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 6th International Conference Humanoid, Nanotechnology, Information Technology
Communication and Control, Environment and Management (HNICEM)
The Institute of Electrical and Electronics Engineers Inc. (IEEE) – Philippine Section
12-14 November 2013 Henry Sy Hall, De La Salle University, Manila, Philippines

Association Between Outdoor Air Pollution and

Cardiovascular Mortality in Bangalore
Anitha Chinnaswamy1, Raouf N.G. Naguib1, Lateef Olayanju1, Quynh T. Nguyen1, Rajeev K. Bali1,
Ian M. Marshall1 and Mohyi H. Shaker2
1
Biomedical Computing and Engineering Technologies
Applied Research Group (BIOCORE), Coventry University,
Coventry, UK
2
Ecology & Environment, Inc.
Buffalo, USA

Abstract—Bangalore, India, is witnessing a dramatic increase countries. China and India alone account for 45% of these
in the levels of pollutants as a result of rapid urbanisation and its deaths [3].
consequent economic growth. A wealth of studies from around
the world have shown an association between high levels of In the UK, the British Heart Foundation acknowledges that
outdoor pollutants and cardiovascular health. Given the fact air pollution can aggravate heart conditions and can also be a
that India, and in particular Bangalore, lacks studies in this area, precursor for heart attacks and strokes among the most
the paper intends to address this gap in knowledge. We vulnerable [4]. Similarly, in the US, the American Heart
conducted a cross-sectional descriptive study covering a sample Association also reinstates that exposure to fine particulate
of 34,034 residents of the city to examine the association between matter, either on a long- or short-term basis, can initiate or
outdoor air pollutants (Particulate Matter <10µm in exacerbate cardiovascular deaths, heart attacks, strokes, heart
aerodynamic diameter (PM 10), Sulphur Dioxide (SO2) and Oxides failure and irregular heartbeats, especially in susceptible
of Nitrogen (NOx)) and cardiovascular disease (CVD) mortality individuals [5]. In addition, a large number of studies from
over the years 2010-2012. Simple and Multivariable Logistic developed nations have highlighted the detrimental effects of
Regression models were used to estimate the association between air pollutants on cardiovascular health [6-8].
predictors (age, gender and outdoor pollutants – PM10, SO2 and
NOx levels) and CVD mortality. The analysis highlights In Asia, air pollution is of great concern. The rapid
significant associations between PM 10/NOx levels and CVD urbanisation in some Asian cities has favoured economic
mortality, and provides an important contribution to the growth at the expense of environmental welfare. The world’s
scientific literature addressing issues related to the impact of top 2 most polluted cities are in the Asian continent; Beijing in
outdoor air pollution on health in Bangalore. China and New Delhi in India contend for the 1st place as the
city with the worst air quality [9]. New Delhi has Particulate
Keywords—India; Ambient Air; Pollutants; Particulate Matter; Matter (PM) concentrations up to 10 times higher than the
Cardiovascular Disease WHO standard, with the main causes of high pollution levels
being attributed to dust and transport emissions [10]. One
study [11] found that 2 out of every 5 people suffer from
I. INTRODUCTION respiratory illnesses in the city due to the high levels of
Air pollution is a significant environmental health concern pollution. Whilst New Delhi, the nation’s capital and the
for both the developing and the developed world. The World country’s most populous city, is battling with high levels of
Health Organization (WHO) estimates that urban outdoor air pollution, Bangalore, which is rapidly growing and is the
pollution causes 1.3 million deaths worldwide with most of country’s third most populous city, is following closely with
these deaths occurring in developing countries [1]. With PM levels up to 6 times higher than the standard levels.
developing countries showing increasing interest in economic Over the last decade, Bangalore has been transformed from
growth and diminishing concern for pollution control, levels a quiet retreat to an economically booming city. With the
of hazardous air pollutants in such countries often exceed highest number of IT companies [12], it is emerging as the
WHO guidelines [2]. Particulate Matter (PM) is especially of country’s economic powerhouse. In addition to economic
growing concern due to its hazardous effects on health and growth, the city has witnessed increased social development
85% of the global deaths due to PM occur in developing with a large expansion of occupied urban areas. This has also
 6th International Conference Humanoid, Nanotechnology, Information Technology
Communication and Control, Environment and Management (HNICEM)
The Institute of Electrical and Electronics Engineers Inc. (IEEE) – Philippine Section
12-14 November 2013 Henry Sy Hall, De La Salle University, Manila, Philippines

