Morbidity and Risk Factors of Diarrheal Diseases ... - Oxford Journals [PDF]

by Khaled Yassin. Department 2: Public Health Medicine, School of Public Health, University of Bielefeld, Germany. Summa

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Morbidity and Risk Factors of Diarrheal Diseases Among Under-®ve Children in Rural Upper Egypt by Khaled Yassin Department 2: Public Health Medicine, School of Public Health, University of Bielefeld, Germany Summary Diarrhea is a leading cause of mortality and morbidity in developing countries. In Egypt, researchers have traditionally been targeting diarrhea-related mortality. This study is an attempt to portray the morbidity and risk factors of diarrhea among children under 5 years old (under-®ves) in rural Upper Egypt. The incidence of diarrhea in the 6 months before the study was determined among 1025 under-®ves in six sentinel sites by inverviewing mothers or caretakers. The association between diarrhea and a set of risk variables was examined using a multivariate logistic regression model. Variables that appeared to have a signi®cant predictive power were then included in a forward wald stepwise logit analysis model to estimate statistical functions which best predict the diarrheal morbidity. The incidence rate of diarrhea was found to be 3.6 episodes per child semiannually and the point prevalence was 19.5 per cent. The average duration of current episodes was 4:8 6 3:7 days; 33.6 per cent of children had had diarrhea more than three times (recurrent diarrhea). Four variables were found to have a signi®cant association with recurrent diarrhea. The logit coef®cients and their signi®cance levels indicated that, in order of contribution to risk prediction, the variables ranked as follows: household meat consumption, mother's age at the time of birth of the child, child's age, and father's illiteracy. A total of 74.8 per cent of overall children were correctly predicted by these risk factors, a ®gure which indicates the goodness of ®t of the model. It is concluded that the diarrheal morbidity is still unacceptably high in rural Upper Egypt. More interventions are needed to control for speci®c risk factors.

Introduction Diarrheal diseases continue to be a primary cause of childhood mortality in developing countries. The World Health Organization estimates that over two million children die each year in developing countries from diarrheal diseases.1 Moreover, diarrhea is the leading cause of malnutrition in more than 40 million children under the age of ®ve in developing countries,2 which in turn increases the risk of death from other infectious diseases and interferes with their physical growth and mental development. In Egypt, diarrhea alone resulted in more than 50 Acknowledgements This work was supported and sponsored by the Institute of Cultural Affairs-Middle East and North Africa (ICA-MENA). I am indebted to Ms Hala El-Kholy (Director of ICA-MENA), Mr Y. Mohamed (Director of ICA Beni Suef Of®ce), and to all ICA staff who participated in the ®eld work and data entry. I am also indebted to the local authority of Beni Suef Governorate for their support and logistic facilitation. Finally, this work would never have been completed without the voluntary contribution of the members of the local Community Development Associations (CDAs) in data collection and quality control work. Correspondence: Khaled Yassin, Postfach 100131, UniversitaÈtstrasse, D-33501 Bielefeld, Germany. Tel. 449 0172 5688013. E-mail: . 282

q Oxford University Press 2000

percent of under-®ves mortality before 1985.3 As a result, in 1981 the Egyptian Ministry of Health started a national program to combat mortality from diarrheal diseases. The National Control of Diarrheal Diseases Program (NCDDP) aimed at improving case-management through assured production and distribution of oral rehydration salts, and promoting its use through the mass media.4 Data from the national civil register show that diarrhea-speci®c mortality has declined substantially after the implementation of the NCDDP.3,5,6 However, the magnitude of improvement has been questioned by other studies, which checked the validity of causes of death information in the civil register.7,8 Some other studies suggest that diarrhea is still the leading cause of death, in spite of the substantial decline of diarrhea-related mortality.4,9 The strategy of the NCDDP has focused on preventing death from dehydration by improving rehydration resources. However, very limited efforts have been made to combat the morbidity from diarrheal diseases. Concentrating efforts and resources on preventing death from dehydration while the burden of diarrhea is kept constant is expected to be associated with an increase in the incidence rate of malnutrition and death from other causes, especially acute respiratory tract infections. This argument ®nds support in studies that have observed increasing rates of both problems.10±12 Journal of Tropical Pediatrics

