Risk factors for food contamination among children 6-59 months discharged from community management of acute malnutrition (CMAM) programmes for severe acute malnutrition (SAM) in Aweil East, South Sudan

Children under-five years of age are particularly vulnerable to severe acute malnutrition (SAM), and the risk factors associated with relapse to SAM are poorly understood. Possible causes are asymptomatic or symptomatic infection with enteric pathogens, with contaminated food as a critical transmission route. This cross-sectional study comprised a household survey with samples of child food (n=382) and structured observations of food preparation (n=197) among children aged 6-59 months that were discharged from treatment in community management of acute malnutrition (CMAM) programmes in Aweil East, South Sudan. We quantified Escherichia coli and total faecal coliforms (TFCs), measured in colony forming units per g of food (CFU/g), as indicators of microbial contamination of child food. A modified hazard analysis critical control point (HACCP) approach was utilised to determine critical control points (CCPs) followed by multivariate logistic regression analysis to understand the risk factors associated with contamination. Over 40% of samples were contaminated with E. coli (43% >0 E. coli CFU/g, 95%CI 38-48%), and 90% had >10 TFCs (CFU/g) (>10TFC CFU/g, 95%CI 87-93%). Risk factors associated (p<0.05) with child food contamination included if the child fed themselves (95% CI 1.16, 3.44, log[odds] = 2.20), exposure to animals (95% CI 0.28, 1.68, log[odds] = 0.97), and protective factors for contamination included feeding with a spoon (95% CI -7.81, -1.54, log[odds] = -4.17). This study highlights strategies that can support interventions that reduce food contamination exposure in young children and help further protect those that are highly vulnerable to recurrent exposure to diarrhoeagenic pathogens. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement This study is made possible by the generous support of the American People through the United States Agency for International Development (USAID). The contents are the responsibility of the London School of Hygiene and Tropical Medicine and Action Against Hunger and do not necessarily reflect the views of USAID or the United States Government. USAID played no role in neither the design of the study, the collection, analysis and interpretation of data, nor the writing of this manuscript. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: Ethics committee/IRB of London School of Hygiene and Tropical Medicine gave ethical approval for this work. Ethics committee/IRB of Ministry of Health in South Sudan gave ethical approval for this work. Ethics committee/IRB of Solutions IRB gave ethical approval for this work. I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes All data produced in the present study are available upon reasonable request to the authors