John McCracken

Effect of reduction in household air pollution on childhood pneumonia in Guatemala (RESPIRE): a randomised controlled trial

BACKGROUND Pneumonia causes more child deaths than does any other disease. Observational studies have indicated that smoke from household solid fuel is a significant risk factor that affects about half the worlds children. We investigated whether an intervention to lower indoor wood smoke emissions would reduce pneumonia in children. METHODS We undertook a parallel randomised controlled trial in highland Guatemala, in a population using open indoor wood fires for cooking. We randomly assigned 534 households with a pregnant woman or young infant to receive a woodstove with chimney (n=269) or to remain as controls using open woodfires (n=265), by concealed permuted blocks of ten homes. Fieldworkers visited homes every week until children were aged 18 months to record the childs health status. Sick children with cough and fast breathing, or signs of severe illness were referred to study physicians, masked to intervention status, for clinical examination. The primary outcome was physician-diagnosed pneumonia, without use of a chest radiograph. Analysis was by intention to treat (ITT). Infant 48-h carbon monoxide measurements were used for exposure-response analysis after adjustment for covariates. This trial is registered, number ISRCTN29007941. FINDINGS During 29,125 child-weeks of surveillance of 265 intervention and 253 control children, there were 124 physician-diagnosed pneumonia cases in intervention households and 139 in control households (rate ratio [RR] 0·84, 95% CI 0·63-1·13; p=0·257). After multiple imputation, there were 149 cases in intervention households and 180 in controls (0·78, 0·59-1·06, p=0·095; reduction 22%, 95% CI -6% to 41%). ITT analysis was undertaken for secondary outcomes: all and severe fieldworker-assessed pneumonia; severe (hypoxaemic) physician-diagnosed pneumonia; and radiologically confirmed, RSV-negative, and RSV-positive pneumonia, both total and severe. We recorded significant reductions in the intervention group for three severe outcomes-fieldworker-assessed, physician-diagnosed, and RSV-negative pneumonia--but not for others. We identified no adverse effects from the intervention. The chimney stove reduced exposure by 50% on average (from 2·2 to 1·1 ppm carbon monoxide), but exposure distributions for the two groups overlapped substantially. In exposure-response analysis, a 50% exposure reduction was significantly associated with physician-diagnosed pneumonia (RR 0·82, 0·70-0·98), the greater precision resulting from less exposure misclassification compared with use of stove type alone in ITT analysis. INTERPRETATION In a population heavily exposed to wood smoke from cooking, a reduction in exposure achieved with chimney stoves did not significantly reduce physician-diagnosed pneumonia for children younger than 18 months. The significant reduction of a third in severe pneumonia, however, if confirmed, could have important implications for reduction of child mortality. The significant exposure-response associations contribute to causal inference and suggest that stove or fuel interventions producing lower average exposures than these chimney stoves might be needed to substantially reduce pneumonia in populations heavily exposed to biomass fuel air pollution. FUNDING US National Institute of Environmental Health Sciences and WHO.

Global and regional burden of hospital admissions for severe acute lower respiratory infections in young children in 2010: a systematic analysis.

Summary Background The annual number of hospital admissions and in-hospital deaths due to severe acute lower respiratory infections (ALRI) in young children worldwide is unknown. We aimed to estimate the incidence of admissions and deaths for such infections in children younger than 5 years in 2010. Methods We estimated the incidence of admissions for severe and very severe ALRI in children younger than 5 years, stratified by age and region, with data from a systematic review of studies published between Jan 1, 1990, and March 31, 2012, and from 28 unpublished population-based studies. We applied these incidence estimates to population estimates for 2010, to calculate the global and regional burden in children admitted with severe ALRI in that year. We estimated in-hospital mortality due to severe and very severe ALRI by combining incidence estimates with case fatality ratios from hospital-based studies. Findings We identified 89 eligible studies and estimated that in 2010, 11·9 million (95% CI 10·3–13·9 million) episodes of severe and 3·0 million (2·1–4·2 million) episodes of very severe ALRI resulted in hospital admissions in young children worldwide. Incidence was higher in boys than in girls, the sex disparity being greatest in South Asian studies. On the basis of data from 37 hospital studies reporting case fatality ratios for severe ALRI, we estimated that roughly 265 000 (95% CI 160 000–450 000) in-hospital deaths took place in young children, with 99% of these deaths in developing countries. Therefore, the data suggest that although 62% of children with severe ALRI are treated in hospitals, 81% of deaths happen outside hospitals. Interpretation Severe ALRI is a substantial burden on health services worldwide and a major cause of hospital referral and admission in young children. Improved hospital access and reduced inequities, such as those related to sex and rural status, could substantially decrease mortality related to such infection. Community-based management of severe disease could be an important complementary strategy to reduce pneumonia mortality and health inequities. Funding WHO.

