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Childhood tuberculosis and exposure to indoor air pollution: a systematic review and meta-analysis

15 April 2015 10:09 (America/New_York)

Childhood tuberculosis and exposure to indoor air pollution: a systematic review and meta-analysisThe International Journal of Tuberculosis and Lung Disease, May 2015.

Authors: Jafta, N.; Jeena, P. M.; Barregard, L.; Naidoo, R. N.

BACKGROUND: Indoor air pollution (IAP) from environmental tobacco smoke (ETS) and biomass fuel smoke (BMS) poses respiratory health risks, with children and women bearing the major burden.

OBJECTIVES: We used a systematic review and meta-analysis to investigate the relation between childhood tuberculosis (TB) and exposure to ETS and BMS.

METHODS: We searched three databases for epidemiological studies that investigated the association of childhood TB with exposure to ETS and BMS. We calculated pooled estimates and heterogeneity for studies eligible for inclusion in the meta-analysis and stratified studies on ETS by outcome.

RESULTS: Five case-control and three cross-sectional studies were eligible for inclusion in the meta-analysis and quality assessment. Pooled effect estimates showed that exposure to ETS is associated with tuberculous infection and TB disease (OR 1.9, 95%CI 1.4–2.9) among exposed compared to non-exposed children. TB disease in ETS studies produced a pooled OR of 2.8 (95%CI 0.9–4.8), which was higher than the OR for tuberculous infection (OR 1.9, 95%CI 0.9–2.9) for children exposed to ETS compared to non-exposed children. Studies on BMS exposure were too few and too small to permit a conclusion.

CONCLUSION: Exposure to ETS increases the risk of childhood TB disease or tuberculous infection.

Advancing Communication and Behavior Change Strategies for Cleaner Cooking

15 April 2015 10:06 (America/New_York)

Advancing Communication and Behavior Change Strategies for Cleaner Cooking – Announcing a special issue of the Journal of Health Communication: International Perspectives funded by the USAID | TRAction Project.

This special issue presents exciting findings on methods to promote the adoption of clean cooking technologies and fuels. The issue aims to advance our understanding of behavior change related to the technology, the enabling environment, and demand creation. Lessons are intended to inform household energy policy and program strategies. (Link to flyer, pdf)

Guest editors: Jay Graham, Assistant Professor,George Washington University; Sumi Mehta, Director of Research and Evaluation, Global Alliance for Clean Cookstoves; Julia Rosenbaum, Deputy Director, FHI360,USAID/WASHplus Project; Brendon Barnes, Professor, University of Johannesburg.

Advancing Communication and Behavior Change Strategies for Cleaner Cooking | Complete issue |

  • Saving Lives by Building Bridges Between User Needs and Clean Cooking Technology– Joshua P. Rosenthal, John Borrazzo
  • Behavior Change Communication: A Key Ingredient for Advancing Clean Cooking – Brendon Barnes, Julia Rosenbaum, Sumi Mehta, Kendra N. Williams, Kirstie Jagoe , Jay Graham
  • Quantitative Stove Use and Ventilation Guidance for Behavior Change Strategies – Michael A. Johnson, Ranyee A. Chiang
  • Advocate Program for Healthy Traditional Houses, Ume Kbubu, in a Timor Community: Preserving Traditional Behavior and Promoting Improved Health Outcomes – Rachmalina Prasodjo, D. Anwar Musadad, Salut Muhidin, Jerico Pardosi, Maria Silalahi
  • Understanding Consumer Preference and Willingness to Pay for Improved Cookstoves in Bangladesh – Julia Rosenbaum, Elisa Derby, Karabi Dutta
  • Piloting Improved Cookstoves in India – Jessica J. Lewis, Vasundhara Bhojvaid, Nina Brooks, Ipsita Das, Marc A. Jeuland, Omkar Patange, Subhrendu K. Pattanayak
  • Use of Behavior Change Techniques in Clean Cooking Interventions: A Review of the Evidence and Scorecard of Effectiveness – Nicholas J. Goodwin , Sarah Ellen O’Farrell, Kirstie Jagoe, Jonathan Rouse, Elisa Roma, Adam Biran, Eric A. Finkelstein
  • Does Peer Use Influence Adoption of Efficient Cookstoves? Evidence From a Randomized Controlled Trial in Uganda - Theresa Beltramo , Garrick Blalock , David I. Levine , Andrew M. Simons
  • Agency-Based Empowerment Training Enhances Sales Capacity of Female Energy Entrepreneurs in Kenya - Anita V. Shankar , MaryAlice Onyura , Jessica Alderman
  • Factors Influencing the Acquisition and Correct and Consistent Use of the Top-Lit Updraft Cookstove in Uganda - Allen Namagembe , Nancy Muller , Lisa Mueller Scott , Greg Zwisler , Michael Johnson , Jennifer Arney , Dana Charron , Emmanuel Mugisha
  • The Role of Mixed Methods in Improved Cookstove Research - Debbi Stanistreet , Lirije Hyseni , Michelle Bashin , Ibrahim Sadumah , Daniel Pope , Michael Sage , Nigel Bruce
  • Integrating Behavior Change Theory and Measures into Health-Based Cookstove Interventions: A Proposed Epidemiologic Research Agenda - Maggie L. Clark , Judy M. Heiderscheidt , Jennifer L. Peel
  • Impact of indoor air pollution from the use of solid fuels on the incidence of life threatening respiratory illnesses in children in India

    2 April 2015 12:02 (America/New_York)

    Impact of indoor air pollution from the use of solid fuels on the incidence of life threatening respiratory illnesses in children in India. BMC Public Health, Marc 2015.

