Effect of COVID-19 pandemic on the incidence of acute diarrheal disease and pneumonia among under 5 children in Ethiopia- A database study

COVID-19 has had a devastating impact on preventable and treatable pediatric diseases in Ethiopia. This study looks at the impact of COVID-19 on pneumonia and acute diarrheal diseases in the country, as well as the differences between administrative regions. In Ethiopia, we conducted a retrospective pre-post study to assess the impact of COVID-19 on children under the age of five who had acute diarrhea and pneumonia and were treated in health facilities during the pre-COVID-19 era (March 2019 to February 2020) and the COVID-19 era (March 2020 to February 2021). From the National Health Management District Health Information System (DHIS2, HMIS), we retrieved data on total acute diarrheal disease and pneumonia, along with their regional and monthly distribution. We calculated incidence rate ratios comparing the rates of acute diarrhea and pneumonia during the pre-and post-COVID-19 eras and adjusted for the year, using Poisson regression. The number of under-five children treated for acute pneumonia decreased from 2,448,882 before COVID-19 to 2,089,542 ((14.7% reduction (95%CI;8.72–21.28), p<0.001)) during COVID-19. Similarly, the number of under-five children treated for acute diarrheal disease decreased from 3,287,850 in pre-COVID-19 to, 2,961,771((9.91% reduction (95%CI;6.3–17.6%),p<0.001)) during COVID-19. In the majority of the administrative regions studied, pneumonia and acute diarrhea diseases decreased during COVID-19, but they increased in Gambella, Somalia, and Afar. During the COVID-19 period, the greatest reduction of children with pneumonia (54%) and diarrhea disease (37.3%) was found in Addis Ababa (p<0.001). The majority of administrative regions included in this study have seen a decrease in pneumonia and acute diarrheal diseases among children under the age of five, while three regions namely, Somalia, Gambela, and Afar saw an increase in cases during the pandemic. This emphasizes the importance of using tailored approaches in mitigating the impact of infectious diseases such as diarrhea and pneumonia during situations of a pandemic such as COVID-19.


Introduction
Acute diarrhea and pneumonia are leading causes of morbidity and mortality in children under the age of five worldwide, especially in Sub-Saharan Africa and South Asia [1]. Globally, 1.23 million children die of pneumonia and diarrhea before reaching their 5 th birthday-the equivalent of over 141 child deaths per hour or 3,400 deaths per day [2]. They share several risk factors and can be avoided by implementing proven interventions such as improved personal hygiene and routine vaccinations. Prompt detection and treatment can aid in the avoidance of complications. The current COVID-19 pandemic has not only posed a challenge, but also an opportunity to observe the several pandemic control measures implemented to bring down the transmission of these diseases and, as a result, under-five mortality [3].
With reference to the Millennium Development Goal 4 (MDG 4), child survival has improved significantly globally. It was planned to reduce the under-five mortality rate by two-thirds, between 1990 and 2015 [4]. Currently, the Sustainable Development Goals (SDGs 3.2) are being implemented in various nations including Ethiopia to reduce child mortality to less than 25 per 1000 by 2035 [5]. COVID-19 has threatened to undo the progress made thus far, casting doubt on the SDG targets due to its effect on socioeconomic issues, nutrition, and disruption of basic healthcare delivery systems [6]. Because 88% of diarrhea and pneumonia cases among under-five children are due to inadequate hygiene, COVID-19 prevention precautions such as mandatory mask-wearing and hand hygiene practices have undoubtedly added to a reduction in the incidence of these preventable diseases in the community [7]. However, two out of every five people lack access to basic hand-washing facilities, mostly in developing countries [8]. This makes it difficult for people to fully adhere to COVID-19 preventative measures like hand washing.
Ethiopia is one of the top five nations in the world for childhood pneumonia and diarrheal disease, with only three out of ten children under the age of five receiving treatment [9]. Keeping in line with the Sustainable Development Goals (SDG), under-five mortality must be reduced by more than half to meet the SDG target [10]. Even though the country has been able to reduce this problem by two-thirds in the past decade, under-five child mortality, which is primarily caused by diarrhea and pneumonia, remains a serious issue in the country [11]. In addition, the ongoing COVID-19 pandemic is expected to worsen the problem. So, this is crucial to the assessment of the actual nature of the damage.
Ethiopia has the most confirmed COVID-19 cases in East Africa (149,689) as of February 2021, with reported COVID-19 cases varying by administrative region [12]. As of February 2022, Addis Ababa had the most COVID-19 cases. In resource-limited countries like Ethiopia, children disproportionately suffered from the pandemic's indirect effects. In a prospective vaccination card review study in northern Ethiopia, age-eligible vaccination coverage among children during the COVID-19 outbreak was 12.5% lower compared to the pre-COVID time [13]. However, no extensive data on the impact of COVID-19 on prevalent childhood diseases such as diarrhea and pneumonia in Ethiopia is available. Here, we have used secondary data (health management information system) collected from health institutions in the country to assess the impact of the COVID-19 pandemic on under-five children's diarrheal disease and pneumonia across different regions. We further investigated monthly trends of diarrhea and pneumonia in the epicenter of COVID-19, Addis Ababa.

