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Linking Exposure To Health Wolfgang Babisch Martin van den Berg

Meeting of the Eionet National Reference Centres for Noise Copenhagen, 14 th - 15 th 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.

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Linking Exposure To Health Wolfgang Babisch Martin van den Berg

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

  2. Calm NetworkVision 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 andPotential 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 andPotential Health Impact • Introduction • Health endpoints • Exposure-response curves • Risk assessment • Cost-benefit analysis • Implications for END • References

  7. Hazard identification Exposure assessment Exposure-response assessment Risk characterization Attributable risk concept END ? Link Risk management Regulatory options Quantitative Risk Assessment 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%-CriterionCommon rule Source: Miedema and Oudshoorn, 2001European 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 NoiseUpdate "Little annoyed" "Annoyed" "Highly annoyed" Newer studiesincluded Newer studiesincluded Newer studiesincluded 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" Noise induced awakening 33 dB (Changes to wake or to sleep-stage S1 within 90 seconds) Probability of sleep stage changes to awake 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, 2009Griefahn and Basner (Internoise), 2009

  16. Hypertension"Spandau Health Survey" Significant effects only with respect to the exposure of the bedroom OR = 1.9 Cross-sectional study, 1718 males and females, aged 18-90 yrsRelative prevalence of treated high blood pressure by road traffic noise level Day - Living room Night - Bedroom Source: UBA - Maschke et al. (2003)

  17. Sleep Disturbance (Subjective) "Highly Sleep Disturbed" WHO Community Noise Guidelines (1999): "Sleep disturbance, window open" WHO Night Noise Guidelines For Europe (2009): "Night noise guideline" 5%-Criterion (?) 35 Aircraft 30 Road 25 Railway 20 Percent highly sleep disturbed (HSD) [%] 15 10 5 0 35 40 45 50 55 60 65 70 75 80 Noise level (Lnight) [dBA] Source: Miedema and Oudshoorn, 2001European Commission Working Group on Health and Socio-Economic Aspects, 2004

  18. Cognitive Impairment"Munich Study" noise no noise 10 New airport Old airport 9 8 7 6 Mean errors 5 Mean errors Mean errors 4 3 2 1 0 Wave 1 Wave 2 Wave 3 Old airport closed 10 9 8 7 6 Mean errors 5 4 3 2 1 0 Wave 1 Wave 2 Wave 3 New airport opened Difficult word list, 326 children 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 ModelRead – Listen - Learn Staffan Hygge Phonological loop Visual loop Working memory Episodic memory Ldn Noise Read Listen 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. Source: Hygge, 2009 (presentation in Helsinki)

  21. Hypothetical Exposure-Response Curve- Cognitively Affected - Staffan Hygge 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. Source: Hygge, 2009 (presentation in Helsinki)

  22. Mental Health No evidence 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. Stress Model Perceived Stimulus Coping PatternsEarly ExperienceGenetics Threat to Control Loss of Control Fight - Flight Depression Nervous System + Adrenaline + Noradrenaline o Cortisol Hypophysis (Pituitary Gland) + ACTH + Cortisol o Catecholamines Sympathetic-Adrenal-Medullar Axis Hypophysio-Pituitary-Adrenal-Cortical Axis Source: Henry & Stephens, 1977

  24. Stress Hormones"Berlin Traffic and Health Study" 26 25 24 Noradrenaline per Creatinine 23 [µg/g] 22 Mean +/- SE 21 20 <14,000 (mean = 2,300) >20,000 (mean = 31,000) Traffic volume [vehicles/day] Cross-sectional study, 195 females, aged 30-45 yrsOvernight excretion of norepinephrine in urine by road traffic volume 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 Disturbance of activities, sleep communication Hearing loss Annoy-ance Cognitive and emotional response Stress Indicators Physiological stress reactions (homeostasis) Autonomic nervous system (sympathetic nerve) Endocrine system (pituitary gland, adrenal gland) Risk Factors Blood pressure Blood lipids Blood viscosity Cardiac output Blood glucose Blood clotting factors Manifest Disorders Cardiovascular Diseases Hypertension Arteriosclerosis Ischaemic heart diseases Sound exposure Disturbance ofintended activities Stress indicators Biologicalrisk factors Cardiovasculardiseases Source: Babisch, 2002

