Targeting Household Air Pollution for Curbing the Cardiovascular Disease Burden: A Health Priority in Sub-Saharan Africa

Pulmonary hypertension

Pulmonary hypertension encompasses a range of conditions directly or indirectly leading to elevated pressures within the pulmonary arteries. Five main groups of pulmonary hypertension are recognized, all defined by a mean pulmonary artery pressure of >20 mmHg: pulmonary arterial hypertension (rare), pulmonary hypertension associated with left-sided heart disease (very common), pulmonary hypertension associated with lung disease (common), pulmonary hypertension associated with pulmonary artery obstructions, usually related to thromboembolic disease (rare), and pulmonary hypertension with unclear and/or multifactorial mechanisms (rare). At least 1% of the world's population is affected, with a greater burden more likely in low-income and middle-income countries. Across all its forms, pulmonary hypertension is associated with adverse vascular remodelling with obstruction, stiffening and vasoconstriction of the pulmonary vasculature. Without proactive management this leads to hypertrophy and ultimately failure of the right ventricle, the main cause of death. In older individuals, dyspnoea is the most common symptom. Stepwise investigation precedes definitive diagnosis with right heart catheterization. Medical and surgical treatments are approved for pulmonary arterial hypertension and chronic thromboembolic pulmonary hypertension. There are emerging treatments for other forms of pulmonary hypertension; but current therapy primarily targets the underlying cause. There are still major gaps in basic, clinical and translational knowledge; thus, further research, with a focus on vulnerable populations, is needed to better characterize, detect and effectively treat all forms of pulmonary hypertension.

Exposome and unhealthy aging: environmental drivers from air pollution to occupational exposures

The aging population worldwide is facing a significant increase in age-related non-communicable diseases, including cardiovascular and brain pathologies. This comprehensive review paper delves into the impact of the exposome, which encompasses the totality of environmental exposures, on unhealthy aging. It explores how environmental factors contribute to the acceleration of aging processes, increase biological age, and facilitate the development and progression of a wide range of age-associated diseases. The impact of environmental factors on cognitive health and the development of chronic age-related diseases affecting the cardiovascular system and central nervous system is discussed, with a specific focus on Alzheimer's disease, Parkinson's disease, stroke, small vessel disease, and vascular cognitive impairment (VCI). Aging is a major risk factor for these diseases. Their pathogenesis involves cellular and molecular mechanisms of aging such as increased oxidative stress, impaired mitochondrial function, DNA damage, and inflammation and is influenced by environmental factors. Environmental toxicants, including ambient particulate matter, pesticides, heavy metals, and organic solvents, have been identified as significant contributors to cardiovascular and brain aging disorders. These toxicants can inflict both macro- and microvascular damage and many of them can also cross the blood-brain barrier, inducing neurotoxic effects, neuroinflammation, and neuronal dysfunction. In conclusion, environmental factors play a critical role in modulating cardiovascular and brain aging. A deeper understanding of how environmental toxicants exacerbate aging processes and contribute to the pathogenesis of neurodegenerative diseases, VCI, and dementia is crucial for the development of preventive strategies and interventions to promote cardiovascular, cerebrovascular, and brain health. By mitigating exposure to harmful environmental factors and promoting healthy aging, we can strive to reduce the burden of age-related cardiovascular and brain pathologies in the aging population.

Exposure and Public Health Effects of Polycyclic Aromatic Hydrocarbon Compounds in Sub-Saharan Africa: A Systematic Review

BACKGROUND AND AIM

In order to achieve improved global health, environmental health risks that could affect this goal have to be reduced as much as possible. This review thus aimed at determining the exposure levels, health risk assessments, and public health effects of polycyclic aromatic hydrocarbons (PAHs) in sub-Saharan Africa (SSA). This review was developed using guidelines provided for Preferred Reporting Items for Systematic Review and Meta-Analysis. Search was done on Google Scholar, Scopus, and PubMed databases. A study was included if it was carried out in SSA from 2000 to 2020 and written in English language. Fifty-two studies were finally retained and used for the review. Extracted data included the concentrations of 8 selected priority PAHs (including the PAHs prioritized for their carcinogenic potentials), their sources and reported outcomes. In SSA, PAHs exposure has been linked to the use of unprocessed biomass fuels for cooking, release of poorly treated petrochemical effluents into water bodies, and so on. Related public health effects included the occurrence of respiratory, cardiovascular abnormalities, and so on. Others included destruction of natural biodiversity in soil, water, and atmospheric environmental media. Health risk assessments also buttressed the occurrence of these public health effects of PAHs. In SSA, the region is exposed to a substantial amount of PAHs pollution which is associated with deleterious environmental and epidemiological effects. The adoption of healthier forms of energy, a change of attitude to one that favors environmental sustainability, and proper enforcement of environmental regulations are, however, necessary for attaining environmental sanity in SSA.

