Exposure to aflatoxin and fumonisin in children at risk for growth impairment in rural Tanzania

listen audio

Study Justification:
– Growth impairment is a major public health issue for children in Tanzania.
– The study aims to investigate whether dietary mycotoxins, specifically aflatoxin and fumonisin, play a role in compromising children’s growth.
– The study focuses on children under 36 months of age in Haydom, Tanzania, where there are comparatively high rates of growth impairment.
Study Highlights:
– Plasma samples from 60 children at 24 months of age were analyzed for aflatoxin B1-lysine (AFB1-lys) adducts, and urine samples from 94 children between 24 and 36 months of age were analyzed for urinary fumonisin B1 (UFB1).
– 72% of the children had detectable levels of AFB1-lys, with a mean level of 5.1 pg/mg albumin.
– 80% of the children had detectable levels of UFB1, with a mean level of 1.3 ng/ml.
– The cohort had a 75% stunting rate (height-for-age z-scores < -2) at 36 months.
– No associations were found between aflatoxin exposures and growth impairment, but fumonisin exposure was negatively associated with underweight.

Recommendations:
– Further research is needed to understand the relationship between fumonisin exposure and growth impairment.
– Breastfeeding and weaning practices should be further investigated as potential factors contributing to the high growth impairment rate in Haydom, Tanzania.

Key Role Players:
– Researchers and scientists specializing in mycotoxins and child growth.
– Medical professionals and public health officials in Tanzania.
– Community leaders and organizations in Haydom, Tanzania.

Cost Items for Planning Recommendations:
– Research funding for further studies and investigations.
– Resources for data collection, analysis, and interpretation.
– Training and capacity building for local healthcare professionals and researchers.
– Community outreach and education programs.
– Monitoring and evaluation of interventions and strategies implemented to address growth impairment.

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is relatively strong, but there are some areas for improvement. The study design is well-described, and the sample size is adequate. The biomarker measurements for aflatoxin and fumonisin exposure are reliable. However, the abstract does not provide detailed information on the statistical methods used, such as the specific regression models or adjustments for confounding variables. Additionally, the abstract does not mention any limitations of the study. To improve the evidence, the authors should provide more information on the statistical analysis methods used and discuss any limitations of the study.