Study design
We conducted a retrospective pre-and post-COVID-19 study using health management information system data to assess the impact of COVID-19 on diarrheal and pneumonia diseases treated at health facilities before (March 2019-February 2020) and during the pandemic (March 2020-February 2021).

Study setting
Ethiopia is the second-most populous country in Africa, with an estimated population size of over 115 million in 2021 [14]. The country has ten administrative regions, which are: Tigray, Afar, Amhara, Oromia, Somalia, Sidama, Benishangul-Gumuz, Harari, Gambella, and the Southern Nations, Nationalities, and Peoples' Region (SNNPR), and two city administrations (Addis Ababa and Dire-Dawa). According to the most recent national EDHS (2016), more than a third of the population in Afar, Somalia, SNNPR, and Amhara travel more than 30 minutes round-trip for household water. Only 13% of homes have soap and water for handwashing, 93% of households cook with solid fuel, and only 47% of households have separate cooking buildings [15]. The Ethiopian government had put in place some steps to stop COVID-19 from spreading across the country, including handwashing with soap and water or alcohol-based hand rub and universal mask use ( Table 1).
The Addis Ababa city, Oromia, and Amhara regions reported the majority of COVID-19 cases, while Gambella, Somalia, and Afar reported the least ( Table 2). All regions are included in this analysis, except Tigray, which has been under conflict since November 2020, and Sidamo, which is a newly constituted region Table 1. Hand hygiene and mask use guidelines to prevent COVID-19 in Ethiopia.

Cough hygiene
Universal mask-wearing should be practiced by everyone. The type of mask use is based on the level of risk of acquiring COVID-19.
Material &procedure • Proper mask utilization is any medical, non-medical, respirator, or cloth mask, which covers the nose, mouth, and chin of an individual.
• The public should implement cough hygiene, including covering the mouth during coughing and sneezing with a tissue or flexed elbow.
Hand hygiene Access • It should provide universal access to hand hygiene facilities in front of public buildings and transport hubs-such as markets, shops, places of worship, schools, and train or bus stations Material and procedure • Hands with visible dirt should be washed with soap and water for 40-60 seconds.

Study population, inclusion, and exclusion criteria
All under-five children who were treated for acute diarrheal diseases and pneumonia in the health facilities during the study periods were the study population. Children with missing information including child age, months, and/or year of treatment were excluded from the study.

Data source and variables
We used data generated from the National Health Management District Health Information System (DHIS2 HMIS) between March 2019 and February 2021. We included data on the Hospital/Clinic Monthly Service Delivery Report based on the priorities of the Plan for Accelerated and Sustained Development to end poverty. We divided the data into two periods: the COVID-19 era (March 2020 to February 2021 and above) and the Pre-COVID-19 era (March 2019 to February 2020). We collected data based on the national DHIS2 HIMs indicators for diarrheal disease and pneumonia reported every month. Specifically, we extracted data that included a year of study(months), years, region, total pneumonia cases, and total diarrheal cases treated using oral rehydration solution with or without Zinc. The proportion of underfive children treated for diarrhea and pneumonia during the COVID-19 and pre-COVID-19 periods was the outcome variable studied.

Operational definitions
Diarrhea: defined as three or more loose or liquid stools per day (or more frequent passage than is normal for the individual). When diarrhea lasts less than 14 days, it is referred to as acute, and when it lasts more than 14 days, it is referred to as chronic or persistent [16]. Pneumonia: is defined as an infection of one or both of the lungs caused by bacteria, viruses, or fungi [17].

