CONTAMINATION OF TODDLERS WITH P0l!|lSW3y-'r?E,eES

Fecal Contamination of Shanty Town Toddlers in Households with feccs-to-mouth episodes were performed with the following 37°C under microaerophilic conditions. Camp.yJb.&S§jjgj&spe- variables: number of fowl, hours in the house/12 hours, and cics were identified based on colony morphojjjgy. oxidase Non-corralled Poultry, Lima, Peru number poultry stools/12 hours. production, and spiral appearance in the GranTsfain. 10 Poultry Raising Practices and Beliefs GRACE S. MARQUIS, MS, GLADYS VENTURA, BS, ROBERT H. GILMAN, MD, ESPERANZA PORRAS, BS, Results o ELBA MIRANDA, MS, Luz CARBAJAL, MS, AND MARTA PENTAFIEL, BS We surveyed a group of !08 families living in Las Pampas de San Juan to document their practices and beliefs regarding Direct Observation in the Homes w the raising of chickens and other fowl. The survey identified The interaction between toddlers and poult© was ob- Abstract: We used direct observer techniques to measure the association between feces-to-mouth contamination and the number the reasons families gave for raising or not raising poultry, served for a total of 119 hours in 10 Huascar hoiisthoja's. The frequency with which toddlcr-agcd children were contaminated by of stools deposited in the house (r - 0.66). For each additional their beliefs about corralling the poultry, and the effect that majority of the poultry were chickens (fowWVbusfc = 5:4. poultry (trees in homes in a peri-urban shanty town in Lima, Peru. chicken stool deposited during the day, there was an average confinement has on the growth and the health of the animal, chickens/house = 4.4). Three out of 10 families also had The mean number of fowl was 5.4 (SD 3.11. with 10.0 home ducks and turkeys. Chickens and ducks only were allowed to poultry defecations per 12 hours. Toddlers' hand contact with We collected feecs from 68 infected chickens and found viable compared to buying them commercially, and the mothers' roam freely through the house for about one-third of the poultry feces occurred a mean of 2.9 (SD 3.0) times/12 hours. A mean Cwnpytobacler jejuni for up to 48 hours after deposition. Yet, a perception concerning whether poultry roaming within the 12-hour observation period (Table 1). The number of poultry of 3.9 (SD 4.6) feces-to-mouth episodes per houschold/12 hours survey of 108 families demonstrated that free-roaming poultry were house presented a health risk to young children. and the time they were in the house were correlated (r = 0.64), as were the number of observed stools and the time the occurred both by direct hand-to-mouth contamination and indirectly often not thought of as a health risk for children. An intervention Socioeconomic Data by handling soiled objects which were then placed in the mouth. program to reduce oral-fecal contamination should emphasize that all animals spent within the house (r = 0.86). There was a strong correlation between feces-to-hand contamination poultry be corralled and not allowed access into the house. [Am 3 As part of a longitudinal study of Enterobitts vermicu- The children had approximately three feces-to-hand and feces-to-mouth contamination (r - 0.94). There was also an Public Health I99O;80:146-149.) laris. 121 randomly selected families from Huascar were episodes per 12 hours (Table I). The risk of feces-to-hand included in a socioeconomic survey. The same data were contamination was from both fresh stool and from that collected for the Pampas families that participated in the deposited several days previously but not removed from the poultry raising practices survey. The socioeconomic survey household surfaces. In three households where no observed Introduction shanty towns): Huascar, Canto Grande'' and Las Pampas dc detailed age, sex. level of education, and occupation of all defecations occurred, hand and oral contamination still San Juan, San Juan de Miraflores, in Lima Peru. The majority members of the family. Questions on housing quality in- Diarrhea! disease is an important factor in Ihe infection- happened with stools that had been deposited prior to the day of the study population are rural immigrants who are daily cluded the materials used to build the house, number of of