Effects of road traffic noise on the prevalence of cardiovascular diseases: The case of Thessaloniki, Greece

Journal Pre-proofs Effects of road traffic noise on the prevalence of cardiovascular diseases: The case of Thessaloniki, Greece Begou Paraskevi, Kassomenos Pavlos, Kelessis Apostolos PII: DOI: Reference:

S0048-9697(19)34468-7 https://doi.org/10.1016/j.scitotenv.2019.134477 STOTEN 134477

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Science of the Total Environment

Received Date: Revised Date: Accepted Date:

25 July 2019 13 September 2019 14 September 2019

Please cite this article as: B. Paraskevi, K. Pavlos, K. Apostolos, Effects of road traffic noise on the prevalence of cardiovascular diseases: The case of Thessaloniki, Greece, Science of the Total Environment (2019), doi: https:// doi.org/10.1016/j.scitotenv.2019.134477

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1

Effects of road traffic noise on the prevalence of cardiovascular diseases: The case of Thessaloniki, Greece

Begou Paraskevi1, Kassomenos Pavlos1, Kelessis Apostolos2

1Laboratory

of Meteorology, Department of Physics, University of Ioannina, GR-45110, Ioannina, Greece 2Environmental

Department, Municipality of Thessaloniki, Paparigopoulou 7, Thessaloniki

54630, Greece

Abstract Road traffic noise is a growing challenge for human health in the last decades. World Health Organization (WHO) summarized the scientific evidence on side effects of noise on public health and wellbeing since 1999 in its publication ˝Guidelines for community noise˝. The WHO’s documentation was completed in 2009 with the Night Noise Guidelines for Europe and in 2011 with the Burden of disease from environmental noise highlighting the negative effects of environmental noise on health. In this paper, we studied and presented the overall noise levels and the exposure of the population in the city of Thessaloniki, Greece. The estimation of the exposure to road traffic noise was based on the census data for a 15-year time period (e.g. 2000 to 2015). The quantification of the environmental burden of cardiovascular diseases, due to urban traffic noise, is calculated in terms of DALYs. The calculation is based on the morbidity and mortality data from the hypertensive, ischemic heart, and cerebrovascular diseases of the total population. Our analysis proved that the road traffic noise in Thessaloniki causes almost 2000 DALYs lost in the total population each year. Also, the exposure to road traffic noise was estimated by three measuring points, two of them located in the urban Thessaloniki (a high traffic highway and a residential area) and the third one situated in one urban background area in the urban outskirts of Thessaloniki. The noise levels were measured for a 24-hour period during a 3 year time period for every measuring point. The imposed WHO noise levels were exceeded in both high traffic highway and residential areas for almost the whole time of the measurement period.

Key Words: Road Traffic Noise Levels, Noise Exposure, Heart Disease, Cardiovascular Risk, DALYs (Disability Adjusted Life Years)

2 1. Introduction In the last decades numerous studies have investigated health damage caused by environmental noise. The adverse effects of the exposure to road traffic noise are a complex problem involving the harmful effects of environmental influences and biological risk factors. Over the last 30 years, the biological effects of noise in both laboratory animal research (Ising, 1993) and epidemiological studies in humans have been investigated (Babisch,1999). The well-known direct effects of noise to the auditory system, evoking tinnitus, hearing impairment, and disability or permanent loss of hearing were studied in the works of Sliwinska-Kowalska and Zaborowski, 2017; Basner et al.,2014, among others. On the other hand, the main biological reactions for the non-auditory responses to noise were based on the general stress theory. The general stress theory involves physical responses to three external stressors: alarm, resistance, and exhaustion (Seley, 1953; Babisch, 2002). Since the 1990s it has been known that environmental noise affects the cardiovascular system (Babisch et al., 1999), evokes chronic stress (Henry et al.,1992), with the noise exposure being linked to cardiovascular diseases (myocardial infarction, hypertension, stroke) (Babisch, 2008; Babisch, 2011; Eriksson et al., 2012; Basner et al., 2014). The pathophysiological mechanism explains these associations related by two different systems, SAM (Sympathetic-Adrenal-Medullary) axis and the HPA (Hypothalamic-Pituitary-Adrenal) axis (Lundberg, 1999; Spreng, 2000a; Spreng 2000b). The hormonal system and the sympathetic nervous system are inextricably linked to disturbance due to noise-induced stress. SAM and HPA axes are responsible for the increase in stress hormones (adrenaline, noradrenaline, cortisol). With the increase of these hormonesthe levels of glucose and lipids in the blood rise as well, with the risk of coagulation infarction (Babisch, 2003). Furthermore, these have an influence on hemodynamic factors (blood pressure, heart rate, stroke volume, cardiac output, and vasoconstriction), increasing the risk of hypertension, arterial, and possibly myocardial infarction (Lundberg, 1999, Lusk et al., 2004). Furthermore, the response to environmental noise mediated to the hypothalamus through the limbic system in an endocrine process and release the aforementioned stress hormones in the adrenal cortex (Belojevic, 1997; Barcelo et al., 2016). The elevation of cortisol levels influences the occurrence of hypercortisolemia in blood vessels, causing the development and progression of atherosclerosis. In response to stress, cortisol activates the metabolism of adipose tissue in order to increase the available energy in the body (Tobias et al., 2015). Moreover, the elevated cortisol levels increase the risk of hypertension by an increasing sensibility of the adrenergic receptors, thereby leading to vasoconstriction (Spreng, 2000a; Spreng 200b). Several studies have demonstrated that exposure to transportation noise is associated with the risk of cardiovascular events (Babisch, 2008; Lercher, 2011; Munzel et al., 2014; Munzel et al.,2018). A meta-analysis conducted by Vienneau et al. (2015) with data collected mainly from road traffic and aircraft noise, investigates the relationship between noise exposure and ischemic heart disease. In another study, evidence collected from Selander et al. (2009) has shown that exposure to road traffic noise can lead to myocardial infarction. Morbidity from stroke was also investigated in association with the exposure to traffic-related pollutants and road traffic noise by Sorensen et al.2011; 2012; 2014. In addition, the association between road traffic noise and the prevalence of hypertension was identified by Belojevic et al. (2008) and Bodin et al. (2009).

