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Checkley W, Thompson LM, Hossen S, Nicolaou L, Williams KN, Hartinger SM, Chiang M, Balakrishnan K, Garg SS, Thangavel G, Aravindalochanan V, Rosa G, Mukeshimana A, Ndagijimana F, McCracken JP, Diaz-Artiga A, Sinharoy SS, Waller L, Wang J, Jabbarzadeh S, Chen Y, Steenland K, Kirby MA, Ramakrishnan U, Johnson M, Pillarisetti A, McCollum ED, Craik R, Ohuma EO, Dávila-Román VG, de Las Fuentes L, Simkovich SM, Peel JL, Clasen TF, Papageorghiou AT. Cooking with liquefied petroleum gas or biomass and fetal growth outcomes: a multi-country randomised controlled trial. Lancet Glob Health 2024; 12:e815-e825. [PMID: 38614630 PMCID: PMC11027158 DOI: 10.1016/s2214-109x(24)00033-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 10/26/2023] [Accepted: 01/12/2024] [Indexed: 04/15/2024]
Abstract
BACKGROUND Household air pollution might lead to fetal growth restriction during pregnancy. We aimed to investigate whether a liquefied petroleum gas (LPG) intervention to reduce personal exposures to household air pollution during pregnancy would alter fetal growth. METHODS The Household Air Pollution Intervention Network (HAPIN) trial was an open-label randomised controlled trial conducted in ten resource-limited settings across Guatemala, India, Peru, and Rwanda. Pregnant women aged 18-34 years (9-19 weeks of gestation) were randomly assigned in a 1:1 ratio to receive an LPG stove, continuous fuel delivery, and behavioural messaging or to continue usual cooking with biomass for 18 months. We conducted ultrasound assessments at baseline, 24-28 weeks of gestation (the first pregnancy visit), and 32-36 weeks of gestation (the second pregnancy visit), to measure fetal size; we monitored 24 h personal exposures to household air pollutants during these visits; and we weighed children at birth. We conducted intention-to-treat analyses to estimate differences in fetal size between the intervention and control group, and exposure-response analyses to identify associations between household air pollutants and fetal size. This trial is registered with ClinicalTrials.gov (NCT02944682). FINDINGS Between May 7, 2018, and Feb 29, 2020, we randomly assigned 3200 pregnant women (1593 to the intervention group and 1607 to the control group). The mean gestational age was 14·5 (SD 3·0) weeks and mean maternal age was 25·6 (4·5) years. We obtained ultrasound assessments in 3147 (98·3%) women at baseline, 3052 (95·4%) women at the first pregnancy visit, and 2962 (92·6%) at the second pregnancy visit, through to Aug 25, 2020. Intervention adherence was high (the median proportion of days with biomass stove use was 0·0%, IQR 0·0-1·6) and pregnant women in the intervention group had lower mean exposures to particulate matter with a diameter less than 2·5 μm (PM2·5; 35·0 [SD 37·2] μg/m3vs 103·3 [97·9] μg/m3) than did women in the control group. We did not find differences in averaged post-randomisation Z scores for head circumference (0·30 vs 0·39; p=0·04), abdominal circumference (0·38 vs 0·39; p=0·99), femur length (0·44 vs 0·45; p=0·73), and estimated fetal weight or birthweight (-0·13 vs -0·12; p=0·70) between the intervention and control groups. Personal exposures to household air pollutants were not associated with fetal size. INTERPRETATION Although an LPG cooking intervention successfully reduced personal exposure to air pollution during pregnancy, it did not affect fetal size. Our findings do not support the use of unvented liquefied petroleum gas stoves as a strategy to increase fetal growth in settings were biomass fuels are used predominantly for cooking. FUNDING US National Institutes of Health and Bill & Melinda Gates Foundation. TRANSLATIONS For the Kinyarwanda, Spanish and Tamil translations of the abstract see Supplementary Materials section.
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Affiliation(s)
- 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.
| | - Lisa M Thompson
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA, USA
| | - 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
| | - Laura Nicolaou
- 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
| | - 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
| | - Stella M Hartinger
- Latin American Center of Excellence on Climate Change and Health, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Marilu Chiang
- Biomedical Research Unit, Asociación Benéfica PRISMA, Lima, Perú
| | - 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, India
| | - Sarada S Garg
- 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, India
| | - Gurusamy Thangavel
- 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, India
| | - Vigneswari Aravindalochanan
- 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, India
| | - Ghislaine Rosa
- Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
| | | | | | - John P McCracken
- Epidemiology and Biostatistics Department, University of Georgia, Athens, GA, USA; Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala
| | - Anaité Diaz-Artiga
- Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala
| | - Sheela S Sinharoy
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Lance Waller
- Department of Biostatistics and Bioinformatics, Emory University, Atlanta, GA, USA
| | - Jiantong Wang
- Department of Biostatistics and Bioinformatics, Emory University, Atlanta, GA, USA
| | - Shirin Jabbarzadeh
- Department of Biostatistics and Bioinformatics, Emory University, Atlanta, GA, USA
| | - Yunyun Chen
- Department of Biostatistics and Bioinformatics, Emory University, Atlanta, GA, USA
| | - Kyle Steenland
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Miles A Kirby
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Usha Ramakrishnan
- Hubert Department of Global Health, 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
| | - Eric D McCollum
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, MD, USA; Global Program in Pediatric Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences, School of Medicine, Johns Hopkins University, Baltimore, MD, USA; Eudowood Division of Pediatric Respiratory Sciences, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Rachel Craik
- Nuffield Department of Women's & Reproductive Health, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | - Eric O Ohuma
- Centre for Maternal, Adolescent, Reproductive & Child Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Victor G Dávila-Román
- Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St Louis, St Louis, MO, USA
| | - Lisa de Las Fuentes
- Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St Louis, St Louis, MO, USA
| | - Suzanne M Simkovich
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, MD, USA; Division of Healthcare Delivery Research, MedStar Health Research Institute, Hyattsville, MD, USA; Division of Pulmonary and Critical Care Medicine, Georgetown University, Washington, DC, USA
| | - Jennifer L Peel
- Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins, CO, USA
| | - Thomas F Clasen
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Aris T Papageorghiou
- Nuffield Department of Women's & Reproductive Health, University of Oxford, John Radcliffe Hospital, Oxford, UK.
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Younger A, Ye W, Alkon A, Harknett K, Kirby MA, Elon L, Lovvorn AE, Wang J, Diaz-Artiga A, McCracken JP, Castañaza Gonzalez A, Alarcon LM, Mukeshimana A, Rosa G, Chiang M, Balakrishnan K, Garg SS, Pillarisetti A, Piedrahita R, Johnson MA, Craik R, Papageorghiou AT, Toenjes A, Williams KN, Underhill LJ, Hartinger SM, Nicolaou L, Chang HH, Naeher LP, Rosenthal J, Checkley W, Peel JL, Clasen TF, Thompson LM. Effects of a liquefied petroleum gas stove intervention on stillbirth, congenital anomalies and neonatal mortality: A multi-country household air pollution intervention network trial. Environ Pollut 2024; 345:123414. [PMID: 38286258 DOI: 10.1016/j.envpol.2024.123414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 01/18/2024] [Accepted: 01/19/2024] [Indexed: 01/31/2024]
Abstract
Household air pollution (HAP) from cooking with solid fuels used during pregnancy has been associated with adverse pregnancy outcomes. The Household Air Pollution Intervention Network (HAPIN) trial was a randomized controlled trial that assessed the impact of a liquefied petroleum gas (LPG) stove and fuel intervention on health in Guatemala, India, Peru, and Rwanda. Here we investigated the effects of the LPG stove and fuel intervention on stillbirth, congenital anomalies and neonatal mortality and characterized exposure-response relationships between personal exposures to fine particulate matter (PM2.5), black carbon (BC) and carbon monoxide (CO) and these outcomes. Pregnant women (18 to <35 years of age; gestation confirmed by ultrasound at 9 to <20 weeks) were randomly assigned to intervention or control arms. We monitored these fetal and neonatal outcomes and personal exposure to PM2.5, BC and CO three times during pregnancy, we conducted intention-to-treat (ITT) and exposure-response (E-R) analyses to determine if the HAPIN intervention and corresponding HAP exposure was associated with the risk of fetal/neonatal outcomes. A total of 3200 women (mean age 25.4 ± 4.4 years, mean gestational age at randomization 15.4 ± 3.1 weeks) were included in this analysis. Relative risks for stillbirth, congenital anomaly and neonatal mortality were 0.99 (0.60, 1.66), 0.92 (95 % CI 0.52, 1.61), and 0.99 (0.54, 1.85), respectively, among women in the intervention arm compared to controls in an ITT analysis. Higher mean personal exposures to PM2.5, CO and BC during pregnancy were associated with a higher, but statistically non-significant, incidence of adverse outcomes. The LPG stove and fuel intervention did not reduce the risk of these outcomes nor did we find evidence supporting an association between personal exposures to HAP and stillbirth, congenital anomalies and neonatal mortality.
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Affiliation(s)
- Ashley Younger
- School of Nursing, University of California, San Francisco, CA, USA.
| | - Wenlu Ye
- Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley, CA, USA
| | - Abbey Alkon
- School of Nursing, University of California, San Francisco, CA, USA
| | - Kristen Harknett
- School of Nursing, University of California, San Francisco, CA, USA
| | - Miles A Kirby
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Harvard University, Boston, MA, USA
| | - Lisa Elon
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Amy E Lovvorn
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, CA, USA
| | - Jiantong Wang
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Anaité Diaz-Artiga
- Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala
| | - John P McCracken
- Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala; Department of Environmental Health Science, College of Public Health, University of Georgia, Athens, GA, USA
| | | | - Libny Monroy Alarcon
- 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
| | - Marilu Chiang
- Division of Pulmonary and Critical Care, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - 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
| | - 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
| | - Ajay Pillarisetti
- Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley, CA, USA
| | | | | | - Rachel Craik
- Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford, UK
| | - Aris T Papageorghiou
- Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford, UK
| | - Ashley Toenjes
- Cardiovascular Division, Department of Medicine, Washington University in St. Louis, St. Louis, MO, USA
| | - Kendra N Williams
- 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
| | - Lindsay J Underhill
- Cardiovascular Division, Department of Medicine, Washington University in St. Louis, St. Louis, MO, USA
| | - Stella M Hartinger
- Latin American Center of Excellence on Climate Change and Health, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Laura Nicolaou
- 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
| | - Howard H Chang
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Luke P Naeher
- Department of Environmental Health Science, College of Public Health, University of Georgia, Athens, GA, USA
| | - Joshua Rosenthal
- Division of Epidemiology and Population Studies, Fogarty International Center, National Institutes of Health, Bethesda, MD, 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
| | - Jennifer L Peel
- Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins, CO, USA
| | - Thomas F Clasen
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, CA, USA
| | - Lisa M Thompson
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, CA, USA; Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA, USA
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Liu E, Manji KP, Kirby MA, Kisenge R, Lauer JM, Fawzi WW, Sudfeld CR, Duggan CP. Effects of Zinc Supplementation on Metabolomic Profiles in Tanzanian Infants: A Randomized Trial. J Nutr 2024; 154:403-411. [PMID: 38092153 PMCID: PMC10900136 DOI: 10.1016/j.tjnut.2023.12.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Revised: 11/27/2023] [Accepted: 12/04/2023] [Indexed: 12/31/2023] Open
Abstract
BACKGROUND Provision of zinc supplementation to young children has been associated with reduced infectious morbidity and better growth outcomes. However, the metabolic pathways underlying these outcomes are unclear, and metabolomic data from humans undergoing zinc supplementation, particularly infants, are generally lacking. OBJECTIVES This study aimed to examine the effect of zinc supplementation on metabolic profiles in Tanzanian infants aged 6 wk and 6 mo. METHODS Blood samples were collected at age 6 wk and 6 mo from 50 Tanzanian infants who were enrolled in a randomized placebo-controlled trial of zinc supplementation (5 mg oral daily). Metabolomic analysis using an ultrahigh-performance liquid chromatography/tandem mass spectroscopy platform was performed to identify potential metabolomic profiles and biomarkers associated with zinc supplementation. Principal component analysis (PCA) was used to summarize metabolomic data from all samples. Two-way repeated measures analysis of variance with compound symmetry covariance structures were used to compare metabolome levels over time between infants in the 2 treatment arms. RESULTS In PCA, the samples tended to be more separated by child age (6 wk compared with 6 mo) than by zinc supplementation status. We found that zinc supplementation affected a variety of metabolites associated with amino acid, lipid, nucleotide, and xenobiotic metabolism, including indoleacetate in the tryptophan metabolism pathway; 3-methoxytrosine and 4-hydrxoyphenylphruvate in the tyrosine pathway; eicosanedioate, 2-aminooctanoate, and N-acetyl-2-aminooctanoate in the fatty acid pathway; and N6-succinyladenosine in the purine metabolism pathway. Compared to the relatively small number of metabolites associated with zinc supplements, many infant metabolites changed significantly from age 6 wk to 6 mo. CONCLUSIONS Zinc supplementation, despite having overall clinical benefits, appears to induce limited metabolomic changes in blood metabolites in young infants. Future larger studies may be warranted to further examine metabolic pathways associated with zinc supplementation. The parent trial was registered at clinicaltrials.gov as NCT00421668.
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Affiliation(s)
- Enju Liu
- Institutional Centers for Clinical and Translational Research, Boston Children's Hospital, Boston, MA, United States; Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA, United States
| | - Karim P Manji
- Department of Pediatrics and Child Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Miles A Kirby
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, United States
| | - Rodrick Kisenge
- Department of Pediatrics and Child Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Jacqueline M Lauer
- Department of Health Sciences, College of Health & Rehabilitation Sciences: Sargent College, Boston University, Boston, MA, United States
| | - Wafaie W Fawzi
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, United States; Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, United States; Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA, United States
| | - Christopher R Sudfeld
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, United States; Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA, United States
| | - Christopher P Duggan
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA, United States; Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, United States; Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA, United States.
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4
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Checkley W, Thompson LM, Sinharoy SS, Hossen S, Moulton LH, Chang HH, Waller L, Steenland K, Rosa G, Mukeshimana A, Ndagijimana F, McCracken JP, Díaz-Artiga A, Balakrishnan K, Garg SS, Thangavel G, Aravindalochanan V, Hartinger SM, Chiang M, Kirby MA, Papageorghiou AT, Ramakrishnan U, Williams KN, Nicolaou L, Johnson M, Pillarisetti A, Rosenthal J, Underhill LJ, Wang J, Jabbarzadeh S, Chen Y, Dávila-Román VG, Naeher LP, McCollum ED, Peel JL, Clasen TF. Effects of Cooking with Liquefied Petroleum Gas or Biomass on Stunting in Infants. N Engl J Med 2024; 390:44-54. [PMID: 38169489 DOI: 10.1056/nejmoa2302687] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2024]
Abstract
BACKGROUND Household air pollution is associated with stunted growth in infants. Whether the replacement of biomass fuel (e.g., wood, dung, or agricultural crop waste) with liquefied petroleum gas (LPG) for cooking can reduce the risk of stunting is unknown. METHODS We conducted a randomized trial involving 3200 pregnant women 18 to 34 years of age in four low- and middle-income countries. Women at 9 to less than 20 weeks' gestation were randomly assigned to use a free LPG cookstove with continuous free fuel delivery for 18 months (intervention group) or to continue using a biomass cookstove (control group). The length of each infant was measured at 12 months of age, and personal exposures to fine particulate matter (particles with an aerodynamic diameter of ≤2.5 μm) were monitored starting at pregnancy and continuing until the infants were 1 year of age. The primary outcome for which data are presented in the current report - stunting (defined as a length-for-age z score that was more than two standard deviations below the median of a growth standard) at 12 months of age - was one of four primary outcomes of the trial. Intention-to-treat analyses were performed to estimate the relative risk of stunting. RESULTS Adherence to the intervention was high, and the intervention resulted in lower prenatal and postnatal 24-hour personal exposures to fine particulate matter than the control (mean prenatal exposure, 35.0 μg per cubic meter vs. 103.3 μg per cubic meter; mean postnatal exposure, 37.9 μg per cubic meter vs. 109.2 μg per cubic meter). Among 3061 live births, 1171 (76.2%) of the 1536 infants born to women in the intervention group and 1186 (77.8%) of the 1525 infants born to women in the control group had a valid length measurement at 12 months of age. Stunting occurred in 321 of the 1171 infants included in the analysis (27.4%) of the infants born to women in the intervention group and in 299 of the 1186 infants included in the analysis (25.2%) of those born to women in the control group (relative risk, 1.10; 98.75% confidence interval, 0.94 to 1.29; P = 0.12). CONCLUSIONS An intervention strategy starting in pregnancy and aimed at mitigating household air pollution by replacing biomass fuel with LPG for cooking did not reduce the risk of stunting in infants. (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)
- William Checkley
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty 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., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research 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 (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Lisa M Thompson
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty 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., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research 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 (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Sheela S Sinharoy
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty 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., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research 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 (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Shakir Hossen
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty 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., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research 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 (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Lawrence H Moulton
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty 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., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research 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 (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Howard H Chang
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty 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., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research 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 (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Lance Waller
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty 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., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research 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 (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Kyle Steenland
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty 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., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research 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 (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Ghislaine Rosa
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty 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., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research 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 (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Alexie Mukeshimana
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty 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., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research 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 (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Florien Ndagijimana
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty 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., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research 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 (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - John P McCracken
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty 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., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research 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 (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Anaité Díaz-Artiga
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty 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., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research 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 (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Kalpana Balakrishnan
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty 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., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research 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 (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Sarada S Garg
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty 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., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research 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 (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Gurusamy Thangavel
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty 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., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research 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 (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Vigneswari Aravindalochanan
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty 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., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research 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 (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Stella M Hartinger
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty 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., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research 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 (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Marilú Chiang
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty 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., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research 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 (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Miles A Kirby
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty 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., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research 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 (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Aris T Papageorghiou
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty 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., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research 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 (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Usha Ramakrishnan
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty 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., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research 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 (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Kendra N Williams
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty 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., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research 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 (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Laura Nicolaou
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty 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., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research 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 (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Michael Johnson
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty 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., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research 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 (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Ajay Pillarisetti
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty 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., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research 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 (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Joshua Rosenthal
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty 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., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research 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 (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Lindsay J Underhill
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty 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., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research 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 (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Jiantong Wang
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty 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., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research 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 (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Shirin Jabbarzadeh
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty 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., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research 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 (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Yunyun Chen
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty 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., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research 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 (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Victor G Dávila-Román
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty 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., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research 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 (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Luke P Naeher
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty 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., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research 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 (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Eric D McCollum
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty 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., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research 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 (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Jennifer L Peel
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty 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., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research 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 (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Thomas F Clasen
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty 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., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research 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 (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
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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. Environ Int 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] [What about the content of this article? (0)] [Affiliation(s)] [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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7
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Younger A, Alkon A, Harknett K, Kirby MA, Elon L, Lovvorn AE, Wang J, Ye W, Diaz-Artiga A, McCracken JP, Castañaza Gonzalez A, Monroy Alarcon L, Mukeshimana A, Rosa G, Chiang M, Balakrishnan K, Garg SS, Pillarisetti A, Piedrahita R, Johnson M, Craik R, Papageorghiou AT, Toenjes A, Quinn A, Williams KN, Underhill L, Chang HH, Naeher LP, Rosenthal J, Checkley W, Peel JL, Clasen TF, Thompson LM. Effects of a LPG stove and fuel intervention on adverse maternal outcomes: A multi-country randomized controlled trial conducted by the Household Air Pollution Intervention Network (HAPIN). Environ Int 2023; 178:108059. [PMID: 37413928 PMCID: PMC10445187 DOI: 10.1016/j.envint.2023.108059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 06/08/2023] [Accepted: 06/21/2023] [Indexed: 07/08/2023]
Abstract
Household air pollution from solid cooking fuel use during gestation has been associated with adverse pregnancy and birth outcomes. The Household Air Pollution Intervention Network (HAPIN) trial was a randomized controlled trial of free liquefied petroleum gas (LPG) stoves and fuel in Guatemala, Peru, India, and Rwanda. A primary outcome of the main trial was to report the effects of the intervention on infant birth weight. Here we evaluate the effects of a LPG stove and fuel intervention during pregnancy on spontaneous abortion, postpartum hemorrhage, hypertensive disorders of pregnancy, and maternal mortality compared to women who continued to use solid cooking fuels. Pregnant women (18-34 years of age; gestation confirmed by ultrasound at 9-19 weeks) were randomly assigned to an intervention (n = 1593) or control (n = 1607) arm. Intention-to-treat analyses compared outcomes between the two arms using log-binomial models. Among the 3195 pregnant women in the study, there were 10 spontaneous abortions (7 intervention, 3 control), 93 hypertensive disorders of pregnancy (47 intervention, 46 control), 11 post postpartum hemorrhage (5 intervention, 6 control) and 4 maternal deaths (3 intervention, 1 control). Compared to the control arm, the relative risk of spontaneous abortion among women randomized to the intervention was 2.32 (95% confidence interval (CI): 0.60, 8.96), hypertensive disorders of pregnancy 1.02 (95% CI: 0.68, 1.52), postpartum hemorrhage 0.83 (95% CI: 0.25, 2.71) and 2.98 (95% CI: 0.31, 28.66) for maternal mortality. In this study, we found that adverse maternal outcomes did not differ based on randomized stove type across four country research sites.
