Table 8.

Control measures to prevent exposure to animal feces in LMIC.

Category	Major pathway	Targeted arrow	Intervention	Major findings	References
Animal waste management	Waterborne/ environmental	Animal feces –> fluids, fields	Biogas digesters	A low-cost plastic type digester in Cameroon considerably decreased the mean counts of coliform and E. coli in the slurries of chicken feces to 138 and 87 CFU/mL, respectively, after a five-week retention time in the digester	(247)
				The concentration of Enterococcus spp., E. coli and spores of Cl. Perfringens in pig slurries was reduced by 1–2 log CFU/mL after the treatment of biogas digesters in Vietnamese pig farms	(248)
				Biogas digesters with various designs can reduce the concentration of Enterococci, E. coli, and coliforms by 1 ~ 3.5 log10 CFU/mL in the manure	(249)
			Composting	The concentration of E. coli was reduced from 4 log10 CFU/g to below the detection limit in composted pig manure added 2% urea within 2 weeks. The counts of total coliforms decreased to 0.72 log10 CFU/g at day 45	(250)
Corralling domestic small animal	Animal contact	Animal feces –> fingers	Corralling free-range chicken	Corralling didn't fully achieve the goal of separating children from poultry as children in the household persistently played with corrals and with chickens in the corrals	(251)
				A significant higher (two-fold) incidence of Campylobacter-related diarrhea in children living in the corral group than in the control group	(252)
				The participant households in the corral group were revisited 10 years after the intervention, and majority of them (92.3%) had a positive change in their attitudes toward corral use	(253)
			Hutching small animals inside home	Participants reported that the three-level animal hatches constructed in kitchen and living space prevented rabbits and guinea pigs from defecating throughout the house which thus prevented children from eating animal feces on the floor	(254)
Baby WaSH	Animal contact/ environmental	Animal feces –> fingers, fields –> future victim	Provision of play-yard/play pen	The WaSH intervention package including providing plastic manufactured play-yards showed non-statistically significant effects on reducing both enteric infections and pathogen-attributable diarrhea caused by individual pathogens	(36, 255)
				The community-built play-yards (play-yards made from local materials) protected the young children from ingesting soil and livestock feces	(256)
			Provision of plastic playmats	Locally sourced plastic playmats were provided to caregivers in a pilot study, and they reported that use of playmats reduced the mouthing of dirt by children	(254)
Milk hygiene	Foodborne	Animal feces –> food, food –> future victim	Boiling or heating raw milk	The application of pasteurization in raw milk can cause the pathogen's probability of surviving to be reduced by a factor of 106, and, consequently, destroy all vegetative microbes in the milk	(257, 258)
			Natural fermentation	The reduced pH along with the release of antimicrobial compounds by fermenting bacteria synergistically inhibit the growth of pathogenic microbes in the milk	(257)
			Smoking the inner surface of milk-handling containers	The mean microbial load in the smoked containers was reduced from 5.99 to 4.64 log10 cfu/cm2 for total viable count (TVC), from 5.07 to 4.00 log10 cfu/cm2 for total coliform count (TCC), and from 4.81 to 3.75 log10 cfu/cm2 for LAB	(259)
				The qualitative study conducted in Ethiopia identified the smoking of milk-handling containers as one of potential risk mitigation practices in the pastoral communities	(260)
Complementary food hygiene	Foodborne	Animal feces –> food, animal feces –> fomites, fomites –> food, fingers –> food, fomites –> future victim	Cleaning and disinfecting baby feeding bottles	Rinsing baby bottles with soapy water followed by tap water can reduce the load of fecal bacteria including EPEC and Salmonella spp. by 3.1 ~ 3.7 log10 CFU/mL	(261)
				The trial of improved practices showed that caregivers preferred the protocol of brushing the bottle with dish detergent for 30 s after every use than boiling the bottle for several minutes daily	(262)
			Intervention package of critical food hygiene behaviors	Six critical behaviors were identified and targeted: (1) handwashing before cooking; (2) handwashing before feeding; (3) washing cooking utensils with safe water and soap and drying them on a clean and elevated surface; (4) proper and safe storage of cooked food and utensils; (5) reheating food before feeding; (6) boiling drinking water. The results suggested a varying degree of increase in targeted complementary food hygiene behaviors	(263–269)
				Food samples collected 3 weeks after mother taking the training showed a significant reduction in the thermotolerant coliform (TTC) contamination levels which were reduced below 10 TTC/g for most samples cooled after cooking or reheated after storage	(270, 271)
				Besides the increased adoption rate of improved behaviors, children's reported diarrhea was reduced by 60 and 30% at 6 and 32 months post-intervention, respectively	(272)
Handwashing	Foodborne	Fingers –> food, fingers –> future victim	Handwashing at critical time points	Promotions of handwashing after defecation or after disposal of children's feces and before eating, preparing, or handling foods prevent around 25% of diarrhea episodes in LMIC settings	(273)
Improvement of water quality	Waterborne	Fluids –> food, fluids –> future victim	Source-based and point-of-use water improvements	Distributing disinfection products (chlorine products, flocculation and disinfection sachets) to households may reduce diarrhea by around 25% (RR 0.77, 95% CI 0.65–0.91 for chlorine products; RR 0.69, 95% CI 0.58–0.82 for flocculation and disinfection sachets). POU filtration systems may lower diarrhea episodes by around a half (RR: 0.48; 95% CI: 0.38–0.59). Proper application of solar disinfection may reduce diarrhea by around 30% (RR: 0.62; 95% CI: 0.42–0.94)	(274)