Nearly 3 billion people continue to use solid fuels (coal, biomass, animal dung) for household energy needs, primarily in low- and middle-income countries. The household air pollution resulting from cooking with solid fuels is responsible for an estimated 2.3 million premature deaths and additional morbidity burden each year. Household air pollution emissions from cooking with solid fuels (carbon dioxide and black carbon) are also major sources of climate warming gases at the global level. Our Household Air Pollution Intervention Network (HAPIN) trial (NIH UM1HL134590) is evaluating the effect of a free LPG (liquefied petroleum gas) stove and fuel intervention among 800 pregnant women in each of 4 countries (Guatemala, India, Peru, Rwanda) on birth outcomes and child health through age 1; data collection has been extended through age 2. The trial has achieved excellent retention (92%), high adherence to the intervention, and a substantial reduction in personal exposure to fine particulate matter (PM2.5) and black carbon, a contributor to climate change. Preliminary results suggest the intervention improves length and weight at birth. Research suggests that exposure experienced during gestation and early life is linked to a range of longer-term outcomes, and that the benefits of reduced exposure will continue even if the intervention ends. Therefore, we propose to continue to follow HAPIN children through age 5 to evaluate the effects of the original HAPIN intervention on neurologic and physical development (Aim 1). Further, given that the intervention ends at age 1, we will continue to characterize the children’s personal exposure to PM2.5 and black carbon (Aim 2), allowing us the unique ability to evaluate exposure-response for several relevant periods of gestation and early childhood (Aim 3). The HAPIN trial is uniquely positioned to address these questions, with a large exposure contrast during the trial and the generation of a rich dataset to examine exposure-response given the expected heterogeneity in exposures among control households and all participants post-trial as they adopt the various fuels and cooking practices typical in LMIC settings. The selected health outcomes are supported by previous literature and have important implications for policy. Our overarching hypotheses are that 1) the original intervention has longer term benefits for neurologic and physical development after the intervention ends, and 2) that personal exposure to PM2.5 and black carbon during critical developmental periods will be inversely associated with neurologic and physical development. We propose to explore these aims and hypotheses in HAPIN children in Guatemala, India, and Rwanda (n=2,175 children remaining in the 3 study sites). The proposed work builds on the major investment already made in the HAPIN trial by evaluating whether the benefits of the intervention extend beyond pregnancy and the child’s first year of life, leveraging a well-characterized cohort in 3 diverse settings, providing rigorous and widely generalizable answers to questions important for both science and policy. We are maximizing potential for success by extending our prior research, using an experienced and proven research team, with strong and ongoing relationships with participants.

NARRATIVE Household air pollution resulting from cooking with solid fuels (wood, charcoal, animal dung, coal), the primary household energy source for nearly 3 billion people, is responsible for an estimated 2.3 million premature deaths and additional morbidity burden each year, primarily in low- and middle income countries, and are also major sources of climate warming gases. The proposed work will leverage the ongoing Household Air Pollution Intervention Network (HAPIN) trial by evaluating whether a liquefied petroleum gas (LPG) stove and fuel intervention during the first 500 days of life (pregnancy and early childhood) and the substantial differences in personal exposure (fine particulate matter and black carbon) and preliminary indications of improvements in health outcomes, impact child development beyond the child’s first year of life. The proposed work will impact health, environmental, climate and energy policies by providing rigorous and widely generalizable insight to questions regarding the impact of this intervention and a range of exposure levels on child neurologic and physical development through the age of 5, indicators of longer-term educational achievement, economic productivity and health.