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|Year : 2013
: 15 | Issue : 62 | Page
|Environmental noise and cardiovascular disease in adults: Research in Central, Eastern and South-Eastern Europe and Newly Independent States
L'ubica Argalášová-Sobotová1, Jurgita Lekaviciute2, Sonja Jeram3, L'udmila Ševcíková1, Jana Jurkovicová1
1 Comenius University, Faculty of Medicine, Institute of Hygiene, Bratislava, Slovakia
2 European Commission-Joint Research Centre, Institute for Health and Consumer Protection, Chemical Assessment and Testing Unit, Ispra (VA), Italy
3 National Institute of Public Health, Communicable Diseases and Environmental Health Center, Ljubljana, Slovenia
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|Date of Web Publication||14-Feb-2013|
The adverse effects of noise on health have been intensely explored in the past 50 years. However, the scope of research conducted in the Central and Eastern Europe, South-East Europe, and Newly Independent States is not well-known. The aim of this review was to present studies on cardiovascular effects of environmental noise in adults published since 1965 and to point out the most important issues that need to be addressed in the future. More than 100 papers on noise and health and about 20 papers on cardiovascular effects of environmental noise in adults were identified by literature search. The authors reviewed scientific international and local journals, conference proceedings, and local reports published in national languages. The major endpoints were high blood pressure, ischemic heart disease, and myocardial infarction. The target populations were adults. Experimental and exposure-assessment studies, field, empirical studies, social surveys, and epidemiological studies are presented. The major sources of environmental noise were road and air traffic. The results were presented in tables and the most relevant articles were briefly discussed. The importance of this review is that it refers to some countries that no longer exist in the same political and governmental systems. The strength of this paper is that it includes publications that were not evaluated in earlier systematic reviews. Strategies for future noise-related research on national and global level are proposed.
Keywords: Cardiovascular effects, environmental noise, review, Central and Eastern Europe, Newly Independent States, South-East Europe
|How to cite this article:|
Argalášová-Sobotová L, Lekaviciute J, Jeram S, Ševcíková L, Jurkovicová J. Environmental noise and cardiovascular disease in adults: Research in Central, Eastern and South-Eastern Europe and Newly Independent States. Noise Health 2013;15:22-31
|How to cite this URL:|
Argalášová-Sobotová L, Lekaviciute J, Jeram S, Ševcíková L, Jurkovicová J. Environmental noise and cardiovascular disease in adults: Research in Central, Eastern and South-Eastern Europe and Newly Independent States. Noise Health [serial online] 2013 [cited 2014 Mar 13];15:22-31. Available from: http://www.noiseandhealth.org/text.asp?2013/15/62/22/107149
| Introduction|| |
Besides the psychosocial effects of community noise, there is concern about the impact of noise on public health, particularly regarding cardiovascular outcomes. The cardiovascular effects of noise have been the source of growing interest in the recent years. This is because of the increased evidence of noise effects on cardiovascular diseases that have a high prevalence in industrialized countries, and which are a major cause of death.  The cardiovascular effects of noise have been intensely explored in the last 50 years. Experiments on animals and humans were carried out, aiming to explore the basic biological mechanisms. Several biological reaction models were developed, based on the general stress concept. One of the most explored hypotheses is that persistent noise stress increases risk of cardiovascular disorders, including high blood pressure (hypertension) and ischemic heart disease. ,,,,
Several community noise studies show an increased risk of high blood pressure and myocardial infarction (MI) in relation to exposure to environmental noise. ,,,,,,,, Meta-analyses have developed exposure-response curves that can be used for quantitative health impact assessment. Many recent systematic and quantitative reviews provide evidence of a relationship between transportation noise exposure and the development of cardiovascular diseases. ,,,,,,,,
However, the scope of research conducted in Central and Eastern Europe (CEE), South-East Europe (SEE) and Newly Independent States (NIS) is not well known, due to language, financial, or political barriers. We have, therefore, decided to present these studies to the wider scientific community. This review focuses on the studies on cardiovascular effects of environmental noise in adults conducted since 1965 in these countries and points out the most important issues that need to be addressed in the future.
