1. Water, Sanitation & Hygiene (WASH) Impacts on
Maternal and Child Mortality, Malnutrition
and Impaired Development
Tom Mahin – Centre for Affordable Water & Sanitation Technology
Rachel Peletz - London School of Hygiene & Tropical Medicine
CAWST Learning Exchange
June 28, 2010
By Pierre Holtz UNICEF

2. Introduction

3. Situation in 2010 in Sub-Saharan Africa
“Over 13,000 mothers,newborns,
and children die every day
in sub-Saharan Africa”
- Friberg et al. (2010) Sub-Saharan Africa’s Mothers, Newborns, and
Children: How Many Lives Could Be Saved with Targeted Health
Interventions? PLOS Medicine Vol 7, Issue 6, e1000295

4. Maternal Mortality Ratios

5. Deaths for Children < 5 Years Old & Malnutrition
From: Müller and
Krawinkel (2005)
“Malnutrition and health
in developing countries”
CMAJ 173 (3)

6. Diarrhea May Increase Acute Lower
Respiratory Infections
“In this analysis, we found that diarrhoea
may increase the risk of ALRI (Acute
Lower Respiratory Infections) … in
malnourished child populations. The
results suggest that prevention of diarrhoea
may contribute to a reduction in ALRI, the
leading immediate cause of death in
children.”
Schmidt et al. (2009) “Recent diarrhoeal illness and risk of lower
respiratory infections in children under the age of 5 years” International
Journal of Epidemiology 38:766–772

7. Diarrhea and Pneumonia - Infants
• “For example, comorbidity of pneumonia and
diarrhea is high, suggesting shared risk
“
factors and exacerbation of risk due to
coexistence of multiple morbidities”
From: Nutrition and Health in Developing Countries 2nd Edition, Humana Press,
Chapter 4 “Infant Mortality” by Parul Christian

8. Risk of Acute Respiratory Infections for Children
vs. Diarrhea Days over Last 14 Days (Ghana)
Schmidt et al. (2009) “Recent diarrhoeal illness and risk of lower respiratory infections in
children under the age of 5 years” International Journal of Epidemiology 38:766–772

9. Waterborne Infections, Malnutrition
and Impaired Development
• “A rate-limiting step in achieving normal nutrition
may be impaired absorptive function due to
multiple repeated enteric infections. This is
especially problematic in children whose diets are
marginal.”
• “In malnourished individuals, the infections are
even more devastating…Malnutrition is a major
contributor to mortality and is increasingly
recognized as a cause of, potentially lifelong,
functional disability.”
- Guerrant et al. (2008) “Malnutrition as an enteric infectious disease
with long-term effects on child development” Nutr Rev. 66(9): 487–505.

10. Enteric Pathogens Impair Absorption of Nutrients
• ”The morbidity impact of enteric pathogens is
related to their ability to directly impair intestinal
absorption as well as their ability to cause
diarrhea, both of which impair nutritional
status”
• “The absorptive function of a healthy intestinal tract
is especially critical in the first few formative years
of life. This is because, unlike many other species,
the predominant brain and synapse development in
humans occurs in the first 2 years after birth.”
- Petri et al. (2008) “Enteric infections, diarrhea, and their impact on
function and development” J Clin Invest. April 1; 118(4): 1277–1290.

11. Modified from Caulfield and Black Chapter 5 - Zinc deficiency in
Comparative Quantification of Health Risks WHO 2004

12. Kinney et al.(2010) “Sub-Saharan Africa’s Mothers, Newborns, and Children:
Where and Why Do They Die?” PLOS Medicine Vol 7, Iss 6 e1000294

13. Kinney et al.(2010) “Sub-Saharan Africa’s Mothers, Newborns, and Children: Where
and Why Do They Die?” PLOS Medicine Vol 7, Iss 6 e1000294

14. Key After Birth Interventions
Recommended by Friberg et al.
Friberg et al. (2010) Sub-Saharan Africa’s Mothers, Newborns, and Children: How Many
Lives Could Be Saved with Targeted Health Interventions? PLOS Medicine Vol 7, Issue 6,

15. Part I
Diarrhea & Waterborne Pathogens as
Contributors to Maternal and Child Malnutrition

16. Definitions
• Malabsorption – reduced absorption of nutrients
• Persistent diarrhea – diarrhea lasting > 14 days
• Stunting – a longer-term measure of malnutrition. Defined as
the height/length for age (HAZ) below minus two standard
deviations from the standard median height for age
• Weight for age - weight for age (WAZ) or “underweight” is a
shorter-term measurement of malnutrition
• Protein–energy malnutrition - measurements that fall below 2
standard deviations under the normal HAZ, WAZ or WHZ
(weight for height or wasting)

17. Malnutrition
• Malnutrition has two constituents:
1. Protein–energy malnutrition
2. Micronutrient deficiencies - e.g. iron (anemia),
vitamin A and zinc
• Malnutrition - “It is globally the most important
risk factor for illness and death, with hundreds
of millions of pregnant women and young
children particularly affected.”
– from Müller and Krawinkel (2005) “Malnutrition and health in
developing countries” Canadian Medic. Assoc. Journ. 173 (3)

18. Malnutrition and Pathogens -
Persistent Infections
“Not only are the effects of malnutrition complex,
its causes are as well. Worrisome food insecurity
is obviously critical, but a factor that is
potentially even more important (especially for
children with marginal intake) is the inability to
absorb what they do take in because of
repeated or persistent intestinal infections.”
– Guerrant et al. (2008) Malnutrition as an enteric infectious disease with long-
term effects on child development Nutr Rev. September; 66(9): 487–505.

