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Social Science & Medicine 57 (2003) 20132022

* o Paulo (19861998) Air pollution and childrens health in Sa

Helena Ribeiro*, Maria Regina Alves Cardoso
School of Public Health, University of Sao * Paulo, Av. Dr. Arnaldo, 715, Sao * Paulo, 01246-904 Brazil

Abstract * o Paulo, Brazil, with 17 million inhabitants, has been measured from air quality Air pollution in the conurbation of Sa monitoring stations. In three contrasted sample areas, childrens respiratory health parameters were collected to assess the role of air pollution in 1986. Twelve years later, in 1998, a similar study was undertaken to evaluate the impact of pollution control programs on the respiratory symptoms of children living in the same neighborhoods previously studied. Results indicated that pollution control programs were in part neutralized by increased number of cars and that the control of a single pollutant was not enough to protect childrens health. In the area where both particulate matter and sulfur dioxide levels decreased, there was a reduction in the prevalence of respiratory symptoms. r 2003 Elsevier Science Ltd. All rights reserved.
* o Paulo; Brazil Keywords: Air pollution; Respiratory ill-health; Child health; Sa

Introduction * o Paulo, in The metropolitan region of the city of Sa Brazil, comprises 39 municipalities and forms a continuous urban sprawl of 1051 km2 with approximately 17 million inhabitants. It is the third most populous city in the world. In spite of the decrease in the * o Paulo is annual growth rate in the last decades, Sa responsible for 18% of the countrys GDP, 11% of the Brazilian population, and 6 million jobs (Ribeiro & * o, 2001). More than 40,000 industries with Assun@a pollution potential are located in the metropolitan region and 5.7 million vehicles (21% of the domestic eet) are registered in the area. Of these, 3 million circulate daily and 1 million enter the city every day, including 350,000 trucks (CETESB, 2001). This situation is responsible for the delivery of large amounts of pollutants to the air. The implementation of a strong air pollution control for xed sources of particulate matter and sulfur dioxide since 1970s and a program of emission control for new vehicles established by federal law in 1986 had positive
*Corresponding author. Tel.: +55-11-3066-7712; fax: +5511-3066-7732. E-mail address: lena@usp.br (H. Ribeiro).

results on the air quality of the city as compared to * o & Galva * o Filho, 1999). previous decades (Assun@a Nevertheless, efforts have been in great part neutralized by larger numbers of cars on the streets. Sulfur dioxide concentrations reduction was the most successful program over all the urban area and, nowadays, all 33 monitoring stations indicate that daily and yearly standards are being respected. Other pollutants concentrations, like particulate matter (total suspended particles, smoke and inhalable particles), carbon monoxide (CO), ozone (O3), and nitrogen dioxide (NO2) still surpass daily and yearly primary and secondary standards in some neighborhoods, during some occasions, mainly in wintertime (CETESB, 2001). During the winter, temperature inversions and lack of rainfall favor concentration of air pollutants above the city. Since 1969, studies have been done in order to * o Paulo investigate health effects of air pollution in Sa metropolitan area. The pioneer ones found a correlation between acute episodes of air pollution and children morbidity by respiratory infection, chronic bronchitis, and asthma (Ribeiro, 1971; Wandalsen, Althertum, & Agostinho, 1975; Ribeiro et al., 1976; Mendes & Wakamatsu, 1976). In 1986, this author (Ribeiro Sobral, 1989) conducted a geographic analysis to evaluate

0277-9536/03/$ - see front matter r 2003 Elsevier Science Ltd. All rights reserved. doi:10.1016/S0277-9536(03)00068-6

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long-term effects of air pollution on childrens respiratory health.1 The research conducted by Ribeiro Sobral, in 1986, consisted of mapping air pollution by SO2 and by dust particles using the average of 11 years records for the * o Paulo, based on data collected metropolitan area of Sa by 39 monitoring stations managed by the Environment Bureau (CETESB). The mapping of carbon monoxide (CO) and photochemical pollutants was not possible because their levels were registered by only a few monitoring stations. The second step of that research was to select three areas for study; one with very low pollution level, Juquitiba, to be used as control area; one with a medium pollution level, Osasco, just lower the CETESB Air Quality Standard; and one with very high ! (Ribeiro Sobral, 1989, pollution all the year, Tatuape p. 959). A survey was conducted in these areas and the results indicated a correlation between air pollution levels, due to sulfur dioxide and particulate matter, and respiratory symptoms in children from 11 to 13 years of age. In the last decade the Environment Bureau put in place several air pollution control programs. The main objective of the study presented in this paper was to evaluate, 12 years later, these programs impact on the pollution levels and on the respiratory symptoms of children belonging to the same age group living in the same neighborhoods.