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The ignorance of the morbidity of diarrheal diseases is re¯ected in the scarcity of studies on its incidence, duration or consequences in comparison with studies on mortality from diarrhea. Reduction of the morbidity is expected to reduce not only the mortality from diarrhea, but also to reduce the mortality from other causes by promoting the well-being of children and improving their resistance. Reduction of morbidity depends on identifying effective interventions and ensuring that they are delivered to the population at risk. Identi®cation of children at higher risk for diarrhea is a crucial step for a better and a more ef®cient utilization of resources that are usually too limited in developing countries. Furthermore, determining risk factors for diarrheal morbidity helps to identify effective intervention measures, both on the preventive and on the curative levels. This study is an attempt to portray the morbidity of acute and recurrent diarrhea and the risk factors among children under the age of ®ve in six rural areas in upper Egypt. Study Design This study was conducted in six selected sites, using a sentinel community surveillance approach, which is a modi®ed version of the standard cluster survey. The standard cluster survey was modi®ed by increasing the cluster size without sampling in each cluster. The clusters were then handled as a representative panel of mini-universes. In each mini-universe, a comprehensive micro-level survey was carried out to assess the morbidity of diarrheal disease among children under the age of ®ve. The descriptive component was followed by a case-control analysis. Children who had had diarrhea at the time of the survey were assigned as cases, and those who had not were designated as controls. Then, the demographic, social, economic, and environmental characteristics of both groups were statistically compared. This research was carried out during the second investigation cycle of the surveillance scheme. In the ®rst cycle, 1025 children under the age of ®ve were identi®ed. A comprehensive house-to-house survey was conducted to gather data about the demographic, social,

economic, and environmental characteristics of the children and their families. Furthermore, indices, leading causes, and determinants of childhood mortality were determined. In the second cycle, all 1025 under-®ves were included. Caretakers, usually mothers, were interviewed using a standardized structured interview format. The interview included questions about the incidence of diarrheal episodes in the 6 months before the survey. The mothers were asked to report on details for the last diarrheal episode. Children who had a current episode of diarrhea were examined clinically by the author. An episode of diarrhea begins with a 24-h period characterized by three or more loose or watery stools. Distinction between acute watery diarrhea and recurrent diarrhea was done using WHO guidelines. Risk assessment Risk assessment in this study encompassed the estimation of a statistical model to identify combinations of certain risk factors, which reliably predict the morbidity of childhood diarrhea. The analytic approach included two stages. The ®rst used a multivariate logistic regression scheme to determine those risk factors, which were associated with diarrheal morbidity. The second stage included application of a logit analysis model. The logit analysis estimates statistical functions, which best predict morbidity outcomes. Only risk factors, which appeared to have a signi®cant predictive power in the logistic regression, were included in the logit model, which describes children at risk by de®ning groups in terms of various levels of outcome probability. Results A total of 1025 under-®ves were included in the study. All children had had at least one episode of diarrhea in the 6 months before the study (May±September 1996). The incidence rate of diarrhea for this period was 3.6 episode per child semiannually. Two hundred children had had a current episode of diarrhea; this corresponds to a point prevalence of 19.5 per cent. The average duration of current episodes was 4:8 6 3:7 days; 7.5 per cent of current episodes started more than 2 weeks before the interview and were classi®ed as persistent diarrhea.

TABLE 1 Diarrheal disease morbidity among under-®ves in rural Upper Egypt Indicator

Proportion

Point prevalence of diarrhea (current episode) Average duration Persistent diarrhea Blood in stool Incidence of vomiting Semiannual incidence of diarrhea

19.5% (n ˆ 200) 4:8 6 3:7 days 7.5 (n ˆ 15) 4.5 (n ˆ 9) 64.0 (n ˆ 128) 3.6 episode per child

Recurrent diarrhea (>3 episode per child semiannually)

33.6% (n ˆ 244)

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TABLE 2 Risk factors of recurrent diarrheal disease Exposure (%)

Child's age (< 1 year) Child's sex (female) Child's order (> 3) Preceding pregnancy interval (< 18 months) Mother's age (< 20 years old) Mother's age at marriage (< 18 years old) Mother's age at ®rst pregnancy (< 18 years old) Parental age difference (> 10 years) Parity Mother's illiteracy Father's illiteracy Father's occupation (farmer) No entitlement to land ownership No entitlement to house ownership No entitlement to cattle ownership No access to safe water Meat consumption (< 4 times per month)

