Policy trade-offs between climate mitigation and clean cook-stove access in South Asia

Household air pollution from traditional cook stoves presents a greater health hazard than any other environmental factor. Despite government efforts to support clean-burning cooking fuels, over 700 million people in South Asia could still rely on traditional stoves in 2030. This number could rise if climate change mitigation efforts increase energy costs. Here we quantify the costs of support policies to make clean cooking affordable to all South Asians under four increasingly stringent climate policy scenarios. Our most sringent mitigation scenario increases clean fuel costs 38% in 2030 relative to the baseline, keeping 21% more South Asians on traditional stoves or increasing the minimum support policy cost to achieve universal clean cooking by up to 44%. The extent of this increase depends on how poliymakers allocate subsidies between clean fuels and stoves. These additional costs are within the range of financial transfers to South Asia estimated in efforts-sharing scenarios of international climate agreements. Three billion people globally burn solid fuels such as firewood, charcoal, coal, dung, and crop resides in open fires and traditional stoves for cooking and heating. Household air pollution from the incomplete combustion of these fuels globally leads to 4.3 million premature deaths each year, with 1.7 million of those in South Asia. This exceeds the burden of disease from any other energy-related or environmental risk factor. Solid-fuel use also perpetuates income and gender inequality by forcing users, mostly poor women and children, to spend long hours collecting fuels and to suffer from its adverse health effects. To address this problem, the United Nations Secretary-General's Sustainable Energy for All (SE4All) initiative and the new Sustainable Development Goals aim to achieve universal access to modern energy services by 2030. Numerous intervention efforts have focused on distributing more efficient and cleaner burning biomass stoves, but several of these programmes have had little or no demonstrable impact on health outcomes. In India, the nation with the largest population of solid-fuel users globally, government interventions have sought to make petroleum-based fuels, such as kerosene and liquefied petroleum gas (LPG), more affordable through subsidy at an estimated cost of over US$6 billion per year. Although LPG use has grown rapidly, particularly in rural areas, over 72% of Indians continued to rely primarily on solid fuels in 2012. In the future, expanding clean cooking may become more challenging if climate policies increase the cost of fuels. Previous research has found that greenhouse gas (GHG) emissions reductions in Asia and Africa would increase the cost of kerosene and LPG. However, these studies do not explore compensatory policies that could counteract these effects, and assess only a limited set of climate mitigation scenarios. Only two studies explore normative scenarios that achieve access and climate goals simultanously, both of which do not explore the cost-effectiveness or distributional impacts on population subgroups of these policies. Meanwhile, studies that have evaluated the cost-effectiveness of energy access policies have not considered the impact of climate policy. Te latest assessment of the Intergovernmental Panel on Climate Change (IPCC) concludes that we have only low confidence in our understanding of the possible impacts of climate policy on access to modern energy services, and medium confidence in the policies needed to counteract them. In this study, we contribute new insights to the interaction of climate policy and clean cooking acces policies by quantifying the feasibility and costs of achieving universal access by 2030 for a range of climate policy stringencies, and under a wide range of fuel and stove price support policies. Our analysis suggests that the potential trade-offs between the two goals might be arger than suggested by previous studies. However, we find that efficient policy design could partially compensate for the additional access policy costs associated with climate mitigation. Furthermore, these costs fall below the level of potential financial transfers to South Asia that may result from international climate agreements

Non-adherence to community oral-antibiotic treatment in children with fast-breathing pneumonia in Malawi– secondary analysis of a prospective cohort study

Background Despite significant progress, pneumonia is still the leading cause of infectious deaths in children under five years of age. Poor adherence to antibiotics has been associated with treatment failure in World Health Organisation (WHO) defined clinical pneumonia; therefore, improving adherence could improve outcomes in children with fast-breathing pneumonia. We examined clinical factors that may affect adherence to oral antibiotics in children in the community setting in Malawi. Methods We conducted a sub-analysis of a prospective cohort of children aged 2–59 months diagnosed by community health workers (CHW) in rural Malawi with WHO fast-breathing pneumonia. Clinical factors identified during CHW diagnosis were investigated using multivariate logistic regression for association with non-adherence, including concurrent diagnoses and treatments. Adherence was measured at both 80% and 100% completion of prescribed oral antibiotics. Results Eight hundred thirty-four children were included in our analysis, of which 9.5% and 20.0% were non-adherent at 80% and 100% of treatment completion, respectively. A concurrent infectious diagnosis (OR: 1.76, 95% CI: 0.84–2.96/OR: 1.81, 95% CI: 1.21–2.71) and an illness duration of >24 h prior to diagnosis (OR: 2.14, 95% CI: 1.27–3.60/OR: 1.88, 95% CI: 1.29–2.73) had higher odds of non-adherence when measured at both 80% and 100%. Older age was associated with lower odds of non-adherence when measured at 80% (OR: 0.41, 95% CI: 0.21–0.78). Conclusion Non-adherence to oral antibiotics was not uncommon in this rural sub-Saharan African setting. As multiple diagnoses by the CHW and longer illness were important factors, this provides an opportunity for further investigation into targeted interventions and refinement of referral guidelines at the community level. Further research into the behavioural drivers of non-adherence within this setting is needed

