1Fifth Humanoid, Nanotechnology, Information Technology, Communication and

Control Environment and Management (HNICEM) International Conference The

Institute of Electrical and Electronics Engineers Inc. (IEEE) – Philippine Section March
9-13, 2011 Century Park Hotel, Manila, Philippines

EFFECTS OF AIR POLLUTION ON CARDIOVASCULAR DISEASES IN

THE PHILIPPINES: RESULTS OF A SURVEY ASSESSING
CARDIOLOGISTS’ AWARENESS

ABSTRACT cardiologists who

are members of the
The poor air quality
Philippines Heart
situation as well as
Association (PHA) as
the predominant
well as a number of
mortality and
cardiologists from
morbidity rates of
Davao province in
cardiovascular
the south of the
diseases (CVD) have
Philippines, and the
been problematic to
paper reports on
citizens in the
some of the salient
Philippines in the
results obtained.
last few decades.
The aim of this paper
1
is to understand the
awareness of Key Words – Air
Filipino Pollution,
cardiologists with Particulate
regard to the Matter,
potential impacts of Cardiovascular
air pollution on disease,
CVDs. A survey has Pathophysiologica
l pathway.
been conducted on a
sample of 142
Filipino
I.INTRODUCTION
World Health
recently, a wealth Organization (WHO),
of epidemiologic, have widely
cohort and cross
sectional studies acknowledged, and
have affirmed that are fully aware of,
airborne pollutants the importance of
have deleterious
effects on this issue. However,
cardiovascular in many developing
mortality and countries, such as
morbidity in
the Philippines, which
relation to long-
suffer from high
term and short-term
concentrations of
exposures.
ambient particulate
Developed countries,
matter (PM) and
where the standards
where the mortality
of the environment in
from
ambient and indoor
cardiovascular
areas are in line
diseases (CVD) is in
with the Air Quality
the top ten of all
Standards from the
causes of death, air
pollution is a
significant problem.
Therefore, one aim
of this study is to
examine the possible
links that may exist
between airborne
pollutants and CVD
in the Philippines.
Another aim is to
explore the pollution in
awareness of Philippines; Section III
cardiologists about provides some
the potential epidemiological
impacts of air data relating to CVD
pollution on CVD. It is incidence in the
of importance to country, along with
understand various mortality
physicians’ and morbidity rates
evaluations of the from the disease;
various risk factors Section IV describes
to CVD, which may the survey
include undertaken for the
environmental purposes of this
aspects, and to study and results
suggest measures to obtained through a
overcome any descriptive analysis,
shortcomings. as well as from the
Logistic Regression
The paper is divided
technique. Finally, in
as follows: Section II
Section V,
gives a brief
conclusions are
account of the
given.
current state of
ambient air

1
 Fifth Humanoid, Nanotechnology, Information Technology,
Communication and Control Environment and Management
(HNICEM) International Conference The Institute of Electrical
and Electronics Engineers Inc. (IEEE) – Philippine Section
March 9-13, 2011 Century Park Hotel, Manila, Philippines

mortality rate of
II. CURRENT CVD between male
STATE OF AMBIENT and female
AIR POLLUTION IN
THE PHILIPPINES 1. Indoor and
Outdoor
The population of Pollution in
the Philippines was the Philippines
estimated at
The development of
approximately 92
industrialization,
million in 2009 with a
growing
population growth
urbanization and
rate of 1.8%. The
motorization, which
economic growth is
are the attributes
primarily driven by
of any emerging
private consumption
economy, leads to a
[1]. It slowed down
significantly air
in 2008 and recorded polluted
a growth rate of environment.The
5.2% in the second Philippines is in line
quarter [2]. with other
According to the WHO developing countries
[3], life expectancy in the region,
figures at birth for endeavouring to
male and female improve the economy
were 64 and 71, rapidly. Hence,
respectively, in 2006. environmental
This fact reflects issues have not been
the actual of major concern as
much as the economic 20% from mobile
issues, in spite of the sources, and the
many environmental remaining 26% from
lessons available area sources.
from developed Carbon monoxide is a
countries. In major pollutant
consequence, the compared to other
Philippines has been concentrations of
known as one the NO , SO and PM [4].
x x

worst polluted The data

countries in the measurement of lead
world, especially (Pb) and Ozone (O ) 3

insofar as air was not included.