Data analysis, sources of data, and data collection
We used Stata (ver. 16) software to analyze the data [18]. We used descriptive analysis to describe the counts across the regions. Between the COVID-19 and pre-COVID-19 eras, we compared the rate of pneumonia and diarrhea cases treated in health facilities, the difference across the administrative regions, and study months. We used poison regression to estimate the difference between the COVID-19 era and the pre-COVID-19 period per month. In Poisson regression, we adjusted for the month. A 95% confidence interval (CI) with a level of significance set at 5% (P <0.05) was considered.

Ethical considerations
Since this was a secondary data analysis based on an existing database, a waiver of written informed consent from participants was obtained. This resulted in a reduction of 326,079 instances (9.9%, CI (6.3-17.6) reduction, p<0.001). Table 3 shows the total number of instances recorded across the administrative region.

National level: Pattern of pneumonia and diarrheal diseases
During the COVID-19 era, there was a 15% reduction in under-five children treated for pneumonia at health facilities (rate ratio = 0.85, p<0.001) compared to pre-COVID-19(244,882 versus 2089542). From June to October, we found the highest decline in pneumonia cases (Fig 1).
In under-five children with acute diarrhea treated at health facilities throughout the COVID-19 era, there was a 10% reduction (328,850 versus 296,1771) in comparison to pre-

Regional level: Pattern pneumonia and diarrheal diseases
During the COVID-19 period, the trend of pneumonia and diarrhea disease among under-five children decreased in most regions. During the COVID-19 era, pneumonia declined in seven of the 12 regions studied, ranging from 3% in SNNPR to 54.2% in Addis Ababa city. Acute diarrhea disease also decreased, with rates from 3.5%in Amhara to 45% in Harer during the COVID-19 era (Fig 3).   previous study (19)).
Pneumonia and acute diarrhea diseases increased during the COVID-19 era compared to the pre-COVID-19 period in the remaining three regions, namely Somalia, Gambela, and Afar. Pneumonia cases increased from 1% in Afar to 10% in Gambela, and acute diarrhea disease increased from 23.3% in Somalia to 29% in Afar (Fig 4).

Addis Ababa level: Pattern pneumonia and diarrheal diseases
During the COVID-19 era, we found that the number of under-five children treated at health institutions for pneumonia reduced by 54% (50773 vs 17885) (rate ratio = 0.46 p0.001). When compared to the pre-COVID-19 months, the average monthly reported cases of pneumonia was reduced by more than half from April to December 2020 (Fig 5).
During the same study period, diarrheal diseases treated during COVID-19 periods decreased by 37.3% (108240 versus 61456) (rate ratio = 0.627 p<0.001). Between April and August 2020, the average monthly reported cases of diarrheal diseases decreased by more than 50% compared to the pre-COVID-19 months (Fig 6).

Discussion
This study summarizes the evidence on the impact of COVID-19 on pneumonia and acute diarrheal diseases under-five children who were treated in Ethiopian healthcare facilities during COVID-19. The findings reveal a reduction in the number of diseases in under-five children treated at health facilities for pneumonia and acute diarrheal diseases over the COVID-19 period, with differences across the country's administrative regions.
This study found that during the COVID-19 period (March 2020-February 2021), there was a significant reduction in cases of pneumonia and acute diarrheal diseases treated at health