| Methods|| |
This review includes papers on the cardiovascular effects of environmental noise published since 1965. The papers were identified by literature search of all accessible databases (PubMed, Embase, Scopus, BioMed Central, Web of Science, Toxline, Scientia, Science Direct, etc.) using the terms "environmental noise; community noise; road-traffic noise; transportation noise; noise sources; aircraft noise; railway noise; adults; cardiovascular effects; MI; ischemic heart disease, hypertension, high blood pressure" as key words; and using country denomination (in alphabetical order: Armenia, Azerbaijan, Belarus, Bulgaria, Bosnia and Herzegovina, Croatia, Czech Republic, Georgia, German Democratic Republic (1965-1990), Hungary, Kazakhstan, The Former Yugoslav Republic of Macedonia (FYRM), Moldova, Montenegro, Poland, Romania, Russian federation, Serbia, Slovakia, Slovenia, former Yugoslavia, Ukraine). The authors reviewed the scientific international and local journals, conference proceedings and local reports. Some papers were published in national languages. This review includes proceedings, diploma theses, national reports, and articles from the local sources to fill the white gaps on the map of noise reviews on environmental noise and cardiovascular disease.
The studies we mentioned in this review are the selection of the more comprehensive material we collected during the last 2 years within the framework of the European Network on Noise and Health project (ENNAH) and its Work package 2 (WP2) aimed at reviewing the existing literature on environmental noise-exposure and health, focusing on the consolidation of existing state-of-the-art knowledge and the identification of gaps in the evidence. 
The studies with their characteristics are listed in the chronological order by year of issue and by country. The tables contain the location of the study (town and country where the study was performed), the reference (first author, journal, and year of publication), the aim and the design of the study, study subjects, sample size, exposure assessment (O = objective [noise level outdoors]; S = subjective [annoyance]), outcome of the study, and control for covariates. Statistical control of covariates in the analyses was classified as: 0 = no control, 1 = group comparison, 2 = stratification/standardization, 3 = model adjustment, 4 = matching. In addition, noise exposure and study outcome were described as subjective (S = subjective, indicating self-reporting questionnaire survey), or as objective (O = objective, indicating measurement or clinical examination). The findings of the study are presented in the last column of the tables.
| Results and Discussion|| |
The major endpoints under the study were blood pressure related to road-traffic noise [Table 1], ischemic heart disease, and MI related to road-traffic noise exposure [Table 2], and cardiovascular effects related to aircraft noise [Table 3]. Road- traffic noise and aircraft noise were the only sources of environmental noise identified in the reviewed literature. The target populations were adults. Experimental and exposure-assessment studies, field, empirical studies, social surveys, and epidemiological studies are presented. The brief description of the most relevant articles according to each endpoint from different countries and major results are presented in [Table 1],[Table 2] and [Table 3].
|Table 1: Studies on road traffic noise and blood pressure in adults in Central and Eastern Europe, South - East Europe and Newly Independent States|
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|Table 2: Studies on road traffic noise, ischemic heart disease and myocardial infarction in adults in Central and Eastern Europe, South - East Europe and Newly Independent States|
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|Table 3: Studies on aircraft noise and cardiovascular effects in selected Central and Eastern Europe South - East Europe and Newly Independent States|
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Studies on road-traffic noise and high blood pressure
The studies on road-traffic noise and high blood pressure were either of experimental or epidemiological design. Many experimental studies were carried out in the 1980s and 1990s of the last century, but epidemiological studies were performed mostly after the year 2000. The studies generally concluded that the increase of heart rate, diastolic and systolic blood pressure was related to road-traffic noise exposure. Nine most important studies were identified and are represented in [Table 1].
