Epidemiological Study PHM

Public Health Monitoring of the Metro Manila Air Quality Improvement Sector Development Program
6. Epidemiological study
The study was undertaken by prospectively collecting environmental and health data over the period January to May 2003. The components of the study are (i) ambient air monitoring in six sites, (ii) identification of high, medium and low-exposure areas to air pollution, (iii) household survey, (iv) child health monitoring, (v) adult health monitoring, (vi) health center monitoring, (vii) indoor and outdoor air monitoring, (viii) biological monitoring for blood lead, (viii) hospital ER monitoring, (ix) private clinic monitoring, and (x) GIS mapping. 6.1 Identification of exposure risk areas The ambient PM10 monitoring data obtained in 2002 from six sites for the health risk assessment (HRA) component of the project were modeled using raster GIS technique to categorize the level of risk of exposure associated with the ambient PM levels in Metro Manila. The categories of exposure risks to air pollution are shown in Table 5.32. Further, the results of the application of classification scheme are shown in Figures 5.15a and 5.15b. Antipolo consistently showed the lowest ambient PM levels therefore it was designated the low exposure risk area. Eight (8) sentinel barangays were randomly chosen in each of the high, medium, and low exposure risk areas. A total of 24 Barangays were selected representing sentinel communities all over Metro Manila and Antipolo. The barangays randomly selected in the exposure areas are summarized in Table 6.1
Table 6.1 Sentinel barangays in the exposure areas Exposure Area Barangays High Bagbaguin Mapulang Lupa Paso de Blas Parada Paltok Nayong Kanluran Bungad Pinyahan Bambang Calzada Lidig Tipas Ibayo Tipas Palingon Tuktukan Pineda Martirez/Aguho Sta. Cruz Mayamot Mambugan San Isidro Dela Paz San Luis Inarawan Bagong Nayon
City/Municipality
Kalookan Valenzuela Valenzuela Valenzuela Quezon City Quezon City Quezon City Quezon City Taguig Taguig Taguig Taguig Taguig Taguig Pasig Pateros Antipolo Antipolo Antipolo Antipolo Antipolo Antipolo Antipolo Antipolo
Medium
Low
Main Report. March 2004
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6.2 Socio-demographic and health profile of sentinel households A total of one hundred (100) households were randomly selected in each sentinel barangay. The sentinel household should meet the following requirements: The household should have been a resident of the barangay for at least 2 years prior to the study; Should have at least one member who is a child with age ranging from 6 to 10 years old; and, Willing to participate in the study.
A total of two thousand four hundred (2400) households were randomly selected to participate in the study. The household survey component of the study was conducted to obtain vital socio-economic, demographic, environmental exposure and health outcome data among sentinel households randomly selected in barangays located in the predicted low, medium and high exposure risk areas. This section of the report provides descriptive information of the characteristics and profile of the study households, potential exposures to indoor and outdoor air pollution and possible health outcomes. Aside from the descriptive section of the report, analysis of the relationships between potential environmental exposures and specific health outcome variables using a cross-sectional study approach was also performed. Baseline data from the household survey were further used in the analysis of the prospective monitoring of health outcomes from the sentinel household as well as in the assessment of exposure to air pollution. The main data collection tool used in the survey is an interviewer-administered questionnaire (Appendix 6-1) developed and pre-tested in communities not included in the study scope to ensure appropriateness and accuracy. Interviewers were provided training by the consultants and hands-on experience prior to the commencement of the actual data collection. Data accuracy and completeness were insured by thorough review of the completed questionnaire by the interviewers and conducting a re-visit or repeat interview in cases where information provided is unclear or conflicts with other responses The following assumptions were made in this study: The minimum requirement of 2-year residency in the community as inclusion criteria was based on the assumption that health impacts of air pollution (PM10) can be possibly observed with a minimum of 2 years community exposures. Furthermore it is assumed that on the average it takes 2 years for a household informant to have detailed awareness and information on the true state of affairs of health in their community. The classification into high, medium and low exposure risk areas of Metro Manila were based on air pollution models using actual ambient air monitoring data that are robust.
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6.2.1 Results of the household survey 6.2.1.1 Study household distribution across study area Table 6.2 shows the frequency distribution of study households by air pollution exposure risk category. Table 6.2 Frequency distribution of study households by air pollution exposure category
Household location Low air pollution area Medium air pollution area High air pollution area Total Number 800 800 777 2,377 Percent 33.7 33.7 32.7 100
6.2.1.2 Socio- demographic characteristics Age The study communities are relatively young with majority of the members 15 years old and lower. No significant differences in age distribution can be recognized between the various air pollution exposure risk areas. This is shown in Figure 6.1 .
Fig. 6.1 Percentage age distribution of study HH by exposure area

30 25
Percent
20 15 10 5 0 1 to 5 6 to 10 11 to 16 to 21 to 26 to 31 to 36 to 41 to 46 to 51 to 56 to 61 to 15 20 25 30 35 40 45 50 55 60 65 66 +
Low Medium High
Age
Educational profile Majority of the survey informants have finished high school education. A high school graduate respondent is assumed to provide assurance that they have understood and responded appropriately to the study questions as compared to a respondent with a lower educational background. Educational profile of respondents across various air pollution exposure risk areas does not vary significantly as shown by Figure 6.2 .
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Fig. 6.2 Education profile of survey respondents by location

60 50 No Formal Education Elemantary Level High School Level College Level or Higher Vocational Low Medium High 40 30 20 10 0
Percent
Air Pollution Exposure Areas
Figure 6.3 shows that respondents in the medium exposure risk areas in Metro Manila have the highest average level of formal schooling (9.5 years) as compared to high and low exposure study households.
Fig. 6.3 Average years of formal schooling of respondents by location
10
Years
9.5 9 8.5 8 1 Air Pollution Exposure Areas
Low Medium High
Household income Majority of the study households have monthly income of P 8,000.00 and below, Table 6.3 shows the distribution of households across various income categories. Table 6.3 Household distribution by monthly income
Income level (Pesos) Less than 5,000 pesos 5,001 to 8,000 8,001 to 15,000 Greater than 15,000 Total Number 920 914 405 136 2,375 Percent 38.7 38.5 17.1 5.7 100
Available data show slight but significant (p =. 000) differences in the income profile across various air pollution exposure groups. Households in the low exposure areas have reported lower incomes (higher proportion of families earning less than PhP 5,000) as compared to the other exposure risk areas. Households in the medium exposure category appear to have better income profile than the rest as shown in Figure 6.4.
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Fig. 6.4 Average household income distribution of barangays by location

50 40
Percent
Low Medium High
30 20 10 0 < 5,000 5,001 - 8,000 8,001 - 15,000 > 15,000
Pesos per month
Housing Aside from income, proxy indicators of socio-economic status commonly used in community surveys include the construction material used in building the house and the current condition of repair of the house. Households were classified as to type of construction materials as follows: Temporary house predominantly made of temporary materials such as recycled boards and cardboards, commonly observed amongst informal settlers in MetroManila Semi-permanent houses are usually made of wood with concrete for flooring or walls, which can easily be dismantled and transferred to another site. Permanent house commonly made of concrete. Classification based on the state of repairs of house, yielded the following categorization: Good no repairs needed Fair house needs minor repair Poor signs indicating that no repair has been done on many aspects of the house. House in danger of breaking down and generally unsafe to live in requiring major renovation and repair. Table 6.4 and Table 6.5 below indicate the frequency distribution of households by building material type and state of repair respectively. Table 6.4 Household classification by construction materials used in building
Building material Temporary Semi-permanent Permanent Total Number 634 817 920 2,371 Percent 26.7 34.5 38.8 100
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Table 6.5 Household classification by house condition

House condition Good Fair Poor Total Number 678 1,212 464 2,354 Percent 28.8 51.5 19.7 100
Majority of the houses surveyed are mostly constructed of permanent and semi-permanent materials, typical of houses that can be found in Metro Manila although a significant portion are temporary in nature. Furthermore, majority of the houses only need minor repairs. There appears to be a small but statistically significant (p = .000) difference in the type of housing amongst the households located in the pollution exposure risk areas. Although comparable in proportion to houses made of permanent materials, there are a higher proportion of houses made of temporary material in the low exposure areas as shown in Figures 6.5 and 6.6.
Fig.6.5 Distribution of type of household construction in study barangays by location
50 40
Percent
30 20 10 0 Temporary Semi-permanent Permanent
Low Medium High
House Construction
Fig. 6.6 Distribution of household in housing condition by exposure area

