Review for 10.1186/s12876-022-02255-4 (2022)

Title: Fecal biomarkers of environmental enteric dysfunction and associated factors among
children aged 24-59 months in east Dembiya district, northwest Ethiopia
Version: 2 Date: 20 Feb 2022
Reviewer's report:
Title of the manuscript
I suggest the title to be modified as ‘’ Fecal biomarkers of environmental enteric dysfunction
and associated factors among children aged 24-59 months in east Dembiya district, northwest
Ethiopia’’
Abstract
Providing explanation for the result section of an abstract is not usual. For instance, the  statement
’’These elevated concentrations were explained by open defecation practice, mouthing of soil
contaminated materials, E. coli contamination of drinking water, E. coli contamination of foods,
E. coli contamination of soil, and intestinal parasites are indicated as reasons for the presence
of elevated fecal biomarkers. Instead of these, mention the variables which were significantly
associated with the elevated fecal biomarkers. Otherwise, suggesting possible explanations in
the abstract section seems a discussion. Moreover, other factors that may cause elevation of fecal
biomarkers were not controlled. Therefore, line 39-42 needs revision.
Keywords:  Keywords must possess, children, fecal biomarkers and Ethiopia. Choose keywords
that best represent your findings
Background
Line 77 .  Infection versus disease? Enteric infections such as diarrhea and intestinal parasitic
infections is a very confusing phrase. Diarrhea is a disease not an infection. It is a fact that
Intestinal infection may or may not leads to diarrhea. Please rephrase this sentence.
In your background section please  define diarrhea and operationalize it according to your study.
Rephrase line79- 82. E.g pesticides, drugs and aflatoxin  is. Make it are. The points related to
aflatoxin and mycotoxin from fungi are repetitions. As you know afflation is a type of mycotoxin
released from the fungus Aspergilus flavus. Minimize redundancies of ideas
Methods
Add the phrase study period in the subheading study design and setting
Remove the sentence ‘’ the detail of sampling procedure is presented elsewhere? This is a
careless way of writing a manuscript. Exactly show the sampling used for this particular
manuscript.
What are your inclusion and exclusion criteria? Were the study participants had intestinal
discomfort or Gastroenteritis or Not? Regardless of their age, which types of children were
qualified for this study and which type were not. Nothing stated in the inclusion and exclusion
criteria. This is very important to clearly describe the actual study participants that gave stool
sample.
How was diarrhea determined, based on history from the care giver? Or by looking the nature
of the stool? How was differentiated between children with and without diarrhea?
Stool sample collection
Where the stool sample collected? By whom the sample collected? How did you deal
contamination of the stool with urine particularly to female children? Amount of stool sample
collected and processed for stool wet mount. Amount of stool sample processed for fecal
biomarkers determination. Transportation condition of stool sample? How they were transported
from rural Dembiya to UoG? For how long the sample frozen at -20 o C? The maximum time
or date.
With what standard protocols the biomarkers measured? Please put a standard citation. From
which country the ELISA kits obtained? Show the company name and its country in the
determination section of fecal biomarkers.
How the results interpreted? Standard protocol or software used to interpret the levels of the
fecal biomarkers. Line 180-186 under the statistical analysis section are standards for the
interpretation of fecal biomarkers. Therefore, move this information to the determination of the
fecal biomarkers.
How E. coli was detected from drinking water, ready-to-eat foods and courtyard soil and their
interpretation as well?
Results
Omit the sentence ‘’majority of the children lived in extensively contaminated living’’ which is
not directly supported by data from Table 1.  Directly describe the actual data from the table.
Table 1 is okay but its description is very confusing and looks general information. No need
explain the description of a table for a table.
The detection frequencies of the parasites are not supported by data from table 2 and I don’t think
describing their frequency is important for this study. The magnitude of intestinal parasitosis and
the type of infection (single or multiple) are enough to consider this as an independent variable.
Moreover, correct the spelling mistake for Hymenolopsis nana. Hook worm is not a scientific
name to be written in italics. Correct this
Overall, how many of the children had elevated fecal biomarkers? What does it mean related to
EED? This should be presented in table, discussed and proper conclusion and recommendation
should be forwarded. To me, this is the main aim of this manuscript.
The conclusion should reflect the level of EED based on the measured fecal biomarkers instead
of comparing the level of fecal biomarkers with the general population of high-income countries.
I think you are not screening a normal value rather you are screening a disease condition EED
among children. Therefore, make your conclusion synergy with the title and main aim of the
study and forward pertinent recommendations based on the main result of this study.