Geophagy is associated with environmental enteropathy and stunting in children in rural Bangladesh

Assessing E. coli levels in surface soils of informal settlements using boot sock and standard grab methods

Rapid urbanization leads to the growth of informal settlements, where inadequate sanitation infrastructure is common, thus promoting environmental contamination and risk of gastrointestinal infection. Soil contamination contributes to the transmission of enteropathogens, but traditional sampling approaches may poorly indicate public health risks due to limited spatial representation. This study compares traditional grab sampling of soil with a boot sock method, a composite technique designed to better reflect human-pathogen interactions. The boot sock method provided more sensitive detection of E. coli and lower inter-replicate variation compared to grab samples. Post hoc power analyses indicated that the boot sock technique required fewer samples to achieve adequate spatial representation across a sampling area than grab samples, potentially improving time and cost efficiency in pathogen exposure risk estimation.

Dirt floors and domestic animals are associated with soilborne exposure to antimicrobial resistant E. coli in rural Bangladeshi households

Soil can harbor enteropathogens and antimicrobial-resistant organisms in settings with domestic animals. We enrolled 49 households with young children (28 soil floors, 21 concrete floors) in Bangladesh and recorded animal ownership/management. Staff swabbed the floor of children's sleeping area with a sterile sponge and collected floor dust and a child hand rinse. We used IDEXX QuantiTray/2000 with and without cefotaxime supplementation to enumerate cefotaxime-resistant and generic E. coli . There was 8.0 g/m 2 of dust on soil floors vs. 0.2 g/m 2 on concrete floors (p-value=0.005). We detected E. coli on 100% of soil vs. 86% of concrete floors and cefotaxime-resistant E. coli on 89% of soil vs. 43% of concrete floors (p-values<0.05). Cefotaxime-resistant E. coli prevalence on floors was 36% in compounds without animals, 79% in compounds with animals and 100% if animals stayed indoors overnight or the floor had animal feces; associations were strongest for chickens. In multivariable models, generic and cefotaxime-resistant E. coli counts were 1.5-2 log higher on soil vs. concrete floors, and counts on floors and child hands were 0.17-0.24 log higher for every 10 additional chickens owned (p-values<0.05). Efforts to mitigate infections and antimicrobial resistance in low-income countries should test flooring improvements and hygienic animal management.

Synopsis

In rural Bangladeshi households, generic and cefotaxime-resistant E. coli were more common on soil floors than concrete floors and among households with higher cohabitation intensity with domestic animals, especially chickens.

Isolation and characterization of cefotaxime resistant Escherichia coli from household floors in rural Bangladesh

Antimicrobial resistance (AMR) is a rising health concern worldwide. As an indicator organism, E. coli, specifically extended-spectrum β-lactamase (ESBL) producing E. coli, can be used to detect AMR in the environment and estimate the risk of transmitting resistance among humans, animals and the environment. This study focused on detecting cefotaxime resistant E. coli in floor swab samples from 49 households in rural villages in Bangladesh. Following isolation of cefotaxime resistant E. coli, DNA extracted from isolates was subjected to molecular characterization for virulence and resistance genes, determination of resistance to multiple classes of antibiotics to define multidrug resistant (MDR) and extensively drug resistant (XDR) strains, and the biofilm forming capacity of the isolates. Among 49 households, floor swabs from 35 (71 %) households tested positive for cefotaxime resistant E. coli. Notably, all of the 91 representative isolates were ESBL producers, with the majority (84.6 %) containing the bla CTX-M gene, followed by the bla TEM and bla SHV genes detected in 22.0 % and 6.6 % of the isolates, respectively. All isolates were MDR, and one isolate was XDR. In terms of pathogenic strains, 8.8 % of the isolates were diarrheagenic and 5.5 % were extraintestinal pathogenic E. coli (ExPEC). At 25 °C, 45 % of the isolates formed strong biofilm, whereas 43 % and 12 % formed moderate and weak biofilm, respectively. On the other hand, at 37 °C, 1.1 %, 4.4 % and 93.4 % of the isolates were strong, moderate and weak biofilm formers, respectively, and 1.1 % showed no biofilm formation. The study emphasizes the importance of screening and characterizing cefotaxime resistant E. coli from household floors in a developing country setting to understand AMR exposure associated with floors.

Animal Handling Practice Among Rural Households in Northwest Ethiopia Increases the Risk of Childhood Diarrhea and Exposure to Pathogens From Animal Sources

Background

In Ethiopia, domestic animals and their feces are not properly contained. However, the risk of exposure to zoonotic pathogens is not well documented. This study was conducted to assess animal handling practices and the risk of childhood diarrhea among rural households in northwest Ethiopia.

Methods

This study was done among 403 randomly selected households. Information on animal handling was collected using a questionnaire and spot-check observation. The occurrence of childhood diarrhea in 14 days prior to the survey was assessed based on the reports of female head of households. Multivariable binary logistic regression analysis was performed to identify the association between animal handling practices and childhood diarrhea.

Results

All the female head of households had contact with animal feces when preparing fuel disks and plastering the house components with animal dung. Domestic animals shared a corral within the living space of the humans in 20% of the households. Animals entered the human living quarters and accessed foods in 32% of the households. Moreover, 24% of the children aged 24 to 59 months had diarrhea in a 2-week period prior to the survey. Childhood diarrhea was associated with domestic animals sharing the same house as humans (AOR: 3.3, 95% CI: 1.3, 8.6), presence of animal excreta in child playing areas (AOR: 2.4, 95% CI: 1.2, 4.6), contact of domestic animals with stored foods (AOR: 3.5, 95% CI: 2.0, 5.9), trapped dirt under fingernails of female heads (AOR: 3.7, 95% CI: 1.9, 7.5), open defecation (AOR: 3.24, 95% CI: 1.8, 5.9), and unprotected sources (AOR: 4.2, 95% CI: 1.1, 15.3).

Conclusion

Domestic animals and their excreta are not hygienically contained in the area. Animal handling practices including their excreta and the hygiene behavior of female head of households (eg, handwashing and food handling practices) should be improved to prevent childhood diarrhea.

Perspective: Connecting the dots between domestic livestock ownership and child linear growth in low- and middle-income countries

Child stunting due to linear growth faltering remains a pervasive issue in low- and middle-income countries. Two schools of thought have existed pertaining to the role of domestic livestock ownership (DLO) in child linear growth. On one hand, it is argued that DLO leads to greater income and financial security, resulting in better child-raising conditions, including greater animal-source food (ASF) consumption, having protective effects towards child stunting. On the other hand, researchers argue that DLO contributes to faecal contamination and transmission of zoonotic enteric infections from animals to children, thus having destructive effects on child growth. Reviews of this association have revealed ambiguous findings. In this perspective, we argue that measuring the association between exposures to domesticated animals and child stunting is difficult and the ambiguous associations revealed are a result of confounding and differences in the management of DLO. We also argue that the increasingly prominent area of research of environmental enteric dysfunction, a sub-clinical condition of the small intestine thought to be due to frequent faecal pathogen exposure and associated with stunting, will be a useful tool to measure the potential destructive effects of DLO on child growth. We present our argument and identify challenges and considerations and directions for future research.

Revisiting geophagy: An evolved sickness behavior to microbiome-mediated gastrointestinal inflammation

Geophagy, the consumption of clay or similar substances, is known as an evolved behavior that protects vulnerable populations, such as pregnant women and children, against gastrointestinal injury. However, perplexing questions remain, like the presence of geophagy in the absence of overt gastrointestinal infection and the potential causal relationship between geophagy and iron deficiency anemia. In this review, we hypothesize that geophagy is an inflammation-mediated sickness behavior regulated via the vagus nerve. We further hypothesize that the gut microbiome plays a critical role in mediating the relationship between inflammation and geophagy. By including inflammation and the microbiome within the existing protection hypothesis, we can explain how subclinical gastrointestinal states induce geophagy. Furthermore, we can explain how gastrointestinal inflammation is responsible for both geophagy and iron-deficiency anemia, explaining why the two phenomena frequently co-occur. Ultimately, defining geophagy as a sickness behavior allows us to integrate the gut-brain axis into geophagy research.

Effect of a Homestead Food Production and Food Hygiene Intervention on Biomarkers of Environmental Enteric Dysfunction in Children Younger Than 24 Months in Rural Bangladesh: A Cluster-Randomized Controlled Trial

Poor sanitation and hygiene practices and inadequate diets can contribute to environmental enteric dysfunction (EED). We evaluated the impact of a combined homestead food production and food hygiene intervention on EED biomarkers in young children in rural Bangladesh. The analysis was conducted within the Food and Agricultural Approaches to Reducing Malnutrition (FAARM) cluster-randomized trial in Sylhet, Bangladesh. The FAARM trial enrolled 2,705 married women and their children younger than 3 years of age in 96 settlements (geographic clusters): 48 intervention and 48 control. The 3-year intervention (2015-2018) included training on gardening, poultry rearing, and improved nutrition practices and was supplemented by an 8-month food hygiene behavior change component, implemented from mid-2017. We analyzed data on 574 children age 0 to 24 months with multilevel linear regression. We assessed fecal myeloperoxidase (MPO), neopterin (NEO), and alpha-1-antitrypsin (AAT) as biomarkers of EED, and serum C-reactive protein (CRP) and alpha-1-acid glycoprotein (AGP) as biomarkers of systemic inflammation, using ELISA. There was no intervention effect on NEO, AAT, CRP, and AGP concentrations, but, surprisingly, MPO levels were increased in children of the intervention group (0.11 log ng/mL; 95% CI, 0.001-0.22). This increase was greater with increasing child age and among intervention households with poultry that were not kept in a shed. A combined homestead food production and food hygiene intervention did not decrease EED in children in our study setting. Small-scale poultry rearing promoted by the intervention might be a risk factor for EED.

