Health trends in Canada 1990-2019: An analysis for the Global Burden of Disease Study.

OBJECTIVE: Monitoring trends in key population health indicators is important for informing health policies. The aim of this study was to examine population health trends in Canada over the past 30 years in relation to other countries. METHODS: We used data on disability-adjusted life years (DALYs), years of life lost (YLL), years lived with disability, life expectancy (LE), and child mortality for Canada and other countries between 1990 and 2019 provided by the Global Burden of Disease Study. RESULTS: Life expectancy, age-standardized YLL, and age-standardized DALYs all improved in Canada between 1990 and 2019, although the rate of improvement has leveled off since 2011. The top five causes of all-age DALYs in Canada in 2019 were neoplasms, cardiovascular diseases, musculoskeletal disorders, neurological disorders, and mental disorders. The greatest increases in all-age DALYs since 1990 were observed for substance use, diabetes and chronic kidney disease, and sense organ disorders. Age-standardized DALYs declined for most conditions, except for substance use, diabetes and chronic kidney disease, and musculoskeletal disorders, which increased by 94.6%, 14.6%, and 7.3% respectively since 1990. Canada's world ranking for age-standardized DALYs declined from 9th place in 1990 to 24th in 2019. CONCLUSION: Canadians are healthier today than in 1990, but progress has slowed in Canada in recent years in comparison with other high-income countries. The growing burden of substance abuse, diabetes/chronic kidney disease, and musculoskeletal diseases will require continued action to improve population health.

RéSUMé: OBJECTIF: La surveillance des tendances des indicateurs clés de la santé de la population est importante pour éclairer les politiques de santé. Dans cette étude, nous avons examiné les tendances de la santé de la population au Canada au cours des 30 dernières années par rapport à d'autres pays. MéTHODES: Nous avons utilisé des données sur les années de vie ajustées en fonction de l'incapacité (DALY), les années de vie perdues (YLL), les années vécues avec un handicap, l'espérance de vie (LE) et la mortalité infantile pour le Canada et d'autres pays entre 1990 et 2019, fournies par l'Étude mondiale sur le fardeau de la maladie. RéSULTATS: L'espérance de vie, les YLL ajustées selon l'âge et les DALY ajustées selon l'âge ont tous connu une amélioration au Canada entre 1990 et 2019, bien que le taux d'amélioration se soit stabilisé depuis 2011. Les cinq principales causes des DALY pour tous les âges au Canada en 2019 étaient les néoplasmes, les maladies cardiovasculaires, les affections musculosquelettiques, les affections neurologiques et les troubles mentaux. Les plus fortes augmentations des DALY pour tous les âges depuis 1990 ont été observées pour l'usage de substances, le diabète et les maladies rénales chroniques, ainsi que les troubles des organes sensoriels. Les DALY ajustées selon l'âge ont diminué pour la plupart des conditions, à l'exception de l'usage de substances, du diabète et des maladies rénales chroniques, ainsi que des troubles musculosquelettiques, qui ont augmenté de 94,6 %, 14,6 % et 7,3 % respectivement depuis 1990. Le classement mondial du Canada pour les DALY ajustées selon l'âge est diminué de la 9ième place en 1990 à la 24ième place en 2019. CONCLUSION: Les Canadiens sont en meilleure santé aujourd'hui qu'en 1990, mais les progrès se sont ralentis ces dernières années par rapport à d'autres pays à revenu élevé. La croissance du fardeau lié à l'abus de substances, au diabète/maladies rénales chroniques et aux affections musculosquelettiques exigera des actions continues pour améliorer la santé de la population.

Air quality and respiratory health in children.

Air pollution is a leading modifiable risk factor for various cardio-respiratory outcomes globally, both for children and for adults. Children are particularly susceptible to the adverse effects of air pollution due to various physiological and behavioural factors. Children are at a higher risk of outcomes such as acute respiratory infections, asthma and decreased lung function due to air pollution exposure; the risk varies in different geographical regions, depending on the source of air pollution, duration of exposures and concentration. Prenatal exposure to air pollution may also contribute to adverse respiratory outcomes later in life.

Effects of Household Air Pollution (HAP) on Cardiovascular Diseases in Low- and Middle-Income Countries (LMICs): A Systematic Review and Meta-Analysis.

