Lung health and exposure to household air pollution in rural Malawi

Lead Research Organisation: Liverpool School of Tropical Medicine
Department Name: Clinical Sciences

Abstract

Across Africa around 700 million people use biomass fuel (animal or plant material) to provide energy for cooking, heating and lighting. Women and young children experience high levels of smoke exposure when meals are cooked over open fires inside homes due to partial combustion of fuel and poor ventilation. Household air pollution from open fires is a major threat to health, ranking 4th in the recently updated World Health Organization (WHO) comparative risk assessment for the global burden of disease. WHO estimates around 4 million premature deaths are caused by household air pollution worldwide every year. A substantial proportion of these deaths is attributed to lung disease with pneumonia in young children and chronic obstructive pulmonary disease (COPD) in adult women dominating the picture. Other adverse health effects associated with biomass smoke exposure include stillbirth, low birth weight, cardiovascular disease and lung cancer.

In Malawi, where at least 95% of households depend on biomass as their main source of fuel and household air pollution levels are high, biomass smoke exposure is likely to be responsible for a substantial burden of pneumonia in young children and COPD in adults. Effective strategies for reducing both biomass fuel consumption and smoke exposure include improved stoves, ventilation, cleaner fuels and behaviour modification but are out of reach for the majority of the population due to a wide range of largely poverty-related factors. The Global Alliance for Clean Cookstoves was launched in 2010 to tackle this energy poverty issue through public private partnerships. A central aim of the Alliance is for 100 million homes to adopt clean and efficient stoves and fuels by 2020. However, there is very limited evidence to assess the potential benefits of such an approach.

The proposed research will be integrated with the Cookstoves And Pneumonia Study (CAPS) which is a £2.7 million investment from the Joint Global Health Trials Schemein a village level cluster randomised controlled trial of an advanced cookstove intervention to prevent pneumonia in children under 5 years old in Malawi.

The proposed research will determine:
1) the association between exposure to household air pollution (carbon monoxide) and the development of pneumonia in children under the age of 5 in rural Malawi.
2) the prevalence and determinants of obstructive lung disease in adults in rural Malawi.
3) the extent to which exposure to household air pollution (carbon monoxide and particulate matter) explains the rate of decline in lung function in adults in rural Malawi.

This research is needed now to deliver relevant and timely evidence for communities and policy makers about the adverse health effects of exposure to household air pollution in Malawi and the potential for biomass smoke exposure reduction strategies to impact on the incidence of pneumonia in young children and the development and progression of COPD in adults. The results of this research will be relevant to local policy makers in Malawi who will have new data to guide decisions about prioritising funding for biomass smoke exposure reduction strategies for improving lung health; to regional commercial, non-governmental (NGO) and governmental organisations in sub Saharan Africa manufacturing and distributing cookstove solutions with uncertain health benefits; and to international decision and policy makers (e.g. DFID, WHO and Global Alliance for Clean Cookstoves) by providing new evidence about the health impacts of reducing biomass smoke exposure of broadly generalisable relevance to areas of the world where biomass fuel use is common.

Technical Summary

Design:
1) An exposure-incidence study will be conducted within CAPS to determine the association between exposure to household air pollution (carbon monoxide [CO]) and pneumonia in children under the age of 5 in rural Malawi.
2) A cross-sectional study will be conducted to determine the prevalence and determinants of obstructive lung disease in adults in rural Malawi.
3) A prospective cohort study will be conducted within CAPS to determine the extent to which exposure to CO and particulate matter (PM2.5) explains the rate of decline in lung function in adults in rural Malawi.
Study population:
Exposure-incidence study - Children up to 5 years old included in CAPS
Cross-sectional and cohort studies - Non-institutionalised adults aged 18 and above
Exposures:
CO (Lascar CO monitors) and particulate matter (UCB particle monitors) exposures from biomass smoke
Outcomes:
Exposure-incidence study - Pneumonia in children under 5 years of aged diagnosed by blinded physicians or medical officers using the WHO Integrated Management of Childhood Illness (IMCI) pneumonia assessment protocol
Cross-sectional and cohort studies - Post bronchodilator spirometry in adults
Sample size and potential power:
Exposure-incidence study - With 2000 children this study will have 90% power to detect a minimum mean difference between the controls and cases of 6.53 (40%) ppm CO.
Cross-sectional and cohort study - With 2000 adults these studies will provide an estimate of prevalence of acceptable precision (e.g. with an estimated prevalence of 15% the estimated 95% CI for each gender would be 15% +/- 4%) and have 90% power to detect a correlation between particulate matter exposure and change in FEV1 level of 0.102 (or greater) in both age group combined and 0.144 (or greater) in each age group separately.
Consumer involvement: Villagers, local stove producers and community leaders have been involved with the development of this work.