pollution is There are not many
concerned due to Air Quality
exhaust from the Monitoring (AQM)
large number of stations spread
vehicles, emissions across different
from industrial parts of the
plants, cooking and country; some AQM
plant combustions, stations have been
re-suspension and installed at high-
construction, waste traffic roads and
burning and road some at crowded
dust. The Philippines residential areas.
Emissions Inventory Hence, the accurate
estimated that, in assessment of
2005, 54% of the quality of air is by
pollutants, no means a simple
comprising PM, SO , NO
x x task. According to
and CO, came from the latest Clean Air
stationary sources, Initiative – Asia (CAI-
Asia) report [5],
Philippines and some
there are a total of
stations monitor the
44 air quality
air quality from the
monitoring stations
Manila Observatory
which are operated
and the Philippines
by the Department
Nuclear Research
of Environment and
Institute (PNRI).
Natural Resources Among those
(DENR) in 15 regions stations, only 4
of the measure PM and 7
10

measure gaseous
pollutants. The
Filipino government
issued ambient air
quality guidelines
for common
pollutants in 1999.
Comparing the
standards between
the Philippines and
the US, some of the
pollutants, such as
PM , are at the same
10

levels of
concentration as
stipulated by the
relevant standards.
This demonstrates
the attempt of the
government to
achieve an
acceptable
Metro Manila is the
environment.
capital of the
However, in reality,
Philippines with an
the Philippines has
approximate
exceeded the
population of 12
concentrations of
million. It has been
ambient particles
identified by the WHO
proposed in its
and the United
guidelines. The
Nations Environment
remaining values of
Program (UNEP) as
the Philippines
one of the five most
ambient air quality
polluted cities in the
components are
world [6]. The
higher than the US
quality of air in the
Environmental
city is harmful and
Protection Agency
unsafe with its
(USEPA) standards
pollutants at
by a large margin.
unacceptable
Metro Manila can be
levels, compared to
qualified as the
worldwide
most polluted city in
statistics. The DENR,
the country. Thus,
WHO and Asian
airborne pollutants
Development Bank
in Metro Manila are
(ADB) have
discussed in this
conducted a study
paper as a typical
which demonstrated
illustration of the
that the volume of
situation in the
particulate matter
Philippines.
in its atmosphere
2. Air Pollution in was at 57µg/m , which
3

Metro Manila is above the

baseline level of Jeepneys, which are
50µg/m for clean air
3
converted Jeep
[7]. This level can vehicles, are the
translate to cheapest and most
diseases and deaths. common choice for
On the other hand, daily
the level of lead in transportation in
the air, due to heavy the city. In 1996,
use of leaded fuel, is approximately 10
in excess of three million residents of
times the Metro Manila took
established safety over 23 million trips
limit [8]. Studies daily, with Jeepneys
reveal that the accounting for over
combustion of 40% of these trips.
gasoline and diesel Furthermore,
fuel from public according to [9],
utility vehicles tricycles generate
makes up for a 15.4% of emissions
large proportion of from vehicles in the
air pollution in
Metro Manila.