observation. The two most important variables were malnutrition cycle of infants and young children in develop- laborers or street vendors with low, unstable incomes. rooms, ownership of functioning radios, televisions, and ing countries. In Peru, children under three years of age have number of droppings and number of minutes chickens were Housing materials in Huascar and San Juan range from refrigerators, and presence or absence of a latrine. Finally the in the house. a diarrhea! incidence of 10 episodes per child-year, which can woven cane matting to permanent structures of brick and number and types of animals belonging to the home owners significantly affect their growth rales.' One important cause were also registered. There were about four feces-to-mouth episodes per child of diarrhea in Lima children less than one year of age is cement. Although the majority of pueblos jovenes do not (Table 1). Children only rarely washed their hands after Campylobacier jejuni. This organism was found in 15 percent have electrical installations, most of our study households The practices and beliefs of mothers who did and did not touching feces, and often put their fingers in their mouths, so of diarrhea stool samples2 and accounted for the majority of had them. Water is scarce in both pueblos. It is provided raise poultry were compared using Chi square analysis. Each feces-to-hand and feces-to-mouth episodes were highly cor- dysenteric diarrheas. through tanker trucks, and in half of San Juan through piped socioeconomic data set from the two pueblos jovenes was related (r = 0.94); feces-to-hand episodes and the number of communal water spigot, ln-housc sewage systems arc not In Peru, C. jejuni has heen isolated from 88 percent of analyzed individually, and compared for socioeconomic poultry accounted for 93 percent of the variation in the commercial chickens and 50 percent of free-ranging domestic available. indicators, using Student t test and Chi-Square analysis. dependent variable—the number of feces-to-mouth episodes. Direct Observation Data chickens in a pueblo joven (a peri-urban shanty town Survlvabillly of C. jtjuni In Deposited Chicken Kee« Neither feces-to-hand nor feces-to-mouth episodes were community).' In an aged-matched case-control study of Lima Ten families from Huascar participated in an in-depth related to the number of young children in study families. For Stool samples were taken from C. x/7m/-positive chick- each additional chicken stool deposited during the day, there peri-urban households, children in families with chickens had behavioral observation study, with a total of 21 children ens, raised in a household in Huascar, Canto Grande. A a Ihree-fold relative risk of having C. jejuni diarrhea which under five years of age. All the families had at least one child was an average increase of 0.27 in feces-to-mouth episodes. cloaca! swab was taken immediately after Ihc chicken defe- Poultry Raising Practices increased to 12.5 in families with C. jejuni infected chickens.- under two years of age, and domestic chickens which were cated and another swab was taken from the stool on the These risk factors suggest thai direct contact with free- not corralled at least part of the day. They gave informed ground. These served as baseline samples. The stool sample, roaming C. ./yam-infected chickens (hat defecate on house- One hundred and eight mothers from the Pampas de San verbal consent prior to their participation. The study received on the ground of a sun-cxposcd patio, was fenced in with a Juan participated in the poultry raising practices survey. hold surfaces is an important transmission vehicle for young ethical approval by all involved Peruvian institutions (Uni- metallic wire and marked with its respective identification children. Eighty-one (75 percent) of the mothers were migrants, versidad Peruana Cayetano Hcredia, Instituto de Investiga- number and code. After 24 and 48 hours, additional samples usually from the sierra zones. Whereas 88 percent (14/16) of Direct observation of the personal hygiene of small cion Nutricional, and PRISMA - Proyectos en Informatica, were taken. All the samples were immediately placed in Cary 7 the Lima-born mothers raised multiple