Semin Respir Crit Care Med 2015; 36(03): 408-421
DOI: 10.1055/s-0035-1554846
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Chronic Obstructive Pulmonary Disease Secondary to Household Air Pollution

Nour A. Assad
1   Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, University of New Mexico Health Sciences Center School of Medicine, 1 University of New Mexico, Albuquerque, New Mexico
,
John Balmes
2   Division of Occupational and Environmental Medicine, Department of Internal Medicine, University of California San Francisco School of Medicine, San Francisco, California
3   Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley, California
,
Sumi Mehta
4   Department of Research and Evaluation, Global Alliance For Clean Cookstoves, Pennsylvania, Washington, District of Columbia
,
Umar Cheema
5   Dow University of Health Sciences, Ojha Campus, Karachi, Pakistan
,
Akshay Sood
1   Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, University of New Mexico Health Sciences Center School of Medicine, 1 University of New Mexico, Albuquerque, New Mexico
› Author Affiliations
Further Information

Publication History

Publication Date:
29 May 2015 (online)

Abstract

Approximately 3 billion people around the world cook and heat their homes using solid fuels in open fires and rudimentary stoves, resulting in household air pollution. Household air pollution secondary to indoor combustion of solid fuel is associated with multiple chronic obstructive pulmonary disease (COPD) outcomes. The exposure is associated with both chronic bronchitis and emphysema phenotypes of COPD as well as a distinct form of obstructive airway disease called bronchial anthracofibrosis. COPD from household air pollution differs from COPD from tobacco smoke with respect to its disproportionately greater bronchial involvement, lesser emphysematous change, greater impact on quality of life, and possibly greater oxygen desaturation and pulmonary hypertensive changes. Interventions that decrease exposure to biomass smoke may decrease the risk for incident COPD and attenuate the longitudinal decline in lung function, but more data on exposure–response relationships from well-designed longitudinal studies are needed.

 
  • References

  • 1 World Health Organization (WHO) Media Center. Fact sheet no: 292: Available at: http://www.who.int/mediacentre/factsheets/fs292/en/ . Accessed January 1, 2015
  • 2 Pandey MR. Domestic smoke pollution and chronic bronchitis in a rural community of the Hill Region of Nepal. Thorax 1984; 39 (5) 337-339
  • 3 Anderson HR. Chronic lung disease in the Papua New Guinea Highlands. Thorax 1979; 34 (5) 647-653
  • 4 Rai UC, Srinivasan V, Veliath S, Krishnan B, Rao AS. Cow dung smoke—A causative factor for chronic bronchitis & emphysema. Indian J Exp Biol 1982; 20 (9) 696-700
  • 5 Gordon SB, Bruce NG, Grigg J , et al. Respiratory risks from household air pollution in low and middle income countries. Lancet Respir Med 2014; 2 (10) 823-860
  • 6 Smith KR, Bruce N, Balakrishnan K , et al; HAP CRA Risk Expert Group. Millions dead: how do we know and what does it mean? Methods used in the comparative risk assessment of household air pollution. Annu Rev Public Health 2014; 35: 185-206
  • 7 World Health Organization. Indoor air quality guidelines: household fuel combustion. Available at: http://www.who.int/indoorair/guidelines/hhfc/en/ . Accessed January 1, 2015
  • 8 Sood A. Indoor fuel exposure and the lung in both developing and developed countries: an update. Clin Chest Med 2012; 33 (4) 649-665
  • 9 Zhang J, Smith KR. Indoor air pollution: a global health concern. Br Med Bull 2003; 68: 209-225
