Air quality & EPIC report

2
“Air pollution is one of the major man–made environmental risks to public health.
ASSOCHAM is acknowledged as a significant voice of Indian industry and is
focussed on engaging with all important stakeholders to implement short-term and
long-term solutions to prevent episodic rise in air pollution. RB’s efforts, under
Dettol Banega Swachh India (BSI) initiative, complements the National Clean Air
Programme (NCAP). We are committed towards our partnership with RB to fight air
pollution and there is a need to have such transformation initiatives across the
country.”
D.S. Rawat
Secretary General, Associated Chambers of
Commerce & Industry of India (ASSOCHAM)
“On behalf of RB India and ASSOCHAM, I am pleased to present to you the Air
Quality Report under Dettol Banega Swachh India (BSI) initiative. In India, air
pollution is now ranked as the leading cause of death and disability. Our efforts to
increase India’s green cover through the planting trees initiative and to educate the
farmers in Punjab to reduce stubble burning and crop Management has been
gaining a lot of momentum and is likely to proliferate widely across rural India. I
look forward to a fruitful partnership with ASSOCHAM, Jagran Pehel and EY, as
we take the project forward together.”
Gaurav Jain
Senior Vice President, AMESA, Health
RB
“Air pollution is no longer a problem restricted to India’s metros but it is a national
problem that is killing 1.2 million Indians every year. If the country’s development is
important, fighting air pollution has to be a priority. An increase in vehicular traffic,
growing number of industries, heavy metals, dust and debris from construction
sites are some of the major causes of rising air pollution levels. ASSOCHAM and
RB have initiated the ‘Ab Hogi Har Saans Swachh’ campaign which aims to arrest
the impact of air pollution. We at Jagran Pehel applaud these novel initiatives and
look forward to the stellar results for the benefit of all.”
Sameer Gupta
Executive President, Jagran Prakashan
Limited
“Air pollution is a complex issue, requiring an array of solutions. There are many
sources that contribute to pollution across the country. Irrespective of where you
live, air pollution contributes majorly to health hazards faced by citizens across
regions. I am proud that we are working on the Hygiene Index initiative, a part of
RB’s Dettol Banega Swachh India (DBSI) campaign and contribute to the overall
objective of achieving clean India.”
Pinakiranjan Mishra
Partner & Sector Leader, Consumer Products
& Retail, Ernst & Young LLP
Key Messages

3
Contents
1. Executive Summary.........................................................................................................................4
2.Background .....................................................................................................................................6
Need to measure Air Pollution............................................................................................................8
Air Quality: Indian Scenario ...............................................................................................................9
Evaluation steps taken by Government of India ....................................................................................9
Perception & Awareness regarding Air Quality ...................................................................................10
3.Hygiene Index 2.0 ..........................................................................................................................11
How will Air Quality be measured in HI 2.0?.......................................................................................12
Revised framework for HI 2.0 ..........................................................................................................13
Next steps: ....................................................................................................................................13
4.Action plan to improve Air Quality ...................................................................................................14
Phase 1: Measure Air Quality- Hygiene index 2.0................................................................................14
Phase 2: Understand & measure health impact of air pollution- E.P.I.S..................................................14
Phase 3: Interventions to improve Air Quality ....................................................................................16
Individual level............................................................................................................................16
City officials ...............................................................................................................................17
State/Centre officials...................................................................................................................18
Corporates .................................................................................................................................19
5. Media coverage: RB’s initiative to curb stubble burning in Punjab......................................................20

Air Quality Report July 2018
4
1. Executive Summary
A report published earlier this year by the World Health Organization, air pollution, resulting from
emissions from different sources including industry, motor vehicles, heating and commercial
sources, household fuels as well as tobacco smoke, kills approximately 7 million people annually
1
,
worldwide. This accounts for as much as one in eight deaths, and is by far the single largest
environmental health risk. Air pollution is a stumbling block preventing people from leading healthy
and happy lives. It not only causes respiratory illnesses, but also leads to obesity, cardiovascular
diseases, diabetes, neurological disorders and infertility.
Various NGOs and corporates have taken steps to curb air pollution. Clean Air Asia, is providing
scientific input to city governments for better air quality, sustainable mobility programs and
awareness creation for cleaner air. Chintan India has launched a campaign to buy anti-pollution
masks for the poor to protect them against the toxic smog. Jindal Steel and Power, through its CSR
initiatives, works at improving air quality around its plants.
RB launched its ambitious multi strand Dettol Banega
Swachh India initiative (DBSI) that aims to help 100
million Indians lead healthier and better lives by
2020. One of the strands of this initiative is Mere Dus
Guz that focuses on clean air, clean water and clean
land. As an extension to this, Hygiene Index, another
programme under DBSI initiative is to measure city’s
Air Quality status during its hygiene assessment as
the measurement of air quality is a stepping stone
towards improvement in the sector. The erstwhile
Hygiene Index tool measured city’s performance for
6 sectors namely water, sewerage, solid waste
management (SWM), toilet, health and behaviour
change communication (BCC) and the sector wise
investment made by the Urban Local bodies (ULB).
Going forward, the Hygiene Index tool, will measure
Air Quality in addition to these existing 6 hygiene
sectors and sector wise ULB investment for a 360 degree perspective to hygiene measurement.
Various pollutants including PM10, PM2.5, NO2, SO2, CO, O3, NH3 etc.
2
, degrade the quality of air.
To quantify Air Quality under the Hygiene Index Programme, the technical committee
3
in the meeting
held on 13th
April, 2018, decided to use PM 2.5 level of the cities to measure air quality as it is
expected to give a genuine representation of the same. PM 2.5 is considered to have the most
harmful impact on human health. It is also the most consistent and robust predictor of air quality.
Hygiene Index (HI) evaluation for 2017 was conducted for 25 cities. The data to prepare the
scorecard was collected through consultation discussions with the officials of municipal corporations
and will be similarly collected and re-evaluated in 2018 and 2019. However, during 2018
evaluations, data of PM 2.5 level of various cities which will gauge the Air Quality level will be
collected from authentic secondary sources. Going forward, during 2019 evaluations, Dettol SiTi
1
Report available at https://www.envirotech-
online.com/news/airmonitoring/6/breaking_news/why_is_it_important_to_measure_air_pollution/37243
2
http://www.airveda.com/blog/Understanding-Particulate-Matter-and-Its-Associated-Health-
Impact?seo_data=%5Bobject%20Object%5D
3
Technical Committee members include- Dr. Narendra Saini, Dr. Indira Chakravarty, Dr. Ajay Khera, Ms. Tinni Sahwney, Mr.
Paul A. Seong, Mr. Vipin Yadav, Mr. Vineet Chatwal, Mr. Ravi Bhatnagar, Prof. T. Sundararaman, Mr. Arumugam Kalimuthu,
Mr. Mark Peters, Mr. Vivek Jain, Ms. Shagufta Khan, Dr. Pramod Jog, Mr. Neeraj Jain
“Measurement of Air
Quality is an important first step. I
appreciate this step taken by RB. This
will be helpful in creating mass
sensitisation and awareness on air
pollution and ways to curb it.”
- Dr. K. B. Gupta, ASSOCHAM (Associated
Chambers of Commerce and Industry of
India)

