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Butzin-Dozier Z, Mertens AN, Tan ST, Granger DA, Pitchik HO, Il'yasova D, Tofail F, Rahman MZ, Spasojevic I, Shalev I, Ali S, Karim MR, Shahriar S, Famida SL, Shuman G, Shoab AK, Akther S, Hossen MS, Mutsuddi P, Rahman M, Unicomb L, Das KK, Yan L, Meyer A, Stewart CP, Hubbard AE, Naved RT, Parvin K, Mamun MMA, Luby SP, Colford JM, Fernald LCH, Lin A. Stress biomarkers and child development in young children in Bangladesh. Psychoneuroendocrinology 2024; 164:107023. [PMID: 38522372 DOI: 10.1016/j.psyneuen.2024.107023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2023] [Revised: 01/31/2024] [Accepted: 03/09/2024] [Indexed: 03/26/2024]
Abstract
BACKGROUND Hundreds of millions of children in low- and middle-income countries are exposed to chronic stressors, such as poverty, poor sanitation and hygiene, and sub-optimal nutrition. These stressors can have physiological consequences for children and may ultimately have detrimental effects on child development. This study explores associations between biological measures of chronic stress in early life and developmental outcomes in a large cohort of young children living in rural Bangladesh. METHODS We assessed physiologic measures of stress in the first two years of life using measures of the hypothalamic-pituitary-adrenal (HPA) axis (salivary cortisol and glucocorticoid receptor gene methylation), the sympathetic-adrenal-medullary (SAM) system (salivary alpha-amylase, heart rate, and blood pressure), and oxidative status (F2-isoprostanes). We assessed child development in the first two years of life with the MacArthur-Bates Communicative Development Inventories (CDI), the WHO gross motor milestones, and the Extended Ages and Stages Questionnaire (EASQ). We compared development outcomes of children at the 75th and 25th percentiles of stress biomarker distributions while adjusting for potential confounders using generalized additive models, which are statistical models where the outcome is predicted by a potentially non-linear function of predictor variables. RESULTS We analyzed data from 684 children (49% female) at both 14 and 28 months of age; we included an additional 765 children at 28 months of age. We detected a significant relationship between HPA axis activity and child development, where increased HPA axis activity was associated with poor development outcomes. Specifically, we found that cortisol reactivity (coefficient -0.15, 95% CI (-0.29, -0.01)) and post-stressor levels (coefficient -0.12, 95% CI (-0.24, -0.01)) were associated with CDI comprehension score, post-stressor cortisol was associated with combined EASQ score (coefficient -0.22, 95% CI (-0.41, -0.04), and overall glucocorticoid receptor methylation was associated with CDI expression score (coefficient -0.09, 95% CI (-0.17, -0.01)). We did not detect a significant relationship between SAM activity or oxidative status and child development. CONCLUSIONS Our observations reveal associations between the physiological evidence of stress in the HPA axis with developmental status in early childhood. These findings add to the existing evidence exploring the developmental consequences of early life stress.
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Affiliation(s)
| | - Andrew N Mertens
- School of Public Health, University of California, Berkeley, CA, USA
| | - Sophia T Tan
- Division of Infectious Diseases and Geographic Medicine, Stanford University, Stanford, CA, USA
| | - Douglas A Granger
- Institute for Interdisciplinary Salivary Bioscience Research, University of California, Irvine, CA, USA; Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Helen O Pitchik
- School of Public Health, University of California, Berkeley, CA, USA
| | | | - Fahmida Tofail
- International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Md Ziaur Rahman
- International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | | | - Idan Shalev
- Department of Biobehavioral Health, Pennsylvania State University, University Park, PA, USA
| | - Shahjahan Ali
- International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | | | - Sunny Shahriar
- International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | | | - Gabrielle Shuman
- School of Public Health, University of California, Berkeley, CA, USA
| | - Abul K Shoab
- International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Salma Akther
- International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Md Saheen Hossen
- International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Palash Mutsuddi
- International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Mahbubur Rahman
- International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Leanne Unicomb
- International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Kishor K Das
- International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | | | | | | | - Alan E Hubbard
- School of Public Health, University of California, Berkeley, CA, USA
| | | | - Kausar Parvin
- International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | | | - Stephen P Luby
- Division of Infectious Diseases and Geographic Medicine, Stanford University, Stanford, CA, USA
| | - John M Colford
- School of Public Health, University of California, Berkeley, CA, USA
| | - Lia C H Fernald
- School of Public Health, University of California, Berkeley, CA, USA
| | - Audrie Lin
- Department of Microbiology and Environmental Toxicology, University of California, Santa Cruz, CA, USA.
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Grembi JA, Nguyen AT, Riviere M, Heitmann GB, Patil A, Athni TS, Djajadi S, Ercumen A, Lin A, Crider Y, Mertens A, Karim MA, Islam MO, Miah R, Famida SL, Hossen MS, Mutsuddi P, Ali S, Rahman MZ, Hussain Z, Shoab AK, Haque R, Rahman M, Unicomb L, Luby SP, Arnold BF, Bennett A, Benjamin-Chung J. Influence of hydrometeorological risk factors on child diarrhea and enteropathogens in rural Bangladesh. PLoS Negl Trop Dis 2024; 18:e0012157. [PMID: 38739632 PMCID: PMC11115220 DOI: 10.1371/journal.pntd.0012157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 05/23/2024] [Accepted: 04/18/2024] [Indexed: 05/16/2024] Open
Abstract
BACKGROUND A number of studies have detected relationships between weather and diarrhea. Few have investigated associations with specific enteric pathogens. Understanding pathogen-specific relationships with weather is crucial to inform public health in low-resource settings that are especially vulnerable to climate change. OBJECTIVES Our objectives were to identify weather and environmental risk factors associated with diarrhea and enteropathogen prevalence in young children in rural Bangladesh, a population with high diarrheal disease burden and vulnerability to weather shifts under climate change. METHODS We matched temperature, precipitation, surface water, and humidity data to observational longitudinal data from a cluster-randomized trial that measured diarrhea and enteropathogen prevalence in children 6 months-5.5 years from 2012-2016. We fit generalized additive mixed models with cubic regression splines and restricted maximum likelihood estimation for smoothing parameters. RESULTS Comparing weeks with 30°C versus 15°C average temperature, prevalence was 3.5% higher for diarrhea, 7.3% higher for Shiga toxin-producing Escherichia coli (STEC), 17.3% higher for enterotoxigenic E. coli (ETEC), and 8.0% higher for Cryptosporidium. Above-median weekly precipitation (median: 13mm; range: 0-396mm) was associated with 29% higher diarrhea (adjusted prevalence ratio 1.29, 95% CI 1.07, 1.55); higher Cryptosporidium, ETEC, STEC, Shigella, Campylobacter, Aeromonas, and adenovirus 40/41; and lower Giardia, sapovirus, and norovirus prevalence. Other associations were weak or null. DISCUSSION Higher temperatures and precipitation were associated with higher prevalence of diarrhea and multiple enteropathogens; higher precipitation was associated with lower prevalence of some enteric viruses. Our findings emphasize the heterogeneity of the relationships between hydrometeorological variables and specific enteropathogens, which can be masked when looking at composite measures like all-cause diarrhea. Our results suggest that preventive interventions targeted to reduce enteropathogens just before and during the rainy season may more effectively reduce child diarrhea and enteric pathogen carriage in rural Bangladesh and in settings with similar meteorological characteristics, infrastructure, and enteropathogen transmission.