3 However, fewer studies investigated the relationship between road traffic noise and coronary heart disease mortality caused by transportation noise (Gan et al, 2012). In summary, according to the EU., 40% of the total population of the European member states is exposed to road traffic noise of above 55 dB(A). This means that in terms of DALYs the total burden of disease from traffic-related noise in the Western-European countries would be at least 1 million DALYs lost every year. In EUR-A, WHO epidemiological sub-region, the burden of ischemic heart diseases are 3,376,000 DALYs due to each pathological cause, of which 60,768 DALYs (1.8 % of the 3,376,000 DALYs) is attributable to transportation noise (WHO, 2002). The aim of this study is twofold: 1) To investigate the relation between urban road traffic noise and the adverse health effects in the human circulatory system of the urban population of the Prefecture of Thessaloniki, Greece. 2) To calculate the Disability-Adjusted Life Years (DALYs) for cardiovascular diseases (hypertensive heart disease, ischemic heart disease, cerebrovascular disease) attributable to road traffic noise in the same area.

2. Data and Methodology 2.1 Noise exposure assessment The Environmental Department of Municipality of Thessaloniki performed systematic measurements of environmental hazards, such as urban traffic noise and atmospheric pollutants, in the Greater Thessaloniki Area. The measurements were performed in three areas namely: Egnatia street, 25th Martiou street, and Eptapirgio. Egnatia street is the busiest road in the urban area of Thessaloniki with the highest traffic load and the maximum vehicle fleet during the day. 25th Martiou street is an urban road with high traffic load, while Eptapirgio is a region at the urban outskirts of Thessaloniki with the lowest traffic load. Therefore, Egnatia and 25th Martiou streets represent the noisy investigated areas in our study characterized as Highway-Hot Spot and Residential area, respectively. Eptapirgio represents the quiet investigated area characterized as the Urban Background. In the past, by using sporadic measurements in the above-mentioned areas Kelessis et al.(2005) investigated the urban traffic noise levels in the city center of Thessaloniki between 1989 and 2004. Their analysis showed that the city of Thessaloniki has a significant traffic noise problem due to the recorded 5.4 % annual increase in traffic volume. Measurements were performed with a Noise Level Analyzer, type Solo Master (01dB-Stell-ΜVI Technologies Group, France) which records continuous steady noise levels during a 24-hour period and automatically calculates the equivalent noise levels (LAeq,T). The equivalent noise level represents the sound pressure level in decibels averaged over a certain period of the time (T) in terms of energy, with frequency ranges, being measured according to the sensitivity scale A of the human ear.

