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Hospital waste management in Rawalpindi: A threat to urban environmental sustainability.

Author(s) Shahid Mehmood1, Audil Rashid2, Irfan Khawar3, Fakhra Rashid 4
Affiliation(s) 1Urban Health Division, City coordination, Punjab Local Government, Pakistan, Lahore, Pakistan, 2EcoHealth Research Group, Department of Environmental Sciences, PMAS Arid Agriculture University, Rawalpindi, Pakistan, 3Haemotology Department , Holy Family Hospital, Rawalpindi, Pakistan, 4EcoHealth Research Group, Department of Environmental Sciences, PMAS Arid Agriculture University, Rawalpindi, Pakistan.
Country - ies of focus Pakistan
Relevant to the conference tracks Environment and Sustainability
Summary One of the constraints in hospital waste management in Pakistan is ineffective legislation and the improper training about the collection, transportation and disposal of waste. In addition, unavailability of appropriate equipment for disposal (incinerators, autoclaves etc.) and insufficient budget to meet the expenses of waste management has led to many hospitals burning their waste in open environments. Lack of professional waste management teams, both at upper and lower levels, is another cause of hospital waste management failures in Pakistan. Unfortunately, scarce data is available on this issue therefore, this study has provided some of the baisc facts needed to improve hospital waste management.
Background Open dumping of hospital waste is one of the biggest threats to the urban environments in Pakistan. Unprecedented risks are posed to public health when infectious hospital waste is openly burnt along with municipal waste. This has undermined the sustainability of breathing air quality in Rawalpindi city where population has been complaining about this issue but no proper action has been initiated to solve the problem.
Objectives This study aimed to evaluate the waste generation, collection, segregation, transportations and disposal from major hospitals of Rawalpindi and its effect on the urban environment. An effort was made to document the effects of hospital waste burning on urban populations in order to find out the relation between ill-health effects faced by the people directly exposed to hospital waste burning.
Methodology Primary data was collected through comprehensive surveys which included questionnaire form, personal observations, formal and informal meetings. Secondary data was collected from hospital records. Logistic Regression analysis was performed to evaluate the first hand response obtained during surveys and the presence/absence of any ill-health effect was analyzed in the context of exposure extent.
Results The result indicated that approximately one sweeper is used for the cleaning of six beds and average daily waste generation rate was 1.55 kg day each bed,  which contains 71% non-infectious and 14% infectious waste with 91% average bed occupancy rate. Three of the studied hospitals have separates waste bins for infectious and non-infectious waste collection. But unfortunately, the segregation of waste is only at the point of generation. Two of the studied hospital had wheel trolleys for waste collections while other used manpower for waste collection. Two of the studied hospitals had no proper place for the temporary storage of waste and none of the hospital had refrigerators/cooling room for the storage of pathological waste. Out of 254 responses collected during  the questionnaire survey, 85% regarded themselves as directly exposed to waste burning fumes. Among ill-health effects attributed to hospital & municipal burning exposure includes in respiratory tract infections (Odds ratio = 3.18; 95% confidence interval 1.17 – 7.89) and eye irritations (Odds ratio = 2.66; 95% confidence interval 1.37 – 8.11).
Conclusion Open burning of hospital and municipal waste must be immediately stopped as it appears to be an urban health issue. A well-managed waste administration team is required for all hospitals in Rawalpindi city to develop a multidirectional co-operation from all stakeholders, including federal and provincial governments, public, private hospitals and waste disposal staff.

Health as an indicator of sustainable development: How health can contribute to and benefit from sustainable policies.