60 50 40 30 20 10 0 Good (little or no evidence of dilapidation Fair (needs minor repair) Poor (dilapidated, needs major repair
Percent
Low Medium High
House Condition
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6.2.1.3 Exposure factors There are several environmental factors that can contribute to pollution exposures to members of the household. These can include any of the following sources: Exposure from air pollution generated by mobile sources (jeepneys, buses, tricycles, etc.). Potential exposure of the study households from these sources has been estimated using proxy variable of house location vs. major/minor traffic routes. Major determinants of indoor air pollution were also covered to include: type of cooking fuel used, frequency and duration of cooking activity, location of kitchen within and outside the house, and smoking behavior among household members The level of household congestion as reflected in the crowding index indicates further susceptibility of household members to respiratory infection House location vs. traffic Table 6.6 shows that majority of the houses (88.8%) are located along major traffic roads where ambient air pollution from mobile sources are expected to be higher compared to residents in minor routes. Contributors to air pollution along major traffic routes include public utility vehicles (buses and jeepneys) and private vehicles (trucks and cars). Along minor traffic routes private vehicles and emissions coming from tricycles are the main contributors.
Table 6.6 Frequency distribution of study household location by traffic route Household location Number Percent Along minor traffic route Along major traffic route Total 264 1,097 2,361 11.2 88.8 100
Available data shown in Figure 6.7 below indicate a small but statistically significant difference (p = .02) in the location of study households to major/minor roads across the different air pollution exposure areas.
Fig. 6.7 Proximity of study HH to roads by exposure area
100 80
Percent
60 40 20 0 Major traffic route Minor traffic route
Low Medium High
Location of Study Households (p = 0.02)
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Household cooking fuel and cooking activities The type of cooking fuel used has been identified in the literature as one of the primary determinants of indoor air pollution. Amongst the fuels used in Filipino households, electricity followed by liquefied petroleum gas (LPG) are two of the lowest generators of indoor air pollution as compared to kerosene and wood. Table 6.7 shows the profile of cooking fuel used in the study households. Table 6.7. Profile of cooking fuel used in the study households
Type of cooking fuel LPG Wood Kerosene No. of households using 1,766 289 498 Percent 74.5 12.2 21.0
Note: Category are not mutually exclusive, households may use multiple cooking fuel types
Majority (74.5 %) of the study households use LPG for cooking. A small fraction (21%) use kerosene and with wood only occasionally used (12.2%). This is an expected profile amongst households in Philippines urban areas. Figure 6.8 below shows that LPG remain the most commonly used cooking fuel amongst the three exposure clusters
Fig. 6.8 Distribution of HH by cooking fuel used and by location
90 80 70 60 50 40 30 20 10 0 LPG Wood Kerosene Others
Percent
Low Medium High
Cooking Fuel Used
The average cooking duration per day is highest among households located in medium exposure areas with an average of 2.3 hours per day. Households located in the high and low exposure areas have comparable cooking duration of 2.1 hours per day. This is shown in Figure 6.9.
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Fig. 6.9 Average cooking duration of households per day by exposure area
2.35 2.3 2.25 2.2 2.15 2.1 2.05 2 1.95 1 Air Pollution Exposure Area
Hours
Low Medium High
Table 6.8 shows that most study households do their cooking inside the house. This is a common observation among households located in highly urbanized areas like Metro Manila. The location of the kitchen is an important indoor air pollution determinant. Cooking inside the house exposes occupants to higher levels of indoor air pollution due to inadequacy of appropriate ventilation and exhaust systems especially in the lower social strata of society.
Table 6.8 Frequency distribution of study households by kitchen location Kitchen location Number Percent Inside the house Outside the house Total 2,077 291 2,361 87.7 12.3 100
Figure 6.10 shows the location of kitchen in a household is equally distributed across the various air pollution exposure areas.
Fig. 6.10 Distribution of HH by location of kitchen by exposure areas
100 80
Percent
60 40 20 0 Inside the House Outside the House
Low Medium High
Location of Kitchen
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Household crowding index The crowding index is a composite variable composed of the number of household members as the numerator and the number of rooms used for sleeping as the denominator. The higher the index, the more congested is the household putting the household members at risk for indoor air pollution exposure as well as cross-infection of communicable diseases specially respiratory illnesses. The crowding index is highest (4.8) among households located in low air pollution exposure areas, and lowest (4.3) amongst households in the medium exposure area. Households in the high pollution areas have an average crowding index of 4.75 as shown in Figure 6.11.
Fig. 6.11 Average crowding Index of HH by exposure area
4.9 4.8 4.7 4.6 4.5 4.4 4.3 4.2 4.1 4 1 Air Pollution Exposure Areas
Congestion Index
Low Medium High
Smoking profile Smoking is another major contributor to indoor air pollution. Second-hand smoke is a potential source of multiple chemical exposure that among other things can cause respiratory symptoms among the vulnerable members of the households. Figure 6.12 shows the average number of smokers per household across the various pollution exposure areas. Households located in the medium exposure areas have the highest number of smokers (0.95). Households in the high exposure risk areas have the lowest number of smokers (0.83).
Fig. 6.12 Average number of smokers per HH by exposure areas
1 Average Number of Smokers 0.95 0.9 0.85 0.8 0.75 1 Air Pollution Exposure Areas Low Medium High
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Other environmental considerations Finally, other environmental factors such as drinking water quality, waste disposal and sanitation contribute to the overall health of a particular household. Although they do not have direct impact on respiratory conditions, these variables may affect indirectly the respiratory health of people through weakening of the resistance, leading to increased vulnerability to respiratory infections. A significant proportion of households in the low exposure area have access to common sources of drinking water (Figure 6.13 ) as compared to the other households.
Fig. 6.13 Source of drinking water of HH by exposure area

80 70 60 50 40 30 20 10 0 Faucet Inside the Source Inside the House House Public Faucet/Well Neighbor's Faucet/Well Other Sources
Percent
Low Medium High
Drinking Water Source
Available data indicate that a significant majority of houses have access to their own toilet (Figure 6.14). There is no difference in toilet access amongst households located in various exposure risk areas.
Fig. 6.14 Proportion of houses with toilet by exposure area
100 90 80 70 60 50 40 30 20 10 0 With Own Toilet Toilet Ownership Without Own Toilet
Percent
Low Medium High
80
Of the 10% study households (n = 238) without toilet, dispose of their wastes in alternative ways, commonly through the used of their neighbors toilet. Waste disposal strategy is comparable across the various households in the exposure risk areas. This is illustrated in Figure 6.15 .
Fig. 6.15 Type of waste disposal by exposure area
70 60 50 40 30 20 10 0 Discarded in Public Toilet Discarded in Neighbors Toilet Discarded Wrap and Throw Discarded in River, Canals Streams Discarded Elsewhere
Percent
Low Medium High
6.2.1.4. Health profile and access to health resources of study households In order to assess the respiratory health status of household members, the respiratory symptoms experienced by household members and consultations made for the year 2002 were obtained from the survey. Utilization of health resources A significant number of households (21.4%) reported that at least one member of the household was brought to the hospital in 2002, while 30.6% have at least one member consulting the local health center or being brought to a doctor for consultation. Statistical analysis shows no significant differences in the proportion of household members being brought to the hospital or consulting the health center/private doctor in 2002 in the various air pollution exposure areas. Data on access to health resources are shown in Table 6.9. Table 6.9 Household consultation to a health facility for 2002
Facility accessed Hospital Health Center/Private MD Note: Categories are not mutually exclusive Number 509 725 Percent 21.4 30.6
Sub-analysis conducted in the same section of the population showed some interesting findings as follows: 1. There is a statistically significant finding that less number of household members were brought to a hospital in 2002 amongst households which use LPG as cooking fuel. The table below shows this relationship:
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Household member brought to the hospital in 2002

HH using LPG No Yes Total
Note: p value = 0.000
No N (%) 438 (72.3) 1,424 (80.7) 1,862
Yes N (%) 168 (27.7%) 340 (19.3) 508
Total 606 1,764 2,370
2. There is a statistically significant finding that more number of household members were brought to the hospital in 2002 amongst households which are using wood as the main cooking fuel as shown in the table below.
Household member brought to the hospital in 2002 No N (%) Yes N (%) Total 1,652 (79.4) 210 (72.7) 1,862 429 (20.6) 79 (27.3) 508 2,081 289 2,370
HH using wood No Yes Total

3. There is a statistically significant finding that more household members were brought to the hospital in 2002 amongst households which are using kerosene as the main cooking fuel. The table below shows this finding.
Household member brought to the hospital in 2002 No N (%) Yes N (%) Total 1,490 (79.6) 372 (74.7) 1,862 382 (20.4) 126 (25.3%) 508 1,872 498 2,370
HH using wood No Yes Total

4. Logistic regression analysis using members of the household brought to the hospital in 2002 as dependent variable against independent variables such as: air pollution exposure area, household income, cooking fuel used (LPG, wood and kerosene), crowding index, household size, and number of smokers in the household resulted in the protective effect of LPG used as cooking fuel and negative effect of increasing household size resulting in more hospital consultations in 2002 as shown in Table 6.10 Table 6.10 Determinants of hospital admissions, 2002
Determinants LPG as cooking fuel Household size Beta - .431 +.053 S.E. .111 .024 Significance .000 .025
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5. Logistic regression analysis using members of the household consulting the health center in 2002 as dependent variable and independent variables such as: air pollution exposure, household income, cooking fuel used (LPG, wood and kerosene), crowding index, household size, and number of smokers in the household resulted in the following variable as main determinants as shown in Table 6.11. a) b) Negative effect of increasing household size resulting in more health center consultations in 2002. Living in medium and high air pollution exposure areas were not significant but showed trends of increasing health center consultations
Table 6.11 Determinant of health center consultations, 2002