4 The microphone used is MCE 212 (class 1) which is covered by a windscreen. In order to monitor the credibility of the results through the duration of the recordings of the acoustic environment, the instruments were calibrated with an acoustical calibrator. In accordance with the European and Greek legislation (Directive 2002/49/EC) the noise level analyzer was mounted on a tripod at a height of 4.0 ± 0.2 m above the ground and at a 2 m minimum resolution on each building facade. Furthermore, the instruments were equipped with noise statistical analyzers and the appropriate weather protection. The hourly measurements were performed for 365 days yearly, in each of the three investigated areas. Overall, there were a total of 8‚760 measurements per examined area for each year. The measurement noise period was 2004 to 2006 for Highway-Hot Spot, 2006 to 2008 for Residential Area, and for the Urban Background 2011-2013.

For the estimation of the impact of road traffic noise on human health and wellbeing, the exposure to noise, has been estimated on the total population of the Prefecture of Thessaloniki. The total population, based on the national census data of 2011, amounted to 1,110,312 inhabitants. Based on the same census data the cases characterized as cardiovascular disease episodes were identified for the period of 2000-2015. According to the Directive 2002/49/EC the member states apply the noise indicators Lden and Lnight for the assessment of harmful effects on human health and wellbeing. From the measurements of equivalent noise levels we estimate the A-weighted day-evening-night equivalent sound level Lden in decibels (dB), calculated for the 24-hour period of the day with the following equation:

Lden

1  10  log (12  10 24

Lday 10

 4  10

Levening 5 10

 8  10

Lnight 10 10

) (Equation 1)

in which:   

Lday indicator is the A-weighted long-term average sound level, determined for 12 hours of the day between 07.00 to 19.00 local time. Levening indicator is the A-weighted long-term average sound level, determined for the evening during four hours between 19.00 to 23.00 local time. Lnight indicator is the A-weighted long-term average sound level, determined for 8 hours during the night between 23.00 to 07.00 local time.

 The 10 dBs penalty in the Equation 1 was added to the sound levels between 22.00 and 07.00, while the 5 dBs penalty was added to the levels between 19.00 and 22.00 to reflect individual’s sensitivity to noise pollution during the night and the evening. The 24-hours A-weighted equivalent continuous sound levels are available during the years 20042006, 2006-2008, and 2011-2013 for the three investigated areas in Thessaloniki: Egnatia street, 25th Martiou street, and Eptapirgio, respectively. Therefore, we calculated the noise indicators Lden and Lnight from the available noise measurements using the Equation 1. The noise values for the indicators Lday, Levening, and Lnight, as calculated in

5 the Equation 1, collected from the 24-hour measurements adjust for the mean values for the time period 07.00 to 19.00, 19.00 to 23.00 and 23.00 to 07.00, respectively. 2.2 Definition of the Population-Attributable Fraction (PAF) The quantification of the proportion of diseases in a population that can be attributed to a specified exposure to an environmental risk factor is carried out by the Population-Attributable Fraction (PAF). In this study, the PAF is the proportion of ischemic heart diseases in the population that is estimated to be caused by road traffic noise exposure. The equation (2) used for the calculation of the PAF for each noise category is: 𝐏𝐀𝐅 =

(𝐏𝐢 × 𝐑𝐑𝐢) - 𝟏 ∑𝐏𝐢 × 𝐑𝐑𝐢

(Equation 2)

where Pi is the proportion of the population in the exposure category i and RRi is the Relative Risk in the exposure category i compared to the reference level.

2.3 Definition of Disability-Adjusted Life Years (DALYs) Health indicators have been used extensively to monitor the health state of the population and to describe the impact of environmental exposure on humans. In this section, we present the types of environmental health indicators, based on the population´s exposure to environmental risk factors, which negatively influence human health. In order to estimate the impact of both premature mortality and disability or health impairment, a single measure of disease burden is required. In this case, Murray and Lopez (1996) proposed a new approach to measure health status, called Disability-Adjusted Life Year (DALY). The DALY expresses years of life lost (YLLs) to premature death and years lived with disability (YLDs). In general terms, the disease burden captures the gap between a population’s actual health status and the ideal situation where everyone lives up to the age of the standard life expectancy and in perfect health. According to Murray and Lopez (1996) and the WHO (2011) the burden of disease in terms of DALY in the general population is expressed with equation (3): DALY = YLL + YLD (Equation 3) In this equation, YLL expresses the number of ‹‹years of life lost›› due to premature death and the YLD express the number of ‹‹years lived with disability›› of specified severity and duration. Thus, one DALY is one lost year of a healthy life. YLL and YLD are mathematically expressed with the following equations (4) and (5), respectively: YLL=N × L (Equation 4) where N is the number of deaths multiplied by the standard life expectancy (L) at the age at which the death occurs.