Author(s) Natalie Mrak1, Callum Brindley2
Affiliation(s) 1Development studies, The Graduate Institute for International and Development Studies, Geneva, Switzerland, 2Development Studies , The Graduate Institute for International and Development Studies, Geneva, Switzerland.
Country - ies of focus Switzerland
Relevant to the conference tracks Environment and Sustainability
Summary This study highlights how health can be a cross-sectoral indicator for the proposed 2015 sustainable development goals. The impacts of environmental changes on human wellbeing have been clearly established but insufficient work has been done to show how sustainable policies can also benefit health. This study recommends health indicators that can be used to measure sustainable progress in the sectors of water, food, energy, housing and transportation within the urban environment. It also provides suggestions on accountability and governance mechanisms that should put be in place at local, national and global levels to ensure that everyone takes responsibility for sustainable development.
Background Growing concerns about the impact of environmental changes on health have emerged as middle-income countries have adopted the consumption and greenhouse gas emission behaviours of high-income countries. The same economic trajectory that has created a global marketplace dependent on increasing volumes of production, consumption and the long-distance transport of goods, has also led to the overexploitation of finite natural resources, energy shortages and the overburdening of the natural environment. The affects from this trajectory not only pose challenges to the sustainability of the environment but to human health as well. About 24 per cent of the global burden of disease and 23 per cent of deaths are attributable to environmental causes and around 36 per cent of the disease burden in children is caused by environmental factors. Despite this information, health has been an omitted aspect in climate policies. The collective health benefits that can be gained from a low carbon economy have been overlooked when they can actually be motivation for further cutting greenhouse emissions. Emphasizing the joint benefits could make reducing greenhouse emissions attractive since they serve as a means towards achieving both public health and climate goals.
Objectives The primary objective of this study is to demonstrate how health is a cross-sectoral theme of sustainable development that can be used to motivate behaviour change. The secondary objective is to show how human wellbeing will be impacted if sustainable approaches to development are not pursued. Since the MDGs were established in 2000, tremendous progress has been made to improve health outcomes but this progress will become compromised if measures are not taken to improve the current state of the environment. Everyone will be impacted but particularly the poorest and most vulnerable whose already scarce access to public goods could be further compromised as governments grapple with economic devastation as result of changes in the climate and environment. Urban areas will continue to grow, unable to accommodate their expanding population, which could lead to increased food insecurity as dry arable rural lands become incapable of producing crops. Prolonged drought conditions and increased occurrence of natural disasters could also lead to water insecurity. This situation, combined with poor housing conditions, unsustainable energy sources and carbon-motorized transport will negatively impact health and the environment. The tertiary objective is to show how policies across diverse sectors can improve human wellbeing and the environment. Health can be used to measure the effectiveness of policies in various sectors as well as benefit from policies that also improve the environment. In order to tackle the health risks that environmental changes pose, an integrated, cross-sectoral approach needs to be taken since human wellbeing is not only affected by such factors as health systems as but also other factors like pollutants and physical activity. The additional objective is to analyse the opportunities and challenges to promoting more sustainable behaviour. Everyone can contribute to a sustainable future from healthcare workers to businesses as well as governments and civil society. The post-2015 development agenda provides an opportunity to implement accountability mechanisms that do not currently exist. As cities become centres of human settlement, there is also a need to implement environmental-friendly policies that enhance rather than detract from economic growth.
Methodology The main question of this study is to see how health is a cross-sectoral indicator of sustainable development. The study was conducted between June and September 2013. The search strategy sourced reports and articles primarily published by the United Nations, especially the WHO, UNICEF and UNEP as well as the below leading health and development journals. We reviewed only articles published in English and concentrated on the period from 1990 to 2012. Our principal search terms were: “health” AND “sustainable development”; “environmental burden of disease”; “healthy environment”; “urban health”; “healthy cities”; “health” and “results-based management”; “health indicators.” In total, we closely reviewed over 100 reports and articles. To analyse the literature, the following questions were posed:• How can health and sustainable development be linked?
• How is health positioned in the post-2015 development agenda and the sustainable development goals debate?
• What are the strengths and limitations of indicators
• What current health indicators exist and what are their merits?
• What lessons can be drawn from the WHO’s Healthy Cities programme?
• How can inter-sectoral cooperation be promoted?The study looks at sustainable development within the context of urban areas, focusing on five key areas – food, water, energy, households and transport. Cities were selected as the geographic area of focus since their populations are expected to continue to increase over the course of this century. The five areas of focus were selected on the basis of their strong cross-sectoral communications with health and the burden of disease from their associated risk factors. The study demonstrates how the relationship between health and sustainable development can be thought of in three ways: health contributes to the achievement of sustainable goals, health can benefit from sustainable development and health is a way to measure progress across all three pillars of sustainable development policy.
Results The results of the study clearly demonstrate that health is an integral part of sustainable development whose contributions should be considered more seriously in the post-2015 development agenda discussions. First, climate change is contributing to the increased incidence of natural disasters and disease outbreaks, increasing the global burden of disease. Second, urban areas will endure great burdens as a result of climate change, which will be primarily due to the increased migration to cities. Third, there are measures that can be implemented across sectors, which can reduce greenhouse gas and pollutant emissions as well as improve human well-being. Last, this study also found that while there is an abundance of data on health as an indicator of sustainable development and the distinctiveness of each country’s context make it difficult to discern which existing indicators are most practical and useful, there are a series of assessments that can be carried out to develop a fit-for-purpose complement of indicators. The below tool outlines the method for conducting these assessments by focusing on a country’s:• Burden of disease
• Level of economic and social development, and
• Environmental condition and pressuresTables of indicators by income-level for the health-sustainable development nexus were created. It was found that each indicator has the following four strengths;