5
devices will be installed in 3 landmark locations of each city and will be used to measure the PM 2.5
level for the cities. Correlations will be drawn between the Air Quality of the city and its hygiene
status to support in policy making at the ULB level.
The purpose of the Hygiene Index programme is to help in improving the health and hygiene status
of the cities by identifying priority focus areas and recommending corrective actions which can be
taken by the ULBs. To curb air pollution, in addition to identification of Air Quality, it is crucial for
the ULB officials and the community at large, to be able to identify early pollution induced physical
symptoms. The Air pollution Institute of Research (AIR) has termed these specific symptoms as Early
Pollutant Induced Syndrome (E.P.I.S)
4
marking the onset of the harmful impact of air pollution.
Identification of E.P.I.S can be instrumental in impeding the exacerbations, both in otherwise healthy
individuals or those with underlying conditions, through prompt interventions towards prevention
and management of symptoms.
Air pollution is a complex issue, which requires a well thought out strategy and a detailed action plan.
Upon the identification of E.P.I.S, dedicated and multi-
faceted actions would be required to be taken jointly by
various stakeholders including citizens, city officials,
state/centre officials and corporates as elaborated
below-
The citizens should-
 Adhere to the rules and regulations,
 Practise car-pooling
 Prefer and use public transport
 Segregate waste before disposal
 Spread awareness among peers
The City officials should ensure-
 Proper implementation of pollution controlling
measures
 Collection and eco-friendly treatment of waste
 Forest conservation and tree plantation drives
The State and Centre officials should-
 Take policy decisions aligned towards sustainable development
 Create market demand for carpooling
 Promote renewable forms of energy and use of electric vehicles
 Create Adequate infrastructure for health problems
 Identify substitutes to stubble crop burning
 Introduce environment compliant fertilisers
The Corporates should-
 Promote car-pooling among employees
 Dedicate CSR funds for Air Pollution Controlling activities
 Sensitise and educate employees
 Ensure plantation in the company premise
 Use technology to develop innovative solutions to curb Air
pollution
These steps when taken together will have a tangible impact on the peril of air pollution.
4
Air Pollution and its impact on human health. Time to recognise Early Pollutant Induced Syndrome (E.P.I.S). By Air
Pollution Institute of Research Council.
“Air Pollution is one of
the significant causes of illness
amongst kids. It is extremely important
that we take dedicated steps to tackle
this problem of air pollution and protect
the future generation from its harmful
effects.”
- Dr. Pramod Jog, Paediatrician and
member of AIR (Air Pollution Institute of
Research Council)
Report reviewed by:
Ravi Bhatnagar
Director – External Affairs &
Partnerships, AMESA, RB

6
2. Background
Hygiene Index was launched as one of the programmes under Dettol Banega Swachh
India to complement Government of India’s Swachh Bharat Mission and focus on
assessing the current hygiene status of cities across India. The Hygiene Index programme
spans over a period of 3 years, from October 2016 to September 2019 and involves
partnerships and extensive consultation with concerned stakeholders with a focus to
strengthen current monitoring mechanism. Ernst & Young LLP (EY) is the technical
partner responsible for the implementation of this project. United States Agency for
International Development (USAID) and Reckitt Benckiser (RB) are the co-funding
partner of this programme.
The Hygiene index covers six sectors, collectively referred to as hygiene sectors, namely
water, sewerage, solid waste management (SWM), toilet, health and behaviour change
communication (BCC), which were identified to have an impact on the hygienic condition
of a city. Key performance indicators (KPIs) were defined to quantify hygiene and
exhaustively measure the status across cities. The HI evaluation for 2017 concluded with
assigning a scorecard to all the 25 cities covered depending upon their performance in
each of the 6 sectors. The below diagram shows the ranking of 25 cities covered under
the HI programme.
Figure 1: Performance of 25 cities
Based on the resultant score, the cities have been rated on a scale across categories:
Savdhaan (cautious), Shuruaat (beginner), Samarpit (dedicated), Sambhav (possible)
and Swachh (clean) signifying the below statuses.
Score Scorecard Status
0.0 - 1.5 Savdhan Alarming condition & needs immediate activity
1.5 - 2.5 Shuruaat Initial stage and efforts need to be put in
2.5 - 3.5 Samarpit Promising and dedicated towards the actions
3.5 - 4.5 Sambhav Potential and has scope of improvement
4.5 - 5.0 Swachh Leading practices in urban sanitation
Table 1: Scorecard and their status

7
“The (Hygiene Index) programme has been
useful to understand city’s progress in the WASH sectors. The
workshop has been helpful in understanding various best
practices. I am looking forward to their analysis on Air
Quality.”
- Suhas LY, DM, Allahabad Municipal Corporation
The Pune Municipal Corporation and New Delhi Municipal Council
have been identified as the highest-performing cities in the 2017 HI
evaluation, both in terms of investment and execution. Whereas,
Bhubaneshwar and Aligarh were the lowest-performing cities
according to the index. The HI programme led to adoption of best
practices across sanitation, identification of the sectors demanding
investment, capacity enhancement of city officials along with
increased healthy competition within the states for better HI score.
The programme laid great emphasis on Behaviour change and
communication among the citizens.
The HI programme has also led the widespread awareness creation
through the media collaboration. The concept of HI was announced
at the Global Citizen Festival in Mumbai, on 19 November 2016, the
World Toilet Day, which sensitised more than 80,000 people which
attended the event. The report for 25 cities for the year 2016-17
was launched on 2nd October 2017, at the NDTV Cleanathon event
reaching a population of more than 1, 90,000. Further, to
disseminate the critical findings, call-to-action workshops were
conducted for 10 cities. Together, these workshops have led to
capacity enhancement of 300+ bureaucrats and ULB Officals. The
workshops have been covered by various local and national media
houses. For instance, the Varanasi and Gurugram workshops were
covered by more than 20 publications including Hindustan Times,
Amar Ujala, Dainik Bhaskar, Punjab Kesri, Amar Bharti, Dainik
Jagran, the Pioneer etc., reaching to more than 2 million people.
The HI tool is dynamic and can be customised to provide greater
robustness to the scale. The need for the measurement of Air Quality
was established and subsequently, Air Quality was added to the
existing HI tool as an independent measurement parameter similar
to sector wise investment.
HI- Reach:
2.3 + million
citizens
260+
Bureaucrats
7million +
Annual deaths due
to air pollution

8
Need to measure Air Pollution
A broad spectrum of acute and chronic health effects ranging from irritant effects to death are
described by the WHO that includes subclinical effects, symptoms and health services utilization
5
.
Air pollution can cause both short term and long term effects on health ranging from respiratory
diseases to neurological disorders.
Almost everyone is affected by air
pollution, especially due to prolonged
periods of exposure. However, certain
groups are potentially more vulnerable
than others and may get affected with
minimal exposure and show symptoms
early such as infants, people with heart
or lung conditions, or other breathing
problems and the elderly.
Among the various sources adding to air
pollution, the main sources include
industrial emissions, waste and crop
burning, fuel burning, vehicular
transportation and construction and
emission dust. The adjacent diagram
shows various sources which add to air
pollution.
5
Report of a WHO Working Group. Bilthoven, the Netherlands: World Health Organization, 2000. Available at
http://www.euro.who.int/__data/assets/pdf_file/0011/112160/E74256.pdf
Figure 3: Sources of Air Pollution
Air pollution has
adverse impact on
human health.
It can lead to
multiple illness,
some of which are
represented in the
adjacent diagram.
Figure 2: Health Impact from Air Pollution

9
Air Quality: Indian Scenario
Air pollution has been ranked as a leading cause of death and disability in India, by a report of the
Global Burden of Disease 2010 (GBD), relating
PM2.5 exposures to approximately 1.6 million
premature deaths and 49 million Disability-
Adjusted Life Years
6
. India has registered an
alarming increase of nearly 50 percent in
premature deaths from particulate matter
between 1990 and 2015, as per the report.
This is evident from the fact that half of world’s
20 most polluted cities are in India including
Gwalior, Allahabad, Patna, Raipur, Delhi,
Ludhiana, Kanpur, Khanna, Firozabad and
Lucknow as shown in the adjacent figure.
The country is in a dire need of controlling air
pollution. Different sources emit various
polluting substances like sulphur dioxide,
nitrogen dioxide particulate matter (PM) 10
and 2.5 and others. It is the emission of these
substances which eventually lead to mortality,
respiratory disorders, cardiovascular issues and many other health problems.
It is therefore pertinent to address the issue of air pollution at levels of policy, healthcare and
personal protection. An increased level of awareness of air pollution can bring about motivating
changes in public policy, individual behaviour and bring medical attention to the problem at an early
stage. Along with this, solutions to tackle the increased pollution levels are also required to maintain
the liveability of our cities. The first step in this direction is evaluation of the current situation of air
quality across different cities.
Evaluation steps taken by Government of India
Under the Swachh Bharat Abhiyan, the National Air
Quality Index (AQI) was launched on 17 September
2014. AQI categorises the area air quality in six
buckets namely Good, Satisfactory, Moderately
polluted, Poor, Very Poor, and Severe as shown in
the adjacent figure. The proposed AQI considers
eight pollutants including, PM10, PM2.5, NO2, SO2,
CO, O3, NH3, and Pb. Based on the measured
ambient concentrations, corresponding standards
and likely health impact; a sub-index is calculated for
each of these pollutants.
Each day, monitors record concentrations of the
major pollutants at more than a hundred locations
across the country. These raw measurements are
converted into a separate AQI value for each
pollutant using standard formulas developed by the
Pollution Board. The highest of these pollutant’s value is reported as the AQI value for that day.
6
Report of the Steering Committee on Air Pollution and Health Related Issues. August 2015 Available at
https://www.mohfw.nic.in/sites/default/files/5412023661450432724_0.pdf accessed on Oct 25th 2017
Figure 4: Global pollution: Top 20 cities
Table 2: Air Quality Index

