Original Articles
18 September 2025
Vol. 20 No. 2 (2025)
Spatial analysis of congenital heart disease in São Paulo State, Brazil 2012-2022: associations with air pollution, maternal factors and social vulnerability
Publisher's note
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.
0
Views
0
Downloads
Authors
Congenital Heart Disease (CHD) is a major cause of neonatal and infant morbidity and mortality and it has a multifactorial aetiology. This study aimed to analyse the spatial association between exposure to air pollutants during the first trimester of pregnancy, social vulnerability, and maternal factors with the occurrence of CHD between 2012 and 2022 in the state of São Paulo, Brazil. Data were obtained from the live birth information system for maternal outcomes and characteristics, the São Paulo social vulnerability index as a contextual indicator, and concentrations of fine particulate matter (PM2.5), Carbon Monoxide (CO) and ozone, estimated using the Copernicus Atmosphere Monitoring Service (CAMS-EAC4) reanalysis dataset of environmental exposure. A Bayesian hierarchical spatial model with a Besag–York– Mollié 2 (BYM2) specification was applied using the INLA approach. The results showed that exposure to PM2.5 was significantly associated with an increased risk of CHD (RR = 1.022; 95% CrI: 1.005-1.040), as were advanced maternal age (>35 years) (RR = 1.649; 95% CrI: 1.587-1.715) and inadequate prenatal care (RR = 1.112; 95% CrI: 1.070-1.155). Conversely, municipalities classified as having medium (RR = 0.757; 95% CrI: 0.641-0.894) and high social vulnerability (RR = 0.643; 95% CrI: 0.492-0.844) showed a significantly lower adjusted risk compared to those with low vulnerability. No significant associations were identified for CO or ozone. Spatial analysis revealed persistently high risks in municipalities within the São Paulo Metropolitan Region, even after adjusting for environmental and socio-demographic variables, highlighting population profiles and priority areas for public health surveillance and targeted interventions.
Altmetrics
Downloads
Download data is not yet available.
Citations
Abellan A, Warembourg C, Mensink-Bout SM, Ambros A, de Castro M, Fossati S, Guxens M, Jaddoe VW, Nieuwenhuijsen MJ, Vrijheid M, Santos S, Casas M, Duijts L, 2024. Urban environment during pregnancy and lung function, wheezing, and asthma in school-age children. The Generation R study. Environ Pollut 344:123345. DOI: https://doi.org/10.1016/j.envpol.2024.123345
Agay-Shay K, Friger M, Linn S, Peled A, Amitai Y, Peretz C, 2013. Air pollution and congenital heart defects. Environ Res 124:28-34. DOI: https://doi.org/10.1016/j.envres.2013.03.005
Barrozo LV, Fornaciali M, de André CDS, Morais GAZ, Mansur G, Cabral-Miranda W, de Miranda MJ, Sato JR, Amaro Júnior E, 2020. GeoSES: A socioeconomic index for health and social research in Brazil. PLoS One 15:e0232074. DOI: https://doi.org/10.1371/journal.pone.0232074
Besag J, York J, Mollié A, 1991. Bayesian image restoration, with two applications in spatial statistics. Ann Inst Stat Math 43:1-20. DOI: https://doi.org/10.1007/BF00116466
Bezerra AB, 2025. R script and data used for the analysis of factors associated with congenital heart disease in the state of São Paulo, Brazil (2012–2022). Zenodo. https://doi.org/10.5281/zenodo.16897066
Buteau S, Veira P, Bilodeau-Bertrand M, Auger N, 2023. Association between first trimester exposure to ambient PM2.5 and NO2 and congenital heart defects. Environ Health Perspect 131:067009. DOI: https://doi.org/10.1289/EHP11120
Choi J, Henze DK, Nawaz MO, Malley CS, 2024. Source attribution of health burdens from ambient PM2.5, O3, and NO2 exposure for assessment of South Korean national emission control scenarios by 2050. Geohealth 8:e2024GH001042. DOI: https://doi.org/10.1029/2024GH001042
Cohen AJ, Brauer M, Burnett R, Anderson HR, Frostad J, Estep K, Balakrishnan K, Brunekreef B, Dandona L, Dandona R, Feigin V, Freedman G, Hubbell B, Jobling A, Kan H, Knibbs L, Liu Y, Martin R, Morawska L, Pope CA 3rd, Shin H, Straif K, Shaddick G, Thomas M, van Dingenen R, van Donkelaar A, Vos T, Murray CJL, Forouzanfar MH, 2017. Estimates and 25-year trends of the global burden of disease attributable to ambient air pollution. Lancet 389:1907-18. DOI: https://doi.org/10.1016/S0140-6736(17)30505-6
Dadvand P, Rankin J, Rushton S, Pless-Mulloli T, 2011. Ambient air pollution and congenital heart disease. Environ Res 111:435-41. DOI: https://doi.org/10.1016/j.envres.2011.01.022
DATASUS, 2025. Transferência de Arquivos. Available from: https://datasus.saude.gov.br/transferencia-de-arquivos/.
