AIR POLLUTION JOURNAL

Impact of ambient Air Pollution

Developing Countrie

TEKNIK SIPIL BANGUNAN GEDUNG 04/D

KELOMPOK 2
1. ST ANNISA AULIA AILSA [ 240201602062 ]
2. SITI NUR AISYAH [ 240201602057 ]
3. HERLAN FAJAR [ 240201602053 ]

UNIVERSITAS NEGERI MAKASSAR

JURUSAN PENDIDIKAN TEKNIK SIPIL DAN

FAKULTAS TEKNIK

PERENCANAAN TAHUN AJARAN 2024/2025

 Impact of Ambient air Pollution
in Developing Countries

Abstract: The effects of ambient air pollution on human health have been
consistently documented by many epidemiologic studies worldwide, and it has
been calculated that globally at least seven million deaths are annually
attributable to the effects of air pollution. The major air pollutants emitted into
the atmosphere by a number of natural processes and human activities include
nitrogen oxides, volatile organic compounds, and particulate matter. In
addition to the poor ambient air quality, there is increasing evidence that
indoor air pollution also poses a serious threat to human health, especially in
low-income countries that still use biomass fuels as an energy resource. This
review summarizes the current knowledge on ambient air pollution in
financially deprived populations.

1. Introduction
It is well known that air pollution has a number of detrimental effects on
human health and is considered a major issue for the global community. The
World Health Organization (WHO) estimated that, in the year 2012, ambient air
pollution was responsible for nearly seven million deaths, representing more
than 10% of all-cause deaths and more than doubling previous estimates. Air
pollution accounts worldwide for an estimated 9% of deaths due to lung cancer,
17% due to chronic obstructive pulmonary disease, more than 30% due to
ischemic heart disease and stroke, and 9% due to respiratory [Link]
Global Burden of Disease report identified in 2012 that air pollution was among
the leading risk factors for disease burden, being globally responsible alone for
3.1% of all Disability-Adjusted Life Years (DALYs). All these findings confirm that
air pollution is now the world’s largest environmental health risk.
Outdoor air pollution is a mixture of thousands of components. Among them,
airborne particulate matter (PM) and the gaseous pollutants ozone, nitrogen
dioxide (NO2), volatile organic compounds (including benzene), carbon monoxide
(CO), and sulphur dioxide (SO2) are the most important from a health
perspective. Primary pollutants such as soot particles and oxides of nitrogen and
sulphur are emitted directly into the air by the combustion of fossil fuels. Major
sources of primary particles include motorized road traffic, power generation,
industrial sources, and residential heating. Secondary pollutants, formed when
primary pollutants react or interact in the atmosphere, include mainly ozone
(O3) and PM. The latter, primary or secondary in origin, consists of
particles that, on the basis of their size, are classified as coarse (diameter <
10 µm; PM10), fine (diameter < 2.5 µm; PM2.5), or ultrafine (<0.1 µm; PM0.1).
PM2.5 are contained within the coarse particle fraction, broadly representing
approximately 50% of the total mass of PM10. The resuspension of soil and road
dust by wind or moving vehicles, as well as construction work and industry.

emissions, results in coarse particles (PM10). Fine particles are derived

primarily from direct emissions from combustion processes such as gasoline and
diesel fuel, wood burning, coal burning for power generation, and industrial
processes [11]. Fine particles can travel large distances (more than 100 km), with
the potential for high background concentrations over a wide area [12]. As a
consequence, their composition may be extremely heterogeneous, depending on
the meteorological conditions and human activities in a particular geographical
area [12]. Ultrafine particles are fresh emissions from combustion-related sources
such as vehicle exhaust and atmospheric photochemical reactions and are
recognized as important markers of exposure to traffic exhaust along main roads
[13]. Fine and ultrafine particles are those associated with the worst effects on
health as they can reach the deepest portions of the airways or even reach the
blood stream directly [5,14].

