Documenti di Didattica
Documenti di Professioni
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Environmental Pollution
journal homepage: www.elsevier.com/locate/envpol
Environmental Science and Engineering Ph.D. Program, The University of Texas, El Paso, TX 79968, USA
Department of Environmental Health, Rollins School of Public Health at Emory University, Atlanta, GA 30322, USA
Centro de Investigacin y Desarrollo Tecnolgico, Tecnolgico de Monterrey, Campus Ciudad Jurez, Ciudad Jurez, Chihuahua 32470, Mexico
d
University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
e
Interdisciplinary Health Science Ph.D. Program, College of Health Sciences, The University of Texas, El Paso, TX 79968, USA
f
Department of Civil Engineering, The University of Texas, El Paso, TX 79968, USA
b
c
a r t i c l e i n f o
a b s t r a c t
Article history:
Received 18 February 2011
Received in revised form
9 June 2011
Accepted 19 June 2011
Paired indoor and outdoor concentrations of ne and coarse particulate matter (PM), PM2.5 reectance
[black carbon(BC)], and nitrogen dioxide (NO2) were determined for sixteen weeks in 2008 at four
elementary schools (two in high and two in low trafc density zones) in a U.S.eMexico border
community to aid a binational health effects study. Strong spatial heterogeneity was observed for all
outdoor pollutant concentrations. Concentrations of all pollutants, except coarse PM, were higher in high
trafc zones than in the respective low trafc zones. Black carbon and NO2 appear to be better trafc
indicators than ne PM. Indoor air pollution was found to be well associated with outdoor air pollution,
although differences existed due to uncontrollable factors involving student activities and building/
ventilation congurations. Results of this study indicate substantial spatial variability of pollutants in the
region, suggesting that childrens exposures to these pollutants vary based on the location of their
school.
2011 Elsevier Ltd. All rights reserved.
Keywords:
Air pollution
Particulate matter
Nitrogen dioxide
Black carbon
USeMexico border
Spatiotemporal variation
1. Introduction
Epidemiologic investigations have identied a link between
trafc-related air pollution and respiratory disorders (Adar et al.,
2007; Finkelstein et al., 2004; Jansen et al., 2005; Peters et al.,
2004; Schwartz et al., 2005), especially in sensitive populations
like the elderly and children with preexisting respiratory disease
(Fischer et al., 2002; Koenig et al., 2005; McConnell et al., 1999;
Steerenberg et al., 2003). Concerns regarding the health impacts
of trafc-related pollution are also pronounced for populations
along the U.S.eMexico border, where high rates of urbanization
and industrial development have led to rapidly deteriorating air
quality. For example, the Paso del Norte (PdN) border region
(comprising the cities of El Paso, Texas, Ciudad Jurez, Chihuahua,
and Sunland Park, New Mexico) has experienced signicant population and economic growth since the passage of the North
* Corresponding author.
E-mail
addresses:
auraysoni@miners.utep.edu,
(A.U. Raysoni).
amit.raysoni@gmail.com
0269-7491/$ e see front matter 2011 Elsevier Ltd. All rights reserved.
doi:10.1016/j.envpol.2011.06.024
American Free Trade Agreement (NAFTA) in 1994, which accelerated binational commerce between these two countries. This
region has also seen an increase in the overall number of motor
vehicles in the cities as well as at the international border crossings (15e16 million passenger cars and 750,000 commercial
vehicles across the four international ports of entry between El
Paso and Ciudad Jurez each year according to the U.S. Department
of Transportation). The PdN region is an area heavily impacted by
trafc emissions from one of the busiest USeMexico border
crossings as well as high local vehicle usage. While Ciudad Juarez
has about four times the population density of El Paso, the daily
vehicles miles traveled for El Paso (15.8 106, EPMPO, 2007) is
likely at least three times higher than that reported for Ciudad
Juarez (4.1 106, Wolf et al., 2003). This leads to high idling time
at the crossings, subsequent border congestion (Currey et al.,
2005), and high trafc emissions in the cities. The PdN, situated
approximately 3800 ft above sea level, represents a paradigmatic
exposure-air pollution challenge in an international setting due
to a large segment of its citizenry residing adjacent to
congested roadways and a further exacerbation of their corresponding health exposures to arid weather, unique topography
2477
am. The sampling durations for the pollutant measurements were selected to
correspond with childrens time-activity patterns, to collect sufcient quantity of
mass for gravimetric analysis, and to provide sufcient time-resolved data for the
epidemiologic component of the study.
