Efficacy of Air Filtration and Education Interventions on Indoor Fine Particulate Matter and Child Lower Respiratory Tract Infections among Rural U.S. Homes Heated with Wood Stoves: Results from the KidsAIR Randomized Trial

BACKGROUND: Millions of rural U.S. households are heated with wood stoves. Wood stove use can lead to high indoor concentrations of fine particulate matter [airborne particles [Formula: see text] in aerodynamic diameter ([Formula: see text])] and is associated with lower respiratory tract infection (LRTI) in children. OBJECTIVES: We assessed the impact of low-cost educational and air filtration interventions on childhood LRTI and indoor [Formula: see text] in rural U.S. homes with wood stoves. METHODS: The Kids Air Quality Interventions for Reducing Respiratory Infections (KidsAIR) study was a parallel three-arm (education, portable air filtration unit, control), post-only randomized trial in households from Alaska, Montana, and Navajo Nation (Arizona and New Mexico) with a wood stove and one or more children [Formula: see text] of age. We tracked LRTI cases for two consecutive winter seasons and measured indoor [Formula: see text] over a 6-d period during the first winter. We assessed results using two analytical frameworks: a) intervention efficacy on LRTI and [Formula: see text] (intent-to-treat), and b) association between [Formula: see text] and LRTI (exposure–response). RESULTS: There were 61 LRTI cases from 14,636 child-weeks of follow-up among 461 children. In the intent-to-treat analysis, children in the education arm [[Formula: see text]; 95% confidence interval (CI): 0.35, 2.72] and the filtration arm ([Formula: see text]; 95% CI: 0.46, 3.32) had similar odds of LRTI vs. control. Geometric mean [Formula: see text] concentrations were similar to control in the education arm (11.77% higher; 95% CI: [Formula: see text] , 49.72) and air filtration arm (6.96% lower; 95% CI: [Formula: see text] , 24.55). In the exposure–response analysis, odds of LRTI were 1.45 times higher (95% CI: 1.02, 2.05) per interquartile range ([Formula: see text]) increase in mean indoor [Formula: see text]. DISCUSSION: We did not observe meaningful differences in LRTI or indoor [Formula: see text] in the air filtration or education arms compared with the control arm. Results from the exposure–response analysis provide further evidence that biomass air pollution adversely impacts childhood LRTI. Our results highlight the need for novel, effective intervention strategies in households heated with wood stoves. https://doi.org/10.1289/EHP9932