2
 Fifth Humanoid, Nanotechnology, Information Technology, Communication and

Control Environment and Management

(HNICEM) International Conference
The Institute of Electrical and
Electronics Engineers Inc. (IEEE) –
Philippine Section March 9-13, 2011
Century Park Hotel, Manila,
Philippines
cigarette smoking, since
city with significantly high statistics show that at
concentration levels of least one household
CO. This type of vehicle in member actively smokes,
Metro Manila failed to
and mainly indoors [11].
meet the Philippines
Those factors have
regulatory emission limits
contributed to a major
of CO and NO . x
impact on the quality of
Most industrial sources indoor air, not only in the
are located within the city, but also in the entire
city, including thermal country.
power stations, cement
manufacturing plants and The Environmental
oil refineries. In [10], Management Bureau (EMB)
Krupnick et al found that of the National Capital
the total industrial Region (NCR) in the
emission was 37,000 tons of Philippines used, at the
PM in 2000. This amount
10 onset, a total suspended
was nearly equal to the particles (TSP) indicator
total vehicular emissions to measure the mass
which accounted for 39,000 concentration of PM in the
tons of PM .
10
outdoor air of Metro
Other issues which directly Manila from 1995 to 2001.
contribute to air The ADB carried out the
pollution, and which give measurement at 8
cause for concern, are locations in the capital
waste and biomass fuel from 2001 to 2005 and the
smoke arising from burning ambient TSP concentration
wood, dung or charcoal improved from 2003 to 2005,
for cooking, heating and however the
lighting. The most concentration still
significant indoor exceeded the 24-hour
pollutant source is from average (short term) of
the National Ambient Air
Quality Guideline Values
TSP standard of 90µg/m³
with the highest TSP value
of 695µg/m³ being recorded
at the major EDSA
which is 36% below the 24-
hour standard of 0.08ppm
[13]. Furthermore, the
ambient concentrations of
PM and other nitrogen
10
oxides (NO ) are similar in
X

roadside [12] indoor and outdoor

conditions [14]. Therefore,
In 2003, the EMB, under the
this particular aspect
Metro Manila Air Quality
contributes considerably
Improvement Sector
to the consequences of the
Development Program,
current state of filipinos’
launched some new
health.
monitoring stations in
Metro Manila that can According to the WHO,
measure not only TSP but concentrations of PM and
10

also PM
10 and PM2.5 PM had been collected at
2.5

concentrations. The data some busy roads and high

of long-term PM 10 population and industrial
concentration since 1997 cities in Metro during the
to 2002 were below the period January to
standard which is 60µg/ m³. December 2002. The results
This fact has also been of the ambient air quality
proven by the WHO and ADB. assessment
The values of ambient indicate that PM , PM and
10 2.5

concentration of nitrogen O3 pose considerable

dioxide (NO ) did not exceed
2 health risks to the
the 0.05 parts per million population in
(ppm) level, except in 1998 Metro Manila. Extensive
where the maximum daily monitoring of PM shows
average was 0.051ppm spatial differences in
ambient levels. The high
mean 24-hr levels of PM 10

were measured along the

major road of EDSA in
Quezon City at 96.9μg/m³
and in the industrial area
of Valenzuela City at
70.5μg/m³. The low mean 24-
hr levels were observed in
the residential areas of
Antipolo and Las Piñas at
31.9μg/m³ and 33.1μg/m³,
respectively [15]. Long-
term concentrations of
PM are likely to violate
10
the national air quality
Average [5]
The trend of ambient
concentration of sulfur
dioxide (SO ) has been
2

guideline value of 60μg/m³. below the standard in the

The annual concentration period 1986-1996. At some
levels of PM in all of the
2.5 stage during the period
PNRI sampling sites in 1992 to 1996, the value
Metro Manila also showed an increase at
exceeded the WHO long some stations. The value
term guideline value of of lead (Pb) has been
10μg/m³ [5] as shown in Fig. plummeting since 1987
1. compared to set
standards. The
explanation for the
downtrend is that leaded
gasoline has been
replaced by unleaded
gasoline. Leaded gasoline
was phased out in Metro
Manila
Fig. 1. PM Concentration
2.5