Effects of an integrated poultry value chain, nutrition, gender and WASH intervention (SELEVER) on hygiene and child morbidity and anthropometry in Burkina Faso: A secondary outcome analysis of a cluster randomised trial

Nutrition-sensitive agriculture programmes have the potential to improve child nutrition outcomes, but livestock intensification may pose risks related to water, sanitation and hygiene (WASH) conditions. We assessed the impact of SELEVER, a nutrition- and gender-sensitive poultry intervention, with and without added WASH focus, on hygiene practices, morbidity and anthropometric indices of nutrition in children aged 2-4 years in Burkina Faso. A 3-year cluster randomised controlled trial was implemented in 120 villages in 60 communes (districts) supported by the SELEVER project. Communes were randomly assigned using restricted randomisation to one of three groups: (1) SELEVER intervention (n = 446 households); (2) SELEVER plus WASH intervention (n = 432 households); and (3) control without intervention (n = 899 households). The study population included women aged 15-49 years with an index child aged 2-4 years. We assessed the effects 1.5-years (WASH substudy) and 3-years (endline) post-intervention on child morbidity and child anthropometry secondary trial outcomes using mixed effects regression models. Participation in intervention activities was low in the SELEVER groups, ranging from 25% at 1.5 years and 10% at endline. At endline, households in the SELEVER groups had higher caregiver knowledge of WASH-livestock risks (∆ = 0.10, 95% confidence interval [CI] [0.04-0.16]) and were more likely to keep children separated from poultry (∆ = 0.09, 95% CI [0.03-0.15]) than in the control group. No differences were found for other hygiene practices, child morbidity symptoms or anthropometry indicators. Integrating livestock WASH interventions alongside poultry and nutrition interventions can increase knowledge of livestock-related risks and improve livestock-hygiene-related practices, yet may not be sufficient to improve the morbidity and nutritional status of young children.

Factors Associated with Carriage of Enteropathogenic and Non-Enteropathogenic Viruses: A Reanalysis of Matched Case-Control Data from the AFRIBIOTA Site in Antananarivo, Madagascar

Environmental Enteric Dysfunction (EED) is an associate driver of stunting in poor settings, and intestinal infections indirectly contribute to the pathophysiology underlying EED. Our work aimed at assessing whether enteric viral carriage is determinant to stunting. A total of 464 healthy and asymptomatic children, aged 2 to 5 years, were recruited, and classified as non-stunted, moderately stunted, or severely stunted. Among the recruited children, 329 stool samples were obtained and screened for enteric and non-enteric viruses by real-time polymerase chain reaction. We statistically tested for the associations between enteric viral and potential risk factors. Approximately 51.7% of the stool samples were positive for at least one virus and 40.7% were positive for non-enteric adenoviruses. No statistical difference was observed between virus prevalence and the growth status of the children. We did not find any statistically significant association between viral infection and most of the socio-demographic risk factors studied, except for having an inadequate food quality score or an over-nourished mother. In addition, being positive for Ascaris lumbricoides was identified as a protective factor against viral infection. In conclusion, we did not find evidence of a direct link between stunting and enteropathogenic viral carriage in our population.

Environmental enteropathy and its association with water sanitation and hygiene in slum areas of Jimma Town Ethiopia

BACKGROUND

Environmental Enteropathy is an inflammatory condition of the gut that leads to intestinal barrier dysfunction. It is a common problem in resource-limited countries and results from exposure to larger quantities of fecal bacteria to poor personal hygiene and environmental sanitation. Due to poor intestinal permeability, there is a problem with absorption of nutrients, which in turn leads to growth faltering, poor cognitive development, and oral-vaccine failure. The aim of this study was to identify the children with an elevated lactulose to mannitol ratio (indicative of possible environmental enteropathy) and its association with water sanitation and hygiene in slum areas of Jimma Town so as to mitigate the problem of malnutrition in under-five children.

METHODS

A community-based cross-sectional study was carried out from January to April 2021. A Lactulose mannitol test was performed to determine the prevalence of elevated lactulose to mannitol ratio (possibly environmental enteropathy) in children aged 12 to 59 months. A pretested questionnaire was used to collect data on water sanitation and hygiene (WASH) indicators and sociodemographic characteristics. A multivariable logistic regression analysis was used to isolate independent predictors for possible environmental enteropathy. All tests were two-sided and statistical significance was declared at P<0.05.

RESULTS

The results of this study showed that 19.3% (95%CI: 14.8-23.7) of children had an increased lactulose to mannitol ratio (>0.15). On multivariable logistic regression analysis, the variables drinking water from unimproved water sources (AOR 3.741; 95%CI: 0.914-15.310,p = 0.048), unsafe coverage of water storage (AOR 0.363; 95%CI: 0.169-0.777, P = 0.009), public latrine utilization (AOR 0.139 95%CI: 0.024-0.816, P = 0.029),and hand washing less than 3 critical time of hand washing practices (AOR 4.369;95%CI: 1.411-13.524,P = 0.011) were significantly associated with an increased in lactulose mannitol ratio (possible indicative of intestinal permeability/environmental enteropathy).

CONCLUSION

This study showed that one fifth of under-five children in Jimma Town had an elevated lactulose to mannitol ratio (possibly environmental enteropathy). The WASH sectors and other governmental organizations should give emphasis to areas with poor water sanitation and hygiene to mitigate the problem of environmental enteropathy and related consequences like growth faltering, poor cognitive development, and oral-vaccine failure in the study area.

Food Hygiene and Fecal Contamination on the Household Compound are Associated with Increased Pediatric Diarrhea in Urban Bangladesh (CHoBI7 Program)

In this prospective cohort study, we explored individual- and household-level risk factors associated with diarrheal diseases among 251 children younger than 5 years in slum areas of urban Dhaka, Bangladesh. During the 3-month study period, diarrhea surveillance was conducted monthly, and spot checks of the household compound were performed at baseline to assess the presence of feces (animal or human) in the household compound and in cooking and food storage areas, and to assess whether cooked food was covered and refrigerated. We also collected caregiver reports on child mouthing behaviors. Children living in households with feces within 10 steps of cooking and food storage areas (odds ratio [OR], 8.43; 95% CI, 1.01-70.18), those with visible feces found on the ground of the household compound (OR, 4.05; 95% CI, 1.24-13.22), and those in households found to keep cooked food uncovered and without refrigeration (OR, 6.16; 95% CI, 1.11-34.25) during spot checks had a significantly greater odds of diarrhea. There was no significant association between pediatric diarrhea and caregiver-reported child mouthing behaviors or presence of animals in the cooking area. These study findings demonstrate that presence of visible feces in the household compound and near cooking and food storage areas, and poor household food hygiene practices, were significant risk factors for diarrheal disease among young children in Dhaka, Bangladesh. Health communication programs are needed to target these exposure pathways to fecal pathogens.

Current status of research and gaps in knowledge of geophagic practices in Africa

This article synthesises current knowledge and identifies research gaps on the still intriguing aspects of the subject of geophagy as practised in Africa. Despite the voluminous research literature that exists on the subject, geophagy in Africa is still a largely misunderstood phenomenon. Although the practice is not confined to any particular age group, race, gender, or geographical region, in Africa it is most commonly recorded among pregnant women and children. Till now, the precise aetiology of geophagy remains obscure; but the practice is thought to have both beneficial effects such as having a role as a nutrient supplement, as well as several demerits. An updated critical review of human geophagy in Africa - with a section on (other) animal geophagy -, highlights several aspects of the practice that need further research. A comprehensive bibliography is assembled, comprising some of the more pertinent and recently published papers (mostly post-dating the year 2005), as well as older seminal works, providing a baseline and robust framework for aiding the search process of Medical Geology researchers and those from allied fields wanting to explore the still poorly understood aspects of geophagy in Africa.

Environmental Enteropathy and Anaemia Status Among Under-Five Children, in Slum Areas of Jimma Town, Ethiopia

Background

The most important anemia next to iron deficiency is anemia of inflammation. Micronutrient deficits, such as those in zinc and iron, can be caused by intestinal permeability and gut inflammation brought on by environmental enteric dysfunction. This study was aimed to evaluate the prevalence and association of anemia with Environmental Enteropathy.

Methods

Data on water sanitation and hygiene indicators and sociodemographic characteristics were collected using structured questionnaire. The lactulose to mannitol ratio (L:M) was calculated from the concentration of both sugars in the urine. Level of Hemoglobin was detected by using Hemocue-301 digital photometer. Blood and urine sample was collected from three hundred children aged 12-59 months to determine the status of Anaemia and Environmental Enteropathy respectively.

Results

Data were analyzed by using Descriptive statistics, cross-tabulation, and logistic regression model to indicate prevalence and association of anemia with environmental Enteropathy in children less than five years old. The prevalence of anemia in children with environmental enteropathy was 63.8% (95% CI: 57.6, 71.7), and there was a significant association (p = 0.0001, AOR 3.502, 95% CI: 1.929-6.371) between anemia and environmental enteropathy. In a multivariate analysis, children aged 1-3 years with caretakers who had no or only primary education and with monthly income of less than 3000 ETB were more likely to develop anemia.

Conclusion

The result of this study indicated that two-thirds of children less than five with environmental enteropathy had developed anemia, and there is a significant association between environmental enteropathy and anemia. Even though there are other causes of anemia, based on the findings of this study, more research is needed to identify factors associated with environmental enteropathy to mitigate anemia due to intestinal permeability or malabsorption and its impact in children under the age of five.

Protocol for a parallel group, two-arm, superiority cluster randomised trial to evaluate a community-level complementary-food safety and hygiene and nutrition intervention in Mali: the MaaCiwara study (version 1.3; 10 November 2022)

BACKGROUND

Diarrhoeal disease remains a significant cause of morbidity and mortality among the under-fives in many low- and middle-income countries. Changes to food safety practices and feeding methods around the weaning period, alongside improved nutrition, may significantly reduce the risk of disease and improve development for infants. We describe a protocol for a cluster randomised trial to evaluate the effectiveness of a multi-faceted community-based educational intervention that aims to improve food safety and hygiene behaviours and enhance child nutrition.

