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.

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

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

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:

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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

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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

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

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

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.

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#

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

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.

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)
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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

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

Florian

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.