Investigating the Relationship Between Environmental Conditions and Environmental Enteropathy


Globally, undernutrition is a serious threat to early childhood health. It is estimated to be an underlying cause of more than 50% of all deaths in young children globally. However, undernutrition and childhood growth stunting are disproportionately concentrated in low-income areas. Environmental enteropathy (EE), a condition thought to be caused by frequent intestinal infections has been shown to be associated stunting in children. By World Health Organization Standards, stunting is defined as significantly low height-for-age measurements. Recent literature suggests that increased exposure to enteric pathogens is directly related to EE. 

In a June 2015 publication in the American Journal of Tropical Medicine and Hygiene, Faculty Working Group Member Christine Marie George, PhD, investigates the relationship between environmental conditions, such as exposure to domestic animals and caregiver hygiene, and fecal markers of EE. The study followed 216 children, 6-30 months of age, in rural Bangladesh, recording the environmental and hygienic conditions in each household and analyzing stool for fecal markers of environmental enteropathy. These markers were alpha-1-antitrypsin, myeloperoxidase, neopterin, and calprotectin.

A major goal of the study was to investigate whether household environmental conditions were significantly associated with EE and stunting in children.. Beyond measuring the children’s height and weight and collecting stool, the researchers made note of the environmental conditions in each house. They observed whether soap was present at the household water source, the sleeping room floor type, the presence of domestic animals both in and around the house, the location of an animal corral, and the sanitation option type. An “unimproved sanitation option” was defined as no sanitation option, an open-pit latrine, a pit latrine with a broken slab, a bucket toilet, or a hanging toilet. Finally, they checked the hand cleanliness of both the child and the caregiver as a proxy measure of hygiene practices.

The study found a significant association (1.0 point difference, 95% confidence interval [CI]: 0.13, 1.88) between having an animal corral in a child’s sleeping room and elevated EE disease activity scores. They also found that these children had a two times higher odds of stunting (odds ratio [OR]: 2.53, 95% CI: 1.08, 5.43). In addition, they found that children of caregivers with visibly soiled hands had significantly elevated levels of fecal calprotectin, a neutrophil protein that is elevated in infectious and inflammatory conditions of the bowel. The results of the study suggest that unsanitary environmental conditions in the home and poor hygiene practices by caregiver are linked to EE and stunting in children in low-income countries. Dr, George recommends that future studies investigate the relationship between environmental conditions and EE in other settings where children are high risk for stunting globally.

Faculty Working Group Member, Christine Marie George, PhD, is an Assistant Professor in the Department of International Health.

George CM, Oldja L, Biswas S, Perin J, Lee GO, Kosek M, Sack RB, AhmedS, Haque R, Parvin T, Azmi IJ, BhuyianSI, Talukder KA, Faruque AG. "Fecal Markers of Environmental Enteropathy are Associated with Animal Exposure and Caregiver Hygiene in Bangladesh". Am J Trop Med Hyg. 2015 Jun 8. pii: 14-0694. 


Christine Marie George, Environmental Enteropathy, stunting

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