METHODS

We describe a mixed-methods, parallel group, two-arm, superiority cluster randomised controlled trial with baseline measures. One hundred twenty clusters comprising small urban and rural communities will be recruited in equal numbers and randomly allocated in a 1:1 ratio to either treatment or control arms. The community intervention will be focussed around an ideal mother concept involving all community members during campaign days with dramatic arts and pledging, and follow-up home visits. Participants will be mother-child dyads (27 per cluster period) with children aged 6 to 36 months. Data collection will comprise a day of observation and interviews with each participating mother-child pair and will take place at baseline and 4 and 15 months post-intervention. The primary analysis will estimate the effectiveness of the intervention on changes to complementary-food safety and preparation behaviours, food and water contamination, and diarrhoea. Secondary outcomes include maternal autonomy, enteric infection, nutrition, child anthropometry, and development scores. A additional structural equation analysis will be conducted to examine the causal relationships between the different outcomes. Qualitative and health economic analyses including process evaluation will be done.

CONCLUSIONS

The trial will provide evidence on the effectiveness of community-based behavioural change interventions designed to reduce the burden of diarrhoeal disease in the under-fives and how effectiveness varies across different contexts.

TRIAL REGISTRATION

ISRCTN14390796. Registration date December 13, 2021.

Stunting among children aged 24-59 months and associations with sanitation, enteric infections, and environmental enteric dysfunction in rural northwest Ethiopia

Stunting is a public health issue of global concern. Despite, poor sanitation, diarrhea, parasitic infections, and environmental enteric dysfunction (EED) are associated with stunting, their link is poorly understood and has not been investigated in Ethiopia. This study was conducted to assess the associations of stunting with sanitation, enteric infections, and EED among children aged 24-59 months in rural northwest Ethiopia. A community-based cross-sectional study was conducted among 224 randomly selected children aged 24-59 months in rural areas of the east Dembiya district. We collected information on household food insecurity and dietary diversity using pre-tested questionnaires adopted from the food and nutrition technical assistance (FANTA) project. We used height-for-age-z score (HAZ) to define stunting. We also used the data collected to measure the environmental exposures of children to intestinal parasitic infections and fecal biomarkers of EED. A multivariable binary logistic regression model was used to assess the association of stunting with sanitation, enteric infections, and EED. Of the 224 children, 33% (95% CI 27, 39%) were stunted. Stunting in children was significantly associated with poor dietary intake (AOR 3.0, 95% CI 1.2, 7.3), open defecation practice (AOR 3.0, 95% CI 1.2, 7.9), presence of animal excreta in the living environment (AOR 3.4, 95% CI 1.2, 9.9), E. coli contamination of drinking water (AOR 4.2, 95% CI 1.1, 15.3), diarrheal disease incidence (AOR 3.4, 95% CI 1.5, 7.7), intestinal parasites in children (AOR 3.3, 95% CI 1.3, 8.8), and higher EED disease activity scores (AOR 2.9, 95% CI 1.2, 6.7). One-third of the children in the study area were stunted and this high prevalence of stunting was associated with poor dietary intake, poor hygiene and sanitation conditions, enteric infections, and EED. Thus, stunting can be prevented by improving sanitation and hygienic conditions to prevent repeated enteric infections in children and by promoting dietary diversity of children.

Iron deficiency and soil-transmitted helminth infection: classic and neglected connections

Beyond participating in the oxygen transport by red blood cells, iron is an essential micronutrient and contributes to different physiological pathways and processes, such as cell proliferation, DNA repair, and other homeostatic functions. Iron deficiency affects millions of people, especially children and pregnant women. The consequences of iron deficiency are diverse, including inadequate child development, impaired cognition, and reduced productivity. Several factors contribute to iron deficiency, such as iron-poor diet, genetic factors, and infection with soil-transmitted helminths (STHs), especially roundworms (Ascaris lumbricoides), hookworms (Necator americanus and Ancylostoma duodenale), and whipworms (Trichuris trichiura). This review updates and summarizes the role of STHs as drivers of iron deficiency. Also, the poorly explored connections between STH infection, geophagia (a pica manifestation), immune response, and iron deficiency are discussed, highlighting how iron deficiency may act as a risk factor for infections by STHs, in addition to being a consequence of intestinal parasitic infections. Finally, strategies for control and management of iron deficiency and STH infection are described.

Gut biomolecules (I-FABP, TFF3 and lipocalin-2) are associated with linear growth and biomarkers of environmental enteric dysfunction (EED) in Bangladeshi children

In the current world, a major challenge to diagnose environmental enteric dysfunction (EED) is the lack of validated non-invasive biomarkers. Intestine derived molecules, including intestinal fatty acid binding protein (I-FABP), trefoil factor-3 (TFF3), lactoferrin, lipocalin-2 (LCN2), and mucin-2, have been reported as indicators of intestinal inflammation and gut health. Therefore, we aimed to investigate the levels of these bio-molecules as biomarkers of EED among under-2 children in Bangladesh. A total of 140 children were recruited in a case-control design. All the biomarkers were measured by ELISA. Spearman's rank correlation was performed to see the correlation between the biomarkers and the EED score. Moreover, multivariable linear regression was performed to investigate the association of biomarkers with length-for-age z-score (LAZ). TFF3 correlates positively with myeloperoxidase (r = 0.26, p < 0.05) and EED score (r = 0.17, p < 0.05). Likewise, LCN2 correlates positively with myeloperoxidase (r = 0.37, p < 0.05), neopterin (r = 0.33, p < 0.05) and EED score (r = 0.31, p < 0.05). Moreover, multivariable linear regression revealed a negative association of I-FABP with LAZ of the study participants. Our results imply that TFF3 and LCN2 might be promising biomarkers to diagnose intestinal inflammation and EED, while I-FABP is negatively associated with linear growth of Bangladeshi children.

Fecal Sampling of Soil, Food, Hand, and Surface Samples from Households in Urban Slums of Dhaka, Bangladesh: An Evidence-Based Development of Baby Water, Sanitation, and Hygiene Interventions

The aim of this study was to identify the exposure pathways of fecal pathogens for a pediatric population living in the urban slums of Bangladesh. A total of 252 soil, food, surface, and hand rinse samples were collected from the pilot households with children less than 5 years of age. All samples were analyzed using the IDEXX Quanti-Tray System (Colilert-18) to enumerate fecal indicator bacteria Escherichia coli. Escherichia coli was detected in all soil samples collected from children play spaces (N = 46), 35% of objects and surfaces children frequently put in their mouths, and 31% of child food samples. Thirty-three percent of hand samples from the child and 46% of hand samples from the caregiver had detectable E. coli. These findings showed high fecal contamination of soil, food, and on hands and surfaces in households with young children and demonstrate the need for interventions reducing these exposure pathways for susceptible pediatric populations.

Association between intestinal bacterial carriage, biomarkers of environmental enteric dysfunction, and stunting in rural Malawian children

Background. Available data from murine studies suggest that intestinal bacteria may have a role in modulating growth phenotypes in the host. We investigated the prevalence of four gut bacteria known in murine models to impair growth (Bifidobacterium longum, Faecalibacterium prausnitzii, Dorea formicigenerans, and Akkermansia muciniphila), the level of fecal biomarkers of environmental enteric dysfunction (EED) and stunting in rural Malawian children. Methods. DNA and protein were extracted from fecal samples of rural Malawian children (aged 1-59 months) at a baseline cross-sectional survey in the Mangochi district of Malawi conducted within the framework of the Macrolides Oraux pour Réduire les Décès avec un Oeil sur la Résistance (MORDOR) trial. Intestinal carriage of bacteria was measured by PCR. Neopterin (NEO), myeloperoxidase (MPO), and alpha-1 antitrypsin (AAT), biomarkers of EED, were measured by an enzyme-linked immunosorbent assay (ELISA) test. Height-for-age Z (HAZ) score <-2 defined stunting. Tests of proportions and regression models were used to explore the relationship between bacterial carriage, EED, and stunting. Results. Fecal samples from 613 children were available for laboratory analyses. F. prausnitzii and D. formicigenerans were prevalent in over 70% of children while B. longum was the least prevalent. B. longum carriage in younger children was associated with elevated EED biomarkers. Two thirds of children had elevated NEO, 33% had elevated MPO, and 16% had elevated AAT. Stunting was found in 38%. No significant associations were found between EED biomarkers or intestinal bacteria carriage and stunting. Conclusion. Intestinal carriage of these four bacteria was not associated with stunting in Malawian children. Carriage was also not associated with EED, nor EED biomarker levels associated with stunting. Further factors acting in concert are necessary to impact EED, perturb growth, and alter gut bacterial carriage.

Characterizing Behaviors Associated with Enteric Pathogen Exposure among Infants in Rural Ecuador through Structured Observations

The relative importance of environmental pathways that results in enteropathogen transmission may vary by context. However, measurement of contact events between individuals and the environment remains a challenge, especially for infants and young children who may use their mouth and hands to explore their environment. Using a mixed-method approach, we combined 1) semistructured observations to characterize key behaviors associated with enteric pathogen exposure and 2) structured observations using Livetrak, a customized software application, to quantify the frequency and duration of contacts events among infants in rural Ecuador. After developing and iteratively piloting the structured observation instrument, we loaded the final list of prompts onto a LiveTrak pallet to assess environmental exposures of 6-month infants (N = 19) enrolled in a prospective cohort study of diarrheal disease. Here we provide a detailed account of the lessons learned. For example, in our field site, 1) most mothers reported washing their hands after diaper changes (14/18, 77.8%); however only a third (4/11, 36.4%) were observed washing their hands; 2) the observers noted that animal ownership differed from observed animal exposure because animals owned by neighboring households were reported during the observation; and 3) using Livetrak, we found that infants frequently mouthed their hands (median = 1.9 episodes/hour, median duration: 1.6 min) and mouthed surroundings objects (1.8 episodes/hour, 1.9 min). Structured observations that track events in real time, can complement environmental sampling, quantitative survey data and qualitative interviews. Customizing these observations enabled us to quantify enteric exposures most relevant to our rural Ecuadorian context.

