Take pre-emptive measures voluntarily to tackle air pollution

An emergency plan called the Graded Response Action Plan has been notified by the Ministry of Environment, Forest & Climate Change for implementation under different Air Quality Index (AQI) categories.

The different AQI categories are Severe, Very poor and Moderate & Poor. The cut-off levels of PM2.5 or PM10 have been defined for each category as have been the actions to be implemented and the agency responsible for implementing the specified actions.

The actions to be implemented under the Severe or Emergency category defined as “ambient PM 2.5 or PM 10 concentration values of 300μg/m3 or 500 μg/m3 respectively persist for 48 hours or more” are:

• Stop entry of truck traffic into Delhi (except essential commodities)
• Stop construction activities
• Introduce odd and even scheme for private vehicles based on license plate numbers and minimize exemptions
• Task Force to take decision on any additional steps including shutting of schools

The graded response action plan, as the name suggests, also lists action to be taken under different categories such as severe, very poor and moderate to poor (defined as below).

• Severe (ambient PM2.5or PM10 concentration value is more than 250 μg/m3or 430μg/m3 respectively)
• Very poor (ambient PM2.5or PM10 concentration value is between 121-250μg/m3or 351-430 μg/m3 respectively)
• Moderate to poor (ambient PM2.5 or PM10 concentration value is between 61-120 μg/m3 or 101-350 μg/m3 respectively)

What stands out in this Action Plan is the time period of 48 hours specified only for the Severe or Emergency category, but not for other categories.

The question here is why this time period of 48 hours?

One cannot wait for 48 hours to declare an emergency. If AQI remains high in the severe or emergency category, even for a very short period of time, a person will have suffered the ill-effects. They will not wait for 48 hours to set in.

AQI in the severe category not only affects those with underlying heart or lung disease, but also those who are healthy.

Breathing polluted air for even two hours can increase blood pressure, potentially raising the risk of cardiovascular disease in those exposed to smog. In susceptible patients, this small increase may actually be able to trigger a heart attack or stroke.  . 

Short-term exposure to air pollutants (both ozone and fine particulate matter) has been associated with total mortality¹ and acute coronary ischemic events^2-5

·          In a case-crossover study of more than 22 million deaths between 2000 and 2012 identified from the United States Medicare population, increased risk of all-cause mortality was seen with short-term increases in fine particulate matter (RR increase 1.05 percent for each 10 mcg/m3 increase) and ozone (RR increase 0.51 percent for each 10 part per billion increase). ¹ The increased risk occurred at levels of air pollution that are lower than the currently suggested air quality standards.

·          In a study of over 12,000 patients living in a defined geographic area, a short-term increase in fine ambient particulate matter positively correlated with an increase in acute ischemic coronary events. ²

·          In a systematic review and meta-analysis of data from 34 studies, carbon monoxide, nitrogen dioxide, sulfur dioxide, and small particulate matter (less than 10 microns and less than 2.5 microns) were all associated with an increased risk of myocardial infarction (MI), with the overall population attributable risk ranging from 1 to 5 percent. ⁶

Possible mechanisms by which fine particulate air pollution may increase the risk of CVD include:⁷

·          An increase in mean resting arterial blood pressure through an increase in sympathetic tone and/or the modulation of basal systemic vascular tone⁸

·          An increase in the likelihood of intravascular thrombosis through transient increases in plasma viscosity and impaired endothelial dysfunction⁹

·          The initiation and promotion of atherosclerosis^10,11

When the AQI reaches the level, high enough to be categorized as emergency, the pre-emptive measures should start automatically by the concerned agency including us, as individuals.

For instance, if the AQI is in the emergency category, schools/colleges should stop all outdoor activities including sports and the school medical officer should advise closing of the school.