BACKGROUND: Out of over 3 billion people exposed to household air pollution (HAP), approximately 4 million die prematurely, most from cardiorespiratory diseases. Although many recent studies have reported adverse effects of HAP on cardiovascular outcomes, the findings are inconsistent. OBJECTIVES: The primary aim of this systematic review is to critically appraise the published studies and report the pooled summary of the findings on the association between HAP and cardiovascular outcomes, particularly in LMICs. METHODS: During this systematic review and meta-analysis, six databases were searched systematically, and the protocol was published in PROSPERO (CRD 42021248800). Only peer-reviewed English-language studies published from 1980 to March 2021 were included. We extracted data for the population ≥ 18 years old. Newcastle-Ottawa Criteria were used to assess the quality of evidence. The heterogeneity and publication bias of the studies was evaluated. A meta-analysis was conducted using a random-effect model to pool the findings from published studies. RESULTS: In sixteen studies totaling 547,463 cases, 319,180 were exposed to HAP. The pooled estimate suggested an overall 13% higher risk of CVDs, and a 21% higher risk of CVD mortality in LMICs among those exposed to HAP. Similarly, the increased risk of stroke and cerebrovascular accidents, heart failure, and hypertension was statistically significant among those exposed to HAP but not with myocardial infarction, IHD, eclampsia/preeclampsia, and carotid intima-media thickness. CONCLUSIONS: Our findings suggest exposure to HAP increases the risk of cardiovascular outcomes.

Effect of exposure to biomass smoke from cooking fuel types and eye disorders in women from hilly and plain regions of Nepal.

BACKGROUND/AIM: To study the association between exposure to biomass smoke from cooking fuels andi cataract, visual acuity and ocular symptoms in women. METHODS: We conducted a community-based cross-sectional study among women (≥20 years and without a previous diagnosis of cataract, ocular trauma or diabetes or those taking steroids) from hilly and plain regions of Nepal. Eligible participants received an interview and a comprehensive eye assessment (cataract development, visual acuity test and ocular symptoms). Participants' data on demographics, cooking fuel type and duration of use, and cooking habits were collected. We addressed potential confounders using the propensity score and other risk factors for ocular diseases through regression analysis. RESULTS: Of 784 participants, 30.6% used clean fuel (liquefied petroleum gas, methane, electricity) as their primary current fuel, and the remaining 69.4% used biomass fuels. Thirty-nine per cent of the total participants had cataracts-about twofold higher in those who currently used biomass fuel compared with those who used clean fuel (OR=2.27; 95% CI 1.09 to 4.77) and over threefold higher in those who always used biomass. Similarly, the nuclear cataract was twofold higher in the current biomass user group compared with the clean fuel user group (OR=2.53; 95% CI 1.18-5.42) and over threefold higher among those who always used biomass. A higher proportion of women using biomass had impaired vision, reported more ocular symptoms compared with those using clean fuel. Severe impaired vision and blindness were only present in biomass fuel users. However, the differences were only statistically significant for symptoms such as redness, burning sensation, a complaint of pain in the eye and tear in the eyes. CONCLUSIONS: Cataract was more prevalent in women using biomass for cooking compared with those using clean fuel.

Breastfeeding and risk of childhood asthma: a systematic review and meta-analysis.

OBJECTIVE: To investigate the relationship between breastfeeding and the development of paediatric asthma. METHODS: A systematic review and meta-analysis was conducted with MEDLINE, Embase, CINAHL and ProQuest Nursing and Allied Health source databases. Retrospective/prospective cohorts in children aged <18 years with breastfeeding exposure reported were included. The primary outcome was a diagnosis of asthma by a physician or using a guideline-based criterion. A secondary outcome was asthma severity. RESULTS: 42 studies met inclusion criteria. 37 studies reported the primary outcome of physician-/guideline-diagnosed asthma, and five studies reported effects on asthma severity. Children with longer duration/more breastfeeding compared to shorter duration/less breastfeeding have a lower risk of asthma (OR 0.84, 95% CI 0.75-0.93; I2 = 62.4%). Similarly, a lower risk of asthma was found in children who had more exclusive breastfeeding versus less exclusive breastfeeding (OR 0.81, 95% CI 0.72-0.91; I2=44%). Further stratified analysis of different age groups demonstrated a lower risk of asthma in the 0-2-years age group (OR 0.73, 95% CI 0.63-0.83) and the 3-6-years age group (OR 0.69, 95% CI 0.55-0.87); there was no statistically significant effect on the ≥7-years age group. CONCLUSION: The findings suggest that the duration and exclusivity of breastfeeding are associated with a lower risk of asthma in children aged <7 years.

