IndustrialAS

ODOUR Health 2017, 55, 127–137

A DETERMINANT OF PERSISTENT SYMPTOMS Original Article
127

Odour as a determinant of persistent symptoms

after a chemical explosion, a longitudinal study
Gro TJALVIN1, 2*, Nils MAGERØY2, Magne BRÅTVEIT1, Stein Håkon Låstad LYGRE2,
Bjørg Eli HOLLUND2 and Bente Elisabeth MOEN3

1
Department of Global Public Health and Primary Care, Faculty of Medicine and Dentistry, University of Bergen, Norway
2
Department of Occupational Medicine, Haukeland University Hospital, Norway
3
Centre for International Health, Faculty of Medicine and Dentistry, University of Bergen, Norway

Received August 31, 2016 and accepted November 28, 2016

Published online in J-STAGE December 2, 2016

Abstract: Foul-smelling environmental pollution was a major concern following a chemical work-
place explosion. Malodorous pollution has previously been associated with aggravated physical and
psychological health, and in persons affected by a trauma, an incidence-related odour can act as a
traumatic reminder. Olfaction may even be of significance in the development and persistence of
post-traumatic stress symptoms (PTSS). The present longitudinal study assessed whether perceived
smell related to malodorous environmental pollution in the aftermath of the explosion was a deter-
minant of subjective health complaints (SHC) and PTSS among gainfully employed adults, when the
malodorous pollution was present, and after pollution clean-up. Questionnaire data from validated
instruments were analysed using mixed effects models. Individual odour scores were computed, and
the participants (n = 486) were divided into high and low odour score groups, respectively. Partici-
pants in the high odour score group (n = 233) reported more SHC and PTSS than those in the low
odour score group (n = 253), before and even after the pollution was eliminated. These associations
lasted for at least three years after the pollution was removed, and might indicate that prompt clean-
up is important to avoid persistent health effects after malodorous chemical spills.

Key words: Odour, Chemical explosion, Subjective health complaints, Post-traumatic stress symptoms,
Industrial accident

Introduction followed by a second explosion, and a fire that emitted

black smoke which remained in the air for several hours,
Malodorous environmental pollution was a major con- and a foul-smelling pollution was spread in the industrial
cern following an explosion in an oil tank containing low area and to the residential areas close by2). Part of the area
quality gasoline and a sulphurous waste product in an around the explosion site was covered with sludge from
industrial harbour area in Norway in May 20071). Many the tanks. The clean-up operation was tedious, as polluted
workers were present in the industrial area during the soil was found several kilometres from the explosion site.
explosion, some only a few metres away from the tank. Employees in the industrial area and near-by inhabit-
Despite this, no lives were lost, and there were no serious ants complained about the putrid smell for months after the
injuries caused by the accident. The first explosion was accident. They reported the following health complaints
to their local health care service: sore and irritated eyes,
*To whom correspondence should be addressed. sore throat, cough, headache, sleep problems, and nausea,
E-mail: gro.tjalvin@uib.no which they related to the pollution caused by the explo-
©2017 National Institute of Occupational Safety and Health sion1). The accident and the malodorous pollution received

This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial No Derivatives (by-nc-nd) License.
128 G TJALVIN et al.