• The odd and even scheme can be self-implemented in such a situation.
• Walk or cycle for short distance commutes or to the neighborhood market. Plan and combine all your errands in one area or close by areas for one trip. Limit driving and make use of carpool.
• Use public transport as much as possible for longer distances. If you have to use your vehicle keep it well maintained for efficient functioning with regular servicing to reduce harmful exhaust emissions and get pollution check done as required. Follow speed limits. Avoid buying diesel vehicle.
• Avoid burning candles dhoop or incense sticks at home or workplace.
• Wet mop the floors at home or workplace

The AQI varies from area to area. It may be higher in some parts of Delhi, for example; at places, it may be lower. Hourly AQIs can be obtained for different areas of Delhi at http://www.dpccairdata.com/.

Each of one of us should act, instead of waiting for the government to enforce the graded action plan after a period of 48 hours.

Check the daily pollution levels in your area and be proactive in taking precautions.

Self-regulation is the answer…

References

1.    Di Q, Dai L, Wang Y, et al. Association of short-term exposure to air pollution with mortality in older adults. JAMA 2017;318:2446.

2.    Pope CA 3rd, et al. Ischemic heart disease events triggered by short-term exposure to fine particulate air pollution. Circulation 2006;114:2443.

3.    Ruidavets JB, Cournot M, Cassadou S, et al. Ozone air pollution is associated with acute myocardial infarction. Circulation 2005; 111:563.

4.    Tonne C, Wilkinson P. Long-term exposure to air pollution is associated with survival following acute coronary syndrome. Eur Heart J 2013;34:1306.

5.    Sinharay R, Gong J, Barratt B, et al. Respiratory and cardiovascular responses to walking down a traffic-polluted road compared with walking in a traffic-free area in participants aged 60 years and older with chronic lung or heart disease and age-matched healthy controls: a randomised, crossover study. Lancet 2018;391:339.

6.    Mustafic H, Jabre P, Caussin C, et al. Main air pollutants and myocardial infarction: a systematic review and meta-analysis. JAMA 2012;307:713.

7.    Newby DE, Mannucci PM, Tell GS, et al. Expert position paper on air pollution and cardiovascular disease. Eur Heart J 2015;36:83.

8.    Brook RD, Brook JR, Urch B, et al. Inhalation of fine particulate air pollution and ozone causes acute arterial vasoconstriction in healthy adults. Circulation 2002;105:1534.

9.    Pekkanen J, Peters A, Hoek G, et al. Particulate air pollution and risk of ST-segment depression during repeated submaximal exercise tests among subjects with coronary heart disease: the Exposure and Risk Assessment for Fine and Ultrafine Particles in Ambient Air (ULTRA) study. Circulation 2002;106:933.

10. Sun Q, Hong X, Wold LE. Cardiovascular effects of ambient particulate air pollution exposure. Circulation 2010; 121:2755.

11. Bauer M, Moebus S, Möhlenkamp S, et al. Urban particulate matter air pollution is associated with subclinical atherosclerosis: results from the HNR (Heinz Nixdorf Recall) study. J Am Coll Cardiol 2010;56:1803.

 Dr KK Aggarwal

Padma Shri Awardee

President Elect Confederation of Medical Associations in Asia and Oceania   (CMAAO)

Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Immediate Past National President IMA

A daylong conference on 20th January

eMedinewS and Heart Care Foundation of India will be organizing a daylong conference on 20^th January, 2013 at Maulana Azad Medical College and will be attended by over 1000 doctors. The conference will revisit the happenings of the year 2012.

Addressing a press conference here Padma Shri & Dr. BC Roy National Awardee, Dr. KK Aggarwal, Group Editor-in-Chief eMedinewS and President Heart Care Foundation of India, and Dr Ganesh Mani, Dr Ashish Jain, Dr. Vivek Bhatia, Dr. Praveen Bhatia, Dr Jugal Mishra, Dr. N.K.Bhatia, Dr. Neeraj Jain, Dr Kailash Singla and Dr. Praveen Chandra, in a joint statement said that a lot has changed in the last one year. Following were a few of the new advancements:

1. The new mantra for Cardiopulmonary Resuscitation (CPR10) – Over 25000 people in the city of Delhi alone have been trained in CPR10 to revive people out of sudden death. The mantra created by Dr. KK Aggarwal simplifies the course of action to be taken by people – “within 10 minutes of death (earlier the better), at least for the next 10 minutes (longer the better – upto 25 minutes), compress the centre of the chest of the victim effectively and continuously with a speed of 10x10 i.e. 100 per minutes”.

