Who benefits most from a prenatal HEPA filter air cleaner intervention on childhood cognitive development? The UGAAR randomized controlled trial.

BACKGROUND: Air pollution exposure during pregnancy affects children's brain function. Maternal stress and nutrition, socioeconomic status, and the child's sex may modify this relationship. OBJECTIVE: To identify characteristics of children with the largest increases in full-scale IQ (FSIQ) after their mothers used HEPA filter air cleaners during pregnancy. METHODS: In this randomized controlled trial we randomly assigned women to receive 1-2 air cleaners or no air cleaners during pregnancy. We analyzed maternal hair samples for cortisol and dehydroepiandrosterone (DHEA). When the children were 48 months old, we measured FSIQ with the Wechsler Preschool and Primary Scale of Intelligence. We evaluated ten potential modifiers of the intervention-FSIQ relationship using interaction terms in separate regression models. To account for correlations between modifiers, we also used a single regression model containing main effects and intervention x modifier terms for all potential modifiers. RESULTS: Among 242 mother-child dyads with complete data, the intervention was associated with a 2.3-point increase (95% CI: -1.5, 6.0 points) in mean FSIQ. The intervention improved mean FSIQ among children of mothers in the bottom (5.4 points; 95% CI: -0.8, 11.5) and top (6.1 points; 95% CI: 0.5, 11.8) cortisol tertiles, but not among those whose mothers were in the middle tertile. The largest between-group difference in the intervention's effect was a 7.5-point (95% CI: -0.7, 15.7) larger increase in mean FSIQ among children whose mothers did not take vitamins than among children whose mothers did take vitamins (interaction p-value = 0.07). We also observed larger benefits among children whose mothers did not complete university, and those with lower hair DHEA concentrations, hair cortisol concentrations outside the middle tertile, or more perceived stress. CONCLUSION: The benefits of reducing air pollution during pregnancy on brain development may be greatest for children whose mothers who do not take vitamins, experience more stress, or have less education.

Portable HEPA filter air cleaner use during pregnancy and children's behavior problem scores: a secondary analysis of the UGAAR randomized controlled trial.

BACKGROUND: Developmental exposure to particulate matter (PM) air pollution may impair children's behaviors. Our objectives were to quantify the impact of reducing indoor PM using portable HEPA filter air cleaners during pregnancy on behavioral problems in children and to assess associations between indoor fine PM (PM2.5) concentrations during pregnancy and children's behavior. METHODS: This is a secondary analysis of a single-blind parallel-group randomized controlled trial in which we randomly assigned 540 non-smoking pregnant women to receive 1 or 2 HEPA filter air cleaners or no air cleaners. We administered the Behavior Assessment System for Children (BASC-3) to caregivers when children were a mean age of 23 months, and again at a mean age of 48 months. Primary outcomes were the four BASC-3 composite scales: externalizing problems, internalizing problems, adaptive skills, and the behavioral symptoms index. We imputed missing data using multiple imputation with chained equations. The primary analysis was by intention-to-treat. In a secondary analysis, we evaluated associations between BASC-3 composite indices and modeled trimester-specific PM2.5 concentrations inside residences. RESULTS: We enrolled participants at a median of 11 weeks gestation. After excluding miscarriages, still births and neonatal deaths, our analysis included 478 children (233 control and 245 intervention). We observed no differences in the mean BASC-3 scores between treatment groups. An interquartile increase (20.1 µg/m3) in first trimester PM2.5 concentration was associated with higher externalizing problem scores (2.4 units, 95% CI: 0.7, 4.1), higher internalizing problem scores (2.4 units, 95% CI: 0.7, 4.0), lower adaptive skills scores (-1.5 units, 95% CI: -3.0, 0.0), and higher behavior symptoms index scores (2.3 units, 95% CI: 0.7, 3.9). Third trimester PM2.5 concentrations were also associated with some behavioral indices at age 4, but effect estimates were smaller. No significant associations were observed with PM2.5 concentrations during the second trimester or for any of the BASC indices when children were 2 years old. CONCLUSION: We found no benefit of reducing indoor particulate air pollution during pregnancy on parent-reported behaviors in children. Associations between indoor PM2.5 concentrations in the first trimester and behavioral scores among 4-year old children suggest that it may be necessary to intervene early in pregnancy to protect children, but these exploratory findings should be interpreted cautiously. TRIAL REGISTRATION: ClinicalTrials.gov: NCT01741051.