The studies in an experimental setting in former Czechoslovakia evaluated the reaction of the cardiovascular system to sound or combined muscular and thermic load in human volunteers. ,, Healthy adult men aged 22-34 or 25-45 years were exposed to broadband white noise,  road-traffic noise stimulus,  and broadband noise  from the tape or random noise generator. The outcome was assessed subjectively by a psychological test,  noise-annoyance questionnaire,  or subjective rating of strain,  as well as objectively by heart rate, blood pressure, , and urinary vanillylmandelic acid quantification.  The results illustrate the increased heart rate, systolic and diastolic blood pressure, or no effect in all model situations. The general problem of these studies is the simulated noise exposure and small sample size of study objects.
One experimental study and several epidemiological surveys were conducted in Serbia (cities Belgrade and Pancevo). Experimental exposure to noise (L eq = 89 dB (A)) had a hypodynamic effect, meaning that noise induced a significant decrease of the cardiac index, cardiac work, and pump performance. The vasoconstrictive effect of noise was shown through the significant elevation of after-load. 
In a cross-sectional population study that was carried out in the year 2001 on 3,622 residents in Pancevo City, the response rate was 79%, i.e., 2,874 residents (1243 males and 1631 females). Men who were highly annoyed by noise had significantly higher odds ratios (ORs) for self-reported hypertension (OR = 1.8, 95% confidence interval (CI) = 1.0-2.4) and MI (OR = 1.7 (95% CI = 1.0-2.9), compared to men who were less annoyed by road-traffic noise. This relationship was significant after adjustment for age, body mass index, and smoking habits. 
In another study performed during the years 2006-2007 on 2,503 residents (995 men and 1,508 women) of Belgrade, the proportion of men with hypertension in the noisy areas (defined as Lnight , 8h > 45 dB (A)) was 23.6%. The proportion of men with hypertension in the quiet areas (defined as Lnigh , 8h ≤ 45 dB (A)) was 17.5%. Night-time noise was measured in 70 downtown streets. The adjusted OR for hypertension of the noisy area was 1.58 (95% CI = 1.03-2.42), where men living in quiet streets were taken as a reference category. The outcomes were controlled for possible confounding factors, such as family history of arterial hypertension, age, body mass index, smoking habits, physical activity, and alcohol consumption. On the other side, the observed relationship between noise exposure and arterial hypertension was statistically insignificant among women. This cross-sectional study showed that night-time urban road-traffic noise might be related to the occurrence of arterial hypertension in men. 
Another cross-sectional study on a large sample of pregnant women was performed in Lithuania in 2011.  The authors estimated the hypertension risk and examined the dose-response relationship for this susceptible group. An effect was seen at noise levels 51-60 dB (A) (adjusted OR = 1.03; 95% CI = 0.72-1.49) and at > 61 dB (A) (adjusted OR = 1.94; 95% CI = 1.01-3.72).
The major findings of a case-control study in Lithuania on the male residents of Kaunas city, aged 25-64 years, treated in hospitals from 1997 to 2000  showed that living in a noisy district increased the risk of arterial hypertension in the exposed population group (RR - Relative risk = 1.13; 95% CI = 0.90-1.43). Cases of elevated blood pressure were identified if BP ≥ 160/95 mmHg, whereas control subjects had normal blood pressure. Noise levels were measured and linked to Geographic information system (GIS). Noise during the night was found to be especially harmful.
In The Former Yugoslav Republic of Macedonia, the cross-sectional questionnaire-based study on noise annoyance and health determined by a physician was performed in the year 2006 in the adult population in Skopje. Noise-exposure indicators Lday , Lnight , Lden were determined and subjective noise annoyance was assessed using a 5-point verbal scale and an 11-point numerical scale. As a result, 13% of subjects reported a high level of noise annoyance and 33.5% reported moderate level of annoyance. Annoyance was significantly associated with the prevalence of hypertension (P = 0.02) in study subjects. The most important noise sources were noise from construction activities, road-traffic noise, and noise from entertainment facilities.  The prospective study in adult population (from the year 2006-2008) has shown that subjects exposed to Lday above 65 dB (A) and Lnight above 55 dB (A) had a high relative risk for hypertension (RR = 1.8; 95% CI = 0.75-2.03). 