The Effects of Household Air Pollution (HAP) on Lung Function in Children: A Systematic Review.

The World Health Organization (WHO) estimates that around 3 billion people today are exposed to smoke from the household combustion of solid fuels. While the household use of solid fuels has decreased over the last few decades, it remains a leading modifiable risk factor for the global burden of disease. This systematic review analyzed the impact of Household Air Pollution (HAP) on lung function in children (under 18 years of age), as this is the time period of accelerated growth rate until full skeletal maturity. Data from 11 published studies demonstrated that exposure to smoke from solid fuel was associated with a lower growth rate of several lung function indices (FVC, FEV1, FEF25-75) in children. However, there was no observed association between HAP and the FEV1/FVC ratio over time. Although the evidence suggests an inverse association between high exposure to HAP and lung function indices, there is a lack of longitudinal data describing this association. Therefore, precaution is needed to reduce the smoke exposure from solid fuel burning.

Prevalence of Stroke and Stroke Risk Factors in a South-Western Community of Nepal.

BACKGROUND: Stroke related studies in Nepal are primarily hospital-based and mainly from the capital city. OBJECTIVES: We aimed to estimate the prevalence of stroke and stroke risk factors in the South-Western community of Nepal. METHODS: A cross-sectional study was conducted from May to August 2018 among 549 randomly selected Nepalese participants from diverse ethnicity, aged ≥15 years, in a region with the availability of neurological support facilities. Data were collected using a stroke questionnaire designed for the purpose. Stroke was identified by enumerators using the Balance-Eyes-Face-Arms-Speech-Time (BEFAST) scale, and a senior neurologist confirmed it. We assessed the presence of major risk factors associated with stroke. RESULTS: The crude and age-standardised prevalence of stroke were 2368 and 2967 per 100,000 respectively. Of all the surveyed participants, 61% (n=335) reported consumption of full-fat dairy products >3 days per week, 87.6% (n=481) reported a high intake of salt (>5 g/day), 83.6% (n=459) with a low intake of fruits and vegetables (<400 g/day), 45.2% (n=248) with perceived stress related to work or home, 51.6% (n=283) with financial stress (283, 51.6%), 86.7% (n=457) with low high-density lipoprotein, 96.2% (n=507) with high blood urea nitrogen, 47.1% (n=356) were either overweight or obese 20.4% (n=112) with hypertension and 6.2% (n=34) with diabetes. CONCLUSIONS: The prevalence of stroke in the community of the South-Western part of Nepal is relatively higher than that estimated in South-Asia and global context. Our findings suggest an urgent community intervention, particularly with healthy lifestyles changes for future stroke prevention in the high-risk group.

Impact of deprivation, dementia prevalence and regional demography on prescribing of antidementia drugs in England: A time trend analysis.

AIM: This study aimed to examine trends in prescribing of antidementia drugs in primary care in England between 2009 and 2019, and investigate the impact of deprivation, regional demography and disease prevalence on prescribing practices. METHODS: Analysis of publicly available government data from various sources pertaining to primary care prescribing and demographics was conducted. All primary care prescription data pertaining to antidementia drugs in England between 2009 and 2019 were extracted and adjusted for inflation and population changes. Data across English clinical commissioning regions were compared to explore the association between prescribing trend, deprivation, regional demography and dementia prevalence. RESULTS: The number of prescription items for antidementia drugs in England increased by approximately 3-fold (195.4%) from 24 items/1000 population in 2009 to 70.9 items/1000 population in 2019. In 2019, the least-deprived areas had approximately twice the rate of prescribing of antidementia drugs compared to the most-deprived areas (median [IQR] values of 46.7 [36.6-64.8] vs 91.23 [76.2-95.1] items/1000 population, respectively). In the multivariable analysis, the number of prescription items showed an inverse relationship with deprivation (coefficient -0.046, 95% CI -0.47 to -0.045) after adjustment for number of populations aged 65+ years and prevalence of dementia. CONCLUSIONS: The 3-fold rise in the number of prescription items for antidementia drugs in the study period reflects the policy emphasis on early diagnosis and treatment of dementia. Higher rates of prescribing in the least-deprived areas may be reflective of better and early diagnoses and access to treatments. Such inequality in access to the treatments needs to be investigated further.

