Research on systematic noise effects started in Germany back in the fifties with basic experimental studies on humans. As a result, noise was classified as a non-specific stressor, which could cause an ergotropic activation of the complete organism. In the light of this background research a hypothesis was proposed that long-term noise exposure could have an adverse effect on health. This hypothesis was further supported by animal studies. Since the sixties, the adverse effects of chronic road traffic noise exposure were further examined in humans with the help of epidemiological studies. More epidemiological aircraft noise studies followed in the 1970s and thereafter. The sample size was increased, relevant confounding factors were taken into account, and the exposure and health outcomes were investigated objectively and with higher quality measures. To date, more than 20 German epidemiological traffic noise studies have focused on noise-induced health effects, mainly on the cardiovascular system. In particular, the newer German noise studies demonstrate a clear association between residential exposure to traffic noise (particularly night noise) and cardiovascular outcomes. Nevertheless, additional research is needed, particularly on vulnerable groups and multiple noise exposures. The epidemiological findings have still not been fully considered in German regulations, particularly for aircraft noise. The findings, however, were taken into account in national recommendations. The Federal Environment Agency recommends noise rating levels of 65 dB(A) for the day and 55 dB(A) for the night, as a short-term goal. In the medium term, noise rating levels of 60 / 50 (day, night) should be reached and noise rating levels of 55 / 45 in the long run.
Keywords: Epidemiological study, experimental study, health outcomes, recommendations, traffic noise
|How to cite this article:|
Maschke C. Cardiovascular effects of environmental noise: Research in Germany. Noise Health 2011;13:205-11
| Introduction|| |
According to the probabilistic exposure model (reference year 2000) of the German Environment Agency, 16% of the German population are exposed to road traffic noise levels of more than 65 dB(A) during the daytime (L day,16h ), and 49% are exposed to noise levels exceeding 55 dB(A).  During the night time 17% are exposed to road traffic noise levels (L night,8h ) of more than 55 dB(A), and 49% to noise levels exceeding 45 dB(A). Road traffic noise is the environmental noise source causing the highest annoyance reactions within communities. Twelve percent of the German population is highly annoyed (upper two categories of the five-point International Commission on the Biological Effects of Noise (ICBEN) scale) by road traffic noise, 6% by aircraft noise, 5% by neighbor noise, 4% by industrial / commercial noise, and 3% by railway noise.
| Experimental Studies|| |
Systematic noise effect research started in Germany in the post-war period (e.g., Meyer-Delius 1957, Lehmann et al. 1958, Jansen 1967, and Klosterkötter 1968). ,,, To begin with, the studies concentrated on the physiological reactions caused by artificial sound as well as on the clarification of the underlying mechanisms. In the 1950s, Lehmann and Tamm had already published an article, which stated that the acute reaction of the cardiovascular system to noise was characterized by a decrease in the stroke volume and a simultaneous increase in peripheral vascular resistance. , The method of the finger pulse amplitude was then predominantly used as an indicator to verify acute noise effects in the organism, by Jansen. ,,, Noise was classified as a non-specific stressor, which could cause an ergotropic (Ergotropic: a functional status of the nervous system that favor the organism's capacity to expend energy, as distinguished from the trophotropic mechanisms promoting rest and reconstitution of energy stores; in general, the balance between ergotropic and trophotropic nervous mechanisms corresponds in a large part to that between the sympathetic and parasympathetic subdivisions of the autonomic nervous system) activation of the complete organism. Experimental studies had shown that besides a blood pressure increase, a blood pressure decrease was also found in subjects under acute noise exposure. , Mean blood pressure readings, in this respect, were not likely to be adequate health effect indicators in epidemiological studies. Rather the prevalence of hypertension (or hypotension) should be investigated. In the following years, the effects of noise on sleep became a topic of increasing interest in the research of noise effects. ,,,,,, With electroencephalographic measurements it could be shown that nocturnal noise that was discontinuous in time and frequency and that contained high information, activated the autonomic and the endocrine systems. Two of the best known German immission limit values for aircraft noise, the vegetative overloading criterion 19 × 99 dB (A) and the night protection concept of 6 × 60 dB (A), were based on the early experimental studies of the task force of Jansen and co-workers. , However, the Jansen-criteria do not agree with the newer results of the sleep-related noise effect research carried out in Germany. ,
The hypothesis that long-term noise exposure can have an adverse effect on health has been supported by animal studies. ,,, German and international experiments with rats has shown that chronic noise pollution alone or in combination with other stressors (e.g., magnesium deficient diet) can lead to high blood pressure, increased stress hormone secretion, as well as, an accelerated aging of the heart. 