• Relates closely to both health and sustainable development
• Relies on data that is easily accessible and reliable
• Communicates clearly a development challenge
• Facilitates practical policy interventions

The primary limitation of this study was the lack of first-hand qualitative data which is due to the top-down approach of the study. A complementary bottom-up study containing ethnographic work could help confirm these findings and provide a people centered-approach to seeing how health is an integral part of sustainable development.

Conclusion Health can be a useful focal point to promote inter-sectoral cooperation at the local level but there is unfortunately no set of health indicators that are relevant to all contexts. A drawback to the work that has been done on health as an indicator of sustainable development in urban settings has been the emphasis on the quantitative aspect of indicators. This has made it difficult to single out a set of best practices and to actually see whether these interventions improve well-being. As urban populations continue to expand in the coming decades, new approaches to urban planning need to be taken which engage a variety of stakeholders and adapt to the dynamic nature of cities. Small-scale interventions in urban areas can be key to providing insights into what does and does not work. To ensure the work on health and sustainable development continues, health needs to be an integral component of the post-2015 development agenda. The sustainable development goals of the post-2015 agenda will not be achieved if a concerted effort is not made to assist low and middle-income countries in developing and implementing renewable energy techniques as their populations and economies continue to grow in the coming decades. Mechanisms should be created that not only transfer funds but knowledge and technology as well. Governance mechanisms need to be set in place, which marry policy and scientific evidence and impose accountability. Increasing public awareness of the intricate relationship between public health and the environment could help promote sustainable behaviour and raise attention to the need of holding all stakeholders accountable. Ultimately, there needs to be commitment at all levels of government and society in order for sustainable development to become a reality.

Empirical Exploration of the Three Dimensions of Energy Insecurity Among Urban Low–Income Communities: United States.

