Prof Agus - Outdoor dan Indoor Pollution dan Kesehatan Paru.pdf

Implication of Indoor and
Outdoor Air Pollution
for Lung Health
Prof. Dr. dr. Agus Dwi Susanto, Sp.P(K)

INTRODUCTION
• Air pollution is contamination of the
indoor or outdoor environment by
any chemical, physical or biological
agent that modifies the natural
characteristics of the atmosphere
• Air pollution is a complex mixture of
gases and particles whose source
and composition are varied by place
and time
• One of the main cause of lung
diseases
WHO. Air pollution [internet]. who.int.[cited 2021Dec 4]. Available from:https://www.who.int/health-topics/air-pollution
Fontan J. Air pollution [internet]. encyclopedie-environnement.org. [updated 2019 Mar 7, cited 2021 Dec 4]. Available from: https://www.encyclopedie-environnement.org/en/air-en/air-pollution/

Air Pollution
Indoor
• Cigarette
• Fireplace
Outdoor
• Exhaust
• Dust
Workplace
• Chemical
gas

Outdoorvs Indoor Air Pollution
Leung DYC. Outdoor-indoor air pollution in urban environment: challenges andopportunity. Front Environ Sci. 2015.2(69)_:1-7.
Indoor Air Pollution Outdoor Air Pollution
– Mold and mildew
– Tobacco smoke
– Household products
– Toxic gas
– Pet dander
– Fossil fuels
– Landfills
– Factories
– Mining
– Vehicles
– Agriculture
• Based on its source, air pollution is divided to outdoor (ambient) and
indoor (household) air pollution

Outdoorvs Indoor Air Pollution
• Statistically,outdoor air pollution causes more deaths than indoor air
pollution
• In some contexts, indoor air pollution can be more harmful than
outdoor air pollution  higher concentrations, longer exposure
times, poor ventilation
• Women and children (who spend more time on domestic matters) are
more affected by indoor air pollution

• In 2019, 99% of the world’s population was living in places where the
WHO air quality guidelines levels were not met
• Ambient (outdoor) air pollution is estimated to have caused 4.2
million premature deaths worldwide in 2019
• 37%  ischaemic heart disease and stroke
• 23%  acute lower respiratory infections
• 18%  chronic obstructive pulmonary disease
• 11%  lung cancer
WHO. Ambient (outdoor) air pollution. WHO; Dec 12 2022[CitedJul 252023]. Available from: https://www.who.int/news-room/fact-sheets/detail/ambient-(outdoor)-air-quality-and-health

Major sources
for outdoor
(ambient) air
pollution
Hahad O, Lelieveld J, Birklein F, LiebK. Ambient Air Pollution Increases the Risk of Cerebrovascular and Neuropsychiatric Disorders through Induction of Inflammation and Oxidative Stress. Int J Mol Sci. 2020;21:4306:1-24.
Outdoor Air
Pollution

Fontan J. Air pollution [internet]. encyclopedie-environnement.org. [updated 2019 Mar 7, cited 2021 Dec 4]. Available from: https://www.encyclopedie-environnement.org/en/air-en/air-pollution/

Indoor Air Pollution
• Around 2.4 billion people worldwide (around 1/3 of the global
population) cook using open fires or inefficientstoves fuelled by
kerosene, biomass (wood, animal dung and crop waste) and coal, which
generates harmful household air pollution
• Household (indoor) air pollution was responsible for an estimated 3.2
million deaths per year in 2020, including over 237.000 deaths of
children under the age of 5
• 32%  ischaemic heart disease
• 23%  stroke
• 21%  lower respiratory infection
• 19%  chronic obstructive pulmonary disease
• 6%  lung cancer
WHO. Household air pollution. WHO; Nov 28 2022[Cited Jul25 2023]. Available from: https://www.who.int/news-room/fact-sheets/detail/household-air-pollution-and-health

Ravindra K, Mor S. Phytoremediation potential of indoor plants in reducing air pollutants. Front Sustain Cities. 2022;4:1039710.
• Major
sources for
indoor air
pollution

Type &
sources of
indoor air
pollutants

PM Type and Penetratibility
Manisalidis I, Stavropoulou E, Stavropoulos A, Bezirtzoglou E. Environmental and Health Impacts of Air Pollution: A Review. Front Public Health. 2020;8(14):1-13.

