Impact of outdoor air pollution by A fertilizer plant on childhood respiratory morbidity By

Sabry M. Hammad*, Saad M. Motawea* and ElSayed El-Shafei** *Community Medicine department, Mansoura faculty of medicine, **Mechanical Power Engineering department, Mansura faculty of Engineering.

Abstract:

In response to community concern about the possible respiratory effects of emissions from Talkha fertilizer plant in Dakahlia Governorate, a household cross sectional survey was carried out in a downwind area (Olengil, Mansoura district) and in another upwind area (El-Danabik, Mansoura district) to determine whether 3-15 years children in the downwind area (n=800) exposed to air pollution from the plant have an excess of respiratory problems particularly, asthma compared with children in the upwind control area (n=800). Questionnaires were completed from care givers of eligible children in the studied areas. The outdoor air pollutants were measured in the studied areas. A sample of 50 apparently healthy children aged 12-15 years from each studied area were subjected to pulmonary functions assessment. Analysis of the results showed significantly higher prevalence of symptoms suggestive of asthma in the last year in the downwind area (13.4 %, 5.6 %, 12%, 10.8% &8.3 %) than in the upwind one (9.6 %, 2.8 %, 8.4 %, 7.4 % &4.4 %) for recurrent wheeze, exertional wheeze, cough during night, exertional cough and asthmatic attacks respectively. A significantly frequent Common cold and bronchitis was observed in the exposed area than in the non-exposed area. The indoor environmental triggering factors for respiratory morbidity particularly asthma showed no significant difference between the 2 studied areas. Family history of chest and nasal allergy were significantly higher in the downwind area than in the upwind one and after controlling for these potential cofounders children in the downwind area were observed to still suffer from respiratory morbidity at an increased frequency. The downwind area showed significant higher

concentrations of outdoor air pollutants (NO, NO2, ammonia, SO2, , O3, total suspended particulates) than the upwind area. Children in the downwind area showed significant decrease in pulmonary function tests more than the upwind area children. We concluded that emissions from Talkha fertilizer plant were associated with higher prevalence of reparatory morbidity particularly asthma symptoms and decreased pulmonary function tests. Therefore, placement of filters on the plant chimneys and periodic assessment of outdoor air pollutants in the nearby areas to the fertilizer plant is recommended.

Introduction:
Air pollution and its impact on human health is increasingly becoming an important subject for consideration and indeed concern throuhout the world (WHO, 1992).Several emissions are emitted from Nitrogen fertilizer industrial plants mainly Nitrogen oxides, Sulfur oxides and suspended particulates (Bojanic et al,1977 ; Spuzic et al,1977 and Wilkie et al, 1995). Outdoor air pollution is associated with increased prevalence of respiratory tract infections among children (McConnell et al, 1999). Total suspended particulate, nitrogen dioxide, carbon monoxide, ozone, and airborne dust particles all displayed an independent association with asthma, respectively (Abramson et al, 1995 ; Wang et al, 1996 and Goldsmith et al, 1999).

Aim of the work:

Assessment of outdoor air pollution by a fertilizer industrial plant and studying its impact on childhood respiratory morbidity particularly, asthma.

Subjects and Methods:

Locality: Talkha fertilizer plant in Dakahlia Governorate is located on the Nile bank, emitting several gaseous emissions. Two villages were selected, the expoesd village is about one Kilometer downwind of the plant (Olengil, Mansoura district) and the other is about 10 kilometers upwind (El-danabik, Mansoura district). Both villages nearly have the same number of population. Target population and study design: A cross sectional household survey was carried out in both villages where a systematic random sample of children aged 3-15 years were selectd (n=800 from each). Questionnaire A questionnaire was designed and completed from care givers of eligible children in the studied areas as regards : Socio-demographic data and Housing condition with special attention to crowding index, parental smoking, pet ownership, presence of carpets, separate kitchen, type of fuel and Insecticide usage. Past history of symptoms related to respiratory morbidity particularly symptoms suggestive of asthma (ISAAC, 1998) and frequent Respiratory tract infections (RTIs) as Common cold, pharyngitis, tonsilitis, otitis media, bronchitis and pneumonia in the last 12 months Family history of chest or nasal allergy or allergic dermatitis.

