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Sultan M, Zewdie A, Priyadarshani D, Hassen E, Tilahun M, Geremew T, Beane A, Haniffa R, Berenholtz SM, Checkley W, Hansoti B, Laytin AD. Implementing an ICU registry in Ethiopia-Implications for critical care quality improvement. J Crit Care 2024; 81:154525. [PMID: 38237203 PMCID: PMC10996997 DOI: 10.1016/j.jcrc.2024.154525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 01/02/2024] [Accepted: 01/04/2024] [Indexed: 03/14/2024]
Abstract
PURPOSE Intensive care units (ICUs) in low- and middle-income countries have high mortality rates, and clinical data are needed to guide quality improvement (QI) efforts. This study utilizes data from a validated ICU registry specially developed for resource-limited settings to identify evidence-based QI priorities for ICUs in Ethiopia. MATERIALS AND METHODS A retrospective cohort analysis of data from two tertiary referral hospital ICUs in Addis Ababa, Ethiopia from July 2021-June 2022 was conducted to describe casemix, complications and outcomes and identify features associated with ICU mortality. RESULTS Among 496 patients, ICU mortality was 35.3%. The most common reasons for ICU admission were respiratory failure (24.0%), major head injury (17.5%) and sepsis/septic shock (13.3%). Complications occurred in 41.0% of patients. ICU mortality was higher among patients with respiratory failure (46.2%), sepsis (66.7%) and vasopressor requirements (70.5%), those admitted from the hospital ward (64.7%), and those experiencing major complications in the ICU (62.3%). CONCLUSIONS In this study, ICU mortality was high, and complications were common and associated with increased mortality. ICU registries are invaluable tools to understand local casemix and clinical outcomes, especially in resource-limited settings. These findings provide a foundation for QI efforts and a baseline to evaluate their impact.
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Affiliation(s)
- Menbeu Sultan
- St. Paul's Hospital Millennium Medical Center, Addis Ababa, Ethiopia
| | - Ayalew Zewdie
- St. Paul's Hospital Millennium Medical Center, Addis Ababa, Ethiopia; Addis Ababa Burn, Emergency and Trauma Hospital, Addis Ababa, Ethiopia
| | | | - Ephrem Hassen
- St. Paul's Hospital Millennium Medical Center, Addis Ababa, Ethiopia
| | - Melkamu Tilahun
- St. Paul's Hospital Millennium Medical Center, Addis Ababa, Ethiopia
| | - Tigist Geremew
- Addis Ababa Burn, Emergency and Trauma Hospital, Addis Ababa, Ethiopia
| | - Abi Beane
- Centre for Inflammation Research, University of Edinburgh, Scotland, UK.
| | - Rashan Haniffa
- Centre for Inflammation Research, University of Edinburgh, Scotland, UK.
| | - Sean M Berenholtz
- Johns Hopkins University School of Medicine, Department of Anesthesia and Critical Care Medicine, Baltimore, MD, USA.
| | - William Checkley
- Johns Hopkins University School of Medicine, Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, Baltimore, MD, USA.
| | - Bhakti Hansoti
- Johns Hopkins University School of Medicine, Department of Emergency Medicine, Baltimore, MD, USA.
| | - Adam D Laytin
- Johns Hopkins University School of Medicine, Department of Anesthesia and Critical Care Medicine, Baltimore, MD, USA; Johns Hopkins University School of Medicine, Department of Emergency Medicine, Baltimore, MD, USA.
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Checkley W, Thompson LM, Hossen S, Nicolaou L, Williams KN, Hartinger SM, Chiang M, Balakrishnan K, Garg SS, Thangavel G, Aravindalochanan V, Rosa G, Mukeshimana A, Ndagijimana F, McCracken JP, Diaz-Artiga A, Sinharoy SS, Waller L, Wang J, Jabbarzadeh S, Chen Y, Steenland K, Kirby MA, Ramakrishnan U, Johnson M, Pillarisetti A, McCollum ED, Craik R, Ohuma EO, Dávila-Román VG, de Las Fuentes L, Simkovich SM, Peel JL, Clasen TF, Papageorghiou AT. Cooking with liquefied petroleum gas or biomass and fetal growth outcomes: a multi-country randomised controlled trial. Lancet Glob Health 2024; 12:e815-e825. [PMID: 38614630 PMCID: PMC11027158 DOI: 10.1016/s2214-109x(24)00033-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 10/26/2023] [Accepted: 01/12/2024] [Indexed: 04/15/2024]
Abstract
BACKGROUND Household air pollution might lead to fetal growth restriction during pregnancy. We aimed to investigate whether a liquefied petroleum gas (LPG) intervention to reduce personal exposures to household air pollution during pregnancy would alter fetal growth. METHODS The Household Air Pollution Intervention Network (HAPIN) trial was an open-label randomised controlled trial conducted in ten resource-limited settings across Guatemala, India, Peru, and Rwanda. Pregnant women aged 18-34 years (9-19 weeks of gestation) were randomly assigned in a 1:1 ratio to receive an LPG stove, continuous fuel delivery, and behavioural messaging or to continue usual cooking with biomass for 18 months. We conducted ultrasound assessments at baseline, 24-28 weeks of gestation (the first pregnancy visit), and 32-36 weeks of gestation (the second pregnancy visit), to measure fetal size; we monitored 24 h personal exposures to household air pollutants during these visits; and we weighed children at birth. We conducted intention-to-treat analyses to estimate differences in fetal size between the intervention and control group, and exposure-response analyses to identify associations between household air pollutants and fetal size. This trial is registered with ClinicalTrials.gov (NCT02944682). FINDINGS Between May 7, 2018, and Feb 29, 2020, we randomly assigned 3200 pregnant women (1593 to the intervention group and 1607 to the control group). The mean gestational age was 14·5 (SD 3·0) weeks and mean maternal age was 25·6 (4·5) years. We obtained ultrasound assessments in 3147 (98·3%) women at baseline, 3052 (95·4%) women at the first pregnancy visit, and 2962 (92·6%) at the second pregnancy visit, through to Aug 25, 2020. Intervention adherence was high (the median proportion of days with biomass stove use was 0·0%, IQR 0·0-1·6) and pregnant women in the intervention group had lower mean exposures to particulate matter with a diameter less than 2·5 μm (PM2·5; 35·0 [SD 37·2] μg/m3vs 103·3 [97·9] μg/m3) than did women in the control group. We did not find differences in averaged post-randomisation Z scores for head circumference (0·30 vs 0·39; p=0·04), abdominal circumference (0·38 vs 0·39; p=0·99), femur length (0·44 vs 0·45; p=0·73), and estimated fetal weight or birthweight (-0·13 vs -0·12; p=0·70) between the intervention and control groups. Personal exposures to household air pollutants were not associated with fetal size. INTERPRETATION Although an LPG cooking intervention successfully reduced personal exposure to air pollution during pregnancy, it did not affect fetal size. Our findings do not support the use of unvented liquefied petroleum gas stoves as a strategy to increase fetal growth in settings were biomass fuels are used predominantly for cooking. FUNDING US National Institutes of Health and Bill & Melinda Gates Foundation. TRANSLATIONS For the Kinyarwanda, Spanish and Tamil translations of the abstract see Supplementary Materials section.
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Affiliation(s)
- William Checkley
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, MD, USA; Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, MD, USA.
| | - Lisa M Thompson
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA, USA
| | - Shakir Hossen
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, MD, USA; Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Laura Nicolaou
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, MD, USA; Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Kendra N Williams
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, MD, USA; Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Stella M Hartinger
- Latin American Center of Excellence on Climate Change and Health, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Marilu Chiang
- Biomedical Research Unit, Asociación Benéfica PRISMA, Lima, Perú
| | - Kalpana Balakrishnan
- ICMR Center for Advanced Research on Air Quality, Climate and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute for Higher Education and Research, Chennai, India
| | - Sarada S Garg
- ICMR Center for Advanced Research on Air Quality, Climate and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute for Higher Education and Research, Chennai, India
| | - Gurusamy Thangavel
- ICMR Center for Advanced Research on Air Quality, Climate and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute for Higher Education and Research, Chennai, India
| | - Vigneswari Aravindalochanan
- ICMR Center for Advanced Research on Air Quality, Climate and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute for Higher Education and Research, Chennai, India
| | - Ghislaine Rosa
- Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
| | | | | | - John P McCracken
- Epidemiology and Biostatistics Department, University of Georgia, Athens, GA, USA; Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala
| | - Anaité Diaz-Artiga
- Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala
| | - Sheela S Sinharoy
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Lance Waller
- Department of Biostatistics and Bioinformatics, Emory University, Atlanta, GA, USA
| | - Jiantong Wang
- Department of Biostatistics and Bioinformatics, Emory University, Atlanta, GA, USA
| | - Shirin Jabbarzadeh
- Department of Biostatistics and Bioinformatics, Emory University, Atlanta, GA, USA
| | - Yunyun Chen
- Department of Biostatistics and Bioinformatics, Emory University, Atlanta, GA, USA
| | - Kyle Steenland
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Miles A Kirby
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Usha Ramakrishnan
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | | | - Ajay Pillarisetti
- Division of Environmental Health Sciences, University of California at Berkeley, Berkeley, CA, USA
| | - Eric D McCollum
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, MD, USA; Global Program in Pediatric Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences, School of Medicine, Johns Hopkins University, Baltimore, MD, USA; Eudowood Division of Pediatric Respiratory Sciences, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Rachel Craik
- Nuffield Department of Women's & Reproductive Health, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | - Eric O Ohuma
- Centre for Maternal, Adolescent, Reproductive & Child Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Victor G Dávila-Román
- Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St Louis, St Louis, MO, USA
| | - Lisa de Las Fuentes
- Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St Louis, St Louis, MO, USA
| | - Suzanne M Simkovich
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, MD, USA; Division of Healthcare Delivery Research, MedStar Health Research Institute, Hyattsville, MD, USA; Division of Pulmonary and Critical Care Medicine, Georgetown University, Washington, DC, USA
| | - Jennifer L Peel
- Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins, CO, USA
| | - Thomas F Clasen
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Aris T Papageorghiou
- Nuffield Department of Women's & Reproductive Health, University of Oxford, John Radcliffe Hospital, Oxford, UK.
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Lai PS, Lam NL, Gallery B, Lee AG, Adair-Rohani H, Alexander D, Balakrishnan K, Bisaga I, Chafe ZA, Clasen T, Díaz-Artiga A, Grieshop A, Harrison K, Hartinger SM, Jack D, Kaali S, Lydston M, Mortimer KM, Nicolaou L, Obonyo E, Okello G, Olopade C, Pillarisetti A, Pinto AN, Rosenthal JP, Schluger N, Shi X, Thompson C, Thompson LM, Volckens J, Williams KN, Balmes J, Checkley W, Ozoh OB. Household Air Pollution Interventions to Improve Health in Low- and Middle-Income Countries: An Official American Thoracic Society Research Statement. Am J Respir Crit Care Med 2024; 209:909-927. [PMID: 38619436 DOI: 10.1164/rccm.202402-0398st] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/16/2024] Open
Abstract
Background: An estimated 3 billion people, largely in low- and middle-income countries, rely on unclean fuels for cooking, heating, and lighting to meet household energy needs. The resulting exposure to household air pollution (HAP) is a leading cause of pneumonia, chronic lung disease, and other adverse health effects. In the last decade, randomized controlled trials of clean cooking interventions to reduce HAP have been conducted. We aim to provide guidance on how to interpret the findings of these trials and how they should inform policy makers and practitioners.Methods: We assembled a multidisciplinary working group of international researchers, public health practitioners, and policymakers with expertise in household air pollution from within academia, the American Thoracic Society, funders, nongovernmental organizations, and global organizations, including the World Bank and the World Health Organization. We performed a literature search, convened four sessions via web conference, and developed consensus conclusions and recommendations via the Delphi method.Results: The committee reached consensus on 14 conclusions and recommendations. Although some trials using cleaner-burning biomass stoves or cleaner-cooking fuels have reduced HAP exposure, the committee was divided (with 55% saying no and 45% saying yes) on whether the studied interventions improved measured health outcomes.Conclusions: HAP is associated with adverse health effects in observational studies. However, it remains unclear which household energy interventions reduce exposure, improve health, can be scaled, and are sustainable. Researchers should engage with policy makers and practitioners working to scale cleaner energy solutions to understand and address their information needs.
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Flores-Flores O, Zevallos-Morales A, Pollard SL, Checkley W, Siddharthan T, Hurst JR, Bernabé-Ortiz A, Runzer-Colmenares FM, Witham MD, Parodi JF. Sarcopenia and sarcopenic obesity among community-dwelling Peruvian adults: A cross-sectional study. PLoS One 2024; 19:e0300224. [PMID: 38593158 PMCID: PMC11003669 DOI: 10.1371/journal.pone.0300224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2023] [Accepted: 02/25/2024] [Indexed: 04/11/2024] Open
Abstract
INTRODUCTION Sarcopenia and sarcopenic obesity (SO) have emerged as significant contributors to negative health outcomes in the past decade. We aimed to estimate the prevalence of probable sarcopenia, sarcopenia, and SO in a community-dwelling population of 1151 adults aged ≥55 years in Lima, Peru. METHODS This cross-sectional study was conducted between 2018 and 2020. Sarcopenia was defined as the presence of low muscle strength (LMS) and low muscle mass (LMM) according to European (EWGSOP2), US (FNIH) and Asian (AWGS2) guidelines. We measured muscle strength by maximum handgrip strength and muscle mass using bioelectrical impedance analyzer. SO was defined as a body mass index ≥ 30 kg/m2 and sarcopenia. RESULTS The study participants had a mean age of 66.2 years (SD 7.1), age range between 60 to 92 years old, of which 621 (53.9%) were men. Among the sample, 41.7% were classified as obese (BMI ≥30.0 kg/m²). The prevalence of probable sarcopenia was estimated to be 22.7% (95%CI: 20.3-25.1) using the EWGSOP2 criteria and 27.8% (95%CI: 25.2-30.4) using the AWGS2 criteria. Sarcopenia prevalence, assessed using skeletal muscle index (SMI), was 5.7% (95%CI: 4.4-7.1) according to EWGSOP2 and 8.3% (95%CI: 6.7-9.9) using AWGS2 criteria. The prevalence of sarcopenia based on the FNIH criteria was 18.1% (95%CI: 15.8-20.3). The prevalence of SO, considering different sarcopenia definitions, ranged from 0.8% (95%CI: 0.3-1.3) to 5.0% (95%CI: 3.8-6.3). CONCLUSION Our findings reveal substantial variation in the prevalence of sarcopenia and SO, underscoring the necessity for context-specific cut-off values. Although the prevalence of SO was relatively low, this result may be underestimated. Furthermore, the consistently high proportion of probable sarcopenia and sarcopenia point to a substantial public health burden.
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Affiliation(s)
- Oscar Flores-Flores
- Universidad de San Martin de Porres, Facultad de Medicina Humana, Centro de Investigación del Envejecimiento (CIEN), Lima, Peru
- Asociación Benéfica PRISMA, Lima, Peru
| | - Alejandro Zevallos-Morales
- Universidad de San Martin de Porres, Facultad de Medicina Humana, Centro de Investigación del Envejecimiento (CIEN), Lima, Peru
- Asociación Benéfica PRISMA, Lima, Peru
| | - Suzanne L. Pollard
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, Maryland, United States of America
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - William Checkley
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, Maryland, United States of America
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Trishul Siddharthan
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, Maryland, United States of America
- Division of Pulmonary and Critical Care, Miller School of Medicine, University of Miami, Miami, Florida, United States of America
| | - John R. Hurst
- UCL Respiratory, University College London, London, United Kingdom
| | | | - Fernando M. Runzer-Colmenares
- Universidad de San Martin de Porres, Facultad de Medicina Humana, Centro de Investigación del Envejecimiento (CIEN), Lima, Peru
- Universidad Científica del Sur, Facultad de Ciencias de la Salud, Lima, Peru
| | - Miles D. Witham
- NIHR Newcastle Biomedical Research Centre, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Jose F. Parodi
- Universidad de San Martin de Porres, Facultad de Medicina Humana, Centro de Investigación del Envejecimiento (CIEN), Lima, Peru
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5
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Younger A, Ye W, Alkon A, Harknett K, Kirby MA, Elon L, Lovvorn AE, Wang J, Diaz-Artiga A, McCracken JP, Castañaza Gonzalez A, Alarcon LM, Mukeshimana A, Rosa G, Chiang M, Balakrishnan K, Garg SS, Pillarisetti A, Piedrahita R, Johnson MA, Craik R, Papageorghiou AT, Toenjes A, Williams KN, Underhill LJ, Hartinger SM, Nicolaou L, Chang HH, Naeher LP, Rosenthal J, Checkley W, Peel JL, Clasen TF, Thompson LM. Effects of a liquefied petroleum gas stove intervention on stillbirth, congenital anomalies and neonatal mortality: A multi-country household air pollution intervention network trial. Environ Pollut 2024; 345:123414. [PMID: 38286258 DOI: 10.1016/j.envpol.2024.123414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 01/18/2024] [Accepted: 01/19/2024] [Indexed: 01/31/2024]
Abstract
Household air pollution (HAP) from cooking with solid fuels used during pregnancy has been associated with adverse pregnancy outcomes. The Household Air Pollution Intervention Network (HAPIN) trial was a randomized controlled trial that assessed the impact of a liquefied petroleum gas (LPG) stove and fuel intervention on health in Guatemala, India, Peru, and Rwanda. Here we investigated the effects of the LPG stove and fuel intervention on stillbirth, congenital anomalies and neonatal mortality and characterized exposure-response relationships between personal exposures to fine particulate matter (PM2.5), black carbon (BC) and carbon monoxide (CO) and these outcomes. Pregnant women (18 to <35 years of age; gestation confirmed by ultrasound at 9 to <20 weeks) were randomly assigned to intervention or control arms. We monitored these fetal and neonatal outcomes and personal exposure to PM2.5, BC and CO three times during pregnancy, we conducted intention-to-treat (ITT) and exposure-response (E-R) analyses to determine if the HAPIN intervention and corresponding HAP exposure was associated with the risk of fetal/neonatal outcomes. A total of 3200 women (mean age 25.4 ± 4.4 years, mean gestational age at randomization 15.4 ± 3.1 weeks) were included in this analysis. Relative risks for stillbirth, congenital anomaly and neonatal mortality were 0.99 (0.60, 1.66), 0.92 (95 % CI 0.52, 1.61), and 0.99 (0.54, 1.85), respectively, among women in the intervention arm compared to controls in an ITT analysis. Higher mean personal exposures to PM2.5, CO and BC during pregnancy were associated with a higher, but statistically non-significant, incidence of adverse outcomes. The LPG stove and fuel intervention did not reduce the risk of these outcomes nor did we find evidence supporting an association between personal exposures to HAP and stillbirth, congenital anomalies and neonatal mortality.
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Affiliation(s)
- Ashley Younger
- School of Nursing, University of California, San Francisco, CA, USA.
| | - Wenlu Ye
- Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley, CA, USA
| | - Abbey Alkon
- School of Nursing, University of California, San Francisco, CA, USA
| | - Kristen Harknett
- School of Nursing, University of California, San Francisco, CA, USA
| | - Miles A Kirby
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Harvard University, Boston, MA, USA
| | - Lisa Elon
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Amy E Lovvorn
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, CA, USA
| | - Jiantong Wang
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Anaité Diaz-Artiga
- Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala
| | - John P McCracken
- Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala; Department of Environmental Health Science, College of Public Health, University of Georgia, Athens, GA, USA
| | | | - Libny Monroy Alarcon
- Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala
| | | | - Ghislaine Rosa
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London, UK
| | - Marilu Chiang
- Division of Pulmonary and Critical Care, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Kalpana Balakrishnan
- Department of Environmental Health Engineering, ICMR Center for Advanced Research on Air Quality, Climate and Health, Sri Ramachandra Institute for Higher Education and Research (Deemed University), Chennai, India
| | - Sarada S Garg
- Department of Environmental Health Engineering, ICMR Center for Advanced Research on Air Quality, Climate and Health, Sri Ramachandra Institute for Higher Education and Research (Deemed University), Chennai, India
| | - Ajay Pillarisetti
- Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley, CA, USA
| | | | | | - Rachel Craik
- Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford, UK
| | - Aris T Papageorghiou
- Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford, UK
| | - Ashley Toenjes
- Cardiovascular Division, Department of Medicine, Washington University in St. Louis, St. Louis, MO, USA
| | - Kendra N Williams
- Division of Pulmonary and Critical Care, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Lindsay J Underhill
- Cardiovascular Division, Department of Medicine, Washington University in St. Louis, St. Louis, MO, USA
| | - Stella M Hartinger
- Latin American Center of Excellence on Climate Change and Health, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Laura Nicolaou
- Division of Pulmonary and Critical Care, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Howard H Chang
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Luke P Naeher
- Department of Environmental Health Science, College of Public Health, University of Georgia, Athens, GA, USA
| | - Joshua Rosenthal
- Division of Epidemiology and Population Studies, Fogarty International Center, National Institutes of Health, Bethesda, MD, USA
| | - William Checkley
- Division of Pulmonary and Critical Care, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Jennifer L Peel
- Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins, CO, USA
| | - Thomas F Clasen
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, CA, USA
| | - Lisa M Thompson
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, CA, USA; Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA, USA
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McCollum ED, Checkley W, Balakrishnan K, Clasen TF, Peel JL. Fetal and Early-Life Stove and Fuel Interventions and Respiratory Oscillometry Lung Function Measures in Preschool-Aged Children from Ghana. Am J Respir Crit Care Med 2024; 209:625-626. [PMID: 38290112 PMCID: PMC10945070 DOI: 10.1164/rccm.202311-2197ed] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 01/30/2024] [Indexed: 02/01/2024] Open
Affiliation(s)
- Eric D McCollum
- School of Medicine
- Bloomberg School of Public Health Johns Hopkins University Baltimore, Maryland
| | - William Checkley
- School of Medicine
- Bloomberg School of Public Health Johns Hopkins University Baltimore, Maryland
| | - Kalpana Balakrishnan
- Department of Environmental Health Engineering Sri Ramachandra Institute for Higher Education and Research Chennai, India
| | - Thomas F Clasen
- Rollins School of Public Health Emory University Atlanta, Georgia
| | - Jennifer L Peel
- Department of Environmental and Radiological Health Sciences Colorado State University Fort Collins, Colorado
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7
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Checkley W, Hurst JR, Wise RA. Funding Population-based Cohorts: Still Relevant for Respiratory Epidemiology in the Era of Big Data. Am J Respir Crit Care Med 2024. [PMID: 38358824 DOI: 10.1164/rccm.202401-0172ed] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Accepted: 02/14/2024] [Indexed: 02/17/2024] Open
Affiliation(s)
- William Checkley
- Johns Hopkins University, 1466, Division of Pulmonary and Critical Care, School of Medicine, Baltimore, Maryland, United States;
| | - John R Hurst
- University College London, 4919, UCL Respiratory, London, United Kingdom of Great Britain and Northern Ireland
| | - Robert A Wise
- Johns Hopkins University School of Medicine, Medicine, Baltimore, Maryland, United States
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McCollum ED, McCracken JP, Kirby MA, Grajeda LM, Hossen S, Moulton LH, Simkovich SM, Goodman-Palmer D, Rosa G, Mukeshimana A, Balakrishnan K, Thangavel G, Garg SS, Castañaza A, Thompson LM, Diaz-Artiga A, Papageorghiou AT, Davila-Roman VG, Underhill LJ, Hartinger SM, Williams KN, Nicolaou L, Chang HH, Lovvorn AE, Rosenthal JP, Pillarisetti A, Ye W, Naeher LP, Johnson MA, Waller LA, Jabbarzadeh S, Wang J, Chen Y, Steenland K, Clasen TF, Peel JL, Checkley W. Liquefied Petroleum Gas or Biomass Cooking and Severe Infant Pneumonia. N Engl J Med 2024; 390:32-43. [PMID: 38169488 PMCID: PMC10768798 DOI: 10.1056/nejmoa2305681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2024]
Abstract
BACKGROUND Exposure to household air pollution is a risk factor for severe pneumonia. The effect of replacing biomass cookstoves with liquefied petroleum gas (LPG) cookstoves on the incidence of severe infant pneumonia is uncertain. METHODS We conducted a randomized, controlled trial involving pregnant women 18 to 34 years of age and between 9 to less than 20 weeks' gestation in India, Guatemala, Peru, and Rwanda from May 2018 through September 2021. The women were assigned to cook with unvented LPG stoves and fuel (intervention group) or to continue cooking with biomass fuel (control group). In each trial group, we monitored adherence to the use of the assigned cookstove and measured 24-hour personal exposure to fine particulate matter (particles with an aerodynamic diameter of ≤2.5 μm [PM2.5]) in the women and their offspring. The trial had four primary outcomes; the primary outcome for which data are presented in the current report was severe pneumonia in the first year of life, as identified through facility surveillance or on verbal autopsy. RESULTS Among 3200 pregnant women who had undergone randomization, 3195 remained eligible and gave birth to 3061 infants (1536 in the intervention group and 1525 in the control group). High uptake of the intervention led to a reduction in personal exposure to PM2.5 among the children, with a median exposure of 24.2 μg per cubic meter (interquartile range, 17.8 to 36.4) in the intervention group and 66.0 μg per cubic meter (interquartile range, 35.2 to 132.0) in the control group. A total of 175 episodes of severe pneumonia were identified during the first year of life, with an incidence of 5.67 cases per 100 child-years (95% confidence interval [CI], 4.55 to 7.07) in the intervention group and 6.06 cases per 100 child-years (95% CI, 4.81 to 7.62) in the control group (incidence rate ratio, 0.96; 98.75% CI, 0.64 to 1.44; P = 0.81). No severe adverse events were reported to be associated with the intervention, as determined by the trial investigators. CONCLUSIONS The incidence of severe pneumonia among infants did not differ significantly between those whose mothers were assigned to cook with LPG stoves and fuel and those whose mothers were assigned to continue cooking with biomass stoves. (Funded by the National Institutes of Health and the Bill and Melinda Gates Foundation; HAPIN ClinicalTrials.gov number, NCT02944682.).
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Affiliation(s)
- Eric D McCollum
- From the Global Program in Pediatric Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences (E.D.M.), the Division of Pulmonary and Critical Care (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Center for Global Non-Communicable Disease Research and Training, School of Medicine (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Department of International Health (E.D.M.) and the Program in Global Disease Epidemiology and Control, Department of International Health (L.H.M.), Bloomberg School of Public Health, Johns Hopkins University, Baltimore, the Division of Healthcare Delivery Research, MedStar Health Research Institute, Hyattsville (S.M.S.), and Fogarty International Center, National Institutes of Health, Bethesda (J.P.R.) - all in Maryland; the Global Health Institute, Department of Epidemiology and Biostatistics (J.P.M., L.M.G.), and the Department of Environmental Health Science, College of Public Health (L.P.N.), University of Georgia, Athens, and the Department of Biostatistics and Bioinformatics (H.H.C., L.A.W., S.J., J.W., Y.C.) and the Gangarosa Department of Environmental Health (A.E.L., K.S., T.F.C.), Rollins School of Public Health, and the Nell Hodgson Woodruff School of Nursing (L.M.T.), Emory University, Atlanta - both in Georgia; the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City (J.P.M., L.M.G., A.C., A.D.-A.); the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Division of Pulmonary and Critical Care Medicine, Georgetown University, Washington DC (S.M.S.); the Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute for Higher Education and Research, Chennai, India (K.B., G.T., S.S.G.); the Global Health Center, Institute for Public Health and Cardiovascular Division, Department of Medicine, Washington University, St. Louis, MO (V.G.D.-R., L.J.U.); the Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley (A.P., W.Y.), and Berkeley Air Monitoring Group (M.A.J.) - both in Berkeley, CA; and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - John P McCracken
- From the Global Program in Pediatric Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences (E.D.M.), the Division of Pulmonary and Critical Care (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Center for Global Non-Communicable Disease Research and Training, School of Medicine (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Department of International Health (E.D.M.) and the Program in Global Disease Epidemiology and Control, Department of International Health (L.H.M.), Bloomberg School of Public Health, Johns Hopkins University, Baltimore, the Division of Healthcare Delivery Research, MedStar Health Research Institute, Hyattsville (S.M.S.), and Fogarty International Center, National Institutes of Health, Bethesda (J.P.R.) - all in Maryland; the Global Health Institute, Department of Epidemiology and Biostatistics (J.P.M., L.M.G.), and the Department of Environmental Health Science, College of Public Health (L.P.N.), University of Georgia, Athens, and the Department of Biostatistics and Bioinformatics (H.H.C., L.A.W., S.J., J.W., Y.C.) and the Gangarosa Department of Environmental Health (A.E.L., K.S., T.F.C.), Rollins School of Public Health, and the Nell Hodgson Woodruff School of Nursing (L.M.T.), Emory University, Atlanta - both in Georgia; the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City (J.P.M., L.M.G., A.C., A.D.-A.); the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Division of Pulmonary and Critical Care Medicine, Georgetown University, Washington DC (S.M.S.); the Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute for Higher Education and Research, Chennai, India (K.B., G.T., S.S.G.); the Global Health Center, Institute for Public Health and Cardiovascular Division, Department of Medicine, Washington University, St. Louis, MO (V.G.D.-R., L.J.U.); the Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley (A.P., W.Y.), and Berkeley Air Monitoring Group (M.A.J.) - both in Berkeley, CA; and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Miles A Kirby
- From the Global Program in Pediatric Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences (E.D.M.), the Division of Pulmonary and Critical Care (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Center for Global Non-Communicable Disease Research and Training, School of Medicine (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Department of International Health (E.D.M.) and the Program in Global Disease Epidemiology and Control, Department of International Health (L.H.M.), Bloomberg School of Public Health, Johns Hopkins University, Baltimore, the Division of Healthcare Delivery Research, MedStar Health Research Institute, Hyattsville (S.M.S.), and Fogarty International Center, National Institutes of Health, Bethesda (J.P.R.) - all in Maryland; the Global Health Institute, Department of Epidemiology and Biostatistics (J.P.M., L.M.G.), and the Department of Environmental Health Science, College of Public Health (L.P.N.), University of Georgia, Athens, and the Department of Biostatistics and Bioinformatics (H.H.C., L.A.W., S.J., J.W., Y.C.) and the Gangarosa Department of Environmental Health (A.E.L., K.S., T.F.C.), Rollins School of Public Health, and the Nell Hodgson Woodruff School of Nursing (L.M.T.), Emory University, Atlanta - both in Georgia; the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City (J.P.M., L.M.G., A.C., A.D.-A.); the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Division of Pulmonary and Critical Care Medicine, Georgetown University, Washington DC (S.M.S.); the Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute for Higher Education and Research, Chennai, India (K.B., G.T., S.S.G.); the Global Health Center, Institute for Public Health and Cardiovascular Division, Department of Medicine, Washington University, St. Louis, MO (V.G.D.-R., L.J.U.); the Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley (A.P., W.Y.), and Berkeley Air Monitoring Group (M.A.J.) - both in Berkeley, CA; and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Laura M Grajeda
- From the Global Program in Pediatric Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences (E.D.M.), the Division of Pulmonary and Critical Care (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Center for Global Non-Communicable Disease Research and Training, School of Medicine (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Department of International Health (E.D.M.) and the Program in Global Disease Epidemiology and Control, Department of International Health (L.H.M.), Bloomberg School of Public Health, Johns Hopkins University, Baltimore, the Division of Healthcare Delivery Research, MedStar Health Research Institute, Hyattsville (S.M.S.), and Fogarty International Center, National Institutes of Health, Bethesda (J.P.R.) - all in Maryland; the Global Health Institute, Department of Epidemiology and Biostatistics (J.P.M., L.M.G.), and the Department of Environmental Health Science, College of Public Health (L.P.N.), University of Georgia, Athens, and the Department of Biostatistics and Bioinformatics (H.H.C., L.A.W., S.J., J.W., Y.C.) and the Gangarosa Department of Environmental Health (A.E.L., K.S., T.F.C.), Rollins School of Public Health, and the Nell Hodgson Woodruff School of Nursing (L.M.T.), Emory University, Atlanta - both in Georgia; the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City (J.P.M., L.M.G., A.C., A.D.-A.); the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Division of Pulmonary and Critical Care Medicine, Georgetown University, Washington DC (S.M.S.); the Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute for Higher Education and Research, Chennai, India (K.B., G.T., S.S.G.); the Global Health Center, Institute for Public Health and Cardiovascular Division, Department of Medicine, Washington University, St. Louis, MO (V.G.D.-R., L.J.U.); the Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley (A.P., W.Y.), and Berkeley Air Monitoring Group (M.A.J.) - both in Berkeley, CA; and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Shakir Hossen
- From the Global Program in Pediatric Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences (E.D.M.), the Division of Pulmonary and Critical Care (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Center for Global Non-Communicable Disease Research and Training, School of Medicine (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Department of International Health (E.D.M.) and the Program in Global Disease Epidemiology and Control, Department of International Health (L.H.M.), Bloomberg School of Public Health, Johns Hopkins University, Baltimore, the Division of Healthcare Delivery Research, MedStar Health Research Institute, Hyattsville (S.M.S.), and Fogarty International Center, National Institutes of Health, Bethesda (J.P.R.) - all in Maryland; the Global Health Institute, Department of Epidemiology and Biostatistics (J.P.M., L.M.G.), and the Department of Environmental Health Science, College of Public Health (L.P.N.), University of Georgia, Athens, and the Department of Biostatistics and Bioinformatics (H.H.C., L.A.W., S.J., J.W., Y.C.) and the Gangarosa Department of Environmental Health (A.E.L., K.S., T.F.C.), Rollins School of Public Health, and the Nell Hodgson Woodruff School of Nursing (L.M.T.), Emory University, Atlanta - both in Georgia; the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City (J.P.M., L.M.G., A.C., A.D.-A.); the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Division of Pulmonary and Critical Care Medicine, Georgetown University, Washington DC (S.M.S.); the Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute for Higher Education and Research, Chennai, India (K.B., G.T., S.S.G.); the Global Health Center, Institute for Public Health and Cardiovascular Division, Department of Medicine, Washington University, St. Louis, MO (V.G.D.-R., L.J.U.); the Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley (A.P., W.Y.), and Berkeley Air Monitoring Group (M.A.J.) - both in Berkeley, CA; and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Lawrence H Moulton
- From the Global Program in Pediatric Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences (E.D.M.), the Division of Pulmonary and Critical Care (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Center for Global Non-Communicable Disease Research and Training, School of Medicine (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Department of International Health (E.D.M.) and the Program in Global Disease Epidemiology and Control, Department of International Health (L.H.M.), Bloomberg School of Public Health, Johns Hopkins University, Baltimore, the Division of Healthcare Delivery Research, MedStar Health Research Institute, Hyattsville (S.M.S.), and Fogarty International Center, National Institutes of Health, Bethesda (J.P.R.) - all in Maryland; the Global Health Institute, Department of Epidemiology and Biostatistics (J.P.M., L.M.G.), and the Department of Environmental Health Science, College of Public Health (L.P.N.), University of Georgia, Athens, and the Department of Biostatistics and Bioinformatics (H.H.C., L.A.W., S.J., J.W., Y.C.) and the Gangarosa Department of Environmental Health (A.E.L., K.S., T.F.C.), Rollins School of Public Health, and the Nell Hodgson Woodruff School of Nursing (L.M.T.), Emory University, Atlanta - both in Georgia; the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City (J.P.M., L.M.G., A.C., A.D.-A.); the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Division of Pulmonary and Critical Care Medicine, Georgetown University, Washington DC (S.M.S.); the Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute for Higher Education and Research, Chennai, India (K.B., G.T., S.S.G.); the Global Health Center, Institute for Public Health and Cardiovascular Division, Department of Medicine, Washington University, St. Louis, MO (V.G.D.-R., L.J.U.); the Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley (A.P., W.Y.), and Berkeley Air Monitoring Group (M.A.J.) - both in Berkeley, CA; and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Suzanne M Simkovich
- From the Global Program in Pediatric Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences (E.D.M.), the Division of Pulmonary and Critical Care (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Center for Global Non-Communicable Disease Research and Training, School of Medicine (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Department of International Health (E.D.M.) and the Program in Global Disease Epidemiology and Control, Department of International Health (L.H.M.), Bloomberg School of Public Health, Johns Hopkins University, Baltimore, the Division of Healthcare Delivery Research, MedStar Health Research Institute, Hyattsville (S.M.S.), and Fogarty International Center, National Institutes of Health, Bethesda (J.P.R.) - all in Maryland; the Global Health Institute, Department of Epidemiology and Biostatistics (J.P.M., L.M.G.), and the Department of Environmental Health Science, College of Public Health (L.P.N.), University of Georgia, Athens, and the Department of Biostatistics and Bioinformatics (H.H.C., L.A.W., S.J., J.W., Y.C.) and the Gangarosa Department of Environmental Health (A.E.L., K.S., T.F.C.), Rollins School of Public Health, and the Nell Hodgson Woodruff School of Nursing (L.M.T.), Emory University, Atlanta - both in Georgia; the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City (J.P.M., L.M.G., A.C., A.D.-A.); the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Division of Pulmonary and Critical Care Medicine, Georgetown University, Washington DC (S.M.S.); the Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute for Higher Education and Research, Chennai, India (K.B., G.T., S.S.G.); the Global Health Center, Institute for Public Health and Cardiovascular Division, Department of Medicine, Washington University, St. Louis, MO (V.G.D.-R., L.J.U.); the Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley (A.P., W.Y.), and Berkeley Air Monitoring Group (M.A.J.) - both in Berkeley, CA; and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Dina Goodman-Palmer
- From the Global Program in Pediatric Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences (E.D.M.), the Division of Pulmonary and Critical Care (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Center for Global Non-Communicable Disease Research and Training, School of Medicine (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Department of International Health (E.D.M.) and the Program in Global Disease Epidemiology and Control, Department of International Health (L.H.M.), Bloomberg School of Public Health, Johns Hopkins University, Baltimore, the Division of Healthcare Delivery Research, MedStar Health Research Institute, Hyattsville (S.M.S.), and Fogarty International Center, National Institutes of Health, Bethesda (J.P.R.) - all in Maryland; the Global Health Institute, Department of Epidemiology and Biostatistics (J.P.M., L.M.G.), and the Department of Environmental Health Science, College of Public Health (L.P.N.), University of Georgia, Athens, and the Department of Biostatistics and Bioinformatics (H.H.C., L.A.W., S.J., J.W., Y.C.) and the Gangarosa Department of Environmental Health (A.E.L., K.S., T.F.C.), Rollins School of Public Health, and the Nell Hodgson Woodruff School of Nursing (L.M.T.), Emory University, Atlanta - both in Georgia; the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City (J.P.M., L.M.G., A.C., A.D.-A.); the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Division of Pulmonary and Critical Care Medicine, Georgetown University, Washington DC (S.M.S.); the Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute for Higher Education and Research, Chennai, India (K.B., G.T., S.S.G.); the Global Health Center, Institute for Public Health and Cardiovascular Division, Department of Medicine, Washington University, St. Louis, MO (V.G.D.-R., L.J.U.); the Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley (A.P., W.Y.), and Berkeley Air Monitoring Group (M.A.J.) - both in Berkeley, CA; and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Ghislaine Rosa