Regional and seasonal variations in household and personal exposures to air pollution in one urban and two rural Chinese communities: A pilot study to collect time-resolved data using static and wearable devices.

BACKGROUND: Previous studies of the health impact of ambient and household air pollution (AAP/HAP) have chiefly relied on self-reported and/or address-based exposure modelling data. We assessed the feasibility of collecting and integrating detailed personal exposure data in different settings and seasons. METHODS/DESIGN: We recruited 477 participants (mean age 58 years, 72% women) from three (two rural [Gansu/Henan] and one urban [Suzhou]) study areas in the China Kadoorie Biobank, based on their previously reported fuel use patterns. A time-resolved monitor (PATS+CO) was used to measure continuously for 120-hour the concentration of fine particulate matter (PM2.5) at personal and household (kitchen and living room) levels in warm (May-September 2017) and cool (November 2017-January 2018) seasons, along with questionnaires on participants' characteristics (e.g. socio-demographic, and fuel use) and time-activity (48-hour). Parallel local ambient monitoring of particulate matter (PM1, PM2.5 and PM10) and gaseous pollutants (CO, ozone, nitrogen oxides) was conducted using regularly-calibrated devices. The air pollution exposure data were compared by study sites and seasons. FINDINGS: Overall 76% reported cooking at least weekly (regular-cooks), and 48% (urban 1%, rural 65%) used solid fuels (wood/coal) for cooking. Winter heating was more common in rural sites than in urban site (74-91% vs 17% daily), and mainly involved solid fuels. Mixed use of clean and solid fuels was common for cooking in rural areas (38%) but not for heating (0%). Overall, the measured mean PM2.5 levels were 2-3 fold higher in the cool than warm season, and in rural (e.g. kitchen: Gansuwarm_season = 142.3 µg/m3; Gansucool_season = 508.1 µg/m3; Henanwarm_season = 77.5 µg/m3; Henancool_season = 222.3 µg/m3) than urban sites (Suzhouwarm_season = 41.6 µg/m3; Suzhoucool_season = 81.6 µg/m3). The levels recorded tended to be the highest in kitchens, followed by personal, living room and outdoor. Time-resolved data show prominent peaks consistently recorded in the kitchen at typical cooking times, and sustained elevated PM2.5 levels (> 100 µg/m3) were observed in rural areas where use of solid fuels for heating was common. DISCUSSION: Personal air pollution exposure can be readily assessed using a low-cost time-resolved monitor in different settings, which, in combination with other personal and health outcome data, will enable reliable assessment of the long-term health effects of HAP/AAP exposures in general populations.

A child with a foreign body in bronchus misdiagnosed as asthma.

Foreign body ingestion should be considered as an important differential in a child with difficult asthma. We report an 11-year-old male child with foreign body aspiration who initially was diagnosed and treated as difficult asthma. Later on, he was diagnosed to have a foreign body in the right bronchus, which was successfully removed by flexible bronchoscopy.

Clinical predictors of radiological pneumonia: A cross-sectional study from a tertiary hospital in Nepal.

BACKGROUND: Despite readily availability of vaccines against both Hemophilus influenzae and Pneumococcus, pneumonia remains the most common cause of morbidity and mortality in children under the age of five years in Nepal. With growing antibiotic resistance and a general move towards more rational antibiotic use, early identification of clinical signs for the prediction of radiological pneumonia would help practitioners to start the treatment of patients. The main aim of this study was to reassess the clinical predictors of pneumonia in Nepal. METHODS: This cross-sectional study was conducted between June 2015 and November 2015 at Tribhuvan University Teaching Hospital, a tertiary hospital in Kathmandu, Nepal. Children aged 3-60 months with a clinical diagnosis of pneumonia by a physician were enrolled in the study. Radiological pneumonia was identified and categorized as per World Health Organization guidelines by an experienced radiologist blinded to patient characteristics. We calculated sensitivity and specificity of clinical signs and symptoms for radiological pneumonia. RESULTS: Out of 1021 children with fever, 160 cases were clinically diagnosed as pneumonia and were enrolled for this study. Among the enrolled patients, 61% had radiological pneumonia. Tachypnea had the highest sensitivity of 99%, while bronchial breathing had the highest specificity of 100%. During univariate analysis, grunting, wheezing, nasal discharge, decreased breath sounds, noisy breathing and hypoxemia were associated with radiological pneumonia. Only hypoxemia remained an independent predictor when adjusted for all the factors. CONCLUSION: Tachypnea was the most sensitive sign, whereas bronchial breathing was most specific sign for radiological pneumonia.