2. For patients whose blood pressure is not getting under control, new treatment is denervation of the nerves connected to the kidney.

3. For suspected rheumatic heart diseases, echo screening and not clinical screening is the answer.

4. Bypass surgery is better than drug quoted stents in patients with diabetes.

5. Pre-exposure prophylaxes with tenofvir and emtricitadine is now an established way of preventing HIV in high risk individuals.

6. New guidelines suggest that all patients of HIV+ should be treated regardless of CD4 T cells count.

7. Bacterial nasal sinusitis needs to be treated by anti-biotic and should be differentiated from viral nasal sinusitis.

8. In patients over the age of 70 years being treated with enema for constipation, one should use warm water enema rather than sodium phosphate enema.

9. In women of 65 years of age and older with a normal or slightly low bone mass at baseline measurement and with no risk factors of accelerated bone loss, follow-up bone densitometry should be done between 10-15 years.

10. Patients with high cholesterol on statin no more require monitoring of liver functions. They should be done only at baseline and not thereafter

11. Patients of depression on citalopriam should not be given a dose more than 40 mg and in 60+, it should not be more than 20mg.

12. Bio-absorbable polymers stent are now available in India.

13. Without surgery aortic valve replacement via catheter has now started in India.

14. Small intestinal transplant has been added to the list of transplant in the country.

15. Recently, a patient from Delhi who was brain dead donated his organs to 37 people.

16. A circular from Ministry of Health and Family Welfare has clarified that under the PNDT Act, medical practitioners with post graduation in gynecology and obstetrics are qualified to do obstetric ultrasound.

17. Suspect bacterial infection if:

a. Persistent symptoms or signs lasting more than 10 days with no improvement.

b. Onset with fever of more than 102 degree and purulent nasal discharge lasting three consecutive days.

c. Onset with worsening symptoms following a viral URI lasting 5-6 days which was initially improving.

Mr Gursharan Singh former Indian Cricketer was the special guest of the day.

The conference will be followed by ‘Doctor of the year’ awards and cultural evening.

Dr KK Answers: What is the link between alcohol and blood pressure?

One should limit consumption to no more than two drinks (1 oz or 30 ml ethanol; e.g., 24 oz beer, 10 oz wine, or 3 oz 80-proof whiskey) per day in most men and to no more than one drink per day in women and lighter weight persons. It can alone reduce blood pressure by 2-4 mmHg.

Dr KK Answers: Can exercise lower blood pressure?

One should engage in regular aerobic physical activity such as brisk walking (atleast 30 min/day, most days of the week). It can alone reduce blood pressure by 4-9 mmHg.

Dr KK Answers: Can reducing salt lower blood pressure?

One should reduce dietary sodium intake to no more than 100 mmol/day (2.4 g sodium or 6 g sodium chloride). It can alone reduce blood pressure by 2-8 mmHg.

Dr KK Answers: Can eating fruits reduce blood pressure?

One should consume a diet rich in fruits, vegetables, and low fat dairy products with a reduced content of saturated and total fat. It can reduce a blood pressure of 8-14 mmHg.

Dr KK Answers: Can reducing weight lower blood pressure?

One can achieve a reduction of 5-20 mmHg of blood pressure for every 10 kg weight loss.

Dr KK Answers: Why should one treat high blood pressure?

Antihypertensive therapy is associated with reductions in paralysis incidence averaging 35-40%, heart attack 20-25%; and heart failure, more than 50%.

Dr KK Answers: What is silent blood pressure?

Of people with high blood pressure, 31.6% don’t know they have it (India 75%).