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Cycle 1

Principal Investigator:  Sharat Verma, National Tuberculosis Center
NIH-Supported Collaborator: Kirk Smith, University of California, Berkeley
Title of NIH Award: Investigation of indoor solid fuel and kerosene use as Tuberculosis risk factors
Project Dates: October 2013 - February 2019

Project Overview

Acute Respiratory Infection (ARI) is the leading cause of childhood morbidity and mortality in Nepal. The Ministry of Health and Population has recognized ARI as one of the major public health problems. It has given due importance to improve medical case management strategies to lower the incidence of ARI. In spite of such strategies, incidence of ARI is still prevalent. Household air pollution (HAP) from solid-fuel-burning stoves has been causally linked to ARI in children. In Nepal, about 83% of households use solid fuel for cooking and heating. A study conducted in Dhading district has attributed 50% of ARI, mainly ALRI or pneumonia to HAP. While we apply antibiotics to improve medical case management to lower the incidence of ARI, it is prudent also to more thoroughly explore the roles of clean cookstoves in lowering the incidence of ARI and under-five mortality in the country. For example, WHO and GACC have identified reduction of HAP as one of the potential intervention areas to prevent ARI related morbidity and mortality in children. In Nepal, government has installed around 450,000 biomass improved cookstove and 132,000 biogas systems throughout the country. However, there has been no survey conducted to assess their effectiveness in either reducing HAP or health burden in the community. This prospective cohort study, seeks to assess whether clean cookstove technologies complement Nepal Government’s effort of lowering the incidence of ARI in the country. It also seeks to assess, which levels of air pollution reduction is necessary to meaningfully improve children’s health. The specific objectives are: a) To investigate the effectiveness of biogas cookstove technologies being promoted by the government of Nepal in a) household smoke reduction, and b) reduction of ARI, mainly the acute lower respiratory tract infection (ALRI) or pneumonia in children under-5-years of age. This will be an exposure based prospective cohort study. The study team will longitudinally monitor the fuel/stove use pattern and levels of particulate matters in the home, and the incidence of ALRI—mainly pneumonia in children ≤3 years of age living in households using traditional and biogas stoves over the course of 2 years. The study will help evaluate the benefits, and the effectiveness of national cookstove programs in reduction of HAP and occurrences of pneumonia among children ≤5 years of age in Nepal. This study will also help identify behavior change interventions among cookstove users that could be applied at a large, e.g. national, scale.
The findings of this study will help develop a plan to scale-up the best cookstove interventions.

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Awareness rally on air pollution and pneumonia organized by Female Community Health Volunteers (FCHV). (photo courtesy of PI Verma S)Evaluation of weekly morbidity assessments in HH level and health posts by PI Verma S and Investigators. (photo courtesy of PI Verma S)

Summary of Recent Activities

The project ended in February 2019. The main aim of the PEER project was to evaluate whether the use of biogas, one of the clean cooking fuels that the Nepal government is promoting, protects children from an acute respiratory infection (ARI) or acute lower respiratory infection (ALRI). The second aim was to assess household fuel use patterns and the level of indoor air pollution associated with fuel usage. The third aim was to understand the levels of air pollution reduction that is necessary to meaningfully improve children’s health.

The study followed 541 children for two years. These children had either biogas or open wood-fired cookstoves in their home. The 28 community nurses--Female Community Health Volunteers (FCHVs) made 107 (104 for pneumonia study, one pre, and one post-earthquake data collection, and two health awareness visits after the earthquake) weekly home visits and collected information on the incidence of ARI and ALRI, diarrhea in children. The FCHVs also collected information on child’s food habit, fuel, and stove use during the week, and collected the child’s anthropometric data. The ARI or ALRI in study children was documented by using the WHO - IMCI guideline. Initially, a total of 550 children were recruited into the study. However, three children died during the April 25, 2015 earthquake. After that, another six children moved to another location. At the end of the study, there were 541 children, of which 349 had traditional biomass cookstove and 192 had a biogas cookstove in their home.

During the study period, five repeated kitchen level air pollution (PM2.5 and carbon monoxide), and the duration and pattern of stove usage by 541 homes were measured. Two rounds of personal exposure to carbon monoxide were measured on 61 children (20 from biogas and 40 from biomass households). In one of the study sites, the outdoor level of PM2.5 was measured for two years. In addition, the researchers involved in the study were able to mentor many students and establish a productive and collaborative relationship with many individuals and institutions.

At present, we have cleaned the baseline study data collected from the homes of 550 study children and performed descriptive analysis for each of the variables. About 3075 raw stove usage data files have also been cleaned and edited for subsequent analysis. We have cleaned the follow-up study data set (weekly fuel use and ARI and pneumonia incident data), and subsequent analysis is undergoing. The 3075-kitchen level air pollution (PM2.5) data and personal exposure to carbon monoxide data from a subset of children are also being processed. We are also in the process of combining all these data sets to evaluate the association between household air pollution and ARI and ALRI in under five children. The team is anticipating to complete the analysis and summary of results in 2020.

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Weekly morbidity assessment performed by FCHV. (photo courtesy of PI Verma S)Installation of SUMS on biomass and Biogas stoves. (photo courtesy of PI Verma S)

Health Cycle 1 Recipients