19. A Substantial Proportion of Malnutrition is
Due to Repeated Enteric Infections
• “A substantial proportion of global
malnutrition is due to impaired intestinal
absorptive function resulting from multiple
and repeated enteric infections”
• “These include recurrent acute … as well as
persistent infections, even those without
overt liquid diarrhea.”
- Guerrant et al. (2008) “Malnutrition as an enteric infectious disease with
long-term effects on child development” Nutr Rev.

20. Nutrient Malabsorption
“Impaired … host immune responses and disrupted
intestinal barrier function due to malnutrition and
diarrheal illnesses likely combine to render
weaning children susceptible to repeated bouts
of enteric infections leading to intestinal injury and
consequently, nutrient malabsorption during
the developmentally critical first 2 years of life.”
- Guerrant et al. (2008) “Malnutrition as an enteric infectious disease with long-
term effects on child development” Nutr Rev.

21. Malnutrition and Developing Countries
• “The high prevalence of bacterial and parasitic
diseases in developing countries contributes
greatly to malnutrition there. Similarly,
malnutrition increases one’s susceptibility to
and severity of infections, and is thus a major
component of illness and death from disease.”
• “Malnutrition is …the most important risk factor for
the burden of disease in developing countries. It is
indirectly responsible for about half of all deaths
in young children. The risk of death is directly
correlated with the degree of malnutrition.”
- Müller and Krawinkel (2005) “Malnutrition and health in
developing countries” Canadian Medic. Assoc. Journ. 173 (3)

22. Malnutrition – Waterborne Pathogens Cycle
Modified from Guerrant et al. (2008) “Malnutrition as an enteric infectious
disease with long-term effects on child development” Nutr Rev.

23. Reduced Weight Gain vs. % of Days with
Diarrhea for Malnourished Children
Petri et al. (2008) “Enteric infections, diarrhea, and their impact on function and
development” The Journal of Clinical Investigation

24. Adapted from: “Tackling the silent killer, The case for sanitation” by
WaterAid (2008)

25. Weight-for-age (WAZ) as a Proxy for
Diarrhea in Last 14 Days
Schmidt et al. (2009) “Weight-for-age z-score as a proxy marker for diarrhoea in
epidemiological studies” J Epidemiol Community Health. Dec 1 (Epub)

26. Lack of Full Success of Dietary Approaches
• “Under the plausible assumption that children grow
poorly because they do not eat enough of the right
foods, research efforts have focused on
identifying dietary solutions. Numerous studies
have tested many nutrient-dense foods and
supplements, nutrition education interventions, and
infant feeding behavioural change strategies.”
• “A recent review of 38 of these studies showed
that …none of these interventions achieved
normal growth: the growth effect of even the most
successful of these studies (~ +0·7 Z) is equivalent
to about 1/3 of the average deficit of Asian & African
children (~ –2·0 Z).”
– Humphrey J H (2009) Lancet 374: 1032-35

27. Maternal Undernutrition
Low Birthweight - Infant Mortality
• “Low birthweight is related to maternal
undernutrition; it contributes to infections and
asphyxia, which together account for 60 per cent
of neonatal deaths”.
• “An infant born weighing between 1,500 and
2,000 grams is eight times more likely to die
than an infant born with an adequate weight of
at least 2,500 grams.” – UNICEF 2009

28. From: Müller and Krawinkel
(2005) “Malnutrition and
health in developing countries”
CMAJ 173 (3)

29. Malnutrition, Children and Water
• “Severe malnutrition ... occurs almost
exclusively in children.”
• “…in order to address infectious diseases
as a cause of protein–energy malnutrition
it is likewise important to promote breast-
feeding, improve the water supply and
sanitation, and educate people about
hygiene.”
- from: Müller and Krawinkel (2005) “Malnutrition and health in
developing countries” Canadian Medic. Assoc. Journ. 173 (3)

30. Protein–energy Malnutrition and Diarrhea
• “Protein–energy malnutrition and diarrhea
typically interact in a vicious cycle…”
Modified from: Müller
and Krawinkel (2005)
“Malnutrition and health
in developing countries”
CMAJ” 173 (3)

31. Diarrhea as a Major Risk Factor for
Severe Malnutrition in South Africa
Saloojee et al. (2007) “What’s new? Investigating risk factors for severe
childhood malnutrition in a high HIV prevalence South African setting”
Scandinavian Journal of Public Health, 35(Suppl 69): 96–106

32. Underweight
Adapted from Shrimpton et al. (2001) “Worldwide Timing of Growth Faltering:
Implications for Nutritional Interventions” PEDIATRICS Vol. 107 No. 5 May

33. Stunting
Adapted from Shrimpton et al. (2001) “Worldwide Timing of Growth Faltering:
Implications for Nutritional Interventions” PEDIATRICS Vol. 107 No. 5 May

34. Once Children are Stunted, It’s Difficult to Catch
Up Later On
• “Whether a child has experienced chronic
nutritional deficiencies and frequent bouts of illness
in early life is best indicated by the infant’s growth
in length and the child’s growth in height. Day-to-
day nutritional deficiencies over a period of time
lead to diminished, or stunted, growth.
• “Once children are stunted, it is difficult for them to
catch up in height later on, especially if they are
living in conditions that prevail in many developing
countries.”
- TRACKING PROGRESS ON CHILD AND MATERNAL NUTRITION,
A survival and development priority” (2009) UNICEF

