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Hossain MS, Begum SMKN, Rahman MM, Parvez M, Mazumder RN, Sarker SA, Hasan MM, Fahim SM, Gazi MA, Das S, Mahfuz M, Ahmed T. Environmental enteric dysfunction and small intestinal histomorphology of stunted children in Bangladesh. PLoS Negl Trop Dis 2023; 17:e0010472. [PMID: 36656867 PMCID: PMC9888706 DOI: 10.1371/journal.pntd.0010472] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 01/31/2023] [Accepted: 01/10/2023] [Indexed: 01/20/2023] Open
Abstract
There is lack of information on the histological characteristics of the intestinal mucosa in Bangladeshi children. Collection of intestinal biopsy samples and assessment of the histomorphological features is considered to be the traditional gold standard for diagnosis of environmental enteric dysfunction (EED). The purpose of the study was to evaluate the intestinal histological characteristics of stunted children aged between 12-18 months with possible EED. 110 children with chronic malnutrition (52 stunted with length-for-age Z score, LAZ<-2 and 58 at risk of stunting with LAZ <-1 to -2) from the Bangladesh Environmental Enteric Dysfunction (BEED) study protocol who underwent upper gastrointestinal (GI) endoscopy were selected for this study. To explore the association of EED with childhood stunting, upper GI endoscopy was done and the biopsy specimens were studied for histopathology. Villous height and crypt depth were measured and the presence and intensity of inflammatory infiltrates in the lamina propria was investigated. Bivariate analysis was performed to examine the relationship between stunting and histologic morphology. More than 90% children irrespective of nutritional status were diagnosed to have chronic non-specific duodenitis on histopathology. Half of the children from both groups had villous atrophy as well as crypt hyperplasia and lymphocytic infiltration was present in more than 90% children, irrespective of groups. However, no statistically significant difference was observed when compared between the groups. The prevalence of chronic non-specific duodenitis in Bangladeshi children, irrespective of nutritional status, was high. A significant number of these children had abnormal findings in intestinal histomorphology. Trial registration number: ClinicalTrials.gov ID: NCT02812615 Date of first registration: 24/06/2016. https://clinicaltrials.gov/ct2/results?cond=NCT02812615&term=&cntry=&state=&city=&dist.
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Affiliation(s)
- Md. Shabab Hossain
- Nutrition and Clinical Services Division, International Centre for Diarrheal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
- * E-mail:
| | | | - M Masudur Rahman
- Department of Gastroenterology, Sheikh Russel National Gastroliver Institute and Hospital, Dhaka, Bangladesh
| | - Mashud Parvez
- Department of Pathology, Bangladesh Specialized Hospital, Dhaka, Bangladesh
| | - Ramendra Nath Mazumder
- Nutrition and Clinical Services Division, International Centre for Diarrheal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Shafiqul Alam Sarker
- Nutrition and Clinical Services Division, International Centre for Diarrheal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Md. Mehedi Hasan
- Nutrition and Clinical Services Division, International Centre for Diarrheal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Shah Mohammad Fahim
- Nutrition and Clinical Services Division, International Centre for Diarrheal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Md. Amran Gazi
- Nutrition and Clinical Services Division, International Centre for Diarrheal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Subhasish Das
- Nutrition and Clinical Services Division, International Centre for Diarrheal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Mustafa Mahfuz
- Nutrition and Clinical Services Division, International Centre for Diarrheal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Tahmeed Ahmed
- Nutrition and Clinical Services Division, International Centre for Diarrheal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
- Department of Public Health Nutrition, James P Grant School of Public Health, BRAC University, Dhaka, Bangladesh
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Affiliation(s)
- Peter B Sullivan
- Department of Paediatrics, University of Oxford, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
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Bhattacharjee A, Burr AHP, Overacre-Delgoffe AE, Tometich JT, Yang D, Huckestein BR, Linehan JL, Spencer SP, Hall JA, Harrison OJ, Morais da Fonseca D, Norton EB, Belkaid Y, Hand TW. Environmental enteric dysfunction induces regulatory T cells that inhibit local CD4+ T cell responses and impair oral vaccine efficacy. Immunity 2021; 54:1745-1757.e7. [PMID: 34348118 DOI: 10.1016/j.immuni.2021.07.005] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 04/21/2021] [Accepted: 07/09/2021] [Indexed: 12/13/2022]
Abstract
Environmental enteric dysfunction (EED) is a gastrointestinal inflammatory disease caused by malnutrition and chronic infection. EED is associated with stunting in children and reduced efficacy of oral vaccines. To study the mechanisms of oral vaccine failure during EED, we developed a microbiota- and diet-dependent mouse EED model. Analysis of E. coli-labile toxin vaccine-specific CD4+ T cells in these mice revealed impaired CD4+ T cell responses in the small intestine and but not the lymph nodes. EED mice exhibited increased frequencies of small intestine-resident RORγT+FOXP3+ regulatory T (Treg) cells. Targeted deletion of RORγT from Treg cells restored small intestinal vaccine-specific CD4 T cell responses and vaccine-mediated protection upon challenge. However, ablation of RORγT+FOXP3+ Treg cells made mice more susceptible to EED-induced stunting. Our findings provide insight into the poor efficacy of oral vaccines in EED and highlight how RORγT+FOXP3+ Treg cells can regulate intestinal immunity while leaving systemic responses intact.
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Affiliation(s)
- Amrita Bhattacharjee
- R.K. Mellon Institute for Pediatric Research, Pediatrics Department, Infectious Disease Section, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA 15224 USA
| | - Ansen H P Burr
- R.K. Mellon Institute for Pediatric Research, Pediatrics Department, Infectious Disease Section, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA 15224 USA; Program in Microbiology and Immunology, Department of Immunology, University of Pittsburgh, School of Medicine, Pittsburgh, PA 15261, USA
| | - Abigail E Overacre-Delgoffe
- R.K. Mellon Institute for Pediatric Research, Pediatrics Department, Infectious Disease Section, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA 15224 USA
| | - Justin T Tometich
- R.K. Mellon Institute for Pediatric Research, Pediatrics Department, Infectious Disease Section, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA 15224 USA
| | - Deyi Yang
- R.K. Mellon Institute for Pediatric Research, Pediatrics Department, Infectious Disease Section, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA 15224 USA; Central South University, Xiangya School of Medicine, Changsha, PRC
| | - Brydie R Huckestein
- Program in Microbiology and Immunology, Department of Immunology, University of Pittsburgh, School of Medicine, Pittsburgh, PA 15261, USA
| | - Jonathan L Linehan
- Metaorganism Immunity Section, Laboratory of Immune System Biology, National Institute of Allergy and Infectious Disease, National Institutes of Health, Bethesda, MD, USA
| | - Sean P Spencer
- Metaorganism Immunity Section, Laboratory of Immune System Biology, National Institute of Allergy and Infectious Disease, National Institutes of Health, Bethesda, MD, USA
| | - Jason A Hall
- Metaorganism Immunity Section, Laboratory of Immune System Biology, National Institute of Allergy and Infectious Disease, National Institutes of Health, Bethesda, MD, USA
| | - Oliver J Harrison
- Metaorganism Immunity Section, Laboratory of Immune System Biology, National Institute of Allergy and Infectious Disease, National Institutes of Health, Bethesda, MD, USA
| | - Denise Morais da Fonseca
- Metaorganism Immunity Section, Laboratory of Immune System Biology, National Institute of Allergy and Infectious Disease, National Institutes of Health, Bethesda, MD, USA
| | - Elizabeth B Norton
- Department of Microbiology and Immunology, Tulane University School of Medicine, New Orleans, LA, USA
| | - Yasmine Belkaid
- Metaorganism Immunity Section, Laboratory of Immune System Biology, National Institute of Allergy and Infectious Disease, National Institutes of Health, Bethesda, MD, USA
| | - Timothy W Hand
- R.K. Mellon Institute for Pediatric Research, Pediatrics Department, Infectious Disease Section, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA 15224 USA; Program in Microbiology and Immunology, Department of Immunology, University of Pittsburgh, School of Medicine, Pittsburgh, PA 15261, USA.