Davtyan A, Ostler H, Golding IF, Sun HY, 2023. Prenatal diagnosis rate of critical congenital heart disease remains inadequate with significant racial/ethnic and socioeconomic disparities and technical barriers. Pediatr Cardiol 45:1713-23. DOI: https://doi.org/10.1007/s00246-023-03262-2
Gelb BD, Chung WK, 2014. Complex genetics and the etiology of human congenital heart disease. Cold Spring Harb Perspect Med 4:a013953. DOI: https://doi.org/10.1101/cshperspect.a013953
Girotti C, Oliveira MCQD, Sato AE, Chiquetto JB, Santos AP, de Miranda RM, Mülfarth RCK, Shimomura ARP, Lopez JMR, 2024. Urban mobility and air pollution at the neighbourhood scale in the Megacity of São Paulo, Brazil. Discover Cities 1:13. DOI: https://doi.org/10.1007/s44327-024-00016-4
Guo X, Song Q, Wang H, Li N, Su W, Liang M, et al, 2022. Systematic review and meta-analysis of studies between short-term exposure to ambient carbon monoxide and non-accidental, cardiovascular, and respiratory mortality in China. Environ Sci Pollut Res 29:35707-22. DOI: https://doi.org/10.1007/s11356-022-19464-9
IBGE, 2025. Panorama. Available from: https://cidades.ibge.gov.br/brasil/sp/panorama.
Kang SY, Cramb SM, White NM, Ball SJ, Mengersen KL, 2016. Making the most of spatial information in health: a tutorial in Bayesian disease mapping for areal data. Geospat Health 11:428. DOI: https://doi.org/10.4081/gh.2016.428
Lindgren F, Rue H, 2015. Bayesian spatial modelling with R-INLA. J Stat Softw 63:i19. DOI: https://doi.org/10.18637/jss.v063.i19
Ma Z, Cao X, Chang Y, Li W, Chen X, Tang N-jun, 2021. Association between gestational exposure and risk of congenital heart disease. Environ Res 197:111014. DOI: https://doi.org/10.1016/j.envres.2021.111014
Mamasoula C, Bigirumurame T, Chadwick T, Addor MC, Cavero-Carbonell C, Dias CM, Echevarría-González-de-Garibay LJ, Gatt M, Khoshnood B, Klungsoyr K, Randall K, Stoianova S, Haeusler M, Nelen V, Neville AJ, Perthus I, Pierini A, Bertaut-Nativel B, Rissmann A, Rouget F, Schaub B, Tucker D, Wellesley D, Zymak-Zakutnia N, Barisic I, de Walle HEK, Lanzoni M, Sayers G, Mullaney C, Pennington L, Rankin J, 2023. Maternal age and the prevalence of congenital heart defects in Europe, 1995–2015. Birth Defects Res 115:583-94. DOI: https://doi.org/10.1002/bdr2.2152
Mathiarasan S, Hüls A, 2021. Impact of environmental injustice on children’s health—interaction between air pollution and socioeconomic status. Int J Environ Res Public Health 18:795. DOI: https://doi.org/10.3390/ijerph18020795
Miller A, Riehle-Colarusso T, Siffel C, Frías JL, Correa A, 2011. Maternal age and prevalence of isolated congenital heart defects in an urban area of the United States. Am J Med Genet A 155:2137-45. DOI: https://doi.org/10.1002/ajmg.a.34130
Nogueira T, Kamigauti LY, Pereira GM, Gavidia-Calderón ME, Ibarra-Espinosa S, Oliveira GL, Miranda RM, Vasconcellos PC, Freitas ED, Andrade MF, 2021. Evolution of vehicle emission factors in a megacity affected by extensive biofuel use. Environ Sci Technol 55:6677-87. DOI: https://doi.org/10.1021/acs.est.1c01006
