"A study from Italy showed the correlation between COVID19 and infections and air pollution maps, and another study from Harvard highlighted there is a correlation between COVID19 mortalities and increasing level of air pollution," said Dr Arvind Kumar in a discussion with DataBaaz.
Dr Arvind Kumar, founder & managing trustee of Lung Care Foundation. He is also the chairman of Centre for Chest Surgery and director of Institute of Robotic Surgery at Shree Ganga Ram Hospital, New Delhi. Dr Kumar also discussed the recent spike in COVID cases in Delhi.
According to a report by the IMA, Delhi's sharp spike in COVID19 cases in the first week of November might be linked to increased air pollution. Dr Rajan Sharma, president of IMA told NDTV, "Patients who are sensitive to respiratory diseases may find it difficult to breathe if air quality levels (AQI) is between 50 and 100. An AQI of 300 makes it difficult even those who are otherwise healthy."
As of November 11, Delhi reported 7,830 new COVID-19 cases, bringing up the total case tally to 4,51,382. ICMR reported that Delhi is witnessing a third spike in coronavirus cases.
This according to Dr Arvind, is a result of the high levels of air pollution.
Here are the edited excerpts of the interview
You've spotted this trend many, many months ago. And you in our earlier conversation you correlated the higher deaths in parts of Italy with pollution. So tell us what it was like then, and what we are seeing today in Delhi and maybe potentially in other parts of the country where pollution levels are rising? And what is common between these two aspects?
What I had mentioned a couple of months back to you is actually the same as what is happening in the city of Delhi. At that time, I had quoted a study which had come from Italy, which had looked at the incidence of COVID cases across Italy, from North Italy to South Italy, and correlated it with the PM 2.5 levels of air pollution across Italy. And they found that when they plotted a heat map of COVID cases, and PM 2.5, they found the two maps to be a replica of each other, which means areas with higher concentrations of PM 2.5 reported a much higher per lakh population incidence of COVID cases. Now, this was one of the first reports which directly linked the increased incidence of COVID cases to air pollution. A couple of months later came another report from Harvard, which looked at the mortality rates. Now, this Italy report was about the incidence, Harvard analysed the mortality correlating to PM 2.5 to COVID mortality. And they reported that if there is a one microgram rise in chronic PM 2.5 exposure, they noted an 8% increase in mortality, and this was pooled data from over 300 counties across the US. Now, from these two studies have very clear, convincing evidence says that COVID is increasing in incidence and causing more mortality in communities which are affected by pollution. And now, what we are seeing in Delhi for the last two weeks has actually proved and confirmed that. Till few weeks back we were having a decline in the number of cases across the country and also in Delhi, but as soon as there was a spike in pollution cases in Delhi, that decline converted into a steep incline, and today we have amongst the highest cases per day being reported ever in city of Delhi, this is directly an effect of air pollution.
We know why pollution rises, but why do COVID cases specifically rise assuming all other factors are constant at a time like this?
So, there are many theories which are available. One says that this virus particle actually piggybacks on the PM 2.5, it gets absorbed on the surface of the Pm 2.5. And when a person inhales these large number of particles absorbed on this surface, this virus particle also goes deep down into the chest, thereby increasing the total dose delivered there and total duration for which the virus stayed there. That's number one. But that's not the only cause.
We know that pollution badly affects the lungs, it causes inflammation of the lining of the windpipe, as well as the lungs, which reduces their immunity and increases their vulnerability to the infections. So when you have an inflamed and injured lung, and you have a certain dose of virus entering into the lungs, that injured and inflamed lung will be more prone to get infected, as compared to a healthy lung. So this is what explains the higher incidence plus these people may otherwise also have low immunity because of various other toxins in air pollution.
So overall, you have low body immunity, you have lower lung immunity, and then on top of that, if you have the same dose of virus, I think it proves to be the crucial dose which converts into a clinical infection. So this was about the high incidence. Now why do we have higher mortality, it has been proved that people who have a higher incidence of heart disease, hypertension, lung problems, low immunity, and all other problems, they have higher mortality when they get COVID. This is a link which has been established across the world, in every country.
And these are the diseases which are caused by pollution. So when you have a pollution affected community, they would have lungs affected, they would have a higher incidence of hypertension, heart disease, brain attack, all these problems with increase the mortality rate of COVID is present in pollution afflicted communities. So people are more prone to getting the disease and more prone to death, if they get the disease. And this is the direct effect of pollution.
Does this also mean that people are not taking sufficient care? So for instance, let's say people were to continue to wear good quality masks or like N95 masks, which were originally meant for pollution, we started using it for COVID. Now I'm assuming it works against both, but is that not a sufficient guard or barrier?
So there are two aspects, one is the prevention of the COVID. So for COVID, we know that as of today, there are three golden principles. One is wearing the mask, social distancing, and third is hand hygiene. So if we say goodbye to any of these three, we are increasing our dose exposure, and therefore more chances of getting COVID. That's one aspect which is directly related to COVID. But then, on top of that, if I'm also affected by the effects of pollution, and I am also lenient in the precautions for COVID, then my chances of getting COVID are increased that many times. So, therefore, wearing a mask will prevent us from getting corona because of COVID norms, and we'll also have protection against pollution. Therefore, it becomes mandatory for all of us to wear masks, practice social distancing, and follow the rules of hand hygiene and along with that, also do everything possible to reduce the level of air pollution.
