The state of indoor air quality in Pakistan--a review

Assessing the health consequences of indoor air pollution from biomass fuel combustion on pediatric populations in rural communities of Pakistan

Indoor air pollution arising from burning of biomass fuels poses a significant threat to child health in rural areas of Pakistan. This cross-sectional study aimed to assess health implications associated with indoor air pollution resulting from biomass burning among children under 12 years of age in rural Punjab. A questionnaire-based survey was conducted in six randomly selected rural districts of Punjab, characterized by their primary reliance on biomass fuels. The findings revealed that several characteristics, such as monthly household income, number of living rooms, secondary use of solid fuels, kitchen type, type of cooking stove, and presence of child in the kitchen with their mother, exhibited significant associations (p < 0.05) with negative health impacts among children. Reported health effects among the children included coughing (18.7%), watery eyes (17.7%), eye irritation (12.3%), runny nose (11.8%), breathing difficulties (8.5%), phlegm (38%), headache (25%), nausea (20.1%), dizziness (6.7%), asthma (6.4%), tuberculosis (1.8%), and pneumonia (1.5%).

Household energy stacking and structures in Pakistan - Results from a multiple-energy study in Azad Kashmir and Punjab

Solid fuel use (SFU) is common in most developing countries and would release many hazardous air pollutants posing high risks on human health. The Global Burden of Disease (GBD) study highlighted risks associated with household SFU in Pakistan, however, high uncertainties prevail because of scanty data on SFU and unaccounted energy stacking. This study conducted a field campaign aiming at collecting first-hand data on household energy mix in Pakistan. The first survey was in Punjab and Azad Kashmir, and revealed that stacked energy use was pervasive, especially for cooking. The stacking was found to be much more obvious in SFU households (defined as those using SFU dominantly) compared to those non-SFU. There were significantly substantial differences between Azad Kashmir and Punjab because of distinct resources available and economic conditions. Woody materials comprised up to nearly 70% in Azad Kashmir, but in Punjab, gas was frequently used for cooking. Only investigating primary household energy would probably overestimate main energy types that being used for a longer time but underestimated other supplements, suggesting the preference of multiple-energy surveys in household energy studies.

Access to sustainable healthcare infrastructure: a review of industrial emissions, coal fires, and particulate matter

Environmental health is critical for the economy's social welfare and environmental sustainability. Using time series data from 1975 to 2020, the research examines the short- and long-run relationship between environmental pollutants and healthcare costs in the context of Pakistan. The study's results reveal that short-term and long-term efforts towards cleaner development in terms of carbon emissions, coal combustion, nitrous oxide (N₂O) emissions, and industrial value-added have resulted in significant reductions in healthcare expenses due to improved management of industrial emissions. However, in the long run, particulate matter (PM_2.5) has a detrimental effect on a country's sustainable healthcare agenda, leading to increased healthcare costs. Furthermore, the increased use of coal-fired power plants that release polycyclic aromatic hydrocarbons (PAH) and revenue generated by contaminated production lead to higher out-of-pocket healthcare costs, increasing a country's risk of morbidity and mortality. The study's Granger causality estimations demonstrate that carbon emissions are responsible for emissions-driven healthcare expenses in a nation. Additionally, economic growth leads to increased carbon emissions and industrial toxins, which are also emission-led. Through variance decomposition analysis (VDA), the study finds that carbon emissions have the highest variance shock of 32.702% on healthcare expenditures in the next ten years. This is followed by polluted income and continued economic growth, which have a variance shock of 13.243% and 8.858%, respectively, over the same period. The findings indicate that the maximum healthcare benefits may be acquired by mitigating environmental pollutants via stringent environmental regulations, reducing industrial toxins through solid waste management techniques, and minimizing coal combustion reliance through renewable fuels. Environmental research is still required to provide more sustainable solutions to the sustainability of the global healthcare agenda.