Relationship between dietary patterns and COPD: a systematic review and meta-analysis.

BACKGROUND: Findings from previous studies reporting on the associations between chronic obstructive pulmonary disease (COPD) and various dietary patterns have been inconsistent. This review aims to summarise the evidence on the strength of the association between dietary patterns and the prevalence and incidence of COPD. METHODS: We conducted a comprehensive search of seven databases between 1 January 1980 and 30 November 2019. Two reviewers independently reviewed each manuscript through the screening, selection, data extraction and quality assessment stages. Data from eight observational studies that met the inclusion criteria were extracted and random-effects meta-analysis was subsequently conducted. RESULTS: Eight observational studies (all eight reporting on healthy dietary patterns and three on unhealthy dietary patterns) met the inclusion criteria and data were extracted to include in the meta-analysis. Consumption of a healthy dietary pattern was associated with a lower risk of COPD (pooled OR 0.88, 95% CI 0.82-0.94). Consumption of unhealthy dietary patterns was associated with a higher risk of COPD (OR 1.22, 95% CI 0.84-1.76); however, the results were not statistically significant and had high heterogeneity (I2=91%). CONCLUSION: Our results suggests that healthy dietary patterns are associated with a lower prevalence of COPD, while unhealthy dietary patterns are not. More studies, particularly adequately powered longitudinal studies, are needed to further elucidate the effects of healthy and unhealthy dietary patterns on risk of COPD.

Occupational exposure to inhaled pollutants and risk of airflow obstruction: a large UK population-based UK Biobank cohort.

BACKGROUND: Although around 10% to 15% of COPD burden can be attributed to workplace exposures, little is known about the role of different airborne occupational pollutants (AOP). The main aim of the study was to assess the effect size of the relationship between various AOP, their level and duration of exposure with airflow obstruction (AFO). METHODS: A cross-sectional analysis was conducted in 228 614 participants from the UK Biobank study who were assigned occupational exposure using a job exposure matrix blinded to health outcome. Adjusted prevalence ratios (PRs) and 95% CI for the risk of AFO for ever and years of exposure to AOPs were estimated using robust Poisson model. Sensitivity analyses were conducted for never-smokers, non-asthmatic and bi-pollutant model. RESULTS: Of 228 614 participants, 77 027 (33.7%) were exposed to at least one AOP form. 35.5% of the AFO cases were exposed to vapours, gases, dusts or fumes (VGDF) and 28.3% to dusts. High exposure to vapours increased the risk of occupational AFO by 26%. Exposure to dusts (adjusted PR=1.05; 95% CI 1.01 to 1.08), biological dusts (1.05; 1.01 to 1.10) and VGDF (1.04; 1.01 to 1.07) showed a significantly increased risk of AFO, however, statistically not significant following multiple testing. There was no significant increase in risk of AFO by duration (years) of exposure in current job. The results were null when restricted to never-smokers and when a bi-pollutant model was used. However, when data was analysed based on the level of exposure (low, medium and high) compared with no exposure, directionally there was increase in risk for those with high exposure to vapours, gases, fumes, mists and VGDF but statistically significant only for vapours. CONCLUSION: High exposure (in current job) to airborne occupational pollutants was suggestive of higher risk of AFO. Future studies should investigate the relationship between lifetime occupational exposures and COPD.

Solid fuels for cooking and tobacco use and risk of major chronic liver disease mortality: a prospective cohort study of 0.5 million Chinese adults.

BACKGROUND: Harmful substances in solid fuel and tobacco smoke are believed to enter the bloodstream via inhalation and to be metabolized in the liver, leading to chronic liver damage. However, little is known about the independent and joint effects of solid fuel use and smoking on risks of chronic liver disease (CLD) mortality. METHODS: During 2004-08, ∼0.5 million adults aged 30-79 years were recruited from 10 areas across China. During a 10-year median follow-up, 2461 CLD deaths were recorded. Multivariable Cox regression yielded adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) for the individual associations of self-reported long-term cooking fuel and tobacco use with major CLD death. RESULTS: Overall, 49% reported solid fuel use and 26% smoked regularly. Long-term solid fuel use for cooking and current smoking were associated with higher risks of CLD deaths, with adjusted HRs of 1.26 (95% CI, 1.02-1.56) and 1.28 (1.13-1.44), respectively. Compared with never-smoking clean fuel users, the HRs were 1.41 (1.10-1.82) in never-smoking solid fuel users, 1.55 (1.17-2.06) in regular-smoking clean fuel users and 1.71 (1.32-2.20) in regular-smoking solid fuels users. Individuals who had switched from solid to clean fuels (1.07, 0.90-1.29; for median 14 years) and ex-regular smokers who stopped for non-medical reasons (1.16, 0.95-1.43; for median 10 years) had no evidence of excess risk of CLD deaths compared with clean fuel users and never-regular smokers, respectively. CONCLUSIONS: Among Chinese adults, long-term solid fuel use for cooking and smoking were each independently associated with higher risks of CLD deaths. Individuals who had stopped using solid fuels or smoking had lower risks.