6 YLD = I × DW × D (Equation 5) where I is the number of incident cases multiplied by the disability weight (DW) and the average duration (D) of disability in years. The value of disability weight associated with the health conditions caused by diseases or injuries ranges on a scale 0 to 1. The disability weight used in DALY calculation quantifies societal preferences for different health states. For DW=1 the health condition is equivalent to full health and for DW=0 the health condition is equivalent to death. For the calculation of the YLD term of DALY equation the following mean values were used for the weight of the diseases: DW=0.246 for hypertensive heart disease, DW=0.439 for acute myocardial infarction (ischemic heart disease), DW=0.266 for long-term stroke survivors (cerebrovascular disease) (WHO, 2008), and for the meantime duration of disability (D) we assume D=1. In the calculations the duration was considered equal to 1 as the assessment was over one calendar year (WHO, 2011).

3. Results Figure 1 presents the mean daily road traffic noise levels estimated by the noise indicators Lden and Lnight for the three measuring points in Thessaloniki. The noise indicator Lden is calculated from the noise measurements using Equation 1.

Road Traffic Noise Levels (dB(A))

100 90 80 70 60 50 40 30 20 10 0 Lden Lnight

HighwayHot Spot (2004) 77.4 70.5

HighwayHot Spot (2005) 77.1 70.2

Highway- Residential Residential Residential Urban Urban Urban Hot Spot Area Area Area Background Background Background (2006) (2006) (2007) (2008) (2011) (2012) (2013) 76.3 72.6 72.2 72.0 59.5 59.2 58.8 69.4 65.2 64.9 64.5 52.0 51.6 51.0

Figure 1. Road Traffic Noise levels estimated with Lden and Lnight Indicators for the three measurement points during a 3 year period

7 The mean daily values for the Lden in the Highway-Hot Spot area were 77.4 dB(A), 77.1 dB(A), and 76.3 dB(A) for each year for the period 2004 to 2006, respectively. Also, the mean daily values for the Lnight noise indicator were 70.4, 70.2, and 69.4 for the same study period. In the residential area the mean daily values for Lden were 72.6, 72.2, and 72.0, while for Lnight they were 65.2, 64.9, and 64.5 for each year during the period 2006-2008, respectively. As expected in the Urban Background Area the noise levels were below the national and EU limits values, specifically, the Lden levels were 59.5, 59.2, and 58.8, and the Lnight were 52.0, 51.6, and 51.0 for the years 2011 to 2013, respectively. In our study, we used the Lden noise indicator as an approximate relative measure of the overall sound emission, in both day and night time, to investigate the association between road traffic noise and cardiovascular diseases. In the Highway-Hot Spot Area the hourly LAeq noise levels obtained during the study period (20042006) ranged from 65 to 89 dB. In association between Lden noise levels and cardiovascular diseases the value of 60 dB(A) is classified as NOAEL (No Observed Adverse Effect Level) (Tobias et al., 2015). The value of 60dB(A) Lden seems to be exceeded for 100% of the days. Moreover, the limits of 80dB(A) Lden and 70dB Lnight seems to be exceeded for 1% of the days and 50% of the nights respectively. In the Residential Area, the LAeq hourly values ranged between 57 to 85 dB(A) during 2006-2008. The limit values for the same area exceeded the Lden upper limit of 70 dB(A) for the 95% of the days and the Lnight upper limit of 60dB(A) for the 100% of the nights. In the Urban Background Area, the hourly LAeq noise levels obtained during the 2011-2013 period ranged from 42 dB(A) to 74 dB(A). The mean values were almost 15 dB(A) less than the upper limits imposed by the European and Greek legislation (Directive 2002/49/EC). Therefore, there is no morbidity and mortality due to cardiovascular diseases attributable to noise for the aforementioned area. The exposure to noise was divided into 6 dB categories (<55dB, 55-59 dB, 60-64dB, 65-69 dB, 70-74 dB, and >75dB Lden) in accordance to the Directive 2002/49/EC and WHO (2011) dealing with European agglomerations with more than 250,000 inhabitants. Table 1 presents the population’s relative risk and attributable fraction for each noise category in the estimation of ischemic heart disease burden from road traffic noise.