Chimney Stove Intervention to Reduce Long-term Wood Smoke Exposure Lowers Blood Pressure among Guatemalan Women

Background and Objective RESPIRE, a randomized trial of an improved cookstove, was conducted in Guatemala to assess health effects of long-term reductions in wood smoke exposure. Given the evidence that ambient particles increase blood pressure, we hypothesized that the intervention would lower blood pressure. Methods Two study designs were used: a) between-group comparisons based on randomized stove assignment, and b) before-and-after comparisons within subjects before and after they received improved stoves. From 2003 to 2005, we measured personal fine particle (particulate matter with aerodynamic diameter < 2.5 μm; PM2.5) exposures and systolic (SBP) and diastolic blood pressure (DBP) among women > 38 years of age from the chimney woodstove intervention group (49 subjects) and traditional open wood fire control group (71 subjects). Measures were repeated up to three occasions. Results Daily average PM2.5 exposures were 264 and 102 μg/m3 in the control and intervention groups, respectively. After adjusting for age, body mass index, an asset index, smoking, secondhand tobacco smoke, apparent temperature, season, day of week, time of day, and a random subject intercept, the improved stove intervention was associated with 3.7 mm Hg lower SBP [95% confidence interval (CI), −8.1 to 0.6] and 3.0 mm Hg lower DBP (95% CI, −5.7 to −0.4) compared with controls. In the second study design, among 55 control subjects measured both before and after receiving chimney stoves, similar associations were observed. Conclusion The between-group comparisons provide evidence, particularly for DBP, that the chimney stove reduces blood pressure, and the before-and-after comparisons are consistent with this evidence.

Effect of Reducing Indoor Air Pollution on Women's Respiratory Symptoms and Lung Function: The RESPIRE Randomized Trial, Guatemala

Exposure to household wood smoke from cooking is a risk factor for chronic obstructive lung disease among women in developing countries. The Randomized Exposure Study of Pollution Indoors and Respiratory Effects (RESPIRE) is a randomized intervention trial evaluating the respiratory health effects of reducing indoor air pollution from open cooking fires. A total of 504 rural Mayan women in highland Guatemala aged 15-50 years, all using traditional indoor open fires, were randomized to either receive a chimney woodstove (plancha) or continue using the open fire. Assessments of chronic respiratory symptoms and lung function and individual measurements of carbon monoxide exposure were performed at baseline and every 6 months up to 18 months. Use of a plancha significantly reduced carbon monoxide exposure by 61.6%. For all respiratory symptoms, reductions in risk were observed in the plancha group during follow-up; the reduction was statistically significant for wheeze (relative risk = 0.42, 95% confidence interval: 0.25, 0.70). The number of respiratory symptoms reported by the women at each follow-up point was also significantly reduced by the plancha (odds ratio = 0.7, 95% confidence interval: 0.50, 0.97). However, no significant effects on lung function were found after 12-18 months. Reducing indoor air pollution from household biomass burning may relieve symptoms consistent with chronic respiratory tract irritation.

Impact of improved stoves, house construction and child location on levels of indoor air pollution exposure in young Guatemalan children

The goal of this study was to assess the impact of improved stoves, house ventilation, and child location on levels of indoor air pollution and child exposure in a rural Guatemalan population reliant on wood fuel. The study was a random sample of 204 households with children less than 18 months in a rural village in the western highlands of Guatemala. Socio-economic and household information was obtained by interview and observation. Twenty-four hour carbon monoxide (CO) was used as the primary measure of kitchen pollution and child exposure in all homes, using Gastec diffusion tubes. Twenty-four hour kitchen PM3.5 was measured in a random sub-sample (n=29) of kitchens with co-located CO tubes. Almost 50% of the homes still used open fires, around 30% used chimney stoves (planchas) mostly from a large donor-funded programme, and the remainder of homes used various combinations including bottled gas and open fires. The 24-h kitchen CO was lowest for homes with self-purchased planchas: mean (95% CI) CO of 3.09 ppm (1.87–4.30) vs. 12.4 ppm (10.2–14.5) for open fires. The same ranking was found for child CO exposure, but with proportionately smaller differentials (P<0.0001). The 24-h kitchen PM3.5 in the sub-sample showed similar differences (n=24, P<0.05). The predicted child PM for all 203 children (based on a regression model from the sub-sample) was 375 μg/m3 (270–480) for self-purchased planchas and 536 μg/m3 (488–584) for open fires. Multivariate analysis showed that stove/fuel type was the most important determinant of kitchen CO, with some effect of kitchen volume and eaves. Stove/fuel type was also the key determinant of child CO, with some effect of child position during cooking. The improved stoves in this community have been effective in reducing indoor air pollution and child exposure, although both measures were still high by international standards. Large donor-funded stove programmes need to aim for wider acceptance and uptake by the local families. Better stove maintenance is also required.

