Commission for Environmental Cooperation

and the Environment in North America

Children’s Health

A First Report on Available Indicators and Measures
ii

DISCLAIMER

This report was prepared by the CEC Secretariat in coordination with the Steering Group for the Development 

of Indicators of Children’s Health and the Environment in North America, which is composed of officials of 

the Governments of Canada, Mexico and the United States, and representatives of the CEC, the International 

Joint Commission’s Health Professionals Task Force (IJC HPTF), the Pan American Health Organization 

(PAHO), and the World Health Organization (WHO). This North American report is based primarily on 

information contained in separate “country reports” prepared by Canada, Mexico and the United States 

(available at http://www.cec.org/pubs_docs/documents/index.cfm?varlan=english&ID=1813). 

Not all information and statements in the report necessarily reflect the views of the Governments of Canada, 

Mexico and/or the United States, or the CEC Secretariat, IJC, PAHO and/or WHO, in part because the report 

is a compilation of information provided separately by the three different countries.

Commission for Environmental Cooperation

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© Commission for Environmental Cooperation, 2006

Legal Deposit-Bibliothèque nationale du Québec, 2006

Legal Deposit-Bibliothèque nationale du Canada, 2006

ISBN: 2-923358-32-5

All images used with permission
Prepared by:

Secretariat—Commission for Environmental Cooperation 

In collaboration with:

International Joint Commission—Health Professionals Task Force

Pan American Health Organization

World Health Organization

The Governments of Canada, Mexico and the United States 

and the Environment in North America

Children’s Health

A First Report on Available Indicators and Measures

JANUARY 2006
Table of Contents

Preface _______ _ vii

Executive Summary _______ _ xi

1.0 An Overview of the Children’s Health and the Environment Indicators Initiative _______ _ 1

1.1 Children’s Health and the Environment _______ _ 1

1.2 The Need for North American Indicators of Children’s Health and the Environment _______ _ 2

1.3 Who Will Use This Report _______ _ 4

1.4 Selecting the Indicators for This Report _______ _ 5

1.5 A Common Approach to Indicator Development _______ _ 7

1.6 The First North American Report _______ _ 9

2.0 An Introduction to the Participating Countries _______ _ 11

2.1 Population Data and Birth Rates _______ _ 12

2.2 Child Mortality and Morbidity _______ _ 12

2.3 Immunization Rates as an Indicator of Availability of Public Health Services _______ _ 13

2.4 Socioeconomic Determinants of Health _______ _ 13

3.0 Asthma and Respiratory Disease _______ _ 15

3.1 Outdoor Air Pollution _______ _ 16

 3.1.1 Canada

 3.1.2 Mexico

 3.1.3 United States

 3.1.4 Opportunities for Strengthening Indicators of Outdoor 

 Air Pollution in North America

3.2 Indoor Air Pollution _______ _ 24

 3.2.1 Canada

 3.2.2 Mexico

 3.2.3 United States

 3.2.4 Opportunities for Strengthening Indicators 

 of Indoor Air Pollution in North America

3.3 Asthma _______ _ 30

 3.3.1 Canada

 3.3.2 Mexico

 3.3.3 United States

 3.3.4 Opportunities for Strengthening Indicators of Asthma 

 and Respiratory Disease in North America

This report represents North America’s contribution to the Global Initiative on 

Children’s Environmental Health Indicators, as well as its commitment to continuing 

to work together to ensure a safe and healthy environment for our children. 
4.0 Lead and Other Chemicals, including Pesticides _______ _ 39

4.1 Blood Lead Levels _______ _ 40

 4.1.1 Canada

 4.1.2 Mexico

 4.1.3 United States

 4.1.4 Opportunities for Strengthening Indicators 

 of Children’s Exposure to Lead in North America

4.2 Lead in the Home _______ _ 51

 4.2.1 Canada

 4.2.2 Mexico

 4.2.3 United States

 4.2.4 Opportunities for Strengthening the Indicator on Children’s 

 Exposure to Lead in the Home, in North America

4.3 Industrial Releases of Lead _______ _ 55

 4.3.1 Canada

 4.3.2 Mexico

 4.3.3 United States

 4.3.4 Opportunities for Strengthening Indicators of Lead 

 from Industrial Activities in North America

4.4 Industrial Releases of Selected Chemicals _______ _ 59

 4.4.1 Canada

 4.4.2 Mexico

 4.4.3 United States

 4.4.4 Opportunities for Strengthening PRTR-based Indicators in North America

4.5 Pesticides _______ _ 65

 4.5.1 Canada

 4.5.2 Mexico

 4.5.3 United States

 4.5.4 Opportunities for Strengthening Indicators of Children’s 

 Exposure to Pesticides in North America 

5.0 Waterborne Diseases _______ _ 71

5.1 Drinking Water _______ _ 72

 5.1.1 Canada

 5.1.2 Mexico 

 5.1.3 United States

 5.1.4 Opportunities for Strengthening Indicators on Availability 

 and Quality of Drinking Water in North America

5.2 Sanitation _______ _ 81

 5.2.1 Canada

 5.2.2 Mexico

 5.2.3 United States

 5.2.4 Opportunities for Strengthening Indicators on Sewage Systems 

 and Treatment in North America

5.3 Waterborne Diseases _______ _ 84

 5.3.1 Canada

 5.3.2 Mexico

 5.3.3 United States

 5.3.4 Opportunities for Strengthening Indicators on Childhood Morbidity 

 and Mortality from Waterborne Diseases in North America 

6.0 Lessons Learned and Actions Needed _______ _ 93

 List of Figures and Charts _______ _ 96

 List of Abbreviations _______ _ 98

 Glossary _______ _ 99

 References _______ _ 104

 Appendix 1: Council Resolution 02-06 _______ _ 107

 Appendix 2: Overview of Recommended Indicators from the CEC Council _______ _ 109

 Appendix 3: Council Resolution 03-10 _______ _ 111

 Appendix 4: Members of the Steering Group for the Development 

 of Indicators of Children’s Health and theEnvironment in North America _______ _ 112

 Appendix 5: Expert Review Panel _______ _ 115

 Appendix 6: 153 Matched Chemicals _______ _ 116

Children's Health and the Environment in North America 
Children deserve not only our love and affection; they deserve special diligence on our part 

 to ensure that they have the chance to thrive in a safe and nurturing world. 

PHOTO: CHRIST CHAVEZ / CEC
Preface

Indicators play a key role in informing us about the status of an issue, encouraging action and tracking 

progress towards stated goals. We use indicators every day for numerous purposes, from tracking the 

stock market to following trends in diseases to measuring unemployment. What are much less common, 

however, are indicators that tell us about the environmental health challenges facing our children. 

The WHO-led “Global Initiative on Children’s Environmental Health Indicators,” spearheaded by the 

US Environmental Protection Agency and launched at the World Summit on Sustainable Development 

(Johannesburg, 2002), is an effort to change all that. There is increasing recognition that unless we 

get serious about systematically tracking environmental infl uences on children’s health, our efforts 

to prevent and mitigate those effects will remain piecemeal. This report represents North America’s 

contribution to the Global Initiative, as well as its commitment to continuing to work together to ensure 

a safe and healthy environment for our children. 

The partial picture provided by this fi rst report shows us that, despite improvements on many 

fronts, our children remain at risk from environmental threats. In the area of air quality and 

respiratory health, we see that childhood asthma continues to increase across North America; 

levels of ozone and particulate matter remain a problem; and, despite declines in exposure to 

environmental tobacco smoke in Canada and the US, the US data suggest that certain minority 

groups are disproportionately affected. In Mexico, exposure to smoke from the indoor burning 

of biomass fuels is still widespread. With respect to toxics and pesticides, we see that toxic 

chemicals—including lead, a metal well known for its damaging effects on the neurological 

development of children—continue to be released in large amounts from industrial activities. 

Although the data are thin, it appears that while lead levels in children’s blood are on the decline 

in many parts of the continent, particular socio-economic groups remain at higher risk. On the 

positive side, available data indicate that pesticides residues in foods in Canada and the US, and 

acute poisonings in Mexico, are on the decline. With respect to water quality and waterborne 

disease, Mexico continues to face the largest challenges regarding access to safe drinking water 

and sanitation services, although progress is being made which no doubt is contributing to the 

decline in diarrheal diseases among Mexican children. 

Children deserve not only our love and affection, they deserve special diligence on our part 

to ensure that they have the chance to thrive in a safe and nurturing world. On an individual 

level, we can do our part to care for our children and keep them out of harm’s way. But the everincreasing evidence of the overt and subtle effects that a degraded environment can have on 

children’s health means that we also must act collectively. Acting alone, none of us can stem 

the problems of urban air pollution, toxic contamination, or poor water quality. But working as 

neighbors, communities, countries, and globally, we can make a difference. 

This report marks the beginning of an important new direction for North America. It is 

the culmination of many months of work by dedicated people from across the continent 

and globally, representing the governments of Canada, Mexico and the United States and 

the partner institutions, namely CEC, IJC, PAHO and WHO. It refl ects the expertise of a 

trinational review panel and the ideas of members of the public who provided their input. It 

is also a refl ection of the efforts of the countless many who have worked tirelessly over recent 

decades to promote environmental and child health protection. With this depth of support and 

momentum, this report is a reaffi rmation of the importance that North Americans place on the 

health and well-being of their children. It is also an acknowledgement of the value of information 

in guiding our decision-making and shaping our priorities. 

CHILDREN’S HEALTH AND THE ENVIRONMENT IN NORTH AMERICA

Children's Health and the Environment in North America vii
viii

In this report, we look at indicators in three thematic areas: (1) asthma and respiratory disease; 

(2) lead and other chemicals, including pesticides; and (3) waterborne diseases. These areas refl ect 

the priorities set by the three countries in the Cooperative Agenda for Children’s Health and the 

Environment in North America, adopted by the CEC Council in June 2002. The preparation of 

the present report was among the specifi c actions called for in the Cooperative Agenda, again 

demonstrating the importance that the three countries place on indicators as tools for informing 

decision-making and increasing public awareness. 

It should be recognized, however, that this report is only a fi rst step. It will be evident to its users that 

much work remains to be done. Of the thirteen indicators presented in the following pages, only 

one—addressing asthma in children—has been fully reported by all three countries. For the rest, 

useful information is provided but there remain signifi cant data gaps and issues of comparability 

that will need to be addressed before we can achieve a robust reporting system. Additionally, there 

are many other facets of children’s health and the environment that have not been tackled here, 

but are nonetheless worthy of attention. The scope of this report was limited to issues for which 

data are currently available. An expanded set of indicators that could draw upon richer and more 

conclusive data sets—such as biomonitoring data—is clearly desirable. Throughout the report, 

recommendations are made on how the set of indicators and their cross-border comparability 

can be improved. This will require the concerted efforts of all three governments and continued 

interaction through fora such as the CEC. 

Acknowledgements

This report could not have come about without the dedication and hard work of many individuals. From the initial 

planning stage and feasibility study, through the creation of the country reports, and fi nally to the completion of 

this fi rst-ever North American report, this has been a truly collaborative endeavor involving numerous people from 

the Governments of Canada, Mexico and the United States, the Commission for Environmental Cooperation (CEC), 

the International Joint Commission (IJC), the Pan American Health Organization (PAHO) and the World Health 

Organization (WHO). The Organization for Economic Cooperation and Development (OECD) participated as an 

observer. All of the countries and partner institutions were involved through their membership in a CEC-led Steering 

Group that not only guided the report’s development but contributed actively to its creation. 

“Country reports” prepared by Canada, Mexico and the United States (available at <www.cec.org/children>) provided 

the foundation upon which this report was built. Numerous government offi cials worked diligently over a span of more 

than two years to pull together relevant data sets and create the indicators that are presented in the country reports and 

in the following pages. Each country had a “country lead” who took on the task of coordinating the development of and, 

in some cases, writing the bulk of, the country reports. They were assisted not only by their colleagues in the Steering 

Group but also by staff in various governmental departments who reviewed and commented on drafts of the report. 

The following governmental offi cials deserve particular recognition for their valuable contributions: 

For the Government of Canada (Environment Canada and Health Canada), Annie Bérubé, former country lead, 

played a leading role in compiling the Canadian country report and, along with Nicki Sims-Jones and Vincent Mercier 

(current country lead), contributed greatly to bringing both the Canadian report and this North American volume to 

fruition. Others who contributed from Canada include Julie Charbonneau, Andrea Ecclestone, Susan Ecclestone, Kerri 

Henry, Amber McCool, Anthony Myres, Daniel Panko, Risa Smith, and Emma Wong. For the Government of Mexico

(Ministry of Health), Antonio Barraza, former country lead, was the primary author of the Mexican country report and 

thus a main contributor to this volume. Matiana Ramírez, the current country lead, played a key role by bringing the 

Mexican country report as well as the Mexican sections of this report to completion. Other contributors from Mexico 

include Rocio Alatore and Martha Plascencia. For the Government of the United States (Environmental Protection 

Agency), Ann Carroll (current country lead), Tracey Woodruff (technical expert), Daniel Axelrad (technical expert) 

and Edward Chu (former country lead) were the authors of the US country report and contributed greatly to this North 

American compilation. Catherine Allen (former country lead) and Evonne Marzouk (former country lead) played key 

roles in the Steering Group during the early stages of the report’s development. Brad Hurley provided technical support 

and served as a consultant for the US country report. Martha Berger served as observer.

Offi cials from each of the partner institutions also contributed their time, vision and expertise to this undertaking. 

In addition to this in-kind support, the IJC and PAHO also provided fi nancial contributions to the CEC for the 
Children's Health and the Environment in North America ix

On behalf of all of the partners in this indicators initiative—the three North American countries 

and our four respective institutions—we hope that you will fi nd this report useful, and that you 

will join us in our common pursuit of a safe and sustainable environment for our children and 

for future generations. 

William V. Kennedy

EXECUTIVE DIRECTOR

Commission 

for Environmental 

Cooperation 

of North America 

(CEC) 

The Rt. Hon. Herb Gray 

CHAIRMAN, 

CANADIAN SECTION,

The Hon. Dennis Schornack 

CHAIRMAN, US SECTION,

International Joint

Commission 

(IJC) 

Luiz A. Galvão

AREA MANAGER

Sustainable 

Development 

and Environmental 

Health Pan American 

Health Organization 

(PAHO) 

Dr. Maria Neira

DIRECTOR

Protection of the 

Human Environment

World Health 

Organization 

(WHO)

implementation of the project. WHO staff provided a vital link to the Global Initiative on Children’s Environmental 

Health Indicators, fostering the exchange of ideas and approaches with other regions of the world. Special thanks go 

to the following individuals from the partner institutions who contributed through their involvement in the Steering 

Group: For the IJC (Health Professionals Task Force): Irena Buka, James Houston, Pierre Gosselin, and Peter Orris; for 

PAHO: Luiz Augusto (‘Guto’) Galvão, Pierre Gosselin, Samuel Henao, and Alfonzo Ruiz; and for WHO: Fiona Gore 

and Eva Rehfuess. Pierre Gosselin is specially noted for his role in advocating for the project in its early days. 

It would be impossible to overstate the important contribution of the panel of experts who generously gave of their time 

and expertise to the development and improvement of the report. The nine-person panel, composed of three experts 

nominated by each of the three countries, met in Ottawa, Canada, in March 2004 to provide guidance and expertise based 

on their review of a fi rst draft of the report. The panel conducted a second in-depth written review of a subsequent draft 

in December 2004/January 2005. The experts also offered information and input on an ad hoc basis at various points 

during the project as the Steering Group worked to improve the report. Heartfelt thanks go to: Pumolo Roddy, Teresa To 

and Don Wigle from Canada; Enrique Cifuentes García, Cristina Cortinas de Nava, and Alvaro Román Osornio Vargas 

from Mexico, and Patricia Butterfi eld, Daniel Goldstein, and Melanie Marty from the United States.

Numerous people from the CEC Secretariat played a role in bringing this report to fruition. Erica Phipps, former 

program manager for the CEC’s work on children’s health and the environment and now a consultant to the CEC, 

has coordinated the work of the Steering Group since its inception and was instrumental in getting the project off the 

ground. Victor Shantora, the former head of the CEC’s pollutants and health program, provided unfailing support and 

guidance. Keith Chanon, current program manager, helped see the report through to its publication. Marilou Nichols, 

program assistant, provided effi cient support for the project. The CEC’s communications staff has played a vital role, 

especially Jeffrey Stoub, who tirelessly managed the editing and translation of numerous drafts of the report and the 

publication of the fi nal version. 

Very special thanks are due to Bruce Dudley of the Delphi Group who, under contract with the CEC, undertook the 

tremendous job of compiling this report. Bruce contributed many long hours to the writing, research and coordination 

required to bring the report to completion. He was assisted for most of the project by Samantha Baulch, whose careful 

attention to detail and unfailing good nature contributed greatly to its success. Erin Down provided assistance as the 

report neared completion. 

It is our hope that the excellent collaboration and good will that led to the creation of this fi rst report will carry through 

into future efforts to build on the indicators presented herein and, most importantly, to safeguard the health of our 

children and our shared environment. 
 An important determinant of child health is economic status. 

 Children living in poverty are more likely to be exposed to multiple environmental risks.

PHOTO: PABLO AÑÌELI / CEC
Executive Summary

As we learn more about the unique vulnerabilities and susceptibilities of children to environmental 

risks, there is an increasing call for data and information that can be used to improve public policy in 

this area. This document, Children’s Health and the Environment in North America: A First Report on 

Available Indicators and Measures, is the fi rst integrated, regional report providing indicators for a 

series of children’s health and environment issues. 

The objective of this report is to inform decision-makers and the public as to the status of key 

factors related to children’s health and the environment in North America. The aim is to increase awareness of the relationship between environmental risks and children’s health and to 

provide a means of measuring and promoting change. Since this is the first report of its kind, 

it also marks an initial step towards the goal of improving the reporting over time, through 

trilateral collaboration.

CHILDREN’S HEALTH AND THE ENVIRONMENT IN NORTH AMERICA

Commission for Environmental Cooperation xi
xii

The First Regional Initiative on Indicators of Children’s Health and the Environment

In June 2002, the Council of the Commission for Environmental Cooperation (CEC) of North America 

adopted, through Resolution 02-06 (see APPENDIX 1), the Cooperative Agenda for Children’s Health and the 

Environment in North America, a blueprint for regional action on children’s health and the environment. 

Among the elements of the Cooperative Agenda was a commitment to develop indicators of children’s 

health and the environment for North America.1

 The CEC joined forces with the International Joint 

Commission Health Professionals Task Force (IJC HPTF), the World Health Organization (WHO), the Pan 

American Health Organization (PAHO), and together with the three member countries, Canada, Mexico 

and the United States, embarked upon the development of the fi rst regional report on indicators of 

children’s health and the environment. The Organization for Economic Cooperation and Development 

(OECD) participated in this initiative as an observer.

This CEC-led effort also forms part of the Global Initiative on Children’s Environmental Health 

Indicators (CEHI), which was endorsed at the World Summit on Sustainable Development (WSSD) 

and is led by WHO (<http://www.who.int/ceh/indicators/en/>) with support from the US 

Environmental Protection Agency (EPA). As such, this report represents a signifi cant regional 

learning opportunity that may help to inform similar projects in other parts of the world.

The indicators in this report refl ect the CEC priorities, as defi ned by the Council. The CEC 

priority areas for children’s health and the environment include: asthma and respiratory 

disease, lead and other toxic substances, and waterborne diseases. The countries committed 

to presenting information on an initial set of twelve indicators (see APPENDIX 2). These were 

selected based on the availability of data to present information on them, and on their relevance 

to the priority issues. From this initial set of twelve indicators, the Steering Group for this report 

elected to add an additional pollutant release and transfer register (PRTR) indicator on lead. 

Also, for reporting purposes, the Steering Group elected to merge two indicators on drinking 

water into one, and two indicators on waterborne diseases into one. Essentially, there are thirteen 

indicators, organized under eleven thematic headings, for this report. Recognizing the value of 

building on existing data and improving over time, a fl exible approach was adopted to enable 

countries to report related information if they were not able to present information on any of 

these indicators. As a result, not all indicators are comparable across the three countries.

1The CEC Council is composed of the top-ranking environmental officials from the three North American countries, 

Canada, Mexico and the United States. Council Resolutions, including CR02-06, can be found at <http://www.cec.

org/who_we_are/council/members/>.
Children's Health and the Environment in North America xiii

Children in North America

The following information serves as a brief introduction to the populations of children in each country, 

their health status and several other important determinants of health to provide context for this report. 

For the purposes of this report, the defi nition of children includes all persons up to the age of 18 years, 

although other age distributions are sometimes cited, depending on the data involved.

As of 2003, there were approximately 7 million children in Canada, or 22 percent of the total 

population. Mexico had nearly 40 million children in 2003, representing approximately 38 

percent of its total population. US children numbered almost 76 million, or nearly 26 percent of 

the total population for the same year. All three countries have a high rate of urbanization, with 

the majority of their populations living in cities: Canada (80 percent), Mexico (75 percent) and 

United States (80 percent) (UNICEF, State of the World’s Children 2005).

The infant mortality rates were 5.1, 16.8 and 6.9 deaths per 1,000 live births in Canada (2001), 

Mexico (2002) and the United States (2000), respectively. The leading cause of death for children 

in all three countries was unintentional injuries (e.g., accidents and poisonings). The leading 

cause of death for children under one year of age in Canada (1999) was birth defects. In Mexico 

(2002), the leading cause of death for children under one year of age was complications associated 

with pregnancy and birth (including prematurity, complications of delivery, and major birth 

defects). The leading cause of death for children under one year of age in the United States was 

birth defects, including structural and chromosomal abnormalities. The primary reason for 

hospitalization in children in all three countries was respiratory conditions.

The availability and accessibility to public health services are important contributing factors to the 

health status of children. Measles immunization rates were selected as an indicator of the availability 

of public health services for children. All three countries posted rates above 90 percent. 

An important determinant of child health is economic status. Children living in poverty 

are more likely to be exposed to multiple environmental risks. While poverty is defi ned and 

measured differently in the three countries, a proportion of children are living in poverty in all 

of them. In Canada, 15.6 percent of children lived in families with an income level below the 

low-income cut-off, in 2001, while 24.2 percent of Mexico’s total population reported diffi culty 

in obtaining basic necessities such as food. In the United States, 16.1 percent of children were 

living in conditions below the nationally defi ned poverty level, in 2001. 
xiv

The Indicators

The report presents thirteen indicators that fall within three priority areas that have been defi ned by the 

CEC Council for the countries’ cooperative work on children’s health and the environment, namely: asthma 

and respiratory disease, lead and other chemicals, and waterborne diseases. These thirteen indicators, 

which are organized under eleven thematic headings, are summarized in CHART I-1 below.

 CHART 1: List of Indicators for Children’s Health and the Environment in North America

 Asthma and Respiratory Disease

I

____________________________I_________________________________________________________________________I

 Issue Area Current Indicator

I

____________________________I_________________________________________________________________________I

 Outdoor Air Pollution Percentage of children living in areas where air pollution levels 

 exceed relevant air quality standards 

I

____________________________I_________________________________________________________________________I

 Indoor Air Pollution Measure of children exposed to environmental tobacco smoke 

 (Canada, United States); measure of children exposed to emissions 

 from the burning of biomass fuels (Mexico)

I

____________________________I_________________________________________________________________________I

 Asthma Prevalence of asthma in children 

I

____________________________I_________________________________________________________________________I

 Effects of Exposure to Lead and Other Toxic Substances

I

____________________________I_________________________________________________________________________I

 Issue Area Current Indicator

I

____________________________I_________________________________________________________________________I

 Lead Body Burden Blood lead levels in children

I

____________________________I_________________________________________________________________________I

 Lead in the Home Children living in homes with a potential source of lead I

____________________________I_________________________________________________________________________I

 Industrial Releases of Lead Pollutant release and transfer register (PRTR) data on industrial 

 releases of lead

I

____________________________I_________________________________________________________________________I

 Industrial Releases PRTR data on industrial releases of 153 chemicals

 of Selected Chemicals

I ____________________________I

_________________________________________________________________________I

 Pesticides Pesticide residues on foods

I

____________________________I_________________________________________________________________________I

 Waterborne Diseases

I

____________________________I_________________________________________________________________________I

 Issue Area Current Indicator

I

____________________________I_________________________________________________________________________I

 Drinking Water (a) Percentage of children (households) without access to treated water

 (b) Percentage of children living in areas served by public 

 water systems in violation of local standards

I

____________________________I_________________________________________________________________________I

 Sanitation Percentages of children (households) that are not served with sanitary sewers

I

____________________________I_________________________________________________________________________I

 Waterborne Diseases (a) Morbidity: number of cases of childhood illnesses attributed to 

 waterborne diseases (Canada, Mexico, United States)

 (b) Mortality: number of child deaths attributed to waterborne diseases (Mexico)

I

____________________________I_________________________________________________________________________I

Source: Compiled by author.

The countries’ efforts to compile these indicators revealed a number of data gaps and opportunities for 

improvement. None of the countries was able to compile all of the indicators but often they were able to 

present related data sets. Lack of comparability among the data held by the three countries also posed a 

considerable challenge to compiling a North American set of indicators.
Children's Health and the Environment in North America xv

INDICATORS RELATED TO ASTHMA AND RESPIRATORY DISEASE

Indicator No. 1—Outdoor Air Pollution I

_____________________________________________________________________________________________________I

Exposure to ambient air pollution has been associated with the development and exacerbation of asthma 

and other respiratory diseases in healthy children. More recent evidence suggests that maternal exposure 

to air pollution during pregnancy is associated with adverse pregnancy outcomes. This indicator is 

intended to measure the percentage of children living in areas where air pollution levels exceed relevant 

air quality standards.

Canada is unable to present information on this indicator, but in its place Canada presents ambient 

air quality monitoring trends for several common air contaminants. Existing information on 

ambient air quality shows that levels of several important air pollutants have dropped over the 

last 10 years, in Canadian urban areas. However, levels of ground-level ozone, which have not 

dropped in most areas, and fi ne particulate matter (PM2.5) are still of concern. Within Canada, 

southern Ontario experienced the highest numbers of days on which ground-level ozone and 

PM2.5 levels exceeded the Canadian standards.

In Mexico, population-based exceedance data are not available; however, air quality data for 

ground-level ozone and PM10 for several major urban air monitoring zones are presented as a 

proxy indicator. The observations from this data indicate that air quality standards for groundlevel ozone and particulate matter (PM10) were exceeded in key metropolitan areas, most notably 

for ground-level ozone in Mexico City and for particulate matter (PM10) in Guadalajara, Mexico 

City, Monterrey, Toluca and Ciudad Juárez. 

The United States presents data on the percentage of children living in counties in which air 

quality standards were exceeded. The data indicate that a high percentage of children are living 

in counties where levels of ground-level ozone exceed standards. A smaller, but still signifi cant, 

percentage of children are living in counties where PM2.5 levels exceed standards; however, this has 

been decreasing. 

Indicator No. 2—Indoor Air Pollution I

_____________________________________________________________________________________________________I

This indicator measures children’s potential exposure to indoor air pollution, with a focus on environmental 

tobacco smoke (in the case of Canada and the United States) and emissions from burning of biomass fuels 

(in the case of Mexico). Children who are exposed to environmental tobacco smoke are at increased risk 

of adverse health effects, including sudden infant death syndrome, pneumonia and asthma. Children 

exposed to emissions from burning of biomass fuels are at increased risk for respiratory problems and 

exacerbation of asthma.

For this indicator, Canada presents survey data on the percentage of children, of various age 

groups from zero (birth) to 19 years old, who are exposed to environmental tobacco smoke in 

the home. Canada’s survey data suggest that the exposure of children to environmental tobacco 

smoke has declined in the last four years (1999–2002). For example, the percent of children aged 

zero to fi ve who are exposed to environmental tobacco smoke in the home decreased from 23 

percent in 1999 to 14 percent in 2002.

Mexico presents geographical data on the use of wood fuel at the municipal level. Indoor air 

pollution in homes caused by the burning of fi rewood or charcoal for cooking is a public health 

problem in Mexico. The map indicates that biomass use is highest in southern Mexico and north 

central Mexico.
xvi

The United States reports survey data for children aged six and under who were regularly exposed 

to environmental tobacco smoke in the home. The percent of children exposed to environmental 

tobacco smoke in the home declined 16 percent between 1994 and 2003, from 27 percent to 

11 percent. The United States also presents data on the measurement of cotinine levels in blood 

(cotinine is a breakdown product of nicotine and is a marker for recent exposure to ETS). These 

data show reduced cotinine levels in children between 1988 and 2000. Detectable levels of serum 

cotinine in blood fell 24 percent over this period for children aged four to 11 years. The US 

data for 1999–2000 also indicate that 86 percent of Black, non-Hispanic children aged four to 

11 had cotinine in their blood, compared with 63 percent of White, non-Hispanic children and 

49 percent of Mexican American children.

Indicator No. 3—Asthma I

_____________________________________________________________________________________________________I

This indicator tracks asthma in children, a disease of the lungs that affects millions of children in North 

America. Asthma is a major cause of child hospitalization and is the most common chronic disease of 

childhood in North America.

Canada reports on the prevalence of physician-diagnosed asthma among children. These data 

indicate that asthma prevalence among children has continued to increase in most age groups, 

between 1994 and 1999. For example, the percent of boys aged eight to 11 who were diagnosed 

with asthma increased from approximately 16 percent in 1994/1995 to approximately 20 percent 

in 1998/1999. For girls of the same age range, the increase was from approximately 11 percent to 

approximately 15 percent.

Mexico presents data on the incidence of asthma among children. These data show an increase 

in nearly all age groups over the period 1998 to 2002. For example, in 2002, 35 children out 

of every 10,000 aged fi ve to 14 years had asthma, up from 28 per 10,000 in 1998. Mexico also 

presents national incidence of acute respiratory infections (ARI) among children. The number 

of new cases of ARI was stable or up slightly over the period 1998 to 2002, with the highest 

prevalence among children under one year of age. 

The United States presents survey data on asthma prevalence for all age groups between 1980 and 

2003. Over the period 1980 to 1995, the percentage of children with asthma doubled. In 2003, 13 percent of American children had been diagnosed with asthma at some point in their lives.
Children's Health and the Environment in North America xvii

INDICATORS RELATED TO LEAD AND OTHER CHEMICALS, INCLUDING PESTICIDES 

Indicator No. 4—Blood Lead Levels I

_____________________________________________________________________________________________________I

Lead is a major environmental hazard for young children. Exposure to lead can result in neurological 

damage in young children that can lead to behavioral disorders, learning disabilities and lower IQ. The 

selected indicator provides information on blood lead levels in children.

Canada is unable to report this indicator, as there are no recent nationally representative data 

on blood lead levels in children. Instead, Canada presents a case study on blood lead levels in 

children in Ontario. This case study shows the association between decreasing blood lead levels 

in Ontario children and the removal of lead from gasoline, over the period 1982 to 1992. 

Mexico is also unable to present this indicator, as it does not have national data on blood lead 

levels. Instead, Mexico presents data from a series of local studies involving children in rural 

and urban populations. The data, which cover the period 1979 to 2000, show blood lead levels 

in children. Mexico also presents a case study on air monitoring for lead, for the period 1990 

to 2000, that confi rms the substantive drop in lead in ambient air that was achieved with the 

introduction of unleaded fuel. Another case study illustrates that industrial releases of lead can 

accumulate in suffi cient quantities in neighboring communities and pose a serious health threat 

for children. It also illustrates that remediation is possible and that some of the potential health 

effects can be mitigated if actions are taken.

The United States presents blood lead level data from its national lead biomonitoring program 

for children. The median concentration of lead in the blood of children fi ve years old and under 

dropped from 15 micrograms per deciliter (μg/dL) during 1976–80 to 1.7 μg/dL during 2001–

2002, a decline of about 85 percent. In 1999–2000, Mexican-Americans and non-Hispanic 

African-Americans had higher blood lead levels than non-Hispanic whites. The United States 

presents a case study on the relationship between blood lead levels in children, the removal of 

lead from gasoline and the implementation of other lead reduction measures. 

Indicator No. 5—Lead in the Home I

_____________________________________________________________________________________________________I

Children may be exposed to lead found in homes and other indoor environments due to the widespread past 

uses of lead in gasoline, paint, plumbing and building products and other consumer goods. Indoor lead sources 

include lead in dust, lead-based paint and lead in plumbing, in Canada and the United States. In Mexico, a 

major source of indoor lead is home-based pottery operations using lead-based glaze. Lead-based glazes may 

also result in exposure to lead through the use of this pottery in food preparation, serving and storage. This 

indicator provides information on children’s potential exposures to sources of lead in the home.

For this indicator, Canada presents information on the percentage of children living in homes 

built before 1960. In Canada, homes built before 1960 are more likely to contain paint with high 

concentrations of lead. This lead can increase the potential for exposure through lead dust if the 

older paint is exposed due to renovations or deterioration (i.e., peeling and fl aking). According 

to the data provided, there has been a modest decline in the number of children living in homes 

built before 1960. For example, in 1991, 28 percent of children four years and under lived in 

housing built prior to 1960. This had declined to 24 percent by 2001. 

Mexico is unable to present data on this indicator. Instead, Mexico presents geographic 

information on the density of home-based pottery operations in various states. The map shows 

that the distribution of pottery facilities is most dense in southern Mexico. 
xviii

The United States is unable to present child-specifi c information for this indicator. Instead, 

the United States provides data from a nationally representative sample on the percentage of 

housing contaminated with lead-based paint, lead-based dust or lead-based soil. This indicator 

shows that between 1998 and 2000, 40 percent of homes had some lead-based paint. Twenty-fi ve 

percent of the homes had a signifi cant lead-based paint hazard.

Indicator No. 6—Industrial Releases of Lead I

_____________________________________________________________________________________________________I

In this section, PRTR data2 serve as an action indicator and depict trends in industrial releases of lead to the 

environment over time, including on-site releases to air, water, land and underground injection as well as off-site 

releases. While they do not provide information on children’s exposures, the data can indicate whether actions 

are being taken to reduce or prevent industrial releases of lead to the environment. The PRTR data come from 

manufacturing facilities that are subject to similar reporting requirements in Canada and the United States. 

Canada reports an overall reduction of 46 percent in on-site and off-site releases of lead and its 

compounds from manufacturing facilities, between 1995 and 2000 (from 4,124 tonnes in 1995 

to 2,220 tonnes in 2000). Off-site releases (primarily transfers to landfi lls) accounted for the 

largest portion of releases and also for the largest portion of reductions over this time period.

Mexico’s PRTR system, the Registro de Emisiones y Transferencia de Contaminantes (RETC), is 

not yet fully operational and, therefore, Mexico does not have data to report on this indicator.

The United States reports an increase of 9 percent in on-site and off-site releases of lead and 

its compounds from manufacturing facilities, between 1995 and 2000, from 19,492 tonnes in 

1995 to 21,211 tonnes in 2000. The largest decreases in lead releases over the reporting period 

occurred for on-site releases to air and land, while the largest increases were in off-site releases 

(off-site releases are primarily transfers to landfi lls).

Indicator No. 7—Industrial Releases of Selected Chemicals I

_____________________________________________________________________________________________________I

There are 153 chemicals for which both the Canadian and US governments require industrial facilities to 

report their releases and transfers to the national PRTR programs over the period 1998-2002. With the 

aim of tracking progress in reducing or preventing the release of such chemicals from industrial activities, 

this PRTR data–based indicator presents trends in on-site releases to air, water, land and underground 

injection, as well as in off-site releases (primarily off-site disposal in landfi lls). 

In Canada, on-site and off-site releases of the 153 matched chemicals decreased by 11 percent, 

from 1998 to 2002 (from 154,000 tonnes in 1998 to 137,000 tonnes in 2002), while the number 

of facilities reporting over that period increased by 41 percent. The reduction in releases was 

realized in part through reductions reported by the primary metals sector (with a decrease of 33 

percent) and the chemical manufacturing sector (a decrease of 36 percent).

Mexico did not report this indicator, given that the mandatory PRTR program in Mexico is not 

yet operational.

2 Data reported by industrial facilities to the National Pollutant Release Inventory (NPRI) in Canada and the Toxics 

Release Inventory (TRI) in the United States on certain chemical substances released to air, water, land or transferred 

off-site for further management. Only those data elements (i.e., chemicals and industry sectors) that are comparable 

between the Canadian and US systems are included. Comparable data are not yet available under the Mexican PRTR.
Children's Health and the Environment in North America xix

The US data for the 153 matched chemicals depict an overall reduction of 11 percent, from 

1998 to 2002 (from 1.45 million tonnes in 1998 to 1.28 million tonnes in 2002), with a slight 

reduction in the number of reporting facilities over the same period. Reductions were reported 

by various sectors, including the electric utilities sector (9 percent reduction), the chemical 

manufacturing sector (24 percent reduction) and the hazardous waste management/solvent 

recovery sector (36 percent reduction). The primary metals sector, reporting the second largest 

amount of releases behind electric utilities in 2002, had an increase of 16 percent.

Indicator No. 8—Pesticides I

_____________________________________________________________________________________________________I

Children and infants may be more vulnerable to potential health effects from pesticides, due to their unique 

susceptibilities (especially the growth and development of body systems) and higher intake as a result 

of their dietary habits and immature detoxifi cation systems. While there are numerous ways in which a 

child may be exposed to pesticides (e.g., exposure to pesticides used on lawns or in the home, or through 

contaminated drinking water), the focus of the present indicator is on pesticide residues in foods.

Canada reports on the percentage of fresh fruits and vegetables, both domestic and imported, 

that have detectable residues of organophosphate pesticides. The percentage of imported and 

domestic fruit and vegetables sampled that had organophosphate pesticides decreased from 

12 percent in 1995 to 3 percent in 2002.

Mexico reports on the incidence of pesticide poisonings for the general public and for children 

under 15 years of age. The data suggest that the number of poisonings reported for children 

under the age of 15 has fallen by half between 1998 and 2002. In 2001, the total number of 

reported pesticide poisonings among children under the age of 15 in Mexico was 2,532.

The United States presents data on the percentage of fruits, vegetables, and grains with 

detectable residues of organophosphate pesticides. Between 1994 and 2001, the proportion of 

fruits, vegetable and grains sampled with detectable organophosphate residues ranged between 

19 percent and 29 percent.
x x

INDICATORS RELATED TO WATERBORNE DISEASES

Indicators No. 9 and 10—Drinking Water I

_____________________________________________________________________________________________________I

The presence of pathogens and chemical contaminants in drinking water can result in a wide range of 

health effects for children, from gastrointestinal discomfort to death. The indicators in this section 

measure the percentage of children (represented by households containing children) without access to 

treated water, as well as the percentage of children living in areas served by public water systems in 

violation of local standards.

