Effects of Cooking with Liquefied Petroleum Gas or Biomass on Stunting in Infants.

BACKGROUND: Household air pollution is associated with stunted growth in infants. Whether the replacement of biomass fuel (e.g., wood, dung, or agricultural crop waste) with liquefied petroleum gas (LPG) for cooking can reduce the risk of stunting is unknown. METHODS: We conducted a randomized trial involving 3200 pregnant women 18 to 34 years of age in four low- and middle-income countries. Women at 9 to less than 20 weeks' gestation were randomly assigned to use a free LPG cookstove with continuous free fuel delivery for 18 months (intervention group) or to continue using a biomass cookstove (control group). The length of each infant was measured at 12 months of age, and personal exposures to fine particulate matter (particles with an aerodynamic diameter of ≤2.5 µm) were monitored starting at pregnancy and continuing until the infants were 1 year of age. The primary outcome for which data are presented in the current report - stunting (defined as a length-for-age z score that was more than two standard deviations below the median of a growth standard) at 12 months of age - was one of four primary outcomes of the trial. Intention-to-treat analyses were performed to estimate the relative risk of stunting. RESULTS: Adherence to the intervention was high, and the intervention resulted in lower prenatal and postnatal 24-hour personal exposures to fine particulate matter than the control (mean prenatal exposure, 35.0 µg per cubic meter vs. 103.3 µg per cubic meter; mean postnatal exposure, 37.9 µg per cubic meter vs. 109.2 µg per cubic meter). Among 3061 live births, 1171 (76.2%) of the 1536 infants born to women in the intervention group and 1186 (77.8%) of the 1525 infants born to women in the control group had a valid length measurement at 12 months of age. Stunting occurred in 321 of the 1171 infants included in the analysis (27.4%) of the infants born to women in the intervention group and in 299 of the 1186 infants included in the analysis (25.2%) of those born to women in the control group (relative risk, 1.10; 98.75% confidence interval, 0.94 to 1.29; P = 0.12). CONCLUSIONS: An intervention strategy starting in pregnancy and aimed at mitigating household air pollution by replacing biomass fuel with LPG for cooking did not reduce the risk of stunting in infants. (Funded by the National Institutes of Health and the Bill and Melinda Gates Foundation; HAPIN ClinicalTrials.gov number, NCT02944682.).

Liquefied Petroleum Gas or Biomass Cooking and Severe Infant Pneumonia.

BACKGROUND: Exposure to household air pollution is a risk factor for severe pneumonia. The effect of replacing biomass cookstoves with liquefied petroleum gas (LPG) cookstoves on the incidence of severe infant pneumonia is uncertain. METHODS: We conducted a randomized, controlled trial involving pregnant women 18 to 34 years of age and between 9 to less than 20 weeks' gestation in India, Guatemala, Peru, and Rwanda from May 2018 through September 2021. The women were assigned to cook with unvented LPG stoves and fuel (intervention group) or to continue cooking with biomass fuel (control group). In each trial group, we monitored adherence to the use of the assigned cookstove and measured 24-hour personal exposure to fine particulate matter (particles with an aerodynamic diameter of ≤2.5 µm [PM2.5]) in the women and their offspring. The trial had four primary outcomes; the primary outcome for which data are presented in the current report was severe pneumonia in the first year of life, as identified through facility surveillance or on verbal autopsy. RESULTS: Among 3200 pregnant women who had undergone randomization, 3195 remained eligible and gave birth to 3061 infants (1536 in the intervention group and 1525 in the control group). High uptake of the intervention led to a reduction in personal exposure to PM2.5 among the children, with a median exposure of 24.2 µg per cubic meter (interquartile range, 17.8 to 36.4) in the intervention group and 66.0 µg per cubic meter (interquartile range, 35.2 to 132.0) in the control group. A total of 175 episodes of severe pneumonia were identified during the first year of life, with an incidence of 5.67 cases per 100 child-years (95% confidence interval [CI], 4.55 to 7.07) in the intervention group and 6.06 cases per 100 child-years (95% CI, 4.81 to 7.62) in the control group (incidence rate ratio, 0.96; 98.75% CI, 0.64 to 1.44; P = 0.81). No severe adverse events were reported to be associated with the intervention, as determined by the trial investigators. CONCLUSIONS: The incidence of severe pneumonia among infants did not differ significantly between those whose mothers were assigned to cook with LPG stoves and fuel and those whose mothers were assigned to continue cooking with biomass stoves. (Funded by the National Institutes of Health and the Bill and Melinda Gates Foundation; HAPIN ClinicalTrials.gov number, NCT02944682.).

