The molecular epidemiology of chronic aflatoxin driven impaired child growth

Association Between Aflatoxin Exposure and Haemoglobin, Zinc, and Vitamin A, C, and E Levels/Status: A Systematic Review

Background: Aflatoxin, produced by Aspergillus flavus and Aspergillus parasiticus fungi, contaminates a broad range of crops such as maize, nuts, and cotton. Aflatoxin exposure causes growth failure, immune suppression, and liver cancer. While several systematic reviews have assessed the link between aflatoxin exposure and growth development in humans, there is a lack of reviews on the associations between aflatoxin exposure and micronutrient levels/status. This review addresses that gap by compiling studies on the association between aflatoxin exposure and micronutrient levels/status in humans. Methods: A comprehensive search of the SCOPUS, PUBMED, EMBASE, and Web of Science databases was conducted, focusing on studies published between 2003 and 2023. Only English-language studies using urine, blood, serum, or plasma biomarkers were included to assess the exposure and outcomes. The risk of bias in these studies was evaluated using the Academy of Nutrition and Dietetics Quality Criteria for human studies. Results: Ten observational studies were included in the systematic review, which collectively reported the association between aflatoxin exposure and haemoglobin, zinc, and vitamin A, E, and C levels. This review suggests that aflatoxin exposure is associated with micronutrient deficiencies, such as anaemia (low haemoglobin levels (<11 g/dL)) in pregnant women and vitamin A deficiency in adults and children. Conclusions: This review highlights the link between aflatoxin exposure and micronutrient deficiencies, emphasizing the need for aflatoxin mitigation within micronutrient interventions. Future studies should focus on longitudinal and interventional research to establish causal relationships and assess the effectiveness of mitigation strategies. Additionally, further research is needed to explore the interaction between aflatoxin exposure and other potential confounding factors such as dietary patterns, socioeconomic status, and genetic predisposition.

Dietary Mycotoxins: An Overview on Toxicokinetics, Toxicodynamics, Toxicity, Epidemiology, Detection, and Their Mitigation with Special Emphasis on Aflatoxicosis in Humans and Animals

Mycotoxins are secondary metabolites of filamentous fungi and ubiquitous dietary contaminants. Aflatoxins, a group of mycotoxins with high prevalence and toxicity, have raised a high level of public health concern, the most prevalent and toxic being aflatoxin B1 (AFB1). Many aspects appertaining to AFB1 poisoning are not well understood. Yet this information is necessary to devise appropriate surveillance and mitigation strategies against human and animal aflatoxicosis. This review provides an in-depth update of work carried out on mycotoxin poisoning, particularly aflatoxicosis in humans and animals, to identify gaps in knowledge. Hypotheses explaining the functional significance of mycotoxins in fungal biology and their dietary epidemiological data are presented and briefly discussed. The toxicology of aflatoxins and the challenges of their mitigation are discussed in depth. It was concluded that the identification of potential mycotoxin-hazard-prone food items and quantification of the associated risk of cancer ailments in humans is a prime priority. There is a dearth of reliable sampling methodologies for estimating AFB1 in animal feed. Data update on AFB1 in animal feed and its implication in animal production, mitigation strategies, and elucidation of risk factors to this hazard is required. To reduce the burden of aflatoxins, surveillance employing predictive technology, and biocontrol strategies seem promising approaches.

Aflatoxin M1 levels in urine and breast milk of lactating mothers in Kuala Lumpur, Malaysia

Aflatoxins are carcinogens that can contaminate food and affect various body organs especially liver and kidney. When consumed, aflatoxin B1 (AFB1) is partially metabolised into aflatoxin M1 (AFM1), which is excreted in the urine. Breast milk may also contain AFM1 due to maternal dietary intake from contaminated food. This cross-sectional study aimed to determine the levels of AFM1 in both urine and breast milk among breastfeeding mothers (n = 256). The mother's demographic information was collected during recruitment. Mothers were then scheduled for an appointment to provide a morning urine sample along with five to ten mL samples of breast milk. AFM1 levels in both samples were analysed using an enzyme-linked immunosorbent assay (ELISA). Spearman's rho and Chi-square were used to determine the associations between mean levels of AFM1 in urine and breast milk. Findings show 68.0% of urine samples were contaminated with AFM1 (mean levels = 0.08 ± 0.04 ng/mL), while 14.8% of breast milk samples had AFM1 (mean levels = 5.94 ± 1.81 ng/kg). Urine AFM1 levels were not significantly associated with AFM1 levels in breast milk (p > 0.05). This study can act as a baseline for future research examining long-term aflatoxin exposure among both mothers and infants.

Cellular and molecular mechanisms of aflatoxin B1-mediated neurotoxicity: The therapeutic role of natural bioactive compounds

Aflatoxin B1 (AFB1), a dietary toxin from the mold Aspergillus species, is well acknowledged to elicit extra-hepatic toxicity in both animals and humans. The neurotoxicity of AFB1 has become a global public health concern. Contemporary research on how AFB1 enters the brain to elicit neuronal dysregulation leading to noxious neurological outcomes has increased greatly in recent years. The current review discusses several neurotoxic outcomes and susceptible targets of AFB1 toxicity at cellular, molecular and genetic levels. Specifically, neurotoxicity studies involving the use of brain homogenates, neuroblastoma cell line IMR-32, human brain microvascular endothelial cells, microglial cells, and astrocytes, as well as mammalian and non-mammalian models to unravel the mechanisms associated with AFB1 exposure are highlighted. Further, some naturally occurring bioactive compounds with compelling therapeutic effects on AFB1-induced neurotoxicity are reviewed. In conclusion, available data from literature highlight AFB1 as a neurotoxin and its possible pathological contribution to neurological disorders. Further mechanistic studies aimed at discovering and developing effective therapeutics for AFB1 neurotoxicity is warranted.

