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Crow R, Satav A, Potdar V, Satav S, Dani V, Simões EAF. Risk factors for the development of severe or very severe respiratory syncytial virus-related lower respiratory tract infection in Indian infants: A cohort study in Melghat, India. Trop Med Int Health 2024; 29:612-621. [PMID: 38741367 DOI: 10.1111/tmi.14003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/16/2024]
Abstract
OBJECTIVES Respiratory syncytial virus (RSV) is undoubtedly the single most important cause of severe lower respiratory tract infection (LRTI) globally. While new prevention measures in young infants have become available, their use in developing countries is likely many years away. While risk factors for severe or very severe RSV LRTI in impoverished rural areas likely differ to urban areas, there are very few studies, especially those conducted in India, the major country contributing to the global burden of disease. METHODS Active surveillance for acute LRTI in enrolled infants and children <2 years of age, was conducted through weekly home visits in 93 villages of Melghat, India, from August 2016 to December 2020. Local hospitals and primary health centres were surveyed for admissions of enrolled subjects. Nasopharyngeal swabs were collected from children with severe, or very severe LRTIs and all who died, with RSV testing using nucleic acid tests at ICMR, National Institute of Virology Pune. Risk factors for both RSV associated and non-RSV associated, severe and very severe LRTI were identified through univariate and multivariate logistic regression. RESULTS There were 483 severe or very severe RSV LRTI cases and 2807 non-RSV severe or very severe LRTI infections in a cohort of 13,318 children. Weight for age z-score ≤-2, the use of kerosene or wood for cooking, obtaining drinking water from a public tap and low gestational age significantly increased the risk of RSV LRTI. A higher wealth score index and water purification were protective. Comparison with non-RSV LRTI showed male sex as an additional risk factor. The analysis highlighted the risk of kerosene use [OR = 17.8 (3.0-104.4) (p ≤ 0.001)] and [OR = 3.4 (0.8-14.4) (p ≤ 0.05)] for RSV and non-RSV LRTIs, respectively. CONCLUSIONS Nutritional status and environmental air quality are predisposing factors for developing an RSV LRI in young children, factors which are amenable to environmental and behavioural interventions.
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Affiliation(s)
- Rowena Crow
- Department of Paediatric Infectious Diseases, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, Colorado, USA
| | - Ashish Satav
- MAHAN Trust Mahatma Gandhi Tribal Hospital, Amravati, India
| | - Varsha Potdar
- National Institute of Virology, Indian Council of Medical Research, Pune, India
| | - Shilpa Satav
- MAHAN Trust Mahatma Gandhi Tribal Hospital, Amravati, India
| | - Vibhawari Dani
- MAHAN Trust Mahatma Gandhi Tribal Hospital, Amravati, India
| | - Eric A F Simões
- Department of Paediatric Infectious Diseases, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, Colorado, USA
- Centre for Global Health, Department of Epidemiology, Colorado School of Public Health, Aurora, Colorado, USA
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Lai PS, Lam NL, Gallery B, Lee AG, Adair-Rohani H, Alexander D, Balakrishnan K, Bisaga I, Chafe ZA, Clasen T, Díaz-Artiga A, Grieshop A, Harrison K, Hartinger SM, Jack D, Kaali S, Lydston M, Mortimer KM, Nicolaou L, Obonyo E, Okello G, Olopade C, Pillarisetti A, Pinto AN, Rosenthal JP, Schluger N, Shi X, Thompson C, Thompson LM, Volckens J, Williams KN, Balmes J, Checkley W, Ozoh OB. Household Air Pollution Interventions to Improve Health in Low- and Middle-Income Countries: An Official American Thoracic Society Research Statement. Am J Respir Crit Care Med 2024; 209:909-927. [PMID: 38619436 DOI: 10.1164/rccm.202402-0398st] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/16/2024] Open
Abstract
Background: An estimated 3 billion people, largely in low- and middle-income countries, rely on unclean fuels for cooking, heating, and lighting to meet household energy needs. The resulting exposure to household air pollution (HAP) is a leading cause of pneumonia, chronic lung disease, and other adverse health effects. In the last decade, randomized controlled trials of clean cooking interventions to reduce HAP have been conducted. We aim to provide guidance on how to interpret the findings of these trials and how they should inform policy makers and practitioners.Methods: We assembled a multidisciplinary working group of international researchers, public health practitioners, and policymakers with expertise in household air pollution from within academia, the American Thoracic Society, funders, nongovernmental organizations, and global organizations, including the World Bank and the World Health Organization. We performed a literature search, convened four sessions via web conference, and developed consensus conclusions and recommendations via the Delphi method.Results: The committee reached consensus on 14 conclusions and recommendations. Although some trials using cleaner-burning biomass stoves or cleaner-cooking fuels have reduced HAP exposure, the committee was divided (with 55% saying no and 45% saying yes) on whether the studied interventions improved measured health outcomes.Conclusions: HAP is associated with adverse health effects in observational studies. However, it remains unclear which household energy interventions reduce exposure, improve health, can be scaled, and are sustainable. Researchers should engage with policy makers and practitioners working to scale cleaner energy solutions to understand and address their information needs.
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Agyapong PD, Jack D, Kaali S, Colicino E, Mujtaba MN, Chillrud SN, Osei M, Gennings C, Agyei O, Kinney PL, Kwarteng A, Perzanowski M, Dwommoh Prah RK, Tawiah T, Asante KP, Lee AG. Household Air Pollution and Child Lung Function: The Ghana Randomized Air Pollution and Health Study. Am J Respir Crit Care Med 2024; 209:716-726. [PMID: 38016085 DOI: 10.1164/rccm.202303-0623oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 11/28/2023] [Indexed: 11/30/2023] Open
Abstract
Rationale: The impact of a household air pollution (HAP) stove intervention on child lung function has been poorly described. Objectives: To assess the effect of a HAP stove intervention for infants prenatally to age 1 on, and exposure-response associations with, lung function at child age 4. Methods: The Ghana Randomized Air Pollution and Health Study randomized pregnant women to liquefied petroleum gas (LPG), improved biomass, or open-fire (control) stove conditions through child age 1. We quantified HAP exposure by repeated maternal and child personal carbon monoxide (CO) exposure measurements. Children performed oscillometry, an effort-independent lung function measurement, at age 4. We examined associations between Ghana Randomized Air Pollution and Health Study stove assignment and prenatal and infant CO measurements and oscillometry using generalized linear regression models. We used reverse distributed lag models to examine time-varying associations between prenatal CO and oscillometry. Measurements and Main Results: The primary oscillometry measure was reactance at 5 Hz, X5, a measure of elastic and inertial lung properties. Secondary measures included total, large airway, and small airway resistance at 5 Hz, 20 Hz, and the difference in resistance at 5 Hz and 20 Hz (R5, R20, and R5-20, respectively); area of reactance (AX); and resonant frequency. Of the 683 children who attended the lung function visit, 567 (83%) performed acceptable oscillometry. A total of 221, 106, and 240 children were from the LPG, improved biomass, and control arms, respectively. Compared with control, the improved biomass stove condition was associated with lower reactance at 5 Hz (X5 z-score: β = -0.25; 95% confidence interval [CI] = -0.39, -0.11), higher large airway resistance (R20 z-score: β = 0.34; 95% CI = 0.23, 0.44), and higher AX (AX z-score: β = 0.16; 95% CI = 0.06, 0.26), which is suggestive of overall worse lung function. The LPG stove condition was associated with higher X5 (X5 score: β = 0.16; 95% CI = 0.01, 0.31) and lower small airway resistance (R5-20 z-score: β = -0.15; 95% CI = -0.30, 0.0), which is suggestive of better small airway function. Higher average prenatal CO exposure was associated with higher R5 and R20, and distributed lag models identified sensitive windows of exposure between CO and X5, R5, R20, and R5-20. Conclusions: These data support the importance of prenatal HAP exposure on child lung function. Clinical trial registered with www.clinicaltrials.gov (NCT01335490).
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Affiliation(s)
- Prince Darko Agyapong
- Kintampo Health Research Centre, Research and Development, Division Ghana Health Service, Bono East Region Kintampo North, Ghana
| | - Darby Jack
- Department of Environmental Health Sciences, Mailman School of Public Health, Columbia University, New York, New York
| | - Seyram Kaali
- Kintampo Health Research Centre, Research and Development, Division Ghana Health Service, Bono East Region Kintampo North, Ghana
| | | | - Mohammed Nuhu Mujtaba
- Kintampo Health Research Centre, Research and Development, Division Ghana Health Service, Bono East Region Kintampo North, Ghana
| | - Steven N Chillrud
- Lamont-Doherty Earth Observatory at Columbia University, Palisades, New York; and
| | - Musah Osei
- Kintampo Health Research Centre, Research and Development, Division Ghana Health Service, Bono East Region Kintampo North, Ghana
| | - Chris Gennings
- Department of Environmental Medicine and Public Health
- Institute for Exposomic Research, and
| | - Oscar Agyei
- Kintampo Health Research Centre, Research and Development, Division Ghana Health Service, Bono East Region Kintampo North, Ghana
| | - Patrick L Kinney
- Department of Environmental Health, Boston University School of Public Health, Boston, Massachusetts
| | - Adolphine Kwarteng
- Kintampo Health Research Centre, Research and Development, Division Ghana Health Service, Bono East Region Kintampo North, Ghana
| | - Matthew Perzanowski
- Department of Environmental Health Sciences, Mailman School of Public Health, Columbia University, New York, New York
| | - Rebecca Kyerewaa Dwommoh Prah
- Kintampo Health Research Centre, Research and Development, Division Ghana Health Service, Bono East Region Kintampo North, Ghana
| | - Theresa Tawiah
- Kintampo Health Research Centre, Research and Development, Division Ghana Health Service, Bono East Region Kintampo North, Ghana
| | - Kwaku Poku Asante
- Kintampo Health Research Centre, Research and Development, Division Ghana Health Service, Bono East Region Kintampo North, Ghana
| | - Alison G Lee
- Division of Pulmonary, Critical Care and Sleep Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
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Nassikas NJ, McCormack MC, Ewart G, Balmes JR, Bond TC, Brigham E, Cromar K, Goldstein AH, Hicks A, Hopke PK, Meyer B, Nazaroff WW, Paulin LM, Rice MB, Thurston GD, Turpin BJ, Vance ME, Weschler CJ, Zhang J, Kipen HM. Indoor Air Sources of Outdoor Air Pollution: Health Consequences, Policy, and Recommendations: An Official American Thoracic Society Workshop Report. Ann Am Thorac Soc 2024; 21:365-376. [PMID: 38426826 PMCID: PMC10913763 DOI: 10.1513/annalsats.202312-1067st] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2024] Open
Abstract
Indoor sources of air pollution worsen indoor and outdoor air quality. Thus, identifying and reducing indoor pollutant sources would decrease both indoor and outdoor air pollution, benefit public health, and help address the climate crisis. As outdoor sources come under regulatory control, unregulated indoor sources become a rising percentage of the problem. This American Thoracic Society workshop was convened in 2022 to evaluate this increasing proportion of indoor contributions to outdoor air quality. The workshop was conducted by physicians and scientists, including atmospheric and aerosol scientists, environmental engineers, toxicologists, epidemiologists, regulatory policy experts, and pediatric and adult pulmonologists. Presentations and discussion sessions were centered on 1) the generation and migration of pollutants from indoors to outdoors, 2) the sources and circumstances representing the greatest threat, and 3) effective remedies to reduce the health burden of indoor sources of air pollution. The scope of the workshop was residential and commercial sources of indoor air pollution in the United States. Topics included wood burning, natural gas, cooking, evaporative volatile organic compounds, source apportionment, and regulatory policy. The workshop concluded that indoor sources of air pollution are significant contributors to outdoor air quality and that source control and filtration are the most effective measures to reduce indoor contributions to outdoor air. Interventions should prioritize environmental justice: Households of lower socioeconomic status have higher concentrations of indoor air pollutants from both indoor and outdoor sources. We identify research priorities, potential health benefits, and mitigation actions to consider (e.g., switching from natural gas to electric stoves and transitioning to scent-free consumer products). The workshop committee emphasizes the benefits of combustion-free homes and businesses and recommends economic, legislative, and education strategies aimed at achieving this goal.
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Katoto PDMC, Bihehe D, Brand A, Mushi R, Kusinza A, Alwood BW, van Zyl-Smit RN, Tamuzi JL, Sam-Agudu NA, Yotebieng M, Metcalfe J, Theron G, Godri Pollitt KJ, Lesosky M, Vanoirbeek J, Mortimer K, Nawrot T, Nemery B, Nachega JB. Household air pollution and risk of pulmonary tuberculosis in HIV-Infected adults. Environ Health 2024; 23:6. [PMID: 38233832 PMCID: PMC10792790 DOI: 10.1186/s12940-023-01044-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 12/19/2023] [Indexed: 01/19/2024]
Abstract
BACKGROUND In low- and middle-income countries countries, millions of deaths occur annually from household air pollution (HAP), pulmonary tuberculosis (PTB), and HIV-infection. However, it is unknown whether HAP influences PTB risk among people living with HIV-infection. METHODS We conducted a case-control study among 1,277 HIV-infected adults in Bukavu, eastern Democratic Republic of Congo (February 2018 - March 2019). Cases had current or recent (<5y) PTB (positive sputum smear or Xpert MTB/RIF), controls had no PTB. Daily and lifetime HAP exposure were assessed by questionnaire and, in a random sub-sample (n=270), by 24-hour measurements of personal carbon monoxide (CO) at home. We used multivariable logistic regression to examine the associations between HAP and PTB. RESULTS We recruited 435 cases and 842 controls (median age 41 years, [IQR] 33-50; 76% female). Cases were more likely to be female than male (63% vs 37%). Participants reporting cooking for >3h/day and ≥2 times/day and ≥5 days/week were more likely to have PTB (aOR 1·36; 95%CI 1·06-1·75) than those spending less time in the kitchen. Time-weighted average 24h personal CO exposure was related dose-dependently with the likelihood of having PTB, with aOR 4·64 (95%CI 1·1-20·7) for the highest quintile [12·3-76·2 ppm] compared to the lowest quintile [0·1-1·9 ppm]. CONCLUSION Time spent cooking and personal CO exposure were independently associated with increased risk of PTB among people living with HIV. Considering the high burden of TB-HIV coinfection in the region, effective interventions are required to decrease HAP exposure caused by cooking with biomass among people living with HIV, especially women.
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Affiliation(s)
- Patrick D M C Katoto
- Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa.
- Office of the President and CEO, South African Medical Research Council, Cape Town, South Africa.
- Centre for Tropical Diseases and Global Health, Catholic University of Bukavu, Bukavu, Democratic Republic of the Congo.
- Centre for Environment and Health, Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium.
| | - Dieudonné Bihehe
- Department of Internal Medicine, Université Evangélique en Afrique, Bukavu, DR, Congo
| | - Amanda Brand
- Centre for Evidence-Based Health Care, Division of Epidemiology and Biostatistics, Department of Global Health, Stellenbosch University, Cape Town, South Africa
| | - Raymond Mushi
- Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Aline Kusinza
- Department of Medicine, Division of Pulmonology, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Brian W Alwood
- Department of Medicine, Division of Pulmonology, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Richard N van Zyl-Smit
- Division of Pulmonology & UCT Lung Institute, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Jacques L Tamuzi
- Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Nadia A Sam-Agudu
- International Research Center of Excellence, Institute of Human Virology Nigeria, Abuja, Nigeria
- Division of Epidemiology and Prevention, Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Marcel Yotebieng
- Department of Medicine, Albert Einstein College of Medicine, New York, NY, USA
| | - John Metcalfe
- Division of Pulmonary and Critical Care Medicine, Trauma Center, Zuckerberg San Francisco General Hospital, University of California, San Francisco, CA, USA
| | - Grant Theron
- South African Medical Research Council Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, NRF-DST Centre of Excellence for Biomedical Tuberculosis Research, Stellenbosch University, Cape Town, South Africa
| | - Krystal J Godri Pollitt
- Department of Environmental Health Sciences, School of Public Health, Yale University, New Haven, CT, USA
| | - Maia Lesosky
- Division of epidemiology and Biostatistics, University of Cape Town, Rondebosch, Western Cape, South Africa
| | - Jeroen Vanoirbeek
- Centre for Environment and Health, Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
| | - Kevin Mortimer
- Liverpool School of Tropical Medicine, Liverpool, L3 5QA, UK
| | - Tim Nawrot
- Centre for Environment and Health, Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
- Centre of Environmental Health, University of Hasselt, Hasselt, Belgium
| | - Benoit Nemery
- Centre for Environment and Health, Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
| | - Jean B Nachega
- Department of Medicine, Albert Einstein College of Medicine, New York, NY, USA.
- Department of Medicine, Center for Infectious Diseases, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa.
- Department of Epidemiology and Center for Global Health, Infectious Diseases and Microbiology, University of Pittsburgh Graduate School of Public Health, 130 DeSoto St., Room A522 Crabtree Hall, Pittsburgh, 15260, PA, USA.
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Li S, Mohamed Nor N, Kaliappan SR. Social determinants of child malnutrition outcomes: Evidence from CHNS in China. Heliyon 2024; 10:e23887. [PMID: 38187311 PMCID: PMC10767191 DOI: 10.1016/j.heliyon.2023.e23887] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2023] [Revised: 12/13/2023] [Accepted: 12/14/2023] [Indexed: 01/09/2024] Open
Abstract
China is committed to reduce child malnutrition outcomes (CMO) rates to less than 5 % by 2030 in order to meet the Sustainable Development Goal (SDG). Yet, this is still an enormous challenge for China, particularly in disadvantaged areas, due to regional and urban-rural disparities. Using China Health and Nutrition Survey (CHNS) data from 1991 to 2015 and fixed-effect models, this study investigates the social determinants of stunting (n = 4012) measured by height-for-age z score (HAZ) and wasting (n = 4229) measured by weight-for-height z score (WHZ) in children under the age of five. According to the empirical findings, the significant social determinants of child stunting encompassed whether the child is insured (p < 0.01), maternal education level (primary school (p < 0.01) low middle school (p < 0.01); vocational school (p < 0.01)), maternal employment status (p < 0.05), mother's average working days (p < 0.05), average household per capita income (p < 0.01), household asset index (p < 0.01), urbanization index living in a community (medium (p < 0.05); higher (p < 0.01); highest (p < 0.01)) and living regions (west (p < 0.01); northeast (p < 0.05)). Children's maternal employment status (p < 0.05), mother's average working days (p < 0.05), living areas (p < 0.05) and living regions (central (p < 0.01); west (p < 0.01); north-east (p < 0.05)) are the significant factors impacting child wasting. Furthermore, the interaction impact between maternal employment and have one additional working day per week is positive. To attain SDGs, the Chinese government should priorities lowering stunting and wasting among 5-year-olds in the western region, particularly in impoverished regions. Also, it is possible to develop tailored policies for the growth and development of children under the age of five by addressing pertinent socio-economic factors.
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Affiliation(s)
- Sa Li
- School of Business and Economics, Universiti Putra Malaysia, 43400, UPM, Serdang, Selangor, Malaysia
- School of Business, Zhengzhou College of Finance and Economics, Zhengzhou, 450000, China
| | - Norashidah Mohamed Nor
- School of Business and Economics, Universiti Putra Malaysia, 43400, UPM, Serdang, Selangor, Malaysia
| | - Shivee Ranjanee Kaliappan
- School of Business and Economics, Universiti Putra Malaysia, 43400, UPM, Serdang, Selangor, Malaysia
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7
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McCollum ED, McCracken JP, Kirby MA, Grajeda LM, Hossen S, Moulton LH, Simkovich SM, Goodman-Palmer D, Rosa G, Mukeshimana A, Balakrishnan K, Thangavel G, Garg SS, Castañaza A, Thompson LM, Diaz-Artiga A, Papageorghiou AT, Davila-Roman VG, Underhill LJ, Hartinger SM, Williams KN, Nicolaou L, Chang HH, Lovvorn AE, Rosenthal JP, Pillarisetti A, Ye W, Naeher LP, Johnson MA, Waller LA, Jabbarzadeh S, Wang J, Chen Y, Steenland K, Clasen TF, Peel JL, Checkley W. Liquefied Petroleum Gas or Biomass Cooking and Severe Infant Pneumonia. N Engl J Med 2024; 390:32-43. [PMID: 38169488 PMCID: PMC10768798 DOI: 10.1056/nejmoa2305681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2024]
Abstract
BACKGROUND Exposure to household air pollution is a risk factor for severe pneumonia. The effect of replacing biomass cookstoves with liquefied petroleum gas (LPG) cookstoves on the incidence of severe infant pneumonia is uncertain. METHODS We conducted a randomized, controlled trial involving pregnant women 18 to 34 years of age and between 9 to less than 20 weeks' gestation in India, Guatemala, Peru, and Rwanda from May 2018 through September 2021. The women were assigned to cook with unvented LPG stoves and fuel (intervention group) or to continue cooking with biomass fuel (control group). In each trial group, we monitored adherence to the use of the assigned cookstove and measured 24-hour personal exposure to fine particulate matter (particles with an aerodynamic diameter of ≤2.5 μm [PM2.5]) in the women and their offspring. The trial had four primary outcomes; the primary outcome for which data are presented in the current report was severe pneumonia in the first year of life, as identified through facility surveillance or on verbal autopsy. RESULTS Among 3200 pregnant women who had undergone randomization, 3195 remained eligible and gave birth to 3061 infants (1536 in the intervention group and 1525 in the control group). High uptake of the intervention led to a reduction in personal exposure to PM2.5 among the children, with a median exposure of 24.2 μg per cubic meter (interquartile range, 17.8 to 36.4) in the intervention group and 66.0 μg per cubic meter (interquartile range, 35.2 to 132.0) in the control group. A total of 175 episodes of severe pneumonia were identified during the first year of life, with an incidence of 5.67 cases per 100 child-years (95% confidence interval [CI], 4.55 to 7.07) in the intervention group and 6.06 cases per 100 child-years (95% CI, 4.81 to 7.62) in the control group (incidence rate ratio, 0.96; 98.75% CI, 0.64 to 1.44; P = 0.81). No severe adverse events were reported to be associated with the intervention, as determined by the trial investigators. CONCLUSIONS The incidence of severe pneumonia among infants did not differ significantly between those whose mothers were assigned to cook with LPG stoves and fuel and those whose mothers were assigned to continue cooking with biomass stoves. (Funded by the National Institutes of Health and the Bill and Melinda Gates Foundation; HAPIN ClinicalTrials.gov number, NCT02944682.).