with Long-Term

3
 Fifth Humanoid, Nanotechnology, Information Technology, Communication and
Control Environment and Management (HNICEM) International Conference The
Institute of Electrical and Electronics Engineers Inc. (IEEE) – Philippine Section March
9-13, 2011 Century Park Hotel, Manila,
Philippines
the 10 leading causes of mortality
in April 2000 and, nationwide on did not significantly change during
December 31, 2000 [16]. The the period from 1985 to 2005, with
concentration of CO did not heart disease being consistently one
generally exceed the ambient air of the leading causes of death. In
quality standard of 9ppm (8-hour) 1985, heart disease ranked second
during the period of 1975 to 1998. in the 10 leading causes of deaths
However, experts concur that this and in 2005 it rose to the top.
concentration has possibly and Noticeably, CVDs have seen an
occasionally exceeded the standard, uptrend in mortality in the
especially at some stations in the Philippines, from 1985 to 2005,
vicinity of heavy traffic. while the morbidity trend has been
decreasing in recent years due to
In order to gain an understanding of the number of unreported cases
the knowledge of the Filipinos (Fig. 2). In 2005, Acute Myocardial
about the quality of the Infarction (AMI) was responsible
environment and the impact on for 30,822 mortality cases out of
health from air pollution, a wealth the total 77,060 heart disease deaths
of surveys and studies have been in the country [20].
carried out. They revealed that the
majority of people were not
satisfied with the quality of the
environment. Results from an Asian
air pollution survey conducted in
2005 show that 98% of the
residents in Manila City are
affected by air pollution, and 71%
believe that air quality has
increasingly worsened over the
years [17]. The Tokyo Institute of
Technology, under the Japan
Society for the Promotion of
Science Manila Project, conducted
a survey in 2000 which showed that
over 70% of the 490 respondents in
Makati City and Quezon City were
always worried about the effects of
motorized vehicle emission on their
health [18].