Planned Impact

Research participants: The proposed research will be integrated with the Cookstoves And Pneumonia Study (CAPS) which is a £2.7 million investment from the Joint Global Health Trials Scheme in a village level cluster randomised controlled trial of an advanced cookstoves intervention to prevent pneumonia in children under 5 years old in Malawi. The benefits from participation in this broader project include a quarterly allocation of maize, access to a mobile phone, access to antibiotics for pneumonia if indicated but unavailable at the local health facilities and two advanced cookstoves per household either at the beginning or end of the trial.
Local staff: A number of local people will be employed directly through this grant with many other local people involved indirectly. The training and experience gained should lead to improved work opportunities in the future. In addition there will be immediate financial benefits for individuals receiving a salary. Such financial benefits typically extend widely beyond these individuals to families and home villages.
Women and children living in poverty in developing countries: Should clear exposure-response relationships be seen between biomass smoke exposure (carbon monoxide and particulate matter) and pneumonia in children and decline in lung function in adults, these findings will be relevant across populations of people who cook using open fires living in the developing world well beyond the immediate trial setting. The benefits of reducing biomass smoke exposure could extend beyond health effects to economic, quality of life and well-being effects.
Local, national and international policy and decision makers: High quality evidence about the health and impacts possible with reductions in biomass smoke exposure is needed to inform policy and decision makers across commercial, health, development and community sectors at local, national and international levels. The results of this research will be relevant to local policymakers in Malawi who will have new data to guide decisions about prioritising funding for biomass smoke exposure reduction strategies for improving lung health; to regional commercial, non-governmental (NGO) and governmental organisations in sub Saharan Africa manufacturing and distributing cookstove solutions with uncertain health benefits; and to international decision and policy makers (e.g. DFID, WHO and Global Alliance for Clean Cookstoves) by contributing new evidence about the health impacts of reducing biomass smoke exposure of broadly generalisable relevance to areas of the world where biomass fuel use is common.
Public sector: I will work clinically at CAPS trial health centres in Malawi in place of my current NHS commitments to support local clinical services, research and teaching activities. The teaching will help maintain knowledge and skills and will hopefully have positive impacts on the management of adults and children with lung disease in Malawi.
Business: The new scientific knowledge including exposure-response data from this research could be exploited by businesses locally and internationally developing biomass smoke exposure reduction interventions. This could contribute to wealth creation and economic prosperity in individual developing countries.
Third sector: NGOs implementing cookstove programmes are expected to benefit from new knowledge about exposure-response effects of biomass smoke exposure reduction strategies that could be used to guide future activities.
Other: LSTM, MLW and COM have public engagement programmes that contribute to increasing public awareness and understanding of science, economic and societal issues which I will contribute to with the results of this research.
Environment and climate change: The widespread adoption of technologies that translate into reduced biomass use and smoke emissions will put less pressure of forests and could contribute to environmental sustainability and protection.

