Indoor exposure levels of bacteria and fungi in residences,schools, and offices in China: A systematic review

Microbes in buildings have attracted extensive attention from both the research community and the general public due to their close relationship with human health. However, there still lacks comprehensive information on the indoor exposure level of microbes in China. This study systematically reviews exposure levels, the community structures, and the impact factors of airborne bacteria and fungi in residences, schools, and offices in China. We reviewed the major literature databases between 1980 and 2019 and selected 55 original studies based on a set of criteria. Results show that the concentration of indoor bacteria varies from 72.5 to 7500 CFU/m³, with a median value of 1000 CFU/m³, and the concentration of fungi varies from 12 to 9730 CFU/m³, with a median value of 526 CFU/m³. The concentration level of microbes varies in different climate zones, with higher bacterial concentrations in the severe cold zone, and higher fungal concentrations in the hot summer and warm winter zone. Among different buildings, classrooms have the highest average bacteria and fungi levels. This review reveals that a unified assessment system based on health effects is needed for evaluating the exposure levels of bacteria and fungi.     

Mono‐, di‐, and trichlorinated biphenyls (PCB 1‐PCB 39) in the indoor air of office rooms and their relevance on human blood burden

Exposure to polychlorinated biphenyls (PCBs) from indoor air can lead to a significant increase in lower chlorinated congeners in human blood. Lower chlorinated congeners with short biological half‐lives can exhibit an indirect genotoxic potential via their highly reactive metabolites. However, little is known about their occurrence in indoor air and, therefore, about the effects of possible exposure to these congeners. We analyzed all mono‐, di‐, and trichlorinated biphenyls in the indoor air of 35 contaminated offices, as well as in the blood of the 35 individuals worked in these offices for a minimum of 2 years. The median concentration of total PCB in the indoor air was 479 ng/m³. The most prevalent PCBs in the indoor air samples were the trichlorinated congeners PCB 31, PCB 18, and PCB 28, with median levels of 39, 31, and 26 ng/m³, respectively. PCB 8 was the most prevalent dichlorinated congener (median: 9.1 ng/m³). Monochlorinated biphenyls were not detected in relevant concentrations. In the blood samples, the most abundant congener was PCB 28; nearly 90% of all mono‐, di‐, and trichlorinated congeners were attributed to this congener (median: 12 ng/g blood lipid).     

An energy impact assessment of ventilation for indoor airborne bacteria exposure risk in air-conditioned offices

Treatment of fresh air in ventilation systems for air-conditioned offices consumes a significant amount of energy and affects the indoor air quality (IAQ). In this study, energy impact on the ventilation systems was examined against certain IAQ objectives for indoor airborne bacteria exposure risk in air-conditioned offices of Hong Kong. The relationship between thermal energy consumptions and indoor airborne bacteria exposure levels based on regional surveys was investigated. The thermal energy consumptions of ventilation systems operating for carbon dioxide (CO₂) exposure concentrations between 800 and 1200 ppmv for typical office buildings and the corresponding failure probability against some target bacteria exposure levels were evaluated. The results showed that, for a reference indoor environment at a CO₂ exposure concentration of 1000 ppmv, the predicted average thermal energy saving of ventilation system for a unit increment of the expected risk of unsatisfactory IAQ of 1% was 55 MJ m⁻² yr⁻¹ and for a unit decrement of 1%, the predicted additional thermal energy consumption was 58 MJ m⁻² yr⁻¹ respectively. This study would be a useful source of reference in evaluation of the energy performance of ventilation strategies in air-conditioned offices at a quantified exposure risk of airborne bacteria.     