Liquefied Petroleum Gas or Biomass for Cooking and Effects on Birth Weight.

BACKGROUND: Exposure during pregnancy to household air pollution caused by the burning of solid biomass fuel is associated with adverse health outcomes, including low birth weight. Whether the replacement of a biomass cookstove with a liquefied petroleum gas (LPG) cookstove would result in an increase in birth weight is unclear. METHODS: We performed a randomized, controlled trial involving pregnant women (18 to <35 years of age and at 9 to <20 weeks' gestation as confirmed on ultrasonography) in Guatemala, India, Peru, and Rwanda. The women were assigned in a 1:1 ratio to use a free LPG cookstove and fuel (intervention group) or to continue using a biomass cookstove (control group). Birth weight, one of four prespecified primary outcomes, was the primary outcome for this report; data for the other three outcomes are not yet available. Birth weight was measured within 24 hours after birth. In addition, 24-hour personal exposures to fine particulate matter (particles with a diameter of ≤2.5 µm [PM2.5]), black carbon, and carbon monoxide were measured at baseline and twice during pregnancy. RESULTS: A total of 3200 women underwent randomization; 1593 were assigned to the intervention group, and 1607 to the control group. Uptake of the intervention was nearly complete, with traditional biomass cookstoves being used at a median rate of less than 1 day per month. After randomization, the median 24-hour personal exposure to fine particulate matter was 23.9 µg per cubic meter in the intervention group and 70.7 µg per cubic meter in the control group. Among 3061 live births, a valid birth weight was available for 94.9% of the infants born to women in the intervention group and for 92.7% of infants born to those in the control group. The mean (±SD) birth weight was 2921±474.3 g in the intervention group and 2898±467.9 g in the control group, for an adjusted mean difference of 19.6 g (95% confidence interval, -10.1 to 49.2). CONCLUSIONS: The birth weight of infants did not differ significantly between those born to women who used LPG cookstoves and those born to women who used biomass cookstoves. (Funded by the National Institutes of Health and the Bill and Melinda Gates Foundation; HAPIN ClinicalTrials.gov number, NCT02944682.).

Household Air Pollution Interventions to Improve Health in Low- and Middle-Income Countries: An Official American Thoracic Society Research Statement.

Background: An estimated 3 billion people, largely in low- and middle-income countries, rely on unclean fuels for cooking, heating, and lighting to meet household energy needs. The resulting exposure to household air pollution (HAP) is a leading cause of pneumonia, chronic lung disease, and other adverse health effects. In the last decade, randomized controlled trials of clean cooking interventions to reduce HAP have been conducted. We aim to provide guidance on how to interpret the findings of these trials and how they should inform policy makers and practitioners.Methods: We assembled a multidisciplinary working group of international researchers, public health practitioners, and policymakers with expertise in household air pollution from within academia, the American Thoracic Society, funders, nongovernmental organizations, and global organizations, including the World Bank and the World Health Organization. We performed a literature search, convened four sessions via web conference, and developed consensus conclusions and recommendations via the Delphi method.Results: The committee reached consensus on 14 conclusions and recommendations. Although some trials using cleaner-burning biomass stoves or cleaner-cooking fuels have reduced HAP exposure, the committee was divided (with 55% saying no and 45% saying yes) on whether the studied interventions improved measured health outcomes.Conclusions: HAP is associated with adverse health effects in observational studies. However, it remains unclear which household energy interventions reduce exposure, improve health, can be scaled, and are sustainable. Researchers should engage with policy makers and practitioners working to scale cleaner energy solutions to understand and address their information needs.

Associations between Child Opportunity Index and Pediatric Cardiac Surgical Outcomes.