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Affiliation(s)
- Eric D McCollum
- From the Global Program in Pediatric Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences (E.D.M.), the Division of Pulmonary and Critical Care (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Center for Global Non-Communicable Disease Research and Training, School of Medicine (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Department of International Health (E.D.M.) and the Program in Global Disease Epidemiology and Control, Department of International Health (L.H.M.), Bloomberg School of Public Health, Johns Hopkins University, Baltimore, the Division of Healthcare Delivery Research, MedStar Health Research Institute, Hyattsville (S.M.S.), and Fogarty International Center, National Institutes of Health, Bethesda (J.P.R.) - all in Maryland; the Global Health Institute, Department of Epidemiology and Biostatistics (J.P.M., L.M.G.), and the Department of Environmental Health Science, College of Public Health (L.P.N.), University of Georgia, Athens, and the Department of Biostatistics and Bioinformatics (H.H.C., L.A.W., S.J., J.W., Y.C.) and the Gangarosa Department of Environmental Health (A.E.L., K.S., T.F.C.), Rollins School of Public Health, and the Nell Hodgson Woodruff School of Nursing (L.M.T.), Emory University, Atlanta - both in Georgia; the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City (J.P.M., L.M.G., A.C., A.D.-A.); the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Division of Pulmonary and Critical Care Medicine, Georgetown University, Washington DC (S.M.S.); the Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute for Higher Education and Research, Chennai, India (K.B., G.T., S.S.G.); the Global Health Center, Institute for Public Health and Cardiovascular Division, Department of Medicine, Washington University, St. Louis, MO (V.G.D.-R., L.J.U.); the Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley (A.P., W.Y.), and Berkeley Air Monitoring Group (M.A.J.) - both in Berkeley, CA; and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - John P McCracken
- From the Global Program in Pediatric Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences (E.D.M.), the Division of Pulmonary and Critical Care (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Center for Global Non-Communicable Disease Research and Training, School of Medicine (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Department of International Health (E.D.M.) and the Program in Global Disease Epidemiology and Control, Department of International Health (L.H.M.), Bloomberg School of Public Health, Johns Hopkins University, Baltimore, the Division of Healthcare Delivery Research, MedStar Health Research Institute, Hyattsville (S.M.S.), and Fogarty International Center, National Institutes of Health, Bethesda (J.P.R.) - all in Maryland; the Global Health Institute, Department of Epidemiology and Biostatistics (J.P.M., L.M.G.), and the Department of Environmental Health Science, College of Public Health (L.P.N.), University of Georgia, Athens, and the Department of Biostatistics and Bioinformatics (H.H.C., L.A.W., S.J., J.W., Y.C.) and the Gangarosa Department of Environmental Health (A.E.L., K.S., T.F.C.), Rollins School of Public Health, and the Nell Hodgson Woodruff School of Nursing (L.M.T.), Emory University, Atlanta - both in Georgia; the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City (J.P.M., L.M.G., A.C., A.D.-A.); the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Division of Pulmonary and Critical Care Medicine, Georgetown University, Washington DC (S.M.S.); the Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute for Higher Education and Research, Chennai, India (K.B., G.T., S.S.G.); the Global Health Center, Institute for Public Health and Cardiovascular Division, Department of Medicine, Washington University, St. Louis, MO (V.G.D.-R., L.J.U.); the Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley (A.P., W.Y.), and Berkeley Air Monitoring Group (M.A.J.) - both in Berkeley, CA; and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Miles A Kirby
- From the Global Program in Pediatric Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences (E.D.M.), the Division of Pulmonary and Critical Care (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Center for Global Non-Communicable Disease Research and Training, School of Medicine (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Department of International Health (E.D.M.) and the Program in Global Disease Epidemiology and Control, Department of International Health (L.H.M.), Bloomberg School of Public Health, Johns Hopkins University, Baltimore, the Division of Healthcare Delivery Research, MedStar Health Research Institute, Hyattsville (S.M.S.), and Fogarty International Center, National Institutes of Health, Bethesda (J.P.R.) - all in Maryland; the Global Health Institute, Department of Epidemiology and Biostatistics (J.P.M., L.M.G.), and the Department of Environmental Health Science, College of Public Health (L.P.N.), University of Georgia, Athens, and the Department of Biostatistics and Bioinformatics (H.H.C., L.A.W., S.J., J.W., Y.C.) and the Gangarosa Department of Environmental Health (A.E.L., K.S., T.F.C.), Rollins School of Public Health, and the Nell Hodgson Woodruff School of Nursing (L.M.T.), Emory University, Atlanta - both in Georgia; the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City (J.P.M., L.M.G., A.C., A.D.-A.); the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Division of Pulmonary and Critical Care Medicine, Georgetown University, Washington DC (S.M.S.); the Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute for Higher Education and Research, Chennai, India (K.B., G.T., S.S.G.); the Global Health Center, Institute for Public Health and Cardiovascular Division, Department of Medicine, Washington University, St. Louis, MO (V.G.D.-R., L.J.U.); the Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley (A.P., W.Y.), and Berkeley Air Monitoring Group (M.A.J.) - both in Berkeley, CA; and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Laura M Grajeda
- From the Global Program in Pediatric Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences (E.D.M.), the Division of Pulmonary and Critical Care (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Center for Global Non-Communicable Disease Research and Training, School of Medicine (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Department of International Health (E.D.M.) and the Program in Global Disease Epidemiology and Control, Department of International Health (L.H.M.), Bloomberg School of Public Health, Johns Hopkins University, Baltimore, the Division of Healthcare Delivery Research, MedStar Health Research Institute, Hyattsville (S.M.S.), and Fogarty International Center, National Institutes of Health, Bethesda (J.P.R.) - all in Maryland; the Global Health Institute, Department of Epidemiology and Biostatistics (J.P.M., L.M.G.), and the Department of Environmental Health Science, College of Public Health (L.P.N.), University of Georgia, Athens, and the Department of Biostatistics and Bioinformatics (H.H.C., L.A.W., S.J., J.W., Y.C.) and the Gangarosa Department of Environmental Health (A.E.L., K.S., T.F.C.), Rollins School of Public Health, and the Nell Hodgson Woodruff School of Nursing (L.M.T.), Emory University, Atlanta - both in Georgia; the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City (J.P.M., L.M.G., A.C., A.D.-A.); the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Division of Pulmonary and Critical Care Medicine, Georgetown University, Washington DC (S.M.S.); the Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute for Higher Education and Research, Chennai, India (K.B., G.T., S.S.G.); the Global Health Center, Institute for Public Health and Cardiovascular Division, Department of Medicine, Washington University, St. Louis, MO (V.G.D.-R., L.J.U.); the Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley (A.P., W.Y.), and Berkeley Air Monitoring Group (M.A.J.) - both in Berkeley, CA; and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Shakir Hossen
- From the Global Program in Pediatric Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences (E.D.M.), the Division of Pulmonary and Critical Care (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Center for Global Non-Communicable Disease Research and Training, School of Medicine (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Department of International Health (E.D.M.) and the Program in Global Disease Epidemiology and Control, Department of International Health (L.H.M.), Bloomberg School of Public Health, Johns Hopkins University, Baltimore, the Division of Healthcare Delivery Research, MedStar Health Research Institute, Hyattsville (S.M.S.), and Fogarty International Center, National Institutes of Health, Bethesda (J.P.R.) - all in Maryland; the Global Health Institute, Department of Epidemiology and Biostatistics (J.P.M., L.M.G.), and the Department of Environmental Health Science, College of Public Health (L.P.N.), University of Georgia, Athens, and the Department of Biostatistics and Bioinformatics (H.H.C., L.A.W., S.J., J.W., Y.C.) and the Gangarosa Department of Environmental Health (A.E.L., K.S., T.F.C.), Rollins School of Public Health, and the Nell Hodgson Woodruff School of Nursing (L.M.T.), Emory University, Atlanta - both in Georgia; the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City (J.P.M., L.M.G., A.C., A.D.-A.); the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Division of Pulmonary and Critical Care Medicine, Georgetown University, Washington DC (S.M.S.); the Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute for Higher Education and Research, Chennai, India (K.B., G.T., S.S.G.); the Global Health Center, Institute for Public Health and Cardiovascular Division, Department of Medicine, Washington University, St. Louis, MO (V.G.D.-R., L.J.U.); the Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley (A.P., W.Y.), and Berkeley Air Monitoring Group (M.A.J.) - both in Berkeley, CA; and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Lawrence H Moulton
- From the Global Program in Pediatric Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences (E.D.M.), the Division of Pulmonary and Critical Care (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Center for Global Non-Communicable Disease Research and Training, School of Medicine (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Department of International Health (E.D.M.) and the Program in Global Disease Epidemiology and Control, Department of International Health (L.H.M.), Bloomberg School of Public Health, Johns Hopkins University, Baltimore, the Division of Healthcare Delivery Research, MedStar Health Research Institute, Hyattsville (S.M.S.), and Fogarty International Center, National Institutes of Health, Bethesda (J.P.R.) - all in Maryland; the Global Health Institute, Department of Epidemiology and Biostatistics (J.P.M., L.M.G.), and the Department of Environmental Health Science, College of Public Health (L.P.N.), University of Georgia, Athens, and the Department of Biostatistics and Bioinformatics (H.H.C., L.A.W., S.J., J.W., Y.C.) and the Gangarosa Department of Environmental Health (A.E.L., K.S., T.F.C.), Rollins School of Public Health, and the Nell Hodgson Woodruff School of Nursing (L.M.T.), Emory University, Atlanta - both in Georgia; the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City (J.P.M., L.M.G., A.C., A.D.-A.); the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Division of Pulmonary and Critical Care Medicine, Georgetown University, Washington DC (S.M.S.); the Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute for Higher Education and Research, Chennai, India (K.B., G.T., S.S.G.); the Global Health Center, Institute for Public Health and Cardiovascular Division, Department of Medicine, Washington University, St. Louis, MO (V.G.D.-R., L.J.U.); the Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley (A.P., W.Y.), and Berkeley Air Monitoring Group (M.A.J.) - both in Berkeley, CA; and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Suzanne M Simkovich
- From the Global Program in Pediatric Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences (E.D.M.), the Division of Pulmonary and Critical Care (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Center for Global Non-Communicable Disease Research and Training, School of Medicine (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Department of International Health (E.D.M.) and the Program in Global Disease Epidemiology and Control, Department of International Health (L.H.M.), Bloomberg School of Public Health, Johns Hopkins University, Baltimore, the Division of Healthcare Delivery Research, MedStar Health Research Institute, Hyattsville (S.M.S.), and Fogarty International Center, National Institutes of Health, Bethesda (J.P.R.) - all in Maryland; the Global Health Institute, Department of Epidemiology and Biostatistics (J.P.M., L.M.G.), and the Department of Environmental Health Science, College of Public Health (L.P.N.), University of Georgia, Athens, and the Department of Biostatistics and Bioinformatics (H.H.C., L.A.W., S.J., J.W., Y.C.) and the Gangarosa Department of Environmental Health (A.E.L., K.S., T.F.C.), Rollins School of Public Health, and the Nell Hodgson Woodruff School of Nursing (L.M.T.), Emory University, Atlanta - both in Georgia; the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City (J.P.M., L.M.G., A.C., A.D.-A.); the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Division of Pulmonary and Critical Care Medicine, Georgetown University, Washington DC (S.M.S.); the Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute for Higher Education and Research, Chennai, India (K.B., G.T., S.S.G.); the Global Health Center, Institute for Public Health and Cardiovascular Division, Department of Medicine, Washington University, St. Louis, MO (V.G.D.-R., L.J.U.); the Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley (A.P., W.Y.), and Berkeley Air Monitoring Group (M.A.J.) - both in Berkeley, CA; and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Dina Goodman-Palmer
- From the Global Program in Pediatric Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences (E.D.M.), the Division of Pulmonary and Critical Care (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Center for Global Non-Communicable Disease Research and Training, School of Medicine (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Department of International Health (E.D.M.) and the Program in Global Disease Epidemiology and Control, Department of International Health (L.H.M.), Bloomberg School of Public Health, Johns Hopkins University, Baltimore, the Division of Healthcare Delivery Research, MedStar Health Research Institute, Hyattsville (S.M.S.), and Fogarty International Center, National Institutes of Health, Bethesda (J.P.R.) - all in Maryland; the Global Health Institute, Department of Epidemiology and Biostatistics (J.P.M., L.M.G.), and the Department of Environmental Health Science, College of Public Health (L.P.N.), University of Georgia, Athens, and the Department of Biostatistics and Bioinformatics (H.H.C., L.A.W., S.J., J.W., Y.C.) and the Gangarosa Department of Environmental Health (A.E.L., K.S., T.F.C.), Rollins School of Public Health, and the Nell Hodgson Woodruff School of Nursing (L.M.T.), Emory University, Atlanta - both in Georgia; the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City (J.P.M., L.M.G., A.C., A.D.-A.); the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Division of Pulmonary and Critical Care Medicine, Georgetown University, Washington DC (S.M.S.); the Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute for Higher Education and Research, Chennai, India (K.B., G.T., S.S.G.); the Global Health Center, Institute for Public Health and Cardiovascular Division, Department of Medicine, Washington University, St. Louis, MO (V.G.D.-R., L.J.U.); the Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley (A.P., W.Y.), and Berkeley Air Monitoring Group (M.A.J.) - both in Berkeley, CA; and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Ghislaine Rosa
- From the Global Program in Pediatric Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences (E.D.M.), the Division of Pulmonary and Critical Care (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Center for Global Non-Communicable Disease Research and Training, School of Medicine (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Department of International Health (E.D.M.) and the Program in Global Disease Epidemiology and Control, Department of International Health (L.H.M.), Bloomberg School of Public Health, Johns Hopkins University, Baltimore, the Division of Healthcare Delivery Research, MedStar Health Research Institute, Hyattsville (S.M.S.), and Fogarty International Center, National Institutes of Health, Bethesda (J.P.R.) - all in Maryland; the Global Health Institute, Department of Epidemiology and Biostatistics (J.P.M., L.M.G.), and the Department of Environmental Health Science, College of Public Health (L.P.N.), University of Georgia, Athens, and the Department of Biostatistics and Bioinformatics (H.H.C., L.A.W., S.J., J.W., Y.C.) and the Gangarosa Department of Environmental Health (A.E.L., K.S., T.F.C.), Rollins School of Public Health, and the Nell Hodgson Woodruff School of Nursing (L.M.T.), Emory University, Atlanta - both in Georgia; the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City (J.P.M., L.M.G., A.C., A.D.-A.); the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Division of Pulmonary and Critical Care Medicine, Georgetown University, Washington DC (S.M.S.); the Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute for Higher Education and Research, Chennai, India (K.B., G.T., S.S.G.); the Global Health Center, Institute for Public Health and Cardiovascular Division, Department of Medicine, Washington University, St. Louis, MO (V.G.D.-R., L.J.U.); the Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley (A.P., W.Y.), and Berkeley Air Monitoring Group (M.A.J.) - both in Berkeley, CA; and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Alexie Mukeshimana
- From the Global Program in Pediatric Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences (E.D.M.), the Division of Pulmonary and Critical Care (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Center for Global Non-Communicable Disease Research and Training, School of Medicine (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Department of International Health (E.D.M.) and the Program in Global Disease Epidemiology and Control, Department of International Health (L.H.M.), Bloomberg School of Public Health, Johns Hopkins University, Baltimore, the Division of Healthcare Delivery Research, MedStar Health Research Institute, Hyattsville (S.M.S.), and Fogarty International Center, National Institutes of Health, Bethesda (J.P.R.) - all in Maryland; the Global Health Institute, Department of Epidemiology and Biostatistics (J.P.M., L.M.G.), and the Department of Environmental Health Science, College of Public Health (L.P.N.), University of Georgia, Athens, and the Department of Biostatistics and Bioinformatics (H.H.C., L.A.W., S.J., J.W., Y.C.) and the Gangarosa Department of Environmental Health (A.E.L., K.S., T.F.C.), Rollins School of Public Health, and the Nell Hodgson Woodruff School of Nursing (L.M.T.), Emory University, Atlanta - both in Georgia; the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City (J.P.M., L.M.G., A.C., A.D.-A.); the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Division of Pulmonary and Critical Care Medicine, Georgetown University, Washington DC (S.M.S.); the Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute for Higher Education and Research, Chennai, India (K.B., G.T., S.S.G.); the Global Health Center, Institute for Public Health and Cardiovascular Division, Department of Medicine, Washington University, St. Louis, MO (V.G.D.-R., L.J.U.); the Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley (A.P., W.Y.), and Berkeley Air Monitoring Group (M.A.J.) - both in Berkeley, CA; and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Kalpana Balakrishnan
- From the Global Program in Pediatric Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences (E.D.M.), the Division of Pulmonary and Critical Care (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Center for Global Non-Communicable Disease Research and Training, School of Medicine (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Department of International Health (E.D.M.) and the Program in Global Disease Epidemiology and Control, Department of International Health (L.H.M.), Bloomberg School of Public Health, Johns Hopkins University, Baltimore, the Division of Healthcare Delivery Research, MedStar Health Research Institute, Hyattsville (S.M.S.), and Fogarty International Center, National Institutes of Health, Bethesda (J.P.R.) - all in Maryland; the Global Health Institute, Department of Epidemiology and Biostatistics (J.P.M., L.M.G.), and the Department of Environmental Health Science, College of Public Health (L.P.N.), University of Georgia, Athens, and the Department of Biostatistics and Bioinformatics (H.H.C., L.A.W., S.J., J.W., Y.C.) and the Gangarosa Department of Environmental Health (A.E.L., K.S., T.F.C.), Rollins School of Public Health, and the Nell Hodgson Woodruff School of Nursing (L.M.T.), Emory University, Atlanta - both in Georgia; the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City (J.P.M., L.M.G., A.C., A.D.-A.); the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Division of Pulmonary and Critical Care Medicine, Georgetown University, Washington DC (S.M.S.); the Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute for Higher Education and Research, Chennai, India (K.B., G.T., S.S.G.); the Global Health Center, Institute for Public Health and Cardiovascular Division, Department of Medicine, Washington University, St. Louis, MO (V.G.D.-R., L.J.U.); the Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley (A.P., W.Y.), and Berkeley Air Monitoring Group (M.A.J.) - both in Berkeley, CA; and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Gurusamy Thangavel
- From the Global Program in Pediatric Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences (E.D.M.), the Division of Pulmonary and Critical Care (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Center for Global Non-Communicable Disease Research and Training, School of Medicine (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Department of International Health (E.D.M.) and the Program in Global Disease Epidemiology and Control, Department of International Health (L.H.M.), Bloomberg School of Public Health, Johns Hopkins University, Baltimore, the Division of Healthcare Delivery Research, MedStar Health Research Institute, Hyattsville (S.M.S.), and Fogarty International Center, National Institutes of Health, Bethesda (J.P.R.) - all in Maryland; the Global Health Institute, Department of Epidemiology and Biostatistics (J.P.M., L.M.G.), and the Department of Environmental Health Science, College of Public Health (L.P.N.), University of Georgia, Athens, and the Department of Biostatistics and Bioinformatics (H.H.C., L.A.W., S.J., J.W., Y.C.) and the Gangarosa Department of Environmental Health (A.E.L., K.S., T.F.C.), Rollins School of Public Health, and the Nell Hodgson Woodruff School of Nursing (L.M.T.), Emory University, Atlanta - both in Georgia; the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City (J.P.M., L.M.G., A.C., A.D.-A.); the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Division of Pulmonary and Critical Care Medicine, Georgetown University, Washington DC (S.M.S.); the Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute for Higher Education and Research, Chennai, India (K.B., G.T., S.S.G.); the Global Health Center, Institute for Public Health and Cardiovascular Division, Department of Medicine, Washington University, St. Louis, MO (V.G.D.-R., L.J.U.); the Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley (A.P., W.Y.), and Berkeley Air Monitoring Group (M.A.J.) - both in Berkeley, CA; and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Sarada S Garg
- From the Global Program in Pediatric Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences (E.D.M.), the Division of Pulmonary and Critical Care (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Center for Global Non-Communicable Disease Research and Training, School of Medicine (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Department of International Health (E.D.M.) and the Program in Global Disease Epidemiology and Control, Department of International Health (L.H.M.), Bloomberg School of Public Health, Johns Hopkins University, Baltimore, the Division of Healthcare Delivery Research, MedStar Health Research Institute, Hyattsville (S.M.S.), and Fogarty International Center, National Institutes of Health, Bethesda (J.P.R.) - all in Maryland; the Global Health Institute, Department of Epidemiology and Biostatistics (J.P.M., L.M.G.), and the Department of Environmental Health Science, College of Public Health (L.P.N.), University of Georgia, Athens, and the Department of Biostatistics and Bioinformatics (H.H.C., L.A.W., S.J., J.W., Y.C.) and the Gangarosa Department of Environmental Health (A.E.L., K.S., T.F.C.), Rollins School of Public Health, and the Nell Hodgson Woodruff School of Nursing (L.M.T.), Emory University, Atlanta - both in Georgia; the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City (J.P.M., L.M.G., A.C., A.D.-A.); the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Division of Pulmonary and Critical Care Medicine, Georgetown University, Washington DC (S.M.S.); the Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute for Higher Education and Research, Chennai, India (K.B., G.T., S.S.G.); the Global Health Center, Institute for Public Health and Cardiovascular Division, Department of Medicine, Washington University, St. Louis, MO (V.G.D.-R., L.J.U.); the Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley (A.P., W.Y.), and Berkeley Air Monitoring Group (M.A.J.) - both in Berkeley, CA; and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Adly Castañaza
- From the Global Program in Pediatric Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences (E.D.M.), the Division of Pulmonary and Critical Care (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Center for Global Non-Communicable Disease Research and Training, School of Medicine (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Department of International Health (E.D.M.) and the Program in Global Disease Epidemiology and Control, Department of International Health (L.H.M.), Bloomberg School of Public Health, Johns Hopkins University, Baltimore, the Division of Healthcare Delivery Research, MedStar Health Research Institute, Hyattsville (S.M.S.), and Fogarty International Center, National Institutes of Health, Bethesda (J.P.R.) - all in Maryland; the Global Health Institute, Department of Epidemiology and Biostatistics (J.P.M., L.M.G.), and the Department of Environmental Health Science, College of Public Health (L.P.N.), University of Georgia, Athens, and the Department of Biostatistics and Bioinformatics (H.H.C., L.A.W., S.J., J.W., Y.C.) and the Gangarosa Department of Environmental Health (A.E.L., K.S., T.F.C.), Rollins School of Public Health, and the Nell Hodgson Woodruff School of Nursing (L.M.T.), Emory University, Atlanta - both in Georgia; the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City (J.P.M., L.M.G., A.C., A.D.-A.); the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Division of Pulmonary and Critical Care Medicine, Georgetown University, Washington DC (S.M.S.); the Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute for Higher Education and Research, Chennai, India (K.B., G.T., S.S.G.); the Global Health Center, Institute for Public Health and Cardiovascular Division, Department of Medicine, Washington University, St. Louis, MO (V.G.D.-R., L.J.U.); the Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley (A.P., W.Y.), and Berkeley Air Monitoring Group (M.A.J.) - both in Berkeley, CA; and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Lisa M Thompson
- From the Global Program in Pediatric Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences (E.D.M.), the Division of Pulmonary and Critical Care (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Center for Global Non-Communicable Disease Research and Training, School of Medicine (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Department of International Health (E.D.M.) and the Program in Global Disease Epidemiology and Control, Department of International Health (L.H.M.), Bloomberg School of Public Health, Johns Hopkins University, Baltimore, the Division of Healthcare Delivery Research, MedStar Health Research Institute, Hyattsville (S.M.S.), and Fogarty International Center, National Institutes of Health, Bethesda (J.P.R.) - all in Maryland; the Global Health Institute, Department of Epidemiology and Biostatistics (J.P.M., L.M.G.), and the Department of Environmental Health Science, College of Public Health (L.P.N.), University of Georgia, Athens, and the Department of Biostatistics and Bioinformatics (H.H.C., L.A.W., S.J., J.W., Y.C.) and the Gangarosa Department of Environmental Health (A.E.L., K.S., T.F.C.), Rollins School of Public Health, and the Nell Hodgson Woodruff School of Nursing (L.M.T.), Emory University, Atlanta - both in Georgia; the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City (J.P.M., L.M.G., A.C., A.D.-A.); the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Division of Pulmonary and Critical Care Medicine, Georgetown University, Washington DC (S.M.S.); the Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute for Higher Education and Research, Chennai, India (K.B., G.T., S.S.G.); the Global Health Center, Institute for Public Health and Cardiovascular Division, Department of Medicine, Washington University, St. Louis, MO (V.G.D.-R., L.J.U.); the Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley (A.P., W.Y.), and Berkeley Air Monitoring Group (M.A.J.) - both in Berkeley, CA; and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Anaite Diaz-Artiga
- From the Global Program in Pediatric Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences (E.D.M.), the Division of Pulmonary and Critical Care (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Center for Global Non-Communicable Disease Research and Training, School of Medicine (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Department of International Health (E.D.M.) and the Program in Global Disease Epidemiology and Control, Department of International Health (L.H.M.), Bloomberg School of Public Health, Johns Hopkins University, Baltimore, the Division of Healthcare Delivery Research, MedStar Health Research Institute, Hyattsville (S.M.S.), and Fogarty International Center, National Institutes of Health, Bethesda (J.P.R.) - all in Maryland; the Global Health Institute, Department of Epidemiology and Biostatistics (J.P.M., L.M.G.), and the Department of Environmental Health Science, College of Public Health (L.P.N.), University of Georgia, Athens, and the Department of Biostatistics and Bioinformatics (H.H.C., L.A.W., S.J., J.W., Y.C.) and the Gangarosa Department of Environmental Health (A.E.L., K.S., T.F.C.), Rollins School of Public Health, and the Nell Hodgson Woodruff School of Nursing (L.M.T.), Emory University, Atlanta - both in Georgia; the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City (J.P.M., L.M.G., A.C., A.D.-A.); the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Division of Pulmonary and Critical Care Medicine, Georgetown University, Washington DC (S.M.S.); the Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute for Higher Education and Research, Chennai, India (K.B., G.T., S.S.G.); the Global Health Center, Institute for Public Health and Cardiovascular Division, Department of Medicine, Washington University, St. Louis, MO (V.G.D.-R., L.J.U.); the Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley (A.P., W.Y.), and Berkeley Air Monitoring Group (M.A.J.) - both in Berkeley, CA; and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Aris T Papageorghiou
- From the Global Program in Pediatric Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences (E.D.M.), the Division of Pulmonary and Critical Care (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Center for Global Non-Communicable Disease Research and Training, School of Medicine (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Department of International Health (E.D.M.) and the Program in Global Disease Epidemiology and Control, Department of International Health (L.H.M.), Bloomberg School of Public Health, Johns Hopkins University, Baltimore, the Division of Healthcare Delivery Research, MedStar Health Research Institute, Hyattsville (S.M.S.), and Fogarty International Center, National Institutes of Health, Bethesda (J.P.R.) - all in Maryland; the Global Health Institute, Department of Epidemiology and Biostatistics (J.P.M., L.M.G.), and the Department of Environmental Health Science, College of Public Health (L.P.N.), University of Georgia, Athens, and the Department of Biostatistics and Bioinformatics (H.H.C., L.A.W., S.J., J.W., Y.C.) and the Gangarosa Department of Environmental Health (A.E.L., K.S., T.F.C.), Rollins School of Public Health, and the Nell Hodgson Woodruff School of Nursing (L.M.T.), Emory University, Atlanta - both in Georgia; the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City (J.P.M., L.M.G., A.C., A.D.-A.); the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Division of Pulmonary and Critical Care Medicine, Georgetown University, Washington DC (S.M.S.); the Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute for Higher Education and Research, Chennai, India (K.B., G.T., S.S.G.); the Global Health Center, Institute for Public Health and Cardiovascular Division, Department of Medicine, Washington University, St. Louis, MO (V.G.D.-R., L.J.U.); the Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley (A.P., W.Y.), and Berkeley Air Monitoring Group (M.A.J.) - both in Berkeley, CA; and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Victor G Davila-Roman
- From the Global Program in Pediatric Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences (E.D.M.), the Division of Pulmonary and Critical Care (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Center for Global Non-Communicable Disease Research and Training, School of Medicine (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Department of International Health (E.D.M.) and the Program in Global Disease Epidemiology and Control, Department of International Health (L.H.M.), Bloomberg School of Public Health, Johns Hopkins University, Baltimore, the Division of Healthcare Delivery Research, MedStar Health Research Institute, Hyattsville (S.M.S.), and Fogarty International Center, National Institutes of Health, Bethesda (J.P.R.) - all in Maryland; the Global Health Institute, Department of Epidemiology and Biostatistics (J.P.M., L.M.G.), and the Department of Environmental Health Science, College of Public Health (L.P.N.), University of Georgia, Athens, and the Department of Biostatistics and Bioinformatics (H.H.C., L.A.W., S.J., J.W., Y.C.) and the Gangarosa Department of Environmental Health (A.E.L., K.S., T.F.C.), Rollins School of Public Health, and the Nell Hodgson Woodruff School of Nursing (L.M.T.), Emory University, Atlanta - both in Georgia; the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City (J.P.M., L.M.G., A.C., A.D.-A.); the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Division of Pulmonary and Critical Care Medicine, Georgetown University, Washington DC (S.M.S.); the Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute for Higher Education and Research, Chennai, India (K.B., G.T., S.S.G.); the Global Health Center, Institute for Public Health and Cardiovascular Division, Department of Medicine, Washington University, St. Louis, MO (V.G.D.-R., L.J.U.); the Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley (A.P., W.Y.), and Berkeley Air Monitoring Group (M.A.J.) - both in Berkeley, CA; and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Lindsay J Underhill
- From the Global Program in Pediatric Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences (E.D.M.), the Division of Pulmonary and Critical Care (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Center for Global Non-Communicable Disease Research and Training, School of Medicine (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Department of International Health (E.D.M.) and the Program in Global Disease Epidemiology and Control, Department of International Health (L.H.M.), Bloomberg School of Public Health, Johns Hopkins University, Baltimore, the Division of Healthcare Delivery Research, MedStar Health Research Institute, Hyattsville (S.M.S.), and Fogarty International Center, National Institutes of Health, Bethesda (J.P.R.) - all in Maryland; the Global Health Institute, Department of Epidemiology and Biostatistics (J.P.M., L.M.G.), and the Department of Environmental Health Science, College of Public Health (L.P.N.), University of Georgia, Athens, and the Department of Biostatistics and Bioinformatics (H.H.C., L.A.W., S.J., J.W., Y.C.) and the Gangarosa Department of Environmental Health (A.E.L., K.S., T.F.C.), Rollins School of Public Health, and the Nell Hodgson Woodruff School of Nursing (L.M.T.), Emory University, Atlanta - both in Georgia; the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City (J.P.M., L.M.G., A.C., A.D.-A.); the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Division of Pulmonary and Critical Care Medicine, Georgetown University, Washington DC (S.M.S.); the Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute for Higher Education and Research, Chennai, India (K.B., G.T., S.S.G.); the Global Health Center, Institute for Public Health and Cardiovascular Division, Department of Medicine, Washington University, St. Louis, MO (V.G.D.-R., L.J.U.); the Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley (A.P., W.Y.), and Berkeley Air Monitoring Group (M.A.J.) - both in Berkeley, CA; and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Stella M Hartinger
