Randomized trial in rural Native American homes heated with wood stoves: results from the EldersAIR study.

Residential wood burning has both practical and traditional value among many indigenous communities of the United States Mountain West, although household biomass burning also results in emissions that are harmful to health. In a household-level three-arm placebo-controlled randomized trial we tested the efficacy of portable filtration units and education interventions on improving pulmonary function and blood pressure measures among elder participants that use wood stoves for residential heating. A total of 143 participants were assigned to the Education (n=49), Filter (n=47), and Control (n=47) arms. Blood pressure and spirometry measures were collected multiple times during a per-intervention winter period and during a follow-up post-intervention winter period. Despite strong PM2.5 exposure reduction results with the Filter arm (50% lower compared to Control arm), neither this intervention nor the Education intervention translated to improvements in the selected health measures among this population with a mixture of chronic conditions. Intention to treat analysis failed to demonstrate evidence that either of the intervention arms had beneficial effects on the blood pressure or the spirometry measures. Post-hoc evaluation of effect modification for blood pressure and spirometry outcomes did not reveal any interaction influence on the outcomes according to sex, residential smoking, chronic disease history and study area.

Wildland Firefighter Work History and Clinical Indicators of Cardiovascular Health.

OBJECTIVE: To determine the association between the occupational history as a wildland firefighter (WFF) and clinical indicators of cardiovascular health. METHODS: Among 2862 WFFs, we evaluated associations between the number of total days assigned on fire and high-risk categories of three clinically measured cardiovascular indicators. RESULTS: Almost one-third (32%) of WFFs had one or more clinical measures that would place them in high-risk categories for body mass index, blood pressure, and total cholesterol. WFF work history was associated with some of these measures: odds ratio (and 95% confidence interval) for highest versus lowest tertile of days on fire were 1.4 (1.2, 1.8) and 1.2 (1.0, 1.5) for high-risk categories of body mass index and cholesterol, respectively. CONCLUSION: More frequent screening and targeted health promotion programs for WFFs are warranted to increase awareness of cardiovascular risk and prevention strategies.

Seasonal extreme temperatures and short-term fine particulate matter increases pediatric respiratory healthcare encounters in a sparsely populated region of the intermountain western United States.

BACKGROUND: Western Montana, USA, experiences complex air pollution patterns with predominant exposure sources from summer wildfire smoke and winter wood smoke. In addition, climate change related temperatures events are becoming more extreme and expected to contribute to increases in hospital admissions for a range of health outcomes. Evaluating while accounting for these exposures (air pollution and temperature) that often occur simultaneously and may act synergistically on health is becoming more important. METHODS: We explored short-term exposure to air pollution on children's respiratory health outcomes and how extreme temperature or seasonal period modify the risk of air pollution-associated healthcare events. The main outcome measure included individual-based address located respiratory-related healthcare visits for three categories: asthma, lower respiratory tract infections (LRTI), and upper respiratory tract infections (URTI) across western Montana for ages 0-17 from 2017-2020. We used a time-stratified, case-crossover analysis with distributed lag models to identify sensitive exposure windows of fine particulate matter (PM2.5) lagged from 0 (same-day) to 14 prior-days modified by temperature or season. RESULTS: For asthma, increases of 1 µg/m3 in PM2.5 exposure 7-13 days prior a healthcare visit date was associated with increased odds that were magnified during median to colder temperatures and winter periods. For LRTIs, 1 µg/m3 increases during 12 days of cumulative PM2.5 with peak exposure periods between 6-12 days before healthcare visit date was associated with elevated LRTI events, also heightened in median to colder temperatures but no seasonal effect was observed. For URTIs, 1 unit increases during 13 days of cumulative PM2.5 with peak exposure periods between 4-10 days prior event date was associated with greater risk for URTIs visits that were intensified during median to hotter temperatures and spring to summer periods. CONCLUSIONS: Delayed, short-term exposure increases of PM2.5 were associated with elevated odds of all three pediatric respiratory healthcare visit categories in a sparsely population area of the inter-Rocky Mountains, USA. PM2.5 in colder temperatures tended to increase instances of asthma and LRTIs, while PM2.5 during hotter periods increased URTIs.