Determinant Household Size Residing in moderate air pollution area Residing in high air pollution area Beta .084 .309 .198 S.E. .021 .111 .113 Sig. .000. .06 .08
Health symptoms and status of households, 2002 The most common reported respiratory symptom amongst household members for 2002 is the occurrence of severe cough. The proportion of respondents reporting severe cough for 2002 appear to be highest in high pollution exposure areas. This relationship, however, was not observed for reports on other air pollution-related symptoms such as chest tightness, wheezing, and chest pain. Figure 6.16 below summarizes the symptoms profile of household members for 2002.
Fig. 6.16 Symptoms expereinced by HH members in 2002 by exposure areas
60 50
Percent
40 30 20 10 0 Chest Tightness Wheezing Severe Cough Chest Pain
Low Medium High
Symptoms
Available interview data indicate that respiratory diseases often account for a significant proportion of hospitalization amongst study households in 2002. There appears to be no correlation between the percentages of hospital admission for respiratory diseases across the various air pollution exposures areas as shown Figure 6.17:
83
Fig. 6.17 History of hospitalization of HH members in 2002 by exposure areas
70
Percent of HH
60 50 40 30 20 10 0 Respiratory Diseases Cardiovascular Diseases Other Diseases (Accidental, Non-Accidental) Low Medium High
Symptoms Causing Hospitalization
Deaths in the study households in 2002 due to respiratory diseases appear to be higher in high exposure area compared to households in the middle and low air pollution exposure areas as shown in Figure 6.18. Death due to cardiovascular diseases is highest among households in the medium exposure category. Majority of mortality reports were due to other accidental and non-accidental illnesses. Difference in death rates across air pollution exposure categories, however, is not statistically significant.
Fig. 6.18 Cause of death amongst HH reporting death in the family for 2002
70 60 50
Percent
40 30 20 10 0 Respiratory Diseases Cardiovascular Diseases Other Diseases (Accidental, Non-Accidental)
Low Medium High
Access to health service providers, 2002 All study households across the various exposure categories have nearly universal access to local health care center services, traditional healers, and private doctors. Available data indicate that access to traditional healers are higher compared to private doctors. Differences on health seeking behavior maybe influenced heavily by cost, and accessibility of the health resource. This is reflected in Figure 6.19 below:
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Fig. 6.19 Access to specific health providers of study HH by exposure location

120 100
Percent
80 60 40 20 0 Health Center Traditional Hilot Private Doctor
Low Medium High
Health Provider
Health perception of respondents An inquiry was made on the perception of respondents with regards to the general health of the community residents in their area. Majority of respondents rated the health of the community residents as good and fair while some 15% estimate that community members have a low level of health as shown in Table 6.12. Table 6.12 Respondents perception of community health status
Health status Good Fair Poor Total Number 1,011 1,020 315 2,346 Percent 43.1 43.5 13.4 100
Although not statistically significant, there is a higher perception among respondents of poor community health as the exposure to air pollution becomes higher. This is shown in Figure 6.20 below:
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Fig. 6.20 Respondent's estimate of health status in their barangay by exposure area
50 40
Percent
30 20 10 0 Good Fair Poor
Low Medium High
Health Status
On the other hand, estimates on the health of their own households tend to be better compared to estimates of community health status. Majority of respondents (59.4%) have rated their family health to be good. Less than 5% have rated the health of their household members to be poor as shown in Table 6.13 below. Table 6.13 Respondents perception of own household health status
Health status Good Fair Poor Total Number 1,409 881 83 2,373 Percent 58.7 36.7 3.5 100
Although not statistically significant, there is a higher perception among respondents of poor health of household members as the exposure to air pollution becomes higher as demonstrated in Figure 6.21.
Fig. 6.21 Respondent's estimate of health status of their household by exposure area
70 60 50
Percent
40 30 20 10 0 Good Fair Poor
Low Medium High
Health Status
86
6.3 Exposure to air pollution The assessment of exposure to air pollution involves the (i) ambient air monitoring for 24-hr PM in six sites within the study areas , (ii) indoor air measurements of 24-hr PM, 8-hr nitrogen dioxide, and 24-hr carbon monoxide (iii) outdoor air measurements of 24-hr PM10, (iv) measurements of indoor and outdoor lead levels, and (v) biological monitoring of blood lead. 6.3.1 Ambient air monitoring
Ambient 24-hr PM10 samples were collected January to May 2003 from six sites (2 stations in each defined high, medium and low exposure areas) as presented in Section 5.1 of this report. The results of the ambient monitoring are described in Figure 5.1 of this report. The exposure assessment for the prospective study aims to determine the exposure of the sentinel households to ambient air pollution. Thus, the ambient PM10 levels obtained from the six sites stated above were extrapolated using the geographic information system to the specific barangays where the sentinel households are located. The results of the extrapolation are shown in Appendix 6-2. The results are graphically illustrated in Figure 6.22 in terms of mean levels of ambient PM10 in the high-, medium-, and low exposure risk areas. It can be seen that the levels obtained for the high exposure areas are consistently higher than those in the medium- and low-exposure areas. It should be noted that these levels are only the average values for January to May 2003. If this trend would continue, then the long term levels in the high and medium exposure risk areas would exceed the national guideline of 60 ug/m3.
Fig. 6.22
150
Am bient PM 10 levels in the exposure areas
100
3
25th % tile m in m ax m ean 75th % tile
PM10 g/m
50 0
H igh
M edium R isk Areas
Low
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6.3.2 Indoor /Outdoor Air Monitoring A total of 120 households were selected from the 2400 sentinel households for the indoor and outdoor air monitoring. The selection was undertaken through the following procedures. There are 100 sentinel households in each of the 24 study barangays. The 100 sentinel households in a study barangay were mapped out using GIS and the centerpoint determined. From this point and within 500 meter-radius, the households for indoor/outdoor air monitoring were randomly selected. The assumption is that ambient air quality particularly of PM10 is highly stable within this distance and the levels obtained from the sampled households could represent the other households within the radius. Parameters measured in the indoor air were PM10, NO2 , CO, and environmental lead. For the outdoor air monitoring, only PM10 and environmental lead were determined. 24-hr PM10 samples were collected using personal air sampling equipment at a flow rate of 3 liters per minute. The sampling filters were pre-weighed and analyzed by PNRI. For the 8-hr NO2, the same sampling equipment were used but using a flow rate of 0.4 liters per minute. NO2 was analyzed in the laboratory using the Griess Saltzman method. 24-hr CO was measured using low range passive dosimeter tubes. Environmental lead was determined from the PM filter samples using atomic absorption spectrophotometry.
PM10 Levels Table 6.14 shows the indoor and outdoor air 24-hr PM10 levels at the exposure areas (high,medium- and low-risk areas).
Table 6.14 Indoor and outdoor 24-hr PM10 levels in exposure areas N Mean SD Indoor: High Medium Low Overall Outdoor: High Medium Low Overall Range
40 40 40 120 39 40 40 119
111.04 141.25 183.65
116.43 96.92 456.35
7.54 730.53 60.63 442.95 13.37 2,906.56
102.6 128.46 99.24
55.31 70.95 134.00
16.6 246.45 29.52 317.28 17.74 866.16
Correlation analysis between indoor and outdoor PM10 levels indicate that the two parameters are highly correlated (0.847) and statistically significant at p=.000. This indicates that as the outdoor PM10 level increases, the indoor air PM10 level likewise increases. It should be noted further that the mean indoor PM10 level is statistically higher than outdoor air PM10 level in all the exposure risk areas. Factors that may have influenced this result is the quality of ventilation inside the house and the lack of regular dusting practices of the households allowing accumulation of dust indoors.
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Further statistical analysis show that no significant association can be established between outdoor PM10 and the high, medium and low exposure risk areas (p=0.193). The same is observed in the case of indoor PM10 levels (p=0.274). Another correlation analysis was also performed to determine if there is a significant association between indoor and outdoor PM10 levels and the ambient PM10 concentrations. The results of analysis indicated that both indoor PM10 (Beta= -.068) and outdoor PM10 (Beta=.045) levels are weakly correlated with ambient PM10 levels. The indoor air PM10 levels were regressed against several contributory variables such as the location of the household along near major and minor roads; the use of various cooking fuel such as LPG, kerosene and wood; location of cooking facility inside or outside the house; the number of smokers in the household; the number of smokers who smoke inside the house; and the outdoor PM10 levels. The significant results of regression are shown in Table 6.15. The contributory factors significantly correlated with indoor PM10 levels are the location of the house (using the minor road as reference group), the number of household members who smoke (using number of non-smokers as reference group), the number of household members who smoke inside the house, and the outdoor PM10 levels. These findings concur with that of the baseline health study in 2000 (6). Table 6.15 Regression analysis of indoor PM10 against contributory factors
Independent variables
No. of HH members who smoke inside house Outdoor PM10 levels
Dependent variable: indoor PM10 *Significant @ p = 0.05
coefficient 20.778 0.433
p-value 0.006 0.000
coefficient 21.703 0.425
p-value 0.003* 0.000*
Comparative statistics of indoor PM10 levels obtained from other studies are presented in Table 6.16. It can be seen from the results of these studies that the Metro Manila households in urban slums and along high traffic density areas have higher indoor exposure levels to PM10 than those in randomly selected households in the entire Metro Manila. The indoor PM levels in the urban slums were highly correlated with number of smokers in the households. Rural households are not spared as well to the risk of elevated exposure to indoor PM10, These levels at rural households are highly associated with the type of fuel used for cooking and lighting, particularly wood and kerosene. In the present study, the higher indoor PM10 levels in the barangays of Antipolo which are supposed to be in the low exposure area, may be due to poor ventilation in the house or accumulation of road dusts inside the house.
Table 6.16 Comparative statistics of 24-hr indoor PM10, 1993 2003 N Mean Study characteristics g/m3 186 117* Metro Manila in randomly selected households, 1993 (2) 60 221 Metro Manila in urban slum households,1995 (5) 108 209 Metro Manila in households along high density traffic, 2000(6) 80 126 Metro Manila in high and medium exposure areas, 2003 63 196 Rural households in Quezon 1999 100 132 Rural households in Pangasinan 2001 40 183 Antipolo City, 2003
*
Estimated from TSP @ 55% of TSP is PM10
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Environmental lead (Pb)

