ETHIOPIAN JOURNAL OF

PEDIATRICS AND CHILD

HEALTH

July 2011, Volume VII, Number 7

Original articles Pursuance of Quality Child Survival, Development, and Wellbeing Strategic Re- directions in

settings such as the Contemporary Ethiopia

Mullugeta Betre Gebremariam (MD, MPH)

Antiretroviral Related adverse drug reactions among HIV-1 infected children on first line

regimen at Tikur Anbesa Specialized Hospital, Addis Ababa-Ethiopia.

Anteneh.A MD , Amha M ekasha MD , Endale. T, MD, Wubegzier.M BSC

Measles outbreak investigation in west Hararghie zone of Oromia region, Ethiopia, 2007

Kassahun Mitik. , MD, MPH , Wendemagegn Kegne ,MD,MPH

Assessment of knowledge, Attitude, and Practice about immediate newborn care among health

care providers in Addis Ababa Public Health Centers

Meseret Tesfaye Wondafrash Alemaya University

Case Report

Atnafu Mekonnen , MD

Notes for contributors Acknowledgments

Ethiopian Pediatric Society Tele: 251-011-860-28-43

E-mail: eps@ethionet.et P.O. Box- 14205

Addis Ababa, Ethiopia

Ethiopian Journal of Pediatrics and Child Health The official organ of Ethiopian Pediatric Society

Tel-251-01-860-28-43 E-mail eps@ethionet.et / eps_2011@yahoo.com

Addis Ababa Ethiopia

The Ethiopian Journal of Pediatrics and Child Health aims to contribute towards the

improvement of child health in developing countries, particularly in Ethiopia. The journal

publishes original articles, reviews, case reports pertaining to health problems of children.

Editorial board Bogale Worku ,Prof Editor-in-chief

Amha Mekasha, MD, Msc

Kassahun Mitiku, MD

Sirak Hialu, MD

Table of contents Original articles Pursuance of Quality Child Survival, Development, and Wellbeing Strategic Re- directions in

settings such as the Contemporary Ethiopia --------------------------------------------

Mullugeta Betre Gebremariam (MD, MPH)

Antiretroviral Related adverse drug reactions among HIV-1 infected children on first line

regimen at Tikur Anbesa Specialized Hospital, Addis Ababa-Ethiopia.---------------

Anteneh.A MD , Amha M ekasha MD , Endale. T, MD, Wubegzier.M BSC

Measles outbreak investigation in west Hararghie zone of Oromia region, Ethiopia, 2007 --------

Kassahun Mitik. , MD, MPH , Wendemagegn Kegne ,MD,MPH

Assessment of knowledge, Attitude, and Practice about immediate newborn care among health

care providers in Addis Ababa Public Health Centers ----------------------------------------

Meseret Tesfaye Wondafrash Alemaya University

Case Report --------------------------------------------------------------------------------------------

Atnafu Mekonnen , MD

Notes for contributors --------------------------------------------------------------------------------------------- Acknowledgments --------------------------------------------------------------------------------------------------

Pursuance of Quality Child Survival, Development, and Wellbeing Strategic Re-directions

in settings such as the Contemporary Ethiopia

Mulugeta Betre Gebremariam (MD, MPH)

Abstract

This article draws balanced attention of Academicians, Researchers, Service Providers,

Program Managers, and Policy Makers together with all the other broader arrays of

stakeholders of Pediatrics and Child Health, within Ethiopia and around the globe, towards

concerted pursuance of Quality Child Survival, Development, and Wellbeing Strategic

Redirections agenda.

To this effect, through a systematic review discourse, the article does concisely discuss the

background contexts of Child Health and Child Survival Movement, value additions of the global

Child Survival endeavoring, inherent limitations of the conventional Child Survival movement,

moral grounding of the Quality Child Survival, Development, and Wellbeing Strategic

Redirections, anticipated comparative benefits, and proposed essential considerations. The

review had focused on and drawn from the set of selectively pertinent published and unpublished

resource materials.

By spotlighting and thus stimulating the necessary level of dialogue around the theme among all

the ranges of key players and stakeholders, this piece of work attempts to complement further

reinvigorating of the Child Health, Development, and Wellbeing policy, program and service

development dynamics, particularly, in settings similar with that of the contemporary Ethiopia.

Presumably plausible pathways of pursuance are highlighted.

Key words: Child Health, Child Survival,

Child Development, Quality Child Survival

and Development, Child Wellbeing, etc.

Brief background of child health and

global child survival movement

(“revolution)

Progressive improvement of the quality of

health and wellbeing of the child is going to

remain one of the lifetime priority agendas

of human beings of all races. In this respect,

successively global, regional and local level

child health care initiatives have been

entertained, particularly, during the 20th

and

21st centuries (1-8). One of these initiatives

is the Child Survival Strategic Programming

(2, 3, 6-8). In fact, it was not uncommon to

read about the particular strategy as a global

“Child Survival and Development

Revolution (CSDR)” already since the early

1980s and onward (9, 10). The Child

Survival Strategy has been further endorsed

making the essential component of the

Millennium Development Goals (MDGs) of

the Millennium Declaration Summit (11).

The Millennium Development Goals

together with the correspondingly specified

set of targets and indicators are seen

relatively comprehensive and broadly

rallying milestones (6, 11). Accordingly,

paces of implementation, coverage and

improvement child and maternal survival, in

particular, have been streamlined with the

launch of Countdown 2015 (12).

At the same time, however, we really have

been witnessing dynamic conceptual

transitioning from the merely “Child

Survival”, “MDG4”, “etc.” calls (2, 3, 6-8,

11) to a a more broader perspectives of “A

World Fit to Children” resolution (13, 14).

Contemporary individuals and states alike

are being charged with and hence challenged

to fulfilling this global promise. It means

that concrete programmatic translation of

the quoted aspirations, principles and

declarations are essentially desired simply

because every child „demands‟ optimal adult

action no later than now.

Important value additions of the global

child survival movement (“revolution”)

Undoubtedly, averting and reducing of

mortalities at the earliest possible timing

along the lifecycle is legitimate and

foundational. In this particular respect, the

accomplishments globally over the years

have been steadily encouraging (Figure 1).

Mortality decline patterns and trends have

been progressively favorable if yet not

optimal. Again, although not evenly enough

across all of the countries, under-five, infant

and neonatal mortality rates have been

declining, including among the high burden

countries in Africa since 1990 (2, 12, 17-

18). On aggregate, globally, it was possible

to reduce from an estimated 15 million in

1980 to 8.8 million in 2009/10 of the under-

five death occurrence. Despite the lagging

and/or slow progress, and still, consistent

features have been prevailing for Ethiopia

over these decades (Figure 2) (2, 12, 15-17).

Therefore, mortality reduction contributions

of the Child Survival movement remain

undisputable. Moreover, the Child Survival

movement has been highly instrumental in

garnering and consolidation of broader

collaboration and partnerships mechanisms

among diversity of players and stakeholders

around child health in general. Growth

monitoring, oral rehydration, breastfeeding,

immunization (GOBI), expanded

programme of immunization, (EPI), baby

friendly hospital/health facility initiative

(BFHI), global alliance for vaccine initiative

(GAVI), integrated management of

(maternal) newborn and childhood illnesses

(I[M]MNCI), partnership for maternal,

newborn and child health (PMNCH), etc are

just few of the examples (2,12,17-18).

However, unless properly re-oriented and

consolidated, the scale of focus on Survival

per se may tend to somehow undermine

other important dimensions and most

importantly around effectively addressing

the quality of child survival and

development.

Inherent limitations of the global as well as

the national child survival movement

(“revolution”)

With all the recognition of its advantages

and successes, the Child Survival Strategy

cannot escape some criticisms. As important

as it is, however, mortality reduction on its

own is just one piece along the whole

equation of survival and wellness (3-5, 18-

19, 21). Quality of survival, development

and wellness will continue surfacing

considerably extent to the indefinite future

(10, 13-14, 18-22). For instance, even with

the notions of “essential” and “maximum”

packaging of interventional approaches (6)

apparently embedded, and still, the greater

emphasis has been on mortality reduction in

connection to which several dimensions of

quality of child survival, development, and

wellness have been destined to receiving

relatively insignificant attention by all the

concerned at all levels. Moreover, with the

emergence and consolidation of the broad-

based and widely cross-cutting “Health

Promotion” ever since the mid-1980s

already (20), the quest for the advancement

of holistic quality child survival,

development and wellness must bear

overarching legitimacy of paramount

importance with ultimate far-reaching

dividends. Pursuance of quality of health

and development perspective may as well be

an effective avenue in respect to addressing

the prevailing equity gaps. At the same time,

bridging the quality gap is going to remain a

timeless demand.

Suffice to simply cite the following vivid

illustrative example on why we need to exert

concerted and sustained effort on optimal or

quality child health (survival), development

and wellness. Due to ranges of

developmental risk factors involved during

the under-five years of age alone, on top of

the nearly 9 million deaths, we still have up

to 200 million more children (Figure 3),

largely in developing countries, which have

not been able to attain their potentials

annually given the current mode as well as

state of survival interventions (19, 21). As

very clearly depicted in Figure 3, several

Sub-Saharan African countries, including

Ethiopia, are among the highest child risk

burden countries of the world. This huge

level of estimate should warrant greatest

interest of all. There is a lot to learn from

compellingly illustrative study of the

Guatemala example on how long-term

socio-economic may be adversely affected

due to poor quality of survival which had

gotten compounded by multiple early

childhood risks (Figure 4).

In connection, seriously intriguing queries

such as “but what kind of survival, why and

so forth?” are supposed to become of main

logical interests. Partly, as also, such kinds

of queries may get generated due to the

incremental demand equation nature of

human beings. At the very least, with the

very rigorous increase of access and

coverage to child survival, presumably the

demand to quality will ultimately grow.

On the other hand, whether dictated by

resource availability, accountability‟s sake,

or any other reasons, the conventional Child

Survival programming IMNCI included had

often ended up with relatively disease-

driven, isolated, narrowly short-termed,

partial and sub-optimally flexible outlooks,

structures and tools (4-5,10, 18). Also, over

the years it has been becoming more and

more apparent that the whole array of child

health matters being simply equated to

nothing else other than the mere under-five

childhood survival issues and, as a matter of

fact, even by health professionals (4-5, 10).

Another inherent shortcoming of child

survival could have been inadvertent

underestimation of national potentials (5,

17-18). Often several of the initiatives have

been externally and/or medical technology

driven and not system oriented for quite

long. Again, in connection, there have been

seriously gray areas prevailing around

making critical balance between “project” vs

“program” with potential susceptibility to

the cycle of unjustified “dependency” (3, 5,

10, 17). In contrast, over the recent years,

we have been witnessing what it really

would mean about the shift in favor of

concerted national leadership, social

mobilization and system-wide approaches,

including systems strengthening in particular

(16-18), again, lending important lessons

towards further boosting the pursuance of

quality child health and development

strategizing in settings such as the

contemporary Ethiopia.

Therefore, in order for survival to become

increasingly and rightfully rewarding to both

the individual and to the larger society

(nation), it is highly desirable to minimize

all forms of risks to disability and to

impaired functional ability along the

lifespan continuum. Otherwise, for each of

the under-five childhood mortality that

could have been averted, we may still end

up with hundreds and even thousands of

disabilities cumulating (19)

Premises of the moral grounding,

timeliness and comparative benefits of the

strategic re-direction for quality child

survival, development, wellbeing in settings

such as the contemporary Ethiopia

A contemporary developing country such as

Ethiopia is expected to catch up and then

remain solidly competitive practically in all

dimensions in to the future, including in the

health sector and more particularly in

respect to the health and well-being of the

generations to come. In order to result in

real qualitative, substantive, and sustainable

difference, therefore, “the business as usual”

paradigm of the institutional, together with

the programmatic, framework of any given

setting had to get constantly challenged and

„modernized‟ or transformed. Also, access,

coverage and quality should not be matters

of one after the other logical sequencing but

should rather become foundationally and

cohesively concomitant and synergistic in-

built instrumentation to each other‟s

complementarities and best (maximal)

effects.

Generally, again, the re-focus on quality

child survival, development, and wellbeing

pursuance can be viewed soundly consistent

with all other important initiatives such as

quality education, quality products, quality

services, etc. Notwithstanding the favorably

promising patterns and trends of the poly-

sectoral growth and development dynamics

in ranges of developing countries, including

contemporary Ethiopia, it practically will be

impossible to soundly as well as sustainably

realize the national vision and the

corresponding goals without properly

ensuring quality survival, development, and

wellbeing of young people. The notions

such as: “A World Fit for Children” (13) and

the “Convention on the Right of the Child

(14), essentially, will mean to propagate this

very re-direction.

In a nutshell, it simply means that whatever

kind of initiative we are implementing,

pursuance of quality child survival,

development, and wellbeing perspective will

occupy the center most stage and thus

everything that we are doing will meet

highest quality of standards. Whilst stated

simply, at the same time, we do recognize

well that it has got diversity of moral and

system-wide commitment implications.

On the other hand, for some of us,

emphasizing on quality child survival,

development, and wellbeing strategic

redirection might sound a miss focus and a

miss prioritization. We bet it is by no means.

First and foremost, it may just be the case

that some of us at this particular time may

find ourselves challenged to properly

addressing these kinds of prevailing

misconceptions or misperceptions.

Secondly, “priority” setting and

“prioritization”, essentially, should mean

properly tailoring and targeting but never

undermining one or the other aspects of the

continuum or spectrum. Thirdly, in the same

notion, it can never be too ambitious, too

undoable, and too early to be able to

institutionalizing increasingly more

farsighted, integrative, of highest quality and

sustainable enough program pathways (13-

14, 18-22). Fourthly, it becomes more of

about striking the right balance between the

short- and long-term benefits (1, 3-5, 13-14,

20). Fifthly, often than rare, for one or

another factoring, there is a very high

temptation and hence tendency to looking

only to the very immediate, partial, quick-fix

and short-term solutions (4, 10, 19). Despite

these kinds of temptations, the glaring truth

is that we can do something tangibly better

in the very light of the available means and

resources to date. We may draw appropriate

lessons from the unprecedented degree of

resource arrays mobilization that has been

dynamically evolving toward facing the

challenges of HIV/AIDS since the early

1980s.

At the very same time, it is equally

important to underscore that such a strategic

re-directional perspective should by no

means be any reasoning to unwarrantedly

compromising the desired level of tailored

prioritization and strategization along the

spectra of quality child survival,

development, and wellbeing continuum.

Rather the approach should be viewed as

logically essential augment and synergistic

pathway of maximization. Furthermore, it

only means all about most rationally

tailoring all the possible investments in the

respective directions for far better rewarding

outcomes.

Therefore, in very light of this discourse,

child health expert academicians,

researchers, program leaders, and policy

makers together with all the concerned

stakeholders in unison are expected to be

constantly conscious of the complexity and

diversity of the child health, development

and wellbeing needs or demands in any

given contemporary society, including

Ethiopia. The periodical national and

international review processes such as the

Health Sector Development Programme

(HSDP) and something at similar scale may

be found important and timely avenues

towards timely as well as viable pursuance.

Coherent strategizing and programming with

clear view of both the short and long term

outcome perspectives cannot be an

overemphasis - Never easy or simple but, by

any standard, very correct, just and rightful

pathway.

Essential considerations toward fairly

holistic, systematic as well as sustainable

advancement of quality child survival,

development, and wellbeing in settings

such as the contemporary Ethiopia

Admittedly this rather simplified and, at the

same time, of paramount discourse will

serve sensible provocations around

generating incrementally evidenced debates

and dialogues for informing dynamic policy

formulation, developing strategies,

designing programmes, and rendering

optimal services at all levels. Accordingly:

1. Institutionalizing systematic inquiry

mechanisms for greater more evidences

and thereby facilitating the advancement

of progressive innovations on quality child

survival, development, and wellbeing as

rightfully inseparable necessity. It,

therefore. is a high time to ensuring

progressively proactive consolidation of

comprehensive Quality Child Survival,

Development, and Wellbeing Agenda

Framework at the respective levels;

2.Reframing comprehensive enough Quality

Child Survival, Development, and

Wellbeing policy, strategic and

programmatic endeavoring with broader

view of “total” societal mobilization,

including effectively harmonizing and

harnessing family, community‟s and

societal level capitals may still be

warranted;

3. Strengthening coordinated, coherent and

systematic investment on comprehensive

Early Childhood Development avenues is

viewed highly promising and timely;

4. Ensuring the necessary degree of

preparedness and readiness toward

maximizing cohesive, optimal and

sustainable use of all the possible ranges

of available expertise so that all the

possible pathways concertedly connected

together are going to effectively as well as

efficiently leading to ever better quality of

health (survival), development and

wellbeing of the child+ cannot be an over

emphasis;

5. Establishing the necessary institutional

frameworks of regular systematic review

and learning for improvement

opportunities is equally timely; systematic

and timely documentation-exchanges of

the pertinent lessons and best practices

within and outside of given country should

help quite a lot;

6.Maximizing for an ever greater expansion

and consolidation of the broader child+

public health (holistic and quality clinical

care inclusive) and social safety or

security schemes will remain a timeless

agenda. In this connection, suffice to

simply highlight that: “Successful societies

safeguard their future by continually

striving to improve the well-being of their

children. They understand that healthy,

well-developed, educated, and respected

progeny ensure that past achievements

serve as the foundation for continuing

progress” (22).

Sub Saharan Africa’s

Figure 1: Sub Saharan Africa‟s Rate of Performance Progress towards MDG4 by 2006/07

(Source: Reference number 17, Opportunities for African Newborns …)

ETHIOPIA’S

Figure 2: Ethiopia‟s MDG4 Performance Progress by 2006/07 (Source: Reference number 17,

Opportunities for Africa Newborns …)

Global Under-Five Children’s Disadvantages Burden Profiling

Figure 3: Percentage of disadvantaged children under five years in year 2004 (Source: Reference

number 21, Sally Grantham-McGregor et al.)

Early Childhood Risk Burden and Performance Potentials

Figure 4: Relationships between risk factors in early childhood in Guatemala children and

achievement scores in adolescence (source: Reference number 19, Susan P. Walker et al.)

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Acknowledgements

The author duly acknowledged the sources of this discourse. Equally, the author is grateful to the

Ethiopian Pediatric Society for all the motivation and support around this piece of work.

The author declares no conflict of interest of what so ever form and there are no other ethical

implications around this piece of work.