Growth impairment is a major public health issue for children in Tanzania. The question remains as to whether dietary mycotoxins play a role in compromising children’s growth. We examined children’s exposures to dietary aflatoxin and fumonisin and potential impacts on growth in 114 children under 36 months of age in Haydom, Tanzania. Plasma samples collected from the children at 24 months of age (N = 60) were analyzed for aflatoxin B1-lysine (AFB1-lys) adducts, and urine samples collected between 24 and 36 months of age (N = 94) were analyzed for urinary fumonisin B1 (UFB1). Anthropometric, socioeconomic, and nutritional parameters were measured and growth parameter z-scores were calculated for each child. Seventy-two percent of the children had detectable levels of AFB1-lys, with a mean level of 5.1 (95% CI: 3.5, 6.6) pg/mg albumin; and 80% had detectable levels of UFB1, with a mean of 1.3 (95% CI: 0.8, 1.8) ng/ml. This cohort had a 75% stunting rate [height-for-age z-scores (HAZ) < −2] for children at 36 months. No associations were found between aflatoxin exposures and growth impairment as measured by stunting, underweight [weight-for-age z-scores (WAZ) < −2], or wasting [weight-for-height z-scores (WHZ) 1500 g. Exclusion criteria included diagnosis of congenital disease or severe neonatal disease (MAL-ED Network Investigators, 2014). IRB approval was obtained from the National Health Research Ethics Committee, which is part of the National Institute for Medical Research of Tanzania, and Michigan State University. In total, plasma samples collected at 24 months of age (N = 60) were utilized for measuring aflatoxin B1-lysine (AFB1-lys) biomarker concentrations and urine samples collected between 24 and 36 months of age (N = 94) were analyzed for urinary fumonisin B1 (UFB1) concentrations. Eighteen of the participants had both a plasma and a urine sample for the AFB1-lys and UFB1 analysis at the same timepoint of 24 months. AFB1-lys is a well-established biomarker of long-term dietary aflatoxin exposure during the past 2–3 months. Its concentrations were determined by liquid chromatography isotope dilution mass spectrometry (LC/MS) as described in Groopman et al. (2004) and McCoy et al. (2008). Briefly, plasma (200 μl) was vortexed with internal standard, 10 μl × 0.1 ng AFB1-D4-lys/ml, and pronase and incubated for 18 h at 37 °C. Samples were passed through solid-phase extraction (SPEs) columns and the eluent analyzed using ultra performance liquid chromatography – tandem mass spectrometer (UPLC-MS/MS). The parent ion for AFB1-D4-lys [(M+H)+, m/z 461.3] fragmented to yield a daughter ion at m/z 398.2. The AFB1-lys ion (m/z 457.2) fragmented to yield a daughter ion at m/z 394.1. This methodology had a limit of detection of 0.4 pg AFB1-lys/mg albumin and was run with quality control samples run in triplicate. Urinary fumonisin B1 (UFB1) has been proposed as an effective biomarker for dietary fumonisin exposure over the past 24 h, and is currently used worldwide for biomonitoring of human fumonisin exposure (van der Westhuizen et al., 2013). A significant correlation in a positive dose-dependent manner was observed between dietary fumonisin exposure and the UFB1 levels in human populations (Riley et al., 2015). The analytical method used for UFB1 was a minor modification of a method described previously (Riley et al., 2012). Briefly, urine samples (2 ml) containing 10 ng of U-[13C34]-FB1 (33621 Sigma-Aldrich Corp. St. Louis, MO, USA 33621) were extracted for FB1 with C18-SPE cartridges. The loaded cartridges were eluted using 2 ml of 70% acetonitrile: 30% water made to 0.1% formic acid as previously described (Riley et al., 2012). The eluates were concentrated under N2 at room temperature, so that the final acetonitrile-to-water concentration (based on specific gravity) was 30%–70%, and approximately 0.1% formic acid. Quantitation was accomplished by LC/MS as previously described. Normalization of UFB1 concentrations was described in the Supplemental material. The limit of detection for UFB1 is 0.01 ng/ml. The detection limits for FB2 and FB3 are similar (Riley et al., 2012). MAL-ED trained staff members measured anthropometrics of children enrolled in the study on a monthly basis. Quality control measures included standardized techniques and instruments across study sites, and measurements were repeated on a subset of participants. Standard infant scales (SECA) were used to measure weight at the nearest 0.1 kg and length measuring board or non-stretch Teflon synthetic tape (SECA) was used to measure height at the nearest 0.1 cm, respectively. Socioeconomic status (SES) is a conceptualization of an individual’s, household’s or community’s access to resources and can be measured using various methodologies. Prior to initiation of recruitment and consent among participants, the MAL-ED network undertook preliminary research to determine an appropriate methodology to measure SES that could be applicable in a multi-country study. Determination of the critical variables and resources allowed the MAL-ED network to formulate an index of household SES called the Water/sanitation, Assets, Maternal education, and Income (WAMI) to be applied and comparable across multiple countries (Psaki et al., 2014). Components included in the WAMI index include improved access to water and sanitation, wealth measured by a set of assets, maternal education, and monthly household income. In the present study, the methodology used for combining these components into a WAMI score was conducted according to Psaki et al. (2014). Mothers or other adult household members were queried monthly (months 9–36 of the children’s lives) to collect the children’s 24-hour dietary recall data, which were used to derive food and nutrient intake information. For our analyses, we averaged monthly data points to produce estimated intakes for two age ranges: 16–24 months and 25–36 months. These data were analyzed in relation to mycotoxin biomarker concentrations. Using Haydom’s food composition tables, we quantified energy, macronutrient and micronutrient intakes including vitamin A, zinc, iron, folate, protein, animal protein, and protein from milk, meat, fish, poultry, eggs, and insects (Lukmanji et al., 2008). These variables were adjusted for average total energy intake (kcal), by calculation of the residuals from an ordinary least squares regression analysis (Willett and Stampfer, 1986). The residual values were used in all statistical analyses (MAL-ED Network Investigators, 2017a). Grain-based food items measured in the dietary recall questionnaire included rice, maize, wheat, millet, sorghum, and common beans; whereas chickpeas and mung beans are consumed at much lower frequencies. Maize makes up the main part of the children’s weaning foods (Kimanya et al., 2010). These data were averaged over the timepoints 16–24 months for aflatoxin and 24–36 months for fumonisin. The data were normally distributed (goodness of fit test, p < 0.27) and not adjusted for statistical analysis. The AFB1-lys data were not normally distributed, even following lognormal transformation. Therefore, all statistical analyses of AFB1-lys were conducted utilizing tests for non-parametric data. UFB1 was not normally distributed and had a significant portion of non-detectable values, therefore they were log (x + 1) transformed prior to statistical analysis. AFB1-lys, UFB1 and growth indicators were analyzed by univariate analysis with all possible confounding variables (dietary intake variables including plasma vitamin A, iron, zinc, protein and animal protein, folate, SES index, and gender). Anthropometric data (HAZ, WAZ and WHZ z-scores) were normally distributed and were not altered for statistical analysis. Wilcox-rank sum tests were used to analyze statistical differences between AFB1-lys or UFB1 concentrations and categorical data. Linear regression models were built with each growth indicator – HAZ, WAZ, and WHZ at 36 months of age – as dependent variables, and AFB1-lys or UFB1 concentrations as independent variables. A p value ≤ 0.05 (two-tailed) was considered statistically significant. All statistical analyses were conducted with JMP software version 13.1 (SAS Institute, Cary, NC, USA). In addition, both AFB1-lys and UFB1 concentrations were categorized by quartile, and assessed by z-scores using ANOVA followed by Tukey HSD tests to compare between quartiles and all other variables.

