Noise Exposure and Public Health Willy Passchier-Vermeer1 and Wim F

Noise Exposure and Public Health Willy Passchier-Vermeer1 and Wim F. Passchier2 1TNO Prevention and Health, Leiden, The Netherlands; 2Department of Health Risk Analysis and Toxicology, Universiteit Maastricht, Maastricht, The Netherlands Exposure to noise constitutes a health risk. There is sufficient scientific evidence that noise newer data stem from epidemiologic studies. exposure can induce hearing impairment, hypertension and ischemic heart disease, annoyance, If politicians had taken a more protective sleep disturbance, and decreased school performance. For other effects such as changes in the stance in the 1970s-which would have been immune system and birth defects, the evidence is limited. Most public health impacts of noise legitimate on the basis of the then-available were already identified in the 1 960s and noise abatement is less of a scientific but primarily a policy data-this review probably would have been problem. A subject for further research is the elucidation of the mechanisms underlying noise- superfluous, as new data would not have induced cardiovascular disorders and the relationship of noise with annoyance and nonacoustical been published, but also harm would have factors modifying health outcomes. A high priority study subject is the effects of noise on children, been avoided. including cognitive effects and their reversibility. Noise exposure is on the increase, especially in the In this review we emphasize development general living environment, both in industrialized nations and in developing world regions. This of insights into the effects of noise exposure implies that in the twenty-first century noise exposure will still be a major public health problem. on health and quality of life. In accordance Key words: annoyance, cardiovascular effects, children's health, environmental health, with the relevant literature, we use the term environmental noise, hearing impairment, noise exposure, noise metrics, occupational noise, noise to represent sounds generated by performance. - Environ Health Perspect 1 08(suppl 1):1 23-131 (2000). http.//ehpnetl.niehs.nih.gov/docs/2000/suppl-1/123-131passchier-vermeer/abstract.html sources in the environment (indoors, outdoors, at work, etc.); noise is often appreci- ated negatively. Because several reviews on this subject have been published recently- Noise Exposure and Health The model considers effects on health some by international groups of scientists and quality of life as the outcome of a pro- (6)-we refer to original research papers Assessment of the human health risk cessing of exogenous determinants or envi- only when necessary for our argument. associated with the presence of a xenobiotic ronmental factors-in this case, noise Furthermore, given our background in envi- substance in the environment usually follows exposure. Exposure, processing, and effect ronmental health sciences, we also discuss the relatively simple scheme depicted in take place within economic and social envi- policy instruments for health protection. Figure 1. The substance occurs in environ- ronments and all are modified by societal fac- mental media at certain concentrations, tors. Furthermore, lifestyle and concurrent Characterization of Noise depending on, among other factors, lifestyle, exposure to other factors play a role. An Exposure residence time, and dietary habits, that people example of the former was given above. An Sound Pressure Level and Sound Level may be exposed to this xenobiotic. Any sub- example of the latter is the finding that the sequent harm depends on the level of expo- perceived presence of the risk of an aircraft Sound is a physical phenomenon consisting sure. The modifying impact of exogenous crash has been found to augment annoyance of alternating compression and expansion of determinants and personal characteristics on (and vice versa) (1). This processing of air that propagate in all directions from a the level of exposure and sensitivity with sounds is influenced by the genetic and source. These alternating compressions and respect to the toxic action usually are not acquired characteristics of the organism. For expansions can be described as small taken into account or are only considered in a example, some people have a specific sensitiv- changes in pressure around atmospheric standardized way, at least for risk assessment ity to noise and will be more susceptible to pressure. The frequency of the alternations and standard-setting purposes. The data one or all of its effects than other people. determines the pitch of a sound: a high- available, often derived from animal experi- Examples of societal factors that determine pitched tone (e.g., 4,000 Hz) has a squeak- ments and surveys of population behavior, do the adverse effects associated with noise ing sound; a low-pitched tone (e.g., 200 not allow a more refined analysis. exposure are insulation of houses, noise level- Hz), a humming sound. The environmental In the case of the assessment of the health related depreciation of house prices, and noise sources discussed in this review usu- effects of noise exposure, the scheme in individual and societal appreciation of the ally generate sounds within a broad fre- Figure 1 is too simple. With the exception of activities generating the noise. quency range. Sound pressures, relative to damage to the hearing organ, the exposed These insights, as depicted in the model in the atmospheric pressure, range from < 20 organism's reaction to the perception of Figure 2, are not new. On the contrary, it is micropascal to > 200 pascal, a range of sound is strongly dependent on the context striking that in the 1960s most ofthe effects of 1-10 million. Therefore, in acoustics, the of the exposure. The effects of noise exposure sound on health and quality of life were logarithm of sound pressure relative to a ref- cannot be understood only by taking mecha- already known or at least hypothesized, indud- erence sound pressure is used as a basis for a nisms of toxic action into account. For ing the variety of modifying factors referred to sound (and noise) exposure measure: the example, the sounds in a discotheque are above (2). In the 1970s the research results physical quantity sound pressure level music to the dancers but noise to the neigh- were sufficiently reviewed to allow science- expressed in decibel (dB). bors. In the first case, the exposure would based recommendations to be made for policy not be annoying but is expected to con- measures to protect public health (3-5). In the tribute to hearing loss; for the neighbors, last three decades new data have confirmed the Address correspondence to W. Passchier-Vermeer, hearing loss would be improbable, but earlier insights and, as reviewed here in our TNO Prevention and Health, PO Box 2215, 2301 CE, The Netherlands. 31 71 518 1786. annoyance would occur. A concep- have made more assess- Leiden, Telephone: certainly present paper, precise Fax: 31 71 518 1920. E-mail: [email protected] tual model to address the health effects of ments of exposure-response relationships and Received 4 August 1999; accepted 30 November noise exposure is presented in Figure 2. observation thresholds possible. Many of the 1999.

Environmental Health Perspectives * Vol 108, Supplement l * March 2000 123 PASSCHIER-VERMEER AND PASSCHIER

Cause-effect sequence

Environmental Exposure Harm :... agent :.. 0 g Figure 1. Simple cause-effect chain for the assessment of the health effects of an environmental agent, such as a xenobiotic substance.

