








key: cord-269568-vwkawh6x
authors: Ten Hulzen, Richard D.; Fabry, David A.
title: Impact of Hearing Loss and Universal Face Masking in the COVID-19 Era.
date: 2020-08-03
journal: Mayo Clin Proc
DOI: 10.1016/j.mayocp.2020.07.027
sha: 
doc_id: 269568
cord_uid: vwkawh6x

nan

Abbreviations: COVID-19 = coronavirus disease 2019; dB = decibel; ED = Emergency Department; FFP = filtering face piece; FM = frequency modulation; Hz = Hertz; ICU = Intensive Care Unit; N95 mask = a particulate-filtering face mask that filters at least 95% of airborne particles; PPE = personal protective equipment; PSAPs -personal sound amplification products; SARS-CoV-2 = severe acute respiratory syndrome-coronavirus-2.

In the current coronavirus disease 2019 (COVID-19) pandemic, health and government officials are encouraging, even mandating, community-wide face mask wearing (i.e., universal masking) to reduce potential pre-symptomatic or asymptomatic transmission of severe acute respiratory syndromecoronavirus-2 (SARS-CoV-2) to others. There are three major categories of masks being used to limit the airborne transmission of large respiratory droplets and infectious agents: a respirator, or filtering face piece (FFP), such as a N95 mask; medical face masks, such as a surgical or procedure mask; and nonmedical masks, such as commercially-or self-made masks usually made of cloth or other textiles. Based on mechanistic plausibility and the desire to reduce SARS-CoV-2 transmission and community impact, universal masking is recommended as a means of source control of both symptomatic and pre-symptomatic/asymptomatic individuals to prevent the spread of infectious respiratory droplets to others.

In addition to universal masking, the community can mitigate the risk of transmitting and acquiring SARS-CoV-2 by physical distancing (> 6 feet apart), remaining at home, avoiding crowded or public places, working remotely from home, respiratory etiquette, frequent handwashing, and avoiding unnecessary hand-face contact. 1 Health care facilities may also restrict family members and interpreters from accompanying patients during surgery, Emergency Department (ED) visits, Intensive Care Unit (ICU) stays, or hospitalizations. While these measures arguably are epidemiologically-appropriate, the negative impact these measures have had on the short supply of masks and other personal protective equipment (PPE) has been widely reported. In addition, universal masking is a barrier to clear empathetic communication.

We'd like to call attention to the negative impacts of universal masking and social distancing in both health-care and community settings for individuals with hearing loss. Approximately 14.1% of American adults (27.7 million) aged 18 and over report some difficulty hearing. 2 Hearing loss impacts all age groups, yet it is more prevalent among unscreened older adults-who are also likely to be without hearing assistance. For 60-69 year-olds, the prevalence for hearing loss affecting speech intelligibility was 39.3%. 2 In addition, COVID-19 fatality rates are higher in older adults who are frail with other comorbidities. Current policies often require patients to be unaccompanied by supporting family members. This can be detrimental to effective communication, patient safety, and quality healthcare with individuals with hearing loss who cannot understand attenuated and distorted speech nor gain clues from lip-reading and facial expressions due to universal masking. A recent study showed each type of mask wearing causes a low-pass filter effect attenuating the higher frequencies (2000-7000 Hertz, or dB for the N95 mask (respirator/FFP). 3 While both age-related hearing loss and FFP masking portend substantial high-frequency region (2000-4000 Hz) inaudibility and speech understanding reduction compared to normal hearing individuals when no mask is worn, the addition of a noisy background setting (e.g., ED/ICU) further confounds this and makes communication extremely difficult, if not impossible.

Social distancing also has an impact on speech audibility. Sounds rapidly become quieter as they travel away from their sources. The decibel (dB) scale logarithmically quantitates the relative intensities of sound-a sound with an intensity of half that of a reference sound corresponds to a decrease of little more than 3 dB. The inverse square law states that doubling the distance reduces the sound intensity to a quarter of its initial value. If the distance is doubled, then a 6 dB reduction in sound intensity is noted.

While conversational distances between two talkers in the United States typically ranges from 1.5 to 3 feet, the currently recommended social distancing of at least 6 feet (which translates to a doubling or even quadrupling of the distance) means the sound pressure level drops by 6 to 12 dB, or more. Social Healthcare professionals should recognize that, with the loss of visual cues (i.e., lip reading) and support systems (e.g., family members), current COVID-19 policies such as universal masking, social distancing, and unaccompanied patients may "unmask" significant hearing loss-related issues that previously had been diminished or ignored. Personal sound amplification products (PSAPs) tend to work best for individuals with rather mild hearing loss, while those with more advanced hearing loss may benefit from further audiologic evaluation for hearing aids or even cochlear implants. Hospitals and clinics may wish to consider loaner amplification systems (e.g., hearing aids) or use a FM system where the physician uses a microphone lanyard)-however this may be a challenging endeavor given the issues of cost, device decontamination, and potential cross-infection. Additional resources and temporary recommendations for healthcare facilities are continually updated and available online (https://www.nad.org/covid19-communication-access-recs-for -hospital/). 6 Healthcare professionals • Speak slightly louder, and with a minimally-reduced rate • Rephrase-rather than repeating the same words, shouting, exaggerated pronunciation, etc.

• Take turns when speaking

• Optimize positioning (i.e., face-to-face, not moving around or walking)

• Use low-tech methods (e.g., pen-and-paper, clear partitions)

• Use high-tech methods (e.g., Wi-Fi enabled tablets, video chat apps on smartphones)

• Use video-conferencing platforms (e.g., telemedicine, unmasked, without PPE)

• Use clear (or clear-paneled) masks to improve visibility of facial expressions / lip-reading cues • Use personal sound amplification products (PSAPs)

• Use loaner hearing aids or frequency modulation (FM) systems along with a microphone lanyard

• Use scribes or professional support staff to assist healthcare professionals with hearing loss a FM = frequency modulation; PPE = personal protective equipment; PSAPs = personal sound amplification products

European Centre for Disease Prevention and Control

Declining Prevalence of Hearing Loss in US Adults Aged 20 to 69 Years

Speech blocked by surgical masks becomes a more important issue in the Era of COVID-19. The Hearing Review

Effect of facemasks on empathy and relational continuity: a randomized controlled trial in primary care

Time to take hearing loss seriously

COVID-19: Deaf and Hard of Hearing Communication Access Recommendations for the Hospital. NAD website