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Abstract
Sometimes referred to as hidden hunger, micronutrient deficiencies persist on a global scale. For some micronutrients this appears to be due to inadequate intake, for others intake may not match increased requirements. However, for most micronutrient deficiencies there is uncertainty as to the dominant driver, and the question about the contribution of malabsorption is open. Environmental enteropathy (EE), formerly referred to as tropical enteropathy and also referred to as environmental enteric dysfunction, is an asymptomatic disorder of small intestinal structure and function which is very highly prevalent in many disadvantaged populations. Recent studies of the pathology and microbiology of this disorder suggest that it is driven by very high pathogen burdens in children and adults living in insanitary environments and is characterised by major derangements of the epithelial cells of the intestinal mucosa. Transcriptomic data suggest that it may lead to impaired digestion and absorption of macronutrients. Given the very high prevalence of EE, marginal malabsorption could have large impacts at population scales. However, the relative contributions of inadequate soil and crop micronutrient contents, inadequate intake, malabsorption and increased requirements are unknown. Malabsorption may compromise attempts to improve micronutrient status, but with the exception of zinc there is currently little evidence to confirm that malabsorption contributes to micronutrient deficiency. Much further research is required to understand the role of malabsorption in hidden hunger, especially in very disadvantaged populations where these deficiencies are most prevalent.
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Hossain MS, Begum SMKN, Rahman MM, Mazumder RN, Parvez M, Gazi MA, Hasan MM, Fahim SM, Das S, Mahfuz M, Sarker SA, Ahmed T. Alterations in the histological features of the intestinal mucosa in malnourished adults of Bangladesh. Sci Rep 2021; 11:2355. [PMID: 33504937 PMCID: PMC7840936 DOI: 10.1038/s41598-021-82079-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Accepted: 01/13/2021] [Indexed: 12/20/2022] Open
Abstract
There is paucity of knowledge on the histological features of the intestinal mucosa in malnourished adults of Bangladesh. The purpose of the study was to explore the histological features of the intestinal mucosa in malnourished adults of Bangladesh and to compare the findings with their well-nourished counterparts. 64 adults (37 malnourished with body mass index, BMI < 18.5 kg/m2 and 27 controls with BMI > 18.5 kg/m2) from the Bangladesh Environmental Enteric Dysfunction (BEED) study, who underwent upper-gastrointestinal endoscopy, were selected for this study. With a view to address the association of environmental enteric dysfunction (EED) with malnutrition, upper-gastrointestinal endoscopy was performed and mucosal biopsies from the distal duodenum were studied for histopathology. Villous height, crypt depth, and presence of inflammatory infiltrates in lamina propria were investigated. Bivariate analysis was performed to quantify the relation between malnutrition and the histological features. About 95% adults, irrespective of nutritional status, were diagnosed to have chronic non-specific duodenitis on histopathology. Malnourished adults suffered significantly more from chronic active duodenitis compared to their well-nourished counterparts (p = 0.003). Malnourished adults also had significantly higher frequency of subtotal villous atrophy, crypt hyperplasia and marked cellular infiltration in the lamina propria than the healthy controls (p < 0.05).
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Affiliation(s)
- Md Shabab Hossain
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), 68, Shaheed Tajuddin Ahmed Sarani, Mohakhali, Dhaka, 1212, Bangladesh.
| | | | - M Masudur Rahman
- Department of Gastroenterology, Sheikh Russel National Gastroliver Institute and Hospital, Dhaka, 1212, Bangladesh
| | - Ramendra Nath Mazumder
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), 68, Shaheed Tajuddin Ahmed Sarani, Mohakhali, Dhaka, 1212, Bangladesh
| | - Mashud Parvez
- Department of Pathology, Bangladesh Specialized Hospital, Dhaka, 1207, Bangladesh
| | - Md Amran Gazi
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), 68, Shaheed Tajuddin Ahmed Sarani, Mohakhali, Dhaka, 1212, Bangladesh
| | - Md Mehedi Hasan
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), 68, Shaheed Tajuddin Ahmed Sarani, Mohakhali, Dhaka, 1212, Bangladesh
| | - Shah Mohammad Fahim
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), 68, Shaheed Tajuddin Ahmed Sarani, Mohakhali, Dhaka, 1212, Bangladesh
| | - Subhasish Das
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), 68, Shaheed Tajuddin Ahmed Sarani, Mohakhali, Dhaka, 1212, Bangladesh
| | - Mustafa Mahfuz
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), 68, Shaheed Tajuddin Ahmed Sarani, Mohakhali, Dhaka, 1212, Bangladesh
| | - Shafiqul Alam Sarker
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), 68, Shaheed Tajuddin Ahmed Sarani, Mohakhali, Dhaka, 1212, Bangladesh
| | - Tahmeed Ahmed
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), 68, Shaheed Tajuddin Ahmed Sarani, Mohakhali, Dhaka, 1212, Bangladesh
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Morais MBD, Silva GAPD. Environmental enteric dysfunction and growth. Jornal de Pediatria (Versão em Português) 2019; 95:85-94. [DOI: 10.1016/j.jpedp.2019.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Abstract
OBJECTIVE To describe the current indicators of environmental enteric dysfunction and its association with linear growth deficit and the height-for-age anthropometric indicator. DATA SOURCES Narrative review with articles identified in PubMed and Scopus databases using combinations of the following words: environmental, enteric, dysfunction, enteropathy, and growth, as well as the authors' personal records. DATA SYNTHESIS In the last 15 years, new non-invasive markers have been investigated to characterize environmental enteric dysfunction; however, the best tests to be used have not yet been identified. There is evidence that, in environmental enteric dysfunction, a systemic inflammatory process may also occur as a consequence of increased intestinal permeability, in addition to intestinal mucosa abnormalities. Bacterial overgrowth in the small intestine and changes in fecal microbiota profile have also been identified. There is evidence indicating that environmental enteric dysfunction can impair not only full growth but also the neuropsychomotor development and response to orally administered vaccines. It is important to emphasize that the environmental enteric dysfunction is not a justification for not carrying out vaccination, which must follow the regular schedule. Another aspect to emphasize is the greater risk for those children who had height impairment in early childhood, possibly associated with environmental enteric dysfunction, to present overweight and obesity in adulthood when exposed to a high calorie diet, which has been called "triple burden." CONCLUSIONS According to the analyzed evidence, the control of environmental enteric dysfunction is very important for the full expression of growth, development, and vaccine response in the pediatric age group.
