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Fifth Humanoid, Nanotechnology, Information Technology, Communication and Control Environment and Management (HNICEM) International Conference The

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

QUYNH T. NGUYEN and RAOUF N.G. NAGUIB Biomedical Computing and Engineering Technologies Applied Research Group (BIOCORE) Faculty of Engineering and Computing Coventry University, UK MICHAIL PAPATHOMAS Department of Mathematics, Coventry University, UK

MOHYI H. SHAKER Ecology and Environment, Inc, USA ALVIN B. CULABA Centre for Engineering and Sustainable Development Research (CESDR), De La Salle University, the Philippines

ABSTRACT The poor air quality situation as well as the predominant mortality and morbidity rates of cardiovascular diseases (CVD) have been problematic to citizens in the Philippines in the last few decades. The aim of this paper is to understand the awareness of Filipino cardiologists with regard to the potential impacts of air pollution on CVDs. A survey has been conducted on a sample of 142 Filipino cardiologists who are members of the Philippines Heart Association (PHA) as well as a number of cardiologists from Davao province in the south of the Philippines, and the paper reports on some of the salient results obtained. Key Words Air Pollution, Particulate Matter, Cardiovascular disease, Pathophysiological pathway. I. INTRODUCTION

World Health Organization (WHO), have widely acknowledged, and are fully aware of, the importance of this issue. However, in many developing countries, such as the Philippines, which suffer from high concentrations of ambient particulate matter (PM) and where the mortality from cardiovascular diseases (CVD) is in the top ten of all causes of death, air pollution is a significant problem. Therefore, one aim of this study is to examine the possible links that may exist between airborne pollutants and CVD in the Philippines. Another aim is to explore the awareness of cardiologists about the potential impacts of air pollution on CVD. It is of importance to understand physicians evaluations of the various risk factors to CVD, which may include environmental aspects, and to suggest measures to overcome any shortcomings. The paper is divided as follows: Section II gives a brief account of the current state of ambient air pollution in Philippines; Section III provides some epidemiological data relating to CVD incidence in the country, along with various mortality and morbidity rates from the disease; Section IV describes the survey undertaken for the purposes of this study and results obtained through a descriptive analysis, as well as from the Logistic Regression technique. Finally, in Section V, conclusions are given.

ecently, a wealth of epidemiologic, cohort and cross sectional studies have affirmed that airborne pollutants have deleterious effects on cardiovascular mortality and morbidity in relation to long-term and short-term exposures. Developed countries, where the standards of the environment in ambient and indoor areas are in line with the Air Quality Standards from the

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

II. CURRENT STATE OF AMBIENT AIR POLLUTION IN THE PHILIPPINES The population of the Philippines was estimated at approximately 92 million in 2009 with a population growth rate of 1.8%. The economic growth is primarily driven by private consumption [1]. It slowed down in 2008 and recorded a growth rate of 5.2% in the second quarter [2]. According to the WHO [3], life expectancy figures at birth for male and female were 64 and 71, respectively, in 2006. This fact reflects the actual mortality rate of CVD between male and female 1. Indoor and Outdoor Pollution in the Philippines The development of industrialization, growing urbanization and motorization, which are the attributes of any emerging economy, leads to a significantly air polluted environment. The Philippines is in line with other developing countries in the region, endeavouring to improve the economy rapidly. Hence, environmental issues have not been of major concern as much as the economic issues, in spite of the many environmental lessons available from developed countries. In consequence, the Philippines has been known as one the worst polluted countries in the world, especially insofar as air pollution is concerned due to exhaust from the large number of vehicles, emissions from industrial plants, cooking and plant combustions, re-suspension and construction, waste burning and road dust. The Philippines Emissions Inventory estimated that, in 2005, 54% of the pollutants, comprising PM, SOx, NOx and CO, came from stationary sources, 20% from mobile sources, and the remaining 26% from area sources. Carbon monoxide is a major pollutant compared to other concentrations of NOx, SOx and PM [4]. The data measurement of lead (Pb) and Ozone (O3) was not included. There are not many Air Quality Monitoring (AQM) stations spread across different parts of the country; some AQM stations have been installed at high-traffic roads and some at crowded residential areas. Hence, the accurate assessment of quality of air is by no means a simple task. According to the latest Clean Air Initiative Asia (CAI-Asia) report [5], there are a total of 44 air quality monitoring stations which are operated by the Department of Environment and Natural Resources (DENR) in 15 regions of the

