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International Health

A common childhood playtime behavior linked to serious health risks in Bangladesh

Assistant Professor Christine Marie George’s research team conducts the first study to link geophagy (consumption of soil) with reduced gut function and stunting in young children

Assistant Professor Christine Marie George from the Department’s Program in Global Disease Epidemiology and Control (GDEC) recently led the first prospective cohort study to investigate whether geophagy (consumption of soil) could be linked to reduced gut function and stunting in children. Dr. George worked in collaboration with faculty from Hopkins and the Department’s longstanding partner, International Center for Diarrheal Disease Research, Bangladesh (icddr,b) to develop and conduct this cohort study based in Mirzapur, Bangladesh. Dr. ASG Faruque was the icddr,b principal investigator and Lauren Oldja, MSPH ’13, Health Systems, was the field-based research coordinator. “Lauren was an amazing coordinator. Her organization and drive made the study run seamlessly,” says Dr. George,  “I was very lucky to have her as part of our team.” 

Assistant Professor Christine George (back row, center) & members of her field team based in Mirzapur, Bangladesh.
Geophagy team

The project was also a learning experience for Ms. Oldja who was able to gain valuable field experience working with local partners. “The icddr,b research assistants and field attendants bring invaluable local experience,” says Ms. Oldja. “Dr. Faruque’s team was dedicated and conducted the direct household observations very effectively.”

Child in Bangladesh studyAn unobserved pathway

Most studies in this area focus on the fecal-oral pathways of enteric infections described in the “F Diagram” (fluids, fingers, fields, flies, food). However there has been a growing body of evidence suggesting that geophagy is an overlooked pathway that could contribute substantially to stunting and environmental enteropathy (impaired gut function) in children. For over a decade, Professor Jean Humphrey from the Department’s Program in Human Nutrition and her team based in Zimbabwe have been building evidence that poor sanitary conditions contribute to stunting and anemia in children. As part of the Sanitation, Hygiene, Infant Nutrition Efficacy Project (SHINE) their team conducted one of the first formative studies to observe how often children ingest soil and animal feces. 

Finding a link 

Building on SHINE’s findings, the study team set out to investigate the association between geophagy, stunting, and gut function. With funding Dr. George received from the Sherrilyn and Ken Fisher Center for Environmental Infectious Diseases, the team observed over 200 children while they played outdoors—amounting to over 1,000 hours of child outdoor playtime. The team also collected reports of geophagy from caregivers and took soil samples from where children played to test for E.coli.  

Measuring environmental enteropathy

The study employed the environmental enteropathy disease activity score to measure overall gut function health. The score is a composite of several fecal markers of gut function. Children with higher scores have been shown to have significantly impaired growth. Assistant Professor Margaret Kosek led the development of the score as part of her work with the Malnutrition and Enteric Disease Study (MAL-ED). MAL-ED established a network of sites that focused on studying populations with a high prevalence of malnutrition and enteric infections in eight countries across the globe. As the lead investigator at the Peru site, Dr. Kosek developed and tested the application of the score and published the results in 2012 in the American Society of Tropical Medicine and Hygiene,

New evidence for building better interventions

Nearly a third of children were observed putting dirt in their mouths while they played. Not only did these children have significantly higher environmental enteropathy disease activity scores, they were twice as likely to be stunted compared to the other children in the study. In addition, nearly all soil samples had detectable E. coli and 14% had pathogenic E. coli, one of the most common enteric pathogens found in children under five years of age globally. These findings taken together demonstrate how geophagy puts children at risk for environmental enteropathy and can lead to stunting. Dr. George believes 

These results can help advance our understanding of risk factors for environmental enteropathy and stunting that could in turn lead to more effective interventions for susceptible pediatric populations.

Two articles based on this prospective cohort study are currently in press, and a third is under review: George CM, Oldja L, Biswas S, Perin J, Lee GO, Kosek M, Sack RB, Ahmed S, Haque R, Parvin T, Azmi IJ, Bhuyian SI, Talukder KA, Faruque AG. Fecal Markers of Environmental Enteropathy are Associated with Animal Exposure and Caregiver Hygiene in Bangladesh. Am J Trop Med Hyg. In Press. and George CM, Oldja L, Biswas S, Perin J, Lee GO, Kosek M, Sack RB, Ahmed S, Haque R, Parvin T, Azmi IJ, Bhuyian SI, Talukder KA, Faruque AG. Geophagy is Associated with Environmental Enteropathy and Stunting in Children in Rural Bangladesh. Am J Trop Med Hyg. In Press.

George and Oldja

Alumna Lauren Oldja

MSPH ‘13, Health Systems

After graduating from the MSPH program in Health Systems in 2013, Lauren served as a technical advisor on the South Sudan Guinea Worm Eradication Program. Currently, she’s the monitoring and evaluation manager on “MINE-TB,” an active case-finding project for TB/HIV in KwaZulu-Natal, South Africa—a project funded by the UN’s Stop TB Partnership and operated jointly by IRD South Africa and the Aurum Institute.

Assistant Professor Christine George (left) carrying an anthropometric tool used in data collection and Lauren Oldja who managed the study locally.