Coal smoke, gestational cadmium exposure, and fetal growth.

BACKGROUND: Gestational cadmium exposure may impair fetal growth. Coal smoke has largely been unexplored as a source of cadmium exposure. We investigated the relationship between gestational cadmium exposure and fetal growth, and assessed coal smoke as a potential source of airborne cadmium, among non-smoking pregnant women in Ulaanbaatar, Mongolia, where coal combustion in home heating stoves is a major source of outdoor and indoor air pollution. METHODS: This observational study was nested within the Ulaanbaatar Gestation and Air Pollution Research (UGAAR) study, a randomized controlled trial of portable high efficiency particulate air (HEPA) filter air cleaner use during pregnancy, fetal growth, and early childhood development. We measured third trimester blood cadmium concentrations in 374 out of 465 participants who had a live birth. We used multiple linear and logistic regression to assess the relationships between log2-transformed maternal blood cadmium concentrations and birth weight, length, head circumference, ponderal index, low birth weight, small for gestational age, and preterm birth in crude and adjusted models. We also evaluated the relationships between log2-transformed blood cadmium concentrations and the density of coal-burning stoves within 5000 m of each participant's apartment as a proxy of coal smoke emissions from home heating stoves. RESULTS: The median (25th,75th percentile) blood cadmium concentration was 0.20 (0.15, 0.29) µg/L. A doubling of blood cadmium was associated with a 95 g (95% CI: 34, 155 g) reduction in birth weight in adjusted models. An interquartile range increase in coal stove density (from 3.4 to 4.9 gers/hectare) surrounding participants' apartments was associated with a 12.2% (95% CI: 0.3, 25.6%) increase in blood cadmium concentrations. CONCLUSIONS: Gestational cadmium exposure was associated with reduced birth weight. In settings where coal is a widely used fuel, cadmium may play a role in the putative association between air pollution and impaired fetal growth.

The influence of season and living environment on children's urinary 1-hydroxypyrene levels in Ulaanbaatar, Mongolia.

BACKGROUND: Heating indoor living environments elevates air pollution in Ulaanbaatar, Mongolia. OBJECTIVE: This study was conducted to investigate the influence of season and living environment on children's urinary 1-hydroxypyrene (1-OHP) levels in Ulaanbaatar, Mongolia. METHODS: Our study subjects were 320 children aged 11-15 years living in gers, brick houses and apartments, in ger and non-ger areas of Ulaanbaatar. Spot urine samples and questionnaires were collected three times from each subject in three seasons, September (warm) and December (cold) in 2011 and March (moderate) in 2012. Urinary 1-OHP was analyzed by high-performance liquid chromatography with fluorescent detection (HPLC/FLD). Generalized estimating equation (GEE) models were applied to estimate the seasonal and residential effects on 1-OHP levels, adjusting for demographic and environmental factors. RESULTS: Children's urinary 1-OHP levels showed significant seasonal differences with 0.30 ± 0.57 µmol/mol creatinine in cold season, 0.14 ± 0.12 µmol/mol creatinine in moderate season, and 0.14 ± 0.21 µmol/mol creatinine in warm season. After controlling confounding factors, the GEE model showed that season, living area, and housing type had significant influence on children's urinary 1-OHP levels. Urinary 1-OHP levels in the cold and moderate seasons were, respectively 2.13 and 1.37 times higher than the warm season. Urinary 1-OHP levels for children living in ger areas were 1.27 times higher than those living in non-ger areas. Children who lived in gers or brick houses had 1.58 and 1.34 times higher 1-OHP levels, respectively, compared with those living in apartments. Children's urinary 1-OHP levels were associated with either estimated NO2 or SO2 concentrations at their home addresses in Ulaanbaatar. CONCLUSION: Mongolian children's urinary 1-OHP levels were significantly elevated during the cold season, and for those living in ger areas, gers, or brick houses in Ulaanbaatar. Children's urinary 1-OHP levels were associated PAH co-pollutants SO2 and NO2, suggesting elevated 1-OHP levels may be attributable to PAH emissions from coal burning and traffic respectively, with indoor emissions from stoves further contributing to elevated 1-OHP in some children.

