1. A Review: The Health Impact of Cooking with
Solid Fuels in the Developing World
Maximo R. Prescott, B.S. Public Health Candidate, UCSD School of Medicine, Department of Family Medicine and Public Health
Advisor: Dr. Wael Al-Delaimy, Professor of Epidemiology, Chief of the Division of Global Health, Department of Family Medicine and Public Health
The
objec)ve
of
this
study
was
to
was
to
conduct
a
review
on
the
associa)on
between
biomass
fuel
use
during
cooking
and
its
health
consequences.
A
literature
search
was
conducted
on
PubMed
using
MESH
for
recent
epidemiological
studies
that
reported
associa)ons
between
between
solid
biomass
fuel
use
and
respiratory
health
consequences.
For
a
study
to
be
included
for
analysis,
the
study
must
have
met
the
following
criteria:
sufficient
par)cipant
size
(100+),
published
between
2009-­‐2015,
measurement
of
a
specific,
health
outcome,
and
conducted
in
a
developing
country.
All
health
outcomes
that
were
included
in
our
final
analysis
determined
solid
or
biomass
fuel
use
to
be
a
risk
factor
for
their
respec)ve
health
consequence
under
study.
However,
most
studies
relied
on
survey
data
to
assess
exposure
levels,
and
a
lack
of
reliable
biomarkers
for
the
assessment
of
exposure
in
developing
countries
was
apparent.
Similarly,
the
effec)veness
of
improved
cook
stove
interven)ons
was
inconclusive.
Future
studies
are
needed
to
clarify
the
effec)veness
of
improved
cook
stoves
on
reducing
household
air
pollu)on
and
its
influence
on
objec)ve
health
outcomes.
References
1. Alim
MA,
Sarker
MA,
Selim
S,
Karim
MR,
Yoshida
Y,
Hamajima
N.
Respiratory
involvements
among
women
exposed
to
the
smoke
of
tradi)onal
biomass
fuel
and
gas
fuel
in
a
district
of
Bangladesh.
Environ
Health
Prev
Med.
2014;19(2):126-­‐34.
2. Bau)sta
LE,
Correa
A,
Baumgartner
J,
Breysse
P,
Matanoski
GM.
Indoor
charcoal
smoke
and
acute
respiratory
infec)ons
in
young
children
in
the
Dominican
Republic.
Am
J
Epidemiol.
2009;169(5):572-­‐80.
3. Da
silva
LF,
Saldiva
SR,
Saldiva
PH,
Dolhnikoff
M.
Impaired
lung
func)on
in
individuals
chronically
exposed
to
biomass
combus)on.
Environ
Res.
2012;112:111-­‐7.
4. Epstein
MB,
Bates
MN,
Arora
NK,
Balakrishnan
K,
Jack
DW,
Smith
KR.
Household
fuels,
low
birth
weight,
and
neonatal
death
in
India:
the
separate
impacts
of
biomass,
kerosene,
and
coal.
Int
J
Hyg
Environ
Health.
2013;216(5):523-­‐32.
5. Foote
EM,
Gieraltowski
L,
Ayers
T,
et
al.
Impact
of
locally-­‐produced,
ceramic
cookstoves
on
respiratory
disease
in
children
in
rural
western
Kenya.
Am
J
Trop
Med
Hyg.
2013;88(1):132-­‐7.
6. Global
Alliance
for
Clean
Cook
Stoves.
(2010,
January
1).
Phase
I
Report
(2010-­‐2014).
Retrieved
April
1,
2015,
from
hgp://cleancookstoves.org/binary-­‐data/RESOURCE/file/000/000/283-­‐1.pdf
7. Gordon
SB,
Bruce
NG,
Grigg
J,
et
al.
Respiratory
risks
from
household
air
pollu)on
in
low
and
middle
income
countries.
Lancet
Respir
Med.
2014;2(10):823-­‐60.
8. Janjua
NZ,
Mahmood
B,
Dharma
VK,
Sathiakumar
N,
Khan
MI.
Use
of
biomass
fuel
and
acute
respiratory
infec)ons
in
rural
Pakistan.
Public
Health.
2012;126(10):855-­‐62.
9. Johnson
P,
Balakrishnan
K,
Ramaswamy
P,
et
al.
Prevalence
of
chronic
obstruc)ve
pulmonary
disease
in
rural
women
of
Tamilnadu:
implica)ons
for
refining
disease
burden
assessments
agributable
to
household
biomass
combus)on.
Glob
Health
Ac)on.
2011;4:7226.
10. Kim
C,
Gao
YT,
Xiang
YB,
et
al.
