The Critical Importance of Cleaner Fuels | Source: S Patel and S Mehta, Global Alliance for Clean Cookstoves, Aug 2014.

Preliminary exposure results from Alliance-supported child survival research studies in Ghana, Nigeria, and Nepal were unveiled at a special symposium held in Seattle at the annual meeting of the International Society for Environmental Epidemiology (ISEE), the premier technical conference for environmental health researchers.  Results indicate substantial reductions in exposure associated with the adoption of cleaner cookstoves and fuels.  Moreover, researchers reported high rates of study compliance, and solid evidence that study participants were actively using the intervention stoves.  There were also discussions on the implication of these results for achieving the World Health Organizations (WHO) indoor air quality guidelines for household fuel combustion, with a special emphasis on estimating the impact of ‘stove stacking’, or continued use of traditional cookstoves, on the ability to meet air quality guidelines.

These study results will have far reaching implications for Alliance focus countries such as Ghana, Kenya, China, and India, where policy makers and health professionals are well-positioned to increase awareness of the links between household air pollution, fuel switching, and health.  For example, given Ghana’s commitment to scaling adoption of clean cookstoves, and providing 50% of the population with access to clean fuels by 2020, the study will provide policy-relevant information for Ghana and the broader global public health community.

Respiratory risks from household air pollution in low and middle income countries. Lancet Respir Med. 2014 Sep 2. pii: S2213-2600(14)70168-7. doi: 10.1016/S2213-2600(14)70168-7.

Authors: Gordon SB, Bruce NG, et al.

A third of the world’s population uses solid fuel derived from plant material (biomass) or coal for cooking, heating, or lighting. These fuels are smoky, often used in an open fire or simple stove with incomplete combustion, and result in a large amount of household air pollution when smoke is poorly vented. Air pollution is the biggest environmental cause of death worldwide, with household air pollution accounting for about 3·5-4 million deaths every year. Women and children living in severe poverty have the greatest exposures to household air pollution.

In this Commission, we review evidence for the association between household air pollution and respiratory infections, respiratory tract cancers, and chronic lung diseases. Respiratory infections (comprising both upper and lower respiratory tract infections with viruses, bacteria, and mycobacteria) have all been associated with exposure to household air pollution. Respiratory tract cancers, including both nasopharyngeal cancer and lung cancer, are strongly associated with pollution from coal burning and further data are needed about other solid fuels. Chronic lung diseases, including chronic obstructive pulmonary disease and bronchiectasis in women, are associated with solid fuel use for cooking, and the damaging effects of exposure to household air pollution in early life on lung development are yet to be fully described.

We also review appropriate ways to measure exposure to household air pollution, as well as study design issues and potential effective interventions to prevent these disease burdens. Measurement of household air pollution needs individual, rather than fixed in place, monitoring because exposure varies by age, gender, location, and household role. Women and children are particularly susceptible to the toxic effects of pollution and are exposed to the highest concentrations. Interventions should target these high-risk groups and be of sufficient quality to make the air clean. To make clean energy available to all people is the long-term goal, with an intermediate solution being to make available energy that is clean enough to have a health impact.

Household Cooking with Solid Fuels Contributes to Ambient PM2.5 Air Pollution and the Burden of Disease. Environ Health Perspect. 2014 Sep 5.

Authors: Chafe ZA1, Brauer M2, Klimont Z3, Van Dingenen R4, Mehta S5, Rao S3, Riahi K3, Dentener F4, Smith KR6.
Author information
1Energy and Resources Group; and Environmental Health Sciences, University of California, Berkeley, California, USA.
2School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada.
3International Institute for Applied Systems Analysis, Laxenburg, Austria.
4European Commission Joint Research Centre, Institute for Environment and Sustainability, Air and Climate Unit, Ispra, Italy.
5Global Alliance for Clean Cookstoves, Washington, DC, USA.
6Environmental Health Sciences, University of California, Berkeley, California, USA.

