Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.
Air Pollution and Cardiovascular Disease in
India
D Prabhakaran DM, FRCP, FNASc
Director, Center for Chronic Condition and...
Cardiovascular Disease…………
Hypertension and Diabetes
CVD in India : The High Burden
Diseases Death per 100 000 population
Male Female Total
IHD 178 (128) 112 (85) 144 (106)
Ce...
Air Pollution likely increases the risk for both CVD
and risk factors
Grim Portends for the future………
Persons with 2000 (Million) 2030 (Million)
Hypertension 118
139 (2008)
214
Diabetes 30 (20...
Top CVD influenced by Air pollution
Cardiovascular Effect Increased Risk (95% CI) Source
Myocardial Infarction RR = 1.16 (...
Burden of AP-mediated Cardiovascular Diseases (GBD
2015)
832,000 cardiovascular disease deaths
due to air pollution (30% o...
Mechanisms of increased risk for CVD from air pollution : A summary
• Endothelial
dysfunction
• Inflammation/
Lipid peroxi...
Overlapping risk factor attributions from
categories of combustion particles in India
(based on GBD 2010 for the case of I...
Expanding the Evidence Base
• Review published by the Ministry of Health in
2015
• Documented best available evidence in I...
Current the Evidence Base in India
• Most studies deficient in exposure or outcome assessment
• Most studies based on RSPM...
12
Goal: A fully integrated research and training program on air pollution and
cardiometabolic diseases with policy releva...
13
The CARRS (Centre for cArdiometabolic Risk Reduction in South-asia) Surveillance Study,
• Representative cohort of 12,2...
• Potential to provide Framingham like data
• Understand Social determinants
• Bio repositories that can help in understan...
1515
AIM 1: Developing a model to estimate ambient exposure to air
pollution (AP) in Chennai and Delhi
• Estimate daily av...
1616
AIM 2: Estimate association between exposure to AP, temperature,
CM risk factors, and CM diseases and characterize su...
1717
AIM 3: Characterize DNA methylation patterns associated with
CM events & investigate whether they mediate AP effects ...
1818
AIM 4: Estimate the association between AP &
Vitamin D in Chennai & New Delhi (N=1000)
Variation in Vitamin D exposur...
1919
Prospective Aim – Personal Exposure
● Personal exposure to be assessed in a sub-set of
the CARRS cohort as part of 6t...
Conclusions
• CVD major cause of death and disability in India
• Exponential increase in CVD and Risk Factors in India
• P...
Upcoming SlideShare
Loading in …5
×

Air Pollution and Cardiovascular Disease in India

Presentation by D Prabhakaran DM during the panel on 'Health Effects of Exposure to Air Pollution, as part of the CPR Initiative on Climate, Energy and Environment Clearing the Air Seminar Series. This event was organised in partnership with the Public Health Foundation of India (PHFI)