35. UNICEF 2009

36. Mortality Risks
for 2,446 Hospitalized Children (Uganda)
TUMWINE et al. (2003) “CRYPTOSPORIDIUM PARVUM IN CHILDREN WITH DIARRHEA
IN MULAGO HOSPITAL, KAMPALA, UGANDA” Am. J. Trop. Med. Hyg., 68(6),, 710–715

37. Cryptosporidium Infection Rates in Infants
in India and Jamaica
Das et al. (2006) “Molecular
Characterization of Cryptosporidium
spp. from Children in Kolkata, India” LINDO et al. (1998) “EPIDEMIOLOGY OF
JOURNAL OF CLINICAL GIARDIASIS AND CRYPTOSPORIDIOSIS IN
MICROBIOLOGY,, 44, No. 11 JAMAICA” Am. J. Trop. Med. Hyg., 59(5), 717–721

38. Cryptosporidium – High Infection Rates in
Children < 24 Months (Pakistan)
IQBAL et al. (1999) “CRYPTOSPORIDIUM INFECTION IN YOUNG CHILDREN WITH
DIARRHEA IN RAWALPINDI, PAKISTAN” Am. J. Trop. Med. Hyg., 60(5), 868–870

39. CDC Study of Pathogen Antibodies in Children
(Guatemala)
STEINBERG et al. (2004) “PREVALENCE OF INFECTION WITH WATERBORNE
PATHOGENS: A SEROEPIDEMIOLOGIC STUDY IN CHILDREN 6–36 MONTHS OLD IN S
JUAN” SACATEPEQUEZ, GUATEMALA Am. J. Trop. Med. Hyg., 70(1), pp. 83–88

40. Common Waterborne Protozoan Pathogens
Young Children (Pakistan)
Adapted from IQBAL et al. (1999) “CRYPTOSPORIDIUM INFECTION IN YOUNG CHILDREN
WITH DIARRHEA IN RAWALPINDI, PAKISTAN” Am. J. Trop. Med. Hyg., 60(5), 868–870

41. Impact of Cryptosporidium Infection on
Ability of Intestines to Absorb Nutrients
Guerrant et al.
(2008)
“Malnutrition as
an enteric
infectious disease
with long-term
effects on child
development”
Nutr Rev.

42. Relative Risk Factors for Acute Malnutrition
(Botswana)
Mach et al. (2009) “Population-Based Study of a Widespread Outbreak of
Diarrhea Associated with Increased Mortality and Malnutrition in Botswana,
January – March, 2006” Am. J. Trop. Med. Hyg., 80(5),pp. 812-818

43. Asymptomatic Cryptosporidium Infection
and Malnutrition
• Cryptosporidium infection can be
associated with malnutrition with
or without overt diarrhea
(symptomatic or asymptomatic).

44. Impact of Asymptomatic Cryptosporidiosis on
Monthly Weight Gain in Peruvian Infants
Checkleyet al. (1997). "Asymptomatic and symptomatic cryptosporidiosis: their
acute effect on weight gain in Peruvian children." Am J Epidemiol 145(2): 156-163.

45. Repeated Enteric Infections Reduce
Availability of Nutrients
Repeated enteric pathogen infections reduce
availability of nutrients due to:
• Intestinal malabsorption - studies show that
damage to the small intestine mucosa (resulting in
decreased permeability) occurs as a result of
pathogen infection and resulting diarrhea.
• Increased losses due to diarrhea
• Increased metabolic needs

46. Diarrhea Outbreak Followed by
Severe Acute Malnutrition (Botswana)
Mach et al. (2009) “Population-Based Study of a Widespread Outbreak of Diarrhea Associated with Increased
Mortality and Malnutrition in Botswana, January – March, 2006” Am. J. Trop. Med. Hyg., 80(5), 812-818

47. HIV Negative Patients With
Malabsorption Syndrome
Adapted from: Behera et al. Parasites in Patients with Malabsorption Syndrome:
A Clinical Study in Children and Adults Dig Dis Sci (2008) 53:672–679

48. Top 3 Pathogens Associated with Malnourished
Zambian Children with Persistent Diarrhea
Amadi et al. (2001) “Intestinal and Systemic Infection, HIV, and Mortality in Zambian
Children With Persistent Diarrhea and Malnutrition” Journal of Pediatric Gastroenterology
and Nutrition

49. Giardia Infection and Zinc Malabsorption
Quihui et al. (2010) “Could giardiasis be a risk factor for low zinc status in schoolchildren from
northwestern Mexico? A cross-sectional study with longitudinal follow-up” BMC Public Health
10:85

50. Reduced Blood Levels of Zinc & Iron
Turkish Children with Giardia
= children with Giardia
= children without Giardia
Modified from Ertan et al. (2002) “Serological levels of zinc, copper and iron elements
among Giardia lamblia infected children in Turkey” Pediatrics International 44, 286–288

51. Reduced Blood Levels of Zinc & Iron
Egyptian Children with Giardia
Modified from Abou-Shady et al. Impact of Giardia lamblia on Growth, Serum Levels
of Zinc, Copper, and Iron in Egyptian Children (2010) Biol Trace Elem Res