Canada is unable to present child-specifi c data for the percentage of children without access to 

treated water, but presents data on the percentage of the general population not connected to 

public water distribution systems, for the period 1991 to 1999. The percentage for this period 

remained stable, with, approximately 24 percent of Canadians without central water distribution 

systems in 1999. It is assumed that this group relies on private water supplies, with the principal 

source being groundwater wells. Canada does not report on the second indicator in this section, 

the percentage of children served by drinking water systems with violations. Such data are 

requested from the municipal systems and collected by the provinces, but are not available in a 

consistent form that could be used to generate a national indicator. 

Mexico is unable to present child-specifi c data for the percentage of children without access to 

treated water, but instead presents the percentage of the general population without access to 

potable water. Between 1980 and 2000, the percentage of the population without access to potable 

water decreased from approximately 29 to 12. The indicator shows that urban populations have 

greater access, with only 5 percent of people without access, while in rural areas 32 percent lack 

access as of 2000. Mexico also provides a geographic representation of the lack of piped water as 

of 2000. The northern and central states of Mexico were the best served, with between 0 to 20 

percent without coverage. Mexico is not able to report on the second indicator, the percentage of 

children served by drinking water systems with violations. 

The United States does not present data for the percentage of children not served with treated 

water. For the second indicator, the United States reports on the percentage of children served by 

public water systems that exceed or violate a drinking water standard. Between 1993 and 1999, 

the percentage of children living in areas with any health-based violation decreased from 20 

percent to 8 percent. The United States also reports on the percentage of children living in areas 

with major violations of drinking water monitoring and reporting requirements. From 1993 to 

1999, the percentage of children living in areas that had any major violation of water monitoring 

and reporting dropped from 22 to approximately 10 percent.
Children's Health and the Environment in North America xxi

Indicator No. 11—Sanitation I

_____________________________________________________________________________________________________I

Untreated human sewage is an important source of bacterial contamination for surface and ground 

water. Contamination of source waters with pathogens presents risk to children through drinking water, 

bathing and swimming. This indicator measures the percentages of children (represented as households 

containing children) that are not served by sanitary sewers.

Mexico is unable to provide child-specifi c data; instead Mexico provides data on the percentage 

of the population that does not have sewage removed from its immediate surroundings, between 

1980 and 2000. The indicator demonstrates that the percentage of the population without 

sewage removal decreased from 50 percent in 1980 to 24 percent by 2000. The indicator shows 

that urban populations have greater access, with 10 percent of people in urban setting without 

sewage removal, whereas 63 percent lack access in rural areas, as of 2000. Mexico also provides 

a geographic representation of households without sewer services as of 2000. The northern and 

central states of Mexico were the best served.

Canada and the United States elected not to report on this indicator due to the high percentage 

of sewage collection and treatment in both urban and rural environments in both countries. 

Most urban and rural communities are served by sewer and sanitation services or have septic 

systems to collect and treat sewage. Canada has presented this indicator in its country report 

(see <www.cec.org/children>).

Indicator No. 12 and 13—Waterborne Diseases I

_____________________________________________________________________________________________________I

The risk of microbial disease associated with drinking water continues to be a concern in North America. 

Numerous past outbreaks, together with recent studies suggesting that drinking water may be a 

substantial contributor to endemic (non-outbreak-related) gastroenteritis, demonstrate the need to 

monitor waterborne illnesses, which is the focus of this indicator. However, enteric infections can be foodborne, waterborne or occur through a fecal-oral route, thus identifying the actual cause of the infection 

can be problematic. The indicators in this section measure the number of childhood illnesses attributed 

to waterborne diseases (in the case of Canada and Mexico) and the number of child deaths attributed to 

waterborne diseases (in the case of Mexico).

Canada reports on the number of cases of childhood illness attributed to waterborne diseases by 

presenting incidence of giardiasis among different age groups, between 1988 and 2000. Giardiasis, 

sometimes called “beaver fever,” is an intestinal parasitic infection characterized by chronic 

diarrhea and other symptoms. Giardiasis may be foodborne, but waterborne transmission is 

common where unsanitary conditions exist or animal contamination occurs. The data show 
xxii

that children aged one to four are more likely to be infected with giardiasis than the rest of the 

population and that the number of cases of giardiasis in Canada has been declining since 1992. 

Canada has elected not to report on the second indicator, mortality from waterborne diseases, 

due to low mortality rates.

Mexico reports on the number of cases of childhood illness attributed to waterborne diseases 

by presenting incidence of giardiasis, by age group, for the period 1998 to 2002. The prevalence 

of giardiasis for all three age groups has declined since 1998. Children one to four years of age 

seem to be the most likely to be infected; however, the number of new cases declined from 21 

per 10,000 in 1998 to 16 per 10,000 in 2002. Mexico also reports on the percentage of cases of 

cholera among children of various age groups. The age group most affected by cholera is that 

of one to four years old, with the percentage of cases ranging from 6 percent to 18 percent of all 

cases. Mexico also presents on the second indicator by supplying data on the mortality rates for 

diarrhea. The mortality rate, of children under fi ve, for diarrheic diseases declined from 125 

per 100,000 in 1990 to 20 per 100,000 in 2002. These data suggest that advances are being made 

through actions to improve sewage management and drinking water treatment. In addition, 

programs to manage diarrheic diseases are reducing the mortality from this illness. 

The United States is unable to provide child-specifi c data for the numbers of childhood illnesses 

attributed to waterborne diseases, but is able to present some data on reported waterborne 

disease outbreaks for the general population by year and type of water system. The data show 

that there were 751 voluntarily reported waterborne disease outbreaks associated with drinking 

water systems between 1971 and 2000. The last two years of the monitoring presented a total of 

44 outbreaks associated with drinking water, reported by 25 states (18 from private wells, 14 from 

non-community systems, and 12 from community systems). The United States has elected not to 

report on the second indicator, mortality from waterborne diseases, due to low mortality rates.
Children's Health and the Environment in North America xxiii

CONCLUSIONS AND OPPORTUNITIES FOR IMPROVEMENT

This report represents a first step in creating a set of indicators of children’s health and 

the environment for the North American region. Increased effort, including trilateral collaboration, is needed to improve the quality of future reports. The following are some of the 

observations and opportunities for improvement:

• Despite an overall picture of stable or improving national indicators of child health, specifi c and 

substantial sub-populations of children remain at risk from environmental risks. Future indicator 

reports will need to better track such populations. Case studies, regional monitoring and data mapping could be used to increase our understanding of those specifi c populations of children at risk.

• The impacts of social and economic disparities are an important feature in defi ning sub-populations 

of children that are disproportionately at risk from environmental exposures. Some of the indicators 

and measures investigated highlight the importance of socio-economic conditions in determining a 

child’s risk of exposure and the risk of a poor health outcome. 

• Data were unavailable or limited for a number of the indicators. Where data were not available, 

countries utilized a fl exible approach to present related data or elected not to report on the indicator. 

Addressing data gaps will be part of the ongoing efforts of the countries to present information on 

these indicators in the future.

• There is a considerable amount of epidemiological research linking environmental exposures to 

health effects. However, there remain major questions in understanding the specifi c susceptibilities of children to environmental risks. Likewise, many uncertainties remain in understanding the 

environmental contribution to many common childhood diseases. The need to develop more defi nitive evidence in these areas should be the focus of ongoing scientifi c inquiry.

• More research is also needed to better understand the pathways of children’s exposure to 

environmen tal contaminants, including how contaminants cycle in the environment, patterns 

of dietary exposure, behavioral activities that put children at increased risk of exposure, and 

other such issues. This information is required to support better assessment of risks, for 

the development of more accurate indicators, and to improve our ability to target exposure 

prevention and reduction efforts.

• Evidence from biomonitoring programs offers measures of direct exposure (e.g., blood cotinine 

indicates exposure to nicotine). This information can be extremely valuable to government 

decision makers in order to target policies and program actions to reduce exposures. The use 

of biomonitoring as a means of identifying and quantifying exposures should be encouraged 

and the resulting information used to create more specifi c indicators. By utilizing the results 

biomonitoring efforts, future indicators reports could address chemicals such as mercury that 

have known effects on children, as well as chemicals of emerging concern (e.g., brominated 

fl ame retardants).

• Indicators which report prevalence and incidence offer different information useful to understanding 

and interpreting the progress of disease and disorders (e.g., asthma). This report refl ects a greater 

use of prevalence data; however, to the extent that indicators will continue to evolve, there may be 

more focus on indicators of incidence in the future.

• The thematic areas investigated in this report represent a relatively small sample of all potential 

environmental risks to children’s health. Furthermore, the primary focus is on pollutants known to 

pose risk to children’s health, but it is well accepted that there are thousands of substances that 

have yet to be fully tested for their potential to harm children. Therefore, this effort should not be 

thought of as comprehensive, but rather as indicative of the relationship between children’s health 

and the environment.
Children’s vulnerability is infl uenced by their limited knowledge of potential risks. 

 Children must rely upon adults to provide safe conditions for them. 
1.0 An Overview of the Children’s Health 

and the Environment Indicators Initiative

1.1 CHILDREN’S HEALTH AND THE ENVIRONMENT

The recognition that children have unique and specifi c vulnerabilities to certain environmental risks has 

resulted in increased attention among the scientifi c community, policy makers and the public. Children are 

not little adults; relative to their size, children breathe more air, eat more food and drink more water than 

adults and thus may have a relatively higher exposure to contaminants per body weight. In addition, children 

have unique exposure patterns and behaviors, such as putting things in their mouths, that may put them in 

contact with different contaminants (US EPA 2003). 

Children also may be more vulnerable to the effects of exposure to some contaminants. There 

are specifi c windows of vulnerability, from conception through infancy and childhood, when 

the child may be particularly sensitive to the deleterious effects of environmental contaminants. 

In addition, exposures in the womb can lead to health outcomes later in life, and can 

potentially affect subsequent generations. Furthermore, children may have less protection from 

environmental risks because their bodies’ natural defenses may be less developed. For example, 

an immature immune system may increase a child’s risk of contracting a waterborne disease and 

may increase the severity of the illness.

Furthermore, children’s vulnerability is infl uenced by their limited knowledge of potential 

risks and their inability to shape their own environment to avoid risks to their health. For 

protection from environmental risks, children must rely upon adults to provide safe conditions 

for them. There are many organizations and individuals that share a responsibility for creating 

safer environments for children in which to live, learn and play. Federal governments have a 

particularly important role to ensure that national policies are in place to address environmental 

risks to human health, and that these policies are effective at protecting the health of the most 

vulnerable populations.

CHILDREN’S HEALTH AND THE ENVIRONMENT IN NORTH AMERICA

Commission for Environmental Cooperation 1
2

1.2 THE NEED FOR NORTH AMERICAN INDICATORS OF CHILDREN’S HEALTH AND THE ENVIRONMENT

Indicators improve our understanding of the quality of the environment that infl uences children’s health, 

assist in assessing the effectiveness of our interventions and policies, and allow us to identify priority 

areas for future actions. An important lesson learned through this fi rst regional effort is that the process 

of compiling health-environment indicators also can reveal gaps and weaknesses in our knowledge and 

information resources, and underscores the importance of enhancing data comparability within and 

among countries. 

In 1999, the top-ranking environmental offi cials from Canada, Mexico and the United States, as 

members of the Council of the Commission for Environmental Cooperation (CEC), initiated a 

process to investigate the environmental risks to children’s health and to consider opportunities for 

greater coordination and cooperation to protect children from such threats in North America. The 

investigation, which included a broad-based consultation with experts and the general public, identifi ed 

children as having particular vulnerabilities to environmental risks and identifi ed the need to develop 

a cooperative agenda that would promote the protection of children’s health from those risks.

In June 2002, the CEC Council adopted the “Cooperative Agenda for Children’s Health and the 

Environment in North America,” through Resolution 02-06 (see APPENDIX 1), which includes a 

commitment to publish a set of indicators of children’s health and the environment in North 

America. This commitment was reaffi rmed by the CEC Council Session of June 2003, through the 

adoption of Council Resolution 03-10 (see APPENDIX 3).

The Cooperative Agenda builds upon CEC Council Resolution 00-10,

3

 which identifi ed respiratory 

diseases and exposure to lead and toxic substances as priority areas for consideration. The list of 

priorities was later expanded to include waterborne diseases, recognizing water as an important 

source of enteric disease and exposure to other contaminants that can lead to illness in children.

3

 CEC Council Resolution 00-10 is available at <www.cec.org/children>.
Children's Health and the Environment in North America 3

The CEC’s Cooperative Agenda recognizes the valuable role that indicators can play in assessing 

the status of an issue, raising its profi le, and tracking the progress of the issue relative to set goals. 

The Cooperative Agenda states that the objective of the indicators report is to provide decisionmakers and the public with periodic (e.g., every two to three years), understandable information 

on the status of key parameters related to children’s health and the environment in North America 

as a means of measuring and promoting change (CEC June 2002). 

The CEC Secretariat, in collaboration with the governments of Canada, Mexico and the United 

States, and working in partnership with the International Joint Commission Health Professionals 

Task Force (IJC HPTF), the Pan American Health Organization (PAHO) and the World Health 

Organization (WHO), established a Steering Group to oversee the development of the fi rst North 

American indicators report (see APPENDIX 4). The Organization for Economic Cooperation and 

Development (OECD) participated as an observer. A feasibility study 4

 was completed and the 

Steering Group developed recommendations for the development of a core set of indicators.5

 

The development of this North American report was based on country reports prepared by 

the governments of Canada, Mexico and the United States in 2003–2005. The country reports, 

available at <www.cec.org/children>, provide data, where feasible, for the set of thirteen agreedupon indicators. They also present additional contextual information, supporting data and 

technical templates for the indicators.

This North American report has been reviewed by experts in the respective governmental 

departments. In addition, both this report and the country reports have been subject to an in-depth 

review by a panel of nine nongovernmental experts (see APPENDIX 5), as well as a public consultation 

process, to ensure that the information is both technically sound and relevant to the reader.6

4

 Feasibility Study for the Development of Indicators of Children’s Health and the Environment in North America, 

 April 2003 is available at <http://www.cec.org/files/pdf/POLLUTANTS/CHE-Feasibility-Study_en.pdf>.

5

 Recommendations for the Development of Children’s Health and the Environment Indicators in North America, 

 June 2003 is available at <http://www.cec.org/files/pdf/POLLUTANTS/CHE-Recommendations_en.pdf>.

6

 The comments submitted by the public, as well as a “response to comments” document, are available at <www.cec. 

 org/children>.
4

1.3 WHO WILL USE THIS REPORT

Government policy makers are the primary audience for this report, as they play a key role in 

designing and implementing policies that will impinge upon the health of children and their 

environments. Indicators can assist policy makers as they prioritize issues, implement monitoring 

and surveillance programs and develop policies to better protect children. The report also 

provides information that can help measure the effectiveness of existing policies. It identifi es 

trends over time for indicators on numerous issues of concern for protecting children’s health 

from environmental risks, in the areas of toxic substances, air quality, and water quality. In 

some cases, these trends may suggest the need for additional action on the part of governments, 

such as to address specifi c research objectives or policy interventions. In other cases, this report 

identifi es opportunities to improve data availability and consistency, and to develop future 

indicators that can be used to better assess the health of children and their environment.

Governments, though, are not the only potential users of this report. Other groups and 

individuals actively involved in the protection of children’s health may fi nd this information 

useful in their efforts to communicate and to advocate for policy change. Members of the 

general public, parents, grandparents, teachers and caregivers, who also play an active part in 

protecting children’s health from environmental exposures, also may fi nd this report useful. In 

all instances, increased awareness of the role of the environment as a determinant of children’s 

health is important knowledge that can result in changes to improve the health of children.
Children's Health and the Environment in North America 5

1.4 SELECTING THE INDICATORS FOR THIS REPORT

The selection of a core set of indicators for this fi rst North American report began with three 

priority areas previously identifi ed by the CEC Council for the countries’ cooperative work 

on children’s health and the environment, namely asthma and respiratory disease, the effects 

of exposure to lead and other toxic substances, and waterborne diseases. The Steering Group 

applied the criteria listed in BOX 1 to identify a set of recommended indicators that would be 

useful and relevant, scientifi cally sound, available and understandable. 

BOX 1: Criteria Used by the Steering Group in Selecting the Recommended Indicators

I

_____________________________________________________________________________________________________I

1. Useful and relevant. Each indicator must be related to a specifi c question or issue of interest 

 that highlights a trend or concern regarding children’s health and the environment.

2. Scientifi cally sound and credible. Each indicator must be unbiased, reliable, valid, and 

 based upon high-quality data. The methodology for collecting the data should be robust 

 and repeatable. There must be a credible link between the environmental condition that the 

 indicator addresses and the health outcome (for example air quality and asthma rates).

3. Availability. It is agreed that because not all countries will be able to report on all indicators, 

 countries will choose indicators from this list that are most appropriate and available, 

 from their national perspective (e.g., whether or not nationally representative) and based 

 on information that already exists, since governments may be unable to commit resources 

 for collecting new data.

4. Applicable and understandable. The indicator must be useful for policy-makers and a non- 

 specialist audience. 

 

 (CEC JUNE 2003)

I

_____________________________________________________________________________________________________I

The CEC Council endorsed the Steering Group’s set of 12 recommended indicators in June 2003 

through Council Resolution 03-10 (see APPENDIXES 2 and 3), and committed to providing the 

information needed to report this initial set in 2004 and periodically thereafter. In compiling 

the indicators for the fi rst report, the Steering Group made several minor adjustments to improve 

the relevance and consistency of certain indicators. The current set of 13 target indicators is 

summarized in CHART 1-1. The table also shows which countries were able to fully meet each 

indicator. In most cases, all three countries were able to report at least some relevant data.
6

CHART 1-1: North American Indicators for Children’s Health and the Environment, by Issue Area

Asthma and Respiratory Disease

I

________________________I_____________________________I______________________________I__________________I Countries Currently 

 Issue area Current Indicator Purpose of Indicator Reporting the Indicator* 

I

________________________I_____________________________I______________________________I__________________I

Outdoor Air Pollution Percentage of children To provide information on UNITED STATES

 living in areas where children’s potential exposures

 air pollution levels to outdoor air pollution, with

 exceed relevant air a focus on common

 quality standards air contaminants

I

________________________I_____________________________I______________________________I__________________I

Indoor Air Pollution Measure of children exposed To provide information on CANADA

 to environmental tobacco smoke children’s potential exposures UNITED STATES

 (Canada, United States); to indoor air pollution, with

 measure of children exposed a focus on environmental

 to emissions from the burning tobacco smoke and emissions

 of biomass fuels (Mexico) from the burning of biomass fuels

I

________________________I_____________________________I______________________________I__________________I

Asthma Prevalence of asthma To track asthma CANADA, MEXICO

 in children in children UNITED STATES

I

________________________I_____________________________I______________________________I__________________I

Effects of Exposure to Lead and Other Toxic Substances

I

________________________I_____________________________I______________________________I__________________I

Lead Body Burden Blood lead levels To provide information on UNITED STATES

 in children children’s exposure to lead

I

________________________I_____________________________I______________________________I__________________I

Lead in the Home Percentage of children living To provide information on CANADA

 in homes with a potential children’s potential exposure

 source of lead to sources of lead in the home 

I

________________________I_____________________________I______________________________I__________________I

Industrial Releases Pollutant release and transfer To provide information CANADA

of Lead register (PRTR) data on on industrial releases UNITED STATES

 industrial releases of lead of lead

I

________________________I_____________________________I______________________________I__________________I

Industrial Releases PRTR data on industrial To provide information CANADA

of Selected Chemicals releases of 153 chemicals on industrial releases of UNITED STATES

 selected chemicals

I

________________________I_____________________________I______________________________I__________________I

Pesticides Pesticide residues To provide information on CANADA

 in foods children’s potential United States

 exposure to pesticides

I

________________________I_____________________________I______________________________I__________________I

Waterborne Diseases

I

________________________I_____________________________I______________________________I__________________I

Drinking Water (a) Percentage of children To provide information on the (a) none

 (households) without percentage of children potentially 

 access to treated water exposed to contaminants

 (b) Percentage of children living and pathogens in drinking water (b) UNITED STATES

 in areas served by public water 

 systems in violation of local standards

I

________________________I_____________________________I______________________________I__________________I

Sanitation Percentages of children To provide information on the None **

 (households) that are not percentage of children who are

 served by sanitary sewers potentially exposed to untreated

 sewage in their immediate 

 surroundings

I

________________________I_____________________________I______________________________I__________________I

Waterborne Diseases (a) Morbidity: number of cases To provide information on (a) CANADA, MEXICO

 of childhood illnesses attributed children who have been sick 

 to waterborne diseases (Canada, from or have died as a result 

 Mexico, United States) of waterborne diseases

 (b) Mortality: number of child (b) MEXICO**

 deaths attributed to waterborne 

 diseases (Mexico) 

I

________________________I_____________________________I______________________________I__________________I

Source: Compiled by author.

Notes: * Denotes countries that were able to fully report the specifi ed indicator. In the majority of cases, all countries 

 provided at least some relevant data. 

 ** Canada and the United States elected not to report this indicator. 
Children's Health and the Environment in North America 7

It was understood that not all countries would be able to report on all indicators, depending on 

data availability. The Steering Group recommended that a fl exible approach be used that would 

allow countries to report other relevant data in the event that they were not able to present 

information for a specifi c indicator. This approach was designed to allow the countries to use 

existing data and methodologies, while building over the longer term towards a core set of 

harmonized indicators for the region.

1.5 A COMMON APPROACH TO INDICATOR DEVELOPMENT

The relationships between environmental exposures and human health effects are complex 

and multifaceted. In previous indicator efforts, models have been developed to explain these 

relationships and to serve as a guiding framework for indicator development. The Steering 

Group for the North American report concluded that the World Health Organization’s multiple 

exposure–multiple effect (MEME) model best captured the complex interactions between the 

environment and children’s health. The MEME model highlights that exposure and health 

outcomes are based on many links between the environment and health and are rarely based on 

simple, direct relationships (see FIGURE 1, adapted from Briggs 2003).

The model also illustrates that environmental exposures and health outcomes are infl uenced 

by social, economic and demographic factors. These factors are among a number of aspects 

that are known to infl uence health outcomes and are frequently referred to as socioeconomic 

determinants of health. For example, being poor may mean that families are forced to live in 

sub-standard housing, are less able to afford nutritious food and may have limited or no access 

to clean drinking water. These circumstances contribute to poor health while increasing the 

likelihood of environmental exposures and related health outcomes.

SECTIONS 3–5 present topic-specifi c MEME models that have been included to illustrate the issues 

addressed by each set of indicators. On the environment side, the models indicate the range of 

possible exposures, from distal (e.g., in the wider community) to proximal (e.g., in the home). 

Where applicable, possible sources of the pollutant(s) are also indicated. On the health side, the 

models list a variety of health outcomes that can be associated with the exposure(s) in question. 

An attempt has been made to order the health outcomes from less severe to more severe, although 

it is recognized that the severity of any given outcome (with the exception of death) can vary 

from one instance to the next.

Each of the indicators in this report is focused on a specifi c aspect of the complex relationships 

illustrated by the MEME models. For example, the indicator on outdoor air quality is focused 

on the exposure side of the picture, while the asthma indicator refl ects a specifi c health outcome. 

In the topic-specifi c MEME models presented in the following sections, the relevant box (either 

the exposure box or the child health outcome box) is highlighted to refl ect the focus of the 

particular indicator. Within the exposure box, a further distinction can be made between the 

agent and its source(s). For example, if the indicator is focused on the agent (e.g., common air 

pollutants) the agent will be capitalized and italicized.

As noted in SECTION 1.4, most of the indicators presented in this report are measures of 

exposure. In some cases, direct measures of exposure (e.g., blood lead levels) were not possible 

and surrogate exposures were chosen (e.g., children living in homes with a potential source of 

lead). Surrogate exposures are an important source of information as specifi c exposure data 

are rarely available for national indicators. Health outcome indicators are presented for asthma 

and for waterborne diseases, while action indicators have been presented for industrial releases 

of pollutants. In several cases, indicators present information on various sub-populations of 

children at increased risk.
Preventive

actions

Remedial

actions

ACTIONS

Social conditions

Economic conditions

Demographic conditions

EXPOSURE HEALTH OUTCOME

Ambient

environment

Community

Home

Well-being

Morbidity

Mortality

Distal

Proximal

Less

severe

More

severe

CONTEXTS

causes or is associated with

attributable to or

is associated with

8

The linkages between environmental exposure and health outcomes are important to consider. 

For some of the substances for which exposure or surrogate exposure is presented, the presence 

or extent of cause-effect relationships may not be fully understood (e.g., pesticides). In these 

cases, it is advisable to refer to the link between environmental exposures and health outcomes 

by referring to these factors as “associated with” one another. Limited evidence can refl ect a 

number of research challenges in health and environment, such as the challenge of estimating 

the dose or timing of exposures which may have occurred many years earlier and relating the 

exposure to illness or disease in a population. For some indicators, exposure and the presence of 

illness have a well-established link, as with giardiasis.

FIGURE 1: Multiple Exposure – Multiple Effect (MEME) Framework

Source: Adapted from Briggs 2003.

The indicators presented in this report refl ect areas of concern where there is scientifi c evidence 

of a relationship between the exposure to an environmental contaminant(s) and related health 

effects, although in some of these cases the evidence may not be conclusive. The need for 

additional research to ensure that the potential risks from these exposures are better understood 

and managed is of paramount importance. 
Children's Health and the Environment in North America 9

1.6 THE FIRST NORTH AMERICAN REPORT

Never before has an integrated report on indicators of children’s health and the environment 

for North America been available. This CEC-led effort forms part of the Global Initiative on 

Children’s Environmental Health Indicators. Initiated by the US Environmental Protection 

Agency (EPA), the Global Initiative was launched at the WSSD in August 2002. The Global 

Initiative is being coordinated and implemented by WHO with EPA support. Partners for 

the Global Initiative include: the governments of Canada, Mexico, Italy, South Africa and 

the United States; international organizations: OECD, CEC, UNEP, UNICEF, and WHO; 

and nongovernmental organizations: International Society of Doctors for the Environment, 

International Network for Children’s Health and Environmental Safety, and Physicians for Social 

Responsibility. This CEC report represents a signifi cant regional contribution to the global effort 

and is further distinguished as the fi rst regional product of that effort. This regional pilot will 

hopefully be informative to similar projects in other parts of the world. More information on the 

Global Initiative is available online at <www.who.int/ceh/indicators/>.

The outcome of this effort will allow those involved in various aspects of health and environmental 

protection to consider what information is available and what is not. This initial effort is very 

much a learning process where the partners have agreed to share information in order to advance 

thinking on the creation of a set of unique North American indicators of children’s health and 

the environment. It also will make that learning available to a broader audience in a way that will 

improve similar initiatives that are planned elsewhere in the world. 

All three countries have policies and programs in place to reduce the threats of exposure to 

environmental contaminants, and the corresponding risks to health. These actions clearly 

contribute to the protection of children’s health; however, no single source of information enables 

interested parties to look at the effectiveness of these measures collectively. The indicators presented 

in this North American report provide an important fi rst effort to track the status and trends of 

these issues on a broad scale. As such, caution is in order when attempting to draw comparisons 

between countries, given the differences in defi nitions, methodologies and standards. Efforts to 

increase the comparability among these indicators over time and to identify the need for further 

research and collaboration on data collection and analysis will be ongoing.

While considerable effort has been made to select indicators that are important to children’s 

health, the information in this report is by no means exhaustive. Many environmental risks and 

thousands of substances have yet to be fully investigated for their potential impact on the health 

of children. Thus this report presents only a fraction of the information that could be included. 

Inevitably, those who review this report will fi nd gaps or limited dialogue on issues that are 

important to children’s health and the environment. 
Poverty is a major determinant of health outcomes and is an important 

 contributor to increased exposure to environmental risks among children.

10
2.0 An Introduction to 

the Participating Countries

Canada, Mexico and the United States, as this report will illustrate, share some common 

areas of interest and approach where the environment is concerned. For example, all three 

countries have approached air quality through the use of national air quality standards/

objectives and all have made investments in drinking water treatment and the management of 

sewage to better protect the health of their citizens. These similarities are important to note; 

however, it is equally important to look at differences among the three countries to better 

interpret the indicators of children’s health and the environment presented in this report. 

Although this introduction is not a comprehensive picture of the countries, the information 

presented here provides context on various aspects of each country’s population and factors 

that are important to health outcomes. 

In addition to the introductory health status indicators presented in this section, additional data 

and source information are also contained in the country reports (available on the CEC web site). 

For the purposes of this report, the defi nition of children includes all persons up to the age of 

18 years, although other age distributions are sometimes cited, depending on the data involved.

CHILDREN’S HEALTH AND THE ENVIRONMENT IN NORTH AMERICA

Commission for Environmental Cooperation 11
12

2.1 POPULATION DATA AND BIRTH RATES

The percentage of each country’s population under 18 years of age is presented, as are the birth rates, which 

provide an indicator of the rate of population growth.

As of 2003, there were approximately 7 million children in Canada, or 22 percent of the total 

population of 31.5 million (UNICEF 2005). Canada’s birthrate was approximately 11 live births 

per 1000 population, as of 2000 (see Canada’s country report). As of 2003, 80 percent of the 

Canada’s population lived in urban areas (UNICEF 2005). 

Mexico had nearly 40 million children in 2003, representing approximately 38 percent of its total 

population of nearly 103.5 million (UNICEF 2005). Mexico’s birthrate was 17 live births per 

1000 population, as of 2000 (see Mexico’s country report). As of 2003, 75 percent of Mexico’s 

population lived in urban settings (UNICEF 2005).

In 2003, US children numbered nearly 76 million, or almost 26 percent of the total population of 

294 million (UNICEF 2005). The United States' birth rate in 2000 was 14 live births per 1000 population (United States Census Bureau 2004). As of 2003, 80 percent of the population of the United 

States lived in urban areas (UNICEF 2005).

2.2 CHILD MORTALITY AND MORBIDITY

Mortality rates for infants (under one year of age) and children (one to four years of age) are presented, as are 

morbidity rates and the primary causes of death and hospitalization for a number of age groups. 

Canada’s infant mortality rate was 5.1 deaths per 1000 live births in 2001 and the child mortality 

rate per 1000 for ages one to four years was 0.2 in the same year. The leading cause of infant death 

in Canada in 1999 was birth defects, while unintentional injuries were the leading cause of death 

for children after the fi rst year of life. The leading cause of infant hospitalization was respiratory 

disease. Children from one to 14 years of age were also most likely to be hospitalized due to illnesses 

of the respiratory system (see Canada’s country report).

Mexico’s infant mortality rate was 16.8 deaths per 1000 live births in 2002 and the child mortality 

rate per 1000 was 0.75 in 2002. Perinatal complications were the leading cause of infant mortality, 

while accidents were the leading cause of death for all age groups after the fi rst year of life. The 

leading cause of infant and child hospitalization for all age groups was respiratory diseases (see 

Mexico’s country report).

In the United States, infant mortality rates were 6.9 deaths per 1000 live births in 2000, while child 

mortality for children one to four years old was 0.3 per 1000, in the same year. The leading cause 

of child mortality for children up to one year was congenital malformations, deformations and 

chromosomal abnormalities. The leading cause of death for children after the fi rst year of life was 

injuries, both intentional and unintentional. The leading cause of hospitalization for ages one to nine 
Children's Health and the Environment in North America 13

years was respiratory disease, whereas the leading cause of hospitalization for children 10 to 14 years of 

age was mental disorders. Lastly, for 15- to 19-year-olds, the leading cause of hospitalization in the 

United States was pregnancy/childbirth (see the US country report). 

2.3 IMMUNIZATION RATES AS AN INDICATOR OF AVAILABILITY OF PUBLIC HEALTH SERVICES 

The presence and availability of public health services and health care have been shown to infl uence child 

health in a positive way. Immunization programs are one example of public heath services that provide 

protection from communicable diseases; thus immunization rates provide an indicator of the access to public 

health for the population.

All three countries reported immunization rates for measles of more than 90 percent. Canada 

provided immunization for 94.5 percent of two-year-old children by 2002. Mexico posted immunization rates of close to 100 percent for a series of diseases in 2002/2003 while the United States 

presented a measles immunization rate of 91 percent in 2000 (see the US country report). 

2.4 SOCIOECONOMIC DETERMINANTS OF HEALTH

It is widely recognized that poverty is a major determinant of health outcomes and is an important contributor 

to increased exposure to environmental risks among children (see Canada’s country report). Children living 

in poverty are more likely to be exposed to multiple environmental risks. For example, children living in poor 

families are more likely to live near industrial sources of pollution and live in substandard housing (European 

Environment Agency and the WHO Regional Offi ce of Europe 2002). 

Maternal education has also been shown to be important to a child’s development and higher 

maternal education levels contribute to improved academic and social performance in children 

(see Canada’s country report). Children born to mothers with less education can be at higher 

risk for other fetal exposures, such as exposures to alcohol and tobacco during pregnancy.

Children living in poor families in Canada are more likely to live in areas of heavy traffic, 

to live in substandard housing and to be exposed to environmental tobacco smoke in their 

homes (see Canada’s country report). In 2001, 15.6 percent of children in Canada lived 

in families with income levels below the low-income cut-off. In 1994/1995, 17.2 percent 

of children under the age of two years had a mother who had not completed high school, 

compared with 13.4 percent in 1998/1999 (Statistics Canada 2001).

In Mexico, the proportion of children under 18 years of age living in poverty (homes with 

per capita income below the requirements to satisfy basic food needs, equivalent to 15.4 and 

20.9 pesos per day in rural and urban areas) was 27.4 percent in 2003. Women’s levels of 

education have increased over the last 40 years. Women in Mexico with postsecondary and 

higher education increased from 2.4 percent in 1960 to 26.7 percent in 2000. (See <http://

biblioteca.itam.mx/docs/infogob02/118-131.pdf>.)

In the United States, 21.7 percent of children were born to mothers with less than 12 years 

of education in 2000 (Centers for Disease Control 2003). The proportion of children living 

in absolute poverty (living under nationally defined poverty level) in 2000 was 16.1 percent 

(United States Census Bureau 2001). 

Although not covered here, there are other socioeconomic determinants of child health that 

may also be important to consider, such as race, ethnicity, geographic distribution (e.g., urban 

versus rural) and parental occupation, among others.
Children spend more time outside and inhale more air per unit body weight compared to adults, 

 potentially exposing them to higher concentrations of outdoor air pollutants.
3.0 Asthma and Respiratory Disease

The air children breathe is an important source of exposure to substances that may potentially 

harm their health (US EPA 2003). Exposures in early childhood when the lungs and immune 

systems are not fully developed raise concerns that children may respond more adversely 

than adults would (Schwartz 2004). The specific health concerns associated with exposure 

to air pollutants can vary considerably depending on the pollutant of concern and the nature 

of the exposure.

The indicators presented in this chapter reflect the “common” air-borne pollutants of 

concern present in outdoor air and other select sources of indoor air pollutants and the 

associated respiratory illness and disease. As illustrated in the MEME diagrams, some of 

the measures presented here address environmental sources of exposure (e.g., outdoor air 

pollutants) while others address health outcomes (e.g., asthma).

SECTION 3.1 presents indicators of exposure to common air pollutants of concern to human 

health. These indicators indirectly measure the potential for exposure for a population 

(United States). Where population-based indicators are not available, air quality monitoring 

data are presented (Canada and Mexico). 

SECTION 3.2 presents data on the number of children exposed in the home to environmental 

tobacco smoke (Canada and the United States) and to non-vented biomass emissions 

(Mexico). These two sources of pollution in indoor environments are considered important 

factors in the development and exacerbation of asthma and respiratory diseases in children.

SECTION 3.3 provides data and trends on the prevalence of asthma among children in all three 

countries. This indicator provides a direct measure of the prevalence of the disease, using 

survey data (Canada and the United States) and physician reporting (Mexico).

CHILDREN’S HEALTH AND THE ENVIRONMENT IN NORTH AMERICA

Commission for Environmental Cooperation 15
16

 3.1 OUTDOOR AIR POLLUTION

I

_____________________________________________________________________________________________________I

Purpose: This indicator provides information on children’s potential exposure to outdoor air pollution, 

with a focus on common air contaminants. 

Current indicator: Percentage of children living in areas where air pollution levels exceed relevant 

air quality standards. 

I

_____________________________________________________________________________________________________I

Children spend more time outside and inhale more air per unit body weight compared to adults, potentially 

exposing them to higher concentrations of outdoor air pollutants emitted from traffi c, power plants, and 

other sources such as wood smoke and forest fi res. These exposures can begin before a child’s immune 

system and lungs are fully developed, giving rise to concerns that their responses may be different from 

those of adults. 

Air pollution has long been considered a source of exacerbation of asthma and other 

respiratory conditions; however, recent studies of the effects of air pollution on children’s 

health suggest that air pollution is associated with infant mortality and the development of 

asthma, and may influence lung development, causing lasting effects on respiratory health 

(Schwartz 2004). A long-term study of the effects of chronic air pollution in California on 

children’s respiratory health indicated that children’s health is adversely affected by current 

ambient levels of air pollution. The study’s results indicated that children’s lung function 

growth was adversely affected by the chronic exposures and that new cases of asthma and 

asthma exacerbations were also associated with these levels (Peters et al. 2004).

Particulate matter, a common air pollutant, has been associated with acute bronchitis in 

children. Research has shown that rates of bronchitis and chronic cough are reduced when 

particulate levels decline. There is new evidence that air pollution may also play a role in 

adverse birth outcomes, such as early fetal loss, pre-term delivery and lower birth weight 

associated with prenatal exposures (Schwartz 2004). 

Air pollutants such as ground-level ozone can also cause a variety of respiratory health effects 

from short-term exposure, including inflammation of the lung, reduced lung function, 

and respiratory symptoms such as cough, chest pain, and shortness of breath. Short-term 

exposures to ambient concentrations of ground-level ozone have been associated with 

the exacerbation of asthma, bronchitis and respiratory effects serious enough to require 

emergency room visits and hospital admissions (US EPA 2003).

Other air pollutants of concern include carbon monoxide, nitrogen dioxide, sulfur dioxide 

and lead. Ground-level ozone and particulate matter are two common pollutants of concern 

to public health and are the focus of national air quality standards in all three countries.

