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Exposure to Animal Feces and Human Health: A Systematic Review and Proposed Research Priorities
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Department of Environmental Health, Emory University, Atlanta, Georgia 30322 United States
*Phone: (404) 712-8767; e-mail: [email protected]
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Environmental Science & Technology

Cite this: Environ. Sci. Technol. 2017, 51, 20, 11537–11552
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https://doi.org/10.1021/acs.est.7b02811
Published September 19, 2017

Copyright © 2017 American Chemical Society. This publication is licensed under CC-BY.

Abstract

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Humans can be exposed to pathogens from poorly managed animal feces, particularly in communities where animals live in close proximity to humans. This systematic review of peer-reviewed and gray literature examines the human health impacts of exposure to poorly managed animal feces transmitted via water, sanitation, and hygiene (WASH)-related pathways in low- and middle-income countries, where household livestock, small-scale animal operations, and free-roaming animals are common. We identify routes of contamination by animal feces, control measures to reduce human exposure, and propose research priorities for further inquiry. Exposure to animal feces has been associated with diarrhea, soil-transmitted helminth infection, trachoma, environmental enteric dysfunction, and growth faltering. Few studies have evaluated control measures, but interventions include reducing cohabitation with animals, provision of animal feces scoops, controlling animal movement, creating safe child spaces, improving veterinary care, and hygiene promotion. Future research should evaluate: behaviors related to points of contact with animal feces; animal fecal contamination of food; cultural behaviors of animal fecal management; acute and chronic health risks associated with exposure to animal feces; and factors influencing concentrations and shedding rates of pathogens originating from animal feces.

Copyright © 2017 American Chemical Society

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Introduction

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Nearly two-thirds of human pathogens and three-quarters of emerging pathogens are zoonotic in origin. (1, 2) While research has focused on zoonotic transmission of respiratory and vector-borne pathogens, such as Ebola and West Nile Virus, less attention has been given to pathogens found in animal feces that are transmitted via water, sanitation, and/or hygiene (WASH)-related pathways, as illustrated by the classic “F-diagram” (Figure 1). (3) According to the Food and Agricultural Organization (FAO), “domestic animals such as poultry, cattle, sheep, and pigs generate 85% of the world’s animal faecal waste, proportionally a far greater amount than the contribution by the human population”; the fecal production rate can total to 2.62 × 1013 kg/year. (4) Insufficient separation of animal feces from human domestic environments, common in low-income countries, can lead to fecal-oral transmission of zoonotic pathogens through direct contact with humans and/or fecal contamination of fingers, food, and water sources.

Figure 1

Figure 1. Traditional F-Diagram showing potential fecal-oral transmission pathways. Adapted from Wagner, E.; Lanoix, J., Excreta disposal for rural areas and small communities. Monograph Series World Health Organization.1958, 39, 182. Copyright 1958, World Health Organization.

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Several pathogens of zoonotic origin are associated with acute gastrointestinal symptoms that can arise from contact with animal feces. (5) Children may experience long-term growth shortfalls after exposure to these pathogens, and pregnant women and the immunocompromised may also experience severe and/or long-term adverse health effects after infection with pathogens carried in animal feces. (6-9) Approximately one-third of deaths among children under five years due to diarrhea in the Global Burden of Disease 2015 report are attributed to pathogens that can be found in animal feces. (10) While some studies seek to identify a relationship between animal contact and diarrhea, not all etiologies of diarrhea are transmitted through animal feces. While many important viral enteropathogens (e.g., rotavirus) have limited zoonotic transmission, animal feces may play an important role in the transmission of some important etiologies of childhood diarrhea, such as Cryptosporidium, which substantially contributes to the childhood burden of diarrheal disease and has been associated with severe acute and long-term clinical manifestations, including child growth faltering. (11) Unlike rotavirus, there is currently no vaccine for Cryptosporidium and treatment options are limited and often unavailable in developing countries. Thus, preventive measures for such zoonotic pathogens are important for reducing disease burden. Though the total contribution of zoonotic transmission is unknown, it may be substantial, and it may vary by the virulence and animal host(s) of the specific etiologic agent, geographic and cultural context, and environmental conditions. (12)
Recent reviews, predominantly using observational data, suggest that improved WASH conditions are associated with better children’s health outcomes. (13-15) Yet randomized controlled trials in low-income rural settings have demonstrated mixed effects of such interventions on diarrhea, soil-transmitted helminth (STH) infection, trachoma, and stunting. (16-23) Even comprehensive WASH interventions may be insufficient to prevent growth faltering in rural settings. (24) One possible reason for the lack of health effects is suboptimal program fidelity and adherence, yielding less than universal coverage and use. (25) An alternative explanation is that because sanitation interventions have focused primarily on containment of human excrement, the lack of evidence for health effects in large intervention trials could be due to persistent exposure to fecal pathogens of animal origin among the study populations. (5, 26, 27) A recent systematic review and meta-analysis noted that domestic poultry and livestock exposure are associated with diarrheal illness in humans; (5) we expand on this review by exploring the risk of animal exposure on diarrhea, child growth outcomes, environmental enteric dysfunction (EED), pathogenic infection, trachoma, and STH infection.
Human exposure to animal feces is more common in developing countries where domestic animals and their animal feces may not be properly contained or separated from domestic environments. Though children and adults in high-income countries (HIC) can also be exposed to animals and/or their feces, potentially causing bacterial, helminth, and/or protozoan infections, (28-33) the risk may be greater in low- and middle-income countries (LMIC), where domestic animal ownership and middle- and small-scale animal production is more common in both rural and urban households (34) compared to households in HIC.
The primary objective of this systematic review was to examine what is known about human health impacts of exposure to poorly managed animal feces transmitted via WASH-related pathways in LMIC. We identified and synthesized existing literature to assess the extent to which exposure to poorly managed animal feces could affect health outcomes in humans. We modified the traditional “F-diagram” to focus on animal feces exposure in households and small-scale animal operations, in households with pets, and in communities with synanthropic rodents; through this lens we propose research priorities to better understand human exposure to poorly managed animal feces. We identified interventions that have been used to control human exposure to animal feces and summarized what is known about their effectiveness in reducing the presence of animal feces in the environment, preventing human exposure to animal feces, and/or limiting negative human health outcomes. Based on this review, we identified a set of priority research areas to improve our understanding of the human health burden associated with exposure to animal feces, with the ultimate goal of identifying potential control measures to reduce this burden in LMIC.

Materials and Methods

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Search Strategy

To assess the impacts of animal feces on human health, we searched for papers with terms for “animals, feces, exposure, and humans” (Supporting Information (SI) 1, p. 2). The search was limited to English- and Spanish-language studies and included papers published before October 3, 2016. We searched in the following databases: PubMed, Web of Science, Cochrane Library, EMBASE, and CAB Direct. We also included a partial search of the Environmental Sciences and Pollution Management (ESPM) database, but due to host database server challenges at the time of the search, 26% of full search results from this database could not be downloaded. We conducted a search of gray literature in International Food Policy Research Institute (IFPRI), Consultative Group on International Agricultural Research (CGIAR), International Livestock Research Institute (ILRI), Food and Agriculture Organization of the United Nations (FAO), U.S. Centers for Disease Control and Prevention (CDC), and the World Health Organization (WHO). We also included papers from personal libraries and literature collections, including a limited number of highly relevant studies that were published between October 2016 and September 2017. We included experimental and observational study designs. All study settings and populations were eligible for inclusion.

Selection of Studies

Search results were cataloged and organized in EndNote X7 (Clarivate Analytics, Boston, MA). Four researchers (GP, JS, LM, BW) examined every publication’s title and abstract to assess if the publication met one or more of the following inclusion criteria: (a) human exposure to poorly managed animal feces; (b) negative human health outcomes from exposure to animal feces (e.g., diarrhea, gastroenteritis, EED, trachoma, STH infections, child growth (anthropometric) outcomes, and infection by zoonotic pathogens); and (c) animal feces contamination of the environment (e.g., water or fields). First, the four researchers all independently reviewed an initial 150 publications to ensure consistency among the study team when determining if papers met the above inclusion criteria. Afterward, the remaining search results were divided equally among the four researchers who independently reviewed the title and abstract of their designated search results. We define poorly managed feces as animal feces that are not contained or separated from human domestic and public environments. We define exposure to animal feces as behaviors related to handling animal feces (e.g., spreading manure on fields or removing domesticated cat feces from litter) and human activity conducted in close proximity to animals and their feces (e.g., children playing on the ground where chickens also roam). While identifying publications that met the inclusion criteria, we simultaneously identified papers that discussed animal husbandry practices and animal feces/manure management, and we identified papers that discussed control measures for reducing human exposure to animal waste. If researchers were unable to make a decision about including or excluding a publication during the title and abstract review process, the publication’s features were discussed among the four researchers and a decision was made.
We excluded publications that discussed one or more of the following: no exposure to animals or animal feces, exposure to animal or animal feces in occupational or industrial settings (e.g., commercial farms), exposure to animal urine, animal health outcomes, human respiratory health outcomes, and diseases related to exposure to insect feces (e.g., Chagas Disease). We excluded papers from HIC because piped sanitation and piped water infrastructure are prevalent, and we wanted to explore how humans are exposed to animal feces in LMIC where sanitation and water infrastructure may be limited or nonexistent.
Two researchers (GP, JS) reviewed the full-text of publications that met the inclusion criteria to confirm the publication met the inclusion criteria as well as one of the following: (a) risk factors, such as exposure to or contact with animals or animal feces, associated with zoonotic infection; (b) animal husbandry practices/behaviors and information about animal feces management; or (c) control measures or interventions aimed at reducing human exposure to animal waste. Other areas of potential interest that were beyond the scope of this review include papers that focused on the epidemiology and etiology, antibiotic resistance, or animal shedding of zoonotic fecal pathogens. No publications from the gray literature met our inclusion criteria for this review.

Data Extraction and Synthesis

Data from papers deemed to meet the inclusion criteria were extracted into a prepiloted extraction form, which included research objectives, key findings, descriptions of study populations, descriptions of health outcomes, and descriptions of exposures to animals and/or their feces (SI Table S1). During synthesis, data were classified by health outcomes, pathogens of concern, exposures to common domestic animals, and regions in which the studies were conducted. Health outcomes, such as diarrhea and trachoma, were assessed by individual studies in a variety of methods including recall, health professional diagnosis, and/or testing. Publications that discussed control measures to remove or reduce the presence of animal feces were identified and classified according to control approach. We did not conduct a meta-analysis or a risk of bias assessment because of the heterogeneity of methods, exposures, and outcomes used across the studies included in the review. We conducted the systematic review according the evidence-based minimum requirements identified by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist (SI Table S2). (35)

Results & Discussion

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Our search yielded 12 425 unique results, of which the full texts of 329 articles were reviewed. A total of 62 publications met the inclusion criteria (SI Figure S1). Characteristics of publications included in this review are summarized in Table 1 (regions, health outcomes, and animals) and Table 2 (pathogens).
Table 1. Summary of Characteristics of Studies (n = 62)a Included in Review of Potential Health Impacts from Exposure to Animal Feces
Regionn (%)
Africa 
North Africa1 (2%)
Sub-Saharan Africa19 (31%)
Asia 
Middle East1 (2%)
South Asia19 (31%)
Southeast Asia9 (15%)
East Asia1 (2%)
South America12 (19%)
Oceania1 (2%)
Global1 (2%)
Health Outcomesn (%)
Diarrhea18 (29%)
Environmental Enteric Dysfunction2 (3%)
Helminth Seropositivity5 (8%)
Mortality1 (2%)
Nutrition and Growth Outcomes8 (13%)
Pathogens Found in Stool17 (27%)
Trachoma3 (5%)
Hookworm-Related Cutaneous Larva Migrans1 (2%)
Other: human behaviors/practices5 (8%)
No Health Outcomes Specified14 (23%)
Animaln (%)
Livestock 
Buffalo5 (8%)
Cattle25 (40%)
Goats19 (30%)
Sheep14 (22%)
Pigs9 (14%)
Poultry (chickens, ducks, geese, quail)29 (46%)
Synanthropic Rodents3 (5%)
Pets/Free-Roaming 
Cats11 (17%)
Dogs14 (22%)
Other (horses, guinea pigs, rabbits)2 (3%)
Not Specified13 (21%)
a

A total of 62 unique publications were reviewed. The total N for Regions, Health, Outcomes, and Animals is greater than 62 because publications that assessed multiple regions, health outcomes, or animals in their study were counted for each unique region, health outcome, or animal.

Table 2. Summary of Pathogen Characteristics of Studies (n = 62)a Included in Review of Potential Health Impacts from Exposure to Animal Feces
Pathogensn (%)
Bacteria 
Aeromonas hydrophila1 (2%)
Bacteriodales spp.1 (2%)
Campylobacter spp.9 (15%)
Chlamydia trachomatis3 (5%)
Escherichia coli11 (17%)
Klebsiella spp.1 (2%)
Salmonella spp.5 (8%)
Shigella spp.5 (8%)
Vibrio spp.4 (7%)
Yersinia spp.2 (3%)
Helminths 
Ascaridia spp.1 (2%)
Ascaris spp.4 (7%)
Clonorchis spp.1 (2%)
Echinococcus spp.2 (3%)
Enterobius spp.1 (2%)
Hookworm (Ancylostoma spp.)7 (11%)
Hymenolepis spp.1 (2%)
Schistosoma spp.3 (5%)
Spirometra spp.1 (2%)
Strongyloides spp.3 (5%)
Taenia spp.1 (2%)
Toxocara spp.6 (10%)
Trichuris spp.6 (10%)
Microsporidia 
Enterocytozoon bieneusi1 (2%)
Protozoa 
Blastocystis hominis1 (2%)
Cryptosporidium spp.10 (16%)
Cyclospora cayetanensis2 (3%)
Entamoeba spp.6 (10%)
Giardia spp.15 (24%)
Isospora belli2 (3%)
Toxoplasma spp.1 (2%)
Trichomonas hominis1 (2%)
Viruses 
Adenovirus2 (3%)
Astrovirus1 (2%)
Hepatitis E virus1 (2%)
Rotavirus5 (8%)
a

A total of 62 unique publications were reviewed. The total N for all pathogens is greater than 62 because publications that assessed multiple pathogens were counted for each unique pathogen.

Most of the studies we identified for this review were cross-sectional studies (n = 42); other study designs included case-control (n = 3), experimental and quasi-experimental (n = 2), longitudinal (n = 2), cohort (n = 4), and qualitative studies (n = 1). The remaining publications, reported on secondary data analyses (n = 1), a conceptual model (n = 1), or systematic review/meta-analysis (n = 1). Study populations included children, adults, animals, and environmental samples (e.g. stool, blood, water). Most of the studies were conducted in Asia (n = 30), but this review also includes studies conducted in Africa (n = 20), South America (n = 12), and Oceania (n = 1) as well; one literature review included papers from around the globe. Relevant characteristics of the publications included in this review are presented in SI Table S3.

Impact of Exposure to Animals and/or Animal Feces on Human Health

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Most studies assessed exposure to animal feces based on contact with or presence of animals in the environment. Few (n = 9) measured direct human contact with animal feces per se. We illustrate the role of exposure to animal feces and/or contact with or presence of animals and its impact on WASH-related health outcomes in Figure 2. Below we synthesize findings for each of the health outcomes considered, including diarrhea, child growth, EED, pathogen isolation in human stool (bacterial, protozoan, microsporidian, viral), trachoma, and STH infections.

Figure 2

Figure 2. Impact of exposure to animal feces and/or contact with animals to human health.

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Diarrhea

Heterogeneous effects of exposure to animals and animal feces on human diarrheal illness were observed among the 18 studies examining diarrhea in this review. A systematic review and meta-analysis found consistent evidence of a positive association between domestic poultry and livestock exposure and diarrheal illness. (5) Animals housed in living quarters increased the risk of diarrhea and/or infection by enteric pathogens in several studies and increased the risk of longer durations of diarrhea. (36-41) Living with chickens infected by zoonotic enteric pathogens increased the risk of diarrhea among children in Lima, Peru. (39)
No associations were found between the presence of animals or animal feces and diarrhea or enteric infection in urban Accra, Ghana and rural Odisha, India. (42, 43) An assessment of Demographic Health Surveys (DHS) from 30 sub-Saharan African countries found an inconsistent relationship across contexts between childhood diarrhea and household livestock ownership; 13 countries indicated livestock ownership as a risk factor but 10 countries exhibited a protective association likely due to confounding with socio-economic status and varied access to improved water and sanitation infrastructure. (26) Cattle ownership in Madagascar was found to be protective against severe diarrhea. (44)

Child Growth

Exposure to fecal pathogens of animal origin may impair child growth, although these effects are not consistently found in the literature (n = 8). For most studies, child growth was measured using anthropometric measurements to calculate standardized age- and sex-specific height-for-age Z-scores (HAZ), weight-for-age Z-scores (WAZ), and weight-for-height Z-scores (WHZ) to classify levels of stunting, being underweight, and wasting, respectfully. In a study in rural Ethiopia, poultry ownership was positively associated with child HAZ, but corralling poultry indoors at night was negatively associated with child HAZ; no association was found between corralling animals indoors at night and child HAZ for other animal species (cattle, goats, sheep, pack animals). (45, 46) Several studies found no association between livestock ownership and child HAZ and WAZ, though livestock diseases might be related to lower child HAZ and WHZ in some groups in rural Kenya. (43, 47) The presence of animal feces in household compounds was negatively associated with child HAZ in rural Bangladesh and Ethiopia. (40)
A recent analysis of agricultural, nutritional, and interview data, along with anthropometric measurements from sub-Saharan Africa, revealed inconsistent evidence for the effects of animal ownership and consumption of animal-sourced foods on child growth. Children in households that consumed animal-sourced foods in Rwanda, Uganda, and Malawi had better anthropometric scores (WHZ and HAZ) than those that did not consume animal-sourced foods; however, children who consumed animal-sourced foods in Ghana and Senegal had lower relative anthropometric scores (WHZ (Ghana only) and HAZ). (46) The analysis of DHS from 30 sub-Saharan African countries similarly found inconsistent results, but data revealed a slight protective effect of the number of animals owned on child stunting. (26)
Child growth effects may be mediated by animal containment and housing practices. Children in households that kept poultry outside the home had significantly better HAZ compared to those in households that kept poultry inside the home in rural Ethiopia. (45) Similarly, in rural Bangladesh the odds of being stunted were higher among children in households with animals corralled in sleeping quarters versus households where animals were not corralled in sleeping quarters. (48)

Environmental Enteric Dysfunction (EED)

Two studies in this review suggest that exposure to animals and animal feces might increase the risk of EED, also referred to as environmental enteropathy, an impairment of intestinal function evident in many young children in low-resource settings that leads to growth faltering and cognitive impairment. (49-54) Children sleeping in households with animal corrals in the sleeping quarters had significantly higher EED scores (calculated from fecal biomarker measurements) than those without animals in the sleeping quarters in rural Bangladesh. (48) Among rural Malawian children, animals sleeping in the same room as the children, combined with use of potentially contaminated water sources and the absence of household pit latrines, was positively associated with EED. (55)

Pathogen Isolation in Human Stool

Several studies examined associations between exposure to animals and/or their feces to subsequent isolation of pathogens in human stool.
Among bacteria, Campylobacter spp. infection was common among children living with domesticated animals, especially poultry, compared to children not living with animals, because children were likely to be in direct contact with chicken feces. (5, 41, 56, 57) A study in peri-urban Peru noted that chickens, dogs, and cats were commonly infected with C. jejuni. (36) Genetic analysis of animal and child stool samples in semirural Ecuador found that C. jejuni sequence types were identical between children and chickens, dogs, guinea pigs, and rabbits; atypical enteropathogenic Escherichia coli (aEPEC) sequence types were identical between children and pigs, dogs, and chickens. (58)
Among protozoal pathogens, Cryptosporidium spp., Giardia spp., and Entamoeba spp. have been associated with exposure to animals. Cryptosporidium spp. identification in child stool was associated with the presence of chickens in the household in Cambodia. (59) In urban Kenya, a study among HIV/AIDS patients found that cryptosporidiosis was associated with contact with animals, (60) and in urban Democratic Republic of the Congo, exposure to farm pigs increased the odds of Cryptosporidium infection among HIV/AIDS patients. (61) Individuals with household pets were 2.6 times more likely to be infected with G. duodenalis assemblage A compared to those without pets in Malaysia. (62) A study of outpatient stool samples from an urban hospital in Yemen found that contact with animals increased the risk of any intestinal protozoan infection (G. duodenalis, E. histolytica, E. dispar) and single infection with Entamoeba spp.; single infection of G. duodenalis was not associated with contact with animals. (63) A study in rural China among individuals with pulmonary tuberculosis found that those raising chickens, ducks, or pigs, and working farmlands barefoot to be significantly associated with protozoan (Blastocystis hominis, Entamoeba spp., Trichomonas hominis) and helminthic infections (hookworm, Trichuris trichiura, Ascaris lumbricoides, Clonorchis sinensis), respectively. (64)
Immunocompromised populations are particularly susceptible to infection by microsporidia, specifically Enterocytozoon bieneusi. A study of microsporidiosis in HIV patients in hospitals in Lima, Peru found that contact with duck or chicken fecal droppings was a risk factor for infection with the E. bieneusi genotype, Peru-1, as were lack of running water, flush toilets, or garbage collection. (65) Among HIV/AIDS patients in Kinshasa, Democratic Republic of the Congo, exposure to farm pigs was associated with higher odds of infection with E. bieneusi or Cryptosporidium spp. (61) In urban India, a study among HIV-positive individuals found that contact with pets and other animals increased the odds of infection with enteric pathogens, including bacterial, protozoan, helminthic, and microsporidian species. (66)
Several studies reported no association between presence of or contact with domestic animals or rodents and their feces and pathogenic infection with certain species of bacteria, (42, 67, 68) protozoans, (59, 63) and viruses. (69)

Trachoma

Exposure to animals and animal feces might increase the risk of trachoma, an infection by the bacterium Chlamydia trachomatis, by potentially providing breeding sites for flies that propagate the infection. The studies in this review do not assess if flies carrying C. trachomatis actually bred on animal feces; the presence of human feces in or near study sites may be a confounding factor. In rural Nigerian households, the presence of animal feces in household compounds was a risk factor for trachomatous inflammation-follicular (TF), a precursor condition to blinding trachoma. (70) In rural Ethiopian households, active trachoma, measured by TF and trachomatous inflammation (TI), was more common in children in families who specifically housed their cattle in their sleeping quarters, though cattle ownership was not associated with trachoma risk. (71) Another study in rural Ethiopia also noted that the presence of animal feces near the house was associated with active trachoma in at least one child in the study households. (72)

Soil-Transmitted Helminth (STH) Infection

Evidence suggests that exposure to animals and animal feces, particularly those of cats and dogs, leads to an increased risk of STH infections. Individuals in urban, low-income households in Brazil were more likely to be diagnosed with hookworm-related cutaneous larva migrans (HrCLM), a parasitic skin disease caused by feline or canine hookworms, if animal feces were present in the compound. (73) Dog owners in Chile and Argentina displayed positive human seropositivity to Echinococcus granulosus and Toxocara canis, respectively. (74, 75) Similarly, the presence of dogs and their feces significantly contributed to children being seropositive for toxocariasis in Sri Lanka. (76) Pregnant women in Bali exposed to oocyst-positive cat feces in their environment were more likely to be serologically positive for Toxoplasma gondii than pregnant women who were not exposed to oocyst-positive cat feces. (77)

Pathways of Exposure to Animal Feces

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The means of characterizing exposure to animals and animal feces varied considerably in the literature we reviewed. Researchers assessed presence of or contact with animals, presence of or contact with animal feces, animal ownership, environmental contamination of public and domestic spaces, and risky husbandry practices (e.g., using cow dung as cooking fuel and slaughtering practices) through structured observations and semistructured interviews. Most publications assessed impacts of raising poultry (chickens, duck, geese, quail) and cattle; studies also assessed impacts of exposure to goats, dogs, sheep, cats, pigs, buffalo, synanthropic rodents (mice, rats), and less commonly, horses, guinea pigs, and rabbits.
We reviewed the literature to identify the extent of human-animal contact with attention to regional, cultural, and urban-rural contextual differences. The evidence of human-animal contact between regional and cultural contexts revealed anecdotal study site-specific information, but did not provide a sufficiently generalizable set of behaviors. The comparative risk of exposure to animal feces in urban compared to rural areas is therefore difficult to determine.
Figure 3 illustrates the pathways for human exposure to zoonotic fecal pathogens using a modified F-diagram. We distinguished transmission pathways dependent on animal species and behaviors versus pathways dependent on human behaviors and practices; the pathways corresponding to human behaviors are independent of the animal species that is the source of the fecal exposure. Below we present the evidence around each of the exposure pathways highlighted in Figure 3; the numbers correspond to the pathways in Figure 3.

Figure 3

Figure 3. Modified F-diagram showing transmission routes of animal feces to humans. Adapted from Wagner, E.; Lanoix, J., Excreta disposal for rural areas and small communities. Monograph Series World Health Organization.1958, 39, 182. Copyright 1958, World Health Organization.

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Pathway 1: Contamination of Water Sources

Contamination of both source and stored drinking waters is an important human exposure to animal feces. Several studies demonstrated that open ponds and surface waters are more susceptible to contamination by animal feces, though significant contamination has been observed in public and private tube wells also. (27, 78, 79) In rural India, higher sheep populations in villages increased the odds of detecting higher concentrations of Cryptosporidium spp. in public ponds. (80) Humans sharing water sources with livestock represents a particularly risky behavior in low-income settings. (78, 81-83)

Pathway 2: Contamination of Soil

Many of the pathways for exposure to animal feces occur directly in and around the domestic environment. We found consistent evidence of animals contaminating fields and soil by indiscriminate defecation. Positive associations were found between seropositivity for helminths and soil contaminated by dog and cat feces in households and public settings (e.g., parks, playgrounds). (74, 76) Stray, free-roaming cats and dogs contaminated domestic and public environments with Toxoplasma spp. and helminth eggs in rural and urban communities in LMIC. (29, 30, 84, 85)
Ruminant fecal markers were observed in soil and hand rinse samples from households that did and did not own ruminant species in Bangladesh. (86, 87) Widespread chicken feces contamination has been observed in household kitchens and backyards; (88) chickens might therefore be of particular concern in household environments, because children (up to five years old) have been observed to have contact with chicken feces an average of 2.9 times in a 12 hour span. (57)
Soil was contaminated during the use and disposal of manure on agricultural or residential areas as fertilizer. (83, 89, 90) Manure effluents may also be discharged from cattle storage, potentially contaminating surrounding land. (81)

Pathway 3: Contamination of Food

In the United States and other HIC, where human waste is arguably well-controlled, the burden of enteric disease is largely related to foodborne or animal-associated outbreaks. Most of the important bacterial pathogens of foodborne illness in the United States are transmitted by animals. (91) Even in the case of sophisticated human waste containment, pathogens from poorly managed animal feces can directly contaminate food during the food production process, particularly related to slaughter. As such, foodborne exposure to animal feces in LMIC is likely an important pathway that warrants further research.
Our search, however, uncovered few studies (n = 2) that reported on the contamination of food from animal feces. Campylobacter spp. contamination was found in 34.6% of samples of various types of goat meat collected in the Democratic Republic of Congo. (92) Fresh produce collected from a suburban market in Vietnam was widely contaminated with parasite ova excreted by both humans and animals. (90)

Pathway 4: Contamination via Flies

Flies, potential vectors of fecal contamination, may be associated with negative health outcomes. Three studies specifically examined flies as vectors for trachoma infection (70, 72) and diarrheal illness. (38) In rural Ethiopia and Nigeria, the presence of flies in the home (due to presence of cows, waste disposed near the home, and defecation near the home) (72) and on the face (70) was positively associated with trachoma. In rural India, higher fly densities were associated with longer durations of diarrhea. (38) Also, the absence of animals in or near the home was protective against high fly densities. An additional study in rural Indian households assessing the presence of cowsheds and the presence of flies noted that fly counts were higher in households owning cowsheds versus those without cowsheds. (43)

Pathway 5: Contamination of Human Hands

Cohabitation of animals and humans is a common practice in LMIC and is one of the primary risk factors we identified in this review. Though most studies did not explicitly observe human-to-animal contact, we used animal ownership and the presence of animals in and around households as a proxy for direct contact with animals, a pathway important for exposure to animal feces. In many domestic settings, livestock, including cattle and poultry, were housed in the family’s sleeping quarters, (45, 48, 63, 89) increasing the potential for contamination in the household environment. Households kept livestock in sleeping quarters at night to protect them from thieves or from being hunted by other animals. (89) Poultry were generally allowed to scavenge for food inside and outside living quarters in rural villages in Bangladesh. (89) Household members directly contacted animal feces when handling manure, sometimes handling cow manure from E. coli-positive and negative herds with bare hands. (81, 83, 93)
Multiple studies in rural and urban settings found positive associations between high levels of contact with animals and/or animal feces and negative health outcomes. (33, 62, 69, 74, 94, 95) The presence of animal feces in household compounds has been associated with diarrhea, lower HAZ, and HrCLM. (37, 40, 73) Contact with manure has also been associated with the presence of antibodies to C. jejuni and pathogenic E. coli. (28)

Pathway 6: Contamination of Fomites

Other sources of direct or indirect contamination by animal feces include fomites, such as cooking and infant feeding utensils and toys. Two studies in South Asia evaluated environmental fecal contamination in rural households using toys which may be more likely to come into direct contact with animal feces as they are used for play. In rural India, the average fecal contamination of toys increased as the number of animal fecal piles observed in the household or within the compound increased. (96) The authors suggest that the fecal contamination detected on the toys is likely from both human and animal feces. In rural Bangladesh, fewer toys were contaminated with E. coli (used as a fecal indicator bacteria) in households in villages with more than 50% latrine coverage, no open defecation, handwashing facilities with soap, protected source water in dwellings, safe disposal of child feces, and no animals present in the household but used plaster floors with cow dung. (97) In this study, the households’ substantial WASH infrastructure used to limit human fecal contamination likely played a role in minimizing fecal contamination in the household, but the absence of animals is also noteworthy. Interestingly, the study noted that households with floors of soil or mud surfaces in the living and entrance areas had statistically lower amounts of bacteria on toys compared to households with cement floors, but there was no difference in contamination levels of the toys between households that plastered with cow dung versus households that did not plaster with cow dung. (97)
Two studies in this review examined fecal contamination on cooking and feeding utensils. In a peri-urban community in Lima, Peru, a study of environmental contamination of household objects, including infant bottle nipples, feeding bottles, spoons, and can openers, found that 35% of the objects (n = 80) were positive for E. coli cultures. (36) Another household-level study found that infants’ cups and spoons yielded E. coli cultures in 23% of households (n = 5). (88) In these studies, indirect contamination of fomites likely occurred when the fomites dropped onto contaminated floors or were handled by contaminated fingers; direct exposures of fomites to animal feces were not addressed in these studies. (36, 88)

Interventions Limiting Exposure to Animal Feces

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We adapted the traditional F-diagram to show pathways of human exposure to animal feces and assessed potential interventions along those pathways (Figure 4). While “secondary” barriers to block transmission of animal feces to humans are capable of controlling both human and animal feces, “primary” barriers are specific to controlling exposure to animal feces. These primary barriers have largely not been considered in traditional WASH interventions designed to limit exposure to human feces, and few studies have evaluated their potential in reducing the burden of animal feces on human health. Our review uncovered only seven intervention studies specifically aimed at controlling this primary barrier of exposure to animal feces. The control measures that have been evaluated and/or suggested as potential interventions in the studies included in this review are described below; Table 3 summarizes these intervention studies.

Figure 4

Figure 4. Modified F-diagram including interventions that can block human exposure to animal feces. Adapted from Wagner, E.; Lanoix, J., Excreta disposal for rural areas and small communities. Monograph Series World Health Organization.1958, 39, 182. Copyright 1958, World Health Organization.

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Table 3. Summary of Trials Evaluating Potential Interventions Limiting Exposure to Animal Feces
interventioninterrupted fecal-oral pathwayreferencedescription of interventionstudy contexteffectiveness of intervention
separating chickens from human living quartersfeces → fluids, food, fingersHarvey et al. (2003)provided wooden corrals with commercial fish netting walls and fiberglass roofsperi-urban Peruuptake was low among households that did not corral their poultry before the study
 separated poultry by age, sex, and/or species corralling did not eliminate child exposure to poultry
Oberhelman et al. (2006)provided corrals sized based on number of chickens in household and the size of available areas on the property outside living quartersperi-urban Peruchicken feces from corralled chickens was colonized with Campylobacter spp. more often than control group
     corralling might have increased the risk of campylobacteriosis in children
 
providing animal feces scoopsfeces → fluids, fields, fingersBoehm et al. (2016)provided metal scoops for removal of animal feces and safe disposal in a dual-pit latrinerural Bangladeshruminant fecal markers detected more often in stored water of control vs sanitation compounds
 provided concrete ring-based dual-pit latrines with slabs, water seals, and superstructures impossible to disentangle effects of provision of metal scoop from other components
 provided ″potties″ for young children  
Hussain (2013)provided “sani-scoops” for disposal of child and animal fecesrural Bangladeshreported use of the hardware was relatively high
   provide “potties” for young children minimal differences detected in the presence of human and animal feces in compounds between baseline and follow-up visits
 
creating safe child play spacesfeces → fingers; fields → humanSHINE Trial et al. (2015)provided safe play areas among a package of other WASH interventionsrural Zimbabweongoing trial; results not yet published
 
improving animal veterinary careanimal → fecesHall et al. (2012)increased veterinary care of dairy cattlerural Bangladeshincreased access to health services, human and veterinary, in most villages reduces exposure to emerging infectious disease hazards, as well as removing livestock from one in three households, improving manure management in all villages, and improving water and latrines in all villages
   encouraged behavior change to reduce exposure to manure  
   improved agricultural production  

Separating Chickens from Human Living Quarters

Cohabitation with animals has been associated with negative health outcomes. Animal containment practices can reduce human exposure to animal feces contamination in domestic environments. However, according to two studies that evaluated the effects of separating chickens from human living quarters in peri-urban areas of Lima, Peru, corralling chickens did not eliminate child exposure to poultry; it might actually increase the risk of campylobacteriosis potentially due to continued exposure to chickens and/or from increased concentrations of Campylobacter spp. in the corralling area. (41, 98) Harvey et al. evaluated an intervention to contain poultry in wooden corrals with commercial fish netting walls and fiberglass roofs, in addition to separating poultry by age, sex, and/or species. (98) Households that used corrals most of the time before the study consistently used the experimental corrals from the start; households who let their poultry roam before the study intervention housed their poultry in corrals less consistently. Despite efforts to separate children from poultry, some children were still exposed because they helped catch poultry and move them into the corral, climbed on corral walls and doors, poked fingers through the netting, entered corrals to play with the poultry, or helped with daily animal care. In another area of peri-urban Lima, researchers installed chicken corrals in intervention households. (41) They found that chicken feces from the control group were colonized with Campylobacter spp. more often than that from the corral group, but both groups were heavily colonized (63.9% and 58.1% of chicken stool samples, respectively). The rate of diarrhea in children was higher in the corral group (2.79 episodes per person per year [epy]) than the group without corrals (2.07 epy; p = 0.017), suggesting that chicken corralling may have increased the risk of Campylobacter-related diarrhea in children from children entering and handling the chickens in the corrals and/or encouraged the children to interact with the chickens due to close proximity of the corrals to the home. In addition, the corrals concentrated chicken feces in a single area that could have contributed to an increased concentration of Campylobacter spp. in the area.

Providing Animal Feces Scoops

Similar to animal containment practices, promotion of animal waste removal from the domestic environment and proper disposal could disrupt the contamination of environmental reservoirs by animal feces. Though sanitation interventions have primarily focused on containing human feces by providing improved latrines, some studies have added components to encourage the safe disposal of animal feces as well. The WASH Benefits trial provided a metal scoop to households for removal of animal feces from the environment and safe disposal in a dual-pit latrine as part of a sanitation intervention in rural Bangladesh. (99) The authors hypothesize that the use of the metal scoops might remove animal feces from sanitation compounds, but might ultimately contaminate the community’s water source downstream of the disposed animal feces. While the intervention group had lower ruminant fecal markers, the scoop was coupled with provision of a household dual-pit latrine as well as potties for young children, so disaggregating the impact of animal feces disposal was not feasible. (86)
In rural Bangladesh, households were provided potties and “sani-scoops”, hoe-like tools for disposal of child and animal feces. Although reported use of the hardware was relatively high, minimal differences were detected between the presence of human and animal feces in compounds at baseline and follow-up visits. (100) Interviews with study participants revealed that liquid feces was hard to remove from uneven or hard surfaces with the sani-scoop, and animal feces was not generally perceived as “disgusting”. Additionally, household members were unlikely to change their habits of sweeping and cleaning courtyards of feces only at certain times during the day, potentially exposing them to fecal contamination at other times of day. (100) To reduce exposure to animal feces, education regarding safe animal feces disposal methods might be necessary as a complement to provision of sanitary scoops designed to remove animal feces.