Publications

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Banda H (2016) The 'Practical Approach to Lung Health' in sub-Saharan Africa: a systematic review. in The international journal of tuberculosis and lung disease : the official journal of the International Union against Tuberculosis and Lung Disease

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Bel EH (2014) Oral glucocorticoid-sparing effect of mepolizumab in eosinophilic asthma. in The New England journal of medicine

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Gordon SB (2014) Respiratory risks from household air pollution in low and middle income countries. in The Lancet. Respiratory medicine

 
Title Cooking And Pneumonia Study film 
Description 3 minute film about the MRC, Wellcome Trust and DfID funded Cooking And Pneumonia Study 
Type Of Art Film/Video/Animation 
Year Produced 2014 
Impact Film captured interest of the BBC News. Victoria Gill (BBC News Science Reporter) has been out to Malawi to cover the story of the Cooking And Pneumonia Study. Media coverage expected shortly. 
URL http://www.capstudy.org
 
Guideline Title Mepolizumab for treating severe refractory eosinophilic asthma
Description Citation in NICE guideline
Geographic Reach Europe 
Policy Influence Type Citation in clinical guidelines
 
Guideline Title WHO Guidelines for Indoor Air Quality
Description Citation in WHO Guidelines for Indoor Air Quality
Geographic Reach Africa 
Policy Influence Type Citation in clinical guidelines
 
Description Input into DfID policy on household air pollution
Geographic Reach Multiple continents/international 
Policy Influence Type Participation in advisory committee
 
Description BREATHE
Amount £580,000 (GBP)
Funding ID MR/L009242/1 
Organisation Medical Research Council (MRC) 
Department MRC Partnership Grant
Sector Public
Country United Kingdom
Start  
 
Description Bill and Melinda Gates Foundation
Amount $343,147 (USD)
Organisation Andrew W. Mellon Foundation 
Sector Private
Country United States
Start 08/2015 
End 08/2016
 
Description Children's health research award
Amount £50,912 (GBP)
Organisation Medical Research Council (MRC) 
Department Medical Research Foundation
Sector Charity/Non Profit
Country United Kingdom
Start 02/2016 
End 01/2017
 
Description Doctoral Training Partnership
Amount £1,288,660 (GBP)
Funding ID MR/N013514/1 
Organisation Medical Research Council (MRC) 
Sector Academic/University
Country United Kingdom
Start 10/2016 
End 09/2022
 
Description Funding for CAHRD meeting
Amount £5,000 (GBP)
Organisation Liverpool School of Tropical Medicine 
Sector Academic/University
Country United Kingdom
Start 05/2014 
End 06/2014
 
Description Funding for CAHRD meeting (on behalf of CAHRD cross cutting theme).
Amount £5,000 (GBP)
Organisation French National Cancer Institute (INCA) 
Sector Public
Country France
Start 05/2014 
End 06/2014
 
Description Funding for PATS MECOR.
Amount £10,000 (GBP)
Organisation Aldama Foundation 
Sector Charity/Non Profit
Country Unknown
Start 09/2014 
End 10/2014
 
Description Funding in support of MRC Doctoral Training Programme
Amount £80,000 (GBP)
Organisation Aldama Foundation 
Sector Charity/Non Profit
Country Unknown
Start 01/2016 
End 01/2021
 
Description GCRF Research Grant
Amount £606,000 (GBP)
Funding ID MR/P022006/1 
Organisation Medical Research Council (MRC) 
Sector Academic/University
Country United Kingdom
Start 04/2017 
End 04/2019
 
Description International Engagement Award
Amount £3,000 (GBP)
Organisation Wellcome Trust 
Sector Charity/Non Profit
Country United Kingdom
Start 01/2015 
End 02/2015
 
Description MRC GCRF
Amount £218,000 (GBP)
Organisation Medical Research Council (MRC) 
Sector Academic/University
Country United Kingdom
Start 06/2017 
End 12/2018
 
Description MRC NPIF Skills Development Fellowship
Amount £286,000 (GBP)
Organisation Medical Research Council (MRC) 
Sector Academic/University
Country United Kingdom
Start 11/2017 
End 11/2020
 