  • 10 Sällsten G, Gustafson P, Johansson L , et al. Experimental wood smoke exposure in humans. Inhal Toxicol 2006; 18 (11) 855-864
  • 11 Kurmi OP, Lam KB, Ayres JG. Indoor air pollution and the lung in low- and medium-income countries. Eur Respir J 2012; 40 (1) 239-254
  • 12 Environmental Protection Agency. National ambient air quality standards for particulate matter. Fed Register 2013; 78 (10) 3086-3089
  • 13 Ezzati M, Kammen DM. The health impacts of exposure to indoor air pollution from solid fuels in developing countries: knowledge, gaps, and data needs. Environ Health Perspect 2002; 110 (11) 1057-1068
  • 14 Ellegård A. Cooking fuel smoke and respiratory symptoms among women in low-income areas in Maputo. Environ Health Perspect 1996; 104 (9) 980-985
  • 15 Kim KH, Jahan SA, Kabir E. A review of diseases associated with household air pollution due to the use of biomass fuels. J Hazard Mater 2011; 192 (2) 425-431
  • 16 Sussan TE, Ingole V, Kim JH , et al. Source of biomass cooking fuel determines pulmonary response to household air pollution. Am J Respir Cell Mol Biol 2014; 50 (3) 538-548
  • 17 Lim SS, Vos T, Flaxman AD , et al. 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 2012; 380 (9859) 2224-2260
  • 18 World Health Organization. Media Center. Fact sheet no: 315. Available at: http://www.who.int/mediacentre/factsheets/fs315/en/ . Accessed January 1, 2015
  • 19 Salvi S, Barnes PJ. Is exposure to biomass smoke the biggest risk factor for COPD globally?. Chest 2010; 138 (1) 3-6
  • 20 Salvi S. The silent epidemic of COPD in Africa. Lancet Glob Health 2015; 3 (1) e6-e7
  • 21 van Gemert F, Kirenga B, Chavannes N , et al. Prevalence of chronic obstructive pulmonary disease and associated risk factors in Uganda (FRESH AIR Uganda): a prospective cross-sectional observational study. Lancet Glob Health 2015; 3 (1) e44-e51
  • 22 Sood A, Petersen H, Blanchette CM , et al. Wood smoke exposure and gene promoter methylation are associated with increased risk for COPD in smokers. Am J Respir Crit Care Med 2010; 182 (9) 1098-1104
  • 23 Vestbo J, Hurd SS, Agustí AG , et al. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: GOLD executive summary. Am J Respir Crit Care Med 2013; 187 (4) 347-365
  • 24 Caballero A, Torres-Duque CA, Jaramillo C , et al. Prevalence of COPD in five Colombian cities situated at low, medium, and high altitude (PREPOCOL study). Chest 2008; 133 (2) 343-349
  • 25 Kurmi OP, Devereux GS, Smith WC , et al. Reduced lung function due to biomass smoke exposure in young adults in rural Nepal. Eur Respir J 2013; 41 (1) 25-30
  • 26 Johnson P, Balakrishnan K, Ramaswamy P , et al. Prevalence of chronic obstructive pulmonary disease in rural women of Tamilnadu: implications for refining disease burden assessments attributable to household biomass combustion. Glob Health Action 2011; 4: 7226
  • 27 Liu S, Zhou Y, Wang X , et al. Biomass fuels are the probable risk factor for chronic obstructive pulmonary disease in rural South China. Thorax 2007; 62 (10) 889-897
  • 28 da Silva LF, Saldiva SR, Saldiva PH, Dolhnikoff M ; Bandeira Científica Project. Impaired lung function in individuals chronically exposed to biomass combustion. Environ Res 2012; 112: 111-117
  • 29 Hu G, Zhou Y, Tian J , et al. Risk of COPD from exposure to biomass smoke: a metaanalysis. Chest 2010; 138 (1) 20-31
  • 30 Ekici A, Ekici M, Kurtipek E , et al. Obstructive airway diseases in women exposed to biomass smoke. Environ Res 2005; 99 (1) 93-98