led to a transition in lifestyles with increased consumption of levels, with recordings up to 3 times the recommended
fatty foods, carbohydrates and western style fast foods. standards, and thus making the air quality critical.
Alcoholism is also of growing concern in the city. India, and
consequently Bangalore, is also facing a rise in the number of
people contracting Diabetes and Hypertension that are all key III. METHODS
contributors to CVDs.
A. Bangalore Data Collection
As mentioned earlier, despite indicative signs of grave
public health issue, research output from Asia has been 1) Air pollution data
limited. Su et al [13] report that there is a noticeable Air quality in the city of Bangalore is monitored through the
knowledge gap in Asia pertaining to ambient outdoor air National Ambient Air Quality Monitoring Programme and
pollution and CVD. They identified that, since 1980, only recorded by the Karnataka State Pollution Control Board
about 400 epidemiological studies were published on the (KSPCB) at 6 fixed locations:
adverse effects of air pollution, which mainly focused on  Graphite India Limited, Whitefield Road
respiratory outcomes. Of these, only about 50 studies  KHB Industrial Area, Yelahanka
evaluated cardiovascular outcomes relating to short-term air  Peenya Industrial area, Regional Office Peenya
exposure with the majority focusing on countries such as  Victoria Hospital, Chamrajpet
Japan, South Korea, China and Hong Kong. Another study
 Amco batteries, Mysore Road
[14] investigated the epidemiological literature until January
2013 relating to long- term exposure to outdoor ambient air  Yeshwanthpur Police Station
pollution and mortality. The majority of studies overviewed
emanated explicitly from the US, UK and Europe. Although In addition there are many mobile locations distributed
the authors emphasised the fact that new studies were across the city [18].
emerging from Asia, these studies were mainly limited to
China and Japan, highlighting an obvious gap in the lack of Air pollutants in the city were measured over the study
studies from India. period by the KSPCB in the above locations using Respirable
Dust Samplers (RDS) by conventional methods. The sites are
representative of the various characteristics of the city, i.e.,
II. BACKGROUND Industrial, Commercial, Residential and Sensitive areas. Four
air pollutants, namely SO2, NOx, Suspended Particulate
A. CVD in India Matter (SPM) and Respirable Suspended Particulate Matter
India has seen an explosion in cardiovascular diseases over (RSPM/PM10), are regularly monitored at all locations.
the last decade. The Registrar General of India (RGI)’s report
stated that the highest cause of mortality for all age groups, The monitoring of pollutants is carried out for 24 hours (4-
areas and genders is CVD [15]. The report also states that hourly sampling for gaseous pollutants and 8-hourly
Non-Communicable Diseases are the leading causes of death sampling for PM) with a frequency of twice a week. The
in India, accounting for 42% of total deaths. It highlights that KSPCB laboratories are fully equipped with experienced
for ages >25, the highest cause of death is CVD, followed by analysts, sophisticated equipment and approved standard test
respiratory diseases. Although CVD is the leading cause of methods to carry out comprehensive analyses of ambient air
death in all regions, the highest proportion of deaths are in the
[18]. In India, the Central Pollution Control Board (CPCB)
Southern region of the country. Similarly in a recent WHO
study, it was estimated that by 2010, 60% of the world’s coordinates the air quality monitoring network and is
cardiac patients would be Indians and that 50% of the Indian responsible for pollution control [19]. CPCB sets the
population dying as a result of CVD would be below the age standard that is followed by the State Pollution Control
of 70 [16]. Moreover, there is scientific evidence that Indians Boards. In order to calculate annual average values (which
tend to acquire the disease at least 10 years earlier than their are used in our analyses), the daily means of >104
western counterparts [17]. measurements (twice a week at uniform intervals) are
considered [19]. The data for the years 2010 - 2012 for the
B. Air Pollution in Banglore SO2, NOx and PM10 pollutants recorded at all 6 fixed
The main sources of pollution in Bangalore are vehicles, stations was obtained from the KSPCB.
unpaved roads and construction activities [12]. Analysis of the
levels of pollutants in Bangalore revealed that while SO2 2) CVD Mortality data
levels were well within the prescribed standards, NOx levels A sample of all-cause mortality data (n=34,034) classified
were higher than those standards. The pollutant of major according to ward, gender, cause of death and age was
concern, however, is PM10 which in most locations in obtained from Bruhat Bangalore Mahanagara Palike (BBMP)
Bangalore city has been consistently above the recommended for the years 2010 - 2012. Of the 34,034 records considered,
mortality numbers were as follows: 14,592 for CVD, 16,277
 6th International Conference Humanoid, Nanotechnology, Information Technology
Communication and Control, Environment and Management (HNICEM)
The Institute of Electrical and Electronics Engineers Inc. (IEEE) – Philippine Section
12-14 November 2013 Henry Sy Hall, De La Salle University, Manila, Philippines