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Affiliation(s)
- Mauro Batista de Morais
- Universidade Federal de São Paulo (UNIFESP), Escola Paulista de Medicina, Disciplina de Gastroenterologia Pediátrica, São Paulo, SP, Brazil.
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Marie C, Ali A, Chandwe K, Petri WA, Kelly P. Pathophysiology of environmental enteric dysfunction and its impact on oral vaccine efficacy. Mucosal Immunol 2018; 11:1290-1298. [PMID: 29988114 DOI: 10.1038/s41385-018-0036-1] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Revised: 04/03/2018] [Accepted: 04/11/2018] [Indexed: 02/08/2023]
Abstract
Environmental enteric dysfunction (EED) refers to a subclinical disorder of intestinal function common in tropical countries and in settings of poverty and economic disadvantage. The enteropathy that underlies this syndrome is characterized by mucosal inflammation and villus blunting mediated by T cell activation. Epithelial cell disruption and microbial translocation drive systemic inflammation. EED in young children is associated geographically with growth failure, malnutrition, and greatly impaired responses to oral vaccines, notably rotavirus and poliovirus vaccines. In this review, we describe the pathophysiology of EED and examine the evidence linking EED and oral vaccine failure. This evidence is far from conclusive. Although our understanding of EED is still sketchy, there is limited evidence of disturbed innate immunity, B cell disturbances including aggregation into lymphoid follicles, and autoantibody generation. Pathways of T cell activation and the possibility of dendritic cell anergy, which could help explain oral vaccine failure, require further work.
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Affiliation(s)
- Chelsea Marie
- The University of Virginia, Charlottesville, VA, USA
| | - Asad Ali
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Kanta Chandwe
- Tropical Gastroenterology and Nutrition group, University of Zambia School of Medicine, Lusaka, Zambia
| | | | - Paul Kelly
- Tropical Gastroenterology and Nutrition group, University of Zambia School of Medicine, Lusaka, Zambia. .,Barts & The London School of Medicine, Queen Mary University of London, London, E1 4AT, UK.
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Vonaesch P, Randremanana R, Gody JC, Collard JM, Giles-Vernick T, Doria M, Vigan-Womas I, Rubbo PA, Etienne A, Andriatahirintsoa EJ, Kapel N, Brown E, Huus KE, Duffy D, Finlay B, Hasan M, Hunald FA, Robinson A, Manirakiza A, Wegener-Parfrey L, Vray M, Sansonetti PJ. Identifying the etiology and pathophysiology underlying stunting and environmental enteropathy: study protocol of the AFRIBIOTA project. BMC Pediatr 2018; 18:236. [PMID: 30025542 PMCID: PMC6053792 DOI: 10.1186/s12887-018-1189-5] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Accepted: 06/21/2018] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Globally one out of four children under 5 years is affected by linear growth delay (stunting). This syndrome has severe long-term sequelae including increased risk of illness and mortality and delayed psychomotor development. Stunting is a syndrome that is linked to poor nutrition and repeated infections. To date, the treatment of stunted children is challenging as the underlying etiology and pathophysiological mechanisms remain elusive. We hypothesize that pediatric environmental enteropathy (PEE), a chronic inflammation of the small intestine, plays a major role in the pathophysiology of stunting, failure of nutritional interventions and diminished response to oral vaccines, potentially via changes in the composition of the pro- and eukaryotic intestinal communities. The main objective of AFRIBIOTA is to describe the intestinal dysbiosis observed in the context of stunting and to link it to PEE. Secondary objectives include the identification of the broader socio-economic environment and biological and environmental risk factors for stunting and PEE as well as the testing of a set of easy-to-use candidate biomarkers for PEE. We also assess host outcomes including mucosal and systemic immunity and psychomotor development. This article describes the rationale and study protocol of the AFRIBIOTA project. METHODS AFRIBIOTA is a case-control study for stunting recruiting children in Bangui, Central African Republic and in Antananarivo, Madagascar. In each country, 460 children aged 2-5 years with no overt signs of gastrointestinal disease are recruited (260 with no growth delay, 100 moderately stunted and 100 severely stunted). We compare the intestinal microbiota composition (gastric and small intestinal aspirates; feces), the mucosal and systemic immune status and the psychomotor development of children with stunting and/or PEE compared to non-stunted controls. We also perform anthropological and epidemiological investigations of the children's broader living conditions and assess risk factors using a standardized questionnaire. DISCUSSION To date, the pathophysiology and risk factors of stunting and PEE have been insufficiently investigated. AFRIBIOTA will add new insights into the pathophysiology underlying stunting and PEE and in doing so will enable implementation of new biomarkers and design of evidence-based treatment strategies for these two syndromes.
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Affiliation(s)
- Pascale Vonaesch
- Unité de Pathogénie Microbienne Moléculaire, Institut Pasteur, 28 Rue du Dr. Roux, 75015 Paris, France
| | - Rindra Randremanana
- Unité d’Epidémiologie et de Recherche Clinique, Institut Pasteur de Madagascar, BP 1274 Ambatofotsikely, Avaradoha, 101 Antananarivo, Madagascar
| | - Jean-Chrysostome Gody
- Centre Pédiatrique de Bangui, Avenue de l’Indépendance, Bangui, Central African Republic
| | - Jean-Marc Collard
- Unité de Bactériologie Expérimentale, Institut Pasteur de Madagascar, BP 1274 Ambatofotsikely, Avaradoha, 101 Antananarivo, Madagascar
| | - Tamara Giles-Vernick
- Unité d’Epidémiologie des Maladies Emergentes, Institut Pasteur, 28 Rue du Dr. Roux, 75015 Paris, France
| | - Maria Doria
- Unité de Pathogénie Microbienne Moléculaire, Institut Pasteur, 28 Rue du Dr. Roux, 75015 Paris, France
| | - Inès Vigan-Womas
- Unité d’Immunologie des Maladies Infectieuses, Institut Pasteur de Madagascar, BP 1274 Ambatofotsikely, Avaradoha, 101 Antananarivo, Madagascar
| | - Pierre-Alain Rubbo
- Laboratoire d’Analyses Médicales, Institut Pasteur de Bangui, Avenue de l’Indépendance, Bangui, Central African Republic
| | - Aurélie Etienne
- Unité d’Epidémiologie et de Recherche Clinique, Institut Pasteur de Madagascar, BP 1274 Ambatofotsikely, Avaradoha, 101 Antananarivo, Madagascar
| | - Emilson Jean Andriatahirintsoa
- Centre Hospitalier Universitaire Mère-Enfant de Tsaralalàna (CHUMET), rue Patrice Lumumba, Tsaralalàna, 101 Antananarivo, Madagascar
| | - Nathalie Kapel
- Laboratoire de Coprologie Fonctionnelle, Hôpital Pitié-Salpêtrière, 47-83 Bd de l’Hôpital, 75013 Paris, France
| | - Eric Brown
- Michael Smith Laboratories, University of British Columbia, 2185 East Mall, Vancouver, V6T1Z4 Canada
| | - Kelsey E. Huus
- Michael Smith Laboratories, University of British Columbia, 2185 East Mall, Vancouver, V6T1Z4 Canada
| | - Darragh Duffy
- Unité de la Biologie des Cellules Dendritiques, Institut Pasteur, 25 Rue du Dr. Roux, 75015 Paris, France
| | - B.Brett Finlay