  • Be the first to comment

Air Pollution and Cardiovascular Disease in India

  1. 1. Air Pollution and Cardiovascular Disease in India D Prabhakaran DM, FRCP, FNASc Director, Center for Chronic Condition and Injuries and Vice President ( Research and Policy), Public Health Foundation of India, Gurgaon, India Professor, Department of Epidemiology, London School of Hygiene and Tropical Medicine, London, UK Adjunct Professor, Rollins School of Public Health, Emory University, Atlanta , GA, USA
  2. 2. Cardiovascular Disease………… Hypertension and Diabetes
  3. 3. CVD in India : The High Burden Diseases Death per 100 000 population Male Female Total IHD 178 (128) 112 (85) 144 (106) Cerebro-vascular 90 (99) 75 (79) 82 (88) RHD 11 (5) 10 (5) 10 (5) Hypertensive HD 18 (14) 15 (13) 17 (13) Total CVD 321 (273) 225 (200) 272 (235) Prabhakaran D, Jeemon P and Roy A. Circulation 2016;133:1605-1620 Numbers in parenthesis are world average
  4. 4. Air Pollution likely increases the risk for both CVD and risk factors
  5. 5. Grim Portends for the future……… Persons with 2000 (Million) 2030 (Million) Hypertension 118 139 (2008) 214 Diabetes 30 (2000) 61 (2011) 67 (2014) 69 (2015) 79 (2000) 101 (2011) 109 (2014) 124 (2015)* Persons dying from 2004 (Million) 2030 (Million) Tobacco 0.9 2 + CVD 2.7 4 Cancer 0.73 1.5 Reddy K et al. Lancet 2005; 366:1744-49, Patel V et al. Lancet 2011; 377:413-28, IDF Diabetes Atlas, 2011,2013,2015 5 * 2040
  6. 6. Top CVD influenced by Air pollution Cardiovascular Effect Increased Risk (95% CI) Source Myocardial Infarction RR = 1.16 (1.04-1.29) RR = 1.025 (1.015-1.036) OR = 1.022 (1.015–1.030) (Teng et al., 2014) Ischaemic heart disease OR = 1.17; (0.98-1.40) (Gardner et al., 2014) Heart failure RR = 1.21 (1.14–1.28) (Shah et al., 2013) Stroke RR = 1.011; (1.011-1.012) (Shah et al., 2015) (Tian et al., 2017) Thrombosis OR = 1.70; (1.30-2.23) (Baccarelli et al., 2008) Hypertension Adjusted OR of 1.14 for each 10μg/m3 increase in PM2.5 (Lin et al., 2017) OR = 1.098, (1.015–1.188) for each 10 10μg/m3 increase in PM2.5 (Cai et al., 2016) Arrhythmias RR = 1.053 (1.012-1.094) for PM2.5 ≥ 25µg/m3 (Song et al., 2016) OR = 1.59 (1.12-2.25) (Folino et al., 2017) Strongest effect observed for heart failure, thrombosis and arrhythmias
  7. 7. Burden of AP-mediated Cardiovascular Diseases (GBD 2015) 832,000 cardiovascular disease deaths due to air pollution (30% of total) in 2015 ~ 1.8 million deaths (1.1 million Ambient; 700,000 Household) 49 million DALYs (#1 of any risk factor) Majority of burden from NCDs DALY = Years of life lost + years lived with disability
  8. 8. Mechanisms of increased risk for CVD from air pollution : A summary • Endothelial dysfunction • Inflammation/ Lipid peroxidation • Increased BP • Abnormalities of Heart rhythm • Metabolic abnormalities • Atherosclerosis • Hypertension • Arrhythmias • LV dysfunction • IHD • PVD • CHF • Arrhythmias/ Sudden death PM2.5 & others
  9. 9. Overlapping risk factor attributions from categories of combustion particles in India (based on GBD 2010 for the case of Ischemic Heart Disease and Child ALRI) Smith et al. ARPH, 2014 Burnett et al EHP 2014 PAF for IHD and ALRI remarkably similar Highly levels of PM2.5 similar to active smoking Modelled data and needs proof
  10. 10. Expanding the Evidence Base • Review published by the Ministry of Health in 2015 • Documented best available evidence in India on air pollution exposure and health impacts • Review acknowledged that while evidence for policy development was there, further strengthening of the Indian evidence base was essential
  11. 11. Current the Evidence Base in India • Most studies deficient in exposure or outcome assessment • Most studies based on RSPM, SPM, PM10 • Little to no examination of: o Cardio-metabolic diseases – outcomes and risk factors o Prenatal/early childhood exposures o Neurodevelopmental effects • Most studies either time-series or cross-sectional o Long-term exposure? • Microenvironment profiles o E.g. in-transit/in-vehicle exposures
  12. 12. 12 Goal: A fully integrated research and training program on air pollution and cardiometabolic diseases with policy relevance to improve health of Indians 1. Research • Advancing science of ambient air pollution (AP) epidemiology on cardio- metabolic (CM) risk factors and outcomes • Evidence and knowledge to inform development of policy on transportation, energy, urban planning, etc. 2. Training and Capacity Building • Developing a cadre of environmental health researchers and faculty in India • Skill building for effective translation of evidence into policy 12 GEOHealth Hub