ANTIRETROVIRAL RELATED ADVERSE DRUG REACTIONS AMONG HIV-1

INFECTED CHILDREN ON FIRST LINE REGIMEN AT TIKUR ANBESA

SPECIALIZED HOSPITAL, ADDIS ABABA-ETHIOPIA

Anteneh.A (MD, Resident in pediatrics, PI), Amha.M (MD, Pediatrician, Associate professor,

advisor, AAU-MF), Endale.T (MD, Pediatrician, advisor, AAU-MF), Wubegzier.M (Bsc,

AAU-MF)

DEPARTEMENT OF PEDIATRICS AND CHILD HEALTH, TASH, AAU-MEDICAL

FACULTY, ADDIS ABABA-ETHIOPIA

ABSTRACT

Background: ART has brought significant change in morbidity and mortality among children on HAART. However, antiretroviral related adverse drug reactions are one of the leading causes of drug changes, poor adherence and treatment failure.

Objective: To determine the prevalence, severity and time of occurrence of antiretroviral adverse drug reactions among HIV-1 infected children taking HAART at Tikur Anbesa Specialized Hospital.

Methodology: This is a retrospective analytic cohort study conducted in the department of pediatrics and child health. A special questionnaire was designed to collect parameters from follow up charts of patients on HAART.

Results: A total of 1000 children were enrolled and 600 were eligible and started HAART between Jan 2005-Jan 2010. Out of 600 on ART, 25 (4.2%) died, 75 (12.5%) lost, 50 (8.33%) transferred out and 450 (75%) continued ART until the time of data collection. Fifty patients on HAART were having incompletely filled charts and excluded from the study. Total eligible group for the study were 400 children on HAART of which 212(53%) were males and 188(47%) were females. Majority (83%) had started ART with immune category III and most of them were WHO grade III (50%) and IV (32%). The age at the beginning of ART ranges from 8-180 months and 50% of them were in the range of 60-120 months. There was a total of 12% (48/400) of drug changes due to various reasons. ARV related adverse drug reactions were the leading cause of drug change constituting 41.7% (20/48) of total drug changes. Treatment failure 31.25% (15/48), shifting regimen to FDC 16.7% (8/48) and TB treatment 10.4% (5/48) were other common reasons of drug changes. The prevalence of severe anemia (HCT<21%) was 3.13% (10/320) which occurred exclusively among children taking AZT containing regimen. The prevalence of NVP induced skin rash and hepatitis was 3.34% (6/177) and 1.7% (3/177) respectively. Three cases of neuropathy 3.8% (3/79) and two cases of lipo-dystrophy 2.5% (2/79) were recorded in d4T containing regimen. Chronic illness with concomitant non-ARV drug use had strong association with the development of anemia and hepatitis (P-value <0.005). No other predictive factor was found to have statistically significant association with commonly encountered adverse drug reactions.

Conclusion: ARV related adverse drug reactions are the leading causes of drug changes among children on HAART at Tikur Anbesa Specialized Hospital. Skin rash, anemia, hepatitis, neuropathy and dystrophy are the major adverse drug reactions which required drug changes. Severe skin rash ascribed to nevirapine use appeared early in the course of antiretroviral therapy while neuropathy and lipo-dystrophy due to stavudine administration developed late in the course of treatment. In addition, moderate to severe anemia and hepatitis occurred in patients with chronic illness and concomitant non-ARV medications.

Recommendation: Patient counseling regarding signs and symptoms of ARV related adverse drug reaction and time of occurrence is paramount. Early recognition of side effects and timely intervention could lead to reduction of morbidity and poor adherence. Due attention should be paid for children who have chronic illness and concomitant non-ARV medications. Finally, I recommend prospective trial to demonstrate all types of ARV related adverse drug reactions, grade severity, determine time of occurrence and identify risk factors.

Introduction

HIV/AIDS created enormous challenge to

mankind since it‟s recognition in 1981.

Close to 60 million people are infected out

of which about 40 million are living with

HIV/AIDS. There are more than 2.1 million

under 15 children living with HIV/AIDS of

which 90% live in sub-Saharan African

countries (1, 2).

Ethiopia has an estimated population of 77

million people of whom 44% are children

below 15 years. The adult prevalence of

HIV is 7.7% in urban and 0.9% in rural with

average population prevalence of HIV

around 2.1%. The prevalence of HIV in

children is unknown but there are 134,586

children living with HIV/AID and out of

whom more than 67,000 are estimated to be

eligible for ART but only 4863 were taking

HAART as of March 2008 (3, 4).

More than 90% of children acquire the

infection through mother to child HIV

transmission (MTCT). Despite this, only

10% of HIV infected pregnant ladies are

offered any form of prevention of mother to

child HIV transmission (PMTCT) in sub-

Saharan countries (5).

In resource rich settings HAART has

changed the face of Pediatrics AIDS. HIV

infected children now survive to adolescents

and adult hood. In developed and some areas

of developing nations which have already

implemented pediatrics ART, witnessed

significant reduction of HIV associated

childhood morbidity and mortality (6, 7).

Despite this, antiretroviral therapy has

brought its own challenge which is observed

in different age groups since the time of

initiation. Lifelong drug use, pill burden,

stigma and discrimination, adverse drug

reaction and treatment failure are the leading

challenges of HAART. By and large

antiretroviral adverse drug reactions are

major causes of drug discontinuation, drug

changes, poor adherence, dropouts and

treatment failure (8).

There are no data regarding the prevalence

of antiretroviral adverse drug reactions

among children on HAART in Ethiopia.

Some data from developed nations are very

limited and were done in few children (9).

Most data are from adult HIV/AIDS patients

but extrapolation to children is difficult as

the two groups have different drug dynamics

(10).

The Federal HAPCO of Ethiopia has

developed pediatric ART guide line.

Combinations of NNRTIs and NRTIs are

used as a first line antiretroviral therapy in

ART naïve children throughout the country.

AZT, D4T and 3TC are drugs used in NRTI

group while NVP and EFV are drugs in

NNRTI group. Second line options are

combinations of ABC, DDI, boosted LPV/R

and other PIs.

Among first line antiretroviral drugs, several

side effects have been observed in children

taking HAART. NVP taking children have

developed skin rashes of variable degree

within few weeks of therapy while those on

AZT manifested with moderate to severe

anemia. GIT upsets are also frequent and

develop almost in all types of antiretroviral

therapy. In addition, longer duration of

antiretroviral therapy particularly stavudine

(d4T) leads to the development of peripheral

neuropathy and lypodystrophy syndromes in

adolescents (11).

Both adults and children on first line agents

are observed to develop anemia, skin rashes,

hepatitis and peripheral neuropathy. The

occurrence of neuropathy, lipodystrophy and

lactic acidosis are higher in adults than

children (12). Commonly encountered ART

related adverse drug reactions are analyzed

in this study but adverse drug reactions

which are difficult neither to document

clinically nor require expensive laboratory

test and imaging are left unstudied such as

lactic acidosis, hyperlipidemia and other

metabolic complications.

Objectives

General objectives

To determine the prevalence of antiretroviral

adverse drug reactions among children on

first line regimen between Jan 2005- Jan

2010 at Tikur Anbesa Specialized hospital,

department of Pediatrics and child health,

AAU-MF.

Specific objectives

1. To determine the prevalence of different

types of antiretroviral adverse drug

reactions among children on first line

antiretroviral therapy.

2. To assess the severity of adverse drug

reactions by determining the rate of drug

change due to HAART related severe

toxicity.

3. To estimate the average time of

occurrence of specific adverse drug

reactions in children taking HAART.

4. To determine factors associated with the

development of ARV related adverse drug

reactions among children taking HAART.

Operational definitions

Adverse drug reactions: WHO definitions

of an adverse drug reaction is stated as „‟any

response to the drug that is noxious or

unintended and which occurs at doses used

in man for the purpose of prophylaxis,

diagnosis or treatment‟‟.

Drug interaction: Any unwanted drug side

effect resulting from the opposing or

additive effect of two or more drugs taken

together.

Drug change: Drug changes are made for

treatment failure, severe adverse drug

reactions, and drug interactions or due to

other reasons. Drug change in the context of

ART consists of drug substitution or

switching. Total regimen switching from

first line to second line ART is made during

treatment failure. In case of drug

substitution only the offending drug will be

replaced by better alternative especially

when severe adverse effect is observed.

Anemia: A decrement in red blood cell

mass or packed cell volume apparent

clinically as palmar pallor, fatigue,

dizziness, dyspnea and even over congestive

heart failure. It is confirmed by doing HB or

HCT level which is also helpful for grading

of severity. Mild –grade 1 (10-8.5mg/dl),

Moderate of grade 2(7.5- <8.5 mg/dl),

Severe-grade 3(6.5-<7.5 mg/dl) and life

threatening –grade 4(<6.5mg/dl). The

grading is defined based on PACTG.

Peripheral neuropathy: It is clinically

apparent as tingling sensation, pricking pain

over the extremities and even progressive

weakness. Depressed reflexes and loss of

deep sensations can be elicited in late

complication. Electromyography may illicit

axonal degeneration or demylination as a

cause of the peripheral neuropathy.

Hepatitis: It may manifest as unicteric or

icteric hepatitis. Children often have

anorexia, vomiting and right upper quadrant

pain. On physical examination tender

hepatomegaly, jaundice and bleeding

diathesis. Severity is assessed by laboratory

tests especially liver function tests

comprising AST, ALT, BIL, TSP, and

PT/PTT. Based on PACTG grading system

ALT and AST values between 1.25-2.5 X

ULN is mild ( grade 1); 2.6-5.0 X UNL

moderate(grade 2);5.1-10.0 X UNL severe (

grade 3) and >10 X UNL life threatening

(grade 4). Hepatitis can occur along with

skin rash as a hypersensitivity syndrome in

early phase of ART or it may occur along

with lactic acidosis as hepatic steatosis in

late stages of ART due to mitochondrial

toxicity.

Skin rash: It is the appearance of urticarial,

maculopapular or vesicular generalized itchy

lesions on the average within 8 weeks of

ART initiation. The rash is also graded for

management purpose as follow as. Grade 1

(mild) cases are localized macular or

urticarial rash, Grade 2(moderate) lesions

are diffuse macular, maculopapular or

morbilli form rashes or target lesions,

Grade 3 (severe) lesions characterized by

diffuse macular, maculopapular or morbilli

form rash accompanied with limited number

of vesicles or bullae or superficial

ulcerations, Grade 4 life threatening bulous

lesions like SJS and TEN.

Toxicity Management: - Management

depends on the degree of toxicity. In general

Grade 1 and Grade 2 toxicities are

managed with supportive care. Grade 3

toxicities require substitution of the

offending drug whereas Grade 4 toxicities

necessitate whole regimen discontinuation

and re- initiation of adjusted regimen after

the acute toxicity has subsided.

Prevalence of ARV related adverse

reaction: is defined as the proportion of

specific ARV adverse drug reactions

developed among children taking ART

regimen containing the incriminated ARV

drug.

Chronic illness: An illness which has

occurred more than three months prior to the

time of data collection and includes

Tuberculosis, cardiac, renal, neurologic,

endocrine and other organic disorders.

Treatment failure: Based on WHO guide

line, it is the development of new

opportunistic infection with a decline in

CD4 count after 24 weeks of HAART

considering clinical and immunologic

criteria.

Malnutrition: Based on NCHS, it is defined

as moderate (-3< Z score <-2) and severe (Z

score < -3). Wasting (Wt/Ht), stunting

(HT/age) and underweight (Wt/age) are

graded based on NCHS classification.

Materials and Methods

Study area: The study was conducted in the

department of pediatrics and child health,

Addis Ababa University –Medical faculty.

The department has three outpatient

pediatric clinics, one emergency room, one

pediatric ICU, one neonatal ICU, three in

patient wards comprising 120 beds and more

than eight subspecialty clinics. Pediatric

infectious disease clinic is one of the leading

overburden subspeicalilty clinics where

HIV/AIDS children are enrolled and

followed regularly. There are nearly 1000

HIV-1 infected children enrolled since 2004

out of which more than 600 children were

eligible and started on HAART by the end

of 2009.

Source population: There were a total of

1000 cases of children registered in

pediatrics ART clinic. Out of which 600

cases have been eligible and started on ART

between Jan 2005-Jan 2010. Among six

hundred cases, 450 children were still taking

HAART, 25 died, 75 lost to follow up, 50

transferred out by the time of data

collection.

Study subjects: Charts of 400 patients on

HAART were eligible in the study as it

contains completely filled documents.

Study design: A retrospective analytic study

was made from follow up charts of children

taking HAART of variable period in

pediatrics ART clinic. Data were collected

from each patient record chart using a

questionnaire which contains important

parameters. Important variables recorded

include: age, sex, CD4 count, weight,

height, ART regimen, treatment for TB,

chronic illness, immune status, concomitant

drug use and WHO clinical stage.

Documented HAART related adverse drug

reactions including the time of occurrence,

degree of severity and requirement for drug

changes were also included in the record

format.

Assessment was made for prevalence,

severity, time of occurrence and associated

factors for the development of HAART

related side effects over a period of

treatment. Results were compared with each

antiretroviral regimen group. In addition

analysis was made to evaluate statistical

significance of independent variables on the

occurrence of adverse drug reaction.

Inclusion criteria: A total of 400 cases on

ART were included in the study as all bear

completely filled parameters in the record

format.

Exclusion criteria: Exclusion was made

for cases whose charts were incompletely

filled, died, lost to follow up, transferred in

and transferred out to other facilities.

Data entry and processing: EPI info soft

ware was used for data entry and analysis of

anthropometry pre and post HAART. Data

was directly transferred to SPSS version 17

for calculations of important parameters,

significance testing and data output in

graphs and tables.

Variables of the study: Dependant

variables include anemia, skin rash,

hepatitis, neuropathy and lipodystrophy.

Independent/predictor variables include:

base line age, sex, immune category, WHO

clinical stage, chronic illness, base line CD4

count and duration of therapy.

Statistical methods: Risk factor

determinations for association of predictors

and dependant variables have been

compared using logistic regression and chi-

square tests. Relative risk, odds ratio and

paired-t tests were also used to compare

statistically significant associations (P-value

<0.05).

Ethical consideration: The research was

approved by the department of pediatrics

research committee and institutional review

board of medical faculty (IRB), AAU-MF.

Results

There were a total of 1000 children enrolled

since 2004 in pediatrics ART clinic out of

whom 600 started on HAART between Jan

2005-Jan 2010. Out of 600 children on

HAART, 25 died (4.2%), 75 lost to follow

up (12.5%), 50 transferred out to other

facilities (8.3%) and 450 (75%)

continued ART until the time of data

collection (Jan 2010). A total of 400

children on ART whose charts had complete

data were included in the study while 50

cases dropped due to incomplete data. Males

constitute 53% (212/400) while females

contribute 47% (188/400).

The minimum age at the start of ART was 8

months and the highest being 180 months

(inter quartile range 60-120 years). Those

who were started at the age of less than 12

months constitute the least number 4%

(16/400) and those who started treatment

between 60-120 months were by far the

largest 46.5% (186/400).

The average duration of antiretroviral

therapy was 37 months and ranged from 2-

68 months. Majority of patients took ART

for a longer period (60% took ART for more

than 36 months) and there was a drop in rate

of ART initiation in recent years. For

instance proportion of children who took

ART < 12 months, 12-24 months, 24-36

months, 36-48 months and > 48 months

were 6.8% (28/400), 13% (53/400), 19.8%

(81/400), 31.1% (127/400) and 29%

(120/400) respectively.

Majority of patients (83.25%), were immune

category III at base line, 15.25% were

immune category II and 1.5% had immune

category I. In addition, base line WHO

clinical stages II, III and IV were 15.5%,

50.5% and 32.25% respectively. Base line

CD4 count ranged from 2-2203 c/ml with

inter quartile range of 129-370 c/ml and

average CD4 count of 275 c/ml.

After an average of 37 months of HAART,

82.25% were immune category I, 12.5%

immune category II and 5.25% were

immune category III. The CD4 count has

also increased to average count of 645 c/ml

and ranged from 42-2309 c/ml with inter

quartile range of 429-804 c/ml.

Using paired t-test the mean of CD4 count

pre and post HAART was compared. The

result is a statistically significant value with

mean CD4 count difference of 365, 95% CI

(334.46-396.88); P-value <0.005.

Tuberculosis diagnosis and treatment was

made in 48% (193/400) of children before

the initiation of HAART. However, after

antiretroviral therapy was initiated only

3.5% (14/400) cases diagnosed and treated

for tuberculosis showing a 92% decline in

rate of infection.

Majority have been on cotrimoxazole

prophylaxis 98% (398/400) at base line

which was discontinued in 30% of cases

(120/400) after adequate immune

reconstitution (CD4>25%) following ART.

There were four (1%) recorded cases of

severe cotrimoxazole allergy and the drug

was substituted by doxycycline.

NRTI group proportion at base line

revealed that AZT containing regimen was

prescribed for 317 children (79.25%) and

d4T containing regimen constitute 19.75%

(79/400). Four cases, 1% were taking

boosted lopinavir (LPV/r) containing

regimen due to prior PMTCT exposure.

NNRTIs group at base line showed that

44.25% (177/400) were taking NVP

containing regimen while 54.75% (219/400)

were on EFV containing regimen.

There were a total of 33 (8.25%) cases with

documented chronic illness including new

development of tuberculosis. New onset

tuberculosis, acquired cardiac illnesses,

chronic kidney disease, seizure disorder,

developmental delay and chronic otitis

media were among the frequently registered

chronic illnesses.

Table 1: Base line values of children before HAART initiation; department of Pediatrics,

AAU-MF, Jan 2010

Base line value Category Male Female TOTAL Percentage

Sex 212 188 400

Base line Age <12 months 6 10 16 4%

12-60 months 72 48 120 30%

60-120 months 93 93 186 46.5%

>120 months 41 37 78 19.5%

Total 212 188 400 100%

Immune

Category

(CD4

Percentage)

>25% (Category I) 4 2 6 1.5%

15-25% (Category II) 33 28 61 15.3%

<15% ( Category III) 175 158 333 83.3%

Total 212 188 400 100%

CD4 count in

c/ml

<200 99 89 188 47%

200-350 53 49 102 25.5%

350-500 37 27 64 16%

=>500 23 23 46 11.5%

Total 212 188 400 100%

Base line anthropometric data showed that

total cases wasted were 9.25%, moderate

and severe wasting being 6.25% and 2.75%

respectively. In addition moderate stunting

at base line was 26.1% (107/400) and severe

stunting was 30.6% (126/400) with total of

stunting being 56.7%. In general 51%

(204/400) were underweight before the start

of antiretroviral therapy. The average base

line Z score value of underweight, stunting

and wasting was -1.88, -2.17 and 0.94

respectively.

After the initiation of antiretroviral therapy,

there was a decrement in the rate of

malnutrition. Moderate wasting was 4%

(16/400) and no severe wasting recorded.

