An Overview of the Non-Auditory Effects of Noise

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2 An Overview of the Non-Auditory Effects of Noise Stephen Stansfeld Centre for Psychiatry, Wolfson Institute of Preventive Medicine, Barts & the London School of Medicine and Dentistry, London UK Environmental noise from transportation and its impacts on health, Centre Médical Universitaire, Faculté de Médecine, Université de Genève, Geneva, Switzerland, 4th June 2018

3 Overview Introduction, exposures, mechanisms and outcomes Evidence on environmental noise and health: Metabolic syndrome, Diabetes, Mental Health, Cognitive Performance Noise and the burden of disease Conclusion

4 The Policy Background in Europe It is estimated that 125 million people are exposed to road traffic noise levels above 55dBA L den (European Environment Agency, 2014). Environmental noise is the second major environmental risk in Europe after air pollution (Hanninen et al, 2014). The Environmental Noise Directive [END] [Directive 2002/49/EC] defines a common approach across the European Union for avoiding, preventing or reducing the harmful effects of environmental noise exposure. Develop noise maps to describe the exposure of the population to noise from sources including aircraft, road, railway, industry: and develop action plans to enable the preservation of quality areas and to reduce noise pollution where necessary.

5 Health effects of transportation noise Primary health outcomes: Cardiovascular disease (hypertension, myocardial infarction, stroke) Sleep disturbance Annoyance Cognitive impairment Secondary health outcomes: Diabetes and metabolic outcomes Adverse birth outcomes Quality of life, wellbeing and mental ill-health

6 Noise metrics Most health effects result from long duration exposures, thus energy-averaged exposures are suitable for most epidemiological studies- (effect of a combination of noise events is normally related to the combined sound energy of those events) L AeqT where T is from 1-24 hours Day-night Average Levels L dn or L den, with 10dBA penalty for night and a 5dBA penalty for evening Maximum level L Amax maximal level of a noise event may be useful in sleep studies Time above (total time in seconds) or number above (number of events above threshold) above a certain threshold, often 70dBA

7 Noise and the Arousal Hypothesis Coping Noise Physiological hyper-reactivity Illness Appraisal

8 Relation between air traffic noise exposure and morning saliva cortisol levels among 439 subjects in six European Countries* All Women Men L Aeq, 24h (db) No. Coefficient (95% CI) No. Coefficient (95% CI) No. Coefficient (95% CI) Categorical <50** > 50 to <60 > (-1.61 to 3.68) 1.83 (-0.90 to 4.35) (-1.26 to 5.59) 6.07 (2.32 to 9.81) (-3.64 to 3.76) (-5.61 to 1.61) *All analyses adjusted for road traffic, country, age, sex, employment status, occupational status, medication use, BMI, alcohol, diet, remedy during night and other noise sources in living environment. ** Reference category, arithmetic mean cortisol level: all = nmo/l, women = 17.7 nmol/l, men = nmol/l. (Selander et al, 2009)

9 Aircraft noise and salivary cortisol: DEBATS Study (Lefèvre et al, 2016) 1244 subjects exposed to aircraft noise around 3 French international airports Morning and evening cortisol measurements Significant association between aircraft noise exposure and evening cortisol levels In fully adjusted model exp (B)= %CI for 10dB increase in Lden corresponding to a 15-17% increase in mean cortisol level for each 10dBA rise in noise level Indicates a smaller daytime variation in cortisol than normal

10 Noise exposure and risk of Diabetes (van Kempen et al, 2018) Noise source Outcome RR per 10dB Participants Air traffic Prev 1.01 ( ) 9365 Inc 0.99 ( ) 5156 Road traffic Prev Inc 1.08 ( ) Rail traffic Prev 0.21 ( ) 9365 Inc 0.97 ( ) 57053