For outdoor measurements, the monitoring units were set up on the roof (4e5 m
above the ground) of each school. For indoor measurements, the samplers were
located in a room reecting the general indoor environment of the school and where
students were likely to spend substantial amount of their time. Indoor locations
included: space near a teachers work desk in a computer room (EP-A); a library
reference room (EP-B); on top of a locker in a classroom (CJ-A); and a library (CJ-B).
2.3. Sample collection and laboratory analyses
PM samples were collected using Harvard 5LPM cascade impactors (Demokritou
et al., 2002). The impactors operated with two impaction stages resulting in the
collection of PM102.5 on polyurethane foam (PUF, Lee et al., 2006) and PM2.5 on
Teon lter. The lters used were 37 mm diameter, 2 mm pore size PTFE (polytetrauoroethylene) lters (Pall Life Sciences, Ann Arbor, MI). MEDO Pumps (Model
No.VP0125) were employed to generate a constant air stream of 5 5% l/min into
the cascade samplers. The sampling ow rate was determined onsite with the
sampler in place before and after the sampling period using a Buck ow calibrator
(Model M-30, 0.1-30 LPM, A.P.Buck, Inc.). PM2.5 and PM102.5 mass concentrations
(mg/m3) were quantied by gravimetric analysis at the University of Texas at El Paso
(UTEP) Air Quality Laboratory using a CAHN model C-33 microbalance (Orion
Research, 1997) and a Mettler MX5 (Mettler-Toledo, Greifensee, Switzerland),
respectively. All samples were pre- and post- conditioned to room temperature
(25 3 C) and humidity (30 5%) for at least 24 h in the laboratory by storing them
in a custom-made storage cabinet prior to weighing. Detailed laboratory operating
procedures are provided by Li et al. (2001) and Orquiz (2001). PM10 values were
obtained by summing PM2.5 and PM102.5 masses collected on the two stages of the
impactor.
PM2.5 lters were further analyzed by reectometry for the blackness or loss of
reectance, as a proxy for soot or black carbon, which is considered a good indicator of trafc-related emissions (Gtschi et al., 2002; Kinney et al., 2000). Reectance was measured using a Digital Smoke Stain Reectometer (Model No: EEL 43D,
Diffusion Systems Ltd). The lab blank lters were used to set reectance at 100
percent, and the sampled lter was measured 5 times on different locations (5-point
method); the average of these ve measurements was used in the calculations.
Percentage of the reectance was transformed into absorption coefcients using the
standard ISO approved method (ISO 9835, 1993(E)). The absorption coefcient was
multiplied by 105 (Cyrys et al., 2003; Fischer et al., 2000) and was used to estimate
mg BC on the lter and subsequently the BC concentrations (mg/m3) in the air
collected.
Nitrogen dioxide concentrations were measured using passive badge samplers
(Ogawa & Company, Pompano Beach, Florida, USA) containing a single cellulose
lter coated with triethanolamine to collect NO2. All samplers were prepared at the
Harvard School of Public Health (HSPH). Loaded samples collected from the eld
were stored at 4 C in the UTEP Air Quality Laboratory before shipping to HSPH for
subsequent extraction and ion chromatography analysis (Ogawa, 1997).
Hourly air quality data from six TCEQ CAMS sites in the region were also
collected (Fig. 1). Variables of interest included PM10, PM2.5, NO2, relative humidity,
temperature, wind speed, wind direction, and wind gust. These data were averaged
over 48- and 96-h to correspond with the eld-based measurements.
2.4. QA/QC of the data
Data quality assurance procedures were enforced to ensure minimal contamination in sample handling and eld work. A set of eld blanks and duplicate samples
were collected on both sides of the border for each eld sampling session. Limit of
Detection (LOD) was determined as three times the standard deviation of the eld
blanks. For a given pollutant, precision was estimated as the root mean squared
difference between the collocated samplers, divided by the square root of 2 (Sarnat
et al., 2000). Completeness was calculated as the number of samples collected
divided by the target number of samples. LOD, precision and completeness values
for the measured pollutants are shown in Table 1. Mean (S.D.) eld blank values
were: 15.5 (21.8) mg for PM2.5, 14.3 (12.4) mg for PM102.5, 1.6 (2.0) mg for BC, and 0.06
(0.96) ppb for NO2, representing errors of less than 0.04%, 0.04%, 0.1%, and 0.002% in
the respective PM2.5, PM102.5, BC, and NO2 measurements. For all measured species,
the percentage of valid samples was well above the acceptable value of 90% (Sarnat
et al., 2000).
