WHO LARES

Final report
Noise effects and morbidity

By:
Dr Hildegard Niemann / Dr Christian Maschke
Interdisciplinary research network
„Noise and Health“
 ABSTRACT

This document represents the final report of an analysis on the health effects of noise exposure. The
analysis is based on the WHO Large Analysis and Review of European housing and health Status (LARES),
which combines the data of eight city studies in European countries. It was presented at a WHO housing
and health technical meeting on the analysis of evidence, and was subject to peer review by other analysis
teams of the LARES study and three external reviewers.

The document presents the analytical approach and the statistical procedures used for assessing the
impact of residential noise exposure on noise induced annoyance and noise induced sleep disturbances.
Split into traffic noise and neighbourhood noise for annoyance. The results are identified individually for
children, adults and elderly, acknowledging that each age group is affected by noise in a different way and
consequently shows a different pattern of morbidity potentially related to noise subjective exposure.

One of the main conclusions of this work is that for noise induced sleep disturbances, traffic noise
annoyance and neighbourhood noise annoyance, the identified health effects are independent of socio-
economic status and housing conditions. The elevated relative risks are expressed in the cardiovascular
system, the respiratory system and the musculoskeletal system, as well as through depression.

Keywords

NOISE
NOISE EFFECTS
RESIDENTIAL NOISE EXPOSURE
HOUSING
ENVIRONMENTAL HEALTH
ANNOYANCE
SLEEP DISTURBANCE

© World Health Organization 2004

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CONTENTS

Introduction ..................................................................................................2

Data processing ............................................................................................2

Logistic regression ....................................................................................................... 2
Control variables .......................................................................................................... 3

Effect of noise annoyance ..............................................................................3

Adults ......................................................................................................................... 5
Children ...................................................................................................................... 8
Elderly....................................................................................................................... 11

Effect of noise induced disturbed sleep.......................................................... 12

Adults ....................................................................................................................... 13
Children .................................................................................................................... 14
Elderly....................................................................................................................... 15

Discussion................................................................................................... 15

Conclusions................................................................................................. 18

Literature …………………………………………………………………………………………………20
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Noise effects and morbidity

Introduction

Environmental noise, irrespective of its source – road, rail or air traffic, or neighbourhood
activities – remains a key issue in most European countries.
The predominant health effect of noise is auditory damage which includes hearing loss. This is
frequently caused by loud work noise or by loud music (i.e. from continuous high exposure to
walkmans and discotheques) as well as by loud fireworks. But besides these auditory noise
effects attention must also be paid to the non-auditory effects of noise. Non-auditory effects of
noise appear to occur at levels far below those required to damage the hearing organ.
Environmental noise acts as a stressor at night by disturbing sleep and via annoyance (or
bothering) during the day.
The effect of environmental noise on sleep and annoyance were included as were several
morbidities in the LARES study. The final report examines the strength of the association
between noise induced annoyance or noise induced sleep disturbances with stress mediated
diseases.

Data processing

The examination of the statistical association between noise annoyance as well as noise induced
sleep disturbances and diseases must do justice to the fact, that both diseases and risk factors are
affected by many other factors other than noise. Therefore, for a meaningful statistical analysis
multiple methods must be applied, orientated by the knowledge of noise effect research, the
underlying pathogenesis model and the scale level of the collected variables. With respect to the
different health end-points the control variable set has to be regarded as less complete. Therefore
a careful interpretation of the statistical effects is necessary.

Logistic regression
In all analysis, multiple logistic regressions were used. Normally, a logistic regression is used to
analyse an event which may or may not occur (e. g. fall ill or not, medical treatment or not). By
means of the logistic regression an estimator (“odds ratio”, OR) for the relative risk of the
occurrence of an event depending on the examined factor (e. g. sleep disturbance) was calculated
taking into consideration other influence factors (control variables).
Odds Ratios (OR) were calculated as an estimator of the relative risk (RR) of the occurrence of
an event (e. g. prevalence of a disease) and its dependents on the examined factor (disturbances)
and maybe other influencing factors (Confounder, moderator).
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Control variables
In total, 16 control variables were included in the logistic regression, which, in the case of the
diseases, are assumed to influence the result. The well known control variables “age”, “gender”,
“consumption of alcohol”, “smoking behaviour”, “sports”, “body mass index”, and the “social-
economic state” were completed by housing factors. To identify housing factors from the large
housing und health questionnaire a dimension testing was carried out in the form of a factor
analysis (SPSS 11.0). According to the factor analysis six relevant housing dimensions were
extracted.
In Table 1 the six housing dimensions are introduced by factor labels together with the variables
used in the statistical calculations to control the housing factors. The presented control variables
were suggested by the competent expert groups. Otherwise the variable correlating most strongly
with the extracted factor was used.
Table 1: Housing and health dimensions extracted by factor analysis and control variables used in the statistical
calculations
Factor labels Control variables
Inner housing factor: dampness in dwelling Total mould rating (Mouldy2)
Inner housing factor: air quality in dwelling Air quality in dwelling (aq_1)
Visible vegetation in housing environment
Outside housing factor: green areas
(he_6_1)
Outside housing factor: Satisfaction with
Residential areas (iesc4gr)
residential areas
Inner housing factor: temperature and heating
Problem with temperature in winter (t_7_1)
in winter
Inner housing factor: daylight in dwelling Need to turn on light (li_1)
Furthermore the different European cities of the LARES study were taken into account as
additional control variable (city_nr) as well as their averaged temperatures (av°c_yea ) and
humidities (rh_av).