The Epidemiology of Hypoxemic Pneumonia among Young Infants in Malawi

We describe hypoxemic pneumonia prevalence in outpatient and inpatient settings, in-hospital mortality, and clinical guideline performance for identifying hypoxemia in young infants in Malawi. In this retrospective analysis of a prospective cohort study, we investigate infants younger than 2 months participating in pneumonia surveillance at seven hospitals and 18 outpatient health centers in Malawi between 2011 and 2014. Logistic regression, multiple imputations with chained equations, and pattern mixture modeling were used to determine the association between peripheral oxyhemoglobin saturation (SpO2) levels and hospital mortality. We describe referral recommendations based on clinical characteristics and SpO2 distributions. Among 1,879 analyzed cases, SpO2 < 90% was more prevalent among outpatient health center cases than that among hospitalized cases (22.6% versus 13.5%, 95% CI: 17.6–28.4% and 12.0–15.3%, respectively). A larger proportion of hospitalized infants had signs of respiratory distress than infants at health centers (67.7% versus 56.6%, P < 0.001) and the signs were higher in male versus female infants (56.7% versus 40.6%, P < 0.001). An SpO2 of 90–92% and < 90% was associated with similarly increased odds of in-hospital mortality (adjusted odds ratio [aOR]: 4.3 and 4.4, 95% CI: 1.7–11.1 and 1.8–10.5, respectively). Unrecorded, or unobtainable, SpO2 was highly associated with mortality (n = 127, aOR: 18.1; 95% CI: 7.6–42.8). Four of 22 (18%) infants at health centers who did not meet clinical referral criteria had an SpO2 ≤ 92%. Clinicians should consider hospital referral in young infants with SpO2 ≤ 92%. Infants with unobtainable SpO2 readings should be considered a high-risk group, and hospital referral of these cases may be appropriate

Effects of sorghum wet distillers grains plus solubles in steam-flaked corn–based finishing diets on steer performance, carcass characteristics, and digestibility characteristics

Two studies were conducted to evaluate the effects of sorghum wet distillers grains (SWDGS) in finishing diets on steer performance, carcass characteristics, and nutrient digestibility. In Exp. 1, 240 steers (initial BW = 379 ± 1 kg) were fed steam-flaked corn–based diets with or without 25% SWDGS and 7.5, 10.0, or 12.5% alfalfa hay. There were no effects of alfalfa hay concentration on BW, DMI, ADG, or G:F (P ≥ 0.16). Including SWDGS reduced (P ≤ 0.05) ADG and G:F. Fat thickness decreased (P = 0.03) and DP tended to decrease (P = 0.09) linearly as level of alfalfa hay increased. Final BW of steers consuming diets containing 25% SWDGS were 12 kg lighter (P = 0.05) than those of steers fed diets without SWDGS. Hot carcass weight tended (P = 0.09) to be lighter for steers fed SWDGS. In Exp. 2, effects of corn processing method (steam-flaked corn and dry-rolled corn) and 20% corn wet distillers grains with solubles (CWDGS) or SWDGS inclusion on ruminal pH and in situ digestibility were evaluated. Cattle consuming diets containing SWDGS had a greater (P ≤ 0.05) ruminal pH than steers consuming diets with CWDGS or no wet distillers grains with solubles. Including wet distillers grains with solubles did not affect (P ≥ 0.37) steam-flaked corn or dry-rolled corn in situ DM digestibility. In situ digestibility of DM and NDF differed between CWDGS and SWDGS (P \u3c 0.0001). Differences in performance and nutrient digestibility between CWDGS and SWDGS are the result of differences in the product rather than an interaction with corn processing method

