Research Article| Volume 3, ISSUE 3, P119-129, March 1999

Download started.


Biomass cooking fuels and prevalence of tuberculosis in India

      This paper is only available as a PDF. To read, Please Download here.


      Objectives: To examine the relation between use of biomass cooking fuels (wood or dung) and prevalence of active tuberculosis in India.
      Methods: The analysis is based on 260,162 persons age 20 and over in India's 1992–1993 National Family Health Survey. Logistic regression is used to estimate the effects of biomass fuel use on prevalence of active tuberculosis, as reported by household heads, after controlling for a number of potentially confounding variables.
      Results: Persons living in households that primarily use biomass for cooking fuel have substantially higher prevalence of active tuberculosis than persons living in households that use cleaner fuels (odds ratio [OR] = 3.56; 95% confidence interval [Cl] = 2.82−4.50). This effect is reduced somewhat when availability of a separate kitchen, house type, indoor crowding, age, gender, urban or rural residence, education, religion, caste or tribe, and geographic region are statistically controlled (OR = 2.58; 95% Cl = 1.98−3.37). Fuel type also has a large effect when the analysis is done separately for men (OR = 2.46; 95% Cl = 1.79−3.39) and women (OR = 2.74; 95% Cl = 1.86−4.05) and separately for urban areas (OR = 2.29; 95% Cl = 1.61−3.23) and rural areas (OR = 2.65; 95% Cl = 1.74−4.03). The analysis also indicates that, among persons age 20 years and over, 51% of the prevalence of active tuberculosis is attributable to cooking smoke.
      Conclusions: Results strongly suggest that use of biomass fuels for cooking substantially increases the risk of tuberculosis in India.