  • 31 Orozco-Levi M, Garcia-Aymerich J, Villar J, Ramírez-Sarmiento A, Antó JM, Gea J. Wood smoke exposure and risk of chronic obstructive pulmonary disease. Eur Respir J 2006; 27 (3) 542-546
  • 32 Sezer H, Akkurt I, Guler N, Marakoğlu K, Berk S. A case-control study on the effect of exposure to different substances on the development of COPD. Ann Epidemiol 2006; 16 (1) 59-62
  • 33 Köksal H, Saygı A, Sarıman N , et al. Evaluation of clinical and functional parameters in female subjects with biomass smoke exposure. Respir Care 2013; 58 (3) 424-430
  • 34 Camp PG, Ramirez-Venegas A, Sansores RH , et al. COPD phenotypes in biomass smoke- versus tobacco smoke-exposed Mexican women. Eur Respir J 2014; 43 (3) 725-734
  • 35 Rivera RM, Cosio MG, Ghezzo H, Salazar M, Pérez-Padilla R. Comparison of lung morphology in COPD secondary to cigarette and biomass smoke. Int J Tuberc Lung Dis 2008; 12 (8) 972-977
  • 36 Golpe R, Sanjuán López P, Cano Jiménez E, Castro Añón O, Pérez de Llano LA. Distribution of clinical phenotypes in patients with chronic obstructive pulmonary disease caused by biomass and tobacco smoke. Arch Bronconeumol 2014; 50 (8) 318-324
  • 37 González-García M, Maldonado Gomez D, Torres-Duque CA , et al. Tomographic and functional findings in severe COPD: comparison between the wood smoke-related and smoking-related disease. J Bras Pneumol 2013; 39 (2) 147-154
  • 38 Zou Y, Li S, Zou W , et al. Upregulation of gelatinases and epithelial-mesenchymal transition in small airway remodeling associated with chronic exposure to wood smoke. PLoS ONE 2014; 9 (5) e96708
  • 39 Celli BR, MacNee W ; ATS/ERS Task Force. Standards for the diagnosis and treatment of patients with COPD: a summary of the ATS/ERS position paper. Eur Respir J 2004; 23 (6) 932-946
  • 40 Pérez-Padilla R, Regalado J, Vedal S , et al. Exposure to biomass smoke and chronic airway disease in Mexican women. A case-control study. Am J Respir Crit Care Med 1996; 154 (3 Pt 1) 701-706
  • 41 Mahesh PA, Jayaraj BS, Prabhakar AK, Chaya SK, Vijaysimha R. Identification of a threshold for biomass exposure index for chronic bronchitis in rural women of Mysore district, Karnataka, India. Indian J Med Res 2013; 137 (1) 87-94
  • 42 Uzun K, Ozbay B, Ceylan E, Gencer M, Zehir I. Prevalence of chronic bronchitis-asthma symptoms in biomass fuel exposed females. Environ Health Prev Med 2003; 8 (1) 13-17
  • 43 Malik SK. Exposure to domestic cooking fuels and chronic bronchitis. Indian J Chest Dis Allied Sci 1985; 27 (3) 171-174
  • 44 Desalu OO, Adekoya AO, Ampitan BA. Increased risk of respiratory symptoms and chronic bronchitis in women using biomass fuels in Nigeria. J Bras Pneumol 2010; 36 (4) 441-446
  • 45 Kiraz K, Kart L, Demir R , et al. Chronic pulmonary disease in rural women exposed to biomass fumes. Clin Invest Med 2003; 26 (5) 243-248
  • 46 Akhtar T, Ullah Z, Khan MH, Nazli R. Chronic bronchitis in women using solid biomass fuel in rural Peshawar, Pakistan. Chest 2007; 132 (5) 1472-1475
  • 47 Golshan M, Faghihi M, Marandi MM. Indoor women jobs and pulmonary risks in rural areas of Isfahan, Iran, 2000. Respir Med 2002; 96 (6) 382-388
  • 48 Kurmi OP, Semple S, Simkhada P, Smith WC, Ayres JG. COPD and chronic bronchitis risk of indoor air pollution from solid fuel: a systematic review and meta-analysis. Thorax 2010; 65 (3) 221-228
  • 49 Po JY, FitzGerald JM, Carlsten C. Respiratory disease associated with solid biomass fuel exposure in rural women and children: systematic review and meta-analysis. Thorax 2011; 66 (3) 232-239
  • 50 Moreira MA, Barbosa MA, Jardim JR, Queiroz MC, Inácio LU. Chronic obstructive pulmonary disease in women exposed to wood stove smoke. Rev Assoc Med Bras 2013; 59 (6) 607-613