Particulate matter and gaseous pollutants in residences in Antwerp, Belgium

This comprehensive study, a first in Flanders, Belgium, aimed at characterizing the residential indoor air quality of subgroups that took part in the European Community Respiratory Health Survey (ECRHS I—1991 and ECHRS II—1996) questionnaire-based asthma and related illnesses studies. This pilot study aimed at the evaluation of particulate matter and various inorganic gaseous compounds in residences in Antwerp. In addition personal exposure to the gaseous compounds of one individual per residence was assessed. The main objective was to obtain some base-line pollutant levels and compare these with studies performed in other cities, to estimate the indoor air quality in residences in Antwerp. Correlations between the various pollutant levels, indoor:outdoor ratios and the micro-environments of each residence were investigated. This paper presents results on indoor and ambient PM₁, PM_2.5 and PM₁₀ mass concentrations, its elemental composition in terms of K, Ca, Ti, V, Cr, Mn, Fe, Ni, Cu, Zn, Br, Pb, Al, Si, S and Cl and the water-soluble ionic concentrations in terms of SO₄²⁻, NO₃²⁻, Cl⁻, NH₄⁺ K⁺, Ca²⁺. In addition, indoor, ambient and personal exposure levels of the gases NO₂, SO₂, and O₃ were determined. Elevated indoor:outdoor ratios were found for NO₂ in residences containing gas stoves. In smoker's houses increased PM concentrations of 58 and 43% were found for the fine and coarse fractions respectively. Contrary to the fact that all I/O ratios of the registered elements in each individual house were significantly correlated to each other, no correlation could be established between the I/O ratios of the different houses, thus indicating a unique micro-environment for each residence. Linear relationships between the particulate matter elemental composition, SO₂ and O₃ levels indoors and outdoors could be established. No linear relationships between indoor and outdoor NO₂ and particulate mass concentrations were found.     

Exposure to fine particulate matter in ten night clubs in Athens Greece: Studying the effect of ventilation, cigarette smoking and resuspension

The aim of the present work is to study the occupants' exposure to fine particulate concentrations in ten nightclubs (NCs) in Athens, Greece. Measurements of PM₁ and PM_2.5 were made in the outdoor and indoor environment of each NC. The average indoor PM₁ and PM_2.5 concentrations were found to be 181.77 μg m^− 3 and 454.08 μg m^− 3 respectively, while the corresponding outdoor values were 11.04 μg m^− 3 and 32.19 μg m^− 3. Ventilation and resuspension rates were estimated through consecutive numerical experiments with an indoor air quality model and were found to be remarkably lower than the minimum values recommended by national standards. The relative effects of the ventilation and smoking on the occupants' exposures were examined using multiple regression techniques. It was found that given the low ventilation rates, the effect of smoking as well as the occupancy is of the highest importance. Numerical evaluations showed that if the ventilation rates were at the minimum values set by national standards, then the indoor exposures would be reduced at the 70% of the present exposure values.     

Real-time measurements of PM2.5 and ozone to assess the effectiveness of residential indoor air filtration in Shanghai homes

Portable air cleaners are increasingly used in polluted areas in an attempt to reduce human exposure; however, there has been limited work characterizing their effectiveness at reducing exposure. With this in mind, we recruited forty-three children with asthma from suburban Shanghai and deployed air cleaners (with HEPA and activated carbon filters) in their bedrooms. During both 2-week filtration and non-filtration periods, low-cost PM_2.5 and O₃ air monitors were used to measure pollutants indoors, outdoors, and for personal exposure. Indoor PM_2.5 concentrations were reduced substantially with the use of air cleaners, from 34 ± 17 to 10 ± 8 µg/m³, with roughly 80% of indoor PM_2.5 estimated to come from outdoor sources. Personal exposure to PM_2.5 was reduced from 40 ± 17 to 25 ± 14 µg/m³. The more modest reductions in personal exposure and high contribution of outdoor PM_2.5 to indoor concentrations highlight the need to reduce outdoor PM_2.5 and/or to clean indoor air in multiple locations. Indoor O₃ concentrations were generally low (mean = 8±4 ppb), and no significant difference was seen by filtration status. The concentrations of pollutants and the air cleaner effectiveness were highly variable over time and across homes, highlighting the usefulness of real-time air monitors for understanding individual exposure reduction strategies.     

Advanced buffer materials for indoor air CO2 control in commercial buildings

In this study, we evaluated solid sorbents for their ability to passively control indoor CO₂ concentration in buildings or rooms with cyclic occupancy (eg, offices, bedrooms). Silica supported amines were identified as suitable candidates and systematically evaluated in the removal of CO₂ from indoor air by equilibrium and dynamic techniques. In particular, sorbents with various amine loadings were synthesized using tetraethylenepentamine (TEPA), poly(ethyleneimine) (PEI) and a silane coupling agent 3‐aminopropyltriethoxysilane (APS). TGA analysis indicates that TEPA impregnated silica not only displays a relatively high adsorption capacity when exposed to ppm level CO₂ concentrations, but also is capable of desorbing the majority of CO₂ by air flow (eg, by concentration gradient). In 10 L flow‐through chamber experiments, TEPA‐based sorbents reduced outlet CO₂ by up to 5% at 50% RH and up to 93% of CO₂ adsorbed over 8 hours was desorbed within 16 hours. In 8 m³ flow‐through chamber experiments, 18 g of the sorbent powder spread over a 2 m² area removed approximately 8% of CO₂ injected. By extrapolating these results to real buildings, we estimate that meaningful reductions in the CO₂ can be achieved, which may help reduce energy requirements for ventilation and/or improve air quality.     