8 Table 1. Estimated road-traffic noise exposure, population relative risk, and attributable fraction for the European countries Percentage of the Noise exposure Road traffic noise exposed Population Attributable category Lden (dB(A)) population Relative Risk Fraction (%) 1 <55 50% 1.000 0.00 2 55-59 17% 1.000 0.00 3 60-64 19% 1.015 1.48 4 65-69 9% 1.067 6.29 5 70-74 4% 1.161 13.87 6 >75 1% 1.301 23.20 (Source: WHO, 2011) Figure 2 presents the percentage of the population exposed to six noise categories due to road traffic noise in the Prefecture of Thessaloniki.

percentage of population exposed (%)

50 45 40 35 30 25 20 15 10 5 0 <55

55-59

60-64 65-69 Lden (dB)

70-74

>75

Figure 2. Percentage of the population exposed to noise categories based on the noise indicator Lden The percentage of the total population in Prefecture of Thessaloniki exposed to road traffic noise < 59 dB Lden (Noise categories 1 and 2) amounts to 67 %, which means that the relative risk of the occurrence of ischemic heart diseases is equal to RR=1.00 and is not affected by the traffic noise (Table 1).

9 The road traffic noise levels range from 60-69 dB Lden (Noise categories 3 and 4) which represent relative risks of 1.067 to 1.161. The population exposed to 60-69 dB Lden amounts to 28% of the total population. The population exposed to noise levels higher than the standard limit of 70 dB Lden (Noise categories 5 and 6) represents about 5 % of the total population. Only 1 % of the total population is exposed to road traffic noise over the 75 dB Lden (Noise category 6) with relative risk equal to RR=1.301. Calculation of DALYs For the calculation of DALYs we use the data obtained from the Greek Statistical Authority for deaths caused by cardiovascular diseases using the health interview survey. Our study was performed in the Prefecture of Thessaloniki for the years 2000 to 2015 and we examined the following three cardiovascular diseases: hypertensive heart disease (ICD 10 codes I10-I11), ischemic heart disease (ICD 10 codes I21-I24), and cerebrovascular disease (ICD 10 code I63). As reported by the WHO (2011) it has been identified that the aforementioned cardiovascular diseases occur due to exposure to high and prolonged noise levels. However, since ischemic heart disease has been more extensively analyzed in epidemiological studies, we assume the same distribution of population exposure to road traffic noise levels as for myocardial infarction, hypertension and stroke. In Table 2 the percentage of morbidity due to cardiovascular diseases in the Greek population during 2014 is shown. Based on this, the percentage of hypertensive heart disease morbidity was 20.20% and the percentage of diagnosed cases with ischemic heart and cerebrovascular diseases were 1.40% and 1.70%, respectively. This means that 1 out of 5 Greeks suffered from hypertension during the year 2014, while the proportion of hypertensive women is 22% and hypertensive men 19% (interview survey of Hellenic Statistical Authority, 2014). In general, 51.1% of the hypertensive patients were aged 65-74 years old. Using Equation 2 we calculated the PAF for cardiovascular diseases due to road traffic noise. In accordance with WHO (2011), the resulting PAF for cardiovascular disease due to road traffic noise for the Prefecture of Thessaloniki is 1.8%. We assume that approximately 1.8 % of all ischemic heart disease could be attributed to road traffic noise as it is concluded by the extended epidemiological studies referring to Western Europe (EUR-A epidemiological sub-region). Furthermore, the impact fraction of traffic noise could be applied to all types of cardiovascular diseases and could be used for the calculation of DALYs. In addition, since hypertension may cause ischemic heart and/or cerebrovascular diseases, we assume the same PAF for the calculation of morbidity due to road traffic noise. Despite hypertensive heart disease cases caused by other pathological causes (e.g. hereditary factors or kidney diseases), not directly linked to the exposure to environmental noise, we consider synergetic factors across the health outcomes.

10 Table 2. Prevalence of cardiovascular diseases: percentage distribution of the population aged 15 and over, 2014 Percentage of morbidity in the Greek Cardiovascular disease population aged 15 and over (%) Hypertensive heart disease 20.20% Ischemic heart disease 1.40% Cerebrovascular disease 1.70% Total morbidity from cardiovascular diseases 23.30% (Source: Hellenic Statistical Authority,2014) In Figure 3 we present the Years of Life Lost (YLL) from cardiovascular diseases due to road traffic noise in the Prefecture of Thessaloniki during the period 2000-2015. YLL was calculated using the Equation 4. We consider the number of deaths (N) from cardiovascular diseases due to noise during the period 2000-2015 and we assumed the life expectancy (L) of 30 years from the onset of hypertensive heart disease to death, and life expectancy (L) of 15 years from the onset of ischemic heart disease and cerebrovascular disease to death. In Figure 4, the DALY’s for the same heart diseases as in Figure 3, due to road traffic noise, are presented. It is found that there is a sharp increase in both YLL and DALYs due to hypertensive disease after 2011.

