AIR POLLUTION
AND LUNG
DISEASES
IN OPORTO
AREA
M . C . A L V I M F E R R A Z * , M. C. F A R I A F E R R A Z * , J. M . F E R R A Z * * and P . I. F O N S E C A * * Centro de Engenharia Qu(mica (INIC), Faculdade de Engenharia, Rua dos Bragas, 4099 Porto Codex, PortugaL ** Hospital Eduardo Santos Silva, Centro Hospitalar de V.N. de Gaia, Portugal
(Received October 1988) Abstract. This area has a rate of patients with obstructive chronic lung disease that is the highest in Portugal and the second in Europe. Levels of pollution observed in 1985/86 and 1986/87 allowed evaluating the effects of concentrations lower t h a n those that usually cause acute episodes. It was observed that even low levels of strong acidity can be related with lung diseases, when observed simultaneously with appreciable levels of black smoke; climatic factors have a synergetic effect.
1. Introduction
O p o r t o is the second largest city of Portugal and is situated in the North (latitude and longitude approximately 41010 ' N and 8040 ' E). The center part is rather old, with very narrow, dark streets, bordered by high houses which visibly hinders the dispersion of pollutants. Residential areas surround the center of the town. Industrial activity is composed of small enterprises. The older factories spread over the region in an unruly manner. Major factories are localized in Matosinhos which is a deep-water port serving the region. The most important fixed sources o f air pollutants are f r o m the oil refinery and the petrochemical factory. In urban areas, m o t o r traffic is without doubt the main reason for the pollution levels [1]. The region is limited on the west by Atlantic Ocean and southerly by river Douro. Topographically the zone is rather uneven; altitude decreases with proximity to the coast the m a x i m u m being about 300 m. There are no outstanding relief areas, therefore it should not interfere in normal circulation of winds. In climatic terms, this area is designated as maritime North and it is characterized by w a r m and dry summers and mild and wet winters with two transition seasons: spring and autumn. The yearly mean air temperature varies between 12.5 and 15 ~ the difference between warmer and colder monthly averages being less than 10 ~ Annual air humidity averages between 75 and 80~ and the annual mean precipitation is between 1000 and 1200 m m , being more than a hundred the number of days during the year in which precipitation is equal or higher than 1.0 m m . Prevailing winds are f r o m W and NW. This area has a rate of patients with obstructive chronic pulmonary disease (OCPD) that is the highest in Portugal and the second one in Europe, immediately after London. Environmental Monitoring and Assessment 11: 183-192, 1988. 9 1988 Kluwer Academic Publishers. Printed in the Netherlands.
184
M. C. ALV1M FERRAZ
ET AL.
Several researchers have referred to the existence of a very close relationship between levels of atmospheric pollution and h u m a n health relating to lung diseases. This is why the impact study reported in the present paper was undertaken. This preliminary study, allowed the establishment of a methodology to be followed in the epidemiological study now in progress. Acute episodes as ocurred in L o n d o n in 1952 have been thoroughly studied. The hospitalization of more than 10,000 people victims of respiratory deficiency and the four-fold increase in mortality rate showed the existence of a very clear dependence relationship. Nevertheless, knowledge about health effects of 'admissible' pollutant concentrations when maintained for a long time, is still scanty. Since the air quality in the O p o r t o Area is generally in compliance with these standards, a study was conducted to relate monthly levels o f pollution observed during two years, with O C P D morbidity and mortality. It was tried as well, to relate O C P D mortality rate with Air Quality over several years.
2. Experimental and methodology of analysis Strong acidity (expressed as sulfur dioxide) and black smoke, were respectively determined by hydrogen peroxide and shade-reflectance methods [2,3]. A data bank of daily averages determined from our pollutant measuring network was created and statistically analysed using a W A N G - V S computer. The twelve m o n t h period f r o m 1st of April of each year until 31st of March of the next year was used. As pollutant levels in 1985/86 and 1986/87 were low enough to make possible the study of low concentration effects on health, those periods were analysed in a more detailed way. Percentages o f valid observations were calculated for each site of the network. Monthly, six-monthly and yearly averages were calculated when there were at least 20~ of valid daily averages. For six-monthly and yearly means it was also necessary, to verify that percentage, at each calender quarter [4]. Arithmetic and geometric means and respective standard deviations were determined. Values below the detection limit of the method were considered as one half of that limit [4]. Pollution episodes were detected comparing attained levels with guide and limit values for the European Economic C o m m u n i t y (EEC) [5]. As these values are not fixed for strong acidity, to simplify the analysis they were considered similar to those imposed for sulfur dioxide. Therefore with the objective of detecting the referred episodes, tables relative to the frequency of the persistence of exceeding determined pollution levels were elaborated. The Air Pollution characterization for the 1985/86 and 1986/87 periods presented here, was previously analysed in a more detailed way [1].
17,2 12.3 15,2 16.6 15.7 36.8 39,5 ?6.0 31.5 28,8 23.2 ?0.4
!II.0 19.71 )6.57 !8,52 !6.03 ~27.3 !13.0 I15,4 ~18-6 !33.8 !28,3 !2~,3
15.8 9.48 11.7 15.0 12.5 --40.9 26,0 34.4 22.0 14.4 14.5
85
!5.00 12.1 !5.00 9,77 )5,00 8.27 ~5.D0 ?.5& !S.00 14.6 !16.5 33.6 ! . . . . . . !10,5 56.9 ! . . . . . . !5,20 2&,4 !7.61 16.7 !9.00 18.5
4
!
! . . ! . . ! . . ! . . ! . . ! . . ! . . 1 . . ! . . !45,8 ! . . !32.4
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. . . . . . . . .
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. . . . . . . . . 23.5 . . . . 12.3
. . . . . . . . .
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1560 !17.1 !16.7 0.0 ! I~ ) 54 ! 67 88.0 !11.5 !2.38
35& !332 20.6 !7.90 19.3 !7,50 1,0! 0.0 14 ! 5 65 ! 24 79 ! 35 94.0! 51.0 13.9 !6.36 2.42 11.73
327 !125 22.4 ! . . . 25.9 ! . . . 1.0! 0.0 13 ) . . . 77 ! . . . 99 ! . . . 210.0!135.0 13.2 ! . . . 2.29 ! . . .
. .
. . .
. .
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. . . . . . . .
. .
. . .
. .
. . . . . . . .
7
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. . . .