- Michael Smith Laboratories, University of British Columbia, 2185 East Mall, Vancouver, V6T1Z4 Canada
| | - Milena Hasan
- Centre de Recherche Translationnelle, Institut Pasteur, 28 Rue du Dr. Roux, 75015 Paris, France
| | - Francis Allen Hunald
- Centre Hospitalier Universitaire Joseph Ravoahangy Andrianavalona (CHUJRA), Antananarivo, Madagascar
| | - Annick Robinson
- Centre Hospitalier Universitaire Mère Enfant de Tsaralalana, Antananarivo, Madagascar
| | - Alexandre Manirakiza
- Unité d’Epidémiologie, Institut Pasteur de Bangui, Avenue de l’Indépendance, Bangui, Central African Republic
| | - Laura Wegener-Parfrey
- Departments of Botany and Zoology, and Biodiversity Research Centre, University of British Columbia, 3200-6270 University Boulevard, Vancouver, V6T1Z4 Canada
| | - Muriel Vray
- Unité d’Epidémiologie des Maladies Emergentes, Institut Pasteur, 28 Rue du Dr. Roux, 75015 Paris, France
| | - Philippe J. Sansonetti
- Unité de Pathogénie Microbienne Moléculaire, Institut Pasteur, 28 Rue du Dr. Roux, 75015 Paris, France
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Church JA, Parker EPK, Kosek MN, Kang G, Grassly NC, Kelly P, Prendergast AJ. Exploring the relationship between environmental enteric dysfunction and oral vaccine responses. Future Microbiol 2018; 13:1055-1070. [PMID: 29926747 PMCID: PMC6136084 DOI: 10.2217/fmb-2018-0016] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Accepted: 03/26/2018] [Indexed: 12/11/2022] Open
Abstract
Oral vaccines significantly underperform in low-income countries. One possible contributory factor is environmental enteric dysfunction (EED), a subclinical disorder of small intestinal structure and function among children living in poverty. Here, we review studies describing oral vaccine responses and EED. We identified eight studies evaluating EED and oral vaccine responses. There was substantial heterogeneity in study design and few consistent trends emerged. Four studies reported a negative association between EED and oral vaccine responses; two showed no significant association; and two described a positive correlation. Current evidence is therefore insufficient to determine whether EED contributes to oral vaccine underperformance. We identify roadblocks in the field and future research needs, including carefully designed studies those can investigate this hypothesis further.
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Affiliation(s)
- James A Church
- Zvitambo Institute for Maternal & Child Health Research, Harare, Zimbabwe
- Centre for Genomics & Child Health, Blizard Institute, Queen Mary University of London, UK
| | - Edward PK Parker
- Department of Infectious Disease Epidemiology, St Mary's Campus, Imperial College London, London, UK
| | - Margaret N Kosek
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA
| | - Gagandeep Kang
- Department of Gastrointestinal Sciences, Christian Medical College, Vellore, Tamil Nadu, India
| | - Nicholas C Grassly
- Department of Infectious Disease Epidemiology, St Mary's Campus, Imperial College London, London, UK
| | - Paul Kelly
- Centre for Genomics & Child Health, Blizard Institute, Queen Mary University of London, UK
- Tropical Gastroenterology & Nutrition group, University of Zambia School of Medicine, Lusaka, Zambia
| | - Andrew J Prendergast
- Zvitambo Institute for Maternal & Child Health Research, Harare, Zimbabwe
- Centre for Genomics & Child Health, Blizard Institute, Queen Mary University of London, UK
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA
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11
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Bhattacharjee A, Hand TW. Role of nutrition, infection, and the microbiota in the efficacy of oral vaccines. Clin Sci (Lond) 2018; 132:1169-77. [PMID: 29925624 DOI: 10.1042/CS20171106] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Revised: 05/15/2018] [Accepted: 05/21/2018] [Indexed: 12/11/2022]
Abstract
Oral vaccines (OVs), provide protection against pathogens that infect mucosal surfaces and their potency relies on their capacity to elicit T- and B-cell responses directed to these surfaces. Oral vaccination efficacy has been found to vary considerably with differences in geographical locations and socioeconomic status. Specifically, in children living in resource-poor countries, undernourishment and chronic gastrointestinal (GI) infection are associated with the failure of OVs, which is a tragic outcome for the children who would benefit most from mucosal-based protection from infection. Both undernutrition and GI infection have been shown to profoundly affect the microbiota, inducing 'dysbiosis' characterized by narrowed bacterial diversity and increased frequency of bacterial clades associated with the induction of inflammation. Recent studies have demonstrated that the microbiota exerts a profound effect on the development of mucosal immune responses. Therefore, it seems likely that OV failure in resource-poor regions is affected by alterations to the immune response driven by dysbiotic changes to the microbiota. Here, we review the contribution of the microbiota to OV efficacy in the context of diet and GI infection.
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12
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Wright SG. Tropical Enteritis: A Review. J R Soc Med 2018; 71:910-3. [PMID: 368336 PMCID: PMC1436314 DOI: 10.1177/014107687807101213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Abstract
Purpose of Review The term ‘tropical enteropathy’ originated in observations in the 1960s that small intestinal morphology and function differed in the tropics from the norms found in temperate climates. It was subsequently shown that this enteropathy is more closely related to environmental conditions than latitude, and it was re-labelled ‘environmental enteropathy’. It is now recognised that environmental enteropathy (also now called environmental enteric dysfunction) has implications for the health and linear growth of children in low- and middle-income countries, and it may underlie poor responses to oral vaccination in these countries. The purpose of this review is to define and clarify this enteropathy despite the confusing terminology it has attracted and to contrast it with other enteropathic states. Recent Findings Recent work has begun to demonstrate the nature of the mucosal lesion and the relationship with microbial translocation which is currently thought to link a failure of mucosal barrier function and the cascade of systemic inflammation which inhibits growth. The evidence is still correlative rather than definitive, but derives some additional support from animal models. There are some common features between environmental enteropathy and other enteropathies, but there are important differences also. The mechanism of the link between enteropathy and vaccine failure is not understood, and neither is it clear how the more severe form of enteropathy, which we refer to as malnutrition enteropathy, is driven by nutrient depletion and intestinal infection. Summary Tropical enteropathies form a group of disorders which include environmental and nutritional enteropathies. The long-term health implications of these disorders for health in low-income countries are just being explored, but the scale of their effects is very large, with millions of people affected.
