Association of airborne particles, protein, and endotoxin with emergency department visits for asthma in Kyoto, Japan

Exploring the anti-inflammatory and anti-fibrotic activity of NFκB decoy oligodeoxynucleotide-loaded spermine-functionalized acetalated nanoparticles

Chronic inflammation, oxidative stress, and airway remodelling represent the principal pathophysiological features of chronic respiratory disorders. Inflammation stimuli like lipopolysaccharide (LPS) activate macrophages and dendritic cells, with concomitant M1 polarization and release of pro-inflammatory cytokines. Chronic inflammation and oxidative stress lead to airway remodelling causing irreversible functional and structural alterations of the lungs. Airway remodelling is multifactorial, however, the hormone transforming growth factor-β (TGF-β) is one of the main contributors to fibrotic changes. The signalling pathways mediating inflammation and remodelling rely both on the transcription factor nuclear factor-κB (NFκB), underlying the potential of NFκB inhibition as a therapeutic strategy for chronic respiratory disorders. In this study, we encapsulated an NFκB-inhibiting decoy oligodeoxynucleotide (ODN) in spermine-functionalized acetalated dextran (SpAcDex) nanoparticles and tested the in vitro anti-inflammatory and anti-remodelling activity of this formulation. We show that NF-κB ODN nanoparticles counteract inflammation by reversing LPS-induced expression of the activation marker CD40 in myeloid cells and counteracts remodelling features by reversing the TGF-β-induced expression of collagen I and α-smooth muscle actin in human dermal fibroblast. In summary, our study highlights the great potential of inhibiting NFκB via decoy ODN as a therapeutic strategy tackling multiple pathophysiological features underlying chronic respiratory conditions.

Agarwood oil nanoemulsion counteracts LPS-induced inflammation and oxidative stress in RAW264.7 mouse macrophages

PURPOSE

Oxidative stress and inflammation are key pathophysiological features of chronic respiratory diseases, including asthma and chronic obstructive pulmonary disease (COPD). Agarwood oil obtained from Aquilaria trees has promising antioxidant and anti-inflammatory activities. However, its clinical application is hampered by poor solubility. A viable approach to overcome this involves formulation of oily constituents into emulsions. Here, we have investigated the antioxidant and anti-inflammatory potential of an agarwood oil-based nanoemulsion (DE'RAAQSIN) against lipopolysaccharide (LPS)-induced RAW264.7 mouse macrophages in vitro.

METHODS

The antioxidant and anti-inflammatory activity of DE'RAAQSIN was assessed by measuring the levels of ROS and nitric oxide (NO) produced, using the DCF-DA assay and the Griess reagent assay, respectively. The molecular pathways activated by DE'RAAQSIN were investigated via qPCR.

RESULTS

LPS stimulation of RAW264.7 cells increased the production of nitric oxide (NO) and ROS and resulted in the overexpression of the inducible nitric oxide synthase (iNOS) gene. Furthermore, LPS induced the upregulation of the expression of key proinflammatory genes (IL-6, TNF-α, IL-1β, and CXCL1) and of the antioxidant gene heme oxygenase-1 (HO-1). DE'RAAQSIN demonstrated potent antioxidant and anti-inflammatory activity by significantly reducing the levels of ROS and of secreted NO, simultaneously counteracting the LPS-induced overexpression of iNOS, IL-6, TNF-α, IL-1β, and HO-1. These findings were corroborated by in silico activity prediction and physicochemical analysis of the main agarwood oil components.

CONCLUSIONS

We propose DE'RAAQSIN as a promising alternative managing inflammatory disorders, opening the platform for further studies aimed at understanding the effectiveness of DE'RAAQSIN.

Assessing oxidative stress induction ability and oxidative potential of PM2.5 in cities in eastern and western Japan