Unexpected increase in indoor pollutants after the introduction of a smoke‐free policy in a correctional center

Correctional centers (prisons) are one of the few non‐residential indoor environments where smoking is still permitted. However, few studies have investigated indoor air quality (IAQ) in these locations. We quantified the level of inmate and staff exposure to secondhand smoke, including particle number (PN) count, and we assessed the impact of the smoking ban on IAQ. We performed measurements of indoor and outdoor PM_2.5 and PN concentrations, personal PN exposure levels, volatile organic compounds (VOCs), and nicotine both before and after a complete indoor smoking ban in an Australian maximum security prison. Results show that the indoor 24‐h average PM_2.5 concentrations ranged from 6 (±1) μg/m³ to 17 (±3) μg/m³ pre‐ban. The post‐ban levels ranged from 7 (±2) μg/m³ to 71 (±43) μg/m³. While PM_2.5 concentrations decreased in one unit post‐ban, they increased in the other two units. Similar post‐ban increases were also observed in levels of PN and VOCs. We describe an unexpected increase of indoor pollutants following a total indoor smoking ban in a prison that was reflected across multiple pollutants that are markers of smoking. We hypothesise that clandestine post‐ban smoking among inmates may have been the predominant cause.     

Indoor NH3 variation and its relationship with outdoor NH3 in urban Beijing

Online measurements of indoor and outdoor ammonia (NH₃) were conducted at a university building in Haidian District, Beijing, to investigate their variation characteristics, indoor-outdoor differences, influencing factors, and possible contribution of indoor NH₃ to atmospheric NH₃. Indoor NH3 mixing ratios varied greatly among the rooms of the same building. Indoor NH₃ mixing ratio peaked at 1.43 ppm in a toilet. Both indoor and outdoor NH₃ mixing ratios exhibited higher values during summer and lower values during winter and correlated significantly with relative humidity and temperature. Moreover, their daily mean mixing ratios were significantly correlated with each other. But indoor and outdoor NH₃ in cold months exhibited quite different diurnal variations. During the measurement period, indoor NH₃ mixing ratios were substantially higher than those outdoors, by an average factor of 3.1 (1.0–6.6). This indicates that indoor NH₃ could be a source of outdoor atmospheric NH₃. The contribution of indoor NH₃ to atmospheric NH₃ was estimated at 0.7 ± 0.5 Gg NH₃-N·a⁻¹, accounting for approximately 1.0 ± 0.7% of total emissions in Beijing and being comparable to industry, biomass combustion, and soil emissions, but lower than transportation emissions. The influence of COVID-19 control measures caused indoor and outdoor NH₃ mixing ratios to decrease by 22.8% and 19.3%, respectively—attributable to decreased human activity and traffic flow.     

Evaluation on potential for assessing indoor formaldehyde using biosensor system based on swimming behavior of Japanese medaka (oryzias latipes)

In order to develop an early-warning biosensor system for predicting the impact on health of long-term and low-level exposure to indoor chemical compounds, e.g. volatile organic compounds (VOCs), we evaluated the potential for assessing indoor air quality using the biosensor system based on the swimming behavior of Japanese medaka (oryzias latipes) as an indicator of indoor air quality in the beginning. As a technology to dissolve chemical compounds into water efficiently, a micro bubble generator was introduced. The test chemical was formaldehyde which is a representative of chemical compounds existing indoors. The result of the measuring solubility of formaldehyde was that formaldehyde concentration in water was raised to 0.12 mg/L when 1.0 mg/m³ of formaldehyde in air was bubbled for approximately 44 h. The correlation between the 0.1 mg/L of formaldehyde in water, which is roughly equivalent to 0.83 mg/m³ of formaldehyde in air, and the swimming activities of medaka was investigated. The fish showed abnormal behavior compared to one under a control treatment, e.g. the body movement distance decreased and the duration time near the upper water column increased significantly. It was verified that it is possible to detect concentrations of formaldehyde of 0.83 mg/m³ in indoor air using this proposed biosensor system.     