Author(s) Diana Hernández 1, Brennan Rhodes-Bratton2.
Affiliation(s) 1Department of Sociomedical Sciences, Columbia University, Mailman School of Public Health , New York , United States, 2Department of Sociomedical Sciences , Columbia University, Mailman School of Public Health , New York, United States.
Country - ies of focus United States
Relevant to the conference tracks Environment and Sustainability
Summary This study explores hardships associated with energy insecurity (EI), and introduces a framework based on three dimensions of EI that describes the experiences of low-income households in a major city in the Northeast, USA.
Background As energy prices rise in the United States and abroad, low-income families face a challenge to achieve consistent and affordable access to enough of the forms of energy needed to sustain a healthy and safe life compared to similar households in the region (Cook et al, 2008). The concept of energy insecurity does not have a universal definition or sufficient public awareness. This study aims to provide a deeper understanding of EI by introducing a framework grounded in the following three dimensions: inadequate housing conditions, disproportionate energy expenditure, and behavioural responses to energy inefficiencies. These respective conditions are defined as physical EI, economic EI and coping EI. Health risks associated with EI as well as the stress and anxiety it may cause, can restrict productivity for parents or children as manifested in days lost from work or school and thus potentially reduce household income and increase risk for cyclical poverty.
Objectives The aims of this research are twofold; first to explore the experience of energy insecurity (EI) among low-income families and second to propose a framework that explains EI through the three dimensions of physical EI, economic EI, and coping EI.
Methodology This study examines the challenges and strategies used to address energy insecurity (EI) among low-income households in Boston, Massachusetts. Specifically, it addresses the following research questions: (1) What physical housing challenges do families living in low-income communities face? (2) What economic challenges and trade-offs exist when energy burden is a persistent concern? (3) What strategies do families employ to cope with the hardships of EI? (4) What implications do both the challenges and strategies used to address them have on the well-being of families experiencing EI?
Study participants were parents recruited through community health centres that met criteria for the 10-question eligibility pre-screening survey. Eligible study participants included those with at least one self-reported housing hardship such as frequent moves and hazardous housing conditions, an income at or below 150 % of the 2008 poverty level ($21,000 for a household of 4) and residence in Dorchester, Massachusetts. This research primarily draws on 72 in-depth interviews with a parent or legal guardian of paediatric patients residing in Dorchester.The study sample is compromised of 70 female and 2 male heads of household ranging from 18 to 59 years old. Most of the respondents were single mothers of Black or Hispanic descent, U.S. citizens, held a high school education, earned less than $30,000 per year and many had housing subsidies.A thematic analytical technique was used to reveal the nature of EI circumstances and the corresponding approaches used to contend with related problems. The data analytical plan encompasses an iterative process to explore EI. The initial phase identified quotes from respondents that described managing utility bill payments. Review of these quotes pointed to an organization of EI based on the three dimensions of physical, economic and coping EI. The third phase of analysis produced a list of overarching themes that reflect the most common experiences of the tenants. Each of the emerging themes was categorized based on the definitions of physical, economic and coping EI. Then this list was refined after the entire list of utility quotes was reviewed a third time. Each quote was then reviewed and categorized by dimension. Lastly, the quotes were organized by the finalized themes for each dimension. The final analysis included 3 dimensions and 19 themes. Please see Table 1 in the attached documents for the complete list.
Results The data analysis exposed the presence of physical, economic, and coping energy insecurities, thus reinforcing the developed framework. The dimension of physical EI initially represented inadequate appliances, structural issues of the home and other needed repairs. The five themes that consistently evolved from respondents’ experiences, however, were as follows: Inadequate/inefficient heat/cooling systems including poor installation and non-functioning appliances; Improper connections of wiring or connectivity of utilities to multiple units; Landlord abuse of power and privileges; Structural infractions of building, e.g. Broken meter; and Seasonal variation impact on home conditions.The dimension of economic EI, which describes financial hardship associated with energy expenditures relative to income and other expenses, is also composed of five themes. These themes include insufficient funds and tenuous employment; energy burden; debt and arrearages; trade offs between basic needs of food, housing, and energy; billing issues such as double charges.The strategies used to manage physical and economic EI are examined in the third dimension of EI, coping and is comprised of nine themes that explain the consequences of EI and how respondents deal with the daily crisis of inadequate access to energy. Coping EI includes vigilance about expenditures and active energy conservation, which urge householders to sacrifice comfort and potentially safety in response to heating/cooling costs (e.g. using space heaters or ovens for heating). They also sought medical and legal recourse and negotiated with the utility companies.In regards to the consequences of EI, participants often reported symptoms of adverse mental health including depression, anxiety, stress, hopelessness, and a sense of defeat. The physical condition of asthma was also commonly reported. Moreover, families residing in homes with inadequate heating/cooling as well as broken appliances risk exposure to harmful temperatures as well as toxic substances in addition to absence from work and school due to EI-induced illnesses.EI was not the intended subject of research in this study. Instead, it was an emergent theme that surfaced in the analysis of the larger study on the role of legal services in mitigating the link between poor housing and poor health. Future studies should focus on EI as a source of hardship and a threat to health among vulnerable households in the U.S.
Conclusion Energy Insecurity is an underexplored but pertinent phenomenon in the US. Our findings suggest the EI has three main dimensions: inadequate housing conditions, disproportionate energy expenditure, and behavioural responses to energy inefficiencies. These respective conditions are defined as physical EI, economic EI and coping EI. Physical EI represents conditions such as drafts from windows/doors and holes/cracks in the walls, floors or ceilings that induce energy inefficiencies and reduce "tightness" in the home. These conditions, in turn, create difficulties in regulating home temperatures and produce vulnerabilities in a home’s physical infrastructure that provoke mould, moisture and dampness, and the presence of dust mites, vermin and air pollution- all established concomitants of asthma. The economic ratio represented as "low household income/high energy expenditures” is used by the Department of Energy in its estimates of US energy burden and in Europe to describe fuel poverty. However, this ratio fails to account for deficient housing structures that determine energy expenditures beyond basic patterns of consumption (i.e., inefficient appliances and single pane windows). Coping EI includes vigilance about expenditures, which urge householders to sacrifice comfort and potentially safety in response to heating/cooling costs (e.g. using space heaters or ovens for heating). Paradoxically, these practices may lead to higher utility bills compared to more efficient heating alternatives while also increasing exposure to indoor air pollutants. Health risks associated with EI as well as the stress and anxiety, can restrict productivity for parents or children as manifested in days lost from work or school and thus potentially reduce household income and increase risk for cyclical poverty. EI merits more attention in the academic literature and in public policy.