Independent and combined associations of solid-fuel use and smoking with obesity among rural Chinese adults

Although solid-fuel use or smoking is associated with obesity measured by body mass index (BMI), research on their interactive effects on general and central obesity is limited. Data of 20,140 individuals in the Henan Rural Cohort Study was examined the independent and combined associations of solid-fuel use and smoking with prevalent obesity, which was measured by BMI, waist circumference (WC), waist-to-hip ratio (WHR), waist-to-height ratio (WHtR), body fat percentage (BFP), and visceral fat index (VFI). Multiple adjusted logistic regression models showed that the OR (95% CI) of prevalent obesity measured by BMI associated with exposure to solid fuels alone or with smoking was 0.78 (0.70, 0.86) or 0.46 (0.32, 0.66), compared with neither smoking nor solid-fuel exposure. Similar results had been found in other obese anthropometric indices and in the results of linear regression analysis. The results indicated that solid-fuel use and smoking have a synergistic effect on reduction in obesity indices. The effects of household air pollution from solid-fuel use and smoking on obesity should be considered when exploring the influencing factors of obesity.

Association of biomass fuel use with reduced body weight of adult Ghanaian women

The association of biomass fuel use with body weight has never been investigated. We therefore examined the effect of biomass fuel use on body weight of adult Ghanaian women. Data from the 2014 Ghana Demographic and Health Survey, a nationally representative population-based survey was analysed for this study. A total of 4751 women who had anthropometric (height and weight) data qualified for inclusion in this study. In linear regression modelling, charcoal use resulted in 3.08 kg (95% CI: 2.04, 4.12) and 0.81 kg/m² (95%CI: 0.29, 1.33) reduction in weight and body mass index (BMI), respectively, compared to clean fuel (electricity, liquefied petroleum gas and natural gas) use. Use of wood resulted in much higher reduction in weight and BMI. In modified Poisson regression, charcoal users had 19% (Adjusted Prevalence Ratio [aPR] = 0.81; 95%CI: 0.71, 0.92) and 29% (aPR = 0.71; 95%CI: 0.61, 0.83) decreased risk of overweight and obesity, respectively, compared to clean fuel users. Wood users had much higher decreased risk of overweight and obesity. In conclusion, biomass fuel use was associated with reduced body weight and BMI of Ghanaian women and is the first report on the relationship. However, it is important that our findings are confirmed and the biological mechanisms elucidated through rigorous study designs.

Cardiovascular Effects of Indoor Air Pollution from Solid Fuel: Relevance to Sub-Saharan Africa

PURPOSE OF REVIEW

This research aims to summarize evidence on the cardiovascular effects of indoor air pollution (IAP) from solid fuel and identify areas for research and policy for low- and middle-income countries.

RECENT FINDINGS

IAP affects people from low socioeconomic status in Latin America, Asia, and Africa, who depend upon biomass as a fuel for cooking, heating, and lighting. In these settings, IAP disproportionately affects women, children, the elderly, and people with cardiopulmonary disease. The health effects of IAP include acute respiratory infections, chronic obstructive pulmonary disease, pneumoconiosis, cataract and blindness, pulmonary tuberculosis, adverse effects to pregnancy, cancer, and cardiovascular and cerebrovascular disease. New methods for assessing individual IAP exposure, exposing pathways of IAP-related cardiovascular disease, and performing qualitative research focusing on population preferences regarding strategies to reduce IAP exposure have been the most important developments in tackling the burden of IAP. Unfortunately, major disparities exist regarding research into the cardiovascular effects of IAP, with only few studies coming from sub-Saharan Africa, despite this region having the highest proportion of households using solid fuels. Premature cardiovascular deaths and disability can be averted in low-middle income countries by addressing biomass fuel usage by the most disadvantaged settings. While research is needed to uncover the mechanisms involved in cardiovascular outcomes linked to IAP, immediate action is needed to educate the most affected populations on IAP health hazards and to reduce their exposure to this environmental risk through promoting improved housing and better ventilation, as well as increasing access to affordable clean cooking energy.

