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Background  Indoor air pollution is an important risk factor for health in low- and middle-income countries.    Methods  We measured indoor fine particulate matter (PM 2.5 ) and carbon monoxide (CO) concentrations in 617 houses across four settings with varying urbanisation, altitude, and biomass cookstove use in Peru, between 2010 and 2016. We assessed the associations between indoor pollutant concentrations and blood pressure (BP), exhaled carbon monoxide (eCO), C-reactive protein (CRP), and haemoglobin A1c (HbA1c) using multivariable linear regression among all participants and stratifying by use of biomass cookstoves.    Results  We found high concentrations of indoor PM 2.5  across all four settings (geometric mean ± geometric standard deviation of PM 2.5  daily average in μg/m 3 ): Lima 41.1 ± 1.3, Tumbes 35.8 ± 1.4, urban Puno 14.1 ± 1.7, and rural Puno 58.8 ± 3.1. High indoor CO concentrations were common in rural households (geometric mean ± geometric standard deviation of CO daily average in ppm): rural Puno 4.9 ± 4.3. Higher indoor PM 2.5  was associated with having a higher systolic BP (1.51 mmHg per interquartile range (IQR) increase, 95% CI 0.16 to 2.86), a higher diastolic BP (1.39 mmHg higher DBP per IQR increase, 95% CI 0.52 to 2.25), and a higher eCO (2.05 ppm higher per IQR increase, 95% CI 0.52 to 3.57). When stratifying by biomass cookstove use, our results were consistent with effect measure modification in the association between PM 2.5  and eCO: among biomass users eCO was 0.20 ppm higher per IQR increase in PM 2.5  (95% CI − 2.05 to 2.46), and among non-biomass users eCO was 5.00 ppm higher per IQR increase in PM 2.5  (95% CI 1.58 to 8.41). We did not find associations between indoor air concentrations and CRP or HbA1c outcomes.    Conclusions  Excessive indoor concentrations of PM 2.5  are widespread in homes across varying levels of urbanisation, altitude, and biomass cookstove use in Peru and are associated with worse BP and higher eCO.

Indoor air pollution concentrations and cardiometabolic health across four diverse settings in Peru: a cross-sectional study