52. Waterborne Protozoa Infection Levels in
Children with “Malabsorption Syndrome” (India)
Behera et al.

53. Some of the Impacts of Maternal
Zinc Deficiency
• Preterm delivery
• Low birth weight
• Maternal and infant mortality

54. Zinc and Diarrhea
Some possible mechanisms of the effect of zinc on
the duration and severity of diarrhea include:
• Improved absorption of water and electrolytes by
the intestines,
• Regeneration of gut lining,
• Improved immunity

55. Zinc Deficiencies, Children &
Multiple Diseases
• “A systematic review of relevant epidemiological
research involved meta-analysis from 11 intervention
trials. Results of our review indicate that zinc
deficiency in children aged <5 years increases the
risk of incidence for diarrhoeal disease by 1.28 (28%),
pneumonia by 1.52 (52%) and malaria by 1.56 (56%)”.
- from Caulfield and Black “Chapter 5 - Zinc deficiency” in
Comparative Quantification of Health Risks WHO

56. Zinc Deficiencies and Stunting
Black et al. (2008)
“Maternal and child
undernutrition: global
and regional exposures
and health
consequences” Lancet

57. Some Impacts of Maternal Anemia
• Increased maternal deaths
• Low birth weight
• Neonatal mortality
• Impaired cognition

58. Anemia, Children and Chronic Infection
• Anemia is highly prevalent among children in
developing countries
• SE Asia has the highest prevalence of anemia in
children, affecting approximately 2/3 of children
• Anemia caused by chronic infection may
account for a substantial proportion of anemia
among children

59. Ecuador
Adapted from Sackey et al. (2003) “Predictors and Nutritional Consequences of Intestinal
Parasitic Infections in Rural Ecuardorian Children” Journal of Tropical Pediatrics; Feb; 49

60. Adapted from: Sackey et al. (2003) “Predictors and Nutritional Consequences of Intestinal
Parasitic Infections in Rural Ecuardorian Children Journal of Tropical Pediatrics; Feb; 49

61. Key Messages
WASH and Malnutrition
• Waterborne pathogens cause “enteric infections”
that significantly contribute to malnutrition by
either (a) recurring or persistent diarrhea (b)
asymptomatic impacts to the intestines that
interfere with nutrient absorption (malabsorption)
• Cryptosporidium and Giardia appear to
particularly result in malabsorption/malnutrition

62. Key Messages Part I (cont.)
• Diarrhea and/or “asymptomatic” enteric
infections significantly contribute to or
cause zinc deficiencies, iron deficiencies
(anemia) and likely Vitamin A deficiencies

63. Part II
Waterborne Pathogens, Malnutrition and
Maternal/Child Mortality Rates

64. Introductory Quote
When a woman dies in childbirth, amid the
shock is the haunting question of “why? What
went wrong?”
Answering the question of “what went wrong?”
is .. critical to strengthening health systems.
– Quote from “Unaccountable - Addressing Reproductive Health Care
Gaps” (2010) Human Rights Watch

65. Definitions
• Anemia – is a decrease in normal number of red
blood cells (RBCs) or less than the normal
quantity of hemoglobin in the blood
• Bacteremia - is the presence of bacteria in the
blood
• Perinatal - the period occurring "around the time
of birth", up to 7 completed days after birth

66. Hepatitis E & Maternal Mortality
Adapted from Purcell & Emerson (2008) “Hepatitis E: an emerging awareness
of an old disease” J Hepatol. Mar;48(3):494-503

67. Percent of Hepatitis Due to Hep E
Purcell & Emerson (2008) “Hepatitis E: an emerging awareness of an
old disease” J Hepatol. Mar;48(3):494-503

69. Hepatitis E
• Because diagnostic tests vary greatly in
specificity, sensitivity and availability,
Hepatitis E is probably underdiagnosed.
• “Most outbreaks have occurred following
monsoon rains, heavy flooding,
contamination of well water, or massive
uptake of untreated sewage into city water
treatment plants.” - WHO

70. Diarrhea and Anemia
From: “Maternal Anemia: A Preventable Killer” USAID

71. Anemia - From USAID
• “Anemia is one of the most widely prevalent disorders,
affecting the lives of almost half a billion women of
reproductive age. Iron deficiency anemia, alone,
contributes to over 100,000 maternal and almost
600,000 perinatal deaths each year… impacts include
increased risk of infant mortality, pre-term delivery, low
birth weight, and reduced cognitive development in
children.
• Anemia has multiple causes: increased iron requirements
during pregnancy, inadequate intake of micronutrients…
and malaria, hookworm, HIV, diarrhea and other
infections.”

72. % Anemia & Low Birthweight - Nepal
%
TRACKING PROGRESS ON CHILD AND MATERNAL NUTRITION,
A survival and development priority” (2009) UNICEF

73. > 600% Increase in Maternal Mortality Rate
(MMR) Due to Anemia (Gambia)
ANYA S. A. (2004) “SEASONAL VARIATION IN THE RISK AND CAUSES OF
MATERNAL DEATH IN THE GAMBIA: MALARIA APPEARS TO BE AN IMPORTANT
FACTOR” Am. J. Trop. Med. Hyg., 70(5)

74. IDA = Iron Deficiency
Anemia
From: “Maternal Anemia: A Preventable Killer” USAID

75. Anemia - Mechanisms of Maternal/Child Mortality
• “Women do not die in childbirth as a direct effect
of iron deficiency, but rather die of heart failure
due to blood loss, which is made more
precipitous by iron deficiency anaemia.”
• “Similarly, babies do not die in the perinatal
period from iron deficiency, but rather die of other
causes, some of which are related to preterm
birth, for which maternal iron deficiency is a risk
factor.”
Stoltzfus et al. (2004) “Chapter 3 – Iron deficiency anaemia” in Comparative
Quantification of Health Risks Global and Regional Burden of Disease
Attributable to Selected Major Risk Factors

76. Zinc and Mortality in Young
Children
• Zinc deficiency contributes substantially to
and mortality of young children throughout the
world.