OBJECTIVE: To assess the relationship between the Child Opportunity Index (COI), a comprehensive measurement of social determinants of health, and specific COI domains on patient-specific outcomes following congenital cardiac surgery in the metropolitan region of Atlanta, Georgia. STUDY DESIGN: In this retrospective chart review, we included patients who underwent an index operation for congenital heart disease between 2010 and 2020 in a single pediatric health care system. Patients' addresses were geocoded and mapped to census tracts. Descriptive statistics, univariable analysis, and multivariable regression models were employed to assess associations between variables and outcomes. RESULTS: Of the 7460 index surgeries, 3798 (51%) met eligibility criteria. Presence of an adverse outcome, defined as either mortality or 1 of several other major postoperative morbidities, was significantly associated with COI in the univariable model (P = .008), but not the multivariable regression model (P = .39). Postoperative hospital length of stay was significantly associated with COI (P < .001) in univariable and multivariable regression models. There was no significant association between COI and readmission within 30 days of hospital discharge in univariable (P < .094) and multivariable (P = .49) models. CONCLUSION: COI is associated with postoperative hospital length of stay but not all outcomes in patients after congenital heart surgery. By understanding the role of COI in outcomes related to cardiac surgery, targeted interventions can be developed to improve health equity.

Factors Determining Black Carbon Exposures among Pregnant Women Enrolled in the HAPIN Trial.

Residential biomass burning is an important source of black carbon (BC) exposure among rural communities in low- and middle-income countries. We collected 7165 personal BC samples and individual/household level information from 3103 pregnant women enrolled in the Household Air Pollution Intervention Network trial. Women in the intervention arm received free liquefied petroleum gas stoves and fuel throughout pregnancy; women in the control arm continued the use of biomass stoves. Median (IQR) postintervention BC exposures were 9.6 µg/m3 (5.2-14.0) for controls and 2.8 µg/m3 (1.6-4.8) for the intervention group. Using mixed models, we characterized predictors of BC exposure and assessed how exposure contrasts differed between arms by select predictors. Primary stove type was the strongest predictor (R2 = 0.42); the models including kerosene use, kitchen location, education, occupation, or stove use hours also provided additional explanatory power from the base model adjusted only for the study site. Our full, trial-wide, model explained 48% of the variation in BC exposures. We found evidence that the BC exposure contrast between arms differed by study site, adherence to the assigned study stove, and whether the participant cooked. Our findings highlight factors that may be addressed before and during studies to implement more impactful cookstove intervention trials.

Shiga Toxin-Producing Escherichia coli Testing in New York 2011-2022 Reveals Increase in Non-O157 Identifications.

Shiga toxin-producing Escherichia coli (STEC) are an important cause of bacterial enteric infection. STEC strains cause serious human gastrointestinal disease, which may result in life-threatening complications such as hemolytic uremic syndrome. They have the potential to impact public health due to diagnostic challenges of identifying non-O157 strains in the clinical laboratory. The Wadsworth Center (WC), the public health laboratory of the New York State Department of Health, has isolated and identified non-O157 STEC for decades. A shift from initially available enzyme immunoassay testing to culture-independent diagnostic tests (CIDTs) has increased the uptake of testing at clinical microbiology laboratories. This testing change has resulted in an increased number of specimen submissions to WC. During a 12-year period between 2011 and 2022, WC received 5037 broths and/or stool specimens for STEC confirmation from clinical microbiology laboratories. Of these, 3992 were positive for Shiga toxin genes (stx1 and/or stx2) by real-time PCR. Furthermore, culture methods were utilized to isolate, identify, and characterize 2925 STEC from these primary specimens. Notably, WC observed a >200% increase in the number of STEC specimens received in 2021-2022 compared with 2011-2012 and an 18% increase in the number of non-O157 STEC identified using the same methodologies. During the past decade, the WC testing algorithm has been updated to manage the increase in specimens received, while also navigating the novel COVID-19 pandemic, which took priority over other testing for a period of time. This report summarizes updated methods for confirmation, surveillance, and outbreak detection of STEC and describes findings that may be related to our algorithm updates and the increased use of CIDTs, which is starting to elucidate the true incidence of non-O157 STEC.

Resources and Geographic Access to Care for Severe Pediatric Pneumonia in Four Resource-limited Settings.