If acute and long-term exposure to ambient air pollution represents a serious

threat for health in western industrialized countries, the burden of this problem
is even higher in developing countries, where population explosion along with
widespread industrialization coupled with urbanization have resulted in dense
urban centers with poor air quality [15,16]. In such developing countries,
however, huge economic and social disparities coexist; thus, in addition to the
poor ambient air quality, people can be also exposed, especially in rural areas, to
high concentrations of indoor air pollution due to the use of biomass fuels (coal,
wood, and other solid fuels) as an energy resource [17,18]. Worldwide, more than
three billion people, largely in developing countries, rely on biomass fuels for
their domestic energy needs [8].

As a consequence, household air pollution from solid fuel use has become a
serious threat to health and has been estimated to be one of the top five major
risk factors for the global burden of disease (4.3% of global DALYs), accounting
for 3.9 million premature deaths in 2010 [17]. In this regard, the best example is
provided by Asia, which has experienced rapid and disharmonic industrialization,
urbanization, and transportation development in the recent decades, with
resulting outdoor and indoor air pollution levels that are constantly well above
the upper limits indicated by the WHO guidelines [19,20]. China, in particular,
the Asian country with the fastest industrial development and population
increase, is now facing the worst air pollution problem in the world [21,22]. This
review focuses on this particularly vulnerable population living in low- and
middle-income countries and highly exposed to both household and outdoor
pollutants.

2. Health Effects in Adult Population

A number of studies and meta-analyses have shown that increased mortality
is associated with short- and long-term exposure to PM, both in developed and
developing countries. The percentage relative risk (RR) increase for all-cause
mortality related to short-term PM exposure has been estimated to range from
0.4% to 1.5% per 20 µg/m3 increase in coarser PM10 and from 0.6% to 1.2%
per 10 µg/m3 increase in finer PM2.5 [23]. Interestingly, the results of a recent
large study conducted in the United States by Di and colleagues [24], including
more than 60 million Medicare beneficiaries from 2000 through 2012, found that,
for every increase of 10 µg/m3 in PM2.5, there was an associated 7.3% increase in
all-cause mortality. This robust association was even more evident when the
analysis was restricted to the Medicaid-eligible sub-group, documenting that
persons with low socioeconomic status are more likely to be exposed to higher
pollutant levels (and thus experience an increased incidence of adverse effects)
than the rest of population [24]. As previously mentioned, this association may
particularly important in East-Asian countries, which, due to their rapidly
developing economies and dense populations, are exposed to very high levels of
air pollution [25]. For instance, with urbanization increasing from 26% in 1990 to
50% in 2010, China has undergone dramatic epidemiological transitions [26,27],
and, among the risk factors responsible for DALYs, ambient and household air
pollution ranked fourth and fifth, respectively [28]. A recent meta-analysis of 33
time-series and case-crossover studies conducted in China to assess the mortality
effects of short-term exposure to air pollution observed that each 10 µg/m3
increase in PM2.5 was associated with a 0.38% (95% CI 0.31–0.45) increase in
total mortality, a 0.51% increase in respiratory mortality (95% CI 0.30–0.73), and
a 0.44% (95% CI 0.33–0.54) increase in cardiovascular mortality [25].