Background: Approximately 2.8 billion people cook with solid fuels. Research has focused on the health impacts of indoor exposure to fine particulate pollution. Here, for the 2010 Global Burden of Disease project (GBD 2010), we evaluate the impact of household cooking with solid fuels on regional population-weighted ambient PM2.5 pollution (APM2.5).

Objectives: We estimated the proportion and concentrations of APM2.5 attributable to household cooking with solid fuels (PM2.5-cook) for the years 1990, 2005, and 2010 in 170 countries; and associated ill-health.

Methods: We used an energy supply-driven emissions model (GAINS) and source-receptor model (TM5-FASST) to estimate the proportion of APM2.5 produced by households and the proportion of household PM2.5 emissions from cooking with solid fuels. We estimated health effects using GBD 2010 data on ill-health from APM2.5 exposure.

Results: In 2010, household cooking with solid fuels accounted for 12% of APM2.5 globally, varying from 0% of APM2.5 in five higher-income regions to 37% (2.8 µg/m3 of 6.9 µg/m3 total) in Southern sub-Saharan Africa. PM2.5-cook constituted >10% of APM2.5 in seven regions housing 4.4 billion people. South Asia showed the highest regional concentration of APM2.5 from household cooking (8.6 µg/m3). Based on GBD 2010, we estimate that exposure to APM2.5 from cooking with solid fuels caused the loss of 370,000 lives and 9.9 million disability-adjusted life years globally in 2010.

Conclusions: PM2.5 emissions from household cooking constitute an important portion of APM2.5 concentrations in many places, including India and China. Efforts to improve ambient air quality will be hindered if household cooking conditions are not addressed.

WHO Indoor air quality guidelines on household fuel combustion: Strategy implications of new evidence on interventions and exposure-risk functions. Atmospheric Environment, 27 August 2014, In Press.

Nigel Brucea, b, , , Dan Popea, Eva Rehfuessc, Kalpana Balakrishnand, Heather Adair-Rohanib, Carlos Dorab
a Department of Public Health and Policy, University of Liverpool, UK
b Department of Public Health, Environmental and Social Determinants of Health, World Health Organisation, Geneva
c Institute for Medical Informatics, Biometry and Epidemiology, Ludwig-Maximilians-University, Munich, Germany
d Department of Environmental Health Engineering, Sri Ramachandra University, Chennai, India

• 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 forPM2.5, 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.

Highway proximity and black carbon from cookstoves as a risk factor for higher blood pressure in rural China. Proc Natl Acad Sci U S A. 2014 Aug 25.

Baumgartner J1, Zhang Y2, Schauer JJ3, Huang W2, Wang Y2, Ezzati M4.
1Institute for Health and Social Policy and Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, QC, Canada H3A 1A3; Institute on the Environment, University of Minnesota, St. Paul, MN 55108;
2College of Resources and Environment, University of Chinese Academy of Sciences, Beijing 100049, China;
3Environmental Chemistry and Technology Program, Department of Civil and Environmental Engineering, University of Wisconsin-Madison, Madison, WI 53706; and.
4MRC-PHE Centre for Environment and Health, Department of Epidemiology and Biostatistics, School of Public Health, Imperial College London, London W2 1PG, United Kingdom.