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Affiliation(s)
- Jessica A. Grembi
- Division of Infectious Diseases and Geographic Medicine, Department of Medicine, School of Medicine, Stanford University, Stanford, California, United States of America
| | - Anna T. Nguyen
- Department of Epidemiology and Population Health, School of Medicine, Stanford University, Stanford, California, United States of America
| | - Marie Riviere
- Department of Epidemiology and Population Health, School of Medicine, Stanford University, Stanford, California, United States of America
| | - Gabriella Barratt Heitmann
- Department of Epidemiology and Population Health, School of Medicine, Stanford University, Stanford, California, United States of America
| | - Arusha Patil
- Department of Epidemiology and Population Health, School of Medicine, Stanford University, Stanford, California, United States of America
| | - Tejas S. Athni
- Harvard Medical School, Harvard University, Boston, Massachusetts, United States of America
| | - Stephanie Djajadi
- Division of Epidemiology, School of Public Health, University of California, Berkeley, Berkeley, California, United States of America
| | - Ayse Ercumen
- Department of Forestry and Environmental Resources, North Carolina State University, Raleigh, North Carolina, United States of America
| | - Audrie Lin
- Department of Microbiology and Environmental Toxicology, University of California, Santa Cruz, Santa Cruz, California, United States of America
| | - Yoshika Crider
- King Center on Global Development, Stanford University, Stanford, California, United States of America
| | - Andrew Mertens
- Harvard Medical School, Harvard University, Boston, Massachusetts, United States of America
| | - Md Abdul Karim
- Infectious Disease Division, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Md Ohedul Islam
- Infectious Disease Division, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Rana Miah
- Infectious Disease Division, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Syeda L. Famida
- Infectious Disease Division, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Md Saheen Hossen
- Infectious Disease Division, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Palash Mutsuddi
- Infectious Disease Division, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Shahjahan Ali
- Infectious Disease Division, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Md Ziaur Rahman
- Infectious Disease Division, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Zahir Hussain
- Infectious Disease Division, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Abul K. Shoab
- Infectious Disease Division, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Rashidul Haque
- Infectious Disease Division, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Mahbubur Rahman
- Infectious Disease Division, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Leanne Unicomb
- Infectious Disease Division, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Stephen P. Luby
- Division of Infectious Diseases and Geographic Medicine, Department of Medicine, School of Medicine, Stanford University, Stanford, California, United States of America
| | - Benjamin F. Arnold
- Francis I. Proctor Foundation and Department of Ophthalmology, University of California, San Francisco, San Francisco, California, United States of America
| | - Adam Bennett
- Malaria Elimination Initiative, Global Health Group, University of California San Francisco, San Francisco, California, United States of America
- PATH, Seattle, Washington, United States of America
| | - Jade Benjamin-Chung
- Department of Epidemiology and Population Health, School of Medicine, Stanford University, Stanford, California, United States of America
- Chan Zuckerberg Biohub, San Francisco, California, United States of America
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Lin A, Mertens AN, Rahman MZ, Tan ST, Il'yasova D, Spasojevic I, Ali S, Stewart CP, Fernald LCH, Kim L, Yan L, Meyer A, Karim MR, Shahriar S, Shuman G, Arnold BF, Hubbard AE, Famida SL, Akther S, Hossen MS, Mutsuddi P, Shoab AK, Shalev I, Rahman M, Unicomb L, Heaney CD, Kariger P, Colford JM, Luby SP, Granger DA. A cluster-randomized trial of water, sanitation, handwashing and nutritional interventions on stress and epigenetic programming. Nat Commun 2024; 15:3572. [PMID: 38670986 PMCID: PMC11053067 DOI: 10.1038/s41467-024-47896-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 04/16/2024] [Indexed: 04/28/2024] Open
Abstract
A regulated stress response is essential for healthy child growth and development trajectories. We conducted a cluster-randomized trial in rural Bangladesh (funded by the Bill & Melinda Gates Foundation, ClinicalTrials.gov NCT01590095) to assess the effects of an integrated nutritional, water, sanitation, and handwashing intervention on child health. We previously reported on the primary outcomes of the trial, linear growth and caregiver-reported diarrhea. Here, we assessed additional prespecified outcomes: physiological stress response, oxidative stress, and DNA methylation (N = 759, ages 1-2 years). Eight neighboring pregnant women were grouped into a study cluster. Eight geographically adjacent clusters were block-randomized into the control or the combined nutrition, water, sanitation, and handwashing (N + WSH) intervention group (receiving nutritional counseling and lipid-based nutrient supplements, chlorinated drinking water, upgraded sanitation, and handwashing with soap). Participants and data collectors were not masked, but analyses were masked. There were 358 children (68 clusters) in the control group and 401 children (63 clusters) in the intervention group. We measured four F2-isoprostanes isomers (iPF(2α)-III; 2,3-dinor-iPF(2α)-III; iPF(2α)-VI; 8,12-iso-iPF(2α)-VI), salivary alpha-amylase and cortisol, and methylation of the glucocorticoid receptor (NR3C1) exon 1F promoter including the NGFI-A binding site. Compared with control, the N + WSH group had lower concentrations of F2-isoprostanes isomers (differences ranging from -0.16 to -0.19 log ng/mg of creatinine, P < 0.01), elevated post-stressor cortisol (0.24 log µg/dl; P < 0.01), higher cortisol residualized gain scores (0.06 µg/dl; P = 0.023), and decreased methylation of the NGFI-A binding site (-0.04; P = 0.037). The N + WSH intervention enhanced adaptive responses of the physiological stress system in early childhood.
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Affiliation(s)
- Audrie Lin
- Department of Microbiology and Environmental Toxicology, University of California, Santa Cruz, Santa Cruz, CA, USA.
| | - Andrew N Mertens
- School of Public Health, University of California, Berkeley, Berkeley, CA, USA
| | - Md Ziaur Rahman
- Infectious Diseases Division, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Sophia T Tan
- Division of Infectious Diseases and Geographic Medicine, Stanford University, Stanford, CA, USA
| | - Dora Il'yasova
- Department of Medicine, Duke University, Durham, NC, USA
| | - Ivan Spasojevic
- Department of Medicine, Duke University, Durham, NC, USA
- PK/PD Core Laboratory, Duke Cancer Institute, Durham, NC, USA
| | - Shahjahan Ali
- Infectious Diseases Division, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Christine P Stewart
- Institute for Global Nutrition, University of California Davis, Davis, CA, USA
| | - Lia C H Fernald
- School of Public Health, University of California, Berkeley, Berkeley, CA, USA
| | - Lisa Kim
- School of Public Health, University of California, Berkeley, Berkeley, CA, USA
| | | | | | - Md Rabiul Karim
- Infectious Diseases Division, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Sunny Shahriar
- Infectious Diseases Division, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Gabrielle Shuman
- School of Public Health, University of California, Berkeley, Berkeley, CA, USA
| | - Benjamin F Arnold
- Francis I. Proctor Foundation, University of California, San Francisco, CA, USA
| | - Alan E Hubbard
- School of Public Health, University of California, Berkeley, Berkeley, CA, USA
| | - Syeda L Famida
- Infectious Diseases Division, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Salma Akther
- Infectious Diseases Division, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Md Saheen Hossen
- Infectious Diseases Division, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Palash Mutsuddi
- Infectious Diseases Division, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Abul K Shoab
- Infectious Diseases Division, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Idan Shalev
- Department of Biobehavioral Health, Pennsylvania State University, University Park, PA, USA
| | - Mahbubur Rahman
- Infectious Diseases Division, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Leanne Unicomb
- Infectious Diseases Division, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Christopher D Heaney
- Department of Environmental Health and Engineering, Johns Hopkins University, Baltimore, MD, USA
| | - Patricia Kariger
- School of Public Health, University of California, Berkeley, Berkeley, CA, USA
| | - John M Colford
- School of Public Health, University of California, Berkeley, Berkeley, CA, USA
| | - Stephen P Luby
- Division of Infectious Diseases and Geographic Medicine, Stanford University, Stanford, CA, USA
| | - Douglas A Granger
- Institute for Interdisciplinary Salivary Bioscience Research, University of California, Irvine, Irvine, CA, USA
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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4
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Butzin-Dozier Z, Ji Y, Coyle J, Malenica I, McQuade ETR, Grembi JA, Platts-Mills JA, Houpt ER, Graham JP, Ali S, Rahman MZ, Alauddin M, Famida SL, Akther S, Hossen MS, Mutsuddi P, Shoab AK, Rahman M, Islam MO, Miah R, Taniuchi M, Liu J, Alauddin S, Stewart CP, Luby SP, Colford JM, Hubbard AE, Mertens AN, Lin A. Treatment Heterogeneity of Water, Sanitation, Hygiene, and Nutrition Interventions on Child Growth by Environmental Enteric Dysfunction and Pathogen Status for Young Children in Bangladesh. medRxiv 2024:2024.03.21.24304684. [PMID: 38585931 PMCID: PMC10996736 DOI: 10.1101/2024.03.21.24304684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/09/2024]
Abstract
Background Water, sanitation, hygiene (WSH), nutrition (N), and combined (N+WSH) interventions are often implemented by global health organizations, but WSH interventions may insufficiently reduce pathogen exposure, and nutrition interventions may be modified by environmental enteric dysfunction (EED), a condition of increased intestinal permeability and inflammation. This study investigated the heterogeneity of these treatments' effects based on individual pathogen and EED biomarker status with respect to child linear growth. Methods We applied cross-validated targeted maximum likelihood estimation and super learner ensemble machine learning to assess the conditional treatment effects in subgroups defined by biomarker and pathogen status. We analyzed treatment (N+WSH, WSH, N, or control) randomly assigned in-utero, child pathogen and EED data at 14 months of age, and child LAZ at 28 months of age. We estimated the difference in mean child length for age Z-score (LAZ) under the treatment rule and the difference in stratified treatment effect (treatment effect difference) comparing children with high versus low pathogen/biomarker status while controlling for baseline covariates. Results We analyzed data from 1,522 children, who had median LAZ of -1.56. We found that myeloperoxidase (N+WSH treatment effect difference 0.0007 LAZ, WSH treatment effect difference 0.1032 LAZ, N treatment effect difference 0.0037 LAZ) and Campylobacter infection (N+WSH treatment effect difference 0.0011 LAZ, WSH difference 0.0119 LAZ, N difference 0.0255 LAZ) were associated with greater effect of all interventions on growth. In other words, children with high myeloperoxidase or Campylobacter infection experienced a greater impact of the interventions on growth. We found that a treatment rule that assigned the N+WSH (LAZ difference 0.23, 95% CI (0.05, 0.41)) and WSH (LAZ difference 0.17, 95% CI (0.04, 0.30)) interventions based on EED biomarkers and pathogens increased predicted child growth compared to the randomly allocated intervention. Conclusions These findings indicate that EED biomarker and pathogen status, particularly Campylobacter and myeloperoxidase (a measure of gut inflammation), may be related to impact of N+WSH, WSH, and N interventions on child linear growth.
