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Health impact of air pollution in Mexico A review of selected investigations

Mauricio Pardn Ojeda (1) Ana Patricia Martnez (2)

(1) Environmental Health Advisor - Pan American Health Organization PAHO/WHO-Mxico.


Tel (525)2028200; Fax (525)5228868; Email mpardon@infoabc.com (2) External consultant, Pan American Health Organization PAHO/WHO. Tel & Fax (525)3080674; Email 103144.3655@compuserve.com

Key Words: air pollution, health, research.

Health impact of air pollution in Mexico A review of selected investigations Mauricio Pardn Ojeda (1) Ana Patricia Martnez (2) Key words: air pollution, health, research.

SUMMARY This paper presents a critical review of investigations on health effects of air pollution in Mexico covering a 31 year period (1966-97). The selected papers include research at different levels: urban and rural, general public and occupational, and indoor and outdoor environments. The discussion considers major contaminants, e.g. lead exposures in the air and in ceramic glazes, suspended particulate matter, sulphur and nitrogen oxides, carbon monoxide, and ozone and their demonstrated health impact. The major conclusions include: a) a change in focus from rural areas, leaded pottery, craftsmen and miners of the 60s through the 80s, to a focus on urban areas, impact on general and specific public, ozone and concern about exacerbating and attenuating factors; b) the support of policy decisions and air quality management strategies by the demonstration of health impact associated with various air pollutants; and c) exacerbating factors on health (e.g. pregnancy, infancy and groups with high exposure), as well as attenuating factors (e.g. diet). INTRODUCTION This paper is based on articles selected by four institutions working in Mexico the National Institute of Public Health, the Institute of Environmental and Occupational Health of the University of California, 47 and the Pan American Centre of Human Ecology and Health PAHO . The articles cover the period 1966-97 and were used for an international expert meeting on air pollution risk management for the City of Mexico. Additional recent publications are included by the authors for this review. This review includes clinical, environmental and epidemiological studies. The analysis aims to show health impact of air pollutants under defined circumstances. Also there is a description of the impact of such investigations on public awareness, which has led to mitigation of exposures and improvements of health through air quality management in Mexico. Research on health impact of lead (Pb) ingestion derived from the use of Pb glazed ceramics, canned foodstuff and working environment were the basis of subsequent research on Pb air pollution. Articles on this subject are consequently included. Chronologically, health impact related to glazed ceramics was followed by concern and research on Pb in air. At the same time sulphur and particulate matter, and subsequently carbon and nitrogen oxides, ozone and photochemical oxidants in the environment became important factors in air pollution. This paper presents tables of the information reviewed and a critical discussion of the main findings and evolution of health and air pollution research in Mexico.

ANALYSIS OF INFORMATION In the tables, studies are grouped by contaminant and presented chronologically. Table 1 includes major studies on health effects related to Pb pollution in both rural and urban environments. Table 2 is related to ozone. Table 3 groups the effects of diverse pollutants. All studies presented in Tables 2 and 3 were conducted in urban environments. Table 1 shows how studies in the 60s and 70s focused on clinical cases of acute intoxication and saturnism. Glazed ceramics used for cooking and food storage, and ingestion were identified as 1-7,9 causes . Studies in the 80s begun to focus on inhaled Pb associated with vehicular fuel 11,12,18 combustion . An association was found between Pb blood and urinary concentrations and air contamination. This association has been reported among people living in high traffic areas and commuters . 19 Blood Pb concentrations have been related to long term exposure . The Pb concentration (in blood, urine or bone) is exacerbated by
13,16-20

Use of Pb glazed ceramics 8 Industrial or heavy traffic residence area 14 Canned food or beverage consumption 21 Living more than 20 years in a high Pb concentration environment 21-22 Low calcium (Ca) diet 21 Smoking 15 Pregnancy 14 Extended breast feeding 17 Age less than 1 year 46 Cardiovascular diseases