The Evaluation of Clinical Signs and Symptoms of Malignant Tumors Involving the Maxillary Sinus: Recommendation of an Examination Sieve and Risk Alarm Score

This observational study was conducted to evaluate the clinical signs and symptoms of maxillary sinus tumors and to propose a clinical examination sieve and a unique risk alarm score to be used for timely patient referral and vigilance. The study consisted of 70 patients between 20 to 82 years of age from both sexes. The clinical information gained was collected from the upper dentoalveolar segment, orbit, and nasal sites. Regarding the early clinical sign and symptoms of patients, nasal obstruction was found in 67 patients (95.7%), facial swelling in 69 patients (98.6%), paresthesia in 41 patients (58.6%), and epistaxis in 50 patients (71.4%). Furthermore, in terms of the late signs and symptoms, a palpable mass in buccal sulcus was observed in 65 (92.9%) of the patients, lymphadenopathy in 24 (34.3%), paresthesia in 38 (54.3%), and diplopia in 22 (31.4%). Furthermore, general sign and symptoms like exophthalmos was present in 35 patients (50%), anosmia was observed in 37 patients (52.9%), and oroantral fistula was noted in 37 patients (55.9%). Additionally, 67 (95.7%) of the patients complained of nasal obstruction. Similarly, facial asymmetry was observed in 69 (98.6%) of the patients and double vision was observed in 24 (34.4%). Tumors of the maxillary sinus have a very insidious course of spread and uncertain clinical signs and symptoms. What makes diagnosis worse is the fact that the symptoms of these tumors are so well hidden in the sponge-like nature of the midfacial region that they are easily misinterpreted by patients. Therefore, diagnoses must be made early, dentists must be vigilant, and patients must be fully investigated at the slightest suspicion of a tumor, albeit benign.

Does improving indoor air quality lessen symptoms associated with chemical intolerance?

Aim:

To determine whether environmental house calls that improved indoor air quality (IAQ) is effective in reducing symptoms of chemical intolerance (CI).

Background:

Prevalence of CI is increasing worldwide. Those affected typically report symptoms such as headaches, fatigue, ‘brain fog’, and gastrointestinal problems – common primary care complaints. Substantial evidence suggests that improving IAQ may be helpful in reducing symptoms associated with CI.

Methods:

Primary care clinic patients were invited to participate in a series of structured environmental house calls (EHCs). To qualify, participants were assessed for CI with the Quick Environmental Exposure and Sensitivity Inventory. Those with CI volunteered to allow the EHC team to visit their homes to collect air samples for volatile organic compounds (VOCs). Initial and post-intervention IAQ sampling was analyzed by an independent lab to determine VOC levels (ng/L). The team discussed indoor air exposures, their health effects, and provided guidance for reducing exposures.

Findings:

Homes where recommendations were followed showed the greatest improvements in IAQ. The improvements were based upon decreased airborne VOCs associated with reduced use of cleaning chemicals, personal care products, and fragrances, and reduction in the index patients’ symptoms. Symptom improvement generally was not reported among those whose homes showed no VOC improvement.

Conclusion:

Improvements in both IAQ and patients’ symptoms occur when families implement an action plan developed and shared with them by a trained EHC team. Indoor air problems simply are not part of most doctors’ differential diagnoses, despite relatively high prevalence rates of CI in primary care clinics. Our three-question screening questionnaire – the BREESI – can help physicians identify which patients should complete the QEESI. After identifying patients with CI, the practitioner can help by counseling them regarding their home exposures to VOCs. The future of clinical medicine could include environmental house calls as standard of practice for susceptible patients.

Housing quality and its impact on Acute Respiratory Infection (ARI) symptoms among children in Punjab, Pakistan

Exposure to poor housing quality and household air pollution (HAP) are significant factors for morbidity and mortality in Pakistan. Children under five are particularly at risk of acute respiratory infections (ARIs). Globally, it has been estimated that 6.6 million children less than five years of age die every year from this disease. Little is known regarding the effect of HAP and poor housing quality on children's respiratory symptoms in Pakistan. Statistics concerning Pakistan's largest province, Punjab, are also not promising. Hence, an association between housing quality and respiratory symptoms among children under the age of five in Punjab has been studied in this paper. Using data from MICS 2017-18, logistic regression models were applied to the sample of 35000 children under the age of five living in poor housing quality. We estimated that acute respiratory infection (ARI) symptoms are higher among children when the floor of a house is made of natural material. However, the lower ARI symptoms were found among children living in a house with a wall made of natural material. On the other hand, we found that children residing in the western region of Punjab are at a higher risk of ARI symptoms. The findings remain consistent with the previous researchers. In addition to promoting increased access to quality housing material during construction activities, we suggest that critical community-based interventions are required to combat local issues and problems at the micro-level.

