Indo-US Joint Centre To Research Link Between IAP And COPD

Chronic Obstructive Pulmonary Disorder (COPD) is a major public health problem affecting millions of people in both developed and developing countries. There is no effective treatment for COPD, which is characterised by chronic bronchitis and emphysema.

Whilst many millions of people in the developed world suffer from COPD, the problem is particularly severe in rural communities in the developing world. As a report on Healthcanal.com explains, high incidences of environmental lung disease are being caused primarily by indoor cooking using biomass and other solid fuels.

A recent report by the World Health Organisation (WHO) breaks down the causes of COPD further.

“COPD has opposite patterns according to geographic areas. In high- and middle-income countries, tobacco smoke is the biggest risk factor, while in low-income countries exposure to indoor air pollution, such as the use of biomass fuels for cooking and heating, causes the COPD burden. Almost 3 billion people worldwide use biomass and coal as their main source of energy for cooking, heating, and other household needs. In these communities, indoor air pollution is responsible for a greater fraction of COPD risk than smoking or outdoor air pollution.Biomass fuels used by women for cooking account for the high prevalence of COPD among non-smoking women in parts of the Middle East, Africa and Asia. Indoor air pollution resulting from the burning of wood and other biomass fuels is estimated to kill two million women and children each year.”

Despite research by the WHO into COPD occurrence in non-smokers, the pathobiology and a definitive link between indoor air pollution (caused by burning  solid fuels and cooking over traditional stoves) and the disease is still unclear.

To address this issue, the Indo-US Science & Technology Forum (IUSSTF) has awarded funding to The Johns Hopkins Bloomberg School of Public Health to establish the first centre to study COPD and other lung diseases in non-smokers living in rural India.

The centre, to be called the Indo-US Center of Excellence for Environmental Lung Diseases, will be led jointly by Shyam Biswal, Professor at the Bloomberg School’s Department of Environmental Health Sciences, Sundeep Salvi, Director of India’s Chest Research Foundation at Pune and Anurag Agrawal, MD of the Institute of Genomics and Integrative Biology, Council of Scientific and Industrial Research in Delhi.

Speaking to Healthcanal.com, Biswal said “We are beginning to appreciate the global problem of non-smoker COPD but our understanding of pathobiology is unclear. This Centre will attempt to bring together experts from both countries to face this public health challenge”.

The Indian investigators will share data with their US counterparts on a number of factors influencing levels of IAP. These include firewood consumption in rural homes, duration of time spent cooking, level of exposure to toxic fumes and gene-environment interaction. Such information will provide a clearer understanding of susceptibility to the disease, leading to the development of new treatments for the affected population.

Read the full story on: Indo-U.S. Center Established to Study Nonsmoking-Related Causes of COPD

Re-emerging TB in Africa Linked To Poverty

According to a recent report by STOP TB department of the World Health Organization, high poverty levels in Africa are driving the re-emerging tuberculosis pandemic. According to the report in VaccineNewsDaily.com, over 1.7 million people died from TB (including 380,000 women) in 2009. TB is among the three greatest causes of death among women aged 15-44 years.

TB is thought of as more likely to spread in these low-income regions as a result of overcrowding, malnutrition, lack of proper housing ventilation, indoor air pollution and long distances to health centers.

“TB in Africa is precipitated by poverty and social conditions that elevate the risk of infection,” said Mario Raviglione, director of the STOP TB department of the WHO.

A recent study by Professor Anthony Harries, a senior advisor to the Union against Tuberculosis and Lung Disease, showed that many patients in Malawi who tested positive for pulmonary TB had related low-income social conditions. Thirty-six percent of the patients lived in mud hut houses, 75 percent had no access to piped water, 45 percent had a monthly income of less than $10 and 92 percent had no electricity in their homes.

Another factor in the spread of the pandemic is that many patients visit traditional healers before attempting mainstream medical treatment. This causes the condition to worsen and makes the medical treatment less effective.

Kitchen Smoke Higher Cause Of COPD Than Smoking In India

Smoke in the kitchen is the most important cause of chronic obstructive pulmonary disease (COPD) in India, says a study conducted by Pune-based Chest Research Foundation (CRF) in collaboration with the KEM Hospital, Pune, and the Imperial College, London. According to a report in The Times of India, the study says that smoking is the second biggest cause of COPD in India.

The study also says that 6.9 per cent in the Indian population suffers from respiratory diseases. Among those identified with COPD, only 7 per cent were smokers while the remaining 93 per cent were non-smokers. Over 700 million people in India suffer from high levels of indoor air pollution affecting women and young children as 75 per cent homes use biomass fuel like wood, crop residue and dung cakes.