Philippines and some stations monitor the air quality from the Manila Observatory and the Philippines Nuclear Research Institute (PNRI). Among those stations, only 4 measure PM10 and 7 measure gaseous pollutants. The Filipino government issued ambient air quality guidelines for common pollutants in 1999. Comparing the standards between the Philippines and the US, some of the pollutants, such as PM10, are at the same levels of concentration as stipulated by the relevant standards. This demonstrates the attempt of the government to achieve an acceptable environment. However, in reality, the Philippines has exceeded the concentrations of ambient particles proposed in its guidelines. The remaining values of the Philippines ambient air quality components are higher than the US Environmental Protection Agency (USEPA) standards by a large margin. Metro Manila can be qualified as the most polluted city in the country. Thus, airborne pollutants in Metro Manila are discussed in this paper as a typical illustration of the situation in the Philippines. 2. Air Pollution in Metro Manila Metro Manila is the capital of the Philippines with an approximate population of 12 million. It has been identified by the WHO and the United Nations Environment Program (UNEP) as one of the five most polluted cities in the world [6]. The quality of air in the city is harmful and unsafe with its pollutants at unacceptable levels, compared to worldwide statistics. The DENR, WHO and Asian Development Bank (ADB) have conducted a study which demonstrated that the volume of particulate matter in its atmosphere was at 57g/m3, which is above the baseline level of 50g/m3 for clean air [7]. This level can translate to diseases and deaths. On the other hand, the level of lead in the air, due to heavy use of leaded fuel, is in excess of three times the established safety limit [8]. Studies reveal that the combustion of gasoline and diesel fuel from public utility vehicles makes up for a large proportion of air pollution in Metro Manila. Jeepneys, which are converted Jeep vehicles, are the cheapest and most common choice for daily transportation in the city. In 1996, approximately 10 million residents of Metro Manila took over 23 million trips daily, with Jeepneys accounting for over 40% of these trips. Furthermore, according to [9], tricycles generate 15.4% of emissions from vehicles in the

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

city with significantly high concentration levels of CO. This type of vehicle in Metro Manila failed to meet the Philippines regulatory emission limits of CO and NOx. Most industrial sources are located within the city, including thermal power stations, cement manufacturing plants and oil refineries. In [10], Krupnick et al found that the total industrial emission was 37,000 tons of PM10 in 2000. This amount was nearly equal to the total vehicular emissions which accounted for 39,000 tons of PM10. Other issues which directly contribute to air pollution, and which give cause for concern, are waste and biomass fuel smoke arising from burning wood, dung or charcoal for cooking, heating and lighting. The most significant indoor pollutant source is from cigarette smoking, since statistics show that at least one household member actively smokes, and mainly indoors [11]. Those factors have contributed to a major impact on the quality of indoor air, not only in the city, but also in the entire country. The Environmental Management Bureau (EMB) of the National Capital Region (NCR) in the Philippines used, at the onset, a total suspended particles (TSP) indicator to measure the mass concentration of PM in the outdoor air of Metro Manila from 1995 to 2001. The ADB carried out the measurement at 8 locations in the capital from 2001 to 2005 and the ambient TSP concentration improved from 2003 to 2005, however the concentration still exceeded the 24-hour average (short term) of the National Ambient Air Quality Guideline Values TSP standard of 90g/m with the highest TSP value of 695g/m being recorded at the major EDSA roadside [12] In 2003, the EMB, under the Metro Manila Air Quality Improvement Sector Development Program, launched some new monitoring stations in Metro Manila that can measure not only TSP but also PM10 and PM2.5 concentrations. The data of long-term PM10 concentration since 1997 to 2002 were below the standard which is 60g/ m. This fact has also been proven by the WHO and ADB. The values of ambient concentration of nitrogen dioxide (NO2) did not exceed the 0.05 parts per million (ppm) level, except in 1998 where the maximum daily average was 0.051ppm

which is 36% below the 24-hour standard of 0.08ppm [13]. Furthermore, the ambient concentrations of PM10 and other nitrogen oxides (NOX) are similar in indoor and outdoor conditions [14]. Therefore, this particular aspect contributes considerably to the consequences of the current state of Filipinos health. According to the WHO, concentrations of PM10 and PM2.5 had been collected at some busy roads and high population and industrial cities in Metro during the period January to December 2002. The results of the ambient air quality assessment indicate that PM10, PM2.5 and O3 pose considerable health risks to the population in Metro Manila. Extensive monitoring of PM shows spatial differences in ambient levels. The high mean 24-hr levels of PM10 were measured along the major road of EDSA in Quezon City at 96.9g/m and in the industrial area of Valenzuela City at 70.5g/m. The low mean 24-hr levels were observed in the residential areas of Antipolo and Las Pias at 31.9g/m and 33.1g/m, respectively [15]. Long-term concentrations of PM10 are likely to violate the national air quality guideline value of 60g/m. The annual concentration levels of PM2.5 in all of the PNRI sampling sites in Metro Manila also exceeded the WHO long term guideline value of 10g/m [5] as shown in Fig. 1.