    Authors: Ashish Kumar Upadhyay, Abhishek Singh, et al.

    Background – India contributes 24% of the global annual child deaths due to acute respiratory infections (ARIs). According to WHO, nearly 50% of the deaths among children due to ARIs is because of indoor air pollution (IAP). There is insufficient evidence on the relationship between IAP from the use of solid fuels and incidence of life threatening respiratory illnesses (LTRI) in children in India.

    Methods – Panel data of children born during 2001–02, from the Young Lives Study (YLS) conducted in India during 2002 and 2006–07 was used to estimate the impact of household use of solid fuels for cooking on LTRI in children. Multivariable two-stage random effects logistic regression model was used to estimate the odds of suffering from LTRI among children from households using solid fuels relative to children from households using other fuels (Gas/Electricity/Kerosene).

    Results – Bivariate results indicate that the probability of an episode of LTRI was considerably higher among children from households using solid fuels for cooking (18%) than among children from households using other fuels (10%). Moreover, children from households using solid fuels in both the rounds of YLS were more likely to suffer from one or more than one episode of LTRI compared to children from households using solid fuels in only one round. Two stage random effects logistic regression result shows that children from households using solid fuels were 1.78 (95% CI: 1.05-2.99) times as likely to suffer from LTRI as those from households using other fuels.

    Conclusion The findings of this paper provide conclusive evidence on the harmful effects of the use of solid fuels for cooking on LTRI in India. The Government of India must make people aware about the health risks associated with the use of solid fuels for cooking and strive to promote the use of cleaner fuels.

    Quantification of climate related emission reductions of Black Carbon and Co-emitted Species due to the replacement of less efficient cookstoves with improved efficiency cookstoves

    2 April 2015 11:55 (America/New_York)

    Quantification of climate related emission reductions of Black Carbon and Co-emitted Species due to the replacement of less efficient cookstoves with improved efficiency cookstoves, March 2015. The Gold Standard.

    This methodology is applicable to project activities that introduce efficient cookstove technologies and/or practices or switch from non-renewable to renewable biomass for meeting thermal energy requirements for cooking regimes.

    Using objective measures of stove use and indoor air quality to evaluate a cookstove intervention in rural Uganda

    2 April 2015 10:46 (America/New_York)

    Using objective measures of stove use and indoor air quality to evaluate a cookstove intervention in rural Uganda. Energy for Sustainable Development, April 2015.

    Authors: Steve Hankey, Kelly Sullivan, et al.


    • We recruited 54 households in 6 communities in rural Uganda to study the introduction of a locally manufactured rocket stove.
    • We measured PM2.5 (n = 28), CO (n = 34), and stove use (n = 32) before and 1 month after introduction of the stove.
    • After introduction of the stove, there were statistically significant reductions in concentrations of PM2.5 but not CO.
    • After Ugastove introduction, half of the households primarily used the Ugastove. Most others used the stoves in tandem.

    Exposure to combustion byproducts from cooking is a major health concern globally. Alternative stoves may reduce the burden of disease associated with exposure to household air pollution. We subsidized Ugastove-brand rocket stoves to 54 households in six rural Ugandan villages. We monitored kitchen concentrations of fine particles (PM2.5) and carbon monoxide (CO) before and one month after introduction of the Ugastove. Temperature data-loggers were affixed to each Ugastove and to the traditional stove (three‐stone fire) during the 1-month Ugastove acclimation period to record temporal patterns in stove use and adoption. Household surveys were administered to collect household information that may impact stove use or indoor air quality.

    PM2.5 kitchen concentrations were 37% lower after introduction of the Ugastove (mean reduction: 0.68 mg/m3; 95% confidence interval [CI]: 0.2–1.2; p < 0.01). Changes in CO concentrations were small (8% lower; mean reduction: 1.4 ppm, 95% CI: – 5.2–7.9) and not statistically significant. During the 1-month acclimation period, 47% of households used primarily the Ugastove, 12% used primarily the three stone fire, and 41% used both stoves in tandem. PM2.5 concentrations were generally lowest in households that used primarily the Ugastove, followed by households that used stoves in tandem and that primarily used a three‐stone fire. In summary, introduction of the Ugastove in 54 rural Ugandan households was associated with modest reductions in kitchen concentrations of PM2.5 but not CO. Objective measures of stove use reveal that short-term stove use varied by household.

    Socio-economic determinants of charcoal expenditures in Tanzania: Evidence from panel data

    2 April 2015 10:41 (America/New_York)

    Socio-economic determinants of charcoal expenditures in Tanzania: Evidence from panel dataEnergy Economics, April 2015.

    Authors: Anthony L. D’Agostinoa, Johannes Urpelainena, Alice Xub


    • Analysis of Tanzanian panel data on household charcoal consumption
    • Urbanization and income increase charcoal consumption
    • Household size has no effect on charcoal consumption

    Compared to firewood, charcoal is a relatively clean and convenient fuel. Nevertheless, the mass production of charcoal can contribute substantially to deforestation, rendering it imperative to regulate charcoal use. This article uses nationally representative panel data on Tanzania conducted in 2008 and 2010 to examine how charcoal expenditures change over time within any given household. The focus of the analysis will be on identifying certain socio-economic factors that affect charcoal use at the household level. The framing of the analysis on variation in time within each household addresses the omitted variables bias that often undermines inference from comparisons across different households.

