Biomass smoke exposure and somatic growth among children: The RESPIRE and CRECER prospective cohort studies in rural Guatemala.

BACKGROUND: Cooking-related biomass smoke is a major source of household air pollution (HAP) and an important health hazard. Prior studies identified associations between HAP exposure and childhood stunting; less is known for underweight and wasting. Few studies had personal HAP measurements. METHODS: 557 households in rural Guatemala were enrolled in the CRECER study, the follow-up study of the RESPIRE randomized intervention trial. They were assigned to three groups that received chimney stoves at different ages of the study children. Multiple personal carbon monoxide (CO) exposure measurements were used as proxies for HAP exposures. Children's heights and weights were measured from 24 to 60 months of age. Height-for-age z-score (HAZ), weight-for-age z-score (WAZ), and weight-for-height z-score (WHZ) were calculated based on the World Health Organization's Multicentre Growth Reference Study. HAZ, WAZ, and WHZ below -2 were classified as stunting, underweight, and wasting, respectively. Generalized linear models and mixed effects models were applied. RESULTS: 541 children had valid anthropometric data, among whom 488 (90.2 %) were stunted, 192 (35.5 %) were underweight, and 2 (0.3 %) were wasted. A 1 ppm higher average CO exposure was associated with a 0.21 lower HAZ (95 % CI: 0.17-0.25), a 0.13 lower WAZ (95 % CI: 0.10-0.17) and a 0.06 lower WHZ (95 % CI: 0.02-0.10).The associations for HAZ were stronger among boys (coefficient = -0.29, 95 % CI: -0.35 - -0.22) than among girls (coefficient = -0.15, 95 % CI: -0.20 - -0.10). A 1 ppm-year higher cumulative CO exposure was associated with a higher risk of moderate stunting among boys (OR = 1.27, 95 % CI: 1.05-1.59), but not among girls. DISCUSSION: In this rural Guatemalan population, higher HAP exposure was associated with lower HAZ and WAZ. The associations between HAP and HAZ/stunting were stronger among boys. Reducing HAP might benefit childhood somatic growth in rural populations of low-income countries.

Biomass Smoke Exposure and Atopy among Young Children in the Western Highlands of Guatemala: A Prospective Cohort Study.

Women and children in rural regions of low-income countries are exposed to high levels of household air pollution (HAP) as they traditionally tend to household chores such as cooking with biomass fuels. Early life exposure to air pollution is associated with aeroallergen sensitization and developing allergic diseases at older ages. This prospective cohort study assigned HAP-reducing chimney stoves to 557 households in rural Guatemala at different ages of the study children. The children's air pollution exposure was measured using personal CO diffusion tubes. Allergic outcomes at 4-5 years old were assessed using skin prick tests and International Study of Asthma and Allergies in Childhood (ISAAC)-based questionnaires. Children assigned to improved stoves before 6 months old had the lowest HAP exposure compared to the other groups. Longer exposure to the unimproved stoves was associated with higher risks of maternal-reported allergic asthma (OR = 2.42, 95% CI: 1.11-5.48) and rhinitis symptoms (OR = 2.01, 95% CI: 1.13-3.58). No significant association was found for sensitization to common allergens such as dust mites and cockroaches based on skin prick tests. Reducing HAP by improving biomass burning conditions might be beneficial in preventing allergic diseases among children in rural low-income populations.

Effectiveness of Gas and Chimney Biomass Stoves for Reducing Household Air Pollution Pregnancy Exposure in Guatemala: Sociodemographic Effect Modifiers.