Rationale: Pneumonia is the leading cause of death in children worldwide. Identifying and appropriately managing severe pneumonia in a timely manner improves outcomes. Little is known about the readiness of healthcare facilities to manage severe pediatric pneumonia in low-resource settings. Objectives: As part of the HAPIN (Household Air Pollution Intervention Network) trial, we sought to identify healthcare facilities that were adequately resourced to manage severe pediatric pneumonia in Jalapa, Guatemala (J-GUA); Puno, Peru (P-PER); Kayonza, Rwanda (K-RWA); and Tamil Nadu, India (T-IND). We conducted a facility-based survey of available infrastructure, staff, equipment, and medical consumables. Facilities were georeferenced, and a road network analysis was performed. Measurements and Main Results: Of the 350 healthcare facilities surveyed, 13% had adequate resources to manage severe pneumonia, 37% had pulse oximeters, and 44% had supplemental oxygen. Mean (±SD) travel time to an adequately resourced facility was 41 ± 19 minutes in J-GUA, 99 ± 64 minutes in P-PER, 40 ± 19 minutes in K-RWA, and 31 ± 19 minutes in T-IND. Expanding pulse oximetry coverage to all facilities reduced travel time by 44% in J-GUA, 29% in P-PER, 29% in K-RWA, and 11% in T-IND (all P < 0.001). Conclusions: Most healthcare facilities in low-resource settings of the HAPIN study area were inadequately resourced to care for severe pediatric pneumonia. Early identification of cases and timely referral is paramount. The provision of pulse oximeters to all health facilities may be an effective approach to identify cases earlier and refer them for care and in a timely manner.

Adverse birth outcomes associated with household air pollution from unclean cooking fuels in low- and middle-income countries: A systematic review.

Approximately 3.8 billion people in low- and middle-income countries use unclean fuels as a source of primary cooking fuel as well as for heating. For pregnant women, the toxic chemicals produced by combustion of unclean fuels not only affect women's health directly, but particulate matter and carbon monoxide are absorbed in maternal blood and cross the placental barrier impairing fetal tissue growth. PRISMA 2009 guidelines were used for this systematic review. The inclusion criteria were quantitative, peer reviewed journal articles published within a date range of May 1, 2013-June 12, 2021 examining birth outcomes related to household air pollution from type of cooking fuel in low- and middle-income countries. The quality of available evidence was evaluated using the Office of Health Assessment and Translation (OHAT) risk of bias rating tool. Of the 553 studies screened, 23 satisfied the inclusion criteria. Of the studies that met the inclusion criteria, 14 were cross-sectional, 5 cohort, 1 case-control and 3 randomized control trials conducted across 15 different countries. A range of birth outcomes are reported across studies including birthweight (19), small for gestational age (6), spontaneous abortion (3), preterm birth (6), stillbirth (7) and neonatal mortality (6). The reviewed studies presented evidence for an increased risk of low birth weight (LBW), preterm birth (PTB), small for gestational age (SGA), stillbirth, neonatal mortality and reduction in birthweight with solid fuel and kerosene use compared to cleaner fuels like gas and LPG. Systematically reviewing the evidence and risk of bias ratings illuminated several gaps in the current literature related to exposure assessment, outcome measurement and adequacy of adjustment for confounding.

A risk assessment tool for resumption of research activities during the COVID-19 pandemic for field trials in low resource settings.

RATIONALE: The spread of severe acute respiratory syndrome coronavirus-2 has suspended many non-COVID-19 related research activities. Where restarting research activities is permitted, investigators need to evaluate the risks and benefits of resuming data collection and adapt procedures to minimize risk. OBJECTIVES: In the context of the multicountry Household Air Pollution Intervention (HAPIN) trial conducted in rural, low-resource settings, we developed a framework to assess the risk of each trial activity and to guide protective measures. Our goal is to maximize the integrity of reseach aims while minimizing infection risk based on the latest scientific understanding of the virus. METHODS: We drew on a combination of expert consultations, risk assessment frameworks, institutional guidance and literature to develop our framework. We then systematically graded clinical, behavioral, laboratory and field environmental health research activities in four countries for both adult and child subjects using this framework. National and local government recommendations provided the minimum safety guidelines for our work. RESULTS: Our framework assesses risk based on staff proximity to the participant, exposure time between staff and participants, and potential viral aerosolization while performing the activity. For each activity, one of four risk levels, from minimal to unacceptable, is assigned and guidance on protective measures is provided. Those activities that can potentially aerosolize the virus are deemed the highest risk. CONCLUSIONS: By applying a systematic, procedure-specific approach to risk assessment for each trial activity, we were able to protect our participants and research team and to uphold our ability to deliver on the research commitments we have made to our staff, participants, local communities, and funders. This framework can be tailored to other research studies conducted in similar settings during the current pandemic, as well as potential future outbreaks with similar transmission dynamics. The trial is registered with clinicaltrials.gov NCT02944682 on October 26. 2016 .

