Assessment of prevalence of elevated blood lead levels and risk factors among children and pregnant women in Bihar, India.

BACKGROUND: While modeled estimates and studies in contaminated areas indicate high lead exposure among children in Bihar, India, local data on lead exposure in the child population is limited. OBJECTIVES: To characterize lead exposure, and assess potential sources of lead exposure among a state-representative sample of children and their pregnant mothers residing in Bihar. METHODS: Blood samples were collected from 697 children under five and 55 pregnant women from eight districts in Bihar. Blood lead levels were determined using capillary blood and a portable lead analyzer. Household demographics, home environment, behavior, and nutrition information were collected through computer-assisted personal interviews with primary caregivers. Logistic regression was used to assess associations between potential risk factors and elevated blood lead levels. RESULTS: More than 90% of children and 80% of pregnant women reported blood lead levels ≥5 µg/dL. Living near a lead-related industry and pica behavior of eating soil were significantly associated with increased odds of having elevated blood lead levels. Additional risk factors for having a blood level ≥5 µg/dL included the use of skin lightning cream (aOR = 5.11, 95%CI: 1.62, 16.16) and the use of eyeliners (aOR = 2.81, 95%CI: 1.14, 6.93). Having blood lead levels ≥10 µg/dL was also significantly associated with the household member who had an occupation or hobby involving the use of lead (aOR = 1.75, 95%CI: 1.13, 2.72). DISCUSSION: Elevated blood lead levels were prevalent among children and pregnant women in Bihar, indicating the urgent need for a comprehensive lead poisoning prevention strategy.

Beyond air pollution: a national assessment of cooking-related burns in Ghana.

INTRODUCTION: Household energy transitions have the potential to reduce the burden of several health outcomes but have narrowly focused on those mediated by reduced exposure to air pollution, despite concerns about the burden of injury outcomes. Here, we aimed to describe the country-level incidence of severe cooking-related burns in Ghana and identify household-level risk factors for adults and children. METHODS: We conducted a national household energy use survey including 7389 households across 370 enumeration areas in Ghana in 2020. In each household, a pretested version of the Clean Cooking Alliance Burns Surveillance Module was administered to the primary cook. We computed incidence rates of severe cooking-related burns and conducted bivariate logistic regression to identify potential risk factors. RESULTS: We documented 129 severe cooking-related burns that had occurred in the previous year. The incidence rate (95% CI) of cooking-related burns among working-age females was 17 (13 to 21) per 1000 person-years or 8.5 times higher than that of working-age males. Among adults, the odds of experiencing a cooking-related burn were 2.29 (95% CI 1.02 to 5.14) and 2.40 (95% CI 1.04 to 5.55) times higher among primary wood and charcoal users respectively compared with primary liquified petroleum gas users. No child burns were documented in households where liquified petroleum gas was primarily used. CONCLUSION: Using a nationally representative sample, we found that solid fuel use doubled the odds of cooking-related burns compared with liquified petroleum gas. Ghana's efforts to expand access to liquified petroleum gas should focus on safe use.

The design and evaluation of a system for improved surveillance and prevention programmes in resource-limited settings using a hospital-based burn injury questionnaire.

BACKGROUND: Limited and fragmented data collection systems exist for burn injury. A global registry may lead to better injury estimates and identify risk factors. A collaborative effort involving the WHO, the Global Alliance for Clean Cookstoves, the CDC and the International Society for Burn Injuries was undertaken to simplify and standardise inpatient burn data collection. An expert panel of epidemiologists and burn care practitioners advised on the development of a new Global Burn Registry (GBR) form and online data entry system that can be expected to be used in resource-abundant or resource-limited settings. METHODS: International burn organisations, the CDC and the WHO solicited burn centre participation to pilot test the GBR system. The WHO and the CDC led a webinar tutorial for system implementation. RESULTS: During an 8-month period, 52 hospitals in 30 countries enrolled in the pilot and were provided the GBR instrument, guidance and a data visualisation tool. Evaluations were received from 29 hospitals (56%). KEY FINDINGS: Median time to upload completed forms was <10 min; physicians most commonly entered data (64%), followed by nurses (25%); layout, clarity, accuracy and relevance were all rated high; and a vast majority (85%) considered the GBR 'highly valuable' for prioritising, developing and monitoring burn prevention programmes. CONCLUSIONS: The GBR was shown to be simple, flexible and acceptable to users. Enhanced regional and global understanding of burn epidemiology may help prioritise the selection, development and testing of primary prevention interventions for burns in resource-limited settings.

