References

1. Mc Michael AJ (1994) Molecular Epidemiology: new pathway or new traveling companion?

American Journal of Epidemiology 140, 1-11.
2. Todd JA (1995) Genetic analysis of type 1 diabetes using whole genome approaches.
Proceedings of the National Academy of Sciences of the USA 92, 8560–8565.
3. Wild C, Vineis P, Garte S (2008) Molecular Epidemiology of Chronic Disease. John Wiley &
Sons, Ltd.

Assignment - the first study

Now, there is concern that aflatoxin exposure could also be responsible for growth
retardation in children in West Africa (Benin and Togo). Many people in those countries are not
only malnourished but also chronically exposed to high levels of aflatoxins, which are known to
cause growth retardation in animals. Aflatoxins contaminate staple foods in West Africa,
particularly maize and groundnuts, as a result of hot, humid storage conditions that promote
fungal growth. High exposure to aflatoxins occurs throughout childhood in the region suggesting
that growth and development could be critically affected. Thus it is needed to assess whether
exposure to aflatoxins are related to anthropometric measures in children in Benin and Togo.
Please design a study in which the hypothesis that aflatoxin exposure in children in Benin
and Togo leads to reduced growth. The study should include both non molecular measurements
and biomarkers of exposure.
a. What question is being addressed for this study?
b. What type of study design will be adopted?
c. Which samples should be selected?
d. How can exposed and control groups be defined?
e. What is the outcome of the study? And how will you measure it?
f. What biomarkers will be measured? Why and how?
g. What is the advantage of using a biomarker of exposure versus measuring food samples
for aflatoxin levels?
h. What is the appropriate statistical analysis?
i. What would be the main confounding factor?
j. What ethical aspects should be considered?
k. According to figure-4 (the pathway of aflatoxin metabolism) what is the potential
susceptibility factors that could be considered? How could you test them?

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Assignment – the second study
Several approaches can prevent aflatoxin exposure in developing countries. Because
much food contamination occurs during post harvest storage, methods to remove nuts or kernels
damaged by fungus before storage and to restrict humidity during storage could reduce fungal
growth and toxin production. However, the effect of this strategy on exposure in subsistence-
farming communities in Africa has not been assessed. If we assumed that the first study has
established an association between aflatoxin exposure and child growth retardation, and you are
asked to design an intervention trial using the same markers to assess the use of improved
methods of groundnut storage for subsistence farmers in a rural area of Benin and Togo to reduce
the exposure of the aflatoxin. We introduced a package of intervention measures to improve the
drying and storage of groundnuts. Local government agricultural advisers, who were employed to
provide guidance to subsistence farmers, explained the intervention strategy to the farmers and
demonstrated the different techniques. Families included in the study stored between ten and 25
bags of groundnuts (each bag weighed about 50 kg). The panel shows the intervention methods.
In the control villages, farmers were left to follow their usual post harvest practices, which
sometimes included one or more of the parts of the intervention package (table below).

1. Hand sorting
Farmers were shown how to identify groundnuts that were visibly mouldy or had damaged shells.
Damaged kernels were removed and discarded before storage.

2. Drying on mats
Groundnuts are commonly spread on the ground for sun drying, making them susceptible to
humidity and difficult to gather in the event of unexpected rain. Therefore, locally produced natural-
fibre mats for the sun-drying process were provided.

3. Sun drying
Incomplete sun drying leaves residual humidity in the groundnuts during storage. Farmers were
shown how to judge the completeness of sun drying by shaking the kernels to listen for the free
movement of the dried nuts.

4. Storage in natural-fibre bags

Farmers most frequently use plastic or other synthetic bags for storage, which promote humidity. We
therefore provided natural-fibre jute bags.

5. Wooden pallets
In the storage facilities, bags of groundnuts are often stored on the floor or on stones leading to the
risk of humidity from the earthen floors. We provided locally made wooden pallets on which to store
the bags.

6. Insecticide
One of the main factors affecting aflatoxin formation is the presence of insects in storage facilities
and bags, which produce humidity via metabolic activity and spread fungal spores. We gave about
10 kg of a locally available insecticide to every family to be sprinkled in small quantities on the floor
of the storage facility under the wooden pallets at the start of storage and intermittently afterwards.

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 Please design a study in which the hypothesis that post harvest measures to restrict
aflatoxin contamination of groundnut crops could reduce exposure. The study should include
molecular measurements of biomarkers of exposure.
a. What question is being addressed for this study?
b. What type of study design will be adopted?
c. Which samples should be selected?
d. How can exposed and control groups be defined?
e. What is the outcome of the study? And how would you measure it?
f. What biomarkers will be measured? Why and how?
g. What is the appropriate statistical analysis?
h. What would be the main confounding factor?
i. What ethical aspects should be considered?

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