  • 51 Xu F, Yin X, Shen H, Xu Y, Ware RS, Owen N. Better understanding the influence of cigarette smoking and indoor air pollution on chronic obstructive pulmonary disease: a case-control study in Mainland China. Respirology 2007; 12 (6) 891-897
  • 52 Bruse S, Sood A, Petersen H , et al. New Mexican Hispanic smokers have lower odds of chronic obstructive pulmonary disease and less decline in lung function than non-Hispanic whites. Am J Respir Crit Care Med 2011; 184 (11) 1254-1260
  • 53 Behera D, Jindal SK. Respiratory symptoms in Indian women using domestic cooking fuels. Chest 1991; 100 (2) 385-388
  • 54 Kara M, Bulut S, Tas F, Akkurt I, Seyfikli Z. Evaluation of pulmonary changes due to biomass fuels using high-resolution computed tomography. Eur Radiol 2003; 13 (10) 2372-2377
  • 55 Ozbay B, Uzun K, Arslan H, Zehir I. Functional and radiological impairment in women highly exposed to indoor biomass fuels. Respirology 2001; 6 (3) 255-258
  • 56 Moreira MA, Barbosa MA, Queiroz MC , et al. Pulmonary changes on HRCT scans in nonsmoking females with COPD due to wood smoke exposure. J Bras Pneumol 2013; 39 (2) 155-163
  • 57 Moran-Mendoza O, Pérez-Padilla JR, Salazar-Flores M, Vazquez-Alfaro F. Wood smoke-associated lung disease: a clinical, functional, radiological and pathological description. Int J Tuberc Lung Dis 2008; 12 (9) 1092-1098
  • 58 González-García M, Torres-Duque CA, Bustos A, Jaramillo C, Maldonado D. Bronchial hyperresponsiveness in women with chronic obstructive pulmonary disease related to wood smoke. Int J Chron Obstruct Pulmon Dis 2012; 7: 367-373
  • 59 Moreira MA, Moraes MR, Silva DG , et al. Comparative study of respiratory symptoms and lung function alterations in patients with chronic obstructive pulmonary disease related to the exposure to wood and tobacco smoke. J Bras Pneumol 2008; 34 (9) 667-674
  • 60 Shen S, Qin Y, Cao Z , et al. Indoor air pollution and pulmonary function in children. Biomed Environ Sci 1992; 5 (2) 136-141
  • 61 Azizi BH, Henry RL. Effects of indoor air pollution on lung function of primary school children in Kuala Lumpur. Pediatr Pulmonol 1990; 9 (1) 24-29
  • 62 Jedrychowski W, Maugeri U, Jedrychowska-Bianchi I, Flak E. Effect of indoor air quality in the postnatal period on lung function in pre-adolescent children: a retrospective cohort study in Poland. Public Health 2005; 119 (6) 535-541
  • 63 Kalhan R, Arynchyn A, Colangelo LA, Dransfield MT, Gerald LB, Smith LJ. Lung function in young adults predicts airflow obstruction 20 years later. Am J Med 2010; 123 (5) 468.e1-468.e7
  • 64 Ramirez-Venegas A, Sansores RH, Quintana-Carrillo RH , et al. FEV1 decline in patients with chronic obstructive pulmonary disease associated with biomass exposure. Am J Respir Crit Care Med 2014; 190 (9) 996-1002
  • 65 Díaz E, Bruce N, Pope D , et al. Lung function and symptoms among indigenous Mayan women exposed to high levels of indoor air pollution. Int J Tuberc Lung Dis 2007; 11 (12) 1372-1379
  • 66 Alim MA, Sarker MA, Selim S, Karim MR, Yoshida Y, Hamajima N. Respiratory involvements among women exposed to the smoke of traditional biomass fuel and gas fuel in a district of Bangladesh. Environ Health Prev Med 2014; 19 (2) 126-134
  • 67 Sertogullarindan B, Gumrukcuoglu HA, Sezgi C, Akil MA. Frequency of pulmonary hypertension in patients with COPD due to biomass smoke and tobacco smoke. Int J Med Sci 2012; 9 (6) 406-412
  • 68 Ramírez-Venegas A, Sansores RH, Pérez-Padilla R , et al. Survival of patients with chronic obstructive pulmonary disease due to biomass smoke and tobacco. Am J Respir Crit Care Med 2006; 173 (4) 393-397