As the multiple exposure–multiple effects (MEME) model for ambient air pollution in FIGURE 2 

suggests, a number of air contaminants—individually or in combination—can produce a number 

of health outcomes (Briggs 2003). Conversely, a single health outcome may be associated with 

multiple exposures to multiple substances over time. 

Socio-economic conditions and other factors affect the risk of exposure, as well as the health 

outcomes. For example, families living in low-income housing in crowded inner city environments 

may be at increased risk from higher concentrations of airborne pollutants, in particular where 

there is close proximity to high-traffi c density (Peters et al. 2004). Other conditions such as a 

region’s geography and weather patterns may contribute to greater (or lesser) exposures. Adverse 

health outcomes associated with exposure to outdoor air pollution may have a greater impact in 

communities where there is limited access to health care services and medications.
Preventive

actions

Remedial

actions

ACTIONS

Social conditions 

Economic conditions

Demographic conditions

EXPOSURE HEALTH OUTCOMES 

IN CHILDREN

AGENTS*

Common air pollutants 

(carbon monoxide, 

ground-level ozone, 

nitrogen oxides, 

particulate matter, 

sulfur oxides)*

SOURCES

Transportation

Industrial and

institutional releases

Natural sources

Household releases

Combustion

causes or is associated with

Infl ammation of the lung

Reduced lung functioning 

and other respiratory effects

Exacerbation of asthma and 

other respiratory conditions

Low birth weight and other 

adverse birth outcomes

Death

CONTEXTS

attributable to or

is associated with

Children's Health and the Environment in North America 17

Each country uses different air quality standards to report on their indicators (for more 

information, please see the country reports). These standards are not comparable, as they 

have been developed through differing processes and taking into account various factors, 

including health-based considerations, among others. Current scientific evidence does not 

point to discernable thresholds for ambient air pollutants below which there are no adverse 

health effects. As a result, even air pollutant levels below current air quality standards should 

be treated with caution. Even in areas that meet a nation’s air quality standards, there are 

likely some children who could experience adverse health effects, especially children with 

pre-existing medical conditions.

The indicator “percentage of children living in areas where air pollution levels exceed 

relevant air quality standards” is intended to reflect the percentage of children that are 

exposed to exceedances in national standards. To present information on this indicator, 

countries require ongoing local or regional air quality monitoring that can be combined 

with population census data to determine the percentage of children that are experiencing 

exposures above the established standards over time. 

FIGURE 2: MEME Framework for Issues Covered in the Section on Outdoor Air Pollution

Source: Adapted from Briggs 2003.

Note: * Mexico and the United States include lead in their lists of criteria air contaminants.
Parts per Billion (ppb)

Years

1989 1991 1993 1995 1997 1999 2001

30

40

50

60

70

80

90

100

Southern Ontario

Eastern Ontario and Quebec

Atlantic Provinces

Prairies and Northern Ontario

British Columbia

0

18

3.1.1 Canada 

In Canada, the ability to adequately model the spatial dispersion of specific air pollutants 

and to link this information to populations in matching areas was not sufficiently developed 

to present information on the current indicator at this time. Canada is currently reviewing 

options to address the outdoor air pollution indicator identified in SECTION 3.1, including an 

assessment of the national ambient monitoring network. In the interim, Canada presents 

information based on data collected at ambient monitoring stations.

CHART 3-1 displays peak levels of ground-level ozone for selected regions of Canada for the 

period 1989–2002. 

CHART 3-2 illustrates the number of days in 2002 on which ground-level ozone levels exceeded 

the Canada-wide Standard of 65 ppb, for various locales across Canada.

CHART 3-3 presents the number of days in 2002 on which PM2,5 levels exceeded the Canadawide Standard of 30 μg/m3

, in various locales across Canada.

CHART 3-1: Peak Levels of Ground-level Ozone, for Selected Regions of Canada, 1989–2002

Source: National Air Pollution Surveillance Network, Environment Canada.

Note: The yearly values for each station were calculated by averaging the peaks (i.e., four highest measurements over 

eight hours) for three consecutive years. The yearly values for each station were then averaged for the region.
Toronto

Montreal ontreal Ottawa

Quebec

Charlottetown harlottetown

Fredericton redericton Saint John aint John

Halifax

Vancouver

Victoria

Number of days

<1

1-10

11-20

>20

Charlottetown harlottetown

Fredericton redericton Saint John aint John

Halifax

Toronto

Montreal ontreal Ottawa

Quebec

Vancouver

Victoria

Number of days

<1

1-10

11-20

>20

Children's Health and the Environment in North America 19

CHART 3-2: Number of Days in 2002 on which Ground-level Ozone Levels Exceeded 

the Canada-wide Standard 

Source: National Air Pollution Surveillance Network Database, Environment Canada (consulted March 2004). 

Note: The points represent the number of days on which 8-hour ground-level ozone measurements exceeded the Canada-wide 

Standard of 65 ppb. The standard comes into force in 2010 and achievement will be measured using three years of data.

CHART 3-3: Number of Days in 2002 on which PM2.5 Levels Exceeded the Canada-wide Standard

Source: National Air Pollution Surveillance Network Database, Environment Canada (consulted March 2004).

Note: The points represent the number of days on which 24-hour PM2.5 measurements exceeded the Canada-wide Standard of 30 ppb.
0

40

80

120

Parts per Billion (ppb)

Years

160

200

240

280

1990 1992 1994 1996 1998 2000 2002

ZMVM

ZMVG

ZMM

ZMVT

CD Juárez

20

KE Y OBSERVATIONS :

■ Although ground-level ozone levels fl uctuate from year to year, they have not decreased signifi cantly in 

the Prairies, Ontario and Quebec over the last 13 years (CHART 3-1).

■ Ground-level ozone levels have decreased in British Columbia and the Atlantic provinces (CHART 3-1). 

■ In 2002, southern Ontario experienced the highest numbers of days on which ground-level ozone levels 

exceeded the Canada-wide Standard. The number of high-ozone days will fl uctuate from year to year, 

which can partly depend on the occurrence of hot, stagnant weather conditions (CHART 3-2). 

■ Southern Ontario experiences the highest number of days with elevated PM2.5, followed by the eastern 

Ontario/southern Quebec region (CHART 3-3).

3.1.2 Mexico

Mexico does not currently have the ability to link local air quality monitoring data to populationbased data for the corresponding locales. Therefore, Mexico was unable to report the current 

indicator. Instead, Mexico presents data for peak levels of ozone and suspended particles (PM10) for 

fi ve cities, as well as data on violations of its national air quality standards for “common” pollutants 

in key urban centers.

CHART 3-4 presents the peak levels of ground-level ozone for fi ve Mexican urban air monitoring 

zones during the period 1990–2002. 

CHART 3-5 presents annual mean PM10 levels for fi ve Mexican urban air monitoring zones during 

the period 1995–2002. 

CHART 3-6 illustrates metropolitan areas with air quality programs including information from the 

Indice Metropolitano de la Calidad del Aire (Metropolitan Air Quality Index)—Imeca for ground-level 

ozone and PM10. The Imeca is an air quality indicator in which the value of 100 is associated with 

the maximum allowable limit of each pollutant’s health standard.

CHART 3-4: Peak Levels of Ground-level Ozone for Five Mexican Urban Air Monitoring Zones, 1990–2002 

Source: Segundo Almanaque de datos y tendencias de la calidad del aire en seis ciudades Mexicanas (Second Almanac of 

Data and Air Quality Trends in Six Mexican Cities). Secretaría del Medio Ambiente y Recursos Naturales (Semarnat). 

Instituto Nacional de Ecología (INE). 2004 <http://www.ine.gob.mx/publicaciones/descarga.html?cv_pub=419>.

Note: ZMVM = Valley of Mexico City Metropolitan Zone, ZMVG = Valley of Guadalajara Metropolitan Zone, ZMM = 

Monterrey Metropolitan Zone, ZMVT = Valley of Toluca Metropolitan Zone, CD Juárez = Ciudad Juárez.
0

15

30

μg/m3

Years

1996 1998 2000 2002

45

60

75

90

ZMVM

ZMVG

ZMM

ZMVT

CD Juárez

Valle de México

Toluca

Guadalajara

Tijuana

Monterrey

Ciudad Juárez Mexicali

0

10

20

30

40

50

60

70

80

90

Percentage of days exceeding the 

standard

Ground level

ozone

PM10

7

6.5

7.5

8.5

Percentage of days exceeding the 

standard

Ground level

ozone

PM10

8

9

5

10

20

Percentage of days exceeding the 

standard

Ground level

ozone

PM10

30

0

15

25

1

Percentage of days exceeding the 

standard

Ground level

ozone

PM10

0

2

3

4

5

6

5

10

20

Percentage of days exceeding the 

standard

Ground level

ozone

PM10

0

15

25

5

10

Percentage of days exceeding the 

standard

Ground level

ozone

PM10

0

15

20

25

0

10

15

20

25

30

35

40

Percentage of days exceeding the 

standard

Ground level

ozone

PM10

5

Children's Health and the Environment in North America 21

CHART 3-5: Annual Mean Levels of Particulate Matter (PM10) for Five Mexican 

Urban Air Monitoring Zones, 1995–2002

Source: Segundo Almanaque de datos y tendencias de la calidad del aire en seis ciudades Mexicanas (Second Almanac of 

Data and Air Quality Trends in Six Mexican Cities). Secretaría del Medio Ambiente y Recursos Naturales (Semarnat). 

Instituto Nacional de Ecología (INE). 2004 <http://www.ine.gob.mx/publicaciones/descarga.html?cv_pub=419>.

Note: ZMVM = Valley of Mexico City Metropolitan Zone, ZMVG = Valley of Guadalajara Metropolitan Zone, ZMM = 

Monterrey Metropolitan Zone, ZMVT = Valley of Toluca Metropolitan Zone, CD Juárez = Ciudad Juárez.

CHART 3-6: Metropolitan Areas in Mexico with Air Quality Programs Including Air Monitoring, 1999–2002*

Source: Segundo Almanaque de datos y tendencias de la calidad del aire en seis ciudades Mexicanas (Second Almanac of 

Data and Air Quality Trends in Six Mexican Cities). Secretaría del Medio Ambiente y Recursos Naturales (Semarnat). 

Instituto Nacional de Ecología (INE). 2004 <http://www.ine.gob.mx/publicaciones/descarga.html?cv_pub=419>.

Note: *4-year arithmetic mean; but for Mexicali and Tijuana, 3-year arithmetic mean, 1997–99.
22

KE Y OBSERVATIONS :

■ Peak levels of ground-level ozone have decreased since 1990; however, the Mexican standard of 

110 ppb has been violated in almost all years in Mexico City. Guadalajara has reported violations 

for 1996 and 1997. Monterrey, Toluca and Ciudad Juárez have not reported any exceedances of the 

standard from 1990 to 2002 (CHART 3-4). 

■ The annual mean levels for PM10 exceeded the Mexican mean annual standard of 50 micrograms 

per cubic meter in Guadalajara, Mexico City, and Ciudad Juárez in most years in the reporting 

period (1995 to 2002) (CHART 3-5)

■ The Mexican daily maximum standard of 150 micrograms per cubic meter for suspended particles 

(PM10) was exceeded on 20 percent or more days in the reporting period (1999–2002) in Mexicali, 

Guadalajara, Ciudad Juárez and Monterrey. In Mexicali, exceedances occurred on approximately 

35 percent of the days (CHART 3-6). [Note: In September 2005, regulations were published lowering 

the daily maximum standard for PM10 to 120 μg/m3 (NOM-026-SSA1-1993).]

■ The standard for ground-level ozone was exceeded in the Valley of Mexico City Metropolitan Zone 

on more than 80 percent of the days during the reported period (CHART 3-6).

■ Although most of the metropolitan zones did not exceed the standard for carbon monoxide (11.00 

ppm for a moving 8-hour daily average, not to be exceeded more than once per year [see NOM021-SSA1-1993, Salud Ambiental. Criterio para evaluar la calidad del aire ambiente con respecto 

al monoxido de carbono (CO) en el aire ambiente, como medida de protección a la salud de la 

población]), in Mexicali, it was exceeded on 19 percent of the days (data not shown).

3.1.3 United States

The United States reports the current indicator by using EPA air quality data from counties 

with monitors, across the United States, as compared to the National Ambient Air Quality 

Standards (NAAQS). The indicator shows the percentage of children living in counties 

where any of the standards was exceeded at any time during the year. These children may 

be exposed to poor daily air quality at some point during a year. The measure includes air 

quality data for ozone, particulate matter, lead, and carbon monoxide (nitrogen dioxide and 

sulfur dioxide had essentially no exceedances).

CHART 3-7 presents the percentage of children living in counties in which air quality 

standards were exceeded for 1990–2003. The measure indicates whether the level of any 

standard was exceeded at any time during a year. This measure does not differentiate between 

counties in which the indicators are exceeded frequently or by a large margin and counties in 

which indicators are exceeded only rarely or by a small margin.
0

Percent (%)

Years

1990

50

60

70

40

30

20

10

1992 1994 1996 1998 2000 2002

Ground-level

ozone

PM2.5

Lead

PM10

CO

Children's Health and the Environment in North America 23

CHART 3-7: Percentage of Children Living in Counties in the United States in which Air Quality 

Standards were Exceeded, 1990–2003

Source: US EPA 2003. America’s Children and the Environment: Measures of Contaminants, Body Burdens, and Illnesses. 

<www.epa.gov/envirohealth/children>.

Data Source: US EPA, Office of Air and Radiation, Aerometric Information Retrieval System.

Note: It should be noted that this measure is slightly different from the air quality standard used by EPA to identify areas 

that must develop plans to lower air pollution levels. For example, for ozone, the standard for developing plans is based 

on the day with the fourth-highest eight-hour average ozone concentration.

KE Y OBSERVATIONS :

■ The highest number of exceedances is consistently reported for ground-level ozone. In 1990, approximately 55 percent of children lived in counties in which the eight-hour ozone standard was exceeded on 

at least one day per year. In 2003, approximately 58 percent of children lived in such counties (CHART 3-7).

■ In 2000, approximately 30 percent of children lived in counties that exceeded the annual PM2.5 

standard. In 2003, approximately 19 percent of children lived in such counties. The standard for 

particulate matter was revised in 1997 to include PM2.5. The standard is intended to protect 

against both short-term and long-term health effects (CHART 3-7).

■ In 1990, approximately 13 percent of children lived in counties in which the carbon monoxide 

standard was exceeded. In 2003, approximately 1 percent of children lived in such counties (CHART 3-7).

■ From 1990 to 2001, the percentage of children living in counties that exceeded the one-day 

standard for PM10 fluctuated, but was as high as 14 percent in 1990 and 1991, and 11 percent in 

1999. The percentage remained around 6 to 9 percent during 2000–2003 (CHART 3-7).

■ In 1990, about 2 percent of children lived in counties that exceeded the three-month standard 

for lead. In 2003, only one county, less than 0.1% of children, had lead air measurements that 

exceeded the standard for lead (CHART 3-7).

■ Few exceedances of the sulfur dioxide and nitrogen dioxide standards have occurred since 1993. 

Consequently, they were not included on the graph.
24

3.1.4 Opportunities for Strengthening Indicators of Outdoor Air Pollution in North America 

All of the indicators for outdoor air pollution rely on ambient air quality monitoring for 

national data. Only the United States was in a position to combine population data with air 

quality monitoring data to report the percentage of children that are exposed to degraded air 

quality. The following opportunities were identified for future improvement:

• Determining the percentage of children living in areas where air pollution levels exceed relevant air 

quality standards requires a more common understanding of the relationship between population and air 

quality monitors among the three countries. 

• The ability to identify the specifi c geographic areas of high pollutant levels (e.g., along main 

transportation corridors or downwind from pollutant sources), would improve our ability to identify 

potential populations at risk.

• The percentage of children living in areas where air pollution levels exceed relevant air quality standards 

does not provide a complete measure of the degree of exposure for the population. For example, the 

indicator does not tell the user where the highest rates of exceedance for multiple pollutants occur, nor 

does it reveal how high the pollution was above the standard. Future efforts could attempt to provide 

more information relative to the intensity of local/regional exceedances.

• Future efforts to improve the utility of this indicator could include linking of ambient concentrations 

of air pollutants with health outcomes. This could include links with health outcome data such as 

emergency room visits and admissions for respiratory and other related illnesses, school absenteeism 

and medication usage.

• Given that some pollutants have no discernable thresholds, future indicators should look beyond 

standards-based reporting to other measures.

• There is a need to improve the understanding of the chemistry of pollutants in the atmosphere, their migration 

and the health effects associated with aggregate exposure to multiple air pollutants in children.

• The ideal indicator would provide for consistent measures across all three countries over a reasonable 

time period (e.g., 10 years) so that trends could be monitored. The indicator would provide information that 

was nationally relevant to all children within a country while providing detail on the situation in various 

subpopulations according to their race/ethnicity, economic status, and specifi c geographic locales. 

• These outdoor air indicators refl ect only a few of the pollutants of concern to children’s health. There are 

other air pollutants of concern to children’s health that could be included in future indicators work.

3.2 INDOOR AIR POLLUTION

I

_____________________________________________________________________________________________________I

Purpose: This indicator provides information on children’s potential exposures to indoor air pollu tion, 

with a focus on environmental tobacco smoke and emissions from the burning of biomass fuels.

Current indicator: Indoor air quality: Measure of children exposed to environmental tobacco smoke 

(Canada, United States); measure of children exposed to emissions from the burning of biomass fuels 

(Mexico). I

_____________________________________________________________________________________________________I

Children who are exposed to environmental tobacco smoke (ETS) indoors are at increased risk 

of adverse health effects. Exposure to ETS 7

 is associated with an increased risk for bronchitis, 

pneumonia, lower respiratory tract infections, otitis media (fluid in the middle ear), and 

sudden infant death syndrome (SIDS) (President’s Task Force on Environmental Health 

Risks and Safety Risks to Children 2000a, US EPA 2003, California Air Resources Board 

2005, Health Canada 2005). Furthermore, ETS is one of the irritants known to trigger asthma 

attacks and plays a role in the development of asthma (US EPA 2003). Other contributions to 

the cause and exacerbation of asthma remain the subject of ongoing research.

7 Canada refers to fugitive emissions associated with smoking as “secondhand smoke” (SHS). Mexico refers to fugitive 

emissions associated with smoking as “passive smoke.”
Preventive

actions

Remedial

actions

ACTIONS

Social conditions

Economic conditions

Demographic conditions

EXPOSURE HEALTH OUTCOMES

IN CHILDREN

AGENTS

Environmental tobacco smoke

Biomass emissions

SOURCES

Smoking

Burning of wood and charcoal

Middle ear infections

Bronchitis

Pneumonia and other acute 

respiratory conditions

Development and

Exacerbation of asthma

Low birth weight

Sudden infant death syndrome (SIDS)

CONTEXTS

causes or is associated with

attributable to or

is associated with

Children's Health and the Environment in North America 25

Children who are exposed to biomass emissions from the burning of wood are also at risk for a number 

of health effects. These may include susceptibility to sinus and respiratory infections, bronchitis, 

exacerbation of asthma, and decreased lung function. The World Health Organization notes 

that “there is consistent evidence that exposure to indoor air pollution can lead to acute lower 

respiratory infections in children under five” (World Health Organization 2005a). Indoor 

smoke contains a number of pollutants associated with potential health effects, including: 

particles (complex mixtures of chemicals in solid form and droplets), carbon monoxide, 

nitrous oxides, sulfur oxides (mainly from coal), formaldehyde and carcinogens (chemical 

substances known to increase the risk of cancer) such as benzo[a]pyrene and benzene (World 

Health Organization 2005b). Indoor air pollution in homes, caused by the burning of fi rewood 

or charcoal for cooking, is a public health problem in Mexico (see Mexico’s country report).

Other pollutants of concern that may be found in North American homes include PM2.5, 

dusts and allergens such as pet dander, molds, gases and aerosols from consumer products 

such as cleaners and furniture polishes, pesticides, and other gases and vapors associated 

with combustion sources in the home. Outdoor air pollution that finds its way into the home 

is another source of pollution. 

As the MEME model in FIGURE 3 indicates, the measures for indoor air pollution present 

surrogate exposure measures of the percentage of children exposed to ETS in their homes in 

Canada and the United States, and fugitive emissions from the burning of biomass indoors 

in Mexico. The United States also provides an additional measure of exposure with blood 

cotinine levels (cotinine is a breakdown product of nicotine and is a marker for recent 

exposure to ETS) (US EPA 2003). Blood cotinine provides a marker of exposure to ETS from 

all exposure sources, including exposure to ETS in the home and in public places.

FIGURE 3: MEME Framework for Issues Covered in the Section on Indoor Air Pollution

Source: Adapted from Briggs 2003.
0

10

15

25

20 

35

30

1999 2000 2001 2002

Age 15-19

Age 12-14

Age 6-11

Age 0-5

Years

Percent (%)

26

3.2.1 Canada 

Canada addresses the current indicator by using data obtained from the Canadian Tobacco Use 

Monitoring Survey (CTUMS) Report and the National Population Health Survey (NPHS). 

CHART 3-8 shows the percentage of children exposed to environmental tobacco smoke in Canadian 

homes, for ages zero to fi ve years, six to 11 years, 12 to 14 years, and 15 to 19 years.

CHART 3-8: Percentage of Children Exposed to Environmental Tobacco Smoke in Canadian Homes, by 

Age Groups, 1999–2002

Source: Health Canada, Canadian Tobacco Use Monitoring Survey (CTUMS) report and Statistics Canada, the National 

Population Health Survey.

KE Y OBSERVATIONS :

■ Generally, the percentages of children (in all four age categories: zero to fi ve, six to 11, 12 to 14, 

 and 15 to 19) exposed to ETS in Canadian homes is decreasing (CHART 3-8). 

■ In 2002, more than one in four children aged 15 to 19 years were exposed to tobacco smoke 

 in the home (CHART 3-8).

■ Approximately 14 percent of infants and young children (aged zero to fi ve years) were 

 exposed in 2002, down from 23 percent in 1999 (CHART 3-8).

■ It is also evident that for all four years, (1999–2002) exposure to ETS was highest among 

 children aged 15 to 19 years and lowest among those aged zero to fi ve years (CHART 3-8).
Percentage of users

0-20%

20-40%

40-70%

70-90%

90-100%

States

Children's Health and the Environment in North America 27

3.2.2 Mexico 

Mexico reports on the current indicator by providing information on the use of biomass 

fuels, which includes wood and charcoal, at the municipal level in Mexico. Data on the 

percentage of children exposed to environmental tobacco smoke in Mexican households are 

not available. However, environmental tobacco smoke is recognized as a significant public 

health threat in Mexico. Mexico, therefore, provides data on smoking prevalence in urban 

and rural populations, as well as survey data of smoking percentages of urban adolescents, 

in its country report. 

CHART 3-9 is a map of the geographical distribution of the percentage of total households of 

fuel wood users, at the municipal level, in Mexico.

CHART 3-9: Percentage of Fuel Wood Users, at the Municipal Level, in Mexico, 2000

Source: Masera, O.R, Drigo, R., and Trossero, M.A. 2003. Woodfuels Integrated Supply/Demand Overview Mapping. 

Universidad Autónoma de México, FAO-EC Partnership Programme. Food and Agriculture Organization of the United 

Nations, p. 23.

KE Y OBSERVATIONS :

■ The heaviest biomass usage is in southern Mexico and north central Mexico, where areas 

 of 90–100 percent utilization may be found in some locales. These are largely rural states 

 with some of Mexico’s poorest populations (CHART 3-9, see also Mexico’s country report). 

3.2.3 United States 

The United States presents several measures of ETS exposure in children to fulfill the current 

indicator. National surveillance data, which are collected annually, provide information on 

smoking in the home, where children are present. The United States also has included an 

additional indicator, serum cotinine, which is a bio-marker for ETS exposure. 

CHART 3-10 shows the percentage of children aged six and under who are regularly exposed to 

environmental tobacco smoke in US homes, for the years 1994–2003. 

CHART 3-11 shows the percentage of children aged four to 11 with detectable levels of blood 

cotinine, by race and ethnicity, in the United States, for the periods 1988–94 and 1999–2000.
10

20

30

40

50

60

70

80

90

Percent (%)

Total

100

White, Non-Hispanic Black, Non-Hispanic Mexican-American

1988-1994

1999-2000

1988-1994

1999-2000

1988-1994

1999-2000

1988-1994

1999-2000

0

30

10

5

15

25 

Percent (%)

Years

20 

1994 1996 1998 2000 2002

0

28

CHART 3-10: Percentage of Children Aged Six and Under Regularly Exposed to Environmental 

Tobacco Smoke in US Homes, 1994–2003

Source: Data for 1994 and 1998: National Health Interview Survey. National Center for Health Statistics, Centers for 

Disease Control and Prevention. Data for 2003: National Survey on Environmental Management of Asthma and Children’s 

Exposure to Tobacco Smoke. United States Environmental Protection Agency, Indoor Environments Division.

CHART 3-11: Percentage of Children Aged Four to 11 with Detectable Levels of Blood Cotinine, by 

Race and Ethnicity, in the United States, 1988–1994 and 1999–2000

Source: National Health and Nutrition Examination Survey. National Center for Health Statistics, Centers for Disease 

Control and Prevention.

Note: Cotinine is detectable at or above 0.05 nanograms per milliliter (ng/mL) in both the 1988–1994 and the 1999–2000 data sets. 
Children's Health and the Environment in North America 29

KE Y OBSERVATIONS :

■ The percentage of children aged six and under who are regularly exposed to environmental tobacco 

smoke in the home decreased from 27 percent in 1994 to 20 percent in 1998 and 11 percent in 2003 

(CHART 3-10).

■ In 1999–2000, the median levels of cotinine in children aged three to 11 and 12 to 19 were more than 

twice the median levels in non-smoking adults. (Data not shown; see the Centers for Disease Control 

and Prevention, 2003, Second National Report on Human Exposure to Environmental Chemicals, 

<http://www.cdc.gov/exposurereport/>.)

■ The percentage of children exposed to environmental tobacco smoke, as indicated by presence of 

detectable blood cotinine levels, dropped between the periods 1988–94 and 1999–2000. Overall, 64 

percent of children aged four to 11 had cotinine in their blood in 1999–2000, down from 88 percent in 

1988–94 (CHART 3-11).

■ In 1999–2000, 86 percent of Black, non-Hispanic children aged four to 11 were exposed to environmental 

tobacco smoke, compared with 63 percent of White, non-Hispanic children and 49 percent of Mexican 

American children (CHART 3-11).

3.2.4 Opportunities for Strengthening Indicators of Indoor Air Pollution in North America

Exposure to environmental tobacco smoke and biomass emissions are important environmental 

indicators for child health because of the substantive health risks associated with these sources 

of indoor air pollution. A number of indicators have been presented, as well as suggestions to 

improve the quality and comparability of the indicators for future reports.

■ Different time frames and age groups have been used to reflect household exposure to 

environmental tobacco smoke (Canada and the United States) and biomass emissions 

(Mexico). Use of standard age groups and time periods would improve subsequent reports 

and provide better comparability of results. 

■ Some of the surveillance activities (e.g., national surveys) are not annual events; thus 

it would be helpful to look for the most comprehensive sample period, as well as make 

efforts to synchronize future survey periods.

■ Biomonitoring data (e.g., blood cotinine levels) provide an excellent source of information 

that can augment data obtained by surveys. Biomonitoring of blood cotinine levels in 

Canada and Mexico would provide additional information on exposure to environmental 

tobacco smoke. 

■ The need for better monitoring of exposure to environmental tobacco smoke during the 

age bracket birth-to-three-years was identified. This is an important area for improvement, 

given the concerns over the susceptibility of infants.

■ Cotinine levels in the United States, by race and ethnicity, and indoor biomass use in 

Mexico, by municipality, suggest that in these two countries’ socio-economic conditions 

are important factors influencing exposure to environmental tobacco smoke and fugitive 

emissions from biomass use. These indicators suggest that increased attention should be 

paid to subpopulations at risk in future reporting efforts.

■ The focus on environmental tobacco smoke and biomass emissions present two priority 

indoor air issues, however, there are numerous other indoor pollutants of concern. Future 

efforts could develop indicators for other sources of indoor air pollutants such as consumer 

products and radon, particularly those most likely to impact children. Additionally, other 

indoor environments frequented by children, such as day-care centers and schools, could 

be included in indicators reporting. 
30

3.3 ASTHMA

I

_____________________________________________________________________________________________________I

Purpose: This indicator tracks asthma in children.

Current indicator: Prevalence of asthma in children.

I

_____________________________________________________________________________________________________I

Asthma is a chronic infl ammatory disease of the lungs that affects millions of children and adults in 

North America (National Institutes of Health 1997). It is a major cause of child hospitalization and is the 

most common chronic disease of childhood in North America. Asthma can produce wheezing, diffi culty in 

breathing, and chest pain (US EPA 2003), symptoms that can be triggered and exacerbated by numerous 

environmental factors. Thus, children with asthma are considered to be among the most sensitive to 

the respiratory effects of air pollution (US EPA 2003). Many children and family members suffer from 

poor quality of life associated with asthma and asthma-related morbidities. Children with severe and 

uncontrolled asthma have to reduce their levels of physical activity and require regular and heavy use of 

medications to effectively manage their asthma.

While the incidence of asthma varies throughout North America, it has been noted that its 

prevalence among children has been increasing for several decades. In some regions of North 

America there has been a four-fold increase in asthma prevalence in the last 20 years. This 

increase represents a tremendous human and economic burden for millions of children and 

adults in North America (President’s Task Force on Environmental Health Risks and Safety 

Risks to Children 2000b).

The exact cause of asthma in children is unknown, (President’s Task Force on Environmental 

Health Risks and Safety Risks to Children 2000b) but it appears to be the result of a complex 

interaction of many factors (see Canada’s country report): 

1. Predisposing factors, such as atopy—a tendency to have an allergic reaction to foreign 

substances.

2. Environmental causal factors, such as indoor air pollutants (e.g., environmental tobacco smoke 

and house dust mite antigen) and outdoor air pollutants (e.g., ground-level ozone).

3. Aggravating factors, which increase the frequency and/or severity of asthma episodes and 

include environmental tobacco smoke, certain indoor air allergens, outdoor air pollutants, 

including PM and ground-level ozone, and respiratory infections. 

While heredity plays a role in the development of asthma, it alone cannot adequately explain 

the large increase in asthma prevalence (US EPA 2003). Research into the causes of asthma 

has identified factors in the environment as being important to the frequency and severity of 

asthma episodes. More recent evidence suggests that environmental exposures such as smoking 

(or environmental tobacco smoke) and poor air quality contribute to pro-inflammatory 

effects and airway remodeling (Black and Johnson 2002). A long-term study investigating 

the chronic effects of air pollution on children’s health has identified an association between 

outdoor air pollutants and the development of the disease among healthy children (Peters 

et al. 2004). There is also growing evidence that very young children exposed to dust mite 

antigen and environmental tobacco smoke can develop new-onset asthma. Other indoor 

pollutants, such as nitrogen dioxide, pesticides, plasticizers, and volatile organic compounds, 

may play a role in the development of the disease (US EPA 2003). Some pollutants may trigger 

the development of asthma, and precipitate wheezing and coughing episodes in asthmatic 

children (Schwartz 2004).
Preventive

actions

Remedial

actions

ACTIONS

Social conditions 

Economic conditions

Demographic conditions

EXPOSURE HEALTH OUTCOMES 

IN CHILDREN

AGENTS

Common air pollutants 

(biomass emissions, 

ground-level ozone,

particulate matter,

nitrogen oxides, 

sulfur oxides, 

other toxic 

air contaminants)

SOURCES

Indoor air pollutants

(environmental tobacco smoke,

biomass emissions,

house dust, mite antigens,

animal dander, molds)

causes or is associated with

Induction and 

exacerbation of asthma

CONTEXTS

attributable to or

is associated with

Children's Health and the Environment in North America 31

FIGURE 4: MEME Framework for Issues Covered in the Section on Asthma

Source: Adapted from Briggs 2003.

Asthma is known for its disproportionate burden on certain populations (US EPA 2003). 

For example, lower-income inner-city populations are at greater risk of developing asthma 

because of sub-optimal levels of care and control, and because they may have higher exposures. 

Therefore, lower-income inner-city populations may suffer more morbidities associated with 

the disease. 

In Mexico, it has been reported that the residents of coastal states are more likely to exhibit 

asthma. Researchers have speculated that this may be due to the high ambient humidity, 

where dust in homes has a higher probability of entering the respiratory tract in the form 

of suspended particles. The higher prevalence of asthma in these regions has also been 

attributed to the use of air conditioning systems, which harbor a large quantity of dust and 

molds that can trigger asthmatic episodes (see Mexico’s country report).

Asthma is a complex disease. Diagnosing asthma is often a challenge in infants, where 

bronchiolitis, is common in children under six years of age, who may have common wheezing 

disorders that may not be associated with asthma. Clinical diagnosis of asthma in young 

children is often based on reported risk factors, symptoms, and response to medications. 

Therefore, the clinical definitions of asthma may vary between countries. As well, the 

surveillance techniques used in identifying asthmatics vary amongst countries. For example, 

as of 1997, the US National Health Interview Survey began differentiating between those 

children who may no longer have asthma and those whose asthma is well controlled. Based 

on these differences, the indicators presented should be interpreted with caution and 

comparisons between countries should be avoided. 
10

15 

20

1994/95 1996/97 1998/99

Boys 8-11

Boys 4-7

Girls 8-11

Girls 4-7

Years

Percent (%)

 0

32

3.3.1 Canada

Canada reports on the percentage of children who have been diagnosed with asthma by their 

physician. This information is provided through the National Longitudinal Survey of Children 

and Youth, which poses questions to parents on the health of their children. The survey provides 

data on the percentage of children who have reported a diagnosis of asthma. Since it is diffi cult 

to differentiate in the survey those with other respiratory conditions (such as wheezing) from 

those with asthma, children under the age of four were excluded from the analyses.

CHART 3-12 presents prevalence of physician-diagnosed asthma among children, by age group and 

by gender, in national survey results for three periods: 1994/1995, 1996/1997 and 1998/1999.

CHART 3-12: Prevalence of Physician-diagnosed Asthma (ever) among Children, by Age Group, in 

Canada, 1994/1995, 1996/1997 and 1998/1999

Source: Centre for Chronic Disease Prevention and Control, Health Canada, using data adapted from the National Longitudinal 

Survey of Children and Youth (cross-sectional component), Statistics Canada, 1994/1995, 1996/1997, 1998/1999.

KE Y OBSERVATIONS :

■ Since 1994, asthma prevalence has increased among children (except for boys aged four to seven 

years) (CHART 3-12).

■ Boys of all ages have a higher prevalence of asthma than girls (CHART 3-12).

■ Currently, approximately 20 percent of boys aged eight to 11 have been diagnosed with asthma, 

the highest prevalence group among children (CHART 3-12). 
60

20

10

0

30

50 

70

1998 1999 2000 2001 2002

40 

1 to 4 years

< 1 year

5 to 14 years

Years

Number of Cases/10 000

Children's Health and the Environment in North America 33

3.3.2 Mexico 

Mexico presents data on childhood asthma. Furthermore, Mexico also includes national 

surveillance data for acute respiratory infections (ARI), a condition that is also associated 

with exposure to air pollution. 

CHART 3-13 depicts the incidence of asthma for the age groups of under one, one to four and 

five to 14 years. Incidence rates were calculated as number of new cases per 10,000 population 

and were provided for the years 1998 to 2002. 

CHART 3-14 depicts incidence of acute respiratory infections. This chart provides ARI rates 

for 1998 to 2002, based on the number of new cases per 100,000 population.

CHART 3-13: Incidence of Asthma among Children, by Age Group, in Mexico, 1998–2002

Source: Boletín de Información Epidemiológica 1998–2002 (Epidemiological Information Bulletin 1998–2002). Dirección 

General de Epidemiología. Secretaría de Salud (Secretariat of Health) <http://www.dgepi.salud.gob.mx/suave/index.htm>. 
2000

4000

6000

8000

10000

12000

14000

16000

18000

20000

0

1998 1999 2000 2001 2002

<1 year

5 to 14 years

1 to 4 years

Years

Number of Cases/100 000

34

CHART 3-14: Incidence of Acute Respiratory Infections (ARI) among Children, by Age Group, Mexico, 

1998–2002

Source: Boletín de Información Epidemiológica 1998–2002 (Epidemiological Information Bulletin 1998–2002). Dirección

General de Epidemiología. Secretaría de Salud (Secretariat of Health) <http://www.dgepi.salud.gob.mx/suave/index.htm>. 

KE Y OBSERVATIONS :

■ The highest rates of asthma appear consistently for the group aged one to four years, with a trend 

of increase, from 54 new cases per 10,000 children in 1998 to 63 new cases per 10,000 children in 

2002 (CHART 3-13).

■ The asthma incidence rate in children less than one year old showed a decline since 1999, and 

currently remains at 33 new cases per 10,000 population/children (CHART 3-13). As opposed to 

a true change in disease incidence, this decline was directly attributable to a change in the 

immediate notice form (Epi-1 2000) for medical unit reporting. This occurred due to the difficulty 

in diagnosing asthma in this age group.

■ In the five to 14 age group, the rates have grown slightly, from 28 to 32 new cases per 10,000 

children over the sampling period (CHART 3-13).

■ For acute respiratory infections (ARI), the most affected population is children below one year of 

age, with annual new cases averaging 16,000 per 100,000 children. Only in 1998 were fewer new 

cases reported during this period. Children aged one to four years showed a slight increase in new 

cases, from 7500 in 1998 to 8100 per 100,000 children in 2002. The lowest rates are observed for 

children aged five to 14 years (CHART 3-14).
0

Percent (%)

Years

1980 1982 1984 1986 1988 1990 1992 1994 1996 1997 1999 2001 2003

2

4

6

8

10

12

14

Had asthma in the last 12 months

Ever had asthma

Currently have asthma

Asthma attack in the last 12 months

Children's Health and the Environment in North America 35

3.3.3 United States 

The United States reports on the current indicator by providing national asthma data 

obtained through the National Health Interview Survey. 

CHART 3-15 shows the percentage of children with asthma, taken from annual survey results 

since 1980. This indicator covers the period 1980 to 2003.

CHART 3-15: Percentage of Children with Asthma, in the United States, 1980–2003

Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Health Interview Survey.