Enhancing Access and Quality of Care in Developing Countries through Integrated Provider Empowerment and Environmental Safety

Author(s): E. I. Okechukwu*1, A. C. Onyenwenyi2, G. F. Upham3, B. M. Kady4
Affiliation(s): 1Action Family Foundation, 2Institute of Child Health & Primary Care, Lagos, Nigeria, 3Safe Observer Int’l, France, 4Society for Women and AIDS in Africa, Kinshasa, Democratic Republic of the Congo
Keywords: Healthcare, safety, stigma, waste management, provider confidence

The weak healthcare in developing countries engenders chaotic management of medical wastes, thereby exposing care providers and patients to risk of injuries and infections by deadly blood-borne pathogens aside environmental degradation. Millions of women as healthcare personnel, domestic care providers or pregnant mothers and babies on immunization or children at play are primary casualties of unsafe healthcare practices especially improper handling of medicare wastes. In the absence of safety nets among health providers, the fear of contracting infections at the workplace compromises the quality of services rendered to patients especially those infected or affected by HIV/AIDS. WHO estimates that in developing countries, over 60% of injections are unsafe, and 10% of the global workforce are at risk of needle stick injuries capable of transmitting blood-borne pathogens. A survey of five West African countries (including Nigeria) revealed that public containers meant for household refuse receive more than 50% of medical wastes. There are anarchical practices at the collection, sorting and stocking, transport and elimination phases.


In 2005, Action Family Foundation, civil society groups, Safe Observer International and academics from the Institute of Child Health and Primary Care of the Lagos University Teaching Hospital initiated interventions to mainstream proper healthcare waste management in Nigeria through capacity building, community mobilization and practical medical waste handling services. We developed survey instruments and obtained baseline data on the knowledge, attitude and practices of stakeholders; co-hosted with the state agency two annual medical waste management summits and raised community awareness to the hazards of unsafe medicare waste practices as well as organized sensitization sessions for different professional groups. We are engaging in the project as an intervention research work to build the local capacity, conduct research and generate data to inform scaling up and replication to other regions.


Presently, about 15% of the over 3000 healthcare facilities are being covered. Generators are sorting waste at source, and are expected to budget for waste disposal while the government Waste Management Authority supplies consumables and carts waste regularly. The public is more aware and empowered, including holding their care providers accountable for medicare waste.

Lessons learned:

The advocacy and community mobilization expertise of civil society groups when matched with political will of public service organs can reconstruct people’s attitudes and enforce desired practices with modest investments. Our initiative brought together patients, practitioners, consumer groups along with persons living with, or affected by nasocomial pathogens. The presentation will draw on work in process in Nigeria, Uganda, India and globally. We shall share the locally applied strategies, challenges and success stories of Action Family Foundation’s pioneering work in mainstreaming integrated medical waste management.

Do Doctors Inform Patients about Effects of Environmental Pollution and Adulteration in Food: Scenario in Bangladesh

Author(s): S. K. Chanda*1, K. R. Bhowmik1, M. H. Molla2
Affiliation(s): 1Research and Training, SARPV Bangladesh, 2ISSPH- Bangladesh, Dhaka, Bangladesh
Keywords: Health effects, pollution, adulteration, information gap

Pollution and adulterated food has a detrimental effect on health, on emerging and re-emerging disease pattern and on medication as well. Ailment is very much linked to changed natural environment, adulterated foods, poor living conditions and life style. Medical records show alarming increase of hypertension, diabetes, renal diseases and carcinoma among Bangladeshi population in last decades. Bangladesh is facing enormous degradation of environment, witnessed massive deforestation in the name of urbanization and industrialization. Also adulteration in food and adding up carcinogenous substances such as formalin in fishes, Copper Sulphate solution in vegetables, even in adulteration in life-saving medicines are a big issue now-a-days. Doctors are accomplished in communicating with people directly through treatment and advice regarding all health and associated issues. It is their responsibility to inform patients about the ill-effects of pollution on health and how to save them from these effects. Providing such information to patients is also a part of medical ethics and proper service delivery.