considerable attention in national media, emphasizing the tal pollution was a determinant of persistent adverse health
possibility of toxic health effects due to the pollution. The outcomes. We also wanted to study a possible association
sulphurous odour was continuously present, and odour between perception of the specific odour and subjective
intensity fluctuated only due to meteorological conditions psychological distress in response to the traumatic inci-
such as wind direction and velocity, and temperature2, 3). dent. The aim of the present study was to assess whether
After the initial clean-up, large amounts of the pollutants perceived smell related to a malodorous environmental
were stored in tanks and big bags in the industrial harbour pollution following a chemical explosion was a determi-
area. The last remnants of the solid pollutants were shipped nant of SHC and PTSS among gainfully employed adults,
by boat for destruction from the industrial harbour in Feb- when the malodorous pollution was still present, as well as
ruary 2010. after pollution clean-up.
Low levels of different sulphurous compounds, includ-
ing mercaptans (methyl mercaptan: 0.006 ppm, ethyl mer- Subjects and Methods
captan: 0.022 to 0.056 ppm and propyl mercaptan: 0.008
ppm), were detected in air samples from the industrial area In 2008, one and a half years after the accident in the
2 – 3 weeks after the incident2 – 4). One and a half years after industrial harbour, authorities initiated a comprehensive
the explosion, both hydrogen sulphide (0.03 to higher than health examination among the affected population. All
2.7 ppm) and different mercaptans (methyl mercaptan: less employees in the industrial harbour area, rescue personnel,
than 0.010 to 0.61 ppm, ethyl mercaptan: less than 0.008 fire fighters, clean-up personnel and all residents above the
to 2.24 ppm, propyl mercaptan: less than 0.006 to 0.16 age of two years and living within a distance of 6 km from
ppm and butyl mercaptan: less than 0.005 to 0.03 ppm) the explosion site were invited to participate. The examina-
were detected in air samples taken at the top of two tanks tion also included inhabitants living in the same geographi-
containing sludge and wash water from tank cleaning or cal area, but more than 20 km away, - and hence not directly
sludge mixed with water from the fire extinction after the affected by the disaster. These persons were matched by
explosion2 – 5). age and gender to the employees and residents close to
A cross sectional study performed when the pollution the industrial area. In total, 1016 persons were invited in
was still present found that employees and clean-up work- 2008 (responders n = 734, 72%) (Fig. 1). The 2008 survey
ers in the industrial area had significantly more subjec- consisted of a questionnaire and a clinical examination. In
tive health complaints compared to controls3). A longitu- 2010, a questionnaire survey was conducted (responders
dinal study indicated that the removal of the malodorous n = 554, 76% of the responders in 2008) and in 2012, a sur-
pollution during the study period was associated with a vey similar to the 2008 survey was performed (responders
reduction of the subjective health complaints among the n = 506, 69% of the responders in 2008).
workers in the industrial area6). However, these workers In the present study, we included all adults from the
still reported significantly more subjective neurological main cohort, aged between 18 and 67, and who were gain-
complaints compared to controls6). In both studies, percep- fully employed in 2008 (Fig. 1). We decided to exclude
tion of the incidence-related smell was suggested to be of all who were not gainfully employed in 2008 (including
importance for the development of SHC3, 6), but this pos- 41 persons who received sickness or disability benefits) to
sible association was not examined. avoid possible biases introduced by participants who were
Exposure to malodorous pollution has previously been out of work due to illnesses diagnosed before the explosion
associated with physical and psychological health prob- accident.
lems7 – 10). Even very low levels of exposure to sulphu- In the 2008 survey, the participants were asked if they
rous compounds has been shown to cause adverse health had noticed a characteristic putrid smell originating in the
effects7, 10). In persons previously affected by a traumatic industrial area in the aftermath of the explosion (yes/no). If
incident involving an odour specifically related to the inci- yes, they were asked to indicate the months in the period
dent, this odour can act as a traumatic reminder11). It has between May 2007 and August 2008 (a total of 16 months)
even been suggested that olfaction can be of significance during which they had been aware of the odour (Fig. 2).
in the development and persistence of post-traumatic stress Because no suitable method for objective measurement
disorder (PTSD)12). of malodorous pollutants exists, and using geographical
In the present study, we wanted to investigate whether area or distance to odour source as an exposure measure is
the perception of smell related to malodorous environmen- prone to exposure misclassifications13), an individual odour

Industrial Health 2017, 55, 127–137

ODOUR AS A DETERMINANT OF PERSISTENT SYMPTOMS 129

Time

2007
Explosion

24 May 2007 Start

clean-up

2008

All persons invited Responders

Study popula�on in 2008 survey
in 2008 in 2008
(n = 486)
(n = 1016) (n = 734)

Non-responders in 2010 Clean-up

completed
(n = 107)
2010
Responders in 2010 survey

(n = 379)

Non-responders in 2012

(n = 134)
2012
Responders in 2012 survey

(n = 352)

Fig. 1. The present study is a part of a comprehensive study started in 2008 after a chemical explosion in May 2007. The
study population (shaded grey), comprised all adults (18 – 67) from the main cohort who were gainfully employed in 2008.
These participants were surveyed when the malodorous pollution was present in the area (in 2008), as well as 1 and 3 years
after it was removed (in 2010 and 2012, respectively).
Photo: Lars Fossedal

score was developed as a proxy for perceived smell related score of 100. The participants were grouped according to
to the incidence. This odour score was computed as the their odour score, and not according to where they worked
percentage of months each participant had noticed the spe- or lived. The study population was divided into two groups
cific foul odour in the 2008 assessment, giving a maximum by the odour score median (31.25), giving the high odour
130 G TJALVIN et al.

