Environmental Pollution - Jindal Chest Clinic

1
Environment

• Surroundings Conditions of life or growth
• Air, water, soil, light, sound, vegetation,
  forests, animals and micro-organisms
• Outdoor Indoor
• Home Work place
• Micro-environments

2
What is a Pollutant?

• Abnormal presence or concentrations of a
  constituent / substance or compound
• Physical, chemical, biological..
• Inert or toxic
• Indoor Air Micro environment
• Home Work-place
• Vehicles (cars, buses, trains, plains)
• Crowded restaurants, clubs, bars
• Theatres, shops, subways

3
Outdoor Air Pollution

• Automobiles Transportation exhausts
• Industry Gaseous and particulate
• Fly ash
• Liquid effluents etc.
• Organic waste Excreta
• Vegetative matter
• Material waste Plastic pouches
• Package material wrappings
• Quarries, Mines
• Dust storms

4
Gaseous Pollutants

• Irritant
• Sulphur dioxide
• Chlorine
• Phosgene
• Ozone
• Nitrogen dioxide
• Ammonia
• Cigarette smoke

• Non-irritant
• Carbon dioxide
• Carbon mono-oxide

5
Ambient Air Quality Standards (Central Pollution
Control Board)
Area Category SPM Permissible conc. Permissible conc. Permissible conc.
Area Category SPM SO2 NOx CO
A Industrial mixed use 500 120 120 5000
B Residential / Rural 200 80 80 2000
C Sensitive 100 30 30 1000
6
Deposition and clearance of Inhaled Particles

• Deposition Sedimentation, Impaction,
  Interception, Diffusion, Electro-static
  precipitation
• Clearance Muco-cilliary clearance, alveolar
  macrophages, type I pneumocytes, lymphatics or
  blood stream
• (4 kilos of dust may be inhaled in lifetime but
• only 10-80 g remain in lungs).

7
Harmful Effects of inhaled particles

• Biological factors e.g. allergens, pollens
• Chemical factors e.g. gases, quartz
• Physical factors asbestos fibers
• Total Mass of dust inhaled is important

8
Environmental Health Problems

• General
• Specific (Occupational)
• Inorganic dusts
• Organic dusts
• Gaseous pollutants

9
Respiratory

• General respiratory symptoms Cough
• Infections Tuberculosis
• Asthma Environmental factors
• Occupational asthma
• Chronic Obstructive Pulmonary Disease (COPD)
• Pneumoconioses Silicosis
• Lung cancer
• Interstitial Lung Disease
• Nonspecific respiratory symptoms

10
Cardiovascular

• Hypertension Atherosclerosis
• Ischaemic heart disease heart attacks
• Cardiomyopathies

11
Gastrointestinal

• Parasitic infestations
• Infections - Diarrhoeas
• Dysenteries
• Hepatitis
• Dyspepsia ulcers
• Cancers - Oesophageal
• Colon
• Others

12
Neurological

• Atherosclerosis cerebral, cardiovasc. Accidents
• Cerebellar, cerebral and spinal syndromes
• Musculoskeletal
• Neuro-psychiatric Depression and other
  emotional disturbances

13
Inorganic Dust Exposures

• Silicosis
• Coal Workers Pneumoconiosis
• Asbestosis
• Others

14
SILICOSIS

• Commonest, reported from all over the country
• Pottery, ceramic, cutlery, slate, pencil, metal
  casting, boiler scaling, grinding, polishing,
  Glass, paints, rubber, sand stone quarry, stone
  crushers
• Non occupational

15
Other Silicate Materials

• Nonfibrous
• Talc, Kaolin, Mica, Cement
• Fibrous
• Erionite (Fibrous aluminium silicate)
• Man made vitreous fibres e.g.
• Glass wool, rock wool, ceramic fibres

16
Asbestosis

• Asbestosis highly dangerous, but extremely useful
  industrial material.
• Used in cement, building material, plastic,
  insulation, fire proofing, ship building, Railway
  workshops, cement friction product manufacture
• Environmental pollution is known.