Reducing Contamination of Environmental Sources by Controlling Animal Movement

Soil is oftentimes a reservoir for animal feces contamination in both public and domestic areas, and animal containment measures may reduce animal fecal contamination. In urban Brazil, fencing around public sandboxes was a significant protective factor against soil contamination of helminths from dog feces because the fences prevented stray dogs from accessing the area. (84)

Creating Safe Child Spaces

Rather than corralling animals, protective and hygienic barriers may prevent humans, specifically children, from coming into contact with animal feces. Since there are constant opportunities for young children to put contaminated fingers in their mouths or ingest feces-contaminated soil, creating spaces for children separate from livestock could reduce exposure to animal feces. The Sanitation, Hygiene, and Infant Nutrition Efficacy (SHINE) trial in Zimbabwe is testing this approach by providing households with safe play areas for children in addition to a package of other water and sanitation interventions. (101) The trial is ongoing, and results have not yet been published.

Improving Animal Veterinary Care

Veterinary care may reduce the spread of zoonotic fecal pathogens from livestock and domestic animals by reducing pathogen carriage in animals. In Bangladesh, exposure to emerging infectious disease hazards were significantly reduced by removing livestock from one in three households, improving manure management in all villages, improving water and latrines in all villages, and increasing access to health services–human and veterinary–in most villages. (102) The intervention also increased income from animal agriculture.

Promoting Handwashing and Domestic Environment Hygiene

Handwashing and domestic hygiene have been recommended by several studies finding positive associations between animal exposure, raw vegetable consumption, geophagy, or lack of handwashing before meals and zoonotic pathogenic infection. (36, 56, 62, 74, 103) Unlike the animal feces “sanitation” interventions, handwashing and domestic hygiene are designed to protect humans from exposure to both animal and human feces. Lack of handwashing might be a generalizable and important behavior to target; another study found that handwashing by mothers was infrequent and children placed their hands in their mouths 38 times in 130 h on average. (88) However, we did not find any studies that explicitly examined the effects of handwashing after contact with animals.

Limitations

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We included all studies that meet the inclusion criteria regardless of methodological rigor. A majority of the publications are cross-sectional studies, making it difficult to assess the causal attribution of exposure to animal feces on human health. Due to the lack of in-home observations, most studies we reviewed used surveys and interviews assessing animal ownership or contact with animals as proxies for exposure to animal feces. Such exposure measures might be poor indicators of true exposure to animal feces, and in fact, could measure behaviors associated with potential health benefits to households. For example, a study in rural Ethiopia carefully looked at the benefits of poultry ownership on egg consumption versus the risks posed by corralling poultry inside the home, (45) but few studies empirically address these competing risks and benefits. There is also limited research on specific exposure pathways to animal feces and important confounding variables are not well understood or quantified. Due to the use of household interviews, studies were subject to recall bias when participants were asked to self-report past bouts of diarrhea. The use of convenience sampling methods, instead of random sampling methods, may have led to selection bias. Many of the studies included in this review had small sample sizes, thus preventing them from achieving sufficient power to detect many of the health outcomes examined in this review.

Future Research

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Our review highlights the scarcity of information available on the human health impacts of exposure to poorly managed animal feces transmitted via WASH-related pathways. To accurately capture human exposure to animal feces, future research could prioritize longitudinal studies with in-home observation methodologies. In addition, data to inform a rigorous assessment of the contribution of poorly managed animal feces to the global burden of disease is not available. Yet many associations between some measure of animal or animal feces exposure and health effects have been explored, and interventions designed to control human fecal waste will likely lead to suboptimal health gains in the absence of efforts to control animal feces in the same environment. Understanding the true burden of disease from poorly managed animal feces given the current infrastructure and behavioral contexts would provide important guidance for policy and programs.
It would be of considerable value to categorize and measure exposure to animal feces and to develop and evaluate interventions to mitigate that risk. Using direct observations and interviews/discussion with domestic animal owners, household members including women and children, veterinarians, and community leaders, more data are needed to

  • understand the key behaviors and contexts associated with exposure to animal feces;

  • identify key points (“hot spots”) of human contact with animals and/or their feces in different contexts (e.g., domestic, community);

  • understand the factors associated with direct contamination of food from poorly managed animal feces, particularly in food markets and noncommercial agricultural/meat production facilities; and

  • identify cultural behaviors that influence animal husbandry and animal feces management practices.

Understanding the various pathways and behaviors that expose humans to animal feces could allow researchers develop innovative interventions limiting such exposures in LMIC. Behavioral approaches to WASH should be evaluated further to understand their potential for controlling human exposure to animal feces. Our review demonstrates that many people did not feel disgust toward animal feces (100) and exposure to poorly managed animal feces might occur at the community-level rather than just the household-level. An evaluation of a community-led total sanitation (CLTS) program in rural Mali found that households that participated in the CLTS program were less likely to have observable animal feces in their compound courtyard; (20) CLTS programs integrating animal feces management could therefore be considered as potential control measures. Interventions executed in HIC, such as building bridges across streams to reduce point source contamination of waterways by livestock, could be also adapted for LMIC. (104)
Once the various pathways of human exposure to animal feces are explored and understood, it would be possible to calculate specific health risks associated with exposure to animal feces, including both acute infectious diseases and chronic sequelae, such as EED and growth faltering, by conducting intervention trials. These intervention trials can measure before-and-after health outcomes among study populations who are provided interventions to limit or eliminate exposure to animal feces across multiple pathways compared to health outcomes in similar study populations who are not provided interventions to limit or eliminate exposure to animal feces. In addition to understanding the human behaviors and possible health outcomes associated with exposure to animal feces, future laboratory and field-based research must also consider pathogen biology by

  • quantifying the concentration and shedding rates of pathogens in the feces of animal hosts and understanding the factors that determine variability in these parameters;

  • quantifying die-off rates of pathogens outside of animal hosts and the factors that determine them;

  • understanding the factors controlling the fate and transport processes of pathogens outside of the animal host, under varying environmental conditions; and

  • understanding how antibiotic usage in humans and animals may be contributing to antibiotic resistance of zoonotic pathogens.

These types of data will be critical for parametrizing quantitative microbial risk assessment models and transmission models that can provide important insights on zoonotic transmission of pathogens from animal feces to humans. Studies could also take advantage of new molecular techniques that provide insights into transmission processes, such as microbial source tracking, (105) strain typing, multiplex enteropathogen assays, (106, 107) and metagenomics. (108)
In addition, work is needed to understand the role of exposure to animal feces on negative human health outcomes in various rural, urban, and peri-urban contexts, from human host and pathogen biology to overarching public policy. This is illustrated in Figure 5, a diagram showing priority research gaps in assessing the role of contact with animal feces on human health, which we adapted from the socio-ecological model. (109) The potential for acute and chronic human health impacts to manifest from exposure to animal feces is dependent on biology within the human host (i.e., intestinal microbiome), including age- and sex-dependent susceptibilities to different zoonotic fecal pathogens and potential immunities developed from low-level exposures to animals and their feces. To understand the health risks associated with exposure to animal feces, it is crucial to understand the microbiology of pathogens found in animal feces, including their shedding and die-off rates and their transport processes. Human behaviors and practices are additional vital elements to assessing human health outcomes from exposure to animal feces. At the individual level, it is important to understand knowledge around risks and preventions of exposure to animal feces. In LMIC, gender and age divisions in responsibility for care, decisions, and the control of livestock production are common. (93, 110) Gender and age divisions in labor should be explored further to understand how these variables influence risk of exposure to animal feces. Future research could characterize human behaviors in the household that result in exposure to animal feces, such as animal housing and containment practices or animal feces management. Our review points to the probable importance of community-level animal feces contamination on the human health burden, particularly in regards to food contamination in markets, soil contamination in the public environment from free-roaming animals, and contamination of community water sources; as such future research should investigate traditional husbandry practices in different regions and contexts. At the policy level, it would be valuable to monitor and evaluate the effect of national policies and regulations aimed at promoting animal health (e.g., immunization, feed standards), veterinary care (e.g., neutering/spaying policies), and safe management of animal manure and feces.

Figure 5

Figure 5. Priority research gaps in assessing human health impacts from exposure to poorly managed animal feces. This figure, an adaption from the socio-ecological model, represents how the “spheres of influence,” from human host and zoonotic pathogen biology to national policies, influence the health of the human host. Example items for future research within each sphere are provided.

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One particularly interesting line of inquiry would be to evaluate the trade-off between the nutritional benefits of livestock ownership with the health risks associated with exposure to animals. Many development projects promote animal husbandry as a way to improve nutrition and livelihoods, yet this review highlights the ways that contact between animal feces and humans may potentially be deleterious to health, especially in children. This trade-off was highlighted by several of the articles in this review. (26, 44) Once more information is available on the magnitude of the health risk posed by animal feces exposure, knowledge around animal feces management, and key points of contact between humans and animals, culturally appropriate intervention strategies can be developed and rigorously evaluated.

Conclusions

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As envisioned by the Sustainable Development Goals, the world will achieve universal access to safe water, coverage of safely managed sanitation, and handwashing with soap by 2030. (111) However, even if these ambitious targets are met, effectively eliminating direct and indirect exposure to human feces, risks associated with exposure to animal feces will remain. The literature in this review suggests that exposure to animals and animal feces has mixed effects on diarrhea and child growth, potentially increases risks of EED, STH infection, and trachoma, and has mixed effects on isolation of zoonotic pathogens in human stool. There is some evidence for the WASH-related pathways by which humans are exposed to animals and animal feces, but more research on pathogen transmission parameters, animal husbandry practices, and cultural/social influences is warranted. Furthermore, few studies have tested interventions that control the transmission of pathogens in animal feces and limit human exposure to animal feces. As we increasingly understand the contribution of poorly managed animal feces to the overall global burden of disease, it is important to gain insights into the routes by which humans are exposed to animal feces to design efforts to interrupt these pathways and reduce subsequent human health impacts.

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The Supporting Information is available free of charge on the ACS Publications website at DOI: 10.1021/acs.est.7b02811.

  • Further details about methods including full search string and databases used, global PRISMA chart, data extraction form, PRISMA checklist, and table of study characteristics (PDF)

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Author Information

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  • Corresponding Author
  • Authors
    • Gauthami Penakalapati - Department of Environmental Health, Emory University, Atlanta, Georgia 30322 United States;  Orcidhttp://orcid.org/0000-0003-2119-7431
    • Jenna Swarthout - Department of Environmental Health, Emory University, Atlanta, Georgia 30322 United States
    • Miranda J. Delahoy - Department of Environmental Health, Emory University, Atlanta, Georgia 30322 United States
    • Lydia McAliley - Department of Environmental Health, Emory University, Atlanta, Georgia 30322 United States
    • Breanna Wodnik - Department of Environmental Health, Emory University, Atlanta, Georgia 30322 United States
    • Karen Levy - Department of Environmental Health, Emory University, Atlanta, Georgia 30322 United States
  • Notes
    The authors declare no competing financial interest.

Acknowledgment

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This work was supported by the Bill & Melinda Gates Foundation (grant OPP1157522 to Emory University). K.L. is supported by the National Institute for Allergy and Infectious Diseases, NIH (grant 1K01AI103544). The content is solely the responsibility of the authors and does not necessarily represent the official views of the funders.

