tropical enteropathy - key cause of child undernutrition?

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tropical enteropathy - key cause of child undernutrition?

Dear all,

within the SuSanA working group 5 (food security and productive sanitation) we stumbled upon an interesting 'viewpoint' article by Jean Humphrey in the Lancet on a phenomenon known as tropical enteropathy caused by the ingestion of fecal bacteria in larger quantities which is assumed to be one of the key causes of child undernutrition and stunting (see email from Ken Maskall with the respective link below).

Since this is a viewpoint article only, does anyone know if there is any further investigation undertaken on this or does anyone have any more recent information on tropical enteropathy?

Thanks in advance and best regards

rob#

Robert Gensch
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___________________________________________________


I wanted to draw your attention to some recent research evidence which points to a more insidious cause of stunting in children due to chronic ingestion of feacal matter during the critical growth years between 0-2 years of age. Our conventional justification for sanitation programmes has usually be based upon diarrhoeal disease reduction. This new research suggests that rather than diarrhoea episodes being responsible for growth stunting it seems that a phenomenon known as Tropical Enteropathy is a more likely candidate. Essentially this is caused by chronic fecal matter ingestion and associated damage to the small intestines which are responsible for severe nutrient uptake inhibition - leading to stunting.

The attached article published in the Lancet describes the findings more fully. As we seem to be searching for strong correlative links between improved sanitation and increased food security, I feel that these findings need to be highlighted in the paper as they provide a much stronger rationale for toilets and handwashing than hitherto believed.

Here is the link:

www.thelancet.com/journals/lancet/articl...(09)60950-8/fulltext

(note by moderator: you are unfortunately not allowed to place the full article here, only the abstract, because of copyright issues. It can be sent out by e-mail one by one but not placed on a discussion forum. Contact us at This email address is being protected from spambots. You need JavaScript enabled to view it. for clarification - Elisabeth von Muench)


Many thanks again for sharing - we await the final draft with considerable interest.

Best wishes

Ken Maskall


Ken Maskall

Chief of WASH Programme

UNICEF South Sudan
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Robert Gensch

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  • mwink
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Re: tropical enteropathy - key cause of child undernutrition?

A pity that nobody answered so far. I would be very interested in the answer! :(

Reports and papers always refer to the figure of "children under five (years of age)". Why exactly five years?
- Is there such a large change between children with an age of 5 compared to those with an age of 6?
- Or is this just statistics and somewhere one had to draw the line? Hence "children under five" is an artificial border.

Hope somebody is able to answer these questions.
Yours, Martina.

Research unit Water infrastructure and risk analyses
Institute for Social-Ecological Research (ISOE)
Frankfurt, Germany

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  • Florian
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Re: tropical enteropathy - key cause of child undernutrition?

Hi, Duncun Mara commented on the same article a while ago: duncanmarasanitation.blogspot.com/2009/0...cal-enteropathy.html

To me that feels rather like medical science details, and not like something that changes much for us sanitation people. The fact that envrionmental health and nutrition are closely linked and impacting child health is not so new I think. Another example are helminth infections (see also current discussion on helminths ) that are not really life threatening alone, but most harmfull in combination with other risk factors for child health, especially malnutrition.

As for the "under-five" criterion, this is one of the most commonly used indicators to measure child health by WHO and others, also used in MDG 4. Other common indicators are infant mortality (under 1 year) and neonatal mortality (under 1 month). Why exactly under 5 and not under 6 I do not know, probably both of your assumptions played a role when the indicator was defined.


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Re: tropical enteropathy - key cause of child undernutrition?

Hi Florian,

did you read the article in the Lancet? If not you really should do so.
Because, if you follow the reasoning of the author, it becomes clear that this is not just

medical science details

. However, it left us unsure how to wait it.

Thanks for forwarding the citation of Duncan Mara. It gives me a better feeling when he judges the article as worthwhile. However, I didn't find a critical commenting of this article besides that he stated that he liked the article and his message.
Together with some other articles he quoted he came to the interpreation that

...the message [is]: clean up the environment, especially the immediate domestic and peri-domestic environment, by the provision and sustained use of sanitation and handwashing facilities, educate girls, and put public health right up very high on the political agenda. Fingers crossed − it could just work...

.
Or did I miss an important part?

Regards,
Martina.

Research unit Water infrastructure and risk analyses
Institute for Social-Ecological Research (ISOE)
Frankfurt, Germany

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  • Florian
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Re: tropical enteropathy - key cause of child undernutrition?

Hi Martina,
yes I did read it. Of course that's interesting and important research, I don't want to dissmiss that. But if the research results are to be confirmed, what do they mean for me, as a sanitation engineer?
- another argument why sanitation and hygiene is so important (or maybe change from the "diarrhea argument" to "Tropical Enteropathy argument").
- nothing new for the solutions we need to provide, we still need to cut the fecal-oral transmission pathes


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  • mwink
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Re: tropical enteropathy - key cause of child undernutrition?

Hi Florian,

okay, now I got your point. Thanks for the clarification. :)

I see it slightly different regarding your question

What is changing for me as a sanitation engineer?

