Disability-adjusted life years DALY is a population-related indicator of the burden of disease, measuring the gap between current health status and an ideal health situation where the en
Trang 1Environmental noise presents a large public health problem
in many countries Back in 2009, Serbia implemented the law
on the protection from environmental noise,[1] harmonized
with the European Union Directive 2002/49/EC relating to
the assessment and management of environmental noise.[2]
The law and its amendments oblige authorities to create noise
maps for agglomerations above 250,000 inhabitants by June
30, 2015, as well as for agglomerations above 100,000
inhabitants by June 30, 2020.[1,3] At the same time, the
estimated population of Serbia was 7,320,807 inhabitants.[4]
The country is divided into 25 administrative regions; 9 out
of 25 regions are inhabited by more than 250,000 persons
Within these administrative regions, the cities of Belgrade,
Novi Sad, Kragujevac and Niš can be defined as urban
agglomerations according to the directive 2002/49/EC
Consequently, the first round of noise mapping should take
place in these cities Until date, however, noise mapping of any city in Serbia is still at the planning stage
Disability-adjusted life years (DALY) is a population-related indicator of the burden of disease, measuring the gap between current health status and an ideal health situation where the entire population lives to an advanced age, free of disease and disability.[5] DALY is calculated as the sum of the number
of life years lost due to premature death (years of life lost [YLL]) and the number of years lived with disability due to
a given disease or condition or its consequences (years lost due to disability [YLD]).[5,6] One DALY can be interpreted as one lost year of healthy life Key advantages of DALY are that it combines the quantity of life (premature death) with the quality of life (time spent with disability) and that it helps compare various risk factors and diseases with the burden of disease.[7]
Global and regional burden of disease was estimated for many diseases,[8] as well as for some environmental factors, including unsafe water, sanitation and hygiene,[9,10]
indoor smoke,[11] and outdoor air pollution.[12] As for environmental noise, World Health Organization (WHO) has recently published two guidelines for risk assessment and quantification of the burden of disease in relation to noise exposure.[5,13]
Burden of myocardial infarction attributable
to road-traffic noise: A pilot study in Belgrade
Katarina Paunović, Goran Belojević
Institute of Hygiene and Medical Ecology, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
Abstract
The aim of this pilot study was to calculate the disability-adjusted life years (DALY) as a quantification of the burden
of myocardial infarction (MI) attributable to road-traffic noise in Belgrade, Serbia Exposure to road-traffic noise was estimated on a sample of almost 6000 adult inhabitants living in the central municipality Stari Grad in Belgrade, Serbia Each participant was assigned to daytime noise levels for 16 h exposure measured on the street of current residence Population-attributable fraction of MI due to road-traffic noise was calculated based on the distribution of the population in different noise exposure categories and the respective relative risk of MI compared to the reference level DALYs due to noise-related MI were calculated as the sum of years of life lost and years with disability The contribution of road traffic noise to the occurrence of MI for the population of the municipality Stari Grad in Belgrade equals 2.518% Total DALY for MI due to road-traffic noise results in 176 years, that is, 115 years for men and 61 years for women When adjusted for the present size of the population in Belgrade, total DALY due to road-traffic noise equals
107 years/million inhabitants that is, 70/million inhabitants for men and 37/million inhabitants for women The burden
of disease due to road-traffic noise in Belgrade is relatively small but noteworthy from the public health point of view.
