Household air pollution: a call to action Evidence is mounting that household air pollution is a serious global public health concern, particularly in Africa. As discussed by Gordon and colleagues,1 household air pollution caused by burning of solid fuels accounts for 3·5 million to 4 million premature deaths per year worldwide. Africa, a continent with 13% of the world’s population, disproportionately bears 32% of the total attributable burden of disease.2 Early life exposure to household air pollution has been linked to a range of adverse child health outcomes, including low birth weight and pneumonia.1 Continued exposure can lead to chronic obstructive pulmonary disease, lung cancer, and cardiovascular disease. Burning of solid fuels emits a complex mixture of particulate matter less than 2·5 μm in diameter and gases. Convincing evidence exists that links this particulate matter to adverse health effects.3 Personal assessments of exposure to this particulate matter, although deemed the gold standard, need expensive equipment and substantial technical skills and laboratory support. Quality exposure monitoring is necessary to adequately assess personal exposure, define dose–response relationships, and establish the existence and timing of critical and sensitive exposure periods. These data are imperative to establish whether existing, cheap cookstove interventions that offer modest exposure reductions are sufficient, or if expensive interventions that provide large exposure reductions are needed to measurably improve health outcomes. Large, randomised cookstove intervention trials with high-quality, quantitative exposure monitoring assessments are underway in Ghana (NCT01335490) and Malawi to begin to understand dose–response relationships and further define health effects. Studies from other African countries, however, are desperately Vol 3 January 2015

needed. Regional and temporal differences in cooking practices, ventilation, and fuel type probably alter both the intensity and composition of household air pollution exposure, thereby affecting dose–response relationships and health outcomes. Data from the two large, well-designed cookstove intervention trials in Ghana and Malawi are crucially important, but might not be representative of household air pollution exposure across Africa. More quality data are needed than are currently available. Household air pollution affects the poorest households that are unable to afford clean, efficient cooking practices. Research findings need to translate into public health cookstove distribution policies that allow all households to access clean fuels, not just those that can afford them. This initiation of widespread public health policy will need strong relationships with governmental bodies and an intricate knowledge of local and national governments and cultures. In this regard, African researchers, who frequently have longstanding relationships with their government’s Ministry of Health, are uniquely qualified to ensure that these policy changes occur. At the 2014 American Thoracic Society Methods in Epidemiologic, Clinical, and Operations Research conference,4 African researchers expressed strong interest in investigation of the health effects of household air pollution exposure. 20 researchers representing seven African countries developed exciting research protocols that have the potential to make substantial contributions to the household air pollution literature and, most importantly, public health policy. However, because of the absence of exposure monitoring equipment, technical skills, and laboratory support needed for quality exposure assessments, these researchers face substantial barriers. Without any intervention, 2·7 billion people will be reliant on

biomass fuels by 2030.5 In view of the enormous burden of disease and the crucial need for quality exposure data, we call on the international scientific biomedical community, along with potential funders, to convene and form partnerships with these and other promising African researchers. Existing research centres, such as those in Ghana and Malawi, should be leveraged to build centres of excellence to train and supervise burgeoning African research sites. Provision of monitoring equipment and on-the-ground technical training and support would build desperately needed capacity and allow African researchers to lead research and public health efforts to combat the devastating health effects of household air pollution.

If you would like to respond to an article published in The Lancet Respiratory Medicine, please submit your correspondence online at: http://

HL, JI, BPK, NM, NL, EN, ONN, GI, EA, GAA, PROCA, AA, BA, OA, OO, SO, and PO report grants from the UK Medical Research Council and the UK Department for International Development (BREATHE Partnership Grant). AL reports grants from the Thrasher Research Fund, the Chest Foundation, and the Respiratory Health Association. MMN, JK, and FOA declare no competing interests.

*Alison Lee, Paul R O C Adobamen, Orighomisan Agboghoroma, Fahmi Oumer Ahmed, Adesuwa Aigbokhaode, Ganiyu Adeniyi Amusa, Euripide Avokpaho, Babatunde Awokola, Joy Ibeh, Godsent Isiguzo, Jacqueline Kagima, Bankole Peter Kuti, Hervé Lawin, Norman Lufesi, Ndubuisi Mokogwu, Esther Ngadaya, Motto Malea Nganda, Ogonna Nwota Nwankwo, Perpetua Obiajunwa, Sunday Oghuvwu, Obianuju Ozoh [email protected] Icahn School of Medicine at Mount Sinai, New York, NY 10029-6574, USA (AL); University of Benin Teaching Hospital, Edo State, Nigeria (PROCA, NM, SO); Obafemi Awolowo University, Ile-Ife, Nigeria (BPK, PO); College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia (FOA); Federal Medical Centre, Asaba, Nigeria (AA); Jos University Teaching Hospital, Jos, Nigeria (OA, GAA); Faculty of Medicine, University of Parakou, Parakou, Benin (EA); Lily Hospitals, Warri, Nigeria (BA); University College Hospital, Ibadan, Nigeria (JI); Federal Teaching Hospital Abakaliki, Ebonyi State, Nigeria (GI); Faculty of Health Sciences, Egerton University, Egerton, Kenya (JK); University of Abomey Calavi, Abomey Calavi, Benin (HL); Ministry of Health, Lilongwe, Malawi (NL); Douala General Hospital,