Fine and ultrafine particle exposures on 73 trips by car to 65 non‐smoking restaurants in the San Francisco Bay Area

A number of studies indicate cooking is a major source of exposure to particulate matter, but few studies have measured indoor air pollution in restaurants, where cooking predominates. We made 73 visits by car to 65 different non‐smoking restaurants in 10 Northern California towns while carrying portable continuous monitors that unobtrusively measured ultrafine (down to 10 nm) and fine (PM_2.5) particles to characterize indoor restaurant exposures, comparing them with exposures in the car. The mean ultrafine number concentrations in the restaurants on dinner visits averaging 1.4 h was 71 600 particles/cm³, or 4.3 times the mean concentration on car trips, and 12.3 times the mean background concentration in the residence. Restaurants that cooked dinner in the same room as the patrons had higher ultrafine concentrations than restaurants with separate kitchens. Restaurant PM_2.5 mass concentrations averaged 36.3 μg/m³, ranging from 1.5 to 454 μg/m³, but were relatively low on most visits: 43% of the indoor means were below 10 μg/m³ and 66% were below 20 μg/m³, with 5.5% above 100 μg/m³. Exposure to fine and ultrafine particles when visiting a restaurant exceeded the exposure a person received while traveling by car to and from the restaurant.     

Radon measurement studies in workplace buildings of the Rawalpindi region and Islamabad Capital area, Pakistan

A survey concerning measurement of the indoor radon levels has been carried out in 105 workplaces of the Rawalpindi region and Islamabad Capital Territory using CR-39 based radon detectors. The main objective of this study was to assess the health hazard due to the indoor radon. CR-39 based NRPB type detectors were installed in offices/rooms located on first floors, ground floors and basements and were exposed to indoor radon for six months. The measured indoor radon concentration in the buildings surveyed ranged from 12 ± 5 to 293 ± 19 Bq m⁻³ with an overall mean value of 64 ± 32 Bq m⁻³. The highest mean radon concentration (113 ± 48 Bq m⁻³) was observed in the offices located in basements of the Rawalpindi city. The overall average annual effective dose in the studied workplaces was estimated to be 0.61 ± 0.30 mSv. The mean annual effective doses in basements, ground floor and first floor were found to be 0.87 ± 0.34 mSv, 0.55 ± 0.28 mSv, and 0.47 ± 0.29 mSv, respectively. These values are less than the action level recommended by International Commission on Radiological Protection.     

Combined use of an electrostatic precipitator and a high‐efficiency particulate air filter in building ventilation systems: Effects on cardiorespiratory health indicators in healthy adults

High‐efficiency particulate air (HEPA) filtration in combination with an electrostatic precipitator (ESP) can be a cost‐effective approach to reducing indoor particulate exposure, but ESPs produce ozone. The health effect of combined ESP‐HEPA filtration has not been examined. We conducted an intervention study in 89 volunteers. At baseline, the air‐handling units of offices and residences for all subjects were comprised of coarse, ESP, and HEPA filtration. During the 5‐week long intervention, the subjects were split into 2 groups, 1 with just the ESP removed and the other with both the ESP and HEPA removed. Each subject was measured for cardiopulmonary risk indicators once at baseline, twice during the intervention, and once 2 weeks after baseline conditions were restored. Measured indoor and outdoor PM_2.5 and ozone concentrations, coupled with time‐activity data, were used to calculate exposures. Removal of HEPA filters increased 24‐hour mean PM_2.5 exposure by 38 (95% CI: 31, 45) μg/m³. Removal of ESPs decreased 24‐hour mean ozone exposure by 2.2 (2.0, 2.5) ppb. No biomarkers were significantly associated with HEPA filter removal. In contrast, ESP removal was associated with a ?16.1% (?21.5%, ?10.4%) change in plasma‐soluble P‐selectin and a ?3.0% (?5.1%, ?0.8%) change in systolic blood pressure, suggesting reduced cardiovascular risks.     

