A population‐based study of how children are exposed to saliva in KwaZulu‐Natal Province, South Africa: implications for the spread of saliva‐borne pathogens to children

Summary Objectives  In sub‐Saharan Africa, many viral infections, including Epstein–Barr virus, cytomegalovirus, Kaposi’s sarcoma‐associated herpesvirus and hepatitis B are acquired in childhood. While saliva is an important transmission conduit for these viruses, little is known about how saliva is passed to African children. We endeavoured to identify the range and determinants of acts by which African children are exposed to saliva. Methods  To identify the range of acts by which African children are exposed to saliva, we conducted focus groups, semi‐structured interviews and participant observations in an urban and a rural community in South Africa. To measure the prevalence and determinants of the identified acts, we administered a questionnaire to a population‐based sample of caregivers. Results  We identified 12 caregiving practices that expose a child’s oral–respiratory mucosa, cutaneous surfaces or anal–rectal mucosa to saliva. Several acts were heretofore not described in the contemporary literature (e.g., caregiver inserting finger lubricated with saliva into child’s rectum to relieve constipation). Among 896 participants in the population‐based survey, many of the acts were commonly practised by all respondent types (mothers, fathers, grandmothers and siblings). The most common were premastication of food, sharing sweets and premastication of medicinal plants that are spit onto a child’s body. Conclusions  African children are exposed to saliva through a variety of acts, practised by a variety of caregivers, with no single predominant practice. This diversity poses challenges for epidemiologic work seeking to identify specific saliva‐passing practices that transmit viruses. Most acts could be replaced by other actions and are theoretically preventable.