2.5. Data analysis
Descriptive statistics, wind roses, correlation coefcients, coefcient of divergence (COD), and indooreoutdoor ratios were computed to characterize the data
and conduct data comparisons. Indooreoutdoor ratios were computed to assess
indooreoutdoor associations. Specically, Spearmans correlation coefcients were
computed to assess the inter-site associations for each pollutant and the intrapollutant associations at each site, which helped understand any temporal
2478
Fig. 1. Map of the study area, including school locations and TCEQ CAMS sites.
similarity in pollutant concentrations at the paired sites (Pinto et al., 2004; Wilson
et al., 2005). COD analyses were performed to evaluate the spatial contrast
between the four schools and corresponding CAMS sites (Pinto et al., 2004; Krudysz
et al., 2008). The COD provides a degree of uniformity between two simultaneously
sampled sites, j and k by:
v
#2
u p "
u1 X x x
i;j
i;k
CODj;k t
p i1 xi;j xi;k
3. Results
where xi,j is the ith concentration measured at site j over the sampling period, and p
is the number of observations. A small COD (r < 0.2) indicates similar pollutant
concentrations between two sites, whereas a value approaching unity indicates
Table 1
LOD, precision, and completeness.
PM102.5
PM2.5
BC
NO2
Units
LOD
Precision
Completeness
n LOD
mg/m3
mg/m3
mg/m3
2.69
4.62
0.42
2.88
0.16
0.12
0.12
0.09
266/270
265/270
270/270
127/127
265
246
192
117
ppb
signicant difference in the absolute concentrations and subsequent spatial nonuniformity between the sites. All analyses were performed using SPSS for
Windows, v. 17.0 (SPSS, Inc., Chicago, IL). Wind roses were plotted using Wind Rose
software from Lakes Environmental Inc, CA.
(98.5%)
(98%)
(100%)
(100%)
(99.6%)
(92.8%)
(71.1%)
(92.1%)
2479
Table 2
Summary statistics of indoor, outdoor, and CAMS pollutant concentrations and corresponding indoor (I)-outdoor (O) ratios and correlations.
Pollutant
Site
Indoor Concentrations
Mean
Median
SD
Min
Max
Mean
I/O Ratios
I/O Correlations
Median
SD
Min
Max
Median
Min
Max
R2
48-h PM10
(mg/m3)
EP-A
EP-B
CJ-A
CJ-B
CAMS12
CAMS41
CAMS49
29
31
28
27
31
32
32
18.4
39.0
93.0
63.2
35.2
34.6
43.6
17.3
38.5
84.8
53.7
29.2
30.3
41.3
8.8
17.6
41.3
40.1
22.8
20.3
23.6
5.9
15.1
40.1
20.0
13.3
14.1
20.4
39.5
100.5
237.4
214.2
124.2
114.5
142.9
29
30
28
27
16.7
19.7
71.4
45.8
15.9
16.3
63.4
43.7
6.6
16.1
34.8
18.9
7.0
4.6
17.7
17.9
35.7
90.5
166.9
87.1
0.89
0.47
0.77
0.81
2.05
0.9
1.15
2.26
0.48
0.26
0.17
0.41
0.59
0.68
0.62
0.10
48-h PM102.5
(mg/m3)
EP-A
EP-B
CJ-A
CJ-B
CAMS12
CAMS41
31
31
28
27
31
32
9.9
24.5
57.9
37.5
26.3
24.9
9.3