The overall underweight rate was 38.5%

(157/400). Total cases stunted were 45.1%,

moderate and severe stunting being 18.5%

and 26.6% respectively. Moreover, the

average Z score value of underweight,

stunting and wasting has increased to -1.51,

-1.73 and 4.33 respectively.

The improvement of underweight, stunting

and wasting after antiretroviral therapy

showed statistically significant changes

using paired T-test. For instance the average

wasting pre and post HAART showed

statistically significant improvements with

the average mean difference of wasting

being 3.39, 95% CI (2.89-3.88), P-value <

0.005. Likewise average mean difference of

stunting was 0.44, 95% CI (0.25-0.63), P-

value <0.005 and average mean difference

of underweight was 0.38 95% CI (0.245-

0.522), P-value <0.005.

Stunting Moderate to severe 120 113 233 56.7%

Wasted Moderate to severe 21 15 37 9.25%

Underweight Moderate to severe 114 90 204 51%

ART regimen D4T +3TC+NVP 29 24 53 13.3%

D4T+3TC+EFV 14 12 26 6.4%

AZT+3TC+NVP 58 66 124 31%

AZT+3TC+EFV 110 83 193 48.3%

LPV/r+3TC+D4T/AZT 1 3 4 1%

Total 212 188 400 100%

TB before

HAART

YES 104 89 193 48.2%

NO 108 99 207 51.8%

Total 212 188 400 100%

Cotrimoxazole

prophylaxis

Yes 205 187 392 98%

No 7 1 8 2%

Total 212 188 400 100%

Chronic illness Yes 15 18 33 8.2%

No 197 170 367 91.8%

Total 212 188 400 100%

Paired t-test comparing pre and post HAART stunting

Paired Differences

t df

Sig. (2-

tailed)

Mean

Std.

Deviation

Std.

Error

Mean

95% Confidence

Interval of the

Difference

Lower Upper

Pair 1 haz_cur -

haz_base .44320 1.95789 .09669 .25312 .63327 4.584 409 .000

There were a total of 15 (3.5%) treatment

failures out of 4OO children on HAART.

The large proportion of children who failed

antiretroviral therapy were Males 80%

(12/15) while (20% 3/15) were Females.

Rate of treatment failure in NVP containing

regimen was 5.65% (10/177) while on EFV

containing regimen was 1.8% (4/219).

Moreover, treatment failure in AZT group

was 4.3% (14/319) while in d4T regimen

was 1.3% (1/79).

The average time of drug switch to second

line regimen due to treatment failure was 49

months and ranged from 30-59 months. No

significant antiretroviral related adverse

drug reactions occurred prior to the

diagnosis of first line treatment failure.

Moreover, there were no reasonable prior

drug changes made in patients who failed

first line antiretroviral therapy. There were

more cases of treatment failure 9.1% (3/33)

among patients who have concomitant

chronic illness compared with 3.3%

(12/367) patients without accompanying

chronic illness though statistically

significant association is lacking. Otherwise,

there was equal proportion of treatment

failure in different age groups except infants

in whom no failure was recorded. Moreover,

no marked difference was noted between the

development of treatment failure and WHO

clinical staging or immune category at

baseline.

Table 2: Profile of children after antiretroviral therapy, department of Pediatrics, Jan 2010

Profile after ART Category Male Female Total Percentage

CD4 count <200 9 9 18 4.5%

200-350 29 21 50 12.5%

350-500 42 33 75 18.8%

>500 132 125 257 64.3%

Total 212 188 400 100%

Immune

category

Category I 174 155 329 82.25%

Category II 26 24 50 12.5%

Category III 12 9 21 5.5%

Total 212 188 400 100%

Stunting Moderate to severe 95 90 185 45.1%

Wasted Moderate to severe 12 4 16 4%

Underweight Moderate to severe 93 61 154 38.5%

Treatment

failure

Yes 12 3 15 3.75%

No 200 185 385 96.25%

Total 212 188 400 100%

Cotrimoxazole

prophylaxis

discontinued

yes 62 58 120 30%

No 150 130 280 70%

Total 212 188 400 100%

Drug change Yes 27 21 48 12%

No 185 167 352 88%

Total 212 188 400 100%

Duration of ART

therapy

<12 months 13 15 28 6.8%

12-24 months 27 26 53 13%

24-36 months 44 37 81 19.8%

36-48 months 73 54 127 31.1%

>48 months 58 62 120 29.3%

Total 212 188 400 100%

There were a total of 48 drug changes (12%)

among 400 cases on first line antiretroviral

regimen. Antiretroviral related adverse drug

reactions are the leading cause of drug

changes constituting 41.65% of all drug

changes followed by treatment failure

31.25%, switching to fixed dose

combination (FDC) 16.7% and due to

tuberculosis treatment 10.4%.

Anemia occurred almost exclusively in AZT

containing regimen. There were a total of

11 severe cases of anemia with hematocrit

level of less than 21%. Anemia occurred in

3.125% of AZT regimen (10/320) and

1.25% (1/80) from d4T taking group. The

hematocrit level ranged from 6-21% with

average count of 13.7% (inter quartile range

12-16%). All except anemia in d4Tarm,

required blood transfusion and drug change

from AZT to d4T. The average level of

MCV at the occurrence of anemia was 101fl

and ranged from 92-110 fl. The average time

of anemia detection was 23 weeks but

anemia developed as early as 8 weeks and as

late as 48 weeks.

Chronic illness with concomitant non-ARV

medications had statistically significant

association with the development of AZT

related anemia using Fischer exact test (P-

value=0.019) and binomial logistic

regression (OR: 7.03, 95% CI 1.95- 25.37,

P=0.003). There were 4 cases of severe

anemia developed in 33 (12.12%) patients

who had chronic illness compared to 7 cases

of

anemia among 367 (1.9%) patients without

associated chronic illness (RR=6.4). Chronic

illness found to have association with

development of anemia were tuberculosis,

seizure disorder and chronic kidney

diseases. Moreover, anticonvulsants and

antituberculosis medications have been used

in these patients who developed anemia in

addition to antiretroviral

therapy. Otherwise, the occurrence of

anemia was not affected by other predictor

factor factors.

Table 3:Profile of drug changes among children on HAART, department of Pediatrics,

Jan 2010

Reason of drug change Frequency Percentage

Antiretroviral Side effects total 20 42.%

1. Anemia

2. Rash

3. Hepatitis

4. Neuritis

5. Dystrophy

10

5

2

1

2

20.8%

10.4%

4.3%

2.2%

4.3%

Shift to fixed dose combination 8 16.6%

Tuberculosis treatment 5 10.2%

Treatment failure 15 31.2%

Total drug changes 48 100%

Logistic regression showing chronic illness as a factor in the development of AZT induced anemia

Skin rash developed mainly in NVP

containing regimen. There were a total of

five severe skin rashes (grade III &IV)

which warrant NVP discontinuation and

substitution with EFV. NVP taking children

were 177 (44.25%) out of which 6

developed severe skin rash (3.4%). EFV

taking children were 219(54.75%) out of

which only one moderate rash recorded

(0.45%). The average time of skin rash

occurrence was 4 weeks and ranged as early

as 2 weeks up to 8 weeks. All except EFV

related moderate rash, required drug change

from NVP to EFV. Five females and two

males developed severe skin rash. Mild to

moderate rashes which didn‟t require drug

withholding or substitution were not found

recorded in the follow up charts of patients.

The occurrence of rash was compared if it is

affected by predictor variables like sex,

WHO, base line CD4 and chronic illness but

none were found to have statistically

significantly associations. The effect of

cotrimoxazole on skin rash development has

no significant association. Chemo-

prophylaxis in children prior to ART

initiation showed the occurrence of severe

skin reaction in four cases who took

cotrimoxazole (1%) and required drug

switching to doxycycline. Children who

developed NVP induced rash while on

cotrimoxazole prophylaxis didn‟t show

recurrence or aggravation of rash despite

continuation of the prophylaxis.

Hepatitis cases were observed in 3 patients

taking NVP containing regimen (1.7%). The

minimum time to develop clinical hepatitis

was 28 weeks and occurred as late as 128

weeks. A liver function test during the

occurrence of hepatitis was above 10X UNL

in two cases and 5-10X UNL in one case

who didn‟t require drug change. There was

no concomitant HBV or HCV co-infection

in patients who developed NVP related

hepatitis. However, two of severe hepatitis

cases have been taking anticonvulsant

concomitantly for seizure disorder and

required substitution of NVP with EFV.

The use of these drugs has strong

association with the development of

hepatitis using Fischer exact test. No other

independent variable had strong association

with the development of hepatitis which was

tested using multinomial logistic regression.

There were two cases of peripheral neuritis

(2.5%) among 79 children taking d4T

regimen, one of which required drug change

to AZT. Peripheral neuropathy was observed

in adolescents after longer period of d4T

therapy. The time of occurrence of

peripheral neuropathy ranged from 128-192

weeks after HAART initiation.

Two (2.5%) patients developed clinically

observed lipodystrohy among 79 children on

d4T containing regimen. Both cases required

drug substitution from d4T to ABC. The

time of occurrence of dystrophy was 192

weeks for the first case and 200 weeks for

the second case after ART initiation and

both were adolescents.

Table 4: Profile of Antiretroviral adverse drug reaction among 400 children on HAART

from Jan 2005- Jan 2010

Major Side

effects

Frequency Associated

ARV drug

Percentage

per regimen

Changes

made

Average

time of

occurrence

Time in

range

Anemia 11 AZT(10) 10/317=3.13% 10

(3.13%)

23 weeks 8-48

weeks

Skin rash 7 NVP(6) 6/177=3.4% 5 (2.8%) 4 weeks 2-8 weeks

Hepatitis 3 NVP(3) 3/177=1.7% 2(1.1%) 64 weeks 28-128

weeks

Peripheral

neuropathy

3 D4T(3) 3/79=3.8% 2(2.5%) 169 weeks 128-192

weeks

Lipo-

dystrophy

2 D4T(2) 2/79=2.5% 2(2.5%) 196 weeks 192-200

weeks

Discussion

Morbidities and mortalities due to

HIV/AIDS have been extremely reduced

worldwide when appropriate ART initiated

timely. In this study anthropometry, clinical

and immunological evidences witnessed the

efficacy of HAART in children. Similar

studies in Vietnam and Burkinafaso

elaborates the efficacy of ART (13, 14). For

instance a study done in Vietnam where 252

children were started on first line ART

regimen and followed for 12 months period

showed CD4 percentage increment by 10%,

reduction of new opportunistic infection by

50% and a marked improvement of weight

for age and Height for age Z scores.

Anthropometry data also revealed the

advantage of antiretroviral therapy in

making a significant improvement of

malnutrition in HIV-1 infected children. A

similar study in Kenya also confirmed the

use of HAART as a potent tool to alleviate

malnutrition in HIV-1 infected children (15).

After adequate antiretroviral therapy in this

study, the prevalence of malnutrition HIV-1

infected children is equivalent to the rate of

malnutrition in the general population

(under 5 children) described in the Ethiopian

demographic and health survey 2005 report

(16).

Moreover, immune restoration is the basic

mechanism that ART could do in fighting

HIV infection. This is reflected very well in

this study and similar study in Cambodia

where children

on first line therapy followed for more than

three years showed marked increment in

immune status and reduction of viral load

(17). The reduction of new opportunistic infection

following HAART has been evidenced by

the rate of tuberculosis development pre and

post HAART in this study. Similar studies

also showed significant improvement in

HIV morbidities and mortalities merely due

to a reduction in the rate of AIDS defining

illnesses (17).

Despite improvements in morbidities and

mortalities after administration of

antiretroviral therapy, there are emerging

issues related to HIV/AIDS treatment.

Several ARV related adverse drug reactions,

drug switches and treatment failures have

been observed in this study (Table-3). A

similar study in Rwanda showed a total of

46(14.6%) drug changes out of 315 children

on HAART mainly due o drug reactions 28

(60%) of total drug changes followed by

changes due to tuberculosis treatment(18).

There were a total of 20/400 (5%) severe

drug reactions warranting substitution of

offending drug in this study (Table-4). A

similar study done in Jamaica where 77

children enrolled from Sep 2002 up to Apr

2005 in Kingston pediatric ART clinic and

followed prospectively showed a total of ten

drug changes among 77 children on HAART

due to antiretroviral related severe toxicity

(12.9%). Three cases were severe anemia

related to AZT (3.9%), three were due to

NVP induced severe skin rash (3.9%) and

four cases were due to indinavir related

hematuria (19).

As high as 19% (31/160) drug changes due

to ARV related adverse drug reactions have

been observed in Uzbekistan study among

160 children on HAART for two years (20).

The marked Variability in the difference of

adverse drug reactions among children

taking HAART in different countries could

be genetic makeup of an individual, study

design, type and doses of antiretroviral

drugs and duration of therapy.

Anemia related to AZT administration is

said to occur due to bone marrow

suppression, evidenced by progressive

decline in hemoglobin, macrocytosis and

physical symptoms of anemia around 3-4

months after HAART initiation (21). The

occurrence of anemia is highly associated

with AZT administration than d4T regimen

in this study (10/320 vs. 1/80, RR=2.5).

Moreover, majority of children in this study

developed anemia on average 23 weeks after

ART and ranged from 8-48 weeks. In other

studies the occurrence of AZT related

anemia is earlier than this study (22). The

relative late occurrence anemia in this study

could be due to late detection of the signs

and symptoms related to anemia and

infrequent laboratory monitoring. Moreover

two cases of anemia were detected very late

at 48 weeks and both cases were taking

anticonvulsants (phenobarbitone) which

could aggravate AZT toxicity.

This study also showed macrocytosis

(MCV>95 fl) in 81% (9/11) of AZT related

anemia which is a feature of AZT reaction in

the bone marrow as it is witnessed in other

study (22).

Chronic diseases including HIV infection

and non-ARV medications which suppress

bone marrow brings about anemia and could

aggravate AZT induced anemia (23). The

occurrence of AZT associated anemia in

four patients with chronic illness in this

study speaks for the above statement.

Overall the development of anemia is

comparable to other studies (24) but

significantly lower than reported in adults

(25).

The prevalence of mild to moderate anemia

(HB level between 8-10gm/dl) is less

prevalent in this study than other studies

among patients taking HAART (26). The

lower prevalence rate could be failure to

detect mild to moderate anemia due to

infrequent laboratory monitoring or

inconsistent recording of the result.

In this study, severe skin rash has occurred

mainly in NVP containing regimen than

EFV group (7/177 vs.1/219, RR=8.6). Rash

is due to a hypersensitivity reaction

principally due to NVP administration. It

ranges from simple macular rash to severe

toxic epidermal necrolyis and SJS (27). In

this study, severe cases of skin rash

happened in 2-8 weeks of ART initiation

with average time of occurrence being four

weeks which is the usual trend in other

studies as well (27).

The prevalence of skin rash in children

could reach as high as 20% but severe cases

requiring drug discontinuation is nearly 3-

5% among NVP regimen as it is revealed in

this study and other studies (28). The

prevalence of mild to moderate skin rash in

this study is significantly lower than other

studies where the reverse is true (28). The

reason could be either there is failure to

report mild and moderate cases or failure of

detection or documentation of grade I and II

skin rashes. Besides, the variability in rate of

NVP related skin rash depends on genetic

makeup, gender, base line CD4, dosage of

nevirapine and concomitant non-ARV drug

use (29).

Peripheral neuropathy and lypo-dystrophy

are said to occur due antiretroviral related

mitochondrial toxicity especially marked

effect on adipocytes (30). Nucleoside

reverse transcriptase inhibitors are more

potent than non nucleoside reverse

transcriptase inhibitors as a cause of

mitochondrial DNA polymerase gamma

inhibitor. Zalcitabine, didanosine, stavudine,

zidovudine, lamivudine, abacavir and

tenofivir are known potent inhibitors of

mitochondrial DNA synthesis in decreasing

order of potency (31). A study confirmed

progressive adipocyte atrophy using tissue

biopsy in patients taking NRTIs for more

than a year (32).

In this study, lipodystrophy and peripheral

neuropathy occurred in adolescents and after

longer duration of therapy (>160 weeks).

Similar study has also reflected the

importance of age, duration of therapy and

type of ARV regimen as a risk of developing

neuropathy and dystrophy (33). More over

a study done in Burkinafaso where 52 HIV-

1 infected children started on daily DDI

based regimen and followed for two years

manifested neither lipodystrophy nor

peripheral neuropathy clearly depicting the

importance of duration of therapy in the

manifestation of adverse drug reactions (34).

Due to few numbers of cases who developed

neuropathy and dystrophy, comparison

didn‟t show any statistically significant

correlations with predictor variables. This

could be either there is

decreased rate of reporting from caregivers

or there is failure to detect and document the

occurrence of side effects as it was

witnessed in other forms of adverse drug

reactions. Otherwise children do have lower

rate of developing both neuropathy and

lipodystrophy compared to the rate of

development in adults (35).

Hepatitis in children is often times witnessed

in NVP containing regimen. It may be

clinically evident or confirmed by laboratory

as an isolated liver function test elevation.

Liver function tests 5-10X above the normal

range are classified as grade III toxicity

while LFT above 10x of normal are grade

IV hepatotoxicity. ARV related hepatitis

develop in two phases. The acute form of

hepatitis develop along with skin rash due to

NVP related liver toxicity and manifesting

in the range of 6-18 weeks (36) while the

late form of hepatitis appears with lactic

acidosis due to NRTIs on average after 3-4

months of antiretroviral therapy (37).

In this study hepatitis occurred relatively

longer than from actually expected period.

This could be due to the effect of

concomitant hepatotoxic non-ARV drug use

which has aggravated the development of

hepatitis later than the expected period.

Moreover no hepatitis cases were identified

along with skin reactions due to NVP related

reaction in this study which was supposed to

happen early. This study showed three cases

of clinically apparent hepatitis among

children taking NVP regimen. Both hepatitis

B and C viral markers were negative in

patients with hepatitis which is a common

factor in aggravating drug related hepatitis

(38). In this stud, Liver function tests were

elevated 10X above normal range in two

patients who required NVP discontinuation

and substitution with EFV.

Asymptomatic elevation of liver function

tests and mild to moderate hepatits which

doesn‟t require drug change is relatively

common in other studies (39). However, the

prevalence of mild to moderate hepatitis and

asymptomatic liver function test elevation

are few in number. This could be due to

infrequent laboratory monitoring or

probably failure of reporting of mild

symptoms and inconsistent recording of non

severe drug reactions by attending

physicians.

Chronic illness with concomitant drug use

had statistically significant association with

the development of hepatitis. Two patients

who developed hepatitis were taking

anticonvulsants, namely phenobarbitone and

valproic acid respectively in this study.