The lead content of the particulate matter obtained from indoor and outdoor air samples was determined to assess if the elimination of lead from gasoline has resulted to improvement in air quality. The results are shown in Table 6.17. The mean outdoor lead ranged from 0.11 to 0.37g/m3 which are much lower than the National Air Quality Guideline of 1.0 g/m3. Although there are high values for outdoor lead(1.48 and 4.28 g/m3) obtained, the frequency of occurrence is only once in both cases. The mean lead level is highest in the high exposure risk area and lowest in the low exposure risk areas. However, the differences are not statistically significant. Table 6.17 Environmental lead in exposure areas
Exposure area N High Medium Low Overall 40 40 40 120 Indoor Outdoor Mean 0.27 0.37 0.11 0.25
Mean
0.21 0.18 0.15 0.18
Range 0.01 0.87 0.01 0.57 0.01 0.77 0.01 0.87
N 39 40 40 119
Range 0.005 1.48 0.003 4.28 0.01 0.67 0.005 4.28
Statistical test was done to verify if outdoor lead levels are correlated with indoor lead. As shown in Table 6.18, the correlation is very weak. Nevertheless, these results indicate that lead is still in the environment and may continue to pose serious threat to health particularly to children. Table 6.18 Result of paired samples correlation
Indoor Lead Outdoor Lead N 116 116 Correlation 0.210 Significance 0.023
Comparative statistics for environmental lead exposures (24-hr) in Metro Manila are shown in Table 6.19. The WHO study in 1990 showed that the exposure of study populations to environmental lead in Metro Manila on the average was 1.2 g/m3 among commuters and 1.4 g/m3 among air-conditioned bus drivers which are almost three times the health guideline set by WHO at 0.5 g/m3. The jeepney drivers were the highest risk group in 1990. These elevated levels were attributed then to the high lead content of gasoline of 0.84 g/liter up to 1991 and 0.6 g Pb per liter of gasoline in 1992. The reduction of ambient lead levels in 1994 may be attributed to the further reduction of lead in gasoline to 0.15 g/liter in mid -1993 and unleaded gasoline was introduced in early 1994 to key urban centers in the country. The unleaded fuel policy was implemented nationwide in 2000 with the passing of the Clean Air Act of 1999. In the 2000 and 2003 studies, the effect of this reduction is apparent.
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Table 6.19
24-hr environmental lead exposures in Metro Manila

N 71 38 37 74 No data 51 80 Values (g/m3) 3.6 1.4 1.2 1.0 2.3 0.3 0.6 0.214 0.195 Reference WHO-UP Manila WHO-UP Manila WHO-UP Manila DENR* DENR* DOH-WHO DOH-ADB-WHO
Year 1990 1990 1990 1992 1993 1994 2003

*
Source: URBAIR-Metro Manila, 1996 (4)
Blood lead
A total of 450 children (6-10 year-old) in the sentinel barangays participated in the determination of blood lead. Figure 6.23 shows the blood lead levels of children in the high-, medium-, and low-exposure areas. Statistical analysis indicate significant differences between the exposure areas (p=.000). On the average study children from the high-risk areas have blood lead levels 2.5 times higher than those from medium exposure areas and 1.5 times elevated compared with those from the low exposure areas.
Fig. 6.23 Blood lead levels in exposure areas

Blood Pb Levels (g/dl)
60.0 50.0 25th % tile (g/dl) 40.0 30.0 20.0 10.0 0.0 High Medium Low min max mean (g/dl) 75th % tile (g/dl)
Risk Areas
High (N = 146) Medium (N = 152) Low (N = 152)
Regression analysis was conducted to determine what child or household attributes have significant association with blood lead. Among these attributes are age and sex of the study child, location of the house, and indoor/outdoor lead levels. The results of regression indicate that all these variables tend not to exert influence on the levels of blood lead. Although the blood lead levels, on the average, has significantly reduced from 2000 to 2003, the lingering presence of lead in children is still a health concern. Considering that no risk factors can be identified from the regression analysis, the levels of blood lead may be explained by past exposures of children to lead from the air and from those deposited in the soil. In such case, the deposited lead in the bones tend to equilibrate with the lead in blood. Another possibility is that there are other sources of lead to which the present study children are exposed to, for example, lead in soil and food.
91
These recent findings on blood lead are compared with the results of previous studies on blood lead among children in Metro Manila. For the 2003 children group, those from Antipolo City (N= 152) have been excluded in the computation. Comparative statistics of blood lead levels among children in Metro Manila since 1993 are shown in Table 6.20. It should be noted that the study children in 1993 were school children randomly selected all over Metro Manila while the 2000 study children were selected from study households that reside along major routes of land transportation and heavy traffic. This could explain for the higher mean values of blood lead in 2000 as compared with the 1993 result. Apparently, the blood lead levels have significantly reduced by more than fifty percent since the implementation of unleaded gasoline in 2000.
Table 6.20 Mean blood lead (Pb) levels among children in Metro Manila, 1993 - 2003
Population N Mean Blood Pb, g/dl Study Characteristics
Children (6 14 y.o.) Children 6 10 y.o.) Children 6 10 y.o)
Schoolchildren and street child vendors, July 1993 488 207 298 14.8 16.3 9.3 Children living along heavy traffic density April 2000 Children in high, medium exposure areas April May 2003
Figure 6.24 below shows that a considerable reduction of blood lead levels among children is obtained with the reduction and elimination of lead in gasoline. Before June 1993, the lead content of gasoline was 0.6 g/liter. After this period the lead content was reduced to 0.15 g/liter. The 1993 children study was conducted in July of that year therefore the effect of lead reduction in gasoline cannot be ascertained. The actual values are presented below. The children study of 2000 was conducted in April 2000 just when the unleaded gasoline policy of the government was then enforced. In the 2003 study, the mean blood level among children in Metro Manila of 9.3 g/dl is significantly much lower than the 2000 level. However, all the studies were cross-sectional in nature and there was no regular blood lead monitoring program in between the years of implementing the lead elimination policy. Therefore, the decreasing trend of blood lead through the years cannot be ascertained.
Fig. 6.24 Lead content of gasoline and mean blood lead levels among children in Metro Manila, 1993-2003
blood lead level (ug/dl)
20
School children Children in high traffic areas
16 12 8 4 0 1991 1992 1993 2000 2003

lead gasoline
0.84 0.6 Children
blood lead
N.B. lead in gasoline not actual values but highlighted for illustration purpose only
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Although there are other sources of lead exposure among children, it should be noted that together with the complete elimination of lead in gasoline, the distribution of children having blood lead levels below the biological limits have considerably increased and those exceeding the limits have reduced. These results are presented in Table 6.21 below using the biological limit for blood lead of US-CDC at 10g/dl.
Table 6.21 Frequency distribution of blood lead levels of children in Metro Manila, 2003
Population
6 14 y.o. children, 1993 (N = 488) 6 10 y.o. children, 2000 (N = 207) 6 10 y.o. children, 2003 (N = 298)
0.15 Percent of children with blood lead levels < 10 g/dl >10g/dl 0.0 0.0
17.8% 9.67% 65.4%
82.2% 90.33% 34.6%
Although this project did not look at the effects of elevated blood levels among children, previous studies have estimated effects of lead on intelligence quotient (IQ) of study children. A World Bank assessment in 1996 have estimated an average loss of 5 IQ points among all children due to exposure to lead levels in 1990(PEHAS) (3). Eventually, the IQ increment of children due to exposure to lead in gasoline will be drastically reduced with the elimination of lead in gasoline. However, other sources of lead (industrial, soil, food) still remain a concern in reducing exposure to lead.
Nitrogen dioxide and carbon monoxide

Table 6.22 provides information pertaining to levels of indoor nitrogen dioxide (NO2). The levels are way below the national air quality guidelines . A major source of indoor NO2 is combustion of cooking fuel, particularly LPG. However, result of correlation analysis indicated that indoor NO2 is weakly associated with LPG (p= 0.82) as well as with kerosene (p=0.3)
Table 6.22 Levels of indoor 8-hr NO2 Exposure area N Mean SD Range
High Medium Low
39 40 40
4.93 6.29 10.15
4.31 5.9 9.04
0.57 20.53 0.3 173.87 0.58 42.3
Levels of indoor carbon monoxide(CO) were measured for 24 hours. The results shown in Table 6.23. indicate that the CO levels are way below the guideline. CO levels are weakly correlated with the number of household members who smoke (Beta=.095). CO is likewise weakly correlated with the number of household members who smoke inside the house (Beta= 0.013) Table 6.23 Levels of indoor 24-hr CO
Exposure area N Mean SD Range
High Medium Low
40 40 40
2.24 1.25 0.9
0.78 0.52 0.57
1.04 5.21 0.52 2.60 0.26 2.60
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6.4 Health Impact of Air Pollution