Univariate analysis

Multivariate analysis

Cases

Controls

OR

Cl

OR

p value

48.0 47.4 44.5 16.3 52.3 57.0 27.0 18.9 30.8 82.3 50.9 27.9 77.6 07.6 62.2 78.8 52.3

16.7 48.5 41.7 15.0 16.5 56.4 44.8 16.3 31.3 59.2 39.1 26.6 81.9 04.3 61.4 53.9 14.4

4.6 0.96 1.1 1.1 5.6 1.02 0.99 1.2 0.98 3.2 1.6 1.1 0.8 1.8 1.1 3.2 6.5

3.4±6.2 0.7±1.3 0.9±1.5 0.8±1.6 4.1±7.6 0.8±1.3 0.8±1.3 0.8±1.7 0.7±1.3 2.3±4.5 1.2±2.1 0.8±1.4 0.6±1.1 1.1±3.3 0.8±1.4 2.3±4.3 4.8±8.9

1.8 1.0 1.2 1.4 2.6 1.1 1.0 1.1 0.8 1.2 1.7 0.8 0.8 2.1 1.3 1.4 3.4

0.000 0.949 0.316 0.125 0.000 0.566 0.891 0.672 0.216 0.390 0.003 0.207 0.2669 0.02 0.162 0.072 0.000

Vomiting and blood in stools occured in 64.0 and 4.5 per cent of the cases, respectively. Risk assessment Seventeen risk factors for recurrent diarrhea (> three episodes semiannually) were examined. They re¯ect child, mother, and father demographic variables and some socioeconomic indicators. Only six factors appeared to be signi®cantly associated with recurrent diarrhea ( p < 0:01). These variables included child's age, mother's age, mother's education, father's education, access to safe water, and average times of the household's meat consumption per month. Infants were found to have a 4.6 higher risk of recurrent diarrhea than older children. Furthermore, a 5.6 higher risk was reported among children whose mothers were teenagers than among children with older mothers. Similarly, mother's illiteracy and father's illiteracy were associated with 3.2 and 1.6 times higher risks, respectively. Finally, children whose families had no access to safe water or who consumed meat less than four times a month had a 3.2 and 6.5 higher risk, respectively. However, mother's illiteracy and access to safe water

were found to have no statistically signi®cant association with recurrent diarrhea in the multivariate analysis. Also, the strength of association between the other four variables and recurrent diarrhea decreased but remained signi®cant. Table 2 shows the statistical association between risk factors and recurrent diarrhea. Logit model estimation Four variables shown in the logistic regression analysis to be signi®cantly associated with recurrent diarrhea were included in the logit model. A forward wald stepwise model was used. Variables were entered according to the strength of association. In order of entry, they were average household meat consumption per month, mother's age, child's age, and father's illiteracy. The contribution of these variables is shown by the logit coef®cients (Table 3). The size of the coef®cients and their signi®cance levels indicated that in order of contribution to risk prediction the variables ranked as follows: average meat consumption, mother's age, child's age, and father's illiteracy. The goodness-of-®t of the model was evaluated by assessing the overall accuracy of the prediction of

TABLE 3 Logit model result Variable Household meat consumption < 4 times per month Mother's age (< 20 years old) Child's age (< 12 months) Father's education (illiterate) Constant

284

Coef®cient

Coef®cient/standard error

1.3 1.1 0.7 0.5 1.8

Journal of Tropical Pediatrics

7.6 5.8 3.7 3.1 14.2

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TABLE 4 Classi®cation of children by actual and predicted occurrence of recurrent diarrhea Predicted

Observed

Recurrent diarrhea

Not

Total

260 174

84 507

344 681

Recurrent diarrhea Not

74.8% of children are correctly classi®ed. Sensitivity ˆ 75.6, speci®city ˆ 74.5.

according to the absence or presence of the predictor. As a result, a score of 0 means the absence of all predictors and a score of 4 indicates the presence of all risk factors. Then, the odds ratio for recurrent diarrheal disease was estimated for each score. Children whose score was 0 were assigned as a reference group. From Fig. 1, it is evident that the risk of recurrent diarrheal disease is proportionally related to the score of the risk index.