The short-term effects of air pollution on health have also been the object of
intense research in developing countries outside the Asiatic region. For instance,
the ESCALA (Estudio de Salud y Contaminacion del Aire en Latinoamerica)
study, which was conducted in nine Latin American cities, found a significant
association between daily exposure to PM 10 and O3 and daily mortality [29].
Likewise, indoor air pollution has been shown to have a significant impact on the
health of populations living in rural areas in less industrialized countries such as
Pakistan and India [30,31].
Pertaining to the adverse effects on the lungs, air pollution, as previously
mentioned, is the cause and aggravating factor of many respiratory diseases like
chronic obstructive pulmonary disease, asthma, and lung cancer [32]. Increased
ambient O3, NO2, PM2.5, and SO2 levels were consistently associated with
increased hospital admission for asthma and pneumonia in various studies
conducted in Hong Kong and Taipei [33–36]. A systematic review confirmed that
indoor air pollution due to solid fuel combustion was also an important risk factor
for chronic obstructive pulmonary disease in adult populations living in low-
income countries, particularly in non-smoking women [37].
In addition, a number of studies have consistently documented the
association between air pollution and the risk of developing lung cancer; women
carry the highest risk, probably due to their increased exposure to indoor air
pollution [38–40]. Time-based multiple risk factor models have shown that
smoking and solid-fuel use collectively contributed to 75% of lung cancer deaths
in China [41]. Each 10 µg/m3 increase in the two-year average of PM2.5
correlated significantly with an increased risk of lung cancer in both males (RR
1.055; 95% CI 1.038 to 1.072) and females (RR 1.149; 95% CI 1.120 to 1.178)
[42].
In addition to respiratory diseases, there is also increasing evidence that
sustained exposure to ambient and household air pollution has a particularly
deleterious effect on the cardiovascular system, and an association has been
found between hypertension, coronary heart disease, and stroke [16]. A 2013
review reported a pooled effect of 11% (95% CI 6 to 16%) for cardiovascular
mortality with a 10 µg/m3 PM2.5 increase [43]. Although populations in low- and
middle-income countries are highly exposed to environmental pollution, the bulk
of evidence that links these exposures to cardiovascular disease is derived mostly
from populations in high-income countries [16]. Pertaining to developing
countries, for instance, the results of a recent study conducted by Chen and
colleagues [44] clearly indicate that life-expectancy in Northern China, where air
quality is particularly poor, is 5.5 years lower owing to an increased incidence of
cardiorespiratory mortality.
Notably, a study on long-term exposure to ambient air pollution conducted in
Shenyang, the largest and most heavily industrialized city in China, showed that
an increase of 10 µg/m3 in the yearly average concentration of PM10
corresponded to 55% and 49% increases in the risk of death due to
cardiovascular and cerebrovascular diseases, respectively [45]. In addition to the
close link between air pollution and arterial thrombosis, there is also some
evidence of the association with venous thromboembolism [45], as suggested by
a recent systematic review [46]. A study conducted in Santiago, Chile (a city with
a high level of air pollution) between 2001 and 2005 reported that the short-term
increase in hospital admissions for venous thrombosis and pulmonary events was
proportional to the elevations in the concentration of fine PM, documenting that
the burden of this phenomenon is significant also for developing countries [47].

3. Health Effects in Particularly Vulnerable Populations

If air pollution, both outdoor and indoor, is considered a major health
problem in developing countries, the burden of this issue is even greater in those
population groups that are particularly vulnerable such as pregnant women,
newborns, and children [48,49]. In particular, exposure to indoor air pollution
from the combustion of solid biofuels is a significant public health hazard
predominantly affecting women and small children living in poor households in
both rural and urban communities in developing countries [50]. Recent studies
have shown that air pollution can affect the developing fetus via maternal
exposure, resulting in preterm birth, low birth weight, growth restriction, and
potentially adverse cardiovascular and respiratory outcomes [51]. In this regard, a
number of epidemiological and clinical studies conducted in low-income countries
found an association between exposure to indoor