Pulse oximetry for children with pneumonia treated as outpatients in rural Malawi

OBJECTIVE: To investigate implementation of outpatient pulse oximetry among children with pneumonia, in Malawi. METHODS: In 2011, 72 health-care providers at 18 rural health centres and 38 community health workers received training in the use of pulse oximetry to measure haemoglobin oxygen saturations. Data collected, between 1 January 2012 and 30 June 2014 by the trained individuals, on children aged 2-59 months with clinically diagnosed pneumonia were analysed. FINDINGS: Of the 14 092 children included in the analysis, 13 266 (94.1%) were successfully checked by oximetry. Among the children with chest indrawing and/or danger signs, those with a measured oxygen saturation below  90% were more than twice as likely to have been referred as those with higher saturations (84.3% [385/457] vs 41.5% [871/2099]; P < 0.001). The availability of oximetry appeared to have increased the referral rate for severely hypoxaemic children without chest indrawing or danger signs from 0% to 27.2% (P < 0.001). In the absence of oximetry, if the relevant World Health Organization (WHO) guidelines published in 2014 had been applied, 390/568 (68.7%) severely hypoxaemic children at study health centres and 52/84 (61.9%) severely hypoxaemic children seen by community health workers would have been considered ineligible for referral. CONCLUSION: Implementation of pulse oximetry by our trainees substantially increased the referrals of Malawian children with severe hypoxaemic pneumonia. When data from oximetry were excluded, retrospective application of the guidelines published by WHO in 2014 failed to identify a considerable proportion of severely hypoxaemic children eligible only via oximetry

Grafting and Paladin Pic-21 for Nematode and Weed Management in Vegetable Production

Two years of field trials conducted in a Meloidogyne incognita-infested field evaluated grafting and Paladin Pic-21 (dimethyl disulfide:chloropicrin [DMDS:Pic] 79:21) for root-knot nematode and weed control in tomato and melon. Tomato rootstocks evaluated were; 'TX301', 'Multifort', and 'Aloha'. 'Florida 47' was the scion and the nongrafted control. A double crop of melon was planted into existing beds following tomato harvest. Melon rootstocks, C. metulifer and 'Tetsukabuto', were evaluated with nongrafted 'Athena' in year 1. In year 2, watermelon followed tomato with scion variety 'Tri-X Palomar' as the control and also grafted onto 'Emphasis' and 'Strongtosa' rootstocks. Four soil treatments were applied in fall both years under Canslit metalized film; Paladin Pic-21, methyl bromide:chloropicrin (MeBr:C33, 67:33), Midas (iodomethane:chloropicrin 50:50), and a herbicide-treated control. M.incognita J2 in soil were highest in herbicide control plots and nongrafted tomato. All soil treatments produced similar tomato growth,which was greater than the herbicide control. All treatments reduced M. incognita J2 in roots compared to the herbicide control. 'Multifort' rootstock produced the largest and healthiest roots; however, the number of M. incognita isolated from roots did not differ among the tomato rootstocks tested. Galling on tomato was highest in herbicide control plots and nongrafted plants. In melon, M.incognita J2 in soil did not differ among melon rootstocks, but numbers isolated from melon rootstocks increased in 'Tetsukabuto' compared with C. metuliferus. 'Tetsukabuto' were larger root systems than nongrafted 'Athena'. All fumigants provided protection for all melon rootstocks against galling by M.incognita compared to the herbicide control. Galling on C. metuliferus rootstock was less in all fumigant treatments compared with nongrafted 'Athena' and 'Tetsukabuto'. In watermelon, M. incognita in soil and roots did not differ among soil treatments or watermelon rootstocks, and yield was lower in both grafted rootstocks compared with the nongrafted control. All soil treatments increased average fruit weight of watermelon compared with the herbicide control, and provided effective weed control, keeping the most predominant weed, purple nutsedge (Cyperus rotundus L.), density at or below 1/m row. Grafting commercial scions onto M. incognita-resistant rootstocks has potential for nematode management combined with soil treatments or as a stand-alone component in crop production systems

Opportunities and barriers in paediatric pulse oximetry for pneumonia in low-resource clinical settings: a qualitative evaluation from Malawi and Bangladesh

