tropical enteropathy - key cause of child undernutrition?

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

Dear all,

Like Martina, I am also quite fascinated by this article. Florian is right when he says it just shows once more how important sanitation is on child health. Yes, but I like the new angle, which we could use to sell our sanitation argument, and that is that lack of toilets causes stunting in children (and this is irreversible!). So there is death, diarrhoea and stunting of children, all caused by lack of sanitation (+ clean water + hygiene, which is pretty much linked to sanitation). Who wants to have children that are stunted, i.e. shorter than they should be and possibly with a lower IQ than they could have had otherwise.

For those without access to the article, I copy some key bits of the 4-page document here (in Duncan Mara's blog, which Florian gave us the link for, some more paragraphs are also cited).

How can children be protected from faeces? Safe
disposal of stools (ie, toilets) and handwashing with soap
after faecal contact are the primary barriers to faecal-oral
transmission because they prevent faeces from entering
the domestic environment. Many randomised trials of
handwashing16 have shown substantial reductions in
diarrhoea, although none included the eff ect of these
interventions on tropical enteropathy or child growth.
Surprisingly, there are no published randomised trials of
toilet provision on child growth or even diarrhoea.
Almost all existing evidence that sanitation benefi ts
human health comes from cross-sectional, prospective
cohort, case-control, and non-randomised intervention
studies. Thus, all have methodological issues, including
potential confounding by socioeconomic status, lack of
adequate control in before–after programme
assessments, and inadequate statistical power when a
single control community is compared with a single
intervention community.17 Nonetheless, many of these
studies have documented benefi ts on child growth.18

Indeed, in an analysis of demographic and health survey
data from eight countries, Esrey19 estimated that
improvements in sanitation were associated with
length-for-age Z score increments of 0·06–0·62 in
children living in rural areas and 0·26–0·65 in children
living in urban areas, which are similar to the growth
eff ects of dietary interventions reviewed earlier in this
report4 (ie, 0·00–0·64). Moreover, from a mean
length-for-age Z score (SD) of –1·69 (1·45) in rural
children and –1·19 (1·45) in urban children, these
increments correspond to 4–37% and 20–46% decreases
in stunting prevalence in rural and urban children,
respectively, suggesting a considerably greater eff ect
than the 2·4% decrease previously estimated in the
Lancet Series.7

Undoubtedly, the complex problem of child
undernutrition will not be solved with toilets and
handwashing alone. Interventions focused on gut
microbial populations20 and improved drinking water
quality21 might be important, together with continued
eff orts to improve infant diets. However, I hypothesise
that prevention of tropical enteropathy, which affl icts
almost all children in the developing world, will be
crucial to normalise child growth, and that this will not
be possible without provision of toilets. Randomised
controlled trials of toilet provision and handwashing
promotion that include tropical enteropathy and child
growth as outcomes will give valuable evidence for this
premise, and might off er a solution to the intractable
problem of child undernutrition.


And this is the all important hypothesised "Model of the mechanisms from poor sanitation and hygiene to tropical enteropathy, child undernutrition, and child development and survival. Thick lines indicate primary pathways and thin lines secondary pathways, as hypothesised in this report".:


Would be great to see further research results from our health colleagues on this topic.

Regards,
Elisabeth

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

Just to kind of "close this", I am copying below some further information on this condition called tropical enteropathy sent by our colleagues from the Philippines:

+++++++++
Dear Elisabeth,

I agree with Bella that Tropical Enteropathy is not being monitored by the Philippines Department of Health. Neither am I familiar with any screening being done at a public health scale. From what I know, this is diagnosed with evidence of the fat malabsorption in the stools and atrophied intestinal villi through a biopsy. Recently, a breath test has been developed to assess gut absorption and can be used in suspect cases. Unfortunately, I am not aware of the epidemiology of Tropical Entropathy in the Philippines.

I hope this helps.

Best regards,

Johann

++++++++

Bella's response:

Thank you Johann,
I think it is clear, that Tropical Enteropathy is a condition that can explain why many children have a low body mass index, but there is no measure in place to assess the prevalence and diagnose this condition easily. Therefor it is not monitored and the condition is not screened for. This is true in particular, if a biopsy is required to confirm the status.

Thank you Elisabeth for your ongoing interest in the impact of sanitation on health conditions.

Greetings from Bella

+++++++++

(My own note: a biopsy is an investigation that is done on a corpse, i.e. a dead person)

Community manager and chief moderator of this forum via SEI project ( www.susana.org/en/resources/projects/details/127 )

Dr. Elisabeth von Muench
Independent consultant in Frankfurt, Germany
This email address is being protected from spambots. You need JavaScript enabled to view it. Twitter: @EvMuench
Sanitation Wikipedia project leader: en.wikipedia.org/wiki/Wikipedia:WikiProject_Sanitation
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  • JKMakowka
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Re: tropical enteropathy - key cause of child undernutrition?

Exciting news as the Gates Foundation has included in their Grand Challenges a very interesting and promising approach through "Bacteriophage-Mediated Microbiome Engineering":

gcgh.grandchallenges.org/challenge/addre...ediated-microbiome-0

It might seem a bit too "high-tech" at first glance, but Bacteriophages were actually used for not all that different purposes even before antibiotics were invented.

Anyways... sounds like a really interesting research opportunity and I will definitely try to follow the selected teams closely (I hope we can encourage some of them to share their results on the SuSanA forum).

P.S.: also relevant, a maybe more simple way to lessen the impact of EE I posted about a while ago:
forum.susana.org/forum/categories/163-en...erinary-science#6538

Microbiologist & emergency WASH specialist
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  • Marijn Zandee
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Re: tropical enteropathy - key cause of child undernutrition?

Dear Colleagues,

This article from Bangladesh gives some more insight/weight to the Environmental Entropathy (EE) discussion. The authors examined Bacterial overgrowth in the low intestine (SIBO) in children. SIBO is thought to be part of the not very well understood EE "pathological mechanism".

The researchers found correlations between stunting, lack of sanitation and SIBO in a group of 90 children of 2 years old.

mbio.asm.org/content/7/1/e02102-15.full

Regards

Marijn

Marijn Zandee

Kathmandu, Nepal

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

Please read widely...the etiology of tropical/environmental enteropathy is not known with certainty and is likely to be more complex than a sanitation issue alone...as is its prevention and treatment. A broader picture suggests that a range of insults to the gut microbiome lead to the condition now labelled as environmental enteric dysfunction. Such insults may come from dietary sources, from the ingestion of animal/human feces or other contaminants, from environmental toxins such as aflatoxin, and from elsewhere. We are learning more every day, but we don't have that many answers yet.
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