air pollution during pregnancy and low birth weight and still birth [52–57], and a
meta-analysis by Pope and colleagues calculated that the RR of low birth weight
and stillbirth attributable to indoor air pollution in developing countries was 21%
and 26%, respectively [58]. Another more recent systematic review and meta-
analysis found a strong association between household air pollution from solid
fuel use and the risk of adverse pregnancy outcomes; such exposure resulted in
an 86.43 g reduction in birth weight and a 35% and 29% increased risk of low
birth weight and stillbirth, respectively [59]. Interventions aimed at reducing
exposure to household air pollution will result in an improvement of survival
outcomes for all children [19]. Notably, a study evaluating the mortality effects of
indoor air pollution and ambient urban PM pollution in Mexico estimated that the
annual child mortality rate would decrease by 0.1 per 1000 children in the
absence of these environmental exposures [60].
There is also consistent evidence that smoke from biofuels can cause acute
lower respiratory infections in childhood [61–63]. Notably, a randomized
controlled trial performed in Guatemala found that a reduction in exposure to
household air pollution led to a significant one-third reduction of severe childhood
pneumonia, with possible important implications for the reduction of child
mortality [64]. In addition, air pollution has been found to be an important
contributor to the increased prevalence of allergic diseases in children in
developing countries, including asthma [32,65,66]. Coal combustion for heating
(odds ratio (OR) 1.5, 95% CI 1.1 to 1.9) and cooking (OR 2.3. 95% CI 1.5 to 3.5)
conferred higher risks of childhood asthma in China [67]. Each 10 µg/m3 increase
in NO2 corresponded to an adjusted OR of 1.25 (95% CI 1.16 to 1.36) for
diagnosed asthma in six to 13 year-old Chinese children [68]. In addition,
increased ambient O3, NO2, PM2.5, and SO2 levels were associated with increased
hospital admission for asthma in children [33–35,69,70]. For instance, Ko and
colleagues [34] retrospectively reviewed the relationship between daily
emergency hospital admissions and asthma and indices of air pollutants (SO2,
NO2, O3, PM10, and PM2.5 levels) for 15 major hospitals in Hong Kong between
January 2000 and December 2005. A total of 69,716 admissions were assessed,
and significant associations were found between hospital admissions for asthma
and NO2, O3, PM10, and PM2.5 levels (respective RRs, 1.04, 1.03, 1.02, and 1.02
per 10 µg/m3 increases). However, the adverse effects of early-life exposure to air
pollution could be long lasting. In China, each 15 µg/m3 and 50 µg/m3 increase in
NO2 and SO2 levels was associated with an adjusted OR of 1.90 (95% CI 1.20 to
3.00) and 1.62 (95% CI 1.01 to 2.60) for asthma, respectively, whereas the
combined exposure to high levels of NO2 and SO2 further increased the OR to
1.85 (95% CI 1.22 to 2.79) in the first year of life [71].

4. Conclusions
Compared with most developed countries that have completed
industrialization programs for several years, low- and middle-income countries
have experienced an intense process of urbanization and industrial development
in a very short period of time, which has led them to become the countries with
the largest air pollution-related burdens in recent years. This phenomenon has
deleterious effects on the health of people resident in these developing countries,
as they are exposed to the joint toxic effects of household and ambient air
pollution (Table 1).
In particular, women and children living in severe poverty have the greatest
exposure to indoor air pollution from solid fuel use as they spend a lot of time near
stoves [72]. As a consequence, such vulnerable populations have an increased risk
of developing short-term and long-lasting adverse effects related to air pollution
and thus need a closer follow-up. In this regard, the systematic monitoring of
ambient air quality by national authorities in such countries will enable the
implementation and evaluation of interventions aimed at lowering dangerous air
pollutant levels [19,73]. The expenditures of these programs will be largely
amortized by the costs saved by the prevention of air pollution-related morbidity
and mortality in the population [20]. An impressive example of the potential
beneficial effects of such interventions on the health of the population stems
from the Beijing 2008 Olympic Games, when maintaining the exposure to PM10
under the limit of 100 µg/m3 during the period of the Games was associated with
a nearly 40% reduction in health-related economic costs, compared with the
period before the Games [21]. In conclusion, further epidemiological and
clinical studies on air.
pollution in the developing world are warranted for assessing the degree of
the burden of air pollution on health outcomes and for setting priorities in taking
environmental local control measures.

Table 1. The burden of air pollution in developing versus developed countries.

Issue References
Higher household exposures due to biomass fuels [8,18,22,30,49,61]
More rapid and disharmonic industrialization, [8,19,22,26,28]
urbanization and
transportation development
 Fewer preventative health services and generally less surveillance

[18,19,73] Higher maternal exposure during pregnancy

[52,53,56–59] Higher children exposure

[66–
71]

Author Contributions: P.M.M. conceived the study; M.F. wrote the paper; and
P.M.M. critically revised the manuscript.
Conflicts of Interest: The authors declare no conflicts of interest.

