Sanitation in Rural India: Exploring the Associations between Dwelling Space and Household Latrine Ownership.

In 2017, the Joint Monitoring Programme estimated that 520 million people in India were defecating in the open every day. This is despite efforts made by the government, Non-Governmental Organizations (NGOs), and multilaterals to improve latrine coverage throughout India. We hypothesize that this might be because current interventions focus mostly on individual-level determinants, such as attitudes and beliefs, instead of considering all possible social determinants of latrine ownership. Given this, we ask two questions: what is the association between the amount of dwelling space owned by households in rural India and their likelihood of toilet ownership and what proportion of the variation in household latrine ownership is attributable to villages and states? We used multilevel modeling and found significant associations between the amount of household dwelling space and the likelihood of latrine ownership. Furthermore, considerable variation in latrine ownership is attributable to villages and states, suggesting that additional research is required to elucidate the contextual effects of villages and states on household latrine ownership. Thus, sanitation interventions should consider household dwelling space and village and state context as important social determinants of latrine ownership in rural India. Doing so could bolster progress towards Sustainable Development Goal (SDG) 6.

A Low-Cost Stove Use Monitor to Enable Conditional Cash Transfers.

Conditional cash transfers (CCTs)-cash payments provided to households or specific household members who meet defined conditions or fulfill certain behaviors-have been extensively used in India to encourage antenatal care, institutional delivery, and vaccination. This paper describes the social design and technical development of a low-cost, meal-counting stove use monitor (the Pink Key) that enables a CCT based on liquefied petroleum gas (LPG) usage and presents pilot data from its testing and the initial deployment. The system consists of a sensing harness attached to a two-burner LPG stove and an easily removable datalogger. For each cooking event with LPG, households receive 2 rupees-less than the cost of fuel, but enough to partially defray LPG refill costs. The system could enable innovative "self-monitoring" at a large scale-participants initiate the CCT by bringing their Pink Key to antenatal clinic visits, where care providers download data and initiate payments, and participants return the sensor to their stove at home. The system aligns with existing Indian programs to improve health among poor, pregnant women, and contributes a new method to encourage the use of clean cooking technologies.

Better kitchens and toilets: both needed for better health.

Both poor water, sanitation, hygiene (WaSH) and household air pollution (HAP) adversely affect the health of millions of people each year around the globe and specifically in developing countries. The objective of current work is to highlight the importance of HAP in parallel to WaSH for decision making to achieve better health specially in developing countries. There are examples, where developing countries are strengthening efforts to tackle the issue of poor water and sanitation such as 'Clean India Mission' was recently launched by the Government of India. However, there is lack of actions to address the issue related to HAP-to extend the coverage of clean fuel, efficient stoves and ventilated kitchens to the deprived population under the 'Clean India Mission'. Most of the rural household and urban slums in developing countries have only a single room, where people cook and sleep. This leads them to exposure to toxic HAP, which can be minimized by developing country specific indoor air quality guidelines and action framework. Hence, there should be policies to provide them not only the subsidy for clean fuel but also to build properly ventilated kitchens along with the promotion of clean toilets and water supplies. There is a need to strengthen global efforts, to jointly address the challenges associated with the risks related to WaSH and HAP in order to efficiently reduce the global burden of disease. Further, this will also help to timely attain the sustainable development goals for better health and environment.