Air pollution and respiratory diseases The main adverse effects of atmospheric pollutants are: ophthalmic problems, skin injuries, gastro-intestinal, cardio-vascular and respiratory diseases, and some types of cancer. Effects on the nervous system have also been associated with high levels of carbon monoxide in the air. Indirect health effects may be related to climatic changes caused by air pollution. An increase in air temperature has impacts on the distribution of fauna and ora, thus affecting the space distribution of some vector-borne diseases. In addition, heat accumulation in urban centers, associated with air pollution (Landsberg, 1956), has adverse health effects especially for old people (Ribeiro, 1996). Since the etiology of most diseases is multi-causal, it is not easy to evaluate health effects of pollutants. Scientic research on the impacts on health has focused mainly on respiratory diseases because the association in this case is more evident. The rst studies correlating respiratory diseases with air pollution date from the 1950s. Those pioneer studies and many others that followed them were undertaken
1 Spatial analysis of the ecological relationships between humans and their environment is a tradition dating back at least to the 18th Century. The interested reader is referred to Barrett (2000), and Sorre (1947).

mainly in cities and metropolitan areas with acute problems of air pollution, aggravated by unfavorable weather conditions: Los Angeles, London, Tokyo, and * o, 2001). These inquiries New York (Ribeiro & Assun@a were in great part motivated by acute episodes of air pollution that became famous for their intensity, duration, and negative impacts on the population. The most widely known are the episodes that occurred in 1903 in the Meuse Valley in Belgium; in 1948 in Donora, Pennsylvania, which lasted 5 days, affected 43% of its inhabitants, and caused 20 deaths; and in 1952 in London, that also lasted 5 days and caused 4000 deaths (Revelle & Revelle, 1981). In 1969, a widespread episode affected 20 states in the industrial zone of the United States, in an area that covered from the Great Lakes to the Gulf of Mexico. These studies had an important role in promoting air quality control policies in those areas, and the levels of pollutants have decreased since then. As a consequence of the United States Clean Air Act of 1963, that established Air Quality Standards for various pollutants, the mean annual average of particulate matter decreased from 90 mg/m3 in 1960 to 60 mg/m3 in 1978 and the level of SO2 from 55 mg/m2 in 1962 to 19 mg/m3 in 1978, in the whole country (Whittemore, 1981). In 1956, England also passed a Clean Air Act restricting coal combustion for domestic use. Although air quality standards were not established, signicant improvement in the London atmosphere was obtained. Already at that time, there was no doubt that high levels of atmospheric pollutants were deleterious to health in short-term. However, it was more difcult to detect the long-term adverse health effects. In 1979, the World Health Organization (WHO) and the United Nations Environmental Program (UNEP) published a report which reviewed and evaluated all available information on the biological effects of sulfur dioxide and particulate matter, in order to provide scientic basis for government decisions directed to human health protection, both in outdoor and indoor environment (WHO, 1979). The objective of that report was to suggest Air Quality Standards and to discuss research methods. In the rst decades the studies focused on sulfur dioxide and suspended particulate matter. From the 1980s onwards, concerns were directed to other pollutants as well. Sulfur dioxide and suspended particulate matter are produced by the combustion of coal, wood, petrol, and oil in various industrial and transportation activities. Suspended particulate matter may also have other sources as dust from roads and streets, tires, pollen from vegetation, etc. The WHO and the UNEP set up the Global Environmental Monitoring (GEM) System in 1973, with about 170 monitoring stations in urban areas of different countries, where pollution levels are the highest and most threatening to human health. In the initial stages of the program only sulfur dioxide and

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suspended particulate matter were measured. More recently, the GEM Program started to monitor also nitrogen dioxide and lead. This new trend in the studies was greatly due to the fact that pollution from industrial sources is being progressively controlled and sulfur dioxide levels in the air have decreased in most cities where control measures were implemented. On the other hand, particulate matter control has not been so effective since it comes from different sources and, consequently, the control measures are more complex. In developing countries, studies on air pollution and health also appeared in the early 1970s. The rst work * o Paulo undertaken in the metropolitan area of Sa involved collection of data on visits to medical services due to airway infections and bronchitis in children under the age of 12 years. The research covered a 2-year period (August 1967August 1969) in the health centers of ! , a municipality with intense industrial Santo Andre * o Paulo metropolitan area. A positive activity in the Sa relationship was found between annual levels of particulate matter and visits due to bronchitis (Ribeiro, 1971). A follow-up study, done in 1973 and 1974, conrmed higher incidences of asthma with increase in particulate matter in the air. There was also a positive correlation between air pollution levels and acute episodes of asthma in children living in the area (Wandalsen et al., 1975). Mendes and Wakamatsu (1976) observed acute health effects during air pollution * o Paulo. Eight thousand episodes in the city of Sa consultations done during July 1976, in the municipality * o Caetano do Sul, another industrial neighborhood of Sa of the metropolitan area, were analyzed regarding time distribution, age groups, and type of disease or of symptom. Three air pollution episodes, with particulate matter and sulfur dioxide concentrations above air quality standard, coincided with peaks in hospital admissions caused mainly by respiratory and cardiovascular diseases. Children from 1 to 4 years old were the most affected. In that same year, a large study analyzed respiratory conditions of 2000 children aged 712.9 years in two different neighborhoods with different * o Paulo to verify long-term health pollution levels in Sa effects. Respiratory function and clinical tests indicated a higher prevalence of illnesses in children living in the more polluted area (Ribeiro et al., 1976). At about the same time, a study in Rio de Janeiro veried respiratory symptoms of healthy, non-smoking women between 20 and 46 years old, living for more than 4 years in two different areas with low and high pollution levels. The results also indicated that air pollution was affecting the respiratory system of women living in the more polluted district (Lemle, 1979). * o Paulo by During the 1980s, continuing studies in Sa Ribeiro Sobral (1988, 1989) revealed that prevalence rates of respiratory symptoms among children of low-