Quantitative assessment of aflatoxin exposure and hepatocellular carcinoma (HCC) risk associated with consumption of select Nigerian staple foods

Aflatoxin contamination of staple grains and legumes has been linked to hepatocellular carcinoma (HCC) and other adverse health outcomes, constituting a substantial public health concern globally. Low-resource food environments in sub-Saharan Africa are often under-regulated and are particularly vulnerable to adverse health and nutrition outcomes associated with aflatoxin exposure. This study identifies levels of HCC risk in the northern Nigerian adult population, leveraging a systematic review of available evidence on aflatoxin contamination in Nigerian maize, groundnut, rice, cowpea, and soybean. Estimated dietary intake (EDI) was computed using publicly available dietary consumption data and a probabilistic quantitative risk assessment was conducted to determine the relative risk of HCC associated with consumption of selected aflatoxin-contaminated commodities. In total, 41 eligible studies reporting aflatoxin contamination were used to model the distribution of aflatoxin concentrations in Nigerian commodities. EDIs for maize, groundnut, rice, and cowpea exceeded the provisional maximum tolerable daily intake (PMTDI) level of 1 kgbw-1 day-1, with maize yielding the highest mean EDI (36.7 kgbw-1 day-1). The quantitative risk assessment estimated that 1.77, 0.44, 0.43, 0.15, and 0.01 HCC cases per year/100,000 population were attributable to aflatoxin exposure through maize, groundnut, rice, cowpea, and soybean, respectively. Sensitivity analysis revealed that aflatoxin concentration, dietary consumption levels, consumption frequency, and other variables have differing relative contributions to HCC risk across commodities. These findings constitute a novel multi-study risk assessment approach in the Nigerian context and substantiate existing evidence suggesting that there is reason for public health concern regarding aflatoxin exposure in the Nigerian population.

A preliminary study on aflatoxin exposure by urine biomonitoring in Chile

We assessed the occurrence of aflatoxin M₁ (AFM₁) in urine in a sample of the MAUCO population-based cohort (n = 120) using an enzyme-linked immune sorbent assay (ELISA) kit specially designed for the analysis of AFM₁ in urine. We found AFM₁ in the urine of 59% of the participants (> limit of detection), with 12% of the samples being over the limit of quantification. The mean of the quantifiable samples was 0.66 (± 0.35) ng/mg adjusted creatinine, ranging from 0.31 to 1.39 ng/mg creatinine. The mean probable daily intake (PDI) of AFB₁ was 0.23 (± 0.37) ng/kg bw according to the upper bound (UB), being significantly higher in women and 0.14 (± 0.23) ng/kg bw in the modified lower bound (mLB) approach, ranging from 0.01 to 1.98 ng/kg bw. The risk of AFB₁ was assessed with the margin of exposure (MOE) approach estimated at 2800 in the mean mLB and 1733 in the mean UB. According to the MOE values obtained in this study, aflatoxin B₁ exposure must be considered a public health concern and must be taken as a priority for food risk management.

Validation of a HACCP community-based infants' complementary food safety assurance method in cash crop producing communities in Gedeo zone, Southern Ethiopia

A method based on a hazard analysis critical control point (HACCP)-based standard operating procedure (SOP) has been developed and implemented in community-based (CB) production of complementary foods (CFs) in agrarian regions in rural Ethiopia. The objective of this study was to validate the method in another setup, more specifically in cash crop (coffee and khat) producing communities in Southern Ethiopia. A quasi-experimental study was employed for the method validation. Two villages in the Gedeo zone, Southern Ethiopia were selected and a total of 40 mother-child pairs, 20 in each village, were involved in the study. Sociodemographic data, knowledge, and complementary feeding practices were collected using pretested questionnaires. The training was given to each mother for 1 h about community-based CFs production and implementation of the method. Then, 30 CF samples were collected and the level of aflatoxins (AFB1, AFB2, AFG1, and AFG2) was determined using a validated method. The majority (77.5%) of the mothers understand the importance of complementary feeding and give it to their infants beyond 6 months. Nearly two-thirds (62.5%) of the mothers had knowledge about the health impacts of aflatoxins, but the remaining 37.5% lacked awareness about the health risks of aflatoxins. Mothers were very well-motivated for the training and they promised to implement the knowledge and skill gained from the training for improving the nutritional status of their children. Overall, 23.3% of the CFs were contaminated by aflatoxins. AFB1 and AFG1 were detected in 6.7 and 16.7% of the CF samples, respectively. In cash crop-producing communities around the country, the HACCP-based SOP is easily validated in CB CFs production. Therefore, a scaleup of the method at the national level and beyond is recommended.

Mycotoxin exposure biomonitoring in breastfed and non-exclusively breastfed Nigerian children

A multi-specimen, multi-mycotoxin approach involving ultra-sensitive LC-MS/MS analysis of breast milk, complementary food and urine was applied to examine mycotoxin co-exposure in 65 infants, aged 1-18 months, in Ogun state, Nigeria. Aflatoxin M₁ was detected in breast milk (4/22 (18%)), while six other classes of mycotoxins were quantified; including dihydrocitrinone (6/22 (27%); range: 14.0-59.7 ng/L) and sterigmatocystin (1/22 (5%); 1.2 ng/L) detected for the first time. Seven distinct classes of mycotoxins including aflatoxins (9/42 (21%); range: 1.0-16.2 µg/kg) and fumonisins (12/42 (29%); range: 7.9-194 µg/kg) contaminated complementary food. Mycotoxins covering seven distinct classes with diverse structures and modes of action were detected in 64/65 (99%) of the urine samples, demonstrating ubiquitous exposure. Two aflatoxin metabolites (AFM₁ and AFQ₁) and FB₁ were detected in 6/65 (9%), 44/65 (68%) and 17/65 (26%) of urine samples, respectively. Mixtures of mycotoxin classes were common, including 22/22 (100%), 14/42 (33%) and 56/65 (86%) samples having 2-6, 2-4, or 2-6 mycotoxins present, for breast milk, complementary food and urine, respectively. Aflatoxin and/or fumonisin was detected in 4/22 (18%), 12/42 (29%) and 46/65 (71%) for breast milk, complimentary foods and urine, respectively. Furthermore, the detection frequency, median concentrations and occurrence of mixtures were typically greater in urine of non-exclusively breastfed compared to exclusively breastfed infants. The study provides novel insights into mycotoxin co-exposures in early-life. Albeit a small sample set, it highlights transition to higher levels of infant mycotoxin exposure as complementary foods are introduced, providing impetus to mitigate during this critical early-life period and encourage breastfeeding.