Home
kitchen
ven)la)on,
cooking
fuels,
and
lung
cancer
risk
in
a
prospec)ve
cohort
of
never
smoking
women
in
Shanghai,
China.
Int
J
Cancer.
2015;136(3):632-­‐8.
Chart
1:
Forest
plot
of
associa4ons
between
Improved
Cookstove
(ICS)
Interven4ons
and
health
outcomes.
As
shown
in
the
forest
plot,
all
5
interven)ons
were
shown
to
be
effec)ve
in
reducing
the
amount
of
respiratory
symptoms
or
burden
of
disease
in
the
interven)on
group.
However,
most
ICS
interven)ons
only
measure
respiratory
symptoms
and
few
measured
actual
respiratory
diseases,
such
as
COPD.
As
for
the
most
recent
improved
cookstove
(ICS)
interven)ons,
our
review
indicates
that
there
has
been
some
level
of
success.
Out
of
the
5
interven)ons
evaluated,
each
was
shown
to
make
a
sta)s)cally
significant
(as
indicated
by
a
confidence
interval
below
1.00
in
Chart
1)
difference
in
the
respiratory
symptom
or
disease
studied.
The
overall
effec)veness
of
these
improved
cookstoves
was
rather
inconclusive,
as
the
majority
of
studies
did
not
study
a
disease,
but
rather
a
respiratory
symptom.
Similarly,
the
interven)ons
we
reviewed
did
not
show
sta)s)cally
significant
reduc)ons
in
exposure
to
par)culate
mager.
The
results
of
our
review
have
limited
implica)ons
for
the
condi)ons
of
chronic
obstruc)ve
pulmonary
disease,
lung
cancer,
and
pulmonary
tuberculosis
due
to
a
limited
amount
of
studies
included.
However,
solid
fuel
use
during
cooking
has
been
consistently
shown
to
increase
the
risk
of
both
acute
lower
respiratory
infec)ons
and
respiratory
symptoms.
A
significant
issue
that
arose
while
reviewing
the
literature
was
a
lack
of
field-­‐tested,
reliable,
long-­‐term
biomarkers
for
assessing
the
individual
levels
of
exposure.
The
majority
of
studies
that
were
reviewed
used
survey
data
to
assess
exposure
levels
or
used
short-­‐
term
exposure
indicators.
Our
recommenda)on
would
be
for
more
long-­‐term
studies
with
increased
follow-­‐up,
and
for
the
use
of
efficient
cookstoves
that
are
capable
of
making
substan)al
objec)ve
health
impacts.
Abstract Methods Results
Background
Conclusion
Figure
1:
Flow
chart
showing
selec)on
process
for
determining
studies
to
include
in
the
review
of
respiratory
health
outcomes
and
exposure
to
solid
fuel
cooking
exposure.
COPD,
chronic
obstruc)ve
pulmonary
disease;
LC,
lung
cancer;
TB,
tuberculosis;
RS,
respiratory
symptoms;
ALRI,
acute
lower
respiratory
infec)on;
PN,
pneumonia;
LF,
lung
func)on;
CB,
chronic
bronchi)s;
MT,
mortality.
According
to
the
World
Health
Organiza)on,
nearly
4
million
people
die
prematurely
from
non-­‐communicable
diseases
including
stroke,
ischemic
heart
disease,
chronic
obstruc)ve
pulmonary
disease
and
lung
cancer
agributable
to
household
air
pollu)on.
The
vast
majority
of
these
deaths
occur
in
the
developing
world,
where
it’s
es)mated
that
three
billion
people
con)nue
to
rely
on
solid
biomass
fuels
for
cooking
(Global
Alliance
for
Clean
Cookstoves,
2010).
Those
most
at
risk
for
the
health
consequences
associated
with
solid
fuel
use
are
women
and
children,
who
are
frequently
exposed
to
the
resul)ng
household
air
pollu)on
while
cooking
occurs.
Solid
fuel
use
for
cooking
contributes
significantly
to
household
air
pollu)on,
which
has
become
the
leading
cause
of
environmental
death
in
the
world
(Gordon
et
al,
2014).
Inclusion Criteria for Review
1. English
language
only.
2. Popula)on
under
study
was
women
and/or
children
from
developing
or
underdeveloped
regions.
3. Full-­‐length
peer-­‐reviewed
papers
of
cohort,
case-­‐control,
or
cross
sec)onal
studies
4. Quan)ta)ve
effect
es)mates
of
the
associa)ons
between
solid
fuel
use
during
cooking
and
respiratory
health.