    We find that while charcoal expenditures increase with household income, the rise in charcoal use with income is relatively gradual. Household size is unrelated to charcoal expenditures, but urban-rural differences in fuel choice are large even though we include household fixed effects in all specifications. In this regard, policymakers and urban planners need to pay particular attention to the role of urbanization in predicting trends in charcoal expenditures in developing countries like Tanzania.

    Exposure to Household Air Pollution from Wood Combustion and Association with Respiratory Symptoms and Lung Function in Nonsmoking Women: Results from the RESPIRE Trial, Guatemala

    2 April 2015 10:31 (America/New_York)

    Exposure to Household Air Pollution from Wood Combustion and Association with Respiratory Symptoms and Lung Function in Nonsmoking Women: Results from the RESPIRE Trial, Guatemala. Env Health Perspec, April 2015.

    Authors: Daniel Pope, Esperanza Diaz, Tone Smith-Sivertsen, Rolv T. Lie, Per Bakke, John R. Balmes, Kirk R. Smith, and Nigel G. Bruce

    Background: With 40% of the world’s population relying on solid fuel, household air pollution (HAP) represents a major preventable risk factor for COPD (chronic obstructive pulmonary disease). Meta-analyses have confirmed this relationship; however, constituent studies are observational, with virtually none measuring exposure directly.
    Objectives: We estimated associations between HAP exposure and respiratory symptoms and lung function in young, nonsmoking women in rural Guatemala, using measured carbon monoxide (CO) concentrations in exhaled breath and personal air to assess exposure.

    Methods: The Randomized Exposure Study of Pollution Indoors and Respiratory Effects (RESPIRE) Guatemala study was a trial comparing respiratory outcomes among 504 women using improved chimney stoves versus traditional cookstoves. The present analysis included 456 women with data from postintervention surveys including interviews at 6, 12, and 18 months (respiratory symptoms) and spirometry and CO (ppm) in exhaled breath measurements. Personal CO was measured using passive diffusion tubes at variable times during the study. Associations between CO concentrations and respiratory health were estimated using random intercept regression models.

    Results: Respiratory symptoms (cough, phlegm, wheeze, or chest tightness) during the previous 6 months were positively associated with breath CO measured at the same time of symptom reporting and with average personal CO concentrations during the follow-up period. CO in exhaled breath at the same time as spirometry was associated with lower lung function [average reduction in FEV1 (forced expiratory volume in 1 sec) for a 10% increase in CO was 3.33 mL (95% CI: –0.86, –5.81)]. Lung function measures were not significantly associated with average postintervention personal CO concentrations.

    Conclusions: Our results provide further support for the effects of HAP exposures on airway inflammation. Further longitudinal research modeling continuous exposure to particulate matter against lung function will help us understand more fully the impact of HAP on COPD.

    Quantitative Guidance for Stove Usage and Performance to Achieve Health and Environmental Targets

    30 March 2015 10:08 (America/New_York)

    Quantitative Guidance for Stove Usage and Performance to Achieve Health and Environmental Targets. Env Health Perspec, March 2015.

  • Full text
  • Authors: Michael A. Johnson and Ranyee A. Chiang

    Background: Displacing the use of polluting and inefficient cookstoves in developing countries is necessary to achieve the potential health and environmental benefits sought through clean cooking solutions. Yet little quantitative context has been provided on how much displacement of traditional technologies is needed to achieve targets for household air pollutant concentrations or fuel savings.

    Objectives: This paper provides instructive guidance on the usage of cooking technologies required to achieve health and environmental improvements.

    Methods: We evaluate different scenarios of displacement of traditional stoves with use of higher performing technologies. The air quality and fuel consumption impacts were estimated for these scenarios using a single zone box model of indoor air quality and ratios of thermal efficiency. Results: Stove performance and usage must be considered together, as lower performing stoves can result in similar or greater fuel savings than a higher performing stove if the lower performing stove has considerably higher displacement of the baseline stove. Similarly, based on the indoor air quality model, there are multiple performance-usage scenarios for achieving modest indoor air quality improvements. To meet World Health Organization targets, three-stone-fire and basic charcoal stove usage must be nearly eliminated to achieve the particulate matter target (<1-3 hours per week), and substantially limited to meet the carbon monoxide (<7-9 hours per week).

    Conclusions: Moderate health gains may be achieved with various performance-usage scenarios. The greatest benefits are estimated to be achieved by near complete displacement of traditional stoves with clean technologies, emphasizing the need to shift in the long term to near exclusive use of clean fuels and stoves. The performance-usage scenarios are also provided as a tool to guide technology selection and prioritize behavior change opportunities to maximize impact.

    BMJ Editorial: Air pollution, stroke, and anxiety

    30 March 2015 9:56 (America/New_York)

    BMJ Editorial: Air pollution, stroke, and anxiety. British Medical Journal, March 24, 2015.