10
Perception & Awareness regarding Air Quality
In order to gauge the perception and awareness of Indian citizens’ towards Air Quality, a study was
conducted by RB citizens’ mindset and awareness
on the state of air quality in India. The study analysed the historical digital conversations from June-
August 2017 to determine themes and seasonal trends
pertaining to air pollution and air quality. The study also
analysed historical data from Google AdWords and
trends since year 2016 to ascertain keyword usage
patterns and themes.
The key inferences from the study were:
1. Most people have who have used online media to
express their opinion regarding Air Quality in India
have a negative opinion regarding the current
situation.
2. Categories of online Impressions
The below graph shows the various topics/ themes on which there are conversations in the
online media. The sample size for below analysis was ~ 10,000 impressions.
Awareness: 68% of awareness driven conversations were by WHO globally during World
Environment Day
Complaints (4% of the total): These tagged ministers and urge them to take required actions.
Innovations: These included innovative technologies to monitor and curb air pollution
Conversations: 45% of the conversations were sarcastic remarks around pollution conditions.
3. Keywords identified in the impressions
Top ranking keywords by volume included Air pollution, Delhi air pollution, Air purifier, Causes of
air pollution, Effects of air pollution, Particulate matter etc. Analyzing the key words trending in
the online media, we can infer that citizens of the country have started searching about air
pollution, its causes and effects. New Delhi, Bengaluru, Mumbai, Kolkata have the highest
impressions regarding Air pollution on online media. There is certainly a curiosity around air
pollution as it has started dominating daily conversations. ‘Indoor air pollution’ and ‘air pollution
for kids’ searches suggest that people living with families are searching for solutions.
Understanding the perception of citizens will be instrumental in devising targeted sensitisation
programs and creating awareness as a part of the action plan to curb air pollution. These tools can
also be helpful to evaluate the impact and the usefulness of the various implementation activities.
10 99 291 306 307 483 535
793
1194 1350
3758
0
500
1000
1500
2000
2500
3000
3500
4000
73%
12%
15%
Negative
Neutral
Positive
Figure 5: Sentiments on Online media
Figure 6: Categories of online impressions

11
Sky symbolises infinity and unlimited potential.
Unprecedented reforms by ULBs are envisaged to follow from
HI learnings. This correlates to the element – Sky.
3. Hygiene Index 2.0
As it has been established, polluted air has fatal effects on human
health causing asthma, heart attacks and pre mature deaths and
particularly affects health of children, sensitive people and the
elderly. Apart from this, bad air degrades the environment causing
acid rains and destruction of flora and fauna. Clean air is an
important factor contributing to our healthy, subtropical, outdoor
way of life that makes a city liveable and affects economy of a city.
Polluted air contains chemical pollutants which can create imbalance
in nature and deteriorate hygiene conditions. A city will be truly
hygienic when the air that its citizens breathe is also healthy and
clean.
Considering this, Air Quality has been included in the Hygiene Index
Programme along with the measurement of existing 6 hygiene
sectors and sector wise ULB investment. However, Air Quality will
be measured separately and won’t have any impact on the city
rankings. Inclusion of Air Quality measurement would strengthen the
index, give a holistic perspective to hygiene measurement and at the
same time connect with all the 5 elements of nature.
The matter in this universe is composed of 5 elements namely water, earth, air, sky and fire. Hygiene
Index measures the hygiene status of 25 cities through 6 hygiene sectors including Water, Sewerage,
Solid Waste Management (SWM), Toilet, Health and BCC. In HI 2.0, Air Quality will also be measured.
As shown below, the hygiene assessment corresponds to the 5 elements of nature and hence
holistically measures the hygiene status of the cities.
Air Quality
incorporated in
HI 2.0
Water
HI measures coverage and quality of water supply. It also
measures coverage of sewerage system, quality and adequacy
of treatment. All these KPIs correlate to the element- Water.
Earth
HI measures coverage and efficiency in SWM. It also measures
individual and public toilets aiming to prevent Open Defecation
on the land. All these KPIs correlate to the element- Earth.
Air
HI 2.0 will measure the quality of air by measuring PM 2.5
levels in the city. This KPI correlates to the element – Air.
Sky
Fire
Fire symbolises creation and transformation. HI has aimed at
transforming existing hygiene methods and creating a robust
new system. This correlates to the element- Fire.
Figure 7: HI 2.0 mapped with the 5 elements of nature

12
How will Air Quality be measured in HI 2.0?
The HI 2.0 tool will be launched in the 25 cities where the hygiene assessment was performed for the
year 2016-17. It will measure PM 2.5 to gauge the air quality of different cities. PM 2.5 count has
been chosen as an indicator for air quality for the reasons mentioned below.
During the evaluation for the year 2018, the data for PM 2.5 to measure air quality will be taken
through reliable secondary sources.
Going forward, during the evaluation of the
year 2019, HI 2.0 will use Dettol SiTi
Shield device to measure PM 2.5 values.
Dettol SiTi Shield device has been shown in
the adjacent diagram.
Dettol SiTi Shield device captures data in
real time by sensing the degree scattering
of light by pollution particles. When the
pollution particles are pulled into the
device via a fan, they pass through a laser
beam where they scatter the light. The
degree of light scattering is measured by a
sensor attached in the device. The
Pollution level (ug/m3) is calculated via an
internal algorithm pre-loaded onto the
devices firmware. The device takes
measurements every 1s and forms a rolling
average every 15s. The rolling average produced is then visible on a mobile application.
Dettol SiTi Shield devices will be placed in 3 landmark locations of each city. These will be high footfall
locations of the city. The devices will be placed for one month and the average value will be used to
calculate the Air Quality score. However, for the assessment in the current year, data available
through authentic secondary sources will be used to measure Air Quality.
Figure 8: PM 2.5 to be used to measure Air Quality
HI 2.0 will measure PM 2.5
to gauge the air quality of
different cities.
“There are many ways to measure air
pollution, but a key indicator is called
"PM 2.5" — one of the most harmful
classes of airborne pollutants” World
Economic Forum
“Air pollution is a complex mixture of gases
and particles whose sources and
composition vary spatially and temporally.
PM 2·5 is the most consistent and robust
predictor of mortality in studies of long-
term exposure.” Cohen et al 2017
The composition of PM accounts for
contributions from various pollutants. By
restricting the impact assessments to
PM, double counting of impact is
controlled. Measurement of PM 2.5 will
provide a genuine representation of the
air quality of the city.
Although the AQI is defined as a measure
of eight pollutants (PM10, PM2.5, NO2,
SO2, CO, O3, NH3, and Pb), every
pollutant is not currently being
measured by each city.
Figure 9: Dettol SiTi Shield Device

13
Revised framework for HI 2.0
With the incorporation of Air Quality, the frame work of HI 2.O has been revised as illustrated
below.
Next steps:
Pilot Implementation- Air Quality measurement will commence as a pilot in 2 cities namely NDMC
and Gurugram. PM 2.5 data will be collected from authentic secondary sources for the two cities and
Air quality of the cities will be determined.
Scale up- After the pilot completion, the programme will be rolled out in all the 25 cities. PM 2.5
data will be collected from authentic secondary sources for all the cities. Along with the air quality
measurement, the six hygiene sectors namely water, sewerage, SWM, toilets, health and BCC will
also be evaluated along with the investment analysis.
Next Phase- For the hygiene assessment in 2019, 3 landmark locations for air quality measurement
will be identified in all the cities
7
. The device will be installed for a month and data collected will be
used to quantify air quality.
7
High footfall areas will been chosen as the landmark locations for all the cities
Access to
clean water
Coverage of
water supply
connection
Quality of
water
supplied
Coverage of
sewerage
system
Adequacy of
STP
Household
coverage
Extent of
segregation
of waste
Efficiency in
collection
Extent of
scientific
disposal
Access to
individual
toilets
(coverage)
Incidence of
GI disease
Quality of
sewerage
treatment
Septage
management
Public/
Community
toilets
Awareness
& behavior
change
Water Sewerage SWM Toilets Health BCC
HI 2.0 Framework
Six
Hygiene
Sectors
Investment
Heat Map
Air Quality
Budget statement of each city will be reviewed to understand the focus of
the cities on Hygiene Sectors and investment heat maps will be created
PM 2.5 value will be used to determine the Air Quality of the city.
Figure 10: HI 2.0 Framework