The social score was calculated according to El-Sherbini and Fahmy (1983) with some modification. Outdoor air pollution assessment Assessment of the degree of outdoor air pollution was carried out using a mobile laboratory fully computerized, which was equipped with a dynamic gas caliberated system that was used for measurement of different air pollutants. Outdoor air pollutants were measured in the studied areas where, CO was measured by gas filter correlation analyzer. Chemilumescent analyzer was used for measuring NO X (NO&NO2) and Ammonia. SOX was measured by pulsed fluorescent analyzer. Ultraviolet photometry was used for measurement of O 3. Total suspended particulates were measured by a dust counter. Measurements were taken for three days seasonally for one year and the annual mean of the different pollutants was calculated. Pulmonary function tests: A sample of 50 apparently healthy children aged 12-15 years from each studied area were selected randomly and were subjected to pulmonary function assessment. The ventillatory function tests were performed using Vitalograph Model. Discom 21FXII. Vital capacity, Forcd vital capacity (FVC), Forced expiratory volume in the first second (FEV 1), FEV1/ FVC% and Peak expiratory flow (PEF) were measured and caculated as a percentage of the predicted: Statistical analysis Data entry, processing and statistical analysis was carried out using SPSS (Statistical Package for Social Sciences) program for windows (ver 9.5). Chi square and student t- tests of significance

were used to compare between the studied groups. The p value was considered significant at p 0.05.

Results:
Table (1) showed that the studied children in both villages were matched where there was no statistical significant difference as regards age, sex and social score. Table (2) showed that there was no statistical significant difference between the exposed and non exposed children as regards risk factors of respiratory morbidity except for family history of nasal and chest allergy. Table (3) demonstrated significant higher prevalence of symptoms suggestive of asthma in the last year in the downwind area (13.4 %, 5.6 %, 12%, 10.8% &8.3 %) than in the upwind one (9.6 %, 2.8 %, 8.4 %, 7.4 % &4.4 %) for recurrent wheeze, exertional wheeze, cough during night, exertional cough and asthmatic attacks respectively. There was a significantly frequent respiratory tract infections namely; Common cold and bronchitis, in the last 12 months in the exposed village (Olengil) than in the nonexposed village (El-Danabik). Table (4) showed significant higher concentrations of outdoor air pollutants (NO, NO2, ammonia, SO2, O3, total suspended particulates) in the downwind village than the upwind one. Table (5) showed significant lowering of the mean quantitative pulmonary function tests among exposed children in Olengil than among the non-exposed children in El-Danabik.

Table (1) Comparison of socio-demographic characteristics between exposed locality children and non-exposed locality children Characteristic Childs age (years): 36912-15 Childs sex: Male Female Social score: Low Middle High Exposed Children N=800 N (%) 101 (12.6) 151 (18.9) 255 (31.9) 293 (36.6) Non exposed Children N=800 N (%) 117 (14.6) 156 (19.5) 240 (30.0) 287 (35.9) Significance P value test

X =1.77

0. 621 (NS)

439 (54.9) 361 (45.1) 178 (22.3) 515 (64.4) 107 (13.4)

411 (51.4) 389 (48.6) 212 (26.5) 489 (61.4) 99 (12.4)

X2 =1.96

0.16 (NS)

X2 = 3.95

0.139 (NS)

NS= Non significant

S= Significant

Table (2) Risk factors for respiratory morbidity in exposed locality children in comparison to non-exposed locality children Risk factor Exposed Children N=800 N (%) Non-exposed Significance Children test N=800 N (%) X2 =3.09 X2 =2.56 X2 =1.49 X2 =1.64 X2 =0.31 X2 =0.25 X2 =0.846 X2 =14.1 X2 =4.3 X2 =0.34 P value