What do these levels of air pollution which have an AQI of 400, which is moderate to severe, do to the body, and what are the other problems that it causes typically before the weakness caused by COVID?
So when you have such inhuman levels of air pollution, and you know we breathe 25,000 times a day, we inhale nearly 10,000 litres of air in 24 hours. Children breathe much faster than that and the per body surface area inhalation is much more air than adults do. When you have these huge amounts of toxins, whether it is the particulate matter or it is the toxic gases going inside the body, the first thing that they damage is our nose, our respiratory tract, and our lungs.
But the story doesn't end there. Most of these chemicals whether this is PM 2.5, they cross the lung lining, enter the blood and through the blood, they go into every organ which gets blood, which ranges from brain to your bones, every part of the body, and they cause damage. Now, the worst affected are pregnant women. And now it has been proved that this damage actually starts from the intrauterine life. So all the pregnant ladies who are inhaling this toxic air, there is some amount of damage which is occurring to the baby who's being nurtured in their uterus. So this damage starts there.
When the baby comes out and takes his or her first breath if you have PM 2.5, which is close to 500-600AQI. Now that's divided by 22, that's equal to about 30 cigarettes of smoke in terms of damage, so, your newborn becomes a smoker from the first breath of his life, imagine the amount of damage that will occur to his lungs and other parts of his body. And similarly, this continues through childhood and adulthood. But even in older people, immunity is reduced. So the worst affected are the extremes of age, and pregnant women, and children, but nobody escapes the elephant. The only way you can escape the elephant is if you stop breathing.
So what does one do, are there solutions to this problem, I mean, which is the twin problems of COVID-19 as well as high AQI?
So for the time being, you know, what are the immediate measures? the immediate measures is the must continue to practice the three golden principles for COVID prevention, which is -- never go out of your house without a mask. Always practice social distancing.
And I give a very simple rule that please presume everybody to be COVID positive, everybody is COVID positive, keep one and a half to two metres distance from everybody and insist on everyone around you wearing a mask if the other people wear masks, especially if its N95 and you are also getting a good quality mask, then the chances of transmission and you maintain 1.5-2 metres distance. Even if one of them is positive, the chances of transmission are drastically reduced.
Presume every surface, every article you touch to be positive and practise hand hygiene. So these are the three golden principles for covid precaution, which need to be continued to be practised during pollution also, that's part one.
Now part two is coming to spot the pollution, well, whatever is the preventable part of air pollution. So whatever little contribution is coming from our streets, from our garbage burning, from other sources, which we all citizens can control by our little actions, we must do so immediately. The N95 mask or any other mask that we are wearing, will give whatever little protection it can for pollution, but mind you, the gases cannot be stopped by any mask. So they will anyway go in. So we need to work on reducing air pollution, we cannot presume that an air purifier or a mask will give us that all the protection.
We are recommending air purifiers for lung patients, for little children, for people who are having any comorbidities, for post-COVID patients or post-COVID patients are facing a very serious problem because they continue to have lung involvement for quite some time even after they're discharged from the hospital. On top of that, if they breathe in polluted air, the problems get worse.
So we advise these patients that please have plants in your room, please get an air purifier so that the impact is to some extent reduced. But side by side, I think we all should start reducing pollution by 20-30%; by things like taking out of cars, and what I call my solution to pollution. If each person starts thinking that I have to reduce smoke, and I have to reduce dust. If each one of us starts doing our own little contribution to reducing pollution, collectively, I think we would have made substantial improvement in levels of pollution.
In the last four or five months, doctors like yourself, are far more confident of treating COVID-19; and though we don't have a cure, and we do have a vaccine around the corner. What's your sense for how should people who have COVID should go around receiving treatment? Do they need to be in any different way alert from before?
What has crystallised is that the indications for admission today are more streamlined than what we had when we had our last discussion. So there are clear cut divisions between mild and moderate cases which are actually being home managed and oxygen monitoring is also important.
Because at that time, this term happy hypoxia was not that well known that people were waiting for some patient to develop breathlessness as a sign of their lung involvement, which unfortunately was not true because many people had lung involvement without developing breathlessness. And a lot of lives were lost. Today, we understand it better. So we are proactively monitoring the oxygen of people. And everybody is advised that if there is a fall below 95, you must report to a doctor.
And there are clear cut guidelines. There are more oxygen centres available now in the hospitals where they can go and a large number of these patients can only be managed with only oxygen. And a good number of these people are now improving with oxygen therapy, a very small number actually needs a BiPAP or ventilator therapy, which also is available in a more organised manner today than it was when we had our last discussion.
So we are still in November, do you see a long winter for yourself ahead?
A long winter?
Definitely yes.
But what I fear and do not want to see is a massive spike in the number of COVID cases. And my fear is that the festivities which will occur over the next few days, will be coupled with this steep rise in pollution. Now this deadly cocktail, if it has an effect on COVID, and we see a massive spike, it will be disastrous for the people as well as for the healthcare sector. Because the ICUs are almost choked, at least in all Delhi hospitals, which I can comment on. And on top of that, if there is a massive increase in the number of patients, then we have a serious problem at hand. And as a doctor, I would like to see it prevented rather than facing this unfortunate situation.