1. Update on the development of WHO Environmental noise guidelines for the European Region
Marie-Eve Héroux
Technical Officer, Air Quality and Noise
WHO European Centre for Environment and Health 1

2. Presentation Outline WHO Guideline development process
Scope of the guidelines
Developing recommendations
Target audience and expected use of guidelines
Conclusions

3. WHO Guideline Development Group members
Wolfgang Babisch, Private Consultant
Goran Belojevic, Institute of Hygiene, Faculty of Medicine, University of Belgrade
Mark Brink, Swiss Federal Office for the Environment
Sabine Janssen, Netherlands Organization for Applied Scientific Research
Peter Lercher, Medizinische Universität Innsbruck ( )
Marco Paviotti, European Commission, DG Environment
Goran Pershagen, Institute of Environmental Medicine, Karolinska Institute
Kerstin Persson Waye, The Sahlgrenska Academy at the University of Gothenburg
Anna Preis, Adam Mickiewicz University
Stephen Stansfeld, Wolfson Institute of Preventive Medicine, Queen Mary University of London
Martin van den Berg, Chiaramonte Noise Consult
Jos Verbeek, Finnish Institute of Occupational Health

4. WHO Guidelines
Represent the most widely accepted set of public health recommendations, intended to assist policy-makers, health-care providers, and other relevant stakeholders to make informed decisions for the protection of public health.
Based on a comprehensive and objective assessment of the available evidence.
Generally intended for worldwide use, and therefore recognize the heterogeneity on technological feasibility, economic development and other political and economical factors.
Remove?
WHO adopted internationally recognized standards and methods to ensure that guidelines are free from biases and meet public health needs.

5. WHO process for guideline development
WHO Guidelines Review Committee reviews and approves guideline proposals and final set of recommendations
Declaration of potential personal, financial and academic interests of all experts involved
Establishment of guideline groups:
Guideline Development Group: Leading experts and end- users responsible for the process of developing the health- based recommendations
Systematic Review Team: responsible for reviewing the literature and performing systematic reviews of evidence
External peer-review by experts
Separate consultation with stakeholders and end users

6. Main objectives of the guidelines
To systematically review the scientific literature on:
The health effects of environmental noise
The effectiveness of interventions to reduce noise exposure and improve health
To provide evidence-based recommendations for protecting public health from the health risks of environmental noise, in the form of:
Exposure-response relationships / quantitative guideline values
Effectiveness of interventions

7. Noise sources considered
Noise exposure to the following sources in such relevant settings as residences, hospitals, educational settings and public venues:
Aircraft noise
Railroad noise
Road noise
Wind turbine noise
Leisure noise (including personal listening devices)

8. Health outcomes included in the review
WHO definition of health:
State of complete physical, mental, and social well-being and not merely the absence of disease or infirmity
1. CRITICAL HEALTH OUTCOMES
(critical for guideline development):
- cardiovascular diseases
- annoyance
- effects on sleep
- cognitive impairment
- hearing impairment and tinnitus
2. IMPORTANT HEALTH OUTCOMES
(less critical for guideline development):
- diabetes and metabolic diseases
- adverse birth outcomes
- quality of life, mental health and wellbeing

9. Interventions
Interventions and their effect on change in population exposure and on adverse health outcomes
Interventions can be defined as:
Source interventions
Path interventions
Infrastructure change interventions
Indirect interventions
Change in behaviour interventions

10. Intervention framework for environmental noise
Reference: Brown and van Kamp (unpublished)

11. Grading the evidence
Assessment of the overall quality of evidence for relationship between environmental noise and a certain health outcome / effectiveness of intervention:
Study limitations
Inconsistency of results
Indirectness of evidence
Imprecision
Publication bias
Magnitude of effect
Plausible confounding
Dose-response gradient
OVERALL QUALITY OF EVIDENCE:
High quality
Moderate quality
Low quality
Very low quality

12. Developing recommendations1
Quality of evidence (high / moderate / low / very low) 2
Balance of benefits and harms (when implementing the recommendation) 3
Values and preferences (of general population and/or specific groups) 4
Resource use (more or less resource-intensive to implement a recommendations)
‘strong’: the guideline is based on the confidence that the desirable effects of adherence to the recommendation outweigh the undesirable consequences. The quality of the evidence combined with certainty about the values, preferences, benefits and feasibility inform this recommendation, which should be implemented in most circumstances; or
‘conditional’: there was less certainty about the combined quality of evidence, values and preferences of individuals and populations affected, benefits and feasibility of this recommendation meaning there may be circumstances or settings in which it will not apply.