Designing a Graphic Novel: Engaging Community, Arts, and Culture Into Public Health Initiatives.

The opioid epidemic was declared a national public health emergency in 2017. In Georgia, standing orders for the opioid antagonist, naloxone, have been implemented to reduce mortality from opioid overdoses. Service industry workers in the Atlanta, Georgia, inner-city community of Little Five Points (L5P) have access to naloxone, potentially expanding overdose rescue efforts in the community setting. To explore the issues facing L5P, our research brings together qualitative descriptive inquiry, ethnography, community-based research, a community advisory board, and a local artist to maximize community dissemination of research findings through a graphic novel that describes encountering an opioid overdose. This format was chosen due to the ethical responsibility to disseminate in participants' language and for its potential to empower and educate readers. This article describes the process of working on this study with the community and a local artist to create sample pages that will be tested for clarity of the message in a later phase. Working with an artist has revealed that while dissemination and implementation for collaboration begin before findings are ready, cross-collaboration with the artist requires early engagement, substantial funding, artist education in appropriate content, and member checking to establish community acceptability altering illustrations that reinforce negative stereotypes. By sharing the experiences of actions taken during an opioid overdose in L5P through a graphic novel, we can validate service industry workers' experiences, acknowledge their efforts to contribute to harm reduction, and provide much-needed closure to those who encounter opioid overdoses in the community.

Advancing the symptom science model with environmental health.

OBJECTIVE: Globally, indoor and outdoor pollutants are leading risk factors for death and reduced quality of life. Few theories explicitly address environmental health within the nursing discipline with a focus on harmful environmental exposures. The objective here is to expand the National Institutes of Health Symptom Science Model to include the environmental health concepts of environmental endotype (causative pathway) and environmental exposure. DESIGN: Meleis' research to theory strategy for theory refinement was used. Research workshop proceedings, environmental health nursing research expert consensus, panelist research trajectories, and review of the literature were utilized as data sources. RESULTS: Ongoing emphasis on the physical environment as a key determinant of health and theoretical perspectives for including environmental exposures and endotypes in symptom science are presented. Definitions of these concepts, further developed, are provided. Recommendations to strengthen environmental health nursing research and practice through capacity building/infrastructure, methods/outcomes, translational/clinical research, and basic/mechanistic research are included. CONCLUSION: The revised model deepens theoretical support for clinical actions that include environmental modification, environmental health education, and exposure reduction. This modification will enable a middle-range theory and shared mental model to inspire the prioritization of environmental health in nursing leadership, research, practice, and education.

An exploratory study of knowledge, attitudes, and beliefs related to tobacco use and secondhand smoke among women in Aleta Wondo, Ethiopia.

BACKGROUND: By 2030, the Sub-Saharan African region is projected to be the epicenter of the tobacco epidemic. While smoking prevalence is currently low among women (< 2%), the prevalence among men (7.7% overall and up to 27% depending on region) makes exposure to secondhand smoke a pressing concern for women and children. To prevent the uptake of smoking among women and address tobacco-related risks, including secondhand smoke exposure, a greater understanding of women's related perceptions is needed. The purpose of this study was to explore Ethiopian women's knowledge, attitudes, and beliefs related to tobacco use and secondhand smoke exposure, and the potential influence of contextual factors including; khat use, exposure to pro- and anti-tobacco messaging, and religious affiliation. METHODS: A cross-sectional study using a systematic household sampling technique and an adapted interviewer-administered survey was conducted in Southern Ethiopia. The survey was administered to 353 women, 18-55 years of age, in Aleta Wondo town and surrounding districts between August-October 2014 (95.2% cooperation rate). RESULTS: General awareness of harm associated with personal tobacco use and exposure to secondhand smoke was high (> 94%); however, specific knowledge of associated health-risks was limited. More than 96% perceived female tobacco use as socially unacceptable. At the same time, more than 70% were able to name potential benefits of using tobacco for both personal consumption and non-personal use. Respondents reported greater experimentation with khat versus tobacco and 73% reported that their religion significantly influenced their tobacco-related attitudes. Overall, there were higher reports of exposure to anti-tobacco (70%) versus pro-tobacco (49%) messaging, in the last 30 days. CONCLUSIONS: The high level of awareness of health risks associated with tobacco use and SHS exposure and the high exposure to anti-tobacco messaging are community-level strengths that can proactively be built on to prevent the projected disease burden associated with tobacco. Findings have implications for the development of contextualized gender-specific tobacco control interventions, particularly in relation to the promotion of smoke-free homes.