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14
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Affiliation(s)
- Donna M Denno
- Department of Pediatrics, University of Washington, Seattle, Washington.,Department of Global Health, University of Washington, Seattle, Washington
| | - Phillip I Tarr
- Department of Pediatrics, Washington University in St. Louis School of Medicine, St. Louis, Missouri
| | - James P Nataro
- Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, Virginia
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15
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Watanabe K, Petri WA. Environmental Enteropathy: Elusive but Significant Subclinical Abnormalities in Developing Countries. EBioMedicine 2016; 10:25-32. [PMID: 27495791 PMCID: PMC5006727 DOI: 10.1016/j.ebiom.2016.07.030] [Citation(s) in RCA: 85] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Revised: 07/07/2016] [Accepted: 07/22/2016] [Indexed: 12/26/2022] Open
Abstract
Environmental enteropathy/Environmental enteric dysfunction (EE/EED) is a chronic disease of small intestine characterized by gut inflammation and barrier disruption, malabsorption and systemic inflammation in the absence of diarrhea. It is predominantly diseases of children in low income countries and is hypothesized to be caused by continuous exposure to fecally contaminated food, water and fomites. It had not been recognized as a priority health issue because it does not cause overt symptoms and was seen in apparently healthy individuals. However, there is a growing concern of EE/EED because of its impact on longitudinal public health issues, such as growth faltering, oral vaccine low efficacy and poor neurocognitive development. Recent works have provided important clues to unravel its complex pathogenesis, and suggest possible strategies for controlling EE/EED. However, effective diagnostic methods and interventions remain unsettled. Here, we review the existing literature, especially about its pathogenesis, and discuss a solution for children living in the developing world. EE/EED is acquired by the close contact with unsanitary condition, and abnormalities of EE/EED are reversible over time. EE/EED should be diagnosed as young as possible because poor growth is often evident within 1-2 years of life. EE/EED should be diagnosed by simple, noninvasive and low-cost methods, such as fecal biomarkers. It is hard to diagnose EE/EED and to predict consequences by a single marker/test due to the complexity in pathogenesis. Interventions for EE/EED other than sanitary reform are under investigation although no reports showed favorable outcomes currently.
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Affiliation(s)
- Koji Watanabe
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, VA, USA; AIDS Clinical Center, National Center for Global Health and Medicine, Tokyo, Japan.
| | - William A Petri
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, VA, USA.
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16
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Kent TH, Moon HW. The Comparative Pathogenesis of Some Enteric Diseases. Based on Cases Presented at the 22nd Annual Seminar of the American College of Veterinary Pathologists. Vet Pathol 2016. [DOI: 10.1177/030098587301000506] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Basic reactions of the intestinal tract to injury are discussed using cases presented at the American College of Veterinary Pathologists' Seminar on Intestinal Pathology. Reports of the individual cases are cited in the text. Material reported during discussions is presented to preserve something of the tenor of the Seminar. First, the morphogenesis of the lesions in each case will be discussed, followed by the resultant functional changes related to clinical signs, and comparisons to other similar diseases.
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Affiliation(s)
- T. H. Kent
- Department of Pathology, College of Medicine, University of Iowa, Iowa City; and The National Animal Disease Laboratory, North Central Region, Agricultural Research Service, U. S. Department of Agriculture, Ames, Iowa
| | - H. W. Moon
- Department of Pathology, College of Medicine, University of Iowa, Iowa City; and The National Animal Disease Laboratory, North Central Region, Agricultural Research Service, U. S. Department of Agriculture, Ames, Iowa
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17
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Mbuya MNN, Humphrey JH. Preventing environmental enteric dysfunction through improved water, sanitation and hygiene: an opportunity for stunting reduction in developing countries. Matern Child Nutr 2015; 12 Suppl 1:106-20. [PMID: 26542185 PMCID: PMC5019251 DOI: 10.1111/mcn.12220] [Citation(s) in RCA: 124] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/26/2015] [Revised: 07/27/2015] [Accepted: 08/18/2015] [Indexed: 12/14/2022]
Abstract
In 2011, one in every four (26%) children under 5 years of age worldwide was stunted. The realization that most stunting cannot be explained by poor diet or by diarrhoea, nor completely reversed by optimized diet and reduced diarrhoea has led to the hypothesis that a primary underlying cause of stunting is subclinical gut disease. Essentially, ingested microbes set in motion two overlapping and interacting pathways that result in linear growth impairment. Firstly, partial villous atrophy results in a reduced absorptive surface area and loss of digestive enzymes. This in turn results in maldigestion and malabsorption of much needed nutrients. Secondly, microbes and their products make the gut leaky, allowing luminal contents to translocate into systemic circulation. This creates a condition of chronic immune activation, which (i) diverts nutrient resources towards the metabolically expensive business of infection fighting rather than growth; (ii) suppresses the growth hormone‐IGF axis and inhibits bone growth, leading to growth impairment; and (iii) causes further damage to the intestinal mucosa thereby exacerbating the problem. As such, the unhygienic environments in which infants and young children live and grow must contribute to, if not be the overriding cause of, this environmental enteric dysfunction. We suggest that a package of baby‐WASH interventions (sanitation and water improvement, handwashing with soap, ensuring a clean play and infant feeding environment and food hygiene) that interrupt specific pathways through which feco‐oral transmission occurs in the first two years of a child's life may be central to global stunting reduction efforts.
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Affiliation(s)
- Mduduzi N N Mbuya
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe.,Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, 21205, USA
| | - Jean H Humphrey
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe.,Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, 21205, USA
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18
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Kosek M, Guerrant RL, Kang G, Bhutta Z, Yori PP, Gratz J, Gottlieb M, Lang D, Lee G, Haque R, Mason CJ, Ahmed T, Lima A, Petri WA, Houpt E, Olortegui MP, Seidman JC, Mduma E, Samie A, Babji S. Assessment of environmental enteropathy in the MAL-ED cohort study: theoretical and analytic framework. Clin Infect Dis 2015; 59 Suppl 4:S239-47. [PMID: 25305293 DOI: 10.1093/cid/ciu457] [Citation(s) in RCA: 114] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Individuals in the developing world live in conditions of intense exposure to enteric pathogens due to suboptimal water and sanitation. These environmental conditions lead to alterations in intestinal structure, function, and local and systemic immune activation that are collectively referred to as environmental enteropathy (EE). This condition, although poorly defined, is likely to be exacerbated by undernutrition as well as being responsible for permanent growth deficits acquired in early childhood, vaccine failure, and loss of human potential. This article addresses the underlying theoretical and analytical frameworks informing the methodology proposed by the Etiology, Risk Factors and Interactions of Enteric Infections and Malnutrition and the Consequences for Child Health and Development (MAL-ED) cohort study to define and quantify the burden of disease caused by EE within a multisite cohort. Additionally, we will discuss efforts to improve, standardize, and harmonize laboratory practices within the MAL-ED Network. These efforts will address current limitations in the understanding of EE and its burden on children in the developing world.