income families were much higher in areas with median and high pollution levels but similar to the totality of children in the low pollution area. This emphasized the higher risk to poor people living in regions with elevated pollution. In the 1990s, a laboratory of atmospheric pollution was created at the Medical School of the * o Paulo. Time-series studies have University of Sa veried the effect of air pollution on respiratory mortality of under-5-years and over-65-years popula* o Paulo (Saldiva et al., 1994; tions in the city of Sa Saldiva et al., 1995). The authors reported that for each 100 mg/m3 in the 24 h concentration of PM10, there was an increase of 8.17 adult deaths per day, representing 13% of daily mortality. For children, the association * o, was signicant only with NOx. Miraglia, Concei@a Saldiva, and Strambi (1997) correlated mortality of elderly people by respiratory and cardio-vascular causes with type of fuel used in vehicles in the city and concluded that wider use of ethanol led to lower levels of PM10 and lower numbers of deaths. Pereira et al. (1998) found an association between daily numbers of intrauterine deaths (over 28 weeks of gestation) and air pollution, mainly by NO2, and carboxyhemoglobin levels in the umbilical chord of 47 fetus of non-smoking mothers and carbon monoxide levels in the air of the city. Gouveia and Fletcher (2000a) veried that the *o association between air pollution and mortality in Sa Paulo was particularly strong for respiratory disease among people over 65 years old and less important for all causes and all ages. Lin et al. (1999) found increased risk of morbidity by respiratory diseases and emergency room visits of children up to 13 years with increase in particulate matter and in ozone levels in the city air. Braga et al. (1999) studied the relationship between hospital admissions of children up to 13 years and PM10 levels. Gouveia and Fletcher (2000b) studied short-term effects of air pollution by PM10 and ozone on hospital admissions due to pneumonia in children from 28 days to 1 year. A relative risk of admissions of 1.04 was found for an increase of 100 mg/m3. Correia (2001) indicated that high levels of CO in areas near to schools in the city * o Paulo might be affecting not only the respiratory of Sa systems of children, but also behavioral aspects such as irritability and difculty in concentration, thus affecting learning ability. In Mexico City, many studies have also been done to identify air pollution effects on childrens health (Romieu et al., 1996). In developing countries the focus has also been shifting from sulfur dioxide and particulate matter to other pollutants such as nitrogen oxides, carbon monoxide and ozone originating from mobile sources (Farhat, 1999; Saldiva et al., 1992; Saldiva et al, 1994; Saldiva et al, 1995; Penna & Duchiade, 1991; Pereira et al, 1998). However, the study of health effects of sulfur dioxide and particulate matter pollution remains paramount. Concern remains about the safety

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provided by existing standards for environmental exposures and about long-term effects.

Methodology The methodology used in the present study replicated that of the 1986 study. In the earlier research, after mapping sulfur dioxide and particulate air pollution in * o Paulo, three areas were the metropolitan region of Sa ! ), chosen: one with very high air pollution levels (Tatuape one with intermediate levels (Osasco), and one with low levels (Juquitiba). These areas were chosen based on the analysis of the average values of SO2 and particulate matter obtained from 39 monitoring stations of the State Agency responsible for pollution control (CETESB) during an 11-year period (19731983). Other pollutants like photochemicals (NO, NO2, NOx and ozone) and carbon monoxide were not mapped because they were only monitored by a few monitoring stations, and thus did not provide enough spatial data for the whole area. In the 19731983 period, Juquitibathe area with a low pollution levelhad an average of 13 mg/m3 of SO2 and 38 mg/m3 of particulate matter. Osasco, with an intermediate pollution level, had an average of 79 mg/m3 !, of SO2 and 73 mg/m3 of particulate matter, and Tatuape with the highest pollution level, had 124 mg/m3 of SO2 and 127 mg/m3 of particulate matter. In 1998, air quality conditions from 1984 to 1998, in the three areas, were analyzed. No data were available from Juquitiba because the monitoring station was discontinued. As the area still maintains its rural characteristics we can surmise that the pollution levels there continue to be low. In both 1986 and 1998 studies, children from 11 to 13 years old were chosen as the study group because they are more sensitive to air pollution, do not smoke, and are not affected by occupational pollution. The research tool employed was a questionnaire developed for this purpose by the Epidemiology Standardization Project (Ferris, 1978) of the Pulmonary Disease Division of the National Heart, Lung and Blood Institute, US for children up to 13 years old. Children in the same age group and from the same schools answered a similar questionnaire, 12 years apart. The schools chosen belonged to the Government School System, and they were located no more than 2 km from the abovementioned monitoring stations. These criteria were adopted in previous studies conducted in the US (Whittemore & Korn, 1980; Detels et al., 1981), indicating that the air conditions in the study areas would be the same as close to the monitoring station. Only children from government schools were chosen in an attempt to control social differences. In 1986, 140 questionnaires had been applied in Juquitiba, 145 in ! and 108 in Osasco. In 1998, 109 questionnaires Tatuape