Concomitant hepatotoxic drug

administration with NVP based ART like

aniconvuslants and antituberculosis brings

about profound effect on rate of liver

toxicity (40). Conclusion This study showed that antiretroviral side

effects are the leading cause of drug

substitution and regimen changes followed

by treatment failure as it is witnessed in

similar studies. The prevalence of severe

antiretroviral drug reaction is comparable to

other studies. However, the prevalence of

mild to moderate adverse drug reactions is

significantly lower in this study. Severe skin

rash is an earlier noticed drug reaction while

neuropathy and dystrophy appeared late in

the course of antiretroviral therapy. Chronic

illnesses and concomitant medications have

aggravated the development of ARV related

adverse drug reactions like anemia and

hepatitis.

Recommendation

Timely identification and appropriate

intervention of antiretroviral related adverse

drug reaction is paramount. This can be

accomplished by repeated counseling of

parents on the sign and symptoms of

commonly encountered adverse drug

reactions. Physicians caring for children

should anticipate the time of occurrence of

each ARV related adverse drug reactions

and request appropriate laboratory tests in

relation to the type of regimen. Non-ARV

drugs and diseases which will worsen

adverse drug reaction should also be given

due attention. The overall management of

adverse drug reactions requires WHO

grading system. Besides, unnecessary and

premature drug switches could lead to

shortage of options of first line ART

regimen. In conclusion, prospective study

should be done to determine all types of

adverse drug reactions and determinant

factors, magnitude of severity and impact of

ARV related adverse drug reaction on

adherence and treatment failure.

Limitation of the study

As a retrospective study, it is dependent on

the quality of secondary data. The overall

prevalence of adverse drug reaction depends

on thorough reporting, detection and

documentation of events. Failure of

reporting, inconsistent detection and

documentation may be reasons for lower

prevalence of mild to moderate adverse drug

reactions in this study. Moreover, infrequent

laboratory monitoring could miss

asymptomatic and mild cases of anemia and

hepatitis.

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Acknowledgment

I express my deepest gratitude to pediatrics ART team who assisted me a lot on the process of

data collection. I also extend my thanks to advisors of mine, Dr Amha Mekasha and Dr Endale

Tefera who helped me starting from developing appropriate proposal until completion of the

write up of this research. Great thanks to Wubegzier Mekonnen, lecturer of biostatistics (AAU-

MF) who addressed the statistical part of the study. Finally immense thanks and love to my wife

Seble mekonnen who cared me and my children during the time of physical, emotional and

financially unrest.

Measles outbreak investigation in west Hararghie zone of Oromia region , Ethiopia ,2007

Kassahun Mitiku( MD,MPH ) , Wendemagegn Kegne,(MD,MPH)

Abstract

Background

This epidemic investigation was conducted in West Harargie zone of Oromia Region, Ethiopia.

The zone had a total population of 1,900,412 in 2007. Measles catch-up SIAs were conducted in

2002 followed by 2 rounds of follow up SIAs in 2005 and 2007 (with 93% administrative

coverage in both rounds). The measles routine immunization administrative coverage has shown

an improvement from 34% in 2002 to 71% in 2007. With an improving surveillance system there

was no adequate documentation of measles outbreaks and mortality due to measles throughout

the country. This paper describes the findings of an investigation of a confirmed measles

outbreak in this zone between WHO epidemiological weeks 2 and 29 of 2007

Methods

A household retrospective surveys was conducted in 7 Woreda of west Harargie zone of Oromia

region from 1August to 3 September 2007. A house-to-house search for measles cases was

conducted in each village of the 8 Woredas where the measles epidemic was reported (from

January to June of 2007). Guardian of the cases (ascertained based on the WHO cases

definition) were interviewed based on the questionnaire. Data was collected by trained health

workers. The data was checked by WHO surveillance officer. EPI2000 and SPSS statistical

packages were used for data analysis. The investigation team carried out a time, place and

person analysis, and estimated the case fatality rate, X2 test used whenever necessary.

Results

A total of 718 cases were identified and interviewed during the survey period; of which 54% are

males and the same percentage is under age of five years old. 84.4 % of the cases were from 3

Woredas. Among the investigated patients, 579 (80.6%) were unvaccinated for measles, 96 (13.2

%) reported to have received at least one dose of measles vaccine. There were a total of 48

(6.7%) deaths and the cases fatality rate was highest between 12 and 23 months of age and in

subjects older than 14 years. the case fatality rate is higher among the non vaccinated children.

Conclusions & recommendations

Despite availability of measles vaccine unvaccinated children are dying and the notification

efficiency is still low. The routine surveillance system picks only fewer deaths than found by the

outbreak investigation report. The surveillance system needs to be expanded up to community

level and the outbreaks need to investigate appropriately and fully to document all cases and

deaths. Late out break response immunization didn’t help. Early Intensified routine and selective

immunization might have a better result with lesser cost.

Introduction

Following the adoption of the measles

mortality reduction goals in the African

Region, Ethiopia implemented the strategies

of improving routine immunization

coverage, conducting supplemental

immunization activities to provide a second

opportunity for measles immunization, and

established case based surveillance (1,2).

Since 2002, when these strategies were first

implemented, remarkable progress has been

attained with measles control. However, the

routine immunization and supplemental

immunization coverage levels were not high

enough to provide herd immunity to

interrupt transmission of measles virus.

There was a big outbreak of measles in west

Harargie zone in 2007 that lasted for

around 26 weeks. West Harerghe is one of

the 17 zones of Oromia Region, is

administratively divided in 14 Woredas and

had a total population of 1,900,412 in

2007(3,4). Measles catch-up SIAs was

conducted in 2002 targeting children 6

months to 14 years of age and had a reported

administrative coverage of 101%, followed

by 2 rounds of follow up SIAs in 2005 and

2007 targeting children from 6 months to 59

months of age and had a 93%

administrative coverage in both follow up

SIA rounds. The measles vaccine routine

immunization administrative coverage in

West Harerghe has shown an improvement

from 34% in 2002 to 71% in 2007(4).

Despite the high SIA coverage and

improving routine immunization we had a

report of continued epidemic in different

parts of the zone for which the magnitude

and cause of the epidemic was not clearly

described by the routine surveillance.

This community survey was to describe the

magnitude and probable cause of the

confirmed measles outbreak reported in

West Harerghe zone between

epidemiological weeks 2 and 29 in 2007.

Methodology

The Ethiopian measles surveillance

guidelines define confirmed measles

outbreaks as the occurrence of 3 lab

confirmed measles cases reported from the

same district or from the same catchment

area of a health facility with onset of rash

within a period of a month(4). Once an

outbreak is confirmed, the additional

collection of blood specimens is stopped and

the concept of epidemiological linkage is

used to confirm additional cases reported

from the same district (or adjacent districts

with plausibility of transmission) with onset

of rash within 30 days. These cases are

expected to be reported through a line listing

as part of the outbreak investigation reports.

Through a case based system we had 4

confirmed epidemics I 4 districts of West

Harargie zone with a total reported cases of

117 and 24 of them were laboratory

confirmed.

A retrospective, community-based outbreak

investigation was conducted from August 1st

to September 3rd

2007 in the 7 Woredas of

West Harerghe zone (Anchar, Chiro, Daro

Lebu, Gemechis, Guba Koricha, and

Habro).

The investigation included interviews with

the district health management teams,

hospitals, health centers and communities

and conducting discussions with the staff of

the health institutions and community

leaders. A house-to-house search for

measles cases was conducted in each village

of the Woredas where the measles epidemic

was reported from January to June of 2007.

All households were visited and were asked

whether any household members had had

measles. In households in which a measles

case was identified, patients (or guardians,

in the case of children less than 10 years old

) were interviewed after verbal consent was

obtained, and a questionnaire was completed

for each case that fulfill the WHO cases

definition of measles(1,2 ) from 14 Jan to 30

July 2007 . The team collected information

on age, address, date of onset, date of

admission, immunization status, and the

outcome of the illness within a month of

onset of rash. Information on vaccination

status was obtained from caretaker history as

written documentation of vaccination history

was not available for most cases.

Data collection was done by health workers

and health extension workers who have

training on measles surveillance under the

supervision of WHO medical surveillance

officer and got orientation on how to

ascertain measles cases and deaths based

on the case definitions and be able to fill the

case investigation form correctly.

The outbreak had earlier been confirmed in

each of the Woredas through the appropriate

collection of specimens and laboratory

testing which resulted in the finding of at

least 3 measles IgM positive cases from

each of the Woredas according to the

African regional and national surveillance

guidelines. (1, 2)

Definition of terms:

A suspected measles case was defined as

illness characterized by fever, rash, and

either cough, or coryza, or conjunctivitis,

with rash onset in the period from January

14 to 30 July 2007 in the mentioned

Woredas, and measles death was a death

occurring within 30 days after rash onset in

a measles patient(1,2).

The data analysis is solely from the cross

sectional survey, EPI2000 and SPSS

statistical packages were used for data

analysis. The investigation team carried out

a time, place and person analysis, and

estimated the case fatality rate and X2

statistical test was used when necessary.

Results

In the 2007 outbreak a total 718 cases of

measles from 7 Woreda were investigated

during the survey period, of which 53.9 %

were male. The age of patients ranged from

3 months to 65 years (mean, 68 months and

median 48 months)

Most of the cases are from 3 Woredas

(Habro, Guba Koricha and Daro lebu) which

accounts for 84.4 % of the entire cases table

2.

The epidemic started in the second

epidemiologic week of 2007 and ends in the

29th

week, the peak was at the 10th

week,

unlike many of the epidemics that occurred

after the catch up campaigns, it was

prolonged fig 2.

Among the investigated patients, 579

(80.6%) were unvaccinated for measles, 96

(13.2 %) reported to have received at least

one dose of measles vaccine.

A total of 48 (6.7%) measles deaths were

reported to have occurred within 30 days

after rash onset. The mortality rate was

highest between 12 and 23 months of age

and in subjects older than 14 years. (table4).

No significant difference by sex was

observed in CFR (X2=0.002, P>0.98).

Vaccinated children are less likely to die

than those who are unvaccinated and whose

vaccination status is unknown. The case

fatality is very high in those whose

vaccination status is unknown. Individuals

who died with unknown vaccination status

are young adults in the age group between

15-37 years, (table5)

Figure1: Spot map of measles cases East Harargie zone Oromia region, Ethiopia 2007

Table1: Age and vaccination status of measles cases. West Harargie, Oromia Region,

Ethiopia. 2007

Vaccination status

Age group

not vaccinated 1+ doses unknown Total

No % No % No % No %

0-11 month 61 92.40% 5 7.60% 0 0.00% 66 9.2%

12-59 months 267 82.90% 50 15.50% 5 1.60% 322 44.8%

5-9 years 142 73.20% 36 18.60% 16 8.20% 194 27.0%

10-14 years 70 79.50% 2 2.30% 16 18.20% 88 12.3%

15+ years 39 81.30% 3 6.30% 6 12.50% 48 6.7%

Total 579 80.60% 96 13.40% 43 6.00% 718 100.0%

Table 2: Distribution of measles cases and their outcome by Woreda, East Harargie zone

Oromia region, Ethiopia 2007

Woredas

Alive

Died

Total

No % No % NO %

Anchar 24 88.9% 3 11.1% 27 3.8%

Chiro 14 100.0% 0 0.0% 14 1.9%

Daro Lebu 89 87.3% 13 12.7% 102 14.2%

Gemechis 20 90.9% 2 9.1% 22 3.1%

Guba Koricha 215 98.2% 4 1.8% 219 30.5%

Habro 259 90.9% 26 9.1% 285 39.7%

Messela 49 100.0% 0 0.0% 49 6.8%

Total 670 93.3% 48 6.7% 718 100.0%

Figure2 : The epidemic curve that shows the trend of the epidemic in East Harargie zone of

Oromia region Ethiopia, 2007, from survey data ( N=718)

figure 3: Age by Vaccination status of measles cases. West Harargie zone, Oromia region,

Ethiopia 2007.

SIA (93%)

Table 4. Outcome of outbreak cases by age groups in west Harargie zone of Oromia region

Ethiopia, 2007

Age groups

OUTCOME

Alive Died Total

No % No % died No %

0 - 11 m 63 95.5% 3 4.50% 66 9.2%

12-23 m 82 86.3% 13 13.70% 95 13.2%

23-35 m 92 92.9% 7 7.10% 99 13.8%

36-59 m 117 91.4% 11 8.60% 128 17.8%

5-9 yrs 189 97.4% 5 2.60% 194 27.0%

10-14yrs 103 96.3% 4 3.70% 107 14.9%

15 + yrs 24 82.8% 5 17.20% 29 4.0%

Total 670 93.3% 48 6.70% 718 100.0%

Table5: Outcome of measles patients by reported vaccination status in West Harargie zone

of Oromia Ethiopia 2007.

Vaccine dose

OUTCOME

Alive Died Total

No % No % died No %

Unvaccinated 541 93.4% 38 6.60% 579 81.0%

1 or more doses 95 100.0% 1 1.10% 95 13.3%

Unknown / missing 31 77.5% 9 22.50% 40 5.6%

Total 667 93.3% 48 6.70% 715 100.0%

Discussion

The age distribution of cases has shown a

dramatic change from that of pre-catch up

campaign era (5, 6) The Mean and median

age of measles patients has shifted to the

right and the Epidemiology is changing, that

means the proportion of older children is

higher than it used to be before the catch

up campaign more over some previously

immunized children have been infected.

This changing epidemiology is probably due

the improved routine immunization and

SIAs (7, 8). The change in the age

distribution of measles cases after the catch

up campaign was in conformity with other

studies. There is no significant difference

in the sex distribution of measles cases in

this zone. (X2=0.002, P>0.98)

The epidemic curve of west Harargie

epidemic is a typical curve of propagated

epidemic which results from person to

person transmission (9). The number of

cases reported was maintained at high level

from 8th to 19th

WHO epidemiologic week

(more than 10 weeks) this shows the

accumulation of susceptible in the

community as a result of low level of

routine immunization and most probability

non optimal SIAs.

The outbreak response immunization at the

20th

week was done. This immunization

conducted long after the epidemic stated and

it was at the time the epidemic was

declining. As a result the outbreak response

immunization didn‟t help to avert cases and

deaths significantly (10)

More than 80% of the cases were not

vaccinated, this indicate the cause of the

epidemic is failure of vaccinating children

with at least one dose of measles vaccine

(10). Unlike other major illnesses that cause

sickness and kill large numbers of young

children, measles can be prevented through

use of a safe, highly effective, and

inexpensive vaccine (9,). Unfortunately, in

many of the cases in this rural community of

west Harargie, large numbers of children

remain unvaccinated.

Our investigation revealed that 6.7 % of

measles case died within 30 days after rash

onset. Unlike the usual routine reports from

Ethiopian case based data (WHO

unpublished report) we observed

unacceptably high mortality. The CFR found

in our investigation was 5-fold higher than

that reported through routine surveillance. It

is known that the case fatality rate during

epidemics is higher than during the routine

surveillance (11), but there are reports which

are even higher than our report from some

countries of West Africa and parts of

Ethiopia (11-16)

If we want to know the cases fatality rate of

measles, the cases of interest are those who

have had measles and have survived the

following one month rather than current

cases (17); however data for reports of the

case fatality in many parts of the country are

usually obtained during searching for

additional cases to treat them, before the

epidemic is closed. As death may occur any

time between the first and 30th

day after the

onset of rash, all deaths may have not been

reported, and this might be the cause of

low case fatality rate in many of previous

reports in the country.

the case fatality rate is high in unvaccinated

children, and also remained high in the

adolescent and young adult age groups (15-

37 years) moreover many of the deaths in

this age group have unknown immunization

status. Even if we assume that all cases are

unvaccinated, we don‟t expect this high

number of deaths in this age group, unless

there is an underlying illness that was

complicated by measles and result in high

case fatality rate. The most probable

underlying illness in this age group might be

HIV/ AIDS and other immunosuppressive

illnesses. It is proved that, measles on

patients who have underlying

immunosuppressive illnesses including

malnutrition is very fatal. Reports have

shown that measles can cause death up to 70

% of cancer and 40% of HIV positive adult

patients (19).

Parents in rural area often preferred to keep

the child at home and they purchase

treatment outside of a health-care facility,

rather than to seek treatment at a health-care

facility (18). In our survey many of the

patients didn‟t visit modern health facility

and most probably died at home, this shows

that mothers are still hiding their children

when they have measles. This implies we

didn‟t get adequate desired change in health

seeking behavior of the community when

their child catches measles.

Conclusion and recommendation

The Ethiopian measles surveillance system

is based on fairly quality case based

surveillance system; but all the cases

investigated by the survey in west Hararghie

was not captured by the routine surveillance

system, there were more cases by the survey

than the routine surveillance system. This

tells us the investigation of all epidemics is

mandatory.

The probable cause of the epidemic is

failure of vaccinating children and is

unlikely to be vaccine failure, we need to do

a lot of work to improve routine

immunization and quality of SIAs

Outbreak response immunization was very

late and didn‟t help much to avert cases

and deaths, it should be conducted based

on the risk of extended out break and

should be conducted as early as possible

covering the high risk age group

. References

1. World Health Organization Regional Office for Africa Guidelines for Measles

Surveillance Revised December 2004

2. Federal Ministry of Health and WHO Ethiopia; National guideline for measles

surveillance and outbreak investigation April 2007

3. Federal democratic Republic of Ethiopia population census commission Summary

and Statistical Report of the 2007 Population and Housing Census

4. Federal Ministry of Health Annual report 2007/2008

5. SINGH J. DATTA K. K. Epidemiological considerations of the age distribution of

measles in India. Journal of tropical pediatrics ISSN 0142-6338

CODEN JTRPAO: 1997, vol. 43, no2, pp. 111-115

6. TAKAYAMA NAOHIDE, Change in the Age-distribution of Measles Patients

Admitted to Our Hospital from 1981 to 2002. Journal of the Japanese Association

for Infectious Diseases VOL.77; NO. 7; PAGE. 488-492(2003

7. Family Health department , Federal Ministry of Health in collaboration with WHO

and UNICEF; evaluation of measles control activities including impact of SIAs in

Ethiopia ( unpublished report)

8. Family health Department FMoH, WHO Ethiopia, and AAU-MF; Measles Case

fatality in Ethiopia – reported by Mesganaw Fantahun (MD,PhD) ; 2001(

unpublished Report )

9. Epidemiology of measles virus infection http://virology-online.com/index.html

accesses on 20 Dec 2008 pp-3

10. D.H. WHO. Guidelines for Epidemic Preparedness and Response to Measles

Outbreaks, Geneva, February 1999; pp. 47

11. Nandy R, Handzel T, Zaneidou M, Biey J, Coddy RZ, et al. (2006) Case-fatality

rate during a measles outbreak in eastern Niger in 2003. Clin Infect Dis 42: 322–

328.