The age factor was particularly disturbing. "Nearly 23 per cent of COPDs occurred in people less than 40 years of age. It was believed that COPD starts after 40 in people who have been smoking for over 15-20 years. In India, where the exposure to indoor air pollution begins from childhood, it occurs in younger people," said chest physician Sundeep Salvi, director of the CRF to Times of India.

According to a report published by the Maharashtra State Health Resource Centre in March 2010 that examined the top 10 causes of deaths in Maharashtra, COPD was the number one cause.

The study was conducted in 22 rural villages in Pune district with a population of over 1 lakh. As many as 3,000 adults over the age of 25 years were randomly selected for the study which used a standardised respiratory health questionnaire and spirometry (lung function test for determining COPD).

Read the Times of India Story, "Young Lungs At Higher Risk From Wood Smoke, Dung Cakes"

Nailing the Biomass Connection to COPD

The linkage of biomass burning with COPD has got a closer look in a research by a group of Indian researchers. N K Mondal, A Roy, B Mukherjee, D Das and M R Ray have collaborated on a research on "Indoor Air Pollution from Biomass Burning Activates Akt in Airway Cells and Peripheral Blood Lymphocytes: A Study among Premenopausal Women in Rural India."

Buring of wood, dung, and crop wastes have been linked with IAP related mortality. This study underscores the linkage by tracking data on the activation of the serine/threonine kinase Akt in airway cells and peripheral blood lymphocytes (PBL) due to cumulative exposures to biomass smoke. Akt is a serine/threonine protein kinase closely associated with key membrane-bound receptors and represents a convergent integration point for multiple stimuli implicated in COPD pathogenesis, according to to an early study on "Akt in the pathogenesis of COPD" by S Bozinovski, R Vlahos, M Hansen, K Liu, and GP Anderson.

The study covered 87 premenopausal non-smoking women of an average of 34 years who used to cook with wood, dung and crop wastes. The study also did a comparison with 85 women in the same age-group who cooked with cleaner fuel liquefied petroleum gas.

The study found significantly higher levels of Akt protein in PBL, airway epithelial cells, alveolar macrophages, and neutrophils in sputum of biomass-using women as opposed to those cooking on LPG stoves.

The study also found 2 to 4 times more particulate pollution in biomass-using households. The study says that its finding suggests that that chronic exposure to biomass smoke activates Akt, possibly via generation of oxidative stress.

20% Of All Indian Child Mortality in Ages 1-4 Due To IAP: Study

A BMC Public Health Research Paper by Diego G Bassani, Prabhat Jha, Neeraj Dhingra and Rajesh Kumar on "Child mortality from solid-fuel use in India: a nationally-representative case-control study" says that Child mortality risks from all causes due to solid fuel exposure were lower than previous estimates, but as exposure was common, solid fuel caused 6% of all deaths at ages 0-4, 20% of deaths at ages 1-4 or 128000 child deaths in India in 2004. Solid fuel use has declined only modestly in the last decade. According to the authors, aside from reducing exposure, complementary strategies such as immunization and treatment could also reduce child mortality from acute respiratory infections.

The paper finds that solid fuel use was very common (87% in households with child deaths and 77% in households with living children).

The paper notes that more girls than boys died from exposure to solid fuels. Solid fuel use was also associated with non-fatal pneumonia (boys: PR 1.54 95%CI 1.01-2.35; girls: PR 1.94 95%CI 1.13-3.33). After adjustment for demographic factors and living conditions, solid-fuel use significantly increase child deaths at ages 1-4 (prevalence ratio (PR) boys: 1.30, 95%CI 1.08-1.56; girls: 1.33, 95%CI 1.12-1.58).

The researchers find that with the exception of the colder regions of India, girl deaths at ages 1-4 years had higher prevalence of solid-fuel use when compared to living girls of the same age than did boys. The frequency of self-reported pneumonia was not different between boys and girls but they observed higher solid-fuel use among girls with self-reported pneumonia. Time spent indoors and proximity to pollution source influence the level of exposure and data also suggest that girls spend more time indoors than boys. Other factors such as gender preference, believe the researchers, may also influence treatment access and we believe that differential access to health services may explain the higher mortality among girls. Indeed, hospital based studies have shown that boys are more likely than girls to be admitted for acute respiratory infections.

Such findings are sometimes interpreted as if boys had a higher susceptibility to respiratory infections than girls, but the higher hospital admission rates for boys may be a consequence of the gender differences in access to health care, according to the study. Treating child respiratory symptoms from solid fuel smoke may prevent child deaths while not affecting the incidence of respiratory symptoms, and indeed boys and girls had equal incidence of self-reported pneumonia but girls had higher mortality.