11 Road traffic noise and incidence of Diabetes mellitus (Sørensen et al, 2013)

12 Road traffic noise, waist circumference and obesity Road traffic noise associated with yearly weight gain (15.4g 95%CI 2.14,28.7) and waist circumference (0.22mm 95%CI 0.018,0.43) per 10 db in 39,720 Danish middle-aged men and women followed for 5.3 years (Christensen et al, 2015) Road traffic noise associated with BMI (slope, beta %CI 1.01,1.03 and waist hip ratio (OR=1.24, 95%CI 1.01,1.53) per 10dB increase in noise level in noise sensitive women only from the population based Norwegian HUBRO Study (Oftedal et al, 2015) Road traffic noise associated with waist circumference, central obesity for exposure >45dB (OR= %CI 1.03,1.34) but not BMI in 5075 Swedish men and women (Pyko et al, 2015)

13 Air and road traffic noise and low birth weight Mark Nieuwenhuijsen (WHO systematic review) Aircraft noise Road traffic noise Authors Ando & Hattori, 1973 Low birth weight + Gestation length Comments Schell Lbw boys only Knipschild Girls only Matsui Smoking not accounted for Wu et al Gehring Dadvand Explained by heat and air pollution

14 Mental health and cognitive effects of environmental noise

15 Health outcomes assessed in WHO reviews of cognition and mental health Cognitive function: narrative reviews of reading comprehension, standardised achievement tests, short and long term memory, attention, working memory, executive function Mental ill-health: narrative reviews of quality of life, depressive and anxiety disorders, psychotropic medication in adults, emotional and behavioural disorders and wellbeing in children

16 Cognitive function WHO Review (Clark et al, 2018) 34 papers 18 from systematic search, 16 additional searches All in children, mainly 8-12 years Cross-sectional 82%, Longitudinal 21%, intervention 15% Reading comprehension aircraft noise 10/14 studies high quality evidence (not road traffic noise, no rail studies) Standardised assessment tests (SATS) aircraft noise 4/7 studies, high quality evidence; road traffic noise 4/4, low quality; railway noise 2/2, high quality

17 Exposure-effect relationship between aircraft noise at school and reading comprehension Reading Z-score.4 Reading age was delayed by up to 2 months in the UK and 1 month in the NL for a 5dB change in noise exposure aircraft noise db(a) Increasing aircraft noise exposure was associated with impairment of reading comprehension (B=-0.008, 95% CI to , p=0.001) (Stansfeld et al, 2005; Clark et al, 2006)

18 Exposure-effect between aircraft noise at school & reading comprehension Aircraft noise exposure LAeq 8am-2pm The RANCH Project: Stansfeld et al 2005; Clark et al, 2006 The NORAH Study: Klatte et al, 2014

19 Cognitive Function 2 WHO Review (Clark et al, 2018) Long term memory: aircraft noise 6/11moderate quality; road traffic noise 2/7 very low quality; railway noise 1/1 low quality Attention: aircraft noise 5/10 moderate quality; road traffic noise 2/5 low quality; railway noise 0/1 low quality Working memory: aircraft noise 0/9 very low quality; road traffic noise 0/5 low quality; railway noise no studies

20 Road Traffic Noise and Mean Anxiety Score Caerphilly Study Noise level (db(a)) Anxiety Symptoms (N=1853) * Adjusted for age, social class, noise sensitivity and baseline anxiety *P<0.03 (Stansfeld et al, 1996)

21 Aircraft and Psychiatric Disorder: Elmas Survey (n=71) Composite International Diagnostic Interview Control Exposed OR CI Generalised Anxiety Disorder Generalised Anxiety Disorder nos Major Depressive Disorder Major Depressive Disorder nos No measurement of noise levels; response rate low (Hardoy et al, 2005)

