Nutrition Working Group -- Rosenbaum

1. SOMETHING TO SQUAK ABOUT…
Turning our attention to
neglected disease pathways …
Julia Rosenbaum, FHI360
USAID/WASHPaLS Project
April 2017

2. Pervasive growth stunting
• Achieving widespread reductions in child stunting in
LMICs remains elusive.
• Reduction of diarrheal morbidity and rigorous dietary
interventions have proven to be only modestly
successful at reducing stunting. (Bhutta et al., 2008; Dewey &
Adu-afarwuah, 2008; Humphrey, 2009)

3. The relationship between WASH
and growth faltering
• Poor conditions of water, sanitation and hygiene (WASH),
inadequate caregiving and food insecurity underlie these
immediate causes of child growth faltering.
• Some researchers have demonstrated that
inadequate WASH is responsible for over half the
global diarrheal disease burden. (Prüss-Ustün et al. 2014)
• Water, sanitation and hygiene interventions can reduce
diarrhea by 21% -50%+

5. • Evidence exists that the effect of WASH
interventions on linear growth is independent
of its effect on diarrhea
• In several studies, WASH had a bigger effect on
growth than it did on diarrhea.
The relationship between WASH and
growth faltering … BEYOND DIARRHEA

6. Evidence for the contribution of diarrhea
to chronic child undernutrition is mixed
• Evidence consistent that a higher cumulative burden of
diarrhea increases stunting risk (Checkley et al. 2008)
• Pervasive stunting increasingly attributed to
Environmental Enteric Disfuntion (EED or EE), associated
with poor WASH conditions. (Humphrey, 2009)

7. The Environmental Enteropathy Hypothesis
• A subclinical condition of the small intestine, called
environmental enteropathy (EE) or environmental
enteric disfunction (EED)
• Flattening of the villi of the gut, reducing its surface area
• Thickening of the surface through which nutrients must be
absorbed
• Increased permeability to large molecules and cells (microbes)
• Likely causes:
• Too many microbes in the gut
• Effects of toxins on the gut
Slides stolen from Cornell U Division of Nutritional Sciences, Laura Smith . R Stoltzfus, F Ngure, B Reid, G Pelto, M Mbuya, A Prendergast, J Humphrey

9. Sneak Preview…
WASHPaLS Literature Review:
Toward a hygienic environment
for infants and young children

10. Neglected pathways
• Interventions to improve WASH and reduce fecal
pathways to disease generally focus on
• increasing water supply,
• improving drinking water quality,
• hand hygiene, and
• sanitation (both through the reduction of OD and the adoption
of improved toilets).
• Largely absent/ not emphasized:
• Animal husbandry practices or proper disposal of animal
wastes
• IYC handwashing
• Geophagy

11. Safe Disposal of
Infant & Young
Child Feces

12. Unsafe IYC Feces linked with
• … higher environmental enteropathy scores
(0.82-point difference, 95% CI 0.11-1.53)
• …. significantly greater odds of being wasted
(weight-for-height z score <−2 SDs) (9% vs 0%, P = .024)
• … significantly reduced change in weight-for-age z-score
(−0.34 [95% CI −0.68, −0.01)
• … 5 times greater odds of detecting E. coli in areas
where children were observed playing. (George et al., 2015)
• … 97% of households had detectable E. coli
George et al “Unsafe Child Feces Disposal is Associated with Environmental
Enteropathy and Impaired Growth”

13. Exposure to Animal Feces

14. Animal feces are everywhere!
In one analysis in rural India (Schriewer et al., 2015)
• Microbial source tracking (MST) markers of animal
fecal contamination widely detected in households and
water sources.
• Nearly every fecal-oral pathway explored was
contaminated with animal feces in both the public and
private domains.
• Over 50% of household-stored water samples, 90% of
mothers’ and children’s hands, and 74% of public ponds
were contaminated with animal feces (mainly
ruminants).

15. Exposure to livestock a significant risk factor
• In a recent systematic review, 69% of studies reported an
association between exposure to domestic food-producing
animals and diarrheal illness. (Zambrano et al., 2014) Exposure to
domestic poultry doubled risk.
• In rural India, levels of both human and animal (mainly ruminant) fecal
contamination in households showed significant associations with subsequent
child diarrhea (Odagiri et al., 2016)
• Widespread fecal contamination found in rural settings in Bangladesh and
Ethiopia, where non-human fecal contamination increased with animal
ownership and contact. (Boehm et al., 2016) (Wegayehu, et al, 2013)
• Presence of animal feces in the domestic environment has been negatively
associated with hand cleanliness in mothers. (Headey et al., 2016)
• Children from households with animals with digestive disorders experienced
slower growth. (Mosites et al., 2016)

16. IYC frequently explore, crawl, sleep and
feed on contaminated environments
• In high-density, low-income neighborhoods in Accra,
Ghana, children <1 spend most of the time playing or
sleeping on the ground, while older children played on
the ground (but didn’t sleep outside) (Teunis et al., 2016).
• Animal feces more widespread where free-range animal husbandry
and corralling animals within children’s sleeping & play
environments are common.
• Several studies have isolated pathogenic bacteria
(Simango, 2006; Marquis, 1990) and other fecal bacteria
from sampled soil and chicken feces (Pickering et al.,
2012; Ngure et al., 2013).