Clinical profile, complications and outcome of scrub typhus in children: A hospital based observational study in central Nepal.

BACKGROUND: Scrub typhus, an important cause of unexplained fever, is grossly neglected and often misdiagnosed in low and middle income countries like Nepal. The main aim of this study was to report on the clinical profile and complications of scrub typhus and its outcome in Nepalese children. METHODS: A prospective observational study was carried out in children aged 1-16 years, admitted to a tertiary care hospital of central Nepal in between July 2016- Aug 2017. Scrub typhus was diagnosed with IgM ELISA. RESULTS: All cases of scrub typhus (n = 76) presented with fever and commonly had other symptoms such as headache (75%), myalgia (68.4%), vomiting (64.5%), nausea (59.2%), abdominal pain (57.9%), cough (35.5%), shortness of breath (22.4%), altered sensorium (14.5%), rashes (13.2%) and seizures (11.8%). Important clinical signs noticed were lymphadenopathy (60.5%), hepatomegaly (47.4%), edema (26.3%), jaundice (26.3%), and splenomegaly (15.8%). About 12% (n = 9) had necrotic eschar. Similarly, thrombocytopenia, raised liver enzymes and raised creatinine values were seen in 36.9%, 34.2% and 65.8% respectively. The most common complications were myocarditis (72.4%), hypoalbuminemia (71.1%), severe thrombocytopenia (22.4%), renal impairment (65.8%), hyponatremia (48.7%) and hepatitis (34.2%). Over two-thirds (69.70%) of the cases were treated with doxycycline followed by combination with azithromycin in the remaining 18.4%. Overall, mortality rate in this group was 3.9%. CONCLUSIONS: Scrub typhus should be considered as a differential in any community acquired acute undifferentiated febrile illness regardless of the presence of an eschar. Myocarditis and acute kidney injury are important complications which when addressed early can prevent mortality. Use of doxycycline showed a favorable outcome.

Health Effects of Household Solid Fuel Use: Findings from 11 Countries within the Prospective Urban and Rural Epidemiology Study.

BACKGROUND: Household air pollution (HAP) from solid fuel use for cooking affects 2.5 billion individuals globally and may contribute substantially to disease burden. However, few prospective studies have assessed the impact of HAP on mortality and cardiorespiratory disease. OBJECTIVES: Our goal was to evaluate associations between HAP and mortality, cardiovascular disease (CVD), and respiratory disease in the prospective urban and rural epidemiology (PURE) study. METHODS: We studied 91,350 adults 35­70 y of age from 467 urban and rural communities in 11 countries (Bangladesh, Brazil, Chile, China, Colombia, India, Pakistan, Philippines, South Africa, Tanzania, and Zimbabwe). After a median follow-up period of 9.1 y, we recorded 6,595 deaths, 5,472 incident cases of CVD (CVD death or nonfatal myocardial infarction, stroke, or heart failure), and 2,436 incident cases of respiratory disease (respiratory death or nonfatal chronic obstructive pulmonary disease, pulmonary tuberculosis, pneumonia, or lung cancer). We used Cox proportional hazards models adjusted for individual, household, and community-level characteristics to compare events for individuals living in households that used solid fuels for cooking to those using electricity or gas. RESULTS: We found that 41.8% of participants lived in households using solid fuels as their primary cooking fuel. Compared with electricity or gas, solid fuel use was associated with fully adjusted hazard ratios of 1.12 (95% CI: 1.04, 1.21) for all-cause mortality, 1.08 (95% CI: 0.99, 1.17) for fatal or nonfatal CVD, 1.14 (95% CI: 1.00, 1.30) for fatal or nonfatal respiratory disease, and 1.12 (95% CI: 1.06, 1.19) for mortality from any cause or the first incidence of a nonfatal cardiorespiratory outcome. Associations persisted in extensive sensitivity analyses, but small differences were observed across study regions and across individual and household characteristics. DISCUSSION: Use of solid fuels for cooking is a risk factor for mortality and cardiorespiratory disease. Continued efforts to replace solid fuels with cleaner alternatives are needed to reduce premature mortality and morbidity in developing countries. https://doi.org/10.1289/EHP3915.