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Affiliation(s)
| | - Yunwen Ji
- School of Public Health, University of California, Berkeley, Berkeley, CA USA
| | - Jeremy Coyle
- School of Public Health, University of California, Berkeley, Berkeley, CA USA
| | - Ivana Malenica
- School of Public Health, University of California, Berkeley, Berkeley, CA USA
| | | | - Jessica Anne Grembi
- Division of Infectious Diseases and Geographic Medicine, Stanford University, Stanford, CA USA
| | | | - Eric R. Houpt
- School of Medicine, University of Virginia, Charlottesville, VA, USA
| | - Jay P. Graham
- School of Public Health, University of California, Berkeley, Berkeley, CA USA
| | - Shahjahan Ali
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Md Ziaur Rahman
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Mohammad Alauddin
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Syeda L. Famida
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Salma Akther
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Md. Saheen Hossen
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Palash Mutsuddi
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Abul K. Shoab
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Mahbubur Rahman
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Md. Ohedul Islam
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Rana Miah
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Mami Taniuchi
- School of Medicine, University of Virginia, Charlottesville, VA, USA
| | - Jie Liu
- School of Public Health, Qingdao University, Qingdao, China
| | | | | | - Stephen P. Luby
- Division of Infectious Diseases and Geographic Medicine, Stanford University, Stanford, CA USA
| | - John M. Colford
- School of Public Health, University of California, Berkeley, Berkeley, CA USA
| | - Alan E. Hubbard
- School of Public Health, University of California, Berkeley, Berkeley, CA USA
| | - Andrew N. Mertens
- School of Public Health, University of California, Berkeley, Berkeley, CA USA
| | - Audrie Lin
- Department of Microbiology and Environmental Toxicology, University of California, Santa Cruz, Santa Cruz, CA USA
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5
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Butzin-Dozier Z, Mertens AN, Tan ST, Granger DA, Pitchik HO, Il’yasova D, Tofail F, Rahman MZ, Spasojevic I, Shalev I, Ali S, Karim MR, Shahriar S, Famida SL, Shuman G, Shoab AK, Akther S, Hossen MS, Mutsuddi P, Rahman M, Unicomb L, Das KK, Yan L, Meyer A, Stewart CP, Hubbard A, Tabassum Naved R, Parvin K, Mamun MMA, Luby SP, Colford JM, Fernald LCH, Lin A. Stress Biomarkers and Child Development in Young Children in Bangladesh. medRxiv 2023:2023.09.12.23295429. [PMID: 37745503 PMCID: PMC10516093 DOI: 10.1101/2023.09.12.23295429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/26/2023]
Abstract
Background Hundreds of millions of children in low- and middle-income countries are exposed to chronic stressors, such as poverty, poor sanitation and hygiene, and sub-optimal nutrition. These stressors can have physiological consequences for children and may ultimately have detrimental effects on child development. This study explores associations between biological measures of chronic stress in early life and developmental outcomes in a large cohort of young children living in rural Bangladesh. Methods We assessed physiologic measures of stress in the first two years of life using measures of the hypothalamic-pituitary-adrenal (HPA) axis (salivary cortisol and glucocorticoid receptor gene methylation), the sympathetic-adrenal-medullary (SAM) system (salivary alpha-amylase, heart rate, and blood pressure), and oxidative status (F2-isoprostanes). We assessed child development in the first two years of life with the MacArthur-Bates Communicative Development Inventories (CDI), the WHO gross motor milestones, and the Extended Ages and Stages Questionnaire (EASQ). We compared development outcomes of children at the 75th and 25th percentiles of stress biomarker distributions while adjusting for potential confounders (hereafter referred to as contrasts) using generalized additive models, which are statistical models where the outcome is predicted by a potentially non-linear function of predictor variables. Results We analyzed data from 684 children (49% female) at both 14 and 28 months of age; we included an additional 765 children at 28 months of age. We observed 135 primary contrasts of the differences in child development outcomes at the 75th and 25th percentiles of stress biomarkers, where we detected significant relationships in 5 out of 30 contrasts (17%) of HPA axis activity, 1 out of 30 contrasts (3%) of SAM activity, and 3 out of 75 contrasts (4%) of oxidative status. These findings revealed that measures of HPA axis activity were associated with poor development outcomes. We did not find consistent evidence that markers of SAM system activity or oxidative status were associated with developmental status. Conclusions Our observations reveal associations between the physiological evidence of stress in the HPA axis with developmental status in early childhood. These findings add to the existing evidence exploring the developmental consequences of early life stress.