Effect of noise annoyance

A central effect of noise is annoyance. Annoyance is defined as a feeling of discomfort which is

related to adverse influencing of an individual or a group by any substances or circumstances.
Annoyance express itself e. g. by malaise, fear, threat, trouble, uncertainty restricted liberty
experience, excitability or defencelessness. With chronically strong annoyance a causal chain
may exist between the three steps health - annoyance - disease.
By means of the questions „Thinking about the last 12 month, when you are here at home, how
much would you say that noise from following sources bothers or annoys you?”, the individual
annoyance by out-door and indoor noise sources was determined. The percentage frequency of
different noise sources which bothers or annoys is presented in including the intensity of the
effect.

To fill in the LARES-questionnaire regarding noise annoyance, it is necessary to be aware of the

annoyance. That is not always the case for sleeping persons and a general problem for younger
 EUR/04/5047477
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children. Annoyance therefore has a closer link with day time noise and the interpretation could
be difficult in young children.
The individual annoyance from road noise, airplane noise, train noise, as well as parking noise,
were summarized to examine the effect of traffic noise altogether, because traffic noise is one of
the predominant noise source in the living environment. The second major noise source is the
neighbourhood. General annoyance from neighbourhood noise was therefore additionally
summarized by neighbour flat, staircase, playing children, as well as by noise within dwelling.
Both sum scores were subdivided into 3 categories (with the expressions: not at all, moderately
and strongly (cut-off point 8)). The 3-scale variables, simply called traffic annoyance and
neighbourhood annoyance were subsequently used for the analyses carried out with disturbance
and annoyance. The percentage frequency of each 3-scale variable is presented in Figure 2.

noise - traffic

neighbour flat

noise - parking

animals/birds Slightly
Moderately
noise within dwelling
Strongly
staircase use Extremely

noise - airplane

0 5 10 15 20 25 30 35 40 45

surrounding area

commercial etc. sites

playing children

playgrounds etc. Slightly

Moderately
ventilation system etc.
Strongly
lift Extremely

noise - train

0 5 10 15 20 25 30 35 40 45

Figure 1: Percentage frequency of different sources which bothers or annoys adults, children and elderly (in 4
scales: slightly, moderately, strongly, extremely) N = 7949
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not at all 47,7

moderatly 37,9

strongly 14,4

0 10 20 30 40 50 60
percentage brothered or annoyed by general traffic noise

not at all 52,4

moderatly 35,2

strongly 12,4

0 10 20 30 40 50 60
percentage brothered or annoyed by general neighbourhood noise

Figure 2: Percentage frequency for general traffic noise (road, airplane, train, and parking noise) (N = 7817) as
well as for general neighbourhood noise (neighbour flat, staircase, playing children, and noise within
dwelling) (N=7789) for all valid cases (adults, children and elderly)

Adults
In the following figures the Relative Risk of diseases (Odds Ratio) including the 95% confidence
interval are represented for such adults (18-59 years) who indicated annoyance by traffic or
neighbourhood noise, in comparison with a reference group. For annoyance by traffic noise the
reference group are adults without traffic noise induced annoyance, for annoyance by
neighbourhood the reference group are adults without neighbourhood noise induced annoyance.
The Relative Risks are statistically significant if the drawn confidence interval did not include
the value 1. Note that for adults the correlation between traffic noise induced annoyance and
neighbourhood noise induced annoyance is significant but low (r=0.29). The variables are
therefore not statistically independent but the overlapping variance is less than 9%.

The evaluation of the effect of moderate annoyance by general traffic noise shows for asthma,
diabetes, and migraine slight but significantly elevated disease risk (see Figure 4). With the
complexities of arthritic, respiratory and cardiovascular (CV) symptoms, disease symptoms are
additional collected for the musculoskeletal and the respiratory system as well as for the
cardiovascular system. Furthermore, the complex of SALSA considers the "trend to depression".
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Adults: general traffic noise which bothers or annoys moderately

related to diseases

4
Adjusted Odds Ratio

1,1 1,1 1,6 1,2 1,1 1,1 1,7 1,1 1,1 1,1 1,3 1,3 1,1 1,2 1,1 1,1

3
1

0
ce 223 205 =66 =73 220 110 =46 =79 =14 212 =20 181 138 318 =69 N=8
en = = = N= N= N= N= N= e N
fer gy N t. N ma N itis N s N sN rN kN rN ke
e
R ller m p t h c h o m si on bete ulce ttac sion umo aine mpt. LSA eas Stro
A s y A s on pt es i a r i c rt a e n . T i gr sy A di s #
r r t t S
# th. # # B V sy
m ep # D Gas Hea yper ali
g
# M esp
. kin
Ar #D # #M #S
C # #H R

# diagnosed by physician

Figure 3: Relative disease risks for adults who indicated moderate noise induced annoyance by general traffic
noise within the last 12 months, in comparison with adults without noise induced annoyance. Adjusted
for "age", "gender", "socio-economic state", "consumption of alcohol", "smoking behaviour", "sports",
"body mass index", “dampness in dwelling”, “air quality in dwelling”, “winter temperature in dwelling”,
“daylight in dwelling”, “green areas”, “satisfaction with residential areas”, "cities", "averaged outdoor
temperature", and "averaged outdoor humidity” (N=3279).