Environmental Health Research in Africa: Important Progress and Promising Opportunities

The World Health Organization in 2016 estimated that over 20% of the global disease burden and deaths were attributed to modifiable environmental factors. However, data clearly characterizing the impact of environmental exposures and health endpoints in African populations is limited. To describe recent progress and identify important research gaps, we reviewed literature on environmental health research in African populations over the last decade, as well as research incorporating both genomic and environmental factors. We queried PubMed for peer-reviewed research articles, reviews, or books examining environmental exposures and health outcomes in human populations in Africa. Searches utilized medical subheading (MeSH) terms for environmental exposure categories listed in the March 2018 US National Report on Human Exposure to Environmental Chemicals, which includes chemicals with worldwide distributions. Our search strategy retrieved 540 relevant publications, with studies evaluating health impacts of ambient air pollution (n=105), indoor air pollution (n = 166), heavy metals (n = 130), pesticides (n = 95), dietary mold (n = 61), indoor mold (n = 9), per- and polyfluoroalkyl substances (PFASs, n = 0), electronic waste (n = 9), environmental phenols (n = 4), flame retardants (n = 8), and phthalates (n = 3), where publications could belong to more than one exposure category. Only 23 publications characterized both environmental and genomic risk factors. Cardiovascular and respiratory health endpoints impacted by air pollution were comparable to observations in other countries. Air pollution exposures unique to Africa and some other resource limited settings were dust and specific occupational exposures. Literature describing harmful health effects of metals, pesticides, and dietary mold represented a context unique to Africa. Studies of exposures to phthalates, PFASs, phenols, and flame retardants were very limited. These results underscore the need for further focus on current and emerging environmental and chemical health risks as well as better integration of genomic and environmental factors in African research studies. Environmental exposures with distinct routes of exposure, unique co-exposures and co-morbidities, combined with the extensive genomic diversity in Africa may lead to the identification of novel mechanisms underlying complex disease and promising potential for translation to global public health.

Implementation of clean cookstove interventions and its effects on blood pressure in low-income and middle-income countries: systematic review

OBJECTIVE

A review of the implementation outcomes of clean cookstove use, and its effects on blood pressure (BP) in low-income and middle-income countries (LMICs).

DESIGN

Systematic review of studies that reported the effect of clean cookstove use on BP among women, and implementation science outcomes in LMICs.

DATA SOURCES

We searched PubMed, Embase, INSPEC, Scielo, Cochrane Library, Global Health and Web of Science PLUS. We conducted searches in November 2017 with a repeat in May 2018. We did not restrict article publication date.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

We included only studies conducted in LMICs, published in English, regardless of publication year and studies that examined the use of improved or clean cookstove intervention on BP. Two authors independently screened journal article titles, abstracts and full-text articles to identify those that included the following search terms: high BP, hypertension and or household air pollution, LMICs, cookstove and implementation outcomes.

RESULTS

Of the 461 non-duplicate articles identified, three randomised controlled trials (RCTs) (in Nigeria, Guatemala and Ghana) and two studies of pre-post design (in Bolivia and Nicaragua) met eligibility criteria. These articles evaluated the effect of cookstove use on BP in women. Two of the three RCTs reported a mean reduction in diastolic BP of -2.8 mm Hg (-5.0, -0.6; p=0.01) for the Nigerian study; -3.0 mm Hg; (-5.7, -0.4; p=0.02) for the Guatemalan study; while the study conducted in Ghana reported a non-significant change in BP. The pre-post studies reported a significant reduction in mean systolic BP of -5.5 mm Hg; (p=0.01) for the Bolivian study, and -5.9 mm Hg (-11.3, -0.4; p=0.05) for the Nicaraguan study. Implementation science outcomes were reported in all five studies (three reported feasibility, one reported adoption and one reported feasibility and adoption of cookstove interventions).

CONCLUSION

Although this review demonstrated that there is limited evidence on the implementation of clean cookstove use in LMICs, the effects of clean cookstove on BP were significant for both systolic and diastolic BP among women. Future studies should consider standardised reporting of implementation outcomes.

Pregnancy outcomes and ethanol cook stove intervention: A randomized-controlled trial in Ibadan, Nigeria

BACKGROUND

Household air pollution (HAP) exposure has been linked to adverse pregnancy outcomes.

