Acute lower respiratory infections (ALRIs), predominantly pneumonia, account for more deaths among children under-five than any other infectious disease. India has almost three times the number of ALRI deaths of any other country. Vaccination is an important tactic to reduce childhood bacterial pneumonia and the conjugate pneumococcal and Hemophilus influenzae B vaccinations are increasingly available to children in low- and lower-middle-income countries. Both vaccines are recommended in India, but the conjugate pneumococcal vaccine was not available outside the private sector until May 2017. While the immune response to the vaccines are developing in the first six months of life, there is an important role for other strategies to prevent ALRIs.

Household air pollution (HAP) from cooking and heating the home with solid fuels such as wood, crop waste, coal and animal dung on open fires or inefficient cookstoves is responsible for more disease and illness than any other environmental risk factor worldwide, including India. The inefficient burning of solid fuels releases harmful levels of pollutants, including fine particulate matter. Fine particulate matter, or PM 2.5, can travel deep into the lungs and enter the blood stream when inhaled leading to increased risk for respiratory and cardiac diseases [10]. The World Health Organization set the 24-hour standard for mean concentration of fine particulate matter in the ambient air at 25 μg/m3. Rural households burning solid fuels can reach mean daily PM 2.5 concentrations of 609 μg/m3 in the kitchen. Women and children have the highest personal exposures to HAP because of the time they spend inside the house and in the proximity of cookstoves. HAP exposure due to cooking from solid fuels increases the risk for ALRIs among children, although a recent meta-analysis reported no benefit of improved cookstoves on ALRIs either. In India, there is evidence that exposure to HAP increases the incidence of life-threatening respiratory illnesses, such as ALRIs, in children under the age of six. While no evidence exists that quantifies the risk between duration of exposure to HAP and ALRI incidence within the Indian context, this relationship has been observed in Sierra Leone.

The critical need to reduce HAP has been recognized in recent years and was reaffirmed by the 2018 Global Burden of Disease Study. The Global Alliance for Clean Cookstoves is leading the effort in driving adoption of clean cookstoves and fuel. However, rollout and acceptance of clean cooking alternatives is progressing slowly. The Indian Government’s initiative Pradhan Mantri Ujjwala Yojina, launched in May 2016, is already providing access to clean cooking gas for about 31 million of the 50 million households below the poverty line. However, there are an additional 50 million households in India still using solid fuel and the children living there are at risk of death from ALRI. If there is a direct association between duration of exposure to pollutants from use of solid fuel and risk of developing ALRI, potential interim strategies need to be considered such as educating the mothers to limit the child’s exposure to burning solid fuel, reducing the number of hours of cooking time or encouraging other household members to care for the infant away from the stove while the mother is cooking.

The Eunice Kennedy Shriver National Institute of Child Health and Human Development’s Global Network for Women and Children’s Health Research supports a Maternal and Newborn Health (MNH) Registry of pregnant women and their babies living in rural communities in six low- and lower-middle-income countries. In the Nagpur site in India, we have the Institutional Review Board approval to follow the infants born to women enrolled in the Registry for six months after birth. Therefore, the Nagpur site of the Registry provides an ideal population to address questions about risk factors for ALRI in rural communities where about two thirds of households use solid fuels. We hypothesized that the number of hours per day a child’s mother spent in front of a lit or smoldering solid fuel cookstove would be an easily measurable proxy for duration of exposure of the child to HAP as the child is often in the house while the mother is cooking. The aim of the HAP-ALRI add-on study to the MNH Registry is to determine whether there is an association between duration of time in front of burning solid fuel and ALRI in the rural villages near Nagpur, India.

By: Arlington L, Patel AB, Simmons E, Kurhe K, Prakash A, Rao SR, Hibberd PL.

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