for non-CVD and 3,165 related to unknown causes of death. Multivariable Logistic Regression model to test their
The number of male and female deaths in the sample was relationship with the occurrence of CVD mortality – in other
21,064 and 12,970, respectively. The cause of death was words, to explore their predictive strength. The robustness of
classified according to the WHO’s International Classification the emerging model was assessed with the Omnibus Chi-
of Diseases (ICD-10); Cardiovascular deaths were coded from square statistical test, with p<0.05 indicating good-fit. The
I00-I99, with the following sub-groups: contributions of individual factors to the goodness-of-fit were
further assessed through a Wald test, with the significant
 Acute Rheumatic Fever and Chronic Rheumatic contribution of each individual variable indicated by odds
Heart Diseases (I00-I09) ratios, 95% Confidence Intervals and p-values.
 Hypertensive Diseases (I10-I15)
 Ischemic Heart Diseases (I20-I25)
 Diseases of Pulmonary Circulation and Other forms IV. RESULTS
of Heart Disease (I26-I52)
 Cerebrovascular Diseases (I60-I69) A. Characteristics of Study Population and Distribution of
 Other Diseases of the Circulatory System (I70-I99) Pollutants
Following exploration of the characteristics of the study
Based on the above, and for the purposes of this analysis, I00- population, the descriptive statistical results, as displayed in
I99 were grouped into CVD, while all other causes of death Table II, show that the highest proportion of deaths (54.9%) as
were grouped into non-CVD categories. Age at time of death a result of CVD occurred in older individuals with an age
was aggregated into 8 groups i.e. ≤ 16, 16-25, 26-35, 36-45, range of 65-74 years. In terms of gender, the results show that
46-55, 56-65, 66-74 and ≥75. Table I provides the distribution there is no significant difference between cardiovascular
of the number of deaths over the 3 years. mortality amongst males and females, although men exhibit a
lower rate of CVD mortality (48.5%) as compared with that of
TABLE I. YEAR AND CAUSE OF DEATH
women (50%).
Cause of Death Total
CVD Non-CVD With regard to air pollution distribution, the measurements
Year
shown in Table III indicate that the concentration levels of all
2010 6,376 7,284 13,660
2011 4,091 4,706 8,797 the pollutants considered have decreased over the years,
2012 4,125 4,287 8,412 although the rate of decrease is marginal. Taken individually,
Total 14,592 16,277 30,869 the results show that the mean NOx concentration level in
2010 (35.41µg/m3), as well as its maximum level (37.1µg/m3),
were the highest throughout the three years considered in the
B. Data Analysis Strategy study. In terms of PM10 concentration, the highest mean and
Data collected was carefully input into a statistical maximum levels (112.42µg/m3 and 214.51µg/m3,
software package, IBM SPSS Statistics 20, and subjected to respectively) were also recorded in the same year (2010). For
descriptive statistical analysis to acquire an idea of the SO2, there was no discernable difference in the mean levels
distribution of the data in terms of demographics (i.e., age and over the three years; however in 2010 the mean value
gender) and air pollution exposure. Subsequent to studying the (14.82µg/m3) was higher than that of the other years. The
emergent patterns from the initial set of analysis, inferential highest maximum SO2 concentration level (17.8µg/m3)
statistical analysis was performed to further investigate the occurred in 2012.
relationship between the earlier mentioned independent factors
(age, gender and air pollution parameters) and the nature of
death (i.e., CVD or non-CVD). As the dependent variable B. Multivariable Logistic Regression Model
(nature of death) is categorical in nature, the form of The Multivariable Logistic Regression model was
inferential statistical analysis that was deemed appropriate was designed based on the results of the Simple Logistic
Logistic Regression analysis. Regression which indicated that age, NOx and PM10 levels all
Logistic Regression was conducted in two phases. First, a associate significantly with occurrence of CVD for year 2012
Simple Logistic Regression analysis was conducted to study only. The results of the Multivariable Logistic Regression
the relationship between each of the independent variables and model are presented in Table IV. This Table shows the details
the dependent variable. The second phase of the inferential of the variables in the parsimonious model fitted for the
analysis was designed as a follow-up to the first phase of the prediction of cardiovascular mortality [2 (14, N=8,412) =
analysis process, and involved the selection of variables that 1084.73, p<0.001], considering 14 degrees of freedom and a
were statistically significant (p<0.05) in the initial inferential total of 8,412 samples for 2012. Variables including age at
statistical analysis. Following the selection process, the death, PM10 concentrations for the years 2010-2012 were all
eligible variables/factors were then analysed through a statistically related to cardiovascular mortality in the fitted
 6th International Conference Humanoid, Nanotechnology, Information Technology
Communication and Control, Environment and Management (HNICEM)
The Institute of Electrical and Electronics Engineers Inc. (IEEE) – Philippine Section
12-14 November 2013 Henry Sy Hall, De La Salle University, Manila, Philippines

