This document discusses the link between tuberculosis (TB) and environmental factors. It notes that while clinical solutions like drugs and vaccines are emphasized, TB incidence is not falling rapidly enough. To better address long-term trends, social and environmental interventions must also be delivered, such as improvements to housing, energy access, and education. These sectors need to work together with health to help control TB on a broader level. The environment plays an overlooked role in TB transmission that could be mitigated through multi-sectoral public health strategies.

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LATE PROF NILAY CHOUDHARY MEMORIAL LECTURE
21.12.2013
DR.AMITA ATHAVALE
PROFESSOR & HEAD
DEPT.OF CHEST MEDICINE & ENVIRONMENTAL POLLUTION RESEARCH
CENTRE,KEM HOSPITAL & SETH G.S.MEDICAL
COLLEGE,PAREL,MUMBAI,INDIA.

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Lungs:largest surface area
Intake of “Air”-10 times Food
Every misery has it’s cry ….
….Health remains silent
When You Can’t Breathe,
Nothing Else Matters

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IRRITATION INFLAMMATION
ASPHYXIATION DESTRUCTION
MUTATION

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1954 LONDON
BHOPAL 1984
2009 DELHI DEATH
TOLL?
A SILENT
KILLER
MUMBAI 2005

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WORK HOME
23 hours indoors: home or work, transit
US EPA ranked American home 4th in list of serious health hazard
CHANGING CLIMATE…
CHANGING ENVIRONMENT

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Do you feel sick in office or home
environment ?
• ETS
• Dust mites- 1 mcg – 10 mcg
• Mould- visible mould damage,odour
• Radon- 200-400bq/m3
• VOC’S
• Asbestos
• Man made mineral fibers
• SPM
• CO2
• SICK BUILDING SYNDROME

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Melting Glaciers…
Rising Temperature
Changing Lifestyles
Dampness Dust HVAC

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Source apportionment

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SPM LEVELS-2002-2011
0
200
400
600
800
1000
1200
1400
Worli
Khar
Andheri
Bhandup
Borivali
marvali
Deonar
SPM LEVELS-2002-2011
AQMRL (CRITERIA POLLUTANTS)
MUNICIPAL CORPORATION OF GREATER MUMBAI

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CENSUS BY SOCIAL
WORKER & HEALTH VISITOR
QUESTIONNAIRE FILLING
CLINICAL EXAMINATION PORTABLE LUNG FUNCTION
S
T
U
D
Y
M
E
T
H
O
D
O
L
O
G
Y

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Equipment Used
Personal
monitor Indoor particulate monitorPortable lung function
PULMONARY FUNCTION TESTING LAB
Chest Medicine & EPRC

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Profile of Diagnosis - MoEF
Normal
Bronchitis
Eosino
Other chest
Cardiac
URTI
Asthma
General diseases
Allergic rhintis
OAD
Diagnosis
Pies show counts
Normal
56.92%
Bronchitis
3.56%
Eosino
0.11%
Other chest
2.63%Cardiac
2.35%URTI
2.57%
Asthma
4.16%
General diseases
10.29%
Allergic rhintis
5.69%
OAD
11.71%
DIAGNOSIS

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Why study asthma air pollution link?
ENVIRONMENT
INDOOR
OUTDOOR
A
s
th
m
a
GENETICS

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Peak morning traffic ……decreased by 23%
Peak ozone levels ………..decreased by 28%
Emergency room visits for Asthma ………decreased by …..42%

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ASTHMA PREVALENCE SCHOOL
CHILDREN 3947

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Chafa flower Pollen grain
Drum stick flower Pollen grain

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August 2005
2
1
2 2 2
3
6
1
9
3
2 2
11
2
6
4
7
4
5
11
4
2
0
1
2
3
4
5
6
7
8
9
JAN
FEB
M
A
R
A
PR
M
A
Y
JUN
JUL
A
U
G
SEPT
O
C
T
N
O
V
D
EC
ASTHMA ADMISSIONS
2001
2005
n=39
n=34

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ILD
?Nox ?RSPM
Pigeons
Hypersensitivity
pneumonitis
Genetics
Hypersensitivity
pneumonitis
Incidence of ILD
Year Total
No. of
New
Cases
ILD %
2000 1479 62 4.1%
2010 1871 95 5.1%