1-7, 9,12, 13,18-22

The main findings reported associated with blood Pb concentration are diminished weight and height at 23 15 10, 13 birth , diminished cranial circumference , and diminished IQ . A reduction of 0.25 points in IQ 3 46 per 3.9 g/dl Pb in blood per change of 1g/m in air was reported . Changes in arterial hypertension, premature deaths for cardiovascular diseases and non mortal strokes were reported in 46 association with high concentrations of Pb in air . It was demonstrated that a Ca rich diet and the 22 intake of Ca supplements reduce Pb absorption . Finally, studies have demonstrated that the introduction of unleaded gasoline has resulted in a reduction of blood Pb concentration among children 24 in Mexico City . Table 2 presents health effects related to ozone in air . The impact of ozone is related to respiratory effects, e.g. acute respiratory infections, cough, phlegm, wheezing, nasal mucous atrophy, decrements in Peak Expiratory Flow rate, emergency visits for asthma. Observed effects include an increase in the amount of people with respiratory problems one day after the ozone concentration 26,29 exceed 110 ppb . Exacerbating factors associated with health effects are 26,30 Low temperature 25,29 Presence of SO2 28,30 Presence of TSP, PM10 or PM2.5 29 Age less than 5 years 29,30 Asthma or respiratory diseases 27 It has been observed that vitamin supplements reduce the health effects of ozone pollution . Table 3 presents the effects of other pollutants on health. Two studies of carbon monoxide and 39-41 several studies of general pollutants that focus on PM10 and PM2.5 show associations of pollutants 32,34,37,38 42 with infant mortality, respiratory effects , and daily mortality . Difference in carbon monoxide 36 emissions have been reported for different vehicles . Another article compares curbside pollution levels with official air quality monitoring data. The curbside measurements indicate that pedestrians and street vendors can be exposed to levels of pollutants up to five times greater than those stated in 35,36 Mexican Standards and WHO Guidelines . Identified high risk population includes: children less than 5 years, elderly grater than 65 years, and people with respiratory diseases (e.g. asthmatics). Sulphur dioxide emissions markedly increased between 1972 and 1976. Specific research evaluated 43 diseases among children, chronically ill and the elderly . Environmental and epidemiological studies were associated with suspended particular matter SPM because it has been suggested that SO 2 and 44,45 SPM are usually associated in the environment .
35,36 25, 27, 28

TABLE 1. STUDIES OF HEALTH EFFECTS RELATED TO LEAD


REF.
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16

YEAR
1966 1972 1978 1979 1981 1982 1983 1989 1991 1992 1992 1993 1993 1993 1993 1992 ??? X

ENVIRONMENT
Urban Rural X Occup.

