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   Abstract
   Introduction
   Studies Investig...
   Descriptives
   Comparison of th...
   Public Health Issues
   Dutch Noise Legi...
   The European Noi...
   Conclusion
   Acknowledgments
   References
   Article Figures
   Article Tables
 

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ARTICLE  
Year : 2011  |  Volume : 13  |  Issue : 52  |  Page : 221-228
Cardiovascular effects of environmental noise: Research in The Netherlands

National Institute for Public Health and the Environment (RIVM), Antonie van Leeuwenhoeklaan 9, 3721 MA Bilthoven, The Netherlands

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Date of Web Publication29-Apr-2011
 
  Abstract 

The impact of environmental noise on public health, in The Netherlands, is limited: Less than 1% of the myocardial infarction cases per year are attributable to long-term exposure to road traffic noise. Furthermore, although the Dutch noise policy is not directed to prevent cardiovascular disease due to noise exposure, health does play a role in Dutch noise policy. These are the main conclusions of a systematic review of Dutch observational studies, investigating the possible impact of road traffic and aircraft noise exposure on the cardiovascular system. Since 1970, 14 Dutch studies were published investigating the possible impact of road traffic and aircraft noise exposure on the cardiovascular system. Within these studies a large variety of outcomes were investigated, ranging from blood pressure changes to cardiovascular mortality. The results of the studies were not consistent and only weak associations were found.

Keywords: Aircraft noise, cardiovascular disease, exposure-response relationship, risk assessment, road traffic noise

How to cite this article:
Kempen Ev. Cardiovascular effects of environmental noise: Research in The Netherlands. Noise Health 2011;13:221-8

How to cite this URL:
Kempen Ev. Cardiovascular effects of environmental noise: Research in The Netherlands. Noise Health [serial online] 2011 [cited 2019 Sep 19];13:221-8. Available from: http://www.noiseandhealth.org/text.asp?2011/13/52/221/80158

  Introduction Top


Environmental noise can lead to environmental distress. Approximately 14% of the population in agglomerations that were mapped by European Union countries, is exposed to road traffic noise levels of 65 dB and more during day, evening and night time (L den ). A set of outcomes often reported in relation to environmental noise exposure can be identified: for example, 'social' responses such as annoyance or perceived sleep disturbance, chronic physiological responses (e.g., blood pressure changes), and clinical morbidity such as mental health impairments and cardiovascular disease (including medication use). [1],[2],[3],[4] Several reviews [5],[6],[7] have suggested that noise exposure is associated with blood pressure changes and ischemic heart disease. In 1999, the World Health Organization (WHO)-guidelines [2] have concluded that, 'epidemiological studies show that cardiovascular effects occur after long-term exposure to noise with L Aeq24hr values of 65 - 70 dB. However, the associations are weak. The association is somewhat stronger for ischemic heart disease than for hypertension'. According to the Health Council of The Netherlands, in 1993 and 2004, [3],[4] there was sufficient evidence for an association between environmental noise exposure and hypertension and ischemic heart disease. The observed threshold for hypertension was estimated to correspond to an L den value of 70 dB for outdoor environmental noise exposure. The same was suggested for ischemic heart disease. [3] The biological plausibility of the hypothesis of the effects of noise on the cardiovascular system is substantial and assumes that noise acts as a stress factor, and as such, has the potential of directly and indirectly precipitating diseases. [3] The conclusions of the World Health Organization and the Health Council of The Netherlands were partly confirmed by a recent meta-analyses, [6],[7],[8],[9] showing that the results of the studies investigating the association between road and aircraft noise exposure and cardiovascular disease converged. Data-aggregation produced weak associations. No definite conclusions can be drawn about the slope of the exposure-effect relations nor about a possible threshold. Restricting is that cardiovascular effects have only been investigated in a limited set of populations: most studies were carried out among middle-aged men and few were carried out among children. On the other hand, since 2000, more case-control studies have been carried out, increasing the validity and credibility of the effect of noise on cardiovascular disease. [7],[8] There are indications that exposure to air pollution is also associated with effects on the cardiovascular system. [10] As people are often exposed to both air pollution and noise, the effects on the cardiovascular system could be attributed to both exposure types. [11],[12],[13],[14],[15] Epidemiological data linking cardiovascular disease incidence with traffic-related air pollution and transportation noise are scarce. [14],[15] This article focuses on the effects of environmental noise on the cardiovascular system, in The Netherlands.