- From the Global Program in Pediatric Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences (E.D.M.), the Division of Pulmonary and Critical Care (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Center for Global Non-Communicable Disease Research and Training, School of Medicine (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Department of International Health (E.D.M.) and the Program in Global Disease Epidemiology and Control, Department of International Health (L.H.M.), Bloomberg School of Public Health, Johns Hopkins University, Baltimore, the Division of Healthcare Delivery Research, MedStar Health Research Institute, Hyattsville (S.M.S.), and Fogarty International Center, National Institutes of Health, Bethesda (J.P.R.) - all in Maryland; the Global Health Institute, Department of Epidemiology and Biostatistics (J.P.M., L.M.G.), and the Department of Environmental Health Science, College of Public Health (L.P.N.), University of Georgia, Athens, and the Department of Biostatistics and Bioinformatics (H.H.C., L.A.W., S.J., J.W., Y.C.) and the Gangarosa Department of Environmental Health (A.E.L., K.S., T.F.C.), Rollins School of Public Health, and the Nell Hodgson Woodruff School of Nursing (L.M.T.), Emory University, Atlanta - both in Georgia; the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City (J.P.M., L.M.G., A.C., A.D.-A.); the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Division of Pulmonary and Critical Care Medicine, Georgetown University, Washington DC (S.M.S.); the Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute for Higher Education and Research, Chennai, India (K.B., G.T., S.S.G.); the Global Health Center, Institute for Public Health and Cardiovascular Division, Department of Medicine, Washington University, St. Louis, MO (V.G.D.-R., L.J.U.); the Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley (A.P., W.Y.), and Berkeley Air Monitoring Group (M.A.J.) - both in Berkeley, CA; and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Kendra N Williams
- From the Global Program in Pediatric Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences (E.D.M.), the Division of Pulmonary and Critical Care (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Center for Global Non-Communicable Disease Research and Training, School of Medicine (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Department of International Health (E.D.M.) and the Program in Global Disease Epidemiology and Control, Department of International Health (L.H.M.), Bloomberg School of Public Health, Johns Hopkins University, Baltimore, the Division of Healthcare Delivery Research, MedStar Health Research Institute, Hyattsville (S.M.S.), and Fogarty International Center, National Institutes of Health, Bethesda (J.P.R.) - all in Maryland; the Global Health Institute, Department of Epidemiology and Biostatistics (J.P.M., L.M.G.), and the Department of Environmental Health Science, College of Public Health (L.P.N.), University of Georgia, Athens, and the Department of Biostatistics and Bioinformatics (H.H.C., L.A.W., S.J., J.W., Y.C.) and the Gangarosa Department of Environmental Health (A.E.L., K.S., T.F.C.), Rollins School of Public Health, and the Nell Hodgson Woodruff School of Nursing (L.M.T.), Emory University, Atlanta - both in Georgia; the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City (J.P.M., L.M.G., A.C., A.D.-A.); the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Division of Pulmonary and Critical Care Medicine, Georgetown University, Washington DC (S.M.S.); the Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute for Higher Education and Research, Chennai, India (K.B., G.T., S.S.G.); the Global Health Center, Institute for Public Health and Cardiovascular Division, Department of Medicine, Washington University, St. Louis, MO (V.G.D.-R., L.J.U.); the Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley (A.P., W.Y.), and Berkeley Air Monitoring Group (M.A.J.) - both in Berkeley, CA; and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Laura Nicolaou
- From the Global Program in Pediatric Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences (E.D.M.), the Division of Pulmonary and Critical Care (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Center for Global Non-Communicable Disease Research and Training, School of Medicine (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Department of International Health (E.D.M.) and the Program in Global Disease Epidemiology and Control, Department of International Health (L.H.M.), Bloomberg School of Public Health, Johns Hopkins University, Baltimore, the Division of Healthcare Delivery Research, MedStar Health Research Institute, Hyattsville (S.M.S.), and Fogarty International Center, National Institutes of Health, Bethesda (J.P.R.) - all in Maryland; the Global Health Institute, Department of Epidemiology and Biostatistics (J.P.M., L.M.G.), and the Department of Environmental Health Science, College of Public Health (L.P.N.), University of Georgia, Athens, and the Department of Biostatistics and Bioinformatics (H.H.C., L.A.W., S.J., J.W., Y.C.) and the Gangarosa Department of Environmental Health (A.E.L., K.S., T.F.C.), Rollins School of Public Health, and the Nell Hodgson Woodruff School of Nursing (L.M.T.), Emory University, Atlanta - both in Georgia; the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City (J.P.M., L.M.G., A.C., A.D.-A.); the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Division of Pulmonary and Critical Care Medicine, Georgetown University, Washington DC (S.M.S.); the Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute for Higher Education and Research, Chennai, India (K.B., G.T., S.S.G.); the Global Health Center, Institute for Public Health and Cardiovascular Division, Department of Medicine, Washington University, St. Louis, MO (V.G.D.-R., L.J.U.); the Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley (A.P., W.Y.), and Berkeley Air Monitoring Group (M.A.J.) - both in Berkeley, CA; and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Howard H Chang
- From the Global Program in Pediatric Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences (E.D.M.), the Division of Pulmonary and Critical Care (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Center for Global Non-Communicable Disease Research and Training, School of Medicine (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Department of International Health (E.D.M.) and the Program in Global Disease Epidemiology and Control, Department of International Health (L.H.M.), Bloomberg School of Public Health, Johns Hopkins University, Baltimore, the Division of Healthcare Delivery Research, MedStar Health Research Institute, Hyattsville (S.M.S.), and Fogarty International Center, National Institutes of Health, Bethesda (J.P.R.) - all in Maryland; the Global Health Institute, Department of Epidemiology and Biostatistics (J.P.M., L.M.G.), and the Department of Environmental Health Science, College of Public Health (L.P.N.), University of Georgia, Athens, and the Department of Biostatistics and Bioinformatics (H.H.C., L.A.W., S.J., J.W., Y.C.) and the Gangarosa Department of Environmental Health (A.E.L., K.S., T.F.C.), Rollins School of Public Health, and the Nell Hodgson Woodruff School of Nursing (L.M.T.), Emory University, Atlanta - both in Georgia; the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City (J.P.M., L.M.G., A.C., A.D.-A.); the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Division of Pulmonary and Critical Care Medicine, Georgetown University, Washington DC (S.M.S.); the Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute for Higher Education and Research, Chennai, India (K.B., G.T., S.S.G.); the Global Health Center, Institute for Public Health and Cardiovascular Division, Department of Medicine, Washington University, St. Louis, MO (V.G.D.-R., L.J.U.); the Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley (A.P., W.Y.), and Berkeley Air Monitoring Group (M.A.J.) - both in Berkeley, CA; and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Amy E Lovvorn
- From the Global Program in Pediatric Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences (E.D.M.), the Division of Pulmonary and Critical Care (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Center for Global Non-Communicable Disease Research and Training, School of Medicine (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Department of International Health (E.D.M.) and the Program in Global Disease Epidemiology and Control, Department of International Health (L.H.M.), Bloomberg School of Public Health, Johns Hopkins University, Baltimore, the Division of Healthcare Delivery Research, MedStar Health Research Institute, Hyattsville (S.M.S.), and Fogarty International Center, National Institutes of Health, Bethesda (J.P.R.) - all in Maryland; the Global Health Institute, Department of Epidemiology and Biostatistics (J.P.M., L.M.G.), and the Department of Environmental Health Science, College of Public Health (L.P.N.), University of Georgia, Athens, and the Department of Biostatistics and Bioinformatics (H.H.C., L.A.W., S.J., J.W., Y.C.) and the Gangarosa Department of Environmental Health (A.E.L., K.S., T.F.C.), Rollins School of Public Health, and the Nell Hodgson Woodruff School of Nursing (L.M.T.), Emory University, Atlanta - both in Georgia; the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City (J.P.M., L.M.G., A.C., A.D.-A.); the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Division of Pulmonary and Critical Care Medicine, Georgetown University, Washington DC (S.M.S.); the Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute for Higher Education and Research, Chennai, India (K.B., G.T., S.S.G.); the Global Health Center, Institute for Public Health and Cardiovascular Division, Department of Medicine, Washington University, St. Louis, MO (V.G.D.-R., L.J.U.); the Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley (A.P., W.Y.), and Berkeley Air Monitoring Group (M.A.J.) - both in Berkeley, CA; and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Joshua P Rosenthal
- From the Global Program in Pediatric Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences (E.D.M.), the Division of Pulmonary and Critical Care (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Center for Global Non-Communicable Disease Research and Training, School of Medicine (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Department of International Health (E.D.M.) and the Program in Global Disease Epidemiology and Control, Department of International Health (L.H.M.), Bloomberg School of Public Health, Johns Hopkins University, Baltimore, the Division of Healthcare Delivery Research, MedStar Health Research Institute, Hyattsville (S.M.S.), and Fogarty International Center, National Institutes of Health, Bethesda (J.P.R.) - all in Maryland; the Global Health Institute, Department of Epidemiology and Biostatistics (J.P.M., L.M.G.), and the Department of Environmental Health Science, College of Public Health (L.P.N.), University of Georgia, Athens, and the Department of Biostatistics and Bioinformatics (H.H.C., L.A.W., S.J., J.W., Y.C.) and the Gangarosa Department of Environmental Health (A.E.L., K.S., T.F.C.), Rollins School of Public Health, and the Nell Hodgson Woodruff School of Nursing (L.M.T.), Emory University, Atlanta - both in Georgia; the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City (J.P.M., L.M.G., A.C., A.D.-A.); the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Division of Pulmonary and Critical Care Medicine, Georgetown University, Washington DC (S.M.S.); the Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute for Higher Education and Research, Chennai, India (K.B., G.T., S.S.G.); the Global Health Center, Institute for Public Health and Cardiovascular Division, Department of Medicine, Washington University, St. Louis, MO (V.G.D.-R., L.J.U.); the Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley (A.P., W.Y.), and Berkeley Air Monitoring Group (M.A.J.) - both in Berkeley, CA; and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Ajay Pillarisetti
- From the Global Program in Pediatric Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences (E.D.M.), the Division of Pulmonary and Critical Care (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Center for Global Non-Communicable Disease Research and Training, School of Medicine (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Department of International Health (E.D.M.) and the Program in Global Disease Epidemiology and Control, Department of International Health (L.H.M.), Bloomberg School of Public Health, Johns Hopkins University, Baltimore, the Division of Healthcare Delivery Research, MedStar Health Research Institute, Hyattsville (S.M.S.), and Fogarty International Center, National Institutes of Health, Bethesda (J.P.R.) - all in Maryland; the Global Health Institute, Department of Epidemiology and Biostatistics (J.P.M., L.M.G.), and the Department of Environmental Health Science, College of Public Health (L.P.N.), University of Georgia, Athens, and the Department of Biostatistics and Bioinformatics (H.H.C., L.A.W., S.J., J.W., Y.C.) and the Gangarosa Department of Environmental Health (A.E.L., K.S., T.F.C.), Rollins School of Public Health, and the Nell Hodgson Woodruff School of Nursing (L.M.T.), Emory University, Atlanta - both in Georgia; the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City (J.P.M., L.M.G., A.C., A.D.-A.); the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Division of Pulmonary and Critical Care Medicine, Georgetown University, Washington DC (S.M.S.); the Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute for Higher Education and Research, Chennai, India (K.B., G.T., S.S.G.); the Global Health Center, Institute for Public Health and Cardiovascular Division, Department of Medicine, Washington University, St. Louis, MO (V.G.D.-R., L.J.U.); the Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley (A.P., W.Y.), and Berkeley Air Monitoring Group (M.A.J.) - both in Berkeley, CA; and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Wenlu Ye
- From the Global Program in Pediatric Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences (E.D.M.), the Division of Pulmonary and Critical Care (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Center for Global Non-Communicable Disease Research and Training, School of Medicine (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Department of International Health (E.D.M.) and the Program in Global Disease Epidemiology and Control, Department of International Health (L.H.M.), Bloomberg School of Public Health, Johns Hopkins University, Baltimore, the Division of Healthcare Delivery Research, MedStar Health Research Institute, Hyattsville (S.M.S.), and Fogarty International Center, National Institutes of Health, Bethesda (J.P.R.) - all in Maryland; the Global Health Institute, Department of Epidemiology and Biostatistics (J.P.M., L.M.G.), and the Department of Environmental Health Science, College of Public Health (L.P.N.), University of Georgia, Athens, and the Department of Biostatistics and Bioinformatics (H.H.C., L.A.W., S.J., J.W., Y.C.) and the Gangarosa Department of Environmental Health (A.E.L., K.S., T.F.C.), Rollins School of Public Health, and the Nell Hodgson Woodruff School of Nursing (L.M.T.), Emory University, Atlanta - both in Georgia; the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City (J.P.M., L.M.G., A.C., A.D.-A.); the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Division of Pulmonary and Critical Care Medicine, Georgetown University, Washington DC (S.M.S.); the Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute for Higher Education and Research, Chennai, India (K.B., G.T., S.S.G.); the Global Health Center, Institute for Public Health and Cardiovascular Division, Department of Medicine, Washington University, St. Louis, MO (V.G.D.-R., L.J.U.); the Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley (A.P., W.Y.), and Berkeley Air Monitoring Group (M.A.J.) - both in Berkeley, CA; and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Luke P Naeher
- From the Global Program in Pediatric Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences (E.D.M.), the Division of Pulmonary and Critical Care (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Center for Global Non-Communicable Disease Research and Training, School of Medicine (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Department of International Health (E.D.M.) and the Program in Global Disease Epidemiology and Control, Department of International Health (L.H.M.), Bloomberg School of Public Health, Johns Hopkins University, Baltimore, the Division of Healthcare Delivery Research, MedStar Health Research Institute, Hyattsville (S.M.S.), and Fogarty International Center, National Institutes of Health, Bethesda (J.P.R.) - all in Maryland; the Global Health Institute, Department of Epidemiology and Biostatistics (J.P.M., L.M.G.), and the Department of Environmental Health Science, College of Public Health (L.P.N.), University of Georgia, Athens, and the Department of Biostatistics and Bioinformatics (H.H.C., L.A.W., S.J., J.W., Y.C.) and the Gangarosa Department of Environmental Health (A.E.L., K.S., T.F.C.), Rollins School of Public Health, and the Nell Hodgson Woodruff School of Nursing (L.M.T.), Emory University, Atlanta - both in Georgia; the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City (J.P.M., L.M.G., A.C., A.D.-A.); the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Division of Pulmonary and Critical Care Medicine, Georgetown University, Washington DC (S.M.S.); the Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute for Higher Education and Research, Chennai, India (K.B., G.T., S.S.G.); the Global Health Center, Institute for Public Health and Cardiovascular Division, Department of Medicine, Washington University, St. Louis, MO (V.G.D.-R., L.J.U.); the Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley (A.P., W.Y.), and Berkeley Air Monitoring Group (M.A.J.) - both in Berkeley, CA; and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Michael A Johnson
- From the Global Program in Pediatric Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences (E.D.M.), the Division of Pulmonary and Critical Care (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Center for Global Non-Communicable Disease Research and Training, School of Medicine (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Department of International Health (E.D.M.) and the Program in Global Disease Epidemiology and Control, Department of International Health (L.H.M.), Bloomberg School of Public Health, Johns Hopkins University, Baltimore, the Division of Healthcare Delivery Research, MedStar Health Research Institute, Hyattsville (S.M.S.), and Fogarty International Center, National Institutes of Health, Bethesda (J.P.R.) - all in Maryland; the Global Health Institute, Department of Epidemiology and Biostatistics (J.P.M., L.M.G.), and the Department of Environmental Health Science, College of Public Health (L.P.N.), University of Georgia, Athens, and the Department of Biostatistics and Bioinformatics (H.H.C., L.A.W., S.J., J.W., Y.C.) and the Gangarosa Department of Environmental Health (A.E.L., K.S., T.F.C.), Rollins School of Public Health, and the Nell Hodgson Woodruff School of Nursing (L.M.T.), Emory University, Atlanta - both in Georgia; the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City (J.P.M., L.M.G., A.C., A.D.-A.); the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Division of Pulmonary and Critical Care Medicine, Georgetown University, Washington DC (S.M.S.); the Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute for Higher Education and Research, Chennai, India (K.B., G.T., S.S.G.); the Global Health Center, Institute for Public Health and Cardiovascular Division, Department of Medicine, Washington University, St. Louis, MO (V.G.D.-R., L.J.U.); the Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley (A.P., W.Y.), and Berkeley Air Monitoring Group (M.A.J.) - both in Berkeley, CA; and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Lance A Waller
- From the Global Program in Pediatric Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences (E.D.M.), the Division of Pulmonary and Critical Care (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Center for Global Non-Communicable Disease Research and Training, School of Medicine (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Department of International Health (E.D.M.) and the Program in Global Disease Epidemiology and Control, Department of International Health (L.H.M.), Bloomberg School of Public Health, Johns Hopkins University, Baltimore, the Division of Healthcare Delivery Research, MedStar Health Research Institute, Hyattsville (S.M.S.), and Fogarty International Center, National Institutes of Health, Bethesda (J.P.R.) - all in Maryland; the Global Health Institute, Department of Epidemiology and Biostatistics (J.P.M., L.M.G.), and the Department of Environmental Health Science, College of Public Health (L.P.N.), University of Georgia, Athens, and the Department of Biostatistics and Bioinformatics (H.H.C., L.A.W., S.J., J.W., Y.C.) and the Gangarosa Department of Environmental Health (A.E.L., K.S., T.F.C.), Rollins School of Public Health, and the Nell Hodgson Woodruff School of Nursing (L.M.T.), Emory University, Atlanta - both in Georgia; the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City (J.P.M., L.M.G., A.C., A.D.-A.); the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Division of Pulmonary and Critical Care Medicine, Georgetown University, Washington DC (S.M.S.); the Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute for Higher Education and Research, Chennai, India (K.B., G.T., S.S.G.); the Global Health Center, Institute for Public Health and Cardiovascular Division, Department of Medicine, Washington University, St. Louis, MO (V.G.D.-R., L.J.U.); the Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley (A.P., W.Y.), and Berkeley Air Monitoring Group (M.A.J.) - both in Berkeley, CA; and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Shirin Jabbarzadeh
- From the Global Program in Pediatric Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences (E.D.M.), the Division of Pulmonary and Critical Care (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Center for Global Non-Communicable Disease Research and Training, School of Medicine (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Department of International Health (E.D.M.) and the Program in Global Disease Epidemiology and Control, Department of International Health (L.H.M.), Bloomberg School of Public Health, Johns Hopkins University, Baltimore, the Division of Healthcare Delivery Research, MedStar Health Research Institute, Hyattsville (S.M.S.), and Fogarty International Center, National Institutes of Health, Bethesda (J.P.R.) - all in Maryland; the Global Health Institute, Department of Epidemiology and Biostatistics (J.P.M., L.M.G.), and the Department of Environmental Health Science, College of Public Health (L.P.N.), University of Georgia, Athens, and the Department of Biostatistics and Bioinformatics (H.H.C., L.A.W., S.J., J.W., Y.C.) and the Gangarosa Department of Environmental Health (A.E.L., K.S., T.F.C.), Rollins School of Public Health, and the Nell Hodgson Woodruff School of Nursing (L.M.T.), Emory University, Atlanta - both in Georgia; the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City (J.P.M., L.M.G., A.C., A.D.-A.); the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Division of Pulmonary and Critical Care Medicine, Georgetown University, Washington DC (S.M.S.); the Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute for Higher Education and Research, Chennai, India (K.B., G.T., S.S.G.); the Global Health Center, Institute for Public Health and Cardiovascular Division, Department of Medicine, Washington University, St. Louis, MO (V.G.D.-R., L.J.U.); the Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley (A.P., W.Y.), and Berkeley Air Monitoring Group (M.A.J.) - both in Berkeley, CA; and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Jiantong Wang
- From the Global Program in Pediatric Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences (E.D.M.), the Division of Pulmonary and Critical Care (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Center for Global Non-Communicable Disease Research and Training, School of Medicine (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Department of International Health (E.D.M.) and the Program in Global Disease Epidemiology and Control, Department of International Health (L.H.M.), Bloomberg School of Public Health, Johns Hopkins University, Baltimore, the Division of Healthcare Delivery Research, MedStar Health Research Institute, Hyattsville (S.M.S.), and Fogarty International Center, National Institutes of Health, Bethesda (J.P.R.) - all in Maryland; the Global Health Institute, Department of Epidemiology and Biostatistics (J.P.M., L.M.G.), and the Department of Environmental Health Science, College of Public Health (L.P.N.), University of Georgia, Athens, and the Department of Biostatistics and Bioinformatics (H.H.C., L.A.W., S.J., J.W., Y.C.) and the Gangarosa Department of Environmental Health (A.E.L., K.S., T.F.C.), Rollins School of Public Health, and the Nell Hodgson Woodruff School of Nursing (L.M.T.), Emory University, Atlanta - both in Georgia; the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City (J.P.M., L.M.G., A.C., A.D.-A.); the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Division of Pulmonary and Critical Care Medicine, Georgetown University, Washington DC (S.M.S.); the Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute for Higher Education and Research, Chennai, India (K.B., G.T., S.S.G.); the Global Health Center, Institute for Public Health and Cardiovascular Division, Department of Medicine, Washington University, St. Louis, MO (V.G.D.-R., L.J.U.); the Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley (A.P., W.Y.), and Berkeley Air Monitoring Group (M.A.J.) - both in Berkeley, CA; and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Yunyun Chen
- From the Global Program in Pediatric Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences (E.D.M.), the Division of Pulmonary and Critical Care (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Center for Global Non-Communicable Disease Research and Training, School of Medicine (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Department of International Health (E.D.M.) and the Program in Global Disease Epidemiology and Control, Department of International Health (L.H.M.), Bloomberg School of Public Health, Johns Hopkins University, Baltimore, the Division of Healthcare Delivery Research, MedStar Health Research Institute, Hyattsville (S.M.S.), and Fogarty International Center, National Institutes of Health, Bethesda (J.P.R.) - all in Maryland; the Global Health Institute, Department of Epidemiology and Biostatistics (J.P.M., L.M.G.), and the Department of Environmental Health Science, College of Public Health (L.P.N.), University of Georgia, Athens, and the Department of Biostatistics and Bioinformatics (H.H.C., L.A.W., S.J., J.W., Y.C.) and the Gangarosa Department of Environmental Health (A.E.L., K.S., T.F.C.), Rollins School of Public Health, and the Nell Hodgson Woodruff School of Nursing (L.M.T.), Emory University, Atlanta - both in Georgia; the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City (J.P.M., L.M.G., A.C., A.D.-A.); the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Division of Pulmonary and Critical Care Medicine, Georgetown University, Washington DC (S.M.S.); the Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute for Higher Education and Research, Chennai, India (K.B., G.T., S.S.G.); the Global Health Center, Institute for Public Health and Cardiovascular Division, Department of Medicine, Washington University, St. Louis, MO (V.G.D.-R., L.J.U.); the Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley (A.P., W.Y.), and Berkeley Air Monitoring Group (M.A.J.) - both in Berkeley, CA; and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Kyle Steenland
- From the Global Program in Pediatric Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences (E.D.M.), the Division of Pulmonary and Critical Care (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Center for Global Non-Communicable Disease Research and Training, School of Medicine (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Department of International Health (E.D.M.) and the Program in Global Disease Epidemiology and Control, Department of International Health (L.H.M.), Bloomberg School of Public Health, Johns Hopkins University, Baltimore, the Division of Healthcare Delivery Research, MedStar Health Research Institute, Hyattsville (S.M.S.), and Fogarty International Center, National Institutes of Health, Bethesda (J.P.R.) - all in Maryland; the Global Health Institute, Department of Epidemiology and Biostatistics (J.P.M., L.M.G.), and the Department of Environmental Health Science, College of Public Health (L.P.N.), University of Georgia, Athens, and the Department of Biostatistics and Bioinformatics (H.H.C., L.A.W., S.J., J.W., Y.C.) and the Gangarosa Department of Environmental Health (A.E.L., K.S., T.F.C.), Rollins School of Public Health, and the Nell Hodgson Woodruff School of Nursing (L.M.T.), Emory University, Atlanta - both in Georgia; the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City (J.P.M., L.M.G., A.C., A.D.-A.); the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Division of Pulmonary and Critical Care Medicine, Georgetown University, Washington DC (S.M.S.); the Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute for Higher Education and Research, Chennai, India (K.B., G.T., S.S.G.); the Global Health Center, Institute for Public Health and Cardiovascular Division, Department of Medicine, Washington University, St. Louis, MO (V.G.D.-R., L.J.U.); the Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley (A.P., W.Y.), and Berkeley Air Monitoring Group (M.A.J.) - both in Berkeley, CA; and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Thomas F Clasen
- From the Global Program in Pediatric Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences (E.D.M.), the Division of Pulmonary and Critical Care (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Center for Global Non-Communicable Disease Research and Training, School of Medicine (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Department of International Health (E.D.M.) and the Program in Global Disease Epidemiology and Control, Department of International Health (L.H.M.), Bloomberg School of Public Health, Johns Hopkins University, Baltimore, the Division of Healthcare Delivery Research, MedStar Health Research Institute, Hyattsville (S.M.S.), and Fogarty International Center, National Institutes of Health, Bethesda (J.P.R.) - all in Maryland; the Global Health Institute, Department of Epidemiology and Biostatistics (J.P.M., L.M.G.), and the Department of Environmental Health Science, College of Public Health (L.P.N.), University of Georgia, Athens, and the Department of Biostatistics and Bioinformatics (H.H.C., L.A.W., S.J., J.W., Y.C.) and the Gangarosa Department of Environmental Health (A.E.L., K.S., T.F.C.), Rollins School of Public Health, and the Nell Hodgson Woodruff School of Nursing (L.M.T.), Emory University, Atlanta - both in Georgia; the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City (J.P.M., L.M.G., A.C., A.D.-A.); the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Division of Pulmonary and Critical Care Medicine, Georgetown University, Washington DC (S.M.S.); the Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute for Higher Education and Research, Chennai, India (K.B., G.T., S.S.G.); the Global Health Center, Institute for Public Health and Cardiovascular Division, Department of Medicine, Washington University, St. Louis, MO (V.G.D.-R., L.J.U.); the Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley (A.P., W.Y.), and Berkeley Air Monitoring Group (M.A.J.) - both in Berkeley, CA; and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Jennifer L Peel
- From the Global Program in Pediatric Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences (E.D.M.), the Division of Pulmonary and Critical Care (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Center for Global Non-Communicable Disease Research and Training, School of Medicine (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Department of International Health (E.D.M.) and the Program in Global Disease Epidemiology and Control, Department of International Health (L.H.M.), Bloomberg School of Public Health, Johns Hopkins University, Baltimore, the Division of Healthcare Delivery Research, MedStar Health Research Institute, Hyattsville (S.M.S.), and Fogarty International Center, National Institutes of Health, Bethesda (J.P.R.) - all in Maryland; the Global Health Institute, Department of Epidemiology and Biostatistics (J.P.M., L.M.G.), and the Department of Environmental Health Science, College of Public Health (L.P.N.), University of Georgia, Athens, and the Department of Biostatistics and Bioinformatics (H.H.C., L.A.W., S.J., J.W., Y.C.) and the Gangarosa Department of Environmental Health (A.E.L., K.S., T.F.C.), Rollins School of Public Health, and the Nell Hodgson Woodruff School of Nursing (L.M.T.), Emory University, Atlanta - both in Georgia; the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City (J.P.M., L.M.G., A.C., A.D.-A.); the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Division of Pulmonary and Critical Care Medicine, Georgetown University, Washington DC (S.M.S.); the Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute for Higher Education and Research, Chennai, India (K.B., G.T., S.S.G.); the Global Health Center, Institute for Public Health and Cardiovascular Division, Department of Medicine, Washington University, St. Louis, MO (V.G.D.-R., L.J.U.); the Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley (A.P., W.Y.), and Berkeley Air Monitoring Group (M.A.J.) - both in Berkeley, CA; and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - William Checkley
- From the Global Program in Pediatric Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences (E.D.M.), the Division of Pulmonary and Critical Care (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Center for Global Non-Communicable Disease Research and Training, School of Medicine (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Department of International Health (E.D.M.) and the Program in Global Disease Epidemiology and Control, Department of International Health (L.H.M.), Bloomberg School of Public Health, Johns Hopkins University, Baltimore, the Division of Healthcare Delivery Research, MedStar Health Research Institute, Hyattsville (S.M.S.), and Fogarty International Center, National Institutes of Health, Bethesda (J.P.R.) - all in Maryland; the Global Health Institute, Department of Epidemiology and Biostatistics (J.P.M., L.M.G.), and the Department of Environmental Health Science, College of Public Health (L.P.N.), University of Georgia, Athens, and the Department of Biostatistics and Bioinformatics (H.H.C., L.A.W., S.J., J.W., Y.C.) and the Gangarosa Department of Environmental Health (A.E.L., K.S., T.F.C.), Rollins School of Public Health, and the Nell Hodgson Woodruff School of Nursing (L.M.T.), Emory University, Atlanta - both in Georgia; the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City (J.P.M., L.M.G., A.C., A.D.-A.); the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Division of Pulmonary and Critical Care Medicine, Georgetown University, Washington DC (S.M.S.); the Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute for Higher Education and Research, Chennai, India (K.B., G.T., S.S.G.); the Global Health Center, Institute for Public Health and Cardiovascular Division, Department of Medicine, Washington University, St. Louis, MO (V.G.D.-R., L.J.U.); the Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley (A.P., W.Y.), and Berkeley Air Monitoring Group (M.A.J.) - both in Berkeley, CA; and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
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Lu W, Jenny A, Romero C, Diaz-Artiga A, Kuster A, Canuz E, Pillarisetti A, McCracken JP, Huang W, Smith KR, Balmes J, Thompson LM. Biomass smoke exposure and somatic growth among children: The RESPIRE and CRECER prospective cohort studies in rural Guatemala. ENVIRONMENT INTERNATIONAL 2024; 183:108401. [PMID: 38147790 DOI: 10.1016/j.envint.2023.108401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Revised: 12/11/2023] [Accepted: 12/20/2023] [Indexed: 12/28/2023]
Abstract
BACKGROUND Cooking-related biomass smoke is a major source of household air pollution (HAP) and an important health hazard. Prior studies identified associations between HAP exposure and childhood stunting; less is known for underweight and wasting. Few studies had personal HAP measurements. METHODS 557 households in rural Guatemala were enrolled in the CRECER study, the follow-up study of the RESPIRE randomized intervention trial. They were assigned to three groups that received chimney stoves at different ages of the study children. Multiple personal carbon monoxide (CO) exposure measurements were used as proxies for HAP exposures. Children's heights and weights were measured from 24 to 60 months of age. Height-for-age z-score (HAZ), weight-for-age z-score (WAZ), and weight-for-height z-score (WHZ) were calculated based on the World Health Organization's Multicentre Growth Reference Study. HAZ, WAZ, and WHZ below -2 were classified as stunting, underweight, and wasting, respectively. Generalized linear models and mixed effects models were applied. RESULTS 541 children had valid anthropometric data, among whom 488 (90.2 %) were stunted, 192 (35.5 %) were underweight, and 2 (0.3 %) were wasted. A 1 ppm higher average CO exposure was associated with a 0.21 lower HAZ (95 % CI: 0.17-0.25), a 0.13 lower WAZ (95 % CI: 0.10-0.17) and a 0.06 lower WHZ (95 % CI: 0.02-0.10).The associations for HAZ were stronger among boys (coefficient = -0.29, 95 % CI: -0.35 - -0.22) than among girls (coefficient = -0.15, 95 % CI: -0.20 - -0.10). A 1 ppm-year higher cumulative CO exposure was associated with a higher risk of moderate stunting among boys (OR = 1.27, 95 % CI: 1.05-1.59), but not among girls. DISCUSSION In this rural Guatemalan population, higher HAP exposure was associated with lower HAZ and WAZ. The associations between HAP and HAZ/stunting were stronger among boys. Reducing HAP might benefit childhood somatic growth in rural populations of low-income countries.
