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Background and Objectives: The proximity of wind turbines to residential areas has been associated with a higher level of complaints compared to the general population. The study objective was to search the literature investigating whether an association between wind turbines and human distress exists. Methods: A systematic search of the following databases (EMBASE, PubMed, OvidMedline, PsycINFO, The Cochrane Library, SIGLE, and Scirus) and screening for duplication led to the identification of 154 studies. Abstract and full article reviews of these studies led to the identification of 18 studies that were eligible for inclusion as they examined the association of wind turbines and human distress published in peer-review journals in English between 2003-2013. Outcome measures, including First Author, Year of Publication, Journal Name, Country of Study, Study Design, Sample Size, Response Rate, Level of Evidence, Level of Potential Bias, and Outcome Measures of Study, were captured for all studies. After data extraction, each study was analyzed to identify the two primary outcomes: Quality of Study and Conclusion of Study Effect. Results: All peer-reviewed studies captured in our review found an association between wind turbines and human distress. These studies had levels of evidence of four and five. Two studies showed a doseresponse relationship between distance from wind turbines and distress, and none of them concluded no association. Conclusions: In this review, we have demonstrated the presence of reasonable evidence (Level Four and Five) that an association exists between wind turbines and distress in humans. The existence of a doseresponse relationship (between distance from wind turbines and distress) and the consistency of association across studies found in the scientific literature argues for the credibility of this association. Future research in this area is warranted as to whether or not a causal relationship exists. Introduction Unlike most industries, the global wind industry grows annually by 21% despite the recent economic challenges. Canada is the ninth largest producer of wind energy in the world with a 45-fold growth in the industry in the year 2012 relative to 2000 [1-2]. The invention of the wind turbine as an electricity generating machine dates back to 1887 by James Blyth, a Scottish academic, and it used to light his holiday home in Marykirk, Scotland [3]. Wind turbines were at first welcomed by the public as being a source of energy that is both renewable and carbon emission-free. The need to generate electrical power on a large scale was the main driver in establishing the industrial wind turbines (IWTs) [4]. Wind turbines can be located as solo wind or in groups called "Wind Farms". In either form and for various reasons (e.g., minimizing transmission costs), wind turbines are usually positioned in close proximity to residential areas (farms, villages, towns, and cities). This proximity to residential areas has been associated with a higher level of complaints compared to the general population [5]. These complaints are coined in research conducted and articles written on the subject under different terms, such as "Extreme Annoyance", "Wind Turbine Syndrome (WTS)", and "Distress", among others. In this article, the term "distress" will be used unless we are quoting other articles. Complaints resulting from the proximity to wind turbines vary in their nature, and distress is often attributed to different mechanisms, such as noise, visual impact, sleep disturbance, infrasound, and others [5-7]. Noise is the complaint that has been studied most often, especially given that environmental noise has become one of the major public health concerns of the 21st century [8]. These complaints triggered the debate about possible mechanisms of effect. Several hypothetical mechanisms have been suggested to explain the possible link(s) between wind turbines and the reported distress; some of these hypotheses attribute distress to one or more of the following: chronic noise exposure, infrasound effect, visual impact, perceived lack of control over noise, attitudes, personality, and age [5-6]. To assess the possible effects of wind turbines on human health, different outcome measures have been suggested, including annoyance, sleep disturbance, and cortisol levels. An alternative approach to health assessment involves the subjective appraisal of health-related quality of life, a concept that measures general wellbeing in all domains, including physical, psychological, and social domains [8]. Although the focus on researching mechanisms of effect may very well be a good first step to identifying the cause, finding an association is a cornerstone of establishing any causality, according to Hill's Criteria of Causality [9]. A key missing piece of the scientific literature is that of an up-to-date and thorough review that examines 2014 Arra et al. Cureus 6(5): e183. DOI 10.7759/cureus.183 Page 2 of 15 the possible existence of an association between wind turbine and human distress. Therefore, the objective of our study was to search the literature investigating whether or not an association between wind turbines and human distress exists. Materials And Methods Study design A systematic review of the existing literature of published peerreviewed studies investigating the association between wind turbines and human distress between January 2003 January 2013 was undertaken. This study was conducted as a collaboration between the Northern Ontario School of Medicine (NOSM), Sudbury, and Grey Bruce Health Unit, Owen Sound, Ontario, Canada. Eligibility criteria Inclusion Criteria: Peer-reviewed studies Studies examining association between wind turbines and distress Studies published in peer-review journals

Systematic Review 2013: Association between Wind Turbines and Human Distress