17
OTHER DEPOSITION DISEASES

• Siderosis, Stannosis, Baritosis,
• Tungston, Carbon, Antimony
• Produce X-ray abnormalities, but no functional
  change
• Minimal inflammatory response

18
ORGANIC DUST DISEASES

• OCCUPATIONAL ASTHMA
• ALLERGIC ALVEOLITIS (HP)
• Agricultural exposures,
• drug and chemical Industry
• Clinical picture
• Treatment
• Outcome

19
Byssinosis

• Cotton, Textile, Jute Industry
• 7-9 in Textile workers
• Monday morning illness, Acute Mill Fever,
  weavers cough
• Grades 0-3
• No long term effects
• Prevention dust levels lt 0.5 mg/m3

20
TOXIC GASES FUMES

• Accidental leakage
• BHOPAL TRAGEDY (MIC)
• 2000 dead
• Residual lung damage
• Pulmonary fibrosis
• NITRIC OXIDES

21
INFECTIONS

• Anthrax
• Tuberculosis
• HIV
• PREVENT AS THERE IS NO CURE

22
Indoor Air Pollution

• Exhaust vapors
• Particulate matter
• Gases
• Organic chemicals volatile
• Spores Allergens
• Micro-organisms
• Radon daughters

23
Indoor Air Pollution Sources

• Biomass Fuel Combustion
• Environmental Tobacco Smoke (ETS)
• Others
• Environmental Air conditioning
• Biological
• Construction related Paints, resins
• Consumer products - Vapors
• House dust (etc.)
• Pet animals
• 4. Occupational

24
IAP Burden (Y 2000)

• Global 2.7 of global disease burden.
• gt 1.5 million deaths
• India 3.5 of national burden of disease
• due to solid-fuel use.
• gt 0.4 million deaths

25
Health Effects

• Acute/Chronic/Cumulative
• Non-specific
• General eye, skin,
• throat irritation,
• cough,
• headaches/psychological
• Specific Respiratory
• Malignancies
• Miscellaneous

26
WHO Estimates on India (Y 2000)

• Solid Fuel use 82 population
• Deaths due to solid fuel use
• ALRI (lt 5 yrs) 251560
• COPD (gt 30 yrs) 155250
• Lung cancer 340
• Total 407100
• Total DALYs gt 10 million
• Percentage national burden
• of disease
  3.5

27
Effects attributed to short-term exposure

• Daily mortality
• Respiratory and cardiovascular hospital
  admissions
• Respiratory and cardiovascular emergency
  department visits
• Respiratory and cardiovascular primary care
  visits
• Use of respiratory and cardiovascular medications
• Days of restricted activity
• Work absenteeism
• School absenteeism
• Acute symptoms (wheezing, coughing, phlegm, resp.
  infections)
• Physiological changes (e.g. lung function)

28
Effects attributed to long term exposure

• Mortality due to cardiovascular and respiratory
  disease
• Chronic respiratory disease incidence and
  prevalence (asthma, COPD, chronic pathological
  changes)
• Chronic changes in physiologic functions
• Lung cancer
• Chronic cardiovascular disease
• Intrauterine growth restriction (low birth weight
  at term, intrauterine growth retardation, small
  for gestational age
• Source World Health
  Organization

29
Pyramid of health effects associated with air
pollution

• Premature mortality
• Hospital admissions
• Emergency department visits
  
• Visits to doctor
  Severity
  
  of health
• 
  Restricted activity/reduced
  effect
• performance
• Medication use
• Symptoms
• Physiological changes in cardiovascular system
• Impaired pulmonary function
• Subclinical (subtle) effects
• Proportion of population affected

Source American Thoracic Society
30
Sick Building Syndrome (SBS)

• General malaise, fatigue, pains
• Increased secretions lacrimation, nasal
  discharge, spits
• Chronic cough
• Headache, heaviness
• Irritation, insomnia
• Depression - suicides

31
Respiratory effects of IAP

• Infections Upper respiratory
• Pneumonias, AECB
• 2. Ch. Cough Bronchial hyper-responsiveness
• 3. Asthma exacerbations
• 4. Chronic obstructive pulmonary disease
• 5. Lung function deterioration
• 6. Hyper-sensitivity pneumonias
• 7. Carcinogenesis

32
Miscellaneous

• Low relative humidity
• Dryness of eyes respiratory tract
• Electromagnetic hypersensitivity
• Deleterious effects in patients with asthma,
  diabetes, multiple sclerosis, ch. fatigue,
  fibromyalgia

33
Indoor Aero-allergens

• Sources
• Dampness, Pets
• Poor ventilation
• Thermophilic actinomycetes
• Fungi, Aspergillosis, Bacteria
• Other sensitizing antigens

34
Solid/Biomass Fuel Combustion

• Increased BR in women exposed to BFC
• 
  (Jindal et al
  IJMR 1996)
• 2. Increased prevalence of respiratory
  symptoms in women. 3608 of 3701 NS women 13
• CB 1.9 (Highest in chullah users)
• 
  (Behera Jindal, Chest 1991)
• Higher prevalence of chronic bronchitis in rural
  nonsmoker women (Jindal SK,
  IJMR 1993)
• Poorer lung function in children (Behera et
  al 1998)