Analysis of Selected Mycotoxins in Maize from North-West South Africa Using High Performance Liquid Chromatography (HPLC) and Other Analytical Techniques

Contamination of foods by mycotoxins is linked to various health and economic implications. This study evaluated the incidence of mycotoxins in commercial and small-scale maize and evaluated potential health risks for consumers based on South African and international regulations. The sensitivity/specificity of HPLC over other analytical methods used was also ascertained. In total, 100 maize samples were analyzed using immuno-affinity column for extraction and clean-up, thin layer chromatography (TLC), HPLC, and enzyme linked immunosorbent assay (ELISA) for quantification. Results revealed that fumonisinB1 was the most contaminant mycotoxin in both small-scale and commercial samples with incidence rates of 100% and 98.6%, respectively. Aflatoxins contamination occurred at incidences of 26.7% in small-scale and 25.0% in commercial samples. Furthermore, ochratoxin A had high incidence rates of 97.8% and 93.0% and ranged from 3.60–19.44 µg/kg and 1.60–9.89 µg/kg, respectively, in small-scale and commercial samples, while ZEA occurred in 50% and 55% of small-scale and commercial samples, respectively. Results demonstrate that maize, especially from small-scale farmers, may contribute to dietary exposure to mycotoxins. Farmers and consumers should be alerted to the dangers of mycotoxins contamination in maize with resultant health risks. Additionally, HPLC method was also found to be more specific for mycotoxin detection than ELISA.

Aflatoxin Biosynthesis, Genetic Regulation, Toxicity, and Control Strategies: A Review

Aflatoxins (AFs) are highly toxic and cancer-causing compounds, predominantly synthesized by the Aspergillus species. AFs biosynthesis is a lengthy process that requires as minimum as 30 genes grouped inside 75 kilobytes (kB) of gene clusters, which are regulated by specific transcription factors, including aflR, aflS, and some general transcription factors. This paper summarizes the status of research on characterizing structural and regulatory genes associated with AF production and their roles in aflatoxigenic fungi, particularly Aspergillus flavus and A. parasiticus, and enhances the current understanding of AFs that adversely affect humans and animals with a great emphasis on toxicity and preventive methods.

Occurrence of aflatoxin M1 in human breast milk in Bangladesh

Breast milk is the best, most complete form of nutrition for newborns and infants. However, human milk can contain aflatoxin M₁ (AFM₁) upon ingestion of dietary mycotoxin contaminants, namely, aflatoxin B₁ (AFB₁), by lactating mothers. AFB₁ and its hydroxylated metabolite AFM₁ are potent carcinogens and thus an important issue in food safety and public health. This study is the first to explore the presence of AFM₁ in breast milk samples from Bangladesh and assess infant exposure to this toxin, as a consequence of maternal mycotoxin intake. A total of 62 breast milk samples were collected from nursing mothers in Sylhet region of Bangladesh. The milk samples were collected between October 2019 and March 2020 and analyzed by a sensitive enzyme-linked immunosorbent assay. AFM₁ was detected in 51.6% of the breast milk samples (colostrum, transitional and mature milk), with a mean concentration of 4.42 ± 0.56 pg/mL, and in the range between LOD (4.0 pg/mL) and 6.66 pg/mL. The frequent detection of AFM₁ in breast milk indicates widespread dietary exposure to mycotoxins in our cohort. The estimated average daily intake of AFM₁ for all nursed infants was 0.49 ng/kg b.w./day. No significant correlations were observed between AFM₁ levels in human milk and food items regularly consumed by nursing women. Overall, AFM₁ levels in breast milk samples from the Sylhet region of Bangladesh are moderate, and lower than the permissible levels established for AFM₁ in dairy milk or infant formulae (50 and 25 ng/kg, respectively). Yet, this first data for AFM₁ breast milk contaminant levels just reflect the recent situation in one cohort, and monitoring should be continued.

Complementary feeding in Kongwa, Tanzania: Findings to inform a mycotoxin mitigation trial

Complementary feeding of 6‐ to 24‐month‐old infants and young children with adequate, safe and developmentally appropriate food is essential to child health. Inappropriate complementary foods and feeding practices are linked to the high incidences of undernutrition among infant and young children in most developing countries, including Tanzania. Mycotoxin risk is an additional concern, given the documented presence of aflatoxin and fumonisin in food systems of Africa, especially maize and groundnut. In preparation for a trial of mycotoxin mitigation, we conducted focus group discussions and recipe trials to explore complementary foods and feeding practices in Kongwa, a rural district of central Tanzania. Sixty mothers of infants from 6 to 18 months of age in five villages across the district were purposefully sampled. During focus group discussions, mothers reported to mostly feed their children with cereal and groundnut‐based foods as thin or thick porridges. The most common porridge preparations contained cereal (mostly, maize) ranging from 66.7% to 80.0% by weight and groundnuts from 7.7% to 33.3%. The ratio of cereal to groundnut ranged from 3:1 to 4:1. For the recipe trial sessions, mothers chose similar ingredients reported during discussions to prepare complementary foods. The reliance on maize and groundnuts in complementary foods predisposes the children to undernutrition and exposure to aflatoxins and fumonisins. These formative research results suggest multiple intervention points to improve complementary feeding and reduce mycotoxin exposure in this population, including education messages package on feeding practices, mycotoxin control practices and complementary food formulation.

Development and Limitations of Exposure Biomarkers to Dietary Contaminants Mycotoxins

Mycotoxins are toxic secondary fungal metabolites that frequently contaminate cereal crops globally, presenting exposure hazards to humans and livestock in many settings. The heterogeneous distribution of mycotoxins in food restricts the usefulness of food sampling and intake estimates for epidemiological studies, making validated exposure biomarkers better tools for informing epidemiological investigations. While biomarkers of exposure have served important roles for understanding the public health impact of mycotoxins such as aflatoxins (AF), the science of biomarkers must continue advancing to allow for better understanding of mycotoxins' roles in the etiology of disease and the effectiveness of mitigation strategies. This review will discuss mycotoxin biomarker development approaches over several decades for four toxins of significant public health concerns, AFs, fumonisins (FB), deoxynivalenol (DON), and ochratoxin A (OTA). This review will also highlight some knowledge gaps, key needs and potential pitfalls in mycotoxin biomarker interpretation.

