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Survival status of children treated for severe acute malnutrition in outpatient therapeutic program by season in Kembata Tembaro Zone, Southern Ethiopia Wondwosen Fikreselam1*, Samson Mideksa2 and Sintayehu Abate Temesgen3 1School of nutrition, food science and technology, Hawassa University, Hawassa, Ethiopia 2Knowledge Translation Directorate, Ethiopian Public Health Institute, Addis Ababa, Ethiopia 3Scientif and Ethical Review Office, Ethiopian Public Health Institute, Addis Ababa, Ethiopia *Corresponding author: [email protected] Abstract Background: Malnutrition is a deficiency state of both macro and micronutrients (under-nutrition) and their over consumption (over-nutrition) causing measurable adverse effects on human body structure and function, resulting in specific physical and clinical outcomes. Nearly 52 million under five children globally are malnourished, and in Africa it is about 14 million. However, there is little information known about seasonal variations of admission. Objective: To assess seasonal variations of admission of children treated for Severe Acute Malnutrition at Outpatient Therapeutic Program in Kembata Tembaro Zone, Southern Ethiopia. Methods: A retrospective facility based cross-sectional study was conducted from records of outpatient therapeutic program from January 01 to December 30, 2017. Four hundred thirty three children represented by their Outpatient Therapeutic Program card were included from three Woredas selected by simple random sampling technique. From these three Woredas, 18 health posts were selected by simple random sampling. Population Proportion to size allocation was used to assign sample for each selected Woredas. Systematic sampling technique was used to assign child card for each selected health posts in the study area. Data entered, cleaned and analyzed using SPSS version 20. Results: Seasonal distribution of Sever Acute Malnutrition admission to outpatient therapeutic program in Kembata Tembaro Zone shows 55.7% at 95% CI were admitted from December to May, 2017. Children survival rate through time was affected in statistically significant figures by distance from home to health posts <30 minutes (AHR=1.28; (95% CI=1.04-1.58)) Conclusions: Large extents of children were admitted to the program in dry season with climax admission at May. The survival rate was higher in wet season. The stakeholders should recognize as food insecurity can happen in dry season and focus on creating the capacity of the OTP providers on proper management of SAM. Keywords: Outpatient therapeutic program, seasonal variations, severe acute malnutrition, Southern Ethiopia, Kembata Tembaro Introduction climate-related hazards are expected to magnify Malnutrition is defined as disorder resulting from a seasonal stresses on livelihoods, food and water deficiency or excess of one or more essential nutrients. security (Sullivan 2013). Seasonal variations in Usually under nutrition is more common in developing temperature and rainfall can significantly impact countries (Alemu 2020). Although the prevalence may public health risks and disease incidence (Patz et al. differ, it is also found in developed countries (WHO 2000). In terms of food security, availability of food and UNICEF 2009). Severe acute malnutrition (SAM) decreases prior to harvest periods for agricultural is defined as a weight-for-height measurement of 70% producers and prior to rains for pastoralists. At the or more below the median, or three SD or more below same time, food prices rise due to limited availability the mean WHO reference values, which is called further impeding access for the majority of households “wasted,” the presence of bilateral pitting oedema of reliant on the market to cover at least some of their nutritional origin, which is called “edematous food needs. This period is commonly known as the malnutrition,” or a mid-upper-arm circumference of ‘lean’ season, or hunger period, when many less than 110 mm in children age 1–5 years (UNICEF households are teetering on the edge of food et al. 2018; Shanka et al. 2015). Under-nutrition and insecurity, and usually coincides with the rainy season, nutritional disorders are major problems, which are when disease strikes hardest. The end result is seasonal resulting from inadequate food intake both in quality peaks in acute malnutrition (Sullivan et al. 2013). In and quantity. Inadequate intake of carbohydrates, some studies conducted in Ethiopia, seasons were protein, vitamins and mineral supply to the cells of the classified into four: spring (September – November), body to satisfy the physiological requirements is one winter (December – February), autumn (March - of the causes for malnutrition (Chamois et al. 2007). May), and summer (June –August) to identify the Seasonality refers to any regular pattern or variation prevalence of infectious diseases. The first two that is correlated with the seasons. It is well known that classifications above are predominantly dry seasons