The impact of air pollution to health was assessed by prospectively collecting health information from January to May 2003. For each sentinel household, a child (6-10 years old) and an adult (more than 18 years old) were identified to participate in the health monitoring. In the case of child health, a profile of the respiratory health is likewise presented. This profile was obtained from the survey of the sentinel households and by health monitoring using a health calendar for study children (Appendix 6-3). For monitoring health of the general population, a health center from each city and municipality in Metro Manila were identified to participate in the pilot study on recording, reporting and monitoring daily consultations of air-pollution related symptoms and diseases. In addition, emergency room consultations in hospitals and consultations in private clinics located in the exposure areas were likewise monitored during the same period. Additional information required for the assessment are the mean 5-month (January to May) ambient PM10 in exposure areas, environmental (indoor and outdoor measurements) and biological monitoring results, and certain household and child attributes obtained from the household survey. 6. 4.1 Child health To better assess the impact of air pollution on the health of children, the respiratory health profile of the children as obtained from the household survey is presented together with the health monitoring results . 6.4.1.1 Respiratory health profile of study children The results presented herein were obtained from the household survey where more than 75 % of the respondents are the mothers of the study children . The mean age of study children in the low air pollution exposure area is slightly higher (8.15 years) compared with those in the medium and low air pollution exposure areas (8.05 years). Frequent cough
Available data indicate that there is a higher prevalence of frequent cough among children residing in high air pollution areas in the study; however, differences did not reach statistical significance (p = .083). These results are presented in Figure 6.25 below.
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Fig. 6.25 Distribution of study child with frequent cough by study area
32 31 30 29 28 27 26 25 24 1
Percent
Low Medium High
Air Pollution Exposure Areas
A closer look at the data further indicates that the children reported to have frequent cough experience it less than once a month (>60%) in all exposure groups as shown in Figure 6.26 .
Fig. 6.26 Distribution of frequency of cough by exposure area

70 60 50 40 30 20 10 0 Less than once a month Once to twice a month More than twice a month Low Medium High
Reports of frequent cough amongst the study children has been shown to be associated with the type of cooking fuel used. Table 6.24 below shows that there is a statistically significant lower prevalence of frequent cough amongst household which use LPG as cooking fuel (p = .005).
Table 6.24 Frequency distribution of children with reported frequent cough among household using LPG vs. other cooking fuels
Percent
Children reported to have frequent cough

Use of LPG as cooking fuel No N (%) Yes N (%) 476 (27.1) 197 (32.8) 673 Total
Yes No
Total
1,279 (72.9) 404 (57.2) 1,683
1,755 601 2,356
95
Although not reaching statistical significance (p=.208), the distribution of children reporting frequent cough among household using wood as cooking fuel (30.8%) are higher as compared to households using other fuel types (28.3%) as shown in Table 6.25. As presented in Table 6.26, similar trend is observed amongst household using kerosene as cooking fuel (31.5%) as compared to households using other type of fuels (27.8%), although the difference between the two groups did not reach statistical significance (p = .058).
Table 6.25 Frequency distribution of children with reported frequent cough among household using wood as cooking fuel vs. other fuels Children reported to have frequent cough Use of wood as cooking fuel No N (%) Yes N (%) Total
Yes No
Total
198 (69.2) 1,485 (71.7) 1,683
88 (30.8) 585 (28.3) 673
286 2.070 2,356
Table 6.26
Frequency distribution of children with reported frequent cough among household using kerosene as cooking fuel vs. other fuels Children reported to have frequent cough Use of kerosene as cooking fuel No N (%) Yes N (%) Total
Yes No
Total
339 (68.5) 1,344 (72.2) 1,683
156 (31.5) 517 (27.8) 673
495 1,861 2,356
It should be noted that smoking practice of parents, and location of the house in a major road network have not been identified to be significantly associated with episodes of frequent cough amongst the study children. However the results of the logistic regression analysis (Table 6.27) conducted on various possible predictors of frequent cough in children have yielded the following as major predictors: Living in an area designated as high pollution exposure area, and Use of LPG as household cooking fuel showing a statistically significant lower cough prevalence compared to other household fuel types such as kerosene and wood.
Sig.
Table 6.27 Predictors of prevalence of frequent cough among study children Predictor Beta Standard Error
Living in high pollution area LPG as cooking fuel
.245 -.385
.123 .180
.036 .004
96
Tightness of the chest Difficulty of breathing as indicated by episodes of chest tightness is a symptom which can be related to acute effects of air pollution. Available data indicate a comparable prevalence on occurrence of chest tightness among children in the high and low pollution exposure areas (Figure 6.27). Furthermore, the most common occurrence of difficulty of breathing as reported by the respondents is less than once per month.
Fig. 6.27 Percentage of children with frequent chest tightness by exposure area
12 10
Percent
8 6 4 2 0 1
Low Medium High
Exposure Area
As shown in Table 6.28, available data indicate a trend for higher prevalence of chest tightness among children residing in high pollution areas in Metro Manila, although not statistically significant (p=.099)
Table 6.28 Frequency distribution of children with reported frequent tightness of the chest by air pollution exposure area. Children reported to have frequent chest tightness Exposure Area No N (%) Yes N (%) Total
Low Pollution Medium Pollution High Pollution Total
693 (86.7) 694 (88.1) 654 (84.4) 2,041
106 (13.3) 94 (11.9) 121 (15.6) 321
799 788 775 2,362
Wheezing Occurrence of wheezing may indicate a possible allergic response due to air pollution, which in many cases is associated with bronchial asthma. Existing data indicate a higher occurrence (approx. 13.2%) of wheezing of the chest among children residing in high air pollution exposure areas (Figure 6.28). A closer look of the data show that the frequency of wheezing commonly encountered is for less than once up to twice a month across all exposure areas.
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Fig. 6.28 Percentage distribution of study child with frequent wheezing by study area
13.5 13 12.5 12 11.5 11 10.5 10 1
Percent
Low Medium High
Exposure areas
Report of frequent wheezing amongst the study children has been shown to be associated with the type of cooking fuel used. Table 6.29 shows that there is a statistically significant lower prevalence of wheezing among household which use LPG as cooking fuel (p = .005) .
Table 6.29 Frequency distribution of children with reported frequent wheezing among household using LPG vs. other cooking fuels
Children reporting to have frequent wheezing

Use of LPG As Cooking Fuel Yes No No N (%) Yes N (%) 193 (11.0) 91 (15.1) 284 Total
Total
1,562 (89.0) 511 (84.9) 2,073
1,755 602 2,346
Available data further indicates a statistically significant (p = .022) higher prevalence of frequent wheezing among children living in households which use wood as the main type of cooking fuel (Table 6.30).
Table 6.30 Frequency distribution of children with reported frequent wheezing among household using wood vs. other cooking fuels Children reported to have frequent wheezing Use of wood as cooking fuel No N (%) Yes N (%) Total
Yes No
Total
243 (84.1) 1,830 (88.5) 1,073
46 (15.9) 238 (11.5) 284
289 2,068 2,357
The results of the logistic regression analysis of data indicate that the main predictor of frequent wheezing which carries a protective effect is the use of LPG as household cooking fuel (Beta = .670, Standard Error = .201, and Significance = .001).This means that the use of LPG as cooking fuel predicts the lesser frequency of wheezing among the study children.
98
Doctor- diagnosed asthma The prevalence of doctor-diagnosed asthma among study children is higher (18%) in high pollution exposure areas, gradually tapering off in the medium and low exposure areas. There is significant difference (p = .013) in the prevalence of doctor-diagnosed asthma between high and low exposure areas . Additional details are presented in Table 6.31.
Table 6.31 Frequency distribution of doctor-diagnosed asthma in children by air pollution exposure area. Children reported to have doctor-diagnosed asthma Exposure Area No N (%) Yes N (%) Total
Low Pollution Medium Pollution High Pollution Total
688 (87.4) 654 (84.5) 631 (82.1) 1,973
99 (12.6) 120 (15.5) 138 (17.9) 357
787 774 769 2,330
Other respiratory illnesses The study also inquired about the occurrence of respiratory diseases in the study child. Data from the respondents show that measles is the most common respiratory illness encountered by the child followed by sinusitis and asthma. The profile of past respiratory illness is similar across all exposure risk areas as shown in Figure 6. 29. In particular, the prevalence of bronchitis (<20%) and asthma (25 to 30%) is similar across exposure areas.
Fig. 6.29 Distribution of study children with reported respiratory illness by exposure area
70 60 50 40 30 20 10 0 Low Medium High Measles Sinusitis Bronchitis Pulmonya Asthma
6.4.1.2
Percent
Child health monitoring
Approximately 98.8 % (2,373) of the target of 2,400 study children participated in the health monitoring in January to May 2003. The same children from whom the respiratory health profile was established participated in the health monitoring activity. Health calendars developed by the project were given to the mothers or caretaker of study children to record any respiratory symptom or asthma episode the qualified child may have experienced. These calendars were collected by research assistants each month from February to June 2003 and verified by short interviews of the mothers or caretakers.
Main Report. March 2004 99
The respiratory symptoms listed in the health calendar are cough (ubo); cough without phlegm production, nasal discharges (sipon), wheezing (paghuni), difficulty of breathing (hirap sa paghinga), flu, colds and fever. For the analysis, any of the symptoms or any combination thereof were lumped together into one health outcome category. A second health outcome was asthma attack or episode for those with doctor-diagnosed asthma. From the calendar, crude incidence rates were calculated and the individual probable risk factors were analyzed. The regression analysis tried to identify the significant risk factors contributing to the incidences of asthma attacks and respiratory symptoms. Crude incidence rates Differences in incidences of asthma episodes are shown in Table 6.32. From this table, it is seen that the distribution of the disease incidences follow the pollution exposure pattern. Thus, the high pollution exposure areas have the highest incidence, the low pollution areas have the lowest incidence. However, in Table 6.33 showing incidence rates of the respiratory symptoms, this gradient is not as obvious. The high pollution areas have the highest incidence of respiratory symptoms but the low pollution areas have a slightly higher incidence than the medium pollution areas. The significance of this slight reversal in incidences is tested in the succeeding analysis.
Table 6.32 Asthma episodes among 6-10 y.o. and incidence rates per 1000 population exposure areas for January-May, 2003 Pollution exposure No. of cases No. of person-months Incidence rate per level 1000 population in
HIGH MEDIUM LOW Total
56 44 32 132
3749 3829 3874 11452
14.94 11.49 8.26 11.53
Table 6.33
Incidence rates per 1000 population of respiratory symptoms among 6-10 y.o. in exposure areas , January-May, 2003 Pollution level (according to a No. of cases No. of person-months Incidence rate per priori barangay classification) 1000 population
HIGH MEDIUM LOW