Studies on road-traffic noise and ischemic heart disease and myocardial infarction
The studies on road-traffic noise, ischemic heart disease, and MI were mostly epidemiological, performed in the 1990s and after the year 2000. Some recent studies used novel approaches  or GIS techniques in road-traffic noise exposure and effects quantification. , The five most important studies are included into [Table 2]. Thorough research on road-traffic noise exposure and the risk of MI was performed in Lithuania in the town of Kaunas. , The ecological study among 25-64-year-old men in the general population comprised all the first-time cases of MI among the permanent residents of Kaunas, treated in hospitals in 1998-2001.  GIS techniques were used in the road-traffic noise exposure quantification. The results indicated a relationship between traffic noise exposure and MI incidence among 55-64-year-old men. In this subgroup, the risk ratios increased by 92% (RR = 1.92; 95% CI = 1.00-3.62). 
The case-control study included in the PhD thesis proposed an innovative approach of environmental-noise exposure assessment in Lithuania, applying modeling by GIS for determination of individual noise exposure.  After adjustment for potential MI risk factors, the increase of MI risk was 29% in the highest noise-exposure zone > 65 dB (A). Noise at night > 55 dB (A) correlated with the MI risk-increase by 36%.
Finally, the results of the both Lithuanian studies support the hypothesis that exposure to road-traffic noise might increase the risk for MI. ,
In a recent study from Slovakia, the authors have made a novel approach in the assessment of cardiovascular risk on a sample of young, healthy individuals.  The study showed that exposure to road traffic noise was associated with elevations in risk-factor scores from predictive models developed to predict the risk for coronary heart disease (CHD) in asymptomatic subjects. These models used different combinations of risk factors to determine overall cardiovascular risk ([Framingham scoring, SCORE60 [SCORE chart at the projected age of 60], and the relative risk SCORE chart]). ,, The study identiﬁed an association between noise and these cardiovascular risk-score models in the exposed group of young, healthy individuals in spite of no significant differences in blood pressure and blood lipids observed in a bivariate analysis. This outcome was explained by a multiplicative effect of particular risk factors (e.g., gender, cigarette smoking, systolic blood pressure, total cholesterol, high density lipoprotein C, or atherogenic plasma index) in the cardiovascular risk-score models toward noise exposure and their contribution to the overall risk of developing future CHD. 
Several studies, predominantly cross-sectional studies on noise exposure and annoyance were published in Eastern Germany. In the cross-sectional and follow-up study of Wolke et al. (1990), the authors investigated the health status of people exposed to noise, including their cardiovascular symptoms. Subjects living in noisy streets reported worst health status, and 49% of those subjects were getting a disease (cardiovascular symptoms). 
A lot of studies on noise and health were published in the former Soviet Union, specifically in Russia. In the study of Stolbun et al. (1989), the influence of road-traffic noise on cardiovascular system was assessed cross-sectionally in a sample of 100 adults in two residential areas (noisy area vs. less noisy area with noise-level difference of 13.6 dB (A)). The risk of the occurrence of cardiovascular disease was higher in the population exposed to noise, than in the control group. 
Studies on aircraft noise and cardiovascular effects
The studies on the effects of other noise sources such as railways, leisure time, construction activities, neighborhood noise, etc., related to cardiovascular diseases were not found in the available literature from CEE, SEE, and NIS.
The data related to aircraft noise were reported in the late 1960s and 1980s in the former USSR-The Union of Soviet Socialist Republics. In the cross-sectional study on a large sample of adults and children living close to the nine major airports, the disturbance by aircraft noise was related to the distance from the airports. By analyzing medical records of the population in these areas, the authors found a higher prevalence of cardiovascular diseases, neurological and gastrointestinal disorders among people living close to these airports. 
Another experimental, comparative study was conducted on a sample of healthy men living and working close to the Moscow airport. Among the persons living and/or working at airports, exposed to intense noise (up to 67-92 dB (A) during take-off at the place of residence, and up to 117 dB (A) at the place of work), the authors found reduced myocardial contractility, predominance of the sympathicotonic type of cardiac activity regulation, increased rigidity of elastic vessels, and increased vascular resistance to blood flow using several methods (blood-pressure monitoring, pulsemetrics, ballistocardiography, and electrocardiography). The magnitude of these functional disturbances correlated with the intensity of noise. 