Summary/Objectives: Objectives of this study were to explore doctors’ attitude towards patients regarding the conveying of information and to examine the awareness level of patients about the adulterated food and pollution issues, their effects on health, and sources of information.
Results: Cross-sectional data have been obtained from a face-to-face interviews by a structured questionnaire with patients (n=624) and doctors (n=41) in six public hospitals and twelve private facilities. Environmental pollution, adulterated food issues, source of information, and amount of education received from their doctors were questions answered by patients. Almost all patients expressed high level of concern for adulterated food and environmental pollution, 23% of patients mentioned doctors as source of information while 26% of doctors said that they really talk about this issue. 65% of patients said that they should know more about air and water pollution, effects of adulterated and genetically modified food, related diseases, etc. It has come out in discussions that majority of the doctors never consider themselves as part of the environment while in practice, just providing treatment based on clinical diagnosis. Many patients said that it is the doctor’s responsibility to inform them about these issues. And it is a fact that the patient always tries to follow what the doctor says. The main source of information and education about environmental pollution and insecure food has come from media and NGOs working on these issues, true for both doctors and patients. Some of the doctors are very much up-to-date about medical and scientific literature on these issues; still they very seldom discuss this with patients.
Lessons learned:

There is a huge information gap between doctors and patients regarding health impact of pollution and food adulteration, and doctors have major responsibility to minimize the gap. By discussing these issues, people would be able to understand the need for behavioural changes in order to protect them from many ailments. Doctors would be able to help people to overcome their avoidance, denial and confusion and to motivate them for good practice in everyday life. It is essential to inform patients on implication of changes on health and therefore many tend to take the issue appallingly seriously and doctors should take time and have patience to pass this message, which is a part of their ethical practice and providing good quality of health service as well.