Health effects of household solid fuel use: findings from 11 countries within the prospective urban and rural epidemiology study

Approximately 2.5 billion individuals globally are exposed to household air pollution (HAP) from cooking with solid fuels such as coal, wood, dung, or crop residues (Smith et al. 2014). Concentrations of air pollutants, especially fine particulate matter [PM≤2:5 lminaerodynamicdiameterðPM2:5)], can be several orders of magnitude higher in homes cooking with solid fuels compared with those using clean fuels such as electricity or liquefied petroleum gas (LPG) (Clark et al. 2013; Shupler et al. 2018). PM2:5 in outdoor air has been linked to mortality, Address correspondence to Perry Hystad, School of Public Health and Human Sciences, Oregon State University, Milam Hall 10, 2520 SW Campus Way, Corvallis, OR 97331 USA. Telephone: (541) 737-4829. Email: Perry. hystad@oregonstate.edu SupplementalMaterialisavailableonline(https://doi.org/10.1289/EHP3915). The authors declared hey have no actual or potential competing financial interests. Received 16 May 2018; Revised 16 April 2019; Accepted 16 April 2019; Published 8 May 2019. Note to readers with disabilities: EHP strives to ensure that all journal content is accessible to all readers. However, some figures and Supplemental Material published in EHP articles may not conform to 508 standards due to the complexity of the information being presented. If you need assistance accessing journal content, please contact ehponline@niehs.nih.gov. Our staff will work with you to assess and meet your accessibility needs within 3 working days.is chemic heart disease (IHD), stroke, and respiratory diseases (Kim et al. 2015). Despite the large population exposed and the potential for adverse health effects, few prospective cohort studies have examined the health effects of HAP. Only four studies have examined HAP and mortality and reached contradictory conclusions (Alam et al. 2012; Kim et al. 2016; Mitter et al. 2016; Yu et al. 2018). Further, studies have not examined HAP and fatal as well as nonfatal cardiovascular disease (CVD) events. There is growing evidence of the adverse effects of HAP on respiratory diseases and lung cancer; however, most studies are cross sectional or case control in design, with relatively small sample sizes and limited geographic coverage (Gordon et al. 2014). To date, few prospective studies have examined HAP exposures and respiratory events in adults, and the existing studies have reported contradictory findings (Chanetal.2019; Ezzati and Kammen 2001; Mitter et al. 2016). Given the absence of direct epidemiological data, the Global Burden of Disease (GBD) study estimated the potential impact of HAP on health using exposure response relationships that pooled data from studies on outdoor air pollution, secondhand smoke, and active smoking (Burnett et al. 2014). These predictions indicated that 1.6 million deaths were attributable to HAP exposure in 2017, of which 39% were from IHD and stroke and 55% from respiratory outcomes [>90% from chronic obstructive pulmonary disease (COPD) and acute lower respiratory infections (ALRI)] (GBD 2017 Risk Factor Collaborators 2018). Given the lack of direct epidemiological evidence and this large predicted burden, there is an urgent need to directly characterize the health effects associated with HAP. Within the Prospective Urban and Rural Epidemiology (PURE) study, we conducted an analysis of 91,350 adults from 467 urban and rural communities in 11 low to middle-income countries (LMICs) where solid fuels are commonly used for cooking. We examined associations between cooking with solid fuels as a proxy indicator of HAP exposure and cause specific mortality, incident cases of CVD [ CVD death and incidence of nonfatal myocardial infarction (MI), stroke, and heart failure (HF)] and incident cases of respiratory disease [respiratory death, nonfatal COPD, pulmonary tuberculosis (TB), pneumonia, or lung cancer].We estimated associations between solid fuel use for cooking and these outcomes, controlling for extensive individual, household, and community covariates. (AU)

Under- and over-diagnosis of COPD: a global perspective.