Afecciones respiratorias por el uso de leña y carbón en comunidades de Paraguay

Introducción: El uso de combustibles sólidos está asociado con más de 4 millones de muertes prematuras anuales en el mundo, especialmente de mujeres y niños. El uso del carbón y la leña son todavía muy prevalentes en Paraguay donde el 21% de la población urbana y 71% de la población rural utilizan estos combustibles para cocinar. Objetivo: Describir el uso de energía en los hogares de dos comunidades en Paraguay, una semi urbana y una rural. Metodología: Se trata de un estudio de tipo descriptivo y de corte transverso que se realizó por medio de una encuesta en 250 casas seleccionadas aleatoriamente. Resultados: El análisis de los datos obtenidos muestra que más del 74% de los hogares usan carbón vegetal, ya sea como combustible principal o secundario, el gas licuado del petróleo (GLP) es más usado en la comunidad semiurbana (59% > 43%) y la leña es más usada en la comunidad rural (49.6% >22.8%). El uso de leña implica un mayor tiempo destinado a la recolección, acondicionamiento y cocinado de alimentos. El uso de leña y carbón se hace predominantemente al aire libre (84% de los hogares) en cocinas sin chimenea. Se encontró una mayor prevalencia de enfermedades respiratorias en los hogares que utilizan carbón o leña (45%> 29%). El uso de electricidad para cocinar no es muy prevalente (únicamente el 7% lo usa como combustible principal). Conclusión: El uso de carbón y leña en los hogares del Paraguay es alto lo que tiene repercusiones en la salud y favorece las condiciones de inequidad social en el país. Se considera que una buena alternativa al uso de biomasa en Paraguay sería la electricidad, debido a que cuenta con grandes recursos hidroeléctricos y la red eléctrica cubre a casi la totalidad de la población (99%).

Introduction: The use of solid fuels is associatedwith more than 4 million premature deaths annually in the world, especially in women and children. The use of charcoal and firewood is still very prevalent in Paraguay, where 21% of the urban population and 71% of the rural population use these fuels for cooking. Objective: To describe the use of energy in the homes of two communities in Paraguay, a semi-urban and a rural one. Material and Methods: This was a descriptive and cross-sectional study that was carried out by means of a survey in 250 randomly selected households. Results: The analysis of the data obtained showed that more than 74% of households used charcoal, either as a primary or a secondary fuel. Liquefied petroleum gas (LPG) was more commonly used in the semi-urban community (59%> 43%) and firewood was more used in the rural community (49.6%> 22.8%). The use of firewood implies a longer time for the collection, preparation and cooking of food. The use of firewood and charcoal was predominantly outdoors ( 84 % of households) in kitchens without a fireplace. A higher prevalence of respiratory diseases was found in households that used charcoal or firewood (45%> 29%). The use of electricity for cooking was not very prevalent (only 7% used it as the main fuel). Conclusion: The prevalence of the use of charcoal and wood in homes was high and has repercussions on collective health and favors the conditions of social inequality in the country. We suggest that promotion of electricity for cooking would be a viable clean alternative, because the country has large hydroelectric resources and the electric network covers almostthe entire population(99%).

Health assessment of future PM2.5 exposures from indoor, outdoor, and secondhand tobacco smoke concentrations under alternative policy pathways in Ulaanbaatar, Mongolia.

INTRODUCTION: Winter air pollution in Ulaanbaatar, Mongolia is among the worst in the world. The health impacts of policy decisions affecting air pollution exposures in Ulaanbaatar were modeled and evaluated under business as usual and two more-strict alternative emissions pathways through 2024. Previous studies have relied on either outdoor or indoor concentrations to assesses the health risks of air pollution, but the burden is really a function of total exposure. This study combined projections of indoor and outdoor concentrations of PM2.5 with population time-activity estimates to develop trajectories of total age-specific PM2.5 exposure for the Ulaanbaatar population. Indoor PM2.5 contributions from secondhand tobacco smoke (SHS) were estimated in order to fill out total exposures, and changes in population and background disease were modeled. The health impacts were derived using integrated exposure-response curves from the Global Burden of Disease Study. RESULTS: Annual average population-weighted PM2.5 exposures at baseline (2014) were estimated at 59 µg/m3. These were dominated by exposures occurring indoors, influenced considerably by infiltrated outdoor pollution. Under current control policies, exposures increased slightly to 60 µg/m3 by 2024; under moderate emissions reductions and under a switch to clean technologies, exposures were reduced from baseline levels by 45% and 80%, respectively. The moderate improvement pathway decreased per capita annual disability-adjusted life year (DALY) and death burdens by approximately 40%. A switch to clean fuels decreased per capita annual DALY and death burdens by about 85% by 2024 with the relative SHS contribution increasing substantially. CONCLUSION: This study demonstrates a way to combine estimated changes in total exposure, background disease and population levels, and exposure-response functions to project the health impacts of alternative policy pathways. The resulting burden analysis highlights the need for aggressive action, including the elimination of residential coal burning and the reduction of current smoking rates.