24.6
52.9
31.5
20.1
20.5
5.1
10.8
21.6
19.4
19.6
16.8
2.8
9.5
26.7
9.6
10.6
10.4
25.0
66.0
109.9
83.8
104.2
94.3
31
31
28
27
8.9
9.9
42.2
24.7
8.2
6.1
39.8
22.1
4.0
10.1
18.0
10.0
3.5
1.2
10.0
12.6
22.0
56.8
101.2
53.6
0.89
0.39
0.8
0.67
0.38
0.09
0.13
0.28
1.57
0.86
1.25
2.88
0.72
0.55
0.35
0.75
48-h PM2.5
(mg/m3)
EP-A
EP-B
CJ-A
CJ-B
CAMS12
CAMS41
29
31
29
28
31
32
8.3
14.5
34.6
26.2
9.0
9.7
7.7
13.7
30.4
19.8
8.2
9.0
4.1
7.8
22.9
22.9
4.4
4.7
2.6
1.2
12.1
7.5
2.6
2.4
20.9
39.1
127.5
130.4
20.0
21.9
29
30
29
28
7.5
9.6
29.4
21.5
6.4
8.8
24.5
19.2
3.3
6.3
19.3
11.6
2.6
1.5
7.7
5.4
15.8
33.7
104.3
59.8
0.91
0.59
0.91
0.86
0.26
0.24
0.26
0.46
3.04
2.74
1.37
1.69
0.10
0.77
0.79
0.42
48-h BC
(mg/m3)
EP-A
EP-B
CJ-A
CJ-B
31
31
29
28
0.52
0.71
0.95
0.89
0
0.2
0.19
0.67
1.39
1.22
1.57
1.43
0.68
0.84
0.87
0.89
96-h NO2
(ppb)
EP-A
EP-B
CJ-A
CJ-B
CAMS12
CAMS37
CAMS41
15
16
16
16
16
16
16
1.02
0.61
1.02
3.45
0.23
0.33
0.51
1.17
2.05
0.94
2.3
8.1
0.53
2.56
0.49
0.63
0.23
0.75
1.81
2.48
4.5
14.2
18.8
26.8
18.4
20.4
13.9
0.16
0.67
1.63
2.39
3.6
14.0
18.1
23.0
17.3
17.5
12.0
0.2
0.39
1.07
1.27
3.5
3.2
5.6
10.2
5.6
4.9
6.5
0.00
0.15
0.38
0.65
1.7
9.0
13.0
15.2
11.6
15.0
6.0
0.65
1.74
5.54
5.08
15.3
21.2
36.6
50.4
33.3
30.0
29.8
30
31
29
28
16
16
16
16
0.14
0.56
1.74
2.28
4.0
8.1
22.8
114.9
0.09
0.50
1.35
2.10
3.5
7.9
19.8
82.8
0.15
0.36
1.20
1.33
2.2
1.1
12.5
98.9
0.00
0.03
0.33
0.84
1.2
6.4
8.8
24.3
0.53
1.59
5.27
6.15
10.2
10.4
59.2
328.3
2480
Fig. 2. Temporal Variations of the monitored pollutants at the four schools (indoor and outdoor) and TCEQ CAMS sites.
4. Discussion
4.1. Spatial contrast between the four schools
As part of the rst binational health effects study investigating
the impact of trafc-related air pollution on asthmatic children, we
assessed the level of intra-urban spatial variability among trafc
pollutants in El Paso and Ciudad Jurez. Substantial spatial
contrasts were observed for all the measured pollutants in this
study. This nding is consistent with previous studies in the PdN
that have demonstrated considerable spatial and temporal variation in major trafc air pollutants like PM and NO2 at the intraurban level (Eineld and Church, 1995; Holguin et al., 2007;
Li et al., 2001, 2003; Noble et al., 2003). Eineld and Church
(1995) documented that winter season PM10 levels were greater
in the central areas of El Paso-Ciudad Jurez and the incremental
concentration gradients were observed toward Ciudad Jurez.
Li et al. (2001) found higher ne and coarse PM concentrations in
2481
Table 3
Coefcient of divergence (COD) values for the monitored pollutants (Indoor and Outdoor).
