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Mr Sourav Ganguly
President, Board of Cricket Control of India
Dear Sourav Ji
Delhi is hosting the first T20 international cricket match between India and Bangladesh scheduled to be played at Arun Jaitley Stadium on 3rd November, 2019.
However, the air quality in the national capital has deteriorated, especially after Diwali. Delhi has been enveloped in a thick layer of smog leading to a fall in air quality and visibility. Since the last few days, the Air Quality Index (AQI) in most parts of Delhi continues to be in the severe to very poor category with pollution levels being several times higher than the permissible limits. The AQI has crossed the 400 mark in several places in Delhi.
An AQI reading of 50 or less is generally considered as good. AQI level from 51-100 is considered satisfactory, 101-200 is moderate, 201-300 is poor 301-400 is very poor, 401 and above is considered severe.
The World Health Organization (WHO) recommends a upper limit of10 μg/ cu mm (annual mean) and 25 μg/ cu mm (24-hour mean) for fine particulate matter (PM2.5) and 20 μg/cu mm (annual mean) and 50 μg/ cu mm (24-hour mean) for coarse particulate matter (PM10) in the atmosphere.
For India, the permissible levels for PM2.5 are less than 60 and for PM10 less than 100.
The dangerously high air pollution levels are a cause of concern for us as the air pollution is a well-recognized health hazard. There is sufficient evidence in medical literature documenting the adverse effects of air pollution on the human body.
Exposure to high levels of air pollution increases the risk of lung and heart disease and may precipitate an acute potentially life-threatening event. It can exacerbate asthma or other existing lung disease such as chronic obstructive pulmonary disease (COPD). Breathing polluted air can increase blood pressure; it can also precipitate an acute cardiovascular event such as heart attack or stroke in patients with known heart disease or those who are at risk of heart disease. Patients of heart disease are also at a risk of sudden cardiac death.
AQI in the severe category not only affects those with underlying heart or lung disease, but also those who are healthy, who may experience cough or some breathlessness on exertion.
Air pollution also reduces performance of athletes and endangers their health as they are especially at a greater risk of inhaling toxic air pollutants.
Some physiological changes that occur during exercise may aggravate the harmful effects of air pollution on health. Breathing becomes faster and deeper during exercise or running. The increased respiratory minute ventilation means people inhale more of toxic pollutants. Changeover to mouth breathing from nasal breathing means the nasal filtration mechanism is bypassed. Exercise practice in polluted outdoor environment, over a period of 5 days, impairs nasal mucociliary clearance in young healthy amateur runners. (J Breath Res. 2016 Dec 21;10(4):046018). As a result of the reduced nasal mucociliary clearance, more air pollutants are absorbed instead of being cleared by the respiratory system (Br J Sports Med. 2001 Aug;35(4):214-22). Because of the increase in airflow velocity, pollutants travel much deeper into the airways, which further adds to the amount of pollutants inhaled.
Air pollution also has a significant negative effect on performance of the athletes. PM10 has a significant correlation with reduced performance in marathon runners. Under normal breathing conditions, PM10 is filtered through the nose. But, because of mouth breathing during exercise, PM10 is not removed and is instead inhaled in large amounts (Med Sci Sports Exerc. 2010 Mar;42(3):585-91).
- If the air quality index (AQI) is between 151 and 200, it is recommended that outdoor exercises should be reduced.
- If the AQI is between 201 and 300, all outdoor activities and sports should be reduced.
- If the AQI is more than 300, all outdoor exercise and activities should be avoided as much as possible.
- If the AQI crosses 400, indoor activities too should be reduced and no exercise even at home is recommended.
In 2017, I had written to the then President, Board of Cricket Control of India (BCCI) and the then President, International Cricket Council (ICC) expressing concern about the cricket match between India and Sri Lanka played in Delhi under conditions of extremely high levels of air pollution. A copy of the letter is enclosed.
It has been two years since then, yet there is no clear policy directive from the Health Ministry as well as the Sports Ministry to also include air quality as a part of weather forecast, when determining suitable playing conditions - for cricket or any other outdoor sport - just as rain and bad light determine the conditions of play.
Now that another international cricket match will be played on Sunday, 3rd November, under similarly dangerously high levels of air pollution, will the Health Ministry intervene in time?
I appeal to you to give a serious thought to the prevailing hazardous air quality in Delhi, before going ahead with the match, so that no player or volunteer or spectator suffers an ill-effect due to exposure to dangerous levels of air pollution
I also request you to consider including air pollution levels in the weather forecast for cricket matches.
Dr KK Aggarwal
President, Confederation of Medical Associations of Asia and Oceania (CMAAO) and Heart Care Foundation of India (HCFI)
Past President, Indian Medical Association (IMA)
Enclosed: Copy of the letter to the President BCCI
Straight from the heart 30: IMA writes to BCCI
Mr CK Khanna
Mr Vinod Rai
Head, Committee of Administrators
Board of Cricket Control of India
Date: 6th December 2017
The Indian Medical Association (IMA) is greatly troubled about the recent cricket match between India and Sri Lanka in Delhi played under conditions of high levels of air pollution.
