QUALITY OF AIR, AND CAUSE OF VARIOUS DISEASES

1. ASSOCIATION OF AIR QUALITY INDEX WITH
CAUSES OF DEATHS DUE TO POSSIBLE
HYPERTENSION INDUCED TARGET ORGAN
DAMAGE IN NORTH INDIA
Dr. Ghizal Fatima
Assistant Professor,
Department of Biotechnology,
Era’s Medical College and Hospital,
Lucknow, India

2. Introduction
• Rapid increase in Industrialization may cause
rapid changes in ambient pollution and
increased air quality index (AQI), which may
alter the pattern of risk factors and causes of
death due to increased target organ damage
and mortality.
• There is little knowledge and data on
association of increase in environmental
pollution, on risk of NCDs

3. The World Health Organization released data that
shows a dangerous increase in air pollution levels.
According to the data, over 2 million people die every
year from air pollution, and the collected air quality
levels are alarmingly threatening people’s health in
many cities.
According to WHO, the responsible element in air
pollution are PM10 particles, pieces that are 10
micrometers or less, which can “penetrate into the
lungs and may enter the bloodstream, can cause heart
disease, lung cancer, asthma, and acute lower
respiratory infections.”

4. • In the majority of the cities and regions of India,
annual averages of air pollution are higher than
the WHO air quality guideline (AQG). Among
newly industrialized countries, high exposures of
pollution have also been reported in the Eastern
Mediterranean, South‐East Asian and Western
Pacific regions [1,2].
• Annual mean concentration of PM2.5 is highly
relevant for estimating health impacts and used
as exposure indicator for calculating the burden
of disease attributable to ambient air pollution

5. • Based on the modelled data, 91% of the world
population are exposed to PM2.5 air pollution
concentrations that are above the annual mean WHO
air quality guideline levels.
• Air pollution also has emerged as a growing health risk
in India, which has some of the most polluted air in the
world [3-4 ]. Outdoor pollution has increased from
power production, industry, vehicles, construction, and
waste burning which is emerging as major risk factor
for rapid increase in NCDs [5,6,7]; respiratory diseases,
sleep disorders, CVDs including hypertension.
• The average total suspended particulate (TSP) level in
Delhi was approximately five-times the WHO's annual
average standard [8-10].

6. • In the present study, we attempt to develop a
verbal autopsy questionnaire, based on medical
records and, interview of the family member, for
assessment of causes of deaths due to
hypertension induced target organ damage with
reference to AQI, among urban decedents.
LUCKNOW the 7th most
polluted city in the WORLD

7. WELCOME TO LUCKNOW
• Lucknow has a area of 349 km²
• Population: 28.7 lakhs (2018)
• We studied the randomly selected records of death of 2521 (1580
men and 941 women) decedents, aged 25 years and above out of
3034 death records overall from the records at Municipal
Corporation. Obtained 2521 responded to cooperate for this study
and 513 either could not be traced or failed to cooperate during
the study period of, January 2016 to February 2017. After
informed consent and ethical clearance all the families of these
2521 victims were contacted individually to find out the causes of
deaths by verbal autopsy questionnaire.

8. • The questionnaire was administered by the
scientists which was completed with the help of
interview of spouse/relative and local family
doctor.
• Clinical data and causes of death were assessed
by a validated questionnaire based on available
hospital records and a modified WHO verbal
autopsy questionnaire, indicating systemic causes
of deaths, beginning from diseases of brain,
heart, lungs, liver, kidneys and cancers.
• Knowledge about health education and general
education were also assessed by a questionnaire
based on education up to 5,10 and 12 years in
school.

9. AIR QUALITY INDEX
• The criteria for grading of pollution were
based on those advised by Expert Group
constituted by Central Pollution Control Board

10. • In India, an equation has been developed by the
pollution experts based on 4 pollutants; nitrogen
dioxide, sulphur dioxide, suspended particulate matter,
and respirable particulate matter.
• Pollution levels were examined in 3 different sites in
which the victims included in this study, were
residents for the last one year or more.
• The AQI values based on annual average concentration
of pollutants were calculated by using the proposed
equation for 3 locations in Lko. The values obtained
were compared with the ORAQI equation modified for
the pollutants. The air quality was very critical in all the
included residential areas.
• In the concerned area of Lucknow city, AQI was
assessed with respect to suspended particulate matter
(PM), SO2 and NO2 considered over a period of one
year from Jan 2016 to February 2017

11. • The AQI was determined at concerned three
different sites; Police Training College, a open green
area (Site I), Tal katora, a congested traffic area (Site
II) and Gomtinagar, a very congested area with
heavy traffic (Site III) of Lucknow city.
• The results obtained from the different air quality
categories according to National Ambient Air
quality Standard revealed; Site I (45.38 µg/m3)
indicating slight air pollution (satisfactory), Site
II,(99.39 µg/m3) high air pollution (Poor) and Site
III, (117.87 µg/m3) showing very high air
pollution(Very poor) as per given criteria.