PM Type and Penetratibility
IQAir. World Air Quality Report 2021. 2021

Air Quality
• Air pollution is one of the main environmental problem in the
world
• Most important cause of death
• Kills ±7 millionspeople worldwide every year
• Air pollution causes millions of premature deaths every year,
largely as a result of increased mortality from stroke, heart
disease, chronic obstructive pulmonary disease, lung cancer and
acute respiratory infections.
Susanto AD. Air pollution and human health. Med J. 2020;29(1):8–10.

WHO Air Quality Standards
• Designed to offer
guidance in reducing
the health impacts of
air pollution based on
expertevaluationof
currentscientific
evidence
• Governmentscan use in
differentways
dependingon their
technical capabilities,
economiccapacity, air
quality management
policiesand other
factors
World Health Organization. WHO global air quality guidelines. Particulate matter (PM2.5 and PM10), ozone, nitrogen dioxide, sulfur dioxide and carbon monoxide. Geneva:World Health Organization; 2021.

WHO Air Quality Standards

Health Effects Institute. State of global air 2017: special report.Boston: Health Effects Institute; 2017. p.1 –15.

• Air quality in Indonesia has
improved from an average
PM2.5 concentration of 40.7
µg/m3 in 2020 to 34.3 µg/m3 in
2021
• Persistently poor air quality in
the country’s most populous
cities continues continue to
endanger the health of
residents
• Worst air quality in Indonesia
 Jakarta, annual average
PM2.5 concentration:39.2
µg/m3 (>7 times exceeding the
WHO guideline)
Air Quality in
Indonesia

WHO. WHO indoor air quality guidelines: household fuel combustion. Geneva: WHO; 2014.
WHO Guidelines for
Indoor Air Quality
• Guideline specifically for
indoor air quality
especially for household
fuel combustion
• Encourage the use of fuels
& technologies that are
clean for health (LPG,
biogas, electricity, etc.)
instead of kerosone/coal

Impacts of Air
Pollution to
Health
• Both indoor & outdoor
air pollution have
adverse health effects
to human health at all
ages
Farmer SA, Nelin TD, Falvo MJ, Wold LE. Ambient and household air pollution: complex triggers of disease. Am J Physiol Heart Circ Physiol. 2014. 307: H467–H476.

SOURCE
EMISSIONS
CONCENTRATIONS
EXPOSURE DOSE
HEALTH
EFFECTS
“the event when a person comes into
contact
with a pollutantof a certain concentration
during a certain period of time”
a quantitative
expression of the amount
of pollutantwithin a given
environmentalmedium.
amount of pollution
that actually
crosses one of the
body boundaries.
WHO AirQuality Guidelines2005
- AIR POLLUTION AND HEALTH EFFECT-

Effects of Air Pollution to Human Lung
• PM are extremely irritant to the respiratory tract, induces oxidative
stress that can lead to pulmonary and systemic inflammation. Some of it
can be carcinogenic. Chronic exposures to oxidative stress can cause
bronchialremodellingand COPD.
• O3 can induces mucosal inflammation of respiratory tract and airways
obstructionin the presence of stimuli (ex: cold, exercise)
• SO2, NO and NO2 are irritant and can increases bronchial reactivity
(lead to bronchoconstriction) and susceptibility to infections and
allergen
• CO can bind with hemoglobin and interfering with oxygen transport. It
can causes nausea, dizziness, and headache.
Arbex MA, Santos UP, Martims LC, Saldiva PH, Pereira LA, Braga AL. Air pollution and the respiratory system. J Bras Pneumol. Sep-Oct 2012;38(5):643-55.