Fecal biomarkers of environmental enteric dysfunction and associated factors among children aged 24-59 months in east Dembiya district, northwest Ethiopia

Background

Environmental enteric dysfunction is a subclinical intestinal disorder characterized by gut inflammation accompanied by morphological changes, such as blunted villi and crypt hyperplasia. This is a common illness in low and middle-income countries. However, environmental enteric dysfunction evidence is limited in Ethiopia. Accordingly, this study was conducted to measure fecal biomarkers of environmental enteric dysfunction and associated factors among children aged 24–59 months in rural northwest Ethiopia.

Methods

A community-based cross-sectional study was employed among 235 randomly selected children in a rural setting of the east Dembiya district. Stool samples were collected without fixative and analyzed for fecal biomarkers of environmental enteric dysfunction (Alpha-1-antitrypsin, neopterin, and myeloperoxidase) using commercial enzyme-linked immunosorbent assay kits and analyzed for intestinal parasites using wet mount and Kato-Katz techniques. Child behaviors related with exposure to enteropathogens, condition of the living environment and socio-demographic information were collected using interviewer-administered questionnaire and structure observation. We fitted multivariable linear regression model to assess the association between environmental factors and concentration of fecal biomarkers of environmental enteric dysfunction in the stool. Statistically significant associations were declared based on adjusted betas with the corresponding 95% confidence interval and p-value < 0.05.

Results

The median concentration of fecal markers of environmental enteric dysfunction was 350 μg/ml for Alpha-1-antitrypsin, 3320.2 ng/ml for myeloperoxidase, and 1562 nmol/l for neopterin. The median concentration of Alpha-1-antitrypsin among 161 (68.5%), myeloperoxidase among 168 (71.5%), and neopterin among 188 (80%) of the stool samples were above the normal values in non-tropical settings. Moreover, 100 (42.6%) of the children had high EED disease activity score (above the median score). The elevated concentrations of fecal biomarkers of gut inflammation and the high EED disease activity score were significantly associated with open defecation practice, mouthing of soil contaminated materials, Escherichia coli (E. coli)  contamination of drinking water, E. coli contamination of foods, E. coli contamination of soil, and intestinal parasites.

Conclusion

Overall, Alpha-1-antitrypsin, myeloperoxidase, and neopterin levels among the children in the studied region were highly elevated in comparison to populations in high-income countries. Moreover, the EED disease activity score in significant proportion of children was high, suggesting widespread intestinal inflammation and increased intestinal permeability. Extensive E. coli contamination of the living environment (drinking water, ready-to-eat foods, and courtyard soil), hygiene and sanitation behaviors (such as open defecation and mouthing of soil contaminated materials), and a high burden of intestinal parasites were identified as factors associated with the elevated concentration of fecal biomarkers of environmental enteric dysfunction. Parental care to children to avoid mouthing of soil contaminated materials and other risky behaviors that increase exposure enteric infections, and protecting the living environment (water, food and soil) from fecal contamination are important.

Associations between Gut Microbiota and Intestinal Inflammation, Permeability and Damage in Young Malawian Children

BACKGROUND

Environmental enteric dysfunction (EED) is common in low- and middle-income countries and associated with childhood undernutrition. The composition of gut microbiota has been implicated in the pathogenesis of EED. Our aim was to assess the associations between gut microbiota and EED biomarkers in rural Malawian children. We hypothesized that there would be an inverse association between microbiota maturity and diversity and fecal concentrations of EED biomarkers.

METHODS

We used data from fecal samples collected at 6, 18 and 30 months from 611 children who were followed up during a nutrition intervention trial. The primary time point for analysis was 18 months. Microbiota data were obtained through 16S rRNA sequencing and variables included microbiota maturity and diversity, phylogenetic dissimilarity and relative abundances of individual taxa. EED biomarkers included calprotectin (marker of inflammation), alpha-1 antitrypsin (intestinal permeability) and REG1B (intestinal damage).

RESULTS

There was an inverse association between microbiota maturity and diversity and fecal concentrations of all 3 EED biomarkers at 18 months (p≤0.001). The results were similar at 30 months, while at 6 months inverse associations were found only with calprotectin and alpha-1 antitrypsin concentrations. At 18 months, EED biomarkers were not associated with phylogenetic dissimilarity, but at 6 and 30 months several associations were observed. Individual taxa predicting EED biomarker concentrations at 18 months included several Bifidobacterium and Enterobacteriaceae taxa as well as potentially displaced oral taxa.

CONCLUSIONS

Our findings support the hypothesis of an inverse association between microbiota maturity and diversity and EED in rural Malawian children.

Ruminant-Related Risk Factors are Associated with Shiga Toxin-Producing Escherichia coli Infection in Children in Southern Ghana

Livestock can provide benefits to low-income households, yet may expose children to zoonotic enteropathogens that cause illness and negative long-term health outcomes. The aim of this cross-sectional study was to determine whether livestock-related risk factors, including animal ownership, exposure to animal feces, and consumption of animal-source foods, were associated with bacterial zoonotic enteropathogen infections in children 6-59 months old in Greater Accra, Ghana. Stool samples from 259 children and 156 household chickens were analyzed for atypical enteropathogenic Escherichia coli (aEPEC), Campylobacter jejuni/coli (C. jejuni/coli), Salmonella, and Shiga toxin-producing Escherichia coli (STEC) using quantitative polymerase chain reaction (qPCR). aEPEC, C. jejuni/coli, STEC, and Salmonella were detected in 45.6%, 11.6%, 4.3%, and 0.8% of children's stool samples, respectively. In adjusted logistic regression models, household ownership of goats or sheep was associated with STEC detection in children (odds ratio [95% confidence interval]: 4.30 [1.32, 14.08]), as were positive detection of STEC in chicken feces (7.85 [2.54, 24.30]) and frequent consumption of fresh cow's milk (3.03 [1.75, 5.24]). No livestock-related risk factors were associated with aEPEC or C. jejuni/coli infection in children. Our findings suggest that ruminant ownership in southern Ghana may expose children to STEC through household fecal contamination and foodborne routes. The lack of association between livestock risk factors and the more commonly detected pathogens, aEPEC and C. jejuni/coli, warrants further research, particularly to help explain how animal-keeping and sanitation practices affect transmission of fecal pathogens that were highly prevalent in chicken feces.

OUP accepted manuscript

The intestinal microbiota plays a crucial role in health and changes in its composition are linked with major global human diseases. Fully understanding what shapes the human intestinal microbiota composition and knowing ways of modulating the composition are critical for promotion of life-course health, combating diseases, and reducing global health disparities. We aim to provide a foundation for understanding what shapes the human intestinal microbiota on an individual and global scale, and how interventions could utilize this information to promote life-course health and reduce global health disparities. We briefly review experiences within the first 1,000 days of life and how long-term exposures to environmental elements or geographic specific cultures have lasting impacts on the intestinal microbiota. We also discuss major public health threats linked to the intestinal microbiota, including antimicrobial resistance and disappearing microbial diversity due to globalization. In order to promote global health, we argue that the interplay of the larger ecosystem with intestinal microbiota research should be utilized for future research and urge for global efforts to conserve microbial diversity.

Fecal biomarkers of environmental enteric dysfunction and the gut microbiota of rural Malawian children: An observational study

Environmental enteric dysfunction (EED) is a subclinical condition of the gut characterized by changes in morphology and function with underlying chronic inflammatory responses. This study characterized composition and diversity of the gut microbiota in rural Malawian children with and without signs of EED. Fecal samples were collected from children aged 1-59 months. Neopterin, myeloperoxidase and alpha-1 antitrypsin concentrations were quantified by ELISA and combined to form a composite EED score using principal component analysis. DNA was extracted from fecal samples and V4-16S rRNA gene sequencing was used to characterize the gut microbiota. The concentrations of all three biomarkers decreased with increasing age, which is consistent with other studies of children living in similar low-income settings. Firmicutes, Bacteroidetes, Proteobacteria and Actinobacteria were the dominant phyla while Faecalibacterium and Bifidobacterium were the most prevalent genera. Increased alpha diversity was associated with a reduction in neopterin concentration. Microbiota composition was different between fecal samples with low and high composite EED scores; increased abundance of Succinivibrio was associated with reduced composite EED scores.

Predicting the risk of mortality during hospitalization in sick severely malnourished children using daily evaluation of key clinical warning signs

BACKGROUND

Despite adherence to WHO guidelines, inpatient mortality among sick children admitted to hospital with complicated severe acute malnutrition (SAM) remains unacceptably high. Several studies have examined risk factors present at admission for mortality. However, risks may evolve during admission with medical and nutritional treatment or deterioration. Currently, no specific guidance exists for assessing daily treatment response. This study aimed to determine the prognostic value of monitoring clinical signs on a daily basis for assessing mortality risk during hospitalization in children with SAM.

METHODS

This is a secondary analysis of data from a randomized trial (NCT02246296) among 843 hospitalized children with SAM. Daily clinical signs were prospectively collected during ward rounds. Multivariable extended Cox regression using backward feature selection was performed to identify daily clinical warning signs (CWS) associated with time to death within the first 21 days of hospitalization. Predictive models were subsequently developed, and their prognostic performance evaluated using Harrell's concordance index (C-index) and time-dependent area under the curve (tAUC).

RESULTS

Inpatient case fatality ratio was 16.3% (n=127). The presence of the following CWS during daily assessment were found to be independent predictors of inpatient mortality: symptomatic hypoglycemia, reduced consciousness, chest indrawing, not able to complete feeds, nutritional edema, diarrhea, and fever. Daily risk scores computed using these 7 CWS together with MUAC<10.5cm at admission as additional CWS predict survival outcome of children with SAM with a C-index of 0.81 (95% CI 0.77-0.86). Moreover, counting signs among the top 5 CWS (reduced consciousness, symptomatic hypoglycemia, chest indrawing, not able to complete foods, and MUAC<10.5cm) provided a simpler tool with similar prognostic performance (C-index of 0.79; 95% CI 0.74-0.84). Having 1 or 2 of these CWS on any day during hospitalization was associated with a 3 or 11-fold increased mortality risk compared with no signs, respectively.