The evaluation of the effect of strong annoyance by general traffic noise reveals that annoyance
could be a serious risk factor for many of the examined health endpoints (see Figure 4). For
Asthma, diabetes, gastric ulcer, heart attack, malignant tumour, skin disease and stroke there is
no significant increased risk.

Adults: general traffic noise which bothers or annoys strongly

related to diseases
1,4 1,8 1,7 1,9 1,5 2,2 1,3 1,1 1,4 1,6 1,6 2,4 2,0 1,9 1,2 0,8
4
Adjusted Odds Ratio

3
1
2

0
ce 112 105 =28 =53 127 =71 =14 =37 N=9 123 =10 =97 =94 180 =28 N=4
en = = = = rN =
e fer gy N t. N ma N itis N s N ion N tes N lcer N ttack on N o ine
N t. N
p
N
A N se rok
e
R ller
ymp Asth onch ptom ress iabe ic u rt a ensi . Tum igra sym ALS disea # St
# A rth.s # r m
# B V sy # D e
p r a
# D Gast # He yper
t lig # M esp
. S in
k
A
C # H # Ma R #S
#
# diagnosed by physician
 EUR/04/5047477
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Figure 4: Relative disease risks for adults who indicated strong noise induced annoyance by general traffic noise
within the last 12 months, in comparison with adults without noise induced annoyance. Adjusted for
"age", "gender", "socio-economic state", "consumption of alcohol", "smoking behaviour", "sports",
"body mass index", “dampness in dwelling”, “air quality in dwelling”, “winter temperature in dwelling”,
“daylight in dwelling”, “green areas”, “satisfaction with residential areas”, "cities", "averaged outdoor
temperature", and "averaged outdoor humidity”” (N=2163).

The evaluation of the effect of general neighbourhood noise show that not only traffic noise
could influence the health risk, and that the risk pattern for strong annoyance is nearly the same
as for traffic noise.
With moderate annoyance by general neighbourhood noise the relative risks for allergy, arthritic
symptoms, CV-symptoms and hypertension are significantly but slightly increased (see Figure
5), whereas by traffic noise the risks asthma, diabetes, and migraine are slightly elevated.

Adults: general neighbourhood noise which bothers or annoys

moderately related to diseases

4
Adjusted Odds Ratio

1,3 1,3 1,2 1,0 1,3 1,1 0,9 1,3 1,4 1,3 0,8 1,2 1,2 1,2 1,3 0,9

3
1

0
ce 230 185 =55 =63 225 =96 =30 =76 =18 214 =14 158 147 291 =61 N=8
en = = = = rN = = =
e fer gy N t. N ma N itis N s N ion N tes N lcer N ack N on N o
N
e N t. N A N se rok
e
R ler
l ymp Asth onch ptom ress iabe ic u t att ensi . Tum grain symp ALS disea # St
# A rth.s # r m
# B V sy # D e
p r r
# D Gast Hea yper
t lig # Mi sp. S in
k
A
C # # H # Ma Re #S
#
# diagnosed by physician

Figure 5: Relative disease risks for adults who indicated moderate noise induced annoyance by general
neighbourhood noise within the last 12 months, in comparison with adults without neighbourhood noise
induced annoyance. Adjusted for "age", "gender", "socio-economic state", "consumption of alcohol",
"smoking behaviour", "sports", "body mass index", “dampness in dwelling”, “air quality in dwelling”,
“winter temperature in dwelling”, “daylight in dwelling”, “green areas”, “satisfaction with residential
areas”, "cities", "averaged outdoor temperature", and "averaged outdoor humidity” (N=3402).
Strong annoyance by general neighbourhood noise is associated with significant and high
increased risks for many diseases. For diabetes, gastric ulcer, heart attack, malignant tumour, and
stroke there is no statistical association and significance is just missed for Asthma and skin
disease.
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Adults: general neighbourhood noise which bothers or annoys

strongly related to diseases

4
Adjusted Odds Ratio

1,4 2,3 1,6 1,9 1,6 1,8 1,3 1,3 2,0 1,7 0,9 1,8 1,6 2,3 1,7 0,6

3
1

0
ce =56 =85 =29 =56 =87 =60 =15 =33 N=8 =85 N=4 =85 =80 178 =30 N=2
en =
e fer rgy N pt. N ma N itis N ms N ion N tes N lcer N ttack ion N our ine N pt. N A N ase N roke
R lle ym sth nc h p t o
e ss be u t a ns um
g ra ym LS se # S t
# A rth. s # A Bro sym epr # Dia astric Hear perte lig. T # Mi sp. s SA i n d i
# D y a e k
#A CV # #G #
#H #M R #S
# diagnosed by physician
Figure 6: Relative disease risks for adults who indicated strong noise induced annoyance by general neighbourhood
noise within the last 12 months, in comparison with adults without neighbourhood noise induced
annoyance. Adjusted for "age", "gender", "socio-economic state", "consumption of alcohol", "smoking
behaviour", "sports", "body mass index", “dampness in dwelling”, “air quality in dwelling”, “winter
temperature in dwelling”, “daylight in dwelling”, “green areas”, “satisfaction with residential areas”,
"cities", "averaged outdoor temperature", and "averaged outdoor humidity” (N=2227).