Interventions to mitigate indoor air pollution: A cost-benefit analysis

Globally, around three billion people depend upon solid fuels such as firewood, dry animal dung, crop residues, or coal, and use traditional stoves for cooking and heating purposes. This solid fuel combustion causes indoor air pollution (IAP) and severely impairs health and the environment, especially in developing countries like Pakistan. A number of alternative household energy strategies can be adopted to mitigate IAP, such as using liquefied petroleum gas (LPG), natural gas, biogas, electric stoves, or improved cook stoves (ICS). In this study, we estimate the benefit-cost ratios and net present value of these interventions over a ten-year period in Pakistan. Annual costs include both fixed and operating costs, whereas benefits cover health, productivity gains, time savings, and fuel savings. We find that LPG has the highest benefit-cost ratio, followed by natural gas, while ICS has the lowest benefit-cost ratio. Electric stoves and biogas have moderate benefit-cost ratios that nevertheless exceed one. To maximize the return on cleaner burning technology, the government of Pakistan should consider encouraging the adoption of LPG, piped natural gas, and electric stoves as means to reduce IAP and adopt clean technologies.

An Emerged Challenge of Air Pollution and Ever-Increasing Particulate Matter in Pakistan; A Critical Review

This study, for the first time, aims to evaluate the situation of air quality in Pakistan critically; through a detailed assessment of sources, policies, and key challenges to identify the plausible way forward. Air pollution and particulate matter have merged as a global challenge in recent years because of its growing health and socio-economic risks. The intensity and impacts of these risks have become more pronounced, especially in developing countries like Pakistan that lack adequate warning, protection, and management systems. Various epidemiological studies have linked poor air quality with different health disorders and increasing death rates. In Pakistan, mortality rates as a result of exposure to increased levels of air pollutants, especially particulate matter, are alarming. According to the World Bank's estimates, Pakistan's annual burden of disease from outdoor air pollution is responsible for around 22,000 premature adult deaths and 163,432 DALYs (disability-adjusted life years) lost. The concentration of major air pollutants in Pakistan, such as NOx, O_3, and SO₂ have also been increasing significantly over the last two decades. Several studies are also reporting multiple instances of air quality around the major cities of Pakistan being consistently exceeding the national guidelines. During teh year 2019 PM_2.5 cocnentrations in the city of Lahore revealed that almost every single day was in exceedance of the WHO and national air quality standards. Although the substantial effects of these rising pollutant concentrations in Pakistan have been stated in a few studies, however, the total extent, nature of contributing factors, and consequences remain inadequately understood. This study aims to use data available from monitoring stations, satellites, and literature to highlight the gaps in our understanding and emphasize the critical challenges associated with poor air quality faced in Pakistan. Topmost is the lack of air quality monitoring systems followed by poor initiatives by policymakers and enforcement agencies. A way forward while addressing these key challenges is also discussed, which focuses on the development of flexible monitoring, new technologies, and monitoring approaches in addition to communications among the various public, private agencies, and all relevant stakeholders.

Assessing the prevalence trend of childhood pneumonia associated with indoor air pollution in Pakistan

The indoor air pollution (IAP) is one of the leading risk factors of childhood pneumonia in developing countries. This study makes the first attempt to examine the prevalence trend of pneumonia among under-five children in Pakistan in association with IAP-related factors, using bivariate and multivariate statistical methods. Three waves of Pakistan Demographic Health Survey for 2006-2007, 2012-2013, and 2017-2018 were used. Our study findings showed a steady decline in the prevalence of pneumonia synchronized with the decreased use of polluting fuel during the last decade (2006-2017). In bivariate regression, odd ratios of childhood pneumonia were 1.27 and 1.21 times higher in overcrowded houses in 2006-2007 and 2012-2013, respectively, and 1.25 times higher in families relying on biomass for cooking in 2017-2018. In the multivariate model, polluting fuel and overcrowded homes had higher adjusted odd ratios of pneumonia in all survey years, and children age 37-48 months, older mothers, and large birth sized children had lower AOR of pneumonia in 2006-2007 and 2012-2013. Countrywide promotion of IAP mitigation measures such as sponsoring cleaner fuels, separate place for cooking, and lessening home overcrowding may play a vital role in alleviating the prevalence of childhood pneumonia.

