1. Linking Exposure To Health
Meeting of the Eionet National Reference Centres for Noise Copenhagen, 14th - 15th October 2009
Linking Exposure To Health
Wolfgang Babisch Martin van den Berg
European Environment Agency Expert Panel on Noise (EPoN)
European Environment Information and Observation Network

2. Calm Network Vision for the Year 2020
“Avoid harmful effects of noise exposure from all sources and preserve quiet areas.”
Community Research Strategy Plan
Source: CALM, 2004
Coordination of European Research for Advanced Transport Noise Mitigation

3. Health
WHO Constitution (1948):
Health is a state of complete
physical
mental and
social well-being
and not merely the absence of disease or infirmity.

4. Well-being and Ill-health

5. Expert Panel on Noise (EPoN) Fact Sheet
Fact-sheet on Noise Exposure and Potential Health Impact
Introduction
Health endpoints
Exposure-response curves
Risk assessment
Cost-benefit analysis
Implications for END
References

6. Expert Panel on Noise (EPoN) Fact Sheet
Fact-sheet on Noise Exposure and Potential Health Impact
Introduction
Health endpoints
Exposure-response curves
Risk assessment
Cost-benefit analysis
Implications for END
References

7. Quantitative Risk Assessment
Hazard identification
Exposure-response assessment
Exposure assessment
Risk characterization
Attributable risk concept
Risk management
Regulatory options
END ?
Link
Research !

8. Health Endpoints "Hazard Identification"
Hearing loss
Annoyance
Sleep disturbance (objective and subjective)
Cognitive impairment
Mental health
Physiological stress reaction
Cardiovascular risk

9. Annoyance "Highly Annoyed"
WHO Community Noise Guidelines (1999):
"Serious annoyance"
25%-Criterion Common rule
Source: Miedema and Oudshoorn, 2001 European Commission Working Group on Dose-Effect Relations, 2002

10. Change of Annoyance "Hyena Study"
Road traffic noise
Aircraft noise
Δ = 7-8 dB(A)
Source: Babisch et al., 2009

11. Annoyance Due To Aircraft Noise Update
"Little annoyed"
"Annoyed"
"Highly annoyed"
Newer studies included
Newer studies included
Newer studies included
Older studies
Older studies
Older studies
Source: TNO, 2009

12. Sleep
Normal sleep
Noise disturbed sleep
Source: Maschke et al., 2000

13. Sleep Disturbance (Objective) Awakenings (Single Aircraft Flyover) – "DLR Laboratory Study"
(Changes to wake or to sleep-stage S1 within 90 seconds)
Probability of sleep stage changes to awake
Noise induced awakening
33 dB
Spontaneous awakening
Maximum Sound Pressure Level LAS,max [dB]
Source: Basner et al., 2006

14. Sleep Disturbance (Objective) Aircraft Noise Simulation – "DLR Field Study"
Moderate Effects in Vulnerable Groups
Steep Increase of Adverse Effects
Public Health Hazard
Lnight, outside (aircraft)
365 EEG awakenings per year
Figure 1: The average number of additionally aircraft noise induced awakenings per night. Altogether, 10 million 8-hour nights with 1 to 200 (1, 2, 3,…, 200) noise events randomly drawn from the DLR field study 20 were simulated. The lines represent (from below to above) 2.5, 25, 50, 75, and 97.5 percentiles. In an 8 h undisturbed night of a healthy sleeper, on average 24 spontaneous EEG awakenings (as defined by Rechtschaffen and Kales1) can be observed (equaling 8,760 spontaneous awakenings per year).
Source: Basner and Griefahn, 2008

15. Sleep Disturbance  Health (?)
Noise and transient sleep disturbance - well developed area with statistically robust data and dose-response relationships.
No quantitative link yet established between acute or transient sleep disturbance caused by noise and any long term adverse health effects.
No consensus on any single dose-response relationship which could be used to inform cost benefit analysis, monetary evaluation of adverse health effects, policy etc.
Source: Bell report, 2009 Griefahn and Basner (Internoise), 2009 15