100
90
80
70
60
% 50
40
30
20
10
0

Fig. 2. Percentage of participants (n = 486) who reported the characteristic odour at some time
each month between May 2007 and August 2008.

score and low odour score groups, with mean scores 77.8 To study a possible association between perception
and 10.7, respectively. This odour group assignment was of the specific odour and subjective psychological dis-
maintained throughout the follow-up assessments. tress in response to the explosion we used the Impact of
We used questionnaire data from the surveys performed Event Scale-Revised (IES-R), a validated instrument that
in 2008, 2010 and 2012 in the analyses. Identical instru- measures current (previous 7 days) subjective distress in
ments were used to survey health outcomes in 2008, 2010 response to a specific traumatic event15). This instrument
and 2012, respectively. is a short, self-report questionnaire that is easily scored.
Subjective health complaints were measured by The IES-R correlates well with the Diagnostic and Statistical
Subjective Health Complaints Inventory (SHC) a vali- Manual of Mental Disorders (4th Edition) criteria for post-
dated instrument that measures 29 common physical and traumatic stress disorder (PTSD)16, 17), but the diagnosis
psychological symptoms experienced during the preceding cannot be made based on IES-R score alone. The instru-
30 days14). This instrument includes symptoms, even with ment can be used repeatedly to assess progress or regress
no or minimal clinical findings, which is of importance of post-traumatic stress symptoms. The responders were
when surveying the assumedly healthiest part of the popu- asked to indicate how much they were distressed or both-
lation. The respondents were asked to grade the intensity ered by 22 listed difficulties by using a Likert scale from
of each item experienced during the previous 30  days by 0 (not at all) to 4 (extremely). A higher score indicates a
using a Likert scale from 0 (no complaints) to 3 (severe higher degree of distress. The 22 items have previously
complaints). A higher score indicates a higher number of been grouped into three subscales or response sets: intru-
complaints and/or a higher degree of complaints. Based on sion (intrusive thoughts, nightmares, intrusive feelings and
previous factor analysis, the 29 items have been grouped imagery associated with the traumatic event), avoidance
into five subscales: Musculoskeletal complaints (eight (avoidance of feelings and situations, numbing of respon-
items: headache, neck pain, upper back pain, low back siveness), and hyperarousal (anger and irritability, hyper-
pain, arm pain, shoulder pain, migraine and pain in the vigilance, difficulty concentrating, heightened startle). The
feet), subjective neurological complaints (seven items: maximum total sum score was 88.
extra heartbeats, hot flushes, sleep problems, tiredness, From the questionnaire in 2008, we used data about
dizziness, anxiety and sadness/depression), gastrointestinal gender, age, educational level (0, 1 – 3 or 4 or more years
complaints (seven items: heartburn, stomach discomfort, after nine years of elementary school) and proximity to
ulcer/non-ulcer dyspepsia, stomach pain, gas discomfort, the explosion (1 km or less was used to classify the par-
diarrhoea and constipation), allergy (five items: asthma, ticipants as present in the industrial area during the explo-
breathing difficulties, eczema, allergies and chest pain), sion). We also collected information about working status
and flu (two items: cold/flu and coughing)14). The maxi- for the participants (worker/have a job or not) in 2008,
mum total sum score was 87. and how far away from the explosion site they lived (kilo-