12. Moss WJ (2007) Measles Still Has a Devastating Impact in Unvaccinated

Populations. PLoS Med 4(1): e24.

13. Lee , H . Lee , J . Hur , J . Kang , B . Lee; The changing epidemiology of

hospitalized pediatric patients in three measles outbreaks. Journal of Infection

, Volume 54 , Issue 2 , Pages 167 - 172

14. R. F. Grais , C. Dubray Unacceptably High Mortality Related to Measles

Epidemics in Niger, Nigeria, and Chad, PLoS Medicine , Volume 4 (1): e16 Public

Library of Science (PLoS) Journal – Jan 2, 2007

15. Salama P, Assefa F, Talley L, Spiegel P, van der Veen A, Gotway C, 2001.

Malnutrition, measles, mortality, and the humanitarian response during a famine in

Ethiopia. JAMA 286: 563–571.

16. Mortality During a Famine --- Gode District, Ethiopia, July 2000 Morbidity and

Mortality Weekly 20 April 01

17. Byass P (1993) Measles control in the 1990s: Generic protocol for determining

measles case fatality rates in a community, either during an epidemic or in a highly

endemic area. WHO/EPI/GEN/93.3 Geneva:

18. World Health Organization.Kaplan LJ Severe measles in immuno-compromised

patients. - JAMA - 4-MAR-1992; 267(9): 1237-41 (From NIH/NLM MEDLINE)

ASSESSMENT OF KNOWLEDGE, ATTITUDE, AND PRACTICE

ABOUT IMMEDIATE NEWBORN CARE AMONG HEALTH CARE

PROVIDERS IN ADDIS ABABA PUBLIC HEALTH CENTERS

A Thesis Submitted to college of Health Sciences, School of graduate studies

Haramaya University

Meseret Tesfaye Wondaferash

ALEMAYA UNIVERSITY

ABSTRACT

Background: Globally 4 million neonatal deaths every year, 75% (3 million) of this are in the

first week and highest is in the first day of life. Ethiopia has Neonatal Mortality rate of

39/1000 LB (EDHS 2005) and contributes for more than 50% of infant mortality.

Objective: To assess knowledge, attitude and practice of health care providers and explore

factors affecting provision of immediate newborn care in Addis Ababa public health centers.

Methods: This facility based cross sectional study is conducted from January to March 2011.

The study used both quantitative and qualitative approaches; structured questioner for

providers, observation of cases managed, in-depth interview of managers and record review.

Results: Over half (51.4%) of providers have satisfactory knowledge in immediate newborn

care. The overall knowledge related to essential newborn care is better than care for LBW and

sick newborn. Those with long years of service year, > 10 years, have a better knowledge than

others. Overall, the health providers interviewed had a very positive attitude towards newborn

care interventions, 98.6% of the responses from the providers had good and very good attitude

towards newborn care. The overall essential newborn care practice by providers in the last

case they provided service is satisfactory, 80.7% had a correct practice. The overall extra

care for premature or LBW practiced by providers in the last case they provided service was

not satisfactory, only 40.4% did practice at least half of the standard actions.

1. INTRODUCTION

Millennium Development Goal for child

survival cannot be met without substantial

reductions in neonatal mortality. Many

countries including Ethiopia have set

under-five and maternal mortality

reduction as their key development goal. In

preparing child mortality reduction

strategies, it is important for countries to

implement effective interventions strategy

available to save lives of newborn babies in

order to avoid newborn deaths more

quickly [Darmstadt „et al‟, 2005]. These

interventions are bundled in very cost-

effective way and it has the greatest effect

on neonatal deaths and yet simple

interventions. It‟s less dependent on

technology and commodities than on

people with skills [Haws „et al‟, 2007].

Every year an estimated 4 million babies

die in the first 4 weeks of life (the neonatal

period). And three-quarters of neonatal

deaths happen in the first week; the highest

risk of death is on the first day of life.

Almost all (99%) neonatal deaths arise in

low-income and middle-income countries.

The highest numbers of neonatal deaths are

in south-central Asian countries and in sub-

Saharan Africa. The countries in these

regions (with some exceptions) have made

little progress in reducing such deaths in

the past 10–15 years [Lawn „et al‟, 2005].

Although being newborn is not a disease,

large numbers of newborn die soon after

birth; especially neonatal deaths occur

during the perinatal period. Intra partum

deaths are closely linked to place of care at

delivery. In addition, neonatal deaths and

stillbirths stem from poor maternal health

and the first critical hours after birth with

lack of newborn care. Furthermore,

services meet minimum standards for safe

childbirth and newborn care, outdated

knowledge and inadequate skills, lack of

essential medicines, supplies and

equipment, overcrowding and inadequate

hygiene are common [WHO 2006]. The

major causes of neonatal death globally

were estimated to be infections

(sepsis/pneumonia, tetanus, and diarrhea;

35%), preterm birth (28%), and asphyxia

(23%) [Lawn „et al‟, 2006].

The focus to neonatal health was delayed

due to different reasons in past decades.

Child survival approach lead by

interventions targeting child beyond

neonatal age; newborn and

their care was considered to be maternal issue and newborn health care was thought

to be provided with high technology as in

the developed nations. Recently there are

major shift made to the care in the neonatal

period by implementing cost effective

intervention.

Since Ethiopia is one of the poorest

countries in the world, have multiple

maternal and newborn health related

problems like other developing countries.

The neonatal health is not improving unlike

health of less than five years old. Neonatal

death account for more than 50% of the

infant mortality and about 31% of under

five morality [EDHS, 2005].

The health of newborn is affected by the

magnitude of problems and quality of care.

As described above, the risk of mortality is

high during birth and in the early period of

life. Clearly good essential care of the

newborn will prevent many newborn

emergences, like neonatal sepsis and

tetanus infection by maintaining clean

chain [Lawn „et al‟, 2002].

The level of care during this risky period in

Ethiopia is very low. According to the

national EmONC baseline assessment,

2007_2008, the use of specific evidence

based intervention is low; use of parental

antibiotics for newborn is 24% and

provision of extra care to premature or low

birth weight is 24% [FMOH, 2008].

Now a day‟s, neonatal mortality is

increasingly recognized as an important

public health challenge and there is a shift

of focus to newborn care to achieve MDG-

4 through proven cost effective

interventions. The implementation of these

interventions is highly affected by the

performance of health professionals so it is

mandatory to know the knowledge, attitude

and practice of health professionals [Qazi

„et al‟, 2009].

Since programs focusing on neonatal

period are new in Ethiopia, study

conducted in this area is very limited and

specific. Conducting study on assessing the

knowledge, attitude and practice of health

care providers in different aspect of

immediate newborn care are essential. It

will also strategically contribute for

designing programs, focusing on

improving care and reducing neonatal

mortality. The acceptance and utilization of

new intervention in improving neonatal

health can largely affected by many

factors. This study do also explore factor

that affect the knowledge, attitude and

practice of health care providers towards immediate newborn care.

2. LITERATURE REVIEW

2.1. Newborn Care Intervention

Package

Newborn care Intervention package are

effective interventions strategy available to

save lives of newborn babies. The

Newborn care Intervention package is

divided in to three Intervention sub

packages:-

Essential Newborn care for all Babies

Intervention sub package

Extra Newborn care for LBW Babies

Intervention sub package

Emergency Newborn care for sick

Babies Intervention sub package

Essential Newborn Care Intervention sub

package is for every baby to have routine

newborn care to enhance normal growth

and development and to minimize risk

factors for complications. The key

interventions for essential newborn care

includes: neonatal resuscitation, the clean

chain (clean hands, clean surfaces, clean

blade to cut cord, clean cord tie, clean

cloth), the warm chain (dry baby, warm

room, warm mother, wrap up, use hat),

breast feeding, cord, eye, and skin care,

immunization, Vitamin K and MTCT/HIV.

Extra Newborn cares for the LBW

newborn sub package includes:

identification of the LBW baby, extra

clinical care of the LBW baby, extra

support for feeding, extra support for

warmth and provision of Vitamin K.

Emergency newborn care sub package for

sick babies includes: identification of

neonatal danger signs, severe neonatal

infection, neonatal tetanus, neonatal

asphyxia, neonatal jaundice, birth defects

and giving appropriate emergency care for

the sick newborn [Knippenberg „et al‟,

2005; Post, 2006; Bridget „et al, 2007;

Journal of Hospital Medicine, 2010].

2.2. Magnitude and Distribution of

Newborn Health Problems

Under five and infant mortality rates are

decreasing at a faster pace than neonatal

mortality; consequently, neonatal deaths

will represent an increasing proportion of

child deaths [WHO 2006]. Every year over

4 million babies die in the first four weeks

of life; 3 million of these deaths occur in

the early neonatal period, about 75% of

neonatal death occur in the first week of

life. Ninety-eight per cent of the deaths

take place in the developing world. In

developing countries, the risk of death in

the neonatal period is six times greater than

in developed countries; in the least

developed countries it is over eight times

higher. With 41 neonatal deaths per 1000

live births, the risk of neonatal death is

highest in Africa. The sub-Saharan regions

of Eastern, Western and Central Africa

have between 42 and 49 neonatal deaths

per 1000 live births [Bahl „et al‟, 2009;

Shifman, 2010].

Ethiopia is one of the poorest countries in

sub-Saharan Africa and has problem

related to newborn health. As EDHS 2005

indicated there is progress in the reduction

of under five than neonatal mortality

[neonatal mortality 39/1000 LB; infant

mortality 77/1000 LB and under five

mortality 123/1000 LB [EDHS 2005].

2.3. Factor Affecting Newborn Care

Globally, 60–80% of neonatal deaths arise

in low birth weight babies. The main direct

causes of neonatal death are estimated to

be infections (sepsis/pneumonia, tetanus,

and diarrhea; 35%), preterm birth (28%)

and asphyxia (23%). Neonatal tetanus

accounts for a smaller proportion of deaths

(7%), but is easily preventable. Low birth

weight is an important indirect cause of

death. Maternal complications in labour

carry a high risk of neonatal death, and

poverty is strongly associated with an

increased risk [WHO and UNICEF, 2009].

Although effective and simple

interventions for prevention of newborn

death exist, it doesn‟t reach for the majority

of neonates in the developing countries.

With in sub-Saharan African and south

Asian countries for which DHS data are

available, the NMR is consistently higher

and Lack of skilled personnel is one of the

most important cause for neonatal death.

Many Africa countries train insufficient

numbers of providers and programs

competes for in adequate health personnel.

There is lack of standards for care in the

health system and even those guidelines

available at national level are not known by

majority of health providers. The poor

management, lack of supervision and low

pay for care providers are also contributes

for low standard for care [Lawn „et al,

2002; Bahl „et al‟, 2009].

Labour and the time around birth are the

riskiest time in the human life cycle. Lack

of immediate newborn care leads to

neonatal problem like newborn infections,

it claim an estimated 1.4 million lives each

year. The risk of dying due to birth

asphyxia is about eight times higher for

babies in countries with very high NMRs

[Bahl „et al‟, 2009].

A series of reviews in the International

journal of obstetrics and Gynecology in

September 2009 summarize, Neonatal

resuscitation in a facility could reduce

mortality of term and intra partum related

neonatal death by 30%. And studies also

showed that it reduce death of preterm

babies [Lawn „et al‟, 2009].

A retrospective record review conducted in

Gonder college pediatrics ward showed

that Hypothermia was prevented by

rubbing the newborn in dry cotton, towel

and keeping under the radiant [Teshome &

Dejene, 2005]. A randomized control trial

conducted over one year period in Addis

Ababa showed that survival for preterm

low birth weight infant was remarkably

better for the early kangaroo mother care

group than the baby with conventional

method of care in the first 12 hr and

thereafter [Bogale 2005].

Universal (99%) coverage of cost effective

newborn intervention packages could avert

an estimated 41–72% of neonatal deaths

worldwide. At 90% coverage, intrapartum

and Postnatal packages have similar effects

on neonatal mortality, two-fold to three-

fold greater than that of antenatal. This

intervention mostly affected by knowledge,

attitude and practice (KAP) of health

professional [Darmstadt „et al‟, 2005].

A needs assessment at Tansen Mission

Hospital in Nepal established gaps in

knowledge, skills and attitudes of health

professionals, contributing to the high

neonatal mortality. After intervention,

consisted of four teaching sessions,

significant improvements were observed in

all groups (nurses, doctors and community

health workers) [Allen 2006]. A Study that

documented the pre-service training of

nurses on newborn care in Brazil showed

scientific knowledge and technical skills

are essential for a rigorous control of vital

functions to ensure the survival of

newborns [Costa „et al‟, 2010].

The Making Pregnancy Safer initiative

project in Ethiopia that was piloted in four

hospitals and 16 health centers provided

training on EmOC and found that five year

later the trained staff had improved over

untrained staff in practical test score on

both knowledge and skill for infection

prevention, new born resuscitation and

vacuum extraction [FMOH 2009].

Study conducted in Zambia to determine

the association of ENC with all cause 7 day

(early) neonatal mortality among the

infants of less educated mothers compared

to those of more educated ones. ENC

training for health care workers is

associated with decreases in early neonatal

mortality; rates decreased from 11.2/1000

live births pre-ENC to 6.2/1000 following

ENC implementation (p<0.001), who treat

women with less formal education

[Chomba „et al, 2008].

In order to decrease the mortality caused

by Asphyxia and to practice a scientific

method for resuscitation. A descriptive

cross sectional study was conducted in

Sari, Iran, to determine the rate of

knowledge, attitude and practice of every

learner about neonatal resuscitation in the

governmental hospitals. Results obtained

suggest that 44.5% had good knowledge

and 11.7% had very good knowledge on

neonatal Resuscitation. The Data also

suggested that 96.3% of the subjects had

good and very good attitudes towards

neonatal resuscitation and the results show

that only 38.4% of the subjects under the

study had a good level practice [Ahmady

„et al‟, 2005].

Ethiopia Federal Ministry of Health

proposed implementation of high impact

and cost effective child survival

interventions in the child survival strategy

for the country to reduce neonatal

mortality, so as to reach MDG.

2.4. Importance of the Study

To reduce neonatal mortality and to

achieve the Millennium Development Goal

for child survival by 2015, much more

needs to be accomplished. A study specific

to KAP of immediate newborn care will

strategically contribute for designing

programs focusing on improving skilled

care [Bahl „et al‟, 2009].

A study conducted in Ethiopia on

knowledge, attitude and practice of the

health care providers about immediate

newborn care are very limited and specific

to single component of newborn care. This

study can be used as a base line study. One

of the key reasons for inadequate and

ineffective interventions is lack of

knowledge. This gap in knowledge can

only be filled by appropriately targeted

research [Bahl „et al‟, 2009]. This study

assessed the knowledge, attitude and

practice of health care providers and

factors affecting care provision so as to

recommend possible action.

Since the Ethiopian government prioritize

maternal and newborn care and promotes

facility based delivery care, this study

would potential identify gaps related to

providers capacity in provision of

immediate newborn care. This study also

indicates some other gaps in providing

quality immediate newborn care that would

be further investigated by others, it will

provoke further study.

3. OBJECTIVES

3.1. General Objective

To assess knowledge, attitude and practice

of health care providers and explore factors

affecting provision of immediate newborn

care in Addis Ababa public Health centers.

3.2 Specific Objectives

1. To identify the level of Health care

providers‟ knowledge, attitude and

practice about immediate Newborn

care.

2. To explore factors affecting

provision of immediate Newborn

care by health care providers.

4. MATERIALS AND METHODS

4.1. Study Setting

The study covered twenty four public

Health centers which provide delivery and

other MCH related services from all twenty

six health centers that are owned by Addis

Ababa city administration. Addis Ababa is

the capital city of Ethiopia and sit of

African Union & Economic Commission

for Africa. The Addis Ababa city

Administration is further structured into 10

Sub cities and 116 woreda. Based on 2007

census and annual growth rate of 2.1

percent, the estimated population of Addis

Ababa for the year 2010 is 2,914,404 and

women of reproductive age group accounts

for 34.6% of the total population.

4.2. Study Design

It is a health facility based cross sectional

study. The study uses both quantitative and

qualitative approaches. The quantitative

study section includes questionnaire and

record review. The qualitative study section

includes observation of cases managed and

in-depth interview of the head of the

facility.

4.3. Study Population

The source population was health care

providers who were working in public

health centre of A.A. The study populations

were those health care providers who were

engaged in immediate newborn care service

provision in these facilities during the data

collection period.

Inclusion criterion: Health care providers

who were providing immediate newborn

care were included in the study.

Exclusion criteria: Health care providers

who were not providing immediate

newborn care for more than three months

were excluded from the study.

4.4. Sample Size Determination

4.4.1. Sample size for quantitative

study

To determine the sample size to study

health care providers‟ knowledge, attitude

and practice about immediate newborn

care, the formula for single population

proportion used and the following

assumptions made. A Significance level of

95% and 5% margin of error was taken.

The study on assessment of Knowledge,

Attitude and Practice of health care

provider about Neonatal Resuscitation in

the Health centre in Sari-Iran showed a

prevalence levels for knowledge, attitude

and practice of 56%, 96% and 38%

respectively [Ahmady „et al‟, 2005].

n = (Zα/2) ² p (1-p)

(d) ²

Assumption

n= number of the study subjects

Z= is standardized normal distribution

curve/value for the 95% confidence interval

(1.96)

p = proportion of knowledge, attitude and

practice of the health care providers about

immediate newborn care (Knowledge,

attitude and practice levels are 56%,

96%and 38% respectively)

d = the margin of error taken (0.05 taken)

Since expected population is less than

10000, population correction is done using

the formula no/(1+n/N)

Non response rate=10%

Table 1: Sample size calculation for Knowledge, Attitude and Practice

Variable Prevalence Confidence

Level

Degree

of

Precision

no Sample

size

calculated

Non-response

rate (10%)

Total

sample

size

Knowledge 56% 95% 0.05 378 114 11 125

Attitude 96% 95% 0.05 59 112 11 123

Practice 38% 95% 0.05 362 114 11 125

Of the three sections used to calculate the

sample size, a larger sample size was found

in a section for Knowledge and practice

study (table 1). Therefore a sample size of

125 was considered as appropriate for this

study. However, since the number of

health care provider fulfilling the inclusion

criteria in the study area did not reach 125,

all health professionals (census) involved

in provision of newborn care in all public

health centers were enrolled in the study.

Of the total 26 public health centers that

are owned by the city administration, only

24 health centers that were providing

delivery and other MCH serves during the

time of data collection were enrolled in this

study. The study managed to interview 109

out of 114 health care providers who were

actively providing services during the time

of data collection.