Fig. 1. PM2.5 Concentration with Long-Term Average [5] The trend of ambient concentration of sulfur dioxide (SO2) has been below the standard in the period 1986-1996. At some stage during the period 1992 to 1996, the value showed an increase at some stations. The value of lead (Pb) has been plummeting since 1987 compared to set standards. The explanation for the downtrend is that leaded gasoline has been replaced by unleaded gasoline. Leaded gasoline was phased out in Metro Manila

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

in April 2000 and, nationwide on December 31, 2000 [16]. The concentration of CO did not generally exceed the ambient air quality standard of 9ppm (8-hour) during the period of 1975 to 1998. However, experts concur that this concentration has possibly and occasionally exceeded the standard, especially at some stations in the vicinity of heavy traffic. In order to gain an understanding of the knowledge of the Filipinos about the quality of the environment and the impact on health from air pollution, a wealth of surveys and studies have been carried out. They revealed that the majority of people were not satisfied with the quality of the environment. Results from an Asian air pollution survey conducted in 2005 show that 98% of the residents in Manila City are affected by air pollution, and 71% believe that air quality has increasingly worsened over the years [17]. The Tokyo Institute of Technology, under the Japan Society for the Promotion of Science Manila Project, conducted a survey in 2000 which showed that over 70% of the 490 respondents in Makati City and Quezon City were always worried about the effects of motorized vehicle emission on their health [18]. III. CARDIOVASCULAR DISEASE IN THE PHILIPPINES According to a Department of Health (DOH) report in 2005 [19], the 10 leading causes of mortality did not significantly change during the period from 1985 to 2005, with heart disease being consistently one of the leading causes of death. In 1985, heart disease ranked second in the 10 leading causes of deaths and in 2005 it rose to the top. Noticeably, CVDs have seen an uptrend in mortality in the Philippines, from 1985 to 2005, while the morbidity trend has been decreasing in recent years due to the number of unreported cases (Fig. 2). In 2005, Acute Myocardial Infarction (AMI) was responsible for 30,822 mortality cases out of the total 77,060 heart disease deaths in the country [20].

Fig. 2. Mortality and Morbidity Trends of Cardiovascular Diseases in the Philippines, 19852005 [20]. The DOH reported that the percentages of hypertensive heart disease, ischaemic heart disease or coronary artery diseases in Filipinos are higher compared to other non-infectious diseases. According to the history of ischaemic heart disease and hypertensive disease, the mortality rates have been soaring massively in both men and women during the period 1963-1976 [21]. Till now they are still leading the top mortality rates of cardiovascular diseases in the country. In 1994 the morbidity rate was 206.3 cases per 100,000 population, while the mortality rate was 73.7 deaths per 100,000 population. The total mortality rate due to CVDs represented 25% of all deaths in 2000 [22]. It was also estimated that the excess deaths due to cardiovascular causes attributable to PM10 levels above 50g/m were 40-200 persons in Metro Manila, alone, in 2002. As mentioned above, Jeepneys are one of the cheapest means of transportation. Those dieselbased vehicles are a major source of air pollutants, posing a health risk for drivers and commuters. The WHO sponsored a study on the exposure of a sample population to vehicular emissions in 1990 and 1991 in Metro Manila and the result showed that Jeepney drivers had significantly higher chronic respiratory symptoms than commuters and air-conditioned bus drivers. In [23], the World Bank concluded that Jeepney and bus drivers are the main victims of air pollution, being highly at risk of acquiring pulmonary tuberculosis and chronic obstructive pulmonary disease. However, there is no official figure to indicate the