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Affiliation(s)
- Wenxin Lu
- School of Public Health, University of California, Berkeley, 94720 Berkeley, CA, USA.
| | - Alisa Jenny
- Institute for Global Health Sciences, University of California, San Francisco, 94158 San Francisco, CA, USA.
| | - Carolina Romero
- Centro de Estudios en Salud, Universidad del Valle de Guatemala, Guatemala City, Guatemala.
| | - Anaite Diaz-Artiga
- Centro de Estudios en Salud, Universidad del Valle de Guatemala, Guatemala City, Guatemala.
| | - Andrea Kuster
- School of Nursing, University of California, San Francisco, 94158 San Francisco, CA, USA.
| | - Eduardo Canuz
- Centro de Estudios en Salud, Universidad del Valle de Guatemala, Guatemala City, Guatemala.
| | - Ajay Pillarisetti
- School of Public Health, University of California, Berkeley, 94720 Berkeley, CA, USA.
| | - John P McCracken
- Epidemiology and Biostatistics Department, University of Georgia, 30606 Athens, GA, USA.
| | - Wenzhong Huang
- Climate, Air Quality Research Unit, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia.
| | - Kirk R Smith
- School of Public Health, University of California, Berkeley, 94720 Berkeley, CA, USA
| | - John Balmes
- School of Public Health, University of California, Berkeley, 94720 Berkeley, CA, USA; Department of Medicine, University of California, San Francisco, San Francisco, CA, USA.
| | - Lisa M Thompson
- Nell Hodgson Woodruff School of Nursing, Emory University, 30322 Atlanta, GA, USA.
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Kearns KA, Naeher LP, McCracken JP, Boyd Barr D, Saikawa E, Hengstermann M, Mollinedo E, Panuwet P, Yakimavets V, Lee GE, Thompson LM. Estimating personal exposures to household air pollution and plastic garbage burning among adolescent girls in Jalapa, Guatemala. CHEMOSPHERE 2024; 348:140705. [PMID: 37981014 PMCID: PMC10714129 DOI: 10.1016/j.chemosphere.2023.140705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 11/10/2023] [Accepted: 11/11/2023] [Indexed: 11/21/2023]
Abstract
Waste collection services are uncommon in rural areas of low-resource countries, causing waste accumulation and subsequent dumping and burning of garbage. Air pollution from household garbage burning, including plastics, has been observed in Jalapa, Guatemala in addition to household air pollution (HAP) from cooking. Adolescent girls often help with these cooking and household tasks, but little is known about their exposures. We characterized 24-h exposures to HAP and household garbage burning in adolescent girls by measuring fine particulate matter (PM2.5), black carbon (BC), urinary biomarkers of polycyclic aromatic hydrocarbons (PAHs), bisphenol A (BPA), and phthalates. We recruited 60 girls between 13 and 17 years of age who helped with cooking activities and lived with participants of the Household Air Pollution Intervention Network (HAPIN) trial. We recruited n = 30 girls each from the control (wood-burning stove) and intervention (liquefied petroleum gas stove) arms. We also measured real-time kitchen concentrations of BC in 20 homes (33%). PM2.5 and BC were measured in n = 21 control and n = 20 intervention participants. Median concentrations of personal PM2.5 and BC and kitchen BC were lower (p < 0.05) in the intervention arm by 87%, 80%, and 85%, respectively. PAH metabolite concentrations were lower (p < 0.001) for all nine metabolites in intervention (n = 26) compared to control participants (n = 29). Urinary BPA concentrations were 66% higher in participants who reported using cosmetics (p = 0.02), and phthalate concentrations were 63% higher in participants who had reported using hair products during the sample period (p = 0.05). Our results suggest that gas stoves can reduce HAP exposures among adolescents who are not primary cooks at home. Biomarkers of plastic exposure were not associated with intervention status, but some were elevated compared to age- and sex-matched participants of the National Health and Nutrition Examination Survey (NHANES).
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Affiliation(s)
- Katherine A Kearns
- University of Georgia, Department of Environmental Health Science, College of Public Health, Athens, GA, USA
| | - Luke P Naeher
- University of Georgia, Department of Environmental Health Science, College of Public Health, Athens, GA, USA
| | - John P McCracken
- University of Georgia, Department of Environmental Health Science, College of Public Health, Athens, GA, USA; Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala
| | - Dana Boyd Barr
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Eri Saikawa
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Mayari Hengstermann
- Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala
| | - Erick Mollinedo
- University of Georgia, Department of Environmental Health Science, College of Public Health, Athens, GA, USA; Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala
| | - Parinya Panuwet
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Volha Yakimavets
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Grace E Lee
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Lisa M Thompson
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA; Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA, USA.
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10
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Katoto PDMC, Bihehe D, Brand A, Mushi R, Kusinza A, Alwood BW, van Zyl-Smit RN, Tamuzi JL, Sam-Agudu NA, Yotebieng M, Metcalfe J, Theron G, Godri Pollitt KJ, Lesosky M, Vanoirbeek J, Mortimer K, Nawrot T, Nemery B, Nachega JB. Household Air Pollution and Risk of Pulmonary Tuberculosis in HIV-Infected Adults. RESEARCH SQUARE 2023:rs.3.rs-3410503. [PMID: 37886487 PMCID: PMC10602081 DOI: 10.21203/rs.3.rs-3410503/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/28/2023]
Abstract
Background In developing countries, millions of deaths occur annually from household air pollution (HAP), pulmonary tuberculosis (PTB), and HIV-infection. However, it is unknown whether HAP influences PTB risk among people living with HIV-infection. Methods We conducted a case-control study among 1,277 HIV-infected adults in Bukavu, eastern Democratic Republic of Congo (February 2018 - March 2019). Cases had current or recent (<5y) PTB (positive sputum smear or Xpert MTB/RIF), controls had no PTB. Daily and lifetime HAP exposure were assessed by questionnaire and, in a random sub-sample (n=270), by 24-hour measurements of personal carbon monoxide (CO) at home. We used multivariable logistic regression to examine the associations between HAP and PTB. Results We recruited 435 cases and 842 controls (median age 41 years, [IQR] 33-50; 76% female). Cases were more likely to be female than male (63% vs 37%). Participants reporting cooking for >3h/day and ≥2 times/day and ≥5 days/weekwere more likely to have PTB (aOR 1·36; 95%CI 1·06-1·75) than those spending less time in the kitchen. Time-weighted average 24h personal CO exposure was related dose-dependently with the likelihood of having PTB, with aOR 4·64 (95%CI 1·1-20·7) for the highest quintile [12·3-76·2 ppm] compared to the lowest quintile [0·1-1·9 ppm]. Conclusion Time spent cooking and personal CO exposure were independently associated with increased risk of PTB among people living with HIV. Considering the high burden of TB-HIV coinfection in the region, effective interventions are required to decrease HAP exposure caused by cooking with biomass among people living with HIV, especially women.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - John Metcalfe
- Zuckerberg San Francisco General Hospital, University of California
| | - Grant Theron
- NRF-DST Centre of Excellence for Biomedical Tuberculosis Research, Stellenbosch University
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Stafford L, Sinclair M, Butow P, Hughes J, Park A, Gilham L, Rose A, Mann GB. Is de-escalation of treatment by omission of radiotherapy associated with fear of cancer recurrence in women with early breast cancer? An exploratory study. Breast Cancer Res Treat 2023; 201:367-376. [PMID: 37480383 PMCID: PMC10460737 DOI: 10.1007/s10549-023-07039-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 07/05/2023] [Indexed: 07/24/2023]
Abstract
PURPOSE Safe de-intensification of adjuvant radiotherapy (RT) for early breast cancer (BC) is currently under evaluation. Little is known about the patient experience of de-escalation or its association with fear of cancer recurrence (FCR), a key issue in survivorship. We conducted a cross-sectional study to explore this association. METHODS Psychometrically validated measures including the Fear of Cancer Recurrence Inventory-Short Form were completed by three groups of women with early BC: Women in the PROSPECT clinical trial who underwent pre-surgical MRI and omitted RT (A), women who underwent pre-surgical MRI and received RT (B); and women who received usual care (no MRI, received RT; C). Between group differences were analysed with non-parametric tests. A subset from each group participated in a semi-structured interview. These data (n = 44) were analysed with directed content analysis. RESULTS Questionnaires from 400 women were analysed. Significantly lower FCR was observed in Group A (n = 125) than in Group B (n = 102; p = .002) or Group C (n = 173; p = .001), and when participants were categorized by RT status (omitted RT vs received RT; p < .001). The proportion of women with normal FCR was significantly (p < .05) larger in Group A (62%) than in Group B (35%) or Group C (40%). Two qualitative themes emerged: 'What I had was best' and 'Coping with FCR'. CONCLUSIONS Omitting RT in the setting of the PROSPECT trial was not associated with higher FCR than receiving RT. Positive perceptions about tailored care, lower treatment burden, and trust in clinicians appear to be protective against FCR.
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Affiliation(s)
- Lesley Stafford
- Familial Cancer Centre, Royal Melbourne Hospital, Melbourne, VIC Australia
- Melbourne School of Psychological Sciences, University of Melbourne, Victoria, Australia
| | | | - Phyllis Butow
- School of Psychology, University of Sydney, Sydney, NSW Australia
| | - Janemary Hughes
- The Breast Service, The Royal Melbourne and Royal Women’s Hospitals, Parkville, VIC Australia
| | - Allan Park
- The Breast Service, The Royal Melbourne and Royal Women’s Hospitals, Parkville, VIC Australia
| | | | - Allison Rose
- The Breast Service, The Royal Melbourne and Royal Women’s Hospitals, Parkville, VIC Australia
- Northwestern BreastScreen, The Royal Melbourne Hospital, Parkville, VIC Australia
| | - G. Bruce Mann
- Department of Surgery, University of Melbourne, Victoria, Australia
- The Breast Service, The Royal Melbourne and Royal Women’s Hospitals, Parkville, VIC Australia
- Breast Cancer Trials, Newcastle, NSW Australia
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Raqib R, Akhtar E, Ahsanul Haq M, Ahmed S, Haque F, Chowdhury MAH, Shahriar MH, Begum BA, Eunus M, Sarwar G, Parvez F, Sharker Y, Ahsan H, Yunus M. Reduction of household air pollution through clean fuel intervention and recovery of cellular immune balance. ENVIRONMENT INTERNATIONAL 2023; 179:108137. [PMID: 37579572 PMCID: PMC11062205 DOI: 10.1016/j.envint.2023.108137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 08/01/2023] [Accepted: 08/07/2023] [Indexed: 08/16/2023]
Abstract
BACKGROUND We conducted a clean fuel intervention trial (Bangladesh Global Environmental and Occupational Health (GEOHealth) (NCT02824237) with liquefied petroleum gas (LPG) for 26 months among rural Bangladeshi women chronically exposed to household air pollution (HAP) from biomass fuel (BMF) use. We aimed to evaluate the effect of HAP reduction following LPG intervention on immune response outcome. METHODS We supplied LPG cook stove and refills in cylinder in 200 households for 26 months. We measured personal exposure to HAP [particulate matter 2.5 (PM2·5), black carbon (BC) and carbon monoxide (CO)] in 200 women (main cook) by personal monitors at pre- and post-intervention. Immune function was assessed before and after intervention, in blood collected within 2 weeks of HAP measurements. Primary endpoints included reduction in HAP, lymphocyte proliferation and oxidative stress response, and alterations in T and B cell proportions. FINDINGS Exclusive LPG use for 26 months resulted in significant reduction in PM2·5 (43.5%), BC (13%) and CO (48%) exposure in the women. For one unit decrease in BC, Treg cells and memory B cells increased by 7% and 34% respectively, in the peripheral circulation. One unit decrease in CO was significantly associated with increase in early B cells and plasmablasts by 66% and 5% respectively. For one unit decrease in BC, percent-dividing cells, proliferation and expansion indices increased by 2%, 0.4%, and 1%, respectively. INTERPRETATION Reduced personal exposure to HAP through clean fuel intervention was related to a return towards cellular immune balance.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Mahbub Eunus
- U-Chicago Research Bangladesh, Mohakhali, Dhaka, Bangladesh
| | - Golam Sarwar
- U-Chicago Research Bangladesh, Mohakhali, Dhaka, Bangladesh
| | - Faruque Parvez
- Mailman School of Public Health, Columbia University, New York, USA
| | | | - Habibul Ahsan
- Department of Public Health Sciences, University of Chicago, Chicago, USA; U-Chicago Research Bangladesh, Mohakhali, Dhaka, Bangladesh
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13
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Williams KN, Quinn A, North H, Wang J, Pillarisetti A, Thompson LM, Díaz-Artiga A, Balakrishnan K, Thangavel G, Rosa G, Ndagijimana F, Underhill LJ, Kirby MA, Puzzolo E, Hossen S, Waller LA, Peel JL, Rosenthal JP, Clasen TF, Harvey SA, Checkley W. Fidelity and adherence to a liquefied petroleum gas stove and fuel intervention: The multi-country Household Air Pollution Intervention Network (HAPIN) trial. ENVIRONMENT INTERNATIONAL 2023; 179:108160. [PMID: 37660633 PMCID: PMC10512198 DOI: 10.1016/j.envint.2023.108160] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Revised: 07/24/2023] [Accepted: 08/17/2023] [Indexed: 09/05/2023]
Abstract
BACKGROUND Reducing household air pollution (HAP) to levels associated with health benefits requires nearly exclusive use of clean cooking fuels and abandonment of traditional biomass fuels. METHODS The Household Air Pollution Intervention Network (HAPIN) trial randomized 3,195 pregnant women in Guatemala, India, Peru, and Rwanda to receive a liquefied petroleum gas (LPG) stove intervention (n = 1,590), with controls expected to continue cooking with biomass fuels (n = 1,605). We assessed fidelity to intervention implementation and participant adherence to the intervention starting in pregnancy through the infant's first birthday using fuel delivery and repair records, surveys, observations, and temperature-logging stove use monitors (SUMs). RESULTS Fidelity and adherence to the HAPIN intervention were high. Median time required to refill LPG cylinders was 1 day (interquartile range 0-2). Although 26% (n = 410) of intervention participants reported running out of LPG at some point, the number of times was low (median: 1 day [Q1, Q3: 1, 2]) and mostly limited to the first four months of the COVID-19 pandemic. Most repairs were completed on the same day as problems were reported. Traditional stove use was observed in only 3% of observation visits, and 89% of these observations were followed up with behavioral reinforcement. According to SUMs data, intervention households used their traditional stove a median of 0.4% of all monitored days, and 81% used the traditional stove < 1 day per month. Traditional stove use was slightly higher post-COVID-19 (detected on a median [Q1, Q3] of 0.0% [0.0%, 3.4%] of days) than pre-COVID-19 (0.0% [0.0%, 1.6%] of days). There was no significant difference in intervention adherence pre- and post-birth. CONCLUSION Free stoves and an unlimited supply of LPG fuel delivered to participating homes combined with timely repairs, behavioral messaging, and comprehensive stove use monitoring contributed to high intervention fidelity and near-exclusive LPG use within the HAPIN trial.
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Affiliation(s)
- Kendra N Williams
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, MD, USA; Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | | | - Hayley North
- Fogarty International Center, National Institutes of Health, Bethesda, MD, USA
| | - Jiantong Wang
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Ajay Pillarisetti
- Division of Environmental Health Sciences, University of California at Berkeley, Berkeley, CA, USA
| | - Lisa M Thompson
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA, USA
| | - Anaité Díaz-Artiga
- Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala
| | - Kalpana Balakrishnan
- ICMR Center for Advanced Research on Air Quality, Climate and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute of Higher Education and Research, Chennai, India
| | - Gurusamy Thangavel
- ICMR Center for Advanced Research on Air Quality, Climate and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute of Higher Education and Research, Chennai, India
| | - Ghislaine Rosa
- Public Health, Policy & Systems, Institute of Population Health, University of Liverpool, Liverpool, UK
| | | | - Lindsay J Underhill
- Cardiovascular Division, John T. Milliken Department of Medicine, Washington University School of Medicine in St. Louis, MO, USA
| | - Miles A Kirby
- Department of Global Health and Population, Harvard University T.H. Chan School of Public Health, Boston, MA, USA
| | - Elisa Puzzolo
- Public Health, Policy & Systems, Institute of Population Health, University of Liverpool, Liverpool, UK
| | - Shakir Hossen
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, MD, USA; Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Lance A Waller
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Jennifer L Peel
- Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins, CO, USA
| | - Joshua P Rosenthal
- Fogarty International Center, National Institutes of Health, Bethesda, MD, USA
| | - Thomas F Clasen
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Steven A Harvey
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - William Checkley
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, MD, USA; Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, MD, USA.
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Starnes JR, Rogers A, Wamae J, Okoth V, Mudhune SA, Omondi A, Were V, Baraza Awino D, Lefebvre CH, Yap S, Otieno Odhong T, Vill B, Were L, Wamai R. Childhood mortality and associated factors in Migori County, Kenya: evidence from a cross-sectional survey. BMJ Open 2023; 13:e074056. [PMID: 37607788 PMCID: PMC10445361 DOI: 10.1136/bmjopen-2023-074056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 08/08/2023] [Indexed: 08/24/2023] Open
Abstract
OBJECTIVES The under-five mortality (U5M) rate in Kenya (41 per 1000 live births) remains significantly above international goals (25 per 1000 live births). This is further exacerbated by regional inequalities in mortality. We aimed to describe U5M in Migori County, Kenya, and identify associated factors that can serve as programming targets. DESIGN Cross-sectional observational survey. SETTING Areas served by the Lwala Community Alliance and control areas in Migori County, Kenya. PARTICIPANTS This study included 15 199 children born to respondents during the 18 years preceding the survey. PRIMARY AND SECONDARY OUTCOME MEASURES The primary outcome was mortality in the first 5 years of life. The survey was powered to detect a 10% change in various health metrics over time with 80% power. RESULTS A total of 15 199 children were included in the primary analyses, and 230 (1.5%) were deceased before the fifth birthday. The U5M rate from 2016 to 2021 was 32.2 per 1000 live births. Factors associated with U5M included year of birth (HR 0.926, p<0.001), female sex (HR 0.702, p=0.01), parental marriage (HR 0.642, p=0.036), multiple gestation pregnancy (HR 2.776, p<0.001), birth spacing less than 18 months (HR 1.894, p=0.005), indoor smoke exposure (HR 1.916, p=0.027) and previous familial contribution to the National Hospital Insurance Fund (HR 0.553, p=0.009). The most common cause of death was malaria. CONCLUSIONS We describe factors associated with childhood mortality in a Kenyan community using survival analyses of complete birth histories. Mortality rates will serve as the baseline for future programme evaluation as a part of a 10-year study design. This provides both the hyperlocal information needed to improve programming and generalisable conclusions for other organisations working in similar environments.
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Affiliation(s)
- Joseph R Starnes
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Lwala Community Alliance, Rongo, Kenya
| | | | | | | | | | - Alyn Omondi
- Adaptive Model for Research and Empowerment of Communities in Africa, Kisumu, Kenya
| | - Vincent Were
- Kenya Medical Research Institute, Nairobi, Kenya
| | | | - Christina Hope Lefebvre
- Department of Cultures, Societies, and Global Studies, Northeastern University, Boston, Massachusetts, USA
| | - Samantha Yap
- Department of Cultures, Societies, and Global Studies, Northeastern University, Boston, Massachusetts, USA
| | - Tom Otieno Odhong
- Department of Health Services, Migori County Government, Migori, Kenya
| | - Beffy Vill
- Department of Health Services, Migori County Government, Migori, Kenya
| | - Lawrence Were
- Department of Global Health, Boston University, Boston, Massachusetts, USA
| | - Richard Wamai
- Department of Cultures, Societies, and Global Studies, Northeastern University, Boston, Massachusetts, USA
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15
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Jana A, Singh A, Adar SD, D'Souza J, Chattopadhyay A. In-utero exposure to multiple air pollutants and childhood undernutrition in India. JOURNAL OF EXPOSURE SCIENCE & ENVIRONMENTAL EPIDEMIOLOGY 2023:10.1038/s41370-023-00591-5. [PMID: 37563211 DOI: 10.1038/s41370-023-00591-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 07/25/2023] [Accepted: 07/25/2023] [Indexed: 08/12/2023]
Abstract
BACKGROUND Several studies have been conducted to understand the impact of socioeconomic and maternal factors on child undernutrition. However, the past literature has not directly examined the joint impacts of fuel use and ambient pollution and have primarily focused on PM2.5. OBJECTIVE This study explored the individual and community-level associations of both indoor (cooking fuel type) and ambient air pollution (PM2.5, NO2 and SO2) during maternal gestation on child undernutrition. METHODS This study analysed stunting, being underweight, and anaemia of children aged 0-59 months (n = 259,627) using the National Family Health Survey. In-utero exposures to ambient PM2.5, NO2, and SO2 were measured using satellite data and self-reported fuel type was a marker of indoor pollution exposure. The study used univariate and bivariate Moran's I, spatial lag model and multivariable logistic regression models after adjusting for other covariates to understand the effect of pollution on in-utero exposure and child health status at the individual and community-levels. RESULTS Higher concentration of indoor and ambient air pollution was found in the Northern and parts of Central regions of India. Estimates of spatial modelling show that each 1 μg/m-3 increase in maternal exposure to ambient PM2.5 across the clusters of India was associated with a 0.11, 9 and 19 percentage points increase in the prevalence of stunting, underweight and anaemia, respectively. The results of multi-pollutant model show that a higher ambient PM2.5 exposure during pregnancy was linked to higher odds of stunting (AOR:1.38; 95% CI:1.32-1.44), underweight (AOR:1.59; 95% CI:1.51-1.67) and anaemia (AOR:1.61; 95% CI:1.52-1.69) in children. Weaker but similar associations were observed for NO2, but not with SO2. Indoor pollution exposure during in-utero periods was also significantly associated with childhood undernutrition and this association was modified by ambient PM2.5 levels, where exposure to both indoor and ambient air pollution had even greater odds of being undernourished. IMPACT STATEMENT Our research on multi-pollutant models has revealed the initial proof of the individual impacts of indoor and outdoor pollution (PM2.5, NO2, and SO2) exposure during fetal development on children's nutrition.
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Affiliation(s)
- Arup Jana
- Department of Population & Development, International Institute for Population Sciences, Deonar, Mumbai, 400088, India
| | - Akancha Singh
- Department of Population & Development, International Institute for Population Sciences, Deonar, Mumbai, 400088, India
| | - Sara D Adar
- Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, MI, 48109, USA
| | - Jennifer D'Souza
- Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, MI, 48109, USA
| | - Aparajita Chattopadhyay
- Department of Population & Development, International Institute for Population Sciences, Deonar, Mumbai, 400088, India.
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16
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Kaali S, Jack DW, Mujtaba MN, Chillrud SN, Ae-Ngibise KA, Kinney PL, Boamah Kaali E, Gennings C, Colicino E, Osei M, Wylie BJ, Agyei O, Quinn A, Asante KP, Lee AG. Identifying sensitive windows of prenatal household air pollution on birth weight and infant pneumonia risk to inform future interventions. ENVIRONMENT INTERNATIONAL 2023; 178:108062. [PMID: 37392730 PMCID: PMC10911234 DOI: 10.1016/j.envint.2023.108062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 06/02/2023] [Accepted: 06/22/2023] [Indexed: 07/03/2023]
Abstract
BACKGROUND Prenatal household air pollution impairs birth weight and increases pneumonia risk however time-varying associations have not been elucidated and may have implications for the timing of public health interventions. METHODS The Ghana Randomized Air Pollution and Health Study (GRAPHS) enrolled 1,414 pregnant women from Kintampo, Ghana and measured personal carbon monoxide (CO) exposure four times over pregnancy. Birth weight was measured within 72-hours of birth. Fieldworkers performed weekly pneumonia surveillance and referred sick children to study physicians. The primary pneumonia outcome was one or more physician-diagnosed severe pneumonia episode in the first year of life. We employed reverse distributed lag models to examine time-varying associations between prenatal CO exposure and birth weight and infant pneumonia risk. RESULTS Analyses included n = 1,196 mother-infant pairs. In models adjusting for child sex; maternal age, body mass index (BMI), ethnicity and parity at enrollment; household wealth index; number of antenatal visits; and evidence of placental malaria, prenatal CO exposures from 15 to 20 weeks gestation were inversely associated with birth weight. Sex-stratified models identified a similar sensitive window in males and a window at 10-weeks gestation in females. In models adjusting for child sex, maternal age, BMI and ethnicity, household wealth index, gestational age at delivery and average postnatal child CO exposure, CO exposure during 34-39 weeks gestation were positively associated with severe pneumonia risk, especially in females. CONCLUSIONS Household air pollution exposures in mid- and late- gestation are associated with lower birth weight and higher pneumonia risk, respectively. These findings support the urgent need for deployment of clean fuel stove interventions beginning in early pregnancy.