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17~ 28.3 19.9 1.0! 26 67 7o 98.0! 21.0 2.52
182 18,9 13.5 ?.0! 14 45 53 73.0! 15.0 2.01
GSD - g e ~ t r l c
s t a n d a r d deviation;
GM - g e o m e t r i c mean;
ASD - arithmetic
181 !149 25.5 !9.18 22.~ !8.44 1.0! 0.0 17 ) 5 74 ) 25 86 ! 36 94.01 51.0 16,3 !7.15 2.74 11,87
173 !183 15.5 !6.85 12.7 !6.4q I,0! 0,0 11 ! 5 43 ! 22 51 ~ 32 71.01 46,0 11.7 !5.78 2.12 !1.58 . . . . . .
. . . . . . . . .
. . . . . .
s t a n d a r d deviation.
. . . . . .
. . . . . . . . .
!301 !10.1 110,8 0.0 ! 5 ) 34 ) &2 70,0 !7.36 )Z.O0
!
159 !182 32.3 !20.0 29,1 )I~.3 1,0! 0.0 22 ) 13 90 ! 49 112 ! 53 146.0!102.0 21.0 !14.0 2.72 !2.41
132 !183 --!13.1 --!12,5 1.0! 0.0 --" ! 5 --! 37 --! 4? 84.0! 78.0 "'!9.28 --!2.19
296 !365 26.5 !16.5 25.1 !14.9 1,0! 0.0 18 ! 11 83 ! 46 105 ! 53 166.0!102.0 17.1 111.4 2.67 !2.36
117.9 )l&.3 ill.; !12.5 !6.55 !16.3 117.2 121.~ !23.0 !23.4 !13.3 !18.8
~ SA
10
!APR !MAY )JUN !JUL !AUG !$EP !OCT !NOV )DEC !JAN !FEB !~AR ! .
) I I ) ! ! ) ) ! ! ~ ~
179 !NOB! 25.5 t A~ 24.5 !ASD 1.O!M[N 17 !50~ ?5 !95I 98 !9BX 107.0!MAX 14.8 ) GM 3.07 !GSO
! ! ! ! ! ! ! ! !
!
129 iN OB! 1 1 . 9 ! A~ ~ 11.4 )~$0 ! 1,O)R(N ! B !50X ! 37 !95x ! 46 !98X ! 61.O)MAX ! 8 . 2 5 ! GR ! 2 . 3 3 !GSD !
)'
358 IN 0 8 ! 1 8 . 5 ! AM ! 20,2 !ASD ! 1.O!RlN i 10 !53X ) 63 !95X ! ?6 198X ! 107.0IRAX ! 11.3 ) GM ! 2.83 !GSP '
12.7 8.55 6.97 6,77 8.9~ 27.6 40.2 26.6 30.~ 23,4 13.4 14.4
!SITE! o .......... @ 8S ~ AM !
N 08 - n u m b e r of valid o b s e r v a t i o n s ;
164 !163 31.5 !8.79 2~,2 )S.82 1.0! 0.0 21 ) 5 84 ! 32 133 ~ 39 130.0! 48.0 18.9 !6.78 3.05 !1.8&
127 !138 15,7 ~11,? 15.3 112.7 1.0! 0,0 11 ! 5 47 ! 35 35 ! 53 96.01 70.0 11.0 !8.11 2,31 !2.16
341 23.3 25.8 1,0! 14 77 57 130.0! 14.3 2.76
BS
!9.10 22.5 !II,0 15.1 ! . . . . . . !6.68 11.7 !13.3 11.7 ! . . . . . . !10.0 30,4 112.B 12,1 !12.1 39.2 ~7.00 33.0 ! . . . . . . )5.00 15.9
! 9 _ ........................... 8S ! SA
50%~ 95% and 98% - 50th, 9 5 t h and 9 8 t h percentiles;
to l~rch;
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. . . . . .
TO
. . . . . .
. . . . . . . . .
. . . . . .
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37
A P R . . . M A R - April
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(O~TOBER ~2 . . . . . . 1.0! 0.0 ! . . . ! . . . ! . . . 88.0! 27~ ! . . . ! . . .
80
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MAX - mexl " = m value;
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. . . . . .
. . . . . . . . .
. . . . . .
SERESTEM
! 4& ! . . . ! . . . 0,0 ! . . . ! . . . ! . . . 74.0 ! . . . ! . . .
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180 15.2 15.2 1.0! q 47 61 85.0! 10.3 2.36
MIN - m i n i m u m value;
~A - strong acidity;
1181 123.1 119,1 0.0 ) 18 ! 61 ! 73 88.0 !16.2 12,41
~12t ~11.1 !11,2 0,0 I 5 ! 34 I 49 76.0 !8.16 )2.03
A M - a r l t h m e t l c mean;
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!
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8
114.2 13,6 !17.6 9.74 19.85 8.78 115.3 13.8 !17.a 1~.0 !34.2 37,5 !25.1 45,6 t25.3 35.7 !27.? 36.3 !31.1 33.4 ! . . . . . . !41.1 l&.O
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YEAR .................................................................................................................................
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TO SEPTEMBER)
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strong
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deviation;
SA -
standard
mean;
BS -
black
standard
deviation.
APR...NAR
- Apt1| MAX - m e x t m u m v a T u e ;
smoke;
MI N - m ~ n i m u m v a l u e ;
acidtty;
' ....................................................................................................
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to March;
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percentl|es;
observations; and 981h
valid gSth
of
3.....
23 58 64 73.8 18.5 2 36
.4
163 25.2 17.7
1~6 24.5 19.4
.~ 15 53 39 73.8 1~.1 2.38
~0 19.9 15.9
17.1 12.6 12,B 13.9 13.5 15.6 3~.3 32.7 27.6 ~2.1 19.5 14.5
8S
127 13.0 9.71 1.0 9 33 37 ~9.4 9.9~ 2.11
8
127 24.1 20.3 0.0 19 63 75 83.4 16.0 ~.61
273 24.3 19.S O.~ 21 62 75 1OO.2 16.6 2.5~
26.7 5.7~ 24.1 26.0 25.3 23.4 29.0 33.3 23.~ 21.3 20.3 13.6
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123 1~.2 10.6 1.1 12 35 38 66.5 11.0 2.08
NOB
. . . . . .
. .
. . . . . . .