Industrial Health 2017, 55, 127–137

ODOUR AS A DETERMINANT OF PERSISTENT SYMPTOMS 131

metres). For smoking habits (non-smoker/daily smoker) Results

we used data from the surveys in 2008, 2010 and 2012,
respectively. In the 2010 and 2012 surveys, the participants Characteristics of the participants
were asked if they had experienced the characteristic odour The present study, which comprises adults between the
the previous month (yes/no). age of 18 and 67 who were gainfully employed in 2008,
included a total of 486 participants in the 2008 survey, 253
Statistics in the low odour score group and 233 in the high odour score
group. For 2010 and 2012, the total numbers were 379 and
Mean total scores and mean subscale scores were cal- 352, respectively (Table 1 and Fig. 1). In all three surveys,
culated from the scores of each item in the SHC and more men than women participated in the study (Table 1).
IES-R instruments, respectively. Some participants did In the 2008 survey, 24% of the participants were employed
not answer all the questions. A missing score for an item in the industrial area at the time of the disaster, 18% were
was substituted by the mean score of the valid items within present in the industrial area ( < 1 km) during the explosion
the respective subscale for that individual. A subscale was and 11% participated in the clean-up operation (Table 1). In
regarded as invalid for an individual if more than half of 2008, before the malodorous pollution was removed from
the items within a SHC subscale were missing14) and if the area, 81% of the participants (n = 394) reported that they
more than two items within a IES-R subscale were miss- had noticed the characteristic putrid smell after the explo-
ing. sion. 1 and 3 years after clean-up (in 2010 and 2012), only
A study design with repeated measures imposes cor- 2% (n = 9) and 3% (n = 12), respectively, had been aware of
related data. We used mixed effects models (MEM) with the odour the previous month (Table 1).
random intercept and slope to account for such dependen- A weak negative correlation was found for odour score
cies when estimating differences in mean outcomes in and distance to residency from explosion site (correlation
the odour score groups and to assess possible difference coefficient − 0.38, p < 0.001).
in development/change over time. In all the analyses we
adjusted for age (18 – 36, 37 – 44, 45 – 51 or 52 – 67 years), Subjective health complaints
gender, smoking habits (non-smoker/daily smoker, time When the malodorous pollution was present in the area,
dependent, in 2008, 2010 and 2012, respectively), edu- as well as 1 and 3 years after clean-up, participants who
cational level (0, 1 – 3 or 4 or more years after nine years had a high odour score reported significantly more SHC
elementary school), and whether or not the participant was (p < 0.001, p = 0.002, p = 0.009 in 2008, 2010 and 2012,
present in the industrial area during the explosion ( > 1 km respectively) compared to those in the low odour score
or ≤ 1 km), as these factors are known to be possible con- group, adjusted for gender, age, smoking habits, education
founding factors for the development of SHC as well as level and proximity to the explosion (Table 2 and Fig. 3).
PTSS18 – 26). To assess possible time-dependent differences During the study period, there was a significant decrease
between odour score groups, we included an interaction in total SHC score among participants in the high odour
term between group and measurement time. score group (p = 0.02), but no significant interaction
Because living close to the industrial area, and hence between odour score group and time, indicating no dif-
near the odorous source, could be associated with a higher ferences in change between the two odour score groups
degree of odour perception among the participants, we (p = 0.16) (Table 2 and Fig. 3). For the subjective neurolog-
assessed by correlation analysis (Pearson correlation) the ical subscale score, however, there was a significant reduc-
possible relation between odour score and distance to resi- tion, with a significant interaction between odour score and
dency from explosion site. time, indicating a difference in change in scores between
We applied IBM SPSS Statistics version 22 and STATA the two odour score groups (p = 0.04) (Table 2).
version 14 for the analyses, and the level of significance In the mixed effects models, proximity to the explosion
was set to 0.05. was not of significance for the total SHC score (p = 0.84).
Each participant gave informed consent. The study was However, it was of significance for the occurrence of sub-
conducted in accordance with the Helsinki Declaration. jective neurological complaints as those who were present
The study was approved by the Regional Committee for in the industrial area during the explosion had a signifi-
Medical Ethics of Western Norway and Norwegian Social cantly higher score on this subscale (p = 0.02), compared to
Science Data Services. those who were not at the explosion site (results not shown).
 Table 1. Descriptive data among 486 participants studied in the aftermath of a chemical expolosion, when malodorous pollution was present in the industrial area (2008), as well as 1 and 3 years
132

after clean-up (2010 and 2012, respectively).

2008 2010 2012
Total Low odour scorea High odour scorea Total Low odour scorea High odour scorea Total Low odour scorea High odour scorea
Participants 486 253 233 379 197 182 352 178 174
Men, n (%) 314 (65) 164 (65) 150 (64) 239 (63) 123 (62) 116 (64) 216 (61) 108 (61) 108 (62)
Women, n (%) 172 (35)   89 (35)   83 (36) 140 (37)   74 (38)   66 (36) 136 (39)   70 (39)   66 (38)

43.8 (45) 44.7 (46) 42.9 (44) 45.4 (46) 46.0 (47) 44.8 (45) 45.0 (46) 45.86 (47) 44.24 (45)
Age in 2008, mean (median) min-max
18 – 67 18 – 67 18 – 67 19 – 67 19 – 67 19 – 67 18 – 67 18 – 67 19 – 67
18 – 36, n (%) 135 (28)   65 (26)   70 (30)   84 (22)   40 (20)   44 (24)   80 (23)   38 (21)   42 (24)
37 – 44, n (%) 107 (22)   53 (21)   54 (23)   84 (22)   40 (20)   44 (24)   79 (22)   36 (20)   43 (25)
45 – 51, n (%) 112 (23)   62 (25)   50 (22)   92 (24)   53 (27)   39 (21)   89 (25)   47 (26)   42 (24)
52 – 67, n (%) 132 (27)   73 (29)   59 (25) 119 (31)   64 (33)   55 (30) 104 (30)   57 (32)   47 (27)

