Ghana randomized air pollution and health study (GRAPHS): study protocol for a randomized controlled trial

Jack, Darby; Asante, Kwaku Poku; Wylie, Blair J.; Chillrud, S. N.; Whyatt, Robin M.; Ae-Ngibise, Kenneth Ayuurebobi; Quinn, Ashlinn; Yawson, Abena Konadu; Boamah, Ellen Abrafi; Agyei, Oscar; Mujtaba, Mohammed; Kaali, Seyram; Kinney, Patrick L.; Owusu‐Agyei, Seth

doi:10.1186/s13063-015-0930-8

Cited by 65 publications

(69 citation statements)

References 35 publications

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“…34,35 A pair of randomised controlled trials found little statistical evidence of a reduction in pneumonia incidence with provision of chimneys 36 or cleaner burning cookstoves, 37 and several more studies investigating household air pollution and childhood pneumonia are in progress. 38,39 This suggests that the provision of chimneys or cleaner burning practices does not result in a sufficient reduction of air pollution to translate into a reduction in health effects. This finding is consistent with the analysis and recommendations by the WHO guidelines.…”

Section: Discussionmentioning

confidence: 99%

Quantifying risks and interventions that have affected the burden of lower respiratory infections among children younger than 5 years: an analysis for the Global Burden of Disease Study 2017

Troeger¹,

Khalil²,

Blacker³

et al. 2020

The Lancet Infectious Diseases

110

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Background Despite large reductions in under-5 lower respiratory infection (LRI) mortality in many locations, the pace of progress for LRIs has generally lagged behind that of other childhood infectious diseases. To better inform programmes and policies focused on preventing and treating LRIs, we assessed the contributions and patterns of risk factor attribution, intervention coverage, and sociodemographic development in 195 countries and territories by drawing from the Global Burden of Diseases, Injuries, and Risk Factors Study 2017 (GBD 2017) LRI estimates. MethodsWe used four strategies to model LRI burden: the mortality due to LRIs was modelled using vital registration data, demographic surveillance data, and verbal autopsy data in a predictive ensemble modelling tool; the incidence of LRIs was modelled using population representative surveys, health-care utilisation data, and scientific literature in a compartmental meta-regression tool; the attribution of risk factors for LRI mortality was modelled in a counterfactual framework; and trends in LRI mortality were analysed applying changes in exposure to risk factors over time. In GBD, infectious disease mortality, including that due to LRI, is among HIV-negative individuals. We categorised locations based on their burden in 1990 to make comparisons in the changing burden between 1990 and 2017 and evaluate the relative percent change in mortality rate, incidence, and risk factor exposure to explain differences in the health loss associated with LRIs among children younger than 5 years.Findings In 2017, LRIs caused 808 920 deaths (95% uncertainty interval 747 286-873 591) in children younger than 5 years. Since 1990, there has been a substantial decrease in the number of deaths (from 2 337 538 to 808 920 deaths; 65·4% decrease, 61·5-68·5) and in mortality rate (from 362·7 deaths [330·1-392·0] per 100 000 children to 118·9 deaths [109·8-128·3] per 100 000 children; 67·2% decrease, 63·5-70·1). LRI incidence declined globally (32·4% decrease, 27·2-37·5). The percent change in under-5 mortality rate and incidence has varied across locations. Among the risk factors assessed in this study, those responsible for the greatest decrease in under-5 LRI mortality between 1990 and 2017 were increased coverage of vaccination against Haemophilus influenza type b (11·4% decrease, 0·0-24·5), increased pneumococcal vaccine coverage (6·3% decrease, 6·1-6·3), and reductions in household air pollution (8·4%, 6·8-9·2).Interpretation Our findings show that there have been substantial but uneven declines in LRI mortality among countries between 1990 and 2017. Although improvements in indicators of sociodemographic development could explain some of these trends, changes in exposure to modifiable risk factors are related to the rates of decline in LRI mortality. No single intervention would universally accelerate reductions in health loss associated with LRIs in all settings, but emphasising the most dominant risk factors, particularly in countries with high case fatality, can contribut...