CONCLUSIONS

This study provides evidence for structured monitoring of daily CWS as recommended clinical practice as it improves prediction of inpatient mortality among sick children with complicated SAM. We propose a simple counting-tool to guide healthcare workers to assess treatment response for these children.

TRIAL REGISTRATION

NCT02246296.

Association of lipocalin-2 and low-density lipoprotein receptor-related protein-1 (LRP1) with biomarkers of environmental enteric dysfunction (EED) among under 2 children in Bangladesh: results from a community-based intervention study

Background

Environmental enteric dysfunction (EED) is thought to occur from persistent intestinal inflammation. Studies also revealed the association of lipocalin-2 (LCN2) and low-density lipoprotein receptor-related protein-1 (LRP1) with intestinal inflammation. Therefore, we intended to explore the relationship of LCN2 and LRP1 with gut inflammation and biomarkers of EED in Bangladeshi malnourished children.

Methods

A total of 222 children (length-for-age z-score (LAZ) <-1) aged 12-18 months were enrolled in this study in a cross-sectional manner. Among the participants, 115 were stunted (LAZ <-2) and 107 were at risk of being stunted (LAZ -1 to -2) children. Plasma and faecal biomarkers were measured using ELISA. Spearman's rank correlation was done to see the correlation among LCN2, LRP1 and biological biomarkers.

Results

LCN2 correlates positively with myeloperoxidase (r=0.19, p=0.005), neopterin (r=0.20, p=0.004), calprotectin (r=0.3, p=0.0001), Reg1B (r=0.20, p=0.003) and EED score (r=0.20, p=0.003). Whereas, LRP1 correlates negatively with myeloperoxidase (r = -0.18, p=0.006), neopterin (r = -0.30, p=0.0001), alpha-1-antitrypsin (r = -0.18, p=0.006), Reg1B (r=-0.2, p=0.003) and EED score (r = -0.29, p=0.0001).

Conclusions

Our findings imply that LCN2 might be a promising biomarker to predict gut inflammation and EED. Whereas, increased level of LRP1 may contribute to alleviating intestinal inflammation.

Child Mouthing of Soil and Contaminated Fomites and Unimproved Sanitation are Associated with Subsequent Poor Child Developmental Outcomes in Urban Bangladesh (CHoBI7 Program)

OBJECTIVE

To evaluate the relationship between mouthing of soil and living in unsanitary conditions and child cognitive development in urban Bangladesh.

STUDY DESIGN

This prospective cohort study of 224 children under 5 years of age was conducted in urban Dhaka, Bangladesh. Developmental outcomes were assessed by communication, fine motor, gross motor, personal social, problem solving, and combined developmental scores measured by the Extended Ages and Stages Questionnaire (EASQ) at a 12-month follow-up visit.

RESULTS

Children who had caregiver reports of puting soil in their mouths at the majority of surveillance visits had significantly lower combined EASQ Z scores (coefficient, -0.53; 95% CI, -0.83 to -0.22) at the 12-month follow-up visit. Children who had caregiver reports of putting visibly dirty objects in their mouths at the majority of visits had significantly lower combined EASQ Z scores (-0.50; 95% CI, -0.79 to -0.22). Children in households with unimproved sanitation had significantly lower combined EASQ Z scores (-0.63; 95% CI, -1.11 to -0.16).

CONCLUSIONS

Children found to frequently put soil and visibly dirty objects in their mouths, and those who resided in households using unimproved sanitation, had lower subsequent cognitive developmental outcomes. These findings demonstrate the importance of interventions targeting child mouthing behaviors and sanitation infrastructure to decrease exposure to fecal pathogens and improve child cognitive developmental outcomes.

Fecal Contamination on the Household Compound and in Water Sources are Associated with Subsequent Diarrhea in Young Children in Urban Bangladesh (CHoBI7 Program)

We investigated the environmental and individual-level risk factors for diarrheal disease among young children in slum areas of Dhaka, Bangladesh. A prospective cohort study was conducted among 884 children under 5 years of age. Caregiver reports were collected on sociodemographic factors and hygiene behaviors. Diarrhea surveillance data was collected monthly based on caregiver-reported diarrhea for children in the past 2 weeks during the 12-month study period. Unannounced spot checks of the household compound were performed at 1, 3, 6, 9, and 12 months after enrollment to check for the presence of feces (animal or human) and the presence of animals in the child's sleeping space, to assess child and caregiver hands for the presence of dirt, and to collect samples of the household's source and stored drinking water. Children with feces found on the household compound during spot checks had a significantly higher odds of diarrhea (odds ratio: 1.71; 95% confidence interval: 1.23-2.38). Children residing in households with > 100 colony forming units/100 mL Escherichia coli in source drinking water had a significantly higher odds of diarrhea (OR: 1.43; 95% CI: 1.06-1.92). The presence of feces on the household compound and source drinking water with > 100 colony forming units/100 mL E. coli were significant risk factors for diarrheal disease for children < 5 years of age in slum areas of Dhaka, Bangladesh. These findings demonstrate the urgent need for comprehensive interventions to reduce fecal contamination on the household compound to protect the health of susceptible pediatric populations.

Geographical variation and factors associated with unsafe child stool disposal in Ethiopia: A spatial and multilevel analysis

Background

Unsafe disposal of children’s stool makes children susceptible to fecal-oral diseases and children remain vulnerable till the stools of all children are disposed of safely. There is a paucity of data on spatial distribution and factors associated with unsafe child stool disposal in Ethiopia. Previous estimates, however, do not include information regarding individual and community-level factors associated with unsafe child stool disposal. Hence, the current study aimed (i) to explore the spatial distribution and (ii) to identify factors associated with unsafe child stool disposal in Ethiopia.

Methods

A secondary data analysis was conducted using the recent 2016 Ethiopian demographic and health survey data. A total of 4145 children aged 0–23 months with their mother were included in this analysis. The Getis-Ord spatial statistical tool was used to identify high and low hotspots areas of unsafe child stool disposal. The Bernoulli model was applied using Kilduff SaTScan version 9.6 software to identify significant spatial clusters. A multilevel multivariable logistic regression model was fitted to identify factors associated with unsafe child stool disposal.

Results

Unsafe child stool disposal was spatially clustered in Ethiopia (Moran’s Index = 0.211, p-value< 0.0001), and significant spatial SaTScan clusters of areas with a high rate of unsafe child stool disposal were detected. The most likely primary SaTScan cluster was detected in Tigray, Amhara, Afar (north), and Benishangul-Gumuz (north) regions (LLR: 41.62, p<0.0001). Unsafe child stool disposal is more prevalent among households that had unimproved toilet facility (AOR = 1.54, 95%CI: 1.17–2.02) and those with high community poorer level (AOR: 1.74, 95%CI: 1.23–2.46). Higher prevalence of unsafe child stool disposal was also found in households with poor wealth quintiles. Children belong to agrarian regions (AOR: 0.62, 95%CI 0.42–0.91), children 6–11 months of age (AOR: 0.65, 95%CI: 0.52–0.83), 12–17 months of age (AOR: 0.68, 95%CI: 0.54–0.86), and 18–23 months of age (AOR: 0.58, 95%CI: 0.45–0.75) had lower odds of unsafe child stool disposal.

Conclusions

Unsafe child stool disposal was spatially clustered. Higher odds of unsafe child stool disposal were found in households with high community poverty level, poor, unimproved toilet facility, and with the youngest children. Hence, the health authorities could tailor effective child stool management programs to mitigate the inequalities identified in this study. It is also better to consider child stool management intervention in existing sanitation activities considering the identified factors.

A One Health Approach to Child Stunting: Evidence and Research Agenda

Stunting (low height for age) affects approximately one-quarter of children aged < 5 years worldwide. Given the limited impact of current interventions for stunting, new multisectoral evidence-based approaches are needed to decrease the burden of stunting in low- and middle-income countries (LMICs). Recognizing that the health of people, animals, and the environment are connected, we present the rationale and research agenda for considering a One Health approach to child stunting. We contend that a One Health strategy may uncover new approaches to tackling child stunting by addressing several interdependent factors that prevent children from thriving in LMICs, and that coordinated interventions among human health, animal health, and environmental health sectors may have a synergistic effect in stunting reduction.

Formative research for the development of baby water, sanitation, and hygiene interventions for young children in the Democratic Republic of the Congo (REDUCE program)

BACKGROUND

Research exploring the unique exposure pathways to fecal pathogens for young children and innovative water, sanitation, and hygiene (WASH) interventions for susceptible pediatric populations is needed to reduce the burden of diarrheal diseases and stunting globally. The Reducing Enteropathy, Diarrhea, Undernutrition, and Contamination in the Environment (REDUCE) program seeks to 1) identify exposure pathways to fecal pathogens that are significant contributors to morbidity for young children in South Kivu, Democratic Republic of the Congo, and 2) develop and evaluate scalable interventions that reduce fecal contamination and exposure from these pathways. The formative research portion of the project sought to identify feasible and acceptable WASH interventions to modify behaviors found to be associated with diarrheal disease and impaired growth in our REDUCE cohort study.

METHODS

Ninety-one semi-structured interviews, 6 focus group discussions, and a pilot study of 102 households were conducted during 24 months of formative research. Thirty-one interviews and six focus group discussions were conducted with caregivers, community health workers, and village leaders to explore existing WASH practices and to identify barriers and facilitators to WASH behaviors. Findings were organized using the Integrated Behavioral Model for Water, Sanitation and Hygiene to facilitate interpretation and identify determinants to Baby WASH behaviors in this setting. Care Group modules and enabling technology were developed based on exploratory findings and then revised during a two-part, iterative pilot study. Sixty interviews were conducted with participants in a pilot study of the REDUCE Baby WASH Care Group modules to learn about their experiences with the intervention.

RESULTS

Six REDUCE Baby WASH Care Group modules were developed based on formative research findings and covered the following topics: 1) living with animals; 2) child mouthing of fomites and feces; 3) composting animal feces; 4) child feces disposal; 5) handwashing with soap; and 6) water treatment.