77. Zinc, Vitamin A and Malaria
• “Although the association is complex and
requires additional research, ….Existing
evidence strongly suggests that micronutrient
deficiencies and general undernutrition
increase the burden of malaria morbidity and
mortality.”
• “Large numbers of children less than five
years old suffer and die of malaria due to
nutritional inadequacies in terms of protein
energy, zinc, and vitamin A.”
CAULFIELD et al. (2004) “UNDERNUTRITION AS AN UNDERYING
CAUSE OF MALARIA MORBIDITY AND MORTALITY IN CHILDREN LESS
THAN FIVE YEARS OLD” Am. J. Trop. Med. Hyg.71(Suppl 2), 55–63

78. Pakistan Railway Hospital Rawalpindi (2004 to 2005)
Modified from Bakhtiar et al. (2007) “Relationship between maternal hemoglobin
and perinatal outcome” The Journal of the Pakistan Medical Association

79. Brabin et al. (2001) “Analysis of Anemia and Child Mortality” The Journal of Nutrition

80. Brabin et al. (2001) “Analysis of Anemia and Child Mortality” The Journal of Nutrition

81. Maternal Anemia and Stillbirths
“It has been suggested that low
hemoglobin (iron) concentrations can
cause a state of chronic hypoxia, which is
presumably exacerbated in pregnancy
when oxygen demands are particularly
high because of the metabolism of the
mother and the fetus, and that oxygen
transfer to the fetus is probably reduced in
anemic women.”
- Yatich et al. (2010) “Malaria, Intestinal Helminths and
Other Risk Factors for Stillbirth in Ghana” Infectious
Diseases in Obstetrics and Gynecology Article ID 350763

82. Stillbirths and Anemia
• “Of the 130 million babies born worldwide every
year, approximately 4 million are stillborn, more
than 98% of these occur in developing countries.
Stillbirth accounts for more than half of perinatal
mortality in developing countries.”
• “Stillbirths have not been widely studied, have
been under-reported, and rarely have been
considered in attempts to improve birth
outcomes in developing countries.”
- Yatich et al. (2010) “Malaria, Intestinal Helminths and Other
Risk Factors for Stillbirth in Ghana” Infectious Diseases in
Obstetrics and Gynecology Article ID 350763

84. Modified from Yatich et al. (2010) “Malaria, Intestinal Helminths and
Other Risk Factors for Stillbirth in Ghana” Infectious Diseases in
Obstetrics and Gynecology Article ID 350763

85. Zupan J “Perinatal Mortality in Developing Countries” (2005) N Engl J Med 352;20

86. Schistosomiasis & Maternal/Infant Mortality
• “Approximately, 10 million women in Africa
have schistosomiasis in pregnancy. Pregnant
women infected with schistosomiasis develop
severe anemia, have low birth weight infants,
and an increased infant and maternal mortality
rate. Schistosomiasis has been detected in the
placenta and newborns”
• “Data suggest that infected women have a higher
rate of spontaneous abortions and a higher risk for
ectopic pregnancies.”
- N. M.Nour (2010) “Schistosomiasis: Health Effects on Women”
REVIEWS IN OBSTETRICS & GYNECOLOGY VOL. 3 NO. 1

87. Countries at High Risk of Schistosomiasis (in red)

88. Reduction in Schistosomiasis & Trachoma
from Watsan Interventions
Esrey et al. (1991) “Effects of improved water supply and sanitation on ascariasis,
diarrhoea, dracunculiasis, hookworm infection, schistosomiasis, and trachoma”
Bulletin of the World Health Organization, 69 (5): 609-621

89. Mortality Risks for Cryptosporidiosis
2,446 Hospitalized Children (Uganda)
TUMWINE et al. (2003) “CRYPTOSPORIDIUM PARVUM IN CHILDREN WITH DIARRHEA IN
MULAGO HOSPITAL, KAMPALA, UGANDA” Am. J. Trop. Med. Hyg., 68(6), 710–715

90. Cryptosporidiosis in Infancy and Mortality
Molbak et al. (1993) “Cryptosporidiosis in infancy and childhood mortality in
Guinea Bissau, West Africa” British Medical Journal;307:417-20

91. Chlorinating Water is Not Enough!
• “Our findings demonstrate a high incidence of
acute Cryptosporidium infection in children in
Mexico City with no immune disorders and
apparently adequate sanitary conditions at home
and in the surrounding environment.
• The families of the children in this study had
chlorinated water....The parents of these children
washed their hands before preparing and eating
meals …”
- SANCHEZ-VEGA et al. (2006) “CRYPTOSPORIDIOSIS AND
OTHER INTESTINAL PROTOZOAN INFECTIONS IN CHILDREN
- LESS THAN ONE YEAR OF AGE IN MEXICO CITY” Am. J. Trop.
Med. Hyg., 75(6), pp. 1095–1098