Air pollution in China and other parts of Asia poses large health risks and is an important contributor to global climate change. Almost half of Chinese homes use biomass and coal fuels for cooking and heating. China’s economic growth and infrastructure development has led to increased emissions from coal-fired power plants and an expanding fleet of motor vehicles. Black carbon (BC) from incomplete biomass and fossil fuel combustion is the most strongly light-absorbing component of particulate matter (PM) air pollution and the second most important climate-forcing human emission. PM composition and sources may also be related to its human health impact. We enrolled 280 women living in a rural area of northwestern Yunnan where biomass fuels are commonly used. We measured their blood pressure, distance from major traffic routes, and daily exposure to BC (pyrolytic biomass combustion), water-soluble organic aerosol (organic aerosol from biomass combustion), and, in a subset, hopane markers (motor vehicle emissions) in winter and summer. BC had the strongest association with systolic blood pressure (SBP) (4.3 mmHg; P < 0.001), followed by PM mass and water-soluble organic mass. The effect of BC on SBP was almost three times greater in women living near the highway [6.2 mmHg; 95% confidence interval (CI), 3.6 to 8.9 vs. 2.6 mmHg; 95% CI, 0.1 to 5.2]. Our findings suggest that BC from combustion emissions is more strongly associated with blood pressure than PM mass, and that BC’s health effects may be larger among women living near a highway and with greater exposure to motor vehicle emissions.

Sustained high incidence of injuries from burns in a densely populated urban slum in Kenya: An emerging public health priority. Burns. 2014 Sep;40(6):1194-200.

Authors: Wong JM1, Nyachieo DO1, Benzekri NA1, Cosmas L1, Ondari D1, Yekta S2, Montgomery JM1, Williamson JM1, Breiman RF3.
1Global Disease Detection Division, Center for Global Health, Centers for Disease Control and Prevention (CDC), Nairobi, Kenya and the Kenya Medical Research Institute (KEMRI)-CDC Research Collaboration.
2Division of Plastic and Reconstructive Surgery, University of Toronto, Toronto, ON, Canada.
3Global Disease Detection Division, Center for Global Health, Centers for Disease Control and Prevention (CDC), Nairobi, Kenya and the Kenya Medical Research Institute (KEMRI)-CDC Research Collaboration. Electronic address:

INTRODUCTION: Ninety-five percent of burn deaths occur in low- and middle-income countries (LMICs); however, longitudinal household-level studies have not been done in urban slum settings, where overcrowding and unsafe cook stoves may increase likelihood of injury.

METHODS: Using a prospective, population-based disease surveillance system in the urban slum of Kibera in Kenya, we examined the incidence of household-level burns of all severities from 2006-2011.

RESULTS: Of approximately 28,500 enrolled individuals (6000 households), we identified 3072 burns. The overall incidence was 27.9/1000 person-years-of-observation. Children <5 years old sustained burns at 3.8-fold greater rate compared to (p<0.001) those ≥5 years old. Females ≥5 years old sustained burns at a rate that was 1.35-fold (p<0.001) greater than males within the same age distribution. Hospitalizations were uncommon (0.65% of all burns).

CONCLUSIONS: The incidence of burns, 10-fold greater than in most published reports from Africa and Asia, suggests that such injuries may contribute more significantly than previously thought to morbidity in LMICs, and may be increased by urbanization. As migration from rural areas into urban slums rapidly increases in many African countries, characterizing and addressing the rising burden of burns is likely to become a public health priority.

Factors Influencing Household Uptake of Improved Solid Fuel Stoves in Low- and Middle-Income Countries: A Qualitative Systematic Review. Int. J. Environ. Res. Public Health, Aug 2014.

Authors: Stanistreet Debbi 1,*, Puzzolo Elisa 1, Bruce Nigel 1, Pope Dan 1 and Rehfuess Eva 2
1 Department of Public Health and Policy, Institute of Psychology, Health and Society, Whelan Building, University of Liverpool, Liverpool L69 3GB, UK; E-Mails: (P.E.); (B.N.); (P.D.)
2 Institute for Medical Informatics, Biometry and Epidemiology, University of Munich, Marchioninistr. 15, Munich 81377, Germany; E-Mail:
* Author to whom correspondence should be addressed; E-Mail:; Tel.: +44-151-794-5583.