Note: The survey questions for asthma changed in 1997; data before 1997 cannot be directly compared to data in 1997 or later.

KE Y OBSERVATIONS :

■ In 2003, about 13 percent of children had been diagnosed with asthma at some time in their 

lives, though some of those children may no longer have asthma (CHART 3-15).

■ About 9 percent of children were reported to currently have asthma. These include children 

with active asthma symptoms and those whose asthma is well-controlled (CHART 3-15).

■ Between 1980 and 1995, the percentage of children with asthma (as measured by “children 

with asthma in past twelve months”) doubled, from 3.6 percent in 1980 to 7.5 percent in 1995. 

A decrease in the percentage of children occurred between 1995 and 1996, but it is difficult to 

interpret single-year changes (CHART 3-15).
36

■ Prior to 1997, the percentage of children with asthma was measured by asking parents if a 

child in their family had asthma during the previous 12 months. In 1997–2000, a parent was 

asked if his or her child had ever been diagnosed with asthma by a health professional. If the 

parent answered yes, then he or she was asked if the child had an asthma attack or episode 

in the last 12 months. The percentage of children with an asthma attack in the last 12 months 

measures the population with incomplete control of asthma. For 1997–2000, available data 

do not distinguish between those children who may no longer have active asthma and those 

whose asthma is well controlled. In 2001, a question was added to ask the parents if their 

child currently had asthma (CHART 3-15).

■ Approximately 6 percent of all children had one or more asthma attacks in the previous 12 months. 

These children have ongoing asthma symptoms that could put them at risk for poorer outcomes, including hospitalizations and death. About two-thirds of children who currently have 

asthma have on-going asthma symptoms (CHART 3-15).
Children's Health and the Environment in North America 37

3.3.4 Opportunities for Strengthening Indicators of Asthma and Respiratory Disease in North America

The prevalence of asthma in all three countries appears to be stable or increasing. However, 

the specific rate of increase may be confounded by a number of issues related to the definition 

of the illness and the methods of surveillance. The following suggestions have been made 

to increase the reliability of data and the comparability of future indicators on asthma 

prevalence and on the incidence of pneumonia and other forms of acute lower respiratory 

infection: 

• The data periods reported by each country currently differ. Some standardization of reporting periods 

and defi nitions would improve future comparability. To achieve a better view of trends, future reports 

of asthma prevalence could include historical data or narrative that is several decades in duration (e.g., 

20–30 years, where possible).

• Changes to defi nitions (e.g., ever diagnosed versus active illness) and data collection methods (e.g., 

Canada and the United States use surveys, while Mexico data are based on physician reporting) have 

increased the challenges associated with comparing within and between countries. Where possible, the 

clinical and survey defi nitions of asthma used by the three countries should be made uniform or at least 

be described in detail so that variations can be addressed in future reports. Common diagnostic criteria 

for young children (i.e., aged zero to fi ve) could assist with more consistent diagnosis in an age group 

where differential diagnosis is diffi cult. Through the CEC and other fora, the three countries have begun 

to work together towards more comparable asthma surveillance systems. 

• Further efforts of the international community (International Study of Asthma and Allergies in Childhood—

ISAAC) to develop globally applicable asthma diagnostics could enhance future comparability of North 

American indicator efforts with other international asthma initiatives.

• Future research initiatives that collect information on environmental factors that may contribute to 

the development of asthma and to the triggering and severity of asthma attacks could provide further 

opportunities for indicator development and analysis.

• Acute lower respiratory infections are most closely correlated to indoor smoke from biomass burning. 

It would be useful to have acute lower respiratory infections (rather than all respiratory infections) as 

a separate indicator. Furthermore, this indicator could be broken down by state to synchronize with the 

biomass fuel use indicator.
38

Reducing the presence of contaminants in different media with which children 

 may come into contact is an important step in protecting children’s health. 
4.0 Lead and Other Chemicals, 

including Pesticides

Children can be exposed to toxic substances from multiple sources or exposure pathways, 

including air (indoor and outdoor), soil, food, water, building materials, and consumer 

products. Exposure may result from local sources such as lead-based paint used in 

homes, local applications of pesticides, nearby industrial emissions, consumption of fish 

contaminated with methylmercury, or the use of chemicals in the home. By contrast, some 

environmental contaminants may originate from activities thousands of miles away, having 

been transported long distances by wind or water and/or bioaccumulated in the food chains 

on which humans depend.

The degree of risk varies with the toxicity of the contaminant, the magnitude and duration 

of the exposure, and the susceptibility of the individual. In some cases the health effects in 

children are reasonably well understood, as in the cases of lead and mercury, whereas knowledge 

of health effects associated with exposure to other toxic substances is still evolving. 

Determining the body burden of contaminants such as lead in children and the presence of 

contaminants in different media with which children may come into contact are important 

steps in protecting children’s health. This chapter provides several indicators, as well as case 

studies, that present information on the presence of toxic substances in children (i.e., body 

burden) and in their environments.

SECTION 4.1 provides a measure of body burden for lead in children (US biomonitoring data—blood 

lead levels) and presents several case studies in Canada, Mexico and the United States investigating 

blood lead levels in children and adults. The relationship between the elimination of lead from 

gasoline and other sources and the decline in children’s blood levels is also reviewed.

SECTION 4.2 presents data on lead in homes. Canada provides data on the percentage of children 

living in homes with a potential source of lead. The United States presents data on housing units 

with lead-based paint, lead-contaminated dust, and lead-contaminated soil. These are proxy 

exposure indicators that provide a measure of potential exposure to lead in the home.

SECTION 4.3 provides estimated releases of lead emitted from industrial facilities in Canada and 

the United States. This is an action indicator that presents data and trends for releases of lead to 

different media from manufacturing sectors.

SECTION 4.4 provides estimated releases of selected chemicals emitted from industrial facilities in 

Canada and the United States. This is an action indicator that presents data and trends for releases 

of selected chemicals to different media and from various sectors. 

SECTION 4.5 presents various indicators on exposure to pesticides. Mexico provides data on pesticide 

poisonings in children and adults, while the United States and Canada present detectable levels of 

organophosphate pesticide residues on fruits and vegetables as a proxy exposure indicator.

CHILDREN’S HEALTH AND THE ENVIRONMENT IN NORTH AMERICA

Commission for Environmental Cooperation 39
40

4.1 BLOOD LEAD LEVELS

I

_____________________________________________________________________________________________________I

Purpose: This indicator provides information on children’s exposure to lead. 

Current indicators: Blood lead levels in children.

I

_____________________________________________________________________________________________________I

Lead is an environmental contaminant of major concern to children’s health. Health effects associated 

with exposure to lead include, but are not limited to, cognitive defi cits, developmental delays, 

hypertension, impaired hearing acuity, impaired hemoglobin synthesis, and male reproductive 

impairment. Importantly, many of lead’s health effects may occur without overt signs of toxicity. 

Exposure to lead early in childhood has been shown to contribute to learning disabilities, such as 

reduced intelligence and cognitive defi cits. Other studies have found relationships between exposures 

to lead and attention problems, hyperactivity, and impulsivity, which are the common behavioral 

problems of attention defi cit hyperactivity disorder (ADHD) (US EPA 2003). In the United States 

and Mexico a blood lead level of 10 micrograms per deciliter (μg/dL) or greater is considered elevated 

(Meyers et al. 2003; Cofepris date unknown). It is now recognized that there is no known “safe” blood 

lead level for children and no level of exposure that is not without some risk of adverse health effects, 

though the risks are less at lower concentrations (US EPA 1997).

Children and the developing fetus are more susceptible to the negative effects of lead exposure than 

adults. Studies suggest that children are most susceptible to the neurological effects of lead in the fi rst 

three years of life because of the brain development that takes place during this time (US EPA 2003). 

Children are more effi cient than adults at absorbing and retaining some substances such as lead. It 

has been estimated that children and pregnant women can absorb up to 50 percent of the dietary 

source of lead, whereas adults absorb 10 percent to 15 percent) (see Canada’s country report). This 

means that more lead is available to damage developing organs like the brain (Wigle 2003). Children 

under the age of six are more likely to be exposed to lead that is present in dust and soils because of 

hand-to-mouth behavior and a tendency to mouth or eat objects in their environments. 
Preventive

actions

Remedial

actions

ACTIONS

Social conditions 

Economic conditions

Demographic conditions

EXPOSURE HEALTH OUTCOMES 

IN CHILDREN

AGENT

Lead 

Sources

Mining operations

Lead smelters

Mine tailings

Soil

Lead paint in older homes 

Consumer products 

(leaded pottery)

Lead pipes and solder

causes or is associated with

Anemia and other effects 

on blood and bones

Learning disabilities

Behavioral disorder

Lower IQ

Death

CONTEXTS

attributable to or

is associated with

Children's Health and the Environment in North America 41

FIGURE 5: MEME Framework for Issues Covered in the Sections on Blood Lead Levels, Lead in the 

Home, and Industrial Releases of Lead

Source: Adapted from Briggs 2003. 

As the MEME model in FIGURE 5 illustrates, numerous sources of lead continue to pose risk to 

children. There have been considerable improvements in the reduction of lead exposure with the 

elimination of lead from gasoline. Some of the decline in later years was also due to various other 

management efforts, such as reductions in the number of homes with lead-based paint, reducing 

lead levels in drinking water, reducing the use of lead in food and beverage containers and/or ceramic 

ware, and in addressing the lead content in products such as toys, miniblinds, and playground 

equipment. Several case studies provided by Canada, Mexico and the United States illustrate the 

strong correlation between the removal of lead from gasoline and decreases in ambient lead levels. 

In several of the case studies, reductions in children’s blood lead levels have been observed. 

The US national biomonitoring program for blood lead suggests that despite overall reductions 

of lead, there are situations where children may continue to be exposed. The US data suggest 

that children in low-income households are at the greatest risk of being exposed to lead from 

their environments.

4.1.1 Canada 

There is no recent nationally representative survey of blood lead levels in children in Canada; 

thus Canada has not reported on the current indicator. However, there have been some 

samplings of blood lead levels conducted in certain regions of the country. The following 

case study in Ontario reveals that, as lead in gasoline for on-road vehicles was eliminated, 

children’s blood lead levels also declined. While the blood lead level data is not sufficient to 

present information on a national indicator, it does provide a regional perspective.

CHART 4-1 shows the decline in the geometric mean of blood lead concentrations related to a decline 

in the consumption of leaded gasoline. This chart illustrates a timeline from 1983 to 1992.
0

10

12

14

16

18

Blood Lead Level (μg/dL)

Years

2

4

6

8

1982 1983 1984 1985 1986 1987 1988 1989 1990 1991

250

500

750

1000

1250

1500

1750

2000

2250

2500

2750

3000

0

1992

Toronto Eastern Health Unit

Toronto Western Health Unit

City of Toronto

Other Ontario regions

Total Pb (Mg/year)

Total Lead Level (million g/year)

42

I

______________________________________________________________________________________________________I 

CASE STUDY 

Blood Lead Levels in Children in Ontario, Canada—A Local Case Study

Since 1980, health departments in Ontario have conducted several blood lead screening surveys in children 

living in several cities and regions of the province. These surveys were not conducted on a random sample of 

children, as they were undertaken in response to a concern about an exposure to lead. The collection procedure 

of capillary fi nger-prick blood samples and the method for blood lead analysis were used identically in all the 

blood lead analyses across the province.

CHART 4-1: Decline in the Geometric Mean of the Blood Lead Concentrations related to a Decline in 

Consumption of Leaded Gasoline, in Ontario, Canada, 1983–1992

Source: Adapted from Wang, S.T., S. Pizzolato, H.P. Demshar, and L. Smith. 1997. Decline in blood lead in Ontario 

children correlated to decreasing consumption of leaded gasoline, 1983–92. Clinical Chemistry 43: 1251–1252. 

<http://www.clinchem.org/cgi/content/full/43/7/1251>.

KE Y OBSERVATIONS :

■ The fi ndings from this analysis indicate that as lead levels in gasoline declined, so did children’s 

blood lead levels in Ontario (CHART 4-1).

I

______________________________________________________________________________________________________I

4.1.2 Mexico 

A nationally representative sample of blood lead levels in children is not available in Mexico; 

therefore, Mexico is not able to present data on the current indicator. Instead, Mexico presents 

several independent studies that have measured blood lead levels in children exposed to lead 

occupationally and non-occupationally. Mexico also presents a case study that reveals how lead 

emissions have decreased with the reduction of leaded gasoline. A fi nal case study is also presented 

on lead exposure in the city of Torreón, Coahuila, a city that contains Latin America’s largest 

mining-metallurgical company.

In Mexico, the main source of lead exposure for children is from the use of lead oxide in low-temperature 

ceramic glazes (see Mexico’s country report). Children can be exposed to leaded glaze by helping with 

the production of pottery, by being exposed to lead contamination in the home, and through the 

contamination of food prepared and/or stored in pottery with lead-based glazes. Lead is also mined 

and processed in Mexico. Lead emissions from this sector create another source of lead exposure in 

nearby communities through emissions to the air, water and soil and through “take-home exposures” 

from family members who work in the mining and smelting sectors (see Mexico’s country report). 
Children's Health and the Environment in North America 43

CHART 4-2 presents blood lead levels of children in rural and urban populations. It illustrates the results 

of several studies conducted in Mexico that have measured blood lead levels in children exposed to lead 

occupationally and non-occupationally.

CHART 4-3 shows the atmospheric monitoring of lead and principal activities to reduce lead emissions in 

the Mexico City Metropolitan Zone. This chart illustrates a timeline from 1990 to 2000.

CHART 4-4 depicts the local air quality data from metallurgical activities in the city of Torreón in North 

Mexico. This chart illustrates a timeline from 1999 to 2003.

CHART 4-5 shows the lead content in local soil samples taken in the area around the mining-metallurgical 

company Met-Mex Peñoles. Met-Mex Peñoles is a major producer of lead, silver and gold.

CHART 4-6 depicts the blood lead levels in children, after fi ve years of participation in the Metals 

Program. This program was established to coordinate health-related actions (detection, treatment and 

rehabilitation) for the population with environmental lead exposure.

CHART 4-2: Blood Lead Levels of Children in Rural and Urban Populations, in Mexico

 Exposure Blood Lead Levels

 to Ceramic Glazes μg/dL

__________________________________________________________________________________________________________ _______

 Author and Year Place Community Population General Occ. N Mean SD 

 Public _________________________________________________________________________________________________________________

 Azcona-Cruz, M., et al., 2000 Oaxaca Rural Children Yes Yes 220 10.50** ±7.0

 (9 years of age)

 _________________________________________________________________________________________________________________

 Olaiz, F.G., et al., 1997 Michoacán Rural Children No Yes 181 26.20** -

 (less than 16 years old)

 _________________________________________________________________________________________________________________

 Batres, L., et al., 1994 San Luis Potosí Rural Children Yes No 37 26.50* ±1.3

 (3 to 6 years old)

 _________________________________________________________________________________________________________________

 Carrizales et al., 2005 San Luis Potosí Rural Children Yes No 30 14,80* -

 (3 to 6 years old) 

 _________________________________________________________________________________________________________________

 Romieu, I., et al., 1992 Mexico City Urban Children Yes No 40 12,60* ±4.6

 (6 to 8 years old) 

 (Living near Yes No 15 15,10* ±3.9

vehicular traffi c)

 _________________________________________________________________________________________________________________

 Molina, B.G., et al., 1990 Tonalá, Jalisco Rural Children No Yes 9 81.90*

 (0 to 9 years old) 

_________________________________________________________________________________________________________________

 Díaz-Barriga, F., et al. 1997 Ciudad Juárez, Semi-urban Children Yes No 44 9.70** -

 Chihuahua (5 to 13 years old)

Sources: Azcona-Cruz, M.I. et al. 2000; Olaiz, F.G. et al. 1997; Batres, L. et al. 1994; Carrizales et al. 2005; Romieu, I. et al. 1992;

Molina-Ballesteros, G. et al. 1980; Díaz-Barriga, F. et al. 1997. 

Note: * Arithmetic mean. ** Geometric mean. N = Sample size; Occ. = Occupational; SD=Standard Deviation. Please see 

the Glossary for definitions of geometric mean and arithmetic mean.

KE Y OBSERVATIONS :

■ Studies indicate that some populations of Mexican children have very elevated levels of 

blood lead (CHART 4-2), in some cases more than five times the action level of 10 μg/dL 

(Cofepris, date unknown).
0.0

1.5

2.5 

Lead Ambient Air Concentration (g/m3

) 2.0 

3.0 

0.5

1.0

Prior to 1986, the maximum tetraethyl lead (TEL) content in nova plus gasoline was 3.5ml/gal (0.92 ml/L) 

and it was reduced to 0.5-1.0 ml/gal (0.13-0.26 ml/L).

In June 1991, the specifi ed range for TEL content was reduced and a new content range of 0.3-

0.54 ml/gal (0.079-0.14 ml/L) was established for both gasolines.

In October 1992, a new TEL content specifi cation was established for nova and 

nova plus gasolines with a range of 0.2-0.3 ml/gal (0.03-0.05 ml/L).

In 1994, the maximum TEL content in gasoline during winter was 

reduced from 0.2-0.3 ml/gal to 0.1-0.2 ml/gal (0.03-0.05 ml/L).

Lead content of nova plus magna gasoline was 2.64 mg/L.

Distribution of prenium gasoline with a fi xed 

lead concentration of 2.64 mg/L began in 1996.

End of distribution in ZMVM of 

nova gasoline with an average TEL 

concentration of 0.3 ml/gal (0.08 

ml/L).

Lowest annual average lead concen- owest annual average lead concentration for gasolines distributed in the ration for gasolines distributed in the 

ZMVM is 0.001 g/gal (0.26 mg/L). MVM is 0.001 g/gal (0.26 mg/L).

Standard: 1.5 μg/m3

Years

Air monitoring stations:

1991 1993 1992 1994 1995 1996 1997 1998 1999 2000

Tlalnepantla Xalostoc Merced Pedregal Cerro de la estrella

44

I

______________________________________________________________________________________________________I 

CASE STUDY 

The Integrated Program for Air Pollution Control in the Valley of Mexico City Metropolitan 

Zone, Mexico

Ambient lead levels and lead exposures were dramatically reduced through a series of initiatives to reduce 

lead in gasoline and consumer products in Mexico. These actions, which were supported with regulations and 

consumer education, have produced substantial reduction in childhood exposure to lead.

In October 1990, it was agreed to establish the Integrated Program for Air Pollution Control in the Valley of 

Mexico City Metropolitan Zone (Programa Integral Contra la Contaminación Atmosférica en el Valle de México—

PICCA). Lead levels in Mexican gasoline were reduced by 88 percent (average of 0.2 g/L) by 1992 (Michaelowa 

1997). The transition to unleaded gasoline was assisted with a reduction of the price of lead-free gasoline to 

encourage its use. Over the course of the program a series of further reductions in the allowable levels of lead 

in gasoline were implemented across Mexico. These reductions resulted in an average annual and minimum 

recorded lead concentration in gasoline of 0.001 g/gal in the Valley of Mexico City Metropolitan Zone.

CHART 4-3: Atmospheric Monitoring of Lead, and Principal Activities to Reduce Lead Emissions, in 

the Valley of Mexico City Metropolitan Zone (ZMVM), 1990–2000

Source: Programa para Mejorar la Calidad del Aire de la Zona Metropolitana del Valle de México 2002–2010 (Program to 

Improve the Quality of Air in the Valley of Mexico City Metropolitan Zone—Proaire). <http://www.sma.df.gob.mx/

sma/download/archivos/proaire_2002-2010.pdf>.

Note: Tetraethyl lead (TEL) is a liquid. Nova, nova plus, and nova plus magna are grades of gasoline, ranked according 

to increasing octane levels.

KE Y OBSERVATIONS :

■ Actions to eliminate lead from gasoline have reduced airborne emissions of lead in the 

Valley of Mexico City Metropolitan Zone (CHART 4-3).

I

______________________________________________________________________________________________________I 
Children's Health and the Environment in North America 45

I

______________________________________________________________________________________________________I 

CASE STUDY

Levels of Lead in Blood in a Child Population in Northern Mexico due to Metallurgical 

Activities—A Local Case Study 

The city of Torreón, Coahuila, located in northern Mexico, has a population of approximately 530,000 inhabitants. Latin America’s largest, and the world’s fourth-largest mining-metallurgical company, Met-Mex 

Peñoles, is located in this town, producing lead, silver and gold. The presence of this industry has led to the 

chronic environmental exposure to lead in the non-occupational population, particularly in children.

The results of formal studies performed since 1997 have shown a high concentration of lead in the soil and air, 

thereby documenting prolonged, historic pollution. One of these studies (García et al. 2001) corroborated the 

presence of lead in the blood of school children in a relationship directly proportional to their proximity to the 

metallurgical plant. This problem gave rise to an environmental emergency situation, as it represented both 

public health and social problems.

To handle this situation, the state Secretariat of Health (Secretaría de Salud), the Offi ce of the Federal Attorney 

for Environmental Protection (Procuraduría Federal de Protección Ambiental—Profepa) and the company Peñoles 

implemented a series of actions including, among others, emissions control and reductions and improved 

smelting processes in the facility, the oversight of the environmental authority by Profepa, and the oversight by 

the Secretaría de Salud of the medical care provided by the state secretariat of health for the environmentally 

exposed population. 

A trust was set up with funding (60 million pesos) provided by the company in 1999, creating a Metals Program 

(Programa de Metales) to coordinate health-related actions (detection, treatment and rehabilitation) for the 

population with environmental lead exposure. To remediate the environment, teams with high-effi ciency 

vacuums cleaned the streets, building roofs and house interiors within a radius of four kilometers of the facility 

to reduce the accumulated concentration of lead on surfaces and in the soil. Contaminated soil was removed, 

thorough cleaning of public and private living spaces was aggressively conducted, and streets and patios near 

the facility were paved.

On 31 May 2004, fi ve years after its creation, the trust that originated the Metals Program ended, having 

accomplished its immediate goals of gradually reducing the risks and health effects of lead to the population. 

However, the success attained required vigilance and continuing efforts to assure the maintenance of good 

environmental quality and the health of the population, so the fi rm developed a new program for the protection 

and treatment of the population exposed to lead and other heavy metals in the ambient environment in Torreón, 

and funds it annually in the amount of 18 million pesos. 

The following graphs show the results of the intervention of the health and environmental authorities to reduce 

the concentrations of lead in blood, as well as the decreased concentrations of lead in soil and air.
0

5

6

7

8

μg/m3

Dates

1

2

3 

4

4/13/19997/13/1999

10/13/1999

1/13/2000

4/13/20007/13/2000

10/13/2000

1/13/2001

4/13/20017/13/2001

10/13/2001

1/13/2002

4/13/20027/13/2002

10/13/2002

4/13/20037/13/2003

1/13/2004

10/13/2003

1/13/2003

Limit according to

standard 

NOM-020-SSA1-1993

60

20

10

0

30

50

Aug

99

40

Oct

99 Dec99 Feb00 Apr00

Jun

00 Aug00 Oct00 Dec00 Feb01 Apr01

Jun

01 Aug01 Oct01 Dec01 Feb02 Apr02

Jun

02 Aug02 Oct02 Dec02 Feb03 Apr03

Jun

03

Limit (34 mg/m2)

Dates

mg/m2

46

CHART 4-4: Local Air Quality Data from Metallurgical Activities, in Torreón, Mexico, 1999–2003

Source: Programa de Metales, Secretaría de Salud del Estado de Coahuila, 1999–2003.

Note: Red line indicates level of the air quality standard for lead (NOM-026-SSA1-1993) =1.5 μg/m3

.

CHART 4-5: Lead Content in Local Soil Samples Taken around Met-Mex Peñoles, in Mexico, 1999–2003

Source: Programa de Metales, Secretaría de Salud del Estado de Coahuila, 1999–2003.
30

10

5

0

15

25 

μg/dL

Years

1998

20 

1999 2000 2001 2002 2003 2004

Children's Health and the Environment in North America 47

CHART 4-6: Annual Average Blood Lead Levels in Children 15 and Under Who Participated in the 

Metals Program in Torreón, Mexico, 1998–2004

Source: Programa de Metales, Secretaría de Salud del Estado de Coahuila, 1999–2003.

KE Y OBSERVATIONS :

■ The average concentration of lead in the air around the mine changed from nearly 8 

μg/m3

 in April 1999 to less than 1 μg/m3 in December 2003 (the limit under Mexican 

Official Standard [Norma Oficial Mexicana] NOM-026-SSA1-1993 is 1.5 μg/m3

). Starting 

in August 1999, lead concentrations remained below the official standard (CHART 4-4).

■ The actions dictated by the environmental authorities enabled a decline in lead levels in 

both air and soil. Lead concentrations found in soil samples taken in the area around the 

site of the company Peñoles dropped from 50 mg/m2

 in 1999 to 9 mg/m2 in 2003. Since 

2000, lead concentrations have remained below the standard’s limit of 34 mg/m2

 (CHART 4-5).

■ This chart demonstrates that 70 percent of the child population that has been attended to since 

the start of the Metals Program now has blood lead levels below 10μg/dL (CHART 4-6).

■ Although the population’s blood lead levels have declined, the risks of exposure persist. 

Children’s exposure to lead continues to be a public health problem (CHART 4-6).

I

_____________________________________________________________________________________________________I
30

10

5

0

15

25 

Blood Lead Concentrations (μg/dL)

Years

1976–1980

20 

1988–1991 1992–1994 1999–2000 2001–2002

90th percentile

50th percentile

48

4.1.3 United States

The United States provides data from its national biomonitoring program, which include 

the measurement of blood lead levels in children of ages one to five years. The data are from 

the National Health and Nutrition Examination Survey (NHANES), a large survey sample 

of the general population of the United States. These data are intended to represent average 

population exposures and would not represent higher blood lead concentrations that could 

occur from exposures to particular sources. The United States also presents a case study on 

how removing lead from gasoline and other lead reduction policies have led to reduced blood 

lead levels in children.

CHART 4-7 shows the concentrations of lead in the blood of children, aged five and under. This chart 

illustrates the time trend of blood lead levels during 1976–2002.

CHART 4-8 shows the distribution of concentrations of lead in blood of children, aged one to five, 

for the period 1999–2000.

CHART 4-9 shows median concentrations of lead in blood of children, aged one to five, by race/

ethnicity and family income, 1999–2000.

CHART 4-10 depicts the impact of lead poisoning prevention policy on reducing children’s blood 

lead levels, for the period 1971–2002.

CHART 4-7: Concentration of Lead in the Blood of Children Five and Under, in the United States, 1976–2002

Source: United States Environmental Protection Agency 2003. America’s Children and the Environment: Measures of 

Contaminants, Body Burdens, and Illnesses. <www.epa.gov/envirohealth/children>.

Data: Centers for Disease Control and Prevention, National Center for Health Statistics, National Health and Nutrition 

Examination Survey.
All Races/Ethnicities

Median Concentrations of Lead in Blood (μg/dL)

0 0.5 1 1.5 2 2.5 3

White Non-Hispanic

Black Non-Hispanic

Hispanic

3.5 4 

> 200% of Poverty Level

100-200% of Poverty Level

< Poverty Level

All Incomes

> 200% of Poverty Level

100-200% of Poverty Level

< Poverty Level

All Incomes

> 200% of Poverty Level

100-200% of Poverty Level

< Poverty Level

All Incomes

> 200% of Poverty Level

100-200% of Poverty Level

< Poverty Level

All Incomes

Children's Health and the Environment in North America 49

CHART 4-8: Distribution of Concentrations of Lead in Blood of Children, Aged One to Five, in the 

United States, 1999–2000

 

Source: US EPA 2003. America’s Children and the Environment: Measures of Contaminants, Body Burdens, and Illnesses. 

<www.epa.gov/envirohealth/children>.

CHART 4-9: Median Concentrations of Lead in Blood of Children, Aged One to Five, by Race/Ethnicity 

and Family Income, in the United States, 1999–2000

Source: US EPA 2003. America’s Children and the Environment: Measures of Contaminants, Body Burdens, and Illnesses. 

<www.epa.gov/envirohealth/children>.

KE Y OBSERVATIONS :

■ The median concentration of lead in the blood of children fi ve years old and under dropped from 

15 micrograms per deciliter (μg/dL) during 1976–80 to 1.7 μg/dL during 2001–2002, a decline of 

about 85 percent (CHART 4-7).

■ The concentration of lead in blood at the 90th percentile in children fi ve years old and under 

dropped from 25 μg/dL during 1976–80 to 4.2 μg/dL during 2001–2002. This means that 10 

percent of children had blood lead levels above 4.2 μg/dL and 90 percent had blood lead levels 

below 4.2 μg/dL (CHART 4-7).

0

10

15

25

20 

35

30

Percentage (%) of Children

Blood Lead Concentrations (μg/dL)

<1

5

1-2 2-3 3-4 4-5 5-6 6-7 >7
0

50

100

150

200

250

0

Blood Lead Levels (μg/dL)

Years

1970

10

12

14

16

18

2

4

6

8

20

1974 1978 1982 1986 1990 1994 1998 2002

Lead in Gasoline (KTons)

Ban on lead

solder in food

cans (1995)

Lead in plumbing

banned (1986)

Housing unit

with leadbased

paint hazards

reduced by

40% since 

1990

Lead Title X

(1992)

Lead Contamination

Control Act (1988)

Virtual elimination of

lead in gasoline

Lead Gasoline

Phase-out

(1973)

Lead-based 

Point

Poisoning

Prevention Act

(1971)

Residential 

Lead

Paint Ban

(1978)

Lead in Gasoline

Blood Lead Levels

50

■ Based on the 1999–2000 survey, 2.2 percent, or 434,000, of US children aged one to fi ve years had 

a blood lead level greater than or equal to 10 μg/dL. In the 1976–80 survey (data not shown), 88.2 

percent of children had a blood lead level greater than or equal to 10 μg/dL (CHART 4-8).

■ In the 1976–1980 survey, 88.2 percent of US children or approximately 13,500,000 children aged 

one to fi ve years had a blood lead level above or equal to 10 μg/dL (data not shown). The most 

current estimate of the number of children in the US with a blood level greater than or equal to 10 

μg/dL is 310,000 for the period 1999–2002 (data not shown).

■ In the 1999–2000 the median blood lead level in children aged one to fi ve was 2.2 μg/dL. The median 

blood lead level for children living in families with incomes below the poverty level was 2.8 μg/dL 

and for children living in families with incomes above the poverty level it was 1.9 μg/dL (CHART 4-9).

■ In 1999–2000, White non-Hispanic children aged one to fi ve had a median blood lead level of 

about 2 μg/dL, unchanged from the level in 1992–94. In 1992–94, Black non-Hispanic children 

ages one to fi ve had a median blood lead level of 3.9 μg/dL (data not shown) and, in 1999–2000, 

they had a median blood lead level of 2.8 μg/dL (CHART 4-9).

I

_____________________________________________________________________________________________________I

CASE STUDY

Blood Lead Levels in Response to Restrictions on Lead in Gasoline, in the United States, 1971–2003 

The decline in blood lead levels is due largely to the phasing out of lead in gasoline between 1973 and 1995 (US 

EPA 2000) and, to some extent, to the reduction in the number of homes with lead-based paint, from 64 million 

in 1990 to 38 million in 2000 (Jacobs et al. 2002). Some decline also was a result of EPA regulations reducing 

lead levels in drinking water, as well as legislation banning lead from paint and restricting the content of lead in 

solder, faucets, pipes, and plumbing. Lead also has been eliminated or reduced in food and beverage containers 

and ceramic ware, and in products such as toys, mini-blinds, and playground equipment. As a result of these 

past and ongoing efforts, children’s blood-lead levels have declined over 80 percent since the mid-1970s.

CHART 4-10: Impact of Lead Poisoning Prevention Policy on Reducing Children’s Blood Lead Levels, 

in the United States, 1971–2002

Source: Blood lead levels: National Health and Nutrition Examination Survey, National Center for Health Statistics, 

Centers for Disease Control and Prevention. Lead in gasoline: 1967–75: Unpublished data from industry, provided by US 

EPA. 1976–91: Unpublished data from refiner reports to US EPA.

KE Y OBSERVATIONS :

■ The median (50th percentile) concentration of lead in the blood of children five years old 

and under dropped from 15 micrograms per deciliter (μg/dL) during 1976–80 to 1.7μg/dL 

during 2001–2002, a decline of about 85 percent (CHART 4-10).

I

_____________________________________________________________________________________________________I
Children's Health and the Environment in North America 51

4.1.4 Opportunities for Strengthening Indicators of Children’s Exposure to Lead in North America 

The measures presented in this section highlight the correlation between the reduction of lead 

from gasoline, local industrial emissions and other sources with the corresponding reductions 

in blood lead levels in children. The indicators also present the utility of blood lead levels 

as indicators of child exposure to lead and for monitoring the impact of policy initiatives. 

Furthermore, detailed results from a national biomonitoring program, such as those in the 

United States, can be used to direct future policy efforts at populations that remain at risk from 

exposure to lead (see SECTION 4.1.3 and CHARTS 4-7 and 4-8). The following opportunities address 

biomonitoring and other means of improving future indicators of lead exposure. 

• National biomonitoring programs for lead in Canada and in Mexico would provide a direct measure of lead 

exposure in children. In addition, detailed information on blood lead levels by region, and by ethnic and 

socioeconomic groups, would identify sub-populations most at risk of lead exposure in those countries. 

This would also improve the comparability of this indicator between countries in future reports. 

• Additional efforts, whether through national surveillance, targeted screening or localized surveys, to ensure 

a reasonable sampling of populations at greater risk of lead exposure could help focus government actions 

on improving public policy and programs so that better health benefi ts could be delivered. Collaboration 

between local and national authorities in study design, sampling and collection methods may ensure local 

and national information needs are met.

• Continuation of study efforts in the United States would be valuable, with publication of reports at least 

every two years on the continuing monitoring of blood lead levels in children.

• The established blood lead levels for the management of lead in children vary across governments and 

agencies. Currently, blood lead levels at which concerns are generated [10μg/dL for the United States 

(Centers for Disease Control and Prevention 2002), Mexico (Cofepris date unknown) and WHO (Gordon 

et al. 2004)] do not necessarily refl ect the fact that there is no demonstrated safe concentration of blood 

lead. Future reporting efforts should refl ect on the reference levels in use while ensuring that the reader 

understands that there is no safe level of blood lead.

4.2 LEAD IN THE HOME

I

_____________________________________________________________________________________________________I

Purpose: This indicator provides information on children’s potential exposures to sources of lead in the home.

Current indicators: Percentage of children living in homes with a potential source of lead.

I

_____________________________________________________________________________________________________I

Indoor environments, particularly in older homes where lead paint or plumbing was used, remain 

important sources of lead exposure for children. As illustrated by the MEME model for lead (see 

FIGURE 5, in SECTION 4.1), there can be numerous sources of exposure to lead indoors in North 

America, including contaminated dust, paint and lead-based pottery glazes. Other consumer 

products may also contain lead. Cases have been found of inexpensive jewelry, candy wrappers 

and certain toys containing lead. In Mexico, home-based pottery operations can be a signifi cant 

source of lead contamination when glazes containing lead oxides are used (see Mexico’s country 

report). In Canada and the United States, lead paint and contaminated dust are the sources 

of lead of greatest concern indoors (US EPA 2003). Soil is a primary concern outdoors, where 

contamination may result from exterior paint, industrial emissions or historical deposits from 

vehicle emissions (prior to the elimination of lead from fuel) (US EPA 2003).
30

10

5

0

15

25 

Percent (%)

Age Groups

0-4 years

20 

5-9 years 10-14 years 15-19 years

1991

1996

2001

52

Children living in older homes are more likely to experience elevated blood lead levels (US EPA 

2003). In the United States, children from low-income households can experience increased risk 

of exposure to lead, as they are more likely to live in older homes where paint deteriorates into 

dust, increasing opportunities for exposure. There is also an additional risk of exposure during 

renovations when scraping, sanding, and heating are used to remove older contaminated paint, 

making the lead available in the form of scrapings, dust and fumes. 

The indicators presented in this section utilize information on the age of housing stock to report 

on the potential for exposure to lead. Canada presents data and trends on the number of children 

that live in pre-1960 homes. The United States presents data on the percentage of houses that have 

lead contamination in the house or soil around the house, above EPA standards.

In Mexico, the cottage pottery industry continues to use glazes that are high in lead. Often based in 

or near the home, these pottery operations can cause lead exposures for children living and, in some 

cases, working there. People are also exposed to lead when ceramics containing lead in the glaze are 

used to cook or store food or beverages. Mexico provides a regional map illustrating the number of 

home-based pottery operations situated in various states. This is an exposure surrogate indicator that 

provides a general sense of the distribution of pottery operations that may cause increased exposure 

of children to lead from lead-based glaze or through contamination due to pottery operations.

4.2.1 Canada 

Canada provides data on the percentage of children living in homes built prior to 1960. 

Children may be exposed to lead in these homes, as most indoor and outdoor paints produced 

before 1960 contained substantial amounts of lead (see Canada’s country report). Also, as 

noted in SECTION 4.2, renovations can increase the amount of lead dust in a home. 

CHART 4-11 shows the percentage of children living in pre-1960 homes in Canada for the years 1991, 

1996, 2001.

CHART 4-11: Percentage of Children Living in Pre-1960 Homes, by Age Group, in Canada, 1991, 1996, 2001

Source: Statistics Canada, Census of Population, 1991, 1996, 2001.
Communities with Pottery Workshops 

October 2001

Without Pottery Workshops (12 states)

1 to 5 (12 states)

6 to 7 (4 states)

11 to 20 (4 states)

Children's Health and the Environment in North America 53

KE Y OBSERVATIONS :

■ In 2001, 24 percent of Canadian children under five years of age lived in housing built 

prior to 1960 (CHART 4-11). 

■ The number of children in the four age categories (under fi ve, fi ve to nine, 10 to 14 and 15 to 19) 

living in homes built prior to 1960 has declined slightly, between 1991 and 2001 (CHART 4-11).

4.2.2 Mexico

In Mexico, home-based pottery operations are a potential source of exposure to lead for 

children. While Mexico does not have data on the number of children living in homes 

with a potential source of lead, Mexico provides information on the number of pottery 

communities throughout the country. This artisanal craft is carried on in 20 Mexican states, 

by approximately 5 million potters, many of whom are members of indigenous groups. As 

noted in SECTION 4.2, one of the main causes of environmental exposure to lead in Mexico 

derives from the manufacture of pottery with glaze containing lead oxide, as well as the use 

of this pottery in food preparation. 

