Household Air Pollution as a Regional Target for Prevention and Control of Non-Communicable Diseases

Transcription

1 Household Air Pollution as a Regional Target for Prevention and Control of Non-Communicable Diseases Dr. Dheeraj Gupta MD, DM, FRCP, FAMS Professor Department of Pulmonary Medicine [WHO Collaborating Center for Research and Capacity Building in Chronic Respiratory Diseases] Postgraduate Institute of Medical Education and Research (PGIMER) Chandigarh. India

2 Introduction Household Air Pollution (HAP) also known as Indoor Air Pollution (IAP) is known to have multiple adverse outcomes on health and environment Globally HAP is the 2 nd most important risk factor for DALYs for females and 5 th most important for males It is the leading cause for both sexes in South Asia and for women in Sub-Saharan Africa Lim SS, et al. Lancet. 2012;380(9859):

3 Public health Significance of HAP 2 million premature HAP related deaths from ALRI in young, COPD and Lung Cancer [WHO 2009] 3.5 million (4 million including HAP s contribution to 16% of outdoor air pollution deaths), due to the inclusion of HAP deaths from cardiovascular disease and lung cancer from biomass smoke [GBD2010] [Lim SS, et al. Lancet. 2012;380(9859): ]

4 SFU: Burden

5 SFU Estimates: These estimates were used for GBD and CRA studies of 2010 Derived by multilevel modeling and used data from National surveys covering 85% of world s population SFU has declined from 62% (95%CI: 58-66) in 1980 to 41% (95%CI: 37-44) in 2010 globally The total number of people exposed has largely remained unchanged ( billion) due to population growth Bonjour S, et al. Environ Health Perspectives Epub 03 May 2013

6 SFU Estimates: Africa: SFU households is increasing (77% prevalence in 2010 and 646 million people exposed) Eastern Mediterranean: slight increase in the population exposed although prevalence has fallen South East Asia: decrease in SFU from 95% to 61%, but population cooking with solid fuels static Europe, the Americas, and Western Pacific: declines in both SFU prevalence and the populations exposed Bonjour S, et al. Environ Health Perspectives Epub 03 May 2013

7 SFU Estimates: Bonjour S, et al. Environ Health Perspectives Epub 03 May 2013

8 SFU Estimates: SEAR Entire Region Households with SFU 83 (74, 93) 71 (62, 80) 61 (52, 70) [% (95%CI, %)] Population Exposed million (95% CI) 1100 (979, 1221) 1112 (972, 1253) 1097 (934, 1260) Proportions of Households with SFU in member countries [% (95%CI, %)] Bangladesh 91 (78, 100) 89 (76, 100) 91 (78, 100) Bhutan 78 (65, 93) 58 (45, 71) 40 (27, 53) DPR of Korea 98 (85, 100) 93 (80, 100) 91 (78, 100) India 87 (73, 99) 71 (58, 84) 58 (45, 71) Indonesia 67 (53, 81) 59 (46, 73) 55 (42, 68) Maldives 64 (15, 78) 35 (22, 48) 8 (0, 22) Myanmar 98 (89, 100) 95 (83, 100) 92 (79, 100) Nepal 74 (61, 88) 77 (64, 90) 82 (69, 95) Sri Lanka 89 (76, 100) 80 (68, 94) 75 (62, 88) Thailand 63 (50, 77) 43 (30, 57) 26 (13, 39) Bonjour S, et al. Environ Health Perspectives Epub 03 May 2013

9 Distribution of households by type of fuel used for cooking Total No. of 24,66,92,667 Households Fire wood 49.0 Crop residue 8.9 Cowdung cake 8.0 Coal, Lignite, 1.5 Charcoal Kerosene 2.9 LPG 28.6 Electricity 0.1 Biogas 0.4 Any other 0.5 No cooking 0.3 Fire wood Crop residue Cowdung cake Coal, Lignite, Charcoal Kerosene LPG Electricity Biogas Any other No cooking Census of India 2011