OBJECTIVES

A randomized controlled trial was undertaken in Ibadan, Nigeria to determine the impact of cooking with ethanol on pregnancy outcomes.

METHODS

Three-hundred-twenty-four pregnant women were randomized to either the control (continued cooking using kerosene/firewood stove, n=162) or intervention group (received ethanol stove, n=162). Primary outcome variables were birthweight, preterm delivery, intrauterine growth restriction (IUGR), and occurrence of miscarriage/stillbirth.

RESULTS

Mean birthweights for ethanol and controls were 3076 and 2988g, respectively; the difference, 88g, (95% confidence interval: -18g to 194g), was not statistically significant (p=0.10). After adjusting for covariates, the difference reached significance (p=0.020). Rates of preterm delivery were 6.7% (ethanol) and 11.0% (control), (p=0.22). Number of miscarriages was 1(ethanol) vs. 4 (control) and stillbirths was 3 (ethanol) vs. 7 (control) (both non-significant). Average gestational age at delivery was significantly (p=0.015) higher in ethanol-users (39.2weeks) compared to controls (38.2weeks). Perinatal mortality (stillbirths and neonatal deaths) was twice as high in controls compared to ethanol-users (7.9% vs. 3.9%; p=0.045, after adjustment for covariates). We did not detect significant differences in exposure levels between the two treatment arms, perhaps due to large seasonal effects and high ambient air pollution levels.

CONCLUSIONS

Transition from traditional biomass/kerosene fuel to ethanol reduced adverse pregnancy outcomes. However, the difference in birthweight was statistically significant only after covariate adjustment and the other significant differences were in tertiary endpoints. Our results are suggestive of a beneficial effect of ethanol use. Larger trials are required to validate these findings.

Biomass Cooking Fuels and Health Outcomes for Women in Malawi

In sub-Saharan Africa, biomass fuels account for approximately 90% of household energy consumption. Limited evidence exists on the association between different biomass fuels and health outcomes. We report results from a cross-sectional sample of 655 households in Malawi. We calculated odds ratios between hypothesized determinants of household air pollution (HAP) exposure (fuel, stove type, and cooking location) and five categories of health outcomes (cardiopulmonary, respiratory, neurologic, eye health, and burns). Reliance on high- or low-quality firewood or crop residue (vs. charcoal) was associated with significantly higher odds of shortness of breath, difficulty breathing, chest pains, night phlegm, forgetfulness, dizziness, and dry irritated eyes. Use of high-quality firewood was associated with significantly lower odds of persistent phlegm. Cooks in rural areas (vs. urban areas) had significantly higher odds of experiencing shortness of breath, persistent cough, and phlegm, but significantly lower odds of phlegm, forgetfulness, and burns. With deforestation and population pressures increasing reliance on low-quality biomass fuels, prevalence of HAP-related cardiopulmonary and neurologic symptoms will likely increase among cooks. Short- to medium-term strategies are needed to secure access to high-quality biomass fuels given limited potential for scalable transitions to modern energy.

Attributable risk of ambient PM10 on daily mortality and years of life lost in Chengdu, China

Attributable risk is an important indicator for planning and evaluating public health interventions. However, most current measures of the attributable risk of air pollutants have not considered temporal relationships between exposure and risk. More importantly, limited information is available regarding the attributable risk due to ambient air pollutants in basin regions like the Sichuan Basin, China. To quantify the association between PM₁₀ and deaths in the Basin region, we used a measure proposed recently within the framework of the distributed lag non-linear model to estimate the attributable risk in Chengdu, China. Meanwhile, we examined the association between PM₁₀ and years of life lost (YLL). Our analysis showed that population-attributable fractions for non-accidental, respiratory, and cardiovascular mortality were 0.569% (95% CI: -3.474%, 4.374%), 0.695% (95% CI: -5.260%, 6.457%), and 0.631% (95% CI: -6.973%, 7.390%), respectively. On average, a 1μg/m³ increase in PM₁₀ was associated with cumulative increases of 0.26893, 0.30437, and 0.21924 YLL for non-accidental, respiratory, and cardiovascular mortality, respectively, referring to 20μg/m³. In addition, we found an inverse U-shaped pattern for the cumulative risk with 350μg/m³ as the reverse point. With a 1μg/m³ increase in PM₁₀, YLL changed more significantly than mortality. Moreover, PM₁₀ demonstrated remarkable effects on YLL among men and the elderly.