CHART 4-12 shows the number of communities with pottery activities, by state, as of October 2000.

CHART 4-12: Communities with Pottery Activities, by State, in Mexico, October 2001

Source: National Artisan Development Fund (Fondo Nacional para el Fomento de las Artesanías—Fonart), Lead Program.

<http://www.cofepris.gob.mx/bv/libros/l31.pdf>. 

KE Y OBSERVATIONS :

■ Pottery production occurs mainly in the southern part of Mexico, including the heavily 

indigenous-populated state of Chiapas (CHART 4-12).
0

25

30

35

40

Percentage of Houses

Houses

5

With leadbased paint

20

15

10

With any

signifi cant

lead-based

paint hazard

With any

signifi cantly

deteriorated

lead-based

paint

With interior

leadcontaminanted

dust above

EPA standard

With leadcontaminanted

soil above EPA

standard

54

4.2.3 United States 

The United States is not able to provide child-specific information on the current indicator. 

Instead, the United States provides information from the National Survey of Lead and Allergens 

in Housing on lead in US housing. Elevated blood lead levels in the United States are due mostly 

to ingestion of contaminated dust, paint and soil (Centers for Disease Control and Prevention 

1997). Soil and dust that are contaminated with lead are important sources of exposure because 

children play outside, and very young children frequently put their hands in their mouths 

(Mielke and Reagan 1998, Mielke 1999, President’s Task Force on Environmental Health 

Risks and Safety Risks to Children 2000a). Deterioration of lead-based paint can generate 

contaminated dust and soil, and past emissions of lead in gasoline that subsequently were 

deposited in the soil also contribute to lead-contaminated soil and house dust (Mielke and 

Reagan 1998, Mielke 1999, President’s Task Force on Environmental Health Risks and Safety 

Risks to Children 2000a). 

CHART 4-13 shows the percentage of US houses with lead-based paint and the percentage of houses 

that have lead contamination in the house or soil around the house, above EPA standards.

CHART 4-13: Lead in US Housing, 1998–2000

Source: US Department of Housing and Urban Development. 2001. National Survey of Lead and Allergens in Housing, 

Final Report. Volume I, Analysis of lead hazards, Revision 6.0.

KE Y OBSERVATIONS :

■ Forty percent of homes in the United States had some lead-based paint (CHART 4-13).

■ In the United States, 25 percent of houses had a significant lead-based paint hazard, which 

could be from deteriorating paint, contaminated dust, or contaminated soil outside the 

house (CHART 4-13).

■ Fourteen percent of houses had significantly deteriorated lead-based paint and 16 percent 

of US houses showed traces of lead in interior dust, to a level exceeding EPA standards. 

Seven percent of houses had lead in soil outside the house greater than the EPA standard 

(CHART 4-13). This is a reduction from the sixty-six percent of US houses that were found 

in 1990 to have lead-based paint (data not shown) (Jacobs et al. 2002). 
Children's Health and the Environment in North America 55

4.2.4 Opportunities for Strengthening the Indicator on Children’s Exposure to Lead in the Home, in 

North America 

This section highlights the challenges of using surrogate exposure indicators to monitor 

potential lead exposures in indoor environments. Based on the limitations encountered, it 

is recommended that emphasis be placed on reducing exposures and on exposure indicators 

such as blood lead levels, combined with information on children’s potential sources of 

exposure, to provide data on lead exposure in indoor environments.

• Additional efforts to ensure a reasonable sampling of low-income families and other populations at risk 

are an important consideration. Many children in inner-city neighborhoods may reside in poorer-quality 

housing stock where the availability of resources to remediate lead in homes may be limited. 

• Information on renovations to pre-1960s homes could give an indication of the increased risk to children of 

exposure to lead through home renovations. 

• The ability to overlay on a map the data on blood lead levels and housing stock, or on blood lead levels 

and pottery operations, would provide a geographical depiction of where children may be at higher risk of 

exposure to lead.

• Continued efforts on conducting national surveys of lead in housing are necessary in order to estimate the 

levels of lead in paint, dust, and soil and the prevalence of hazardous levels of lead.

• Additional efforts to analyze and report lead levels in the house dust of homes with children would be 

valuable in future indicator efforts. 

4.3 INDUSTRIAL RELEASES OF LEAD

I

_____________________________________________________________________________________________________I

Purpose: This indicator provides information on industrial releases of lead. 

Current indicators: PRTR data on industrial releases of lead. 

I

_____________________________________________________________________________________________________I

Canada, Mexico and the United States all have systems in place to track the release or transfer 

of selected substances from industrial activities. These pollutant release and transfer registers, 

or PRTRs, are described briefly below.

• Canada—The Canadian National Pollutant Release Inventory (NPRI) is a legislated tracking program 

delivered by Environment Canada under the authority of the Canadian Environmental Protection Act 

(CEPA) and currently tracks approximately 270 chemicals.

• Mexico—The Mexican Registro de Emisiones y Transferencia de Contaminantes (RETC), which has 

been voluntary, is soon to be implemented as a mandatory reporting mechanism that will track more 

than 100 substances in addition to criteria air contaminants and data on energy and water use.

• United States—The US Toxics Release Inventory (TRI) is a legislated national program that is 

administered by the Environmental Protection Agency. The TRI tracks approximately 650 chemicals.
56

A core function of a PRTR is to make release and transfer information available to the public. 

The NPRI and TRI databases are communicated to the public through reports from their 

respective governments, and the databases themselves are made publicly accessible. Data 

from these PRTR programs are also presented through the Taking Stock report, an annual 

publication of the CEC. Mexico does not yet have publicly available PRTR data but plans to 

prepare a report for the 2005 reporting year.

As noted in SECTION 4.1, the health effects associated with lead exposure in children are well 

established. Lead is tracked through the PRTR programs of Canada and the United States; 

releases from covered industrial operations are presented for both countries in SECTIONS 4.3.1 

and 4.3.3. It is important to note that PRTR data do not provide information on exposures or 

related health risks. In addition, only facilities that meet reporting thresholds are required to 

report, thus small and diffuse sources (e.g., gas stations, dry cleaners, transportation sources, 

agricultural activities) are not covered. 

The data used for these analyses are for 1995–2000, and cover reporting from the 

manufacturing sectors only. Other sectors, such as mining and electric power–generating 

facilities, are not included since these were not added to the US TRI reporting until 1998. 

The reporting thresholds for lead and its compounds were lowered in both the US TRI and 

the Canadian NPRI, starting with the 2001 reporting year for TRI and 2002 for NPRI. The 

reporting thresholds were lowered from approximately 10 tonnes to approximately 50 kgs 

manufactured, processed or otherwise used during a calendar year. More facilities are now 

subject to reporting, thus a more complete picture of releases and transfers of lead from 

industrial sources will be available for future reports. This change resulted in a break in 

the trends between the 2001 and 2002 which resulted in unmatched data which was not 

comparable. Therefore, matched trend data are available only to the year 2000 for Canada 

and the US. Additional data for 2001, 2002 and 2003 are available from the national databases 

(see Canada and US country reports).
Tonnes of Releases

Years

1995 1996 1997 1998 1999

1,000

500

0

1,500

2,000

2,500

3,000

3,500

4,000

4,500

2000

20

0

40

60

80

100

120

140

Number of Reporting Facilities

On-site Air

Number of

Facilities

On-site Water

On-site 

Underground

Injection

On-site Land

Off-site

Releases

Children's Health and the Environment in North America 57

4.3.1 Canada 

Canada reports on the current indicator using a subset of NPRI data for on-site and off-site releases 

of lead and its compounds from facilities in the manufacturing sector. 

CHART 4-14 depicts on-site and off-site releases of lead and its compounds reported by manufacturing 

facilities, in tonnes, for the period 1995 to 2000. This illustration combines information on the 

environmental releases and the number of facilities reporting for each year.

CHART 4-14: On- and Off-site Releases of Lead (and its compounds), in Canada, 1995–2000 

Source: Data compiled by the CEC from a subset of original PRTR data from the National Pollution Release Inventory (NPRI), 

Environment Canada. The data shown are from a “matched” data set compiled by the CEC, in which only data that are comparable 

between the Canadian NPRI and the US TRI are included.

Note: See Glossary for defi nitions of on-site air releases, on-site water releases, on-site underground injection, on-site land 

releases and off-site releases. 

KE Y OBSERVATIONS :

■ Overall, while the number of reporting facilities increased by 10 percent, total releases of lead 

and its compounds decreased 46 percent between 1995 and 2000. Releases increased moderately 

from 1995 to 1997, followed by a decrease in total releases from 1998 to 2000 (CHART 4-14).

■ Off-site releases (primarily transfers to landfi lls) accounted for the largest portion of releases 

and variation over this time period (CHART 4-14).

■ On-site land releases decreased by 70 percent from 1995 to 2000 (CHART 4-14).

■ On-site releases to the air decreased from 1996 to 1999 but showed an increase (of 0.6 percent) 

from 1999 to 2000 (CHART 4-14).

4.3.2 Mexico 

Mexico has no information for this indicator, due to the fact that the Registro de Emisiones y Transferencia de Contaminantes (RETC) was not yet fully operational. Legislation was enacted in 2001 for a 

mandatory, publicly accessible PRTR, and in June 2004 the implementing regulations were passed, 

thus Mexico will likely be in a position to present information on this indicator in future reports.
1,400

Tonnes of Releases

Years

1995 1996 1997 1998 1999

0

5,000

10,000

15,000

20.000

25,000

30,000

2000

200

0

400

600

800

1,000

1,600

1,800

2,000

Number of Reporting Facilities

1,200

On-site Air

Number of

Facilities

On-site Water

On-site 

Underground

Injection

On-site Land

Off-site

Releases

58

4.3.3 United States 

The United States reports on the current indicator by using a subset of TRI data for on-site and offsite releases of lead and its compounds from manufacturing facilities.

CHART 4-15 depicts on-site and off-site releases of lead and its compounds for the period 1995 to 2000. This 

illustration combines information on the environmental releases and the number of facilities reporting 

for each year.

CHART 4-15: On- and Off-site Releases of Lead (and its compounds), in the United States, 1995–2000 

Source: Data compiled by the CEC from a subset of original PRTR data from the Toxics Release Inventory (TRI), Environmental 

Protection Agency. The data shown are from a “matched” data set compiled by the CEC in which only data that are comparable between 

the Canadian NPRI and the US TRI are included. 

Note: See Glossary for defi nitions of on-site air releases, on-site water releases, on-site underground injection, on-site land 

releases and off-site releases. 

KEY OBSERVATIONS:

■ An increase in the total releases was seen in 1997, with reductions in each subsequent reporting 

year up to 2000. Most of the increase was due to a 50 percent increase in the amount of lead and 

lead compounds released off-site (off-site releases are primarily transfers to landfi lls) between 

1995 and 1997. The decrease in later years was not enough to offset the earlier increase, so that 

the change for the period 1995–2000 was an increase of 9 percent (CHART 4-15).

■ The largest decrease in releases of lead and its compounds over the 1995 to 2000 period occurred for 

releases to on-site land with an overall decrease of 497 tonnes or 8 percent. Air releases of lead and its 

compounds decreased by about 325 tonnes, or 38 percent, over the reporting period (CHART 4-15).

■ All types of releases, except off-site transfers to disposal (mainly landfi lls), increased from 1999 

to 2000. The number of reporting facilities also increased, by 5 percent from 1999 to 2000 and 

overall by 2 percent from 1995–2000 (CHART 4-15).

■ The amount of industrial releases of lead and its compounds was about 196,000 tonnes (metric tons) 

in 2003 (data not shown, see US country report, FIGURE 13.6) for all facilities subject to reporting 

under the TRI rules. These new requirements resulted in an approximately 90 percent change in 

tonnage, to about 175,000 tonnes, between 2000 and 2003. Note that the chart above and the cited 

fi gure in the US country report are not comparable due to the difference in the number of industry 

sectors covered and the change in the reporting threshold (data not shown, see US country report).
Children's Health and the Environment in North America 59

4.3.4 Opportunities for Strengthening Indicators of Lead from Industrial Activities in North America

The indicator on industrial releases of lead features the use of pollutant release and transfer 

register data from Canada and the United States. The anticipated availability of mandatory 

PRTR data in Mexico will be an important step towards making this indicator reportable for 

all of North America. 

• Obtaining data on releases from smaller facilities could improve the quality of these indicators. 

• PRTR data combined with monitoring data of ambient levels of pollutants in the environment 

(air, water and soil) would improve our understanding of the sources and presence of lead in the 

environment and potential contributions to lead exposure.

• Geographically-referenced lead emissions data could be combined with ambient monitoring data 

to get an indicator of communities with a potentially greater exposure to lead emissions due 

to heavy industrial activities. Such an indicator could identify geographic areas of concern for 

priority setting in interventions to reduce children’s exposure to lead.

• Ensuring comparable reporting for lead under the Mexican RETC (i.e., similar reporting threshold and 

coverage of industrial sectors) is needed in order to have trilateral comparability for this indicator.

4.4 INDUSTRIAL RELEASES OF SELECTED CHEMICALS 

I

_____________________________________________________________________________________________________I

Purpose: This indicator provides information on industrial releases of selected chemicals.

Current indicators: PRTR data on industrial releases of 153 chemicals.

I

_____________________________________________________________________________________________________I

Hundreds of potentially toxic substances are released into the environment and transferred 

off-site for disposal or further management by industry each year. The relative toxicity of 

these chemicals varies. Some pose health risks only at high levels of exposure, whereas others 

are highly toxic even in extremely small concentrations. 

As mentioned in SECTION 4.3 above, Canada, Mexico and the United States all have systems 

in place to track the release or transfer of selected chemicals from industrial activities and to 

make this information publicly available. These pollutant release and transfer registers, or 

PRTRs, include:

• the Canadian National Pollutant Release Inventory (NPRI);

• the Mexican Registro de Emisiones y Transferencia de Contaminantes (RETC) (data not yet available); 

• and the US Toxics Release Inventory (TRI).
Preventive

actions

Remedial

actions

ACTIONS

Social conditions 

Economic conditions

Demographic conditions

EXPOSURE HEALTH OUTCOMES 

IN CHILDREN

AGENTS

Industrial chemicals 

SOURCES

Manufacturing facilities

Power plants

Hazardous waste facilities

Landfi lls

causes or is associated with

Behavioral disorders and 

other neurotoxic effects

Developmental disorders

Reproductive disorders

Asthma, Lung damage

Immune and endocrine 

system effects

Cancer

CONTEXTS

attributable to or

is associated with

60

As the MEME model in FIGURE 6 illustrates, industrial chemicals from numerous sources 

may pose health risks to children. There is increasing concern about the adverse effects 

that exposure to certain toxic substances may have on the developing fetus and child. A 

growing body of literature is drawing linkages between toxic exposures at various stages of 

fetal and child development and an array of health impacts, including behavioral disorders, 

neurological disorders, brain and kidney damage, decreased fertility, male reproductive 

disorders, acute toxicity, hormone disruption, various cancers, genetic damage, birth defects, 

developmental effects, immunological effects and other chronic diseases (US EPA 2003). 

It is important to note that PRTR data do not provide information on human exposure to 

the listed chemicals or on related health risks. In addition, only facilities that meet reporting 

thresholds are required to report and thus small and diffuse sources (e.g., gas stations, dry 

cleaners, transportation sources, agricultural activities) are not covered. 

FIGURE 6: MEME Framework for Issues Covered in the Section on Industrial Releases 

of Selected Chemicals

 

Source: Adapted from Briggs 2003.
Tonnes of Releases

Years

1998 1999 2000 2001 2002

40,000

20,000

0

60,000

80,000

100,000

120,000

140,000

160,000

180,000

0

500

1,000

1,500

2,000

Number of Reporting Facilities

On-site Air

Number of

Facilities

On-site Water

On-site 

Underground

Injection

On-site Land

Off-site

Releases

Children's Health and the Environment in North America 61

The indicators presented in this section provide data on releases to air, water and land 

(primarily to landfills) of 153 “matched” chemicals. The matched chemicals are currently 

tracked by both the Canadian NPRI and the US TRI. A listing of the 153 chemicals is provided 

in APPENDIX 6. On-site and off-site releases of the matched chemicals are reported for the 

period 1998 to 2002. Data on transfers off-site for recycling or other management are not 

shown. The data also include the number of facilities reporting and the environmental media 

to which the chemicals are released. The total releases on- and off-site, by industry sector, are 

also provided for the same period.

4.4.1 Canada 

Canada reports on the pollutant releases for 153 “matched” chemicals—those chemicals 

reported in the NPRI that are also required to be reported in the United States. Canada also 

presents additional data on specific substances of concern to children’s health and additional 

PRTR analyses in Canada’s country report.

CHART 4-16 reports on-site and off-site releases for 153 matched chemicals, in tonnes, for the period 

1998 to 2002. This illustration describes the environmental media to which the chemicals were 

released and also provides information on the number of facilities reporting for each year.

CHART 4-17 shows total releases, in tonnes, for on-site and off-site releases for 153 matched 

chemicals, by industry sector, for the period 1998 to 2002.

CHART 4-16: On- and Off-site Releases of Matched Chemicals, in Canada, 1998–2002 

Source: Data compiled by the CEC from a subset of original PRTR data from the National Pollution Release Inventory 

(NPRI), Environment Canada. The data shown are from a “matched” data set compiled by the CEC, in which only data 

that are comparable between the Canadian NPRI and the US TRI are included.

Note: See Glossary for definitions of on-site air releases, on-site water releases, on-site underground injection, on-site 

land releases and off-site releases.
Tonnes

Years

1998

20,000

10,000

0

30,000

40,000

50,000

60,000

70,000

80,000

90,000

1999 2000 2001 2002

All Others

Primary Metals

Paper Products

Chemicals

Electric Utilities

62

CHART 4-17: Total On- and Off-site Releases of Matched Chemicals, by Industry Sector, in Canada, 1998–2002 

Source: Data compiled by the CEC from a subset of original PRTR data from the National Pollution Release Inventory 

(NPRI), Environment Canada. The data shown are from a “matched” data set compiled by the CEC, in which only data 

that are comparable between the Canadian NPRI and the US TRI are included.

Note: The chart depicts industry sectors with the largest total releases on- and off-site, 1998.

KEY OBSERVATIONS:

■ The number of facilities reporting to the NPRI for the matched chemicals set increased by 

41 percent between 1998 and 2002, while total releases decreased by 11 percent during this 

period. Releases to on-site air and water increased, while releases to on-site underground 

injection and off-site transfers (primarily transfers to landfills) decreased and on-site 

land releases were about the same in 1998 and 2002 (CHART 4-16).

■ Of the four industry sectors with the largest total releases in 1998, the primary metals 

and chemical manufacturing sectors reported reductions in releases of the matched set 

of chemicals of 33 percent and 36 percent respectively, between 1998 and 2002, while the 

paper products and electric utilities sectors both reported increases, of 26 percent and 4 

percent respectively, over the same period (CHART 4-17).
Tonnes of Releases

Years

1998 1999 2000 2001 2002

200,000

0

400,000

600,000

800,000

1,000,000

1,200,000

1,400,000

1,600,000

0

5,000

10,000

15,000

20,000

25,000

Number of Reporting Facilities

On-site Air

Number of

Facilities

On-site Water

On-site 

Underground

Injection

On-site Land

Off-site

Releases

Children's Health and the Environment in North America 63

4.4.2 Mexico 

Mexico has no information for this indicator. Legislation was enacted in 2001 for a mandatory, 

publicly accessible PRTR, and in June 2004 the implementing regulations were passed; thus Mexico 

will likely be in a position to present information on this indicator in future reports.

4.4.3 United States 

The United States reports on the pollutant releases for 153 “matched” chemicals—those 

chemicals reported in the TRI that are also required to be reported in Canada. 

CHART 4-18 reports on-site and off-site releases for 153 matched chemicals, in tonnes, for the period 1998 

to 2002. This illustration describes the environmental media to which the chemicals were released and 

also provides information on the number of facilities reporting releases for each year.

CHART 4-19 reports the total releases on-site and off-site releases for 153 matched chemicals, by 

sector, for the period 1998 to 2002. 

CHART 4-18: On- and Off-site Releases of Matched Chemicals, in the United States, 1998–2002

Source: Data compiled by the CEC from a subset of original PRTR data from the Toxics Release Inventory (TRI), US EPA. The 

data shown are from a “matched” data set compiled by the CEC, in which only data that are comparable between the Canadian 

NPRI and the US TRI are included. 

Note: See Glossary for defi nitions of on-site air releases, on-site water releases, on-site underground injection, on-site land releases 

and off-site releases.
Tonnes

Years

1998

200,000

150,000

0

250,000

300,000

350,000

400,000

450,000

500,000

1999 2000 2001 2002

100,000

50,000

Electric Utilities

All Others

Primary Metals

Hazardous Waste

Mgt./Solvent

Recovery

Chemicals

64

CHART 4-19: Total On- and Off-site Releases of Matched Chemicals, by Industry Sector, in the United 

States, 1998–2002

Source: Data compiled by the CEC from a subset of original PRTR data from the Toxics Release Inventory (TRI), US EPA. The 

data shown are from a “matched” data set compiled by the CEC, in which only data that are comparable between the Canadian 

NPRI and the US TRI are included. 

Note: The chart depicts industry sectors with the largest total releases on- and off-site, in 1998.

KEY OBSERVATIONS:

■ The total facilities reporting releases of the 153 matched chemicals decreased over the 

reporting period 1998 to 2002, as did the total releases, which went from a high of 1.45 

million tonnes in 1998 to a low of 1.21 million tonnes in 2001 but then increased to 1.28 

million tonnes in 2002, for an overall decrease of 11 percent from 1998 to 2002. There were 

reductions in releases to on-site air, water and underground injection, with on-site land 

and off-site releases (primarily transfers to landfills) showing an increase (CHART 4-18).

■ The electric utilities sector reported the largest total releases and showed a decrease of 9 

percent from 1998 to 2002. The primary metals sector, the second largest sector, reported an 

increase of 16 percent in releases over the same time period. The chemical manufacturing 

sector and the hazardous waste management sectors reported the third and fourth largest 

total releases, with overall decreases of 24 percent and 36 percent respectively. The other 

industry sectors combined, the “all others” category (which includes, among others, the 

food, paper, transportation equipment and plastics manufacturing industries), had about 

401,000 tonnes of releases in 1998 and about 321,000 tonnes in 2002 (CHART 4-19).
Children's Health and the Environment in North America 65

4.4.4 Opportunities for Strengthening PRTR-based Indicators in North America

The indicator on industrial releases of selected chemicals features the use of pollutant release 

and transfer register data from Canada and the United States. The anticipated availability of 

mandatory PRTR data in Mexico will be an important step towards making this indicator 

reportable for all of North America. Other improvement efforts that are underway include 

the CEC’s Action Plan to Enhance the Comparability of PRTRs in North America, adopted 

by the CEC Council in June 2002, under which the three countries are working together to 

improve the comparability of their PRTR data (available online at <www.cec.org>). As PRTR 

data from the three national systems become more comparable, we will get a clearer picture 

of the sources and management of pollutants that arise from industrial activities across 

North America.

• The indicator could be strengthened if countries could develop a priority list of matched chemicals of 

specifi c concern to children’s health (e.g., carcinogens, developmental toxicants, neurotoxicants).

• Obtaining data on releases from smaller facilities could improve the quality of these indicators. 

• PRTR data combined with monitoring data of ambient levels of pollutants in the environment (air, water 

and soil) would improve our understanding of the presence of these chemicals in the environment, 

potential sources and potential exposure levels.

• Estimation of non-point sources of pollutants (agriculture, transportation) would complement the pointsource data available from the national PRTRs and thereby create a more complete picture of sources of 

toxic substances in North America.

• Geographically-referenced PRTR data could be combined with population data to get an indicator of 

surrogate exposures to the listed substances. Such an indicator could identify geographic areas of 

concern where nations might take action to reduce emissions of some chemicals. It is important to note 

that PRTR data are an input to determine exposure or calculate potential risks to human health and the 

environment, but by themselves are insuffi cient to indicate risk. 

• Ensuring comparable reporting under the Mexican RETC (i.e., similar reporting thresholds and coverage of 

industrial sectors) is needed, in order to have trilateral comparability for this indicator in future reports.

4.5 PESTICIDES

I

_____________________________________________________________________________________________________I

Purpose: This indicator provides information on children’s potential exposures to pesticides. 

Current indicators: Pesticide residues in foods.

I

_____________________________________________________________________________________________________I

Pesticides are in widespread use in North America and their residues can be found in outdoor 

as well as indoor environments where children can be exposed to them in water, air, soil, and 

food. Diet, via pesticide residues in food, is recognized as an important source of exposure 

(National Research Council 1993). Children may also have greater exposure to pesticides 

than most adults, due to their eating habits and behaviors. Pound for pound, children eat 

more than adults and their diets contain foods that tend to have higher levels of pesticide 

residues, such as fruits and vegetables. In addition, behaviors such as crawling and mouthing 

can increase children’s exposure to outdoor and indoor pesticide residues in or on grass, in 

soil or in dust found in indoor environments such as homes, schools or day-care centers. 

Multiple sources of pesticides in a child’s environment can increase the opportunity for 

simultaneous exposures to different pesticides.
Preventive

actions

Remedial

actions

ACTIONS

Social conditions 

Economic conditions

Demographic conditions

EXPOSURE HEALTH OUTCOMES 

IN CHILDREN

AGENT

Pesticides 

SOURCES

Agricultural use

Municipal use

Occupational use

Residential use

Residues in food 

and drinking water

causes or is associated with

Behavioral disorders 

and other neurotoxic effects 

Developmental disorders

Reproductive disorders

Lung damage

Immune and endocrine 

system effects

Cancer

CONTEXTS

attributable to or

is associated with

66

Pesticides vary in their potential to cause harm to children. Organophosphates, which are used in 

the production of many foods consumed by children, can interfere with the proper functioning of 

the nervous system when exposure is suffi ciently high (US EPA 2003). Other pesticides, depending 

on the extent of exposure (i.e., dose), may cause a range of adverse effects on human health, including 

cancer, acute and chronic injury to the nervous system, lung damage, reproductive dysfunction, and 

possibly dysfunction of the endocrine and immune systems (National Research Council 1993). 

FIGURE 7: MEME Framework for Issues Covered in the Section on Pesticides

Source: Adapted from Briggs 2003.

The MEME model in FIGURE 7 illustrates that while food and water are important sources of exposure, 

other sources of pesticide exposure also contribute to a child’s total body burden. Pesticides are used 

widely in agriculture in Canada, Mexico and the United States. Contamination of drinking water 

supplies is one means of exposure, as are exposures from over-spray and plant and soil residues. In 

some cases, children may be present in the fi elds where their parents work and thus be exposed to 

pesticides. In other cases, children may be exposed from parents bringing pesticide residues home 

on their persons. This type of exposure may occur primarily in rural agricultural communities. In urban 

and suburban areas, the more likely sources of exposure include pesticide residues associated with 

lawn care (outdoor) and pest management (indoor) in the places where children live, study and play.

In this section, Canada and the United States provide data on detectible levels of organophosphate 

residues on food. Canada presents the percentage of tested samples of fresh fruit and vegetables 

(imported and domestic) with detectable organophosphate residues for the period 1995 to 2002. 

The United States provides data on detectible quantities of organophosphate residues on fruits, 

vegetables and grains for the period 1994 to 2001. The Canadian and US data are exposure surrogate 

indicators, as they represent the potential for exposure to pesticide residues in food (ingestion). 

Mexico provides trend data for acute pesticide poisonings for adults and for children under the age 

of 15 years. This is an exposure indicator, as the cases were reported to medical facilities; but there 

was no tracking of specifi c health effects. It should be noted that poisonings are acute events and 

are not an indicator of potential exposure levels for the general population and/or children. 
% Positives

Years

0

10

15

20

1998 2000 2002

5

1995 1996 1997 1999 2001

Fruits & Vegetables

Domestic

Imported

Both

Children's Health and the Environment in North America 67

4.5.1 Canada 

Canada reports on the indicator by using data from chemical residue annual reports, 1995–

2002, from the Canadian Food Inspection Agency. The indicator uses a yearly number of 

organophosphate pesticides detected on domestic and imported fruits and vegetables, 

expressed as percentage of sample size.

CHART 4-20 shows the percentage, by weight, of sampled fresh fruit and vegetables with detectable 

organophosphate pesticide residues, for the period 1995 to 2002. 

CHART 4-20: Percentage of Sampled Fresh Fruits and Vegetables with Detectable Organophosphate 

Pesticide Residues, in Canada, 1995–2002

Source: Canadian Food Inspection Agency, Food Safety Directorate, Food Microbiology and Chemical Evaluation, 

Chemical Residue Annual Reports, 1995–2002.

KEY OBSERVATIONS:

■ From 1995 to 2002, the percentage of fresh fruits and vegetables with detectable 

organophosphate pesticide residues has decreased, suggesting reduced exposure from this 

source (CHART 4-20).

4.5.2 Mexico 

Mexico is able to present data on the current indicator by using data on pesticide poisoning 

from health care facilities. In Mexico, incidents of pesticide poisonings are required to be 

reported to a level I or II health care facility. 

CHART 4-21 presents cases of pesticide poisonings in children and the general public, for the period 

1998 to 2002. 
Total Number of Cases

Years

1998

3000

2000

0

4000

5000

6000

7000

1999 2000 2001 2002

1000

General Population

Under 15 years old

68

CHART 4-21: Cases of Pesticide Poisonings in Children (under 15 years old) and the General Public, 

in Mexico, 1998–2002

Source: Secretaría de Salud (Secretariat of Health). Centralized Epidemiological Information System (Sistema Único de 

Información para la Vigilancia Epidemiológica—SUIVE). <http://www.dgepi.salud.gob.mx/suave/index.htm>.

KEY OBSERVATIONS:

■ There were 6422 pesticide poisonings reported in 1998. A steady decline to 2802 in 2002 was 

observed (CHART 4-21).

■ For poisoning cases recorded in children under the age of 15, the number decreased from a high 

of 1335 in 1999 to a low of 672 in 2002 (CHART 4-21).

4.5.3 United States 

The United States is able to present on the current indicator by using data on organophosphate 

pesticides from the US Department of Agriculture’s Pesticide Data Program. Among the foods 

sampled by the Pesticide Data Program in recent years are several that are important parts of 

children’s diets, including apples, apple juice, bananas, carrots, green beans, orange juice, peaches, 

pears, potatoes, and tomatoes.

The chart below displays the percentage of food samples with detectable organophosphate pesticide 

residues reported by the Pesticide Data Program from 1994 to 2001. The 34 organophosphates that 

were sampled in each of these years are included; other organophosphates that have been added to 

the program in recent years are excluded so that the chart represents a consistent set of pesticides 

for all years shown. This measure is a surrogate for children’s exposure to pesticides in foods: If the 

frequency of detectable levels of pesticides in foods decreases, it is likely that exposures will decrease. 

However, this measure does not account for many additional factors that affect the risk to children. 

For example, some organophosphates pose greater risks to children than others do, and residues on 

some foods may pose greater risks than residues on other foods due to differences in amounts consumed. 

In addition, year-to-year changes in the percentage of samples with detectable pesticide residues may 

be affected by changes in the selection of foods that are sampled each year. It is important to note that 

having the technical ability to measure pesticide residues does not equate to a health risk.

CHART 4-22 shows the percentage of fruits, vegetables and grains with detectable residues of organophosphate pesticide reported from 1994–2001. 
Percent (%)

Years

1994

15

10

0

20

25

30

1995 1996 1997 1998 1999 2000 2001

Children's Health and the Environment in North America 69

CHART 4-22: Percentage of Fruits, Vegetables and Grains with Detectable Residues of Organophosphate Pesticides, in the United States, 1994–2001

Source: US EPA 2003. America’s Children and the Environment: Measures of Contaminants, Body Burdens and Illnesses 

<www.epa.gov/envirohealth/children>.

KEY OBSERVATIONS:

■ Between 1994 and 2001, the percentage of food samples with detectable organophosphate pesticide 

residues ranged between 19 percent and 29 percent. The highest detection rates were observed 

during 1996 and 1997, while the lowest detection rate was observed in 2001 (CHART 4-22).

■ Between 1993 and 2001, the amount of organophosphate pesticides used on foods most 

frequently consumed by children declined by 44 percent, from 11.3 million kilograms to 

6.35 million kilograms (data not shown) (Doane Marketing Research 1993–2001).

4.5.4 Opportunities for Strengthening Indicators of Children’s Exposure to Pesticides in North America

The measures presented provide two different approaches to monitoring pesticide exposures, 

namely tracking of organophosphate residues on foods (Canada and US) and acute pesticides 

poisonings (Mexico). As such, they are limited to certain pathways of exposure and do not 

cover all categories of pesticides that may be of concern. The following bullets outline steps 

toward a more ideal indicator of pesticide exposures in children.

• Biomonitoring programs in each country, measuring the levels of pesticides and/or their metabolites 

in children’s blood and urine, would provide the best measure of a child’s exposure to pesticides from 

multiple sources. 

• National surveillance programs for pesticide use in agriculture, the home, schools and elsewhere 

could provide important information on the potential routes of exposure of children to pesticides. The 

measurement of multiple exposures and resulting body burdens and effects in children would greatly 

enhance understanding and reporting in this area.

• Health effects surveillance could provide additional information on the adverse health effects in children 

associated with pesticide exposure.

• In addition to organophosphates, future indicators could address other classes of pesticides that may be of 

concern.

• Data from poison-control centers and emergency clinics for pesticide poisonings, like those reported by 

Mexico, should be examined for potential use in the future.

• Data from state/provincial information systems to develop case study reports from exposure to pesticides 

should also be examined for potential use. 
70

Access to clean water is critical in order to reduce the risks of exposure that are of concern to 

 children’s health. Contaminants can be responsible for a wide range of health effects in children. 
5.0 Waterborne Diseases

Children who are exposed to contaminants in drinking water may experience a range of health 

effects, depending on the nature of the contamination. Pathogens such as E. coli are an important 

source of risk to the health of children. Children’s developing immune systems may not be able 

to protect them from an exposure that could result in serious illness and even death (even people 

with fully developed immune systems can still experience serious adverse effects from exposure 

to E. coli). Other contaminants found in drinking water, such as lead, may cause a range of 

diseases in children, including developmental effects, learning disorders, and cancer (US EPA 

2003). Sources of water contamination can include leachate from landfi lls, runoff of pesticides 

and fertilizers from agricultural operations, effl uent or spills from industrial and other sources, 

and municipal sewage (Canada, Environment Canada 2004). 

The indicators presented in this chapter address a number of potential environmental health 

risks for children, including microbial and chemical contaminants. Data and trends are provided 

on the percentages of the population that are served by drinking water treatment systems and 

sewage removal systems, respectively. Measures of illness and death linked to waterborne 

pathogens are also presented.

SECTION 5.1 provides measures of the availability and quality of drinking water. National data and 

trends for access to treated drinking water are presented by Canada and Mexico. The United States 

presents data on children living in areas where drinking water standards were exceeded, as well as 

children living in areas where drinking water monitoring and reporting requirements were violated. 

SECTION 5.2 presents data on the availability of sewer systems, which is an important component of 

reducing biological contamination of the water supply and thereby preventing illness from waterborne 

diseases. In this section, Mexico reports on the availability of sewer systems over time in Mexico.

SECTION 5.3 focuses on the morbidity and mortality associated with waterborne pathogens. Canada and 

Mexico present data and trends on incidence of giardiasis in children. Mexico also presents infection 

rates for cholera infections and mortality data associated with waterborne diseases. The United States 

presents data on waterborne disease outbreaks.

CHILDREN’S HEALTH AND THE ENVIRONMENT IN NORTH AMERICA

Commission for Environmental Cooperation 71
72

5.1 DRINKING WATER

I

_____________________________________________________________________________________________________I

Purpose: The indicators in this section provide information on the percentage of children potentially 

exposed to contamination and/or pathogens in drinking water. 

Current indicators: 

1. Percentage of children (households) without access to treated water.

2. Percentage of children living in areas served by public water systems in violation of local standards.

I

_____________________________________________________________________________________________________I

Access to clean water is critical in order to reduce the risk of exposure to microbials, chemicals, 

and radionuclides that are of concern to children’s health. Contaminants can be responsible for 

a wide range of health effects in children. Children are sensitive to microbial contaminants, such 

as E. coli, because of their developing or suppressed immune systems. 

Chemical and radionuclide contaminants found in water can produce a wide range of health 

effects, depending on the contaminant, its concentration and the duration of the exposure. 

Contaminants such as lead, which has recognized developmental toxicity, and arsenic, which 

can lead to cancer and other health effects, are some examples. Other metals that are of concern 

include mercury and cadmium, which are also toxic to children and adults. Nitrates and nitrites 

which stem from fertilizer use and animal and human waste can cause methemoglobinemia 

(“blue baby” syndrome) (US EPA 2003).

As the MEME model in FIGURE 8 suggests, there are other situations that may place children at 

risk to exposure of contaminated drinking water. For example, households and communities 

that rely on the use of ground water (i.e., well water) or surface water that is not pre-treated 

for removal of pathogens and other contaminants may be at greater risk of exposure to 

contamination. In Mexico, the availability of water is also a key determinant of risk. Residents 

of regions with limited supplies of water, such as remote rural areas, may have to store water in 

household cisterns or storage tanks, which can lead to contamination from improper sealing 

or cleaning. Residents in these same areas in Mexico may also be forced to use contaminated 

water and, in extreme cases, may not have water available for washing (especially hand washing), 

leading to increased risk of transmission of disease.
Preventive

actions

Remedial

actions

ACTIONS

Social conditions 

Economic conditions

Demographic conditions

EXPOSURE HEALTH OUTCOMES 

IN CHILDREN

AGENTS

Contaminants in water 

(microbial contaminants 

and chemical contaminants)

SOURCES

Industrial discharge

Incomplete sanitation

Run-off

Leaching from pipes

Groundwater

Surface water

Tank water

causes or is associated with

Behavioral disorders and 

other neurotoxic effects

Developmental disorders

Diarrhea and other gastrointestinal illnesses 

Reproductive disorders

Immune and endocrine

 system effects

Cancer 

Death

CONTEXTS

attributable to or

is associated with

Children's Health and the Environment in North America 73

FIGURE 8: MEME Framework for the Issues Covered in the Section on Drinking Water

Source: Adapted from Briggs 2003.