were applied in Juquitiba, 111 in Osasco and 103 in ! . In both studies the questionnaires were Tatuape answered during September, October and November to avoid the inuence of winter temperatures and of acute episodes of air pollution that generally occur at winter time because of lack of rainfall. The questionnaires were administered in schools during classes, so the response rate was 100%. In each school, all children from the age group 1113 years old were listed and then a random sample was selected. The sample size was established using the formula: n0 n ; n0 1 1 N where n0 PQ ; s2 p

n0 is the estimated sample size, n the sample size adjusted for the nite population factor, N the total size of the population, P the prevalence rate of disease expressed as a proportion of the total population, Q the complement (Q 1 P) s2 p the standard error of the prevalence P; s2 adopted was 5%, considered adequate for epidemiop logical studies and within the nancial and personnel constraints of this project.

Air quality Air quality conditions for the 19731984 and 1984 1998 periods were compared in the areas chosen. As mentioned above, no data was available for Juquitiba in the second period. The main trends observed were:
*

Sulfur dioxide concentration decreased in both areas as a result of the industrial pollution control adopted in 1982, of new and lower standards of maximum sulfur levels in fuel oil, and of the substitution of fuel oil by natural gas. In Osasco, concentrations decreased from 79 mg/m3 in the period 19731983 to 22 mg/m3 in the 19841998 period, well below the Air Quality Standards which are: Primary Standard annual average of 80 mg/m3 and Secondary Standard !, annual average of 40 mg/m3 (Fig. 1). In Tatuape sulfur dioxide concentrations also dropped: from 124 mg/m3 in the previous period to 59 mg/m3 in the 19841998 period, and 39 mg/m3 in the 1990s (Fig. 2). The concentration of particulate matter decreased ! and increased greatly in signicantly in Tatuape Osasco as a result of urban dynamics: economic ! many activities increased in Osasco, while in Tatuape industries moved to other areas, making room for ! , the concentration of residential land use. In Tatuape particulate matter decreased from 127 mg/m3 in the 19731983 period to 75 mg/m3 in the 19911992

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Fig. 1. Sulfur Dioxide (SO2) in OsascoAnnual mean

! Annual mean Fig. 2. Sulfur Dioxide (SO2) in Tatuape

! Annual mean Fig. 3. Smoke in Tatuape

period. After that, monitoring also comprised the smoke level. Between 1984 and 1998 smoke concentration was 70 mg/m3, but between 1992 and 1998 smoke concentration was very close to the Primary Air Quality Standards of 60 mg/m3 (Fig. 3). In Osasco, total particulate matter concentrations increased from an average of 73 mg/m3 in the 1973 1983 period to 131 mg/m3 in the 19841998 period. These concentrations were well above Primary and Secondary Air Quality Standards (Fig. 4). Smaller inhalable particles were also above the Standards

(50 mg/m3). Their average concentration during the period 19841998 was 76 mg/m3.

Results: prevalence of respiratory symptoms in 1986 and 1998 The rst study, conducted in 1986, indicated that symptoms of respiratory disease tended to increase in areas with higher pollution levels (Table 1). In 1986, of ! , the most polluted area, the 27 symptoms listed, Tatuape

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Fig. 4. Total particulate matter in Osasco (Annual mean)

Table 1 Prevalence rates of symptoms/disease1986 and 1998 Juquitiba 1986, 140 children N Symptom/disease Cough Apart from colds Most days Phlegm Apart from colds Most days Congested Chest+1week/year Wheezing Apart from colds Most days With shortness of breath Two or more episodes Required medicine Breathing abnormal interval After exercising Chest illness Out of activity 3 days With more phlegm Hospital before 2 years old Other illnesses Sinus trouble Bronchitis Pneumonia Current ear infection Frequent ear infections Between the age of 0 and 2 Between the age of 2 and 5 Over age 5 Ears drained Surgery on tonsils or adenoids Asthma diagnosed by doctor Medicine for asthma 2 Allergy % Osasco 1986, 108 children N % ! Tatuape 1986, 145 children N % Juquitiba 1998, 109 children N % Osasco 1998, 111 children N % ! Tatuape 1998, 103 children N %

16 7 12 11 15 16 10 13 8 5 5 18 5 5 17 13 36 8 48 9 8 20 1 8 2 2 23

11.4 5.0 8.6 7.9 10.7 11.4 7.1 9.3 5.7 3.6 3.6 12.9 3.6 3.6 12.1 9.3 25.7 5.7 34.3 6.4 5.7 14.3 0.7 5.7 1.4 1.4 16.4

33 9 16 11 17 19 6 19 12 13 10 15 10 3 10 6 25 11 63 8 6 33 3 10 3 1 25

30.6 10.2 14.8 10.2 15.7 17.6 5.6 17.6 11.1 12.0 9.3 13.9 11.4 2.8 9.2 5.6 23.1 10.2 58.3 7.4 5.5 30.5 2.8 9.3 2.8 0.9 23.1