g I The human hearing organ is not equally sensitive to sounds of different frequencies. Therefore, a spectral sensitivity factor is used that rates sound pressure levels at different frequencies in a way comparable to that of the human hearing organ; this is called A-weight- ing. The biophysical quantity A-weighted Figure 2. Conceptual model of the interaction of sound with the organism and the occurrence of effects on health sound pressure level (L) is expressed as dB(A) and quality of life. and is referred to as sound level. Examples of sound levels in some common situations are they live. For the Netherlands population this Council of the Netherlands, in 1994 assessed falling leaves (very quiet), 10-20 dB(A); vac- percentage is 4%. It is further estimated that the health effects of environmental and occu- uum cleaner, 55-65 dB(A); location close to a 0.6% of the Netherlands population is pational noise exposure (6). It rated the evi- main road or highway, 70-80 dB(A); pop exposed to traffic noise with Ld,, values of dence in terms of categories used by the music concerts, 100-1 10 dB(A). > 70 dB(A) (8,9). International Agency on the Research of Both in research and in policy, Ld,, or Ld,, is Cancer (11) as "sufficient," "limited," "inade- Equivalent Sound Level applied in a specific way: the metrics are used as quate," or "lacking". The report also presents and Day-Night Level location-specific quantities to be measured in observation thresholds for those adverse Sound level is the basic metric from which front ofthe facade ofresidential buildings. health effects for which sufficient evidence other biophysical metrics to specify long-term was considered available. The observation exposure to noise are derived. Usually a noise Sound Exposure Level threshold for an effect was defined in the metric is assessed on an annual basis. In envi- A single noise event is characterized by its report as the lowest noise exposure value at ronmental and occupational situations, sound sound exposure level. The sound exposure which on average the effect was observed in levels fluctuate with time. From these fluctuat- level (SEL) of a noise event, such as the over- well-designed epidemiologic studies (12). ing sound levels, the equivalent sound level flight of an airplane or the passage of a truck, This definition implies that in the course of (LAeq,T) over a period of time, T, is determined is the equivalent sound level during the event time the observation threshold of an effect from [see (7)]: normalized to a period of 1 sec (10). may have to be lowered if supported by new information from epidemiologic studies. 1 L(t) Exposure Settngs In this review, the 1994 Health LAeq,T = 10log - 1 0 10 dt Council T T In this review we discuss the health effects of report (6) is considered a starting point. occupational and environmental noise expo- More recent reviews (13-19) and papers pre- Common exposure periods T are 24 hr sure. Even though noise sources at work are sented at the November 1998 meeting in (full day) and 8 hr (work day). quite divergent, the exposure setting is well Sydney, Australia, of the International For some environmental health assessment defined; i.e., exposure during the execution of Commission on the Biological Effects of purposes, the day-night level (Ld") is used. occupational tasks. In the living environment Noise (20) were used to extend the 1994 This metric is the equivalent sound level over not only the sources but also the exposure set- evaluation. In general, the more recent 24 hr with the sound levels during the night tings are quite diverse. As mentioned above, a reviews and papers (13-20) concur well with (11 PM-7 AM) increased by 10 dB(A). Also a common environmental noise source is traffic. the conclusions of the Health Council if we day-evening-night level (L1, is used, which is In addition, in industrialized regions indus- take a rating of "inconclusive" (15,16) to be constructed similarly, such that the sound lev- trial noise may affect environmental quality. equivalent to the Health Council's "limited." els during the evening (7 PM-1 1 PM) are Another type of noise is neighbor noise, a fac- With respect to some effects such as ischemic increased by 5 dB(A) and those during the tor frequently mentioned in surveys on resi- heart disease, hypertension, and congenital night (1 1 PM-7 AM) by 10 dB(A). These dential satisfaction. Increasingly, people are defects, there appear to be differences of adjustment factors of 10 or 5 dB(A) take into exposed to noise during recreational activities opinion. This will be further discussed below account that night-time and evening-time such as pop music concerts, motor races, and ("Noise-Induced Stress-Related Health noise are more annoying than day-time noise arcade activities; often these types ofexposures Effects"). with the same equivalent sound level. are undergone consciously or at least taken for In Table 1 information is presented about Because of road, railway, and aircraft traf- granted. In this review emphasis is on chronic the adverse effects related to environmental fic noise, most of the urban population in environmental noise exposures, particularly and occupational noise exposure that have industrialized countries are exposed to out- those due to traffic and industrial noises. If been examined in epidemiologic studies. The door Ld, levels of > 50 dB(A). Rural popula- other sources of noise or exposure settings are table is adapted from Table 1 of the 1994 tions usually are exposed to outdoor traffic meant, this will be mentioned explicitly. Health Council report (6). Changes concern Ld, values of < 50 dB(A). Rough estimates of the noise metric in which the observation the percentage of people in Europe living in Assessment of Health Effects thresholds for hypertension and ischemic locations with Ld,, values > 60 dB(A) vary from The Committee on Noise and Health, an heart disease were originally given (21). Also 2 to 8%, depending on the country in which international committee of the Health the observation threshold for being awakened

124 Environmental Health Perspectives * Vol 108, Supplement l * March 2000 NOISE EXPOSURE AND PUBUC HEALTH by a single noise event was lowered by Table 1. long-term effects related to exposure to noise and classification of the evidence for a causal relationship 5 dB(A). Finally, we have added that the between noise and effect. The last three columns contain information on the observation threshold of an effect for observation threshold for sleep pattern changes which the causal relationship with noise exposure (second column) is judged to be sufficient.a is < 60 dB(A) (expressed in outdoors LAeq,nigh). Observation threshold Several health end points are not specific Classification Exposure Indoors/ to noise exposure. In fact, in accordance with Effect of evidenceb situation Metric Value (dB(A) outdoorsc the conceptual model of Figure 2, factors that Hearing impairment Sufficient Occ LAeq8h 75 Indoors apparently modify the effects of noise expo- Env LAeq,24h 70 Indoors sure may also affect health in ways similar to Occ unb LAeq,8h < 85 Indoors those for noise exposure. Situations exist in Hypertension Sufficient Occ ind LAeq8h < 85 Indoors which it is difficult to identify primary and Env Ldn 70 Outdoors modifying factors. Ischemic heart disease Sufficient Env Ldn 70 Outdoors The following sections highlight the main Biochemical effects Limited Occ aspects of the data presented in Table 1. Env Immune effects Limited Occ Noise-Induced Hearing Impairment Env Hearing impairment is an increase in the Birth weight Limited Occ hearing threshold level. In the International Env air Standard ISO 1999 (22), a hearing handicap Congenital effects Lacking Occ is defined as the disadvantage imposed by Env hearing impairment sufficiently severe to Psychiatric disorders Limited Env air affect one's personal efficiency in the activities Annoyance Sufficient Occ office LAeq,8h < 55 Indoors Occ ind LAeq8h < 85 Indoors of daily living, usually expressed in terms of Env understanding conventional speech in low Ldn' 42d Outdoors Absentee rate Limited Occ ind levels of background noise. Hearing impair- Occ office ment is also associated with aging as well as as certain diseases, exposure to some industrial Psychosocial well-being Limited Env Performance Limited Occ env chemicals, ototoxic drugs, head injuries, acci- Sufficient School dents, or factors that are of hereditary origin. LAeqschool 70 Outdoors Sleep disturbance, changes in ISO 1999 (6) gives a method to estimate Sleep pattern Sufficient Sleep LAegnight < 60 Outdoors noise-induced hearing impairment in popu- Awakening Sufficient Sleep SEL 55 Indoors lations exposed to continuous, intermittent, Sleep stages Sufficient Sleep SEL 35 Indoors or impulse noises during working hours. Subjective sleep quality Sufficient Sleep LAepgnight 40 Outdoors Noise exposure is characterized by the equiv- Heart rate Sufficient Sleep SEL 40 Indoors Hormone levels Limited Sleep alent sound level over an 8-hr work day Immune system Inadequate Sleep (LAeq,8h). Relations are given (for exposure Mood next day Sufficient Sleep LAegnight < 60 Outdoors times up to 40 years) between LAeq,8h and Performance next day Limited Sleep noise-induced hearing impairment at fre- Abbreviations: env, living environment; ind, industrial; occ, occupational situation; school, exposure of children at school; unb, unborn: quencies between 500 and 6,000 Hz. These exposure of pregnant mother. °The table is adapted from Table 1 of the 1994 Health Council report (6 ). bClassification of evidence of relations show that noise-induced hearing causal relationship between noise and health. 'Value relates to indoor or outdoor noise assessment. dthe observation threshold for impairment occurs predominantly in the percentage of highly annoyed persons is about 12 dB(A) lower for environmental impulse noise. higher frequency range of 3,000-6,000 Hz, with largest effects observed at 4,000 Hz. provided the exposures are not too extreme At high instantaneous sound levels, With increasing LAeq,8h and increasing expo- and the exposures are expressed in LAeq,24h mechanical damage to the outer and the inner sure time, noise-induced hearing impair- (because exposure during the full 24-hr day is ear may occur. Occupational limits for such ment can also occur at lower frequencies, important in this case) instead of LAeq,8h types of exposures have been set equal to the more specifically at 2,000 Hz. Even with (6,23-31). This implies that exposure to observation threshold for this effect at a peak prolonged occupational noise exposure, environmental and leisure-time noise with sound pressure level of 140 dB (33). For however, according to ISO 1999 noise- LAeq,24h values < 70 dB(A) does not cause adults, it is reasonable to assume that a similar induced hearing impairment does not occur hearing impairment in the large majority of threshold applies with respect to exposure to at LAq,8h levels of 75 dB(A) and lower. This people (> 95%), even in the case of life-time environmental and leisure-time noise. In the value is equal to the value specified in 1980 exposure (32). It should be considered, how- case of children, however, taking into account by the World Health Organization (23). ever, that there are no large-scale epidemio- their habits of playing with noisy toys, peak Since the method specified in ISO 1999 is logic studies that investigated noise-induced sound pressure levels > 120 dB may cause the only universally adopted method to esti- hearing impairment in the general population mechanical damage to the hearing organ (31). mate occupational noise-induced hearing that support this proposition. Also, data from Noise exposure may also result in tinnitus impairment, attempts have been made to animal experiments indicate that young chil- (ringing in the ears). This effect has been assess whether this method also applies to dren may be more vulnerable to noise- observed among teenagers attending pop hearing impairment due to environmental induced hearing impairments than adults music concerts and discotheques (34). Noise- noise, including leisure-time noise. The (31). For impulsive (shooting) noises with induced tinnitus may be temporary, lasting up results of various studies strongly suggest that LAeq,24h> 80 dB(A) studies on temporary to 24 hr after exposure, or it may have a more the ISO 1999 procedure can also be accepted threshold shifts (26) suggest the possibility of permanent character, such as after prolonged for environmental and leisure-time noise an increased risk for impulse noise-induced occupational noise exposure. Approximately exposures of adults and older children hearing impairment in adults. 25% of workers with both noise-induced