The health burden and economic costs averted by ambient PM2.5 pollution reductions in Nagpur, India.

National estimates of the health and economic burdens of exposure to ambient fine particulate matter (PM2.5) in India reveal substantial impacts. This information, often lacking at the local level, can justify and drive mitigation interventions. Here, we assess the health and economic gains resulting from attainment of WHO guidelines for PM2.5 concentrations - including interim target 2 (IT-2), interim target 3 (IT-3), and the WHO air quality guideline (AQG) - in Nagpur district to inform policy decision making for mitigation. We conducted a detailed assessment of concentrations of PM2.5 in 9 areas, covering urban, peri-urban and rural environments, from February 2013 to June 2014. We used a combination of hazard and survival analyses based on the life table method to calculate attributed annual number of premature deaths and disability-adjusted life years (DALYs) for five health outcomes linked to PM2.5 exposure: acute lower respiratory infection for children <5years, ischemic heart disease, chronic obstructive pulmonary disease, stroke and lung cancer in adults ≥25years. We used GBD 2013 data on deaths and DALYs for these diseases. We calculated averted deaths, DALYs and economic loss resulting from planned reductions in average PM2.5 concentration from current level to IT-2, IT-3 and AQG by the years 2023, 2033 and 2043, respectively. The economic cost for premature mortality was estimated as the product of attributed deaths and value of statistical life for India, while morbidity was assumed to be 10% of the mortality cost. The annual average PM2.5 concentration in Nagpur district is 34±17µgm-3 and results in 3.3 (95% confidence interval [CI]: 2.6, 4.2) thousand premature deaths and 91 (95% CI: 68, 116) thousand DALYs in 2013 with economic loss of USD 2.2 (95% CI: 1.7, 2.8) billion in that year. It is estimated that interventions that achieve IT-2, IT-3 and AQG by 2023, 2033 and 2043, would avert, respectively, 15, 30 and 36%, of the attributed health and economic loss in those years, translating into an impressively large health and economic gain. To achieve this, we recommend an exposure-integrated source reduction approach.

Household cooking with solid fuels contributes to ambient PM2.5 air pollution and the burden of disease.

BACKGROUND: Approximately 2.8 billion people cook with solid fuels. Research has focused on the health impacts of indoor exposure to fine particulate pollution. Here, for the 2010 Global Burden of Disease project (GBD 2010), we evaluated the impact of household cooking with solid fuels on regional population-weighted ambient PM2.5 (particulate matter ≤ 2.5 µm) pollution (APM2.5). OBJECTIVES: We estimated the proportion and concentrations of APM2.5 attributable to household cooking with solid fuels (PM2.5-cook) for the years 1990, 2005, and 2010 in 170 countries, and associated ill health. METHODS: We used an energy supply-driven emissions model (GAINS; Greenhouse Gas and Air Pollution Interactions and Synergies) and source-receptor model (TM5-FASST) to estimate the proportion of APM2.5 produced by households and the proportion of household PM2.5 emissions from cooking with solid fuels. We estimated health effects using GBD 2010 data on ill health from APM2.5 exposure. RESULTS: In 2010, household cooking with solid fuels accounted for 12% of APM2.5 globally, varying from 0% of APM2.5 in five higher-income regions to 37% (2.8 µg/m3 of 6.9 µg/m3 total) in southern sub-Saharan Africa. PM2.5-cook constituted > 10% of APM2.5 in seven regions housing 4.4 billion people. South Asia showed the highest regional concentration of APM2.5 from household cooking (8.6 µg/m3). On the basis of GBD 2010, we estimate that exposure to APM2.5 from cooking with solid fuels caused the loss of 370,000 lives and 9.9 million disability-adjusted life years globally in 2010. CONCLUSIONS: PM2.5 emissions from household cooking constitute an important portion of APM2.5 concentrations in many places, including India and China. Efforts to improve ambient air quality will be hindered if household cooking conditions are not addressed.