35
Environmental Tobacco Smoke (ETS)

• Also called Passive Smoking
• Second-hand smoking
• Side-stream smoking
• Responsible for
• Respiratory problems
• Heart and neurological
  problems
• Cancers
• Miscellaneous (Effects on
  Pregnancy
• and children)

36
ETS Exposure and Respiratory Effects

• Increased infections in children
• LRTI (Pneumonias and bronchitis)
• Middle ear disease
• (Internat
  Consultation Report on ETS 1999)
• 2. Detrimental effects on lung function and/or
  severity of asthma in children
• (Neuspiel et
  al 1989, Cohort study)
• 3. Increased asthma prevalence
• Pooled OR (14 case control studies) 1.37 (95
  C.I. 1.15 1.64)
• 
  (Stracham Cook 1998)
• Pooled OR 1.2 1.4
  (Consultation Report 1999)

37
Pulmonary Effects of ETS (Indian Studies)

• Children
• Respir. Symptoms (31) OR 1.6 to 2.25
• 
  (Gupta et al 2001)
• Ch./Recurrent cough in a sample of 2275
• rural children at Ludhiana
  (Singh et al 2002)
• Asthma Prevalence
• Chd. Of 9090 students (9-20 yrs)
• a greater no. of asthmatics had
  smokers at home (41 vs 28) OR 1.78
• 
  
  (Gupta et al, 2001)
• ISAAC Questionnaire (Haryana) ETS risk OR 3.33

38
ETS and Asthma in Adults

• Increased morbidity in the previous one year
  period
• ER visits
• Hospitalization
• Requirement of parenteral bronchodilators,
  corticosteroids and maintenance drugs
• Absence from work
• 
  (Jindal et al, Chest
  1994)
• 2. Higher prevalence of ETS exposure in nonsmoker
  patients with Acute Exacerbations (41 vs 20)
• 
  (Jindal et al, Lung India 1997)

39
ETS and Lung Cancer

• Life time risk in NS who lived with a smoker
  24 (95 C.I. 13 - 20)
• Detection of tobacco specific carcinogens in
  blood of ETS exposed NS
• Dose-response relationship of risk with
  cumulative ETS exposure. (Review of 37 epidem.
  studies on 4626 cases)
• 
  (Hackshaw et al
  1997)
• Pooled RR (on meta-analysis of 43 of 76
  studies and 20 meta-analysis reports) 1.29 (95
  C.I. 1.17 1.43)
• 
  (Taylor et al
  2001)

40
ETS- Lung Cancer (Indian Studies)

• Smoker NS ratio (12.5 to 4)
• 
  (Jindal et al 1981, 1985 Behera et al 1992)
• 2. O.R. for ever smoking 5.0(M), 2.47 (F)
• 
  (Gupta et al IJMR, 2001)
• ETS exposure in lung Ca (case control)
• During childhood OR 3.9 (95 CI 1.9-8.2)
• Higher estimates for women for cigarette
• A weaker association with smoking from spouse
  workplace and in vehicles
• (Rapiti,
  Jindal, Gupta. Lung Cancer, 1999)

41
Prevention of IAP

1. Improvements in ventilation
2. Control of sources
3. Avoidance of indoor smoking and combustion
4. Prevention of dampness
5. Adequate sunlight exposure
6. Proper disposal of body secretions
7. Care of the pet animals

42

• Most of the health-hazards of environmental
  pollution are man-made -
• result from mans assaults on environment.
• The best way of prevention therefore, is to
  minimise the level and magnitude of these
  assaults.

43
THANKS

• THANKS

44
Lung responses to workplace hazards

• DISEASE MECHANISM EXAMPLE
• Diffuse fibrosis Macrophage damage
  Asbestos Type IV hypersensitivit
  Beryllium
• Nodular Fibrosis Macrophage damage Silica,
  Coal
• Emphysema Neutrophil enzymes Coal
• Bronchitis Mucosal Irritation Dust
• Asthma Chemotoxins Cotton,
  Wood, flour
• Allergic Alveolitis Cell mediated Fungi
• Type II sensitivity
• Malignancy ? DNA damage
  Asbestos,
• Radon