| Epidemiological Studies|| |
The long-term effects of chronic noise exposure in humans were already examined early on in Germany with the help of epidemiological studies. With regard to the environment, the effect of road traffic noise, ,, predominantly, and also aircraft noise studies were carried out. ,, The cardiovascular system as a health effect was mainly considered with reference to the pathogenesis model of Ising and Babisch.  The characteristics of the major studies are listed in [Table 1]. For details of studies not listed in the table see the review by Babisch. 
|Table 1: Characteristics of major epidemiological noise studies (selected) carried out in Germany|
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| Road Traffic Noise|| |
The first German epidemiological study regarding the effect of road traffic noise on cardiovascular outcomes was performed in the 1960s by Karsdorf in the town of Halle.  The blood pressure of school children, exposed to different levels of road traffic noise, was measured in classrooms. In the group with the highest road noise exposure the blood pressures were more than 10 mmHg, higher than in the less exposed reference group, and overall an exposure-effect relationship was found. Confounding factors such as social class were not assessed, but children with clinical manifestations of blood pressure-related diseases were excluded from the analysis. In the 1980s two road traffic studies followed, carried out by von Eiff.  More than 900 normotensive subjects were examined for their blood pressure in the Bonn road traffic noise study. A significantly higher prevalence rate of hypertension (OR = 1.5) was found in subjects from the high noise area (L day > 65 dB (A)) compared to subjects from the low noise area (L day < 60 dB(A)).  The relevant confounding factors were taken into account. A three-year follow-up study failed due to a high and probably selective migration rate among the young subjects under study, particularly, in the noisy areas. No reliable intra-individual comparisons could be made.  The majority of the German traffic noise studies were done in the 1990s. Wölke et al., examined 352 subjects in a before - after study in relation to hypertension and contact rates due to cardiovascular disease.  The study was carried out in a small town near Erfurt. Participants living on the streets where the noise level exceeded L day = 75 dB(AI) showed a significant relative risk of 2.4 for hypertension (period prevalence). The selection criteria of the exposed and unexposed subjects, as well as the possible effects of the confounding factors remained unclear. The longitudinal part of the study was concerned with the health benefit of a 10 dB reduction in the highly exposed streets. Five years after this intervention (five-year follow-up), the recovery rate of patients with hypertension was markedly higher in the previously extremely exposed area, than in the recovery rate of subjects in the control area.
In 1992, the so-called Berlin Studies were carried out. The Berlin studies included two prospective case-control studies, one hospital-based and the other population-based, for the selection of controls. , In the first study, which was designed as a pre-study, all male patients aged between 41 and 70 years, who were treated for acute myocardial infarction (MI), were brought together for one year. Controls with the same age / gender characteristics were chosen from the registers of the same clinics. The response rates were high, around 90%, and the sample consisted of 273 subjects. In the Berlin II study, all acute male MI patients aged between 31 and 70 years, from 17 major hospitals in West Berlin were brought together for one year. There were a total of 693 subjects. Again approximately 90% participated. As a control group, a random sample of 3865 men of the same age distribution was chosen from the local registrar's office (64% response rate). In the Berlin case-control studies, non-significant relative risks of 1.2 - 1.3 were observed in men, when the average outdoor noise levels were higher than 70 dB(A) for L day,16h (in comparison with noise levels less than 60dB(A)). Another study on the relationship between subjective ratings of noise exposure at the place of residence and incidence of cardiovascular effects was published in 1995.  In the cohort study, 1002 test persons were asked to fill in a questionnaire in 1974 as well as in 1985, with regard to lifestyle, stress factors, noise at work, and noise at the place of residence, as well as to health disorders and diseases. Four categories were composed from, 'no noise at home / work' (reference group) to 'irksome noise at home / work'. For the last category the study found an increased relative risk of 2.81 (95% CI: 0.89-8.87) in relation to cardiovascular diseases, 3.54 (95% CI: 0.79-15.75) in relation to myocardial infarction, and a relative risk of 1.32 (95% CI: 0.42-4.11) in relation to hypertension. For noise at the place of residence, in connection with sleep disturbances, the study yielded significant relative risks of 2.34 (95% CI: 1.06-5.18) with regard to cardiovascular diseases and 2.32 (95% CI: 1.16-4.65) with regard to hypertension (in comparison to no noise and no sleep disturbances). However, noise-related questions were asked at the end of the follow-up, which implied a possible risk of reporting bias. The noise part of the study, in this respect, should be viewed as a cross-sectional study, where exposure and outcome were assessed at the same point in time.