  • 69 Kim YJ, Jung CY, Shin HW, Lee BK. Biomass smoke induced bronchial anthracofibrosis: presenting features and clinical course. Respir Med 2009; 103 (5) 757-765
  • 70 Sigari N, Mohammadi S. Anthracosis and anthracofibrosis. Saudi Med J 2009; 30 (8) 1063-1066
  • 71 Gupta A, Shah A. Bronchial anthracofibrosis: an emerging pulmonary disease due to biomass fuel exposure. Int J Tuberc Lung Dis 2011; 15 (5) 602-612
  • 72 Kim HY, Im JG, Goo JM , et al. Bronchial anthracofibrosis (inflammatory bronchial stenosis with anthracotic pigmentation): CT findings. AJR Am J Roentgenol 2000; 174 (2) 523-527
  • 73 Chung MP, Lee KS, Han J , et al. Bronchial stenosis due to anthracofibrosis. Chest 1998; 113 (2) 344-350
  • 74 Gold JA, Jagirdar J, Hay JG, Addrizzo-Harris DJ, Naidich DP, Rom WN. Hut lung. A domestically acquired particulate lung disease. Medicine (Baltimore) 2000; 79 (5) 310-317
  • 75 Sandoval J, Salas J, Martinez-Guerra ML , et al. Pulmonary arterial hypertension and cor pulmonale associated with chronic domestic woodsmoke inhalation. Chest 1993; 103 (1) 12-20
  • 76 Grobbelaar JP, Bateman ED. Hut lung: a domestically acquired pneumoconiosis of mixed aetiology in rural women. Thorax 1991; 46 (5) 334-340
  • 77 Churg A, Myers J, Suarez T , et al. Airway-centered interstitial fibrosis: a distinct form of aggressive diffuse lung disease. Am J Surg Pathol 2004; 28 (1) 62-68
  • 78 Ramage Jr JE, Roggli VL, Bell DY, Piantadosi CA. Interstitial lung disease and domestic wood burning. Am Rev Respir Dis 1988; 137 (5) 1229-1232
  • 79 Ghio AJ, Soukup JM, Case M , et al. Exposure to wood smoke particles produces inflammation in healthy volunteers. Occup Environ Med 2012; 69 (3) 170-175
  • 80 Krimmer D, Ichimaru Y, Burgess J, Black J, Oliver B. Exposure to biomass smoke extract enhances fibronectin release from fibroblasts. PLoS ONE 2013; 8 (12) e83938
  • 81 Ramos C, Cisneros J, Gonzalez-Avila G, Becerril C, Ruiz V, Montaño M. Increase of matrix metalloproteinases in woodsmoke-induced lung emphysema in guinea pigs. Inhal Toxicol 2009; 21 (2) 119-132
  • 82 Mehra D, Geraghty PM, Hardigan AA, Foronjy R. A comparison of the inflammatory and proteolytic effects of dung biomass and cigarette smoke exposure in the lung. PLoS ONE 2012; 7 (12) e52889
  • 83 Guarnieri MJ, Diaz JV, Basu C , et al. Effects of woodsmoke exposure on airway inflammation in rural Guatemalan women. PLoS ONE 2014; 9 (3) e88455
  • 84 Tesfaigzi Y, McDonald JD, Reed MD , et al. Low-level subchronic exposure to wood smoke exacerbates inflammatory responses in allergic rats. Toxicol Sci 2005; 88 (2) 505-513
  • 85 Tesfaigzi Y, Singh SP, Foster JE , et al. Health effects of subchronic exposure to low levels of wood smoke in rats. Toxicol Sci 2002; 65 (1) 115-125
  • 86 Montaño M, Sansores RH, Becerril C , et al. FEV1 inversely correlates with metalloproteinases 1, 7, 9 and CRP in COPD by biomass smoke exposure. Respir Res 2014; 15: 74
  • 87 Kurmi OP, Dunster C, Ayres JG, Kelly FJ. Oxidative potential of smoke from burning wood and mixed biomass fuels. Free Radic Res 2013; 47 (10) 829-835
  • 88 Guzmán-Grenfell A, Nieto-Velázquez N, Torres-Ramos Y , et al. Increased platelet and erythrocyte arginase activity in chronic obstructive pulmonary disease associated with tobacco or wood smoke exposure. J Investig Med 2011; 59 (3) 587-592
  • 89 Liu PL, Chen YL, Chen YH, Lin SJ, Kou YR. Wood smoke extract induces oxidative stress-mediated caspase-independent apoptosis in human lung endothelial cells: role of AIF and EndoG. Am J Physiol Lung Cell Mol Physiol 2005; 289 (5) L739-L749