        • Smith K.R.
        Indoor air pollution in India.
        Natl Med J India. 1996; 9: 103-104
        • Smith K.R.
        • Liu Y.
        Indoor air pollution in developing countries.
        in: Samet J.M. Epidemiology of lung cancer. Lung Biology in Health and Disease Series. 74. 1994: 151-184
        • WHO (World Health Organization)
        Epidemiological, social, and technical aspects of indoor air pollution from biomass fuel: report of a WHO consultation, June 1991.
        in: World Health Organization, Geneva1992
        • Smith K.R.
        Biofuels, air pollution, and health: a global review.
        Plenum Press, New York1987
        • Smith K.R.
        Fuel combustion, air pollution exposure, and health: the situation in developing countries.
        Ann Rev Energy and Env. 1993; 18: 529-566
        • WHO (World Health Organization)
        Health and environment for sustainable development.
        World Health Organization, Geneva1997
        • IIPS (International Institute for Population Sciences)
        National family health survey (MCH and Family Planning): India 1992–1993.
        International Institute for Population Sciences, Bombay1995
        • WHO (World Health Organization)
        WHO report on the tuberculosis epidemic 1997.
        World Health Organization, Geneva1997
        • American Thoracic Society/Center for Disease Control
        Diagnostic standards and classification of tuberculosis.
        Am Rev Respir Dis. 1990; 142: 725-735
      1. Murray C.J.L. Lopez A.D. Global burden of disease. Harvard University Press, Cambridge, MA1996
        • Raviglione M.C.
        • Snider D.E.
        • Kochi A.
        Global epidemiology of tuberculosis: morbidity and mortality of a worldwide epidemic.
        JAMA. 1995; 273: 220-226
        • Piot E.
        Tuberculosis and AIDS: the dual epidemic.
        in: UNAIDS: points of view. UNAIDS, Geneva1997
        • Kochi A.
        Tuberculosis: distribution, risk factors, mortality.
        Immunobiology. 1994; 191: 325-336
        • WHO (World Health Organization)
        Tuberculosis programme review: India.
        World Health Organization, Geneva1992
        • Sawert H.
        The re-emergence of tuberculosis and its economic implications.
        PharmacoEconomics. 1996; 9: 379-381
        • Mishra V.
        • Retherford R.D.
        Cooking smoke increases the risk of acute respiratory infection in children.
        Nat Family Health Survey Bull. 1997; 8: 1-4
        • Kossove D.
        Smoke-filled rooms and lower respiratory disease in infants.
        S Afr Med J. 1982; 63: 622-624
        • Pandey M.R.
        • Boleji J.
        • Smith K.R.
        • Wafula E.
        Indoor air pollution in developing countries and acute respiratory infection in children.
        Lancet. 1989; 25: 427-429
        • Collings D.A.
        • Sithole S.D.
        • Martin K.S.
        Indoor woodsmoke pollution causing lower respiratory disease in children.
        Trop Doct. 1990; 20: 151-155
        • Armstrong J.R.M.
        • Campbell H.
        Indoor air pollution exposure and lower respiratory infection in young Gambian children.
        Int J Epidemiol. 1991; 20: 424-428
        • Malik S.K.
        Exposure to domestic cooking fuels and chronic bronchitis.
        Indian J Chest Dis Allied Sci. 1985; 27: 171-174
        • Pandey M.R.
        Domestic smoke pollution and chronic bronchitis in a rural community of the hill region of Nepal.
        Thorax. 1984; 39: 337-339
        • Behera D.
        • Jindal S.K.
        Respiratory symptoms in Indian women using domestic cooking fuels.
        Chest. 1991; 100: 385-388
        • Perez-Padilla R.
        • Regalado J.
        • Vedal S.
        • et al.
        Exposure to biomass smoke and chronic airway disease in Mexican women: a case-control study.
        Am J Respir Crit Care Med. 1996; 154: 701-706
        • Pandey M.R.
        • Basnyat B.
        • Neupane R.P.
        Chronic bronchitis and cor pulmonare in Nepal.
        Mrigendra Medical Trust, Kathmandu, Nepal1988
        • Padmavati S.
        • Arora S.S.
        Sex differences in chronic cor pulmonale in Delhi.
        Br J Dis Chest. 1976; 70: 251-259
        • Sobue T.
        Association of indoor air pollution and lifestyle with lung cancer in Osaka, Japan.
        Int J Epidemiol. 1990; 19 (Suppl): S62-S66
        • Sun X.W.
        Heating fuels and respiratory diseases in the risks of female lung cancer.
        Chung Hua Chung Liu Tsa Chih. 1992; 13 ([Abstract]): 413-415
        • Gupta B.N.
        • Mathur N.
        • Mahendra P.N.
        • Srivastava A.K.
        A study of the household environmental risk factors pertaining to respiratory diseases.
        Energy Environ Rev. 1997; 13: 61-67
        • Alcaide J.
        • Alter M.N.
        • Plans P.
        • et al.
        Cigarette smoking as a risk factor for tuberculosis in young adults: a case-control study.
        Tuber Lung Dis. 1996; 77: 112-116
        • Ionescu J.
        • Galbenu P.
        • Lutescu L.
        Influence of tobacco smoking on the development of experimental pulmonary tuberculosis.
        Rev Ig [Pneumoftiziol]. 1976; 25 ([Abstract]): 237-244
        • Shprykov A.S.
        • Zhadnov V.Z.
        Effects of tobacco smoking on the course of infiltrative pulmonary tuberculosis and effectiveness of its treatment.
        Probl Tuberk. 1994; 5 ([Abstract]): 26-27
        • Mihaltan F.
        • Defta D.
        • Tabacu E.
        A profile of the smoker with pulmonary tuberculosis.
        Pneumoftiziologia. 1995; 44 ([Abstract]): 33-36
        • Yu G.P.
        • Hsieh C.C.
        • Peng J.
        Risk factors associated with the prevalence of pulmonary tuberculosis among sanitary workers in Shanghai.
        Tubercle. 1988; 69: 105-112
        • Parrella M.
        • Leo R.
        • Liccardo M.
        • Altieri V.
        Negative effects of cigarette smoking on chemo-antibiotic therapy in patients with pulmonary tuberculosis.
