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Interrelationships Among Gastrointestinal Infection, Stunting

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Interrelationships Among Gastrointestinal Infection, Stunting Interrelationships among gastrointestinal infection, stunting, and their socio-ecological determinants in impoverished Panamanian preschool children: A spatio-temporal and ecohealth approach Carli Halpenny Institute of Parasitology & School of Environment McGill University, Montreal, Canada 2012 A thesis submitted to McGill University in partial fulfilment of the requirements of the degree of Doctor of Philosophy © Carli Halpenny, 2012 Abstract Background: Although growth stunting, height for age Z score (HAZ) <-2SD, results from sustained poor diet and frequent infection both of which are influenced by social and biophysical factors, few studies have used a transdisciplinary ecohealth framework for a comprehensive analysis of this relationship. Objective: To examine the interrelationships between preschool child stunting and gastrointestinal infections within the biophysical, social and spatial context of extreme poverty among the Ngäbe in Western Panama where conditional food voucher (FV) and cash transfer (CT) programs occurred. Methods: A 16-mo longitudinal study of 356 preschool children involved two reinfection cycles following albendazole treatment. Data collection included repeated fecal samples, household socio-behavioural questionnaires, multiple dietary records and anthropometric measures, water samples, GPS and participatory workshops. An asset-based household wealth index (HW), an index of household dispersion (HD), index of chronicity of diarrhea (CDI) and protozoan infection (CPI), and dietary pattern scores were generated and incorporated into spatial cluster analysis and multiple regression models of anthropometric and infection outcomes. Influence diagrams created during small group workshops identified participant perceptions of health. Results: Households with higher HWI had a latrine, aqueduct access, cell phone, and/or stove and HD ranged from 5–113 households/km2. High prevalence clusters of hookworm and Trichuris (but not Ascaris) occurred in regions with lowest HWI and HD. Ascaris and hookworm reinfection was driven by individual susceptibility traits (stunting) whereas Trichuris reinfection was dependent on household (maternal education) and regional (high prevalence cluster) characteristics. The high frequency of diarrhea was consistent with community perceptions of health priorities and of the link between diarrhea and poor water quality. Both E. coli counts and CDI i were higher in households without aqueduct access. Sixty percent of children were stunted and 22% were underweight. The detrimental effect of CPI on HAZ was driven by household density but moderated by household wealth. Diet also influenced growth. The basic diet (rice, beans, coffee, sugar) was supplemented with fruits and vegetables (FV region) or market snacks (CT region). A “Market” diet pattern was concentrated in the CT region close to the road. Meat was beneficial for linear growth but only in the FV region whereas carbohydrates (sweets in FV region and root vegetables in CT region) were detrimental, even after controlling for infection and socio-economic status. With regard to weight gain, fish and eggs were beneficial in the FV region whereas, in the CT region, milk products were beneficial, but chips and sweets were detrimental. Implications: This transdisciplinary research highlighted key public health messages necessary to improve growth and reduce infection in this vulnerable population. ii Abrégé Contexte: Le retard de croissance, correspondant à une valeur centrée réduite (z-score) de la taille par rapport à l'âge (ZTA) inférieur à deux écarts type, découle d'une diète pauvre et d'infections fréquentes qui sont influencées par des facteurs sociaux et biophysiques. Seulement peu d'études ont utilisé une approche multidisciplinaire santé-écologie pour analyser la relation entre ces facteurs et la fréquence des arrêt de croissance. Objectif: Examiner les relations entre le retard de croissance chez les enfants en âge préscolaire et les infections gastro-intestinales avec le contexte social, biophysique et spatial dans des conditions de pauvreté extrêmes chez les peoples Ngabe de l'ouest du Panamá, où prennent place des programmes d'aide alimentaire (AA) et de transfert monétaire (TM).Méthodes: Dans le carde d'une étude de 16 mois, nous avons suivi 356 enfants d'âge préscolaire impliqués dans deux cycles de réinfections à la suite d'un traitement à l'albendazole. Les données recueillies inclues des échantillons répétés de matière fécale, questionnaires sur les comportements sociaux des ménages, journaux alimentaires et mesures anthropométriques, échantillons d'eau, données de système de localisation GPS et ateliers