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11.8 12.3 16,0 19.6 9.16
and 98r
! 124 134 ~ 1&3 139 ! 121 13.6 ! 14,~ 1Z.6 ! 61.7 8.65 ! 22.9 9.10 ! IS.D 10.7 ! 26.4 7.37 ! 18.3 1.5 ! 0.0 .6 { 0.0 1.0 } 0.O !50~ ! 12 ! ?0 9 ! 60 6 ! 17 !9SX ! 32 ! 34 32 ! 104 23 ! 59 !9EE ! 35 ! 50 48 ! 105 ]& | 71 !MAK ! 62.0 [ 122.8 54.6 ! 113.2 60.| ! 8B.3 ! Gn ! 32.& 11.2 ! 10.2 9.19 ~ 55.3 6.70 ! 16.~ !GSD ! 2.1D 1,90 ! 2.20 2.21 ! 1*7~ 1.97 ! 2.36 i ................................................................................................................................. SEMESTER (OCTOBER TO MARCH) i ................................................................................................................................. 142 ~ 160 1~1 125 107 O N Oa ~ 161 9t .* ! ~M ! 38.3 30.2 ! 18.6 24.1 ! 19.6 26.5 ! . . . . . !ASD ! 21.0 1B.5 ! 19.5 18.3 ~ 13.~ 16o8 ! . . . . . !MX~ ! 1.6 2.9 ! 0.0 O.0 ! 0.0 .7 ! . . . . . . !$Og! 34 27 ! 13 19 ! 16 23 ! . . . . . !95X ! 73 5B ! 66 53 ! 51 59 ! . . . . . !9gg ! 89 69 ! 80 64 ! 61 61 ! . . . . . !MAX ! 99.4 115.6 ! 119,1 lOB.] ! 67.2 66.7 { . . . . . ! 6fl ! 31.5 24.2 ! 12.5 17.9 ! 15.7 20.7 ! . . . . . !GSD ! 2.01 2.08 } 2,37 2.28 ! 1.98 2.18 . . . . .
SEMESTER
TE~R ! ................................................................................................................................. !N 0 8 ! 319 276 ! 28 ~ 275 ! 268 ! AM ! 39.1 22.2 ! 16.8 18.5 ! 42.1 !ASO ! 11.5 16.8 [ 17.8 16.1 ! 29.0 !M[H ! 0.0 1.5 ! 0.0 0.0 ! 0.0 !SO~ ! 36 17 ! 11 1~ ! 37 !9SX ! 73 5~ ! 53 49 ! 96 !98X ! 85 63 ! 75 55 ! 104 !NRX ! IZ0.6 !15.6 ! 122.8 IO$.5 f 113.2 ! GH ! 32.0 16.6 ! 11.4 12.9 ! 30.8 !GSO ' 2.33 2.20 2.31 2.60 2.40 , 9' 9'
50,~ 26.8 46.6 56.6 3a.~ 31.9 ~7.7 40.6 36.3 36,0 62.9 24.7
....................................................................................................
~
!APR ! !RAY ! ~JU~ ! !JUL ! !AJ~ ! !Ss ! !OCT ! !NO~ ! !DEC ! !J~N ! !FEB ! ~MAR !
.'
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DATE
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! ~ 06102/86
! !
! 04/09/85 ! ! ! ! !
~ ! ! ! ! !
=. ~kAC~ S~tCE-SITE 09 =========================================================================================== ! ! ! ! SO ! 11 3 1 3 1 ! 6
! ~ 19/10/85
! !
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! ! ! ! ! !
MAX - ~ration of the hi~est persistamce OAT[ - last day when the highest persistance was observed lEAN - mean of persistance duration
1r
9 !
86187
Relationship between morbidity and climatic factors. Rainfall / . . . . . . Temperature *__* Emergency room visits
! ! ! !
190
M. C. A L V I M F E R R A Z E T A L .
TABLE IV Frequency of persistences - 1986/87 = s ~ m ~ s ~ s g n = i s = t s ~ l m ~ = s m ~ s i z i s s a R = = ~ l ~ = = = = t ~ = = a i ~ = s s ~ = I = = ~ = = = = l ~ = = = l = ~ = ~ = B = = = = = = s = = i
! $TROIG ZZIZIIIIIt ! 50 ] *. 100 ! ! 150
! ! ! ! ~ !
ACIDITY-SITE O5 iItZIJIIZmlZIIIZSIU=IZIZZWSIWSZZZII~laZZZIIIISZZlIZZ
! !
! !
200
10
3
3
2
1
1
2
1
"1
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! ! ! ! ! !
5,15 2,00
! !
!
I I I I I I = l l l l l = l = l I i I I I i l l l I I I l l l l I I I = l l l l l l I I I I I I I I i l I I I l l l l l l l I I I I l l l l l l l l l II = l I I l l I I I ~ I ~ l
I
!
!
ILACK
SROKE-SZT[
01
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! *. ! !
50 100 150
!
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3
1
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z ~ z = z z ~ z z z z = a ~ z u z ~ z ~
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z ~ z z z z ~ a u
! 311101~6 ! ! 05103/0? ! ~
! ! ! ! ~
!
!
1.~8 1o00
! ! .* ! ! !
IV,X - duration of the highest persistaace DAT[ last clay when the highest persistance ~as observed ~ N - meim o~ Im'Sistaace duration -
Thus, this period seems to be particularly indicated for evaluating effects of pollution levels lower than those that usually cause acute episodes. In Figure 2, strong acidity and black smoke monthly averages and number of emergency r o o m visits of the O C P D nature, are related. It can be observed that during 1985/86, even for very low concentrations, an increase or a decrease in strong acidity levels are generally accompanied by a similar variation in the number of emergency r o o m visits (Figure 3). This is true during all the year, including summer, being to note that the increase of strong acidity levels observed during the last days of September was followed by an increase of morbidity during the first days of October. This excludes influence of some climatic factors like temperature and humidity, which traditionally are believed to have a strong influence on O C P D . During 1986/87 this relationship is not so clear. A marked increase of morbidity is not observed in relation to the June-July strong acidity peak. A relationship between black smoke and morbidity is not to be considered, nevertheless it is interesting to analyse Figure 2, comparing simultaneous evolution of both pollutants. It can be observed that in September 85 strong acidity level increased, accompanied by an increase of black smoke level, this fact being related with an increase of morbidity as was already referred. In June-July 86 there is also an increase of strong acidity concentration, but the level of black smoke was maintained very low, none increase of morbidity corresponding to this period. In October 86 an accentuated increase of black smoke concentration was observed, strong acidity being lower than in June-July. It can be observed that to this period corresponds an elevated number
AIR POLLUTION
191
A N D L U N G D I S E A S E S 1N O P O R T O A R E A
o f O C P D emergency room visits and internments. It is important to note that this happens with climatic factors adverse to O C P D worsening: smooth temperature and low humidity (Figure 4). These remarks show that the influence of temperature and humidity seems to be smaller than pollution influence. Similar results are referred by other authors [6, 7, 8, 9]. (Wind absence and high atmospheric pressure are also related with worsening of O C P D and this can be only explained because these weather conditions are usually associated with high pollution levels [10]. The relative decrease of emergency room visits and internments observed in November 86, associated to considerable pollution levels of both pollutants and worse climatic conditions, was interpreted in relation to the fact that some of the patients hospitalized in October can still be at the Hospital in November. By other hand it can be expected with some patients, a preventive effect through the medical treatment given in the foregoing month. It can be concluded that even low levels of strong acidity can be related with OCPD worsening, when verified simultaneously with appreciable levels of black smoke, the climatic factors having a synergetic effect. By some means, it is important to note that for a study like this, that involves so many parameters, two years is positively a short period. These conclusions should be confirmed with posterior analysis and completed with the epidemiological study now under progress. In Figure 5, strong acidity monthly averages are compared with monthly mortality rates by O C P D in Oporto area. The relationship between these two parameters, presented by other authors [11, 12], is not so clear in this study. A significant similar variation was only observed in December-February 85/86 and in November-December 86. These observations are weak enough to allow some conclusions. In Oporto area, a global decrease on annual strong acidity levels was observed
|
4G
.7
L
O
E 9 a n
8 85/86
Fig. 5.