children at risk. Cross-tabulation of actual and predicted occurrence of recurrent diarrhea (Table 4) showed that the model had an acceptable good ®t; 74.8 per cent of overall children were correctly predicted. Positive prediction was based on a risk probability equal to or greater than 0.4. The probability of recurrent diarrhea was estimated for subgroups de®ned by different combinations of the predictors. Estimates are presented in Table 5, from which four high-risk groups can be de®ned. The ®rst group includes infants whose mothers are younger than 20 years old, whose fathers are illiterate, and whose families consume meat less than four times a month. The second high-risk group includes under ®ves whose fathers are illiterate and whose families consume meat less than four times a month. The third group includes under-®ves whose families consume meat less than four times a month. In order to develop a risk assessment tool, which can be easily applicable in the ®eldwork, we designed a simple risk index in which the four predictors are equally weighted. Each child was given a score of 0 or 1

Discussion There are no reliable data on incidence or prevalence of diarrhea among the under-®ves in Upper Egypt. Most of the interventions and studies of the National Control of Diarrheal Diseases Projects have been concentrated in Lower Egypt.13±20 This study is the ®rst one to give a reliable population-based estimate for diarrheal morbidity and its predictors in Upper Egypt derived from a satisfactory sample size. Diarrhea is one of the major health problems confronting children under the age of ®ve in Upper

TABLE 5 Probability of recurrent diarrhea for different combinations of the predictors Predictors Meat consumption < 4 times per month

Mother's age < 20 years

Child's age < 12 months

Father's illiteracy

n

Proportion with diarrhea

± ± ± ± + ± ± + ± + + ± + + + +

± ± ± + ± ± + ± + ± + + ± + + +

± ± + ± ± + ± ± + + ± + + ± + +

± + ± ± ± + + + ± ± ± + + + ± +

42 29 13 9 17 10 27 27 14 15 15 20 11 13 44 38

0.12 0.14 0.52 0.45 0.65 0.35 0.60 0.74 0.48 0.49 0.54 0.60 0.54 0.52 0.65 0.85

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FIG. 1. Odds ratio of recurrent diarrheal disease by the risk score. Egypt. The incidence rate and the point prevalence rate are unacceptably high. This study reports an incidence rate of 3.6 episode per child semiannually, which is similar to the annual incidence rate reported by some other studies in Lower Egypt.9,19 This simply means that the burden of diarrheal morbidity is nearly two-fold in Upper Egypt. Similarly, the point prevalence is nearly two times that reported for Lower Egypt. The higher rate of point prevalence conforms the high incidence rate and minimizes the possibility that recall bias would tend to overestimate the semiannual incidence rate. The average duration of an episode of diarrhea is estimated to be 4:8 6 3:7 days. Information regarding the duration has been obtained from children with a current episode of diarrhea. Therefore, the true range for the duration is expected to be longer than the obtained duration. A total of 7.5 per cent of children with a current episode of diarrhea had persistent diarrhea. Although this ®gure is substantially higher than that for Lower Egypt (4.1 per cent),10,20 it is congruent with the reported high incidence rate of diarrhea. Nearly one-third of under-®ves in Upper Egypt have recurrent diarrheal disease de®ned as more than three episodes of diarrhea in the 6 months before the study. Average household protein consumption seems to be the strongest predictor for recurrent diarrheal episode. Meat consumption rate less than four times a month is associated with a 3.4 increased risk and this factor alone predicts 56 per cent of cases. Pathways through which household meat consumption can predispose to recurrent diarrhea are not exactly known. Three basic assumptions can explain the association. First, unsatifactory meat consumption can negatively in¯uence resistance resources of children and undermine their immune capabilities against diarrhea-inducing pathogens. Second, it can negatively in¯uence the mother's health. A malnourished mother might not be able to feed her child properly or to carry out satisfactorily childcare activities. In a society where nutritional priority is given to working men, children and mothers are expected to suffer more from food shortage. Third, protein consumption might be a very sensitive indicator of the economic situation of the family in a highly homogenous society where the vast majority of families are poor. Meat is the 286

