Academic journal article Environmental Health Perspectives

Health Effects of Household Solid Fuel Use: Findings from 11 Countries within the Prospective Urban and Rural Epidemiology Study

Academic journal article Environmental Health Perspectives

Health Effects of Household Solid Fuel Use: Findings from 11 Countries within the Prospective Urban and Rural Epidemiology Study

Article excerpt


Approximately 2.5 billion individuals globally are exposed to household air pollution (HAP) from cooking with solid fuels such as coal, wood, dung, or crop residues (Smith et al. 2014). Concentrations of air pollutants, especially fine particulate matter [PM [less than or equal to] 2.5 [micro]m in aerodynamic diameter ([PM.sub.2.5])], can be several orders of magnitude higher in homes cooking with solid fuels compared with those using clean fuels such as electricity or liquefied petroleum gas (LPG) (Clark et al. 2013; Shupler et al. 2018). [PM.sub.2.5] in outdoor air has been linked to mortality, ischemic heart disease (IHD), stroke, and respiratory diseases (Kim et al. 2015).

Despite the large population exposed and the potential for adverse health effects, few prospective cohort studies have examined the health effects of HAP. Only four studies have examined HAP and mortality and reached contradictory conclusions (Alam et al. 2012; Kim et al. 2016; Mitter et al. 2016; Yu et al. 2018). Further, studies have not examined HAP and fatal as well as nonfatal cardiovascular disease (CVD) events. There is growing evidence of the adverse effects of HAP on respiratory diseases and lung cancer; however, most studies are cross sectional or case-control in design, with relatively small sample sizes and limited geographic coverage (Gordon et al. 2014). To date, few prospective studies have examined HAP exposures and respiratory events in adults, and the existing studies have reported contradictory findings (Chan et al. 2019; Ezzati and Kammen 2001; Mitter et al. 2016).

Given the absence of direct epidemiological data, the Global Burden of Disease (GBD) study estimated the potential impact of HAP on health using exposure-response relationships that pooled data from studies on outdoor air pollution, secondhand smoke, and active smoking (Burnett et al. 2014). These predictions indicated that 1.6 million deaths were attributable to HAP exposure in 2017, of which 39% were from IHD and stroke and 55% from respiratory outcomes [>90% from chronic obstructive pulmonary disease (COPD) and acute lower respiratory infections (ALRI)] (GBD 2017 Risk Factor Collaborators 2018). Given the lack of direct epidemiological evidence and this large predicted burden, there is an urgent need to directly characterize the health effects associated with HAP.

Within the Prospective Urban and Rural Epidemiology (PURE) study, we conducted an analysis of 91,350 adults from 467 urban and rural communities in 11 low- to middle-income countries (LMICs) where solid fuels are commonly used for cooking. We examined associations between cooking with solid fuels--as a proxy indicator of HAP exposure--and cause-specific mortality, incident cases of CVD [CVD death and incidence of nonfatal myocardial infarction (MI), stroke, and heart failure (HF)] and incident cases of respiratory disease [respiratory death, nonfatal COPD, pulmonary tuberculosis (TB), pneumonia, or lung cancer]. We estimated associations between solid fuel use for cooking and these outcomes, controlling for extensive individual, household, and community covariates.


The PURE Cohort and Household Air Pollution Substudy

The PURE study is a large multinational cohort study of individuals 35-70 y of age enrolled from 21 countries in five continents. The methodology of the PURE study has been described in detail elsewhere (Dehghan et al. 2017; Teo et al. 2009; Yusuf et al. 2014). Briefly, PURE countries were selected to cover a wide range of socioeconomic and environmental settings, especially in LMICs, where health-related data are sparse. The primary sampling unit was the "community" in urban areas, selected based on known information of the geographical area such as a set of contiguous postal codes or groups of streets corresponding roughly to a neighborhood. Rural communities were small villages at least 50 km from cities. …

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