Metabolite V, an epoxide species is a minor circulating metabolite in humans following a single oral dose of deflazacort

Deflazacort (Emflaza) was approved in the United States in 2017 for the treatment of the Duchenne muscular dystrophy in patients aged 2 years and older. Several deflazacort metabolites were isolated and identified from rats, dogs, monkeys, and humans. Among them, 1ß,2ß-epoxy-3ß-hydroxy-21-desacetyl deflazacort, referred to as Metabolite V, was reported to be one of the major circulating metabolites in humans. However, its quantitative distribution in plasma was not fully characterized. The objective of this study was to determine deflazacort plasma pharmacokinetics, metabolite profiles and their quantitative exposures in humans following a single oral dose. Six healthy male subjects were each administered a single oral dose of 60 mg [14 C]-deflazacort. Plasma and urine were collected and deflazacort metabolites in plasma were quantified by high performance liquid chromatography radio-profiling followed by liquid chromatography-mass spectrometry characterization. Metabolite V was isolated from urine and its structure was further confirmed by nuclear magnetic resonance analysis. These analyses demonstrated that deflazacort was not detectable in plasma; of the eight circulating deflazacort metabolites identified or characterized, the pharmacologically active metabolite 21-desacetyl deflazacort and inactive metabolite 6ß-hydroxy-21-desacetyl deflazacort accounted for 25.0% and 32.9% of the 0-24 hours plasma total radioactivity, respectively, while Metabolite V, an epoxide species, was a minor circulating metabolite, representing only about 4.7% of the total plasma radioactivity.

Aflatoxin exposure among lactating women in southern Ethiopia

In Ethiopia and many other low-income countries, little is known about the exposure of lactating women to aflatoxin, which is a major health concern to the mother and her nursing infant. We determined the aflatoxin B1 contamination of family foods (AFB1) and urinary aflatoxin M1 (AFM1) of lactating women in Sidama, southern Ethiopia, and compared the levels across agroecological settings (lowland, midland, highland) and two seasons. We conducted two surveys (n = 360) that represented the dry and wet seasons of the locality. AFM1 and AFB1 were determined using enzyme-linked immunosorbent assay (ELISA). Statistical analysis was made using Mann-Whitney U test and Kruskal-Wallis test. The median (interquartile range) AFB1 was 0.94 (0.63-1.58) ppb. AFB1 was detected in 95.6% of the food samples, and 13.6% exceeded the 2.0 ppb threshold. We observed an increasing trend for aflatoxin exposure from highland to lowland (p < .001), but there was no difference between seasons (p = .743). The median (interquartile range) urinary AFM1 was 214 (undetectable to 2,582) ppt, and AFM1 was detectable in 53.3% of the samples. Urinary AFM1 showed significant difference among agroecological zones (p < .001) but not between seasons (p = .275). A significant but weak correlation was observed between AFB1 and urinary AFM1 (rs  = 0.177, p = .001). We concluded that lactating women in Sidama, especially those in the lowland area, have unsafe exposure to aflatoxin.

Determination of aflatoxin M1 and deoxynivalenol biomarkers in infants and children urines from Bangladesh

The mycotoxins aflatoxin B1 (AFB1) and deoxynivalenol (DON) are found worldwide in crops and dietary staples. The prevalence and levels of these contaminants can vary greatly, and data in Bangladeshi food commodities are scarce. To characterize human exposure, we have conducted biomonitoring, analyzing AFM1 (a metabolite of AFB1) and DON levels in urines of adult cohorts in Bangladesh. Yet, AFM1 and DON occurrence has not been studied in the very young population of this country. Thus, the same methods, HPLC-FD for AFM1 and LC-MS/MS for DON analysis, were now applied to determine these biomarkers in urines of infants (n = 49) and young children (n = 105) in Rajshahi and Dhaka district. Overall, AFM1 and DON detection frequency was 43.5% and 33.4%, with 34.7% and 11.5% in infant and 47.6% and 39.4% in children urines, respectively. The mean AFM1 levels in all infants (9.1 ± 14.3, max 55.6 pg/mL) and children (8.8 ± 12.9, max 75.3 pg/mL) were not significantly different. The AFM1 mean level was slightly higher in Dhaka (9.4 ± 12.4) compared to Rajshahi (8.5 ± 13.9 pg/mL) district. The average DON level was about 2-fold higher in infant (3.8 ± 2.9, max 6.8 ng/mL) than children urines (1.6 ± 1.8, max 8.6 ng/mL), and higher in Rajshahi (2.1 ± 2.3 ng/mL) than Dhaka (1.4 ± 1.6 ng/mL) district. The biomarker-based estimated average daily DON intake (29.6 ± 108.3 ng/kg bw in infants and 36.4 ± 81.8 ng/kg bw in children) or the maximum exposure (560 ng/kg bw) do not exceed the current maximum provisional tolerable daily intake value of 1 µg/kg bw for DON, although DON exposure in infants and children is higher than that of Bangladeshi adults. The AFM1 urine levels in young children are somewhat lower than those found previously in adult cohorts in Bangladesh, but the frequent detection of this biomarker for AFB1 exposure raises further concerns, also for this vulnerable part of the population. Therefore, continuous surveillance for aflatoxins in Bangladeshi food commodities is clearly required, first to identify major sources of intake and then to reduce exposure.

Protocol for the trial to establish a causal linkage between mycotoxin exposure and child stunting: a cluster randomized trial

Background

The number of stunted children has fallen globally but continues to increase in Africa. Stunting is estimated to contribute to 14–17% of child deaths under 5 years of age and is a risk factor for poor cognitive and motor development and educational outcomes. Inadequate dietary intake and disease are thought to be the immediate causes of undernutrition and stunting. However, improving infant diets through complementary feeding interventions has been shown to only modestly reduce stunting. Multiple observational studies demonstrate a dose response relationship between fetal and post-natal aflatoxin exposure and reduced linear growth.