Oxidative stress is an important cause of respiratory diseases associated with exposure to PM_2.5. Accordingly, acellular methods for assessing the oxidative potential (OP) of PM_2.5 have been evaluated extensively for use as indicators of oxidative stress in living organisms. However, OP-based assessments only reflect the physicochemical properties of particles and do not consider particle-cell interactions. Therefore, to determine the potency of OP under various PM_2.5 scenarios, oxidative stress induction ability (OSIA) assessments were performed using a cell-based method, the heme oxygenase-1 (HO-1) assay, and the findings were compared with OP measurements obtained using an acellular method, the dithiothreitol assay. For these assays, PM_2.5 filter samples were collected in two cities in Japan. To quantitatively determine the relative contribution of the quantity of metals and subtypes of organic aerosols (OA) in PM_2.5 to the OSIA and the OP, online measurements and offline chemical analysis were also performed. The findings showed a positive relationship between the OSIA and OP for water-extracted samples, confirming that the OP is generally well suited for use as an indicator of the OSIA. However, the correspondence between the two assays differed for samples with a high water-soluble (WS)-Pb content, which had a higher OSIA than would be expected from the OP of other samples. The results of reagent-solution experiments showed that the WS-Pb induced the OSIA, but not the OP, in 15-min reactions, suggesting a reason for the inconsistent relationship between the two assays across samples. Multiple linear regression analyses and reagent-solution experiments showed that WS transition metals and biomass burning OA accounted for approximately 30-40% and 50% of the total OSIA or the total OP of water-extracted PM_2.5 samples, respectively. This is the first study to evaluate the association between cellular oxidative stress assessed by the HO-1 assay and the different subtypes of OA.

Impact of Air Pollution on Asthma: A Scoping Review

Asthma is the most common chronic respiratory disease and a major public health problem. Although the causal relationship between air pollution and asthma remains controversial, a large number of studies have provided increasingly consistent evidence of the involvement of air pollutants in asthma onset and exacerbations. We conducted a keyword search-based literature review using PubMed, Scopus and Web of Science databases for studies with titles or abstracts containing predefined terms. This narrative review discusses the current evidence on the pathological effects of pollution throughout life and the mechanisms involved in the onset, development, and exacerbation of asthma, and presents current measures and interventions for pollution damage control. Further global efforts are still needed to improve air quality.

Short-Term Associations between PM10 and Respiratory Health Effects in Visby, Sweden

The old Swedish city Visby, located on the island Gotland, has, for several years, reported higher PM₁₀ concentrations than any other city in Sweden. In Visby, local limestone is used, both in road paving and as sand used for anti-slip measures, resulting in a clear annual pattern of PM₁₀ with the highest concentrations during winter/spring when studded tires are allowed. This study analyzes the short-term associations between PM₁₀ and daily number of patients with acute respiratory problems (ICD–10 diagnoses: J00–J99) seeking care at the hospital or primary healthcare units in Visby during the period of 2013–2019. The daily mean of PM₁₀ was on average 45 µg m⁻³ during winter/spring and 18 µg m⁻³ during summer/autumn. Four outcome categories were analyzed using quasi-Poisson regression models, stratifying for period and adjusting for calendar variables and weather. An increase in respiratory visits was associated with increasing concentrations in PM₁₀ during the summer/autumn period, most prominent among children, where asthma visits increased by 5% (95% CI: 2–9%) per 10 µg m⁻³ increase in PM₁₀. For the winter/spring period, no significant effects were observed, except for the diagnose group ‘upper airways’ in adults, where respiratory visits increased by 1% (95% CI: 0.1–1.9%) per 10 µg m⁻³ increase. According to the results, limestone in particles seem to be relatively harmless at the exposure concentrations observed in Visby, and this is in line with the results from a few experimental and occupational studies.

Occurrence and fate of bacterial endotoxins in the environment (air, water, wastewater) and remediation technologies: An overview

Endotoxins as the outer membrane of most Gram-Negative Bacteria (GNB) and typical toxic biochemical produced by microorganisms are identified as one of the emerging pollutants. These microbial by-products are harmful compounds that can be present in various environments including air, water, soil, and other ecosystems which was discussed in detail in this review. Environmental and occupational exposure caused by endotoxin occurs in water and wastewater treatment plants, industrial plants, farming, waste recovery, and composting facilities. Even though the health risk related to endotoxin injection in intravenous and dialysis are well identified, the harmful effects of ingestion, inhalation, and other way of exposure are not well quantified and there is insufficient information on the potential health risks of endotoxins exposure in water environments, and another exposures. Because of limited studies, the outbreaks of diseases related to endotoxins in the various source of exposure not been well documented. Endotoxin removal from different environments are investigated in this review. The results of various studies have shown that conventional treatment methods have been unable to remove endotoxins from water and wastewater, therefore, monitoring the effectiveness of these processes in controlling this contaminant and also using the appropriate removal method is essential. However, management of water and wastewater treatment processes and the use of advanced processes such as Advanced Oxidation Processes (AOPs) can be effective in monitoring and reducing endotoxin levels during water and wastewater treatment. One of the limitations of endotoxin monitoring is the lack of sufficient information to develop monitoring levels. In addition, the lack of guidelinesand methods of controlling them at high levels may cause irreparable disaster.