Children
Many function systems of little children (e.g. the nervous system and the cognitive system) are
subject to rapid growth and development. The development of the child is not designed to
compensating for high environmental noise exposure. Therefore children could be a risk group
regarding the effect of noise annoyance on health.
In the following figures the Relative Risk of diseases (Odds Ratio) including the 95% confidence
interval are represented for such children (1-17 years) who indicated annoyance by traffic or
neighbourhood noise, in comparison with a reference group. For annoyance by traffic noise the
reference group are children without traffic noise induced annoyance, for annoyance by
neighbourhood noise the reference group are children without neighbourhood noise induced
annoyance. The Relative Risks are statistically significant if the drawn confidence interval did
not include the value 1.
Hypertension, heart attack, gastric ulcer, malignant tumour and stroke are diseases whose
prevalence increase with age and therefore in children only appear rarely. The low number of
cases did not allow a meaningful logistical regression. A second problem is the annoyance rating
from younger children. We assume that the annoyance rating by children is meaningful if
children are 10 years or older. Therefore, for the younger children we use the averaged
annoyance rating of all adults in the household.
Note that for children the correlation between traffic noise induced annoyance and
neighbourhood noise induced annoyance is greater than for adults (r=0,366). The variables
therefore are not independent but the overlapping variance is less than 13%.
 EUR/04/5047477
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Moderate annoyance by general traffic noise in Children (0-17 years) is associated with elevated
risks for respiratory symptoms (RR=1.8) and SALSA (trend of depression, RR=1.8) (Figure 7).
Children: general traffic noise which bothers or annoys moderately related to
diseases
Adjusted Odds Ratio

4
1.0 1.0 1.8 1.4 1.8 1.1
3
1
2

0
ce 78 24 89 62 =5
4 27
feren y N= i s N= t. N= e N= AN e N=
e g it p ain LS s
R ller ch ym igr SA
ea
#A ron p .S M dis
# B s kin
Re #S
# diagnosed by physician
Figure 7: Relative disease risks for children who indicated moderate noise induced annoyance by general traffic
noise within the last 12 months, in comparison with children without traffic noise induced annoyance.
Adjusted for "age", "gender", "socio-economic state", "consumption of alcohol", "smoking behaviour",
"sports", "body mass index", “dampness in dwelling”, “air quality in dwelling”, “winter temperature in
dwelling”, “daylight in dwelling”, “green areas”, “satisfaction with residential areas”, "cities", "averaged
outdoor temperature", and "averaged outdoor humidity”. Note: SALSA is not validated for children
(N=1195).
The examination of strong annoyance by general traffic noise shows that children fall 2.6 times
more ill with bronchitis, than not traffic noise annoyed children. The Relative Risks for
respiratory symptoms (RR=2.6) and SALSA are considerable increased but for SALSA (trend to
depression) the significance is just missed (see Figure 8).
Children: general traffic noise which bothers or annoys strongly related
to diseases
Adjusted Odds Ratio

4
1,1 2,6 2,6 1,1 2,0
3
1
2

ce 9 =6 1 7 =6
en N= =1 N=
fer gy it is
N
t. N ine AN
Re ll e r ch m p
gra LS
#A r on Sy Mi SA
.
#B sp
Re
# diagnosed by physician
Figure 8: Relative disease risks for children who indicated strong noise induced annoyance by general traffic noise
within the last 12 months, in comparison with children without traffic noise induced annoyance. Adjusted
for "age", "gender", "socio-economic state", "consumption of alcohol", "smoking behaviour", "sports",
"body mass index", “dampness in dwelling”, “air quality in dwelling”, “winter temperature in dwelling”,
“daylight in dwelling”, “green areas”, “satisfaction with residential areas”, "cities", "averaged outdoor
temperature", and "averaged outdoor humidity”. Note: SALSA is not validated for children (N=720).
 EUR/04/5047477
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Moderate annoyance by general neighbourhood noise in Children (0-17 years) is associated with
elevated risks for respiratory symptoms (RR=1.6) and skin disease RR=3.1), but the risk of skin
disease are accompanied by a large confidential interval (see Figure 9).
Children: general neighbourhood noise which bothers or annoys
moderately related to diseases
Adjusted Odds Ratio

4
0,9 1,8 1,6 1,3 1,0
3
1 3,1
2

0
ce 2 27 3 4 9 8
ren =8 N= =9 N =6 N =3 =2
efe yN itis t. N ine A eN
R ll erg ch sym
p
gra L S ea
s
#A ron p. Mi SA d is
B s k i n
# Re #S
# diagnosed by physician
Figure 9: Relative disease risks for children who indicated moderate noise induced annoyance by general
neighbourhood noise within the last 12 months, in comparison with children without neighbourhood
noise induced annoyance. Adjusted for "age", "gender", "socio-economic state", "consumption of
alcohol", "smoking behaviour", "sports", "body mass index", “dampness in dwelling”, “air quality in
dwelling”, “winter temperature in dwelling”, “daylight in dwelling”, “green areas”, “satisfaction with
residential areas”, "cities", "averaged outdoor temperature", and "averaged outdoor humidity”. Note:
SALSA is not validated for children (N=1155).
Strong annoyance by general neighbourhood noise is associated with significant and
considerably high increased risks for bronchitis (RR=3.5), respiratory symptoms (RR=2.6),
migraine (RR=2.2), SALSA (RR=3.3) and skin disease (RR=3.0), but the risk of bronchitis and
skin disease are accompanied by large confidential intervals (see Figure 10).
Children: general neighbourhood noise which bothers or annoys strongly
related to diseases
Adjusted Odds Ratio