Subclinical Measures of Cardiovascular Health Among Wildland Firefighters.

OBJECTIVE: The aim of the study is to compare subclinical measures of cardiovascular health among wildland firefighters (WFFs) to the US general population. METHODS: Our cross-sectional study compared body mass index, total cholesterol, and blood pressure in 11,051 WFFs aged 17 to 64 years using Department of the Interior Medical Screening Program clinical screening examinations between 2014-2018 to National Health and Nutrition Examination Survey of 2015-2016 cycle using adjusted logistic regression analyses. RESULTS: The logistic regression model shows significantly higher odds of hypertension and prehypertension in WFFs (2.84 times more with 95% CI: 2.28-3.53) than US general population. There were no consistent differences in body mass index or total cholesterol between the two population. CONCLUSIONS: Hypertension and prehypertension were more prevalent in WFFs compared with the US general population, which suggests the need for actions for protecting against cardiovascular disease among WFFs.

Seasonal extreme temperatures and short-term fine particulate matter increases child respiratory hospitalizations in a sparsely populated region of the intermountain western United States.

Background: Western Montana, USA, experiences complex air pollution patterns with predominant exposure sources from summer wildfire smoke and winter wood smoke. In addition, climate change related temperatures events are becoming more extreme and expected to contribute to increases in hospital admissions for a range of health outcomes. Few studies have evaluated these exposures (air pollution and temperature) that often occur simultaneously and may act synergistically on health. Methods: We explored short-term exposure to air pollution on childhood respiratory health outcomes and how extreme temperature or seasonal period modify the risk of air pollution-associated hospitalizations. The main outcome measure included all respiratory-related hospital admissions for three categories: asthma, lower respiratory tract infections (LRTI), and upper respiratory tract infections (URTI) across western Montana for all individuals aged 0-17 from 2017-2020. We used a time-stratified, case-crossover analysis and distributed lag models to identify sensitive exposure windows of fine particulate matter (PM2.5) lagged from 0 (same-day) to 15 prior-days modified by temperature or season. Results: Short-term exposure increases of 1 µg/m3 in PM2.5 were associated with elevated odds of all three respiratory hospital admission categories. PM2.5 was associated with the largest increased odds of hospitalizations for asthma at lag 7-13 days [1.87(1.17-2.97)], for LRTI at lag 6-12 days [2.18(1.20-3.97)], and for URTI at a cumulative lag of 13 days [1.29(1.07-1.57)]. The impact of PM2.5 varied by temperature and season for each respiratory outcome scenario. For asthma, PM2.5 was associated most strongly during colder temperatures [3.11(1.40-6.89)] and the winter season [3.26(1.07-9.95)]. Also in colder temperatures, PM2.5 was associated with increased odds of LRTI hospitalization [2.61(1.15-5.94)], but no seasonal effect was observed. Finally, 13 days of cumulative PM2.5 prior to admissions date was associated with the greatest increased odds of URTI hospitalization during summer days [3.35(1.85-6.04)] and hotter temperatures [1.71(1.31-2.22)]. Conclusions: Children's respiratory-related hospital admissions were associated with short-term exposure to PM2.5. PM2.5 associations with asthma and LRTI hospitalizations were strongest during cold periods, whereas associations with URTI were largest during hot periods. Classification: environmental public health, fine particulate matter air pollution, respiratory infections.

Daily 1 km terrain resolving maps of surface fine particulate matter for the western United States 2003-2021.

We developed daily maps of surface fine particulate matter (PM2.5) for the western United States. We used geographically weighted regression fit to air quality station observations with Moderate Resolution Imaging Spectroradiometer (MODIS) aerosol optical depth (AOD) data, and meteorological data to produce daily 1-kilometer resolution PM2.5 concentration estimates from 2003-2020. To account for impacts of stagnant air and inversions, we included estimates of inversion strength based on meteorological conditions, and inversion potential based on human activities and local topography. Model accuracy based on cross-validation was R2 = 0.66. AOD data improve the model in summer and fall during periods of high wildfire activity while the stagnation terms capture the spatial and temporal dynamics of PM2.5 in mountain valleys, particularly during winter. These data can be used to explore exposure and health outcome impacts of PM2.5 across spatiotemporal domains particularly in the intermountain western United States where measurements from monitoring station data are sparse. Furthermore, these data may facilitate analyses of inversion impacts and local topography on exposure and health outcome studies.