Crowding index: <2 98 (12.3) 79 (9.9) 2-4 614 (76.8) 619 (77.4) >4 88 (11) 102 (12.8) Parental smoking 417 (52.1) 385 (48.1) Pets 522 (65.3) 545 (68.1) Carpets 321 (40.1) 296 (37.0) Separate kitchen 633 (79.1) 642 (80.3) Fuel: Gas 769 (96.1) 765 (95.6) Kerosine or wood 31 (3.9) 35 (4.4) Insecticde 309 (38.6) 327 (40.9) Family history of chest allergy 143 (17.9) 90 (11.3) Family history of nasal allergy 34 (4.3) 19 (2.4) Family history of allergic dermatitis 84 (10.5) 77 (9.6) NS= Non significant S= Significant

0.213 (NS) 0.109 (NS) 0.222 (NS) 0.199 (NS) 0.576 (NS) 0.615 (NS) 0.358 (NS) 0.0002 (S) 0.036 (S) 0.561 (NS)

Table (3) The last 12 months prevalence of symptoms of respiratory morbidity in exposed locality children in comparison to non-exposed locality children
Respiratory morbidity Exposed Children N=800 N (%) Non-exposed Children N=800 N (%) Significance test P value OR (95 % CI)

Symptoms suggestive of asthma: Recurrent wheeze Exertional wheeze Cough during night Exertional cough Asthmatic attacks Frequent RTIs in last 12 months: Common cold Pharyngitis+/- tonsilitis Otitis media Bronchitis Pneumonia

107 (13.4) 45 (5.6) 96 (12.0) 86 (10.8) 66 (8.3)

77 (9.6) 22 (2.8) 67 (8.4) 59 (7.4) 35 (4.4)

X2 =5.53 X2 =8.24 X2 =5.74 X2 =5.53 X2 =10.16

0.018(S) 0.004 (S) 0.016 (S) 0.018 (S) 0.0014 (S)

1.45 (1.05-2.01) 2.11 (1.22-3.66) 1.49 (1.06-2.1) 1.51 (1.05-2.17) 1.97 (1.26-3.06) 1.24 (1.01-1.52) 1.19 (0.96-1.48) 0.79 (0.55-1.14) 1.54 (1.22-1.94) 1.5 (0.38-6.35)

350 (43.8) 261 (32.6) 64 (8.0) 237 (29.6) 6 (0.8)

308 (38.5) 231 (28.9) 79 (9.9) 172 (21.5) 4 (0.5)

X2 =4.55 X2 =2.6 X2 =1.72 X2 =13.9 X2 =0.402

0.032 (S)
(NS)0.104

0.188(NS) 0.0002 (S) 0.526(NS)

NS= Non significant

S= Significant

OR= Odds ratio

CI= Confidence interval

Table (4) Comparison of mean annual concentrations of outdoor air pollutants in a locality downwind (exposed) & a locality upwind (non exposed) of Talkha fertilizer factory Outdoor air Exposed Nont- value P value Egyptian pollutant locality exposed standards N=12 locality Law X SD N=12 4/1994* X SD 3 No (ug/m ) 187.531.45 12.5 3.7 19.14 0.0001(S) ** 3 NO2 (ug/m ) 191.6743.65 7.67 2.84 14.57 0.0001(S) 400(1hr) 150(24h)# Ammonia 354.1761.53 28.33 8.15 18.19 0.0001 (S) ** 3 (ug/m ) SO2 (ug/m3) 58.72 7.48 25.363.55 13.96 0.0001 (S) 350(1h) 150(24h) 60(annual) 3 CO (mg/m ) 1.9830.435 1.75 0.56 1.14 0.267(NS) 30 (1h) 10 (8h)# 3 O3 (ug/m ) 14.435.26 9.033.49 2.42 0.024 (S) 200 (1h) 120 (8h)# Total 61.39 19.82 20.94 8.57 6.49 0.0001 (S) 60 (annual) suspended 150 (24h) particulate (ug/m3)
NS= Non significant S= Significant

* Law4/1994, (Egyptian Environment Affairs Agency,1995) ** No standards # No annual mean standard. N.B some of (24h) measurements for NO2 & SO2 were above the (24h) Egyptian standard. The calculated annual means for SO2 approximates the Egyptian standards but above WHO standards 50 (ug/m3). TSP was above the Egyptian standards and WHO standards 50 (ug/m3); (WHO, 1987).