One of the most important sources of community noise in The Netherlands is transportation. The highest noise exposure levels can be found in the vicinity of roads, railways, and runways of major airports. More than 3% of the Dutch population is exposed to road traffic noise levels of 65 dB and more during day, evening, and night time (L den ) [8] [Figure 1]. Due to rapid urbanization, areas where people can enjoy quiet will change and become more scarce. As it appears from several policy documents, the Dutch government aims to stop this process (e.g., Fifth National Policy Document on Spatial Planning 2000 / 2020, European Noise Directive); but as yet, their policy has not been successful. However, this does not imply that The Netherlands has become noisier everywhere during the last decades. In the period between 1993 and 2008, the number of houses around Schiphol airport with a noise level of 58 dB (L den ) and over has actually decreased from over 13,000 to almost 5,700. In many residential areas in the vicinity of national medium speed roads (< 80 km) and railways, the noise level has also decreased. This is partly due to noise mitigating measures (such as noise barriers) and partly due to technological developments such as quieter cars and porous asphalt. [16]
Figure 1: Distribution of the Dutch population to road traffic noise levels (Lden)[8]

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  Studies Investigating the Association Between Environmental Noise Exposure and Cardiovascular Disease Top


A considerable amount of research investigating the effects of environmental noise exposure on the cardiovascular system was carried out in The Netherlands. In this article we look into the outcomes and quality of these studies. To this end, observational studies carried out in The Netherlands, involving the association between road traffic and / or aircraft noise exposure and blood pressure, as also ischemic heart disease, published between 1970 and now, were identified and processed according to the methods that were described in Van Kempen et al., (2002). [6] Second, the question addressed was how the knowledge with regard to noise and health (and cardiovascular disease in particular) was implemented in the Dutch noise policy?


  Descriptives Top


Since 1970, 14 Dutch studies were published, which investigated the possible impact of road traffic and aircraft noise exposure on the cardiovascular system. [13],[14],[17],[18],[19],[20],[21],[22],[23],[24],[25],[26] [Table 1] shows some characteristics of these studies. They encompass 13 cross-sectional studies and one follow-up study. The sample sizes range from 396 to 117,528 persons; six studies have investigated the effect of road traffic noise, six studies have investigated the effects of aircraft noise (all carried out in areas around Schiphol-Amsterdam Airport), and two studies have investigated the effects of both aircraft and road traffic noise exposure. Two studies are part of a European multi center study. [25],[26] The older studies have involved between-group comparisons: [17],[18],[20] noise levels have been usually modeled around a residential area, neighborhood or city. Subsequently, these noise levels have been assigned to everybody who lived in that residential area, neighborhood or city.
Table 1: Dutch observational studies that investigated the association among community noise exposure, blood pressure, and ischemic heart disease, published between 1970 and 2008

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In the recent studies, [22],[23],[24],[25],[26] the participants were distributed over a broader exposure range, the exposure was individually assessed, and a continuous noise exposure measure was used, adding to the statistical power of the study. Within the studies, a wide range of effects was investigated: blood pressure, hypertension, use of antihypertensives and / or cardiovascular medicines, angina pectoris, myocardial infarction, consultation of GP / specialist, coronary heart disease, and cardiovascular mortality. Only one study investigated the effects in children.