Coarse particulate matter and airborne endotoxin within wood stove homes

Emissions from indoor biomass burning are a major public health concern in developing areas of the world. Less is known about indoor air quality, particularly airborne endotoxin, in homes burning biomass fuel in residential wood stoves in higher income countries. A filter‐based sampler was used to evaluate wintertime indoor coarse particulate matter (PM_10‐2.5) and airborne endotoxin (EU/m³, EU/mg) concentrations in 50 homes using wood stoves as their primary source of heat in western Montana. We investigated number of residents, number of pets, dampness (humidity), and frequency of wood stove usage as potential predictors of indoor airborne endotoxin concentrations. Two 48‐h sampling events per home revealed a mean winter PM_10‐2.5 concentration (± s.d.) of 12.9 (± 8.6) μg/m³, while PM_2.5 concentrations averaged 32.3 (± 32.6) μg/m³. Endotoxin concentrations measured from PM_10‐2.5 filter samples were 9.2 (± 12.4) EU/m³ and 1010 (± 1524) EU/mg. PM_10‐2.5 and PM_2.5 were significantly correlated in wood stove homes (r = 0.36, P < 0.05). The presence of pets in the homes was associated with PM_10‐2.5 but not with endotoxin concentrations. Importantly, none of the other measured home characteristics was a strong predictor of airborne endotoxin, including frequency of residential wood stove usage.     

Nitrogen and water recovery from animal slurries by a new integrated ultrafiltration,reverse osmosis and cold stripping process: A case study

The correct management of livestock manure represents one of the major challenge for the agricultural sector development, as it may ensure environmental and economic sustainability of livestock farming. In this work, a new treatment process called N-Free^®, was monitored on two plants treating digested cattle manure (DCM) and digested swine manure (DSM). The process is characterized by sequential integration of solid/liquid separations, ultrafiltration, reverse osmosis and cold ammonia stripping. Solid and liquid streams were characterized regarding TS, TKN, N–NH₄⁺, P and K content allowing to draw a complete mass balance. The main results were a substantial reduction of initial digestate volume (38 and 51% in DCM and DSM respectively) as clean water and a high N–NH₄⁺ removal percentage (47 and 71% in DCM and DSM respectively), through cold ammonia stripping, allowing the production of up to 1.8 m³ concentrated ammonium sulfate, every 100 m³ of treated digestate. The concentrated streams, rich in either organic or mineral N, P and K, can be efficiently used for land application. The N-Free^® technology demonstrated to be a valuable candidate for the path toward nutrient and water recycle, in a new sustainable agriculture and farming concept.     

Acute health effects from exposure to indoor ultrafine particles—A randomized controlled crossover study among young mild asthmatics

Particulate matter is linked to adverse health effects, however, little is known about health effects of particles emitted from typical indoor sources. We examined acute health effects of short-term exposure to emissions from cooking and candles among asthmatics. In a randomized controlled double-blinded crossover study, 36 young non-smoking asthmatics attended three exposure sessions lasting 5 h: (a) air mixed with emissions from cooking (fine particle mass concentration): (PM_2.5: 96.1 μg/m³), (b) air mixed with emissions from candles (PM_2.5: 89.8 μg/m³), and c) clean filtered air (PM_2.5: 5.8 μg/m³). Health effects (spirometry, fractional exhaled Nitric Oxide [FeNO], nasal volume and self-reported symptoms) were evaluated before exposure start, then 5 and 24 h after. During exposures volatile organic compounds (VOCs), particle size distributions, number concentrations and optical properties were measured. Generally, no statistically significant changes were observed in spirometry, FeNO, or nasal volume comparing cooking and candle exposures to clean air. In males, nasal volume and FeNO decreased after exposure to cooking and candles, respectively. Participants reported additional and more pronounced symptoms during exposure to cooking and candles compared to clean air. The results indicate that emissions from cooking and candles exert mild inflammation in asthmatic males and decrease comfort among asthmatic males and females.     

Polycyclic aromatic hydrocarbons: levels and phase distributions in preschool microenvironment

This work aims to characterize levels and phase distribution of polycyclic aromatic hydrocarbons (PAHs) in indoor air of preschool environment and to assess the impact of outdoor PAH emissions to indoor environment. Gaseous and particulate (PM₁ and PM_2.5) PAHs (16 USEPA priority pollutants, plus dibenzo[a,l]pyrene, and benzo[j]fluoranthene) were concurrently sampled indoors and outdoors in one urban preschool located in north of Portugal for 35 days. The total concentration of 18 PAHs (ΣPAHs) in indoor air ranged from 19.5 to 82.0 ng/m³; gaseous compounds (range of 14.1–66.1 ng/m³) accounted for 85% ΣPAHs. Particulate PAHs (range 0.7–15.9 ng/m³) were predominantly associated with PM₁ (76% particulate ΣPAHs) with 5‐ring PAHs being the most abundant. Mean indoor/outdoor ratios (I/O) of individual PAHs indicated that outdoor emissions significantly contributed to PAH indoors; emissions from motor vehicles and fuel burning were the major sources.     