types of poultry, only children and mother-child behavioral patterns is the most Salud, Meuicina y Agricultural. Blair media containing Skirrow's antibiotic supplement, and half of the migrant mothers raised other types of poultry in reliable method for obtaining data.' W,e used directed ob- To gather the direct observation data, a field worker processed by direct plating on blood agar with Butzler's addition to chickens (27/54). server techniques to measure the rate at which toddlers in a remained in the toddler's home for one 12-hour observation supplement. Another sample was inoculated into thioglyco- The major reasons given for a raising poultry (Table 2) shanty town contaminate themselves with domestic poultry period (7am to 7pm). At the beginning of the visit, a late broth supplemented with iron and the following antibi- included their use for home consumption and enjoyment of feces. descriptive inventory of the domestic animals was com- otics: vancomycin 10 u.g/ml, polymyxin B 2.5 I.U./ml and raising animals. The majority of mothers realized that com- pleted. During the 12-hour period the observer noted all trimclhoprim lactatc 5 u.g/ml. The plates were incubated mercial chickens were cheaper than those raised at home. Methods activities in the house for each fowl, including the number of immediately while the broth was refrigerated for 24 hours and When mothers were asked whether commercial or domestic Study Sites times the fowl entered the home, the duration of time spent then plated with Butzler's agar. All plates were incubated at chickens cost more, 77/108 (71 percent) thought the commer- inside, and how frequently and where the poultry defecated. The study was done in two pueblos jovencs (recent The observer also tabulated the activities of the toddler, specifically noting the number of times the child's hands were TABLE 1—Number of Domestic Poultry ind Their Interaction* with Toddler-Aged Children, Dlract ObMtvation Households (n«10) Address reprint requests IO Robert H. Oilman, MD. Division ot Disease contaminated with poultry feces (defined as feces-to-hand Control. Department of International Health. Johns Hopkins School of episodes) and the number of times that his/her hands, or other Feces-to-Hand" Feces-tc*Mouih' Hygiene and Public Heallh. 615 N. Wolfe Street. Baltimore, MD2l20S.The objects contaminated with poultry feecs, were introduced authors arc from: Universidad Pcruana Cayctano Hercdia, Lima. Peru into his mouth (defined as feces-to-mouth episodes). Feces- Mean SD Regr Coef 95 Cl Regr Coot 95 Cl IMarquu. Gilman. Miranda. CarbajalK Instilulo de [nvesligacion Nutritional. to-mouth episodes were considered to have been interrupted Lima, Peru (Marquis. Ventura. Porrask Johns Hopkins School of Hygiene and Foul per house 5-4 3.1 -00326 (-0.693*0 628) 02831 (-0.735+1.301) Public Health (Gilmanl: and PRISMA. Lima. Peru ll'cntafiel). This paper, and were not tabulated if the child's contaminated hands had # Min/12 nours (owl in house 14043.0 2099.8 0.0004 (-0.001 +0.0011 00006 (-0.001+0.0O21 submitted to ihc Journal January M. vm. »as revised and accepted (oi been washed before he placed them in his mouth. # Stool5'l2 hours 10 0 10.7 0.1664 (-0.025 + 0.308) 0.2718 ( + 0.057+0.487) publication August 1H, N8y. # Feces-to-hand episodes 29 30 1.474 (+1.101 + 1 846) All feces-to-hand and feccs-lo-mouth episodes were # Feces-to-mouth episodes 39 46 Editor's Note: See also related editorial p 14] this issue. tabulated for each family and analyzed as episodes per child. « l<«0 American Journal of Public Health (XN000 W90SI 50 Correlations and linear regressions for the feces-to-hand and 'Dependent variable in simple iinear regression rrtodel

146 AJPH February 1990. Vol. 80. No. 2 AJPH February 1990, Vol. 80. No 2 MARQUIS. ET AL. CONTAMINATION OF TODDLERS WITH POULTRY FECES