Keywords: Disability-adjusted life years, myocardial infarction, noise, transportation, years of life lost, years lost due to disability
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DOI:
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Trang 2Given the lack of official estimations of the burden of disease
from noise in Serbia, we have decided to undertake a pilot
study in a small urban area, which may initiate similar
large-scale assessments in the selected urban agglomerations The
aim of this study was to calculate DALY as a quantification
of the burden of myocardial infarction (MI) attributable to
road-traffic noise in Belgrade, Serbia Facing the lack of
noise maps for Belgrade we had to extrapolate noise exposure
in a single urban municipality of Stari Grad to the whole
population of Belgrade
Methods
Noise exposure assessment
Exposure to road-traffic noise was estimated on a sample
of almost 6000 inhabitants living in a single municipality
of Belgrade, Serbia The down-town municipality of Stari
Grad is characterized by the predominance of road traffic
over other sources of urban noise According to census
data, the municipality population is about 55,000 adults
Adult residents of every 10th apartment in all streets were
approached by distributing questionnaires to post boxes
inside the buildings according to the list of dwellers The
sampling was conducted from 2004 to 2009 In total, 11,420
questionnaires were distributed, and 6049 were filled out
and returned (response rate 52.9%) Persons who failed to
report their current address or basic socio-demographic data
(n = 188) were excluded from the study The final sample,
therefore, comprised 5861 participants, 2598 men, and 3263
women aged 42.9 ± 17.9 years
Noise levels were measured in the middle of 118 streets of
this municipality during September-October 2008 A
hand-held noise level analyzer type 2250 Brüel and Kjær was used,
according to recommendations of the International Standard
Organization for the measurement of community noise (ISO,
1982) Noise measurements were performed on working days
Equivalent noise levels (Leq) were measured in two intervals
during the daytime (between 8 and 10 am, and between 2 and
4 pm), and in one evening interval (between 6 and 8 pm)
Noise level meter was positioned on the pavement by the
road; the time interval of each measurement was 15 min; the
speed of sampling was 10/s, with 9000 samples collected per
measurement at one site From the obtained Leq levels, the
composite 16-h daytime noise level (Leq16h [decibel – the unit
of A-weighted sound pressure level [dBA]) was calculated
for each street Each participant was assigned to daytime
Leq16h values measured at the street of current residence
The obtained 16-h daytime noise levels were divided into
five exposure categories: <60.0 dBA, 60.0-64.9 dBA,
65.0-69.9 dBA, 70.0-74.9 dBA, and >75.0 dBA The proportion
of participants belonging to each exposure category was
calculated
Calculation of the population-attributable fraction for myocardial infarction due to road-traffic noise
The population-attributable fraction (PAF) was calculated based on the distribution of the population in different exposure categories and the respective relative incidence of disease The method was adapted from the guidelines for the estimation of the burden of disease from environmental noise proposed by the WHO.[5,14]
First, the exposure-response function [Equation 1] was applied to calculate odds ratios (OR) for the occurrence of
MI in relation to Lday16h daytime noise.[5,14,15] The OR is an estimate of thepopulation relativerisk (RR)
OR = 1.63 – 0.000613 (Lday16h)2 + 0.00000736 (Lday16h)3
(Equation 1) Second, the attributable risk percentage (AR%) among the population exposed to a given noise level range was calculated according to the Equation 2, based on the OR (RRs) for all exposure categories
Third, PAF for MI due to road-traffic noise was calculated from the proportion of the population in each exposure
category i (Pi) and the RR (RRi) at each exposure category
i compared to reference level, according to Equation 3.[5,14]
PAF = [Σ (Pi RRi) −1]/ Σ (Pi RRi) (Equation 3)
Calculation of disability-adjusted life years
Newly diagnosed cases and deaths from MI in Belgrade
in 2010 by gender and age groups were obtained from the Serbian Acute Coronary Syndrome Registry.[16] In 2010, the total number of newly diagnosed cases of MI was 4083 (2536 men and 1547 women), and the total number of deaths due to