86/87
Relationship between strong acidity levels and mortality rate in Oporto area. Strong acidity / *__* Mortality rate
192
M.C.
ALV1M FERRAZ ET AL.
along the last years [1], simultaneously with a generic decay on mortality rates by OCPD and general mortality (Table V). TABLE V Mortality rate/1000 - Oporto area
1971 1973 1974 1975 1979 1980 1981 1982 1983 1984 1985
OCPD
General
OCPD/General
0.456 0.448 0.444 0.390 0.326 0.262 0.223 0.242 0.252 0.238 0.236
11.1 10.4 10.6 10.6 10.1 8.86 6.82 8.73 8.95 9.17 8.85
0.041 0.043 0.042 0.037 0.032 0.030 0.033 0.028 0.028 0.026 0.027
The trend toward a decrease of the annual ratio between these two rates (OCPD/General), suggest that the decrease of mortality by OCPD, more than being related with socio-economic factors, should also be correlated with the gradual improvement on Air Quality of the area.
Acknowledgments Support of this work was provided by Comiss~o de Coordenag~o da Regi~o do Norte, Instituto Nacional de Investigag~o Cientifica and Reitoria da Universidade do Porto.
References [1] Alvim Ferraz, M. C. and Faria Ferraz, M. C.: 1987, 'Evolution of Air Pollution in Oporto Area', Istambul, Environment 87, 493. [2] ISO/DIS - 4220. 2, 1982. [3] AFNOR NFX 43/005, 1977. [4] G.E.M.S. 'Analysing and Interpreting Air Monitoring Data', WHO, Geneve, 1980. [5] Journal offieiel des Communaut~s europ~ennes, Directive du Conseil 80/779/CEE, 15 Juillet 1980. [6] Ferris Jr, B. G., Speizer, F. E., Spengler, J. D., Dockery, D., Bishop, Y. M. M., Wolfson, M., and Humble C.: 1979, American Review o f Respiratory Disease 120, 767. [7] Samet, J. M., Speizer, F. E., Bishop, Y., Spengler, J. D., and Ferris Jr. B. G.: 1981, Journal o f the A i r Pollution Control Association 31, 236. [8] Higgins, I. T. T., Cochrane, A. L., Gilson, J. C., and Wood, C. H.: 1959, Brit. J. Industr. Med. 16, 255. [9] Holland, W. W., Spicer, C. C., and Wilson, J. M. G.: 1961, Lancet ii, 338. [10] Mosquera Pestafia, J. A., Fernandez Bustillo, E. and Rodriguez Gonzalez, P.: 1978, Archivos de Bronconeulogia, Vol. 14, No. 2, pp. 66-69, Oviedo, Spain. [11] Stocks, P.: 1963, Proc. Roy, Soc. B. 159, 78. [12] College of General Practitioners, Brit. Med. J. ii, 973, 1961.
AND LUNG
DISEASES
IN OPORTO
AREA
M . C . A L V I M F E R R A Z * , M. C. F A R I A F E R R A Z * , J. M . F E R R A Z * * and P . I. F O N S E C A * * Centro de Engenharia Qu(mica (INIC), Faculdade de Engenharia, Rua dos Bragas, 4099 Porto Codex, PortugaL ** Hospital Eduardo Santos Silva, Centro Hospitalar de V.N. de Gaia, Portugal
(Received October 1988) Abstract. This area has a rate of patients with obstructive chronic lung disease that is the highest in Portugal and the second in Europe. Levels of pollution observed in 1985/86 and 1986/87 allowed evaluating the effects of concentrations lower t h a n those that usually cause acute episodes. It was observed that even low levels of strong acidity can be related with lung diseases, when observed simultaneously with appreciable levels of black smoke; climatic factors have a synergetic effect.
1. Introduction
O p o r t o is the second largest city of Portugal and is situated in the North (latitude and longitude approximately 41010 ' N and 8040 ' E). The center part is rather old, with very narrow, dark streets, bordered by high houses which visibly hinders the dispersion of pollutants. Residential areas surround the center of the town. Industrial activity is composed of small enterprises. The older factories spread over the region in an unruly manner. Major factories are localized in Matosinhos which is a deep-water port serving the region. The most important fixed sources o f air pollutants are f r o m the oil refinery and the petrochemical factory. In urban areas, m o t o r traffic is without doubt the main reason for the pollution levels [1]. The region is limited on the west by Atlantic Ocean and southerly by river Douro. Topographically the zone is rather uneven; altitude decreases with proximity to the coast the m a x i m u m being about 300 m. There are no outstanding relief areas, therefore it should not interfere in normal circulation of winds. In climatic terms, this area is designated as maritime North and it is characterized by w a r m and dry summers and mild and wet winters with two transition seasons: spring and autumn. The yearly mean air temperature varies between 12.5 and 15 ~ the difference between warmer and colder monthly averages being less than 10 ~ Annual air humidity averages between 75 and 80~ and the annual mean precipitation is between 1000 and 1200 m m , being more than a hundred the number of days during the year in which precipitation is equal or higher than 1.0 m m . Prevailing winds are f r o m W and NW. This area has a rate of patients with obstructive chronic pulmonary disease (OCPD) that is the highest in Portugal and the second one in Europe, immediately after London. Environmental Monitoring and Assessment 11: 183-192, 1988. 9 1988 Kluwer Academic Publishers. Printed in the Netherlands.