Canada, Mexico and the United States have standards or guidelines that are designed to protect 

the health of the public from contaminants found in drinking water (US EPA 2003, see the 

country reports from Canada and Mexico). These standards are monitored and enforced for 

public water delivery systems but typically do not cover private wells, which are found more 

frequently in rural and remote communities. In some cases, as in the United States, regulations 

have been established to protect drinking water sources and to require water treatment where 

safety standards cannot be met. These rules apply to all drinking water sources. National rules 

vary, in terms of the contaminants that are included and the acceptable levels in drinking water. 

In some cases they are legally enforceable, while in other cases they are intended as guidelines. 

Therefore, caution is necessary when attempting to compare indicator results between 

countries.

Each of the indicators presented addresses the availability of safe drinking water either through 

measures pertaining to water treatment (e.g., disinfection processes such as chlorination, 

ozonation, and fi ltration) designed to kill bacteria and other pathogens, or through reporting 

on populations served by water systems that violate the existing regulations for safe drinking 

water. It is important to note that not being served by a centralized water system does not itself 

imply a risk. Some of the people not served by treated water may have access to water of good 

quality from private wells or smaller systems, thus this indicator needs to be interpreted with 

caution (US EPA 2003).
Percent (%)

Years

0

50

1991 1995 1997 1999

25

1992 1993 1994 1996 1998

74

5.1.1 Canada

Drinking water pretreatment reduces the risk of exposure to waterborne bacteria and in some cases 

reduces or eliminates other contaminants.8

 Canada is unable to present child-specifi c data for the 

fi rst indicator (percentage of children, expressed as households containing children, without access 

to treated water); instead, Canada presents information on the portion of the general population 

that is not connected to public water distribution systems. This is not meant to indicate that the 

risks associated with private water supplies are necessarily higher—they are less well known on 

a national basis. As such, the information provided below is intended to highlight an important 

information gap. Reporting on the second indicator (percentage of children living in areas served 

by public water systems in violation of local standards) is not currently possible as Canada does not 

have information at the national level, related to water system with violations.

CHART 5-1 shows the percentage of Canadians not connected to public water distribution systems. The 

trend is based on 1991, 1994, 1996 and 1999 data and does not include the child-specifi c population, or 

information on populations that rely on well water. 

CHART 5-1: Percentage of Canadians Not Connected to Public Water Distribution Systems, 1991, 

1994, 1996 and 1999 

Source: Municipal Water Use Database, Environment Canada (consulted December 2003) and Statistics Canada, 2002 (for total population).

Note: It is assumed that Canadians not surveyed by the Municipal Water Use Database (MUD) survey, living in municipalities 

with a population below 1,000, are served by private water systems, mostly groundwater wells.

KE Y OBSERVATIONS :

■ The percentage of Canadians with access, in their home, to water obtained from a private 

individual source has remained constant at about 22–23 percent, between 1991 and 1999. 

This represented about 6.8 million Canadians in 1999 (CHART 5-1). 

■ Canadians not connected to public water distribution systems live mostly in rural areas. 

Nationally, it is not known how many people have wells that are subject to contamination or 

how many treat or disinfect their water before consumption (CHART 5-1).

8 The contaminants that are removed are a function of the technology that is used to treat the water; for example, disinfection 

does not remove chemical contaminants.
Percent (%)

Years

0

20

40

60

1980 1985 1990 1995 2000

National Total

Rural

Urban

Children's Health and the Environment in North America 75

5.1.2 Mexico

Mexico is unable to present child-specifi c data on the fi rst indicator (percentage of children 

[households] without access to treated water), but can supply data on the percentage of the 

general population without access to clean water. Mexico does not present information on water 

systems with violations.

CHART 5-2 shows the percentage of the population without potable water. The trend is presented 

for the years 1980, 1990, 1995, and 2000. 

CHART 5-3 presents the percentage of the population without piped water, by state, based on 2000 

Mexican census data.

CHART 5-2: Percentage of the Population without Potable Water, in Mexico, 1980–2000

Source: Based on database of XII General Census of Population and Housing, 2000, Instituto Nacional de Estadística, 

Geografía e Informatica (National Institute of Statistics, Geography and Informatics—INEGI). 

<http://www.inegi.gob.mx/est/default.asp?c=703>. 

Note: Rural and urban data were not available for 1980.
% of Population

0 to 20%

20 to 30%

30 to 50%

76

CHART 5-3: Percentage of the Population without Piped Water, by State, in Mexico, 2000

Source: Comisión Nacional del Agua (National Water Commission—CNA) <http://www.cna.gob.mx>.

KE Y OBSERVATIONS :

■ The 1980 Mexican census reported only national fi gures. National data show a decrease from 

29 percent to 12 percent of the general population without access to potable water in the 

period 1980 to 2000 (CHART 5-2).

■ The percentage of the population without access to potable water in urban areas decreased by 

5.2 percent, from 10.6 percent in 1990 to 5.4 percent in 2000 (CHART 5-2). 

■ The percentage of the population without access to potable water in rural areas decreased by 

approximately 17 percent, from 48.9 percent in 1990 to 32 percent in the 2000 census (CHART 5-2).

■ The highest percentage of the population without piped water supply is in the southern states, 

with 30 to 50 percent of the population without coverage (CHART 5-3).
Children's Health and the Environment in North America 77

5.1.3 United States

The United States does not present information on the fi rst indicator (percentage of children 

[households] without access to treated water). The United States reports on the second indicator 

by presenting data on the percentage of children served by community water systems for 

which states have reported violations and the percentage of children living in areas with major 

violations of drinking water monitoring and reporting requirements.

EPA sets drinking water standards for public water systems. These standards are designed to 

protect people against adverse health effects from contaminants in drinking water while taking 

into account the technical feasibility of meeting the standard and balancing costs and benefi ts. 

Public water systems are required to monitor individual contaminants at specifi c time intervals 

to assess whether they have achieved compliance with drinking water standards. When a 

violation of a drinking water standard is detected, the public water system is required to report 

the violation to state and federal governments. Information about exceedances can be used as 

a surrogate measure for exposure to unacceptably high levels of drinking water contaminants. 

It should be noted that a violation of drinking water standards does not necessarily mean that 

drinking water from a system is unsafe—it indicates that on at least one occasion, a water quality 

standard has been exceeded (see CHART 5-4).

Public water systems are required to monitor for contaminants and to report violations of 

drinking water standards to EPA. However, some public water systems do not conduct all of the 

required monitoring. Not all systems report violations. Such water systems violate monitoring 

and reporting requirements. Some monitoring and reporting violations, such as late reporting, 

are minor. However, many water systems have major violations. For example, some water systems 

fail to collect any water samples during specifi ed monitoring periods. Children who live in areas 

that are not adequately monitoring for water contaminants or reporting violations may be at 

risk, but the extent of any possible exposures in violations of drinking water standards and their 

associated risks is unknown (see CHART 5-5).

CHART 5-4 shows the estimated percentage of children living in areas served by public water systems 

that exceed a drinking water standard or violate treatment requirements for which states have reported 

violations. A seven-year trend is presented for the period 1993 to 1999. 

CHART 5-5 presents data on the estimated percentage of children living in areas served by public water 

systems with major violations of drinking water monitoring and reporting requirements, for the 

period 1993 to 1999. 
Percent (%)

Years

10

0

15

20

25 

1993 1996 1997 1998

5

1994 1995

All health-based violations

Treatment and fi ltration

Microbial contaminants

Lead and copper

Nitrate/Nitrite

Chemical and radiation

1999

78

CHART 5-4: Percentage of Children Living in Areas Served by Public Water Systems that Exceed a 

Drinking Water Standard or Violate Treatment Requirements, in the United States, 1993–1999

Source: US EPA 2003. America’s Children and the Environment: Measures of Contaminants, Body Burdens, and Illnesses 

<www.epa.gov/envirohealth/children>.

Data Source: Safe Drinking Water Information System. Offi ce of Water, US Environmental Protection Agency.

Note: Percentages are estimated.
Percent (%)

Years

1993

10

0

15

20

25

1994 1997 1998 1999

5

1995 1996

Any major violation

Lead and copper

Chemical and

radiation

Treatment and

fi ltration

Microbial

contaminants

Children's Health and the Environment in North America 79

CHART 5-5: Percentage of Children Living in Areas Served by Public Water Systems with Major Violations of Drinking Water Monitoring and Reporting Requirements, in the United States, 1993–1999

Source: US EPA 2003. America’s Children and the Environment: Measures of Contaminates, Body Burdens, and Illnesses 

<www.epa.gov/envirohealth/children>. 

Data Source: Safe Drinking Water Information System. Offi ce of Water, US Environmental Protection Agency.

Note: Percentages are estimated.

KE Y OBSERVATIONS :

■ The percentage of children served by public water systems that reported exceeding a maximum 

contaminant level or violated a treatment standard decreased from 20 percent in 1993 to 8 

percent in 1999 (CHART 5-4).

■ Every category of reported violation decreased between 1993 and 1999 except for nitrates and 

nitrites, which remained steady. The largest decline was for violations of the treatment and 

fi ltration standards (CHART 5-4).

■ In 1993, approximately 22 percent of children lived in an area served by a public water system 

that had at least one major monitoring and reporting violation. This fi gure decreased to about 

10 percent in 1999 (CHART 5-5).

■ The largest number of monitoring and reporting violations occurred for the lead and copper 

standards. Approximately 11 percent of children in 1993 were served by public water systems 

with monitoring and reporting violations for lead and copper, decreasing to about 5 percent 

in 1995. The number has remained relatively constant since then (CHART 5-5).
80

5.1.4 Opportunities for Strengthening Indicators on Availability and Quality 

of Drinking Water in North America 

The following observations and opportunities may be considered, to improve the indicators and 

the comparability among indicators in future reports:

• Comparability in North America could be enhanced if reporting were to be standardized for key measures 

such as coliform counts, disinfection byproducts, etc.

• Standardization of the reporting cycles for the various data sets used to generate these indicators would be 

helpful for improving the match-up of data across borders. 

• In some cases it was not possible to separate children from adults in the data presented. Aggregate data 

may be reasonable if the distribution of children in rural and urban areas is uniform. If not, it may be possible 

to develop surrogate measures for estimating the population of children.

• In Canada, water quality data would need to be collected by each province in a consistent manner to generate 

comparable data on a national level. Assessment could begin with a selected number of specifi c water 

quality standards that are of particular concern to children’s health (e.g., certain bacteriological standards, 

chlorination disinfection byproducts, nitrates). 

• All three countries reported a high percentage of the population served by treated drinking water. Future 

efforts focusing on the populations not served may be more worthwhile, in particular focusing on rural 

remote communities that are not serviced by sewage treatment or drinking water treatment systems.

• Since the focus of the indicators is on exposure, it may be helpful to categorize the type of water treatment so 

that reduced exposures to chemicals and/or pathogens can be reported where this technology is available.

• Information on whether safety guidelines and/or regulatory standards have been exceeded is useful 

for generating indicators. Ideally, such indicators also should describe the frequency and extent of the 

exceedances, and should specify the level of the safety guideline or regulatory standard in question. It 

would also be useful to collect the actual measurement data. 

• Exceedances of safety guidelines and/or regulations for priority substances of concern to children’s health 

would also be worthwhile if presented geographically. 

• Some representation of water quality for groundwater sources (i.e., rural wells) would be helpful to address the 

rural and remote populations. Ground water quality is especially important in some North American locations.
Preventive

actions

Remedial

actions

ACTIONS

Social conditions 

Economic conditions

Demographic conditions

EXPOSURE HEALTH OUTCOMES 

IN CHILDREN

AGENTS

Contaminants in water 

(microbial contaminants 

and chemical contaminants)

SOURCES

Industrial discharge

Untreated sewage

Run-off

Leaching from pipes

Groundwater

Surface water

Tank water

Consumer products 

(leaded pottery)

Lead pipes and solder

causes or is associated with

Behavioral disorders and 

other neurotoxic effects

Developmental disorders

Diarrhea and other gastrointestinal illnesses 

Reproductive disorders

Immune and endocrine

system effects

Cancer 

Death

CONTEXTS

attributable to or

is associated with

Children's Health and the Environment in North America 81

5.2 SANITATION

I

_____________________________________________________________________________________________________I

Purpose: This indicator provides information on the percentage of children who are potentially exposed 

to untreated sewage in their immediate surroundings. 

Current indicators: Percentages of children (households) that are not served by sanitary sewers. 

I

_____________________________________________________________________________________________________I

Municipal sewage can be an important source of biological and chemical contamination for 

surface water and groundwater. This contamination presents a potential risk for children who 

must rely on untreated water for drinking water, bathing and/or swimming. This is especially 

true in regions where water is in short supply and people are forced to use contaminated water. 

Therefore, untreated sewage remains an important source of water contamination, presenting 

potential health risks to children, as illustrated in FIGURE 9.

In Canada and the United States, most urban and rural communities are served by sewer and 

sanitation services, or have septic systems to collect and treat sewage. Because of the high 

percentage of coverage for sewage collection and treatment in both urban and rural environments, 

Canada and the United States have elected not to report this data in the North American report. 

However, due to the fact that some opportunities for improvement exist, Canada has presented 

this indicator in its country report. 

In Mexico, there remains room for improvement in the availability of sewer collection systems, 

in particular in rural communities. Thus, Mexico is presenting an exposure surrogate indicator 

on the percentage of population served with sewer services for rural areas, urban areas and 

nationally, for the year 2000.

FIGURE 9: MEME Framework for the Issues Covered in the Section on Sanitation

Source: Adapted from Briggs 2003.
82

5.2.1 Canada 

In Canada most urban and rural communities are served by sewers and sanitation services or 

have septic systems to collect and treat sewage. Because of the high percentage of coverage for 

sewage collection and treatment in both urban and rural environments, Canada is not reporting 

these data in the North American report. 

5.2.2 Mexico

Mexico is unable to provide child-specifi c data, but is able to present data on the households 

and general population not served by sewage services. Ensuring the adequate management of 

sewage is a high priority in Mexico, given the relationship between untreated waste and risks of 

waterborne diseases and, more specifi cally, the vulnerability of young children to pathogens and 

other toxic substances in the water.

CHART 5-6 shows the percentage of the population not served by sewer services. This 20-year trend is 

based on census data.

CHART 5-7 shows the percentage of homes without sewer services, by state. This information is presented 

as a map.

CHART 5-6: Percentage of the Population Not Served by Sewer Services, in Mexico, 1980–2000

Source: Based on database of XII General Census of Population and Housing, 2000, Instituto Nacional de Estadística, 

Geografía e Informatica (National Institute of Statistics, Geography and Informatics—INEGI)

<http://www.inegi.gob.mx/est/default.asp?c=703>.

Note: Rural and urban data were not available for 1980. Percent (%)

Years

40

0

60

80

100

1980 1995 2000

20

1985 1990

Rural

National Total

Urban
Percentage of

homes without

sewer services

0 to 20%

20 to 40%

40 to 60%

Children's Health and the Environment in North America 83

CHART 5-7: Percentage of Homes without Sewer Services, by State, in Mexico, 2000

Source: XII General Census of Population and Housing, 2000, Instituto Nacional de Estadística, Geografía e 

Informatica (National Institute of Statistics, Geography and Informatics—INEGI).

<http://www.inegi.gob.mx/est/default.asp?c=2417>.

KE Y OBSERVATIONS :

■ The population without sewer service coverage decreased approximately 27 percent nationally, from 

50 percent to 23 percent, as reported in the 1980 and 2000 censuses respectively (CHART 5-6).

■ Urban areas not covered by sewer services decreased from 21 percent to 10 percent, between 

collection of 1990 and 2000 census data (CHART 5-6).

■ Rural areas without sewer service coverage decreased by approximately 19 percent, from 82 

percent in the 1990 census to 63 percent in the 2000 census (CHART 5-6). 

■ The majority of homes without sewer services are located in southern Mexico, with 40 to 60 

percent of households without coverage (CHART 5-7).

5.2.3 United States 

In the United States, most urban and rural communities are served by sewage and sanitation 

services or have septic systems to collect and treat sewage. Because of the high percentage of 

coverage for sewage collection and treatment in both urban and rural environments, the United 

States is not reporting these data in the North American report. 
84

5.2.4 Opportunities for Strengthening Indicators on Sewage Systems and Treatment in North America 

The following observations and opportunities may be considered, to improve the indicators in 

this area for future reports:

• Data on the populations who are not served by sanitary sewers combined with data on areas where sewage 

is carried away but not treated (disinfected) would provide a better indication of potential risk of exposure, 

since untreated sewage effl uent also can be a source of exposure.

• Additional reporting potential and comparisons between countries could be improved if the countries were 

to categorize the level of treatment, i.e., no treatment, or primary, secondary or tertiary treatment. The 

quality of wastewater effl uent is the focus of increasing attention due to the presence of toxic chemicals 

and pharmaceutical products and metabolites, which pose a potential risk to children, in addition to the 

presence of biological contamination. Determining the degree of wastewater treatment and reporting on the 

availability of such treatment systems and their capacity to address these pollutants could strengthen the 

information contained in future reports.

• An evaluation of the feasibility of separating out data on children from data covering the general population 

could determine whether such efforts would be worthwhile for future reports. 

• Refi ning reporting to address children’s specifi c exposure scenarios, in terms of recreational water quality 

or contact with untreated sewage, would provide more meaningful indicators.

5.3 WATERBORNE DISEASES

I

_____________________________________________________________________________________________________I

Purpose: The indicators in this section provide information on children who have been sick from, or have 

died as a result of, waterborne diseases. 

Current indicators: 

1. Morbidity: number of cases of childhood illnesses attributed to waterborne diseases. 

2. Mortality: number of child deaths attributed to waterborne diseases. 

I

_____________________________________________________________________________________________________I

The relationship between exposure to biologically contaminated water and adverse impacts 

on children’s health is well understood. Recent outbreaks of pathogens, together with recent 

studies, suggest that drinking water may be a substantial contributor to endemic (non-outbreakrelated) gastroenteritis (see Canada’s country report).

In this section, Canada and Mexico present data on giardiasis infections (caused by the 

microscopic parasite Giardia intestinalis). Mexico also presents data on the percentage of cholera 

cases that affect children, as well as mortality rates from diarrheic diseases. The United States 

presents data on voluntarily-reported waterborne disease outbreaks for the whole population, 

by type of water system. The relationships between environmental exposures and the health 

outcomes addressed in this section are illustrated in FIGURE 10.

Giardia is a source of waterborne illness in all three countries and was selected as an indicator 

due to its greater likelihood to cause illness by water contamination than that of Campylobacter

or other bacteria that are more likely to be food-borne. 
Social conditions 

Economic conditions

Demographic conditions

EXPOSURE HEALTH OUTCOMES 

IN CHILDREN

AGENTS

Contaminants in water 

(microbial contaminants)

SOURCES

Industrial discharge

Incomplete sanitation

Run-off

Leaching from pipes

Groundwater

Surface water

Tank water 

causes or is associated with

Waterborne diseases 

(undifferentiated)

Giardiasis

Cholera 

Diarrheic diseases

Other gastro-intestinal 

illnesses

Death

Preventive

actions

Remedial

actions

ACTIONS

CONTEXTS

attributable to or

is associated with

Children's Health and the Environment in North America 85

Cholera has been a signifi cant public health challenge in Mexico. Diarrhea, which can lead to 

death in some cases, is a major health outcome associated with waterborne diseases, thus the 

national mortality rates from diarrheic diseases for children under fi ve years of age are also 

presented. Advances in the availability of sewers and pre-treatment of drinking water have 

contributed to reduced incidence of waterborne diseases and illnesses in Mexico. 

There are many additional health effects associated with exposure to contaminants found in 

the water supply. However, waterborne disease was selected because a causal relationship is well 

established and pathogens are reasonably monitored in all three countries. Despite the presence 

of monitoring and reporting systems for waterborne diseases, there are inherent diffi culties in 

differentiating cases of waterborne illness from food-borne illness. Identifying the causes of 

giardiasis was not possible for any of the countries. 

FIGURE 10: MEME Framework for the Issues Covered in the Section on Waterborne Diseases

Source: Adapted from Briggs 2003.
Number of New Cases/100,000

Years

1988

60

0

100

140

160

1990 1996 1998 2000

40

1992 1994

80

120

20

1989 1991 1993 1995 1997 1999

1-4 years

5-9 years

<1 year

15-19 years

10-14 years

86

5.3.1 Canada 

Canada presents data collected on enteric infections by the Notifi able Disease Registry. Physicians 

report the number of cases of notifi able diseases to provincial/territorial health authorities and, 

in turn, the provincial/territorial health authorities report the number of reported cases per 

100,000 population. Unfortunately, the sources of infection, which may be food-borne or from 

other sources, are not reliably distinguished from waterborne sources. 

CHART 5-8 presents the incidence of giardiasis among children. Giardiasis was selected for 

reporting as it is more likely to be associated with water contamination than Campylobacter or 

other bacteria that are more likely to be food-borne. 

CHART 5-8: Incidence of Giardiasis among Children, by Age Group, in Canada, 1988–2000

Source: Notifi able Diseases Registry, Health Canada.

KE Y OBSERVATIONS :

■ The number of reported cases of giardiasis in Canada has been declining since 1988 (with the 

exception of the age groups 10 to 14 and 15 to 19, which showed an increase). 

■ Children aged one to four are more likely to be reported as infected with Giardia. In 2000, the 

incidence of giardiasis among children aged one to four years was 60 cases per 100,000. This 

may be because they are more likely to be brought to a primary care provider and because 

they are less likely to be breastfed than infants, but more vulnerable to infection than older 

children. They are also more likely to ingest contaminated recreational water.
Number of New Cases/10, 000

Years

1998

10

0

15

20

25

2001 2002

5

1999 2000

1-4 years

<1 year 

5-14 years

Children's Health and the Environment in North America 87

5.3.2 Mexico

Mexico presents morbidity data on giardiasis and cholera, as well as mortality data on diarrheic 

disease. The impacts of waterborne diseases in Mexico have continued to fall, with improved 

coverage of water treatment and wastewater sewage systems. That said, waterborne diseases 

continue to be a high priority, based on the number of cases of illnesses that are thought to be 

linked to waterborne pathogens.

CHART 5-9 shows the incidence of giardiasis for children under the age of 15. The rate is based on 

the number of new cases per 100,000 children and the data are provided in a fi ve-year trend for 

the period 1998 to 2002, for three different age groups.

CHART 5-10 shows the percentage of cholera cases, by age group. The trend was provided over an 

8-year period, from 1991 to 1998, for three age groups. 

CHART 5-11 shows the mortality rate from diarrheic diseases in children under fi ve. This rate is 

based on the number of cases per 10,000 children, in a 13-year period. While there are numerous 

potential causes of diarrhea, including contaminated food, the majority of cases are associated 

with waterborne diseases.

CHART 5-9: Incidence of Giardiasis among Children, by Age Group, in Mexico, 1998–2002

Source: Sistema Único de Información para la Vigilancia Epidemiológica—SUIVE (Centralized Epidemiological Information 

System), Secretaría de Salud (Secretariat of Health—SSa), General Bureau of Epidemiology 

<http://www.dgepi.salud.gob.mx/suave/index.htm>.
Percent (%)

Years

1991

10

0

15

20

25

1997 1999*

5

1992 1995 1996 1998* 1993 1994

5-14 years

1-4 years

<1 year

88

CHART 5-10: Percentage of Cases of Cholera among Children, by Age Group, in Mexico, 1991–99

Source: Secretaría de Salud (Secretariat of Health—SSa), Manual de Vigilancia Epidemiológica del Cólera (Epidemiological 

Oversight Manual for Cholera) <http://www.dgepi.salud.gob.mx/suave/index.htm>.

Note: * Data for children under one year old not available for 1998 or 1999, nor for one to four year olds for 1999.
Percent (%)

Years

1990

60

0

80

120

140

1999 2001

20

1991 1996 1997 2000 1992 1993

100

40

1994 1995 1998 2002

Children's Health and the Environment in North America 89

CHART 5-11: Mortality Rate from Diarrheic Diseases in Children under Five, in Mexico, 1990–2002

Source: INEGI, Dirección General de Estadística—DGE (Statistics Department); Secretaría de Salud (Secretariat of Health—

SSa). Statistical Information Bulletin 1990–2002. 

KE Y OBSERVATIONS :

■ The epidemiological evidence of giardiasis demonstrates that the most vulnerable group is 

that of children one to four years old, showing a rate of incidence of 21 per 10,000 children 

for 1998 and diminishing to 16 in 2002 (CHART 5-9). 

■ In the group of children below one year of age, the measures implemented for the diarrhea 

programs have decreased the incidence of giardiasis, from 18 to 13 per 10,000 children, for 

1998 and 2002, respectively (CHART 5-9).

■ In the period from 1991 to 1998, children under one year of age had the lowest percentage of 

cases of cholera, with a general downward trend (CHART 5-10).

■ The age group most affected by cholera is that from one to four years, with the percentage of 

cases ranging from 6 percent to 18 percent of all cases (CHART 5-10).

■ Cholera declined for the fi ve to 14–year-old age group, from 20 percent in 1991 to 7 percent 

in 1998. This can be attributed to the growing penetration of disinfected drinking water, and 

the fact that prevention measures to limit cholera outbreaks were effective in controlling this 

public health problem (CHART 5-10).

■ The rate of mortality from diarrheic disease per 100,000 children under fi ve decreased from 125.6 

in 1990 to 33.32 in 1997, representing a reduction of 73.5 percent. This was above the original goal 

of 50 percent as stated in the World Children’s Summit. By 2002, the mortality rate for children 

under fi ve decreased to 20 per 100,000 children. This is primarily due to specifi c healthcare actions 

and the actions in other sectors, principally education and basic sanitation. It should be noted that 

the phenomenon is worse in marginalized urban and rural areas (CHART 5-11).

■ In recent years, the main component in reducing mortality in children under fi ve years of age has 

been the decrease in mortality from diarrheic diseases. Between 1990 and 1997, 55,043 deaths 

from such causes have been prevented, and 10,756 more were avoided in 1998 (data not shown).
Number of Outbreaks

Years

1971

30

0

40

10

50

20

19731975197719791981198319851987198919911993199519971999

Noncommunity

Individual

Community

2000

90

5.3.3 United States

The United States is unable to provide child-specifi c data for this indicator, but is able to provide 

data on the number of reported waterborne disease outbreaks for the general population that 

are associated with drinking water. The data are from a voluntary reporting system, covering the 

period 1971–2000, and include community water systems, non-community water systems and 

individual water systems.

Non-community water systems are systems that either: 1) regularly supply water to at least 25 of the 

same people at least 6 months per year but not year-round (e.g., schools, factories, offi ce buildings, 

and hospitals that have their own water systems), or 2) provide water in a place where people do 

not remain for long periods of time (e.g., a gas station or campground). Individual water systems

are not regulated by the Safe Drinking Water Act and serve fewer than 25 persons or 15 service 

connections, including many private wells. Community water systems provide water to at least 

25 of the same people or service connections year-round.

CHART 5-12 shows waterborne disease outbreaks, by year and type of water system. These data 

are for the period 1971 to 2000.

CHART 5-12: Waterborne Disease Outbreaks in the General Population, by Year and Type of Water 

System, in the United States, 1971–2000

Source: Based on data presented by Craun, G.F., and R.L. Calderon. 2003. Waterborne outbreaks in the United States, 1971–2000. 

In Drinking Water Regulation and Health, Frederick W. Pontius (ed.) 2003. (New York, NY: John Wiley & Sons), 40–56.

Note: A waterborne disease outbreak is defi ned as an event in which: 1) more than two persons have experienced an illness 

after either the ingestion of drinking water or exposure to water encountered in recreational or occupational settings, and 2) 

epidemiological evidence implicates water as the probable source of illness.

KE Y OBSERVATIONS :

■ Between 1971 and 2000, there were 751 reported waterborne disease outbreaks associated 

with drinking water from individual, non-community systems and community water systems 

(CHART 5-12).

■ During 1999–2000, a total of 44 outbreaks (18 from private wells, 14 from non-community 

systems, and 12 from community systems) associated with drinking water were reported by 

25 states (CHART 5-12).
Children's Health and the Environment in North America 91

5.3.4 Opportunities for Strengthening Indicators on Childhood Morbidity and Mortality from 

Waterborne Diseases in North America

Waterborne disease is an area with reasonable evidence linking exposure to waterborne 

pathogens and the corresponding health effects in children. Yet the experiences of the three 

countries on reporting waterborne disease highlighted limitations in surveillance activities. 

The following observations and opportunities may be considered in the effort to improve the 

indicators presented in this section in future reports:

• Better surveillance and tracking systems are needed. Furthermore, these should be done in such a way to 

make it possible to distinguish diseases related to water-based exposures as compared to those caused 

by food exposures.

• Exposure data for priority chemicals of concern to children’s health could be a worthwhile future indicator, 

to broaden the scope beyond pathogens. This indicator would need to be based on environmental water 

quality testing. 

• Waterborne disease outbreak data are available in all three countries but differ considerably across the 

regions. The following opportunities could provide improved data quality and comparability:

• Comparability will be enhanced if reporting can be standardized for all waterborne diseases. 

• Standardizing the reporting periods, beginning with the most current year for which all three countries 

can submit data would help with comparisons. Presenting morbidity data for different age groups 

would be worthwhile as well.

• Further categorizing outbreak data to refl ect the type of water system involved may provide additional 

useful information that could aid in defi ning priorities for action. 
92

All three countries recognize that the primary goal is to ensure that our children are healthy 

 by preventing harmful environmental exposures—even when there is some uncertainty 

 
6.0 Lessons Learned and Actions Needed

A key focus of this initiative has been on improving children’s environments and health, and 

to bring attention to children’s health, through a collective commitment to improve indicators 

of children’s health and the environment in North America. Each country has gained considerable experience through the process of creating this initial report. Opportunities for 

improvement have been identified in each of the indicator discussions. In the absence of 

comparable data among the three countries, the use of a flexible approach that allows for the 

use of available data sets has proven to be critical. The active involvement of officials from the 

three countries and their commitment to compiling the country-specific reports on which 

this North American report is based have been other invaluable features of the approach 

taken. The sharing of data, methodologies and surveillance strategies (i.e., experiences 

and approaches of the countries and other partners) presents an excellent opportunity for 

learning from one another. Further efforts should be made to promote improvements based 

on this collaborative approach.

As this is the first integrated regional effort within the broader context of the Global Initiative 

on Children’s Environmental Health Indicators, led by WHO, there is the potential for 

sharing the collective experiences and lessons learned from this North American initiative 

with other interested countries or regions.

Each of the following observations and/or actions will be considered by the participating 

countries and the other partners. It is important to note that each country has unique 

circumstances and is at differing stages in addressing children’s health and environmental 

issues and in developing their national and subnational surveillance systems. Thus these lessons 

and actions will need to be considered within the context of each country’s priorities.

CHILDREN’S HEALTH AND THE ENVIRONMENT IN NORTH AMERICA

Commission for Environmental Cooperation 93
94

Understanding that the reduction/elimination of environmental risks to children’s health is the 

ultimate goal, the following points focus on actions needed to improve our ability to report meaningful 

and useful indicators.

• Exposure surrogate indicators are an important source of information on potential environmental 

exposures that could impact on children’s health. However, in situations where there is evidence 

that poor health outcomes result from exposure to environmental contaminants, future indicators 

should attempt, where possible, to measure and report direct exposures. This approach would 

require a greater reliance on surveillance activities in all three countries.

• Evidence from biomonitoring programs offers measures of direct exposure (e.g., blood 

cotinine indicates exposure to nicotine). This information can be extremely valuable to 

government decision makers in order to target policy and program activity and action to 

reduce exposures. The use of biomonitoring as a means of identifying and quantifying 

exposures should be encouraged and the resulting information used to create more specifi c 

indicators. The CEC’s Sound Management of Chemicals (SMOC) initiative9

 on blood monitoring of PCBs and metals in women of childbearing age is an encouraging example of regional 

cooperation in this area and could be built upon and expanded.10 By utilizing the results of 

this and other biomonitoring efforts, future indicators reports could address chemicals such 

as mercury that have known effects on children, as well as chemicals of emerging concern 

(e.g., brominated fl ame retardants).

• Exposure to environmental contaminants is higher for some segments of society than others. 

These particularly vulnerable sub-populations may also suffer the compounding effects of poverty, 

poorer nutrition and lack of access to health care. Improved surveillance associated with specifi c 

vulnerable sub-populations, including aboriginal children, children of ethnic minorities, and 

children in families who are economically disadvantaged, should be a priority for future reports. 

• The relationship between federal governments, state/provincial and municipal governments 

and the multiple agencies addressing health and environment issues for all segments of 

society is an important consideration of future improvement efforts. Increased involvement 

at state/provincial levels of government in future compilation of the indicators may enhance 

data availability in some cases.

• Greater efforts to collect relevant health effects data from health information systems could 

enhance national surveillance in each country. Improved surveillance data would enhance 

the tracking of health effects indicators on topics such as waterborne morbidity and mortality, 

and asthma. Regional cooperation should also be promoted to ensure that surveillance 

systems generate comparable information (e.g., through the use of common data elements, 

synchronized data collection and similar periodicity of data collection).

9 For more information on the CEC’s SMOC program, please see the pollutants and health section of the CEC website at <www.cec.org>.

10 CEC’s Sound Management of Chemicals (SMOC) initiative will monitor the blood of women of childbearing age for metals in the 

categories (a) As, Cd, Co, Ni, Pb; (b) Be, Cu, Sn, Tl, Zn; and (c) Hg; and for persistent organic pollutants (POPs) in the categories (a) PCB 

congeners 28, 52, 99, 101, 105, 118, 128, 138, 153, 156, 170, 180, 183, and 187; and (b) OCS: aldrin, cis-chlordane, trans-chlordane, pp’-DDE, 

pp’-DDT, dieldrin*, heptachlorepoxide*, hexachlorobenzene, α-hexachlorocyclohexane (α-HCH, or lindane), mirex, cis-nonachlor, 

trans-nonachlor, oxychlordane.
Children's Health and the Environment in North America 95

• Health outcome indicators are constrained by our limited knowledge of cause and effect 

relationships between environmental contaminants and associated health outcomes in 

children. This is particularly challenging given that many of these exposures result from 

chronic low-dose exposures beginning in the womb. Further investment in research to 

improve knowledge in specifi c areas of concern for children’s health should be a priority for 

all governments, and for the region. Regional cooperation and building upon the research 

investigations of the US National Children’s Study should be pursued. 

• More research is also needed to better understand the pathways of children’s exposure to 

environmental contaminants, including how contaminants cycle in the environment, 

patterns of dietary exposure, behavioral activities that put children at increased risk of 

exposure, and other such issues. This information is required to support better assessment of 

risks, for the development of more accurate indicators, and to improve our ability to target 

exposure prevention and reduction efforts.

• Information on whether safety guidelines and/or regulatory standards have been exceeded is 

useful for generating indicators. Ideally, such indicators also should describe the frequency 

and extent of the exceedances, and should specify the level of the safety guideline or regulatory 

standard in question. 

• Indicators which report prevalence and incidence offer different information useful to 

understanding and interpreting the progress of disease and disorders (e.g., asthma). This 

report refl ects a greater use of prevalence data. However, to the extent that indicators will 

continue to evolve there may be more focus on indicators of incidence in the future.

• The current list of indicators is recognized as a starting point based on what was feasible for the 

initial report. The indicator set should be expanded over time as the current list is not suffi cient 

to address all known environmental risks to children’s health. Moreover, indicator development 

needs to keep up with the rapidly evolving epidemiological research in this fi eld, as scientists 

continue to fi nd associations between environmental exposures and child health outcomes.

• In addition to addressing the data gaps identifi ed in the report, the countries should work 

together to develop specifi c action plans to address comparability of indicators of children’s 

health and the environment such as data collection methodologies, comparability of time 

periods for data collection and action levels, etc. 

