Assessing Exposures to Household Air Pollution in Public Health Research and Program Evaluation. Ecohealth. 2014 Nov 8.

Authors: Northcross AL1, Hwang N, Balakrishnan K, Mehta S.
Author information
1Department of Environmental and Occupational Health, George Washington University Milken Institute School of Public Health, 950 New Hampshire Ave 7th Floor, 20057, Washington, DC, USA,

Exposure to smoke from the use of solid fuels and inefficient stoves for cooking and heating is responsible for approximately 4 million premature deaths yearly. As increasing investments are made to tackle this important public health issue, there is a need for identifying and providing guidance on best practices for exposure and stove performance monitoring, particularly for public health research and evaluation studies.

This paper, which builds upon the discussion at an expert consultation on exposure assessment convened by the Global Alliance for Clean Cookstoves, the Centers for Disease Control and Prevention, and PATH in late 2012, aims to provide general guidance on what to monitor, who and where to monitor, and how to monitor household air pollution exposures. In addition, we summarize information about commercially available monitoring equipment and the technical properties of these monitors most important for household air pollution exposure assessment. The target audience includes epidemiologists conducting health studies and program evaluators aiming to quantify changes in exposures to estimate the potential health benefits of cookstoves intervention projects.

Safe Access to Fuel and Energy (SAFE) is a cross-sectoral issue that focuses on ensuring access to fuel and energy for cooking, heating, lighting, and powering for crisis-affected populations.

More than a third of the world’s population relies on traditional fuels—wood, coal, animal dung, and agricultural waste—for their energy needs, including cooking their meals, heating their homes, and lighting their communities. The challenges they face in accessing clean energy are numerous, often dangerous, and incredibly unsustainable, particularly during complex emergencies and protracted crises.

Safe and sustainable access to energy is being increasingly recognized as a human right—essential for the safety, well-being, and productivity of the people the humanitarian community serves. It is also essential for social and economic development, offering opportunities for improved lives and economic progress.

Associations of Respiratory Symptoms and Lung Function with Measured Carbon Monoxide Concentrations among Nonsmoking Women Exposed to Household Air Pollution: The RESPIRE Trial, Guatemala. Environ Health Perspect, Nov 2014.

Authors: Daniel Pope, Esperanza Diaz, et al.

Background: With 40% of the World’s population relying on solid fuel, household air pollution (HAP) represents a major preventable risk factor for COPD. 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, non-smoking women in rural Guatemala, using measured CO concentrations in exhaled breath and personal air to assess exposure.

Methods: The Randomised 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 post-intervention surveys including 6-monthly interviews (respiratory symptoms), 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 six 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 (in mL) 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 post-intervention personal CO concentrations.

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

The effect of exposure to biomass smoke on respiratory symptoms in adult rural and urban Nepalese populations. Environmental Health, Nov 2014.

Authors: Om P Kurmi, Sean Semple, et al.

Background – Half of the world’s population is exposed to household air pollution from biomass burning. This study aimed to assess the relationship between respiratory symptoms and biomass smoke exposure in rural and urban Nepal.

Methods – A cross-sectional study of adults (16+ years) in a rural population (n = 846) exposed to biomass smoke and a non-exposed urban population (n = 802) in Nepal. A validated questionnaire was used along with measures of indoor air quality (PM2.5 and CO) and outdoor PM2.5.

Results – Both men and women exposed to biomass smoke reported more respiratory symptoms compared to those exposed to clean fuel. Women exposed to biomass were more likely to complain of ever wheeze (32.0 % vs. 23.5%; p = 0.004) and breathlessness (17.8% vs. 12.0%, p = 0.017) compared to males with tobacco smoking being a major risk factor. Chronic cough was similar in both the biomass and non-biomass smoke exposed groups whereas chronic phlegm was reported less frequently by participants exposed to biomass smoke. Higher PM2.5 levels (≥2 SDs of the 24-hour mean) were associated with breathlessness (OR = 2.10, 95% CI 1.47, 2.99) and wheeze (1.76, 1.37, 2.26).

Conclusions – The study suggests that while those exposed to biomass smoke had higher prevalence of respiratory symptoms, urban dwellers (who were exposed to higher ambient air pollution) were more at risk of having productive cough.

Can Currently Available Advanced Combustion Biomass Cook-Stoves Provide Health Relevant Exposure Reductions? Results from Initial Assessment of Select Commercial Models in India. Ecohealth. 2014 Oct 8.