10 A Profile of Biomass Stove Use in Sri Lanka Over 78% of Sri Lankans use biomass fuel for cooking Elledge et. Al. Int. J. Environ. Res. Public Health 2012, 9,

11 Reducing SFU: Coherence with major strategies Diseases LRTI in Children COPD/CAD/Lung Cancer in adults Tuberculosis Stillbirth, low birth weight, impaired cognitive development Cataracts and possibly trachoma Burns and scalds Injuries or violence experienced during fuel collection Environmental degradation from fuel gathering Climate change from emissions during combustion Socio-economic benefits

12 REDUCING COPD Is Tobacco Control Enough??

13 COPD in Non-smokers COPD in nonsmokers has been recognized world over, more so in poor and developing countries Up to 25-40% patients of COPD have never smoked [Salvi SS, Barnes PJ. Lancet 2009;374(9691):733-43] PLATINO study: 17-35% COPD were non-smokers [Lancet. 2005;366(9500): ] BOLD: 27.7% COPD were non-smokers (20-33% depending upon the severity of diseases) in data from 14 sites across 5 continents [Chest. 2011;139(4):752-63]

14 1-3. Jindal et al. (IJTUAD 2012;16(9):1270-7; IJCDAS 2001;43(3):139-47; and 2006;48(1): Pandey MR. Thorax. 1984;39(5): Mosharraf-Hossain KM, et al. MMJ. 2009;18(1 Suppl):S Lamprecht B, et al. Chest. 2011;139(4): Oh YM, et al. Int J COPD. 2013;8:31-9 COPD in Non-smokers: SEAR Country Proportion (%) of Non-smoker COPD patients Males Females Overall India (1-3) Nepal (4) Bangladesh (5) Indonesia (6) 29 Thailand (6) 39.7 Sri Lanka (7) 19.1

15 COPD in Non-smokers Significant proportion of COPD among men and a vast majority among women is not caused by tobacco smoking Causes/Risk factors Alfa-1 anti-trypsin deficiency Outdoor air pollution (OAP) Occupational exposures Low socio-economic status Severe childhood infections Tuberculosis Passive smoking HAP due to use of biomass or solid fuels (wood, crop residue, dung, coal and charcoal) for cooking and heating

16 SFU as a risk factor for COPD in non-smokers [Kurmi Op, et al. Thorax 2010; 65: ]

17 SFU as a risk factor for COPD in non-smokers [Kurmi Op, et al. Thorax 2010; 65: ]

18 SFU and COPD: SEAR

19 SFU and COPD: WHY? Biological plausibility In complete combustion of organic matter leads to high concentration of noxious particulate and gaseous emissions

20 The energy ladder Kurmi et al. Eur Respir J 2012; 40:

21 What is in Biomass smoke? Carbon (5 20% of wood smoke as particulate mass) High levels of carbon monoxide, hydrogen cyanide, ammonia and nitrogen oxides >250 organic compounds Polycyclic aromatic hydrocarbons (PAHs) (e.g. benzo[a]pyrene (BaP)), aldehydes and free radicals Contaminated by chemicals such as pesticides, or mixed with plastics Naeher LP, et al. Inhal Toxicol 2007; 19:

22 Biomass fuels: Culprits Carbon (5 20% of wood smoke as particulate mass) >250 organic Tobacco compounds is also High levels of carbon monoxide, hydrogen cyanide, ammonia BIOMASS and nitrogen oxides Polycyclic aromatic hydrocarbons (PAHs) (e.g. benzo[a]pyrene (BaP)), aldehydes and free radicals Contaminated by chemicals such as pesticides, or mixed with plastics Naeher LP, et al. Inhal Toxicol 2007; 19:

23 SFU as an indicator for HAP Solid fuel use vs. exposure Reducing SFU is the most definitive step in controlling HAP (neighborhood pollution) Exposures are difficult to assess and monitor SFU data is widely available and part of census activity in several countries including India Thus proportion of households with SFU as primary source of cooking is the best available indicator for HAP that is based on standardized modeling techniques using large volumes of population based data