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    Burden and aetiology of diarrhoeal disease in infants and young children in developing countries (the Global Enteric Multicenter Study, GEMS): a prospective, case-control study
    Kotloff Karen L; Nataro James P; Blackwelder William C; Nasrin Dilruba; Farag Tamer H; Panchalingam Sandra; Wu Yukun; Sow Samba O; Sur Dipika; Breiman Robert F; Faruque Abu Sg; Zaidi Anita Km; Saha Debasish; Alonso Pedro L; Tamboura Boubou; Sanogo Doh; Onwuchekwa Uma; Manna Byomkesh; Ramamurthy Thandavarayan; Kanungo Suman; Ochieng John B; Omore Richard; Oundo Joseph O; Hossain Anowar; Das Sumon K; Ahmed Shahnawaz; Qureshi Shahida; Quadri Farheen; Adegbola Richard A; Antonio Martin; Hossain M Jahangir; Akinsola Adebayo; Mandomando Inacio; Nhampossa Tacilta; Acacio Sozinho; Biswas Kousick; O'Reilly Ciara E; Mintz Eric D; Berkeley Lynette Y; Muhsen Khitam; Sommerfelt Halvor; Robins-Browne Roy M; Levine Myron M
    Lancet (London, England) (2013), 382 (9888), 209-22 ISSN:.
    BACKGROUND: Diarrhoeal diseases cause illness and death among children younger than 5 years in low-income countries. We designed the Global Enteric Multicenter Study (GEMS) to identify the aetiology and population-based burden of paediatric diarrhoeal disease in sub-Saharan Africa and south Asia. METHODS: The GEMS is a 3-year, prospective, age-stratified, matched case-control study of moderate-to-severe diarrhoea in children aged 0-59 months residing in censused populations at four sites in Africa and three in Asia. We recruited children with moderate-to-severe diarrhoea seeking care at health centres along with one to three randomly selected matched community control children without diarrhoea. From patients with moderate-to-severe diarrhoea and controls, we obtained clinical and epidemiological data, anthropometric measurements, and a faecal sample to identify enteropathogens at enrolment; one follow-up home visit was made about 60 days later to ascertain vital status, clinical outcome, and interval growth. FINDINGS: We enrolled 9439 children with moderate-to-severe diarrhoea and 13,129 control children without diarrhoea. By analysing adjusted population attributable fractions, most attributable cases of moderate-to-severe diarrhoea were due to four pathogens: rotavirus, Cryptosporidium, enterotoxigenic Escherichia coli producing heat-stable toxin (ST-ETEC; with or without co-expression of heat-labile enterotoxin), and Shigella. Other pathogens were important in selected sites (eg, Aeromonas, Vibrio cholerae O1, Campylobacter jejuni). Odds of dying during follow-up were 8·5-fold higher in patients with moderate-to-severe diarrhoea than in controls (odd ratio 8·5, 95% CI 5·8-12·5, p<0·0001); most deaths (167 [87·9%]) occurred during the first 2 years of life. Pathogens associated with increased risk of case death were ST-ETEC (hazard ratio [HR] 1·9; 0·99-3·5) and typical enteropathogenic E coli (HR 2·6; 1·6-4·1) in infants aged 0-11 months, and Cryptosporidium (HR 2·3; 1·3-4·3) in toddlers aged 12-23 months. INTERPRETATION: Interventions targeting five pathogens (rotavirus, Shigella, ST-ETEC, Cryptosporidium, typical enteropathogenic E coli) can substantially reduce the burden of moderate-to-severe diarrhoea. New methods and accelerated implementation of existing interventions (rotavirus vaccine and zinc) are needed to prevent disease and improve outcomes. FUNDING: The Bill & Melinda Gates Foundation.
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    Dufour, A.; Bartram, J.; Bos, R.; Gannon, V. Animal Waste, Water Quality and Human Health; IWA Publishing: London, UK, 2012, 6– 130.
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    Clasen, T. F.; Bostoen, K.; Schmidt, W.-P.; Boisson, S.; Fung, I. C. H.; Jenkins, M. W.; Scott, B.; Sugden, S.; Cairncross, S., Interventions to improve disposal of human excreta for preventing diarrhoea. Cochrane Database of Systematic Reviews 2010, (6). doi:  DOI: 10.1002/14651858.CD007180.pub2 .
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    Stocks, M. E.; Ogden, S.; Haddad, D.; Addiss, D. G.; McGuire, C.; Freeman, M. C. Effect of Water, Sanitation, and Hygiene on the Prevention of Trachoma: A Systematic Review and Meta-Analysis PLoS Medicine. 2014, 11 (2) e1001605 DOI: 10.1371/journal.pmed.1001605
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    Strunz, E. C.; Addiss, D. G.; Stocks, M. E.; Ogden, S.; Utzinger, J.; Freeman, M. C. Water, Sanitation, Hygiene, and Soil-Transmitted Helminth Infection: A Systematic Review and Meta-Analysis PLoS Medicine. 2014, 11 (3) e1001620 DOI: 10.1371/journal.pmed.1001620
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    Barreto, M. L.; Genser, B.; Strina, A.; Assis, A. M. O.; Rego, R. F.; Teles, C. A.; Prado, M. S.; Matos, S. M. A.; Santos, D. N.; dos Santos, L. A.; Cairncross, S.; Teixeira, M. G. Effect of city-wide sanitation programme on reduction in rate of childhood diarrhoea in northeast Brazil: assessment by two cohort studies Lancet 2007, 370 (9599) 1622– 1628 DOI: 10.1016/S0140-6736(07)61638-9
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    16
    Effect of city-wide sanitation programme on reduction in rate of childhood diarrhoea in northeast Brazil: assessment by two cohort studies
    Barreto Mauricio L; Genser Bernd; Strina Agostino; Teixeira Maria Gloria; Assis Ana Marlucia O; Rego Rita F; Teles Carlos A; Prado Matildes S; Matos Sheila M A; Santos Darci N; dos Santos Lenaldo A; Cairncross Sandy
    Lancet (London, England) (2007), 370 (9599), 1622-8 ISSN:.
    BACKGROUND: A city-wide sanitation intervention was started in Salvador, Brazil, in 1997 to improve sewerage coverage from 26% of households to 80%. Our aim was to investigate the epidemiological effect of this city-wide sanitation programme on diarrhoea morbidity in children less than 3 years of age. METHODS: The investigation was composed of two longitudinal studies done in 1997-98 before the intervention (the sanitation programme) and in 2003-04 after the intervention had been completed. Each study consisted of a cohort of children (841 in the preintervention study and 1007 in the postintervention study; age 0-36 months at baseline) who were followed up for a maximum of 8 months. Children were sampled from 24 sentinel areas that were randomly chosen to represent the range of environmental conditions in the study site. At the start of each study an individual or household questionnaire was applied by trained fieldworkers; an environmental survey was done in each area before and after introduction of the sanitation programme to assess basic neighbourhood and household sanitation conditions. Daily diarrhoea data were obtained during home visits twice per week. The effect of the intervention was estimated by a hierarchical modelling approach fitting a sequence of multivariate regression models. FINDINGS: Diarrhoea prevalence fell by 21% (95% CI 18-25%)-from 9.2 (9.0-9.5) days per child-year before the intervention to 7.3 (7.0-7.5) days per child-year afterwards. After adjustment for baseline sewerage coverage and potential confounding variables, we estimated an overall prevalence reduction of 22% (19-26%). INTERPRETATION: Our results show that urban sanitation is a highly effective health measure that can no longer be ignored, and they provide a timely support for the launch of 2008 as the International Year of Sanitation.
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    Clasen, T.; Boisson, S.; Routray, P.; Torondel, B.; Bell, M.; Cumming, O.; Ensink, J.; Freeman, M.; Jenkins, M.; Odagiri, M.; Ray, S.; Sinha, A.; Suar, M.; Schmidt, W.-P. Effectiveness of a rural sanitation programme on diarrhoea, soil-transmitted helminth infection, and child malnutrition in Odisha, India: a cluster-randomised trial Lancet Global Health 2014, 2 (11) e645– e653 DOI: 10.1016/S2214-109X(14)70307-9
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    Emerson, P. M.; Lindsay, S. W.; Alexander, N.; Bah, M.; Dibba, S.-M.; Faal, H. B.; Lowe, K.; McAdam, K. P. W. J.; Ratcliffe, A. A.; Walraven, G. E. L.; Bailey, R. L. Role of flies and provision of latrines in trachoma control: cluster-randomised controlled trial Lancet 2004, 363 (9415) 1093– 1098 DOI: 10.1016/S0140-6736(04)15891-1
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    Patil, S. R.; Arnold, B. F.; Salvatore, A. L.; Briceno, B.; Ganguly, S.; Colford, J. M., Jr.; Gertler, P. J. The Effect of India’s Total Sanitation Campaign on Defecation Behaviors and Child Health in Rural Madhya Pradesh: A Cluster Randomized Controlled Trial PLOS Medicine. 2014, 11 (8) e1001709 DOI: 10.1371/journal.pmed.1001709
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    Pickering, A. J.; Djebbari, H.; Lopez, C.; Coulibaly, M.; Alzua, M. L. Effect of a community-led sanitation intervention on child diarrhoea and child growth in rural Mali: a cluster-randomised controlled trial Lancet Global Health 2015, 3 (11) e701– e711 DOI: 10.1016/S2214-109X(15)00144-8
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    Gyorkos, T. W.; Maheu-Giroux, M.; Blouin, B.; Casapia, M. Impact of Health Education on Soil-Transmitted Helminth Infections in Schoolchildren of the Peruvian Amazon: A Cluster-Randomized Controlled Trial PLoS Neglected Trop. Dis. 2013, 7 (9) e2397 DOI: 10.1371/journal.pntd.0002397
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    West, S.; Muñoz, B.; Lynch, M.; Kayongoya, A.; Chilangwa, Z.; Mmbaga, B. B. O.; Taylor, H. R. Impact of face-washing on trachoma in Kongwa, Tanzania Lancet 1995, 345 (8943) 155– 158 DOI: 10.1016/S0140-6736(95)90167-1
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    Freeman, M. C.; Clasen, T.; Brooker, S. J.; Akoko, D. O.; Rheingans, R. The Impact of a School-Based Hygiene, Water Quality and Sanitation Intervention on Soil-Transmitted Helminth Reinfection: A Cluster-Randomized Trial Am. J. Trop. Med. Hyg. 2013, 89 (5) 875– 883 DOI: 10.4269/ajtmh.13-0237
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    Colford, J. M. J.; Luby, S. P.; Null, C.; Stewart, C. P. In The WASH Benefits Study: Cluster-Randomized Trials in Bangladesh and Kenya to Measure the Effects of Individual and Combined Water Quality, Sanitation, Handwashing and Nutrition Interventions on Child Growth and Diarrhea ASTHM, Atlanta, GA, 2016; Atlanta, GA, 2016.
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    Garn, J. V.; Sclar, G. D.; Freeman, M. C.; Penakalapati, G.; Alexander, K. T.; Brooks, P.; Rehfuess, E. A.; Boisson, S.; Medlicott, K. O.; Clasen, T. F. The impact of sanitation interventions on latrine coverage and latrine use: A systematic review and meta-analysis Int. J. Hyg. Environ. Health 2017, 220 (2, Part B) 329– 340 DOI: 10.1016/j.ijheh.2016.10.001
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    25
    The impact of sanitation interventions on latrine coverage and latrine use: A systematic review and meta-analysis
    Garn Joshua V; Sclar Gloria D; Freeman Matthew C; Penakalapati Gauthami; Alexander Kelly T; Brooks Patrick; Rehfuess Eva A; Boisson Sophie; Medlicott Kate O; Clasen Thomas F
    International journal of hygiene and environmental health (2017), 220 (2 Pt B), 329-340 ISSN:.
    BACKGROUND: An estimated 2.4 billion people still lack access to improved sanitation and 946 million still practice open defecation. The World Health Organization (WHO) commissioned this review to assess the impact of sanitation on coverage and use, as part of its effort to develop a set of guidelines on sanitation and health. METHODS AND FINDINGS: We systematically reviewed the literature and used meta-analysis to quantitatively characterize how different sanitation interventions impact latrine coverage and use. We also assessed both qualitative and quantitative studies to understand how different structural and design characteristics of sanitation are associated with individual latrine use. A total of 64 studies met our eligibility criteria. Of 27 intervention studies that reported on household latrine coverage and provided a point estimate with confidence interval, the average increase in coverage was 14% (95% CI: 10%, 19%). The intervention types with the largest absolute increases in coverage included the Indian government's "Total Sanitation Campaign" (27%; 95% CI: 14%, 39%), latrine subsidy/provision interventions (16%; 95% CI: 8%, 24%), latrine subsidy/provision interventions that also incorporated education components (17%; 95% CI: -5%, 38%), sewerage interventions (14%; 95% CI: 1%, 28%), sanitation education interventions (14%; 95% CI: 3%, 26%), and community-led total sanitation interventions (12%; 95% CI: -2%, 27%). Of 10 intervention studies that reported on household latrine use, the average increase was 13% (95% CI: 4%, 21%). The sanitation interventions and contexts in which they were implemented varied, leading to high heterogeneity across studies. We found 24 studies that examined the association between structural and design characteristics of sanitation facilities and facility use. These studies reported that better maintenance, accessibility, privacy, facility type, cleanliness, newer latrines, and better hygiene access were all frequently associated with higher use, whereas poorer sanitation conditions were associated with lower use. CONCLUSIONS: Our results indicate that most sanitation interventions only had a modest impact on increasing latrine coverage and use. A further understanding of how different sanitation characteristics and sanitation interventions impact coverage and use is essential in order to more effectively attain sanitation access for all, eliminate open defecation, and ultimately improve health.
  26. 26
    Kaur, M.; Graham, J.; Eisenberg, J. N. S. Livestock Ownership among Rural Households and Child Morbidity and Mortality: An Analysis of Demographic Health Survey Data from 30 Sub-Saharan African Countries (2005–2015) Am. J. Trop. Med. Hyg. 2017, 96 (3) 741– 748 DOI: 10.4269/ajtmh.16-0664
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    Odagiri, M.; Schriewer, A.; Daniels, M. E.; Wuertz, S.; Smith, W. A.; Clasen, T.; Schmidt, W.-P.; Jin, Y.; Torondel, B.; Misra, P. R.; Panigrahi, P.; Jenkins, M. W. Human fecal and pathogen exposure pathways in rural Indian villages and the effect of increased latrine coverage Water Res. 2016, 100, 232– 244 DOI: 10.1016/j.watres.2016.05.015
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    Human fecal and pathogen exposure pathways in rural Indian villages and the effect of increased latrine coverage
    Odagiri, Mitsunori; Schriewer, Alexander; Daniels, Miles E.; Wuertz, Stefan; Smith, Woutrina A.; Clasen, Thomas; Schmidt, Wolf-Peter; Jin, Yujie; Torondel, Belen; Misra, Pravas R.; Panigrahi, Pinaki; Jenkins, Marion W.
    Water Research (2016), 100 (), 232-244CODEN: WATRAG; ISSN:0043-1354. (Elsevier Ltd.)
    Efforts to eradicate open defecation and improve sanitation access are unlikely to achieve health benefits unless interventions reduce microbial exposures. This study assessed human fecal contamination and pathogen exposures in rural India, and the effect of increased sanitation coverage on contamination and exposure rates. In a cross-sectional study of 60 villages of a cluster-randomized controlled sanitation trial in Odisha, India, human and domestic animal fecal contamination was measured in community tubewells and ponds (n = 301) and via exposure pathways in homes (n = 354), using Bacteroidales microbial source tracking fecal markers validated in India. Community water sources were further tested for diarrheal pathogens (rotavirus, adenovirus and Vibrio cholerae by quant. PCR; pathogenic Escherichia coli by multiplex PCR; Cryptosporidium and Giardia by immunomagnetic sepn. and direct fluorescent antibody microscopy). Exposure pathways in intervention and control villages were compared and relationships with child diarrhea examd. Human fecal markers were rarely detected in tubewells (2.4%, 95%CI: 0.3-4.5%) and ponds (5.6%, 95%CI: 0.8-10.3%), compared to homes (35.4%, 95%CI: 30.4-40.4%). In tubewells, V. cholerae was the most frequently detected pathogen (19.8%, 95%CI: 14.4-25.2%), followed by Giardia (14.8%, 95%CI: 10.0-19.7%). In ponds, Giardia was most often detected (74.5%, 95%CI: 65.7-83.3%), followed by pathogenic E. coli (48.1%, 95%CI: 34.8-61.5%) and rotavirus (44.4%, 95%CI: 34.2-54.7%). At village-level, prevalence of fecal pathogen detection in community drinking water sources was assocd. with elevated prevalence of child diarrhea within 6 wk of testing (RR 2.13, 95%CI: 1.25-3.63) while within homes, higher levels of human and animal fecal marker detection were assocd. with increased risks of subsequent child diarrhea (P = 0.044 and 0.013, resp.). There was no evidence that the intervention, which increased functional latrine coverage and use by 27 percentage points, reduced human fecal contamination in any tested pathway, nor the prevalence of pathogens in water sources. In conclusion, the study demonstrates that (1) improved sanitation alone may be insufficient and further interventions needed in the domestic domain to reduce widespread human and animal fecal contamination obsd. in homes, (2) pathogens detected in tubewells indicate these sources are microbiol. unsafe for drinking and were assocd. with child diarrhea, (3) domestic use of ponds heavily contaminated with multiple pathogens presents an under-recognized health risk, and (4) a 27 percentage point increase in improved sanitation access at village-level did not reduce detectable human fecal and pathogen contamination in this setting.
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    Belongia, E. A.; Chyou, P. H.; Greenlee, R. T.; Perez-Perez, G.; Bibb, W. F.; DeVries, E. O. Diarrhea Incidence and Farm-Related Risk Factors for Escherichia coli O157:H7 and Campylobacter jejuni Antibodies among Rural Children J. Infect. Dis. 2003, 187 (9) 1460– 1468 DOI: 10.1086/374622
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    Diarrhea incidence and farm-related risk factors for Escherichia coli O157:H7 and Campylobacter jejuni antibodies among rural children
    Belongia Edward A; Chyou Po-Huang; Greenlee Robert T; Perez-Perez Guillermo; Bibb William F; DeVries Edna O
    The Journal of infectious diseases (2003), 187 (9), 1460-8 ISSN:0022-1899.
    Serum samples were obtained from 215 farm-resident children and 396 non-farm-resident children living in a defined rural Wisconsin population. Antibodies to Campylobacter jejuni and Escherichia coli O157:H7 lipopolysaccharide (O157 LPS) immunoglobulin G were measured, and the incidence of clinic visits for diarrheal illness was determined. Risk factors were assessed in a telephone interview. There were 363 children (59%) with C. jejuni antibodies (seropositive for >or=2 immunoglobulin classes) and 86 (14%) with O157 LPS antibodies. Increasing age and farm residence were independently associated with C. jejuni seropositivity by multivariate analysis. O157 LPS antibodies were independently associated with increasing age, female sex, manure contact, and sheep contact. The incidence of clinically recognized diarrhea was similar among children with and without antibodies to C. jejuni and O157 LPS, but the clinic visit rate for diarrhea was 46% lower among farm-resident children. These results are consistent with reduced occurrence of clinical illness from repeated antigenic stimulation in a farm environment.
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    Cinquepalmi, V.; Monno, R.; Fumarola, L.; Ventrella, G.; Calia, C.; Greco, M. F.; de Vito, D.; Soleo, L. Environmental Contamination by Dog’s Faeces: A Public Health Problem? Int. J. Environ. Res. Public Health 2013, 10 (1) 72 DOI: 10.3390/ijerph10010072
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    Jung, B. K.; Lee, S. E.; Lim, H.; Cho, J.; Kim, D. G.; Song, H.; Kim, M. J.; Shin, E. H.; Chai, J. Y. Toxoplasma gondii B1 gene detection in feces of stray cats around Seoul, Korea and genotype analysis of two laboratory-passaged isolates Korean J. Parasitol. 2015, 53 (3) 259– 263 DOI: 10.3347/kjp.2015.53.3.259
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    Toxoplasma gondii B1 Gene Detection in Feces of Stray Cats around Seoul, Korea and Genotype Analysis of Two Laboratory-Passaged Isolates
    Jung Bong-Kwang; Lim Hyemi; Cho Jaeeun; Kim Deok-Gyu; Song Hyemi; Kim Min-Jae; Chai Jong-Yil; Lee Sang-Eun; Shin Eun-Hee
    The Korean journal of parasitology (2015), 53 (3), 259-63 ISSN:.
    The increasing prevalence of Toxoplasma gondii infection in the human population in the Republic of Korea (= Korea) is due to various reasons such as an increase in meat consumption. However, the importance of cats in transmitting T. gondii infection through oocysts to humans has seldom been assessed. A total of 300 fecal samples of stray cats captured around Seoul from June to August 2013 were examined for T. gondii B1 gene (indicating the presence of oocysts) using nested-PCR. Fourteen (4.7%) of 300 cats examined were positive for B1 gene. Female cats (7.5%) showed a higher prevalence than male cats (1.4%). Cats younger than 3 months (5.5%) showed a higher prevalence than cats (1.5%) older than 3 months. For laboratory passage of the positive samples, the fecal suspension (0.2 ml) of B1 gene positive cats was orally inoculated into experimental mice. Brain tissues of the mice were obtained after 40 days and examined for the presence of tissue cysts. Two isolates were successfully passaged (designated KNIH-1 and KNIH-2) and were molecularly analyzed using the SAG5D and SAG5E gene sequences. The SAG5D and SAG5E gene sequences showed high homologies with the ME49 strain (less virulent strain). The results indicated the importance of stray cats in transmitting T. gondii to humans in Korea, as revealed by detection of B1 gene in fecal samples. T. gondii isolates from cats were successfully passaged in the laboratory for the first time in Korea.
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    Tobin, M. R.; Goldshear, J. L.; Price, L. B.; Graham, J. P.; Leibler, J. H. A Framework to Reduce Infectious Disease Risk from Urban Poultry in the United States Public Health Rep. 2015, 130 (4) 380– 391 DOI: 10.1177/003335491513000417
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    A Framework to Reduce Infectious Disease Risk from Urban Poultry in the United States
    Tobin Molly R; Goldshear Jesse L; Price Lance B; Graham Jay P; Leibler Jessica H
    Public health reports (Washington, D.C. : 1974) (2015), 130 (4), 380-91 ISSN:.
    OBJECTIVES: Backyard poultry ownership is increasingly common in U.S. cities and is regulated at the local level. Human contact with live poultry is a well-known risk for infection with zoonotic pathogens, notably Salmonella, yet the ability of local jurisdictions to reduce the risk of infectious disease transmission from poultry to humans is unstudied. We reviewed urban poultry ordinances in the United States and reported Salmonella outbreaks from backyard poultry to identify regulatory gaps in preventing zoonotic pathogen transmission. Based on this analysis, we propose regulatory guidelines for U.S. cities to reduce infectious disease risk from backyard poultry ownership. METHODS: We assessed local ordinances in the 150 most populous U.S. jurisdictions for content related to noncommercial poultry ownership using online resources and communications with government officials. We also performed a literature review using publicly available data sources to identify human infectious disease outbreaks caused by contact with backyard poultry. RESULTS: Of the cities reviewed, 93% (n=139) permit poultry in some capacity. Most urban poultry ordinances share common characteristics focused on reducing nuisance to neighbors. Ordinances do not address many pathways of transmission relevant to poultry-to-human transmission of pathogens, such as manure management. CONCLUSIONS: To reduce the risk of pathogen exposure from backyard poultry, urban ordinances should incorporate the following seven components: limited flock size, composting of manure in sealed containers, prohibition of slaughter, required veterinary care to sick birds, appropriate disposal of dead birds, annual permits linked to consumer education, and a registry of poultry owners.
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    Williams, S.; Patel, M.; Markey, P.; Muller, R.; Benedict, S.; Ross, I.; Heuzenroeder, M.; Davos, D.; Cameron, S.; Krause, V. Salmonella in the tropical household environment - Everyday, everywhere J. Infect. 2015, 71 (6) 642– 648 DOI: 10.1016/j.jinf.2015.09.011
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    Salmonella in the tropical household environment--Everyday, everywhere
    Williams Shellee; Patel Mahomed; Cameron Scott; Markey Peter; Muller Rosanne; Krause Vicki; Benedict Suresh; Ross Ian; Heuzenroeder Michael; Davos Dianne
    The Journal of infection (2015), 71 (6), 642-8 ISSN:.
    OBJECTIVES: To determine the prevalence of Salmonella in the environment of case and control houses, and compare serovars isolated from cases and their houses. METHODS: From 2005 to 2008, we tested samples from houses of 0-4 year old cases and community controls in Darwin and Palmerston for Salmonella. Case isolates were compared with environmental isolates. S. Ball and S. Urbana isolates were compared using Multiple Amplification of Phage Locus Typing (MAPLT) and Multiple-Locus Variable number of tandem repeat Analysis (MLVA). RESULTS: Salmonella were found in 47/65 (72%) case houses and 18/29 (62%) control houses; these proportions were not significantly different. In 21/47 (45%) houses, case and environmental isolates (from animal faeces, soil and vacuums) were indistinguishable. Multiple serovars were isolated from 20 (31%) case and 6 (21%) control houses. All but one environmental isolate are known human pathogens in the Northern Territory (NT). Each of the four pairs of S. Ball and S. Urbana were indistinguishable. CONCLUSIONS: Animal faeces were the most likely source of salmonellosis in cases. The similar prevalence of house isolates suggests that Salmonella is ubiquitous in this environment. The distinction of S. Ball and S. Urbana subtypes enabled linkage of human illness to environmental exposure. Environmental contamination with Salmonella is an important source of sporadic infection in children in the tropics.
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    Williams, S.; Markey, P.; Harlock, M.; Binns, P.; Gaggin, J.; Patel, M. Individual and household-level risk factors for sporadic salmonellosis in children J. Infect. 2016, 72 (1) 36– 44 DOI: 10.1016/j.jinf.2015.09.014
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    Individual and household-level risk factors for sporadic salmonellosis in children
    Williams S; Markey P; Harlock M; Binns P; Gaggin J; Patel M
    The Journal of infection (2016), 72 (1), 36-44 ISSN:.
    OBJECTIVES: To explore risk factors for sporadic salmonellosis at the individual and household level in children in tropical Darwin, where animal faeces contaminated with Salmonella is thought to be common. METHODS: A 2-year community based case-control study of children aged 0-4 years residing in Darwin and Palmerston from June 2006. Variables included behaviour, health, food, family and housing characteristics. Environmental samples were taken from houses of case and control children. RESULTS: Of children whose parents were contacted, 59/131 cases and 95/222 controls were included. Salmonella was isolated from 41/56 (73%) case houses and 18/29 (62%) control houses (p = 0.29). Multivariate analyses showed breastfeeding 0.16 (p = 0.02), increasing age (months) 0.89 (p = 0.00) and daily vacuuming 0.18 (p = 0.06) were protective; consuming powdered formula milk 4.88 (p = 0.02), pet ownership 4.86 (p = 0.02), oral contact with animals 7.85 (p = 0.05), recent antibiotic use 10.01 (p = 0.03) and sweeping in the presence of children 3.73 (p = 0.04) were associated with sporadic salmonellosis. CONCLUSIONS: Salmonellosis in children under 5 years of age is associated with potentially modifiable risk factors other than food. Breastfeeding beyond 6 months, careful hygiene when preparing formula milk and around pets, frequent cleaning of infant play areas especially quick removal of animal faeces are behaviours likely to reduce childhood sporadic salmonellosis.
  34. 34
    Headey, D.Newsflash: Chickens don’t use toilets - Why global WASH efforst should start focusing on animal feces. http://www.ifpri.org/blog/newsflash-chickens-dont-use-toilets (accessed 7 February 2017) .
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    Moher, D.; Liberati, A.; Tetzlaff, J.; Altman, D. G. The, P. G., Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement PLOS Medicine. 2009, 6 (7) e1000097 DOI: 10.1371/journal.pmed.1000097
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    Black, R. E.; Lopez de Romaña, G.; Brown, K. H.; Bravo, N.; Bazalar, O. G.; Kanashiro, H. C. Incidence and etiology of infantile diarrhea and major routes of transmission in Huascar, Peru Am. J. Epidemiol. 1989, 129 (4) 785– 799 DOI: 10.1093/oxfordjournals.aje.a115193
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    Incidence and etiology of infantile diarrhea and major routes of transmission in Huascar, Peru
    Black R E; Lopez de Romana G; Brown K H; Bravo N; Bazalar O G; Kanashiro H C
    American journal of epidemiology (1989), 129 (4), 785-99 ISSN:0002-9262.
    Community-based studies of diarrhea etiology and epidemiology were carried out from July 1982-June 1984 in 153 infants residing in a poor peri-urban community near Lima, Peru. Study infants had nearly 10 episodes of diarrhea in their first year of life. Diarrhea episodes were associated with organisms such as Campylobacter jejuni, enterotoxigenic and enteropathogenic Escherichia coli, Shigella, rotavirus, and Cryptosporidium. These organisms appeared to be transmitted to infants in the home through animal feces, through contaminated water and food, and by direct person-to-person contact. A particularly important route of transmission may have been weaning foods, which were often contaminated because of improper preparation and inadequate cleaning of utensils. Improved feeding practices, along with avoidance of animal feces and improved personal and domestic hygiene, should be considered important interventions in reducing the high incidence of diarrhea in infants in developing countries.
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    Bukenya, G. B.; Nwokolo, N. Compound hygiene, presence of standpipe and the risk of childhood diarrhoea in an urban settlement of Papua New Guinea International Journal of Epidemiology 1991, 20 (2) 534– 539 DOI: 10.1093/ije/20.2.534
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    Compound hygiene, presence of standpipe and the risk of childhood diarrhoea in an urban settlement of Papua New Guinea
    Bukenya G B; Nwokolo N
    International journal of epidemiology (1991), 20 (2), 534-9 ISSN:0300-5771.
    Children below five years of age residing in an urban settlement of Papua New Guinea were monitored from May 1987 to July 1988 in an attempt to identify aetiological factors of childhood diarrhoea. Presence of faeces in the compound was associated with a 48% increase (incidence density ratio (IDR) = 1.48, 95% confidence interval (CI): 1.163-1.897) in diarrhoea morbidity whilst the presence of pigs in the compound was associated with a 69% increase (IDR = 1.694, 95% CI:1.317-2.189). The presence of a standpipe in the compound was associated with a reduction in diarrhoea morbidity of 56%. The effect of presence of faeces, animals, and standpipe on the incidence of diarrhoea was not dependent on whether or not mothers were literate. We conclude that any intervention aimed at these factors is likely to reduce diarrhoea morbidity in similar urban ecosystems.
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    Collinet-Adler, S.; Babji, S.; Sarkar, R.; Kattula, D.; Mohan, V.; Ward, H.; Kang, G.; Balraj, V.; Naumova, E. Environmental indicators of diarrhea in Vellore, India Am. J. Trop. Med. Hyg. 2011, 85 (6) 175
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    Grados, O.; Bravo, N.; Black, R. E.; Butzler, J. P. Paediatric campylobacter diarrhoea from household exposure to live chickens in Lima, Peru Bull. World Health Org. 1988, 66 (3) 369– 374
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    Paediatric campylobacter diarrhoea from household exposure to live chickens in Lima, Peru
    Grados O; Bravo N; Black R E; Butzler J P
    Bulletin of the World Health Organization (1988), 66 (3), 369-74 ISSN:0042-9686.
    Although Campylobacter jejuni is a frequent enteropathogen in cases of paediatric diarrhoea in developing countries, its route of transmission is not well understood. An age-matched, case-control study of children with C. jejuni diarrhoea was therefore carried out in Lima, Peru, from January 1983 to April 1986 to identify the risk factors and vehicles of transmissions. As cases, 104 children less than 3 years of age were selected and compared with controls of the same age with non-gastrointestinal illnesses. Household exposure to live chickens was an important risk factor (odds ratio, 11; after adjusting for socioeconomic and environmental variables). Subjects in index households had a higher frequency of infection than those in control households, and infected young children were more likely to be ill than older children or adults, suggesting that immunity may be acquired from natural infection. The risk factors identified suggest that direct contact with the faeces of C. jejuni-infected chickens in the household environment was largely responsible for transmission of the organism to susceptible infants.
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    Headey, D.; Nguyen, P.; Kim, S.; Rawat, R.; Ruel, M.; Menon, P. Is Exposure to Animal Feces Harmful to Child Nutrition and Health Outcomes? A Multicountry Observational Analysis Am. J. Trop. Med. Hyg. 2017, 96 (4) 961– 969 DOI: 10.4269/ajtmh.16-0270
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    Oberhelman, R. A.; Gilman, R. H.; Sheen, P.; Cordova, J.; Zimic, M.; Cabrera, L.; Meza, R.; Perez, J. An Intervention-Control Study of Corraling of Free-Ranging Chickens to Control Campylobacter Infections Among Children in a Peruvian Periurban Shantytown Am. J. Trop. Med. Hyg. 2006, 74 (6) 6
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    Adjei, A. A.; Armah, H.; Rodrigues, O.; Renner, L.; Borketey, P.; Ayeh-Kumi, P.; Adiku, T.; Sifah, E.; Lartey, M. Cryptosporidium spp., a frequent cause of diarrhea among children at the Korle-Bu Teaching Hospital, Accra, Ghana Jpn. J. Infect. Dis. 2004, 57 (5) 216– 219
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    Cryptosporidium Spp., a frequent cause of diarrhea among children at the Korle-Bu Teaching Hospital, Accra, Ghana
    Adjei Andrew Anthony; Armah Henry; Rodrigues Onike; Renner Lornna; Borketey Patience; Ayeh-Kumi Patrick; Adiku Theophilus; Sifah Eric; Lartey Margaret
    Japanese journal of infectious diseases (2004), 57 (5), 216-9 ISSN:1344-6304.
    This report presents the results of a study conducted at the Child Health Department, Korle-Bu Teaching Hospital, Accra, Ghana, between the months of October 2001 and June 2002. Stool samples from 227 children with diarrhea and 77 children without diarrhea, aged less than 5 years, were tested for Cryptosporidium spp. Prevalence rates were 27.8 and 15.6% in children with and without diarrhea, respectively. Cryptosporidium infection was found to be high in children between the ages of 6 and 24 months. Cryptosporidium spp. was more common in malnourished children, but was not isolated in children under 6 months of age who were exclusively breastfed. Neither the presence of domestic animals, abdominal pain, blood in stool, nausea, vomiting, nor the consumption of untreated water was associated with Cryptosporidium spp. infection. Shigella, Salmonella, and yeast-like organisms were the most frequently identified enteropathogenic bacteria. In summary, this study demonstrates the prevalence of Cryptosporidium spp. among Ghanaian children.
  43. 43
    Schmidt, W. P.; Boisson, S.; Routray, P.; Bell, M.; Cameron, M.; Torondel, B.; Clasen, T. Exposure to cows is not associated with diarrhoea or impaired child growth in rural Odisha, India: a cohort study Epidemiol. Infect. 2016, 144 (1) 53– 63 DOI: 10.1017/S0950268815001090
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    Exposure to cows is not associated with diarrhoea or impaired child growth in rural Odisha, India: a cohort study
    Schmidt W-P; Boisson S; Routray P; Bell M; Cameron M; Torondel B; Clasen T
    Epidemiology and infection (2016), 144 (1), 53-63 ISSN:.
    Exposure to animal livestock has been linked to zoonotic transmission, especially of gastrointestinal pathogens. Exposure to animals may contribute to chronic asymptomatic intestinal infection, environmental enteropathy and child under-nutrition in low-income settings. We conducted a cohort study to explore the effect of exposure to cows on growth and endemic diarrhoea in children aged <5 years in a rural, low-income setting in the Indian state of Odisha. The study enrolled 1992 households with 2739 children. Height measurements were available for 824 children. Exposure to cows was measured as (1) the presence of a cowshed within or outside the compound, (2) the number of cows owned by a household, and (3) the number of cowsheds located within 50 m of a household. In a sub-study of 518 households, fly traps were used to count the number of synanthropic flies that may act as vectors for gastrointestinal pathogens. We found no evidence that environmental exposure to cows contributes to growth deficiency in children in rural India, neither directly by affecting growth, nor indirectly by increasing the risk of diarrhoea. We found no strong evidence that the presence of a cowshed increased the number synanthropic flies in households.
  44. 44
    Randremanana, R. V.; Razafindratsimandresy, R.; Andriatahina, T.; Randriamanantena, A.; Ravelomanana, L.; Randrianirina, F.; Richard, V. Etiologies, Risk Factors and Impact of Severe Diarrhea in the Under-Fives in Moramanga and Antananarivo, Madagascar PLoS One 2016, 11 (7) e0158862 DOI: 10.1371/journal.pone.0158862
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    Headey, D.; Hirvonen, K. Is Exposure to Poultry Harmful to Child Nutrition? An Observational Analysis for Rural Ethiopia PLoS One 2016, 11 (8) e0160590 DOI: 10.1371/journal.pone.0160590
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    Is exposure to poultry harmful to child nutrition? An observational analysis for rural Ethiopia
    Headey, Derek; Hirvonen, Kalle
    PLoS One (2016), 11 (8), e0160590/1-e0160590/16CODEN: POLNCL; ISSN:1932-6203. (Public Library of Science)
    Although strategic thinking on water, sanitation and hygiene (WASH) has prioritized reducing exposure to human feces in order to limit diarrheal infections, recent research suggests that elevated exposure to livestock-particularly poultry and poultry feces-may be an important risk factor for diarrhea, environmental enteric disorder (EED) and respiratory infections, all of which may seriously retard linear growth in young children. Yet a very different literature on nutrition-sensitive agriculture suggests that livestock ownership is highly beneficial for child growth outcomes through its importance for increasing consumption of nutrient-rich animal sourced foods, such as eggs. Together, these two literatures suggest that the net nutritional benefit of poultry ownership is particularly ambiguous and potentially mediated by whether or not children are highly exposed to poultry. We test this novel hypothesis using a large agricultural survey of rural Ethiopian households that includes measures of child height-for-age Z-scores (HAZ), ownership of poultry and other types of livestock, and an indicator of whether livestock are kept within the main household dwelling overnight. We used least squares regression anal. to est. unadjusted and adjusted models that control for a wide range of potentially confounding factors. We find that while poultry ownership is pos. assocd. with child HAZ [β = 0.291, s.e. = 0.094], the practice of corralling poultry in the household dwelling overnight is neg. assocd. with HAZ [β = -0.250, s.e. = 0.118]. Moreover, we find no neg. assocns. between HAZ and corralling other livestock species indoors. These results suggest that 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.
  46. 46
    Hetherington, J. B.; Wiethoelter, A. K.; Negin, J.; Mor, S. M. Livestock ownership, animal source foods and child nutritional outcomes in seven rural village clusters in Sub-Saharan Africa Agriculture and Food Security 2017, 6 (1) 9 DOI: 10.1186/s40066-016-0079-z
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    Mosites, E.; Thumbi, S. M.; Otiang, E.; McElwain, T. F.; Njenga, M. K.; Rabinowitz, P. M.; Rowhani-Rahbar, A.; Neuhouser, M. L.; May, S.; Palmer, G. H.; Walson, J. L. Relations between Household Livestock Ownership, Livestock Disease, and Young Child Growth J. Nutr. 2016, 146 (5) 1118– 1124 DOI: 10.3945/jn.115.225961
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    Relations between household livestock ownership, livestock disease, and young child growth
    Mosites, Emily; Thumbi, Samuel M.; Otiang, Elkanah; McElwain, Terry F.; Njenga, M. K.; Rabinowitz, Peter M.; Rowhani-Rahbar, Ali; Neuhouser, Marian L.; May, Susanne; Palmer, Guy H.; Walson, Judd L.
    Journal of Nutrition (2016), 146 (5), 1118-1124CODEN: JONUAI; ISSN:0022-3166. (American Society for Nutrition)
    Background: In resource-limited settings in which child malnutrition is prevalent, humans live in close proximity to household livestock. However, the relation between household livestock and child nutrition represents a considerable knowledge gap. Objective: We assessed whether household livestock ownership or livestock disease episodes were assocd. with growth in young children in western Kenya. Methods: We incorporated monthly anthropometric measurements for children <5 y of age into an ongoing linked human and animal surveillance cohort in rural western Kenya. Using linear mixed models adjusted for age, sex, and household wealth, we tested whether baseline household livestock ownership was related to baseline child height for age or prospective growth rate. We also evaluated whether livestock disease episodes were assocd. with child growth rate over 11 mo of follow-up. Results: We collected data on 925 children over the course of follow-up. Greater household livestock ownership at baseline was not related to baseline child height-for-age z score (adjusted β: 0.01 SD; 95% CI: -0.02, 0.04 SD) or child growth rate (adjusted β: 0.02 cm/y; 95% CI: -0.03, 0.07 cm/y). Livestock disease episodes were not significantly assocd. with child growth across the entire cohort (adjusted β: -0.007 cm/mo; 95% CI: -0.02, 0.006 cm/mo). However, children in households with livestock digestive disease between June and Nov. gained less height than did children in households that did not report livestock disease (β: -0.063 cm/mo; 95% CI: -0.112, -0.016 cm/mo). Children <2 y of age in households with livestock digestive disease gained less wt. than did those who did not report disease (β: -0.033 kg/mo; 95% CI: -0.063, -0.003 kg/mo). Conclusion: In this cohort of young children in western Kenya, we did not find an assocn. between ownership of livestock and child growth status. However, disease episodes in household livestock may be related to a lower child growth rate in some groups.
  48. 48
    George, C. M.; Oldja, L.; Biswas, S. K.; Perin, J.; Lee, G. O.; Ahmed, S.; Haque, R.; Sack, R. B.; Parvin, T.; Azmi, I. J.; Bhuyian, S. I.; Talukder, K. A.; Faruque, A. G. Fecal Markers of Environmental Enteropathy are Associated with Animal Exposure and Caregiver Hygiene in Bangladesh Am. J. Trop. Med. Hyg. 2015, 93 (2) 269– 275 DOI: 10.4269/ajtmh.14-0694
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    Campbell, D.; Elia, M.; Lunn, P. Growth faltering in rural Gambian infants is associated with impaired small intestinal barrier function, leading to endotoxemia and systematic inflammation J. Nutr. 2003, 133 (5) 1332– 1338
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    Growth faltering in rural Gambian infants is associated with impaired small intestinal barrier function, leading to endotoxemia and systemic inflammation
    Campbell, D. I.; Elia, M.; Lunn, P. G.
    Journal of Nutrition (2003), 133 (5), 1332-1338CODEN: JONUAI; ISSN:0022-3166. (American Society for Nutritional Sciences)
    Growth faltering of rural Gambian infants is assocd. with a chronic inflammatory enteropathy of the mucosa of the small intestine that may impair both digestive/absorptive and barrier functions. The aim of this study was to det. whether the enteropathy was assocd. with a compromised barrier function that allowed translocation of antigenic macromols. from the gut lumen into the body, with subsequent systemic immunostimulation, resulting in growth retardation. Rural Gambian infants were studied longitudinally at regular intervals between 8 and 64 wk of age. On each study day, each child was medically examd., anthropometric measurements were made, a blood sample was taken and an intestinal permeability test performed. Evidence of chronic immunostimulation was provided by abnormally elevated white blood cell, lymphocyte and platelet counts, and frequently raised plasma concn. of C-reactive protein. Intestinal permeability was abnormal and assocd. with impaired growth (r = -0.41, P < 0.001). Plasma concns. of endotoxin and Ig (Ig)G-endotoxin core antibody were also elevated and related to both growth (r = -0.30, P < 0.02; r = -0.64, P < 0.0001, resp.) and measures of mucosal enteropathy. Plasma IgG, IgA and IgM levels increased rapidly with age toward adult concns. Raised values were related to poor growth but also to measures of mucosal enteropathy and the endotoxin antibody titer. The interrelationships among these variables and growth suggested that they were all part of the same growth-retarding mechanism. These data are consistent with the hypothesis of translocation of immunogenic lumenal macromols. across a compromised gut mucosa, leading to stimulation of systemic immune/inflammatory processes and subsequent growth impairment.
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    Goto, R.; Mascie-Taylor, C. G. N.; Lunn, P. G. Impact of intestinal permeability, inflammation status and parasitic infections on infant growth faltering in rural Bangladesh Br. J. Nutr. 2009, 101 (10) 1509– 1516 DOI: 10.1017/S0007114508083554
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    Impact of intestinal permeability, inflammation status and parasitic infections on infant growth faltering in rural Bangladesh
    Goto, Rie; Mascie-Taylor, C. G. Nicholas; Lunn, Peter G.
    British Journal of Nutrition (2009), 101 (10), 1509-1516CODEN: BJNUAV; ISSN:0007-1145. (Cambridge University Press)
    A longitudinal study of 298 rural Bangladeshi infants found evidence of growth faltering starting at 3 mo of age. Anthropometric status declined substantially in the first 2 years of life, with wt.-for-height (WHZ) falling from -0·49 to -1·75, wt.-for-age (WAZ) from -1·18 to -2·87 and height-for-age (HAZ) from -1·00 to -1·88. Higher concns. of the acute-phase protein α-1-acid glycoprotein (AGP) and higher gut mucosal damage (as signified by raised lactulose:mannitol (L:M) ratios) were both assocd. with chronic malnutrition as indicated by poorer HAZ and WAZ scores (P = 0·011 and 0·005 for AGP and 0·039 and 0·019 for L:M ratio, resp.). Higher Hb levels were related to improved z-scores, while elevation of Giardia-specific IgM titer (GSIgM) was assocd. with poor WAZ and WHZ (P = 0·015 and 0·039, resp.). IgG did not show any significant assocn. with z-scores and the L:M ratio did not correlate with any of the inflammation markers or Giardia infection. The prevalence of geohelminth infections was low (only 4 % in the total study period). However, the level of GSIgM indicated high endemicity of Giardia infection from early in life, although very few cysts were detected from stool samples. These findings suggest that rural Bangladeshi infants are being exposed to high levels of infection with concomitant gut damage and growth faltering.
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    Guerrant, R. L.; Oriá, R. B.; Moore, S. R.; Oriá, M. O. B.; Lima, A. A. M. Malnutrition as an enteric infectious disease with long-term effects on child development Nutr. Rev. 2008, 66 (9) 487– 505 DOI: 10.1111/j.1753-4887.2008.00082.x
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    Malnutrition as an enteric infectious disease with long-term effects on child development
    Guerrant Richard L; Oria Reinaldo B; Moore Sean R; Oria Monica O B; Lima Aldo A M
    Nutrition reviews (2008), 66 (9), 487-505 ISSN:.
    Malnutrition is a major contributor to mortality and is increasingly recognized as a cause of potentially lifelong functional disability. Yet, a rate-limiting step in achieving normal nutrition may be impaired absorptive function due to multiple repeated enteric infections. This is especially problematic in children whose diets are marginal. In malnourished individuals, the infections are even more devastating. This review documents the evidence that intestinal infections lead to malnutrition and that malnutrition worsens intestinal infections. The clinical data presented here derive largely from long-term cohort studies that are supported by controlled animal studies. Also reviewed are the mechanisms by which enteric infections lead to undernutrition and by which malnutrition worsens enteric infections, with implications for potential novel interventions. Further intervention studies are needed to document the relevance of these mechanisms and, most importantly, to interrupt the vicious diarrhea-malnutrition cycle so children may develop their full potential.
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    Humphrey, J. H. Child undernutrition, tropical enteropathy, toilets, and handwashing Lancet 2009, 374 (9694) 1032– 1035 DOI: 10.1016/S0140-6736(09)60950-8
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    Lunn, P. G.; Northrop-Clewes, C. A.; Downes, R. M. Intestinal permeability, mucosal injury, and growth faltering in Gambian infants Lancet 1991, 338 (8772) 907– 910 DOI: 10.1016/0140-6736(91)91772-M
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    Lunn, P. G. Growth retardation and stunting of children in developing countries Br. J. Nutr. 2002, 88 (2) 109– 110 DOI: 10.1079/BJN2002652
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    Growth retardation and stunting of children in developing countries
    Lunn, Peter G.
    British Journal of Nutrition (2002), 88 (2), 109-110CODEN: BJNUAV; ISSN:0007-1145. (CABI Publishing)
    There is no expanded citation for this reference.
  55. 55
    Ordiz, M. I.; Shaikh, N.; Trehan, I.; Maleta, K.; Stauber, J.; Shulman, R.; Devaraj, S.; Tarr, P. I.; Manary, M. J. Environmental Enteric Dysfunction is Associated with Poor Linear Growth and Can be Identified by Host Fecal mRNAs J. Pediatr. Gastroenterol. Nutr. 2016, 63 (5) 453 DOI: 10.1097/MPG.0000000000001315
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    55
    Environmental Enteric Dysfunction Is Associated With Poor Linear Growth and Can Be Identified by Host Fecal mRNAs
    Ordiz, Maria Isabel; Shaikh, Nurmohammad; Trehan, Indi; Maleta, Ken; Stauber, Jennifer; Shulman, Robert; Devaraj, Sridevi; Tarr, Phillip I.; Manary, Mark J.
    Journal of Pediatric Gastroenterology and Nutrition (2016), 63 (5), 453-459CODEN: JPGND6; ISSN:0277-2116. (Lippincott Williams & Wilkins)
    Objective: Environmental enteric dysfunction (EED) can be assessed by the lactulose:mannitol (L:M) test. Our objective was to det. if selected host fecal transcripts were correlated with EED, and whether transcripts and clin. characteristics could be used to predict EED in rural African children. Methods: Demog. and sanitation characteristics, along with L:M testing and host fecal transcript analyses from 798 asymptomatic Malawian children aged 12 to 61 mo were compared with linear growth over the subsequent 3 mo. Fecal host mRNA anal. included quantification of expression of 18 transcripts assocd. with L:M. Permeability was categorized as normal (L:M ≤ 0.15), moderate (0.15<L:M<0.45) and severe (L:M ≥ 0.45), and random forest predictive models were created. Results: L:M was inversely correlated with linear growth over the subsequent 3 mo (r=-0.32, P<0.001) and severe EED was assocd. with stunting (P<0.0001). Age younger than 24 mo, wt.-for-height z score <0, domesticated animals in the child's sleep environment, lack of a pit latrine combined with a potentially contaminated water source, and a recent history of diarrhea were assocd. with severe EED. A random forest model using CD53, HLA-DRA, MUC12, and TNF was 84% sensitive for severe EED and 83% sensitive for no EED. Conclusions: Selected host fecal transcripts can be used in a random forest model as a noninvasive biomarker for categories of EED in rural African children.
  56. 56
    El-Tras, W. F.; Holt, H. R.; Tayel, A. A.; El-Kady, N. N. Campylobacter infections in children exposed to infected backyard poultry in Egypt Epidemiol. Infect. 2015, 143 (2) 308– 315 DOI: 10.1017/S095026881400096X
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    Campylobacter infections in children exposed to infected backyard poultry in Egypt
    El-Tras W F; Holt H R; Tayel A A; El-Kady N N
    Epidemiology and infection (2015), 143 (2), 308-15 ISSN:.
    Campylobacteriosis is a zoonotic disease which has a worldwide public health impact. The disease is endemic in Egypt; however, the epidemiology in animals and humans has not been fully characterized. The objective of this study was to compare the risk of Campylobacter faecal carriage in children exposed to Campylobacter-infected vs. non-infected backyard poultry and to identify risk factors for a backyard being classified as infected. A total of 103 households which owned backyard poultry were sampled from a rural community in Egypt. Within these households 379 poultry and 106 children were tested for C. jejuni and C. coli; 23·5% and 5·5% of poultry were positive for C. jejuni and C. coli, respectively. In the studied households; 12·3% of children were positive for C. jejuni, and 2·8% were positive for C. coli. Using logistic regression, households with poultry positive for C. jejuni had 3·86 (95% confidence interval 1·0-15·0) times the odds of having children positive for C. jejuni compared to those housed with poultry which all tested negative. Backyard poultry may present a transmission route of C. jejuni to children. Backyards with poor cleaning and disinfection, wet litter and manure disposed of within the backyard had increased odds of being positive for C. jejuni. Enhancing biosecurity and management in poultry backyards may reduce the risk of the disease.
  57. 57
    Marquis, G. S.; Ventura, G.; Gilman, R. H.; Porras, E.; Miranda, E.; Carbajal, L.; Pentafiel, M. Am. J. Public Health 1990, 80 (2) 146– 149 DOI: 10.2105/AJPH.80.2.146
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    Fecal contamination of shanty town toddlers in households with non-corralled poultry, Lima, Peru
    Marquis G S; Ventura G; Gilman R H; Porras E; Miranda E; Carbajal L; Pentafiel M
    American journal of public health (1990), 80 (2), 146-9 ISSN:0090-0036.
    We used direct observer techniques to measure the frequency with which toddler-aged children were contaminated by poultry feces in homes in a peri-urban shanty town in Lima, Peru. The mean number of fowl was 5.4 (SD 3.1), with 10.0 (SD 10.7) poultry defecations per 12 hours. Toddlers' hand contact with poultry feces occurred a mean of 2.9 (SD 3.0) times/12 hours. A mean of 3.9 (SD 4.6) feces-to-mouth episodes per household/12 hours occurred both by direct hand-to-mouth contamination and indirectly by handling soiled objects which were then placed in the mouth. There was a strong correlation between feces-to-hand contamination and feces-to-mouth contamination (r = 0.94). There was also an association between feces-to-mouth contamination and the number of stools deposited in the house (r = 0.66). For each additional chicken stool deposited during the day, there was an average increase of 0.27 in feces-to-mouth episodes. We collected feces from 68 infected chickens and found viable Campylobacter jejuni for up to 48 hours after deposition. Yet, a survey of 108 families demonstrated that free-roaming poultry were often not thought of as a health risk for children. An intervention program to reduce oral-fecal contamination should emphasize that all poultry be corralled and not allowed access into the house.
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    Vasco, K.; Graham, J. P.; Trueba, G. Detection of Zoonotic Enteropathogens in Children and Domestic Animals in a Semirural Community in Ecuador Appl. Environ. Microbiol. 2016, 82 (14) 4218– 4224 DOI: 10.1128/AEM.00795-16
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    Detection of zoonotic enteropathogens in children and domestic animals in a semirural community in Ecuador
    Vasco, Karla; Graham, Jay P.; Trueba, Gabriel
    Applied and Environmental Microbiology (2016), 82 (14), 4218-4224CODEN: AEMIDF; ISSN:1098-5336. (American Society for Microbiology)
    Animals are important reservoirs of zoonotic enteropathogens, and transmission to humans occurs more frequently in low- and middle-income countries (LMICs), where small-scale livestock prodn. is common. In this study, we investigated the presence of zoonotic enteropathogens in stool samples from 64 asymptomatic children and 203 domestic animals of 62 households in a semirural community in Ecuador between June and August 2014. Multilocus sequence typing (MLST) was used to assess zoonotic transmission of Campylobacter jejuni and atypical enteropathogenic Escherichia coli (aEPEC), which were the most prevalent bacterial pathogens in children and domestic animals (30.7% and 10.5%, resp.). Four sequence types (STs) of C. jejuni and four STs of aEPEC were identical between children and domestic animals. The apparent sources of human infection were chickens, dogs, guinea pigs, and rabbits for C. jejuni and pigs, dogs, and chickens for aEPEC. Other pathogens detected in children and domestic animals were Giardia lamblia (13.1%), Cryptosporidium parvum (1.1%), and Shiga toxin-producing E. coli (STEC) (2.6%). Salmonella enterica was detected in 5 dogs and Yersinia enterocolitica was identified in 1 pig. Even though we identified 7 enteric pathogens in children, we encountered evidence of active transmission between domestic animals and humans only for C. jejuni and aEPEC. We also found evidence that C. jejuni strains from chickens were more likely to be transmitted to humans than those coming from other domestic animals. Our findings demonstrate the complex nature of enteropathogen transmission between domestic animals and humans and stress the need for further studies.
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    Moore, C. E.; Elwin, K.; Phot, N.; Seng, C.; Mao, S.; Suy, K.; Kumar, V.; Nader, J.; Bousfield, R.; Perera, S.; Bailey, J. W.; Beeching, N. J.; Day, N. P. J.; Parry, C. M.; Chalmers, R. M. Molecular Characterization of Cryptosporidium Species and Giardia duodenalis from Symptomatic Cambodian Children PLoS Neglected Trop. Dis. 2016, 10 (7) e0004822 DOI: 10.1371/journal.pntd.0004822
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    Wanyiri, J. W.; Kanyi, H.; Maina, S.; Wang, D. E.; Steen, A.; Ngugi, P.; Kamau, T.; Waithera, T.; O’Connor, R.; Gachuhi, K.; Wamae, C. N.; Mwamburi, M.; Ward, H. D. Cryptosporidiosis in HIV/AIDS Patients in Kenya: Clinical Features, Epidemiology, Molecular Characterization and Antibody Responses Am. J. Trop. Med. Hyg. 2014, 91 (2) 319– 328 DOI: 10.4269/ajtmh.13-0254