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50. Ezzati, M. Indoor air pollution and health in developing countries. Lancet 2005, 366, 104–
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2013, 216, 47–53. [CrossRef] [PubMed]
52. Mishra, V.; Dai, X.; Smith, K.R.; Mika, L. Maternal exposure to biomass smoke and reduced
birth weight in Zimbabwe. Ann. Epidemiol. 2004, 14, 740–747. [CrossRef] [PubMed]
53. Boy, E.; Bruce, N.; Delgado, H. Birth weight and exposure to kitchen wood smoke during
pregnancy in rural Guatemala. Environ. Health Perspect. 2002, 110, 109–114. [CrossRef]
[PubMed]
54. Lakshmi, P.V.M.; Virdi, N.K.; Sharma, A.; Tripathy, J.P.; Smith, K.R.; Bates, M.N.; Kumar, R.
Hosehold air pollution and stillbirth in India: Analysis of the DLHS-II National Survey.
Environ. Res. 2013, 121, 17–22. [CrossRef] [PubMed]
55. Amegah, A.K.; Nayha, S.; Jaakkola, J.J.K. Do biomass fuel use and consumption of unsafe
water mediate educational inequalities in stillbirth risk? An analysis of the 2007 Ghana
Maternal Health Survey. BMJ Open 2017, 7, e012348. [CrossRef] [PubMed]

56. Khan, N.; Nurs, C.Z.B.; Isla, M.M.; Islam, R.; Rahman, M. Household air pollution from
cooking and risk of adverse health and birth outcomes in Bangladesh: A nationwide
population-based study. Environ. Health 2017, 16, 57. [CrossRef] [PubMed]
57. Bruce, N.G.; Dherani, M.K.; Das, J.; Balakrishnan, K.; Adair-Rohani, H.; Bhutta, Z.A.; Pope,
 D. Control of household air pollution for child survival: Estimates for intervention impacts.
BMC Public Health 2013, 13, S8.
58. Pope, D.P.; Mishra, V.; Thompson, L.; Siddiqui, A.R.; Rehfuess, E.A.; Weber, M.; Bruce, N.G.
Risk of low birth weight and stillbirth associated with indoor air pollution from solid fuel
use in developing countries. Epidemiol. Rev. 2010, 32, 70–81. [CrossRef] [PubMed]
59. Amegah, A.K.; Quansah, R.; Jaakkola, J.J.K. Household air pollution from solid fuel use and
risk of adverse pregnancy outcomes: A systematic review and meta-analyisis of the
empirical evidence. PLoS ONE 2014, 9, e113920. [CrossRef] [PubMed]
60. Stevens, G.A.; Dias, R.H.; Ezzati, M. The effect of 3 environmental risks on mortality
disparities across Mexican communities. Proc. Natl. Acad. Sci. USA 2008, 105, 16860–
16865. [CrossRef] [PubMed]
61. Fullerton, D.G.; Bruce, N.; Gordon, S.B. Indoor air pollution from biomass fuel smoke is a
major health concern in the developing world. Trans. R. Soc. Trop. Med. Hyg. 2008, 102,
843–851. [CrossRef] [PubMed]
62. Ezzati, M.; Kammen, D.M. Quantifying the effects of exposure to indoor air pollution from
biomass combustion on acute respiratory infections in developing countries. Environ.
Health Perspect. 2001, 109, 481–488. [CrossRef] [PubMed]
63. Ezzati, M.; Kammen, D. Indoor air pollution from biomass combustion and acute
respiratory infections in Kenya: An exposure-response study. Lancet 2001, 358, 619–624.
[CrossRef]
64. Smith, K.R.; McCracken, J.P.; Weber, M.W.; Hubbard, A.; Jenny, A.; Thompson, L.M.;
Balmes, J.; Diaz, A.; Arana, B.; Bruce, N. Effect of reduction in household air pollution on
childhood pneumonia in Guatemala (RESPIRE): A randomized controlled trial. Lancet 2011,
378, 1717–1726. [CrossRef]
65. Leung, T.F.; Ko, F.W.; Wong, G.W. Roles of pollution in the prevalence and exacerbations of
allergic diseases in Asia. J. Allergy Clin. Immunol. 2012, 129, 42–47. [CrossRef] [PubMed]
66. Nandasena, S.; Wickremasinghe, A.R.; Sathiakumar, N. Indoor air pollution and respiratory
health of children in the developing world. World J. Clin. Pediatr. 2013, 2, 6–15. [CrossRef]
[PubMed]
67. Zheng, T.; Niu, S.; Lu, B.; Fan, X.; Sun, F.; Wang, J.; Zhang, Y.; Zhang, B.; Owens, P.; Hao,
L.; et al. Childhood asthma in Beijing, China: A population-based case-control study. Am. J.
Epidemiol. 2002, 156, 977–983. [CrossRef] [PubMed]
68. Liu, F.; Zhao, Y.; Liu, Y.Q.; Liu, Y.; Sun, J.; Huang, M.M.; Liu, Y.; Dong, G.H. Asthma and
asthma related symptoms in 23326 Chinese children in relation to indoor and outdoor
environmental factors: The Seven Northeastern Cities (SNEC) study. Sci. Total Environ.
2014, 497–498, 10–17. [CrossRef] [PubMed]
69. Wong, G.W.; Ko, F.W.; Lau, T.S.; Li, ST.; Hui, D.; Pang, S.W.; Leung, R.; Fok, T.F.; Lai, C.K.
Temporal relationship between air pollution and hospital admissions for asthmatic
children in Hong Kong. Clin. Exp Allergy 2001, 31, 565–569. [CrossRef] [PubMed]
70. Lee, S.L.; Wong, W.H.S.; Lau, Y.L. Association between air pollution and asthma admission
among children in Hong Kong. Clin. Exp. Allergy 2006, 36, 1138–1146. [CrossRef]
[PubMed]
71. Deng, Q.; Lu, C.; Norback, D.; Bornehag, C.G.; Zhang, Y.; Liu, W.; Yuan, H.; Sundell, J.
Early life exposure to ambient air pollution and childhood asthma in China. Environ. Res.
2015, 143, 83–92. [CrossRef] [PubMed]
72. Gordon, S.B.; Bruce, N.G.; Grigg, J.; Hibberd, P.L.; Kurmi, O.P.; Lam, K.B.; Mortimer, K.;
Asante, K.P.; Balakrishnan, K.; Balmes, J.; et al. Respiratory risks from household air
pollution in low and middle income countries. Lancet Respir. Med. 2014, 2, 823–860.
[CrossRef]
73. Quansah, R.; Semple, S.; Ochieng, C.A.; Juvekar, S.; Armah, F.A.; Luginaah, I.; Emina, J.
Effectiveness of interventions to reduce household air pollution and/or improve health in
homes using solid fuel in low-and-middle income countries: A systematic review and meta-
analysis. Environ. Int. 2017, 103, 73–90. [CrossRef] [PubMed]
 Table 1. The burden of air pollution in developing versus developed countries.