Microenvironment
Outdoor
Pollutant
Site
EP-B
CJ-A
CJ-B
CAMS12
CAMS41
CAMS49
Indoor
PM10
EP-A
EP-B
CJ-A
CJ-B
CAMS12
CAMS41
0.39
0.69
0.42
0.56
0.26
0.24
0.32
0.17
0.5
0.36
0.32
0.14
0.50
0.34
0.1
0.42
0.27
0.41
0.10
0.16
0.14
PM102.5
EP-A
EP-B
CJ-A
CJ-B
CAMS12
0.45
0.73
0.42
0.59
0.25
0.28
0.45
0.19
0.47
0.32
PM2.5
EP-A
EP-B
CJ-A
CJ-B
CAMS12
0.35
0.6
0.43
0.51
0.33
0.20
0.17
0.31
0.58
0.5
BC
EP-A
EP-B
CJ-A
CJ-B
0.63
0.78
0.38
0.84
0.49
0.21
NO2
EP-A
EP-B
CJ-A
CJ-B
CAMS12
CAMS41
0.59
0.65
0.16
0.74
0.31
0.22
0.65
0.15
0.08
0.23
EP-B
CJ-A
CJ-B
CAMS12
CAMS41
CAMS49
0.17
0.62
0.61
0.49
0.48
0.29
0.37
0.33
0.42
0.25
0.36
0.33
0.41
0.23
0.45
0.42
0.33
0.16
0.43
0.16
0.47
0.31
0.13
0.19
0.66
0.68
0.51
0.54
0.33
0.47
0.50
0.38
0.20
0.46
0.49
0.37
0.19
0.17
0.29
0.56
0.49
0.09
0.24
0.58
0.53
0.51
0.46
0.24
0.21
0.21
0.53
0.42
0.22
0.21
0.51
0.41
0.74
0.86
0.50
0.90
0.58
0.25
0.44
0.70
0.45
0.89
0.77
0.59
0.67
0.39
0.20
0.62
0.70
0.43
0.21
0.60
0.56
0.15
0.23
0.36
0.2
CAMS37
0.68
0.18
0.1
0.2
0.09
0.26
CAMS37
0.57
0.30
0.29
0.70
2482
Table 4
Outdoor school inter-site and intra-pollutant Spearmans correlations coefcients.
Pollutant
Site
PM102.5
PM2.5
BC
NO2
EP-B
CJ-A
CJ-B
EP-A
PM2.5
EP-B
CJ-A
CJ-B
EP-A
EP-A
EP-B
CJ-A
CJ-B
1.00
0.81**
0.73*
0.38
1.00
0.82**
0.64*
1.00
0.88**
1.00
EP-A
EP-B
CJ-A
CJ-B
0.97**
0.62*
0.73*
0.33
0.86**
0.90**
0.84**
0.65*
0.83**
0.88**
0.96**
0.81**
0.64*
0.73*
0.89**
0.96**
1.00
0.73**
0.88**
0.66*
1.00
0.90**
0.75*
1.00
0.88**
1.00
EP-A
EP-B
CJ-A
CJ-B
0.94**
0.87**
0.56
0.77*
0.88**
0.93**
0.53
0.81**
0.55
0.74**
0.70*
0.94**
0.42
0.61
0.54
0.91**
0.90**
0.88**
0.53
0.83**
0.76**
0.70**
0.53
0.75**
0.50
0.72*
0.57
0.93**
0.41
0.59
0.49
0.84**
0.01
0.33
0.10
0.27
0.07
0.59
0.23
0.55
0.37
0.26
0.54
0.29
0.12
0.11
0.36
0.15
0.07
0.32
0.04
0.29
0.02
0.55
0.17
0.51
0.39
0.18
0.54
0.42
0.62*
0.52
0.05
0.45
0.23
0.17
0.67**
0.08
0.04
0.02
0.49
0.37
0.50
0.41
0.09
0.43
0.67*
0.42
0.05
0.47
0.39
0.38
0.67**
0.11
EP-A
EP-B
CJ-A
CJ-B
0.26
0.21
0.50
0.28
0.27
0.06
0.38
0.34
EP-A
EP-B
CJ-A
CJ-B
0.46
0.03
0.59*
0.18
0.17
0.15
0.53*
0.20
0.44
0.51
0.02
0.36
1.00
0.85**
0.44
0.56
BC
EP-B
1.00
0.48
0.76**
CJ-A
CJ-B
NO2
EP-A
EP-B
CJ-A
CJ-B
1.00
0.57
1.00
0.36
0.26
0.46
0.50
0.08
0.29
0.22
0.08
0.15
0.21
0.08
0.29
1.00
0.75**
0.83**
0.58
1.00
0.68*
0.74**
1.00
0.80**
1.00
0.31
0.17
0.53*
0.02
0.23
0.36
0.09
0.29
0.38
0.32
0.01
0.25
0.63*
0.83**
0.67**
0.65**
0.70**
0.61*
0.500
0.531*
0.60*
0.78**
0.84**
0.60*
0.73**
0.73*
0.74**
0.61*
EP-A
EB-B
CJ-A
CJ-B
1.00
0.67**
0.58*
0.56*
1.00
0.60*
0.57*
1.00
0.44
1.00
PM10
PM102.5
PM10
EP-A
Indoor
Pollutant
Location
EP-A
EP-B
CJ-A
CJ-B
EP-A
Outdoor
EP-B
CJ-A
CJ-B
PM10
CAMS12
CAMS41
CAMS49
0.47
0.55
0.65
0.71
0.70
0.79
0.47
0.65
0.61
0.66
0.75
0.65
0.81
0.84
0.87
0.65
0.76
0.80
0.78
0.85
0.72
0.69
0.78
0.61
PM102.5
CAMS12
CAMS41
0.57
0.60
0.54
0.50
0.37
0.43
0.55
0.52
0.77
0.82
0.60
0.62
0.66
0.67
0.59
0.65
PM2.5
CAMS12
CAMS41
0.49
0.55
0.78
0.77
0.85
0.80
0.85
0.82
0.68
0.67
0.74
0.76
0.88
0.72
0.86
0.79
NO2
CAMS12
CAMS37
CAMS41
0.87
0.71
0.76
0.12
0.19
0.14
0.40
0.42
0.51
0.43
0.46
0.51
0.54
0.63
0.83
0.77
0.90
0.90
0.77
0.56
0.71
0.53
0.56
0.66
The PM correlations are based on 48-h averages. The NO2 correlations are based on
96-h averages. Correlation coefcients in bold are signicant at 0.05 level. The