All three countries recognize that the primary goal is to ensure that our children are healthy by preventing 

harmful environmental exposures and thereby reducing related diseases—even when there is some 

uncertainty about the exact relationships between environmental threats and children’s health. The 

development and use of indicators play an important role in identifying where disease prevention and 

environmental protection efforts will provide the greatest benefi t to children’s health, including vulnerable 

sub-populations and communities at higher risk. It is our hope that the outcomes of our collective efforts 

to enhance indicators of children’s health and the environment will ultimately result in the reduction of 

exposures and disease.
96

List of Figures and Charts

CHART I-1: List of Indicators for Children’s Health and the Environment in North America xiv

CHART 1-1: North American Indicators for Children’s Health and the Environment, by Issue Area 6

FIGURE 1: Multiple Exposure-Multiple Effect (MEME) Framework 8

FIGURE 2: MEME Framework for Issues Covered in the Section on Outdoor Air Pollution 17

CHART 3-1: Peak Levels of Ground-level Ozone, for Selected Regions of Canada, 1989-2002 18

CHART 3-2: Number of Days in 2002 on which Ground-level Ozone Levels 

 Exceeded the Canada-wide Standard 19

CHART 3-3: Number of Days in 2002 on which PM2.5 Levels Exceeded the Canada-wide Standard 19

CHART 3-4: Peak Levels of Ground-level Ozone for Five Mexican 

 Urbain Air Monitoring Zones, 1990-2002 20

CHART 3-5: Annual Mean Levels of Particulate Matter (PM10) for Five Mexican 

 Urbain Air Monitoring Zones, 1990–2002 21

CHART 3-6: Metropolitan Areas in Mexico with Air Quality Programs 

 Including Air Monitoring, 1999-2002 21 

CHART 3-7: Percentage of Children Living in Counties in the United States 

 in which Air Quality Standards were Exceeded, 1990-2003 23

FIGURE 3: MEME Framework for Issues Covered in the Section on Indoor Air Pollution 25

CHART 3-8: Percentage of Children Exposed to Environmental Tobacco Smoke 

 in Canadian Homes, by Age Groups, 1999-2002 26

CHART 3-9: Percentage of Fuel Wood Users, at the Municipal Level, in Mexico, 2000 27

CHART 3-10: Percentage of Children Aged Six and Under Regularly Exposed 

 to Environmental Tobacco Smoke in US Homes, 1994-2003 28

CHART 3-11: Percentage of Children Aged Four to 11 with Detectable Levels 

 of Blood Cotinine, by Race and Ethnicity, in the United States, 1988-1994 and 1999-2000 28

FIGURE 4: MEME Framework for Issues Covered in the Section on Asthma 31

CHART 3-12: Prevalence of Physician-diagnosed Asthma (ever) among Children, 

 by Age Group, in Canada, 1994/1995, 1996/1997 and 1998/1999 32

CHART 3-13: Incidence of Asthma among Children, by Age Group, in Mexico, 1998-2002 33

CHART 3-14: Incidence of Acute Respiratory Infections (ARI) among Children, 

 by Age Group, Mexico, 1998-2002 34

CHART 3-15: Percentage of Children with Asthma, in the United States, 1980-2003 35

FIGURE 5: MEME Framework for Issues Covered in the Sections on Blood Lead Levels, 

 Lead in the Home, and Industrial Releases of Lead 41

CHART 4-1: Decline in the Geometric Mean of the Blood Lead Concentrations 

 related to a Decline in Consumption of Leaded Gasoline, in Ontario, Canada, 1983-1992 42

CHART 4-2: Blood Lead Levels of Children in Rural and Urban Populations, in Mexico 43

CHART 4-3: Atmospheric Monitoring of Lead, and Principal Activities to Reduce 

 Lead Emissions, in the Valley of Mexico City Metropolitan Zone (ZMVM), 1990-2000 44

CHART 4-4: Local Air Quality Data from Metallurgical Activities, in Torreón, Mexico, 1999-2003 46

CHART 4-5: Lead Content in Local Soil Samples Taken around Met-Mex Peñoles, in Mexico, 1999-2003 46

CHART 4-6: Annual Average Blood Lead Levels in Children under 15 and Who Participated in the 

 Metals Program in Torreón, Mexico, 1998-2004 47

CHART 4-7: Concentration of Lead in the Blood of Children Five and Under, 

 in the United States, 1976-2002 48

CHART 4-8: Distribution of Concentrations of Lead in Blood of Children, Aged One to Five, 

 in the United States, 1999-2000 49
Children's Health and the Environment in North America 97

CHART 4-9: Median Concentrations of Lead in Blood of Children, Aged One to Five, 

 by Race/Ethnicity and Family Income, in the United States, 1999-2000 49

CHART 4-10: Impact of Lead Poisoning Prevention Policy on Reducing Children’s Blood Lead Levels, 

 in the United States, 1971-2002 50

CHART 4-11: Percentage of Children Living in Pre-1960 Homes, by Age Group, 

 in Canada, 1991, 1996, 2001 52

CHART 4-12: Communities with Pottery Activities, by State, in Mexico, October 2001 53

CHART 4-13: Lead in US Housing, 1998-2000 54

CHART 4-14: On- and Off-site Releases of Lead (and its compounds), in Canada, 1995-2000 57

CHART 4-15: On- and Off-site Releases of Lead (and its compounds), in the United States, 1995-2000 58

FIGURE 6: MEME Framework for Issues Covered in the Section on Industrial 

 Releases of Selected Chemicals 60

CHART 4-16: On- and Off-site Releases of Matched Chemicals, in Canada, 1998-2002 61

CHART 4-17: Total On- and Off-site Releases of Matched Chemicals, 

 by Industry Sector, in Canada, 1998-2002 62

CHART 4-18: On- and Off-site Releases of Matched Chemicals, in the United States, 1998-2002 63

CHART 4-19: Total On- and Off-site Releases of Matched Chemicals, by Industry Sector, 

 in the United States, 1998-2002 64

FIGURE 7: MEME Framework for Issues Covered in the Section on Pesticides 66

CHART 4-20: Percentage of Sampled Fresh Fruits and Vegetables with Detectable 

 Organophosphate Pesticide Residues, in Canada, 1995-2002 67

CHART 4-21: Cases of Pesticide Poisonings in Children (under 15 years old) 

 and the General Public, in Mexico, 1998-2002 68

CHART 4-22: Percentage of Fruits, Vegetables and Grains with Detectable 

 Residues of Organophosphate Pesticides, in the United States, 1994-2001 69

FIGURE 8: MEME Framework for the Issues Covered in the Section on Drinking Water 73

CHART 5-1: Percentage of Canadians Not Connected 

 to Public Water Distribution Systems, 1991, 1994, 1996 and 1999 74

CHART 5-2: Percentage of the Population without Potable Water, in Mexico, 1980-2000 75

CHART 5-3: Percentage of the Population without Piped Water, by State, in Mexico, 2000 76

CHART 5-4: Percentage of Children Living in Areas Served by Public Water Systems that Exceed 

 a Drinking Water Standard or Violate Treatment Requirements, in the United States, 1993-1999 78

CHART 5-5: Percentage of Children Living in Areas Served by Public Water Systems 

 with Major Violations of Drinking Water Monitoring and Reporting Requirements, 

 in the United States, 1993-1999 79

FIGURE 9: MEME Framework for the Issues Covered in the Section on Sanitation 81

CHART 5-6: Percentage of the Population Not Served by Sewer Services, in Mexico, 1980-2000 82

CHART 5-7: Percentage of Homes without Sewer Services, by State, in Mexico, 2000 83

FIGURE 10: MEME Framework for the Issues Covered in the Section on Waterborne Diseases 85

CHART 5-8: Incidence of Giardiasis among Children, by Age Group, in Canada, 1988-2000 86

CHART 5-9: Incidence of Giardiasis among Children, by Age Group, in Mexico, 1998-2002 87

CHART 5-10: Percentage of Cases of Cholera among Children, by Age Group, in Mexico, 1991-1999 88

CHART 5-11: Mortality Rate from Diarrheic Diseases in Children under Five, in Mexico, 1990-2002 89

CHART 5-12: Waterborne Disease Outbreaks in the General Population, 

 by Year and Type of Water System, in the United States, 1971-2000 90
98

List of Abbreviations

μg microgram

μg/dL microgram per deciliter

ARI acute respiratory infection

ADHD attention-deficit/hyperactivity disorder

BaP benzo[a]pyrene

BLLs blood lead levels

Conapo Consejo Nacional de Població (National Population Council) (Mexico)

CEC Commission for Environmental Cooperation

CEHI Global Initiative on Children's Environmental Health Indicators (WHO-US EPA)

CEPA Canadian Environmental Protection Act

CNA Comisión Nacional del Agua (National Water Commission) (Mexico)

CO carbon monoxide

CTUMS Canadian Tobacco Use Monitoring Survey 

DGE Dirección General de Estadística (Statistics Department) (Mexico)

EPA (US) Environmental Protection Agency 

ETS environmental tobacco smoke

Fonart Fondo Nacional para el Fomento de las Artesanías (National Artisan 

 Development Fund)(Mexico) 

Imeca Indice Metropolitano de la Calidad del Aire (Metropolitan Air Quality Index) (Mexico) 

INEGI Instituto Nacional de Estadística, Geografía e Informatica (National Institute 

 of Statistics, Geography and Informatics) (Mexico)

ISAAC International Study of Asthma and Allergies in Childhood

IJC HPTF International Joint Commission Health Professionals Task Force

MEME multiple exposure–multiple effect

MUD Municipal Water Use Database (Canada)

NAAQS National Ambient Air Quality Standards (United States)

NO2 Nitrogen dioxide

NPHS National Population Health Survey (Canada) 

NPRI National Pollutant Release Inventory (Canada)

OECD Organization for Economic Cooperation and Development

PAHO Pan American Health Organization

ppb parts per billion

PICCA Programa Integral Contra la Contaminación Atmosférica en el Valle de México 

(Integrated Program for Air Pollution Control in Mexico City) (Mexico)

PM2.5 fine particulate matter

PM10 particulate matter

POPs persistent organic pollutants

PRTR pollutant release and transfer register

RETC Registro de Emisiones y Transferencia de Contaminantes (Pollutant Release and 

 Transfer Register) (Mexico)

SHS secondhand smoke

SIDS sudden infant death syndrome

SSa Secretaría de Salud (Secretariat of Health) (Mexico)

SMOC Sound Management of Chemicals (CEC)

SO2 sulfur dioxide

SUAVE Sistema Único Automatizado de Vigilancia Epidemiológica (Centralized Automated 

 Epidemiological Oversight System)of Mexico's Secretaría de Salud (Secretariat of Health).

SUIVE Sistema Único de Información para la Vigilancia Epidemiológica (Centralized 

 Epidemiological Surveillance System)

TEL tetraethyl lead

TRI Toxics Release Inventory (United States)

UNEP United Nations Environment Programme

UNICEF United Nations Children’s Fund

WHO World Health Organization

WSSD World Summit on Sustainable Development
Children's Health and the Environment in North America 99

Glossary

Action Indicator / An indicator that aims to track actions and/or their impacts (e.g., governmental action, 

private sector action) to address a source of potential environmental health risk. For example, trends in 

PRTR data can provide an indication of the impact of governmental policies/regulations and/or industry 

action to reduce releases of toxic chemicals to the environment.

Acute respiratory infection (ARI) / Any acute viral or bacterial infection of the respiratory tract. Acute 

upper respiratory infections comprise infections of the upper respiratory tract, including the throat, 

nasopharynx, sinuses and larynx. Acute lower respiratory infections affect the trachea, bronchi and lungs.

Air quality standards / Maximum allowable concentrations of pollutants. Typically applies to the common air 

pollutants (carbon monoxide, ground-level ozone, particulate matter, sulfur dioxide, and nitrogen dioxide).

Allergens / An allergen is a substance that can cause an allergic reaction. Allergens are substances which 

are recognized by the immune system in some people as “foreign” or “dangerous,” but cause no reaction in 

most people (US National Library of Medicine 2005).

Ambient air / Outdoor air, any unconfi ned portion of the atmosphere, open air (US EPA 2003).

Arithmetic mean / The sum of all the values of a set of measurements, divided by the number of values in the 

set, usually denoted by x-; a measure of central tendency (US EPA 2005a).

Asthma / A chronic infl ammatory disorder of the lungs. Symptoms include wheezing, breathlessness, chest 

tightening, and cough (US EPA 2003).

Atopy / The increased tendency, seen in some people, to produce immediate hypersensitivity reactions 

(usually mediated by IgE antibodies) against innocuous substances (Janeway et al. 2001).

Attention-defi cit/hyperactivity disorder (ADHD) / A disorder in which the prominent symptoms are hyperactivity, inattention and impulsivity. Also referred to as ADD (attention defi cit disorder) (US EPA 2003).

Benzene / A colorless, volatile, fl ammable, toxic liquid aromatic hydrocarbon. Benzene (C6H6) is used in 

organic synthesis, as a solvent, and as a component of motor fuel. It is a known human carcinogen and an 

important hazardous air pollutant (US EPA 2003).

Benzo[a]pyrene (BaP) / BaP’s molecular structure includes two or more fused aromatic rings and adjacent 

rings share two or more carbon atoms. The principal natural sources of BaP are forest fi res and volcanoes 

during eruptions. Anthropogenic sources include the combustion of fossil fuels, coke oven emissions and 

vehicle exhausts (Health Canada 1988).

Bioaccumulation / A process by which chemical substances are ingested and retained by organisms, either 

from the environment directly or through consumption of food containing the substances (Canada, 

Greening the Government 2005).

Biomonitoring / Assessment of human exposure to chemicals by measuring the chemicals or their 

metabolites in human tissues or fl uids such as hair, urine or blood.

Birth rate / A measurement of the number of births in a year in relation to the population.

Biomass / Biomass can include organic and inorganic matter such as wood, dung, agricultural residues, 

straw and wood. Combustion of these materials for cooking and heating leads to indoor air pollution and 

to the release of hundreds of pollutants which (may) cause mild to severe damage to health.

Blood lead level (BLLs) / Blood lead level is a biomonitoring measure of lead in venous blood to determine 

recent lead exposures. Eliminating blood lead levels (BLLs) >10 μg/dL in children is a goal of many national 

and international health and environmental organizations. 

Body burden / The amount of a substance in the body. Some substances build up in the body because they 

are stored in fat or bone or because they are eliminated from the body (United States Agency for Toxic 

Substances and Disease Registry (ASTDR) 2004).

Bronchiolitis / Bronchiolitis is an infl ammation of the bronchioles (small passages in the lungs), usually 

caused by a viral infection (US National Library of Medicine 2005).
100

Bronchitis / Bronchitis is an infl ammation of the main air passages to the lungs. Bronchitis may be sudden 

(acute) and short-lived, or chronic, meaning that it lasts a long time and often recurs. To be classifi ed as chronic, 

you must have a cough with mucus most days of the month for three months out of the year (US National 

Library of Medicine 2005).

Campylobacter / Campylobacter enteritis is an infection in the small intestine caused by Campylobacter 

jejuni, a type of bacterium (US National Library of Medicine 2005).

Carbon monoxide (CO) / A colorless, odorless, poisonous gas produced by incomplete

combustion of fossil fuels (US EPA 2003).

Carcinogen / Specifi c substance or chemical that gives rise to a cancer. Also, a cancer-forming agent 

(Rothenberg and Chapman 2000).

Cholera / Cholera is an infection of the small intestine caused by the bacterium Vibrio cholerae. It results 

in profuse, watery diarrhea (US National Library of Medicine 2005).

Contaminant / Any physical, chemical, biological, or radiological substance or matter in air, water or soil 

that can have adverse health effects (US EPA 2003).

Cotinine / A major metabolite of nicotine found in blood and urine. Currently regarded as the best 

biomarker for exposure of nonsmokers to environmental tobacco smoke (US EPA 2003).

Deciliter / One-tenth of a liter (0.1 liter) (US EPA 2003).

E. coli / E. coli enteritis is an infl ammation of the small intestine caused by Escherichia coli bacteria (US 

National Library of Medicine 2005).

Effect indicator (health effect indicator) / An effect indicator is intended to measure adverse impacts on health 

that are or may be due to exposures to environmental hazards. For example, an effect indicator could measure 

the number of illnesses or deaths that result from waterborne disease.

Endocrine system / Network of endocrine glands, which produce and secrete hormones directly into the bloodstream for transport to specifi c target organs, where they exert their effect. Along with the nervous system, the 

endocrine system coordinates and regulates many of the activities of the body, including growth, metabolism, 

sexual development, and reproduction (Rothenberg and Chapman 2000).

Environmental health indicator / An expression of the link between environment and health, targeted at an 

issue of specifi c policy or management concern and presented in a form which facilitates interpretation for 

effective decision-making (Corválan, Briggs and Kjellstrom 1996).

Environmental tobacco smoke (ETS) / Mixture of smoke exhaled by a smoker and the smoke from the burning end of 

the smoker’s cigarette, pipe or cigar. Also known as secondhand smoke (SHM), or passive smoke (US EPA 2003). 

Epidemiological studies / Studies that research the incidence, distribution and control of disease in a population (US EPA 2003).

Exacerbation of asthma / Increase in the frequency or severity of asthma attacks or symptoms in individuals 

who have asthma (US EPA 2003).

Exceedance / Occurrence of a pollutant being detected at a quantity above that of a regulatory standard or 

other target level.

Exposure / A measure of the occurrence and/or magnitude of human contact with environmental contaminants 

in media, including air, water, soil and food.

Exposure indicator / An exposure indicator measures exposure to an environmental hazard.

Fetus / The unborn child, at the stage of development occurring from the end of the 8th week after conception 

until birth. For the fi rst eight weeks, the unborn child is called an embryo (Page 2002).

Formaldehyde / A colorless, pungent-smelling gas; an important hazardous air pollutant. High concentrations 

may trigger attacks in people with asthma. Sources include environmental tobacco smoke and other 

combustion sources; pressed wood products (such as particle board); and certain textiles, foams, and glues 

(US EPA 2003).
Children's Health and the Environment in North America 101

Fugitive emission / A release of chemicals to air that occurs through a valve (intentionally or unintentionally) 

or a leak. Classifi ed as a “non-point” emission.

Gastrointestinal / Relating to, affecting, or including the stomach and/or intestine (US EPA 2003).

Geometric mean / The antilogarithm of the mean of the logarithms of all the values in a set (US EPA 2005a).

Giardia intestinalis / Protozoan that causes an infection of the small intestine. Also known as Giardia 

lamblia or Giardia duodenalis (United States National Library of Medicine 2005).

Giardiasis / Intestinal infection caused by the protozoan Giardia, and is spread by contaminated water or 

contact with an infected person (United States National Library of Medicine 2005).

Ground-level ozone / Ground-level ozone (smog) is formed by a chemical reaction between volatile organic 

pollutants (VOCs) and oxides of nitrogen (NOX), in the presence of sunlight. Ozone concentrations can reach 

unhealthy levels when the weather is hot and sunny, with little or no wind. Ozone at ground level causes adverse 

effects on lung function and respiration (US EPA 2003).

Hypertension / Persistently raised blood pressure, exceeding about 140 mm Hg (systolic) and 90 mm Hg 

(diastolic) at rest.

Incidence / The number of new people who develop a condition during a specifi c time period.

Lower respiratory tract infections / Lower respiratory tract infections affect the breathing passage, notably the 

trachea, bronchi, and lungs, and include acute bronchitis, acute bronchiolitis, and pneumonia (Page 2002).

Media / Specifi c environments such as air, water, food, and soil (US EPA 2003).

Methemoglobinemia / A condition that reduces the ability of the blood to transport oxygen throughout 

the body for essential metabolism; it is due to the replacement of hemoglobin with methemoglobin in the 

blood. A small amount of methemoglobin is present in the blood normally, but injury or toxic agents—

such as nitrites—convert a larger proportion of hemoglobin into methemoglobin (US EPA 2003).

Microgram (μg) / One-millionth of a gram (=10-6 g) (US EPA 2003).

μg/dL / Microgram per deciliter (US EPA 2003).

Monitoring and reporting violation / Violation of monitoring and reporting requirements that specify how 

and when water must be tested for the presence of contaminants as defi ned by the US Safe Drinking Water 

Act (US EPA 2003).

Morbidity / Illness or disability rate, usually expressed per 1000 population (World Health Organization—

Regional Offi ce of Europe 2005).

Mortality / Death rate per defi ned population, usually expressed per 1000 (World Health Organization—

Regional Offi ce of Europe 2005).

National Pollutant Release Inventory (NPRI) / The Canadian database of information on annual releases to air, 

water, land and disposal or recycling, from all sectors—industrial, government, commercial and others.

Neuroblastoma / Cancer that arises in immature nerve cells and affects mostly infants and children (US EPA 2003).

Neurotoxicity / Extent of being poisonous or harmful to nerves and nerve cells (Rothenberg and Chapman 2000).

Nitrates (NO3) and nitrites (NO2) / Nitrogen-oxygen chemical units that combine with various organic and 

inorganic compounds. Once taken into the body, nitrates are converted into nitrites. The greatest use of 

nitrates is as a fertilizer. Other sources include animal manure and human sewage (US EPA 2003).

Nitrogen dioxide (NO2) / A chemical that results from nitric oxide combining with oxygen in the atmosphere; 

a major component of photochemical smog (US EPA 2003).

Nitrogen oxides / A family of highly reactive gases (including nitrogen dioxide, above) that form when fuel 

is burned at high temperatures. Emitted principally from motor vehicle exhaust and stationary sources 

such as electric power plants and industrial boilers (US EPA 2003).

Off-site release / Term used in reporting of PRTR data. The disposal of chemicals in waste by removal off the 

grounds of the reporting facility to other facilities or other locations. A similar activity to on-site releases, but 

occurring at other locations. The classifi cation also includes metals sent to disposal, treatment, sewage, and 
102

energy recovery. This approach recognizes the physical nature of metals and acknowledges that metals in such 

wastes are not likely to be destroyed or burned and so may eventually enter the environment (CEC 2004).

On-site release / Term used in reporting of PRTR data. The disposal of chemicals in waste by release on-site 

to air, water, underground injection, or land, at the location of the reporting facility (CEC 2004).

On-site air release / Term used in reporting of PRTR data. Releases to air that occur through identifi ed 

outlets such as stacks (“smokestacks”) or vents are labeled “stack” or “point” emissions. Air releases that 

occur because of leaks or valves are labeled “fugitive” or “non-point” emissions.

On-site land release / Term used in reporting of PRTR data. Methods of release to land at the facility 

include burying chemical waste in landfi lls, incorporating it into soil (“land treatment”), holding it in 

surface impoundments, accumulating it in waste piles, or disposing of it by other means.

On-site underground injection / Term used in reporting of PRTR data. Facilities may inject listed chemicals 

in waste into deep underground wells. Underground injection is regulated, and deep wells that receive toxic 

waste are intended to isolate the pollutants from groundwater sources.

On-site water release / Term used in reporting of PRTR data. Releases to surface water bodies such as 

rivers and lakes generally occur through discharge pipes. Wastewater is usually treated fi rst, to remove or 

minimize its pollutant content. Rainwater may also wash pollutants from on-site waste storage areas into 

surface waters; these releases from run-off should also be reported.

Organophosphate pesticides / A group of approximately 40 closely related pesticides that affect functioning 

of the nervous system. Examples include chlorpyrifos, phosmet, and methyl parathion (US EPA 2003).

Otitis media / Fluid in the middle ear; middle ear infection.

Parts per billion (ppb) / One part or unit of a substance in a billion parts or units of the medium in which 

it is contained (i.e., typically, air or water).

Particulate matter (PM2.5 and PM10) / Particles in the air, such as dust, dirt, soot, smoke, and droplets. Small 

particles (PM10 [diameter 10 microns or less] or PM2.5 [diameter 2.5 microns or less]) have signifi cant 

effects on human health (US EPA 2003).

Passive smoke / Mixture of smoke exhaled by a smoker and smoke from the burning end of the smoker’s 

cigarette, pipe, or cigar. Also known as environmental tobacco smoke (ETS), or secondhand smoke. 

Persistent organic pollutants (POPs) / Chemical substances that persist in the environment, bioaccumulate 

through the food web, and pose a risk of causing adverse health effects to human health and the environment 

(UNEP date unknown).

Pesticides / Chemical agents used to kill insects or other organisms harmful to crops and other cultivated 

plants (Martin 2002).

Plasticizers / Small, often volatile molecules that are added to hard, stiff plastics to make them softer and 

more fl exible (US EPA 2003).

Pollutant release and transfer register (PRTR) / A catalogue, or register, that comprises information on releases 

of specifi c chemicals to air, water and soil, as well as transfers to treatment and disposal sites. Examples 

include NPRI (Canada), RETC (Mexico) and TRI (United States) (Inter-Organisation Programme for the 

Sound Management of Chemicals Pollutant Release and Transfer Registers Coordinating Group 2003).

Potable water / Water that is suitable for human consumption and for all normal domestic purposes, including 

personal hygiene (Pan American Center for Sanitary Engineering and Environmental Sciences et al. 2002). 

Poverty level / There is no offi cial measure of poverty in Canada. However, relatively low-income families 

are categorized using the low-income cut-off (LICO) statistic. Families that spend 20 percent more than 

the average Canadian family on food, clothing and shelter are considered to be living on “low income” 

(Statistics Canada 2001).

Mexico defi nes poverty as households with per capita income below that required to satisfy basic food 

needs, equivalent to 15.4 and 20.9 pesos per day, respectively, in rural and urban areas.

The United States defi nes poverty level as an income level below which an individual or family is considered 

poor. The US Census Bureau defi nes poverty level based on a set of money income thresholds that vary by 

family size and composition. If a family’s total income is less than that family’s threshold, then that family, 

and every individual in it, is considered poor. The Census Bureau updates its poverty thresholds annually. 

In 2000, a family of two adults and two children with total income below $17,463 was considered below the 
Children's Health and the Environment in North America 103

poverty level. Tables showing the Census Bureau’s poverty thresholds are available at: <http://www.census.

gov/hhes/poverty/threshld.html> (US EPA 2003).

Pneumonia / Pneumonia is an infl ammation of the lungs caused by an infection. Many different organisms can 

cause it, including bacteria, viruses, and fungi (US National Library of Medicine 2005).

Prenatal / Occurring, existing, or performed before birth (US EPA 2003).

Prevalence / The number of people in the population who have a condition at a specifi c time. 

Radionuclides / Radioactive isotopes or unstable forms of elements (US EPA 2003).

Registro de Emisiones y Transferencia de Contaminantes (RETC) / Mexico’s pollutant release and transfer 

register (RETC) is a publicly available database (PRTR) that compiles information on toxic chemical 

releases from companies in Mexico that report releases, on an annual basis.

Respiratory effects / Effects on the process of breathing or on the lungs (US EPA 2003).

Secondhand smoke (SHS) / Mixture of smoke exhaled by a smoker and the smoke from the burning end of the 

smoker’s cigarette, pipe, or cigar. Also known as environmental tobacco smoke (ETS), or passive smoke. 

Sensitivity / The ability of a system to detect epidemics and other changes in disease occurrence. The proportion of 

persons with disease who are correctly identifi ed by a screening test or case defi nition as having disease (Centers 

for Disease Control and Prevention (CDC) 2005).

Sewage / Human excreta and wastewater, fl ushed along a sewer pipe or drain (Mara and Cairncross 1989).

Solvent / Substance used to dissolve another substance. Some commonly used solvents, such as trichloroethylene, 

are important environmental contaminants (US EPA 2003).

Sudden infant death syndrome (SIDS) / The sudden and unexpected death of an apparently healthy infant, 

without an apparent cause (US EPA 2003).

Sulfur dioxide (SO2 ) / One of the sulfur oxide (SOx) gases that is formed primarily by the combustion of sulfurcontaining fossil fuels and in various industrial processes. It is a pungent, colorless pollutant, soluble in water, 

irritating to living tissues, and a major constituent of smog (adapted from US EPA 2003). 

Surrogate exposure / A surrogate exposure indicator provides a measure of potential exposure to an environmental hazard. For example, the percentage of children living in urban areas where air pollution levels exceed 

relevant air quality standards is created by cross-referencing air quality data with census data for urban centers. 

The corresponding population-based indicator provides a measure of the potential for exposure for the 

population but does not directly measure exposure in the population.

Tonne / A metric tonne, which is 1,000 kilograms, is equivalent to 1,1023 short tons, or 0.9842 long tons 

(CEC 2004).

Total releases / Term used in reporting of PRTR data. The sum of on-site and off-site releases, including the 

amounts released to the air, water, land and underground injection at the facility and all chemicals sent to other 

locations for disposal and any metals sent to treatment, sewage or energy recovery (CEC 2004).

Toxicity / The inherent potential or capacity of a material to cause adverse effects in a living organism (Canada, 

Greening the Government 2004).

Toxics Release Inventory (TRI) / The Toxics Release Inventory (TRI) is a publicly available United States Environmental Protection Agency (EPA) database (PRTR) that contains information on toxic chemical releases and 

other waste management activities reported annually by certain covered industry groups as well as federal 

facilities (US EPA 2005c).

Volatile organic compound (VOC) / Carbon-containing compound that has a high vapor pressure and easily changes 

from a solid to a gaseous form at normal temperatures and pressure. Sources include household products such as 

paints, paint strippers, and other solvents; wood preservatives; aerosol sprays; cleansers and disinfectants; moth repellents 

and air fresheners; stored fuels and automotive products; hobby supplies; dry-cleaned clothing (US EPA 2003).

Wastewater / Liquid waste discharged from homes, commercial premises and similar sources to individual 

disposal systems or to municipal sewer pipes, and consists mainly of human excreta and used water (Mara and 

Cairncross 1989).
104

References

Azcona-Cruz, M.I., Rothenberg, S., Schnaas, L., Zamora-Muñoz, J., and Romero-Placeres, M. 2000. Leadglazed ceramic ware and blood lead levels of children in the city of Oaxaca, Mexico. Arch Environ Health

May-June, 55(3): 217–22.

Batres, L., Santos, M.A., Mejia, J.J., Yañez, L., Carrizalez, L., Díaz-Barriga, F. 1994. Caracterización del 

riesgo en salud por exposición a metales pesados en la ciudad de San Luis Potosí (Characterization of risks 

to health from exposure to heavy metals in the city of San Luis Potosí). Internal report to the study group 

Environment Council A.C.

Black, Judith, and Peter R.A. Johnson. 2002. Factors controlling smooth muscle proliferation and airway 

remodelling. Current Opinion in Allergy and Clinical Immunology 2(1): 47-51.

Briggs, David. 2003. Making a difference: Indicators to improve children’s environmental health. Prepared 

for the World Health Organization. Geneva, Switzerland: WHO <http://www.who.int/phe/children/en/

cehindicsum.pdf>. (Date viewed: 6 September 2005).

California Air Resources Board. 2005. Proposed identifi cation of environmental tobacco smoke as a toxic air 

contaminant. Part B: Health effects. May 2005, Scientifi c Review Panel 3rd Review Draft. Sacremento: Offi ce 

of Environmental Health Hazard Assessment <http://www.arb.ca.gov/toxics/ets/dreport/dreport.htm>. 

(Date viewed: 6 September 2005).

Canada, Greening the Government. 2005. Glossary. <http://www.greeninggovernment.gc.ca/default.

asp?lang=En&nav=08B72523-1#B> (Date viewed: 6 September 2005).

Carrizales, L., Razo, I., Tellez-Hernandez, J., Torres-Nerio, R., Torres, A, Batres, L., Cubillas, A.C., and 

Díaz-Barriga, F. 2005. Exposure to arsenic and lead of children living near a copper-smelter in San Luis 

Potosí, Mexico: Importance of soil contamination for exposure of children. Environ Res. In press.

Centers for Disease Control and Prevention. 1997. Screening young children for lead poisoning: Guidance for 

state and local public health offi cials. <http://www.cdc.gov/nceh/lead/guide/guide97.htm>. (Date viewed: 

6 September 2005). 

Centers for Disease Control and Prevention. 2002. Managing elevated blood lead levels among young children: 

Recommendations from the Advisory Committee on Childhood Lead Poisoning Prevention. Atlanta, GA. 

<http://www.cdc.gov/nceh/lead/CaseManagement/caseManage_main.htm>. (Date viewed: 6 September 

2005). 

Centers for Disease Control and Prevention. 2005. Glossary of epidemiological terms. <http://www.cdc.gov/

excite/library/glossary.htm#S>. (Date viewed: 6 September 2005). 

Centers for Disease Control and Prevention, National Center for Health Statistics. 2003. National Vital 

Statistics System, Birth Files. Table 10: Maternal education for live births according to detailed race and 

Hispanic origin of mother: United States, selected years 1970–2001. <http://www.cdc.gov/nchs/data/hus/

tables/2003/03hus010.pdf>. (Date viewed: 6 September 2005). 

Cofepris. Date unknown. Norma ofi cial Mexicana. NOM-199-SSA1-2000, salud ambiental. <http://www.

cofepris.gob.mx/mj/documentos/nom32.htm> (Date viewed: 6 September 2005).

Commission for Environmental Cooperation (CEC). June 2002. Cooperative agenda for children’s health 

and the environment in North America. Montreal: CEC Secretariat. <http://www.cec.org/fi les/pdf/

POLLUTANTS/Children_coop_agenda-en.pdf> (Date viewed: 6 September 2005).

Commission for Environmental Cooperation (CEC). 2003. Recommendations for the development of 

children’s health and the environment indicators in North America. June. <http://www.cec.org/fi les/pdf/

POLLUTANTS/CHE-Recommendations_en.pdf>. (Date viewed: 6 September 2005).

Commission for Environmental Cooperation (CEC). 2004. Taking Stock 2001: North American pollutant 

release transfers. Montreal: CEC Secretariat. <http://www.cec.org/fi les/PDF/POLLUTANTS/TS2001-

Report_en.pdf>. (Date viewed: 6 September 2005).

Corválan, C., Briggs D., and Kjellstrom, T. (1996) Development of environmental health indicators. In 

Linkage methods for environment and health analysis: General guidelines. Briggs, D.J., Corválan, C and 

Nurimen, M (eds) Geneva: UNEP, USEPA and WHO: 19-53.

Craun, G.F., and Calderon, R.L. 2003. Waterborne outbreaks in the United States, 1971–2000. In Drinking 

water regulations and health. Pontius. F.W. (ed.) New York: John Wiley & Sons: 40–56.

Díaz-Barriga, F., Batres, L., Calderon, J., Lugo, A., Galvao, L., Lara, I., Rizo, P., Arroyave, M.E., and 

McConnell, R. 1997. The El Paso smelter 20 years later: Residual impact on Mexican children. Environ Res 

74: 11–16.

Doane Marketing Research. 1993–2001. AgroTrack row and specialty crop studies. As quoted in United States 

Environmental Protection Agency. 2003. America’s children and the environment: Measures of contaminants, 

body burdens, and illnesses. Washington, DC: US EPA.
Children's Health and the Environment in North America 105

Environment Canada. 2004. Water pollution. <http://www.ec.gc.ca/water/en/manage/poll/e_poll.htm>. 

(Date viewed: 6 September 2005).

Environment Canada. 2005. Urban air quality. <http://www.ec.gc.ca/soer-ree/English/Indicator_series/

new_issues.cfm?issue_id=8&tech_id=31#bio_pic> (Date viewed: 6 September 2005).

European Environment Agency and the WHO Regional Offi ce of Europe. 2002. Children’s health and 

the environment: A review of recent evidence. G. Tamburlini, O.S. von Ehrenstein, R. Bertollini (eds). 

Luxembourg: Offi ce for Offi cial Publications of the European Communities.

Garcia, V.G., Rubio, A.M., Del Razo, M.L., Borja, A.V., Vera, A.E., and Cebrián, M.E. 2001. Lead exposure in 

children living in a smelter community in Región Lagunera, México. Journal of Toxicology and Environmental 

Health. Part !, 62: 417–29.

Gordon, Bruce; McKay, Richard and Rehfuess, Eva. 2004. Inheriting the world: The atlas of children’s health 

and the environment. Geneva: WHO <http://www.who.int/ceh/publications/atlas/en/index.html>. (Date 

viewed: 6 September 2005).

Health Canada. 1988. Benzo[a]pyrene. <http://dsp-psd.pwgsc.gc.ca/Collection/H48-10-1-16-1988E.pdf> 

(Date viewed: 6 September 2005).

Health Canada. 2005. Make your home and car smoke-free: A guide to protecting your family from secondhand smoke. <http://www.hc-sc.gc.ca/hl-vs/pubs/tobac-tabac/second-guide/index_e.html>. (Date viewed: 

6 September 2005).

Inter-Organisation Programme for the Sound Management of Chemicals Pollutant Release and Transfer 

Registers Co-ordinating Group. 2003. Fourth session of the intergovernmental forum on chemical safety: 

Report to forum IV on pollutant release and transfer registers (PRTRs)/emission inventories. Geneva: World 

Health Organization. <http://www.who.int/ifcs/documents/Forum/ForumIV/Meeting_docs/5INF_en.pdf>. 

(Date viewed: 6 September 2005).

Jacobs, D.E., R.P. Clickner, J.Y. Zhou, S.M. Viet, D.A. Marker, J.W. Rogers, D.C. Zeldin, P. Broene, and 

W. Friedman. 2002. The prevalence of lead-based paint hazards in US housing. Environmental Health 

Perspectives. 110 (10): A599–606.

Janeway, Charles A et al. 2001. Immunobiology: the immune system in health and disease. New York: 

Garland Publishing <http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=imm.glossary.2528>. (Date viewed: 

6 September 2005).

Mara, D., and Cairncross, S. 1989. Guidelines for the safe use of wastewater and excreta in agriculture and 

aquaculture. Geneva: World Health Organisation. 

Martin, Elizabeth. 2002. Oxford concise colour medical dictionary (3rd Edition). Oxford: Oxford University Press.

Meyers, Pamela A. et al. 2003. Surveillance for elevated blood lead levels among children—United States, 

1997–2001. Morbidity and Mortality Weekly Reports 52(SS10): 1–21. <http://www.cdc.gov/mmwr/preview/

mmwrhtml/ss5210a1.htm>. (Date viewed: 6 September 2005).

Michaelowa, Axel. 1997. Phasing out lead in gasoline—how developing countries can learn from the 

experiences of the industrialized world. In World development aid and joint venture fi nance 1997/19998. 

Fairclough, Anthony (ed.). London: Kenningston Publications, 268-272

Mielke, H.W., and P. Reagan. 1998. Soil is an important pathway of human lead exposure. In Environmental 

Health Perspectives 106 (Suppl. 1):217–229.

Mielke, H.W. 1999. Lead in the inner cities. American Scientist 87(1):62–73.

Molina-Ballesteros, G., Zuñiga-Charles, M.A., Garcia-De Alba, A., and Solis-Camara, P. 1980. Lead 

exposure in two pottery handicraft populations. Arch. Invest. Med (Méx) 11: 147–54.

National Institutes of Health, National Heart, Lung, and Blood Institute. 1997. Guidelines for the diagnosis 

and management of asthma. Bethesda, Maryland: National Heart, Lung, and Blood Institute.<http://www.

ncbi.nlm.nih.gov/books/bv.fcgi?rid=asthma>. Date viewed: 6 September 2005).

National Research Council. 1993. Pesticides in the diets of infants and children. Washington, D.C.: National 

Academy Press.

Olaiz, F.G., Rojas, M.R., Fortoul, I.T., and Palazuelos, E. High lead levels in ceramic folk art workers. 1997. 

Arch Environ Health Jan-Feb, 52(1): 51–55.

Page, Martyn (ed). 2002. The British Medical Association illustrated medical dictionary. London: Dorling 

Kindersley.

Pan American Center for Sanitary Engineering and Environmental Sciences et al. 2002. Guidelines for 

the surveillance and control of drinking water quality: Appendix C. Lima, Peru: Pan American Center for 

Sanitary Engineering and Environmental Sciences. <http://whqlibdoc.who.int/paho/2002/AppendC.pdf>. 

(Date viewed: 6 September 2005).
106

Peters, John M. et al. 2004. Epidemiologic investigation to identify chronic effects of ambient air pollutants in 

Southern California. Prepared for the California Air Resources Board and the California Environmental 

Protection Agency (Contract No. 94-331). Sacramento, California: California Air Resources Board and California 

Environmental Protection Agency. <http://www.arb.ca.gov/research/abstracts/94-331.htm#Executive>. (Date 

viewed: 6 September 2005).

President’s Task Force on Environmental Health Risks and Safety Risks to Children. 2000a. Eliminating 

childhood lead poisoning: A federal strategy targeting lead paint hazards. Washington, DC: President’s Task 

Force on Environmental Health Risks and Safety Risks to Children. <http://www.hud.gov/offi ces/lead/

reports/fedstrategy2000.pdf>. (Date viewed: 6 September 2005).

President’s Task Force on Environmental Health Risks and Safety Risks to Children. 2000b. Asthma and 

the environment: A strategy to protect children. Washington, DC: President’s Task Force on Environmental 

Health Risks and Safety Risks to Children. <http://aspe.hhs.gov/sp/asthma/appxd.pdf>. (Date viewed: 6 

September 2005).