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.

Childhood asthma and indoor woodsmoke from cooking in Guatemala.

We estimated the prevalence and severity of asthma, and the association with cooking on open wood fires, as preparation for a large-scale randomized field trial on effects of indoor air pollution and child health. This is one of the first systematic studies of asthma and indoor wood-smoke pollution and to our knowledge the first asthma study in a purely indigeneous population in Latin America. The mothers of 1058 children aged 4–6 years were interviewed, using the standardized ISAAC (International Study of Asthma and Allergies in Childhood) procedures and questionnaire. The study population is a Mam-speaking (Maya), indigenous group living at relatively high altitude (2000 m) in Western Guatemalan Highlands. We found that asthma prevalence is low among indigenous children in Gautemala, compared to other populations in Latin America. Only 3.3% of the children reported wheezing symptoms in the last 12 months, and 72% wheezing symptoms ever. The majority of the current wheezers had at least one of the criteria for severe asthma. The prevalence of all the symptoms of asthma was higher in children from households that used open fires compared to improved stoves with chimneys. In a logistic regression model, use of open fire for cooking was a significant risk factor for a number of asthma symptoms, with odds ratios varying from 2.0 to 3.5. Among the different cooking technologies (1—improved stove with chimney, 2—mixture of gas and open fire, 3—open fire) trends of higher prevalence with more pollution was found for some of the symptoms. Hence use of open fire for cooking, may be an important risk factor for asthma symptoms and severity.

Eye discomfort, headache and back pain among Mayan Guatemalan women taking part in a randomised stove intervention trial

Background: Indoor air pollution (IAP) from combustion of biomass fuels represents a global health problem, estimated to cause 1.6 million premature deaths annually. Aims: RESPIRE (Randomised Exposure Study of Pollution Indoors and Respiratory Effects) Guatemala is the first randomised controlled trial ever performed on health effects from solid fuel use. Its goal is to assess the effect of improved stoves (planchas) on exposure and health outcomes in a rural population reliant on wood fuel. Methods: Questions about symptoms were asked at baseline and periodically after the intervention, to an initial group of 504 women (259 randomly assigned to planchas (mean (standard deviation) age 27.4 (7.2) years) and 245 using traditional open fires (28.1 (7.1) years)). Levels of carbon monoxide (CO) in exhaled breath, a biomarker of recent exposure to air pollution from biomass combustion, were measured at each visit. In addition to reducing IAP levels, the plancha may also have a positive health effect by changing the working posture to an upright position. Results: A high prevalence of eye discomfort, headache and backache was found. The odds of having sore eyes and headache were substantially reduced in the plancha group relative to the group using open fires for the follow-up period (odds ratio (OR) 0.18, 95% confidence interval (CI) 0.11 to 0.29 and (OR) 0.63, 95% CI 0.42 to 0.94, respectively). Median CO in breath among women in the intervention trial was significantly lower than controls. Conclusion: In addition to reducing discomfort for women, tangible improvements in symptoms experienced by a substantial proportion of women may help to gain acceptance and wider use of planchas.

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.

Annual Ambient Black Carbon Associated with Shorter Telomeres in Elderly Men: Veterans Affairs Normative Aging Study

Background Telomere length reflects biological age and is inversely associated with risk of cardiovascular disease (CVD). Ambient air pollution is associated with CVD, but its effect on telomere length is unknown. Objective We investigated whether ambient black carbon (BC), a marker for traffic-related particles, is associated with telomere length in the Normative Aging Study (NAS). Methods Among 165 never-smoking men from the NAS, leukocyte telomere length (LTL) was measured repeatedly approximately every 3 years from 1999 through 2006 using quantitative real-time polymerase chain reaction (qRT-PCR). BC concentration at their residences during the year before each LTL measurement was estimated based on a spatiotemporal model calibrated with BC measurements from 82 locations within the study area. Results The median [interquartile range (IQR)] annual moving-average BC concentration was 0.32 (0.20–0.45) μg/m3. LTL, expressed as population-standardized ratio of telomere repeat to single-copy gene copy numbers, had a geometric mean (geometric SD) of 1.25 (1.42). We used linear mixed-effects models including random subject intercepts and adjusted for several potential confounders. We used inverse probability of response weighting to adjust for potential selection bias due to loss to follow-up. An IQR increase in annual BC (0.25 μg/m3) was associated with a 7.6% decrease (95% confidence interval, −12.8 to −2.1) in LTL. We found evidence of effect modification, with a stronger association among subjects ≥ 75 years of age compared with younger participants (p = 0.050) and statin medications appearing protective of the effects of BC on LTL (p = 0.050). Conclusions Telomere attrition, linked to biological aging, may be associated with long-term exposures to airborne particles, particularly those rich in BC, which are primarily related to automobile traffic.