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March 2012
• Ghatkopar residents say pigeons
are killing them
• Say several of them have
contracted respiratory diseases
due to allergens in the bird
droppings and feathers. Doctor
says four residents have died so
far due to the disease and 12
others have been diagnosed with
it; local Kabutar Khana blamed

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ORGANIC DUST

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Problems reported by citizens
Gorai Dumping ground
Normal
Bronchitis
TB
Others
Cardiac
URTI
Asthma
General
All.rhinitis

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Gorai Dumping Ground Survey
Following concerns raised by the residents of BSES Society and Navlai Society,Gorai a questionnaire survey was
conducted by EPRC, K.E.M Hospital between 7/9/2011 to 28/9/2011.
Gautam Nagar – Deonar
Following the complaint from residents of Gautam Nagar, Opp. Deonar Police Station, Govandi, visit to
area was undertaken on 18-11-2011. This was followed by census and questionnaire survey from
EPRC, K.E.M. Hospital from 23/11/2011 to 25/11/2011.
In the population surveyed 7.6% complained of cough, 17% complained of breathlessness 16% had complained of eye irritation
and 34.9% had complained frequent sneezing. Considering the problem reported by the citizens exposure to cement dust, the
respiratory morbidity observed in this area is significant.
In the population studied 14.5%
complained breathlessness 13.7% had
complained eye irritation and 31.5%
frequent sneezing considering the
problem reported by the citizen regarding
exposure to cement dust, respiratory
morbidity observed in this area is
significant.

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May 2007-
Wadala (Mumbai)
• Respiratory
morbidity
reported
significant
• Studied lung
functions
comparable to
control area.

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To Determine the health effects of the different
modes of travel to place of work

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Impact of COPD in India

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Study of the long term effect of
Indoor biomass smoke on lung
Exposure to long term biomass smoke
is associated with structural and functional
changes in lung.

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Occupation related
Traffic police survey
Obstructive
Restricitve
Mixed
SAO
Normal
Obstructive
Restricitve
Mixed
SAO
Normal
PFT in traffic police in Smokers PFT in traffic police in non-smokers

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Occupation related
Incidence of Silicosis in Flour mill workers
30.4% flour mill workers had Silicosis

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34 yrs GARDENER, WATERED PLANTS
WITH TREATED WASTEWATER

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THERAPEUTIC BAL UNDER GA

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• 52/M
• Non-smoker
• Worked in a bakery for > 30 years
• C/O
• Productive cough and exertional
breathlessness since 2 years
• Treated with AKT on multiple occassions
due to Xray changes with no relief
• No h/o HT/DM/IHD

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Radiology: PMF

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NEEDLE SHAPED (SILICA) BIREFRINGENT
CRYSTALS IN SAMOSA PATTI
(Polarising microscopy)
DEPT. OF PATHOLOGY, K.E.M. HOSPITAL

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Gold Polishing Industry
Bhuleshwar area

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8
6
7.4
12
1.71.7
4.3
0.9
0
2
4
6
8
10
12
14
Bronchitis
A
sthm
a
U
R
TI
O
therC
hestD
iseases
%AGE
Bhuleswar Kalbadevi
n=149 n=116

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Urban outdoor air pollution is estimated to cause 1.3 million
deaths worldwide per year. Those living in middle-income
countries disproportionately experience this burden.
…. Air Quality and Health, WHO Fact Sheet NO -313, Sept. 2011
Deaths and DALYs attributable to five environmental risks,
and to all five risks combined by region, 2004
Source : Global Health Risks, WHO, 2009
India Falls under Low and Middle Income Category

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Carcinogenic potential of PAHs is estimated with equivalent of
Benzo (a) pyrene. On the basis of BaPE calculation, residential
site has the maximum values of 18.8 and 13.6 for ambient and
indoor sampling location respectively.
Colaba Dadar Khar Mahul
BaPE Out 3.5 3.8 18.8 7.9
In 6.4 9.7 13.6 4.5
Lung Cancer Cases
/Yr.
Predicted
(2007)
1 3 16 8
Actual (2007) 8 7 10 13
Sum of PAHs
Identified ng/m3
Out 35.7 42.96 175.7
6
90.78
In 75.10 79.28 134.1
8
46.94
Carcinogenic Potential of PAHs-Mumbai City
SOURCE:NEERI MUMBAI