MI was 1189 (699 men and 490 women).[16]
First, total YLL were calculated by multiplying the number
of deaths from MI for each age category (N) with the standard life expectancy at age of death, or average loss of life years per death due to MI (L) [Equation 4].[6]
In order to calculate the average years lost due to premature death from MI, we relied on the average life expectancy of the population in Serbia, reported by the Institute of Public Health
of the Republic of Serbia.[4] The estimated life expectancy in Belgrade is 71.89 years for men, and 77.18 years for women Therefore, total YLL were calculated for men and women separately Furthermore, YLL due to road-traffic noise were calculated by multiplying total YLL with PAF
Trang 3Second, YLD due to road-traffic noise were calculated by
multiplying the number of non-fatal cases of MI attributable
to road-traffic noise (I) with disability weights (DW) and
average duration of disability (L), according to Equation 5.[6]
The number of non-fatal cases attributable to road-traffic
noise (I) was calculated by multiplying total number of
non-fatal cases of MI with PAF Total number of non-non-fatal cases
of MI was obtained by subtracting the number of deaths
from MI from the number of newly diagnosed cases from
MI, in order to avoid double counting of cases Disability
weight is an index in between 0 and 1 indicating the severity
of the disability associated with the health condition For
the purposes of this study, a DW of 0.405 was applied, in
accordance to WHO guidelines.[5] Average duration of
disability was fixed at 1, to calculate data for each year of life
Finally, to estimate the DALYs lost due to noise-related MI in
Belgrade, YLL and years with disability due to road-traffic noise
were added, according to the following formula [Equation 6].[5,6-14]
Taking into account the size of Belgrade population in
2010,[16] the obtained DALY values were further adjusted per
million inhabitants
Results
Table 1 presents the estimated exposure to road-traffic noise,
RR and attributable fraction for MI The study reveals that almost 65% of the population of Stari Grad is exposed to noise levels <60 dBA for 16 h daytime exposure These persons are considered being at no risk from the development
of MI due to road-traffic noise On the other side, persons exposed to higher noise levels are at some risk from MI Table 1 shows that 3% of the inhabitants exposed to noise ranging from 60 to 64.9 dBA (almost 20% of the population
of Stari Grad) are at high risk of developing MI due to noise Nevertheless, 27% of the inhabitants exposed to noise above 75 dBA (<0.5% of the population of Stari Grad) are
at increased risk of developing MI when compared with the unexposed persons
Using Equation 3, we calculated PAF for MI due to road-traffic noise [Table 1]
PAF = [(1.000 × 0.638 + 1.032 × 0.191 + 1.101 × 0.156 + 1.213 × 0.011 + 1.374 × 0.004) – 1] / (1.000 × 0.638 + 1.032
× 0.191 + 1.101 × 0.156 + 1.213 × 0.011 + 1.374 × 0.004) The resulting contribution of road traffic noise to the occurrence of MI for the population of Stari Grad, Belgrade equals 0.025176 or 2.518%
Table 2 presents the calculation of DALY from MI due to road-traffic noise in the investigated area In total, 73
non-Table 1: Estimated road-traffic noise exposure, population relative risk and attributable fraction for myocardial infarction for the city of Belgrade
Sound pressure
level Leq 16h (dBA) exposed citizens Number of exposed citizens Percentage of Population relative risk of MI Attributable fraction (%)
MI = Myocardial infarction, Leq = Equivalent noise level, dBA = Decibel — The unit of A-weighted sound pressure level
Table 2: Calculation of DALY from myocardial infarction due to road-traffic noise in Belgrade by gender
MI = Myocardial infarction, DALY = Disability-adjusted life years, YLL = Years of life lost, YLD = Years with disability
Trang 4fatal cases of MI and 30 deaths from MI can be attributed
to road-traffic noise in Belgrade in 2010 Persons with
non-fatal MI due to road-traffic noise (46 men and 27 women)
are expected to live with a disability for almost 30 years
Persons who died from MI due to road-traffic noise (18 men
and 12 women) lost 146 years of life The average number
of years lost due to noise-related MI was 4.89 for the whole
sample, that is, 5.45 years for men and 4.09 years for women
Total DALY due to road-traffic noise results in 176 years,
that is, 115 years for men and 61 years for women When