TABLE 2—Pampu Funlly Practices and B»l*ts Concerning tn* Railing TABLE J-HuMMr and Pampas Family Soclovconomlc Statua, Accord- monella species is an infrequent cause of community epi- sion in Huascar. Peru. Am J Epidemiol 1989; 129:785-799. of DomMtlc Poultry ing to S«lKt«d Variables demics of diarrhea. 2. Grudos O. Bravo N. Black R. Butzler Jp; Case-control study to identify mk factors for pcdiatric czmpylobitclCrdiarrhea in Lima. Peru. Bull WHO The present study suggests similar socioeconomic back- ]9K8:(*:369-.n4 Families Huascar tarnMies Pampas families Families without ground and characteristics of families with and without 3. Salazar K, Sack B, Chea E. Kay B, hscoya Z. Leon-Barua R: Early with Poultry Poultry Mean family size 65 SD. 2.5 5 1 SD 1.8 poultry in a pueblo joven population, making it difficult to treatment with erythromycin of Campyhbacter jejuni-asi,tx\iiieCity. Rev Lat-Am Micro- Is there a health risk tor the family. % completing secondary 31/120 26 56/108 52 the household and the need to corral poultry and prevent their hioi )986;2H:.17-38. having poultry loose in the house? % completing primary 66/120 55 42/108 39 entrance into the house. II- Stern NJ Recovery rate of Campyhhacterfetus ssp.yV>/Tj on eviscerated No 20 29 11 28 % not completing pork. lamb, and beef carcasses- J Food Sci 1981,46:1291-1293. Yes. cause illness 16 23 15 38 primary /none 14/120 12 3/108 3 12. Svcdhem A. Kaijser B: Isolation of Campyhbavier jejuni from domestic Yes. dirty or bring flies 13 19 e 21 % absent 5/120 4 4/108 4 ACKNOWLEDGMENTS animals and pets: Probable origin of human infection. J Infect 1981; Don't know 20 29 13 % no response 4/120 3 3'108 3 We would like to thank Sra. Martha KauRuu for her able field support; Drs. 3:37-40. W. Spira. M. Rateman. and R. Black (or advice: and S, U. Phu. D. .Sara, and 13. Svtfdnem A. Kaij.ser B, Sjogren E: The occurrence of Campyhbacter M Mahtico for assistance. We also thank ihe communities of Huascar, jejuni in fresh food and survival under different conditions- J Hyg Camb Hayovar.and Pampas dc San Juan for their collaboration, financial support for 1981; 87:421. cial chickens were cheaper while only 22/108 (20 percent) contaminated with chicken feces in approximately 66 percent this research was provided in part by Harvard L'niversiiy by means of a 14. 7-eitlin M. Guldan G. Klein R. Ahmad N: Sanitary conditions of crawling thought the reverse. 14 cooperative agreement wnh the US Agency for International Development infants in rural Bangfadesh. A summary report to AID Asia Bureau and of the households. Approximately one-half the Bangladeshi Additional funding was provided b> the RUHR fund and Smiih Kline & French HHS Office of International Health of a survey conducted in Bangladesh In 83 percent (58/70) of the families, the poultry roamed mothers claimed to have seen the child touching or eating Company. in July 1985 in partial fulfillment of NIH contract #282-86-0011. freely for much of the day, with access into the house. This animal feces during the previous two weeks. Initial analysis was presented as an abstract at the American Tropical 15. Hutchinson Rl: Some observations on the method of spread of Sonne practice was explained in part by the belief of more than Unwashed hands of toddlers in a pueblo joven arc Medicine ;md Hygiene meeting. November 1987. dysentery. Monthly Bulletin of the Ministry of Health and the Public one-half of the mothers that the animals grew better when frequently contaminated with poultry feces. As 50 percent of Health Laboratory Service (Kngland). 1956; 15:110-118. 4 16. Black RE, Brown KH, Becker S, Alim AR. Huq I: Longitudinal studies they were allowed to wander freely. Seventy four percent of the chickens in a pueblo joven are carriers of C. jejuni, the REFERENCES of infectious disease and physical growih of children in rural Bangladesh. the mothers not raising poultry and 68 percent of the mothers health risk to these toddlers is evident. We found that few of 1- Black R. Lopez de Romana G. Brown K. Bravo N, Grados O. Creed H: 11. Incidences of diarrhea in association with known pathogens. Am J with poultry thought that there was a health risk or a negative these feces-to-hand episodes were interrupted by hand wash- Incidence and etiology of infantile diarrhea and major routes of transmis- Kpidemiol 1982. 