WOLAITA SODDO UNIVERSITY

COLLEGE OF HEALTH SCIENCE AND MEDICINE

SCHOOL OF PUBLIC HEALTH

EPIDEMIOLOGY ASSIGNMENT

Course: Epidemiological Methods for Disease Prevention and Control

Term paper on Determinants of mortality among under five children with SAM in
Ethiopia.

By: -

Wubtaye Hailu
ID number: - pgw/81255/15, Epidemiology and Biostastics (weekned)

Submitted to: Mr.Serawit Samuel (MPH)

October 7, 2023

Wolaita Sodo, Ethiopia

Contents
1. Introduction.............................................................................................................................- 1 -

2. Objective.................................................................................................................................- 2 -

3. Methods...................................................................................................................................- 2 -

Performed activities.................................................................................................................- 2 -

4. Key findings and discussions..................................................................................................- 3 -

4.1. Determinants of mortality among under five children with SAM...................................- 3 -

5. Conclusion..............................................................................................................................- 4 -

6. Recommendation....................................................................................................................- 4 -

7. Reference................................................................................................................................- 5 -
1. Introduction
Ethiopia is a country situated in Sub Saharan Africa, with adequate natural resources, which are
vital for it is growth. However, Ethiopia has a long history of food insecurity and nutritional
disorders aggravated by larger population size, land degradation, and droughts affecting a larger
proportion of population (1). Consequently, the country has been experiencing malnutrition
related problems, although both community- and facility-based interventions are in place.
Recently (2013 to date), there has been a paradigm shift for treating SAM, using updated WHO
treatment guideline published in 2013, with compressive approaches (4).SAM is defined by two
clinical parameters: (1) severe wasting; defined as middle upper arm circumference (MUAC) <
115 mm for children aged > 6 months or a weight-for-height < - 3 z-scores according to WHO’s
growth standards for under-five children; and (2) nutritional edema with kwashiorkor; that is, the
presence of clinically confirmed bilateral, pitting edema (3,4).

Acute malnutrition is a major challenge for achieving sustainable development goals as it is

associated with major causes of under-five mortality. Besides, it leads to adverse maternal and
child health consequences including retarded school performance (5). According to national food
and nutrition strategy baseline survey report, about 11% 0f under five children were wasted;
about 39% and 22% of under five children were stunted and underweight respectively (6).

Ethiopia is placed at the second place in high burden of malnutrition among sub-Saharan
countries (7). In Ethiopia, this indicated by factors like anemia, skin dermatosis, heart failure,
poor adherence to management protocols, and impaired vital signs were reported as contributors
of death among children with SAM (8-10). Prior studies conduct in the different part of the
country revealed that the magnitude of children mortality ranges from 2.1% in Harar to 28.67%
in Waghemra; the issue is still a public health problem (8-10). Even though the data regarding
the determinants of mortality in children with SAM is limited, searching for determinants of
mortality is far more important for strengthening as well as formulating new strategies to come
over it.

The main aim of this term paper is to review studies done on determinants of mortality among
under-five children with SAM in Ethiopia. This will assist decision makers and/or other
stakeholders to practice effective and efficient SAM management.

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2. Objective
The main objective of the paper is to review magnitude and determinants mortality among under
five children with SAM in context of Ethiopia. The specific objectives of the paper are;

 To review the magnitude of mortality among under five children with SAM in Ethiopia
 To review the determinants of mortality among under five children in Ethiopia.

3. Methods
The paper was developed through literature survey approach. A systematic review was carried
out to select 13 eligible articles from identified 1890 studies (conducted from 2018-2023) that
determine the magnitude and determinants of mortality among under five children with SAM.
Databases including PubMed, Web of Science and Google Scholar were reviewed using medical
subject headings. It has collected the secondary information to analyze the qualitative and
quantitative data on magnitude and determinants of mortality among under five children with
SAM in context of Ethiopia.

Finally, the acquired data from these studies were presented narratively or thematically.