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    Wumba, R.; Longo-Mbenza, B.; Menotti, J.; Mandina, M.; Kintoki, F.; Situakibanza, N. H.; Kakicha, M. K.; Zanga, J.; Mbanzulu-Makola, K.; Nseka, T.; Mukendi, J. P.; Kendjo, E.; Sala, J.; Thellier, M. Epidemiology, clinical, immune, and molecular profiles of microsporidiosis and cryptosporidiosis among HIV/AIDS patients Int. J. Gen. Med. 2012, 5, 603– 611
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    Epidemiology, clinical, immune, and molecular profiles of microsporidiosis and cryptosporidiosis among HIV/AIDS patients
    Wumba Roger; Longo-Mbenza Benjamin; Menotti Jean; Mandina Madone; Kintoki Fabien; Situakibanza Nani Hippolyte; Kakicha Marie Kapepela; Zanga Josue; Mbanzulu-Makola Kennedy; Nseka Tommy; Mukendi Jean Pierre; Kendjo Eric; Sala Jean; Thellier Marc
    International journal of general medicine (2012), 5 (), 603-11 ISSN:.
    BACKGROUND: The objective of this study was to determine the prevalence of intestinal parasites, with special emphasis on microsporidia and Cryptosporidium, as well as their association with human immunodeficiency virus (HIV) symptoms, risk factors, and other digestive parasites. We also wish to determine the molecular biology definitions of the species and genotypes of microsporidia and Cryptosporidium in HIV patients. METHODS: In this cross-sectional study, carried out in Kinshasa, Democratic Republic of the Congo, stool samples were collected from 242 HIV patients (87 men and 155 women) with referred symptoms and risk factors for opportunistic intestinal parasites. The analysis of feces specimen were performed using Ziehl-Neelsen stainings, real-time polymerase chain reaction (PCR), immunofluorescence indirect monoclonal antibody, nested PCR-restriction fragment length polymorphism, and PCR amplification and sequencing. Odds ratio (OR) and 95% confidence intervals were used to quantify the risk. RESULTS: Of the 242 HIV patients, 7.8%, 0.4%, 5.4%, 0.4%, 2%, 10.6%, and 2.8% had Enterocytozoon bieneusi, Encephalitozoon intestinalis, Cryptosporidium spp., Isospora belli, pathogenic intestinal protozoa, nonpathogenic intestinal protozoa, and helminths, respectively. We found five genotypes of E. bieneusi: two older, NIA1 and D, and three new, KIN1, KIN2, and KIN3. Only 0.4% and 1.6% had Cryptosporidium parvum and Cryptosporidium hominis, respectively. Of the patients, 36.4%, 34.3%, 31%, and 39% had asthenia, diarrhea, a CD4 count of <100 cells/mm(3), and no antiretroviral therapy (ART), respectively. The majority of those with opportunistic intestinal parasites and C. hominis, and all with C. parvum and new E. bieneusi genotypes, had diarrhea, low CD4+ counts of <100 cells/mm(3), and no ART. There was a significant association between Entamoeba coli, Kaposi sarcoma, herpes zoster, chronic diarrhea, and asthenia, and the presence of 28 cases with opportunistic intestinal parasites. Rural areas, public toilets, and exposure to farm pigs were the univariate risk factors present in the 28 cases with opportunistic intestinal parasites. In logistic regression analysis, a CD4 count of <100 cells/mm(3) (OR = 4.60; 95% CI 1.70-12.20; P = 0.002), no ART (OR = 5.00; 95% CI 1.90-13.20; P < 0.001), and exposure to surface water (OR = 2.90; 95% CI 1.01-8.40; P = 0.048) were identified as the significant and independent determinants for the presence of opportunistic intestinal parasites. CONCLUSION: E. bieneusi and Cryptosporidium are becoming more prevalent in Kinshasa, Congo. Based on the findings, we recommend epidemiology surveillance and prevention by means of hygiene, the emphasis of sensitive PCR methods, and treating opportunistic intestinal parasites that may be acquired through fecal-oral transmission, surface water, normal immunity, rural area-based person-person and animal-human infection, and transmission of HIV. Therapy, including ART and treatment with fumagillin, is needed.
  62. 62
    Anuar, T. S.; Azreen, S. N.; Salleh, F. M.; Moktar, N. Molecular epidemiology of giardiasis among Orang Asli in Malaysia: application of the triosephosphate isomerase gene BMC Infect. Dis. 2014, 14 (1) 78 DOI: 10.1186/1471-2334-14-78
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    Molecular epidemiology of giardiasis among Orang Asli in Malaysia: application of the triosephosphate isomerase gene
    Anuar Tengku Shahrul; Azreen Siti Nor; Salleh Fatmah Md; Moktar Norhayati
    BMC infectious diseases (2014), 14 (), 78 ISSN:.
    BACKGROUND: Giardia duodenalis is a flagellate parasite which has been considered the most common protozoa infecting human worldwide. Molecular characterization of G. duodenalis isolates have revealed the existence of eight groups (Assemblage A to H) which differ in their host distribution. Assemblages A and B are found in humans and in many other mammals. METHODS: This cross-sectional study was conducted to identify assemblage's related risk factors of G. duodenalis among Orang Asli in Malaysia. Stool samples were collected from 611 individuals aged between 2 and 74 years old of whom 266 were males and 345 were females. Socioeconomic data were collected through a pre-tested questionnaire. All stool samples were processed with formalin-ether sedimentation and Wheatley's trichrome staining techniques for the primary identification of G. duodenalis. Molecular identification was carried out by the amplification of a triosephosphate isomerase gene using nested-PCR assay. RESULTS: Sixty-two samples (10.2%) were identified as assemblage A and 36 (5.9%) were assemblage B. Risk analysis based on the detected assemblages using univariate and logistic regression analyses identified subjects who have close contact with household pets i.e. dogs and cats (OR = 2.60; 95% CI = 1.42, 4.78; P = 0.002) was found to be significant predictor for assemblage A. On the other hand, there were three significant risk factors caused by assemblage B: (i) children ≤15 years old (OR = 2.33; 95% CI = 1.11, 4.87; P = 0.025), (ii) consuming raw vegetables (OR = 2.82; 95% CI = 1.27, 6.26; P = 0.011) and (iii) the presence of other family members infected with giardiasis (OR = 6.31; 95% CI = 2.99, 13.31; P < 0.001). CONCLUSIONS: The present study highlighted that G. duodenalis infection among Orang Asli was caused by both assemblages with significant high prevalence of assemblage A. Therefore, taking precaution after having contact with household pets and their stool, screening and treating infected individuals, awareness on the importance of good health practices and washing vegetables are the practical intervention ways in preventing giardiasis in Orang Asli community.
  63. 63
    Alyousefi, N. A.; Mahdy, M. A.; Mahmud, R.; Lim, Y. A. Factors associated with high prevalence of intestinal protozoan infections among patients in Sana’a City, Yemen PLoS One 2011, 6 (7) e22044 DOI: 10.1371/journal.pone.0022044
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    Li, X.-X.; Chen, J.-X.; Wang, L.-X.; Tian, L.-G.; Zhang, Y.-P.; Dong, S.-P.; Hu, X.-G.; Liu, J.; Wang, F.-F.; Wang, Y.; Yin, X.-M.; He, L.-J.; Yan, Q.-Y.; Zhang, H.-W.; Xu, B.-L.; Zhou, X.-N. Prevalence and risk factors of intestinal protozoan and helminth infections among pulmonary tuberculosis patients without HIV infection in a rural county in P. R. China Acta Trop. 2015, 149, 19– 26 DOI: 10.1016/j.actatropica.2015.05.001
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    Prevalence and risk factors of intestinal protozoan and helminth infections among pulmonary tuberculosis patients without HIV infection in a rural county in P. R. China
    Li Xin-Xu; Chen Jia-Xu; Tian Li-Guang; Wang Li-Xia; Zhang Yu-Ping; Dong Shuang-Pin; Hu Xue-Guang; Liu Jian; Wang Feng-Feng; Wang Yue; Yin Xiao-Mei; He Li-Jun; Yan Qiu-Ye; Zhang Hong-Wei; Xu Bian-Li; Zhou Xiao-Nong
    Acta tropica (2015), 149 (), 19-26 ISSN:.
    Although co-infection of tuberculosis (TB) and intestinal parasites, including protozoa and helminths, in humans has been widely studied globally, very little of this phenomenon is known in China. Therefore, a cross-sectional study was conducted in a rural county of China to investigate such co-infections. Patients with pulmonary TB (PTB) undergoing anti-Mycobacterium tuberculosis (anti-MTB) treatment were surveyed by questionnaires, and their feces and blood specimens were collected for detection of intestinal protozoa and helminths, routine blood examination and HIV detection. The χ(2) test and multivariate logistic regression model were used to identify risk factors. A total of 369 patients with PTB were included and all of them were HIV negative. Overall, only 7.3% of participants were infected with intestinal protozoa, among which prevalence of Blastocystis hominis, Entamoeba spp. and Trichomonas hominis were 6.0%, 1.1% and 0.3%, respectively; 7.0% were infected with intestinal helminths, among which prevalence of hookworm, Trichuris trichiura, Ascaris lumbricoides and Clonorchis sinensis were 4.3%, 1.9%, 0.5% and 0.3%, respectively; and 0.5% were simultaneously infected with intestinal protozoa and helminths. Among patients with PTB, body mass index (BMI)≤18 (OR=3.30, 95% CI=1.44-7.54) and raised poultry or livestock (e.g., chicken, duck, pig) (OR=3.96, 95% CI=1.32-11.89) were significantly associated with harboring intestinal protozoan infection, while BMI≤18 (OR=3.32, 95% CI=1.39-7.91), anemia (OR=3.40, 95% CI=1.44-8.02) and laboring barefoot in farmlands (OR=4.54, 95% CI=1.88-10.92) were significantly associated with having intestinal helminth infection. Additionally, there was no significant relationship between duration of anti-MTB treatment and infection rates of intestinal parasites including protozoa and helminths. Therefore, preventing malnutrition, avoiding unprotected contact with reservoirs of protozoa, and improving health education for good hygiene habits, particularly wearing shoes while outdoors, are beneficial in the prevention of intestinal protozoan and helminth infection among patients with PTB.
  65. 65
    Bern, C.; Kawai, V.; Vargas, D.; Rabke-Verani, J.; Williamson, J.; Chavez-Valdez, R.; Xiao, L.; Sulaiman, I.; Vivar, A.; Ticona, E.; Ñavincopa, M.; Cama, V.; Moura, H.; Secor, W.; Visvesvara, G.; Gilman, R. H. The Epidemiology of Intestinal Microsporidiosis in Patients with HIV/AIDS in Lima, Peru J. Infect. Dis. 2005, 191 (10) 1658– 1664 DOI: 10.1086/429674
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    The epidemiology of intestinal microsporidiosis in patients with HIV/AIDS in Lima, Peru
    Bern Caryn; Kawai Vivian; Vargas Daniel; Rabke-Verani Jennifer; Williamson John; Chavez-Valdez Raul; Xiao Lihua; Sulaiman Irshad; Vivar Aldo; Ticona Eduardo; Navincopa Marco; Cama Vitaliano; Moura Hercules; Secor W Evan; Visvesvara Govinda; Gilman Robert H
    The Journal of infectious diseases (2005), 191 (10), 1658-64 ISSN:0022-1899.
    We studied microsporidiosis in human immunodeficiency virus-positive patients in 2 Lima hospitals. Of 2652 patients, 66% were male, 6% received antiretroviral therapy (ART), and the median CD4 lymphocyte count was 131 cells/microL. Sixty-seven patients (3%) had microsporidiosis; stool specimens from 56 were identified as having Enterocytozoon bieneusi of 10 different genotypes. The 2 most common genotypes, Peru-1 and Peru-2, were not associated with significant increases in chronic diarrhea; other genotypes were associated with a 4-fold increased risk. Risk factors for E. bieneusi infection segregated by genotype: contact with duck or chicken droppings and lack of running water, flush toilet, or garbage collection with genotype Peru-1 and watermelon consumption with other genotypes. Shortened survival was associated with low CD4 lymphocyte count (P<.0001), no ART (P<.0001), and cryptosporidiosis (P=.004) but not with microsporidiosis (P=.48). Our data suggest the possibility of zoonotic E. bieneusi transmission and an association with poor sanitary conditions.
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    Dwivedi, K. K.; Prasad, G.; Saini, S.; Mahajan, S.; Lal, S.; Baveja, U. K. Enteric Opportunistic Parasites among HIV Infected Individuals: Associated Risk Factors and Immune Status Jpn. J. Infect. Dis. 2007, 60, 76– 81
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    Enteric opportunistic parasites among HIV infected individuals: associated risk factors and immune status
    Dwivedi Kaushal Kumar; Prasad Ganga; Saini Sanjeev; Mahajan Surbhi; Lal Shiv; Baveja Usha Krishan
    Japanese journal of infectious diseases (2007), 60 (2-3), 76-81 ISSN:1344-6304.
    Data on various etiologic agents causing diarrhea in human immunodeficiency virus type-1 (HIV-1) infected individuals are sparse in Delhi, India. The present study was undertaken to identify various causative agents, the role of associated risk factors and immune status. A case-control study was conducted among 75 HIV-1 infected individuals, 50 with and 25 without diarrheal infection. Fecal samples were screened for coccidian parasites, enteric protozoa, and helminthes by using various staining techniques. The CD4+ T-lymphocyte count was estimated. Enteric parasites were identified among 62.7% individuals, of which Cryptosporidium emerged as the single largest pathogen predominant among 33% of the individuals (P < 0.025). Other parasites diagnosed that were significantly associated with diarrhea were Giardia lamblia (13.3%), microsporidia (6.7%), and Isospora belli (2.7%). Chronic infected diarrheal cases were found to have polyparasitic infections. The mean CD4+ cell count was found to be lower among the diarrheal cases when compared with the non-diarrheal cases (mean, 141 cells/mm(3) versus 390 cells/mm(3)). Similarly, among diarrheal individuals, the chronic diarrheal cases had a comparatively lower CD4+ cell count than the acute cases (mean, 123 cells/mm(3) versus 265 cells/mm(3)). Risk factors found significant during multivariate analysis were: residence in a slum, exposure to pets and animals, use of public toilets, and practice of unsafe homosexual activity. Enteric coccidian parasites were identified as significant agents associated with diarrhea, especially among those with improper hygiene, multiple infections and a lower CD4+ cell count. Thus, this study emphasizes the need for routine screening of enteric parasites as well as education about practicing personal hygiene and taking timely and appropriate prophylactic measures.
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    Bublitz, D. C.; Wright, P. C.; Bodager, J. R.; Rasambainarivo, F. T.; Bliska, J. B.; Gillespie, T. R. Epidemiology of Pathogenic Enterobacteria in Humans, Livestock, and Peridomestic Rodents in Rural Madagascar PLoS One 2014, 9 (7) e101456 DOI: 10.1371/journal.pone.0101456
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    Leung, D.; Das, S.; Malek, M.; Ahmed, D.; Khanam, F.; Qadri, F.; Faruque, A.; Ryan, E. Non-typhoidal Salmonella gastroenteritis at a diarrheal hospital in Dhaka, Bangladesh, 1996–2011 Am. J. Trop. Med. Hyg. 2013, 88 (4) 661– 669 DOI: 10.4269/ajtmh.12-0672
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    Labrique, A. B.; Zaman, K.; Hossain, Z.; Saha, P.; Yunus, M.; Hossain, A.; Ticehurst, J.; Kmush, B.; Nelson, K. E. An Exploratory Case Control Study of Risk Factors for Hepatitis E in Rural Bangladesh PLoS One 2013, 8 (5) e61351 DOI: 10.1371/journal.pone.0061351
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    Mpyet, C.; Lass, B. D.; Yahaya, H. B.; Solomon, A. W. Prevalence of and Risk Factors for Trachoma in Kano State, Nigeria PLoS One 2012, 7 (7) e40421 DOI: 10.1371/journal.pone.0040421
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    Nigusie, A.; Berhe, R.; Gedefaw, M. Prevalence and associated factors of active trachoma among childeren aged 1–9 years in rural communities of Gonji Kolella district, West Gojjam zone, North West Ethiopia BMC Res. Notes 2015, 8 (1) 641 DOI: 10.1186/s13104-015-1529-6
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    Prevalence and associated factors of active trachoma among childeren aged 1-9 years in rural communities of Gonji Kolella district, West Gojjam zone, North West Ethiopia
    Nigusie, Adane; Berhe, Resom; Gedefaw, Molla
    BMC Research Notes (2015), 8 (), 641/1-641/9CODEN: BRNMAT; ISSN:1756-0500. (BioMed Central Ltd.)
    Background: Trachoma is the leading infectious cause of blindness worldwide. Though trachoma can be treated with antibiotic it is still endemic in most part of Ethiopia. Methods: A community based cross-sectional study was conducted among 618 children 1-9 years of age from Dec. 2013 to June 2014. A multistage systematic sampling technique was applied. Data were collected using pretested and structured questionnaire and also observation by using binocular loupe to differentiate active trachoma cases. The World Health Organization's simplified classification scheme for assessing trachoma in community based surveys was used for the purpose. Bivariate and multivariate logistic regression model was fitted to identify factors assocd. with trachoma among children aged 1-9 years. An adjusted odds ratio with 95 % confidence interval was computed to det. the level of significance. Results: The overall prevalence of active trachoma among children aged 1-9 years were 23.1 % Trachomatous inflammation-Follicular, in 22.5 % (95 % CI: 22.3-22.69 %); Trachomatous inflammation-Intense, in 0.6 % (95 % CI: 0.4-0.79 %). Family size (>5) (AOR = 14.32, 95 % CI = 6.108-33.601), no. of children under 10 years of age within household (AOR = 25.53, 95 % CI = 9.774-66.686), latrine utilizations (AOR = 10.274, 95 % CI = 4.274-24.968), route of waste disposal (AOR = 3.717, 95 % CI = 1.538 to -8.981), household literacy (AOR = 2.892, 95 % CI = 1.447-5.780), cattle housing practice (AOR = 4.75, 95 % CI = 1.815-12.431), time to collect water (AOR = 25.530, 95 % CI = 8.995- 72.461), frequency of face washing practice (AOR = 6.384, 95 % CI = 2.860-14.251) and source of water (AOR = 2.353, 95 % CI = 1.134-4.882) were found to be assocd. with the presence of active trachoma in this study population. Conclusion: The prevalence of active trachoma among rural communities of children aged 1-9 years was found to be high in ref. to WHO recommended thresholds to initiate trachoma control recommendation (>10 % prevalence), which indicates that active trachoma is still a major public health concern in the study area. Therefore, it is recommended that coordinated work on implementing the WHO endorsed SAFE strategy in particular and enhancing the overall living conditions of the community is crucial.
  72. 72
    Cumberland, P.; Hailu, G.; Todd, J. Active trachoma in children aged three to nine years in rural communities in Ethiopia: prevalence, indicators and risk factors Trans. R. Soc. Trop. Med. Hyg. 2005, 99 (2) 120– 127 DOI: 10.1016/j.trstmh.2004.03.011
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    Active trachoma in children aged three to nine years in rural communities in Ethiopia: prevalence, indicators and risk factors
    Cumberland Phillippa; Hailu Girum; Todd Jim
    Transactions of the Royal Society of Tropical Medicine and Hygiene (2005), 99 (2), 120-7 ISSN:0035-9203.
    Trachoma is the most important infectious cause of blindness worldwide. In two rural populations in Ethiopia, a programme of preventative and treatment measures was initiated in May 2002. A baseline survey was conducted to evaluate the effect of this programme on the prevalence of active trachoma. A total of 1960 children aged 3-9 years, from 915 households in 40 communities, were examined for the presence of active trachoma. Demographic and household information was collected using questionnaires and household amenities and environmental conditions were observed. Overall, 72% of children had active trachoma. Twenty percent of children aged nine years had trachomatous scarring. In children, discharge in the eyes and flies on the eyes were significant indicators of trachoma (odds ratio [OR] = 3.0, 95% CI 1.94-4.55 and OR = 3.4, 95% CI 2.37-4.88, respectively). Frequency of washing children, a clean environment and hygienic disposal of excrement were significant preventative factors for active trachoma. Prevalence of active trachoma varies widely between and within districts. Risk factors comprise a mix of individual characteristics and household factors. This study demonstrates the need for broad target interventions and a flexible approach to the prevention of trachoma in high prevalence endemic rural populations.
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    Reichert, F.; Pilger, D.; Schuster, A.; Lesshafft, H.; Guedes de Oliveira, S.; Ignatius, R.; Feldmeier, H. Prevalence and Risk Factors of Hookworm-Related Cutaneous Larva Migrans (HrCLM) in a Resource-Poor Community in Manaus, Brazil PLoS Neglected Trop. Dis. 2016, 10 (3) e0004514 DOI: 10.1371/journal.pntd.0004514
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    Acosta-Jamett, G.; Weitzel, T.; Boufana, B.; Adones, C.; Bahamonde, A.; Abarca, K.; Craig, P. S.; Reiter-Owona, I. Prevalence and risk factors for echinococcal infection in a rural area of northern Chile: A household-based cross-sectional study PLoS Neglected Trop. Dis. 2014, 8 (8) 1– 9 DOI: 10.1371/journal.pntd.0003090
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    Chiodo, P.; Basualdo, J.; Ciarmela, L.; Pezzani, B.; Apezteguía, M.; Minvielle, M. Related factors to human toxocariasis in a rural community of Argentina Memorias do Instituto Oswaldo Cruz. 2006, 101 (4) 397– 400 DOI: 10.1590/S0074-02762006000400009
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    Fernando, S.; Wickramasinghe, V.; Kapilananda, G.; Devasurendra, R.; Amarasooriya, J.; Dayaratne, H. Epidemiological aspects and risk factors of Toxocariasis in pediatric population in Sri Lanka Southeast Asian J. Trop. Med. Public Health 2007, 38 (6) 983– 990
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    Epidemiological aspects and risk factors of toxocariasis in a pediatric population in Sri Lanka
    Fernando S D; Wickramasinghe V P; Kapilananda G M G; Devasurendra R L; Amarasooriya J D M S; Dayaratne H G A K
    The Southeast Asian journal of tropical medicine and public health (2007), 38 (6), 983-90 ISSN:0125-1562.
    This cross-sectional study, carried out over a period of 11 months, investigated the relationship between Toxocara seropositivity, socio-demographic and environmental variables in a pediatric population. Risk factors for Toxocara infection were assessed by direct interview of parent or guardian using a structured pre-tested questionnaire. Eosinophilia and presence of helminth eggs or protozoan cysts in a fecal smear were recorded. Diagnosis of Toxocara seropositivity in children was based on IgG Toxocara Microwell Serum Elisa Kits. The ELISA test was regarded as positive if the optical density was 0.3 units or above. Unadjusted and adjusted odds ratios were calculated to determine risk factors for disease. The proportion of children who were positive for Toxocara antibodies in the study population was 20%. Children being exposed to a puppy of less than 3 months at home, visiting a playground frequently, living in a poorly constructed house and dogs having access to playgrounds were significant risk factors on univariate analysis. Of these four variables, only the first three variables (OR 19, OR 4 and OR 3, respectively) remained significant risk factors on the multivariate model. Presence of eosinophilia in seropositive children was significantly higher than the seronegative group (77% vs 40%; p < 0.001). This study indicates that dogs contribute significantly to children being seropositive for toxocariasis in Sri Lanka. Implementation of public health programs specifically focused on anti-parasitic treatment of dogs is recommended.
  77. 77
    Subrata, I. M.; Suryadhi, N. T.; Mantik-Astawa, N.; Damriyasa, I. M. Epidemiological and molecular analysis of Taxoplasa gondii in faecal samples of house cats obtained from house of maternal in Bali Bali Medical Journal 2015, 4 (2) 68– 75 DOI: 10.15562/bmj.v4i2.122
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    Daniels, M. E.; Shrivastava, A.; Smith, W. A.; Sahu, P.; Odagiri, M.; Misra, P. R.; Panigrahi, P.; Suar, M.; Clasen, T.; Jenkins, M. W. Cryptosporidium and giardia in humans, domestic animals, and village water sources in rural India Am. J. Trop. Med. Hyg. 2015, 93 (3) 596– 600 DOI: 10.4269/ajtmh.15-0111
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    Cryptosporidium and Giardia in Humans, Domestic Animals, and Village Water Sources in Rural India
    Daniels Miles E; Shrivastava Arpit; Smith Woutrina A; Sahu Priyadarshi; Odagiri Mitsunori; Misra Pravas R; Panigrahi Pinaki; Suar Mrutyunjay; Clasen Thomas; Jenkins Marion W
    The American journal of tropical medicine and hygiene (2015), 93 (3), 596-600 ISSN:.
    Cryptosporidium parvum and Giardia lamblia are zoonotic enteric protozoa of significant health concern where sanitation, hygiene, and water supplies are inadequate. We examined 85 stool samples from diarrhea patients, 111 pooled fecal samples by species across seven domestic animal types, and water from tube wells (N = 207) and ponds (N = 94) across 60 villages in coastal Odisha, India, for Cryptosporidium oocysts and Giardia cysts to measure occurrence, concentration/shedding, and environmental loading rates. Oocysts/cysts were detected in 12% of diarrhea patients. Detection ranged from 0% to 35% for Cryptosporidium and 0% to 67% for Giardia across animal hosts. Animal loading estimates indicate the greatest contributors of environmental oocysts/cysts in the study region are cattle. Ponds were contaminated with both protozoa (oocysts: 37%, cysts: 74%), as were tube wells (oocysts: 10%, cysts: 14%). Future research should address the public health concern highlighted from these findings and investigate the role of domestic animals in diarrheal disease transmission in this and similar settings.
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    Schriewer, A.; Odagiri, M.; Wuertz, S.; Misra, P. R.; Panigrahi, P.; Clasen, T.; Jenkins, M. W. Human and animal fecal contamination of community water sources, stored drinking water and hands in rural India measured with validated microbial source tracking assays Am. J. Trop. Med. Hyg. 2015, 93 (3) 509– 516 DOI: 10.4269/ajtmh.14-0824
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    Human and Animal Fecal Contamination of Community Water Sources, Stored Drinking Water and Hands in Rural India Measured with Validated Microbial Source Tracking Assays
    Schriewer Alexander; Odagiri Mitsunori; Wuertz Stefan; Misra Pravas R; Panigrahi Pinaki; Clasen Thomas; Jenkins Marion W
    The American journal of tropical medicine and hygiene (2015), 93 (3), 509-516 ISSN:.
    We examined pathways of exposure to fecal contamination of human and animal origin in 24 villages in Odisha, India. In a cross-sectional study during the monsoon season, fecal exposure via community water sources (N = 123) and in the home (N = 137) was assessed using human- and nonhuman-associated Bacteroidales microbial source tracking (MST) markers and fecal coliforms (FCs). Detection rates and marker concentrations were examined to pinpoint pathways of human fecal exposure in the public and domestic domains of disease transmission in study communities. Human fecal markers were detected much more frequently in the domestic domain (45% of households) than in public domain sources (8% of ponds; 4% of groundwater drinking sources). Animal fecal markers were widely detected in both domains (74% of ponds, 96% of households, 10% of groundwater drinking sources), indicating ubiquitous risks of exposure to animal feces and zoonotic pathogens. This study confirms an often suggested contamination link from hands to stored water in the home in developing countries separately for mothers' and children's hands and both human and animal fecal contamination. In contrast to MST markers, FCs provided a poor metric to assess risks of exposure to fecal contamination of human origin in this rural setting.
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    Daniels, M. E.; Smith, W. A.; Schmidt, W. P.; Clasen, T.; Jenkins, M. W. Modeling Cryptosporidium and Giardia in Ground and Surface Water Sources in Rural India: Associations with Latrines, Livestock, Damaged Wells, and Rainfall Patterns Environ. Sci. Technol. 2016, 50 (14) 7498– 7507 DOI: 10.1021/acs.est.5b05797
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    Lupindu, A. M.; Olsen, J. E.; Ngowi, H. A.; Msoffe, P. L. M.; Mtambo, M. M.; Scheutz, F.; Dalsgaard, A. Occurrence and characterization of Shiga toxin-producing Escherichia coli O157:H7 and other non-sorbitol-fermenting E. coli in cattle and humans in urban areas of Morogoro, Tanzania Vector-Borne and Zoonotic Diseases. 2014, 14 (7) 503– 510 DOI: 10.1089/vbz.2013.1502
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    Occurrence and characterization of Shiga toxin-producing Escherichia coli O157:H7 and other non-sorbitol-fermenting E. coli in cattle and humans in urban areas of Morogoro, Tanzania
    Lupindu Athumani M; Olsen John E; Ngowi Helena A; Msoffe Peter L M; Mtambo Madundo M; Scheutz Flemming; Dalsgaard Anders
    Vector borne and zoonotic diseases (Larchmont, N.Y.) (2014), 14 (7), 503-10 ISSN:.
    Escherichia coli strains such as Shiga toxin-producing E. coli (STEC), enteropathogenic E. coli, enterotoxigenic, attaching, and effacing E. coli, and enteroinvasive E. coli cause diarrhea in humans. Although other serotypes exist, the most commonly reported STEC in outbreaks is O157:H7. A cross-sectional study was conducted to isolate and characterize non-sorbitol-fermenting (NSF) E. coli O157:H7 from urban and periurban livestock settings of Morogoro, Tanzania. Human stool, cattle feces, and soil and water samples were collected. Observations and questionnaire interview studies were used to gather information about cattle and manure management practices in the study area. E. coli were isolated on sorbitol MacConkey agar and characterized by conventional biochemical tests. Out of 1049 samples, 143 (13.7%) yielded NSF E. coli. Serological and antimicrobial tests and molecular typing were performed to NSF E. coli isolates. These procedures detected 10 (7%) pathogenic E. coli including STEC (n=7), enteropathogenic E. coli (EPEC) (n=2), and attaching and effacing E. coli (A/EEC) (n=1) strains. The STEC strains had the ability to produce VT1 and different VT2 toxin subtypes that caused cytopathic effects on Vero cells. The prevalence of STEC in cattle was 1.6%, out of which 0.9% was serotype O157:H7 and the overall prevalence of diarrheagenic E. coli in cattle was 2.2%. The serotypes O157:H7, O142:H34, O113:H21, O+:H-, O+:H16, and O25:H4 were identified. One ESBL-producing isolate showed the MLST type ST131. To our knowledge, this is the first finding in Tanzania of this recently emerged worldwide pandemic clonal group, causing widespread antimicrobial-resistant infections, and adds knowledge of the geographical distribution of ST131. Cattle manure was indiscriminately deposited within residential areas, and there was direct contact between humans and cattle feces during manure handling. Cattle and manure management practices expose humans, animals, and the environment to pathogenic E. coli and other manure-borne pathogens. Therefore, there is a need to improve manure management practices in urban and periurban areas to prevent pathogen spread and associated human health risks.
  82. 82
    Nyariki, D. M.; Mwang’ombe, A. W.; Thompson, D. M. Land-use change and livestock production challenges in an integrated system: the Masai-Mara ecosystem, Kenya J. Hum. Ecol. 2009, 26 (3) 11
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    Wolking, D. J.; Clifford, D. L.; Kelly, T. R.; Kamani, E.; Smith, W. A.; Kazwala, R. R.; Mazet, J. A. K. Boma to banda - a disease sentinel concept for reduction of diarrhoea Pastoralism: Research, Policy and Practice 2016, 6 (1) 13 DOI: 10.1186/s13570-016-0059-8
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    Sprenger, L. K.; Green, K. T.; Molento, M. B. Geohelminth contamination of public areas and epidemiological risk factors in Curitiba, Brazil Rev. Bras. Parasitol. Vet. 2014, 23 (1) 69– 73 DOI: 10.1590/S1984-29612014009
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    84
    Geohelminth contamination of public areas and epidemiological risk factors in Curitiba, Brazil
    Sprenger Lew Kan; Green Kerriel Thandile; Molento Marcelo Beltrao
    Revista brasileira de parasitologia veterinaria = Brazilian journal of veterinary parasitology : Orgao Oficial do Colegio Brasileiro de Parasitologia Veterinaria (2014), 23 (1), 69-73 ISSN:.
    This study aimed to investigate the frequency of geohelminthic contamination of public parks and squares in Curitiba, state of Parana, Brazil, between August and December 2010. A total of 345 samples were collected from 69 sandboxes in different areas and were tested using the Faust, Lutz and Baermann parasitological techniques. Potential risk factors associated with soil contamination were also analyzed. A total of 36% of the samples (124/345) were positive for helminths and 65.2% of the areas (45/69) were classified as contaminated in one or more samples. The most commonly identified parasite eggs were Ancylostoma sp. (14.5%; 50/345); followed by Toxocara sp. (9.6%; 33/345) and the Strongyloidea superfamily (excluding hookworms) (2.3%; 8/345). The analysis on the epidemiological risk factors indicated that the presence of dogs and feces in the sandboxes increased the chances of contamination of the site. Use of fences had a protective positive impact that reduced soil contamination. Health education programs should be applied within the community to minimize the risk of human contact with dogs' feces. Use of fencing in these areas is highly recommended to prevent or reduce the users' contact with animal excrement.
  85. 85
    Tun, S.; Ithoi, I.; Mahmud, R.; Samsudin, N. I.; Heng, C. K.; Ling, L. Y. Detection of Helminth Eggs and Identification of Hookworm Species in Stray Cats, Dogs and Soil from Klang Valley, Malaysia PLoS One 2015, 10 (12) e0142231 DOI: 10.1371/journal.pone.0142231
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    Detection of helminth eggs and identification of hookworm species in stray cats, dogs and soil from Klang Valley, Malaysia
    Tun, Sandee; Ithoi, Init; Mahmud, Rohela; Samsudin, Nur Izyan; Heng, Chua Kek; Ling, Lau Yee
    PLoS One (2015), 10 (12), e0142231/1-e0142231/12CODEN: POLNCL; ISSN:1932-6203. (Public Library of Science)
    The present study was conducted to det. the prevalence of helminth eggs excreted in the faces of stray cats, dogs and in soil samples. A total of 505 fresh samples of faeces (from 227 dogs and 152 cats) and soil were collected. The egg stage was detected via microscopy after the application of formalin-ether concn. technique. Genomic DNA was extd. from the samples contg. hookworm eggs and used for further identification to the species level using real-time polymerase chain reaction coupled with high resoln. melting anal. Microscopic observation showed that the overall prevalence of helminth eggs among stray cats and dogs was 75.7% (95% CI = 71.2%-79.9%), in which 87.7% of dogs and 57.9% of cats were infected with at least one parasite genus. Five genera of heliminth eggs were detected in the faecal samples, including hookworms (46.4%), Toxocara (11.1%), Trichuris (8.4%), Spirometra (7.4%) and Ascaris (2.4%). The prevalence of helminth infections among stray dogs was significantly higher than that among stray cats (p < 0.001). Only three genera of helminths were detected in soil samples with the prevalence of 23% (95% CI = 15.1%-31%), consisting of hookworms (16.6%), Ascaris (4%) and Toxocara (2.4%). The mol. identification of hookworm species revealed that Ancylostoma ceylanicum was dominant in both faecal and soil samples. The dog hookworm, Ancylostoma caninum, was also detected among cats, which is the first such occurrence reported in Malaysia till date. This finding indicated that there was a cross-infection of A. caninum between stray cats and dogs because of their coexistent within human communities. Taken together, these data suggest the potential role of stray cats and dogs as being the main sources of environmental contamination as well as for human infections.
  86. 86
    Boehm, A. B.; Wang, D.; Ercumen, A.; Shea, M.; Harris, A. R.; Shanks, O. C.; Kelty, C.; Ahmed, A.; Mahmud, Z. H.; Arnold, B. F.; Chase, C.; Kullmann, C.; Colford, J. M.; Luby, S. P.; Pickering, A. J. Occurrence of Host-Associated Fecal Markers on Child Hands, Household Soil, and Drinking Water in Rural Bangladeshi Households Environ. Sci. Technol. Lett. 2016, 3 (11) 393– 398 DOI: 10.1021/acs.estlett.6b00382
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    86
    Occurrence of Host-Associated Fecal Markers on Child Hands, Household Soil, and Drinking Water in Rural Bangladeshi Households
    Boehm, Alexandria B.; Wang, Dan; Ercumen, Ayse; Shea, Meghan; Harris, Angela R.; Shanks, Orin C.; Kelty, Catherine; Ahmed, Alvee; Mahmud, Zahid Hayat; Arnold, Benjamin F.; Chase, Claire; Kullmann, Craig; Colford, John M.; Luby, Stephen P.; Pickering, Amy J.
    Environmental Science & Technology Letters (2016), 3 (11), 393-398CODEN: ESTLCU; ISSN:2328-8930. (American Chemical Society)
    We evaluated whether provision and promotion of improved sanitation hardware (toilets and child feces management tools) reduced rotavirus and human fecal contamination of drinking water, child hands, and soil among rural Bangladeshi compds. enrolled in a cluster-randomized trial. We also measured host-assocd. genetic markers of ruminant and avian feces. We found evidence of widespread ruminant and avian fecal contamination in the compd. environment; non-human fecal marker occurrence scaled with animal ownership. Strategies for controlling non-human fecal waste should be considered when designing interventions to reduce exposure to fecal contamination in low-income settings. Detection of a human-assocd. fecal marker and rotavirus was rare and unchanged by provision and promotion of improved sanitation to intervention compds. The sanitation intervention reduced ruminant fecal contamination in drinking water and general (non-host specific) fecal contamination in soil but overall had limited effects on reducing fecal contamination in the household environment.
  87. 87
    Harris, A. R.; Pickering, A. J.; Harris, M.; Doza, S.; Islam, M. S.; Unicomb, L.; Luby, S.; Davis, J.; Boehm, A. B. Ruminants Contribute Fecal Contamination to the Urban Household Environment in Dhaka, Bangladesh Environ. Sci. Technol. 2016, 50 (9) 4642 DOI: 10.1021/acs.est.5b06282
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    87
    Ruminants Contribute Fecal Contamination to the Urban Household Environment in Dhaka, Bangladesh
    Harris, Angela R.; Pickering, Amy J.; Harris, Michael; Doza, Solaiman; Islam, M. Sirajul; Unicomb, Leanne; Luby, Stephen; Davis, Jennifer; Boehm, Alexandria B.
    Environmental Science & Technology (2016), 50 (9), 4642-4649CODEN: ESTHAG; ISSN:0013-936X. (American Chemical Society)
    In Dhaka, Bangladesh, the sensitivity and specificity of three human, three ruminant, and one avian source-assocd. QPCR microbial source tracking assays were evaluated using fecal samples collected on site. Ruminant-assocd. assays performed well, whereas the avian and human assays exhibited unacceptable cross-reactions with feces from other hosts. Subsequently, child hand rinses (n = 44) and floor sponge samples (n = 44) from low-income-households in Dhaka were assayed for fecal indicator bacteria (enterococci, Bacteroidales, and Escherichia coli) and a ruminant-assocd. bacterial target (BacR). Mean enterococci concns. were of 100 most probable no. (MPN)/2 hands and 1000 MPN/225 cm2 floor. Mean concns. of Bacteroidales were 106 copies/2 hands and 105 copies/225 cm2 floor. E. coli were detected in a quarter of hand rinse and floor samples. BacR was detected in 18% of hand rinse and 27% of floor samples. Results suggest that effective household fecal management should account not only for human sources of contamination but also for animal sources. The poor performance of the human-assocd. assays in the study area calls into the question the feasibility of developing a human-assocd. marker in urban slum environments, where domestic animals are exposed to human feces that have been disposed in pits and open drains.
  88. 88
    Ngure, F. M.; Humphrey, J. H.; Mbuya, M. N. N.; Majo, F.; Mutasa, K.; Govha, M.; Mazarura, E.; Chasekwa, B.; Prendergast, A. J.; Curtis, V.; Boor, K. J.; Stoltzfus, R. J. Formative Research on Hygiene Behaviors and Geophagy among Infants and Young Children and Implications of Exposure to Fecal Bacteria Am. J. Trop. Med. Hyg. 2013, 89 (4) 709– 716 DOI: 10.4269/ajtmh.12-0568
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    88
    Formative research on hygiene behaviors and geophagy among infants and young children and implications of exposure to fecal bacteria
    Ngure Francis M; Humphrey Jean H; Mbuya Mduduzi N N; Majo Florence; Mutasa Kuda; Govha Margaret; Mazarura Exevia; Chasekwa Bernard; Prendergast Andrew J; Curtis Valerie; Boor Kathyrn J; Stoltzfus Rebecca J
    The American journal of tropical medicine and hygiene (2013), 89 (4), 709-16 ISSN:.
    We conducted direct observation of 23 caregiver-infant pairs for 130 hours and recorded wash-related behaviors to identify pathways of fecal-oral transmission of bacteria among infants. In addition to testing fingers, food, and drinking water of infants, three infants actively ingested 11.3 ± 9.2 (mean ± SD) handfuls of soil and two ingested chicken feces 2 ± 1.4 times in 6 hours. Hand washing with soap was not common and drinking water was contaminated with Escherichia coli in half (12 of 22) of the households. A one-year-old infant ingesting 1 gram of chicken feces in a day and 20 grams of soil from a laundry area of the kitchen yard would consume 4,700,000-23,000,000 and 440-4,240 E. coli, respectively, from these sources. Besides standard wash and nutrition interventions, infants in low-income communities should be protected from exploratory ingestion of chicken feces, soil, and geophagia for optimal child health and growth.
  89. 89
    Sultana, R.; Nahar, N.; Rimi, N. A.; Azad, S.; Islam, M. S.; Gurley, E. S.; Luby, S. P. Backyard poultry raising in Bangladesh: a valued resource for the villagers and a setting for zoonotic transmission of avian influenza. A qualitative study Rural and Remote Health 2012, 12 (1927) 1– 14
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    Uga, S.; Hoa, N. T.; Noda, S.; Moji, K.; Cong, L.; Aoki, Y.; Rai, S. K.; Fujimaki, Y. Parasite egg contamination of vegetables from a suburban market in Hanoi, Vietnam Nepal Med. College J. 2009, 11 (2) 75– 78
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    90
    Parasite egg contamination of vegetables from a suburban market in Hanoi, Vietnam
    Uga S; Hoa N T V; Noda S; Moji K; Cong L; Aoki Y; Rai S K; Fujimaki Y
    Nepal Medical College journal : NMCJ (2009), 11 (2), 75-8 ISSN:.
    Helminth egg contamination of vegetables purchased at suburban market in Hanoi, Vietnam was examined. A total of 317 vegetables were examined and 82 (26%) were revealed to be positive for parasite eggs. Of the 15 varieties, 13 were positive except for horseradish and cucumber. Contamination was highest in leafy vegetables (31%), followed by root vegetables (17%) and fruit vegetables (3%). Throughout the survey, five species of parasite eggs were found: Ascaris sp., Trichuris sp., Toxocara sp., Taenia sp. and Ascaridia galli. In the interview with the villagers, 121 (81%) of 149 adult villagers stated that they usually use not only animal feces but also human feces as a fertilizer. Throughout the survey, a total of 453 eggs were recovered. Number of eggs recovered from vegetables was higher in the dry season (355 eggs) than in the rainy season (98 eggs). The study revealed that vegetables purchased at a market in suburban Hanoi (Vietnam) were highly contaminated with parasite eggs excreted by humans and animals. Considering the eating habits of the Vietnamese and the 17% embryonation rate of detected parasites, vegetables seem to play an important role in soil-transmitted helminth infection in this country.
  91. 91
    Scallan, E.; Hoekstra, R. M.; Angulo, F. J.; Tauxe, R. V.; Widdowson, M.-A.; Roy, S. L.; Jones, J. L.; Griffin, P. M. Foodborne Illness Acquired in the United States—Major Pathogens Emerging Infect. Dis. 2011, 17 (1) 7– 15 DOI: 10.3201/eid1701.P11101
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    Foodborne illness acquired in the United States--major pathogens
    Scallan Elaine; Hoekstra Robert M; Angulo Frederick J; Tauxe Robert V; Widdowson Marc-Alain; Roy Sharon L; Jones Jeffery L; Griffin Patricia M
    Emerging infectious diseases (2011), 17 (1), 7-15 ISSN:.
    Estimates of foodborne illness can be used to direct food safety policy and interventions. We used data from active and passive surveillance and other sources to estimate that each year 31 major pathogens acquired in the United States caused 9.4 million episodes of foodborne illness (90% credible interval [CrI] 6.6-12.7 million), 55,961 hospitalizations (90% CrI 39,534-75,741), and 1,351 deaths (90% CrI 712-2,268). Most (58%) illnesses were caused by norovirus, followed by nontyphoidal Salmonella spp. (11%), Clostridium perfringens (10%), and Campylobacter spp. (9%). Leading causes of hospitalization were nontyphoidal Salmonella spp. (35%), norovirus (26%), Campylobacter spp. (15%), and Toxoplasma gondii (8%). Leading causes of death were nontyphoidal Salmonella spp. (28%), T. gondii (24%), Listeria monocytogenes (19%), and norovirus (11%). These estimates cannot be compared with prior (1999) estimates to assess trends because different methods were used. Additional data and more refined methods can improve future estimates.
  92. 92
    a Mpalang, R. K.; Boreux, R.; Melin, P.; Akir Ni Bitiang, K.; Daube, G.; De Mol, P. Prevalence of Campylobacter among goats and retail goat meat in Congo J. Infect. Dev. Countries 2014, 8 (2) 168– 175 DOI: 10.3855/jidc.3199
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    92
    Prevalence of Campylobacter among goats and retail goat meat in Congo
    a Mpalang Rosette Kabwang; Boreux Raphael; Melin Pierrette; Akir Ni Bitiang Khang'Mate; Daube Georges; De Mol Patrick
    Journal of infection in developing countries (2014), 8 (2), 168-75 ISSN:.
    BACKGROUND: The prevalence of Campylobacter jejuni and Campylobacter coli was determined in goat and goat meat sold at retail outlets in Lubumbashi, Democratic Republic of Congo (DR Congo). METHODOLOGY: A total of 644 samples, including 177 goat meat, 86 goat stomachs, 139 ready to eat (RTE) goat skewers, and 242 goat faecal samples were examined for the presence of Campylobacter jejuni and Campylobacter coli using polymerase chain reaction. RESULTS: Overall, Campylobacter spp. were found in 34.6% of the examined samples. C. jejuni was isolated in 10.1% and C. coli in 26.7% of samples. Only 2.2% of all samples were positive for both species. There was a significant association between the prevalence of C. coli and the type of sample (p < 0.05). The overall prevalence of Campylobacter in different sample groups was 41.2%, 37.2%, 23.7%, and 35.1% for goat meat, goat stomachs, RTE goat skewers, and goat faecal samples, respectively. There was no significant difference (p > 0.05) between the prevalence observed in the rainy season (16.7%) and the dry season (20.0%). Moreover, the overall prevalence of Campylobacter in slaughter sites, open-air markets, warehouses, and semi-open-air markets was 28.2%, 34.2%, 35.4%, and 42.9%, respectively. Statistically, there was no influence of the sample collection site on the frequency of isolation of Campylobacter (p > 0.05). CONCLUSION: This study shows that, considering the relatively high prevalence of this pathogen, live goat and goat meat are major sources of human and environmental contamination by Campylobacter spp. in Lubumbashi.
  93. 93
    Osbjer, K.; Boqvist, S.; Sokerya, S.; Kannarath, C.; San, S.; Davun, H.; Magnusson, U. Household practices related to disease transmission between animals and humans in rural Cambodia BMC Public Health 2015, 15 (1) 476 DOI: 10.1186/s12889-015-1811-5
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    93
    Household practices related to disease transmission between animals and humans in rural Cambodia
    Osbjer Kristina; Magnusson Ulf; Boqvist Sofia; Sokerya Seng; Kannarath Chheng; San Sorn; Davun Holl
    BMC public health (2015), 15 (), 476 ISSN:.
    BACKGROUND: Zoonotic diseases are disproportionately affecting poor societies in low-income countries and pose a growing threat to public health and global food security. Rural Cambodian households may face an increased likelihood of exposure to zoonotic diseases as people there live in close association with livestock. The objectives of the study was to identify practices known to influence zoonosis transmission in rural Cambodian households and relate the practices to agro-ecological region, socio-economic position, demographics, livestock management and zoonosis awareness. METHODS: The study was conducted in three different agro-ecological regions of Cambodia; 10 villages each in the central lowlands, north-west wetlands and on the south coast, where information was obtained in questionnaires administered to 300 households, and 30 village heads and animal health workers. RESULTS: Descriptive analysis revealed a gender difference in responsibility for livestock and that the main purpose of raising livestock was for sale. Few respondents (6%) perceived a likelihood of disease transmission in their village between livestock, humans and wildlife, despite household practices related to zoonosis transmission being common. More than one-forth of households practised behaviours such as culling sick animals for consumption, eating animals found dead and allowing animals to enter sleeping and food preparation areas. Associations between household practices and possible explanatory factors were analysed with multivariable models using generalised estimation equations to account for clustering of practices within villages. Factors found to influence household practices were agro-ecological region, socio-economic position, number of people in the household, livestock species reared and awareness of zoonoses. CONCLUSIONS: Cambodia has experienced numerous fatal human cases of zoonotic influenza and extensive influenza information campaigns have been run, yet only a few of the households surveyed here reported the threat of zoonosis to be a concern in their village. Zoonosis awareness was positively related to hand washing behaviour, but other practices associated with an increased or decreased likelihood of exposure to zoonotic pathogens were unaffected by awareness. The findings indicate a knowledge-to-action gap among rural farmers and highlight the necessity for reconstructed interventions in zoonotic disease control.
  94. 94
    Anuar, T. S.; Sarhan Al-Mekhlafi, H. M.; Abdul Ghani, M. K.; Moktar, N. Prevalence and risk factors associated with Entamoeba histolytica/Entamoeba dispar/Entamoeba moshkovskii complex infection among different tribes of Malaysian aborigines Int. J. Infect. Dis. 2012, 16, e175– e176 DOI: 10.1016/j.ijid.2012.05.725
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    Suwannarong, K.; Chapman, R. S. Characteristics associated with contact with rodents in, around, and outside homes in Khon Kaen Province, Thailand Am. J. Trop. Med. Hyg. 2015, 92 (4) 784– 790 DOI: 10.4269/ajtmh.14-0195
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    Vujcic, J.; Ram, P. K.; Hussain, F.; Unicomb, L.; Gope, P. S.; Abedin, J.; Mahmud, Z. H.; Sirajul Islam, M.; Luby, S. P. Toys and toilets: cross-sectional study using children’s toys to evaluate environmental faecal contamination in rural Bangladeshi households with different sanitation facilities and practices Trop. Med. Int. Health 2014, 19 (5) 528– 536 DOI: 10.1111/tmi.12292
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    96
    Toys and toilets: cross-sectional study using children's toys to evaluate environmental faecal contamination in rural Bangladeshi households with different sanitation facilities and practices
    Vujcic Jelena; Ram Pavani K; Hussain Faruqe; Unicomb Leanne; Gope Partha Sarathi; Abedin Jaynal; Mahmud Zahid Hayat; Islam M Sirajul; Luby Stephen P
    Tropical medicine & international health : TM & IH (2014), 19 (5), 528-36 ISSN:.
    OBJECTIVE: To evaluate household faecal contamination using children's toys among 100 rural Bangladeshi households categorised as 'cleaner' (toilet that reliably separates faeces from the environment and no human faeces in/around living space) or 'less clean' (no toilet or toilet that does not reliably separate faeces from the environment and human faeces in/around living space). METHODS: We distributed toy balls to each household and rinsed each study toy and a toy already owned by the household in 200 ml of Ringer's solution. We enumerated faecal coliforms and faecal streptococci from each rinse using membrane filtration methods. RESULTS: Study toys from 39 cleaner households had lower mean faecal coliform contamination than toys from 61 less clean households (2.4 log10 colony-forming units (CFU)/200 ml vs. 3.2 log10 CFU/200 ml, P = 0.03). However, wealth measures explained a portion of this relationship. Repeat measures were moderately variable [coefficient of variation (CV) = 6.5 between two toys in the household at the same time, CV = 37.6 between toys in the household at two different times 3-4 days apart]. Too few households owned a non-porous toy to compare groups without risk of bias. CONCLUSION: In rural Bangladesh, improved sanitation facilities and practices were associated with less environmental contamination. Whether this association is independent of household wealth and whether the difference in contamination improves child health merit further study. The variation found was typical for measures of environmental contamination, and requires large sample sizes to ascertain differences between groups with statistical significance.
  97. 97
    Torondel, B.; Gyekye-Aboagye, Y.; Routray, P.; Boisson, S.; Schimdt, W.; Clasen, T. Laboratory development and field testing of sentinel toys to assess environmental faecal exposure of young children in rural India Trans. R. Soc. Trop. Med. Hyg. 2015, 109 (6) 386– 392 DOI: 10.1093/trstmh/trv023
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    97
    Laboratory development and field testing of sentinel toys to assess environmental faecal exposure of young children in rural India
    Torondel Belen; Gyekye-Aboagye Yaw; Routray Parimita; Boisson Sophie; Schimdt Wolf; Clasen Thomas
    Transactions of the Royal Society of Tropical Medicine and Hygiene (2015), 109 (6), 386-92 ISSN:.
    BACKGROUND: Sentinel toys are increasingly used as a method of assessing young children's exposure to faecal pathogens in households in low-income settings. However, there is no consensus on the suitability of different approaches. METHODS: We evaluated three types of toy balls with different surfaces (plastic, rubber, urethane) in the laboratory to compare the uptake of faecal indicator bacteria (Escherichia coli) on their surface. We performed bacteria survival analysis under different environmental conditions and tested laboratory methods for bacteria removal and recovery. In a field study we distributed sterile urethane balls to children <5 from 360 households in rural India. After 24 hours, we collected and rinsed the toys in sterile water, assayed for thermotolerant coliforms (TTC) and explored associations between the level of contamination and household characteristics. RESULTS: In the laboratory, urethane foam balls took up more indicator bacteria than the other balls. Bacteria recovery did not differ based on mechanic vs no agitation. Higher temperatures and moisture levels increased bacterial yield. In the field, the only factor associated with a decreased recovery of TTC from the balls was having a soil (unpaved) floor. CONCLUSIONS: Sentinel toys may be an effective tool for assessing young children's exposure to faecal pathogens. However, even using methods designed to increase bacterial recovery, limited sensitivity may require larger sample sizes.
  98. 98
    Harvey, S. A.; Winch, P. J.; Leontsini, E.; Torres Gayoso, C.; López Romero, S.; Gilman, R. H.; Oberhelman, R. A. Domestic poultry-raising practices in a Peruvian shantytown: implications for control of Campylobacter jejuni-associated diarrhea Acta Trop. 2003, 86 (1) 41– 54 DOI: 10.1016/S0001-706X(03)00006-8
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    98
    Domestic poultry-raising practices in a Peruvian shantytown: implications for control of Campylobacter jejuni-associated diarrhea
    Harvey Steven A; Winch Peter J; Leontsini Elli; Torres Gayoso Cecilia; Lopez Romero Sonia; Gilman Robert H; Oberhelman Richard A
    Acta tropica (2003), 86 (1), 41-54 ISSN:0001-706X.
    Raising poultry at home is common in many periurban communities in low-income countries. Studies demonstrate that free-range domestic poultry increase children's risk of infection with diarrhea-causing organisms such as Campylobacter jejuni. Corralling might reduce risk, but research on the socioeconomic acceptability of corralling is lacking. To explore this issue, we studied local knowledge and practices related to poultry-raising in a Peruvian shantytown. Our objectives were to understand: (1). motives for raising domestic poultry; (2). economic and cultural factors that affect the feasibility of corralling; and (3). local perceptions about the relationship between domestic poultry and disease. During 1999-2000, we met with community health volunteers and conducted ethnographic and structured interviews with residents about poultry-raising practices. We then enrolled 12 families in a 2-month trial of corral use during which field workers made biweekly surveillance visits to each family. Most participants reported that they raise birds because home-grown poultry and eggs taste better and are more nutritious and because they enjoy living around animals. Some want to teach their children about raising animals. To prevent theft, many residents shut their birds in provisional enclosures at night, but most stated that birds are healthier, happier, and produce better meat and eggs when let loose by day. Many view bird feces in the house and yard as dirty, but few see a connection to illness. Residents consider chicks and ducklings more innocuous than adult birds and are more likely to allow them inside the house and permit children to play with them. After extensive orientation and technical assistance, participants were willing to corral birds more often. But due to perceived disadvantages, many kept birds penned only intermittently. Additional food and water costs were a significant obstacle for some. Adequate space, bird care and corral hygiene would also need to be addressed to make this intervention viable. Developing a secure, acceptable and affordable corral remains a challenge in this population.
  99. 99
    Arnold, B. F.; Null, C.; Luby, S. P.; Unicomb, L.; Stewart, C. P.; Dewey, K. G.; Ahmed, T.; Ashraf, S.; Christensen, G.; Clasen, T.; Dentz, H. N.; Fernald, L. C. H.; Haque, R.; Hubbard, A. E.; Kariger, P.; Leontsini, E.; Lin, A.; Njenga, S. M.; Pickering, A. J.; Ram, P. K.; Tofail, F.; Winch, P. J.; Colford, J. M. Cluster-randomised controlled trials of individual and combined water, sanitation, hygiene and nutritional interventions in rural Bangladesh and Kenya: the WASH Benefits study design and rationale BMJ. Open 2013, 3 (8) e003476 DOI: 10.1136/bmjopen-2013-003476
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    Hussain, F. Continued household faecal contamination following a sanitation intervention in rural Bangladesh. Health Sci. Bull. 2013, 11 (1), 9–14 (En), 9–14 (Bengali).
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    Sanitation Hygiene Infant Nutrition Efficacy