4
3.0
2.2
3
1 0.9 3.5 3.3
2
3.6
1

0
ce 8 3 23 20 1 =4
en =1 =1 N= N= =2 N
fer yN itis
N
pt. ine AN se
R e e rg ch ym g ra LS s ea
All ron s i SA di
# p. M kin
#B R es #S
# diagnosed by physician
Figure 10: Relative disease risks for children who indicated strong noise induced annoyance by general
neighbourhood noise within the last 12 months, in comparison with children without neighbourhood
noise induced annoyance. Adjusted for "age", "gender", "socio-economic state", "consumption of
alcohol", "smoking behaviour", "sports", "body mass index", “dampness in dwelling”, “air quality in
dwelling”, “winter temperature in dwelling”, “daylight in dwelling”, “green areas”, “satisfaction with
 EUR/04/5047477
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residential areas”, "cities", "averaged outdoor temperature", and "averaged outdoor humidity”. Note:
SALSA is not validated for children (N=660).

Elderly
From general stress research it is well known, that the ability to cope with noise is decreased in
the elderly. Therefore elderly people could be a risk group regarding noise annoyance and health.
In the following figures the Relative Risk of diseases (Odds Ratio) including the 95% confidence
interval are represented for such elderly people (60 and older) who indicated annoyance by
traffic or neighbourhood noise, in comparison with an elderly reference group. For annoyance by
traffic noise the reference group are elderly people without traffic noise induced annoyance, for
annoyance by neighbourhood noise the reference group are elderly people without
neighbourhood noise induced annoyance. The Relative Risks are statistically significant if the
drawn confidence interval did not include the value 1. Note that the correlation between traffic
noise induced annoyance and neighbourhood noise induced annoyance is low for elderly people
(r=0,271). The variables therefore are not independent but the overlapping variance is less than
8%.

For elderly people (60 years and older) the examination shows that strong annoyance by traffic
noise is a significant risk factor only for arthritic symptoms (RR=2.1) and stroke (RR=2.7). That
is nearly the same for strong annoyance by neighbourhood noise (RR=2.1; 2.4), but with
neighbourhood noise the risks for gastric ulcer (RR=3.7) and depression (RR=2.0) are in
additional significantly elevated (see Figure 11). It seems that in comparison with adults for
elderly people other factors than noise annoyance is more decisive for the appearance of a
disease.

Elderly: general neighbourhood noise which bothers or annoys

strongly related to diseases
1,6 2,1 1,1 1,2 1,3 2,0 0,7 1,2 0,9 0,8 1,1 1,0 0,9
4
Adjusted Odds Ratio

2,1 2,4

3
1 3,7

0
ce 15 52 =6 18 58 17 13 23 13 49 =5 13 22 28 =5 11
feren y N= t. N= a N is N= s N= n N= s N= r N= k N= n N= or N e N= t. N= A N= se N e N=
m e c
Re llerg ymp Asth nchit ptom essio bete ulc atta nsio . Tum grain ymp ALS disea Strok
# A rth.s # Bro sym epr # Dia astric eart perte alig # Mi sp. s S in
k #
A # CV #D G H Hy # M R e #S
# # #
# diagnosed by physician
Figure 11: Relative disease risks for elderly people who indicated strong noise induced annoyance by general
neighbourhood noise within the last 12 months, in comparison with elderly people without neighbourhood noise
induced annoyance. Adjusted for "age", "gender", "socio-economic state", "consumption of alcohol", "smoking
behaviour", "sports", "body mass index", “dampness in dwelling”, “air quality in dwelling”, “winter temperature in
dwelling”, “daylight in dwelling”, “green areas”, “satisfaction with residential areas”, "cities", "averaged outdoor
temperature", and "averaged outdoor humidity” (N=936).
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Effect of noise induced disturbed sleep

Sleep is an essential condition for humans and can be severely disturbed by noise. Acute sleep
disturbances affect the subjective wellbeing and with an individual latency, also affect qualitative
or quantitative performance. Chronic forms of sleep disorders are frequently classified as a
health risk.
It is well known that sleep can be disturbed by noise exposure. The effect of noise induced sleep
disturbances was analysed by means of the question “Has your sleep been disturbed by noise
during the past 4 weeks?”. The percentage of sleep disturbances regarding different noise
sources is presented in
Figure 12.

noise - traffic 9,8

neighbour flat 9,5

noise - parking 5,1

surrounding area 4,1

animals/birds 3,4

staircase use 2,7

noise within dwelling 2,4

0 2 4 6 8 10 12
percentage of sleep disturbances

noise - airplane 2,1

commercial etc. sites 1,4

noise - train 1,2

lift 1,2

playing children 1,1

ventilation system etc. 0,8

playgrounds etc. 0,7

0 2 4 6 8 10 12
percentage of sleep disturbances

Figure 12: Percentage frequency of noise sources which induced sleep disturbances N = 8519 (adults, children and
elderly)
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The percentage distribution of noise induced sleep disturbances is presented in Figure 13.
noise induced sleep

Yes 23,3
disturbance

No 76,7

0 10 20 30 40 50 60 70 80 90
percentage

Figure 13: Percentage distribution of noise induced sleep disturbances in the whole sample (N = 8325)

Adults
In the following figure the Relative Risk of diseases (Odds Ratio) including the 95% confidence
interval are represented for such adults (18-59 years) who indicated noise induced sleep
disturbances by noise, in comparison with adults without noise induced sleep disturbances. The
Relative Risks are statistically significant if the drawn confidence interval did not include the
value 1.
The noise induced sleep disturbances are associated for adults with significantly elevated risks
for the vast majority of diseases. Only for diabetes, malignant tumour, skin disease and stroke no
remarkable association were calculated. Furthermore, significance is missed at heart attack (see
Figure 14).