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Affiliation(s)
- Seyram Kaali
- Kintampo Health Research Centre, Research and Development Division, Ghana Health Service, Bono East Region, Kintampo, Ghana.
| | - Darby W Jack
- Department of Environmental Health Sciences, Mailman School of Public Health at Columbia University, 722 W 168(th) Street, New York, NY 10032, USA
| | - Mohammed N Mujtaba
- Kintampo Health Research Centre, Research and Development Division, Ghana Health Service, Bono East Region, Kintampo, Ghana
| | - Steven N Chillrud
- Lamont-Doherty Earth Observatory at Columbia University, Palisades, NY, USA
| | - Kenneth A Ae-Ngibise
- Kintampo Health Research Centre, Research and Development Division, Ghana Health Service, Bono East Region, Kintampo, Ghana
| | - Patrick L Kinney
- Department of Environmental Health, Boston University School of Public Health, Boston, MA, USA
| | - Ellen Boamah Kaali
- Kintampo Health Research Centre, Research and Development Division, Ghana Health Service, Bono East Region, Kintampo, Ghana
| | - Chris Gennings
- Department of Environmental Medicine and Public Health, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Institute for Exposomic Research, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Elena Colicino
- Department of Environmental Medicine and Public Health, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Musah Osei
- Kintampo Health Research Centre, Research and Development Division, Ghana Health Service, Bono East Region, Kintampo, Ghana
| | - Blair J Wylie
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Oscar Agyei
- Kintampo Health Research Centre, Research and Development Division, Ghana Health Service, Bono East Region, Kintampo, Ghana
| | - Ashlinn Quinn
- Berkeley Air Monitoring Group, Fort Collins, CO, USA
| | - Kwaku Poku Asante
- Kintampo Health Research Centre, Research and Development Division, Ghana Health Service, Bono East Region, Kintampo, Ghana
| | - Alison G Lee
- Division of Pulmonary, Critical Care and Sleep Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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17
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Williams KN, Quinn A, North H, Wang J, Pillarisetti A, Thompson LM, Díaz-Artiga A, Balakrishnan K, Thangavel G, Rosa G, Ndagijimana F, Underhill LJ, Kirby MA, Puzzolo E, Hossen S, Waller LA, Peel JL, Rosenthal JP, Clasen TF, Harvey SA, Checkley W. Fidelity and adherence to a liquefied petroleum gas stove and fuel intervention: the multi-country Household Air Pollution Intervention Network (HAPIN) trial. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.06.20.23291670. [PMID: 37425899 PMCID: PMC10327189 DOI: 10.1101/2023.06.20.23291670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/11/2023]
Abstract
Background Reducing household air pollution (HAP) to levels associated with health benefits requires nearly exclusive use of clean cooking fuels and abandonment of traditional biomass fuels. Methods The Household Air Pollution Intervention Network (HAPIN) trial randomized 3,195 pregnant women in Guatemala, India, Peru, and Rwanda to receive a liquefied petroleum gas (LPG) stove intervention (n=1,590), with controls expected to continue cooking with biomass fuels (n=1,605). We assessed fidelity to intervention implementation and participant adherence to the intervention starting in pregnancy through the infant's first birthday using fuel delivery and repair records, surveys, observations, and temperature-logging stove use monitors (SUMs). Results Fidelity and adherence to the HAPIN intervention were high. Median time required to refill LPG cylinders was 1 day (interquartile range 0-2). Although 26% (n=410) of intervention participants reported running out of LPG at some point, the number of times was low (median: 1 day [Q1, Q3: 1, 2]) and mostly limited to the first four months of the COVID-19 pandemic. Most repairs were completed on the same day as problems were reported. Traditional stove use was observed in only 3% of observation visits, and 89% of these observations were followed up with behavioral reinforcement. According to SUMs data, intervention households used their traditional stove a median of 0.4% of all monitored days, and 81% used the traditional stove <1 day per month. Traditional stove use was slightly higher post-COVID-19 (detected on a median [Q1, Q3] of 0.0% [0.0%, 3.4%] of days) than pre-COVID-19 (0.0% [0.0%, 1.6%] of days). There was no significant difference in intervention adherence pre- and post-birth. Conclusion Free stoves and an unlimited supply of LPG fuel delivered to participating homes combined with timely repairs, behavioral messaging, and comprehensive stove use monitoring contributed to high intervention fidelity and near-exclusive LPG use within the HAPIN trial.
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Affiliation(s)
- Kendra N. Williams
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | | | - Hayley North
- Fogarty International Center, National Institutes of Health, Bethesda, MD, USA
| | - Jiantong Wang
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Ajay Pillarisetti
- Division of Environmental Health Sciences, University of California at Berkeley, Berkeley, CA, USA
| | - Lisa M. Thompson
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA, USA
| | - Anaité Díaz-Artiga
- Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala
| | - Kalpana Balakrishnan
- ICMR Center for Advanced Research on Air Quality, Climate and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute of Higher Education and Research, Chennai, India
| | - Gurusamy Thangavel
- ICMR Center for Advanced Research on Air Quality, Climate and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute of Higher Education and Research, Chennai, India
| | - Ghislaine Rosa
- Public Health, Policy & Systems, Institute of Population Health, University of Liverpool, Liverpool, UK
| | | | - Lindsay J. Underhill
- Cardiovascular Division, John T. Milliken Department of Medicine, Washington University School of Medicine in St. Louis, MO, USA
| | - Miles A. Kirby
- Department of Global Health and Population, Harvard University T.H. Chan School of Public Health, Boston, MA, USA
| | - Elisa Puzzolo
- Public Health, Policy & Systems, Institute of Population Health, University of Liverpool, Liverpool, UK
| | - Shakir Hossen
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Lance A. Waller
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Jennifer L. Peel
- Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins, CO, USA
| | - Joshua P. Rosenthal
- Fogarty International Center, National Institutes of Health, Bethesda, MD, USA
| | - Thomas F. Clasen
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Steven A. Harvey
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - William Checkley
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
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18
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Simkovich SM, Hossen S, McCollum ED, Toenjes AK, McCracken JP, Thompson LM, Castañaza A, Diaz A, Rosa G, Kirby MA, Mukeshimana A, Myers R, Lenzen PM, Craik R, Jabbarzadeh S, Elon L, Garg SS, Balakrishnan K, Thangavel G, Peel JL, Clasen TF, Dávila-Román VG, Papageorghiou AT, de Las Fuentes L, Checkley W. Lung Ultrasound Protocol and Quality Control of Image Interpretation Using an Adjudication Panel in the Household Air Pollution Intervention Network (HAPIN) Trial. ULTRASOUND IN MEDICINE & BIOLOGY 2023; 49:1194-1201. [PMID: 36801180 PMCID: PMC10631486 DOI: 10.1016/j.ultrasmedbio.2023.01.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 12/23/2022] [Accepted: 01/03/2023] [Indexed: 05/11/2023]
Abstract
OBJECTIVE Lung ultrasound (LUS) is an alternative to chest radiography to confirm a diagnosis of pneumonia. For research and disease surveillance, methods to use LUS to diagnose pneumonia are needed. METHODS In the Household Air Pollution Intervention Network (HAPIN) trial, LUS was used to confirm a clinical diagnosis of severe pneumonia in infants. We developed a standardized definition of pneumonia, protocols for recruitment and training of sonographers, along with LUS image acquisition and interpretation. We use a blinded panel approach to interpretation with LUS cine-loops randomized to non-scanning sonographers with expert review. DISCUSSION We obtained 357 lung ultrasound scans: 159, 8 and 190 scans were collected in Guatemala, Peru and Rwanda, respectively. The diagnosis of primary endpoint pneumonia (PEP) required an expert tie breaker in 181 scans (39%). PEP was diagnosed in 141 scans (40%), not diagnosed in 213 (60%), with 3 scans (<1%) deemed uninterpretable. Agreement among the two blinded sonographers and the expert reader in Guatemala, Peru and Rwanda was 65%, 62% and 67%, with a prevalence-and-bias-corrected kappa of 0.30, 0.24 and 0.33, respectively. CONCLUSION Use of standardized imaging protocols, training and an adjudication panel resulted in high confidence for the diagnosis of pneumonia using LUS.
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Affiliation(s)
- Suzanne M Simkovich
- Division of Pulmonary and Critical Care, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, MD, USA; Division of Healthcare Delivery, MedStar Health Research Institute, Hyattsville, MD, USA; Division of Pulmonary and Critical Care Medicine, Georgetown University School of Medicine, Washington, DC, USA
| | - Shakir Hossen
- Division of Pulmonary and Critical Care, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Eric D McCollum
- Eudowood Division of Pediatric Respiratory Sciences, Department of Pediatrics, School of Medicine, Johns Hopkins University, Baltimore, MD, USA; Global Program on Pediatric Respiratory Sciences, Department of Pediatrics, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Ashley K Toenjes
- Cardiovascular Division, Department of Medicine, Washington University in St. Louis, St. Louis, MO, USA
| | - John P McCracken
- Global Health Institute, Department of Epidemiology and Biostatistics, College of Public Health, University of Georgia, Athens, GA, USA
| | - Lisa M Thompson
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA, USA
| | - Adly Castañaza
- Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala
| | - Anaite Diaz
- Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala
| | - Ghislaine Rosa
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London, UK
| | - Miles A Kirby
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Harvard University, Boston, MA, USA
| | | | - Rachel Myers
- Cardiovascular Division, Department of Medicine, Washington University in St. Louis, St. Louis, MO, USA
| | - Patricia M Lenzen
- Cardiovascular Division, Department of Medicine, Washington University in St. Louis, St. Louis, MO, USA
| | - Rachel Craik
- Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford, UK
| | - Shirin Jabbarzadeh
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Lisa Elon
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Sarada S Garg
- Department of Environmental Health Engineering, ICMR Center for Advanced Research on Air Quality, Climate and Health, Sri Ramachandra Institute for Higher Education and Research (Deemed University), Chennai, India
| | - Kalpana Balakrishnan
- Department of Environmental Health Engineering, ICMR Center for Advanced Research on Air Quality, Climate and Health, Sri Ramachandra Institute for Higher Education and Research (Deemed University), Chennai, India
| | - Gurusamy Thangavel
- Department of Environmental Health Engineering, ICMR Center for Advanced Research on Air Quality, Climate and Health, Sri Ramachandra Institute for Higher Education and Research (Deemed University), Chennai, India
| | - Jennifer L Peel
- Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins, CO, USA
| | - Thomas F Clasen
- Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Victor G Dávila-Román
- Cardiovascular Division, Department of Medicine, Washington University in St. Louis, St. Louis, MO, USA
| | - Aris T Papageorghiou
- Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford, UK
| | - Lisa de Las Fuentes
- Cardiovascular Division, Department of Medicine, Washington University in St. Louis, St. Louis, MO, USA
| | - William Checkley
- Division of Pulmonary and Critical Care, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, MD, USA.
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19
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Shah S, Kim E, Kim KN, Ha E. Can individual protective measures safeguard cardiopulmonary health from air pollution? A systematic review and meta-analysis. ENVIRONMENTAL RESEARCH 2023; 229:115708. [PMID: 36940818 DOI: 10.1016/j.envres.2023.115708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 03/15/2023] [Accepted: 03/15/2023] [Indexed: 05/09/2023]
Abstract
Evidence supporting the effect of individual protective measures (IPMs) on air pollution is relatively scarce. In this study, we performed a systematic review and meta-analysis to investigate the effects of air purifiers, air-purifying respirators, and cookstove changes on cardiopulmonary health outcomes. We searched PubMed, Scopus, and Web of Science until December 31, 2022, 90 articles and 39,760 participants were included. Two authors independently searched and selected the studies, extracted information, and assessed each study's quality and risk of bias. We performed meta-analyses when three or more studies were available for each IPMs, with comparable intervention and health outcome. Systematic review showed that IPMs were beneficial in children and elderly with asthma along with healthy individuals. Meta-analysis results showed a reduction in cardiopulmonary inflammation using air purifiers than in control groups (with sham/no filter) with a decrease in interleukin 6 by -0.247 μg/mL (95% confidence intervals [CI] = -0.413, -0.082). A sub-group analysis for air purifier as an IPMs in developing counties reduced fractional exhaled nitric oxide by -0.208 ppb (95% confidence intervals [CI] = -0.394, -0.022). However, evidence describing the effects of air purifying respirator and cook stove changes on cardiopulmonary outcomes remained insufficient. Therefore, air purifiers can serve as efficient IPMs against air pollution. The beneficial effect of air purifiers is likely to have a greater effect in developing countries than in developed countries.
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Affiliation(s)
- Surabhi Shah
- Department of Environmental Medicine, Ewha Womans University College of Medicine, Seoul, Republic of Korea
| | - Eunji Kim
- Department of Environmental Medicine, Ewha Womans University College of Medicine, Seoul, Republic of Korea; Graduate Program in System Health Science and Engineering, College of Medicine, Ewha Womans University, Seoul, Republic of Korea
| | - Kyoung-Nam Kim
- Department of Preventive Medicine, Hanyang University College of Medicine, Seoul, Republic of Korea.
| | - Eunhee Ha
- Department of Environmental Medicine, Ewha Womans University College of Medicine, Seoul, Republic of Korea; Graduate Program in System Health Science and Engineering, College of Medicine, Ewha Womans University, Seoul, Republic of Korea; Institute of Ewha-SCL for Environmental Health (IESEH), Ewha Womans University College of Medicine, Seoul, Republic of Korea; Department of Medical Science, Ewha Womans University School of Medicine and Ewha Medical Research Institute, Seoul, Republic of Korea.
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20
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Huang L, Liu Y, Wu Y, Ye Z, Ren F, Liu X, Shen G. Impact of Stove Renovation on PM 2.5 Exposure, Risk Perception, Self-Protective Willingness of Rural Residents. TOXICS 2023; 11:245. [PMID: 36977010 PMCID: PMC10051283 DOI: 10.3390/toxics11030245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 03/01/2023] [Accepted: 03/03/2023] [Indexed: 06/18/2023]
Abstract
To improve household air quality, the Chinese government has launched a number of pilot stove renovation projects, but few studies have explored the impact of the project on people's perception of and willingness to participate in these renovations; moreover, factors affecting willingness to pay for the project in rural China are not yet clear. We conducted a field measurement and a corresponding door-to-door questionnaire survey using the renovated group and the unrenovated group. The results showed that (1) the stove renovation project could not only reduce PM2.5 exposure and the excess mortality risk of rural residents, but also (2) improve residents' risk perception and self-protective willingness. (3) Specifically, the project had a deeper impact on female and low-income residents. (4) Meanwhile, the higher the income and the larger family size, the higher the risk perception and self-protective willingness. (5) Furthermore, willingness to pay for the project was related with residents' support for the project, benefit from renovation, income, and family size. Our results recommended that stove renovation policies should pay more attention to families with lower income and smaller size.
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Affiliation(s)
- Lei Huang
- State Key Laboratory of Pollution Control & Resource Reuse, School of the Environment, Nanjing University, Nanjing 210023, China
- Nanjing University (Suzhou) High-Tech Institute, Suzhou 215123, China
| | - Yuxin Liu
- State Key Laboratory of Pollution Control & Resource Reuse, School of the Environment, Nanjing University, Nanjing 210023, China
| | - Yangyang Wu
- State Key Laboratory of Pollution Control & Resource Reuse, School of the Environment, Nanjing University, Nanjing 210023, China
| | - Ziwen Ye
- State Key Laboratory of Pollution Control & Resource Reuse, School of the Environment, Nanjing University, Nanjing 210023, China
| | - Futian Ren
- State Key Laboratory of Pollution Control & Resource Reuse, School of the Environment, Nanjing University, Nanjing 210023, China
| | - Xinlei Liu
- Laboratory for Earth Surface Processes, College of Urban and Environmental Sciences, Peking University, Beijing 100871, China
| | - Guofeng Shen
- Laboratory for Earth Surface Processes, College of Urban and Environmental Sciences, Peking University, Beijing 100871, China
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21
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Gould CF, Bejarano ML, Kioumourtzoglou MA, Lee AG, Pillarisetti A, Schlesinger SB, Terán E, Valarezo A, Jack DW. Widespread Clean Cooking Fuel Scale-Up and under-5 Lower Respiratory Infection Mortality: An Ecological Analysis in Ecuador, 1990-2019. ENVIRONMENTAL HEALTH PERSPECTIVES 2023; 131:37017. [PMID: 36989076 PMCID: PMC10056314 DOI: 10.1289/ehp11016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 01/09/2023] [Accepted: 02/10/2023] [Indexed: 05/18/2023]
Abstract
BACKGROUND Nationwide household transitions to the use of clean-burning cooking fuels are a promising pathway to reducing under-5 lower respiratory infection (LRI) mortality, the leading cause of child mortality globally, but such transitions are rare and evidence supporting an association between increased clean fuel use and improved health is limited. OBJECTIVES This study aimed to investigate the association between increased primary clean cooking fuel use and under-5 LRI mortality in Ecuador between 1990 and 2019. METHODS We documented cooking fuel use and cause-coded child mortalities at the canton (county) level in Ecuador from 1990 to 2019 (in four periods, 1988-1992, 1999-2003, 2008-2012, and 2015-2019). We characterized the association between clean fuel use and the rate of under-5 LRI mortalities at the canton level using quasi-Poisson generalized linear and generalized additive models, accounting for potential confounding variables that characterize wealth, urbanization, and child health care and vaccination rates, as well as canton and period fixed effects. We estimated averted under-5 LRI mortalities accrued over 30 y by predicting a counterfactual count of canton-period under-5 LRI mortalities were clean fuel use to not have increased and comparing with predicted canton-period under-5 LRI mortalities from our model and observed data. RESULTS From 1990 to 2019, the proportion of households primarily using a clean cooking fuel increased from 59% to 95%, and under-5 LRI mortality fell from 28 to 7 per 100,000 under-5 population. Canton-level clean fuel use was negatively associated with under-5 LRI mortalities in linear and nonlinear models. The nonlinear association suggested a threshold at approximately 60% clean fuel use, above which there was a negative association. Increases in clean fuel use between 1990 and 2019 were associated with an estimated 7,300 averted under-5 LRI mortalities (95% confidence interval: 2,600, 12,100), accounting for nearly 20% of the declines in under-5 LRI mortality observed in Ecuador over the study period. DISCUSSION Our findings suggest that the widespread household transition from using biomass to clean-burning fuels for cooking reduced under-5 LRI mortalities in Ecuador over the last 30 y. https://doi.org/10.1289/EHP11016.
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Affiliation(s)
- Carlos F. Gould
- Department of Environmental Health Sciences, Columbia University Mailman School of Public Health, New York, New York, USA
- Department of Earth System Science, Stanford University, Stanford, California, USA
| | - M. Lorena Bejarano
- Institute for Energy and Materials, Department of Mechanical Engineering, Universidad San Francisco de Quito, Quito, Ecuador
| | - Marianthi-Anna Kioumourtzoglou
- Department of Environmental Health Sciences, Columbia University Mailman School of Public Health, New York, New York, USA
| | - Alison G. Lee
- Division of Pulmonary, Critical Care and Sleep Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Ajay Pillarisetti
- Gangarosa Department of Environmental Health Science, Emory University Rollins School of Public Health, Atlanta, Georgia, USA
- Environmental Health Sciences, University of California, Berkeley, California, USA
| | | | - Enrique Terán
- Colegio de Ciencias de la Salud, Universidad San Francisco de Quito, Quito, Ecuador
| | - Alfredo Valarezo
- Institute for Energy and Materials, Department of Mechanical Engineering, Universidad San Francisco de Quito, Quito, Ecuador
| | - Darby W. Jack
- Department of Environmental Health Sciences, Columbia University Mailman School of Public Health, New York, New York, USA
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22
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Kizhakke Puliyakote AS, Stapleton EM, Durairaj K, Karuppusamy K, Kathiresan GB, Shanmugam K, Abdul Rahim S, Navaneethakrishnan S, Bilas M, Huang R, Metwali N, Jeronimo M, Chan KS, Guo J, Nagpal P, Peters TM, Thorne PS, Comellas AP, Hoffman EA. Imaging-based assessment of lung function in a population cooking indoors with biomass fuel: a pilot study. J Appl Physiol (1985) 2023; 134:710-721. [PMID: 36759166 PMCID: PMC10027118 DOI: 10.1152/japplphysiol.00286.2022] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 02/02/2023] [Accepted: 02/03/2023] [Indexed: 02/11/2023] Open
Abstract
Biomass fuels (wood) are commonly used indoors in underventilated environments for cooking in the developing world, but the impact on lung physiology is poorly understood. Quantitative computed tomography (qCT) can provide sensitive metrics to compare the lungs of women cooking with wood vs. liquified petroleum gas (LPG). We prospectively assessed (qCT and spirometry) 23 primary female cooks (18 biomass, 5 LPG) with no history of cardiopulmonary disease in Thanjavur, India. CT was obtained at coached total lung capacity (TLC) and residual volume (RV). qCT assessment included texture-derived ground glass opacity [GGO: Adaptive Multiple Feature Method (AMFM)], air-trapping (expiratory voxels ≤ -856HU) and image registration-based assessment [Disease Probability Measure (DPM)] of emphysema, functional small airways disease (%AirTrapDPM), and regional lung mechanics. In addition, within-kitchen exposure assessments included particulate matter <2.5 μm(PM2.5), black carbon, β-(1, 3)-d-glucan (surrogate for fungi), and endotoxin. Air-trapping went undetected at RV via the threshold-based measure (voxels ≤ -856HU), possibly due to density shifts in the presence of inflammation. However, DPM, utilizing image-matching, demonstrated significant air-trapping in biomass vs. LPG cooks (P = 0.049). A subset of biomass cooks (6/18), identified using k-means clustering, had markedly altered DPM-metrics: greater air-trapping (P < 0.001), lower TLC-RV volume change (P < 0.001), a lower mean anisotropic deformation index (ADI; P < 0.001), and elevated % GGO (P < 0.02). Across all subjects, a texture measure of bronchovascular bundles was correlated to the log-transformed β-(1, 3)-d-glucan concentration (P = 0.026, R = 0.46), and black carbon (P = 0.04, R = 0.44). This pilot study identified environmental links with qCT-based lung pathologies and a cluster of biomass cooks (33%) with significant small airways disease.NEW & NOTEWORTHY Quantitative computed tomography has identified a cluster of women (33%) cooking with biomass fuels (wood) with image-based markers of functional small airways disease and associated alterations in regional lung mechanics. Texture and image registration-based metrics of lung function may allow for early detection of potential inflammatory processes that may arise in response to inhaled biomass smoke, and help identify phenotypes of chronic lung disease prevalent in nonsmoking women in the developing world.
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Affiliation(s)
- Abhilash S Kizhakke Puliyakote
- Department of Radiology, University of California, San Diego, La Jolla, California, United States
- Department of Biomedical Engineering, University of Iowa, Iowa City, Iowa, United States
| | - Emma M Stapleton
- Department of Internal Medicine, University of Iowa, Iowa City, Iowa, United States
| | - Kumar Durairaj
- Department of Physics, Periyar Maniammai Institute of Science and Technology, Thanjavur, India
| | - Kesavan Karuppusamy
- Department of Physics, Periyar Maniammai Institute of Science and Technology, Thanjavur, India
| | - Geetha B Kathiresan
- Department of Electronics and Communication Engineering, Periyar Maniammai Institute of Science and Technology, Thanjavur, India
| | - Kumaran Shanmugam
- Department of Biotechnology, Periyar Maniammai Institute of Science and Technology, Thanjavur, India
| | | | | | - Monalisa Bilas
- Department of Radiology, University of Iowa, Iowa City, Iowa, United States
| | - Rui Huang
- School of Economics, Nanjing University, Nanjing, People's Republic of China
| | - Nervana Metwali
- Department of Occupational and Environmental Health, University of Iowa, Iowa City, Iowa, United States
| | - Matthew Jeronimo
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - Kung-Sik Chan
- Department of Statistics and Actuarial Science, University of Iowa, Iowa City, Iowa, United States
| | - Junfeng Guo
- Department of Biomedical Engineering, University of Iowa, Iowa City, Iowa, United States
- Department of Radiology, University of Iowa, Iowa City, Iowa, United States
| | - Prashant Nagpal
- Department of Radiology, University of Iowa, Iowa City, Iowa, United States
- Department of Radiology, University of Wisconsin-Madison, Madison, Wisconsin, United States
| | - Thomas M Peters
- Department of Occupational and Environmental Health, University of Iowa, Iowa City, Iowa, United States
| | - Peter S Thorne
- Department of Occupational and Environmental Health, University of Iowa, Iowa City, Iowa, United States
| | - Alejandro P Comellas
- Department of Internal Medicine, University of Iowa, Iowa City, Iowa, United States
| | - Eric A Hoffman
- Department of Biomedical Engineering, University of Iowa, Iowa City, Iowa, United States
- Department of Internal Medicine, University of Iowa, Iowa City, Iowa, United States
- Department of Radiology, University of Iowa, Iowa City, Iowa, United States
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23
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Saleh S, Sambakunsi H, Makina D, Chinouya M, Kumwenda M, Chirombo J, Semple S, Mortimer K, Rylance J. Personal exposures to fine particulate matter and carbon monoxide in relation to cooking activities in rural Malawi. Wellcome Open Res 2023; 7:251. [PMID: 36874568 PMCID: PMC9975423 DOI: 10.12688/wellcomeopenres.18050.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/13/2023] [Indexed: 02/23/2023] Open
Abstract
Background: Air pollution is a major environmental risk factor for cardiorespiratory disease. Exposures to household air pollution from cooking and other activities, are particularly high in Southern Africa. Following an extended period of participant observation in a village in Malawi, we aimed to assess individuals' exposures to fine particulate matter (PM 2.5) and carbon monoxide (CO) and to investigate the different sources of exposure, including different cooking methods. Methods: Adult residents of a village in Malawi wore personal PM 2.5 and CO monitors for 24-48 hours, sampling every 1 (CO) or 2 minutes (PM 2.5). Subsequent in-person interviews recorded potential exposure details over the time periods. We present means and interquartile ranges for overall exposures and summaries stratified by time and activity (exposure). We employed multivariate regression to further explore these characteristics, and Spearman rank correlation to examine the relationship between paired PM 2.5 and CO exposures. Results : Twenty participants (17 female; median age 40 years, IQR: 37-56) provided 831 hours of paired PM 2.5 and CO data. Concentrations of PM 2.5 during combustion activity, usually cooking, far exceeded background levels (no combustion activity): 97.9μg/m 3 (IQR: 22.9-482.0), vs 7.6μg/m 3, IQR: 2.5-20.6 respectively. Background PM 2.5 concentrations were higher during daytime hours (11.7μg/m 3 [IQR: 5.2-30.0] vs 3.3μg/m 3 at night [IQR: 0.7-8.2]). Highest exposures were influenced by cooking location but associated with charcoal use (for CO) and firewood on a three-stone fire (for PM 2.5). Cooking-related exposures were higher in more ventilated places, such as outside the household or on a walled veranda, than during indoor cooking. Conclusions : The study demonstrates the value of combining personal PM 2.5 exposure data with detailed contextual information for providing deeper insights into pollution sources and influences. The finding of similar/lower exposures during cooking in seemingly less-ventilated places should prompt a re-evaluation of proposed clean air interventions in these settings.