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Table (5) Comparison of pulmonary functions tests between exposed locality children and non-exposed locality children Pulmonary function test* VC FVC
FEV1

FEV1/FVC ratio PEF

Exposed children N=50 N (%) 102.2 13.8 103.2 19.9 94.8 15.9 92.8 10.02 99.6 31.6

Non -exposed children N=50 N (%) 92.514.2 96.7 4.4 85.9 12.6 89.3 16.3 87.2 9.3

t-value

P value

3.45 2.25 3.06 1.29 2.67

0.001 (S) 0.029 (S) 0.003 (S) 0.202 (NS) 0.01 (S)

Expressed as percentage of the predicted

Discussion:
The prevalence of respiratory morbidity particularly asthma in children has increased substantially in many countries in recent decades (Venn et al, 1995). Outdoor air pollution is a risk factor for childhood respiratory health (Schmitzberger et al, 1993). Multiple risk factors are associated with higher respiratory morbidity as; age, sex, gender, medical history, socioeconomic status (Ernst et al, 1995; Duran et al, 1999 and Pereira et al, 2000), Crowding index, Parental smoking (Whatling J. 1994, Kay et al,1995; Maier et al, 1997; and Lis and Pietrzyk ,1997.), Pet ownership (Brunekreef, 1992; Abdulrazzaqet al, 1995), Carpets ,Separate kitchen, Fuel whether Gas cooking (Dekker et al 1991),Kerosine or wood (Ponsonby et al, 2000), Insecticdes, Family history of chest allergy, nasal allergy or allergic dermatitis (Shaw et al, 1995 Maier et al, 1997). From the present work, there was no significant difference between the two villages regarding

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such confounding variables except for family history of chest or nasal allergy. This may be due to exposure to higher concentrations of outdoor air pollutants emitted from Talkha fertilizer plant in the downwind area as evidenced by continuity of the significant rise of respiratory morbidity in such area after controlling for the family history of chest or nasal allergy. Marked variations in the prevalence of asthma symptoms with up to 15-fold differences between countries is reported. (ISAAC, 1998). From the present work there was a significantly higher prevalence of symptoms suggestive of asthma in the last year in the exposed downwind area (13.4 %, 5.6 %, 12%, 10.8% &8.3 %) than in the upwind one for recurrent wheeze, exertional wheeze, cough during night, exertional cough and asthmatic attacks respectively. This coincides with Schmitzberger et al, (1993) who reported similar results in areas of increased SO2 and NO2 as well as areas of increased ozone. Also our results agree with (Lis and Pietrzyk ,1997), who reported that dust particles and sulfur dioxide were significantly associated with symptoms suggestive of asthma in their study. De Kok et al,(1996) found significantly higher prevalence rates of key symptoms of asthma in children living in one region of the Netherlands Melick/Herkenbosch Asenray (MHA) compared to another Leek (LK) and the measured outdoor air pollution levels of SO2, NO2, O3 and Particulate matter were in general higher in MHA. Alvarez, (1993) and Bjorksten, (1999) reported that NO2, SO2, ozone, and particles may enhance sensitization of asthma.