    Trial, T.; Humphrey, J. H.; Jones, A. D.; Manges, A.; Mangwadu, G.; Maluccio, J. A.; Mbuya, M. N.; Moulton, L. H.; Ntozini, R.; Prendergast, A. J.; Stoltzfus, R. J.; Tielsch, J. M. The Sanitation Hygiene Infant Nutrition Efficacy (SHINE) Trial: Rationale, Design, and Methods Clin. Infect. Dis. 2015, 61 (Suppl 7) S685– 702
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Cite this: Environ. Sci. Technol. 2017, 51, 20, 11537–11552
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https://doi.org/10.1021/acs.est.7b02811
Published September 19, 2017

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  • Abstract

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    Figure 1

    Figure 1. Traditional F-Diagram showing potential fecal-oral transmission pathways. Adapted from Wagner, E.; Lanoix, J., Excreta disposal for rural areas and small communities. Monograph Series World Health Organization.1958, 39, 182. Copyright 1958, World Health Organization.

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    Figure 2

    Figure 2. Impact of exposure to animal feces and/or contact with animals to human health.

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    Figure 3

    Figure 3. Modified F-diagram showing transmission routes of animal feces to humans. Adapted from Wagner, E.; Lanoix, J., Excreta disposal for rural areas and small communities. Monograph Series World Health Organization.1958, 39, 182. Copyright 1958, World Health Organization.

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    Figure 4

    Figure 4. Modified F-diagram including interventions that can block human exposure to animal feces. Adapted from Wagner, E.; Lanoix, J., Excreta disposal for rural areas and small communities. Monograph Series World Health Organization.1958, 39, 182. Copyright 1958, World Health Organization.

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    Figure 5

    Figure 5. Priority research gaps in assessing human health impacts from exposure to poorly managed animal feces. This figure, an adaption from the socio-ecological model, represents how the “spheres of influence,” from human host and zoonotic pathogen biology to national policies, influence the health of the human host. Example items for future research within each sphere are provided.

