Determinants and Waterborne Pathogens to the Cause of Infant Mortality in Eastern Ethiopia
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Date
2023-12
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Addis Ababa University
Abstract
This dissertation report is for the study entitled ―Determinants and waterborne pathogens to the cause of infant mortality in eastern Ethiopia‖. The main objective of the study was to determine the cause of infant deaths at the population level and analyze patterns of associated factors among the most common deaths; identify facors contribute to diarrhea-related infant deaths; and detect pathogens that cause severe and fatal diarrhea from infant drinking water and analyze their relationship with water quality determinates. Understanding the cause of infant death at population level in developing countries including Ethiopia is still challenging, for the reason that most infants die at home and lost their life without having had contact with health facilities and no civil registration system. Infant cause of death in a range of setting and the pattern of associated factors among the common cause of death against the overall cause is not well known. Infant deaths are intrinsically linked to several causes and influencing factors that need extensive studies. Diarrhea has been shown to be one of the leading causes of infant mortality in Ethiopia, and its burden is still a serious concern. The risk of unsafe water supplies, inadequate sanitation, and insufficient hygiene practices has a substantial association with diarrheal deaths, which attributed to 88% of diarrhea-related deaths. Diarrhea is typically a waterborne disease that is caused by an extensive range of pathogenic microbes. Cryptosporidium, Shigella, a toxinproducing strain of E. coli, and rotavirus have all been reported as the most responsible for causing severe and fatal diarrhea in infants. Many infants died from illnesses caused by these pathogenic agents, which thrive in contaminated water. The first study objective employed a community-based prospective longitudinal survey, which was conducted with routinely enumeration of reported infant deaths for a period of two years (from September 2016 to August 2018) in Eastern part of Ethiopia. Using the two-stage cluster sampling technique, the study was undertaken in four randomly selected districts of West Hararghe zone in Oromia and two districts of zone 3 in Afar regional state. The study included a total of 362 infants who were deceased during the study period. Data was collected by trained enumerators by interviewing the mothers or guardians of the deceased infant using a 2014 standardize World Health Organization (WHO) Verbal Autopsy questionnaire. InterVA-4 model were used for processing and interpreting verbal autopsy data in order to arrive at the most likely causes of infant death. SPSS version 23 was also used for statistical analysis of frequency distribution and logistic regression for the association between covariates and outcomes. The second study objective employed community based unmatched nested case-control study design in Eastern Ethiopia. The cases were infants who died from diarrheal disease while controls were those who survived their first year of life from September 2016 to August 2018. A total of 305 study subjects (61 cases and 244 controls) were included in the study. Infants dying from diarrhea were compared to four neighborhood controls in terms of several risk components of Water, Sanitation and Hygiene. Data were collected from mothers/care takers of infants using pre-tested structured questionnaires, and entered onto CSpro version 5.1 and transform to SPSS version 23 to analyzed potential risk factors. A molecular (LAMP)-based cross-sectional study design was employed. A total of 410 water samples were collected from infant point-of-use at household level and 37 samples from the corresponding water sources from June 2020 to May 2021. Data were collected from the household‘s mothers/care takers of infants using pre-coded structured questionnaires. The LAMP assay was applied for the detection of the targeted pathogens. The data were entered using CSpro version 6.1 and transform to SPSS version 23 for analyses. For the study objective one, the result shows that Of the overall (362) deceased infants‘ during the study period, 53.0% of deaths occurred during neonatal time while 47.0% died in the postneonatal period. Acute respiratory infection including neonatal and post-neonatal pneumonia (38.4%), birth asphyxia (16.4%), diarrheal diseases (16.3%), prematurity (7.4%) and malaria (4.3%) were found to be the leading causes of infant mortality in the study area. The independent factors strongly associated with probable ARI, including pneumonia related mortality as compared to all-causes of death were infants with maternal age lower than 20 years old (p=0.001, AOR: 4.82, 95% CI: 1.88, 12.3) and infant being died outside of heath facilities (P=0.007, AOR: 2.85, 95% CI: 1.33, 6.12). The post-neonatal period (P=0.000, AOR: 15.5, 95% CI: 6.35, 37.8) and infant died in the wet season (P=0.006, AOR: 2.38, 95% CI: 1.28, 4.44) had strong relationship with dying from diarrhea-related death than those infants died from all nondiarrhea. The death due to malaria robustly associated with infants whose mothers age between 20-35 years old (P=0.024, AOR: 4.44, 95% CI: 1.22, 16.2) and infant who was dwelled in the districts