Household air pollution (HAP) due to solid fuel use during pregnancy is associated with adverse birth outcomes. The real-life effectiveness of clean cooking interventions has been disappointing overall yet variable, but the sociodemographic determinants are not well described. We measured personal 24-h PM2.5 (particulate matter <2.5 µm in aerodynamic diameter) thrice in pregnant women (n = 218) gravimetrically with Teflon filter, impactor, and personal pump setups. To estimate the effectiveness of owning chimney and liquefied petroleum gas (LPG) stoves (i.e., proportion of PM2.5 exposure that would be prevented) and to predict subject-specific typical exposures, we used linear mixed-effects models with log (PM2.5) as dependent variable and random intercept for subject. Median (IQR) personal PM2.5 in µg/m3 was 148 (90-249) for open fire, 78 (51-125) for chimney stove, and 55 (34-79) for LPG stoves. Adjusted effectiveness of LPG stoves was greater in women with ≥6 years of education (49% (95% CI: 34, 60)) versus <6 years (26% (95% CI: 5, 42)). In contrast, chimney stove adjusted effectiveness was greater in women with <6 years of education (50% (95% CI: 38, 60)), rural residence (46% (95% CI: 34, 55)) and lowest SES (socio-economic status) quartile (59% (95% CI: 45, 70)) than ≥6 years education (16% (95% CI: 22, 43)), urban (23% (95% CI: -164, 42)) and highest SES quartile (-44% (95% CI: -183, 27)), respectively. A minority of LPG stove owners (12%) and no chimney owner had typical exposure below World Health Organization Air Quality guidelines (35 µg/m3). Although having a cleaner stove alone typically does not lower exposure enough to protect health, understanding sociodemographic determinants of effectiveness may lead to better targeting, implementation, and adoption of interventions.

Correction: The use of bluetooth low energy Beacon systems to estimate indirect personal exposure to household air pollution.

An amendment to this paper has been published and can be accessed via a link at the top of the paper.

The use of bluetooth low energy Beacon systems to estimate indirect personal exposure to household air pollution.

Household air pollution (HAP) generated from solid fuel combustion is a major health risk. Direct measurement of exposure to HAP is burdensome and challenging, particularly for children. In a pilot study of the Household Air Pollution Intervention Network (HAPIN) trial in rural Guatemala, we evaluated an indirect exposure assessment method that employs fixed continuous PM2.5 monitors, Bluetooth signal receivers in multiple microenvironments (kitchen, sleeping area and outdoor patio), and a wearable signal emitter to track an individual's time within those microenvironments. Over a four-month period, we measured microenvironmental locations and reconstructed indirect PM2.5 exposures for women and children during two 24-h periods before and two periods after a liquefied petroleum gas (LPG) stove and fuel intervention delivered to 20 households cooking with woodstoves. Women wore personal PM2.5 monitors to compare direct with indirect exposure measurements. Indirect exposure measurements had high correlation with direct measurements (n = 62, Spearman ρ = 0.83, PM2.5 concentration range: 5-528 µg/m3). Indirect exposure had better agreement with direct exposure measurements (bias: -17 µg/m3) than did kitchen area measurements (bias: -89 µg/m3). Our findings demonstrate that indirect exposure reconstruction is a feasible approach to estimate personal exposure when direct assessment is not possible.

Quantitative metrics of stove adoption using Stove Use Monitors (SUMs).

The sustained use of cookstoves that are introduced to reduce fuel use or air pollution needs to be objectively monitored to verify the sustainability of these benefits. Quantifying stove adoption requires affordable tools, scalable methods and validated metrics of usage. We quantified the longitudinal patterns of chimney-stove use of 80 households in rural Guatemala, monitored with Stove Use Monitors (SUMs) during 32 months. We counted daily meals and days in use at each monitoring period and defined metrics like the percent stove-days in use (the fraction of days in use from all stoves and days monitored). Using robust Poisson regressions we detected small seasonal variations in stove usage, with peaks in the warm-dry season at 92% stove-days (95%CI: 87%,97%) and 2.56 average daily meals (95%CI: 2.40,2.74). With respect to these values, the percent stove-days in use decreased by 3% and 4% during the warm-rainy and cold-dry periods respectively, and the daily meals by 5% and 12% respectively. Cookstove age and household size at baseline did not affect usage. Qualitative indicators of use from recall questionnaires were consistent with SUMs measurements, indicating stable sustained use and questionnaire accuracy. These results reflect optimum conditions for cookstove adoption and for monitoring in this project, which may not occur in disseminations undertaken elsewhere. The SUMs measurements suggests that 90% stove-days is a more realistic best-case for sustained use than the 100% often assumed. Half of sample reported continued use of open-cookfires, highlighting the critical need to verify reduction of open-fire practices in stove disseminations.

Temperature dataloggers as stove use monitors (SUMs): Field methods and signal analysis.