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

proportion of such drivers who have prolonged exposure to vehicular pollution and who are at risk of developing cardiovascular diseases. Following the formal and basic concepts of pathology, common independent risk factors, which Filipino clinicians and physicians usually consider for heart disease, include high cholesterol, high blood pressure, family history, age over 55, smoking, diabetes, obesity and stress. Novel risk factors such as airborne pollutants have also been shown to affect mortality and morbidity rates due to CVDs and are therefore considered to be significantly harmful to the Filipinos. In 2004, a DOH study concluded that the considerable mortality and morbidity rates from cardiovascular and respiratory diseases would have been reduced if Metro Manila had improved the quality of air by 2002 [11]. However, this conclusion is simply too general and lacks the actual facts and/or data from any study or research that solely considers the number of deaths from cardiovascular diseases due to air pollutants in the country. IV. SURVEY ANALYSIS In view of the epidemiological data on CVD and of the various environmental statistics, given above, one of the aims of this study is to assess the awareness of cardiologists, regardless of their experience and sub-specialisation, with regard to the possible deleterious impacts of air pollution on CVD, and whether account is taken of such risks during diagnosis and patient management. Methodology: A questionnaire was devised in collaboration with one of the authors (MHS) who is a cardiologist and an environmental specialist. It was divided into a mixture of multiple-choice and open-ended questions, with a total of 22 items. A pilot study was implemented in two specialist hospitals in Hanoi, Vietnam, with a sample of 55 respondents. The protocol was submitted to the research departments of those hospitals. The questionnaire was translated into Vietnamese and then translated back into English to undergo analysis in SPSS (version 17). A few minor amendments were pointed out in order to carry out a full-scale study in the Philippines. The questionnaire, along with the protocol, was sent out by email to a large sample of cardiologists who practice in a variety of clinical organisations and who are members of the Philippines Heart Association (PHA) practising in Metro Manila,

Davao province and other provinces. In the case of Davao province, the survey was implemented through a self-completion method due to logistical issues. This process followed PHA, Philippines Council for Health Research and Development (PCHRD) and National Ethics Committee (NEC) approvals. The final total number of respondents was 142 cardiologists who are practising in one or more organisations. Those organisations may be private, rural, or at secondary or tertiary levels. Results: The 142 respondents experience ranges from 1 to 43 years (mean 10.25; median: 8) and they have different sub-specialisations: nonclinical (1), clinical cardiology (67), invasive cardiology (28), non-invasive cardiology (38), paediatric cardiology (9) and surgery (2). With regard to air pollution being a potential risk factor to CVD, 58.5% were in agreement with the fact that air pollution is indeed a risk factor, 25.4% of the cardiologists were undecided and 16.2% of the respondents disagreed. However, in order to critically appraise the degree of their comprehension, the following question probed further into their knowledge of at least one possible mechanism for the pathophysiological pathway of air pollution in relation to the disease. In total, there were only 24 physicians who could propose at least one seemingly valid mechanism. In fact, only 19 (13.4%) responses proposed mechanisms matching with the established literature; one response did not match the established literature and 4 proposed invalid mechanisms (Fig. 3).

Fig. 3. Breakdown of Proportional Agreements towards Air Pollution Being a risk factor to CVDs

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

Due to the fact that 2 physicians suggested more than 1 mechanism, therefore, of the 19 cardiologists who suggested mechanisms that matched the established literature, the total occurrences of proposed mechanisms by the physicians were 21. Table I describes in detail the types of pathways articulated in the survey. Table I. General Mechanisms Proposed by the Cardiologists in the Sample

plants are the significant contributors to CVD. This means that those physicians are confidently and absolutely aware of the potential link between air pollution and CVD. Nonetheless, that proportion of 24 cardiologists is quite small in comparison to the entire sample size of 142 respondents. The proportional positive agreement with regard to the exacerbation of CVD conditions due to air pollution, which was approximately 61.3% (i.e., 87 respondents), was slightly higher than air pollution being a risk factor (mentioned above). This figure also reflects the fact that, when asked, out of every three physicians, there would be one cardiologist either doubting the harmful impact of air pollution on CVD patients or unsure of the issue. In addition to concurring to the exacerbation effects of air pollution, physicians were also asked to list at least one harmful airborne pollutant. Only 55 out of 87 cardiologists could propose either one or more. The most common such pollutant articulated by 36 physicians was carbon monoxide (CO), followed by sulphur dioxide (SO2) and nitrogen dioxide (NO2) with 7 occurrences each. Unfortunately, PM, which a substantive number of studies strongly support its impact on CVD, was mentioned only 5 times in the survey. Some other air pollutants, such as metal dust, NH3 and other mixtures, were also mentioned in the survey. Those figures clearly demonstrate that the deeper the knowledge was tested through drilling down the responses, the fewer the number of positive responses the survey showed. In fact, with each drilling down step undertaken, 25% of the sample was being eliminated as a result of their responses. Physicians who tend to agree with the exacerbation impact of air pollution on patients suffering from CVD compared to those who are in disagreement are 6.1 times (95% CI 1.7 to 22.4) more likely to be knowledgeable about the subject. Similarly, cardiologists who could propose some concern that air pollutants can exacerbate CVD conditions, compared to those who disagreed with the harmful impact of air pollution, are 3.7 times (95% CI 1.1 to 12.4) more likely to be knowledgeable about the subject. This figure reduced from 6.1 to 3.7 times due to the limited number of cardiologists who suggested harmful air pollutants of concern.