A meta-analysis-based adverse outcome pathway for the male reproductive toxicity induced by microplastics and nanoplastics in mammals.

The male reproductive toxicity of microplastics (MPs) and nanoplastics (NPs) has attracted great attention, but the latent mechanisms remain fragmented. This review performed the adverse outcome pathway (AOP) analysis and meta-analysis in 39 relevant studies, with the AOP analysis to reveal the cause-and-effect relationships of MPs/NPs-induced male reproductive toxicity and the meta-analysis to quantify the toxic effects. In the AOP framework, increased reactive oxygen species (ROS) is the molecular initiating event (MIE), which triggered several key events (KEs) at different levels. At the cellular level, the KEs included oxidative stress, mitochondrial dysfunction, sperm DNA damage, endoplasmic reticulum stress, apoptosis and autophagy of testicular cells, repressed expression of steroidogenic enzymes and steroidogenic acute regulatory protein, disrupted hypothalamic-pituitary-testicular (HPT) axis, and gut microbiota alteration. These KEs further induced the reduction of testosterone, impaired blood-testis barrier (BTB), testicular inflammation, and impaired spermatogenesis at tissue/organ levels. Ultimately, decreased sperm quality or quantity was noted and proved by meta-analysis, which demonstrated that MPs/NPs led to a decrease of 5.99 million/mL in sperm concentration, 14.62% in sperm motility, and 23.56% in sperm viability, while causing an increase of 10.65% in sperm abnormality rate. Overall, this is the first AOP for MPs/NPs-mediated male reproductive toxicity in mammals. The innovative integration of meta-analysis into the AOP analysis increases the rigorism of the results.

Land use patterns and SO2 and NO2 pollution in Ulaanbaatar, Mongolia.

We proposed to study spatial distribution and source contribution of SO2 and NO2 pollution in Ulaanbaatar, Mongolia. We collected 2-week ambient SO2 and NO2 concentration samples at 38 sites, which were classified by major sources of air pollution such as ger areas and/or major roads, in three seasons as warm (September, 2011), cold (November-December, 2011), and moderate (March, 2012) in Ulaanbaatar. The SO2 and NO2 concentrations were collected by Ogawa ambient air passive samplers and analyzed by ion chromatography and spectrophotometry methods, respectively. Stepwise regression models were used to estimate the contribution of emission proxies, such as the distance to major roads, ger areas, power plants, and city center, to the ambient concentrations of SO2 and NO2. We found that the SO2 and NO2 concentrations were significantly higher in the cold season than in the warm and moderate seasons at all 38 ambient sampling sites. The SO2 concentrations in 20 ger sites (46.60 ppb in the cold season and 17.82 ppb in the moderate season) were significantly higher than in 18 non-ger sites (23.35 ppb in the cold season and 12.53 ppb in the moderate season). The NO2 concentrations at 19 traffic/road sites (12.85 ppb in the warm season and 20.48 ppb in the moderate season) were significantly higher than those at 19 urban sites (7.60 ppb and 14.39 ppb in the moderate season). Multiple regression models show that SO2 concentrations decreased by 23% in the cold and 17% in the moderate seasons at 0.70 km from the ger areas, an average of all sampling sites, and by 29% in the moderate season at 4.83 km from the city center, an average of all sampling sites. Multiple regression models show that the NO2 concentrations at 4.83 km from the city center decreased by 38% in the warm and 29% in the moderate seasons. Our models also report that NO2 concentrations at 0.16 km from the main roads decreased by 15% and 9% in the warm and the moderate seasons, respectively, and by 16% in the cold season decreased at the location 0.70 km from the ger area. The NO2 concentration at the location 4.83 km from the city center was decreased by 18% and at the location 4.79 km from the power plants by 21%. Our study concludes that SO2 and NO2 concentrations are very high in Ulaanbaatar, especially in the winter, and can be explained by several land use variables, including the distance to the ger areas, the city center, the main roads, and the power plants.