Based on the provided information, here are some potential innovations that could be used to improve access to maternal health:

1. Telemedicine: Implementing telemedicine services can help overcome geographical barriers and provide remote access to healthcare professionals for prenatal care, consultations, and monitoring of maternal health.

2. Mobile health (mHealth) applications: Developing mobile applications that provide educational resources, reminders for prenatal appointments, and access to healthcare information can empower pregnant women to take control of their health and make informed decisions.

3. Community health workers: Training and deploying community health workers who can provide basic prenatal care, education, and support to pregnant women in rural areas can improve access to maternal health services and ensure continuity of care.

4. Mobile clinics: Establishing mobile clinics that travel to remote areas can bring essential maternal health services, including prenatal care, vaccinations, and screenings, directly to underserved communities.

5. Health financing innovations: Implementing innovative financing models, such as microinsurance or community-based health financing schemes, can help overcome financial barriers and ensure that pregnant women have access to affordable maternal health services.

6. Public-private partnerships: Collaborating with private sector organizations, such as pharmaceutical companies or technology companies, can leverage their resources and expertise to improve access to maternal health services, including the development of affordable diagnostic tools or medications.

7. Maternal health information systems: Implementing robust information systems that track maternal health indicators, monitor service utilization, and identify gaps in care can help policymakers and healthcare providers make data-driven decisions to improve access and quality of maternal health services.

It is important to note that these recommendations are general and may need to be tailored to the specific context and needs of the community in Haydom, Tanzania.
AI Innovations Description
The study mentioned focuses on the exposure to aflatoxin and fumonisin in children at risk for growth impairment in rural Tanzania. The researchers examined the children’s exposures to dietary aflatoxin and fumonisin and their potential impacts on growth. The study found that fumonisin exposure was negatively associated with underweight in the children, while aflatoxin exposure did not show a significant association with growth impairment.