  27. Serum Cholesterol"Caerphilly & Speedwell Studies" Cross-sectional study, 4860 males, aged 45-63 yrsRelative 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 45-63 yrsRelative 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 InfarctionMeta-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 InfarctionMeta-Analysis: Road Traffic Noise Exposure-response function: OR = 1.629657 – 0.000613*(Lday,16h)2 + 0.000007357*(Lday16h)3, R2 = 0.96 OR per 10 dB(A) = 1.17, 95% CI = 0.87-1.57, range = 60-80 dB(A) Relative risk (odds ratio) Traffic noise level Lday,12hr [dB(A)] Ischaemic Heart Disease pooled(5 studies) Source: Babisch, 2006, 2008

  31. Exposure-Response Curve: HypertensionMeta-Analysis: Aircraft Noise Exposure-response function: OR per 10 dB(A) = 1.13, 95% CI = 1.00-1.28, range = 50-70 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 45-70 yrsRelative prevalence of hypertension by road traffic noise Source: Jarup et al., 2008

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

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

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

  36. Attributable Fraction: Cognitive ImpairmentExample: Sweden, Children Staffan Hygge 7-19 year old children * Approximation: European exposure distribution considered for Sweden (Roovers et al., 2000) Source: Hygge, 2009 (presentation in Helsinki)

  37. Attributable Fraction: Myocardial Infarction / IHDExample: Germany, Adults Moyocardial Infarction (MI) Caused By Traffic Noise Reference year 1999 Attributable fraction: 2.9% Germany 1999: MI: 133,115 cases IHD: 849,557 cases Due to road traffic noise: 3,900 MI cases/year 24,700 IHD cases/year MI = Myocardial infarctionIHD = Ischaemic heart diseases * Probabilistic model

  38. Severity vs. Population Affected Mortality Disease(sleep disturbance, cardiovascular) Risk factors(blood pressure, cholesterol,blood clotting, glucose) Stress Indicators(autonomous response, stress hormones) Feelings of discomfort (annoyance, disturbance) Number of people affected Source: Babisch, 2002 (WHO 1992 - modified)

  39. DALYsDisability Adjusted Life Years Idea: Quantification UnitOne 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 settingDALYs as a public health currency? • Cost-benefit analysisMonetary valuation of external costs and benefits (DALYs vs. QUALYs) • DALY = YLL x YLDYLL = 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 WeightsDALYs Disability weights that have been used • Mortality = 1.000 • Non-fatal acute myocardial infarction = 0.406 (WHO) • Ischaemic heart disease = 0.350 (de Hollander, 1999) • High blood pressure = 0.352 (Mathers, 1999) • Primary insomnia = 0.100 (WHO, 2007) • Sleep disturbance = 0.020 (Knol, 2005);0.055 (Müller-Wenk, 2005) • Annoyance = 0.010 (Stassen, 2008);0.033 (Müller-Wenk, 2005) • Cognitive impairment = 0.006 (Hygge, 2009)

  42. Attributable Fraction: AnnoyanceExample: DALYs Per Year For The Netherlands Adults: Disability weight DW = 0.020 "Severe" annoyance('Miedema' curves) Exposure distribution ('Empara') Reference year 2000 Source: Knol and Staatsen, 2005

  43. DALY Examples

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

  45. 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)

  46. Shielding: Terraced HousesLday,12 h

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

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

  49. Exposure Misclassification"Caerphilly & Speedwell Studies" 2.5 2.25 2 1.75 Incidence odds ratio 1.5 (OR +/- 95% CI) 1.25 1 0.75 0.5 0.25 0 Address + Window + Open + 15 yrs only orientation window residence Prospective study, 3950 men, aged 45-63 yrsExtreme group comparison: LAeq,day = 66-70 dB(A) vs. 51-55 dB(A)Relative incidence of major ischaemic heart diseases Source: Babisch et al. , 1999

  50. Environmental Noise Directive(Directive 2002/49/EG) Phase 1 until 30.06.2007 • Major road network > 6 Mio vehicles per year • Major railway network > 60.000 trains per year • Major airports > 50.000 aircraft movements per year • Major agglomerations > 250,000 inhabitants • Action plans until 2008 Phase 2 until 30.06.2012 • Major roads > 3 Mio vehicles per year • Major railway tracks > 30.000 trains per year • Agglomerations > 100,000 inhabitants • Action plans until 2013

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