30 14 31 23 35 25 14 30 14 17 15 26 22 17 16 19 25 18 87 13 16 38 1 16 9 6 47

26.2 9.7 21.4 15.9 24.1 17.2 9.7 20.7 9.7 11.7 10.3 17.9 15.2 11.7 11.1 13.1 17.2 12.4 60.0 9.0 11.0 26.2 0.7 11.2 6.2 4.1 32.4

33 9 18 7 21 16 17 21 13 12 12 22 7 5 27 6 21 14 63 5 12 23 1 2 2 2 34

30.2 8.2 16.5 6.4 19.2 14.7 15.5 19.2 11.9 11.0 11.0 20.2 6.4 4.5 24.7 5.5 19.2 18.2 57.7 4.5 11.0 21.1 0.9 1.8 1.8 1.8 31.2

34 11 26 16 23 28 21 32 17 14 16 27 10 5 20 23 25 23 79 10 6 34 6 8 3 2 58

30.6 9.9 23.4 14.4 20.7 25.2 18.9 28.8 15.3 12.6 14.4 24.3 9.0 4.5 18.0 5.7 22.5 20.7 71.2 9.0 5.4 30.6 5.4 7.2 2.7 1.8 52.2

47 10 24 10 18 26 21 32 18 21 13 24 15 9 20 12 25 11 68 4 10 24 2 2 5 4 44

45.6 9.7 23.3 9.7 17.7 25.2 20.4 31.0 17.2 20.4 12.6 23.3 14.5 8.7 19.4 11.6 24.2 10.6 66.0 3.8 9.7 23.3 1.9 1.9 4.8 3.8 42.7

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showed a higher prevalence in 18 (66.6%) of them. Osasco showed a higher prevalence in seven symptoms (25.9%) and Juquitiba, the control area, in only two symptoms (7.4%). The difference in prevalence was larger for the symptoms indicating worst health conditions, like cough without cold and wheezing and phlegm on most days during 3 months of the year; these are the symptoms that physicians take into account for the diagnosis of chronic bronchitis. Asthma requiring medical care and treatment and allergies showed a much higher prevalence in the polluted areas, together with childhood diseases and ear and throat infections. Pollution seemed to be an important etiological factor. These settings were further reinforced by poor socioeconomic conditions, especially inadequate housing. Ear infections and tonsillectomies also showed a higher prevalence in the more polluted areas. More than 12 years ago the prevalence of symptoms in Osasco, at the time with lower pollution levels than ! , was closer to Tatuape ! than to Juquitiba and, in Tatuape some cases, surpassed it. This can be explained by the fact that the pollution levels, although below the accepted air quality average standard for 11 years, in some years were above these levels, and the daily standards were constantly surpassed. This tendency continued in the following years and, today, Osascos air pollution levels and number of symptoms with the ! . As shown in highest prevalence exceed those of Tatuape Table 1, in 1998, of the 27 symptoms listed, Osasco had ! in 11 a higher prevalence in 14 (51.8%) of them; Tatuape (40.7%) and Juquitiba, the control area, in 2 (7.4%). On the other hand, in 20 out of 27 symptoms, Juquitiba showed the lowest prevalence rates. Juquitiba, the lowpollution area, presented higher prevalence of hospitalization of children less than 2 years old, and frequent ear infections between the age of 2 and 5. These episodes, however, are not necessarily related to air pollution. On the other hand, symptoms known to be more closely related to chronic obstructive diseases like asthma and bronchitisand to air pollution have a ! , in spite of the higher prevalence in Osasco and Tatuape fact that in 1998 the difference in the percentage between the less polluted and the more polluted area was less than in 1986, as shown in Table 2. The results of this study corroborate those ndings from other countries, which also indicate a higher prevalence of respiratory diseases in areas highly polluted by SO2 and dust particles. In addition, an alarming fact is that the prevalence of respiratory symptoms increased signicantly in the 19861998 period, indicating that the pollution control programs were probably largely neutralized by the higher number of cars (Table 2). It is important to note that with the exception of particulate matter in Osasco, which is well above the primary standard, the other pollutants measured are below the standards. Juquitiba registered

increased prevalence in 22 out of the 27 symptoms; ! presented increases in 13 Osasco in 20, and Tatuape symptoms and decreases in 12 of the 27. It is important ! , the area where all to highlight that in Tatuape pollutants (SO2; particulate matter and smoke) decreased, the number of symptoms with decreases in prevalence rates was almost equal to the number of symptoms with increased prevalence. This indicates that, in spite of the reduction in some symptoms of respiratory ill-health of children due to reduced levels of air contamination, the primary standards might not protect some more vulnerable children. It also indicates that the network of monitoring stations established in the years 1970s and 1980s, destined to monitor air pollution from industrial sources, the most important at that time, is not adequate for today, as only few stations measure pollution originating mainly from mobile ! , might have high sources. Some areas, like Tatuape levels of other pollutants that are not being measured at all. In general, among the symptoms/diseases with the greatest increase are wheezing and allergies in all three areas, bronchial phlegm and pneumonia in Osasco and ! . On the other Juquitiba; and bronchitis in Tatuape hand, a signicant reduction in the number of children undergoing tonsillectomies was noted due to changes in medical practices in the last decade.