Methods

This community-based cluster randomized trial will measure the effect of a reduced aflatoxin diet on length-for-age Z scores at 18 months in central Tanzania. All 52 health facilities in the Kongwa District of Dodoma Region were randomized into two groups. Starting at 6 months of age, participants in the intervention group receive a low-aflatoxin pre-blended porridge flour containing maize and groundnut (ratio 4:1 respectively) and low-aflatoxin groundnut flour, whereas in the control group the same porridge mix and groundnut flour are promoted through education but acquired by the household. Both groups will receive the same infant and young child feeding education and a thermos flask. A total of 3120 infants between 6 weeks and 3 months of age will be recruited into the study over 1 year. Data will be collected four times – at recruitment and when the infants are 6, 12 and 18 months of age. In a cohort of 600 infants, additional data will be collected at 9 and 15 months of age. The primary outcome is length-for-age at 18 months. Secondary outcomes include the Z scores for weight-for-age, middle upper arm circumference and head circumference, and the blood biomarker aflatoxin-albumin in the full sample, with the urine biomarker aflatoxin M1 analyzed in the cohort only.

Discussion

Better understanding the etiology of childhood stunting can lead to more appropriate interventions and policies to further reduce linear growth faltering and meet the Sustainable Development Goals.

Trial registration

NCT03940547, (April 24, 2019).

Dietary exposure assessment and risk characterization of mycotoxins in lactating women: Case study of São Paulo state, Brazil

The exposure and risk characterization of lactating women to aflatoxins (AFs), fumonisins (FBs), ochratoxin A (OTA) and zearalenone (ZEN) due to consumption of different types of food products in Pirassununga, São Paulo, Brazil, was assessed. Lactating women (N = 74) provided samples of foods stored and available at their households between April-August/2018, totaling 184 samples. Mycotoxins were determined in food samples by liquid chromatography-tandem mass spectrometry. According to findings, 20% (n = 36) of all food samples were contaminated with AFs at median concentrations ranging from 9.2 to 18.5 µg/kg, while OTA was detected only in three samples (rice, bread and pasta) at concentrations of 22.3, 23.8 and 48.7 µg/kg, respectively. ZEN was detected in 34 samples (18%) at median levels of 62-195 µg/kg, and FBs at median levels of 58-1546 µg/kg was observed in 22 samples (12%). Moreover, the concentration of AFs, OTA, ZEN and FBs exceeded their respective maximum permitted levels in 11 (6%), 3 (2%), 8 (4%) and 5 (3%) from total samples, respectively. Twenty-eight samples (15%) were contaminated with two or three types of mycotoxins. Corn products contributed for the highest mean probable daily intakes (PDI) of AFs (0.119 ± 0.193 µg/kg body weight (bw)/day), ZEN (0.325 ± 0.097 µg/kg bw/day) and FBs (2.936 ± 1.541 µg/kg bw/day), while wheat-based products contributed for the highest PDI of OTA (0.035 ± 0.028 µg/kg bw/day). The Margin of Exposure (MoE) value for AFs (3.72) demonstrated a high cancer risk (MoE < 10,000), and the Hazard Quotient (HQ) obtained for OTA (24.66), ZEN (4.24) and total FBs (5.01) also resulted in a non-tolerable risk (HQ > 1) via consumption of the investigated food products. Results of this trial indicate high exposure levels of lactating women to dietary mycotoxins in the studied area, which warrant concern about the possible transfer of residual mycotoxins into breast milk.

Aflatoxin exposure in utero and birth and growth outcomes in Tanzania

Some evidence suggests that aflatoxin may contribute to the high prevalence of stunting observed in low-income countries. Whereas several studies have been conducted in West Africa, fewer exist in East Africa and even fewer in nonagricultural contexts. We analyzed serum samples from 400 iron-replete, nonanemic pregnant women from a cohort in Dar es Salaam, Tanzania to determine the extent and magnitude of exposure to aflatoxin and to study the relationship between levels of aflatoxin exposure in utero and infant birth and growth outcomes. Ninety-nine percent of women had detectable concentrations of aflatoxin B1-lysine (AFB1-lysine), with a median level of 1.4-pg/mg albumin, indicating a much lower level compared to studies of rural populations in sub-Saharan Africa. Our results do not show a statistically significant relationship between AFB1-lysine levels and birth weight, small for gestational age, or prematurity. We observe a small statistically significant reduction in gestational age at delivery (0.47 weeks; 95% CI: -0.86, -0.07) as the natural log of AFB1-lysine levels increases by 1 unit of pg/mg of albumin, after controlling for potential confounders. Among a nonrandom set of infants who had measurements for placental weight, haemoglobin at delivery, and follow-up z-score measurements, we find no association between aflatoxin plasma concentrations and these variables. These findings suggest a high prevalence of chronic low-level exposure to aflatoxin, though its effect on birth outcomes in this population remains unclear. Our research adds to a growing body of literature finding mixed associations between aflatoxins on pregnancy outcomes and child growth.

Chronic and Acute Toxicities of Aflatoxins: Mechanisms of Action

There are presently more than 18 known aflatoxins most of which have been insufficiently studied for their incidence, health-risk, and mechanisms of toxicity to allow effective intervention and control means that would significantly and sustainably reduce their incidence and adverse effects on health and economy. Among these, aflatoxin B1 (AFB1) has been by far the most studied; yet, many aspects of the range and mechanisms of the diseases it causes remain to be elucidated. Its mutagenicity, tumorigenicity, and carcinogenicity-which are the best known-still suffer from limitations regarding the relative contribution of the oxidative stress and the reactive epoxide derivative (Aflatoxin-exo 8,9-epoxide) in the induction of the diseases, as well as its metabolic and synthesis pathways. Additionally, despite the well-established additive effects for carcinogenicity between AFB1 and other risk factors, e.g., hepatitis viruses B and C, and the hepatotoxic algal microcystins, the mechanisms of this synergy remain unclear. This study reviews the most recent advances in the field of the mechanisms of toxicity of aflatoxins and the adverse health effects that they cause in humans and animals.