Adults: Noise induced sleep disturbances related to diseases

4
Adjusted Odds Ratio

1,5 1,6 1,7 1,4 1,4 1,4 1,5 1,1 1,6 1,4 1,5 0,6 1,6 1,6 2,3 1,2
3
1
1,2
2

0
ce 83 188 161 =52 =75 199 111 = 32 =75 =17 191 =10 162 138 351 =43 N=8
en =1 = = = = = = = =
e fer gy N t. N is N ma N itis N s N n N tes N lcer N ack N on N or N ne N t. N A N ase N roke
R ler
l ymp hros Asth onch ptom essio iabe ic u t att ensi . Tum grai symp ALS dise # St
# A rth.s # Art # r m r
# B V sy Dep #
D astr ear pert alig # Mi sp.
H
S in
k
A # # G # # Hy # M Re #S
C

# diagnosed by physician
Figure 14: Relative disease risks for adults which indicated noise induced sleep disturbances within the last 4 weeks
in comparison with adults without noise induced sleep disturbances. Adjusted for "age", "gender", "socio-economic
state", "consumption of alcohol", "smoking behaviour", "sports", "body mass index", “dampness in dwelling”, “air
quality in dwelling”, “winter temperature in dwelling”, “daylight in dwelling”, “green areas”, “satisfaction with
residential areas”, "cities", "averaged outdoor temperature", and "averaged outdoor humidity” (N=4309).
 EUR/04/5047477
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Children
The sleep structure and the sleep quality change dramatically in the course of childhood.
Therefore children could be a risk group regarding noise induced sleep disturbances.
In the following figure the Relative Risk of diseases (Odds Ratio) including the 95% confidence
interval are represented for such children (1-17 years) who indicated noise induced sleep
disturbances, in comparison with children without noise induced sleep disturbances. We assume
for the analysis that the rating for noise induced sleep disturbances is more or less reliable for all
children. The Relative Risks are statistically significant if the drawn confidence interval did not
include the value 1.
With children noise induced sleep disturbances are statistically associated with a highly elevated
risk of medical treatments due to bronchitis (RR=3.7) as well as with elevated risks for
respiratory symptoms (RR=1.9) and for ”trend of depression” (SALSA, RR=3.5). For headaches
and migraines, it is well known that in the case of children physicians are consulted only rarely.
Therefore, in the following Figure 15 noise induced sleep disturbances with self reported
migraine were examined. The amount of cases of self reported migraines was more than doubled
in comparison to migraines diagnosed by a physician. Children with noise induced sleep
disturbances fall 2.2 times more ill with migraines. The strongest association was calculated for
arthritic symptoms. Children with noise induced sleep disturbances have 7.3 times more arthritic
symptoms, but the risk is accompanied by an very large confidential interval (CI=2.4-22.2).

Children: Noise indused sleep disturbances related to diseases

2,2
Adjusted Odds Ratio

4
0,8 1,3 1,9
3
1 3,7 1,5
2 7,3
3,5
1

0
ce 30 =1
0 15 24 =5
0 38 40 =9
en N= .N N= N= .N N= N= eN
fer gy pt a tis p t A n e as
Re lle
r m ch
i m L S
gra
i e
#A sym sth
ron sy SA Mi d is
r th. #A B sp. kin
A # Re #S
# diagnosed by physician

Figure 15: Relative disease risks for children which indicated noise induced sleep disturbances within the last 4
weeks in comparison with children without noise induced sleep disturbances. Adjusted for "age", "gender",
"socio-economic state", "consumption of alcohol", "smoking behaviour", "sports", "body mass index",
“dampness in dwelling”, “air quality in dwelling”, “winter temperature in dwelling”, “daylight in
dwelling”, “green areas”, “satisfaction with residential areas”, "cities", "averaged outdoor temperature", and
"averaged outdoor humidity”. Note: SALSA is not validated for children (N=1274).
 EUR/04/5047477
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Elderly
Sleep quality decreases strongly in elderly people. Therefore elderly people could be a risk group
regarding noise induced sleep disturbances.
In the following figure the Relative Risk of diseases (Odds Ratio) including the 95% confidence
interval are represented for such elderly people (1-17 years) who indicated noise induced sleep
disturbances, in comparison with elderly people without noise induced sleep disturbances. The
Relative Risks are statistically significant if the drawn confidence interval did not include the
value 1.
With elderly people noise induced sleep disturbances are statistically associated with arthritic
symptoms (RR=1.6), asthma (RR=2.0), gastric ulcer (RR=2.2) migraine (RR=1.7) and SALSA
(RR=1.4).