184
M. C. ALV1M FERRAZ
ET AL.
Several researchers have referred to the existence of a very close relationship between levels of atmospheric pollution and h u m a n health relating to lung diseases. This is why the impact study reported in the present paper was undertaken. This preliminary study, allowed the establishment of a methodology to be followed in the epidemiological study now in progress. Acute episodes as ocurred in L o n d o n in 1952 have been thoroughly studied. The hospitalization of more than 10,000 people victims of respiratory deficiency and the four-fold increase in mortality rate showed the existence of a very clear dependence relationship. Nevertheless, knowledge about health effects of 'admissible' pollutant concentrations when maintained for a long time, is still scanty. Since the air quality in the O p o r t o Area is generally in compliance with these standards, a study was conducted to relate monthly levels o f pollution observed during two years, with O C P D morbidity and mortality. It was tried as well, to relate O C P D mortality rate with Air Quality over several years.
2. Experimental and methodology of analysis Strong acidity (expressed as sulfur dioxide) and black smoke, were respectively determined by hydrogen peroxide and shade-reflectance methods [2,3]. A data bank of daily averages determined from our pollutant measuring network was created and statistically analysed using a W A N G - V S computer. The twelve m o n t h period f r o m 1st of April of each year until 31st of March of the next year was used. As pollutant levels in 1985/86 and 1986/87 were low enough to make possible the study of low concentration effects on health, those periods were analysed in a more detailed way. Percentages o f valid observations were calculated for each site of the network. Monthly, six-monthly and yearly averages were calculated when there were at least 20~ of valid daily averages. For six-monthly and yearly means it was also necessary, to verify that percentage, at each calender quarter [4]. Arithmetic and geometric means and respective standard deviations were determined. Values below the detection limit of the method were considered as one half of that limit [4]. Pollution episodes were detected comparing attained levels with guide and limit values for the European Economic C o m m u n i t y (EEC) [5]. As these values are not fixed for strong acidity, to simplify the analysis they were considered similar to those imposed for sulfur dioxide. Therefore with the objective of detecting the referred episodes, tables relative to the frequency of the persistence of exceeding determined pollution levels were elaborated. The Air Pollution characterization for the 1985/86 and 1986/87 periods presented here, was previously analysed in a more detailed way [1].
17,2 12.3 15,2 16.6 15.7 36.8 39,5 ?6.0 31.5 28,8 23.2 ?0.4
!II.0 19.71 )6.57 !8,52 !6.03 ~27.3 !13.0 I15,4 ~18-6 !33.8 !28,3 !2~,3
15.8 9.48 11.7 15.0 12.5 --40.9 26,0 34.4 22.0 14.4 14.5
85
!5.00 12.1 !5.00 9,77 )5,00 8.27 ~5.D0 ?.5& !S.00 14.6 !16.5 33.6 ! . . . . . . !10,5 56.9 ! . . . . . . !5,20 2&,4 !7.61 16.7 !9.00 18.5
4
!
! . . ! . . ! . . ! . . ! . . ! . . ! . . 1 . . ! . . !45,8 ! . . !32.4
~ ~A
. . . . . . . . .
. . . . . . . . .
BS
. . . . . . . . . 23.5 . . . . 12.3
. . . . . . . . .
5
! SA
18.93 1 . . ! . . ! . . ) . . ~ . . ! . . ! . . ! . . !26.8 !29o8 !25.5
!
1560 !17.1 !16.7 0.0 ! I~ ) 54 ! 67 88.0 !11.5 !2.38
35& !332 20.6 !7.90 19.3 !7,50 1,0! 0.0 14 ! 5 65 ! 24 79 ! 35 94.0! 51.0 13.9 !6.36 2.42 11.73
327 !125 22.4 ! . . . 25.9 ! . . . 1.0! 0.0 13 ) . . . 77 ! . . . 99 ! . . . 210.0!135.0 13.2 ! . . . 2.29 ! . . .
. .
. . .
. .
124 . . . . 0.0! . . . . . . 88.0! . . . .
!129 ! . . . ! . . . 0.0 ! . . . ! . . . ! . . . 27.0 ! . . . ! . . .
. . . . . . . .
. .
. . .
. .
. . . . . . . .
7
17.7 .
. . . 30.1 13.9 l&.Z
. . . .
SA
17~ 28.3 19.9 1.0! 26 67 7o 98.0! 21.0 2.52
182 18,9 13.5 ?.0! 14 45 53 73.0! 15.0 2.01
GSD - g e ~ t r l c
s t a n d a r d deviation;
GM - g e o m e t r i c mean;
ASD - arithmetic
181 !149 25.5 !9.18 22.~ !8.44 1.0! 0.0 17 ) 5 74 ) 25 86 ! 36 94.01 51.0 16,3 !7.15 2.74 11,87
173 !183 15.5 !6.85 12.7 !6.4q I,0! 0,0 11 ! 5 43 ! 22 51 ~ 32 71.01 46,0 11.7 !5.78 2.12 !1.58 . . . . . .
. . . . . . . . .
. . . . . .
s t a n d a r d deviation.
. . . . . .
. . . . . . . . .
!301 !10.1 110,8 0.0 ! 5 ) 34 ) &2 70,0 !7.36 )Z.O0
!
159 !182 32.3 !20.0 29,1 )I~.3 1,0! 0.0 22 ) 13 90 ! 49 112 ! 53 146.0!102.0 21.0 !14.0 2.72 !2.41
132 !183 --!13.1 --!12,5 1.0! 0.0 --" ! 5 --! 37 --! 4? 84.0! 78.0 "'!9.28 --!2.19
296 !365 26.5 !16.5 25.1 !14.9 1,0! 0.0 18 ! 11 83 ! 46 105 ! 53 166.0!102.0 17.1 111.4 2.67 !2.36
117.9 )l&.3 ill.; !12.5 !6.55 !16.3 117.2 121.~ !23.0 !23.4 !13.3 !18.8
~ SA
10
!APR !MAY )JUN !JUL !AUG !$EP !OCT !NOV )DEC !JAN !FEB !~AR ! .
) I I ) ! ! ) ) ! ! ~ ~
179 !NOB! 25.5 t A~ 24.5 !ASD 1.O!M[N 17 !50~ ?5 !95I 98 !9BX 107.0!MAX 14.8 ) GM 3.07 !GSO
! ! ! ! ! ! ! ! !