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Affiliation(s)
- Ashley Younger
- School of Nursing, University of California, San Francisco, San Francisco, CA, USA
| | - Abbey Alkon
- School of Nursing, University of California, San Francisco, San Francisco, CA, USA
| | - Kristen Harknett
- School of Nursing, University of California, San Francisco, San Francisco, CA, USA
| | - Miles A Kirby
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Harvard University, Boston, MA, USA
| | - Lisa Elon
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Amy E Lovvorn
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Jiantong Wang
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Wenlu Ye
- Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley, CA, USA
| | - Anaité Diaz-Artiga
- Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala
| | - John P McCracken
- Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala; Department of Environmental Health Science, College of Public Health, University of Georgia, Athens, GA, USA
| | | | - Libny Monroy Alarcon
- 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
| | - Marilu Chiang
- Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore MD, USA
| | - 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
| | - 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
| | - Ajay Pillarisetti
- Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley, CA, USA
| | | | | | - Rachel Craik
- Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford, UK
| | - Aris T Papageorghiou
- Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford, UK
| | - Ashley Toenjes
- Cardiovascular Division, Department of Medicine, Washington University in St. Louis, St. Louis, MO, USA
| | | | - Kendra N Williams
- Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore MD, USA; Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Lindsay Underhill
- Cardiovascular Division, Department of Medicine, Washington University in St. Louis, St. Louis, MO, USA
| | - Howard H Chang
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Luke P Naeher
- Department of Environmental Health Science, College of Public Health, University of Georgia, Athens, GA, USA
| | - Joshua Rosenthal
- Division of Epidemiology and Population Studies, Fogarty International Center, National Institutes of Health, Bethesda, MD, USA, Division of Pulmonary and Critical Care, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - William Checkley
- Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore MD, USA; Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Jennifer L Peel
- Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins, CO, USA
| | - Thomas F Clasen
- 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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8
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Pillarisetti A, Ye W, Balakrishnan K, Rosa G, Díaz-Artiga A, Underhill LJ, Steenland K, Peel JL, Kirby MA, McCracken J, Waller L, Chang H, Wang J, Dusabimana E, Ndagijimana F, Sambandam S, Mukhopadhyay K, Kearns KA, Campbell D, Kremer J, Rosenthal J, Ghosh A, Clark M, Checkley W, Clasen T, Naeher L, Piedrahita R, Johnson M. Post-birth exposure contrasts for children during the Household Air Pollution Intervention Network randomized controlled trial. medRxiv 2023:2023.07.04.23292226. [PMID: 37461598 PMCID: PMC10350133 DOI: 10.1101/2023.07.04.23292226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/24/2023]
Abstract
Exposure to household air pollution is a leading cause of ill-health globally. The Household Air Pollution Intervention Network (HAPIN) randomized controlled trial evaluated the impact of a free liquefied petroleum gas stove and fuel intervention on birth outcomes and maternal and child health. As part of HAPIN, an extensive exposure assessment was conducted. Here, we report on PM 2.5 and CO exposures of young children (≤ 15 months old) reconstructed using a Bluetooth-beacon based time-activity monitoring system coupled with microenvironmental pollutant monitors. Median (IQR) exposures to PM 2.5 were 65.1 (33 - 128.2) µg/m 3 in the control group and 22.9 (17.2 - 35.3) µg/m3 in the intervention group; for CO, median (IQR) exposures were 1.1 (0.3 - 2.9) ppm and 0.2 (0 - 0.7) ppm for control and intervention group, respectively. Exposure reductions were stable over time and consistent with previous findings for the children's mothers. In the intervention group, 75% of children's reconstructed exposures were below the WHO interim target guideline value of 35 µg/m 3 , while 26% were below the standard in the control group. Our findings suggest that an LPG fuel and stove intervention can substantially reduce children's exposure to household air pollution.
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9
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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 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] [What about the content of this article? (0)] [Affiliation(s)] [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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10
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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 Med Biol 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] [What about the content of this article? (0)] [Affiliation(s)] [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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11
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Balakrishnan K, Steenland K, Clasen T, Chang H, Johnson M, Pillarisetti A, Ye W, Naeher LP, Diaz-Artiga A, McCracken JP, Thompson LM, Rosa G, Kirby MA, Thangavel G, Sambandam S, Mukhopadhyay K, Puttaswamy N, Aravindalochanan V, Garg S, Ndagijimana F, Hartinger S, Underhill LJ, Kearns KA, Campbell D, Kremer J, Waller L, Jabbarzadeh S, Wang J, Chen Y, Rosenthal J, Quinn A, Papageorghiou AT, Ramakrishnan U, Howards PP, Checkley W, Peel JL. Exposure-response relationships for personal exposure to fine particulate matter (PM 2·5), carbon monoxide, and black carbon and birthweight: an observational analysis of the multicountry Household Air Pollution Intervention Network (HAPIN) trial. Lancet Planet Health 2023; 7:e387-e396. [PMID: 37164515 PMCID: PMC10186177 DOI: 10.1016/s2542-5196(23)00052-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 02/19/2023] [Accepted: 03/02/2023] [Indexed: 05/12/2023]
Abstract
BACKGROUND Household air pollution (HAP) from solid fuel use is associated with adverse birth outcomes, but data for exposure-response relationships are scarce. We examined associations between HAP exposures and birthweight in rural Guatemala, India, Peru, and Rwanda during the Household Air Pollution Intervention Network (HAPIN) trial. METHODS The HAPIN trial recruited pregnant women (9-<20 weeks of gestation) in rural Guatemala, India, Peru, and Rwanda and randomly allocated them to receive a liquefied petroleum gas stove or not (ie, and continue to use biomass fuel). The primary outcomes were birthweight, length-for-age, severe pneumonia, and maternal systolic blood pressure. In this exposure-response subanalysis, we measured 24-h personal exposures to PM2·5, carbon monoxide, and black carbon once pre-intervention (baseline) and twice post-intervention (at 24-28 weeks and 32-36 weeks of gestation), as well as birthweight within 24 h of birth. We examined the relationship between the average prenatal exposure and birthweight or weight-for-gestational age Z scores using multivariate-regression models, controlling for the mother's age, nulliparity, diet diversity, food insecurity, BMI, the mother's education, neonate sex, haemoglobin, second-hand smoke, and geographical indicator for randomisation strata. FINDINGS Between March, 2018, and February, 2020, 3200 pregnant women were recruited. An interquartile increase in the average prenatal exposure to PM2·5 (74·5 μg/m3) was associated with a reduction in birthweight and gestational age Z scores (birthweight: -14·8 g [95% CI -28·7 to -0·8]; gestational age Z scores: -0·03 [-0·06 to 0·00]), as was an interquartile increase in black carbon (7·3 μg/m3; -21·9 g [-37·7 to -6·1]; -0·05 [-0·08 to -0·01]). Carbon monoxide exposure was not associated with these outcomes (1·7; -3·1 [-12·1 to 5·8]; -0·003 [-0·023 to 0·017]). INTERPRETATION Continuing efforts are needed to reduce HAP exposure alongside other drivers of low birthweight in low-income and middle-income countries. FUNDING US National Institutes of Health (1UM1HL134590) and the Bill & Melinda Gates Foundation (OPP1131279).
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Affiliation(s)
- 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.
| | - Kyle Steenland
- Gangarosa Department of Environmental Health, Emory University, Atlanta, GA, USA
| | - Thomas Clasen
- Gangarosa Department of Environmental Health, Emory University, Atlanta, GA, USA
| | - Howard Chang
- Department of Biostatistics and Bioinformatics, Emory University, Atlanta, GA, USA
| | | | - Ajay Pillarisetti
- Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley, CA, USA
| | - Wenlu Ye
- Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley, CA, USA
| | - Luke P Naeher
- Department of Environmental Health Sciences, University of Georgia, Athens, GA, USA
| | - Anaite Diaz-Artiga
- Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala
| | - John P McCracken
- Department of Environmental Health Sciences, University of Georgia, Athens, GA, USA
| | - Lisa M Thompson
- Rollins School of Public Health and Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA, USA
| | - Ghislaine Rosa
- Department of Infectious and Tropical Diseases, London School of Hygiene & 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
| | - 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
| | - Sankar Sambandam
- 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
| | - Krishnendu Mukhopadhyay
- 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
| | - Naveen Puttaswamy
- 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
| | - Vigneswari Aravindalochanan
- 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
| | - Sarada 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
| | | | - Stella Hartinger
- Division of Pulmonary and Critical Care, School of Medicine and Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore, MD, USA
| | - Lindsay J Underhill
- Cardiovascular Division, Washington University School of Medicine, St Louis, MO, USA
| | - Katherine A Kearns
- Department of Environmental Health Sciences, University of Georgia, Athens, GA, USA
| | - Devan Campbell
- Department of Environmental Health Sciences, University of Georgia, Athens, GA, USA
| | - Jacob Kremer
- Department of Environmental Health Sciences, University of Georgia, Athens, GA, USA
| | - Lance Waller
- Department of Biostatistics and Bioinformatics, Emory University, Atlanta, GA, USA
| | - Shirin Jabbarzadeh
- Department of Biostatistics and Bioinformatics, Emory University, Atlanta, GA, USA
| | - Jiantong Wang
- Department of Biostatistics and Bioinformatics, Emory University, Atlanta, GA, USA
| | - Yunyun Chen
- Department of Biostatistics and Bioinformatics, Emory University, Atlanta, GA, USA
| | - Joshua Rosenthal
- Division of Epidemiology and Population Studies, Fogarty International Center, National Institutes of Health, Bethesda, MD, USA
| | | | - Aris T Papageorghiou
- Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford, UK
| | - Usha Ramakrishnan
- Hubert Department of Global Health, Emory University, Atlanta, GA, USA
| | | | - William Checkley
- Division of Pulmonary and Critical Care, School of Medicine and Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore, MD, USA
| | - Jennifer L Peel
- Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins, CO, USA
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Lauer JM, Kirby MA, Muhihi A, Ulenga N, Aboud S, Liu E, Choy RKM, Arndt MB, Kou J, Fawzi W, Gewirtz A, Sudfeld CR, Manji KP, Duggan CP. Assessing environmental enteric dysfunction via multiplex assay and its relation to growth and development among HIV-exposed uninfected Tanzanian infants. PLoS Negl Trop Dis 2023; 17:e0011181. [PMID: 36943785 PMCID: PMC10030025 DOI: 10.1371/journal.pntd.0011181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Accepted: 02/21/2023] [Indexed: 03/23/2023] Open
Abstract
BACKGROUND Environmental enteric dysfunction (EED) may contribute to poor growth and development in young children. While validated EED biomarkers are currently lacking, multiplex assays are able to capture multiple domains of the condition. The purpose of this exploratory study was to examine the relationship between biomarkers of EED and subsequent growth and development among Tanzanian HIV-exposed uninfected (HEU) infants. METHODOLOGY We enrolled 467 infants of mothers living with HIV who had participated in a trial of vitamin D3 supplementation during pregnancy. Infant serum samples collected at 6 weeks (n = 365) and 6 months (n = 266) were analyzed for anti-flagellin and anti-lipopolysaccharide (LPS) IgA and IgG via ELISA as well as the 11-plex Micronutrient and EED Assessment Tool (MEEDAT), which incorporates two biomarkers of EED [intestinal fatty acid-binding protein (I-FABP) and soluble CD14 (sCD14)]. Outcomes were 12-month growth [length-for-age z-score (LAZ), weight-for-length z-score (WLZ), and weight-for-age z-score (WAZ)] and development [Caregiver Reported Early Development Instruments (CREDI) z-scores] and were assessed using linear regression. FINDINGS In primary analyses, higher quartiles of 6-month anti-LPS IgG concentrations were significantly associated with lower LAZ at 12 months (ptrend = 0.040). In secondary analyses, higher log2-transformed 6-week anti-flagellin IgA and 6-month anti-LPS IgA concentrations were significantly associated with lower LAZ at 12 months. No associations were observed between I-FABP or sCD14 and infant growth. However, higher log2-transformed 6-week sCD14 concentrations were significantly associated with lower overall CREDI z-scores, while higher log2-transformed 6-month I-FABP concentrations were significantly associated with higher overall CREDI z-scores. CONCLUSIONS Unlike anti-flagellin and anti-LPS Igs, MEEDAT's biomarkers of EED (I-FABP and sCD14) were not associated with subsequent linear growth among HEU infants in Tanzania. The relationship between EED and infant development warrants further study.
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Affiliation(s)
- Jacqueline M Lauer
- Department of Health Sciences, College of Health & Rehabilitation Sciences: Sargent College, Boston University, Boston, Massachusetts, United States of America
| | - Miles A Kirby
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Alfa Muhihi
- Management and Development for Health, Dar es Salaam, Tanzania
| | - Nzovu Ulenga
- Management and Development for Health, Dar es Salaam, Tanzania
| | - Said Aboud
- Department of Microbiology and Immunology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Enju Liu
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, Massachusetts, United States of America
- Institutional Centers for Clinical and Translational Research, Boston Children's Hospital, Boston, Massachusetts, United States of America
| | - Robert K M Choy
- PATH, Center for Vaccine Innovation and Access, Seattle, Washington, United States of America
| | - Michael B Arndt
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington, United States of America
| | - Jianqun Kou
- Institute for Biomedical Sciences, Georgia State University, Atlanta, Georgia, United States of America
| | - Wafaie Fawzi
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Andrew Gewirtz
- Institute for Biomedical Sciences, Georgia State University, Atlanta, Georgia, United States of America
| | - Christopher R Sudfeld
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Karim P Manji
- Department of Pediatrics and Child Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Christopher P Duggan
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, Massachusetts, United States of America
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
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13
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Clasen TF, Chang HH, Thompson LM, Kirby MA, Balakrishnan K, Díaz-Artiga A, McCracken JP, Rosa G, Steenland K, Younger A, Aravindalochanan V, Barr DB, Castañaza A, Chen Y, Chiang M, Clark ML, Garg S, Hartinger S, Jabbarzadeh S, Johnson MA, Kim DY, Lovvorn AE, McCollum ED, Monroy L, Moulton LH, Mukeshimana A, Mukhopadhyay K, Naeher LP, Ndagijimana F, Papageorghiou A, Piedrahita R, Pillarisetti A, Puttaswamy N, Quinn A, Ramakrishnan U, Sambandam S, Sinharoy SS, Thangavel G, Underhill LJ, Waller LA, Wang J, Williams KN, Rosenthal JP, Checkley W, Peel JL. Liquefied Petroleum Gas or Biomass for Cooking and Effects on Birth Weight. N Engl J Med 2022; 387:1735-1746. [PMID: 36214599 PMCID: PMC9710426 DOI: 10.1056/nejmoa2206734] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Exposure during pregnancy to household air pollution caused by the burning of solid biomass fuel is associated with adverse health outcomes, including low birth weight. Whether the replacement of a biomass cookstove with a liquefied petroleum gas (LPG) cookstove would result in an increase in birth weight is unclear. METHODS We performed a randomized, controlled trial involving pregnant women (18 to <35 years of age and at 9 to <20 weeks' gestation as confirmed on ultrasonography) in Guatemala, India, Peru, and Rwanda. The women were assigned in a 1:1 ratio to use a free LPG cookstove and fuel (intervention group) or to continue using a biomass cookstove (control group). Birth weight, one of four prespecified primary outcomes, was the primary outcome for this report; data for the other three outcomes are not yet available. Birth weight was measured within 24 hours after birth. In addition, 24-hour personal exposures to fine particulate matter (particles with a diameter of ≤2.5 μm [PM2.5]), black carbon, and carbon monoxide were measured at baseline and twice during pregnancy. RESULTS A total of 3200 women underwent randomization; 1593 were assigned to the intervention group, and 1607 to the control group. Uptake of the intervention was nearly complete, with traditional biomass cookstoves being used at a median rate of less than 1 day per month. After randomization, the median 24-hour personal exposure to fine particulate matter was 23.9 μg per cubic meter in the intervention group and 70.7 μg per cubic meter in the control group. Among 3061 live births, a valid birth weight was available for 94.9% of the infants born to women in the intervention group and for 92.7% of infants born to those in the control group. The mean (±SD) birth weight was 2921±474.3 g in the intervention group and 2898±467.9 g in the control group, for an adjusted mean difference of 19.6 g (95% confidence interval, -10.1 to 49.2). CONCLUSIONS The birth weight of infants did not differ significantly between those born to women who used LPG cookstoves and those born to women who used biomass cookstoves. (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)
- Thomas F Clasen
- From Emory University, Atlanta (T.F.C., H.H.C., L.M.T., K.S., D.B.B., Y.C., S.J., A.E.L., U.R., S.S.S., L.A.W., J.W.), and the University of Georgia, Athens (J.P.M., L.P.N.) - both in Georgia; the Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., V.A., S.G., K.M., N.P., S.S., G.T.); Universidad del Valle de Guatemala, Guatemala City (A.D.-A., A.C., L.M.); the London School of Hygiene and Tropical Medicine, London (G.R.), and the University of Oxford, Oxford (A. Papageorghiou) - both in the United Kingdom; the University of California, San Francisco, San Francisco (A.Y.), and the Berkeley Air Monitoring Group (M.A.J., R.P., A.Q.) and the University of California, Berkeley (A. Pillarisetti), Berkeley - all in California; Asociación Benéfica PRISMA (M.C.) and Universidad Peruana Cayetano Heredia (S.H.) - both in Lima, Peru; Colorado State University, Fort Collins (M.L.C., J.L.P.); the National Institutes of Health, Bethesda (D.-Y.K., J.P.R.), and Johns Hopkins University, Baltimore (E.D.M., L.H.M., K.N.W., W.C.) - both in Maryland; the Eagle Research Center, Kigali, Rwanda (A.M., F.N.); and Washington University in St. Louis, St. Louis (L.J.U.)
| | - Howard H Chang
- From Emory University, Atlanta (T.F.C., H.H.C., L.M.T., K.S., D.B.B., Y.C., S.J., A.E.L., U.R., S.S.S., L.A.W., J.W.), and the University of Georgia, Athens (J.P.M., L.P.N.) - both in Georgia; the Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., V.A., S.G., K.M., N.P., S.S., G.T.); Universidad del Valle de Guatemala, Guatemala City (A.D.-A., A.C., L.M.); the London School of Hygiene and Tropical Medicine, London (G.R.), and the University of Oxford, Oxford (A. Papageorghiou) - both in the United Kingdom; the University of California, San Francisco, San Francisco (A.Y.), and the Berkeley Air Monitoring Group (M.A.J., R.P., A.Q.) and the University of California, Berkeley (A. Pillarisetti), Berkeley - all in California; Asociación Benéfica PRISMA (M.C.) and Universidad Peruana Cayetano Heredia (S.H.) - both in Lima, Peru; Colorado State University, Fort Collins (M.L.C., J.L.P.); the National Institutes of Health, Bethesda (D.-Y.K., J.P.R.), and Johns Hopkins University, Baltimore (E.D.M., L.H.M., K.N.W., W.C.) - both in Maryland; the Eagle Research Center, Kigali, Rwanda (A.M., F.N.); and Washington University in St. Louis, St. Louis (L.J.U.)
| | - Lisa M Thompson
- From Emory University, Atlanta (T.F.C., H.H.C., L.M.T., K.S., D.B.B., Y.C., S.J., A.E.L., U.R., S.S.S., L.A.W., J.W.), and the University of Georgia, Athens (J.P.M., L.P.N.) - both in Georgia; the Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., V.A., S.G., K.M., N.P., S.S., G.T.); Universidad del Valle de Guatemala, Guatemala City (A.D.-A., A.C., L.M.); the London School of Hygiene and Tropical Medicine, London (G.R.), and the University of Oxford, Oxford (A. Papageorghiou) - both in the United Kingdom; the University of California, San Francisco, San Francisco (A.Y.), and the Berkeley Air Monitoring Group (M.A.J., R.P., A.Q.) and the University of California, Berkeley (A. Pillarisetti), Berkeley - all in California; Asociación Benéfica PRISMA (M.C.) and Universidad Peruana Cayetano Heredia (S.H.) - both in Lima, Peru; Colorado State University, Fort Collins (M.L.C., J.L.P.); the National Institutes of Health, Bethesda (D.-Y.K., J.P.R.), and Johns Hopkins University, Baltimore (E.D.M., L.H.M., K.N.W., W.C.) - both in Maryland; the Eagle Research Center, Kigali, Rwanda (A.M., F.N.); and Washington University in St. Louis, St. Louis (L.J.U.)
| | - Miles A Kirby
- From Emory University, Atlanta (T.F.C., H.H.C., L.M.T., K.S., D.B.B., Y.C., S.J., A.E.L., U.R., S.S.S., L.A.W., J.W.), and the University of Georgia, Athens (J.P.M., L.P.N.) - both in Georgia; the Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., V.A., S.G., K.M., N.P., S.S., G.T.); Universidad del Valle de Guatemala, Guatemala City (A.D.-A., A.C., L.M.); the London School of Hygiene and Tropical Medicine, London (G.R.), and the University of Oxford, Oxford (A. Papageorghiou) - both in the United Kingdom; the University of California, San Francisco, San Francisco (A.Y.), and the Berkeley Air Monitoring Group (M.A.J., R.P., A.Q.) and the University of California, Berkeley (A. Pillarisetti), Berkeley - all in California; Asociación Benéfica PRISMA (M.C.) and Universidad Peruana Cayetano Heredia (S.H.) - both in Lima, Peru; Colorado State University, Fort Collins (M.L.C., J.L.P.); the National Institutes of Health, Bethesda (D.-Y.K., J.P.R.), and Johns Hopkins University, Baltimore (E.D.M., L.H.M., K.N.W., W.C.) - both in Maryland; the Eagle Research Center, Kigali, Rwanda (A.M., F.N.); and Washington University in St. Louis, St. Louis (L.J.U.)
| | - Kalpana Balakrishnan
- From Emory University, Atlanta (T.F.C., H.H.C., L.M.T., K.S., D.B.B., Y.C., S.J., A.E.L., U.R., S.S.S., L.A.W., J.W.), and the University of Georgia, Athens (J.P.M., L.P.N.) - both in Georgia; the Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., V.A., S.G., K.M., N.P., S.S., G.T.); Universidad del Valle de Guatemala, Guatemala City (A.D.-A., A.C., L.M.); the London School of Hygiene and Tropical Medicine, London (G.R.), and the University of Oxford, Oxford (A. Papageorghiou) - both in the United Kingdom; the University of California, San Francisco, San Francisco (A.Y.), and the Berkeley Air Monitoring Group (M.A.J., R.P., A.Q.) and the University of California, Berkeley (A. Pillarisetti), Berkeley - all in California; Asociación Benéfica PRISMA (M.C.) and Universidad Peruana Cayetano Heredia (S.H.) - both in Lima, Peru; Colorado State University, Fort Collins (M.L.C., J.L.P.); the National Institutes of Health, Bethesda (D.-Y.K., J.P.R.), and Johns Hopkins University, Baltimore (E.D.M., L.H.M., K.N.W., W.C.) - both in Maryland; the Eagle Research Center, Kigali, Rwanda (A.M., F.N.); and Washington University in St. Louis, St. Louis (L.J.U.)
| | - Anaité Díaz-Artiga
- From Emory University, Atlanta (T.F.C., H.H.C., L.M.T., K.S., D.B.B., Y.C., S.J., A.E.L., U.R., S.S.S., L.A.W., J.W.), and the University of Georgia, Athens (J.P.M., L.P.N.) - both in Georgia; the Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., V.A., S.G., K.M., N.P., S.S., G.T.); Universidad del Valle de Guatemala, Guatemala City (A.D.-A., A.C., L.M.); the London School of Hygiene and Tropical Medicine, London (G.R.), and the University of Oxford, Oxford (A. Papageorghiou) - both in the United Kingdom; the University of California, San Francisco, San Francisco (A.Y.), and the Berkeley Air Monitoring Group (M.A.J., R.P., A.Q.) and the University of California, Berkeley (A. Pillarisetti), Berkeley - all in California; Asociación Benéfica PRISMA (M.C.) and Universidad Peruana Cayetano Heredia (S.H.) - both in Lima, Peru; Colorado State University, Fort Collins (M.L.C., J.L.P.); the National Institutes of Health, Bethesda (D.-Y.K., J.P.R.), and Johns Hopkins University, Baltimore (E.D.M., L.H.M., K.N.W., W.C.) - both in Maryland; the Eagle Research Center, Kigali, Rwanda (A.M., F.N.); and Washington University in St. Louis, St. Louis (L.J.U.)
