What is EED, and How is it Linked to Infectious Disease?
EED is not simply an intestinal infection, but a subclinical syndrome of the small intestine characterized by chronic inflammation, reduced absorptive capacity, and impaired intestinal barrier function. It is primarily found in populations living in environments with inadequate water, sanitation, and hygiene (WASH) infrastructure, and features suggestive of EED have been reported in infants as early as 4-6 weeks of age in high-burden settings1.
Unlike acute intestinal infections that cause obvious symptoms like diarrhea, EED does not usually manifest with dramatic symptoms. However, this “silent” nature is what makes it so dangerous. EED is driven by repeated long-term ingestion of fecal pathogens from contaminated food, water, and soil, leading to a state of constant activation of the intestine’s immune cells. This persistent mobilization of the immune cells, otherwise known as inflammation, diverts critical energy and nutrients away from growth and cognitive development2. Consequently, EED is an important suspected direct cause of linear growth faltering, which affects over 150 million children under the age of five worldwide3. Its consequences in children, however, may extend far beyond undernutrition to include problems like impaired brain development and poor vaccine response4.
Updates on the Scientific Evidence Base
Recent scientific advancements have deepened our understanding of EED’s complex pathology. Data from the WHO Water, Sanitation, Hygiene and Waste Strategy 2026-2035 highlights that unsafe WASH still contributes to over 1.4 million preventable deaths annually, many of which are linked to the downstream effects of chronic intestinal dysfunction5. Researchers are increasingly identifying specific bacteria and small intestinal bacterial overgrowth as key drivers of EED. Additionally, accurate diagnosis of EED has traditionally relied on invasive biopsy or complex sugar absorption tests. New research is validating non-invasive and affordable fecal and blood biomarkers, such as myeloperoxidase and alpha-1-antitrypsin, allowing for better screening of components of EED in low-resource settings6. Importantly, studies continue to suggest that intestinal inflammation seen in EED significantly reduces the effectiveness of oral vaccines, such as those for rotavirus and polio, by interfering with the host’s ability to mount a robust immune response7.
Public Health Implications
The implications of EED extend far beyond the intestines. For the millions of children affected, EED represents a lifetime of lost potential. Growth faltering is associated with reduced economic productivity in adulthood and increased susceptibility to non-communicable disease later in life. Furthermore, EED exemplifies the One Health challenge-the interconnectedness of human health and the environment. As climate change alters water availability and exacerbates sanitation challenges, the environmental triggers for EED are likely to intensify, disproportionately affecting vulnerable communities in low-and middle-income countries, which already have the majority of the world’s undernourished children.
Recommended Actions: Standing with Science
Addressing EED requires more than just traditional medical intervention; it demands a multi-sectoral, holistic approach rooted in scientific rigor and global equity.
- Integrate WASH with nutrition: Evidence suggests that providing nutrition supplements alone is insufficient if the underlying intestinal inflammation remains. Programs must integrate high-quality nutrition with robust community-wide sanitation to be effective.
- Support local surveillance: We must strengthen local laboratory capacity to use emerging EED biomarkers for early detection and monitoring of community health interventions.
- More investment in microbiota-directed research: Funding should prioritize the development of specialized “microbiota-directed” foods designed to enrich the quality of healthy intestinal microbial flora and repair damaged intestinal lining rather than just providing generic calories.
- Promote inclusive public health: advocacy must ensure that the most marginalized populations, who bear the largest global death burden from environmental factors like poor sanitation and hygiene, are at the center of research and policy design.
On this World Health Day, the global community needs to renew its commitment to “Stand with Science” by prioritizing the hidden crisis of EED. Some world-leading journals like PLOS Neglected Tropical Disease have created sections on environmental enteric dysfunction, as a means to advocate for more attention from the global community on this silent health crisis8. By investing in science, we can ensure high-quality environmental health conditions, optimal intestinal health, and protect the future of the world’s most vulnerable children.
Written by ISID Emerging Leader, Dr. Benjamin Kadia