14
4. Action plan to improve Air Quality
The action plan to control air pollution can be divided into three phases as shown below-
Phase 1: Measure Air Quality- Hygiene index 2.0
The first step to curb air pollution is to accurately measure it. This step is being performed through
Hygiene Index 2.0 for the 25 cities it covers. However, this should be extended to all the Indian
cities.
Phase 2: Understand & measure health impact of air pollution-
E.P.I.S
The number of premature deaths caused due to air pollution is projected to reach between 6 to 9
million by 2060. Cases of bronchitis are projected to increase substantially, rising from 12 to 36
million new cases per year in children aged 6 to 12; and from 3.5 to 10 million cases in adults
8
.
An increased level of awareness of can bring about motivating changes in public policy, individual
behaviour and bringing medical attention to the menace caused by air pollution. Likewise, it is
important, to identify the early physical symptoms, which are pollution induced - in order to prevent
an exacerbation at a later stage for both the healthy and in populations that are considered ‘at risk’.
These symptoms have been recognized by various health advisories. They have been bought under
a single umbrella term to represent early pollution induced signs and symptoms. The Air pollution
Institute of Research (AIR) has termed these specific symptoms as Early Pollutant Induced Syndrome
(E.P.I.S)
9
.
AIR is a collaboration of senior healthcare experts from across multiple super specialties aiming to
provide education & creating frameworks to tackle the emerging health issues due to air-pollution.
AIR works closely with various stakeholders from the government, non-government and private
sectors to impart education to healthcare practitioners, para medics and the community at large, to
help create awareness and manage the health burden caused due to air pollution. The activities of
the AIR council are supported by Reckitt Benckiser through unrestricted grant in public interest. The
panellists/members of AIR include:
 Chairman: Ashok A. Mahashur - Dr Ashok Mahashur is a consultant chest physician based in
Mumbai, India. He is also the Governor of American College of Chest Physicians - Western India. The
editor of Thorax (India), Dr Mahashur has authored or co-authored over 200 published articles and
serves on the editorial boards of various prestigious international journals. He has delivered a number
of orations and guest lectures both nationally and internationally. The former president of the Indian
Chest Society, he is the only Asian member in Global Respiratory infection program, UK.
 Akshay G. Mehta - Dr. Akshay Mehta is a senior interventional cardiologist, based in Mumbai, with
more than 30 years of clinical experience in cardiology. He has trained many young interventional
cardiologists and has multiple publications to his credit. He is a sought after speaker in major cardiology
conferences.
 Bakul J. Parekh - Dr. Bakul Parekh is senior Pediatrician with more than 35 years of clinical
experience. He is the Secretary General of the Indian Academy of Pediatrics and has actively
participated in the planning for infectious disease protocols and for the rational use of antibiotics in
children.
8
Aman H. A Comprehensive Study of Air Pollution in India. Environ Prot. Jul 2017 Available at
http://www.countercurrents.org/2017/07/19/a-comprehensive-study-of-air-pollution-in-india/ accessed Nov 5th
2017
9
Air Pollution and its impact on human health. Time to recognise Early Pollutant Induced Syndrome (E.P.I.S). By Air
Pollution Institute of Research Council.

15
 D. Vijaya Sekharan - Dr. (Prof) D. Vijayasekaran is a senior pediatric pulmonologist practicing in
Chennai. He is a former professor at Madras Medical college with more than four decades of experience.
He has a keen interest in academics with many publications to his credit.
 Hema Divakar - Dr Hema Divakar, with more than three decades of experience, is a leading
Obstetrician and Gynecologist in Bengaluru, Karnataka. She is ex-president of Federation of Obstetric
and Gynecological Societies of India (FOGSI) and is the recipient of many international awards.
 Pramod Jog - Pramod Jog is a senior Professor of Pediatrics with more than 30 years of experience.
He is ex-president of the India Academy of Pediatrics and has been a faculty in over 600 National and
International conferences.
 Rishma Dhillon Pai -Dr. Rishma Pai is a senior consultant Gynecologist and an infertility specialist,
based in Mumbai. She is the current president of FOGSI and an author of chapters in many books and
journals. She is one of the pioneers in India for a treatment modality for Dysfunctional Uterine Bleeding
(DUB). She is a regular guest speaker at many national and international conferences.
Clinical features:
The symptoms of E.P.I.S generally begin with early exposure to pollutants. Generally, these are
some of the first symptoms to start as soon as the local ambient air quality goes down and shows
an increase in PM2.5 levels. It is important to co-relate the clinical symptoms with the local Air
Quality Index (AQI) values. That helps to link the symptoms with air pollution.
Common symptoms include burning eyes, irritation in throat, cough and chest tightness, coughing
at night, wheezing, unexplained headache/vomiting and increased respiratory infections.
Diagnosis:
While E.P.I.S is usually apparent from the symptoms and a history of current exposure to pollution
or poor air quality, certain complications can be prevented by early detection of E.P.I.S through
techniques such as lung function, hematological tests and imaging.
Management & Prevention:
General symptomatic management helps to produce relief from the irritating symptoms of E.P.I.S
and to improve the quality of life, along with preventing absenteeism at work or school.
Preventive measures at diagnosis of E.P.I.S will help reduce incidence of complications or
exacerbations of the symptoms to a more serious condition. The detrimental effects to health from
air pollution are largely determined by the concentration of air pollutants and the amount of exposure
time. Early identification of E.P.I.S will allow healthcare professionals and individuals to take
appropriate action to reduce the amount of pollutants inhaled and live a healthy life. The full report
of EPIS by AIR is attached at the end of this report for reference.

16
Phase 3: Interventions to improve Air Quality
Air Quality impacts the world at large. Dedicated steps can be taken jointly by Citizens, City
officials, State/Centre officials and corporates to curb air pollution. The below diagram shows the
concept of how the collaborated efforts can improve air quality.
Figure 11: Synergy between Citizens, Officials and Corporates to improve air quality
Citizens, city officials, state/centre officials and corporates can take multiple steps to improve air
quality. The below section enlists steps which will have short and long term improvement impact.
Individual level
Reduction
in Vehicular
Emission
Use of public transport Adhere to rules and regulations
Segregate waste
before disposal
Pool car to work/school
 Actively use
public transport
 Public transport
to be projected as
a symbol of
support to reduce
air pollution
 Coordinate
with colleagues
to pool car to
go to the
workplace
 Citizens to actively
support the
government by
adhering to rules
 Aware citizens
should sensitise
other country mates
about pollution
 Segregate
waste
 Install
composting
facilities
Reduction
in Waste
Burning
Impact
Citizens, Urban local body, state/center government and corporates are four pillars which
need to work in cooperation to create a pollution free environment,
• Use of public
transport
• Pool car to
work/school
• Adhere to
rules
• Strict norm
• Parking fee
hike
• Scientific
waste
treatment
• New policies
• Promote EVs
• HealthCare
infra
• Substitute
crop burning
Improvement in Air Quality
State/ CentreCityIndividuals
GovernmentCitizens Corporates
Organizations
• Effectively
use CSR funds
• Dense
plantation in
company
premises
Tree Plantation
 Plant
trees in
empty
areas
To take individual action to increase India’s green cover by planting trees, click here:
https://goo.gl/LmULpS

17
City officials
Reduce dieselization
 Reduce imbalance
between petrol &
diesel prices
 Discourage use of
diesel generator
sets
Reduction in
Vehicular
Emission
Reduction in
Waste
Burning
ImpactScientific treatment of
waste
Perform mechanical
sweeping of roads
Improve & increase public
transport infrastructure
Reduction in
Construction
Emission
 Increase
bus/metro
services,
reduce
fares
 Allocate
special
municipal
funds
 Sprinkle water
on unpaved
roads
 Encourage
segregation of
waste and
implement
large scale
composting &
bio gas plants
Ensure that the construction
material is stored at
designated places
 Increase in
parking fee at
commercial
areas
 Move towards
the trend of
working from
home while
being virtually
connected
Enforce pollution norms Increase parking fees
Forest conservation and tree planting
 Focus on conserving older trees, preventing deforestation
 Regulating concretization - Urban trees and forests are much threatened
by increasing concretization
 Industries should be mandated to plant trees in their vicinity
 Construction
material to
be stored in a
designated
area rather
than on
roads
 Stop use of
coal and
firewood in
hotels
 Trucks to be
diverted
away from
the city
which are
registered
after 2005