of Afar region (P=0.013, AOR: 4.08, 95% CI: 1.35, 12.4). The factors that found to be significantly associated with infant death from diarrhoea after adjustment for confounding variables included the age of mother with level and 37 samples from the corresponding water sources from June 2020 to May 2021. Data were collected from the household‘s mothers/care takers of infants using pre-coded structured questionnaires. The LAMP assay was applied for the detection of the targeted pathogens. The data were entered using CSpro version 6.1 and transform to SPSS version 23 for analyses. For the study objective one, the result shows that Of the overall (362) deceased infants‘ during the study period, 53.0% of deaths occurred during neonatal time while 47.0% died in the postneonatal period. Acute respiratory infection including neonatal and post-neonatal pneumonia (38.4%), birth asphyxia (16.4%), diarrheal diseases (16.3%), prematurity (7.4%) and malaria (4.3%) were found to be the leading causes of infant mortality in the study area. The independent factors strongly associated with probable ARI, including pneumonia related mortality as compared to all-causes of death were infants with maternal age lower than 20 years old (p=0.001, AOR: 4.82, 95% CI: 1.88, 12.3) and infant being died outside of heath facilities (P=0.007, AOR: 2.85, 95% CI: 1.33, 6.12). The post-neonatal period (P=0.000, AOR: 15.5, 95% CI: 6.35, 37.8) and infant died in the wet season (P=0.006, AOR: 2.38, 95% CI: 1.28, 4.44) had strong relationship with dying from diarrhea-related death than those infants died from all nondiarrhea. The death due to malaria robustly associated with infants whose mothers age between 20-35 years old (P=0.024, AOR: 4.44, 95% CI: 1.22, 16.2) and infant who was dwelled in the districts of Afar region (P=0.013, AOR: 4.08, 95% CI: 1.35, 12.4). The factors that found to be significantly associated with infant death from diarrhoea after adjustment for confounding variables included the age of mother with < 20 years old (P=0.010, AOR: 21.7, 95% CI: 2.10, 224.7), unsafe drinking water storage (P=0.014, AOR: 2.59, 95% CI: 1.22, 5.56), infants in households without point-of-use water treatment practices (P=0.004, AOR: 4.73, 95% CI: 1.66, 13.5), households with unimproved sanitation (P=0.050, AOR: 2.74, 95% CI: 0.99, 7.58), unsafe disposing of child feces (P=0.015, AOR: 2.88, 95% CI: 1.23, 6.75), improper management of solid waste (P=0.003, AOR: 3.33, 95% CI: 1.50, 7.07), households with improper management of liquid waste management (P=0.011, AOR: 3.38, 95% CI: 1.32, 8.66), households did not practiced hand washing at any critical times (P=0.015, AOR: 4.71, 95% CI: 1.34, 16.5) and households practice hand washing in lesser than three critical times (P=0.029, AOR: 2.99, 95% CI: 1.12, 8.04) as compared with their reference group. Cryptosporidium oocysts, Shigella species, a toxin-producing strain of E. coli, and rotavirus were detected in 28.5%, 30.0%, 26.3%, and 32.2%, respectively, of the water samples tested from infant point-of-use. All four pathogens together were detected in about 13.2% of the water samples. Cryptosporidium oocysts, Shigella species, toxin-producing E. coli, and rotavirus were detected in 27.0%, 32.4%, 29.7%, and 37.8%, respectively, of the water samples tested from water sources. For each targeted pathogen, there was a significant positive correlation between the infant's point of ingestion and the water sources it was drawn from. The presence of Shigella species, toxin producing E. coli, and Cryptosporidium oocysts in the water samples was significantly and strongly associated with the unimproved water source. In conclusion, the highest cause of infant mortality was associated with diseases of the respiratory system, followed by diarrheal diseases. Most of the infant deaths that existed were as a result of diseases and conditions that are readily preventable or treatable, similar to those reported worldwide. The patterns of significantly associated factors across the most leading cause-specific mortality against all-causes of death were dissimilar. Infants mother/caretakers whose the age with < 20 years old, households without point-of-use water treatment practices and households did not practiced hand washing at any critical times shows the most higher odds of diarrhea-related infant deaths. Infants demonstrated high levels of exposure to contaminated drinking water by those recognized pathogens that cause the most severe and fatal diarrhea. Unimproved water sources remained the only strong predictors for the presence of these pathogens in infant drinking water. Therefore, strengthening maternal and child health programs with effective preventive interventions emphasizing the most common cause of infant deaths and those factors contributing to raising mortality risk is required. Due attention should be given to the reduction of diarrhea-related infant deaths through WASH intervention, taking into account the strong associated risk factors typically during the infantile period. Efforts should be made to improve water supplies, protect the sources, and educate caregivers of infants about safe drinking water practices and health.
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Keywords
Cause of infant mortality, Diarrhea-related infant death, Risk factors, Water, Sanitation and Hygiene, Cryptosporidium, Shigella, Toxin-producing strain of E. coli, Rotavirus, Drinking water, LAMP