed as a truck driver, greater is the
hearing loss. The finding is consistent with conclusions[3] of
other investigators. This indicated that loud noise exposure
due to driving might have significantly affected the hearing
threshold levels of professional drivers. This may be due to
being in a noisy environment at different locations for several
years as well as continuous exposure to noise driving all day.
Figures 1 and 2 exhibit overall features of current hearing
threshold of truck drivers in this study. These figures show
that hearing threshold pattern is analogues in both ears. Also,
these figures illustrate that hearing frequency of 2000Hz
contains the least hearing impaired cases (about 10%) and
frequency of 4000Hz contains the most hearing impaired
cases (42%).
Also, hearing thresholds for left and right ears were compared
at each test frequency using Students t-test. No significant
difference was determined (P greater than 0.05). It was
deduced that the occupational conditions of truck drivers
have bilateral, symmetrical effect on hearing threshold sense
in all frequencies. In Figure 3, two group of frequencies
were considered, mid frequencies includes 500, 1000
and 2000 Hz that usually contribute to speech and routine
conversation and high frequencies consists of 4000 and 8000
Hz that usually founded in sounds produced by manmade
and mechanical equipments and have little contributions in
normal conversations (in fact mid frequencies include 500,
Noise & Health, January-March 2010, Volume 12

Karimi, et al.: Hearing loss risk assessment of truck drivers

Table 2: Results of pearson chi-square test for left ear

500 Hz (Left ear)

1000 Hz (Left ear)

2000 Hz (Left ear)

4000 Hz (Left ear)

8000 Hz (Left ear)

*Group 1
**Group 2
Total (n)
Total %
*Group 1
**Group 2
Total (n)
Total %
*Group 1
**Group 2
Total (n)
Total %
*Group 1
**Group 2
Total (n)
Total %
*Group 1
**Group 2
Total (n)
Total %

Working experience
Less than 10 year More than 10 year
214 (88.1)
206 (80.2)
29 (11.9)
51 (19.8)
243
257
48.6
51.4
231 (95.1)
230 (89.5)
12 (4.9)
27 (10.5)
243
257
48.6
51.4
231 (95.1)
233 (90.7)
12 (4.9)
24 (9.3)
243
257
48.6
51.4
182 (74.9)
169 (65.8)
61 (25.1)
88 (34.2)
243
257
48.6
51.4
191 (78.6)
196 (76.3)
52 (21.4)
61 (23.7)
243
257
48.6
51.4

Total (n)

Total (%)

420
80
500
100
461
39
500
100
464
36
500
100
351
149
500
100
387
113
500
100

84
16
100
92.2
7.8
100
92.8
7.2
100
70.2
29.8
100
77.4
22.6
100

Chi-squre test
(P value)
0.016

0.020

0.05

0.026

0.532

*Group1: Hearing threshold Level25dB, **Group2: Hearing threshold Level>25dB, Figures in parenthesis are in percentage

Table 3: Results of Pearson chi-square test for right ear

500 Hz (Right ear)

1000 Hz (Right ear)

2000 Hz (Right ear)

4000 Hz (Right ear)

8000 Hz (Right ear)

*Group 1
**Group 2
Total (n)
Total %
*Group 1
**Group 2
Total (n)
Total %
*Group 1
**Group 2
Total (n)
Total %
*Group 1
**Group 2
Total (n)
Total %
*Group 1
**Group 2
Total (n)
Total %

Working experience
Less than 10 year More than 10 year
197 (81.1)
196 (80.2)
46 (18.9)
61 (23.7)
243
257
48.6
51.4
225 (92.6)
218 (84.8)
18 (7.4)
39 (15.2)
243
257
48.6
51.4
230 (94.7)
229 (91.8)
13 (5.3)
28 (10.9)
243
257
48.6
51.4
179 (73.7)
167 (65)
64 (26.3)
243
48.6
184 (76)
58 (24)
243
48.6

90 (58.4)
257
51.4
200 (77.8)
57 (22.2)
257
51.4

Total (n)

Total (%)