model (p<0.05), while gender was only found to be a pollution exposure, and subsequent to controlling for the effect
confounder. of age and gender, the results show that with every increase of
1µg/m3 in PM10 concentration there is a significant increase in
The results show that individuals within the age groups at the chances of dying of CVD which, for the 3 years under
death of 36 – 45, 46 – 55, 56 – 65, 66 – 74 and ≥75 years were consideration, are as follows:
all at least 1.94 times more likely to die of CVD as compared
with those in the age group of ≤15 years. In fact, those in the  2010: OR = 1.30
age group of 66 – 74 years have approximately a 3-fold  2011: OR = 7.9
increase in likelihood of dying of CVD causes. In terms of air  2012: OR = 3.03.

TABLE II. CHARACTERISTICS OF STUDY POPULATION FOR 2012

Cause of death
Characteristics
CVD non-CVD Total
Age
15 years and below 26.8% 73.2% 332
16 – 25 years 35.9% 64.1% 284
26 – 35 years 34.9% 65.1% 499
36 – 45 years 47.2% 52.8% 809
46 – 55 years 50.2% 49.8% 1,238
56 – 65 years 53.5% 46.5% 1,639
66 – 74 years 54.9% 45.1% 1,647
75 years and above 49.7% 50.3% 1,964

Gender
Male 48.5% 51.5% 5,181
Female 50.0% 50.0% 3,231

Total 49.0% 51.0% 8,412

TABLE III. DISTRIBUTION OF POLLUTANTS

Pollutant Year Concentration (µg/m3)
Minimum Maximum Mean SD
NOx 2010 33.87 37.10 35.41 1.29
2011 27.69 30.33 29.03 0.95
2012 28.78 32.77 30.45 1.28

PM10 2010 68.05 214.51 112.42 49.07

2011 68.98 109.12 85.77 13.95
2012 57.29 108.29 77.22 18.36

SO2 2010 13.66 16.21 14.82 0.97

2011 13.16 16.40 14.73 1.11
2012 12.52 17.80 14.39 1.73
SD = Standard Deviation
 6th International Conference Humanoid, Nanotechnology, Information Technology
Communication and Control, Environment and Management (HNICEM)
The Institute of Electrical and Electronics Engineers Inc. (IEEE) – Philippine Section
12-14 November 2013 Henry Sy Hall, De La Salle University, Manila, Philippines