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Our findings were not in agreement with (Wilkie et al ,1995) who reported that There was no evidence of an increase in asthma symptoms reported in children in the industrial area of Hornby as a result of the emissions from a fertilizer plant .This may be explained by the strict filtering control measures and recycling of the emissions practiced in such region. Asthma is one of the commonest of chronic illnesses affecting children (Kay et al, 1995). From the present work, the higher prevalence of symptoms suggestive of asthma in the last year in the downwind area than in the upwind one particularly for recurrent wheeze and asthmatic attacks (13.4 %, 8.3 % respectively) are considered higher rates or similar to those reported in the developed world for example; among the 925 Seattle primary school students, 66 (7%) had wheezing in the last year (Maier et al, 1997). The prevalence of self-reported wheeze and asthma was measured by parental questionnaire in 22,968 children aged 4-11 yrs attending primary schools in the Nottingham area of England, wheezing in the past year was 15.1% (Venn et al, 1998). Mallol et al, (2000) reported similar results in Latin America. The association of outdoor air pollution with the prevalence of respiratory tract infections among children is reported by several researchers (McConnell et al, 1999). From the present work,There was a significantly frequent respiratory tract infections (namely Common cold and bronchitis) in the last 12 months in the exposed village(Olengil) than in the non exposed village (El-Danabik).Our results coincide with McConnell et al, (1999) who reported positive associations between air pollution by ozone, particulate matter and
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NOx and bronchitis and phlegm among children in 12 communities in Southern California. Similar associations were observed between air pollution by NO2 and CO and increased prevalence of cough and bronchitis in children in Dresden, Germany (Hirsch et al, 1999). The Egyptian standards for the ambient air quality (Law 4/1994) lack standards for NO& NH3. Also, There was no standard annual means for NO2, CO &O3. The calculated annual means for SO2 approximates the Egyptian standards but above WHO standards 50 (ug/m3). TSP was above the Egyptian standards and WHO standards 50 (ug/m3); (WHO, 1987). Regarding the effects of air pollution on pulmonary function , the present wok showed significant decrement of the pulmonary function. Similar results were reported by Schmitzberger et al, (1993) who reported that in areas of increased SO2 and NO2 as well as areas of increased ozone, there were significant association with decrements of forced expiratory volume in 1 s (FEV1) and flow rates at 50 and 75% of vital capacity (FEF50, FEF75). In coclusion, Talkha fertilizer plant leads to notorious emissions leading to outdoor air pollution which was associated with higher prevalence of respiratory morbidity particularly asthma symptoms, common cold ,bronchitis and decreased pulmonary functions tests. Therefore, placement of filters on the plant chimneys or recycling of the emissions and periodic assessment of outdoor air pollutants in the nearby areas to the fertilizer plant is recommended. The Egyptian standards for SO 2 and TSP must be

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reviewed and lowered to the WHO standards and the lacked standards must be completed. Referencces: Abdulrazzaq YM, Bener A, DeBuse P. (1995): Pet ownership in the UAE: its effect on allergy and respiratory symptoms. J Asthma;32(2):117-24 Abramson MJ, Marks GB, Pattemore PK. (1995): Are nonallergenic environmental factors important in asthma? Med J Aust 20;163(10):542-5 Alvarez Berciano F.( 1993): [Influence of air pollution on infantile extrinsic asthma]. : An Esp Pediatr ;39 Suppl 55:92-6 Bjorksten B. (1999): The environmental influence on childhood asthma. Allergy;54 Suppl 49:17-23 Bojanic M, Novakovic G, Tesic S, Jovanovic M, Savic S.( 1977): Bronchial asthma in the nitrogen fertilizer industry in Pancev. Glas Srp Akad Nauka [Med] ;(29):55-62 Brunekreef B, Groot B, Hoek G.( 1992): Pets, allergy and respiratory symptoms in children. Int J Epidemiol;21(2):338-42

Dekker C, Dales R, Bartlett S, Brunekreef B, Zwanenburg H. (1991): Childhood asthma and the indoor environment. Chest ; 100(4):922-6

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De Kok ME, Mertens PL, Cuijpers CE, Swaen GM, Wesseling GJ, Broer J, Sturmans F, Wouters EF.( 1996): The rate of respiratory symptoms among primary school children in two Dutch regions. Eur J Pediatr ;155(6):506-11 El-Sherbini A.F. and Fahmy S.I. (1983): determining simple parameter for social classifications for health research. Bulletin of High Institute of Public Health. XIII (5):1-14. Ernst P, Demissie K, Joseph L, Locher U, Becklake MR.(1995): Socioeconomic status and indicators of asthma in children. Am J Respir Crit Care Med;152(2):570-5 Goldsmith CA, Kobzik L.(1999) Particulate air pollution and asthma: a review of epidemiological and biological studies. Rev Environ Health;14(3):121-34 Hirsch T, Weiland SK, von Mutius E, Safeca AF, Grafe H, Csaplovics E, Duhme H, Keil U, Leupold W. (1999): Inner city air pollution and respiratory health and atopy in children. : Eur Respir J ;14(3):669-77. Duran-TE, Rona RJ. (1999):Geographical and socioeconomic variation in the prevalence of asthma symptoms in English and Scottish children. Thorax ;54(6):476-81.