Association of Protein and Endotoxin in Outdoor Air with Emergency Department Visits for Children and Adults with Asthma in Fukuoka, Japan

We examined the association of biological components in airborne particles, i.e., proteins and endotoxins, in outdoor air with asthma exacerbation in the Fukuoka metropolitan area, Fukuoka, Japan. Data on emergency department (ED) visits for asthma in children (age, 0-14 years) and adults (age, 15-64 years) were collected at a medical center from December 2014 to November 2015. One hundred eighty-one children and 143 adults visited the ED for asthma, and the weekly number of ED visits in children increased in autumn, i.e., September (second week) to November (first week). Fine (aerodynamic diameter ≤2.5 µm) and coarse (≥2.5 µm) particles were collected for 3 or 4 weeks per month, and protein and endotoxin concentrations were analyzed. Protein was largely prevalent in fine particles (0.34-7.33 µg/m³), and concentrations were high in April, May, June, and October. In contrast, endotoxin was mainly included in coarse particles (0.0010-0.0246 EU/m³), and concentrations were high in September (third week), October (first, second, and fourth weeks), February (fourth week), and July (first week). The results of a Poisson regression analysis indicated that endotoxin (in fine and coarse particles alike) was a significant factor for ED visits related to asthma in children, even after adjusting for meteorological factors, i.e., temperature, relative humidity, and wind speed. However, there was no association between environmental factors and ED visits for asthma in adults. These results suggest that endotoxin in outdoor air is significantly associated with an increased risk of asthma exacerbation in children.

Indoor Microbial Exposures and Chronic Lung Disease: From Microbial Toxins to the Microbiome

Effects of environmental microbial exposures on human health have long been of interest. Microbes were historically assumed to be harmful, but data have suggested that microbial exposures can modulate the immune system. We focus on the effects of indoor environmental microbial exposure on chronic lung diseases. We found contradictory data in bacterial studies using endotoxin as a surrogate for bacterial exposure. Contradictory data also exist in studies of fungal exposure. Many factors may modulate the effect of environmental microbial exposures on lung health, including coexposures. Future studies need to clarify which method of assessing environmental microbial exposures is most relevant.

Indoor endotoxin, proximity to a major roadway, and severe asthma exacerbations among children in Puerto Rico

BACKGROUND

Few studies have examined concurrent exposure to household endotoxin and traffic-related air pollution in relation to childhood asthma, yet both factors are associated with asthma outcomes.

OBJECTIVE

To examine whether proximity to a major roadway (a traffic-related air pollution proxy) modifies the estimated effects of indoor endotoxin on asthma outcomes in children.

METHODS

Cross-sectional study of 200 children with asthma (ages, 6-14 years) living in Puerto Rico. Residential distance to a major roadway was calculated as the distance from the participant's residential US census block centroid to the nearest major road. The outcomes of interest were severe asthma exacerbations, missed school days for asthma, atopy, lung function, and bronchodilator response (BDR). Logistic, linear, or negative binomial regression was used for the multivariable analysis.

RESULTS

In the multivariable analysis, there was an interaction between indoor endotoxin and residential distance to a roadway on severe asthma exacerbations (P = .02) and BDR (P = .07). In an analysis stratified by distance to a roadway, each log₁₀-unit increase in endotoxin was associated with 4.21 times increased odds of severe asthma exacerbations among children living within 499 m (the lower 3 quartiles of residential distance) to a road (95% confidence interval, 1.5-12.0). Among subjects living further than 499 m away from a roadway, each log₁₀-unit increase in endotoxin was associated with reduced odds of severe asthma exacerbations (odds ratio, 0.03; 95% confidence interval, 0.001-0.67). Similar but less substantial findings were observed for BDR.

CONCLUSION

Our findings suggest that residential proximity to a major road modifies the estimated effect of endotoxin on severe asthma exacerbations in children.