Exposure effect estimates

In [Figure 2], the results of separate studies investigating the effects of road traffic noise are presented, grouped by the outcome. The relation between road traffic noise exposure and the prevalence of hypertension was investigated in five studies. [13],[19],[20],[26] In three studies, hypertension was measured by means of self-report; one study used blood pressure measurements, and one study used both blood pressure measurements and self-report. The figure shows that the effect of road traffic noise exposure on hypertension was inconsistent and rather small with RR 5dB ranging from 0.96 to 1.02.
Figure 2: The association between road traffic noise exposure (LAeq,6-22 hr) and the prevalence of hypertension and angina pectoris, and cardiovascular mortality, derived from Dutch studies. The dotted line corresponds to no effect of road traffic noise exposure. The study effect estimates (RR5dB and their 95% confidence intervals) were derived according to the methods described in Van Kempen et al., 2002[6]

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In relation to aircraft noise exposure, five studies investigated the association with the prevalence of hypertension: one general practitioners survey [18] and four cross-sectional studies. [17],[23],[24],[26] In two of the four cross-sectional studies, the prevalence of hypertension was measured by self-report; [23],[24] one study measured the prevalence of hypertension by means of blood pressure measurements, [17] and one study used both self-report and blood pressure measurements. [26] The estimated RR 5dB ranged from 0.87 to 1.29.

Four Dutch studies have investigated the association between aircraft noise exposure and the self-reported use of cardiovascular medicines. [17],[22],[23],[24] All were cross-sectional and carried out among adults living in the neighborhood of the Schiphol Airport. All but one, found a positive association between aircraft noise exposure during the day-evening-night period and the prevalence of the use of cardiovascular medicines. Estimated RR 5dB ranged from 0.95 to 1.26. Three studies also investigated the effect of night-time exposure, [22],[23],[24] where an RR 5dB ranging from 1.05 - 1.17 was found.

Noise and air pollution

Two Dutch studies investigated the effects of the combined exposure to noise and air pollution. In a cohort study, Beelen et al., (2009), investigated the association between cardiovascular mortality and black smoke, traffic intensity on the nearest road and road traffic noise (L Aeq, 24hr ), at the home address, among 117,528 men and women, aged between 55 and 69 years. Traffic intensity at the nearest road was associated with cardiovascular mortality, with the highest relative risk for ischemic heart disease mortality. Relative risks for black smoke concentrations were elevated for cerebrovascular mortality and heart failure mortality. These associations were insensitive to the assessment of road traffic noise. There was an excess of cardiovascular mortality in the highest noise category, with elevated risks for ischemic heart disease and heart failure mortality. After adjustment for black smoke and traffic intensity, the noise risk reduced slightly. The interaction between road traffic noise and black smoke and traffic intensity was not investigated. [14]

De Kluizenaar et al., (2007), investigated the association between road traffic noise (L den ), air pollution (yearly average PM 10 concentration) and hypertension in a cohort from Groningen, including men and women aged between 28 and 75 years. After correction for potential confounders an OR 10dB of 1.01 (95% CI: 0.96 - 1.06) was estimated as a risk for hypertension. After adjustment for exposure to PM 10 , an OR 10dB of 1.03 (95%CI 0.96 - 1.06) was found. The interaction between road traffic noise and PM 10 was not investigated. [13]


  Comparison of the Dutch Studies with Other Studies Investigating the Effect of Noise Exposure on the Cardiovascular System Top


Overall evidence shows that noise exposure is associated with blood pressure changes and ischemic heart disease. [2],[3],[4],[5],[6],[7],[9] A considerable amount of research in this area was carried out in The Netherlands. [13],[14],[17],[18],[19],[20],[21],[22],[23],[24],[25],[26] In this article we specifically looked into the outcomes and quality of these studies. A systematic evaluation of Dutch epidemiological studies investigating the association between transportation noise exposure and its effects on the cardiovascular system, showed that a large variety of cardiovascular outcomes were investigated, ranging from blood pressure changes to cardiovascular mortality. The results of these studies were not consistent and only weak associations were found. How do the Dutch studies compare with studies carried out in other countries? As is the case with a lot of studies carried out in other countries, [27],[28],[29],[30],[31],[32],[33],[34],[35],[36],[37],[38],[39],[40] most Dutch studies were cross-sectional. [13],[17],[18],[19],[20],[21],[22],[23],[24],[25],[26] Unlike other studies investigating the effects of noise on the cardiovascular system, [11],[12],[27],[28],[36],[38],[40],[41] the participants of most Dutch studies were distributed over a broader exposure range. Moreover, instead of comparing exposure groups (e.g., high vs. low) some Dutch studies used continuous noise exposure measures. [13],[20],[21],[22],[23],[24],[25],[26]