| | - John P McCracken
- From Emory University, Atlanta (T.F.C., H.H.C., L.M.T., K.S., D.B.B., Y.C., S.J., A.E.L., U.R., S.S.S., L.A.W., J.W.), and the University of Georgia, Athens (J.P.M., L.P.N.) - both in Georgia; the Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., V.A., S.G., K.M., N.P., S.S., G.T.); Universidad del Valle de Guatemala, Guatemala City (A.D.-A., A.C., L.M.); the London School of Hygiene and Tropical Medicine, London (G.R.), and the University of Oxford, Oxford (A. Papageorghiou) - both in the United Kingdom; the University of California, San Francisco, San Francisco (A.Y.), and the Berkeley Air Monitoring Group (M.A.J., R.P., A.Q.) and the University of California, Berkeley (A. Pillarisetti), Berkeley - all in California; Asociación Benéfica PRISMA (M.C.) and Universidad Peruana Cayetano Heredia (S.H.) - both in Lima, Peru; Colorado State University, Fort Collins (M.L.C., J.L.P.); the National Institutes of Health, Bethesda (D.-Y.K., J.P.R.), and Johns Hopkins University, Baltimore (E.D.M., L.H.M., K.N.W., W.C.) - both in Maryland; the Eagle Research Center, Kigali, Rwanda (A.M., F.N.); and Washington University in St. Louis, St. Louis (L.J.U.)
| | - Ghislaine Rosa
- From Emory University, Atlanta (T.F.C., H.H.C., L.M.T., K.S., D.B.B., Y.C., S.J., A.E.L., U.R., S.S.S., L.A.W., J.W.), and the University of Georgia, Athens (J.P.M., L.P.N.) - both in Georgia; the Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., V.A., S.G., K.M., N.P., S.S., G.T.); Universidad del Valle de Guatemala, Guatemala City (A.D.-A., A.C., L.M.); the London School of Hygiene and Tropical Medicine, London (G.R.), and the University of Oxford, Oxford (A. Papageorghiou) - both in the United Kingdom; the University of California, San Francisco, San Francisco (A.Y.), and the Berkeley Air Monitoring Group (M.A.J., R.P., A.Q.) and the University of California, Berkeley (A. Pillarisetti), Berkeley - all in California; Asociación Benéfica PRISMA (M.C.) and Universidad Peruana Cayetano Heredia (S.H.) - both in Lima, Peru; Colorado State University, Fort Collins (M.L.C., J.L.P.); the National Institutes of Health, Bethesda (D.-Y.K., J.P.R.), and Johns Hopkins University, Baltimore (E.D.M., L.H.M., K.N.W., W.C.) - both in Maryland; the Eagle Research Center, Kigali, Rwanda (A.M., F.N.); and Washington University in St. Louis, St. Louis (L.J.U.)
| | - Kyle Steenland
- From Emory University, Atlanta (T.F.C., H.H.C., L.M.T., K.S., D.B.B., Y.C., S.J., A.E.L., U.R., S.S.S., L.A.W., J.W.), and the University of Georgia, Athens (J.P.M., L.P.N.) - both in Georgia; the Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., V.A., S.G., K.M., N.P., S.S., G.T.); Universidad del Valle de Guatemala, Guatemala City (A.D.-A., A.C., L.M.); the London School of Hygiene and Tropical Medicine, London (G.R.), and the University of Oxford, Oxford (A. Papageorghiou) - both in the United Kingdom; the University of California, San Francisco, San Francisco (A.Y.), and the Berkeley Air Monitoring Group (M.A.J., R.P., A.Q.) and the University of California, Berkeley (A. Pillarisetti), Berkeley - all in California; Asociación Benéfica PRISMA (M.C.) and Universidad Peruana Cayetano Heredia (S.H.) - both in Lima, Peru; Colorado State University, Fort Collins (M.L.C., J.L.P.); the National Institutes of Health, Bethesda (D.-Y.K., J.P.R.), and Johns Hopkins University, Baltimore (E.D.M., L.H.M., K.N.W., W.C.) - both in Maryland; the Eagle Research Center, Kigali, Rwanda (A.M., F.N.); and Washington University in St. Louis, St. Louis (L.J.U.)
| | - Ashley Younger
- From Emory University, Atlanta (T.F.C., H.H.C., L.M.T., K.S., D.B.B., Y.C., S.J., A.E.L., U.R., S.S.S., L.A.W., J.W.), and the University of Georgia, Athens (J.P.M., L.P.N.) - both in Georgia; the Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., V.A., S.G., K.M., N.P., S.S., G.T.); Universidad del Valle de Guatemala, Guatemala City (A.D.-A., A.C., L.M.); the London School of Hygiene and Tropical Medicine, London (G.R.), and the University of Oxford, Oxford (A. Papageorghiou) - both in the United Kingdom; the University of California, San Francisco, San Francisco (A.Y.), and the Berkeley Air Monitoring Group (M.A.J., R.P., A.Q.) and the University of California, Berkeley (A. Pillarisetti), Berkeley - all in California; Asociación Benéfica PRISMA (M.C.) and Universidad Peruana Cayetano Heredia (S.H.) - both in Lima, Peru; Colorado State University, Fort Collins (M.L.C., J.L.P.); the National Institutes of Health, Bethesda (D.-Y.K., J.P.R.), and Johns Hopkins University, Baltimore (E.D.M., L.H.M., K.N.W., W.C.) - both in Maryland; the Eagle Research Center, Kigali, Rwanda (A.M., F.N.); and Washington University in St. Louis, St. Louis (L.J.U.)
| | - Vigneswari Aravindalochanan
- From Emory University, Atlanta (T.F.C., H.H.C., L.M.T., K.S., D.B.B., Y.C., S.J., A.E.L., U.R., S.S.S., L.A.W., J.W.), and the University of Georgia, Athens (J.P.M., L.P.N.) - both in Georgia; the Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., V.A., S.G., K.M., N.P., S.S., G.T.); Universidad del Valle de Guatemala, Guatemala City (A.D.-A., A.C., L.M.); the London School of Hygiene and Tropical Medicine, London (G.R.), and the University of Oxford, Oxford (A. Papageorghiou) - both in the United Kingdom; the University of California, San Francisco, San Francisco (A.Y.), and the Berkeley Air Monitoring Group (M.A.J., R.P., A.Q.) and the University of California, Berkeley (A. Pillarisetti), Berkeley - all in California; Asociación Benéfica PRISMA (M.C.) and Universidad Peruana Cayetano Heredia (S.H.) - both in Lima, Peru; Colorado State University, Fort Collins (M.L.C., J.L.P.); the National Institutes of Health, Bethesda (D.-Y.K., J.P.R.), and Johns Hopkins University, Baltimore (E.D.M., L.H.M., K.N.W., W.C.) - both in Maryland; the Eagle Research Center, Kigali, Rwanda (A.M., F.N.); and Washington University in St. Louis, St. Louis (L.J.U.)
| | - Dana B Barr
- From Emory University, Atlanta (T.F.C., H.H.C., L.M.T., K.S., D.B.B., Y.C., S.J., A.E.L., U.R., S.S.S., L.A.W., J.W.), and the University of Georgia, Athens (J.P.M., L.P.N.) - both in Georgia; the Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., V.A., S.G., K.M., N.P., S.S., G.T.); Universidad del Valle de Guatemala, Guatemala City (A.D.-A., A.C., L.M.); the London School of Hygiene and Tropical Medicine, London (G.R.), and the University of Oxford, Oxford (A. Papageorghiou) - both in the United Kingdom; the University of California, San Francisco, San Francisco (A.Y.), and the Berkeley Air Monitoring Group (M.A.J., R.P., A.Q.) and the University of California, Berkeley (A. Pillarisetti), Berkeley - all in California; Asociación Benéfica PRISMA (M.C.) and Universidad Peruana Cayetano Heredia (S.H.) - both in Lima, Peru; Colorado State University, Fort Collins (M.L.C., J.L.P.); the National Institutes of Health, Bethesda (D.-Y.K., J.P.R.), and Johns Hopkins University, Baltimore (E.D.M., L.H.M., K.N.W., W.C.) - both in Maryland; the Eagle Research Center, Kigali, Rwanda (A.M., F.N.); and Washington University in St. Louis, St. Louis (L.J.U.)
| | - Adly Castañaza
- From Emory University, Atlanta (T.F.C., H.H.C., L.M.T., K.S., D.B.B., Y.C., S.J., A.E.L., U.R., S.S.S., L.A.W., J.W.), and the University of Georgia, Athens (J.P.M., L.P.N.) - both in Georgia; the Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., V.A., S.G., K.M., N.P., S.S., G.T.); Universidad del Valle de Guatemala, Guatemala City (A.D.-A., A.C., L.M.); the London School of Hygiene and Tropical Medicine, London (G.R.), and the University of Oxford, Oxford (A. Papageorghiou) - both in the United Kingdom; the University of California, San Francisco, San Francisco (A.Y.), and the Berkeley Air Monitoring Group (M.A.J., R.P., A.Q.) and the University of California, Berkeley (A. Pillarisetti), Berkeley - all in California; Asociación Benéfica PRISMA (M.C.) and Universidad Peruana Cayetano Heredia (S.H.) - both in Lima, Peru; Colorado State University, Fort Collins (M.L.C., J.L.P.); the National Institutes of Health, Bethesda (D.-Y.K., J.P.R.), and Johns Hopkins University, Baltimore (E.D.M., L.H.M., K.N.W., W.C.) - both in Maryland; the Eagle Research Center, Kigali, Rwanda (A.M., F.N.); and Washington University in St. Louis, St. Louis (L.J.U.)
| | - Yunyun Chen
- From Emory University, Atlanta (T.F.C., H.H.C., L.M.T., K.S., D.B.B., Y.C., S.J., A.E.L., U.R., S.S.S., L.A.W., J.W.), and the University of Georgia, Athens (J.P.M., L.P.N.) - both in Georgia; the Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., V.A., S.G., K.M., N.P., S.S., G.T.); Universidad del Valle de Guatemala, Guatemala City (A.D.-A., A.C., L.M.); the London School of Hygiene and Tropical Medicine, London (G.R.), and the University of Oxford, Oxford (A. Papageorghiou) - both in the United Kingdom; the University of California, San Francisco, San Francisco (A.Y.), and the Berkeley Air Monitoring Group (M.A.J., R.P., A.Q.) and the University of California, Berkeley (A. Pillarisetti), Berkeley - all in California; Asociación Benéfica PRISMA (M.C.) and Universidad Peruana Cayetano Heredia (S.H.) - both in Lima, Peru; Colorado State University, Fort Collins (M.L.C., J.L.P.); the National Institutes of Health, Bethesda (D.-Y.K., J.P.R.), and Johns Hopkins University, Baltimore (E.D.M., L.H.M., K.N.W., W.C.) - both in Maryland; the Eagle Research Center, Kigali, Rwanda (A.M., F.N.); and Washington University in St. Louis, St. Louis (L.J.U.)
| | - Marilú Chiang
- From Emory University, Atlanta (T.F.C., H.H.C., L.M.T., K.S., D.B.B., Y.C., S.J., A.E.L., U.R., S.S.S., L.A.W., J.W.), and the University of Georgia, Athens (J.P.M., L.P.N.) - both in Georgia; the Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., V.A., S.G., K.M., N.P., S.S., G.T.); Universidad del Valle de Guatemala, Guatemala City (A.D.-A., A.C., L.M.); the London School of Hygiene and Tropical Medicine, London (G.R.), and the University of Oxford, Oxford (A. Papageorghiou) - both in the United Kingdom; the University of California, San Francisco, San Francisco (A.Y.), and the Berkeley Air Monitoring Group (M.A.J., R.P., A.Q.) and the University of California, Berkeley (A. Pillarisetti), Berkeley - all in California; Asociación Benéfica PRISMA (M.C.) and Universidad Peruana Cayetano Heredia (S.H.) - both in Lima, Peru; Colorado State University, Fort Collins (M.L.C., J.L.P.); the National Institutes of Health, Bethesda (D.-Y.K., J.P.R.), and Johns Hopkins University, Baltimore (E.D.M., L.H.M., K.N.W., W.C.) - both in Maryland; the Eagle Research Center, Kigali, Rwanda (A.M., F.N.); and Washington University in St. Louis, St. Louis (L.J.U.)
| | - Maggie L Clark
- From Emory University, Atlanta (T.F.C., H.H.C., L.M.T., K.S., D.B.B., Y.C., S.J., A.E.L., U.R., S.S.S., L.A.W., J.W.), and the University of Georgia, Athens (J.P.M., L.P.N.) - both in Georgia; the Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., V.A., S.G., K.M., N.P., S.S., G.T.); Universidad del Valle de Guatemala, Guatemala City (A.D.-A., A.C., L.M.); the London School of Hygiene and Tropical Medicine, London (G.R.), and the University of Oxford, Oxford (A. Papageorghiou) - both in the United Kingdom; the University of California, San Francisco, San Francisco (A.Y.), and the Berkeley Air Monitoring Group (M.A.J., R.P., A.Q.) and the University of California, Berkeley (A. Pillarisetti), Berkeley - all in California; Asociación Benéfica PRISMA (M.C.) and Universidad Peruana Cayetano Heredia (S.H.) - both in Lima, Peru; Colorado State University, Fort Collins (M.L.C., J.L.P.); the National Institutes of Health, Bethesda (D.-Y.K., J.P.R.), and Johns Hopkins University, Baltimore (E.D.M., L.H.M., K.N.W., W.C.) - both in Maryland; the Eagle Research Center, Kigali, Rwanda (A.M., F.N.); and Washington University in St. Louis, St. Louis (L.J.U.)
| | - Sarada Garg
- From Emory University, Atlanta (T.F.C., H.H.C., L.M.T., K.S., D.B.B., Y.C., S.J., A.E.L., U.R., S.S.S., L.A.W., J.W.), and the University of Georgia, Athens (J.P.M., L.P.N.) - both in Georgia; the Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., V.A., S.G., K.M., N.P., S.S., G.T.); Universidad del Valle de Guatemala, Guatemala City (A.D.-A., A.C., L.M.); the London School of Hygiene and Tropical Medicine, London (G.R.), and the University of Oxford, Oxford (A. Papageorghiou) - both in the United Kingdom; the University of California, San Francisco, San Francisco (A.Y.), and the Berkeley Air Monitoring Group (M.A.J., R.P., A.Q.) and the University of California, Berkeley (A. Pillarisetti), Berkeley - all in California; Asociación Benéfica PRISMA (M.C.) and Universidad Peruana Cayetano Heredia (S.H.) - both in Lima, Peru; Colorado State University, Fort Collins (M.L.C., J.L.P.); the National Institutes of Health, Bethesda (D.-Y.K., J.P.R.), and Johns Hopkins University, Baltimore (E.D.M., L.H.M., K.N.W., W.C.) - both in Maryland; the Eagle Research Center, Kigali, Rwanda (A.M., F.N.); and Washington University in St. Louis, St. Louis (L.J.U.)
| | - Stella Hartinger
- From Emory University, Atlanta (T.F.C., H.H.C., L.M.T., K.S., D.B.B., Y.C., S.J., A.E.L., U.R., S.S.S., L.A.W., J.W.), and the University of Georgia, Athens (J.P.M., L.P.N.) - both in Georgia; the Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., V.A., S.G., K.M., N.P., S.S., G.T.); Universidad del Valle de Guatemala, Guatemala City (A.D.-A., A.C., L.M.); the London School of Hygiene and Tropical Medicine, London (G.R.), and the University of Oxford, Oxford (A. Papageorghiou) - both in the United Kingdom; the University of California, San Francisco, San Francisco (A.Y.), and the Berkeley Air Monitoring Group (M.A.J., R.P., A.Q.) and the University of California, Berkeley (A. Pillarisetti), Berkeley - all in California; Asociación Benéfica PRISMA (M.C.) and Universidad Peruana Cayetano Heredia (S.H.) - both in Lima, Peru; Colorado State University, Fort Collins (M.L.C., J.L.P.); the National Institutes of Health, Bethesda (D.-Y.K., J.P.R.), and Johns Hopkins University, Baltimore (E.D.M., L.H.M., K.N.W., W.C.) - both in Maryland; the Eagle Research Center, Kigali, Rwanda (A.M., F.N.); and Washington University in St. Louis, St. Louis (L.J.U.)
| | - Shirin Jabbarzadeh
- From Emory University, Atlanta (T.F.C., H.H.C., L.M.T., K.S., D.B.B., Y.C., S.J., A.E.L., U.R., S.S.S., L.A.W., J.W.), and the University of Georgia, Athens (J.P.M., L.P.N.) - both in Georgia; the Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., V.A., S.G., K.M., N.P., S.S., G.T.); Universidad del Valle de Guatemala, Guatemala City (A.D.-A., A.C., L.M.); the London School of Hygiene and Tropical Medicine, London (G.R.), and the University of Oxford, Oxford (A. Papageorghiou) - both in the United Kingdom; the University of California, San Francisco, San Francisco (A.Y.), and the Berkeley Air Monitoring Group (M.A.J., R.P., A.Q.) and the University of California, Berkeley (A. Pillarisetti), Berkeley - all in California; Asociación Benéfica PRISMA (M.C.) and Universidad Peruana Cayetano Heredia (S.H.) - both in Lima, Peru; Colorado State University, Fort Collins (M.L.C., J.L.P.); the National Institutes of Health, Bethesda (D.-Y.K., J.P.R.), and Johns Hopkins University, Baltimore (E.D.M., L.H.M., K.N.W., W.C.) - both in Maryland; the Eagle Research Center, Kigali, Rwanda (A.M., F.N.); and Washington University in St. Louis, St. Louis (L.J.U.)
| | - Michael A Johnson
- From Emory University, Atlanta (T.F.C., H.H.C., L.M.T., K.S., D.B.B., Y.C., S.J., A.E.L., U.R., S.S.S., L.A.W., J.W.), and the University of Georgia, Athens (J.P.M., L.P.N.) - both in Georgia; the Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., V.A., S.G., K.M., N.P., S.S., G.T.); Universidad del Valle de Guatemala, Guatemala City (A.D.-A., A.C., L.M.); the London School of Hygiene and Tropical Medicine, London (G.R.), and the University of Oxford, Oxford (A. Papageorghiou) - both in the United Kingdom; the University of California, San Francisco, San Francisco (A.Y.), and the Berkeley Air Monitoring Group (M.A.J., R.P., A.Q.) and the University of California, Berkeley (A. Pillarisetti), Berkeley - all in California; Asociación Benéfica PRISMA (M.C.) and Universidad Peruana Cayetano Heredia (S.H.) - both in Lima, Peru; Colorado State University, Fort Collins (M.L.C., J.L.P.); the National Institutes of Health, Bethesda (D.-Y.K., J.P.R.), and Johns Hopkins University, Baltimore (E.D.M., L.H.M., K.N.W., W.C.) - both in Maryland; the Eagle Research Center, Kigali, Rwanda (A.M., F.N.); and Washington University in St. Louis, St. Louis (L.J.U.)
| | - Dong-Yun Kim
- From Emory University, Atlanta (T.F.C., H.H.C., L.M.T., K.S., D.B.B., Y.C., S.J., A.E.L., U.R., S.S.S., L.A.W., J.W.), and the University of Georgia, Athens (J.P.M., L.P.N.) - both in Georgia; the Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., V.A., S.G., K.M., N.P., S.S., G.T.); Universidad del Valle de Guatemala, Guatemala City (A.D.-A., A.C., L.M.); the London School of Hygiene and Tropical Medicine, London (G.R.), and the University of Oxford, Oxford (A. Papageorghiou) - both in the United Kingdom; the University of California, San Francisco, San Francisco (A.Y.), and the Berkeley Air Monitoring Group (M.A.J., R.P., A.Q.) and the University of California, Berkeley (A. Pillarisetti), Berkeley - all in California; Asociación Benéfica PRISMA (M.C.) and Universidad Peruana Cayetano Heredia (S.H.) - both in Lima, Peru; Colorado State University, Fort Collins (M.L.C., J.L.P.); the National Institutes of Health, Bethesda (D.-Y.K., J.P.R.), and Johns Hopkins University, Baltimore (E.D.M., L.H.M., K.N.W., W.C.) - both in Maryland; the Eagle Research Center, Kigali, Rwanda (A.M., F.N.); and Washington University in St. Louis, St. Louis (L.J.U.)
| | - Amy E Lovvorn
- From Emory University, Atlanta (T.F.C., H.H.C., L.M.T., K.S., D.B.B., Y.C., S.J., A.E.L., U.R., S.S.S., L.A.W., J.W.), and the University of Georgia, Athens (J.P.M., L.P.N.) - both in Georgia; the Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., V.A., S.G., K.M., N.P., S.S., G.T.); Universidad del Valle de Guatemala, Guatemala City (A.D.-A., A.C., L.M.); the London School of Hygiene and Tropical Medicine, London (G.R.), and the University of Oxford, Oxford (A. Papageorghiou) - both in the United Kingdom; the University of California, San Francisco, San Francisco (A.Y.), and the Berkeley Air Monitoring Group (M.A.J., R.P., A.Q.) and the University of California, Berkeley (A. Pillarisetti), Berkeley - all in California; Asociación Benéfica PRISMA (M.C.) and Universidad Peruana Cayetano Heredia (S.H.) - both in Lima, Peru; Colorado State University, Fort Collins (M.L.C., J.L.P.); the National Institutes of Health, Bethesda (D.-Y.K., J.P.R.), and Johns Hopkins University, Baltimore (E.D.M., L.H.M., K.N.W., W.C.) - both in Maryland; the Eagle Research Center, Kigali, Rwanda (A.M., F.N.); and Washington University in St. Louis, St. Louis (L.J.U.)
| | - Eric D McCollum
- From Emory University, Atlanta (T.F.C., H.H.C., L.M.T., K.S., D.B.B., Y.C., S.J., A.E.L., U.R., S.S.S., L.A.W., J.W.), and the University of Georgia, Athens (J.P.M., L.P.N.) - both in Georgia; the Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., V.A., S.G., K.M., N.P., S.S., G.T.); Universidad del Valle de Guatemala, Guatemala City (A.D.-A., A.C., L.M.); the London School of Hygiene and Tropical Medicine, London (G.R.), and the University of Oxford, Oxford (A. Papageorghiou) - both in the United Kingdom; the University of California, San Francisco, San Francisco (A.Y.), and the Berkeley Air Monitoring Group (M.A.J., R.P., A.Q.) and the University of California, Berkeley (A. Pillarisetti), Berkeley - all in California; Asociación Benéfica PRISMA (M.C.) and Universidad Peruana Cayetano Heredia (S.H.) - both in Lima, Peru; Colorado State University, Fort Collins (M.L.C., J.L.P.); the National Institutes of Health, Bethesda (D.-Y.K., J.P.R.), and Johns Hopkins University, Baltimore (E.D.M., L.H.M., K.N.W., W.C.) - both in Maryland; the Eagle Research Center, Kigali, Rwanda (A.M., F.N.); and Washington University in St. Louis, St. Louis (L.J.U.)