Educational level in 2008

0 years after elementary school, n (%)   47 (10)   28 (11)   19 (8)   39 (11)   24 (12)   15 (9)   33 (10)   21 (12)   12 (7)
1 – 3 years after elementary school, n (%) 242 (51) 117 (47) 125 (55) 186 (50)   93 (48)   93 (53) 173 (50)   79 (45)   94 (56)
4 years or more after elementary school, n (%) 186 (39) 103 (42)   83 (37) 145 (39)   76 (39)   69 (39) 137 (40)   75 (43)   62 (37)

Smoking habits
Non-smoker, n (%) 331 (70) 179 (73) 152 (67) 264 (77) 137 (77) 127 (77) 263 (78) 137 (79) 126 (76)
Daily smoker, n (%) 139 (30)   65 (27)   74 (33)   77 (23)   40 (23)   37 (23)   76 (22)   37 (21)   39 (24)

Employed in the industrial area at the time of the explo-

115 (24)   13 (5) 102 (44)   86 (23)   8 (4)   78 (43)   87 (25)   8 (5)   79 (45)
sion, n (%)

Clean-up worker, n (%)   52 (11)   17 (7)   35 (15)   41 (11)   15 (8)   26 (14)   38 (11)   12 (7)   26 (15)
b
Proximity to the explosion
≤ 1 km, n (%)   87 (18)   17 (7)   70 (30)   64 (17)   10 (5)   54 (30)   66 (19)   10 (6)   56 (32)
> 1 km, n (%) 399 (82) 236 (93) 163 (70) 315 (83) 187 (95) 128 (70) 286 (81) 168 (94) 118 (68)

42.78 (31.25) 10.67 (6.25) 77.80 (81.25) 42.81 (31.25) 11.39 (6.25) 76.82 (81.25) 44.46 (31.25) 11.27 (9.38) 78.41 (87.50)
Odour scorea, mean (median) min-max
0 – 100 0 – 31.25 37.50 – 100 0 – 100 0 – 31.25 37.50 – 100 0 – 100 0 – 31.25 37.50 – 100

Reported the characteristic odour sometimes after the

394 (81) 162 (64) 232 (100)
explosion, n (%)
Reported the characteristic odour the previous month, n (%)   9 (2)   1 (1)   8 (4)   12 (3)   3 (2)   9 (5)

11.47 (10)   9.52 (8) 13.54 (11.39) 10.50 (8.29)   8.84 (7.23) 12.00 (9.32) 10.58 (8.06)   8.87 (7.25) 12.26 (8.86)
Total SHC scorec, mean (median) min-max
0 – 46 0 – 41 0 – 46 0 – 49.71 0 – 41.43 0 – 49.71 0 – 47.53 0 – 40.28 0 – 47.53

  2.43 (2)   1.83 (1)   3.07 (2)   2.19 (1)   1.83 (1)   2.37 (2)   2.23 (2)   1.85 (1)   2.62 (2)
Subjective neurological scorec, mean (median) min-max
0 – 17 0–9 0 – 17 0 – 15.75 0 – 15 0 – 11.20 0 – 13 0 – 13 0 – 12

  4.70 (1)   2.11 (0)   7.52 (4)   3.28 (0)   1.38 (0)   5.17 (2)   2.34 (0)   1.17 (0)   3.55 (0)
Total IES-R scored, mean (median) min-max
0 – 61 0 – 61 0 – 45 0 – 42.71 0 – 37.40) 0 – 42.71 0 – 36 0 – 25 0 – 36
a
Odour score computed as the percentage of months each participant had noticed the specific foul odour. The participants were divided by the odour score median into the low odour score and the high odour
score groups, respectively. b Proximity of 1 km or less was used to classify the participants as present in the industrial area during the explosion.c Scores from the Subjective Health Complaints Inventory
(SHC). d Scores from the Impact of Event Scale Revised (IES-R).