393
107
500
100
443
57
500
100
459
41
500
100
346

78.6
21.4
100

154
500
100
384
115
500
100

30.8
100

88.6
11.4
100
91.8
8.2
100

Chi-squre test
(P value)
0.190

0.020

0.024

69.2

77
23
100

0.036

0.636

*Group1: Hearing threshold Level25dB, **Group2: Hearing threshold Level>25dB, Figures in parenthesis are in percentage

1000, 2000 and 3000 Hz and high frequencies includes 4000,

6000 and 8000 Hz, however, in this study some of these
frequencies haven't been measured).
Average hearing threshold level was calculated for both
mid and high frequencies separately to have single value
of hearing threshold level for each group of frequencies.
Figure 3 exhibits per cent of impaired truck drivers in mid
Noise & Health, January-March 2010, Volume 12

and high frequencies hearing thresholds (greater than 25

dB) vs. those how have normal hearing threshold level in
mid and high frequencies (less than or equal to 25 dB) in
both ears. The recent results showed that about 9-12.6%
of truck drivers suffer from hearing impairment in mid
frequencies, meanwhile the percent of truck drivers with
hearing impairment increased to about 45 in high frequencies
for both ears.
52

Karimi, et al.: Hearing loss risk assessment of truck drivers

Discussion
The pure effect of working experience situation on hearing
threshold shift have been calculated previously with the
help of ISO equation, and the results of Chi-square test
revealed significant relationships between adjusted with age
hearing threshold shift and working experience (as duration
of occupational noise exposure) in most of frequencies.
Audiometric analysis also suggested that effect of duration of
exposure was dependent on frequency. Additionally, it may
be concluded that hearing damage at 4000 and 8000 Hz was
expected to occur sooner than losses at lower frequencies
(500, 1000 and 2000 Hz). The finding is consistent with
conclusions of other investigators. Poor audiometric status
of professional drivers may have resulted from damage to
hair cells near the base of cochlea by high frequency or high
pitch sound of automobiles.[3] Plus the fact that occupational
conditions of truck drivers has significant relevant on auditory
health of drivers, noticeable number of drivers currently
suffer from hearing impairment (9-12.6% in mid frequencies
and 45% in high frequencies).

Figure 1: Percent of hearing impaired subjects (hearing threshold

level >25dB) vs. normal subjects (hearing threshold level 25dB)
in right ear

Beyond the known consequences of bilateral high-frequency

hearing loss and the likelihood of persistent tinnitus, there
is growing evidence that workers exposed to noise in the
workplace (daily dose greater than or equal to 80 dB-A) are
also at higher risk of accident. Somehow, it would seem that
noise exposure and hearing loss may interact to interfere with
the safe discharge of occupational activities.[14,15] Stress-related
disorders are also noteworthy[16] as is an increase of the risk
of motor vehicle accidents.[17] When noise in the workplace
induces temporary or permanent hearing loss,[18] it is
reasonable to expect that this will also affect psychoacoustic
performance[19] by compromising the perception and the
localization of environmental signals, including the recognition
of speech and of warning signals.[20] Hearing loss may contribute
to traffic accident risk in several ways. Among children, it
almost doubles the risk of pedestrian injuries,[21] indicating
that audition does contribute to the safe management of road
hazards. This is confirmed by Lundalv,[22] reporting that adult
pedestrians and cyclists with moderate hearing loss are at a
higher risk of being injured by a vehicle. The same applies to
the risk of accidents by mature drivers who are moderately
hearing impaired.[23]

Figure 2: Percent of hearing impaired subjects (hearing threshold

level >25dB) vs. normal subjects (hearing threshold level25dB)
in left ear

Thus, in the presence of hearing impairment, it remains

possible for the noise of an incoming vehicle and other
vehicular warning signals not to be heard or localized for
a timely and appropriate reaction.[3] Also, a comprehensive
study was conducted by Michel Picaed et al.[15] to verify if there
is an association between occupational noise exposure, noiseinduced hearing loss and driving safety. Their investigations
showed that daily occupational noise exposures greater than
or equal to 100 dBA and noise-induced hearing losses, even
when just barely noticeable (16 to 30 dB) may interfere with