| | - Libny Monroy
- From Emory University, Atlanta (T.F.C., H.H.C., L.M.T., K.S., D.B.B., Y.C., S.J., A.E.L., U.R., S.S.S., L.A.W., J.W.), and the University of Georgia, Athens (J.P.M., L.P.N.) - both in Georgia; the Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., V.A., S.G., K.M., N.P., S.S., G.T.); Universidad del Valle de Guatemala, Guatemala City (A.D.-A., A.C., L.M.); the London School of Hygiene and Tropical Medicine, London (G.R.), and the University of Oxford, Oxford (A. Papageorghiou) - both in the United Kingdom; the University of California, San Francisco, San Francisco (A.Y.), and the Berkeley Air Monitoring Group (M.A.J., R.P., A.Q.) and the University of California, Berkeley (A. Pillarisetti), Berkeley - all in California; Asociación Benéfica PRISMA (M.C.) and Universidad Peruana Cayetano Heredia (S.H.) - both in Lima, Peru; Colorado State University, Fort Collins (M.L.C., J.L.P.); the National Institutes of Health, Bethesda (D.-Y.K., J.P.R.), and Johns Hopkins University, Baltimore (E.D.M., L.H.M., K.N.W., W.C.) - both in Maryland; the Eagle Research Center, Kigali, Rwanda (A.M., F.N.); and Washington University in St. Louis, St. Louis (L.J.U.)
| | - Lawrence H Moulton
- From Emory University, Atlanta (T.F.C., H.H.C., L.M.T., K.S., D.B.B., Y.C., S.J., A.E.L., U.R., S.S.S., L.A.W., J.W.), and the University of Georgia, Athens (J.P.M., L.P.N.) - both in Georgia; the Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., V.A., S.G., K.M., N.P., S.S., G.T.); Universidad del Valle de Guatemala, Guatemala City (A.D.-A., A.C., L.M.); the London School of Hygiene and Tropical Medicine, London (G.R.), and the University of Oxford, Oxford (A. Papageorghiou) - both in the United Kingdom; the University of California, San Francisco, San Francisco (A.Y.), and the Berkeley Air Monitoring Group (M.A.J., R.P., A.Q.) and the University of California, Berkeley (A. Pillarisetti), Berkeley - all in California; Asociación Benéfica PRISMA (M.C.) and Universidad Peruana Cayetano Heredia (S.H.) - both in Lima, Peru; Colorado State University, Fort Collins (M.L.C., J.L.P.); the National Institutes of Health, Bethesda (D.-Y.K., J.P.R.), and Johns Hopkins University, Baltimore (E.D.M., L.H.M., K.N.W., W.C.) - both in Maryland; the Eagle Research Center, Kigali, Rwanda (A.M., F.N.); and Washington University in St. Louis, St. Louis (L.J.U.)
| | - Alexie Mukeshimana
- From Emory University, Atlanta (T.F.C., H.H.C., L.M.T., K.S., D.B.B., Y.C., S.J., A.E.L., U.R., S.S.S., L.A.W., J.W.), and the University of Georgia, Athens (J.P.M., L.P.N.) - both in Georgia; the Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., V.A., S.G., K.M., N.P., S.S., G.T.); Universidad del Valle de Guatemala, Guatemala City (A.D.-A., A.C., L.M.); the London School of Hygiene and Tropical Medicine, London (G.R.), and the University of Oxford, Oxford (A. Papageorghiou) - both in the United Kingdom; the University of California, San Francisco, San Francisco (A.Y.), and the Berkeley Air Monitoring Group (M.A.J., R.P., A.Q.) and the University of California, Berkeley (A. Pillarisetti), Berkeley - all in California; Asociación Benéfica PRISMA (M.C.) and Universidad Peruana Cayetano Heredia (S.H.) - both in Lima, Peru; Colorado State University, Fort Collins (M.L.C., J.L.P.); the National Institutes of Health, Bethesda (D.-Y.K., J.P.R.), and Johns Hopkins University, Baltimore (E.D.M., L.H.M., K.N.W., W.C.) - both in Maryland; the Eagle Research Center, Kigali, Rwanda (A.M., F.N.); and Washington University in St. Louis, St. Louis (L.J.U.)
| | - Krishnendu Mukhopadhyay
- From Emory University, Atlanta (T.F.C., H.H.C., L.M.T., K.S., D.B.B., Y.C., S.J., A.E.L., U.R., S.S.S., L.A.W., J.W.), and the University of Georgia, Athens (J.P.M., L.P.N.) - both in Georgia; the Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., V.A., S.G., K.M., N.P., S.S., G.T.); Universidad del Valle de Guatemala, Guatemala City (A.D.-A., A.C., L.M.); the London School of Hygiene and Tropical Medicine, London (G.R.), and the University of Oxford, Oxford (A. Papageorghiou) - both in the United Kingdom; the University of California, San Francisco, San Francisco (A.Y.), and the Berkeley Air Monitoring Group (M.A.J., R.P., A.Q.) and the University of California, Berkeley (A. Pillarisetti), Berkeley - all in California; Asociación Benéfica PRISMA (M.C.) and Universidad Peruana Cayetano Heredia (S.H.) - both in Lima, Peru; Colorado State University, Fort Collins (M.L.C., J.L.P.); the National Institutes of Health, Bethesda (D.-Y.K., J.P.R.), and Johns Hopkins University, Baltimore (E.D.M., L.H.M., K.N.W., W.C.) - both in Maryland; the Eagle Research Center, Kigali, Rwanda (A.M., F.N.); and Washington University in St. Louis, St. Louis (L.J.U.)
| | - Luke P Naeher
- From Emory University, Atlanta (T.F.C., H.H.C., L.M.T., K.S., D.B.B., Y.C., S.J., A.E.L., U.R., S.S.S., L.A.W., J.W.), and the University of Georgia, Athens (J.P.M., L.P.N.) - both in Georgia; the Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., V.A., S.G., K.M., N.P., S.S., G.T.); Universidad del Valle de Guatemala, Guatemala City (A.D.-A., A.C., L.M.); the London School of Hygiene and Tropical Medicine, London (G.R.), and the University of Oxford, Oxford (A. Papageorghiou) - both in the United Kingdom; the University of California, San Francisco, San Francisco (A.Y.), and the Berkeley Air Monitoring Group (M.A.J., R.P., A.Q.) and the University of California, Berkeley (A. Pillarisetti), Berkeley - all in California; Asociación Benéfica PRISMA (M.C.) and Universidad Peruana Cayetano Heredia (S.H.) - both in Lima, Peru; Colorado State University, Fort Collins (M.L.C., J.L.P.); the National Institutes of Health, Bethesda (D.-Y.K., J.P.R.), and Johns Hopkins University, Baltimore (E.D.M., L.H.M., K.N.W., W.C.) - both in Maryland; the Eagle Research Center, Kigali, Rwanda (A.M., F.N.); and Washington University in St. Louis, St. Louis (L.J.U.)
| | - Florien Ndagijimana
- From Emory University, Atlanta (T.F.C., H.H.C., L.M.T., K.S., D.B.B., Y.C., S.J., A.E.L., U.R., S.S.S., L.A.W., J.W.), and the University of Georgia, Athens (J.P.M., L.P.N.) - both in Georgia; the Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., V.A., S.G., K.M., N.P., S.S., G.T.); Universidad del Valle de Guatemala, Guatemala City (A.D.-A., A.C., L.M.); the London School of Hygiene and Tropical Medicine, London (G.R.), and the University of Oxford, Oxford (A. Papageorghiou) - both in the United Kingdom; the University of California, San Francisco, San Francisco (A.Y.), and the Berkeley Air Monitoring Group (M.A.J., R.P., A.Q.) and the University of California, Berkeley (A. Pillarisetti), Berkeley - all in California; Asociación Benéfica PRISMA (M.C.) and Universidad Peruana Cayetano Heredia (S.H.) - both in Lima, Peru; Colorado State University, Fort Collins (M.L.C., J.L.P.); the National Institutes of Health, Bethesda (D.-Y.K., J.P.R.), and Johns Hopkins University, Baltimore (E.D.M., L.H.M., K.N.W., W.C.) - both in Maryland; the Eagle Research Center, Kigali, Rwanda (A.M., F.N.); and Washington University in St. Louis, St. Louis (L.J.U.)
| | - Aris Papageorghiou
- From Emory University, Atlanta (T.F.C., H.H.C., L.M.T., K.S., D.B.B., Y.C., S.J., A.E.L., U.R., S.S.S., L.A.W., J.W.), and the University of Georgia, Athens (J.P.M., L.P.N.) - both in Georgia; the Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., V.A., S.G., K.M., N.P., S.S., G.T.); Universidad del Valle de Guatemala, Guatemala City (A.D.-A., A.C., L.M.); the London School of Hygiene and Tropical Medicine, London (G.R.), and the University of Oxford, Oxford (A. Papageorghiou) - both in the United Kingdom; the University of California, San Francisco, San Francisco (A.Y.), and the Berkeley Air Monitoring Group (M.A.J., R.P., A.Q.) and the University of California, Berkeley (A. Pillarisetti), Berkeley - all in California; Asociación Benéfica PRISMA (M.C.) and Universidad Peruana Cayetano Heredia (S.H.) - both in Lima, Peru; Colorado State University, Fort Collins (M.L.C., J.L.P.); the National Institutes of Health, Bethesda (D.-Y.K., J.P.R.), and Johns Hopkins University, Baltimore (E.D.M., L.H.M., K.N.W., W.C.) - both in Maryland; the Eagle Research Center, Kigali, Rwanda (A.M., F.N.); and Washington University in St. Louis, St. Louis (L.J.U.)
| | - Ricardo Piedrahita
- From Emory University, Atlanta (T.F.C., H.H.C., L.M.T., K.S., D.B.B., Y.C., S.J., A.E.L., U.R., S.S.S., L.A.W., J.W.), and the University of Georgia, Athens (J.P.M., L.P.N.) - both in Georgia; the Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., V.A., S.G., K.M., N.P., S.S., G.T.); Universidad del Valle de Guatemala, Guatemala City (A.D.-A., A.C., L.M.); the London School of Hygiene and Tropical Medicine, London (G.R.), and the University of Oxford, Oxford (A. Papageorghiou) - both in the United Kingdom; the University of California, San Francisco, San Francisco (A.Y.), and the Berkeley Air Monitoring Group (M.A.J., R.P., A.Q.) and the University of California, Berkeley (A. Pillarisetti), Berkeley - all in California; Asociación Benéfica PRISMA (M.C.) and Universidad Peruana Cayetano Heredia (S.H.) - both in Lima, Peru; Colorado State University, Fort Collins (M.L.C., J.L.P.); the National Institutes of Health, Bethesda (D.-Y.K., J.P.R.), and Johns Hopkins University, Baltimore (E.D.M., L.H.M., K.N.W., W.C.) - both in Maryland; the Eagle Research Center, Kigali, Rwanda (A.M., F.N.); and Washington University in St. Louis, St. Louis (L.J.U.)
| | - Ajay Pillarisetti
- From Emory University, Atlanta (T.F.C., H.H.C., L.M.T., K.S., D.B.B., Y.C., S.J., A.E.L., U.R., S.S.S., L.A.W., J.W.), and the University of Georgia, Athens (J.P.M., L.P.N.) - both in Georgia; the Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., V.A., S.G., K.M., N.P., S.S., G.T.); Universidad del Valle de Guatemala, Guatemala City (A.D.-A., A.C., L.M.); the London School of Hygiene and Tropical Medicine, London (G.R.), and the University of Oxford, Oxford (A. Papageorghiou) - both in the United Kingdom; the University of California, San Francisco, San Francisco (A.Y.), and the Berkeley Air Monitoring Group (M.A.J., R.P., A.Q.) and the University of California, Berkeley (A. Pillarisetti), Berkeley - all in California; Asociación Benéfica PRISMA (M.C.) and Universidad Peruana Cayetano Heredia (S.H.) - both in Lima, Peru; Colorado State University, Fort Collins (M.L.C., J.L.P.); the National Institutes of Health, Bethesda (D.-Y.K., J.P.R.), and Johns Hopkins University, Baltimore (E.D.M., L.H.M., K.N.W., W.C.) - both in Maryland; the Eagle Research Center, Kigali, Rwanda (A.M., F.N.); and Washington University in St. Louis, St. Louis (L.J.U.)
| | - Naveen Puttaswamy
- From Emory University, Atlanta (T.F.C., H.H.C., L.M.T., K.S., D.B.B., Y.C., S.J., A.E.L., U.R., S.S.S., L.A.W., J.W.), and the University of Georgia, Athens (J.P.M., L.P.N.) - both in Georgia; the Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., V.A., S.G., K.M., N.P., S.S., G.T.); Universidad del Valle de Guatemala, Guatemala City (A.D.-A., A.C., L.M.); the London School of Hygiene and Tropical Medicine, London (G.R.), and the University of Oxford, Oxford (A. Papageorghiou) - both in the United Kingdom; the University of California, San Francisco, San Francisco (A.Y.), and the Berkeley Air Monitoring Group (M.A.J., R.P., A.Q.) and the University of California, Berkeley (A. Pillarisetti), Berkeley - all in California; Asociación Benéfica PRISMA (M.C.) and Universidad Peruana Cayetano Heredia (S.H.) - both in Lima, Peru; Colorado State University, Fort Collins (M.L.C., J.L.P.); the National Institutes of Health, Bethesda (D.-Y.K., J.P.R.), and Johns Hopkins University, Baltimore (E.D.M., L.H.M., K.N.W., W.C.) - both in Maryland; the Eagle Research Center, Kigali, Rwanda (A.M., F.N.); and Washington University in St. Louis, St. Louis (L.J.U.)
| | - Ashlinn Quinn
- From Emory University, Atlanta (T.F.C., H.H.C., L.M.T., K.S., D.B.B., Y.C., S.J., A.E.L., U.R., S.S.S., L.A.W., J.W.), and the University of Georgia, Athens (J.P.M., L.P.N.) - both in Georgia; the Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., V.A., S.G., K.M., N.P., S.S., G.T.); Universidad del Valle de Guatemala, Guatemala City (A.D.-A., A.C., L.M.); the London School of Hygiene and Tropical Medicine, London (G.R.), and the University of Oxford, Oxford (A. Papageorghiou) - both in the United Kingdom; the University of California, San Francisco, San Francisco (A.Y.), and the Berkeley Air Monitoring Group (M.A.J., R.P., A.Q.) and the University of California, Berkeley (A. Pillarisetti), Berkeley - all in California; Asociación Benéfica PRISMA (M.C.) and Universidad Peruana Cayetano Heredia (S.H.) - both in Lima, Peru; Colorado State University, Fort Collins (M.L.C., J.L.P.); the National Institutes of Health, Bethesda (D.-Y.K., J.P.R.), and Johns Hopkins University, Baltimore (E.D.M., L.H.M., K.N.W., W.C.) - both in Maryland; the Eagle Research Center, Kigali, Rwanda (A.M., F.N.); and Washington University in St. Louis, St. Louis (L.J.U.)
| | - Usha Ramakrishnan
- From Emory University, Atlanta (T.F.C., H.H.C., L.M.T., K.S., D.B.B., Y.C., S.J., A.E.L., U.R., S.S.S., L.A.W., J.W.), and the University of Georgia, Athens (J.P.M., L.P.N.) - both in Georgia; the Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., V.A., S.G., K.M., N.P., S.S., G.T.); Universidad del Valle de Guatemala, Guatemala City (A.D.-A., A.C., L.M.); the London School of Hygiene and Tropical Medicine, London (G.R.), and the University of Oxford, Oxford (A. Papageorghiou) - both in the United Kingdom; the University of California, San Francisco, San Francisco (A.Y.), and the Berkeley Air Monitoring Group (M.A.J., R.P., A.Q.) and the University of California, Berkeley (A. Pillarisetti), Berkeley - all in California; Asociación Benéfica PRISMA (M.C.) and Universidad Peruana Cayetano Heredia (S.H.) - both in Lima, Peru; Colorado State University, Fort Collins (M.L.C., J.L.P.); the National Institutes of Health, Bethesda (D.-Y.K., J.P.R.), and Johns Hopkins University, Baltimore (E.D.M., L.H.M., K.N.W., W.C.) - both in Maryland; the Eagle Research Center, Kigali, Rwanda (A.M., F.N.); and Washington University in St. Louis, St. Louis (L.J.U.)
| | - Sankar Sambandam
- From Emory University, Atlanta (T.F.C., H.H.C., L.M.T., K.S., D.B.B., Y.C., S.J., A.E.L., U.R., S.S.S., L.A.W., J.W.), and the University of Georgia, Athens (J.P.M., L.P.N.) - both in Georgia; the Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., V.A., S.G., K.M., N.P., S.S., G.T.); Universidad del Valle de Guatemala, Guatemala City (A.D.-A., A.C., L.M.); the London School of Hygiene and Tropical Medicine, London (G.R.), and the University of Oxford, Oxford (A. Papageorghiou) - both in the United Kingdom; the University of California, San Francisco, San Francisco (A.Y.), and the Berkeley Air Monitoring Group (M.A.J., R.P., A.Q.) and the University of California, Berkeley (A. Pillarisetti), Berkeley - all in California; Asociación Benéfica PRISMA (M.C.) and Universidad Peruana Cayetano Heredia (S.H.) - both in Lima, Peru; Colorado State University, Fort Collins (M.L.C., J.L.P.); the National Institutes of Health, Bethesda (D.-Y.K., J.P.R.), and Johns Hopkins University, Baltimore (E.D.M., L.H.M., K.N.W., W.C.) - both in Maryland; the Eagle Research Center, Kigali, Rwanda (A.M., F.N.); and Washington University in St. Louis, St. Louis (L.J.U.)
| | - Sheela S Sinharoy
- From Emory University, Atlanta (T.F.C., H.H.C., L.M.T., K.S., D.B.B., Y.C., S.J., A.E.L., U.R., S.S.S., L.A.W., J.W.), and the University of Georgia, Athens (J.P.M., L.P.N.) - both in Georgia; the Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., V.A., S.G., K.M., N.P., S.S., G.T.); Universidad del Valle de Guatemala, Guatemala City (A.D.-A., A.C., L.M.); the London School of Hygiene and Tropical Medicine, London (G.R.), and the University of Oxford, Oxford (A. Papageorghiou) - both in the United Kingdom; the University of California, San Francisco, San Francisco (A.Y.), and the Berkeley Air Monitoring Group (M.A.J., R.P., A.Q.) and the University of California, Berkeley (A. Pillarisetti), Berkeley - all in California; Asociación Benéfica PRISMA (M.C.) and Universidad Peruana Cayetano Heredia (S.H.) - both in Lima, Peru; Colorado State University, Fort Collins (M.L.C., J.L.P.); the National Institutes of Health, Bethesda (D.-Y.K., J.P.R.), and Johns Hopkins University, Baltimore (E.D.M., L.H.M., K.N.W., W.C.) - both in Maryland; the Eagle Research Center, Kigali, Rwanda (A.M., F.N.); and Washington University in St. Louis, St. Louis (L.J.U.)
| | - Gurusamy Thangavel
- From Emory University, Atlanta (T.F.C., H.H.C., L.M.T., K.S., D.B.B., Y.C., S.J., A.E.L., U.R., S.S.S., L.A.W., J.W.), and the University of Georgia, Athens (J.P.M., L.P.N.) - both in Georgia; the Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., V.A., S.G., K.M., N.P., S.S., G.T.); Universidad del Valle de Guatemala, Guatemala City (A.D.-A., A.C., L.M.); the London School of Hygiene and Tropical Medicine, London (G.R.), and the University of Oxford, Oxford (A. Papageorghiou) - both in the United Kingdom; the University of California, San Francisco, San Francisco (A.Y.), and the Berkeley Air Monitoring Group (M.A.J., R.P., A.Q.) and the University of California, Berkeley (A. Pillarisetti), Berkeley - all in California; Asociación Benéfica PRISMA (M.C.) and Universidad Peruana Cayetano Heredia (S.H.) - both in Lima, Peru; Colorado State University, Fort Collins (M.L.C., J.L.P.); the National Institutes of Health, Bethesda (D.-Y.K., J.P.R.), and Johns Hopkins University, Baltimore (E.D.M., L.H.M., K.N.W., W.C.) - both in Maryland; the Eagle Research Center, Kigali, Rwanda (A.M., F.N.); and Washington University in St. Louis, St. Louis (L.J.U.)
| | - Lindsay J Underhill
- From Emory University, Atlanta (T.F.C., H.H.C., L.M.T., K.S., D.B.B., Y.C., S.J., A.E.L., U.R., S.S.S., L.A.W., J.W.), and the University of Georgia, Athens (J.P.M., L.P.N.) - both in Georgia; the Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., V.A., S.G., K.M., N.P., S.S., G.T.); Universidad del Valle de Guatemala, Guatemala City (A.D.-A., A.C., L.M.); the London School of Hygiene and Tropical Medicine, London (G.R.), and the University of Oxford, Oxford (A. Papageorghiou) - both in the United Kingdom; the University of California, San Francisco, San Francisco (A.Y.), and the Berkeley Air Monitoring Group (M.A.J., R.P., A.Q.) and the University of California, Berkeley (A. Pillarisetti), Berkeley - all in California; Asociación Benéfica PRISMA (M.C.) and Universidad Peruana Cayetano Heredia (S.H.) - both in Lima, Peru; Colorado State University, Fort Collins (M.L.C., J.L.P.); the National Institutes of Health, Bethesda (D.-Y.K., J.P.R.), and Johns Hopkins University, Baltimore (E.D.M., L.H.M., K.N.W., W.C.) - both in Maryland; the Eagle Research Center, Kigali, Rwanda (A.M., F.N.); and Washington University in St. Louis, St. Louis (L.J.U.)
| | - Lance A Waller
- From Emory University, Atlanta (T.F.C., H.H.C., L.M.T., K.S., D.B.B., Y.C., S.J., A.E.L., U.R., S.S.S., L.A.W., J.W.), and the University of Georgia, Athens (J.P.M., L.P.N.) - both in Georgia; the Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., V.A., S.G., K.M., N.P., S.S., G.T.); Universidad del Valle de Guatemala, Guatemala City (A.D.-A., A.C., L.M.); the London School of Hygiene and Tropical Medicine, London (G.R.), and the University of Oxford, Oxford (A. Papageorghiou) - both in the United Kingdom; the University of California, San Francisco, San Francisco (A.Y.), and the Berkeley Air Monitoring Group (M.A.J., R.P., A.Q.) and the University of California, Berkeley (A. Pillarisetti), Berkeley - all in California; Asociación Benéfica PRISMA (M.C.) and Universidad Peruana Cayetano Heredia (S.H.) - both in Lima, Peru; Colorado State University, Fort Collins (M.L.C., J.L.P.); the National Institutes of Health, Bethesda (D.-Y.K., J.P.R.), and Johns Hopkins University, Baltimore (E.D.M., L.H.M., K.N.W., W.C.) - both in Maryland; the Eagle Research Center, Kigali, Rwanda (A.M., F.N.); and Washington University in St. Louis, St. Louis (L.J.U.)