Efficacy of air filtration and education interventions on fine particulate matter among rural Native American homes heated with wood stoves: Results from the EldersAIR randomized trial.

BACKGROUND: Native Americans living in rural areas often rely upon wood stoves for home heating that can lead to elevated indoor concentrations of fine particulate matter (PM2.5). Wood stove use is associated with adverse health outcomes, which can be a particular risk in vulnerable populations including older adults. OBJECTIVES: We assessed the impact of portable air filtration units and educational approaches that incorporated elements of traditional knowledge on indoor and personal PM2.5 concentrations among rural, Native American elder households with wood stoves. METHODS: EldersAIR was a three-arm, pre-post randomized trial among rural households from the Navajo Nation and Nez Perce Tribe in the United States. We measured personal and indoor PM2.5 concentrations over 2-day sampling periods on up to four occasions across two consecutive winter seasons in elder participant homes. We assessed education and air filtration intervention efficacy using linear mixed models. RESULTS: Geometric mean indoor PM2.5 concentrations were 50.5 % lower (95 % confidence interval: -66.1, -27.8) in the air filtration arm versus placebo, with similar results for personal PM2.5. Indoor PM2.5 concentrations among education arm households were similar to placebo, although personal PM2.5 concentrations were 33.3 % lower for the education arm versus placebo (95 % confidence interval: -63.2, 21.1). SIGNIFICANCE: The strong partnership between academic and community partners helped facilitate a culturally acceptable approach to a clinical trial intervention within the study communities. Portable air filtration units can reduce indoor PM2.5 that originates from indoor wood stoves, and this finding was supported in this study. The educational intervention component was meaningful to the communities, but did not substantially impact indoor PM2.5 relative to placebo. However, there is evidence that the educational interventions reduced indoor PM2.5 in some subsets of the study households. More study is required to determine ways to optimize educational interventions within Native American communities.

Outdoor and indoor fine particulate matter at skilled nursing facilities in the western United States during wildfire and non-wildfire seasons.

Wildfire activity is increasing in parts of the world where extreme drought and warming temperatures contribute to fireprone conditions, including the western United States. The elderly are among the most vulnerable, and those in long-term care with preexisting conditions have added risk for adverse health outcomes from wildfire smoke exposure. In this study, we report continuous co-located indoor and outdoor fine particulate matter (PM2.5 ) measurements at four skilled nursing facilities in the western United States. Throughout the year 2020, over 8000 h of data were collected, which amounted to approximately 300 days of indoor and outdoor sampling at each facility. The highest indoor 24 h average PM2.5 recorded at each facility was 43.6 µg/m3 , 103.2 µg/m3 , 35.4 µg/m3 , and 202.5 µg/m3 , and these peaks occurred during the wildfire season. The indoor-to-outdoor PM2.5 ratio and calculated infiltration efficiencies indicated high variation in the impact of wildfire events on Indoor Air Quality between the four facilities. Notably, infiltration efficiency ranged from 0.22 to 0.76 across the four facilities. We propose that this variability is evidence that PM2.5 infiltration may be impacted by modifiable building characteristics and human behavioral factors, and this should be addressed in future studies.

Efficacy of Air Filtration and Education Interventions on Indoor Fine Particulate Matter and Child Lower Respiratory Tract Infections among Rural U.S. Homes Heated with Wood Stoves: Results from the KidsAIR Randomized Trial.

