Trends in Childhood Morbidity and Mortality in the Era of Pandemic

Abstract

Introduction: While there has been a steady decline in the rate of under-five mortality globally, sub-Saharan Africa still remains the region with the highest under-five mortality rate in the world, with 1 in 13 children dying before his or her fifth birthday. With the advent of the corona virus pandemic, the dynamism in the childhood morbidity pattern is certain. The objective of this study was to determine the morbidity patterns and outcomes of children seen in selected health care facilities in Southeastern Nigeria from March to October 2020. Methodology: This study was a hospital-based retrospective study carried out in some health care facilities in Southeastern Nigeria. The study instrument was hospital records which were retrieved and relevant variables were collected from the records. The study population were children who were five years and below who had been admitted in the health facilities within the past eight months, from March-October, 2020. The data was analyzed using the Statistical Package for Social Science version 25. Descriptive analysis was computed whereby proportion/percentages and frequency was also calculated. Result: The study found out among other childhood illnesses that; malaria, sepsis and PEM were the top three morbidities that led to hospitalization while 23.1% of children who were non-compliant with their immunization schedule, presented with bronchial pneumonia. The relationship between the age and trends in childhood illness was significant with p-value ≤0.05. Conclusion: Malaria still remains a major cause of hospitalization for children under the ages of five. Notwithstanding, the rate of admission of children into hospitals dropped significantly due to sanitary measures and awareness towards combating the spread of COVID-19 in its early days.

Full text

International Journal of Health Sciences and Research
Vol.12; Issue: 2; February 2022
Website: www.ijhsr.org
Original Research Article ISSN: 2249-9571
International Journal of Health Sciences and Research (www.ijhsr.org) 227
Vol.12; Issue: 2; February 2022
Trends in Childhood Morbidity and Mortality in the
Era of Pandemic
Joy Nkeiruka Ozughalu1, Angela Ezinne Orji2, Onyeka Chukwudalu Ekwebene3,
Chidera Gabriel Edeh4
1Institute of Public Health, College of Medicine, University of Nigeria, Enugu Campus, Nigeria
2University Hospitals Coventry and Warwickshire NHS trust Coventry, UK.
3Nnamdi Azikiwe University Teaching Hospital, Nnewi, Anambra State, Nigeria.
4Faculty of Medicine, NnamdiAzikiwe University, Awka, Nnewi Campus.
Corresponding Author: Onyeka Chukwudalu Ekwebene
DOI: https://doi.org/10.52403/ijhsr.20220232
ABSTRACT
Introduction: While there has been a steady decline in the rate of under-five mortality globally, sub-
Saharan Africa still remains the region with the highest under-five mortality rate in the world, with 1
in 13 children dying before his or her fifth birthday. With the advent of the corona virus pandemic, the
dynamism in the childhood morbidity pattern is certain. The objective of this study was to determine
the morbidity patterns and outcomes of children seen in selected health care facilities in South-eastern
Nigeria from March to October 2020.
Methodology: This study was a hospital-based retrospective study carried out in some health care
facilities in South-eastern Nigeria. The study instrument was hospital records which were retrieved
and relevant variables were collected from the records. The study population were children who were
five years and below who had been admitted in the health facilities within the past eight months, from
March-October, 2020. The data was analyzed using the Statistical Package for Social Science version
25. Descriptive analysis was computed whereby proportion/percentages and frequency was also
calculated.
Result: The study found out among other childhood illnesses that; malaria, sepsis and PEM were the
top three morbidities that led to hospitalization while 23.1% of children who were non-compliant with
their immunization schedule, presented with bronchial pneumonia. The relationship between the age
and trends in childhood illness was significant with p-value ≤0.05.
Conclusion: Malaria still remains a major cause of hospitalization for children under the ages of five.
Notwithstanding, the rate of admission of children into hospitals dropped significantly due to sanitary
measures and awareness towards combating the spread of COVID-19 in its early days.
Keywords: under 5 children, pandemic, trends, childhood illnesses.