| | - Jiantong Wang
- From Emory University, Atlanta (T.F.C., H.H.C., L.M.T., K.S., D.B.B., Y.C., S.J., A.E.L., U.R., S.S.S., L.A.W., J.W.), and the University of Georgia, Athens (J.P.M., L.P.N.) - both in Georgia; the Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., V.A., S.G., K.M., N.P., S.S., G.T.); Universidad del Valle de Guatemala, Guatemala City (A.D.-A., A.C., L.M.); the London School of Hygiene and Tropical Medicine, London (G.R.), and the University of Oxford, Oxford (A. Papageorghiou) - both in the United Kingdom; the University of California, San Francisco, San Francisco (A.Y.), and the Berkeley Air Monitoring Group (M.A.J., R.P., A.Q.) and the University of California, Berkeley (A. Pillarisetti), Berkeley - all in California; Asociación Benéfica PRISMA (M.C.) and Universidad Peruana Cayetano Heredia (S.H.) - both in Lima, Peru; Colorado State University, Fort Collins (M.L.C., J.L.P.); the National Institutes of Health, Bethesda (D.-Y.K., J.P.R.), and Johns Hopkins University, Baltimore (E.D.M., L.H.M., K.N.W., W.C.) - both in Maryland; the Eagle Research Center, Kigali, Rwanda (A.M., F.N.); and Washington University in St. Louis, St. Louis (L.J.U.)
| | - Kendra N Williams
- From Emory University, Atlanta (T.F.C., H.H.C., L.M.T., K.S., D.B.B., Y.C., S.J., A.E.L., U.R., S.S.S., L.A.W., J.W.), and the University of Georgia, Athens (J.P.M., L.P.N.) - both in Georgia; the Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., V.A., S.G., K.M., N.P., S.S., G.T.); Universidad del Valle de Guatemala, Guatemala City (A.D.-A., A.C., L.M.); the London School of Hygiene and Tropical Medicine, London (G.R.), and the University of Oxford, Oxford (A. Papageorghiou) - both in the United Kingdom; the University of California, San Francisco, San Francisco (A.Y.), and the Berkeley Air Monitoring Group (M.A.J., R.P., A.Q.) and the University of California, Berkeley (A. Pillarisetti), Berkeley - all in California; Asociación Benéfica PRISMA (M.C.) and Universidad Peruana Cayetano Heredia (S.H.) - both in Lima, Peru; Colorado State University, Fort Collins (M.L.C., J.L.P.); the National Institutes of Health, Bethesda (D.-Y.K., J.P.R.), and Johns Hopkins University, Baltimore (E.D.M., L.H.M., K.N.W., W.C.) - both in Maryland; the Eagle Research Center, Kigali, Rwanda (A.M., F.N.); and Washington University in St. Louis, St. Louis (L.J.U.)
| | - Joshua P Rosenthal
- From Emory University, Atlanta (T.F.C., H.H.C., L.M.T., K.S., D.B.B., Y.C., S.J., A.E.L., U.R., S.S.S., L.A.W., J.W.), and the University of Georgia, Athens (J.P.M., L.P.N.) - both in Georgia; the Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., V.A., S.G., K.M., N.P., S.S., G.T.); Universidad del Valle de Guatemala, Guatemala City (A.D.-A., A.C., L.M.); the London School of Hygiene and Tropical Medicine, London (G.R.), and the University of Oxford, Oxford (A. Papageorghiou) - both in the United Kingdom; the University of California, San Francisco, San Francisco (A.Y.), and the Berkeley Air Monitoring Group (M.A.J., R.P., A.Q.) and the University of California, Berkeley (A. Pillarisetti), Berkeley - all in California; Asociación Benéfica PRISMA (M.C.) and Universidad Peruana Cayetano Heredia (S.H.) - both in Lima, Peru; Colorado State University, Fort Collins (M.L.C., J.L.P.); the National Institutes of Health, Bethesda (D.-Y.K., J.P.R.), and Johns Hopkins University, Baltimore (E.D.M., L.H.M., K.N.W., W.C.) - both in Maryland; the Eagle Research Center, Kigali, Rwanda (A.M., F.N.); and Washington University in St. Louis, St. Louis (L.J.U.)
| | - William Checkley
- From Emory University, Atlanta (T.F.C., H.H.C., L.M.T., K.S., D.B.B., Y.C., S.J., A.E.L., U.R., S.S.S., L.A.W., J.W.), and the University of Georgia, Athens (J.P.M., L.P.N.) - both in Georgia; the Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., V.A., S.G., K.M., N.P., S.S., G.T.); Universidad del Valle de Guatemala, Guatemala City (A.D.-A., A.C., L.M.); the London School of Hygiene and Tropical Medicine, London (G.R.), and the University of Oxford, Oxford (A. Papageorghiou) - both in the United Kingdom; the University of California, San Francisco, San Francisco (A.Y.), and the Berkeley Air Monitoring Group (M.A.J., R.P., A.Q.) and the University of California, Berkeley (A. Pillarisetti), Berkeley - all in California; Asociación Benéfica PRISMA (M.C.) and Universidad Peruana Cayetano Heredia (S.H.) - both in Lima, Peru; Colorado State University, Fort Collins (M.L.C., J.L.P.); the National Institutes of Health, Bethesda (D.-Y.K., J.P.R.), and Johns Hopkins University, Baltimore (E.D.M., L.H.M., K.N.W., W.C.) - both in Maryland; the Eagle Research Center, Kigali, Rwanda (A.M., F.N.); and Washington University in St. Louis, St. Louis (L.J.U.)
| | - Jennifer L Peel
- From Emory University, Atlanta (T.F.C., H.H.C., L.M.T., K.S., D.B.B., Y.C., S.J., A.E.L., U.R., S.S.S., L.A.W., J.W.), and the University of Georgia, Athens (J.P.M., L.P.N.) - both in Georgia; the Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., V.A., S.G., K.M., N.P., S.S., G.T.); Universidad del Valle de Guatemala, Guatemala City (A.D.-A., A.C., L.M.); the London School of Hygiene and Tropical Medicine, London (G.R.), and the University of Oxford, Oxford (A. Papageorghiou) - both in the United Kingdom; the University of California, San Francisco, San Francisco (A.Y.), and the Berkeley Air Monitoring Group (M.A.J., R.P., A.Q.) and the University of California, Berkeley (A. Pillarisetti), Berkeley - all in California; Asociación Benéfica PRISMA (M.C.) and Universidad Peruana Cayetano Heredia (S.H.) - both in Lima, Peru; Colorado State University, Fort Collins (M.L.C., J.L.P.); the National Institutes of Health, Bethesda (D.-Y.K., J.P.R.), and Johns Hopkins University, Baltimore (E.D.M., L.H.M., K.N.W., W.C.) - both in Maryland; the Eagle Research Center, Kigali, Rwanda (A.M., F.N.); and Washington University in St. Louis, St. Louis (L.J.U.)
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Haque S, Kirby MA, Iyakaremye L, Gebremariam A, Tessema G, Thomas E, Chang HH, Clasen T. Effects of adding household water filters to Rwanda's Community-Based Environmental Health Promotion Programme: a cluster-randomized controlled trial in Rwamagana district. NPJ Clean Water 2022; 5:42. [PMID: 36118619 PMCID: PMC9464616 DOI: 10.1038/s41545-022-00185-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Accepted: 08/19/2022] [Indexed: 06/15/2023]
Abstract
Unsafe drinking water remains a major cause of mortality and morbidity. While Rwanda's Community-Based Environmental Health Promotion Programme (CBEHPP) promotes boiling and safe storage, previous research found these efforts to be ineffective in reducing fecal contamination of drinking water. We conducted a cluster randomized control led trial to determine if adding a household water filter with safe storage to the CBEHPP would improve drinking water quality and reduce child diarrhea. We enrolled 1,199 households with a pregnant person or child under 5 across 60 randomly selected villages in Rwamagana district. CBEHPP implementers distributed and promoted water purifiers to a random half of villages. We conducted two unannounced follow-up visits over 13-16 months after the intervention delivery. The intervention reduced the proportions of households with detectable E. coli in drinking water samples (primary outcome) by 20% (PR 0.80, 95% CI 0.74-0.87, p < 0.001) and with moderate and higher fecal contamination (≥10 CFU/100 mL) by 35% (PR 0.65, 95% CI 0.57-0.74, p < 0.001). The proportion of children under 5 experiencing diarrhea in the last week was reduced by 49% (aPR 0.51, 95%CI 0.35-0.73, p < 0.001). Our findings identify an effective intervention for improving water quality and child health that can be added to the CBEHPP.
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Affiliation(s)
- Sabrina Haque
- Gangarosa Department of Environmental Health, Emory University Rollins School of Public Health, Atlanta, GA USA
| | - Miles A. Kirby
- Gangarosa Department of Environmental Health, Emory University Rollins School of Public Health, Atlanta, GA USA
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA USA
| | | | | | | | - Evan Thomas
- Mortenson Center in Global Engineering, University of Colorado, Boulder, CO USA
| | - Howard H. Chang
- Gangarosa Department of Environmental Health, Emory University Rollins School of Public Health, Atlanta, GA USA
| | - Thomas Clasen
- Gangarosa Department of Environmental Health, Emory University Rollins School of Public Health, Atlanta, GA USA
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15
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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. Environ Health Perspect 2022; 130:97005. [PMID: 36112539 PMCID: PMC9480977 DOI: 10.1289/ehp10295] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [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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16
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Hennessee I, Kirby MA, Misago X, Mupfasoni J, Clasen T, Kitron U, Rosenthal JP, Hakizimana E. Assessing the Effects of Cooking Fuels on Anopheles Mosquito Behavior: An Experimental Study in Rural Rwanda. Am J Trop Med Hyg 2022; 106:1196-1208. [PMID: 35189594 PMCID: PMC8991336 DOI: 10.4269/ajtmh.21-0997] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Accepted: 11/17/2021] [Indexed: 11/07/2022] Open
Abstract
Globally, cleaner cooking fuels are increasingly promoted to reduce household air pollution. However, there is concern that reductions in smoke from biomass fuels could lead to more favorable conditions for mosquitoes and potentially increase vectorborne disease risk. We investigated household entry, host-seeking, household exit, and mortality among Anopheles mosquitoes across three cooking fuel types: wood, charcoal, and liquid petroleum gas (LPG) in six experimental huts in Rwanda. Fifty laboratory-reared Anopheles gambiae mosquitoes were released each night in entry compartments outside each hut, and fuels were burned for 1 hour in the hut verandas. Collectors conducted human landing catch during cooking and for 2 hours afterward, and CDC light traps were used for the rest of the night to measure host-seeking. Differences in each outcome were assessed using generalized linear mixed models with random effects for hut, collector, and day. Cooking with LPG compared with wood and charcoal was associated with substantial increases in household entry and host-seeking. Household exit was not significantly different across fuels, and mortality was lower in LPG-burning huts compared with wood. Although these results are not directly generalizable to field conditions, they indicate a potential for clean fuel adoption to increase exposure to Anopheles mosquitoes compared with traditional biomass fuels. Additional entomological and epidemiological studies are needed to investigate changes in disease vector exposure associated with clean fuel adoption, and evaluate whether enhanced vector control interventions should be promoted in tandem with cleaner cooking fuels.
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Affiliation(s)
- Ian Hennessee
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Miles A. Kirby
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts
| | - Xavier Misago
- Malaria and other Parasitic Diseases Division, Rwanda Biomedical Center, Ministry of Health, Kigali, Rwanda
| | - Jackie Mupfasoni
- Malaria and other Parasitic Diseases Division, Rwanda Biomedical Center, Ministry of Health, Kigali, Rwanda
| | - Thomas Clasen
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Uriel Kitron
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia
- Department of Environmental Sciences, Emory University, Atlanta, Georgia
| | - Joshua P. Rosenthal
- Fogarty International Center, National Institutes of Health, Bethesda, Maryland
| | - Emmanuel Hakizimana
- Malaria and other Parasitic Diseases Division, Rwanda Biomedical Center, Ministry of Health, Kigali, Rwanda
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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. Int J Environ Res 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] [What about the content of this article? (0)] [Affiliation(s)] [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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18
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Simkovich SM, Underhill LJ, Kirby MA, Crocker ME, Goodman D, McCracken JP, Thompson LM, Diaz-Artiga A, Castañaza-Gonzalez A, Garg SS, Balakrishnan K, Thangavel G, Rosa G, Peel JL, Clasen TF, McCollum ED, Checkley W. Resources and Geographic Access to Care for Severe Pediatric Pneumonia in Four Resource-limited Settings. Am J Respir Crit Care Med 2022; 205:183-197. [PMID: 34662531 PMCID: PMC8787246 DOI: 10.1164/rccm.202104-1013oc] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Accepted: 10/14/2021] [Indexed: 11/16/2022] Open
Abstract
Rationale: Pneumonia is the leading cause of death in children worldwide. Identifying and appropriately managing severe pneumonia in a timely manner improves outcomes. Little is known about the readiness of healthcare facilities to manage severe pediatric pneumonia in low-resource settings. Objectives: As part of the HAPIN (Household Air Pollution Intervention Network) trial, we sought to identify healthcare facilities that were adequately resourced to manage severe pediatric pneumonia in Jalapa, Guatemala (J-GUA); Puno, Peru (P-PER); Kayonza, Rwanda (K-RWA); and Tamil Nadu, India (T-IND). We conducted a facility-based survey of available infrastructure, staff, equipment, and medical consumables. Facilities were georeferenced, and a road network analysis was performed. Measurements and Main Results: Of the 350 healthcare facilities surveyed, 13% had adequate resources to manage severe pneumonia, 37% had pulse oximeters, and 44% had supplemental oxygen. Mean (±SD) travel time to an adequately resourced facility was 41 ± 19 minutes in J-GUA, 99 ± 64 minutes in P-PER, 40 ± 19 minutes in K-RWA, and 31 ± 19 minutes in T-IND. Expanding pulse oximetry coverage to all facilities reduced travel time by 44% in J-GUA, 29% in P-PER, 29% in K-RWA, and 11% in T-IND (all P < 0.001). Conclusions: Most healthcare facilities in low-resource settings of the HAPIN study area were inadequately resourced to care for severe pediatric pneumonia. Early identification of cases and timely referral is paramount. The provision of pulse oximeters to all health facilities may be an effective approach to identify cases earlier and refer them for care and in a timely manner.
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Affiliation(s)
- Suzanne M. Simkovich
- Division of Pulmonary and Critical Care
- Center for Global Non-Communicable Disease Research and Training, and
- Medstar Health Research Institute, Hyattsville, Maryland
| | - Lindsay J. Underhill
- Division of Pulmonary and Critical Care
- Center for Global Non-Communicable Disease Research and Training, and
| | - Miles A. Kirby
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Harvard University, Boston, Massachusetts
| | - Mary E. Crocker
- Division of Pulmonary and Sleep Medicine, Seattle Children’s Hospital and School of Medicine, University of Washington, Seattle, Washington
| | - Dina Goodman
- Division of Pulmonary and Critical Care
- Center for Global Non-Communicable Disease Research and Training, and
| | - John P. McCracken
- Global Health Institute, Department of Epidemiology and Biostatistics, College of Public Health, University of Georgia, Athens, Georgia
| | | | - Anaité Diaz-Artiga
- Centro de Estudios de la Salud, Universidad del Valle de Guatemala, Guatemala City, Guatemala
| | - Adly Castañaza-Gonzalez
- Centro de Estudios de la Salud, Universidad del Valle de Guatemala, Guatemala City, Guatemala
| | - Sarada S. Garg
- Department of Environmental Health Engineering, ICMR Center for Advanced Research on Air Quality, Climate and Health, Sri Ramachandra Medical College and Research Institute (Deemed University), Chennai, Tamil Nadu, India
| | - 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 (Deemed University), Chennai, Tamil Nadu, India
| | - Gurusamy Thangavel
- Department of Environmental Health Engineering, ICMR Center for Advanced Research on Air Quality, Climate and Health, Sri Ramachandra Medical College and Research Institute (Deemed University), Chennai, Tamil Nadu, India
| | - Ghislaine Rosa
- Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom; and
| | - Jennifer L. Peel
- Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins, Colorado
| | - Thomas F. Clasen
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Eric D. McCollum
- Eudowood Division of Pediatric Respiratory Sciences and
- Global Program for Pediatric Respiratory Sciences, Department of Pediatrics, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - William Checkley
- Division of Pulmonary and Critical Care
- Center for Global Non-Communicable Disease Research and Training, and
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19
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Liao J, Kirby MA, Pillarisetti A, Piedrahita R, Balakrishnan K, Sambandam S, Mukhopadhyay K, Ye W, Rosa G, Majorin F, Dusabimana E, Ndagijimana F, McCracken JP, Mollinedo E, de Leon O, Díaz-Artiga A, Thompson LM, Kearns KA, Naeher L, Rosenthal J, Clark ML, Steenland K, Waller LA, Checkley W, Peel JL, Clasen T, Johnson M. LPG stove and fuel intervention among pregnant women reduce fine particle air pollution exposures in three countries: Pilot results from the HAPIN trial. Environ Pollut 2021; 291:118198. [PMID: 34740288 PMCID: PMC8593210 DOI: 10.1016/j.envpol.2021.118198] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 09/14/2021] [Accepted: 09/16/2021] [Indexed: 05/26/2023]
Abstract
The Household Air Pollution Intervention Network trial is a multi-country study on the effects of a liquefied petroleum gas (LPG) stove and fuel distribution intervention on women's and children's health. There is limited data on exposure reductions achieved by switching from solid to clean cooking fuels in rural settings across multiple countries. As formative research in 2017, we recruited pregnant women and characterized the impact of the intervention on personal exposures and kitchen levels of fine particulate matter (PM2.5) in Guatemala, India, and Rwanda. Forty pregnant women were enrolled in each site. We measured cooking area concentrations of and personal exposures to PM2.5 for 24 or 48 h using gravimetric-based PM2.5 samplers at baseline and two follow-ups over two months after delivery of an LPG cookstove and free fuel supply. Mixed models were used to estimate PM2.5 reductions. Median kitchen PM2.5 concentrations were 296 μg/m3 at baseline (interquartile range, IQR: 158-507), 24 μg/m3 at first follow-up (IQR: 18-37), and 23 μg/m3 at second follow-up (IQR: 14-37). Median personal exposures to PM2.5 were 134 μg/m3 at baseline (IQR: 71-224), 35 μg/m3 at first follow-up (IQR: 23-51), and 32 μg/m3 at second follow-up (IQR: 23-47). Overall, the LPG intervention was associated with a 92% (95% confidence interval (CI): 90-94%) reduction in kitchen PM2.5 concentrations and a 74% (95% CI: 70-79%) reduction in personal PM2.5 exposures. Results were similar for each site. CONCLUSIONS: The intervention was associated with substantial reductions in kitchen and personal PM2.5 overall and in all sites. Results suggest LPG interventions in these rural settings may lower exposures to the WHO annual interim target-1 of 35 μg/m3. The range of exposure contrasts falls on steep sections of estimated exposure-response curves for birthweight, blood pressure, and acute lower respiratory infections, implying potentially important health benefits when transitioning from solid fuels to LPG.
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Affiliation(s)
- Jiawen Liao
- Gangarosa Department of Environmental Health, Emory University Rollins School of Public Health, Atlanta, GA, USA; Department of Population and Public Health Sciences, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Miles A Kirby
- Gangarosa Department of Environmental Health, Emory University Rollins School of Public Health, Atlanta, GA, USA; Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Ajay Pillarisetti
- Gangarosa Department of Environmental Health, Emory University Rollins School of Public Health, Atlanta, GA, USA; School of Public Health, University of California, Berkeley, CA, USA
| | | | - Kalpana Balakrishnan
- SRU-ICMR Center for Advanced Research on Air Quality, Climate and Health, Sri Ramachandra Institute of Higher Education and Research, Chennai, India
| | - Sankar Sambandam
- SRU-ICMR Center for Advanced Research on Air Quality, Climate and Health, Sri Ramachandra Institute of Higher Education and Research, Chennai, India
| | - Krishnendu Mukhopadhyay
- SRU-ICMR Center for Advanced Research on Air Quality, Climate and Health, Sri Ramachandra Institute of Higher Education and Research, Chennai, India
| | - Wenlu Ye
- Gangarosa Department of Environmental Health, Emory University Rollins School of Public Health, Atlanta, GA, USA
| | - Ghislaine Rosa
- London School of Hygiene and Tropical Medicine, London, UK
| | - Fiona Majorin
- London School of Hygiene and Tropical Medicine, London, UK
| | | | | | - John P McCracken
- Center for Health Studies, Universidad del Valle De Guatemala, Guatemala City, Guatemala; College of Public Health, University of Georgia, Athens, GA, USA
| | - Erick Mollinedo
- Center for Health Studies, Universidad del Valle De Guatemala, Guatemala City, Guatemala; College of Public Health, University of Georgia, Athens, GA, USA
| | - Oscar de Leon
- Gangarosa Department of Environmental Health, Emory University Rollins School of Public Health, Atlanta, GA, USA; Center for Health Studies, Universidad del Valle De Guatemala, Guatemala City, Guatemala
| | - Anaité Díaz-Artiga
- Center for Health Studies, Universidad del Valle De Guatemala, Guatemala City, Guatemala
| | - Lisa M Thompson
- Gangarosa Department of Environmental Health, Emory University Rollins School of Public Health, Atlanta, GA, USA; Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA, USA
| | | | - Luke Naeher
- College of Public Health, University of Georgia, Athens, GA, USA
| | - Joshua Rosenthal
- Fogarty International Center, National Institutes of Health, Bethesda, MD, USA
| | - Maggie L Clark
- Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins, CO, USA
| | - Kyle Steenland
- Gangarosa Department of Environmental Health, Emory University Rollins School of Public Health, Atlanta, GA, USA
| | - Lance A Waller
- Gangarosa Department of Environmental Health, Emory University Rollins School of Public Health, Atlanta, GA, USA
| | - William Checkley
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, MD, USA; Center for Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Jennifer L Peel
- Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins, CO, USA
| | - Thomas Clasen
- Gangarosa Department of Environmental Health, Emory University Rollins School of Public Health, Atlanta, GA, USA
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20
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Quinn AK, Williams KN, Thompson LM, Harvey SA, Piedrahita R, Wang J, Quinn C, Pillarisetti A, McCracken JP, Rosenthal JP, Kirby MA, Diaz Artiga A, Thangavel G, Rosa G, Miranda JJ, Checkley W, Peel JL, Clasen TF. Fidelity and Adherence to a Liquefied Petroleum Gas Stove and Fuel Intervention during Gestation: The Multi-Country Household Air Pollution Intervention Network (HAPIN) Randomized Controlled Trial. Int J Environ Res Public Health 2021; 18:12592. [PMID: 34886324 PMCID: PMC8656791 DOI: 10.3390/ijerph182312592] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 11/16/2021] [Accepted: 11/17/2021] [Indexed: 12/25/2022]
Abstract
BACKGROUND Clean cookstove interventions can theoretically reduce exposure to household air pollution and benefit health, but this requires near-exclusive use of these types of stoves with the simultaneous disuse of traditional stoves. Previous cookstove trials have reported low adoption of new stoves and/or extensive continued traditional stove use. METHODS The Household Air Pollution Intervention Network (HAPIN) trial randomized 3195 pregnant women in Guatemala, India, Peru, and Rwanda to either a liquefied petroleum gas (LPG) stove and fuel intervention (n = 1590) or to a control (n = 1605). The intervention consisted of an LPG stove and two initial cylinders of LPG, free fuel refills delivered to the home, and regular behavioral messaging. We assessed intervention fidelity (delivery of the intervention as intended) and adherence (intervention use) through to the end of gestation, as relevant to the first primary health outcome of the trial: infant birth weight. Fidelity and adherence were evaluated using stove and fuel delivery records, questionnaires, visual observations, and temperature-logging stove use monitors (SUMs). RESULTS 1585 women received the intervention at a median (interquartile range) of 8.0 (5.0-15.0) days post-randomization and had a gestational age of 17.9 (15.4-20.6) weeks. Over 96% reported cooking exclusively with LPG at two follow-up visits during pregnancy. Less than 4% reported ever running out of LPG. Complete abandonment of traditional stove cooking was observed in over 67% of the intervention households. Of the intervention households, 31.4% removed their traditional stoves upon receipt of the intervention; among those who retained traditional stoves, the majority did not use them: traditional stove use was detected via SUMs on a median (interquartile range) of 0.0% (0.0%, 1.6%) of follow-up days (median follow-up = 134 days). CONCLUSIONS The fidelity of the HAPIN intervention, as measured by stove installation, timely ongoing fuel deliveries, and behavioral reinforcement as needed, was high. Exclusive use of the intervention during pregnancy was also high.