Two key studies were carried out after the year 2000, the 'Spandau Health Survey' by  and the 'NARoMi-study'.  The Spandau Health Survey evaluated the prevalence of treatment for stress-related diseases like hypertension in relation to road traffic noise exposure at the home address of 1718 participants (response rate > 80%). The relevant confounding factors were taken into account [see Table]. The period of prevalence (and the lifetime prevalence) of hypertension increased steadily with the road traffic noise in the range of L day < 55 to 70 dB(A) and L night < 50 to 65 dB(A). The relative risks were 1.5 (L day > 65 dB(A)) and 1.9 (L night > 55 dB(A)) with regard to the living room during the day and to the bedroom during the night. The relative risks for the night-time noise were significant for period prevalence OR = 1.9 (95% CI: 1.1 - 3.2) and for the lifetime prevalence OR = 1.8 (95% CI: 1.1 - 2.9). When subjects were analyzed separately, for those who slept nearly every night with an open bedroom window, the relative risk was considerably higher. However, due to the small sub-sample size, this risk estimate in absolute terms cannot be rationally interpreted (large confidence interval). It must be noted that the Spandau Health Survey consists of a selected, predominantly older, health-conscious group of test persons. The NaRoMI (Noise and Risk of Myocardial Infarction) study is a replica of the previous Berlin II study, using the same test hypothesis. The hospital-based case-control study took a larger sample size (4114 patients; age: 20 to 69 years, response rate 86%) and used improved methods for data collection. The study found a clear dose-response relationship: an increasing risk of myocardial infarction with increasing traffic noise levels. The increase in risk started at an average sound level of 60 dB(A). Male subjects that lived on streets with average sound levels of more than 70 dB(A) during the day showed a relative risk of myocardial infarction of OR = 1.27 (95% CI: 0.88 - 1.84), compared to those who lived on streets with less / equal sound levels, of 60 dB(A). In the sub-sample (stratified analyses) of subjects who had been living for at least 10 years at their present address, an odds ratio of OR = 1.81 (95% CI: 1.02-3.21) was found for the same comparison, which was significant. The results of the Berlin II study were largely confirmed.
The newer German road noise studies support the hypothesis of an association between road traffic noise and cardiovascular effects. The relevant confounding factors such as age, hearing ability, smoking, drinking, body mass index, socioeconomic status, and noise sensitivity are taken into account, but confounding due to unknown factors cannot be excluded, for example, noise effects from other noise sources. Exposure is investigated objectively, by measurements or by using noise databases and investigated independently from the health outcomes. Differential misclassification is therefore not very likely, but selection bias cannot always be excluded.
| Aircraft Noise|| |
The first German epidemiological study regarding the effect of aircraft noise on cardiovascular outcomes (blood pressure) was performed in the 1970s, carried out by von Eiff, in the framework of the interdisciplinary German Aircraft Noise Study.  The medical part of the study was carried out around the old Munich airport, with 392 participants in four noise clusters. The noisiest cluster had the highest blood pressure readings, with a mean difference of approximately 3 mmHg (diastolic) as compared to the least exposed group. Overall, a 'u'-shaped association was found across the noise categories (clusters). Also for the diastolic blood pressure the noisiest cluster had the highest blood pressure reading. The differences between the clusters were, however, low. The systolic and diastolic readings of men were considerably higher than the corresponding readings of women.