Effects of Air
Pollution to
Human Lung
• Acute effects: acute
inflammation, impairment
airwayimmunity 
asthma/COPD
exacerbation,susceptibility
to infection
• Chroniceffects: chronic
inflammation, carcinogenic
effects  asthma & COPD,
lung cancer, reduced lung
function
Arbex MA, Santos UP, Martims LC, Saldiva PH, Pereira LA, Braga AL. Air pollution and the respiratory system. J Bras Pneumol. Sep-Oct 2012;38(5):643-55.

Pyramid of Effects from air
pollution:
• Describes the
relationship between the
severity of the impact of
air pollution on health
and the number of
affected populations
How BenMAP-CE Estimates the Health and Economic Effects of Air Pollution | US EPA [Internet]. [cited 2022 Aug 15]. Available from: https://www.epa.gov/benmap/how-benmap-ce-estimates-health-and-economic-effects-air-pollution
Effects of Air Pollution
to Human Lung

PM 2.5 effecton lung in Asia
Efforts to controlairpollutionin the Asia-Pacificregion. YasuoMorimoto,
Hena Khatun,KwokSangWilson Yee,Agus DwiSusantoet.al. Respirology
(2020) doi: 10.1111/resp.13800.

Air Pollution and
mortality caused by
lung disease = 47%

Air Pollution and Respiratory Infection
Horne BD, Joy A, Hofmann MG, Gesteland PH, Cannon JB, Lefler JS, et al. Short-Term Elevation of Fine Particulate Matter Air Pollution and Acute Lower Respiratory Infection. Am J Respir Crit Care Med. 2018;198(6):759-66.
• Putative
mechanism of air
pollution in risk
of respiratory
infection

Bourdrel T, Annesi-Maesano I, Alahmad B, Maesano CN, Bind MA. The impact of outdoor air pollution on COVID-19: a review of evidence from in vitro, animal, and human studies. Eur Resp Review. 2021;30:200242.
Pathogen carried
in air pollution +
decreased immune
respiratory
defense  more
susceptible to
respiratory
infection, including
COVID-19
Air Pollution and Respiratory Infection

Air Pollution and Acute Respiratory Infection
• Air pollution enhances the severity of respiratoryinfections, particularly in
children
• Odo et al. (2022):A multi-countrystudy of 573.950childrenfrom 35
developing countries
• A 10 µg/m3 increasein PM2.5 was associatedwith greaterodds of
having an ARI (OR: 1.06; 95% CI: 1.05–1.07)
• The associationbetween PM2.5 and ARI was robust to adjustmentfor
NO2 and O3.
• Horne et al. (2018): From 146.397childrenin Utah
• The odds of ALRI increasedwithin 1 week of elevatedPM2.5 and
peaked after 3 weeks with a cumulative28-day odds ratio of 1.15 per
+10 μg/m3 (95% confidence interval,1.12–1.19)
Odo DB, Yang IA, Dey S, Hammer MS, van Donkelaar A, Martin RV, et al. Ambient air pollution and acute respiratory infection in children aged under 5 years living in 35 developing countries. Environment International. 2022;159:107019.
Horne BD, Joy A, Hofmann MG, Gesteland PH, Cannon JB, Lefler JS, et al. Short-Term Elevation of Fine Particulate Matter Air Pollution and Acute Lower Respiratory Infection. Am J Respir Crit Care Med. 2018;198(6):759-66.

Study by Nafas at Jakarta(2022)

Indoor Air Pollution and Acute Respiratory
Infection
In children, a meta analysis by Dherani et al. (2008):
• Household air pollution has been found to increase the risk of
childhood acute lower respiratory tract infection (ALRI) by 78%
(pooled odds ratio = 1.78 (95% CI 1.45 to 2.18)
In adults, a meta-analysisby Jary et al., (2016)  limited evidence
• From 8 studies, 2 studies found a significant adjusted increased risk of
acute lower respiratory infection, 2 identified a univariate association
whilst 4 found no significant association
Dherani M, Pope D, Mascarenhas M, Smith KR, Weber M, Bruce N. Indoor air pollution from unprocessed solid fuel use and pneumonia risk in children aged under five years: a systematic review and meta-analysis. Bulletin of the World Health Organization. 2008; 86(5):390–8C
Jary H, Simpson H, Havens D, Manda G, Pope D, Bruce N, et al. Household Air Pollution and Acute Lower Respiratory Infections in Adults: A Systematic Review. PLoS ONE. 2016.11(12):e0167656.

