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 – 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. 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, 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. 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 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. 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. Env Health Perspec, March 2015.

    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. 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

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    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.