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Affiliation(s)
| | - Andrew N. Mertens
- School of Public Health, University of California, Berkeley, Berkeley, CA USA
| | - Sophia T. Tan
- Division of HIV, Infectious Diseases, and Global Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Douglas A. Granger
- Institute for Interdisciplinary Salivary Bioscience Research, University of California, Irvine, Irvine, CA USA
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD USA
| | - Helen O. Pitchik
- School of Public Health, University of California, Berkeley, Berkeley, CA USA
| | | | - Fahmida Tofail
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Md. Ziaur Rahman
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | | | - Idan Shalev
- Department of Biobehavioral Health, Pennsylvania State University, University Park, PA USA
| | - Shahjahan Ali
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | | | - Sunny Shahriar
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Syeda Luthfa Famida
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Gabrielle Shuman
- School of Public Health, University of California, Berkeley, Berkeley, CA USA
| | - Abul K. Shoab
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Salma Akther
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Md. Saheen Hossen
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Palash Mutsuddi
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Mahbubur Rahman
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Leanne Unicomb
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Kishor K. Das
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | | | | | | | - Alan Hubbard
- School of Public Health, University of California, Berkeley, Berkeley, CA USA
| | | | - Kausar Parvin
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Md. Mahfuz Al Mamun
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Stephen P. Luby
- Division of Infectious Diseases and Geographic Medicine, Stanford University, Stanford, CA USA
| | - John M. Colford
- School of Public Health, University of California, Berkeley, Berkeley, CA USA
| | - Lia C. H. Fernald
- School of Public Health, University of California, Berkeley, Berkeley, CA USA
| | - Audrie Lin
- Department of Microbiology and Environmental Toxicology, University of California, Santa Cruz, Santa Cruz, CA USA
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Jung DK, Tan ST, Hemlock C, Mertens AN, Stewart CP, Rahman MZ, Ali S, Raqib R, Grembi JA, Karim MR, Shahriar S, Roy AK, Abdelrahman S, Shoab AK, Famida SL, Hossen MS, Mutsuddi P, Akther S, Rahman M, Unicomb L, Hester L, Granger DA, Erhardt J, Naved RT, Al Mamun MM, Parvin K, Colford JM, Fernald LC, Luby SP, Dhabhar FS, Lin A. Micronutrient status during pregnancy is associated with child immune status in rural Bangladesh. Curr Dev Nutr 2023; 7:101969. [PMID: 37560460 PMCID: PMC10407622 DOI: 10.1016/j.cdnut.2023.101969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 06/26/2023] [Accepted: 06/30/2023] [Indexed: 08/11/2023] Open
Abstract
Background Poor immune function increases children's risk of infection and mortality. Several maternal factors during pregnancy may affect infant immune function during the postnatal period. Objectives We aimed to evaluate whether maternal micronutrients, stress, estriol, and immune status during the first or second trimester of pregnancy were associated with child immune status in the first two years after birth. Methods We conducted observational analyses within the water, sanitation, and hygiene (WASH) Benefits Bangladesh randomized controlled trial. We measured biomarkers in 575 pregnant women and postnatally in their children. Maternal biomarkers measured during the first and second trimester of pregnancy included nutrition status via vitamin D (25-hydroxy-D [25(OH)D]), ferritin, soluble transferrin receptor (sTfR), and retinol-binding protein (RBP); cortisol; estriol. Immune markers were assessed in pregnant women at enrollment and their children at ages 14 and 28 mo, including C-reactive protein (CRP), alpha-1-acid glycoprotein (AGP), and 13 cytokines (including IFN-γ). We generated a standardized sum score of log-transformed cytokines. We analyzed IFN-γ individually because it is a critical immunoregulatory cytokine. All outcomes were prespecified. We used generalized additive models and reported the mean difference and 95% confidence intervals at the 25th and 75th percentiles of exposure distribution. Results At child age 14 mo, concentrations of maternal RBP were inversely associated with the cytokine sum score in children (-0.34 adjusted difference between the 25th and 75th percentile [95% confidence interval -0.61, -0.07]), and maternal vitamin A deficiency was positively associated with the cytokine sum score in children (1.02 [0.13, 1.91]). At child age of 28 mo, maternal RBP was positively associated with IFN-γ in children (0.07 [0.01, 0.14]), whereas maternal vitamin A deficiency was negatively associated with child AGP (-0.07 [-0.13, -0.02]). Maternal iron deficiency was associated with higher AGP concentrations in children at age 14 mo (0.13 [0.04, 0.23]), and maternal sTfR concentrations were positively associated with child CRP concentrations at age 28 mo (0.18 [0, 0.36]). Conclusion Maternal deficiencies in vitamin A or iron during the first 2 trimesters of pregnancy may shape the trajectory of a child's immune status.
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Affiliation(s)
- Da Kyung Jung
- Division of Epidemiology and Biostatistics, School of Public Health, University of California Berkeley, Berkeley, CA, United States
| | - Sophia T. Tan
- Division of Infectious Diseases and Geographic Medicine, Stanford University, Stanford, CA, United States
| | - Caitlin Hemlock
- Division of Epidemiology and Biostatistics, School of Public Health, University of California Berkeley, Berkeley, CA, United States
| | - Andrew N. Mertens
- Division of Epidemiology and Biostatistics, School of Public Health, University of California Berkeley, Berkeley, CA, United States
| | - Christine P. Stewart
- Institute for Global Nutrition, University of California Davis, Davis, CA, United States
| | - Md Ziaur Rahman
- Environmental Interventions Unit, Infectious Diseases Division, icddr,b, Dhaka 1212, Bangladesh
| | - Shahjahan Ali
- Environmental Interventions Unit, Infectious Diseases Division, icddr,b, Dhaka 1212, Bangladesh
| | - Rubhana Raqib
- Environmental Interventions Unit, Infectious Diseases Division, icddr,b, Dhaka 1212, Bangladesh
| | - Jessica A. Grembi
- Division of Infectious Diseases and Geographic Medicine, Stanford University, Stanford, CA, United States
| | - Mohammed Rabiul Karim
- Environmental Interventions Unit, Infectious Diseases Division, icddr,b, Dhaka 1212, Bangladesh
| | - Sunny Shahriar
- Environmental Interventions Unit, Infectious Diseases Division, icddr,b, Dhaka 1212, Bangladesh
| | - Anjan Kumar Roy
- Environmental Interventions Unit, Infectious Diseases Division, icddr,b, Dhaka 1212, Bangladesh
| | - Sarah Abdelrahman
- Division of Epidemiology and Biostatistics, School of Public Health, University of California Berkeley, Berkeley, CA, United States
| | - Abul K. Shoab
- Environmental Interventions Unit, Infectious Diseases Division, icddr,b, Dhaka 1212, Bangladesh
| | - Syeda L. Famida
- Environmental Interventions Unit, Infectious Diseases Division, icddr,b, Dhaka 1212, Bangladesh
| | - Md Saheen Hossen
- Environmental Interventions Unit, Infectious Diseases Division, icddr,b, Dhaka 1212, Bangladesh
| | - Palash Mutsuddi
- Environmental Interventions Unit, Infectious Diseases Division, icddr,b, Dhaka 1212, Bangladesh
| | - Salma Akther
- Environmental Interventions Unit, Infectious Diseases Division, icddr,b, Dhaka 1212, Bangladesh
| | - Mahbubur Rahman
- Environmental Interventions Unit, Infectious Diseases Division, icddr,b, Dhaka 1212, Bangladesh
| | - Leanne Unicomb
- Environmental Interventions Unit, Infectious Diseases Division, icddr,b, Dhaka 1212, Bangladesh
| | - Lisa Hester
- Department of Medicine, University of Maryland, Baltimore, MD USA
| | - Douglas A. Granger
- Institute for Interdisciplinary Salivary Bioscience Research, University of California Irvine, Irvine, CA, United States
| | | | | | - Md Mahfuz Al Mamun
- Health System and Population Studies Division, icddr,b, Dhaka, Bangladesh
| | - Kausar Parvin
- Health System and Population Studies Division, icddr,b, Dhaka, Bangladesh
| | - John M. Colford
- Division of Epidemiology and Biostatistics, School of Public Health, University of California Berkeley, Berkeley, CA, United States
