BACKGROUND Environmental enteric dysfunction (EED) is an enigmatic disorder of the small intestine postulated to play a role in childhood undernutrition, a pressing global health problem. Defining the incidence of EED, its pathophysiology, and its contribution to impaired linear and ponderal growth has been hampered by the difficulty in directly sampling the small intestinal mucosa and microbial community (microbiota). METHODS Slum-dwelling Bangladeshi children aged 18±2 months, with linear growth-faltering (stunting) who failed a nutritional intervention underwent endoscopy to obtain duodenal biopsies and aspirates. Levels of 4077 plasma proteins and 2619 duodenal proteins were quantified in 80 children with histopathologic evidence of EED, and the abundances of bacterial strains in their duodenal microbiota were determined using culture-independent methods. Young germ-free mice, fed a Bangladeshi diet, were colonized with bacterial strains cultured from the duodenal aspirates. RESULTS The absolute abundances of a shared group of 14 bacterial strains recovered from the duodenums of children with EED and not typically classified as enteropathogens were negatively correlated with linear growth (length-for-age Z-score;β=-0.38±0.12(SEM);ρ=-0.49;p=0.003), and positively correlated with duodenal proteins involved in immunoinflammatory responses. Representation of these 14 duodenal taxa was significantly different in fecal microbiota from EED versus healthy children (p<0.001;PERMANOVA). Gnotobiotic mice colonized with cultured EED-donor duodenal strains develop a small intestinal enteropathy. CONCLUSIONS These results provide evidence of a causal relationship between components of the small intestinal microbiota, enteropathy and stunting and offer a rationale for developing therapeutics that target what must no longer remain terra incognita-the small intestinal microbiota. ClinicalTrials.gov identifier: NCT02812615

IntroductionEnvironmental enteric dysfunction (EED) is a subacute inflammatory condition of the small intestinal mucosa with unclear aetiology that may account for more than 40% of all cases of stunting. Currently, there are no universally accepted protocols for the diagnosis, treatment and ultimately prevention of EED. The Bangladesh Environmental Enteric Dysfunction (BEED) study is designed to validate non-invasive biomarkers of EED with small intestinal biopsy, better understand disease pathogenesis and identify potential therapeutic targets for interventions designed to control EED and stunting.Methods and analysisThe BEED study is a community-based intervention where participants are recruited from three cohorts: stunted children aged 12–18 months (length for age Z-score (LAZ) <−2), at risk of stunting children aged 12–18 months (LAZ <−1 to −2) and malnourished adults aged 18–45 years (body mass index <18.5 kg/m2). After screening, participants eligible for study provide faecal, urine and plasma specimens to quantify the levels of candidate EED biomarkers before and after receiving a nutritional intervention. Participants who fail to respond to nutritional therapy are considered as the candidates for upper gastrointestinal endoscopy with biopsy. Histopathological scoring for EED will be performed on biopsies obtained from several locations within the proximal small intestine. Candidate EED biomarkers will be correlated with nutritional status, the results of histochemical and immunohistochemical analyses of epithelial and lamina propria cell populations, plus assessments of microbial community structure.Ethics and disseminationEthics approval was obtained in all participating institutes. Results of this study will be submitted for publication in peer-reviewed journals.Trial registration numberClinicalTrials.gov ID: NCT02812615. Registered on 21 June 2016.

The usefulness of nutritional indices and classifications in predicting the death of children under 5 years old was evaluated by comparing measurements of 34 children with diarrhoea who died in a Dhaka hospital with those of 318 patients who were discharged in a satisfactory condition. In a logistic regression analysis mid-upper arm circumference was found to be as effective as other nutritional indices in predicting death. Combinations of different indices did not improve the prediction.Arm circumference might be preferable to more complex criteria for predicting the death of malnourished children.

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During August 2008–June 2009, an estimated 95,531 suspected cases of cholera and 4,282 deaths due to cholera were reported during the 2008 cholera outbreak in Zimbabwe. Despite the efforts by local and international organizations supported by the Zimbabwean Ministry of Health and Child Welfare in the establishment of cholera treatment centres throughout the country, the case-fatality rate (CFR) was much higher than expected. Over two-thirds of the deaths occurred in areas without access to treatment facilities, with the highest CFRs (>5%) reported from Masvingo, Manicaland, Mashonaland West, Mashonaland East, Midland, and Matabeleland North provinces. Some factors attributing to this high CFR included inappropriate cholera case management with inadequate use of oral rehydration therapy, inappropriate use of antibiotics, and a shortage of experienced healthcare professionals. The breakdown of both potable water and sanitation systems and the widespread contamination of available drinking-water sources were also considered responsible for the rapid and widespread distribution of the epidemic throughout the country. Training of healthcare professionals on appropriate cholera case management and implementation of recommended strategies to reduce the environmental contamination of drinking-water sources could have contributed to the progressive reduction in number of cases and deaths as observed at the end of February 2009.