Dietary determinants of aflatoxin B1-lysine adduct in pregnant women consuming a rice-dominated diet in Nepal

Background

Aflatoxins are found in diverse foods widely consumed worldwide. This study investigated the association between aflatoxin exposure and (a) consumption of specific foods, (b) dietary diversity (DD), and (c) seasonality.

Methods

Women enrolled in the AflaCohort Study in Banke, Nepal (n = 1648) were asked how often they ate certain food items in the past 7 days and 24 h. Serum aflatoxin B₁-lysine (AFB₁-lys) adduct levels, measured during pregnancy, were determined using high-performance liquid chromatography. Multivariable ordinary least squares and quantile regression models were used to examine incremental increases in AFB₁-lys adduct levels per frequency of food consumption and the relationship between DD, seasonality, and increases in AFB₁-lys adduct.

Results

Roughly 94% of women were exposed to aflatoxin (geometric mean 1.37 pg/mg). Women in the 30th, 50th, and 70th quantiles of aflatoxin exposure who reported one more occasion of maize consumption in the past week showed increases in AFB₁-lys adduct levels: 0.094, 0.112, and 0.109 pg/mg (p < 0.05, all). Women in the 30th, 50th, 70th, and 90th quantiles of exposure who reported one more occasion of groundnut consumption in the past week also showed increases in AFB₁-lys adduct levels: 0.058 (p < 0.001), 0.085 (p < 0.01), 0.133 (p < 0.001), and 0.133 (p < 0.001) pg/mg. Winter month recruitment was positively associated with AFB₁-lys adduct levels at all quantiles of aflatoxin exposure (range: 0.313–1.101 pg/mg, p < 0.001). DD was not predictive of aflatoxin exposure.

Conclusions

Our findings justify integrated approaches to aflatoxin reduction, including regulatory, agricultural, and food safety interventions across the value chain and at the household level.

Retrospective and Prospective Look at Aflatoxin Research and Development from a Practical Standpoint

Among the array of structurally and toxicologically diverse mycotoxins, aflatoxins have attracted the most interest of scientific research due to their high toxicity and incidence in foods and feeds. Despite the undeniable progress made in various aspects related to aflatoxins, the ultimate goal consisting of reducing the associated public health risks worldwide is far from being reached due to multiplicity of social, political, economic, geographic, climatic, and development factors. However, a reasonable degree of health protection is attained in industrialized countries owing to their scientific, administrative, and financial capacities allowing them to use high-tech agricultural management systems. Less fortunate situations exist in equatorial and sub-equatorial developing countries mainly practicing traditional agriculture managed by smallholders for subsistence, and where the climate is suitable for mould growth and aflatoxin production. This situation worsens due to climatic change producing conditions increasingly suitable for aflatoxigenic mould growth and toxin production. Accordingly, it is difficult to harmonize the regulatory standards of aflatoxins worldwide, which prevents agri-foods of developing countries from accessing the markets of industrialized countries. To tackle the multi-faceted aflatoxin problem, actions should be taken collectively by the international community involving scientific research, technological and social development, environment protection, awareness promotion, etc. International cooperation should foster technology transfer and exchange of pertinent technical information. This review presents the main historical discoveries leading to our present knowledge on aflatoxins and the challenges that should be addressed presently and in the future at various levels to ensure higher health protection for everybody. In short, it aims to elucidate where we come from and where we should go in terms of aflatoxin research/development.

Aflatoxin levels in maize and peanut and blood in women and children: The case of Timor-Leste

Aflatoxins are toxic fungal metabolites produced by Aspergillus sp. with carcinogenic properties that are a common food contaminant of many crops including maize and peanuts. In Timor-Leste malnutrition and children's stunting are frequent and maize and peanuts are staple foods. This study aimed to provide information on aflatoxin exposure nationally. The study measured levels of aflatoxin in locally-produced maize and peanuts (296 samples) and of aflatoxin-albumin conjugate in blood samples of women and young children (514 and 620 respectively) across all municipalities. The average concentration of aflatoxin in the grain samples was low with most maize (88%) and peanut (92%) samples - lower than European Commission tolerated aflatoxin level. Although aflatoxin-albumin conjugate was detected in more than 80% of blood samples, the average concentration in children and adults of 0.64 and 0.98 pg mg^-1 alb, respectively, is much lower than in other similar rural-based countries. Although low in concentration, blood aflatoxin levels and aflatoxin contamination levels in maize across municipalities were correlated significantly for mothers (R² = 37%, n = 495) but not for children (R² = 10%). It is unlikely that the consumption of aflatoxin contaminated grain is a causative factor in the current level of malnutrition and stunting affecting Timor-Leste children.

Effectiveness of hermetic maize grain storage technology in limiting aflatoxin exposure in women and children from smallholder farming areas

The longitudinal study assessed the effectiveness of hermetic storage technology in limiting aflatoxin exposure among women aged 15-45 years and children under five years of age from households in selected smallholder farming areas of Zimbabwe. Exposure levels were determined by measuring aflatoxin M1 (AFM1) in urine samples from women and children every three months during the 2015/2016 storage season for nine months. After extraction and immunoaffinity column clean up, AFM1 was determined by high performance liquid chromatography. Generally, the proportion of AFM1 positive urine samples from women increased throughout the grain storage season from 5.4% (n=23) (geometric mean (GM) 1.62 μg/l) at harvest to 75% (n=315) (GM 48.35 μg/l) nine months later (range <limit of quantification (LOQ)-217.29 μg/l). In urine samples from children, AFM1 positive samples increased from 2.2% (n=4) (GM 0.78 μg/l) at harvest to 72.5% (n=98) (GM 22.81 μg/l) nine months later (range <LOQ- 135.00 μg/l). Urinary AFM1 was significantly higher in samples from participants using conventional storage (GM 62.28 μg/l; range <LOQ-217.29 μg/l) compared with samples from participants using hermetic technology (GM 31.95 μg/l; range <LOQ-157.71 μg/l. There was no significant difference in AFM1 concentrations in urine samples from participants consuming grain from metal silos and hermetic bags (P>0.05) hence the two technologies are equally effective in limiting exposure to aflatoxins in humans. The study concluded that aflatoxin exposure levels among women and children from small-holder farming areas increase throughout the postharvest season and the use of hermetic storage technology resulted in up to 33.2% decrease in frequency of detection and 48.7% decrease in levels of AFM1 compared to conventional storage technologies. Thus hermetic grain storage can be an effective technology recommended for limiting aflatoxin exposure in smallholder farming populations.