COPD Prevalence among Women due To Indoor Air Pollution: South India

Author(s): Priscilla Johnson1, Padmavathi Ramaswamy2, Kalpana Balakrishnan2, Santu Ghosh2
Affiliation(s): 1Department of Physiology, Sri Ramachandra University, Chennai, India, 2Department of Environmental Health Engineering, Sri Ramachandra University, Chennai, India
1st country of focus: India
Relevant to the conference theme: Non-communicable chronic diseases
Summary (max 100 words): Chronic obstructive pulmonary disease (COPD) is the 4th leading cause of death and 13th leading cause of burden of diseases worldwide. Although smoking remains the predominant risk factor, exposure to solid fuel smoke has also been identified as a risk factor for COPD, with rural women in developing countries bearing most of this disease burden.  Despite the importance of this disease, the fact is that the prevalence of COPD is not well measured due to the uncertainties in the prevalence estimation. Most of the previous studies have focused on prevalence of COPD in men and primarily addressing smoking as a risk factor and relatively few studies have attempted to assess prevalence amongst non-smoking rural women. Moreover, estimates of COPD prevalence were diverse either due to variation in the type of assessment or due to inconsistent physician recognition of COPD. In this study a meticulous diagnostic approach was chosen for identification of the COPD cases, including a complete clinical evaluation with spirometry before and after bronchodilation. Further, a previously developed predicted equation using  a log linear multiple regression model was used for understanding the likely household concentrations experienced by the women dwelling in different type of rural household which may be applied in future to generate exposure response for the development of COPD.
Background (max 200 words): COPD is the 4th leading cause of death and 13th leading cause of burden of diseases worldwide with projected increases in its contributions over the next decade. Active smoking is the major risk factor for COPD. Other risk factors include air pollution, passive smoking, heredity etc., More recently exposure to biomass smoke resulting from household combustion of solid fuels has also been identified as a risk factor for COPD. Solid fuel combustion results in high levels of pollutants like respirable particulate matter, carbon monoxide, oxides of nitrogen and sulphur, formaldehyde, benzo(a)pyrene and benzene which are a  major source of  respiratory irritants in the etiopathogenesis of COPD. Evidence from recent studies which have made contributions to examining temporal, spatial, or multi-pollutant patterns, in addition to day-to-day or seasonal variability in household concentrations,  show that persons in solid fuel using settings experience extremely high levels of noxious pollutants. Moreover, WHO’s Comparative Risk Assessment estimated that about 650,000 premature deaths of women from COPD and lung cancer occurred as a result of these exposures. Despite the importance of this disease, the fact is that the prevalence of COPD is not well measured is due to the uncertainties in the prevalence estimation.
Objectives (max 100 words): The primary aim of this cross sectional study was to estimate the prevalence of COPD among the rural women above 30 years through a primary household level, clinical and spirometric assessment. The secondary objective was to explore the different household level variables that may influence the development of COPD. The additional objective was focused at understanding the likely household concentrations experienced by the women dwelling in different type of rural household which may be applied in future to generate a exposure response for the development of COPD.
Methodology (max 400 words): This cross sectional study was conducted among 900 women from 45 different rural villages in Tiruvallur, a rural district in the state of Tamilnadu in India. The study was approved by the Institutional Ethics committee and was conducted between January and May 2007. The study subjects were selected through cluster sampling using probability proportion to size criteria.  This approach resulted in the selection of 45 out of 612 small villages with populations less than 10,000 in Tiruvallur district. The selection criteria included women aged 30 yrs and above who have been residents of the villages in Tiruvallur District for a minimum period of five years who did not report a history of bronchial asthma, pulmonary tuberculosis, cardiac diseases, pregnancy, diabetes and cancer. Informed written consent was obtained before recruiting any person into the study.  Then, the questionnaire was administered that collected information on known risk factors for COPD, details on type of fuel, duration of cooking etc. A detailed clinical history on respiratory symptoms was also obtained.  All symptomatic women were then subjected to pulmonary function tests. COPD cases were diagnosed based on the three criteria given by the GOLD diagnostic guidelines. Pulmonary function test was performed following American Thoracic Society guidelines using a portable data logging Spiro meter (MIR Spirobank).  This test was performed in a sitting position and the subject was then asked to inhale completely and rapidly and exhale maximally until no more air can be expelled while maintaining an upright posture. The same was repeated for a minimum of three manoeuvres and not more than eight was done for acceptability and repeatability. A complete flow-volume loop was obtained from the Spiro meter. The data were compared with individual predictive values based on age, sex, body weight, standing height and interpreted to arrive at the diagnosis. Spirometry with broncho dilation testing after inhalation of 200 µg of Salbutamol, was carried out in order to confirm COPD. Statistical analysis was performed using “R” Version 2. Prevalence was expressed in terms of percentage. Logistic regression analysis was performed to examine the association between selected risk factors and COPD. The Odds Ratios were calculated. Further, a previously developed predicted equation using  a log linear multiple regression model by Santu Ghosh  et al 2011 that predicts household level concentrations in relation to the household level determinants was assigned to the solid fuel and the clean fuel using households of the study population.
Results (max 400 words): The overall prevalence of COPD in this study was found to be 2.44% (95% CI 1.43- 3.45). COPD prevalence was higher in solid fuel users than the clean fuel users 2.5% vs 2 %, (OR 1.24; 95% CI 0.36 – 6.64) and it was two times higher (3%) in women who spend 2hours/day in the kitchen involved in cooking. Logistic regression analysis was performed to examine the association between COPD and use of solid fuel for cooking. Logistic regression analysis has shown increased risk of COPD in women using solid fuel for cooking, in older women, in women involved in cooking for longer duration, in women living in kutcha houses, and in women with history of passive smoking, though not significant. The concentration of particulate matter (PM2.5 ) of solid fuel using households was found to be 237.4 µg/m3 which was significantly higher than the households using clean fuel (50 µg/m3)
Conclusion (max 400 words): Accurate prevalence information is vital for several reasons such as documentation of COPD’s impact on the morbidity, mortality and economic burden and also for public health planning. This population based cross-sectional study used a meticulous diagnostic approach for the identification of the COPD cases, including a complete clinical evaluation with spirometry before and after bronchodilation, and estimated the COPD prevalence in a non-smoking rural women population primarily using solid fuel. The estimates generated in this study will contribute significantly to the growing database of available information on COPD prevalence and to refine the attributable burden of disease estimates. Besides, this information will help researchers to monitor trends, including the success or failure of control efforts. Moreover, this study has incorporated a previously developed model to assign exposure status in terms of quantitative value for  the categorical variables namely solid fuel and clean fuel using households of the study population which in turn may be applied to generate exposure response relationship with relevant to the development of COPD.