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  • References

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      There is no corresponding record for this reference.
    7. 7
      Moore, S. R.; Lima, N. L.; Soares, A. M.; Oriá, R. B.; Pinkerton, R. C.; Barrett, L. J.; Guerrant, R. L.; Lima, A. A. Prolonged episodes of acute diarrhea reduce growth and increase risk of persistent diarrhea in children Gastroenterology 2010, 139 (4) 1156– 1164 DOI: 10.1053/j.gastro.2010.05.076
      7
      Prolonged episodes of acute diarrhea reduce growth and increase risk of persistent diarrhea in children
      Moore Sean R; Lima Noelia L; Soares Alberto M; Oria Reinaldo B; Pinkerton Relana C; Barrett Leah J; Guerrant Richard L; Lima Aldo A M
      Gastroenterology (2010), 139 (4), 1156-64 ISSN:.
      BACKGROUND & AIMS: Prolonged episodes of acute diarrhea (ProD; duration 7-13 days) or persistent diarrhea (PD; duration ≥14 days) are important causes of undernutrition, yet the epidemiology and nutritional impact of ProD are poorly understood. METHODS: We conducted a 10-year cohort study of 414 children from a Brazilian shantytown who were followed from birth; data were collected on diarrhea, enteric pathogens, and anthropometry. RESULTS: During 1276 child-years of observation, we recorded 3257 diarrheal episodes. ProD was twice as common as PD (12% and 5% of episodes, respectively); ProD and PD together accounted for 50% of all days with diarrhea. ProD was more common in infants whose mothers had not completed primary school (relative risk [RR], 2.1; 95% confidence interval: 1.02-2.78). Early weaning was associated with earlier onset of ProD (Spearman ρ = 0.309; P = .005). Infants with ProD were twice as likely to develop PD in later childhood (log rank, P = .002) compared with infants with only acute diarrhea (AD; duration <7 days), even after controlling for confounders. Children's growth was more severely stunted before their first episode of ProD, compared with AD (mean height-for-age Z score (HAZ) -0.81 vs -0.51, respectively, P < .05, unpaired t test). Following ProD, HAZ (ΔHAZ = -0.232) and weight-for-age (ΔWAZ = -0.26) significantly decreased (P < .005 in paired t tests). ProD was associated with Cryptosporidium and Shigella infections. CONCLUSIONS: ProD accounts for significant morbidity and identifies children at risk of a vicious cycle of diarrhea and malnutrition. Further studies are needed to address the recognition and control of ProD and its consequences in resource-limited settings and assess its role in PD pathogenesis.
    8. 8
      Lorntz, B.; Soares, A. M.; Moore, S. R.; Pinkerton, R.; Gansneder, B.; Bovbjerg, V. E.; Guyatt, H.; Lima, A. M.; Guerrant, R. L. Early childhood diarrhea predicts impaired school performance Pediatric infectious disease journal 2006, 25 (6) 513– 520 DOI: 10.1097/01.inf.0000219524.64448.90
      There is no corresponding record for this reference.
    9. 9
      Robert-Gangneux, F.; Dardé, M.-L. Epidemiology of and diagnostic strategies for toxoplasmosis Clin. Microbiol. Rev. 2012, 25 (2) 264– 296 DOI: 10.1128/CMR.05013-11
      9
      Epidemiology of and diagnostic strategies for toxoplasmosis
      Robert-Gangneux, Florence; Darde, Marie-Laure
      Clinical Microbiology Reviews (2012), 25 (2), 264-296CODEN: CMIREX; ISSN:0893-8512. (American Society for Microbiology)
      A review. The apicomplexan parasite Toxoplasma gondii was discovered a little over 100 years ago, but knowledge of its biol. life cycle and its medical importance has grown in the last 40 years. This obligate intracellular parasite was identified early as a pathogen responsible for congenital infection, but its clin. expression and the importance of reactivations of infections in immunocompromised patients were recognized later, in the era of organ transplantation and HIV infection. Recent knowledge of host cell-parasite interactions and of parasite virulence has brought new insights into the comprehension of the pathophysiol. of infection. In this review, we focus on epidemiol. and diagnostic aspects, putting them in perspective with current knowledge of parasite genotypes. In particular, we provide crit. information on diagnostic methods according to the patient's background and discuss the implementation of screening tools for congenital toxoplasmosis according to health policies.
    10. 10
      Wang, H.; Naghavi, M.; Allen, C.; Barber, R. M.; Bhutta, Z. A.; Carter, A.; Casey, D. C.; Charlson, F. J.; Chen, A. Z.; Coates, M. M.; al, e. Global, regional, and national life expectancy, all-cause mortality, and cause-specific mortality for 249 causes of death: a systematic analysis for the Global Burden of Disease Study Lancet. 2015, 388 (10053) 1459– 1544
      There is no corresponding record for this reference.
    11. 11
      Kotloff, K. L.; Nataro, J. P.; Blackwelder, W. C.; Nasrin, D.; Farag, T. H.; Panchalingam, S.; Wu, Y.; Sow, S. O.; Sur, D.; Breiman, R. F.; Faruque, A. S. G.; Zaidi, A. K. M.; Saha, D.; Alonso, P. L.; Tamboura, B.; Sanogo, D.; Onwuchekwa, U.; Manna, B.; Ramamurthy, T.; Kanungo, S.; Ochieng, J. B.; Omore, R.; Oundo, J. O.; Hossain, A.; Das, S. K.; Ahmed, S.; Qureshi, S.; Quadri, F.; Adegbola, R. A.; Antonio, M.; Hossain, M. J.; Akinsola, A.; Mandomando, I.; Nhampossa, T.; Acácio, S.; Biswas, K.; O’Reilly, C. E.; Mintz, E. D.; Berkeley, L. Y.; Muhsen, K.; Sommerfelt, H.; Robins-Browne, R. M.; Levine, M. M. Burden and aetiology of diarrhoeal disease in infants and young children in developing countries (the Global Enteric Multicenter Study, GEMS): a prospective, case-control study Lancet 2013, 382 (9888) 209– 222 DOI: 10.1016/S0140-6736(13)60844-2
      11
      Burden and aetiology of diarrhoeal disease in infants and young children in developing countries (the Global Enteric Multicenter Study, GEMS): a prospective, case-control study
      Kotloff Karen L; Nataro James P; Blackwelder William C; Nasrin Dilruba; Farag Tamer H; Panchalingam Sandra; Wu Yukun; Sow Samba O; Sur Dipika; Breiman Robert F; Faruque Abu Sg; Zaidi Anita Km; Saha Debasish; Alonso Pedro L; Tamboura Boubou; Sanogo Doh; Onwuchekwa Uma; Manna Byomkesh; Ramamurthy Thandavarayan; Kanungo Suman; Ochieng John B; Omore Richard; Oundo Joseph O; Hossain Anowar; Das Sumon K; Ahmed Shahnawaz; Qureshi Shahida; Quadri Farheen; Adegbola Richard A; Antonio Martin; Hossain M Jahangir; Akinsola Adebayo; Mandomando Inacio; Nhampossa Tacilta; Acacio Sozinho; Biswas Kousick; O'Reilly Ciara E; Mintz Eric D; Berkeley Lynette Y; Muhsen Khitam; Sommerfelt Halvor; Robins-Browne Roy M; Levine Myron M
      Lancet (London, England) (2013), 382 (9888), 209-22 ISSN:.
      BACKGROUND: Diarrhoeal diseases cause illness and death among children younger than 5 years in low-income countries. We designed the Global Enteric Multicenter Study (GEMS) to identify the aetiology and population-based burden of paediatric diarrhoeal disease in sub-Saharan Africa and south Asia. METHODS: The GEMS is a 3-year, prospective, age-stratified, matched case-control study of moderate-to-severe diarrhoea in children aged 0-59 months residing in censused populations at four sites in Africa and three in Asia. We recruited children with moderate-to-severe diarrhoea seeking care at health centres along with one to three randomly selected matched community control children without diarrhoea. From patients with moderate-to-severe diarrhoea and controls, we obtained clinical and epidemiological data, anthropometric measurements, and a faecal sample to identify enteropathogens at enrolment; one follow-up home visit was made about 60 days later to ascertain vital status, clinical outcome, and interval growth. FINDINGS: We enrolled 9439 children with moderate-to-severe diarrhoea and 13,129 control children without diarrhoea. By analysing adjusted population attributable fractions, most attributable cases of moderate-to-severe diarrhoea were due to four pathogens: rotavirus, Cryptosporidium, enterotoxigenic Escherichia coli producing heat-stable toxin (ST-ETEC; with or without co-expression of heat-labile enterotoxin), and Shigella. Other pathogens were important in selected sites (eg, Aeromonas, Vibrio cholerae O1, Campylobacter jejuni). Odds of dying during follow-up were 8·5-fold higher in patients with moderate-to-severe diarrhoea than in controls (odd ratio 8·5, 95% CI 5·8-12·5, p<0·0001); most deaths (167 [87·9%]) occurred during the first 2 years of life. Pathogens associated with increased risk of case death were ST-ETEC (hazard ratio [HR] 1·9; 0·99-3·5) and typical enteropathogenic E coli (HR 2·6; 1·6-4·1) in infants aged 0-11 months, and Cryptosporidium (HR 2·3; 1·3-4·3) in toddlers aged 12-23 months. INTERPRETATION: Interventions targeting five pathogens (rotavirus, Shigella, ST-ETEC, Cryptosporidium, typical enteropathogenic E coli) can substantially reduce the burden of moderate-to-severe diarrhoea. New methods and accelerated implementation of existing interventions (rotavirus vaccine and zinc) are needed to prevent disease and improve outcomes. FUNDING: The Bill & Melinda Gates Foundation.
    12. 12
      Dufour, A.; Bartram, J.; Bos, R.; Gannon, V. Animal Waste, Water Quality and Human Health; IWA Publishing: London, UK, 2012, 6– 130.
      There is no corresponding record for this reference.
    13. 13
      Clasen, T. F.; Bostoen, K.; Schmidt, W.-P.; Boisson, S.; Fung, I. C. H.; Jenkins, M. W.; Scott, B.; Sugden, S.; Cairncross, S., Interventions to improve disposal of human excreta for preventing diarrhoea. Cochrane Database of Systematic Reviews 2010, (6). doi:  DOI: 10.1002/14651858.CD007180.pub2 .
      There is no corresponding record for this reference.
    14. 14
      Stocks, M. E.; Ogden, S.; Haddad, D.; Addiss, D. G.; McGuire, C.; Freeman, M. C. Effect of Water, Sanitation, and Hygiene on the Prevention of Trachoma: A Systematic Review and Meta-Analysis PLoS Medicine. 2014, 11 (2) e1001605 DOI: 10.1371/journal.pmed.1001605
      There is no corresponding record for this reference.
    15. 15
      Strunz, E. C.; Addiss, D. G.; Stocks, M. E.; Ogden, S.; Utzinger, J.; Freeman, M. C. Water, Sanitation, Hygiene, and Soil-Transmitted Helminth Infection: A Systematic Review and Meta-Analysis PLoS Medicine. 2014, 11 (3) e1001620 DOI: 10.1371/journal.pmed.1001620
      There is no corresponding record for this reference.
    16. 16
      Barreto, M. L.; Genser, B.; Strina, A.; Assis, A. M. O.; Rego, R. F.; Teles, C. A.; Prado, M. S.; Matos, S. M. A.; Santos, D. N.; dos Santos, L. A.; Cairncross, S.; Teixeira, M. G. Effect of city-wide sanitation programme on reduction in rate of childhood diarrhoea in northeast Brazil: assessment by two cohort studies Lancet 2007, 370 (9599) 1622– 1628 DOI: 10.1016/S0140-6736(07)61638-9
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      Effect of city-wide sanitation programme on reduction in rate of childhood diarrhoea in northeast Brazil: assessment by two cohort studies
      Barreto Mauricio L; Genser Bernd; Strina Agostino; Teixeira Maria Gloria; Assis Ana Marlucia O; Rego Rita F; Teles Carlos A; Prado Matildes S; Matos Sheila M A; Santos Darci N; dos Santos Lenaldo A; Cairncross Sandy
      Lancet (London, England) (2007), 370 (9599), 1622-8 ISSN:.
      BACKGROUND: A city-wide sanitation intervention was started in Salvador, Brazil, in 1997 to improve sewerage coverage from 26% of households to 80%. Our aim was to investigate the epidemiological effect of this city-wide sanitation programme on diarrhoea morbidity in children less than 3 years of age. METHODS: The investigation was composed of two longitudinal studies done in 1997-98 before the intervention (the sanitation programme) and in 2003-04 after the intervention had been completed. Each study consisted of a cohort of children (841 in the preintervention study and 1007 in the postintervention study; age 0-36 months at baseline) who were followed up for a maximum of 8 months. Children were sampled from 24 sentinel areas that were randomly chosen to represent the range of environmental conditions in the study site. At the start of each study an individual or household questionnaire was applied by trained fieldworkers; an environmental survey was done in each area before and after introduction of the sanitation programme to assess basic neighbourhood and household sanitation conditions. Daily diarrhoea data were obtained during home visits twice per week. The effect of the intervention was estimated by a hierarchical modelling approach fitting a sequence of multivariate regression models. FINDINGS: Diarrhoea prevalence fell by 21% (95% CI 18-25%)-from 9.2 (9.0-9.5) days per child-year before the intervention to 7.3 (7.0-7.5) days per child-year afterwards. After adjustment for baseline sewerage coverage and potential confounding variables, we estimated an overall prevalence reduction of 22% (19-26%). INTERPRETATION: Our results show that urban sanitation is a highly effective health measure that can no longer be ignored, and they provide a timely support for the launch of 2008 as the International Year of Sanitation.
    17. 17
      Clasen, T.; Boisson, S.; Routray, P.; Torondel, B.; Bell, M.; Cumming, O.; Ensink, J.; Freeman, M.; Jenkins, M.; Odagiri, M.; Ray, S.; Sinha, A.; Suar, M.; Schmidt, W.-P. Effectiveness of a rural sanitation programme on diarrhoea, soil-transmitted helminth infection, and child malnutrition in Odisha, India: a cluster-randomised trial Lancet Global Health 2014, 2 (11) e645– e653 DOI: 10.1016/S2214-109X(14)70307-9
      There is no corresponding record for this reference.
    18. 18
      Emerson, P. M.; Lindsay, S. W.; Alexander, N.; Bah, M.; Dibba, S.-M.; Faal, H. B.; Lowe, K.; McAdam, K. P. W. J.; Ratcliffe, A. A.; Walraven, G. E. L.; Bailey, R. L. Role of flies and provision of latrines in trachoma control: cluster-randomised controlled trial Lancet 2004, 363 (9415) 1093– 1098 DOI: 10.1016/S0140-6736(04)15891-1
      There is no corresponding record for this reference.
    19. 19
      Patil, S. R.; Arnold, B. F.; Salvatore, A. L.; Briceno, B.; Ganguly, S.; Colford, J. M., Jr.; Gertler, P. J. The Effect of India’s Total Sanitation Campaign on Defecation Behaviors and Child Health in Rural Madhya Pradesh: A Cluster Randomized Controlled Trial PLOS Medicine. 2014, 11 (8) e1001709 DOI: 10.1371/journal.pmed.1001709
      There is no corresponding record for this reference.
    20. 20
      Pickering, A. J.; Djebbari, H.; Lopez, C.; Coulibaly, M.; Alzua, M. L. Effect of a community-led sanitation intervention on child diarrhoea and child growth in rural Mali: a cluster-randomised controlled trial Lancet Global Health 2015, 3 (11) e701– e711 DOI: 10.1016/S2214-109X(15)00144-8
      There is no corresponding record for this reference.
    21. 21
      Gyorkos, T. W.; Maheu-Giroux, M.; Blouin, B.; Casapia, M. Impact of Health Education on Soil-Transmitted Helminth Infections in Schoolchildren of the Peruvian Amazon: A Cluster-Randomized Controlled Trial PLoS Neglected Trop. Dis. 2013, 7 (9) e2397 DOI: 10.1371/journal.pntd.0002397
      There is no corresponding record for this reference.
    22. 22
      West, S.; Muñoz, B.; Lynch, M.; Kayongoya, A.; Chilangwa, Z.; Mmbaga, B. B. O.; Taylor, H. R. Impact of face-washing on trachoma in Kongwa, Tanzania Lancet 1995, 345 (8943) 155– 158 DOI: 10.1016/S0140-6736(95)90167-1
      There is no corresponding record for this reference.
    23. 23
      Freeman, M. C.; Clasen, T.; Brooker, S. J.; Akoko, D. O.; Rheingans, R. The Impact of a School-Based Hygiene, Water Quality and Sanitation Intervention on Soil-Transmitted Helminth Reinfection: A Cluster-Randomized Trial Am. J. Trop. Med. Hyg. 2013, 89 (5) 875– 883 DOI: 10.4269/ajtmh.13-0237
      There is no corresponding record for this reference.
    24. 24
      Colford, J. M. J.; Luby, S. P.; Null, C.; Stewart, C. P. In The WASH Benefits Study: Cluster-Randomized Trials in Bangladesh and Kenya to Measure the Effects of Individual and Combined Water Quality, Sanitation, Handwashing and Nutrition Interventions on Child Growth and Diarrhea ASTHM, Atlanta, GA, 2016; Atlanta, GA, 2016.
      There is no corresponding record for this reference.
    25. 25
      Garn, J. V.; Sclar, G. D.; Freeman, M. C.; Penakalapati, G.; Alexander, K. T.; Brooks, P.; Rehfuess, E. A.; Boisson, S.; Medlicott, K. O.; Clasen, T. F. The impact of sanitation interventions on latrine coverage and latrine use: A systematic review and meta-analysis Int. J. Hyg. Environ. Health 2017, 220 (2, Part B) 329– 340 DOI: 10.1016/j.ijheh.2016.10.001
      25
      The impact of sanitation interventions on latrine coverage and latrine use: A systematic review and meta-analysis
      Garn Joshua V; Sclar Gloria D; Freeman Matthew C; Penakalapati Gauthami; Alexander Kelly T; Brooks Patrick; Rehfuess Eva A; Boisson Sophie; Medlicott Kate O; Clasen Thomas F
      International journal of hygiene and environmental health (2017), 220 (2 Pt B), 329-340 ISSN:.
      BACKGROUND: An estimated 2.4 billion people still lack access to improved sanitation and 946 million still practice open defecation. The World Health Organization (WHO) commissioned this review to assess the impact of sanitation on coverage and use, as part of its effort to develop a set of guidelines on sanitation and health. METHODS AND FINDINGS: We systematically reviewed the literature and used meta-analysis to quantitatively characterize how different sanitation interventions impact latrine coverage and use. We also assessed both qualitative and quantitative studies to understand how different structural and design characteristics of sanitation are associated with individual latrine use. A total of 64 studies met our eligibility criteria. Of 27 intervention studies that reported on household latrine coverage and provided a point estimate with confidence interval, the average increase in coverage was 14% (95% CI: 10%, 19%). The intervention types with the largest absolute increases in coverage included the Indian government's "Total Sanitation Campaign" (27%; 95% CI: 14%, 39%), latrine subsidy/provision interventions (16%; 95% CI: 8%, 24%), latrine subsidy/provision interventions that also incorporated education components (17%; 95% CI: -5%, 38%), sewerage interventions (14%; 95% CI: 1%, 28%), sanitation education interventions (14%; 95% CI: 3%, 26%), and community-led total sanitation interventions (12%; 95% CI: -2%, 27%). Of 10 intervention studies that reported on household latrine use, the average increase was 13% (95% CI: 4%, 21%). The sanitation interventions and contexts in which they were implemented varied, leading to high heterogeneity across studies. We found 24 studies that examined the association between structural and design characteristics of sanitation facilities and facility use. These studies reported that better maintenance, accessibility, privacy, facility type, cleanliness, newer latrines, and better hygiene access were all frequently associated with higher use, whereas poorer sanitation conditions were associated with lower use. CONCLUSIONS: Our results indicate that most sanitation interventions only had a modest impact on increasing latrine coverage and use. A further understanding of how different sanitation characteristics and sanitation interventions impact coverage and use is essential in order to more effectively attain sanitation access for all, eliminate open defecation, and ultimately improve health.
    26. 26
      Kaur, M.; Graham, J.; Eisenberg, J. N. S. Livestock Ownership among Rural Households and Child Morbidity and Mortality: An Analysis of Demographic Health Survey Data from 30 Sub-Saharan African Countries (2005–2015) Am. J. Trop. Med. Hyg. 2017, 96 (3) 741– 748 DOI: 10.4269/ajtmh.16-0664
      There is no corresponding record for this reference.
    27. 27
      Odagiri, M.; Schriewer, A.; Daniels, M. E.; Wuertz, S.; Smith, W. A.; Clasen, T.; Schmidt, W.-P.; Jin, Y.; Torondel, B.; Misra, P. R.; Panigrahi, P.; Jenkins, M. W. Human fecal and pathogen exposure pathways in rural Indian villages and the effect of increased latrine coverage Water Res. 2016, 100, 232– 244 DOI: 10.1016/j.watres.2016.05.015
      27
      Human fecal and pathogen exposure pathways in rural Indian villages and the effect of increased latrine coverage
      Odagiri, Mitsunori; Schriewer, Alexander; Daniels, Miles E.; Wuertz, Stefan; Smith, Woutrina A.; Clasen, Thomas; Schmidt, Wolf-Peter; Jin, Yujie; Torondel, Belen; Misra, Pravas R.; Panigrahi, Pinaki; Jenkins, Marion W.
      Water Research (2016), 100 (), 232-244CODEN: WATRAG; ISSN:0043-1354. (Elsevier Ltd.)
      Efforts to eradicate open defecation and improve sanitation access are unlikely to achieve health benefits unless interventions reduce microbial exposures. This study assessed human fecal contamination and pathogen exposures in rural India, and the effect of increased sanitation coverage on contamination and exposure rates. In a cross-sectional study of 60 villages of a cluster-randomized controlled sanitation trial in Odisha, India, human and domestic animal fecal contamination was measured in community tubewells and ponds (n = 301) and via exposure pathways in homes (n = 354), using Bacteroidales microbial source tracking fecal markers validated in India. Community water sources were further tested for diarrheal pathogens (rotavirus, adenovirus and Vibrio cholerae by quant. PCR; pathogenic Escherichia coli by multiplex PCR; Cryptosporidium and Giardia by immunomagnetic sepn. and direct fluorescent antibody microscopy). Exposure pathways in intervention and control villages were compared and relationships with child diarrhea examd. Human fecal markers were rarely detected in tubewells (2.4%, 95%CI: 0.3-4.5%) and ponds (5.6%, 95%CI: 0.8-10.3%), compared to homes (35.4%, 95%CI: 30.4-40.4%). In tubewells, V. cholerae was the most frequently detected pathogen (19.8%, 95%CI: 14.4-25.2%), followed by Giardia (14.8%, 95%CI: 10.0-19.7%). In ponds, Giardia was most often detected (74.5%, 95%CI: 65.7-83.3%), followed by pathogenic E. coli (48.1%, 95%CI: 34.8-61.5%) and rotavirus (44.4%, 95%CI: 34.2-54.7%). At village-level, prevalence of fecal pathogen detection in community drinking water sources was assocd. with elevated prevalence of child diarrhea within 6 wk of testing (RR 2.13, 95%CI: 1.25-3.63) while within homes, higher levels of human and animal fecal marker detection were assocd. with increased risks of subsequent child diarrhea (P = 0.044 and 0.013, resp.). There was no evidence that the intervention, which increased functional latrine coverage and use by 27 percentage points, reduced human fecal contamination in any tested pathway, nor the prevalence of pathogens in water sources. In conclusion, the study demonstrates that (1) improved sanitation alone may be insufficient and further interventions needed in the domestic domain to reduce widespread human and animal fecal contamination obsd. in homes, (2) pathogens detected in tubewells indicate these sources are microbiol. unsafe for drinking and were assocd. with child diarrhea, (3) domestic use of ponds heavily contaminated with multiple pathogens presents an under-recognized health risk, and (4) a 27 percentage point increase in improved sanitation access at village-level did not reduce detectable human fecal and pathogen contamination in this setting.
    28. 28
      Belongia, E. A.; Chyou, P. H.; Greenlee, R. T.; Perez-Perez, G.; Bibb, W. F.; DeVries, E. O. Diarrhea Incidence and Farm-Related Risk Factors for Escherichia coli O157:H7 and Campylobacter jejuni Antibodies among Rural Children J. Infect. Dis. 2003, 187 (9) 1460– 1468 DOI: 10.1086/374622
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      Diarrhea incidence and farm-related risk factors for Escherichia coli O157:H7 and Campylobacter jejuni antibodies among rural children
      Belongia Edward A; Chyou Po-Huang; Greenlee Robert T; Perez-Perez Guillermo; Bibb William F; DeVries Edna O
      The Journal of infectious diseases (2003), 187 (9), 1460-8 ISSN:0022-1899.
      Serum samples were obtained from 215 farm-resident children and 396 non-farm-resident children living in a defined rural Wisconsin population. Antibodies to Campylobacter jejuni and Escherichia coli O157:H7 lipopolysaccharide (O157 LPS) immunoglobulin G were measured, and the incidence of clinic visits for diarrheal illness was determined. Risk factors were assessed in a telephone interview. There were 363 children (59%) with C. jejuni antibodies (seropositive for >or=2 immunoglobulin classes) and 86 (14%) with O157 LPS antibodies. Increasing age and farm residence were independently associated with C. jejuni seropositivity by multivariate analysis. O157 LPS antibodies were independently associated with increasing age, female sex, manure contact, and sheep contact. The incidence of clinically recognized diarrhea was similar among children with and without antibodies to C. jejuni and O157 LPS, but the clinic visit rate for diarrhea was 46% lower among farm-resident children. These results are consistent with reduced occurrence of clinical illness from repeated antigenic stimulation in a farm environment.
    29. 29
      Cinquepalmi, V.; Monno, R.; Fumarola, L.; Ventrella, G.; Calia, C.; Greco, M. F.; de Vito, D.; Soleo, L. Environmental Contamination by Dog’s Faeces: A Public Health Problem? Int. J. Environ. Res. Public Health 2013, 10 (1) 72 DOI: 10.3390/ijerph10010072
      There is no corresponding record for this reference.
    30. 30
      Jung, B. K.; Lee, S. E.; Lim, H.; Cho, J.; Kim, D. G.; Song, H.; Kim, M. J.; Shin, E. H.; Chai, J. Y. Toxoplasma gondii B1 gene detection in feces of stray cats around Seoul, Korea and genotype analysis of two laboratory-passaged isolates Korean J. Parasitol. 2015, 53 (3) 259– 263 DOI: 10.3347/kjp.2015.53.3.259
      30
      Toxoplasma gondii B1 Gene Detection in Feces of Stray Cats around Seoul, Korea and Genotype Analysis of Two Laboratory-Passaged Isolates
      Jung Bong-Kwang; Lim Hyemi; Cho Jaeeun; Kim Deok-Gyu; Song Hyemi; Kim Min-Jae; Chai Jong-Yil; Lee Sang-Eun; Shin Eun-Hee
      The Korean journal of parasitology (2015), 53 (3), 259-63 ISSN:.
      The increasing prevalence of Toxoplasma gondii infection in the human population in the Republic of Korea (= Korea) is due to various reasons such as an increase in meat consumption. However, the importance of cats in transmitting T. gondii infection through oocysts to humans has seldom been assessed. A total of 300 fecal samples of stray cats captured around Seoul from June to August 2013 were examined for T. gondii B1 gene (indicating the presence of oocysts) using nested-PCR. Fourteen (4.7%) of 300 cats examined were positive for B1 gene. Female cats (7.5%) showed a higher prevalence than male cats (1.4%). Cats younger than 3 months (5.5%) showed a higher prevalence than cats (1.5%) older than 3 months. For laboratory passage of the positive samples, the fecal suspension (0.2 ml) of B1 gene positive cats was orally inoculated into experimental mice. Brain tissues of the mice were obtained after 40 days and examined for the presence of tissue cysts. Two isolates were successfully passaged (designated KNIH-1 and KNIH-2) and were molecularly analyzed using the SAG5D and SAG5E gene sequences. The SAG5D and SAG5E gene sequences showed high homologies with the ME49 strain (less virulent strain). The results indicated the importance of stray cats in transmitting T. gondii to humans in Korea, as revealed by detection of B1 gene in fecal samples. T. gondii isolates from cats were successfully passaged in the laboratory for the first time in Korea.
    31. 31
      Tobin, M. R.; Goldshear, J. L.; Price, L. B.; Graham, J. P.; Leibler, J. H. A Framework to Reduce Infectious Disease Risk from Urban Poultry in the United States Public Health Rep. 2015, 130 (4) 380– 391 DOI: 10.1177/003335491513000417
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      A Framework to Reduce Infectious Disease Risk from Urban Poultry in the United States
      Tobin Molly R; Goldshear Jesse L; Price Lance B; Graham Jay P; Leibler Jessica H
      Public health reports (Washington, D.C. : 1974) (2015), 130 (4), 380-91 ISSN:.
      OBJECTIVES: Backyard poultry ownership is increasingly common in U.S. cities and is regulated at the local level. Human contact with live poultry is a well-known risk for infection with zoonotic pathogens, notably Salmonella, yet the ability of local jurisdictions to reduce the risk of infectious disease transmission from poultry to humans is unstudied. We reviewed urban poultry ordinances in the United States and reported Salmonella outbreaks from backyard poultry to identify regulatory gaps in preventing zoonotic pathogen transmission. Based on this analysis, we propose regulatory guidelines for U.S. cities to reduce infectious disease risk from backyard poultry ownership. METHODS: We assessed local ordinances in the 150 most populous U.S. jurisdictions for content related to noncommercial poultry ownership using online resources and communications with government officials. We also performed a literature review using publicly available data sources to identify human infectious disease outbreaks caused by contact with backyard poultry. RESULTS: Of the cities reviewed, 93% (n=139) permit poultry in some capacity. Most urban poultry ordinances share common characteristics focused on reducing nuisance to neighbors. Ordinances do not address many pathways of transmission relevant to poultry-to-human transmission of pathogens, such as manure management. CONCLUSIONS: To reduce the risk of pathogen exposure from backyard poultry, urban ordinances should incorporate the following seven components: limited flock size, composting of manure in sealed containers, prohibition of slaughter, required veterinary care to sick birds, appropriate disposal of dead birds, annual permits linked to consumer education, and a registry of poultry owners.
    32. 32
      Williams, S.; Patel, M.; Markey, P.; Muller, R.; Benedict, S.; Ross, I.; Heuzenroeder, M.; Davos, D.; Cameron, S.; Krause, V. Salmonella in the tropical household environment - Everyday, everywhere J. Infect. 2015, 71 (6) 642– 648 DOI: 10.1016/j.jinf.2015.09.011
      32
      Salmonella in the tropical household environment--Everyday, everywhere
      Williams Shellee; Patel Mahomed; Cameron Scott; Markey Peter; Muller Rosanne; Krause Vicki; Benedict Suresh; Ross Ian; Heuzenroeder Michael; Davos Dianne
      The Journal of infection (2015), 71 (6), 642-8 ISSN:.
      OBJECTIVES: To determine the prevalence of Salmonella in the environment of case and control houses, and compare serovars isolated from cases and their houses. METHODS: From 2005 to 2008, we tested samples from houses of 0-4 year old cases and community controls in Darwin and Palmerston for Salmonella. Case isolates were compared with environmental isolates. S. Ball and S. Urbana isolates were compared using Multiple Amplification of Phage Locus Typing (MAPLT) and Multiple-Locus Variable number of tandem repeat Analysis (MLVA). RESULTS: Salmonella were found in 47/65 (72%) case houses and 18/29 (62%) control houses; these proportions were not significantly different. In 21/47 (45%) houses, case and environmental isolates (from animal faeces, soil and vacuums) were indistinguishable. Multiple serovars were isolated from 20 (31%) case and 6 (21%) control houses. All but one environmental isolate are known human pathogens in the Northern Territory (NT). Each of the four pairs of S. Ball and S. Urbana were indistinguishable. CONCLUSIONS: Animal faeces were the most likely source of salmonellosis in cases. The similar prevalence of house isolates suggests that Salmonella is ubiquitous in this environment. The distinction of S. Ball and S. Urbana subtypes enabled linkage of human illness to environmental exposure. Environmental contamination with Salmonella is an important source of sporadic infection in children in the tropics.
    33. 33
      Williams, S.; Markey, P.; Harlock, M.; Binns, P.; Gaggin, J.; Patel, M. Individual and household-level risk factors for sporadic salmonellosis in children J. Infect. 2016, 72 (1) 36– 44 DOI: 10.1016/j.jinf.2015.09.014
      33
      Individual and household-level risk factors for sporadic salmonellosis in children
      Williams S; Markey P; Harlock M; Binns P; Gaggin J; Patel M
      The Journal of infection (2016), 72 (1), 36-44 ISSN:.
      OBJECTIVES: To explore risk factors for sporadic salmonellosis at the individual and household level in children in tropical Darwin, where animal faeces contaminated with Salmonella is thought to be common. METHODS: A 2-year community based case-control study of children aged 0-4 years residing in Darwin and Palmerston from June 2006. Variables included behaviour, health, food, family and housing characteristics. Environmental samples were taken from houses of case and control children. RESULTS: Of children whose parents were contacted, 59/131 cases and 95/222 controls were included. Salmonella was isolated from 41/56 (73%) case houses and 18/29 (62%) control houses (p = 0.29). Multivariate analyses showed breastfeeding 0.16 (p = 0.02), increasing age (months) 0.89 (p = 0.00) and daily vacuuming 0.18 (p = 0.06) were protective; consuming powdered formula milk 4.88 (p = 0.02), pet ownership 4.86 (p = 0.02), oral contact with animals 7.85 (p = 0.05), recent antibiotic use 10.01 (p = 0.03) and sweeping in the presence of children 3.73 (p = 0.04) were associated with sporadic salmonellosis. CONCLUSIONS: Salmonellosis in children under 5 years of age is associated with potentially modifiable risk factors other than food. Breastfeeding beyond 6 months, careful hygiene when preparing formula milk and around pets, frequent cleaning of infant play areas especially quick removal of animal faeces are behaviours likely to reduce childhood sporadic salmonellosis.
    34. 34
      Headey, D.Newsflash: Chickens don’t use toilets - Why global WASH efforst should start focusing on animal feces. http://www.ifpri.org/blog/newsflash-chickens-dont-use-toilets (accessed 7 February 2017) .
      There is no corresponding record for this reference.
    35. 35
      Moher, D.; Liberati, A.; Tetzlaff, J.; Altman, D. G. The, P. G., Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement PLOS Medicine. 2009, 6 (7) e1000097 DOI: 10.1371/journal.pmed.1000097
      There is no corresponding record for this reference.
    36. 36
      Black, R. E.; Lopez de Romaña, G.; Brown, K. H.; Bravo, N.; Bazalar, O. G.; Kanashiro, H. C. Incidence and etiology of infantile diarrhea and major routes of transmission in Huascar, Peru Am. J. Epidemiol. 1989, 129 (4) 785– 799 DOI: 10.1093/oxfordjournals.aje.a115193
      36
      Incidence and etiology of infantile diarrhea and major routes of transmission in Huascar, Peru
      Black R E; Lopez de Romana G; Brown K H; Bravo N; Bazalar O G; Kanashiro H C
      American journal of epidemiology (1989), 129 (4), 785-99 ISSN:0002-9262.
      Community-based studies of diarrhea etiology and epidemiology were carried out from July 1982-June 1984 in 153 infants residing in a poor peri-urban community near Lima, Peru. Study infants had nearly 10 episodes of diarrhea in their first year of life. Diarrhea episodes were associated with organisms such as Campylobacter jejuni, enterotoxigenic and enteropathogenic Escherichia coli, Shigella, rotavirus, and Cryptosporidium. These organisms appeared to be transmitted to infants in the home through animal feces, through contaminated water and food, and by direct person-to-person contact. A particularly important route of transmission may have been weaning foods, which were often contaminated because of improper preparation and inadequate cleaning of utensils. Improved feeding practices, along with avoidance of animal feces and improved personal and domestic hygiene, should be considered important interventions in reducing the high incidence of diarrhea in infants in developing countries.
    37. 37
      Bukenya, G. B.; Nwokolo, N. Compound hygiene, presence of standpipe and the risk of childhood diarrhoea in an urban settlement of Papua New Guinea International Journal of Epidemiology 1991, 20 (2) 534– 539 DOI: 10.1093/ije/20.2.534
      37
      Compound hygiene, presence of standpipe and the risk of childhood diarrhoea in an urban settlement of Papua New Guinea
      Bukenya G B; Nwokolo N
      International journal of epidemiology (1991), 20 (2), 534-9 ISSN:0300-5771.
      Children below five years of age residing in an urban settlement of Papua New Guinea were monitored from May 1987 to July 1988 in an attempt to identify aetiological factors of childhood diarrhoea. Presence of faeces in the compound was associated with a 48% increase (incidence density ratio (IDR) = 1.48, 95% confidence interval (CI): 1.163-1.897) in diarrhoea morbidity whilst the presence of pigs in the compound was associated with a 69% increase (IDR = 1.694, 95% CI:1.317-2.189). The presence of a standpipe in the compound was associated with a reduction in diarrhoea morbidity of 56%. The effect of presence of faeces, animals, and standpipe on the incidence of diarrhoea was not dependent on whether or not mothers were literate. We conclude that any intervention aimed at these factors is likely to reduce diarrhoea morbidity in similar urban ecosystems.
    38. 38
      Collinet-Adler, S.; Babji, S.; Sarkar, R.; Kattula, D.; Mohan, V.; Ward, H.; Kang, G.; Balraj, V.; Naumova, E. Environmental indicators of diarrhea in Vellore, India Am. J. Trop. Med. Hyg. 2011, 85 (6) 175
      There is no corresponding record for this reference.
    39. 39
      Grados, O.; Bravo, N.; Black, R. E.; Butzler, J. P. Paediatric campylobacter diarrhoea from household exposure to live chickens in Lima, Peru Bull. World Health Org. 1988, 66 (3) 369– 374
      39
      Paediatric campylobacter diarrhoea from household exposure to live chickens in Lima, Peru
      Grados O; Bravo N; Black R E; Butzler J P
      Bulletin of the World Health Organization (1988), 66 (3), 369-74 ISSN:0042-9686.
      Although Campylobacter jejuni is a frequent enteropathogen in cases of paediatric diarrhoea in developing countries, its route of transmission is not well understood. An age-matched, case-control study of children with C. jejuni diarrhoea was therefore carried out in Lima, Peru, from January 1983 to April 1986 to identify the risk factors and vehicles of transmissions. As cases, 104 children less than 3 years of age were selected and compared with controls of the same age with non-gastrointestinal illnesses. Household exposure to live chickens was an important risk factor (odds ratio, 11; after adjusting for socioeconomic and environmental variables). Subjects in index households had a higher frequency of infection than those in control households, and infected young children were more likely to be ill than older children or adults, suggesting that immunity may be acquired from natural infection. The risk factors identified suggest that direct contact with the faeces of C. jejuni-infected chickens in the household environment was largely responsible for transmission of the organism to susceptible infants.
    40. 40
      Headey, D.; Nguyen, P.; Kim, S.; Rawat, R.; Ruel, M.; Menon, P. Is Exposure to Animal Feces Harmful to Child Nutrition and Health Outcomes? A Multicountry Observational Analysis Am. J. Trop. Med. Hyg. 2017, 96 (4) 961– 969 DOI: 10.4269/ajtmh.16-0270
      There is no corresponding record for this reference.
    41. 41
      Oberhelman, R. A.; Gilman, R. H.; Sheen, P.; Cordova, J.; Zimic, M.; Cabrera, L.; Meza, R.; Perez, J. An Intervention-Control Study of Corraling of Free-Ranging Chickens to Control Campylobacter Infections Among Children in a Peruvian Periurban Shantytown Am. J. Trop. Med. Hyg. 2006, 74 (6) 6
      There is no corresponding record for this reference.
    42. 42
      Adjei, A. A.; Armah, H.; Rodrigues, O.; Renner, L.; Borketey, P.; Ayeh-Kumi, P.; Adiku, T.; Sifah, E.; Lartey, M. Cryptosporidium spp., a frequent cause of diarrhea among children at the Korle-Bu Teaching Hospital, Accra, Ghana Jpn. J. Infect. Dis. 2004, 57 (5) 216– 219
      42
      Cryptosporidium Spp., a frequent cause of diarrhea among children at the Korle-Bu Teaching Hospital, Accra, Ghana
      Adjei Andrew Anthony; Armah Henry; Rodrigues Onike; Renner Lornna; Borketey Patience; Ayeh-Kumi Patrick; Adiku Theophilus; Sifah Eric; Lartey Margaret
      Japanese journal of infectious diseases (2004), 57 (5), 216-9 ISSN:1344-6304.
      This report presents the results of a study conducted at the Child Health Department, Korle-Bu Teaching Hospital, Accra, Ghana, between the months of October 2001 and June 2002. Stool samples from 227 children with diarrhea and 77 children without diarrhea, aged less than 5 years, were tested for Cryptosporidium spp. Prevalence rates were 27.8 and 15.6% in children with and without diarrhea, respectively. Cryptosporidium infection was found to be high in children between the ages of 6 and 24 months. Cryptosporidium spp. was more common in malnourished children, but was not isolated in children under 6 months of age who were exclusively breastfed. Neither the presence of domestic animals, abdominal pain, blood in stool, nausea, vomiting, nor the consumption of untreated water was associated with Cryptosporidium spp. infection. Shigella, Salmonella, and yeast-like organisms were the most frequently identified enteropathogenic bacteria. In summary, this study demonstrates the prevalence of Cryptosporidium spp. among Ghanaian children.
    43. 43
      Schmidt, W. P.; Boisson, S.; Routray, P.; Bell, M.; Cameron, M.; Torondel, B.; Clasen, T. Exposure to cows is not associated with diarrhoea or impaired child growth in rural Odisha, India: a cohort study Epidemiol. Infect. 2016, 144 (1) 53– 63 DOI: 10.1017/S0950268815001090
      43
      Exposure to cows is not associated with diarrhoea or impaired child growth in rural Odisha, India: a cohort study
      Schmidt W-P; Boisson S; Routray P; Bell M; Cameron M; Torondel B; Clasen T
      Epidemiology and infection (2016), 144 (1), 53-63 ISSN:.
      Exposure to animal livestock has been linked to zoonotic transmission, especially of gastrointestinal pathogens. Exposure to animals may contribute to chronic asymptomatic intestinal infection, environmental enteropathy and child under-nutrition in low-income settings. We conducted a cohort study to explore the effect of exposure to cows on growth and endemic diarrhoea in children aged <5 years in a rural, low-income setting in the Indian state of Odisha. The study enrolled 1992 households with 2739 children. Height measurements were available for 824 children. Exposure to cows was measured as (1) the presence of a cowshed within or outside the compound, (2) the number of cows owned by a household, and (3) the number of cowsheds located within 50 m of a household. In a sub-study of 518 households, fly traps were used to count the number of synanthropic flies that may act as vectors for gastrointestinal pathogens. We found no evidence that environmental exposure to cows contributes to growth deficiency in children in rural India, neither directly by affecting growth, nor indirectly by increasing the risk of diarrhoea. We found no strong evidence that the presence of a cowshed increased the number synanthropic flies in households.
    44. 44
      Randremanana, R. V.; Razafindratsimandresy, R.; Andriatahina, T.; Randriamanantena, A.; Ravelomanana, L.; Randrianirina, F.; Richard, V. Etiologies, Risk Factors and Impact of Severe Diarrhea in the Under-Fives in Moramanga and Antananarivo, Madagascar PLoS One 2016, 11 (7) e0158862 DOI: 10.1371/journal.pone.0158862
      There is no corresponding record for this reference.
    45. 45
      Headey, D.; Hirvonen, K. Is Exposure to Poultry Harmful to Child Nutrition? An Observational Analysis for Rural Ethiopia PLoS One 2016, 11 (8) e0160590 DOI: 10.1371/journal.pone.0160590
      45
      Is exposure to poultry harmful to child nutrition? An observational analysis for rural Ethiopia
      Headey, Derek; Hirvonen, Kalle
      PLoS One (2016), 11 (8), e0160590/1-e0160590/16CODEN: POLNCL; ISSN:1932-6203. (Public Library of Science)
      Although strategic thinking on water, sanitation and hygiene (WASH) has prioritized reducing exposure to human feces in order to limit diarrheal infections, recent research suggests that elevated exposure to livestock-particularly poultry and poultry feces-may be an important risk factor for diarrhea, environmental enteric disorder (EED) and respiratory infections, all of which may seriously retard linear growth in young children. Yet a very different literature on nutrition-sensitive agriculture suggests that livestock ownership is highly beneficial for child growth outcomes through its importance for increasing consumption of nutrient-rich animal sourced foods, such as eggs. Together, these two literatures suggest that the net nutritional benefit of poultry ownership is particularly ambiguous and potentially mediated by whether or not children are highly exposed to poultry. We test this novel hypothesis using a large agricultural survey of rural Ethiopian households that includes measures of child height-for-age Z-scores (HAZ), ownership of poultry and other types of livestock, and an indicator of whether livestock are kept within the main household dwelling overnight. We used least squares regression anal. to est. unadjusted and adjusted models that control for a wide range of potentially confounding factors. We find that while poultry ownership is pos. assocd. with child HAZ [β = 0.291, s.e. = 0.094], the practice of corralling poultry in the household dwelling overnight is neg. assocd. with HAZ [β = -0.250, s.e. = 0.118]. Moreover, we find no neg. assocns. between HAZ and corralling other livestock species indoors. These results suggest that 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.
    46. 46
      Hetherington, J. B.; Wiethoelter, A. K.; Negin, J.; Mor, S. M. Livestock ownership, animal source foods and child nutritional outcomes in seven rural village clusters in Sub-Saharan Africa Agriculture and Food Security 2017, 6 (1) 9 DOI: 10.1186/s40066-016-0079-z
      There is no corresponding record for this reference.
    47. 47
      Mosites, E.; Thumbi, S. M.; Otiang, E.; McElwain, T. F.; Njenga, M. K.; Rabinowitz, P. M.; Rowhani-Rahbar, A.; Neuhouser, M. L.; May, S.; Palmer, G. H.; Walson, J. L. Relations between Household Livestock Ownership, Livestock Disease, and Young Child Growth J. Nutr. 2016, 146 (5) 1118– 1124 DOI: 10.3945/jn.115.225961
      47
      Relations between household livestock ownership, livestock disease, and young child growth
      Mosites, Emily; Thumbi, Samuel M.; Otiang, Elkanah; McElwain, Terry F.; Njenga, M. K.; Rabinowitz, Peter M.; Rowhani-Rahbar, Ali; Neuhouser, Marian L.; May, Susanne; Palmer, Guy H.; Walson, Judd L.
      Journal of Nutrition (2016), 146 (5), 1118-1124CODEN: JONUAI; ISSN:0022-3166. (American Society for Nutrition)
      Background: In resource-limited settings in which child malnutrition is prevalent, humans live in close proximity to household livestock. However, the relation between household livestock and child nutrition represents a considerable knowledge gap. Objective: We assessed whether household livestock ownership or livestock disease episodes were assocd. with growth in young children in western Kenya. Methods: We incorporated monthly anthropometric measurements for children <5 y of age into an ongoing linked human and animal surveillance cohort in rural western Kenya. Using linear mixed models adjusted for age, sex, and household wealth, we tested whether baseline household livestock ownership was related to baseline child height for age or prospective growth rate. We also evaluated whether livestock disease episodes were assocd. with child growth rate over 11 mo of follow-up. Results: We collected data on 925 children over the course of follow-up. Greater household livestock ownership at baseline was not related to baseline child height-for-age z score (adjusted β: 0.01 SD; 95% CI: -0.02, 0.04 SD) or child growth rate (adjusted β: 0.02 cm/y; 95% CI: -0.03, 0.07 cm/y). Livestock disease episodes were not significantly assocd. with child growth across the entire cohort (adjusted β: -0.007 cm/mo; 95% CI: -0.02, 0.006 cm/mo). However, children in households with livestock digestive disease between June and Nov. gained less height than did children in households that did not report livestock disease (β: -0.063 cm/mo; 95% CI: -0.112, -0.016 cm/mo). Children <2 y of age in households with livestock digestive disease gained less wt. than did those who did not report disease (β: -0.033 kg/mo; 95% CI: -0.063, -0.003 kg/mo). Conclusion: In this cohort of young children in western Kenya, we did not find an assocn. between ownership of livestock and child growth status. However, disease episodes in household livestock may be related to a lower child growth rate in some groups.
    48. 48
      George, C. M.; Oldja, L.; Biswas, S. K.; Perin, J.; Lee, G. O.; Ahmed, S.; Haque, R.; Sack, R. B.; Parvin, T.; Azmi, I. J.; Bhuyian, S. I.; Talukder, K. A.; Faruque, A. G. Fecal Markers of Environmental Enteropathy are Associated with Animal Exposure and Caregiver Hygiene in Bangladesh Am. J. Trop. Med. Hyg. 2015, 93 (2) 269– 275 DOI: 10.4269/ajtmh.14-0694
      There is no corresponding record for this reference.
    49. 49
      Campbell, D.; Elia, M.; Lunn, P. Growth faltering in rural Gambian infants is associated with impaired small intestinal barrier function, leading to endotoxemia and systematic inflammation J. Nutr. 2003, 133 (5) 1332– 1338
      49
      Growth faltering in rural Gambian infants is associated with impaired small intestinal barrier function, leading to endotoxemia and systemic inflammation
      Campbell, D. I.; Elia, M.; Lunn, P. G.
      Journal of Nutrition (2003), 133 (5), 1332-1338CODEN: JONUAI; ISSN:0022-3166. (American Society for Nutritional Sciences)
      Growth faltering of rural Gambian infants is assocd. with a chronic inflammatory enteropathy of the mucosa of the small intestine that may impair both digestive/absorptive and barrier functions. The aim of this study was to det. whether the enteropathy was assocd. with a compromised barrier function that allowed translocation of antigenic macromols. from the gut lumen into the body, with subsequent systemic immunostimulation, resulting in growth retardation. Rural Gambian infants were studied longitudinally at regular intervals between 8 and 64 wk of age. On each study day, each child was medically examd., anthropometric measurements were made, a blood sample was taken and an intestinal permeability test performed. Evidence of chronic immunostimulation was provided by abnormally elevated white blood cell, lymphocyte and platelet counts, and frequently raised plasma concn. of C-reactive protein. Intestinal permeability was abnormal and assocd. with impaired growth (r = -0.41, P < 0.001). Plasma concns. of endotoxin and Ig (Ig)G-endotoxin core antibody were also elevated and related to both growth (r = -0.30, P < 0.02; r = -0.64, P < 0.0001, resp.) and measures of mucosal enteropathy. Plasma IgG, IgA and IgM levels increased rapidly with age toward adult concns. Raised values were related to poor growth but also to measures of mucosal enteropathy and the endotoxin antibody titer. The interrelationships among these variables and growth suggested that they were all part of the same growth-retarding mechanism. These data are consistent with the hypothesis of translocation of immunogenic lumenal macromols. across a compromised gut mucosa, leading to stimulation of systemic immune/inflammatory processes and subsequent growth impairment.
    50. 50
      Goto, R.; Mascie-Taylor, C. G. N.; Lunn, P. G. Impact of intestinal permeability, inflammation status and parasitic infections on infant growth faltering in rural Bangladesh Br. J. Nutr. 2009, 101 (10) 1509– 1516 DOI: 10.1017/S0007114508083554
      50
      Impact of intestinal permeability, inflammation status and parasitic infections on infant growth faltering in rural Bangladesh
      Goto, Rie; Mascie-Taylor, C. G. Nicholas; Lunn, Peter G.
      British Journal of Nutrition (2009), 101 (10), 1509-1516CODEN: BJNUAV; ISSN:0007-1145. (Cambridge University Press)
      A longitudinal study of 298 rural Bangladeshi infants found evidence of growth faltering starting at 3 mo of age. Anthropometric status declined substantially in the first 2 years of life, with wt.-for-height (WHZ) falling from -0·49 to -1·75, wt.-for-age (WAZ) from -1·18 to -2·87 and height-for-age (HAZ) from -1·00 to -1·88. Higher concns. of the acute-phase protein α-1-acid glycoprotein (AGP) and higher gut mucosal damage (as signified by raised lactulose:mannitol (L:M) ratios) were both assocd. with chronic malnutrition as indicated by poorer HAZ and WAZ scores (P = 0·011 and 0·005 for AGP and 0·039 and 0·019 for L:M ratio, resp.). Higher Hb levels were related to improved z-scores, while elevation of Giardia-specific IgM titer (GSIgM) was assocd. with poor WAZ and WHZ (P = 0·015 and 0·039, resp.). IgG did not show any significant assocn. with z-scores and the L:M ratio did not correlate with any of the inflammation markers or Giardia infection. The prevalence of geohelminth infections was low (only 4 % in the total study period). However, the level of GSIgM indicated high endemicity of Giardia infection from early in life, although very few cysts were detected from stool samples. These findings suggest that rural Bangladeshi infants are being exposed to high levels of infection with concomitant gut damage and growth faltering.
    51. 51
      Guerrant, R. L.; Oriá, R. B.; Moore, S. R.; Oriá, M. O. B.; Lima, A. A. M. Malnutrition as an enteric infectious disease with long-term effects on child development Nutr. Rev. 2008, 66 (9) 487– 505 DOI: 10.1111/j.1753-4887.2008.00082.x
      51
      Malnutrition as an enteric infectious disease with long-term effects on child development
      Guerrant Richard L; Oria Reinaldo B; Moore Sean R; Oria Monica O B; Lima Aldo A M
      Nutrition reviews (2008), 66 (9), 487-505 ISSN:.
      Malnutrition is a major contributor to mortality and is increasingly recognized as a cause of potentially lifelong functional disability. Yet, a rate-limiting step in achieving normal nutrition may be impaired absorptive function due to multiple repeated enteric infections. This is especially problematic in children whose diets are marginal. In malnourished individuals, the infections are even more devastating. This review documents the evidence that intestinal infections lead to malnutrition and that malnutrition worsens intestinal infections. The clinical data presented here derive largely from long-term cohort studies that are supported by controlled animal studies. Also reviewed are the mechanisms by which enteric infections lead to undernutrition and by which malnutrition worsens enteric infections, with implications for potential novel interventions. Further intervention studies are needed to document the relevance of these mechanisms and, most importantly, to interrupt the vicious diarrhea-malnutrition cycle so children may develop their full potential.
    52. 52
      Humphrey, J. H. Child undernutrition, tropical enteropathy, toilets, and handwashing Lancet 2009, 374 (9694) 1032– 1035 DOI: 10.1016/S0140-6736(09)60950-8
      There is no corresponding record for this reference.
    53. 53
      Lunn, P. G.; Northrop-Clewes, C. A.; Downes, R. M. Intestinal permeability, mucosal injury, and growth faltering in Gambian infants Lancet 1991, 338 (8772) 907– 910 DOI: 10.1016/0140-6736(91)91772-M
      There is no corresponding record for this reference.
    54. 54
      Lunn, P. G. Growth retardation and stunting of children in developing countries Br. J. Nutr. 2002, 88 (2) 109– 110 DOI: 10.1079/BJN2002652
      54
      Growth retardation and stunting of children in developing countries
      Lunn, Peter G.
      British Journal of Nutrition (2002), 88 (2), 109-110CODEN: BJNUAV; ISSN:0007-1145. (CABI Publishing)
      There is no expanded citation for this reference.
    55. 55
      Ordiz, M. I.; Shaikh, N.; Trehan, I.; Maleta, K.; Stauber, J.; Shulman, R.; Devaraj, S.; Tarr, P. I.; Manary, M. J. Environmental Enteric Dysfunction is Associated with Poor Linear Growth and Can be Identified by Host Fecal mRNAs J. Pediatr. Gastroenterol. Nutr. 2016, 63 (5) 453 DOI: 10.1097/MPG.0000000000001315
      55
      Environmental Enteric Dysfunction Is Associated With Poor Linear Growth and Can Be Identified by Host Fecal mRNAs
      Ordiz, Maria Isabel; Shaikh, Nurmohammad; Trehan, Indi; Maleta, Ken; Stauber, Jennifer; Shulman, Robert; Devaraj, Sridevi; Tarr, Phillip I.; Manary, Mark J.
      Journal of Pediatric Gastroenterology and Nutrition (2016), 63 (5), 453-459CODEN: JPGND6; ISSN:0277-2116. (Lippincott Williams & Wilkins)
      Objective: Environmental enteric dysfunction (EED) can be assessed by the lactulose:mannitol (L:M) test. Our objective was to det. if selected host fecal transcripts were correlated with EED, and whether transcripts and clin. characteristics could be used to predict EED in rural African children. Methods: Demog. and sanitation characteristics, along with L:M testing and host fecal transcript analyses from 798 asymptomatic Malawian children aged 12 to 61 mo were compared with linear growth over the subsequent 3 mo. Fecal host mRNA anal. included quantification of expression of 18 transcripts assocd. with L:M. Permeability was categorized as normal (L:M ≤ 0.15), moderate (0.15<L:M<0.45) and severe (L:M ≥ 0.45), and random forest predictive models were created. Results: L:M was inversely correlated with linear growth over the subsequent 3 mo (r=-0.32, P<0.001) and severe EED was assocd. with stunting (P<0.0001). Age younger than 24 mo, wt.-for-height z score <0, domesticated animals in the child's sleep environment, lack of a pit latrine combined with a potentially contaminated water source, and a recent history of diarrhea were assocd. with severe EED. A random forest model using CD53, HLA-DRA, MUC12, and TNF was 84% sensitive for severe EED and 83% sensitive for no EED. Conclusions: Selected host fecal transcripts can be used in a random forest model as a noninvasive biomarker for categories of EED in rural African children.
    56. 56
      El-Tras, W. F.; Holt, H. R.; Tayel, A. A.; El-Kady, N. N. Campylobacter infections in children exposed to infected backyard poultry in Egypt Epidemiol. Infect. 2015, 143 (2) 308– 315 DOI: 10.1017/S095026881400096X
      56
      Campylobacter infections in children exposed to infected backyard poultry in Egypt
      El-Tras W F; Holt H R; Tayel A A; El-Kady N N
      Epidemiology and infection (2015), 143 (2), 308-15 ISSN:.
      Campylobacteriosis is a zoonotic disease which has a worldwide public health impact. The disease is endemic in Egypt; however, the epidemiology in animals and humans has not been fully characterized. The objective of this study was to compare the risk of Campylobacter faecal carriage in children exposed to Campylobacter-infected vs. non-infected backyard poultry and to identify risk factors for a backyard being classified as infected. A total of 103 households which owned backyard poultry were sampled from a rural community in Egypt. Within these households 379 poultry and 106 children were tested for C. jejuni and C. coli; 23·5% and 5·5% of poultry were positive for C. jejuni and C. coli, respectively. In the studied households; 12·3% of children were positive for C. jejuni, and 2·8% were positive for C. coli. Using logistic regression, households with poultry positive for C. jejuni had 3·86 (95% confidence interval 1·0-15·0) times the odds of having children positive for C. jejuni compared to those housed with poultry which all tested negative. Backyard poultry may present a transmission route of C. jejuni to children. Backyards with poor cleaning and disinfection, wet litter and manure disposed of within the backyard had increased odds of being positive for C. jejuni. Enhancing biosecurity and management in poultry backyards may reduce the risk of the disease.
    57. 57
      Marquis, G. S.; Ventura, G.; Gilman, R. H.; Porras, E.; Miranda, E.; Carbajal, L.; Pentafiel, M. Am. J. Public Health 1990, 80 (2) 146– 149 DOI: 10.2105/AJPH.80.2.146
      57
      Fecal contamination of shanty town toddlers in households with non-corralled poultry, Lima, Peru
      Marquis G S; Ventura G; Gilman R H; Porras E; Miranda E; Carbajal L; Pentafiel M
      American journal of public health (1990), 80 (2), 146-9 ISSN:0090-0036.
      We used direct observer techniques to measure the frequency with which toddler-aged children were contaminated by poultry feces in homes in a peri-urban shanty town in Lima, Peru. The mean number of fowl was 5.4 (SD 3.1), with 10.0 (SD 10.7) poultry defecations per 12 hours. Toddlers' hand contact with poultry feces occurred a mean of 2.9 (SD 3.0) times/12 hours. A mean of 3.9 (SD 4.6) feces-to-mouth episodes per household/12 hours occurred both by direct hand-to-mouth contamination and indirectly by handling soiled objects which were then placed in the mouth. There was a strong correlation between feces-to-hand contamination and feces-to-mouth contamination (r = 0.94). There was also an association between feces-to-mouth contamination and the number of stools deposited in the house (r = 0.66). For each additional chicken stool deposited during the day, there was an average increase of 0.27 in feces-to-mouth episodes. We collected feces from 68 infected chickens and found viable Campylobacter jejuni for up to 48 hours after deposition. Yet, a survey of 108 families demonstrated that free-roaming poultry were often not thought of as a health risk for children. An intervention program to reduce oral-fecal contamination should emphasize that all poultry be corralled and not allowed access into the house.
    58. 58
      Vasco, K.; Graham, J. P.; Trueba, G. Detection of Zoonotic Enteropathogens in Children and Domestic Animals in a Semirural Community in Ecuador Appl. Environ. Microbiol. 2016, 82 (14) 4218– 4224 DOI: 10.1128/AEM.00795-16
      58
      Detection of zoonotic enteropathogens in children and domestic animals in a semirural community in Ecuador
      Vasco, Karla; Graham, Jay P.; Trueba, Gabriel
      Applied and Environmental Microbiology (2016), 82 (14), 4218-4224CODEN: AEMIDF; ISSN:1098-5336. (American Society for Microbiology)