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.

An integrated risk function for estimating the global burden of disease attributable to ambient fine particulate matter exposure.

BACKGROUND: Estimating the burden of disease attributable to long-term exposure to fine particulate matter (PM2.5) in ambient air requires knowledge of both the shape and magnitude of the relative risk (RR) function. However, adequate direct evidence to identify the shape of the mortality RR functions at the high ambient concentrations observed in many places in the world is lacking. OBJECTIVE: We developed RR functions over the entire global exposure range for causes of mortality in adults: ischemic heart disease (IHD), cerebrovascular disease (stroke), chronic obstructive pulmonary disease (COPD), and lung cancer (LC). We also developed RR functions for the incidence of acute lower respiratory infection (ALRI) that can be used to estimate mortality and lost-years of healthy life in children < 5 years of age. METHODS: We fit an integrated exposure-response (IER) model by integrating available RR information from studies of ambient air pollution (AAP), second hand tobacco smoke, household solid cooking fuel, and active smoking (AS). AS exposures were converted to estimated annual PM2.5 exposure equivalents using inhaled doses of particle mass. We derived population attributable fractions (PAFs) for every country based on estimated worldwide ambient PM2.5 concentrations. RESULTS: The IER model was a superior predictor of RR compared with seven other forms previously used in burden assessments. The percent PAF attributable to AAP exposure varied among countries from 2 to 41 for IHD, 1 to 43 for stroke, < 1 to 21 for COPD, < 1 to 25 for LC, and < 1 to 38 for ALRI. CONCLUSIONS: We developed a fine particulate mass-based RR model that covered the global range of exposure by integrating RR information from different combustion types that generate emissions of particulate matter. The model can be updated as new RR information becomes available.

State and national household concentrations of PM2.5 from solid cookfuel use: results from measurements and modeling in India for estimation of the global burden of disease.

BACKGROUND: Previous global burden of disease (GBD) estimates for household air pollution (HAP) from solid cookfuel use were based on categorical indicators of exposure. Recent progress in GBD methodologies that use integrated-exposure-response (IER) curves for combustion particles required the development of models to quantitatively estimate average HAP levels experienced by large populations. Such models can also serve to inform public health intervention efforts. Thus, we developed a model to estimate national household concentrations of PM2.5 from solid cookfuel use in India, together with estimates for 29 states. METHODS: We monitored 24-hr household concentrations of PM2.5, in 617 rural households from 4 states in India on a cross-sectional basis between November 2004 and March 2005. We then, developed log-linear regression models that predict household concentrations as a function of multiple, independent household level variables available in national household surveys and generated national / state estimates using The Indian National Family and Health Survey (NFHS 2005). RESULTS: The measured mean 24-hr concentration of PM2.5 in solid cookfuel using households ranged from 163 µg/m3 (95% CI: 143,183; median 106; IQR: 191) in the living area to 609 µg/m3 (95% CI: 547,671; median: 472; IQR: 734) in the kitchen area. Fuel type, kitchen type, ventilation, geographical location and cooking duration were found to be significant predictors of PM2.5 concentrations in the household model. k-fold cross validation showed a fair degree of correlation (r = 0.56) between modeled and measured values. Extrapolation of the household results by state to all solid cookfuel-using households in India, covered by NFHS 2005, resulted in a modeled estimate of 450 µg/m3 (95% CI: 318,640) and 113 µg/m3 (95% CI: 102,127) , for national average 24-hr PM2.5 concentrations in the kitchen and living areas respectively. CONCLUSIONS: The model affords substantial improvement over commonly used exposure indicators such as "percent solid cookfuel use" in HAP disease burden assessments, by providing some of the first estimates of national average HAP levels experienced in India. Model estimates also add considerable strength of evidence for framing and implementation of intervention efforts at the state and national levels.