Sensitivity analysis for live birth bias in the Ulaanbaatar Gestation and Air Pollution Research study.

The Ulaanbaatar Gestation and Air Pollution Research (UGAAR) study is a randomized controlled trial of the effects of portable high efficiency particulate air (HEPA) filter air cleaner use during pregnancy on fetal growth and child health outcomes. A challenge with the study is that the outcome variables cannot be measured in the absence of a live birth. Thus pregnancy loss is a competing event for the outcome variables that can obscure the intervention-outcome relationship. This phenomenon is called "live birth bias" in the epidemiological literature, and it is an example of selection bias due to adjustment for variables affected by previous exposure. Methods: In this investigation, we reanalyzed data from the UGAAR study and examined the impacts of the intervention on three health outcomes: preterm birth (PTB), birth weight, and full-scale IQ (FSIQ) measured with the Wechsler Preschool and Primary Scale of Intelligence III when children were four years old, while accounting for live birth bias. Specifically, we used a novel multiple imputation approach to simulate scenarios in which pregnancy losses had instead been born alive and experienced a range of health outcomes. Results: After accounting for live birth bias, the association between the intervention and PTB diminished. Additionally, the magnitude of intervention effect on birth weight and FSIQ increased. FSIQ was less sensitive to live birth bias than birth weight. Conclusion: We introduced a novel analysis approach to examine the role of live birth bias, and the findings will be useful in environmental epidemiology studies of birth cohorts.

Portable HEPA Filter Air Cleaner Use during Pregnancy and Children's Cognitive Performance at Four Years of Age: The UGAAR Randomized Controlled Trial.

BACKGROUND: Developmental exposure to air pollution is associated with diminished cognitive abilities in observational studies, but no randomized controlled trial has examined the effect of reducing air pollution on cognition in children. OBJECTIVES: We sought to quantify the impact of reducing exposure to particulate matter (PM) during pregnancy on children's cognitive performance at 4 y of age. METHODS: In this single-blind, parallel-group, randomized controlled trial in Ulaanbaatar, Mongolia, we randomly assigned 540 nonsmoking pregnant women (268 intervention and 272 control) to receive 1-2 portable high-efficiency particulate air (HEPA) filter air cleaners or no air cleaners. The air cleaners were used from a median of 11 wk gestation until the end of pregnancy. The primary outcome was full-scale intelligence quotient (FSIQ) assessed using the Wechsler Preschool and Primary Scale of Intelligence, Fourth Edition (WPPSI-IV) when children were a median of 48 months old. We imputed missing outcome data using multiple imputation with chained equations, and our primary analysis was by intention to treat. RESULTS: After excluding known miscarriages, stillbirths, neonatal deaths, and medical conditions that impeded cognitive testing and imputation, 475 (233 control and 242 intervention) children were included in our analyses. In an unadjusted analysis, the mean FSIQ of children who were randomly assigned to the intervention group was 2.5 points [95% confidence interval (CI): -0.4, 5.4 points] higher than that of children in the control group. After adjustment to account for an imbalance in preterm birth between groups, the effect estimate increased to 2.8 points (95% CI: -0.1, 5.7). CONCLUSIONS: Reducing PM air pollution during pregnancy may improve cognitive performance in childhood. https://doi.org/10.1289/EHP10302.

Portable HEPA filter air cleaner use during pregnancy and children's autistic behaviors at four years of age: The UGAAR randomized controlled trial.