13. Framework for guideline development
Definition of noise guideline value:
“noise exposure level above which the guideline development group is confident that there is an increased risk of adverse health effects”
Ranking of priority health outcome measures used for deriving guideline values:
Based on disability weight (DWs), independent of exposure distribution/noise levels and generally informed by large surveys on how people value the outcomes
Lden
incidence of ischemic heart disease
incidence of hypertension
% highly annoyed
permanent hearing impairment
reading and oral comprehension
Lnight
% highly sleep disturbed

14. Transportation noise
Separate recommendations for road, rail and aircraft noise, for Lden and Lnight
Evidence:
Most health evidence on road traffic noise, followed by aircraft noise, little on railway noise
Aircraft noise:
more annoyance and sleep disturbance than other types of noise
issue with noise indicator?
Evidence reviews highlight opportunities for further research, while still proposing actionable guidance for policy makers
Substantial benefit expected from markedly reducing noise

15. Leisure noise Evidence:
Very low quality evidence coming directly from studies relating leisure noise exposure to health outcomes
Difficulty in properly assessing exposure and development of hearing impairment / tinnitus
Strong supportive evidence from occupational noise field
Concern about young population being exposed
Benefit from reducing exposure
Some low cost measures available
Justification for a preventive recommendation

16. Wind turbine noise Evidence:
Very low quality evidence on health outcomes, perhaps except annoyance
Noise exposure assessment is an issue
Aware of new studies currently taking place that may add on to this body of evidence
Hard to dissociate noise impacts from other considerations such as visual aspects, infrasound, amplitude modulation, etc.
Change over time in wind turbines types and size
Concern from population living in vicinity to wind turbines
Community involvement and open communication important

17. Noise interventions Evidence:
Most evidence for road traffic, and less for aircraft
Little/no evidence for rail, wind and leisure noise
Health outcomes most studied are annoyance and sleep disturbance
General benefit from reducing noise
Implementation of interventions:
Effectiveness of implementation is context specific
Resources needed for implementation expected to be highly variable
Importance of community involvement
General recommendation to encourage consideration of health in noise abatement measures and policy

18. Target audience Considered audiences:
European region ≠ Europe ≠ EU
Considered audiences:
Various technical experts and decision-makers at local, national or international level
Health Impact Assessment and Environmental Impact Assessment practitioners and researchers
Authorities and non-governmental organizations engaged in risk communication and general awareness raising
Geographical region: European Region
But: Recommendations may also be applied to countries outside of the WHO European Region
Evidence reviews for the Guidelines considered research from other areas of the world
Users of exposure indicators Lden and Lnight

19. Usefulness of Guidelines
For decision makers and technical experts:
exposure-response relationships give insight into the consequences of certain regulations with regard to the associated health effects
provide basics for developing noise limits and standards in national regulations
can be used to allow comparison amongst different policy options with regard to the associated health effect
can be valuable information to use in cost-effectiveness and cost- benefit analyses of various policies
For Health Impact Assessment and Environmental Impact Assessment specialists:
provide important input to derive the health burden from noise
For scientists and researchers:
clearly identify critical research gaps that will need to be filled in the future

20. Where will the Guidelines be used?
Starting position: National needs, including the need for capacity building, differ in the various countries of the WHO European Region
Thus the level of implementation of the Guidelines will probably vary between countries
The recommendations are more likely to be implemented in EU Member States due to the legally binding provisions of the END
WHO has not (yet) developed specific noise guidelines for other WHO regions
Guidelines for the "European Region" may also be used globally

21. Conclusion Environmental noise is an important public health concern
Only second to air pollution in terms of disease burden
New scientific evidence in the field of environmental noise and public health
WHO will develop the WHO Environmental Noise Guidelines for the European Region
Updated exposure-response functions for noise sources / health outcomes
Recommendations on effectiveness of interventions
The Guidelines will provide evidence-based recommendations in order to support WHO European Member States in their efforts to prevent and control exposure to excessive noise