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Affiliation(s)
- Sepeedeh Saleh
- Liverpool School of Tropical Medicine, LIVERPOOL, L3 5QA, UK
- Malawi Liverpool Wellcome Trust Clinical Research Programme, Blantyre, P.O. Box 30096, Malawi
| | - Henry Sambakunsi
- Malawi Liverpool Wellcome Trust Clinical Research Programme, Blantyre, P.O. Box 30096, Malawi
| | - Debora Makina
- Malawi Liverpool Wellcome Trust Clinical Research Programme, Blantyre, P.O. Box 30096, Malawi
| | - Martha Chinouya
- Liverpool School of Tropical Medicine, LIVERPOOL, L3 5QA, UK
| | - Moses Kumwenda
- Malawi Liverpool Wellcome Trust Clinical Research Programme, Blantyre, P.O. Box 30096, Malawi
| | - James Chirombo
- Malawi Liverpool Wellcome Trust Clinical Research Programme, Blantyre, P.O. Box 30096, Malawi
| | - Sean Semple
- University of Stirling, Stirling, FK9 4LA, UK
| | - Kevin Mortimer
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - Jamie Rylance
- Liverpool School of Tropical Medicine, LIVERPOOL, L3 5QA, UK
- Malawi Liverpool Wellcome Trust Clinical Research Programme, Blantyre, P.O. Box 30096, Malawi
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Elbayoumi M, Albelbeisi AH. Biomass use and its health effects among the vulnerable and marginalized refugee families in the Gaza Strip. Front Public Health 2023; 11:1129985. [PMID: 37089471 PMCID: PMC10117936 DOI: 10.3389/fpubh.2023.1129985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Accepted: 03/15/2023] [Indexed: 04/25/2023] Open
Abstract
Introduction Biomass fuel remains the most common type of fuel used in many developing countries, leading to indoor air pollution and serious health impacts. Objective The objective of this study was to compile evidence on the impact household fuel combustion has on child and adult health, with an emphasis on solid fuel use in Gaza. Methods In this cross-sectional study, 110 structured self-administered questionnaires were distributed in April 2019 among families living in the Al-Maghazi refugee camp. Results Participants reported that the main fuel used were wood, coal, cardboard, and a mix of wood, cardboard, and plastic, which were used for cooking, heating, baking, boiling water, and lighting. The most common symptoms were nasal irritation (71.8%), followed by headache (66.4%) and dizziness (65.4%). The results of logistic regression showed that the participants who used wood fuel had a higher chance of feeling eye irritation than those who used a mix of wood, cardboard, and dried grass (OR = 1.316; 95% CI = 1.54-8.99). The participants who opened windows during the burning process of biomass fuel were five times more likely to develop pneumonia than those who closed windows (OR = 5.53; 95%CI = 11.60-19.0). Conclusion there is an urgent need for community awareness campaigns designed to inform people about the risks of exposure to biomass fuel smoke and how to better implement household ventilation.
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Affiliation(s)
- Maher Elbayoumi
- Energy and Sustainable Environment Center, School of Engineering, Israa University, Gaza Strip, Palestine
- *Correspondence: Maher Elbayoumi,
| | - Ahmed Hassan Albelbeisi
- Medical Services Directorate, Gaza Strip, Palestine
- College of Health Professions, Israa University, Gaza Strip, Palestine
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25
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Mutlu E, Cristy T, Stiffler B, Waidyanatha S, Chartier R, Jetter J, Krantz T, Shen G, Champion W, Miller B, Richey J, Burback B, Rider CV. Do Storage Conditions Affect Collected Cookstove Emission Samples? Implications for Field Studies. ANAL LETT 2022; 56:1911-1931. [PMID: 37200484 PMCID: PMC10054858 DOI: 10.1080/00032719.2022.2150772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Revised: 11/18/2022] [Accepted: 11/18/2022] [Indexed: 05/20/2023]
Abstract
Cookstove emissions are a significant source of indoor air pollution in developing countries and rural communities world-wide. Considering that many research sites for evaluating cookstove emissions and interventions are remote and require potentially lengthy periods of particulate matter (PM) filter sample storage in sub-optimal conditions (e.g., lack of cold storage), an important question is whether samples collected in the field are stable over time. To investigate this, red oak was burned in a natural-draft stove, and fine PM (PM2.5) was collected on polytetrafluoroethylene filters. Filters were stored at either ambient temperature or more optimal conditions (-20°C or -80°C) for up to 3 months and extracted. The effects of storage temperature and length on stability were evaluated for measurements of extractable organic matter (EOM), PM2.5, and polycyclic aromatic compound (PAC) levels in the filter extracts. A parallel, controlled laboratory condition was also evaluated to further explore sources of variability. In general, PM2.5 and EOM in both simulated field and laboratory samples were similar regardless of the storage condition or duration. The extracts were also analyzed by gas chromatography to quantify 22 PACs and determine similarities and/or differences between the conditions. PAC levels were a more sensitive stability measure in differentiating between storage conditions. The findings suggest that measurements are relatively consistent across storage duration/temperatures for filter samples with relatively low EOM levels. This study aims to inform protocols and filter storage procedures for exposure and intervention research conducted in low- and middle-income countries where studies may be budget- and infrastructure-limited.
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Affiliation(s)
- Esra Mutlu
- Center for Computational Toxicology and Exposure, U.S. EPA, RTP, NC, USA
- Division of the Translational Toxicology, National Institute of Environmental Health Sciences, Research Triangle Park, NC, USA
| | | | | | - Suramya Waidyanatha
- Division of the Translational Toxicology, National Institute of Environmental Health Sciences, Research Triangle Park, NC, USA
| | | | - Jim Jetter
- Center for Environmental Measurement and Modelling, U.S. EPA, RTP, NC, USA
| | - Todd Krantz
- Center for Environmental Measurement and Modelling, U.S. EPA, RTP, NC, USA
| | - Guofeng Shen
- Center for Environmental Measurement and Modelling, U.S. EPA, RTP, NC, USA
| | - Wyatt Champion
- Oak Ridge Institute for Science and Education (ORISE) Postdoctoral Fellow at U.S. EPA, Office of Research and Development, Center for Environmental Measurement and Modelling, RTP, NC, USA
| | | | | | | | - Cynthia V. Rider
- Division of the Translational Toxicology, National Institute of Environmental Health Sciences, Research Triangle Park, NC, USA
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Balasubramani K, Prasad KA, Kodali NK, Abdul Rasheed NK, Chellappan S, Sarma DK, Kumar M, Dixit R, James MM, Behera SK, Shekhar S, Balabaskaran Nina P. Spatial epidemiology of acute respiratory infections in children under 5 years and associated risk factors in India: District-level analysis of health, household, and environmental datasets. Front Public Health 2022; 10:906248. [PMID: 36582369 PMCID: PMC9792853 DOI: 10.3389/fpubh.2022.906248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Accepted: 11/07/2022] [Indexed: 12/15/2022] Open
Abstract
Background In India, acute respiratory infections (ARIs) are a leading cause of mortality in children under 5 years. Mapping the hotspots of ARIs and the associated risk factors can help understand their association at the district level across India. Methods Data on ARIs in children under 5 years and household variables (unclean fuel, improved sanitation, mean maternal BMI, mean household size, mean number of children, median months of breastfeeding the children, percentage of poor households, diarrhea in children, low birth weight, tobacco use, and immunization status of children) were obtained from the National Family Health Survey-4. Surface and ground-monitored PM2.5 and PM10 datasets were collected from the Global Estimates and National Ambient Air Quality Monitoring Programme. Population density and illiteracy data were extracted from the Census of India. The geographic information system was used for mapping, and ARI hotspots were identified using the Getis-Ord Gi* spatial statistic. The quasi-Poisson regression model was used to estimate the association between ARI and household, children, maternal, environmental, and demographic factors. Results Acute respiratory infections hotspots were predominantly seen in the north Indian states/UTs of Uttar Pradesh, Bihar, Delhi, Haryana, Punjab, and Chandigarh, and also in the border districts of Uttarakhand, Himachal Pradesh, and Jammu and Kashmir. There is a substantial overlap among PM2.5, PM10, population density, tobacco smoking, and unclean fuel use with hotspots of ARI. The quasi-Poisson regression analysis showed that PM2.5, illiteracy levels, diarrhea in children, and maternal body mass index were associated with ARI. Conclusion To decrease ARI in children, urgent interventions are required to reduce the levels of PM2.5 and PM10 (major environmental pollutants) in the hotspot districts. Furthermore, improving sanitation, literacy levels, using clean cooking fuel, and curbing indoor smoking may minimize the risk of ARI in children.
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Affiliation(s)
| | - Kumar Arun Prasad
- Department of Geography, Central University of Tamil Nadu, Thiruvarur, Tamil Nadu, India
| | - Naveen Kumar Kodali
- Department of Epidemiology and Public Health, Central University of Tamil Nadu, Thiruvarur, Tamil Nadu, India
| | | | - Savitha Chellappan
- Department of Public Health and Community Medicine, ICMR—National Institute of Traditional Medicine, Belgaum, Karnataka, India
| | - Devojit Kumar Sarma
- Department of Molecular Biology, ICMR—National Institute for Research in Environmental Health, Bhopal, Madhya Pradesh, India
| | - Manoj Kumar
- Department of Microbiology, ICMR—National Institute for Research in Environmental Health, Bhopal, Madhya Pradesh, India
| | - Rashi Dixit
- Department of Epidemiology and Public Health, Central University of Tamil Nadu, Thiruvarur, Tamil Nadu, India
| | - Meenu Mariya James
- Department of Epidemiology and Public Health, Central University of Tamil Nadu, Thiruvarur, Tamil Nadu, India
| | - Sujit Kumar Behera
- Department of Epidemiology and Public Health, Central University of Tamil Nadu, Thiruvarur, Tamil Nadu, India
| | - Sulochana Shekhar
- Department of Geography, Central University of Tamil Nadu, Thiruvarur, Tamil Nadu, India
| | - Praveen Balabaskaran Nina
- Department of Epidemiology and Public Health, Central University of Tamil Nadu, Thiruvarur, Tamil Nadu, India,Department of Public Health and Community Medicine, Central University of Kerala, Kasaragod, Kerala, India,*Correspondence: Praveen Balabaskaran Nina
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Wylie BJ, Asante KP. Clean Cooking Fuels to Improve Health during Pregnancy. N Engl J Med 2022; 387:1805-1807. [PMID: 36351272 DOI: 10.1056/nejme2212362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Blair J Wylie
- From the Department of Obstetrics and Gynecology, Columbia University Vagelos College of Physicians and Surgeons, and the Collaborative for Women's Environmental Health - both in New York (B.J.W.); and Kintampo Health Research Centre, Research and Development Ghana Health Service, Kintampo North Municipality, Ghana (K.P.A.)
| | - Kwaku P Asante
- From the Department of Obstetrics and Gynecology, Columbia University Vagelos College of Physicians and Surgeons, and the Collaborative for Women's Environmental Health - both in New York (B.J.W.); and Kintampo Health Research Centre, Research and Development Ghana Health Service, Kintampo North Municipality, Ghana (K.P.A.)
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Qiu AY, Leng S, McCormack M, Peden DB, Sood A. Lung Effects of Household Air Pollution. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2022; 10:2807-2819. [PMID: 36064186 DOI: 10.1016/j.jaip.2022.08.031] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 08/23/2022] [Accepted: 08/25/2022] [Indexed: 06/15/2023]
Abstract
Biomass fuel smoke, secondhand smoke, and oxides of nitrogen are common causes of household air pollution (HAP). Almost 2.4 billion people worldwide use solid fuels for cooking and heating, mostly in low- and middle-income countries. Wood combustion for household heating is also common in many areas of high-income countries, and minorities are particularly vulnerable. HAP in low- and middle-income countries is associated with asthma, acute respiratory tract infections in adults and children, chronic obstructive pulmonary disease, lung cancer, tuberculosis, and respiratory mortality. Although wood smoke exposure levels in high-income countries are typically lower than in lower-income countries, it is similarly associated with accelerated lung function decline, higher prevalence of airflow obstruction and chronic bronchitis, and higher all-cause and respiratory cause-specific mortality. Household air cleaners with high-efficiency particle filters have mixed effects on asthma and chronic obstructive pulmonary disease outcomes. Biomass fuel interventions in low-income countries include adding chimneys to cookstoves, improving biomass fuel combustion stoves, and switching fuel to liquid petroleum gas. Still, the impact on health outcomes is inconsistent. In high-income countries, strategies for reducing biomass fuel-related HAP are centered on community-level woodstove changeout programs, although the results are again inconsistent. In addition, initiatives to encourage home smoking bans have mixed success in households with children. Environmental solutions to reduce HAP have varying success in reducing pollutants and health problems. Improved understanding of indoor air quality factors and actions that prevent degradation or improve polluted indoor air may lead to enhanced environmental health policies, but health outcomes must be rigorously examined.
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Affiliation(s)
- Anna Y Qiu
- Johns Hopkins University, School of Medicine, Baltimore, Md
| | - Shuguang Leng
- University of New Mexico School of Medicine, Albuquerque, NM; University of New Mexico Comprehensive Cancer Center, Albuquerque, NM
| | | | - David B Peden
- University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC
| | - Akshay Sood
- University of New Mexico School of Medicine, Albuquerque, NM; Miners Colfax Medical Center, Raton, NM.
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Lu W, Wang LA, Mann J, Jenny A, Romero C, Kuster A, Canuz E, Pillarisetti A, Smith KR, Balmes J, Thompson L. Biomass Smoke Exposure and Atopy among Young Children in the Western Highlands of Guatemala: A Prospective Cohort Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:14064. [PMID: 36360942 PMCID: PMC9656762 DOI: 10.3390/ijerph192114064] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 10/21/2022] [Accepted: 10/26/2022] [Indexed: 06/16/2023]
Abstract
Women and children in rural regions of low-income countries are exposed to high levels of household air pollution (HAP) as they traditionally tend to household chores such as cooking with biomass fuels. Early life exposure to air pollution is associated with aeroallergen sensitization and developing allergic diseases at older ages. This prospective cohort study assigned HAP-reducing chimney stoves to 557 households in rural Guatemala at different ages of the study children. The children's air pollution exposure was measured using personal CO diffusion tubes. Allergic outcomes at 4-5 years old were assessed using skin prick tests and International Study of Asthma and Allergies in Childhood (ISAAC)-based questionnaires. Children assigned to improved stoves before 6 months old had the lowest HAP exposure compared to the other groups. Longer exposure to the unimproved stoves was associated with higher risks of maternal-reported allergic asthma (OR = 2.42, 95% CI: 1.11-5.48) and rhinitis symptoms (OR = 2.01, 95% CI: 1.13-3.58). No significant association was found for sensitization to common allergens such as dust mites and cockroaches based on skin prick tests. Reducing HAP by improving biomass burning conditions might be beneficial in preventing allergic diseases among children in rural low-income populations.
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Affiliation(s)
- Wenxin Lu
- School of Public Health, University of California, Berkeley, CA 94720, USA
| | - Laura Ann Wang
- Department of Pediatrics, University of Colorado, Aurora, CO 80045, USA
| | - Jennifer Mann
- School of Public Health, University of California, Berkeley, CA 94720, USA
| | - Alisa Jenny
- Institute for Global Health Sciences, University of California, San Francisco, CA 94158, USA
| | - Carolina Romero
- Centro de Estudios en Salud, Universidad del Valle de Guatemala, Guatemala City 01015, Guatemala
| | - Andrea Kuster
- School of Nursing, University of California, San Francisco, CA 94158, USA
| | - Eduardo Canuz
- Centro de Estudios en Salud, Universidad del Valle de Guatemala, Guatemala City 01015, Guatemala
| | - Ajay Pillarisetti
- School of Public Health, University of California, Berkeley, CA 94720, USA
| | - Kirk R. Smith
- School of Public Health, University of California, Berkeley, CA 94720, USA
| | - John Balmes
- School of Public Health, University of California, Berkeley, CA 94720, USA
| | - Lisa Thompson
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA 30322, USA
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Dhital S, Rupakheti D, Rupakheti M, Yin X, Liu Y, Mafiana JJ, Alareqi MM, Mohamednour H, Zhang B. A scientometric analysis of indoor air pollution research during 1990-2019. JOURNAL OF ENVIRONMENTAL MANAGEMENT 2022; 320:115736. [PMID: 35932736 DOI: 10.1016/j.jenvman.2022.115736] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 01/26/2022] [Accepted: 07/09/2022] [Indexed: 06/15/2023]
Abstract
Indoor air pollution (IAP) is one of the leading risk factors for various adverse health outcomes including premature deaths globally. Even though research related to IAP has been carried out, bibliometric studies with particular emphasis on this topic have been lacking. Here, we investigated IAP research from 1990 to 2019 retrieved from the Web of Science database through a comprehensive and systematic scientometric analysis using the CiteSpace 5.7.R2, a powerful tool for visualizing structural, temporal patterns and trends of a scientific field. There was an exponential increase in publications, however, with a stark difference between developed and developing countries. The journals publishing IAP related research had multiple disciplines; 'Indoor Air' journal that focuses solely on IAP issues ranked fifth among top-cited journals. The terms like 'global burden', 'comparative risk assessment,' 'household air pollution (HAP)', 'ventilation', 'respiratory health', 'emission factor', 'impact,' 'energy', 'household', 'India' were the current topical subject where author Kirk R. Smith was identified with a significant contribution. Research related to rural, fossil-fuel toxicity, IAP, and exposure-assessment had the highest citation burst signifying the particular attention of scientific communities to these subjects. Overall, this study examined the evolution of IAP research, identified the gaps and provided future research directions.
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Affiliation(s)
- Sushma Dhital
- School of Public Health, Lanzhou University, Lanzhou 730000, China.
| | - Dipesh Rupakheti
- Jiangsu Key Laboratory of Atmospheric Environment Monitoring and Pollution Control, Collaborative Innovation Center of Atmospheric Environment and Equipment Technology, School of Environmental Science and Engineering, Nanjing University of Information Science & Technology, Nanjing 210044, China
| | | | - Xiufeng Yin
- State Key Laboratory of Cryospheric Science, Northwest Institute of Eco-Environment and Resources, Chinese Academy of Sciences, Lanzhou 730000, China
| | - Yanli Liu
- School of Public Health, Lanzhou University, Lanzhou 730000, China
| | | | | | | | - Benzhong Zhang
- School of Public Health, Lanzhou University, Lanzhou 730000, China.
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Walker ES, Noonan CW, Belcourt A, Boulafentis J, Garcia C, Graham J, Hoskie N, Quintana E, Semmens EO, Simpson J, Smith P, Teasley H, Ware D, Weiler E, Ward TJ. Efficacy of air filtration and education interventions on fine particulate matter among rural Native American homes heated with wood stoves: Results from the EldersAIR randomized trial. THE SCIENCE OF THE TOTAL ENVIRONMENT 2022; 843:157029. [PMID: 35777562 PMCID: PMC9829403 DOI: 10.1016/j.scitotenv.2022.157029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 06/23/2022] [Accepted: 06/24/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Native Americans living in rural areas often rely upon wood stoves for home heating that can lead to elevated indoor concentrations of fine particulate matter (PM2.5). Wood stove use is associated with adverse health outcomes, which can be a particular risk in vulnerable populations including older adults. OBJECTIVES We assessed the impact of portable air filtration units and educational approaches that incorporated elements of traditional knowledge on indoor and personal PM2.5 concentrations among rural, Native American elder households with wood stoves. METHODS EldersAIR was a three-arm, pre-post randomized trial among rural households from the Navajo Nation and Nez Perce Tribe in the United States. We measured personal and indoor PM2.5 concentrations over 2-day sampling periods on up to four occasions across two consecutive winter seasons in elder participant homes. We assessed education and air filtration intervention efficacy using linear mixed models. RESULTS Geometric mean indoor PM2.5 concentrations were 50.5 % lower (95 % confidence interval: -66.1, -27.8) in the air filtration arm versus placebo, with similar results for personal PM2.5. Indoor PM2.5 concentrations among education arm households were similar to placebo, although personal PM2.5 concentrations were 33.3 % lower for the education arm versus placebo (95 % confidence interval: -63.2, 21.1). SIGNIFICANCE The strong partnership between academic and community partners helped facilitate a culturally acceptable approach to a clinical trial intervention within the study communities. Portable air filtration units can reduce indoor PM2.5 that originates from indoor wood stoves, and this finding was supported in this study. The educational intervention component was meaningful to the communities, but did not substantially impact indoor PM2.5 relative to placebo. However, there is evidence that the educational interventions reduced indoor PM2.5 in some subsets of the study households. More study is required to determine ways to optimize educational interventions within Native American communities.
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Affiliation(s)
- Ethan S Walker
- Center for Population Health Research, University of Montana, Missoula, MT, USA; School of Public and Community Health Sciences, University of Montana, Missoula, MT, USA.
| | - Curtis W Noonan
- Center for Population Health Research, University of Montana, Missoula, MT, USA; School of Public and Community Health Sciences, University of Montana, Missoula, MT, USA
| | - Annie Belcourt
- School of Public and Community Health Sciences, University of Montana, Missoula, MT, USA
| | | | | | - Jon Graham
- Center for Population Health Research, University of Montana, Missoula, MT, USA
| | - Nolan Hoskie
- Navajo Nation Environmental Protection Agency, Window Rock, AZ, USA
| | - Eugenia Quintana
- Navajo Nation Environmental Protection Agency, Window Rock, AZ, USA
| | - Erin O Semmens
- Center for Population Health Research, University of Montana, Missoula, MT, USA; School of Public and Community Health Sciences, University of Montana, Missoula, MT, USA
| | - Julie Simpson
- Nez Perce Tribe Air Quality Program, Lapwai, ID, USA
| | - Paul Smith
- Center for Population Health Research, University of Montana, Missoula, MT, USA; School of Public and Community Health Sciences, University of Montana, Missoula, MT, USA
| | - Howard Teasley
- Nez Perce Tribe Forestry and Fire Management Division, Lapwai, ID, USA
| | - Desirae Ware
- Center for Population Health Research, University of Montana, Missoula, MT, USA; School of Public and Community Health Sciences, University of Montana, Missoula, MT, USA
| | - Emily Weiler
- Center for Population Health Research, University of Montana, Missoula, MT, USA; School of Public and Community Health Sciences, University of Montana, Missoula, MT, USA
| | - Tony J Ward
- Center for Population Health Research, University of Montana, Missoula, MT, USA; School of Public and Community Health Sciences, University of Montana, Missoula, MT, USA
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Saleh S, Sambakunsi H, Makina D, Chinouya M, Kumwenda M, Chirombo J, Semple S, Mortimer K, Rylance J. Personal exposures to fine particulate matter and carbon monoxide in relation to cooking activities in rural Malawi. Wellcome Open Res 2022; 7:251. [PMID: 36874568 PMCID: PMC9975423 DOI: 10.12688/wellcomeopenres.18050.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/04/2022] [Indexed: 11/20/2022] Open
Abstract
Background: Air pollution is a major environmental risk factor for cardiorespiratory disease. Exposures to household air pollution from cooking and other activities, are particularly high in Southern Africa. Following an extended period of participant observation in a village in Malawi, we aimed to assess individuals' exposures to fine particulate matter (PM 2.5) and carbon monoxide (CO) and to investigate the different sources of exposure, including different cooking methods. Methods: Adult residents of a village in Malawi wore personal PM 2.5 and CO monitors for 24-48 hours, sampling every 1 (CO) or 2 minutes (PM 2.5). Subsequent in-person interviews recorded potential exposure details over the time periods. We present means and interquartile ranges for overall exposures and summaries stratified by time and activity (exposure). We employed multivariate regression to further explore these characteristics, and Spearman rank correlation to examine the relationship between paired PM 2.5 and CO exposures. Results : Twenty participants (17 female; median age 40 years, IQR: 37-56) provided 831 hours of paired PM 2.5 and CO data. Concentrations of PM 2.5 during combustion activity, usually cooking, far exceeded background levels (no combustion activity): 97.9μg/m 3 (IQR: 22.9-482.0), vs 7.6μg/m 3, IQR: 2.5-20.6 respectively. Background PM 2.5 concentrations were higher during daytime hours (11.7μg/m 3 [IQR: 5.2-30.0] vs 3.3μg/m 3 at night [IQR: 0.7-8.2]). Highest exposures were influenced by cooking location but associated with charcoal use (for CO) and firewood on a three-stone fire (for PM 2.5). Cooking-related exposures were higher in more ventilated places, such as outside the household or on a walled veranda, than during indoor cooking. Conclusions : The study demonstrates the value of combining personal PM 2.5 exposure data with detailed contextual information for providing deeper insights into pollution sources and influences. The finding of similar/lower exposures during cooking in seemingly less-ventilated places should prompt a re-evaluation of proposed clean air interventions in these settings.
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Affiliation(s)
- Sepeedeh Saleh
- Liverpool School of Tropical Medicine, LIVERPOOL, L3 5QA, UK
- Malawi Liverpool Wellcome Trust Clinical Research Programme, Blantyre, P.O. Box 30096, Malawi
| | - Henry Sambakunsi
- Malawi Liverpool Wellcome Trust Clinical Research Programme, Blantyre, P.O. Box 30096, Malawi
| | - Debora Makina
- Malawi Liverpool Wellcome Trust Clinical Research Programme, Blantyre, P.O. Box 30096, Malawi
| | - Martha Chinouya
- Liverpool School of Tropical Medicine, LIVERPOOL, L3 5QA, UK
| | - Moses Kumwenda
- Malawi Liverpool Wellcome Trust Clinical Research Programme, Blantyre, P.O. Box 30096, Malawi
| | - James Chirombo
- Malawi Liverpool Wellcome Trust Clinical Research Programme, Blantyre, P.O. Box 30096, Malawi
| | - Sean Semple
- University of Stirling, Stirling, FK9 4LA, UK
| | - Kevin Mortimer
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - Jamie Rylance
- Liverpool School of Tropical Medicine, LIVERPOOL, L3 5QA, UK
- Malawi Liverpool Wellcome Trust Clinical Research Programme, Blantyre, P.O. Box 30096, Malawi
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Orysiak J, Młynarczyk M, Piec R, Jakubiak A. Lifestyle and environmental factors may induce airway and systemic inflammation in firefighters. ENVIRONMENTAL SCIENCE AND POLLUTION RESEARCH INTERNATIONAL 2022; 29:73741-73768. [PMID: 36094704 PMCID: PMC9465149 DOI: 10.1007/s11356-022-22479-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Accepted: 08/07/2022] [Indexed: 06/15/2023]
Abstract
Health status depends on multiple genetic and non-genetic factors. Nonheritable factors (such as lifestyle and environmental factors) have stronger impact on immune responses than genetic factors. Firefighters work is associated with exposure to air pollution and heat stress, as well as: extreme physical effort, mental stress, or a changed circadian rhythm, among others. All these factors can contribute to both, short-term and long-term impairment of the physical and mental health of firefighters. Increased levels of some inflammatory markers, such as pro-inflammatory cytokines or C-reactive protein (CRP) have been observed in firefighters, which can lead to local, acute inflammation that promotes a systemic inflammatory response. It is worth emphasizing that inflammation is one of the main hallmarks of cancer and also plays a key role in the development of cardiovascular and respiratory diseases. This article presents possible causes of the development of an inflammatory reaction in firefighters, with particular emphasis on airway inflammation caused by smoke exposure.