Development of a system for the detection of the inflammatory response induced by airborne fine particulate matter in rat tracheal epithelial cells

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Atmospheric endotoxin level is related to inflammatory response induction

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Stable cell lines established to determine the expression of pro-inflammatory genes

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Our system serves monitoring of inflammatory response to airborne particulate matter

Exposure to airborne particulate matter (PM) is related to the increased risk of several diseases, including chronic and allergic rhinitis. We have previously shown that atmospheric endotoxin level was positively associated with the number of emergency department visits for asthma even after adjusting for meteorological factors, suggestive of the significant association between atmospheric endotoxin level and asthma exacerbation. Whether atmospheric endotoxin level is related to inflammatory response induction is, however, unclear. Here, we established stable cell lines to determine the promoter activity of the genes encoding pro-inflammatory cytokines such as tumor necrosis factor alpha, interleukin 6 (IL6), and IL33 by transfection of each reporter plasmid into rat tracheal epithelial EGV-4 T cells. These cells could measure the inflammatory response induced by endotoxin treatment more easily, rapidly, and sensitively than the conventional system using immunodetection assays. Furthermore, we revealed a relationship between atmospheric endotoxin level and inflammatory response induction. Thus, the system established herein may serve as a promising tool to monitor inflammatory response induced upon PM exposure.

Development of a system for the detection of the inflammatory response induced by airborne fine particulate matter in rat tracheal epithelial cells

Exposure to airborne particulate matter (PM) is related to the increased risk of several diseases, including chronic and allergic rhinitis. We have previously shown that atmospheric endotoxin level was positively associated with the number of emergency department visits for asthma even after adjusting for meteorological factors, suggestive of the significant association between atmospheric endotoxin level and asthma exacerbation. Whether atmospheric endotoxin level is related to inflammatory response induction is, however, unclear. Here, we established stable cell lines to determine the promoter activity of the genes encoding pro-inflammatory cytokines such as tumor necrosis factor alpha, interleukin 6 (IL6), and IL33 by transfection of each reporter plasmid into rat tracheal epithelial EGV-4 T cells. These cells could measure the inflammatory response induced by endotoxin treatment more easily, rapidly, and sensitively than the conventional system using immunodetection assays. Furthermore, we revealed a relationship between atmospheric endotoxin level and inflammatory response induction. Thus, the system established herein may serve as a promising tool to monitor inflammatory response induced upon PM exposure.

Effects of hourly levels of ambient air pollution on ambulance emergency call-outs in Shenzhen, China

Some researches have shown the associations between air pollution and hospital-based emergency department visits, while the evidence about the acute effects of air pollution on emergency ambulance dispatches for the whole population is rarely available, especially on an hourly time scale. This paper aimed to investigate the effects of hourly concentrations of ambient air pollution on hourly number of ambulance emergency call-outs (AECOs) in Shenzhen, China. AECO data were collected from Shenzhen Emergency Center from January 2013 to December 2016. A time-stratified case-crossover design with conditional Poisson regression was performed to fit the relationship between hourly air pollution and AECOs. The distributed lag model was applied to determine lag structure of the effects of air pollutants. There were a total of 502,862 AECOs during the study period. The significant detrimental effects of SO₂, PM_2.5, and PM₁₀ appeared immediately with a following harvesting effect after 5 h and the effects lasted for about 96 h. The cumulative effect estimates of four pollutants over 0-96 h were 13.99% (95% CI 7.52-20.85%), 2.07% (95% CI 0.72-3.43%), 1.20% (95% CI 0.54-1.87%), and 2.46% (95% CI 1.63-3.29%), respectively. We did not observe significant effects of O₃. This population-based study quantifies the adverse effects of air pollution on ambulance dispatches and provides evidence of the lag structure of the effects on an hourly time scale.