BACKGROUND: Developmental exposure to airborne particulate matter (PM) may increase children's risk of developing autism spectrum disorder. We quantified the impact of reducing PM exposure during pregnancy on the development of autistic traits in children. We also assessed associations between indoor fine PM (PM2.5) concentrations during pregnancy and autistic traits. METHODS: In this parallel-group randomized controlled trial, we randomized 540 non-smoking pregnant women to receive HEPA filter air cleaners or to a control group, which did not receive air cleaners. We administered the Social Responsiveness Scale (SRS-2) to caregivers when children were a median of 48 months (range: 48 to 51 months). Our primary outcome was the SRS-2 total T-score. We imputed missing data using multiple imputation with chained equations and our primary analysis was by intention to treat. In secondary analyses, we estimated associations between full pregnancy and trimester-specific indoor PM2.5 concentrations and T-scores. RESULTS: We enrolled participants at a median of 11 weeks' gestation. Our analysis included 478 children (233 control, 245 intervention). The intervention reduced average indoor PM2.5 concentrations by 29 % (95 % CI: 21, 37 %). The mean SRS-2 total T-score was 0.5 units lower (95 % CI: -2.5, 1.5) among intervention participants, with evidence of larger benefits for children at the high end of the T-score distribution. An interquartile range (9.6 µg/m3) increase in indoor PM2.5 during pregnancy was associated with 1.8-unit (95 % CI: 0.3, 3.2) increase in mean SRS-2 total T-score. Effect estimates for PM2.5 concentrations by trimester were smaller and confidence intervals spanned no effect. CONCLUSION: Reducing indoor PM during pregnancy had little impact on mean autism-related behavior scores in children. However, indoor PM2.5 concentrations during pregnancy were associated with higher scores. Exposure to particulate matter during pregnancy may influence the development of autistic traits in childhood. TRIAL REGISTRATION: ClinicalTrials.gov: NCT01741051.

Portable HEPA filter air cleaner use during pregnancy and children's body mass index at two years of age: The UGAAR randomized controlled trial.

IMPORTANCE: Gestational exposure to particulate matter (PM) air pollution may increase the risk of childhood obesity, but the impact of reducing air pollution during pregnancy on obesity-related outcomes in childhood has not been examined. OBJECTIVE: To assess the impact of reducing gestational PM exposure on body mass index (BMI) at two years of age. METHODS: In this single-blind, parallel group randomized controlled trial in Ulaanbaatar Mongolia, we randomly assigned 540 pregnant women to receive 1-2 portable high efficiency particulate air (HEPA) filter air cleaners or no air cleaners. We measured height and weight when children were a mean age of 23.8 months. Our primary outcome was age- and sex-specific BMI z-score based on the World Health Organization 2007 Growth Charts. Secondary outcomes included age- and sex-specific weight z score, overweight/obesity (defined as BMI z-score > 2.00), and catch-up growth (defined using various cut-offs to identify children with relatively low birth weight for sex and gestational age and relatively high age- and sex-specific weight in childhood). We imputed missing outcome data using multiple imputation with chained equations and our primary analysis was by intention to treat (ITT). We estimated intervention effects on continuous and binary outcomes using linear and logistic regression, respectively. RESULTS: After excluding known miscarriages, still births, and neonatal deaths our analysis included 480 children (235 control and 245 intervention). The mean (SD) child BMI z score was 0.79 (1.0); 9.8% of children were overweight or obese. The mean BMI z score of children who were randomly assigned to the intervention group was 0.16-units lower (95% CI: -0.35, 0.04) than children in the control group. The intervention was also associated with reductions in overweight/obesity (odds ratio = 0.59; 95% CI: 0.31, 1.12). Catch-up growth occurred less frequently in the intervention group, but effect estimates varied depending on the specific definition of catch-up growth and confidence intervals consistently spanned no effect. CONCLUSIONS: We found that the use of portable air cleaners during pregnancy was associated with improvements in obesity-related outcomes, although some effect estimates lacked precision. Reducing PM exposure during pregnancy may lead to improvements in cardiometabolic health in childhood.

Evaluation of random forest regression and multiple linear regression for predicting indoor fine particulate matter concentrations in a highly polluted city.

BACKGROUND: Indoor and outdoor fine particulate matter (PM2.5) are both leading risk factors for death and disease, but making indoor measurements is often infeasible for large study populations. METHODS: We developed models to predict indoor PM2.5 concentrations for pregnant women who were part of a randomized controlled trial of portable air cleaners in Ulaanbaatar, Mongolia. We used multiple linear regression (MLR) and random forest regression (RFR) to model indoor PM2.5 concentrations with 447 independent 7-day PM2.5 measurements and 87 potential predictor variables obtained from outdoor monitoring data, questionnaires, home assessments, and geographic data sets. We also developed blended models that combined the MLR and RFR approaches. All models were evaluated in a 10-fold cross-validation. RESULTS: The predictors in the MLR model were season, outdoor PM2.5 concentration, the number of air cleaners deployed, and the density of gers (traditional felt-lined yurts) surrounding the apartments. MLR and RFR had similar performance in cross-validation (R2 = 50.2%, R2 = 48.9% respectively). The blended MLR model that included RFR predictions had the best performance (cross validation R2 = 81.5%). Intervention status alone explained only 6.0% of the variation in indoor PM2.5 concentrations. CONCLUSIONS: We predicted a moderate amount of variation in indoor PM2.5 concentrations using easily obtained predictor variables and the models explained substantially more variation than intervention status alone. While RFR shows promise for modelling indoor concentrations, our results highlight the importance of out-of-sample validation when evaluating model performance. We also demonstrate the improved performance of blended MLR/RFR models in predicting indoor air pollution.