Air Pollution and Tuberculosis
• Poor air quality is highly likely to link aetiologicallyto the risk of TB
• Lin et al. (2019):
• The increment of the risk of TB occurred in a regionwith a higher level
of air pollution
• Highestpopulation attributablefraction (PAF): CO > NOX & NO2
• Liu et al. (2021): from 83.555 new TB cases in China
• Short and long-termexposures to outdoor ait pollutants (SO2, NO2, CO,
O3, and PM2.5 weresignificantlyassociatedwith new infection TB,
recurrentTB risk, and mortality
• SO2 and PM2.5 exhibited more consistent& strong associations
Lin YJ, Lin HC, Yang YF, Chen CY, Ling MP, Chen SC, et al. Association Between Ambient Air Pollution and Elevated Risk of Tuberculosis Development. Infect Drug Resist. 2019;12:3835-47.
Liu Y, Zhao S, Li Y, Song W, Yu C, Gao L, Ran J, et al. Effect of ambient air pollution on tuberculosis risks and mortality in Shandong, China: a multi-city modeling study of the short- and long-term effects of pollutants. Environ Sci Pollut Res Int. 2021;28(22):27757-68.

Air Pollution and Tuberculosis
• Liu et al. (2018): A time-
series study in Jinan,
China:
• A positive association
between ambient
PM2.5 & CO
exposures and the
risk of newly
diagnosed
pulmonary TB in
China
Liu Y, LiangLiang C, Hou L, Yu CB, Tao NN, Liu JY, et al. Ambient Air Pollution Exposures and Newly Diagnosed Pulmonary Tuberculosis in Jinan, China:A Time Series Study. Scientific Reports. 2018;8:17411.

Indoor Air Pollution and Tuberculosis
Study by Blount RJ, et al. (2021) in Vietnam:
• Children experienced a 2.56-fold increased odds of latent tuberculosis
for each additional household member who smoked (95% confidence
interval, 1.27–5.16)
• Other factors increases latent tuberculosis incidence:
• Motorcycles parked inside children’s homes
• Cooking with liquid petroleum gas compared with electricity
• Kitchen ventilationdecreasedthe incidence
Blount RJ, Phan H, Trinh T, Dang H, Merrifield C, Zavala M, et al. Indoor Air Pollution and Susceptibility to Tuberculosis Infection in Urban Vietnamese Children. American Journal of Respiratory and Critical Care Medicine. 2021;204(10):1211-21.

Air Pollution and COVID-19
• Air pollution can increase COVID-19 transmission, severity of the
disease, and mortality
• Frontera et al. (2020):
• The highest number of COVID-19 cases in Italia was recorded in
the most polluted regions with patients presenting with more
severe forms of the disease requiring ICU admission
• Mortality was two-fold higher in the polluted regions
• Chronic exposure to air pollution causes alveolar ACE-2
overexpression  increase viral load  depleting ACE-2 receptors
and impairing host defences
Wang B, Chen H, Chan YL, Oliver BG. Is there an association between the level of ambient air pollution and COVID -19? Am J Physiol. 2020;319:l416-21.
Frontera A, Cianfanelli L, Vlachos K, Landoni G, Cremona G. Severe air pollution links to higher mortality in COVID-19patients: The “double-hit hypothesis. Journal of Infection. 2020;255-9.

Frontera A, Cianfanelli L, Vlachos K, Landoni G, Cremona G. Severe air pollution links to higher mortality in COVID-19patients: The “double-hit hypothesis. Journal of Infection. 2020;255-9.