Total
2057 1696 1817 5570
3748 3828 3874 11450
548.8 443.1 469.0 486.4
100
Individual analysis of probable risk factors with the health outcomes

Several probable risk factors were analyzed individually to identify which among these factors could be significantly associated with the health outcomes of concern. Significant risk factors affecting asthma episodes in this study are sex or gender, father smokes, monthly income and the different pollution exposure areas as shown in Table 6.34. As can be seen in the table, males have higher risk than females and children with fathers who smoke, belong to higher income families and who live in high pollution areas have higher risk of asthma attacks or episodes. These four significant factors are further analyzed together in the next section.
Table 6.34 Rate ratios of probable risk factors of asthma episodes among 6-10 year old children, January May, 2003 Probable risk factors Rate Ratio Confidence Interval p-Value
1. Age 2. Sex Female* 3.Location of Household: Major Road* 4. Indoor PM10 Level 5. Indoor Nitrogen dioxide level 6. LPG use* 7. Kerosene use* 8. Wood use* 9. Location of Cooking Facility: Inside the House* 10. Congestion Level*** 11. Father Smokes* 12. Mother Smokes* 13. Caretaker Smokes* 14. Number of Smokers 15. Monthly Income* a. Middle b. Middle- low c. Low 16. Education Level* a. High School Level b. Elementary c. No Formal Schooling 17. Exposure Level Area* a. Medium Pollution Area b. High Pollution Area
0.992 0.698 0.911 0.972 1.075 0.711 1.417 0.648 1.349 0.936 1.606 0.659 0.426 0.930 0.295 0.574 0.453 1.151 0.833 2.087 1.391 1.808
0.873-1.126 0.494-0.985 0.540-1.537 0.918-1.028 0.927-1.247 0.494-1.024 0.966-2.079 0.349-1.202 0.846-2.151 0.856-1.023 1.112-2.319 0.334-1.297 0.055-3.277 0.746-1.158 0.140-0.620 0.325-1.012 0.253-0.811 0.751-1.764 0.485-1.431 0.498-8.747 0.882-2.193 1.171-2.791
0.903 0.041** 0.728 0.321 0.337 0.067 0.074 0.169 0.208 0.147 0.011** 0.228 0.413 0.518 0.001** 0.055 0.008** 0.518 0.510 0.314 0.155 0.008**
*Reference Groups :Male, Minor Road, Other Cooking Fuels, Location of Cooking Facility-Outside, Father/Mother/Caretaker do not smoke,Middle- Upper income class, College and Higher/Vocational level, Low exposure level area ** Statistically Significant ***Crowding Index Number of persons per sleeping room
For the respiratory symptoms, the probable risk factors that came out significant are age, indoor nitrogen dioxide level, types of cooking fuel, location of cooking facility, monthly income levels, educational levels and the different exposure pollution areas as shown in Table 6.35.
101
Table 6.35 Rate ratios of probable risk factors of respiratory symptoms among 6-10 year old children, January May, 2003
Probable risk factors Rate Ratio
1. Age 2. Sex Female* 3.Location of Household: Major Road* 4. Indoor PM10 Level 5. Indoor Nitrogen dioxide level 6. LPG use* 7. Kerosene use* 8. Wood use* 9. Location of Cooking Facility: Inside the House* 10. Congestion Level** 11. Father Smokes* 12. Mother Smokes* 13. Caretaker Smokes* 14. Number of Smokers 15. Monthly Income* a. Middle c. Middle- low d. Low 16. Education Level* a. High School Level b. Elementary c. No Formal Schooling 17. Exposure Level Area* a. Medium Pollution Area b. High Pollution Area
1.028 0.998 1.010 1.00004 1.017 0.881 1.085 1.186 1.090 0.998 1.014 0.954 0.845 0.997 1.021 1.086 1.194 1.085 1.167 1.517 0.944 1.170
Confidence Interval 1.008-1.048 0.947-1.052
p-Value
0.005** 0.964 0.803 0.810 0.007** 0.000** 0.011** 0.000** 0.029** 0.771 0.619 0.308 0.140 0.893 0.757 0.187 0.005** 0.017** 0.000** 0.002** 0.092 0.000**
0.929-1.099 0.999-1.0003 1.004-1.029 0.831-0.934 1.019-1.156 1.100-1.279 1.008-1.177 0.985-1.011 0.959-1.071 0.872-1.044 0.676-1.056 0.966-1.030 0.893-1.167 0.960-1.229 1.056-1.349 1.014-1.161 1.080-1.262 1.168-1.971 0.884-1.009 1.098-1.246
*Reference Groups :Male, Minor Road, Other Cooking Fuels, Location of Cooking Facility-Outside, Father/Mother/Caretaker do not smoke, Upper income class, College and Higher/Vocational level, Low exposure level area ** Statistically Significant ***Crowding Index Number of persons per sleeping room
Regression analysis of significant probable risk factors with the health outcomes
Tables 6.36 and 6.37 show the risks posted by the different exposure risk areas in developing asthma episodes and respiratory symptoms, respectively. Controlling for other factors, it is clear that pollution levels affect the incidences of these two health outcomes. Living in the high pollution areas has the highest risk for both health outcomes. With regards the medium pollution areas, although not statistically significant, risks for developing both asthma episodes and respiratory symptoms of children are still higher than the low pollution areas but still lower than in the high pollution areas.
102
Table 6.36 Regression of the exposure areas with the asthma episodes among 6-10 year old children, January May, 2003
Exposure areas Rate Ratio Confidence Interval p-Value
Low Medium High

**Statistically Significant
1.00 1.427 1.800
0.886-2.299 1.141-2.840
0.144 0.012**
Table 6.37 Regression of the exposure areas with the respiratory symptoms among 6-10 year old children, January May, 2003
Exposure areas Rate Ratio Confidence Interval p-Value
Low Medium High