According to a Department of
Health (DOH) report in 2005 [19],

III. CARDIOVASCULAR DISEASE IN
THE PHILIPPINES
Fig. 2. Mortality and Morbidity
Trends of Cardiovascular Diseases
in the Philippines, 1985-2005 [20].
The DOH reported that the
percentages of hypertensive heart
disease, ischaemic heart disease or
coronary artery diseases in Filipinos
are higher compared to other non-
infectious diseases. According to
the history of ischaemic heart
disease and hypertensive disease,
the mortality rates have been
soaring massively in both men and
women during the period 1963-
1976 [21]. Till now they are still
leading the top mortality rates of
cardiovascular diseases in the
country. In 1994 the morbidity rate
was 206.3 cases per 100,000
population, while the mortality rate
4
was 73.7 deaths per 100,000
population. The total mortality rate
due to CVDs represented 25% of all
deaths in 2000 [22].
It was also estimated that the excess
deaths due to cardiovascular causes
attributable to PM10 levels above
50μg/m³ were 40-200 persons in
Metro Manila, alone, in 2002.
As mentioned above, Jeepneys are
one of the cheapest means of
transportation. Those diesel-based
vehicles are a major source of air
pollutants, posing a health risk for
drivers and commuters. The WHO
sponsored a study on the exposure
of a sample population to vehicular
emissions in 1990 and 1991 in
Metro Manila and the result showed
that Jeepney drivers had
significantly higher chronic
respiratory symptoms than
commuters and air-conditioned bus
drivers. In [23], the World Bank
concluded that Jeepney and bus
drivers are the main victims of air
pollution, being highly at risk of
acquiring pulmonary tuberculosis
and chronic obstructive pulmonary
disease. However, there is no
official figure to indicate the
 Fifth Humanoid, Nanotechnology, Information Technology, Communication and
Control Environment and Management (HNICEM) International Conference The
Institute of Electrical and Electronics Engineers Inc. (IEEE) – Philippine Section March
proportion of such drivers who
have prolonged exposure to
vehicular pollution and who are at
risk of developing cardiovascular
diseases.
Following the formal and basic
concepts of pathology, common
independent risk factors, which
Filipino clinicians and physicians
usually consider for heart disease,
include high cholesterol, high blood
pressure, family history, age over
55, smoking, diabetes, obesity and
stress. Novel risk factors such as
airborne pollutants have also been
shown to affect mortality and
morbidity rates due to CVDs and
are therefore considered to be
significantly harmful to the
Filipinos. In 2004, a DOH study
concluded that the considerable
mortality and morbidity rates from
cardiovascular and respiratory
diseases would have been reduced
if Metro Manila had improved the
quality of air by 2002 [11].
However, this conclusion is simply
too general and lacks the actual
facts and/or data from any study or
research that solely considers the
number of deaths from
cardiovascular diseases due to air
pollutants in the country.
IV. SURVEY ANALYSIS
In view of the epidemiological data
on CVD and of the various
environmental statistics, given
above, one of the aims of this study
is to assess the awareness of
cardiologists, regardless of their
experience and sub-specialisation,
9-13, 2011 Century Park Hotel, Manila, Philippines
with regard to the possible
deleterious impacts of air pollution
on CVD, and whether account is
taken of such risks during diagnosis
and patient management.
Methodology: A questionnaire was
devised in collaboration with one of
the authors (MHS) who is a
cardiologist and an environmental
specialist. It was divided into a
mixture of multiple-choice and
open-ended questions, with a total
of 22 items. A pilot study was
implemented in two specialist
hospitals in Hanoi, Vietnam, with a
sample of 55 respondents. The
protocol was submitted to the
research departments of those
hospitals. The questionnaire was
translated into Vietnamese and then
translated back into English to
undergo analysis in SPSS (version
17). A few minor amendments were
pointed out in order to carry out a
full-scale study in the Philippines.
The questionnaire, along with the
protocol, was sent out by email to a
large sample of cardiologists who
practice in a variety of clinical
organisations and who are members
of the Philippines Heart Association
(PHA) practising in Metro Manila,
 appraise the degree of their
Davao province and other comprehension, the following
provinces. In the case of Davao question probed further into their
province, the survey was knowledge of at least one possible
implemented through a self- mechanism for the
completion method due to logistical pathophysiological pathway of air
issues. This process followed PHA, pollution in relation to the disease.
Philippines Council for Health In total, there were only 24
Research and Development physicians who could propose at
(PCHRD) and National Ethics least one seemingly valid
Committee (NEC) approvals. The mechanism. In fact, only 19
final total number of respondents (13.4%) responses proposed
was 142 cardiologists who are mechanisms matching with the
practising in one or more established literature; one response
organisations. Those organisations did not match the established
may be private, rural, or at literature and 4 proposed invalid
secondary or tertiary levels. mechanisms (Fig. 3).
Results: The 142 respondents’
experience ranges
from 1 to 43 years (mean 10.25;
median: 8) and they have different
sub-specialisations: non-clinical
(1), clinical cardiology (67),
invasive cardiology (28), non-
invasive cardiology (38), paediatric
cardiology (9) and surgery (2).
With regard to air pollution being a
potential risk factor to CVD, 58.5%
were in agreement with the fact that Fig. 3. Breakdown of Proportional
air pollution is indeed a risk factor, Agreements
25.4% of the cardiologists were towards Air Pollution Being a risk
undecided and factor to CVDs
16.2% of the respondents disagreed.
However, in order to critically