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Affiliation(s)
- Joanna Orysiak
- Central Institute for Labour Protection - National Research Institute, Czerniakowska St. 16, 00-701, Warsaw, Poland.
| | - Magdalena Młynarczyk
- Central Institute for Labour Protection - National Research Institute, Czerniakowska St. 16, 00-701, Warsaw, Poland
| | - Robert Piec
- Institute of Internal Security, The Main School of Fire Service, Słowackiego St. 52/54, 01-629, Warsaw, Poland
| | - Agnieszka Jakubiak
- Department of Heart Failure and Cardiac Rehabilitation, Medical University of Warsaw, Żwirki and Wigury St. 61, 02-091, Warsaw, Poland
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Kaufman JD. Invited Perspective: A Critical Part of a Real-World Environmental Health Trial Is to Demonstrate That the Intervention Reduced Exposure. ENVIRONMENTAL HEALTH PERSPECTIVES 2022; 130:91304. [PMID: 36112540 PMCID: PMC9480976 DOI: 10.1289/ehp11697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 08/02/2022] [Accepted: 08/19/2022] [Indexed: 06/15/2023]
Affiliation(s)
- Joel D. Kaufman
- Environmental Health Perspectives, National Institute of Environmental Health Sciences, National Institutes of Health, U.S. Department of Health and Human Services, Research Triangle Park, North Carolina, USA
- Department of Environmental & Occupational Health Sciences, University of Washington, Seattle, Washington, USA
- Department of Medicine, University of Washington, Seattle, Washington, USA
- Department of Epidemiology, University of Washington, Seattle, Washington, USA
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Johnson M, Pillarisetti A, Piedrahita R, Balakrishnan K, Peel JL, Steenland K, Underhill LJ, Rosa G, Kirby MA, Díaz-Artiga A, McCracken J, Clark ML, Waller L, Chang HH, Wang J, Dusabimana E, Ndagijimana F, Sambandam S, Mukhopadhyay K, Kearns KA, Campbell D, Kremer J, Rosenthal JP, Checkley W, Clasen T, Naeher L. Exposure Contrasts of Pregnant Women during the Household Air Pollution Intervention Network Randomized Controlled Trial. ENVIRONMENTAL HEALTH PERSPECTIVES 2022; 130:97005. [PMID: 36112539 PMCID: PMC9480977 DOI: 10.1289/ehp10295] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Revised: 07/12/2022] [Accepted: 08/19/2022] [Indexed: 05/26/2023]
Abstract
BACKGROUND Exposure to PM 2.5 arising from solid fuel combustion is estimated to result in ∼ 2.3 million premature deaths and 91 million lost disability-adjusted life years annually. Interventions attempting to mitigate this burden have had limited success in reducing exposures to levels thought to provide substantive health benefits. OBJECTIVES This paper reports exposure reductions achieved by a liquified petroleum gas (LPG) stove and fuel intervention for pregnant mothers in the Household Air Pollution Intervention Network (HAPIN) randomized controlled trial. METHODS The HAPIN trial included 3,195 households primarily using biomass for cooking in Guatemala, India, Peru, and Rwanda. Twenty-four-hour exposures to PM 2.5 , carbon monoxide (CO), and black carbon (BC) were measured for pregnant women once before randomization into control (n = 1,605 ) and LPG (n = 1,590 ) arms and twice thereafter (aligned with trimester). Changes in exposure were estimated by directly comparing exposures between intervention and control arms and by using linear mixed-effect models to estimate the impact of the intervention on exposure levels. RESULTS Median postrandomization exposures of particulate matter (PM) with aerodynamic diameter ≤ 2.5 μ m (PM 2.5 ) in the intervention arm were lower by 66% at the first (71.5 vs. 24.1 μ g / m 3 ), and second follow-up visits (69.5 vs. 23.7 μ g / m 3 ) compared to controls. BC exposures were lower in the intervention arm by 72% (9.7 vs. 2.7 μ g / m 3 ) and 70% (9.6 vs. 2.8 μ g / m 3 ) at the first and second follow-up visits, respectively, and carbon monoxide exposure was 82% lower at both visits (1.1 vs. 0.2 ppm ) in comparison with controls. Exposure reductions were consistent over time and were similar across research locations. DISCUSSION Postintervention PM 2.5 exposures in the intervention arm were at the lower end of what has been reported for LPG and other clean fuel interventions, with 69% of PM 2.5 samples falling below the World Health Organization Annual Interim Target 1 of 35 μ g / m 3 . This study indicates that an LPG intervention can reduce PM 2.5 exposures to levels at or below WHO targets. https://doi.org/10.1289/EHP10295.
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Affiliation(s)
| | - Ajay Pillarisetti
- Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley, California, USA
| | | | - Kalpana Balakrishnan
- Department of Environmental Health Engineering, ICMR Center for Advanced Research on Air Quality, Climate and Health, Sri Ramachandra Medical College and Research Institute, Sri Ramachandra Institute for Higher Education and Research (Deemed University), Chennai, India
| | - Jennifer L. Peel
- Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins, Colorado, USA
| | - Kyle Steenland
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Lindsay J. Underhill
- Cardiovascular Division, School of Medicine, Washington University, St. Louis, Missouri, USA
| | - Ghislaine Rosa
- Department of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
| | - Miles A. Kirby
- Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | | | - John McCracken
- Department of Environmental Health Science, College of Public Health, University of Georgia, Athens, Georgia, USA
| | - Maggie L. Clark
- Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins, Colorado, USA
| | - Lance Waller
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Howard H. Chang
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Jiantong Wang
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | | | | | - Sankar Sambandam
- Department of Environmental Health Engineering, ICMR Center for Advanced Research on Air Quality, Climate and Health, Sri Ramachandra Medical College and Research Institute, Sri Ramachandra Institute for Higher Education and Research (Deemed University), Chennai, India
| | - Krishnendu Mukhopadhyay
- Department of Environmental Health Engineering, ICMR Center for Advanced Research on Air Quality, Climate and Health, Sri Ramachandra Medical College and Research Institute, Sri Ramachandra Institute for Higher Education and Research (Deemed University), Chennai, India
| | - Katherine A. Kearns
- Department of Environmental Health Science, College of Public Health, University of Georgia, Athens, Georgia, USA
| | - Devan Campbell
- Department of Environmental Health Science, College of Public Health, University of Georgia, Athens, Georgia, USA
| | - Jacob Kremer
- Department of Environmental Health Science, College of Public Health, University of Georgia, Athens, Georgia, USA
| | - Joshua P. Rosenthal
- Division of Epidemiology and Population Studies, Fogarty International Center, National Institutes of Health, Bethesda, Maryland, USA
| | - William Checkley
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Thomas Clasen
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Luke Naeher
- Department of Environmental Health Science, College of Public Health, University of Georgia, Athens, Georgia, USA
| | - and the Household Air Pollution Intervention Network (HAPIN) Trial Investigators
- Berkeley Air Monitoring Group, Berkeley, California, USA
- Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley, California, USA
- Department of Environmental Health Engineering, ICMR Center for Advanced Research on Air Quality, Climate and Health, Sri Ramachandra Medical College and Research Institute, Sri Ramachandra Institute for Higher Education and Research (Deemed University), Chennai, India
- Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins, Colorado, USA
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
- Cardiovascular Division, School of Medicine, Washington University, St. Louis, Missouri, USA
- Department of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
- Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
- Universidad del Valle de Guatemala, Guatemala City, Guatemala
- Department of Environmental Health Science, College of Public Health, University of Georgia, Athens, Georgia, USA
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
- Eagle Research Center, Kigali, Rwanda
- Division of Epidemiology and Population Studies, Fogarty International Center, National Institutes of Health, Bethesda, Maryland, USA
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
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Alexis NE, Zhou LY, Burbank AJ, Almond M, Hernandez ML, Mills KH, Noah TL, Wells H, Zhou H, Peden DB. Development of a screening protocol to identify persons who are responsive to wood smoke particle-induced airway inflammation with pilot assessment of GSTM1 genotype and asthma status as response modifiers. Inhal Toxicol 2022; 34:329-339. [PMID: 35968917 PMCID: PMC10519374 DOI: 10.1080/08958378.2022.2110334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Accepted: 07/28/2022] [Indexed: 11/05/2022]
Abstract
BACKGROUND We are currently screening human volunteers to determine their sputum polymorphonuclear neutrophil (PMN) response 6- and 24-hours following initiation of exposure to wood smoke particles (WSP). Inflammatory responders (≥10% increase in %PMN) are identified for their subsequent participation in mitigation studies against WSP-induced airways inflammation. In this report we compared responder status (<i>N</i> = 52) at both 6 and 24 hr time points to refine/expand its classification, assessed the impact of the GSTM1 genotype, asthma status and sex on responder status, and explored whether sputum soluble phase markers of inflammation correlate with PMN responsiveness to WSP. RESULTS Six-hour responders tended to be 24-hour responders and vice versa, but 24-hour responders also had significantly increased IL-1beta, IL-6, IL-8 at 24 hours post WSP exposure. The GSTM1 null genotype significantly (<i>p</i> < 0.05) enhanced the %PMN response by 24% in the 24-hour responders and not at all in the 6 hours responders. Asthma status enhanced the 24 hour %PMN response in the 6- and 24-hour responders. In the entire cohort (not stratified by responder status), we found a significant, but very small decrease in FVC and systolic blood pressure immediately following WSP exposure and sputum %PMNs were significantly increased and associated with sputum inflammatory markers (IL-1beta, IL-6, IL-8, and PMN/mg) at 24 but not 6 hours post exposure. Blood endpoints in the entire cohort showed a significant increase in %PMN and PMN/mg at 6 but not 24 hours. Sex had no effect on %PMN response. CONCLUSIONS The 24-hour time point was more informative than the 6-hour time point in optimally and expansively defining airway inflammatory responsiveness to WSP exposure. GSTM1 and asthma status are significant effect modifiers of this response. These study design and subject parameters should be considered before enrolling volunteers for proof-of-concept WSP mitigation studies.
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Affiliation(s)
- Neil E Alexis
- Center for Environmental Medicine, Asthma and Lung Biology, School of Medicine, University of North Carolina, Chapel Hill, NC, USA
- Division of Allergy & Immunology, Department of Pediatrics, School of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Laura Y Zhou
- Center for Environmental Medicine, Asthma and Lung Biology, School of Medicine, University of North Carolina, Chapel Hill, NC, USA
- Department of Biostatistics, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA
| | - Allison J Burbank
- Division of Allergy & Immunology, Department of Pediatrics, School of Medicine, University of North Carolina, Chapel Hill, NC, USA
- Children's Research Institute, Department of Pediatrics, School of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Martha Almond
- Center for Environmental Medicine, Asthma and Lung Biology, School of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Michelle L Hernandez
- Division of Allergy & Immunology, Department of Pediatrics, School of Medicine, University of North Carolina, Chapel Hill, NC, USA
- Children's Research Institute, Department of Pediatrics, School of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Katherine H Mills
- Division of Allergy & Immunology, Department of Pediatrics, School of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Terry L Noah
- Center for Environmental Medicine, Asthma and Lung Biology, School of Medicine, University of North Carolina, Chapel Hill, NC, USA
- Division of Pulmonology, Department of Pediatrics, School of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Heather Wells
- Center for Environmental Medicine, Asthma and Lung Biology, School of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Haibo Zhou
- Center for Environmental Medicine, Asthma and Lung Biology, School of Medicine, University of North Carolina, Chapel Hill, NC, USA
- Children's Research Institute, Department of Pediatrics, School of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - David B Peden
- Center for Environmental Medicine, Asthma and Lung Biology, School of Medicine, University of North Carolina, Chapel Hill, NC, USA
- Division of Allergy & Immunology, Department of Pediatrics, School of Medicine, University of North Carolina, Chapel Hill, NC, USA
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Ye W, Thangavel G, Pillarisetti A, Steenland K, Peel JL, Balakrishnan K, Jabbarzadeh S, Checkley W, Clasen T. Association between personal exposure to household air pollution and gestational blood pressure among women using solid cooking fuels in rural Tamil Nadu, India. ENVIRONMENTAL RESEARCH 2022; 208:112756. [PMID: 35065931 PMCID: PMC8935388 DOI: 10.1016/j.envres.2022.112756] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 01/06/2022] [Accepted: 01/15/2022] [Indexed: 05/22/2023]
Abstract
BACKGROUND The Household Air Pollution Intervention Network (HAPIN) trial is an ongoing multi-center randomized controlled trial assessing the impact of a liquified petroleum gas (LPG) cookstove and fuel intervention on health. Given the potential impacts of household air pollution (HAP) exposure from burning solid fuels on cardiovascular health during pregnancy, we sought to determine whether baseline exposures to particulate matter with an aerodynamic diameter ≤2.5 μm (PM2.5), black carbon (BC) and carbon monoxide (CO) were associated with blood pressure among 799 pregnant women in Tamil Nadu, India, one of the HAPIN trial centers. METHODS Multivariable linear regression models were used to examine the association between 24-h personal exposure to PM2.5/BC/CO and systolic and diastolic blood pressure, controlling for maternal age, body mass index (BMI), mother's education, household wealth, gestational age, and season. At the time of measurement, women were between 9- and 20-weeks of gestation. RESULTS We found that systolic blood pressure (SBP) and diastolic blood pressure (DBP) were higher in pregnant women exposed to higher levels of HAP, though only the result for CO and DBP reached conventional statistical significance (p < 0.05). We observed a positive association between CO and DBP among the entire study cohort: a 1-log μg/m3 increase in CO exposure was associated with 0.36 mmHg higher DBP (95% confidence interval [CI]: 0.02 to 0.70). The effect was stronger in pregnant women with higher CO exposures (in the 3rd [≥ 0.9 and < 2.1 ppm] and 4th quartiles [≥ 2.1 and ≤ 46.9 ppm]). We also found that pregnant women with PM2.5 exposures in the highest quartile (≥ 129.9 and ≤ 2100 μg/m3) had a borderline significant association (p = 0.054) with DBP compared to those who had PM2.5 exposures in the lowest quartile (≥ 9.4 and < 47.7 μg/m3). No evidence of association was observed for BC exposure and blood pressure. CONCLUSION This study contributes to limited evidence regarding the relationship between HAP exposure and blood pressure among women during pregnancy, a critical window for both mother and child's life-course health. Results from this cross-sectional study suggest that exposures to PM2.5 and CO from solid fuel use are associated with higher blood pressure in pregnant women during their first or second trimester.
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Affiliation(s)
- Wenlu Ye
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA.
| | - Gurusamy Thangavel
- Department of Environmental Health Engineering, Sri Ramachandra Institute of Higher Education and Research, Chennai, Tamil Nadu, India
| | - Ajay Pillarisetti
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA; Environmental Health Sciences, School of Public Health, University of California, Berkeley, California, USA
| | - Kyle Steenland
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Jennifer L Peel
- Dept of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins, CO, USA
| | - Kalpana Balakrishnan
- Department of Environmental Health Engineering, Sri Ramachandra Institute of Higher Education and Research, Chennai, Tamil Nadu, India
| | - Shirin Jabbarzadeh
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - William Checkley
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, MD, USA; Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Thomas Clasen
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
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Mandal TK, Yadav L, Sharma SK, Saxena M, Tomar N, Dutta A, Malik N, Saharan US. Chemical properties of emissions from solid residential fuels used for energy in the rural sector of the southern region of India. ENVIRONMENTAL SCIENCE AND POLLUTION RESEARCH INTERNATIONAL 2022; 29:37930-37953. [PMID: 35072883 DOI: 10.1007/s11356-022-18543-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 01/03/2022] [Indexed: 06/14/2023]
Abstract
In the present study, we have estimated the emission factors (EFs) of particulate matter (PM), organic and elemental carbon (OC and EC), oxide of sulfur and nitrogen, and water-soluble ionic species emitted from residential fuels (fuelwood, crop residue, dung cake) used in the rural sector of five states (Kerala, Karnataka, Andhra Pradesh, Telangana, Tamil Nadu) of the southern region of India. Average EFs of PM, OC, and EC from fuelwood (FW), crop residues (CR), and dung cakes (DC) from southern region of India are estimated as follows: PM: 6.35 ± 5.64 g/kg (FW), 6.99 ± 5.46 g/kg (CR), 9.69 ± 3.73 g/kg (DC); OC: 1.60 ± 1.72 g/kg (FW), 1.50 ± 1.52 g/kg (CR), 3.54 ± 0.75 g/kg (DC); and EC: 0.46 ± 0.53 g/kg (FW), 0.29 ± 0.17 g/kg (CR), 0.21 ± 0.11 g/kg (DC), respectively. Similarly, the average EFs of SO2, NOx from FW, CR, and DC are determined to be as follows: SO2: 0.40 ± 0.37 g/kg (FW), 1.17 ± 0.25 g/kg (CR), and 0.18 ± 0.10 g/kg (DC); NOx: 1.11 ± 1.22 g/kg (FW), 0.69 ± 0.37 g/kg (CR), and 0.91 ± 0.54 g/kg (DC), respectively. PO43- shows the highest EF from FW (646.02 ± 576.35 mg/kg), CR (531.06 ± 678.29 mg/kg) among all anions followed by Cl- (FW: 512.91 ± 700.35 mg/kg, CR: 661.61 ± 865.46 mg/kg and DC: 104.16 ± 54.01 mg/kg); whereas, Na+ shows highest EF from FW (254.05 ± 298.50 mg/kg) and CR (249.36 ± 294.85 mg/kg) among all cations. The total emissions of trace gases, PM, and their chemical composition from FW, CR, and DC have been calculated using laboratory-generated EFs over the southern region of India. CR (1595.58 ± 14.24 Gg) contributes to higher emission of PM as compared to FW (218.78 ± 53.93 Gg), whereas the contribution from DC is negligible.
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Affiliation(s)
- Tuhin Kumar Mandal
- Environmental Sciences and Biomedical Metrology Division, CSIR-National Physical Laboratory, Dr. K. S. Krishnan Road, New Delhi, 110012, India.
- Academy of Scientific and Innovative Research (AcSIR), Ghaziabad, Uttar Pradesh, 201 002, India.
| | - Lokesh Yadav
- Environmental Sciences and Biomedical Metrology Division, CSIR-National Physical Laboratory, Dr. K. S. Krishnan Road, New Delhi, 110012, India
- Academy of Scientific and Innovative Research (AcSIR), Ghaziabad, Uttar Pradesh, 201 002, India
| | - Sudhir Kumar Sharma
- Environmental Sciences and Biomedical Metrology Division, CSIR-National Physical Laboratory, Dr. K. S. Krishnan Road, New Delhi, 110012, India
- Academy of Scientific and Innovative Research (AcSIR), Ghaziabad, Uttar Pradesh, 201 002, India
| | - Mohit Saxena
- Ministry of Environment, Forest and Climate Change (MoEFCC), New Delhi, India
| | - Nidhi Tomar
- Environmental Sciences and Biomedical Metrology Division, CSIR-National Physical Laboratory, Dr. K. S. Krishnan Road, New Delhi, 110012, India
- Guru Govind Singh Indra Prastha University, Dwarka, New Delhi, India
| | - Arindam Dutta
- The Energy Research Institute (TERI), New Delhi, India
| | - Nidhi Malik
- Indian Institute of Technology (Indian School of Mines) (IIT-ISM), Dhanbad, India
| | - Ummed Singh Saharan
- Environmental Sciences and Biomedical Metrology Division, CSIR-National Physical Laboratory, Dr. K. S. Krishnan Road, New Delhi, 110012, India
- Academy of Scientific and Innovative Research (AcSIR), Ghaziabad, Uttar Pradesh, 201 002, India
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Walker ES, Semmens EO, Belcourt A, Boyer BB, Erdei E, Graham J, Hopkins SE, Lewis JL, Smith PG, Ware D, Weiler E, Ward TJ, Noonan CW. Efficacy of Air Filtration and Education Interventions on Indoor Fine Particulate Matter and Child Lower Respiratory Tract Infections among Rural U.S. Homes Heated with Wood Stoves: Results from the KidsAIR Randomized Trial. ENVIRONMENTAL HEALTH PERSPECTIVES 2022; 130:47002. [PMID: 35394807 PMCID: PMC8992966 DOI: 10.1289/ehp9932] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 02/18/2022] [Accepted: 03/18/2022] [Indexed: 05/24/2023]
Abstract
BACKGROUND Millions of rural U.S. households are heated with wood stoves. Wood stove use can lead to high indoor concentrations of fine particulate matter [airborne particles ≤2.5μm in aerodynamic diameter (PM2.5)] and is associated with lower respiratory tract infection (LRTI) in children. OBJECTIVES We assessed the impact of low-cost educational and air filtration interventions on childhood LRTI and indoor PM2.5 in rural U.S. homes with wood stoves. METHODS The Kids Air Quality Interventions for Reducing Respiratory Infections (KidsAIR) study was a parallel three-arm (education, portable air filtration unit, control), post-only randomized trial in households from Alaska, Montana, and Navajo Nation (Arizona and New Mexico) with a wood stove and one or more children <5 years of age. We tracked LRTI cases for two consecutive winter seasons and measured indoor PM2.5 over a 6-d period during the first winter. We assessed results using two analytical frameworks: a) intervention efficacy on LRTI and PM2.5 (intent-to-treat), and b) association between PM2.5 and LRTI (exposure-response). RESULTS There were 61 LRTI cases from 14,636 child-weeks of follow-up among 461 children. In the intent-to-treat analysis, children in the education arm [odds ratio (OR)=0.98; 95% confidence interval (CI): 0.35, 2.72] and the filtration arm (OR=1.23; 95% CI: 0.46, 3.32) had similar odds of LRTI vs. control. Geometric mean PM2.5 concentrations were similar to control in the education arm (11.77% higher; 95% CI: -16.57, 49.72) and air filtration arm (6.96% lower; 95% CI: -30.50, 24.55). In the exposure-response analysis, odds of LRTI were 1.45 times higher (95% CI: 1.02, 2.05) per interquartile range (25 μg/m3) increase in mean indoor PM2.5. DISCUSSION We did not observe meaningful differences in LRTI or indoor PM2.5 in the air filtration or education arms compared with the control arm. Results from the exposure-response analysis provide further evidence that biomass air pollution adversely impacts childhood LRTI. Our results highlight the need for novel, effective intervention strategies in households heated with wood stoves. https://doi.org/10.1289/EHP9932.
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Affiliation(s)
- Ethan S. Walker
- Center for Population Health Research, University of Montana, Missoula, Montana, USA
- School of Public and Community Health Sciences, University of Montana, Missoula, Montana, USA
| | - Erin O. Semmens
- Center for Population Health Research, University of Montana, Missoula, Montana, USA
- School of Public and Community Health Sciences, University of Montana, Missoula, Montana, USA
| | - Annie Belcourt
- School of Public and Community Health Sciences, University of Montana, Missoula, Montana, USA
| | - Bert B. Boyer
- Center for Alaska Native Health Research, University of Alaska Fairbanks, Alaska, USA
- Oregon Health & Science University, Portland, Oregon, USA
| | - Esther Erdei
- Community Environmental Health Program, College of Pharmacy, University of New Mexico Health Sciences Center, University of New Mexico, Albuquerque, New Mexico, USA
| | - Jon Graham
- Center for Population Health Research, University of Montana, Missoula, Montana, USA
| | - Scarlett E. Hopkins
- Center for Alaska Native Health Research, University of Alaska Fairbanks, Alaska, USA
- Oregon Health & Science University, Portland, Oregon, USA
| | - Johnnye L. Lewis
- Community Environmental Health Program, College of Pharmacy, University of New Mexico Health Sciences Center, University of New Mexico, Albuquerque, New Mexico, USA
| | - Paul G. Smith
- Center for Population Health Research, University of Montana, Missoula, Montana, USA
- School of Public and Community Health Sciences, University of Montana, Missoula, Montana, USA
| | - Desirae Ware
- Center for Population Health Research, University of Montana, Missoula, Montana, USA
- School of Public and Community Health Sciences, University of Montana, Missoula, Montana, USA
| | - Emily Weiler
- School of Public and Community Health Sciences, University of Montana, Missoula, Montana, USA
| | - Tony J. Ward
- Center for Population Health Research, University of Montana, Missoula, Montana, USA
- School of Public and Community Health Sciences, University of Montana, Missoula, Montana, USA
| | - Curtis W. Noonan
- Center for Population Health Research, University of Montana, Missoula, Montana, USA
- School of Public and Community Health Sciences, University of Montana, Missoula, Montana, USA
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Thompson LM. Invited Perspective: Household Air Pollution-Can Randomized Controlled Trials Provide the Answers to Complex Intervention Questions? ENVIRONMENTAL HEALTH PERSPECTIVES 2022; 130:41301. [PMID: 35394811 PMCID: PMC8992968 DOI: 10.1289/ehp11096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 03/16/2022] [Accepted: 03/18/2022] [Indexed: 06/14/2023]
Affiliation(s)
- Lisa M. Thompson
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia, USA
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Checkley W, Hossen S, Rosa G, Thompson LM, McCracken JP, Diaz-Artiga A, Balakrishnan K, Simkovich SM, Underhill LJ, Nicolaou L, Hartinger SM, Davila-Roman VG, Kirby MA, Clasen TF, Rosenthal J, Peel JL. Facing the Realities of Pragmatic Design Choices in Environmental Health Studies: Experiences from the Household Air Pollution Intervention Network Trial. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:3790. [PMID: 35409475 PMCID: PMC8997769 DOI: 10.3390/ijerph19073790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Revised: 03/15/2022] [Accepted: 03/18/2022] [Indexed: 11/29/2022]
Abstract
Objective: Household Air Pollution Intervention Network (HAPIN) investigators tested a complex, non-pharmacological intervention in four low- and middle-income countries as a strategy to mitigate household air pollution and improve health outcomes across the lifespan. Intervention households received a liquefied petroleum gas (LPG) stove, continuous fuel delivery and regular behavioral reinforcements for 18 months, whereas controls were asked to continue with usual cooking practices. While HAPIN was designed as an explanatory trial to test the efficacy of the intervention on four primary outcomes, it introduced several pragmatic aspects in its design and conduct that resemble real-life conditions. We surveyed HAPIN investigators and asked them to rank what aspects of the design and conduct they considered were more pragmatic than explanatory. Methods: We used the revised Pragmatic Explanatory Continuum Indicator Summary (PRECIS-2) to survey investigators on the degree of pragmatism in nine domains of trial design and conduct using a five-point Likert rank scale from very explanatory (1) to very pragmatic (5). We invited 103 investigators. Participants were given educational material on PRECIS-2, including presentations, papers and examples that described the use and implementation of PRECIS-2. Results: Thirty-five investigators (mean age 42 years, 51% female) participated in the survey. Overall, only 17% ranked all domains as very explanatory, with an average (±SD) rank of 3.2 ± 1.4 across domains. Fewer than 20% of investigators ranked eligibility, recruitment or setting as very explanatory. In contrast, ≥50% of investigators ranked the trial organization, delivery and adherence of the intervention and follow-up as very/rather explanatory whereas ≤17% ranked them as rather/very pragmatic. Finally, <25% of investigators ranked the relevance of outcomes to participants and analysis as very/rather explanatory whereas ≥50% ranked then as rather/very pragmatic. In-country partners were more likely to rank domains as pragmatic when compared to investigators working in central coordination (average rank 3.2 vs. 2.8, respectively; Wilcoxon rank-sum p < 0.001). Conclusion: HAPIN investigators did not consider their efficacy trial to be rather/very explanatory and reported that some aspects of the design and conduct were executed under real-world conditions; however, they also did not consider the trial to be overly pragmatic. Our analysis underscores the importance of using standardized tools such as PRECIS-2 to guide early discussions among investigators in the design of environmental health trials attempting to measure efficacy.
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Affiliation(s)
- William Checkley
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, MD 21287, USA; (S.H.); (L.J.U.); (L.N.)
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, MD 21287, USA
| | - Shakir Hossen
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, MD 21287, USA; (S.H.); (L.J.U.); (L.N.)