Globally, chronic obstructive pulmonary disease (COPD) is the fourth major cause of mortality and morbidity and projected to rise to third within a decade as our efforts to prevent, identify, diagnose and treat patients at a global population level have been insufficient. The European Respiratory Society and American Thoracic Society, along with the Global Initiative for Chronic Obstructive Lung Disease (GOLD) strategy document, have highlighted key pathological risk factors and suggested clinical treatment strategies in order to reduce the mortality and morbidity associated with COPD. This review focuses solely on issues related to the under- and over-diagnosis of COPD across the main geographical regions of the world and highlights some of the associated risk factors. Prevalence of COPD obtained mainly from epidemiological studies varies greatly depending on the clinical and spirometric criteria used to diagnose COPD, i.e. forced expiratory volume in 1 s to forced vital capacity ratio <0.7 or 5% below the lower limit of normal, and this subsequently affects the rates of under- and over-diagnosis. Although under-utilisation of spirometry is the major reason, additional factors such as exposure to airborne pollutants, educational level, age of patients and language barriers have been widely identified as other potential risk factors. Co-existent diseases, such as asthma, bronchiectasis, heart failure and previously treated tuberculosis, are reported to be the other determinants of under- and over-diagnosis of COPD. KEY POINTS: Globally, there is large variation in the prevalence of COPD, with 10-95% under-diagnosis and 5-60% over-diagnosis (table 1) due to differences in the definition of diagnosis used, and the unavailability of spirometry in rural areas of low- and middle-income countries where the prevalence of COPD is likely to be high.In order to be diagnosed with COPD, patients must have a combination of symptoms with irreversible airflow obstruction defined by a post-bronchodilator FEV1/FVC ratio of <0.7 or below the fifth centile of the lower limit of normal (LLN), and with a history of significant exposure to a risk factor. Repeat spirometry is recommended if the ratio is between 0.6 and 0.8.Not performing spirometry is the strongest predictor for an incorrect diagnosis of COPD; however, additional factors, such as age, gender, ethnicity, self-perception of symptoms, co-existent asthma, and educational awareness of risk factor by patients and their physician, are also important.COPD can be associated with inhalation of noxious particles other than smoking tobacco. EDUCATIONAL AIMS: To summarise the global prevalence of over- and under-diagnosis of COPD.To highlight the risk factors associated with the under- and over-diagnosis of COPD.To update readers on the key changes in the recent progress made regarding the correct diagnosis of COPD.

Solid Fuel Use and Risks of Respiratory Diseases. A Cohort Study of 280,000 Chinese Never-Smokers.

RATIONALE: Little evidence from large-scale cohort studies exists about the relationship of solid fuel use with hospitalization and mortality from major respiratory diseases. OBJECTIVES: To examine the associations of solid fuel use and risks of acute and chronic respiratory diseases. METHODS: A cohort study of 277,838 Chinese never-smokers with no prior major chronic diseases at baseline. During 9 years of follow-up, 19,823 first hospitalization episodes or deaths from major respiratory diseases, including 10,553 chronic lower respiratory disease (CLRD), 4,398 chronic obstructive pulmonary disease (COPD), and 7,324 acute lower respiratory infection (ALRI), were recorded. Cox regression yielded adjusted hazard ratios (HRs) for disease risks associated with self-reported primary cooking fuel use. MEASUREMENTS AND MAIN RESULTS: Overall, 91% of participants reported regular cooking, with 52% using solid fuels. Compared with clean fuel users, solid fuel users had an adjusted HR of 1.36 (95% confidence interval, 1.32-1.40) for major respiratory diseases, whereas those who switched from solid to clean fuels had a weaker HR (1.14, 1.10-1.17). The HRs were higher in wood (1.37, 1.33-1.41) than coal users (1.22, 1.15-1.29) and in those with prolonged use (≥40 yr, 1.54, 1.48-1.60; <20 yr, 1.32, 1.26-1.39), but lower among those who used ventilated than nonventilated cookstoves (1.22, 1.19-1.25 vs. 1.29, 1.24-1.35). For CLRD, COPD, and ALRI, the HRs associated with solid fuel use were 1.47 (1.41-1.52), 1.10 (1.03-1.18), and 1.16 (1.09-1.23), respectively. CONCLUSIONS: Among Chinese adults, solid fuel use for cooking was associated with higher risks of major respiratory disease admissions and death, and switching to clean fuels or use of ventilated cookstoves had lower risk than not switching.