A low-cost particle counter as a realtime fine-particle mass monitor.

Exposure to particles with aerodynamic diameters less than 2.5 µm is estimated to cause significant morbidity and mortality worldwide leading many countries to develop ambient air pollution standards and guidelines. At local scales, community and environmental justice groups are also concerned about PM 2.5 concentrations that may be elevated above regional concentrations typically measured by centrally located monitors and standards as well. In an attempt to develop a low cost, easy to use monitor we evaluated a low-cost optical particle counter, the Dylos™, as a fine particulate mass sensor. Modified into a system called the Berkeley Aerosol Information Recording System (BAIRS), we compared performance against standard commercial instruments in chambers using polystyrene latex spheres, ammonium sulphate, and woodsmoke and in an urban ambient setting. Overall we find that the limit of detection of the BAIRS is less than 1 µg m (-3) and the resolution is better than 1 µg m(-3) for PM 2.5. The BAIRS sizes small (<0.5 µm) particles, and is able to accurately estimate the mass concentration of particles of varying composition including organic, inorganic, and ambient particles. It is able to measure concentrations up to 10.0 mg m (-3). In an ambient roof-top test of the BAIRS and a more expensive commercially available light scattering particle monitor the BAIRS response tracked well with the commercial monitor and daily means were within 80% of each other. We conclude that with appropriate modification the system could be developed into an accurate low cost realtime particle mass monitor for use in a wide range of applications.

Cooking practices, air quality, and the acceptability of advanced cookstoves in Haryana, India: an exploratory study to inform large-scale interventions.

BACKGROUND: In India, approximately 66% of households rely on dung or woody biomass as fuels for cooking. These fuels are burned under inefficient conditions, leading to household air pollution (HAP) and exposure to smoke containing toxic substances. Large-scale intervention efforts need to be informed by careful piloting to address multiple methodological and sociocultural issues. This exploratory study provides preliminary data for such an exercise from Palwal District, Haryana, India. METHODS: Traditional cooking practices were assessed through semi-structured interviews in participating households. Philips and Oorja, two brands of commercially available advanced cookstoves with small blowers to improve combustion, were deployed in these households. Concentrations of particulate matter (PM) with a diameter <2.5 µm (PM2.5) and carbon monoxide (CO) related to traditional stove use were measured using real-time and integrated personal, microenvironmental samplers for optimizing protocols to evaluate exposure reduction. Qualitative data on acceptability of advanced stoves and objective measures of stove usage were also collected. RESULTS: Twenty-eight of the thirty-two participating households had outdoor primary cooking spaces. Twenty households had liquefied petroleum gas (LPG) but preferred traditional stoves as the cost of LPG was higher and because meals cooked on traditional stoves were perceived to taste better. Kitchen area concentrations and kitchen personal concentrations assessed during cooking events were very high, with respective mean PM2.5 concentrations of 468 and 718 µg/m3. Twenty-four hour outdoor concentrations averaged 400 µg/m3. Twenty-four hour personal CO concentrations ranged between 0.82 and 5.27 ppm. The Philips stove was used more often and for more hours than the Oorja. CONCLUSIONS: The high PM and CO concentrations reinforce the need for interventions that reduce HAP exposure in the aforementioned community. Of the two stoves tested, participants expressed satisfaction with the Philips brand as it met the local criteria for usability. Further understanding of how the introduction of an advanced stove influences patterns of household energy use is needed. The preliminary data provided here would be useful for designing feasibility and/or pilot studies aimed at intervention efforts locally and nationally.