For the Malawi cookstove intervention trial see http://



Douala, Cameroon (MMN); National Institute for Medical Research, Dar es salaam, Tanzania (EN); University of Calabar Teaching Hospital, Calabar, Nigeria (ONN); and College of Medicine of the University of Lagos, Lagos, Nigeria (OO) 1





Gordon SB, Bruce NG, Grigg J, et al. Respiratory risks from household air pollution in low and middle income countries. Lancet Respir Med 2014; 2: 823–60. WHO. The world health report 2002. Reducing risks, promoting healthy life. Geneva: World Health Organization, 2002. WHO Regional Office for Europe. Health effects of particulate matter: policy implications for countries in eastern Europe, Caucasus and central Asia. Denmark: World Health Organization, 2013. American Thoracic Society. Methods in Epidemiologic, Clinical and Operations Research (MECOR). global-health/mecor-courses (accessed Oct 28, 2014). International Energy Agency. World energy outlook 2006. Paris: Organisation for Economic Co-operation and Development, 2006.

Cavallini James/Bsip/Science Photo Library

Real engagement with communities In an editorial,1 The Lancet Respiratory Medicine expresses the general thinking in the tuberculosis discipline that a bold approach is needed to eliminate this deadly but curable disease. To do so, the author stresses how important it is to strengthen the engagement of all stakeholders: politicians, funders, medical practitioners, and civil society. The author emphasises the need to renew the commitment to support disease prevention through engagement with the most vulnerable society members.2 As civil society members who work with vulnerable individuals and members of the affected communities, we applaud these statements. However, we urge development of concrete strategies to effectively include the key affected populations in development of plans, research, and discourse on tuberculosis. Even with good intentions, without meaningful inclusion of affected communities, enlightened absolutism could occur. Although the editorial mentions engagement with migrants, prisoners, and the homeless, these populations e2

are rarely, if ever, included in decisionmaking processes, and are treated as passive individuals. Also of concern is the fact that the editorial mentions the need to make resources reach the poorest communities and most marginalised members, and yet does not mention the need to empower and work with them, or to fight the social inequities that put these communities in situations of poverty and marginalisation, of which tuberculosis is a visible consequence. Isolated examples of engagement with communities exist. The Community Research Advisors Group of the Tuberculosis Trials Consortium and the Global TB Community Advisory Board are examples of successfully integrating communities into the research process from protocol conception to results dissemination. Within the International Union Against TB and Lung Disease, efforts exist to improve communication with and engagement and inclusion of affected communities for all activities of the organisation, especially the planning of and participation in their annual Union World Conference on Lung Health. The TB Alliance, a product development partnership, has an integrated community engagement programme that helps give the community perspective on the research that the Alliance implements.3 However, to really eliminate tuberculosis, patients, survivors, and affected communities have to be included from the beginning and throughout the whole process, from research design through to programmatic implementation on a regular basis in all activities to address tuberculosis. The affected communities should no longer be passive recipients of care but valuable partners with decision-making power in choices and policies that affect them. The examples should no longer be the exception. We must address the underlying issue driving the tuberculosis epidemic—inequity.

We declare no competing interests.

*Laia Ruiz Mingote, Wim Vandevelde, Blessina Kumar, Erica Lessem [email protected] Community Research Advisors Group, 08032 Barcelona, Spain (LRM); Global Tuberculosis Community Advisory Board, Cape Town, South Africa (WV); Global Coalition of tuberculosis activists, New Delhi, India (BK); Treatment Action Group, New York, NY, USA (EL) 1



The Lancet Respiratory Medicine. The End TB strategy: a global rally. Lancet Respir Med 2014; 2: 943. WHO. The End TB Strategy. Geneva: World Health Organization, 2014. http://www.who. int/tb/post2015_TBstrategy.pdf (accessed Dec 2, 2014). Boulanger RF, Seidel S, Lessem E, for the Critical Path to TB Drug Regimens’ Stakeholder and Community Engagement Workgroup. Engaging communities in tuberculosis research. Lancet Infect Dis 2013; 13: 540–45.

Corrections Wuyts WA, Antoniou KM, Borensztajn K, et al. Combination therapy: the future of management for idiopathic pulmonary fibrosis? Lancet Respir Med 2014; 2: 933–42—In this Personal View a paragraph in the section “Chronic obstructive pulmonary disease (COPD)” and Table 2 have been amended for clarity. The paragraph should state “Recently approved combination products include longacting β agonists plus longacting muscarinic antagonists (eg, indacaterol plus glycopyrronium [QVA149, Novartis, Basel, Switzerland], and vilanterol plus umeclidinium), and longacting β agonists plus inhaled corticosteroids (eg, vilanterol plus fluticasone furoate). A fixed combination of budesonide plus formoterol has long been approved in COPD” and Table 2 should state “Longacting β agonists with longacting muscarinic antagonists (indacaterol plus glycopyrronium, vilanterol plus umeclidinium); longacting β agonists with inhaled corticosteroids (vilanterol plus fluticasone furoate)”. This correction has been made to the online version as of Jan 5, 2015. Fragaszy E, Hayward A. Emerging respiratory infections: influenza, MERS-CoV, and extensively drug-resistant tuberculosis. Lancet Respir 2014; 2: 970–72—The order of the authors should have been as above with Ellen Fragaszy as lead author and Andrew Hayward as second and corresponding author. These corrections have been made to the online version as of Jan 5, 2015. Vol 3 January 2015

Household air pollution: a call to action.

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