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Affiliation(s)
- Margaret Kosek
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland Asociación Benéfica PRISMA, Iquitos, Peru
| | | | | | - Zulfiqar Bhutta
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Pablo Peñataro Yori
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland Asociación Benéfica PRISMA, Iquitos, Peru
| | - Jean Gratz
- Center for Global Health, University of Virginia, Charlottesville
| | | | - Dennis Lang
- Foundation of the National Institutes of Health Fogarty International Center, National Institutes of Health, Bethesda, Maryland
| | - Gwenyth Lee
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland Asociación Benéfica PRISMA, Iquitos, Peru
| | | | - Carl J Mason
- Walter Reed/Armed Forces Research Institute of Medical Sciences Research Unit, Bangkok, Thailand
| | - Tahmeed Ahmed
- Center for Vaccine Sciences, iccdr,b, Dhaka, Bangladesh
| | - Aldo Lima
- Federal University of Ceará, Fortaleza, Brazil
| | - William A Petri
- Center for Global Health, University of Virginia, Charlottesville
| | - Eric Houpt
- Center for Global Health, University of Virginia, Charlottesville
| | - Maribel Paredes Olortegui
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland Asociación Benéfica PRISMA, Iquitos, Peru
| | - Jessica C Seidman
- Fogarty International Center, National Institutes of Health, Bethesda, Maryland
| | | | - Amidou Samie
- University of Venda, Limpopo Province, South Africa
| | - Sudhir Babji
- Christian Medical College, Vellore, Tamil Nadu, India
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19
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Keusch GT, Denno DM, Black RE, Duggan C, Guerrant RL, Lavery JV, Nataro JP, Rosenberg IH, Ryan ET, Tarr PI, Ward H, Bhutta ZA, Coovadia H, Lima A, Ramakrishna B, Zaidi AKM, Hay Burgess DC, Brewer T. Environmental enteric dysfunction: pathogenesis, diagnosis, and clinical consequences. Clin Infect Dis 2015; 59 Suppl 4:S207-12. [PMID: 25305288 DOI: 10.1093/cid/ciu485] [Citation(s) in RCA: 185] [Impact Index Per Article: 20.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Stunting is common in young children in developing countries, and is associated with increased morbidity, developmental delays, and mortality. Its complex pathogenesis likely involves poor intrauterine and postnatal nutrition, exposure to microbes, and the metabolic consequences of repeated infections. Acquired enteropathy affecting both gut structure and function likely plays a significant role in this outcome, especially in the first few months of life, and serve as a precursor to later interactions of infection and malnutrition. However, the lack of validated clinical diagnostic criteria has limited the ability to study its role, identify causative factors, and determine cost-effective interventions. This review addresses these issues through a historical approach, and provides recommendations to define and validate a working clinical diagnosis and to guide critical research in this area to effectively proceed. Prevention of early gut functional changes and inflammation may preclude or mitigate the later adverse vicious cycle of malnutrition and infection.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | - Aldo Lima
- Federal University of Ceará, Fortaleza, Brazil
| | | | - Anita K M Zaidi
- Aga Khan University, Karachi, Pakistan Bill & Melinda Gates Foundation, Seattle, Washington
| | | | - Thomas Brewer
- Bill & Melinda Gates Foundation, Seattle, Washington
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20
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Wanke CA. Tropical Sprue. Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases 2015. [DOI: 10.1016/b978-1-4557-4801-3.00104-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
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21
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Keusch GT, Rosenberg IH, Denno DM, Duggan C, Guerrant RL, Lavery JV, Tarr PI, Ward HD, Black RE, Nataro JP, Ryan ET, Bhutta ZA, Coovadia H, Lima A, Ramakrishna B, Zaidi AKM, Burgess DCH, Brewer T. Implications of acquired environmental enteric dysfunction for growth and stunting in infants and children living in low- and middle-income countries. Food Nutr Bull 2013; 34:357-64. [PMID: 24167916 DOI: 10.1177/156482651303400308] [Citation(s) in RCA: 128] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Changes in small bowel function early in infancy in developing countries are increasingly being demonstrated, probably accompanied by altered mucosal architecture in most individuals, including reduced enterocyte mass and evidence of immune activation and inflammation in the mucosa. These alterations appear to be the result of factors of uncertain nature in the environment, and may be a cause of growth faltering and stunting in young children. For these reasons, this constellation of findings is being referred to as environmental enteropathy, or as we propose herein, environmental enteric dysfunction. If the causes were known and effective interventions were available, strategies and policies to intervene at--or possibly before--birth could be developed and promoted in order to prevent subsequent malnutrition and recurrent infection, which are known to interact in a cyclical and synergistic manner in a downward clinical course often ending in death. Resources would be mobilized and applied differently, and the emphasis would change from treatment to prevention. In order to move in this highly desired direction, investments in research will be required to establish the criteria to assess environmental enteric dysfunction, determine its predictive value for growth faltering and stunting, identify the causes, and propose and test potential interventions. The concepts and tools are available. What is required is the decision to move forward along this pathway to better health for infants and children in low-income countries.
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Affiliation(s)
- Gerald T Keusch
- Boston University Medical Campus, 620 Albany Street, Boston MA 02118, USA.
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22
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Arnold BF, Null C, Luby SP, Unicomb L, Stewart CP, Dewey KG, Ahmed T, Ashraf S, Christensen G, Clasen T, Dentz HN, Fernald LCH, Haque R, Hubbard AE, Kariger P, Leontsini E, Lin A, Njenga SM, Pickering AJ, Ram PK, Tofail F, Winch PJ, Colford JM. Cluster-randomised controlled trials of individual and combined water, sanitation, hygiene and nutritional interventions in rural Bangladesh and Kenya: the WASH Benefits study design and rationale. BMJ Open 2013; 3:e003476. [PMID: 23996605 PMCID: PMC3758977 DOI: 10.1136/bmjopen-2013-003476] [Citation(s) in RCA: 152] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
INTRODUCTION Enteric infections are common during the first years of life in low-income countries and contribute to growth faltering with long-term impairment of health and development. Water quality, sanitation, handwashing and nutritional interventions can independently reduce enteric infections and growth faltering. There is little evidence that directly compares the effects of these individual and combined interventions on diarrhoea and growth when delivered to infants and young children. The objective of the WASH Benefits study is to help fill this knowledge gap. METHODS AND ANALYSIS WASH Benefits includes two cluster-randomised trials to assess improvements in water quality, sanitation, handwashing and child nutrition-alone and in combination-to rural households with pregnant women in Kenya and Bangladesh. Geographically matched clusters (groups of household compounds in Bangladesh and villages in Kenya) will be randomised to one of six intervention arms or control. Intervention arms include water quality, sanitation, handwashing, nutrition, combined water+sanitation+handwashing (WSH) and WSH+nutrition. The studies will enrol newborn children (N=5760 in Bangladesh and N=8000 in Kenya) and measure outcomes at 12 and 24 months after intervention delivery. Primary outcomes include child length-for-age Z-scores and caregiver-reported diarrhoea. Secondary outcomes include stunting prevalence, markers of environmental enteropathy and child development scores (verbal, motor and personal/social). We will estimate unadjusted and adjusted intention-to-treat effects using semiparametric estimators and permutation tests. ETHICS AND DISSEMINATION Study protocols have been reviewed and approved by human subjects review boards at the University of California, Berkeley, Stanford University, the International Centre for Diarrheal Disease Research, Bangladesh, the Kenya Medical Research Institute, and Innovations for Poverty Action. Independent data safety monitoring boards in each country oversee the trials. This study is funded by a grant from the Bill & Melinda Gates Foundation to the University of California, Berkeley. REGISTRATION Trial registration identifiers (http://www.clinicaltrials.gov): NCT01590095 (Bangladesh), NCT01704105 (Kenya).