18
State/Centre officials
Create adequate healthcare
infrastructure
 Government
subsidies for
production
and sales of
electric
vehicles
Strong focus on eco-friendly
architecture
Promotion of Electric
vehicles
Substitutes to stubble crop burning
 Immediate ban on crop burning
 Provide subsidy while
procurement of crop with
unburnt land
 Technology interventions e.g.
Turbo Happy Seeder
 Recourse to
good-quality
medical
facilities for
suffering
people
 Health
ministry to be
involved in
planning
 Houses made of
eco-friendly
materials are
rising in
demand in
Western
countries
 Promotion of
such eco-
friendly
technologies
Introduce environment compliant
fertilisers
 Introduce new-
end fertilisers
and pesticides
Introduce new economic policies
 Polluter to pay
 Tackling fossil
fuel subsidies
 Extended
Producer
Responsibility
 Change in
Transport Pricing
Reduction in
Vehicular
Emission
Reduction in
Waste Burning
ImpactCreate market demand for
carpooling
Non-conventional electricity
sources
Promote solar power
Reduction in
Construction
Emission
 Dedicated
measures to
promote solar
power through
industry
incentivisation
and subsidies
 Encourage
production
of
electricity
from gas
and nuclear
based
power
plants
 Incentivise
citizens and
the firms to
create a
strong
market
demand for
carpooling
Reduction in
electrical
Emission
 Plant trees
on road
corners
and empty
places
Tree Plantation

19
Corporates
Promote Car Pooling among
employees
 Educate and
sensitize
employee on
ways an
individual
can
contribute
to reduce
pollution
Dedicate CSR funds for Air
Pollution Controlling
activities
Sensitise Employees
Ensure tree plantation in the company premise
 Plant trees in office campus
 Use methods such as vertical
gardening, drip watering etc. to
effective utilise land and water
 Encourage
employees to
pool car to
work
 Create the
infrastructure
for car-
pooling in
major cities
 Use the CSR
funds for
controlling air
pollution,
launch tree
plantation
drives, start
BCC activities
with community
involvement
etc.
Use technology to develop innovative
solutions to curb Air pollution
 Use data and
technology to come
up with innovative
and cost effective
solutions
Leading Practices
RB’s Best Practices
Innovation Hacks
Competition to develop product concepts,
marketing launch plans etc. to create
innovative solutions to curb Air Pollution at
an international scale
Purifying baby pacifier, lung strengthening
musical toy and pollution-trapping paint are
the top ideas from the Hack events
Public Awareness
Yearlong campaign aimed at raising public
awareness on pollution by burning crop
50 camps targeting 2 lakh+ including farmers
and others in 95 villages will be conducted
Alternate solutions promoted through
cooperation and networking with peer groups
Google’s Best Practices
Air Quality Measurement
Google tied up with Aclima to measure air
pollution levels in California and map out the
data collected on its Earth platform
Analyzed factors influencing air pollution
patterns and suggested that traffic-choked
freeways, traffic on local streets and weather
patterns had blown pollution inland.
Carbon Neutrality
Google is carbon neutral since a decade by:
 Reducing energy consumption by pursuing
aggressive energy efficiency initiatives
 Purchasing significant amounts of
renewable energy
 Buying carbon offsets for rest emissions

AirQualityReportJuly2018
20
HindustantimesTheTribuneAmarUjala
Ajit
DailyPost
ThePioneer
5.Mediacoverage:RB’sinitiativetocurbstubbleburninginPunjab
RBinguidanceofGovernmentofPunjabandinassociationwithASSOCHAMFoundationforCorporateSocialResponsibility,launchedabehaviorchangecommunication
programtoreduceStubbleBurninginPunjab
UnderitsDettolHarpicBanegaSwachhIndia(BSI)initiative,‘AbHogiHarSaansSwachh’campaignaimstoarresttheimpactofairpollutioncausedduetoagricultural
stubbleburning,byeducatingfarming
Highlights:
Snapshots:
32mediahousescomprisingof
mainlineandregionalmediaattended
theeventheldinPatiala.Picturesofthe
eventwerefeaturedinkeypublications
AVEgenerated:INR26,48,628approx.
PRValuegenerated:INR79,45,884
approx.
56clipsinprint&onlineacrosskey
publicationsreachingouttoawideaudiencebase
33Tier1exposuresgarnered
98%totalbrandmentions
TheobjectivewastoraiseawarenessaboutRB’s
associationwithGovernmentofPunjaband
ASSOCHAMontheissueofstubbleburningand
collectivelyoffersolutionsforthefarmers

21
Disclaimer
This Air Quality: Vision Document (hereinafter referred to as “the Report”) has been prepared by
Ernst & Young LLP (hereinafter referred to as “EY”) for RB (hereinafter referred to as “the Client”).
The points and inferences made by EY in the Report are based on discussions with the client and
technical committee members along with secondary research. EY has taken due care to validate the
authenticity and correctness of the information from various sources, however, no representations
or warranty, expressed or implied, is given by EY or any of its respective partners, officers,
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provided to Committee Members.
The Report has been prepared only for the internal use of the Client. The Report, or any part
thereof, may not be shared with a third party without written consent of EY.
Nothing contained herein, to the contrary and in no event shall EY be liable for any loss of profit or
revenues and any direct, incidental or consequential damages incurred by USAID, RB or any other
user of the Report. In case the Report is to be made available or disclosed to any third party, this
disclaimer along with all the limiting factors must be issued to the concerned party. The fact that EY
assumes no liability whatsoever, if for the reason any party is led to incur any loss for acting upon
this proposal, must be brought to the notice of the concerned party.

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24
EPIS – Demystified

25
Abstract
Air pollution, irrespective of its source, is accepted to be the single largest environmental health issue
affecting the human population globally. In India, it is now ranked as the leading cause of death and
disability. In addition to respiratory illnesses, increasing evidence now links it to serious
consequences such as increasing obesity, cardiovascular diseases, diabetes, neurological disorders
and also infertility. It is important for experts and the community at large, to be able to identify early
pollution induced physical symptoms - in order to take action to prevent exacerbation of effects, both
in otherwise healthy individuals or those with underlying conditions, that puts them in at particular
risk. Such symptoms have been recognized by various health advisories and can be bought under a
single umbrella term to represent early pollution induced signs and symptoms. The Air pollution
Institute of Research (AIR) collectively proposes that these symptoms be termed under a common
reference as Early Pollutant Induced Syndrome (E.P.I.S).
Identifying E.P.I.S.: Role in real world practice:
Identifying E.P.I.S can help prevent exacerbations by allowing for quicker intervention towards
prevention and management of symptoms. It can also act as a catalyst for community based
counselling and adoption of protective measures to reduce the effects of indoor and outdoor air
pollutants, thereby reducing the adverse effects related to pollution exposure. Identification of
E.P.I.S. also has the potential to reduce long-term healthcare costs; as earlier diagnosis means,
simple preventative measures can be implemented, helping to reduce the risk that more serious
conditions will develop requiring more intensive treatment. The AIR encourages physicians to identify
E.P.I.S as an independent condition – a prelude to the hazards of air pollution and take adequate
preventive and protective measures towards the health hazards of air pollution.