    Author: Michael Brauer, professor

    Particulate air pollution is an emerging risk factor for an increasing number of common conditions

    The effects of air pollution on the lungs and heart are now widely appreciated, with expanding evidence for an important role in cardiac disease.1 The Global Burden of Disease Study identified fine particulate matter (PM2.5) in outdoor air and household air pollution from use of solid fuels as the ninth and fourth leading risk factors, respectively, for disease worldwide,2 and the World Health Organization attributes one in every eight deaths to air pollution.3 The effects of air pollution are not limited to cardiopulmonary diseases. Recent evidence suggests a role in diverse outcomes, including diabetes,4 low birth weight, and preterm birth.5 This research stems from improved understanding of the role of air pollution in initiating systemic inflammation, a response that may affect multiple organ systems. Two linked studies (doi:10.1136/bmj.h1295, doi:10.1136/bmj.h1111) add to growing evidence that air pollution is an important risk factor for an increasing number of common diseases.6 7

    In the first of the two papers, Shah and colleagues6 systematically reviewed and meta-analysed 103 studies conducted in 28 countries and including 6.2 million events to assess the role of short term fluctuations in air pollution as a trigger for stroke. Although evidence from several cohort studies of long term exposure to particulate matter indicates associations with stroke mortality, such findings are not universal.8

    The role of air pollution as a possible trigger for stroke has important implications for disease burden, especially in China where air pollution and the incidence of (especially haemorrhagic) stroke are high. In their analysis, Shah and colleagues found that increases in each of the common gaseous and particulate air pollutants were significantly associated with admission to hospital for stroke or stroke related mortality, with associations strongest for strokes on the same day as exposure; increased ozone was only weakly associated with cerebrovascular events.

    Air pollution remained significantly associated with stroke in sensitivity analyses that adjusted for potential biases related to quality of outcome ascertainment, assessment of exposure, and adjustment for confounders. This analysis supports a role for air pollution as a modifiable risk factor for stroke, although associations with air pollution were less precise for haemorrhagic stroke than for ischaemic stroke. The impact of chronic exposure to air pollution on development of carotid atherosclerosis (a precursor for stroke) remains unclear. Although this is not covered in the analysis, evidence of an association is growing.9

    Since air pollution causes systemic inflammation, it is reasonable that researchers have now turned to the arena of mental health, a leading priority for research given the relative absence of known modifiable risk factors and a high and growing disease burden.10 In the second linked paper, Power and colleagues exploit rich data in the Nurse’s Health Study cohort to assess the role of particulate pollution on prevalent anxiety symptoms.7 They found an exposure dependent association between higher levels of PM2.5 and increased symptoms of anxiety, and indications that associations were stronger for exposures in the month immediately preceding the scoring of anxiety.

    These observations were supported by several sensitivity analyses, which indicated that associations were robust to broad geographical region, health status (to control for the possibility of anxiety as a sequela of cardiopulmonary effects of air pollution), and demographic characteristics, although the study was limited to older women. Power and colleagues’ findings add to a growing literature on the mental health effects of air pollution, including a small but intriguing body of research linking short term variability in air pollution to suicide.11

    Power and colleagues used spatiotemporal exposure estimates and reported stronger effects for more recent exposures, reducing confounding by spatially varying factors correlated with air pollution. Since effects were observed over all time periods, spatial variation seems to have had an important influence on effect estimates. Furthermore, although effects were observed in all geographical regions, the investigators did not examine other potentially adverse (for example, noise, barometric pressure, solar intensity) or healthy (for example, natural spaces) environmental exposures that may operate at different scales. Indeed, evidence is accumulating that natural spaces may have beneficial effects on stress and social cohesion, both of which deserve further study in relation to mental health.12

    As with any observational study, questions remain, as the authors acknowledge, and the findings should be replicated in other populations and with other study designs. Moreover, although these observations are biologically plausible, given links between inflammation and anxiety there is a need for greater mechanistic supporting evidence, of the type that now exists for associations between particulate matter and pulmonary, cardiac, and circulatory disease.

    The findings of these two studies support a sharper focus on air pollution as a leading global health concern. They also suggest opportunities for reducing the prevalence of two debilitating and common diseases. One of the unique features of air pollution as a risk factor for disease is that exposure to air pollution is almost universal. While this is a primary reason for the large disease burden attributable to outdoor air pollution, it also follows that even modest reductions in pollution could have widespread benefits throughout populations. The two linked papers in this issue confirm the urgent need to manage air pollution globally as a cause of ill health and offer the promise that reducing pollution could be a cost effective way to reduce the large burden of disease from both stroke and poor mental health.


    How Cookstoves Research is Changing the World

    30 March 2015 9:42 (America/New_York)

    How Cookstoves Research is Changing the World | Source: American Thoracic Society News, March 2015.

    Three billion people in the world, a number unchanged in nearly 30 years, cook their food with an open fire, causing respiratory problems such as pneumonia in children and COPD and lung cancer in adults, as well as cardiovascular diseases. Estimates in 2012 from the Global Burden of Disease project, indicate that smoke from these traditional cooking methods causes a staggering four million premature deaths each year.

    Until the last decade, this major health issue had gone largely unnoticed by most medical scientists and public health experts. ATS members, in collaboration with organizations, government officials, and institutions across the world, have played important roles in describing the health impacts of cook smoke, conducting clinical trials with cleaner-burning biomass stoves, and highlighting gaps in knowledge of the problem. In recent months, their efforts have gained momentum.

    Their findings have contributed to the publication of the World Health Organization’s Indoor Air Quality Guidelines, a report on childhood pneumonia from the Institute of Health Metrics and Evaluation, and a Lancet Respiratory Household Air Pollution (HAP) Commission.