16. Significant effects only with respect to the exposure of the bedroom
Hypertension "Spandau Health Survey"
Cross-sectional study, 1718 males and females, aged yrs Relative prevalence of treated high blood pressure by road traffic noise level
Significant effects only with respect to the exposure of the bedroom
OR = 1.9
Day - Living room
Night - Bedroom
Source: UBA - Maschke et al. (2003)

17. Percent highly sleep disturbed (HSD) [%] Noise level (Lnight) [dBA]
Sleep Disturbance (Subjective) "Highly Sleep Disturbed" 35
Aircraft 30
Road 25
Railway 20
WHO Night Noise Guidelines For Europe (2009):
"Night noise guideline"
WHO Community Noise Guidelines (1999):
"Sleep disturbance, window open"
Percent highly sleep disturbed (HSD) [%] 15 10
5%-Criterion (?) 5 35 40 45 50 55 60 65 70 75 80
Noise level (Lnight) [dBA]
Source: Miedema and Oudshoorn, 2001 European Commission Working Group on Health and Socio-Economic Aspects, 2004

18. Cognitive Impairment "Munich Study"
no noise
noise
Difficult word list, 326 children
New airport 1 2 3 4 5 6 7 8 9 10
Mean errors
Wave 1
Wave 2
Wave 3
New airport opened
Old airport
Wave 1
Wave 2
Wave 3
Old airport closed 1 2 3 4 5 6 7 8 9 10
Mean errors
Source: Hygge et al., 2002

19. Reading Comprehension "Ranch Study"
Aircraft noise associated with deficits in reading comprehension and recognition memory
2844 children
Reading Z-score
Aircraft noise at school LAeq,16h [dB]
Source: Stansfeld et al., 2005

20. Basic Memory Model Read – Listen - Learn
Ldn
Noise
Working memory
Episodic memory
Read
Listen
Phonological loop
Visual loop
It could be noted that:
Both chronic noise exposure in the field study and acute noise exposure in the experiments impair episodic memory, in particular recall.
There is a strong similarity in how much and in what way children and adults are affected by noise.
Staffan Hygge
Source: Hygge, 2009 (presentation in Helsinki)

21. Hypothetical Exposure-Response Curve - Cognitively Affected -
Assuming that 100% of the noise exposed are cognitively affected at a very high noise level, e.g. 95 Ldn, and that none are affected at a safely low level, e.g. 50 Ldn, a straight line (linear accumulation) connecting these two points, as in the Figure below can be used as basis for approximation.
Staffan Hygge
Source: Hygge, 2009 (presentation in Helsinki)

22. No evidence Mental Health v. Kamp and Davies (2008):
"... there is no direct association between environmental noise and mental health". "Noise annoyance is consistently found to be an important mediator."
Clark and Stansfeld (2007):
"Overall, studies suggest that both adults and children noise exposure is probably not associated with serious psychological illness, but there may be effects on well-being and quality of life."
Source: Bell report, 2009

23. Coping Patterns Early Experience Genetics
Stress Model
Perceived
Stimulus
Coping Patterns Early Experience Genetics
Fight - Flight
Nervous System
+ Adrenaline
+ Noradrenaline o Cortisol
Hypophysis (Pituitary Gland)
+ ACTH
+ Cortisol o Catecholamines
Depression
Threat to Control
Loss of Control
Sympathetic-Adrenal-Medullar Axis
Hypophysio-Pituitary-Adrenal-Cortical Axis
Source: Henry & Stephens, 1977

24. Traffic volume [vehicles/day]
Stress Hormones "Berlin Traffic and Health Study"
Cross-sectional study, 195 females, aged yrs Overnight excretion of norepinephrine in urine by road traffic volume
Mean +/- SE 20 21 22 23 24 25 26
<14,000 (mean = 2,300)
>20,000 (mean = 31,000)
Traffic volume [vehicles/day]
Noradrenaline
per Creatinine
[µg/g]
LAeq,24h < 60 dB
LAeq,24h > 65 dB
Source: Babisch et al. (2001)