numbers in italics and underlined are signicant at 0.01 level. N 26e31 for PM,
and N 15e16 for NO2.
2483
2484
Fig. 3. Wind roses for the TCEQ CAMS sites for the study period.
5. Conclusions
This binational study characterized levels of major air pollutants
(PM10, PM102.5, PM2.5, BC, NO2), indoors and outdoors, at four
schools in two cities in the Paso del Norte region. Strong spatial
heterogeneity in air pollutant concentrations exists with all absolute concentrations higher in Ciudad Jurez than in El Paso. Schools
within the high trafc zone in Ciudad Jurez were observed to have
the highest indoor concentrations of NO2 and BC, but not PM2.5.
Trafc-related PM pollution was confounded by the ubiquitous
fugitive dust emissions, whether from unpaved roads or bare soil
surfaces, such that both ne and coarse PM (PM2.5 and PM102.5)
measured in the low trafc zone surpassed those measured in the
high trafc zone in Ciudad Jurez. Inter-site and intra-pollutant
analyses suggested that BC and NO2 would be better trafc pollution indicators than any of the PM metrics. On the contrary, levels of
all ambient pollutants measured in the high trafc zone exceeded
those measured in the low trafc zone in El Paso where almost all
streets were paved. Indoor air pollution, in general, was found to be
well associated with outdoor air pollution, although differences
existed among all the schools.
Pollutant concentration trends observed during this short study
period may vary temporally if different seasons are taken into
account and that the weekend concentration proles for the
various pollutants might differ since sampling was undertaken only
during weekdays. Nevertheless, our objectives were achieved by
providing indoor and outdoor exposure concentration estimates for
characterizing childrens exposure during weekdays and by
corroborating that central ambient monitoring alone may not
mirror the representative pollutant concentrations in urban areas
that experience varying levels of trafc and other fugitive emission
sources. We concur that pollutant sampling in different microenvironments and different exposure zones as conducted in this study
are central toward estimating childrens true trafc exposures. Our
overall results validate the United States Environment Protection
Agencys recommendations for school-based air pollution monitoring, in lieu of the conventional central site monitoring methodology, for winnowing the best environmental health indicator for
school-going children. Results from this study would also aid in
evaluating the effectiveness of pollution reduction strategies in
majorityeminority communities of the U.S.-Mexico border region
eventually assisting policy makers toward achieving their designated air quality standards.
Acknowledgments
Funding for this research was provided by the Pan American
Health Organization (PAHO). The authors express their gratitude to
the School Districts, principals, nurses and students who participated in this study. We also thank Veronica Guerrero, Mario Garcia,
Patricia Sanchez, and Landy Breton for helping with eld sampling.
The contents of this paper are solely the authors responsibility and
do not represent the ofcial views of PAHO.
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