INTRODUCTION
As the global pandemic caused by
the corona virus disease - COVID-19
sweeps through the planet earth, the death
toll it leaves behind is unprecedented.
Among the high risk groups as stated by the
World Health Organization are the elderly,
persons with underlying diseases such as
diabetes, lung or heart diseases and other
conditions that affect the immune system[1].
A study carried out in China
reported that adverse health outcomes due to
COVID-19 in children (below18 years)
were minimal when compared to adults.[2]
According to mortality and morbidity
weekly reports by the US Centres for
Disease Control, children under the age of
18 were less likely to experience the typical
symptoms of COVID-19 infection including
fever, cough and difficulty in breathing, and

Joy Nkeiruka Ozughalu et.al. Trends in childhood morbidity and mortality in the era of pandemic.
International Journal of Health Sciences and Research (www.ijhsr.org) 228
Vol.12; Issue: 2; February 2022
were less likely to need hospitalization and
to die of the disease. In the reports, children
of all ages appeared susceptible to COVID-
19, though over 90% of them had
asymptomatic, mild or moderate cases. [3]
The index case of Coronavirus
disease in Nigeria according to the Federal
Ministry of Health was seen on February 27,
2020 [4] after which other cases sprung up
in the country leading to a decision of
lockdown of international airspace and other
subsequent measures as deemed necessary
at that time. These measures affected the
educational sector as children have stayed
home and indoors under the care of their
parents or guardians for over four months.
During these periods of
confinement, children had less contact with
their external environment, reduced access
to social activities (schooling. religious
gatherings, leisure or fun outings, sporting
events) and thus were less likely to come in
contact with infectious contaminants lurking
around in the surroundings. Parents also
were more attentive and concerned about
the welfare and well being of the children.
Constant awareness and health education
from health authorities, governmental and
non-governmental organization through
various media has stepped up the level of
general hygiene especially hand hygiene in
most homes. Parents were more than ever
aware of the need to boost up immunity of
their household members through proper
nutrition.
Globally, there has been a steady
decline in the rate of under-five mortality
but sub-Saharan Africa still remains the
region with the highest under-five mortality
rate in the world, with 1 in 13 children
dying before his or her fifth birthday. This
mortality rate is 15 times higher than in high
income countries. Acute respiratory
infections, diarrheal diseases and malaria
are among the leading causes of child
mortality in sub-Saharan Africa [5].
Reports from the 2018 Nigeria
Demographic and Health Survey showed
that the under-five mortality rate in Nigeria
is 132 per 1000 live births. This means that
1 in 8 children never reach the age of 5
years [6]. Much intervention is still needed
if target 3.2 of the sustainable development
goal 3 must be met [7]. The overall
mortality rate in children as indicated in
studies carried out in the south-south and
south-west states of Nigeria are 4.1% and
5.1% respectively [8][9][10][11]
The leading causes of child
morbidity, hospitalization and mortality as
seen in previous studies carried out in
Nigeria were malaria, diarrheal diseases,
respiratory tract infection, sepsis, anaemia
and measles [12][13].
With the knowledge and practice of
various preventive measures, this study aims
to understand the epidemiological trends of
common diseases and their outcomes among
children, five years and below whom were
admitted into some health care facilities in
South-eastern Nigeria.
METHODOLOGY
Study design
This study was a hospital based
retrospective study carried out in some
selected health care institution in South-
eastern Nigeria.
Study Population
The study population were children
who were not above five years, who had
been admitted in the health facilities within
the past eight months from March-October,
2020.
Exclusion criteria
Children who were seen as
outpatient, those admitted in the intensive
care unit, neonates and those with
incomplete records were excluded.
Inclusion criteria
Hospital records of children
admitted within these periods and who met
the inclusion criteria were perused to extract
variables bordering on demographic status,
diagnosis, date of admission, immunization
status and outcome of management.

Joy Nkeiruka Ozughalu et.al. Trends in childhood morbidity and mortality in the era of pandemic.
