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Nigel G Bruce12*, Mukesh K Dherani1, Jai K Das3, Kalpana Balakrishnan4, Heather Adair-Rohani2, Zulfiqar A Bhutta3 and Dan Pope1

* Corresponding author: Nigel G Bruce ngb@liv.ac.uk

Author Affiliations


1 Department of Public Health and Policy, University of Liverpool, Liverpool L693GB, UK

2 Department of Public Health and Environment, World Health Organization, via Appia, 1211 Geneva 27, Switzerland

3 Aga Khan University, Division of Women and Child Health, Aga Khan University, Stadium Road Karachi- 74800, Pakistan

4 ICMR Centre Department of Environmental Health Engineering, Sri Ramachandra University, No.1, Ramachandra Nagar, Porur, Chennai-600116, India

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BMC Public Health 2013, 13(Suppl 3):S8  doi:10.1186/1471-2458-13-S3-S8

The electronic version of this article is the complete one and can be found online at: http://www.biomedcentral.com/1471-2458/13/S3/S8



17 September 2013

© 2013 Bruce et al; licensee BioMed Central Ltd.

This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.



Exposure to household air pollution (HAP) from cooking with solid fuels affects 2.8 billion people in developing countries, including children and pregnant women. The aim of this review is to propose intervention estimates for child survival outcomes linked to HAP.


Systematic reviews with meta-analysis were conducted for ages 0-59 months, for child pneumonia, adverse pregnancy outcomes, stunting and all-cause mortality. Evidence for each outcome was assessed against Bradford-Hill viewpoints, and GRADE used for certainty about intervention effect size for which all odds ratios (OR) are presented as protective effects.


Reviews found evidence linking HAP exposure with child ALRI, low birth weight (LBW), stillbirth, preterm birth, stunting and all-cause mortality. Most studies were observational and rated low/very low in GRADE despite strong causal evidence for some outcomes; only one randomised trial was eligible.Intervention effect (OR) estimates of 0.64 (95% CI: 0.55, 0.75) for ALRI, 0.71 (0.65, 0.79) for LBW and 0.66 (0.54, 0.81) for stillbirth are proposed, specific outcomes for which causal evidence was sufficient. Exposure-response evidence suggests this is a conservative estimate for ALRI risk reduction expected with sustained, low exposure. Statistically significant protective ORs were also found for stunting [OR=0.79 (0.70, 0.89)], and in one study of pre-term birth [OR=0.70 (0.54, 0.90)], indicating these outcomes would also likely be reduced. Five studies of all-cause mortality had an OR of 0.79 (0.70, 0.89), but heterogenity precludes a reliable estimate for mortality impact. Although interventions including clean fuels and improved solid fuel stoves are available and can deliver low exposure levels, significant challenges remain in achieving sustained use at scale among low-income households.


Reducing exposure to HAP could substantially reduce the risk of several child survival outcomes, including fatal pneumonia, and the proposed effects could be achieved by interventions delivering low exposures. Larger impacts are anticipated if WHO air quality guidelines are met. To achieve these benefits, clean fuels should be adopted where possible, and for other households the most effective solid fuel stoves promoted. To strengthen evidence, new studies with thorough exposure assessment are required, along with evaluation of the longer-term acceptance and impacts of interventions.


Household air pollution (HAP) from solid fuels (wood, dung, crop residues, charcoal and coal) used in simple stoves for cooking and heating, is recognized as a risk factor for several health outcomes with important consequences for child survival, including pneumonia [1] and low birth weight and stillbirth [2], in addition to a number of major non-communicable disease outcomes in adults [3,4].

Solid fuels were used by around 2.8 billion people in 2010 [5], a number which has changed little since 1980 due to global population increase, and is closely associated with poverty and high child mortality. Studies consistently show that exposure levels are very high, far exceeding WHO air quality guideline (AQG) levels for small particulate matter (PM2.5), and young children and women, including during pregnancy, are most at risk [6,7]. These factors imply that, if substantial intervention effects can be demonstrated, the removal of HAP exposure could bring large benefits for child survival.

Interventions for reducing HAP exposure include improved solid fuel stoves and clean fuels. Both present challenges for sustainable adoption at scale among the low income populations at risk [8]. For solid fuel stoves the key issues are achieving emissions low enough to deliver health benefits, as well as ensuring acceptability, sustained use, and affordability. Very low exposure would be assured if households used clean fuels such as LPG and electricity exclusively, but affordability and reliable supply remain key barriers. Recent initiatives to increase global access to clean household energy, including the UN Foundation Global Alliance for Clean Cookstoves [9], and the UNs Sustainable Energy for All [10], are now starting to address these issues in a coordinated way. More concerted action on and investment in technology development, stove standards [11], programme delivery, and evaluation can be expected over the next few years.

The objective of this review is to systematically review the evidence on HAP and child survival outcomes and to propose intervention impact estimates that would be suitable for the Lives Saved Tool [12]. While detailed assessment of intervention options, performance and policy for achieving sustained adoption is also important, these topics are beyond the scope of this review. These issues have been discussed elsewhere [8], and extensive review work is currently underway for new WHO Guidelines on household fuel combustion [13].

The scope of the review is as follows. For health outcomes, those listed by Walker et al [14] for children under 5 years and known or suspected to be linked to HAP were included, namely ALRI (pneumonia, including severe and fatal), low birth weight, pre-term birth, stillbirth, stunting, and all-cause mortality. Geographical coverage is global where the use of solid fuels for cooking has been studied. Although there is evidence that kerosene used in simple stoves and lamps is also highly polluting and a health risk for some of these outcomes [15], this was outside the scope of the review, except to note studies which included kerosene within the clean fuel category.