- From the Global Program in Pediatric Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences (E.D.M.), the Division of Pulmonary and Critical Care (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Center for Global Non-Communicable Disease Research and Training, School of Medicine (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Department of International Health (E.D.M.) and the Program in Global Disease Epidemiology and Control, Department of International Health (L.H.M.), Bloomberg School of Public Health, Johns Hopkins University, Baltimore, the Division of Healthcare Delivery Research, MedStar Health Research Institute, Hyattsville (S.M.S.), and Fogarty International Center, National Institutes of Health, Bethesda (J.P.R.) - all in Maryland; the Global Health Institute, Department of Epidemiology and Biostatistics (J.P.M., L.M.G.), and the Department of Environmental Health Science, College of Public Health (L.P.N.), University of Georgia, Athens, and the Department of Biostatistics and Bioinformatics (H.H.C., L.A.W., S.J., J.W., Y.C.) and the Gangarosa Department of Environmental Health (A.E.L., K.S., T.F.C.), Rollins School of Public Health, and the Nell Hodgson Woodruff School of Nursing (L.M.T.), Emory University, Atlanta - both in Georgia; the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City (J.P.M., L.M.G., A.C., A.D.-A.); the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Division of Pulmonary and Critical Care Medicine, Georgetown University, Washington DC (S.M.S.); the Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute for Higher Education and Research, Chennai, India (K.B., G.T., S.S.G.); the Global Health Center, Institute for Public Health and Cardiovascular Division, Department of Medicine, Washington University, St. Louis, MO (V.G.D.-R., L.J.U.); the Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley (A.P., W.Y.), and Berkeley Air Monitoring Group (M.A.J.) - both in Berkeley, CA; and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Alexie Mukeshimana
- From the Global Program in Pediatric Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences (E.D.M.), the Division of Pulmonary and Critical Care (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Center for Global Non-Communicable Disease Research and Training, School of Medicine (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Department of International Health (E.D.M.) and the Program in Global Disease Epidemiology and Control, Department of International Health (L.H.M.), Bloomberg School of Public Health, Johns Hopkins University, Baltimore, the Division of Healthcare Delivery Research, MedStar Health Research Institute, Hyattsville (S.M.S.), and Fogarty International Center, National Institutes of Health, Bethesda (J.P.R.) - all in Maryland; the Global Health Institute, Department of Epidemiology and Biostatistics (J.P.M., L.M.G.), and the Department of Environmental Health Science, College of Public Health (L.P.N.), University of Georgia, Athens, and the Department of Biostatistics and Bioinformatics (H.H.C., L.A.W., S.J., J.W., Y.C.) and the Gangarosa Department of Environmental Health (A.E.L., K.S., T.F.C.), Rollins School of Public Health, and the Nell Hodgson Woodruff School of Nursing (L.M.T.), Emory University, Atlanta - both in Georgia; the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City (J.P.M., L.M.G., A.C., A.D.-A.); the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Division of Pulmonary and Critical Care Medicine, Georgetown University, Washington DC (S.M.S.); the Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute for Higher Education and Research, Chennai, India (K.B., G.T., S.S.G.); the Global Health Center, Institute for Public Health and Cardiovascular Division, Department of Medicine, Washington University, St. Louis, MO (V.G.D.-R., L.J.U.); the Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley (A.P., W.Y.), and Berkeley Air Monitoring Group (M.A.J.) - both in Berkeley, CA; and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Kalpana Balakrishnan
- From the Global Program in Pediatric Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences (E.D.M.), the Division of Pulmonary and Critical Care (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Center for Global Non-Communicable Disease Research and Training, School of Medicine (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Department of International Health (E.D.M.) and the Program in Global Disease Epidemiology and Control, Department of International Health (L.H.M.), Bloomberg School of Public Health, Johns Hopkins University, Baltimore, the Division of Healthcare Delivery Research, MedStar Health Research Institute, Hyattsville (S.M.S.), and Fogarty International Center, National Institutes of Health, Bethesda (J.P.R.) - all in Maryland; the Global Health Institute, Department of Epidemiology and Biostatistics (J.P.M., L.M.G.), and the Department of Environmental Health Science, College of Public Health (L.P.N.), University of Georgia, Athens, and the Department of Biostatistics and Bioinformatics (H.H.C., L.A.W., S.J., J.W., Y.C.) and the Gangarosa Department of Environmental Health (A.E.L., K.S., T.F.C.), Rollins School of Public Health, and the Nell Hodgson Woodruff School of Nursing (L.M.T.), Emory University, Atlanta - both in Georgia; the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City (J.P.M., L.M.G., A.C., A.D.-A.); the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Division of Pulmonary and Critical Care Medicine, Georgetown University, Washington DC (S.M.S.); the Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute for Higher Education and Research, Chennai, India (K.B., G.T., S.S.G.); the Global Health Center, Institute for Public Health and Cardiovascular Division, Department of Medicine, Washington University, St. Louis, MO (V.G.D.-R., L.J.U.); the Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley (A.P., W.Y.), and Berkeley Air Monitoring Group (M.A.J.) - both in Berkeley, CA; and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Gurusamy Thangavel
- From the Global Program in Pediatric Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences (E.D.M.), the Division of Pulmonary and Critical Care (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Center for Global Non-Communicable Disease Research and Training, School of Medicine (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Department of International Health (E.D.M.) and the Program in Global Disease Epidemiology and Control, Department of International Health (L.H.M.), Bloomberg School of Public Health, Johns Hopkins University, Baltimore, the Division of Healthcare Delivery Research, MedStar Health Research Institute, Hyattsville (S.M.S.), and Fogarty International Center, National Institutes of Health, Bethesda (J.P.R.) - all in Maryland; the Global Health Institute, Department of Epidemiology and Biostatistics (J.P.M., L.M.G.), and the Department of Environmental Health Science, College of Public Health (L.P.N.), University of Georgia, Athens, and the Department of Biostatistics and Bioinformatics (H.H.C., L.A.W., S.J., J.W., Y.C.) and the Gangarosa Department of Environmental Health (A.E.L., K.S., T.F.C.), Rollins School of Public Health, and the Nell Hodgson Woodruff School of Nursing (L.M.T.), Emory University, Atlanta - both in Georgia; the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City (J.P.M., L.M.G., A.C., A.D.-A.); the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Division of Pulmonary and Critical Care Medicine, Georgetown University, Washington DC (S.M.S.); the Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute for Higher Education and Research, Chennai, India (K.B., G.T., S.S.G.); the Global Health Center, Institute for Public Health and Cardiovascular Division, Department of Medicine, Washington University, St. Louis, MO (V.G.D.-R., L.J.U.); the Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley (A.P., W.Y.), and Berkeley Air Monitoring Group (M.A.J.) - both in Berkeley, CA; and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Sarada S Garg
- From the Global Program in Pediatric Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences (E.D.M.), the Division of Pulmonary and Critical Care (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Center for Global Non-Communicable Disease Research and Training, School of Medicine (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Department of International Health (E.D.M.) and the Program in Global Disease Epidemiology and Control, Department of International Health (L.H.M.), Bloomberg School of Public Health, Johns Hopkins University, Baltimore, the Division of Healthcare Delivery Research, MedStar Health Research Institute, Hyattsville (S.M.S.), and Fogarty International Center, National Institutes of Health, Bethesda (J.P.R.) - all in Maryland; the Global Health Institute, Department of Epidemiology and Biostatistics (J.P.M., L.M.G.), and the Department of Environmental Health Science, College of Public Health (L.P.N.), University of Georgia, Athens, and the Department of Biostatistics and Bioinformatics (H.H.C., L.A.W., S.J., J.W., Y.C.) and the Gangarosa Department of Environmental Health (A.E.L., K.S., T.F.C.), Rollins School of Public Health, and the Nell Hodgson Woodruff School of Nursing (L.M.T.), Emory University, Atlanta - both in Georgia; the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City (J.P.M., L.M.G., A.C., A.D.-A.); the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Division of Pulmonary and Critical Care Medicine, Georgetown University, Washington DC (S.M.S.); the Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute for Higher Education and Research, Chennai, India (K.B., G.T., S.S.G.); the Global Health Center, Institute for Public Health and Cardiovascular Division, Department of Medicine, Washington University, St. Louis, MO (V.G.D.-R., L.J.U.); the Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley (A.P., W.Y.), and Berkeley Air Monitoring Group (M.A.J.) - both in Berkeley, CA; and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Adly Castañaza
- From the Global Program in Pediatric Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences (E.D.M.), the Division of Pulmonary and Critical Care (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Center for Global Non-Communicable Disease Research and Training, School of Medicine (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Department of International Health (E.D.M.) and the Program in Global Disease Epidemiology and Control, Department of International Health (L.H.M.), Bloomberg School of Public Health, Johns Hopkins University, Baltimore, the Division of Healthcare Delivery Research, MedStar Health Research Institute, Hyattsville (S.M.S.), and Fogarty International Center, National Institutes of Health, Bethesda (J.P.R.) - all in Maryland; the Global Health Institute, Department of Epidemiology and Biostatistics (J.P.M., L.M.G.), and the Department of Environmental Health Science, College of Public Health (L.P.N.), University of Georgia, Athens, and the Department of Biostatistics and Bioinformatics (H.H.C., L.A.W., S.J., J.W., Y.C.) and the Gangarosa Department of Environmental Health (A.E.L., K.S., T.F.C.), Rollins School of Public Health, and the Nell Hodgson Woodruff School of Nursing (L.M.T.), Emory University, Atlanta - both in Georgia; the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City (J.P.M., L.M.G., A.C., A.D.-A.); the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Division of Pulmonary and Critical Care Medicine, Georgetown University, Washington DC (S.M.S.); the Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute for Higher Education and Research, Chennai, India (K.B., G.T., S.S.G.); the Global Health Center, Institute for Public Health and Cardiovascular Division, Department of Medicine, Washington University, St. Louis, MO (V.G.D.-R., L.J.U.); the Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley (A.P., W.Y.), and Berkeley Air Monitoring Group (M.A.J.) - both in Berkeley, CA; and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Lisa M Thompson
- From the Global Program in Pediatric Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences (E.D.M.), the Division of Pulmonary and Critical Care (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Center for Global Non-Communicable Disease Research and Training, School of Medicine (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Department of International Health (E.D.M.) and the Program in Global Disease Epidemiology and Control, Department of International Health (L.H.M.), Bloomberg School of Public Health, Johns Hopkins University, Baltimore, the Division of Healthcare Delivery Research, MedStar Health Research Institute, Hyattsville (S.M.S.), and Fogarty International Center, National Institutes of Health, Bethesda (J.P.R.) - all in Maryland; the Global Health Institute, Department of Epidemiology and Biostatistics (J.P.M., L.M.G.), and the Department of Environmental Health Science, College of Public Health (L.P.N.), University of Georgia, Athens, and the Department of Biostatistics and Bioinformatics (H.H.C., L.A.W., S.J., J.W., Y.C.) and the Gangarosa Department of Environmental Health (A.E.L., K.S., T.F.C.), Rollins School of Public Health, and the Nell Hodgson Woodruff School of Nursing (L.M.T.), Emory University, Atlanta - both in Georgia; the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City (J.P.M., L.M.G., A.C., A.D.-A.); the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Division of Pulmonary and Critical Care Medicine, Georgetown University, Washington DC (S.M.S.); the Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute for Higher Education and Research, Chennai, India (K.B., G.T., S.S.G.); the Global Health Center, Institute for Public Health and Cardiovascular Division, Department of Medicine, Washington University, St. Louis, MO (V.G.D.-R., L.J.U.); the Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley (A.P., W.Y.), and Berkeley Air Monitoring Group (M.A.J.) - both in Berkeley, CA; and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Anaite Diaz-Artiga
- From the Global Program in Pediatric Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences (E.D.M.), the Division of Pulmonary and Critical Care (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Center for Global Non-Communicable Disease Research and Training, School of Medicine (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Department of International Health (E.D.M.) and the Program in Global Disease Epidemiology and Control, Department of International Health (L.H.M.), Bloomberg School of Public Health, Johns Hopkins University, Baltimore, the Division of Healthcare Delivery Research, MedStar Health Research Institute, Hyattsville (S.M.S.), and Fogarty International Center, National Institutes of Health, Bethesda (J.P.R.) - all in Maryland; the Global Health Institute, Department of Epidemiology and Biostatistics (J.P.M., L.M.G.), and the Department of Environmental Health Science, College of Public Health (L.P.N.), University of Georgia, Athens, and the Department of Biostatistics and Bioinformatics (H.H.C., L.A.W., S.J., J.W., Y.C.) and the Gangarosa Department of Environmental Health (A.E.L., K.S., T.F.C.), Rollins School of Public Health, and the Nell Hodgson Woodruff School of Nursing (L.M.T.), Emory University, Atlanta - both in Georgia; the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City (J.P.M., L.M.G., A.C., A.D.-A.); the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Division of Pulmonary and Critical Care Medicine, Georgetown University, Washington DC (S.M.S.); the Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute for Higher Education and Research, Chennai, India (K.B., G.T., S.S.G.); the Global Health Center, Institute for Public Health and Cardiovascular Division, Department of Medicine, Washington University, St. Louis, MO (V.G.D.-R., L.J.U.); the Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley (A.P., W.Y.), and Berkeley Air Monitoring Group (M.A.J.) - both in Berkeley, CA; and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Aris T Papageorghiou
- From the Global Program in Pediatric Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences (E.D.M.), the Division of Pulmonary and Critical Care (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Center for Global Non-Communicable Disease Research and Training, School of Medicine (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Department of International Health (E.D.M.) and the Program in Global Disease Epidemiology and Control, Department of International Health (L.H.M.), Bloomberg School of Public Health, Johns Hopkins University, Baltimore, the Division of Healthcare Delivery Research, MedStar Health Research Institute, Hyattsville (S.M.S.), and Fogarty International Center, National Institutes of Health, Bethesda (J.P.R.) - all in Maryland; the Global Health Institute, Department of Epidemiology and Biostatistics (J.P.M., L.M.G.), and the Department of Environmental Health Science, College of Public Health (L.P.N.), University of Georgia, Athens, and the Department of Biostatistics and Bioinformatics (H.H.C., L.A.W., S.J., J.W., Y.C.) and the Gangarosa Department of Environmental Health (A.E.L., K.S., T.F.C.), Rollins School of Public Health, and the Nell Hodgson Woodruff School of Nursing (L.M.T.), Emory University, Atlanta - both in Georgia; the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City (J.P.M., L.M.G., A.C., A.D.-A.); the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Division of Pulmonary and Critical Care Medicine, Georgetown University, Washington DC (S.M.S.); the Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute for Higher Education and Research, Chennai, India (K.B., G.T., S.S.G.); the Global Health Center, Institute for Public Health and Cardiovascular Division, Department of Medicine, Washington University, St. Louis, MO (V.G.D.-R., L.J.U.); the Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley (A.P., W.Y.), and Berkeley Air Monitoring Group (M.A.J.) - both in Berkeley, CA; and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Victor G Davila-Roman
- From the Global Program in Pediatric Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences (E.D.M.), the Division of Pulmonary and Critical Care (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Center for Global Non-Communicable Disease Research and Training, School of Medicine (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Department of International Health (E.D.M.) and the Program in Global Disease Epidemiology and Control, Department of International Health (L.H.M.), Bloomberg School of Public Health, Johns Hopkins University, Baltimore, the Division of Healthcare Delivery Research, MedStar Health Research Institute, Hyattsville (S.M.S.), and Fogarty International Center, National Institutes of Health, Bethesda (J.P.R.) - all in Maryland; the Global Health Institute, Department of Epidemiology and Biostatistics (J.P.M., L.M.G.), and the Department of Environmental Health Science, College of Public Health (L.P.N.), University of Georgia, Athens, and the Department of Biostatistics and Bioinformatics (H.H.C., L.A.W., S.J., J.W., Y.C.) and the Gangarosa Department of Environmental Health (A.E.L., K.S., T.F.C.), Rollins School of Public Health, and the Nell Hodgson Woodruff School of Nursing (L.M.T.), Emory University, Atlanta - both in Georgia; the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City (J.P.M., L.M.G., A.C., A.D.-A.); the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Division of Pulmonary and Critical Care Medicine, Georgetown University, Washington DC (S.M.S.); the Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute for Higher Education and Research, Chennai, India (K.B., G.T., S.S.G.); the Global Health Center, Institute for Public Health and Cardiovascular Division, Department of Medicine, Washington University, St. Louis, MO (V.G.D.-R., L.J.U.); the Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley (A.P., W.Y.), and Berkeley Air Monitoring Group (M.A.J.) - both in Berkeley, CA; and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Lindsay J Underhill
- From the Global Program in Pediatric Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences (E.D.M.), the Division of Pulmonary and Critical Care (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Center for Global Non-Communicable Disease Research and Training, School of Medicine (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Department of International Health (E.D.M.) and the Program in Global Disease Epidemiology and Control, Department of International Health (L.H.M.), Bloomberg School of Public Health, Johns Hopkins University, Baltimore, the Division of Healthcare Delivery Research, MedStar Health Research Institute, Hyattsville (S.M.S.), and Fogarty International Center, National Institutes of Health, Bethesda (J.P.R.) - all in Maryland; the Global Health Institute, Department of Epidemiology and Biostatistics (J.P.M., L.M.G.), and the Department of Environmental Health Science, College of Public Health (L.P.N.), University of Georgia, Athens, and the Department of Biostatistics and Bioinformatics (H.H.C., L.A.W., S.J., J.W., Y.C.) and the Gangarosa Department of Environmental Health (A.E.L., K.S., T.F.C.), Rollins School of Public Health, and the Nell Hodgson Woodruff School of Nursing (L.M.T.), Emory University, Atlanta - both in Georgia; the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City (J.P.M., L.M.G., A.C., A.D.-A.); the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Division of Pulmonary and Critical Care Medicine, Georgetown University, Washington DC (S.M.S.); the Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute for Higher Education and Research, Chennai, India (K.B., G.T., S.S.G.); the Global Health Center, Institute for Public Health and Cardiovascular Division, Department of Medicine, Washington University, St. Louis, MO (V.G.D.-R., L.J.U.); the Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley (A.P., W.Y.), and Berkeley Air Monitoring Group (M.A.J.) - both in Berkeley, CA; and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Stella M Hartinger
- From the Global Program in Pediatric Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences (E.D.M.), the Division of Pulmonary and Critical Care (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Center for Global Non-Communicable Disease Research and Training, School of Medicine (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Department of International Health (E.D.M.) and the Program in Global Disease Epidemiology and Control, Department of International Health (L.H.M.), Bloomberg School of Public Health, Johns Hopkins University, Baltimore, the Division of Healthcare Delivery Research, MedStar Health Research Institute, Hyattsville (S.M.S.), and Fogarty International Center, National Institutes of Health, Bethesda (J.P.R.) - all in Maryland; the Global Health Institute, Department of Epidemiology and Biostatistics (J.P.M., L.M.G.), and the Department of Environmental Health Science, College of Public Health (L.P.N.), University of Georgia, Athens, and the Department of Biostatistics and Bioinformatics (H.H.C., L.A.W., S.J., J.W., Y.C.) and the Gangarosa Department of Environmental Health (A.E.L., K.S., T.F.C.), Rollins School of Public Health, and the Nell Hodgson Woodruff School of Nursing (L.M.T.), Emory University, Atlanta - both in Georgia; the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City (J.P.M., L.M.G., A.C., A.D.-A.); the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Division of Pulmonary and Critical Care Medicine, Georgetown University, Washington DC (S.M.S.); the Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute for Higher Education and Research, Chennai, India (K.B., G.T., S.S.G.); the Global Health Center, Institute for Public Health and Cardiovascular Division, Department of Medicine, Washington University, St. Louis, MO (V.G.D.-R., L.J.U.); the Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley (A.P., W.Y.), and Berkeley Air Monitoring Group (M.A.J.) - both in Berkeley, CA; and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Kendra N Williams
- From the Global Program in Pediatric Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences (E.D.M.), the Division of Pulmonary and Critical Care (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Center for Global Non-Communicable Disease Research and Training, School of Medicine (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Department of International Health (E.D.M.) and the Program in Global Disease Epidemiology and Control, Department of International Health (L.H.M.), Bloomberg School of Public Health, Johns Hopkins University, Baltimore, the Division of Healthcare Delivery Research, MedStar Health Research Institute, Hyattsville (S.M.S.), and Fogarty International Center, National Institutes of Health, Bethesda (J.P.R.) - all in Maryland; the Global Health Institute, Department of Epidemiology and Biostatistics (J.P.M., L.M.G.), and the Department of Environmental Health Science, College of Public Health (L.P.N.), University of Georgia, Athens, and the Department of Biostatistics and Bioinformatics (H.H.C., L.A.W., S.J., J.W., Y.C.) and the Gangarosa Department of Environmental Health (A.E.L., K.S., T.F.C.), Rollins School of Public Health, and the Nell Hodgson Woodruff School of Nursing (L.M.T.), Emory University, Atlanta - both in Georgia; the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City (J.P.M., L.M.G., A.C., A.D.-A.); the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Division of Pulmonary and Critical Care Medicine, Georgetown University, Washington DC (S.M.S.); the Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute for Higher Education and Research, Chennai, India (K.B., G.T., S.S.G.); the Global Health Center, Institute for Public Health and Cardiovascular Division, Department of Medicine, Washington University, St. Louis, MO (V.G.D.-R., L.J.U.); the Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley (A.P., W.Y.), and Berkeley Air Monitoring Group (M.A.J.) - both in Berkeley, CA; and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Laura Nicolaou
- From the Global Program in Pediatric Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences (E.D.M.), the Division of Pulmonary and Critical Care (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Center for Global Non-Communicable Disease Research and Training, School of Medicine (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Department of International Health (E.D.M.) and the Program in Global Disease Epidemiology and Control, Department of International Health (L.H.M.), Bloomberg School of Public Health, Johns Hopkins University, Baltimore, the Division of Healthcare Delivery Research, MedStar Health Research Institute, Hyattsville (S.M.S.), and Fogarty International Center, National Institutes of Health, Bethesda (J.P.R.) - all in Maryland; the Global Health Institute, Department of Epidemiology and Biostatistics (J.P.M., L.M.G.), and the Department of Environmental Health Science, College of Public Health (L.P.N.), University of Georgia, Athens, and the Department of Biostatistics and Bioinformatics (H.H.C., L.A.W., S.J., J.W., Y.C.) and the Gangarosa Department of Environmental Health (A.E.L., K.S., T.F.C.), Rollins School of Public Health, and the Nell Hodgson Woodruff School of Nursing (L.M.T.), Emory University, Atlanta - both in Georgia; the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City (J.P.M., L.M.G., A.C., A.D.-A.); the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Division of Pulmonary and Critical Care Medicine, Georgetown University, Washington DC (S.M.S.); the Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute for Higher Education and Research, Chennai, India (K.B., G.T., S.S.G.); the Global Health Center, Institute for Public Health and Cardiovascular Division, Department of Medicine, Washington University, St. Louis, MO (V.G.D.-R., L.J.U.); the Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley (A.P., W.Y.), and Berkeley Air Monitoring Group (M.A.J.) - both in Berkeley, CA; and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Howard H Chang
- From the Global Program in Pediatric Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences (E.D.M.), the Division of Pulmonary and Critical Care (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Center for Global Non-Communicable Disease Research and Training, School of Medicine (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Department of International Health (E.D.M.) and the Program in Global Disease Epidemiology and Control, Department of International Health (L.H.M.), Bloomberg School of Public Health, Johns Hopkins University, Baltimore, the Division of Healthcare Delivery Research, MedStar Health Research Institute, Hyattsville (S.M.S.), and Fogarty International Center, National Institutes of Health, Bethesda (J.P.R.) - all in Maryland; the Global Health Institute, Department of Epidemiology and Biostatistics (J.P.M., L.M.G.), and the Department of Environmental Health Science, College of Public Health (L.P.N.), University of Georgia, Athens, and the Department of Biostatistics and Bioinformatics (H.H.C., L.A.W., S.J., J.W., Y.C.) and the Gangarosa Department of Environmental Health (A.E.L., K.S., T.F.C.), Rollins School of Public Health, and the Nell Hodgson Woodruff School of Nursing (L.M.T.), Emory University, Atlanta - both in Georgia; the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City (J.P.M., L.M.G., A.C., A.D.-A.); the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Division of Pulmonary and Critical Care Medicine, Georgetown University, Washington DC (S.M.S.); the Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute for Higher Education and Research, Chennai, India (K.B., G.T., S.S.G.); the Global Health Center, Institute for Public Health and Cardiovascular Division, Department of Medicine, Washington University, St. Louis, MO (V.G.D.-R., L.J.U.); the Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley (A.P., W.Y.), and Berkeley Air Monitoring Group (M.A.J.) - both in Berkeley, CA; and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Amy E Lovvorn
- From the Global Program in Pediatric Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences (E.D.M.), the Division of Pulmonary and Critical Care (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Center for Global Non-Communicable Disease Research and Training, School of Medicine (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Department of International Health (E.D.M.) and the Program in Global Disease Epidemiology and Control, Department of International Health (L.H.M.), Bloomberg School of Public Health, Johns Hopkins University, Baltimore, the Division of Healthcare Delivery Research, MedStar Health Research Institute, Hyattsville (S.M.S.), and Fogarty International Center, National Institutes of Health, Bethesda (J.P.R.) - all in Maryland; the Global Health Institute, Department of Epidemiology and Biostatistics (J.P.M., L.M.G.), and the Department of Environmental Health Science, College of Public Health (L.P.N.), University of Georgia, Athens, and the Department of Biostatistics and Bioinformatics (H.H.C., L.A.W., S.J., J.W., Y.C.) and the Gangarosa Department of Environmental Health (A.E.L., K.S., T.F.C.), Rollins School of Public Health, and the Nell Hodgson Woodruff School of Nursing (L.M.T.), Emory University, Atlanta - both in Georgia; the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City (J.P.M., L.M.G., A.C., A.D.-A.); the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Division of Pulmonary and Critical Care Medicine, Georgetown University, Washington DC (S.M.S.); the Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute for Higher Education and Research, Chennai, India (K.B., G.T., S.S.G.); the Global Health Center, Institute for Public Health and Cardiovascular Division, Department of Medicine, Washington University, St. Louis, MO (V.G.D.-R., L.J.U.); the Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley (A.P., W.Y.), and Berkeley Air Monitoring Group (M.A.J.) - both in Berkeley, CA; and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Joshua P Rosenthal
- From the Global Program in Pediatric Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences (E.D.M.), the Division of Pulmonary and Critical Care (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Center for Global Non-Communicable Disease Research and Training, School of Medicine (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Department of International Health (E.D.M.) and the Program in Global Disease Epidemiology and Control, Department of International Health (L.H.M.), Bloomberg School of Public Health, Johns Hopkins University, Baltimore, the Division of Healthcare Delivery Research, MedStar Health Research Institute, Hyattsville (S.M.S.), and Fogarty International Center, National Institutes of Health, Bethesda (J.P.R.) - all in Maryland; the Global Health Institute, Department of Epidemiology and Biostatistics (J.P.M., L.M.G.), and the Department of Environmental Health Science, College of Public Health (L.P.N.), University of Georgia, Athens, and the Department of Biostatistics and Bioinformatics (H.H.C., L.A.W., S.J., J.W., Y.C.) and the Gangarosa Department of Environmental Health (A.E.L., K.S., T.F.C.), Rollins School of Public Health, and the Nell Hodgson Woodruff School of Nursing (L.M.T.), Emory University, Atlanta - both in Georgia; the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City (J.P.M., L.M.G., A.C., A.D.-A.); the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Division of Pulmonary and Critical Care Medicine, Georgetown University, Washington DC (S.M.S.); the Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute for Higher Education and Research, Chennai, India (K.B., G.T., S.S.G.); the Global Health Center, Institute for Public Health and Cardiovascular Division, Department of Medicine, Washington University, St. Louis, MO (V.G.D.-R., L.J.U.); the Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley (A.P., W.Y.), and Berkeley Air Monitoring Group (M.A.J.) - both in Berkeley, CA; and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Ajay Pillarisetti
- From the Global Program in Pediatric Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences (E.D.M.), the Division of Pulmonary and Critical Care (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Center for Global Non-Communicable Disease Research and Training, School of Medicine (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Department of International Health (E.D.M.) and the Program in Global Disease Epidemiology and Control, Department of International Health (L.H.M.), Bloomberg School of Public Health, Johns Hopkins University, Baltimore, the Division of Healthcare Delivery Research, MedStar Health Research Institute, Hyattsville (S.M.S.), and Fogarty International Center, National Institutes of Health, Bethesda (J.P.R.) - all in Maryland; the Global Health Institute, Department of Epidemiology and Biostatistics (J.P.M., L.M.G.), and the Department of Environmental Health Science, College of Public Health (L.P.N.), University of Georgia, Athens, and the Department of Biostatistics and Bioinformatics (H.H.C., L.A.W., S.J., J.W., Y.C.) and the Gangarosa Department of Environmental Health (A.E.L., K.S., T.F.C.), Rollins School of Public Health, and the Nell Hodgson Woodruff School of Nursing (L.M.T.), Emory University, Atlanta - both in Georgia; the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City (J.P.M., L.M.G., A.C., A.D.-A.); the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Division of Pulmonary and Critical Care Medicine, Georgetown University, Washington DC (S.M.S.); the Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute for Higher Education and Research, Chennai, India (K.B., G.T., S.S.G.); the Global Health Center, Institute for Public Health and Cardiovascular Division, Department of Medicine, Washington University, St. Louis, MO (V.G.D.-R., L.J.U.); the Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley (A.P., W.Y.), and Berkeley Air Monitoring Group (M.A.J.) - both in Berkeley, CA; and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Wenlu Ye
- From the Global Program in Pediatric Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences (E.D.M.), the Division of Pulmonary and Critical Care (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Center for Global Non-Communicable Disease Research and Training, School of Medicine (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Department of International Health (E.D.M.) and the Program in Global Disease Epidemiology and Control, Department of International Health (L.H.M.), Bloomberg School of Public Health, Johns Hopkins University, Baltimore, the Division of Healthcare Delivery Research, MedStar Health Research Institute, Hyattsville (S.M.S.), and Fogarty International Center, National Institutes of Health, Bethesda (J.P.R.) - all in Maryland; the Global Health Institute, Department of Epidemiology and Biostatistics (J.P.M., L.M.G.), and the Department of Environmental Health Science, College of Public Health (L.P.N.), University of Georgia, Athens, and the Department of Biostatistics and Bioinformatics (H.H.C., L.A.W., S.J., J.W., Y.C.) and the Gangarosa Department of Environmental Health (A.E.L., K.S., T.F.C.), Rollins School of Public Health, and the Nell Hodgson Woodruff School of Nursing (L.M.T.), Emory University, Atlanta - both in Georgia; the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City (J.P.M., L.M.G., A.C., A.D.-A.); the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Division of Pulmonary and Critical Care Medicine, Georgetown University, Washington DC (S.M.S.); the Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute for Higher Education and Research, Chennai, India (K.B., G.T., S.S.G.); the Global Health Center, Institute for Public Health and Cardiovascular Division, Department of Medicine, Washington University, St. Louis, MO (V.G.D.-R., L.J.U.); the Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley (A.P., W.Y.), and Berkeley Air Monitoring Group (M.A.J.) - both in Berkeley, CA; and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Luke P Naeher
- From the Global Program in Pediatric Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences (E.D.M.), the Division of Pulmonary and Critical Care (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Center for Global Non-Communicable Disease Research and Training, School of Medicine (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Department of International Health (E.D.M.) and the Program in Global Disease Epidemiology and Control, Department of International Health (L.H.M.), Bloomberg School of Public Health, Johns Hopkins University, Baltimore, the Division of Healthcare Delivery Research, MedStar Health Research Institute, Hyattsville (S.M.S.), and Fogarty International Center, National Institutes of Health, Bethesda (J.P.R.) - all in Maryland; the Global Health Institute, Department of Epidemiology and Biostatistics (J.P.M., L.M.G.), and the Department of Environmental Health Science, College of Public Health (L.P.N.), University of Georgia, Athens, and the Department of Biostatistics and Bioinformatics (H.H.C., L.A.W., S.J., J.W., Y.C.) and the Gangarosa Department of Environmental Health (A.E.L., K.S., T.F.C.), Rollins School of Public Health, and the Nell Hodgson Woodruff School of Nursing (L.M.T.), Emory University, Atlanta - both in Georgia; the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City (J.P.M., L.M.G., A.C., A.D.-A.); the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Division of Pulmonary and Critical Care Medicine, Georgetown University, Washington DC (S.M.S.); the Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute for Higher Education and Research, Chennai, India (K.B., G.T., S.S.G.); the Global Health Center, Institute for Public Health and Cardiovascular Division, Department of Medicine, Washington University, St. Louis, MO (V.G.D.-R., L.J.U.); the Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley (A.P., W.Y.), and Berkeley Air Monitoring Group (M.A.J.) - both in Berkeley, CA; and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Michael A Johnson
- From the Global Program in Pediatric Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences (E.D.M.), the Division of Pulmonary and Critical Care (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Center for Global Non-Communicable Disease Research and Training, School of Medicine (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Department of International Health (E.D.M.) and the Program in Global Disease Epidemiology and Control, Department of International Health (L.H.M.), Bloomberg School of Public Health, Johns Hopkins University, Baltimore, the Division of Healthcare Delivery Research, MedStar Health Research Institute, Hyattsville (S.M.S.), and Fogarty International Center, National Institutes of Health, Bethesda (J.P.R.) - all in Maryland; the Global Health Institute, Department of Epidemiology and Biostatistics (J.P.M., L.M.G.), and the Department of Environmental Health Science, College of Public Health (L.P.N.), University of Georgia, Athens, and the Department of Biostatistics and Bioinformatics (H.H.C., L.A.W., S.J., J.W., Y.C.) and the Gangarosa Department of Environmental Health (A.E.L., K.S., T.F.C.), Rollins School of Public Health, and the Nell Hodgson Woodruff School of Nursing (L.M.T.), Emory University, Atlanta - both in Georgia; the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City (J.P.M., L.M.G., A.C., A.D.-A.); the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Division of Pulmonary and Critical Care Medicine, Georgetown University, Washington DC (S.M.S.); the Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute for Higher Education and Research, Chennai, India (K.B., G.T., S.S.G.); the Global Health Center, Institute for Public Health and Cardiovascular Division, Department of Medicine, Washington University, St. Louis, MO (V.G.D.-R., L.J.U.); the Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley (A.P., W.Y.), and Berkeley Air Monitoring Group (M.A.J.) - both in Berkeley, CA; and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Lance A Waller
- From the Global Program in Pediatric Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences (E.D.M.), the Division of Pulmonary and Critical Care (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Center for Global Non-Communicable Disease Research and Training, School of Medicine (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Department of International Health (E.D.M.) and the Program in Global Disease Epidemiology and Control, Department of International Health (L.H.M.), Bloomberg School of Public Health, Johns Hopkins University, Baltimore, the Division of Healthcare Delivery Research, MedStar Health Research Institute, Hyattsville (S.M.S.), and Fogarty International Center, National Institutes of Health, Bethesda (J.P.R.) - all in Maryland; the Global Health Institute, Department of Epidemiology and Biostatistics (J.P.M., L.M.G.), and the Department of Environmental Health Science, College of Public Health (L.P.N.), University of Georgia, Athens, and the Department of Biostatistics and Bioinformatics (H.H.C., L.A.W., S.J., J.W., Y.C.) and the Gangarosa Department of Environmental Health (A.E.L., K.S., T.F.C.), Rollins School of Public Health, and the Nell Hodgson Woodruff School of Nursing (L.M.T.), Emory University, Atlanta - both in Georgia; the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City (J.P.M., L.M.G., A.C., A.D.-A.); the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Division of Pulmonary and Critical Care Medicine, Georgetown University, Washington DC (S.M.S.); the Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute for Higher Education and Research, Chennai, India (K.B., G.T., S.S.G.); the Global Health Center, Institute for Public Health and Cardiovascular Division, Department of Medicine, Washington University, St. Louis, MO (V.G.D.-R., L.J.U.); the Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley (A.P., W.Y.), and Berkeley Air Monitoring Group (M.A.J.) - both in Berkeley, CA; and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Shirin Jabbarzadeh
- From the Global Program in Pediatric Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences (E.D.M.), the Division of Pulmonary and Critical Care (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Center for Global Non-Communicable Disease Research and Training, School of Medicine (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Department of International Health (E.D.M.) and the Program in Global Disease Epidemiology and Control, Department of International Health (L.H.M.), Bloomberg School of Public Health, Johns Hopkins University, Baltimore, the Division of Healthcare Delivery Research, MedStar Health Research Institute, Hyattsville (S.M.S.), and Fogarty International Center, National Institutes of Health, Bethesda (J.P.R.) - all in Maryland; the Global Health Institute, Department of Epidemiology and Biostatistics (J.P.M., L.M.G.), and the Department of Environmental Health Science, College of Public Health (L.P.N.), University of Georgia, Athens, and the Department of Biostatistics and Bioinformatics (H.H.C., L.A.W., S.J., J.W., Y.C.) and the Gangarosa Department of Environmental Health (A.E.L., K.S., T.F.C.), Rollins School of Public Health, and the Nell Hodgson Woodruff School of Nursing (L.M.T.), Emory University, Atlanta - both in Georgia; the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City (J.P.M., L.M.G., A.C., A.D.-A.); the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Division of Pulmonary and Critical Care Medicine, Georgetown University, Washington DC (S.M.S.); the Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute for Higher Education and Research, Chennai, India (K.B., G.T., S.S.G.); the Global Health Center, Institute for Public Health and Cardiovascular Division, Department of Medicine, Washington University, St. Louis, MO (V.G.D.-R., L.J.U.); the Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley (A.P., W.Y.), and Berkeley Air Monitoring Group (M.A.J.) - both in Berkeley, CA; and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Jiantong Wang