Environmental Health Perspectives * Vol 108, Supplement * March 2000 125 PASSCHIER-VERMEER AND PASSCHIER hearing impairment and tinnitus consider who respond to a question about the degree environmental agents or socially distressing tinnitus the more disturbing effect (35). of annoyance in the worst 25% range of situations, more serious health effects can The main social consequence of hearing answer categories (37). The noise exposure is occur [see Figure 2 and a recent report of impairment is the inability to understand expressed in LdA, assessed in front of another International Health Council speech in daily living conditions-a severe dwellings. The relationships depicted in committee (42)]. social handicap. Even small values of hearing Figure 3 demonstrate that annoyance impairment (10 dB averaged over 2,000 and induced by the different modes of trans- Noise-Induced Stress-Related 4,000 Hz and over both ears) may have an port-air, road, and rail-differs at higher Health Effcs effect on the understanding of speech. When exposure levels. Taking into account the sta- Reactions to a stressor can be psychologic the hearing impairment exceeds 30 dB (again tistical variations within and between the (feelings of fear, depression, sorrow), behav- averaged over 2,000 and 4,000 Hz and both various studies, Miedema and Vos showed ioral (social isolation, aggression, excessive use ears), a social hearing handicap is noticeable. that aircraft noise is statistically significantly of alcohol, tobacco, food, drugs), and somatic more annoying and railway noise is less (cardiovascular, gastrointestinal, respiratory Psychosocial Effects annoying than road traffic noise (36). illnesses) in nature. A large number of labora- Psychosocial effects due to exposure to Environmental noise exposure is only one tory experiments [reviewed by Passchier- environmental noise that have been studied in of the factors that contributes to noise Vermeer (24)] have shown noise-induced epidemiologic investigations include annoy- annoyance, albeit a significant one. The temporal changes in the cardiovascular system. ance, psychosocial well-being, and psychiatric degree of annoyance experienced by an indi- These findings led to several investigations hospitalization. The main psychosocial effect vidual as well as that on a population level in into possible long-term effects associated with from exposure to occupational noise observed practice can differ considerably from the noise exposure, e.g., stress-related cardiovascu- in epidemiologic investigations is annoyance. exposure-response relationships presented in lar disorders. In addition, some research has Noise annoyance is a feeling of resent- Figure 3 because of the influence of so- been conducted on the effects of noise expo- ment, displeasure, discomfort, dissatisfaction, called nonacoustical factors. Important sure on the hormone and immune systems. or offense when noise interferes with some- nonacoustical effect-modifying factors are Effects from occupational or environmental one's thoughts, feelings, or actual activities. It anxiety, fear of the noise source, and a feel- noise on reproduction and development were is not yet possible to predict noise annoyance ing that the noise could be avoided. These also studied. High-frequency hearing impair- on an individual basis because of the large effect-modifying factors have been identi- ment in babies of mothers exposed to high variety of (partly unknown) endogeneous and fied in multivariate analyses of population levels of occupational noise during pregnancy exogeneous characteristics that affect annoy- data (19,38-41). However, general quanti- is also considered to be a consequence of a ance (Figure 2). However, relationships tative multifactorial exposure-response mother's stress induced by exposure to noise between noise annoyance and noise exposure relationships have not yet been published. during pregnancy (43). have been elucidated on a population level Much attention has been paid in laboratory Research into the chronic effects of long- together with several effect-modifying factors. experiments to the effects of uncontrollable term exposure to noise is complicated Annoyance in populations is evaluated using noise exposure on such things as task perfor- because cardiovascular and biochemical questionnaires. Exposure-effect relationships mance and annoyance. No relationships have changes are nonspecific and a number of have been derived for exposure to the three been assessed between general noise annoy- other factors may also cause these changes; main types of traffic noise: road, railway, and ance experienced during working hours and these factors must be controlled for in aircraft. The most recent and comprehensive noise exposure. Epidemiologic studies show research projects. In cross-sectional studies it relationships are shown in Figure 3 (36). that annoyance in offices is considerable at is difficult to obtain appropriate information These relationships pertain to populations equivalent sound levels > 55 dB(A). A few about past noise exposure, and longitudinal chronically exposed to noise at specified levels studies show that 35-40% of office workers studies are time-consuming and financially for periods of more than a year. The effect is are highly annoyed at noise levels from 55 to draining. Furthermore there are large indi- given as the percentage of the population 60 dB(A). If the noise source is more or less vidual differences in susceptibility. Also, peo- highly annoyed by a specific environmental constant, such as the noise produced by ven- ple intervene in their own situations, e.g., by noise. "Highly annoyed" persons are those tilation systems (e.g., fans in computers), the changing jobs [thus contributing to the observation threshold for annoyance in offices "healthy worker effect" (44)] or by moving is lower than a LAeq,8h value of 55 dB(A). In from noisier surroundings to quieter places. Be 80- industrial situations, similar percentages of This may result in "noise proof' populations -0 --Air highly annoyed workers occur at equivalent exposed to the higher noise levels (45). Not . Road 60 Rail sound levels > 85 dB(A). withstanding these complications, conclu- Also at the workplace, nonacoustical sions on the relationship between noise expo- >. 40 - factors have a large effect on the actual noise sure and cardiovascular disease appear annoyance on an individual and on a popula- possible from meta-analyses of the available 20- tion level. These factors include the meaning epidemiologic data (6). Co and information contents of the noise (tele- Cardiovascular effects in adults. = 40 50 60 70 phone conversations and discussions between Epidemiologic environmental noise studies CL Ldn in dB(A) colleagues score high), predictability, avoid- on changes in blood pressure and increased ability, controllability, task Figure 3. Relationships between the percentage of demands, and risk for ischemic heart disease in adults are highly annoyed persons and Ldn for air, road, and railway attitudes toward the noise source. limited mainly to the effects of road traffic traffic noise. Each curve has been derived by a multilevel Noise-related annoyance is widespread in noise, with the exception ofa Dutch study on analysis of all studies for which original data were avail- present-day society. Even though annoyance the effects ofaircraft noise (46,47). In general able. The vertical bars at 60 and 70 dB(A) represent 95% as such is not directly invalidating, there are these studies demonstrate no obvious effects confidence intervals [bar at 60 dB(A) for road has been indications that for sensitive individuals or from noise exposure on mean diastolic and displaced by 0.5 dB(A) for clarity]. in cases of concurrent exposure to other mean systolic blood pressure, but some effects

