This study aimed to develop exposure-response relationships (ERRs) between road, rail, and air traffic noise and high noise annoyance (HNA) and to assess the HNA disease burden. In 2023, 4 640 adults were cross-sectionally sampled from the five largest cities in Bulgaria. Participants' road, rail/tram, and air traffic HNA was defined as the top two categories (60% cut-off point) of a 5-point scale. A 72% cut-off approximation was also used. European Noise Directive maps were used to assign day-evening-night equivalent sound levels (Lden) to residences. ERRs were derived and used, together with the new WHO disability weight for HNA, to calculate disability-adjusted life years (DALYs). DALYs were monetised based on Bulgaria's gross domestic product (GDP) per capita and the value of a life year (VOLY). In fully adjusted models, Lden was non-linearly associated with HNA. Road traffic Lden [range 42.5 - 77.5 dB] was positively associated with HNA only above 62.5 dB, whereas the upward trend for rail [range 37.5 - 72.5 dB] and air traffic Lden [range 37.5 - 57.5 dB] started at 40-45 dB. Using this study's ERRs, the burden among people exposed to ≥ 40 dB was 3 476 (1 896 - 5 056) DALYs, $ 39 138 953 (21 348 520 - 56 929 386) based on GDP, and € 243 310 984 (94 796 487 - 505 581 266) based on VOLY. Using the WHO's curves, the burden was 4 312 (2 352 - 6 273) DALYs, $ 48 559 330 (26 486 907 - 70 631 753), and € 301 873 648 (117 613 110 - 627 269 918). In conclusion, we could only derive a plausible ERR for railway noise annoyance. Until better ERRs are derived for the Bulgarian population, we recommend using the WHO curves for road traffic and aircraft noise annoyance.
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