- From the Global Program in Pediatric Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences (E.D.M.), the Division of Pulmonary and Critical Care (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Center for Global Non-Communicable Disease Research and Training, School of Medicine (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Department of International Health (E.D.M.) and the Program in Global Disease Epidemiology and Control, Department of International Health (L.H.M.), Bloomberg School of Public Health, Johns Hopkins University, Baltimore, the Division of Healthcare Delivery Research, MedStar Health Research Institute, Hyattsville (S.M.S.), and Fogarty International Center, National Institutes of Health, Bethesda (J.P.R.) - all in Maryland; the Global Health Institute, Department of Epidemiology and Biostatistics (J.P.M., L.M.G.), and the Department of Environmental Health Science, College of Public Health (L.P.N.), University of Georgia, Athens, and the Department of Biostatistics and Bioinformatics (H.H.C., L.A.W., S.J., J.W., Y.C.) and the Gangarosa Department of Environmental Health (A.E.L., K.S., T.F.C.), Rollins School of Public Health, and the Nell Hodgson Woodruff School of Nursing (L.M.T.), Emory University, Atlanta - both in Georgia; the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City (J.P.M., L.M.G., A.C., A.D.-A.); the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Division of Pulmonary and Critical Care Medicine, Georgetown University, Washington DC (S.M.S.); the Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute for Higher Education and Research, Chennai, India (K.B., G.T., S.S.G.); the Global Health Center, Institute for Public Health and Cardiovascular Division, Department of Medicine, Washington University, St. Louis, MO (V.G.D.-R., L.J.U.); the Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley (A.P., W.Y.), and Berkeley Air Monitoring Group (M.A.J.) - both in Berkeley, CA; and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Yunyun Chen
- From the Global Program in Pediatric Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences (E.D.M.), the Division of Pulmonary and Critical Care (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Center for Global Non-Communicable Disease Research and Training, School of Medicine (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Department of International Health (E.D.M.) and the Program in Global Disease Epidemiology and Control, Department of International Health (L.H.M.), Bloomberg School of Public Health, Johns Hopkins University, Baltimore, the Division of Healthcare Delivery Research, MedStar Health Research Institute, Hyattsville (S.M.S.), and Fogarty International Center, National Institutes of Health, Bethesda (J.P.R.) - all in Maryland; the Global Health Institute, Department of Epidemiology and Biostatistics (J.P.M., L.M.G.), and the Department of Environmental Health Science, College of Public Health (L.P.N.), University of Georgia, Athens, and the Department of Biostatistics and Bioinformatics (H.H.C., L.A.W., S.J., J.W., Y.C.) and the Gangarosa Department of Environmental Health (A.E.L., K.S., T.F.C.), Rollins School of Public Health, and the Nell Hodgson Woodruff School of Nursing (L.M.T.), Emory University, Atlanta - both in Georgia; the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City (J.P.M., L.M.G., A.C., A.D.-A.); the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Division of Pulmonary and Critical Care Medicine, Georgetown University, Washington DC (S.M.S.); the Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute for Higher Education and Research, Chennai, India (K.B., G.T., S.S.G.); the Global Health Center, Institute for Public Health and Cardiovascular Division, Department of Medicine, Washington University, St. Louis, MO (V.G.D.-R., L.J.U.); the Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley (A.P., W.Y.), and Berkeley Air Monitoring Group (M.A.J.) - both in Berkeley, CA; and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Kyle Steenland
- From the Global Program in Pediatric Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences (E.D.M.), the Division of Pulmonary and Critical Care (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Center for Global Non-Communicable Disease Research and Training, School of Medicine (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Department of International Health (E.D.M.) and the Program in Global Disease Epidemiology and Control, Department of International Health (L.H.M.), Bloomberg School of Public Health, Johns Hopkins University, Baltimore, the Division of Healthcare Delivery Research, MedStar Health Research Institute, Hyattsville (S.M.S.), and Fogarty International Center, National Institutes of Health, Bethesda (J.P.R.) - all in Maryland; the Global Health Institute, Department of Epidemiology and Biostatistics (J.P.M., L.M.G.), and the Department of Environmental Health Science, College of Public Health (L.P.N.), University of Georgia, Athens, and the Department of Biostatistics and Bioinformatics (H.H.C., L.A.W., S.J., J.W., Y.C.) and the Gangarosa Department of Environmental Health (A.E.L., K.S., T.F.C.), Rollins School of Public Health, and the Nell Hodgson Woodruff School of Nursing (L.M.T.), Emory University, Atlanta - both in Georgia; the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City (J.P.M., L.M.G., A.C., A.D.-A.); the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Division of Pulmonary and Critical Care Medicine, Georgetown University, Washington DC (S.M.S.); the Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute for Higher Education and Research, Chennai, India (K.B., G.T., S.S.G.); the Global Health Center, Institute for Public Health and Cardiovascular Division, Department of Medicine, Washington University, St. Louis, MO (V.G.D.-R., L.J.U.); the Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley (A.P., W.Y.), and Berkeley Air Monitoring Group (M.A.J.) - both in Berkeley, CA; and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Thomas F Clasen
- From the Global Program in Pediatric Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences (E.D.M.), the Division of Pulmonary and Critical Care (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Center for Global Non-Communicable Disease Research and Training, School of Medicine (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Department of International Health (E.D.M.) and the Program in Global Disease Epidemiology and Control, Department of International Health (L.H.M.), Bloomberg School of Public Health, Johns Hopkins University, Baltimore, the Division of Healthcare Delivery Research, MedStar Health Research Institute, Hyattsville (S.M.S.), and Fogarty International Center, National Institutes of Health, Bethesda (J.P.R.) - all in Maryland; the Global Health Institute, Department of Epidemiology and Biostatistics (J.P.M., L.M.G.), and the Department of Environmental Health Science, College of Public Health (L.P.N.), University of Georgia, Athens, and the Department of Biostatistics and Bioinformatics (H.H.C., L.A.W., S.J., J.W., Y.C.) and the Gangarosa Department of Environmental Health (A.E.L., K.S., T.F.C.), Rollins School of Public Health, and the Nell Hodgson Woodruff School of Nursing (L.M.T.), Emory University, Atlanta - both in Georgia; the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City (J.P.M., L.M.G., A.C., A.D.-A.); the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Division of Pulmonary and Critical Care Medicine, Georgetown University, Washington DC (S.M.S.); the Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute for Higher Education and Research, Chennai, India (K.B., G.T., S.S.G.); the Global Health Center, Institute for Public Health and Cardiovascular Division, Department of Medicine, Washington University, St. Louis, MO (V.G.D.-R., L.J.U.); the Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley (A.P., W.Y.), and Berkeley Air Monitoring Group (M.A.J.) - both in Berkeley, CA; and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Jennifer L Peel
- From the Global Program in Pediatric Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences (E.D.M.), the Division of Pulmonary and Critical Care (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Center for Global Non-Communicable Disease Research and Training, School of Medicine (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Department of International Health (E.D.M.) and the Program in Global Disease Epidemiology and Control, Department of International Health (L.H.M.), Bloomberg School of Public Health, Johns Hopkins University, Baltimore, the Division of Healthcare Delivery Research, MedStar Health Research Institute, Hyattsville (S.M.S.), and Fogarty International Center, National Institutes of Health, Bethesda (J.P.R.) - all in Maryland; the Global Health Institute, Department of Epidemiology and Biostatistics (J.P.M., L.M.G.), and the Department of Environmental Health Science, College of Public Health (L.P.N.), University of Georgia, Athens, and the Department of Biostatistics and Bioinformatics (H.H.C., L.A.W., S.J., J.W., Y.C.) and the Gangarosa Department of Environmental Health (A.E.L., K.S., T.F.C.), Rollins School of Public Health, and the Nell Hodgson Woodruff School of Nursing (L.M.T.), Emory University, Atlanta - both in Georgia; the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City (J.P.M., L.M.G., A.C., A.D.-A.); the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Division of Pulmonary and Critical Care Medicine, Georgetown University, Washington DC (S.M.S.); the Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute for Higher Education and Research, Chennai, India (K.B., G.T., S.S.G.); the Global Health Center, Institute for Public Health and Cardiovascular Division, Department of Medicine, Washington University, St. Louis, MO (V.G.D.-R., L.J.U.); the Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley (A.P., W.Y.), and Berkeley Air Monitoring Group (M.A.J.) - both in Berkeley, CA; and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - William Checkley
- From the Global Program in Pediatric Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences (E.D.M.), the Division of Pulmonary and Critical Care (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Center for Global Non-Communicable Disease Research and Training, School of Medicine (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Department of International Health (E.D.M.) and the Program in Global Disease Epidemiology and Control, Department of International Health (L.H.M.), Bloomberg School of Public Health, Johns Hopkins University, Baltimore, the Division of Healthcare Delivery Research, MedStar Health Research Institute, Hyattsville (S.M.S.), and Fogarty International Center, National Institutes of Health, Bethesda (J.P.R.) - all in Maryland; the Global Health Institute, Department of Epidemiology and Biostatistics (J.P.M., L.M.G.), and the Department of Environmental Health Science, College of Public Health (L.P.N.), University of Georgia, Athens, and the Department of Biostatistics and Bioinformatics (H.H.C., L.A.W., S.J., J.W., Y.C.) and the Gangarosa Department of Environmental Health (A.E.L., K.S., T.F.C.), Rollins School of Public Health, and the Nell Hodgson Woodruff School of Nursing (L.M.T.), Emory University, Atlanta - both in Georgia; the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City (J.P.M., L.M.G., A.C., A.D.-A.); the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Division of Pulmonary and Critical Care Medicine, Georgetown University, Washington DC (S.M.S.); the Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute for Higher Education and Research, Chennai, India (K.B., G.T., S.S.G.); the Global Health Center, Institute for Public Health and Cardiovascular Division, Department of Medicine, Washington University, St. Louis, MO (V.G.D.-R., L.J.U.); the Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley (A.P., W.Y.), and Berkeley Air Monitoring Group (M.A.J.) - both in Berkeley, CA; and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
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Checkley W, Thompson LM, Sinharoy SS, Hossen S, Moulton LH, Chang HH, Waller L, Steenland K, Rosa G, Mukeshimana A, Ndagijimana F, McCracken JP, Díaz-Artiga A, Balakrishnan K, Garg SS, Thangavel G, Aravindalochanan V, Hartinger SM, Chiang M, Kirby MA, Papageorghiou AT, Ramakrishnan U, Williams KN, Nicolaou L, Johnson M, Pillarisetti A, Rosenthal J, Underhill LJ, Wang J, Jabbarzadeh S, Chen Y, Dávila-Román VG, Naeher LP, McCollum ED, Peel JL, Clasen TF. Effects of Cooking with Liquefied Petroleum Gas or Biomass on Stunting in Infants. N Engl J Med 2024; 390:44-54. [PMID: 38169489 DOI: 10.1056/nejmoa2302687] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2024]
Abstract
BACKGROUND Household air pollution is associated with stunted growth in infants. Whether the replacement of biomass fuel (e.g., wood, dung, or agricultural crop waste) with liquefied petroleum gas (LPG) for cooking can reduce the risk of stunting is unknown. METHODS We conducted a randomized trial involving 3200 pregnant women 18 to 34 years of age in four low- and middle-income countries. Women at 9 to less than 20 weeks' gestation were randomly assigned to use a free LPG cookstove with continuous free fuel delivery for 18 months (intervention group) or to continue using a biomass cookstove (control group). The length of each infant was measured at 12 months of age, and personal exposures to fine particulate matter (particles with an aerodynamic diameter of ≤2.5 μm) were monitored starting at pregnancy and continuing until the infants were 1 year of age. The primary outcome for which data are presented in the current report - stunting (defined as a length-for-age z score that was more than two standard deviations below the median of a growth standard) at 12 months of age - was one of four primary outcomes of the trial. Intention-to-treat analyses were performed to estimate the relative risk of stunting. RESULTS Adherence to the intervention was high, and the intervention resulted in lower prenatal and postnatal 24-hour personal exposures to fine particulate matter than the control (mean prenatal exposure, 35.0 μg per cubic meter vs. 103.3 μg per cubic meter; mean postnatal exposure, 37.9 μg per cubic meter vs. 109.2 μg per cubic meter). Among 3061 live births, 1171 (76.2%) of the 1536 infants born to women in the intervention group and 1186 (77.8%) of the 1525 infants born to women in the control group had a valid length measurement at 12 months of age. Stunting occurred in 321 of the 1171 infants included in the analysis (27.4%) of the infants born to women in the intervention group and in 299 of the 1186 infants included in the analysis (25.2%) of those born to women in the control group (relative risk, 1.10; 98.75% confidence interval, 0.94 to 1.29; P = 0.12). CONCLUSIONS An intervention strategy starting in pregnancy and aimed at mitigating household air pollution by replacing biomass fuel with LPG for cooking did not reduce the risk of stunting in infants. (Funded by the National Institutes of Health and the Bill and Melinda Gates Foundation; HAPIN ClinicalTrials.gov number, NCT02944682.).
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Affiliation(s)
- William Checkley
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate, and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Lisa M Thompson
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate, and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Sheela S Sinharoy
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate, and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Shakir Hossen
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate, and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Lawrence H Moulton
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate, and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Howard H Chang
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate, and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Lance Waller
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate, and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Kyle Steenland
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate, and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Ghislaine Rosa
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate, and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Alexie Mukeshimana
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate, and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Florien Ndagijimana
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate, and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - John P McCracken
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate, and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Anaité Díaz-Artiga
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate, and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Kalpana Balakrishnan
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate, and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Sarada S Garg
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate, and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Gurusamy Thangavel
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate, and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Vigneswari Aravindalochanan
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate, and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Stella M Hartinger
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate, and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Marilú Chiang
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate, and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Miles A Kirby
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate, and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Aris T Papageorghiou
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate, and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Usha Ramakrishnan
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate, and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Kendra N Williams
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate, and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Laura Nicolaou
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate, and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Michael Johnson
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate, and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Ajay Pillarisetti
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate, and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Joshua Rosenthal
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate, and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Lindsay J Underhill
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate, and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Jiantong Wang
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate, and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Shirin Jabbarzadeh
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate, and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Yunyun Chen
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate, and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Victor G Dávila-Román
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate, and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Luke P Naeher
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate, and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Eric D McCollum
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate, and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Jennifer L Peel
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate, and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Thomas F Clasen
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate, and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
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10
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Pollard SL, Siddharthan T, Hossen S, Rykiel NA, Flores-Flores O, Alupo P, Quaderi S, Ascencio I, Barber JA, Chandyo R, Das SK, Gianella G, Kirenga B, Grunstra K, Miranda JJ, Mohan S, Ricciardi F, Sharma AK, Shrestha L, Soares MO, Wosu AC, Hurst JR, Checkley W. Chronic Obstructive Pulmonary Disease Self-Management in Three Low- and Middle-Income Countries: A Pilot Randomized Trial. Am J Respir Crit Care Med 2023; 208:1052-1062. [PMID: 37698443 PMCID: PMC10867931 DOI: 10.1164/rccm.202303-0505oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 09/11/2023] [Indexed: 09/13/2023] Open
Abstract
Objectives: Chronic obstructive pulmonary disease (COPD) disproportionately affects low- and middle-income countries. Health systems are ill prepared to manage the increase in COPD cases. Methods: We performed a pilot effectiveness-implementation randomized field trial of a community health worker (CHW)-supported, 1-year self-management intervention in individuals with COPD grades B-D. The study took place in low-resource settings of Nepal, Peru, and Uganda. The primary outcome was the St. George's Respiratory Questionnaire (SGRQ) score at 1 year. We evaluated differences in moderate to severe exacerbations, all-cause hospitalizations, and the EuroQol score (EQ-5D-3 L) at 12 months. Measurements and Main Results: We randomly assigned 239 participants (119 control arm, 120 intervention arm) with grades B-D COPD to a multicomponent, CHW-supported intervention or standard of care and COPD education. Twenty-five participants (21%) died or were lost to follow-up in the control arm compared with 11 (9%) in the intervention arm. At 12 months, there was no difference in mean total SGRQ score between the intervention and control arms (34.7 vs. 34.0 points; adjusted mean difference, 1.0; 95% confidence interval, -4.2, 6.1; P = 0.71). The intervention arm had a higher proportion of hospitalizations than the control arm (10% vs. 5.2%; adjusted odds ratio, 2.2; 95% confidence interval, 0.8, 7.5; P = 0.15) at 12 months. Conclusions: A CHW-based intervention to support self-management of acute exacerbations of COPD in three resource-poor settings did not result in differences in SGRQ scores at 1 year. Fidelity was high, and intervention engagement was moderate. Although these results cannot differentiate between a failed intervention or implementation, they nonetheless suggest that we need to revisit our strategy. Clinical trial registered with www.clinicaltrials.gov (NCT03359915).
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Affiliation(s)
- Suzanne L. Pollard
- Division of Pulmonary and Critical Care
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, and
| | - Trishul Siddharthan
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, and
- Division of Pulmonary and Critical Care, Miller School of Medicine, University of Miami, Miami, Florida
| | - Shakir Hossen
- Division of Pulmonary and Critical Care
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, and
| | - Natalie A. Rykiel
- Division of Pulmonary and Critical Care
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, and
| | - Oscar Flores-Flores
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, and
- Unidad de Investigación Biomédica, A. B. PRISMA, Lima, Perú
- Facultad de Ciencias de la Salud, Universidad Cientifica del Sur, Lima, Peru
- Facultad de Medicina Humana, Centro de Investigación del Envejecimiento, Universidad de San Martin de Porres, Lima, Peru
| | - Patricia Alupo
- Makerere Lung Institute, Makerere University, Kampala, Uganda
| | | | | | - Julie A. Barber
- Department of Statistical Science, University College London, London, United Kingdom
| | | | - Santa K. Das
- Institute of Medicine, Tribhuvan University, Kathmandu, Nepal
| | | | - Bruce Kirenga
- Makerere Lung Institute, Makerere University, Kampala, Uganda
| | - Kelli Grunstra
- School of Nursing, Johns Hopkins University, Baltimore, Maryland
| | - J. Jaime Miranda
- Centro de Excelencia en enfermedades crónicas CRONICAS, Universidad Peruana Cayetano Heredia, Lima, Peru
| | | | | | | | | | | | - Adaeze C. Wosu
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, and
| | | | - William Checkley
- Division of Pulmonary and Critical Care
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, and
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11
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Schuh HB, Hooli S, Ahmed S, King C, Roy AD, Lufesi N, Islam ASMDA, Mvalo T, Chowdhury NH, Ginsburg AS, Colbourn T, Checkley W, Baqui AH, McCollum ED. Clinical hypoxemia score for outpatient child pneumonia care lacking pulse oximetry in Africa and South Asia. Front Pediatr 2023; 11:1233532. [PMID: 37859772 PMCID: PMC10582699 DOI: 10.3389/fped.2023.1233532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 09/07/2023] [Indexed: 10/21/2023] Open
Abstract
Background Pulse oximeters are not routinely available in outpatient clinics in low- and middle-income countries. We derived clinical scores to identify hypoxemic child pneumonia. Methods This was a retrospective pooled analysis of two outpatient datasets of 3-35 month olds with World Health Organization (WHO)-defined pneumonia in Bangladesh and Malawi. We constructed, internally validated, and compared fit & discrimination of four models predicting SpO2 < 93% and <90%: (1) Integrated Management of Childhood Illness guidelines, (2) WHO-composite guidelines, (3) Independent variable least absolute shrinkage and selection operator (LASSO); (4) Composite variable LASSO. Results 12,712 observations were included. The independent and composite LASSO models discriminated moderately (both C-statistic 0.77) between children with a SpO2 < 93% and ≥94%; model predictive capacities remained moderate after adjusting for potential overfitting (C-statistic 0.74 and 0.75). The IMCI and WHO-composite models had poorer discrimination (C-statistic 0.56 and 0.68) and identified 20.6% and 56.8% of SpO2 < 93% cases. The highest score stratum of the independent and composite LASSO models identified 46.7% and 49.0% of SpO2 < 93% cases. Both LASSO models had similar performance for a SpO2 < 90%. Conclusions In the absence of pulse oximeters, both LASSO models better identified outpatient hypoxemic pneumonia cases than the WHO guidelines. Score external validation and implementation are needed.
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Affiliation(s)
- Holly B. Schuh
- Global Program in Pediatric Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences, Department of Pediatrics, School of Medicine, Johns Hopkins University, Baltimore, MD, United States
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Shubhada Hooli
- Global Program in Pediatric Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences, Department of Pediatrics, School of Medicine, Johns Hopkins University, Baltimore, MD, United States
- Division of Emergency Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, TX, United States
| | | | - Carina King
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | | | | | | | - Tisungane Mvalo
- University of North Carolina (UNC) Project Malawi, Lilongwe, Malawi
- Department of Pediatrics, UNC, Chapel Hill, NC, United States
| | | | - Amy Sarah Ginsburg
- Clinical Trial Center, University of Washington, Seattle, WA, United States
| | - Tim Colbourn
- Institute for Global Health, University College London, London, United Kingdom
| | - William Checkley
- Division of Pulmonary and Critical Care, Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, United States
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, MD, United States
| | - Abdullah H. Baqui
- Health Systems Program, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Eric D. McCollum
- Global Program in Pediatric Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences, Department of Pediatrics, School of Medicine, Johns Hopkins University, Baltimore, MD, United States
- Health Systems Program, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
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12
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Williams KN, Kamenar K, Kephart JL, Chiang M, Hartinger SM, Checkley W. Testing the effectiveness of household fuel conservation strategies: Policy implications for increasing the affordability of exclusive clean cooking. Environ Int 2023; 180:108223. [PMID: 37748372 PMCID: PMC10732248 DOI: 10.1016/j.envint.2023.108223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 08/16/2023] [Accepted: 09/19/2023] [Indexed: 09/27/2023]
Abstract
BACKGROUND Exclusive clean fuel use is essential for realizing health and other benefits but is often unaffordable. Decreasing household-level fuel needs could make exclusive clean fuel use more affordable, but there is a lack of knowledge on the amount of fuel savings that could be achieved through fuel conservation behaviors relevant to rural settings in low- and middle-income countries. METHODS Within a trial in Peru, we trained a random half of intervention participants, who had previously received a liquefied petroleum gas (LPG) stove and were purchasing their own fuel, on fuel conservation strategies. We measured the amount of fuel and mega joules (MJ) of energy consumed by all participants, including control participants who were receiving free fuel from the trial. We administered surveys on fuel conservation behaviors and assigned a score based on the number of behaviors performed. RESULTS Intervention participants with the training had a slightly higher conservation score than those without (7.2 vs. 6.6 points; p = 0.07). Across all participants, average daily energy consumption decreased by 9.5 MJ for each 1-point increase in conservation score (p < 0.001). Among households who used exclusively LPG (n = 99), each 1-point increase in conservation score was associated with a 0.04 kg decrease in LPG consumption per household per day (p = 0.03). Using pressure cookers and heating water in the sun decreased energy use, while using clay pots and forgetting to close stove knobs increased energy use. CONCLUSION Our findings suggest that a household could save 1.16 kg of LPG per month for each additional fuel conservation behavior, for a maximum potential savings of 8.1 kg per month. Fuel conservation messaging could be integrated into national household energy policies to increase the affordability of exclusive clean fuel use, and subsequently achieve the environmental and health benefits that could accompany such a transition.
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Affiliation(s)
- Kendra N Williams
- Division of Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, USA; Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Katarina Kamenar
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Josiah L Kephart
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, MD, USA; Department of Environmental Health and Engineering, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA; Urban Health Collaborative, Dornsife School of Public Health, Drexel University, Philadelphia, PA, USA
| | | | - Stella M Hartinger
- Facultad de Salud Publica y Administración, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - William Checkley
- Division of Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, USA; Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, MD, USA.
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13
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Fujita-Conrads R, Williams KN, Underhill LJ, Herrera P, Rahman N, Romani-Huacani E, Flores-Flores O, Checkley W, Pollard SL. Successes and challenges to implementing the Fondo de Inclusión Social Energético LPG access Program in Peru: novel insights from front-end implementers. Energy Sustain Dev 2023; 76:101267. [PMID: 37484495 PMCID: PMC10361398 DOI: 10.1016/j.esd.2023.101267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/25/2023]
Abstract
Background Household air pollution due to the burning of solid fuels is one of the leading risk factors for disease and mortality worldwide, resulting in an estimated three million deaths annually. Peru's national LPG access program, FISE, aims to reduce the use of biomass fuels and increase access to cleaner fuels for cooking in low-income Peruvian households through public-private partnerships. Perspectives from front-end program implementers are needed to better understand barriers and facilitators to program implementation and to identify strategies to strengthen program reach, uptake, and health impact. Methods We conducted fourteen 30-60-minute, semi-structured interviews with FISE-authorized LPG vendors (also known as agents) in Puno, Peru from November to December of 2019. Questions focused on barriers and facilitators to program enrollment and participation as an LPG agent, and agents' motivations for participating in the program. Results Overall, agents expressed satisfaction with the FISE program and a willingness to continue participating in the program. Distance from main cities and the homes of program participants, knowledge of FISE and LPG stoves among community members, cell service, and lack of communication with FISE authorities were cited as barriers to implementation and LPG distribution. Agents' previous experience selling LPG, as well as their social networks and understanding of the health impacts of household air pollution, aided agents in more effectively navigating the system of FISE rules and regulations and in better serving their clients. Many agents were motivated to participate in FISE because they saw it as a service to their community and were willing to find ways to prioritize the needs of beneficiaries. Conclusion The FISE program provides an example of how a large-scale national program can successfully partner with local private enterprises for program implementation. Building upon the strengths of community-based LPG agents, educating community members on the use and benefits of LPG, incentivizing, and supporting delivery services, and improving communication will be key for increasing program utilization and exclusive use of LPG, and improving health outcomes among Peru's most vulnerable populations.
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Affiliation(s)
- Ryanne Fujita-Conrads
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, USA
| | - Kendra N Williams
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, USA
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, USA
| | - Lindsay J Underhill
- Division of Cardiology, School of Medicine, Washington University in St. Louis, St. Louis, USA
| | - Phabiola Herrera
- Division of Pulmonary, Critical Care and Sleep Medicine, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Nihaal Rahman
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, USA
| | | | - Oscar Flores-Flores
- Universidad de San Martín de Porres, Facultad de Medicina Humana, Centro de Investigación del Envejecimiento (CIEN), Lima, Peru
- Universidad Científica del Sur, Facultad de Ciencias de la Salud, Lima, Peru
| | - William Checkley
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, USA
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, USA
| | - Suzanne L Pollard
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, USA
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, USA
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14
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McCollum ED, Ahmed S, Roy AD, Islam AA, Schuh HB, King C, Hooli S, Quaiyum MA, Ginsburg AS, Checkley W, Baqui AH, Colbourn T. Risk and accuracy of outpatient-identified hypoxaemia for death among suspected child pneumonia cases in rural Bangladesh: a multifacility prospective cohort study. Lancet Respir Med 2023; 11:769-781. [PMID: 37037207 PMCID: PMC10469265 DOI: 10.1016/s2213-2600(23)00098-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 02/02/2023] [Accepted: 02/08/2023] [Indexed: 04/12/2023]
Abstract
BACKGROUND Hypoxaemic pneumonia mortality risk in low-income and middle-income countries is high in children who have been hospitalised, but unknown among outpatient children. We sought to establish the outpatient burden, mortality risk, and prognostic accuracy of death from hypoxaemia in children with suspected pneumonia in Bangladesh. METHODS We conducted a prospective community-based cohort study encompassing three upazila (subdistrict) health complex catchment areas in Sylhet, Bangladesh. Children aged 3-35 months participating in a community surveillance programme and presenting to one of three upazila health complex Integrated Management of Childhood Illness (IMCI) outpatient clinics with an acute illness and signs of difficult breathing (defined as suspected pneumonia) were enrolled in the study; because lower respiratory tract infection mortality mainly occurs in children younger than 1 year, the primary study population comprised children aged 3-11 months. Study physicians recorded WHO IMCI pneumonia guideline clinical signs and peripheral arterial oxyhaemoglobin saturations (SpO2) in room air. They treated children with pneumonia with antibiotics (oral amoxicillin [40 mg/kg per dose twice per day for 5-7 days, as per local practice]), and recommended oxygen, parenteral antibiotics, and hospitalisation for those with an SpO2 of less than 90%, WHO IMCI danger signs, or severe malnutrition. Community health workers documented the children's vital status and the date of any vital status changes during routine household surveillance (one visit to each household every 2 months). The primary outcome was death at 2 weeks after enrolment in children aged 3-11 months (primary study population) and 12-35 months (secondary study population). Primary analyses included estimating the outpatient prevalence, mortality risk, and prognostic accuracy of hypoxaemia for death in children aged 3-11 months with suspected pneumonia. Risk ratios were produced by fitting a multivariable model that regressed predefined SpO2 ranges (<90%, 90-93%, and 94-100%) on the primary 2-week mortality outcome (binary outcome) using Poisson models with robust variance estimation. We established the prognostic accuracy of WHO IMCI guidelines for death with and without varying SpO2 thresholds. FINDINGS Participants were recruited between Sept 1, 2015, to Aug 31, 2017. During the study period, a total of 7440 children aged 3-35 months with the first suspected pneumonia episode were enrolled, of whom 3848 (54·3%) with an attempted pulse oximeter measurement and 2-week outcome were included in our primary study population of children aged 3-11-months. Among children aged 3-11 months, an SpO2 of less than 90% occurred in 102 (2·7%) of 3848 children, an SpO2 of 90-93% occurred in 306 (8·0%) children, a failed SpO2 measurement occurred in 67 (1·7%) children, and 24 (0·6%) children with suspected pneumonia died. Compared with an SpO2 of 94-100% (3373 [87·7%] of 3848), the adjusted risk ratio for death was 10·3 (95% CI 3·2-32·3; p<0·001) for an SpO2 of less than 90%, 4·3 (1·5-11·8; p=0·005) for an SpO2 of 90-93%, and 11·4 (3·1-41·4; p<0·001) for a failed measurement. When not considering pulse oximetry, of the children who died, WHO IMCI guidelines identified only 25·0% (95% CI 9·7-46·7; six of 24 children) as eligible for referral to hospital. For identifying deaths, in children with an SpO2 of less than 90% WHO IMCI guidelines had a 41·7% sensitivity (95% CI 22·1-63·4) and 89·7% specificity (88·7-90·7); for children with an SpO2 of less than 90% or measurement failure the guidelines had a 54·2% sensitivity (32·8-74·4) and 88·3% specificity (87·2-89·3); and for children with an SpO2 of less than 94% or measurement failure the guidelines had a 62·5% sensitivity (40·6-81·2) and 81·3% specificity (80·0-82·5). INTERPRETATION These findings support pulse oximeter use during the outpatient care of young children with suspected pneumonia in Bangladesh as well as the re-evaluation of the WHO IMCI currently recommended threshold of an SpO2 less than 90% for hospital referral. FUNDING Fogarty International Center of the National Institutes of Health (K01TW009988), The Bill & Melinda Gates Foundation (OPP1084286 and OPP1117483), and GlaxoSmithKline (90063241).
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Affiliation(s)
- Eric D McCollum
- Global Program in Pediatric Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences, Department of Pediatrics, School of Medicine, Johns Hopkins University, Baltimore, MD, USA; Department of International Health, School of Medicine, Johns Hopkins University, Baltimore, MD, USA.
| | | | | | | | - Holly B Schuh
- Department of Epidemiology, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Carina King
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Shubhada Hooli
- Section of Emergency Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Mohammad Abdul Quaiyum
- Projahnmo Research Foundation, Dhaka, Bangladesh; International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | | | - William Checkley
- Department of International Health, School of Medicine, Johns Hopkins University, Baltimore, MD, USA; Bloomberg School of Public Health, and Division of Pulmonary and Critical Care, Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, USA; Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Abdullah H Baqui
- Department of International Health, International Center for Maternal and Newborn Health, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Tim Colbourn
- Institute for Global Health, University College London, London, UK
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15
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Williams KN, Quinn A, North H, Wang J, Pillarisetti A, Thompson LM, Díaz-Artiga A, Balakrishnan K, Thangavel G, Rosa G, Ndagijimana F, Underhill LJ, Kirby MA, Puzzolo E, Hossen S, Waller LA, Peel JL, Rosenthal JP, Clasen TF, Harvey SA, Checkley W. Fidelity and adherence to a liquefied petroleum gas stove and fuel intervention: The multi-country Household Air Pollution Intervention Network (HAPIN) trial. Environ Int 2023; 179:108160. [PMID: 37660633 PMCID: PMC10512198 DOI: 10.1016/j.envint.2023.108160] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Revised: 07/24/2023] [Accepted: 08/17/2023] [Indexed: 09/05/2023]
Abstract
BACKGROUND Reducing household air pollution (HAP) to levels associated with health benefits requires nearly exclusive use of clean cooking fuels and abandonment of traditional biomass fuels. METHODS The Household Air Pollution Intervention Network (HAPIN) trial randomized 3,195 pregnant women in Guatemala, India, Peru, and Rwanda to receive a liquefied petroleum gas (LPG) stove intervention (n = 1,590), with controls expected to continue cooking with biomass fuels (n = 1,605). We assessed fidelity to intervention implementation and participant adherence to the intervention starting in pregnancy through the infant's first birthday using fuel delivery and repair records, surveys, observations, and temperature-logging stove use monitors (SUMs). RESULTS Fidelity and adherence to the HAPIN intervention were high. Median time required to refill LPG cylinders was 1 day (interquartile range 0-2). Although 26% (n = 410) of intervention participants reported running out of LPG at some point, the number of times was low (median: 1 day [Q1, Q3: 1, 2]) and mostly limited to the first four months of the COVID-19 pandemic. Most repairs were completed on the same day as problems were reported. Traditional stove use was observed in only 3% of observation visits, and 89% of these observations were followed up with behavioral reinforcement. According to SUMs data, intervention households used their traditional stove a median of 0.4% of all monitored days, and 81% used the traditional stove < 1 day per month. Traditional stove use was slightly higher post-COVID-19 (detected on a median [Q1, Q3] of 0.0% [0.0%, 3.4%] of days) than pre-COVID-19 (0.0% [0.0%, 1.6%] of days). There was no significant difference in intervention adherence pre- and post-birth. CONCLUSION Free stoves and an unlimited supply of LPG fuel delivered to participating homes combined with timely repairs, behavioral messaging, and comprehensive stove use monitoring contributed to high intervention fidelity and near-exclusive LPG use within the HAPIN trial.
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Affiliation(s)
- Kendra N Williams
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, MD, USA; Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | | | - Hayley North
- Fogarty International Center, National Institutes of Health, Bethesda, MD, USA
| | - Jiantong Wang
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Ajay Pillarisetti
- Division of Environmental Health Sciences, University of California at Berkeley, Berkeley, CA, USA
| | - Lisa M Thompson
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA, USA
| | - Anaité Díaz-Artiga
- Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala
| | - Kalpana Balakrishnan
- ICMR Center for Advanced Research on Air Quality, Climate and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute of Higher Education and Research, Chennai, India
| | - Gurusamy Thangavel
- ICMR Center for Advanced Research on Air Quality, Climate and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute of Higher Education and Research, Chennai, India
| | - Ghislaine Rosa
- Public Health, Policy & Systems, Institute of Population Health, University of Liverpool, Liverpool, UK
| | | | - Lindsay J Underhill
- Cardiovascular Division, John T. Milliken Department of Medicine, Washington University School of Medicine in St. Louis, MO, USA
| | - Miles A Kirby
- Department of Global Health and Population, Harvard University T.H. Chan School of Public Health, Boston, MA, USA
| | - Elisa Puzzolo
- Public Health, Policy & Systems, Institute of Population Health, University of Liverpool, Liverpool, UK
| | - Shakir Hossen
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, MD, USA; Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Lance A Waller
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Jennifer L Peel
- Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins, CO, USA
| | - Joshua P Rosenthal
- Fogarty International Center, National Institutes of Health, Bethesda, MD, USA
| | - Thomas F Clasen
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Steven A Harvey
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - William Checkley
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, MD, USA; Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, MD, USA.