24 Proposed Target 50% REDUCTION IN PROPORTION OF HOUSEHOLDS WITH SFU AS PRIMARY SOURCE OF COOKING

25 Availability of Data WHO house hold energy database WHO Global Health Observatory databases

26 Availability of Data: SEAR Country Years Bangladesh 1981, 1991, 2002, 2003, 2004, 2005, 2007 Bhutan 2003, 2007 India 1991, 1992, 1997, 1998, 1999, 2000, 2001, 2003, 2004, 2005, 2006 Indonesia 2002, 2003, 2007 Maldives 2000, 2006 Nepal 1990, 1995, 2000, 2001, 2003, 2004, 2006 Republic of 1983, 1986, 1989, 1992, 1995, 1998 Korea Sri Lanka 1994, 2001, 2003, 2006 Thailand 1990, 1997, 2000, 2001, 2002, 2005 Source: WHO GHO Database

27 Achievability of proposed target Bonjour S, et al. Environ Health Perspectives Epub 03 May 2013

28 Achievability of proposed target Bangladesh Bhutan DPR of Korea India Indonesia Maldives Myanmar Nepal Sri Lanka Thailand Trends in proportion (%) of households using SFU in SEAR Bonjour S, et al. Environ Health Perspectives Epub 03 May 2013

29 Finding Household Energy Solutions The Context Scale of the problem: Nearly 3 billion people (>1 b in SEAR) Gender- and age-specific risks: Women and children have the greatest exposures and may be constrained by cultural and gender-related factors to change their household exposures and risks with fuel gathering Cultural contexts: Traditional methods used for many generations and are adapted to local dietary, environmental, and cultural needs Environmental risks: contribution to outdoor air pollution and climate change(including deforestation) Poverty: Closely linked to poverty, challenge to provide affordable, acceptable and sustainable solutions Martin WJ II, et al. PLoS Med 2013;10(6): e

30 Possible interventions to reduce HAP At the Source Alternative fuels LPG, Bio-gas, Solar Cookers, Electricity, other low fume fuels like, methanol, ethanol, etc. Improved cook stoves for better combustion of biomass fuels Reducing need for fire Retained heat cooker, Pressure cooker, etc. Solar energy Energy efficient house designs Environmental Interventions Improved Ventilation Hoods, chimneys, ventilation holes, etc Improved kitchens Outside the house (cook is not saved) Keeping the cooking shelf at waist height (avoids leaning over the fire) Behavioral Modifications Reducing the source Fuel Drying Good maintenance of cooking stoves, chimneys, etc. Good cooking practices to conserve heat (e.g. use pots with lids, precooking practices to reduce need for heat) Reduce exposure Avoid un-necessary exposure to children WHO Indoor Air thematic Briefing 3

31 Way Forward ADVOCACY: convince users about the importance of CCE: significant awareness campaign AVAILABILITY: ensure availability: e.g. supply of LPG/processed biomass fuels/ improved cookstoves AFFORDABILITY: link CCE programs with poverty reduction/income generation programs integrated approach ALLIANCE: Multi-sectorial efforts involving National Governments, private sector and NGOs need to rally around the UN initiative to achieve Universal access to energy by 2030

32 Conclusions HAP is a major challenge and needs affirmative action by scientists, clinician and public health managers Even though HAP is seemingly problem of poverty and poor access to clean fuels, situation can be improved if flagged We need commitment at all levels; the Governments, industry, NGO and private sector have to join hands

33 TELECOM REVOLUTION

34 LPG Solar energy ENERGY REVOLUTION

35 Rarely does the global community have the opportunity to address a problem where the societal benefits from concerted action are so farreaching. - GACC Report on Universal adoption of Clean cooking stoves Nov. 2011

36 THANK YOU