This was presented at the workshop "Better Targeting Food Safety Investments in Low and Middle Income Countries," hosted by A4NH and LSHTM.

1. Improving*child*health*and*development
2 the*role*of*infant*food*hygiene
Oliver'Cumming'
Assistant'Professor,'Environmental'Health
London'School'of'Hygiene'and'Tropical'Medicine
Better'Targeting'Food'Safety'Investments'in'Low'and'Middle'Income'Countries
Brussels,'24'May'2017

2. Diarrhoeal diseases
Between'2005J2015'(GBD2016):
Diarrhoeal disease'mortality'reduced'by'32%'J 1.3'million'deaths'(Murray'et'al'2016)
Diarrhoeal disease'morbidity'increased'by'7%'J 2.5'billion'cases'(Vos et'al'2016)
Mortality
Morbidity

3. Childhood*Enteric*Infection*Consequences
Environmental'Enteric'Dysfunction'
(Keusch et'al'2015)
Early'childhood'development'
(Piper'et'al'2017)
Growth'faltering'
(Checkley'et'al'2008)
Oral'vaccine'performance'
(Stich'et'al;'Cumming'et'al'2017)
SOURCE:'Garcia'1968
SOURCE:'Checkley'et'al'2008

4. Relative*importance*of*exposure*pathways
SOURCE:'Wagner'&'Lanoix
Foodborne?
Waterborne?
ExcretaJrelated?
“The'separation'of'food'and'water'as'exposure'
vehicles'for'attribution'purposes'is'often'useful'as'
different'regulatory'agencies'may'have'
responsibility'for'each'source.'However,'at'a'
community'level,'the'differentiation'between'food'
and'water'may'not'be'sensible'in'terms'of'how'
risks'are'managed.”
WHO,'2015;'pp.'120
Safe%Drinking%WaterSafe%Sanitation
Safe%hygiene

5. Enteric*infections*&*Foodborne*Burden*of*
Disease
90%*of*foodborne*disease*cases*”diarrhoeal disease*agents”
54%*of*foodborne*disease*burden*(DALYs)
55%*of*foodborne*mortality*(deaths)
43%*of*the*foodborne*disease*burden*among*children*under*5
SOURCE:'WHO'2015;'Pires et'al'2015

6. Toure et'al'(2013)
Faecal contamination'of'infant'foods
High'levels'of'faecal contamination'identified'in'microbiological'surveys'in:
Africa'(Mali'and'Kenya)
Asia''(Nepal'and'Bangladesh)
Often'more'contaminated'than'stored'drinking'water'within'same'households
Islam'et'al'2013

7. Identified*risk*factors*for*faecal contamination*of*
infant*food
Parvez et'al'2017
• Availability'of'safe'drinking'water'for'food'
preparation
• Contact'with'contaminated'hands,'surfaces,'utensils
• Presence'of'flies'
• Unsafe'storage'(containment,'temperature)
• Failure'to'wash'hands'before'preparation,'feeding
SOURCES:'Toure et'al'2012;'Islam'et'al'2013;'Gautam et'
al'2017;'Parvez et'al'2017

8. Critical*control*points
Islam'et'al'2014Prasad'2017

9. Changing*behaviour…
Pooled'analysis'of'42'studies'reported'that'only'19%'of'
the'global'population'washes'their'hands'after'contact'
with'excreta
(Freeman'et'al'2015)

10. Gautam et'al'2017
Effective'scaleable food'hygiene'BC'interventions

11. Policy*– working*across*sectors*and*interventions
Caregiver'hygiene
Safe'drinking'water
Safe'sanitation
Nutrition'
Infrastructure
Behaviour
Technology
Food
Health'extension

12. Research*Priorities
• National/local'studies'of'infant'hygiene'practices/risks
• Assessment'of'human'versus'zoonotic'sources
• Design'and'evaluation'of'scaleable interventions
• Quantification'of'health'impacts*'
*including(enteric(disease(consequences

13. The*Safe*Start*Trial*–
Kisumu,*Kenya
Design'and'evaluation'of'a'novel'infant'food'
hygiene'intervention
HighJdensity,'low'income'informal'settlements'
with'poor'environmental'conditions
Formative'environmental'and'clinical'
microbiological'assessment
Formative'mixed'methods'research'for'design'
and'optimisation of'intervention
cRCT to'evaluate'the'effect'on'infant'enteric'
infections'and'EED

14. PRELIMINARY*formative*results
Health
• High'prevalence'of'child'enteric'infections
• High'prevalence'of'careJgiver'reported'diarrhoea
Environment
• Stored'household'drinking'water'samples'contaminated
• Infant'food'samples'contaminated
Animals
• High'prevalence'of'poultry,'often'kept'indoor'at'night
Food%hygiene%
• Dynamic'caregiving'practices'present'challenges'for'intervention'and'safe'food'hygiene
• Unsafe'preparation,'storage,'reheating'and'feeding
• Very'poor'environmental'conditions'– water'&'sanitation

15. Conclusions
2017
• Contamination'of'infant'food'is'an'important'cause'
of'childhood'diarrhoea and'may'contribute'to'gut'
enteropathy,'undernutrition,'and'other'
consequences
• Effective'and'scaleable behaviour interventions'
needed'which'are'context'specific
• Poor'populations'in'high'density'urban'
environments'with'poor'sanitation'and'limited'
water'supplies'may'face'particular'risks
• Identify'and'target'vulnerable'population'groups'
with'
1909
• Infantile'diarrhoea is'usually'a'form'of'food'
poisoning
• Infection'usually'takes'place'at'the'home
• Urban'conditions'are'chiefly'hazardous'
• Infinite'care'is'needed'if'babies'are'to'be'
handJfed'in'towns
Greenwood'(1909)'–
“The'Causes'of'Infantile'Diarrhoeal Mortality”

16. Acknowledgements:
Dr Jane*Mumma (GLUK)
Dr Robert*Dreibelbis (LSHTM)
Dr Kelly*Baker*(University*of*Iowa)
DFID*funded*SHARE*Research*Programme
Thank*you!
oliver.cumming@lshtm.ac.uk