adjusted for the present size of the population in Belgrade,
total DALY due to road-traffic noise equals 107 years/
million inhabitants, that is, 70/million inhabitants for men
and 37/million inhabitants for women [Table 2]
Discussion
To the authors’ knowledge, this is the first estimation of
the burden of disease from environmental noise in Serbia
The Institute of Public Health in Serbia conducted a
large-scale study on the burden of disease and injury in Serbia in
2000.[17] They reported that ischemic heart disease (IHD)
(including MI) was the leading cause of burden of disease
among men (18.1 DALY/1000 population); at the same time,
it was the third largest contributor to the burden of disease
among women (7.9 DALY/1000 population).[17] At that
time, several risk factors were studied in relation to burden
of disease, such as obesity, physical inactivity, hypertension,
high blood cholesterol, smoking and alcohol consumption;
environmental factors (air pollution, water quality, noise),
however, were not taken into consideration.[17]
Later on, Janković et al reported similar estimations of the
burden of disease in Serbia for 18 diseases and conditions
[18] According to their assessment, IHD contributed to 26.1
DALYs per 1000 population in men, and to 14.1 DALYs
per 1000 for women.[18] Using PAF for road-traffic noise,
we extrapolated these data to 652.5 DALYs from IHD per
million inhabitants among men and to 352.5 DALYs from
IHD per million inhabitants among women attributable
to road-traffic noise When compared with the presented
extrapolations, DALYs from MI obtained in our study are
substantially smaller The differences arise primarily from
the fact that IHD comprises several forms of cardiovascular
diseases (stable angina, unstable angina) that may not
necessarily display in the form of MI
Most recently, Šipetić et al (2013) published
population-ARs of IHD due to several lifestyle factors in Serbia.[19] The
most important risk factors for IHD were physical inactivity
(contributing to 21326 DALYs for men and 15183 DALYs
for women), hypertension (18429 DALYs for men, 13554
DALYs for women), cigarette smoking (21635 DALYs for
men, 6208 DALYs for women), overweight (14101 DALYs
for men, 8414 DALYs for women), high blood cholesterol
(6573 DALYs for men, 2986 DALYs for women), and inadequate intake of fruit and vegetables (4461 DALYs for men, 1993 DALYs for women).[19]
Our results show that the contribution of noise to the burden
of IHD is considerably smaller when compared with other major factors We are aware that environmental noise does not present such a large public health problem as do obesity, diet, hypertension or physical inactivity However, the above-mentioned factors are not the only preventable risk factors; exposure to environmental noise can be modified by adequate public health measures, such as insulation, regulation of transport, and strict adherence to noise regulations
The PAF of 2.5 % calculated in this pilot study is similar
to assessments in other countries, that is, Germany.[5] Other estimations of the transportation noise burden of disease were reported in the Netherlands and in Belgium De Hollander
et al estimated that between 390 and 1020 cases of IHD
per million inhabitants per year were attributable to road-traffic noise, and that the annual number of DALYs ranged from 110 to 295 years/ million inhabitants.[7] Stassen et al
reported that between 1304 and 3377 cases of IHD in 2004 were attributable to environmental noise.[20] They computed that between 456 and 1182 DALYs or between 77 and 199 DALYs/million inhabitants were attributable to road-traffic noise.[20] In comparison to the two presented studies, our estimations of DALYs for MI are considerably smaller We hypothesize that the investigated populations were exposed to different noise levels and that there may be other unidentified population-related factors that affect the occurrence of the disease
The limitations of our pilot study arise from the applied sampling procedure First, the estimated noise exposure
in the municipality of Stari Grad may differ from noise exposure in other parts of Belgrade Being an administrative center of the city, Stari Grad may be noisier than other municipalities in Belgrade Once noise maps for the whole city become available, we should estimate noise exposure for the whole population more precisely To the best of authors’ knowledge, there are no official comparisons between short-term noise measurements and long-short-term noise indicators in Belgrade On the other side, we were not able to estimate the burden of disease in this single municipality, because the data on mortality and morbidity from MI were cumulative for the whole city Second, we may have over-estimated the role