BACKGROUND: Millions of rural U.S. households are heated with wood stoves. Wood stove use can lead to high indoor concentrations of fine particulate matter [airborne particles ≤2.5µm in aerodynamic diameter (PM2.5)] and is associated with lower respiratory tract infection (LRTI) in children. OBJECTIVES: We assessed the impact of low-cost educational and air filtration interventions on childhood LRTI and indoor PM2.5 in rural U.S. homes with wood stoves. METHODS: The Kids Air Quality Interventions for Reducing Respiratory Infections (KidsAIR) study was a parallel three-arm (education, portable air filtration unit, control), post-only randomized trial in households from Alaska, Montana, and Navajo Nation (Arizona and New Mexico) with a wood stove and one or more children <5 years of age. We tracked LRTI cases for two consecutive winter seasons and measured indoor PM2.5 over a 6-d period during the first winter. We assessed results using two analytical frameworks: a) intervention efficacy on LRTI and PM2.5 (intent-to-treat), and b) association between PM2.5 and LRTI (exposure-response). RESULTS: There were 61 LRTI cases from 14,636 child-weeks of follow-up among 461 children. In the intent-to-treat analysis, children in the education arm [odds ratio (OR)=0.98; 95% confidence interval (CI): 0.35, 2.72] and the filtration arm (OR=1.23; 95% CI: 0.46, 3.32) had similar odds of LRTI vs. control. Geometric mean PM2.5 concentrations were similar to control in the education arm (11.77% higher; 95% CI: -16.57, 49.72) and air filtration arm (6.96% lower; 95% CI: -30.50, 24.55). In the exposure-response analysis, odds of LRTI were 1.45 times higher (95% CI: 1.02, 2.05) per interquartile range (25 µg/m3) increase in mean indoor PM2.5. DISCUSSION: We did not observe meaningful differences in LRTI or indoor PM2.5 in the air filtration or education arms compared with the control arm. Results from the exposure-response analysis provide further evidence that biomass air pollution adversely impacts childhood LRTI. Our results highlight the need for novel, effective intervention strategies in households heated with wood stoves. https://doi.org/10.1289/EHP9932.

Case-fatality study of workers and residents with radiographic asbestos disease in Libby, Montana.

BACKGROUND: Vermiculite ore from Libby, Montana contains on average 24% of a mixture of toxic and carcinogenic amphibole asbestiform fibers. These comprise primarily winchite (84%), with smaller quantities of richterite (11%) and tremolite (6%), which are together referred to as Libby amphibole (LA). METHODS: A total of 1883 individuals who were occupationally and/or environmentally exposed to LA and were diagnosed with asbestos-related pleuropulmonary disease (ARPPD) following participation in communitywide screening programs supported by the Agency for Toxic Substances and Disease Registry (ATSDR) and followed up at the Center for Asbestos Related Disease (CARD) between 2000 and 2010. There were 203 deaths of patients with sufficient records and radiographs. Best clinical and radiologic evidence was used to determine the cause of death, which was compared with death certificates. RESULTS: Asbestos-related mortality was 55% (n = 112) in this series of 203 patients. Of the 203 deaths, 34 (17%) were from asbestos-related malignancy, 75 (37%) were from parenchymal asbestosis, often with pleural fibrosis, and 3 (1.5%) were from respiratory failure secondary to pleural thickening. CONCLUSIONS: Asbestos is the leading cause of mortality following both occupational and nonoccupational exposure to LA in those with asbestos-related disease.

Carbon monoxide exposures in wildland firefighters in the United States and targets for exposure reduction.

BACKGROUND: Every year thousands of wildland firefighters (WFFs) work to suppress wildfires to protect public safety, health, and property. Although much effort has been put toward mitigating air pollutant exposures for the public and WFFs, the current burden in this worker population is unclear as are the most effective exposure reduction strategies. OBJECTIVE: Quantify fireline carbon monoxide (CO) exposures in WFFs and identify predictors of exposures. METHODS: We collected 1-min breathing zone CO measurements on 246 WFFs assigned to fires between 2015 and 2017. We used generalized estimating equations to evaluate predictors of CO exposure. RESULTS: Approximately 5% of WFFs had fireline CO exposure means exceeding the National Wildfire Coordinating Group's occupational exposure limit of 16 ppm. Relative to operational breaks, direct suppression-related job tasks were associated with 56% (95% CI: 47%, 65%) higher geometric mean CO concentrations, adjusted for incident type, crew type, and fire location. WFF perception of smoke exposure was a strong predictor of measured CO exposure. SIGNIFICANCE: Specific job tasks related to direct suppression and WFF perceptions of smoke exposure are potential opportunities for targeted interventions aimed at minimizing exposure to smoke.

