Fecal Markers of Environmental Enteropathy are Associated with Animal Exposure and Caregiver Hygiene in Bangladesh

Abstract

Abstract. Undernutrition is estimated to be an underlying cause of over half of all deaths in young children globally. There is a growing body of literature suggesting that increased exposure to enteric pathogens is responsible for environmental enteropathy (EE), a disorder associated with impaired growth in children. To determine if household unsanitary environmental conditions were significantly associated with EE and stunting in children, we conducted a cohort of 216 children (≤ 30 months) in rural Bangladesh. Stool was analyzed for four fecal markers of EE: alpha-1-antitrypsin, myeloperoxidase, and neopterin combined to form an EE disease activity score, and calprotectin. We observed a significant association between having an animal corral in a child's sleeping room and elevated EE scores (1.0 point difference, 95% confidence interval [CI]: 0.13, 1.88) and a two times higher odds of stunting (height-for-age z-score < −2) (odds ratio [OR]: 2.53, 95% CI: 1.08, 5.43) after adjusting for potential confounders. In addition, children of caregivers with visibly soiled hands had significantly elevated fecal calprotectin (μg/g) (384.1, 95% CI: 152.37, 615.83). These findings suggest that close contact with animals and caregiver hygiene may be important risk factors for EE in young children. These findings are consistent with the hypothesis that unsanitary environmental conditions can lead to EE in susceptible pediatric populations.

Unsafe Child Feces Disposal is Associated with Environmental Enteropathy and Impaired Growth

“…42 The significant associations between unsafe child feces disposal and elevated environmental enteropathy scores and faltering growth is consistent with the growing body of literature demonstrating that unsanitary environmental conditions put children at an increased risk of environmental enteropathy and impaired growth. [5][6][7] In our previous studies among children in the cohort, we have found that poor caregiver hand hygiene, presence of animals in the child's sleeping room, and children mouthing dirt during play behavior were all significantly associated with elevated fecal markers of environmental enteropathy. 6,7 In addition, an earlier study in rural Bangladesh found that children in "contaminated" households defined by water quality, unhygienic handwashing conditions, and unimproved sanitation had lower lactulose:mannitol, a measure of intestinal absorptive capacity, and impaired growth.…”

“…[5][6][7] In our previous studies among children in the cohort, we have found that poor caregiver hand hygiene, presence of animals in the child's sleeping room, and children mouthing dirt during play behavior were all significantly associated with elevated fecal markers of environmental enteropathy. 6,7 In addition, an earlier study in rural Bangladesh found that children in "contaminated" households defined by water quality, unhygienic handwashing conditions, and unimproved sanitation had lower lactulose:mannitol, a measure of intestinal absorptive capacity, and impaired growth. 5 Furthermore, these findings build on earlier work demonstrating that unsafe child feces disposal increases the risk of enteric infections and diarrheal disease in pediatric populations.…”

“…[1][2][3][4] There is a growing body of literature demonstrating an association between environmental enteropathy and undernutrition in susceptible pediatric populations. [5][6][7][8][9] Environmental enteropathy is defined by abnormal intestinal morphology, reduced intestinal barrier function, and increased intestinal inflammation resulting in malabsorption of nutrients and growth faltering in children. [10][11][12][13][14][15][16][17][18] This disorder is thought to occur from unsanitary environmental conditions, leading to repeated exposures to enteric pathogens.…”

Nonnative Cattle Ownership, Diet, and Child Height-for-Age: Evidence from the 2011 Uganda Demographic and Health Survey

“…47,48 Child exposure to animal fecal contamination within the living environment has been reported in studies from Zimbabwe, 13 Peru, 49 and Bangladesh. 12,50 Since information on animal corralling was not collected as part of the 2011 UDHS, we were unable to examine these relationships in more detail.…”

New insights into environmental enteric dysfunction

“…There is a strong epidemiological link between EED and poor sanitation, exposure to animal faeces,16 lack of access to soap and water for hand and face washing,27 and consumption of contaminated food and water 28–31. These associations lead to the hypothesis that poor sanitation facilitates a constant exposure to microbes in the small intestine, provoking the chronic inflammatory state and defective integrity of the gut observed in EED.…”