Attributable risk and potential impact of interventions to reduce household air pollution associated with under-five mortality in South Asia

Background: Solid fuel use is the major source of household air pollution (HAP) and accounts for a substantial burden of morbidity and mortality in low and middle income countries. To evaluate and compare childhood mortality attributable to HAP in four South Asian countries. Methods: A series of Demographic and Health Survey (DHS) datasets for Bangladesh, India, Nepal and Pakistan were used for analysis. Estimates of relative risk and exposure prevalence relating to use of cooking fuel and under-five mortality were used to calculate population attributable fractions (PAFs) for each country. Potential impact fractions (PIFs) were also calculated assessing theoretical scenarios based on published interventions aiming to reduce exposure prevalence. Results: There are an increased risk of under-five mortality in those exposed to cooking fuel compared to those not exposed in the four South Asian countries (OR = 1.30, 95% CI = 1.07–1.57, P = 0.007). Combined PAF estimates for South Asia found that 66% (95% CI: 43.1–81.5%) of the 13,290 estimated cases of under-five mortality was attributable to HAP. Joint PIF estimates (assuming achievable reductions in HAP reported in intervention studies conducted in South Asia) indicates 47% of neonatal and 43% of under-five mortality cases associated with HAP could be avoidable in the four South Asian countries studied. Conclusions: Elimination of exposure to use of cooking fuel in the household targeting valuable intervention strategies (such as cooking in separate kitchen, improved cook stoves) could reduce substantially under-five mortality in South Asian countries.