26
Background:
Air pollution (resulting from emissions from different sources: industry, motor vehicles, heating;
biomass burning (wood, animal dung, agricultural residue) and commercial sources including
fireworks, household fuels as well as tobacco smoke) is accepted to be the single largest
environmental health risk of the world. In India, it has been ranked as a leading cause of death and
disability, by a report of the Global Burden of Disease 2010 (GBD), relating PM2.5 exposures to
approximately 1.6 million premature deaths and 49 million Disability-Adjusted Life Years (DALYs).1
While air pollution has been linked with respiratory diseases2
; increasing evidence now shows it to
have far more reaching consequences including - being involved with increasing obesity,3
cardiovascular diseases,4
diabetes5
, neurological disorders6
and also infertility7
.
A broad spectrum of acute and chronic health effects, are described by the WHO in their pyramid of
air pollution-attributable heath impacts.8,9
These include sub-clinical effects, symptoms, health
services utilization and mortality (See figure 1).9
Fig 1: Air pollution health effects pyramid (Adapted from ATS 2000)9
Air pollution: Impact on health
The effects of pollutants on health are both acute as well as chronic. Acute effects manifest shortly
after exposure – within hours or days, while chronic effects are assessed by longitudinal studies over
years or decades. The following chart sums up the acute and chronic effects of pollutants on human
health.10-43

27
Table I: A summary of the health impact of air pollution on human health10-43
Air pollution and respiratory disease
Multiple epidemiological studies have shown exposure to particulate matter (PM) and other gaseous
pollutants to be linked with a higher incidence symptoms of the upper respiratory tract (rhinorrhea,
nasal obstruction, cough, laryngospasm, and vocal cord dysfunction)11
and the lower respiratory
tract (congestion, cough, dyspnea, and wheezing) - especially in children.12
This exposure is also
associated with an increase in cough and wheezing in adults with chronic lung disease and in healthy
adults.12
Air pollution and obesity
An association between air pollution exposure and Body Mass Index (BMI) levels at age 18 years has
been shown in an epidemiological study in South California.13
This study in a large cohort of children
aged 10-18, detected a significant positive association between traffic density around the home and
attained BMI at age 18. A higher association of increased BMI was seen in those having a higher
pollution exposure (from traffic exposures) within 150 m of their homes. This was attributed to
reduced mobility on foot due to the higher pollution and pollution induced reduction in lung function
- that may further reduce the child's ability to exercise, leading to a higher BMI score.13

28
Air pollution and Diabetes
A number of studies have shown a positive association between long-term ambient air pollution
exposures and increased risk of type 2 diabetes mellitus (T2DM).14
Insulin resistance is postulated as a probable mechanism that is an adverse result of air pollution on
incidence of T2DM. Both experimental and epidemiologic studies suggest that environmental
exposures to air pollutants can increase the risk of insulin resistance, which may lead to a link
between air pollution and T2DM. Moreover, inflammation is another potential mechanism explaining
the associations reported in the literature in the pathogenesis underlying the association between air
pollution and T2DM.15
Air pollution and Cardiovascular risk
Results from many research studies have demonstrated a strong relationship between levels of
airborne particles, sulfur dioxide and other air pollutants and risk of early death from heart disease.
Conditions such as vasoconstriction and endothelial dysfunction, high blood pressure (BP), changes
in pro-thrombotic and coagulant status, systemic inflammatory and oxidative stress responses,
autonomic imbalance and arrhythmias, and the progression of atherosclerosis – are all linked with air
pollutants.16
The Air Pollution and Health: A European and North American Approach (APHENA) project – which
examined the link between airborne particles and hospital admission for cardiac causes in eight
European cities – reported the percentage increases associated with a 10 μg/m3
elevation in PM10 to
be 0.5% for cardiac admissions in people of all ages and 0.7% for cardiac admissions in people older
than 65 years.17,18
The risk for cardio-respiratory disease in people over 65 years of age significantly increases with
short-term exposure to PM2.5. It is predicted that there will be one extra admission, for every 100
hospital admissions in heart failure, with every 10μg/m3
increase in PM2.5 levels.19
People with pre-
existing cardiovascular disease, diabetic and elderly individuals are also considered to be more
susceptible to air pollution–mediated cardiovascular effects.20
Chronic exposure to high ambient PM2.5 concentrations in the current scenario (i.e. any increase by
10μg/m³) is shown to reduce life expectancy. As PM2.5 is most strongly associated with
cardiovascular deaths in the cohort studies (65,893 postmenopausal women without previous
cardiovascular disease in 36 U.S. metropolitan areas from 1994 to 1998, with a median follow-up of
6 years were examined for association of long-term exposure to PM2.5 with cardiovascular events),
the reduced life expectancy is most likely due to excess cardiovascular mortality.21
According to more recent studies, the ultrafine particles (PM1.0 or less) may be translocated into the
circulation and directly transported to the vasculature and heart where they can induce cardiac
arrhythmias and decrease cardiac contractility and coronary flow.20

29
Cardiovascular diseases are very common. Since it is established that acute or chronic exposure to
air pollution can contribute to exacerbation of CVD, even modest reductions in exposure can result
in significant health gain.22
Air pollution and pregnancy
Over the last two decades, there have been an increasing number of reports on the negative impact
of air pollution on fetal development, birth and subsequent child development. These include:
preterm births, stillbirths, intrauterine fetus growth retardation, births of newborns with low birth
weight and a risk of newborns’ death because of respiratory system disorders.23,24
Birth weight,
gestational age, and fetal growth are important indicators of perinatal health. Low birth weight
(LBW), preterm birth, or intrauterine growth retardation (IUGR) are strongly associated with infant
mortality and morbidity.25
There is more evidence each year which indicate that maternal exposures to air pollutants, including
particulate matter (PM10 and PM2.5), sulfur dioxide, nitrogen dioxide and benzopyrene, are associated
with adverse pregnancy outcomes.26
Some of polycyclic aromatic hydrocarbons (PAHs), especially benzopyrene, may have carcinogenic
and mutagenic effects - and when penetrating through placenta, can have a negative influence on
the fetus. The research showed that, newborns whose mothers were exposed to PAHs during
pregnancy, are more often born with lower birth weight and smaller head circumference.27-29
Air pollution and neurological disorders
While it is well-known that air pollution affects human health through cardiovascular and respiratory
morbidity and mortality, it has only recently been shown that these deleterious effects extend to the
brain. The impact of air pollution upon the brain was first noted as an increase in ischemic stroke in
individuals exposed to indoor coal fumes.30
In the United States, stroke is the number one cause of adult disability and the third most common
cause of death, behind only cancer and heart disease.31
While data on the association between
cerebrovascular disease and ambient air pollution is limited, exposure to diverse air pollutants (e.g.,
particulate matter, ozone, carbon monoxide, and nitrogen dioxide) is epidemiologically associated
with enhanced risk for ischemic cerebrovascular events.32-34
In fact, current reports demonstrate
that enhanced risk for ischemic stroke correlates with air pollution, even in communities with
relatively low pollutant concentrations [below current Environmental Protection Agency (EPA) safety
standards].33,35
While the mechanisms driving the pathology are unclear, ozone and particulate
matter rapidly modulate the expression of genes involved in key vasoregulatory pathways in the
brain.36
Current reports also indicate that the effects of air pollution invade the brain parenchyma,
causing pathology indicative of neurodegenerative disease.37

30
Neurocognitive impact of exposure to air pollution in children.
Reports in healthy children who receive chronic exposure to airborne pollutants, suggest a
substantial effect on cognitive outcome and neurodevelopment.38
As per reports of a study in Mexico City Metropolitan Area (MCMA) children, the clinically healthy
children from MCMA selected by stringent criteria including the absence of known risk factors for
cognitive or neurological deficits, exhibited structural, neurophysiological and cognitive detrimental
effects compared to low pollution exposed children matched for socio economic status (SES), gender,
age and mother’s IQ. The cognitive deficits in MCMA children were associated with MRI volumetric
alterations in their right parietal and bilateral temporal areas. Dynamic changes of inflammatory
mediators’ influence children’s CNS structural and volumetric MRI responses and cognitive correlates
resulting from environmental pollution exposures. MCMA children performed more poorly across a
variety of cognitive tests, compared to control children. This is indicative of high air pollution
contributing to a negative environment for healthy brain development and cognitive improvement.39
Air pollution and infertility
Similar to its impact on overall health, air quality negatively affects the reproductive function in
humans. In a systematic review of the literature concerning the exposure to environmental air
pollutants and its effects on fertility and reproductive health40
, both animal and human
epidemiological studies showed that air pollution was responsible for gametogenesis.40
Several studies have assessed the impact of air pollutants on the general population, and have found
reduced fertility rates and increased risk of miscarriage. In patients undergoing Artificial
Reproductive Techniques (ART), women who had higher exposure to air pollutants during IVF,
exhibited lower live birth rates and higher rates of miscarriage. After exposure to similar levels of air
pollutants, women who conceived naturally showed similar results, suggesting that infertile women
were not more susceptible to the effects of pollutants than the general population.41
Thus, air pollution has a negative impact on both male and female gametogenesis. These impacts not
only influence the quantity of gametes but also on their quality, at a genetic and epigenetic level.
These impacts also alter the embryo development.40
Air pollution and impact on skin health
Particulate matter can penetrate the skin via the hair follicles or transdermal. It exerts its harmful
effects through oxidative stress generation that contributes to extrinsic skin aging (described by
pigmentation on face and nasolabial folds, coarse wrinkles, solar elastosis and telangiectasia).
Smaller particles (<PM2.5) are the most harmful components that serve as carriers for organic
chemicals and metals which localize in mitochondria to generating reactive oxygen species (ROS).
Reports have indicated an increase in soot (per 0.5 × 10−5
/m) and particles from traffic (per 475 kg
per year and square km) to be associated with 20% higher pigmentation on the forehead and cheeks.