Real-Ambient Particulate Matter Exposure-Induced Cardiotoxicity in C57/B6 Mice

It is generally accepted that exposure to particulate matter (PM) increases the risk of cardiovascular-related morbidity and mortality, though the exact mechanism behind this has yet to be elucidated. Oxidative stress plays a potentially important role in the mechanism of toxicity, with Nrf2 serving as a major antioxidant gene. In the current study, a Nrf2 knockout mouse model was used in combination with an individual ventilated cage (IVC)-based real-ambient PM exposure system to assess the potential cardiotoxicity induced by real-ambient PM exposure and the potential role of Nrf2 and related signaling in this endpoint. After 6- or 11-weeks exposure to PM, ICP-mass spectrometry was used to assess the metal depositions in the heart tissue following PM exposure. Functional and morphological changes in the hearts were investigated with echocardiography and histopathology, and oxidative stress levels were assessed with a serum malondialdehyde content assay. In the further mechanistic study, an RNA-seq technique was utilized to assess the gene transcription status in the hearts of C57/B6 mice exposed to PM with or without Nrf2 knockout. The expression levels of genes of interest were then further investigated with quantitative real-time PCR and western blotting. The results indicated that PM exposure resulted in significant elevation of sodium, potassium, selenium, and ferrum levels in mouse heart tissue. Meanwhile, significantly altered heart function and morphology were observed. Interestingly, Nrf2 knockout led to abolishment of PM-induced effects in several functional parameters but not the morphological changes. Meanwhile, elevated malondialdehyde content was observed in Nrf2 knockout animals. RNA-seq results revealed thousands of genes altered by PM exposure and/or Nrf2 knockout, and this affected several pathways, such as MAPK, phagosome, calcium signaling, and JAK-STAT. In subsequent molecular studies, enhanced nuclear translocation of Nrf2 was also observed following PM exposure, while the MAPK signaling pathway along with related JAK-STAT and TGF-β1 pathway genes, such as p38MAPK, AKT, TAK1, JAK1, STAT3, GRB2, TGFb1, and SMAD2, were confirmed to be affected by PM exposure and/or Nrf2 knockout. The data suggested that PM may induce cardiotoxicity in C57/B6 mice in which Nrf2 plays both protective and detrimental roles involving cardiac-related pathways, such as MAPK, JAK-STAT, and TGF-β1.

Epidemiological characteristics of bacillary dysentery from 2009 to 2016 and its incidence prediction model based on meteorological factors

Background

This study aimed to analyse the epidemiological characteristics of bacillary dysentery (BD) caused by Shigella in Chongqing, China, and to establish incidence prediction models based on the correlation between meteorological factors and BD, thus providing a scientific basis for the prevention and control of BD.

Methods

In this study, descriptive methods were employed to investigate the epidemiological distribution of BD. The Boruta algorithm was used to estimate the correlation between meteorological factors and BD incidence. The genetic algorithm (GA) combined with support vector regression (SVR) was used to establish the prediction models for BD incidence.

Results

In total, 68,855 cases of BD were included. The incidence declined from 36.312/100,000 to 23.613/100,000, with an obvious seasonal peak from May to October. Males were more predisposed to the infection than females (the ratio was 1.118:1). Children < 5 years old comprised the highest incidence (295.892/100,000) among all age categories, and pre-education children comprised the highest proportion (34,658 cases, 50.335%) among all occupational categories. Eight important meteorological factors, including the highest temperature, average temperature, average air pressure, precipitation and sunshine, were correlated with the monthly incidence of BD. The obtained mean absolute percent error (MAPE), mean squared error (MSE) and squared correlation coefficient (R²) of GA_SVR_MONTH values were 0.087, 0.101 and 0.922, respectively.

Conclusion

From 2009 to 2016, BD incidence in Chongqing was still high, especially in the main urban areas and among the male and pre-education children populations. Eight meteorological factors, including temperature, air pressure, precipitation and sunshine, were the most important correlative feature sets of BD incidence. Moreover, BD incidence prediction models based on meteorological factors had better prediction accuracies. The findings in this study could provide a panorama of BD in Chongqing and offer a useful approach for predicting the incidence of infectious disease. Furthermore, this information could be used to improve current interventions and public health planning.

Prevalence and risk factors of pre-sick building syndrome: characteristics of indoor environmental and individual factors

BACKGROUND

With the aim to prevent sick building syndrome and worsening of allergic symptoms, primarily resulting from the indoor environment, the relationships among people's residential environment in recent years, their lifestyle habits, their awareness, and their symptoms were investigated using an online survey.

METHODS

In the survey, respondents experiencing symptoms specific to sick building syndrome, although they were not diagnosed with sick building syndrome, were categorized in the pre-sick building syndrome group. The relationships among individual characteristics, residential environment, and individual awareness were analyzed.