22 Odds Ratios (OR) (95% CIs) of medication use related to aircraft and road traffic noise per 10 db increase Medication group Noise source OR (95% CI) N Anxiolytics L Aeq 16h Aircraft L night Aircraft 1.28 (1.04 to 1.57) 1.27 (1.01 to 1.59) L Aeq 24h Road traffic 1.06 (0.84 to 1.33) 4642 Hypnotics L Aeq 16h Aircraft L night Aircraft 0.96 (0.76 to 1.22) 0.90 (0.70 to 1.14) L Aeq 24h Road traffic 1.28 (0.96 to 1.71) 4642 Antidepressants L Aeq 16h Aircraft L night Aircraft L Aeq 24h Road traffic 1.07 (0.90 to 1.26) 0.96 (0.81 to 1.13) 0.97 (0.78 to 1.21) (Floud et al 2010)

23 Mental Health WHO Review (Clark et al, 2018) Post-2005 review identified 29 papers 66% adult, 34% child populations 83% cross sectional,17% longitudinal, 3% interventions 83% road traffic, 41% aircraft noise Quality of life/health: aircraft noise (5/7), road traffic noise (9/13) very low quality evidence for no substantial effect but railway noise weak effect Self-reported depression or anxiety: road traffic noise (2/4), low quality evidence of no effect

24 Mental Health 2 WHO Review (Clark et al, 2018) Medication for anxiety/depression: aircraft noise (1/1), low quality; road traffic noise (2/3), very low quality for no effect Interview measures of depression/anxiety: aircraft noise (1/1),very low quality for an effect; road traffic noise (0/1), moderate quality for no effect Emotional and Conduct Disorders in children: aircraft noise (0/5), high quality for no effect; road (7/8) and rail noise (1/1), high quality for an effect Hyperactivity Disorder: aircraft (2/3) and road traffic (2/4), for an effect

25 Transport noise and Depression: Frankfurt Study (Seidler et al, 2016) Noise source Noise level OR 95% CI Road traffic 24h >70dB Aircraft db Railway db Combined >50dB ,295 cases, 578,246 controls, 40 yrs+ Insurance claims and prescription data

26 Road traffic noise and depressive symptoms (Orban et al, 2016) 3300 subjects, years, from Heinz Nixdorf recall study followed over 5 years Modelled road traffic noise, CES-D depression>17 RR=1.29 (95%CI ) for exposure>55db vs <55dB Results maintained after adjustment for confounding including individual and neighbourhood level SES Stronger effects in those with baseline insomnia and those with less than 13 yrs of education

27 Evidence for noise-health relationship Effect Passchier-Vermeer& Passchier (2000) Babisch (2004, 2006, 2009) WHO (2009) EEA (2010) Classification of the evidence Annoyance sufficient - sufficient sufficient Hypertension sufficient (inadequate)/ limited/ sufficient (aircraft) limited sufficient Cardiovascular disease (inc. ischemic heart disease and myocardial infarction) sufficient (limited)/ sufficient limited sufficient Self reported sleep disturbance sufficient - sufficient sufficient Awakening sufficient - sufficient sufficient Sleep (arousal, motility, sleep quality) Heart rate, body movements during sleep sufficient - sufficient sufficient sufficient - sufficient - Hormonal changes during sleep limited limited limited - Performance, fatigue next day limited - limited - Stress hormones limited - limited sufficient Learning, memory, performance sufficient - - sufficient Immune effect limited Birth weight limited Well being limited - limited sufficient

28 Environmental noise and the burden of disease DALYS lost from environmental noise: 61,000 years - IHD The WHO has estimated that: 45,000 years - cognitive impairment in children 903,000 years - sleep disturbance 654,000 years - annoyance Based on exposure response relationships, exposure distribution, prevalence of disease and disability weighting 1 million healthy life years lost every year from traffic-related noise in Western Europe (WHO, 2011) (WHO, 2011

29 Conclusions Environmental noise exposure is widespread in Europe Evidence of effects of road traffic noise on metabolic syndrome markers Evidence of effects of aircraft noise on children s reading and standardised test assessment scores Evidence of effect of road noise on children s emotional and conduct disorders Mixed evidence on low birth weight and other birth outcomes