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while the second two are wet seasons (Egata et al. posts, six sites per each Woreda were selected through 2013). In this study, seasons were reclassified into two systematic random sampling technique. A total of 18 major categories: the dry season winter and autumn OTP sites were selected for the study. Finally, OTP (December to May) and the wet season summer and card of children aged 6-59 months were selected by spring (June to November) because they are believed systematic random sampling method from each HP to have an association with the nutritional status of based on their unique identification number. To use children as the Zonal agriculture and health this method, K value was determined at each health department report indicated. post. There were little studies conducted to elucidate the Structured and pretested data collection checklist was effectiveness of Outpatient Therapeutic Program used to collect all the necessary information. The (OTP) in Ethiopia. But as indicated, SAM was checklists were used to collect data from both children identified as public health problem in Southern Nation OTP cards and registration books. The checklist was Nationalities People Region (SNNPR) particularly in initially prepared in English language and translated to Kembata Tembaro Zone. This study is designed to Amharic, and then retranslated back to English to investigate the seasonal variation of admission of check for clarity, consistency and completeness. The children treated for SAM at OTP among children aged main sources of data were children cards and some 6-59 months through time in Kembata Tembaro Zone, variables missing in cards were checked from Southern Ethiopia, 2017. registration book. Materials and Methods Pilot study was done with 5% of the sample size of the A retrospective institutional based cross-sectional study children’s OTP cards in Kedida Gamela study was conducted over the period from February Woreda, which is one of the Woredas found in the 21st to March 10th, 2018 at Kembata Tembaro Zone and its weather condition, people’s life style and administrative Zone, Southern Nation Nationalities the other things are almost proximal to the study areas People Region. The annual report of zonal health of the Zone. Based on the findings of the pilot study, department indicates nearly 1600 under five SAM amendments were conducted and incorporated to the children were managed at OTP in 2017. All SAM checklist prior to actual survey. Survival status (cured children who were following their treatment at 135 or censored) was the dependent variable while socio- Health Posts (HPs) of Kembata Tembaro Zone, in demographic (age and sex of child, distance from 2017 were the source population. All selected SAM home to HPs), weather related factors (seasons of children OTP cards from the 18 specific HPs in 2017 admission) were the independent variables of this were study populations. All SAM children who were study. The collected data were checked for admitted to OTP from January 01 to December 30, completeness and consistency, carefully entered, 2017 were included. Children cards that contain thoroughly cleaned, coded and analyzed using SPSS incomplete information were excluded from the study. version 20. To decide significance, p value <0.05 was considered. The outcome was coded as survived or Representative sample size of 433 was calculated censored and multivariate Cox-regression was used to based on assumptions of single population proportion, determine the average hazard ratio by controlling the 95% confidence level or 5% margin of error and confounding effect of each factors. expected frequencies from study done in Wolaita Zone, SNNPR. Seasonal variation of admission: P = Results 40.3% (0.4), 1-P= 59.7% (0.6), Z= 1.96, and d= 0.05 Socio-demographic characteristics: All the 433 of the (Kabalo and Shanka 2016) were accordingly children’s cards found out to be correctly identified as considered for sample size calculation. Assuming 5% SAM and their socio-demographic characteristics are for the cards or registration books that were not well presented (Table 1). There was greater representation registered or ineligible, the adjusted sample size was of 6 to 23 months old children (53.1%), and females calculated as 412 x 5%= 433. There are seven Woredas (54.7%). Mean and SD of the children’s age at (Kedida Gamela, Kacha Birra, Doyogena, Angecha, admission were 23.28 and 14.86 months, respectively.