5
 Fifth Humanoid, Nanotechnology, Information Technology, Communication and
Control Environment and Management (HNICEM) International Conference The
Institute of Electrical and Electronics Engineers Inc. (IEEE) – Philippine Section March
9-13, 2011 Century Park Hotel, Manila, Philippines
plants, respectively. The
Due to the fact that 2 physicians corresponding Pearson Chi Square
suggested more than 1 mechanism, test is 93.2 and 80.8 with 8 degrees
therefore, of the 19 cardiologists of freedom, p < 0.001, and
who suggested mechanisms that Spearman’s Correlation test result
matched the established literature, is r = 0.474 and 0.393, p < 0.001.
the total occurrences of proposed This can be interpreted such that
mechanisms by the physicians were physicians who concurred with the
21. Table I describes in detail the fact that air pollution is risk factor
types of pathways articulated in the and also proposed a valid
survey. mechanism (n=24), also are in full
agreement that the emissions from
Table I. General Mechanisms either vehicles or manufacturing
Proposed by the
Cardiologists in the Sample

A thorough statistical analysis was

then carried out using SPSS
(version 17). The results revealed
that there was a positive significant
pair association between the
agreement that air pollution is a
potential risk factor to CVD and the
understanding of the harmful
effects of the sources of air
pollutants which are emissions
mainly from vehicles and industrial

plants are the significant
contributors to CVD. This means
that those physicians are
confidently and absolutely aware of
the potential link between air
pollution and CVD. Nonetheless,
that proportion of 24 cardiologists
is quite small in comparison to the
entire sample size of 142
respondents.
The proportional positive
agreement with regard to the
exacerbation of CVD conditions
due to air pollution, which was
approximately 61.3% (i.e., 87
respondents), was slightly higher
than air pollution being a risk factor
(mentioned above). This figure also
reflects the fact that, when asked,
out of every three physicians, there
would be one cardiologist either
doubting the harmful impact of air
pollution on CVD patients or
unsure of the issue. In addition to
concurring to the exacerbation
effects of air pollution, physicians
were also asked to list at least one
harmful airborne pollutant. Only 55
out of 87 cardiologists could
propose either one or more. The
most common such pollutant
articulated by 36 physicians was
carbon monoxide (CO), followed
by sulphur dioxide (SO2) and
nitrogen dioxide (NO2) with 7
occurrences each. Unfortunately,
6
PM, which a substantive number of
studies strongly support its impact
on CVD, was mentioned only 5
times in the survey. Some other air
pollutants, such as metal dust, NH3
and other mixtures, were also
mentioned in the survey. Those
figures clearly demonstrate that the
deeper the knowledge was tested
through drilling down the
responses, the fewer the number of
positive responses the survey
showed. In fact, with each drilling
down step undertaken, 25% of the
sample was being eliminated as a
result of their responses.
Physicians who tend to agree with
the exacerbation impact of air
pollution on patients suffering from
CVD compared to those who are in
disagreement are 6.1 times (95% CI
1.7 to 22.4) more likely to be
knowledgeable about the subject.
Similarly, cardiologists who could
propose some concern that air
pollutants can exacerbate CVD
conditions, compared to those who
disagreed with the harmful impact
of air pollution, are 3.7 times (95%
CI 1.1 to 12.4) more likely to be
knowledgeable about the subject.
This figure reduced from 6.1 to 3.7
times due to the limited number of
cardiologists who suggested
harmful air pollutants of concern.
 Fifth Humanoid, Nanotechnology, Information
Technology, Communication and Control
Environment and Management (HNICEM)
International Conference The Institute of
Electrical and Electronics Engineers Inc. (IEEE) –
Philippine Section March 9-13, 2011 Century Park
Hotel, Manila, Philippines