Similar to many other studies, most Dutch studies used L Aeq, 16 hr as an exposure indicator. The use of this indicator may suggest that night-time noise exposure is not relevant. It is too soon to draw such a conclusion, as only a few studies have actually investigated the effects of night-time exposure. [22],[23],[24],[25],[26],[30],[42],[43] For road traffic noise, the correlation between noise exposure during the day and noise exposure during the night is very high. [8],[42] As a consequence it is very difficult to disentangle the effects of night-time noise exposure and day-time noise exposure. [8] The road traffic noise exposure has also changed: traffic volume is heavier in the morning. The recently published Night Noise Guidelines of the WHO (2009) concluded: "There is limited evidence that noise at night causes clinical conditions such as cardiovascular illness." However, "It should be stressed that a plausible biological model is available with sufficient evidence for the elements of the causal chain". [44]

As is the case of studies carried out in other countries, the prevalence of hypertension and the use of cardiovascular medicines was often measured by means of a self-report: for example, questions about doctor-diagnosed hypertension. As hypertension is usually symptom-free, it is likely that a part of the hypertensive persons will classify themselves as having normal blood pressure. This leads to underreporting. Bias is also possible: studies investigating adults' health have suggested that persons with poorer subjective health often attribute the cause of their symptoms to external conditions such as their living environment. [7],[24]


  Public Health Issues Top


When applying the actual scientific knowledge on noise and cardiovascular disease, it appears that the public health impact of environmental noise is limited: In recent times it was estimated that, in The Netherlands, 21 to 150 myocardial infarction cases per year are attributable to long-term exposure to road traffic noise. The most likely estimate is 84 cases per year. Looking at the total burden of the disease attributable to road traffic noise exposure in The Netherlands, only a small fraction (less than 1%) is related to myocardial infarction; the number of adults that are severely annoyed and severely sleep disturbed is substantially higher and is estimated at 640,000 and 290,000, respectively, [8] contributing to 99% of the road traffic noise-related disease burden.

From the distribution of the additional cases of myocardial infarctions, severe sleep disturbed and severe annoyed per 1 dB class [Figure 3], it appears that the contribution of road traffic noise levels above 70 dB (L Aeq,7-23hr ) to the total number of myocardial infarctions is relatively small. This can be explained by the noise distribution of the Dutch population [Figure 1]. The same is true for annoyance and sleep disturbance: the magnitude of the effects is not determined by the higher noise levels, but by noise levels between 55 and 65 dB (L den ) and 45 and 55 dB (L night ). These results indicate that generic measures at the source such as quieter tyres or asphalt, aimed to reduce the average noise exposure, could decrease the impact of road traffic noise on public health.
Figure 3: The total number of extra myocardial infarctions per year (left), the number of severe sleep-disturbed (middle), and the number of severely annoyed (right) due to road traffic noise exposure per 1 dB class.[8]

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  Dutch Noise Legislation and Policy Top


Since the end of the seventies, the core of the Dutch noise legislation is formed by the so-called Noise Annoyance Law or 'Wet Geluidhinder' (Wgh). The Wgh focuses on the protection of citizens, in their living environment, from the noise of roads, railways, and large industrial zones. Wgh has specific limit values [45] for sensitive buildings such as dwellings and schools, which ensure that noise levels during one year do not exceed certain maximum limit values. [46] It was an unusual legal construction to enter limit values in the law, but it was thought in those days that the parliament should make the decisions about the impact on health. The considered health effects were mainly annoyance; severe health effects such as cardiovascular disease, were not an issue at that time. The basic norm was chosen in line with an acceptable occurrence of annoyance. The Dutch Health Council stated in 1971 [47] that a level of 50 dB(A) (L etm ) during the day was a reasonable basic level, considering the traffic noise. It referred to a percentage of 10% annoyed in the population, which was a stricter norm than that for aircraft noise (25% annoyed). In addition, a legal construction of rules and norms was made to manage the costs that would result from this regulation. [48] The law's structure enabled the authorities to exceed this preferred level up to a maximum level. The value of that maximum strongly depended on the situation. The highest maximum levels were allowed within cities; this pragmatic approach was based on the knowledge of the existing noise exposure. During the years the norms have undergone some minor changes; the principles of the legal construction, however, remain unchanged.