5. Adequate
sample
size
(100+)
6. Standardized
ques)onnaires
or
well
reported
ques)ons
to
measure
respiratory
symptoms
7. PubMed
MESH
Terms:
“Respiratory
Tract
Diseases
AND
Cooking
AND
Air
Pollu)on,
Indoor”
155
papers
selected
for
abstract
review
for
rela)on
to
indoor
air
pollu)on
and
respiratory
health
outcomes
in
developing
countries
434
papers
iden)fied
from
PubMed
database
using
MESH
terms
279
papers
excluded
for
being
published
prior
to
2009.
35
papers
selected
for
whole
ar)cle
review
(3
LC,
4
COPD,
4
TB,
11
RS,
1
Asthma,
8
ALRI,
2
PN,
3
LF,
1
CB,
1
Mortality)
120
papers
excluded
because
did
not
meet
the
inclusion
criteria
(Exposure
not
relevant
to
solid
fuel
use
during
cooking
and/or
did
not
measure
respiratory
health
outcomes
and/or
in
a
developing
region).
25
papers
selected
for
inclusion
in
review
(3
LC,
4
COPD,
2
TB,
5
RS,
7
ALRI,
1
PN,
3
LF,
1
CB,
1
MT)
10
papers
further
excluded
for
not
mee)ng
inclusion
criteria
(women
and
children
studied,
etc.)
or
because
of
inability
to
access.
12. Lakshmi
PV,
Virdi
NK,
Thakur
JS,
Smith
KR,
Bates
MN,
Kumar
R.
Biomass
fuel
and
risk
of
tuberculosis:
a
case-­‐control
study
from
Northern
India.
J
Epidemiol
Community
Health.
2012;66(5):457-­‐61.
13. Lee
A,
Adobamen
PR,
Agboghoroma
O,
et
al.
Household
air
pollu)on:
a
call
to
ac)on.
Lancet
Respir
Med.
2015;3(1):e1-­‐2.
14. Lewis
JJ,
Paganayak
SK.
Who
adopts
improved
fuels
and
cookstoves?
A
systema)c
review.
Environ
Health
Perspect.
2012;120(5):637-­‐45.
15. Murray
EL,
Brondi
L,
Kleinbaum
D,
et
al.
Cooking
fuel
type,
household
ven)la)on,
and
the
risk
of
acute
lower
respiratory
illness
in
urban
Bangladeshi
children:
a
longitudinal
study.
Indoor
Air.
2012;22(2):132-­‐9.
16. Nandasena
S,
Wickremasinghe
AR,
Sathiakumar
N.
Respiratory
health
status
of
children
from
two
different
air
pollu)on
exposure
sesngs
of
Sri
Lanka:
a
cross-­‐sec)onal
study.
Am
J
Ind
Med.
2012;55(12):1137-­‐45.
17. Rehfuess
EA,
Tzala
L,
Best
N,
Briggs
DJ,
Joffe
M.
Solid
fuel
use
and
cooking
prac)ces
as
a
major
risk
factor
for
ALRI
mortality
among
African
children.
J
Epidemiol
Community
Health.
2009;63(11):887-­‐92.
18. Romieu
I,
Riojas-­‐rodríguez
H,
Marrón-­‐mares
AT,
Schilmann
A,
Perez-­‐padilla
R,
Masera
O.
Improved
biomass
stove
interven)on
in
rural
Mexico:
impact
on
the
respiratory
health
of
women.
Am
J
Respir
Crit
Care
Med.
2009;180(7):649-­‐56.
19. Smith
KR,
Mccracken
JP,
Weber
MW,
et
al.
Effect
of
reduc)on
in
household
air
pollu)on
on
childhood
pneumonia
in
Guatemala
(RESPIRE):
a
randomised
controlled
trial.
Lancet.
2011;378(9804):1717-­‐26.
20. Smith-­‐sivertsen
T,
Díaz
E,
Pope
D,
et
al.
Effect
of
reducing
indoor
air
pollu)on
on
women's
respiratory
symptoms
and
lung
func)on:
the
RESPIRE
Randomized
Trial,
Guatemala.
Am
J
Epidemiol.
2009;170(2):211-­‐20.
21. Taylor
ET,
Nakai
S.
Prevalence
of
acute
respiratory
infec)ons
in
women
and
children
in
Western
Sierra
Leone
due
to
smoke
from
wood
and
charcoal
stoves.
Int
J
Environ
Res
Public
Health.
2012;9(6):2252-­‐65
22. Zhou
Y,
Zou
Y,
Li
X,
et
al.