We report the field methodology of a 32-month monitoring study with temperature dataloggers as Stove Use Monitors (SUMs) to quantify usage of biomass cookstoves in 80 households of rural Guatemala. The SUMs were deployed in two stoves types: a well-operating chimney cookstove and the traditional open-cookfire. We recorded a total of 31,112 days from all chimney cookstoves, with a 10% data loss rate. To count meals and determine daily use of the stoves we implemented a peak selection algorithm based on the instantaneous derivatives and the statistical long-term behavior of the stove and ambient temperature signals. Positive peaks with onset and decay slopes exceeding predefined thresholds were identified as "fueling events", the minimum unit of stove use. Adjacent fueling events detected within a fixed-time window were clustered in single "cooking events" or "meals". The observed means of the population usage were: 89.4% days in use from all cookstoves and days monitored, 2.44 meals per day and 2.98 fueling events. We found that at this study site a single temperature threshold from the annual distribution of daily ambient temperatures was sufficient to differentiate days of use with 0.97 sensitivity and 0.95 specificity compared to the peak selection algorithm. With adequate placement, standardized data collection protocols and careful data management the SUMs can provide objective stove-use data with resolution, accuracy and level of detail not possible before. The SUMs enable unobtrusive monitoring of stove-use behavior and its systematic evaluation with stove performance parameters of air pollution, fuel consumption and climate-altering emissions.

Exposures to high levels of carbon monoxide from wood-fired temazcal (steam bath) use in highland Guatemala.

The temazcal is a wood-fired steam bath used in the rural highlands of Guatemala for bathing and healing. We measured carbon monoxide (CO) among 288 participants in 72 temazcales. Participants were drawn from communities who participated in the RESPIRE (Randomized Exposure Study of Pollution Indoors and Respiratory Effects) chimney stove intervention trial. Temazcal CO exposures were extremely high, averaging 431 parts per million (time-weighted average). Compared to kitchen wood-smoke exposures, the temazcal contributes significantly to weekly exposures, despite the fact that the population spends less time in the temazcal than in the kitchen. This report 1) describes temazcal use patterns; 2) reports participants' signs and symptoms during temazcal use; 3) models the distribution of temazcal CO concentrations; 4) assesses reliability of exhaled breath CO as a biomarker of CO exposure; and 5) provides a proportional analysis of CO concentrations from temazcal use, as compared to kitchen concentrations.

Estimating personal PM2.5 exposures using CO measurements in Guatemalan households cooking with wood fuel.

As a part of a longitudinal study in the highlands of Guatemala to elicit the chronic health effects of wood smoke from cooking, mean area and personal 48 h concentrations of 2.5 microm particulate matter (PM2.5) and carbon monoxide (CO) were measured every 3 months over 19 months. Monitoring was conducted in 63 households, 28 using traditional open wood fires and 35 using wood cookstoves with chimneys. The goal of this paper is to estimate personal exposure concentrations to PM2.5 using the measurements from CO diffusion tubes as a proxy. CO tubes are cheaper and easier to use than PM-monitoring devices, and can be worn by all family members, even infants. The relationship of PM2.5 and CO was determined by comparing measurements from both co-located instruments. CO measurements in ppm were corrected for temperature and pressure to mass concentrations. PM2.5 exposure was modeled with the following linear regression created using measured concentrations: PM2.5 (mg m(-3)) = 0.10 (0.093, 0.12) x CO (mg m(-3)) + 0.067 (0.0069, 0.13), R(2) = 0.76. No significant difference was found between the separate regressions for open fires and cookstoves. No significant improvement was obtained by applying a mixed statistical model. The equation was used to estimate personal exposures of PM2.5 using personal CO measurements from CO tubes worn by women, infants under 18 months, and children 48-72 months. Estimated 48 h mean personal PM2.5 concentrations for mother, infants, and children in open-fire homes were 0.27 +/- 0.02, 0.20 +/- 0.02, and 0.16 +/- 0.02 mg m(-3) respectively. In chimney-stove homes, mothers and children experienced PM2.5 personal concentrations of 0.22 +/- 0.03 and 0.14 +/- 0.03 mg m(-3), respectively.

Personal child and mother carbon monoxide exposures and kitchen levels: methods and results from a randomized trial of woodfired chimney cookstoves in Guatemala (RESPIRE).