| | - Lia C.H. Fernald
- Division of Community Health Sciences, School of Public Health, University of California, Berkeley, Berkeley, CA, United States
| | - Stephen P. Luby
- Division of Infectious Diseases and Geographic Medicine, Stanford University, Stanford, CA, United States
| | - Firdaus S. Dhabhar
- Department of Psychiatry & Behavioral Sciences, Department of Microbiology and Immunology, Sylvester Comprehensive Cancer Center, Miller School of Medicine, University of Miami, Miami, FL, United States
| | - Audrie Lin
- Department of Microbiology and Environmental Toxicology, University of California, Santa Cruz, CA, United States
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7
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Lin A, Mertens AN, Arnold BF, Tan S, Lin J, Stewart CP, Hubbard AE, Ali S, Benjamin-Chung J, Shoab AK, Rahman MZ, Famida SL, Hossen MS, Mutsuddi P, Akther S, Rahman M, Unicomb L, Naved RT, Mamun MMA, Parvin K, Dhabhar FS, Kariger P, Fernald LC, Luby SP, Colford JM. Telomere length is associated with growth in children in rural Bangladesh. eLife 2021; 10:60389. [PMID: 34494545 PMCID: PMC8494482 DOI: 10.7554/elife.60389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 09/04/2021] [Indexed: 11/24/2022] Open
Abstract
Background: Previously, we demonstrated that a water, sanitation, handwashing, and nutritional intervention improved linear growth and was unexpectedly associated with shortened childhood telomere length (TL) (Lin et al., 2017). Here, we assessed the association between TL and growth. Methods: We measured relative TL in whole blood from 713 children. We reported differences between the 10th percentile and 90th percentile of TL or change in TL distribution using generalized additive models, adjusted for potential confounders. Results: In cross-sectional analyses, long TL was associated with a higher length-for-age Z score at age 1 year (0.23 SD adjusted difference in length-for-age Z score [95% CI 0.05, 0.42; FDR-corrected p-value = 0.01]). TL was not associated with other outcomes. Conclusions: Consistent with the metabolic telomere attrition hypothesis, our previous trial findings support an adaptive role for telomere attrition, whereby active TL regulation is employed as a strategy to address ‘emergency states’ with increased energy requirements such as rapid growth during the first year of life. Although short periods of active telomere attrition may be essential to promote growth, this study suggests that a longer overall initial TL setting in the first 2 years of life could signal increased resilience against future telomere erosion events and healthy growth trajectories. Funding: Funded by the Bill and Melinda Gates Foundation. Clinical trial number: NCT01590095
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Affiliation(s)
- Audrie Lin
- Division of Epidemiology and Biostatistics, School of Public Health, University of California, Berkeley, Berkeley, United States
| | - Andrew N Mertens
- Division of Epidemiology and Biostatistics, School of Public Health, University of California, Berkeley, Berkeley, United States
| | - Benjamin F Arnold
- Francis I. Proctor Foundation, University of California San Francisco, San Francisco, United States
| | - Sophia Tan
- Division of Epidemiology and Biostatistics, School of Public Health, University of California, Berkeley, Berkeley, United States
| | - Jue Lin
- Department of Biochemistry and Biophysics, University of California, San Francisco, San Francisco, United States
| | - Christine P Stewart
- Department of Nutrition, University of California, Davis, Davis, United States
| | - Alan E Hubbard
- Division of Epidemiology and Biostatistics, School of Public Health, University of California, Berkeley, Berkeley, United States
| | - Shahjahan Ali
- Infectious Disease Division, International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Jade Benjamin-Chung
- Department of Epidemiology & Population Health, Stanford University, Stanford, United States
| | - Abul K Shoab
- Infectious Disease Division, International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Md Ziaur Rahman
- Infectious Disease Division, International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Syeda L Famida
- Infectious Disease Division, International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Md Saheen Hossen
- Infectious Disease Division, International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Palash Mutsuddi
- Infectious Disease Division, International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Salma Akther
- Infectious Disease Division, International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Mahbubur Rahman
- Infectious Disease Division, International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Leanne Unicomb
- Infectious Disease Division, International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Ruchira Tabassum Naved
- Health System and Population Studies Division, International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Md Mahfuz Al Mamun
- Health System and Population Studies Division, International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Kausar Parvin
- Health System and Population Studies Division, International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Firdaus S Dhabhar
- Department of Psychiatry & Behavioral Sciences, Sylvester Comprehensive Cancer Center, Miller School of Medicine, University of Miami, Miami, United States
| | - Patricia Kariger
- Division of Community Health Sciences, School of Public Health, University of California, Berkeley, Berkeley, United States
| | - Lia Ch Fernald
- Division of Community Health Sciences, School of Public Health, University of California, Berkeley, Berkeley, United States
| | - Stephen P Luby
- Division of Infectious Diseases and Geographic Medicine, Stanford University, Stanford, United States
| | - John M Colford
- Division of Epidemiology and Biostatistics, School of Public Health, University of California, Berkeley, Berkeley, United States
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8
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Lin A, Ali S, Arnold BF, Rahman MZ, Alauddin M, Grembi J, Mertens AN, Famida SL, Akther S, Hossen MS, Mutsuddi P, Shoab AK, Hussain Z, Rahman M, Unicomb L, Ashraf S, Naser AM, Parvez SM, Ercumen A, Benjamin-Chung J, Haque R, Ahmed T, Hossain MI, Choudhury N, Jannat K, Alauddin ST, Minchala SG, Cekovic R, Hubbard AE, Stewart CP, Dewey KG, Colford JM, Luby SP. Effects of Water, Sanitation, Handwashing, and Nutritional Interventions on Environmental Enteric Dysfunction in Young Children: A Cluster-randomized, Controlled Trial in Rural Bangladesh. Clin Infect Dis 2021; 70:738-747. [PMID: 30963177 DOI: 10.1093/cid/ciz291] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Accepted: 04/04/2019] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND We hypothesized that drinking water, sanitation, handwashing (WSH), and nutritional interventions would improve environmental enteric dysfunction (EED), a potential contributor to stunting. METHODS Within a subsample of a cluster-randomized, controlled trial in rural Bangladesh, we enrolled pregnant women in 4 arms: control, WSH, child nutrition counseling plus lipid-based nutrient supplements (N), and nutrition plus WSH (N+WSH). Among the birth cohort, we measured biomarkers of gut inflammation (myeloperoxidase, neopterin), permeability (alpha-1-antitrypsin, lactulose, mannitol), and repair (regenerating gene 1β) at median ages 3, 14, and 28 months. Analysis was intention-to-treat. RESULTS We assessed 1512 children. At age 3 months, compared to controls, neopterin was reduced by nutrition (-0.21 log nmol/L; 95% confidence interval [CI], -.37, -.05) and N+WSH (-0.20 log nmol/L; 95% CI, -.34, -.06) interventions; similar reductions were observed at 14 months. At 3 months, all interventions reduced lactulose and mannitol (-0.60 to -0.69 log mmol/L). At 28 months, myeloperoxidase was elevated in the WSH and nutrition arms (0.23-0.27 log ng/mL) and lactulose was higher in the WSH arm (0.30 log mmol/L; 95% CI, .07, .53). CONCLUSIONS Reductions in permeability and inflammation at ages 3 and 14 months suggest that the interventions promoted healthy intestinal maturation; however, by 28 months, the WSH and nutrition arms showed elevated EED biomarkers. These results underscore the importance of developing a better understanding of EED pathophysiology and targeting interventions early in childhood, when they are likely to have the largest benefit to intestinal health. CLINICAL TRIALS REGISTRATION NCT01590095.