Wang B, Chen H, Chan YL, Oliver BG. Is there an association between the level of ambient air pollution and COVID-19? Am J Physiol. 2020;319:l416-21.
• Exposure to air
pollution may
increase the risk of
COVID-19 infection
through
dysregulation
immune responses

Wang B, Chen H, Chan YL, Oliver BG. Is there an association between the level of ambient air pollution and COVID-19? Am J Physiol. 2020;319:l416-21.
• Researchers have found that
aerosolized PM could facilitate COVID-
19 transmission up to 8 meter from
aerosol transmission
• Leifer et al. (2021) in California:
• 3 wildfire in Orange County,
California  increased PM2,5
• Every forest fire incident is always
followed by an increase in COVID-
19 cases after about 1 week of lag
period consistentwith incubation
time and testing/reporting time

Air Pollutionanddecreaseof lung function
development on children
Current levels of air pollution have chronic,adverse effects on lung
development in children from 10-18yo,leading to clinically significant
deficits in attainedFEV1 as children reach adulthood
N Engl J Med 2004;351:1057-67
Air Pollutionand
Lung function

Study Lung Function and air
Pollutionin Indonesia
Populasi Tempat Hasil Tahun
Polisi LaluLintas
(Faisal yunus dkk)
Jakarta Pusat abnormal 19,8% (Obstruksi 8,2%- Restriksi 11,6%) 2012
Jakarta Selatan abnormal 5% (Obstruksi2,8%- Restriksi 2,2%)
Jakarta Timur abnormal 15,3% (Obstruksi 5,3%-Restriksi 10%)
PenyapuJalan Pekanbaru(Dewi) PEFR abnormal 52,9% 2013
Semarang(Meita) abnormal 90%; Mixed6,7% 2015
Surabaya (Bagus) 6/10 atau60% restriksi ringan 2016
Penjual koran
pinggir jalan
Pekanbaru
(Handayani)
PEFR abnormal 52% 2011
Petugas pintu tol
Jagorawi
Tol Jakarta-Bogor
(Ria Anindita)
Abnormal 5,8% (VEP1/KVP) 2009

PenurunanFungsiParuPetugas StasiunPengisianBahanBakarUmum
(SPBU),Jakarta(2018)
56,7
1
42,3
Fungsi Paru (Spirometri)
Normal Obstruksi Restriksi
43,3%
Abnormal
Putri Suci R, Faisal Yunus, Agus Dwi Susanto. Faal Paru Dan Keluhan
Respirasi Petugas Stasiun Pengisian BahanBakar Umum (SPBU) Di Jakarta
Pusat Dan Jakarta Utara Serta Faktor-Faktor yang Mempengaruhi .
Dept Pulmonologi FKUI-RSPersahabatan.2018

IndonesiaResearch :
Decrease of lung function among people at pekanbaru RIAU
Indonesia due to forest fire haze 2015
Definition :
Obstruction : FEV1/FVC ratio <75%
Restriction : FVC < 80%
Jamal Zaini, Agus Dwi Susanto, Erlang Samoedro, Vonni
Christiana Bionika, Budhi Antariksa. Health consequences of
thick forest fire smoke to healthy residents in Riau, Indonesia: a
cross-sectional study.Med J Indones.2020;29:58–63

Air Pollution & COPD
• Acute exposure og PM2,5 induced
inflammatory cells infiltration and
hyperemia in the lung tissue 
stimulation of inflammatory factors 
vicious cycle that damages lung
endothelial cells and further
aggravates lung injury
• PM has the ability to generate oxygen
free radicals  stimulate cells to
ptoduce large number of ROS 
damage lung cells
• ROS production induced by oxidative
stress can lead to DNA damage and
change in gene expression
Duan RR, Hao K,Yang T.Air pollution and chronic obstructive pulmonary disease. ChronicDis Transl Med [Internet]. 2020;6(4):260–9.Available from: https://doi.org/10.1016/j.cdtm.2020.05.004

Susanto AD. Air pollution and human health. Med J. 2020;29(1):8–10.
Air Pollution and COPD
• A study in US observed positive association of COPD with PM2,5,
indicating a 7% increase in COPD exacerbation cases associated
to 3,4 ug/ m3 increase of pm2,5 concentration
• Another study by Bao et al, shows that a 10 ug/ m3 increase of
PM2.5 concentration was associated with 1,190% increase in
hospital admission outpatient for COPD in Lanzhou, China
• PM2.5 exposure has non-negligiblehealth effect on COPD,
implying that air pollution cause adverse consequences at much
lower levels than common cognition.