Chronic obstructive pulmonary disease secondary to household air pollution.

Approximately 3 billion people around the world cook and heat their homes using solid fuels in open fires and rudimentary stoves, resulting in household air pollution. Household air pollution secondary to indoor combustion of solid fuel is associated with multiple chronic obstructive pulmonary disease (COPD) outcomes. The exposure is associated with both chronic bronchitis and emphysema phenotypes of COPD as well as a distinct form of obstructive airway disease called bronchial anthracofibrosis. COPD from household air pollution differs from COPD from tobacco smoke with respect to its disproportionately greater bronchial involvement, lesser emphysematous change, greater impact on quality of life, and possibly greater oxygen desaturation and pulmonary hypertensive changes. Interventions that decrease exposure to biomass smoke may decrease the risk for incident COPD and attenuate the longitudinal decline in lung function, but more data on exposure-response relationships from well-designed longitudinal studies are needed.

Millions dead: how do we know and what does it mean? Methods used in the comparative risk assessment of household air pollution.

In the Comparative Risk Assessment (CRA) done as part of the Global Burden of Disease project (GBD-2010), the global and regional burdens of household air pollution (HAP) due to the use of solid cookfuels, were estimated along with 60+ other risk factors. This article describes how the HAP CRA was framed; how global HAP exposures were modeled; how diseases were judged to have sufficient evidence for inclusion; and how meta-analyses and exposure-response modeling were done to estimate relative risks. We explore relationships with the other air pollution risk factors: ambient air pollution, smoking, and secondhand smoke. We conclude with sensitivity analyses to illustrate some of the major uncertainties and recommendations for future work. We estimate that in 2010 HAP was responsible for 3.9 million premature deaths and ∼4.8% of lost healthy life years (DALYs), ranking it highest among environmental risk factors examined and one of the major risk factors of any type globally.

In praise of fossil fuel subsidies (for cooking).

Households that burn biomass in inefficient open fires - a practice that results in $1.6 trillion in global damages from health impacts and climate-altering emissions yearly - are often unable to access cleaner alternatives, like gas, which is widely available but unaffordable, or electricity, which is unattainable for many due to insufficient supply and reliability of electricity services. Governments are often reluctant to make gas affordable. We argue that condemnation of all fossil fuel subsidies is short-sighted and does not adequately consider subsidizing gas for cooking as a potential strategy to improve public health and reduce greenhouse gas emissions.

In praise of cooking gas subsidies: transitional fuels to advance health and equity.

Households that burn biomass in inefficient open fires-a practice that results in $1.6 trillion in global damages from health impacts and climate-altering emissions yearly-are often unable to access cleaner alternatives, like gas, which is widely available but unaffordable, or electricity, which is unattainable for many due to insufficient supply and reliability of electricity services. Governments are often reluctant to make gas affordable. We argue that condemnation of all fossil fuel subsidies is short-sighted and does not adequately consider subsidizing gas for cooking as a potential strategy to improve public health and reduce greenhouse gas emissions.

Cleaner cooking solutions to achieve health, climate, and economic cobenefits.

Nearly half the world's population must rely on solid fuels such as biomass (wood, charcoal, agricultural residues, and animal dung) and coal for household energy, burning them in inefficient open fires and stoves with inadequate ventilation. Household solid fuel combustion is associated with four million premature deaths annually; contributes to forest degradation, loss of habitat and biodiversity, and climate change; and hinders social and economic progress as women and children spend hours every day collecting fuel. Several recent studies, as well as key emerging national and international efforts, are making progress toward enabling wide-scale household adoption of cleaner and more efficient stoves and fuels. While significant challenges remain, these efforts offer considerable promise to save lives, improve forest sustainability, slow climate change, and empower women around the world.

Impacts of Air Pollution on Health and Cost of Illness in Jakarta, Indonesia.

