Sipraphai Chantha

Effect of a Point-of-Use Water Treatment and Safe Water Storage Intervention on Diarrhea in Infants of HIV-Infected Mothers

Breastfeeding accounts up to one-half of all cases of mother-to child transmission of HIV. Although there have been attempts to reduce HIV transmission from mother-to-child by forgoing breastfeeding and instead bottle feed, there has either been an equal or increased mortality rate. Increase in mortality rates could be due to decrease transfer in maternal antibodies as well as an increase in exposure to contaminated water and food. The World Health Organization (WHO) recommends new mothers infected with HIV to exclusively breastfeed their infants for six months and then rapidly wean infants off breast milk. These recommendations were modified for new mothers with HIV to continue breastfeeding beyond six months if other options of feeding infants were not acceptable, feasible, affordable, safe, and sustainable. In July 2003, The Kisumu Breast-feeding Study (KiBS) began doing research on why infants where experiencing high rates of diarrhea after rapid weaning at six months of age. Safe Water Storage (SWS) was introduced in order to address the diarrhea problem among KiBS infants. Safe Water Storage composed of three components; Disinfection of water with locally produced sodium hypochlorite solution, safe water storage, and education in hand washing methods and hygiene issues. In Uganda, the use of SWS resulted in a 25 % reduction of diarrhea in infants.

The aim of this study was to evaluate if SWS was beneficially in reducing diarrhea and mortality rates amongst infants with mothers who had HIV. The research began in 2003 where the main area of study was in Kenya. New Mothers were enrolled in KiBS at 34 weeks gestation. There were two groups being studied. Group A, infants were born between August 2003-March 2005 before the use of SWS. Group B infants were born between 2005-January 2007 after the use of SWS was put into effect. Both groups were told to exclusively breastfeed for 5.5 months and then to rapidly wean infants over a 2 week period. Schedule clinical and home visits were made throughout the research period, as well as regular water testing at home. Water was treated with Sodium hypochlorite solution and stored in a narrow-mouth clay pot with lid and tap. This was given to group B to keep water from being contaminated. They were also instructed to scrub water vessels weekly with soap, water, and twine. The total number of infants in the diarrhea analysis was 230 in group A and 252 in group B. During the 6 months of exclusive breastfeeding most infant in either group came into clinical visits for problems with diarrhea. During the weaning period was when the researchers experienced frequency in clinical visits due to diarrhea. 16% of both groups came in for clinical visits due to diarrhea during the weaning period, but post weaning period group B had lower rates of diarrhea amongst infants. At the time of rapid weaning SWS did not reduce the risk of diarrhea among infants of HIV-infected mothers. Diarrhea may not be caused by waterborne pathogen transmission, but it could be due to contaminated foods which carry E-coli or Shingella. The World Health Organization encourages mothers to breastfeed to reduce the risk of

severe diarrhea; also breast milk provides important immunologic benefits to infants. WHO also recommends the use of SWS post weaning since it can reduce infants risk of diarrhea and pathogen exposure. Although the research was mostly inconclusive due to death of the infant, mothers not showing up for clinics, mothers pulling out of the research group, or not following directions, WHO still recommends breastfeeding to be the healthiest for infants with HIVinfected mothers. Non-breastfed infants raise the risks of exposure to foodborne pathogens therefore increasing their risk of diarrheal diseases. The study does show that early weaning increases the risk of diarrheal disease among infants with HIV-infected mothers. Even though the study did not conclude that SWS helped reduce diarrhea, it did show the need for further study of the underlying causes and routes of transmission of diarrhea in infants of weaning age.