OBJECTIVE: To gain an understanding of what challenges pulse oximetry for paediatric pneumonia management poses, how it has changed service provision and what would improve this device for use across paediatric clinical settings in low-income countries. DESIGN: Focus group discussions (FGDs), with purposive sampling and thematic analysis using a framework approach. SETTING: Community, front-line outpatient, and hospital outpatient and inpatient settings in Malawi and Bangladesh, which provide paediatric pneumonia care. PARTICIPANTS: Healthcare providers (HCPs) from Malawi and Bangladesh who had received training in pulse oximetry and had been using oximeters in routine paediatric care, including community healthcare workers, non-physician clinicians or medical assistants, and hospital-based nurses and doctors. RESULTS: We conducted six FGDs, with 23 participants from Bangladesh and 26 from Malawi. We identified five emergent themes: trust, value, user-related experience, sustainability and design. HCPs discussed the confidence gained through the use of oximeters, resulting in improved trust from caregivers and valuing the device, although there were conflicts between the weight given to clinical judgement versus oximeter results. HCPs reported the ease of using oximeters, but identified movement and physically smaller children as measurement challenges. Challenges in sustainability related to battery durability and replacement parts, however many HCPs had used the same device longer than 4 years, demonstrating robustness within these settings. Desirable features included back-up power banks and integrated respiratory rate and thermometer capability. CONCLUSIONS: Pulse oximetry was generally deemed valuable by HCPs for use as a spot-check device in a range of paediatric low-income clinical settings. Areas highlighted as challenges by HCPs, and therefore opportunities for redesign, included battery charging and durability, probe fit and sensitivity in paediatric populations. TRIAL REGISTRATION NUMBER: NCT02941237

Locked into Copenhagen pledges - Implications of short-term emission targets for the cost and feasibility of long-term climate goals

This paper provides an overview of the AMPERE modeling comparison project with focus on the implications of near-term policies for the costs and attainability of long-term climate objectives. Nine modeling teams participated in the project to explore the consequences of global emissions following the proposed policy stringency of the national pledges from the Copenhagen Accord and Cancun Agreements to 2030. Specific features compared to earlier assessments are the explicit consideration of near-term 2030 emission targets as well as the systematic sensitivity analysis for the availability and potential of mitigation technologies. Our estimates show that a 2030 mitigation effort comparable to the pledges would result in a further "lock-in" of the energy system into fossil fuels and thus impede the required energy transformation to reach low greenhouse-gas stabilization levels (450 ppm CO2e). Major implications include significant increases in mitigation costs, increased risk that low stabilization targets become unattainable, and reduced chances of staying below the proposed temperature change target of 2 degrees C in case of overshoot. With respect to technologies, we find that following the pledge pathways to 2030 would narrow policy choices, and increases the risks that some currently optional technologies, such as carbon capture and storage (CCS) or the large-scale deployment of bioenergy, will become "a must" by 2030

Non-treatment of children with community health worker-diagnosed fast-breathing pneumonia in rural Malawi: exploratory subanalysis of a prospective cohort study

BACKGROUND: Despite recent progress, pneumonia remains the largest infectious killer of children globally. This paper describes outcomes of not treating community-diagnosed fast-breathing pneumonia on patient recovery. METHODS: We conducted an exploratory subanalysis of an observational prospective cohort study in Malawi. We recruited children (2-59 months) diagnosed by community health workers with fast-breathing pneumonia using WHO integrated community case management (iCCM) guidelines. Children were followed at days 5 and 14 with a clinical assessment of recovery. We conducted bivariate and multivariable logistic regression for the association between treatment of fast-breathing pneumonia and recovery, adjusting for potential confounders. RESULTS: We followed up 847 children, of whom 78 (9%) had not been given antibiotics (non-treatment). Non-treatment cases had higher baseline rates of diarrhoea, non-severe hypoxaemia and fever. Non-recovery (persistence or worsening of symptoms) was 13% and 23% at day 5 in those who did receive and those who did not receive co-trimoxazole. Non-recovery, when defined as worsening of symptoms only, at day 5 was 7% in treatment and 10% in non-treatment cases. For both definitions, combined co-trimoxazole and lumefantrine-artemether (LA) treatment trended towards protection (adjusted OR (aOR) 0.28; 95% CI 0.12 to 0.68/aOR 0.29; 95% CI 0.08 to 1.01). CONCLUSION: We found that children who did not receive co-trimoxazole treatment had worse clinical outcomes; malaria co-diagnosis and treatment also play a significant role in non-recovery. Further research into non-treatment of fast-breathing pneumonia, using a pragmatic approach with consideration for malaria co-diagnosis and HIV status is needed to guide refinement of community treatment algorithms in this region