(1) Background: This study aimed to quantify the health and economic impacts of air pollution in Jakarta Province, the capital of Indonesia. (2) Methods: We quantified the health and economic burden of fine particulate matter (PM2.5) and ground-level Ozone (O3), which exceeds the local and global ambient air quality standards. We selected health outcomes which include adverse health outcomes in children, all-cause mortality, and daily hospitalizations. We used comparative risk assessment methods to estimate health burdens attributable to PM2.5 and O3, linking the local population and selected health outcomes data with relative risks from the literature. The economic burdens were calculated using cost-of-illness and the value of the statistical life-year approach. (3) Results: Our results suggest over 7000 adverse health outcomes in children, over 10,000 deaths, and over 5000 hospitalizations that can be attributed to air pollution each year in Jakarta. The annual total cost of the health impact of air pollution reached approximately USD 2943.42 million. (4) Conclusions: By using local data to quantify and assess the health and economic impacts of air pollution in Jakarta, our study provides timely evidence needed to prioritize clean air actions to be taken to promote the public's health.

Effects of short-term exposure to air pollution on hospital admissions of young children for acute lower respiratory infections in Ho Chi Minh City, Vietnam.

There is emerging evidence, largely from studies in Europe and North America, that economic deprivation increases the magnitude of morbidity and mortality related to air pollution. Two major reasons why this may be true are that the poor experience higher levels of exposure to air pollution, and they are more vulnerable to its effects--in other words, due to poorer nutrition, less access to medical care, and other factors, they experience more health impact per unit of exposure. The relations among health, air pollution, and poverty are likely to have important implications for public health and social policy, especially in areas such as the developing countries of Asia where air pollution levels are high and many live in poverty. The aims of this study were to estimate the effect of exposure to air pollution on hospital admissions of young children for acute lower respiratory infection (ALRI*) and to explore whether such effects differed between poor children and other children. ALRI, which comprises pneumonia and bronchiolitis, is the largest single cause of mortality among young children worldwide and is responsible for a substantial burden of disease among young children in developing countries. To the best of our knowledge, this is the first study of the health effects of air pollution in Ho Chi Minh City (HCMC), Vietnam. For these reasons, the results of this study have the potential to make an important contribution to the growing literature on the health effects of air pollution in Asia. The study focused on the short-term effects of daily average exposure to air pollutants on hospital admissions of children less than 5 years of age for ALRI, defined as pneumonia or bronchiolitis, in HCMC during 2003, 2004, and 2005. Admissions data were obtained from computerized records of Children's Hospital 1 and Children's Hospital 2 (CH1 and CH2) in HCMC. Nearly all children hospitalized for respiratory illnesses in the city are admitted to one of these two pediatric hospitals. Daily citywide 24-hour average concentrations of particulate matter (PM) < or =10 microm in aerodynamic diameter (PM10), nitrogen dioxide (NO2), and sulfur dioxide (SO2) and 8-hour maximum average concentrations of ozone (O3) were estimated from the HCMC Environmental Protection Agency (HEPA) ambient air quality monitoring network. Daily meteorologic information including temperature and relative humidity were collected from KTTV NB, the Southern Regional Hydro-Meteorological Center. An individual-level indicator of socioeconomic position (SEP) was based on the degree to which the patient was exempt from payment according to hospital financial records. A group-level indicator of SEP was based on estimates of poverty prevalence in the districts of HCMC in 2004, obtained from a poverty mapping project of the Institute of Economic Research in HCMC, in collaboration with the General Statistics Office of Vietnam and the World Bank. Poverty prevalence was defined using the poverty line set by the People's Committee of HCMC of 6 million Vietnamese dong (VND) annual income. Quartiles of district-level poverty prevalence were created based on poverty prevalence estimates for each district. Analyses were conducted using both time-series and case-crossover approaches. In the absence of measurement error, confounding, and other sources of bias, the two approaches were expected to provide estimates that differed only with regard to precision. For the time-series analyses, the unit of observation was daily counts of hospital admissions for ALRI. Poisson regression with smoothing functions for meteorologic variables and variables for seasonal and long-term trends was used. Case-crossover analyses were conducted using time-stratified selection of controls. Control days were every 7th day from the date of admission within the same month as admission. Large seasonal differences were observed in pollutant levels and hospital admission patterns during the investigation period for HCMC. Of the 15,717 ALRI admissions occurring within the study period, 60% occurred in the rainy season (May through October), with a peak in these admissions during July and August of each year. Average daily concentrations for PM10, O3, NO2, and