Designing a behavioral intervention using the COM-B model and the theoretical domains framework to promote gas stove use in rural Guatemala: a formative research study.

BACKGROUND: Three billion people use solid cooking fuels, and 4 million people die from household air pollution annually. Shifting households to clean fuels, like liquefied petroleum gas (LPG), may protect health only if stoves are consistently used. Few studies have used an implementation science framework to systematically assess "de-implementation" of traditional stoves, and none have done so with pregnant women who are more likely to adopt new behaviors. We evaluated an introduced LPG stove coupled with a phased behavioral intervention to encourage exclusive gas stove use among pregnant women in rural Guatemala. METHODS: We enrolled 50 women at < 20 weeks gestation in this prospective cohort study. All women received a free 3-burner LPG stove and ten tank refills. We conducted formative research using COM-B Model and Theoretical Domains Framework (TDF). This included thematic analysis of focus group findings and classes delivered to 25 pregnant women (Phase 1). In Phase 2, we complemented classes with a home-based tailored behavioral intervention with a different group of 25 pregnant women. We mapped 35 TDF constructs onto survey questions. To evaluate stove use, we placed temperature sensors on wood and gas stoves and estimated fraction of stove use three times during pregnancy and twice during the first month after infant birth. RESULTS: Class attendance rates were above 92%. We discussed feasible ways to reduce HAP exposure, proper stove use, maintenance and safety. We addressed food preferences, ease of cooking and time savings through cooking demonstrations. In Phase 2, the COM-B framework revealed that other household members needed to be involved if the gas stove was to be consistently used. Social identity and empowerment were key in decisions about stove repairs and LPG tank refills. The seven intervention functions included training, education, persuasion, incentivization, modelling, enablement and environmental restructuring. Wood stove use dropped upon introduction of the gas stove from 6.4 h to 1.9 h. CONCLUSIONS: This is the first study using the COM-B Model to develop a behavioral intervention that promotes household-level sustained use of LPG stoves. This study lays the groundwork for a future LPG stove intervention trial coupled with a behavioral change intervention. TRIAL REGISTRATION: NCT02812914, registered 3 June 2016, retrospectively registered.

Lung function in woodsmoke-exposed Guatemalan children following a chimney stove intervention.

RATIONALE: Household air pollution (HAP) from solid fuel combustion is a major contributor to the global burden of disease, with considerable impact from respiratory infections in children. The impact of HAP on lung function is unknown. OBJECTIVES: The Childhood Exposure to Respirable Particulate Matter (CRECER) prospective cohort study followed Guatemalan children who participated in the Randomised Exposure Study of Pollution Indoors and Respiratory Effects (RESPIRE) trial of a chimney stove intervention to determine the effect of early childhood HAP exposure on growth of lung function. METHODS: RESPIRE households with pregnant women or infant children were randomised to receive a chimney stove at the beginning or at the end of the 18-month trial. During CRECER, a subset of these children, as well as children from households with newly installed stoves, were followed with spirometry beginning at age 5. Biomass smoke exposure was measured using personal carbon monoxide tubes. Two-stage regression models were employed to analyse associations with lung function growth. MEASUREMENTS AND MAIN RESULTS: Longitudinal peak expiratory flow (PEF) and FEV1 data were available for 443 and 437 children, respectively, aged 5-8 (mean follow-up 1.3 years). Decreases in PEF growth of 173 mL/min/year (95% CI -341 to -7) and FEV1 of 44 mL/year (95% CI -91 to 4) were observed with stove installation at 18 months compared with stove installation at birth in analyses adjusted for multiple covariates. No statistically significant associations were observed between personal HAP exposure and lung function. CONCLUSIONS: A significant decrease in PEF growth and a large non-significant decrease in FEV1 growth were observed with later stove installation. Additional studies including longer follow-up and cleaner stoves or fuels are needed.

