Water and Food Safety in the Developing World: Global Implications for Health and Nutrition of Infants and Young Children

Risks to Infants and Children 

Infants and young children are most vulnerable to diarrheal disease, which is one of the leading causes of illness and death in developing countries (9). Annually, 1.6 million children younger than age 5 die of a diarrheal illnesses, a large proportion of which is acquired through exposure to water and foods infested with microorganisms (6, 10, 11). Diarrhea in infants and young children can lead to malnutrition and reduced immune resistance, which in turn increases the risk of prolonged and recurrent diarrhea (8). Improving access to clean drinking water and promoting food safety practices are essential nutritional strategies to prevent this vicious cycle and reduce morbidity and mortality among infants and children worldwide (12).

Infant Feeding 

Breastfeeding may be considered the most basic intervention to protect infants from infectious disease. It is well recognized that breastfeeding protects infants by decreasing their exposure to water and foodborne pathogens, as well as by bolstering their immune defenses. Numerous studies demonstrate the benefit of breastfeeding in reducing diarrheal illness (13, 14, 15, 16, 17). For instance, a case-control study in Brazil has shown that infants younger than 2 months of age who are not breastfed have a 25 times greater risk of dying of diarrhea than those who are exclusively breastfed (14).

Studies have demonstrated that consumption of supplemental fluids and foods by fully breastfed infants greatly increases their risk of diarrheal illnesses and stunting of growth (14, 15, 18). A prospective study of 2,355 urban Filipino infants younger than 6 months of age found that consumption of even small amounts of contaminated liquids to fully breastfed infants nearly doubles their risk of diarrhea (15). In a study of 1,143 Bolivian children who were breastfed, Forste (18) found that the introduction of solid foods to infants between the ages of 6 and 9 months increases the likelihood of growth stunting by approximately 75%. Health concerns for the formula-fed infant include risk of contaminated water and contaminants on bottles and nipples (19, 20). Breastfeeding is most important in those areas where water contamination is more likely and poor sanitation conditions prevail.

Weaning 

Infants are most vulnerable to diarrheal illnesses when weaning begins, sometimes as early as 1 to 2 months of age (17). A case-control study in Brazil found that, compared with infants still exclusively breastfed, the odds ratio for dehydrating diarrhea was 8.4 for infants who had been weaned during the previous 2 months (17). The odds ratio decreased to 3.9 for infants who had been weaned for at least 6 months (17). Studies suggest that the level of contamination may be higher in weaning foods than in drinking water, and it is postulated that weaning foods are probably more important than drinking water for transmission of diarrheal diseases in developing countries (21). Weaning foods frequently become contaminated with pathogens when prepared under unhygienic conditions (22).

Mixed-fed infants have a greater risk of diarrhea than do fully breastfed infants. Mixed-fed infants are those who, in addition to breast milk, are fed supplemental foods such as other types of milk, formula, juices and/or solids. The risk of diarrhea for weaned infants and children is even greater than that of mixed-fed infants, especially if weaning takes place before 6 months of age (16).

Research on infant feeding practices during the first year of life was compiled from Demographic and Health Surveys, a project funded by the US Agency for International Development to improve and institutionalize the collection and use of nationally representative data in 75 host countries (23, 24). A review of Demographic and Health Survey data from 1999-2003 from 20 developing countries found that it was common practice to feed infants milk other than breastmilk and commercial infant formulas, and liquids such as fruit juice, herbal teas, and sugar water (23). These liquids may be prepared with contaminated water or served in contaminated containers.

In addition, infants who are introduced to solid foods are often exposed to pathogens, especially E coli (11, 21, 22). Foods may become contaminated due to exposure to flies, dirt, polluted water, domestic animals, dirty utensils and pots, unwashed hands, and dust (25). Storing food at warmer ambient temperatures when there is a lack of refrigeration, as well as insufficient reheating of food would facilitate bacterial growth (21, 22). These problems may be compounded by limited maternal awareness about the link between diarrhea and improper food handling, insufficient time for cooking, time gaps between meal preparation and feeding, lack of sanitation, lack of refrigeration, inadequate reheating of food, washing utensils in contaminated water, and shortage of fuel for cooking (22, 25). Information about the relative contribution of these various factors to diarrheal risk was not found in the published literature.

Barriers to Clean Water and Food Safety Efforts 

There are numerous obstacles to safe uncontaminated water-based feedings and foods in developing countries. Water is a scarce commodity in many communities, limiting its availability for consumption, hygiene, and cleaning (6). Key food and water safety efforts often are overlooked in community development, and precautions may be less attainable for poor communities (26). Less-than-optimal living conditions contribute to easy food and water contamination, and mothers and caregivers are often uneducated about food safety (11). Due to the necessity of frequent infant and toddler feeding, it is a challenge for mothers to cook and prepare fresh food for each meal, and they often do not have the convenience of refrigeration and plentiful cooking fuel for boiling water and thoroughly cooking/reheating food (27). Use of limited and expensive cooking fuel for boiling water may be resisted because of its expense and lack of acceptance within the community. Finally, beliefs and practices, taboos, ignorance, and weak and underfunded social infrastructures can undermine community water and food safety efforts (22).