Creating Clean Air Spaces During Wildland Fire Smoke Episodes: Web Summit Summary.

Effective strategies to reduce indoor air pollutant concentrations during wildfire smoke events are critically needed. Worldwide, communities in areas prone to wildfires may suffer from annual smoke exposure events lasting from days to weeks. In addition, there are many areas of the world where high pollution events are common and where methods employed to reduce exposure to pollution may have relevance to wildfire smoke pollution episodes and vice versa. This article summarizes a recent virtual meeting held by the United States Environmental Protection Agency (EPA) to share research, experiences, and other information that can inform best practices for creating clean air spaces during wildland fire smoke events. The meeting included presentations on the public health impacts of wildland fire smoke; public health agencies' experiences and resilience efforts; and methods to improve indoor air quality, including the effectiveness of air filtration methods [e.g., building heating ventilation and air conditioning (HVAC) systems and portable, free-standing air filtration systems]. These presentations and related research indicate that filtration has been demonstrated to effectively improve indoor air quality during high ambient air pollution events; however, several research questions remain regarding the longevity and maintenance of filtration equipment during and after smoke events, effects on the pollution mixture, and degree to which adverse health effects are reduced.

Indoor fine particulate matter and demographic, household, and wood stove characteristics among rural US homes heated with wood fuel.

Household heating using wood stoves is common practice in many rural areas of the United States (US) and can lead to elevated concentrations of indoor fine particulate matter (PM2.5 ). We collected 6-day measures of indoor PM2.5 during the winter and evaluated household and stove-use characteristics in homes at three rural and diverse study sites. The median indoor PM2.5 concentration across all homes was 19 µg/m3 , with higher concentrations in Alaska (median = 30, minimum = 4, maximum = 200, n = 10) and Navajo Nation homes (median = 29, minimum = 3, maximum = 105, n = 23) compared with Montana homes (median = 16, minimum = 2, maximum = 139, n = 59). Households that had not cleaned the chimney within the past year had 65% higher geometric mean PM2.5 compared to those with chimney cleaned within 6 months (95% confidence interval [CI]: -1, 170). Based on a novel wood stove grading method, homes with low-quality and medium-quality stoves had substantially higher PM2.5 compared to homes with higher-quality stoves (186% higher [95% CI: 32, 519] and 161% higher; [95% CI:27, 434], respectively). Our findings highlight the need for, and complex nature of, regionally appropriate interventions to reduce indoor air pollution in rural wood-burning regions. Higher-quality stoves and behavioral practices such as regular chimney cleaning may help improve indoor air quality in such homes.

The delayed effect of wildfire season particulate matter on subsequent influenza season in a mountain west region of the USA.

Particularly in rural settings, there has been little research regarding the health impacts of fine particulate matter (PM2.5) during the wildfire season smoke exposure period on respiratory diseases, such as influenza, and their associated outbreaks months later. We examined the delayed effects of PM2.5 concentrations for the short-lag (1-4 weeks prior) and the long-lag (during the prior wildfire season months) on the following winter influenza season in Montana, a mountainous state in the western United States. We created gridded maps of surface PM2.5 for the state of Montana from 2009 to 2018 using spatial regression models fit with station observations and Moderate Resolution Imaging Spectroradiometer (MODIS) aerosol optical thickness data. We used a seasonal quasi-Poisson model with generalized estimating equations to estimate weekly, county-specific, influenza counts for Montana, associated with delayed PM2.5 concentration periods (short-lag and long-lag effects), adjusted for temperature and seasonal trend. We did not detect an acute, short-lag PM2.5 effect nor short-lag temperature effect on influenza in Montana. Higher daily average PM2.5 concentrations during the wildfire season was positively associated with increased influenza in the following winter influenza season (expected 16% or 22% increase in influenza rate per 1 µg/m3 increase in average daily summer PM2.5 based on two analyses, p = 0.04 or 0.008). This is one of the first observations of a relationship between PM2.5 during wildfire season and influenza months later.