International Journal of Health Sciences and Research (www.ijhsr.org) 229
Vol.12; Issue: 2; February 2022
Data collection and Analysis
After an optimal sample size
appropriate for the study has been reached,
the data was computed and analyzed using
the Statistical Package for Social Science
version 25. Descriptive analysis was
computed whereby proportion/percentages
and frequency was also calculated. Cross
tabulation was used to establish the
association between variables.
ETHICAL CONSIDERATION
The entirety of the study was clearly
explained to the health care facilities and
informed consent was also obtained. The
health care facilities were assured of their
confidentiality and anonymity of all
information supplied for the study. Only
health care facilities who gave their consent
were given the opportunity. Ethical approval
was also gotten from the various health care
facilities in other for their data to be used in
this study.
RESULTS
Table 1 Showing the Socio-Demographic Information of the
Study Population
Variable
Frequency
Percentage
Age Group
1 -12 months
66
44.0
13 -24 months
31
20.7
25 -36 months
19
12.7
37-48 months
20
13.3
49 -60 months
14
9.3
Mean Age±Std
Gender
24.8±18.2 months
Female
62
41.3
Male
88
58.7
Out of the 150 children studied, the
age group 1-12 months of age were
predominant with a frequency of 66
(44.0%), followed by age groups 13-24
months and 37-48 months with frequencies
of 31(20.7%) and 20(13.3%) respectively.
The mean age of the children studied were
24.8±18.2 months. The majority of the
studied population were males 88(58.7%).
Table 2 showing the immunization status, diagnosis, co-
morbidities, date of admission and outcome of management of
the study population
Variable
Frequency
Percentage
Immunization Status
Compliant
79
52.7
Non-compliant
26
17.3
Still on it
45
30.0
Childhood Illnesses that Presented
Anemic Heart Failure
4
2.7
Acute Gastroenteritis
4
2.7
Asthma Attack
6
4.0
Bronchial Pneumonia
11
7.3
Intussusception
5
3.3
Malaria
54
36.0
Meningitis
10
6.7
PEM
22
14.7
Sepsis
32
21.3
SCD
2
1.3
Co-morbidities
Non
141
94.0
Delayed Milestone
9
6.0
Date of Admission
March
18
12.0
April
36
24.0
May
27
18.0
June
13
8.7
July
13
8.7
August
13
8.7
September
11
7.3
October
Outcome of Management
19
12.7
Good
132
88.0
Bad
18
12.0
With regard to their immunization
status, 79(52.7%) were compliant, while
45(30.0%) were still on it; however,
26(17.3%) were not complaint with their
immunization schedule. With respect to
presence of co-morbidities at presentation,
majority do not have co-morbidities
141(94.0%). More of the children were
admitted during the month of April
36(24.0%) and May 27(18.0%). The least
admission was around the months of June –
August 13(8.7%) respectively and
September 11(7.3%). Majority of the
childhood illnesses that presented had good
outcome 132(88.0%).
Table 3: Disease Outcomes versus Age and Gender
AGE GROUP
GENDER
1 -12
months
13-24
months
25-36
months
37-48
months
49 – 60
months
Total
Chi-
square
(ᵡ2)
df
p-
value
(≤0.05)
Male
Female
Total
Chi-
square
(ᵡ2)
df
p-
value
(≤0.05)
Anemic Heart
Failure No. (%)
0(0.0)
0(0.0)
1
(5.3)
3
(15.0)
0
(0.0)
4
(2.7)
83.1
36
0.00
1
(1.1)
3
(4.8)
4
(2.7)
12.3
9
0.19
Acute Gastroenteritis
No. (%)
1(1.5)
1
(3.2)
2
(10.5)
0(0.0)
0(0.0)
4
(2.7)
2
(2.3)
2
(3.2)
4
(2.7)
Asthmatic Attack
No. (%)
2
(3.0)
4
(12.9)
0
(0.0)
0(0.0)
0(0.0)
6
(4.0)
2
(2.3)
4
(6.5)
6
(4.0)

Joy Nkeiruka Ozughalu et.al. Trends in childhood morbidity and mortality in the era of pandemic.
