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: 0 Date: 14 Nov 2021
Reviewer's report:
Authors addressed an interesting research topic environmental enteric dysfunction which is a
subclinical intestinal disorder which results growth faltering in children under the age of five.
Data on this major public health problem is rare particular to the context of Ethiopia. Therefore,
I would like congratulate for the authors to present data on fecal biomarkers of EED. However,
the following points need to be revised to benefit the manuscript.
General comments
The main limitation of this manuscript is the lack of information to the status of children for
environmental enteric dysfunction. Were all the included children had EED before recruitment?
If identified with what methods of screening? Did you measure the association between fecal
biomarkers and degree of EED among the children? Detection of the different fecal biomarkers
of EED and identification of their determinant factors is meaningful when the children status
are known and if cases and control groups are included.
Specific comments
1. The abstract is good looking but try to reduce the use of multiple abbreviations
2. Revise the conclusion to address the main findings of this study
3. Though the introduction is well founded for the fecal biomarkers, apparently it lacks the
implications of EED towards children under the age of five. Moreover, authors should explain
the plausible methods of screening of EED and internationally accepted standards to interpret
the fecal biomarkers.
4. The burden of EED in developed and developing countries need to be described in the
introduction part.
5. The study area and sampling technique is not clear in the method section of the manuscript.
Brief information on the study area, selection of children, sampling and eligibility criteria’s
considered to qualify the children should be incorporated.
6. Clear description of the actual study participants to determine the fecal biomarkers is required
7.  Geophagia in table 1 needs to be defined first either in the introduction or variables section
of the manuscript.
8. Table 2 is not related to the objective of this study? It indicates the prevalence of intestinal
parasitic infections and diarrhea without any linkage with EED or their fecal biomarkers.
9. The reference taken to compare the concentration of fecal biomarkers was values from high
income countries. However, children from developed and developing countries have different
living standards, WASH practices, dietary habits and their degree of exposure to enteric bacterial
pathogens such as E. coli, Campylobacter and GIT viruses is definitely variable. So, how can
we generalize the fecal biomarkers of children taken from rural part of Ethiopia using the cut-
off value from western countries? This requires more clarification
10. The discussion needs revision as literatures listed rather than discussed and interpreted based
on the findings of the present study. Example, the median concentration of AAT, MPO and NEO
of the present study revealed variable results in comparison to literatures from other countries
without any scientific explanation for these.
11. Re-write line number 286-292. The median concentration of MPO is lower than all the
comparative studies but why you used the term however on line 289 as long as the paragraph
has a similar message?
12. Why authors gave particular emphasis to E. coli and intestinal parasites? Why not for
Campylobacter and GIT viruses such as Rotavirus, Adenovirus type 40 and 41 and Astrovirus
which are important etiologies of gut infection and EED
13. Line 337 to 338, enteropathogens such as intestinal bacteria is vague? The gut is full of
microbiota and bacteria are the predominant flora? Related to this, is identification of E. coli
from food and drinking water best indicator for fecal contamination?
14. What measures taken for children positive for intestinal parasites as a result of stool wet
mount examination? This should be included in the ethics. The same is true for those who had
elevated fecal biomarkers?
Thank you!