of road-traffic noise over other noise sources (aircraft noise, railway noise), particularly in other parts of the city Third,
we were not able to take the whole population of Serbia into account, primarily due to the lack of noise exposure data Fourth, we were not able to estimate the cost of burden of
MI For example, in the United Kingdom, the cost of cases of
MI, stroke and dementia attributable to daytime noise levels
≥55 dBA was around £1.09 billion.[21] Fifth, for the purposes
of the study, we assumed that the relationship between noise
Trang 5exposure and the occurrence of MI was causal In reality,
the association between noise and cardiovascular health is
not straightforward, and is modified by physiological and
psychological reactions to noise, that is, noise annoyance
[22] From the public health point of view, however, objective
noise pollution is of prime importance when calculating
burden of disease and it accounts for other personal modifiers
of noise exposure Sixth, we were not able to estimate the
role of air pollution, another well-known environmental
factor for IHD.[23] Recent systematic review supports the
hypothesis that noise and air pollution act independently
on cardiovascular health.[24] Finally, our study provides
no evidence of long-term effects of noise, which makes it
inadequate for generalization and future predictions.[25]
Nevertheless, we find that the presented study points to the
magnitude of the problem of road-traffic noise in Belgrade
from the perspective of DALY as acknowledged indicator
of the burden of disease, rather than from the simple
exposure-effect point of view We would like to raise the
awareness of road-traffic noise and to encourage public
health authorities to perform more precise and continuous
estimations of the burden of disease attributable to noise and
other environmental factors in Serbia Such studies would
help policy makers assess the scope of current environmental
problems, identify populations at risk, and initiate adequate
population-oriented interventions.[6]
Conclusion
This pilot study identified that 2.5% of all cases of MI among
the population of the municipality of Stari Grad in the center
of Belgrade may be attributable to road-traffic noise The
estimated burden of MI due to road-traffic noise over 60 dBA
in Belgrade 2010 equals 176 DALYs, or 107 DALYs per
million inhabitants The burden of disease due to road-traffic
noise in Belgrade is relatively small, but may be noteworthy
from the public health point of view
Acknowledgments
The study was financially supported by the Ministry of Education,
Science and Technological Development of the Republic of Serbia,
project No 175078.
Address for correspondence:
Dr Katarina Paunović,
Institute of Hygiene and Medical Ecology,
Faculty of Medicine, University of Belgrade,
Dr Subotica 8, 11000 Belgrade, Serbia
E-mail: katarina.paunovic@mfub.bg.ac.rs
References
1 Law on Noise Protection in the Environment Official Gazette of the
Republic of Serbia 36/09; 2009.
2 Directive 2002/49/EC of the European Parliament and of the Council,
of 25 June 2002, relating to the assessment and management of environmental noise Off J Eur Communities 2002;L189/12-25.
3 Law on Amendments and Supplements of the Law on Noise Protection
in the Environment Official Gazette of the Republic of Serbia 88/10; 2010.
4 Institute of Public Health of Serbia Health Statistical Yearbook of Republic of Serbia 2009 Belgrade: Institute of Public Health of Serbia, Milan Jovanović Batut; 2010.
5 WHO Regional Office for Europe Burden of Disease from Environmental Noise: Quantification of Healthy Life Years Lost in Europe Copenhagen: WHO Regional Office for Europe; 2011.
6 Prüss-Üstün A, Mathers C, Corvalan C, Woodward A Introduction and Methods: Assessing the Environmental Burden of Disease at National and Local Levels WHO Environmental Burden of Disease Series, No
1 Geneva: World Health Organization; 2003.
7 de Hollander AE, van Kempen EM, Staatsen BA Community noise burden of disease: An impossible choice of endpoints? Assessing and evaluating the health impact of environmental exposures Deaths, DALYs or Dollars? 2004 Available from: http://www.dspace.library uu.nl/bitstream/handle/1874/315/c6.pdf [Last accessed on 2014 Jan 23].