In the recent study from Bulgaria, the morbidity rates were compared between adults living close to the airport of Bourgas, and those living far away from the airport. Noise exposure was determined by direct measurements of noise, and by simulation models. The incidence of all diseases was higher among adults living close to the airport, than was in the population living in the town center. The two populations were matched by age and gender distribution. The authors studied several specific diseases which may be associated with the adverse effects of noise, such as diseases of the nervous system, diseases of sensory organs, mental disorders, cardiovascular diseases (arterial hypertension), and diseases of the digestive system. 
Health status of the population residing near the airport in Námest nad Oslavou was investigated in a Czech study. Maximal noise levels in five villages exceeded 95 dB (A) during the day. The authors found significantly higher diastolic blood pressure in the exposed population as compared with the control group. They recorded a significantly higher incidence of hearing loss and the occurrence of neurotization symptoms, compared with controls. 
Studies on environmental noise and cardiovascular effects in CEE, SEE, and NIS were mostly experimental and exposure- assessment studies and social surveys. The most recent epidemiological studies demonstrate a dose-response relationship between noise exposure and negative effects on cardiovascular system, such as elevated blood pressure, MI, and ischemic heart disease. ,,,,,,, Major sources of environmental noise were road-traffic and aircraft noise. The most recent studies published in peer-reviewed journals show elaborated study design and analytical methods, and improved assessment of noise exposure and health outcomes. ,,,,,,, However, future studies from CEE, SEE, and NIS countries should address the joint effects of air pollution and environmental noise. , Furthermore, studies using European Environmental Noise Directive, strategic noise mapping, and capacity-building on these issues are needed in the EU - European Union Member States. Non-EU members are under the process of harmonization of environmental noise-related legislation and the alternative methods for burden of diseases of environmental noise-assessment were proposed. In spite of very crude data presented in some studies, it is very important to identify these "white gaps", representing CEE, SEE, and NIS in the field of noise and health research.
| Conclusions|| |
In this review, we have presented the variety of studies on environmental noise and cardiovascular effects conducted since 1965 in CEE, SEE, and NIS. We have interpreted these studies and pointed out the most important issues that need to be addressed in the future.
The importance of this review is that it refers to some countries that no longer exist in the same political and governmental systems and includes publications that are not mentioned in any other previous systematic reviews.
Future studies should aim to assess the long-term effects of noise exposure on the occurrence of cardiovascular diseases, as well as on the development of complications or outcomes of these diseases. In addition, future studies should explore the relationship between noise exposure and cardiovascular diseases in situations when noise changes permanently. Finally, we need more studies on the biological mechanisms underlying the alterations of cardiovascular functions in people exposed to noise. We invite the wide scientific community to help us develop strategies for the future progress of noise-related research on national and global level.
| Acknowledgment|| |
The research leading to these results has received funding from the European Union's Seventh Framework Programme (FP7/2007-2013 project acronym ENNAH) under grant agreement No 226442. The authors thank Katarina Paunovic, Goran Belojevic from the Institute of Hygiene and Medical Ecology, School of Medicine, University of Belgrade, Belgrade, Serbia, Gordana Ristovska from the Institute of Public Health, Department for Environmental Health, Skopje, The Former Yugoslav Republic of Macedonia, Mariola Sliwinska-Kowalska from the Nofer Institute of Occupational Medicine, Department of Physical Hazards, Lodz, Poland, and Stephen Stansfeld from the School of Medicine & Dentistry, London, UK for their assistance in writing this article.
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Institute of Hygiene, Faculty of Medicine, Comenius University, Špitálska 24, 813 72 Bratislava
[Table 1], [Table 2], [Table 3]
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| ||ArgalĂˇĹˇova-Sobotova, L. and Lekaviciute, J. and Jeram, S. and Ĺ evcĂkovĂˇ, L. and JurkovicovĂˇ, J. |
| ||Noise and Health. 2013; 15(62): 22-31 |