Addressing the Burden of Disease Attributable to Air Pollution in India: The Need to Integrate across Household and Ambient Air Pollution Exposures

In the comparative risk assessment (Lim et al. 2012), performed as part of the Global Burden of Disease (GBD) 2010 Project, air pollution ranked as a leading contributor to the burden of disease in South Asia. Estimates of the burden in India show approximately 1.04 million premature deaths and 31.4 million disability-adjusted life years (DALYs) to be attributable to household air pollution (HAP) resulting from solid cooking fuels, and 627,000 premature deaths and nearly 17.8 million DALYs to be attributable to ambient air pollution (AAP) in the form of fine particulate matter ≤ 2.5 µm in aero dynamic diameter (PM 2.5). HAP and AAP account for 6% and 3%, respectively, of the total national burden of disease, and together they exceed the burden from any other risk factor of the > 60 examined. This burden, borne disproportionately by poor populations who rely on solid fuels for cooking, poses an enormous challenge for air quality management within public health programs in India. There is a need to integrate research and intervention across HAP and AAP exposures in India in order to reduce disease burdens and to efficiently improve health by using intervention efforts. The HAP exposure model used in GBD 2010 (based on measurements and modeling results from India) estimated daily average PM 2.5 exposures of 285 µg/m 3 , 337 µg/m 3 , and 204 µg/m 3 for children, women, and men, respectively (Balakrishnan et al. 2013). The global model used for AAP exposures (which for the first time included ambient air quality of rural areas) estimated a 2010 population-weighted annual mean PM 2.5 of 27.2 µg/m 3 in India, up 6% from 1990, with a distribution that included much higher levels in urban and some rural areas (Brauer et al. 2012). These estimates, which significantly exceed the World Health Organization (WHO) Air Quality Guideline (AQG) levels (WHO 2006), underscore the inter related contribution of these HAP and AAP exposures to the burden of disease in India. In GBD 2010, these quantitative exposure estimates were coupled with an integrated exposure–response function to estimate the burden of disease from ischemic heart disease, stroke, acute lower respiratory infection, and lung cancer for both AAP and HAP by contrasting risk under current exposure conditions with the theoretical-minimum-risk exposure distribution that would apply if exposure were reduced to an annual mean PM 2.5 of approximately 7 µg/m 3 (Lim et al. 2012). The use …