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16
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Florman KE, Siddharthan T, Pollard SL, Alupo P, Barber JA, Chandyo RK, Flores-Flores O, Kirenga B, Mendes RG, Miranda JJ, Mohan S, Ricciardi F, Rykiel NA, Sharma AK, Wosu AC, Checkley W, Hurst JR. Unmet Diagnostic and Therapeutic Opportunities for Chronic Obstructive Pulmonary Disease in Low- and Middle-Income Countries. Am J Respir Crit Care Med 2023; 208:442-450. [PMID: 37369142 PMCID: PMC10449073 DOI: 10.1164/rccm.202302-0289oc] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 06/27/2023] [Indexed: 06/29/2023] Open
Abstract
Rationale: Chronic obstructive pulmonary disease (COPD) is a prevalent and burdensome condition in low- and middle-income countries (LMICs). Challenges to better care include more effective diagnosis and access to affordable interventions. There are no previous reports describing therapeutic needs of populations with COPD in LMICs who were identified through screening. Objectives: To describe unmet therapeutic need in screening-detected COPD in LMIC settings. Methods: We compared interventions recommended by the international Global Initiative for Chronic Obstructive Lung Disease COPD strategy document, with that received in 1,000 people with COPD identified by population screening at three LMIC sites in Nepal, Peru, and Uganda. We calculated costs using data on the availability and affordability of medicines. Measurement and Main Results: The greatest unmet need for nonpharmacological interventions was for education and vaccinations (applicable to all), pulmonary rehabilitation (49%), smoking cessation (30%), and advice on biomass smoke exposure (26%). Ninety-five percent of the cases were previously undiagnosed, and few were receiving therapy (4.5% had short-acting β-agonists). Only three of 47 people (6%) with a previous COPD diagnosis had access to drugs consistent with recommendations. None of those with more severe COPD were accessing appropriate maintenance inhalers. Even when available, maintenance treatments were unaffordable, with 30 days of treatment costing more than a low-skilled worker's daily average wage. Conclusions: We found a significant missed opportunity to reduce the burden of COPD in LMIC settings, with most cases undiagnosed. Although there is unmet need in developing novel therapies, in LMICs where the burden is greatest, better diagnosis combined with access to affordable interventions could translate to immediate benefit.
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Affiliation(s)
- Katia E.H. Florman
- Department of Respiratory Medicine, Royal Free London NHS Foundation Trust, London, United Kingdom
| | - Trishul Siddharthan
- Division of Pulmonary and Critical Care, Miller School of Medicine, University of Miami, Miami, Florida
| | - Suzanne L. Pollard
- Center for Global Non-Communicable Disease Research and Training and
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Patricia Alupo
- Makerere Lung Institute, Makerere University, Kampala, Uganda
| | - Julie A. Barber
- Department of Statistical Science, University College London, London, United Kingdom
| | - Ram K. Chandyo
- Department of Community Medicine, Kathmandu Medical College, Kathmandu, Nepal
| | - Oscar Flores-Flores
- Facultad de Medicina Humana, Centro de Investigación del Envejecimiento, Universidad de San Martin de Porres, Lima, Peru
- Facultad de Ciencias de la Salud, Universidad Cientíifica del Sur, Lima, Peru
| | - Bruce Kirenga
- Makerere Lung Institute, Makerere University, Kampala, Uganda
| | - Renata Gonçalves Mendes
- Cardiopulmonary Physiotherapy Laboratory, Federal University of Sao Carlos, Sao Carlos, Brazil
| | - J. Jaime Miranda
- CRONICAS Centre of Excellence in Chronic Diseases and
- Department of Medicine, School of Medicine, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Sakshi Mohan
- Centre for Health Economics, University of York, York, United Kingdom
| | - Federico Ricciardi
- Department of Statistical Science, University College London, London, United Kingdom
| | - Natalie A. Rykiel
- Center for Global Non-Communicable Disease Research and Training and
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Arun K. Sharma
- Child Health Research Project, Institute of Medicine, Tribhuvan University, Kathmandu, Nepal; and
| | - Adaeze C. Wosu
- Center for Global Non-Communicable Disease Research and Training and
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - William Checkley
- Center for Global Non-Communicable Disease Research and Training and
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - John R. Hurst
- UCL Respiratory, University College London, London, United Kingdom
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17
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Tarazona-Meza C, Williams KN, Malpartida G, Kephart JL, Fandiño-Del-Río M, Simkovich S, Hossen S, Chiang M, Koehler K, Checkley W. Effects of a household air pollution intervention using liquefied petroleum gas stoves, continuous fuel distribution and behavioural messaging on dietary and sodium intake of adult women in Puno, Peru: a randomised controlled trial. Public Health Nutr 2023; 26:1686-1695. [PMID: 36793234 PMCID: PMC10410368 DOI: 10.1017/s1368980023000320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 12/27/2022] [Accepted: 01/27/2023] [Indexed: 02/17/2023]
Abstract
OBJECTIVE Household air pollution (HAP) is a widespread environmental exposure worldwide. While several cleaner fuel interventions have been implemented to reduce personal exposures to HAP, it is unclear if cooking with cleaner fuels also affects the choice of meals and dietary intake. DESIGN Individually randomised, open-label controlled trial of a HAP intervention. We aimed to determine the effect of a HAP intervention on dietary and Na intake. Intervention participants received a liquefied petroleum gas (LPG) stove, continuous fuel delivery and behavioural messaging during 1 year whereas control participants continued with usual cooking practices that involved the use of biomass-burning stoves. Dietary outcomes included energy, energy-adjusted macronutrients and Na intake at baseline, 6 months and 12 months post-randomisation using 24-h dietary recalls and 24-h urine. We used t-tests to estimate differences between arms in the post-randomisation period. SETTING Rural settings in Puno, Peru. PARTICIPANTS One hundred women aged 25-64 years. RESULTS At baseline, control and intervention participants were similar in age (47·4 v. 49·5 years) and had similar daily energy (8894·3 kJ v. 8295·5 kJ), carbohydrate (370·8 g v. 373·3 g) and Na intake (4·9 g v. 4·8 g). One year after randomisation, we did not find differences in average energy intake (9292·4 kJ v. 8788·3 kJ; P = 0·22) or Na intake (4·5 g v. 4·6 g; P = 0·79) between control and intervention participants. CONCLUSIONS Our HAP intervention consisting of an LPG stove, continuous fuel distribution and behavioural messaging did not affect dietary and Na intake in rural Peru.
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Affiliation(s)
- Carla Tarazona-Meza
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
- Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore, MD, USA
- Nutrition and Dietetics, Universidad Científica del Sur, Lima, Perú
| | - Kendra N Williams
- Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore, MD, USA
- Division of Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, 1830 E. Monument Street, Room 555, Baltimore, MD21287, USA
| | | | - Josiah L Kephart
- Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore, MD, USA
- Department of Environmental Health and Engineering, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Magdalena Fandiño-Del-Río
- Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore, MD, USA
- Department of Environmental Health and Engineering, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Suzanne Simkovich
- Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore, MD, USA
- Division of Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, 1830 E. Monument Street, Room 555, Baltimore, MD21287, USA
| | - Shakir Hossen
- Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore, MD, USA
- Division of Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, 1830 E. Monument Street, Room 555, Baltimore, MD21287, USA
| | | | - Kirsten Koehler
- Department of Environmental Health and Engineering, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - William Checkley
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
- Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore, MD, USA
- Division of Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, 1830 E. Monument Street, Room 555, Baltimore, MD21287, USA
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18
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Younger A, Alkon A, Harknett K, Kirby MA, Elon L, Lovvorn AE, Wang J, Ye W, Diaz-Artiga A, McCracken JP, Castañaza Gonzalez A, Monroy Alarcon L, Mukeshimana A, Rosa G, Chiang M, Balakrishnan K, Garg SS, Pillarisetti A, Piedrahita R, Johnson M, Craik R, Papageorghiou AT, Toenjes A, Quinn A, Williams KN, Underhill L, Chang HH, Naeher LP, Rosenthal J, Checkley W, Peel JL, Clasen TF, Thompson LM. Effects of a LPG stove and fuel intervention on adverse maternal outcomes: A multi-country randomized controlled trial conducted by the Household Air Pollution Intervention Network (HAPIN). Environ Int 2023; 178:108059. [PMID: 37413928 PMCID: PMC10445187 DOI: 10.1016/j.envint.2023.108059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 06/08/2023] [Accepted: 06/21/2023] [Indexed: 07/08/2023]
Abstract
Household air pollution from solid cooking fuel use during gestation has been associated with adverse pregnancy and birth outcomes. The Household Air Pollution Intervention Network (HAPIN) trial was a randomized controlled trial of free liquefied petroleum gas (LPG) stoves and fuel in Guatemala, Peru, India, and Rwanda. A primary outcome of the main trial was to report the effects of the intervention on infant birth weight. Here we evaluate the effects of a LPG stove and fuel intervention during pregnancy on spontaneous abortion, postpartum hemorrhage, hypertensive disorders of pregnancy, and maternal mortality compared to women who continued to use solid cooking fuels. Pregnant women (18-34 years of age; gestation confirmed by ultrasound at 9-19 weeks) were randomly assigned to an intervention (n = 1593) or control (n = 1607) arm. Intention-to-treat analyses compared outcomes between the two arms using log-binomial models. Among the 3195 pregnant women in the study, there were 10 spontaneous abortions (7 intervention, 3 control), 93 hypertensive disorders of pregnancy (47 intervention, 46 control), 11 post postpartum hemorrhage (5 intervention, 6 control) and 4 maternal deaths (3 intervention, 1 control). Compared to the control arm, the relative risk of spontaneous abortion among women randomized to the intervention was 2.32 (95% confidence interval (CI): 0.60, 8.96), hypertensive disorders of pregnancy 1.02 (95% CI: 0.68, 1.52), postpartum hemorrhage 0.83 (95% CI: 0.25, 2.71) and 2.98 (95% CI: 0.31, 28.66) for maternal mortality. In this study, we found that adverse maternal outcomes did not differ based on randomized stove type across four country research sites.
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Affiliation(s)
- Ashley Younger
- School of Nursing, University of California, San Francisco, San Francisco, CA, USA
| | - Abbey Alkon
- School of Nursing, University of California, San Francisco, San Francisco, CA, USA
| | - Kristen Harknett
- School of Nursing, University of California, San Francisco, San Francisco, CA, USA
| | - Miles A Kirby
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Harvard University, Boston, MA, USA
| | - Lisa Elon
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Amy E Lovvorn
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Jiantong Wang
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Wenlu Ye
- Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley, CA, USA
| | - Anaité Diaz-Artiga
- Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala
| | - John P McCracken
- Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala; Department of Environmental Health Science, College of Public Health, University of Georgia, Athens, GA, USA
| | | | - Libny Monroy Alarcon
- Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala
| | | | - Ghislaine Rosa
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London, UK
| | - Marilu Chiang
- Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore MD, USA
| | - Kalpana Balakrishnan
- Department of Environmental Health Engineering, ICMR Center for Advanced Research on Air Quality, Climate and Health, Sri Ramachandra Institute for Higher Education and Research (Deemed University), Chennai, India
| | - Sarada S Garg
- Department of Environmental Health Engineering, ICMR Center for Advanced Research on Air Quality, Climate and Health, Sri Ramachandra Institute for Higher Education and Research (Deemed University), Chennai, India
| | - Ajay Pillarisetti
- Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley, CA, USA
| | | | | | - Rachel Craik
- Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford, UK
| | - Aris T Papageorghiou
- Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford, UK
| | - Ashley Toenjes
- Cardiovascular Division, Department of Medicine, Washington University in St. Louis, St. Louis, MO, USA
| | | | - Kendra N Williams
- Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore MD, USA; Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Lindsay Underhill
- Cardiovascular Division, Department of Medicine, Washington University in St. Louis, St. Louis, MO, USA
| | - Howard H Chang
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Luke P Naeher
- Department of Environmental Health Science, College of Public Health, University of Georgia, Athens, GA, USA
| | - Joshua Rosenthal
- Division of Epidemiology and Population Studies, Fogarty International Center, National Institutes of Health, Bethesda, MD, USA, Division of Pulmonary and Critical Care, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - William Checkley
- Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore MD, USA; Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Jennifer L Peel
- Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins, CO, USA
| | - Thomas F Clasen
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Lisa M Thompson
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA; Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA, USA.
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19
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Pillarisetti A, Ye W, Balakrishnan K, Rosa G, Díaz-Artiga A, Underhill LJ, Steenland K, Peel JL, Kirby MA, McCracken J, Waller L, Chang H, Wang J, Dusabimana E, Ndagijimana F, Sambandam S, Mukhopadhyay K, Kearns KA, Campbell D, Kremer J, Rosenthal J, Ghosh A, Clark M, Checkley W, Clasen T, Naeher L, Piedrahita R, Johnson M. Post-birth exposure contrasts for children during the Household Air Pollution Intervention Network randomized controlled trial. medRxiv 2023:2023.07.04.23292226. [PMID: 37461598 PMCID: PMC10350133 DOI: 10.1101/2023.07.04.23292226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/24/2023]
Abstract
Exposure to household air pollution is a leading cause of ill-health globally. The Household Air Pollution Intervention Network (HAPIN) randomized controlled trial evaluated the impact of a free liquefied petroleum gas stove and fuel intervention on birth outcomes and maternal and child health. As part of HAPIN, an extensive exposure assessment was conducted. Here, we report on PM 2.5 and CO exposures of young children (≤ 15 months old) reconstructed using a Bluetooth-beacon based time-activity monitoring system coupled with microenvironmental pollutant monitors. Median (IQR) exposures to PM 2.5 were 65.1 (33 - 128.2) µg/m 3 in the control group and 22.9 (17.2 - 35.3) µg/m3 in the intervention group; for CO, median (IQR) exposures were 1.1 (0.3 - 2.9) ppm and 0.2 (0 - 0.7) ppm for control and intervention group, respectively. Exposure reductions were stable over time and consistent with previous findings for the children's mothers. In the intervention group, 75% of children's reconstructed exposures were below the WHO interim target guideline value of 35 µg/m 3 , while 26% were below the standard in the control group. Our findings suggest that an LPG fuel and stove intervention can substantially reduce children's exposure to household air pollution.
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20
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Williams KN, Quinn A, North H, Wang J, Pillarisetti A, Thompson LM, Díaz-Artiga A, Balakrishnan K, Thangavel G, Rosa G, Ndagijimana F, Underhill LJ, Kirby MA, Puzzolo E, Hossen S, Waller LA, Peel JL, Rosenthal JP, Clasen TF, Harvey SA, Checkley W. Fidelity and adherence to a liquefied petroleum gas stove and fuel intervention: the multi-country Household Air Pollution Intervention Network (HAPIN) trial. medRxiv 2023:2023.06.20.23291670. [PMID: 37425899 PMCID: PMC10327189 DOI: 10.1101/2023.06.20.23291670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/11/2023]
Abstract
Background Reducing household air pollution (HAP) to levels associated with health benefits requires nearly exclusive use of clean cooking fuels and abandonment of traditional biomass fuels. Methods The Household Air Pollution Intervention Network (HAPIN) trial randomized 3,195 pregnant women in Guatemala, India, Peru, and Rwanda to receive a liquefied petroleum gas (LPG) stove intervention (n=1,590), with controls expected to continue cooking with biomass fuels (n=1,605). We assessed fidelity to intervention implementation and participant adherence to the intervention starting in pregnancy through the infant's first birthday using fuel delivery and repair records, surveys, observations, and temperature-logging stove use monitors (SUMs). Results Fidelity and adherence to the HAPIN intervention were high. Median time required to refill LPG cylinders was 1 day (interquartile range 0-2). Although 26% (n=410) of intervention participants reported running out of LPG at some point, the number of times was low (median: 1 day [Q1, Q3: 1, 2]) and mostly limited to the first four months of the COVID-19 pandemic. Most repairs were completed on the same day as problems were reported. Traditional stove use was observed in only 3% of observation visits, and 89% of these observations were followed up with behavioral reinforcement. According to SUMs data, intervention households used their traditional stove a median of 0.4% of all monitored days, and 81% used the traditional stove <1 day per month. Traditional stove use was slightly higher post-COVID-19 (detected on a median [Q1, Q3] of 0.0% [0.0%, 3.4%] of days) than pre-COVID-19 (0.0% [0.0%, 1.6%] of days). There was no significant difference in intervention adherence pre- and post-birth. Conclusion Free stoves and an unlimited supply of LPG fuel delivered to participating homes combined with timely repairs, behavioral messaging, and comprehensive stove use monitoring contributed to high intervention fidelity and near-exclusive LPG use within the HAPIN trial.
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Affiliation(s)
- Kendra N. Williams
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | | | - Hayley North
- Fogarty International Center, National Institutes of Health, Bethesda, MD, USA
| | - Jiantong Wang
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Ajay Pillarisetti
- Division of Environmental Health Sciences, University of California at Berkeley, Berkeley, CA, USA
| | - Lisa M. Thompson
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA, USA
| | - Anaité Díaz-Artiga
- Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala
| | - Kalpana Balakrishnan
- ICMR Center for Advanced Research on Air Quality, Climate and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute of Higher Education and Research, Chennai, India
| | - Gurusamy Thangavel
- ICMR Center for Advanced Research on Air Quality, Climate and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute of Higher Education and Research, Chennai, India
| | - Ghislaine Rosa
- Public Health, Policy & Systems, Institute of Population Health, University of Liverpool, Liverpool, UK
| | | | - Lindsay J. Underhill
- Cardiovascular Division, John T. Milliken Department of Medicine, Washington University School of Medicine in St. Louis, MO, USA
| | - Miles A. Kirby
- Department of Global Health and Population, Harvard University T.H. Chan School of Public Health, Boston, MA, USA
| | - Elisa Puzzolo
- Public Health, Policy & Systems, Institute of Population Health, University of Liverpool, Liverpool, UK
| | - Shakir Hossen
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Lance A. Waller
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Jennifer L. Peel
- Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins, CO, USA
| | - Joshua P. Rosenthal
- Fogarty International Center, National Institutes of Health, Bethesda, MD, USA
| | - Thomas F. Clasen
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Steven A. Harvey
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - William Checkley
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
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21
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Kayongo A, Nyiro B, Siddharthan T, Kirenga B, Checkley W, Lutaakome Joloba M, Ellner J, Salgame P. Mechanisms of lung damage in tuberculosis: implications for chronic obstructive pulmonary disease. Front Cell Infect Microbiol 2023; 13:1146571. [PMID: 37415827 PMCID: PMC10320222 DOI: 10.3389/fcimb.2023.1146571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 06/05/2023] [Indexed: 07/08/2023] Open
Abstract
Pulmonary tuberculosis is increasingly recognized as a risk factor for COPD. Severe lung function impairment has been reported in post-TB patients. Despite increasing evidence to support the association between TB and COPD, only a few studies describe the immunological basis of COPD among TB patients following successful treatment completion. In this review, we draw on well-elaborated Mycobacterium tuberculosis-induced immune mechanisms in the lungs to highlight shared mechanisms for COPD pathogenesis in the setting of tuberculosis disease. We further examine how such mechanisms could be exploited to guide COPD therapeutics.
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Affiliation(s)
- Alex Kayongo
- Department of Medicine, Center for Emerging Pathogens, New Jersey Medical School, Rutgers, The State University of New Jersey, Newark, NJ, United States
- Department of Immunology and Molecular Biology, College of Health Sciences, Makerere University, Kampala, Uganda
- Makerere University College of Health Sciences, Lung Institute, Makerere University, Kampala, Uganda
| | - Brian Nyiro
- Department of Medicine, Center for Emerging Pathogens, New Jersey Medical School, Rutgers, The State University of New Jersey, Newark, NJ, United States
- Department of Immunology and Molecular Biology, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Trishul Siddharthan
- Division of Pulmonary and Critical Care Medicine, University of Miami, Miami, FL, United States
| | - Bruce Kirenga
- Makerere University College of Health Sciences, Lung Institute, Makerere University, Kampala, Uganda
| | - William Checkley
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, United States
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, MD, United States
| | - Moses Lutaakome Joloba
- Makerere University College of Health Sciences, Lung Institute, Makerere University, Kampala, Uganda
| | - Jerrold Ellner
- Department of Medicine, Center for Emerging Pathogens, New Jersey Medical School, Rutgers, The State University of New Jersey, Newark, NJ, United States
| | - Padmini Salgame
- Department of Medicine, Center for Emerging Pathogens, New Jersey Medical School, Rutgers, The State University of New Jersey, Newark, NJ, United States
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22
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Simkovich SM, Foeller ME, Tunçalp Ö, Papageorghiou A, Checkley W. Integrating non-communicable disease prevention and control into maternal and child health programmes. BMJ 2023; 381:e071072. [PMID: 37220922 PMCID: PMC10203824 DOI: 10.1136/bmj-2022-071072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Affiliation(s)
- Suzanne M Simkovich
- Division of Healthcare Delivery Research, MedStar Health Research Institute, Hyattsville, USA
- Division of Pulmonary and Critical Care Medicine, Georgetown University, Washington USA
| | - Megan E Foeller
- Department of Obstetrics and Gynaecology, St Alphonsus Regional Medical Center, Boise, USA
| | - Özge Tunçalp
- UNDP, UNFPA, Unicef, WHO, World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Aris Papageorghiou
- Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford, UK
| | - William Checkley
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, USA
- Division of Pulmonary and Critical Care, Johns Hopkins University School of Medicine, Baltimore, USA
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23
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Simkovich SM, Hossen S, McCollum ED, Toenjes AK, McCracken JP, Thompson LM, Castañaza A, Diaz A, Rosa G, Kirby MA, Mukeshimana A, Myers R, Lenzen PM, Craik R, Jabbarzadeh S, Elon L, Garg SS, Balakrishnan K, Thangavel G, Peel JL, Clasen TF, Dávila-Román VG, Papageorghiou AT, de Las Fuentes L, Checkley W. Lung Ultrasound Protocol and Quality Control of Image Interpretation Using an Adjudication Panel in the Household Air Pollution Intervention Network (HAPIN) Trial. Ultrasound Med Biol 2023; 49:1194-1201. [PMID: 36801180 PMCID: PMC10631486 DOI: 10.1016/j.ultrasmedbio.2023.01.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 12/23/2022] [Accepted: 01/03/2023] [Indexed: 05/11/2023]
Abstract
OBJECTIVE Lung ultrasound (LUS) is an alternative to chest radiography to confirm a diagnosis of pneumonia. For research and disease surveillance, methods to use LUS to diagnose pneumonia are needed. METHODS In the Household Air Pollution Intervention Network (HAPIN) trial, LUS was used to confirm a clinical diagnosis of severe pneumonia in infants. We developed a standardized definition of pneumonia, protocols for recruitment and training of sonographers, along with LUS image acquisition and interpretation. We use a blinded panel approach to interpretation with LUS cine-loops randomized to non-scanning sonographers with expert review. DISCUSSION We obtained 357 lung ultrasound scans: 159, 8 and 190 scans were collected in Guatemala, Peru and Rwanda, respectively. The diagnosis of primary endpoint pneumonia (PEP) required an expert tie breaker in 181 scans (39%). PEP was diagnosed in 141 scans (40%), not diagnosed in 213 (60%), with 3 scans (<1%) deemed uninterpretable. Agreement among the two blinded sonographers and the expert reader in Guatemala, Peru and Rwanda was 65%, 62% and 67%, with a prevalence-and-bias-corrected kappa of 0.30, 0.24 and 0.33, respectively. CONCLUSION Use of standardized imaging protocols, training and an adjudication panel resulted in high confidence for the diagnosis of pneumonia using LUS.
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Affiliation(s)
- Suzanne M Simkovich
- Division of Pulmonary and Critical Care, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, MD, USA; Division of Healthcare Delivery, MedStar Health Research Institute, Hyattsville, MD, USA; Division of Pulmonary and Critical Care Medicine, Georgetown University School of Medicine, Washington, DC, USA
| | - Shakir Hossen
- Division of Pulmonary and Critical Care, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Eric D McCollum
- Eudowood Division of Pediatric Respiratory Sciences, Department of Pediatrics, School of Medicine, Johns Hopkins University, Baltimore, MD, USA; Global Program on Pediatric Respiratory Sciences, Department of Pediatrics, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Ashley K Toenjes
- Cardiovascular Division, Department of Medicine, Washington University in St. Louis, St. Louis, MO, USA
| | - John P McCracken
- Global Health Institute, Department of Epidemiology and Biostatistics, College of Public Health, University of Georgia, Athens, GA, USA
| | - Lisa M Thompson
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA, USA
| | - Adly Castañaza
- Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala
| | - Anaite Diaz
- Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala
| | - Ghislaine Rosa
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London, UK
| | - Miles A Kirby
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Harvard University, Boston, MA, USA
| | | | - Rachel Myers
- Cardiovascular Division, Department of Medicine, Washington University in St. Louis, St. Louis, MO, USA
| | - Patricia M Lenzen
- Cardiovascular Division, Department of Medicine, Washington University in St. Louis, St. Louis, MO, USA
| | - Rachel Craik
- Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford, UK
| | - Shirin Jabbarzadeh
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Lisa Elon
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Sarada S Garg
- Department of Environmental Health Engineering, ICMR Center for Advanced Research on Air Quality, Climate and Health, Sri Ramachandra Institute for Higher Education and Research (Deemed University), Chennai, India
| | - Kalpana Balakrishnan
- Department of Environmental Health Engineering, ICMR Center for Advanced Research on Air Quality, Climate and Health, Sri Ramachandra Institute for Higher Education and Research (Deemed University), Chennai, India
| | - Gurusamy Thangavel
- Department of Environmental Health Engineering, ICMR Center for Advanced Research on Air Quality, Climate and Health, Sri Ramachandra Institute for Higher Education and Research (Deemed University), Chennai, India
| | - Jennifer L Peel
- Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins, CO, USA
| | - Thomas F Clasen
- Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Victor G Dávila-Román
- Cardiovascular Division, Department of Medicine, Washington University in St. Louis, St. Louis, MO, USA
| | - Aris T Papageorghiou
- Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford, UK
| | - Lisa de Las Fuentes
- Cardiovascular Division, Department of Medicine, Washington University in St. Louis, St. Louis, MO, USA
| | - William Checkley
- Division of Pulmonary and Critical Care, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, MD, USA.
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24
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Balakrishnan K, Steenland K, Clasen T, Chang H, Johnson M, Pillarisetti A, Ye W, Naeher LP, Diaz-Artiga A, McCracken JP, Thompson LM, Rosa G, Kirby MA, Thangavel G, Sambandam S, Mukhopadhyay K, Puttaswamy N, Aravindalochanan V, Garg S, Ndagijimana F, Hartinger S, Underhill LJ, Kearns KA, Campbell D, Kremer J, Waller L, Jabbarzadeh S, Wang J, Chen Y, Rosenthal J, Quinn A, Papageorghiou AT, Ramakrishnan U, Howards PP, Checkley W, Peel JL. Exposure-response relationships for personal exposure to fine particulate matter (PM 2·5), carbon monoxide, and black carbon and birthweight: an observational analysis of the multicountry Household Air Pollution Intervention Network (HAPIN) trial. Lancet Planet Health 2023; 7:e387-e396. [PMID: 37164515 PMCID: PMC10186177 DOI: 10.1016/s2542-5196(23)00052-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 02/19/2023] [Accepted: 03/02/2023] [Indexed: 05/12/2023]
Abstract
BACKGROUND Household air pollution (HAP) from solid fuel use is associated with adverse birth outcomes, but data for exposure-response relationships are scarce. We examined associations between HAP exposures and birthweight in rural Guatemala, India, Peru, and Rwanda during the Household Air Pollution Intervention Network (HAPIN) trial. METHODS The HAPIN trial recruited pregnant women (9-<20 weeks of gestation) in rural Guatemala, India, Peru, and Rwanda and randomly allocated them to receive a liquefied petroleum gas stove or not (ie, and continue to use biomass fuel). The primary outcomes were birthweight, length-for-age, severe pneumonia, and maternal systolic blood pressure. In this exposure-response subanalysis, we measured 24-h personal exposures to PM2·5, carbon monoxide, and black carbon once pre-intervention (baseline) and twice post-intervention (at 24-28 weeks and 32-36 weeks of gestation), as well as birthweight within 24 h of birth. We examined the relationship between the average prenatal exposure and birthweight or weight-for-gestational age Z scores using multivariate-regression models, controlling for the mother's age, nulliparity, diet diversity, food insecurity, BMI, the mother's education, neonate sex, haemoglobin, second-hand smoke, and geographical indicator for randomisation strata. FINDINGS Between March, 2018, and February, 2020, 3200 pregnant women were recruited. An interquartile increase in the average prenatal exposure to PM2·5 (74·5 μg/m3) was associated with a reduction in birthweight and gestational age Z scores (birthweight: -14·8 g [95% CI -28·7 to -0·8]; gestational age Z scores: -0·03 [-0·06 to 0·00]), as was an interquartile increase in black carbon (7·3 μg/m3; -21·9 g [-37·7 to -6·1]; -0·05 [-0·08 to -0·01]). Carbon monoxide exposure was not associated with these outcomes (1·7; -3·1 [-12·1 to 5·8]; -0·003 [-0·023 to 0·017]). INTERPRETATION Continuing efforts are needed to reduce HAP exposure alongside other drivers of low birthweight in low-income and middle-income countries. FUNDING US National Institutes of Health (1UM1HL134590) and the Bill & Melinda Gates Foundation (OPP1131279).
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Affiliation(s)
- Kalpana Balakrishnan
- Department of Environmental Health Engineering, ICMR Center for Advanced Research on Air Quality, Climate and Health, Sri Ramachandra Institute for Higher Education and Research (Deemed University), Chennai, India.
| | - Kyle Steenland
- Gangarosa Department of Environmental Health, Emory University, Atlanta, GA, USA
| | - Thomas Clasen
- Gangarosa Department of Environmental Health, Emory University, Atlanta, GA, USA
| | - Howard Chang
- Department of Biostatistics and Bioinformatics, Emory University, Atlanta, GA, USA
| | | | - Ajay Pillarisetti
- Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley, CA, USA
| | - Wenlu Ye
- Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley, CA, USA
| | - Luke P Naeher
- Department of Environmental Health Sciences, University of Georgia, Athens, GA, USA
| | - Anaite Diaz-Artiga
- Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala
| | - John P McCracken
- Department of Environmental Health Sciences, University of Georgia, Athens, GA, USA
| | - Lisa M Thompson
- Rollins School of Public Health and Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA, USA
| | - Ghislaine Rosa
- Department of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
| | - Miles A Kirby
- Department of Global Health and Population, Harvard T H Chan School of Public Health, Harvard University, Boston, MA, USA
| | - Gurusamy Thangavel
- Department of Environmental Health Engineering, ICMR Center for Advanced Research on Air Quality, Climate and Health, Sri Ramachandra Institute for Higher Education and Research (Deemed University), Chennai, India
| | - Sankar Sambandam
- Department of Environmental Health Engineering, ICMR Center for Advanced Research on Air Quality, Climate and Health, Sri Ramachandra Institute for Higher Education and Research (Deemed University), Chennai, India
| | - Krishnendu Mukhopadhyay
- Department of Environmental Health Engineering, ICMR Center for Advanced Research on Air Quality, Climate and Health, Sri Ramachandra Institute for Higher Education and Research (Deemed University), Chennai, India
| | - Naveen Puttaswamy
- Department of Environmental Health Engineering, ICMR Center for Advanced Research on Air Quality, Climate and Health, Sri Ramachandra Institute for Higher Education and Research (Deemed University), Chennai, India
| | - Vigneswari Aravindalochanan
- Department of Environmental Health Engineering, ICMR Center for Advanced Research on Air Quality, Climate and Health, Sri Ramachandra Institute for Higher Education and Research (Deemed University), Chennai, India
| | - Sarada Garg
- Department of Environmental Health Engineering, ICMR Center for Advanced Research on Air Quality, Climate and Health, Sri Ramachandra Institute for Higher Education and Research (Deemed University), Chennai, India
| | | | - Stella Hartinger
- Division of Pulmonary and Critical Care, School of Medicine and Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore, MD, USA
| | - Lindsay J Underhill
- Cardiovascular Division, Washington University School of Medicine, St Louis, MO, USA
| | - Katherine A Kearns
- Department of Environmental Health Sciences, University of Georgia, Athens, GA, USA
| | - Devan Campbell
- Department of Environmental Health Sciences, University of Georgia, Athens, GA, USA
| | - Jacob Kremer
- Department of Environmental Health Sciences, University of Georgia, Athens, GA, USA
| | - Lance Waller
- Department of Biostatistics and Bioinformatics, Emory University, Atlanta, GA, USA
| | - Shirin Jabbarzadeh
- Department of Biostatistics and Bioinformatics, Emory University, Atlanta, GA, USA
| | - Jiantong Wang
- Department of Biostatistics and Bioinformatics, Emory University, Atlanta, GA, USA
| | - Yunyun Chen
- Department of Biostatistics and Bioinformatics, Emory University, Atlanta, GA, USA
| | - Joshua Rosenthal
- Division of Epidemiology and Population Studies, Fogarty International Center, National Institutes of Health, Bethesda, MD, USA
| | | | - Aris T Papageorghiou
- Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford, UK
| | - Usha Ramakrishnan
- Hubert Department of Global Health, Emory University, Atlanta, GA, USA
| | | | - William Checkley
- Division of Pulmonary and Critical Care, School of Medicine and Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore, MD, USA
| | - Jennifer L Peel
- Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins, CO, USA
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25
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Williams KN, Kephart JL, Fandiño-Del-Rio M, Nicolaou L, Koehler K, Harvey SA, Checkley W. Sustained use of liquefied petroleum gas following one year of free fuel and behavioral support in Puno, Peru. Energy Sustain Dev 2023; 73:13-22. [PMID: 36798733 PMCID: PMC9928150 DOI: 10.1016/j.esd.2023.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/18/2023]
Abstract
Background Existing efforts to promote cleaner fuels have not achieved exclusive use. We investigated whether receiving 12 months of free liquefied petroleum gas (LPG) and behavioral support could motivate continued purchase and use. Methods The Cardiopulmonary outcomes and Household Air Pollution (CHAP) trial enrolled 180 women. Half were randomly assigned to an intervention group, which included free LPG delivered in months 1-12 followed by a post-intervention period in which they no longer received free fuel (months 13-24). For the purposes of comparison, we also include months 1-12 of data from control participants. We tracked stove use with temperature monitors, surveys, and observations, and conducted in-depth interviews with 19 participants from the intervention group at the end of their post-intervention period. Results Participants from the intervention group used their LPG stove for 85.4 % of monitored days and 63.2 % of cooking minutes during the post-intervention months (13-24) when they were not receiving free fuel from the trial. They used a traditional stove (fogón) on 45.1 % of days post-intervention, which is significantly lower than fogón use by control participants during the intervention period (72.2 % of days). In months 13-24 post-intervention, participants from the intervention group purchased on average 12.3 kg and spent 34.1 soles (10.3 USD) per month on LPG. Continued LPG use was higher among participants who said they could afford two tanks of LPG per month, did not cook for animals, and removed their traditional stove. Women described that becoming accustomed to LPG, support and training from the project, consistent LPG supply, choice between LPG providers, and access to delivery services facilitated sustained LPG use. However, high cost was a major barrier to exclusive use. Conclusion A 12-month period of intensive LPG support achieved a high level of sustained LPG use post-intervention, but other strategies are needed to sustain exclusive use.