    U.S. Environmental Protection Agency Cookstove Research Meeting, Feb 2015 – Presentations

    23 March 2015 9:23 (America/New_York)

    U.S. Environmental Protection Agency Cookstove Research Meeting, Feb 2015 – Presentations

    Presenter Presentation Title Costa, Dan EPA Cookstoves Research (PDF) (9 pp, 1.38 MB) Moss, Jacob The U.S. Commitment to Clean Cookstoves (PDF) (6 pp, 620 K) Bailis, Robert Experimental Interventions to Facilitate Clean Cookstove Adoption, Promote Clean Indoor Air, and Mitigate Climate Change (PDF) (28 pp, 3.21 MB) Baumgartner, Jill Improving Air Quality, Health and the Environment Through Household Energy Interventions in the Tibetan Plateau (PDF) (34 pp, 3.31 MB) Bond, Tami C. A Global Map of Feasible Residential Solutions, Emphasizing Stoves with Space Heating Uses (PDF) (27 pp, 2.71 MB) Edwards, Rufus Characterization of Emissions from Small, Variable Solid Fuel Combustion Sources for Determining Global Emissions and Climate Impact (PDF) (22 pp, 3.17 MB) Hannigan, Mike REACCTING: Research on Emissions Air Quality, Climate, and Cooking Technology in Northern Ghana (PDF) (49 pp, 5.03 MB) Pierce, Jeff
    Kodros, Jack CSU Global Modeling and Climate Effects (PDF) (40 pp, 3.87 MB) Smith, Kirk SOMAARTH -I Demographic Development and Environment Surveillance Site (DDESS) (PDF) (20 pp, 4.2 MB) Smith, Kirk Household/Outdoor Pollution in India: EPA STAR Grant (PDF) (45 pp, 3.91 MB) Volckens, John
    Pierce, Jeff Quantifying the Climate, Air Quality, and Health Benefits of Improved Cookstoves: An Integrated Laboratory, Field and Modeling Study (PDF) (17 pp, 1.33 MB) Birnbaum, Linda Assessing Exposures and Health Effects Related to Indoor Biomass Fuel Burning (PDF) (13 pp, 1.2 MB) Mehta Sumi Phase 2 Research and Evaluation Roadmap Public Health, Environment, and Climate (PDF) (18 pp, 5.23 MB) Sage, Mike
    Yip, Fuyuen Evaluation of Acceptability and Performance of Stove Options for Reducing Household Air Pollution in Rural West Kenya (PDF) (26 pp, 3.18 MB)


    Sustainable diffusion of sustainable technologies? An entrepreneur-led initiative to promote improved cookstoves in rural western Kenya

    23 March 2015 9:18 (America/New_York)

    Sustainable diffusion of sustainable technologies? An entrepreneur-led initiative to promote improved cookstoves in rural western Kenya. Sustainability: Science, Practice, & Policy, Spring 2015.

    Authors: Barry Ness & Ann Åkerman, Lund University Centre for Sustainability Studies, PO Box 170, Lund, 22100 Sweden (email:;

    This article presents the accomplishments and challenges of a rural sustainable development initiative in Nyanza Province, Kenya. Our focus is on the sale and financing of a simple technology—an improved cookstove—by a local entrepreneur. The theoretical basis of the research is innovation systems and (social) entrepreneurship. We first define the major challenges of the diffusion process encountered throughout the initiative’s early years, with special concentration on maintaining the working capital to sell and finance additional innovations.

    We next present the measures to address the challenge, including detailed written contracts, a modest fee for late payments, a contractsigning witness, and money-transfer options by mobile telephone. We subsequently present repayment rates for up to one year after implementing the changes, which show a general pattern of improvement. Finally, we discuss the sustainability of the technology, repayment rates, innovation systems, and entrepreneurship in sub-Saharan Africa. The main message of the research is that the major challenge is not creating more sustainable technologies, but overcoming difficulties in diffusion processes.

    Household air pollution and cancers other than lung: a meta-analysis

    23 March 2015 9:13 (America/New_York)

    Household air pollution and cancers other than lung: a meta-analysis. Environmental Health, Mar 2015.

    Authors: Sowmya Josyula ( Lin (, et al.

    Household air pollution (HAP) from solid fuel combustion contributes to 2.6% of the global burden of disease. HAP emissions are an established lung carcinogen; however, associations with other cancer sites have not been fully explored. We conducted a meta-analysis of 18 case–control studies. Using fixed-effects models, utilizing the adjusted odds ratios (OR) and 95% confidence intervals (95% CI) from each study, we evaluated the association between HAP and cervical neoplasia (663 cases and 1747 controls) and upper aero-digestive tract cancers (6022 cases and 15 325 controls).

    We found that HAP was associated with cervical neoplasia (OR = 6.45; 95%CI = 3.12-13.35; 4 studies); oral (OR = 2.54; 95% CI = 1.92-3.34; 4 studies; 1000 cases /3450 controls); nasopharyngeal (OR = 1.80; 95%CI = 1.26-2.28; 6 studies; 2231 cases/2160 controls); pharyngeal (OR = 3.56; 95%CI = 2.22-5.70; 4 studies; 1036 cases/3746 controls); and laryngeal (OR = 2.34; 95% CI = 1.71- 3.20; 5 studies; 1416 cases/4514 controls) cancers. The elevated risk for esophageal cancer (OR = 1.92; 95%CI = 0.82-4.48; 2 studies; 339 cases/1455 controls) was non-significant.