Elderly: Noise induced sleep disturbances related to diseases

2,0 2,2
4
Adjusted Odds Ratio

1,4 1,6 1,3 1,0 1,3 0,9 1,2 0,9 1,1 1,7 1,3 1,4 1,3 0,6

3
1

0
ce 45 76 =23 =56 173 =45 =58 =53 =37 155 =15 =59 =70 120 =19 =14
en N= N=1 = nN sN rN kN N = or N e N t. N N= e N e N
fer y . a N is N . N e
Re llerg mpt sthm nchit mpt essio bete ulc attac nsion Tum grain ymp LSA iseas Strok
# A th.sy # A Bro V sy epr # Dia astric eart erte lig. # Mi sp. s SA in d #
Ar # C #D
# G # H
H yp M a R e
# Sk
# #

# diagnosed by physician
Figure 16: Relative disease risks for the elderly which indicated noise induced sleep disturbances within the last 4
weeks in comparison with elderly people without noise induced sleep disturbances. Adjusted for "age",
"gender", "socio-economic state", "consumption of alcohol", "smoking behaviour", "sports", "body mass
index", “dampness in dwelling”, “air quality in dwelling”, “winter temperature in dwelling”, “daylight in
dwelling”, “green areas”, “satisfaction with residential areas”, "cities", "averaged outdoor temperature", and
"averaged outdoor humidity” (N=1404).

Discussion

For noise effect research the disease as a pathological health end-point is of high importance and
can only be examined in epidemiological studies. In epidemiological studies, like the LARES
study, however only statistical associations can be uncovered. The assessment, whether a
calculated association reflects a causal relation has to be carried out according to different
criteria. After exclusion of chance, bias and confounding, the strength of the association,
expressed by the relative risks, as well as the biological plausibility are main topics of these
criteria. Whereby biological plausibility means that there are credible mechanisms which explain
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how the noise exposure can contribute to the development of the illness. Furthermore it has to be
demanded that the confidence intervals should be small for a save point-estimation. The causal
interpretation of the association is finally supported by finding a dose effect relationship and
comparable findings in independent studies.
The presented results fulfils not all but most of the causality-criteria. Change as well as bias can
be excluded with high probability due to the sampling frame and due to the quality control
within the study.
The evaluation of the data was carried out multiple with an extensive control variable set, taking
into account the housing environment, regarding their influence on health. The large control
variable set is, with regard to the variety of the examined diseases, not always to be considered
complete. Furthermore, well known control variables are missing as one noise sensitivity and
occupational noise exposure. Also the family history could not be taken into account. Air
pollution, which has the same origin as traffic noise, could have a confounding impact on the
results, but the effect could not differ essentially, because the risk pattern for traffic noise and
neighbourhood noise does not differ dramatically. Altogether, the control process must be
classified as sufficient according to comparable examinations.
The health effects of noise refer in all analyses to the cardiovascular system, the respiratory
system, and the musculoskeletal system as well as on psychic disturbances. The biological
plausibility for these effects is given due to experimental examinations. With central nervous
processes, noise stress influences the neuro-endocrine system either directly or indirectly about
emotional experience (disturbances, annoyance) or disturbed sleep. In this way noise exposures
can lead to an inadequate and dangerous neuro-endocrine reaction pattern and finally to
regulation diseases (see [Frankenhäuser et al. 1976]. Pathological changes can manifest
themselves in the cardiovascular system (see [Babisch 2001]), in the respiratory system (see
[Langewitz et al. 2003]) as well as in the musculoskeletal system (see [Eich 2003]) or can appear
as psychic disturbances (see [Maschke et al. 2003]).
On the other hand pathological changes reduce more or less the mental well being and therefore
may increase the susceptibility to noise. From this point of view the epidemiological association
between annoyance and health-endpoints could be interpreted as caused by the diseases. For the
association between sleep disturbances and health-endpoints it is nearly the same. Sleep could be
disturbed by diseases, for example by bronchitis or asthma.
That well being as well as sleep could be influenced by individual state of health is well known,
but the thesis that the associations in the LARES-study are essentially caused by the state of
health is not very probable. Most of the examined diseases are heavily dependent on age, with a
considerably higher occurrence among the elderly (with the exception of allergy). If the
epidemiological associations are essentially caused by diseases, the frequency of noise induced
annoyance as well as of noise induced sleep disturbance in the elderly people must be
considerably higher than in adults. That is not the case for noise induced annoyance and noise
induced sleep disturbances. The relative frequencies of noise induced annoyance as well as of
noise induced sleep disturbance in elderly people are remarkably less than in adults. Therefore,
we assume that the epidemiological associations are essentially caused by noise annoyance as
well as by noise induced sleep disturbances, although also influenced by the effect of the
individual state of health.
This assumption of a causal relation between noise induced annoyance and health-endpoints is
supported by dose effect considerations. The relative risks for pathological changes in the
cardiovascular system (hypertension, CV-symptoms) were clearly increased in adults at
chronically strong annoyance (RR=3.0; 3.1), in comparison to adults indicated by moderate
annoyance. At moderate annoyance the Relative Risks are no different than in the reference
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group or only slightly increased (general neighbourhood noise, RR=1.3). This also applies for
pathological changes in the respiratory system (Bronchitis, respiratory symptom), for arthritis
and for depression.
To summarize, it can be concluded that the results of the LARES study confirm increased health
risks at chronically strong noise annoyance as well as for noise induced sleep disturbances on an
epidemiological level.
The health risks are dependent on the age groups. Few differences can be recognized within an
age group regarding the pathogenesis mechanism of annoyance and sleep disturbances. At strong
annoyance the risk pattern between general traffic noise and general neighbourhood noise are
very similar within the age groups (see Table 2). With children the uncertainty of the annoyance
rating is, however, to be taken into account (see chapter 0). The surprisingly high relative risks
for neighbourhood noise partly can be explained by the high information content of
neighbourhood noise.
If the risk pattern of noise induced sleep disturbances compared with the risk pattern of strong
annoyance induced by noise (see Table 2), a good agreement is visible. In the group of elderly
people a remarkable feature is highlighted. A significant increase of the risk of stroke is evident
only at strong noise induced annoyance and only in elderly people.