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Affiliation(s)
- Kendra N. Williams
- Division of Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Josiah L. Kephart
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
- Department of Environmental and Occupational Health, Dornsife School of Public Health, Drexel University, Philadelphia, PA, USA
| | - Magdalena Fandiño-Del-Rio
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
- Department of Environmental Health and Engineering, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Laura Nicolaou
- Division of Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Kirsten Koehler
- Department of Environmental Health and Engineering, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Steven A. Harvey
- Department of International Health, Social and Behavioral Interventions Program, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - William Checkley
- Division of Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
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26
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Kayongo A, Bartolomaeus TUP, Birkner T, Markó L, Löber U, Kigozi E, Atugonza C, Munana R, Mawanda D, Sekibira R, Uwimaana E, Alupo P, Kalyesubula R, Knauf F, Siddharthan T, Bagaya BS, Kateete DP, Joloba ML, Sewankambo NK, Jjingo D, Kirenga B, Checkley W, Forslund SK. Sputum Microbiome and Chronic Obstructive Pulmonary Disease in a Rural Ugandan Cohort of Well-Controlled HIV Infection. Microbiol Spectr 2023; 11:e0213921. [PMID: 36790203 PMCID: PMC10100697 DOI: 10.1128/spectrum.02139-21] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 01/23/2023] [Indexed: 02/16/2023] Open
Abstract
Sub-Saharan Africa has increased morbidity and mortality related to chronic obstructive pulmonary disease (COPD). COPD among people living with HIV (PLWH) has not been well studied in this region, where HIV/AIDS is endemic. Increasing evidence suggests that respiratory microbial composition plays a role in COPD severity. Therefore, we aimed to investigate microbiome patterns and associations among PLWH with COPD in Sub-Saharan Africa. We conducted a cross-sectional study of 200 adults stratified by HIV and COPD in rural Uganda. Induced sputum samples were collected as an easy-to-obtain proxy for the lower respiratory tract microbiota. We performed 16S rRNA gene sequencing and used PICRUSt2 (version 2.2.3) to infer the functional profiles of the microbial community. We used a statistical tool to detect changes in specific taxa that searches and adjusts for confounding factors such as antiretroviral therapy (ART), age, sex, and other participant characteristics. We could cluster the microbial community into three community types whose distribution was shown to be significantly impacted by HIV. Some genera, e.g., Veillonella, Actinomyces, Atopobium, and Filifactor, were significantly enriched in HIV-infected individuals, while the COPD status was significantly associated with Gammaproteobacteria and Selenomonas abundance. Furthermore, reduced bacterial richness and significant enrichment in Campylobacter were associated with HIV-COPD comorbidity. Functional prediction using PICRUSt2 revealed a significant depletion in glutamate degradation capacity pathways in HIV-positive patients. A comparison of our findings with an HIV cohort from the United Kingdom revealed significant differences in the sputum microbiome composition, irrespective of viral suppression. IMPORTANCE Even with ART available, HIV-infected individuals are at high risk of suffering comorbidities, as shown by the high prevalence of noninfectious lung diseases in the HIV population. Recent studies have suggested a role for the respiratory microbiota in driving chronic lung inflammation. The respiratory microbiota was significantly altered among PLWH, with disease persisting up to 3 years post-ART initiation and HIV suppression. The community structure and diversity of the sputum microbiota in COPD are associated with disease severity and clinical outcomes, both in stable COPD and during exacerbations. Therefore, a better understanding of the sputum microbiome among PLWH could improve COPD prognostic and risk stratification strategies. In this study, we observed that in a virologically suppressed HIV cohort in rural Uganda, we could show differences in sputum microbiota stratified by HIV and COPD, reduced bacterial richness, and significant enrichment in Campylobacter associated with HIV-COPD comorbidity.
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Affiliation(s)
- Alex Kayongo
- Makerere University Lung Institute, Makerere University College of Health Sciences, Kampala, Uganda
- Makerere University, College of Health Sciences, Department of Immunology and Molecular Biology, Kampala, Uganda
| | - Theda Ulrike Patricia Bartolomaeus
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
- Experimental and Clinical Research Center, A Cooperation of Charité - Universitätsmedizin Berlin and Max Delbrück Center for Molecular Medicine, Berlin, Germany
- Max Delbrück Center for Molecular Medicine in the Helmholtz Association, Berlin, Germany
- German Centre for Cardiovascular Research, Berlin, Germany
| | - Till Birkner
- Experimental and Clinical Research Center, A Cooperation of Charité - Universitätsmedizin Berlin and Max Delbrück Center for Molecular Medicine, Berlin, Germany
- Max Delbrück Center for Molecular Medicine in the Helmholtz Association, Berlin, Germany
- German Centre for Cardiovascular Research, Berlin, Germany
| | - Lajos Markó
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
- Experimental and Clinical Research Center, A Cooperation of Charité - Universitätsmedizin Berlin and Max Delbrück Center for Molecular Medicine, Berlin, Germany
- Max Delbrück Center for Molecular Medicine in the Helmholtz Association, Berlin, Germany
- German Centre for Cardiovascular Research, Berlin, Germany
| | - Ulrike Löber
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
- Experimental and Clinical Research Center, A Cooperation of Charité - Universitätsmedizin Berlin and Max Delbrück Center for Molecular Medicine, Berlin, Germany
- Max Delbrück Center for Molecular Medicine in the Helmholtz Association, Berlin, Germany
- German Centre for Cardiovascular Research, Berlin, Germany
| | - Edgar Kigozi
- Makerere University, College of Health Sciences, Department of Immunology and Molecular Biology, Kampala, Uganda
| | - Carolyne Atugonza
- Makerere University, College of Health Sciences, Department of Immunology and Molecular Biology, Kampala, Uganda
| | - Richard Munana
- Department of Nephrology and Medical Intensive Care, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Denis Mawanda
- Makerere University Lung Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | - Rogers Sekibira
- Makerere University Lung Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | - Esther Uwimaana
- Makerere University Lung Institute, Makerere University College of Health Sciences, Kampala, Uganda
- Makerere University, College of Health Sciences, Department of Immunology and Molecular Biology, Kampala, Uganda
| | - Patricia Alupo
- Makerere University Lung Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | - Robert Kalyesubula
- African Community Center for Social Sustainability (ACCESS), Department of Research, Nakaseke, Uganda
- Makerere University, College of Health Sciences, Department of Medicine, Kampala, Uganda
| | - Felix Knauf
- Department of Nephrology and Medical Intensive Care, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Trishul Siddharthan
- University of Miami, School of Medicine, Division of pulmonary and critical care medicine, Miami, Florida, USA
| | - Bernard S. Bagaya
- Makerere University, College of Health Sciences, Department of Immunology and Molecular Biology, Kampala, Uganda
| | - David P. Kateete
- Makerere University, College of Health Sciences, Department of Immunology and Molecular Biology, Kampala, Uganda
| | - Moses L. Joloba
- Makerere University, College of Health Sciences, Department of Immunology and Molecular Biology, Kampala, Uganda
| | - Nelson K. Sewankambo
- Makerere University, College of Health Sciences, Department of Medicine, Kampala, Uganda
| | - Daudi Jjingo
- Makerere University, College of Computing and Information Sciences, Department of Computer Science, Kampala, Uganda
- African Center of Excellence in Bioinformatics and Data Science, Infectious Diseases Institute, Kampala, Uganda
| | - Bruce Kirenga
- Makerere University Lung Institute, Makerere University College of Health Sciences, Kampala, Uganda
- Makerere University, College of Health Sciences, Department of Medicine, Kampala, Uganda
| | - William Checkley
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland, USA
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Sofia K. Forslund
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
- Experimental and Clinical Research Center, A Cooperation of Charité - Universitätsmedizin Berlin and Max Delbrück Center for Molecular Medicine, Berlin, Germany
- Max Delbrück Center for Molecular Medicine in the Helmholtz Association, Berlin, Germany
- German Centre for Cardiovascular Research, Berlin, Germany
- Berlin Institute of Health (BIH), Berlin, Germany
- European Molecular Biology Laboratory, Structural and Computational Biology Unit, Heidelberg, Germany
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Bernabe-Ortiz A, Carrillo-Larco RM, Gilman RH, Smeeth L, Checkley W, Miranda JJ. Skeletal muscle mass and all-cause mortality: Findings from the CRONICAS cohort study. Trop Med Int Health 2023; 28:107-115. [PMID: 36573344 PMCID: PMC9945657 DOI: 10.1111/tmi.13844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVE We aimed (1) to evaluate the agreement between two methods (equation and bio-impedance analysis [BIA]) to estimate skeletal muscle mass (SMM), and (2) to assess if SMM was associated with all-cause mortality risk in individuals across different geographical sites in Peru. METHODS We used data from the CRONICAS Cohort Study (2010-2018), a population-based longitudinal study in Peru to assess cardiopulmonary risk factors from different geographical settings. SMM was computed as a function of weight, height, sex and age (Lee equation) and by BIA. All-cause mortality was retrieved from national vital records. Cox proportional-hazard models were developed and results presented as hazard ratios (HRs) with 95% confidence intervals (95% CIs). RESULTS At baseline, 3216 subjects, 51.5% women, mean age 55.7 years, were analysed. The mean SMM was 23.1 kg (standard deviation [SD]: 6.0) by Lee equation, and 22.7 (SD: 5.6) by BIA. Correlation between SMM estimations was strong (Pearson's ρ coefficient = 0.89, p < 0.001); whereas Bland-Altman analysis showed a small mean difference. Mean follow-up was 7.0 (SD: 1.0) years, and there were 172 deaths. In the multivariable model, each additional kg in SMM was associated with a 19% reduction in mortality risk (HR = 0.81; 95% CI: 0.75-0.88) using the Lee equation, but such estimate was not significant when using BIA (HR = 0.98; 95% CI: 0.94-1.03). Compared to the lowest tertile, subjects at the highest SMM tertile had a 56% reduction in risk of mortality using the Lee equation, but there was no such association when using BIA estimations. CONCLUSION There is a strong correlation and agreement between SMM estimates obtained by the Lee equation and BIA. However, an association between SMM and all-cause mortality exists only when the Lee equation is used. Our findings call for appropriate use of approaches to estimate SMM, and there should be a focus on muscle mass in promoting healthier ageing.
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Affiliation(s)
- Antonio Bernabe-Ortiz
- CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Rodrigo M. Carrillo-Larco
- CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru
- Department of Epidemiology and Biostatistics, School of Public Health, Imperial College London, UK
| | - Robert H. Gilman
- CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, USA
| | - Liam Smeeth
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, UK
| | - William Checkley
- CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, USA
| | - J. Jaime Miranda
- CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru
- Department of Medicine, School of Medicine, Universidad Peruana Cayetano Heredia, Lima, Peru
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Checkley W. Tuberculosis, Wildfires, and Case-crossover Studies: An Epidemiological Trifecta? Am J Respir Crit Care Med 2023; 207:242-243. [PMID: 36315435 PMCID: PMC9896637 DOI: 10.1164/rccm.202210-1936ed] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Affiliation(s)
- William Checkley
- Division of Pulmonary and Critical CareJohns Hopkins UniversityBaltimore, Maryland
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Ye W, Pillarisetti A, de León O, Steenland K, Peel JL, Clark ML, Checkley W, Underhill LJ, Quinn A, Balakrishnan K, Garg SS, McCracken JP, Thompson LM, Díaz-Artiga A, Rosa G, Davila-Roman VG, de las Fuentes L, Papageorghiou AT, Chen Y, Wang J, Thomas FC. Baseline associations between household air pollution exposure and blood pressure among pregnant women in the Household Air Pollution Intervention Network (HAPIN) multi-country randomized controlled trial. medRxiv 2023:2023.01.23.23284847. [PMID: 36747716 PMCID: PMC9901046 DOI: 10.1101/2023.01.23.23284847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Cooking and heating using solid fuels can result in dangerous levels of exposure to household air pollution (HAP). HAPIN is an ongoing randomized controlled trial assessing the impact of a liquified petroleum gas stove and fuel intervention on HAP exposure and health in Guatemala, India, Peru, and Rwanda among households that rely primarily on solid cooking fuels. Given the potential impacts of HAP exposure on cardiovascular outcomes during pregnancy, we seek to characterize the relationship between personal exposures to HAP and blood pressure among pregnant women at baseline (prior to intervention) in the study. We assessed associations between PM2.5 (particulate matter with an aerodynamic diameter ≤2.5 μm), BC (black carbon), and CO (carbon monoxide) exposures and blood pressure at baseline, prior to intervention, among 3195 pregnant women between 9 and 19 weeks of gestation. We measured 24-hour personal exposure to PM2.5/BC/CO and gestational blood pressure. Multivariable linear regression models were used to evaluate associations between personal exposures to three air pollutants and blood pressure parameters. Trial-wide, we found moderate increases in systolic blood pressure (SBP) and decreases in diastolic blood pressure (DBP) as exposure to PM2.5, BC, and CO increased. None of these associations, however, were significant at the 0.05 level. HAP exposure and blood pressure associations were inconsistent in direction and magnitude within each country. We observed effect modification by body mass index (BMI) in India and Peru. Compared to women with normal weights, obese women in India and Peru (but not in Rwanda or Guatemala) had higher SBP per unit increase in log transformed PM2.5 and BC exposures. We did not find a cross-sectional association between HAP exposure and blood pressure in pregnant women; however, HAP may be associated with higher blood pressure in pregnant women who are obese, but this increase was not consistent across settings.
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Affiliation(s)
- Wenlu Ye
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
- Environmental Health Sciences, School of Public Health, University of California, Berkeley, California, USA
| | - Ajay Pillarisetti
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
- Environmental Health Sciences, School of Public Health, University of California, Berkeley, California, USA
| | - Oscar de León
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Kyle Steenland
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Jennifer L. Peel
- Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins, Colorado, USA
| | - Maggie L. Clark
- Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins, Colorado, USA
| | - William Checkley
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Lindsay J. Underhill
- Cardiovascular Division, Washington University School of Medicine, St. Louis, MO, USA
| | - Ashlinn Quinn
- Berkeley Air Monitoring Group, Berkeley, California, USA
| | - Kalpana Balakrishnan
- Department of Environmental Health Engineering, Sri Ramachandra Institute for Higher Education and Research (Deemed University), Chennai, India
| | - Sarada S. Garg
- Department of Environmental Health Engineering, Sri Ramachandra Institute for Higher Education and Research (Deemed University), Chennai, India
| | - John P. McCracken
- Global Health Institute, Collage of Public Health, University of Georgia, Athens, Georgia, USA
| | - Lisa M. Thompson
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA, USA
| | - Anaité Díaz-Artiga
- Center for Health Studies, Universidad del Valle de Guatemala, Guatemala
| | - Ghislaine Rosa
- Department of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
| | | | - Lisa de las Fuentes
- Cardiovascular Division, Washington University School of Medicine, St. Louis, MO, USA
| | - Aris T. Papageorghiou
- Nuffield Department of Women’s and Reproductive Health, University of Oxford, Oxford, UK
| | - Yunyun Chen
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Jiantong Wang
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
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Nolley EP, Sahetya SK, Hochberg CH, Hossen S, Hager DN, Brower RG, Stuart EA, Checkley W. Outcomes Among Mechanically Ventilated Patients With Severe Pneumonia and Acute Hypoxemic Respiratory Failure From SARS-CoV-2 and Other Etiologies. JAMA Netw Open 2023; 6:e2250401. [PMID: 36626168 PMCID: PMC9856712 DOI: 10.1001/jamanetworkopen.2022.50401] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
IMPORTANCE Early observations suggested that COVID-19 pneumonia had a higher mortality rate than other causes of pneumonia. OBJECTIVE To compare outcomes between mechanically ventilated patients with pneumonia due to COVID-19 (March 2020 to June 2021) and other etiologies (July 2016 to December 2019). DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study was conducted at the Johns Hopkins Healthcare System among adult patients (aged ≥18 years) with pneumonia who required mechanical ventilation in the first 2 weeks of hospitalization. Clinical, laboratory, and mechanical ventilation data were extracted from admission to hospital discharge or death. EXPOSURES Pneumonia due to COVID-19. MAIN OUTCOMES AND MEASURES The primary outcome was 90-day in-hospital mortality. Secondary outcomes were time to liberation from mechanical ventilation, hospital length of stay, static respiratory system compliance, and ventilatory ratio. Unadjusted and multivariable-adjusted logistic regression, proportional hazards regression, and doubly robust regression were used in propensity score-matched sets to compare clinical outcomes. RESULTS Overall, 719 patients (mean [SD] age, 61.8 [15.3] years; 442 [61.5%] were male; 460 [64.0%] belonged to a minoritized racial group and 253 [35.2%] were White) with severe COVID-19 pneumonia and 1127 patients (mean [SD] age, 60.9 [15.8] years; 586 [52.0%] were male; 459 [40.7%] belonged to a minoritized racial group and 655 [58.1%] were White) with severe non-COVID-19 pneumonia. In unadjusted analyses, patients with COVID-19 pneumonia had higher 90-day mortality (odds ratio, 1.21, 95% CI 1.04-1.41), longer time on mechanical ventilation (subdistribution hazard ratio 0.72, 95% CI 0.63-0.81), and lower compliance (32.0 vs 28.4 mL/kg PBW/cm H2O; P < .001) when compared with those with non-COVID-19 pneumonia. In propensity score-matched analyses, patients with COVID-19 pneumonia were equally likely to die within 90 days as those with non-COVID-19 pneumonia (odds ratio, 1.04; 95% CI, 0.81 to 1.35; P = .85), had similar respiratory system compliance (mean difference, 1.82 mL/cm H2O; 95% CI, -1.53 to 5.17 mL/cm H2O; P = .28) and ventilatory ratio (mean difference, -0.05; 95% CI, -0.22 to 0.11; P = .52), but had lower rates of liberation from mechanical ventilation (subdistribution hazard ratio, 0.81; 95% CI, 0.65 to 1.00) when compared with those with non-COVID-19 pneumonia. Patients with COVID-19 pneumonia had somewhat lower rates of being discharged from the hospital alive at 90 days (subdistribution hazard ratio, 0.83; 95% CI, 0.68 to 1.01) than those with non-COVID-19 pneumonia; however, this was not statistically significant. CONCLUSIONS AND RELEVANCE In this study, mechanically ventilated patients with severe COVID-19 pneumonia had similar mortality rates as patients with other causes of severe pneumonia but longer times to liberation from mechanical ventilation. Mechanical ventilation use in COVID-19 pneumonia should follow the same evidence-based guidelines as for any pneumonia.
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Affiliation(s)
- Eric P. Nolley
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Sarina K. Sahetya
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Chad H. Hochberg
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Shakir Hossen
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - David N. Hager
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Roy G. Brower
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Elizabeth A. Stuart
- Bloomberg School of Public Health, Department of Mental Health, Johns Hopkins University, Baltimore, Maryland
| | - William Checkley
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, Maryland
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Rajamani KD, Sambandam S, Mukhopadhyay K, Puttaswamy N, Thangavel G, Natesan D, Ramasamy R, Sendhil S, Natarajan A, Aravindalochan V, Pillarisetti A, Johnson M, Rosenthal J, Steenland K, Piedhrahita R, Peel J, Clark ML, Boyd Barr D, Rajkumar S, Young B, Jabbarzadeh S, Rosa G, Kirby M, Underhill LJ, Diaz-Artiga A, Lovvorn A, Checkley W, Clasen T, Balakrishnan K. Visualizing Field Data Collection Procedures of Exposure and Biomarker Assessments for the Household Air Pollution Intervention Network Trial in India. J Vis Exp 2022. [PMID: 36622010 DOI: 10.3791/64144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Here, we present a visual representation of standard procedures to collect population-level data on personal exposures to household air pollution (HAP) from two different study sites in a resource-constrained setting of Tamil Nadu, India. Particulate matter PM2.5 (particles smaller than 2.5 microns in aerodynamic diameter), carbon monoxide (CO), and black carbon (BC) were measured in pregnant mothers (M), other adult women (OAW), and children (C) at various times over a 4 year period. In addition, stove usage monitoring (SUMs) with data-logging thermometers and ambient measurements of air pollution were carried out. Furthermore, the feasibility of collecting biological samples (urine and dried blood spots [DBSs]) from study participants at the field sites was successfully demonstrated. Based on findings from this and earlier studies, the methods used here have enhanced the data quality and avoided issues with household air pollution and biological sample collection in resource-constrained situations. The procedures established may be a valuable educational tool and resource for researchers conducting similar air pollution and health studies in India and other low- and middle-income countries (LMICs).
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Affiliation(s)
- Karthikeyan D Rajamani
- Department of Environmental Health Engineering, ICMR Center for Advanced Research on Air Quality, Climate and Health, Faculty of Public Health, Sri Ramachandra Institute of Higher Education and Research (Deemed University)
| | - Sankar Sambandam
- Department of Environmental Health Engineering, ICMR Center for Advanced Research on Air Quality, Climate and Health, Faculty of Public Health, Sri Ramachandra Institute of Higher Education and Research (Deemed University);
| | - Krishnendu Mukhopadhyay
- Department of Environmental Health Engineering, ICMR Center for Advanced Research on Air Quality, Climate and Health, Faculty of Public Health, Sri Ramachandra Institute of Higher Education and Research (Deemed University)
| | - Naveen Puttaswamy
- Department of Environmental Health Engineering, ICMR Center for Advanced Research on Air Quality, Climate and Health, Faculty of Public Health, Sri Ramachandra Institute of Higher Education and Research (Deemed University)
| | - Gurusamy Thangavel
- Department of Environmental Health Engineering, ICMR Center for Advanced Research on Air Quality, Climate and Health, Faculty of Public Health, Sri Ramachandra Institute of Higher Education and Research (Deemed University)
| | - Durairaj Natesan
- Department of Environmental Health Engineering, ICMR Center for Advanced Research on Air Quality, Climate and Health, Faculty of Public Health, Sri Ramachandra Institute of Higher Education and Research (Deemed University)
| | - Rengaraj Ramasamy
- Department of Environmental Health Engineering, ICMR Center for Advanced Research on Air Quality, Climate and Health, Faculty of Public Health, Sri Ramachandra Institute of Higher Education and Research (Deemed University)
| | - Saritha Sendhil
- Department of Environmental Health Engineering, ICMR Center for Advanced Research on Air Quality, Climate and Health, Faculty of Public Health, Sri Ramachandra Institute of Higher Education and Research (Deemed University)
| | - Amudha Natarajan
- Department of Environmental Health Engineering, ICMR Center for Advanced Research on Air Quality, Climate and Health, Faculty of Public Health, Sri Ramachandra Institute of Higher Education and Research (Deemed University)
| | - Vigneswari Aravindalochan
- Department of Environmental Health Engineering, ICMR Center for Advanced Research on Air Quality, Climate and Health, Faculty of Public Health, Sri Ramachandra Institute of Higher Education and Research (Deemed University)
| | - Ajay Pillarisetti
- Division of Environmental Health Sciences, University of California, Berkeley
| | | | - Joshua Rosenthal
- Division of International Epidemiology and Population Studies, National Institutes of Health
| | - Kyle Steenland
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University
| | | | - Jennifer Peel
- Department of Environmental and Radiological Health Sciences, Colorado State University
| | - Maggie L Clark
- Department of Environmental and Radiological Health Sciences, Colorado State University
| | - Dana Boyd Barr
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University
| | - Sarah Rajkumar
- Department of Environmental and Radiological Health Sciences, Colorado State University
| | - Bonnie Young
- Department of Environmental and Radiological Health Sciences, Colorado State University
| | - Shirin Jabbarzadeh
- Department of Biostatistics and Informatics, Rollins School of Public Health, Emory University
| | - Ghislaine Rosa
- Department of Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine
| | - Miles Kirby
- Department of Global Health & Population, Harvard, T.H. Chan School of Public Health
| | - Lindsay J Underhill
- Cardiovascular Division, Washington University School of Medicine, Washington University
| | | | - Amy Lovvorn
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University
| | - William Checkley
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University
| | - Thomas Clasen
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University
| | - Kalpana Balakrishnan
- Department of Environmental Health Engineering, ICMR Center for Advanced Research on Air Quality, Climate and Health, Faculty of Public Health, Sri Ramachandra Institute of Higher Education and Research (Deemed University)
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Jackson P, Padalkar R, Katagira W, Mortimer K, Rykiel NA, Robertson NM, Pollard SL, Alupo P, Checkley W, Kirenga B, Siddharthan T. Development and validation of an interstitial lung disease exposure questionnaire for sub-Saharan Africa. ERJ Open Res 2022; 8:00205-2022. [PMID: 36578631 PMCID: PMC9792102 DOI: 10.1183/23120541.00205-2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 06/06/2022] [Indexed: 02/01/2023] Open
Abstract
Background American Thoracic Society/European Respiratory Society guidelines recommend context-specific exposure assessments to diagnose interstitial lung disease (ILD). In sub-Saharan Africa, ILD diagnoses are rare, and locally validated ILD exposure questionnaires are not used. Methods A physician-administered ILD exposure questionnaire was developed using a four-step mixed-methods modified Delphi approach. First, ILD questionnaires from high-income countries and data from Pneumotox were reviewed, compiled and face-validated. Second, a local pilot group of ILD experts ranked item relevance using a Likert scale and suggested additions. Third, the questionnaire format and pilot rankings were addressed in a focus group discussion that was analysed using grounded theory. Finally, following focus group discussion modifications, the resulting items (with three duplicate item groups for evaluation of internal consistency) were ranked for importance by members of the Pan-African Thoracic Society (PATS). Results Face validation resulted in 82 items in four categories: "Smoking and Drugs", "Environmental Exposures", "Occupations" and "Medications". Pilot group (n=10) ranking revealed 27 outliers and 30 novel suggestions. Focus group (n=12) discussion resulted in 10 item deletions, 14 additions and 22 re-wordings; themes included desire for extensive questionnaires and stigma sensitivity. Final validation involved 58 PATS members (mean±sd age 46±10.6 years, 76% male, from 17 countries) ranking 84 items derived from previous steps and three duplicate question groups. The questionnaire was internally consistent (Cronbach's α >0.80) and ultimately included 73 items. Conclusion This mixed-methods study included experts from 17 countries in sub-Saharan Africa and successfully developed a 73-item ILD exposure questionnaire for sub-Saharan Africa. African pulmonary experts valued region-specific additions and ranked several items from existing ILD questionnaires as unimportant.
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Affiliation(s)
- Peter Jackson
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, MD, USA,Division of Pulmonary and Critical Care, Virginia Commonwealth University, Richmond, VA, USA,Corresponding author: Peter Jackson ()
| | - Roma Padalkar
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, MD, USA,Rowan University School of Osteopathic Medicine, Stratford, NJ, USA
| | | | | | - Natalie A. Rykiel
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, MD, USA,Division of Pulmonary and Critical Care, Johns Hopkins University, Baltimore, MD, USA
| | | | - Suzanne L. Pollard
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, MD, USA,Division of Pulmonary and Critical Care, Johns Hopkins University, Baltimore, MD, USA
| | - Patricia Alupo
- Makerere Lung Institute, Makerere University, Kampala, Uganda
| | - William Checkley
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, MD, USA,Division of Pulmonary and Critical Care, Johns Hopkins University, Baltimore, MD, USA
| | - Bruce Kirenga
- Makerere Lung Institute, Makerere University, Kampala, Uganda
| | - Trishul Siddharthan
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, MD, USA,Division of Pulmonary and Critical Care, University of Miami, Miami, FL, USA
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Clasen TF, Chang HH, Thompson LM, Kirby MA, Balakrishnan K, Díaz-Artiga A, McCracken JP, Rosa G, Steenland K, Younger A, Aravindalochanan V, Barr DB, Castañaza A, Chen Y, Chiang M, Clark ML, Garg S, Hartinger S, Jabbarzadeh S, Johnson MA, Kim DY, Lovvorn AE, McCollum ED, Monroy L, Moulton LH, Mukeshimana A, Mukhopadhyay K, Naeher LP, Ndagijimana F, Papageorghiou A, Piedrahita R, Pillarisetti A, Puttaswamy N, Quinn A, Ramakrishnan U, Sambandam S, Sinharoy SS, Thangavel G, Underhill LJ, Waller LA, Wang J, Williams KN, Rosenthal JP, Checkley W, Peel JL. Liquefied Petroleum Gas or Biomass for Cooking and Effects on Birth Weight. N Engl J Med 2022; 387:1735-1746. [PMID: 36214599 PMCID: PMC9710426 DOI: 10.1056/nejmoa2206734] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Exposure during pregnancy to household air pollution caused by the burning of solid biomass fuel is associated with adverse health outcomes, including low birth weight. Whether the replacement of a biomass cookstove with a liquefied petroleum gas (LPG) cookstove would result in an increase in birth weight is unclear. METHODS We performed a randomized, controlled trial involving pregnant women (18 to <35 years of age and at 9 to <20 weeks' gestation as confirmed on ultrasonography) in Guatemala, India, Peru, and Rwanda. The women were assigned in a 1:1 ratio to use a free LPG cookstove and fuel (intervention group) or to continue using a biomass cookstove (control group). Birth weight, one of four prespecified primary outcomes, was the primary outcome for this report; data for the other three outcomes are not yet available. Birth weight was measured within 24 hours after birth. In addition, 24-hour personal exposures to fine particulate matter (particles with a diameter of ≤2.5 μm [PM2.5]), black carbon, and carbon monoxide were measured at baseline and twice during pregnancy. RESULTS A total of 3200 women underwent randomization; 1593 were assigned to the intervention group, and 1607 to the control group. Uptake of the intervention was nearly complete, with traditional biomass cookstoves being used at a median rate of less than 1 day per month. After randomization, the median 24-hour personal exposure to fine particulate matter was 23.9 μg per cubic meter in the intervention group and 70.7 μg per cubic meter in the control group. Among 3061 live births, a valid birth weight was available for 94.9% of the infants born to women in the intervention group and for 92.7% of infants born to those in the control group. The mean (±SD) birth weight was 2921±474.3 g in the intervention group and 2898±467.9 g in the control group, for an adjusted mean difference of 19.6 g (95% confidence interval, -10.1 to 49.2). CONCLUSIONS The birth weight of infants did not differ significantly between those born to women who used LPG cookstoves and those born to women who used biomass cookstoves. (Funded by the National Institutes of Health and the Bill and Melinda Gates Foundation; HAPIN ClinicalTrials.gov number, NCT02944682.).
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Affiliation(s)
- Thomas F Clasen
- From Emory University, Atlanta (T.F.C., H.H.C., L.M.T., K.S., D.B.B., Y.C., S.J., A.E.L., U.R., S.S.S., L.A.W., J.W.), and the University of Georgia, Athens (J.P.M., L.P.N.) - both in Georgia; the Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., V.A., S.G., K.M., N.P., S.S., G.T.); Universidad del Valle de Guatemala, Guatemala City (A.D.-A., A.C., L.M.); the London School of Hygiene and Tropical Medicine, London (G.R.), and the University of Oxford, Oxford (A. Papageorghiou) - both in the United Kingdom; the University of California, San Francisco, San Francisco (A.Y.), and the Berkeley Air Monitoring Group (M.A.J., R.P., A.Q.) and the University of California, Berkeley (A. Pillarisetti), Berkeley - all in California; Asociación Benéfica PRISMA (M.C.) and Universidad Peruana Cayetano Heredia (S.H.) - both in Lima, Peru; Colorado State University, Fort Collins (M.L.C., J.L.P.); the National Institutes of Health, Bethesda (D.-Y.K., J.P.R.), and Johns Hopkins University, Baltimore (E.D.M., L.H.M., K.N.W., W.C.) - both in Maryland; the Eagle Research Center, Kigali, Rwanda (A.M., F.N.); and Washington University in St. Louis, St. Louis (L.J.U.)
| | - Howard H Chang
- From Emory University, Atlanta (T.F.C., H.H.C., L.M.T., K.S., D.B.B., Y.C., S.J., A.E.L., U.R., S.S.S., L.A.W., J.W.), and the University of Georgia, Athens (J.P.M., L.P.N.) - both in Georgia; the Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., V.A., S.G., K.M., N.P., S.S., G.T.); Universidad del Valle de Guatemala, Guatemala City (A.D.-A., A.C., L.M.); the London School of Hygiene and Tropical Medicine, London (G.R.), and the University of Oxford, Oxford (A. Papageorghiou) - both in the United Kingdom; the University of California, San Francisco, San Francisco (A.Y.), and the Berkeley Air Monitoring Group (M.A.J., R.P., A.Q.) and the University of California, Berkeley (A. Pillarisetti), Berkeley - all in California; Asociación Benéfica PRISMA (M.C.) and Universidad Peruana Cayetano Heredia (S.H.) - both in Lima, Peru; Colorado State University, Fort Collins (M.L.C., J.L.P.); the National Institutes of Health, Bethesda (D.-Y.K., J.P.R.), and Johns Hopkins University, Baltimore (E.D.M., L.H.M., K.N.W., W.C.) - both in Maryland; the Eagle Research Center, Kigali, Rwanda (A.M., F.N.); and Washington University in St. Louis, St. Louis (L.J.U.)
| | - Lisa M Thompson
- From Emory University, Atlanta (T.F.C., H.H.C., L.M.T., K.S., D.B.B., Y.C., S.J., A.E.L., U.R., S.S.S., L.A.W., J.W.), and the University of Georgia, Athens (J.P.M., L.P.N.) - both in Georgia; the Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., V.A., S.G., K.M., N.P., S.S., G.T.); Universidad del Valle de Guatemala, Guatemala City (A.D.-A., A.C., L.M.); the London School of Hygiene and Tropical Medicine, London (G.R.), and the University of Oxford, Oxford (A. Papageorghiou) - both in the United Kingdom; the University of California, San Francisco, San Francisco (A.Y.), and the Berkeley Air Monitoring Group (M.A.J., R.P., A.Q.) and the University of California, Berkeley (A. Pillarisetti), Berkeley - all in California; Asociación Benéfica PRISMA (M.C.) and Universidad Peruana Cayetano Heredia (S.H.) - both in Lima, Peru; Colorado State University, Fort Collins (M.L.C., J.L.P.); the National Institutes of Health, Bethesda (D.-Y.K., J.P.R.), and Johns Hopkins University, Baltimore (E.D.M., L.H.M., K.N.W., W.C.) - both in Maryland; the Eagle Research Center, Kigali, Rwanda (A.M., F.N.); and Washington University in St. Louis, St. Louis (L.J.U.)
| | - Miles A Kirby
- From Emory University, Atlanta (T.F.C., H.H.C., L.M.T., K.S., D.B.B., Y.C., S.J., A.E.L., U.R., S.S.S., L.A.W., J.W.), and the University of Georgia, Athens (J.P.M., L.P.N.) - both in Georgia; the Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., V.A., S.G., K.M., N.P., S.S., G.T.); Universidad del Valle de Guatemala, Guatemala City (A.D.-A., A.C., L.M.); the London School of Hygiene and Tropical Medicine, London (G.R.), and the University of Oxford, Oxford (A. Papageorghiou) - both in the United Kingdom; the University of California, San Francisco, San Francisco (A.Y.), and the Berkeley Air Monitoring Group (M.A.J., R.P., A.Q.) and the University of California, Berkeley (A. Pillarisetti), Berkeley - all in California; Asociación Benéfica PRISMA (M.C.) and Universidad Peruana Cayetano Heredia (S.H.) - both in Lima, Peru; Colorado State University, Fort Collins (M.L.C., J.L.P.); the National Institutes of Health, Bethesda (D.-Y.K., J.P.R.), and Johns Hopkins University, Baltimore (E.D.M., L.H.M., K.N.W., W.C.) - both in Maryland; the Eagle Research Center, Kigali, Rwanda (A.M., F.N.); and Washington University in St. Louis, St. Louis (L.J.U.)
| | - Kalpana Balakrishnan
- From Emory University, Atlanta (T.F.C., H.H.C., L.M.T., K.S., D.B.B., Y.C., S.J., A.E.L., U.R., S.S.S., L.A.W., J.W.), and the University of Georgia, Athens (J.P.M., L.P.N.) - both in Georgia; the Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., V.A., S.G., K.M., N.P., S.S., G.T.); Universidad del Valle de Guatemala, Guatemala City (A.D.-A., A.C., L.M.); the London School of Hygiene and Tropical Medicine, London (G.R.), and the University of Oxford, Oxford (A. Papageorghiou) - both in the United Kingdom; the University of California, San Francisco, San Francisco (A.Y.), and the Berkeley Air Monitoring Group (M.A.J., R.P., A.Q.) and the University of California, Berkeley (A. Pillarisetti), Berkeley - all in California; Asociación Benéfica PRISMA (M.C.) and Universidad Peruana Cayetano Heredia (S.H.) - both in Lima, Peru; Colorado State University, Fort Collins (M.L.C., J.L.P.); the National Institutes of Health, Bethesda (D.-Y.K., J.P.R.), and Johns Hopkins University, Baltimore (E.D.M., L.H.M., K.N.W., W.C.) - both in Maryland; the Eagle Research Center, Kigali, Rwanda (A.M., F.N.); and Washington University in St. Louis, St. Louis (L.J.U.)
| | - Anaité Díaz-Artiga
- From Emory University, Atlanta (T.F.C., H.H.C., L.M.T., K.S., D.B.B., Y.C., S.J., A.E.L., U.R., S.S.S., L.A.W., J.W.), and the University of Georgia, Athens (J.P.M., L.P.N.) - both in Georgia; the Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., V.A., S.G., K.M., N.P., S.S., G.T.); Universidad del Valle de Guatemala, Guatemala City (A.D.-A., A.C., L.M.); the London School of Hygiene and Tropical Medicine, London (G.R.), and the University of Oxford, Oxford (A. Papageorghiou) - both in the United Kingdom; the University of California, San Francisco, San Francisco (A.Y.), and the Berkeley Air Monitoring Group (M.A.J., R.P., A.Q.) and the University of California, Berkeley (A. Pillarisetti), Berkeley - all in California; Asociación Benéfica PRISMA (M.C.) and Universidad Peruana Cayetano Heredia (S.H.) - both in Lima, Peru; Colorado State University, Fort Collins (M.L.C., J.L.P.); the National Institutes of Health, Bethesda (D.-Y.K., J.P.R.), and Johns Hopkins University, Baltimore (E.D.M., L.H.M., K.N.W., W.C.) - both in Maryland; the Eagle Research Center, Kigali, Rwanda (A.M., F.N.); and Washington University in St. Louis, St. Louis (L.J.U.)