Industrial Health 2017, 55, 127–137

G TJALVIN et al.
 ODOUR AS A DETERMINANT OF PERSISTENT SYMPTOMS 133

Table 2. Outcomes comparing the high and low odour score groupsa in 2008, 2010 and 2012, and within the odour score groupsa from
2008 to 2012.
2012 vs 2008 p for
2008 2010 2012 b
MD (95% CI) SMDc p interaction
Total SHC scored
  High odour scorea 13.54 12.37 12.32 − 1.35 ( − 2.52, − 0.18) − 2.26 0.02 0.16
  Low odour scorea  9.52  8.81  8.87 − 0.19 ( − 1.32, 0.94) − 0.32 0.75

MDb (95% CI) 3.70 (2.03, 5.37) 2.83 (1.05, 4.61)   2.54 (0.63, 4.45)
SMDc  4.34  3.12  2.61
p < 0.001   0.002   0.009

Subjective neurological
complaints scored
  High odour scorea  3.07  2.51  2.61 − 0.42 ( − 0.77, − 0.07) − 2.35 0.02 0.04
  Low odour scorea  1.83  1.89  1.85 0.08 ( − 0.26, 0.39) 0.48 0.63

MDb (95% CI) 1.02 (0.56, 1.49) 0.53 (0.02, 1.03) 0.52 ( − 0.02, 1.06)
SMDc  4.29  2.04  1.88
p < 0.001  0.04  0.06

Total IES-R scoree

  High odour scorea  7.52  5.35  3.55
16
− 4.16 ( − 5.19, − 3.14) − 7.99 < 0.001 < 0.001
  Low odour scorea  2.11  1.38  1.17 − 0.81 ( − 1.79, 0.16) − 1.63 0.10
14

b 12
MD (95% CI) 4.59 (3.23, 5.95) 2.94 (1.68, 4.20) 1.24 (0.05, 2.44)
Total SHC score

SMDc  6.62  4.56 10

 2.04
High odour score
p < 0.001 < 0.001  0.048 Low odour score
a 6
Odour score computed as the percentage of months each participant had noticed the specific foul odour. The participants were divided by the
odour score median (31.25) into the high odour score and the low odour score 4groups, respectively.
b
Mean difference. 2
c
Standardized mean difference. 0
d
Scores from the Subjective Health Complaints Inventory (SHC). 2008 2010 2012
e
Scores from the Impact of Event Scale Revised (IES-R).

16 9

14 8

12 7
Total IES-R score
Total SHC score

6
10
High odour score 5 High odour score
8
Low odour score 4 Low odour score
6
3
4 2
2 1
0 0
2008 2010 2012 2008 2010 2012

Fig. 3. Total mean scores with standard errors of the mean of The Subjective Health Complaints Inventory (SHC) and Impact of Event Scale
Revised (IES-R) among participants in the high and low odour score groups, respectively, when the pollution was present in the area (2008), as
well9 as 1 and 3 years after pollution clean-up (2010 and 2012).
8
7
Post-traumatic stress symptoms ent in the industrial area, adjusted for gender, age, smok-
Total IES-R score

6
Compared
5 to participants in the low odour score group,
High odour score ing habits, education level and proximity to the explosion
those
4 who had a high odour score reported significantly
Low odour score (Table 2 and Fig. 3). This difference was also present 1
more
3 PTSS (p < 0.001) when the pollution was still pres- and 3 years after the pollution was eliminated (p < 0.001,
2
1
0
2008 2010 2012
134 G TJALVIN et al.