      Animals are important reservoirs of zoonotic enteropathogens, and transmission to humans occurs more frequently in low- and middle-income countries (LMICs), where small-scale livestock prodn. is common. In this study, we investigated the presence of zoonotic enteropathogens in stool samples from 64 asymptomatic children and 203 domestic animals of 62 households in a semirural community in Ecuador between June and August 2014. Multilocus sequence typing (MLST) was used to assess zoonotic transmission of Campylobacter jejuni and atypical enteropathogenic Escherichia coli (aEPEC), which were the most prevalent bacterial pathogens in children and domestic animals (30.7% and 10.5%, resp.). Four sequence types (STs) of C. jejuni and four STs of aEPEC were identical between children and domestic animals. The apparent sources of human infection were chickens, dogs, guinea pigs, and rabbits for C. jejuni and pigs, dogs, and chickens for aEPEC. Other pathogens detected in children and domestic animals were Giardia lamblia (13.1%), Cryptosporidium parvum (1.1%), and Shiga toxin-producing E. coli (STEC) (2.6%). Salmonella enterica was detected in 5 dogs and Yersinia enterocolitica was identified in 1 pig. Even though we identified 7 enteric pathogens in children, we encountered evidence of active transmission between domestic animals and humans only for C. jejuni and aEPEC. We also found evidence that C. jejuni strains from chickens were more likely to be transmitted to humans than those coming from other domestic animals. Our findings demonstrate the complex nature of enteropathogen transmission between domestic animals and humans and stress the need for further studies.
    59. 59
      Moore, C. E.; Elwin, K.; Phot, N.; Seng, C.; Mao, S.; Suy, K.; Kumar, V.; Nader, J.; Bousfield, R.; Perera, S.; Bailey, J. W.; Beeching, N. J.; Day, N. P. J.; Parry, C. M.; Chalmers, R. M. Molecular Characterization of Cryptosporidium Species and Giardia duodenalis from Symptomatic Cambodian Children PLoS Neglected Trop. Dis. 2016, 10 (7) e0004822 DOI: 10.1371/journal.pntd.0004822
      There is no corresponding record for this reference.
    60. 60
      Wanyiri, J. W.; Kanyi, H.; Maina, S.; Wang, D. E.; Steen, A.; Ngugi, P.; Kamau, T.; Waithera, T.; O’Connor, R.; Gachuhi, K.; Wamae, C. N.; Mwamburi, M.; Ward, H. D. Cryptosporidiosis in HIV/AIDS Patients in Kenya: Clinical Features, Epidemiology, Molecular Characterization and Antibody Responses Am. J. Trop. Med. Hyg. 2014, 91 (2) 319– 328 DOI: 10.4269/ajtmh.13-0254
      There is no corresponding record for this reference.
    61. 61
      Wumba, R.; Longo-Mbenza, B.; Menotti, J.; Mandina, M.; Kintoki, F.; Situakibanza, N. H.; Kakicha, M. K.; Zanga, J.; Mbanzulu-Makola, K.; Nseka, T.; Mukendi, J. P.; Kendjo, E.; Sala, J.; Thellier, M. Epidemiology, clinical, immune, and molecular profiles of microsporidiosis and cryptosporidiosis among HIV/AIDS patients Int. J. Gen. Med. 2012, 5, 603– 611
      61
      Epidemiology, clinical, immune, and molecular profiles of microsporidiosis and cryptosporidiosis among HIV/AIDS patients
      Wumba Roger; Longo-Mbenza Benjamin; Menotti Jean; Mandina Madone; Kintoki Fabien; Situakibanza Nani Hippolyte; Kakicha Marie Kapepela; Zanga Josue; Mbanzulu-Makola Kennedy; Nseka Tommy; Mukendi Jean Pierre; Kendjo Eric; Sala Jean; Thellier Marc
      International journal of general medicine (2012), 5 (), 603-11 ISSN:.
      BACKGROUND: The objective of this study was to determine the prevalence of intestinal parasites, with special emphasis on microsporidia and Cryptosporidium, as well as their association with human immunodeficiency virus (HIV) symptoms, risk factors, and other digestive parasites. We also wish to determine the molecular biology definitions of the species and genotypes of microsporidia and Cryptosporidium in HIV patients. METHODS: In this cross-sectional study, carried out in Kinshasa, Democratic Republic of the Congo, stool samples were collected from 242 HIV patients (87 men and 155 women) with referred symptoms and risk factors for opportunistic intestinal parasites. The analysis of feces specimen were performed using Ziehl-Neelsen stainings, real-time polymerase chain reaction (PCR), immunofluorescence indirect monoclonal antibody, nested PCR-restriction fragment length polymorphism, and PCR amplification and sequencing. Odds ratio (OR) and 95% confidence intervals were used to quantify the risk. RESULTS: Of the 242 HIV patients, 7.8%, 0.4%, 5.4%, 0.4%, 2%, 10.6%, and 2.8% had Enterocytozoon bieneusi, Encephalitozoon intestinalis, Cryptosporidium spp., Isospora belli, pathogenic intestinal protozoa, nonpathogenic intestinal protozoa, and helminths, respectively. We found five genotypes of E. bieneusi: two older, NIA1 and D, and three new, KIN1, KIN2, and KIN3. Only 0.4% and 1.6% had Cryptosporidium parvum and Cryptosporidium hominis, respectively. Of the patients, 36.4%, 34.3%, 31%, and 39% had asthenia, diarrhea, a CD4 count of <100 cells/mm(3), and no antiretroviral therapy (ART), respectively. The majority of those with opportunistic intestinal parasites and C. hominis, and all with C. parvum and new E. bieneusi genotypes, had diarrhea, low CD4+ counts of <100 cells/mm(3), and no ART. There was a significant association between Entamoeba coli, Kaposi sarcoma, herpes zoster, chronic diarrhea, and asthenia, and the presence of 28 cases with opportunistic intestinal parasites. Rural areas, public toilets, and exposure to farm pigs were the univariate risk factors present in the 28 cases with opportunistic intestinal parasites. In logistic regression analysis, a CD4 count of <100 cells/mm(3) (OR = 4.60; 95% CI 1.70-12.20; P = 0.002), no ART (OR = 5.00; 95% CI 1.90-13.20; P < 0.001), and exposure to surface water (OR = 2.90; 95% CI 1.01-8.40; P = 0.048) were identified as the significant and independent determinants for the presence of opportunistic intestinal parasites. CONCLUSION: E. bieneusi and Cryptosporidium are becoming more prevalent in Kinshasa, Congo. Based on the findings, we recommend epidemiology surveillance and prevention by means of hygiene, the emphasis of sensitive PCR methods, and treating opportunistic intestinal parasites that may be acquired through fecal-oral transmission, surface water, normal immunity, rural area-based person-person and animal-human infection, and transmission of HIV. Therapy, including ART and treatment with fumagillin, is needed.
    62. 62
      Anuar, T. S.; Azreen, S. N.; Salleh, F. M.; Moktar, N. Molecular epidemiology of giardiasis among Orang Asli in Malaysia: application of the triosephosphate isomerase gene BMC Infect. Dis. 2014, 14 (1) 78 DOI: 10.1186/1471-2334-14-78
      62
      Molecular epidemiology of giardiasis among Orang Asli in Malaysia: application of the triosephosphate isomerase gene
      Anuar Tengku Shahrul; Azreen Siti Nor; Salleh Fatmah Md; Moktar Norhayati
      BMC infectious diseases (2014), 14 (), 78 ISSN:.
      BACKGROUND: Giardia duodenalis is a flagellate parasite which has been considered the most common protozoa infecting human worldwide. Molecular characterization of G. duodenalis isolates have revealed the existence of eight groups (Assemblage A to H) which differ in their host distribution. Assemblages A and B are found in humans and in many other mammals. METHODS: This cross-sectional study was conducted to identify assemblage's related risk factors of G. duodenalis among Orang Asli in Malaysia. Stool samples were collected from 611 individuals aged between 2 and 74 years old of whom 266 were males and 345 were females. Socioeconomic data were collected through a pre-tested questionnaire. All stool samples were processed with formalin-ether sedimentation and Wheatley's trichrome staining techniques for the primary identification of G. duodenalis. Molecular identification was carried out by the amplification of a triosephosphate isomerase gene using nested-PCR assay. RESULTS: Sixty-two samples (10.2%) were identified as assemblage A and 36 (5.9%) were assemblage B. Risk analysis based on the detected assemblages using univariate and logistic regression analyses identified subjects who have close contact with household pets i.e. dogs and cats (OR = 2.60; 95% CI = 1.42, 4.78; P = 0.002) was found to be significant predictor for assemblage A. On the other hand, there were three significant risk factors caused by assemblage B: (i) children ≤15 years old (OR = 2.33; 95% CI = 1.11, 4.87; P = 0.025), (ii) consuming raw vegetables (OR = 2.82; 95% CI = 1.27, 6.26; P = 0.011) and (iii) the presence of other family members infected with giardiasis (OR = 6.31; 95% CI = 2.99, 13.31; P < 0.001). CONCLUSIONS: The present study highlighted that G. duodenalis infection among Orang Asli was caused by both assemblages with significant high prevalence of assemblage A. Therefore, taking precaution after having contact with household pets and their stool, screening and treating infected individuals, awareness on the importance of good health practices and washing vegetables are the practical intervention ways in preventing giardiasis in Orang Asli community.
    63. 63
      Alyousefi, N. A.; Mahdy, M. A.; Mahmud, R.; Lim, Y. A. Factors associated with high prevalence of intestinal protozoan infections among patients in Sana’a City, Yemen PLoS One 2011, 6 (7) e22044 DOI: 10.1371/journal.pone.0022044
      There is no corresponding record for this reference.
    64. 64
      Li, X.-X.; Chen, J.-X.; Wang, L.-X.; Tian, L.-G.; Zhang, Y.-P.; Dong, S.-P.; Hu, X.-G.; Liu, J.; Wang, F.-F.; Wang, Y.; Yin, X.-M.; He, L.-J.; Yan, Q.-Y.; Zhang, H.-W.; Xu, B.-L.; Zhou, X.-N. Prevalence and risk factors of intestinal protozoan and helminth infections among pulmonary tuberculosis patients without HIV infection in a rural county in P. R. China Acta Trop. 2015, 149, 19– 26 DOI: 10.1016/j.actatropica.2015.05.001
      64
      Prevalence and risk factors of intestinal protozoan and helminth infections among pulmonary tuberculosis patients without HIV infection in a rural county in P. R. China
      Li Xin-Xu; Chen Jia-Xu; Tian Li-Guang; Wang Li-Xia; Zhang Yu-Ping; Dong Shuang-Pin; Hu Xue-Guang; Liu Jian; Wang Feng-Feng; Wang Yue; Yin Xiao-Mei; He Li-Jun; Yan Qiu-Ye; Zhang Hong-Wei; Xu Bian-Li; Zhou Xiao-Nong
      Acta tropica (2015), 149 (), 19-26 ISSN:.
      Although co-infection of tuberculosis (TB) and intestinal parasites, including protozoa and helminths, in humans has been widely studied globally, very little of this phenomenon is known in China. Therefore, a cross-sectional study was conducted in a rural county of China to investigate such co-infections. Patients with pulmonary TB (PTB) undergoing anti-Mycobacterium tuberculosis (anti-MTB) treatment were surveyed by questionnaires, and their feces and blood specimens were collected for detection of intestinal protozoa and helminths, routine blood examination and HIV detection. The χ(2) test and multivariate logistic regression model were used to identify risk factors. A total of 369 patients with PTB were included and all of them were HIV negative. Overall, only 7.3% of participants were infected with intestinal protozoa, among which prevalence of Blastocystis hominis, Entamoeba spp. and Trichomonas hominis were 6.0%, 1.1% and 0.3%, respectively; 7.0% were infected with intestinal helminths, among which prevalence of hookworm, Trichuris trichiura, Ascaris lumbricoides and Clonorchis sinensis were 4.3%, 1.9%, 0.5% and 0.3%, respectively; and 0.5% were simultaneously infected with intestinal protozoa and helminths. Among patients with PTB, body mass index (BMI)≤18 (OR=3.30, 95% CI=1.44-7.54) and raised poultry or livestock (e.g., chicken, duck, pig) (OR=3.96, 95% CI=1.32-11.89) were significantly associated with harboring intestinal protozoan infection, while BMI≤18 (OR=3.32, 95% CI=1.39-7.91), anemia (OR=3.40, 95% CI=1.44-8.02) and laboring barefoot in farmlands (OR=4.54, 95% CI=1.88-10.92) were significantly associated with having intestinal helminth infection. Additionally, there was no significant relationship between duration of anti-MTB treatment and infection rates of intestinal parasites including protozoa and helminths. Therefore, preventing malnutrition, avoiding unprotected contact with reservoirs of protozoa, and improving health education for good hygiene habits, particularly wearing shoes while outdoors, are beneficial in the prevention of intestinal protozoan and helminth infection among patients with PTB.
    65. 65
      Bern, C.; Kawai, V.; Vargas, D.; Rabke-Verani, J.; Williamson, J.; Chavez-Valdez, R.; Xiao, L.; Sulaiman, I.; Vivar, A.; Ticona, E.; Ñavincopa, M.; Cama, V.; Moura, H.; Secor, W.; Visvesvara, G.; Gilman, R. H. The Epidemiology of Intestinal Microsporidiosis in Patients with HIV/AIDS in Lima, Peru J. Infect. Dis. 2005, 191 (10) 1658– 1664 DOI: 10.1086/429674
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      The epidemiology of intestinal microsporidiosis in patients with HIV/AIDS in Lima, Peru
      Bern Caryn; Kawai Vivian; Vargas Daniel; Rabke-Verani Jennifer; Williamson John; Chavez-Valdez Raul; Xiao Lihua; Sulaiman Irshad; Vivar Aldo; Ticona Eduardo; Navincopa Marco; Cama Vitaliano; Moura Hercules; Secor W Evan; Visvesvara Govinda; Gilman Robert H
      The Journal of infectious diseases (2005), 191 (10), 1658-64 ISSN:0022-1899.
      We studied microsporidiosis in human immunodeficiency virus-positive patients in 2 Lima hospitals. Of 2652 patients, 66% were male, 6% received antiretroviral therapy (ART), and the median CD4 lymphocyte count was 131 cells/microL. Sixty-seven patients (3%) had microsporidiosis; stool specimens from 56 were identified as having Enterocytozoon bieneusi of 10 different genotypes. The 2 most common genotypes, Peru-1 and Peru-2, were not associated with significant increases in chronic diarrhea; other genotypes were associated with a 4-fold increased risk. Risk factors for E. bieneusi infection segregated by genotype: contact with duck or chicken droppings and lack of running water, flush toilet, or garbage collection with genotype Peru-1 and watermelon consumption with other genotypes. Shortened survival was associated with low CD4 lymphocyte count (P<.0001), no ART (P<.0001), and cryptosporidiosis (P=.004) but not with microsporidiosis (P=.48). Our data suggest the possibility of zoonotic E. bieneusi transmission and an association with poor sanitary conditions.
    66. 66
      Dwivedi, K. K.; Prasad, G.; Saini, S.; Mahajan, S.; Lal, S.; Baveja, U. K. Enteric Opportunistic Parasites among HIV Infected Individuals: Associated Risk Factors and Immune Status Jpn. J. Infect. Dis. 2007, 60, 76– 81
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      Enteric opportunistic parasites among HIV infected individuals: associated risk factors and immune status
      Dwivedi Kaushal Kumar; Prasad Ganga; Saini Sanjeev; Mahajan Surbhi; Lal Shiv; Baveja Usha Krishan
      Japanese journal of infectious diseases (2007), 60 (2-3), 76-81 ISSN:1344-6304.
      Data on various etiologic agents causing diarrhea in human immunodeficiency virus type-1 (HIV-1) infected individuals are sparse in Delhi, India. The present study was undertaken to identify various causative agents, the role of associated risk factors and immune status. A case-control study was conducted among 75 HIV-1 infected individuals, 50 with and 25 without diarrheal infection. Fecal samples were screened for coccidian parasites, enteric protozoa, and helminthes by using various staining techniques. The CD4+ T-lymphocyte count was estimated. Enteric parasites were identified among 62.7% individuals, of which Cryptosporidium emerged as the single largest pathogen predominant among 33% of the individuals (P < 0.025). Other parasites diagnosed that were significantly associated with diarrhea were Giardia lamblia (13.3%), microsporidia (6.7%), and Isospora belli (2.7%). Chronic infected diarrheal cases were found to have polyparasitic infections. The mean CD4+ cell count was found to be lower among the diarrheal cases when compared with the non-diarrheal cases (mean, 141 cells/mm(3) versus 390 cells/mm(3)). Similarly, among diarrheal individuals, the chronic diarrheal cases had a comparatively lower CD4+ cell count than the acute cases (mean, 123 cells/mm(3) versus 265 cells/mm(3)). Risk factors found significant during multivariate analysis were: residence in a slum, exposure to pets and animals, use of public toilets, and practice of unsafe homosexual activity. Enteric coccidian parasites were identified as significant agents associated with diarrhea, especially among those with improper hygiene, multiple infections and a lower CD4+ cell count. Thus, this study emphasizes the need for routine screening of enteric parasites as well as education about practicing personal hygiene and taking timely and appropriate prophylactic measures.
    67. 67
      Bublitz, D. C.; Wright, P. C.; Bodager, J. R.; Rasambainarivo, F. T.; Bliska, J. B.; Gillespie, T. R. Epidemiology of Pathogenic Enterobacteria in Humans, Livestock, and Peridomestic Rodents in Rural Madagascar PLoS One 2014, 9 (7) e101456 DOI: 10.1371/journal.pone.0101456
      There is no corresponding record for this reference.
    68. 68
      Leung, D.; Das, S.; Malek, M.; Ahmed, D.; Khanam, F.; Qadri, F.; Faruque, A.; Ryan, E. Non-typhoidal Salmonella gastroenteritis at a diarrheal hospital in Dhaka, Bangladesh, 1996–2011 Am. J. Trop. Med. Hyg. 2013, 88 (4) 661– 669 DOI: 10.4269/ajtmh.12-0672
      There is no corresponding record for this reference.
    69. 69
      Labrique, A. B.; Zaman, K.; Hossain, Z.; Saha, P.; Yunus, M.; Hossain, A.; Ticehurst, J.; Kmush, B.; Nelson, K. E. An Exploratory Case Control Study of Risk Factors for Hepatitis E in Rural Bangladesh PLoS One 2013, 8 (5) e61351 DOI: 10.1371/journal.pone.0061351
      There is no corresponding record for this reference.
    70. 70
      Mpyet, C.; Lass, B. D.; Yahaya, H. B.; Solomon, A. W. Prevalence of and Risk Factors for Trachoma in Kano State, Nigeria PLoS One 2012, 7 (7) e40421 DOI: 10.1371/journal.pone.0040421
      There is no corresponding record for this reference.
    71. 71
      Nigusie, A.; Berhe, R.; Gedefaw, M. Prevalence and associated factors of active trachoma among childeren aged 1–9 years in rural communities of Gonji Kolella district, West Gojjam zone, North West Ethiopia BMC Res. Notes 2015, 8 (1) 641 DOI: 10.1186/s13104-015-1529-6
      71
      Prevalence and associated factors of active trachoma among childeren aged 1-9 years in rural communities of Gonji Kolella district, West Gojjam zone, North West Ethiopia
      Nigusie, Adane; Berhe, Resom; Gedefaw, Molla
      BMC Research Notes (2015), 8 (), 641/1-641/9CODEN: BRNMAT; ISSN:1756-0500. (BioMed Central Ltd.)
      Background: Trachoma is the leading infectious cause of blindness worldwide. Though trachoma can be treated with antibiotic it is still endemic in most part of Ethiopia. Methods: A community based cross-sectional study was conducted among 618 children 1-9 years of age from Dec. 2013 to June 2014. A multistage systematic sampling technique was applied. Data were collected using pretested and structured questionnaire and also observation by using binocular loupe to differentiate active trachoma cases. The World Health Organization's simplified classification scheme for assessing trachoma in community based surveys was used for the purpose. Bivariate and multivariate logistic regression model was fitted to identify factors assocd. with trachoma among children aged 1-9 years. An adjusted odds ratio with 95 % confidence interval was computed to det. the level of significance. Results: The overall prevalence of active trachoma among children aged 1-9 years were 23.1 % Trachomatous inflammation-Follicular, in 22.5 % (95 % CI: 22.3-22.69 %); Trachomatous inflammation-Intense, in 0.6 % (95 % CI: 0.4-0.79 %). Family size (>5) (AOR = 14.32, 95 % CI = 6.108-33.601), no. of children under 10 years of age within household (AOR = 25.53, 95 % CI = 9.774-66.686), latrine utilizations (AOR = 10.274, 95 % CI = 4.274-24.968), route of waste disposal (AOR = 3.717, 95 % CI = 1.538 to -8.981), household literacy (AOR = 2.892, 95 % CI = 1.447-5.780), cattle housing practice (AOR = 4.75, 95 % CI = 1.815-12.431), time to collect water (AOR = 25.530, 95 % CI = 8.995- 72.461), frequency of face washing practice (AOR = 6.384, 95 % CI = 2.860-14.251) and source of water (AOR = 2.353, 95 % CI = 1.134-4.882) were found to be assocd. with the presence of active trachoma in this study population. Conclusion: The prevalence of active trachoma among rural communities of children aged 1-9 years was found to be high in ref. to WHO recommended thresholds to initiate trachoma control recommendation (>10 % prevalence), which indicates that active trachoma is still a major public health concern in the study area. Therefore, it is recommended that coordinated work on implementing the WHO endorsed SAFE strategy in particular and enhancing the overall living conditions of the community is crucial.
    72. 72
      Cumberland, P.; Hailu, G.; Todd, J. Active trachoma in children aged three to nine years in rural communities in Ethiopia: prevalence, indicators and risk factors Trans. R. Soc. Trop. Med. Hyg. 2005, 99 (2) 120– 127 DOI: 10.1016/j.trstmh.2004.03.011
      72
      Active trachoma in children aged three to nine years in rural communities in Ethiopia: prevalence, indicators and risk factors
      Cumberland Phillippa; Hailu Girum; Todd Jim
      Transactions of the Royal Society of Tropical Medicine and Hygiene (2005), 99 (2), 120-7 ISSN:0035-9203.
      Trachoma is the most important infectious cause of blindness worldwide. In two rural populations in Ethiopia, a programme of preventative and treatment measures was initiated in May 2002. A baseline survey was conducted to evaluate the effect of this programme on the prevalence of active trachoma. A total of 1960 children aged 3-9 years, from 915 households in 40 communities, were examined for the presence of active trachoma. Demographic and household information was collected using questionnaires and household amenities and environmental conditions were observed. Overall, 72% of children had active trachoma. Twenty percent of children aged nine years had trachomatous scarring. In children, discharge in the eyes and flies on the eyes were significant indicators of trachoma (odds ratio [OR] = 3.0, 95% CI 1.94-4.55 and OR = 3.4, 95% CI 2.37-4.88, respectively). Frequency of washing children, a clean environment and hygienic disposal of excrement were significant preventative factors for active trachoma. Prevalence of active trachoma varies widely between and within districts. Risk factors comprise a mix of individual characteristics and household factors. This study demonstrates the need for broad target interventions and a flexible approach to the prevention of trachoma in high prevalence endemic rural populations.
    73. 73
      Reichert, F.; Pilger, D.; Schuster, A.; Lesshafft, H.; Guedes de Oliveira, S.; Ignatius, R.; Feldmeier, H. Prevalence and Risk Factors of Hookworm-Related Cutaneous Larva Migrans (HrCLM) in a Resource-Poor Community in Manaus, Brazil PLoS Neglected Trop. Dis. 2016, 10 (3) e0004514 DOI: 10.1371/journal.pntd.0004514
      There is no corresponding record for this reference.
    74. 74
      Acosta-Jamett, G.; Weitzel, T.; Boufana, B.; Adones, C.; Bahamonde, A.; Abarca, K.; Craig, P. S.; Reiter-Owona, I. Prevalence and risk factors for echinococcal infection in a rural area of northern Chile: A household-based cross-sectional study PLoS Neglected Trop. Dis. 2014, 8 (8) 1– 9 DOI: 10.1371/journal.pntd.0003090
      There is no corresponding record for this reference.
    75. 75
      Chiodo, P.; Basualdo, J.; Ciarmela, L.; Pezzani, B.; Apezteguía, M.; Minvielle, M. Related factors to human toxocariasis in a rural community of Argentina Memorias do Instituto Oswaldo Cruz. 2006, 101 (4) 397– 400 DOI: 10.1590/S0074-02762006000400009
      There is no corresponding record for this reference.
    76. 76
      Fernando, S.; Wickramasinghe, V.; Kapilananda, G.; Devasurendra, R.; Amarasooriya, J.; Dayaratne, H. Epidemiological aspects and risk factors of Toxocariasis in pediatric population in Sri Lanka Southeast Asian J. Trop. Med. Public Health 2007, 38 (6) 983– 990
      76
      Epidemiological aspects and risk factors of toxocariasis in a pediatric population in Sri Lanka
      Fernando S D; Wickramasinghe V P; Kapilananda G M G; Devasurendra R L; Amarasooriya J D M S; Dayaratne H G A K
      The Southeast Asian journal of tropical medicine and public health (2007), 38 (6), 983-90 ISSN:0125-1562.
      This cross-sectional study, carried out over a period of 11 months, investigated the relationship between Toxocara seropositivity, socio-demographic and environmental variables in a pediatric population. Risk factors for Toxocara infection were assessed by direct interview of parent or guardian using a structured pre-tested questionnaire. Eosinophilia and presence of helminth eggs or protozoan cysts in a fecal smear were recorded. Diagnosis of Toxocara seropositivity in children was based on IgG Toxocara Microwell Serum Elisa Kits. The ELISA test was regarded as positive if the optical density was 0.3 units or above. Unadjusted and adjusted odds ratios were calculated to determine risk factors for disease. The proportion of children who were positive for Toxocara antibodies in the study population was 20%. Children being exposed to a puppy of less than 3 months at home, visiting a playground frequently, living in a poorly constructed house and dogs having access to playgrounds were significant risk factors on univariate analysis. Of these four variables, only the first three variables (OR 19, OR 4 and OR 3, respectively) remained significant risk factors on the multivariate model. Presence of eosinophilia in seropositive children was significantly higher than the seronegative group (77% vs 40%; p < 0.001). This study indicates that dogs contribute significantly to children being seropositive for toxocariasis in Sri Lanka. Implementation of public health programs specifically focused on anti-parasitic treatment of dogs is recommended.
    77. 77
      Subrata, I. M.; Suryadhi, N. T.; Mantik-Astawa, N.; Damriyasa, I. M. Epidemiological and molecular analysis of Taxoplasa gondii in faecal samples of house cats obtained from house of maternal in Bali Bali Medical Journal 2015, 4 (2) 68– 75 DOI: 10.15562/bmj.v4i2.122
      There is no corresponding record for this reference.
    78. 78
      Daniels, M. E.; Shrivastava, A.; Smith, W. A.; Sahu, P.; Odagiri, M.; Misra, P. R.; Panigrahi, P.; Suar, M.; Clasen, T.; Jenkins, M. W. Cryptosporidium and giardia in humans, domestic animals, and village water sources in rural India Am. J. Trop. Med. Hyg. 2015, 93 (3) 596– 600 DOI: 10.4269/ajtmh.15-0111
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      Cryptosporidium and Giardia in Humans, Domestic Animals, and Village Water Sources in Rural India
      Daniels Miles E; Shrivastava Arpit; Smith Woutrina A; Sahu Priyadarshi; Odagiri Mitsunori; Misra Pravas R; Panigrahi Pinaki; Suar Mrutyunjay; Clasen Thomas; Jenkins Marion W
      The American journal of tropical medicine and hygiene (2015), 93 (3), 596-600 ISSN:.
      Cryptosporidium parvum and Giardia lamblia are zoonotic enteric protozoa of significant health concern where sanitation, hygiene, and water supplies are inadequate. We examined 85 stool samples from diarrhea patients, 111 pooled fecal samples by species across seven domestic animal types, and water from tube wells (N = 207) and ponds (N = 94) across 60 villages in coastal Odisha, India, for Cryptosporidium oocysts and Giardia cysts to measure occurrence, concentration/shedding, and environmental loading rates. Oocysts/cysts were detected in 12% of diarrhea patients. Detection ranged from 0% to 35% for Cryptosporidium and 0% to 67% for Giardia across animal hosts. Animal loading estimates indicate the greatest contributors of environmental oocysts/cysts in the study region are cattle. Ponds were contaminated with both protozoa (oocysts: 37%, cysts: 74%), as were tube wells (oocysts: 10%, cysts: 14%). Future research should address the public health concern highlighted from these findings and investigate the role of domestic animals in diarrheal disease transmission in this and similar settings.
    79. 79
      Schriewer, A.; Odagiri, M.; Wuertz, S.; Misra, P. R.; Panigrahi, P.; Clasen, T.; Jenkins, M. W. Human and animal fecal contamination of community water sources, stored drinking water and hands in rural India measured with validated microbial source tracking assays Am. J. Trop. Med. Hyg. 2015, 93 (3) 509– 516 DOI: 10.4269/ajtmh.14-0824
      79
      Human and Animal Fecal Contamination of Community Water Sources, Stored Drinking Water and Hands in Rural India Measured with Validated Microbial Source Tracking Assays
      Schriewer Alexander; Odagiri Mitsunori; Wuertz Stefan; Misra Pravas R; Panigrahi Pinaki; Clasen Thomas; Jenkins Marion W
      The American journal of tropical medicine and hygiene (2015), 93 (3), 509-516 ISSN:.
      We examined pathways of exposure to fecal contamination of human and animal origin in 24 villages in Odisha, India. In a cross-sectional study during the monsoon season, fecal exposure via community water sources (N = 123) and in the home (N = 137) was assessed using human- and nonhuman-associated Bacteroidales microbial source tracking (MST) markers and fecal coliforms (FCs). Detection rates and marker concentrations were examined to pinpoint pathways of human fecal exposure in the public and domestic domains of disease transmission in study communities. Human fecal markers were detected much more frequently in the domestic domain (45% of households) than in public domain sources (8% of ponds; 4% of groundwater drinking sources). Animal fecal markers were widely detected in both domains (74% of ponds, 96% of households, 10% of groundwater drinking sources), indicating ubiquitous risks of exposure to animal feces and zoonotic pathogens. This study confirms an often suggested contamination link from hands to stored water in the home in developing countries separately for mothers' and children's hands and both human and animal fecal contamination. In contrast to MST markers, FCs provided a poor metric to assess risks of exposure to fecal contamination of human origin in this rural setting.
    80. 80
      Daniels, M. E.; Smith, W. A.; Schmidt, W. P.; Clasen, T.; Jenkins, M. W. Modeling Cryptosporidium and Giardia in Ground and Surface Water Sources in Rural India: Associations with Latrines, Livestock, Damaged Wells, and Rainfall Patterns Environ. Sci. Technol. 2016, 50 (14) 7498– 7507 DOI: 10.1021/acs.est.5b05797
      There is no corresponding record for this reference.
    81. 81
      Lupindu, A. M.; Olsen, J. E.; Ngowi, H. A.; Msoffe, P. L. M.; Mtambo, M. M.; Scheutz, F.; Dalsgaard, A. Occurrence and characterization of Shiga toxin-producing Escherichia coli O157:H7 and other non-sorbitol-fermenting E. coli in cattle and humans in urban areas of Morogoro, Tanzania Vector-Borne and Zoonotic Diseases. 2014, 14 (7) 503– 510 DOI: 10.1089/vbz.2013.1502
      81
      Occurrence and characterization of Shiga toxin-producing Escherichia coli O157:H7 and other non-sorbitol-fermenting E. coli in cattle and humans in urban areas of Morogoro, Tanzania
      Lupindu Athumani M; Olsen John E; Ngowi Helena A; Msoffe Peter L M; Mtambo Madundo M; Scheutz Flemming; Dalsgaard Anders
      Vector borne and zoonotic diseases (Larchmont, N.Y.) (2014), 14 (7), 503-10 ISSN:.
      Escherichia coli strains such as Shiga toxin-producing E. coli (STEC), enteropathogenic E. coli, enterotoxigenic, attaching, and effacing E. coli, and enteroinvasive E. coli cause diarrhea in humans. Although other serotypes exist, the most commonly reported STEC in outbreaks is O157:H7. A cross-sectional study was conducted to isolate and characterize non-sorbitol-fermenting (NSF) E. coli O157:H7 from urban and periurban livestock settings of Morogoro, Tanzania. Human stool, cattle feces, and soil and water samples were collected. Observations and questionnaire interview studies were used to gather information about cattle and manure management practices in the study area. E. coli were isolated on sorbitol MacConkey agar and characterized by conventional biochemical tests. Out of 1049 samples, 143 (13.7%) yielded NSF E. coli. Serological and antimicrobial tests and molecular typing were performed to NSF E. coli isolates. These procedures detected 10 (7%) pathogenic E. coli including STEC (n=7), enteropathogenic E. coli (EPEC) (n=2), and attaching and effacing E. coli (A/EEC) (n=1) strains. The STEC strains had the ability to produce VT1 and different VT2 toxin subtypes that caused cytopathic effects on Vero cells. The prevalence of STEC in cattle was 1.6%, out of which 0.9% was serotype O157:H7 and the overall prevalence of diarrheagenic E. coli in cattle was 2.2%. The serotypes O157:H7, O142:H34, O113:H21, O+:H-, O+:H16, and O25:H4 were identified. One ESBL-producing isolate showed the MLST type ST131. To our knowledge, this is the first finding in Tanzania of this recently emerged worldwide pandemic clonal group, causing widespread antimicrobial-resistant infections, and adds knowledge of the geographical distribution of ST131. Cattle manure was indiscriminately deposited within residential areas, and there was direct contact between humans and cattle feces during manure handling. Cattle and manure management practices expose humans, animals, and the environment to pathogenic E. coli and other manure-borne pathogens. Therefore, there is a need to improve manure management practices in urban and periurban areas to prevent pathogen spread and associated human health risks.
    82. 82
      Nyariki, D. M.; Mwang’ombe, A. W.; Thompson, D. M. Land-use change and livestock production challenges in an integrated system: the Masai-Mara ecosystem, Kenya J. Hum. Ecol. 2009, 26 (3) 11
      There is no corresponding record for this reference.
    83. 83
      Wolking, D. J.; Clifford, D. L.; Kelly, T. R.; Kamani, E.; Smith, W. A.; Kazwala, R. R.; Mazet, J. A. K. Boma to banda - a disease sentinel concept for reduction of diarrhoea Pastoralism: Research, Policy and Practice 2016, 6 (1) 13 DOI: 10.1186/s13570-016-0059-8
      There is no corresponding record for this reference.
    84. 84
      Sprenger, L. K.; Green, K. T.; Molento, M. B. Geohelminth contamination of public areas and epidemiological risk factors in Curitiba, Brazil Rev. Bras. Parasitol. Vet. 2014, 23 (1) 69– 73 DOI: 10.1590/S1984-29612014009
      84
      Geohelminth contamination of public areas and epidemiological risk factors in Curitiba, Brazil
      Sprenger Lew Kan; Green Kerriel Thandile; Molento Marcelo Beltrao
      Revista brasileira de parasitologia veterinaria = Brazilian journal of veterinary parasitology : Orgao Oficial do Colegio Brasileiro de Parasitologia Veterinaria (2014), 23 (1), 69-73 ISSN:.
      This study aimed to investigate the frequency of geohelminthic contamination of public parks and squares in Curitiba, state of Parana, Brazil, between August and December 2010. A total of 345 samples were collected from 69 sandboxes in different areas and were tested using the Faust, Lutz and Baermann parasitological techniques. Potential risk factors associated with soil contamination were also analyzed. A total of 36% of the samples (124/345) were positive for helminths and 65.2% of the areas (45/69) were classified as contaminated in one or more samples. The most commonly identified parasite eggs were Ancylostoma sp. (14.5%; 50/345); followed by Toxocara sp. (9.6%; 33/345) and the Strongyloidea superfamily (excluding hookworms) (2.3%; 8/345). The analysis on the epidemiological risk factors indicated that the presence of dogs and feces in the sandboxes increased the chances of contamination of the site. Use of fences had a protective positive impact that reduced soil contamination. Health education programs should be applied within the community to minimize the risk of human contact with dogs' feces. Use of fencing in these areas is highly recommended to prevent or reduce the users' contact with animal excrement.
    85. 85
      Tun, S.; Ithoi, I.; Mahmud, R.; Samsudin, N. I.; Heng, C. K.; Ling, L. Y. Detection of Helminth Eggs and Identification of Hookworm Species in Stray Cats, Dogs and Soil from Klang Valley, Malaysia PLoS One 2015, 10 (12) e0142231 DOI: 10.1371/journal.pone.0142231
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      Detection of helminth eggs and identification of hookworm species in stray cats, dogs and soil from Klang Valley, Malaysia
      Tun, Sandee; Ithoi, Init; Mahmud, Rohela; Samsudin, Nur Izyan; Heng, Chua Kek; Ling, Lau Yee
      PLoS One (2015), 10 (12), e0142231/1-e0142231/12CODEN: POLNCL; ISSN:1932-6203. (Public Library of Science)
      The present study was conducted to det. the prevalence of helminth eggs excreted in the faces of stray cats, dogs and in soil samples. A total of 505 fresh samples of faeces (from 227 dogs and 152 cats) and soil were collected. The egg stage was detected via microscopy after the application of formalin-ether concn. technique. Genomic DNA was extd. from the samples contg. hookworm eggs and used for further identification to the species level using real-time polymerase chain reaction coupled with high resoln. melting anal. Microscopic observation showed that the overall prevalence of helminth eggs among stray cats and dogs was 75.7% (95% CI = 71.2%-79.9%), in which 87.7% of dogs and 57.9% of cats were infected with at least one parasite genus. Five genera of heliminth eggs were detected in the faecal samples, including hookworms (46.4%), Toxocara (11.1%), Trichuris (8.4%), Spirometra (7.4%) and Ascaris (2.4%). The prevalence of helminth infections among stray dogs was significantly higher than that among stray cats (p < 0.001). Only three genera of helminths were detected in soil samples with the prevalence of 23% (95% CI = 15.1%-31%), consisting of hookworms (16.6%), Ascaris (4%) and Toxocara (2.4%). The mol. identification of hookworm species revealed that Ancylostoma ceylanicum was dominant in both faecal and soil samples. The dog hookworm, Ancylostoma caninum, was also detected among cats, which is the first such occurrence reported in Malaysia till date. This finding indicated that there was a cross-infection of A. caninum between stray cats and dogs because of their coexistent within human communities. Taken together, these data suggest the potential role of stray cats and dogs as being the main sources of environmental contamination as well as for human infections.
    86. 86
      Boehm, A. B.; Wang, D.; Ercumen, A.; Shea, M.; Harris, A. R.; Shanks, O. C.; Kelty, C.; Ahmed, A.; Mahmud, Z. H.; Arnold, B. F.; Chase, C.; Kullmann, C.; Colford, J. M.; Luby, S. P.; Pickering, A. J. Occurrence of Host-Associated Fecal Markers on Child Hands, Household Soil, and Drinking Water in Rural Bangladeshi Households Environ. Sci. Technol. Lett. 2016, 3 (11) 393– 398 DOI: 10.1021/acs.estlett.6b00382
      86
      Occurrence of Host-Associated Fecal Markers on Child Hands, Household Soil, and Drinking Water in Rural Bangladeshi Households
      Boehm, Alexandria B.; Wang, Dan; Ercumen, Ayse; Shea, Meghan; Harris, Angela R.; Shanks, Orin C.; Kelty, Catherine; Ahmed, Alvee; Mahmud, Zahid Hayat; Arnold, Benjamin F.; Chase, Claire; Kullmann, Craig; Colford, John M.; Luby, Stephen P.; Pickering, Amy J.
      Environmental Science & Technology Letters (2016), 3 (11), 393-398CODEN: ESTLCU; ISSN:2328-8930. (American Chemical Society)
      We evaluated whether provision and promotion of improved sanitation hardware (toilets and child feces management tools) reduced rotavirus and human fecal contamination of drinking water, child hands, and soil among rural Bangladeshi compds. enrolled in a cluster-randomized trial. We also measured host-assocd. genetic markers of ruminant and avian feces. We found evidence of widespread ruminant and avian fecal contamination in the compd. environment; non-human fecal marker occurrence scaled with animal ownership. Strategies for controlling non-human fecal waste should be considered when designing interventions to reduce exposure to fecal contamination in low-income settings. Detection of a human-assocd. fecal marker and rotavirus was rare and unchanged by provision and promotion of improved sanitation to intervention compds. The sanitation intervention reduced ruminant fecal contamination in drinking water and general (non-host specific) fecal contamination in soil but overall had limited effects on reducing fecal contamination in the household environment.
    87. 87
      Harris, A. R.; Pickering, A. J.; Harris, M.; Doza, S.; Islam, M. S.; Unicomb, L.; Luby, S.; Davis, J.; Boehm, A. B. Ruminants Contribute Fecal Contamination to the Urban Household Environment in Dhaka, Bangladesh Environ. Sci. Technol. 2016, 50 (9) 4642 DOI: 10.1021/acs.est.5b06282
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      Ruminants Contribute Fecal Contamination to the Urban Household Environment in Dhaka, Bangladesh
      Harris, Angela R.; Pickering, Amy J.; Harris, Michael; Doza, Solaiman; Islam, M. Sirajul; Unicomb, Leanne; Luby, Stephen; Davis, Jennifer; Boehm, Alexandria B.
      Environmental Science & Technology (2016), 50 (9), 4642-4649CODEN: ESTHAG; ISSN:0013-936X. (American Chemical Society)
      In Dhaka, Bangladesh, the sensitivity and specificity of three human, three ruminant, and one avian source-assocd. QPCR microbial source tracking assays were evaluated using fecal samples collected on site. Ruminant-assocd. assays performed well, whereas the avian and human assays exhibited unacceptable cross-reactions with feces from other hosts. Subsequently, child hand rinses (n = 44) and floor sponge samples (n = 44) from low-income-households in Dhaka were assayed for fecal indicator bacteria (enterococci, Bacteroidales, and Escherichia coli) and a ruminant-assocd. bacterial target (BacR). Mean enterococci concns. were of 100 most probable no. (MPN)/2 hands and 1000 MPN/225 cm2 floor. Mean concns. of Bacteroidales were 106 copies/2 hands and 105 copies/225 cm2 floor. E. coli were detected in a quarter of hand rinse and floor samples. BacR was detected in 18% of hand rinse and 27% of floor samples. Results suggest that effective household fecal management should account not only for human sources of contamination but also for animal sources. The poor performance of the human-assocd. assays in the study area calls into the question the feasibility of developing a human-assocd. marker in urban slum environments, where domestic animals are exposed to human feces that have been disposed in pits and open drains.
    88. 88
      Ngure, F. M.; Humphrey, J. H.; Mbuya, M. N. N.; Majo, F.; Mutasa, K.; Govha, M.; Mazarura, E.; Chasekwa, B.; Prendergast, A. J.; Curtis, V.; Boor, K. J.; Stoltzfus, R. J. Formative Research on Hygiene Behaviors and Geophagy among Infants and Young Children and Implications of Exposure to Fecal Bacteria Am. J. Trop. Med. Hyg. 2013, 89 (4) 709– 716 DOI: 10.4269/ajtmh.12-0568
      88
      Formative research on hygiene behaviors and geophagy among infants and young children and implications of exposure to fecal bacteria
      Ngure Francis M; Humphrey Jean H; Mbuya Mduduzi N N; Majo Florence; Mutasa Kuda; Govha Margaret; Mazarura Exevia; Chasekwa Bernard; Prendergast Andrew J; Curtis Valerie; Boor Kathyrn J; Stoltzfus Rebecca J
      The American journal of tropical medicine and hygiene (2013), 89 (4), 709-16 ISSN:.
      We conducted direct observation of 23 caregiver-infant pairs for 130 hours and recorded wash-related behaviors to identify pathways of fecal-oral transmission of bacteria among infants. In addition to testing fingers, food, and drinking water of infants, three infants actively ingested 11.3 ± 9.2 (mean ± SD) handfuls of soil and two ingested chicken feces 2 ± 1.4 times in 6 hours. Hand washing with soap was not common and drinking water was contaminated with Escherichia coli in half (12 of 22) of the households. A one-year-old infant ingesting 1 gram of chicken feces in a day and 20 grams of soil from a laundry area of the kitchen yard would consume 4,700,000-23,000,000 and 440-4,240 E. coli, respectively, from these sources. Besides standard wash and nutrition interventions, infants in low-income communities should be protected from exploratory ingestion of chicken feces, soil, and geophagia for optimal child health and growth.
    89. 89
      Sultana, R.; Nahar, N.; Rimi, N. A.; Azad, S.; Islam, M. S.; Gurley, E. S.; Luby, S. P. Backyard poultry raising in Bangladesh: a valued resource for the villagers and a setting for zoonotic transmission of avian influenza. A qualitative study Rural and Remote Health 2012, 12 (1927) 1– 14
      There is no corresponding record for this reference.
    90. 90
      Uga, S.; Hoa, N. T.; Noda, S.; Moji, K.; Cong, L.; Aoki, Y.; Rai, S. K.; Fujimaki, Y. Parasite egg contamination of vegetables from a suburban market in Hanoi, Vietnam Nepal Med. College J. 2009, 11 (2) 75– 78
      90
      Parasite egg contamination of vegetables from a suburban market in Hanoi, Vietnam
      Uga S; Hoa N T V; Noda S; Moji K; Cong L; Aoki Y; Rai S K; Fujimaki Y
      Nepal Medical College journal : NMCJ (2009), 11 (2), 75-8 ISSN:.
      Helminth egg contamination of vegetables purchased at suburban market in Hanoi, Vietnam was examined. A total of 317 vegetables were examined and 82 (26%) were revealed to be positive for parasite eggs. Of the 15 varieties, 13 were positive except for horseradish and cucumber. Contamination was highest in leafy vegetables (31%), followed by root vegetables (17%) and fruit vegetables (3%). Throughout the survey, five species of parasite eggs were found: Ascaris sp., Trichuris sp., Toxocara sp., Taenia sp. and Ascaridia galli. In the interview with the villagers, 121 (81%) of 149 adult villagers stated that they usually use not only animal feces but also human feces as a fertilizer. Throughout the survey, a total of 453 eggs were recovered. Number of eggs recovered from vegetables was higher in the dry season (355 eggs) than in the rainy season (98 eggs). The study revealed that vegetables purchased at a market in suburban Hanoi (Vietnam) were highly contaminated with parasite eggs excreted by humans and animals. Considering the eating habits of the Vietnamese and the 17% embryonation rate of detected parasites, vegetables seem to play an important role in soil-transmitted helminth infection in this country.
    91. 91
      Scallan, E.; Hoekstra, R. M.; Angulo, F. J.; Tauxe, R. V.; Widdowson, M.-A.; Roy, S. L.; Jones, J. L.; Griffin, P. M. Foodborne Illness Acquired in the United States—Major Pathogens Emerging Infect. Dis. 2011, 17 (1) 7– 15 DOI: 10.3201/eid1701.P11101
      91
      Foodborne illness acquired in the United States--major pathogens
      Scallan Elaine; Hoekstra Robert M; Angulo Frederick J; Tauxe Robert V; Widdowson Marc-Alain; Roy Sharon L; Jones Jeffery L; Griffin Patricia M
      Emerging infectious diseases (2011), 17 (1), 7-15 ISSN:.
      Estimates of foodborne illness can be used to direct food safety policy and interventions. We used data from active and passive surveillance and other sources to estimate that each year 31 major pathogens acquired in the United States caused 9.4 million episodes of foodborne illness (90% credible interval [CrI] 6.6-12.7 million), 55,961 hospitalizations (90% CrI 39,534-75,741), and 1,351 deaths (90% CrI 712-2,268). Most (58%) illnesses were caused by norovirus, followed by nontyphoidal Salmonella spp. (11%), Clostridium perfringens (10%), and Campylobacter spp. (9%). Leading causes of hospitalization were nontyphoidal Salmonella spp. (35%), norovirus (26%), Campylobacter spp. (15%), and Toxoplasma gondii (8%). Leading causes of death were nontyphoidal Salmonella spp. (28%), T. gondii (24%), Listeria monocytogenes (19%), and norovirus (11%). These estimates cannot be compared with prior (1999) estimates to assess trends because different methods were used. Additional data and more refined methods can improve future estimates.
    92. 92
      a Mpalang, R. K.; Boreux, R.; Melin, P.; Akir Ni Bitiang, K.; Daube, G.; De Mol, P. Prevalence of Campylobacter among goats and retail goat meat in Congo J. Infect. Dev. Countries 2014, 8 (2) 168– 175 DOI: 10.3855/jidc.3199
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      Prevalence of Campylobacter among goats and retail goat meat in Congo
      a Mpalang Rosette Kabwang; Boreux Raphael; Melin Pierrette; Akir Ni Bitiang Khang'Mate; Daube Georges; De Mol Patrick
      Journal of infection in developing countries (2014), 8 (2), 168-75 ISSN:.
      BACKGROUND: The prevalence of Campylobacter jejuni and Campylobacter coli was determined in goat and goat meat sold at retail outlets in Lubumbashi, Democratic Republic of Congo (DR Congo). METHODOLOGY: A total of 644 samples, including 177 goat meat, 86 goat stomachs, 139 ready to eat (RTE) goat skewers, and 242 goat faecal samples were examined for the presence of Campylobacter jejuni and Campylobacter coli using polymerase chain reaction. RESULTS: Overall, Campylobacter spp. were found in 34.6% of the examined samples. C. jejuni was isolated in 10.1% and C. coli in 26.7% of samples. Only 2.2% of all samples were positive for both species. There was a significant association between the prevalence of C. coli and the type of sample (p < 0.05). The overall prevalence of Campylobacter in different sample groups was 41.2%, 37.2%, 23.7%, and 35.1% for goat meat, goat stomachs, RTE goat skewers, and goat faecal samples, respectively. There was no significant difference (p > 0.05) between the prevalence observed in the rainy season (16.7%) and the dry season (20.0%). Moreover, the overall prevalence of Campylobacter in slaughter sites, open-air markets, warehouses, and semi-open-air markets was 28.2%, 34.2%, 35.4%, and 42.9%, respectively. Statistically, there was no influence of the sample collection site on the frequency of isolation of Campylobacter (p > 0.05). CONCLUSION: This study shows that, considering the relatively high prevalence of this pathogen, live goat and goat meat are major sources of human and environmental contamination by Campylobacter spp. in Lubumbashi.
    93. 93
      Osbjer, K.; Boqvist, S.; Sokerya, S.; Kannarath, C.; San, S.; Davun, H.; Magnusson, U. Household practices related to disease transmission between animals and humans in rural Cambodia BMC Public Health 2015, 15 (1) 476 DOI: 10.1186/s12889-015-1811-5
      93
      Household practices related to disease transmission between animals and humans in rural Cambodia
      Osbjer Kristina; Magnusson Ulf; Boqvist Sofia; Sokerya Seng; Kannarath Chheng; San Sorn; Davun Holl
      BMC public health (2015), 15 (), 476 ISSN:.
      BACKGROUND: Zoonotic diseases are disproportionately affecting poor societies in low-income countries and pose a growing threat to public health and global food security. Rural Cambodian households may face an increased likelihood of exposure to zoonotic diseases as people there live in close association with livestock. The objectives of the study was to identify practices known to influence zoonosis transmission in rural Cambodian households and relate the practices to agro-ecological region, socio-economic position, demographics, livestock management and zoonosis awareness. METHODS: The study was conducted in three different agro-ecological regions of Cambodia; 10 villages each in the central lowlands, north-west wetlands and on the south coast, where information was obtained in questionnaires administered to 300 households, and 30 village heads and animal health workers. RESULTS: Descriptive analysis revealed a gender difference in responsibility for livestock and that the main purpose of raising livestock was for sale. Few respondents (6%) perceived a likelihood of disease transmission in their village between livestock, humans and wildlife, despite household practices related to zoonosis transmission being common. More than one-forth of households practised behaviours such as culling sick animals for consumption, eating animals found dead and allowing animals to enter sleeping and food preparation areas. Associations between household practices and possible explanatory factors were analysed with multivariable models using generalised estimation equations to account for clustering of practices within villages. Factors found to influence household practices were agro-ecological region, socio-economic position, number of people in the household, livestock species reared and awareness of zoonoses. CONCLUSIONS: Cambodia has experienced numerous fatal human cases of zoonotic influenza and extensive influenza information campaigns have been run, yet only a few of the households surveyed here reported the threat of zoonosis to be a concern in their village. Zoonosis awareness was positively related to hand washing behaviour, but other practices associated with an increased or decreased likelihood of exposure to zoonotic pathogens were unaffected by awareness. The findings indicate a knowledge-to-action gap among rural farmers and highlight the necessity for reconstructed interventions in zoonotic disease control.
    94. 94
      Anuar, T. S.; Sarhan Al-Mekhlafi, H. M.; Abdul Ghani, M. K.; Moktar, N. Prevalence and risk factors associated with Entamoeba histolytica/Entamoeba dispar/Entamoeba moshkovskii complex infection among different tribes of Malaysian aborigines Int. J. Infect. Dis. 2012, 16, e175– e176 DOI: 10.1016/j.ijid.2012.05.725
      There is no corresponding record for this reference.
    95. 95
      Suwannarong, K.; Chapman, R. S. Characteristics associated with contact with rodents in, around, and outside homes in Khon Kaen Province, Thailand Am. J. Trop. Med. Hyg. 2015, 92 (4) 784– 790 DOI: 10.4269/ajtmh.14-0195
      There is no corresponding record for this reference.
    96. 96
      Vujcic, J.; Ram, P. K.; Hussain, F.; Unicomb, L.; Gope, P. S.; Abedin, J.; Mahmud, Z. H.; Sirajul Islam, M.; Luby, S. P. Toys and toilets: cross-sectional study using children’s toys to evaluate environmental faecal contamination in rural Bangladeshi households with different sanitation facilities and practices Trop. Med. Int. Health 2014, 19 (5) 528– 536 DOI: 10.1111/tmi.12292
      96
      Toys and toilets: cross-sectional study using children's toys to evaluate environmental faecal contamination in rural Bangladeshi households with different sanitation facilities and practices
      Vujcic Jelena; Ram Pavani K; Hussain Faruqe; Unicomb Leanne; Gope Partha Sarathi; Abedin Jaynal; Mahmud Zahid Hayat; Islam M Sirajul; Luby Stephen P
      Tropical medicine & international health : TM & IH (2014), 19 (5), 528-36 ISSN:.
      OBJECTIVE: To evaluate household faecal contamination using children's toys among 100 rural Bangladeshi households categorised as 'cleaner' (toilet that reliably separates faeces from the environment and no human faeces in/around living space) or 'less clean' (no toilet or toilet that does not reliably separate faeces from the environment and human faeces in/around living space). METHODS: We distributed toy balls to each household and rinsed each study toy and a toy already owned by the household in 200 ml of Ringer's solution. We enumerated faecal coliforms and faecal streptococci from each rinse using membrane filtration methods. RESULTS: Study toys from 39 cleaner households had lower mean faecal coliform contamination than toys from 61 less clean households (2.4 log10 colony-forming units (CFU)/200 ml vs. 3.2 log10 CFU/200 ml, P = 0.03). However, wealth measures explained a portion of this relationship. Repeat measures were moderately variable [coefficient of variation (CV) = 6.5 between two toys in the household at the same time, CV = 37.6 between toys in the household at two different times 3-4 days apart]. Too few households owned a non-porous toy to compare groups without risk of bias. CONCLUSION: In rural Bangladesh, improved sanitation facilities and practices were associated with less environmental contamination. Whether this association is independent of household wealth and whether the difference in contamination improves child health merit further study. The variation found was typical for measures of environmental contamination, and requires large sample sizes to ascertain differences between groups with statistical significance.
    97. 97
      Torondel, B.; Gyekye-Aboagye, Y.; Routray, P.; Boisson, S.; Schimdt, W.; Clasen, T. Laboratory development and field testing of sentinel toys to assess environmental faecal exposure of young children in rural India Trans. R. Soc. Trop. Med. Hyg. 2015, 109 (6) 386– 392 DOI: 10.1093/trstmh/trv023
      97
      Laboratory development and field testing of sentinel toys to assess environmental faecal exposure of young children in rural India
      Torondel Belen; Gyekye-Aboagye Yaw; Routray Parimita; Boisson Sophie; Schimdt Wolf; Clasen Thomas
      Transactions of the Royal Society of Tropical Medicine and Hygiene (2015), 109 (6), 386-92 ISSN:.
      BACKGROUND: Sentinel toys are increasingly used as a method of assessing young children's exposure to faecal pathogens in households in low-income settings. However, there is no consensus on the suitability of different approaches. METHODS: We evaluated three types of toy balls with different surfaces (plastic, rubber, urethane) in the laboratory to compare the uptake of faecal indicator bacteria (Escherichia coli) on their surface. We performed bacteria survival analysis under different environmental conditions and tested laboratory methods for bacteria removal and recovery. In a field study we distributed sterile urethane balls to children <5 from 360 households in rural India. After 24 hours, we collected and rinsed the toys in sterile water, assayed for thermotolerant coliforms (TTC) and explored associations between the level of contamination and household characteristics. RESULTS: In the laboratory, urethane foam balls took up more indicator bacteria than the other balls. Bacteria recovery did not differ based on mechanic vs no agitation. Higher temperatures and moisture levels increased bacterial yield. In the field, the only factor associated with a decreased recovery of TTC from the balls was having a soil (unpaved) floor. CONCLUSIONS: Sentinel toys may be an effective tool for assessing young children's exposure to faecal pathogens. However, even using methods designed to increase bacterial recovery, limited sensitivity may require larger sample sizes.
    98. 98
      Harvey, S. A.; Winch, P. J.; Leontsini, E.; Torres Gayoso, C.; López Romero, S.; Gilman, R. H.; Oberhelman, R. A. Domestic poultry-raising practices in a Peruvian shantytown: implications for control of Campylobacter jejuni-associated diarrhea Acta Trop. 2003, 86 (1) 41– 54 DOI: 10.1016/S0001-706X(03)00006-8
      98
      Domestic poultry-raising practices in a Peruvian shantytown: implications for control of Campylobacter jejuni-associated diarrhea
      Harvey Steven A; Winch Peter J; Leontsini Elli; Torres Gayoso Cecilia; Lopez Romero Sonia; Gilman Robert H; Oberhelman Richard A
      Acta tropica (2003), 86 (1), 41-54 ISSN:0001-706X.
      Raising poultry at home is common in many periurban communities in low-income countries. Studies demonstrate that free-range domestic poultry increase children's risk of infection with diarrhea-causing organisms such as Campylobacter jejuni. Corralling might reduce risk, but research on the socioeconomic acceptability of corralling is lacking. To explore this issue, we studied local knowledge and practices related to poultry-raising in a Peruvian shantytown. Our objectives were to understand: (1). motives for raising domestic poultry; (2). economic and cultural factors that affect the feasibility of corralling; and (3). local perceptions about the relationship between domestic poultry and disease. During 1999-2000, we met with community health volunteers and conducted ethnographic and structured interviews with residents about poultry-raising practices. We then enrolled 12 families in a 2-month trial of corral use during which field workers made biweekly surveillance visits to each family. Most participants reported that they raise birds because home-grown poultry and eggs taste better and are more nutritious and because they enjoy living around animals. Some want to teach their children about raising animals. To prevent theft, many residents shut their birds in provisional enclosures at night, but most stated that birds are healthier, happier, and produce better meat and eggs when let loose by day. Many view bird feces in the house and yard as dirty, but few see a connection to illness. Residents consider chicks and ducklings more innocuous than adult birds and are more likely to allow them inside the house and permit children to play with them. After extensive orientation and technical assistance, participants were willing to corral birds more often. But due to perceived disadvantages, many kept birds penned only intermittently. Additional food and water costs were a significant obstacle for some. Adequate space, bird care and corral hygiene would also need to be addressed to make this intervention viable. Developing a secure, acceptable and affordable corral remains a challenge in this population.
    99. 99
      Arnold, B. F.; Null, C.; Luby, S. P.; Unicomb, L.; Stewart, C. P.; Dewey, K. G.; Ahmed, T.; Ashraf, S.; Christensen, G.; Clasen, T.; Dentz, H. N.; Fernald, L. C. H.; Haque, R.; Hubbard, A. E.; Kariger, P.; Leontsini, E.; Lin, A.; Njenga, S. M.; Pickering, A. J.; Ram, P. K.; Tofail, F.; Winch, P. J.; Colford, J. M. Cluster-randomised controlled trials of individual and combined water, sanitation, hygiene and nutritional interventions in rural Bangladesh and Kenya: the WASH Benefits study design and rationale BMJ. Open 2013, 3 (8) e003476 DOI: 10.1136/bmjopen-2013-003476
      There is no corresponding record for this reference.
    100. 100
      Hussain, F. Continued household faecal contamination following a sanitation intervention in rural Bangladesh. Health Sci. Bull. 2013, 11 (1), 9–14 (En), 9–14 (Bengali).
      There is no corresponding record for this reference.
    101. 101