  13. 13. 13 The CARRS (Centre for cArdiometabolic Risk Reduction in South-asia) Surveillance Study, • Representative cohort of 12,271 adults (> 20 years old) enrolled between 2010-2011 in Delhi and Chennai. • Annual questionnaire follow-up and alternate year biological sample collection • Participants fully phenotyped for Cardio-Metabolic Diseases • Households geocoded and integrated into a GIS database • Cardio-metabolic events and risk factor data collected for 5 years, with a second 5-year exercise getting underway Study Partners 13 About CARRS
  14. 14. • Potential to provide Framingham like data • Understand Social determinants • Bio repositories that can help in understanding mechanisms of disease 600000 aliquots of different components of blood, urine saliva and so on in long term storage; DNA extracted for nearly 8000 individuals
  15. 15. 1515 AIM 1: Developing a model to estimate ambient exposure to air pollution (AP) in Chennai and Delhi • Estimate daily average PM2.5 exposure between 2010-2016 at 1x1 km resolution in Delhi and Chennai • This model will be further developed to cover all of India (Prospective Aim 1) Partners on the modeling exercise: • Urban Emissions Pvt. Ltd. • IIT – Delhi • IIT –Bombay • IIT – Kanpur • CSIR – National Physical Laboratory • St John’s Medical College, Bangalore
  16. 16. 1616 AIM 2: Estimate association between exposure to AP, temperature, CM risk factors, and CM diseases and characterize susceptibility • Estimate effects of temperature and long-term exposure to AP on CM risk factors and diseases • T2DM, HTN , CVD events, dyslipidemia • blood pressure, fasting glucose, serum total cholesterol • Identify susceptible populations based on SES, occupation & built environment • Education, occupation, total household income • Primary and secondary type of cooking fuel • Built environment – GEO-coded addresses • Neighborhood walkability, access to businesses, access to green spaces, access to parks (satellite green space data), health care access and food access • Investigate whether SES, occupation or built environment modify effect of AP through differential exposures & susceptibility to pollution-related health effects • Generalized linear mixed models adjusted for confounders and multiple pollutants, within- subject repeated measures, time varying covariates •
  17. 17. 1717 AIM 3: Characterize DNA methylation patterns associated with CM events & investigate whether they mediate AP effects on CM events • Nested case-control design (N~400), CVD events taken place in CARRS cohort in last 6 years • Case-control design to maximize power • ~400 CVD events in CARRS till date • Age and gender matched controls • Epigenome-wide data will be generated on ~200 CVD events and controls to identify the differentially methylated sites associated with CVD outcomes • Methylation EPICBeadChip: > 850,000 methylation sites • Secondary purpose to undertake mediation analyses to examine if DNA methylation mediates the effect of air pollution on cardiovascular events
  18. 18. 1818 AIM 4: Estimate the association between AP & Vitamin D in Chennai & New Delhi (N=1000) Variation in Vitamin D exposure & up to 6-fold difference in AP levels in Chennai & Delhi • Composition & distribution of AP between 2 cities: • Latitude (Chennai 13.1 degrees vs. Delhi at 28.6 degrees) • Composition (Individual AP pollutants – CO, NO2, SO2, O3) • Within-city geographic variation (tertiles of AP levels) • Compare circulating 2-OH-D levels and prevalence of vitamin D deficiency (controlling for season, matching on sun exposure) in association with AP levels and composition • Are AP-vitamin D links mediated by differences in CM outcomes (eg, CVD, HTN, T2DB, fasting glucose levels)? • Causal mediation analysis – Indirect of AP on CM risk factors mediated by Vitamin D & direct effect of AP not mediated by vitamin D.
  19. 19. 1919 Prospective Aim – Personal Exposure ● Personal exposure to be assessed in a sub-set of the CARRS cohort as part of 6th follow-up in 2018 ● ~250 individuals each in Delhi and Chennai ● Stratified random sampling ● Equipment is currently being finalized ● Protocol being developed with Petros Koutrakis at HSPH ● Will be one of the first large scale personal exposure studies for ambient PM2.5 in India Exposure Profiles Personal Exposure Monitoring Cluster-Level Ambient Monitoring Micro Environment Monitoring
  20. 20. Conclusions • CVD major cause of death and disability in India • Exponential increase in CVD and Risk Factors in India • Putative mechanisms linking Air Pollution with CVD available from small studies • Air Pollution likely major contributor to CVD in India • Evidence in India linking AP and CVD is being generated through elegant research designs addressing both exposure and outcome measurements

×