CONCLUSION

This study took a theory-driven and evidence-based approach to formative research and the development of the REDUCE Baby WASH Care Group modules. Intervention design focused on interrupting the exposure routes for infants and young children to fecal pathogens in the environment and promoting low-cost, low-burden Baby WASH behavioral recommendations and enabling technology. These developed REDUCE Baby WASH Care Group modules are currently being rolled out to over 1,000,000 beneficiaries in Democratic Republic of the Congo.

Quantitative Microbial Risk Assessment of Pediatric Infections Attributable to Ingestion of Fecally Contaminated Domestic Soils in Low-Income Urban Maputo, Mozambique

Rigorous studies of water, sanitation, and hygiene interventions in low- and middle-income countries (LMICs) suggest that children are exposed to enteric pathogens via multiple interacting pathways, including soil ingestion. In 30 compounds (household clusters) in low-income urban Maputo, Mozambique, we cultured Escherichia coli and quantified gene targets from soils (E. coli: ybbW, Shigella/enteroinvasive E. coli (EIEC): ipaH, Giardia duodenalis: β-giardin) using droplet digital PCR at three compound locations (latrine entrance, solid waste area, dishwashing area). We found that 88% of samples were positive for culturable E. coli (mean = 3.2 log10 CFUs per gram of dry soil), 100% for molecular E. coli (mean = 5.9 log10 gene copies per gram of dry soil), 44% for ipaH (mean = 2.5 log10), and 41% for β-giardin (mean = 2.1 log10). Performing stochastic quantitative microbial risk assessment using soil ingestion parameters from an LMIC setting for children 12-23 months old, we estimated that the median annual infection risk by G. duodenalis was 7100-fold (71% annual infection risk) and by Shigella/EIEC was 4000-fold (40% annual infection risk) greater than the EPA's standard for drinking water. Compounds in Maputo, and similar settings, require contact and source control strategies to reduce the ingestion of contaminated soil and achieve acceptable levels of risk.

Exploring the Use and Appeal of Playpens to Protect Infants from Exposure to Animals, Animal Feces, and Dirt in Rural Ethiopia

The persistence and pervasiveness of growth stunting in low- and middle-income countries spur reexamination of disease transmission pathways related to water, sanitation, and hygiene. Animal feces constitute a more important reservoir of enteric pathogens in homes in low-income countries than previously recognized, and exploratory object mouthing and direct ingestion of soil and animal feces represent underexplored exposure pathways. The effectiveness, adoption, constraints, and scale-up potential of measures for reducing infant and young children's exposure to fecal pathogens are recently beginning to be systematically explored. This mixed methods study tested the feasibility and appeal of using playpens to establish a hygienic "safe zone" for infants in rural Ethiopia. We conducted home trials of three playpen designs, including two models made from locally available materials through user-centered design. After using playpens for several weeks, caregivers reported extensive benefits, ranging from perceived safety to developmental and hygiene benefits for infants and relief from physical stress and worry for caregivers. We observed many playpens contaminated with Escherichia coli after weeks of use, though at concentrations below those of the common room floor on which infants might otherwise have played. Caregivers reported daily playpen use, but for intervals likely insufficient to protect infants from pathogen exposure affecting growth. We determine that playpens alone cannot plausibly protect infants from environmental contamination, but our results support further exploration of the potential benefits and commercial viability of scaling up use of playpens in rural, agricultural households as part of a comprehensive approach to child development and women's empowerment.

Soil ingestion among young children in rural Bangladesh

Ingestion of soil and dust is a pathway of children's exposure to several environmental contaminants, including lead, pesticides, and fecal contamination. Empirically based estimates of central tendency for soil consumption by children in high-income countries range from 9 to 135 dry mg/day. Using a Monte Carlo simulation, we modeled the mass of soil directly and indirectly ingested per day by rural Bangladeshi children and identified the parameters that influence the mass ingested. We combined data from observations of direct and indirect ingestion among children with measurements of soil mass on the children's hands, mother's hands, and objects to quantify soil ingestion/day. Estimated geometric mean soil ingestion was 162 dry mg/day for children 3-5 months, 224 dry mg/day for children 6-11 months, 234 dry mg/day for children 12-23 months, 168 dry mg/day for children 24-35 months, and 178 dry mg/day for children 36-47 months old. Across all age groups, children placing their hands in their mouths accounted for 46-78% of total ingestion and mouthing objects contributed 8-12%. Direct ingestion of soil accounted for nearly 40% of soil ingested among children 6-23 months old. Sensitivity analyses identified that the parameters most affecting the estimates were the load of soil on the child's hand, the frequency of hand-to-mouth contacts while not eating, and, for children 6-23 months old, the frequency of direct soil ingestion. In a rural, low-income setting, children's soil consumption was substantially more than the estimates for children in high-income countries. Further characterizing soil ingestion of children in low-income contexts would improve assessments of the risks they face from soil-associated contaminants.

Formative Research for the Design of a Baby Water, Sanitation, and Hygiene Mobile Health Program in Bangladesh (CHoBI7 Mobile Health Program)

Poor food hygiene practices, child feces not being disposed of in a latrine, child mouthing of contaminated fomites, and poor hand hygiene of caregivers have been associated with diarrheal diseases, environmental enteropathy, and impaired growth in young children. Mobile health (mHealth) programs present a low-cost approach to delivering water, sanitation, and hygiene (WASH) programs. We conducted a theory-driven and evidence-based approach to formative research and intervention development to design and pilot test a Baby WASH mHealth program targeting food hygiene, child mouthing, and child feces disposal behaviors in urban Dhaka, Bangladesh. Formative research activities included 31 semi-structured interviews, five group discussions, six mHealth workshops, and a three-phase iterative pilot study among 102 households. Findings from semi-structured interviews and group discussions indicate that caregivers of young children have relatively high awareness of the need for safer food hygiene, child mouthing, and child feces disposal practices, but are limited by existing household responsibilities and restricted access to enabling technology that would facilitate practicing recommended behaviors. The piloted Baby WASH mHealth program was well-received by households. This study presents a theory-driven and evidence-based approach for intervention development that can be implemented for the development of future WASH mHealth programs in low-resource settings.

Multi-Sectoral Participatory Design of a BabyWASH Playspace for Rural Ethiopian Households

Growing evidence suggests current water, sanitation, and hygiene interventions do not improve domestic hygiene sufficiently to improve infant health, nor consider the age-specific behaviors which increase infection risk. A household playspace (HPS) is described as one critical intervention to reduce direct fecal-oral transmission within formative growth periods. This article details both the design and development (materials and methods), and testing (results) of a HPS for rural Ethiopian households. Design and testing followed a multi-sectoral, multistep participatory process. This included a focus group discussion (FGD), two user-centered and participatory design workshops in the United Kingdom and Ethiopia, discussions with local manufacturers, and a Trials by Improved Practices (TIPs) leading to a final prototype design. Testing included the FGD and TIPs study and a subsequent randomized controlled feasibility trial in Ethiopian households. This multi-sectoral, multistage development process demonstrated a HPS is an acceptable and feasible intervention in these low-income, rural subsistence Ethiopian households. A HPS may help reduce fecal-oral transmission and infection-particularly in settings where free-range domestic livestock present an increased risk. With the need to better tailor interventions to improve infant health, this article also provides a framework for future groups developing similar material inputs and highlights the value of participatory design in this field.

Effects of Water, Sanitation, Handwashing, and Nutritional Interventions on Environmental Enteric Dysfunction in Young Children: A Cluster-randomized, Controlled Trial in Rural Bangladesh

BACKGROUND

We hypothesized that drinking water, sanitation, handwashing (WSH), and nutritional interventions would improve environmental enteric dysfunction (EED), a potential contributor to stunting.

METHODS

Within a subsample of a cluster-randomized, controlled trial in rural Bangladesh, we enrolled pregnant women in 4 arms: control, WSH, child nutrition counseling plus lipid-based nutrient supplements (N), and nutrition plus WSH (N+WSH). Among the birth cohort, we measured biomarkers of gut inflammation (myeloperoxidase, neopterin), permeability (alpha-1-antitrypsin, lactulose, mannitol), and repair (regenerating gene 1β) at median ages 3, 14, and 28 months. Analysis was intention-to-treat.

RESULTS

We assessed 1512 children. At age 3 months, compared to controls, neopterin was reduced by nutrition (-0.21 log nmol/L; 95% confidence interval [CI], -.37, -.05) and N+WSH (-0.20 log nmol/L; 95% CI, -.34, -.06) interventions; similar reductions were observed at 14 months. At 3 months, all interventions reduced lactulose and mannitol (-0.60 to -0.69 log mmol/L). At 28 months, myeloperoxidase was elevated in the WSH and nutrition arms (0.23-0.27 log ng/mL) and lactulose was higher in the WSH arm (0.30 log mmol/L; 95% CI, .07, .53).

CONCLUSIONS

Reductions in permeability and inflammation at ages 3 and 14 months suggest that the interventions promoted healthy intestinal maturation; however, by 28 months, the WSH and nutrition arms showed elevated EED biomarkers. These results underscore the importance of developing a better understanding of EED pathophysiology and targeting interventions early in childhood, when they are likely to have the largest benefit to intestinal health.

CLINICAL TRIALS REGISTRATION

NCT01590095.

Child Mouthing of Feces and Fomites and Animal Contact are Associated with Diarrhea and Impaired Growth Among Young Children in the Democratic Republic of the Congo: A Prospective Cohort Study (REDUCE Program)

OBJECTIVE

To identify exposure pathways to fecal pathogens that are significant contributors to diarrheal diseases and impaired growth in young children, and to evaluate scalable interventions to reduce fecal contamination from these pathways.

STUDY DESIGN

Reducing Enteropathy, Undernutrition, and Contamination in the Environment (REDUCE) was a prospective cohort study of 370 children <5 years of age was conducted in Walungu Territory, South Kivu, Democratic Republic of the Congo. Child mouthing behaviors were assessed through caregiver reports and 5-hour structured observations. Caregiver reports of child contact with animals and child diarrhea were also obtained. Anthropometric measurements were collected at baseline and at a 6-month follow-up.