Issue References
Higher household exposures due to biomass fuels [8,18,22,30,49,61]
More rapid and disharmonic industrialization, [8,19,22,26,28]
urbanization and
transportation development
Fewer preventative health services and generally less surveillance
[18,19,73]
Higher maternal exposure during pregnancy [52,53,56–

59] Higher children exposure [66–71]

Author Contributions: P.M.M. conceived the study; M.F. wrote the paper; and P.M.M.
critically revised the manuscript.
Conflicts of Interest: The authors declare no conflicts of interest.

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135. Ezzati, M.; Kammen, D.M. Quantifying the effects of exposure to indoor air pollution from
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142. Wong, G.W.; Ko, F.W.; Lau, T.S.; Li, ST.; Hui, D.; Pang, S.W.; Leung, R.; Fok, T.F.; Lai, C.K.
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144. Deng, Q.; Lu, C.; Norback, D.; Bornehag, C.G.; Zhang, Y.; Liu, W.; Yuan, H.; Sundell, J.
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145. Gordon, S.B.; Bruce, N.G.; Grigg, J.; Hibberd, P.L.; Kurmi, O.P.; Lam, K.B.; Mortimer, K.;
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[CrossRef]
146. Quansah, R.; Semple, S.; Ochieng, C.A.; Juvekar, S.; Armah, F.A.; Luginaah, I.; Emina, J.
Effectiveness of interventions to reduce household air pollution and/or improve health in
homes using solid fuel in low-and-middle income countries: A systematic review and meta-
analysis. Environ. Int. 2017, 103, 73–90. [CrossRef] [PubMed]
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