Romieu, I., Palazuelos, E., Meneses, F., Hernandez-Avila, M. 1992. Vehicular traffi c as a determinant of 

blood-lead levels in children: A pilot study in Mexico City. Arch Environ Health Jul-Aug, 47(4): 246–49.

Rothenberg, Mikel A., and Chapman, Charles C. 2000. Dictionary of Medical Terms, 4th Edition: Medical 

Reference for the NonMedical Person. New York: Barron’s Educational Series.

Schwartz, Joel. 2004. Air pollution and children’s health. Pediatrics 113 (4): 1037-1043.

Statistics Canada. 2001. Income in Canada 1999. Catalogue no. 75-202-XIE.

United Nations Environment Programme (UNEP). Date unknown. Persistent organic pollutants. <http://

www.chem.unep.ch/pops/>. (Date viewed: 1 September 2005).

United States Agency for Toxic Substances and Disease Registry (ASTDR). 2004. ASTDR glossary of terms. 

<http://www.atsdr.cdc.gov/glossary.html>. (Date viewed: 6 September 2005).

United States Census Bureau. 2001. Table 25. Poverty status by state in 2000. <http://ferret.bls.census.gov/

macro/032001/pov/new25_003.htm>. (Date viewed: 6 September 2005).

United States Census Bureau. 2004. IDB summary demographic data for United States <http://www.census.

gov/cgi-bin/ipc/idbsum?cty=us>. (Date viewed: 6 September 2005)

United States Environmental Protection Agency (US EPA). 1997. Integrated Risk Information System 

(IRIS) Risk Information for Lead and Compounds (Inorganic). Washington, DC: National Center for 

Environmental Assessment.

United States Environmental Protection Agency (US EPA). 2000. National air quality and emissions trends 

report, 1998. 454/R-00-003. Research Triangle Park, North Carolina: EPA Offi ce of Air Quality Planning 

and Standards. <http://www.epa.gov/air/airtrends/aqtrnd98/toc.html>. (Date viewed: 6 September 

2005).

United States Environmental Protection Agency (US EPA). 2003. America’s children and the environment: 

Measures of contaminants, body burdens, and illnesses. Washington, DC: US EPA.

United States Environmental Protection Agency (US EPA). 2005a. EMAP QA Glossary. <http://www.epa.

gov/emap/html/pubs/docs/resdocs/qa_terms.html>. (Date viewed: 6 September 2005).

United States Environmental Protection Agency (US EPA). 2005b. Terms of environment: Glossary, 

abbreviations and acronyms. <http://www.epa.gov/OCEPAterms/>. (Date viewed: 6 September 2005).

United States Environmental Protection Agency (US EPA). 2005c. Toxics release inventory (TRI) program. 

<http://www.epa.gov/tri/>. (Date viewed: 6 September 2005).

United States National Library of Medicine. 2005. Medical encyclopedia. <http://www.nlm.nih.gov/

medlineplus/encyclopedia.html>. (Date viewed: 6 September 2005).

Wigle, Don T. 2003. Child health and the environment. Oxford: Oxford University Press

World Health Organization (WHO). 2005a. Health impacts of indoor air pollution. <http://www.who.int/

indoorair/health_impacts/en/>. (Date viewed: 6 September 2005)

World Health Organization (WHO). 2005b. Pollution and exposure levels. <http://www.who.int/indoorair/

health_impacts/exposure/en/>. (Date viewed: 6 September 2005).

World Health Organization (WHO)—Regional Offi ce of Europe. 2005. European observatory on health 

systems and policies—glossary. <http://www.euro.who.int/observatory/Glossary/TopPage?phrase=M>. 

(Date viewed: 6 September 2005).
Children's Health and the Environment in North America 107

Appendix 1: Council Resolution 02-06 Distribution: General

C/02-00/RES/06/Final

 ORIGINAL: ENGLISH

Ottawa, 19 June 2002

COUNCIL RESOLUTION: 02-06 

Cooperative Agenda for Children’s Health and the Environment in North America

THE COUNCIL:

HAVING ADOPTED Council Resolution 00-10, whereby the Parties recognized the particular vulnerabilities of 

children to environmental risks and agreed to collaborate on the development of a cooperative agenda that 

promotes the protection of children’s health from environmental risks;

IN ACCORDANCE with Council Resolution 00-10, whereby the Parties decided to focus, as a starting point, 

on specifi c health outcomes such as asthma and other respiratory diseases, the effects of lead including lead 

poisoning, and the effects of exposure to other toxic substances;

TAKING into consideration, with appreciation, Advice to Council 02-01 from the Expert Advisory Board on 

Children’s Health and the Environment, Advice to Council 02-01 from the Joint Public Advisory Committee 

of the Commission for Environmental Cooperation (CEC), and comments received from the public;

NOTING the productive and informative meeting held with the Expert Advisory Board members during the 

Council’s Ninth Regular Session on 18 June 2002 in Ottawa; ACKNOWLEDGING the progress of the CEC in 

integrating children’s environmental health into its ongoing activities;

RECOGNIZING that effective domestic and trilateral solutions to address children’s health and the environment 

require a solid knowledge base, education and outreach, and partnerships; and

RECOGNIZING that protecting children’s health from environmental risks is an ongoing task and a long-term 

investment, and understanding that increased knowledge will continue to inform and shape planned activities 

and projects to maximize their effectiveness and relevance;

HEREBY:

ADOPTS the Cooperative Agenda for Children’s Health and the Environment in North America (Cooperative 

Agenda);

CALLS UPON the Parties to work together with the CEC Secretariat to implement the Cooperative Agenda by 

undertaking the following new initiatives over the next two years:

• select and publish a core set of children’s environmental health indicators for North America, working 

in partnership with the Pan American Health Organization, the International Joint Commission Health 

Professionals Task Force and others, and in coordination with parallel commitments made by the G-8 

Environment Ministers and the Health and Environment Ministerial of the Americas;

• form strategic partnerships with health organizations, including the trilateral network of Pediatric 

Environmental Health Specialty Units, to strengthen professional training on children’s environmental 

health, with a view toward enabling health professionals to serve as effective conduits of information and 

advice to parents, care givers, children, and communities;

• strengthen decision-making capacity by enhancing the understanding of the economic impacts of 

environment-related illnesses and effects on children, including the implications of action versus inaction;

• advance understanding of risk assessment approaches with a view to increasing collaboration on toxic substances 

and increasing the cadre of risk assessors trained in children’s environmental health risk assessment; and

• work together trilaterally, in the context of increasing cross-border trade, to reduce the risks posed by lead in 

consumer products, in particular those intended for use by children;
108

AGREES to continue the integration of children’s environmental health considerations into the CEC work 

program. This includes continuing work on the following projects:

• facilitating collaboration on longitudinal cohort studies with a view to improving our common 

understanding of children’s exposures, body burdens, and health outcomes during the course of their growth 

and development, building on the National Children’s Study in the United States;

• assessing the impact of diesel exhaust at congested border crossings as part of the CEC’s Air Quality 

project, and exploring the use of the developed methodology to address other regions and contaminants 

of concern;

• working to prevent and reduce children’s exposure to lead by promoting increased public awareness and 

improved practices within selected cottage industries, such as the ceramics industry in Mexico;

• continuing to ensure the integration of a children’s environmental health perspective into the work of the 

CEC’s Sound Management of Chemicals program;

• analyzing and publishing data on toxic chemicals that are of particular concern to children’s health within 

the Taking Stock report series; and

• continuing efforts to build public awareness and facilitate access to information on issues of children’s 

environmental health and preventive measures, through existing CEC projects and publications and in 

partnership with other groups;

AGREES, in addition to the focus on asthma and respiratory diseases and the effects of lead and other toxic 

substances, to include water-borne diseases as a priority health endpoint, and DIRECTS the CEC Secretariat, 

in coordination with the Parties, to develop options for collaborative action in this area;

CALLS FOR the North American Regional Action Plan on environmental monitoring and assessment to include 

bio-monitoring of persistent bioaccumulative toxics – in particular, mercury and lead – in infants, children, 

pregnant women, and women of child-bearing age; and

AGREES to bi-annually review progress achieved, assess relevance of planned activities in light of new 

knowledge acquired, and further advance the implementation of the Cooperative Agenda with the input and 

involvement of interested parties and members of the public.

APPROVED BY THE COUNCIL:

________________________________________________

David Anderson

Government of Canada

________________________________________________

Víctor Lichtinger

Government of the United Mexican States

________________________________________________

Christine Todd Whitman

Government of the United States of America
Children's Health and the Environment in North America 109

Asthma and Respiratory 

Disease

Percent of children 

living in urban areas 

where air pollution 

levels exceed relevant 

air quality standards

Exposure surrogate Obtainable by crossreferencing air quality 

data with census data 

for urban areas such 

as cities with fixed site 

monitoring stations. 

Either national or 

WHO air quality 

standards can be used.

Appendix 2: Overview of Recommended Indicators from the CEC Council

Following is the list of recommended indicators that the Steering Group on Children’s Health 

and Environment Indicators submitted for consideration by the CEC Council in June 2003, 

presented in a document entitled “Recommendations for the Development of Children’s 

Health and the Environment Indicators in North America.” Council subsequently endorsed 

the recommended indicators through Council Resolution 03-10 (see Appendix 3). 

Priority Area Indicator Name Type of Measure Description/Comment

I

________________________I____________________________I_________________________I________________________I

Indoor air quality Exposure surrogate Measure of children 

exposed to secondhand 

smoke in Canada and 

the US, and biomass 

fuels in Mexico.

I

________________________I____________________________I_________________________I________________________I

Prevalence of 

asthma cases

Effect Can be the number of 

children under 18, 14, 

5, or a combination of 

ages. In Canada and 

US, information is 

obtained by household 

surveys. In Mexico, 

doctors report cases on 

a diagnosis form.

I

________________________I____________________________I_________________________I________________________I

Effects of Lead and Other 

Toxic Substances on 

Children’s Health

Blood lead levels 

(presented by range, 

e.g., below detectable 

level)

Exposure Although lead may 

have health effects at 

lower levels, 10 μg/dL 

is considered a trigger 

for public health 

intervention.

I

________________________I____________________________I_________________________I________________________I

Children living in 

homes with a source 

of lead

Exposure Sources of lead 

reflected in the 

indicators may vary 

by country, depending 

on the major sources 

of concern and data 

availability.

I

________________________I____________________________I_________________________I________________________I

Pesticides (body 

burden, residue levels 

on food, use or sales)

Exposure Best measure is body 

burden, followed by 

residue levels on food 

and use data. Sales 

data is not desirable.

I

________________________I____________________________I_________________________I________________________I

Pollutant Release 

and Transfer Register 

(PRTR) data

Exposure PRTR data exist in all 

three countries. These 

data can highlight 

releases of a range of 

chemicals.

I

________________________I____________________________I_________________________I________________________I
110

Water-borne 

Diseases and 

Children’s Health

Percent of children 

(households) served 

by treated water

Exposure Counts how many 

children/ homes/people 

have access in their 

home to water piped 

from a centrally treated 

system. Alternative 

indicator could be 

children (households) 

without access to 

treated water.

I

________________________I____________________________I_________________________I________________________I

Percent of children 

(households) served 

by sanitary sewers

Exposure The percentage of 

children (households) 

who have sewage 

removed from 

their immediate 

surroundings will 

require further 

discussion and 

refinement.

I

________________________I____________________________I_________________________I________________________I

Morbidity (number 

of childhood 

illnesses attributed to 

waterborne disease)

Effect

I

________________________I____________________________I_________________________I________________________I

Mortality (number 

of child deaths 

attributed to 

waterborne disease)

Effect

I

________________________I____________________________I_________________________I________________________I

Percentage of children 

served by drinking 

water systems in 

violation of local 

standards

Action Consider additional 

criteria, such as systems 

with <x violations per 

year, number of days in 

violation, etc. 

I

________________________I____________________________I_________________________I________________________I

I

________________________I____________________________I_________________________I________________________I
Children's Health and the Environment in North America 111

Appendix 3: Council Resolution 03-10 Distribution: General

C/C.01/03-00/RES/10/Final

Washington, DC, 25 June 2003 ORIGINAL: ENGLISH

COUNCIL RESOLUTION: 03-10 

Indicators of Children’s Health and the Environment in North America

THE COUNCIL:

RECOGNIZING the importance of providing decision-makers and the public with periodic, understandable 

information on the status of children’s health and the environment in North America as a means of tracking 

changes and promoting effective preventative action;

NOTING WITH ENCOURAGEMENT the signifi cant progress that has been made, through collaboration among 

the Commission for Environmental Cooperation (CEC), the International Joint Commission (IJC) Health 

Professionals Task Force, the Pan American Health Organization (PAHO) and the World Health Organization 

(WHO), in creating a framework for the development of indicators of children’s health and the environment 

in North America;

FURTHER RECOGNIZING the global partnership launched at the World Summit on Sustainable Development in 

2002 to promote the development of indicators of children’s health and the environment;

WELCOMING the emerging role for North America, through the CEC and its partners, to serve as a global 

leader in this area; and

RECOGNIZING the need for a fl exible approach that takes differing national circumstances, priorities and data 

availability into account, while seeking to continuously improve data quality and comparability;

HEREBY:

DIRECTS the CEC Secretariat, with the involvement of the Parties and in continued partnership with the IJC, PAHO 

and WHO, to prepare a fi rst report on indicators of children’s health and the environment in North America, to 

be published in 2004;

UNDERTAKES to ensure that the CEC Secretariat be provided with the data, where available, to compile 

an initial set of twelve indicators of children’s health and the environment as identifi ed in the document 

“Recommendations for the Development of Children’s Health and the Environment Indicators in North 

America,” for inclusion in this indicator report (other relevant health indicators may be added as decided by 

the Parties and based on data availability);

RESOLVES to continuously improve, thereafter, the quality and comparability of the indicators and data across 

North America, in coordination with, and taking into account the developments of, the international effort 

on children’s environmental health indicators; and

AGREES, in addition to the focus on asthma and respiratory diseases and the effects of lead and other toxic 

substances, to include water-borne diseases as a priority health endpoint, and DIRECTS the CEC Secretariat, 

in coordination with the Parties, to develop options for collaborative action in this area;

FURTHER RESOLVES to undertake a subsequent publication of indicators of children’s health and the 

environment within fi ve years of the publication of the fi rst report, and periodically thereafter.

APPROVED BY THE COUNCIL:

________________________________________________

David Anderson

Government of Canada

________________________________________________

Víctor Lichtinger

Government of the United Mexican States

________________________________________________

Christine Todd Whitman

Government of the United States of America
112

Appendix 4: Members of the Steering Group for the Development of 

Indicators of Children’s Health and the Environment in North America

The Steering Group, composed of representatives of the three governments and the four partner institutions 

as listed below, has played an active role since 2002 in the development of this fi rst report on indicators of 

children’s health and the environment. Each country/institution could designate up to three members and 

two observers. For each country, a “country lead” was designated who was responsible for the country reports 

and for coordinating internal governmental reviews of draft versions of the report. The CEC Secretariat, 

assisted by consultants, facilitated the work of the Steering Group and was responsible for compiling the 

North American report and for publishing both it and the country reports. The partner institutions—IJC, 

PAHO and WHO—provided in-kind support in the form of guidance and expertise, and, in the case of IJC 

and PAHO, some fi nancial support to the CEC Secretariat for the project. 

Following is the list of current Steering Group members. Past members, many of whom played instrumental roles 

in shaping and developing the report, are indicated in the footnoted text. 

CANADA 

 

Vincent Mercier, Country Lead Annie Bérubé Amber McCool

Knowledge Integration Strategies Offi ce of Vulnerable Populations Strategic Policy Branch

Environment Canada Health Canada Environment Canada

Corner Morton Ave. Charles Tupper Building, 10 Wellington Street, 

and University Ave. 4th Floor, Room C487 22nd Floor

Moncton, NB E1A 6S8 2720 Riverside Drive Hull, QC K1A 0H3

T: (506) 851-6244 Ottawa, ON K1A 0K9 T: (819) 997-5087

F: (506) 851-6608 T: (613) 941-3610 F: (613) 952-8857 F: (819) 953-4679

vincent.mercier@ec.gc.ca Annie_a_berube@hc-sc.gc.ca Amber.mccool@ec.gc.ca

 

Andrea Ecclestone, Susan Ecclestone, 

Observer Observer

Offi ce of Vulnerable Populations Health Impacts Bureau 

Health Canada Health Canada

Charles Tupper Building, Charles Tupper Building 

4th Floor, Room C487 2720 Riverside Drive 

2720 Riverside Drive Ottawa, ON K1A 0K9 

Ottawa, ON K1A 0K9 T: (613) 948-9417 

T: (613) 948-2598 F: (613) 952-8857 F: (613) 952-8857 

Andrea_ecclestone@hc-sc.gc.ca Susan_ecclestone@hc-sc.gc.ca 

Former members of the Steering Group from Canada include Julie Charbonneau, Kerri Henry, Anthony Myres, 

Nicki Sims-Jones, and Risa Smith.

MÉXICO 

 

Matiana Ramírez, Country Lead Rocio Alatorre, Observer Martha Plascencia, Observer

Cofepris, Secretaría de Salud Cofepris, Secretaría de Salud Cofepris, Secretaría de Salud

Monterrey #33, Col. Roma Monterrey #33, Col. Roma Monterrey #33, Col. Roma

Delegación Cuauhtémoc Delegación Cuauhtémoc Delegación Cuauhtémoc

México, DF 06700 México, DF 06700 México, DF 06700

T: (52 55) 5208 3032 T: (52 55) 5514 8572 T: (52 55) 5208 3032

F: (52 55) 5208 3032 F: (52 55) 5514 8557 F: (52 55) 5208 3032

mramireza@salud.gob.mx rocioal@salud.gob.mx marthaleonor_ 

 plascencia@yahoo.com.mx 

Antonio Barraza Vasquez served as country lead for Mexico until August 2005.

 
Children's Health and the Environment in North America 113

 UNITED STATES 

Ann Carroll, Country Lead Tracey Woodruff Daniel Axelrad

Acting Program Manager Senior Scientist Environmental Scientist 

Environmental Health National Center for National Center for 

Offi ce of Int’l Environmental Policy Environmental Economics Environmental Economics

Offi ce of International Affairs, US EPA US EPA US EPA

US EPA Headquarters 75 Hawthorne Street, MC PPA-1 US EPA Headquarters

1200 Pennsylvania Ave. NW San Francisco, CA 94105 1200 Pennsylvania Ave. NW

Washington, DC 20460 T: (415) 947-4277 Washington, DC 20460

T: (202) 564-6433 F: (415) 947-3519 T: (202) 566-2304

F: (202) 564-2412 Woodruff.tracey@epa.gov F: (202) 566-2336

Carroll.ann@epa.gov Axelrad.daniel@epa.gov 

Martha Berger, Observer Edward Chu, Observer

Director, International Affairs Acting Director 

Offi ce of Children’s Land Revitalization Offi ce 

Health Protection, US EPA Offi ce of Solid Waste and 

US EPA Headquarters Emergency Response, US EPA

1200 Pennsylvania Ave. NW US EPA Headquarters

Washington, DC 20460 1200 Pennsylvania Ave. NW 

T: (202) 564-2191 Washington, DC 20460 

F: (202) 564-2733 T: (202) 566-2743 

Berger.martha@epa.gov F: (202) 566-0207

 Chu.ed@epa.gov 

Former members of the Steering Group from the United States include Edward Chu (former country lead), Evonne Marzouk, 

and Catherine Allen (former country lead).

IJC HEALTH PROFESSIONALS TASK FORCE 

Irena Buka Pierre Gosselin James Houston

Child Health Clinic WHO-PAHO Collaborating Center on International Joint 

Misericordia Hospital Environmental and Occupational Health Commission Secretariat

16940, 87e Avenue Impact Assessment and Surveillance 234 Laurier Ave. W. 22nd Floor

Edmonton, AB T5R 4H5 (INSPQ-CHUQ-DSP Québec) Ottawa, ON K1P 6K6

T: (780) 930-5731 945, rue Wolfe, Sainte-Foy, QC G1V 5B3 T: (613) 995-0230

P: (780) 930-5794 T: (418) 650-5115, x5205# F: (613) 993-5583

ibuka@cha.ab.ca F: (418) 650-3134 houstonj@ottawa.ijc.org 

 Pierre-l.gosselin@crchul.ulaval.ca 

Peter Orris

Cook County Hospital 

Occupational Medicine 

1900 W. Polk, Room 500 

Chicago, IL 60612 

T: (312) 633-5310 

porris@uic.edu 

PAN AMERICAN HEALTH ORGANIZATION (PAHO) 

 

Luiz Augusto Galvão Samuel Henao Pierre Gosselin

Area Manager Regional Advisor WHO-PAHO Collaborating Center 

Sustainable Development Sustainable Development on Environmental and 

and Environmental Health and Environmental Health Occupational Health 

PAHO PAHO Impact and Surveillance 

525 23rd Street, NW, Room 526 525, 23rd Street, NW (INSPQ-CHUQ-DSP Québec)

Washington, DC 20037 Washington, DC 20037 945, rue Wolfe, Sainte-Foy, QC G1V 5B3

T: (202) 974-3156 T: (202) 974-3315 T: (418) 650-5115, x5205#

F: (202) 974-3645 F: (202) 974-3645 F: (418) 650-3134

galvaolu@paho.org henaosam@paho.org Pierre-l.gosselin@crchul.ulaval.ca

Alfonso Ruiz formerly served on the Steering Group for PAHO.

 
114

WORLD HEALTH ORGANIZATION (WHO)

 

Fiona Gore Eva Rehfuess 

Protection of the Protection of the 

Human Environment Human Environment 

World Health Organization World Health Organization

1211 Geneva 27 1211 Geneva 27 

Switzerland Switzerland 

T: (41 22) 791-1619 T: (41 22) 791-4979 

F: (41 22) 791-1383 F: (41 22) 791-1383 

goref@who.int rehfuesse@who.int 

COMMISSION FOR ENVIRONMENTAL COOPERATION (CEC) OF NORTH AMERICA 

 

Keith Chanon, Program Erica Phipps Bruce Dudley Erin Down

Manager, PRTR & CHE Consultant Consultant Consultant

393 St-Jacques Street W 7351 River Road (PO Box 602) The Delphi Group The Delphi Group 

#200, Montreal, QC Quyon, QC Headquarters Headquarters

Canada H2Y 1N9 Canada J0X 2V0 428 Gilmour Street 428 Gilmour Street

T: (514) 350-4323 T: (819) 458-1681 Ottawa, ON K2P 0R8 Ottawa, ON K2P 0R8

F: (514) 350-4313 F: (819) 458-1681 T: (613) 562-2005 T: (613) 562-2005

kchanon@cec.org ephipps@magma.ca F: (613) 562-2008 F: (613) 562-2008

 bdudley@delphi.ca edown@delphi.ca

Victor Shantora, former head of the CEC’s pollutants and health program, and Samantha Baulch, formerly with the Delphi 

Group, also were involved in the Steering Group. Also, Dr. Stuart Lyon Smith, associate to the Delphi Group, acted as a 

special advisor on the project. The Delphi Group was contracted by the CEC to compile the report. Erica Phipps (former CEC 

program manager) has served as the coordinator of the initiative since its inception.
Children's Health and the Environment in North America 115

Appendix 5: Expert Review Panel

Canada

Teresa To

Senior Scientist

Hospital for Sick Children

Don Wigle

Affiliate Scientist, Institute of Population Health

University of Ottawa 

Pumulo Roddy

Project Manager

International Institute for Sustainable Development

Mexico

Alvaro Román Osornio Vargas

Jefe de Departamento 

Programa Universitario de Medio Ambiente, UNAM

Cristina Cortinas de Nava 

Consultora Ambiental 

Enrique Cifuentes García 

Director del Centro Colaborador en Salud Ambiental 

Instituto Nacional de Salud Pública 

United States 

Melanie Marty

Chief, Air Toxicology and Epidemiology Section

California EPA – Office of Environmental Health 

Hazard Assessment

Patricia Butterfi eld

Associate Professor and Director 

Occupational Health Nursing – University of Washington

Daniel Goldstein 

Director, Medical Toxicology

Monsanto Company
116

Appendix 6: 153 Matched Chemicals 

1995–2002 SPECIAL CHEMICAL NAME NOM CHIMIQUE SUSTANCIA 

MATCHED CHEMICAL

DATA SET GROUP

___________________________________________________________________________________________________________________ 

 1 c,p Formaldehyde Formaldéhyde Formaldehído

 2 Nitroglycerin Nitroglycérine Nitroglicerina

 3 c,p,t Carbon tetrachloride Tétrachlorure de carbone Tetracloruro de carbono

 4 p Aniline Aniline Anilina

 5 c,p Thiourea Thio-urée Tiourea

 6 c,p Diethyl sulfate Sulfate de diéthyle Sulfato de dietilo

 7 Methanol Méthanol Metanol

 8 c,p Chloroform Chloroforme Cloroformo

 9 c,p Hexachloroethane Hexachloroéthane Hexacloroetano

 10 n-Butyl alcohol Butan-1-ol Alcohol n-butílico

 11 c,p,t Benzene Benzène Benceno

 12 p,t Bromomethane Bromométhane Bromometano

 13 Ethylene Éthylène Etileno

 14 p Chloromethane Chlorométhane Clorometano

 15 p Methyl iodide Iodométhane Yoduro de metilo

 16 Hydrogen cyanide Cyanure d’hydrogène Ácido cianhídrico

 17 p Chloroethane Chloroéthane Cloroetano

 18 c,p,t Vinyl chloride Chlorure de vinyle Cloruro de vinilo

 19 Acetonitrile Acétonitrile Acetonitrilo

 20 c,p,t Acetaldehyde Acétaldéhyde Acetaldehído

 21 c,p,t Dichloromethane Dichlorométhane Diclorometano

 22 p Carbon disulfi de Disulfure de carbone Disulfuro de carbono

 23 c,p,t Ethylene oxide Oxyde d’éthylène Óxido de etileno

 24 t Vinylidene chloride Chlorure de vinylidène Cloruro de vinilideno

 25 Phosgene Phosgène Fosgeno

 26 c,p Propylene oxide Oxyde de propylène Óxido de propileno

 27 tert-Butyl alcohol 2-Méthylpropan-2-ol Alcohol terbutílico

 28 Hexachlorocyclopentadiene Hexachlorocyclopentadiène Hexaclorciclopentadieno

 29 c,p Dimethyl sulfate Sulfate de diméthyle Sulfato de dimetilo

 30 Isobutyraldehyde Isobutyraldéhyde Isobutiraldehído

 31 p 1,2-Dichloropropane 1,2-Dichloropropane 1,2-Dicloropropano

 32 sec-Butyl alcohol Butan-2-ol Alcohol sec-butílico

 33 Methyl ethyl ketone Méthyléthylcétone Metil etil cetona

 34 p 1,1,2-Trichloroethane 1,1,2-Trichloroéthane 1,1,2-Tricloroetano

 35 c,p,t Trichloroethylene Trichloroéthylène Tricloroetileno

 36 c,p Acrylamide Acrylamide Acrilamida

 37 Acrylic acid Acide acrylique Ácido acrílico

 38 Chloroacetic acid Acide chloroacétique Ácido cloroacético

 39 Peracetic acid Acide peracétique Ácido peracético

 40 p 1,1,2,2-Tetrachloroethane 1,1,2,2-Tétrachloroéthane 1,1,2,2-Tetracloroetano

 41 c,p 2-Nitropropane 2-Nitropropane 2-Nitropropano

 42 4,4’-Isopropylidenediphenol p,p’-Isopropylidènediphénol 4,4’-Isopropilidenodifenol 

 43 Cumene hydroperoxide Hydroperoxyde de cumène Cumeno hidroperóxido

 44 Methyl methacrylate Méthacrylate de méthyle Metacrilato de metilo

 45 p C.I. Food Red 15 Indice de couleur Rojo 15 alimenticio

 Rouge alimentaire 15

 46 Dibutyl phthalate Phtalate de dibutyle Dibutil ftalato

 47 Phthalic anhydride Anhydride phtalique Anhídrido ftálico

 48 p N-Nitrosodiphenylamine N-Nitrosodiphénylamine N-Nitrosodifenilamina

 49 p 2-Phenylphenol o-Phénylphénol 2-Fenilfenol

 50 c,p Michler’s ketone Cétone de Michler Cetona Michler

 51 c Toluene-2,6-diisocyanate Toluène-2,6-diisocyanate Toluen-2,6-diisocianato

 52 Naphthalene Naphtalène Naftaleno

 53 p Quinoline Quinoléine Quinoleína

 54 Biphenyl Biphényle Bifenilo

 55 Benzoyl peroxide Peroxyde de benzoyle Peróxido de benzoilo

 56 c,p Safrole Safrole Safrol

 57 1,2-Dichlorobenzene o-Dichlorobenzène 1,2-Diclorobenceno

 58 1,2,4-Trimethylbenzene 1,2,4-Triméthylbenzène 1,2,4-Trimetilbenceno

 59 c,p 2,4-Diaminotoluene 2,4-Diaminotoluène 2,4-Diaminotolueno

 60 c,p Styrene oxide Oxyde de styrène Óxido de estireno
Children's Health and the Environment in North America 117

 61 Methyl acrylate Acrylate de méthyle Acrilato de metilo

 62 c,p Ethylene thiourea Imidazolidine-2-thione Etilén tiourea

 63 Cumene Cumène Cumeno

 64 Benzoyl chloride Chlorure de benzoyle Cloruro de benzoilo

 65 c,p Nitrobenzene Nitrobenzène Nitrobenceno

 66 4-Nitrophenol p-Nitrophénol 4-Nitrofenol

 67 c Ethylbenzene Éthylbenzène Etilbenceno

 68 c Styrene Styrène Estireno 

 69 c,p Benzyl chloride Chlorure de benzyle Cloruro de bencilo

 70 c,p 4,4’-Methylenebis p,p’-Méthylènebis 4,4’-Metilenobis 

 (2-chloroaniline) (2-chloroaniline) (2-cloroanilina)

 71 c,p 4,4’-Methylenedianiline p,p’-Méthylènedianiline 4,4’-Metilenodianilina

 72 c,p 1,4-Dichlorobenzene p-Dichlorobenzène 1,4-Diclorobenceno

 73 p-Phenylenediamine p-Phénylènediamine p-Fenilenodiamina

 74 c Quinone p-Quinone Quinona

 75 c 1,2-Butylene oxide 1,2-Époxybutane Óxido de 1,2-butileno

 76 c,p,t Epichlorohydrin Épichlorohydrine Epiclorohidrina

 77 c,p,t 1,3-Butadiene Buta-1,3-diène 1,3-Butadieno

 78 Allyl chloride Chlorure d’allyle Cloruro de alilo

 79 c,p,t 1,2-Dichloroethane 1,2-Dichloroéthane 1,2-Dicloroetano

 80 c,p,t Acrylonitrile Acrylonitrile Acrilonitrilo

 81 Allyl alcohol Alcool allylique Alcohol alílico

 82 Ethylene glycol Éthylèneglycol Etilén glicol

 83 c Vinyl acetate Acétate de vinyle Acetato de vinilo

 84 Methyl isobutyl ketone Méthylisobutylcétone Metil isobutil cetona

 85 Maleic anhydride Anhydride maléique Anhídrido maleico

 86 p Toluene Toluène Tolueno

 87 Chlorobenzene Chlorobenzène Clorobenceno

 88 Phenol Phénol Fenol

 89 p 2-Methoxyethanol 2-Méthoxyéthanol 2-Metoxietanol

 90 p 2-Ethoxyethanol 2-Éthoxyéthanol 2-Etoxietanol

 91 Cyclohexane Cyclohexane Ciclohexano

 92 Pyridine Pyridine Piridina

 93 Diethanolamine Diéthanolamine Dietanolamina

 94 Propylene Propylène Propileno

 95 c,p,t Di(2-ethylhexyl) phthalate Phtalate de bis Di(2-etilhexil) ftalato

 (2-éthylhexyle)

 96 Anthracene Anthracène Antraceno

 97 p Isosafrole Isosafrole Isosafrol

 98 c,p Catechol Catéchol Catecol

 99 1,2,4-Trichlorobenzene 1,2,4-Trichlorobenzène 1,2,4-Triclorobenceno

 100 2,4-Dichlorophenol 2,4-Dichlorophénol 2,4-Diclorofenol

 101 c,p 2,4-Dinitrotoluene 2,4-Dinitrotoluène 2,4-Dinitrotolueno

 102 N,N-Dimethylaniline N,N-Diméthylaniline N,N-Dimetilanilina

 103 Hydroquinone Hydroquinone Hidroquinona

 104 Propionaldehyde Propionaldéhyde Propionaldehído

 105 Butyraldehyde Butyraldéhyde Butiraldehído

 106 c,p 1,4-Dioxane 1,4-Dioxane 1,4-Dioxano

 107 c,p,t Tetrachloroethylene Tétrachloroéthylène Tetracloroetileno

 108 Dimethyl phthalate Phtalate de diméthyle Dimetil ftalato

 109 c,p Nitrilotriacetic acid Acide nitrilotriacétique Ácido nitrilotriacético

 110 c,p Ethyl acrylate Acrylate d’éthyle Acrilato de etilo

 111 Butyl acrylate Acrylate de butyle Acrilato de butilo

 112 Calcium cyanamide Cyanamide calcique Cianamida de calcio

 113 c,p Hydrazine Hydrazine Hidracina

 114 4,6-Dinitro-o-cresol 4,6-Dinitro-o-crésol 4,6-Dinitro-o-cresol

 115 Ethyl chloroformate Chloroformiate d’éthyle Cloroformiato de etilo

 116 C.I. Basic Green 4 Indice de couleur Verde 4 básico

 Vert de base 4

 117 c Toluene-2,4-diisocyanate Toluène-2,4-diisocyanate Toluen-2,4-diisocianato

 118 c,p 2,6-Dinitrotoluene 2,6-Dinitrotoluène 2,6-Dinitrotolueno

 119 p C.I. Solvent Yellow 14 Indice de couleur Amarillo 14 solvente

 Jaune de solvant 14

 120 C.I. Basic Red 1 Indice de couleur Rojo 1 básico

 Rouge de base 1

 121 Decabromodiphenyl oxide Oxyde de Óxido de 

 décabromodiphényle decabromodifenilo

 122 Molybdenum trioxide Trioxyde de molybdène Trióxido de molibdeno
118

 123 p Thorium dioxide Dioxyde de thorium Dióxido de torio

 124 c,p,t Asbestos (friable form) Amiante (forme friable) Asbestos (friables)

 125 Aluminum oxide (fi brous forms) Oxyde d’aluminium Óxido de aluminio 

 (formes fi breuses) (formas fi brosas)

 126 Methyl tert-butyl ether Oxyde de tert-butyle Éter metil terbutílico

 et de méthyle

 127 C.I. Disperse Yellow 3 Indice de couleur Amarillo 3 disperso

 Jaune de dispersion 3

 128 C.I. Solvent Orange 7 Indice de couleur Naranja 7 solvente

 Orange de solvant 7

 129 C.I. Acid Green 3 Indice de couleur Vert acide 3 Verde 3 ácido

 130 m Aluminum (fume or dust) Aluminium Aluminio (humo o polvo)

 (fumée ou poussière)

 131 Titanium tetrachloride Tétrachlorure de titane Tetracloruro de titanio

 132 Hydrochloric acid Acide chlorhydrique Ácido clorhídrico

 133 t Hydrogen fl uoride Fluorure d’hydrogène Ácido fl uorhídrico

 134 Sulfuric acid Acide sulfurique Ácido sulfúrico

 135 Nitric acid*** Acide nitrique*** Ácido nítrico***

 136 Phosphorus (yellow or white) Phosphore (jaune ou blanc) Fósforo (amarillo o blanco)

 137 Chlorine Chlore Cloro

 138 Chlorine dioxide Dioxyde de chlore Dióxido de cloro

 139 p Dinitrotoluene Dinitrotoluène Dinitrotolueno 

 (mixed isomers) (mélange d’isomères) (mezcla de isómeros)

 140 c,p Toluenediisocyanate Toluènediisocyanate Toluendiisocianatos

 (mixed isomers) (mélange d’isomères) (mezcla de isómeros)

 141 m Antimony and its compounds* Antimoine (et ses composés)* Antimonio y compuestos* 

 142 m,c,p,t Chromium and its compounds* Chrome (et ses composés)* Cromo y compuestos*

 143 m,c,p Cobalt and its compounds* Cobalt (et ses composés)* Cobalto y compuestos*

 144 m Copper and its compounds* Cuivre (et ses composés)* Cobre y compuestos*

 145 Cresol (mixed isomers)** Crésol Cresol 

 (mélange d’isomères)** (mezcla de isómeros)**

 146 Cyanide compounds Cyanure (et ses composés) Cianuro y compuestos

 147 m Manganese and its compounds* Manganèse (et ses composés)* Manganeso y compuestos*

 148 m,c,p,t Nickel and its compounds* Nickel (et ses composés)* Níquel y compuestos*

 149 Nitric acid Acide nitrique Ácido nítrico 

 and nitrate compounds*** et composés de nitrate*** y compuestos nitrados***

 150 m Selenium and its compounds* Sélénium (et ses composés)* Selenio y compuestos*

 151 m Silver and its compounds* Argent (et ses composés)* Plata y compuestos*

 152 Xylenes**** Xylènes  Xilenos** **

 153 m Zinc and its compounds* Zinc (et ses composés)* Zinc y compuestos*

 m = Metal and its compounds.

 c = Known or suspected carcinogen 

 p = California Proposition 65 chemical

 t = CEPA toxic chemical

* Elemental compounds are reported separately from their respective element in TRI and aggregated with it in NPRI and in 

the matched data set. 

** o-Cresol, m-cresol, p-cresol and cresol (mixed isomers) are aggregated into one category called cresols in the matched data set.

*** Nitric acid, nitrate ion and nitrate compounds are aggregated into one category called nitric acid and nitrate compounds 

in the matched data set.

**** o-Xylene, m-xylene, p-xylene and xylene (mixed isomers) are aggregated into one category called xylenes in the matched data set.
PHOTO: CHRIST CHAVEZ / CEC
120

Commission for Environmental Cooperation

393, rue St-Jacques Ouest, Bureau 200

Montréal (Québec) Canada H2Y 1N9

(514) 350-4300 f (514) 350-4314

info@cec.org / www.cec.org

This report represents North America’s contribution to the Global Initiative, as well as its commitment 

to continuing to work together to ensure a safe and healthy environment for our children.