title: Cooking and season as risk factors for acute lower respiratory infections in African children: a cross-sectional multi-country analysis.
abstract: BACKGROUND
  Acute lower respiratory infections (ALRI) are a leading cause of death among African children under five. A significant proportion of these are attributable to household air pollution from solid fuel use.
  
  
  METHODS
  We assessed the relationship between cooking practices and ALRI in pooled datasets of Demographic and Health Surveys conducted between 2000 and 2011 in countries of sub-Saharan Africa. The impacts of main cooking fuel, cooking location and stove ventilation were examined in 18 (n = 56,437), 9 (n = 23,139) and 6 countries (n = 14,561) respectively. We used a causal diagram and multivariable logistic mixed models to assess the influence of covariates at individual, regional and national levels.
  
  
  RESULTS
  Main cooking fuel had a statistically significant impact on ALRI risk (p<0.0001), with season acting as an effect modifier (p = 0.034). During the rainy season, relative to clean fuels, the odds of suffering from ALRI were raised for kerosene (OR 1.64; CI: 0.99, 2.71), coal and charcoal (OR 1.54; CI: 1.21, 1.97), wood (OR 1.20; CI: 0.95, 1.51) and lower-grade biomass fuels (OR 1.49; CI: 0.93, 2.35). In contrast, during the dry season the corresponding odds were reduced for kerosene (OR 1.23; CI: 0.77, 1.95), coal and charcoal (OR 1.35; CI: 1.06, 1.72) and lower-grade biomass fuels (OR 1.07; CI: 0.69, 1.66) but increased for wood (OR 1.32; CI: 1.04, 1.66). Cooking location also emerged as a season-dependent statistically significant (p = 0.0070) determinant of ALRI, in particular cooking indoors without a separate kitchen during the rainy season (OR 1.80; CI: 1.30, 2.50). Due to infrequent use in Africa we could, however, not demonstrate an effect of stove ventilation.
  
  
  CONCLUSIONS
  We found differential and season-dependent risks for different types of solid fuels and kerosene as well as cooking location on child ALRI. Future household air pollution studies should consider potential effect modification of cooking fuel by season.
authors.affiliation: Institute for Medical Informatics, Biometry and Epidemiology, Ludwig-Maximilians-University, Munich, Germany.
authors.forename: Hannes
authors.initials: H
authors.lastname: Buchner
authors.affiliation: Institute for Medical Informatics, Biometry and Epidemiology, Ludwig-Maximilians-University, Munich, Germany.
authors.forename: Eva A
authors.initials: EA
authors.lastname: Rehfuess
mesh_terms: D000208:Acute Disease; D000349:Africa / Q000453:epidemiology; D002648:Child; D003296:Cooking; D003430:Cross-Sectional Studies; D019992:Databases as Topic; D005579:Fossil Fuels; D006801:Humans; D016015:Logistic Models; D011891:Rain; D012141:Respiratory Tract Infections / Q000453:epidemiology*; D012307:Risk Factors; D012621:Seasons
chemical_list: D005579:Fossil Fuels