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    Review of 'Assessing the infection burden and associated risk factors in children under 5 across Jaipurs urban slums: A feasibility study using a One Health approach'

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    Assessing the infection burden and associated risk factors in children under 5 across Jaipurs urban slums: A feasibility study using a One Health approach

    Purpose: Infectious diseases are one of the leading causes of death among children under five (U5s) across both India & globally. This is worse in slum environments with poor access to water, sanitation & hygiene (WASH), good nutrition & a safe built environment. Globally, a One Health (e.g. human, animal & environment) approach is increasingly advocated by WHO, FAO & OIE to reduce infections & antimicrobial resistance. As U5s living in peri-urban slums are exposed to household and community owned companion & livestock animals and pests, the CHIP Consortium hypothesized that utilizing a One Health approach to co-produce behavior change & slum upgrading interventions may reduce this burden where other WASH & nutrition interventions have failed. This study aimed to assess the feasibility of utilising a One Health approach to assess U5 infection & risk factor prevalence in Jaipurs urban slums prior to undertaking prospective cohort studies involving culture and culture independent sampling of U5s and animals across our study sites in Jaipur, Jakarta & Antofagasta. Methods: We administered a Rapid Household Survey to 25 purposely selected households across six slums. The questionnaire evaluated infection prevalence, health seeking behaviors, the built environment, presence of animals & pests, and individual to household-level demographics. Associations were calculated using correlations among continuous variables to show strength of significance between continuous variables. Results: We found a high incidence of infections in children under five at 40%. This was most significantly correlated with accessibility of sanitary toilets (r = .62) and household expenditure. Vaccination coverage and child characteristics (such as size) were minimally correlated, while the presence of animals (pets or pests) was not correlated; the latter was likely due to the design of the survey. Conclusion: This study found a higher infection prevalence than previous studies. We also found higher correlations with infection incidence among household-level characteristics, indicating that effective interventions need to address both the built and socio-economic environments. A pilot prospective cohort study, which includes researcher observations for the presence of animals to account for inconsistencies in the survey, is now underway.

      Review information

      This work has been published open access under Creative Commons Attribution License CC BY 4.0, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Conditions, terms of use and publishing policy can be found at www.scienceopen.com.

      Life sciences,Public health,Infectious disease & Microbiology
      Pollution and health,One Health, Infectious Diseases, Children Under Five, Slum, India

      Review text

      1st October 2020

      Title:  Assessing the infection burden and associated risk factors in children under 5 across Jaipur’s urban slums: A feasibility study using a One Health approach

      Authors: Dr Logan Manikam, Spencer Rutherford, Meghan Cupp, Radhika Sharma, Dr Kaushik Sarkar, Dr Dewi Aisyah, Dr Samantha Field, Prof Andrew Hayward, Dr Hector Altamirano, Dr Neha Batura, Prof Rajib Dasgupta, Prof Muki Haklay, Dr Emily Nix, Paula Christen, Prof Monica Lakhanpaul

      Journal: UCL open: Environment


      This study looks at utilising the One Health approach to understand the infection burden and associated risk factors in under 5 children living in Jaipur’s urban slums.

      As stated, the objectives of the research are twofold. They are,

      1) To assess the feasibility of undertaking the above activities in a slum setting in India.

      2) To identify preliminary risk factors and variables of interest for infections in children under 5 in slum environments.

      Abstract: given in four separate paragraphs, is a summary of that has been described in the detailed text.


      This section summarises the “One Health” approach and why it might give a better outcome in understanding the infectious diseases in slum settings than randomized control studies.  It showcases the relevant global (including Indian) references in support of the hypothesis. What was missing in this section was an overview description of Jaipur’s slum setting/environment. Understanding the physical environment, is an important component of a “One Health”. Slums in India are varied, environmental settings can be different too, therefore, capturing the heterogeneity across the slums is vital (notified and non-notified slums etc.). Because the authors refer to the study as a “feasibility study” undertaken prior to a larger study, capturing the nature of the external environment should have been a key component of the study, to understand the risk factors of under 5 children.   


      Household survey: The household survey used in the study appears to be a standard one, used by many. Having a grassroots organization supporting the studies together with a Hindi speaking team for enumeration, is a plus point.  However, self-reporting of illnesses can be problematic, unless traced for accuracy. A 30-day recall period for illness reporting can be too long, especially in settings where the daily household dynamics are a continuous struggle. Further, slums have a large moving population, therefore, attribution can be difficult and confounding too. A more nuanced understanding of health seeking behaviour may be required to collect health data, that are reliable. There is a gamut of issues that are considered under the “One Health” approach, however, the different disciplinary and sectoral involvement is not discussed, although some questions are included in the questionnaire itself.  

      Sampling: This has been carried out in 6 slums found in 3 areas, with the support of a charitable organization. Slum populations are large, therefore, the number sampled (n=15) for a feasibility study appears to be too small. The characteristics of slums can be very different and one would have expected a feasibility study to capture such differences in a “One Health” approach.


      Purposive sampling can be accepted, however, given the small number sampled, in a heterogenic setting, the “One Health” approach is compromised. In terms of health seeking behaviour, especially within India, one has to describe what “private consultation” means. It can vary from a private medical doctor to a wise man/woman in the community. Moving populations are a continuous source of infections and children’s external physical environment can confound it. Exposure to animals are not discussed at all. 


      In this section, the results from questionnaire is discussed. The authors also highlight the need to consider the “One Health” approach as part of future studies, however, the title states otherwise – that a “One Health” approach is being used. There is a contradiction here.

      One health approach has been around for a while and it discusses how multiple disciplines and sectors should look into integrated solutions for health problems. It is said that professionals of human and animal health, environment, law enforcement, policy makers should look for solutions together with communities that are affected. If this study had explored these key issues as part of their study, together with a larger sample size, it could have been considered for publication. However, in its present form, it is not suitable for publication, in this Journal, UCL Open: Environment.   


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