31
Studies have also shown the severity of symptoms of atopic dermatitis to have a direct association
with increased particulate matter.42
Kim et al.43
report that with indoor air quality improvement
program, the level of particulate matter decreased and there was a significant decrease in the
prevalence and severity of atopic dermatitis. It is postulated that particulate matter may induce
inflammation in the skin in a similar fashion as that in the respiratory system.43
Air pollution and mortality
In a review of studies conducted in various countries and investigating the effects of acute changes
in pollution levels, it was suggested that a 0.4-1.3% increase in the relative risk (RR) of death is
associated with a 10-µg/m3
increase in PM2.5 levels or a 20-µg/m3
increase in PM10 levels. The largest
impact on mortality occurs among children under 5 years of age (RR = 1.6%) and among elderly
individuals (RR = 2.0%), for every 10-µg/m3
increase in PM10 concentration.44
Even in developed countries such as the USA, the most relevant studies on the chronic effects of air
pollution on mortality have estimated a 6-17% increase in cardiopulmonary mortality for a 10-µg/m3
increase in PM2.5 levels.44
Early Pollutant Induced Syndrome (E.P.I. S)
E.P.I.S: Background
The number of premature deaths caused due to air pollution is projected to reach between 6 to 9
million by 2060. Cases of bronchitis are projected to increase substantially, rising from 12 to 36
million new cases per year in children aged 6 to 12; and from 3.5 to 10 million cases in adults.45
Thus, from the earlier section of this report, it is clear that poor air quality can have a significant
impact on the health and wellbeing of almost everyone. It is therefore pertinent to address the issue
of air pollution at public policy, healthcare and personal protection level. An increased level of
awareness of air pollution can bring about motivating changes in public policy, individual behavior
and bringing medical attention to the problem at an early stage.46
It is therefore important, to identify the early physical symptoms, that are pollution induced - in order
to prevent an exacerbation at a later stage for both the healthy and in populations that are considered
‘at risk’. While these symptoms have been recognized by various health advisories,47-50
these can be
bought under a single umbrella term to represent early pollution induced signs and symptoms.
These symptoms can be grouped under a common reference as Early Pollutant Induced Syndrome
or E.P.I.S. Identifying E.P.I.S can help prompt interventions aimed at preventing the effects of air
pollution or exacerbating symptoms further in affected individuals.
Risk factors and triggers for E.P.I.S
Risk factors and triggers for development of E.P.I.S are heterogeneous with interplay between

32
endogenous and environmental factors. Based on their experience, and adapting the segmentation
presented for obstructive respiratory conditions in a standard medical textbook, the AIR board
presents the following several risk factors for E.P.I.S –
Table II: Risk & triggers factors for E.P.I.S^
Endogenous Factors Environmental Factors Triggers
Airway hyper
responsiveness
Poor air quality Upper Respiratory Tract
Infections (URTI)
Atopy (history of atopy) Smoking (Passive or active) Being outdoors
Gender Exposure to road traffic
Stress
^
Segmentation adapted from Kasper D, Fauci A et al. Harrison's Principles of Internal Medicine,
19ed. 2015. Ch 24 (Table 309-1).
Populations at risk for E.P.I.S:
Almost everyone is affected by air pollution, especially over prolonged periods of exposure. However,
certain ‘at-risk’ groups are potentially more vulnerable than others and may be affected with a lower
level of exposure and show symptoms early. These susceptible groups are -
Children
Children are highly vulnerable to air pollutant exposure and thereby to E.P.I.S. Children have higher
physical activity levels and therefore higher basal metabolic rates leading to higher minute
ventilation. This is also because compared to adults, children generally spend more time outdoors.
Thus, considering the respective body weights, volume of air passing through the airways of a child
at rest is twice that of an adult under similar conditions. Pollutant-induced irritation, that would
generate only a weak response in adults, can result in significant obstruction in children. An immature
immune system in the children also increases the chances of respiratory infections.10,51
Elderly
The elderly show immunosenescence (i.e. a less efficient immunity) and are therefore highly
susceptible to the adverse effects of air pollutant exposure like E.P.I.S. Furthermore, a progressive
decline in pulmonary function in the elderly also can lead to airway obstruction and limitation in
physical activity. An overall functional decline in organ systems along with decreased chest wall
compliance and lung hyperinflation leading to requirement of additional energy expenditure in
performing respiratory movements.52
Individuals with pre-existing chronic diseases

33
Individuals having a pre-existing chronic diseases – especially of the respiratory system (asthma,
COPD, and fibrosis) or the circulatory system (arrhythmias, hypertension, and ischemic heart
diseases), as well as those with chronic diseases such as diabetes and collagen diseases; regardless
of their age, form a highly susceptible group to develop E.P.I.S.10,53
Pathogenesis
The respiratory tract is a direct route of human exposure to air pollutants that are a combination of
particulate matter (PM), gases, and vapor-phase molecules. Particulate matter, which have their
source primarily in dust pollutants (and from combustions such as crop burning, diesel vehicles,
power plants, etc.), play an important role in the environmental health risk – depending on their
aerodynamic diameter. PM10 (diameter<10μm) are classified as thoracic particles, PM2.5 (diameter<
2.5μm) are classified as fine particles, and those with diameter < 0.1μm are classified as ultrafine
particles (UFPs). Particles larger than 10μm are likely to land in proximal airways, but fine particles
reach the lungs and are deposited in the alveoli, thereby enabling the PM2.5 to cause more harm than
the larger particles.54
Terzano et al.55
observed that ultrafine particles pass into the bloodstream by different routes and
mechanisms, and distributed to other body organs, including brain with potential neurotoxic effects
(See figure 2). Gaseous pollutants, depending on their solubility in the water, are absorbed in the
proximal or the distal parts of the respiratory tract. While sulfur dioxide and formaldehyde, being
highly water-soluble do not reach the lungs – they do irritate the airway epithelium of the upper
respiratory tract. NO2 being poorly water-soluble, reaches deeper but not the alveoli in significant
quantities.55
Ozone, in contrast, being in gaseous form reaches the lungs to negatively affect the
alveolar epithelium.56

34
Fig 2: Systemic health effects caused by Ultra Fine Particles (UFPs) (Adapted from Terzano et al.)55
Clinical features and diagnosis
The symptoms of E.P.I.S generally begin with early exposure to pollutants. Generally, these are some
of the first symptoms to start as soon as the local ambient air quality goes down and shows an
increase in PM2.5 levels. It is important to co-relate the clinical symptoms with the local Air Quality
Index (AQI) values, that helps to link the symptoms with air pollution (as these symptoms may also
be seen in occupational exposure).
Common symptoms are: adapted from 47-50
• Burning eyes
• Irritation in throat.
• Cough and chest tightness
• Coughing at night
• Wheezing
• Unexplained headache/vomiting
• Increased respiratory infections
Additionally, in people with pre-existing conditions like asthma, COPD, coronary heart disease or
diabetes; a lowering of air quality may lead to a worsen of their symptoms or a deterioration in their
conditions.
Diagnosis and tests:
While E.P.I.S is usually apparent from the symptoms and a history of current exposure to pollution or
poor air quality; certain complications can be prevented by early detection through objective
measurements of lung function, hematological tests and imaging.
 Lung Function Tests
Simple spirometry confirms airflow limitation with a reduced FEV1, FEV1/FVC ratio, and PEF.
Further tests are not needed unless the condition extends to an episode of asthma or obstructive
lung disease.
 Hematologic Tests
Blood tests are not directly associated with diagnosis of E.P.I.S, but estimation for blood glucose
and lipid profiles may help to understand any deterioration in associated conditions like diabetes
or cardiovascular condition.
 Imaging:

35
Chest X-ray report could usually be in normal limits, but may also show early signs of
inflammation or congestion.
Differential Diagnosis:
E.P.I.S being a collective set of symptoms – caused by exposure to air pollution – potentially may get
misdiagnosed, if not differentiated from other conditions such as viral cause of upper respiratory
symptoms due to eosinophilia or allergic reactions to non-pollution triggers.
Early awareness of these symptoms and their correlation with poor air quality, can help get timely
medical attention and reduce the harmful effects of ambient air pollution.
Management & Prevention:
General symptomatic management helps to produce relief from the irritating symptoms of E.P.I.S
and to improve the quality of life, along with preventing absenteeism at work or school.
Preventive measures at diagnosis of E.P.I.S will help reduce incidence of complications or
exacerbations of the symptoms to a more serious condition. The detrimental effects to health from
air pollution are largely determined by the concentration of air pollutants and the amount of exposure
time. Early identification of E.P.I.S will allow healthcare professionals and individuals to take
appropriate action to reduce the amount of pollutants inhaled.
Some immediate measures that can be followed by individuals are –
 Regulate daily activity according to the air quality index (AQI)
Detrimental effects of ambient air pollution can be reduced by lowering the time spent on
outdoor activities – especially when the AQI is beyond a certain level – as specified by the local
authorities. The AQI values are known to fluctuate from one time to another, in different place
even in the same city, and on different time for e.g. in urban areas, PM2.5 and CO may be high in
the central area during the rush hours because large amount of vehicles and usually poor air
flow. Accordingly, different groups of people (healthy adults, those with COPD, children, elderly
pregnant women etc.) can regulate their outdoor activities.57
 Use of masks and filters
Wearing personal protective equipment (N95 mask or equivalent – such as the European P2
and P3 masks) might be useful for avoiding detrimental effect of ambient air pollutants. Using
of nasal mask during a ‘haze’ can help people to prevent adverse effects from air pollution.57
While masks have been shown to be beneficial in reducing respiratory virus transmissions, but it
should also be noted that use of surgical or plain face masks do not prevent inhalation of fine particles
like PM2.5. To avoid air pollutants, specific face masks (N95/P3 and R95) are considered to be
efficient filter masks, that filters out around 95% of airborne particles in the inhaled air.58

36
Use of highly efficient face masks – that reduce personal exposure to PM2.5 - have also been reported
to reduce symptoms and improve a range of cardiovascular health measures in patients with
coronary heart disease.59
Thus, use of face masks has potential to protect susceptible individuals and
prevent cardiovascular events in cities with high concentrations of ambient air pollution.60
While face masks do provide personal protection; their usage is in approx. 1% of population. There
are other devices in a similar category – namely the nasal filters. These are worn inside the nose and
collect inhaled particles using the principle of impaction. Nasal filters are easy to breathe through,
and have a high capture efficiency for particles above 8 µm in diameter.61
Another commonly recommended environmental control measure for patients with chronic
respiratory disease is the use of air filtration devices inside the home to reduce the ambient
particulate matter levels. Particle filtration systems can supply filtered air into the room or whole-
house, reducing indoor exposures to particles from outdoor air and reduce the morbidity and
mortality associated with air particles.52
In addition to the above measures, it is also advised to follow some tips for protection against the
dangers of air pollution63
–
 Check daily air pollution forecasts in their residential areas and places of work
 Avoid exercising outdoors when pollution levels are high.
 Use public transport or carpool instead of using cars. Avoid excessive idling of automobiles.
 Conserve energy at home thereby reducing greenhouse emissions.
 Avoid burning wood or trash
 Use electrical equipment over those requiring fuels (Generators etc.)
Final considerations
Approximately half of the people in the world, today, live in cities and urban areas and are exposed
to progressively higher levels of air pollutants (see figures 3 and 4). A similar trend is seen in India
as well.2

37
Fig 3: WHO documented PM10 levels for available mega-cities of more than 14 million habitants in
2015. [Adapted from WHO]2
Fig 4: Annual mean particulate matter concentration of towns and cities across geographies,
compared to the WHO Air Quality Guidelines [Adapted from WHO]2
Afr : Africa ; Amr : Americas ; Emr : Eastern Mediterranean; Eur : Europe ; Sear : South-East Asia ;
Wpr : Western Pacific; LMIC: low- and middle-income countries; HIC : high-income countries ; AQG :
WHO Air Quality Guidelines. a
Annual mean PM10 : 20 μg / m3
; Annual mean PM2.5 : 10 μg / m3
.
Long term exposure to air pollutants aggravates pre-existing diseases and also shows rise in the
number of new cases of respiratory disease such as asthma/COPD and lung cancer. Air pollution
induced worsening of the symptoms, lead to an increase in need for emergency treatment, unplanned
hospitalizations, and even deaths.64

38
Health professionals should recognize the importance of the effects of air pollutants in clinical
practice and properly assess the exposure profile of patients at home, in the workplace, and in the
region of residence. Recognition of early air pollution induced signs and symptoms (E.P.I.S) allows
for quicker intervention and recommendation towards prevention and protective measures.
Wherever it is not possible to reduce the emission of air pollutants in the short or medium term, or
where it is beyond the scope of the healthcare practitioner, patients need to be counselled on
adoption of appropriate personal protective measures to reduce adverse effects. Additionally,
healthcare practitioners should, as appropriate, review existing cases to determine whether pre-
existing conditions (respiratory, cardiac or metabolic) are due to E.P.I.S, and if appropriate,
encourage their patients to follow air pollution reduction measures.

39
Disclaimer
This review is supported by Reckitt Benckiser through an unrestricted grant in public interest.
Scientific writing support for this paper has been provided by McCann Health, India.
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2018
The Air Pollution Institute of Research (AIR):
The Air Pollution Institute of Research (AIR) is a collaboration of senior healthcare experts from
across multiple super specialties aiming to provide education &creating frameworks to tackle the
emerging health issues due to air-pollution.
AIR works closely with various stakeholders from the government, non-government and private
sectors to impart education to healthcare practitioners, para medics and the community at large, to
help create awareness and manage the health burden caused due to air pollution. Experts of the AIR
Council are actively involved in trainings, community programs, debates and in spreading awareness
through articles in print and digital media and creating conversations within their specialties to
collaborate towards managing the health hazards of air pollution.
The activities of the AIR council are supported by Reckitt Benckiser through unrestricted grant in
public interest.
Chairman: Ashok A. Mahashur
Dr Ashok Mahashur is a consultant chest physician based in Mumbai, India. He is also the Governor
of American College of Chest Physicians - Western India. The editor of Thorax (India), Dr Mahashur
has authored or co-authored over 200 published articles and serves on the editorial boards of various
prestigious international journals. He has delivered a number of orations and guest lectures both
nationally and internationally. The former president of the Indian Chest Society, he is the only Asian
member in Global Respiratory infection program, UK.
Panelists:
Akshay G. Mehta
Dr. Akshay Mehta is a senior interventional cardiologist, based in Mumbai, with more than 30 years
of clinical experience in cardiology. He has trained many young interventional cardiologists and has
multiple publications to his credit. He is a sought after speaker in major cardiology conferences.

46
Bakul J. Parekh
Dr. Bakul Parekh is senior Pediatrician with more than 35 years of clinical experience. He is the
Secretary General of the Indian Academy of Pediatrics and has actively participated in the
planning for infectious disease protocols and for the rational use of antibiotics in children.
D. Vijaya Sekharan
Dr. (Prof) D. Vijayasekaran is a senior pediatric pulmonologist practicing in Chennai. He is a
former professor at Madras Medical college with more than four decades of experience. He has a
keen interest in academics with many publications to his credit.
Hema Divakar
Dr Hema Divakar, with more than three decades of experience, is a leading Obstetrician and
Gynecologist in Bengaluru, Karnataka. She is ex-president of Federation of Obstetric and
Gynecological Societies of India (FOGSI) and is the recipient of many international awards.
Pramod Jog
Dr Pramod Jog is a senior Professor of Pediatrics with more than 30 years of experience. He is
ex-president of the India Academy of Pediatrics and has been a faculty in over 600 National and
International conferences.
Rishma Dhillon Pai
Dr. Rishma Pai is a senior consultant Gynecologist and an infertility specialist, based in Mumbai.
She is the current president of FOGSI and an author of chapters in many books and journals. She
is one of the pioneers in India for a treatment modality for Dysfunctional Uterine Bleeding (DUB).
She is a regular guest speaker at many national and international conferences.

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