Promoting sustainability of use of biomass as energy resource: Pakistan's perspective

Biomass is primary source of energy for household in rural communities. Developing countries are focusing on increasing utilization of indigenous energy resources for energy security and to achieve sustainable development goal. Combustion of solid biomass is the primary approach for utilizing biomass to generate electricity and heat. Sixty-eight percent of population of Pakistan is living in rural areas while 30% population is still without electricity. The traditional household appliances used for cooking and heating are less efficient, more hazardous to users, and more damaging to the environment. Low carbon energy system prerequisites access to modern energy services. This paper presents an assessment of biomass resources potential in Pakistan as renewable energy resources and reviews potentials to adopt efficient use of biomass for cooking, heating, and small decentralized electricity generation. Objective of this study is to increase the sustainability of the use of biomass as source of energy in developing countries like Pakistan by an integrating energy-efficient and modern appliances and technologies that fit into a sustainable development path. Promotion of cleaner technologies and efficient use of biomass energy constitute appropriate strategies to mitigate global climate, health risks, and help in attending the targets set by sustainable development goal (SDG) to confirm worldwide access to reliable, affordable, and modern energy services by 2030.

Air Pollution in a Nationally Representative Sample: Findings from the National Adult Tobacco Survey of Lao PDR

In Southeast Asia, household air pollution (HAP) from solid fuel use is the leading cause of disability-adjusted life years (DALYs), a risk which is compounded by exposure to other sources of indoor and outdoor air pollution including secondhand tobacco smoke (SHS). The purpose of this study was to measure the individual and combined prevalence of exposure to household and community sources of air pollution in a national sample of adults in Lao PDR. We analyzed data from the 2012 National Adult Tobacco Survey (NATSL) of Lao PDR-a multi-stage stratified cluster sample of 9706 subjects from 2822 households located in all 17 provinces. Our findings indicate a high prevalence of exposure to household air pollution from cooking fires (78%) and SHS exposure in the home (74.5%). More than a third (32.8%) reported exposure to both inside the home. Exposure to outdoor sources of smoke from cooking, trash, and crop fires was substantial (30.1% to 56.0%). The aggregation of exposures from multiple sources of household air pollution raises the need for initiatives that establish programmatic linkages in the health, environmental, and agricultural sectors to provide a comprehensive strategy to reduce risk factors for respiratory disease in Lao PDR and the region.

Rural household preferences for cleaner energy sources in Pakistan

Dependence of rural population on traditional fuel sources namely biomass has increased because of easy accessibility and affordability. The use of biomass fuels results in many environmental and health-related hazards. Rural households have little awareness about the ill effects of using biomass energy sources. This study investigated the patterns of rural household energy use and identified the role of information on the effects of biomasses on human health, in addition to other factors influencing households' choices of energy sources. For this purpose, primary data from 196 households were collected from four districts of the Punjab province in Pakistan. Results showed that use of clean energy sources was limited to basic appliances and 90% of the respondents depended on biomass fuels. Estimates of the multivariate probit model showed that awareness about adverse impacts of biomass fuels as energy sources were significantly related with the choice of energy sources. Further, household head's education level, household income, landholding, children under the age of 5 years and higher number of adult females were significantly related with the cleaner energy source choices. Distance to market increased the probability of the use of biomass energy sources. The study concluded that awareness campaigns regarding the benefits of using clean energy sources should be launched through print and electronic media while targeting rural women.

Optical microscopic study of surface morphology and filtering efficiency of face masks

Background

Low-cost face masks made from different cloth materials are very common in developing countries. The cloth masks (CM) are usually double layered with stretchable ear loops. It is common practice to use such masks for months after multiple washing and drying cycles. If a CM is used for long time, the ear loops become stretched. The loop needs to be knotted to make the mask loop fit better on the face. It is not clear how washing and drying and stretching practices change the quality of a CM. The particulate matter (PM) filtering efficiency of a mask depends on multiple parameters, such as pore size, shape, clearance, and pore number density. It is important to understand the effect of these parameters on the filtering efficiency.

Methods

We characterized the surface of twenty different types of CMs using optical image analysis method. The filtering efficiency of selected cloth face masks was measured using the particle counting method. We also studied the effects of washing and drying and stretching on the quality of a mask.