Effect of a clean stove intervention on inflammatory biomarkers in pregnant women in Ibadan, Nigeria: A randomized controlled study

BACKGROUND

Exposure to household air pollution (HAP) has been linked to systemic inflammation. We determined the impact of transition from traditional firewood/kerosene stove to bioethanol-burning stove on inflammatory biomarkers in pregnant Nigerian women.

METHODS

Women (n=324), cooking with kerosene/firewood, were recruited during their first trimester of pregnancy from June 2013-October 2015 and were randomly allocated to either control (n=162) or intervention (n=162) group using web-based randomization. Controls continued to use their own firewood/kerosene stove, while intervention participants received bioethanol CleanCook stoves. Serum concentrations of retinol-binding protein (RBP), malondialdehyde (MDA), tumor necrosis factor alpha (TNF)-α, interleukin (IL)-6, and IL-8 were measured by ELISA.

RESULTS

After excluding 53 women (loss of follow-up, untimely biomarker assessments, incorrect dates of enrollment), data from 271 women were included in analysis. Mean (SD) change in RBP, MDA, TNF-α, IL-6, and IL-8 between baseline and third trimester was -2.16 (4.47), -19.6 (46.4), 3.72 (37.2), 0.51 (14.4), and 13.2 (197), respectively, in intervention and -2.25 (4.30), -24.6 (43.6), 7.17 (32.6), -1.79, (11.4), and 31.3 (296) in control groups. None of these changes differed significantly between the two treatment arms. However, changes from baseline in TNF-α levels were significantly different between intervention and control groups in subset of women (n=99) using firewood before trial (-7.03 [32.9] vs. +12.4 [33.6]; 95% CI for group difference: -35.4 to -3.4, p=0.018).

CONCLUSIONS

Decrease in TNF-α concentration from baseline to third trimesters in intervention group women could indicate reduced cardiovascular stress and prothrombotic effects from decreased HAP. Our findings suggest that ethanol-burning stoves may mitigate cardiovascular health risks.

Household air pollution and its effects on health

Household air pollution is a leading cause of disability-adjusted life years in Southeast Asia and the third leading cause of disability-adjusted life years globally. There are at least sixty sources of household air pollution, and these vary from country to country. Indoor tobacco smoking, construction material used in building houses, fuel used for cooking, heating and lighting, use of incense and various forms of mosquito repellents, use of pesticides and chemicals used for cleaning at home, and use of artificial fragrances are some of the various sources that contribute to household air pollution.

Household air pollution affects all stages of life with multi-systemic health effects, and its effects are evident right from pre-conception to old age. In utero exposure to household air pollutants has been shown to have health effects which resonate over the entire lifetime. Exposures to indoor air pollutants in early childhood also tend to have repercussions throughout life. The respiratory system bears the maximum brunt, but effects on the cardiovascular system, endocrine system, and nervous system are largely underplayed. Household air pollutants have also been implicated in the development of various types of cancers.

Identifying household air pollutants and their health implications helps us prepare for various health-related issues. However, the real challenge is adopting changes to reduce the health effects of household air pollution and designing innovative interventions to minimize the risk of further exposure.

This review is an attempt to understand the various sources of household air pollution, the effects on health, and strategies to deal with this emergent risk factor of global mortality and morbidity.

Household air pollution and the sustainable development goals

Globally, 41% of households, over 2.8 billion people, rely on solid fuels (coal and biomass) for cooking and heating. In developing countries in Asia and sub-Saharan Africa where these fuels are predominantly used, women who are customarily responsible for cooking, and their young children, are most exposed to the resulting air pollution. Solid fuels are still in widespread use and it appears that intervention efforts are not keeping pace with population growth in developing countries. Here we pinpoint the challenges and identify opportunities for addressing household air pollution while mitigating global climate change and promoting the sustainable development goals.

We recommend the following actions: implementation of the WHO indoor air quality guidelineson household fuel combustion; effective promotion and dissemination of improved cookstoves through formation of country alliances for clean cookstoves; expansion of liquefied petroleum gas production facilities and distribution networks; harnessing renewable energy potential; promotion of biogas production at both household and community level; ensuring improved ventilation of homes through education and enforcement of building standards; and exploiting opportunities in the health and other sectors for changing health-damaging cooking behaviour.

Indoor and Outdoor Air Pollution- related Health Problem in Ethiopia: Review of Related Literature

BACKGROUND

The health effects of air pollution are generally global problems, but they have, since recently become issues of particular concern for developing countries. This review assessed the situation of air pollution and related health effects in the context of Ethiopia.