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Affiliation(s)
- Benjamin F Arnold
- School of Public Health, University of California, Berkeley, California, USA
| | - Clair Null
- Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
- Innovations for Poverty Action, New Haven, Connecticut, USA
| | - Stephen P Luby
- Centre for Communicable Diseases, International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
- Stanford University, Stanford, California, USA
| | - Leanne Unicomb
- Centre for Communicable Diseases, International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Christine P Stewart
- Program in International and Community Nutrition, University of California, Davis, California, USA
| | - Kathryn G Dewey
- Program in International and Community Nutrition, University of California, Davis, California, USA
| | - Tahmeed Ahmed
- Centre for Nutrition & Food Security, International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
- BRAC University, James P Grant School of Public Health, Dhaka, Bangladesh
| | - Sania Ashraf
- Centre for Communicable Diseases, International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Garret Christensen
- Innovations for Poverty Action, New Haven, Connecticut, USA
- Department of Economics, Swarthmore College, Swarthmore, Pennsylvania, USA
| | - Thomas Clasen
- Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Holly N Dentz
- Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
- Innovations for Poverty Action, New Haven, Connecticut, USA
| | - Lia C H Fernald
- School of Public Health, University of California, Berkeley, California, USA
| | - Rashidul Haque
- Centre for Communicable Diseases, International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
- Centre for Communicable Diseases and Centre for Vaccine Sciences, International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Alan E Hubbard
- School of Public Health, University of California, Berkeley, California, USA
| | - Patricia Kariger
- School of Public Health, University of California, Berkeley, California, USA
| | - Elli Leontsini
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Audrie Lin
- School of Public Health, University of California, Berkeley, California, USA
| | - Sammy M Njenga
- Eastern & Southern Africa Centre of International Parasite Control, Kenya Medical Research Institute, Nairobi, Kenya
| | - Amy J Pickering
- Civil and Environmental Engineering, Stanford University, Stanford, California, USA
| | - Pavani K Ram
- School of Public Health and Health Professions, State University of New York at Buffalo, Buffalo, New York, USA
| | - Fahmida Tofail
- Centre for Nutrition & Food Security, International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Peter J Winch
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - John M Colford
- School of Public Health, University of California, Berkeley, California, USA
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Guerrant RL, DeBoer MD, Moore SR, Scharf RJ, Lima AA. The impoverished gut--a triple burden of diarrhoea, stunting and chronic disease. Nat Rev Gastroenterol Hepatol 2013; 10:220-9. [PMID: 23229327 DOI: 10.1038/nrgastro.2012.239] [Citation(s) in RCA: 375] [Impact Index Per Article: 34.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
More than one-fifth of the world's population live in extreme poverty, where a lack of safe water and adequate sanitation enables high rates of enteric infections and diarrhoea to continue unabated. Although oral rehydration therapy has greatly reduced diarrhoea-associated mortality, enteric infections still persist, disrupting intestinal absorptive and barrier functions and resulting in up to 43% of stunted growth, affecting one-fifth of children worldwide and one-third of children in developing countries. Diarrhoea in children from impoverished areas during their first 2 years might cause, on average, an 8 cm growth shortfall and 10 IQ point decrement by the time they are 7-9 years old. A child's height at their second birthday is therefore the best predictor of cognitive development or 'human capital'. To this 'double burden' of diarrhoea and malnutrition, data now suggest that children with stunted growth and repeated gut infections are also at increased risk of developing obesity and its associated comorbidities, resulting in a 'triple burden' of the impoverished gut. Here, we Review the growing evidence for this triple burden and potential mechanisms and interventions that must be understood and applied to prevent the loss of human potential and unaffordable societal costs caused by these vicious cycles of poverty.
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Prendergast A, Kelly P. Enteropathies in the developing world: neglected effects on global health. Am J Trop Med Hyg 2012; 86:756-63. [PMID: 22556071 PMCID: PMC3335677 DOI: 10.4269/ajtmh.2012.11-0743] [Citation(s) in RCA: 187] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2011] [Accepted: 02/06/2012] [Indexed: 12/12/2022] Open
Abstract
A spectrum of enteropathies, characterized by small intestinal inflammation, reduced absorptive capacity, and increased intestinal permeability, commonly affect people in developing countries. This subclinical intestinal pathology facilitates microbial translocation across the compromised intestinal barrier, leading to chronic systemic inflammation that may adversely impact health. Environmental enteropathy (EE), ubiquitous among people living in unhygienic conditions, likely mediates two interlinked public health problems of childhood, stunting and anemia, and underlies poor oral vaccine efficacy in developing countries. Human immunodeficiency virus (HIV) enteropathy, which frequently overlaps with EE, may contribute to immune activation and modulate HIV disease progression. The interacting effects of infection and enteropathy drive a vicious cycle that can propagate severe acute malnutrition, which underlies almost half of under-5-y deaths. Enteropathies are therefore highly prevalent, interacting causes of morbidity and mortality in developing countries. Interventions to prevent or ameliorate enteropathies have potential to improve the health of millions of people in developing countries.
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Affiliation(s)
- Andrew Prendergast
- Centre for Paediatrics and Centre for Digestive Diseases, Blizard Institute, Queen Mary University of London, United Kingdom.
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25
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Bolin TD. Does subclinical malabsorption of carbohydrates prevent colorectal cancer? A hypothesis. Can J Gastroenterol 2008; 22:627-30. [PMID: 18629392 DOI: 10.1155/2008/275903] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The incidence of colorectal cancer (CRC) is high in the western world and low in Asia and Africa. Fibre and starch are thought to be important protective factors, with a strong inverse relationship between starch consumption and CRC incidence. Whether this is true in Asia, particularly, and Africa is debatable. Because rice is the most easily absorbed of carbohydrates, a mechanism whereby there is an increased starch load in the colon in the Asian population needs to be identified. One possible cause is subclinical malabsorption. This is linked to increased mucosal permeability and low gross domestic product (GDP) per capita, which reflects poor sanitation and water supplies with increased risk for small bowel bacterial overgrowth leading to mucosal cell damage. A potential cause of the dramatic rise in CRC incidence in Japan may relate to its equally dramatic increase in GDP per capita of 600% over 50 years. This correlation appears to be stronger than with other dietary factors including fruit, vegetables and meat. Worldwide, a close correlation exists among low GDP per capita, low CRC incidence and presumed subclinical malabsorption. All these factors combine to maintain a low incidence of CRC in poorly developed countries.