Results

The pore size of masks ranged from 80 to 500 μm, which was much bigger than particular matter having diameter of 2.5 μm or less (PM_2.5) and 10 μm or less (PM₁₀) size. The PM₁₀ filtering efficiency of four of the selected masks ranged from 63% to 84%. The poor filtering efficiency may have arisen from larger and open pores present in the masks. Interestingly, we found that efficiency dropped by 20% after the 4th washing and drying cycle. We observed a change in pore size and shape and a decrease in microfibers within the pores after washing. Stretching of CM surface also altered the pore size and potentially decreased the filtering efficiency. As compared to CMs, the less frequently used surgical/paper masks had complicated networks of fibers and much smaller pores in multiple layers in comparison to CMs, and therefore had better filtering efficiency. This study showed that the filtering efficiency of cloth face masks were relatively lower, and washing and drying practices deteriorated the efficiency. We believe that the findings of this study will be very helpful for increasing public awareness and help governmental agencies to make proper guidelines and policies for use of face mask.

Health Effects of Ambient Air Pollution in Developing Countries

The deleterious effects of ambient air pollution on human health have been consistently documented by many epidemiologic studies worldwide, and it has been calculated that globally at least seven million deaths are annually attributable to the effects of air pollution. The major air pollutants emitted into the atmosphere by a number of natural processes and human activities include nitrogen oxides, volatile organic compounds, and particulate matter. In addition to the poor ambient air quality, there is increasing evidence that indoor air pollution also poses a serious threat to human health, especially in low-income countries that still use biomass fuels as an energy resource. This review summarizes the current knowledge on ambient air pollution in financially deprived populations.

Analysis of baseline and alternative air quality scenarios for Pakistan: an integrated approach

This study aims to assess the current and future air pollution and associated health impacts in Pakistan. In this study, the Pakistan Integrated Energy Model (Pak-IEM) is used to assess current and future energy consumption in Pakistan. To assess air pollution levels and associated health impacts, we used the Greenhouse gas and Air pollution INteractions and Synergies (GAINS) model. A linkage has been established between both the models to feed the energy outputs from Pak-IEM into GAINS for exploring different scenarios. Mainly, the emissions of three air pollutants (SO₂, NO_x, and PM_2.5) as well as the associated health impacts of increased emissions are assessed. Baseline emission scenario (BES) shows a growth in emissions of SO₂, NO_x, and PM_2.5 by a factor of 2.4, 2.2, and 2.5 between 2007 and 2030. In terms of health impacts, by 2030, annual mean concentrations of fine particles (PM_2.5) would increase to more than 150 μg/m³ in some parts of Punjab region of Pakistan, for which loss in statistical life expectancy is calculated to increase from 30 to 60 months in 2007 up to 60-100 months in 2030 on average.

Occupational and environmental exposures and cancers in developing countries

BACKGROUND

Over the past few decades, there has been a decline in cancers attributable to environmental and occupational carcinogens of asbestos, arsenic, and indoor and outdoor air pollution in high-income countries. For low- to middle-income countries (LMICs), however, these exposures are likely to increase as industrialization expands and populations grow.

OBJECTIVE

The aim of this study was to review the evidence on the cancer risks and burdens of selected environmental and occupational exposures in less-developed economies.

FINDINGS

A causal association has been established between asbestos exposure and mesothelioma and lung cancer. For arsenic exposure, there is strong evidence of bladder, skin, lung, liver, and kidney cancer effects. Women are at the highest risk for lung cancer due to indoor air pollution exposure; however, the carcinogenic effect on the risk for cancer in children has not been studied in these countries. Cancer risks associated with ambient air pollution remain the least studied in LMICs, although reported exposures are higher than World Health Organization, European, and US standards. Although some associations between lung cancer and ambient air pollutants have been reported, studies in LMICs are weak or subject to exposure misclassification. For pulmonary cancers, tobacco smoking and respiratory diseases have a positive synergistic effect on cancer risks.

CONCLUSIONS

A precise quantification of the burden of human cancer attributable to environmental and occupational exposures in LMICs is uncertain. Although the prevalence of carcinogenic exposures has been reported to be high in many such countries, the effects of the exposures have not been studied due to varying country-specific limitations, some of which include lack of resources and government support.