SO2 were 73, 75, 22, and 22 microg/m3, respectively, with higher pollutant concentrations observed in the dry season (November through April) compared with the rainy season. As the time between onset of illness and hospital admission was thought to range from 1 to 6 days, it was not possible to specify a priori a single-day lag. We assessed results for single-day lags from lag 0 to lag 10, but emphasize results for an average of lag 1-6, since this best reflects the case reference period. Results were robust to differences in temperature lags with lag 0 and the average lag (1-6 days); results for lag 0 for temperature are presented. Results differed markedly when analyses were stratified by season, rather than simply adjusted for season. ALRI admissions were generally positively associated with ambient levels of PM10, NO2, and SO2 during the dry season (November-April), but not the rainy season (May-October). Positive associations between O3 and ALRI admissions were not observed in either season. We do not believe that exposure to air pollution could reduce the risk of ALRI in the rainy season and infer that these results could be driven by residual confounding present within the rainy season. The much lower correlation between NO2 and PM10 levels during the rainy season provides further evidence that these pollutants may not be accurate indicators of exposure to air pollution from combustion processes in the rainy season. Results were generally consistent across time-series and case-crossover analyses. In the dry season, risks for ALRI hospital admissions with average pollutant lag (1-6 days) were highest for NO2 and SO2 in the single-pollutant case-crossover analyses, with excess risks of 8.50% (95% CI, 0.80-16.79) and 5.85% (95% CI, 0.44-11.55) observed, respectively. NO2 and SO2 effects remained higher than PM10 effects in both the single-pollutant and two-pollutant models. The two-pollutant model indicated that NO2 confounded the PM10 and SO2 effects. For example, PM10 was weakly associated with an excess risk in the dry season of 1.25% (95% CI, -0.55 to 3.09); after adjusting for SO2 and O3, the risk estimate was reduced but remained elevated, with much wider confidence intervals; after adjusting for NO2, an excess risk was no longer observed. Though the effects seem to be driven by NO2, the statistical limitations of adequately addressing collinearity, given the high correlation between PM10 and NO2 (r = 0.78), limited our ability to clearly distinguish between PM10 and NO2 effects. In the rainy season, negative associations between PM10 and ALRI admissions were observed. No association with O3 was observed in the single-pollutant model, but O3 exposure was negatively associated with ALRI admissions in the two-pollutant model. There was little evidence of an association between NO2 and ALRI admissions. The single-pollutant estimate from the case-crossover analysis suggested a negative association between NO2 and ALRI admissions, but this effect was no longer apparent after adjustment for other pollutants. Although associations between SO2 and ALRI admissions were not observed in the rainy season, point estimates for the case-crossover analyses suggested negative associations, while time-series (Poisson regression) analyses suggested positive associations--an exception to the general consistency between case-crossover and time-series results. Results were robust to differences in seasonal classification. Inclusion of rainfall as a continuous variable and the seasonal reclassification of selected series of data did not influence results. No clear evidence of station-specific effects could be observed, since results for the different monitoring stations had overlapping confidence intervals. In the dry season, increased concentrations of NO2 and SO2 were associated with increased hospital admissions of young children for ALRI in HCMC. PM10 could also be associated with increased hospital admissions in the dry season, but the high correlation of 0.78 between PM10 and NO2 levels limits our ability to distinguish between PM10 and NO2 effects. Nevertheless, the results support the presence of an association between combustion-source pollution and increased ALRI admissions. There also appears to be evidence of uncontrolled negative confounding within the rainy season, with higher incidence of ALRI and lower pollutant concentrations overall. Exploratory analyses made using limited historical and regional data on monthly prevalence of respiratory syncytial virus (RSV) suggest that an unmeasured, time-varying confounder (RSV, in this case) could have, in an observational study like this one, created enough bias to reverse the observed effect estimates of pollutants in the rainy season. In addition, with virtually no RSV incidence in the dry season, these findings also lend some credibility to the notion that RSV could influence results primarily in the rainy season. Analyses were not able to identify differential effects by individual-level indicators of SEP, mainly due to the small number of children classified as poor based on information in the hospitals' financial records. Analyses assessing differences in effect by district-level indicator of SEP did not indicate a clear trend in risk across SEP quartiles, but there did appear to be a slightly higher risk among the residents of districts with the highest quartile of SEP. As these are the districts within the urban center of HCMC, results could be indicative of increased exposures for residents living within the city center. (ABSTRACT TRUNCATED)

Ambient and household air pollution on early-life determinants of stunting-a systematic review and meta-analysis.