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Affiliation(s)
- Ashlinn K. Quinn
- Fogarty International Center, National Institutes of Health, Bethesda, MD 20892, USA
- Berkeley Air Monitoring Group, Fort Collins, CO 80524, USA;
| | - Kendra N. Williams
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, MD 21287, USA; (K.N.W.); (W.C.)
- Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore, MD 21287, USA
| | - Lisa M. Thompson
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA 30322, USA;
| | - Steven A. Harvey
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA;
| | | | - Jiantong Wang
- Rollins School of Public Health, Emory University, Atlanta, GA 30322, USA; (J.W.); (A.P.); (T.F.C.)
| | - Casey Quinn
- Department of Mechanical Engineering, Colorado State University, Fort Collins, CO 80523, USA;
| | - Ajay Pillarisetti
- Rollins School of Public Health, Emory University, Atlanta, GA 30322, USA; (J.W.); (A.P.); (T.F.C.)
| | - John P. McCracken
- Department of Epidemiology and Biostatistics, Global Health Institute, College of Public Health, University of Georgia, Athens, GA 30606, USA;
- Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City 01015, Guatemala;
| | - Joshua P. Rosenthal
- Fogarty International Center, National Institutes of Health, Bethesda, MD 20892, USA
| | - Miles A. Kirby
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA 02115, USA;
| | - Anaité Diaz Artiga
- Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City 01015, Guatemala;
| | - Gurusamy Thangavel
- Department of Environmental Health Engineering, Faculty of Public Health, Sri Ramachandra Institute for Higher Education and Research, Porur, Chennai 600116, India;
| | - Ghislaine Rosa
- Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK;
| | - J. Jaime Miranda
- Department of Medicine, School of Medicine, Universidad Peruana Cayetano Heredia, Lima 15102, Peru;
- CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima 15074, Peru
| | - William Checkley
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, MD 21287, USA; (K.N.W.); (W.C.)
- Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore, MD 21287, USA
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA;
| | - Jennifer L. Peel
- Department of Environmental & Radiological Health Sciences, Colorado State University, Fort Collins, CO 80523, USA;
| | - Thomas F. Clasen
- Rollins School of Public Health, Emory University, Atlanta, GA 30322, USA; (J.W.); (A.P.); (T.F.C.)
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21
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Simkovich SM, Thompson LM, Clark ML, Balakrishnan K, Bussalleu A, Checkley W, Clasen T, Davila-Roman VG, Diaz-Artiga A, Dusabimana E, Fuentes LDL, Harvey S, Kirby MA, Lovvorn A, McCollum ED, Mollinedo EE, Peel JL, Quinn A, Rosa G, Underhill LJ, Williams KN, Young BN, Rosenthal J. A risk assessment tool for resumption of research activities during the COVID-19 pandemic for field trials in low resource settings. BMC Med Res Methodol 2021; 21:68. [PMID: 33845785 PMCID: PMC8040756 DOI: 10.1186/s12874-021-01232-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Accepted: 02/17/2021] [Indexed: 12/14/2022] Open
Abstract
RATIONALE The spread of severe acute respiratory syndrome coronavirus-2 has suspended many non-COVID-19 related research activities. Where restarting research activities is permitted, investigators need to evaluate the risks and benefits of resuming data collection and adapt procedures to minimize risk. OBJECTIVES In the context of the multicountry Household Air Pollution Intervention (HAPIN) trial conducted in rural, low-resource settings, we developed a framework to assess the risk of each trial activity and to guide protective measures. Our goal is to maximize the integrity of reseach aims while minimizing infection risk based on the latest scientific understanding of the virus. METHODS We drew on a combination of expert consultations, risk assessment frameworks, institutional guidance and literature to develop our framework. We then systematically graded clinical, behavioral, laboratory and field environmental health research activities in four countries for both adult and child subjects using this framework. National and local government recommendations provided the minimum safety guidelines for our work. RESULTS Our framework assesses risk based on staff proximity to the participant, exposure time between staff and participants, and potential viral aerosolization while performing the activity. For each activity, one of four risk levels, from minimal to unacceptable, is assigned and guidance on protective measures is provided. Those activities that can potentially aerosolize the virus are deemed the highest risk. CONCLUSIONS By applying a systematic, procedure-specific approach to risk assessment for each trial activity, we were able to protect our participants and research team and to uphold our ability to deliver on the research commitments we have made to our staff, participants, local communities, and funders. This framework can be tailored to other research studies conducted in similar settings during the current pandemic, as well as potential future outbreaks with similar transmission dynamics. The trial is registered with clinicaltrials.gov NCT02944682 on October 26. 2016 .
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Affiliation(s)
- Suzanne M Simkovich
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, USA.
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, USA.
- MedStar Health Research Institute, Hyattsville, USA.
| | - Lisa M Thompson
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, USA
| | - Maggie L Clark
- Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins, USA
| | - 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
| | - Alejandra Bussalleu
- A.B. PRISMA, San Miguel, Peru
- CLIMA - Latin American Center of Excellence in Climate Change and Health; and Intercultural Citizenship and Indigenous Health Unit, Faculty of Public Health and Administration, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - William Checkley
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, USA
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, USA
| | - Thomas Clasen
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, USA
| | - Victor G Davila-Roman
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St. Louis, USA
| | - Anaite Diaz-Artiga
- Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala
| | | | - Lisa de Las Fuentes
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St. Louis, USA
| | - Steven Harvey
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, USA
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, USA
| | - Miles A Kirby
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Amy Lovvorn
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, USA
| | - Eric D McCollum
- Global Program for Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences, Department of Pediatrics, School of Medicine, Johns Hopkins University, Baltimore, USA
| | - Erick E Mollinedo
- Department of Environmental Health Science, College of Public Health, University of Georgia, Athens, USA
| | - Jennifer L Peel
- Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins, USA
| | - Ashlinn Quinn
- Division of International Epidemiology and Population Studies, Fogarty International Center, National Institutes of Health, Bethesda, USA
| | - Ghislaine Rosa
- Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | - Lindsay J Underhill
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, USA
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, USA
| | - Kendra N Williams
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, USA
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, USA
| | - Bonnie N Young
- Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins, USA
| | - Joshua Rosenthal
- Division of International Epidemiology and Population Studies, Fogarty International Center, National Institutes of Health, Bethesda, USA
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22
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Ahmed S, Mvalo T, Akech S, Agweyu A, Baker K, Bar-Zeev N, Campbell H, Checkley W, Chisti MJ, Colbourn T, Cunningham S, Duke T, English M, Falade AG, Fancourt NS, Ginsburg AS, Graham HR, Gray DM, Gupta M, Hammitt L, Hesseling AC, Hooli S, Johnson AWB, King C, Kirby MA, Lanata CF, Lufesi N, Mackenzie GA, McCracken JP, Moschovis PP, Nair H, Oviawe O, Pomat WS, Santosham M, Seddon JA, Thahane LK, Wahl B, Van der Zalm M, Verwey C, Yoshida LM, Zar HJ, Howie SR, McCollum ED. Protecting children in low-income and middle-income countries from COVID-19. BMJ Glob Health 2020; 5:bmjgh-2020-002844. [PMID: 32461228 PMCID: PMC7254117 DOI: 10.1136/bmjgh-2020-002844] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 05/08/2020] [Indexed: 02/03/2023] Open
Affiliation(s)
- Salahuddin Ahmed
- Projahnmo Research Foundation, Dhaka, Bangladesh.,NIHR Global Health Unit on Respiratory Health (RESPIRE), London, United Kingdom
| | - Tisungane Mvalo
- University of North Carolina Project Malawi, Lilongwe, Malawi.,Department of Pediatrics, University of North Carolina-Chapel Hill, Chapel Hill, North Carolina, USA
| | - Samuel Akech
- KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | | | | | - Naor Bar-Zeev
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Harry Campbell
- NIHR Global Health Unit on Respiratory Health (RESPIRE), London, United Kingdom.,Center for Global Health, Usher Institute, University of Edinburgh Medical School, Edinburgh, United Kingdom
| | - William Checkley
- Division of Pulmonary and Critical Care, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Mohammod Jobayer Chisti
- Dhaka Hospital, Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease and Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Tim Colbourn
- Global Health Institute, University College London, London, United Kingdom
| | - Steve Cunningham
- NIHR Global Health Unit on Respiratory Health (RESPIRE), London, United Kingdom.,Centre for Inflammation Research, University of Edinburgh, Edinburgh, United Kingdom
| | - Trevor Duke
- Paediatric Intensive Care Unit, Royal Children's Hospital, Melbourne, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia.,School of Medicine and Health Sciences, University of Papua New Guinea, Goroka, Papua New Guinea
| | - Mike English
- KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya.,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxfordshire, United Kingdom
| | - Adegoke G Falade
- Division of Paediatric Pulmonology, Department of Paediatrics, College of Medicine and University College Hospital, Ibadan, Nigeria
| | - Nicholas Ss Fancourt
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
| | - Amy S Ginsburg
- Clinical Trial Center, University of Washington, Seattle, United States
| | - Hamish R Graham
- Centre for International Child Health, MCRI, University of Melbourne, Melbourne, Victoria, Australia.,Department of Paediatrics, University College Hospital Ibadan, Ibadan, Nigeria
| | - Diane M Gray
- Division Paediatric Pulmonology, Department of Paediatrics, University of Cape Town, Cape Town, South Africa
| | - Madhu Gupta
- Department of Community Medicine and School of Public Health, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Laura Hammitt
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Anneke C Hesseling
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Shubhada Hooli
- Department of Pediatrics, Section of Pediatric Emergency Medicine, Baylor College of Medicine, Houston, United States
| | - Abdul-Wahab Br Johnson
- Pulmonology & Infectious Disease Unit, Department of Paediatrics & Child Health, University of Ilorin/University of Ilorin Teaching Hospital, Ilorin, Nigeria
| | - Carina King
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Miles A Kirby
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States.,Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, United States
| | - Claudio F Lanata
- Instituto de Investigación Nutricional, Lima, Peru.,Department of Pediatrics, School of Medicine, Vanderbilt University, Nashville, Tennessee, United States
| | - Norman Lufesi
- Community Health Sciences Unit, Malawi Ministry of Health, Lilongwe, Malawi
| | - Grant A Mackenzie
- MRC Unit, The Gambia at LSHTM, Fajara, Gambia.,Faculty of Infectious & Tropical Diseases, LSHTM, London, United Kingdom.,Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - John P McCracken
- Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala
| | - Peter P Moschovis
- Divisions of Pulmonary Medicine and Global Health, Department of Pediatrics, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Harish Nair
- NIHR Global Health Unit on Respiratory Health (RESPIRE), London, United Kingdom.,Center for Global Health, Usher Institute, University of Edinburgh Medical School, Edinburgh, United Kingdom
| | - Osawaru Oviawe
- Department of Child Health, University of Benin Teaching Hospital, Benin City, Nigeria
| | - William S Pomat
- Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea
| | - Mathuram Santosham
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - James A Seddon
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa.,Department of Infectious Diseases, Imperial College London, London, United Kingdom
| | - Lineo Keneuoe Thahane
- Baylor College of Medicine Children's Foundation - Lesotho, Maseru, Lesotho.,Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA.,The International Pediatric AIDS Initiative (BIPAI) at Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Brian Wahl
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Marieke Van der Zalm
- Department of Paediatrics and Child Health, Stellenbosch University, Cape Town, South Africa
| | - Charl Verwey
- Division of Paediatric Pulmonology, Department of Paediatrics, Chris Hani Baragwanath Academic Hospital, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,Respiratory and Meningeal Pathogens Research Unit, Medical Research Council, University of the Witwatersrand, Johannesburg, South Africa
| | - Lay-Myint Yoshida
- Department of Pediatric Infectious Diseases, Institute of Tropical Medicine, Nagasaki University, Nagasaki, Japan
| | - Heather J Zar
- Department of Paediatrics and Child Health, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa.,SA-MRC Unit on Child and Adolescent Health, University of Cape Town, Cape Town, South Africa
| | - Stephen Rc Howie
- Department of Paediatrics: Child & Youth Health, University of Auckland, Auckland, New Zealand
| | - Eric D McCollum
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA .,Johns Hopkins Global Program in Pediatric Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
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23
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Johnson MA, Steenland K, Piedrahita R, Clark ML, Pillarisetti A, Balakrishnan K, Peel JL, Naeher LP, Liao J, Wilson D, Sarnat J, Underhill LJ, Burrowes V, McCracken JP, Rosa G, Rosenthal J, Sambandam S, de Leon O, Kirby MA, Kearns K, Checkley W, Clasen T. Air Pollutant Exposure and Stove Use Assessment Methods for the Household Air Pollution Intervention Network (HAPIN) Trial. Environ Health Perspect 2020; 128:47009. [PMID: 32347764 PMCID: PMC7228125 DOI: 10.1289/ehp6422] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Revised: 03/27/2020] [Accepted: 04/01/2020] [Indexed: 05/05/2023]
Abstract
BACKGROUND High quality personal exposure data is fundamental to understanding the health implications of household energy interventions, interpreting analyses across assigned study arms, and characterizing exposure-response relationships for household air pollution. This paper describes the exposure data collection for the Household Air Pollution Intervention Network (HAPIN), a multicountry randomized controlled trial of liquefied petroleum gas stoves and fuel among 3,200 households in India, Rwanda, Guatemala, and Peru. OBJECTIVES The primary objectives of the exposure assessment are to estimate the exposure contrast achieved following a clean fuel intervention and to provide data for analyses of exposure-response relationships across a range of personal exposures. METHODS Exposure measurements are being conducted over the 3-y time frame of the field study. We are measuring fine particulate matter [PM < 2.5 μ m in aerodynamic diameter (PM 2.5 )] with the Enhanced Children's MicroPEM™ (RTI International), carbon monoxide (CO) with the USB-EL-CO (Lascar Electronics), and black carbon with the OT21 transmissometer (Magee Scientific) in pregnant women, adult women, and children < 1 year of age, primarily via multiple 24-h personal assessments (three, six, and three measurements, respectively) over the course of the 18-month follow-up period using lightweight monitors. For children we are using an indirect measurement approach, combining data from area monitors and locator devices worn by the child. For a subsample (up to 10%) of the study population, we are doubling the frequency of measurements in order to estimate the accuracy of subject-specific typical exposure estimates. In addition, we are conducting ambient air monitoring to help characterize potential contributions of PM 2.5 exposure from background concentration. Stove use monitors (Geocene) are being used to assess compliance with the intervention, given that stove stacking (use of traditional stoves in addition to the intervention gas stove) may occur. CONCLUSIONS The tools and approaches being used for HAPIN to estimate personal exposures build on previous efforts and take advantage of new technologies. In addition to providing key personal exposure data for this study, we hope the application and learnings from our exposure assessment will help inform future efforts to characterize exposure to household air pollution and for other contexts. https://doi.org/10.1289/EHP6422.
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Affiliation(s)
| | - Kyle Steenland
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | | | - Maggie L Clark
- Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins, Colorado, USA
| | - Ajay Pillarisetti
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - 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
| | - Jennifer L Peel
- Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins, Colorado, USA
| | - Luke P Naeher
- Department of Environmental Health Science, College of Public Health, University of Georgia, Athens, Georgia, USA
| | - Jiawen Liao
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | | | - Jeremy Sarnat
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Lindsay J Underhill
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Vanessa Burrowes
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - John P McCracken
- Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala
| | - Ghislaine Rosa
- Department of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
| | - Joshua Rosenthal
- Division of Epidemiology and Population Studies, Fogarty International Center, National Institutes of Health, Bethesda, Maryland, USA
| | - Sankar Sambandam
- 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
| | - Oscar de Leon
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Miles A Kirby
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Katherine Kearns
- 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
| | - 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
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24
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Simkovich SM, Underhill LJ, Kirby MA, Goodman D, Crocker ME, Hossen S, McCracken JP, de León O, Thompson LM, Garg SS, Balakrishnan K, Thangavel G, Rosa G, Peel JL, Clasen TF, McCollum ED, Checkley W. Design and conduct of facility-based surveillance for severe childhood pneumonia in the Household Air Pollution Intervention Network (HAPIN) trial. ERJ Open Res 2020; 6:00308-2019. [PMID: 32211438 PMCID: PMC7086071 DOI: 10.1183/23120541.00308-2019] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Accepted: 02/06/2020] [Indexed: 12/20/2022] Open
Abstract
Pneumonia is both a treatable and preventable disease but remains a leading cause of death in children worldwide. Household air pollution caused by burning biomass fuels for cooking has been identified as a potentially preventable risk factor for pneumonia in low- and middle-income countries. We are conducting a randomised controlled trial of a clean energy intervention in 3200 households with pregnant women living in Guatemala, India, Peru and Rwanda. Here, we describe the protocol to ascertain the incidence of severe pneumonia in infants born to participants during the first year of the study period using three independent algorithms: the presence of cough or difficulty breathing and hypoxaemia (≤92% in Guatemala, India and Rwanda and ≤86% in Peru); presence of cough or difficulty breathing along with at least one World Health Organization-defined general danger sign and consolidation on chest radiography or lung ultrasound; and pneumonia confirmed to be the cause of death by verbal autopsy. Prior to the study launch, we identified health facilities in the study areas where cases of severe pneumonia would be referred. After participant enrolment, we posted staff at each of these facilities to identify children enrolled in the trial seeking care for severe pneumonia. To ensure severe pneumonia cases are not missed, we are also conducting home visits to all households and providing education on pneumonia to the mother. Severe pneumonia reduction due to mitigation of household air pollution could be a key piece of evidence that sways policymakers to invest in liquefied petroleum gas distribution programmes.
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Affiliation(s)
- Suzanne M. Simkovich
- 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
| | - Lindsay J. Underhill
- 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
| | - Miles A. Kirby
- Dept of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Dina Goodman
- 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
| | - Mary E. Crocker
- Division of Pulmonary and Sleep Medicine, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA, USA
| | - 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
| | - John P. McCracken
- Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala
| | - Oscar de León
- Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala
| | - Lisa M. Thompson
- Dept of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA, USA
| | - Sarada S. Garg
- Dept of Environmental Health Engineering, ICMR Center for Advanced Research on Air Quality, Climate and Health, Sri Ramachandra Institute for Higher Education and Research (Deemed to be University), Chennai, India
| | - Kalpana Balakrishnan
- Dept of Environmental Health Engineering, ICMR Center for Advanced Research on Air Quality, Climate and Health, Sri Ramachandra Institute for Higher Education and Research (Deemed to be University), Chennai, India
| | - Gurusamy Thangavel
- Dept of Environmental Health Engineering, ICMR Center for Advanced Research on Air Quality, Climate and Health, Sri Ramachandra Institute for Higher Education and Research (Deemed to be University), Chennai, India
| | - Ghislaine Rosa
- Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | - Jennifer L. Peel
- Dept of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins, CO, USA
| | - Thomas F. Clasen
- Dept of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Eric D. McCollum
- Eudowood Division of Pediatric Respiratory Sciences, Dept of Pediatrics, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
- Global Program on Pediatric Respiratory Sciences, Dept of Pediatrics, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
- These authors contributed equally
| | - 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
- These authors contributed equally
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Goodman D, Crocker ME, Pervaiz F, McCollum ED, Steenland K, Simkovich SM, Miele CH, Hammitt LL, Herrera P, Zar HJ, Campbell H, Lanata CF, McCracken JP, Thompson LM, Rosa G, Kirby MA, Garg S, Thangavel G, Thanasekaraan V, Balakrishnan K, King C, Clasen T, Checkley W. Challenges in the diagnosis of paediatric pneumonia in intervention field trials: recommendations from a pneumonia field trial working group. Lancet Respir Med 2019; 7:1068-1083. [PMID: 31591066 PMCID: PMC7164819 DOI: 10.1016/s2213-2600(19)30249-8] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 06/27/2019] [Accepted: 07/03/2019] [Indexed: 12/14/2022]
Abstract
Pneumonia is a leading killer of children younger than 5 years despite high vaccination coverage, improved nutrition, and widespread implementation of the Integrated Management of Childhood Illnesses algorithm. Assessing the effect of interventions on childhood pneumonia is challenging because the choice of case definition and surveillance approach can affect the identification of pneumonia substantially. In anticipation of an intervention trial aimed to reduce childhood pneumonia by lowering household air pollution, we created a working group to provide recommendations regarding study design and implementation. We suggest to, first, select a standard case definition that combines acute (≤14 days) respiratory symptoms and signs and general danger signs with ancillary tests (such as chest imaging and pulse oximetry) to improve pneumonia identification; second, to prioritise active hospital-based pneumonia surveillance over passive case finding or home-based surveillance to reduce the risk of non-differential misclassification of pneumonia and, as a result, a reduced effect size in a randomised trial; and, lastly, to consider longitudinal follow-up of children younger than 1 year, as this age group has the highest incidence of severe pneumonia.