| | - John P McCracken
- From Emory University, Atlanta (T.F.C., H.H.C., L.M.T., K.S., D.B.B., Y.C., S.J., A.E.L., U.R., S.S.S., L.A.W., J.W.), and the University of Georgia, Athens (J.P.M., L.P.N.) - both in Georgia; the Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., V.A., S.G., K.M., N.P., S.S., G.T.); Universidad del Valle de Guatemala, Guatemala City (A.D.-A., A.C., L.M.); the London School of Hygiene and Tropical Medicine, London (G.R.), and the University of Oxford, Oxford (A. Papageorghiou) - both in the United Kingdom; the University of California, San Francisco, San Francisco (A.Y.), and the Berkeley Air Monitoring Group (M.A.J., R.P., A.Q.) and the University of California, Berkeley (A. Pillarisetti), Berkeley - all in California; Asociación Benéfica PRISMA (M.C.) and Universidad Peruana Cayetano Heredia (S.H.) - both in Lima, Peru; Colorado State University, Fort Collins (M.L.C., J.L.P.); the National Institutes of Health, Bethesda (D.-Y.K., J.P.R.), and Johns Hopkins University, Baltimore (E.D.M., L.H.M., K.N.W., W.C.) - both in Maryland; the Eagle Research Center, Kigali, Rwanda (A.M., F.N.); and Washington University in St. Louis, St. Louis (L.J.U.)
| | - Ghislaine Rosa
- From Emory University, Atlanta (T.F.C., H.H.C., L.M.T., K.S., D.B.B., Y.C., S.J., A.E.L., U.R., S.S.S., L.A.W., J.W.), and the University of Georgia, Athens (J.P.M., L.P.N.) - both in Georgia; the Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., V.A., S.G., K.M., N.P., S.S., G.T.); Universidad del Valle de Guatemala, Guatemala City (A.D.-A., A.C., L.M.); the London School of Hygiene and Tropical Medicine, London (G.R.), and the University of Oxford, Oxford (A. Papageorghiou) - both in the United Kingdom; the University of California, San Francisco, San Francisco (A.Y.), and the Berkeley Air Monitoring Group (M.A.J., R.P., A.Q.) and the University of California, Berkeley (A. Pillarisetti), Berkeley - all in California; Asociación Benéfica PRISMA (M.C.) and Universidad Peruana Cayetano Heredia (S.H.) - both in Lima, Peru; Colorado State University, Fort Collins (M.L.C., J.L.P.); the National Institutes of Health, Bethesda (D.-Y.K., J.P.R.), and Johns Hopkins University, Baltimore (E.D.M., L.H.M., K.N.W., W.C.) - both in Maryland; the Eagle Research Center, Kigali, Rwanda (A.M., F.N.); and Washington University in St. Louis, St. Louis (L.J.U.)
| | - Kyle Steenland
- From Emory University, Atlanta (T.F.C., H.H.C., L.M.T., K.S., D.B.B., Y.C., S.J., A.E.L., U.R., S.S.S., L.A.W., J.W.), and the University of Georgia, Athens (J.P.M., L.P.N.) - both in Georgia; the Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., V.A., S.G., K.M., N.P., S.S., G.T.); Universidad del Valle de Guatemala, Guatemala City (A.D.-A., A.C., L.M.); the London School of Hygiene and Tropical Medicine, London (G.R.), and the University of Oxford, Oxford (A. Papageorghiou) - both in the United Kingdom; the University of California, San Francisco, San Francisco (A.Y.), and the Berkeley Air Monitoring Group (M.A.J., R.P., A.Q.) and the University of California, Berkeley (A. Pillarisetti), Berkeley - all in California; Asociación Benéfica PRISMA (M.C.) and Universidad Peruana Cayetano Heredia (S.H.) - both in Lima, Peru; Colorado State University, Fort Collins (M.L.C., J.L.P.); the National Institutes of Health, Bethesda (D.-Y.K., J.P.R.), and Johns Hopkins University, Baltimore (E.D.M., L.H.M., K.N.W., W.C.) - both in Maryland; the Eagle Research Center, Kigali, Rwanda (A.M., F.N.); and Washington University in St. Louis, St. Louis (L.J.U.)
| | - Ashley Younger
- From Emory University, Atlanta (T.F.C., H.H.C., L.M.T., K.S., D.B.B., Y.C., S.J., A.E.L., U.R., S.S.S., L.A.W., J.W.), and the University of Georgia, Athens (J.P.M., L.P.N.) - both in Georgia; the Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., V.A., S.G., K.M., N.P., S.S., G.T.); Universidad del Valle de Guatemala, Guatemala City (A.D.-A., A.C., L.M.); the London School of Hygiene and Tropical Medicine, London (G.R.), and the University of Oxford, Oxford (A. Papageorghiou) - both in the United Kingdom; the University of California, San Francisco, San Francisco (A.Y.), and the Berkeley Air Monitoring Group (M.A.J., R.P., A.Q.) and the University of California, Berkeley (A. Pillarisetti), Berkeley - all in California; Asociación Benéfica PRISMA (M.C.) and Universidad Peruana Cayetano Heredia (S.H.) - both in Lima, Peru; Colorado State University, Fort Collins (M.L.C., J.L.P.); the National Institutes of Health, Bethesda (D.-Y.K., J.P.R.), and Johns Hopkins University, Baltimore (E.D.M., L.H.M., K.N.W., W.C.) - both in Maryland; the Eagle Research Center, Kigali, Rwanda (A.M., F.N.); and Washington University in St. Louis, St. Louis (L.J.U.)
| | - Vigneswari Aravindalochanan
- From Emory University, Atlanta (T.F.C., H.H.C., L.M.T., K.S., D.B.B., Y.C., S.J., A.E.L., U.R., S.S.S., L.A.W., J.W.), and the University of Georgia, Athens (J.P.M., L.P.N.) - both in Georgia; the Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., V.A., S.G., K.M., N.P., S.S., G.T.); Universidad del Valle de Guatemala, Guatemala City (A.D.-A., A.C., L.M.); the London School of Hygiene and Tropical Medicine, London (G.R.), and the University of Oxford, Oxford (A. Papageorghiou) - both in the United Kingdom; the University of California, San Francisco, San Francisco (A.Y.), and the Berkeley Air Monitoring Group (M.A.J., R.P., A.Q.) and the University of California, Berkeley (A. Pillarisetti), Berkeley - all in California; Asociación Benéfica PRISMA (M.C.) and Universidad Peruana Cayetano Heredia (S.H.) - both in Lima, Peru; Colorado State University, Fort Collins (M.L.C., J.L.P.); the National Institutes of Health, Bethesda (D.-Y.K., J.P.R.), and Johns Hopkins University, Baltimore (E.D.M., L.H.M., K.N.W., W.C.) - both in Maryland; the Eagle Research Center, Kigali, Rwanda (A.M., F.N.); and Washington University in St. Louis, St. Louis (L.J.U.)
| | - Dana B Barr
- From Emory University, Atlanta (T.F.C., H.H.C., L.M.T., K.S., D.B.B., Y.C., S.J., A.E.L., U.R., S.S.S., L.A.W., J.W.), and the University of Georgia, Athens (J.P.M., L.P.N.) - both in Georgia; the Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., V.A., S.G., K.M., N.P., S.S., G.T.); Universidad del Valle de Guatemala, Guatemala City (A.D.-A., A.C., L.M.); the London School of Hygiene and Tropical Medicine, London (G.R.), and the University of Oxford, Oxford (A. Papageorghiou) - both in the United Kingdom; the University of California, San Francisco, San Francisco (A.Y.), and the Berkeley Air Monitoring Group (M.A.J., R.P., A.Q.) and the University of California, Berkeley (A. Pillarisetti), Berkeley - all in California; Asociación Benéfica PRISMA (M.C.) and Universidad Peruana Cayetano Heredia (S.H.) - both in Lima, Peru; Colorado State University, Fort Collins (M.L.C., J.L.P.); the National Institutes of Health, Bethesda (D.-Y.K., J.P.R.), and Johns Hopkins University, Baltimore (E.D.M., L.H.M., K.N.W., W.C.) - both in Maryland; the Eagle Research Center, Kigali, Rwanda (A.M., F.N.); and Washington University in St. Louis, St. Louis (L.J.U.)
| | - Adly Castañaza
- From Emory University, Atlanta (T.F.C., H.H.C., L.M.T., K.S., D.B.B., Y.C., S.J., A.E.L., U.R., S.S.S., L.A.W., J.W.), and the University of Georgia, Athens (J.P.M., L.P.N.) - both in Georgia; the Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., V.A., S.G., K.M., N.P., S.S., G.T.); Universidad del Valle de Guatemala, Guatemala City (A.D.-A., A.C., L.M.); the London School of Hygiene and Tropical Medicine, London (G.R.), and the University of Oxford, Oxford (A. Papageorghiou) - both in the United Kingdom; the University of California, San Francisco, San Francisco (A.Y.), and the Berkeley Air Monitoring Group (M.A.J., R.P., A.Q.) and the University of California, Berkeley (A. Pillarisetti), Berkeley - all in California; Asociación Benéfica PRISMA (M.C.) and Universidad Peruana Cayetano Heredia (S.H.) - both in Lima, Peru; Colorado State University, Fort Collins (M.L.C., J.L.P.); the National Institutes of Health, Bethesda (D.-Y.K., J.P.R.), and Johns Hopkins University, Baltimore (E.D.M., L.H.M., K.N.W., W.C.) - both in Maryland; the Eagle Research Center, Kigali, Rwanda (A.M., F.N.); and Washington University in St. Louis, St. Louis (L.J.U.)
| | - Yunyun Chen
- From Emory University, Atlanta (T.F.C., H.H.C., L.M.T., K.S., D.B.B., Y.C., S.J., A.E.L., U.R., S.S.S., L.A.W., J.W.), and the University of Georgia, Athens (J.P.M., L.P.N.) - both in Georgia; the Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., V.A., S.G., K.M., N.P., S.S., G.T.); Universidad del Valle de Guatemala, Guatemala City (A.D.-A., A.C., L.M.); the London School of Hygiene and Tropical Medicine, London (G.R.), and the University of Oxford, Oxford (A. Papageorghiou) - both in the United Kingdom; the University of California, San Francisco, San Francisco (A.Y.), and the Berkeley Air Monitoring Group (M.A.J., R.P., A.Q.) and the University of California, Berkeley (A. Pillarisetti), Berkeley - all in California; Asociación Benéfica PRISMA (M.C.) and Universidad Peruana Cayetano Heredia (S.H.) - both in Lima, Peru; Colorado State University, Fort Collins (M.L.C., J.L.P.); the National Institutes of Health, Bethesda (D.-Y.K., J.P.R.), and Johns Hopkins University, Baltimore (E.D.M., L.H.M., K.N.W., W.C.) - both in Maryland; the Eagle Research Center, Kigali, Rwanda (A.M., F.N.); and Washington University in St. Louis, St. Louis (L.J.U.)
| | - Marilú Chiang
- From Emory University, Atlanta (T.F.C., H.H.C., L.M.T., K.S., D.B.B., Y.C., S.J., A.E.L., U.R., S.S.S., L.A.W., J.W.), and the University of Georgia, Athens (J.P.M., L.P.N.) - both in Georgia; the Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., V.A., S.G., K.M., N.P., S.S., G.T.); Universidad del Valle de Guatemala, Guatemala City (A.D.-A., A.C., L.M.); the London School of Hygiene and Tropical Medicine, London (G.R.), and the University of Oxford, Oxford (A. Papageorghiou) - both in the United Kingdom; the University of California, San Francisco, San Francisco (A.Y.), and the Berkeley Air Monitoring Group (M.A.J., R.P., A.Q.) and the University of California, Berkeley (A. Pillarisetti), Berkeley - all in California; Asociación Benéfica PRISMA (M.C.) and Universidad Peruana Cayetano Heredia (S.H.) - both in Lima, Peru; Colorado State University, Fort Collins (M.L.C., J.L.P.); the National Institutes of Health, Bethesda (D.-Y.K., J.P.R.), and Johns Hopkins University, Baltimore (E.D.M., L.H.M., K.N.W., W.C.) - both in Maryland; the Eagle Research Center, Kigali, Rwanda (A.M., F.N.); and Washington University in St. Louis, St. Louis (L.J.U.)
| | - Maggie L Clark
- From Emory University, Atlanta (T.F.C., H.H.C., L.M.T., K.S., D.B.B., Y.C., S.J., A.E.L., U.R., S.S.S., L.A.W., J.W.), and the University of Georgia, Athens (J.P.M., L.P.N.) - both in Georgia; the Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., V.A., S.G., K.M., N.P., S.S., G.T.); Universidad del Valle de Guatemala, Guatemala City (A.D.-A., A.C., L.M.); the London School of Hygiene and Tropical Medicine, London (G.R.), and the University of Oxford, Oxford (A. Papageorghiou) - both in the United Kingdom; the University of California, San Francisco, San Francisco (A.Y.), and the Berkeley Air Monitoring Group (M.A.J., R.P., A.Q.) and the University of California, Berkeley (A. Pillarisetti), Berkeley - all in California; Asociación Benéfica PRISMA (M.C.) and Universidad Peruana Cayetano Heredia (S.H.) - both in Lima, Peru; Colorado State University, Fort Collins (M.L.C., J.L.P.); the National Institutes of Health, Bethesda (D.-Y.K., J.P.R.), and Johns Hopkins University, Baltimore (E.D.M., L.H.M., K.N.W., W.C.) - both in Maryland; the Eagle Research Center, Kigali, Rwanda (A.M., F.N.); and Washington University in St. Louis, St. Louis (L.J.U.)
| | - Sarada Garg
- From Emory University, Atlanta (T.F.C., H.H.C., L.M.T., K.S., D.B.B., Y.C., S.J., A.E.L., U.R., S.S.S., L.A.W., J.W.), and the University of Georgia, Athens (J.P.M., L.P.N.) - both in Georgia; the Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., V.A., S.G., K.M., N.P., S.S., G.T.); Universidad del Valle de Guatemala, Guatemala City (A.D.-A., A.C., L.M.); the London School of Hygiene and Tropical Medicine, London (G.R.), and the University of Oxford, Oxford (A. Papageorghiou) - both in the United Kingdom; the University of California, San Francisco, San Francisco (A.Y.), and the Berkeley Air Monitoring Group (M.A.J., R.P., A.Q.) and the University of California, Berkeley (A. Pillarisetti), Berkeley - all in California; Asociación Benéfica PRISMA (M.C.) and Universidad Peruana Cayetano Heredia (S.H.) - both in Lima, Peru; Colorado State University, Fort Collins (M.L.C., J.L.P.); the National Institutes of Health, Bethesda (D.-Y.K., J.P.R.), and Johns Hopkins University, Baltimore (E.D.M., L.H.M., K.N.W., W.C.) - both in Maryland; the Eagle Research Center, Kigali, Rwanda (A.M., F.N.); and Washington University in St. Louis, St. Louis (L.J.U.)
| | - Stella Hartinger
- From Emory University, Atlanta (T.F.C., H.H.C., L.M.T., K.S., D.B.B., Y.C., S.J., A.E.L., U.R., S.S.S., L.A.W., J.W.), and the University of Georgia, Athens (J.P.M., L.P.N.) - both in Georgia; the Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., V.A., S.G., K.M., N.P., S.S., G.T.); Universidad del Valle de Guatemala, Guatemala City (A.D.-A., A.C., L.M.); the London School of Hygiene and Tropical Medicine, London (G.R.), and the University of Oxford, Oxford (A. Papageorghiou) - both in the United Kingdom; the University of California, San Francisco, San Francisco (A.Y.), and the Berkeley Air Monitoring Group (M.A.J., R.P., A.Q.) and the University of California, Berkeley (A. Pillarisetti), Berkeley - all in California; Asociación Benéfica PRISMA (M.C.) and Universidad Peruana Cayetano Heredia (S.H.) - both in Lima, Peru; Colorado State University, Fort Collins (M.L.C., J.L.P.); the National Institutes of Health, Bethesda (D.-Y.K., J.P.R.), and Johns Hopkins University, Baltimore (E.D.M., L.H.M., K.N.W., W.C.) - both in Maryland; the Eagle Research Center, Kigali, Rwanda (A.M., F.N.); and Washington University in St. Louis, St. Louis (L.J.U.)
| | - Shirin Jabbarzadeh
- From Emory University, Atlanta (T.F.C., H.H.C., L.M.T., K.S., D.B.B., Y.C., S.J., A.E.L., U.R., S.S.S., L.A.W., J.W.), and the University of Georgia, Athens (J.P.M., L.P.N.) - both in Georgia; the Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., V.A., S.G., K.M., N.P., S.S., G.T.); Universidad del Valle de Guatemala, Guatemala City (A.D.-A., A.C., L.M.); the London School of Hygiene and Tropical Medicine, London (G.R.), and the University of Oxford, Oxford (A. Papageorghiou) - both in the United Kingdom; the University of California, San Francisco, San Francisco (A.Y.), and the Berkeley Air Monitoring Group (M.A.J., R.P., A.Q.) and the University of California, Berkeley (A. Pillarisetti), Berkeley - all in California; Asociación Benéfica PRISMA (M.C.) and Universidad Peruana Cayetano Heredia (S.H.) - both in Lima, Peru; Colorado State University, Fort Collins (M.L.C., J.L.P.); the National Institutes of Health, Bethesda (D.-Y.K., J.P.R.), and Johns Hopkins University, Baltimore (E.D.M., L.H.M., K.N.W., W.C.) - both in Maryland; the Eagle Research Center, Kigali, Rwanda (A.M., F.N.); and Washington University in St. Louis, St. Louis (L.J.U.)
| | - Michael A Johnson
- From Emory University, Atlanta (T.F.C., H.H.C., L.M.T., K.S., D.B.B., Y.C., S.J., A.E.L., U.R., S.S.S., L.A.W., J.W.), and the University of Georgia, Athens (J.P.M., L.P.N.) - both in Georgia; the Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., V.A., S.G., K.M., N.P., S.S., G.T.); Universidad del Valle de Guatemala, Guatemala City (A.D.-A., A.C., L.M.); the London School of Hygiene and Tropical Medicine, London (G.R.), and the University of Oxford, Oxford (A. Papageorghiou) - both in the United Kingdom; the University of California, San Francisco, San Francisco (A.Y.), and the Berkeley Air Monitoring Group (M.A.J., R.P., A.Q.) and the University of California, Berkeley (A. Pillarisetti), Berkeley - all in California; Asociación Benéfica PRISMA (M.C.) and Universidad Peruana Cayetano Heredia (S.H.) - both in Lima, Peru; Colorado State University, Fort Collins (M.L.C., J.L.P.); the National Institutes of Health, Bethesda (D.-Y.K., J.P.R.), and Johns Hopkins University, Baltimore (E.D.M., L.H.M., K.N.W., W.C.) - both in Maryland; the Eagle Research Center, Kigali, Rwanda (A.M., F.N.); and Washington University in St. Louis, St. Louis (L.J.U.)
| | - Dong-Yun Kim
- From Emory University, Atlanta (T.F.C., H.H.C., L.M.T., K.S., D.B.B., Y.C., S.J., A.E.L., U.R., S.S.S., L.A.W., J.W.), and the University of Georgia, Athens (J.P.M., L.P.N.) - both in Georgia; the Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., V.A., S.G., K.M., N.P., S.S., G.T.); Universidad del Valle de Guatemala, Guatemala City (A.D.-A., A.C., L.M.); the London School of Hygiene and Tropical Medicine, London (G.R.), and the University of Oxford, Oxford (A. Papageorghiou) - both in the United Kingdom; the University of California, San Francisco, San Francisco (A.Y.), and the Berkeley Air Monitoring Group (M.A.J., R.P., A.Q.) and the University of California, Berkeley (A. Pillarisetti), Berkeley - all in California; Asociación Benéfica PRISMA (M.C.) and Universidad Peruana Cayetano Heredia (S.H.) - both in Lima, Peru; Colorado State University, Fort Collins (M.L.C., J.L.P.); the National Institutes of Health, Bethesda (D.-Y.K., J.P.R.), and Johns Hopkins University, Baltimore (E.D.M., L.H.M., K.N.W., W.C.) - both in Maryland; the Eagle Research Center, Kigali, Rwanda (A.M., F.N.); and Washington University in St. Louis, St. Louis (L.J.U.)
| | - Amy E Lovvorn
- From Emory University, Atlanta (T.F.C., H.H.C., L.M.T., K.S., D.B.B., Y.C., S.J., A.E.L., U.R., S.S.S., L.A.W., J.W.), and the University of Georgia, Athens (J.P.M., L.P.N.) - both in Georgia; the Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., V.A., S.G., K.M., N.P., S.S., G.T.); Universidad del Valle de Guatemala, Guatemala City (A.D.-A., A.C., L.M.); the London School of Hygiene and Tropical Medicine, London (G.R.), and the University of Oxford, Oxford (A. Papageorghiou) - both in the United Kingdom; the University of California, San Francisco, San Francisco (A.Y.), and the Berkeley Air Monitoring Group (M.A.J., R.P., A.Q.) and the University of California, Berkeley (A. Pillarisetti), Berkeley - all in California; Asociación Benéfica PRISMA (M.C.) and Universidad Peruana Cayetano Heredia (S.H.) - both in Lima, Peru; Colorado State University, Fort Collins (M.L.C., J.L.P.); the National Institutes of Health, Bethesda (D.-Y.K., J.P.R.), and Johns Hopkins University, Baltimore (E.D.M., L.H.M., K.N.W., W.C.) - both in Maryland; the Eagle Research Center, Kigali, Rwanda (A.M., F.N.); and Washington University in St. Louis, St. Louis (L.J.U.)
| | - Eric D McCollum
- From Emory University, Atlanta (T.F.C., H.H.C., L.M.T., K.S., D.B.B., Y.C., S.J., A.E.L., U.R., S.S.S., L.A.W., J.W.), and the University of Georgia, Athens (J.P.M., L.P.N.) - both in Georgia; the Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., V.A., S.G., K.M., N.P., S.S., G.T.); Universidad del Valle de Guatemala, Guatemala City (A.D.-A., A.C., L.M.); the London School of Hygiene and Tropical Medicine, London (G.R.), and the University of Oxford, Oxford (A. Papageorghiou) - both in the United Kingdom; the University of California, San Francisco, San Francisco (A.Y.), and the Berkeley Air Monitoring Group (M.A.J., R.P., A.Q.) and the University of California, Berkeley (A. Pillarisetti), Berkeley - all in California; Asociación Benéfica PRISMA (M.C.) and Universidad Peruana Cayetano Heredia (S.H.) - both in Lima, Peru; Colorado State University, Fort Collins (M.L.C., J.L.P.); the National Institutes of Health, Bethesda (D.-Y.K., J.P.R.), and Johns Hopkins University, Baltimore (E.D.M., L.H.M., K.N.W., W.C.) - both in Maryland; the Eagle Research Center, Kigali, Rwanda (A.M., F.N.); and Washington University in St. Louis, St. Louis (L.J.U.)
| | - Libny Monroy
- From Emory University, Atlanta (T.F.C., H.H.C., L.M.T., K.S., D.B.B., Y.C., S.J., A.E.L., U.R., S.S.S., L.A.W., J.W.), and the University of Georgia, Athens (J.P.M., L.P.N.) - both in Georgia; the Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., V.A., S.G., K.M., N.P., S.S., G.T.); Universidad del Valle de Guatemala, Guatemala City (A.D.-A., A.C., L.M.); the London School of Hygiene and Tropical Medicine, London (G.R.), and the University of Oxford, Oxford (A. Papageorghiou) - both in the United Kingdom; the University of California, San Francisco, San Francisco (A.Y.), and the Berkeley Air Monitoring Group (M.A.J., R.P., A.Q.) and the University of California, Berkeley (A. Pillarisetti), Berkeley - all in California; Asociación Benéfica PRISMA (M.C.) and Universidad Peruana Cayetano Heredia (S.H.) - both in Lima, Peru; Colorado State University, Fort Collins (M.L.C., J.L.P.); the National Institutes of Health, Bethesda (D.-Y.K., J.P.R.), and Johns Hopkins University, Baltimore (E.D.M., L.H.M., K.N.W., W.C.) - both in Maryland; the Eagle Research Center, Kigali, Rwanda (A.M., F.N.); and Washington University in St. Louis, St. Louis (L.J.U.)
| | - Lawrence H Moulton
- From Emory University, Atlanta (T.F.C., H.H.C., L.M.T., K.S., D.B.B., Y.C., S.J., A.E.L., U.R., S.S.S., L.A.W., J.W.), and the University of Georgia, Athens (J.P.M., L.P.N.) - both in Georgia; the Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., V.A., S.G., K.M., N.P., S.S., G.T.); Universidad del Valle de Guatemala, Guatemala City (A.D.-A., A.C., L.M.); the London School of Hygiene and Tropical Medicine, London (G.R.), and the University of Oxford, Oxford (A. Papageorghiou) - both in the United Kingdom; the University of California, San Francisco, San Francisco (A.Y.), and the Berkeley Air Monitoring Group (M.A.J., R.P., A.Q.) and the University of California, Berkeley (A. Pillarisetti), Berkeley - all in California; Asociación Benéfica PRISMA (M.C.) and Universidad Peruana Cayetano Heredia (S.H.) - both in Lima, Peru; Colorado State University, Fort Collins (M.L.C., J.L.P.); the National Institutes of Health, Bethesda (D.-Y.K., J.P.R.), and Johns Hopkins University, Baltimore (E.D.M., L.H.M., K.N.W., W.C.) - both in Maryland; the Eagle Research Center, Kigali, Rwanda (A.M., F.N.); and Washington University in St. Louis, St. Louis (L.J.U.)
| | - Alexie Mukeshimana
- From Emory University, Atlanta (T.F.C., H.H.C., L.M.T., K.S., D.B.B., Y.C., S.J., A.E.L., U.R., S.S.S., L.A.W., J.W.), and the University of Georgia, Athens (J.P.M., L.P.N.) - both in Georgia; the Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., V.A., S.G., K.M., N.P., S.S., G.T.); Universidad del Valle de Guatemala, Guatemala City (A.D.-A., A.C., L.M.); the London School of Hygiene and Tropical Medicine, London (G.R.), and the University of Oxford, Oxford (A. Papageorghiou) - both in the United Kingdom; the University of California, San Francisco, San Francisco (A.Y.), and the Berkeley Air Monitoring Group (M.A.J., R.P., A.Q.) and the University of California, Berkeley (A. Pillarisetti), Berkeley - all in California; Asociación Benéfica PRISMA (M.C.) and Universidad Peruana Cayetano Heredia (S.H.) - both in Lima, Peru; Colorado State University, Fort Collins (M.L.C., J.L.P.); the National Institutes of Health, Bethesda (D.-Y.K., J.P.R.), and Johns Hopkins University, Baltimore (E.D.M., L.H.M., K.N.W., W.C.) - both in Maryland; the Eagle Research Center, Kigali, Rwanda (A.M., F.N.); and Washington University in St. Louis, St. Louis (L.J.U.)
| | - Krishnendu Mukhopadhyay
- From Emory University, Atlanta (T.F.C., H.H.C., L.M.T., K.S., D.B.B., Y.C., S.J., A.E.L., U.R., S.S.S., L.A.W., J.W.), and the University of Georgia, Athens (J.P.M., L.P.N.) - both in Georgia; the Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., V.A., S.G., K.M., N.P., S.S., G.T.); Universidad del Valle de Guatemala, Guatemala City (A.D.-A., A.C., L.M.); the London School of Hygiene and Tropical Medicine, London (G.R.), and the University of Oxford, Oxford (A. Papageorghiou) - both in the United Kingdom; the University of California, San Francisco, San Francisco (A.Y.), and the Berkeley Air Monitoring Group (M.A.J., R.P., A.Q.) and the University of California, Berkeley (A. Pillarisetti), Berkeley - all in California; Asociación Benéfica PRISMA (M.C.) and Universidad Peruana Cayetano Heredia (S.H.) - both in Lima, Peru; Colorado State University, Fort Collins (M.L.C., J.L.P.); the National Institutes of Health, Bethesda (D.-Y.K., J.P.R.), and Johns Hopkins University, Baltimore (E.D.M., L.H.M., K.N.W., W.C.) - both in Maryland; the Eagle Research Center, Kigali, Rwanda (A.M., F.N.); and Washington University in St. Louis, St. Louis (L.J.U.)
| | - Luke P Naeher
- From Emory University, Atlanta (T.F.C., H.H.C., L.M.T., K.S., D.B.B., Y.C., S.J., A.E.L., U.R., S.S.S., L.A.W., J.W.), and the University of Georgia, Athens (J.P.M., L.P.N.) - both in Georgia; the Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., V.A., S.G., K.M., N.P., S.S., G.T.); Universidad del Valle de Guatemala, Guatemala City (A.D.-A., A.C., L.M.); the London School of Hygiene and Tropical Medicine, London (G.R.), and the University of Oxford, Oxford (A. Papageorghiou) - both in the United Kingdom; the University of California, San Francisco, San Francisco (A.Y.), and the Berkeley Air Monitoring Group (M.A.J., R.P., A.Q.) and the University of California, Berkeley (A. Pillarisetti), Berkeley - all in California; Asociación Benéfica PRISMA (M.C.) and Universidad Peruana Cayetano Heredia (S.H.) - both in Lima, Peru; Colorado State University, Fort Collins (M.L.C., J.L.P.); the National Institutes of Health, Bethesda (D.-Y.K., J.P.R.), and Johns Hopkins University, Baltimore (E.D.M., L.H.M., K.N.W., W.C.) - both in Maryland; the Eagle Research Center, Kigali, Rwanda (A.M., F.N.); and Washington University in St. Louis, St. Louis (L.J.U.)
| | - Florien Ndagijimana
- From Emory University, Atlanta (T.F.C., H.H.C., L.M.T., K.S., D.B.B., Y.C., S.J., A.E.L., U.R., S.S.S., L.A.W., J.W.), and the University of Georgia, Athens (J.P.M., L.P.N.) - both in Georgia; the Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., V.A., S.G., K.M., N.P., S.S., G.T.); Universidad del Valle de Guatemala, Guatemala City (A.D.-A., A.C., L.M.); the London School of Hygiene and Tropical Medicine, London (G.R.), and the University of Oxford, Oxford (A. Papageorghiou) - both in the United Kingdom; the University of California, San Francisco, San Francisco (A.Y.), and the Berkeley Air Monitoring Group (M.A.J., R.P., A.Q.) and the University of California, Berkeley (A. Pillarisetti), Berkeley - all in California; Asociación Benéfica PRISMA (M.C.) and Universidad Peruana Cayetano Heredia (S.H.) - both in Lima, Peru; Colorado State University, Fort Collins (M.L.C., J.L.P.); the National Institutes of Health, Bethesda (D.-Y.K., J.P.R.), and Johns Hopkins University, Baltimore (E.D.M., L.H.M., K.N.W., W.C.) - both in Maryland; the Eagle Research Center, Kigali, Rwanda (A.M., F.N.); and Washington University in St. Louis, St. Louis (L.J.U.)
| | - Aris Papageorghiou
- From Emory University, Atlanta (T.F.C., H.H.C., L.M.T., K.S., D.B.B., Y.C., S.J., A.E.L., U.R., S.S.S., L.A.W., J.W.), and the University of Georgia, Athens (J.P.M., L.P.N.) - both in Georgia; the Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., V.A., S.G., K.M., N.P., S.S., G.T.); Universidad del Valle de Guatemala, Guatemala City (A.D.-A., A.C., L.M.); the London School of Hygiene and Tropical Medicine, London (G.R.), and the University of Oxford, Oxford (A. Papageorghiou) - both in the United Kingdom; the University of California, San Francisco, San Francisco (A.Y.), and the Berkeley Air Monitoring Group (M.A.J., R.P., A.Q.) and the University of California, Berkeley (A. Pillarisetti), Berkeley - all in California; Asociación Benéfica PRISMA (M.C.) and Universidad Peruana Cayetano Heredia (S.H.) - both in Lima, Peru; Colorado State University, Fort Collins (M.L.C., J.L.P.); the National Institutes of Health, Bethesda (D.-Y.K., J.P.R.), and Johns Hopkins University, Baltimore (E.D.M., L.H.M., K.N.W., W.C.) - both in Maryland; the Eagle Research Center, Kigali, Rwanda (A.M., F.N.); and Washington University in St. Louis, St. Louis (L.J.U.)
| | - Ricardo Piedrahita
- From Emory University, Atlanta (T.F.C., H.H.C., L.M.T., K.S., D.B.B., Y.C., S.J., A.E.L., U.R., S.S.S., L.A.W., J.W.), and the University of Georgia, Athens (J.P.M., L.P.N.) - both in Georgia; the Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., V.A., S.G., K.M., N.P., S.S., G.T.); Universidad del Valle de Guatemala, Guatemala City (A.D.-A., A.C., L.M.); the London School of Hygiene and Tropical Medicine, London (G.R.), and the University of Oxford, Oxford (A. Papageorghiou) - both in the United Kingdom; the University of California, San Francisco, San Francisco (A.Y.), and the Berkeley Air Monitoring Group (M.A.J., R.P., A.Q.) and the University of California, Berkeley (A. Pillarisetti), Berkeley - all in California; Asociación Benéfica PRISMA (M.C.) and Universidad Peruana Cayetano Heredia (S.H.) - both in Lima, Peru; Colorado State University, Fort Collins (M.L.C., J.L.P.); the National Institutes of Health, Bethesda (D.-Y.K., J.P.R.), and Johns Hopkins University, Baltimore (E.D.M., L.H.M., K.N.W., W.C.) - both in Maryland; the Eagle Research Center, Kigali, Rwanda (A.M., F.N.); and Washington University in St. Louis, St. Louis (L.J.U.)
| | - Ajay Pillarisetti
- From Emory University, Atlanta (T.F.C., H.H.C., L.M.T., K.S., D.B.B., Y.C., S.J., A.E.L., U.R., S.S.S., L.A.W., J.W.), and the University of Georgia, Athens (J.P.M., L.P.N.) - both in Georgia; the Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., V.A., S.G., K.M., N.P., S.S., G.T.); Universidad del Valle de Guatemala, Guatemala City (A.D.-A., A.C., L.M.); the London School of Hygiene and Tropical Medicine, London (G.R.), and the University of Oxford, Oxford (A. Papageorghiou) - both in the United Kingdom; the University of California, San Francisco, San Francisco (A.Y.), and the Berkeley Air Monitoring Group (M.A.J., R.P., A.Q.) and the University of California, Berkeley (A. Pillarisetti), Berkeley - all in California; Asociación Benéfica PRISMA (M.C.) and Universidad Peruana Cayetano Heredia (S.H.) - both in Lima, Peru; Colorado State University, Fort Collins (M.L.C., J.L.P.); the National Institutes of Health, Bethesda (D.-Y.K., J.P.R.), and Johns Hopkins University, Baltimore (E.D.M., L.H.M., K.N.W., W.C.) - both in Maryland; the Eagle Research Center, Kigali, Rwanda (A.M., F.N.); and Washington University in St. Louis, St. Louis (L.J.U.)
| | - Naveen Puttaswamy
- From Emory University, Atlanta (T.F.C., H.H.C., L.M.T., K.S., D.B.B., Y.C., S.J., A.E.L., U.R., S.S.S., L.A.W., J.W.), and the University of Georgia, Athens (J.P.M., L.P.N.) - both in Georgia; the Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., V.A., S.G., K.M., N.P., S.S., G.T.); Universidad del Valle de Guatemala, Guatemala City (A.D.-A., A.C., L.M.); the London School of Hygiene and Tropical Medicine, London (G.R.), and the University of Oxford, Oxford (A. Papageorghiou) - both in the United Kingdom; the University of California, San Francisco, San Francisco (A.Y.), and the Berkeley Air Monitoring Group (M.A.J., R.P., A.Q.) and the University of California, Berkeley (A. Pillarisetti), Berkeley - all in California; Asociación Benéfica PRISMA (M.C.) and Universidad Peruana Cayetano Heredia (S.H.) - both in Lima, Peru; Colorado State University, Fort Collins (M.L.C., J.L.P.); the National Institutes of Health, Bethesda (D.-Y.K., J.P.R.), and Johns Hopkins University, Baltimore (E.D.M., L.H.M., K.N.W., W.C.) - both in Maryland; the Eagle Research Center, Kigali, Rwanda (A.M., F.N.); and Washington University in St. Louis, St. Louis (L.J.U.)
| | - Ashlinn Quinn
- From Emory University, Atlanta (T.F.C., H.H.C., L.M.T., K.S., D.B.B., Y.C., S.J., A.E.L., U.R., S.S.S., L.A.W., J.W.), and the University of Georgia, Athens (J.P.M., L.P.N.) - both in Georgia; the Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., V.A., S.G., K.M., N.P., S.S., G.T.); Universidad del Valle de Guatemala, Guatemala City (A.D.-A., A.C., L.M.); the London School of Hygiene and Tropical Medicine, London (G.R.), and the University of Oxford, Oxford (A. Papageorghiou) - both in the United Kingdom; the University of California, San Francisco, San Francisco (A.Y.), and the Berkeley Air Monitoring Group (M.A.J., R.P., A.Q.) and the University of California, Berkeley (A. Pillarisetti), Berkeley - all in California; Asociación Benéfica PRISMA (M.C.) and Universidad Peruana Cayetano Heredia (S.H.) - both in Lima, Peru; Colorado State University, Fort Collins (M.L.C., J.L.P.); the National Institutes of Health, Bethesda (D.-Y.K., J.P.R.), and Johns Hopkins University, Baltimore (E.D.M., L.H.M., K.N.W., W.C.) - both in Maryland; the Eagle Research Center, Kigali, Rwanda (A.M., F.N.); and Washington University in St. Louis, St. Louis (L.J.U.)