A thorough statistical analysis was then carried out using SPSS (version 17). The results revealed that there was a positive significant pair association between the agreement that air pollution is a potential risk factor to CVD and the understanding of the harmful effects of the sources of air pollutants which are emissions mainly from vehicles and industrial plants, respectively. The corresponding Pearson Chi Square test is 93.2 and 80.8 with 8 degrees of freedom, p < 0.001, and Spearmans Correlation test result is r = 0.474 and 0.393, p < 0.001. This can be interpreted such that physicians who concurred with the fact that air pollution is risk factor and also proposed a valid mechanism (n=24), also are in full agreement that the emissions from either vehicles or manufacturing

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

Beyond the clinical expertise of the cardiologists, one of the aims of the survey was to probe into their awareness of the environmental regulations and guidelines stipulated by the government, especially since the South East Asian region, in general, is attempting to put in place enormous efforts in combating the deteriorating air quality through its respective governments. In addition, the survey offered the opportunity to the physicians to recommend possible legislative and regulatory measures to that effect beyond any existing ones in the Philippines. Surprisingly, statistical analysis of the responses reveals that nearly two thirds (66%) of the physicians are not aware of any governmental effort to battle air pollution issues. Although the Philippines Clean Air Act of 1999 became law in that year, with different recommendations such as establishing and developing the criteria of permissible air pollutants levels in the National Ambient Air Quality Guideline and improving the quality of gasoline and fuel, up to date - and it has been more than 10 years since the Act came into force - only 34% of the entire sample of cardiologists are aware of the governments efforts to combat air pollution. The above poses the important question of whether there is a need to provide more comprehensive education on the effects of environmental pollution on CVD onset and exacerbation to upcoming generations of Filipino cardiologists, or to strengthen the effectiveness of the governmental plans, regulations and legislations on air quality. Either way, governmental organisations need to take more positive steps in order to improve both the general and specialist knowledge about air pollution and its health effects, especially on heart diseases. V. CONCLUSIONS Although results from the survey show a moderate (58.5%) positive awareness from the Filipino cardiologists about the link between air pollution and CVD, from the pathophysiological pathway understanding perspective, the proportion of physicians who are able to propose mechanisms matching those reported in the literature are reduced sharply by 13.4%. Furthermore, the majority of cardiologists are not aware of any authoritative documents that relate to the subject.

This factor clearly reflects the serious shortcomings in the knowledge of Filipino physicians about the potential association of air pollution and CVDs.

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

[9] Biona, J.B.M. , Culaba, A.B. and Purvis, M. R. I. (2007) Energy Use and Emissions of Two Stroke-Powered Tricycles in Metro Manila. Journal of Transportation Research Part D Vol. 12 (7): 488-97. [10] Krupnick, A., Morgenstern, R., Fischer, C. , Rolfe, K. , Logarta, J. and Rufo, B. (2003), Air Pollution Control Policy Options for Metro Manila [online] Available from <> [Accessed 31st December 2010]. [11] Torres, E. B. , Subida, R. D. , Gapas, J. L. , Sarol, J. N. , Villarin, J. T. , Vinluan, R. J. N. , Ramos, B. M. R. and Quirit, L. L. (2004), Public Health Monitoring: A Study Under The Metro Manila Air Quality Improvement Sector Development Program - Executive Summary [online] Available from < A-4141-4A35-9194D1E16B475986/0/Execsummary.pdf> [Accessed 27 December 2010]. [12] USAID (2007), Annex 10: Data Annex: Philippines [online] Available from < 0Data.pdf> [Accessed 19 November 2010]. [13] Vergel, K.B.N. (2004), Urban Transportation and the Environment in Metro Manila: Programs and Initiatives for Clean Air [online] Available from < 003/K.Vergel.pdf> [Accessed on the 27 December]. [14] Subida, R. , Velas, M. A. and McNamara, D. (2004), Integrated Environmental Strategies Philippines Project Report/Metropolitan Manila: A Focus on the Transport Sector [online] Available from < te.pdf> [Accessed 25th April 2010]. [15] Department of Environment and Natural Resources (2003), National Air Quality Status Report [online] Available from < qualitystatusreport/partone.pdf> [Accessed 27 December 2010].

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