25. Habituation / Adaption
With respect to environmental noise acute noise effects occur, in particular, when certain activities such as concentration, relaxation or sleep are disturbed.
Even subjects that have been living for many years in exposed homes show physiological stress reactions.
During sleep no complete habituation takes place. Even subjects who are subjectively disturbed by the noise show acute physiological reactions to single noise events.
Figure: Maschke, 2004

26. Simplified Noise Reaction Model
Noise Exposure (Sound Level)
Direct pathway
Indirect pathway
Hearing loss
Disturbance of activities, sleep communication
Cognitive and emotional response
Annoy-ance
Autonomic nervous system (sympathetic nerve)
Endocrine system (pituitary gland, adrenal gland)
Cardiovascular Diseases
Hypertension Arteriosclerosis Ischaemic heart diseases
Stress Indicators
Risk Factors
Blood pressure
Blood lipids
Blood viscosity
Cardiac output
Blood glucose
Blood clotting factors
Manifest Disorders
Physiological stress reactions (homeostasis)
Sound exposure
Disturbance of intended activities
Stress indicators
Biological risk factors
Cardiovascular diseases
Source: Babisch, 2002

27. Serum Cholesterol "Caerphilly & Speedwell Studies"
Cross-sectional study, 4860 males, aged yrs Relative concentration of serum cholesterol by road traffic noise
Traffic noise level Lday,16h [dB(A)]
Source: Babisch et al., 1993

28. Plasma Viscosity "Caerphilly & Speedwell Studies"
Cross-sectional study, 4860 males, aged yrs Relative concentration of plasma viscosity by road traffic noise
Traffic noise level Lday,16h [dB(A)]
Source: Babisch et al., 1993

29. Exposure-Response Curve: Myocardial Infarction Meta-Analysis: Road Traffic Noise
5 studies
Heterogeneity: p = 0.943
Traffic noise level Lday,12hr [dB(A)]
Source: Babisch, 2006

30. Exposure-Response Curve: Myocardial Infarction Meta-Analysis: Road Traffic Noise
Exposure-response function:
OR = – *(Lday,16h) *(Lday16h)3, R2 = 0.96
OR per 10 dB(A) = 1.17, 95% CI = , range = dB(A)
Traffic noise level Lday,12hr [dB(A)]
Relative risk (odds ratio)
Ischaemic Heart Disease
pooled (5 studies)
Source: Babisch, 2006, 2008

31. Exposure-Response Curve: Hypertension Meta-Analysis: Aircraft Noise
Exposure-response function:
OR per 10 dB(A) = 1.13, 95% CI = , range = dB(A)
pooled (5 studies)
Heterogeneity: p = 0.002
Source: Babisch und van Kamp, 2008

32. Road Traffic Noise - Hypertension "Hyena Study"
Hyena study, 4861 subjects, age yrs Relative prevalence of hypertension by road traffic noise
Source: Jarup et al., 2008

33. Quantitative Risk Assessment
Hazard identification
Exposure-response assessment
Exposure assessment
Risk characterization
Attributable risk concept
Risk management
Regulatory options
Link

34. Established Exposure Response Relationships
Annoyance
Sleep disturbance (subjective)
Cognitive impairment (children)
Cardiovascular

35. Population attributable risk
Attributable Fraction Formula
Population attributable risk
Impact fraction
AF = {(Pi * RRi) - 1} /  (Pi * RRi)
where: Pi = Proportion of the population in exposure category i RRi = relative risk at exposure category i compared to the reference level

36. Attributable Fraction: Cognitive Impairment Example: Sweden, Children
7-19 year old children
Noise exposure level Ldn
No. of children exposed *
% who will develop noise-induced cognitive impairment
N with noise-induced cognitive impairment per year
< % % 20
56 599 % 50
81 919
> %
29 789 75
22 342
Total %
* Approximation: European exposure distribution considered for Sweden (Roovers et al., 2000)
Staffan Hygge
Source: Hygge, 2009 (presentation in Helsinki)