International Journal of Health Sciences and Research (www.ijhsr.org) 230
Vol.12; Issue: 2; February 2022
Table 3 Continued…
Bronchial
Pneumonia
No. (%)
8
(12.1)
2
(6.5)
1(5.3)
0(0.0)
0(0.0)
11
(7.3)
9
(10.2)
2
(3.2)
11
(7.3)
Intussusception
No. (%)
5
(7.6)
0(0.0)
0(0.0)
0(0.0)
0(0.0)
5
(3.3)
4
(4.5)
1
(1.6)
5
(3.3)
Malaria/Plasmodiasis
No. (%)
13
(19.7)
13
(41.9)
7
(36.8)
10
(50.0)
11
(78.6)
54
(36.0)
32
(36.4)
22
(35.5)
54
(36.0)
Meningitis
No. (%)
4
(6.1)
0(0.0)
2
(10.5)
2
(10.0)
2
(14.3)
10
(6.7)
7
(8.0)
3
(4.8)
10
(6.7)
PEM
No. (%)
10
(15.2)
8
(25.8)
3
(15.8)
1(5.0)
0(0.0)
22
(14.7)
11
(12.5)
11
(17.7)
22
(14.7)
Sepsis
No. (%)
23
(34.8)
1
(3.2)
3
(15.8)
4
(20.0)
1
(7.1)
32
(21.3)
18
(20.5)
14
(22.6)
32
(21.3)
SCD
No. (%)
0(0.0)
2(6.5)
0(0.0)
0(0.0)
0(0.0)
2
(1.3)
2
(2.3)
0
(0.0)
2
(1.3)
Total
66
(100.0)
31
(100)
19
(100)
20
(100.0)
14
(100.0)
150
(100)
88
(100.0)
62
(100.0)
150
(100.0)
The table above shows that malaria
54(36.0%), sepsis 32(21.3%) and PEM
22(14.7%) were the top three disease
outcome seen in hospitalised children
during the study. The age group 1-12
months presented more with sepsis
23(34.8%), malaria 13(19.7%), PEM
10(15.2%), bronchial pneumonia 8(12.1%)
and intussusception 5(7.6%). Anaemic heart
failure was more prevalent among the age
group 37-48 months. The relationship
between the age and trends in childhood
illness was significant with p-value ≤0.05.
With respect to the relationship
between gender and childhood illnesses, the
male presented more with malaria
32(36.4%), sepsis 18(20.5%), PEM
11(12.5%), bronchial pneumonia 9(10.2%),
meningitis 7(8.0%) and intussusception
4(4.5%) The female however presented
more with Asthmatic attack 4(6.5%) and
Anaemic heart failure 3(4.8%). The least
childhood illness that presented during this
period was sickle cell disease (SCD)
2(1.3%). The relationship between gender
and trends in childhood illness was not
statistically significant (P-value≥0.05).
Table 4: Disease Outcome and Immunization Statuses
Immunization Status
Non - compliant
Compliant
Still on it
Total
Chi-square (ᵡ2)
Df
p-value (≤0.05)
Anemic Heart Failure No. (%)
0(0.0)
4(5.1)
0(0.0)
4(2.7)
70.9
18
0.00
Acute Gastroenteritis No. (%)
1(3.8)
2(2.5)
1(2.2)
4(2.7)
Asthmatic Attack No. (%)
0(0.0)
6(7.6)
0(0.0)
6(4.0)
Bronchial Pneumonia No. (%)
6(23.1)
3(3.8)
2(4.4)
11(7.3)
Intussusception No. (%)
0(0.0)
1(1.3)
4(8.9)
5(3.3)
Malaria/Plasmodiasis No. (%)
6(23.1)
43(54.4)
5(11.1)
54(36.0)
Meningitis No. (%)
3(11.5)
6(7.6)
1(2.2)
10(6.7)
PEM No. (%)
5(19.2)
9(11.4)
8(17.8)
22(14.7)
Sepsis No. (%)
5(19.2)
4(5.1)
23(51.1)
32(21.3)
SCD No. (%)
0(0.0)
1(1.3)
1(2.2)
2(1.3)
Total
26(100.0)
79(100.0)
45(100.0)
150(100.0)
Table 4 shows that 23.1% of those
not complaint with their immunization
schedule presented with bronchial
pneumonia and malaria respectively,
however those that were compliant with
their immunization schedule still presented
with malaria 43(54.4%), PEM 9(11.4%),
Asthmatic attack 6(7.6%), meningitis
6(7.6%), Anaemic heart failure 4(5.1%) and
Acute gastroenteritis 2(2.5%).