Other factors may explain the gender differences in survival after the onset of pneumonia and further studies are needed to clarify the role of severity of respiratory diseases and other biological factors (i.e. ability to overcome disease/survive), says the paper. The study says it is less subject to gender-based selection bias because it collects information directly in the household.

The researchers compared household solid fuel use in 1998 between 6790 child deaths, from all causes, in the previous year and 609601 living children from 1.1 million nationally-representative homes in India. Analysis were stratified by child’s gender, age (neonatal, post-neonatal, 1-4 years) and colder versus warmer states. They also examined the association of solid fuel to non-fatal pneumonias.

Most households in developing countries, including in India, use solid fuels (coal/coke/lignite, firewood, dung, and crop residue) for cooking and heating. Such fuels increase child mortality, chiefly from acute respiratory infection. There are, however, few direct estimates of the impact of solid fuel on child mortality in India.

Read the Full Paper here:

Child mortality from solid-fuel use in India: a nationally-representative case-control study

BMC Public Health 2010

by Diego G Bassani, Prabhat Jha, Neeraj Dhingra, Rajesh Kumar

Wood smoke exposure multiplies damage from smoking

Smokers who are exposed to wood smoke, either through home heating and cooking or through ambient neighborhood pollution, are not only at increased risk of COPD, but are also more likely to have epigenetic changes in the DNA that further increase their risk of COPD and related pulmonary problems, says a research in the American Thoracic Society's American Journal of Respiratory and Critical Care.

Together, smoking, wood smoke exposure and these epigenetic changes can increase an individual's risk of COPD fourfold.

According to the report, lead author Yohannes Tesfaigzi, Ph.D. senior scientist and director of COPD Program at the Lovelace Respiratory Research Institute, where the research was completed, administered questionnaires to more than 1800 current and former smokers between 40 and 75 years old, and obtained demographic and smoke exposure information, as well as sputum samples which were analyzed for epigenetic changes to eight genes known to be associated with lung cancer.

They found that wood smoke exposure was significantly and independently associated with an increased risk of respiratory disease, especially among current smokers, non-Hispanic whites and men. Furthermore, wood smoke exposure was associated with specific COPD outcomes in people who had aberrantly methylated p16 or GATA4 genes, and both factors together increased the risk more than the additive of the two risk factors together. They also found that people with more than two of the eight genes analyzed showing methylation were also significantly more likely to have a lower than predicted FEV1 than those with fewer than two methylated genes.

"Because exposure to wood smoke appears to increase the risk of reducing lung function, cigarette smokers should try to avoid heating their homes or cooking with wood stoves and try to avoid environments where wood smoke is likely (for example, neighborhoods where wood smoke is common)," said Dr. Tesfaigzi. "Because the same gene changes were associated with increased risk for lung cancer one would assume that wood smoke exposure also increases the risk of developing lung cancer. Future studies may show that it would be appropriate to screen patients for lung cancer if these exposures were present for prolonged periods."

COPD and Indoor Air Pollution

Katelyn Harding writing in the COPD Foundation blog takes note of the Indoor Air Pollution Campaigns and the question of impact on COPD:

"Here’s something I learned while working on the latest issue of the Digest: Every year 2 million people in developing countries die from Indoor Air Pollution [IAP]. Of those 2 million deaths, 54 percent are from COPD.

Imagine that. These people, who cook their food using biomass fuels—wood, charcoal, crop residues, animal dung, coal—are using primitive and inefficient stoves, which results in IAP, or fumes, smoke and contaminants created from the indoor cook stoves.

According to a 2009 study from the World Health Organization and the United Nations Development Programme, 3 billion people—or almost half of humanity—rely on traditional biomass as the available modern energy services fail to meet their needs.

So what can be done to combat this massive problem that affects 600-800 million households worldwide?

Simon Bishop, head of Policy and Communications at the Shell Foundation, says the most effective solution is Improved Cook Stoves [ICS].

The Shell Foundation, the corporate foundation of the energy company and Envirofit International, a US non-profit, began a partnership in 2007 designed to create a global ICS business distributing millions of ICS to developing countries in an effort to reduce IAP. Their goal is to see 10 million stoves sold in 5 countries over the next 5 years.

So far, Envirofit have sold more than 100,000 ICS in southern India.

Simon says it’s hard to predict if ICS will lead to a reduction in health impacts, including COPD.

“If you’ve got indoor air pollution, and you put an improved cook stove in a home, it will reduce pollution by anything between 40 and 90 percent. But is that enough to reduce COPD cases by 40-90 percent as well? At this stage there is not enough medical evidence to prove this link. We urgently need to plug this gap in medical research.”

It will take time to prove the impact of putting an ICS in someone’s home and the incidence it has on COPD, but for now, I think it’s a pretty great start, don’t you?