Lead (Pb)
Ingested X X X X X X X Inhaled

MAIN FINDINGS
The risk of saturnism is associated with Pb glazed ceramics. Crafts in the State of Guanajuato showed the highest Pb concentrations at 1264 ppm. Orange juice stored in Pb glazed vessels. Highest conc. of Pb in the boy: 81g/dl blood & 3000g/dl urine. Increased neurological symptoms in the daughter and the father. Saturnism associated with Pb glazed ceramics; Pb levels ranges 59-102 g/dl blood and 180-570 g/dl urine. Saturnism ranked third occupational health disease by the Mexican Institute of Occupational Health IMSS. Use of Pb glazed ceramics with conc. of Pb 7 g/ml, associated with levels of Pb of 30.5 - 52.5 g/dl blood and 250 - 270 g/dl urine. Mean blood conc. of Pb in potters (children) 39.5 g/dl. Non potters children control families: 24.8 g/dl. Higher conc. of Pb in blood in children of potter families; negative correlation between Pb in blood and IQ. Zone differences of Pb conc. in blood in the city of Mexico. Higher in men; higher in women living in the eastern area and lower in the north; overall mean 19.5 g/ dl. High conc. of Pb in blood correlate with the use of l-glazed ceramics. Mean 10.6 g/dl; range 1-52 g/dl. Decrease in childrens IQ associated with increase in Pb conc. in blood . Demonstration of vehicular traffic impact on Pb conc. in childrens blood. Ranges of 0.17 -1.21 mol/l; 31% exceeded 0.73 mol/l. Determinants of Pb conc. in blood: exposure to vehicular traffic (more than 30 min); followed by open air sports, and use of glazed ceramics. Concentrations 10 g/dl in 76% of cases. Greater conc. of Pb in children living in high traffic areas and using Pb glazed ceramics. Inverse correlation between Pb in blood and IQ. Mean 17.8 g/dl. High levels of Pb associated with caned milk, soft drinks, and extended breast feeding. Conc. of Pb in blood 10 g/dl at 24 months in 70% cases; 15 g/dl at 21 m for 38% cases; and 25 g/dl at 18 m for 8% of cases. Inverse correlation between Pb conc. in mother blood and umbilical cord at 36 months pregnancy, and Pb blood conc. in children at 6, 18 & 36 months. Also inverse correlation with cranial circumference at 36 months. Correlation of Pb conc. in blood of children aged 1 to 10 years and vehicular traffic in home residence area. Mean 10 g/dl (range 6-14) in residential areas; 14 g/dl (11-17) moderate traffic; 15.5 g/dl (11.5-19) heavy traffic. Greater conc. of Pb in blood in mothers and children living in high Pb air conc. (study conducted in two areas of Mexico City: Xalostoc and Tlalpan). Marked difference in children under 1 year: mean 4.3 g/dl in Tlalpan vs. 8.5g/dl in Xalostoc. Correlation between mother and child: 0.58 (p=0.0001). Blood Pb conc. in mother predictor of Blood Pb conc. in her children. Mayor sources of Pb: fuel combustion emissions, Pb glazed ceramics, leaded paints, and canned foodstuff. Mean conc. of Pb in blood of children living in secondary streets 10.3 g/dl vs. 15.5g/dl in main avenues; overall mean 12.7g/dl; and 80% greater than 10g/dl. Relation between blood Pb conc. and levels of Pb in air 3 months prior to blood sampling. Mean 9.9 g/dl, range 1-30g/dl. Higher levels in Xalostoc 10.5g/dl vs. Tlalpan 9.4g/dl correlating with higher air pollution in Xalostoc. 44% of children aged over 18 months showed Pb levels 10g/dl. Also association with Pb-glazed ceramics, vehicle emissions and dust in childrens hands.

X X X X X X X X indoor / outdoor X X X X X X

X X X

X X X X X X X X

17

1994

18

1994

19

1995

TABLE 1. STUDIES OF HEALTH EFFECTS RELATED TO LEAD (continued)


REF.
20

YEAR
1996

ENVIRONMENT
Urban X Rural Occup.

Lead (Pb)
Ingested X Inhaled X

MAIN FINDINGS
Pb blood conc. in umbilical cord increase with mother use of Pb glazed ceramics and residence area in Mexico City. Maximum mean in Southeast 8g/dl (range 2.3-20.4). Use of Pb-glazed ceramics: mean 7.6g/dl (1.620.4); non users mean 6.3g/dl (2.0-17.7). Positive comparison between bone Pb conc. and more than 20 yrs. Living in Mexico City, low consumption of Ca rich food, no Ca supplements, use of Pb glazed ceramics and smoking. Pb in patella contributes significantly to Pb blood conc. during pregnancy and breast feeding. Mean Pb conc. in blood 9.6 g/dl; in tibia 12.5g/g and in patella 16.7g/g of mineral bone. An estimated mean difference of 20g Pb/g in patella, between women living less than 5 and more than 20 years in Mexico City. Greater conc. of Pb associated with use of Pb glazed ceramics, living in busy traffic areas, and in the industrial area of Xalostoc. Inverse correlation with Ca rich foods consumption. Mean Pb conc. in blood 9.7 g/dl. Decrease of 73g at birth correlated with each 10 g Pb/g mineral bone in tibia increment. Mean Pb in mothers blood of 8.9g/dl, in umbilical cord 7.1g/dl, in mothers tibia 9.8g/g and in patella 14.2g/g of mineral bone. Decrease of Pb conc. in womens blood from 10.5 to 7.47g/dl in the period 1992 - 95. Mean values of 8.7g/dl in blood (range 0.5-66.2) and 7.9g/dl (range 0.4-50.6) in umbilical cord.