Nowadays, the limiting values are more or less the same, 48 dB (L den ), with a maximum upper limit value for road traffic noise in an urban area of 63 dB (L den ), (excluding the still existing 'temporary' flexibilization of the norm). Furthermore, additional legislation for the urban environment (Wet Stad and Milieu) creates a possibility to exceed the maximum levels, if special procedures are followed. In that case, a minor acoustical quality has to be compensated for, with façade insulation and some other (environmental) quality. The complexity of the Wgh and the desire to create more options for local noise policy are the main reasons that the law has been 'under reconstruction' for the last decade.

Since the beginning of the 1990s, the Dutch government has implemented targets for noise abatement policy. The first National Environmental Policy Plan put it in words as follows: "The local environmental quality of 2010 has to be in such a way that people run negligible health risks in their direct living environment and that the number of severely annoyed persons is zero". [49] According to the third National Environmental Policy Plan this target was too ambitious and had to be modified. [50] This happened in the fourth National Environmental Policy Plan. The fourth NMP not only contained a new, but also a different kind of target for "achieving acoustic quality in 2030, in-keeping with the use of the relevant area. In order to achieve this, the limit value of 70 dBA in homes may no longer be exceeded in 2010". [51] Although the noise policy is not directed to prevent cardiovascular disease due to noise, health does play a role in the noise policy: The Health Council of The Netherlands has provided the Dutch government with specific information with which to underpin their noise regulations. [3]


  The European Noise Directive Top


In 2004, the European Noise Directive was implemented in The Netherlands. The Directive applies for environmental noise to which people are exposed and is valid for dwellings, quiet areas, and noise sensitive buildings (e.g., hospitals, schools). In the framework of the European Noise Directive, six agglomerations and administrators of infrastructures were mandated to create noise maps and to report the total number of people exposed to noise levels of 55 dB L den and more, the number of people exposed to noise levels of 50 dB L night and more, and the number of noise-sensitive buildings and areas. In addition, the number of people annoyed and sleep-disturbed had to be reported as well. It was remarkable that only the number of people exposed to noise levels of 55 dB (L den ) and over had to be reported: [Figure 4] shows the mapping results of the six Dutch agglomerations for road traffic noise. It appears that the main part of the population (57 to 76%) living in these agglomerations is exposed to road traffic noise levels of < 55 dB(A). In The Netherlands about 65% live in areas with road traffic noise levels < 55 dB see [Figure 1] also; from [Figure 3] it can be estimated that about one-third of the severely annoyed people in The Netherlands live in these areas.
Figure 4: The exposure distribution for road traffic noise in six agglomerations according to the EU Environmental Noise Directive.[52]

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  Conclusion Top


The overall evidence shows that noise exposure is associated with blood pressure changes and ischemic heart disease. During the past three decades a considerable number of Dutch studies have been carried out investigating the relation between noise exposure and cardiovascular disease. It appears that the quality of these studies has improved. Looking at a recent estimate of the total burden of disease attributable to road traffic noise exposure in The Netherlands, only a small fraction (less than 1%) is related to myocardial infarction. Although noise policy is not directed to prevent cardiovascular disease due to noise, health does play a role in noise policy: the Dutch Government underpins their noise regulations with specific scientific information, with regard to noise and health.


  Acknowledgments Top


This article is based on a study on the burden on health and well-being by road and rail traffic noise exposure in The Netherlands, commissioned by The Netherlands Environmental Assessment Agency (PBL). Furthermore, the authors gratefully acknowledge the contributions and suggestions of Irene van Kamp and Danny Houthuijs from the National Institute for Public Health and the Environment (RIVM) and Annemarie van Beek from The Netherlands Environmental Assessment Agency.[52]

 
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Correspondence Address:
Elise van Kempen
National Institute for Public Health and the Environment (RIVM), Antonie van Leeuwenhoeklaan 9, 3721 MA Bilthoven
The Netherlands
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1463-1741.80158

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