A systematic review of air pollution as a risk factor for cardiovascular disease in South Asia: limited evidence from India and Pakistan

Cardiovascular diseases (CVD) are major contributors to mortality and morbidity in South Asia. Chronic exposure to air pollution is an important risk factor for cardiovascular diseases, although the majority of studies to date have been conducted in developed countries. Both indoor and outdoor air pollution are growing problems in developing countries in South Asia yet the impact on rising rates of CVD in these regions has largely been ignored. We aimed to assess the evidence available regarding air pollution effects on CVD and CVD risk factors in lower income countries in South Asia. A literature search was conducted in PubMed and Web of Science. Our inclusion criteria included peer-reviewed, original, empirical articles published in English between the years 1990 and 2012, conducted in the World Bank South Asia region (Afghanistan, Bangladesh, Bhutan, India, Maldives, Nepal, Pakistan and Sri Lanka). This resulted in 30 articles. Nine articles met our inclusion criteria and were assessed for this systematic review. Most of the studies were cross-sectional and examined measured particulate matter effects on CVD outcomes and indicators. We observed a bias as nearly all of the studies were from India. Hypertension and CVD deaths were positively associated with higher particulate matter levels. Biomarkers of oxidative stress such as increased levels of P-selection expressing platelets, depleted superoxide dismutase and reactive oxygen species generation as well as elevated levels of inflammatory-related C-reactive protein, interleukin-6 and interleukin-8 were also positively associated with biomass use or elevated particulate matter levels. An important outcome of this investigation was the evidence suggesting important air pollution effects regarding CVD risk in South Asia. However, too few studies have been conducted. There is as an urgent need for longer term investigations using robust measures of air pollution with different population groups that include a wider range of air pollutants and outcomes, including early indicators of CVD. These regions are facing burdens from increasing urbanization, air pollution and populations, generally weaker health infrastructure, aging populations and increased incidence of non-communicable diseases, included CVD. The extent to which the problem of air pollution and CVD will impact these countries will depend largely on the information available to inform policy and programs, which are still lacking, political will as well as social and economic development.

Instrumental neutron activation analysis for the study of size-fractionated airborne particulate matter samples

In order to devise methodology to study various environmental matrices 28 pairs of coarse and fine air particulate samples were collected in the vicinity of an automotive workshop located at Tasmasipabad on Chaklala Road, Rawalpindi. The samples were collected using a Gent sampler and polycarbonate filters during the period 7 to 27 April 2009. These samples were analyzed using instrumental neutron activation analysis (INAA) using the low power Pakistan Atomic Research Reactor-2 (PARR-2). Reference materials (RMs) IAEA-SL1 and IAEA-S7 were used for calibration and quality assurance (QA) purpose. The gravimetric data for these samples were found to exceed the PM2.5 and PM10 national limits. Up to 34 elements were measured using the INAA optimized procedure.

Nitrogen dioxide and household fuel use in the Pakistan

More than half the world's population use biomass fuels as a household energy source and, hence, face significant exposure to a number of air pollutants. In Pakistan about 90% of rural households and 22% of urban households use biomass fuels. In order to assess the levels of NO(2) in the residential micro-environment, two sampling campaigns were carried out at different times of the year (summer and winter) at an urban and two rural sites during 2005 and 2007. Rural site I used biomass fuels while natural gas was utilized at rural site II and the urban site. In winter NO(2) concentrations at all three sites were higher in the kitchens than living rooms and outdoors. ANOVA showed that, although, there was a significant difference among NO(2) concentrations in the kitchens, living rooms and courtyards, at all the three sites, there was no significant different between kitchens using biomass fuels and natural gas. During the summer NO(2) levels fell sharply at both rural sites (from 256 μg/m(3) and 242 μg/m(3) to 51 μg/m(3) and 81 μg/m(3)). However at the urban site the mean levels were slightly higher in summer (234 μg/m(3)) than in winter (218 μg/m(3)). The considerable seasonal variation at the rural sites was due to a shift of indoor kitchens to open outdoor kitchens at rural site I and more ventilation at rural site II during summer. There was no significant difference between kitchens using biomass (site I) or natural gas (site II), however the kitchens at rural site II and urban site showed a significant difference. Overall fuel selection showed no significant effect on NO(2) levels. However the NO(2) concentrations may pose a significant threat to the health of people, especially women and children.