!
129 iN OB! 1 1 . 9 ! A~ ~ 11.4 )~$0 ! 1,O)R(N ! B !50X ! 37 !95x ! 46 !98X ! 61.O)MAX ! 8 . 2 5 ! GR ! 2 . 3 3 !GSD !
)'
358 IN 0 8 ! 1 8 . 5 ! AM ! 20,2 !ASD ! 1.O!RlN i 10 !53X ) 63 !95X ! ?6 198X ! 107.0IRAX ! 11.3 ) GM ! 2.83 !GSP '
12.7 8.55 6.97 6,77 8.9~ 27.6 40.2 26.6 30.~ 23,4 13.4 14.4
!SITE! o .......... @ 8S ~ AM !
N 08 - n u m b e r of valid o b s e r v a t i o n s ;
164 !163 31.5 !8.79 2~,2 )S.82 1.0! 0.0 21 ) 5 84 ! 32 133 ~ 39 130.0! 48.0 18.9 !6.78 3.05 !1.8&
127 !138 15,7 ~11,? 15.3 112.7 1.0! 0,0 11 ! 5 47 ! 35 35 ! 53 96.01 70.0 11.0 !8.11 2,31 !2.16
341 23.3 25.8 1,0! 14 77 57 130.0! 14.3 2.76
BS
!9.10 22.5 !II,0 15.1 ! . . . . . . !6.68 11.7 !13.3 11.7 ! . . . . . . !10.0 30,4 112.B 12,1 !12.1 39.2 ~7.00 33.0 ! . . . . . . )5.00 15.9
! 9 _ ........................... 8S ! SA
50%~ 95% and 98% - 50th, 9 5 t h and 9 8 t h percentiles;
to l~rch;
!168 !29.5 122.1 1.01 0.0 ! 25 ! 71 ! 85 83~ !20,5 !2.56
88
M&RCH)
. . . . . .
TO
. . . . . .
. . . . . . . . .
. . . . . .
!178 !18.3 !17.5 1.01 0,0 ! 14 ! 52 ! 66 &3.0!101,0 !12.2 )2.45
37
A P R . . . M A R - April
! ! !
(O~TOBER ~2 . . . . . . 1.0! 0.0 ! . . . ! . . . ! . . . 88.0! 27~ ! . . . ! . . .
80
! ! !
57 . . . . . . 0.0! 0.0 ! . . . ! . . . ! . . . 40.0! 32,0 ! . . . ! . . .
44
MAX - mexl " = m value;
BS - blmck umoke;
. . . . . .
. . . . . . . . .
. . . . . .
SERESTEM
! 4& ! . . . ! . . . 0,0 ! . . . ! . . . ! . . . 74.0 ! . . . ! . . .
147 ! 81 31.3 ! . . . 32.? ! . . . 1.0! 0.0 19 ) . . . 98 ! . . . 111 ! . . . 210.0!135.0 17.9 ! . . . 3.11 ! . . .
180 15.2 15.2 1.0! q 47 61 85.0! 10.3 2.36
MIN - m i n i m u m value;
~A - strong acidity;
1181 123.1 119,1 0.0 ) 18 ! 61 ! 73 88.0 !16.2 12,41
~12t ~11.1 !11,2 0,0 I 5 ! 34 I 49 76.0 !8.16 )2.03
A M - a r l t h m e t l c mean;
IN 0 6 ! 1 8 2 ) AR ! 3 4 . 2 !ASO ! 1 8 . 2 !R%N ! 0.0 ! 5 0 1 ! 54 !95X ! 66 ! 9 8 ~ ! 74 IMAX ! 9 1 . 0 ! ~H ! 2 8 . 1 !GSO ! 2 . 0 4
!
IN 08!183 ! AR ! 2 5 . 7 !ASO ! 1 6 , 9 )R%M ) 0.0 ! 5 3 ~ ! 25 )95r ! 53 I~3~ ! 66 )RAX 1 1 1 2 , 0 ! 6R ) 1 9 . 9 !GS~ !2.21
8
114.2 13,6 !17.6 9.74 19.85 8.78 115.3 13.8 !17.a 1~.0 !34.2 37,5 !25.1 45,6 t25.3 35.7 !27.? 36.3 !31.1 33.4 ! . . . . . . !41.1 l&.O
!
)
125 !346 . . !23.? . . !20.6 1,0! 0,0 . . ! 18 . . ! 61 . . ! 81 83.0!109.0 . . !15.7 . . !2.59
. . . . . . . .
DS
) ................................................................................................................................. sE,=sT. (~,*XL ?o ss,,~,,~
361 23.6 17.0 1.0! 18 -59 73 98.0! 17.7 2.21
YEAR .................................................................................................................................
117.9 !25,3 !25.1 !27.8 !14.2 !44.3 !28.9 !27.5 !27,5 !44.5 936.4 !40.3
Ifl 081565 ! AM ! 2 9 . 9 !A$6 !18.0 !RIN i 0,0 !50X ! 29 195~ ) 63 ) BX ) 73 )MIX !112.0 ) GR !23.6 'GS6 12.12
!
!APR !RAY !JUN !JUL !AUG !$EP !OCt tMOV !DEC !J~N !FEB !RA~
!SXTE) 1 ! 3 ! , ......................................................................................... AM ~ QA BS ! SA BS 4 SA
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.
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20.9 21.0 29.4 23.7 12.7 . . . . . . . . . . . . . .
SA
TO SEPTEMBER)
.7 10 51 60 66.7 10.9 2.~9
246 16.4 15.2
1~.3 2S.3 35.0 30.0 20.6 22.0 "**
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aS
. . . . . . .
. . . . . . .
7
. . . . . . .
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40,) 22.D 3.0 38 73 83 120.6
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134
arithmetic
GH - g e o m e t r i c
AS0 -
AM - a r i t h m e t i c
mean;
strong
GSD - g e o m e t r i c
deviation;
SA -
standard
mean;
BS -
black
standard
deviation.
APR...NAR
- Apt1| MAX - m e x t m u m v a T u e ;
smoke;
MI N - m ~ n i m u m v a l u e ;
acidtty;
' ....................................................................................................
! AM ! ~50 ! !MI~ f
IN
50r
95r
to March;
22 61 70 100.2 17.1 2.~9
O.O
number - 50th,
! ! !
i
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* AM
~ ....
~$|TE!
percentl|es;
observations; and 981h
valid gSth
of
3.....