Hadero, Tembaro and Damboya) and three Table 1: Socio-demographic characteristics of children with SAM administrative towns in Kembata Tembaro Zone. treated at OTP in Kembata Tembaro Zone, Southern Ethiopia, Among these, three Woredas were selected by simple 2017. random sampling. The study area in average hold four Variables Categories Frequency % health centers per Woreda and five satellite health Age 6-23 months 230 53.1 24-59 months 203 46.9 posts per health center in their catchment area. Sex Male 196 45.3 Therefore, in average there are 20 health posts per Female 237 54.7 Woreda in Kembata Tembaro Zone. Of those health Distance from <30 min 209 48.3
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home to HP ≥30 min 224 51.7
Children admitted from a distance of 30 minutes or 24 months (12,36) for children with marasmus, more were 51.7% with mean and SD of 31.8 and 20.0 kwashiorkor and marasmic kwash, respectively. The minutes, respectively. median (IQR) time to recovery was 42 days (40.4, 43.6) for children with marasmus, 35 days (31.6, 38.4) SAM cases: The overall median (inter quartile range, for children with kwashiorkor and 49 days (31.0, 67.0) IQR) age was 15 months (8,22), 36 months (24,48) and for children with marasmic kwash (Table 2). Table 2: Median and mean rates of recovered children from SAM treated at OTP in Kembata Tembaro Zone, Southern Ethiopia, 2017 Recovered children Variables Median age Median recovery time Mean rate of weight gain Mean rate of MUAC gain Marasmus 15 months 42 days 3.44 g/kg/day 0.24 mm/day Kwashiorkor 36 months 35 days 3.50 g/kg/day 0.27 mm/day Marasmic kwash 24 months 49 days 3.53 g/kg/day 0.22 mm/day SPHERE standard < 28 days ≥5 gm/kg/day
Seasonal variations: Among the 433 children November (5.8%) (Figure 1). Participants admitted in admitted to OTP, large number of the participants dry season (December to May) and in wet season (June were admitted in May (14.1%) and least admission in to November) were 55.7% and 44.3%, respectively.
70 61 60 50 No.of ademision 49 40 40 33 35 39 32 30 29 29 31 30 20 25 10 0
Figure 1: Admissions of children with SAM treated at OTP in Kembata Tembaro Zone, Southern Ethiopia, 2017
Children aged 6-12 months were admitted more in dry multivariable Cox regression. Controlling for the season (21.2%) than wet season (18.0%). From a total effects of admission weight, routine medication and of 433 children admitted at OTP, large number of deworming; the distance, symptoms, type of SAM and children stayed for eight weeks and more during dry amoxicillin drug were independently associated with season (14.1%) than wet season (9.0%). The number the time to survive. With these factors, the final model of children survived in the program were (91.1%) was highly significant to predict survival rate of during wet season and 85.5% during the dry season. children from SAM after the OTP intervention The mean weight gain of children was 3.40 g/kg/day (X2=63.29 P<0.0001). Children reside in <30 minutes in dry season and 3.45 g/kg/day in wet season. were with 1.28 times higher odds to survive than reside in >=30 minutes [AHR=1.28 at 95% CI (1.04, 1.58)] For clinical significance and control of confounding, at multivariate regression (Table 3). age, sex and season of the year were included in the
Table 3: Predictors of time to recovery in the bivariate and multivariate Cox Regressions in children with SAM treated at OTP in Kembata Tembaro Zone, Southern Ethiopia, 2017 Event Censored Variables Categories No. (%) No. (%) CHR(95% CI) AHR (95% CI) Age of the child 6-23 months 202(87.8%) 28(12.2%) 1 1 24-59 months 179(88.2%) 24(11.8%) 1.094(0.894,1.337) 0.853(0.660,1.103) Sex of the child Male 163(83.2%) 33(16.8%) 1.037(0.846,1.270) 1.117(0.904,1.380) Female 218(92.0%) 19(8.0%) 1 1 <30 min 189(90.4%) 20(9.6%) 1.341(1.096,1.640)** 1.282(1.041,1.579)*
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Distance from ≥30 min 192(85.7%) 32(14.3%) 1 1 home to HP