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dos Reis JC, de Morais MB, Oliva CAG, Fagundes-Neto U. Breath hydrogen test in the diagnosis of environmental enteropathy in children living in an urban slum. Dig Dis Sci 2007; 52:1253-8. [PMID: 17372830 DOI: 10.1007/s10620-006-9288-9] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2005] [Accepted: 03/02/2006] [Indexed: 12/09/2022]
Abstract
The aim of this study was to evaluate the breath hydrogen test in the diagnosis of small intestine bacterial overgrowth associated with asymptomatic environmental enteropathy in children living in an urban slum. Fifty school-age children living in a slum and 50 children who attended a private health clinic in the same town were included in the study. Breath hydrogen test was carried out after the administration of lactulose or glucose on two different days. Bacterial overgrowth was diagnosed when the hydrogen concentration increased more than 20 ppm in a sample collected for up to 60 min. Production of hydrogen was greater after the ingestion of lactulose than after the ingestion of glucose. Bacterial overgrowth was noted in 37.5% of the children living in the slum and in 2.1% of the control group (P<0.001). The children living in the slum presented a higher proportion of bacterial overgrowth when lactulose was used in the breath hydrogen test.
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Abstract
Tropical sprue (TS) is a clinical entity of unknown etiology characterized by an acquired chronic diarrheal illness and malabsorption that affects indigenous inhabitants and expatriates, either long-term residents or short-term visitors, in the tropical countries. The exact pathogenetic sequence of TS remains incompletely characterized. Bacterial overgrowth, disturbed gut motility, and hormonal and histopathologic abnormalities contribute to the development of TS in a susceptible host. Treatment with tetracycline and folate is effective in some patients, although relapses after treatment are common. Research in the areas of microbial factors, pathogenesis, immunogenetics, and hormonal and immune regulation, using modern diagnostic techniques, may be able to settle some of the unanswered issues and open new venues for diagnosis, prevention, and treatment of tropical sprue.
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Affiliation(s)
- Samir Kumar Nath
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, University of Texas Medical Branch, Galveston, TX 77555-0174, USA.
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28
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Abstract
One of the important consequences of the infection-nutrition interaction is mediated by malabsorption associated with chronic inflammation in the intestine, enteritis. Studies made possible after development of the peroral intestinal biopsy technique in the 1950s indicated the wide prevalence of enteropathy, particularly in tropical developing countries with poor levels of sanitation. Some consider this so-called subclinical tropical malabsorption to be the base of an iceberg, whose tip is tropical sprue, a severe form of malabsorption leading to nutritional deficiency that had been reported in colonial expatriates in tropical countries for 200 y. Some of the first demonstrations of the prevalence of tropical enteritis in Asia were made in quest of the pathologic lesion of cholera, and further examination of the water and electrolyte, as well as nutrient, malabsorption in cholera led serendipitously to the discovery of the oral rehydration solution for the treatment of diarrheal disease.
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Affiliation(s)
- Irwin H Rosenberg
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA, USA.
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29
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Abstract
OBJECTIVE Tropical enteropathy is widespread throughout the tropics, but its pathogenesis is unknown. T-cell activation has been demonstrated to result in enteropathy in vitro and in animal models, and occurs in untreated patients with coeliac disease. We have therefore examined the hypothesis that T-cell activation is important in the pathogenesis of tropical enteropathy. PATIENTS AND METHODS Healthy black Zambian subjects were compared with black and white South Africans. Quantitative microscopy was conducted on distal duodenal biopsies. Mucosal T-cell activation was quantitated by dual colour immunofluorescence staining for CD3 plus CD69 or HLA-DR. Crypt proliferation was measured by direct counting of Feulgen-stained mitotic figures, and systemic immune activation by assay of serum tumour necrosis factor alpha (TNF-alpha). RESULTS Villous height was reduced (P = 0.0004), crypt depth increased (P < 0.0001), and mitoses per crypt increased (P = 0.014) in black Zambians compared with black and white South Africans. Mucosal thickness was similar. Intraepithelial lymphocyte count was increased in the black groups compared with whites (P = 0.03). CD3+CD69+ (P = 0.0007) and CD3+HLA-DR+ (P < 0.0001) expression was increased in black Zambians compared with black and white South Africans. Serum TNF-alpha was similar in all groups. CONCLUSIONS Tropical enteropathy is associated with mucosal T-cell activation and crypt hyperplasia. Tropical enteropathy occurs in the absence of malnutrition, diarrhoea or systemic illness.
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Affiliation(s)
- A M Veitch
- Digestive Diseases Research Centre, St. Bartholomew's and the Royal London School of Medicine and Dentistry, London, UK.
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Abstract
BACKGROUND Little is known about the small intestinal mucosal pattern of Myanmar children. METHODS Duodenal, jejunal and ileal mucosal specimens obtained from children within 6 h of death were examined under a dissecting microscope with the objective of determining villus pattern in relation to site within the small intestine and then correlated with age. RESULTS Abnormalities in the small intestinal mucosa were detected at a very young age. In children under 1 year of age, the changes are more marked proximally and become less marked distally, perhaps reflecting exposure to the causative agent(s) in early life. Presumably these agents are ingested orally and inactivated progressively. The pattern in older children reflects more severe changes in the ileum. CONCLUSIONS It is postulated that frequent intestinal infections or small bowel bacterial contamination could lead to damage of the intestinal mucosa.
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Affiliation(s)
- W M Aye
- Department of Child Health, Institute of Medicine (I), Yangon, Myanmar
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Abstract
Aside from infectious intestinal diseases with known etiology, there is a group of gastrointestinal disorders mainly affecting the small intestine of individuals predominantly living in and less often visiting or returning from the Third World, usually the tropics, and ranging from asymptomatic structural and/or functional abnormalities of the gastrointestinal mucosa (subclinical enteropathy, SE) to a fully symptomatic condition highlighted by malabsorption of nutrients with associated nutritional deficiencies responsive to folate and broad spectrum antibiotic treatment (tropical sprue, TS). Mounting evidence supports an infectious cause in many instances. The exact nature of the infection, whether initiated and/or perpetuated by enterotoxigenic coliform bacteria, virus(es) or a combination of these, is not clear. Further studies, including those using molecular techniques, are needed in order to clarify various aspects of these widely prevalent disorders.
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Affiliation(s)
- P Haghighi
- Laboratory Service, University of California, USA
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Affiliation(s)
- L Mata
- Instituto de Investigaciones en Salud (INISA), Universidad de Costa Rica
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Abstract
The major host defense mechanisms against bacterial overgrowth in the small bowel are the normal propulsive activity of the bowel itself and gastric acid secretion. Microbial interactions are a major factor in regulating the indigenous bacterial flora. Studies of the bacterial enzymes of the gut suggest that changes in diet may lead to marked changes in the colonic flora. Antibiotics affect the composition of the colonic microflora. The microflora also influence the degradation of mucin, the conversion of urobilin to urobilinogen, of cholesterol to coprostanol, and the production of short chain fatty acids. Current interests are focused on the bacterial flora of tropical sprue, the role of bacteria in colorectal cancer, and the involvement of intestinal microflora in the enterohepatic circulation of sex steroid hormones.
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Abstract
Morphometric measurements have been performed on small intestinal biopsy specimens obtained from 18 healthy adult Indian volunteers. The measurements were made using a computer aided measuring system, and results were similar to those previously reported for an adult Caucasian population.
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Wardle EN. Letter: Human placental lactogen and diabetic pregnancy. Lancet 1975; 2:180-9. [PMID: 49770 DOI: 10.1016/s0140-6736(75)90086-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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