Beyond the clinical expertise of the
cardiologists, one of the aims of the
survey was to probe into their
awareness of the environmental
regulations and guidelines
stipulated by the government,
especially since the South East
Asian region, in general, is
attempting to put in place enormous
efforts in combating the
deteriorating air quality through its
respective governments. In
addition, the survey offered the
opportunity to the physicians to
recommend possible legislative and
regulatory measures to that effect
beyond any existing ones in the
Philippines.
Surprisingly, statistical analysis of
the responses reveals that nearly
two thirds (66%) of the physicians
are not aware of any governmental
effort to battle air pollution issues.
Although the Philippines Clean Air
Act of 1999 became law in that
year, with different
recommendations such as
establishing and developing the
criteria of permissible air pollutants
levels in the National Ambient Air
Quality Guideline and improving
the quality of gasoline and fuel, up
to date - and it has been more than
10 years since the Act came into
force - only 34% of the entire
sample of cardiologists are aware of
the government’s efforts to combat
air pollution.
The above poses the important
question of whether there is a need
to provide more comprehensive
education on the effects of
environmental pollution on CVD
onset and exacerbation to upcoming
generations of Filipino
cardiologists, or to strengthen the
effectiveness of the governmental
plans, regulations and legislations
on air quality. Either way,
governmental organisations need to
take more positive steps in order to
improve both the general and
specialist knowledge about air
pollution and its health effects,
especially on heart diseases.
V. CONCLUSIONS
Although results from the survey
show a moderate (58.5%) positive
awareness from the Filipino
cardiologists about the link between
air pollution and CVD, from the
pathophysiological pathway
understanding perspective, the
proportion of physicians who are
able to propose mechanisms
matching those reported in the
literature are reduced sharply by
13.4%. Furthermore, the majority
of cardiologists are not aware of
any authoritative documents that
relate to the subject.

This factor clearly reflects the
serious shortcomings in the
knowledge of Filipino physicians
about the potential association of
air pollution and CVDs.
REFERENCES
[1] National Statistics Office
(2008), Philippines: Total
Population Count as of August 1,
2007[online] Available from
<http://www.census.gov.ph/data/ce
nsus2007/inde x.html> [Accessed
19 November 2010].
[2] Department of Foreign Affairs
and Trade
(2008), Republic of the Philippines
Country Brief: November 2008
[online] Available from
<http://www.dfat.gov.au/geo/philip
pines/philippin es_brief.html>
[Accessed 19 September 2010].
[3] WHO (2008) Mortality Country
Fact Sheet
2006: Philippines [online]
Available from
<http://www.who.int/whosis/mort/p
rofiles/mort_
wpro_phl_philippines.pdf>
[Accessed on the 23 December
2010].
7
[4] ADB (2006), Country
Synthesis Report on Urban Air
Quality Management: Philippines
[online] Available from <
http://www.adb.org/Documents/Re
ports/Urban-Air-Quality-
Management/philippines.pdf>
[Accessed 27 December 2008].
[5] CAI-Asia (2010) Philippines:
Air Quality
Profile: 2010 Edition [online]
Available from <
http://www.cleanairinitiative.org/po
rtal/node/6591 > [Accessed 31st
December 2010].
[6] The Philippine Daily Inquirer
(2005), Air Pollution - Killing Us
Softly and Quietly [online]
Available from <
http://www.rense.com/general63/aa
ir.htm> [Accessed 10 October
2008].
[7] Alave, K.L. (2004), Metro
Manila Air Polluted Beyond
Acceptable Levels [online]
Available from
<http://www.cleanairnet.org/caiasia
/1412/article-58903.html>
[Accessed 19 November 2008].
[8] Wallerstein, C. (1999),
Philippines Tackles Air Pollution.
British Medical Journal, Vol. 318
(7185): 689.
 Fifth Humanoid, Nanotechnology, Information
Technology, Communication and Control
Environment and Management (HNICEM)
International Conference The Institute of
Electrical and Electronics Engineers Inc. (IEEE) –
Philippine Section March 9-13, 2011 Century Park
Hotel, Manila, Philippines
Philippines%2 0Data.pdf>
[9] Biona, J.B.M. , Culaba, A.B. [Accessed 19 November 2010].
and Purvis, M. R. I. (2007) Energy
Use and Emissions of Two Stroke- [13] Vergel, K.B.N. (2004),
Powered Tricycles in Metro Urban Transportation and the
Manila. Journal of Transportation Environment in Metro Manila:
Research Part D Vol. 12 Programs and Initiatives for
(7): 488-97. Clean Air
[online] Available from
[10] Krupnick, A., Morgenstern, R., <http://www.cv.titech.ac.jp/~js
Fischer, C. , Rolfe, K. , Logarta, J. ps/activity_report/2
and Rufo, B. (2003), Air Pollution 003/K.Vergel.pdf> [Accessed
Control Policy Options for Metro on the 27 December].
Manila [online] Available from
<http://www.rff.org/documents/RF [14] Subida, R. , Velas, M. A.
F-DP-03-30.pdf> [Accessed 31st and McNamara, D. (2004),
December 2010]. Integrated Environmental
Strategies – Philippines Project
[11] Torres, E. B. , Subida, R. D. , Report/Metropolitan Manila: A
Gapas, J. L. , Sarol, J. N. , Villarin, Focus on the Transport Sector
J. T. , Vinluan, R. J. N. , Ramos, B. [online]
M. R. and Quirit, L. L. (2004), Available from
Public Health Monitoring: A Study <http://www.epa.gov/ies/pdf/ph
Under The Metro Manila Air ilippines/ies_upda te.pdf>
Quality Improvement Sector [Accessed 25th April 2010].
Development Program - Executive
Summary [15] Department of
[online] Available from < Environment and Natural
http://www.wpro.who.int/NR/rdonl Resources (2003), National Air
yres/917E331 A-4141-4A35-9194- Quality Status Report [online]
D1E16B475986/0/Execsummary.p Available from
df> [Accessed 27 December 2010]. <http://www.emb.gov.ph/eeid/
publicationfiles/air
[12] USAID (2007), Annex 10: qualitystatusreport/partone.pdf
Data Annex: > [Accessed 27 December
Philippines [online] Available from 2010].
<http://usaid.eco-
asia.org/programs/cdcp/reports/Idea
s-to-
Action/annexes/Annex%2010_%20