Service utilization data were extracted

from all 24 public health centers of Addis

Ababa by reviewing records for the time

period of January 1st to December 31

st,

2010.

4.4.2. Sample size for qualitative study

An in-depth interview was conducted with

the head of each public health centers. Of

the total eligible 24 public health centers in

Addis Ababa, the head of all 24 facilities

were interviewed.

The study planned to observe all newborns

that were managed during the data

collection periods. The study managed to

observe 18 newborns that received care

during data collection period.

4.5. Sampling Procedures

The list of facilities that were providing

delivery and other MCH services was

found from Addis Ababa Regional Health

Bureau. A list of providers that were

involved in neonatal care was received

from the head of delivery/MCH department

of the respective health centers. The

maximum effort was done to ensure that all

the providers involved in immediate

newborn care provision during the study

period were interviewed. The data

collection was conducted during working

hours in week days but data collectors

reach to each health center as early as

possible to make possible arrangements for

interviewing night duty providers. The data

collectors also reached those providers, not

available during data collection, and

arranged time for interview. An in-depth

interview was conducted with the head of

all 24 public health centers.

The data collection process was set up to

facilitate that all newborns receiving care

during data collection period are observed

by data collectors. The registers available

in the facility were identified to determine

the source of data for record review.

4.6. Data Collection Procedure

The time and location for one-to-one

questionnaire interview with health care

provider was arranged based on

convenience for each provider. The

interview started with explaining the

purpose of the study and after informed

consent. The data collector preceded the

interview with each part of the questioner.

An in-depth interview with head of the

facility was conducted on a time

convenient at his/her office. All efforts

were done to observe all newborn cases

that received care during the day of data

collection, interview with health care

providers were reschedule a few times to

observe these cases. The proper register

identified and records of interest were

reviewed from record.

The questionnaire was prepared and used

in English. The data collectors were four

BSc Midwifes and one BSc Nurse that

have the technical knowledge about the

subject of interest, capacity to understand

the questioner and experience in data

collection. The data collectors were trained

on content of each questionnaire, data

collection techniques and procedures. The

data collectors further enriched their

understanding through pretesting the

instruments and ongoing support from the

investigator. The detailed logistics and

field schedule was prepared with data

collectors.

4.6.1. Pre-test

Before conducting the study, pre test was

carried out in one of non-governmental

health centre called SIPAR MCH Health

centre, which would not be included in this

study. All parts of the study tools were

tested for its clarity, understandability,

completeness, and reliability. The

questionnaire that assesses Knowledge,

Attitude and Practice were administered for

10 neonatal health care providers. A two

separate in-depth interview was conducted

with the heads of labour and neonatal ward

of the facility. Two cases were observed

while receiving care during pretesting.

Record review format was also pretested

using General admission and

discharge register along with maternity

and delivery register. The questionnaires

were reconstructed based on the additional

information that was obtained during the

pre-test.

4.7. Variables of the Study

This study focus on the Knowledge,

attitude and practice of health providers

about immediate newborn care, which are

comprehensive and cost effective

interventions provided to newborns to save

life, prevent morbidity and mortality.

The independent variables that looked in

the study are:

i. Socio demographic characteristics:

Age and sex of the health care

provider

ii. Professional category

iii. Service year of health care

providers

iv. In service training

4.8. Operational Definition

The key danger signs in the newborn

include: poor sucking or not sucking at all;

inactivity or lethargy; fever or

hypothermia; respiratory distress;

convulsions; vomiting; abdominal

distension; umbilical infection and baby

very small.

Immediate Newborn Care: is care

provided to a newborn immediately after

delivery which includes the time between

birth to 24 hours care.

Thermal care is keeping the baby dry,

clean and warm and avoiding bathing

within 24 hours after birth.

Intervention package: A group of

evidence based interventions proven to be

individually effective in reducing neonatal

mortality and are combined to apply to the

same time period.

LBW (Low birth weight): Birth weight less

than 2500gram.

Satisfactory Knowledge: Those health

providers who correctly answer to at least

half of the knowledge questions are

categorized as having satisfactory

knowledge.

Good Attitude: Those health providers

who responded agree to strongly agree for

attitude questions are categorized as having

good attitude.

Satisfactory Practice: Those health

providers who were able to provide half of

the standard actions during the last care

they provided services are categorized as

having satisfactory practice.

4.9. Data Quality Management

In order to have credible result, it is very

crucial to ensure the quality of data

controls at all levels of design and

implementation of the study. When the

questionnaire was designed, attention was

given to have standard questions which

were stated in clear, complete and simple

language. It was pre tested in similar

population for clarity and sensitivity and

then made necessary modifications. To

ensure the quality of data, data collectors

were senior BSc Midwife and Nurse, who

were working in hospitals and NGO sector.

The data collectors were trained on all data

collection tools and procedures through

reviewing, discussing and field testing the

tools. A close supervision, daily visit by

the investigator, was done on site during

data collection period to ensure that quality

information were collected and recorded.

Proper coding of data carried out after the

information was checked again for

completeness and internal consistency. The

investigator and data collector took

corrective discussion. Remarks were given

every day on how to minimize errors and

took corrective actions timely.

4.10. Data Analysis

After all the necessary data collected, the

collected data were cleaned, coded and

entered using EPI-Info version 3.5.1,2008

then transferred to SPSS, recoding and

categorizing made through transformation.

Descriptive analysis of major dependent

and independent variables are made

through univariant analysis and frequency

distribution produced accordingly. The

association of the dependent variables to

socio-demographic, professional category,

training and service year was tested using

cross tab and logistic regression. Crude and

adjusted OR with 95% confidence interval

(CI) was seen to appreciate the level of

association. The association of selected

knowledge variable like the time that takes

to clear the airway and stimulate breathing

and treatment of neonatal jaundice was

tested with training, professional category

service year and age.

The level of Knowledge about immediate

newborn care was assessed based on

whether the providers know all

intervention package of newborn care or

not (Essential or Basic, Extra and

Emergency newborn care). A criterion used

to level whether the provider is

knowledgeable or not are: if he/she

answers all of the responses for questions

related to classification (component);

mention at least half of the options for

multiple responses and correctly responded

to questions with single response. The total

knowledge score of providers is calculated

from all the questions related to

knowledge; range and median is also

looked. To have satisfactory knowledge

they have to answer at least 19 out of 38

knowledge questions correctly.

A scale of one for strongly disagree to four

for strongly agree are used to evaluate

providers attitude. A median attitude score

is calculated and histogram is used to look

for the distribution of the score. A provider

is considered having good practice when

he/she provides all essential/basic care to

all newborns during labor and birth;

diagnose and provide appropriate care for

LBW and sick newborn consult seniors and

refer cases timely.

The qualitative data for practical

observation and in-depth interview of head

of health centers are summarized

thematically to relate with other section of

the study.

4.11. Ethical Consideration

Ethical approval obtained from university

of Haramaya and Addis Continental

institute of public health. An official letter

of cooperation was also obtained from

Health Bureau of Addis Ababa City

Administration, which communicated to

each public health centre enrolled in the

study. The study participants were

informed about the purpose of the study

and the importance of their participation in

the study, and then verbal consent was

taken from each study participants to

confirm willingness. In order to ensure

confidentiality of respondents, their name

was not mentioned. In the process of

observing care for mothers and newborns,

the data collector or investigator support

and ensure proper care of those exposed to

mismanagement or with serious

complications.

4.12. Dissemination of Results

The result of the study will be

communicated to the relevant organizations

and submitted to Addis Continental

institute of public health and to the school

of public health in Haramaya. The study

will be presented to relevant forums,

professional conferences and workshops. A

paper will be sent for publishing in one of

the local scientific journals.

5. RESULT AND DISCUSSION

5.1. Result

5.1.1. Knowledge, Attitude and Practice

on Immediate Newborn Care

5.1.1.1. General

A total of 109 health professionals, with a

response rate of 95.6%, interviewed in all

24 public health centers. Three to eight

providers, on average of five, providers

interviewed from each health center. The

average age of respondents is 31 years and

most are females (78.9%). Almost equal

proportion of Midwives (50.4%) and

Nurses (49.6%) are interviewed for the

study. The mean service year of providers

interviewed is about 6 years. A little over

one third (38.5%) of providers are trained

on newborn care (table 2). Of those trained,

66.7% are trained in the last one year and

78.6% had training for duration of at least

three days. The training content reported

by those providers trained, included:

resuscitation (95.2%), thermal care

(47.6%), clean chain (45.2%), MTCT/HIV

(33.3%), immunization (31.0%) and breast

feeding (4.8%). There was no one reporting

training on treatment of severe neonatal

infection.

Table 2: Characteristics of immediate newborn care providers working in 24 public

health centers of Addis Ababa, 2011

No. Characteristics Response Frequency # (%)

1 Age (Years) 20 – 30

31 – 40

41 – 50

51 – 60

68 (62.4%)

26 (23.9%)

13 (11.9%)

2 (1.8%)

Mean = 30.7+ 7.8 years

2 Sex Male

Female

23 (21.1%)

86 (78.9%)

3 Professional Category Midwife – BSc

Midwife – Diploma

Nurse – BSc

Nurse – Diploma

18 (16.5%)

37 (33.9%)

16 (14.7%)

38 (34.9%)

4 Service Year after last graduation 1 – 3

4 – 6

7 – 9

> 10

38 (34.9%)

37 (33.9%)

11 (10.1%)

23 (21.1%)

Mean = 5.68 + 1.12 years

5 Ever trained on newborn care Yes

No

42 (38.5%)

67 (61.5%)

5.1.1.2. Knowledge

The knowledge of describing the

interventions under each category of

newborn care is low. Only 27 (24.8%) of

the providers correctly classified the three

newborn care interventions. Fifty one

(46.8%) providers know all the

interventions under essential newborn care.

All the interventions under extra care for

LBW and emergency newborn care are

listed in 19.3% and 4.6% of providers

respectively. Over half (55%) of the

providers know all the components of clean

chain (table 3).

Table 3: Knowledge of immediate newborn care providers on classification and packages

of newborn care interventions working in 24 public health center of Addis Ababa, 2011

No. Knowledge Response Frequency # (%)

1 Know classification of newborn care

interventions

Yes

No

27 (24.8%)

82 (75.2%)

2 Know interventions under essential

newborn care

Yes

No

51 (46.8%)

58 (53.2%)

3 Know interventions under extra care for

LBW

Yes

No

21 (19.3%)

88 (80.7%)

4 Know interventions under emergency

newborn care

Yes

No

5 (4.6%)

104 (95.4%)

5 Know components of clean chain Yes

No

60 (55.0%)

49 (45.0%)

The same proportion (96.3%) of providers

correctly knows the first action for a baby

with clear amniotic fluid or meconium

stained amniotic fluid. The right time, < 1

minute, which takes to dry baby, clear

airway and stimulates breathing, was

reported by 35.8% of providers. Close to a

quarter (28.4%) of providers know the time

to clamp or tie cord, wait 1 to 3 minutes.

Over half (57.8%) of providers listed at

least half of the options for alternative

methods to keep baby warm. The most

commonly mentioned methods are: wrap

up and use hat for baby (80.7%); dry

thoroughly (79.8%) and keep baby skin to

skin of mother (79.7%). The least

mentioned method is post pond bathing for

24 hours (14.7%). Over ninety percent

(92.7%) of providers interviewed know

what to do for bleeding from umbilical

cord, applying another tie between first one

and baby skin. Though 105 (96.3%) of

providers stated that Vitamin K should be

given for all newborn, only 52 (47.7%)

know the correct dose for normal newborn.

The two common vaccination given at

birth, BCG and Oral polio, are known by

106 (97.2%) of providers. The knowledge

for how to care baby eye and when to

initiate breast feeding was found to be

77.1% and 89.9% respectively (table 4).

Table 4: Knowledge of immediate newborn care providers on Essential Newborn Care

Interventions working in 24 public health centers of Addis Ababa, 2011

No. Knowledge Response Frequency # (%)

1 First action for a baby with

meconium stained amniotic

fluid

Clear air way

Drying

Breast feeding

105 (96.3%)

12 (11.0%

10 (9.2%)

2 How long it take to dry baby,

clear airway & stimulate

breathing

< 1 minute

2 -3 minute

5 minute

> 10 minute

39 (35.8%)

50 (45.9%)

14 (12.8%)

6 (5.4%)

3 Time to clamp or tie cord Immediately

Wait 1 -3 minutes

78 (71.6%)

31 (28.4%)

4 Alternative methods to keep

baby warm

Dry thoroughly

Wrap up and use hat for baby

Warm mother

Warm the room

Baby skin to skin of the mother

Put under incubator

Post pond bathing for 24 hours

87 (79.8%)

88 (80.7%)

50 (45.9%)

63 (57.8%)

76 (79.7%)

38 (34.9%)

16 (14.7%)

5 Know how to care for baby eye

(clean eye and give eye drop)

Yes

No

84 (77.1%)

25 (22.9%)

6 When to start breast feeding? Within one hour of delivery

After one hour of delivery

98 (89.9%)

11 (10.1%)

The definition for LBW, weight < 2.5 kgs,

is known by 93 (85.3%) of providers. Over

half (54.1%) of providers listed at least

three kinds of extra care for newborn

weighs < 2.5 kgs. The most common kind

of care listed by providers are: thermal

protection (87.2%) and extra support to

establish breast feeding (86.2%) followed

by monitor ability to breast feed (59.6%)

and ensure infection prevention (32.1%).

Only 7 (6.4%) providers correctly

responded to the dose of Vitamin K for

LBW.

Only nine (8.3%) providers listed over half

of the danger signs in newborn. The most

common danger signs listed are: poor

sucking (86.2%), respiratory distress

(78.9%), fever or hypothermia (46.8%) and

inactivity or lethargy (43.1%). Eighty nine

(81.7%) providers are able to diagnose

birth asphyxia using at least two of the

criteria. The most common signs providers‟

looks for diagnosing asphyxia are

depressed breathing (85.3%) and central

cyanosis (63.3%), (table 5).

Over half (54.1%) of providers know on

how to identify baby for resuscitation but

only 11 (10.1%) and 24 (22.0%) know all

the steps of resuscitation and at least half of

the actions to do when baby fails to breath

after ventilation respectively. Though a

high proportion (88.1%) of providers

knows on how to select the correct mask,

it‟s only 42 (38.1%) providers who know

what to do when resuscitating with bag and

mask or tube and mask. Ninety Eight

(89.9%) providers know the position of

baby head, slightly extended, to open the

airway. Over half (59.6%) of the providers

know when to check heart rate, after 1

minute of ventilation, while breathing with

bag and mask. In response to what the

provider will do in case when bag and

mask or oxygen is not available for

resuscitation to save baby life, 70 (64.2%)

mentioned mouth to mouth resuscitation

with care. Over half (58.7%) of providers

listed at least two of the newborn

resuscitation practices that should be

discouraged. Of those practices that should

be discouraged, 94.5%, 54.1% and 37.6%

of providers listed holding baby upside

down, heavy suctioning of back of the

throat and routine suctioning of mouth and

nose of a well baby respectively.

Thirty one (28.4%) providers know at least

half of the signs and symptoms of infection

in newborn. Most providers listed

hypothermia or hyperthermia (79.8%) and

poor or no breast feeding (66.1%) followed

by less movement or poor muscle tone

(44.0%); restlessness or irritability (42.2%)

and difficulty or fast breathing (41.3%).

The most common action that the providers

know for newborn with signs of infection

are beginning antibiotics (71.6%) followed

by referral (58.7%), continue breast

feeding (44.0%) and keep airways open

(22.9%). Close to two third (63.3%) of the

respondents know at least three of the

common way to prevent infection in

neonate. The most common ways of

prevention listed by providers are clean

delivery (87.2%) followed by eye

prophylaxis (60.6%), good cord care

(59.6%), treatment of STI in the mother

during pregnancy (55.0%) and antibiotics

for prolonged rupture of membrane

(41.2%).

Table 5: Knowledge of immediate newborn care providers on Extra care for LBW and

Emergency Newborn Care working in 24 public health centers, Addis Ababa, 2011

No. Knowledge Response Frequency # (%)

1 Kind of extra care for

newborn weighs <2.5 kgs

Ensure thermal protection

Support to establish breast feeding

Monitor ability to breast feed

Monitor baby for first 24 hour

Ensure infection prevention

95 (87.2%)

94 (86.2%)

65 (59.6%)

12 (11.0%)

35 (32.1%)

2 Danger signs in newborn Poor sucking or not sucking well

Inactivity or lethargy

Fever or hypothermia

Respiratory distress

Convulsions

Vomiting

Abdominal distension

Umbilical infection

Baby very small

Jaundice, pale and bleeding

Serious abnormality

94 (86.2%)

47 (43.1%)

51 (46.8%)

86 (78.9%)

16 (14.7%)

16 (14.7%)

9 (8.3%)

16 (14.7%)

26 (23.9%)

41 (37.6%)

13 (11.9%)

3 How you diagnose birth

asphyxia?

Depressed breathing

Floppiness

Heart rate <100 beats/minute

Central cyanosis

93 (85.3%)

30 (27.5%)

44 (40.4%)

69 (63.3%)

4 Signs and symptoms of

infection in newborn

Less movement

Poor or no breast feeding

Hypothermia or hyperthermia

Restlessness or irritability

Difficult or fast breathing

Deep jaundice

Severe abdominal distension

Others

48 (44.0%)

72 (66.1%)

87 (79.8%)

46 (42.2%)

45 (41.3%)

15 (13.8%)

13 (11.9%)

2 (1.8%)

5 Actions when newborn

presents with signs of

infection:

Explain to mother or care giver

Continue breast feeding

Keep airways open

Begin antibiotics

Refer

15 (13.0%)

48 (44.0%)

25 (22.9%)

78 (71.6%)

64 (58.7%)

6 Prevention of infection in

neonate:

Treatment of STI during

pregnancy

Antibiotics for PROM

Clean delivery

Good cord care

Eye prophylaxis

60 (55.0%)

45 (41.3%)

95 (87.2%)

65 (59.6%)

66 (60.6%)

Twenty seven (24.8%) of providers are

able to diagnose neonatal jaundice. Almost

similar proportion (25.7%) of providers

knows on how to treat neonatal jaundice.

The most common treatment option

mentioned was phototherapy (44.0%)

followed by exchange transfusion (28.4%)

and antibiotic therapy if infection is

suspected (17.4%). Only 11 (10.1%) of

respondents know at least three serious

abnormalities of newborn.