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Affiliation(s)
- Dina Goodman
- Division of Pulmonary and Critical Care, Johns Hopkins University, Baltimore, MD, USA; Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore, MD, USA
| | - Mary E Crocker
- Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore, MD, USA; Division of Pediatric Pulmonology, School of Medicine, University of Washington, Seattle, WA, USA
| | - Farhan Pervaiz
- Division of Pulmonary and Critical Care, Johns Hopkins University, Baltimore, MD, USA; Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore, MD, USA
| | - Eric D McCollum
- Eudowood Division of Pediatric Respiratory Sciences, Department of Pediatrics, Johns Hopkins University, Baltimore, MD, USA; School of Medicine, and Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Kyle Steenland
- Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Suzanne M Simkovich
- Division of Pulmonary and Critical Care, Johns Hopkins University, Baltimore, MD, USA; Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore, MD, USA
| | - Catherine H Miele
- Division of Pulmonary and Critical Care, Johns Hopkins University, Baltimore, MD, USA; Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore, MD, USA
| | - Laura L Hammitt
- School of Medicine, and Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Phabiola Herrera
- Division of Pulmonary and Critical Care, Johns Hopkins University, Baltimore, MD, USA; Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore, MD, USA
| | - Heather J Zar
- Department of Pediatrics and Child Health, SA-MRC Unit on Child & Adolescent Health, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa
| | - Harry Campbell
- Centre for Global Health Research, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - Claudio F Lanata
- Instituto de Investigación Nutricional, Lima, Peru; Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - John P McCracken
- Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala
| | - Lisa M Thompson
- Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA; Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | - Ghislaine Rosa
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA, USA
| | - Miles A Kirby
- Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Sarada Garg
- Department of Environmental Health Engineering, ICMR Center for Advanced Research on Air Quality, Climate and Health, Sri Ramachandra Medical College & Research Institute (Deemed University), Chennai, India
| | - Gurusamy Thangavel
- Department of Environmental Health Engineering, ICMR Center for Advanced Research on Air Quality, Climate and Health, Sri Ramachandra Medical College & Research Institute (Deemed University), Chennai, India
| | - Vijayalakshmi Thanasekaraan
- Department of Environmental Health Engineering, ICMR Center for Advanced Research on Air Quality, Climate and Health, Sri Ramachandra Medical College & Research Institute (Deemed University), Chennai, India
| | - Kalpana Balakrishnan
- Department of Environmental Health Engineering, ICMR Center for Advanced Research on Air Quality, Climate and Health, Sri Ramachandra Medical College & Research Institute (Deemed University), Chennai, India
| | - Carina King
- Institute for Global Health, University College London, London, UK
| | - Thomas Clasen
- Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - William Checkley
- Division of Pulmonary and Critical Care, Johns Hopkins University, Baltimore, MD, USA; Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore, MD, USA; School of Medicine, and Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA.
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Kirby MA, Nagel CL, Rosa G, Umupfasoni MM, Iyakaremye L, Thomas EA, Clasen TF. Use, microbiological effectiveness and health impact of a household water filter intervention in rural Rwanda—A matched cohort study. Int J Hyg Environ Health 2017; 220:1020-1029. [DOI: 10.1016/j.ijheh.2017.05.013] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Revised: 05/29/2017] [Accepted: 05/29/2017] [Indexed: 11/27/2022]
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Kirby MA, Nagel CL, Rosa G, Iyakaremye L, Zambrano LD, Clasen TF. Faecal contamination of household drinking water in Rwanda: A national cross-sectional study. Sci Total Environ 2016; 571:426-34. [PMID: 27470017 DOI: 10.1016/j.scitotenv.2016.06.226] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Revised: 06/26/2016] [Accepted: 06/28/2016] [Indexed: 05/21/2023]
Abstract
Unsafe drinking water is a leading cause of morbidity and mortality, especially among young children in low-income settings. We conducted a national survey in Rwanda to determine the level of faecal contamination of household drinking water and risk factors associated therewith. Drinking water samples were collected from a nationally representative sample of 870 households and assessed for thermotolerant coliforms (TTC), a World Health Organization (WHO)-approved indicator of faecal contamination. Potential household and community-level determinants of household drinking water quality derived from household surveys, the 2012 Rwanda Population and Housing Census, and a precipitation dataset were assessed using multivariate logistic regression. Widespread faecal contamination was present, and only 24.9% (95% CI 20.9-29.4%, n=217) of household samples met WHO Guidelines of having no detectable TTC contamination, while 42.5% (95% CI 38.0-47.1%, n=361) of samples had >100TTC/100mL and considered high risk. Sub-national differences were observed, with poorer water quality in rural areas and Eastern province. In multivariate analyses, there was evidence for an association between detectable contamination and increased open waste disposal in a sector, lower elevation, and water sources other than piped to household or rainwater/bottled. Risk factors for intermediate/high risk contamination (>10TTC/100mL) included low population density, increased open waste disposal, lower elevation, water sources other than piped to household or rainwater/bottled, and occurrence of an extreme rain event the previous day. Modelling suggests non-household-based risk factors are determinants of water quality in this setting, and these results suggest a substantial proportion of Rwanda's population are exposed to faecal contamination through drinking water.
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Affiliation(s)
- Miles A Kirby
- London School of Hygiene and Tropical Medicine, Keppel St, London WC1E 7HT, United Kingdom.
| | - Corey L Nagel
- Oregon Health and Science University, School of Nursing Portland Campus, 3455 SW US Veterans Hospital Road, SN-6S, Portland, OR 97239, USA.
| | - Ghislaine Rosa
- London School of Hygiene and Tropical Medicine, Keppel St, London WC1E 7HT, United Kingdom.
| | - Laurien Iyakaremye
- DelAgua Health Rwanda Implementation, Ltd., 3rd Fl KG 19 Avenue, Kibagabaga Rd, Kigali, Rwanda.
| | - Laura Divens Zambrano
- Emory University Rollins School of Public Health, 1518 Clifton Road, NE, Atlanta, GA 30322, USA.
| | - Thomas F Clasen
- London School of Hygiene and Tropical Medicine, Keppel St, London WC1E 7HT, United Kingdom; Emory University Rollins School of Public Health, 1518 Clifton Road, NE, Atlanta, GA 30322, USA.
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Nagel CL, Kirby MA, Zambrano LD, Rosa G, Barstow CK, Thomas EA, Clasen TF. Study design of a cluster-randomized controlled trial to evaluate a large-scale distribution of cook stoves and water filters in Western Province, Rwanda. Contemp Clin Trials Commun 2016; 4:124-135. [PMID: 29736475 PMCID: PMC5935890 DOI: 10.1016/j.conctc.2016.07.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Revised: 07/11/2016] [Accepted: 07/29/2016] [Indexed: 02/01/2023] Open
Abstract
Background In Rwanda, pneumonia and diarrhea are the first and second leading causes of death, respectively, among children under five. Household air pollution (HAP) resultant from cooking indoors with biomass fuels on traditional stoves is a significant risk factor for pneumonia, while consumption of contaminated drinking water is a primary cause of diarrheal disease. To date, there have been no large-scale effectiveness trials of programmatic efforts to provide either improved cookstoves or household water filters at scale in a low-income country. In this paper we describe the design of a cluster-randomized trial to evaluate the impact of a national-level program to distribute and promote the use of improved cookstoves and advanced water filters to the poorest quarter of households in Rwanda. Methods/Design We randomly allocated 72 sectors (administratively defined units) in Western Province to the intervention, with the remaining 24 sectors in the province serving as controls. In the intervention sectors, roughly 100,000 households received improved cookstoves and household water filters through a government-sponsored program targeting the poorest quarter of households nationally. The primary outcome measures are the incidence of acute respiratory infection (ARI) and diarrhea among children under five years of age. Over a one-year surveillance period, all cases of acute respiratory infection (ARI) and diarrhea identified by health workers in the study area will be extracted from records maintained at health facilities and by community health workers (CHW). In addition, we are conducting intensive, longitudinal data collection among a random sample of households in the study area for in-depth assessment of coverage, use, environmental exposures, and additional health measures. Discussion Although previous research has examined the impact of providing household water treatment and improved cookstoves on child health, there have been no studies of national-level programs to deliver these interventions at scale in a developing country. The results of this study, the first RCT of a large-scale programmatic cookstove or household water filter intervention, will inform global efforts to reduce childhood morbidity and mortality from diarrheal disease and pneumonia. Trial registration This trial is registered at Clinicaltrials.gov (NCT02239250).
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Key Words
- ARI, acute respiratory infection
- Acute respiratory infection
- CHW, community health worker
- Cluster randomized controlled trial
- DBSS, dried blood spot samples
- Diarrhea
- H-PEM, Harvard Personal Exposure Monitor
- HAP, household air pollution
- Household water treatment
- ICCM, Integrated Community Case Management of Childhood Illness
- IMCI, Integrated Management of Childhood Illness
- Improved stoves
- MFI, mean fluorescence intensity
- MOH, Rwanda Ministry of Health
- MOLG, Rwandan Ministry of Local Government
- RCT, randomized controlled trial
- Rwanda
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Affiliation(s)
- Corey L Nagel
- OHSU/PSU School of Public Health, Oregon Health & Science University, Portland, OR, USA
| | - Miles A Kirby
- Department of Disease Control, London School of Hygiene & Tropical Medicine, London, UK
| | - Laura D Zambrano
- Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Ghislane Rosa
- Department of Disease Control, London School of Hygiene & Tropical Medicine, London, UK
| | - Christina K Barstow
- Department of Civil, Environmental and Architectural Engineering, University of Colorado, Boulder, CO, USA
| | - Evan A Thomas
- Department of Mechanical Engineering, Portland State University, Portland, OR, USA
| | - Thomas F Clasen
- Department of Disease Control, London School of Hygiene & Tropical Medicine, London, UK.,Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
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Roy M, Benedict K, Deak E, Kirby MA, McNiel JT, Sickler CJ, Eckardt E, Marx RK, Heffernan RT, Meece JK, Klein BS, Archer JR, Theurer J, Davis JP, Park BJ. A large community outbreak of blastomycosis in Wisconsin with geographic and ethnic clustering. Clin Infect Dis 2013; 57:655-62. [PMID: 23735332 DOI: 10.1093/cid/cit366] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Blastomycosis is a potentially life-threatening infection caused by the soil-based dimorphic fungus Blastomyces dermatitidis, which is endemic throughout much of the Midwestern United States. We investigated an increase in reported cases of blastomycosis that occurred during 2009-2010 in Marathon County, Wisconsin. METHODS Case detection was conducted using the Wisconsin Electronic Disease Surveillance System (WEDSS). WEDSS data were used to compare demographic, clinical, and exposure characteristics between outbreak-related and historical case patients, and to calculate blastomycosis incidence rates. Because initial mapping of outbreak case patients' homes and recreational sites demonstrated unusual neighborhood and household case clustering, we conducted a 1:3 matched case-control study to identify factors associated with being in a geographic cluster. RESULTS Among the 55 patients with outbreak-related cases, 33 (70%) were hospitalized, 2 (5%) died, 30 (55%) had cluster-related cases, and 20 (45%) were Hmong. The overall incidence increased significantly since 2005 (average 11% increase per year, P < .001), and incidence during 2005-2010 was significantly higher among Asians than non-Asians (2010 incidence: 168 vs 13 per 100 000 population). Thirty of the outbreak cases grouped into 5 residential clusters. Outdoor activities were not risk factors for blastomycosis among cluster case patients or when comparing outbreak cases to historical cases. CONCLUSIONS This outbreak of blastomycosis, the largest ever reported, was characterized by unique household and neighborhood clustering likely related to multifocal environmental sources. The reasons for the large number of Hmong affected are unclear, but may involve genetic predisposition.
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Affiliation(s)
- Monika Roy
- Epidemic Intelligence Service, Scientific Education and Professional Development Program Office, Centers for Disease Control and Prevention, 1600 Clifton Rd NE, MS C-09, Atlanta, GA 30307, USA.
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Abstract
OBJECTIVE This review focuses on the contribution of immune cell trafficking and activities during the initial phase of activation in the process of parturition. Although uterine contractile activity has been the predominant focus for the mechanism that initiates labor, significant cellular and biochemical changes cause remodeling of the cervix well before term. A convergence of evidence suggests that inflammatory processes that involve prostaglandins, nitric oxide, cytokines, as well as systemic and paracrine endocrine mediators may enhance uterine contractility, promote ripening of the cervix, and thus constitute an integrative hypothesis for the initiation of labor. METHODS Techniques to study the uterus and cervix of pregnant and virgin C3H/HeN mice included light and fluorescence microscopy. Tissues were processed by histochemistry and immunofluorescence. Analytic approaches to enumerate macrophages and assess activation included quantitative stereologic morphometry and laser scanning cytometry. RESULTS The transition between relative quiescence of the uterus and enhanced contractility involved migration of macrophages from the uterine endometrium and activation of macrophages in the cervix. Before birth, macrophages migrate into the cervix and are activated in the myometrium. CONCLUSION Immune cell trafficking and activation are part of the initial mechanism that promotes ripening of the cervix, enhances uterine contractility, and initiates parturition. Markers for the conclusion of pregnancy may have diagnostic or therapeutic value to assess the normal progress of labor or identify women at risk of preterm labor.
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Affiliation(s)
- S M Yellon
- Loma Linda University School of Medicine, Center for Perinatal Biology, Department of Physiology, Loma Linda, California 92350, USA.
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Allen GW, Liu J, Kirby MA, De León M. Induction and axonal localization of epithelial/epidermal fatty acid-binding protein in retinal ganglion cells are associated with axon development and regeneration. J Neurosci Res 2001; 66:396-405. [PMID: 11746357 DOI: 10.1002/jnr.1232] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Epithelial/epidermal fatty acid-binding protein (E-FABP) is induced in peripheral neurons during nerve regeneration and is found at high levels in central neurons during neuronal migration and development. Furthermore, E-FABP expression is required for normal neurite outgrowth in PC12 cells treated with nerve growth factor (NGF). The present study examined whether E-FABP plays a role in retinal ganglion cell (RGC) differentiation and axon growth. Rat retinal tissues from embryonic (E) and postnatal (P) development through adulthood were examined using immunocytochemical labeling with E-FABP and growth-associated protein 43 (GAP-43) antibodies. E-FABP colocalized with GAP-43 at E14 through P10. At E14, E-FABP immunoreactivity was confined to the somas of GAP-43-positive cells in the ganglion cell layer, but it was localized to their axons by E15. The axons in the optic nerve were GAP-43-positive and E-FABP-negative on E15, but the two proteins were colocalized by E18. Retinal cultures at E15 confirmed that E-FABP and GAP-43 colocalize in RGCs. Postnatally, labeling was present between P1 and P10 but decreased at older ages and was minimally present or absent in adult animals. Western immunoblotting revealed that at E18, P1, and P10 E-FABP levels were at least fourfold greater than those in the adult. By P15, protein levels were only twofold greater, with adult levels reached by P31. Furthermore, E-FABP could be reinduced during axon regeneration. Dissociated P15 retinal cells cultured in the presence of brain-derived neurotrophic factor, ciliary neurotrophic factor, and basic fibroblast growth factor exhibited sixfold more GAP-43 and E-FABP double-positive RGCs (cell body and axons) than controls. Moreover, all GAP-43-immunoreactive RGCs were also positive for E-FABP. Taken together, these results indicate the following: 1) E-FABP is expressed in RGCs as they reached the ganglion cell layer and 2) E-FABP plays a functional role in the elaboration of RGC axons in both development and regeneration.
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Affiliation(s)
- G W Allen
- Department of Physiology and Pharmacology, Center for Molecular Biology and Gene Therapy, Loma Linda University, Loma Linda, California 92350, USA
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Abstract
Deferoxamine is commonly used for treatment of iron intoxication. Because the usual dose is unable to chelate sufficient iron before severe injury occurs, "high-dose" deferoxamine treatment has been proposed. However, several authors have reported severe toxicity after deferoxamine therapy. Although the hemodynamic effects are well described, the cellular toxicity of deferoxamine is unknown. Accordingly, we investigated the cellular toxicity of deferoxamine using in vitro techniques in two cell lines. Brain cells were harvested from fetal rats and cultured for 14-21 days before deferoxamine exposure. Using similar techniques, rat hepatoma cells were grown until confluent. Deferoxamine was added to the cultures to achieve final concentrations of 200-800 microg/ml, corresponding to in vivo infusion rates of 15-60 mg/kg/h. Deferoxamine was removed after 3 or 6 days by changing the medium. Subtoxic FeCl3 (500 mg/dl) was concurrently added to identical cultures to determine if deferoxamine potentiated iron toxicity. Cell viability was measured by a colorimetric assay. The addition of deferoxamine (0.2, 0.4, 0.8 mg/ml) significantly decreased cell viability in both cell groups. The effect of deferoxamine on primary cortical brain cultures was similar for the three concentrations used, and was similar when examined either 72 h or 6 days later. In contrast, hepatoma cell cultures evidenced a dose- dependent cell loss that increased with the length of exposure. The addition ofsubtoxic amounts of FeCl3 (500 microg/dl) in the presence of deferoxamine was protective in all cultures, and abolished deferoxamine-induced cell loss. Interestingly, the addition of serum albumin significantly reduced the amount of iron present in cells, suggesting its potential use to treat iron toxicity. These results suggest that deferoxamine, in the absence of iron, is toxic to cortical brain and hepatoma cells in vitro.
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Affiliation(s)
- D W Christensen
- Department of Pediatrics, Loma Linda University School of Medicine, California 92350, USA
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Erkman L, Yates PA, McLaughlin T, McEvilly RJ, Whisenhunt T, O'Connell SM, Krones AI, Kirby MA, Rapaport DH, Bermingham JR, O'Leary DD, Rosenfeld MG. A POU domain transcription factor-dependent program regulates axon pathfinding in the vertebrate visual system. Neuron 2000; 28:779-92. [PMID: 11163266 DOI: 10.1016/s0896-6273(00)00153-7] [Citation(s) in RCA: 131] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Axon pathfinding relies on the ability of the growth cone to detect and interpret guidance cues and to modulate cytoskeletal changes in response to these signals. We report that the murine POU domain transcription factor Brn-3.2 regulates pathfinding in retinal ganglion cell (RGC) axons at multiple points along their pathways and the establishment of topographic order in the superior colliculus. Using representational difference analysis, we identified Brn-3.2 gene targets likely to act on axon guidance at the levels of transcription, cell-cell interaction, and signal transduction, including the actin-binding LIM domain protein abLIM. We present evidence that abLIM plays a crucial role in RGC axon pathfinding, sharing functional similarity with its C. elegans homolog, UNC-115. Our findings provide insights into a Brn-3.2-directed hierarchical program linking signaling events to cytoskeletal changes required for axon pathfinding.
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Affiliation(s)
- L Erkman
- Howard Hughes Medical Institute and, Department of Medicine, University of California, San Diego, La Jolla, CA 92093, USA
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Abstract
PURPOSE We have examined the effects of proton irradiation on the histologic and receptive field properties of thalamic relay cells in the cat visual system. The cat lateral geniculate nucleus (LGN) is a large structure with well-defined anatomical boundaries, and well-described afferent, efferent, and receptive field properties. METHODS AND MATERIALS A 1.0-mm proton microbeam was used on the cat LGN to determine short-term (3 months) and long-term (9 months) receptive field effects of irradiation on LGN relay cells. The doses used were 16-, 40-, and 60-gray (Gy). RESULTS Following irradiation, abnormalities in receptive field organization were found in 40- and 60-Gy short-term animals, and in all of the long-term animals. The abnormalities included "silent" areas of the LGN where a visual response could not be evoked and other regions that had unusually large or small compound receptive fields. Histologic analysis failed to identify cellular necrosis or vascular damage in the irradiated LGN, but revealed a disruption in retinal afferents to areas of the LGN. CONCLUSIONS These results indicate that microbeam proton irradiation can disrupt cellular function in the absence of obvious cellular necrosis. Moreover, the area and extent of this disruption increased with time, having larger affect with longer post-irradiation periods.
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Affiliation(s)
- C S Reder
- Department of Pediatrics, Loma Linda University, Loma Linda, CA 92350, USA.
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Moyers MF, Galindo RA, Yonemoto LT, Loredo L, Friedrichsen EJ, Kirby MA, Slater JD, Slater JM. Treatment of macular degeneration with proton beams. Med Phys 1999; 26:777-82. [PMID: 10360542 DOI: 10.1118/1.598587] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Subfoveal neovascular membranes (SNVMs) are a leading cause of severe visual loss in the elderly in the United States. Previously, the only treatment that could halt progression of this disease was laser photocoagulation, which was, however, accompanied by immediate reduction in visual acuity. A single narrow proton beam was used to irradiate 45 patients to either 8 or 14 Cobalt Gray Equivalent. The alignment technique and dosimetry of these treatments are described. The proton beam direction, range, and modulation were planned with the assistance of an eye-specific planning program. A single anterior beam was used, with patients looking nasally toward a blinking fixation light at an angle of 30 degrees. Patients were aligned using a light field projected through a slit collimator. Patients' positions were monitored during treatment with a short-focal-length camera. Depth dose in a flat phantom was measured with a small-diameter parallel plate ionization chamber. Lateral profiles were measured at several depths with silver halide film. Each treatment session lasted 15 min, of which 1 min consisted of beam delivery. The proton beam stopped in the orbital cavity, delivering no primary proton dose to the brain. Dose to the center of the lens of the involved eye was less than 0.5% of the dose delivered to the macula. Treatments of SNVMs with proton beams require only a short visit to the hospital, little immobilization effort, and a minimal amount of treatment room and beam time. Compared to previous treatment trials using x-ray beams, the dose to nonocular tissues is reduced significantly.
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Affiliation(s)
- M F Moyers
- Department of Radiation Medicine, Loma Linda University Medical Center, California 92354, USA
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36
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Allen UD, King SM, Gomez MP, Lapointe N, Forbes JC, Thorne A, Kirby MA, Bowker J, Raboud J, Singer J, Mukwaya G, Tobin J, Read SE. Serum immunoreactive erythropoietin levels and associated factors amongst HIV-infected children. AIDS 1998; 12:1785-91. [PMID: 9792379 DOI: 10.1097/00002030-199814000-00010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To determine the spectrum of serum immunoreactive erythropoietin (SIE) levels amongst HIV-infected children aged < 13 years in relation to the levels among healthy children as well as those with renal failure; to examine the relationship between clinical and laboratory parameters and SIE levels. DESIGN A cross-sectional study with a descriptive non-interventional format. HIV-infected Canadian subjects were recruited through four tertiary Canadian and one Bahamian centre. Children with renal failure and healthy children were recruited from one of the Canadian centres. METHODS Study subjects had clinical and laboratory profiles determined at baseline and at each of five follow-up periods over 1 year. SIE levels were measured by radioimmunoassay with a normal range of 12-28 IU/I. Data handling and statistical functions were performed by the Canadian HIV Trials Network. RESULTS The study enrolled 133 HIV-infected subjects and 38 controls. Of these, 117 HIV-infected subjects, 24 healthy controls, and 11 controls with renal failure were eligible for analysis. The median age of infected subjects was 44 months, whereas that of healthy controls was 56 months, and 95 months for controls with renal failure. The median SIE levels were 14 and 11 IU/I for subjects with renal failure and healthy subjects, respectively. The median SIE level was 61 IU/I among zidovudine (ZDV)-treated subjects and 22 IU/I among ZDV-naive HIV-infected subjects. HIV-infected children almost invariably had SIE levels < 200 IU/I. The median SIE levels amongst HIV-infected subjects whose hemoglobin levels were < 100 g/l were 98 and 31 IU/I for ZDV-treated and ZDV-naive subjects, respectively (P = 0.002). This difference in median SIE levels between ZDV-treated subjects and ZDV-naive subjects was also observed among subjects whose hemoglobin levels were > 100 g/l (median, 58 and 15 IU/l, respectively; P < 0.001). Hemoglobin level was the most important predictor of log10 SIE (P < 0.01 for ZDV-treated and ZDV-naive subjects). CONCLUSIONS SIE levels amongst HIV-infected children were affected by HIV infection, use of ZDV, and presence or absence of anemia. SIE levels amongst HIV-infected children were generally lower than 200 IU/I. This characterization of SIE levels will facilitate clinical trials of exogenous recombinant human erythropoietin in HIV-infected children with anemia.