METHODS

The materials reviewed in this publication are published scientific papers from online search engines, unpublished government reports and academic theses/dissertations. In addition, interview data obtained from authorities and experts involved in the management of air quality were analyzed, interpreted and reported in the article.

RESULTS

Review of the few studies conducted in Ethiopia showed that average concentrations of PM2.5 reached as high as 280 µg/m3 for 24-hour measurements (range: 2,417-12,739 µg/m3). Indoor carbon monoxide (CO) levels were universally higher than regulatory limits for the United States and were found to be much higher among households using traditional stoves and solid biomass fuels. The use of traditional stoves and solid biomass fuels was reported in >95% of the households considered. High average levels of NO2 (97 ppb) were reported in a large longitudinal study. The ambient PM10 level was below the WHO guideline values in the majority of the samples. About 50% of the on-road CO samples taken from traffic roads in Addis Ababa were found to be less than the guideline values while the number of motor vehicles in Ethiopia is reported to be increasing by more than 9% per annum. There is a very limited air quality monitoring capacity in the country. The co-ordination between stakeholders in this regard is also inadequate. The limited evidence available on health effects of air pollution indicates that the prevalence of acute respiratory illness among children living in households using crude biomass fuels is significantly higher than the national average figures.

CONCLUSION

The limited evidence reviewed and reported in this article indicates high levels of indoor air pollution and trends of worsening outdoor air pollution. This tentative conclusion carries with it the urgent need for more evidence-based research and capacity building in the areas of indoor and outdoor air pollution.

Hypertension prevalence, incidence and risk factors among children and adolescents in Africa: a systematic review and meta-analysis protocol

INTRODUCTION

The African adult population is facing a growing epidemic of hypertension. Establishment of accurate epidemiological data on hypertension in African children and adolescents may have important implications for hypertension preventive strategies in Africa.

METHODS AND ANALYSIS

This systematic review and meta-analysis will follow the MOOSE Guidelines. Relevant abstracts published in English/French from 1 January 1985 to 31 July 2015 will be searched in PubMed, Google Scholar and Online African journals. Full texts of eligible studies will then be accessed through PubMed, Google Scholar, HINARI and the respective journals' websites. Relevant unpublished papers and conference proceedings will also be checked. Data will be analysed using R statistical software. The study-specific estimates will be pooled through a random-effects meta-analysis model to obtain an overall summary estimate of the prevalence/incidence of hypertension across studies. Also, we will assess the association between risk factors and hypertension. Heterogeneity of studies will be evaluated by the χ(2) test on Cochrane's Q statistic. Funnel plots analysis and Egger's test will be done to detect publication bias. Results will be presented by geographic region (central, eastern, northern, southern and western Africa). A p value less than 0.05 will be considered significant for factors that predicted hypertension.

ETHICS AND DISSEMINATION

The current study is based on published data, and thus ethical approval is not required. This systematic review and meta-analysis is expected to serve as input for designing early life preventive and control strategies, and as a guide for future research based on existing gaps. The final report of the systematic review in the form of a scientific paper will be published in peer-reviewed journals. Findings will further be presented at conferences and submitted to relevant health authorities.

TRIAL REGISTRATION NUMBER

CRD42015019029.

Are the current recommendations for the use of aspirin in primary prevention of cardiovascular disease applicable in low-income countries?

Although evidence has accumulated that long-term aspirin therapy is beneficial in secondary prevention of cardiovascular disease (CVD), a lot of controversies persist regarding the benefit of aspirin use in primary prevention of CVD. In low-income countries (LIC) specifically, the decision to prescribe aspirin for primary CVD prevention is more problematic, as there is a dearth of evidence in this regard. Aspirin has been shown to have relative beneficial effects in preventing a first myocardial infarction, but not stroke. However, as stroke is the prevailing CVD in many LIC, especially in Africa, the benefit of aspirin in these settings is therefore questionable. Indeed, there is no published trial that has evaluated the benefits and risks of continuous aspirin therapy in populations of LIC. Furthermore, though cardiovascular risk assessment is crucial in decision-making for the use of aspirin in primary prevention of CVD, there are no risk assessment tools that have been validated in African populations. Studies are urgently warranted, to determine the usefulness of aspirin in primary prevention of CVD in low-income settings where the drug is highly available and affordable, as CVD is becoming the leading cause of deaths in LIC.