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Section: Discussionmentioning

confidence: 99%

Quantifying risks and interventions that have affected the burden of lower respiratory infections among children younger than 5 years: an analysis for the Global Burden of Disease Study 2017

Troeger¹,

Khalil²,

Blacker³

et al. 2020

The Lancet Infectious Diseases

110

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“…In brief, GRAPHS is a community-level clustered randomized controlled trial of a cookstove intervention in a predominantly rural area of Ghana (Jack et al 2015) (NCT01335490). Inclusion criteria for enrollment include being in the first or second trimester of pregnancy, living in one of 35 communities in the Kintampo Health Research Center (KHRC) catchment area, being the primary cook of the household, and being a non-smoker.…”

Section: Methodsmentioning

confidence: 99%

Association of Carbon Monoxide exposure with blood pressure among pregnant women in rural Ghana: Evidence from GRAPHS

Quinn

Ae-Ngibise

Jack

et al. 2016

International Journal of Hygiene and Environmental Health

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Background and Objective The Ghana Randomized Air Pollution and Health Study (GRAPHS) is a community-level randomized controlled trial of cookstove interventions for pregnant women and their newborns in rural Ghana. Given that household air pollution from biomass burning may be implicated in adverse cardiovascular outcomes, we sought to determine whether exposure to carbon monoxide (CO) from woodsmoke was associated with blood pressure (BP) among 817 adult women. Methods Multivariate linear regression models were used to evaluate the association between CO exposure, determined with 72-hour personal monitoring at study enrollment, and BP, also measured at study enrollment. At the time of these assessments, women were in the first or second trimester of pregnancy. Results A significant positive association was found between CO exposure and diastolic blood pressure (DBP): on average, each 1ppm increase in exposure to CO was associated with 0.43 mmHg higher DBP [0.01, 0.86]. A non-significant positive trend was also observed for systolic blood pressure (SBP). Conclusion This study is one of very few to have examined the relationship between household air pollution and blood pressure among pregnant women, who are at particular risk for hypertensive complications. The results of this cross-sectional study suggest that household air pollution from wood-burning fires is associated with higher blood pressure, particularly DBP, in pregnant women at early to mid-gestation. The clinical implications of the observed association toward the eventual development of chronic hypertension and/or hypertensive complications of pregnancy remain uncertain, as few of the women were overtly hypertensive at this point in their pregnancies.

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“…We will also seek to define local thresholds for oxyhaemoglobin saturation and respiratory rate at altitudes 2500 m above sea level. The HAPIN trial, the Ghana randomised air pollution and health study (GRAPHS), 117 and the Nepal trials 118 will inform the literature on the nature of the relationship between various definitions of pneumonia and household air pollution exposure in young children. The HAPIN definition focuses on severe pneumonia diagnosed by field workers using objective criteria (figure 1).…”

Section: Figure 2: Example Of a Framework Of Health-seeking Behaviourmentioning

confidence: 99%

“…The HAPIN definition focuses on severe pneumonia diagnosed by field workers using objective criteria (figure 1). The GRAPHS trial uses a physician assessed definition of severe pneumonia in the first year of life, 117 whereas the Nepal trials use the incidence of acute lower respiratory infection during the first 36 months of age, determined by maternal report and field worker assessment for more severe cases. 118 As study objectives differ based on the type of intervention and study setting, the pneumonia case definition and surveillance strategy should be carefully considered before implementing pneumonia outcome studies.…”

Section: Figure 2: Example Of a Framework Of Health-seeking Behaviourmentioning

confidence: 99%

Challenges in the diagnosis of paediatric pneumonia in intervention field trials: recommendations from a pneumonia field trial working group

Goodman¹,

Pervaiz²,

McCollum³

et al. 2019

The Lancet Respiratory Medicine

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Pneumonia is a leading killer of children younger than 5 years despite high vaccination coverage, improved nutrition, and widespread implementation of the Integrated Management of Childhood Illnesses algorithm. Assessing the effect of interventions on childhood pneumonia is challenging because the choice of case definition and surveillance approach can affect the identification of pneumonia substantially. In anticipation of an intervention trial aimed to reduce childhood pneumonia by lowering household air pollution, we created a working group to provide recommendations regarding study design and implementation. We suggest to, first, select a standard case definition that combines acute (≤14 days) respiratory symptoms and signs and general danger signs with ancillary tests (such as chest imaging and pulse oximetry) to improve pneumonia identification; second, to prioritise active hospital-based pneumonia surveillance over passive case finding or home-based surveillance to reduce the risk of non-differential misclassification of pneumonia and, as a result, a reduced effect size in a randomised trial; and, lastly, to consider longitudinal follow-up of children younger than 1 year, as this age group has the highest incidence of severe pneumonia.

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Ghana randomized air pollution and health study (GRAPHS): study protocol for a randomized controlled trial

Cited by 65 publications

References 35 publications

Quantifying risks and interventions that have affected the burden of lower respiratory infections among children younger than 5 years: an analysis for the Global Burden of Disease Study 2017

Quantifying risks and interventions that have affected the burden of lower respiratory infections among children younger than 5 years: an analysis for the Global Burden of Disease Study 2017

Association of Carbon Monoxide exposure with blood pressure among pregnant women in rural Ghana: Evidence from GRAPHS

Challenges in the diagnosis of paediatric pneumonia in intervention field trials: recommendations from a pneumonia field trial working group

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