23 58 64 73.8 18.5 2 36
.4
163 25.2 17.7
1~6 24.5 19.4
.~ 15 53 39 73.8 1~.1 2.38
~0 19.9 15.9
17.1 12.6 12,B 13.9 13.5 15.6 3~.3 32.7 27.6 ~2.1 19.5 14.5
8S
127 13.0 9.71 1.0 9 33 37 ~9.4 9.9~ 2.11
8
127 24.1 20.3 0.0 19 63 75 83.4 16.0 ~.61
273 24.3 19.S O.~ 21 62 75 1OO.2 16.6 2.5~
26.7 5.7~ 24.1 26.0 25.3 23.4 29.0 33.3 23.~ 21.3 20.3 13.6
~ .................
! ! ! ! ! ~
!
! !
t
0
! ~ ! ! i ~ ! ! ! !
! ! ! ! ! ! ~ ! ! ! !
! ! ! ! ! ! ! ! !
-
Sk
: .......................
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123 14.2 10.6 1.1 12 35 38 66.5 11.O 2.08
123 1~.2 10.6 1.1 12 35 38 66.5 11.0 2.08
NOB
. . . . . .
. .
. . . . . . .
BS
11.8 12.3 16,0 19.6 9.16
and 98r
! 124 134 ~ 1&3 139 ! 121 13.6 ! 14,~ 1Z.6 ! 61.7 8.65 ! 22.9 9.10 ! IS.D 10.7 ! 26.4 7.37 ! 18.3 1.5 ! 0.0 .6 { 0.0 1.0 } 0.O !50~ ! 12 ! ?0 9 ! 60 6 ! 17 !9SX ! 32 ! 34 32 ! 104 23 ! 59 !9EE ! 35 ! 50 48 ! 105 ]& | 71 !MAK ! 62.0 [ 122.8 54.6 ! 113.2 60.| ! 8B.3 ! Gn ! 32.& 11.2 ! 10.2 9.19 ~ 55.3 6.70 ! 16.~ !GSD ! 2.1D 1,90 ! 2.20 2.21 ! 1*7~ 1.97 ! 2.36 i ................................................................................................................................. SEMESTER (OCTOBER TO MARCH) i ................................................................................................................................. 142 ~ 160 1~1 125 107 O N Oa ~ 161 9t .* ! ~M ! 38.3 30.2 ! 18.6 24.1 ! 19.6 26.5 ! . . . . . !ASD ! 21.0 1B.5 ! 19.5 18.3 ~ 13.~ 16o8 ! . . . . . !MX~ ! 1.6 2.9 ! 0.0 O.0 ! 0.0 .7 ! . . . . . . !$Og! 34 27 ! 13 19 ! 16 23 ! . . . . . !95X ! 73 5B ! 66 53 ! 51 59 ! . . . . . !9gg ! 89 69 ! 80 64 ! 61 61 ! . . . . . !MAX ! 99.4 115.6 ! 119,1 lOB.] ! 67.2 66.7 { . . . . . ! 6fl ! 31.5 24.2 ! 12.5 17.9 ! 15.7 20.7 ! . . . . . !GSD ! 2.01 2.08 } 2,37 2.28 ! 1.98 2.18 . . . . .
SEMESTER
TE~R ! ................................................................................................................................. !N 0 8 ! 319 276 ! 28 ~ 275 ! 268 ! AM ! 39.1 22.2 ! 16.8 18.5 ! 42.1 !ASO ! 11.5 16.8 [ 17.8 16.1 ! 29.0 !M[H ! 0.0 1.5 ! 0.0 0.0 ! 0.0 !SO~ ! 36 17 ! 11 1~ ! 37 !9SX ! 73 5~ ! 53 49 ! 96 !98X ! 85 63 ! 75 55 ! 104 !NRX ! IZ0.6 !15.6 ! 122.8 IO$.5 f 113.2 ! GH ! 32.0 16.6 ! 11.4 12.9 ! 30.8 !GSO ' 2.33 2.20 2.31 2.60 2.40 , 9' 9'
50,~ 26.8 46.6 56.6 3a.~ 31.9 ~7.7 40.6 36.3 36,0 62.9 24.7
....................................................................................................
~
!APR ! !RAY ! ~JU~ ! !JUL ! !AJ~ ! !Ss ! !OCT ! !NO~ ! !DEC ! !J~N ! !FEB ! ~MAR !
.'
~ SXTE!
I
N
1~' ! RAX ~x~=~=~=~=~z~=~=~===~==~=~==~=~=~=~=~=~=~=~=~===~===~===~= ! $ ~'RONG ACZDZTY-S~TE 01 =========================================================================================== ! ! ! ! ~0 ! ~3 6 2 ! :,
!
DATE
!
MEAkl
! ~ 06102/86
! !
! 04/09/85 ! ! ! ! !
~ ! ! ! ! !
=. ~kAC~ S~tCE-SITE 09 =========================================================================================== ! ! ! ! SO ! 11 3 1 3 1 ! 6
! ~ 19/10/85
! !
Z.16
!
100
!
!
~
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!
150
!
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100 150 200
!
! ] ! ! : !
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! !
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! ! ! ! ! !
MAX - ~ration of the hi~est persistamce OAT[ - last day when the highest persistance was observed lEAN - mean of persistance duration
1r
9 !
86187
Relationship between morbidity and climatic factors. Rainfall / . . . . . . Temperature *__* Emergency room visits
! ! ! !
190
M. C. A L V I M F E R R A Z E T A L .
TABLE IV Frequency of persistences - 1986/87 = s ~ m ~ s ~ s g n = i s = t s ~ l m ~ = s m ~ s i z i s s a R = = ~ l ~ = = = = t ~ = = a i ~ = s s ~ = I = = ~ = = = = l ~ = = = l = ~ = ~ = B = = = = = = s = = i
! $TROIG ZZIZIIIIIt ! 50 ] *. 100 ! ! 150
! ! ! ! ~ !
ACIDITY-SITE O5 iItZIJIIZmlZIIIZSIU=IZIZZWSIWSZZZII~laZZZIIIISZZlIZZ
! !
! !
200
10
3
3
2
1
1
2
1
"1
1
!
1 IIZSZIUIZII*SIZZRIUIZSSIZmII ! ! 1 ! 57 ! 28/07186 ! ! ! 5 ! 21/07/86 ! ! ! ! ! !
! ! ! ! ! !
.~ !
! ! ! ! ! !
5,15 2,00
! !
!