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Affiliation(s)
- U D Allen
- Canadian Pediatric AIDS Research Group
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Allen UD, Kirby MA, Goeree R. Cost-effectiveness of recombinant human erythropoietin versus transfusions in the treatment of zidovudine-related anemia in HIV-infected children. Pediatr AIDS HIV Infect 1997; 8:4-11. [PMID: 11361510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 04/16/2023]
Abstract
The objectives of this study were to compare the costs and benefits of recombinant human erythropoietin (r-HuEPO) relative to repeated transfusions in the treatment of zidovudine (AZT)-related anemia among HIV-infected children. The study was based on a tertiary care Canadian Pediatric Hospital Model. A decision analytic structure was used for the evaluation of cost-effectiveness. The decision tree involved two options. In option A:r-HuEPO, subjects receive r-HuEPO three times weekly at home for 1 year, whereas in B:no r-HuEPO, transfusions are given on a monthly basis in a medical short-stay unit over a 1-year period. Probabilities of various outcomes and downstream events were obtained from a literature review. The analysis was conducted from the perspective of the health-care system and utilized standard cost-effectiveness methodology. The results indicated that for every child receiving r-HuEPO, the total cost is Can $11,245 for 1 year compared with $3,130 per year for those in B:no r-HuEPO. The incremental cost effectiveness of A:r-HuEPO relative to B:no r-HuEPO is $1,373 per transfusion episode averted. The order of magnitude of the results was not significantly affected by changes in any of the assumptions used for the cost estimates or baseline probability values.
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Affiliation(s)
- U D Allen
- Department of Pediatrics, Children's Hospital of Eastern Ontario, Ottawa, Canada
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Abstract
The topographic organization of the developing retinocollicular pathway was assessed by making focal deposits of a retrograde tracer (usually rhodamine latex beads) into the superficial layers of the superior colliculus of fetal cats at known gestational ages. Subsequently, the distributions of labeled cells in the contralateral and ipsilateral retinas were examined. At all stages of development, a high density of labeled cells was found in a delimited area (core region) of both retinas. The locations of the retinal regions containing the high density of labeled cells varied with the locus of the tracer deposit in the superior colliculus in a manner consistent with the topographic organization of the mature cat's retinocollicular pathway. Additionally, some labeled ganglion cells, considered to be ectopic, were found to be scattered throughout the contralateral and ipsilateral fetal retinas. Such ectopic cells were few in number throughout prenatal development. For every 100 cells projecting to the appropriate region of the colliculus, we estimate that less than one ganglion cell makes a gross projection error. The incidence of ectopic cells did not differ between the contralateral and ipsilateral retina, even though the overall density of crossed labeled cells was always greater than that of uncrossed labeled cells. In the youngest fetal animals, tracer deposits into the caudal portion of the superior colliculus resulted in a core region of labeled cells in the contralateral nasal retina as well as in the nasal ipsilateral retina. Such uncrossed nasal cells, not seen in more mature animals, appear to innervate the appropriate topographic location of the superior colliculus, but on the wrong side of the brain. Most likely, these uncrossed nasal ganglion cells contribute to the widespread distribution of the ipsilateral retinocollicular pathway observed in fetal cats after intraocular injections of anterograde tracers (Williams and Chalupa, 1982). Collectively, our findings demonstrate that the developing retinocollicular pathway of the fetal cat is characterized by a remarkable degree of topographic precision.
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Affiliation(s)
- L M Chalupa
- Department of Psychology, University of California, Davis 95616, USA
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Abstract
We investigated the morphology and spatial distribution of retinal astrocytes in newborn and early postnatal macaque monkeys. As in adults, retinal astrocytes in neonatal animals were closely associated with ganglion cell axons and blood vessels. However, in contrast with adults, astrocytes transiently occupied the fovea and perifoveal region in newborns and, to a lesser degree, also in early postnatal animals. The density of the perifoveal astrocytes rapidly declined during the first 2-3 months of life. The results are discussed in relationship to foveal development.
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Affiliation(s)
- C Distler
- Allgemeine Zoologie & Neurobiologie, Ruhr-Universität Bochum, Bochum, Germany
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40
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Abstract
Employing retinal explants and retrograde transport techniques, we studied the formation of the arcuate fascicles by examining the growth of the central retina, the emergence of the adult fiber layer pattern, and the projections of retinal ganglion cells in the central and peripheral retina. Sixty days prior to foveal pit formation, the distance from the incipient fovea to the optic disk was equal to the adult, even though the retinal area was only 8% of the adult. Arcuate fibers, at this age, were observed to avoid the incipient fovea, with no fascicles and few axons projecting over this region. A small population of 15.2% of the ganglion cells located within 2 mm of the incipient fovea possessed an axon with an aberrant trajectory that wound around and projected 50 to several hundred microns away from the optic disk, compared to only 3% at other retinal locations. The incidence of disorder decreased with increasing fetal age, establishing mature values in late fetal periods. These findings suggest that the area of the central retina does not increase after embryonic day 60 and that guidance factors are present that allow outgrowing ganglion cell axons to distinguish and avoid that portion of the retina that will become the fovea.
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Affiliation(s)
- T C Steineke
- Department of Pediatrics, School of Medicine, Loma Linda University, CA 92350
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41
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Abstract
Retinal projections to the suprachiasmatic nucleus (SCN) mediate the effect of photoperiod to entrain circadian rhythms and to control reproductive maturation in the Djungarian hamster. To determine whether the retinal innervation of the SCN had fully developed by the onset of puberty in this hamster species, prepubertal and postpubertal hamsters received an intraocular unilateral injection of horseradish peroxidase (HRP), and after 24 h, the anterograde transport of HRP to the SCN was studied. In prepubertal hamsters, the retinohypothalamic tract (RHT) was found to project to the medial and caudal SCN, principally the ventrolateral regions and, to an extent, the dorsomedial portion of the nucleus. RHT innervation was asymmetric; the SCN contralateral to the monocular injection received the dominant projection. A similar pattern of retinal projections was found postpubertally; however, the ipsilateral SCN was less extensively labelled with HRP and smaller as determined by Nissl counterstain compared to that in prepubertal hamsters. These findings indicate that modifications in the retinal innervation of the SCN occur as late as puberty, and may be part of a developmental change in the mechanism which processes photoperiodic information during sexual maturation.
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Affiliation(s)
- S M Yellon
- Department of Physiology, Loma Linda University School of Medicine, CA 92350
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42
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Abstract
The morphology of retinal ganglion cells within the central retina during formation of the fovea was examined in retinal explants with horseradish-peroxidase histochemistry. A foveal depression was first apparent in retinal wholemounts at embryonic day 112 (E112; gestational term is approximately 165 days). At earlier fetal ages, the site of the future fovea was identified by several criteria that included peak density of ganglion cells, lack of blood vessels in the inner retinal layers, arcuate fiber bundles, and the absence of rod outer segments in the photoreceptor layer. Prior to E112, the terminal dendritic arbor of retinal ganglion cells within the central retina extended into the inner plexiform layer and were located directly beneath their somas of origin or at most were slightly displaced from it. For example, at E90 the mean horizontal displacement of the geometric center of the dendritic arbor from the somas of cells within 600 microns of the estimated center of the future fovea was 4.1 microns (S.D. 2.7, range 1.0-10.0, n = 97). Following formation of the foveal depression the dendritic arbors of cells were significantly displaced from their somas. For example, at E138 the mean displacement was 41.2 microns (S.D. 12.2, range 12.0-56.0, n = 97). The displacement of the dendritic arbor which occurred during this period was not accounted for by areal growth of the dendritic arbor, the somas, or the retina, but was produced by the lengthening of the primary dendritic trunk. Moreover, no significant displacement was observed within the remaining 1.5-6.5 mm of the central retina. These observations provide evidence supporting early speculations that the formation of the foveal pit occurs, in part, by the radial migration of ganglion cells from the center of the fovea during its formation. Our analyses suggest that this migration occurs by the lengthening of the primary dendrite presumably by the addition of membrane. This migration is in a direction opposite to the inward movement of photoreceptors that occurs during late fetal and early postnatal periods (Packer et al., 1990, Journal of Comparative Neurology 298, 472-493).
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Affiliation(s)
- M A Kirby
- Department of Pediatrics, School of Medicine, Loma Linda University, CA 92350
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Blanchette VS, Kirby MA, Turner C. Role of intravenous immunoglobulin G in autoimmune hematologic disorders. Semin Hematol 1992; 29:72-82. [PMID: 1509297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
The data presented in this review established IVIG therapy as an important treatment modality in the autoantibody-mediated cytopenias and coagulation disorders of both children and adults. The immediate response to therapy is thought to be related to nonspecific Fc-receptor blockade of mononuclear phagocytes in the reticuloendothelial system (autoimmune cytopenias), or to idiotypic antibody interaction with pathologic autoantibodies (in acquired coagulation disorders). Although less frequent, long-term responses to IVIG therapy are reported. Such responses must involve an immunomodulating effect of IgG that influences T- and B-cell function, with inhibition of pathologic autoantibody formation. It is possible that idiotypic antibody interactions play a part in long-term responses. The experience with IVIG therapy in the decade following Imbach's important observations reported in 1981 has provided a sound data base regarding the use of this important therapy in patients with autoimmune hematologic disorders. The challenge of the next decade should be to further investigate mechanisms of action of this important therapy and to conduct carefully controlled studies to answer specific clinical questions. Examples of such questions include the following: (1) Can IVIG therapy, administered early in the course of illness in selected children with acute ITP, decrease the incidence of chronic ITP?; (2) Is maintenance, high-dose IVIG therapy a cost-effective method for the management of patients with chronic ITP refractory to corticosteroid therapy and splenectomy?; and (3) Can IVIG therapy administered to selected pregnant women with ITP significantly reduce the incidence of serious thrombocytopenia in their offspring? In conducting these studies, consideration should be given to the type of IVIG preparation used and to the treatment protocol implemented. It is evident that responses to unmodified IgG preparations (with the Fc-receptor part of the molecule left largely intact) are superior to preparations that have been modified during preparation. Responses are also likely to be dose-related. The data reported for IVIG therapy in patients with acquired factor VIII deficiency suggests that the idiotypic antibody content of IgG preparations is also of importance; if so, preparations selected from specific donor pools (for example, multiparous women) known to contain higher levels of circulating autoantibodies (than those from primiparous women or untransfused males) may provide a degree of benefit not seen with standard IVIG preparations. It is therefore important that clinicians and laboratory specialists work closely together in the design and conduct of future clinical trials initiated to answer those important clinical questions raised by the first decade of observations with IVIG therapy for autoimmune hematologic disorders.
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Affiliation(s)
- V S Blanchette
- Division of Hematology, Hospital for Sick Children, Toronto, Ontario, Canada
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Abstract
The pattern of dendritic stratification of retinal ganglion cells in the fetal monkey (Macaca mulatta) was examined using horseradish peroxidase and retinal explants. Ganglion cells in the rhesus monkey are born between embryonic day (E) 30-70 (LaVail et al., 1983). At E60, E67, and E68, approximately 50% of all ganglion cells within the central 3.0 mm of the retina had dendritic arbors that were unistratified within the inner plexiform layer (IPL), while the remaining 50% had bistratified arbors. Unistratified cells had relatively flat arbors that ramified within a restricted portion of the IPL. In contrast, bistratified cells had one portion of the arbor that branched in the inner half of the IPL and a second portion that branched in the outer half of the IPL. Relatively few bistratified cells were encountered in the central 1.0 mm of the retina but were more numerous with increasing eccentricity. At E81, E90, and E110, the dendritic arbors of ganglion cells increased in both area and complexity, but occupied a relatively small percentage of the total depth of the IPL. The bistratified cells encountered at these fetal ages were typically located in the far retinal periphery. Between E125-E140, the dendritic arbors of individual ganglion cells increased in area and depth to occupy a greater proportion of the total IPL than at earlier fetal ages. These observations suggest that ganglion cells in the macaque undergo at least three stages of dendritic stratification: (1) an initial period of dendritic growth during which the cells have either unistratified or bistratified dendritic arbors; (2) a loss of the majority of bistratified cells through cell death or remodeling of the arbor; and (3) growth or expansion of the arbor to occupy a greater percentage of the total depth of the IPL. The first two stages are similar to recent observations in the fetal cat (Maslim & Stone, 1988) with the exception that dendritic development in the primate lacks an initial diffuse ingrowth to the IPL. Additionally, primate ganglion cells undergo a third stage of dendritic growth in late fetal development during which the arbor occupies a greater proportion of the depth of the IPL.
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Affiliation(s)
- M A Kirby
- Department of Pediatrics, School of Medicine, Loma Linda University, CA 92350
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Abstract
The number of retinal ganglion cells in Papio anubis was determined from light microscopic observations of wholemounted and vertically sectioned retinal tissue and electron microscopic examination of optic nerve cross sections. The total number of ganglion cells ranged from 1.41 to 1.81 million (mean 1.58 million, n = 6, SD = 169,927) per retina. The distribution of ganglion cells in cresyl violet stained wholemounts was also examined. Isodensity contours were almost circular perifoveally, but became horizontally elongated outside of the central retina, providing strong evidence for a visual streak. Ganglion cell somata within the streak were found to be significantly smaller than those outside of the streak in comparing regions of equal density. Finally, the distribution of blood vessels within the retina formed a watershed pattern with its crux centered on the ridge of this horizontally oriented high-density zone. Combined, these features indicate that anubis baboons possess a visual streak specialization as reported for lagomorphs, felines, and several primate species. Further, the visual streak appears more pronounced in anubis baboons than in any other primate species studied to date, with the possible exception of Homo sapiens, a similarly ground-dwelling/foraging and secondarily terrestrial species.
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Affiliation(s)
- Q S Fischer
- Department of Psychology, University of California, Riverside
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Abstract
The topographic order of the retinocollicular projection in the rat was examined from birth until maturity. Small, localized deposits of rhodamine-filled latex microspheres were placed into the superior colliculus at different locations. To minimize labeling fibers of passage deposit sites were typically, although not exclusively, placed into the caudal-lateral pole of the colliculus. Examination of the area and density of labeled cells in the retinae of these animals led to the following conclusions: (1) At each age examined, the location of the majority of labeled cells was observed to be in appropriate topographic register with the deposit site in the superior colliculus. (2) Confirming the work of previous investigators, errors in topographic projection were observed. These were present in both the contralateral and ipsilateral retinae and decreased with increasing postnatal age. The mature pattern was present by P10. (3) Quantitatively, the number of retinal ganglion cells terminating nontopographically within the colliculus constituted a relatively minor proportion of the total number of labeled cells in both retinae. It is concluded that the majority of the retinal ganglion cells make topographically appropriate terminations within the superior colliculus during development.
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Affiliation(s)
- J P Yhip
- Department of Pediatrics, School of Medicine, Loma Linda University, CA 92350
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Kirby MA, Weitzman S, Freedman MH. Juvenile chronic myelogenous leukemia: differentiation from infantile cytomegalovirus infection. Am J Pediatr Hematol Oncol 1990; 12:292-6. [PMID: 2173439 DOI: 10.1097/00043426-199023000-00007] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Differentiation between cytomegalovirus (CMV)-associated disease and juvenile chronic myelogenous leukemia (JCML) in infants excreting CMV may be difficult. It is important to make a prompt, definitive diagnosis since the management differs. A 3-month-old infant presented with clinical findings that mimicked both disorders and a plan was developed to make the correct diagnosis. Clonogenic assays and liquid cultures of patients' peripheral blood and bone marrow showed findings that are recognized as the hallmark of JCML, namely, impaired growth of normal hematopoietic progenitors, and excessive, autonomous proliferation of monocyte/macrophage elements. The urine was positive for CMV, and there was a significant rise in the anti-CMV antibody titer over 4 weeks, indicating a postnatal CMV infection. Despite this, freshly obtained and cultured marrow cells as well as a liver biopsy were negative for CMV by immunoassay, by anti-CMV monoclonal antibody testing, and by electron microscopy. Because of these results, the diagnosis of CMV infection was established but could not account for all of the abnormal clinical and hematological findings. Thus, the diagnosis of JCML was also substantiated and antileukemic therapy was initiated with confidence.
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MESH Headings
- Antibodies, Viral/analysis
- Cytomegalovirus/immunology
- Cytomegalovirus/isolation & purification
- Cytomegalovirus Infections/complications
- Cytomegalovirus Infections/diagnosis
- Cytomegalovirus Infections/microbiology
- Diagnosis, Differential
- Humans
- Infant
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/complications
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/diagnosis
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/urine
- Male
- Pierre Robin Syndrome/complications
- Tumor Stem Cell Assay
- Urine/microbiology
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Affiliation(s)
- M A Kirby
- Division of Hematology/Oncology, Hospital for Sick Children, Toronto, Canada
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White CA, Chalupa LM, Maffei L, Kirby MA, Lia B. Response properties in the dorsal lateral geniculate nucleus of the adult cat after interruption of prenatal binocular interactions. J Neurophysiol 1989; 62:1039-51. [PMID: 2585038 DOI: 10.1152/jn.1989.62.5.1039] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
1. Single-cell recordings were made in the magnocellular layer of the dorsal lateral genicule nucleus (dLGN) of five adult cats in which prenatal binocular interactions were interrupted by monocular enucleation at known gestational ages. Three cats (early enucleates) had one eye removed on either embryonic day 44.48, or 49, before retinogeniculate inputs are segregated into uniocular layers. Two other (late enucleates) underwent this procedure on embryonic days 55 and 58, when segregation is well advanced. Responses were compared with those obtained from recordings in the A and A1 layers of the dLGN of seven normal adult cats. 2. Cells were classified as ON or OFF by the use of spots of light and as X or Y based on a test of linearity of spatial summation with the use of counterphased sinusoidal gratings. Receptive-field size and spatial resolution were also obtained. 3. The dLGN of prenatally enucleated cats contains a dorsal magnocellular layer and a ventral parvocellular layer. In early enucleates, only an occasional hint of a cell-sparse interlaminar zone was apparent, located between the magnocellular and parvocellular layers. In late enucleates, a prominent cell-sparse band was observed contralateral to the remaining eye, in a region that would most likely correspond to layer A1 in the normal dLGN. No such cell-sparse band was seen ipsilateral to the remaining eye in late enucleates. 4. Eighty-six X cells and 22 Y cells were studied in the enucleates. Both cell types were found at all depths of the magnocellular layer. All but a few neurons had concentric ON-center or OFF-center receptive fields that were normal in size. The topography of receptive fields also appeared normal. In addition, spatial resolution of X and Y cells was similar in experimental and control animals. 5. In early enucleates there was a higher percentage of X cells and a lower percentage of Y cells than normal. The change in X-to-Y ratio was shown to be because of both a gain in cells with X properties and a loss of cells with Y properties. The distribution of dLGN somal sizes in the early enucleates was comparable with controls, so the change in X-to-Y ratio most likely did not result from an electrode sampling bias. It was suggested that the X-to-Y ratio difference could stem from the abnormalities in retinogeniculate terminal arbors that have been shown to follow early eye removal.(ABSTRACT TRUNCATED AT 400 WORDS)
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Affiliation(s)
- C A White
- Department of Psychology, University of California, Davis 95616
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Abstract
The development of the optic nerve of a marsupial, the North American opossum, was examined in 24 animals from postnatal days 5 to 78 (P5-P78): gestation is 13 days. The estimated number of axons increased from 24,000 at P5, to 267,000 at P27, approximately 2.7 times the mean number in the adult. Following P27, axon numbers decreased rapidly to 140,000 at P40, then decreased more slowly, attaining adult values between P50 and P59. Thus, the opossum is similar to placental mammals examined in evidencing an overproduction and later attenuation to adult values in the number of axons in the optic nerve during development. Monocular enucleation of 3 animals at P17, 10 days before peak axon counts, resulted in a mean population increase of 24,000 (range 19,000-30,000) above the normal adult mean. Additionally, a 4th animal monocularly enucleated on P7, 3 days prior to the arrival of migrating fibers to central target sites, had a similar value of 26,500 supernumerary axons. Our findings in the opposum, when coupled with previous reports in other mammals, suggest that binocular interactions during development account only for optic nerve axon loss approximately equal in magnitude to the ipsilateral projection from one eye.
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Affiliation(s)
- M A Kirby
- Department of Pediatrics School of Medicine, Loma Linda University, CA 92350
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Kirby MA, Wilson PD. Receptive field properties and latencies of cells in the lateral geniculate nucleus of the North American opossum (Didelphis virginiana). J Neurophysiol 1986; 56:907-33. [PMID: 3097274 DOI: 10.1152/jn.1986.56.4.907] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Relay cells in the lateral geniculate nucleus (LGN) of the North American opossum were classified as types 1, 2, and 3 on the basis of their receptive field properties and afferent latencies to optic nerve (ON) and optic chiasm (OX) stimulation and antidromic latencies to stimulation of cortex. Type 1 and type 3 cells gave transient responses and type 2 cells gave sustained responses to appropriate standing contrast in the receptive field center. The differences in response pattern were quantified with a phasic-tonic index (PTI); the PTI values for type 2 cells (PTI less than 63) did not overlap those for type 1 cells (PTI greater than 68) or type 3 cells (PTI greater than 80). With a homogeneous field (1.3 cd/m2), the maintained discharge rates (spikes/s) of type 3 cells (less than 1-11) were significantly lower than those of type 1 cells (3-23) and of type 2 cells (1-22). For all type 2 cells tested with a counterphased sine-wave grating, a null position of the grating was found and the cells were classified as linear. The type 1 and type 3 cells tested were nonlinear (i.e., exhibited excitatory doubling and did not have a null grating position). The maximum velocity of movement that reliably elicited responses (cut-off velocity) was low for type 3 cells (mean = 29.1 degrees/s) and relatively high for type 1 cells (mean = 70.3 degrees/s). Cut-off velocities for type 2 cells (mean = 61.2 degrees/s) were slightly lower than for type 1 cells. Type 1 cells had relatively short afferent (ON and OX) latencies, fast afferent conduction velocities, and short antidromic (cortex) latencies; type 2 cells had intermediate afferent and antidromic latencies and intermediate afferent conduction velocities; and type 3 cells had relatively long afferent and antidromic latencies and slow afferent conduction velocities. The receptive field center diameters were similar for type 1 (4.2-25.5 degrees; mean = 11.4 degrees) and type 3 cells (2.8-23.7 degrees; mean = 11.0 degrees), whereas the receptive field centers for type 2 cells (2.9-15.1 degrees; mean = 6.9 degrees) were significantly smaller. The majority of type 1 (66.7%) and type 3 cells (63.3%) had on-center receptive fields, whereas the proportion of on-center fields was even greater for type 2 cells (83.0%). Only a few of the cells encountered in the opossum LGN (6%) had on-off receptive fields, and a portion of these could not be shown to be relay cells.(ABSTRACT TRUNCATED AT 400 WORDS)
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