126 Environmental Health Perspectives * Vol 108, Supplement 1 * March 2000 NOISE EXPOSURE AND PUBUC HEALTH were observed in terms of an increase in the and stress-related health effects are associated, were also examined. Overnight resting levels percentage of people with hypertension and taking into account that the observation ofepinephrine and norepinephrine levels were (including those who use medication for threshold for annoyance in offices is much significantly higher in children exposed to air- hypertension). The observation threshold for lower than that for industrial situations, we craft noise at the old Munich airport com- hypertension is estimated to correspond to an hypothesize that the observation threshold pared to control groups. There were no Ldn value of 70 dB(A) for environmental for noise-induced risk for hypertension in differences in cortisol levels. After the airport noise exposure. The Health Council of the office workers is about 30 dB(A) lower than was moved, overnight resting levels of epi- Netherlands in 1994 (6) suggested the same that for hypertension in blue-collar workers. nephrine and norepinephrine rose signifi- observation threshold for ischemic heart dis- The data in more recent publications on car- cantly among children living under the flight ease (Table 1). The relative risks (compared diovascular effects from exposure to noise are paths of the new airport. Again, no effects to populations with low environmental noise not in disagreement with the previous find- were observed on urinary cortisol levels. We exposure) for both hypertension and ischemic ings (51-53). However, one must be careful propose that this subject be studied further. heart disease for exposure levels above the interpreting the results of these studies, as Effects on the unborn child. Data from observation thresholds are estimated to be either noise measurements or proper control older studies suggest that it is possible that about 1.5 (48). groups are lacking or the size of populations when pregnant women are exposed to high In 1997 a Chinese study (49) was studied is small. levels of aircraft noise [Ldn > 62 dB(A)], small conducted among a large sample of more Only few epidemiologic studies considered reductions in birthweight occur. In a more than 20,000 residents in rural communities. biochemical and immunologic effects recent study of 200 Taiwanese women, noise The results show that self-reported exposure (54,55). More recently, overnight resting lev- exposure was measured by personal noise to noise (unfortunately, exposure was not els of epinephrine and norepinephrine levels dosimeters on three occasions during preg- assessed objectively) is an important determi- were assessed in a study of middle-aged nancy (65). Noise exposure was not related to nant of systolic and diastolic blood pressure. women living in Berlin (56). Significantly birthweight after adjustment for social class, Of special interest is the outcome of the elevated levels of norepinephrine were found smoking and alcohol use, maternal weight recent, unique longitudinal study (50) on the in women whose bedrooms faced busy streets gain in pregnancy, gender of the child, and effect of road traffic noise exposure on the (> 20,000 vehicles a day) and epinephrine duration of pregnancy. Older and more incidence of ischemic heart disease. In this levels were also higher in women reporting recent investigations do not show statistically Caerphilly and Speedwell study, two cohorts high disturbances of communication and significant effects of occupational or environ- of about 2,500 middle-aged men in the sleep under closed window conditions. Some mental exposure of pregnant women to noise United Kingdom were recruited for a study smaller studies in industrial settings showed in the course of pregnancy and congenital of the predictive power ofalready-known and the effects ofwearing personal hearing protec- defects of babies, with the exception of high- new risk factors for ischemic heart disease. tion on urinary excretion of catecholamines frequency hearing damage mentioned at the Noise measurements were performed in each (epinephrine and norepinephrine) and corti- beginning of this section. ofthe streets where subjects lived. Even in the sol (57,58). On the days hearing protectors Absences due to accident and sickness. highest noise exposure class, Ldn did not were worn, urinary catecholamine levels were Epidemiologic studies suggest that the absen- exceed 70 dB(A). Statistical analysis on the statistically significantly lower than on days tee rate of industrial workers increases when relationships between incidence of ischemic protectors were not worn. they are exposed to equivalent sound levels heart disease (classified in a standardized way) Cardiovascular effects in children. Two during working hours of over 75 dB(A) and environmental noise exposure was con- early studies (59,60) showed an increase in [CORDIS study, (66)] or over 90 dB(A) trolled for potentially confounding factors. systolic and diastolic blood pressure in chil- (67). The CORDIS study also showed that The average annual incidence rate of ischemic dren exposed to very high road traffic noise the number of accidents increases with rises heart disease appeared to be 1.4% during the levels or aircraft noise levels. The increases in equivalent sound levels during working second phase of the study (6 year follow-up; were assumed to be of a transient nature. hours. Mortality from injury was studied in mean age of the men, 57 years). Iforientation Recently, Slovakian researchers studied 1,542 more than 20,000 steelworkers (68). On the of the living room and the bedroom, window children 3-7 years of age in kindergartens basis of job and workplace information, opening habits, and years of residence over 15 (61). The authors observed significantly industrial hygienists estimated noise exposure years were taken into account, the relative higher systolic and diastolic blood pressures as high [LAq,8h > 95 dB(A)], medium [LAeq8h risk for incidence of ischemic heart disease of among children in noisy environments [> 60 90-95 dB(A)], low [LAeq,8h 85-90 dB(A)], the highest exposed group relative to the dB(A)] compared to those among children in and minor. Hearing damage and noise expo- group exposed to levels between 50 and 55 quieter environments. Although the study is sure in the high and medium noise classes dB(A) was 1.6, which statistically is not sig- carefully designed, the possibility that social appeared to be factors that contributed statis- nificantly different from 1 at the 5% level class has confounded the results cannot be tically significantly to mortality. The study (p < 0.10). This study fits in with the earlier excluded [see also Lercher et al. (62)]. In the did not identify the mechanisms behind evaluation that above levels of 70 dB(A) there Munich airport study (63,64), schoolchildren these findings. Moreover the impact of using is sufficient evidence for a noise exposure- were examined during the years Munich air- personal hearing protectors is unclear. related effect, and provides no support for port moved from one location to another. Wearing of hearing protection by workers lowering the observation level of70 dB(A) for One study location was close to the old air- with substantial noise-induced hearing ischemic heart disease. port and another was close to the new airport. impairment reduces the possibility of hearing Through analysis of twelve studies on the The cross-sectional part of the study showed a moving sound sources, warning signals, or risk of hypertension among occupational marginally significant higher systolic blood colleagues shouting and hampers localization noise-exposed workers, the observation pressure in children highly exposed at school. of moving sound sources because of reduced threshold for industrial noise exposure was Children were matched on socioeconomic capacities to determine the direction of a determined to be at most equal to an LAC 8h characteristics. In the study, neuroendocrine sound source. Therefore, we hesitate to con- value of 85 dB(A) (24). No data are availatle indices of chronic stress (urinary cortisol levels sider stress as the underlying mechanism for for noise exposure in offices. If annoyance and levels of epinephrine and norepinephrine) the increase in mortality.

Environmental Health Perspectives * Vol 108, Supplement 1 * March 2000 127 PASSCHIER-VERMEER AND PASSCHIER