To plan culturally acceptable interventions, the impact of customs, beliefs, and rituals on community food safety and water problems must be considered. Common habits that could impact food safety in the developing world include insufficient washing of hands and utensils, insufficient cooking of foods, and storage of perishable foods at ambient temperatures (22). Although these behaviors are often due to shortages of water, fuel, or time, they also reflect a lack of understanding about the link between contamination and disease. In many cultures the relationship between diarrhea and food and water contamination is not well understood. In some cultures mothers may blame the evil eye or even their own breastmilk for causing diarrhea, or they may not consider that the stools of their baby are contaminating (22). Because of mothers’ central role in food preparation, culturally relevant education in food safety is essential to the nutrition and health of infants and young children (22).

Community Strategies for Clean Water and Food Safety 

There is a tremendous need worldwide for household water treatment strategies that are safe, accessible, and affordable (2). Considerable field research has been conducted to identify effective strategies in making clean water available for drinking and food preparation (10, 28, 29). The Centers for Disease Control and Prevention water storage vessel and the use of chlorine and iodine drops have been found to be a successful method of sanitizing water (28). Health educators have successfully promoted methods for household-level water disinfection and safe water and food storage. Studies have indicated that communities using these methods greatly reduce microbial load and decrease the prevalence of waterborne diarrheal diseases (28, 29, 30, 31, 32). For example, the impact of interventions to promote water disinfection and safe water storage within households in peri-urban communities was measured in Zambia. Stored water in intervention households was significantly less contaminated with E coli than water in control households (P<0.001), and diarrheal risk was 48% less (32).

Based on these findings, the Centers for Disease Control and Prevention and the Pan American Health Organization have developed an effective community water quality initiative called Safe Water System, which uses simple and inexpensive technologies appropriate for the developing world (33). The three steps of the intervention include: point-of-use treatment of water using sodium hypochlorite solution that can be easily purchased or produced locally; safe water storage in plastic containers with a narrow mouth, lid, and a spigot to prevent recontamination; and behavior-change techniques to increase awareness of the benefits of safe water and hygiene behaviors.

Implementation of the Safe Water System requires community mobilization; the support of health clinics, religious leaders, and community organizations, and one-on-one communication (28, 29, 34). Maintaining long-term use of the Safe Water System requires that there be sufficient resources and support through health promotion to individuals and communities (29, 34).

One of the greatest challenges for implementing Safe Water System measures in communities is encouraging people to modify their behaviors. Motivational interviewing is a unique intervention that encourages behavior change by helping individual resolve obstacles and eliciting self-motivation. The person-centered, empathic motivational interviewing approach has been successfully adapted to water and sanitation issues in the developing world, and has been successful in promoting the Safe Water System program (30, 35). Rates of purchase and use of Safe Water System disinfectants were significantly higher in geographic zones using motivational interviewing techniques as compared with geographic zones using traditional health education alone (35). By using typical motivational interviewing techniques such as open-ended questions, reflective listening, and personalized feedback sensitive to the social and cultural needs of the individual, health promoters collaborate with people in partnership to assist in resolution of barriers to Safe Water System adoption (35).

Complementing motivational interviewing is social marketing, a strategy by which the widespread purchase of tools for water safety, such as sodium hypochlorite solution, is encouraged and facilitated within communities (28). In Kenya and Zambia, social marketing activities implemented by nonprofit organizations to promote use and purchase of water disinfectant products include use of street theater, billboards, and sponsored events (30). Demand for these products was also accomplished by prominent placement of the water disinfectant solution in local stores and kiosks (30). Findings suggest that social marketing of the Safe Water System has been most successful with more health-conscious individuals, whereas the addition of motivational interviewing techniques enhances the effects of social marketing among more cautious individuals (30).

These interventions are designed for communities that rely on water sources at high risk of contamination with pathogens, such as rivers and lakes, groundwater wells, intermittent piped water systems, water tankers, and water vendors (36). Successful implementation of the Safe Water System strategy has been demonstrated in select communities in numerous countries, including Zambia, Madagascar, and Kenya (30). In Madagascar, community sales agents effectively motivated their neighbors to adopt new health behaviors to prevent diarrhea (31). Community sales agent effectiveness was determined by measuring the percentage of households self-reporting and actually using the water disinfectant sold by these agents. Outcomes in a study in Zambia included significant reductions in bacterial loads in stored drinking water, and a 48% reduction in diarrheal illnesses (32). In Kenya, diarrhea rates decreased 58% in children younger than 5 years of age (30).

School-based water and hygiene programs have been promoted to complement education of parents and community members (37, 38). In a program in western Kenya, Safe Water System–trained teachers educated students in correct water treatment procedures and handwashing. A final evaluation of 363 students and their parents was compared with a baseline survey (37). Sixty-five percent of students knew the dose of sodium hypochlorite solution, compared with 21% who knew this at baseline (P<0.01); 14% of parents reported treating their water compared with 6% at baseline (P<0.01); and school absenteeism decreased by 35% (37). In a similar study in Kenya, diarrheal illnesses decreased significantly after teachers taught students about safe water and hygiene, safe water storage vessels were placed between classrooms, and water tanks for hand-washing were placed between the kitchen and latrines (38).