93. Non-typhoid Salmonella & African Children
• “Nontyphoidal salmonellae (NTS) have long been
a common but relatively neglected cause of
invasive disease in children living in tropical
Africa especially during rainy seasons.”
• “NTS bacteraemia has consistently been
associated with young age (most cases present
between 6 months and 3 years of age), anaemia,
malnutrition and more recently with HIV infection,
with reported case-fatality rates of over 20%.”
• “NTS are also a common and frequently fatal
cause of meningitis.”
Graham and English (2009) “Nontyphoidal salmonellae: a management challenge for
children with community acquired invasive disease in tropical African countries” Lancet.
January 17; 373(9659): 267–269

94. Non-Typhoid Salmonella Infections in
Children & Rainfall (Malawi)

95. NTS Increasingly Common Cause of
Severe Bacterial Disease in Africa
• “As immunisation with Haemophilus influenzae
type b (Hib) vaccine becomes more widely
available, NTS together with Streptococcus
pneumoniae are the major causes of severe
bacterial disease in African children from
2 months to 5 years of age.”
• “Future implementation of pneumococcal
vaccines is likely to further emphasise their (NTS)
relative importance as a pathogen …”
– Graham and English (2009) “Nontyphoidal salmonellae: a
management challenge for children with community acquired invasive
disease in tropical African countries” Lancet 373(9659): 267–269

96. Non-typhoid Salmonella Bacteremia vs. Age
MacLennan et al.
(2008) “The
neglected role of
antibody in protection
against bacteremia
caused by
nontyphoidal
strains of Salmonella
in African children”
The Journal of
Clinical Investigation

97. Anti-Salmonella Antibodies are Lower in Infants
MacLennan et al. (2008) “The neglected role of antibody in protection against bacteremia
caused by nontyphoidal strains of Salmonella in African children” J. Clin. Invest.
118:1553–1562

98. Bacteremia Prevention
(e.g. safe water and food)
• “The considerable mortality associated with
community- acquired bacteremia and the short
interval between admission and death, despite
careful implementation of the WHO
recommendations for treatment, highlight the need
for prevention.”
• “Even where microbiologic facilities exist, causative
organisms can be identified only after 24 to 48
hours, by which time most deaths in children with
bacteremia have already occurred.”
Berkely et al. (2005) N Engl J Med;352:39-47.

99. Morpeth et al.
(2009) “Invasive
Non-Typhi
Salmonella”
Disease in Africa
Clin Infect Dis. Aug
15;49(4)

100. Reddy et al. (2010)
“Community-acquired
bloodstream infections
in Africa: a systematic
review and meta-
analysis” Lancet
Infectious Disease Vol
10 June

101. Bacterial Contamination of Water Can Also Contaminate Food
Adapted from: “Tackling the silent killer, The case for sanitation” by
WaterAid (2008)

102. Reduced Risk of Neonatal Mortality
for Maternal Handwashing (Nepal)
Days Since Delivery
Modified from Rhee et al. (2008) “Impact of Maternal and Birth Attendant Hand-washing on
Neonatal Mortality in Southern Nepal” Arch Pediatr Adolesc Med. July ; 162(7): 603–608

103. Key Messages
Maternal and Child Mortality and WASH
• Waterborne Hepatitis E infections during
pregnancy result in high mortality rates to
mothers (up to 20%)
• Cryptosporidium contributes to high mortality
rates in children < 5 particularly where
malnutrition rates are high
• Diarrhea contributes to anemia which results in
significantly higher mortality rates for mothers,
and infants

104. Key Messages Part II (cont.)
• Diarrhea and/or reoccurring or persistent
“enteric infection” driven zinc deficiency results
in increased child mortality rates
• Schistosomiasis results in significantly higher
maternal and infant mortality rates
• Non-typhoid Salmonella commonly originates
from water or food and in sub-Saharan Africa
can spread from the gut (becomes invasive) to
becomes a common cause of fatal blood
infections in children

105. Part III
Waterborne Pathogens-Malnutrition-
Impaired Development in Children

106. Definitions
• Cognitive – the “process of thought”
• Schizophrenia – a mental disorder characterized
by abnormalities in the perception or expression
of reality.

107. Long-Term Impacts of Malnutrition
“Malnutrition is well recognized as a widespread
health problem with consequences that are both
acute and, even more often, long-term. However,
the long-term effects, especially from
nutritional deficits early in life, on children
who don't die, but have their development
impaired, may exceed even the troubling
mortality.”
- Guerrant et al. (2008) “Malnutrition as an enteric infectious disease with long-
term effects on child development” Nutr Rev. September; 66(9): 487–505.