8 Lopez AD, Mathers CD, Ezzati M, Jamison DT, Murray CJ Global and regional burden of disease and risk factors, 2001: systematic analysis of population health data Lancet 2006;367:1747-57.
9 Ezzati M, Lopez AD, Rodgers A, Vander Hoorn S, Murray CJ, Comparative Risk Assessment Collaborating Group Selected major risk factors and global and regional burden of disease Lancet 2002;360:1347-60.
10 Prüss A, Kay D, Fewtrell L, Bartram J Estimating the burden of disease from water, sanitation, and hygiene at a global level Environ Health Perspect 2002;110:537-42.
11 Smith KR, Mehta S The burden of disease from indoor air pollution
in developing countries: comparison of estimates Int J Hyg Environ Health 2003;206:279-89.
12 Ostro B Outdoor Air Pollution: Assessing the Environmental Burden of Disease at National and Local Levels WHO Environmental Burden of Disease Series, No 5 Geneva: World Health Organization; 2003.
13 WHO Regional Office for Europe Night Noise Guidelines for Europe Copenhagen: WHO Regional Office for Europe; 2009.
14 Classen T Calculating DALYs for cardiovascular diseases and sleep disturbance related to environmental noise using strategic noise maps: Step-by-step guidance In: Hellmuth T, Classen T, Kim R, Kephalopoulos S, editors Methodological Guidance for Estimating the Burden of Disease from Environmental Noise Copenhagen, Denmark: WHO Regional Office for Europe; 2012 p 19-29.
15 Babisch W Road traffic noise and cardiovascular risk Noise Health 2008;10:27-33.
16 Institute of Public Health of Serbia Incidence and Mortality of Acute Coronary Syndrome in Serbia Serbian Acute Coronary Syndrome Registry, Report No 5 Belgrade: Institute of Public Health of Serbia, Milan Jovanović Batut, RAKSS; 2011.
17 Institute of Public Health of Serbia Health of Population of Serbia Analytical study 1997-2007 Belgrade: Institute of Public Health of Serbia, Dr Milan Jovanović-Batut; 2009.
18 Jankovic S, Vlajinac H, Bjegovic V, Marinkovic J, Sipetic-Grujicic S,
Markovic-Denic L, et al The burden of disease and injury in Serbia Eur
J Public Health 2007;17:80-5.
19 Sipetic S, Bjegovic-Mikanovic V, Vlajinac H, Marinkovic J, Jankovic
S, Terzic Z, et al The burden of disease preventable by risk factor
reduction in Serbia Vojnosanit Pregl 2013;70:445-51.
20 Stassen KR, Collier P, Torfs R Environmental burden of disease due
to transportation noise in Flanders (Belgium) 2004 Transp Res Part D Transp Environ 2008;13:355-8.
21 Harding AH, Frost GA, Tan E, Tsuchiya A, Mason HM The cost of hypertension-related ill-health attributable to environmental noise Noise Health 2013;15:437-45.
22 Babisch W, Pershagen G, Selander J, Houthuijs D, Breugelmans O,
Cadum E, et al Noise annoyance – a modifier of the association between
noise level and cardiovascular health? Sci Total Environ 2013;452-453:50-7.
Trang 623 Beckerman BS, Jerrett M, Finkelstein M, Kanaroglou P, Brook JR,
Arain MA, et al The association between chronic exposure to
traffic-related air pollution and ischemic heart disease J Toxicol Environ
Health A 2012;75:402-11.
24 Tétreault LF, Perron S, Smargiassi A Cardiovascular health,
traffic-related air pollution and noise: are associations mutually confounded? A
systematic review Int J Public Health 2013;58:649-66.
25 Briggs D Environmental pollution and the global burden of disease Br Med Bull 2003;68:1-24.
How to cite this article: Paunovic K, Belojević G Burden of myocardial
infarction attributable to road-traffic noise: A pilot study in Belgrade Noise Health 2014;16:374-9.
Source of Support: Nil, Conflict of Interest: None declared.
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