  • 90 Awji EG, Chand H, Bruse S , et al. Wood Smoke Enhances Cigarette Smoke-Induced Inflammation by Inducing the Aryl Hydrocarbon Receptor Repressor in Airway Epithelial Cells. Am J Respir Cell Mol Biol 2014; (e-pub ahead of print). doi: 10.1165/rcmb.2014-0142OC
  • 91 Loke J, Paul E, Virgulto JA, Smith GJ. Rabbit lung after acute smoke inhalation. Cellular responses and scanning electron microscopy. Arch Surg 1984; 119 (8) 956-959
  • 92 Fick Jr RB, Paul ES, Merrill WW, Reynolds HY, Loke JS. Alterations in the antibacterial properties of rabbit pulmonary macrophages exposed to wood smoke. Am Rev Respir Dis 1984; 129 (1) 76-81
  • 93 Zelikoff JT, Chen LC, Cohen MD, Schlesinger RB. The toxicology of inhaled woodsmoke. J Toxicol Environ Health B Crit Rev 2002; 5 (3) 269-282
  • 94 Rylance J, Fullerton DG, Scriven J , et al. Household Air Pollution Causes Dose-dependent Inflammation and Altered Phagocytosis in Human Macrophages. Am J Respir Cell Mol Biol 2014; (e-pub ahead of print). doi: 10.1165/rcmb.2014-0188OC
  • 95 Balakrishnan K, Sankar S, Parikh J , et al. Daily average exposures to respirable particulate matter from combustion of biomass fuels in rural households of southern India. Environ Health Perspect 2002; 110 (11) 1069-1075
  • 96 Albalak R, Frisancho AR, Keeler GJ. Domestic biomass fuel combustion and chronic bronchitis in two rural Bolivian villages. Thorax 1999; 54 (11) 1004-1008
  • 97 Kodgule R, Salvi S. Exposure to biomass smoke as a cause for airway disease in women and children. Curr Opin Allergy Clin Immunol 2012; 12 (1) 82-90
  • 98 Alexander D, Linnes JC, Bolton S, Larson T. Ventilated cookstoves associated with improvements in respiratory health-related quality of life in rural Bolivia. J Public Health (Oxf) 2014; 36 (3) 460-466
  • 99 Chapman RS, He X, Blair AE, Lan Q. Improvement in household stoves and risk of chronic obstructive pulmonary disease in Xuanwei, China: retrospective cohort study. BMJ 2005; 331 (7524) 1050
  • 100 Zhou Y, Zou Y, Li X , et al. Lung function and incidence of chronic obstructive pulmonary disease after improved cooking fuels and kitchen ventilation: a 9-year prospective cohort study. PLoS Med 2014; 11 (3) e1001621
  • 101 Smith KR, McCracken JP, Weber MW , et al. Effect of reduction in household air pollution on childhood pneumonia in Guatemala (RESPIRE): a randomised controlled trial. Lancet 2011; 378 (9804) 1717-1726
  • 102 Ward T, Palmer C, Bergauff M, Hooper K, Noonan C. Results of a residential indoor PM2.5 sampling program before and after a woodstove changeout. Indoor Air 2008; 18 (5) 408-415
  • 103 Thompson LM, Bruce N, Eskenazi B, Diaz A, Pope D, Smith KR. Impact of reduced maternal exposures to wood smoke from an introduced chimney stove on newborn birth weight in rural Guatemala. Environ Health Perspect 2011; 119 (10) 1489-1494
  • 104 Romieu I, Riojas-Rodríguez H, Marrón-Mares AT, Schilmann A, Perez-Padilla R, Masera O. Improved biomass stove intervention in rural Mexico: impact on the respiratory health of women. Am J Respir Crit Care Med 2009; 180 (7) 649-656
  • 105 Pope D, Diaz E, Smith-Sivertsen T , et al. Associations of Respiratory Symptoms and Lung Function with Measured Carbon Monoxide Concentrations among Nonsmoking Women Exposed to Household Air Pollution: The RESPIRE Trial, Guatemala. Environ Health Perspect 2014; (e-pub ahead of print). doi: 10.1289/ehp.1408200
  • 106 Noonan CW, Ward TJ, Navidi W, Sheppard L. A rural community intervention targeting biomass combustion sources: effects on air quality and reporting of children's respiratory outcomes. Occup Environ Med 2012; 69 (5) 354-360