Air quality in the Delhi-NCR region has been ranging between ‘very poor’ and ‘severe’ since last several days. This has been a cause of great concern to us. Exposure to air pollution increases the risk of lung and heart disease and may precipitate an acute potentially life-threatening event. But, when pollution levels are this high, everyone, including healthy persons may experience some level of discomfort.
Air pollution also reduces performance of the athletes. In a situation where milliseconds and millimetres often determine success of athletes, air pollution can be an important factor in affecting their performance.
Rain and poor light are taken into consideration when determining suitable playing conditions, we suggest that atmospheric pollution should now also be included in the assessing criteria for a match.
The safe levels of atmospheric particulate matter (PM), according to the World Health Organization (WHO) air quality guidelines, are 20 μg/cu mm (annual mean) for PM10 and 10 μg/ cu mm (annual mean) for PM2.5.
If the air quality index (AQI) is between 151 and 200, it is recommended that outdoor exercises should be reduced. If the AQI is between 201 and 300, all outdoor activities and sports should be reduced. If the AQI is more than 300, all outdoor exercise and activities should be avoided as much as possible. If the AQI crosses 400, indoor activities too should be reduced and no exercise even at home is recommended.
The message from the India and Sri Lanka cricket match that has gone home is that it is safe for children to play cricket even when the PM 2.5 levels are more than 300.
There is sufficient evidence in medical literature documenting the adverse effects of air pollution on the human body.
Following are the evidence
· A meta-analysis of seven trials has revealed that a one-unit (μg/m3) increase in ambient PM2.5 concentration in adults is associated with an increase in the odds of physical inactivity by 1.1% (odds ratio = 1.011; 95% confidence interval = 1.001, 1.021; p-value < .001). (Perspect Public Health. 2017 Aug 1:1757913917726567)
· Poor air quality can adversely affect athletes with asthma or other pulmonary disorders. As the AQI rises above 100 to 150, athletes and volunteers can be adversely affected. If the AQI is above 100, it is prudent for race administrators to warn participants and volunteers, particularly those with lung conditions, about the potential risk. (J Am Coll Cardiol. 2005;46(7):1373-4)
· PM10 is associated with decrements in performance of women. For every 10-microg x m (-3) increase in PM10, performance can be expected to decrease by 1.4% (Med Sci Sports Exerc. 2010 Mar;42(3):585-91).
Short-term exposure to air pollutants (both ozone and fine particulate matter) is associated with acute coronary ischemic events
In addition to long-term risk, short-term exposure to air pollutants (both ozone and fine particulate matter) is associated with acute heart attacks (Circulation. 2006; 114:2443; Circulation. 2005;111:563; Eur Heart J. 2013; 34:1306).
· In a study of over 12,000 patients living in a defined geographic area, a short-term increase in fine ambient particulate matter positively correlated with an increase in acute ischemic coronary events (Circulation. 2006;114:2443).
· In a systematic review and meta-analysis of data from 34 studies, carbon monoxide, nitrogen dioxide, sulfur dioxide, and small particulate matter (less than 10 microns and less than 2.5 microns) were all associated with an increased risk of myocardial infarction (MI), with the overall population attributable risk ranging from 1-5% (JAMA. 2012;307:713).
· In a study of 772 patients with an acute myocardial infarction (MI), the risk of an MI was increased in the two hours after exposure to elevated levels of fine particles in the air (odds ratio 1.48 compared to low levels of fine particles); this effect lasted for up to 24 hours after exposure (Circulation. 2001;103:2810).
The possible mechanism by which fine particulate air pollution may increase the risk of cardiovascular disease include
· An increase in mean resting arterial blood pressure through an increase in sympathetic tone and/or the modulation of basal systemic vascular tone (Circulation. 2002;105:1534).
· An increase in the likelihood of intravascular thrombosis through transient increases in plasma viscosity and impaired endothelial dysfunction (Circulation. 2002;106:933).
· The initiation and promotion of atherosclerosis (Circulation. 2010;121:2755; J Am Coll Cardiol. 2010;56:1803).
· There is 0.13% reduction in peak expiratory flow rate (PEFR) per 10 µg/m3 of PM 2.5.
· Asthma is linked to high NO2 (nitrogen dioxide) levels and bronchitis is linked to high levels of SO2 (sulphur dioxide).
· Compared to during rest, the air pollution dosage is much higher during exercise because of a higher ventilatory rate and both nasal and oral breathing. SO2, a highly water-soluble gas, is almost entirely absorbed in the upper respiratory tract during nasal breathing. However, with oral pharyngeal breathing, the amount of SO2 that is absorbed is significantly less, and with exercise and oral pharyngeal breathing a significant decrease in upper airway absorption occurs, resulting in a significantly larger dosage of this pollutant being delivered to the tracheobronchial tree.
· Combination of exercise and pollutant exposure (SO2 or ozone [O3]) leads to marked bronchoconstriction and reduced ventilatory flow when compared to pollution exposure at rest.
