Dear Bill,

Thanks for your post. I've looked up the mentioned article on Google and found it here (it is open access - yay!):
www.ebiomedicine.com/article/S2352-3964(15)30152-3/fulltext

Could you please tell us more about your work in rural Zimbabwe? How did you derive a "prevalence of between 30 and 60 per cent of under 5s"?

Who do you work for/with?

I look forward to seeing your comparison table when you're finished.

As you work in Zimbabwe, could you also comment in this thread, please?:
forum.susana.org/forum/categories/92-nut...ing-minds-and-growth

Mughal had asked there:

Aspect of lack of toilets, as was the reflection in India’s case, is not mentioned in the post. This tends to suggest that either sanitation is good in Zimbabwe (improved sanitation, so to say), or the comments in the post confined purposely to poverty.

Poverty and lack of toilets are, beyond doubt, major reasons for stunting among children.
Could any user kindly give some information on sanitation in Zimbabwe?

By the way, do you know Peter Morgan, who made the opening post in that thread? He is/was also working on rural Zimbabwe (on sanitation issues), and in case you don't know him yet, I would be happy to make an e-introduction (as he's also got an interest in stunting in Zimbabwean children; he lives in Harare).

Regards,
Elisabeth

Re Q1 on prevalence, there is a recent article by Caitlin Naylor et al. in EBioMedicine 2 (2015) which used clinical diagnoses and reports that EE was present in more than 80% of infants by the age of 12 weeks. The setting was an urban slum in Dhaka.

My work in rural Zimbabwe--without clinical diagnoses--suggests a prevalence of between 30 and 60 per cent of under 5s.

I'm currently working on a 'league table' of prevalence from studies worldwide, and I'll post this when it's ready.

Cheers Bill

These are some good and thought provoking questions, but I don't think that the condition is already sufficiently well understood to answer most of these. In fact I suspect that it might never be, as it is one of those (for a lack of a better word) complex "systemic" conditions without a simple cause and effect relation nor an easy to determine set of symptoms.

For me as a practitioner (who understands that things can be complex, but even without full understanding one can still try to make the best out of it) the idea/concept behind this condition is strong enough to advise preemptive prevention/mitigation. But I understand that for researchers (and "evidence" enthusiasts ) this is not a very satisfying situation...

Use of cow dung is common in the rural areas of Sindh, Pakistan. Women collect the cow dung, make cakes and put them on the walls of their houses. The walls are usually of mud + straw. The cakes get glued to the walls. The dried cakes are then used as fuel for cooking. Back in 1960s, I used to see womenfolks do this.

While, generally, the sanitation is poor in the rural areas, personal hygiene is poor and handwashing rates are extremely low, the women do not wash their hands after making cow dung cakes.

F H Mughal

Dear Elizabeth,

I am sorry but none of us were at the Forum (hence the questions were submitted to various people and via the blog post (www.communityledtotalsanitation.org/blog...nutrition-forum-bonn) and forum) so I don't know if they were answered there. I emailed some of the people involved but have not heard back. So far, no one has responded to the call for information.

Regards,

Petra

Dear Petra,
Very interesting questions you posed here. (I had to remind myself what FTI stands for: faecally transmitted infections; currently explained on Wikipedia like this: en.wikipedia.org/wiki/Fecal-oral_route)

I am just wondering if you received any answers on your questions during the Bonn WASH and Nutrition forum? If yes, perhaps you or others could also feed this into the Wikipedia article on environmental enterepathy which could benefit from more detail (and more references): en.wikipedia.org/wiki/Environmental_enteropathy

Regards,
Elisabeth

Note by moderator: This post was originally in this thread about the Bonn WASH and Nutrition conference: forum.susana.org/forum/categories/228-bo...utrition-forum#16119

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Environmental enteropathy. What is the latest state of knowledge?

Prevalence especially among children (and in the first 1,000 days). Stephen Luby has been quoted as asking ‘Is it fifty per cent? Ninety per cent? That’s a question worth answering’ quoted in G. Harris New York Times 13 July 2014. Has anything come to light?

Causality. To what extent is it FTIs from humans, and to what extent general environmental dirt, and/or FTIs from animals?

Assessing its presence, intensity and scale?. What progress has there been finding cheaper, quicker, easier ways of assessing its presence, intensity and scale? I have heard there is progress with biomarkers used on faeces. What about the C-Sucrose breath test described in Pediatrics vol 124 no 2 pp 620-626, August 1, 2009 (published on line)? What work is here in hand by SHARE, ICDDRB, others?

Prevalence of other FTIs: What is the state of knowledge? Do WHO and Unicef have on-going programmes to keep data up to date? For diarrhoeas, there is intermittent data (but usually two or more years out of date). But for other FTIs? If so, what are the latest estimates globally and nationally (especially in India) at least for for ascaris, trichuris and hookworm? And other FTIs? Should such data be collected and published regularly?

Cow dung in India? Cow dung is widely believed to have ayurvedic properties. Without taking a position on that, the question has to be asked how - much human infection is there from cow dung? Like other dung, it carries a load of bacteria. Hands, usually women’s, are used to collect it and make it into pats for fuel. I have done this with my lady host in an immersion in Gujarat. Wash as I did I could not get the smell off my hands. Is this a significant route of gut infection, for EE, e.g. through preparing food after handling cow dung? Has this topic been explored? If so, what are the findings? If not why not?

Antibodies. How much nutritional energy is consumed in immune responses to FTIs? I have not been able to get anything beyond that it is all very complicated. Is it not possible to make a guess within orders of magnitude? Can someone press immunologists on this?

Severe acute malnutrition (SAM): With SAM, are there studies of the relative causal significance of FTIs, lack of food, and lack of micronutrients?

FTIs and food losses: In child feeding programmes what proportion of the food is lost to FTIs (stolen by intestinal parasites, used up in immune response etc)? At national levels, and globally, how many millions of tonnes of foodgrain equivalents are lost annually through FTIs?

If you have answers or know of research relevant to any of these questions, please get in touch with us at the CLTS Knowledge Hub at IDS by email (This email address is being protected from spambots. You need JavaScript enabled to view it.)