[16] Environmental
Management Bureau
(2004), Air Quality Monitoring Systems
[online]
Available from
<http://www.emb.gov.ph/eeid/publicati
onfiles/stat report04content.pdf>
[Accessed 31st December 2010].
[17] McCafferty (2005), Air pollution
adversely affecting 98% of residents
[online] Available from
<http://www.cleanairnet.org/caiasia/14
12/articles-59870_survey.pdf>
[Accessed 19 October 2008].
[18] Yai, T. and Vergel, K. N. (2002),
Outline of microscopic traffic
simulation. In: Metro Manila: Towards
A Sustainable Future-Impact Analysis
of Metropolitan Policies for
Development and Environmental
Conservation (Ohmachi, T. and
Roman, E. R., eds.), pp. 135-148. Japan
Society for the Promotion of Science.
[19] Department of Health (2010a),
Health Indicator Mortality and
Morbidity [online] Available from <
http://www.doh.gov.ph/kp/statistics/lea
ding_mort ality.html> [Accessed 27
December 2010].
View publication stats
[20] Department of Health
(2010b), The 2005 Philippines
Health Statistics [online] Available
from
<http://www.doh.gov.ph/files/phs2
005.pdf> [Accessed 27 December
2010].
[21] Tuomileht, J., Morelos, S.,
Yason, J., Guzman, S.V. and
Geizerova, H. (1984), Trends in
cardiovascular diseases mortality
in the Philippines. International
Journal of Epidemiology Vol. 13
(2): 168-76.
[22] Library of Congress
(2006), Country Profile:
Philippines. Report.
[23] World Bank (2006), Chapter 4:
Special
Focus: Environmental Health,
Poverty and Vulnerability [online]
Available from
<http://siteresources.worldbank.org
/INTPHILIPPI
NES/Resources/PEM06-
chapter4.pdf> [Accessed 27
December 2010].