Stunting is an important risk factor for early growth and health implications throughout the life course, yet until recently, studies have rarely focused on populations exposed to high levels of particulate matter pollution or on developing countries most vulnerable to stunting and its associated health and developmental impacts. We systematically searched for epidemiologic studies published up to 15 August 2020 that examined the association between ambient and household particulate exposure and postnatal stunting (height-for-age z-score) and prenatal determinants (small for gestational age or SGA, or equivalent) of stunting. We conducted the literature search in PUBMED, MEDLINE, EMBASE, and Web of Science databases in August 2020, using keywords including, but not limited to, "particulate matter," "indoor/household air pollution," and "adverse birth outcomes," to identify relevant articles. Forty-five studies conducted in 29 countries met our inclusion criteria for meta-analysis. We found significant positive associations between SGA and a 10 µg/m3 increase in fine particulate matter (PM2.5) exposure over the entire pregnancy [OR = 1.08; 95% confidence interval (CI): 1.03-1.13], with similar SGA impact during the second and third trimesters, and from high exposure quartile of PM2.5 exposure during the entire pregnancy. A 19% increased risk of postnatal stunting (95% CI: 1.10, 1.29) was also associated with postnatal exposure to household air pollution. Our analysis shows consistent, significant, and noteworthy evidence of elevated risk of stunting-related health outcomes with ambient PM2.5 and household air pollution exposure. This evidence reinforces the importance of promoting clean air as part of an integrated approach to preventing stunting.

Reducing Premature Mortality from Cardiovascular and Other Non-Communicable Diseases by One Third: Achieving Sustainable Development Goal Indicator 3.4.1.

Non-communicable diseases (NCDs) are the world's leading causes of death and disability, with cardiovascular disease (CVD) accounting for half of NCD deaths. An ambitious global target established by the United Nations Sustainable Development Goals - indicator 3.4.1 - aims to reduce the risk of premature death among people aged 30-69 years from CVD, cancer, diabetes, and chronic lung disease by one third by 2030. This article reviews the science and practice informing what is required to achieve this target, identifying seven interventions that can accelerate progress: 1) tobacco control; 2) treatment to reduce cardiovascular risk; 3) reduction of dietary sodium; 4) reduction of household air pollution; 5) elimination of artificial trans fat; 6) reduction of alcohol use; and 7) prevention, detection, and treatment of cancers. Achieving the target is possible - there has already been progress in some areas, particularly related to CVD reduction - but only if there is faster, more concerted action.

An analysis of efforts to scale up clean household energy for cooking around the world.

Approximately 3 billion people, most of whom live in Asia, Africa, and the Americas, rely on solid fuels (i.e. wood, crop wastes, dung, charcoal) and kerosene for their cooking needs. Exposure to household air pollution from burning these fuels is estimated to account for approximately 3 million premature deaths a year. Cleaner fuels - such as liquefied petroleum gas, biogas, electricity, and certain compressed biomass fuels - have the potential to alleviate much of this significant health burden. A wide variety of clean cooking intervention programs are being implemented around the world, but very few of these efforts have been analyzed to enable global learning. The Clean Cooking Implementation Science Network (ISN), supported by the U.S. National Institutes of Health (NIH) and partners, identified the need to augment the publicly available literature concerning what has worked well and in what context. The ISN has supported the development of a systematic set of case studies, contained in this Special Issue, examining clean cooking program rollouts in a variety of low- and middle-income settings around the world. We used the RE-AIM (reach, effectiveness, adaptation, implementation, maintenance) framework to coordinate and evaluate the case studies. This paper describes the clean cooking case studies project, introduces the individual studies contained herein, and proposes a general conceptual model to support future planning and evaluation of household energy programs.

Global household air pollution database: Kitchen concentrations and personal exposures of particulate matter and carbon monoxide.