Factors associated with secondhand tobacco smoke in the home: an exploratory cross-sectional study among women in Aleta Wondo, Ethiopia.

BACKGROUND: In Ethiopia, female smoking rates are currently low (1 %). However, because of male smoking rates (overall 7.7 % and up to 27 % depending on region), women and children's risk of second hand smoke (SHS) exposure is a pressing concern. In order to develop effective public health interventions that prevent the uptake and exposure to smoking, thereby averting the projected increase in tobacco-induced disease, an understanding of Ethiopian women's practices regarding tobacco is needed. The purpose of this study was to explore Ethiopian women's tobacco use and prevalence of SHS exposure, and to identify covariates associated with SHS exposure. METHODS: We conducted an exploratory cross-sectional study in Southern Ethiopia between August and October 2014, and systematically sampled households in Aleta Wondo town and surrounding districts. Trained interviewers verbally administered surveys to women 18-55 years of age. Descriptive statistics and multiple logistic regression analyses were performed. RESULTS: None of the 353 participants reported current tobacco use and less than 1 % reported ever use, however, 11 % reported ever use of the stimulant leaf khat. Twenty-seven women (7.6 %) reported living with a tobacco user, however, twice that number (14.4 %) overall, and 22 % of urban participants reported that smoking occurred daily in their home. When controlling for other factors, living with a tobacco user (OR = 9.91, 95 % CI [3.32, 29.59]), allowing smoking in the home (OR = 5.67, 95 % CI [2.51, 12.79]), place of residence (OR = 2.74, 95 % CI [1.11, 6.74)]), and exposure to point-of-sale advertising within the last 30 days (OR = 2.87, 95 % CI [1.26, 6.54]) contributed significantly to a model predicting the likelihood of reporting daily occurrence of smoking/SHS in the home. CONCLUSIONS: While few women reported having ever used tobacco, one in seven women in this study reported that smoking/SHS occurred daily in their homes. Therefore SHS exposure is a potential health concern for women and children in this rural community. Findings from this study provide baseline data for monitoring tobacco control policies in Ethiopia, particularly in relation to the promotion of smoke-free homes, and could be used to inform prevention program development.

Childhood trauma is associated with depressive symptoms in Mexico City women.

OBJECTIVE: To describe childhood trauma and depressive symptoms in Mexican women and to explore the relationships between number and type of childhood traumatic events and depressive symptoms. METHODS: A community-based sample of 100 women was interviewed using a demographic questionnaire, the Life Stressor Checklist-Revised (LSC-R), and the Center for Epidemiologic Studies Depression Scale (CES-D). Childhood trauma (trauma at or before 16 years of age) and depressive symptoms were described, and logistic and linear regressions were used to analyze the relationship between childhood traumatic events and current depressive symptoms. RESULTS: Participants reported a mean of 9.46 (standard deviation (SD): 4.18) lifetime traumas and 2.76 (SD: 2.34) childhood traumas. The mean CES-D score was 18.9 (SD: 12.0) and 36.0% of participants had clinically significant depression (CES-D > 24). Depression scores were correlated with lifetime trauma, childhood trauma, education level, employment status, and number of self-reported current medical conditions. Depression scores were not significantly correlated with age, marital status, number of children, or socioeconomic status. For every additional childhood trauma experienced, the odds of clinically significant depressive symptoms (CES-D > 24) increased by 50.0% (adjusted odds ratio (OR): 1.50; 95% confidence interval: 1.14-1.96), after controlling for number of children, age, education level, employment status, and number of self-reported medical conditions. CONCLUSIONS: The results indicated that the number of childhood trauma exposures is associated with current depression among urban Mexican women, suggesting a need for trauma-informed care in this setting.

Incidence, risk factors, and management of infusion-related reactions in breast cancer patients receiving trastuzumab.