45
Toxic biomass combustion pollutants and potential
toxicity
Pollutant Known toxicological characteristics
Particulates (PM10, PM25) Bronchial irritation, inflammation, increased reactivity, reduced muco-ciliary clearance, reduced macrophage response
Carbon monoxide Reduced oxygen delivery to tissue owing to formation of carboxy-hemoglobin
Nitrogen dioxide (relative small amounts from low temperature combustion) Bronchial reactivity, increased susceptibility to bacterial and viral lung infections
Sulfur dioxide (relatively small amounts from most bio-fuels) Bronchial reactivity (other toxic end-points common to particulate fractions)
Organic air pollutants Formaldehyde 1,3 butadiene Benzene Acetaldehyde Phenols, Benzoapyrene Dibenzopyrenes Dibenzocarbazoles, cresols Carcinogenicity Co-carcinogenicity Mucus coagulation, cilia toxicity Increased allergic sensitization Increased airway reactivity
Source Bruce, Perez-Padila Albalak Cooper Smith Smith Liu Source Bruce, Perez-Padila Albalak Cooper Smith Smith Liu
46
Major health-damaging pollutants from indoor
sources
Pollutant Major indoor sources
Fine particles Fuel/tobacco combustion, cleaning operations, cooking
Carbon monoxide Fuel / tobacco combustion
Polycyclic aromatic hydrocarbons Fuel / tobacco combustion, cooking
Nitrogen oxides Fuel combustion
Sulfur oxides Coal combustion
Arsenic and fluorine Coal combustion
Volatile semi-volatile organic compounds Fuel / tobacco combustion, consumer products, furnishings, construction materials, cooking
Aldehydes Furnishings, construction materials, cooking
Pesticides Consumer products, dust from outside
Asbestos Remodelling / demolition of construction materials
Lead Remodelling / demolition of painted surfaces
Biological pollutants Damp materials / furnishings, components of climate control systems, occupants, outdoor air, pets
Radon Soil under buildings, construction materials
Free radicals and other short-lived, highly reactive compounds Indoor chemistry
Source Zhang Smith Source Zhang Smith
47
HISTORY

• Prehistoric Mining fit for convicts and slaves
• (1556) Georgius Agricola dangers of suffocation
• (1713) Ramazzini Breathlessness in grain
  handlers Father of occupational medicine
• (1879) Lung cancer in metal miners
• Asbestos related diseases
• 1930 fibrosis
• 1949 - Carcinoma
• 1960 Mesothelioma

48
HUMIDIFIER FEVER

• Microbial contamination of
• Humidifiers/Air-conditioners

49
Particulate levels in developing countries
Location Averaging time/size fraction Type of fuel Mean levels/range (?g/m3)
1. Nepal Cooking period/PM25 Wood/crop residues 8200 (traditional stove) 300 (improved stove)
2. Garhwal, India Cooking period/TSP 24-h exposure/TSP Wood/shrubs 4500 (GM) 700-1690 (winter) 250-1130 (summer)
3. Pune, India 12-24 h/PM10 Wood 2000 (area) 1100 (personal)
4. Mozambique Cooking period/PM10 Wood 1200
5. Rural Bolivia 6h/PM10 Dung 1830 (GM, indoor kitchens) 280 (GM, outdoor kitchens)
6. Kenya Daily average exposure/ PM10 Mixed 1000-4800
7. Tamil Nadu, India Cooking period/respirable fraction (d504 ? m) Daily average exposure/ respirable fraction(d504 ? m) Wood/agricultural waste Wood/agricultural waste 1307-1535 (GM, personal) 172 226
8. Guatemala 24 h/PM35 Wood 1560 (GM, traditional stove) 250 (GM, improved stove) 850 (GM, LPG/open fire combination)
9. Andhra Pradesh, India 24 h/respirable fraction (d504 ? m) Daily average exposure/respirable fraction (d504 ? m) Wood/dung/agricultural waste Wood/dung/agricultural waste 297-666 (kitchen area) 215-357 (living area) 431-467
10. Bangladesh 24 h/PM10 Wood/dung/agricultural waste 196-264 (personal) 60-1165 (area)
Note GM Geometric mean TSP Total suspended particulates RSP Respirable suspended particulates Note GM Geometric mean TSP Total suspended particulates RSP Respirable suspended particulates Note GM Geometric mean TSP Total suspended particulates RSP Respirable suspended particulates Note GM Geometric mean TSP Total suspended particulates RSP Respirable suspended particulates
50
TOXIC GASES FUMES

• Mechanisms
• Asphyxiation CO2, Nitrogen, Methane
• Irritation NH3, Chlorine, SO2, O3, Phosgene

51

• Increased BR in ETS exposed nonsmoker women with
  asthma
• (Jindal et al
  IJCDAS 1999)
• Increased BR in nonsmoking asymptomatic ETS
  exposed women
• 
  (Jindal et al IJMR 1996)