Sleep Disturbance From the epidemiologic studies there well-being of subjects exposed to high levels Sleep is a recovery process essential for appears to be sufficient evidence for a causal of road traffic noise was not related to day- humans to function properly. In addition, relationship between exposure to night-time time noise exposure but to night-time equiva- people like to sleep and usually consider a noise and changes in sleep pattern, sleep lent sound level in the bedroom and to good night's sleep to be an important aspect stages, awakenings, subjective sleep quality, subjectively experienced sleep quality (71). of an individual's quality of life. Deleterious heart rate, and mood the next day (6). Although in the 1990s several field studies health effects are expected from chronic noise- Observation thresholds for these effects are were started (72) or completed (73-76), induced interference with sleep, as it impairs given in Table 1. Evidence for other effects is there still is an urgent need for a tested model the functions ofsleep such as brain restoration limited (hormone levels and performance the on sleep disturbance, environmental noise and provision of a period of respite for the next day) or inadequate (immune system). exposure, and secondary effects, in which cardiovascular system (69,70). In addition to Exposure-response functions have been causal and modifying factors and their the physiologic aspects of a noise-induced derived from field studies for only some of mutual relations are assessed. reduction of sleep quality, night-time noise these effects, among others or reduction of exposure of sufficient intensity (Table 1) is subjective sleep quality and increase in num- Efects on Performance also related to subjectively experienced sleep ber of awakenings during sleep period time. There is overwhelming evidence from quality (71). Reduced sleep quality also inter- The relationship between the risk of awaken- laboratory experiments that the presence of feres with daytime functioning and can have ing and exposure to night-time environmen- uncontrollable noise can significantly impair adverse effects on mood next day and possibly tal noise is established only for single noise cognitive performance. Noise can induce on vigilance and cognitive performance. events, with exposure specified by the indoor learned helplessness, increase arousal, alter Sleep quality can be quantified by subjec- SEL values of the events. the choice of task strategy, and decrease tive and objective methods. The most com- An international group of experts who attention to the task. Noise may also affect monly applied subjective methods are were convened in 1997 by the Health social performance, mask speech and other self-reporting using sleep logs or diaries and, Council of the Netherlands assessed the sound signals, impair communication, and to a lesser extent, behavioral observations. observation threshold for awakening due to distract attention from relevant social clues. The most commonly used objective methods single noise events at the lower indoor SEL Adverse acute effects already have been are electroencephalograph (EEG) recordings value of 55 dB(A) (Table 1) instead of 60 assessed at low levels. Performance of a task and actimetry. In field studies on noise- dB(A) (8). This change reflected improved involving motor and monotonous activities is induced sleep disturbance subjects usually knowledge of the transfer functions of SEL sometimes not only is not decreased, but on wear watchlike actimeters for movement values measured outdoors compared to those the contrary, is enhanced. detection at their wrist. Sleep quality may be measured indoors in some of the underlying Two older epidemiologic studies have adversely affected by studies. Using the relationship between shown that schoolchildren when exposed to * changes in the cardiovascular system; indoor SEL value and the risk of awakening high levels of traffic noise show impairments * changes in sleep pattern such as increased due to single noise events, the expected maxi- in performing cognitive tasks (59,60). The sleep latency time and reduced sleep time mal number of awakenings per year in an observation threshold derived from these data because ofpremature awakening; adult habituated to night-time noise expo- is 70 dB(A) (expressed in LAeq,schoolour). More * changes in sleep stages from deeper to sure was estimated as a function of the equiv- recently this subject has received renewed less-deep sleep; alent sound level during the night. The latter attention (64,77-78). In the Munich airport * increases in motility during the sleep quantity was calculated from the number of study mentioned previously, reading compre- period; single noise events during the night and their hension and long-term memory were * increases in number of awakenings during indoor SEL values (8). The result, which impaired in children attending schools the sleep period; represents a worst-case situation, is depicted located around the old Munich airport and * changes in subjectively experienced sleep in Figure 4. reading comprehension improved after the quality; and Apart from the direct effects of night-time closing of the airport. However, reading com- * changes in the hormonal and immune noise on sleep, various authors point to the prehension deteriorated in children subjected systems. importance of the impact of sleep disturbance to aircraft noise exposure near the new Present knowledge about the relationships on quality of life, including such factors as Munich airport. Recently, in the United between awakening and exposure to single somatic health and annoyance. Such observa- Kingdom a field study with tests repeated noise events indicates that habituation or tions had already been made in the 1950s. annually was conducted to assess whether the adaptation occurs. This insight is not new. Cohen, referring to a paper of Borsky from association between aircraft noise exposure Cohen stated in 1968 [in Ward and Fricke 1958, states and reading comprehension was mediated (2)] that Field studies have shown that much greater -300- Aspects of adaptation to noise with regard annoyance results when sleep and rest are 0 to sleep disturbance also need to be evalu- disturbed than when only talking or listen- am > C ated. Common experience has found that ing activities are interrupted. This finding ._ o 200- the city dweller, frequently encountering plus the health significance attributed to rest " significant levels of outdoor and indoor and sleep suggest that criteria for annoyance C E= c noise, becomes accustomed to such expo- be based on noise-induced disturbances to = CB sures and can sleep in their presence. The sleep. [in Ward and Fricke (2)] same individual vacationing in the quiet CD -r.. T atmosphere of the country finds it difficult Babisch et al. reported larger overnight 0 30 35 40 45 50 55 60 to sleep because of the background of LAeq,23-07h in dB(A) cricket noise. The degree of familiarity or changes in epinephrine levels in subjects meaningfulness ofthe noise has a consider- reporting high disturbance of sleep than in Figure 4. The maximum number of awakenings per year able effect on its disturbing quality. those without severe complaints (56). as a function of the outdoors night-time equivalent Another study showed that psychosocial sound level (8).