I would argument that yes, there is changing something for us working in the sanitation scene.
1) This means (or even puts more emphasizes on the fact) that with toilets/safe treatment/disposal - the whole chain alone - we will never reach our goals, even if we would be able to provide nice porcelain flush toilets to the whole world, as long as people don't wash their hands afterwards. We can only reach our goal when hygienic standards are reached by everybody.
2) The whole aspect of reuse becomes more tricky. I have to step back from reuse much earlier when I see that the level of hygienic measures applied is not working.
3) Maybe we should even stop thinking of toilets etc. at all and concentrate on hygiene education only (- taken to extrems. Not my personal opinion.)

To me it seems (my impression from the article) that this issue of "stunting" is even more sensitive than "diarrhea". But I would love to be proven wrong!

Yours, Martina.

Research unit Water infrastructure and risk analyses
Institute for Social-Ecological Research (ISOE)
Frankfurt, Germany

winker[AT]isoe.de
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  • Florian
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Re: tropical enteropathy - key cause of child undernutrition?

Hi Martina,

1) Sure, but that is common ground already now, isn't it?
2) Why does it become more tricky? Already now we are aiming at containing or killing all fecal microorganisms in feces, urine, wastewater for reuse (which is tricky enough, true).
3) I think it is widely accepted and has been demonstrated by many studies, that handwashing campaings are the single most effecive measure in improving health situation related to waterborne diseases; but of course the impact is much better and more sustainable when combined with improved water and sanitation infrastructure.

Tell me if I am missing something :unsure:

Florian


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Re: tropical enteropathy - key cause of child undernutrition?

I am posting an answer by Bella Monse about this topic, which she sent to us by e-mail. Bella works in the amazing Fit for School Program in the Philippines, which has achieved great health impacts for school children at very low cost. So far the focus was on handwashing with soap, deworming and teeth brushing, but sanitation is now being added as well and it is going beyond the Philippines. See their website for more details: Fit for School Website (posted by Elisabeth von Muench)
++++++++++++++

Dear Martina,

So sorry for the late reply.
I have read the Lancet Article and we highly recommend to cite the reference in the fact sheet. The TheLancet is the medical journal with the highest impact factor and it is very very difficult, to get an article published there. The peer review process is most rigorous and anything published here has highest weight in the medical world and any quote from theLancet has highest value. Therefor I would include it into the factsheet.

I have forwarded the article to Dr. Belizario, who is the chairman of the board of Fit for School and who is an expert of tropical diseases.

With respect to consequences : improvement of toilets, water and sanitation is the only way to go!

I await the answer of Dr. Belizairo and will get back to you.

Hope this helps a bit.

Greetings form Bella

Posted by a member of the SuSanA secretariat held by the GIZ Sustainable sanitation sector program
Located at Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) GmbH, Eschborn, Germany
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  • Bellamonse
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Re: tropical enteropathy - key cause of child undernutrition?

Robert, I just want to correct you. The article is NOT a simple viewpoint of one expert. If it is published in theLancet, it has gone through the most rigorous peer review process which gives the article highest credibility.
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Re: tropical enteropathy - key cause of child undernutrition?

Dear Martina,

Thank you for raising the important question regarding under-five mortality! Just to introduce myself briefly, I work for the Fit for School Regional Program in the Philippines. Before I came to the Philippines I was working on child health and intersectoral approaches in a Sector Initiative in the Health KC in GIZ Eschborn.

To answer your question:

The first five years of life are the most vulnerable time for dying from infectious diseases like diarrhea or pneumonia. After this first 5 years children are usually much less susceptible to pathogenic organisms. So after this 5-year period children have a much higher chance to survive a serve infection. Which not means that they are all healthy, it just means that they will most probably not die from these diseases anymore.

Therefore the MGG 4, which is on the reduction of child mortality, is focusing on children under the age of 5.

If you have a more detailed look at it you will find that within this 5 years the first year is the most vulnerable time. Over 70 percent of under-five deaths occur within the first year of life.

Within this first year the first 28 days – the so-called neonatal period - are the time when the newborn is at the greatest risk to die from a disease. If a child dies within this first 28 days we are talking about neonatal mortality. Among the under-five death 40 percent occur within this 28-day (or first month) period.

A helpful like could be the following: www.childinfo.org/mortality.html

There you can find more detailed information, especially on the causes of death during the first 28 days of life and the first five years of life as well as the regional differences.

All the best from Manila,
Nicole

Nicole Siegmund
Regional Program Coordinator

GIZ Regional Fit for School Program
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  • rob#
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Re: tropical enteropathy - key cause of child undernutrition?

Hi Bella,

Thanks a lot for the clarification. Such a rigorous reviewing process certainly gives the whole article a lot more strength. However, I am still wondering if there has been any additional research carried out yet to further confirm this article.

Best regards

rob#

Robert Gensch

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Re: tropical enteropathy - key cause of child undernutrition?

Dear Bella and Nicole,

thanks for your input. That's really helpful. As you might have seen in the discussion going on beforehand, we really need the input of health experts.

One additional question (Florian and I discussed before you got involved): Is there a difference for action/measures if I have in mind to decrease the risk of diarrhea infection versus tropical enteropathy when I look at sanitation and hygiene interventions?
To me it seems (but this is just a feeling, I have no proofs and readings for this) that to minimising tropical enteropathy (stunting) measures have to be even more senstive and carefully selcted than for fighting diarrhea. Is this correct?

Best regards,
Martina.

Research unit Water infrastructure and risk analyses
Institute for Social-Ecological Research (ISOE)
Frankfurt, Germany

winker[AT]isoe.de
www.isoe.de
www.saniresch.de
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