Urinary aflatoxin exposure monitoring in rural and semi-urban populations in Ogun state, Nigeria

Aflatoxins are a major class of fungal toxins that have food safety importance due to their economic and health impacts. This pilot aflatoxin exposure biomonitoring study on 84 individuals was conducted in a rural (Ilumafon) and a semi-urban community (Ilishan Remo) of Ogun state, Nigeria, to compare aflatoxin exposures among the two population cohorts. First morning urine samples were obtained from the participants, and the urinary aflatoxin M1 (AFM1) levels were measured by a quantitative Helica Biosystems Inc. ELISA kit assay. About 99% (83 out of 84) of the urine samples had detectable AFM1 levels in the range of 0.06 to 0.51 ng mL-1 (median: 0.27 ng mL-1). The mean urinary AFM1 levels were significantly (p = 0.001) higher in the semi-urban population (0.31 ± 0.09 ng mL-1) compared to the rural population (0.24 ± 0.07 ng mL-1). There were, however, no significant differences in mean urinary AFM1 levels of males and females, and among children, adolescents and adults. This study indicates high aflatoxin exposure to the extent of public health concerns in the studied populations. Thus, more efforts are required for aflatoxin exposure monitoring and control in high-risk regions.

Aflatoxin-lysine adducts in blood serum of the Malawian rural population and aflatoxin contamination in foods (groundnuts, maize) in the corresponding areas

Aflatoxin-lysine (AFB₁-lys) adduct levels in blood samples collected from 230 individuals living in three districts of Malawi (Kasungu, Mchinji, and Nkhotakota) and aflatoxin B₁ (AFB₁) levels in groundnut and maize samples collected from their respective homesteads were determined using indirect competitive enzyme-linked immunosorbent assay (IC-ELISA) methods. AFB₁-lys adducts were detected in 67% of blood samples, with a mean concentration of 20.5 ± 23.4 pg/mg of albumin. AFB₁ was detected in 91% of groundnut samples and in 70% of maize samples, with mean AFB₁ levels of 52.4 and 16.3 μg/kg, respectively. All participants of this study reported consuming maize on a daily basis and consuming groundnuts regularly (mean consumption frequency per week: 3.2 ± 1.7). According to regression analysis, a frequency of groundnut consumption of more than four times per week, being female, and being a farmer were significant (p < 0.05) contributors to elevated AFB₁-lys adduct levels in the blood. This is the first report on AFB₁-lys adducts in blood samples of residents in Malawi. The results reinforce the urgent need for interventions, aiming at a reduction of aflatoxin exposure of the population.

How immediate and significant is the outcome of training on diversified diets, hygiene and food safety? An effort to mitigate child undernutrition in rural Malawi

Objective

The present study examined the impacts of training on nutrition, hygiene and food safety designed by the Nutrition Working Group, Child Survival Collaborations and Resources Group (CORE).

Design

Adapted from the 21d Positive Deviance/Hearth model, mothers were trained on the subjects of appropriate complementary feeding, water, sanitation and hygiene (WASH) practices, and aflatoxin contamination in food. To assess the impacts on child undernutrition, a randomised controlled trial was implemented on a sample of 179 mothers and their children (<2 years old) in two districts of Malawi, namely Mzimba and Balaka.

Settings

A 21d intensive learning-by-doing process using the positive deviance approach.

Subjects

Malawian children and mothers.

Results

Difference-in-difference panel regression analysis revealed that the impacts of the comprehensive training were positive and statistically significant on the Z-scores for wasting and underweight, where the effects increased constantly over time within the 21d time frame. As for stunting, the coefficients were not statistically significant during the 21d programme, although the level of significance started increasing in 2 weeks, indicating that stunting should also be alleviated in a slightly longer time horizon.

Conclusions

The study clearly suggests that comprehensive training immediately guides mothers into improved dietary and hygiene practices, and that improved practices take immediate and progressive effects in ameliorating children’s undernutrition.

Aflatoxin Exposure During Pregnancy, Maternal Anemia, and Adverse Birth Outcomes

Pregnant women and their developing fetuses are vulnerable to multiple environmental insults, including exposure to aflatoxin, a mycotoxin that may contaminate as much as 25% of the world food supply. We reviewed and integrated findings from studies of aflatoxin exposure during pregnancy and evaluated potential links to adverse pregnancy outcomes. We identified 27 studies (10 human cross-sectional studies and 17 animal studies) assessing the relationship between aflatoxin exposure and adverse birth outcomes or anemia. Findings suggest that aflatoxin exposure during pregnancy may impair fetal growth. Only one human study investigated aflatoxin exposure and prematurity, and no studies investigated its relationship with pregnancy loss, but animal studies suggest aflatoxin exposure may increase risk for prematurity and pregnancy loss. The fetus could be affected by maternal aflatoxin exposure through direct toxicity as well as indirect toxicity, via maternal systemic inflammation, impaired placental growth, or elevation of placental cytokines. The cytotoxic and systemic effects of aflatoxin could plausibly mediate maternal anemia, intrauterine growth restriction, fetal loss, and preterm birth. Given the widespread exposure to this toxin in developing countries, longitudinal studies in pregnant women are needed to provide stronger evidence for the role of aflatoxin in adverse pregnancy outcomes, and to explore biological mechanisms. Potential pathways for intervention to reduce aflatoxin exposure are urgently needed, and this might reduce the global burden of stillbirth, preterm birth, and low birthweight.