| | - Usha Ramakrishnan
- From Emory University, Atlanta (T.F.C., H.H.C., L.M.T., K.S., D.B.B., Y.C., S.J., A.E.L., U.R., S.S.S., L.A.W., J.W.), and the University of Georgia, Athens (J.P.M., L.P.N.) - both in Georgia; the Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., V.A., S.G., K.M., N.P., S.S., G.T.); Universidad del Valle de Guatemala, Guatemala City (A.D.-A., A.C., L.M.); the London School of Hygiene and Tropical Medicine, London (G.R.), and the University of Oxford, Oxford (A. Papageorghiou) - both in the United Kingdom; the University of California, San Francisco, San Francisco (A.Y.), and the Berkeley Air Monitoring Group (M.A.J., R.P., A.Q.) and the University of California, Berkeley (A. Pillarisetti), Berkeley - all in California; Asociación Benéfica PRISMA (M.C.) and Universidad Peruana Cayetano Heredia (S.H.) - both in Lima, Peru; Colorado State University, Fort Collins (M.L.C., J.L.P.); the National Institutes of Health, Bethesda (D.-Y.K., J.P.R.), and Johns Hopkins University, Baltimore (E.D.M., L.H.M., K.N.W., W.C.) - both in Maryland; the Eagle Research Center, Kigali, Rwanda (A.M., F.N.); and Washington University in St. Louis, St. Louis (L.J.U.)
| | - Sankar Sambandam
- From Emory University, Atlanta (T.F.C., H.H.C., L.M.T., K.S., D.B.B., Y.C., S.J., A.E.L., U.R., S.S.S., L.A.W., J.W.), and the University of Georgia, Athens (J.P.M., L.P.N.) - both in Georgia; the Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., V.A., S.G., K.M., N.P., S.S., G.T.); Universidad del Valle de Guatemala, Guatemala City (A.D.-A., A.C., L.M.); the London School of Hygiene and Tropical Medicine, London (G.R.), and the University of Oxford, Oxford (A. Papageorghiou) - both in the United Kingdom; the University of California, San Francisco, San Francisco (A.Y.), and the Berkeley Air Monitoring Group (M.A.J., R.P., A.Q.) and the University of California, Berkeley (A. Pillarisetti), Berkeley - all in California; Asociación Benéfica PRISMA (M.C.) and Universidad Peruana Cayetano Heredia (S.H.) - both in Lima, Peru; Colorado State University, Fort Collins (M.L.C., J.L.P.); the National Institutes of Health, Bethesda (D.-Y.K., J.P.R.), and Johns Hopkins University, Baltimore (E.D.M., L.H.M., K.N.W., W.C.) - both in Maryland; the Eagle Research Center, Kigali, Rwanda (A.M., F.N.); and Washington University in St. Louis, St. Louis (L.J.U.)
| | - Sheela S Sinharoy
- From Emory University, Atlanta (T.F.C., H.H.C., L.M.T., K.S., D.B.B., Y.C., S.J., A.E.L., U.R., S.S.S., L.A.W., J.W.), and the University of Georgia, Athens (J.P.M., L.P.N.) - both in Georgia; the Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., V.A., S.G., K.M., N.P., S.S., G.T.); Universidad del Valle de Guatemala, Guatemala City (A.D.-A., A.C., L.M.); the London School of Hygiene and Tropical Medicine, London (G.R.), and the University of Oxford, Oxford (A. Papageorghiou) - both in the United Kingdom; the University of California, San Francisco, San Francisco (A.Y.), and the Berkeley Air Monitoring Group (M.A.J., R.P., A.Q.) and the University of California, Berkeley (A. Pillarisetti), Berkeley - all in California; Asociación Benéfica PRISMA (M.C.) and Universidad Peruana Cayetano Heredia (S.H.) - both in Lima, Peru; Colorado State University, Fort Collins (M.L.C., J.L.P.); the National Institutes of Health, Bethesda (D.-Y.K., J.P.R.), and Johns Hopkins University, Baltimore (E.D.M., L.H.M., K.N.W., W.C.) - both in Maryland; the Eagle Research Center, Kigali, Rwanda (A.M., F.N.); and Washington University in St. Louis, St. Louis (L.J.U.)
| | - Gurusamy Thangavel
- From Emory University, Atlanta (T.F.C., H.H.C., L.M.T., K.S., D.B.B., Y.C., S.J., A.E.L., U.R., S.S.S., L.A.W., J.W.), and the University of Georgia, Athens (J.P.M., L.P.N.) - both in Georgia; the Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., V.A., S.G., K.M., N.P., S.S., G.T.); Universidad del Valle de Guatemala, Guatemala City (A.D.-A., A.C., L.M.); the London School of Hygiene and Tropical Medicine, London (G.R.), and the University of Oxford, Oxford (A. Papageorghiou) - both in the United Kingdom; the University of California, San Francisco, San Francisco (A.Y.), and the Berkeley Air Monitoring Group (M.A.J., R.P., A.Q.) and the University of California, Berkeley (A. Pillarisetti), Berkeley - all in California; Asociación Benéfica PRISMA (M.C.) and Universidad Peruana Cayetano Heredia (S.H.) - both in Lima, Peru; Colorado State University, Fort Collins (M.L.C., J.L.P.); the National Institutes of Health, Bethesda (D.-Y.K., J.P.R.), and Johns Hopkins University, Baltimore (E.D.M., L.H.M., K.N.W., W.C.) - both in Maryland; the Eagle Research Center, Kigali, Rwanda (A.M., F.N.); and Washington University in St. Louis, St. Louis (L.J.U.)
| | - Lindsay J Underhill
- From Emory University, Atlanta (T.F.C., H.H.C., L.M.T., K.S., D.B.B., Y.C., S.J., A.E.L., U.R., S.S.S., L.A.W., J.W.), and the University of Georgia, Athens (J.P.M., L.P.N.) - both in Georgia; the Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., V.A., S.G., K.M., N.P., S.S., G.T.); Universidad del Valle de Guatemala, Guatemala City (A.D.-A., A.C., L.M.); the London School of Hygiene and Tropical Medicine, London (G.R.), and the University of Oxford, Oxford (A. Papageorghiou) - both in the United Kingdom; the University of California, San Francisco, San Francisco (A.Y.), and the Berkeley Air Monitoring Group (M.A.J., R.P., A.Q.) and the University of California, Berkeley (A. Pillarisetti), Berkeley - all in California; Asociación Benéfica PRISMA (M.C.) and Universidad Peruana Cayetano Heredia (S.H.) - both in Lima, Peru; Colorado State University, Fort Collins (M.L.C., J.L.P.); the National Institutes of Health, Bethesda (D.-Y.K., J.P.R.), and Johns Hopkins University, Baltimore (E.D.M., L.H.M., K.N.W., W.C.) - both in Maryland; the Eagle Research Center, Kigali, Rwanda (A.M., F.N.); and Washington University in St. Louis, St. Louis (L.J.U.)
| | - Lance A Waller
- From Emory University, Atlanta (T.F.C., H.H.C., L.M.T., K.S., D.B.B., Y.C., S.J., A.E.L., U.R., S.S.S., L.A.W., J.W.), and the University of Georgia, Athens (J.P.M., L.P.N.) - both in Georgia; the Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., V.A., S.G., K.M., N.P., S.S., G.T.); Universidad del Valle de Guatemala, Guatemala City (A.D.-A., A.C., L.M.); the London School of Hygiene and Tropical Medicine, London (G.R.), and the University of Oxford, Oxford (A. Papageorghiou) - both in the United Kingdom; the University of California, San Francisco, San Francisco (A.Y.), and the Berkeley Air Monitoring Group (M.A.J., R.P., A.Q.) and the University of California, Berkeley (A. Pillarisetti), Berkeley - all in California; Asociación Benéfica PRISMA (M.C.) and Universidad Peruana Cayetano Heredia (S.H.) - both in Lima, Peru; Colorado State University, Fort Collins (M.L.C., J.L.P.); the National Institutes of Health, Bethesda (D.-Y.K., J.P.R.), and Johns Hopkins University, Baltimore (E.D.M., L.H.M., K.N.W., W.C.) - both in Maryland; the Eagle Research Center, Kigali, Rwanda (A.M., F.N.); and Washington University in St. Louis, St. Louis (L.J.U.)
| | - Jiantong Wang
- From Emory University, Atlanta (T.F.C., H.H.C., L.M.T., K.S., D.B.B., Y.C., S.J., A.E.L., U.R., S.S.S., L.A.W., J.W.), and the University of Georgia, Athens (J.P.M., L.P.N.) - both in Georgia; the Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., V.A., S.G., K.M., N.P., S.S., G.T.); Universidad del Valle de Guatemala, Guatemala City (A.D.-A., A.C., L.M.); the London School of Hygiene and Tropical Medicine, London (G.R.), and the University of Oxford, Oxford (A. Papageorghiou) - both in the United Kingdom; the University of California, San Francisco, San Francisco (A.Y.), and the Berkeley Air Monitoring Group (M.A.J., R.P., A.Q.) and the University of California, Berkeley (A. Pillarisetti), Berkeley - all in California; Asociación Benéfica PRISMA (M.C.) and Universidad Peruana Cayetano Heredia (S.H.) - both in Lima, Peru; Colorado State University, Fort Collins (M.L.C., J.L.P.); the National Institutes of Health, Bethesda (D.-Y.K., J.P.R.), and Johns Hopkins University, Baltimore (E.D.M., L.H.M., K.N.W., W.C.) - both in Maryland; the Eagle Research Center, Kigali, Rwanda (A.M., F.N.); and Washington University in St. Louis, St. Louis (L.J.U.)
| | - Kendra N Williams
- From Emory University, Atlanta (T.F.C., H.H.C., L.M.T., K.S., D.B.B., Y.C., S.J., A.E.L., U.R., S.S.S., L.A.W., J.W.), and the University of Georgia, Athens (J.P.M., L.P.N.) - both in Georgia; the Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., V.A., S.G., K.M., N.P., S.S., G.T.); Universidad del Valle de Guatemala, Guatemala City (A.D.-A., A.C., L.M.); the London School of Hygiene and Tropical Medicine, London (G.R.), and the University of Oxford, Oxford (A. Papageorghiou) - both in the United Kingdom; the University of California, San Francisco, San Francisco (A.Y.), and the Berkeley Air Monitoring Group (M.A.J., R.P., A.Q.) and the University of California, Berkeley (A. Pillarisetti), Berkeley - all in California; Asociación Benéfica PRISMA (M.C.) and Universidad Peruana Cayetano Heredia (S.H.) - both in Lima, Peru; Colorado State University, Fort Collins (M.L.C., J.L.P.); the National Institutes of Health, Bethesda (D.-Y.K., J.P.R.), and Johns Hopkins University, Baltimore (E.D.M., L.H.M., K.N.W., W.C.) - both in Maryland; the Eagle Research Center, Kigali, Rwanda (A.M., F.N.); and Washington University in St. Louis, St. Louis (L.J.U.)
| | - Joshua P Rosenthal
- From Emory University, Atlanta (T.F.C., H.H.C., L.M.T., K.S., D.B.B., Y.C., S.J., A.E.L., U.R., S.S.S., L.A.W., J.W.), and the University of Georgia, Athens (J.P.M., L.P.N.) - both in Georgia; the Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., V.A., S.G., K.M., N.P., S.S., G.T.); Universidad del Valle de Guatemala, Guatemala City (A.D.-A., A.C., L.M.); the London School of Hygiene and Tropical Medicine, London (G.R.), and the University of Oxford, Oxford (A. Papageorghiou) - both in the United Kingdom; the University of California, San Francisco, San Francisco (A.Y.), and the Berkeley Air Monitoring Group (M.A.J., R.P., A.Q.) and the University of California, Berkeley (A. Pillarisetti), Berkeley - all in California; Asociación Benéfica PRISMA (M.C.) and Universidad Peruana Cayetano Heredia (S.H.) - both in Lima, Peru; Colorado State University, Fort Collins (M.L.C., J.L.P.); the National Institutes of Health, Bethesda (D.-Y.K., J.P.R.), and Johns Hopkins University, Baltimore (E.D.M., L.H.M., K.N.W., W.C.) - both in Maryland; the Eagle Research Center, Kigali, Rwanda (A.M., F.N.); and Washington University in St. Louis, St. Louis (L.J.U.)
| | - William Checkley
- From Emory University, Atlanta (T.F.C., H.H.C., L.M.T., K.S., D.B.B., Y.C., S.J., A.E.L., U.R., S.S.S., L.A.W., J.W.), and the University of Georgia, Athens (J.P.M., L.P.N.) - both in Georgia; the Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., V.A., S.G., K.M., N.P., S.S., G.T.); Universidad del Valle de Guatemala, Guatemala City (A.D.-A., A.C., L.M.); the London School of Hygiene and Tropical Medicine, London (G.R.), and the University of Oxford, Oxford (A. Papageorghiou) - both in the United Kingdom; the University of California, San Francisco, San Francisco (A.Y.), and the Berkeley Air Monitoring Group (M.A.J., R.P., A.Q.) and the University of California, Berkeley (A. Pillarisetti), Berkeley - all in California; Asociación Benéfica PRISMA (M.C.) and Universidad Peruana Cayetano Heredia (S.H.) - both in Lima, Peru; Colorado State University, Fort Collins (M.L.C., J.L.P.); the National Institutes of Health, Bethesda (D.-Y.K., J.P.R.), and Johns Hopkins University, Baltimore (E.D.M., L.H.M., K.N.W., W.C.) - both in Maryland; the Eagle Research Center, Kigali, Rwanda (A.M., F.N.); and Washington University in St. Louis, St. Louis (L.J.U.)
| | - Jennifer L Peel
- From Emory University, Atlanta (T.F.C., H.H.C., L.M.T., K.S., D.B.B., Y.C., S.J., A.E.L., U.R., S.S.S., L.A.W., J.W.), and the University of Georgia, Athens (J.P.M., L.P.N.) - both in Georgia; the Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., V.A., S.G., K.M., N.P., S.S., G.T.); Universidad del Valle de Guatemala, Guatemala City (A.D.-A., A.C., L.M.); the London School of Hygiene and Tropical Medicine, London (G.R.), and the University of Oxford, Oxford (A. Papageorghiou) - both in the United Kingdom; the University of California, San Francisco, San Francisco (A.Y.), and the Berkeley Air Monitoring Group (M.A.J., R.P., A.Q.) and the University of California, Berkeley (A. Pillarisetti), Berkeley - all in California; Asociación Benéfica PRISMA (M.C.) and Universidad Peruana Cayetano Heredia (S.H.) - both in Lima, Peru; Colorado State University, Fort Collins (M.L.C., J.L.P.); the National Institutes of Health, Bethesda (D.-Y.K., J.P.R.), and Johns Hopkins University, Baltimore (E.D.M., L.H.M., K.N.W., W.C.) - both in Maryland; the Eagle Research Center, Kigali, Rwanda (A.M., F.N.); and Washington University in St. Louis, St. Louis (L.J.U.)
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Nicolaou L, Underhill L, Hossen S, Simkovich S, Thangavel G, Rosa G, McCracken JP, Davila-Roman V, Fuentes LDL, Quinn AK, Clark M, Diaz A, Pillarisetti A, Steenland K, Waller LA, Jabbarzadeh S, Peel JL, Checkley W. Cross-sectional analysis of the association between personal exposure to household air pollution and blood pressure in adult women: Evidence from the multi-country Household Air Pollution Intervention Network (HAPIN) trial. Environ Res 2022; 214:114121. [PMID: 36029836 PMCID: PMC9492861 DOI: 10.1016/j.envres.2022.114121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 07/20/2022] [Accepted: 08/13/2022] [Indexed: 06/18/2023]
Abstract
Elevated blood pressure (BP) is a leading risk factor for the global burden of disease. Household air pollution (HAP), resulting from the burning of biomass fuels, may be an important cause of elevated BP in resource-poor communities. We examined the exposure-response relationship of personal exposures to HAP -fine particulate matter (PM2.5), carbon monoxide (CO), and black carbon (BC) - with BP measures in women aged 40-79 years across four resource-poor settings in Guatemala, Peru, India and Rwanda. BP was obtained within a day of 24-h personal exposure measurements at baseline, when participants were using biomass for cooking. We used generalized additive models to characterize the shape of the association between BP and HAP, accounting for the interaction of personal exposures and age and adjusting for a priori identified confounders. A total of 418 women (mean age 52.2 ± 7.9 years) were included in this analysis. The interquartile range of exposures to PM2.5 was 42.9-139.5 μg/m3, BC was 6.4-16.1 μg/m3, and CO was 0.5-2.9 ppm. Both SBP and PP were positively associated with PM2.5 exposure in older aged women, achieving statistical significance around 60 years of age. The exact threshold varied by BP measure and PM2.5 exposures being compared. For example, SBP of women aged 65 years was on average 10.8 mm Hg (95% CI 1.0-20.6) higher at 232 μg/m3 of PM2.5 exposure (90th percentile) when compared to that of women of the same age with personal exposures of 10 μg/m3. PP in women aged 65 years was higher for exposures ≥90 μg/m3, with mean differences of 6.1 mm Hg (95% CI 1.8-10.5) and 9.2 mm Hg (95% CI 3.3-15.1) at 139 (75th percentile) and 232 μg/m3 (90th percentile) respectively, when compared to that of women of the same age with PM2.5 exposures of 10 μg/m3. Our findings suggest that reducing HAP exposures may help to reduce BP, particularly among older women.
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Affiliation(s)
- Laura Nicolaou
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, USA; Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore, USA
| | - Lindsay Underhill
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, USA; Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore, USA
| | - Shakir Hossen
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, USA; Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore, USA
| | - Suzanne Simkovich
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, USA; Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore, USA; Division of Healthcare Delivery Research, MedStar Health Research Institute, Hyattsville, USA; Division of Pulmonary and Critical Care Medicine, Georgetown University School of Medicine, Washington, USA
| | - Gurusamy Thangavel
- Sri Ramachandra Institute for Higher Education and Research, Chennai, India
| | - Ghislaine Rosa
- Faculty of Infectious and Tropical Diseases, London School of Tropical Medicine and Hygiene, London, UK
| | - John P McCracken
- Center for Health Studies, Universidad Del Valle de Guatemala, Guatemala City, Guatemala; Global Health Institute, Epidemiology and Biostatistics Department, University of Georgia, Athens, GA, USA
| | | | | | - Ashlinn K Quinn
- Environmental Health Sciences, School of Public Health, University of California, Berkeley, CA, USA
| | - Maggie Clark
- Department of Environmental & Radiological Health Sciences, Colorado State University, Fort Collins, CO, USA
| | - Anaite Diaz
- Center for Health Studies, Universidad Del Valle de Guatemala, Guatemala City, Guatemala
| | - Ajay Pillarisetti
- Environmental Health Sciences, School of Public Health, University of California, Berkeley, CA, USA
| | - Kyle Steenland
- Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Lance A Waller
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Shirin Jabbarzadeh
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Jennifer L Peel
- Department of Environmental & Radiological Health Sciences, Colorado State University, Fort Collins, CO, USA
| | - William Checkley
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, USA; Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore, USA; Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, USA.
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Kamenar K, Hossen S, Gupte AN, Siddharthan T, Pollard S, Chowdhury M, Rubinstein AL, Irazola VE, Gutierrez L, Miranda JJ, Bernabe-Ortiz A, Alam D, Kirenga B, Jones RC, van Gemert F, Wise RA, Checkley W. Previous tuberculosis disease as a risk factor for chronic obstructive pulmonary disease: a cross-sectional analysis of multicountry, population-based studies. Thorax 2022. [DOI: 10.1136/thoraxjnl-2020-216500
expr 887205246 + 805797734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/16/2023]
Abstract
BackgroundRisk factors for COPD in high-income settings are well understood; however, less attention has been paid to contributors of COPD in low-income and middle-income countries (LMICs) such as pulmonary tuberculosis. We sought to study the association between previous tuberculosis disease and COPD by using pooled population-based cross-sectional data in 13 geographically diverse, low-resource settings.MethodsWe pooled six cohorts in 13 different LMIC settings, 6 countries and 3 continents to study the relationship between self-reported previous tuberculosis disease and lung function outcomes including COPD (defined as a postbronchodilator forced expiratory volume in one second (FEV1)/forced vital capacity (FVC) below the lower limit of normal). Multivariable regressions with random effects were used to examine the association between previous tuberculosis disease and lung function outcomes.ResultsWe analysed data for 12 396 participants (median age 54.0 years, 51.5% male); 332 (2.7%) of the participants had previous tuberculosis disease. Overall prevalence of COPD was 8.8% (range 1.7%–15.5% across sites). COPD was four times more common among those with previous tuberculosis disease (25.7% vs 8.3% without previous tuberculosis disease, p<0.001). The adjusted odds of having COPD was 3.78 times higher (95% CI 2.87 to 4.98) for participants with previous tuberculosis disease than those without a history of tuberculosis disease. The attributable fraction of COPD due to previous tuberculosis disease in the study sample was 6.9% (95% CI 4.8% to 9.6%). Participants with previous tuberculosis disease also had lower prebronchodilator Z-scores for FEV1(−0.70, 95% CI −0.84 to −0.55), FVC (−0.44, 95% CI −0.59 to −0.29) and the FEV1:FVC ratio (−0.63, 95% CI −0.76 to −0.51) when compared with those without previous tuberculosis disease.ConclusionsPrevious tuberculosis disease is a significant and under-recognised risk factor for COPD and poor lung function in LMICs. Better tuberculosis control will also likely reduce the global burden of COPD.
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Soriano-Moreno AN, Flores EC, Hartinger SM, Mallma CY, Diaz AA, Gianella GE, Galvez-Buccollini JA, Coico-Lama AH, Malaga G, Fajardo E, Paredes-Angeles R, Otazú-Alfaro S, Lescano AG, Checkley W. Home-Based Respiratory Physiotherapy and Telephone-Based Psychological Support for COVID-19 Survivors in Peru: Protocol for a Randomized Controlled Trial. JMIR Res Protoc 2022; 11:e36001. [PMID: 36108135 PMCID: PMC9595592 DOI: 10.2196/36001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 07/19/2022] [Accepted: 08/02/2022] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Both pulmonary and mental health are affected following hospitalization for COVID-19 pneumonia. Pulmonary rehabilitation therapy has demonstrated benefits in improving mental health, but no validated combined programs that include mental health have been proposed. OBJECTIVE This article presents the design of a trial that aimed to assess whether the participation in a combined rehabilitation program that includes home-based respiratory physiotherapy and telephone-based psychological support is associated with a greater improvement of pulmonary and mental health outcomes 7-12 weeks after COVID-19 hospitalization discharge compared with posthospital usual care provided by a public Peruvian hospital. METHODS WAYRA (the word for air in the Quechua language) was an open-label, unblinded, two-arm randomized controlled trial. We recruited 108 participants aged 18-75 years who were discharged from the hospital after COVID-19 pneumonia that required >6 liters/minute of supplemental oxygen during treatment. Participants were randomly assigned at a 1:1 ratio to receive the combined rehabilitation program or usual posthospital care provided by a public Peruvian hospital. The intervention consisted of 12 at-home respiratory rehabilitation sessions and 6 telephone-based psychological sessions. The primary outcome was the 6-minute walk distance. Secondary outcomes included lung function, mental health status (depression, anxiety, and trauma), and quality of life. Outcomes were assessed at baseline (before randomization) and at 7 and 12 weeks after hospital discharge to assess the difference between arms. RESULTS This study was funded by the Peruvian National Council of Science Technology and Technology Innovation in July 2020. Ethics approval was obtained on September 2, 2020. Recruitment and data collection occurred between October 2020 and June 2021. Results are expected to be published by the end of 2022. CONCLUSIONS WAYRA was the first randomized controlled trial evaluating combined pulmonary-mental health rehabilitation for hospitalized COVID-19 survivors in resource-limited settings, potentially providing a foundation for the cost-effective scale-up of similar multidisciplinary rehabilitation programs. TRIAL REGISTRATION ClinicalTrials.gov NCT04649736; https://clinicaltrials.gov/ct2/show/NCT04649736. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) RR1-10.2196/36001.
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Affiliation(s)
- Anderson N Soriano-Moreno
- Pulmonary Training Program in Peru, Universidad Peruana Cayetano Heredia, Lima, Peru
- Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore, MD, United States
- Clima, Latin American Center of Excellence on Climate Change and Health, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Elaine C Flores
- Centre on Climate Change and Planetary Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Center for Innovation in Global Health, Stanford University, Palo Alto, CA, United States
| | - Stella M Hartinger
- Pulmonary Training Program in Peru, Universidad Peruana Cayetano Heredia, Lima, Peru
- Clima, Latin American Center of Excellence on Climate Change and Health, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Claudia Y Mallma
- Escuela Profesional de Tecnología Médica, Universidad Nacional Mayor de San Marcos, Lima, Peru
| | - Arnold A Diaz
- Department of Physical Medicine and Rehabilitation, Hospital EsSalud Alberto Sabogal Sologuren, Lima, Peru
- Emerge, Climate Change and Emerging Disease Research Unit, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Gonzalo E Gianella
- CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru
- School of Medicine, Universidad Peruana Cayetano Heredia, Lima, Peru
| | | | - Abdiel H Coico-Lama
- Emerge, Climate Change and Emerging Disease Research Unit, Universidad Peruana Cayetano Heredia, Lima, Peru
- Clinical and Epidemiological Research Unit, School of Medicine, Universidad Peruana Unión, Lima, Peru
| | - German Malaga
- Department of Medicine, Hospital Nacional Cayetano Heredia, Lima, Peru
| | - Eufemia Fajardo
- Department of Physical Medicine and Rehabilitation, Hospital Nacional Cayetano Heredia, Lima, Peru
| | - Rubí Paredes-Angeles
- CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru
- Grupo de Estudios Avances en Medición Psicológica, Universidad Nacional Mayor de San Marcos, Lima, Peru
| | - Sharlyn Otazú-Alfaro
- Mental Health Research Unit, Instituto Peruano de Orientación Psicológica, Lima, Peru
| | - Andres G Lescano
- Pulmonary Training Program in Peru, Universidad Peruana Cayetano Heredia, Lima, Peru
- Clima, Latin American Center of Excellence on Climate Change and Health, Universidad Peruana Cayetano Heredia, Lima, Peru
- Emerge, Climate Change and Emerging Disease Research Unit, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - William Checkley
- Pulmonary Training Program in Peru, Universidad Peruana Cayetano Heredia, Lima, Peru
- Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore, MD, United States
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, MD, United States
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Johnson M, Pillarisetti A, Piedrahita R, Balakrishnan K, Peel JL, Steenland K, Underhill LJ, Rosa G, Kirby MA, Díaz-Artiga A, McCracken J, Clark ML, Waller L, Chang HH, Wang J, Dusabimana E, Ndagijimana F, Sambandam S, Mukhopadhyay K, Kearns KA, Campbell D, Kremer J, Rosenthal JP, Checkley W, Clasen T, Naeher L. Exposure Contrasts of Pregnant Women during the Household Air Pollution Intervention Network Randomized Controlled Trial. Environ Health Perspect 2022; 130:97005. [PMID: 36112539 PMCID: PMC9480977 DOI: 10.1289/ehp10295] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Revised: 07/12/2022] [Accepted: 08/19/2022] [Indexed: 05/26/2023]
Abstract
BACKGROUND Exposure to PM 2.5 arising from solid fuel combustion is estimated to result in ∼ 2.3 million premature deaths and 91 million lost disability-adjusted life years annually. Interventions attempting to mitigate this burden have had limited success in reducing exposures to levels thought to provide substantive health benefits. OBJECTIVES This paper reports exposure reductions achieved by a liquified petroleum gas (LPG) stove and fuel intervention for pregnant mothers in the Household Air Pollution Intervention Network (HAPIN) randomized controlled trial. METHODS The HAPIN trial included 3,195 households primarily using biomass for cooking in Guatemala, India, Peru, and Rwanda. Twenty-four-hour exposures to PM 2.5 , carbon monoxide (CO), and black carbon (BC) were measured for pregnant women once before randomization into control (n = 1,605 ) and LPG (n = 1,590 ) arms and twice thereafter (aligned with trimester). Changes in exposure were estimated by directly comparing exposures between intervention and control arms and by using linear mixed-effect models to estimate the impact of the intervention on exposure levels. RESULTS Median postrandomization exposures of particulate matter (PM) with aerodynamic diameter ≤ 2.5 μ m (PM 2.5 ) in the intervention arm were lower by 66% at the first (71.5 vs. 24.1 μ g / m 3 ), and second follow-up visits (69.5 vs. 23.7 μ g / m 3 ) compared to controls. BC exposures were lower in the intervention arm by 72% (9.7 vs. 2.7 μ g / m 3 ) and 70% (9.6 vs. 2.8 μ g / m 3 ) at the first and second follow-up visits, respectively, and carbon monoxide exposure was 82% lower at both visits (1.1 vs. 0.2 ppm ) in comparison with controls. Exposure reductions were consistent over time and were similar across research locations. DISCUSSION Postintervention PM 2.5 exposures in the intervention arm were at the lower end of what has been reported for LPG and other clean fuel interventions, with 69% of PM 2.5 samples falling below the World Health Organization Annual Interim Target 1 of 35 μ g / m 3 . This study indicates that an LPG intervention can reduce PM 2.5 exposures to levels at or below WHO targets. https://doi.org/10.1289/EHP10295.
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Affiliation(s)
| | - Ajay Pillarisetti
- Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley, California, USA
| | | | - Kalpana Balakrishnan
- Department of Environmental Health Engineering, ICMR Center for Advanced Research on Air Quality, Climate and Health, Sri Ramachandra Medical College and Research Institute, Sri Ramachandra Institute for Higher Education and Research (Deemed University), Chennai, India
| | - Jennifer L. Peel
- Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins, Colorado, USA
| | - Kyle Steenland
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Lindsay J. Underhill
- Cardiovascular Division, School of Medicine, Washington University, St. Louis, Missouri, USA
| | - Ghislaine Rosa
- Department of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
| | - Miles A. Kirby
- Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | | | - John McCracken
- Department of Environmental Health Science, College of Public Health, University of Georgia, Athens, Georgia, USA
| | - Maggie L. Clark
- Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins, Colorado, USA
| | - Lance Waller
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Howard H. Chang
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Jiantong Wang
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | | | | | - Sankar Sambandam
- Department of Environmental Health Engineering, ICMR Center for Advanced Research on Air Quality, Climate and Health, Sri Ramachandra Medical College and Research Institute, Sri Ramachandra Institute for Higher Education and Research (Deemed University), Chennai, India
| | - Krishnendu Mukhopadhyay
- Department of Environmental Health Engineering, ICMR Center for Advanced Research on Air Quality, Climate and Health, Sri Ramachandra Medical College and Research Institute, Sri Ramachandra Institute for Higher Education and Research (Deemed University), Chennai, India
| | - Katherine A. Kearns
- Department of Environmental Health Science, College of Public Health, University of Georgia, Athens, Georgia, USA
| | - Devan Campbell
- Department of Environmental Health Science, College of Public Health, University of Georgia, Athens, Georgia, USA
| | - Jacob Kremer
- Department of Environmental Health Science, College of Public Health, University of Georgia, Athens, Georgia, USA
| | - Joshua P. Rosenthal
- Division of Epidemiology and Population Studies, Fogarty International Center, National Institutes of Health, Bethesda, Maryland, USA
| | - William Checkley
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Thomas Clasen
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Luke Naeher
- Department of Environmental Health Science, College of Public Health, University of Georgia, Athens, Georgia, USA
| | - and the Household Air Pollution Intervention Network (HAPIN) Trial Investigators
- Berkeley Air Monitoring Group, Berkeley, California, USA
- Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley, California, USA
- Department of Environmental Health Engineering, ICMR Center for Advanced Research on Air Quality, Climate and Health, Sri Ramachandra Medical College and Research Institute, Sri Ramachandra Institute for Higher Education and Research (Deemed University), Chennai, India
- Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins, Colorado, USA
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
- Cardiovascular Division, School of Medicine, Washington University, St. Louis, Missouri, USA
- Department of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
- Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
- Universidad del Valle de Guatemala, Guatemala City, Guatemala
- Department of Environmental Health Science, College of Public Health, University of Georgia, Athens, Georgia, USA
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
- Eagle Research Center, Kigali, Rwanda
- Division of Epidemiology and Population Studies, Fogarty International Center, National Institutes of Health, Bethesda, Maryland, USA
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
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Mohan S, Cárdenas MK, Ricciardi F, Siddharthan T, Pollard SL, Rykiel NA, Checkley W, Hurst JR, Soares MO. Cost-Accuracy Analysis of Chronic Obstructive Pulmonary Disease Screening in Low- and Middle-Income Countries. Am J Respir Crit Care Med 2022; 206:353-356. [PMID: 35442182 PMCID: PMC9890258 DOI: 10.1164/rccm.202201-0071le] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Affiliation(s)
| | | | | | | | | | | | | | - John R. Hurst
- University College LondonLondon, United Kingdom,Corresponding author (e-mail: )
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Ye W, Steenland K, Quinn A, Liao J, Balakrishnan K, Rosa G, Ndagijimana F, Ntivuguruzwa JDD, Thompson LM, McCracken JP, Díaz-Artiga A, Rosenthal JP, Papageorghiou A, Davila-Roman VG, Pillarisetti A, Johnson M, Wang J, Nicolaou L, Checkley W, Peel JL, Clasen TF. Effects of a Liquefied Petroleum Gas Stove Intervention on Gestational Blood Pressure: Intention-to-Treat and Exposure-Response Findings From the HAPIN Trial. Hypertension 2022; 79:1887-1898. [PMID: 35708015 PMCID: PMC9278708 DOI: 10.1161/hypertensionaha.122.19362] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Approximately 3 to 4 billion people worldwide are exposed to household air pollution, which has been associated with increased blood pressure (BP) in pregnant women in some studies. METHODS We recruited 3195 pregnant women in Guatemala, India, Peru, and Rwanda and randomly assigned them to intervention or control groups. The intervention group received a gas stove and fuel during pregnancy, while the controls continued cooking with solid fuels. We measured BP and personal exposure to PM2.5, black carbon and carbon monoxide 3× during gestation. We conducted an intention-to-treat and exposure-response analysis to determine if household air pollution exposure was associated with increased gestational BP. RESULTS Median 24-hour PM2.5 dropped from 84 to 24 μg/m3 after the intervention; black carbon and carbon monoxide decreased similarly. Intention-to-treat analyses showed an increase in systolic BP and diastolic BP in both arms during gestation, as expected, but the increase was greater in intervention group for both systolic BP (0.69 mm Hg [0.03-1.35]; P=0.04) and diastolic BP (0.62 mm Hg [0.05-1.19]; P=0.03). The exposure-response analyses suggested that higher exposures to household air pollution were associated with moderately higher systolic BP and diastolic BP; however, none of these associations reached conventional statistical significance. CONCLUSIONS In intention-to-treat, we found higher gestational BP in the intervention group compared with controls, contrary to expected. In exposure-response analyses, we found a slight increase in BP with higher exposure, but it was not statistically significant. Overall, an intervention with gas stoves did not markedly affect gestational BP.
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Affiliation(s)
- Wenlu Ye
- Gangarosa Department of Environmental Health, Rollins School of Public Health (W.Y., K.S., A. Pillarisetti, T.F.C.), Emory University, Atlanta, GA.,Environmental Health Sciences, School of Public Health, University of California, Berkeley (W.Y., A. Pillarisetti)
| | - Kyle Steenland
- Gangarosa Department of Environmental Health, Rollins School of Public Health (W.Y., K.S., A. Pillarisetti, T.F.C.), Emory University, Atlanta, GA
| | - Ashlinn Quinn
- Berkeley Air Monitoring Group, Berkeley, CA (A.Q., M.J.)
| | - Jiawen Liao
- Department of Population and Public Health Sciences, Keck School of Medicine of the University of Southern California, Los Angeles (J.L.)
| | - Kalpana Balakrishnan
- Department of Environmental Health Engineering, ICMR Center for Advanced Research on Air Quality, Climate and Health, Sri Ramachandra Institute for Higher Education and Research (Deemed University), Chennai, India (K.B.)
| | - Ghislaine Rosa
- Department of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, United Kingdom (G.R.)
| | | | | | - Lisa M. Thompson
- Nell Hodgson Woodruff School of Nursing (L.M.T.), Emory University, Atlanta, GA
| | - John P. McCracken
- Department of Environmental Health Sciences, University of Georgia, Athens (J.P.M.)
| | | | - Joshua P. Rosenthal
- Division of Epidemiology and Population Studies, Fogarty International Center, National Institutes of Health, Bethesda, MD (J.P.R.)
| | - Aris Papageorghiou
- Nuffield Department of Women’s and Reproductive Health, University of Oxford, United Kingdom (A. Papageorghiou)
| | | | - Ajay Pillarisetti
- Gangarosa Department of Environmental Health, Rollins School of Public Health (W.Y., K.S., A. Pillarisetti, T.F.C.), Emory University, Atlanta, GA.,Environmental Health Sciences, School of Public Health, University of California, Berkeley (W.Y., A. Pillarisetti)
| | | | - Jiantong Wang
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health (J.W.), Emory University, Atlanta, GA
| | - Laura Nicolaou
- Division of Pulmonary and Critical Care, School of Medicine (L.N., W.C.), Johns Hopkins University, Baltimore, MD.,Center for Global Non-Communicable Disease Research and Training (L.N., W.C.), Johns Hopkins University, Baltimore, MD
| | - William Checkley
- Division of Pulmonary and Critical Care, School of Medicine (L.N., W.C.), Johns Hopkins University, Baltimore, MD.,Center for Global Non-Communicable Disease Research and Training (L.N., W.C.), Johns Hopkins University, Baltimore, MD
| | - Jennifer L. Peel
- Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Thomas F. Clasen
- Gangarosa Department of Environmental Health, Rollins School of Public Health (W.Y., K.S., A. Pillarisetti, T.F.C.), Emory University, Atlanta, GA
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Checkley W, Hossen S, McCollum ED, Pervaiz F, Miele CH, Chavez MA, Moulton LH, Simmons N, Roy AD, Chowdhury NH, Ahmed S, Begum N, Quaiyum A, Santosham M, Baqui AH. Effectiveness of the 10-valent pneumococcal conjugate vaccine on pediatric pneumonia confirmed by ultrasound: a matched case-control study. Respir Res 2022; 23:198. [PMID: 35915495 PMCID: PMC9341060 DOI: 10.1186/s12931-022-02115-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Accepted: 07/05/2022] [Indexed: 11/23/2022] Open
Abstract
Background Bangladesh introduced the 10-valent pneumococcal conjugate vaccine (PCV10) for children aged < 1 year in March 2015. Previous vaccine effectiveness (VE) studies for pneumonia have used invasive pneumococcal disease or chest X-rays. None have used ultrasound. We sought to determine the VE of PCV10 against sonographically-confirmed pneumonia in three subdistrict health complexes in Bangladesh. Methods We conducted a matched case–control study between July 2015 and September 2017 in three subdistricts of Sylhet, Bangladesh. Cases were vaccine-eligible children aged 3–35 months with sonographically-confirmed pneumonia, who were matched with two types of controls by age, sex, week of diagnosis, subdistrict health complex (clinic controls) or distance from subdistrict health complex (community controls) and had an illness unlikely due to Streptococcus pneumoniae (clinic controls) or were healthy (community controls). VE was measured using multivariable conditional logistic regression. Results We evaluated 8926 children (average age 13.3 months, 58% boys) with clinical pneumonia by ultrasound; 2470 had pneumonia with consolidations ≥ 1 cm; 1893 pneumonia cases were matched with 4238 clinic controls; and 1832 were matched with 3636 community controls. VE increased with the threshold used for consolidation size on ultrasound: the adjusted VE of ≥ 2 doses vs. non-recipients of PCV10 against pneumonia increased from 15.8% (95% CI 1.6–28.0%) for consolidations ≥ 1 cm to 29.6% (12.8–43.2%) for consolidations ≥ 1.5 cm using clinic controls and from 2.7% (− 14.2–17.2%) to 23.5% (4.4–38.8%) using community controls, respectively. Conclusions PCV10 was effective at reducing sonographically-confirmed pneumonia in children aged 3–35 months of age when compared to unvaccinated children. VE increased with the threshold used for consolidation size on ultrasound in clinic and community controls alike. This study provides evidence that lung ultrasound is a useful alternative to chest X-ray for case–control studies evaluating the effectiveness of vaccines against pneumonia.