128 Environmental Health Perspectives * Vol 108, Supplement * March 2000 NOISE EXPOSURE AND PUBLIC HEALTH through sustained attention and whether it Noise-Induced Hearing Impainment confidence intervals than those from the other was confounded by social deprivation and Sound exposure measures were already being metrics. However, a decision based on statisti- language spoken at home. The 340 children proposed in the 1960s and 1970s that would cal grounds could not be made (81). Because who participated were about 9 to 10 years of apply to a variety of settings and, if an expo- from a policy viewpoint, using Lden would age. They attended a school classified either sure-response relationship were known, would result in somewhat more plausible protection as a high-noise school [LA ,I6h > 66 dB(A)] be a good predictor of effects to be expected and mitigation measures, the committee or as a low-noise school [Aeq,16 h < 57 for any case at the population level. A good finally expressed its preference for this metric. dB(A)]. There appeared to be a high correla- example is the equivalent sound level over an In Europe Ldn may become the future noise tion between the noise at school and the air- 8-hr work period (LAeq,8h), which correlates metric to represent general noise-related craft noise exposure at home. Results show well on a population level with noise-induced annoyance (82). that the average reading comprehension of hearing impairment. Confidence in the expo- When using the adjusted Lden levels, the children attending the high-noise schools was sure-response relationships is such that they exposure-response relationships are statisti- poorer at both measuring times compared have been standardized by ISO (22). This is cally significantly different for different modes with that of children from the low-noise reflected in policy debates; such debates focus of transport. One might envisage performing schools. Sustained attention, measured only on the measures to be taken ifcertain exposure a further adjustment that would result in a at follow-up, was poorer in children at the levels are exceeded, and not on the validity of single relationship for all types of transporta- high-noise schools than in children at the the exposure-response relationships. tion noise and possibly industrial noise; in fact low-noise schools. Sustained attention did A value of LAeq,8h of 85 dB(A) (some- recommendations for such a further integra- not play a significant role in explaining the times lower) has been almost universally tion were made in the Health Council report relation between reading comprehension and adopted as a limit for unprotected occupa- (8). We strongly support such a development aircraft noise exposure. However, if adjust- tional noise exposure, with additional that would require standardization of the ments are made for age, main language spo- requirements for personal hearing protection noise exposure-general annoyance relation- ken at home, and social deprivation, the above this value (79). However, among ship; basic data for reaching that goal are differences in reading comprehension failed workers exposed to an LA 8 hr value of 85 presently available (36). The final step to rep- to be significant. These results are not in dis- dB(A), some noise-induced'hearing impair- resenting general annoyance with a universal agreement with the 1994 evaluation (6) lead- ment will occur. Given such exposure over a noise metric would be a procedure to combine ing to an observation threshold of 70 dB(A) lifetime in a job, a hearing impairment at concurrent noise exposures from different (expressed in LAeq,schoolhours), but setting the 4,000 Hz of about 5-10 dB is estimated for sources. This step requires further research, as threshold at a lower level does not appear to most workers, although for those persons limited data have been published on exposure be warranted. Given the possible long-term highly sensitive to noise, noise-induced to two or more sources at the same time. consequences of cognitive effects in children, impairment is considerably greater. This However, in most practical situations we feel that further research into mechanisms implies that a lifetime of exposure to 85 exposure from one source will dominate. and contributing factors is urgently needed. dB(A) of occupational noise will slightly A question arises about whether noise increase the risk for a hearing handicap in a abatement policies based on the adjusted Ld, Noise Metrics and Noise small proportion ofexposed persons. are also effective in reducing the prevalence of Limits for Health Protection We concur with the suggestion to use the other noise-induced health effects such as Several biophysical quantities to represent equivalent noise level over a period of 24 hr, hypertension, ischemic heart disease, and noise exposure were introduced in the sec- to set targets for the exposure during the full cognitive performance in schoolchildren. tion "Characterization of Noise Exposure." 24-hr day for protecting the hearing of the Although this appears to be plausible, further Exposure quantities are not only of scientific general population (80). Setting such targets study is needed. interest, i.e., for recording data and commu- appears to be warranted, given the increasing A cautionary remark is in order here. As nicating research results; policymakers and number of noisy activities and exposure dura- previously indicated, many other factors in risk managers need exposure quantities to tion, such as loud music in cars, the use of addition to noise exposure influence noise- judge the necessity of taking protection or portable music cassette and CD players, and related health effects on a population level. mitigation measures and to evaluate the the playing of loud computer games at home The exposure-response relationships effectiveness of such measures. Criteria for and in arcades. between, for example, the percentage of noise exposure metrics to be used in health highly annoyed persons and Lden should be and environmental policy (8) are that they Annoyance and Stress-Related Diorders used for policy guidance rather than to obtain should be a) relatively simple to determine Metrics such as LAeq,24 , Ldn, and Lde came accurate predictions of effects expected in or measure; b) transparent with respect to into use several decades ago (3,4) to regulate specific situations. However, the quantitative exposure-response relationships; c) corre- general annoyance. Recently, an international relationships presented here are the best sci- lated with health effects on a population group of experts convened by the Health ence has to offer today and appear to be level; d) applicable to all outdoors noise Council of the Netherlands again studied rather robust. sources; e) universal; and J) communicative. specification of a biophysical metric to express In practice it appears almost impossible to noise-induced general annoyance for public Sleep Disturbance derive a single metric and at the same time health purposes (8). The Health Council There appears to be consensus that for fulfill all these criteria because noise sources, committee agreed on adjustment factors to be protection against sleep disturbance a separate noise characteristics, and exposure situations applied to the metrics to account for differ- night-time noise exposure metric is required, differ extensively. ences in annoyance related to the tonal and even though limiting exposure using Ld, or a One application of noise metrics is to set impulse characteristics of noise. The commit- similar 24-hr metric would also provide some exposure limits. Because such limits are tee extensively debated the choice between limitation of night-time noise exposure. The intended for health protection it is essential Lden and Ld,. Analysis of available data indi- Health Council committee report (8) men- that the science policy decisions made to derive cated that for road traffic noise, general tioned previously proposed the night-time the metrics be known to the policymaker. annoyance is estimated from Lde, with smaller equivalent sound level (see Figure 4). A

