Diarrheal diseases are among the leading causes of childhood illness and death in developing countries, killing an estimated 1.3 million children less than five years of age annually (Black et al., 2010).
The World Health Organization outlines several aspects critical to the prevention of diarrhea. They include improved drinking water systems and sanitation facilities, improved nutrition (through breast-feeding and better weaning practices), and good personal and domestic hygiene, among others (United Nations Children's Fund/World Health Organization [WHO], 2009). Several studies have demonstrated a high prevalence of bacterial contamination of water and foods within households (Black et al., 1989; Lanata, 2003; Wright et al., 2004), which is likely associated with incidence of infections in susceptible individuals, especially children.
A need exists for effective interventions in developing countries that can minimize food and water contamination at the household level and therefore reduce the rate of diarrhea in these environments (Hunter, 2009; Lanata, 2003). By measuring risky practices and behaviors and identifying kitchen sites, niches, and surfaces that harbor pathogenic microorganisms, we can provide a basis from which to develop effective interventions. The aim of our study was to identify those potential exposures at the household level, specifically those associated with contamination of food, drinking water, kitchen utensils and surfaces, and caregivers' and children's hands. Our study was conducted to inform a subsequent randomized trial that evaluated the health effects of an integrated home-based intervention package in a rural area of Peru. In addition, we tested for the presence of diarrheagenic E. coli (Nataro & Kaper, 1998) as an indicator of pathogenic E. coli in this setting.
Materials and Methods
Our study was conducted in rural communities of San Marcos Province, Cajamarca, situated at 2,200 to 3,900 m above sea level in the highlands of Peru. Daily temperatures ranged from 7.6[degrees]C-25.0[degrees]C during the study period and relative humidity was between 59% and 73%. Agriculture and subsistence farming are the major economic activities in this area. Houses are mud brick structures with clay tile roofs supported by tree rods, earthen floors, and few open windows. A typical house consists of three rooms: a kitchen and dining room, a living and sleeping room, and a storage area. Water supply for about 61% of rural homes in San Marcos comes from a piped gravity system that transports untreated water captured from springs through individual or small-scale collective plastic piping to a tap in the courtyard. Only 9% of households have electricity, 2% have a closed sewage system, and 75% have access to a pit latrine (Instituto Nacional de Estadistica e Informatica, 2007).
Meals are based mainly on potatoes and other tubers and legumes, eaten with rice or boiled in a soup or a stew. Red meat and chicken are seldom consumed due to their high cost. Animals like dogs, guinea pigs, and chickens roam free in kitchens and households. The latter two are bred at home for sale or reserved for festive meals. Meals are prepared three to four times a day and eaten by adults and children alike. Leftover food is not consumed but discarded or fed to the animals. No time is set at which to start cooking the midday meal. Mothers start cooking anywhere from 8:00 a.m. to 12:00 p.m. and keep the food on the fire until lunch. Meals are served directly from pots to plates using wooden ladles. Kitchen utensils are washed with water brought from an outside faucet in a plastic basin, and a malla, a local kitchen cloth, also is used to clean dirty surfaces and caregivers' hands while cooking. The malla is kept wet after rinsing in the same washing up water, which is not changed very often.
Most households have access to tap water from a faucet installed in the yard. The gravity-based piped water supply system provides spring water to each household. The water is unfiltered, untreated, and chlorination is uncommon. Drinking water is either consumed directly from the faucet or boiled with herbs for children's consumption only. Hygiene practices include hand washing with water only; soap and detergent are rarely used.
Households were identified in 32 communities based on home visits and enrolled by a trained field worker between April and September 2008 if they had a child aged 6 to 35 months. Field workers visited each participating household (N = 64) once, mostly at noon, to sample food, water, and kitchen environments.
In each household approximately 20 g of each food served to the child was collected. If the child had already eaten, samples were taken from the pot. Between 50 and 100 mL of the child's drinking water and one sample from each of the available kitchen utensils (i.e., dish, cup, pot, cutlery, cutting board, and kitchen cloth) were also collected. For both the child and the caregiver, one hand was rinsed in buffer solution for microbiological testing. Samples were collected following standard procedures (Swanson, Busta, Peterson, & Johnson, 1992; WHO, 1997).
For kitchen surfaces, a 10 x 10 cm area of...