In addition to improved water, the WHO has identified global food safety as one of its top priorities. It has developed a global strategy for food safety, with the goal of reducing the health and social burden of foodborne disease (39, 40). Key elements of the strategy rely on interdisciplinary and interagency collaboration as well as strategies to enhance risk communication and advocacy efforts and to strengthen capacity-building in developing countries (38, 39, 40). The full-text version of the WHO Global Strategy for Food Safety: Safer Food for Better Health is available on the WHO Web site in six languages (39). Several full-text food safety capacity-building resources are also available online, including Food Safety for Nutritionists and other Health Professionals-Teachers Handbook (41).

To spread its food safety message, the WHO has also published the manual Five Keys to Safer Food for use by health professionals and a poster that has been translated into 40 languages (42). The WHO food safety manual includes five core messages for safer food: keep clean, separate raw and cooked, cook thoroughly, keep food at safe temperatures, and use safe water and raw materials.

Specific practical household strategies have been recommended to make weaning safer. Once prepared, foods should be kept covered to protect food from flies and dust. To keep food cool and prevent microorganisms from proliferating, foods can be stored in running water or in porous pots standing in water. Storing foods in baskets hanging from the ceiling also allows the wind to cool it and also keeps insects and rodents away (27). Improved cookstoves allow families on a limited budget to thoroughly reheat food before serving (27). Dietetic professionals can work with community leaders and public health workers on culturally appropriate strategies specific to the circumstances of the community to reduce risks of food and water contamination.

Role of Food and Nutrition Professionals and Unique Contributions 

Food and nutrition professionals have the training and background to play an essential role in solving water and food safety problems that threaten the nutritional health of individuals and communities. Public health nutritionists and dietetic professionals can use their expert competencies to educate individuals, train health workers and teachers, and collaborate with other experts in water and food safety. By emphasizing activities that expand the understanding and capabilities of individuals within communities, there are opportunities to empower individuals to promote food safety and health within their family and community (43).

Because socioeconomic and cultural constraints can contribute to insufficient supplies of safe water and cooking fuel and inadequate sanitation, cooking, and food storage, it is unrealistic for dietetic professionals to attempt to address water and food safety in isolation. For example, whereas dietetic professionals understand food safety principles and educational methods important for health, they would need assistance in navigating through the water and sanitation infrastructures, cultural norms, and social networks. Collaboration with water-safety experts, sanitarians, epidemiologists, local leaders, and other health care educators and workers is essential for an integrated food and water safety approach (1).

Food and nutrition professionals can familiarize themselves with the Safe Water System initiatives and strategies such as motivational interviewing and incorporate these into their educational activities at the family, community, and institutional levels. Similarly, the resources from the WHO global food safety strategy can be integrated into nutrition education, training, and programs.

Nutrition professionals can also take advantage of the breastfeeding promotion initiatives of international organizations. The Baby Friendly Hospital Initiative sponsored by UNICEF/WHO promotes breastfeeding in maternity wards worldwide and has proven to be successful for increasing breastfeeding rates and duration (44, 45). Established in 1992, The Baby Friendly Hospital Initiative seeks to limit the marketing and promotion of breast milk substitutes within member clinics and hospitals and to actively support exclusive breastfeeding during the first months of life. The Baby Friendly Hospital Initiative has been identified as one of the most successful international efforts to promote and support breastfeeding (44). Involvement of nutrition professionals in the Baby Friendly Hospital Initiative at the local, regional, or country levels can help this unique program gain additional momentum and support.

Education of parents and caregivers in food safety, especially for prolonging breastfeeding and appropriate selection and handling of weaning foods, should be a high priority. More attention must be given to teach mothers and caregivers about food safety in an integrated manner, making the connections between health, malnutrition, and food/water safety (11). This approach can be incorporated into community programs for childhood nutrition, growth, and development. For example, food and water safety awareness and education can be incorporated into growth monitoring and supplemental food and milk distribution programs sponsored by governmental and nongovernmental organizations.

Another effective educational strategy is utilizing the skills of women as community health promoters and peer educators (46). Public health nutritionists can assist in training health promoters and supporting peer education programs that improve community food and water safety and that promote breastfeeding. Health promoter and peer education programs have been effective ways to motivate, build capacity, and mobilize communities for change (47).

Critical objectives of all these activities are to educate individuals, especially mothers and other food preparers, and to implement water and food safety strategies aimed at optimizing nutritional intake while minimizing risks of gastrointestinal illnesses.

Conclusions 

The high prevalence of malnutrition and mortality due to diarrheal illnesses related to contaminated water and food demonstrates that dietary instruction and strategies must extend beyond nutritional requirements, food content, and feeding schedules. Dietetic professionals must be attuned to issues of clean water and safe food environments, and they must be prepared to extend their expertise into effective strategies to assure that individuals (especially children) consume water and food that is safe and free from pathogens. Because water and food safety is intertwined with infrastructural, cultural, financial, and social issues unique to each community, implementation strategies require an interdisciplinary collaborative approach with other health and community professionals.