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Affiliation(s)
- Audrie Lin
- Division of Epidemiology and Biostatistics, School of Public Health, University of California-Berkeley
| | - Shahjahan Ali
- Infectious Diseases Division, International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Benjamin F Arnold
- Division of Epidemiology and Biostatistics, School of Public Health, University of California-Berkeley
| | - Md Ziaur Rahman
- Infectious Diseases Division, International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | | | - Jessica Grembi
- Division of Infectious Diseases and Geographic Medicine, Stanford University, California
| | - Andrew N Mertens
- Division of Epidemiology and Biostatistics, School of Public Health, University of California-Berkeley
| | - Syeda L Famida
- Infectious Diseases Division, International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Salma Akther
- Infectious Diseases Division, International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Md Saheen Hossen
- Infectious Diseases Division, International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Palash Mutsuddi
- Infectious Diseases Division, International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Abul K Shoab
- Infectious Diseases Division, International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Zahir Hussain
- Infectious Diseases Division, International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Mahbubur Rahman
- Infectious Diseases Division, International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Leanne Unicomb
- Infectious Diseases Division, International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Sania Ashraf
- Infectious Diseases Division, International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Abu Mohd Naser
- Infectious Diseases Division, International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Sarker M Parvez
- Infectious Diseases Division, International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Ayse Ercumen
- Division of Epidemiology and Biostatistics, School of Public Health, University of California-Berkeley
| | - Jade Benjamin-Chung
- Division of Epidemiology and Biostatistics, School of Public Health, University of California-Berkeley
| | - Rashidul Haque
- Infectious Diseases Division, International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Tahmeed Ahmed
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Md Iqbal Hossain
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Nuzhat Choudhury
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Kaniz Jannat
- Infectious Diseases Division, International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Sarah T Alauddin
- Department of Chemistry, Wagner College, Staten Island, New York
| | | | - Rabije Cekovic
- Department of Chemistry, Wagner College, Staten Island, New York
| | - Alan E Hubbard
- Division of Epidemiology and Biostatistics, School of Public Health, University of California-Berkeley
| | | | | | - John M Colford
- Division of Epidemiology and Biostatistics, School of Public Health, University of California-Berkeley
| | - Stephen P Luby
- Division of Infectious Diseases and Geographic Medicine, Stanford University, California
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9
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Grembi JA, Lin A, Karim MA, Islam MO, Miah R, Arnold BF, McQuade ETR, Ali S, Rahman MZ, Hussain Z, Shoab AK, Famida SL, Hossen MS, Mutsuddi P, Rahman M, Unicomb L, Haque R, Taniuchi M, Liu J, Platts-Mills JA, Holmes SP, Stewart CP, Benjamin-Chung J, Colford JM, Houpt ER, Luby SP. Effect of water, sanitation, handwashing and nutrition interventions on enteropathogens in children 14 months old: a cluster-randomized controlled trial in rural Bangladesh. J Infect Dis 2020; 227:jiaa549. [PMID: 32861214 PMCID: PMC9891429 DOI: 10.1093/infdis/jiaa549] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 08/25/2020] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND We evaluated the impact of low-cost water, sanitation, handwashing (WSH) and child nutrition interventions on enteropathogen carriage in the WASH Benefits cluster-randomized controlled trial in rural Bangladesh. METHODS We analyzed 1411 routine fecal samples from children 14±2 months old in the WSH (n = 369), nutrition counseling plus lipid-based nutrient supplement (n = 353), nutrition plus WSH (n = 360), and control (n = 329) arms for 34 enteropathogens using quantitative PCR. Outcomes included the number of co-occurring pathogens; cumulative quantity of four stunting-associated pathogens; and prevalence and quantity of individual pathogens. Masked analysis was by intention-to-treat. RESULTS 326 (99.1%) control children had one or more enteropathogens detected (mean 3.8±1.8). Children receiving WSH interventions had lower prevalence and quantity of individual viruses than controls (prevalence difference for norovirus: -11% [95% confidence interval [CI], -5 to -17%]; sapovirus: -9% [95%CI, -3 to -15%]; and adenovirus 40/41: -9% [95%CI, -2 to - 15%]). There was no difference in bacteria, parasites, or cumulative quantity of stunting-associated pathogens between controls and any intervention arm. CONCLUSIONS WSH interventions were associated with fewer enteric viruses in children aged 14 months. Different strategies are needed to reduce enteric bacteria and parasites at this critical young age.
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Affiliation(s)
- Jessica A Grembi
- Division of Infectious Diseases and Geographic Medicine, Stanford University, Stanford, California, USA
| | - Audrie Lin
- Division of Epidemiology and Biostatistics, School of Public Health, University of California, Berkeley, Berkeley, California, USA
| | - Md Abdul Karim
- Infectious Diseases Division, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Md Ohedul Islam
- Infectious Diseases Division, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Rana Miah
- Infectious Diseases Division, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Benjamin F Arnold
- Francis I. Proctor Foundation, University of California, San Francisco, San Francisco, California, USA
| | - Elizabeth T Rogawski McQuade
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, Virginia, USA
| | - Shahjahan Ali
- Infectious Diseases Division, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Md Ziaur Rahman
- Infectious Diseases Division, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Zahir Hussain
- Infectious Diseases Division, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Abul K Shoab
- Infectious Diseases Division, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Syeda L Famida
- Infectious Diseases Division, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Md Saheen Hossen
- Infectious Diseases Division, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Palash Mutsuddi
- Infectious Diseases Division, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Mahbubur Rahman
- Infectious Diseases Division, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Leanne Unicomb
- Infectious Diseases Division, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Rashidul Haque
- Infectious Diseases Division, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Mami Taniuchi
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, Virginia, USA
| | - Jie Liu
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, Virginia, USA
| | - James A Platts-Mills
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, Virginia, USA
| | - Susan P Holmes
- Department of Statistics, Stanford University, Stanford, California, USA
| | - Christine P Stewart
- Institute for Global Nutrition, University of California, Davis, Davis, California, USA
| | - Jade Benjamin-Chung
- Division of Epidemiology and Biostatistics, School of Public Health, University of California, Berkeley, Berkeley, California, USA
| | - John M Colford
- Division of Epidemiology and Biostatistics, School of Public Health, University of California, Berkeley, Berkeley, California, USA
| | - Eric R Houpt
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, Virginia, USA
| | - Stephen P Luby
- Division of Infectious Diseases and Geographic Medicine, Stanford University, Stanford, California, USA
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10
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Unicomb L, Horng L, Alam MU, Halder AK, Shoab AK, Ghosh PK, Islam MK, Opel A, Luby SP. Health-Care Facility Water, Sanitation, and Health-Care Waste Management Basic Service Levels in Bangladesh: Results from a Nation-Wide Survey. Am J Trop Med Hyg 2019; 99:916-923. [PMID: 30152311 DOI: 10.4269/ajtmh.18-0133] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
We conducted a nationally representative cross-sectional study of 875 health-care facilities (HCFs) to determine water, sanitation, and health-care waste disposal service levels in Bangladesh for doctors, staff, and patients/caregivers in 2013. We calculated proportions and prevalence ratios to compare urban versus rural and government versus other HCFs. We report World Health Organization (WHO)-defined basic HCF service levels. The most common HCF was nongovernmental private (80%, 698/875), with an average of 25 beds and 12 admissions per day. There was an improved water source inside the HCF for doctors (79%, 95% confidence intervals [CI]: 75, 82), staff (59%, 95% CI: 55, 64), and patients/caregivers (59%, 95% CI: 55, 63). Improved toilets for doctors (81%, 95% CI: 78, 85) and other staff (73%, 95% CI: 70, 77) were more common than for patients/caregivers (54%, 95% CI: 50, 58). Forty-three percentage (434/875) of HCFs had no disposal method for health-care waste. More urban than rural and more government than other HCFs had an improved water source on the premises and improved toilets for staff. WHO-defined basic service levels were detected in > 90% of HCFs for drinking water, among 46-77% for sanitation, and 68% for handwashing at point of care but 26% near toilets. Forty-seven percentage of HCFs attained basic health-care waste management service levels. Patient/caregiver access to water, sanitation, and hygiene facilities is inadequate in many HCFs across Bangladesh. Improving facilities for this group should be an integral part of accreditation.
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Affiliation(s)
- Leanne Unicomb
- Environmental Interventions Unit, Enteric and Respiratory Infections Program, Infectious Disease Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Lily Horng
- Stanford University, Stanford, California
| | - Mahbub-Ul Alam
- Environmental Interventions Unit, Enteric and Respiratory Infections Program, Infectious Disease Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Amal K Halder
- Environmental Interventions Unit, Enteric and Respiratory Infections Program, Infectious Disease Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Abul K Shoab
- Environmental Interventions Unit, Enteric and Respiratory Infections Program, Infectious Disease Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Probir K Ghosh
- Environmental Interventions Unit, Enteric and Respiratory Infections Program, Infectious Disease Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
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11
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Nizame FA, Alam MU, Masud AA, Shoab AK, Opel A, Islam MK, Luby SP, Unicomb L. Hygiene in Restaurants and among Street Food Vendors in Bangladesh. Am J Trop Med Hyg 2019; 101:566-575. [PMID: 31333161 DOI: 10.4269/ajtmh.18-0896] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Poor hand hygiene and food handling put consumers of restaurant and street food at risk of enteric disease, especially in low-income countries. This study aimed to collect hygiene indicators from a nationally representative sample of restaurants and street food vendors. The field team collected data from 50 rural villages and 50 urban administrative units (mahallas). We explored restaurant service staff, cook, and food vendor hygiene practices (N = 300 restaurants and 600 street food vendors), by observing hygiene facilities, food handling, and utensil cleaning. A qualitative assessment explored perceptions of hygiene related to food handling. During restaurant spot checks, 91% (273/300) had soap and water at handwashing location for customers but in only 33% (100) at locations convenient for restaurant staff. Among street food-vending stalls, 11% (68/600) had soap and water when observed. During 90-minute structured observations, cooks used soap to wash hands on 14/514 (3%) of occasions before food preparation, 6/82 (8%) occasions after cutting fish/meat/vegetables, 3/71 (4%) occasions before serving food, and 0/49 (0%) occasions) before hand-mashing food/salad preparation; no street food vendors washed hands with soap during these food-handling events. Most of the qualitative study participants perceived that customers select a vendor based on tastiness of the food, whereas no one mentioned the importance of food hygiene. The study demonstrates widespread poor hygiene and food-handling practices in restaurants and among food vendors. Based on our study findings, we proposed a food premises Hygiene Investigation Model to create action plans to improve food safety.