Environmental Health Perspectives * Vol 108, Supplement 1 * March 2000 129 PASSCHIER-VERMEER AND PASSCHIER

science policy question arises about whether REFERENCES AND NOTES 24. Passchier-Vermeer W. Noise and Health [Geluid en gezond- the worst-case approach in converting SEL to heidi. Review. nr A93/02E. The Hague:Health Council of the 1. Reijneveld SA. The impact of the Amsterdam aircraft disaster Netherlands, 1993. LAeq,23-07h is acceptable in policy situations. on reported annoyance by aircraft noise and on psychiatric dis- 25. Passchier-Vermeer W, Vos H, Steenbekkers JHM. Popmusic In specific situations, for example, popula- orders. lnt J Epidemiol 23:333-340 (1994). through Headphones and Hearing Loss. Rpt 98.036. Leiden:TNO tions in the vicinity of large airports, eco- 2. Ward WD, Fricke JE. Proceedings of the Conference Noise as a Prevention and Health, 1998. nomic consequences of the noise Public Health Hazard (Washington). Washington:American 26. Smoorenburg GF. Effects of impulse noise on man. In: abatement Speech and Hearing Association, 1969. Proceedings of Noise as a Public Health Problem (Vols 1, 2), measures may be severe, although from a 3. U.S. EPA. Information on Levels of Environmental Noise (Carter NL, Job RFS, eds). Sydney, Australia:University of health protection viewpoint using the equiva- Requisite to Protect Public Health and Welfare with an Sydney, 1998j1-10. lent sound level could be defended. Adequate Margin of Safety. EPA/ONAC 550/9-74-004. 27. Struwe F, Jansen G, Schwarze S, Schwenzer C, Nitzsche M. Washington, DC:U.S. Environmental Protection Agency, 1974. Untersuchung von Horgewohnheiten und moglichen 4. U.S. FAA. Aviation Noise Effects. Rpt ADA-154319. Gehorrisiken durch Schalleinwirkungen in der Freizeit unter The Way Ahead Washington, DC:U.S. Federal Aviation Administration, 1985. besonderer BerOcksichtigung des Walkman-Hbrens [Study on In addition to natural sounds, speech, and 5. Health Council of the Netherlands: Committee on Noise listening behavior and hearing risks from sound exposure during Annoyance and Noise Abatement. Geluidhinder [Noise leisure time with an emphasis on listing to walkmans]. In: music, noise is widespread and becoming Annoyance]. The Hague:Health Council of the Netherlands, 1971. Gehbrgefardung durch laute Musik und Freizeitlarm (Babisch W, more so in our present day society. Major 6. Health Council of the Netherlands: Committee on Noise and Bambach G, Ising H, Kruppa B, Plath P, Rebentisch E, Struwe F, factors are the increase in motorized traffic, Health. Noise and Health [Geluid en gezondheid]. nr 1994/15E. eds). Berlin:lnstitut fOr Wasser-, Boden- und Lufthygiene des The Hague:Health Council of the Netherlands, 1994. Umweltbundesamtes, 1996;44-154. apparent preferences for noisy leisure and 7. In the equivalent sound level over a period T, the highest sound 28. Babisch W, Ising H. Zum Einfluss von Musik in Diskotheken auf recreational activities among large groups in levels occurring during this period are counted more heavily die Horfahigkeit [The effect of music in discotheques on hearing industrialized societies, and increasing than those in the 'normal' average sound level over period T. ability]. Soz Praventivmed 34:239-242 (1989). This is demonstrated by the following example. Suppose that 29. Pfander F, Bongartz H, Brinkmann H, Kietz H. Danger of auditory urbanization, particularly in the Third during half of period Tthe sound level is 80 dB(A) and during impairment from impulse noise: a comparative study of the World, resulting in megacities where high the other half it is 40 dB(A). Then the equivalent sound level CHABA damage-risk criteria and those of the Federal Republic noise levels 24 hr a day have become com- over period T is 77 dB(A), whereas the arithmetic average of Germany. J Acoust Soc Am 67:628-633 (1980). sound level is 60 dB(A). 30. Ising H, Hanel J, Pilgramm M, Babisch W, Lindthammer A. monplace. Although at the beginning of the 8. Health Council of the Netherlands: Committee on an Uniform Gehorschadensrisiko durch Musikhoren mit Kopfhorern [Risk of 1960s the major effects of noise exposure Noise Metric. Assessing Noise Exposure for Public Health hearing loss caused by listening to music with head phones]. were already known, at the beginning of the Purposes [Omgevingslawaai besordelen]. nr 1997/23E. The Hans Nasen Ohren 42:764-768 (1994). 21st century noise exposure still is a major Hague:Health Council of the Netherlands, 1997. 31. Passchier-Vermeer W. Noise from toys and the hearing of chil- 9. Volksgezondheid Toekomst Verkenningen 1997 [Public Health dren. Report 91.032. Leiden:NIPG TNO Prevention and Health, public health problem. Given our view that Status and Forecasts 1997]. Bilthoven:Rijksinstituut voor 1991. knowledge about effective noise abatement Volksgezondheid en Milieu, 1997. 32. An LAeq,h value of X dB(A) corresponds to a LAeq,24h value of measures for public health protection has 10. If during a period T(in s) n noise events occur with the same X - 5 dB(A). Therefore the exposure-response relationships of SEL value, the following formula applies: LAeqT= SEL + 10 lgn ISO 1999 that are expressed in LAeq.8h should be shifted with 5 been available for decades, solving the prob- -101g T dB(A) to be applicable to environmental exposures expressed lem appears now to be primarily in the 11. Preamble to the IARC Monographs. http://193.51. in LAeq,24h. hands of policymakers. In addition to regu- monoeval/preamble.html, 12-6-1997. Consulted: 3-4-1998. 33. European Council. Council Directive 86/188/EEC of 12 May 12. An observatidn threshold concerns an average population of 1986 on the Protection of Workers from the Risks Related to latory measures, activities in the realm of adults or adult workers or an average population otherwise Exposure to Noise at Work. Offl JEC 137:24-36 (1986). health education with respect to the impact specified, such as babies of women exposed to noise during 34. Axelsson A, Prasher DK. Tinnitus: a warning signal to teenagers of noise exposure in everyday life appear to pregnancy. attending discotheques? Noise Health 2:1-2 (1999). 13. The Non-Auditory Effects of Noise. Rpt R10. Leicester, UK: 35. Passchier-Vermeer W. Het equivalente geluidniveau en be warranted. Concerns are increasing that Institute for Environment and Health, 1997. gehoorschade door lawaai op de arbeidsplaats bij groepen noise-induced hearing loss is not only an 14. Berglund B. Aircraft noise and health. Workshop 1: Noise and werknemers [The equivalent sound level and occupational occupational risk but may become an Pollution. In: The Second Airport Regions Conference, 28-29 noise-induced hearing damage among groups of workers. In November 1996, Vantaa, Finland, 1996. Dutch]. Rpt 88.072. Leiden:Nederlands Instituut voor environmental risk as well. 15. Morrell S, Taylor R, Lyle D. A review of health effects of aircraft Preventieve Gezondheidszorg TNO, 1989. Science still has important contributions noise. Aust NZ J Public Health 21:221-236 (1997). 36. Miedema HM, Vos H. Exposure-response relationships for to make. We mentioned in the previous sec- 16. Porter N, Flindell IH, Berry BF. Health Effect-based Noise transportation noise. J Acoust Soc Am 104:3432-3445 (1998). tion the study of policy-relevant metrics, for Assessment Methods: A Review and Feasibility Study. NPLRpt 37. In the various surveys on which the exposure-response rela- CMAM 16. Teddington, Middlesex, UK:National Physical tionships of Figure 3 are based, various measuring scales were which more insight in the exposure-response Laboratory, 1998. used to assess the responses to annoyance questions. The pro- relationships for different types of noise and 17. Shaw E. Noise environments and the effect of community noise cedures for converting the different measuring scales to a com- exposure settings is required. The modifying exposure. Noise Contr Eng J 44:109-119 (1996). mon one is discussed in Miedema and Vos (36). 18. Thompson SJ. Non-auditory health effects of noise: an updated 38. Guski R. Personal and social variables as co-determinants of influence of nonacoustical factors is of review. In: Proceedings of Inter-Noise 96, August 1996, noise annoyance. Noise Health 3:45-56 (1999). utmost importance, as these influences may Liverpool, UK (Hill FA, Lawrence R, eds). St. Albans, UK:lnstitute 39. Job RFS. Noise sensitivity as a factor influencing human reac- to a large degree determine the effectiveness of Acoustics, 1996;2177-2182. tion to noise. Noise Health 3:57-68 (1999). 19. Job RFS. The influence of subjective reactions to noise on 40. Miedema HME, Vos H. Demographic and attitudinal factors that and efficiency of noise abatement measures health effects of noise. Environ Intern 22:93-104 (1996). modify annoyance from transportation noise. J Acoust Soc Am directed at reducing effects other than noise- 20. Carter NL, Job RFS, eds. Noise as a Public Health Problem, Vols 105:3336-3344 (1999). induced hearing impairment. This is obvious 1, 2. Sydney, Australia:University of Sydney, 1998. 41. Stallen PJM. A theoretical framework for environmental noise in case 21. The conversions are between the day-time equivalent sound annoyance. Noise Health 3:69-79 (1999). the ofenvironmental exposures, but it level and Ld, For most situations with higher environmental 42. Health Council of the Netherlands: Committee on the Public may also be relevant for the workplace, for noise exposures, daytime and nighttime exposures are highly Health Impact of Large Airports. Public Health Impact of Large example, the possible differences between correlated. For road traffic noise, the average difference Airports. nr 1999/14E. The Hague:Health Council of the observation thresholds for cardiovascular between daytime and nighttime equivalent sound levels is Netherlands, 1999. approximately 8 dB(A). This implies that the difference Ld, - 43. The American Academy of Pediatrics recently issued a state- disorders in white and blue collar workers LA,q24h is about 2 dB(A), and the difference between the day- ment warning against the risks of high-frequency hearing loss mentioned previously. time equivalent sound level and Ld, about -1 dB(A). In Table 1, in unborn babies (83). We believe that two subjects should be also taking into account the accuracy with which the observa- 44. Dijk FJ van, Ettema JH, Zielhuis RL. Non-auditory effects of tion thresholds for hypertension and ischemic heart disease noise in industry. VIl: Evaluation, conclusions and recommenda- priorities in research: the study ofcardiovascu- could be established, for those noise-induced effects Ld, is tions. Int Arch Occup Environ Health 59:133-145 (1987). lar effects and the underlying mechanisms and taken to be equal to the daytime equivalent sound level. 45. Hinder, slaapverstoring, gezondheids- en belevingsaspecten in the study of the effects of noise on children. 22. International Organization for Standardization. Acoustics- de regio Schiphol, resultaten van een vragenlijstonderzoek Determination of Occupational Noise Exposure and Estimation of [Annoyance, sleep disturbance, health aspects and the percep- Attention to effects on children is particularly Noise-induced Hearing Impairment. International Standard ISO tion of the living environment around Schiphol airport, results of urgent, as such effects in terms of years of life 1999. Geneva:lnternational Organization for Standardization, a questionnaire survey]. RIVM: 441520010; TNO: 98.039. with a reduced quality oflife or a handicap are 1990. Bilthoven:Leiden:Rijksinstituut voor Volksgezondheid en Milieu 23. WHO. Noise. Environmental Health Criteria Document No. 12. (RIVM) and Nederlandse Drganisatie your toegepast-natuur- greater for children than for adults. Geneva: World Health Organization, 1980. wetenschappelijk onderzoek (TND), 1998.