p = 0.04 in 2010 and 2012, respectively) (Table 2 and Fig. In the present study, the posttraumatic stress symptoms
3). declined over time among participants who reported long-
During the study period, there was a significant decrease lasting perception of the accident-related odour. To our
in total IES-R score among those who had a high odour knowledge, there are no other longitudinal studies of PTSS
score (p < 0,001). There was a significant interaction following chemical accidents in which malodorous pollu-
between exposure group and time, indicating a difference tion is a major issue, but in general, PTSS diminishes with
in change in scores between the two odour score groups time28).
(p < 0.001) (Table 2 and Fig. 3). The mechanisms behind the reported association
In the mixed effects models, proximity to the explosion between perceived odour and subjective health complaints
was of significance for the occurrence of PTSS. Those who in the present study are presumably complex and involve
were present in the industrial area during the explosion both psychological and physiological responses 29, 30).
had a significantly higher total IES-R-score ( < 0.001), and Through evolution, the human olfactory sense seems
subscale scores (p < 0.001, p < 0.001, p < 0.001 for hyper- to have lost some of its importance, but olfaction is still
arousal, avoidance and intrusion, respectively), compared essential for humans’ ability to detect potential hazards
to those who were not present at the explosion site (results in the environment31). Odours elicit emotions in humans
not shown). depending on how the stimulus is processed by the brain8).
An olfactory stimulus can activate amygdala directly
Discussion through neural communication30) even without involving
initial processing by the olfactory cortex32).
In this longitudinal study, participants who had per- Previous studies of the development of SHC following
ceived the foul odour for a longer period of months repeat- odorous exposure have suggested a mechanism mediated
edly reported more SHC and PTSS than those who had by odour perception and odour annoyance8, 18, 27, 29, 33, 34).
perceived the odour for fewer or no months. Significant Annoyance is the feeling of displeasure associated with
differences were found both when the malodorous pollu- any agent believed to have an adverse effect18) and involves
tion was present and after pollution clean-up. an individual’s perceptions, emotions and attitudes towards
The increased prevalence of reported symptoms in the the exposure29). Involuntary psychological mechanisms
high-odour score group is in line with previous studies of mediated by perception and previous experience seem to
health effects related to malodorous emissions. Adverse be involved8, 27, 29, 35, 36). In studies involving odour, the
health effects were found among residents who were term Proust phenomenon is often encountered30, 37, 38). This
exposed to low levels of sulphurous emissions from a pulp phenomenon occurs when a certain odour evokes a specific
mill10), and in the aftermath of a fire in an agrochemical memory30, 37, 38). According to previous studies, olfactory
storage house9). Few have studied health effects of long- memory triggers are more evocative than other modality
lasting malodorous pollution followings accidents, but triggers resulting in more emotional and detailed memo-
results comparable to ours were found in a cross-sectional ries37). Olfactory memories might also last for longer37),
study of physical and psychological health complaints fol- and might result in persistent health complaints like in the
lowing several years of malodorous exposure in the after- present study.
math of a mercaptan spill7). Most previous studies of health In the present study, the extensive and lengthy media
effects due to malodorous, chemical air pollution have coverage emphasizing the probability of toxic health
cross-sectional designs, making assessments over time effects from the pollution, as along with the lawsuit result-
impossible7, 9, 10). ing in the maximum sentence for environmental crime in
In the present study, the participants in the high odour Norway, may have been of importance to the persistence
score group reported the same amount of subjective health of symptoms, even after clean-up. In previous studies,
complaints, even after pollution clean-up. A similar effect worries about a possible health risk have been shown to
was found in a longitudinal study of health complaints increase subjective health complaints in residents living
among residents living close to a petroleum refinery, which close to hazardous waste sites39). A study among residents
implemented odour reduction measures during the study exposed to malodorous emissions from a biofuel facility
period8, 27). A mechanism deriving from perceptual and suggested that both symptoms and annoyance were medi-
behavioural sensitization was hypothesized to be the cause ated by perceived pollution and health risk perception, not
of the persistence of symptoms in that study27). by the pollution itself29). Similarly, strong dose-response

