Food insecurity and cholera risk: An Exploratory Analysis of Potential Mediators

BackgroundFood insecurity has been independently associated with cholera infection and there is an inverse relationship between national food security and annual cholera incidence. However, factors that mediate increased cholera risk among food insecure households remain largely unexplored. MethodsIn a cross-sectional survey of rural households in Haiti, we explored the role of food behaviors (i.e., dietary choices and food-handling practices) as mediators of cholera risk among food-insecure families. We generated multivariable regression models to test hypothesized associations between severity of food insecurity (measured by the Household Hunger Scale), hygiene and food behaviors, and history of severe, medically-attended cholera. ResultsCompared with little to no household hunger, moderate hunger (Adjusted Odds Ratio [AOR] 1.62, 95% Confidence Interval (CI) 1.12--2.36; p=0.011) and severe hunger (AOR 2.32, 95% CI 1.27--4.22; p=0.006) were positively associated with history of severe, medically-attended cholera. Household hunger was positively associated with three behaviors: antacid use, consumption of leftover non-reheated food, and eating food and beverages prepared outside of the home (i.e., at a restaurant or from a vendor). Consumption of outside food items and antacid use were positively associated with a history of cholera. ConclusionOur findings suggest that food behaviors may mediate the association between food insecurity and cholera and contribute to an understanding of how interventions could be designed to target food insecurity as part of cholera prevention and control. Author summaryFood insecurity has been found to be a risk factor for cholera at the household and national level;[1-3] however the mechanism through which food insecurity may increase the risk of cholera remains unknown. In a large cross-sectional survey of 1072 households in rural Haiti, we observed a robust independent association between food insecurity--defined as a persistent lack of access to food in adequate quantity or quality and measured by the Household Hunger Scale--and severe, medically-attended cholera. This relationship appears to be linear, conferring a dose-dependent risk of cholera by severity of food insecurity. We found household food insecurity to be associated with three high-risk behaviors: antacid use, consumption of leftover non-reheated food, and eating food and beverages prepared outside of the home. Two high-risk behaviors--including antacid use and consumption food and beverages prepared outside of the home (i.e., at a restaurant or from a vendor)--were independent risk factors for cholera. High-risk food handling practices may be one causal pathway whereby food insecurity increases risk of cholera infection. Future longitudinal and qualitative studies should investigate whether interventions targeting food insecurity could reduce cholera risk among populations who face a high burden of both conditions.