Authors:Sambandam S1, Balakrishnan K, Ghosh S, Sadasivam A, Madhav S, Ramasamy R, Samanta M, Mukhopadhyay K, Rehman H, Ramanathan V.
Author information
1World Health Organisation Collaborating Center for Occupational and Environmental Health, Department of Environmental Health Engineering, Sri Ramachandra University, No.1, Ramachandra Nagar, Porur, Chennai, 600116, India,

Household air pollution from use of solid fuels is a major contributor to the national burden of disease in India. Currently available models of advanced combustion biomass cook-stoves (ACS) report significantly higher efficiencies and lower emissions in the laboratory when compared to traditional cook-stoves, but relatively little is known about household level exposure reductions, achieved under routine conditions of use. We report results from initial field assessments of six commercial ACS models from the states of Tamil Nadu and Uttar Pradesh in India. We monitored 72 households (divided into six arms to each receive an ACS model) for 24-h kitchen area concentrations of PM2.5 and CO before and (1-6 months) after installation of the new stove together with detailed information on fixed and time-varying household characteristics. Detailed surveys collected information on user perceptions regarding acceptability for routine use.

While the median percent reductions in 24-h PM2.5 and CO concentrations ranged from 2 to 71% and 10-66%, respectively, concentrations consistently exceeded WHO air quality guideline values across all models raising questions regarding the health relevance of such reductions. Most models were perceived to be sub-optimally designed for routine use often resulting in inappropriate and inadequate levels of use. Household concentration reductions also run the risk of being compromised by high ambient backgrounds from community level solid-fuel use and contributions from surrounding fossil fuel sources. Results indicate that achieving health relevant exposure reductions in solid-fuel using households will require integration of emissions reductions with ease of use and adoption at community scale, in cook-stove technologies. Imminent efforts are also needed to accelerate the progress towards cleaner fuels.

Patterns of stove usage after introduction of an advanced cookstove: the long-term application of household sensors. Environ Sci Technol. 2014 Nov 12.

Authors: Pillarisetti A, Vaswani M, Jack D, Balakrishnan K, Bates MN, Arora NK, Smith KR.

Household air pollution generated from solid fuel use for cooking is one of the leading risk factors for ill-health globally. Deployment of advanced cookstoves to reduce emissions has been a major focus of intervention efforts. However, household usage of these stoves and resulting changes in usage of traditional polluting stoves is not well characterized. In Palwal District, Haryana, India, we carried out an intervention utilizing the Philips HD4012 fan-assisted stove, one of the cleanest biomass stoves available. We placed small, unobtrusive data-logging iButton thermometers on both the traditional and Philips stoves to collect continuous data on use patterns in 200 homes over 60 weeks.

Intervention stove usage declined steadily over time and stabilized after approximately 200; use of the traditional stove remained relatively constant. We additionally evaluated how well short-duration usage measures predicted long-term use. Measuring usage over time of both traditional and intervention stoves provides better understanding of cooking behaviors and can lead to more precise quantification of potential exposure reductions and consequent health benefits attributable to interventions.

Indoor air quality guidelines: household fuel combustion, 2014. World Health Organization

These new indoor air quality guidelines for household fuel combustion aim to help public health policy-makers, as well as specialists working on energy, environmental and other issues understand best approaches to reducing household air pollution — the greatest environmental health risk in the world today.

Recommendations, general to specific

  • The recommendations include general considerations for policy, a set of four specific recommendations, and a best-practice recommendation addressing linked health and climate impacts.
  • Among the general considerations, or overarching advice, is that policies should promote community-wide action, and that the safety of new fuels and technologies must be assessed rather than assumed.

Dan Sweeney is a D-Lab Biomass Fuel Research Scientist at the Massachusetts Institute of Technology.  His blog post below was originally published on October 30, 2014 on the MIT D-Lab blog. Read about other events on D-Lab News.

D-Lab’s Dan Sweeney attends ISO Clean Cooking Solutions Meeting in Guatemala

Last week, I returned from a nine-day visit to Antigua, Guatemala. Working with D-Lab partner organization Soluciones Comunitarias (SolCom), I performed field tests on a couple of their improved, wood-fired cookstoves. And, I participated in a meeting of the working and task groups for the International Standards Organization (ISO) Technical Committee on Clean Cooking Solutions. For my blog about cookstove testing on this trip read here.