        Arch Monaldi. 1980; 35 ([Abstract]): 313-326
        • Altet M.N.
        • Alcaide J.
        • Plans P.
        • et al.
        Passive smoking and risk of pulmonary tuberculosis in children immediately following infection: a case-control study.
        Tuber Lung Dis. 1996; 77: 537-544
        • Xu Z.
        • Chen B.H.
        • Kjellstrom T.
        • Xu X.
        • Lin Y.
        • Daqian Y.
        Study of severe air pollution and mortality in Shenyang, China.
        in: Chen B.H. Air pollution and its health effects in China. World Health Organization, Geneva1995: 47-88
        • Zelikoff J.T.
        Woodsmoke emissions: effects on host pulmonary immune defense.
        CIAR Currents. 1994; (Nov): 1-3
        • Wang J.
        • Hu S.M.
        The effects of kitchen air pollution on animals' immune function.
        Chung HuaYu Fang I Hsueh Tsa Chih. 1992; 26 ([Abstract]): 86-88
        • Sopori M.L.
        • Cherian S.
        • Chilukuri R.
        • Shopp G.M.
        Cigarette smoke causes inhibition of the immune response to intratracheally administered antigens.
        Toxicol Appl Pharmacol. 1989; 97: 489-499
        • Jacob C.V.
        • Stelzer G.T.
        • Wallace J.H.
        The influence of cigarette tobacco smoke products on the immune response. The cellular basis of immunosuppression by a water-soluble condensate of tobacco smoke.
        Immunology. 1980; 40: 621-627
        • Hersey P.
        • Prendergast D.
        • Edwards A.
        Effects of cigarette smoking on the immune system. Follow-up studies in normal subjects after cessation of smoking.
        Med J Aust. 1983; 2: 425-429
        • de Cremoux H.
        • Bernaudin J.F.
        • Laurent P.
        • Brochard P.
        • Bignon J.
        Interactions between cigarette smoking and the natural history of idiopathic pulmonary fibrosis.
        Chest. 1990; 98: 71-76
        • Johnson J.D.
        • Houchens D.P.
        • Kluwe W.M.
        • Craig D.K.
        • Fisher G.L.
        Effects of mainstream and environmental tobacco smoke on the immune system in animals and humans: a review.
        Crit Rev Toxicol. 1990; 20: 369-395
        • Taszakowski W.
        • Dwornicki J.
        Effect of environmental factors on the defense system of the respiratory tract.
        Pol Tyg Lek. 1992; 47 ([Abstract]): 763-765
        • Kilburn K.H.
        Particles causing lung disease.
        Environ Health Perspect. 1984; 55: 97-109
        • Green G.M.
        • Jakab G.J.
        • Low R.B.
        • Davis G.S.
        Defense mechanisms of the respiratory membrane.
        Am Rev Respir Dis. 1977; 115: 479-514
        • Kong L.Y.
        • Luster M.I.
        • Dixon D.
        • O'Grady J.
        • Rosenthal G.J.
        Inhibition of lung immunity after intratracheal instillation of benzo(a)pyrene.
        Am J Respir Crit Care Med. 1994; 150: 1123-1129
        • Kawabata T.T.
        • White Jr, K.L.
        Suppression of the vitro humoral immune response of mouse splenocytes by benzo[α]pyrene metabolites and inhibition of benzo[α]pyrene-induced immunosuppression by alpha-naphthoflavone.
        Cancer Res. 1987; 47: 2317-2322
        • Kawabata T.T.
        • White Jr, K.L.
        Benzo[α]pyrene metabolism by murine spleen microsomes.
        Cancer Res. 1989; 49: 5816-5822
        • Holladay S.D.
        • Smith B.J.
        Benzo[α]pyrene-induced alterations in total immune cell number and cell-surface antigen expression in the thymus, spleen, and bone marrow of B6C3F1 mice.
        Vet Hum Toxicol. 1995; 37: 99-104
        • Hardin J.A.
        • Hinoshita F.
        • Sherr D.H.
        Mechanisms by which benzo[a]pyrene, an environmental carcinogen, suppresses B cell lymphopoiesis.
        Toxicol Appl Pharmacol. 1992; 117: 155-164
        • Silkworth J.B.
        • Lipinskas T.
        • Stoner C.R.
        Immunosuppressive potential of several polycyclic aromatic hydrocarbons (PAHs) found at a Superfund site: new model used to evaluate additive interactions between benzo[α]pyrene and TCDD.
        Toxicology. 1995; 105: 375-386
        • Schnizlein C.T.
        • Bice D.E.
        • Mitchell C.E.
        • Hahn F.E.
        Effects on rat lung immunity by acute lung exposure to benzo[α]pyrene.
        Arch Environ Health. 1982; 37: 201-206
        • Davila D.R.
        • Romero D.L.
        • Burchiel S.W.
        Human T cells are highly sensitive to suppression of mitogenesis by polycyclic aromatic hydrocarbons and this effect is differentially reversed by alpha-naphthoflavone.
        Toxicol Appl Pharmacol. 1996; 139: 333-341
        • Lei Z.M.
        The relationship between concentrations of B[α]P in blood, urine, and immune function of coking workers.
        Chung Hua Yu Fang I Hsueh Tsa Chih. 1993; 27 ([Abstract]): 212-214
        • Szczeklik A.
        • Szczeklik J.
        • Galuszka Z.
        • Musial J.
        • Kolarzyk E.
        • Targosz D.
        Humoral immunosuppression in men exposed to polycyclic aromatic hydrocarbons and related carcinogens in polluted environments.
        Environ Health Perspect. 1994; 102: 302-304
        • Singh S.
        • Singh N.
        • Razvi S.K.
        Tuberculosis following immunosuppressive treatment after exposure to toxic smoke.
        Lancet. 1995; 345 ([Letter]): 1379-1380
        • Ravindranath N.H.
        • Hall D.O.
        Biomass, energy, and environment: a developing country perspective from India.
        Oxford University Press, Oxford1995
        • Stata Corporation
        Stata reference Manual. Vol. PZ. Stata Press, College Station, Texas1997 (Release 5.)
        • Retherford R.D.
        • Choe M.K.
        Statistical models for causal analysis.
        John Wiley & Sons, New York1993
        • WHO (World Health Organization)
        Tobacco or health: a global status report.
        World Health Organization, Geneva1997
        • Mausner J.S.
        • Kramer S.
        Epidemiology: an introductory text.
        WB Saunders, Philadelphia1985