The Global Household Air Pollution (HAP) Measurements database, commissioned by the World Health Organization, provides an organized summary of data reported in the literature describing HAP microenvironments, methods and measurements. As of June 2018, the database contains measurements from 43 countries obtained from 196 studies published through 2016. The database includes information useful for understanding the range of household and personal air pollution measurements that have been collected in a country, as well as characteristics of the cooking environment, including primary cooking fuel type, stove type, heating fuel type and kitchen location. Quantitative particulate matter (PM) of various size fractions and/or carbon monoxide (CO) exposure measurements included in the database can be aggregated and analyzed to generate summary statistics (e.g. average sub-national, national, regional and global HAP exposures) to assess temporal and spatial relationships. The quantitative PM exposure measurements in the database have been used in global predictive modeling of HAP-PM2.5 exposures ("Global Estimation of Exposure to Fine Particulate Matter (PM2.5) from Household Air Pollution" (Shupler et al., 2018) [1]).

Assessing household solid fuel use: multiple implications for the Millennium Development Goals.

OBJECTIVE: The World Health Organization is the agency responsible for reporting the Millennium Development Goal (MDG) indicator "percentage of population using solid fuels." In this article, we present the results of a comprehensive assessment of solid fuel use, conducted in 2005, and discuss the implications of our findings in the context of achieving the MDGs. METHODS: For 93 countries, solid fuel use data were compiled from recent national censuses or household surveys. For the 36 countries where no data were available, the indicator was modeled. For 52 upper-middle or high-income countries, the indicator was assumed to be < 5%. RESULTS: According to our assessment, 52% of the world's population uses solid fuels. This percentage varies widely between countries and regions, ranging from 77%, 74%, and 74% in Sub-Saharan Africa, Southeast Asia, and the Western Pacific Region, respectively, to 36% in the Eastern Mediterranean Region, 16% in Latin America and the Caribbean and in Central and Eastern Europe. In most industrialized countries, solid fuel use falls to the < 5% mark. DISCUSSION: Although the "percentage of population using solid fuels" is classified as an indicator to measure progress towards MDG 7, reliance on traditional household energy practices has distinct implications for most of the MDGs, notably MDGs 4 and 5. There is an urgent need for development agendas to recognize the fundamental role that household energy plays in improving child and maternal health and fostering economic and social development.

Assessing exposures to household air pollution in public health research and program evaluation.

Exposure to smoke from the use of solid fuels and inefficient stoves for cooking and heating is responsible for approximately 4 million premature deaths yearly. As increasing investments are made to tackle this important public health issue, there is a need for identifying and providing guidance on best practices for exposure and stove performance monitoring, particularly for public health research and evaluation studies. This paper, which builds upon the discussion at an expert consultation on exposure assessment convened by the Global Alliance for Clean Cookstoves, the Centers for Disease Control and Prevention, and PATH in late 2012, aims to provide general guidance on what to monitor, who and where to monitor, and how to monitor household air pollution exposures. In addition, we summarize information about commercially available monitoring equipment and the technical properties of these monitors most important for household air pollution exposure assessment. The target audience includes epidemiologists conducting health studies and program evaluators aiming to quantify changes in exposures to estimate the potential health benefits of cookstoves intervention projects.

Exposure assessment for respirable particulates associated with household fuel use in rural districts of Andhra Pradesh, India.

Indoor air pollution associated with combustion of solid fuels seems to be a major contributor to the national burden of disease in India, but relatively few quantitative exposure assessment studies are available. This study quantified the daily average concentrations of respirable particulates (50% cut-off at 4 microm) in 412 rural homes selected through stratified random sampling from three districts of Andhra Pradesh, India and recorded time activity data from 1400 individuals to reconstruct 24-h average exposures. The mean 24-h average concentrations ranged from 73 to 732 microg/m(3) in gas- versus solid fuel-using households, respectively. Concentrations were significantly correlated with fuel type, kitchen type, and fuel quantity. The mean 24-h average exposures ranged from 80 to 573 microg/m(3). Among solid fuel users, the mean 24-h average exposures were the highest for women cooks and were significantly different from men and children. Among women, exposures were the highest in the age group of 15-40 years (most likely to be involved in cooking or helping in cooking), while among men, exposures were highest in the age group of 65-80 years (most likely to be indoors). The data are being used to develop a model to predict quantitative categories of population exposure based on survey information on housing and fuel characteristics. This would facilitate the development of a regional exposure database and enable better estimation of health risks.