Food insecurity and risk of cholera: A cross-sectional study and exploratory analysis of potential mediators

Food insecurity has been independently associated with developing cholera and there is an inverse relationship between national food security and annual cholera incidence. However, the factors that mediate the risk of cholera among food insecure households remain largely unexplored. In 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 a series of multivariable regression models to test hypothesized associations between the severity of food insecurity (measured by the Household Hunger Scale), hygiene and food behaviors, and history of severe, medically-attended cholera. Moderate household hunger (Adjusted Odds Ratio [AOR] 1.47, 95% Confidence Interval (CI) 1.05-2.04; p = 0.021) and severe hunger (AOR 2.45, 95% CI 1.45-4.15; p = 0.001) were positively associated with a history of severe, medically-attended cholera compared with little to no household hunger. 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. Our 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.