5.1.1.3. Practice

The overall essential (basic) newborn care

practice by providers in the last case they

provided service is satisfactory, 80.7% had

a correct practice. Only 22.0% of providers

practiced at least two ways that helped the

baby to cry or breath immediately after

birth, majority (93.6%) did rub or massage

the baby. The practice of drying and

wrapping baby immediately after birth

(97.2%) and Keeping the baby on the

mother abdomen or chest immediately after

birth (95.4%) are almost universal. At least

half of the reasons why the newborn kept

close to the mother was listed in 71

(65.1%) of providers, the reasons

mentioned most by providers are for

bonding (90.8%) followed by to keep baby

warm (69.7%) and stimulate breast feeding

(11.9%).The advice for immediate

initiation of breast feeding, before the

placenta is delivered/ immediately after

birth, was given by 63 (57.8%) providers.

70.6% of the providers did bath the baby

for the first time after 24 hours of birth

(table 6).

The extra care for premature or LBW was

provided by 68 (62.4%) of providers. The

overall extra care for premature or LBW

practiced by providers in the last case they

provided service was not satisfactory, only

40.4% did practice at least half of the

standard actions. Of those extra care

services provided for premature or LBW in

the last three months, the most common are

thermal protection (89.7%) and support to

establish breast feeding (88.2%) followed

by ensuring infection prevention (22.9%)

and monitor baby for the first 24 hours

(14.7%).

Over three quarter (78.0%) of providers

reported practice in neonatal resuscitation

in the past three months. There is no

provider that reported providing parenteral

antibiotics for newborn infection in the last

three months. The reasons listed for not

having practice on provision of parenteral

antibiotics by all providers are: lack of

supplies, equipment and drugs; no training

related to care provision and management

issues. All of the providers did practice

testing for HIV and providing ARV for

mothers and newborn. Though counseling

on clean cord care during last postnatal

visit was given by 105 (96.3%) providers,

good postnatal care with at least half of the

standard activities were performed in only

19 (17.4%) of providers. Checking and

counseling for danger signs are practiced in

only 11.0% and 4.6% of the providers

respectively. The providers weighed baby

and counseled skin to skin contact /warmth

in 27.5% and 19.3% of cases respectively.

Table 6: Immediate Newborn Care provider Practice during the last care they provided

in 24 public health centers, Addis Ababa, 2011

No. Practice Response Frequency # (%)

1 What do you do for the baby to

cry or breath easily immediately

after birth?

Rubbed/massaged

Dried

Mouth cleared

102 (93.6%)

22 (20.1%)

17 (15.6%

2 Did you dry and wrapped baby

immediately after birth?

Yes

No

106 (97.2%)

3 (2.8%)

3 Where was the baby put

immediately after birth?

Mother abdomen or chest

With someone else

Separate abdomen

104 (95.4%)

4 (3.7%)

1 (0.9%)

4 Did you advice to immediately

breast feed the baby after birth?

Yes

No

63 (57.8%)

46 (42.2%)

5 How long after birth was the baby

bathed for the first time?

6 hours

24 hours

72 hours

Don‟t know

17 (15.6%)

77 (70.6%)

8 (7.3%)

7 (6.4%)

6 Provided extra care for premature

or LBW

Yes

No

68 (62.4%)

41 (37.6%)

7 Of those who do practice extra

care for LBW, kind of care

Thermal protection

Establish breast feeding

Monitor breast feeding

Monitor baby for 1st 24 hours

Ensure infection prevention

61 (89.7%)

60 (88.2%)

50 (73.5%)

10 (14.7%)

25 (22.9%)

8 Has neonatal Resuscitation with

bag and mask been performed in

the last three months

Yes

No

85 (78.0%)

24 (22.0%)

9 Has parenteral antibiotics given

for newborn with infection in the

last three months

Yes

No

0

109 (100%)

10 HIV rapid testing been performed

and ARV given to mothers &

newborns in the last three months

Yes

No

109 (100%)

0

5.1.1.4. Attitude

One hundred three (94.5%) providers said

providing newborn care is part of their job.

100 (91.7%) of the respondent said they are

happy to practice neonatal care. 101

(92.7%) of the respondent said they are

willing to give care for neonate in the

future. The reasons mentioned by those not

happy to practice neonatal care or not

willing to give care for neonate in the

future are work load, lack of equipment

and supply and low salary.

Overall, the health providers interviewed

had a very positive attitude towards

newborn care interventions, 98.6% of the

response from the providers had good and

very good attitude towards newborn care.

Almost all agree to strongly agree for care

related to maintaining clean and warm

chain; screening for HIV and giving ARV

and immediate initiation of breast feeding.

Only few providers (4.6%) disagree for

avoiding bath within 24 hrs of birth and

provision of Vitamin K for all newborn, the

others agree to strongly agree for these

interventions (table 7). An average attitude

score of 27.5 (out of 28) is found and more

skewed distribution towards positive

attitude is seen (figure 1).

Table 7: Attitude of immediate newborn care provider to the newborn care interventions

in 24 public health centers, Addis Ababa, 2011

No

Do you agree:

Frequency # (%)

Strongly

agree

Agree Disagree Strongly

disagree

1 To Maintain clean chain? 108

(99.1%)

1 (0.9%) 0 0

2 To Maintain warm chain? 107

(98.2%)

2 (1.8%) 0 0

3 To avoid bathing of baby within 24

hours after birth

96

(88.1%)

8 (7.3%) 5

(4.6%)

0

4 To give Vitamin K for all newborn? 95

(87.2%)

9 (8.3%) 5

(4.6%)

0

5 To give screening test for the mother? 107

(98.2%)

2 (1.8%) 0 0

6 To give ARV to newborns in the

maternity/labour ward (MTCT/HIV)?

105

(96.3%)

4 (3.7%) 0 0

7 To counsel postpartum woman on

immediate initiation of breast feeding?

102

(93.6%)

6 (5.5%) 1

(0.9%)

0

Figure 1: Attitude Score of immediate newborn care providers to the newborn care

intervention in 24 public health centres, Addis Ababa, 2011

5.1.2. Practical Observation

A total of 18 cases were observed during

the data collection period. Of these, 16

(88.8%) are essential care for newborn

immediately after birth and the other two

are care for LBW and neonate with

complications. Most of these cases were

attended by midwife (61.11%) and the

remaining cases (38.9%) are attended by

nurses.

During labor and birth; proper support to

mother and newborn and maintaining clean

chain was done in 83.3% and 77.8% of the

cases respectively. The provider supported

early initiation of breast feeding and gave

proper cord and skin care in 27.8% and

66.7% of the cases respectively. Provision

of Vitamin K, Immunization and

MTCT/HIV services are observed in

83.3%, 94.4% and 100% of the cases

respectively. The other observations are:

suturing episiotomy without giving

anesthesia in nine cases; lack of clean

clothes in 15 of the cases and lack of

Vitamin K and TTC eye ointments in three

and one facilities respectively. Overall,

29.00 28.00 27.00 26.00 25.00 24.00 23.00

80

60

40

20

Mean =27.50 Std. Dev= 0.987

N =109

F

r

e

q

u

e

n

c

y

good basic care was given to 55.6% of the

cases observed during the study period.

The only case of neonate with LBW was

not given appropriate care. In most of the

health centers there was no heater or cotton

cloth. A case of neonate with complication

observed during the study period was

referred to higher facility for appropriate

care. Most of the health centers are not

ready to respond to emergencies. In most

of the health centers, there was no neonatal

corner.

Except in one case, findings from all the

other cases (94.4%) were properly recorded

on the registration book.

5.1.3. Interview with Key Informant

(Head of Health Center)

The type of immediate newborn care

services provided by health centers are

listed by head of the facilities. Except

thermal care (37.5%) and resuscitation

(50.0%), all the other essential care

services are available in all health centers.

All the health centers reported that they

don‟t have services related to care for

LBW or for the sick.

The most common problems in provision

of immediate newborn care listed by head

of the facilities are related to lack of

supplies and equipment followed by lack of

trained staff and budget. Twenty one

(87.5%) of the health centers reported

stock out of supplies/equipment to give

immediate newborn care. Twenty (83.3%)

facilities reported having at least one

trained provider. A total of 50 providers

have been trained in these facilities, an

average of two providers are trained in

each health center.

Fourteen (58.3%) health centers have

protocols for management of obstetric and

newborn complications. Eighteen (75.0%)

health centers have protocol on essential

newborn care. All managers of study

facilities responded that immediate

newborn care is a priority for their facility.

Three fourth (75.0%) of managers

interviewed said that the quality of

immediate newborn care services has

improved during the past one year. The

changes in quality of immediate newborn

care services listed by managers are:

procurement of drugs and equipments;

facilitation of training and assignment of

staff. Almost all managers would like to

improve immediate newborn care services

in their facility through training and

assigning staff; allocating more budgets;

improving supply and equipment and

establishing neonatal corner.

5.1.4. Record Review

All the registers are looked for

information‟s related to delivery and

immediate postnatal care. Each health

center have at least two register with key

information related to immediate newborn

care. The type of register are Maternity and

delivery register (24, 100%); General

admission and discharge (20, 83.3%);

Postnatal (9, 37.5%); Referral (5, 28.8%)

and HMIS (3, 12.5%). The quality of data

was also looked in these facilities: missing

data reported only in four health centers

and all the health centers have up to date

information in their registers

A twelve month (one year) service

utilization data was collected from all 24

study health centers. A total of 20,007

deliveries registered in these facilities. The

average delivery per facility per year is

834. The median number of deliveries

reported in all facilities per month is 69 +

4, no special variation observed in month

(figure 2). The few of institutional based

quality and outcome indicators are:

newborn complication rate of 0.3 per 100

live births; LBW rate of 4.0 per 100 live

births and still birth rate of 7.7 per 1000

total deliveries (table 8).

Figure 2: Average number of deliveries per month in 24 public health centers of Addis

Ababa, 2011

Table 8: Service related to immediate newborn care provided from the period of

January to December 2010, in 24 public health centers of Addis Ababa

Number of cases received care during a year (January to December 2010)

Services # of HCs reporting Total # of cases in a year

1. Delivery 24 20,007

2. Mode of Delivery

2.1. Normal (SVD) 24 19,952

2.2. Instrumental (Forceps & vacuum) 10 55

3. Live births and Deaths

3.1. Still Births 22 154

3.2. Live Births 24 19,853

3.3. Early Neonatal deaths 4 10

4. Preterm and LBW

4.1. Preterm 2 2

4.2. LBW 23 800

5. Newborn Complications

5.1. Asphyxia 7 51

5.2. Aspiration Pneumonia 0 0

5.3. Sepsis 0 0

5.4. Congenital Anomalies 2 5

5.1.5. Factors Affecting Providers

Knowledge, Attitude and Practice

The median knowledge score for

knowledge is 19 out of 38 and range from

9 to 31. Based on the total average score

for knowledge, 51.4% of providers have

satisfactory knowledge. Those who are

trained on newborn care, midwife by

profession and long years of service looks

more knowledgeable than the other group.

The result is only significant for those with

ten and over years of service (table 9).

The knowledge of providers on how long

should it take to dry baby, clear air way

and stimulate breathing is slightly more in

ever trained than not trained; midwives

than nurses and those with 7 - 9 years

service than the other but the result are not

significant (table 10).

Table 9: Association of immediate newborn care provider’s knowledge on immediate

newborn care with training, professional category, service year and age working in 24

public health centers, Addis Ababa, 2011

Variable Response Knowledgeable, (#,%)

N = 109

Crude OR with

95% CI

Adjusted OR with

95% CI

Yes No Total

Ever

Trained

Yes

No

24 (57.1%)

32 (47.8%)

18 (42.9%)

35 (52.2%)

42

67

1.46 (0.67-3.17) 1.27 (0.53-3.04)

Professional

category

Midwife

Nurses

31 (56.4%)

25 (46.3%)

24 (43.6%)

29 (53.7%)

55

54

1.50 (0.70-3.19) 0.87 (0.37-2.07)

Service year 1 -3

4 -6

7 -9

10+

19 (50.0%)

13 (35.1%)

7 (63.6%)

17 (73.9%)

19 (50.0%)

24 (64.9%)

4 (36.4%)

6 (26.1%)

38

37

11

23

1.88 (0.73-4.67)

1

3.23 (0.80-13.12)

5.23 (1.66-16.52)

1.86 (0.70-4.94)

1

3.06 (0.73-12.84)

4.15 (1.19-14.50)*

Age 20 – 30

31 – 40

41 – 50

51 – 60

31 (45.6%)

15 (57.7%)

9 (69.2%)

1 (50.0%)

37 (54.4%)

11 (42.3%)

4 (31.8%)

1 (50.0%)

68

26

13

2

1

1.19 (0.07-19.88)

1.63 (0.65-4.05)

2.69 (0.75-9.57)

1

1.28 (0.46-3.51)

2.10 (0.53-8.38)

0.71 (0.04-13.93)

*- Made to show statistical significant association. 1- is representing referent

Table 10: Association of Knowledge of immediate newborn care providers on how long

should it take to dry the baby, clear the airway and stimulate breathing by training,

professional category, service year and age working in 24 public health centers, Addis

Ababa, 2011

Variable Response Knowledgeable, (#,%)

N = 109

Crude OR with

95% CI

Adjusted OR with

95% CI

Yes No Total

Ever

Trained

Yes

No

17 (40.5%)

22 (32.8%)

25 (59.5%)

45 (67.2%)

42

67

1.39 (0.63-3.01) 1.18 (0.49-2.85)

Professional

category

Midwife

Nurses

23 (41.8%)

16 (29.6%)

32 (58.2%)

38 (70.4%)

55

54

2.08 (0.49-8.79) 0.62 (0.26-1.51)

Service year 1 -3

4 -6

7 -9

10+

11 (28.9%)

12 (32.4%)

6 (54.6%)

10 (43.5%)

27 (71.1%)

25 (67.6%)

5 (45.5%)

13 (56.5%)

38

37

11

23

1

1.18 (0.44-3.15)

2.95 (0.74-11.69)

1.89 (0.64-5.57)

1

1.40 (0.50-3.95)

2.93 (0.72-11.92)

1.79 (0.54- 6.01)

Age 20 – 30

31 – 40

41 – 50

51 – 60

24 (35.3%)

8 (30.8%

6 (46.2%)

1 (50.0%)

44 (64.7%)

18 (69.2%)

7 (53.8%)

1 (50.0%)

68

26

13

2

1

1.23 (0.47-3.24)

1.93 (0.49-7.61)

2.25 (0.13-40.65)

1

1.32 (0.46-3.79)

1.98 (0.47-8.23)

2.51 (0.12-52.44)

1- is representing referent

Those who are trained on newborn care,

midwife by professional and long years of

service looks more knowledgeable on

treatment of neonatal jaundice than the

other group. Before adjusting, the

difference is significant among trained,

those who are midwives and with ten and

over years of service. But after adjusted,

the adjusted odds ratio, only service years

has significant relation with treatment of

jaundice. The knowledge of providers on

treatment of jaundice increases with

increase in service years (table 11).

Table 11: Knowledge of immediate newborn care providers on treatment of neonatal

jaundice by training, professional category and service year working in 24 public health

centers, Addis Ababa, 2011

Variable Response Knowledgeable, (#,%)

N =

Crude OR with

95% CI

Adjusted OR with

95% CI

Yes No Total

Ever

Trained

Yes

No

17 (40.5%)

11 (16.4%)

25 (59.5%)

56 (83.6%)

42

67

3.46 (1.42-8.46) 2.37 (0.91-6.20)

Professional

category

Midwife

Nurses

20 (36.4%)

8 (25.7%)

35 (63.6%)

46 (85.2%)

55

54

3.29 (1.30-8.33) 2.72 (0.91-7.71)

Service year 1 -3

4 -6

7 -9

10+

7 (18.4%)

7 (18.9%)

3 (27.3%)

11 (47.8%)

31 (81.6%)

30 (81.1%)

8 (72.7%)

12 (52.2%)

38

37

11

23

1

0.97 (0.30-3.10)

1.61 (0.34-7.66)

3.93 (1.23-12.54)

1

1.38 (0.39-4.87)

1.38 (0.27-7.22)

3.63 (1.05-12.53) *

*- Made to show statistical significant association. 1- is representing referent

5.2. Discussion

The three newborn care intervention

packages are: essential newborn care for all

babies, extra newborn care for LBW babies

and emergency newborn care for sick

babies. Universal implementation of these

intervention packages could avert up to 41-

72% of neonatal death. The

implementation of these interventions is

highly affected by the performance of

health professionals which could mostly be

related to knowledge, attitude and practice

(KAP) of health professional.

A study conducted in Ethiopia on

knowledge, attitude and practice of health

care providers in relation to immediate

newborn care are very limited and specific

to single component of newborn care. This

facility based cross sectional study is

conducted to assess the knowledge, attitude

and practice of health care providers and

explore factors affecting care provision.

The study could be used as a base to

strategically design facility based newborn

care interventions.

The study included administration of

questioner to all providers involved in

newborn care provision; observation of

cases managed during data collection

period; interview head of health centers

and review one year service utilization data

from the facilities. A total of 109, with

response rate of 95.6%, providers were

responded to questioner and 18 cases

observed while receiving care. The head of

all public health centers (24) were

interviewed and data on service utilizations

extracted from all these facilities.

Of those with ten and more years of

service, 61% are Midwives. Similar (61%)

proportions of providers with less than four

year of experience are with BSc education.

This is related to both the current system

for higher education and the previous

training program for nurse midwife. It‟s

only 42 (38.5%) providers, similar to what

managers reported (50), received training

on newborn care. The training on newborn

care with focus on neonatal resuscitation in

the last year relates with focused program

effort to address the common neonatal

health problem, Asphyxia. This figure of

trained providers is a little higher than what

is found in 2008 national EmONC

assessment, 24% of providers received in-

service training on neonatal resuscitation.

This is also reflected on availability of

neonatal resuscitation services in over three

fourth of the facilities (83%). The

availability of neonatal resuscitation is

higher than what the national EmONC

assessment reported for the health centers,

41%. The study in Zambia even showed a

higher level impact of the training, a

decrease in early neonatal moratlity from

11.5 to 6.8 deaths per 1000 LB [Waldemar

„et al‟ 2010].

Though infection is the major cause of

neonatal death, no one had training related

to managing neonatal infection and there is

no health center providing paraenteral

antibiotics or managing sick newborn. This

figure is lower than what is reported in

national EmONC assessment, 15% of

health centers provided parenteral

antibiotics for newborn during three month

before the survey. These figures are very

low compare to what other countries are

reached to expand the services to the

community level.