Environmental and individual exposure to secondhand aerosol of electronic cigarettes in confined spaces: Results from the TackSHS Project†

Secondhand electronic cigarette (e-cigarette) aerosol (SHA) might impair indoor air quality and expose bystanders. This study aims to investigate exposure to SHA in controlled conditions of enclosed settings simulating real-world scenario. An experiment was performed in a car and in a room, in which SHA was generated during a 30-minute ad libitum use of an e-cigarette. The experiment was replicated on five consecutive days in each setting. We measured PM_2.5, airborne nicotine concentrations, and biomarkers of exposure to SHA, such as nicotine metabolites, tobacco-specific nitrosamines, propylene glycol, and glycerol in bystanders’ saliva samples before, during, and after the exposure period. Self-reported health symptoms related to exposure to SHA were also recorded. The results showed that the highest median PM_2.5 concentration was recorded during the exposure period, being 21 µg/m³ in the room setting and 16 µg/m³ in the car setting—about twofold increase compared to the baseline. Most concentrations of the airborne nicotine and all biomarkers were below the limit of quantification in both settings. Bystanders in both settings experienced some short-term irritation symptoms, expressed as dry throat, nose, eyes, and phlegm. In conclusion, short-term use of an e-cigarette in confined spaces increased indoor PM_2.5 level and caused some irritation symptoms in bystanders.     

Seasonal variability in environmental tobacco smoke exposure in public housing developments

The risk of tobacco smoking and second‐hand smoke (SHS) exposure combined are the leading contributors to disease burden in high‐income countries. Recent studies and policies are focusing on reducing exposure to SHS in multiunit housing (MUH), especially public housing. We examined seasonal patterns of SHS levels within indoor common areas located on Boston Housing Authority (BHA) properties. We measured weekly integrated and continuous fine particulate matter (PM_2.5) and passive airborne nicotine in six buildings of varying building and occupant characteristics in summer 2012 and winter 2013. The average weekly indoor PM_2.5 concentration across all six developments was 9.2 μg/m³, higher during winter monitoring period (10.3 μg/m³) compared with summer (8.0 μg/m³). Airborne nicotine concentrations ranged from no detection to about 5000 ng/m³ (mean 311 ng/m³). Nicotine levels were significantly higher in the winter compared with summer (620 vs. 85 ng/m³; 95% CI: 72–998). Smoking‐related exposures within Boston public housing vary by season, building types, and resident smoking policy. Our results represent exposure disparities that may contribute to health disparities in low‐income communities and highlight the potential importance of efforts to mitigate SHS exposures during winter when outdoor–indoor exchange rates are low and smokers may tend to stay indoors. Our findings support the use of smoke‐free policy as an effective tool to eliminate SHS exposure and protect non‐smokers, especially residents of MUH.     

Indoor fine particulate matter and demographic,household, and wood stove characteristics among rural US homes heated with wood fuel

Household heating using wood stoves is common practice in many rural areas of the United States (US) and can lead to elevated concentrations of indoor fine particulate matter (PM_2.5). We collected 6-day measures of indoor PM_2.5 during the winter and evaluated household and stove-use characteristics in homes at three rural and diverse study sites. The median indoor PM_2.5 concentration across all homes was 19 µg/m³, with higher concentrations in Alaska (median = 30, minimum = 4, maximum = 200, n = 10) and Navajo Nation homes (median = 29, minimum = 3, maximum = 105, n = 23) compared with Montana homes (median = 16, minimum = 2, maximum = 139, n = 59). Households that had not cleaned the chimney within the past year had 65% higher geometric mean PM_2.5 compared to those with chimney cleaned within 6 months (95% confidence interval [CI]: −1, 170). Based on a novel wood stove grading method, homes with low-quality and medium-quality stoves had substantially higher PM_2.5 compared to homes with higher-quality stoves (186% higher [95% CI: 32, 519] and 161% higher; [95% CI:27, 434], respectively). Our findings highlight the need for, and complex nature of, regionally appropriate interventions to reduce indoor air pollution in rural wood-burning regions. Higher-quality stoves and behavioral practices such as regular chimney cleaning may help improve indoor air quality in such homes.