Patel SS, Burns TL, 2013. Nongenetic risk factors and congenital heart defects. Pediatr Cardiol 34:1535-55. DOI: https://doi.org/10.1007/s00246-013-0775-4
Perez MT, Bucholz E, Asimacopoulos E, Ferraro AM, Salem SM, Schauer J, Holleman C, Sekhavat S, Tworetzky W, Powell AJ, Sleeper LA, Beroukhim RS, 2022. Impact of maternal social vulnerability and timing of prenatal care on outcome of prenatally detected congenital heart disease. Ultrasound Obstet Gynecol 60:346-58. DOI: https://doi.org/10.1002/uog.24863
Pinto Júnior VC, Branco KM, Cavalcante RC, Carvalho Junior W, Lima JR, Freitas SM, Fraga MN, Souza NM, 2015. Epidemiology of congenital heart disease in Brazil. Rev Bras Cir Cardiovasc 30:219-24.
QGIS Development Team, 2025. QGIS Geographic Information System. Open Source Geospatial Foundation Project. Available from: https://qgis.org.
R Core Team, 2022. R: A language and environment for statistical computing. Available from: https://www.r-project.org/
Ribeiro AI, Krainski ET, Carvalho MS, de Pina MF, 2017. The influence of socioeconomic deprivation, access to healthcare and physical environment on old-age survival in Portugal. Geospat Health 12:581. DOI: https://doi.org/10.4081/gh.2017.581
Riebler A, Sørbye SH, Simpson D, Rue H, 2016. An intuitive Bayesian spatial model for disease mapping that accounts for scaling. Stat Methods Med Res 25:1145–65. DOI: https://doi.org/10.1177/0962280216660421
Silva MD, Oliveira MCQD, Drumond A, Rizz LV, 2021. Air pollutants associated with surface meteorological conditions in São Paulo’s ABC region. Rev Bras Cienc Ambient 56:459–69. DOI: https://doi.org/10.5327/Z21769478917
Sun L, Wu Q, Wang H, Liu J, Shao Y, Xu R, Gong T, Peng X, Zhang B, 2023. Maternal exposure to ambient air pollution and risk of congenital heart defects in Suzhou, China. Front Public Health 10:1017644. DOI: https://doi.org/10.3389/fpubh.2022.1017644
van der Linde D, Konings EEM, Slager MA, Witsenburg M, Helbing WA, Takkenberg JJM, et al, 2011. Birth prevalence of congenital heart disease worldwide. J Am Coll Cardiol 58:2241-7. DOI: https://doi.org/10.1016/j.jacc.2011.08.025
Wang G, 2015. Effects of weather and landscape on the equine West Nile virus infection risk in Mississippi, USA. Geospat Health 10:357. DOI: https://doi.org/10.4081/gh.2015.357
World Health Organization, 2025. Impact. Congenital disorders. Available from: https://www.who.int/health-topics/congenital-anomalies#tab=tab_3.
Zhan C, Xie M, Lu H, Liu B, Wu Z, Wang T, et al, 2023. Impacts of urbanization on air quality and the related health risks in a city with complex terrain. Atmos Chem Phys 23:771–88. DOI: https://doi.org/10.5194/acp-23-771-2023
How to Cite
Spatial analysis of congenital heart disease in São Paulo State, Brazil 2012-2022: associations with air pollution, maternal factors and social vulnerability. (2025). Geospatial Health, 20(2). https://doi.org/10.4081/gh.2025.1407
Copyright (c) 2025 the Author(s)
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
PAGEPress has chosen to apply the Creative Commons Attribution NonCommercial 4.0 International License (CC BY-NC 4.0) to all manuscripts to be published.
