4/22/2017 Indoor Burning of Biomass or Solid Fuels: the number one environmental cause of death in the world William J. Martin II, M.D. Dean and professor, The Ohio State University College of Public Health

Smoke and Malaria, WHO 2008

Woman in Guatemala Cooking Indoors Courtesy of Kirk Smith, PI of RESPIRE study

Biomass/Solid Fuels Widely Used for Heating and Cooking Around the World Primary fuel source for the poor in low and middle income countries (2.8 Billion) Common terms: Biomass or solid fuels 1) Biomass fuels (variable content of water) Wood/ charcoal Crop residues/ leaves/ combustible debris Dung 2) Solid fuels Biomass Coal 5

The Numbers “B” is for Billion 3

Table 1: Deaths attributable to environmental risk worldwide1 Exposures Deaths (in millions) 2010 Air pollution Ambient 3.22 (2.82-3.62) HAP* 3.55 (2.68-3.62) Second hand smoke 0.60 (0.45-0.52) Unimproved water source 0.12 (0.01-0.23) Unimproved sanitation 0.24 (0.01-0.48) Residential radon 0.10 (0.01-0.22) Lead exposure 0.67 (0.58-.78) Occupational risk factors (total) 0.85 (0.66-1.06) Adapted from “Table 3: Deaths attributable to risk factors and risk factor clusters, worldwide”, Lim et al (Lancet, December 2012) with numbers in parentheses representing 95% uncertainty intervals. *HAP has been estimated to also contribute 16% to the world wide burden of ambient air pollution.1

The Numbers “M” is for Million 4.3

It’s like Smoking without Cigarettes The Diseases It’s like Smoking without Cigarettes COPD in Never Smokers Pneumonia in Children Cardiovascular Disease

Infancy: low birth weight, perinatal morbidity and mortality, sepsis ? Health Effects from Exposure to Household Smoke from Burning of Biomass/Solid Fuels Infancy: low birth weight, perinatal morbidity and mortality, sepsis ? Respiratory: ALRI in children, COPD, asthma, otitis media Cancer: lung and upper airway cancers Cardiovascular: hypertension, coronary heart disease Infection: tuberculosis, acute pneumonia in adults (?) Ocular: cataracts Musculoskeletal injuries/ hernias Burn injuries

It’s the most Vulnerable The People It’s the most Vulnerable

Simple Question What is the Best Estimate of the % of Low Income Americans who Live with Household Air Pollution? Assumption: That Americans who live below the FPL are less likely to have highly efficient indoor stoves due to high costs

Methods Publically available county level data from the US Census, USDA, and HHS were downloaded and merged using the Federal Information Processing Standards (FIPS) codes. The data were then imported into geographic information system (GIS) mapping tool (Health Landscape LLC) and displayed. A review of the relevant literature was then conducted and an estimate for the number of persons at risk generated.

% of US population Using Wood, Coal or Coke as Primary Fuel

% of US Population Below Federal Poverty Level

High Priority Areas Non-High Priority High Priority

= 500,000-600,000 900,000 x 53-65% Our Estimate Not Rocket Science 900,000 people live in poverty and heat their homes with solid fuel 53-65% of these households have household air pollution 900,000 x 53-65% = 500,000-600,000

Review of Scientific Literature by Region Appalachia Northwest Southwest Alaska

Appalachia The BOLD study in Southeastern Kentucky found an elevated odds ratio for ever having cooked indoors with wood or coal and reporting current asthma [9] . A recent study of Appalachian homes that heat with wood or coal found an average 24 hour ambient PM2.5 of well in excess of the World Health Organization (WHO) Air Quality Guidelines [6,10].

Upper Northwest Studies in Libby, MT demonstrated measurable reductions in community reported respiratory symptoms after a woodstove changeout program that reduced annual average ambient particulate matter by 28% [11]. Two wood stove changeout studies, 42 homes total, one in Libby and the other on the Nez Perce Reservation, demonstrated significant reductions in 24 hour average indoor PM2.5, 45.0 to 21.0µg/m3 and 39.2 to 19.0µg/m3 respectively [3,5].

The Southwest In 1990 and 1996 two case-control studies found an increased risk for acute lower respiratory track infections requiring hospitalization in children under 2 years of age from heating with wood [12,13]. The 1996 study and another study in 2010 measured indoor air quality and found that the majority of homes that heated with wood or coal had levels of indoor PM2.5 well in excess of the WHO guidelines [4,13].