Table 2: Significantly Odds Ratio for diseases calculated in the LARES-study

Significantly OR for diseases Adults Elderly Children

Hypertension 1,588 ---- ----
CV symptoms 1,545 ---- (5,455)*
Stroke ---- 2,718 nc
Asthma ---- ---- ----
general traffic noise
strongly annoyed Bronchitis 1,861 ---- 2,624
Resp. Sympt. 1,969 ---- 2,563
Arthr. Sympt. 1,754 2,066 ----
Depression 2,229 ---- nc
SALSA 1,879 ---- ----
Hypertension 1,706 ---- nc
CV symptoms 1,601 ---- ----
Stroke ---- 2,415 nc
Asthma ---- ---- ----
general neighbourhood noise
strongly annoyed Bronchitis 1,907 ---- 3,453
Resp. Sympt. 1,572 ---- 3,562
Arthr. Sympt. 2,346 1,885 ----
Depression 1,78 1,989 nc
SALSA 2,276 ---- 3,322
Hypertension 1,485 ---- ----
CV symptoms 1,449 ---- ----
Stroke ---- ---- nc
Asthma ---- 2,019 ----
sleep been disturbed by noise Bronchitis 1,455 ---- 3,674
Resp. Sympt. 1,632 ---- 1,943
Arthr. Sympt. 1,598 1,617 (7,308)*
Depression 1,466 ---- ----
SALSA 2,26 1,413 3,413
( )* very large confidence intervals
nc = not calculable
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Regarding the different age groups pathological changes appear in adults both in the
cardiovascular system, the respiratory system, the musculoskeletal system and in depression (see
Table 2). Unlike this, with older people significantly increased risks exist only for the
musculoskeletal system (arthritic symptoms) independent of the noise source. With strong
annoyance, furthermore the risk is increased significantly for stroke among the elderly. The
results of the LARES study do not confirm the thesis that older persons are subjects of an
increased noise induced health risk.
A comparable result is published by Maschke [2004] for the Spandau Health-Survey (SHS). The
SHS shows a stronger association between treatments of hypertension and the nightly noise level
for adults less than 60 years in comparison with elderly people.

Adults, older than 60 years Adults, 20 to 60 years

Relative Risik (Odds Ratio)

Relative Risik (Odds Ratio)

5 1,52 5 2,87
4 1,38 4 2,52
3 1,00 3 1,00
2 2
1 1
0 0
< 50 dB(A) 50-55 dB(A) > 55 dB(A) < 50 dB(A) 50-55 dB(A) > 55 dB(A)

equivalent sound level during night (8h) equivalent sound level during night (8h)

Figure 17: Statistical association between nightly road traffic noise and hypertension treatments in the 9th repetition
cycle. Adjusted for "age", “sex”, "consumption of alcohol", "consumption of tobacco", "professional
mobility", "sports", "body mass index", "social economic index", "loss of spouse", "hearing ability", "noise
sensitivity" and "season of the medical examination".

With children the effects of noise is to be seen primarily in the respiratory system (see Table 2).
Strongly annoyed children fall 2-3.7 times more in ill with respiratory diseases than non noise
annoyed children. The same effect exists for noise disturbed sleep with approximately the same
range of risk. In contrast, allergy, one of the most frequent illnesses of children, does not seem to
respond to noise. According to the presented results, children have to be classified as particularly
sensitive to noise with regard to the respiratory system.

Conclusions

The result confirms the thesis that for chronically strong annoyance a causal chain exists
between the three steps health – strong annoyance – increased morbidity.
For adults with strong annoyance, significantly elevated relative risks exist both in the
cardiovascular system, the respiratory system, and the musculoskeletal system as well as by
depression. Elderly people with strong annoyance respond less than adults with the exception of
stroke. With children the effects of noise is to be seen primarily in the respiratory system.
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A further effect of noise is sleep disturbances. Sleep can be severely disturbed by noise. Acute
sleep disturbances effect performance and in the long run health. For adults significantly
elevated relative risks in the cardiovascular system, the respiratory system, and the
musculoskeletal system as well as with depression exist with noise induced sleep disturbances.
Many of these diseases increase with age and therefore in children only appear rarely. With
children significantly elevated relative risks in the respiratory system as well as in migraines
(self reported) are of great importance.
The association between noise induced sleep disturbances and morbidity are approximately in
the same range as the consequences of noise induced strong annoyance. By noise induced sleep
disturbances more people are effected (23.3%) than by noise induced strong annoyance (12.4%
neighbourhood noise; 14.4% traffic noise). Therefore, particular attention must be paid to nightly
environmental noise exposure.
Little attention was paid to neighbourhood noise till now and therefore pathological effects are
considerably underestimated. The health effect of neighbourhood noise induced annoyance is
approximately in the same range as the health effect of traffic noise induced annoyance. The
results point out that it is necessary to improve the sound insulation in residential buildings.
The respiratory system also reacts to neighbourhood noise with increased relative risks. In
contrast to traffic noise, with neighbourhood noise, air pollution cannot be responsible as an
alternative reason for the increased health risks in the respiratory system. The noise has to be
classified as an independent risk factor for the respiratory system.
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