Figure 3: Percent of truck drivers with normal mid and high

frequency hearing thresholds (25dB) vs. impaired mid and high
frequency hearing thresholds (>25dB) in both ears

53

the safe operation of motor vehicles. Hence auditory health

of truck drivers may have noteworthy influence on severity
and frequency rates of traffic accidents. However, having
Noise & Health, January-March 2010, Volume 12

Karimi, et al.: Hearing loss risk assessment of truck drivers

a hearing loss does not necessarily mean that you are more
accident prone.

Conclusions
It may be concluded that the described risk of hearing
impairment of truck drivers is high due to their occupational
hazard. The study highlights the need to take up interventions
to reduce potential harmful effect of noisy situations for the
occupationally exposed truck drivers. Vehicle noise cannot
be totally eliminated, but a lot could be done to reduce it.
Better maintenance of roads, steps may also be taken by
automobile industry to reduce the noise level emission
of vehicles, which will need introduction of improved
automobile technology like masking of engine noise, sound
proofing of vehicles etc. The year of manufacture and
location of engine were two factors that contributed highly
to the level of noise reaching the drivers. Potential harmful
effects of noise exposure to drivers may also be reduced
by reducing number of working hours per day of drivers or
by use of hearing protection devices (HPDs). HPDs reduce
sound in the driving environment, including noise and
signals that may be of interest to drivers. HPDs may reduce
the audibility of certain sounds. There is some concern that
hearing protection devices may contribute to accidents by
interfering with speech communications, the ability to detect
horns or ability to localize incoming sounds.[3] Periodic check
up of drivers audiogram is extremely necessary to determine
auditory threshold levels of the persons working in noisy
area.
A truck driver can be exposed to intense noise over long
periods of time. Continued audiometric evaluation is
necessary among existing drivers to ensure not only that a
driver meets the hearing criteria, but also to examine for any
threshold shift due to noise exposure or any reason. However,
the problem with identifying NIHL in truck drivers, though,
is the lack of reliable baseline data (threshold measures before
the person began the noise-related occupation), the influence
of age on hearing, and individual susceptibility. Bi-annual
medical examinations are required for existing truck drivers
focus on hearing screening and provide data regarding
the change that might be occurring in hearing thresholds.
Training is a crucial component of an effective hearing loss
prevention program. With education comes knowledge and
motivation to protect hearing, but this is the most neglected
aspect of hearing conservation programs about truck drivers
in Iran.
Thus, this study shows that a noticeable number of truck
drivers may have some deficiencies in hearing sense.
Immediate measures such as training, reducing number of
working hours per day of drivers, better maintenance of
roads and reducing vehicle noise emission should be taken
Noise & Health, January-March 2010, Volume 12

to control noise in truck cabins, as this will not only affects

drivers health but also the accident frequency and severity
rates may be influenced thereby.
Address for correspondence:
Dr. Ali Karimi,
Occupational Health Department,
Faculty of Health,
Tehran University of Medical Scinces,
Tehran, Iran.
E-mail: alikarimi57@gmail.com

References
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Karimi, et al.: Hearing loss risk assessment of truck drivers

19. Moore BC. Effects of noise-induced hearing loss on temporal resolution.
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Source of Support: Nil, Conflict of Interest: None declared.

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Sheahan P, Oleary G, Lee G, Fitzgibbon J. Cystic cervical metastases: Incidence and diagnosis using fine needle aspiration biopsy.
Otolaryngol Head Neck Surg 2002;127:294-8.
Only the references from journals indexed in PubMed will be checked.
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Add up to a maximum of 15 references at a time.
If the reference is correct for its bibliographic elements and punctuations, it will be shown as CORRECT and a link to the correct article
in PubMed will be given.
If any of the bibliographic elements are missing, incorrect or extra (such as issue number), it will be shown as INCORRECT and link to
possible articles in PubMed will be given.
Noise & Health, January-March 2010, Volume 12

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