Tahery N, Zarea K, Cheraghi M, Hatamzadeh N, FarhadiM, Dobaradarn S, Mohammadi MJ. Chronic Obstructive Pulmonary Disease (COPD) andAir Pollution: A Review. Junidshapur J Chronic Dis Care. 2021;10(1):e110273.
• Chronic
inflammation due
to the effects of air
pollutants
exposure on
respiratory
systems  COPD
• Also including the
binding of
pathogenic
antibodies to pro-
inflammatory cell
receptors

COPD & Air pollution
• In pathological level,
exposure to smoke 
infiltration by inflammatory
cell to mucosa, submucosa,
and glandular tissue 
mucus content increases,
ephitel- cell hyperplasia, &
disturbed tissue repair
• Progressive & obliteration of
terminal bronchioles is
accompanied by
emphysema.
Normal airway Airway in COPD
Decramer M, Janssens W, Miravitlles M. Chronic obstructive pulmonary disease. Lancet [Internet]. 2012;379(9823):1341–51.Available from: http://dx.doi.org/10.1016/S0140-6736(11)60968-9

COPD & Air pollution
Normal airway Airway in COPD
Decramer M, Janssens W, Miravitlles M. Chronic obstructive pulmonary disease. Lancet [Internet]. 2012;379(9823):1341–51.Available from: http://dx.doi.org/10.1016/S0140-6736(11)60968-9
• Thickening of airway and
destruction of lungs involves
multifactorial pathological
processes that areinteracting
on a complex background of
genetic determinants, lung
growth, & environmental
stimuli

COPD Prevalence among non-smokers
• Viet et.al researchin Vietnam and Indonesia (2015)
found COPDprevalenceamong non-smokers in urban
and rural 6.9% (Indonesia 6.3%)
• Risk factors of COPD :
1. Air pollution exposure(indoors dan outdoors)
2. Dust exposure in work place
3. Recurrent respiratory infection
4. History of TB
5. Chronic Asthma
6. Social-economy aspect
Respirology2015;20(4):602-11

Air Pollution & COPD
Study in RSUP
Persahabatan, 2019:
• There is a significant
relationship between
poor air quality and
COPD exacerbations
Andari F, Susanto AD, Wiyono WH. Hubungan Polutan Udara Jakarta Timur dengan Angka Kunjungan Eksaserbasi Asma di IGD Rumah Sakit Rujukan Respirasi Nasional (RSRRN) Persahabatan Tahun 2019. Dep Pulmonologi danKedokt Respirasi FKUI-RSUP Persahabatan

Indoor Air Pollution & COPD
SystematicReview & Meta-analysis by Shetty et al. (2021):
• Long term exposure to indoor pollution had a significant effect on COPD
deaths (OR 2,13) as well as its symptoms (OR 2,08).
• Primary cause of COPD in women is indoor air pollution exposure, while
tobacco smoking is the leading cause in men
Shetty BSP, D’Souza G, Anand MP. Effect of Indoor Air Pollution on Chronic Obstructive Pulmonary Disease (COPD) Deaths in Sou thern Asia – A Systematic Review and Meta-Analysis. Toxics. 2021;9(4):85.

Indoor Air Pollution & COPD
Hansel NN, et al. (2022):
• Among 183 COPD patients, 77% were exposed to at least 1 indoor allergen
(dust mite, cockroach, cat, dog, mouse, etc.)
• Exposure & sensitization were associated with 8,3% lower lung fuction
worse respiratory questionnaire scores, and 2,3-fold excess risk for
exacerbations
• In a study of 116 COPD patients, group with 6 months’ use of inhome air
cleaners with both high-efficiency particulate absolute (HEPA) & carbon
filters used less rescue medication; had lower symptom scores; and 68%
fewer moderate exacerbations
Hansel NN et al. Randomized clinical trial of air cleaners to improve indoor air quality and chronic obstructive pulmonary disease health: Results of the CLEAN AIR study. Am J Respir Crit Care Med 2022 Feb 15; 205:421.