RESULTS

Children observed putting soil in their mouth during structured observation at baseline had a significantly higher odds of diarrhea at the 6-month follow-up (OR, 1.79; 95% CI, 1.04 to 3.07). Children observed mouthing feces during structured observation had a significant reduction in height-for-age z-score (HAZ) from baseline to the 6-month follow-up (ΔHAZ, -0.69; 95% CI, -1.34 to -0.04). A significant reduction in HAZ was also observed for children with caregiver reports of touching guinea pigs (-0.33; 95% CI, -0.58 to -0.08) and rabbits (-0.34; 95% CI, -0.64 to -0.04) and children with feces in their sleeping space during unannounced spot checks (-0.41; 95% CI, -0.74 to -0.09).

CONCLUSIONS

These findings emphasize the urgent need for infant water, sanitation, and hygiene interventions targeting child mouthing behaviors, fecal contamination in child living spaces, and child contact with domestic animals to reduce exposure to fecal pathogens among susceptible populations.

Ingestion of Fecal Bacteria along Multiple Pathways by Young Children in Rural Bangladesh Participating in a Cluster-Randomized Trial of Water, Sanitation, and Hygiene Interventions (WASH Benefits)

Quantifying the contribution of individual exposure pathways to a child's total ingestion of fecal matter could help prioritize interventions to reduce environmental enteropathy and diarrhea. This study used data on fecal contamination of drinking water, food, soil, hands, and objects and second-by-second data on children's contacts with these environmental reservoirs in rural Bangladesh to assess the relative contribution of different pathways to children's ingestion of fecal indicator bacteria and if ingestion decreased with the water, sanitation, and hygiene interventions implemented in the WASH Benefits Trial. Our model estimated that rural Bangladeshi children <36 months old consume 3.6-4.9 log₁₀ most probable number E. coli/day. Among children <6 months, placing objects in the mouth accounted for 60% of E. coli ingested. For children 6-35 months old, mouthing their own hands, direct soil ingestion, and ingestion of contaminated food were the primary pathways of E. coli ingestion. The amount of E. coli ingested by children and the predominant pathways of E. coli ingestion were unchanged by the water, sanitation, and hygiene interventions. These results highlight contaminated soil, children's hands, food, and objects as primary pathways of E. coli ingestion and emphasize the value of intervening along these pathways.

Relationship between Stunting, Wasting, Underweight and Geophagy and Cognitive Function of Children

OBJECTIVES

The aim of this study was to investigate the relationship between anthropometric characteristics and both geophagy and cognitive function of children.

STUDY DESIGN

The study prospectively followed singleton children whose mothers participated in the MiPPAD clinical trial in Allada, Benin, from birth to age 12 months. Anthropometric measurements were taken at birth and 9 and 12 months. Wasting, stunting and underweight were defined as weight-for-length, length-for-age and weight-for-age Z-scores less than -2, respectively. Cognitive and motor functions were assessed using the Mullen Scales of Early Learning. Parent-reported geophageous habits of children were collected when the children were 12 months. Multiple linear and logistic regressions were used to analyse the data.

RESULTS

A total of 632 children (49.7% girls) were involved in the study. Stunting, wasting and underweight were observed in 14.1%, 13.6% and 17.7%, respectively, at 9 months and 17.3%, 12.7% and 17.2%, respectively, at 12 months. The prevalence of geophagy among the children was 48.2%. Impaired growth at 9 and 12 months was consistently associated with low cognitive and gross motor (GM) score. Children stunted at 9 months had lower GM scores at 12 months compared with their non-stunted peers (β = -3.48, 95% confidence interval -6.62 to -0.35).

CONCLUSIONS

Stunting, wasting and underweight are associated with cognitive and GM deficits in infants. In this setting, impaired growth was not associated with geophagy. Further research evaluating geophagy and growth prospectively and concurrently from birth to 36 months is needed.

Faecal contamination of the environment and child health: a systematic review and individual participant data meta-analysis

BACKGROUND

Exposure to faecal contamination is believed to be associated with child diarrhoea and possibly stunting; however, few studies have explicitly measured the association between faecal contamination and health. We aimed to assess individual participant data (IPD) across multiple trials and observational studies to quantify the relationship for common faecal-oral transmission pathways.

METHODS

We did a systematic review and meta-analysis of IPD from studies identified in an electronic search of PubMed, Web of Science, and Embase on May 21, 2018. The search was done in English, but full texts published in French, Portuguese, and Spanish were also reviewed. Eligible studies quantified (1) household-level faecal indicator bacteria concentrations along common faecal-oral transmission pathways of drinking water, soil, or food, on children's hands or fomites, or fly densities in food preparation areas; and (2) individual-level diarrhoea or linear growth measures for children younger than 5 years in low-income and middle-income countries. For the diarrhoea analysis, all definitions of diarrhoea were eligible but studies were excluded if they used a recall period longer than 7 days. For the linear growth analysis (using height-for-age Z scores [HAZ]), cross-sectional studies were excluded, because of the absence of longitudinal environmental contamination data measured before the growth outcomes. We used multilevel generalised mixed-effects models to estimate the odds ratio (OR) for diarrhoea and the difference in HAZ scores for individual studies associated with a 1-log₁₀ higher measure of faecal contamination. Estimates from each study were combined under a random-effects meta-analysis framework. The study protocol was pre-registered with PROSPERO (CRD42018102114).

FINDINGS

From 72 eligible studies, we included IPD for 20 studies in the meta-analyses, totalling 54 225 diarrhoea or linear growth observations matched to faecal indicator bacteria concentrations in drinking water, and a further 35 010 observations with faecal contamination data for the other transmission pathways. Child diarrhoea was associated with 1-log₁₀ higher faecal indicator bacteria concentrations in drinking water (OR 1·09, 95% CI 1·04 to 1·13; p=0·0002, I²=34%, 95% CI 0 to 62) and on children's hands (1·11, 1·02 to 1·22; p=0·021, I²=0%, 0 to 71). Lower HAZ scores were associated with 1-log₁₀ higher median faecal indicator bacteria concentrations in drinking water (HAZ -0·04, 95% CI -0·06 to -0·01; p=0·0054; I²=19%, 95% CI 0 to 63) and on fomites (-0·06, -0·12 to 0·00; p=0·044, I²=57%, 0 to 90).

INTERPRETATION

Although summary measures from individual studies often report little or no effect of measured faecal contamination on child health, this multi-study IPD analysis indicates that household faecal indicator bacteria concentrations are associated with important adverse health outcomes in young children. Improved direct measures of exposure and enteric pathogens could help to better characterise the relationship and inform intervention design in future studies.

FUNDING

None.

Prospective cohort study of child mouthing of faeces and fomites in Dhaka, Bangladesh (CHoBI7 Program)

OBJECTIVE

To characterise childhood mouthing and handling behaviours and to assess the association between hand-to-object and object-to-mouth contacts and diarrhoea prevalence in young children in urban Dhaka, Bangladesh.

METHODS

A prospective cohort study was conducted among 494 children under 5 years of age in Dhaka, Bangladesh. This study was nested within the randomised controlled trial of the Cholera Hospital-Based Intervention for 7 Days (CHoBI7) mobile health (mHealth) program. The CHoBI7 mHealth program focuses on promoting handwashing with soap and water treatment to diarrhoea patients and their household members through mobile messages and a single in person visit. Mouthing and handling of faeces and fomites among young children was measured by five-hour structured observation and caregiver reports. Diarrhoea surveillance data was collected monthly for 12 months.

RESULTS

Fifty five percent of caregivers reported that their child put a visibly dirty fomite (object or soil) in their mouth in the past week. Caregivers reported that 50% of children had mouthed visibly dirty objects, 26% had mouthed dirt, and 2% had mouthed faeces. Forty five percent of children were observed mouthing a visibly dirty fomite during structured observation, 40% of children were observed mouthing a visibly dirty object, 10% were observed mouthing soil, and one child (0.2%) was observed mouthing faeces. Mouthing of visibly dirty fomites was highest for children 12-18 months of age with 69% of these children having caregiver reports and 54% having observed events. Children with caregiver reports of mouthing faeces had a significantly higher odds of diarrhoea over the subsequent month (Odds Ratio: 4.54; 95% Confidence Interval: 1.06, 19.48).

CONCLUSION

These findings demonstrate that mouthing of contaminated fomites among young children is frequent in urban environments in Bangladesh, and that mouthing faeces is associated with a significantly higher odds of diarrhoea. Interventions are urgently needed to protect young children from faecal pathogens in their play spaces.

Impact of Different Strategies for Delivering Supplemental Zinc on Selected Fecal Markers of Environmental Enteric Dysfunction among Young Laotian Children: A Randomized Controlled Trial

The objective of this study was to assess the impact of different strategies for delivering supplemental zinc on fecal myeloperoxidase (MPO), neopterin (NEO), and calprotectin (CAL) among young Laotian children. In a double-blind controlled trial, children aged 6-23 months were randomized to receive either daily preventive zinc (PZ) tablets (7 mg/day), daily micronutrient powder (MNP; containing 10 mg zinc and 14 other micronutrients), therapeutic zinc (TZ) supplements for diarrhea treatment (20 mg/day for 10 days), or daily placebo powder and followed for ∼36 weeks. Stool samples were collected at baseline and endline. Fecal MPO, NEO, and CAL concentrations were determined in a randomly selected subsample of 720 children using commercially available ELISA kits. At baseline, the mean age was 14.1 ± 4.9 months and prevalence of stunting was 39%. The endline prevalence of stunting was 43%; there was no overall treatment effect on physical growth in the parent trial. At endline, the mean (95% CI) MPO in the PZ group was 1,590 [1,396; 1,811] ng/mL and did not differ from that in the MNP (1,633 [1,434; 1,859] ng/mL), TZ (1,749 [1,535; 1,992] ng/mL), and control (1,612 [1,415; 1,836] ng/mL) groups (P = 0.749). Similarly, there was no overall treatment effect on NEO and CAL concentrations (P = 0.226 and 0.229, respectively). In this population, the provision of PZ or TZ supplements or MNP had no impact on growth or environmental enteric dysfunction (EED) as assessed by fecal MPO, NEO, and CAL. Additional research is needed to better understand the etiology and proposed mechanisms of EED pathogenesis.