I I I I I I = l l l l l = l = l I i I I I i l l l I I I l l l l I I I = l l l l l l I I I I I I I I i l I I I l l l l l l l I I I I l l l l l l l l l II = l I I l l I I I ~ I ~ l
I
!
!
ILACK
SROKE-SZT[
01
zauuzzszsuzumzzu~zaa~a~azua~u~sz~zaz~z~u~z~z~uz~uu~zu
! *. ! !
50 100 150
!
! ! ! ! !
1~
3
1
!
1
z ~ z = z z ~ z z z z = a ~ z u z ~ z ~
! ! ~ ! ~ !
3 1
z ~ z z z z ~ a u
! 311101~6 ! ! 05103/0? ! ~
! ! ! ! ~
!
!
1.~8 1o00
! ! .* ! ! !
IV,X - duration of the highest persistaace DAT[ last clay when the highest persistance ~as observed ~ N - meim o~ Im'Sistaace duration -
Thus, this period seems to be particularly indicated for evaluating effects of pollution levels lower than those that usually cause acute episodes. In Figure 2, strong acidity and black smoke monthly averages and number of emergency r o o m visits of the O C P D nature, are related. It can be observed that during 1985/86, even for very low concentrations, an increase or a decrease in strong acidity levels are generally accompanied by a similar variation in the number of emergency r o o m visits (Figure 3). This is true during all the year, including summer, being to note that the increase of strong acidity levels observed during the last days of September was followed by an increase of morbidity during the first days of October. This excludes influence of some climatic factors like temperature and humidity, which traditionally are believed to have a strong influence on O C P D . During 1986/87 this relationship is not so clear. A marked increase of morbidity is not observed in relation to the June-July strong acidity peak. A relationship between black smoke and morbidity is not to be considered, nevertheless it is interesting to analyse Figure 2, comparing simultaneous evolution of both pollutants. It can be observed that in September 85 strong acidity level increased, accompanied by an increase of black smoke level, this fact being related with an increase of morbidity as was already referred. In June-July 86 there is also an increase of strong acidity concentration, but the level of black smoke was maintained very low, none increase of morbidity corresponding to this period. In October 86 an accentuated increase of black smoke concentration was observed, strong acidity being lower than in June-July. It can be observed that to this period corresponds an elevated number
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o f O C P D emergency room visits and internments. It is important to note that this happens with climatic factors adverse to O C P D worsening: smooth temperature and low humidity (Figure 4). These remarks show that the influence of temperature and humidity seems to be smaller than pollution influence. Similar results are referred by other authors [6, 7, 8, 9]. (Wind absence and high atmospheric pressure are also related with worsening of O C P D and this can be only explained because these weather conditions are usually associated with high pollution levels [10]. The relative decrease of emergency room visits and internments observed in November 86, associated to considerable pollution levels of both pollutants and worse climatic conditions, was interpreted in relation to the fact that some of the patients hospitalized in October can still be at the Hospital in November. By other hand it can be expected with some patients, a preventive effect through the medical treatment given in the foregoing month. It can be concluded that even low levels of strong acidity can be related with OCPD worsening, when verified simultaneously with appreciable levels of black smoke, the climatic factors having a synergetic effect. By some means, it is important to note that for a study like this, that involves so many parameters, two years is positively a short period. These conclusions should be confirmed with posterior analysis and completed with the epidemiological study now under progress. In Figure 5, strong acidity monthly averages are compared with monthly mortality rates by O C P D in Oporto area. The relationship between these two parameters, presented by other authors [11, 12], is not so clear in this study. A significant similar variation was only observed in December-February 85/86 and in November-December 86. These observations are weak enough to allow some conclusions. In Oporto area, a global decrease on annual strong acidity levels was observed
|
4G
.7
L
O
E 9 a n
8 85/86
Fig. 5.
86/87
Relationship between strong acidity levels and mortality rate in Oporto area. Strong acidity / *__* Mortality rate
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M.C.
ALV1M FERRAZ ET AL.
along the last years [1], simultaneously with a generic decay on mortality rates by OCPD and general mortality (Table V). TABLE V Mortality rate/1000 - Oporto area
1971 1973 1974 1975 1979 1980 1981 1982 1983 1984 1985
OCPD
General
OCPD/General
0.456 0.448 0.444 0.390 0.326 0.262 0.223 0.242 0.252 0.238 0.236
11.1 10.4 10.6 10.6 10.1 8.86 6.82 8.73 8.95 9.17 8.85
0.041 0.043 0.042 0.037 0.032 0.030 0.033 0.028 0.028 0.026 0.027
The trend toward a decrease of the annual ratio between these two rates (OCPD/General), suggest that the decrease of mortality by OCPD, more than being related with socio-economic factors, should also be correlated with the gradual improvement on Air Quality of the area.
Acknowledgments Support of this work was provided by Comiss~o de Coordenag~o da Regi~o do Norte, Instituto Nacional de Investigag~o Cientifica and Reitoria da Universidade do Porto.
References [1] Alvim Ferraz, M. C. and Faria Ferraz, M. C.: 1987, 'Evolution of Air Pollution in Oporto Area', Istambul, Environment 87, 493. [2] ISO/DIS - 4220. 2, 1982. [3] AFNOR NFX 43/005, 1977. [4] G.E.M.S. 'Analysing and Interpreting Air Monitoring Data', WHO, Geneve, 1980. [5] Journal offieiel des Communaut~s europ~ennes, Directive du Conseil 80/779/CEE, 15 Juillet 1980. [6] Ferris Jr, B. G., Speizer, F. E., Spengler, J. D., Dockery, D., Bishop, Y. M. M., Wolfson, M., and Humble C.: 1979, American Review o f Respiratory Disease 120, 767. [7] Samet, J. M., Speizer, F. E., Bishop, Y., Spengler, J. D., and Ferris Jr. B. G.: 1981, Journal o f the A i r Pollution Control Association 31, 236. [8] Higgins, I. T. T., Cochrane, A. L., Gilson, J. C., and Wood, C. H.: 1959, Brit. J. Industr. Med. 16, 255. [9] Holland, W. W., Spicer, C. C., and Wilson, J. M. G.: 1961, Lancet ii, 338. [10] Mosquera Pestafia, J. A., Fernandez Bustillo, E. and Rodriguez Gonzalez, P.: 1978, Archivos de Bronconeulogia, Vol. 14, No. 2, pp. 66-69, Oviedo, Spain. [11] Stocks, P.: 1963, Proc. Roy, Soc. B. 159, 78. [12] College of General Practitioners, Brit. Med. J. ii, 973, 1961.