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ISAAC , (1998):Worldwide variations in the prevalence of asthma symptoms: the International Study of Asthma and Allergies in Childhood Eur Respir J;12(2):315-35. Kay J, Mortimer MJ, Jaron AG.(1995):Do both paternal and maternal smoking influence the prevalence of childhood asthma? A study into the prevalence of asthma in children and the effects of parental smoking. J Asthma;32(1):47-55. Lis G, Pietrzyk JJ. (1997): The effect of air pollution on the prevalence of asthma in schoolchildren from Krakow. Pneumonol Alergol Pol;65(9-10):611-20 McConnell R, Berhane K, Gilliland F, London SJ, Vora H, Avol E, Gauderman WJ, Margolis HG, Lurmann F, Thomas DC, Peters JM. (1999): Air pollution and bronchitic symptoms in Southern California children with asthma. Environ Health Perspect ; 107(9):757-60. Maier WC, Arrighi HM, Morray B, Llewellyn C, Redding GJ.(1997): Indoor risk factors for asthma and wheezing among Seattle school children. : Environ Health Perspect ;105(2):208-14 Mallol J, Sole D, Asher I, Clayton T, Stein R, Soto-Quiroz M. (2000): Prevalence of asthma symptoms in Latin America: the International Study of Asthma and Allergies in Childhood (ISAAC). Pediatr Pulmonol ;30(6):439-44

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Schmitzberger R, Rhomberg K, Buchele H, Puchegger R, Schmitzberger-Natzmer D, Kemmler G, Panosch B.( 1993): Effects of air pollution on the respiratory tract of children. Pediatr Pulmonol ;15(2):68-74 Shaw R, Woodman K, Crane J, Moyes C, Kennedy J, Pearce N. (1995 ): Risk factors for asthma symptoms in Kawerau children. N Z Med J. 10;108(999):178-9 Spuzic V, Bojanic M, Djordjevic S, Petrovic M.( 1977): Allergic status of workers in the nitrogen fertilizer industry in Pancev. Glas Srp Akad Nauka [Med] ;(29):51-4 Pereira ED, Torres L, Macedo J, Medeiros MM. (2000): Effects of environmental tobacco smoke on lower respiratory system of children under 5 years of age. Rev Saude Publica ;34(1):39-43. Ponsonby AL, Couper D, Dwyer T, Carmichael A, Kemp A, ochrane J. (2000): The relation between infant indoor environment and subsequent asthma. Epidemiology. ;11(2):100-4 Venn A, Lewis S, Cooper M, Hill J, Britton J. (1998): Increasing prevalence of wheeze and asthma in Nottingham primary schoolchildren 1988-1995.Eur Respir J ;11(6):1324-8. Wang TN, Ko YC, Chao YY, Huang CC, Lin RS. (1999): Association between indoor and outdoor air pollution and adolescent asthma from 1995 to 1996 in Taiwan. Environ Res ;

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81(3):239-47 WHO, (1987): Air Quality Guidelines, WHO Regional Publications: European Series No.23. WHO,(1992): selected presentations. Regional Training Course on Air pollution. CEHA document No.TLM-2. Wilkie AT, Ford RP, Pattemore P, Schluter PJ, Town I, Graham P. (1995): Prevalence of childhood asthma symptoms in an industrial suburb of Christchurch. N Z Med J 24;108(1000):188-90 Whatling J.( 1994): Childhood asthma and passive smoking. Nurs Stand ;8(46):25-7

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 ) 800 (. 50 . ) (%8.3 %10.8 %12 %5.6 %13.4 )%9.6 (%4.4 %7.4 %8.4 %2.8 ) ( . . . , , , , . .

20