Healthcare waste management in the capital city of Mongolia.

Inconsistencies are present in the management options for healthcare wastes in Mongolia. One of the first critical steps in the process of developing a reliable waste management plan requires the performance of a waste characterization analysis. The objectives of this study were an assessment of the current situation of healthcare waste management (HCWM) and characterization of healthcare wastes generated in Ulaanbaatar. A total about 2.65 tonnes of healthcare wastes are produced each day in Ulaanbaatar (0.78 tons of medical wastes and 1.87 tons of general wastes). The medical waste generation rate per kg/patient-day in the inpatient services of public healthcare facilities was 1.4-3.0 times higher than in the outpatient services (P<0.01). The waste generation rate in the healthcare facilities of Ulaanbaatar was lower than in some other countries; however, the percentage of medical wastes in the total waste stream was comparatively high, ranging from 12.5% to 69.3%, which indicated poor waste handling practices. Despite the efforts for the management of wastes, the current system of healthcare waste management in Ulaanbaatar city of Mongolia is under development and is in dire need of immediate attention and improvement. It is essential to develop a national policy and implement a comprehensive action plan for HCWM providing environmentally sound technological measures to improve HCWM in Mongolia.

The effect of portable HEPA filter air cleaners on indoor PM2.5 concentrations and second hand tobacco smoke exposure among pregnant women in Ulaanbaatar, Mongolia: The UGAAR randomized controlled trial.

BACKGROUND: Portable HEPA filter air cleaners can reduce indoor fine particulate matter (PM2.5), but their use has not been adequately evaluated in high pollution settings. We assessed air cleaner effectiveness in reducing indoor residential PM2.5 and second hand smoke (SHS) exposures among non-smoking pregnant women in Ulaanbaatar, Mongolia. METHODS: We randomized 540 participants to an intervention group receiving 1 or 2 HEPA filter air cleaners or a control group receiving no air cleaners. We followed 259 intervention and 253 control participants to the end of pregnancy. We measured one-week indoor residential PM2.5 concentrations in early (~11weeks gestation) and late (~31weeks gestation) pregnancy and collected outdoor PM2.5 data from centrally-located government monitors. We assessed blood cadmium in late pregnancy. Hair nicotine was quantified in a subset (n=125) to evaluate blood cadmium as a biomarker of SHS exposure. We evaluated air cleaner effectiveness using mixed effects and multiple linear regression models and used stratified models and interaction terms to evaluate potential modifiers of effectiveness. RESULTS: The overall geometric mean (GM) one-week outdoor PM2.5 concentration was 47.9µg/m3 (95% CI: 44.6, 51.6µg/m3), with highest concentrations in winter (118.0µg/m3; 110.4, 126.2µg/m3). One-week indoor and outdoor PM2.5 concentrations were correlated (r=0.69). Indoor PM2.5 concentrations were 29% (21, 37%) lower in intervention versus control apartments, with GMs of 17.3µg/m3 (15.8, 18.8µg/m3) and 24.5µg/m3 (22.2, 27.0µg/m3), respectively. Air cleaner effectiveness was greater when air cleaners were first deployed (40%; 31, 48%) than after approximately five months of use (15%; 0, 27%). Blood cadmium concentrations were 14% (4, 23%) lower among intervention participants, likely due to reduced SHS exposure. CONCLUSIONS: Portable HEPA filter air cleaners can lower indoor PM2.5 concentrations and SHS exposures in highly polluted settings.