37. Moyocardial Infarction (MI) Caused By Traffic Noise
Attributable Fraction: Myocardial Infarction / IHD Example: Germany, Adults
Moyocardial Infarction (MI) Caused By Traffic Noise
Reference year 1999
Average sound pressure level during the day (6-22 h) Lday,16hr [dB(A)]*
Percentage exposed [%]
Relative risk of myocardial infarction [OR] *)
<= 60
69.1
1.000
>60 – 65
15.3
1.031
>65 – 70
9.0
1.099
>70 – 75
5.1
1.211
>75
1.5
1.372
Attributable fraction: 2.9%
Germany 1999:
MI: ,115 cases
IHD: 849,557 cases
Due to road traffic noise:
3,900 MI cases/year
24,700 IHD cases/year
MI = Myocardial infarction IHD = Ischaemic heart diseases
* Probabilistic model

38. Severity vs. Population Affected
Mortality
Disease (sleep disturbance,
cardiovascular)
Stress Indicators (autonomous response, stress hormones)
Risk factors (blood pressure, cholesterol, blood clotting, glucose)
Feelings of discomfort
(annoyance, disturbance)
Number of people affected
Source: Babisch, 2002 (WHO modified)

39. DALYs Disability Adjusted Life Years
Idea: Quantification Unit One figure to aggregate different effects of different severity
Life expectancy: mortality, morbidity, loss of healthy life-years    
Quality of life: severe feelings of discomfort, reduced ability to concentrate, unfavourable health perception and stress in relation to poor quality of the local environment
Social magnitude: number of people affected
Source: de Hollander et al., 2001, 2004

40. DALYs
Priority setting DALYs as a public health currency?
Cost-benefit analysis Monetary valuation of external costs and benefits (DALYs vs. QUALYs)
DALY = YLL x YLD YLL = ND (number of deaths) x DW (disability weight) x LD (standard life expectancy at age of death in years) YLD = NI (number of incident cases) x DW (disability weight) x LI (average duration of disability in years)
Severity weight factors (disability weights) Ethics (dependent on cultural weighing systems), who decides (experts)?

41. Disability Weights DALYs
Disability weights that have been used
Mortality = 1.000
Non-fatal acute myocardial infarction = (WHO)
Ischaemic heart disease = (de Hollander, 1999)
High blood pressure = (Mathers, 1999)
Primary insomnia = (WHO, 2007)
Sleep disturbance = (Knol, 2005); (Müller-Wenk, 2005)
Annoyance = (Stassen, 2008); (Müller-Wenk, 2005)
Cognitive impairment = (Hygge, 2009)

42. Attributable Fraction: Annoyance Example: DALYs Per Year For The Netherlands
Adults:
Disability weight DW = 0.020
"Severe" annoyance ('Miedema' curves)
Exposure distribution ('Empara')
Noise exposure level Lden
No. exposed population
< 40
3 %
40-50
17 %
50-60
56 %
> 60
24 %
Total
100 %
Noise source
DALYs per million people per reference year
Road
1122
Air 16
Rail 65
Total
1203
Reference year 2000
Source: Knol and Staatsen, 2005

43. DALY Examples Example: Severe annoyance Netherlands
Severe sleep disturbance Netherlands
Cognitive effects Sweden
Ischaemic heart diseases Germany
Subjects
Adults
Children 7-19 yrs
Total population
Ca. 14 Mio
Ca. 1.5 Mio
Ca. 70 Mio
Exposure
Empara
EU estimate
Probabilistic UBA
Reference year
2000
1999
Disability weight
0.02
0.006
0.350
DALYs per Million of people
1203
591
648
361

44. Economic Valuation Example: Switzerland
Source: Swiss Federal Office for Spatial Development, 2004, 2008 44

45. Environmental Noise Directive, Noise Mapping Which purpose?
Exposure Assessment
Environmental Noise Directive, Noise Mapping
Which purpose?
Identification of hot spots (exposure)
Public health (affected population in general)
Action plans
Regulatory (limit values)
Epidemiological study (individual exposure) 45