21

1996

22 23 24

1996 1997 1997

X X X

TABLE 2. STUDIES OF HEALTH EFFECTS RELATED TO OZONE


REF. YEAR O3 association with other pollutants
PM2.5 25 26 1990 1992 SO2 X

MAIN FINDINGS

27 28 29

1993 1995 1995 X

30

1997

TSP and PM10

NOx

Relation between acute respiratory diseases and levels of ozone and sulphur dioxide. Effects at lung level. Positive relation between ozone level and school absenteeism. Increase in absenteeism with increase in ozone levels: 49% for medium ozone exposures (13-22 ppb) and 92% for days with high levels (23-34 ppb), using a 1-day lag time and comparing with days with low ozone levels. 50% of the children had at least one respiratory-related absenteeism period, and 11.75 had two or more. Children exposed for two consecutive days to high ozone levels (13 ppb) had a 20% increase in risk of respiratory illness. The risk reached 40% when children were exposed for two consecutive days to high ozone levels, and the previous day to low temperature (5C). Increment of neutrophils (PMN) with ozone levels 0.11 ppm. Increment in squamous metaplasia, nasal mucous atrophy and hyperaemia, in the group without vitamin supplement. Report of 33% of the children had chronic cough or phlegm, and 30% had wheezing history associated with high ozone pollution episodes The levels of ozone and sulphur dioxide exposure were significantly associated with the number of emergency visits for asthma. An increase of 50 ppb in the 1-hour maximum ozone level is related to a 43% increase in the number of emergency visits for asthma on the following day. Main effects were observed 1 day after exposure. Exposure to high ozone levels (>110 ppb) for 2 consecutive days increased the number of asthmarelated emergency visits by 68%. Interaction between ozone levels and age suggesting that young children (<5 years) may be more susceptible to ozone exposure. Levels of SO2 (daily 1-h max) were related to the total number of emergency visits for respiratory diseases on the same day. Children with mild asthma who resided in the south of Mexico City were affected adversely by the high ozone ambient levels observed in this area. Decrements in peak expiratory flow rate were associated with ozone, and respiratory symptoms were associated with both ozone and ambient particulate matter(<10 m) levels. An increase of 50 ppb in a daily ozone 1- h maximum was related to an 8% increase in cough, a 24% increase in phlegm and an 11% increase in low respiratory symptoms index. Increase in the adverse effects of O3 when low temperatures and PM10 are simultaneously present.

TABLE 3. STUDIES OF HEALTH EFFECTS RELATED TO GENERAL POLLUTANTS


REF.
31

YEAR
1978

POLLUTANT
Sodium hypochlorite spill TSP y SO2 O3, CO, SO2, NOx, PM10 y Pb. O3, NO2, PM10 y Pb. CO

MAIN FINDINGS
Intoxication symptoms of 52% because of chlorine exposure. Mucous irritation, cough, and lost of conscience. 10% present shock. Detected chlorine air conc. 3ppm. Increase in infant mortality and mortality by respiratory disease in Atzcapotzalco as compared to Tlalpan (north and south of Mexico City respectively). Environmental monitoring information, pollutants levels in the ZMCM. Studies in children 5 years, asthmatics and elderly were recommended. Greater frequency of respiratory disease effects in days with higher air pollution levels. Curbside CO conc. of 26ppm reported (range 2-70). Average curside/background rate of 2.2. The study reports 1000 street vendors exposed over periods of 10 hrs per day and 6 days a week. Reports rates of pollution of different types of public transport against background: cars 5.2, minivans 5.2, minibus 4.3, lorries 3.1, trolleys 3, and underground 2.2. Observations of 26% children with FVC90% and 52% with FEF90% were reported in five Mexico City monitoring zones. Alterations in the children mucous membrane and FVC90% were observed mainly in the SE followed in severity by the NE. SW children present normal FVC, but show the highest proportion of FEF90%. A high risk of respiratory diseases was associated with an increase in number of hours that pollutants exceed standards. The following symptoms were observed: headache, eye and throat irritation and otitis. Report of mean values of 1,81ml FEV and 2.11ml FVC. These values were higher in men and in night school attendants. The centre zone of Mexico City show the lower values, together with NO2 maximum levels. Inverse relation between FVC, and SO2 conc. in air 15 days prior to tests, and with SPM 2 days prior to the PFM tests. Description of epidemiological methods for the development of a cohort of asthmatic children and air pollution exposure. Increase in PM10 related to increase in adverse respiratory symptoms: 10% cough and 62% breathing difficulties. An increase in 10 g/m3 of PM2.5 associated with an increase of 19% cough and 16% phlegm. An increase of 6% in daily mortality associated with an increase of 100 g/m3 of TSP was observed in a model adjusted for temperature and long time trend, O 3 and SO2. Total mortality, cardiovascular mortality, and mortality for those over 65 years were associated with ozone concentration after adjusting for minimum temperature (2.4%, 2.3% and 3.9% increase for each 100 ppb change in daily maximum ozone level, respectively), but dropped when adjusted for TSP.