most expensive foodstuff in the local market. Poor families cope with their limited resources by reducing their meat consumption. Consequently, the poorest consumes the least. Poverty can predispose to diarrhea independently of nutritional practices. The ®nding that children of teenage mothers have a signi®cant higher risk of recurrent diarrhea adds further evidence for the importance of avoiding pregnancy before the age of 20. Also, prevention and health promotion efforts should focus more on infants as they are at higher risk for recurrent diarrhea. Illiteracy in the fathers also has a statistical power in predicting and predisposing for recurrent diarrhea. Fathers' education has long been ignored by traditional conceptions as an important determinant of child health. The reason for this is that in most cultural contexts fathers are not involved in the daily activities of child rearing. Fathers' education has been treated less as an indicator of quality of child-rearing skills than as a predictor of economic status. Increased education of the father may improve the housing and sanitation conditions and the quality of food and enable parents to take better advantage of healthcare. Improved knowledge may undermine the traditional beliefs and practices that are detrimental to child health.20 References 1. World Health Organization. Reducing mortality from major childhood killer diseases. Fact Sheet No. 180, September 1997. 2. UNICEF. State of the World Children. UNICEF, 1998. 3. Central Agency for Public Mobilization and Statistics. Infants and Child Mortality Rates in Egypt, 1980±87. CAPMAS, Cairo, 1989. 4. P. Miller, N. Hirschhorn. The effect of a national control of diarrheal diseases program on mortality: the case of Egypt. Soc Sci Med 1995; 40: S1±S30. 5. Central Agency for Public Mobilization and Statistics. The state of the Egyptian child. CAPMAS, Cairo, 1988. 6. Central Agency for Public Mobilization and Statistics (CAPMAS) population studies and research center. Infant and Child Mortality in Egypt. CAPMAS, Cairo, 1986. 7. Becker S, Waheeb Y, el-Deeb B, Khallaf N, Black R. Estimating the completeness of under-5 death registration in Egypt. Demography 1996; 33: 329±39. Journal of Tropical Pediatrics

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8. Committee on Population and Demography. The Estimation of Recent Trends in Fertility and Mortality in Egypt. National Academy Press, Washington, D.C. 1982. 9. Langsten R, Hill K. Diarrheal disease, oral rehydration, and childhood mortality in rural Egypt. J Trop Pediatr 1994; 40: 272±78. 10. Aref GH, Osman MZ, Zaki A, Amer MA, Hanna SS. Clinical and radiologic study of the frequency and presentation of chest infection in children with severe protein energy malnutrition. Egypt Pub Hlth Assoc 1992; 67: 655±73. 11. Allen LH. Malnutrition and human function: a comparison of conclusions from the INCAP and nutrition CRSP studies. J Nutr 1995; 125(Suppl 4): 119S±1126S. 12. Khallaf N, el-Ansary S, Hassan M. Acute respiratory infections: sentinel survey in Egypt. World Health Forum 1996; 17: 297±300. 13. National Control of Diarrheal Diseases Project. Impact of the National Control of Diarrheal Diseases Project on infant and child mortality in Dakahlia, Egypt. Lancet 1988; 2: 145±48. 14. Tecke B. Oral rehydration therapy: an assessment of

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18. 19. 20.

mortality effects in rural Egypt. Studies Fam Plann 1982; 13: 315±27. Abdel-Azeem F, Farid SM, Khalifa AM. Egyptian maternal and child health survey 1991. Pan Arab Project for Child Development, Cairo, 1993. El-Zanaty F, Sayed HA, Zaky HM, Way A. Egypt Demographic and Health Survey 1992. National Population Council, Cairo, 1993. Keilman AA, Mobarek AB, Hammamy MT, et al. Control of death from diarrheal diseases in rural communities. I. Design of an intervention study and effects on child mortality. Trop Med Parasitol 1985; 36: 191. Langsten R, Hill K. Child Survival in Rural Egypt: Final report. Social Research Center, American University in Cairo, Johns Hopkins University, Baltimore, 1992. Jousilahti P, Madkour SK. Diarroeal disease morbidity and home treatment practices in Egypt. Public Health 1997; 111: 5±10. United Nations. Socio-economic differentials in child mortality in developing countries. Department of International Economic and Social Affairs, New York, 1985.

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