Description MRC NPIF Studentships
Amount £260,000 (GBP)
Organisation Medical Research Council (MRC) 
Sector Academic/University
Country United Kingdom
Start 09/2017 
End 08/2021
 
Description MRC Skills Development Fellowship Programme
Amount £600,000 (GBP)
Organisation Medical Research Council (MRC) 
Sector Academic/University
Country United Kingdom
Start 04/2018 
End 04/2021
 
Description NIH (R56)
Amount $100,000 (USD)
Organisation National Institutes of Health (NIH) 
Sector Public
Country United States
Start 08/2014 
End 08/2015
 
Description NIHR Global Health Research Unit
Amount £7,000,000 (GBP)
Organisation National Institute for Health Research 
Sector Public
Country United Kingdom
Start 06/2017 
End 03/2021
 
Description Newton Advanced Fellowship: Biostatistical Methods for Bayesian Analysis of Multilevel Models of Lung Health in Africa.
Amount £92,600 (GBP)
Funding ID NAF\R2\180681 
Organisation Academy of Medical Sciences (AMS) 
Sector Charity/Non Profit
Country United Kingdom
Start 12/2018 
End 12/2021
 
Description Wellcome Trust Clinical PhD scheme
Amount £455,000 (GBP)
Organisation Wellcome Trust 
Sector Charity/Non Profit
Country United Kingdom
Start 12/2018 
End 09/2021
 
Description Biomass Reduction and Environmental Air Towards Health Effects in Africa (BREATHE -Africa) 
Organisation Liverpool School of Tropical Medicine
Country United Kingdom 
Sector Academic/University 
PI Contribution Theme leader for health Effects. Teach level 1 students at the annual PATS MECOR course.
Collaborator Contribution •Draw together experts and investigators in major air pollution trials in order to share findings and plans •Harmonise specific aspects of trial methodology to ensure that exposure monitoring and health effect evaluation are comparable among active trials and those in development, as well as other research and evaluation with similar exposure and outcome assessment needs. •Optimise the opportunity to undertake mechanistic work, including testing of new biomarkers, not funded by current trials •Engage African researchers and trainees in existing and new studies by a bottom-up approach offering mentored research training and projects.
Impact The publication of a Commissioned Review for The Lancet Respiratory Medicine journal has been an early success for the Partnership. This is wide-ranging review of 'Respiratory risks from household air pollution in low and middle income countries' is available on the Lancet website. http://www.thelancet.com/journals/lanres/article/PIIS2213-2600(14)70168-7/fulltext. CAHRD meeting [Centre for Applied Health Research & Delivery]
Start Year 2014
 
Description 47th World Conference on Lung Health 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact Scientific presentation on the challenges of implementing new models of care in low- and middle- income countries which generated discussion .
Year(s) Of Engagement Activity 2016
 
Description Action for Interdisciplinary air pollution Research workshop 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Public/other audiences
Results and Impact Engagement with community of Mukuru informal settlement in Nairobi, Kenya to explore research priorities relating to air pollution from the community perspective and to start developing collaborative inter-disciplinary research project ideas.
Year(s) Of Engagement Activity 2018
 
Description African Utility Week 2016 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Industry/Business
Results and Impact Presentation about the potential for clean energy solutions to improve health and save lives in Africa which was followed by questions and discussion and potential areas for future collaborative work.
Year(s) Of Engagement Activity 2016
 
Description American Thoracic Society Conference 2015 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact Participation in American Thoracic Society Task Force Workshop and preparation of a report about the adverse health effects of household air pollution.
Year(s) Of Engagement Activity 2015
 
Description BBC News coverage of Cooking And Pneumonia Study programme of work 
Form Of Engagement Activity A press release, press conference or response to a media enquiry/interview
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Media (as a channel to the public)
Results and Impact Coverage of the story of the Cooking And Pneumonia Study (CAPS) by BBC News Science Reporter Victoria Gill who visited the study location in Malawi and prepared reports that were shown widely on BBC News outlets. This generated considerable global interest in the study and the topic of household air pollution and the adverse health effects associated with this.
Year(s) Of Engagement Activity 2014
URL http://www.bbc.co.uk/news/health-30448559
 