Performed activities
No Activities done Week one Week Two
1 Topic selection and study
proposal
2 Data collection
3 Data interpretation and
write up
4 Finalize paper and prepare
power point
5 Paper submission and
presentation

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4. Key findings and discussions
4.1. Determinants of mortality among under five children with SAM
This paper examined different articles on magnitude and determinants of mortality among under
five children with SAM in Ethiopia. A study conducted in Ayder referral hospital, Mekele,
Tirgay; Out of 195 children admitted with SAM 3.6% were died (11). In contrast to this finding,
A retrospective cohort study conducted by reviewing 610 charts in Addis Ababa revealed that
about 61,(10%) children were died ,Which was comparable with the value put forth by the
Sphere standard and the national SAM management protocol (<10%) (12). Shock,
supplementing F100, Zinc and IV fluid infusion were find to be the determinant of death among
under five children participated in the study, off these shock and IV infusion were increase
death, whereas F100 and Zinc supplementation reduce the occurrence of death(13).

In contrast to this, a study conducted in Pawe general hospital Northwest Ethiopia among 568
under five children with SAM, the death rate was 16.02% and vomiting, diarrhea, needing of
nasogastric therapy, anemia and being readmitted with the diagnosis of SAM were the
independent risk factors for death (14). It shows SAM mortality rate was high in under five
children (12).

A total of 500 children were enrolled in the study done in Hadiya zone,south Ethiopia. In this
study, Kwashiorkor was the most frequently recorded morbidity accounting for 43.0% with
commonest form of morbidity being Pneumonia. And the overall mortality rate was 7% (15).

Similar to this study, A meta-analysis of inpatient treatment outcomes of severe acute

malnutrition and predictors of mortality among under-five children in Ethiopia revealed that the
proportion of children that died was not achieve the minimum SPHERE standard and WHO
management protocol for SAM (i.e., < 10% death rate and > 75%) (16,17). This high death rate
and low recovery rate could be a result of delay at presentation to a stabilization center, the
occurrence of recurrent infections, presence of co-morbidities and non-adherence (by healthcare
providers) to the current SAM treatment guideline. In terms of determinants of mortality in SAM

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children, the association of diarrhea and SAM is a well-recognized fact (18, 19). This could have
a vital role for treatment outcomes.

This possibly is attributed by the fact that children with diarrhea have concurrent clinical features
including severe dehydration, impaired perfusion, and severe metabolic acidosis that would raise
mortality. Moreover, gram-negative bacteremia is normally allied with diarrhea and is the major
risk factor for death, nonetheless of HIV or anthropometric status (20).

In a retrospective cohort study was conducted among a total of 665 under-five children admitted
with complicated SAM in Dilchora hospital, eastern Ethiopia; a total of 60 (9%) deaths were
observed. Admitted children having good appetite, pneumonia), diarrhea, tuberculosis and
having a nasogastric tube inserted (AHR=2.33, 95% CI: 1.15, 4.72) were significant predictors of
time to death among SAM children (21). A study conducted among 361 children who were
admitted with diagnosis of malnutrition Ilu Aba Bor Zone Health Facilities, South West
Ethiopia, shows very low mortality rate (1%) in under five children with prevalent predictors of
death being Pneumonia, anemia and diarrhea with the percentage of 69%, 63% and 58%
respectively (22).

5. Conclusion
Mortality trends of SAM vary irregularly across the year as well as regions however it is still
unacceptably high as it was not within the range put forth by the Sphere standard and the
national SAM management protocol. The major determinants of mortality in under five children
with SAM being shock, anemia, diarrhea, pneumonia and tuberculosis. Importantly the mortality
is being predicted by comorbidities at admission.

6. Recommendation
Healthcare facilities and providers are strongly advised to adhere to and implement based on the
up-to-date inpatient SAM treatment and management protocol. Moreover, Health facilities
should also pay attention beside treatment of malnutrition on identifying and treating of
associated co morbidities.

Federal ministry of health, regional health bureau and zonal health office should focus on
training of diagnosis, treatment practice, and facilities by special focusing on this age group.

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7. Reference
1. Organization WH, UNICEF: community-based management of severe acute malnutrition: a
joint statement by the World Health Organization, the world food Programme, the United
Nations system standing committee on nutrition and the United Nations Children's fund. 2007.

2. WHO. Guideline: updates on the management of severe acute malnutrition in infants and
children: World Health Organization; 2013. https://www.ncbi. nlm.nih.gov/books/NBK190328/

3. Organization WH. Pocket book of hospital care for children: guidelines for the management of
common childhood illnesses: World Health Organization;2013.

4. Organization WH. Guideline: updates on the management of severe acute malnutrition in

infants and children: World Health Organization;2013.