Approximately 51% of those still on their
vaccine regimen presented with sepsis. The
association between immunization status
and trends in childhood illness among the
study population was statistically significant
with p-value ≤0.05.
DISCUSSION
The unequal distributions of
childhood admissions among the boys and
girls as observed in this study was in tandem
with the findings by Abhulimhen-Iyoha and

Joy Nkeiruka Ozughalu et.al. Trends in childhood morbidity and mortality in the era of pandemic.
International Journal of Health Sciences and Research (www.ijhsr.org) 231
Vol.12; Issue: 2; February 2022
Okolo [14] in Benin and Ibeziako and
Ibekwe [15] in Enugu, respectively where
male admissions were predominant.
However, the reason for the variations has
not been ascertained, it may be due to
regional variation in the health seeking
behavior on behalf of children for socio
cultural reasons of attaching more value to
male children. [16]
Ninety-four percent of the children
studied did not have co-morbidities. More
of the children were admitted during the
month of April and May. This was at the
beginning of the lockdown period when
COVID-19 cases were still minimal and the
level of fear was gradually mounting. The
next four month saw a reduction in the rate
of admission as most household resorted to
alternative medicine with the collapse of
economic activities, which distorted income
flow and purchasing power. Majority of the
children had good outcome with full
recovery and therefore duly discharged.
However, a few of the children had bad
outcomes ranging from delayed milestones,
severe weight loss to mortality.
Malaria, Sepsis and PEM were the
top three morbidities seen in the study
population. This finding is similar to
findings by some studies from Nigeria
[16][17] and Mozambique,[18] were the
most common causes of morbidity in
children. The least childhood illness that
presented during this period was Sickle cell
disease. This may be highly expected given
the various educational interventions on
genotype to enlighten adults of reproductive
age. Of all the age groups studied, age 1-
12 months presented more with sepsis,
PEM, malaria, bronchopneumonia and
intussusception. This might possibly be non
compliant of mothers to exclusive breast
feeding thereby denying this young age
groups the benefits of exclusive breast milk.
Results from the analysis done on
immunization status and childhood illnesses
showed that children who were not
complaint with their immunization schedule
presented more with bronchial pneumonia.
Childhood immunization remains the safest
preventive intervention that protects against
diseases.
CONCLUSIONS
Protective measures like exclusive
breastfeeding, adequate complementary
feeding, immunizations, reduced household
air pollution, safe drinking water, sanitation,
hygiene and vitamin A supplementation
provide the foundation for keeping children
healthy and free of disease. Efforts should
be made to design appropriate health care
model that would facilitate a considerable
reduction in childhood morbidity in the
country
ACKNOWLEDGMENTS
The authors hereby acknowledge all
the health care facilities who allowed their
facilities data to be used for this study.
Conflict Of Interest
The authors declared that there is no
conflict of interest.
Source of Funding: None
Ethical Approval: Approved
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How to cite this article: Joy Nkeiruka Ozughalu,
Angela Ezinne Orji, Onyeka Chukwudalu
Ekwebene et.al. Trends in childhood morbidity
and mortality in the era of pandemic. Int J
Health Sci Res. 2022; 12(2): 227-232. DOI:
https://doi.org/10.52403/ijhsr.20220232
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