TABLE IV. ADJUSTED ODDS RATIOS (OR)*, 95% CONFIDENCE INTERVALS (CI) AND P-VALUES OF THE MULTIVARIABLE LOGISTIC REGRESSION MODEL FOR
CARDIOVASCULAR MORTALITY IN BANGALORE IN 2012

Variable OR (95% CI) p-value

Age at death 0.001
15 years and under 1
16 – 25 years 1.16 (0.80 – 1.67) 0.439
26 – 35 years 1.17 (0.84 – 1.62) 0.354
36 – 45 years 1.98 (1.46 – 2.68) 0.000
46 – 55 years 2.23 (1.67 – 2.97) 0.000
56 – 65 years 2.65 (1.99 – 3.51) 0.000
66 – 74 years 2.71 (2.04 – 3.59) 0.000
75 years and above 1.94 (1.47 – 2.57) 0.000

Gender 0.484
Female 1

Male 0.97 (0.88 – 1.06) 0.484

NOx level for the year 2012 2.95 (0.09 – 102.61) 0.551

PM10 levels for the year 2010 1.30 (1.14 – 1.49) 0.000

PM10 levels for the year 2011 7.90 (2.80 – 29.8) 0.000

PM10 levels for the year 2012 3.03 (2.17 – 4.23) 0.000

*Odds ratio adjusted for all the variables in the table (model)
OR = Odds ratio, CI = Confidence Interval
N/A = Not applicable

V. DISCUSSION AND CONCLUSION China. Nonetheless, a study conducted in Hong Kong [22]
suggested a one-weekend intervention to reduce sulphur
The findings of this study suggest that air pollution is content in fuels and witnessed a substantial reduction in
associated with CVD mortality. This research observation is childhood respiratory diseases, all age mortalities and related
supported by using Simple Logistic Regression which health effects over a period of time extending up to 5 years.
indicated that NOx and PM10 levels were both statistically Besides, other studies have observed closer association
related to cardiovascular mortality. This was further explored between SO2 levels and respiratory mortality [23].
through a Multivariable Logistic Regression model that Considering these facts, the lack of association regarding SO 2
included age at death, gender and the two pollutants. The in this study may be due to the study’s focus on cardiovascular
corresponding results also showed PM10 to be statistically mortality as opposed to respiratory.
significant even after controlling for the effects of other
variables in the model (i.e., age, gender and level of NO x). Moreover, the results in this study also show that PM 10
levels increased the likelihood of cardiovascular mortality by
Furthermore, the results in this study also support some of approximately 2 folds to as high as 7.9 folds, which further
the evidence available in existing literature. The WHO found corroborate the findings of [23].
that with 10, 50 and 100µg/m3 increase in the level of PM10,
there is consistent increase in the magnitude of cardiovascular This study shows that the air pollution issue in the city of
deaths [20]. Bangalore is dire and requires urgent attention to prevent mass
cardiovascular mortality and unnecessary expenditure that
With regard to the level of other pollutants, results from might have otherwise gone into the treatment of ordinarily
this study show that the levels of SO2 in the city of Bangalore preventable cardiovascular conditions. Besides, the results of
are within the limits of the Indian and International standards this study show that PM10 (the levels of which are consistently
and as such not evidently associated with CVD mortality. This high across the city) is highly associated with cardiovascular
finding is also supported by those of [21], who found that SO 2 mortality. Therefore if carefully regulated, the level of
levels were not significantly associated with any cardiovascular death, and perhaps other forms of mortality,
cerebrovascular or cardiovascular mortality in Shenyang city, could be greatly reduced.
 6th International Conference Humanoid, Nanotechnology, Information Technology
Communication and Control, Environment and Management (HNICEM)
The Institute of Electrical and Electronics Engineers Inc. (IEEE) – Philippine Section
12-14 November 2013 Henry Sy Hall, De La Salle University, Manila, Philippines

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