During the first randomized intervention trial (RESPIRE: Randomized Exposure Study of Pollution Indoors and Respiratory Effects) in air pollution epidemiology, we pioneered application of passive carbon monoxide (CO) diffusion tubes to measure long-term personal exposures to woodsmoke. Here we report on the protocols and validations of the method, trends in personal exposure for mothers and their young children, and the efficacy of the introduced improved chimney stove in reducing personal exposures and kitchen concentrations. Passive diffusion tubes originally developed for industrial hygiene applications were deployed on a quarterly basis to measure 48-hour integrated personal carbon monoxide exposures among 515 children 0-18 months of age and 532 mothers aged 15-55 years and area samples in a subsample of 77 kitchens, in households randomized into control and intervention groups. Instrument comparisons among types of passive diffusion tubes and against a continuous electrochemical CO monitor indicated that tubes responded nonlinearly to CO, and regression calibration was used to reduce this bias. Before stove introduction, the baseline arithmetic (geometric) mean 48-h child (n=270), mother (n=529) and kitchen (n=65) levels were, respectively, 3.4 (2.8), 3.4 (2.8) and 10.2 (8.4) p.p.m. The between-group analysis of the 3355 post-baseline measurements found CO levels to be significantly lower among the intervention group during the trial period: kitchen levels: -90%; mothers: -61%; and children: -52% in geometric means. No significant deterioration in stove effect was observed over the 18 months of surveillance. The reliability of these findings is strengthened by the large sample size made feasible by these unobtrusive and inexpensive tubes, measurement error reduction through instrument calibration, and a randomized, longitudinal study design. These results from the first randomized trial of improved household energy technology in a developing country and demonstrate that a simple chimney stove can substantially reduce chronic exposures to harmful indoor air pollutants among women and infants.

An ultrasound personal locator for time-activity assessment.

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

An inexpensive light-scattering particle monitor: field validation.

We have developed a small, light, passive, inexpensive, datalogging particle monitor called the "UCB" (University of California Berkeley particle monitor). Following previously published laboratory assessments, we present here results of tests of its performance in field settings at high particle concentrations. We demonstrate the mass sensitivity of the UCB in relation to gravimetric filter-based PM(2.5) mass estimates as well as commercial light-scattering instruments co-located in field chamber tests and in kitchens of wood-burning households. The coefficient of variation of the unadjusted UCB mass response in relation to gravimetric estimates was 15%. Although requiring adjustment for differences in sensitivity, inter-monitor performance was consistently high (r(2) > 0.99). Moreover, the UCB can consistently estimate PM(2.5) mass concentrations in wood-burning kitchens (Pearson r(2) = 0.89; N = 99), with good agreement between duplicate measures (Pearson r(2) = 0.94; N = 88). In addition, with appropriate cleaning of the sensing chamber, UCB mass sensitivity does not decrease with time when used intensively in open woodfire kitchens, demonstrating the significant potential of this monitor.

Urinary methoxyphenol biomarkers and woodsmoke exposure: comparisons in rural Guatemala with personal CO and kitchen CO, levoglucosan, and PM2.5.

Urinary methoxyphenols have been proposed as biomarkers for woodsmoke exposure, but few field studies have been undertaken. We evaluated these biomarkers for assessing the exposure to woodsmoke of householders in rural Guatemala. The study population was a subset (10 female cooks, 2 female non-cooks, and 8 male non-cooks ranging in age from 7 to 60) drawn from those participating in a longterm randomized intervention trial (RESPIRE) in the highlands. All households rely solely on woodburning for cooking and home heating. Approximately half of the homes in the trial used open woodfires in the home, while the intervention group used cookstoves, called "planchas, "that vent most of the woodsmoke outdoors through a chimney. Corrected for creatinine levels, 16 of the 19 methoxyphenols measured were lower in the urine of cooks using the plancha; and 11 of the 19 compounds were lower in the urine of non-cooks from homes using the plancha. Furthermore, the 4 low-molecular-weight syringyl methoxyphenols (syringol, methysyringol, ethylsyringol, propylsyringol) were each moderately correlated (r2 = 0.71,0.64, 0.68, 0.53 respectively, with all p < 0.05) with personal exposure measurements determined by carbon monoxide (CO) passive diffusion tubes, but not with CO in exhaled breath. 48-Hour kitchen area measurements of PM2.5 mass, PM2.5 levoglucosan, and CO were highly correlated (>0.89) with each other and moderately correlated (0.54-0.78) with personal CO measurements. Although based on relatively few measurements, this study demonstrates that the urinary concentrations of specific methoxyphenols may be effective biomarkers of short-term exposures to inhaled woodsmoke in field conditions.