Industrial Health 2017, 55, 127–137

ODOUR AS A DETERMINANT OF PERSISTENT SYMPTOMS 135

associations between annoyance due to odour and non- High response rates in all three surveys reduced the effect
specific symptoms, but only indirect associations between of a possible non-response bias. However, there was no
odorous exposures and non-specific symptoms, were found available information about health complaints before the
among residents experiencing malodorous air pollution explosion accident among the participants, and there was
from biodegradable wastes13). no control group lacking accident experience.
The higher prevalence of PTSS in the high-odour score Two validated instruments, The Subjective Health Com-
group when the malodorous pollution still was present plaints Inventory (SHC)14) and Impact of Event Scale-
could be attributable to the potential effect of the incident- Revised (IES-R)15), were used to survey SHC and PTSS,
related odour as a traumatic reminder11, 38). The foul odour respectively. Both instruments study health complaints,
was continuously present in the industrial area for more not diagnoses, which is of importance when examining
than two years post-disaster, acting as a constant reminder assumedly healthy participants. Previous studies showed
of the actual incident as well as a cue to the possibility of low agreement between report of symptoms when sur-
another, similar accident. veyed twice42), which introduces the risk of recall biases.
Classical conditioning could also be of importance for To minimize such biases, the instruments we used enquired
the occurrence of symptoms when the malodorous pollu- about SHC and PTSS during the previous 30 and 7 days,
tion was still present. Several studies have proposed that respectively. The IES-R is designed to be used repeatedly
classical conditioning is involved in the development of to assess progress or regress of PTSS. An obvious problem
health complaints attributed to unpleasant odours11, 12, 40). in this context, is the difficulty in relating present stress
However, few have studied possible odour-related mech- symptoms to the accident when the respondents are asked
anisms in connection with PTSS and the development of 5 ½ years post-disaster.
PTSD. In one study among patients currently suffering The odour score is a subjective measure established
from PTSD, it was found that these patients are better at because there are no methods for objective measurement
recognizing odours, and that they more readily respond of odour. A subjective exposure measure like this intro-
to unpleasant olfactory stimuli41). A single study among duces the risk of self-report bias. The score is even prone
soldiers has put forward the hypothesis that odours play a to recall biases since the participants in the first survey
significant role in the pathophysiology of PTSD12). In clas- (autumn or winter 2008) were asked to list the months in
sical conditioning, acquired fear is supposed to diminish the period from May 2007 through August 2008 during
as time pass by, but studies have suggested that fear con- which they had perceived the specific odour. Participants
ditioned to odours wanes very slowly40), and there is even who were more annoyed by the malodorous pollution
an inability to extinguish the conditioned fear response in might also have a tendency to report perceived odour dur-
soldiers who develop PTSD12). ing a longer period of months, thus yielding a higher odour
For employees in the industrial area and workers living score. Despite these limitations, an individual odour score
nearby or frequently passing by the industrial area, visual is a better indicator of odour exposure than, for instance,
cues could also be of importance for the development and distance to the odorous source, which previously has been
persistence of PTSS. The burnt-out offices and large pieces shown to be prone to exposure misclassifications13).
of metal from the destroyed tanks strewn about the area, SHC is very common, and even though participants in
and later on, large bags containing solid pollutants are the high-odour score group had higher SHC scores than
all items that might act as constant reminders of the acci- those in the low-odour score group, their scores are not
dent. Even pictures of the accident site in different media high compared to the mean scores in a normal Norwegian
such as newspapers, the Internet or television could act as population23). The scores of the low-odour score group
visual cues. In an experimental study, offensive memories are even lower. This probably reflects a healthy worker
precipitated by olfactory triggers were more detailed, agi- effect43), and is as expected in a study of the supposedly
tating and unpleasant than memories induced by auditory healthiest part of the population.
triggers, but not more haunting or emotional than visual
triggers38). Conclusions
A major strength of the present study is the longitudi-
nal design. By using this design, we were able to follow Perception of malodorous environmental air pollution
the participants over time, starting when the malodorous was a determinant of both SHC and PTSS among gainfully
pollution was present, and up to three years after clean-up. employed adults after a chemical explosion. The effect of
136 G TJALVIN et al.

the determinant lasted for at least three years after the mal- explosion: a longitudinal study. Occup Med (Lond) 65,
odorous pollution was removed. In terms of the develop- 202 – 9. [Medline] [CrossRef]
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Morrison M, McIntyre MG, Knight M, Eichold B, Yip F
nificant determinant. A possible implication of the present
(2014) Community health assessment following mercaptan
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Funding   8) Luginaah IN, Taylor SM, Elliott SJ, Eyles JD (2000) A lon-
gitudinal study of the health impacts of a petroleum refin-
The study was funded by the Ministry of Health and ery. Soc Sci Med 50, 1155 – 66. [Medline] [CrossRef]
Care Services, Norway, Haukeland University Hospital,   9) Ackermann-Liebrich UA, Braun C, Rapp RC (1992) Epide-
miologic analysis of an environmental disaster: the Sch-
Bergen, Norway, and University of Bergen, Norway.
weizerhalle experience. Environ Res 58, 1 – 14. [Medline]
[CrossRef]
Conflicts of interest 10) Partti-Pellinen K, Marttila O, Vilkka V, Jaakkola JJ,
Jäppinen P, Haahtela T (1996) The South Karelia Air Pollu-
No conflicts of interest were declared by any of the tion Study: effects of low-level exposure to malodorous sul-
authors. fur compounds on symptoms. Arch Environ Health 51,
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reminder in posttraumatic stress disorder: case reports and
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Irgens, Berit Johannessen, Arnt Troland, Svein Gunnar sensitivity in PTSD: Implications for treatment and future
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