An official American Thoracic Society workshop report: Climate change and human health.

This document presents the proceedings from the American Thoracic Society Climate Change and Respiratory Health Workshop that was held on May 15, 2010, in New Orleans, Louisiana. The purpose of the one-day meeting was to address the threat to global respiratory health posed by climate change. Domestic and international experts as well as representatives of international respiratory societies and key U.S. federal agencies convened to identify necessary research questions concerning climate change and respiratory health and appropriate mechanisms and infrastructure needs for answering these questions. After much discussion, a breakout group compiled 27 recommendations for physicians, researchers, and policy makers. These recommendations are listed under main issues that the workshop participants deemed of key importance to respiratory health. Issues include the following: (1) the health impacts of climate change, with specific focus on the effect of heat waves, air pollution, and natural cycles; (2) mitigation and adaptation measures to be taken, with special emphasis on recommendations for the clinical and research community; (3) recognition of challenges specific to low-resource countries when coping with respiratory health and climate change; and (4) priority research infrastructure needs, with special discussion of international needs for cooperating with present and future environmental monitoring and alert systems.

Prevalence of chronic obstructive pulmonary disease in rural women of Tamilnadu: implications for refining disease burden assessments attributable to household biomass combustion.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is the 13th leading cause of burden of disease worldwide and is expected to become 5th by 2020. Biomass fuel combustion significantly contributes to COPD, although smoking is recognized as the most important risk factor. Rural women in developing countries bear the largest share of this burden resulting from chronic exposures to biomass fuel smoke. Although there is considerable strength of evidence for the association between COPD and biomass smoke exposure, limited information is available on the background prevalence of COPD in these populations. OBJECTIVE: This study was conducted to estimate the prevalence of COPD and its associated factors among non-smoking rural women in Tiruvallur district of Tamilnadu in Southern India. DESIGN: This cross-sectional study was conducted among 900 non-smoking women aged above 30 years, from 45 rural villages of Tiruvallur district of Tamilnadu in Southern India in the period between January and May 2007. COPD assessments were done using a combination of clinical examination and spirometry. Logistic regression analysis was performed to examine the association between COPD and use of biomass for cooking. R software was used for statistical analysis. RESULTS: The overall prevalence of COPD in this study was found to be 2.44% (95% CI: 1.43-3.45). COPD prevalence was higher in biomass fuel users than the clean fuel users 2.5 vs. 2%, (OR: 1.24; 95% CI: 0.36-6.64) and it was two times higher (3%) in women who spend >2 hours/day in the kitchen involved in cooking. Use of solid fuel was associated with higher risk for COPD, although no statistically significant results were obtained in this study. CONCLUSION: The estimates generated in this study will contribute significantly to the growing database of available information on COPD prevalence in rural women. Moreover, with concomitant indoor air pollution measurements, it may be possible to increase the resolution of the association between biomass use and COPD prevalence and refine available attributable burden of disease estimates.

An ultrasound personal locator for time-activity assessment.

The UC Berkeley Time-Activity Monitoring System (UCB-TAMS) was developed to measure time-activity in exposure studies. The system consists of small, light, inexpensive battery-operated 40-kHz ultrasound transmitters (tags) worn by participants and an ultrasound receiver (locator) attached to a datalogger fixed in an indoor location. Presence or absence of participants is monitored by distinguishing the unique ultrasound ID of each tag. Efficacy tests in rural households of highland Guatemala showed the system to be comparable to the gold-standard time-activity measure of direct observation by researchers, with an accuracy of predicting time-weighted averages of 90-95%, minute-by-minute accuracy of 80-85%, and sensitivity/specificity values of 86-89%/71-74% for one-minute readings on children 3-8 years-old. Additional controlled tests in modern buildings and in rural Guatemalan homes confirmed the performance of the system with the presence of other ultrasound sources, with multiple tags, covered by clothing, and in other non-ideal circumstances.