The health centers in Addis Ababa are

attending over one third of births expected

in the city. This could be related to easy

access and strong referral system. Almost

all health centers are attending normal

deliveries and serious cases seems to go for

higher facilities. The findings on

complication and still birth rate of 0.3 per

1000 LB and 7.7 per 1000 total deliveries

respectively are very low compare to other

national studies; national EmONC study

found a still birth rate of 22/1000 total

deliveries at health center level.

Based on the total average score for all

knowledge related variables, little over half

(51.4%) providers have satisfactory

knowledge and this figure varies for

different component of newborn care

interventions. Though midwives and those

trained on newborn care looks to have a

better total average score, significant

relation is only observed in those with

service year ten and over. This could be

related to: most of those who are ten and

over years of experience are midwives;

strong nurse midwife training program in

previous years and poor quality of pre-

service education in the recent years. The

overall knowledge related to essential

newborn care is better than care for LBW

and sick newborn.

Overall, the health providers interviewed

had a very positive attitude towards

newborn care interventions, 98.6% of the

responses from the providers had good and

very good attitude towards newborn care.

This figure is higher than what the study in

Sari, Iran, reported; 96.34% had good to

very good attitudes towards neonatal

resuscitation.

The overall essential newborn care practice

by providers in the last case they provided

service is satisfactory, 80.7% had a correct

practice. The overall extra care for

premature or LBW practiced by providers

in the last case they provided service was

not satisfactory, only 40.4% did practice at

least half of the standard actions. This

figure is almost similar to what the national

EmONC assessment in 2008 found;

average score of 2.5 out of 5 for essential

care and similar proportion in terms of

different care components; most common

care practiced were thermal protection and

support to establish breast feeding.

The quality of postpartum/post natal

counseling seems poor. Though 96.3% of

providers did counseling in the last three

months before the study, only 17.4% of

providers were able to perform at least half

of the standard list of activities.

In the cases observed while receiving care

in the facilities, good care was given to

55.6% of the cases. Since most cases

observed were essential care (89%) for

newborn, the overall care observed was

much lower than what they reported in

their practice in the last case they attended.

This figure is higher than what the study in

Sari, Iran, reported; only 38.4% had good

level of practice.

The steps of clearing airway and drying

baby immediately after birth are known by

most (96.3%) of the providers. Almost all

(97.2%) providers dried and wrapped the

baby immediately after birth during the last

time they attended birth. The knowledge

and practice of these basic newborn cares

are almost universal.

The provider‟s knowledge of the time for

critical step is limited; time to clear

airways is known only by 35.8% of

providers. The sense of emergency to

prepare and respond depends on knowing

the right time to wait or act. This limited

knowledge could lead to complications and

delay in referral to higher facilities.

Though over half (57.8%) of providers

know most of the methods to keep the baby

warm, post pond bath for 24 hours is

indicated in only 14.7% of providers. Over

two third (70.6%) of providers did bath the

baby for the first time after 24 hrs of birth

during the last time they attended birth.

Though most (89.9%) of the providers

know on when to initiate breast feeding;

only 57.8% advice for immediate initiation

of breast feeding in the last birth they

attended and 27.8% supported early

initiation of breast feeding in the cases

observed. The differences in knowledge

and practice related to initiation of breast

feeding could be related to roles of

providers, flow of care and assumption that

the mothers know it.

The universal knowledge and availability

of immunization and PMTCT services are

related to focused program efforts and

supports. In those cases observed while

receiving care, 94.4% and 100% received

immunization and PMTCT services.

Vitamin K was also given to 83.3% of

those cases observed.

In the year before the survey, one year

service data from the facilities, the rate of

LBW in the study facilities was found to be

4.0 per 100 LB. Over half (54.1%) knows

the kinds of care for newborn who weighs

<2500kgs. Though close to two third

(62.4%) of providers reported practice of

caring newborn with LBW in the last three

month before the survey, the managers feel

that there is no extra care services for LBW

in their facilities. The national EmONC

assessment also showed a lower rate, 16%,

of care for LBW at the health center level.

The providers have better knowledge on

danger signs of newborn related to

respiratory problems than LBW newborn

and baby with infection. Over eighty

percent (81.7%) of providers have a good

knowledge on how to diagnose asphyxia.

Though over half (54.1%) know on how to

identify baby for resuscitation, only 10%

know all the steps for resuscitation. This

figure is almost similar to what is reported

in Sari, Iran, study; 44.5% have good and

11.7% very good knowledge about

neonatal resuscitation.

The providers interviewed have better

knowledge on how to prevent infection

(63.3%) than actions for newborn with sign

of infections (36.7%) and listing most of

the signs and symptoms of infection in

newborn (28.4%). This figure is similar to

what the 2008 national EmONC

assessment indicated; low average score

for action (2.1 out of 5) and for signs and

symptoms of infection (3.1 out of 7). This

could be related to the content/curriculum

of pre-service education for midlevel

providers and lack of in-service training

program focusing on managing infections

in newborn.

The effort to improve the quality of

newborn care services in some of the

health centers focused on ensuring

supplies/equipment, training and assigning

staff. 87.5% and 20.8% of health centers

reported stock out of supplies/equipment

and lack of trained provider respectively.

Three fourth (75%) and over half (58.3%)

of facilities have protocols for essential

newborn care and management of newborn

complications respectively. The

registration books for keeping information

on newborn care services are complete and

of good quality in most of the facilities.

Strength and Limitation of the Study:

The strengths of the study are:

Inclusion of all public health centers

providing newborn care services

Inclusion of all health professionals

who are involved in newborn care

service provision

Comprehensiveness (all components of

care) of the study to assess KAP of

providers in newborn care

Looked complementary areas:

observation of case management,

review of service records and interview

of facility managers

The limitations of the study are:

Since the study on KAP of providers in

immediate newborn care are limited

and focused, it was not easy to design

some of the study sections and compare

results.

Since the study is on KAP, it is not

easy to find standards that defines the

cut off point for satisfactory

knowledge, attitude and practice for

providing newborn care services and

compare across different study settings

Though the study focused on KAP of

providers at health center level, it also

included observation of care provision,

review of records and interview of

facility managers. But this study is not

exhaustive enough to identify factors

affecting KAP of providers. Other

enabling or restraining factors like

facility infrastructure,

equipment/supplies, set up of services,

management and policy issues were not

looked in detail in this study.

6. CONCLUSION AND

RECOMMENDATIONS

Those who serve long years, > 10 years,

have a better knowledge than others. Those

with long years of service are more

midwives than nurses. The knowledge for

prevention is better than clinical care

component for newborn care intervention.

Improve quality of pre-service

education and ensuring adequate

exposure for clinical practices

Assigning midwives for obstetric and

newborn care services

A little over one third (38.5%) of providers

had focused training on neonatal

resuscitation, those trained have better

knowledge than non trained providers. The

report on improved performance,

availability (78%) of neonatal resuscitation

services, is related to the proportion of

facilities with trained providers (83%).

Though providers are trained on one of the

major cause of neonatal death, asphyxia,

they are not trained on the other two major

causes of deaths, infection and LBW.

Organize comprehensive in-service

training program to address all the

major causes of neonatal deaths.

Encourage trained providers to transfer

knowledge and skill to others and

organize on job training.

The knowledge and practice for essential

care are better than for LBW and sick

newborn. A clear gap is observed in

knowledge and practice in some of the

newborn care intervention. Though

providers have good attitude for newborn

care, most couldn‟t able to put it in to

practice what they know.

Create an enabling environment for

providers to practice what they learn

and know

The vertical programs with a lot of efforts

and resources are doing well. Almost all

health centers have testing services for HIV

and provide ARV.

Integration of services to ensure that all

clients are getting comprehensive care

and available resources are used

effectively.

The effort to improve quality of newborn

care services included a few traditional

approaches of procuring

supplies/equipment and training providers.

Introduce a system of continuous

quality improvement in the facilities.

The study mainly focused on providers

KAP at health center level, which indicated

some of the gap in provision of quality

immediate newborn care that relates with

the provider at health center level. But

most of the factors related to level of care,

facility infrastructure, management and

policy issues are not captured in this study.

Conduct comprehensive study to assess

quality of immediate newborn care

services by including all levels of care

and issues related to facility

infrastructure, management and policy.

Conclusionand Recommendations:

The knowledge and practice for essential

care are better than for LBW and sick

newborn. A clear gap is observed in

knowledge and practice in some of the

newborn care intervention.

Improve quality of pre-service

education, organize comprehensive in-

service training program and encourage

trained providers to transfer knowledge

and skill to others.

Create an enabling environment and

introduce a system of continuous

quality improvement in the facilities.

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ACKNOWLEDGEMENTS

I would like to thank my advisor, Dr ALEMAYEHU WORKU, for his ongoing support and

constant comment throughout my thesis work.

I would also like to extend my gratitude to all of Addis Continental staff especially my

instructors and those working in Library and Computer Lab., for their encouragement and

support during the whole research process.

My special thanks go to Professor BOGALE WORKU, for his critical review, comment and

support in the thesis work.

I would also like to express my respect and appreciation to all my close relatives and friends who

showed their love and support to me and this helped me in one way or other to reach the end of

this thesis work.

At last, but not least, I would like to thank Addis Ababa Regional Health Bureau and respective

health offices at sub cities for their support and facilitation; all senior providers who serve as data

collectors; study participants (providers, head of facilities and clients) in Addis Ababa Public

Health Centers, without their kind support it would have been impossible to accomplish the

study.

Case Report 1 Atnafu M. (MD)

*

This case report is about a female neonate

who was admitted to the NICU of Girum

General Hospital at the age of 3hr on Dec,

28, 2010 after she was delivered at another

private hospital.

The baby was born to 25 years old para I

lady at gestational age of 34+5

week by date.

Delivery was by emergency C/S for severe

maternal preeclampsia. It was a twin

pregnancy and this baby is twin B with birth

weight of 1680gm and apgar score of 6 and

7 at 1st and 5

th minute respectively. Twin A

is also an alive male baby with birth weight

of 2.5kg. The pregnancy was uneventful till

two weeks back before the delivery when

the mother was diagnosed to have

hypertension. Since then the mother was

taking methyl dopa for the hypertension.

This baby was referred to our NICU for

respiratory distress and admitted to our

NICU at the age of 3hours on 28/12/2010/.

At admission she had heart rate of 37beat

per min and respiratory rate of 68 breath per

min with mild intercostals retraction. There

was no organomegaly and edema. She was

alert and had appropriate neonatal reflexes.

After detecting the brady cardia, ECG was

taken and revealed third degree AV block.

Neonatal serum electrolytes,

Echocardiography, CBC, and maternal and

neonatal ANA and rheumatoid factors were

determined and found to be normal. From

this Isolated congenital heart block was

considered. After communicating with

pediatric cardiologist, atropine, drenaline

and dexamethasone were given with the

intention to raise the heart rate; but the heart

rate persisted with in the range of38 to 45

beats per minute despite the effort. The baby

stayed for a week in the NICU and

discharged after writing a case report for

possible pace maker implantation abroad

and arranging follow up at the pediatric

cardiologist. The purpose of the case report

is to bring the case in to medical

professionals attention and so that better

ideas will be forwarded on how to manage

and handle such cases in our set up. Besides

this, isolated congenital heart block is a rare

condition and this will give us the chance to

review literatures on the issue.

ECG Taken at admission to the NICU i.e. on Dec 28/2010 (picture below)

ECG Taken on 3/1/2011 at the age of 6days (picture below)

Literature Review

The incidence rate of congenital heart block

is about 1 in 11000 to 1 in 20000 per live

births (1). Autopsy studies of fetal hearts

with congenital heart block and born to

mothers having auto antibodies indicated

that there is an exaggerated apoptosis most

pronounced in regions containing

conductive tissue and this is probably

thought to be caused by IgG binding and

also ingestion by macrophage initiated by

the maternal antibodies. Persistence of this

pathologic change after birth may be is the

cause of heart block seen in infants

postpartum (2). In a mother with

autoimmune disease, the maternal immune

system forms antibodies which includes

anti-sjogren‟s syndrome A(SSA/Ro) anti-

sjogren‟s syndrome B(SSB/La), ribonuclear

protein (RNP) and DNA anti bodies. These

auto anti-bodies can induce inflammatory

damage to tissues which can lead to clinical

autoimmune diseases. Auto antibodies can

cross the placenta and target fetal or

neonatal antigens leading to neonatal lupus

syndrome (3).

Isolated Congenital heart block occurs

commonly in babies born from mothers with

rheumatic disease like SLE and sjogrens

syndrome even though some of the mothers

can be initially asymptomatic and later

develops the symptoms (4). Follow up of

babies born to mothers with connective

tissue disease and positive autoantibodies

showed that they are at risk of developing

neonatal lupus syndrome in addition to

cardiac rhythm alteration (5). Rashes,

cytopineas and hepatobiliary disease are the

most common clinical manifestations as

compared to heart block and

cardiomyopaties which are known to pose

significant morbidity and mortality (3). In a

pregnant lady with SLE during pregnancy,

the maternal serum levels of anti-Ro/SS-A

and anti-Ro-B auto antibodies do not predict

exactly the occurrence of congenital heart

block in the fetus (6).

Congenital heart block is known to occur

due to many reasons. Cardiac malformation,

presence of maternal antinuclear antibodies

and reasons other than these two have been

mentioned as possible causes (7). Review of

the Finish hospital registry revealed that

most babies with congenital heart block

(90%) are born to mothers with antibodies to

SSA or SSB (8). With proper follow up

during the pregnancy, the median time for

the detection of bradyarhythmia due to the

congenital heart block is about 23 weeks of

gestational age (9). Presence of hydrops and

cardiac malformation found to predict poor

out come. Sympatomimetic treatment for the

cases with cardiac malformation and

hydrops didn‟t show any benefit (8).

Screening for auto immune disease has to be

considered for those mothers who have

clinical clues of auto immune disease or if

there is strong family history of auto

immune disease. Pregnancy related –

hormones can also trigger auto immune

disease. Evaluation for maternal auto

antibodies also has to be done when there is

any clinical evidence suggestive of neonatal

lupus syndrome. These screening tests

include ANA, SSA and SSB. Similar tests

has to be done for the infant if neonatal

lupus is suspected beside other tests like

complete blood count, liver function test,

ECG and Echocardiography (3). In fetuses

at risk to develop heart block, fetal

kinetocardiogram can be used for accurate

measurement of AV conduction time and

detection of first degree AV block and helps

to decide early management (10).

Recent review of papers indicates that the

efficacy of steroid treatment is inconclusive

in treating congenital heart block in the fetus

(1). But previous reports had shown that

dexamethasone was successfully used in

treating fetal myocardial dysfunction and

dysrhythmia in a mother with sjogrens

syndrome (11). Similar finding was also

reported about the beneficial effect of

corticosteroids in improving the fetal cardiac

hemodynamics and conduction system in the

presence of maternal auto antibodies (12).

On the other hand, fluorinated steroids were

shown to be useful for fetuses with

incomplete heart block and hydropic

changes as compared to those who have

received no intervention (10, 13). The risk

of developing antibody mediated congenital

heart block in the new born was reduced by

administration of steroids starting early in

pregnancy (14).

Analysis of the Research Registry for the

Neonatal lupus of New York University

School of Medicine found that the

cumulative probability of three year survival

to be 79% after following a cohort of 113

infants who have congenital heart block

born to mothers whose sera contain anti-

SSA/Ro or anti-SSB/La antibodies, or both.

Of those who are live born, 67% of them

required pace makers (9).

Isolated

congenital heart block due to maternal

rheumatic disease can lead to death in the

early neonatal period of which up to one

third of them found to die during this period

and those who survive, most of them require

pace maker (4). Myocardial dysfunction

due to cardiomyopathy is one cause of death

due to congestive heart failure. This can

occur even with early implantation of

cardiac pace maker (15). Factors like

presence of maternal auto antibodies,

increased heart size at initial evaluation and

failure to improve after pace maker

implantation are found to be predicting

factors for the development of

cardiomyopathy (16). Progression of

incomplete heart block to higher degrees of

heart block years after the neonatal period is

also possible. Other ECG abnormalities in

the neonate include transient sinus

bradycardia, QT interval prolongations, and

wolff-parkinson-white syndrome (3). Babies

with auto anti body mediated second degree

and above heart block are reported to have

retarded growth with no catch up growth

during the infancy period (17). Review of a

30 years experience of a single institution

has shown that patients with isolated

congenital atrioventricular block have

different mortality rates depending on the

time of diagnosis of the block. Patients with

the heart block having diagnosed during

fetal time have higher mortality rate in the

first two decades of life than diagnosis

during neonatal and child hood time. Similar

difference in the need of pace maker

implantation among the groups was also

observed in the same study (18). Congenital

heart block associated with structural heart

defect as well as presence of hydrops, and

lower atrial and ventricular rates in isolated

congenital heart block were associated with

higher fetal or neonatal deaths (19, 20, 21).

The congenital heart block has a risk of

recurrence in the subsequent pregnancy with

two to three folds higher in a mother who

had an affected baby as compared to those

who never had an affected child (9). But in

another different study the risk of recurrence

in such condition is found to be low (22).

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2. Clancy RM, Kapur RP, Molad Y, Askanase AD, Buyon JP. Immunohistologic

evidence supports apoptosis, IgG deposition, and novel macrophage/fibroblast

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Rheum. 2004 Jan;50(1):173-82

3. Jennifer Frankovich, MD, Christy Sandborg, MD, Pat Barnes, MD, Susan Hintz,

MD, Eliza Chakravarty, MD

. Neonatal Lupus and Related Autoimmune

Disorders of Infants. NeoReviews (2008) 9, 206-217

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5. Antonio Alberto Zuppa, MD. Infants Born to Mothers With Anti-SSA/Ro

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6. Derksen RH, Meilof JF. Anti-Ro/SS-A and anti-La/SS-B autoantibody levels in

relation to systemic lupus erythematosus disease activity and congenital heart

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7. Berg C, Geipel A, Kohl T, Breuer J, Germer U, Krapp M, Baschat AA,

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9. JP Buyon, R Hiebert, J Copel etal. Autoimmune-associated congenital heart

block: demographics, mortality, morbidity and recurrence rates obtained from a

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10. A.J.J.T. Rein, MD; D. Mevorach, MD; Z. Perles, MD etal. Early Diagnosis and

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Oct;42(4):226-32

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fluorinated glucocorticoids to the natural history of autoantibody-associated

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17. Amanda Skog, Marie Wahren-Herlenius, MD, PhD, Birgitta Sundström, RN,

Katarina Bremme, MD, PhD, Sven-Erik Sonesson, MD, PhD.Outcome and

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18. Edgar T. Jaeggi, MD, Robert M. Hamilton, MD, Earl D. Silverman, MD, Samuel

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20. Lilian M. Lopes, MD; Gláucia Maria Penha Tavares, MD; Ana Paula Damiano,

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