Social conditions and possible confounding factors In the previous study, it was seen that poor housing conditions reinforced ill-health effects in the more polluted area. Thus, a comparison on housing conditions of children studied in the two periods was undertaken using as indicator the percentage of children who lived in houses with more than 1 person per room2. Table 3 indicates that there was an improvement in the housing conditions in the three areas that was statistically signicant in Juquitiba and Osasco. We can thus surmise that the deterioration of housing conditions does not explain the rise in respiratory symptoms observed in Juquitiba and Osasco. ! , economic and social improvements were In Tatuape noted throughout the district. Since only children of the government school system were interviewed, however, it is possible that they belonged to the poorest families. ! were The data showed that children from Tatuape actually living in similar housing conditions in both study periods even though the largest decrease in prevalence of symptoms was observed among them.
2 Indicator used by the Instituto Brasileiro de Geograa e Estat! stica (IBGE) for inadequate housing including all rooms except bathroom.

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2020 H. Ribeiro, M.R.A. Cardoso / Social Science & Medicine 57 (2003) 20132022 Table 2 Differences in prevalence rates of symptoms between the years 1986/1998 Symptoms Cough Apart from colds Most days Phlegm Apart from colds Most days Congested chest 1 week/year Wheezing Apart from colds Most days With shortness of breath Two or more episodes Required medicine Breathing abnormal interval After exercising Chest illness Out of activity for 3 days With more phlegm Hospital before 2 years old Other illness Sinus trouble Bronchitis Pneumonia Ear infection Frequent ear infections Between the age of 0 and 2 Between the age of 2 and 5 Over the age of 5 Ears drained Surgery of tonsils or adenoids Asthma diagnosed by doctor Medicine for asthma Juquitiba: %, 19861998 18.9* 3.2 Osasco: %, 19861998 0 0.3 ! : %, 19861998 Tatuape 19.4* 0

7.9 1.5 8.5

8.6 4.2 5.0

1.9 6.2 6.7

3.3 8.4***** 9.9**** 6.2 7.4**** 7.4**** 7.3

7.6 13.3*** 11.2 4.2 0.6 5.1 10.4

8.0 10.7**** 10.3 7.8 8.7 2.3 5.4

2.8 0.9 12.6****

2.4 1.7 8.8

0.7 3.0 8.3

3.8 6.5 7.1 23.4**

15.1*** 0.6 0.5***** 12.9

1.5 7.0 1.8 6.0

1.9 5.3 6.8 0.2 3.9 0.4 0.4

1.6 0.1 0.1 2.6 2.1 0.1 0.9

5.2 1.3 2.9 1.2 9.3***** 1.4 0.3

*po0.0001, **po0.0001, ***po0.01, ****po0.05, *****p=0.05

Table 3 Percentage of children who live in houses with more than one person per room Area Juquitiba n Year 1986 1998 X2-test % Osasco n % ! Tatuape n %

89 63.3 45 41.2 po0:001

56 51.8 27 24.3 po0:0001

62 42.7 43 41.7 po0:87

Another social indicator in both studies was the level of schooling of the childrens parents. This also corroborated the fact that there have been social

improvements in the families of the studied children, as well as the country as a whole, according to the last National Census in Brazil. As can be observed in Table 4, the level of schooling increased with statistical signicance in Juquitiba and Osasco. This suggests that the worsening of respiratory symptoms in children was not due to substandard social conditions, but probably ! to air pollution levels. On the contrary, in Tatuape where air pollution levels improved and many respiratory symptoms of children also improved, social indicators like housing conditions and level of schooling of parents did not change in the 12 years period, except for mothers with university-level education. Another possible confounding factor is parental smoking. Data collected by the questionnaires in 1986

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H. Ribeiro, M.R.A. Cardoso / Social Science & Medicine 57 (2003) 20132022 Table 4 Schooling level of parents in 1986 and 1998 Area Year Juquitiba 1986 1998 4.5% 5.5% 4.5% 7.3% Osasco 1986 2.7% 4.6% 1.8% 0.9% 1998 0.9% 0% 9.9% 12.6% ! Tatuape 1986 1.4% 1.4% 11.7% 6.9% 1998 3.8% 3.8% 5.8% 11.6% 2021

Illiterate Fathers 11.4% Mothers 27.9% University degree Fathers 2.1% Mothers 0

X2-test: po0:0001 for the comparisons of levels of schooling for both fathers and mothers in 1986 and 1998, in all three study areas.

Table 5 Percentage of parents who were smokers in 1986 and 1998 % smokers Fathers Year 1986 1998 1986 1998 Juquitiba 35.0% 26.6% p 0:16 14.0% 23.8%3 p 0:05 Osasco 31.4% 17.1% p 0:01 14.8% 19.8% p 0:03 ! Tatuape 37.2% 32.0% p 0:40 31.0% 42.7% p 0:06

public transportation resulted in much higher number of cars on the streets. The eet jumped from around 2 million vehicles in 1986 to 5.7 million in 1999. Another serious problem is that about 46% of the cars are over 10 years old and thus are not equipped with pollution control devices that have been adopted in 1992 and 1997. However, the most important nding is that the decrease in the level of all contaminants measured in ! resulted in lower prevalence rates of many Tatuape respiratory symptoms in children, indicating the relevance of control measures. It also indicates the need of updating the monitoring stations network of the * o Paulo in order to better reect metropolitan area of Sa air quality inuenced by the continuously increasing number of cars. There is a need to reinforce the control programs so that all areas comply to secondary standards of all pollutants year round to protect childrens health.