Description COPD conference presentation 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact Invited talk as Long Investigator at the COPD11 conference on 'learning from global studies'. Following this I was invited to participate in a Global Initiative for Chronic Obstructive Lung Disease (GOLD) meeting on how to make the international GOLD guidelines more relevant to LMIC populations. An output from this meeting was the drafting of a position statement.
Year(s) Of Engagement Activity 2018
 
Description Cambridge University Visit 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Professional Practitioners
Results and Impact Seminar delivered at Cambridge University Hospitals' Respiratory Research event about household air pollution and lung disease in Africa. Questions and discussion followed. Opportunities for future clinical and academic collaboration explored.
Year(s) Of Engagement Activity 2017
 
Description Citizen News Service Webinar for World Asthma Day 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Media (as a channel to the public)
Results and Impact Approx. 50 media-linked participants linked in to this webinar.
Year(s) Of Engagement Activity 2017
URL http://www.citizen-news.org/2017/04/webinar-world-asthma-day-2017-manage.html
 
Description Community engagement activities (Malawi) 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Participants in your research and patient groups
Results and Impact All communities participating in the Cooking And Pneumonia Study we consulted about the study which sparked questions and discussion.

The communities have asked us to return. We are planning additional engagement activities to explore community-identified research priorities for the future
Year(s) Of Engagement Activity 2014
 
Description Conference (The Union 2016) 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Public/other audiences
Results and Impact Raising awareness about the global health problem of household air pollution to a wide range of audiences through engagement with community activities of the 2016 World Lung Health Conference.
Year(s) Of Engagement Activity 2016
URL http://www.thelancet.com/journals/lanres/article/PIIS2213-2600(16)30413-1/abstract?cc=y=
 
Description Ethiopian Thoracic Society Conference 2016 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Professional Practitioners
Results and Impact Invited talk on the effects of air pollution on lung health at the 2nd annual meeting of the Ethiopian Thoracic Society which generated interest in the topic and discussion of potential future research and collaboration in this area.
Year(s) Of Engagement Activity 2016
 
Description Global Health Film Festival 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Media (as a channel to the public)
Results and Impact Contributed to the development and implementation of a Workshop at the Global Health Film Festival: "Research in Focus - the role of video film in global health research". Discussion followed and interest was expressed in further Workshops being held at the Festival in the future.
Year(s) Of Engagement Activity 2018
 
Description MRC Unit The Gambia talk 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact Talk to academic audience at the MRC Unit in The Gambia about the Cooking And Pneumonia Study which led to questions and discussion about opportunities for future collaboration.
Year(s) Of Engagement Activity 2017
 
Description Presentations at meetings in Nepal 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Postgraduate students
Results and Impact Invited talks in Nepal - at Patan Hospital and the Institute of Medicine - on "Household air pollution and the improved cookstove: a story of smoke and mirrors?" These talks led to discussion and meetings particularly focused on opportunities to collaborate in the future
Year(s) Of Engagement Activity 2018
 
Description School Visit (Liverpool) 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach Local
Primary Audience Schools
Results and Impact Involved Liverpool Life Sciences UTC students in discussing Malawi-based work and preparing for community participation in The World Lung Health Conference in Liverpool 2016
Year(s) Of Engagement Activity 2016
 
Description Smart Villages Webinar 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Other audiences
Results and Impact Participation as panelist in seminar: Healthy villages are smart villages: Health, energy, and development which generated questions and discussion and potentially influenced future decision making.
Year(s) Of Engagement Activity 2017
 
Description Warwick University Visit 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Postgraduate students
Results and Impact Talk to Doctoral students at Warwick University Medical School about 'life post PhD' which led to questions and discussion.
Year(s) Of Engagement Activity 2017