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Conclusions
INDOORS
 Ratio at control sites (>1) indicates that there is a strong indoor
source for fine particles. At kerbsite I/0 ratio was 1.02 ± 0.14, close
to 1 indicating equal indoor and outdoor levels.
 Theoretical I/O ratio and RCS model supports that indoor air
particles are derived from outdoor air at kerb and residential sites.
 Highest BaPE was also observed at residential site indoors.
Though I/O ratio is less than one at residential site toxic pollution
characteristics of fine particles is greater. High indoor toxic
pollution affects personal exposure.
 Control systems are primarily:
 Creation of Ventilation Systems
 AC premises: proper HVAC system
 Indoor material selections

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Indoor
Air
Indoor air affects
vulnerable
population as they
spend maximum
time indoors.
Controlling indoor
air pollution will
help to achieve
millennium
development goal
4 and 5 related to
mortality and
morbidity of
women and
children.
 Use of clean fuel like LPG
 Ventilation standards and building codes for
Indian condition
 Adoption of Leadership in Energy &
Environmental Design (LEED) Standards for
indoor air improvement in residential and
commercial places.
 Indoor air quality surveillance by corporation
and pollution control boards at regular
interval/on request due to health effects
 Manufacturing standards for Indoor air
quality products eg paints, cleaners etc.
Recommendations

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ENVIRONMENTAL PROBLEMS
45.1
52.2
41.6
38.4
28.2
56.6
38.9
0
10
20
30
40
50
60
70
80
90
100
Vehicular Pollution Vehicle Noise
Pollution
Solid Waste
Pollution
Ground Water
Pollution
Rain Water Pollution Indoor Pollution Industrial Pollution
ENVIRONMENT
People’s perception of
environmental problems

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4522.96 million Rupees…..50
microgram rise particulates
• Monetary burden of health impacts of air
pollution in Mumbai, India
• Public Health. 2011 Mar;125(3):157-64.
• Monetary burden of health impacts of air
pollution in Mumbai, India: Implications for
public health policy.
• Patankar AM, Trivedi PL. K.J. Somaiya Institute
of Management Studies and Research,
Vidyavihar (East), Mumbai 400077, India.

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APRIL 2004 SARS
APRIL 2009
NOVEL FLU
PANDEMIC

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Vector borne diseases & Lung
• P. Vivax malaria – Thrombocytopenia , acute
lung injury, ARDS
• Dengue- ARDS
• Leptospirosis Water scarcity
Construction
Water logging

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Survival of the fittest
• Susceptible population at greatest risk
Genetically susceptible
Geographically susceptible
? Economically susceptible

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DIET IN HEALTH & DISEASE

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Environ Health Perspect. 2008 November; 116(11): A478–A485.
PMCID: PMC2592293
Linking TB and the Environment: An Overlooked Mitigation
Strategy
Charles W. Schmidt
“But doing that won’t be easy. Social and environmental interventions aren’t usually
delivered or funded by the health sector, so that means we all have to work with
other sectors, in particular housing, energy, and education, to
move them forward.”
TB control strategies adopted by the WHO and other organizations emphasize clinical
solutions in the form of drugs, vaccines, and access to health care. But despite the
success of these programs, TB incidence and mortality aren’t falling rapidly enough to
meet WHO targets, and in some areas, particularly in parts of Asia and throughout sub-
Saharan Africa, they continue to climb
“Better treatment is essential, but if we want to affect longer-term trends in the
epidemic we will also have to deal with risk factors,” asserts Eva Rehfuess, a scientist
with the WHO Department of Public Health and Environment

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SCIENTIFIC EVIDENCE CAN BOLSTER
CONTROVERSIAL POLICY DECISIONS?
FLYOVERS
SKYWALKS

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“Those who contemplate the beauty of the
earth find reserves of strength that will
endure as long as life lasts.”