46. Shielding: Terraced Houses Lday,12 h

47. Distance from the road (meters)
Exposed Side: High Blood Pressure "Inn Valley Study"
Proximity to road, room orientation
Distance from the road (meters)
Proportion with hypertension
Source: Lercher et al. (2000)

48. Systolic blood pressure
Modifiers of Exposure: Windows "Inn Valley Study"
Systolic blood pressure
Source: Lercher et al, 2000

49. Exposure Misclassification "Caerphilly & Speedwell Studies"
Prospective study, 3950 men, aged yrs Extreme group comparison: LAeq,day = dB(A) vs dB(A) Relative incidence of major ischaemic heart diseases
0.25
0.5
0.75 1
1.25
1.5
1.75 2
2.25
2.5
Address
only
+ Window
orientation
+ Open
window
+ 15 yrs
residence
Incidence odds ratio
(OR +/- 95% CI)
Source: Babisch et al. , 1999

50. Environmental Noise Directive (Directive 2002/49/EG)
Phase 1 until
Major road network > 6 Mio vehicles per year
Major railway network > trains per year
Major airports > aircraft movements per year
Major agglomerations > 250,000 inhabitants
Action plans until 2008
Phase 2 until
Major roads > 3 Mio vehicles per year
Major railway tracks > trains per year
Agglomerations > 100,000 inhabitants
Action plans until 2013

51. Augsburg Noise Maps House At A Close Distance To A Major Road
City Map ("RLS90")
END Map ("VBUS")
Software: Cadna

52. Augsburg Noise Maps House At A Close Distance To A Major Road
City Map
END Map
Front / back side Lday, 16h: 70/50 dB(A)
Δ = 20 dB(A)
Front / back side Lday, 12h: 67/44 dB(A)
Δ = 23 dB(A)
Software: Cadna

53. Augsburg Noise Maps House At A Far Distance To A Major Road
City Map
END Map
Software: Cadna

54. Augsburg Noise Maps House At A Far Distance To A Major Road
City Map
END Map
Front / back side Lday, 16h: 62/46 dB(A)
Δ = 16 dB(A)
Front / back side Lday, 12h: 44/43 dB(A)
Δ = 1 dB(A)
Software: Cadna

55. Conclusions
Exposure-response relationships are available
Methods for quantitative risk assessment are established
Applicable for general noise policies and action planning ("what happens - if" scenarios)
DALYs for combining effects (?)
Economic valuation for decision making (?)
Exposure assessment must be comprehensive
END underestimates the true exposure

56. Thank You For Listening
“Calling noise a nuisance is like calling smog an inconvenience” (W. H. Steward, former Surgeon General of USA)
Contact:

57. Environmental Noise Quality Targets
Cardiovascular: Lday ≤ 65 dB(A)
Serious annoyance: Lday ≤ 55 dB(A)
Moderate annoyance: Lday ≤ 50 dB(A)
Cardiovascular: Lnight ≤ 55 dB(A)
Sleep disturbance: Lnight ≤ 45/40 dB(A)
Outdoors

58. UBA Quality Targets "Federal Environment Agency, Germany"
Short-term Prevention of health risk Lden = 65, Lnight = 55
Intermediate Reduction of serious annoyance Lden = 60, Lnight = 50
Long-term Avoidance of serious annoyance Lden = 55, Lnight = 45

59. Epidemiological Reasoning
Coherence (biological plausibility)
Consistency with other studies in different populations and with different methodology
Presence of dose-response relationship
Magnitude of effect
Even small relative risks may be relevant for public health

60. Coping: Stress Hormones "Berlin Traffic And Health Study"
Cross-sectional study, 195 females, aged yrs Overnight excretion of nor-epinephrine in urine by road traffic volume
Subjects had no control over the noise
Subjects had control over the stimulus
Source: Babisch et al., 2001