108. Weight of Child at 4-5 Years Old
Can Mask Earlier Deficiencies
• “Whereas a deficit in height (stunting) is difficult
to correct, a deficit in weight (underweight) can
be recouped if nutrition and health improve later
in childhood.”
• “The weight of a child at 4–5 years old, when it
is adequate for the child’s age, can therefore
mask deficiencies that occurred during
pregnancy or infancy, and growth and
development that have been compromised.”
- TRACKING PROGRESS ON CHILD AND MATERNAL NUTRITION,
A survival and development priority” (2009) UNICEF

109. Chronic Undernutrition in Early Childhood &
Diminished Cognitive Development
•“Chronic undernutrition in early childhood also
results in diminished cognitive and physical
development, which puts children at a
disadvantage for the rest of their lives. They may
perform poorly in school, and as adults they may
be less productive, earn less and face a higher
risk of disease than adults who were not
undernourished as children.”
- “TRACKING PROGRESS ON CHILD AND MATERNAL NUTRITION, A survival
and development priority” (2009) UNICEF

110. Diarrhea and Anemia
From: “Maternal Anemia: A Preventable Killer” USAID

111. Anemia as a “Direct” Cause of
Impaired Child Development
“Decreased work productivity and altered
child development (or intelligence) were
considered to be direct sequelae (result)
of iron deficiency, the assumption being
that iron deficiency directly causes
decreased oxygen delivery to muscles and
the brain.”
Stoltzfus et al. (2004) “Chapter 3 – Iron deficiency anaemia” in
Comparative Quantification of Health Risks Global and Regional Burden of
Disease Attributable to Selected Major Risk Factors WHO

112. Low Birthweight & Impaired Development
“Some reviews also suggest high rates
of cognitive impairment, learning disability,
and behavioural problems among children
who were born with lower birthweight, which
is likely to be caused by sub-optimum
development of the brain”.
- Desai et al. (2007) “Epidemiology and burden of malaria
in pregnancy” Lancet Infect Dis; 7:93–104

113. Child Underweight and Stunting
• “Of the 555 million preschool children in developing
countries, 32% are stunted and 20% are
underweight …and leads to long-term cognitive
deficits, poorer performance in school and
fewer years of completed schooling, and lower
adult economic productivity.
• Child underweight state or stunting mainly
develops during the first 2 years of life, when
mean weight-for-age and length-for-age Z scores of
children in Africa and Asia drop to about –2.0, with
little or no recovery thereafter.”
Humphrey (2009) “Child undernutrition, tropical enteropathy, toilets, and
handwashing” Lancet; 374: 1032–35

114. Giardia and Cryptosporidium
& Impaired Development
• “Giardia and Cryptosporidium are ubiquitous enteric
protozoan pathogens…Both pathogens are significant
causes of diarrhea and nutritional disorders …”
• “In developing regions of the world, Giardia and
Cryptosporidium constitute part of the complex group
of parasitic, bacterial and viral diseases that impair
the ability to achieve full potential and impair
development and socio-economic improvements.”
- from article by the WHO Coordinator, Parasitic Diseases and Vector
Control - Savioli et al. (2006) “Giardia and Cryptosporidium join the
‘Neglected Diseases Initiative” Trends in Parasitology Vol.22 No.5 May

115. Guerrant et al. (2008) “Malnutrition as an enteric infectious disease with long-
term effects on child development” Nutr Rev. September; 66(9): 487–505.

116. Impact of Giardia on
Cognitive Development
“Giardiasis can lead to zinc and other
micronutrient deficiencies that have
been associated with deficits in
cognitive development.”
- Berkman et al. (2002) The Lancet

117. Impact of Giardia and Severe Stunting
on Test Scores
Berkman et al. (2002) “Effects of stunting, diarrhoeal disease, and parasitic infection
during infancy on cognition in late childhood: a follow-up study” The Lancet

118. Impact of Early Childhood Persistent Diarrhea on Intelligence
NIEHAUS et al.
EARLY
CHILDHOOD
DIARRHEA IS
ASSOCIATED WITH
DIMINISHED
COGNITIVE
FUNCTION 4 TO 7
YEARS LATER IN
CHILDREN IN A
NORTHEAST
BRAZILIAN
SHANTYTOWN Am.
J. Trop. Med. Hyg.,
66(5), 2002

120. Early Cryptosporidiosis and Lasting
Impairments in Growth and Development
• “Without question, cryptosporidiosis
constitutes a leading cause of persistent
diarrhea in tropical, developing areas, …among
children, in whom it often signals a period of
increased diarrhea burden or nutrition shortfalls…
• The impact and consequences of
cryptosporidiosis may well be far greater than
generally appreciated, because of the lasting
impairments in growth and development that
may follow, especially with early childhood
infections in impoverished areas”
- From Dillingham et al. (2002) “Cryptosporidiosis: epidemiology
and impact” Microbes and Infection 4 1059–1066
–

121. Diarrhea and Growth in Children
• “Cryptosporidial infections and persistent diarrhoea
predispose to increased diarrhoea morbidity and
nutritional shortfalls for up to 18 months”.
• “Cryptosporidial infections at <6 months of age and
in stunted children predispose to 0.95–1.05 cm
growth deficits one year later.”
• “Early childhood diarrhoea (at 0–2 years old)
associates with lasting growth shortfalls, persisting
at 3.6 cm at seven years old, and additive to 8.2 cm
with intestinal helminths at 0–2 years old”.
– Guerrant et al. (2002) “Updating the DALYs for diarrhoeal
disease” TRENDS in Parasitology Vol.18 No.5

122. Malnutrition, Loss of Cognitive Function
and Specific Pathogens
“Studies linking specific microbes with
malnutrition are limited, but currently there
are data linking malnutrition and attendant
loss of cognitive function to infection with
EAEC, ETEC, Shigella, Ascaris,
Cryptosporidium, E. histolytica, Giardia, and
Trichuris trichiura”
- Petri et al. (2008) “Enteric infections, diarrhea, and their impact on function and
development” J Clin Invest. April 1; 118(4): 1277–1290