Discussions travel more distance. Distance may affect health The findings of this research mainly indicate seasonal seeking practice of the families that in turn could affect distribution of SAM admission to OTP of children treatment outcome of OTP among the children. through time per length of stay at Kembata Tembaro The finding of at least one symptom during admission Zone, Southern Ethiopia. This study shows that there and follow up period was also in agreement with the was greater representation (54.7%) of female adjusted hazard ratio to recovery of children with admission. This result is in line with the study finding diarrhea of Enderta Woreda, Tigray (Yebyo et al. from Northern Ethiopia, which reported 55.4% 2013). Inablity to assess household and environmental (Mengesha et al. 2016). Children were admitted to the factors, and socio-economic and demographic OTP throughout the year in the study area. However, characteristics of the caretakers and other important majority of the cases (55.7%, CI 95%) were admitted variables that would have associations with seasonal during dry season of the year in the study area. This variation of admission are limitations of this study. season is considered to be food scarce season. Hence, most households exist without any support from Conclusion and recommendations organizations and other concerned bodies during the The highest number of children were admitted to OTP wet season. According to the unpublished reports of from December to May (dry season) 2017 with climax Kembata Tembaro Zonal Health and Agricultural admission in May. There was large seasonal variation Departments and study conducted on treatment in SAM admission rate to OTP in the study area, the outcome of children with SAM admitted to TFC in highest number being recorded in dry season, where as Southern Region of Ethiopia (Teferi et al. 2010), the higher number of children survived in the program study area is highly vulnerable to food insecurity and during wet season. The median (IQR) time to recovery malnutrition throughout a year. In a similar study was 42 days for children with marasmus, 35 days for conducted in rural Ethiopia (Egata et al. 2013), food children with kwashiorkor and 49 days for children insecurity was found to be associated with seasonality. with marasmic kwashiorkor. The sphere standard is 28 Accordingly, acute child under–nutrition was days and it is a maximum of 60 days in Ethiopia. This relatively higher in the dry season. The prevalence of study can be used as a reference in priority setting to acute child under nutrition was 7.4% in wet and 11.2% bridge the knowledge gap of the community and in dry seasons. designing effective nutritional programs. Researchers should conduct further prospective study for better In a study conducted in South Sudan the peak of information by considering other factors that were not malnutrition occurs every year between April and included under this study such as existence of sharing June, which coincides with the dry season and of Plumpy’Nut, proper provision of treatment to the diminishes with the up coming rain season. In the wet indexed child at home, household income level, season, there are more water sources closer to the perception of mother on the diseases and effect of the homestead. In the dry season, water sources are maternal educational level. Considering the extent of significantly depleted, and water points get congested admission rate variation by season, it is recommended and contaminated (Bolton and Thompson 2015). A to provide attention to preparedness during times of study conducted by Kabalo and Shanka (2016) in vulnerable seasons, and outpatient therapeutic feeding Wolaita Zone of Southern Ethiopia showed 40.3% of program should be monitored regularly. Capacity study participants were admitted to OTP from January building to service providers is also recommended as to April (dry season). In contrast, the least frequencies the program is being implemented at health post level. of the admissions (28.0%) were reported from September to December (wet season). Thus, higher Acknowledgements admission rate of SAM children to OTP during dry We would like to extend deepest gratitude to Kembata season in the study area may be attributed to lack of Tembaro Zone Health Department staff and Health adequate extra support in the season. Extension Workers in Kembata Tembaro Zone for The finding on the effect of distance (time to travel) their cooperation and provision of necessary from residents’ home to health post on treatment information. outcome of SAM was in agreement with the study References findings from Northern Ethiopia (Massa et al. 2016). Alemu EA (2020) Malnutrition and Its Implications These study results showed that rate of recovery from on Food Security. Zero Hunger. Encyclopedia of OTP was higher among children whose mothers travel the UN Sustainable Development Goals. less distance as compared with children whose mother
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