12. COLLECTION OF DATA.
• Detailed interviews was taken from families
approached. Clinical data on age, sex, height,
weight, marital status, occupation, education,
past and family history, history of hypertension,
diabetes, stroke, heart attack, kidney disease,
alcohol intake, drug intake, tobacco intake,
asthma, cancer, mental diseases, diarrhoea and
dysentery.
• Questions were asked from Dr. to find out the
cause of death in each case beginning from
diseases of the brain, CVD, infections; malaria,
dengue and accidents, etc, which were recorded
based on medical record of the victim.

13. • Subjects were classified according to BMI into
underweight (BMI<18.5), normal weight (18.5-
22.9 kg/m2), overweight (23-24.9 kg/m2), and
obese (25-29.9kg/m2) and obesity (>30kg/m2)
[26].
• Lack of health education was assessed by
finding out level of general education from 1-12
class and knowledge about beneficial effects of
physical activity, Indo-Mediterranean style diet,
yoga therapy, no tobacco and no alcoholism.
• Per capita income was calculated by dividing
the total income of the family, by the number
of family members.

14. • STATISTICAL ANALYSIS
• Data were analyses via the chi-square test for
the comparison of frequencies in the two
groups. Only P values <0.05 and the two tailed
t-test were considered significant to ascertain
level of significance. A relation was
determined between causes of deaths and
the significance of any trend was calculated
using Chi square for trend.

15. Results
• Causes of deaths due to circulatory diseases
(24.1%,n=608 were highest. Apart from
circulatory diseases, other body systemic
related causes of deaths were; brain diseases
including stroke (7.9%, n=200) and kidney
diseases (11.2%, n=283). Stroke, heart attack
and kidney failure were were common target
organ damage due to hypertension.

16. • The relation of pollution with causes of death
revealed that the trends of deaths with AQI was
continuous and graded for deaths due to stroke
and other circulatory diseases, as well as for
chronic kidney disease and pulmonary diseases in
both sexes. The trends and levels of significance
were much greater in both sexes, for causes of
deaths due to circulatory diseases compared to
deaths due to other diseases. The trends for
miscellaneous causes of deaths in relation to
graded rise in AQI, in both sexes, were also highly
significant.

17. • Multivariate logistic regression analysis for
association of various risk factors with risk of
death revealed that after adjustment of age and
body mass index, AQI, odds ratio;1.11(confidence
interval 1.06-1.18male,OR 1.09;CI 1.04-1.16
female) and pollution; OR 1.07 (CI, 1.02-1.12
males; 1.05; CI 0.99-1.11 female) were highly
significant risk factors of deaths (Table 5).
Western type diet, sedentary behavior and lack of
health education were also associated with risk
from various causes of deaths. Tobacco and
alcohol intake was also weakly associated with
risk of deaths in both sexes.

18. Results
• The results are based on the records and those
obtained by verbal autopsy questionnaire. Table
1 indicate the results for sex and associated
clinical data, among 2521 victims (1580 males
and 941 females), aged 25 years and above,
dying due to various causes.
• The prevalence of alcohol and tobacco intake
were significantly more common among men
compared to women

19. Clinical Data
Male (n=1580) Female (n=941)
Mean (Standard deviation)
Mean age 46.42±14.12 45.15 ± 12.62
Body weight 61.52±7.24** 54.83±6.98
Body mass index
(kg/m)
23.58± 2.35 23.68±2.47
Table 1: Clinical data and risk factors among decedents, based on
records and answers given by spouse.
*=P <0.05,**=P <0.001, P values were obtained by Students t test by comparison of mean and
(standard deviation) in the two groups.
The mean age, and body mass index were similar but mean
body weight was significantly greater among men compared
to women victims.

20. Risk Factors, n (%) Male (n=1580) Female (n=941)
Obesity (BMI>25kg/m2) 534 (33.79) 337 (35.81)
Poor air quality index (>100 µg/m3) 470 (39.74) 384 (40.80)
Known hypertension (>140/90mmHg) 468 (29..62) 269 (28.58)
Known diabetes mellitus (by records) 114 (7.21) 66 (7.0)
Central obesity (by records and interview) 899(64.9) 484(57.8 )
Poverty (< US$ 300.00 per month) 517(32.72) 374(39.74)
Sedentary behavior 747(47.27) 368(39.10)
Tobacco intake (>Once per week) 654(41.39)** 188(19.97)
Salt intake (>10g/day)
Western type diet
782(49.49)
783(49.55)
491(52.17)
455(48.3)
Alcoholism (>20 drinks/week)
Alcohol intake (4-20 drinks/week)
Lack of knowledge on health education
68(4.30)**
285(18.0)**
1215(76.89)
2(0.21)
30(3.18)
742(78.85)
Table 2. Prevalence of risk factors among patients dying due to various causes.