5. Organization WH, UNICEF: community-based management of severe acute malnutrition: a

joint statement by the World Health Organization, the world food Programme, the United
Nations system standing committee on nutrition and the United Nations Children's fund. 2007.

6. National food and nutritional strategy, baseline survey: key findings preliminary report, march
2023

7. Demissie S. Magnitude and factors associated with malnutrition in children 6-59 months of
age in pastoral community of Dollo Ado district, Somali region, Ethiopia. Sci J Public Health.
2013;1(4):175–83

8. Guesh G, Degu G, Abay M, Beyene B, Brhane E, Brhane K. Survival status and predictors of
mortality among children with severe acute malnutrition admitted to general hospitals of Tigray,
North Ethiopia: a retrospective cohort study. BMC Res Notes. 2018;11(1):832.
9. Wagnew F, Tesgera D, Mekonnen M, Abajobir AA. Predictors of mortality among under-five

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children with severe acute malnutrition, Northwest Ethiopia: an institution based retrospective
cohort study. Arch Public Health. 2018;76:64.
10. Girum T, Kote M, Tariku B, Bekele H. Survival status and predictors of mortality among
severely acute malnourished children< 5 years of age admitted to stabilization centers in Gedeo
zone: a retrospective cohort study. Ther Clin Risk Manag. 2017;13:101.

11. Mengistu Girma Tirore, Tesfay Mehari Atey and Haftay Berhane Mezgebe: Survival status
and factors associated with treatment outcome of severely malnourished children admitted to
Ayder referral hospital: a cross-sectional study, 2015.

12. Federal Democratic Republic of Ethiopia MoH: Training course on the management of
severe acute malnutrition. 2013. https://motherchildnutrition.org/resources/pdf/mcn-ethiopia-
sam-guidelines.pdf

13. Zebenay Workneh Bitew , Ermias Getaneh Ayele, Teshager Worku, Animut Alebel,
Ayinalem Alemu,Frehiwot Worku and Aman Yesuf: Determinants of mortality among underfive
children admitted with severe acute malnutrition in Addis Ababa, Ethiopia,2021

14. Fassikaw Kebed, Tsehay Kebede, Belete Negese, Atitegeb Abera, Getahun Fentaw, Ayalew
Kasaw: Incidence and predictors of severe acute malnutrition mortality in children aged 6–59
months admitted at Pawe general hospital, Northwest Ethiopia, February 25,2022

15. Tadele Yohannes, Tariku Laelago, Menen Ayele and Temesgen Tamrat Mortality and
morbidity trends and predictors of mortality in under-five children with severe acute malnutrition
in Hadiya zone, South Ethiopia: a four-year retrospective review of hospital-based records
(2012–2015).
16. Fasil Wagnew, Getenet Dessie, Wubet Worku Takele, Aster Tadesse, and Amanuel Alemu
Abajobir:A meta-analysis of inpatient treatment outcomes of severe acute malnutrition and
predictors of mortality among under-five children in Ethiopia
17. SPHERE: Sphere project: humanitarian charter and minimum standards in disaster response.
2011.

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18. Irena AH, Mwambazi M, Mulenga V. Diarrhea is a major killer of children with severe acute
malnutrition admitted to inpatient set-up in Lusaka, Zambia. Nutr J. 2011;10(1):110.
19. Anand K, Sundaram K, Lobo J, Kapoor S. Are diarrheal incidence and malnutrition related
in under five children? A longitudinal study in an area of poor sanitary conditions. Indian
Pediatr. 1994;31(8):943–8.

20. Micek ST, Welch EC, Khan J, Pervez M, Doherty JA, Reichley RM, Kollef MH. Empiric
combination antibiotic therapy is associated with improved outcome against sepsis due to gram-
negative bacteria: a retrospective analysis. Antimicrob Agents Chemother. 2010;54(5):1742–8.

21. Abdu Oumer,Leul Mesfin, Esubalew Tesfahun, Ahmed Ale: Predictors of Death from
Complicated Severe Acute Malnutrition in East Ethiopia: Survival Analysis,2021

22. Sileshi Dubale, Efrem Negash and Muluneh Shuramu: Treatment Outcomes and Determinant
Factors of Under- Five Children with Malnutrition Treated in Ilu Aba Bor Zone Health Facilities,
South West Ethiopia,August, 2019.