115315-324. hygienic aspect associated with free-roaming poultry. ing. Socloeconomk: Data Many pueblo joven mothers do not believe that chicken stools provoke illness. Similar results were found in the Table 3 shows the socioeconomic indicators studied in Bangladesh study, where over one-half of the mothers also both pueblo joven communities. No socioeconomic differ- did not recognize animal feces as disease-producing.14 ences were found in families that did or did not raise chickens and other poultry. The absence of running water in pueblo jovenes and the I 8th Competition Announced for Health Professions Students I high cost of the water used may be important factors Microbiological Results discouraging hand washing. Even in developed countries Dr. Louis W. Sullivan, Secretary of Health and Human Services, has announced the 8th annual Forty percent (27/68) of the stool samples from C, where water is easily available, oral-fecal contamination is national competition among health professions students for the "Secretary's Award for Innovations in jV/Mm-positive chickens deposited in sun-exposed patios still common. Direct observations in an English nursery school Health Promotion and Disease Prevention." Winners will receive awards of $3,000 for first place, $2,000 had viable organisms demonstrable after 24 hours. At 48 during an epidemic of shigellosis showed that 50 percent of for second, and $1,000 for third; up to 17 semifinalists will receive $250 each. hours, only 18 percent (10/57) of the samples were positive. the children had contaminated their hands with Shigella sonnet after using the school toilet. Moreover, one-third of The competition is open to a broad range of health professions students enrolled in baccalaureate the children handled their face or sucked their fingers after or higher degree programs affiliated with the Federation of Associations of Schools of the Health Discussion using the toilet.'5 Professions, cosponsor of the competition. Those eligible to compete include students of medicine, Campyhbacter jejuni infection most commonly occurs The risk of acquiring viable C. jejuni in the study area is osteopathic medicine, nursing, veterinary medicine, opiometry, pharmacy, podiatric medicine, public through human fecal-oral transmission or through contam- augmented because the house floors are usually made of dirt health, health administration, health education, and allied health. inated food or water.9"11 This transmission is difficult to or unfinished concrete, so the complete removal of poultry Papers should present innovative proposals for health promotion or disease prevention in the document, unless direct observation of family hygienic prac- feces is difficult to achieve, and C. jejuni can survive in the community, at the worksite, in an educational setting, or for a special population group. tices is used. Stanton, et at, demonstrated that responses to ambient environment for several days. Even where water is The deadline for submitting entries is March 15, 1990. A paper must be submitted to the school 24-hour recall and knowledge-attitude-practices question- plentiful, in homes with free-roaming chickens, it is not attended by the author or authors. Papers will be judged first by the school and then by the professional naires do not reliably reflect observed hygienic household realistic to assume that mothers will be able to effectively practices.s The direct observation method is a strength of this interrupt transmission by handwashing. associations. A departmental panel will make the final selections, and HHS Secretary Sullivan will announce the winners in July. For further information, contact Blake Crawford, Health Resources and study. Ajimitation is that the sample size is small. These data In addition to C. jejuni, a small percentage (2 percent) of nonetheless demonstrate that contamination of toddlers' poultry were fecal carriers of Aeromonas species.4 The Services Administration (HRSA), US Public Health Service, DHHS, 5600 Fishers Lane, Rockville, MD hands with feces deposited in the house by free-roaming birds relationship of this organism to diarrhea has not been estab- 20857; tel: (301)443-3376. is extremely common in Peruvian pueblo jovenes. In Bang- lished. None of the free-roaming chickens sampled excreted ladesh, play areas of infants and toddlers were also seen to be Salmonella species. In both Peru and Bangladesh,1"16 Sal-

146 AJPH February 1990, Vol. 80, No. 2 AJPH February 1990, Vol. 80, No. 2 149