      Sanitation Hygiene Infant Nutrition Efficacy

      Trial, T.; Humphrey, J. H.; Jones, A. D.; Manges, A.; Mangwadu, G.; Maluccio, J. A.; Mbuya, M. N.; Moulton, L. H.; Ntozini, R.; Prendergast, A. J.; Stoltzfus, R. J.; Tielsch, J. M. The Sanitation Hygiene Infant Nutrition Efficacy (SHINE) Trial: Rationale, Design, and Methods Clin. Infect. Dis. 2015, 61 (Suppl 7) S685– 702
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    102. 102
      Hall, D.; Alam, M. G. S.; Raha, S. K. Reducing risk of emerging infectious diseases in Bangladesh through ecohealth Int. J. Infect. Dis. 2012, 16, e38 DOI: 10.1016/j.ijid.2012.05.096
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    103. 103
      Cassenote, A. J. F.; de Abreu Lima, A. R.; Pinto Neto, J. M.; Rubinsky-Elefant, G. Seroprevalence and Modifiable Risk Factors for Toxocara spp. in Brazilian Schoolchildren PLoS Neglected Trop. Dis. 2014, 8 (5) e2830 DOI: 10.1371/journal.pntd.0002830
      There is no corresponding record for this reference.
    104. 104
      Smolders, A.; Rolls, R. J.; Ryder, D.; Watkinson, A.; Mackenzie, M. Cattle-derived microbial input to source water catchments: An experimental assessment of stream crossing modification J. Environ. Manage. 2015, 156, 143– 149 DOI: 10.1016/j.jenvman.2015.03.052
      There is no corresponding record for this reference.
    105. 105
      Harwood, V. J.; Staley, C.; Badgley, B. D.; Borges, K.; Korajkic, A. Microbial source tracking markers for detection of fecal contamination in environmental waters: relationships between pathogens and human health outcomes FEMS Microbiology Reviews. 2014, 38 (1) 1– 40 DOI: 10.1111/1574-6976.12031
      There is no corresponding record for this reference.
    106. 106
      Liu, J.; Gratz, J.; Amour, C.; Kibiki, G.; Becker, S.; Janaki, L.; Verweij, J. J.; Taniuchi, M.; Sobuz, S. U.; Haque, R.; Haverstick, D. M.; Houpt, E. R. A Laboratory-Developed TaqMan Array Card for Simultaneous Detection of 19 Enteropathogens Journal of Clinical Microbiology 2013, 51 (2) 472– 480 DOI: 10.1128/JCM.02658-12
      106
      A laboratory-developed TaqMan Array Card for simultaneous detection of 19 enteropathogens
      Liu, Jie; Gratz, Jean; Amour, Caroline; Kibiki, Gibson; Becker, Stephen; Janaki, Lalitha; Verweij, Jaco J.; Taniuchi, Mami; Sobuz, Shihab U.; Haque, Rashidul; Haverstick, Doris M.; Houpt, Eric R.
      Journal of Clinical Microbiology (2013), 51 (2), 472-480CODEN: JCMIDW; ISSN:0095-1137. (American Society for Microbiology)
      The TaqMan Array Card (TAC) system is a 384-well singleplex real-time PCR format that has been used to detect multiple infection targets. Here we developed an enteric TaqMan Array Card to detect 19 enteropathogens, including viruses (adenovirus, astrovirus, norovirus GII, rotavirus, and sapovirus), bacteria (Campylobacter jejuni/C. coli, Clostridium difficile, Salmonella, Vibrio cholerae, diarrheagenic Escherichia coli strains including enteroaggregative E. coli [EAEC], enterotoxigenic E. coli [ETEC], enteropathogenic E. coli [EPEC], and Shiga-toxigenic E. coli [STEC]), Shigella/enteroinvasive E. coli (EIEC), protozoa (Cryptosporidium, Giardia lamblia, and Entamoeba histolytica), and helminths (Ascaris lumbricoides and Trichuris trichiura), as well as two extrinsic controls to monitor extn. and amplification efficiency (the bacteriophage MS2 and phocine herpesvirus). Primers and probes were newly designed or adapted from published sources and spotted onto microfluidic cards. Fecal samples were spiked with extrinsic controls, and DNA and RNA were extd. using the QiaAmp Stool DNA minikit and the QuickGene RNA Tissue kit, resp., and then mixed with Ag-Path-ID One Step real-time reverse transcription-PCR (RT-PCR) reagents and loaded into cards. PCR efficiencies were between 90% and 105%, with linearities of 0.988 to 1. The limit of detection of the assays in the TAC was within a 10-fold difference from the cognate assays performed on plates. Precision testing demonstrated a coeff. of variation of below 5% within a run and 14% between runs. Accuracy was evaluated for 109 selected clin. specimens and revealed an av. sensitivity and specificity of 85% and 77%, resp., compared with conventional methods (including microscopy, culture, and immunoassay) and 98% and 96%, resp., compared with our lab.-developed PCR-Luminex assays. This TAC allows fast, accurate, and quant. detection of a broad spectrum of enteropathogens and is well suited for surveillance or clin. purposes.
    107. 107
      Platts-Mills, J. A.; Babji, S.; Bodhidatta, L.; Gratz, J.; Haque, R.; Havt, A.; McCormick, B. J. J.; McGrath, M.; Olortegui, M. P.; Samie, A.; Shakoor, S.; Mondal, D.; Lima, I. F. N.; Hariraju, D.; Rayamajhi, B. B.; Qureshi, S.; Kabir, F.; Yori, P. P.; Mufamadi, B.; Amour, C.; Carreon, J. D.; Richard, S. A.; Lang, D.; Bessong, P.; Mduma, E.; Ahmed, T.; Lima, A. A. A. M.; Mason, C. J.; Zaidi, A. K. M.; Bhutta, Z. A.; Kosek, M.; Guerrant, R. L.; Gottlieb, M.; Miller, M.; Kang, G.; Houpt, E. R. Pathogen-specific burdens of community diarrhoea in developing countries: a multisite birth cohort study (MAL-ED) Lancet Global Health 2015, 3 (9) e564– e575 DOI: 10.1016/S2214-109X(15)00151-5
      There is no corresponding record for this reference.
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      McLellan, S. L.; Eren, A. M. Discovering new indicators of fecal pollution Trends Microbiol. 2014, 22 (12) 697– 706 DOI: 10.1016/j.tim.2014.08.002
      108
      Discovering new indicators of fecal pollution
      McLellan, Sandra L.; Eren, A. Murat
      Trends in Microbiology (2014), 22 (12), 697-706CODEN: TRMIEA; ISSN:0966-842X. (Elsevier Ltd.)
      A review. Fecal pollution indicators are essential to identify and remediate contamination sources and protect public health. Historically, easily cultured facultative anaerobes such as fecal coliforms, Escherichia coli, or enterococci have been used but these indicators generally provide no information as to their source. More recently, mol. methods have targeted fecal anaerobes, which are much more abundant in humans and other mammals, and some strains appear to be assocd. with particular host sources. Next-generation sequencing and microbiome studies have created an unprecedented inventory of microbial communities assocd. with fecal sources, allowing reexamn. of which taxonomic groups are best suited as informative indicators. The use of new computational methods, such as oligotyping coupled with well-established machine learning approaches, is providing new insights into patterns of host assocn. In this review we examine the basis for host-specificity and the rationale for using 16S rRNA gene targets for alternative indicators and highlight two taxonomic groups, Bacteroidales and Lachnospiraceae, which are rich in host-specific bacterial organisms. Finally, we discuss considerations for using alternative indicators for water quality assessments with a particular focus on detecting human sewage sources of contamination.
    109. 109
      McLeroy, K. R.; Bibeau, D.; Steckler, A.; Glanz, K. An Ecological Perspective on Health Promotion Programs Health Education Quarterly. 1988, 15 (4) 351– 377 DOI: 10.1177/109019818801500401
      109
      An ecological perspective on health promotion programs
      McLeroy K R; Bibeau D; Steckler A; Glanz K
      Health education quarterly (1988), 15 (4), 351-77 ISSN:0195-8402.
      During the past 20 years there has been a dramatic increase in societal interest in preventing disability and death in the United States by changing individual behaviors linked to the risk of contracting chronic diseases. This renewed interest in health promotion and disease prevention has not been without its critics. Some critics have accused proponents of life-style interventions of promoting a victim-blaming ideology by neglecting the importance of social influences on health and disease. This article proposes an ecological model for health promotion which focuses attention on both individual and social environmental factors as targets for health promotion interventions. It addresses the importance of interventions directed at changing interpersonal, organizational, community, and public policy, factors which support and maintain unhealthy behaviors. The model assumes that appropriate changes in the social environment will produce changes in individuals, and that the support of individuals in the population is essential for implementing environmental changes.
    110. 110
      Mupawaenda, A. C.; Chawatama, S.; Muvavarirwa, P. Gender issues in livestock production: a case study of Zimbabwe Trop. Anim. Health Prod. 2009, 41 (7) 1017 DOI: 10.1007/s11250-008-9268-5
      110
      Gender issues in livestock production: a case study of Zimbabwe
      Mupawaenda Anna C; Chawatama Shingirai; Muvavarirwa Plaxidia
      Tropical animal health and production (2009), 41 (7), 1017-21 ISSN:.
      The importance of main streaming gender issues in development programmes is now recognized by governments and development agents. This paper evaluates the role of gender in smallholder livestock production using Zimbabwe as a case study. It draws on several studies and assesses the gender dimension in terms of access and control, decision making and, division of labour. It is shown that for mainly traditional and historical reasons men continue to dominate livestock production although the situation is gradually changing. Men eclipse women in terms of ownership of more valuable stock, the making of decisions and the control of livestock production. This suggests that gender is important in livestock production and must be considered among other factors. The complexity of the system is noted but more gender disaggregated quantitative data is required if gender is to be effectively mainstreamed in livestock development programmes.
    111. 111
      WHO; UNICEF. WASH Post-2015: Proposed indicatorsfor drinkingwater, sanitation, and hygiene. WHO/UNICEF Joint Monitoring Programmefor Water Supply and Sanitation, Geneca. (2015.
      There is no corresponding record for this reference.

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