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Affiliation(s)
- William Checkley
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, 1830 E. Monument St, Room 555, Baltimore, MD, 21287, USA. .,Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, USA. .,Department of Biostatistics, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, USA.
| | - Shakir Hossen
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, 1830 E. Monument St, Room 555, Baltimore, MD, 21287, USA
| | - Eric D McCollum
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, USA.,Department of Pediatrics, School of Medicine, Johns Hopkins University, Baltimore, USA
| | - Farhan Pervaiz
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, 1830 E. Monument St, Room 555, Baltimore, MD, 21287, USA
| | - Catherine H Miele
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, 1830 E. Monument St, Room 555, Baltimore, MD, 21287, USA
| | - Miguel A Chavez
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, 1830 E. Monument St, Room 555, Baltimore, MD, 21287, USA
| | - Lawrence H Moulton
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, USA.,Department of Biostatistics, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, USA
| | - Nicole Simmons
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, USA
| | | | | | | | - Nazma Begum
- Johns Hopkins University -Bangladesh, Dhaka, Bangladesh
| | - Abdul Quaiyum
- Johns Hopkins University -Bangladesh, Dhaka, Bangladesh
| | - Mathuram Santosham
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, USA.,Department of Pediatrics, School of Medicine, Johns Hopkins University, Baltimore, USA
| | - Abdullah H Baqui
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, USA
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Nicolaou L, Steinberg A, Carrillo-Larco RM, Hartinger S, Lescano AG, Checkley W. Living at High Altitude and COVID-19 Mortality in Peru. High Alt Med Biol 2022; 23:146-158. [PMID: 35483043 PMCID: PMC10024074 DOI: 10.1089/ham.2021.0149] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
Nicolaou, Laura, Anne Steinberg, Rodrigo M. Carrillo-Larco, Stella Hartinger, Andres G. Lescano, and William Checkley. Living at high altitude and COVID-19 mortality in Peru. High Alt Med Biol. 23:146-158, 2022. Background: Previous studies have reported a lower severity of COVID-19 infections at higher altitudes; however, this association may be confounded by various factors. We examined the association between living at altitude and COVID-19 mortality in Peru adjusting for population density, prevalence of comorbidities, indicators of socioeconomic status, and health care access. Methods: Utilizing administrative data across 196 provinces located at varying altitudes (sea level to 4,373 m), we conducted a two-stage analysis of COVID-19 deaths between March 19 and December 31, 2020, Peru's first wave. We first calculated cumulative daily mortality rate for each province and fit lognormal cumulative distribution functions to estimate total mortality rate, and start, peak, and duration of the first wave. We then regressed province-level total mortality rate, start, peak, and duration of the first wave as a function of altitude adjusted for confounders. Results: There were 93,528 recorded deaths from COVID-19 (mean age 66.5 years, 64.5% male) for a cumulative mortality of 272.5 per 100,000 population between March 19 and December 31, 2020. We did not find a consistent monotonic trend between living at higher altitudes and estimated total mortality rate for provinces at 500 - 1,000 m (-12.1 deaths per 100,000 population per 100 m, 95% familywise confidence interval -27.7 to 3.5) or > 1,000 m (-0.3, -2.7 to 2.0). We also did not find consistent monotonic trends for the start, peak, and duration of the first wave beyond the first 500 m. Conclusions: Our findings suggest that living at high altitude may not confer a lower risk of death from COVID-19.
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Affiliation(s)
- Laura Nicolaou
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, USA.,Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore, Maryland, USA
| | - Anne Steinberg
- Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | - Rodrigo M Carrillo-Larco
- Department of Epidemiology and Biostatistics, School of Public Health, Imperial College London, London, United Kingdom
| | - Stella Hartinger
- UDIAS, School of Public Health and Administration, Universidad Peruana Cayetano Heredia, Lima, Peru.,Clima, Latin American Center of Excellence in Climate Change and Health, School of Public Health and Administration, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Andres G Lescano
- Clima, Latin American Center of Excellence in Climate Change and Health, School of Public Health and Administration, Universidad Peruana Cayetano Heredia, Lima, Peru.,Emerge, Emerging Diseases, and Climate Change Research Unit, School of Public Health and Administration, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - William Checkley
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, USA.,Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore, Maryland, USA.,Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
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Burnim MS, Wang K, Checkley W, Nolley EP, Xu Y, Garibaldi BT. The authors reply. Crit Care Med 2022; 50:e592-e594. [PMID: 35275595 PMCID: PMC9112511 DOI: 10.1097/ccm.0000000000005530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- Michael S Burnim
- Division of Pulmonary and Critical Care, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Kunbo Wang
- Department of Applied Mathematics and Statistics, Johns Hopkins University, Baltimore, MD
| | - William Checkley
- Division of Pulmonary and Critical Care, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Eric P Nolley
- Division of Pulmonary and Critical Care, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Yanxun Xu
- Department of Applied Mathematics and Statistics, Johns Hopkins University, Baltimore, MD
- Division of Biostatistics and Bioinformatics at The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Brian T Garibaldi
- Division of Pulmonary and Critical Care, Johns Hopkins University School of Medicine, Baltimore, MD
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Ye W, Thangavel G, Pillarisetti A, Steenland K, Peel JL, Balakrishnan K, Jabbarzadeh S, Checkley W, Clasen T. Association between personal exposure to household air pollution and gestational blood pressure among women using solid cooking fuels in rural Tamil Nadu, India. Environ Res 2022; 208:112756. [PMID: 35065931 PMCID: PMC8935388 DOI: 10.1016/j.envres.2022.112756] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 01/06/2022] [Accepted: 01/15/2022] [Indexed: 05/22/2023]
Abstract
BACKGROUND The Household Air Pollution Intervention Network (HAPIN) trial is an ongoing multi-center randomized controlled trial assessing the impact of a liquified petroleum gas (LPG) cookstove and fuel intervention on health. Given the potential impacts of household air pollution (HAP) exposure from burning solid fuels on cardiovascular health during pregnancy, we sought to determine whether baseline exposures to particulate matter with an aerodynamic diameter ≤2.5 μm (PM2.5), black carbon (BC) and carbon monoxide (CO) were associated with blood pressure among 799 pregnant women in Tamil Nadu, India, one of the HAPIN trial centers. METHODS Multivariable linear regression models were used to examine the association between 24-h personal exposure to PM2.5/BC/CO and systolic and diastolic blood pressure, controlling for maternal age, body mass index (BMI), mother's education, household wealth, gestational age, and season. At the time of measurement, women were between 9- and 20-weeks of gestation. RESULTS We found that systolic blood pressure (SBP) and diastolic blood pressure (DBP) were higher in pregnant women exposed to higher levels of HAP, though only the result for CO and DBP reached conventional statistical significance (p < 0.05). We observed a positive association between CO and DBP among the entire study cohort: a 1-log μg/m3 increase in CO exposure was associated with 0.36 mmHg higher DBP (95% confidence interval [CI]: 0.02 to 0.70). The effect was stronger in pregnant women with higher CO exposures (in the 3rd [≥ 0.9 and < 2.1 ppm] and 4th quartiles [≥ 2.1 and ≤ 46.9 ppm]). We also found that pregnant women with PM2.5 exposures in the highest quartile (≥ 129.9 and ≤ 2100 μg/m3) had a borderline significant association (p = 0.054) with DBP compared to those who had PM2.5 exposures in the lowest quartile (≥ 9.4 and < 47.7 μg/m3). No evidence of association was observed for BC exposure and blood pressure. CONCLUSION This study contributes to limited evidence regarding the relationship between HAP exposure and blood pressure among women during pregnancy, a critical window for both mother and child's life-course health. Results from this cross-sectional study suggest that exposures to PM2.5 and CO from solid fuel use are associated with higher blood pressure in pregnant women during their first or second trimester.
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Affiliation(s)
- Wenlu Ye
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA.
| | - Gurusamy Thangavel
- Department of Environmental Health Engineering, Sri Ramachandra Institute of Higher Education and Research, Chennai, Tamil Nadu, India
| | - Ajay Pillarisetti
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA; Environmental Health Sciences, School of Public Health, University of California, Berkeley, California, USA
| | - Kyle Steenland
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Jennifer L Peel
- Dept of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins, CO, USA
| | - Kalpana Balakrishnan
- Department of Environmental Health Engineering, Sri Ramachandra Institute of Higher Education and Research, Chennai, Tamil Nadu, India
| | - Shirin Jabbarzadeh
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - William Checkley
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, MD, USA; Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Thomas Clasen
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
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Hochberg CH, Psoter KJ, Sahetya SK, Nolley EP, Hossen S, Checkley W, Kerlin MP, Eakin MN, Hager DN. Comparing Prone Positioning Use in COVID-19 Versus Historic Acute Respiratory Distress Syndrome. Crit Care Explor 2022; 4:e0695. [PMID: 35783548 PMCID: PMC9243245 DOI: 10.1097/cce.0000000000000695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Use of prone positioning in patients with acute respiratory distress syndrome (ARDS) from COVID-19 may be greater than in patients treated for ARDS before the pandemic. However, the magnitude of this increase, sources of practice variation, and the extent to which use adheres to guidelines is unknown.
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Fandiño-Del-Rio M, Kephart JL, Williams KN, Shade T, Adekunle T, Steenland K, Naeher LP, Moulton LH, Gonzales GF, Chiang M, Hossen S, Chartier RT, Koehler K, Checkley W. Household Air Pollution Concentrations after Liquefied Petroleum Gas Interventions in Rural Peru: Findings from a One-Year Randomized Controlled Trial Followed by a One-Year Pragmatic Crossover Trial. Environ Health Perspect 2022; 130:57007. [PMID: 35549716 PMCID: PMC9097958 DOI: 10.1289/ehp10054] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 03/25/2022] [Accepted: 03/28/2022] [Indexed: 05/29/2023]
Abstract
BACKGROUND Household air pollution (HAP) from biomass fuel combustion remains a leading environmental risk factor for morbidity worldwide. OBJECTIVE Measure the effect of liquefied petroleum gas (LPG) interventions on HAP exposures in Puno, Peru. METHODS We conducted a 1-y randomized controlled trial followed by a 1-y pragmatic crossover trial in 180 women age 25-64 y. During the first year, intervention participants received a free LPG stove, continuous fuel delivery, and regular behavioral messaging, whereas controls continued their biomass cooking practices. During the second year, control participants received a free LPG stove, regular behavioral messaging, and vouchers to obtain LPG tanks from a nearby distributor, whereas fuel distribution stopped for intervention participants. We collected 48-h kitchen area concentrations and personal exposures to fine particulate matter (PM) with aerodynamic diameter ≤ 2.5 μ m (PM 2.5 ), black carbon (BC), and carbon monoxide (CO) at baseline and 3-, 6-, 12-, 18-, and 24-months post randomization. RESULTS Baseline mean [ ± standard deviation ( SD ) ] PM 2.5 (kitchen area concentrations 1,220 ± 1,010 vs. 1,190 ± 880 μ g / m 3 ; personal exposure 126 ± 214 vs. 104 ± 100 μ g / m 3 ), CO (kitchen 53 ± 49 vs. 50 ± 41 ppm ; personal 7 ± 8 vs. 7 ± 8 ppm ), and BC (kitchen 180 ± 120 vs. 210 ± 150 μ g / m 3 ; personal 19 ± 16 vs. 21 ± 22 μ g / m 3 ) were similar between control and intervention participants. Intervention participants had consistently lower mean ( ± SD ) concentrations at the 12-month visit for kitchen (41 ± 59 μ g / m 3 , 3 ± 6 μ g / m 3 , and 8 ± 13 ppm ) and personal exposures (26 ± 34 μ g / m 3 , 2 ± 3 μ g / m 3 , and 3 ± 4 ppm ) to PM 2.5 , BC, and CO when compared to controls during the first year. In the second year, we observed comparable HAP reductions among controls after the voucher-based intervention for LPG fuel was implemented (24-month visit PM 2.5 , BC, and CO kitchen mean concentrations of 34 ± 74 μ g / m 3 , 3 ± 5 μ g / m 3 , and 6 ± 6 ppm and personal exposures of 17 ± 15 μ g / m 3 , 2 ± 2 μ g / m 3 , and 3 ± 4 ppm , respectively), and average reductions were present among intervention participants even after free fuel distribution stopped (24-month visit PM 2.5 , BC, and CO kitchen mean concentrations of 561 ± 1,251 μ g / m 3 , 82 ± 124 μ g / m 3 , and 23 ± 28 ppm and personal exposures of 35 ± 38 μ g / m 3 , 6 ± 6 μ g / m 3 , and 4 ± 5 ppm , respectively). DISCUSSION Both home delivery and voucher-based provision of free LPG over a 1-y period, in combination with provision of a free LPG stove and longitudinal behavioral messaging, reduced HAP to levels below 24-h World Health Organization air quality guidelines. Moreover, the effects of the intervention on HAP persisted for a year after fuel delivery stopped. Such strategies could be applied in LPG programs to reduce HAP and potentially improve health. https://doi.org/10.1289/EHP10054.
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Affiliation(s)
- Magdalena Fandiño-Del-Rio
- Department of Environmental Health and Engineering, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
- Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore, Maryland, USA
| | - Josiah L. Kephart
- Department of Environmental Health and Engineering, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
- Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore, Maryland, USA
| | - Kendra N. Williams
- Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore, Maryland, USA
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Timothy Shade
- Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore, Maryland, USA
| | - Temi Adekunle
- Department of Environmental Health and Engineering, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | - Kyle Steenland
- Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Luke P. Naeher
- Environmental Health Science Department, College of Public Health, University of Georgia, Athens, Georgia, USA
| | - Lawrence H. Moulton
- Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | - Gustavo F. Gonzales
- Laboratories of Investigation and Development, Department of Biological and Physiological Sciences, Faculty of Sciences and Philosophy, Universidad Peruana Cayetano Heredia, Lima, Perú
- High Altitude Research Institute, Universidad Peruana Cayetano Heredia, Lima, Perú
| | - Marilu Chiang
- Biomedical Research Unit, Asociación Benéfica PRISMA, Lima, Perú
| | - Shakir Hossen
- Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore, Maryland, USA
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | | | - Kirsten Koehler
- Department of Environmental Health and Engineering, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | - William Checkley
- Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore, Maryland, USA
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
- Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | - Cardiopulmonary outcomes and Household Air Pollution (CHAP) Trial Investigators
- Department of Environmental Health and Engineering, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
- Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore, Maryland, USA
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
- Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
- Environmental Health Science Department, College of Public Health, University of Georgia, Athens, Georgia, USA
- Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
- Laboratories of Investigation and Development, Department of Biological and Physiological Sciences, Faculty of Sciences and Philosophy, Universidad Peruana Cayetano Heredia, Lima, Perú
- High Altitude Research Institute, Universidad Peruana Cayetano Heredia, Lima, Perú
- Biomedical Research Unit, Asociación Benéfica PRISMA, Lima, Perú
- RTI International, Durham, North Carolina, USA
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Checkley W, Hossen S, Rosa G, Thompson LM, McCracken JP, Diaz-Artiga A, Balakrishnan K, Simkovich SM, Underhill LJ, Nicolaou L, Hartinger SM, Davila-Roman VG, Kirby MA, Clasen TF, Rosenthal J, Peel JL. Facing the Realities of Pragmatic Design Choices in Environmental Health Studies: Experiences from the Household Air Pollution Intervention Network Trial. Int J Environ Res Public Health 2022; 19:3790. [PMID: 35409475 PMCID: PMC8997769 DOI: 10.3390/ijerph19073790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Revised: 03/15/2022] [Accepted: 03/18/2022] [Indexed: 11/29/2022]
Abstract
Objective: Household Air Pollution Intervention Network (HAPIN) investigators tested a complex, non-pharmacological intervention in four low- and middle-income countries as a strategy to mitigate household air pollution and improve health outcomes across the lifespan. Intervention households received a liquefied petroleum gas (LPG) stove, continuous fuel delivery and regular behavioral reinforcements for 18 months, whereas controls were asked to continue with usual cooking practices. While HAPIN was designed as an explanatory trial to test the efficacy of the intervention on four primary outcomes, it introduced several pragmatic aspects in its design and conduct that resemble real-life conditions. We surveyed HAPIN investigators and asked them to rank what aspects of the design and conduct they considered were more pragmatic than explanatory. Methods: We used the revised Pragmatic Explanatory Continuum Indicator Summary (PRECIS-2) to survey investigators on the degree of pragmatism in nine domains of trial design and conduct using a five-point Likert rank scale from very explanatory (1) to very pragmatic (5). We invited 103 investigators. Participants were given educational material on PRECIS-2, including presentations, papers and examples that described the use and implementation of PRECIS-2. Results: Thirty-five investigators (mean age 42 years, 51% female) participated in the survey. Overall, only 17% ranked all domains as very explanatory, with an average (±SD) rank of 3.2 ± 1.4 across domains. Fewer than 20% of investigators ranked eligibility, recruitment or setting as very explanatory. In contrast, ≥50% of investigators ranked the trial organization, delivery and adherence of the intervention and follow-up as very/rather explanatory whereas ≤17% ranked them as rather/very pragmatic. Finally, <25% of investigators ranked the relevance of outcomes to participants and analysis as very/rather explanatory whereas ≥50% ranked then as rather/very pragmatic. In-country partners were more likely to rank domains as pragmatic when compared to investigators working in central coordination (average rank 3.2 vs. 2.8, respectively; Wilcoxon rank-sum p < 0.001). Conclusion: HAPIN investigators did not consider their efficacy trial to be rather/very explanatory and reported that some aspects of the design and conduct were executed under real-world conditions; however, they also did not consider the trial to be overly pragmatic. Our analysis underscores the importance of using standardized tools such as PRECIS-2 to guide early discussions among investigators in the design of environmental health trials attempting to measure efficacy.
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Affiliation(s)
- William Checkley
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, MD 21287, USA; (S.H.); (L.J.U.); (L.N.)
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, MD 21287, USA
| | - Shakir Hossen
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, MD 21287, USA; (S.H.); (L.J.U.); (L.N.)
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, MD 21287, USA
| | - Ghislaine Rosa
- Faculty of Infectious and Tropical Diseases, London School of Tropical Medicine and Hygiene, London WC1E 7HT, UK;
| | - Lisa M. Thompson
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA 30332, USA;
| | - John P. McCracken
- Epidemiology and Biostatistics Department, University of Georgia, Athens, GA 30606, USA;
| | - Anaite Diaz-Artiga
- Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City 01015, Guatemala;
| | - Kalpana Balakrishnan
- ICMR Center for Advanced Research on Air Quality, Climate and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute for Higher Education and Research, Chennai 600116, India;
| | - Suzanne M. Simkovich
- Division of Healthcare Delivery Research, Medstar Health Research Institute, Hyattsville, MD 20782, USA;
- Division of Pulmonary and Critical Care Medicine, Georgetown University, Washington, DC 20007, USA
| | - Lindsay J. Underhill
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, MD 21287, USA; (S.H.); (L.J.U.); (L.N.)
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, MD 21287, USA
| | - Laura Nicolaou
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, MD 21287, USA; (S.H.); (L.J.U.); (L.N.)
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, MD 21287, USA
| | - Stella M. Hartinger
- Latin American Center of Excellence on Climate Change and Health, Universidad Peruana Cayetano Heredia, Lima 15102, Peru;
| | - Victor G. Davila-Roman
- Cardiovascular Imaging and Clinical Research Core Laboratory, Cardiovascular Division, Department of Medicine, Washington University in St. Louis, St. Louis, MO 63110, USA;
| | - Miles A. Kirby
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA 02115, USA;
| | - Thomas F. Clasen
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA 30322, USA;
| | - Joshua Rosenthal
- Fogarty International Center, National Institutes of Health, Bethesda, MD 20892, USA;
| | - Jennifer L. Peel
- Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins, CO 80523, USA;
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Bernabe-Ortiz A, Carrillo-Larco RM, Gilman RH, Smeeth L, Checkley W, Miranda JJ. High-sensitivity C-reactive protein and all-cause mortality in four diverse populations: The CRONICAS Cohort Study. Ann Epidemiol 2022; 67:13-18. [PMID: 34923118 PMCID: PMC8960343 DOI: 10.1016/j.annepidem.2021.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 12/06/2021] [Accepted: 12/12/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE To assess the association between all-cause mortality and hs-CRP, based mainly on the cumulative burden approach. METHODS Cohort study with adults ≥35 years from general population, using hs-CRP at two timepoints: at baseline and 30 months later to establish different exposures: change over time, cumulative, and weighted cumulative hs-CRP. The outcome was all-cause mortality assessed 7 years later. Cox models were generated to quantify the association. RESULTS Data from 3,119 participants (mean age 55.6 years, and 51.2% females), were analyzed. During follow-up, 164 (5.6%) deaths occurred over 20,314.5 person-years, indicating an overall mortality rate of 8.1 per 1,000 person-years. In multivariable model, hs-CRP at baseline was associated with high risk of mortality (HR = 1.77; 95%CI: 1.28-2.46). Similarly, hs-CRP change over time (HR = 2.50; 95%CI: 1.46-4.29), as well as cumulative and weighted cumulative hs-CRP (HR = 2.05; 95%CI: 1.31-3.20) were associated with greater risk of all-cause mortality. The weighted cumulative hs-CRP had the best goodness-of-fit for mortality prediction. CONCLUSIONS In this cohort across diverse geographical low-resource settings, high levels of hs-CRP were strongly associated with all-cause mortality. Two measurements of hs-CRP are better than one to predict mortality, and the weighted cumulative approach had the best prognostic fit.
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Affiliation(s)
- Antonio Bernabe-Ortiz
- CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru.
| | - Rodrigo M. Carrillo-Larco
- CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru.,Department of Epidemiology and Biostatistics, School of Public Health, Imperial College London, London, UK
| | - Robert H. Gilman
- CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru.,Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Liam Smeeth
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - William Checkley
- CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru.,Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - J. Jaime Miranda
- CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru.,Department of Medicine, School of Medicine, Universidad Peruana Cayetano Heredia, Lima, Peru
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Simkovich SM, Underhill LJ, Kirby MA, Crocker ME, Goodman D, McCracken JP, Thompson LM, Diaz-Artiga A, Castañaza-Gonzalez A, Garg SS, Balakrishnan K, Thangavel G, Rosa G, Peel JL, Clasen TF, McCollum ED, Checkley W. Resources and Geographic Access to Care for Severe Pediatric Pneumonia in Four Resource-limited Settings. Am J Respir Crit Care Med 2022; 205:183-197. [PMID: 34662531 PMCID: PMC8787246 DOI: 10.1164/rccm.202104-1013oc] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Accepted: 10/14/2021] [Indexed: 11/16/2022] Open
Abstract
Rationale: Pneumonia is the leading cause of death in children worldwide. Identifying and appropriately managing severe pneumonia in a timely manner improves outcomes. Little is known about the readiness of healthcare facilities to manage severe pediatric pneumonia in low-resource settings. Objectives: As part of the HAPIN (Household Air Pollution Intervention Network) trial, we sought to identify healthcare facilities that were adequately resourced to manage severe pediatric pneumonia in Jalapa, Guatemala (J-GUA); Puno, Peru (P-PER); Kayonza, Rwanda (K-RWA); and Tamil Nadu, India (T-IND). We conducted a facility-based survey of available infrastructure, staff, equipment, and medical consumables. Facilities were georeferenced, and a road network analysis was performed. Measurements and Main Results: Of the 350 healthcare facilities surveyed, 13% had adequate resources to manage severe pneumonia, 37% had pulse oximeters, and 44% had supplemental oxygen. Mean (±SD) travel time to an adequately resourced facility was 41 ± 19 minutes in J-GUA, 99 ± 64 minutes in P-PER, 40 ± 19 minutes in K-RWA, and 31 ± 19 minutes in T-IND. Expanding pulse oximetry coverage to all facilities reduced travel time by 44% in J-GUA, 29% in P-PER, 29% in K-RWA, and 11% in T-IND (all P < 0.001). Conclusions: Most healthcare facilities in low-resource settings of the HAPIN study area were inadequately resourced to care for severe pediatric pneumonia. Early identification of cases and timely referral is paramount. The provision of pulse oximeters to all health facilities may be an effective approach to identify cases earlier and refer them for care and in a timely manner.
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Affiliation(s)
- Suzanne M. Simkovich
- Division of Pulmonary and Critical Care
- Center for Global Non-Communicable Disease Research and Training, and
- Medstar Health Research Institute, Hyattsville, Maryland
| | - Lindsay J. Underhill
- Division of Pulmonary and Critical Care
- Center for Global Non-Communicable Disease Research and Training, and
| | - Miles A. Kirby
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Harvard University, Boston, Massachusetts
| | - Mary E. Crocker
- Division of Pulmonary and Sleep Medicine, Seattle Children’s Hospital and School of Medicine, University of Washington, Seattle, Washington
| | - Dina Goodman
- Division of Pulmonary and Critical Care
- Center for Global Non-Communicable Disease Research and Training, and
| | - John P. McCracken
- Global Health Institute, Department of Epidemiology and Biostatistics, College of Public Health, University of Georgia, Athens, Georgia
| | | | - Anaité Diaz-Artiga
- Centro de Estudios de la Salud, Universidad del Valle de Guatemala, Guatemala City, Guatemala
| | - Adly Castañaza-Gonzalez
- Centro de Estudios de la Salud, Universidad del Valle de Guatemala, Guatemala City, Guatemala
| | - Sarada S. Garg
- Department of Environmental Health Engineering, ICMR Center for Advanced Research on Air Quality, Climate and Health, Sri Ramachandra Medical College and Research Institute (Deemed University), Chennai, Tamil Nadu, India
| | - Kalpana Balakrishnan
- Department of Environmental Health Engineering, ICMR Center for Advanced Research on Air Quality, Climate and Health, Sri Ramachandra Medical College and Research Institute (Deemed University), Chennai, Tamil Nadu, India
| | - Gurusamy Thangavel
- Department of Environmental Health Engineering, ICMR Center for Advanced Research on Air Quality, Climate and Health, Sri Ramachandra Medical College and Research Institute (Deemed University), Chennai, Tamil Nadu, India
| | - Ghislaine Rosa
- Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom; and
| | - Jennifer L. Peel
- Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins, Colorado
| | - Thomas F. Clasen
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Eric D. McCollum
- Eudowood Division of Pediatric Respiratory Sciences and
- Global Program for Pediatric Respiratory Sciences, Department of Pediatrics, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - William Checkley
- Division of Pulmonary and Critical Care
- Center for Global Non-Communicable Disease Research and Training, and
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Siddharthan T, Pollard SL, Quaderi SA, Rykiel NA, Wosu AC, Alupo P, Barber JA, Cárdenas MK, Chandyo RK, Flores-Flores O, Kirenga B, Miranda JJ, Mohan S, Ricciardi F, Sharma AK, Das SK, Shrestha L, Soares MO, Checkley W, Hurst JR. Discriminative Accuracy of Chronic Obstructive Pulmonary Disease Screening Instruments in 3 Low- and Middle-Income Country Settings. JAMA 2022; 327:151-160. [PMID: 35015039 PMCID: PMC8753498 DOI: 10.1001/jama.2021.23065] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
IMPORTANCE Most of the global morbidity and mortality in chronic obstructive pulmonary disease (COPD) occurs in low- and middle-income countries (LMICs), with significant economic effects. OBJECTIVE To assess the discriminative accuracy of 3 instruments using questionnaires and peak expiratory flow (PEF) to screen for COPD in 3 LMIC settings. DESIGN, SETTING, AND PARTICIPANTS A cross-sectional analysis of discriminative accuracy, conducted between January 2018 and March 2020 in semiurban Bhaktapur, Nepal; urban Lima, Peru; and rural Nakaseke, Uganda, using a random age- and sex-stratified sample of the population 40 years or older. EXPOSURES Three screening tools, the COPD Assessment in Primary Care to Identify Undiagnosed Respiratory Disease and Exacerbation Risk (CAPTURE; range, 0-6; high risk indicated by a score of 5 or more or score 2-5 with low PEF [<250 L/min for females and <350 L/min for males]), the COPD in LMICs Assessment questionnaire (COLA-6; range, 0-5; high risk indicated by a score of 4 or more), and the Lung Function Questionnaire (LFQ; range, 0-25; high risk indicated by a score of 18 or less) were assessed against a reference standard diagnosis of COPD using quality-assured postbronchodilator spirometry. CAPTURE and COLA-6 include a measure of PEF. MAIN OUTCOMES AND MEASURES The primary outcome was discriminative accuracy of the tools in identifying COPD as measured by area under receiver operating characteristic curves (AUCs) with 95% CIs. Secondary outcomes included sensitivity, specificity, positive predictive value, and negative predictive value. RESULTS Among 10 709 adults who consented to participate in the study (mean age, 56.3 years (SD, 11.7); 50% female), 35% had ever smoked, and 30% were currently exposed to biomass smoke. The unweighted prevalence of COPD at the 3 sites was 18.2% (642/3534 participants) in Nepal, 2.7% (97/3550) in Peru, and 7.4% (264/3580) in Uganda. Among 1000 COPD cases, 49.3% had clinically important disease (Global Initiative for Chronic Obstructive Lung Disease classification B-D), 16.4% had severe or very severe airflow obstruction (forced expiratory volume in 1 second <50% predicted), and 95.3% of cases were previously undiagnosed. The AUC for the screening instruments ranged from 0.717 (95% CI, 0.677-0.774) for LFQ in Peru to 0.791 (95% CI, 0.770-0.809) for COLA-6 in Nepal. The sensitivity ranged from 34.8% (95% CI, 25.3%-45.2%) for COLA-6 in Nepal to 64.2% (95% CI, 60.3%-67.9%) for CAPTURE in Nepal. The mean time to administer the instruments was 7.6 minutes (SD 1.11), and data completeness was 99.5%. CONCLUSIONS AND RELEVANCE This study demonstrated that screening instruments for COPD were feasible to administer in 3 low- and middle-income settings. Further research is needed to assess instrument performance in other low- and middle-income settings and to determine whether implementation is associated with improved clinical outcomes.
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Affiliation(s)
- Trishul Siddharthan
- Division of Pulmonary and Critical Care, Miller School of Medicine, University of Miami, Miami, Florida
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, Maryland
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Suzanne L. Pollard
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, Maryland
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, Maryland
- Now with the National Institutes of Health, Bethesda, Maryland
| | | | - Natalie A. Rykiel
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, Maryland
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Adaeze C. Wosu
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, Maryland
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Patricia Alupo
- Makerere Lung Institute, Makerere University, Kampala, Uganda
| | - Julie A. Barber
- Department of Statistical Science, University College London, London, United Kingdom
| | - Maria Kathia Cárdenas
- CRONICAS Centre of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Ram K. Chandyo
- Department of Community Medicine, Kathmandu Medical College, Nepal
| | - Oscar Flores-Flores
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, Maryland
- Biomedical Research Unit, A.BPRISMA, Lima, Peru
- Centro de Investigación del Envejecimiento (CIEN), Facultad de Medicina Humana, Universidad de San Martin de Porres, Lima, Peru
| | - Bruce Kirenga
- Makerere Lung Institute, Makerere University, Kampala, Uganda
| | - J. Jaime Miranda
- CRONICAS Centre of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru
- Department of Medicine, School of Medicine, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Sakshi Mohan
- Centre for Health Economics, University of York, York, United Kingdom
| | - Federico Ricciardi
- Department of Statistical Science, University College London, London, United Kingdom
| | - Arun K. Sharma
- Child Health Research Project, Institute of Medicine Tribhuvan University, Kathmandu, Nepal
| | - Santa Kumar Das
- Child Health Research Project, Institute of Medicine Tribhuvan University, Kathmandu, Nepal
| | - Laxman Shrestha
- Child Health Research Project, Institute of Medicine Tribhuvan University, Kathmandu, Nepal
| | - Marta O. Soares
- Centre for Health Economics, University of York, York, United Kingdom
| | - William Checkley
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, Maryland
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - John R. Hurst
- UCL Respiratory, University College London, London, United Kingdom
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Lazo-Porras M, Bernabe-Ortiz A, Gilman RH, Checkley W, Smeeth L, Miranda JJ. Population-based stroke incidence estimates in Peru: Exploratory results from the CRONICAS cohort study. Lancet Reg Health Am 2022; 5:100083. [PMID: 35224529 PMCID: PMC8880839 DOI: 10.1016/j.lana.2021.100083] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/16/2023]
Abstract
BACKGROUND Limited information exists about the incidence of first-ever stroke at the population level, particularly in low- and middle-income countries (LMIC). Longitudinal data from the CRONICAS Cohort Study includes both altitude and urbanization and allows a detailed assessment of stroke incidence in resource constrained settings. The aim of this study was to estimate the incidence and explore risk factors of first-ever stroke at the population level in Peru. METHODS Stroke was defined using a standardised approach based on information from cohort participants or family members. This information was adjudicated centrally by trained physicians using common definitions. Time of follow-up was calculated as the difference between date of enrolment and the reported date of the stroke event. Unstandardised and age-standardised, first-ever stroke incidence rate and 95% confidence intervals (95% CI) were calculated. Generalized linear models, assuming Poisson distribution and link log, were utilized to determine potential factors to develop stroke. FINDINGS 3,601 individuals were originally enrolled in the cohort and 2,471 provided data for the longitudinal analysis. The median time of follow-up was 7.0 (range: 1 - 9) years, accruing a total of 17,308 person-years. During followup, there were 25 incident cases of stroke, resulting in an age-standardised incidence of stroke of 98.8 (95% CI: 63.8 - 154.0) per 100,000 person-years. After adjustment by age and sex, stroke incidence was higher among people with hypertension (incidence risk ratio (IRR) = 5.18; 95% CI: 1.89 - 14.16), but lower among people living at high altitude (IRR = 0.09; 95% CI: 0.01 - 0.63). INTERPRETATION Our results indicate a high incidence of first-ever strokes in Peruvian general population. These results are consistent with the estimates found in previous LMIC reports. Our study also found a contributing role of hypertension, increasing the risk of having a first-ever stroke. This work further advances the field of stroke epidemiology by identifying high altitude as a factor related to lower incidence of stroke in a longitudinal study. However, this information needs to be considered with cautions because of the study limitations.
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Affiliation(s)
- Maria Lazo-Porras
- CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru
- Division of Tropical and Humanitarian Medicine, Geneva University Hospitals & University of Geneva, Switzerland
- Corresponding author. Antonio Bernabe-Ortiz, MD, MPH, PhD, CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Av. Armendariz 445, Miraflores, Lima, Peru, Phone: 511-241-6978
| | - Antonio Bernabe-Ortiz
- CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru
- Corresponding author. Antonio Bernabe-Ortiz, MD, MPH, PhD, CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Av. Armendariz 445, Miraflores, Lima, Peru, Phone: 511-241-6978
| | - Robert H. Gilman
- CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, USA
- Área de Investigación y Desarrollo, Asociación Benéfica PRISMA, Lima, Peru
| | - William Checkley
- CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, USA
| | - Liam Smeeth
- Faculty of Epidemiology and Population Health; London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - J. Jaime Miranda
- CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru
- Department of Medicine, School of Medicine, Universidad Peruana Cayetano Heredia, Lima, Peru
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