In the 1990s some studies with regard to noise from low-flying military aircraft, were also carried out in Germany. ,,, Areas with different low-amplitude flight noise were compared for subjective annoyance, blood pressure, and hearing. At that time the German Air Force was interested in confirming areas for pilot training. The studies took place in low-flying areas in northern (Münsterland) and southern (Franken) Germany. Cardiovascular studies were carried out both in children (age - 9 to 13 years) and adults (age - 20 to 60 years). The studies normally consisted of a telephone survey with regard to cardiovascular details and a medical examination of a sub-sample recruited from those participating in the telephone survey. In children, the blood pressure study in Franken revealed higher readings of up to 9 mmHg in systolic blood pressure, in extremely low-flying areas (75 m). This effect was found in girls, but not in boys. However, these findings could not be confirmed in the study in Münsterland. In adults, the telephone survey in northern Germany (response rate 56%) did not reveal any differences in the prevalence of hypertension. The clinical examinations carried out on adults in Münsterland found non-significant prevalence ratios of 1.0 and 0.9 for hypertension in males and females, respectively, for highly exposed areas, as compared to less exposed areas. The examinations suffered, however, from a very low response rate (6%). The second study on adults carried out in Franken (response rate 49%) revealed non-significant prevalence ratios, of less than 1.0, in the exposed subjects. Due to the results of the studies the German Federal Ministry of Defence raised the minimum altitude of low-flying military aircraft in Germany to 300 m in 1990.
The effect of civilian aircraft noise on children was also examined in the Nineties. A cross-sectional study carried out around the old Munich airport found 2 mmHg higher systolic blood pressure readings in school children from noise-exposed areas (L eq , 24 hours = 68 dB (A) as compared to children from unexposed areas (L eq , 24 hour = 59 dBA).  This difference was of borderline statistical significance. No noise effect was found with regard to diastolic blood pressure. In a longitudinal approach, the blood pressure readings were analyzed in school children before and after the opening of the new Munich airport in an air traffic noise exposed and unexposed control area.  In the noise exposed areas the 24 hour average sound pressure level (L eq ) was 53 dB(A), before the opening, as compared to 62 dB(A) after the opening of the airport. In the control area the before and after noise levels were 53 dB(A) and 55 dB(A), respectively. Children from the noisy areas showed a 2 to 4 mmHg higher increase in blood pressure readings than their counterparts from the quiet areas. However, 18 months after the opening, no difference in blood pressure readings was found between the children from both areas. The higher change in blood pressure was probably due to lower values at the beginning of the follow-up.
Two studies have been done in Germany since 2000, the 'Cologne-Bonn study' by Greiser  and a time series study by Aydin.  In the Cologne-Bonn study, the individual prescription data of 809.379 health-insured subjects (all ages) were linked, to address specific noise data (air traffic, road traffic, train traffic). , Multivariate logistic analyses were conducted on quartiles of night-time aircraft noise for different periods of the night, with special focus on the late night aircraft noise exposure (3:00 - 5:00 hours). Adjustments were made for age, gender, noise from road and train, density of nursing homes, prevalence of social welfare recipients in the local community quarters, and the possibility of reimbursement for noise protection of sleeping rooms, as well as for the interaction of aircraft noise, with age and the social welfare indicator. In this cross-sectional registry study, noise-dependent increases of the prevalence of antihypertensive drugs and cardiovascular drugs were found, especially when prescribed in combination and in conjunction with anxiolytic drugs. When different periods of the night were compared, the strongest association was found with respect to the noise exposure at the end of the night (3:00 - 5:00 hours) compared to the beginning of the night (23:00 - 1:00 hours), the whole night, or the exposure during the day. The time-series study by Aydin, in the vicinity of the Frankfurt airport, was performed by asking the question, "does nocturnal aircraft noise have an influence on the physiological parameters of cardiovascular function".  The participants had their heart rate and blood pressure measured twice daily (in the morning and evening) over a period of 12 weeks. Thirty-one subjects lived west of the airport (West group) and were exposed to a nocturnal equivalent continuous air traffic noise level of L eq = 50 dB(A) outside, during flight direction 25 to the west; 22 subjects lived east of the airport (East group) and were exposed to L eq = 50 dB(A) during flight direction 07 to the east. The opposite flight directions corresponded to the aircraft noise of less than 40 dB(A) in both areas. The Frankfurt airport operates on direction 25 about 75% of the time, on an average, and on direction 07 about 25% of the time. The average blood pressure was significantly higher in the west group where the noise exposure (equivalent continuous aircraft noise level) was higher. Morning systolic blood pressure was 10 mmHg and diastolic pressure 8 mmHg higher in the west group. Throughout the observation period, the east group showed a parallel between daily changes in noise and subjective noise perception. In the west group such a parallel did not appear. This reaction was considered to be the consequence of higher noise stress (overstimulation of the sympathetic system) in the west group.