Based on this study, a recommendation to improve access to maternal health and potentially reduce growth impairment in children could be to implement interventions that address dietary mycotoxin exposure. This could include:

1. Education and awareness: Providing education to mothers and caregivers about the risks of aflatoxin and fumonisin exposure and how to minimize it through proper food storage, handling, and preparation.

2. Improved food storage and processing: Promoting the use of proper storage techniques, such as drying, to reduce the growth of molds and mycotoxin production in food. Encouraging the use of safe and effective food processing methods, such as fermentation or cooking, to reduce mycotoxin levels.

3. Access to safe and nutritious food: Ensuring access to a diverse and nutritious diet for pregnant women and young children, including foods that are less prone to mycotoxin contamination. This could involve promoting the cultivation and consumption of crops that are less susceptible to mycotoxin contamination, as well as supporting local food production and distribution systems.

4. Regular monitoring and surveillance: Implementing regular monitoring and surveillance systems to assess mycotoxin levels in food and to identify high-risk areas or populations. This information can help inform targeted interventions and ensure the effectiveness of existing strategies.

5. Collaboration and partnerships: Collaborating with local communities, healthcare providers, researchers, and policymakers to develop and implement comprehensive strategies to address mycotoxin exposure and improve maternal health outcomes. This could involve partnerships with agricultural and food safety agencies, as well as engagement with community leaders and organizations.

By implementing these recommendations, it is possible to reduce the exposure to aflatoxin and fumonisin in pregnant women and young children, potentially improving maternal health and reducing the risk of growth impairment in children.
AI Innovations Methodology
To improve access to maternal health, here are some potential recommendations:

1. Mobile Health (mHealth) Solutions: Utilize mobile technology to provide maternal health information, reminders for prenatal care appointments, and access to telemedicine consultations.

2. Community Health Workers: Train and deploy community health workers to provide maternal health education, prenatal care, and postnatal support in rural areas where access to healthcare facilities is limited.

3. Telemedicine: Implement telemedicine programs to connect pregnant women in remote areas with healthcare professionals for prenatal check-ups, consultations, and monitoring.

4. Transportation Support: Establish transportation systems or provide subsidies to pregnant women in remote areas to ensure they can access healthcare facilities for prenatal care and delivery.

5. Maternal Health Vouchers: Introduce voucher programs that provide financial assistance to pregnant women, enabling them to access quality maternal healthcare services.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could include the following steps:

1. Define Key Metrics: Identify key metrics to measure the impact of the recommendations, such as the number of prenatal care visits, the percentage of women receiving skilled birth attendance, and maternal and neonatal mortality rates.

2. Data Collection: Gather baseline data on the current state of maternal health access in the target area, including the number of healthcare facilities, availability of healthcare professionals, and utilization rates.

3. Model Development: Develop a simulation model that incorporates the recommended interventions and their potential impact on the key metrics. This model should consider factors such as population demographics, geographical distribution, and existing healthcare infrastructure.

4. Input Data: Input relevant data into the simulation model, including the number of pregnant women, the coverage of the interventions, and the expected outcomes based on existing evidence and expert opinions.

5. Simulation Runs: Run the simulation model multiple times, varying the input parameters to assess different scenarios and their potential impact on improving access to maternal health.

6. Analysis and Evaluation: Analyze the simulation results to evaluate the effectiveness of the recommendations in improving access to maternal health. Compare the outcomes of different scenarios to identify the most impactful interventions.

7. Recommendations and Implementation: Based on the simulation results, make recommendations for the implementation of specific interventions that have shown the greatest potential for improving access to maternal health. Consider factors such as feasibility, cost-effectiveness, and scalability.

8. Monitoring and Evaluation: Continuously monitor and evaluate the implementation of the recommended interventions to assess their real-world impact on improving access to maternal health. Adjust the interventions as needed based on ongoing data analysis and feedback from stakeholders.

By following this methodology, policymakers and healthcare providers can make informed decisions on which interventions to prioritize and invest in to improve access to maternal health.

Yabelana ngalokhu:
Facebook
Twitter
LinkedIn
WhatsApp
Email