Dan Sweeney & Marta Rivera (Fundacion Solar) during an ISO Fuels task group meeting.

Global Alliance for Clean Cookstoves connection

So you may be asking “how the heck did Dan get wrapped up in all of this?” Many of you may be familiar with the Global Alliance for Clean Cookstoves (aka The Alliance,, a public-private partnership at the UN Foundation, initiated by Hillary Clinton to bring awareness to the three billion people worldwide who use biomass to meet their household energy needs through advocacy, funding opportunities and other efforts to scale improved cooking technologies. The Harvest Fuel Initiative (HFI), which I focus most of my efforts on at D-Lab, is a member of the Alliance and over the past couple of months we have become a greater voice in Alliance conversations about cooking fuels which recognize improved fuels as a needed innovation in improved cooking (the Alliance recently hired a fuels technical expert, Seema Patel, who is one of my new best friends).

International Standards OrganizationTechnical Committee on Clean Cooking Solutions

The Alliance has also convened experts from various backgrounds and locations, ISO Technical Committee 285 (TC285), tasked with producing a globally recognized ISO standard for “Improved Cooking Solutions” – in short, a comprehensive, globally adopted guide for evaluating, rating, certifying and measuring impacts from cooking technology. The challenge is that cooking practices and technology are different everywhere and stakeholders have a wide variety of opinions about what is important when evaluating a cookstove- should tests be performed in a controlled-laboratory environment (like D-Lab’s stove lab), or should tests be performed in the field during actual use conditions? And what tests should be required by the standard so as to sufficiently measure important aspects of the technology (e.g. fuel efficiency, emissions, pollutant exposure, durability, safety) but not be prohibitively expensive for stove manufacturers who may not be able to afford an expensive lab or field test campaign.

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Viewpoint – Making the clean available: Escaping India’s Chulha TrapEnergy Policy, October 2014

Authors: Kirk R. Smith, Ambuj Sager


  • Pollution from cooking with solid fuels is largest health hazard for Indian women and girls.
  • 700 million Indians are caught in a trap using solid fuels with little change in number exposed for decades.
  • Efforts to make the biomass fuel clean through advanced stoves have made only modest progress in decades.•A major new effort is needed to make the clean available, in the form of gas and electricity.
  • This will require forging new partnerships and rethinking how these fuels are currently promoted.

Solid cookfuel pollution is the largest energy-related health risk globally and most important cause of ill-health for Indian women and girls. At 700 million cooking with open biomass chulhas, the Indian population exposed has not changed in several decades, in spite of hundreds of programs to make the “available clean”, i.e. to burn biomass cleanly in advanced stoves. While such efforts continue, there is need to open up another front to attack this health hazard. Gas and electric cooking, which are clean at the household, are already the choice for one-third of Indians. Needed is a new agenda to make the “clean available”, i.e., to vigorously extend these clean fuels into populations that are caught in the Chulha Trap. This will require engaging new actors including the power and petroleum ministries as well as the ministry of health, which have not to date been directly engaged in addressing this problem. It will have implications for LPG imports, distribution networks, and electric and gas user technologies, as well as setting new priorities for electrification and biofuels, but at heart needs to be addressed as a health problem, not one of energy access, if it is to be solved effectively.


Human health: impacts, adaptation, and co-benefits. In: Climate Change 2014: Impacts, Adaptation, and Vulnerability. Part A: Global and Sectoral Aspects. Contribution of Working Group II to the Fifth Assessment Report of the Intergovernmental Panel on Climate Change. Cambridge University Press, Cambridge, United Kingdom and New York, NY, USA, pp. 709-754.

Authors: Smith, K.R., A. Woodward, D. Campbell-Lendrum, D.D. Chadee, Y. Honda, Q. Liu, J.M. Olwoch, B. Revich, and R. Sauerborn, 2014:

→ Download PDF
→ View and Download Graphics from Chapter 11
→ Visit IPCC WGII, where the Full WGII report can be downloaded

We review diseases and other aspects of poor health that are sensitive to weather and climate. We examine the factors that influence the susceptibility ofpopulations and individuals to ill health due to variations in weather and climate, and describe steps that may be taken to reduce the impacts of climate change on human health.The chapter also includes a section on health “co-benefits.” Co-benefits are positive effects on human health that arise from interventions to reduce emissions of those CAPs that warm the planet or vice versa.