Determinants of Childhood Zoonotic Enteric Infections in a Semirural Community of Quito, Ecuador

Domestic animals in the household environment have the potential to affect a child's carriage of zoonotic enteric pathogens and risk of diarrhea. This study examines the risk factors associated with pediatric diarrhea and carriage of zoonotic enteric pathogens among children living in communities where smallholder livestock production is prevalent. We conducted an observational study of children younger than 5 years that included the analysis of child (n = 306) and animal (n = 480) fecal samples for Campylobacter spp., atypical enteropathogenic Escherichia coli, Shiga toxin-producing E. coli, Salmonella spp., Yersinia spp., Cryptosporidium parvum, and Giardia lamblia. Among these seven pathogens, Giardia was the most commonly identified pathogen among children and animals in the same household, most of which was found in child-dog pairs. Campylobacter spp. was also relatively common within households, particularly among child-chicken and child-guinea pig pairs. We used multivariable Poisson regression models to assess risk factors associated with a child being positive for at least one zoonotic enteric pathogen or having diarrhea during the last week. Children who interacted with domestic animals-a behavior reported by nearly three-quarters of households owning animals-were at an increased risk of colonization with at least one zoonotic enteric pathogen (prevalence ratio [PR] = 1.56, 95% CI: 1.00-2.42). The risk of diarrhea in the last seven days was elevated but not statistically significant (PR = 2.27, CI: 0.91, 5.67). Interventions that aim to reduce pediatric exposures to enteric pathogens will likely need to be incorporated with approaches that remove animal fecal contamination from the domestic environment and encourage behavior change aimed at reducing children's contact with animal feces through diverse exposure pathways.

Unsafe child feces disposal status in Ethiopia: what factors matter? Analysis of pooled data from four demographic and health surveys

Background

The only safest way to dispose of a child’s feces is to help the child use a toilet or, for very young children, to put or rinse their feces into a toilet, whereas other methods are considered unsafe. This study aimed to determine the magnitude and factors associated with unsafe child feces disposal in Ethiopia.

Methods

This was a cross-sectional study using pooled data from the four rounds of Demographic and Health Surveys (DHS) conducted in Ethiopia (2000, 2005, 2011, and 2016). Data on child feces disposal practice was collected for all children born during the 5 years preceding survey. Mothers were asked for the youngest child born, “The last time child passed stools, what was done to dispose of the stools?”.Descriptive statistics were computed to illustrate the given data. Multivariable logistic regression was performed to identify factors associated with unsafe child feces disposal.

Results

The pooled dataset contains data for 40,520 children younger than 5 years, male accounts 20,629 (50.9%). Overall, 77.7% (95%CI: 76.3–79.0) of children feces disposed of unsafely. In the multivariable logistic regression model, those mothers whose child was 13–24 months [AOR: 0.68, 95% CI: (0.60–0.78)] and ≥ 25 months [AOR: 0.66, 95% CI: (0.60–0.72)] were lower odds of unsafe child’s feces disposal. Children born into households having two or fewer children were 33% lower [AOR: 0.67, 95% CI: (0.56–0.79)] odds of unsafe child’s feces disposal than their counterparts. The odds of disposing of feces unsafely among households having improved toilet facility was 76% lower [AOR: 0.24, 95% CI: (0.19–0.29)] that of households lacking such facilities. Further, being an urban resident, having improved drinking water facility, a high level of maternal and paternal education, paternal occupational status (work in non-agriculture), and maternal age (25–34 and ≥ 35 years) were factors that associated with lower odds of unsafe child’s feces disposal.

Conclusions

Three in four Ethiopian children feces disposed of unsafely. Household and socio-demographic factors, such as access to improved toilet facility, the child’s age (older age), and both higher maternal and paternal education levels were important factors that significantly associated with lower odds of unsafe child feces disposal.

A Retrospective Case-Control Study of the Relationship between the Gut Microbiota, Enteropathy, and Child Growth

The microbial communities residing in the child gut are thought to play an important role in child growth, although the relationship is not well understood. We examined a cohort of young children from Mirzapur, Bangladesh, prospectively over 18 months. Four fecal markers of environmental enteropathy (EE) (high levels of alpha-1-antitrypsin, calprotectin, myeloperoxidase, and neopterin) were examined and anthropometric measures obtained from a cohort of 68 children. The 16S rRNA gene of bacterial DNA was sequenced from stool samples and used to estimate amplicon sequence variants (ASVs). We age-matched children with poor growth to children with normal growth within 1 month and compared the change in abundance and diversity of ASVs over time. Elevated EE markers and poor linear growth in children were associated with changes in microbial communities in the gut. There were increased amounts of Escherichia/Shigella and Proteobacteria and decreased amounts of Prevotella associated with poorly growing children consistent with the mounting evidence supporting the relationship between intestinal inflammation, child growth, and changes in gut microbiota composition. Future research is needed to investigate this association among young children in low- and middle-income countries.

Risk factors and transmission pathways associated with infant Campylobacter spp. prevalence and malnutrition: A formative study in rural Ethiopia

Early infection from enteropathogens is recognised as both a cause and effect of infant malnutrition. Specifically, evidence demonstrates associations between growth shortfalls and Campylobacter infection, endemic across low-income settings, with poultry a major source. Whilst improvements in water, sanitation and hygiene (WASH) should reduce pathogen transmission, interventions show inconsistent effects on infant health. This cross-sectional, formative study aimed to understand relationships between infant Campylobacter prevalence, malnutrition and associated risk factors, including domestic animal husbandry practices, in rural Ethiopia. Thirty-five households were visited in Sidama zone, Southern Nations, Nationalities and Peoples' region. Infant and poultry faeces and domestic floor surfaces (total = 102) were analysed for presumptive Campylobacter spp. using selective culture. Infant anthropometry and diarrhoeal prevalence, WASH facilities and animal husbandry data were collected. Of the infants, 14.3% were wasted, 31.4% stunted and 31.4% had recent diarrhoea. Presumptive Campylobacter spp. was isolated from 48.6% of infant, 68.6% of poultry and 65.6% of floor surface samples. Compared to non-wasted infants, wasted infants had an increased odds ratio (OR) of 1.41 for a Campylobacter-positive stool and 1.81 for diarrhoea. Positive infant stools showed a significant relationship with wasting (p = 0.026) but not stunting. Significant risk factors for a positive stool included keeping animals inside (p = 0.027, OR 3.5), owning cattle (p = 0.018, OR 6.5) and positive poultry faeces (p<0.001, OR 1.34). Positive floor samples showed a significant correlation with positive infant (p = 0.023), and positive poultry (p = 0.013, OR 2.68) stools. Ownership of improved WASH facilities was not correlated with lower odds of positive stools. This formative study shows a high prevalence of infants positive for Campylobacter in households with free-range animals. Findings reaffirm contaminated floors as an important pathway to infant pathogen ingestion and suggest that simply upgrading household WASH facilities will not reduce infection without addressing the burden of contamination from animals, alongside adequate separation in the home.

Helicobacter pylori infection is associated with fecal biomarkers of environmental enteric dysfunction but not with the nutritional status of children living in Bangladesh

Background

Because Helicobacter pylori (H. pylori) infection and Environmental Enteric Dysfunction (EED) follow a similar mode of transmission, there can be a complex interplay between H. pylori infection and EED, both of which can influence childhood growth. We sought to investigate the factors associated with H. pylori infection and identify its relationship with the fecal biomarkers of EED including Myeloperoxidase (MPO), Neopterin (NEO), Calprotectin, Reg1B and Alpha-1 antitrypsin (AAT), and nutritional status of the children.

Methodology

Data from an on-going community-based nutrition intervention study was used for this analysis. Total 319 children aged between 12–18 months were evaluated at enrolment and at the end of a 90-day nutrition intervention. Multivariable linear regression with generalized estimating equations was done to examine the association of H. pylori infection with stool biomarker of EED and nutritional status of the children.

Principal findings

One-fifth of the participants had H. pylori infection at both the time points, with 13.8% overall persistence. Children living in crowded households had higher odds of being infected by H. pylori (AOR = 2.02; 95% CI = 1.02, 4.10; p-value = 0.045). At enrolment, 60%, 99%, 69% and 85% of the stool samples were elevated compared to the reference values set for MPO, NEO, AAT and Calprotectin in the non-tropical western countries. The proportions reduced to 52%, 99%, 67%, and 77% for the same biomarkers after the nutrition intervention. Infection with H. pylori had significant positive association with fecal AAT concentrations (Coefficient = 0.26; 95% CI = 0.02, 0.49; p-value = 0.03) and inverse relationship with Reg1B concentrations measured in the stool samples (Coefficient = -0.32; 95% CI = -0.59, -0.05; p-value = 0.02). However, H. pylori infection was not associated with the indicators of childhood growth.

Conclusions

The study findings affirmed that the acquisition and persistence of H. pylori infection in the early years of life may exert an adverse impact on intestinal health, induce gut inflammation and result in increased intestinal permeability.

Infection with H. pylori, a substantial public health burden in the tropical countries, follows the similar mode of transmission analogous to Environmental Enteric Dysfunction (EED). There can be a complex interplay between H. pylori infection and EED–both of which can influence childhood growth–but the definite role of H. pylori infection contributing to EED and subsequent growth failure is poorly understood. In this study, the authors present data from an ongoing community-based nutrition intervention study and investigated the factors associated with H. pylori infection and identify its relationship with fecal biomarkers of EED and indicators of the nutritional status of the children hailing from a resource-poor urban settlement. They demonstrated the acquisition and persistence of H. pylori infection during early childhood. The study results also corroborate that infection with H. pylori had significant positive association with fecal Alpha-1 antitrypsin concentrations and an inverse relationship with Reg1B concentrations measured in stool samples of the children. The findings revealed in this study may contribute to a better understanding of the role of H. pylori infection in contributing to EED as well as alteration of gut function in the early years of life.