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, MD 21287, USA
| | - Ghislaine Rosa
- Faculty of Infectious and Tropical Diseases, London School of Tropical Medicine and Hygiene, London WC1E 7HT, UK;
| | - Lisa M. Thompson
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA 30332, USA;
| | - John P. McCracken
- Epidemiology and Biostatistics Department, University of Georgia, Athens, GA 30606, USA;
| | - Anaite Diaz-Artiga
- Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City 01015, Guatemala;
| | - Kalpana Balakrishnan
- ICMR Center for Advanced Research on Air Quality, Climate and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute for Higher Education and Research, Chennai 600116, India;
| | - Suzanne M. Simkovich
- Division of Healthcare Delivery Research, Medstar Health Research Institute, Hyattsville, MD 20782, USA;
- Division of Pulmonary and Critical Care Medicine, Georgetown University, Washington, DC 20007, USA
| | - Lindsay J. Underhill
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, MD 21287, USA; (S.H.); (L.J.U.); (L.N.)
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, MD 21287, USA
| | - Laura Nicolaou
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, MD 21287, USA; (S.H.); (L.J.U.); (L.N.)
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, MD 21287, USA
| | - Stella M. Hartinger
- Latin American Center of Excellence on Climate Change and Health, Universidad Peruana Cayetano Heredia, Lima 15102, Peru;
| | - Victor G. Davila-Roman
- Cardiovascular Imaging and Clinical Research Core Laboratory, Cardiovascular Division, Department of Medicine, Washington University in St. Louis, St. Louis, MO 63110, USA;
| | - Miles A. Kirby
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA 02115, USA;
| | - Thomas F. Clasen
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA 30322, USA;
| | - Joshua Rosenthal
- Fogarty International Center, National Institutes of Health, Bethesda, MD 20892, USA;
| | - Jennifer L. Peel
- Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins, CO 80523, USA;
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Younger A, Alkon A, Harknett K, Jean Louis R, Thompson LM. Adverse birth outcomes associated with household air pollution from unclean cooking fuels in low- and middle-income countries: A systematic review. ENVIRONMENTAL RESEARCH 2022; 204:112274. [PMID: 34710435 DOI: 10.1016/j.envres.2021.112274] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 10/08/2021] [Accepted: 10/21/2021] [Indexed: 06/13/2023]
Abstract
Approximately 3.8 billion people in low- and middle-income countries use unclean fuels as a source of primary cooking fuel as well as for heating. For pregnant women, the toxic chemicals produced by combustion of unclean fuels not only affect women's health directly, but particulate matter and carbon monoxide are absorbed in maternal blood and cross the placental barrier impairing fetal tissue growth. PRISMA 2009 guidelines were used for this systematic review. The inclusion criteria were quantitative, peer reviewed journal articles published within a date range of May 1, 2013-June 12, 2021 examining birth outcomes related to household air pollution from type of cooking fuel in low- and middle-income countries. The quality of available evidence was evaluated using the Office of Health Assessment and Translation (OHAT) risk of bias rating tool. Of the 553 studies screened, 23 satisfied the inclusion criteria. Of the studies that met the inclusion criteria, 14 were cross-sectional, 5 cohort, 1 case-control and 3 randomized control trials conducted across 15 different countries. A range of birth outcomes are reported across studies including birthweight (19), small for gestational age (6), spontaneous abortion (3), preterm birth (6), stillbirth (7) and neonatal mortality (6). The reviewed studies presented evidence for an increased risk of low birth weight (LBW), preterm birth (PTB), small for gestational age (SGA), stillbirth, neonatal mortality and reduction in birthweight with solid fuel and kerosene use compared to cleaner fuels like gas and LPG. Systematically reviewing the evidence and risk of bias ratings illuminated several gaps in the current literature related to exposure assessment, outcome measurement and adequacy of adjustment for confounding.
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Affiliation(s)
- Ashley Younger
- University of California, San Francisco (UCSF), School of Nursing, United States.
| | - Abbey Alkon
- University of California, San Francisco (UCSF), School of Nursing, United States
| | - Kristen Harknett
- University of California, San Francisco (UCSF), Department of Social and Behavioral Sciences, United States
| | | | - Lisa M Thompson
- Emory University Nell Hodgson Woodruff School of Nursing, United States
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Rahman AE, Hossain AT, Nair H, Chisti MJ, Dockrell D, Arifeen SE, Campbell H. Prevalence of hypoxaemia in children with pneumonia in low-income and middle-income countries: a systematic review and meta-analysis. THE LANCET GLOBAL HEALTH 2022; 10:e348-e359. [PMID: 35180418 PMCID: PMC8864303 DOI: 10.1016/s2214-109x(21)00586-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 10/31/2021] [Accepted: 12/07/2021] [Indexed: 12/23/2022] Open
Abstract
Background Pneumonia accounts for around 15% of all deaths of children younger than 5 years globally. Most happen in resource-constrained settings and are potentially preventable. Hypoxaemia is one of the strongest predictors of these deaths. We present an updated estimate of hypoxaemia prevalence among children with pneumonia in low-income and middle-income countries. Methods We conducted a systematic review using the following key concepts “children under five years of age” AND “pneumonia” AND “hypoxaemia” AND “low- and middle-income countries” by searching in 11 bibliographic databases and citation indices. We included all articles published between Nov 1, 2008, and Oct 8, 2021, based on observational studies and control arms of randomised and non-randomised controlled trials. We excluded protocol papers, articles reporting hypoxaemia prevalence based on less than 100 pneumonia cases, and articles published before 2008 from the review. Quality appraisal was done with the Joanna Briggs Institute tools. We reported pooled prevalence of hypoxaemia (SpO2 <90%) by classification of clinical severity and by clinical settings by use of the random-effects meta-analysis models. We combined our estimate of the pooled prevalence of pneumonia with a previously published estimate of the number of children admitted to hospital due to pneumonia annually to calculate the total annual number of children admitted to hospital with hypoxaemic pneumonia. Findings We identified 2825 unique records from the databases, of which 57 studies met the eligibility criteria: 26 from Africa, 23 from Asia, five from South America, and four from multiple continents. The prevalence of hypoxaemia was 31% (95% CI 26–36; 101 775 children) among all children with WHO-classified pneumonia, 41% (33–49; 30 483 children) among those with very severe or severe pneumonia, and 8% (3–16; 2395 children) among those with non-severe pneumonia. The prevalence was much higher in studies conducted in emergency and inpatient settings than in studies conducted in outpatient settings. In 2019, we estimated that over 7 million children (95% CI 5–8 million) were admitted to hospital with hypoxaemic pneumonia. The studies included in this systematic review had high τ2 (ie, 0·17), indicating a high level of heterogeneity between studies, and a high I2 value (ie, 99·6%), indicating that the heterogeneity was not due to chance. This study is registered with PROSPERO, CRD42019126207. Interpretation The high prevalence of hypoxaemia among children with severe pneumonia, particularly among children who have been admitted to hospital, emphasises the importance of overall oxygen security within the health systems of low-income and middle-income countries, particularly in the context of the COVID-19 pandemic. Even among children with non-severe pneumonia that is managed in outpatient and community settings, the high prevalence emphasises the importance of rapid identification of hypoxaemia at the first point of contact and referral for appropriate oxygen therapy. Funding UK National Institute for Health Research (Global Health Research Unit on Respiratory Health [RESPIRE]; 16/136/109).
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Affiliation(s)
- Ahmed Ehsanur Rahman
- The University of Edinburgh, Edinburgh, UK; International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh.
| | - Aniqa Tasnim Hossain
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | | | | | | | - Shams El Arifeen
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
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Wallach ES, Lam NL, Nuwagira E, Muyanja D, Tayebwa M, Valeri L, Tsai AC, Vallarino J, Allen J, Lai PS. Effect of a solar lighting intervention on fuel-based lighting use and exposure to household air pollution in rural Uganda: A randomized controlled trial. INDOOR AIR 2022; 32:e12986. [PMID: 35225388 PMCID: PMC9059846 DOI: 10.1111/ina.12986] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 01/07/2022] [Accepted: 01/08/2022] [Indexed: 06/14/2023]
Abstract
Solar lighting is an alternative to polluting kerosene and other fuel-based lighting devices relied upon by millions of families in resource-limited settings. Whether solar lighting provides sustained displacement of fuel-based lighting sources and reductions in personal exposure to fine particulate matter (PM2 .5 ) and black carbon (BC) has not been examined in randomized controlled trials. Eighty adult women living in rural Uganda who utilized fuel-based (candles and kerosene lamps) and/or clean (solar, grid, and battery-powered devices) lighting were randomized in a 1:1 ratio to receive a home solar lighting system at no cost to study participants (ClinicalTrials.gov NCT03351504). Among intervention group participants, kerosene lamps were completely displaced in 92% of households using them. The intervention led to an average exposure reduction of 36.1 μg/m3 (95% CI -70.3 to -2.0) in PM2 .5 and 10.8 μg/m3 (95% CI -17.6 to -4.1) in BC, corresponding to a reduction from baseline of 37% and 91%, respectively. Reductions were greatest among participants using kerosene lamps. Displacement of kerosene lamps and personal exposure reductions were sustained over 12 months of follow-up. Solar lighting presents an immediate opportunity for achieving sustained reductions in personal exposure to PM2.5 and BC and should be considered in household air pollution intervention packages.
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Affiliation(s)
- Eli S. Wallach
- Schatz Energy Research Center, Humboldt State University
| | | | | | | | | | - Linda Valeri
- Department of Biostatistics, Columbia University Mailman School of Public Health
| | - Alexander C. Tsai
- Mass General Global Health, Massachusetts General Hospital
- Harvard Medical School
| | - Jose Vallarino
- Department of Environmental Health, Harvard T.H. Chan School of Public Health
| | - Joseph Allen
- Department of Environmental Health, Harvard T.H. Chan School of Public Health
| | - Peggy S. Lai
- Harvard Medical School
- Department of Environmental Health, Harvard T.H. Chan School of Public Health
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital
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45
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Lin B, Wei K. Does Use of Solid Cooking Fuels Increase Family Medical Expenses in China? INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19031649. [PMID: 35162671 PMCID: PMC8835481 DOI: 10.3390/ijerph19031649] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 01/27/2022] [Accepted: 01/28/2022] [Indexed: 01/27/2023]
Abstract
China has tried to replace solid fuels with cleaner energy in households. The benefits of fuel switching need to be identified. This article shows that households using solid cooking fuels suffer heavier medical expenses than those using non-solid cooking fuels. After accounting for family characteristics, using solid fuels is associated with 1.4–1.9% increases in medical care. Through the analysis of the impact mechanism, we found that solid cooking fuels harm the health conditions of family members and increase the probability of illness, thereby increasing medical expenses, while the ratio of fuel fees does not change significantly if switching cooking fuels. Furthermore, we explored heterogeneity to better understand the underlying relationship. For urban and higher-educated families with house ownership, the impact of solid fuels on medical expenses was weaker compared to rural and lower-educated households without owned houses. Therefore, considering the costs and benefits, we recommend continuing the conversion from solid fuels to non-solid fuels. In the fuel transition process, it is beneficial to raise residents’ awareness and improve behavior to avoid indoor air pollution.
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McAlister M, Zhang Q, Annis J, Schweitzer RW, Guidotti S, Mihelcic JR. Systems Thinking for Effective Interventions in Global Environmental Health. ENVIRONMENTAL SCIENCE & TECHNOLOGY 2022; 56:732-738. [PMID: 34982546 PMCID: PMC8969763 DOI: 10.1021/acs.est.1c04110] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Indexed: 05/24/2023]
Abstract
Environmental health risks such as household air pollution due to burning solid fuels, inadequate water, sanitation, and hygiene, and chemical pollution disproportionately affect the poorest and most marginalized populations. While billions of dollars and countless hours of research have been applied toward addressing these issues in both development and humanitarian contexts, many interventions fail to achieve or sustain desired outcomes over time. This pattern points to the perpetuation of linear thinking, despite the complex nature of environmental health within these contexts. There is a need and an opportunity to engage in critical reflection of the dominant paradigms in the global environmental health community, including how they affect decision-making and collective learning. These paradigms should be adapted as needed toward the integration of diverse perspectives and the uptake of systems thinking. Participatory modeling, complexity-aware monitoring, and virtual simulation modeling can help achieve this. Additionally, virtual simulation modeling is relatively inexpensive and can provide a low-stakes environment for testing interventions before implementation.
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Affiliation(s)
- Martha
M. McAlister
- Department
of Civil & Environmental Engineering, University of South Florida, 4202 E Fowler Ave, Tampa, Florida 33620, United States
| | - Qiong Zhang
- Department
of Civil & Environmental Engineering, University of South Florida, 4202 E Fowler Ave, Tampa, Florida 33620, United States
| | - Jonathan Annis
- USAID
Uganda Sanitation for Health Activity, Tetra
Tech, Plot 12A, Farady
Road, Bugolobi, Kampala, Uganda
| | - Ryan W. Schweitzer
- Independent, 349 West Parkwood Road, Decatur, Georgia 30030, United States
| | - Sunny Guidotti
- Latin
America and Caribbean Regional Office, UNICEF, PO Box 0843-03045, Panama City, 07144, Panama
| | - James R. Mihelcic
- Department
of Civil & Environmental Engineering, University of South Florida, 4202 E Fowler Ave, Tampa, Florida 33620, United States
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Sundararajan R, D’Couto H, Mugerwa J, Tayebwa M, Lam N, Wallach E, Wiens M, Ponticiello M, Stanistreet D, Tsai AC, Vallarino J, Allen JG, Muyanja D, Shrime MG, Nuwagira E, Lai PS. Use, cost-effectiveness, and end user perspectives of a home solar lighting intervention in rural Uganda: a mixed methods, randomized controlled trial. ENVIRONMENTAL RESEARCH LETTERS : ERL [WEB SITE] 2022; 17:015002. [PMID: 35295194 PMCID: PMC8923618 DOI: 10.1088/1748-9326/ac3f05] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Energy poverty is prevalent in resource-limited settings, leading households to use inefficient fuels and appliances that contribute to household air pollution. Randomized controlled trials of household energy interventions in low and middle income countries have largely focused on cooking services. Less is known about the adoption and impact of clean lighting interventions. We conducted an explanatory sequential mixed methods study as part of a randomized controlled trial of home solar lighting systems in rural Uganda in order to identify contextual factors determining the use and impact of the solar lighting intervention. We used sensors to track usage, longitudinally assessed household lighting expenditures and health-related quality of life, and performed cost-effectiveness analyses. Qualitative interviews were conducted with all 80 trial participants and coded using reflexive thematic analysis. Uptake of the intervention solar lighting system was high with daily use averaging 8.23 ± 5.30 hours per day. The intervention solar lighting system increased the EQ5D index by 0.025 [95% CI 0.002 - 0.048] and led to an average monthly reduction in household lighting costs by -1.28 [-2.52, -0.85] US dollars, with higher savings in users of fuel-based lighting. The incremental cost-effectiveness ratio for the solar lighting intervention was $2025.72 US dollars per quality adjusted life year (QALY) gained making the intervention cost-effective when benchmarked against the gross domestic product (GDP) per capita in Uganda. Thematic analysis of qualitative data from individual interviews showed that solar lighting was transformative and associated with numerous benefits that fit within a Social Determinants of Health (SDOH) framework. The benefits included improved household finances, improved educational performance of children, increased household safety, improved family and community cohesion, and improved perceived household health. Our findings suggest that household solar lighting interventions may be a cost-effective approach to improve health-related quality of life by addressing SDOH.
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Affiliation(s)
- Radhika Sundararajan
- Department of Emergency Medicine, Weill Cornell Medicine, 525 East 68 street, New York, New York, 10065 USA
- Weill Cornell Center for Global Health, 402 East 67 Street, New York, New York 10065 USA
| | - Helen D’Couto
- Massachusetts General Hospital, 55 Fruit Street, Boston, Massachusetts, 02114 USA
| | - Joseph Mugerwa
- Mbarara University of Science and Technology, PO Box 1410, Mbarara, Uganda
| | - Mellon Tayebwa
- Mbarara University of Science and Technology, PO Box 1410, Mbarara, Uganda
| | - Nicholas Lam
- Schatz Energy Research Center, Humboldt University, 1 Harpst Street, Arcata, California USA
| | - Eli Wallach
- Schatz Energy Research Center, Humboldt University, 1 Harpst Street, Arcata, California USA
| | - Matthew Wiens
- University of British Columbia, 2329 West Mall, Vancouver, British Columbia Canada
| | - Matthew Ponticiello
- Weill Cornell Center for Global Health, 402 East 67 Street, New York, New York 10065 USA
| | - Debbi Stanistreet
- Royal College of Surgeons in Ireland, 123 Saint Stephen’s Green, Saint Peter’s, Dublin, Ireland
| | - Alexander C. Tsai
- Massachusetts General Hospital, 55 Fruit Street, Boston, Massachusetts, 02114 USA
- Harvard Medical School, 25 Shattuck Street, Boston, Massachusetts, 02115 USA
| | - Jose Vallarino
- Department of Environmental Health, Harvard T.H. Chan School of Public Health, 677 Huntington Avenue, Boston, Massachusetts, 02115 USA
| | - Joseph G. Allen
- Department of Environmental Health, Harvard T.H. Chan School of Public Health, 677 Huntington Avenue, Boston, Massachusetts, 02115 USA
| | - Daniel Muyanja
- Mbarara University of Science and Technology, PO Box 1410, Mbarara, Uganda
| | - Mark G Shrime
- Royal College of Surgeons in Ireland, 123 Saint Stephen’s Green, Saint Peter’s, Dublin, Ireland
| | - Edwin Nuwagira
- Mbarara University of Science and Technology, PO Box 1410, Mbarara, Uganda
| | - Peggy S. Lai
- Massachusetts General Hospital, 55 Fruit Street, Boston, Massachusetts, 02114 USA
- Harvard Medical School, 25 Shattuck Street, Boston, Massachusetts, 02115 USA
- Department of Environmental Health, Harvard T.H. Chan School of Public Health, 677 Huntington Avenue, Boston, Massachusetts, 02115 USA
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Bonell A, Badjie J, Jammeh S, Ali Z, Hydara M, Davies A, Faal M, Ahmed AN, Hand W, Prentice AM, Murray KA, Scheelbeek P. Grassroots and Youth-Led Climate Solutions From The Gambia. Front Public Health 2022; 10:784915. [PMID: 35462834 PMCID: PMC9021377 DOI: 10.3389/fpubh.2022.784915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 03/15/2022] [Indexed: 11/13/2022] Open
Abstract
Climate change and environmental degradation are among the greatest threats to human health. Youth campaigners have very effectively focused global attention on the crisis, however children from the Global South are often under-represented (sometimes deliberately) in the dialogue. In The Gambia, West Africa, the impacts of climate change are already being directly experienced by the population, and this will worsen in coming years. There is strong government and community commitment to adapt to these challenges, as evidenced by The Gambia currently being the only country on target to meet the Paris agreement according to the Nationally Determined Contributions, but again children's voices are often missing-while their views could yield valuable additional insights. Here, we describe a "Climate Change Solutions Festival" that targeted and engaged school children from 13 to 18 years, and is to our knowledge, the first peer-to-peer (and student-to-professional) learning festival on climate change solutions for students in The Gambia. The event gave a unique insight into perceived climate change problems and scalable, affordable and sometimes very creative solutions that could be implemented in the local area. Logistical and practical methods for running the festival are shared, as well as details on all solutions demonstrated in enough detail to be duplicated. We also performed a narrative review of the most popular stalls to explore the scientific basis of these solutions and discuss these in a global context. Overall, we find extremely strong, grass-roots and student engagement in the Gambia and clear evidence of learning about climate change and the impacts of environmental degradation more broadly. Nevertheless, we reflect that in order to enact these proposed local solutions further steps to evaluate acceptability of adoption, feasibility within the communities, cost-benefit analyses and ability to scale solutions are needed. This could be the focus of future experiential learning activities with students and partnering stakeholders.
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Affiliation(s)
- Ana Bonell
- Medical Research Council Unit The Gambia at London School of Hygiene and Tropical Medicine, Fajara, The Gambia
- Centre on Climate Change and Planetary Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
- *Correspondence: Ana Bonell
| | - Jainaba Badjie
- Medical Research Council Unit The Gambia at London School of Hygiene and Tropical Medicine, Fajara, The Gambia
| | - Sariba Jammeh
- Medical Research Council Unit The Gambia at London School of Hygiene and Tropical Medicine, Fajara, The Gambia
| | - Zakari Ali
- Medical Research Council Unit The Gambia at London School of Hygiene and Tropical Medicine, Fajara, The Gambia
| | | | | | | | - Aliyu Nuhu Ahmed
- Medical Research Council Unit The Gambia at London School of Hygiene and Tropical Medicine, Fajara, The Gambia
| | - William Hand
- Banjul American International School, Fajara, The Gambia
| | - Andrew M. Prentice
- Medical Research Council Unit The Gambia at London School of Hygiene and Tropical Medicine, Fajara, The Gambia
| | - Kris A. Murray
- Medical Research Council Unit The Gambia at London School of Hygiene and Tropical Medicine, Fajara, The Gambia
- Centre on Climate Change and Planetary Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Medical Research Council (MRC) Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, United Kingdom
| | - Pauline Scheelbeek
- Centre on Climate Change and Planetary Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
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Woolley KE, Dickinson-Craig E, Lawson HL, Sheikh J, Day R, Pope FD, Greenfield SM, Bartington SE, Warburton D, Manaseki-Holland S, Price MJ, Moore DJ, Thomas GN. Effectiveness of interventions to reduce household air pollution from solid biomass fuels and improve maternal and child health outcomes in low- and middle-income countries: A systematic review and meta-analysis. INDOOR AIR 2022; 32:e12958. [PMID: 34989443 DOI: 10.1111/ina.12958] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 11/03/2021] [Accepted: 11/06/2021] [Indexed: 06/14/2023]
Abstract
Interventions to reduce household air pollution (HAP) are key to reducing associated morbidity and mortality in low- and middle- income countries (LMICs); especially among pregnant women and young children. This systematic review aims to determine the effectiveness of interventions aimed to reduce HAP exposure associated with domestic solid biomass fuel combustion, compared to usual cooking practices, for improving health outcomes in pregnant women and children under five in LMIC settings. A systematic review and meta-analysis was undertaken with searches undertaken in MEDLINE, EMBASE, CENTRAL, GIM, ClinicalTrials.gov, and Greenfile in August 2020. Inclusion criteria were experimental, non-experimental, or quasi-experimental studies investigating the impact of interventions to reduce HAP exposure and improve associated health outcomes among pregnant women or children under 5 years. Study selection, data extraction, and quality assessment using the Effective Public Health Practice Project tool were undertaken independently by two reviewers. Seventeen out of 7293 retrieved articles (seven pregnancy, nine child health outcome; 13 studies) met the inclusion criteria. These assessed improved cookstoves (ICS; n = 10 studies), ethanol stoves (n = 1 study), and Liquefied Petroleum Gas (LPG; n = 2 studies) stoves interventions. Meta-analysis showed no significant effect of ICS interventions compared to traditional cooking for risk of preterm birth (n = 2 studies), small for gestational age (n = 2 studies), and incidence of acute respiratory infections (n = 6 studies). Although an observed increase in mean birthweight was observed, this was not statistically significant (n = 4). However, ICS interventions reduced the incidence of childhood burns (n = 3; observations = 41 723; Rate Ratio: 0.66 [95% CI: 0.45-0.96]; I2 : 46.7%) and risk of low birth weight (LBW; n = 4; observations = 3456; Odds Ratio: 0.73 [95% CI: 0.61-0.87]; I2 : 21.1%). Although few studies reported health outcomes, the data indicate that ICS interventions were associated with reduced risk of childhood burns and LBW. The data highlight the need for the development and implementation of robust, well-reported and monitored, community-driven intervention trials with longer-term participant follow-up.
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Affiliation(s)
- Katherine E Woolley
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | | | - Heidi L Lawson
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Jameela Sheikh
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Rosie Day
- School of Geography, Earth and Environmental Sciences, University of Birmingham, Birmingham, UK
| | - Francis D Pope
- School of Geography, Earth and Environmental Sciences, University of Birmingham, Birmingham, UK
| | - Sheila M Greenfield
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | | | - David Warburton
- Children's Hospital Los Angeles, University of Southern California, Los Angeles, California, USA
| | | | - Malcolm J Price
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
- NIHR Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust, University of Birmingham, Birmingham, UK
| | - David J Moore
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - G Neil Thomas
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
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50
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Liao J, Liu Y, Steenland K, Pillarisetti A, Thompson LM, Dey S, Balakrishnan K, Clasen T. Child Survival and Early Lifetime Exposures to Ambient Fine Particulate Matter in India: A Retrospective Cohort Study. ENVIRONMENTAL HEALTH PERSPECTIVES 2022; 130:17009. [PMID: 35080433 PMCID: PMC8791069 DOI: 10.1289/ehp8910] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/01/2021] [Revised: 11/17/2021] [Accepted: 12/20/2021] [Indexed: 05/26/2023]
Abstract
BACKGROUND Ambient fine particulate matter [PM ≤2.5μm in aerodynamic diameter (PM2.5)] is a major health risk for children, particularly in South Asia, which currently experiences the highest PM2.5 levels globally. Nevertheless, there is comparatively little epidemiological evidence from this region to quantify the effects of PM2.5 on child survival. OBJECTIVES We estimated the association between PM2.5 exposure and child survival in India. METHODS We constructed a large, retrospective, and nationally representative cohort of children <5 years of age, born between 2009-2016, from the publicly available, cross-sectional 2015-2016 Demographic Health Surveys in India. In utero and post-delivery lifetime average ambient PM2.5 exposures were estimated with data from satellite remote sensing, meteorology, and land use information (model R2= 0.82). We used Cox proportional hazards regression to estimate the association between both average in utero and post-delivery lifetime PM2.5 and all-cause child mortality, controlling for individual- and household-level covariates, seasonality, location, and meteorology. RESULTS Over 7,447,724 child-months of follow-up, there were 11,559 deaths at <5 years of age reported by the children's mothers. The mean concentrations of 9-month in utero and post-delivery lifetime average ambient PM2.5 exposure were 71.1 μg/m3 (range: 20.9-153.5 μg/m3) and 73.7 μg/m3 (range: 14.0-247.3 μg/m3), respectively. Estimated child mortality adjusted hazard ratios were 1.023 [95% confidence interval (CI): 1.008, 1.038] and 1.013 (95% CI: 1.001, 1.026) per 10-μg/m3 increase of in utero and post-delivery lifetime PM2.5, with both exposures in the model. DISCUSSION This study adds to the growing body of evidence about the adverse health effects of PM2.5 by demonstrating the association between exposure, both in utero and post-delivery, on child survival at the national level in India. Strategies to reduce ambient air pollution levels, including steps to minimize in utero and early life exposures, are urgently needed in India and other countries where exposures are above recommended guideline values. https://doi.org/10.1289/EHP8910.
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Affiliation(s)
- Jiawen Liao
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
- Department of Population and Public Health Sciences, Keck School of Medicine of the University of Southern California, Los Angeles, California, USA
| | - Yang Liu
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Kyle Steenland
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Ajay Pillarisetti
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
- Environmental Health Sciences, School of Public Health, University of California, Berkeley, California, USA
| | - Lisa M. Thompson
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia, USA
| | - Sagnik Dey
- Centre for Atmospheric Sciences, Indian Institute of Technology Delhi (IIT Delhi), New Delhi, India
- Centre of Excellence for Research on Clean Air, IIT Delhi, New Delhi, India
| | - Kalpana Balakrishnan
- Department of Environmental Health Engineering, ICMR Center for Advanced Research on Air Quality, Climate and Health, Sri Ramachandra Institute for Higher Education and Research (Deemed University), Chennai, Tamil Nadu, India
| | - Thomas Clasen
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
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