Lung
func)on
and
incidence
of
chronic
obstruc)ve
pulmonary
disease
awer
improved
cooking
fuels
and
kitchen
ven)la)on:
a
9-­‐year
prospec)ve
cohort
study.
PLoS
Med.
2014;11(3):e1001621.
Efforts
have
been
increasingly
made
to
address
solid
fuel
and
cook
stove
use
in
the
developing
world
with
improved
cook
stoves
interven)ons
and
campaigns,
but
the
results
have
largely
scagered
and
qualita)ve
(Lewis,
2012).
For
example,
personal
assessments
of
exposure
to
par)culate
mager,
which
is
emiged
while
solid
fuels
are
burned,
requires
expensive
equipment
and
substan)al
laboratory
support
(Lee,
2015).
This
has
been
par)cularly
difficult
to
achieve
in
the
resource-­‐limited
sesngs
where
most
solid
fuel
use
occurs.
However,
this
informa)on
is
vital
in
assessing
individual
exposure
and
dose-­‐response
rela)onships
between
health
outcomes
and
exposure
to
cooking-­‐related
household
air
pollu)on.
Kenyan
woman
cooking
with
tradi)onal
3-­‐
stone
stove
indoors.
Source:
CDC
COPD
(OR)
ZHOU
ET
AL.
RESPIRATORY
SYMPTOMS
(OR)
WHEEZE
(RR)
SMITH-­‐SIVERSTEN
ET
AL.
PNEUMONIA
(RR)
SMITH
ET
AL.
WHEEZE
(RR)
COUGH
(RR)
ROMIEU
ET
AL.
SEVERE
PNEUMONIA
(RR)
PNEUMONIA
(RR)
COUGH
(RR)
FOOTE
ET
AL.
INTERVENTION
STUDIES
0.28
[0.11,
0.73]
0.70
[0.50,
0.97]
0.42
[0.25,
0.70]
0.82
[0.70,
0.98]
0.29
[0.11,
0.77]
0.77
[0.62,
0.95]
0.39
[0.37,
0.42]
0.66
[0.24,
1.48]
0.48
[0.22,
1.03]
ASSOCIATION
(RR
OR
OR)
[95%
CI]
0.00
0.20
0.40
0.60
0.80
1.00
1.20
1.40
1.60
ASSOCIATION
(OR
OR
RR)
[95%
CI]
OLUFEMI
ET
AL.
(OR)
FERRAZ
DA
SILVA
ET
AL.
(OR)
NANDASENA
ET
AL.
(OR)
ALIM
ET
AL.
(OR)
RESPIRATORY
SYPMTOMS
KIM
ET
AL.
(HR)
LUNG
CANCER
LAKSHMI
ET
AL.
(OR)
PULMONARY
TUBERCULOSIS
JOHNSON
ET
AL.
(OR)
COPD
BAUTISTA
ET
AL.
(OR)
MURRAY
ET
AL.
(OR)
TAYLOR
ET
AL.
(WOMEN
OR)
TAYLOR
ET
AL.
(CHILDREN
OR)
JANJUA
ET
AL.
(RR)
REHFUESS
ET
AL.
(MORTALITY
HR)
BATES
ET
AL.
(OR)
ALRI
STUDIES
2.22
[0.60,
8.20]
2.93
[1.68,
5.10]
1.57
[1.01,
2.46]
3.23
[1.30,
8.01]
1.49
[1.15,
1.95]
3.14
[1.14,
8.30]
1.24
[0.36,
6.64]
1.56
[1.23,
1.97]
1.05
[0.87,
1.27]
1.14
[0.71,
1.82]
2.03
[1.31,
3.13]
2.60
[1.50,
4.50]
2.68
[1.38,
5.23]
1.93
[1.24,
2.98]
ASSOCIATION
(OR
OR
HR)
[95%
CI]
0.00
1.00
2.00
3.00
4.00
5.00
6.00
7.00
8.00
9.00
ASSOCIATION
(OR
OR
HR)
[95%
CI]
Chart
2:
Forest
plot
of
associa4ons
between
solid
biomass
fuel
use
during
cooking
and
health
outcomes.
The
majority
of
studies
(10
of
14
shown
here)
were
able
to
conclude
a
significant
associa)on
between
the
health
outcome
of
interest
and
biomass
fuel
use.
Consistently,
ALRI
and
respiratory
symptoms
have
been
shown
to
be
associated
with
solid
fuel
use
while
cooking
in
many
studies.
However,
not
many
students
were
included
in
this
review
to
determine
the
effect
of
solid
fuels
on
COPD,
TB,
or
lung
cancer.