21. Causes of death Men (=1580) Women(n=941) Total (n=2521)
1. Circulatory diseases; CAD,
hypertension, diabetic vascular disease etc,
392(24.6) 216(22.5) 608(24.1)
2.Nervous system diseases; stroke,
encephalitis, meningitis, degenerative etc
195(12.3)* 87(9.4) 282(11.2)
3.Malignant neoplasm; cancers of all
organs;
92(5.8) 61(6.5) 153(6.1)
4.Injury, accidents; accidents, falls, fires,
poisoning etc
219(13.9) 122(12.9) 341(13.5)
5.Kindney diseases; renal and due to
diabetes and hypertension etc
180(11.4)* 82(8.7) 262(10.4)
6.Pulmonary disease; COPD, asthma,
tuberculosis, pneumonia etc
312(19.9) 214(22.7) 526(20.9)
7.Liver disease; hepatitis, cirrhosis etc 75(4.7) 32(3.4) 107(4.2)
8. Diarrhea/dysentery 40(2.5) 23(2.5) 63(2.5)
9.Miscellaneous; pregnancy, burns,
suicides perinatal, congenital,
75(4.7) 104(11.1)* 179(7.1)
Total 1580(100) 941(100) 2521(100)
Table 3. Causes of deaths based on available records and verbal autopsy
questionnaire (modified from WHO). Values are number (%).

22. • The relation of pollution with causes of death
revealed that the trends of deaths with AQI
was continuous and graded for deaths due to
brain and circulatory diseases, as well as for
malignancies and pulmonary diseases in both
sexes (table-4).
• The trends and levels of significance were
much greater in both sexes, for causes of
deaths due to circulatory diseases compared
to deaths due to other diseases.

23. • The trends for miscellaneous causes of deaths in relation to
graded rise in AQI, in both sexes, were also highly significant.
• Multivariate logistic regression analysis for association of various
risk factors with risk of death revealed that after adjustment of
age and body mass index, AQI, odds ratio;1.11(confidence interval
1.06-1.18 male, OR 1.09; CI 1.04-1.16 female) and pollution; OR
1.07 (CI, 1.02-1.12 males;OR 1.05; CI 0.99-1.11 female) were
highly significant risk factors of deaths.
• Western type diet, sedentary behavior and lack of health
education were also associated with risk from various causes of
deaths. Tobacco and alcohol intake was also weakly associated
with risk of deaths in both sexes.

24. Air quality
index,
n
Brain
diseases
n=282
Circulatory
diseases.
n=631
Malignan
t
n=153
Pulmonar
y diseases.
n=536
Miscellaneo
us
n=919
Men n (%) n=1580
Mild 589 29 (4.9) 62(10.5) 18(3.1) 43(7.3) 89(15.1)
Moderate 406 50 (12.3) 104(25.6) 20(4.9) 92(22.6) 126(31.0)
High
585 106 (18.1)* 216(36.9)** 44(7.5)*
167(28.1)*
290 (49.5)**
Total 1580 185(11.7) 382(24.1) 82(5.0) 302(19.0) 505(7.9_
Chi square
for trend
P value
47.7
0.01
67.8
0.002
43.8
0.01
45.9
0.01
96.1
0.001
Women n (%) n=941
Mild 353 11(3.1) 45(12.7) 13(3.7) 62(17.5) 67(19.0)
Moderate 251 28(11.1) 64(25.5) 18(7.2) 67(26.6) 120( 47.8)
High 337 58(17.2)* 140(41.5)** 40 (11.8)* 105(31.1)* 227(67.3)*
Total 941 97(10.3) 249(26.4) 71(17.5) 234(24.6) 414(43.6)
Grand total 282 631 153 536 919
Chi Square
for trend
41.9 72.5 37.4 75.8 106.3
Table 4: Causes of deaths in relation to grade of pollution, due to NCD according to
classification by UN HLM.

25. Table 5: Multivariate logistic regression analysis for association of
environmental risk factors with risk of death from non-communicable
diseases, after adjustment of age and body mass index among men and
women
Risk factor Men Women
Odd,s ratio,(95% confidence interval) Odd,s ratio,(95% confidence
interval)
Air quality index 201-450 1.11(1.06-1.18)** 1.09 (1.04- 1.16)**
Pollution 100-200 1.07(1.02-1.12)** 1.05 (0.99-1.11)**
Western type diet 1.02(0.95- 1.09)* 1.00 (0.94-1.06)*
Sedentary behavior 1.00 (0.94-1.06)* 0.98 (0.93-1.04)*
Tobacco 0.98 (0.91- 1.05)* 0.95( 0.89-1.02)*
Alcoholism 1.02 (0.93-1.08)* 0.96 (0.91-1.05)*
Lack of health education 1.19 (1.10-1.28)* 1.17 (1.12-1.23)*
P value <0.01, ** <0.001. OR= Odds ratio.

26. Conclusions
• This study shows that the association of pollution
with causes of death observed indicate trends of
deaths with AQI which is continuous and graded.
• It is possible that AQI could be an important risk
factor of cause of deaths due to circulatory
diseases; stroke, heart attack, chronic kidney
disease etc that occur due to target organ
damage in hypertension. The causes of deaths
can be accurately assessed by a modified verbal
autopsy questionnaire.

27. Era’s Lucknow Medical College
and Hospital,