The effect of portable HEPA filter air cleaner use during pregnancy on fetal growth: The UGAAR randomized controlled trial.

BACKGROUND: Fine particulate matter (PM2.5) exposure may impair fetal growth. AIMS/OBJECTIVES: Our aim was to assess the effect of portable high efficiency particulate air (HEPA) filter air cleaner use during pregnancy on fetal growth. METHODS: The Ulaanbaatar Gestation and Air Pollution Research (UGAAR) study is a single-blind randomized controlled trial conducted in Ulaanbaatar, Mongolia. Non-smoking pregnant women recruited at ≤18 weeks gestation were randomized to an intervention (1-2 air cleaners in homes from early pregnancy until childbirth) or control (no air cleaners) group. Participants were not blinded to their intervention status. Demographic, health, and birth outcome data were obtained via questionnaires and clinic records. We used unadjusted linear and logistic regression and time-to-event analysis to evaluate the intervention. Our primary outcome was birth weight. Secondary outcomes were gestational age-adjusted birth weight, birth length, head circumference, gestational age at birth, and small for gestational age. The study is registered at ClinicalTrials.gov (NCT01741051). RESULTS: We recruited 540 participants (272 control and 268 intervention) from January 9, 2014 to May 1, 2015. There were 465 live births and 28 losses to follow up. We previously reported a 29% (95% CI: 21, 37%) reduction in indoor PM2.5 concentrations with portable HEPA filter air cleaner use. The median (25th, 75th percentile) birth weights for control and intervention participants were 3450 g (3150, 3800 g) and 3550 g (3200, 3800 g), respectively (p = 0.34). The intervention was not associated with birth weight (18 g; 95% CI: -84, 120 g), but in a pre-specified subgroup analysis of 429 term births the intervention was associated with an 85 g (95% CI: 3, 167 g) increase in mean birth weight. CONCLUSIONS: HEPA filter air cleaner use in a high pollution setting was associated with greater birth weight only among babies born at term.

An assessment of air pollution and its attributable mortality in Ulaanbaatar, Mongolia.

Epidemiologic studies have consistently reported associations between outdoor fine particulate matter (PM2.5) air pollution and adverse health effects. Although Asia bears the majority of the public health burden from air pollution, few epidemiologic studies have been conducted outside of North America and Europe due in part to challenges in population exposure assessment. We assessed the feasibility of two current exposure assessment techniques, land use regression (LUR) modeling and mobile monitoring, and estimated the mortality attributable to air pollution in Ulaanbaatar, Mongolia. We developed LUR models for predicting wintertime spatial patterns of NO2 and SO2 based on 2-week passive Ogawa measurements at 37 locations and freely available geographic predictors. The models explained 74% and 78% of the variance in NO2 and SO2, respectively. Land cover characteristics derived from satellite images were useful predictors of both pollutants. Mobile PM2.5 monitoring with an integrating nephelometer also showed promise, capturing substantial spatial variation in PM2.5 concentrations. The spatial patterns in SO2 and PM, seasonal and diurnal patterns in PM2.5, and high wintertime PM2.5/PM10 ratios were consistent with a major impact from coal and wood combustion in the city's low-income traditional housing (ger) areas. The annual average concentration of PM2.5 measured at a centrally located government monitoring site was 75 µg/m3 or more than seven times the World Health Organization's PM2.5 air quality guideline, driven by a wintertime average concentration of 148 µg/m3. PM2.5 concentrations measured in a traditional housing area were higher, with a wintertime mean PM2.5 concentration of 250 µg/m3. We conservatively estimated that 29% (95% CI, 12-43%) of cardiopulmonary deaths and 40% (95% CI, 17-56%) of lung cancer deaths in the city are attributable to outdoor air pollution. These deaths correspond to nearly 10% of the city's total mortality, with estimates ranging to more than 13% of mortality under less conservative model assumptions. LUR models and mobile monitoring can be successfully implemented in developing country cities, thus cost-effectively improving exposure assessment for epidemiology and risk assessment. Air pollution represents a major threat to public health in Ulaanbaatar, Mongolia, and reducing home heating emissions in traditional housing areas should be the primary focus of air pollution control efforts.