Wood stove interventions and child respiratory infections in rural communities: KidsAir rationale and methods.

BACKGROUND: Acute lower respiratory tract infections (LRTIs) account for >27% of all hospitalizations among US children under five years of age. Residential burning of biomass for heat leads to elevated indoor levels of fine particulate matter (PM2.5) that often exceed current health based air quality standards. This is concerning as PM2.5 exposure is associated with many adverse health outcomes, including a greater than three-fold increased risk of LRTIs. Evidence-based efforts are warranted in rural and American Indian/Alaska Native (AI/AN) communities in the US that suffer from elevated rates of childhood LRTI and commonly use wood for residential heating. DESIGN: In three rural and underserved settings, we conducted a three-arm randomized controlled, post-only intervention trial in wood stove homes with children less than five years old. Education and household training on best-burn practices were introduced as one intervention arm (Tx1). This intervention was evaluated against an indoor air filtration unit arm (Tx2), as well as a control arm (Tx3). The primary outcome was LRTI incidence among children under five years of age. DISCUSSION: To date, exposure reduction strategies in wood stove homes have been either inconsistently effective or include factors that limit widespread dissemination and continued compliance in rural and economically disadvantaged populations. As part of the "KidsAIR" study described herein, the overall hypothesis was that a low-cost, educational intervention targeting indoor wood smoke PM2.5 exposures would be a sustainable approach for reducing children's risk of LRTI in rural and AI/AN communities.

Group Gardening in a Native American Community: A Collaborative Approach.

Background. There is increasing awareness of the potential health benefits derived from gardening activities. Gardening practices are gaining momentum in Native American (NA) communities, yet no efforts have applied a community-based participatory research approach within a social-ecological model to understand opportunities and barriers for group gardening on an American Indian reservation. Objectives. The primary objective of this study was to identify influences across social-ecological levels that promote or hinder the implementation of community gardens and use of locally grown foods on the reservation; a secondary objective was to assess the feasibility of implementing a group gardening program for NA adults and potential of collecting health outcome measures. Method. Community members and academicians collaborated to develop and implement this study. The study (1) conducted interviews with key stakeholders to identify influences across social-ecological levels that promote or hinder the implementation of community gardens and using locally produced food and (2) assessed the physical and psychological well-being of NA adults participating in a group gardening feasibility study. Results. Major factors influencing using locally grown food and community gardens that emerged from nine interviews included knowledge/experience, self-efficacy, Elders, traditional ways, community values, generational gaps, and local tribal policies. Twenty NA adults with prediabetes or diabetes participated in the feasibility study. The Profile of Mood States Inventory showed consistently positive change in score for participants in the group gardening program versus the comparison group. Conclusions. This study identified key influences for growing locally grown food, and approaches for implementing group gardening programs for NA adults.

Growing from Our Roots: Strategies for Developing Culturally Grounded Health Promotion Interventions in American Indian, Alaska Native, and Native Hawaiian Communities.

Given the paucity of empirically based health promotion interventions designed by and for American Indian, Alaska Native, and Native Hawaiian (i.e., Native) communities, researchers and partnering communities have had to rely on the adaptation of evidence-based interventions (EBIs) designed for non-Native populations, a decidedly sub-optimal approach. Native communities have called for development of Indigenous health promotion programs in which their cultural worldviews and protocols are prioritized in the design, development, testing, and implementation. There is limited information regarding how Native communities and scholars have successfully collaborated to design and implement culturally based prevention efforts "from the ground up." Drawing on five diverse community-based Native health intervention studies, we describe strategies for designing and implementing culturally grounded models of health promotion developed in partnership with Native communities. Additionally, we highlight indigenist worldviews and protocols that undergird Native health interventions with an emphasis on the incorporation of (1) original instructions, (2) relational restoration, (3) narrative-[em]bodied transformation, and (4) indigenist community-based participatory research (ICBPR) processes. Finally, we demonstrate how culturally grounded interventions can improve population health when they prioritize local Indigenous knowledge and health-positive messages for individual to multi-level community interventions.