participatifs. Des indices de richesse des ménages (IRM) basé sur le patrimoine, de dispersion des ménages (IDM), de chronicité des la diarrhée (ICD) et de l'infection aux protozoaires (CIP), et une note sur les habitude alimentaires ont été calculés. Ces indices ont été inclus dans une analyse spatiale de regroupement et des analyses de régression linéaire multiple pour prédire les mesures anthropométriques et le résultat des infections. Les diagrammes d'influence créés durant les ateliers ont permis d'évaluer les perceptions des participants par rapport à la santé. RésultatsLes ménages avec les IRM élevés avaient une toilette, l'accès à l'aqueduc, un téléphone cellulaire et/ou un poêle. Leur IDM variait de 5-113 ménages/km2. Des regroupements de prévalence d'ankylostome et de Trichuris (mais pas d'Ascaris) étaient présents dans les régions avec les IRM et les IDM les plus faibles. Les réinfections par Ascaris et par iii des ankylostomes étaient influencées par des traits de sensibilité personnelle (retard de croissance): la réinfection par Trichuris dépendait des caractéristiques du ménage (éducation maternelle) et de la région (regroupement de prévalence élevée). La fréquence élevé de diarrhée correspondait avec la perception de la communauté sur les priorité en matière de santé et avec la mauvaise qualité des eaux. Les dénombrements d'E. coli et le ICD étaient plus élevés dans les ménages qui n'avaient pas accès à l'aqueduc. Soixante-six pour cent des enfants étaient atteints d'arrêt de croissance et 22% souffraient d'insuffisance pondérale. L'effet nuisible de la CIP sur la ZTA était principalement influencé par la densité de ménage mais aussi par le patrimoine du ménage. Le régime alimentaire avait aussi un effet sur la croissance. Le régime de base (riz, haricots, café, sucre) était complété avec des fruits et des légumes (région AA) ou des friandises du marché (région TM). Un régime « du marché » était concentré dans la région TM proche de la route. La présence de viande avait un effet bénéfique sur la croissance linéaire seulement dans la région AA alors que les glucides (sucreries dans la région AA et légumes racines dans le région TM) avait un effet néfaste, même en tenant compte des infections et du statut socio-économique. Le poisson et les œufs avaient un effet bénéfique sur le gain de masse corporelle dans la région AA. Dans la région TM, les produits laitiers avait un effet bénéfique sur la prise de masse alors que les croustilles et les sucreries avaient un effet néfaste. Implications: Cette étude multidisciplinaire souligne des messages important en santé publique pour améliorer la croissance et diminuer les infections dans cette population vulnérable. iv Acknowledgements First and foremost I would like to thank the communities that opened their doors to me during the 2 years in Panamá. Their generous participation in the research project and their willingness to share their daily activities with me made the experience valuable in ways beyond the research alone. I would especially like to thank the men and women who acted as my translators, guides and educators. Their commitment to the project as well as the stories and observations they shared on those long hikes opened my eyes to new dimensions of the comarca. I am grateful to the nutritionists who stepped outside their comfort zones to experience a new part of Panamá and to the lab technicians who worked well into the night on the big collection days. In Panamá City the informative support and guidance of Emerita Pons, Flavia Fontes and Odalis Sinisterra made the collaboration between MINSA and McGill University not only possible but so productive. I will forever be grateful to Vicky Valdés, whose mentorship during my stay in Panamá not only provided invaluable logistical advice but also sound cultural counsel. In Montreal, I have been lucky to have the opportunity to work with my supervisors, Dr. Marilyn Scott and Dr. Kristine Koski who have challenged me to develop as a researcher and given me the freedom to explore such a diverse project. I respect their unflagging energy and enthusiasm for research as well as their willingness to delve into such a transdisciplinary project. I have enjoyed sharing these last years with my lab mates, past and present (Felipe, Doris, Rachel, Marie-Pierre, Lisa, Javier, Candice and Maurice), who have kept all aspects of this project fun. Shannon, Christina, Shirley and all the members of the Institute of Parasitology and School of Environment thank you for the smiles, hallway conversations and helping hands. I gratefully acknowledge the National Sciences and Engineering Research Council (NSERC), the International Development Research Centre (IDRC) and the v Secretaria Nacional de Ciencia, Tecnología y Innovación (SENACYT) for the financial support that made this research possible. I am also appreciative
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