Is Drinking Water in Abidjan, Côte d'Ivoire, Safe for Infant Formula?

In developed countries, HIV transmission from mother-to-child has decreased dramatically by the use of antiretroviral therapy and replacement of breast-feeding with infant formula. In developing countries, short-course zidovudine and nevirapine regimens have recently proven effective in preventing mother-to- child transmission. Nevertheless, because most HIV-1-infected women breast-feed their infants, transmission of HIV through breast milk may still occur despite antiretroviral treatment. Up to 16 percent of children born to HIV-infected mothers acquire HIV-1 through breast milk in Africa.

Recently, the Joint United Nations Program on HIV/AIDS recommended that HIV-positive mothers be informed of the risks and benefits of breast-feeding and that they be given guidance in considering all options, including substituting formula for breast milk as one means to reduce the risk of mother-to-child HIV transmission. However, the use of infant formula in developing countries has been associated with higher rates of diarrheal morbidity and mortality, in part, because it may be prepared from contaminated water and because the high nutrient content and low acidity of formula provide a favorable growth medium for bacterial enteric pathogens. It is, thus, important to assess the microbiological quality of water used to prepare formula.

This study was conducted in a community in Abidjan, Côte d'Ivoire, to evaluate the quality of water available to prepare infant formula as well as knowledge, attitudes and practices regarding water practices and infant formula.

One hundred twenty selected households represented by women who attended the HIV clinic at the Koumassi mother-child clinics were surveyed between April and June 1999 in Adidjan. Information was obtained by interviewing in French, Dioula or Baoule the mother or caretaker using a field-tested questionnaire. Local dialects were also used in the interviews. A sample of stored water given to the youngest child for drinking and a sample of the source water from which it was obtained were tested for coliform and E. coli fecal contamination.

Seventy-five respondents (63 percent) lived in a home with a courtyard shared by 6 to 10 households. Seventy-four (60 percent) caretakers had received prenatal consultations at the Koumassi clinic. There were 1 to 3 children age 3 or younger in each household. The median age of the caretakers was 27 years. Forty- nine (41 percent) caretakers had no formal education.

Drinking water was typically collected from the municipal system by a family member and was stored in 99 (83 percent) of the households. Sixty-two (71 percent) of stored samples had a free chlorine level =0.10mg/dl compared with 11 (10 percent) of source water. Children were first exposed to drinking water at an early age.

Virtually all (98 percent) caretakers believed breast- feeding was best for infants because of nutrition, tradition and cost. Sixty-three (52 percent) caretakers expressed concerns about infant formula. These concerns included risk of diarrhea (33 percent), need for meticulous preparation (21 percent), and decreased nutritional value (6 percent). Only 12 caretakers (10 percent) were formula-feeding their infants at the time of the study.

Stored water was considerably more likely than source water to be contaminated with coliform bacteria and E. coli. Coliform bacteria were detected in 64 (74 percent) of samples of stored water and in 2 (2 percent) samples of source water. In 2 samples of stored water, both coliform bacteria and E. coli were too numerous to count.

According to the researchers, treating water with a low-cost sodium hypochlorite solution (point-of-use chlorination) and storing treated water in vessels designed to prevent recontamination (safe storage) have been sustainable means of improving household drinking water. An alternative would be for mothers to routinely boil their water. This is costly, time- consuming and destructive to the environment. In the setting of Koumassi, the authors stressed, adequate chlorine residues in municipal source were found and safe storage may be all that is required to improve water quality. A safe water storage container is now sold in South Africa for $2.30 (Megapack, Nampac Corporation, Johannesburg, South Africa).

The researchers recommend that maternal health settings in developing counties, especially those implementing formula-feeding programs to prevent mother-to-child HIV transmission, need to evaluate the water used and make provisions for safe water for their clients.

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