BACKGROUND: Trastuzumab has become a mainstay of therapy for human epidermal growth factor receptor-2 overexpressed breast cancer in nearly all stages of the disease. Like many monoclonal antibodies, trastuzumab is associated with infusion-related reactions (IRRs) that are not well described, and incidence varies widely between reports (0.7%-40% of patients). MATERIALS AND METHODS: A retrospective chart review of breast cancer patients who received trastuzumab was conducted. The primary objective was to describe the incidence, risk factors, and management of IRRs during the first 12 weeks of trastuzumab therapy in a general population of breast cancer patients. RESULTS: A total of 197 patients who received trastuzumab (1,788 doses) were evaluated. Thirty-three IRRs were identified in 32 patients, resulting in an incidence of 16.2% of patients and 1.8% of doses. All IRRs were mild or moderate in severity and were successfully managed with supportive medications and/or by temporarily stopping the infusion. All patients received subsequent cycles of trastuzumab, with only one patient experiencing a subsequent reaction. Body mass index, stage of disease, and use of premedications were significantly associated with IRRs by multivariate logistic regression analysis. CONCLUSION: Overall, these results support that the vast majority of IRRs occur with the first infusion, are mild in severity, and are easily managed. In addition, risk factors were identified that may help to identify a population of patients at increased risk of IRRs who may benefit from premedication.

Premature or just small? Training Guatemalan birth attendants to weigh and assess gestational age of newborns: an analysis of outcomes.

We describe Guatemalan birth attendants' identification of vulnerable newborns, their evaluation of gestational age and anthropometry, and the validity of the Capurro and New Ballard newborn gestational age assessment methods. We interviewed 49 birth attendants and trained 10 of these women to assess 63 newborns. The Capurro and Ballard methods were correlated (Spearman rho = .75, p < .001) and showed agreement (Bland-Altman plot, difference and bias, -0.33 ± 1.3 weeks). Prematurity was estimated at 27% (Ballard) and 24% (Capurro); low birth weight (LBW) was 30%. Capurro provided a simplified, equivalent estimate of gestational age compared with New Ballard that could be used by birth attendants.

Addressing Fear of Negative Consequences of Overdose Response: A Qualitative Study of the Perceptions of Service Industry Workers Who Encounter an Opioid Overdose in an Urban Commercial District in Atlanta, Georgia.

BACKGROUND: The increased contamination of illicit drugs with fentanyl in the United States drug market has contributed to escalating mortality from drug overdose. Leisure and hospitality service industry workers are encountering opioid-triggered overdoses in their workplaces, such as restaurants and bars. Consequently, this increases the need for overdose education and naloxone distribution (OEND) training, which has been limited. We aimed to describe the experiences among service industry workers encountering an overdose in their workplace. METHODS: We conducted in-depth qualitative interviews with service industry workers in Little Five Points (L5P), Atlanta, between October 2019 and April 2020 and triangulated methods with participant observations and fieldwork. Purposive criterion sampling methods were applied to recruit from different establishments in the L5P commercial district, which comprised restaurants, bars, retail shops, and theaters. After an initial seed sample was identified by engaging key stakeholders during fieldwork (business owners, managers, and the business association), a snowball sample followed for a final sample of N = 15. To contextualize the local population of harm reduction workers, people who use drugs and/or obtain safer drug consumption supplies in L5P (sterile syringes, safer using kits, naloxone), and service industry workers and their customers in L5P, the first author volunteered with an Atlanta syringe services program from October 2019 to April 2020. The first author conducted participant observations during the syringe exchange program and field notes were taken during observation (44 hours). This engagement ensured a rich, thick description. We used a pragmatic approach to thematic data analysis for this study. Data were analyzed iteratively and inductively from interviews and observations. Two independent researchers reviewed transcripts to identify passages in the data related to the question of interest. The passages were contextualized within the full data set independently to understand the relationships in developing a theory of what was commonly occurring across participants' experiences, and these relationships led to emerging salient themes regarding encountering an opioid overdose at work. RESULTS: One salient theme related to overdose response emerged with the service industry workers included fear of negative consequences of overdose response, specifically, fear of disease transmission from artifacts of drug use and overdose response, including the spread of blood-borne disease, violence, and exposure to unintentional overdose. When discussing drug use, participants' beliefs about the potential for personal danger from drug use artifacts (syringes and discarded drugs) and violence were identified as barriers to opioid overdose responses. CONCLUSIONS/IMPLICATIONS FOR OCCUPATIONAL HEALTH PRACTICE: Our findings provide valuable insights for tailoring OEND training for service industry workers to confront fears associated with opioid overdose response in their places of work to decrease mortality from the opioid epidemic. Harm reduction approaches need to be sensitive to the places in which overdose occurs and who the overdose responder is likely to be, which requires appropriately tailoring OEND training for service industry workers.