Aflatoxin M1 in human breast milk in southeastern Turkey

This study was performed to determine aflatoxin M₁ (AFM₁) in human breast milk samples collected in Şanlıurfa, located in Southeastern region of Turkey, and to investigate a possible correlation between AFM₁ occurrence (frequency and levels) and sampling seasons. Human breast milk samples collected in December 2014 and in June 2015 from a total of 74 nursing women, both outpatient and inpatient volunteers in hospitals located in Şanlıurfa, Turkey, were analyzed using competitive enzyme-linked immunosorbent assay (ELISA) for the presence of AFM₁. AFM₁ was detected in 66 (89.2%) out of 74 samples at an average concentration of 19.0 ± 13.0 ng/l (min.-max., 9.6-80 ng/l). There was a statistically significant difference between December and June concerning AFM₁ levels (p < 0.05). Further detailed studies will be needed to determine the main sources of aflatoxins in food, to establish protection strategies against maternal and infant exposure to these mycotoxins.

Adult height, nutrition, and population health

In this review, the potential causes and consequences of adult height, a measure of cumulative net nutrition, in modern populations are summarized. The mechanisms linking adult height and health are examined, with a focus on the role of potential confounders. Evidence across studies indicates that short adult height (reflecting growth retardation) in low- and middle-income countries is driven by environmental conditions, especially net nutrition during early years. Some of the associations of height with health and social outcomes potentially reflect the association between these environmental factors and such outcomes. These conditions are manifested in the substantial differences in adult height that exist between and within countries and over time. This review suggests that adult height is a useful marker of variation in cumulative net nutrition, biological deprivation, and standard of living between and within populations and should be routinely measured. Linkages between adult height and health, within and across generations, suggest that adult height may be a potential tool for monitoring health conditions and that programs focused on offspring outcomes may consider maternal height as a potentially important influence.

RNAi-mediated Control of Aflatoxins in Peanut: Method to Analyze Mycotoxin Production and Transgene Expression in the Peanut/Aspergillus Pathosystem

The Food and Agriculture Organization of the United Nations estimates that 25% of the food crops in the world are contaminated with aflatoxins. That represents 100 million tons of food being destroyed or diverted to non-human consumption each year. Aflatoxins are powerful carcinogens normally accumulated by the fungi Aspergillus flavus and A. parasiticus in cereals, nuts, root crops and other agricultural products. Silencing of five aflatoxin-synthesis genes by RNA interference (RNAi) in peanut plants was used to control aflatoxin accumulation following inoculation with A. flavus. Previously, no method existed to analyze the effectiveness of RNAi in individual peanut transgenic events, as these usually produce few seeds, and traditional methods of large field experiments under aflatoxin-conducive conditions were not an option. In the field, the probability of finding naturally contaminated seeds is often 1/100 to 1/1,000. In addition, aflatoxin contamination is not uniformly distributed. Our method uses few seeds per transgenic event, with small pieces processed for real-time PCR (RT-PCR) or small RNA sequencing, and for analysis of aflatoxin accumulation by ultra-performance liquid chromatography (UPLC). RNAi-expressing peanut lines 288-72 and 288-74, showed up to 100% reduction (p ≤ 0.01) in aflatoxin B1 and B2 compared to the control that accumulated up to 14,000 ng · g(-1) of aflatoxin B1 when inoculated with aflatoxigenic A. flavus. As reference, the maximum total of aflatoxins allowable for human consumption in the United States is 20 ng · g(-1). This protocol describes the application of RNAi-mediated control of aflatoxins in transgenic peanut seeds and methods for its evaluation. We believe that its application in breeding of peanut and other crops will bring rapid advancement in this important area of science, medicine and human nutrition, and will significantly contribute to the international effort to control aflatoxins, and potentially other mycotoxins in major food crops.

The Potential Role of Mycotoxins as a Contributor to Stunting in the SHINE Trial

Children in developing countries experience multiple exposures that are harmful to their growth and development. An emerging concern is frequent exposure to mycotoxins that contaminate a wide range of staple foods, including maize and groundnuts. Three mycotoxins are suspected to contribute to poor child health and development: aflatoxin, fumonisin, and deoxynivalenol. We summarize the evidence that mycotoxin exposure is associated with stunting, and propose that the causal pathway may be through environmental enteric dysfunction (EED) and disturbance of the insulin-like growth factor 1 (IGF-1) axis. The objectives of this substudy are to assess the relationship between agricultural and harvest practices and mycotoxin exposure; to evaluate associations between mycotoxin exposure and child stunting; and to investigate EED as a potential pathway linking mycotoxin exposure to child stunting, to inform potential areas for intervention.

Plasma Proteome Biomarkers of Inflammation in School Aged Children in Nepal

Inflammation is a condition stemming from complex host defense and tissue repair mechanisms, often simply characterized by plasma levels of a single acute reactant. We attempted to identify candidate biomarkers of systemic inflammation within the plasma proteome. We applied quantitative proteomics using isobaric mass tags (iTRAQ) tandem mass spectrometry to quantify proteins in plasma of 500 Nepalese children 6–8 years of age. We evaluated those that co-vary with inflammation, indexed by α-1-acid glycoprotein (AGP), a conventional biomarker of inflammation in population studies. Among 982 proteins quantified in >10% of samples, 99 were strongly associated with AGP at a family-wise error rate of 0.1%. Magnitude and significance of association varied more among proteins positively (n = 41) than negatively associated (n = 58) with AGP. The former included known positive acute phase proteins including C-reactive protein, serum amyloid A, complement components, protease inhibitors, transport proteins with anti-oxidative activity, and numerous unexpected intracellular signaling molecules. Negatively associated proteins exhibited distinct differences in abundance between secretory hepatic proteins involved in transporting or binding lipids, micronutrients (vitamin A and calcium), growth factors and sex hormones, and proteins of largely extra-hepatic origin involved in the formation and metabolic regulation of extracellular matrix. With the same analytical approach and the significance threshold, seventy-two out of the 99 proteins were commonly associated with CRP, an established biomarker of inflammation, suggesting the validity of the identified proteins. Our findings have revealed a vast plasma proteome within a free-living population of children that comprise functional biomarkers of homeostatic and induced host defense, nutrient metabolism and tissue repair, representing a set of plasma proteins that may be used to assess dynamics and extent of inflammation for future clinical and public health application.