    HAP was associated with cervical neoplasia among studies that accounted for HPV infection (OR = 9.60; 95%CI = 3.79-24.32) and smoking (OR = 4.72; 95%CI = 1.84-12.07). Similarly, our observed associations between HAP and upper aero-digestive tract cancers remained significantly elevated when analyses were restricted to studies that controlled for smoking. No significant publication bias was detected. Our results suggest that the carcinogenic effect of HAP observed for lung cancer may extend to other cancers, including those of the cervix and the upper aero-digestive tract. Further research is needed to confirm these associations in prospective studies.


    Prevalence of chronic obstructive pulmonary disease and variation in risk factors across four geographically diverse resource-limited settings in Peru

    23 March 2015 9:07 (America/New_York)

    Prevalence of chronic obstructive pulmonary disease and variation in risk factors across four geographically diverse resource-limited settings in Peru. Respiratory Research, Feb 2015,

    Authors, Devan Jaganath ( Jaime Miranda (, et al.

    Background – It is unclear how geographic and social diversity affects the prevalence of chronic obstructive pulmonary disease (COPD). We sought to characterize the prevalence of COPD and identify risk factors across four settings in Peru with varying degrees of urbanization, altitude, and biomass fuel use.

    Methods – We collected sociodemographics, clinical history, and post-bronchodilator spirometry in a randomly selected, age-, sex- and site-stratified, population-based sample of 2,957 adults aged ≥35 years (median age was 54.8 years and 49.3% were men) from four resource-poor settings: Lima, Tumbes, urban and rural Puno. We defined COPD as a post-bronchodilator FEV1/FVC < 70%.

    Results – Overall prevalence of COPD was 6.0% (95% CI 5.1%–6.8%) but with marked variation across sites: 3.6% in semi-urban Tumbes, 6.1% in urban Puno, 6.2% in Lima, and 9.9% in rural Puno (p < 0.001). Population attributable risks (PARs) of COPD due to smoking ≥10 pack-years were less than 10% for all sites, consistent with a low prevalence of daily smoking(3.3%). Rather, we found that PARs of COPD varied by setting. In Lima, for example, thehighest PARs were attributed to post-treatment tuberculosis (16% and 22% for men andwomen, respectively). In rural Puno, daily biomass fuel for cooking among women wasassociated with COPD (prevalence ratio 2.22, 95% CI 1.02–4.81) and the PAR of COPD dueto daily exposure to biomass fuel smoke was 55%.

    Conclusions – The burden of COPD in Peru was not uniform and, unlike other settings, was not predominantly explained by tobacco smoking. This study emphasizes the role of biomass fuel use, and highlights pulmonary tuberculosis as an often neglected risk factor in endemic areas

    Does household use of biomass fuel cause lung cancer? A systematic review and evaluation of the evidence for the GBD 2010 study

    12 March 2015 11:04 (America/New_York)

    Does household use of biomass fuel cause lung cancer? A systematic review and evaluation of the evidence for the GBD 2010 study. Thorax, March 2015.

    Authors: Nigel Bruce1, Mukesh Dherani1, Rui Liu2, H Dean Hosgood III3,4, Amir Sapkota5, Kirk R Smith2, Kurt Straif6, Qing Lan3, Daniel Pope1

    + Author Affiliations

    1Department of Public Health and Policy, University of Liverpool, Liverpool, UK
    2Environmental Health Sciences, School of Public Health, University of California Berkeley, California, USA
    3Division of Cancer Epidemiology and Genetics, Department of Health and Human Services, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA
    4Division of Epidemiology, Albert Einstein College of Medicine, Bronx, New York, USA
    5Maryland Institute for Applied Environmental Health, University of Maryland, School of Public Health, College Park, Maryland, USA
    6International Agency for Research on Cancer, Lyon, France
    Correspondence to: Dr Nigel G Bruce, Department of Public Health and Policy, University of Liverpool, Whelan Building, Quadrangle, Liverpool L69 3GB, UK;

    Background – Around 2.4 billion people use traditional biomass fuels for household cooking or heating. In 2006, the International Agency for Research on Cancer (IARC) concluded emissions from household coal combustion are a Group 1 carcinogen, while those from biomass were categorised as 2A due to epidemiologic limitations. This review updates the epidemiologic evidence and provides risk estimates for the 2010 Global Burden of Disease study.

    Methods – Searches were conducted of 10 databases to July 2012 for studies of clinically diagnosed or pathologically confirmed lung cancer associated with household biomass use for cooking and/or heating.

    Findings – Fourteen eligible studies of biomass cooking or heating were identified: 13 had independent estimates (12 cooking only), all were case-control designs and provided 8221 cases and 11 342 controls. The ORs for lung cancer risk with biomass for cooking and/or heating were OR 1.17 (95% CI 1.01 to 1.37) overall, and 1.15 (95% CI 0.97 to 1.37) for cooking only. Publication bias was not detected, but more than half the studies did not explicitly describe a clean reference category. Sensitivity analyses restricted to studies with adequate adjustment and a clean reference category found ORs of 1.21 (95% CI 1.05 to 1.39) for men (two reports, compiling five studies) and 1.95 (95% CI 1.16 to 3.27) for women (five reports, compiling eight studies). Exposure–response evidence was seen for men, and higher risk for women in developing compared with developed countries, consistent with higher exposures in the former.

