Understanding inorganic arsenic exposure in Bangladesh and respiratory health consequences using a life course approach

Inorganic arsenic exposure is a well-known toxicant of which we are still discovering harmful effects. People are exposed to inorganic arsenic in the environment through either drinking arsenic-contaminated groundwater or consuming arsenic-contaminated food. Regarding global public health, drinking water is still the most important source of inorganic arsenic exposure and is the main focus of this work. The overall goal of this dissertation is to answer some pointing epidemiological questions about exposure to inorganic arsenic: How much do we know about inorganic arsenic and non-malignant lung disease in the general population? To what extent are adolescents with lifetime arsenic exposure susceptible to the respiratory consequences seen in adults? And what actions can be taken to effectively reduce exposure from arsenic-contaminated drinking water? First, we conducted a systematic review of 29 peer-reviewed articles from various populations around the world. The review focused on the different ways in which arsenic is associated with respiratory health to help inform policy makers and public health researchers on the existing evidence. In short, associations between arsenic and respiratory health were noted throughout the lifespan: in infancy, there was growing evidence that in utero arsenic exposure was associated with increased frequency and severity of respiratory tract infections; in childhood, evidence of respiratory symptoms also began to appear; and in adulthood, there was consistent evidence that arsenic exposure was associated with deficits in lung function and increased reports of coughing and breathing problems. The review also uncovered some research gaps, including few studies with strong exposure history from early life and few studies examining respiratory effects during adolescence. Next, we used a life course epidemiological approach to create a more precise understanding of arsenic exposure and respiratory health during the teenage years. This study examined the relationship between lifetime arsenic exposure and lung function in 14-17 year olds, thus studying the period of maximal lung function before natural decline. Overall, higher arsenic exposure was associated with lower lung function levels; however, these associations were only observed in males. This study used a sensitive marker of lung function to investigate early signs of small airway disease. Incorporating this common marker of small airway disease and airflow limitation in future studies on arsenic and respiratory health may help clarify how inorganic arsenic contributes to the development of chronic respiratory disease. Lastly, we evaluated the effectiveness of arsenic removal filters at the household-level in rural Bangladesh. Identifying sustainable ways of reducing exposure to arsenic from naturally contaminated groundwater has been a major environmental health challenge. Although lab-approved arsenic removal water filters exist, there was limited evidence of their prolonged efficacy in the field. To our knowledge, this was the largest and longest deployment of filters accompanied by monitoring of urinary arsenic. Our results demonstrated that filters can temporarily reduce arsenic exposure for weeks to a few months, but should not be considered as a long-term arsenic mitigation option. This failed attempt to reduce exposure confirmed that alternative mitigation strategies need to be employed in Bangladesh, particularly among more vulnerable populations, including pregnant women and young children. This dissertation has important policy implications for future arsenic research and mitigation efforts and should be effectively communicated to policy makers, public health officials, and the general population. Given the pervasive nature of arsenic exposure and the growing evidence of health consequences at different stages throughout the life course, the continued integration of information on inorganic arsenic and research collaborations across disciplines is critical for the prevention and mitigation of arsenic-induced health consequences.