Household Air Pollution and Respiratory Health in Rural Crete, Greece: An Observational FRESH AIR Study

BACKGROUND AND AIM: During the Greek austerity, the unusual outdoor air-quality deterioration observed in cities was attributed to the increased use of biomass-burning fireplaces for domestic heating, resulting from rises in the price of conventional fuels. Indoor air data, particularly for the disproportionally affected rural periphery, was lacking. We explored levels of household air pollution and respiratory health in rural Crete, Greece. METHODS: An observational, implementation science study with repeated design was conducted (November 2017- March 2018). PM2.5 and CO levels were measured in 32 purposively selected rural households, during periods of lesser (baseline) versus extensive (follow-up) heating. Residents’ fuel-use practices, respiratory symptoms and respective awareness were assessed through questionnaires. McNemar and Wilcoxon tests were used to explore outcome differences between assessments. RESULTS: Mean PM2.5 levels were not significantly different between measurements (36.34µg/m³ versus 54.38µg/m³; p=0.60) but exceeded WHO’s air-quality guidelines (25µg/m³ for 24-hours mean). Mean CO levels were 0.56ppm (baseline) and 0.34ppm (follow-up; p=0.414). Maximal CO levels reached 26.1ppm (baseline) and 9.72ppm (follow-up; p=0.007). CO values were below WHO’s cut-offs (26.6ppm for 1-hour and 6.1ppm for 24-hours mean). Overall, 90.6% of households were using wood-burning fireplaces/stoves, but half also owned clean-fuel devices. Differences between devices owned versus used were attributed to financial constraints. Most frequently reported respiratory symptoms [N=42 residents, 72.7% women, mean (SD) age: 66.8(14.9) years] were phlegm (27.3% versus 15.2%; p=0.34) and cough (24.2% versus 12.1%; p=0.22). Less than half of residents (48.5%) knew that indoor biomass-burning can harm health. CONCLUSIONS: Levels of PM2.5 exceeding international standards were documented, in line with evidence regarding the return to harmful practices. Further research is required to confirm results. Advocating for fuel poverty, raising awareness and empowering communities seem important Public Health targets during austerity/energy crisis periods. KEYWORDS: household air pollution, PM2.5, CO, respiratory health, fuel poverty, economic crisis, Greece