    Conclusions – There is now stronger evidence for biomass fuel use causing lung cancer, but future studies need better exposure assessment to strengthen exposure–response evidence.


    Characterization of biomass burning emissions from cooking fires, peat, crop residue, and other fuels with high-resolution proton-transfer-reaction time-of-flight mass spectrometry

    12 March 2015 10:43 (America/New_York)

    Characterization of biomass burning emissions from cooking fires, peat, crop residue, and other fuels with high-resolution proton-transfer-reaction time-of-flight mass spectrometry. Atmos. Chem. Phys., 15, 845–865, 2015.

    Authors: C. E. Stockwell1, P. R. Veres2,3, J. Williams4, and R. J. Yokelson1
    1University of Montana, Department of Chemistry, Missoula, MT, USA
    2Cooperative Institute for Research in Environmental Sciences, University of Colorado, Boulder, CO, USA
    3Chemical Sciences Division, Earth System Research Laboratory, National Oceanic and
    Atmospheric Administration, Boulder, CO, USA
    4Max Planck Institute for Chemistry, Atmospheric Chemistry Department, 55128 Mainz, Germany
    Correspondence to: R. J. Yokelson (

    We deployed a high-resolution proton-transfer reaction time-of-flight mass spectrometer (PTR-TOF-MS) to measure biomass-burning emissions from peat, crop residue,cooking fires, and many other fire types during the fourth FireLab at Missoula Experiment (FLAME-4) laboratory campaign.A combination of gas standard calibrations and composition sensitive, mass-dependent calibration curves was applied to quantify gas-phase non-methane organic compounds(NMOCs) observed in the complex mixture of fire emissions. We used several approaches to assign the best identities to most major “exact masses”, including many high molecular mass species. Using these methods, approximately 80–96 % of the total NMOC mass detected by the PTR-TOFMSand Fourier transform infrared (FTIR) spectroscopy was positively or tentatively identified for major fuel types.

    We report data for many rarely measured or previously unmeasured emissions in several compound classes including aromatic hydrocarbons, phenolic compounds, and furans; many of these are suspected secondary organic aerosol precursors.A large set of new emission factors (EFs) for a range of globally significant biomass fuels is presented. Measurements show that oxygenated NMOCs accounted for the largest fraction of emissions of all compound classes. In a brief studyof various traditional and advanced cooking methods, the EFs for these emissions groups were greatest for open three stone cooking in comparison to their more advanced counterparts. Several little-studied nitrogen-containing organic compounds were detected from many fuel types, that together accounted for 0.1–8.7 % of the fuel nitrogen, and some may play a role in new particle formation.

    Innovating Energy Access for Remote Areas: Discovering Untapped Resources

    12 March 2015 10:35 (America/New_York)

    Innovating Energy Access for Remote Areas: Discovering Untapped Resources: Proceedings, 2014.

    Martina Schäfer | Daniel Kammen | Noara Kebir | Daniel Philipp (editors)

    Some of the papers in the proceedings are:

    • The influence of the end user’s context on the dissemination of domestic biogas systems in developing countries
    • Scale vs. Substance? Lessons from a Context-responsive Approach to Market-based Stove Development in Western Kenya
    • Feasibility study assessing the impact of biogas digesters on indoor air pollution in households in Uganda
    • How to Scale Up Green Microfinance? A Comparative Study of Energy Lending in Peru
    • Microfinancing decentralized solar energy systems in India: Innovative products through group approach
    • Innovative Energy Access for Remote Areas – “The LUAV-Light Up a Village” project

    Relationship Between Daily Exposure to Biomass Fuel Smoke and Blood Pressure in High-Altitude Peru

    12 March 2015 10:18 (America/New_York)

    Relationship Between Daily Exposure to Biomass Fuel Smoke and Blood Pressure in High-Altitude Peru. Hypertension, Mar 2015.

    Authors: Melissa Burroughs Peña, Karina M. Romero, Eric J. Velazquez, Victor G. Davila-Roman, Robert H. Gilman, Robert A. Wise, J. Jaime Miranda, William Checkley

    Correspondence to William Checkley, Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, 1800 Orleans St, Suite 9121, Baltimore, MD 21205.

    Household air pollution from biomass fuel use affects 3 billion people worldwide; however, few studies have examined the relationship between biomass fuel use and blood pressure. We sought to determine if daily biomass fuel use was associated with elevated blood pressure in high altitude Peru and if this relationship was affected by lung function. We analyzed baseline information from a population-based cohort study of adults aged ≥35 years in Puno, Peru. Daily biomass fuel use was self-reported. We used multivariable regression models to examine the relationship between daily exposure to biomass fuel smoke and blood pressure outcomes. Interactions with sex and quartiles of forced vital capacity were conducted to evaluate for effect modification. Data from 1004 individuals (mean age, 55.3 years; 51.7% women) were included.

    We found an association between biomass fuel use with both prehypertension (adjusted relative risk ratio, 5.0; 95% confidence interval, 2.6–9.9) and hypertension (adjusted relative risk ratio, 3.5; 95% confidence interval, 1.7–7.0). Biomass fuel users had a higher systolic blood pressure (7.0 mm Hg; 95% confidence interval, 4.4–9.6) and a higher diastolic blood pressure (5.9 mm Hg; 95% confidence interval, 4.2–7.6) when compared with nonusers. We did not find interaction effects between daily biomass fuel use and sex or percent predicted forced vital capacity for either systolic blood pressure or diastolic blood pressure. Biomass fuel use was associated with a higher likelihood of having hypertension and higher blood pressure in Peru. Reducing exposure to household air pollution from biomass fuel use represents an opportunity for cardiovascular prevention.