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Affiliation(s)
- Fosiul A Nizame
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Mahbub U Alam
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Abdullah A Masud
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Abul K Shoab
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | | | | | | | - Leanne Unicomb
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
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12
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Delea MG, Nagel CL, Thomas EA, Halder AK, Amin N, Shoab AK, Freeman MC, Unicomb L, Clasen TF. Comparison of respondent-reported and sensor-recorded latrine utilization measures in rural Bangladesh: a cross-sectional study. Trans R Soc Trop Med Hyg 2018; 111:308-315. [PMID: 29126213 PMCID: PMC5914303 DOI: 10.1093/trstmh/trx058] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Accepted: 10/11/2017] [Indexed: 11/26/2022] Open
Abstract
Background Health improvements realized through sanitation are likely achieved through high levels of facilities utilization by all household members. However, measurements of sanitation often rely on either the presence of latrines, which does not guarantee use, or respondent-reported utilization of sanitation facilities, which is prone to response bias. Overstatement of sanitation metrics limits the accuracy of program outcome measures, and has implications for the interpretation of related health impact data. Methods We conducted a cross-sectional study of 213 households in 14 village water, sanitation and hygiene committee clusters throughout rural Bangladesh and used a combined data- and relationship-scale approach to assess agreement between respondent-reported latrine utilization and sensor-recorded measurement. Results Four-day household-level respondent-reported defecation averaged 28 events (inter-quartile range [IQR] 20–40), while sensor-recorded defecation averaged 17 events (IQR 11–29). Comparative analyses suggest moderately high accuracy (bias correction factor=0.84), but imprecision in the data (broad scatter of data, Pearson’s r=0.35) and thus only weak concordance between measures (ρc=0.29 [95% BCa CI 0.15 to 0.43]). Conclusions Respondent-reported latrine utilization data should be interpreted with caution, as evidence suggests use is exaggerated. Coupling reported utilization data with objective measures of use may aid in the estimation of latrine use.
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Affiliation(s)
- Maryann G Delea
- Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Corey L Nagel
- School of Public Health, Oregon Health and Science University, Portland State University, Portland, OR, USA
| | - Evan A Thomas
- School of Public Health, Oregon Health and Science University, Portland State University, Portland, OR, USA
| | - Amal K Halder
- Environmental Intervention Unit, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Nuhu Amin
- Environmental Intervention Unit, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Abul K Shoab
- Environmental Intervention Unit, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Matthew C Freeman
- Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Leanne Unicomb
- Environmental Intervention Unit, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Thomas F Clasen
- Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
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13
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Islam M, Ercumen A, Ashraf S, Rahman M, Shoab AK, Luby SP, Unicomb L. Unsafe disposal of feces of children <3 years among households with latrine access in rural Bangladesh: Association with household characteristics, fly presence and child diarrhea. PLoS One 2018; 13:e0195218. [PMID: 29621289 PMCID: PMC5886761 DOI: 10.1371/journal.pone.0195218] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Accepted: 03/02/2018] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Young children frequently defecate in the living environment in low-income countries. Unsafe child feces disposal has been associated with risk of diarrhea. Additionally, reported practices can underestimate socially undesirable unhygienic behaviors. This analysis aimed to assess (1) the sensitivity of reported child feces disposal practices as an indicator for observed presence of human feces in the domestic environment, (2) household characteristics associated with reported unsafe feces disposal and (3) whether unsafe feces disposal is associated with fly presence and diarrhea among children <3 years. METHODS We recorded caregiver-reported feces disposal practices for children <3 years; unsafe disposal was defined as feces put/rinsed into a drain, ditch, bush or garbage heap or left on the ground and safe disposal as feces put/rinsed into latrine or specific pit or buried. We conducted spot checks for human feces, counted flies in the compound and recorded caregiver-reported child diarrhea prevalence among 803 rural Bangladeshi households. We assessed associations using generalized estimating equations (GEE) and generalized linear models (GLM) with robust standard errors. RESULTS Unsafe disposal of child feces was reported by 80% of households. Reported disposal practices had high sensitivity (91%) but low positive predictive value (15%) as an indicator of observed feces in the compound. Unsafe disposal was more common among households that reported daily adult open defecation (PR: 1.13, 1.02-1.24) and had children defecating in a nappy or on the ground versus in a potty (PR: 2.92, 1.98-4.32), and less common in households where adults reported always defecating in latrines (PR: 0.91, 0.84-0.98). The presence of observed human feces was similarly associated with these household characteristics. Reported unsafe feces disposal or observed human feces were not associated with fly detection or child diarrhea. CONCLUSION Despite access to on-site sanitation, unsafe child feces disposal was reported by the majority of households. However, this practices was not associated with diarrhea; suggesting that child feces may not be the most important fecal exposure. Before resources are invested to improve child feces management practices, studies should explore whether these contribute meaningfully to risk of enteric disease.