Rate of increase of pneumonia and acute diarrheal disease across different administrative regions among under-five children during the study periods (Base layer map is adapted from a previous study (19)).
https://doi.org/10.1371/journal.pgph.0000304.g004 facilities at the national level. Considering the bright side, a decrease in the incidence of these preventable diseases had a significant impact on reducing the mortality rate among under-five children. On the other hand, COVID-19's indirect effects, which are linked to poor access to health services, are expected to account for 40% of all additional child deaths globally [19]. In Ethiopia, particularly during the first six months of the pandemic, there was widespread public fear of contracting the disease from healthcare facilities, resulting in a reduction in the number of people seeking medical attention. Parents may be forced to care for their sick children at home as a result of these circumstances. For example, pneumonia significantly dropped more than diarrhea, indicating that the family is worried about COVID-19-related cough and may keep the baby at home. A previous study in Ethiopia found a 35% decline in under-five children's services [20], and a significant drop in the use of reproductive, maternal, and newborn healthcare services [21]. COVID-19 has been shown to have an effect in previous studies, with 30% and 36% reductions in Sierra Leone and South Africa, respectively [22,23]. The COVID-19 pandemic could compromise vaccine delivery among under-five children, with an estimated 80 million children globally affected by disrupted immunization services and campaigns [24]. Ethiopia, which already has a low vaccine coverage rate [25], could have been affected by the pandemic. For example, the coverage of the first dose of pentavalent vaccines was lowered in two recent studies undertaken in the country during the pandemic period, one evaluating age-eligible vaccination coverage [26] and the other evaluating the first dose of pentavalent vaccine coverage [27]. As a result, vaccine-preventable illnesses in children, such as pneumonia and diarrhea, intensify during the COVID-19 period. During the pandemic, community members are encouraged to wash their hands with soap and wear masks, which helps to reduce the spread of diarrheal diseases [28] and respiratory infections, respectively [29,30]. However, in Ethiopia, 43% of the rural population lacks access to improved sources of clean water, making regular hand-washing practices difficult during COVID-19 [31]. Furthermore, investigations conducted during COVID-19 revealed decreased adherence to the COVID-19 preventive actions that were advised [32-34]. Given the aforementioned factors and challenges, the decrease in pneumonia and diarrhea we observed could be due to the pandemic's indirect detrimental impact. This has a long-term negative impact on children's well-being, as well as reversing hard-won progress in achieving SDG 3.2 targets [35]. This highlights the importance of reducing COVID-19's detrimental impact on children and achieving universal health coverage targets for child health services post-pandemic period.
We found considerable regional disparities in pneumonia and diarrhea disease among under-five children treated at health facilities across administrative regions during COVID-19. We found an increased report of these diseases in the Gambella, Somalia, and Afar regions. These regions are predominantly pastoralist (85%), with most people living in hard-to-reach/ remote areas facing developmental inequities. According to the most recent Ethiopia Demographic and Health Survey (2016), more than two-thirds of people in Afar and Somalia found it difficult to find water sources for their households, and less than 1.4% of the population in these regions possessed soap and water for hand hygiene [36]. Previous research found that areas with limited access to water and sanitation facilities have been disproportionately affected by diarrhea and pneumonia diseases; conditions that could have been avoided if effective hygiene had been implemented [37]. In the previous two years, the Ministry of Health, in partnership with regional health, has opened over ten new health posts and trained a large number of health professionals and health extension workers [38]. The first incidence of COVID-19 was found in each of the three regions within a month following the national report, and they were listed as the country's least three COVID-19 reporting regions [39]. As a result, preventive measures such as hand washing and universal making may not be practiced regularly in these areas. Therefore, the pattern of childhood preventive diseases, such as acute diarrheal disease and pneumonia, was unaffected and continued to rise, as seen in the pre-COVID-19 years.
Since the first few COVID-19 cases were reported in Ethiopia, Addis Ababa has accounted for the vast majority of COVID-19 cases (up to 90%) [40]. As a result, the city is expected to see the greatest impact of the pandemic on crucial health care. During the COVID-19 period, we found a significant reduction in the number of under-five children treated for diarrheal disease and pneumonia in the city. In Addis Ababa, access to safe drinking water and deprivation rates in access to a safe source of drinking water and solid waste disposal are near zero, in stark contrast to the rest of the country [15]. Furthermore, because the city is the epicenter of the pandemic, COVID-19 preventive methods such as handwashing with soap or alcohol-based hand rub and community mask-wearing have been heavily promoted. It appears logical that the most impacted area will be given priority in terms of implementing preventive actions to contain the infection in that area and concomitantly affect the pattern (negatively or positively) of acute diarrheal and pneumonia among under five-year children [41].
This study attempted to understand the impact of COVID-19 on preventable childhood illnesses by using large sample size, multicenter data, and a comparative analysis of routine data to reveal the national picture. However, we were unable to determine individual socio-demographic variables and COVID-19 public health preventative interventions on acute diarrheal disease and pneumonia, as well as trends because we employed aggregated data. In addition, more research is needed to determine if the reduction of these acute illnesses among underfive children is a negative or positive effect of COVID-19 in the areas.
In conclusion, the result of this study revealed that COVID-19 has an effect on common acute illnesses among under-five children. To address these challenges, the SDG program should promptly adjust to the new normal, bolstering the patient-centered approach to child care and community-based child care to reach individuals who have not attended health facilities.
Personal and environmental hygiene practices like hand washing with soap and water, wearing a mask, and alcohol hand rubbing are the main preventive measures against COVID-19 infection. These activities also are important to prevent and control acute diarrheal diseases and pneumonia. To maintain the progress made in achieving the millennium development goal of reducing under-five child mortality over the past ten years and achieving the SDG targets in the country, these measures must be implemented consistently over the post-COVID-19 era.