Alaska A 2012 case-control study published in Pediatrics showed that having a wood stove in the home was a significant independent risk factor for acute lower respiratory tract infection requiring hospitalization in children under age 3 [14]. Another study by the same group demonstrated that hospitalizations for acute lower respiratory tract infections within the first 3 years of life was a significant predictor of future respiratory morbidity in childhood [15].

Household Air Pollution in the USA Where does HAP and poor lung health occur together? Stove Change out Improves Respiratory Health Increased risk of Childhood Pneumonia Increased odds of Asthma Increased risk of Childhood Pneumonia

What are the Solutions? What can you do?

EPA-certified stoves are 50% more energy efficient than non-certified stoves. Source: www.epa.gov/burnwise

EPA-Certified Wood Heaters Examples of Labels Source: www.epa.gov/burnwise

Conclusion We estimate that there are between 500,000 and 600,000 low income Americans concentrated in rural areas who are at risk for poor health as a result of exposure to household air pollution. Household air pollution is a recognized problem internationally but is underappreciated in the U.S. Cost effective wood stove solutions are available We hope this study serves as a call to action for the U.S. scientific and policy-making communities and spark further research both at home and abroad.

References Lim SS, Vos T, Flaxman AD, Danaei G, Shibuya K, Adair-Rohani H, et al. 2012. A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions, 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet 380(9859): 2224-2260. US Census Bureau. 2012. http://dataferrett.census.gov/. [accessed July 20 2012]. Ward T, Boulafentis J, Simpson J, Hester C, Moliga T, Warden K, et al. 2011. Lessons learned from a woodstove changeout on the Nez Perce Reservation. Sci Total Environ 409(4): 664-670 Bunnell JE, Garcia LV, Furst JM, Lerch H, Olea RA, Suitt SE, et al. 2010. Navajo coal combustion and respiratory health near Shiprock, New Mexico. Journal of environmental and public health 2010: 260525. Noonan CW, Navidi W, Sheppard L, Palmer CP, Bergauff M, Hooper K, et al. 2012. Residential indoor PM(2.5) in wood stove homes: follow-up of the Libby changeout program. Indoor air. World Health Organization. 2005. WHO Air quality guidelines for particulate matter, ozone, nitrogen dioxide and sulfur dioxide. Global update 2005. Summary of risk assessment. Geneva, Switzerland: WHO. US Department of Agriculture. 2012. http://ers.usda.gov/data-products.aspx. [accessed July 9 2012]. US Department of Health and Human Services. 2012. http://www.communityhealth.hhs.gov/homepage.aspx?j=1. [accessed June 15 2012]. Barry AC, Mannino DM, Hopenhayn C, Bush H. 2010. Exposure to indoor biomass fuel pollutants and asthma prevalence in Southeastern Kentucky: Results from the Burden of Lung Disease (BOLD) study. Journal of Asthma 47(7): 735-741 Paulin LM, Williams D, Oberweiser C, Diette GB, Breysse PN, McCormack MM, et al. 2013. Indoor air quality in Central Appalachia homes impacted by wood and coal use. J Environmental Protection. 4: 67-71. Noonan CW, Ward TJ, Navidi W, Sheppard L. 2012. A rural community intervention targeting biomass combustion sources: effects on air quality and reporting of children's respiratory outcomes. Occupational and environmental medicine 69(5): 354-360. Morris K, Morgenlander M, Coulehan JL, Gahagen S, Arena VC. 1990. Wood-burning stoves and lower respiratory tract infection in American Indian children. Am J Dis Child 144(1): 105-108. Robin LF, Less PS, Winget M, Steinhoff M, Moulton LH, Santosham M, et al. 1996. Wood-burning stoves and lower respiratory illnesses in Navajo children. The Pediatric infectious disease journal 15(10): 859-865. Bulkow LR, Singleton RJ, DeByle C, Miernyk K, Redding G, Hummel KB, et al. 2012. Risk factors for hospitalization with lower respiratory tract infections in children in rural Alaska. Pediatrics 129(5): e1220-1227. Singleton RJ, Redding GJ, Lewis TC, et al. 2003 Sequelae of severe respiratory syncytial virus infection in infancy and early childhood among Alaska Native children. Pediatrics.112(2):285-290 Rogalsky, D.K.; Mendola, P.; Metts, T.A.; Martin, W.J. Environ. Health Perspect. “Estimating the Number of Low-Income Americans Exposed to Household Air Pollution from Burning Solid Fuels.” 2014, 122, 806-810.

“For in the final analysis, our most basic common link is that we all inhabit this small planet. We all breathe the same air. We all cherish our children's future. And we are all mortal.” -John F. Kennedy