**Statistically Significant
1.00 1.214 1.435
0.898-1.641 1.064-1.936
0.207 0.018**
Table 6.38 below shows the effect of the other probable risk factors on asthma episodes. Significant factors are female sex, father smokes and monthly income. Children with fathers who smoke are shown to have higher risk as compared to those with fathers who do not smoke. Lesser risk is also seen among the female children as compared to the males. Lower income groups have also lower risk as compared to the higher income groups. This latter association may be due to more cases of doctor-diagnosed asthma reported among the higher income groups. These higher income groups may have more means to bring their children to the doctor as compared to the lower income groups. Thus, recognition of asthma attacks or episodes are more accurate for the higher income groups than the lower income groups. Table 6.38 Regression of the other significant probable risk factors with the asthma episodes among 6-10 year old children, January May, 2003
Rate Ratio Confidence Interval P Value
Probable risk factors
1. Sex Female* 2. LPG Use* 3. Kerosene Use* 4. Father Smokes* 5. Monthly Income* a. Middle c. Middle- low d. Low
0.662 0.660 1.012 1.598 0.210 0.497 0.355
0.464-0.945 0.377-1.154 0.569-1.798 1.102-2.318 0.093-0.474 0.274-0.900 0.189-0.665
0.023** 0.145 0.967 0.013** 0.000** 0.021** 0.001**
*Reference Groups :Male, Other Cooking Fuels, Father do not smoke, Upper income class **Statistically Significant
Apart from the exposure areas as a significant risk factor, other factors are identified in the occurrence of respiratory symptoms not seen in asthma episodes. Table 6.39 presents these factors namely the age of the child, the indoor nitrogen dioxide level and educational level of the respondent. This study shows that the older the child, the risk of developing respiratory symptoms is also much less. Young children are more sensitive to insults to their respiratory system than older children probably because of the young childs level of maturity of the organ system.
103
With regards to nitrogen dioxide levels, the results show that per unit increase in the level of this pollutant inside the house also increases the risk for respiratory symptoms by about 2.8%. Nitrogen dioxide is a known respiratory irritant and the probable sources inside the house could be the cooking fuel and the inflow of emissions from transport vehicles especially for those living along major roads. Finally, pertaining to educational level as a risk factor, the children in households with lower educational level of respondents have been shown to have higher risk for experiencing respiratory symptoms. Educational level is often used as an indicator of socio-economic status. The finding in this study is consistent with other studies which have shown that health of individuals is more compromised among those in the lower socio-economic groups. An example is the reanalysis of the Pope et al study where the educational attainment had been shown to be a predictor of mortality in association with air pollution (37). Table 6.39 Regression of the other significant probable risk factors with the respiratory symptoms among 6-10 year old children, January May, 2003
Probable risk factors Rate Ratio Confidence Interval p-Value
1. Age 2. Nitrogen dioxide 3. LPG Use* 4. Kerosene Use* 5. Wood Use* 6. Location of Cooking Facility: Inside the House* 7. Monthly Income* a. Middle c. Middle- low d. Low 8. Education Level* a. High School Level b. Elementary
0.897 1.028 0.967 1.081 0.851 0.923 1.137 1.061 1.135 1.287 1.819
0.826-0.974 1.0123-1.044 0.640-1.460 0.696-1.678 0.565-1.280 0.605-1.409 0.730-1.771 0.709-1.586 0.749-1.720 0.989-1.674 1.335-2.478
0.010** 0.000** 0.874 0.727 0.440 0.713 0.569 0.773 0.549 0.060 0.000**
*Reference Groups: Other Cooking Fuels, Father do not smoke, Upper income class, Low exposure level area **Statistically Significant
6.4.2
Adult health
For the qualified adults, the research assistants interviewed them monthly as to any respiratory symptom and asthma episodes experienced. The monitoring form developed for the interview is shown in Appendix 6-4. The data were encoded and entered into a spreadsheet for analysis. The analysis of these outcome variables included the different exposure areas and other variables that may influence the health outcomes. The data pertaining to these variables were taken from the results of the household survey. The results of the analysis of the health outcomes among the adult population were less interesting than the results of the child health analysis. First of all, very few cases of asthma for the adults were observed. In addition, the individual analysis of the probable risk factors for asthma did not yield anything significant. Thus, no regression analysis could be done for asthma. Secondly, for the respiratory symptoms, although the individual analysis of probable risk factors revealed a few significant factors, the results of the regression analysis yielded only one significant risk factor age.
Main Report. March 2004 104
The individual analysis of the probable risk factors for respiratory symptoms showed the following as significant: age of the adult, cooking fuel used, number of smokers and educational attainment as shown in Table 6.40. The exposure area variable, although not statistically significant, show some gradient among the three areas. However, as mentioned earlier, only age of the adult came out as significant in the regression analysis. The results of the regression analysis are shown in Table 6.41. The older the subject is, the higher the risk of developing respiratory symptoms.
Table 6.40 Rate ratios of probable risk factors of the respiratory symptoms among adults in sentinel barangays, January May, 2003 Probable risk factors Rate Ratio Confidence Interval p-Value
1.Age 2. Sex* 3. House location Major Road* 4. Indoor PM10 level 5.Indoor Nitrogen dioxide 6. LPG Use* 7. Kerosene Use* 8. Wood Use* 9.Location of Cooking Facility: Inside the house* 10. Congestion Level*** 11. Number of Smokers 12. Monthly Income* a. Middle c. Middle- low d. Low 13. Education Level* a. High School Level b. Elementary c, No Formal Schooling 14. Exposure Level Area* a. Medium Pollution Area b. High Pollution Area
1.012 1.098 0.985 1.0003 0.954 0.846 1.122 1.133 1.134 1.016 1.060 1.090 1.062 1.217 1.140 1.333 1.310 1.099 1.110
1.006-1.017 0.990-1.218 0.845-1.148 0.999-1.0008 0.915-0.994 0.760-0.941 1.0002-1.259 0.983-1.305 0.985-1.305 0.992-1.040 1.002-1.121 0.853-1.392 0.845-1.334 0.970-1.527 1.004-1.295 1.155-1.539 0.781-2.199 0.976-1.238 0.985-1.251
0.000** 0.074 0.851 0.258 0.026** 0.002** 0.049** 0.083 0.080 0.174 0.042** 0.490 0.605 0.088 0.043** 0.000** 0.305 0.118 0.086
*Reference Groups :Male, Minor Road, Other Cooking Fuels, Location of Cooking Facility-Outside, Upper income class, College and Higher/Vocational level, Low exposure level area ** Statistically Significant ***Crowding Index Number of persons per sleeping room
105
Table 6.41
Regression of the significant probable risk factors with the respiratory symptoms among adults in sentinel barangays, January May, 2003
Rate Ratio Confidence Interval p-Value
Probable Risk Factors
1.Age 2. House location Major Road* 3.Indoor Nitrogen dioxide 4. LPG Use* 5. Kerosene Use 7. Number of Smokers 8. Educational Level a. High School Level b. Elementary
1.048 1.854 0.954 0.616 0.768 1.210 1.010 0.829
1.024-1.071 0.733-4.685 0.910-1.0002 0.238-1.594 0.285-2.065 0.850-1.724 0.559-1.825 0.389-1.765
0.000 0.192 0.051 0.318 0.601 0.289 0.971 0.627
106
6.4.3 Health center monitoring