Acknowledgements CNPq-Conselho Nacional de Desenvolvimento Cient! ! co e Tecnologico for funding this research. Schools and schoolchildren who participated in this research.

Mothers

and 1998 indicated that a smaller percentage of fathers smoked in all three areas in 1998, as compared to 1986, but a larger percentage of mothers smoked in 1998 than in 1986 (see Table 5). In Osasco, smoking among fathers decreased most between 1986 and 1998, and the proportion of mothers who were smokers dropped, in contrast to the other two areas. On the other hand, it is where the prevalence of respiratory symptoms among children increased the most. This emphasizes the importance of air pollution as an etiological factor in the area.

References
* o, J. V., & Galva * o Filho. J. B. (1999). Discussing the Assun@a * o Paulo cityBrazil. 92nd meeting and air pollution of Sa exhibition of the air & waste management association. Missouri: Saint Louis. Barret, F. A. (2000). Disease & geography: The history of an idea. Geographical monographs no. 23. Geography Department York University, Toronto, Ontario. * o, G. M. S., Pereira, L. A. A., Kishi, Braga, A. L. F., Concei@a H. S., Pereira, J. C. R., Andrade, M. F., Gon@alves, F. L. T., Saldiva, P. H. N., & Latorre, M. R. D. O. (1999). Air pollution and pediatric respiratory hospital admissions in * o Paulo, Brazil. Journal of Environmental Medicine, 1, Sa 95102. C.E.T.E.S.B.Companhia de Tecnologia de Saneamento Ambiental (2001). Qualidade do Ar na Regiao * Metropolitana * o Paulo. de Sao * Paulo e em Cubatao * , 2000, Sa !rica e uxo expiratCorreia, J. E. M. (2001). Polui@ao * Atmosfe ! de pico (peak ow) em crian@as de 7 a 9 anos na cidade orio * o de Mestrado. Faculdade de de Sao * Paulo, S.P. Disserta@a ! Publica, ! * o Paulo, Np. Saude Universidade de Sa Detels, R., Sayre, J. W., Coulson, A. H., Rokaw, S. N., Massey Jr., F. J., Tashkin, D. P., & Wu, M. (1981). The UCLA population studies of chronic obstructive respiratory diseaseIV. Respiratory effect of long-term exposure to photochemical oxidants, nitrogen dioxide and sulfates on current and never smokers. American Review of Respiratory Disease, 123, 637680.

Conclusions These data, when analyzed from the standpoint of the evolution of air quality in the metropolitan region of * o Paulo, illustrate the inuence of air pollution as an Sa etiological factor in the development of respiratory diseases in children. The data reinforce the need for pollution control programs and also indicate that the control of a single pollutant is not enough to protect childrens health. Control measures included lower standards of maximum sulfur levels in fuel oil, substitution of fuel oil by natural gas or electricity in industries, emissions control in industries, trucks and buses. On the other hand, lack of investments in clean technology for