· Each 10 mcg/m3 increase in PM 2.5 levels can increase the chances of death from heart disease by 1.76 times and each decrease in PM 2.5 levels by 10 mcg/m3 life can increase life expectancy by 0.77 year.
· A PM <2.5 reduction of 6.8 mcg/m3 can decrease asthma prevalence by 15.4% and a median reduction in NO2 of 4.9 parts per billion can decrease asthma prevalence by 10%.
· The Womens Health Initiative Observational study database of more than 65,000 postmenopausal women without prior CVD was used to evaluate the relation between a womans long-term exposure to air pollutants and the risk for a first cardiovascular event . Unlike prior studies, potential confounding factors such as age, body mass index (BMI), and traditional cardiovascular risk factors were taken into account. The principle findings were that for each 10 mcg/m3 increase in pollution concentration, there were significant increases in the risk of any cardiovascular event (hazard ratio [HR] 1.24), death from CVD (HR 1.76), and cerebrovascular events (HR 1.35) (N Engl J Med. 2007;356:447).
· For every increase of 10 μg/m3 in PM10, the lung cancer rate rises by 22% and for PM 2.5 by 36%
· By reducing particulate (PM10) pollution from 70 to 20 μg/m, air pollution-related deaths could be reduced by roughly 15%.
· Mortality in Utah Valley decreased by 3% when average particulate air pollution (PM10) concentrations decreased by 15 µg/m3 as the result of a 13-month strike at a local steel mill (Arch Environ Health. 1992;42:211-7).
Air pollution and the heart
· Air pollution, and specifically fine particulate matter, is associated with increased cardiovascular mortality.
· Air pollution has emerged as a potentially modifiable risk factor for the development of cardiovascular disease.
· The association of air pollution with episodes of atrial fibrillation (AF) was evaluated in a study of 176 patients with dual chamber implantable cardioverter-defibrillators (ICDs) that were capable of detecting episodes of AF. After follow-up of nearly two years, there were 328 episodes of AF lasting 30 seconds or more found in 49 patients. The potential impact of multiple parameters of air pollution, (measured hourly) on the development of AF was examined. The odds of AF increased significantly as the concentration of particulate matter increased in the two hours prior to the event (J Am Coll Cardiol. 2013;62:816).
· Multiple observational studies have demonstrated an association between fine particulate air pollution (primarily from the use of fossil fuels in automobiles, power plants, and for heating purposes) and cardiovascular and cardiopulmonary mortality as well as an increased risk for the development of acute coronary syndromes
· Mortality data from nearly 450,000 patients in the American Cancer Society Cancer Prevention Study II data base were correlated to air pollution data, including average concentrations of ozone and fine particulate matter (≤2.5 micrometers in diameter [PM2.5]). In multivariate analysis PM2.5, but not ozone, concentration was significantly associated with the risk of death from cardiovascular causes (relative risk 1.2) (N Engl J Med. 2009;360:1085).
· Further support for the significance of air pollution comes from a study of death rates in Dublin, Ireland before and after a ban on coal sales that led to a 70 percent reduction in black smoke concentrations (Lancet. 2002; 360:1210). Adjusted cardiovascular deaths fell by 10.3 percent in the six years after the ban.
· Both the American Heart Association (2010) and the European Society of Cardiology (2015) have issued official statements discussing the association between long-term exposure to fine particulate air pollution and increased risk of developing cardiovascular disease (Circulation. 2010;121:2331; Eur Heart J. 2015;36:83).
· Multiple observational studies have demonstrated an association between fine particulate air pollution and distance from a major urban road or freeway and cardiovascular and cardiopulmonary mortality. However, there is conflicting evidence concerning whether air pollution is (J Thromb Haemost. 2010;8:669) or is not (J Thromb Haemost. 2011;9:672), causally related to development of venous thromboembolism (VTE).
· In a multivariate analysis PM2.5 was significantly associated with the risk of death from cardiovascular causes (relative risk 1.2) (N Engl J Med. 2009;360:1085).
· In the prospective MESA Air cohort study involving 6795 participants in six US metropolitan areas, each increase in PM2.5 of 5 mcg/m3was associated with 4.8 Agatston units per year progression of coronary calcification (Lancet. 2016; 388:696).
· American Heart Association (AHA), European Society of Cardiology (ESC), Indian Medical Association (IMA) and Heart Care Foundation of India (HCFI) have issued official statements discussing the association between long-term exposure to fine particulate air pollution and increased risk of developing cardiovascular disease
Dr KK Aggarwal
Indian Medical Association and Heart Care Foundation of India
Vice President CMAAO
Dr RN Tandon
Honorary Secretary General IMA
Mr Dipak Misra
Chief Justice, Supreme Court of India
Mr Zaheer Abbas
President, International Cricket Council
Dr KK Aggarwal
Padma Shri Awardee
President Confederation of Medical Associations in Asia and Oceania (CMAAO)
Group Editor-in-Chief IJCP Publications
President Heart Care Foundation of India
Past National President IMA