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Affiliation(s)
- Mahfuza Islam
- Environmental Intervention Unit, Enteric and Respiratory Infections Program, Infectious Disease Division, International Centre for Diarrheal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Ayse Ercumen
- University of California, Berkeley, CA, United States of America
| | - Sania Ashraf
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America
| | - Mahbubur Rahman
- Environmental Intervention Unit, Enteric and Respiratory Infections Program, Infectious Disease Division, International Centre for Diarrheal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Abul K. Shoab
- Environmental Intervention Unit, Enteric and Respiratory Infections Program, Infectious Disease Division, International Centre for Diarrheal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Stephen P. Luby
- Woods Institute for the Environment, Stanford University, Stanford, United States of America
| | - Leanne Unicomb
- Environmental Intervention Unit, Enteric and Respiratory Infections Program, Infectious Disease Division, International Centre for Diarrheal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
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Lin A, Arnold BF, Mertens AN, Lin J, Benjamin-Chung J, Ali S, Hubbard AE, Stewart CP, Shoab AK, Rahman MZ, Hossen MS, Mutsuddi P, Famida SL, Akther S, Rahman M, Unicomb L, Dhabhar FS, Fernald LCH, Colford JM, Luby SP. Effects of water, sanitation, handwashing, and nutritional interventions on telomere length among children in a cluster-randomized controlled trial in rural Bangladesh. eLife 2017; 6:29365. [PMID: 28980942 PMCID: PMC5675593 DOI: 10.7554/elife.29365] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Accepted: 10/03/2017] [Indexed: 01/17/2023] Open
Abstract
Background: Shorter childhood telomere length (TL) and more rapid TL attrition are widely regarded as manifestations of stress. However, the potential effects of health interventions on child TL are unknown. We hypothesized that a water, sanitation, handwashing (WSH), and nutritional intervention would slow TL attrition during the first two years of life. Methods: In a trial in rural Bangladesh, we randomized geographical clusters of pregnant women into individual water treatment, sanitation, handwashing, nutrition, combined WSH, combined nutrition plus WSH (N + WSH), or control arms. We conducted a substudy enrolling children from the control arm and the N + WSH intervention arm. Participants and outcome assessors were not masked; analyses were masked. Relative TL was measured at 1 and 2 years after intervention, and the change in relative TL was reported. Analysis was intention-to-treat. Results: Between May 2012 and July 2013, in the overall trial, we randomized 720 geographical clusters of 5551 pregnant women to a control or an intervention arm. In this substudy, after 1 year of intervention, we assessed a total of 662 children (341 intervention and 321 control) and 713 children after 2 years of intervention (383 intervention and 330 control). Children in the intervention arm had significantly shorter relative TL compared with controls after 1 year of intervention (difference −163 base pairs (bp), p=0.001). Between years 1 and 2, TL increased in the intervention arm (+76 bp) and decreased in the controls (−23 bp) (p=0.050). After 2 years, there was no difference between the arms (p=0.305). Conclusions: Our unexpected finding of increased telomere attrition during the first year of life in the intervention group suggests that rapid telomere attrition during this critical period could reflect the improved growth in the intervention group, rather than accumulated stress. Funding: Funded by The Bill and Melinda Gates Foundation. Clinical trial number: NCT01590095. Stress negatively affects health by causing changes in cells. As a result, excess stress may predispose people to fall ill more often or age faster. It is difficult to measure stress. Some studies suggest that measuring the ends of chromosomes, known as telomeres, may be one way to measure stress. Like the plastic tips on shoelaces, telomeres protect chromosomes from fraying. All peoples’ telomeres shorten over their lifetime with each cell division. Many studies show that telomeres shorten faster in people who experience more stress. When telomeres become too short, cells die faster without being replaced, and the body ages. Most studies on telomere length have looked at adults. Few studies have looked at children early in life or asked whether there are ways to intervene to stop or reverse stress-related telomere shortening. The first two years of life are a crucial period for the developing brain and immune system, which could set children on a lifelong course toward health or disease. Young children living in low-resource settings often encounter many sources of stress, like poor nutrition, infectious diseases or violence. Studies are needed to determine if interventions in early childhood aimed at reducing some sources of stress improve telomere length or long-term health. Now, Lin et al. show that interventions to provide safe water, sanitation, handwashing facilities, and better nutrition to children in rural Bangladesh unexpectedly shortened telomeres. As part of a larger study, pregnant women in rural Bangladesh were divided, at random, into groups. One group received a suite of interventions, which included more sanitary toilets, handwashing facilities, and nutritional supplements for their infants. Another group served as a control and did not receive this extra help. Lin et al. looked at telomere length, growth, and infections in a subset of 713 children whose mothers participated in the study. Children who got the extra help grew faster and were less likely to get diarrhea or parasitic infections than the children in the control group. Unexpectedly, children in the intervention group had shorter telomeres at 14 months of age than the children in the control group. Lin et al. suggest that the telomere shortening in the intervention group might be a consequence of rapid growth and immune system development in the first year of life rather than resulting from biological stress. More studies are needed to ask whether telomere shortening is indeed linked to faster growth and development early in life. The strong and unexpected findings highlight how little is known about how the length of telomeres can be used to predict future health or disease. Interpreting the length of telomeres over a person’s lifetime could prove more nuanced than originally thought.
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Affiliation(s)
- Audrie Lin
- School of Public Health, University of California, Berkeley, Berkeley, United States
| | - Benjamin F Arnold
- School of Public Health, University of California, Berkeley, Berkeley, United States
| | - Andrew N Mertens
- School of Public Health, University of California, Berkeley, Berkeley, United States
| | - Jue Lin
- Department of Biochemistry and Biophysics, University of California, San Francisco, San Francisco, United States
| | - Jade Benjamin-Chung
- School of Public Health, University of California, Berkeley, Berkeley, United States
| | - Shahjahan Ali
- Infectious Disease Division, International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Alan E Hubbard
- School of Public Health, University of California, Berkeley, Berkeley, United States
| | - Christine P Stewart
- Department of Nutrition, University of California, Davis, Davis, United States
| | - Abul K Shoab
- Infectious Disease Division, International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Md Ziaur Rahman
- Infectious Disease Division, International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Md Saheen Hossen
- Infectious Disease Division, International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Palash Mutsuddi
- Infectious Disease Division, International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Syeda L Famida
- Infectious Disease Division, International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Salma Akther
- Infectious Disease Division, International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Mahbubur Rahman
- Infectious Disease Division, International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Leanne Unicomb
- Infectious Disease Division, International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Firdaus S Dhabhar
- Sylvester Comprehensive Cancer Center, Department of Psychiatry and Behavioral Sciences, Miller School of Medicine, University of Miami, Miami, United States
| | - Lia C H Fernald
- School of Public Health, University of California, Berkeley, Berkeley, United States
| | - John M Colford
- School of Public Health, University of California, Berkeley, Berkeley, United States
| | - Stephen P Luby
- Division of Infectious Diseases and Geographic Medicine, Stanford University, Stanford, United States
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Alam MU, Luby SP, Halder AK, Islam K, Opel A, Shoab AK, Ghosh PK, Rahman M, Mahon T, Unicomb L. Menstrual hygiene management among Bangladeshi adolescent schoolgirls and risk factors affecting school absence: results from a cross-sectional survey. BMJ Open 2017; 7:e015508. [PMID: 28694347 PMCID: PMC5541609 DOI: 10.1136/bmjopen-2016-015508] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2016] [Revised: 05/08/2017] [Accepted: 05/10/2017] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Many adolescent girls in low-income and middle-income countries lack appropriate facilities and support in school to manage menstruation. Little research has been conducted on how menstruation affects school absence. This study examines the association of menstrual hygiene management knowledge, facilities and practice with absence from school during menstruation among Bangladeshi schoolgirls. METHODS We conducted a nationally representative, cross-sectional study in Bangladeshi schools from March to June 2013 among girls 11 to 17 years old who reached menarche. We sampled 700 schools from 50 urban and 50 rural clusters using a probability proportional to size technique. We interviewed 2332 schoolgirls and conducted spot checks in each school for menstrual hygiene facilities. To assess factors associated with reported school absence, we estimated adjusted prevalence difference (APD) for controlling confounders' effect using generalised estimating equations to account for school-level clustering. RESULTS Among schoolgirls who reached menarche, 41% (931) reported missing school, an average of 2.8 missed days per menstrual cycle. Students who felt uncomfortable at school during menstruation (99% vs 32%; APD=58%; CI 54 to 63) and who believed menstrual problems interfere with school performance (64% vs 30%; APD=27; CI 20 to 33) were more likely to miss school during menstruation than those who did not. School absence during menstruation was less common among girls attending schools with unlocked toilet for girls (35% vs 43%; APD=-5.4; CI -10 to -1.6). School absence was more common among girls who were forbidden from any activities during menstruation (41% vs 33%; APD=9.1; CI 3.3 to 14). CONCLUSION Risk factors for school absence included girl's attitude, misconceptions about menstruation, insufficient and inadequate facilities at school, and family restriction. Enabling girls to manage menstruation at school by providing knowledge and management methods prior to menarche, privacy and a positive social environment around menstrual issues has the potential to benefit students by reducing school absence.
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Affiliation(s)
- Mahbub-Ul Alam
- Environmental Interventions Unit, Infectious Disease Division, International Center for Diarrheal Disease Research, Dhaka, Bangladesh
| | - Stephen P Luby
- Environmental Interventions Unit, Infectious Disease Division, International Center for Diarrheal Disease Research, Dhaka, Bangladesh
- Stanford Woods Institute for the Environment, Stanford University, Stanford, California, USA
| | - Amal K Halder
- Environmental Interventions Unit, Infectious Disease Division, International Center for Diarrheal Disease Research, Dhaka, Bangladesh
| | | | | | - Abul K Shoab
- Environmental Interventions Unit, Infectious Disease Division, International Center for Diarrheal Disease Research, Dhaka, Bangladesh
| | - Probir K Ghosh
- Environmental Interventions Unit, Infectious Disease Division, International Center for Diarrheal Disease Research, Dhaka, Bangladesh
| | - Mahbubur Rahman
- Environmental Interventions Unit, Infectious Disease Division, International Center for Diarrheal Disease Research, Dhaka, Bangladesh
| | | | - Leanne Unicomb
- Environmental Interventions Unit, Infectious Disease Division, International Center for Diarrheal Disease Research, Dhaka, Bangladesh
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