Pollution
AIR POLLUTION AND ASTHMA
Huang SK, Zhang Q, Qiu Z, Chung KF. Mechanistic Impact of OutdoorAir
Pollution on Asthma and Allergic Disease. J Thorac Dis. 2015;(1):22-33.
Pollutant,especiallydiesel
(DEP)/PM10 increased
allergic inflammation
 ASTHMA

Air Pollution & Asthma
• Air pollution exposures
represent significant risk
factors for asthma
development in children
• Exposure to air pollutants can
induce asthma symptoms,
exacerbations, decreases in
lung function, respiratory
symptoms and healthcare
utilization
Tiotiu AI, Novakova P, Nedeva D, Chong-Neto HJ, Novakova S, Steiropoulos P, et al. Int J Environ Res Public Health. 2020;17:6212.

Air Pollution &
Asthma
• Several
types of
outdoor &
indoor air
pollution
have
various
negative
impacts on
asthma
Tiotiu AI, Novakova P, Nedeva D, Chong-Neto HJ, Novakova S, Steiropoulos P, et al. Int J Environ Res Public Health. 2020;17:6212.

Air Pollution & Asthma
Study in RSUP
Persahabatan,
2019:
• There is a
significant
relationship
between poor air
quality and
asthma
exacerbations
Habibi J, Susanto AD, Ratnawati. Hubungan Kadar Polutan Udara Jakarta Timur dengan Angka Eksaserbasi PPOK di IGD RSRRN Persah abatan Tahun 2019. DepPulmonologi dan Kedokt Respirasi FKUI-RSUP Persahabatan

ASTHMAprevalenceat JAKARTA (youngpeople)
Pedesaan = I Gede Pande Sastrawan, Ketut Suryana, I B Ngurah Rai . Prevalensi AsmaBronkial
Atopi pada Pelajar di Desa Tenganan Bali. J Peny Dalam 2008;9:47-53
Jakarta (2008)= YunusF, dkk. Asthma prevalence among 13-14 yearsold student using ISAAC
questionnaire in Jakarta. J Respir Indo 2011; 31:176-80.
7
11,5
12,2
0
2
4
6
8
10
12
14
Pedesaan Jakarta (2001) Jakarta (2008)
Prevalensi asma Remaja
Prevalensi
Asma pada
Remaja di
Jakartalebih
tinggi dari
pedesaan.
Salah satu
Faktor 
POLUSI UDARA
7 %
12,2%

ASTHMAat streetsweaper ( Jakarta)
Country Prevalence
India 1,8%
Denmark 2,3%
Jakarta- Indonesia3 3,1%
3 Mirza PURWITASARI, Agus dwi SUSANTO, Budhi ANTARIKSA. Prevalens Asma Pada Penyapu Jalan
Raya di Jakarta.DepartemenPulmonologi FKUI-RSPersahabatan.2016

|Kesimpulan Penelitian
Rerata usia pasien asma eksaserbasi di IGD RSRRN tahun
2019 adalah 49 tahun, rerata IMT adalah 24,3 kg/m3 , mayoritas
perempuan (72,2%)
Jumlah eksaserbasi asma terbanyak tahun 2019 adalah pada
bulan Juli
Nilai ISPU tertinggi setiap polutan berbeda-beda waktunya
Terdapat hubungan yang bermakna antara nilai ISPU PM10
dengan angka kunjungan eksaserbasi asma di IGD RSRRN
Persahabatan
Penelitian ini hanya mencari hubungan antara 2 variabel, tidak
menunjukkan hubungan sebab akibat.
6
3

Kadar PM10
Angka eksaserbasi asma r =0,501
p =0,045
Korelasi PM10 dan eksaserbasi asma (n=12 bulan)
Nilai Interpretasi
0,0 - <0,2 Sangat lemah
0,2 - <0,4 Lemah
0,4 - <0,6 Sedang
0,6 - <0,8 Kuat
0,8 - 1,0 Sangat kuat
6
4