Abstract: Household burning of solid fuels in traditional stoves is detrimental to health, the environment and development. A range of improved solid fuel stoves (IS) are available but little is known about successful approaches to dissemination. This qualitative systematic review aimed to identify factors that influence household uptake of IS in low- and middle-income countries. Extensive searches were carried out and studies were screened and extracted using established systematic review methods. Fourteen qualitative studies from Asia, Africa and Latin-America met the inclusion criteria. Thematic synthesis was used to synthesise data and findings are presented under seven framework domains.

Findings relate to user and stakeholder perceptions and highlight the importance of cost, good stove design, fuel and time savings, health benefits, being able to cook traditional dishes and cleanliness in relation to uptake. Creating demand, appropriate approaches to business, and community involvement, are also discussed. Achieving and sustaining uptake is complex and requires consideration of a broad range of factors, which operate at household, community, regional and national levels. Initiatives aimed at IS scale up should include quantitative evaluations of effectiveness, supplemented with qualitative studies to assess factors affecting uptake, with an equity focus.

Liverpool School of Tropical Medicine - CAPS Study: An advanced cookstove intervention to prevent pneumonia in children under 5 years old in Malawi: a cluster randomised controlled trial.


  • Malawi has one of the highest rates of death among infants and the under fives (69 and 110 per 1000 live births respectively in 2009) despite having made progress towards meeting the Millennium Development Goal of reducing child mortality.
  • Pneumonia is the leading cause of death and one of the commonest causes of morbidity: around 300 per 1000 children under the age of 5 are diagnosed with pneumonia every year.
  • Exposure to smoke produced when biomass fuels (animal or plant material) are burned in open fires is a major avoidable risk factor for pneumonia.
  • In Malawi, where at least 95% of households depend on biomass as their main source of fuel, biomass smoke exposure is likely to be responsible for a substantial burden of this disease.
  • Smoke from burning biomass in open fires also causes other health problems including chronic lung disease, lung cancer, heart disease, stillbirth and low birth weight; it is also thought to be an important driver of global climate change.
  • The problem of biomass smoke exposure is seen across Africa where around 700 million people burn biomass fuels to provide energy for cooking, heating and lighting.
  • The problem extends right around the globe where around half the worlds population are dependent on biomass fuels for their day-to-day energy requirements.
  • Around 4 million people die every year around the world from the effects of biomass smoke.

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EPA/Winrock Webinar – Results from CCT Studies and Stove Design and Performance Testing Workshops in Vietnam, Mexico, and Nepal, July 29, 2014.

In 2012 and 2013 Aprovecho Research Center, with support from the U.S. EPA and Winrock International, conducted Controlled Cooking Test (CCT) field studies and provided technical training for organizations working to promote cleaner, more efficient cooking technologies in Vietnam (2012), Mexico (2013), and Nepal (2013). On July 2, 2014 Winrock and the U.S. EPA hosted a webinar to present results and lessons learned from the studies and information about how these results can inform and improve cookstove design, performance and use. The webinar also provided context and outcomes from the regional technical capacity building workshops that complemented each field study. Mike Hatfield presented on behalf of Aprovecho Research Center.

Perspectives in Household Air Pollution Research: Who Will Benefit from Interventions? Curr Envir Health Rpt, July 2014.

Authors: Maggie L. Clark & Jennifer L. Peel

Despite increasing recognition surrounding this global environmental health problem, much remains to be elucidated regarding exposure response relationships, particularly among potentially susceptible population subgroups. Given that many of the communities most affected by household air pollution exposures also experience elevated exposures to poverty, psychosocial stressors, other environmental pollutants, and comorbid conditions, research needs to correctly specify risks due to these potentially interacting risk factors. Although suggestive evidence exists for differential improvements in health following reductions in ambient air pollution concentrations among specific subgroups, the question remains as to who will benefit and to what extent from efforts to reduce exposures to emissions from household solid fuel combustion. The ability to know what to expect from cookstove interventions and to accurately describe the presence of distinct subgroup responses is crucial to reduce uncertainty and to encourage policy makers to enact change.