A pilot study was conducted among selected health centers in Metro Manila to determine the relationship between reported morbidity cases from respiratory symptoms and diseases over the period that ambient air monitoring for PM10 was conducted. Eighteen health centers within Metro Manila participated in the pilot study: one health center from each city/municipality except San Juan which has two. These health centers were nominated by their respective health offices based on their performance. Standardized extraction forms and definitions of the illnesses to be monitored were provided to the health center personnel (Appendix 6-5). Respiratory symptoms were recorded daily by the health center nurse while illnesses were diagnosed by the health center physician. The 18 health centers have a total catchment population of about 479,043. Shown in Table 6.42 are the health centers which participated in this study: Table 6.42 Participating health centers in health monitoring, January to May 2003
Health Center B. F. Homes Bagbaguin I. Mendoza HC Ibayo-Tipas Pamplona Ma. Clara Pugad Lawin Paso De Blas Pineda HC Project 7 Quintin de Borja San Isidro Bagong Lipunan San Juan Main Santulan Sucat West Crame West Rembo Catchment Population 73,430 23,817 30,854 16,014 46,908 7,047 37,000 15,604 16,665 26,046 12,745 40,136 22,983 49,000 10,132 52,426 13,946 30,465 City/Municipality Paraaque Kalookan Manila Taguig Las Pias Mandaluyong Marikina Valenzuela Pasig Quezon City Pateros Pasay Navotas San Juan Malabon Muntinlupa San Juan Makati
Four symptoms were regularly recorded which included cough with or without any other symptoms (colds, fever, headache), nasal discharge, wheezing and difficulty of breathing. Respiratory diseases such as sore throat, acute bronchitis, asthma and chronic bronchitis, and ischemic heart disease were the health outcomes monitored for this study. Weekly incidences of the said symptoms and illnesses were gathered from the health centers by the research assistants. Data were collected weekly for 24 weeks, January to June, 2003. For the exposure variable, PM10 levels were monitored for the same period from 6 ambient monitoring stations around the metropolis. Weekly averages were modeled from these stations using GIS. Each health centers area of coverage was assigned weekly exposure level for 20 weeks from January to May, 2003.
107
Weekly time series technique was used to analyze the association between PM10 and the health outcomes of concern. Three lag times were evaluated namely, lag 0 exposure and health outcome occur on the same week, lag 1 health outcome occurs 1 week after the exposure and lag 2 health outcome occurs 2 weeks after exposure. Analysis by age groups was undertaken. Table 6.43 below shows only the significant findings of this analysis. A complete listing of the results can be seen in Appendix 6-6. The most significant relative risks were for the following health outcomes: cough with or without any other symptoms for those less than 15 years old, nasal discharge among those less than 15 years old wheezing among less than 15 years old and15-64 years old difficulty of breathing among less than 15 years old and 15-64 years old acute bronchitis for those less than 15 years old and15-64 years old acute respiratory illness for those 1-4 years old and 5-14 years old asthma for those less than 15 years old upper respiratory tract illness for those less than 15 years old and 15-64 years old
A less significant relative risk is seen for sore throat among 65 years old and above individuals. The relative risks reported are increases in the health outcome per unit increase in PM10. For example, an increase of 0.38% is expected in the incidence of acute bronchitis among those who are less than 15 years old for every 1 ug/m3 increase in PM10. This means an increase of about 4 cases per thousand population is expected for every ug/m3 increase in PM10 level. Most of the symptoms and illnesses which were found to be significant tend to affect the younger age groups with greater magnitude except for wheezing and sore throat. This observation is not surprising because younger children are regarded as a vulnerable part of the population. These acute morbidity findings are generally consistent with international findings. The table also shows that acute respiratory illness defined as pneumonia and associated with PM10 pollution, affects the older children more than the infants. This result may primarily be due to the differences in their exposure time. Older children are more exposed to ambient air than infants. Significant findings for the elderly, >/= 65 years old, are quite limited in this study. Small number of cases and perhaps less elderly population in the study areas could account for this. Nevertheless, this study has shown positive associations between health outcomes and PM10 pollution in different age groups. Apart from demonstrating the association of PM10 with certain symptoms and illnesses, the main use of the relative risks calculated in this study is in future health risk assessments. This is until a more rigid time series analysis study, for example, daily instead of weekly, level of analysis and the control of variables such as temperature and humidity, could be undertaken.
108
Table 6.43 Time series analysis results of air pollution-related symptoms and illness and ambient PM levels in 18 health centers in Metro Manila, January-May 2003
Morbidity Endpoints: Symptoms Cough a. With other symptoms+ < 15 y/o*** 15-64* 65 />*** b. W/o other symptoms < 15 y/o** 15-64*** 65 />*** Wheezing < 15 y/o** 15-64*** 65 />** Difficulty of Breathing < 15 y/o** 15-64*** 65 />*** Nasal Discharge < 15 y/o*** 15-64*** 65 />** Morbidity Endpoints: Illnesses Sore Throat < 15 y/o*** 15-64** 65 />*** Acute Bronchitis < 15 y/o*** 15-64* 65 />** Asthma < 15 y/o*** >/= 15*** Acute Respiratory Illness <1 y/o** 1-4** 5-14*** Upper Respiratory Tract Illnesses < 15 y/o*** 15-64*** 65 />*** Relative Risks Confidence Intervals P Value
1.0012 1.0002 1.0021
1.0003- 1.0021 0.9977- 1.0027 0.9919- 1.0123
<0.05@@ >0.10 >0.10 <0.05@@ >0.10 >0.10 <0.05@@ <0.05@@ >0.10 0.000@@@ <0.05@@ >0.10 0.000@@@ >0.10 >0.10 P Value
1.0028 0.9994 1.0060 1.0045 1.0066 1.0020 1.0077 1.0051 1.0032 1.0034 1.0005 0.9985 Relative Risks
1.0014- 1.0042 0.9844- 1.0028 0.9925- 1.0197 1.0013- 1.0076 1.0005- 1.0127 0.9774- 1.0271 1.0049- 1.0103 1.0007- 1.0094 0.9892- 1.0173 1.0004- 1.0026 0.9964- 1.0045 0.9749- 1.0226 Confidence Intervals
1.0011 1.0023 1.0090 1.0038 1.0025 1.0013 1.0017 1.0014
0.9978- 1.0045 0.9967- 1.0079 0.9991- 1.0190 1.0032- 1.0044 1.0004- 1.0045 0.9888- 1.0138 1.0004- 1.0031 0.9981- 1.0047
>0.10 >0.10 <0.10@ <0.001@@@ <0.05@@ >0.10 <0.05@@ >0.10
1.0007 1.0018 1.0027
0.9987- 1.0027 1.0004- 1.0032 1.0002- 1.0052
>0.10 <0.05@@ <0.05@@ 0.000@@@ 0.000 @@@ >0.10
1.0021 1.0014 1.0016
1.0017- 1.0024 1.0006- 1.0022 0.9971- 1.0061
*lag 0, **lag 1, ***lag 2 + symptoms refer to any of the following: colds, headache, fever @ statistically significant at 0.10, @@ statistically significant at 0.05, @@@ highly statistically significant
109
6.4.4 Hospital emergency room and private clinic consultations An attempt to collect data was made to identify associations and trends between monthly air pollution levels and consultations to private doctors clinics and hospital emergency room consultation. A primary assumption made is that consultations done in these health facilities are from the population of the barangay where the facility is physically situated. A total of 11 private practitioners in private clinics and 5 hospitals in Metro Manila were recruited to provide prospective morbidity statistics data. A pro-forma patient consultation record to be accomplished by the private practitioner was developed by the project (Appendix 6-7). Project research associates collected hospital emergency room consultations on a monthly interval in sentinel hospitals in Metro Manila using a form developed for that purpose (Appendix 6-8) Monthly morbidity summary trends covering respiratory and cardiovascular symptoms and illnesses were prepared and compared with recorded levels of ambient air pollution near the clinic or hospital location. Analysis of trends between respiratory and cardiovascular illness from private clinics and hospital emergency room consultations vs. monthly levels of ambient air pollution did not show any correlation. (Appendix 6-9). Possible explanation for the non-correlation between the private clinic and hospital emergency room consultation rates and monthly PM10 levels can be attributed to the following: 1. Data limitations in terms of accuracy and completeness of data provided at source, and, 2. Inadequate data management by available sentinel hospital emergency room units resulting in missing records and absence of summary statistics.
110
6.5 GIS analysis

Ambient PM10 levels were measured several times in a week from January to May 2003 at eight monitoring stations, namely Mapulang Lupa in Valenzuela, the National Printing Office in Quezon City, the Manila Observatory in Quezon City, Calzada in Taguig, Martirez del 96 in Pateros, Almanza II in Las Pias, and Inarawan and Dela Paz in Antipolo City.
These measurements were then aggregated at the weekly and monthly time scales in order to estimate weekly and monthly ambient PM10 levels in each health center. The method by which the ambient PM10 levels were estimated is the same as that described in section 4.4.2 of the health risk assessment report. Figures 6.30a to 6.34e show the monthly variations in ambient PM10 levels for each health center in Metro Manila. From the figures, it may be inferred that (a) the northern part of Metro Manila has perennially high levels of ambient PM10 compared to the central and southern parts, and (b) the dry season (March to May) exhibits higher ambient PM10 levels than the wet season (January to February).
Representative ambient PM10 values for each health center and the 24 study barangays were extracted from the ambient PM10 grids using an ArcView GIS extension called Get Grid Values (v. 2.1). The extension calculates the centroid of each health center and study barangay, extracts the ambient PM 10 value from the relevant grid, and stores the value in the database. GIS maps for exposure to air pollutants are presented in Appendix 6-10.
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Fig. 6.30a Ambient PM10 levels in January 2003.
112
Fig. 6.30b Ambient PM10 levels in February 2003.
113
Fig. 6.30c Ambient PM10 levels in March 2003.
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Fig. 6.30d Ambient PM10 levels in April 2003.
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Fig. 6.30e Ambient PM10 levels in May 2003.
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Public Health Monitoring of the Metro Manila Air Quality Improvement Sector Development Program

Main Report. March 2004

Main Report. March 2004

Fig. 6.1 Percentage age distribution of study HH by exposure area

Low Medium High

Main Report. March 2004

Fig. 6.2 Education profile of survey respondents by location

Air Pollution Exposure Areas

9.5 9 8.5 8 1 Air Pollution Exposure Areas

Low Medium High

Main Report. March 2004

Fig. 6.4 Average household income distribution of barangays by location

Low Medium High

30 20 10 0 < 5,000 5,001 - 8,000 8,001 - 15,000 > 15,000

Pesos per month

Main Report. March 2004

Table 6.5 Household classification by house condition

30 20 10 0 Temporary Semi-permanent Permanent

Low Medium High

Fig. 6.6 Distribution of household in housing condition by exposure area

Low Medium High

Main Report. March 2004

60 40 20 0 Major traffic route Minor traffic route

Low Medium High

Location of Study Households (p = 0.02)

Main Report. March 2004

Low Medium High

Cooking Fuel Used

Main Report. March 2004

Low Medium High

60 40 20 0 Inside the House Outside the House

Low Medium High

Main Report. March 2004

Low Medium High

Main Report. March 2004

Fig. 6.13 Source of drinking water of HH by exposure area

Low Medium High

Drinking Water Source

Low Medium High

Main Report. March 2004

Low Medium High

Main Report. March 2004

Household member brought to the hospital in 2002

No N (%) 438 (72.3) 1,424 (80.7) 1,862

Yes N (%) 168 (27.7%) 340 (19.3) 508

Total 606 1,764 2,370

HH using wood No Yes Total

HH using wood No Yes Total

Main Report. March 2004

Table 6.11 Determinant of health center consultations, 2002

40 30 20 10 0 Chest Tightness Wheezing Severe Cough Chest Pain

Low Medium High

Main Report. March 2004

Fig. 6.17 History of hospitalization of HH members in 2002 by exposure areas

Symptoms Causing Hospitalization

40 30 20 10 0 Respiratory Diseases Cardiovascular Diseases Other Diseases (Accidental, Non-Accidental)

Low Medium High

Main Report. March 2004

Fig. 6.19 Access to specific health providers of study HH by exposure location

80 60 40 20 0 Health Center Traditional Hilot Private Doctor

Low Medium High

Main Report. March 2004

30 20 10 0 Good Fair Poor