Case series: rheumatological manifestations attributed to exposure to Libby Asbestiform Amphiboles.

An increased risk for Systemic Autoimmune Diseases (SAID) has been reported in Libby, Montana, where extensive exposures to fibrous amphiboles occurred due to mining and use of asbestos-laden vermiculite. In addition, positive antinuclear autoantibody tests are associated with exposure to Libby Asbestiform Amphiboles (LAA) in both humans and mice. Among 6603 subjects who underwent health screening at the Center for Asbestos Related Diseases (CARD, Libby MT), 13.8% were diagnosed with an autoimmune disease, with prevalence values for the most common SAID being significantly higher than expected in the United States. Among the CARD screening population, serological and clinical profiles are diverse, representing symptoms and autoantibodies reflective of systemic lupus erythematosus (SLE), scleroderma, rheumatoid arthritis, and other rheumatic syndromes, including undifferentiated connective tissue disease (UCTD). Based upon screening of medical records by physicians with rheumatology expertise, the evolving nature of rheumatological disease in these patients is often atypical, with mixed diagnostic criteria and with a 1:1 male-to-female ratio. Through the Libby Epidemiology Research Program, cases were identified that illustrate clinical autoimmune outcomes with LAA exposure. Our goal was to better characterize SAID in Libby, MT in order to improve recognition of autoimmune outcomes associated with this exposure. In view of recent discoveries of widespread exposure to fibrous minerals in several areas of the U.S. and globally, it is critical to evaluate rheumatologic manifestations in other cohorts so that screening, surveillance, and diagnostic procedures are able to detect and recognize potential autoimmune outcomes of asbestos exposure. ABBREVIATIONS: ANA, antinuclear autoantibody; ARD, Asbestos-Related Diseases; ATSDR, Agency for Toxic Substances & Disease Registry; CARD, Center for Asbestos Related Diseases; CCP, Cyclic citrullinated peptide antibody; CREST, limited cutaneous form of scleroderma; CT, computed tomography; DIP, Distal Interphalangeal Joint; DLCO, Diffusing Capacity of the Lung for CO2; DMARD, Disease Modifying Anti-Rheumatic Drugs; ENA, Extractable Nuclear Antigen antibodies; FVC, Forced Vital Capacity; LAA, Libby Asbestiform Amphiboles; LERP, Libby Epidemiology Research Program; MCP, Metacarpal Phalangeal Joint; PIP, Proximal Interphalangeal Joint; PIP, rheumatoid arthritis; RV, Residual Volume; SAID, Systemic autoimmune diseases; SLE, systemic lupus erythematosus; SSc, Systemic Sclerosis; TLC, Total Lung Capacity.

ERS/ATS workshop report on respiratory health effects of household air pollution.

Exposure to household air pollution (HAP) from solid fuel combustion affects almost half of the world population. Adverse respiratory outcomes such as respiratory infections, impaired lung growth and chronic obstructive pulmonary disease have been linked to HAP exposure. Solid fuel smoke is a heterogeneous mixture of various gases and particulates. Cell culture and animal studies with controlled exposure conditions and genetic homogeneity provide important insights into HAP mechanisms. Impaired bacterial phagocytosis in exposed human alveolar macrophages possibly mediates several HAP-related health effects. Lung pathological findings in HAP-exposed individuals demonstrate greater small airways fibrosis and less emphysema compared with cigarette smokers. Field studies using questionnaires, air pollution monitoring and/or biomarkers are needed to better establish human risks. Some, but not all, studies suggest that improving cookstove efficiency or venting emissions may be associated with reduced respiratory symptoms, lung function decline in women and severe pneumonia in children. Current studies focus on fuel switching, stove technology replacements or upgrades and air filter devices. Several governments have initiated major programmes to accelerate the upgrade from solid fuels to clean fuels, particularly liquid petroleum gas, which provides research opportunities for the respiratory health community.