11

150

450

400

100

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Years of life lost (YLL) per year

Years of life lost (YLL) per year

350

100

50

Hypertensive Disease

year Cerebrovascular Disease

201 5

201 4

201 3

201 2

201 1

201 0

200 9

200 8

200 7

200 6

200 5

200 4

200 3

200 2

200 1

0

200 0

0

Ischemic Heart Disease

Figure 3. Years of Life Lost (YLL) due to road traffic noise during the 2000-2015time period, in the Prefecture of Thessaloniki. (Note: YLL due to hypertensive heart disease corresponds to the left axis, while YLL due to cerebrovascular and ischemic heart disease corresponds to the right axis of the diagram)

12

600

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1250

500 450 1150

400 350

1100

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1050

DALYs lost per year

DΑLYs lost per year

1200

250 1000

200 950

150 100

Hypertensive Disease Ischemic Heart Disease

5

4

201

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1

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year

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7

200

200

6

5

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0

900

Cerebrovasular Disease

Figure 4. DALYs due to road traffic noise during the 2000-2015 time period, in the Prefecture of Thessaloniki (Note: DALYs due to hypertensive heart disease correspond to the left axis while DALYs due to cerebrovascular and ischemic heart disease correspond to the right axis of the diagram) Below an attempt was made to find a possible correlation between the motor vehicles fleet and DALYs attributable to road traffic noise. According to the Hellenic Statistical Authority for the years 2000 to 2015, the average number of total motor vehicles per year, for private and public use, in the Prefecture of Thessaloniki accounted to 1,391,154±190,472 vehicles. There is an increasing tendency in traffic fleet from 2000 to 2010, before the economic crisis. During the economic crisis, from 2012 to 2015, the traffic fleet experienced a decreasing tendency. In order to correlate the relationship between the Greek financial crisis and the prevalence of cardiovascular diseases, we first need to investigate the circulation of motor vehicles on urban roads of the Greater Thessaloniki Area. Further, excluding the number of buses and motor vehicles for public use, we have focused on private vehicles only.

13

DALYs

5

4

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Year Private cars in circulation Cerebrovascular Disease

3

300

2

40.0

1

350

0

45.0

9

400

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50.0

7

450

6

55.0

5

500

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60.0

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550

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65.0

1

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70.0

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Private cars in circulation

x 10000

In Figures 5a and 5b, we present the private cars in circulation, during 2010-2015, in conjunction with the DALYs lost due to ischemic, cerebrovascular and hypertensive heart diseases caused by the exposure to road traffic noise.

Ischemic Heart Disease

Figure 5a. Private cars in circulation and DALYs lost from ischemic heart and cerebrovascular diseases occurred due to road traffic noise during 2000-2015 in the Prefecture of Thessaloniki

DALYs

5

4

201

201

201

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1250

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Private cars in circulation

x 10000

14

Year

Private cars in circulation

Hypertensive Heart Disease

Figure 5b. Private cars in circulation and DALYs lost from hypertensive heart disease occurred due to road traffic noise during 2000-2015 in the Prefecture of Thessaloniki 4. Discussion First, we estimated the noise levels in the city of Thessaloniki in terms of Lden and Lnight. These results are presented in Figure 1. Concerning the levels of Lden and Lnight estimated in the three measuring points in Thessaloniki, presented in Figure 1, it is clear that in the highway hot spot and residential area they are high enough and higher than the imposed levels from the national and EU legislation, violating the existing limits of 70 and 60 dBs for Lden and Lnight respectively. This is not the case for the third urban background measuring point. Our findings are in line with similar findings from previous studies that examined the traffic noise levels in the Greater Area of Thessaloniki (Kelesis et al., 2005). The noise levels in the countryside were low while in the suburban areas near the city of Thessaloniki the traffic noise was reported high during both day and night. Furthermore, Paschalidou et al. (2019), found that the traffic noise levels are considerably higher around Thessaloniki during night-time. Also, the calculation of Leq in the three measuring areas revealed significant exceedances of the limits for many days, especially in the highway hot spot and residential areas. The percentage of the population exposed to certain traffic noise levels is shown in Table 1. Table 1 is in line with most recent estimates by the WHO (2011) for the Western-European countries with more than 250,000 inhabitants. The AF (Attributable Fraction) of ischemic heart disease due to exposure to road traffic noise increases for the Noise categories 4-6 (Table 1). Similar behavior presents the RR (Relative Risk),