ARTICLE IN PRESS
2022 H. Ribeiro, M.R.A. Cardoso / Social Science & Medicine 57 (2003) 20132022 * o, J. V. (2001). Historical overview of Ribeiro, H., & Assun@a * o Paulo metropolitan area, Brazil: air pollution in Sa Inuence of mobile sources and related health effects. In L. J. Sucharov, & C. A. Brebbia (Eds.), Urban transport VIIurban transport and the environment in the 21st century (pp. 351360). UK: WIT Press. ! Ribeiro, H. P. et al. (1976). Estudo da Fun@ao * Ventilatoria em ! Escolares vivendo em areas com diferentes n! veis de polui@ao * ! do ar. Santa Casa de Misericordia de S. Paulo, N.p. Ribeiro Sobral, H. (1988). Polui@ao * do Ar e doen@as respirat! orias em crian@as da Grande Sao * Paulo: um estudo de !dica. Tese de Doutoramento, Departamento Geograa Me * o Paulo. de Geograa, F.F.L.C.H., Universidade de Sa Ribeiro Sobral, H. (1989). Air pollution and respiratory * o Paulo, Brazil. Social Science & diseases in children in Sa Medicine, 29(8), 959964. Romieu, I., Meneses, F., Ruiz, S., Sienra, J. J., Huerta, J., White, M. C., & Etzel, R. A. (1996). Effects of air pollution on the respiratory health of asthmatic children living in Mexico City. American Review of Respiratory and Critical Care Medicine, 154, 300307. Saldiva, P. H. N., King, M., Delmonte, V. L. C., Macchione, M., Parada, M. A. C., Daliberto, M. L., Sakae, R. S., . Criado, P. M. P., Silveira, P. L. P., Zin, W. A., & Bohm, G. M. (1992). Respiratory alterations due to urban air pollution: An experimental study in rats. Environmental Research, 57, 1933. Saldiva, P. H. N., Lichtenfels, A. J. F. C., Paiva, P. S. O., Barone, I. A., Martins, M. A., Massad, E., Pereira, J. C. R., . Xavier, V. P., Singer, J. M., & Bohm, G. M. (1994). Association between air pollution and mortality due to * o Paulo, Brazil. respiratory diseases in children in Sa Environmental Research, 65, 218225. Saldiva, P. H. N., Pope III, C. A, Schwartz, J., Dockery, D. W., . Lichtenfels, A. J., Salge, J. M., Barone, I., & Bohm, G. M. (1995). Air pollution and mortality in elderly people: A * o Paulo, Brazil. Archives of Environtime-series study in Sa mental Health, 50, 159163. Sorre, M. (1947). Les Fondements Biologiques, Tome Premier. Les Fondements de la Geographie Humaine (2eme ed.). Paris: Colin. Whittemore, A. S. (1981). Air pollution and respiratory disease. Annual Review of Public Health, 2, 397429. Whittemore, A. S., & Korn, E. L. (1980). Asthma and air pollution in the Los Angeles Area. American Journal of Public Health, 70(7), 687696. Wandalsen, N. F., Althertum, M., & Agostinho, J.D. (1975). ! #ncia dos Fatores Meteorologicos Inue e de alguns poluentes #ncia de crises de asma bronquica # sobre a ocorre em crian@as de !. CEFAISA, Monograa. Np. Santo Andre WHOWorld Health Organization (1979). Sulfur oxides and suspended particulate matter (pp. 107). Environmental Health Criteria. United Nations Environment Programme & World Health Organization, Geneva. !rica sobre o Farhat, S. C. L. (1999). Efeitos da Polui@ao * Atmosfe ! ! trato Respiratorio Inferior em uma Popula@ao * Pediatrica . ! ! Tese de Doutorado. Faculdade de Saude Publica da * o Paulo. Universidade de Sa Ferris, B. G. (1978). Epidemiology standardization project. American Review of Respiratory Disease, 118, 6. Gouveia, N., & Fletcher, T. (2000a). Time series analysis of air pollution and mortality: Effects by cause, age and socioeconomic status. Journal of Epidemiology and Community Health, 54, 066. Gouveia, N., & Fletcher, T. (2000b). Respiratory diseases and * o Paulo, Brazil: A time series outdoor air pollution in Sa analysis. Occupational and Environmental Medicine, 57, 477483. Landsberg, H. E. (1956). The climate of towns. In W. L. Thomas (Ed.), Mans role in changing the face of the earth: Vol. 2. Chicago: University of Chicago Press. ! ujo, C. A., Motta, A. R., Legay, Lemle, A., Castro, P., Ara L. F., Lima, L. C. W., Granato, R., et al. (1979). Sintomas ! ! cos de populacoes * sadiase Respiratorios e testes espirogra ! reas com grau diferente de polui@a * o fumantes de duas a *o na ! rica no Rio de Janiero. Rev. Div. Nac. Pneumoatmosphe ! , 23 (89/90), 1723. logia Sanitaria Lin, C. A., Martins, M. A., Farhat, S. C., Pope III, C. A., ! cio, V. M., Hatanaka, M., * o, G. M., Anasta Concei@a . Andrade, W. C., Hamaue, W. R., Bohm, G. M., & Saldiva, P. H. N. (1999). Air Pollution and respiratory illness of * o Paulo, Brazil. Paediatric and Perinatal children in Sa Epidemiology, 13, 475488. * o dos Efeitos Mendes, R., & Wakamatsu, C. T. (1976). Avalia@a ! * o do Ar sobre a Saude. Agudos da Polui@a CETESB. N.p. * o, G. M. S., Saldiva, P. H. N., & Miraglia, S. G. E. K., Concei@a Strambi, O. (1997). Analysis of the impact of fuel * o Paulo. In L. J. consumption on mortality rates in Sa Sucharov, et al. (Ed.), Urban transport ant the environment for the 21st century III. Southampton: Computational Mechanics Publications. Penna, M. L., & Duchiade, M. P. (1991). Air pollution and infant mortality from pneumonia in the Rio de Janeiro metropolitan area. Bulletin of Pan-American Health Organization, 25(1), 4754. * o, G. M. S., Braga, A. Pereira, L. L. A., Loomis, D., Concei@a . L. F., Arcas, R. M., Kishi, H. S., Singer, J. M., Bohm, G. M., & Saldiva, P. H. N. (1998). Association between air * o Paulo, Brazil. pollution and intrauterine mortality in Sa Environmental Health Perspective, 106, 325329. Revelle, P., & Revelle, C. (1981). The environment issues and choices for society. Boston, MA: Willard Grant Press. * entre infec@oes * Ribeiro, H. P. (1971). Estudo das Correla@oes ! reas superiores, bronquite asmatiforme e das vias ae !. * do ar em menores de 12 anos em Santo Andre polui@oo ! Pratica Pediatria, 4249. Ribeiro, H. (1996). Ilha de Calor na Cidade de Sao * Paulo: sua ! da popula@ao # dinamica e efeitos na saude * . Tese de livre# ncia. Faculdade de Saude ! Publica, ! *o doce Universidade de Sa Paulo. Np.