Indoor Air Pollution & Asthma
• Active wheezing
was associated
with high NO2
exposure
• Reduced lung
function was
associated with
high PM2.5 and O3
exposure
Branco PTBS, Alvim-Ferraz MCM, Martins FG, Ferraz C, Vaz LG, Sousa SIV. Impact of indoor air pollution in nursery and primary schools on childhood asthma. Sci Tot Environ. 2020;745:140982.
Study by Branco et al., (2020) in indoor school environment in
Portuguese

Air Pollution and Lung Cancer
• Main risk factor of lung cancer is
active smoking. But, exposure to
environmental occupational
carcinogens is also recognized as risk
factors.
• Meta-analysis from Hamra, et all
shows that: meta relative risk was
1.09 for lung cancer relared to PM 2,5
and PM 10 respectively.
• For each 10 ug/m3 increased in
ambient PM2,5, incidence of lung
cancer increased.
• Tudorache E, Oancea C. Air pollution
exposure — the ( in ) visible risk
factor for respiratory diseases.
2021;19615–28.
TudoracheE, OanceaC. Air pollutionexposure— the ( in ) visible riskfactor for respiratorydiseases. 2021;19615–28.

Shahadin MS, Mutalib NS Ab, Latif MT, Catherine Greene M, Tidi H.Challenges and FutureDirection of Molecular Research in Air Pollution-Related Lung Cancers. Lung Cancer. 2018;5002(18):30230-7.
Upregulated or
downregulated
DNA function
due to air
pollution 
Lung Cancer

• Exposing human bronchial epithelial
(HBE) cells to ambient PM2,5  down
regulation of microRNAs (misR- 182 and
miR- 185)
• PM 2,5 induced DNA (cytisine-5-)-
methyltransferase 3B (DNMTEB)
metylation resulted in p53 (tumor gene)
inactivation.
• Pm 2,5 induced macrophage autophagy &
mediate Src/STAT-3 signaling pathway 
increase the expression of VEGF-A, an
important pro-angiogenic factor.
• PM 2,5 induces inflammatory cell
infiltration resulted in apoptosis of
alveolar epithelial cells.
Li R, Zhou R, Zhang J. Function of PM2.5 in the pathogenesis of lung cancer and chronic airway inflammatory diseases. Oncol Lett.2018;15(5):7506–14.

Indonesian research
Lung cancer and air pollutionin Jakarta
• Research September 2012- Nov 2013 on 300 lung cancer patients at Persahabatan Hospital,
Jakarta
Sita Andarini, Nugroho Prayogo, Agus Dwi Susanto dkk.
Study and guideline on prevention, diagnosis and surveilance of occupational and
environmental cancers in Indonesia. 2013
4% from all
cases of lung
cancer
patients
correlated
with air
pollution

Indoor Air Pollution & Lung Cancer
Study by Chen KC, et al (2022):
• The risk of lung adenocarcinoma increased with habitual cooking at
home (OR: 2,22; 95% CI 0,77-6,44) and indoor incense burning (OR:
3,05; 95% CI 1,06-8,84)
• The risks are increased in female: habitual cooking at home (OR:
5,39; 95% CI 1,11–26,20); indoor incense burning (OR: 6,01; 95% CI
1,14-31,66)
• In pleural fluid, the most important exposure biomarkers for lung
cancer were naphthalene, ethylbenzene, and o-xylene
Chen KC, Tsai SW, Shie RH, Zeng C, Yang HY. Indoor Air Pollution Increases the Risk of Lung Cancer. Int J Environ Res Public Health. 2022;19(3):1164.

Conclusion
• Air pollution is one of main environmental problem in the world
and causes many illnesses and deaths from respiratory diseases
• Air pollution can causes chronic irritation of respiratory tract,
mucosal inflammation,induce oxidative stress, and trigger allergic
reaction that can lead to various lung diseases such COPD, asthma,
and lung cancer
• Base on several study, air Pollution had implication on lung health
in Indonesian population

Prof Agus - Outdoor dan Indoor Pollution dan Kesehatan Paru.pdf

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