15 which range between 1.067 and 1.301 (e.g. 6.7% to 30.1% higher possibility for people exposed to these noise levels to develop ischemic heart disease). Figure 2 shows the percentage of the population exposed to noise categories from Table 1. The main finding is that the population exposed to noise levels higher than 70 dB Lden constitutes about 5% of the total population, while 1% is exposed to road traffic noise higher than 75 dB Lden. The later means that 11,000 inhabitants in Thessaloniki Greater Area have 30.1% higher risk to suffer from ischemic heart disease due to traffic noise. The environmental burden of diseases from road traffic noise in Thessaloniki corresponds to other similar scientific studies (Paschalidou et al., 2019) which investigated the health impact of transportation noise in Greece, in terms of DALYs. Also, the results reported by Erikson et al. (2017) show that the percentage of the total population in Sweden related to cardiovascular diseases due to road traffic noise is estimated to be 0.5 %. The years of life lost from cerebrovascular diseases and ischemic heart diseases have a weak decreasing trend since 2010 (Figure 4). On the contrary, hypertensive heart diseases have an increasing trend in the last years of the analyzed period due to the increase of deaths of hypertensive patients. This incident is depicted with the increasing rate of years of life lost due to hypertension (Figure 3). Specifically, in 2000 the years of life lost due to road traffic noise in the hypertensive patients were 26 years while in 2015 the years of life lost due to the same reason were almost 5 times higher (127 years). The reason for this huge increase in the prevalence of hypertension is possibly the effect of environmental and socioeconomic factors (among them urban road traffic) in the human circulatory system. Moreover, compared to the health statistics of 2009, there was an increase in the prevalence of hypertension by 3.4% in 2014 (Hellenic Statistical Authority; Michas et al., In press). As mentioned above, in Figure 4, there is a sharp ascending trend in DALYs lost due to hypertensive heart disease, in 2011, which continues until 2015. To try to explain this we must refer to the conclusion of some investigators that the reason for this might be the economic crisis. Specifically, Fillipidis et al. (2014) examined the cardiovascular risk factors in Greece before, at the beginning, and during the current financial crisis and revealed an unequal impact of cardiovascular risk factors among different socioeconomic groups. Also, with the outbreak of the debt crisis, the Greek health care system, dealing with deficiencies and the weakness of some patients, to afford private health services and medication (Kentikelenis and Papanicolas, 2012). Based on the above, we try to further investigate the effect of the economic crisis on the vehicles fleet. As shown in Figure 5a there was a significant decrease in both the number of private vehicles and DALYs due to ischemic heart and cerebrovascular diseases. After the economic crisis outbreak of 2010, we can see in both Figures 5a and 5b the decreasing tendency in the number of private vehicles in use. However, the huge increase in DALYs due to hypertensive heart disease, presented in Figure 5b, does not support the correlation between the number of vehicles and the prevalence of cardiovascular diseases. This increasing trend in hypertensive patients, explained previously in this paper, is the result of the Greek financial crisis. These findings suggest that a weak link may exist between road traffic circulation and adverse health effects on human’s circulatory system. Some studies were published to gain insight into this significant topic of the effect of the economic crisis in Greece.

16 To the author’s knowledge, beside some sporadic attempts, no comprehensive study of actual road traffic noise measurements has been carried out during the prolonged Greek economic crisis in the Greater Thessaloniki Area. Vogiatzis and Kopelias (2015) compared road traffic noise measurements for the period 2005-2013 (e.g. road traffic volume, fleet, vehicles speed) on the Athens Ring Road for both before and during the Greek economic crisis. They found that in 57% of the measurements locations on the Ring Road, Lden and Lnight present a decreasing trend. Therefore, the total traffic noise levels have been reduced as a result of the reduction in the road traffic volume and fleet due to economic crisis. On the other hand, we must note that traffic volume and the relative ambient noise from the road traffic do not always immediately correlate. The reason for this is that the road traffic noise levels are influenced by some additional factors (e.g. configuration of road networks or urban and town planning). Likewise, Vlachokostas et al. (2013) identified that the urban center of Thessaloniki suffers from the exceeded road traffic noise levels as a result of the traffic activity and problematic public transportation system. Moreover, Profillidis et al. (2019) conducted research on road traffic noise reduction before and after Greek economic crisis. The research was based on personal interviews on a sample of participants from Athens and Thessaloniki. The questionnaire focused on participant’s perception about the diminution of road traffic noise levels. The mean value for the cardiovascular diseases during 2000-2015 was almost 2000 DALYs lost each year from the total population of the Prefecture. In addition, the burden of disease caused by road traffic noise is similar to asthma, due to all pathological causes, which is almost 2000 DALYs per 1 million persons per year (WHO, 2002). In order to compare our finding with the EU´s similar findings, in EUR-A, almost 60,000 DALYs are attributed to transportation noise (WHO, 2011). To give an indication of the total burden of DALYs attributable to various environmental risk factors, the airborne particulate matter is the leading risk factor. Particulate matter is associated with 6,000 to 10,000 DALYs per year for 1 million people (Hanninen et al., 2014). This burden predominantly occurs in developing countries. Also, the exposure to noise levels above 85 dB and over in 8 working hours are considered to be hazardous for workers. Worldwide, about 16% of hearing loss is attributable to occupational noise exposure, which amounts to about 415,000 DALYs. It must be noted that the total number of DALYs lost in Europe from cardiovascular diseases represent 23% of the total DALYs (Luengo-Fernandez et al., 2017). Of course, the important contribution of this study is the estimation of road traffic noise, which was based on measured values in three urban areas in Thessaloniki and the calculation of DALYs based on mortality and morbidity data obtained from the Hellenic Statistical Authority. One limitation is the lack of information about the medical history of the population of Thessaloniki, to estimate the risk factors for the outbreak of cardiovascular diseases. Other studies have found that the association with the adverse health effects of noise is stronger when medical factors and co-morbidity, such as diabetes and cardiovascular diseases, are considered (Recio et al., 2016a; 2016b). However, the calculation of DALYs is a significant population-related indicator of the burden of disease measuring the gap between the current health status and an ideal health situation where the population lives to an advanced age free of disease and disability.