123. Waterborne Toxoplasma Infections
Impacts on Pregnant Women & Offspring
From CDC

124. Toxoplasma Infection During
Pregnancy and Impaired Development
• “Acute infection with Toxoplasma during
pregnancy and its potentially tragic outcome for
the fetus and newborn continue to occur …
worldwide”
• “Transmission to the fetus occurs almost solely in
women who acquire their primary infection during
gestation and can result in visual and hearing
loss, mental and psychomotor retardation,
seizures, …. or death. Toxoplasmosis in
pregnant women most often goes
unrecognized.”
– from Montoya and Remington (2008)
“Management of Toxoplasma gondii Infection during
Pregnancy” Clinical Infectious Diseases 47:554–66

125. Pregnancy, Immunity and
Toxoplasma Infection
Production of progesterone during
pregnancy leads to downregulation of
immune functions, and therefore
increases the risk of Toxoplasma
infection in pregnant women.

126. Toxoplasma Infection During Pregnancy
Impacts on Offspring
Adapted from: McLeod et al. (2006)
“Outcome of Treatment for
Congenital Toxoplasmosis,
1981–2004: The National
Collaborative Chicago-
Based, Congenital Toxoplasmosis
Study” Clinical Infectious Diseases
42:1383–94

127. Toxoplasma Infection and Risk of Infection
and Clinical Signs
Adapted from: Montoya and Remington (2008) “Management of
Toxoplasma gondii Infection during Pregnancy” Clinical Infectious
Diseases; 47:554–66

128. Toxoplasma Contamination by Water Source
(Polish Farms)
Sroka et al. (2006) “OCCURRENCE OF TOXOPLASMA GONDII IN WATER FROM
WELLS LOCATED ON FARMS” Ann Agric Environ Med, 13, 169–175

129. Toxoplasma and Lack of Protective
Antibodies in Pregnant Women (cont.)
Elsheikha H.M, (2008) “Review
Paper Congenital
toxoplasmosis: Priorities for
further health promotion action”
Public Health 122, 335–353

130. Toxoplasma - CDC
“If you are newly infected with Toxoplasma while
you are pregnant, or just before pregnancy, then
you can pass the infection on to your baby. You
may not have any symptoms from the infection.
Most infected infants do not have symptoms
at birth but can develop serious symptoms
later in life, such as blindness or mental
disability.”
CDC (2008)

131. Toxoplasma, Pregnancy & Schizophrenia
• “Previous studies have shown that maternal
antibodies to Toxoplasma measured during
pregnancy are associated with an increased
risk of schizophrenia and other psychoses in
adult offspring.”
• “Recently, it has been recognized that different
genotypes of Toxoplasma have distinct
neuropathogenic potential.”
– Xiao et al. (2009) “Serological pattern consistent with infection with
type I Toxoplasma gondii in mothers and risk of psychosis among
adult offspring” Microbes and Infection 11 1011-1018

132. Toxoplasma and Schizophrenia
• From 1953 - 2003, 19 studies reported of
Toxoplasma antibodies in persons with
schizophrenia and other severe psychiatric
disorders
• 18 of the 19 reported a higher percentage of
Toxoplasma antibodies in the affected patients;
in 11 studies the difference was statistically
significant.
Source - Torrey and Yolken (2003) “Toxoplasma gondii and
Schizophrenia” Emerging Infectious Diseases

133. Chlorine is Not Effective for Toxoplasma
• “Toxoplasma is increasingly recognized as a
waterborne pathogen. Infection can be acquired
by drinking contaminated water …..
• Oocysts were exposed to 100 mg/L of chlorine for
30 min, or for 2, 4, 8, 16, and 24 hr.
• Results of the chemical exposure experiments
indicate that neither sodium hypochlorite nor
ozone effectively inactivate T. gondii oocysts,
even when used at high concentrations.”
Wainwright et al. (2007) “CHEMICAL INACTIVATION OF
TOXOPLASMA GONDII OOCYSTS IN WATER” J. Parasitol., 93(4)

134. Trachoma
• “6 million people worldwide are blind because
of trachoma—the leading cause of
preventable blindness—and more than 150
million people need treatment.”
• “Improving access to water and better hygiene
can reduce trachoma morbidity by 27%”
– Bartram et al. (2005) “Focusing on improved water and sanitation for health” The
Lancet

135. Trachoma Prevalence by Age
Burton et al. (2003) “Which Members of a Community Need Antibiotics to Control
Trachoma? Conjunctival Chlamydia trachomatis Infection Load in Gambian
Villages” Investigative Ophthalmology & Visual Science, 44, 10

136. Trachoma Risk and Latrines
(Villages in Gambia)
Note that since “Water supply was equally good in all villages, water
could not be assessed as a risk factor” in this study.
Burton et al. (2003) “”Which Members of a Community Need Antibiotics to Control
Trachoma? Conjunctival Chlamydia trachomatis Infection Load in Gambian Villages”
Investigative Ophthalmology & Visual Science,, 44, 10

137. Key Messages Part III
Impaired Development & Waterborne Pathogens
• Giardia and Cryptosporidium likely negatively
impact cognitive development in children
• Toxoplasma infection (from water or certain
undercooked meats) usually has very
serious development impacts on offspring

138. Key Messages Part III (cont.)
• Diarrhea contributes to anemia which can
have impacts on child development due to
reduced oxygen to the fetus
• Trachoma is a common cause of
blindness in children in some countries
significantly impacting child development.
WASH interventions such as hygiene can
significantly lower Trachoma rates