RESULTS

Results showed that the prevalence of pre-sick building syndrome was high among young (aged 20-29 years) population of both sexes. In addition, "condensation," "moisture," "musty odors" in the house, and the "use of deodorant and fragrance" were all significantly associated with pre-sick building syndrome. Conversely, there was no significant association with recently built "wooden" houses that are highly airtight and have thermal insulation.

CONCLUSIONS

Efficient "ventilation" plans and "ventilation" improvement and air conditioning systems to prevent mold and condensation in rooms are necessary to maintain a good, indoor environment that is beneficial for health. Efforts should also be made to encourage individuals to regularly clean and effectively ventilate their homes.

The Impact of Ambient Environmental Exposures to Microbial Products on Asthma Outcomes from Birth to Childhood

Purpose of Review

Asthma is a chronic respiratory condition with increasing domestic and worldwide prevalence that burdens individuals and the healthcare system with high costs associated with long-term treatments and acute emergency room (ER) visits. It can be triggered by ambient microbes, including bacteria, viruses, and fungi. In this review, we examine the outcomes of asthma patients in relation to environmental exposures to ambient microbe products, focusing on whether exposure leads to asthma development from birth to childhood and if particular microbes are associated with worsened asthma exacerbations.

Recent Findings

Bacterial endotoxin is more prominent in homes with pets and may cause cytokine cascades that lead to asthma exacerbation. However, some studies have demonstrated a protective effect with early exposure. Patients with positive Aspergillus skin testing are more prone to moderate-severe or severe-uncontrolled asthma. Fungal sensitization is also associated with earlier onset of asthma and demonstrates a dose-dependent relationship of symptom severity and duration. Among viruses, rhinovirus has the greatest association with decreased lung function, severe asthma, and asthma-related hospital admissions. Distribution of microbial products and associated asthma symptoms depends on the geographical climate. Genetic variations among individuals also mitigate the effects of microbial products on asthma development and symptom severity.

Summary

Microbial products of bacteria, fungi, and viruses are associated with the development of asthma, more severe asthma symptoms, and worse outcomes. However, some early exposure studies have also demonstrated a protective effect. Bacterial and fungal products are related to decreased lung function and earlier onset of asthma. Viral products are related to asthma-associated hospital admissions; and the climate and patient genetics can also temper or intensify the relationships between microbial products, asthma development, and asthma symptom severity. Further research should focus on the effects of early microbe exposure and its interaction with human immune systems and asthma-related outcomes.

Association of biomass fuel smoke with respiratory symptoms among children under 5 years of age in urban areas: results from Bangladesh Urban Health Survey, 2013

BACKGROUND

Little is known regarding the effect of exposure to biomass fuel smoke inhalation on respiratory symptoms in the Bangladeshi population which is a major health hazard in most of the developing countries. This study aims to explore the association between respiratory symptoms and biomass fuel smoke exposure among children under 5 years of age.

METHODS

Data were extracted from the Bangladesh Urban Health Survey conducted in 2013. A total of 10,575 mothers with at least one surviving children were selected. Respiratory symptoms among children under 5 years of age were considered as the primary outcome. Sequential multiple logistic regression models were used to observe the association between respiratory symptoms and biomass fuel smoke exposure adjusting the effect of residential factors and mother and child characteristics.

RESULTS

Around 40% of the mothers exclusively used biomass fuel irrespective of the kitchen location and 54% of them were habituated in indoor cooking. The prevalence of respiratory symptoms of under-five children among in-house and outdoor biomass fuel users was 23.0% and 21.9%, respectively. Results of fitted multiple logistic regression models showed that the odds of having respiratory symptoms among children under 5 years of age were increased due to in-house biomass fuel use [OR = 1.18; 95% CI, 1.04-1.36] compared with the non-biomass user. An increased risk of respiratory symptoms was also significantly associated with mother's birth complication [OR = 1.51; 95% CI, 1.36-1.67], non-government organization (NGO) membership of mothers [OR = 1.32; 95% CI, 1.16-1.51], age of the child (6-23m) [OR = 1.29; 95% CI, 1.10-1.52], and nutritional status (stunting) [OR = 1.18; 95% CI, 1.06-1.31].

CONCLUSION

This study found the use of in-house biomass fuel as a significant risk factor associated with respiratory symptoms of children under 5 years of age. More longitudinal studies should be designed to establish a causal relationship between HAP (household air pollution) and respiratory symptoms among children with more direct measures of HAP and clinical procedure.