17 5. Conclusions and recommendations In this paper we examined the levels of noise in Thessaloniki, the second-largest city in Greece for several years (e.g. 2004-2013) in three measuring points, which included an urban highway hot spot, an urban background, and residential area of the city. We also estimated the DALYs during a 15-year period due to various kinds of heart diseases. We found that: The inhabitants of Thessaloniki are exposed to road traffic noise levels of 60 dB(A) Lden or higher, especially in the urban hot spot and residential areas. The recorded noise levels are significantly higher than the national and EU limit values for the transportation noise, which are 70 dB and 60 dB respectively for the Lden and Lnight noise indicators. The instantaneous noise levels recorded in the Highway-Hot Spot area reached up to 88 dB of road traffic during the rush hours of the day. About 28 % of the total population of the city is exposed to 60-69 dB Lden, which represents a relative risk of 1.067 to 1.161. The population exposed to noise levels higher than 70 dB Lden is about 5 % of the total population while only 1 % of the total population is exposed to road traffic noise over the 75 dB Lden, representing a relative risk equal to 1.301. Overall, the prolonged exposure to daily urban road traffic noise or other environmental noise sources (e.g. railway or aircraft noise) evokes adverse health effects in the circulatory system and reflects both morbidity and mortality cases attributable to noise. We also examined cardiovascular diseases since they are the leading cause of mortality in Europe, while the ischemic heart and cerebrovascular diseases are the most common single causes of death. Based on morbidity and mortality data from the ischemic heart, cerebrovascular, and hypertensive heart diseases during a 15-year time period (2000-2015), we estimated the DALYs for each year, attributable to road traffic noise in the Prefecture of Thessaloniki. The mean value for the cardiovascular diseases during 2000-2015 was almost 2000 DALYs lost each year in the total population of the Prefecture. The hypothesis that the financial crisis plays a key role in the levels of urban traffic noise was examined but needs further investigation. However, the present study makes several noteworthy contributions to this important issue. Furthermore, additional information on this topic would help establish a higher degree of accuracy for DALYs attributable to road traffic noise. Future research is required to investigate personal exposure to road traffic noise. Given that the inhabitants in the urban areas exposed to environmental noise and other risk factors in a synergetic way. In order to correlate the relationship between the road traffic noise and cardiovascular diseases outbreak, developing a questionnaire investigating inhabitant’s medical history is required or personal interviews should be conducted, both which were not carried out in Thessaloniki to the author's knowledge. It is believed that the aforementioned recommendations will improve the understanding of the assessment of DALYs in the investigated area.

18 In summary, regarding the magnitude of the adverse health effects due to noise exposure, the findings of this study support the hypothesis that the exceeding limits of road traffic noise lead to an increase of the risk of cardiovascular diseases. 6. Acknowledgments We would like to thank the Municipality of Thessaloniki, Department of Environment, which shared the noise data used in this study. We also thank the Hellenic Statistical Authority for the health and other data shared with us.

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23 HIGHLIGHTS • The noise levels in Prefecture of Thessaloniki were found significantly higher than the national limit values for the transportation noise. • The mean value for the cardiovascular diseases during 2000-2015 was almost 2000 DALYs lost from the total population of Prefecture each year. • The prolonged exposure to daily urban road traffic noise evokes adverse health effects in circulatory system and reflects both morbidity and mortality cases attributable to noise.