2. In recent decades, reported evidence on the association between air pollutants and the increase in emergency visits for respiratory diseases Recent estimates from WHO suggest that more than 100 million people in Latin America and the Caribbean are exposed to levels of outdoor air pollutants that exceed the guideline values ​​ recommended by WHO The air pollution levels are alarming. This is among the 10 leading causes of death worldwide. An estimated 3 million people annually die of diseases caused by polluted air, according to statistics from the World Health Organization (WHO).

3.  Comprises those aspects of human health determined by the interaction of man withbiological, chemical, physical, social and psychosocial present in the environment. Includesthe theory and practice to prevent, monitor, evaluate and correct the factors in the environment that may affect the health of present and future generations. WHO 2008

6. Global disease burden 23%of the global disease burden is attributable to the environment Household air pollution burden 2 million deaths every year as a result of exposure to indoor smoke from cooking fuels Water and sanitation burden 88%of the diarrhoal deaths are due to unsafe water, inappropriate sanitation and lack of hygiene www.who.int/gho/phe/indoor_air_pollution/burden www.who.int/gho/phe/en/index

11. Validation of questionnaires to detect asthma:  Burney PGJ, Laitinen LA, Perdrizet S et al. Validity and repeatability of the IUATLD (1984) Bronchial Symptoms Questionnaire: an international comparison. Eur Respir J 1989; 2: 940-945.  Jenkins MA, Clarke JR, Carlin JB et al. Validation of questionnaire and bronchial hyper-responsiveness against respiratory physician assessment in the diagnosis of asthma. Int J Epidemiol 1996: 25: 609.

13. Acumulative Prevalence Actual Prevalence

14. Smoking, PM, SO, CO, Bio mass, etc PROTEASAS PROTEASAS Alveolar wall destruction Mucose hypersecretions (crónic bronchitis) Fibrosis Fibrosis (small air way) Fibroblast TGF-β CTG Neutróphils Chemotáctics factors Lymphocite CD8 + Monocyte Alveolar Macrophage EpihtelialsCéls INFLAMMATORY MECHANISM INFLAMMATORY MECHANISM Increased Oxidative Stress on Epithelial cells and macrophages. Free radicals increase Apoptosis Garbo 2008 Neutrophil elastase cathepsins Metalloproteinasas Matrix

17.  In communities with high ozone concentrations, the relative risk of developing asthma in children playing three or more sports was 3.3 (95% CI 1.9-5.8), compared with children playing no sports. Sports had no effect in areas of low ozone concentration (0.8, 0.4-1.6). Time spent outside was associated with a higher incidence of asthma in areas of high ozone (1.4, 1.0-2.1), but not in areas of low ozone. Exposure to pollutants other than ozone did not alter the effect of team sports.  Incidence of new diagnoses of asthma is associated with heavy exercise in communities with high concentrations of ozone, thus, air pollution and outdoor exercise could contribute to the development of asthma in children.

18.  BACKGROUND:  Little is known about the effect of exposure to air pollution during exercise or time spent outdoors on the development of asthma. We investigated the relation between newly- diagnosed asthma and team sports in a cohort of children exposed to different concentrations and mixtures of air pollutants.

19.  The results of this study indicate that current levels of air pollution have chronic, adverse effects on lung development in children from the age of 10 to 18 years, leading to clinically significant deficits in attained FEV 1 as children reach adulthood.  Gauderman WJ, Avol E, Gilliland F, Vora H, Thomas D, Berhane K, et al. The effect of air pollution on lung development from 10 to 18 years of age. N Engl J Med 2004;351:1057-67

20.  Conclusions: The physical and social environments interacted in predicting both biologic and clinical outcomes in children with asthma, suggesting that when pollution exposure is more modest, vulnerability to asthma exacerbations may be heightened in children with higher chronic stress.

26.  Global pollution (SO2, NOx, CO, PM…) differently implicated in population ‐ based surveys: ‐ peaks →↑↑asthma attacks, asthma drugs, hospital admissions ‐ chronic exposure →irritant effect, ↑↑BHR, asthma, rhinitis  Ozone: ‐ ↑↑allergic rhinitis (Parker, Health perspect 2009)  PM: implicated by both population and experimental studies ‐ PM2.5 o PM10 and asthma and allergies development ( Annesi ‐ Maesano, Respir Med 2007, Morgenstern, AJRCCM 2008) -PM2.5 o PM10 and lung function in asthmatics (McCreanor, NEJM 2007 )

27. In allergic rhinitis patients, smoking was significantly related to the risk of incident asthma, both in uni- variate analysis (OR 2.67; 95% CI 1.70–4.19) and in multi-variate analysis (OR 2.98; 95% CI 1.81–4.92). Having an allergic disease does not seem to be a barrier to smoke as active smoking was reported among those adolescents having concomitant lifetime asthma and hay fever.

28.  pollutants responsible for the increased risk/ prevalence of allergic sensitization and symptoms of allergic disease indicated that increased levels of nitrogen oxides (NOx), sulphur dioxide (SO2), ozone (O3), and particulates with aerodynamic diameter of 10 um or less (PM10) are important.

29.  Paraguay : Cual es el problema actual de nuestras ciudades ?

30. Thank You-Muchas Gracias !!!!