130 Environmental Health Perspectives * Vol 108, Supplement 1 * March 2000 NOISE EXPOSURE AND PUBLIC HEALTH

46. Knipschild P. V: Medical effects of aircraft noise: community 57. Melamed S, Bruhis S. The effects of chronic industrial noise 72. Passchier-Vermeer W, Vos H, Gils K van, Miedema HME, cardiovascular survey. lnt Arch Occup Environ Health exposure on urinary cortisol, fatigue and irritability: a controlled Middlekoop HMA, de Roo F, Verhoeff E. Aircraft Noise and 40:185-190 (1977). field experiment. J Occup Environ Med 38:252-256 (1996). Sleep Disturbance. Pilot study. Rpt 98.040. Leiden:TNO 47. Knipschild PG. Medische gevolgen van viiegtuiglawaai (Medical 58. Sudo A, Nguyen AL, Jonai H, Matsuda S, Villanueva MB, Prevention and Health, 1998. effects of aircraft noise). PhD Thesis. Amsterdam:University of Sotoyama M, Nguyen TC, Le VT, Hoang MH, Nguyen DT, et al. 73. Fidell S, Howe R, Tabachnick B, Pearsons K, Silvati L, Sneddon Amsterdam, 1976. Effects of earplugs on catecholamine and cortisol excretion in M, Fletcher E. Field Studies of Habituation to Change in Night- 48. Although the relative risk for hypertension and ischemic heart noise-exposed textile workers. Ind Health 34:279-286 (1996). Time Aircraft Noise and of Sleep Motility Measurement disease at exposures above the observation threshold are both 59. Cohen S, Evans GW, Krantz DS, Stokols D. Physiological, moti- Nethods. Rpt 8195. Canogan Park (A), CA:BBN Systems and equal to 1.5, this does not imply that the noise-induced vational and cognitive effects of aricraft noise on children: mov- Technologies Corporation, 1998. increases in persons with such disease are equal. For example, ing from the laboratory to the field. Am Psychol 35:231-243 74. Griefahn B, Mehnert P, Moehler U, Schuemer-Kohrs A, in the Netherlands about 10% of the adult population is hyper- (1980). Schuemer R. Design of a field study on the effects of railway tensive or is using medication for hypertension. There are no 60. Karsdorf G, Klappach H. Einflusse des Verkehrslarms auf noise and road traffic noise. In: Proceedings of Inter-Noise 96, data on the prevalence of ischemic heart disease in the Gesundheit und Leistung bei Oberschulern einer Grossstadt August 1996, Liverpool, UK. St. Albans, UK:lnstitute of Netherlands, but data on the admission to hospitals (including [Effects of traffic noise on health and achievement of high school Acoustics, 1996;2183-2188. death) due to ischemic heart disease give 0.5%. This implies students of a large city]. Z Gesamte Hyg 14:52-54 (1968). 75. Fidell S, Howe R, Tabachnick B, Pearsons K, Sneddon M. Noise- that the noise-induced increase in hypertensives is 20 times as 61. Regecova V, Kellerova E. Effects of urban noise pollution on Induced Sleep Disturbance in Residences near Two Civil large as the noise-induced increase in admission to hospitals blood pressure and heart rate in preschool children. J Airports. NASA Contractor Rpt 198252. Hampton, VA:NASA due to ischemic heart disease. Hypertens 13:405-412 (1995). Langley Research Center, 1995. 49. Xu X, Niu T, Christiani DC, Weiss ST, Zhou Y, Chen C, Yang J, 62. Lercher P, Stansfeld SA, Thompson SJ. Non-auditory health 76. Fidell S, Pearsons K, Tabachnick B, Howe R, Silvati L, Barber Fang Z, Jiang Z, Liang W, Zhang F. Environmental and occupa- effects of noise: review of the 1993-1998 period. In: DS. Field study of noise-induced sleep disturbance. J Acoust tional determinants of blood pressure in rural communities in Proceedings of Noise as a Public Health Problem, Vols 1, 2. Soc Am 98:1025-1033 (1995). China. Ann Epidemiol 7:95-106 (1997). (Carter NL, Job RFS, eds). Sydney, Australia:University of 77. Evans GW, Hygge S, Bullinger M. Chronic noise and psychologi- 50. Babisch W, Ising H, Gallacher JEJ, Sweetnam PM, Elwood PC. Sidney, 1998;213-220. cal stress. Psychol Sci 6:333-338 (1995). The Caerphilly and Speedwell studies, 10 year followup. In: 63. Evans GW, Bullinger M, Hygge S. Chronic noise exposure and 78. Haines MM, Stansfeld SA, Job RFS, Berglund B. Chronic air- Proceedings of Noise as a Public Health Problem (Vols 1, 2), physiological response: a prospective study of children living craft noise exposure and child cognitive performance and (Carter NL, Job RFS, eds). Sydney, Australia:University of under environmental stress. Psychol Sci 9:75-77 (1998). stress. In: Proceedings of Noise as a Public Health Problem, Sydney, 1998;230-235. 64. Hygge S, Evans G, Bullinger M. The Munich airport noise study: Vols 1, 2 (Carter NL, Job RFS, eds). Sydney, Australia:University 51. Ising H, Babisch W, Kruppa B, Lindthammer A, Wiens D. cognitive effects on children from before to after the change of Sydney, 1998;329-335. Subjective work noise: a major risk factor in myocardial infarc- over of airports. In: Proceedings of Inter-Noise 96, August 1996, 79. Franks JH. Preventing noise-induced hearing loss: a perspective tion. Soz Praventivmed 42:216-222 (1997). Liverpool, UK. St. Albans, UK:Institute of Acoustics, 1996. view from the next millennium. In: Proceedings of Noise as a 52. Melamed S, Froom P, Kristal-Boneh E, Gofer D, Ribak J. 65. Wu TN, Chen LJ, Lai JS, Ko GN, Shen CY, Chang PY. Public Health Problem, Vols 1, 2 (Carter NL, Job RFS, eds). Industrial noise exposure, noise annoyance, and serum lipid lev- Prospective study of noise exposure during pregnancy on birth Sydney, Australia:University of Sydney, 1998;1 1-16. els in blue-collar workers-the CORDIS Study Arch Environ weight. Am J Epidemiol 143:792-796 (1996). 80. It would be worthwhile to study whether metrics related to Health 52:292-298 (1997). [Published erratum appears in Arch 66. Melamed S, Luz J, Green MS. Noise exposure, noise annoyance annoyance, such as Lde,, might also be instrumental in prevent- Environ Health 52(5(:389 (1997)]. and their relation to psychological distress, accident and sick- ing hearing impairment among the general population. The 53. Tomei F, Papaleo B, Baccolo TP, Tomao E, Alfi P, Fantini S. ness absence among blue-collar workers-the Cordis Study. lsr problem here is that a metric like Lden is location specific (usu- Esposizione cronica a rumore e apparato cardiovascolare in J Med Sci 28:629-635 (1992). ally specified in front of the facade of a building), whereas met- piloti di aeromobili [Chronic noise exposure and the cardiovas- 67. Schwarze S. Langjarige Larmbelastung und Gesundheit. rics to prevent hearing impairment are person specific and cular system in aircraft pilots]. Med Lav 87:394-410 (1996). Dortmund: Bundesanstalt fur Arbeitsschutz. Rapport nr FB 636. should give the noise exposure at the ear. 54. Babisch W, Ising H, Elwood PC, Sharp DS, Bainton D. Traffic noise Dortmund:Bundesanstalt fur Arbeitsschutz, 1991. 81. On average the differences between Lden and Ldn are only mar- and cardiovascular risk: the Caerphilly and Speedwell studies, 68. Barreto SM, Swerdlow AJ, Smith PG, Higgins CD. A nested ginal. By analyzing over 60,000 situations with road, railway, or second phase. Risk estimation, prevalence, and incidence of case-control study of fatal work related injuries among Brazilian aircraft noise, the average difference between Lden and Ldn ischemic heart disease. Arch Environ Health 48:406-413 (1993). steel workers. Occup Environ Med 54:599-604 (1997). appeared to be less than 0.5 dB(A). In specific situations, how- 55. Babisch W, Gallacher JE, Elwood PC, Ising H. Traffic noise 69. Horne J. Why We Sleep: The Functions of Sleep in Humans and ever, the difference may be substantially larger. and cardiovascular risk. The Caerphilly study, first phase. Other Mammals. New York:Oxford University Press, 1990. 82. EU Working Group on noise indicators. Position paper on EU Outdoor noise levels and risk factors. Arch Environ Health 70. Carter NL. Cardiovascular response to environmental noise dur- noise indicators [draft]. Brussels:European Commission, DG 43:407-414 (1988). ing sleep. In: Proceedings of Noise as a Public Health Problem, Xl, 1999. 56. Babisch W, Fromme H, Beyer A, Ising H. Elevated cate- Vols 1, 2 (Carter NL, Job RFS, eds). Sydney, Australia:University 83. American Academy of Pediatrics: Committee on Environmental cholamine levels in urine in traffic noise exposed subjects. In: of Sydney, 1998;439-444 Health. Noise: a hazard for the fetus and newborn. Pediatrics Proceedings of Inter-Noise 96, August 1996 Liverpool, UK. St. 71. Ohrstrom E. Psycho-social effects of traffic noise. J Sound Vib 100:724-727 (1997). Albans, UK:lnstitute of Acoustics, 1996;2153-2158. 151:513-517 (1991).

Environmental Health Perspectives * Vol 108, Supplement 1 * March 2000 131