32 33 34 35

1982 1990 1990 1993

36

1995

CO

37

1995

O3, CO, SO2, NOx, PM10 y Pb.

38

1996

O3, CO, SO2, NOx, PM10 y Pb. O3, CO, SO2, NOx, PM10 y Pb.

39

1996

40 41

1996 1996

O3, NO2, PM10 y Pb. PM2.5 , PM10, NO2, SO2, O3 TSP, SO2, O3

42

1997

FVC: Forced Vital Capacity. FEF: Forced Expiratory Fraction. FEV: Forced Expiratory Volume. PFM: Peak Flow Meter. ZMCM: Mexico City Metropolitan Zone.

CONCLUSIONS The major conclusions on the Mexican research reviewed are: 1. The early focus on rural areas, leaded pottery, craftsmen and miners of the 60s through the 80s, has evolved to a focus on urban areas, the general and specific public, ozone, and concern for exacerbating & attenuating factors. 2. The following represent the main findings and elements of health impact associated with air pollution in Mexico Lead a) Extended Pb exposure first related to glazed ceramics (foodstuff consumption, workplace, households), and from vehicular fuel combustion increased contributions. b) The presence of Pb in blood and urine, and accumulation in bone tissue. c) Demonstrated impact on weight at birth, IQ reduction, and neurological and metabolic disorders related to lead. d) Reduction of blood Pb associated with reduction of airborne Pb from change to unleaded gasoline. Ozone and general pollutants e) Increasing quantities of photochemical oxidants in the air of Mexico City. f) Demonstrated exacerbation of respiratory effects due to the synergism between pollutants, specially ozone and SPM. g) Increased school absences, reduction of Forced Vital Capacity (FVC) and Forced Expiratory Volume (FEV), and increased number of visits to emergency wards for respiratory problems 3. Recent research has demonstrated that the health impact of air pollution is exacerbated in pregnancy, infancy, and among groups with high exposure (e.g. street vendors), as well as attenuated by factors such as diet.

4. Scientific research has unequivocally demonstrated the health impact associated with various air
pollutants, and has supported policy decisions and air quality management strategies. Mexico has seen improvements associated with the control of particles, SO 2 and Pb, and now concentrates its efforts on photochemical oxidants in the air.

5. For Mexico, demonstration of health effects to justify interventions is not the only option. A wealth of
information regarding health effects of air pollution already exists. Therefore monitoring systems should be perfected, and corrective actions taken upon evidence of exposure. A substantial part of the research effort should be directed toward interventions and participatory strategies. The authors are confident that this strategy will prove cost effective over time.

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IMSS: Instituto Mexicano del Seguro Social. OPS: Organizacin Panamericana de la Salud. 3 CONSERVA: Consejo de Estudios para la Restauracin y Valoracin Ambiental. 4 DDF: Departamento del Distrito Federal.

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INER: Instituto Nacional de Enfermedades Respiratorias. RCCM: Respir. Crit. Care Med. 7 ZMCM: Zona Metropolitana de la Ciudad de Mxico. 8 UAM: Universidad Autnoma Metropolitana. 9 INSP: Instituto Nacional de Salud Pblica.

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ECO/OPS: Centro Panamericano de Ecologa Humana y Salud/Organizacin Panamericana de la Salud. 11 UNAM: Universidad Autnoma de Mxico.

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