    Effectiveness of interventions to reduce indoor air pollution and/or improve health in homes using solid fuel in lower and middle income countries: protocol for a systematic review

    6 March 2015 11:25 (America/New_York)

    Effectiveness of interventions to reduce indoor air pollution and/or improve health in homes using solid fuel in lower and middle income countries: protocol for a systematic review. Systematic Reviews, March 2015, 4:22 doi:10.1186/s13643-015-0012-8

    Authors: Reginald Quansah, Caroline A Ochieng, Sean Semple, Sanjar Juvekar, Jacques Emina, Frederick Ato Armah and Isaac Luginaah

    Background – Indoor air pollution (IAP) interventions are widely promoted as a means of reducing indoor air pollution/health from solid fuel use; and research addressing impact of these interventions has increased substantially in the past two decades. It is timely and important to understand more about effectiveness of these interventions. We describe the protocol of a systematic review to (i) evaluate effectiveness of IAP interventions to improve indoor air quality and/or health in homes using solid fuel for cooking and/or heating in lower- and middle-income countries, (ii) identify the most effective intervention to improve indoor air quality and/or health, and (iii) identify future research needs.

    Methods – This review will be conducted according to the National Institute for Health and Care Excellence (NICE) guidelines and will be reported following the PRISMA statement. Ovid MEDLINE, Ovid Embase, SCOPUS, and PubMed searches were conducted in September 2013 and updated in November 2014 (and include any further search updates in February 2015). Additional references will be located through searching the references cited by identified studies and through the World Health Organization Global database of household air pollution measurements. We will also search our own archives. Data extraction and risk of bias assessment of all included papers will be conducted independently by five reviewers.

    Discussion – The study will provide insights into what interventions are most effective in reducing indoor air pollution and/or adverse health outcomes in homes using solid fuel for cooking or heating in lower- or middle-income countries. The findings from this review will be used to inform future IAP interventions and policy on poverty reduction and health improvement in poor communities who rely on biomass and solid fuels for cooking and heating.

    WHO indoor air quality guidelines on household fuel combustion: Strategy implications of new evidence on interventions and exposure–risk functions

    6 March 2015 11:17 (America/New_York)

    WHO indoor air quality guidelines on household fuel combustion: Strategy implications of new evidence on interventions and exposure–risk functions. Atmospheric Environment,  April 2015.

    Authors: Nigel Bruce, Dan Pope, Eva Rehfuess, Kalpana Balakrishnan, Heather Adair-Rohani, Carlos Dora


    • New WHO air quality guidelines will address household air pollution (HAP).
    • Action on HAP could lower risk of multiple child and adult diseases by 20–50%.
    • New evidence shows levels at or below 35 μg/m3 PM2.5 (WHO IT-1) are needed.
    • Most improved solid fuel stoves result in PM2.5 levels well above IT-1.
    • Intervention strategy must shift towards accelerating access to clean fuels.

    Background: 2.8 billion people use solid fuels as their primary cooking fuel; the resulting high levels of household air pollution (HAP) were estimated to cause more than 4 million premature deaths in 2012. The people most affected are among the world’s poorest, and past experience has shown that securing adoption and sustained use of effective, low-emission stove technologies and fuels in such populations is not easy. Among the questions raised by these challenges are (i) to what levels does HAP exposure need to be reduced in order to ensure that substantial health benefits are achieved, and (ii) what intervention technologies and fuels can achieve the required levels of HAP in practice? New WHO air quality guidelines are being developed to address these issues.

    Aims: To address the above questions drawing on evidence from new evidence reviews conducted for the WHO guidelines.

    Methods: Discussion of key findings from reviews covering (i) systematic reviews of health risks from HAP exposure, (ii) newly developed exposure–response functions which combine combustion pollution risk evidence from ambient air pollution, second-hand smoke, HAP and active smoking, and (iii) a systematic review of the impacts of solid fuel and clean fuel interventions on kitchen levels of, and personal exposure to, PM2.5 and carbon monoxide (CO).

    Findings: Evidence on health risks from HAP suggest that controlling this exposure could reduce the risk of multiple child and adult health outcomes by 20–50%. The new integrated exposure–response functions (IERs) indicate that in order to secure these benefits, HAP levels require to be reduced to the WHO IT-1 annual average level (35 μg/m3 PM2.5), or below. The second review found that, in practice, solid fuel ‘improved stoves’ led to large percentage and absolute reductions, but post-intervention kitchen levels were still very high, at several hundreds of μg/m3 of PM2.5, although most solid fuel stove types met the WHO 24-hr average guideline for CO of 7 mg/m3. Clean fuel user studies were few, but also did not meet IT-1 for PM2.5, likely due to a combination of continuing multiple stove and fuel use, other sources in the home (e.g. kerosene lamps), and pollution from neighbours and other outdoor sources.

    Conclusions: Together, this evidence implies there needs to be a strategic shift towards more rapid and widespread promotion of clean fuels, along with efforts to encourage more exclusive use and control other sources in and around the home. For households continuing to rely on solid fuels, the best possible low-emission solid fuel stoves should be promoted, backed up by testing and in-field evaluation.


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