17. Nutritional and economic benefit of
animals seems to wash out
While poultry ownership may be beneficial to child
growth…
• overnight corralling of poultry within the household dwelling may
present a concurrent risk for undernutrition. (Headey, 2016)
• having an animal corral within a child’s sleeping room was
associated with elevated EED scores and doubled the odds of
stunting. (George et al., 2015)

18. Alive & Thrive – Poultry and IYC Growth
Ethiopia, Vietnam, Bangladesh
• Animal feces were visible in 38–42% of household compounds
• Positively associated with household livestock ownership and
negatively associated with maternal and child cleanliness
• Presence of animal feces is associated with stunting
• in Ethiopia (β = −0.22),
• Bangladesh (β = −0.13), and in a
• pooled sample (β = −0.11),
• but not in Vietnam.
• Suggestive evidence that animal feces may be positively
associated with diarrhea symptoms in Bangladesh.
• While poultry ownership can be beneficial to child growth,
overly close exposure to poultry poses a concurrent risk factor
for undernutrition, most likely because of increased risk of
infection. (Headley et al 2016)

19. Some contrary evidence
• Ownership of healthy livestock may improve child
baseline health and decrease the impact of
infectious diseases that would otherwise lead to
stunting.
• Modest child growth benefit of owning household
livestock, with a ten-fold increase of livestock
ownership associated with lower stunting
prevalence in Ethiopia and Uganda (though not in
Kenya).
• Authors say that but that the “pathway has not been
well-evaluated and further research is needed.” Mosites et
al. (2016)

20. Little has been documented about the human
health risk from productive uses of animal feces
such as fuel, building material and/or fertilizer.

21. Household hygiene
• Poor environmental hygiene has been linked to EED and
growth faltering
• more hygienic household environment had lower levels of
parasitic infection, improved gut function, and improved growth
compared to their peers living in a contaminated environment
(Lin et al., 2013).
• Children living in clean household environments had 0.54 higher
HAZ, 22% lower stunting and 0.32 SD lower lactulose:mannitol
ratio (a test of EED) than children living in dirtier households.

23. Direct ingestion of feces and soil
Children learn by exploring their environment,
putting their hands and objects in their mouths
Hands into mouth
38 times in 6 hours
93% children eat dirt
17% eat chicken turds

24. Emerging Evidence and Renewed
Focus on Food Hygiene
• Food is among the most important factors in
transmitting pathogens that cause diarrheal illness.
(Motarjemi et al., 2012)
• An estimated 15%-70% of DD among young
children could be due to pathogens transmitted
through food. (Motarjemi et al. 1993; Esrey and Feachem 1989)
• Appropriate food hygiene practices have been
shown to reduce the risk of diarrhea by 33%.
(Sheth et al. 2006)

25. COMPLEMENTARY FOOD HYGIENE
• Most decline in HAZ IYC occurs during the
complementary feeding age. (Saha et al., 2009)
• In rural and urban Bangladesh, 18% of tested
complementary food samples for children were
contaminated with high levels of fecal coliforms (≥
100 CFU/g of food) and 29% were positive for E. coli.
(Islam et al., 2012)
• Freshly prepared foods had lower fecal indicator
bacteria counts as compared to leftover foods meant
for multiple feeding, and microbial counts increased
with the duration of storage at room temperature for
the leftover food.

26. % HH with E
coli + sample
E coil/
Per gram
Average E Coli
Per Day
Infant Food 0% 0 0
Drinking Water
54% 2 800
Soil in
laundry area 60-80% 70 1,400
Chicken feces
100% 10,000,000 10,000,000
So what is the relative risk of the pathways???

27. Laundry
Water
for IYC!
Playmats and pens
Animal corraling

30. Pioneering projects incorporate
products and behaviors

31. Explicit addition of improved
IYC behaviors to outreach

32. Playmats and Playpens

33. Animal corralling?? Chicken
diapers?

34. Reactions? Additions please!!??
Julia Rosenbaum
jrosenbaum@fhi360.org