The newer German aircraft noise studies, including the Berlin sample of the HYENA study (see the UK article in this issue), support the hypothesis of an association between aircraft noise, primarily night time aircraft noise, and hypertension as well as cardiovascular diseases. The exposure was investigated objectively, by measurements or standardized calculation programs (GIS technology) and investigated independently from the health outcomes. Differential misclassification was therefore not very likely, but selection bias and confounding due to individual risk factors could not always be excluded.
| Public Health Issues|| |
In Germany noise exposure is generally characterized by noise rating levels, separated for the day (6:00 - 22:00 hours) and the night (22:00 - 6:00 hours). According to the German Federal Immission Control Act,  it is required that no harmful environmental impact is caused by new or considerably modified ground traffic (§41); if such impacts can be avoided through technical means, it should be done, unless the costs are disproportionate to the preventive objective. Furthermore, through the involvement of town planning schemes, the assessment values of the German standard DIN 18005 (Supplement 1) shall be adhered to.  Legally binding noise limits for road and railway noise in Germany are only established for new or considerably modified projects, as regulated by the German Traffic Noise Directive (16 th BImSchV).  For solely residential areas, the noise rating level should not exceed 59 dB(A) during the day and 49 dB(A) at night. If the noise rating level is exceeded, a claim for soundproofing or compensation can be made. No such limit values are established for the existing road or railway lines. As a partial substitute, however, noise redevelopment programs have been provided for national inter-urban roads, since 1976, and for the railway lines of the German Rail Company (Deutsche Bahn AG), since 1999. Noise redevelopment actions are only implemented as far as the budgetary funds allow.
The Federal Immission Control Act  does not as yet cover aircraft noise. However, new or considerably extended airports must comply with the German law on prevention of aircraft noise (FlugLärmG).  This includes structural sound protection measures as well as building restrictions. According to the law, noise protection zones have to be defined around airports for the day and the night. Within the protected zones a claim for technical soundproofing or compensation can be made. Protection during the day is regulated by two zones. For new or considerably extended civil airports the first zone comprises all areas where the average aircraft noise level during the day (six busiest months of the year) exceeds 55 dB(A). Collective facilities with protection requirements (e.g., schools or hospitals) may only be built in exceptional cases. Private clients have to pay for increased technical soundproofing. The second zone comprises of all areas where the average aircraft noise level exceeds 60 dB(A). The airport operator has to finance technical soundproofing and has to financially compensate the impairment of the living space outdoors. For the night noise protection zone, two criteria are established. First, it comprises all areas where the average noise level during the night exceeds 50 dB(A) or where more than six flight events occur with maximum levels of 53 dB(A) or higher (valid, as of the year 2011). In the night zone the airport operator has to finance technical soundproofing. With respect to the already existing airports the values for the protection zones are 4 (L max) to 5 (L Aeq) dB higher than for the new or considerably extended airports.
Besides the laws and regulations, the recommendations of the Federal Environment Agency and the German Advisory Council for Environment have to be taken into account in Germany. Day / night noise rating levels of 65 / 55 dB(A) within a short time, 62 / 52 dB(A) in the medium term, and 55 / 45 dB(A) as a precautionary objective have been formulated.  For transportation noise, the German Federal Environment Agency (Umweltbundesamt) recommends noise rating levels of 65 dB(A) and 55 dB(A) for L den and L night as a short-term goal to prevent major health effects. Medium-term goal noise rating levels of 60 / 50 dB(A) (day / night) are anticipated to reduce annoyance and disturbance reactions and 55 / 45 dB(A) in the long run, to largely avoid annoyance and disturbance reactions. 
| Summary and Conclusion|| |
Germany has developed into a noisy country in the last 30 years. Today, not only traffic noise, but also leisure and neighbourhood noise affect people, particularly in the metropolitan areas. There is an increased public interest in the consequences of noise with respect to health. More than 20 epidemiological studies have therefore focused on noise-induced health effects in Germany. These studies demonstrate a clear association between residential exposure to traffic noise and cardiovascular outcomes. Further prospective research is needed. Future epidemiological noise research will have to focus on vulnerable groups, effect modifiers, sensitive hours of the day, differences between noise sources, possible confounding and / or interaction with air pollution, differences between objective (noise level) and subjective (perception of the noise) exposure, and particularly on multiple exposures (home, work, and leisure environment).
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