Diarrhea remains a leading killer of young children, despite the availability of a simple treatment solution, accounting for approximately 8% of all deaths among children under-five worldwide in 2017 (38). Pneumonia, diarrheal diseases, malaria and measles are the four major infectious diseases that cause death in under-five children globally (39). And about 25% of the overall diarrheal burden has been attributed to diarrhea among under-five in Africa (39). The global sustainable developmental goal aimed to reduce the prevalence of neonatal mortality to 12.5% and under-five mortality to 25% by the year 2030 (27). However, the COVID-19 pandemic brought many health emergencies (30) and would have negative impacts in achieving the goal as the plan. The present study determines burden of diarrhea using data before and during COVID-19 pandemic.
The overall prevalence of diarrhea in under-five children in this study was 19.8%. This finding is similar with studies done in Northwest Ethiopia, 19.8%(40), Debre Berhan, 16.4%(24), Southwest Ethiopia, 21.8% (41), Eastern Ethiopia, 22.5%(42), Somalia, 22.4% (43), Kenya, 18.7%(44), and India, 21.7%(45). Furthermore, a systematic review and meta-analysis study done in Ethiopia revealed similar finding, 22% prevalence of diarrhea in under-five children (18). Inconsistent to the present finding, higher prevalence of diarrhea in under-five children reported in Southern Ethiopia, 30.9% (46), North Central Ethiopia, 29.9% (25), North Shoa of Ethiopia, 31.4%(47), Western Ethiopia, 24%(19), Cameroon, 26.1%(48), and north Sudan, 28% (49). This discrepancy may be due to different in exposure to risk factors of diarrhea present in different area. On the other hand, there are other studies done that reported lower prevalence in compare to the present study. Some of these studies include 8.5% in Addis Ababa (50), 13.6% in Southern Ethiopia (51), 14.5% in Bahr Dar (21), 14.5% in Western Ethiopia (52), 12.1% in Tanzania (53), 11.2% in Nigeria (54), and 4.4% in Malaysia (55). The Ethiopian DHS 2016 reported 12% prevalence of diarrhea (17) which is lower than the present study. The differences may be due to different in study design (e.g. facility based vs community based) that the present study was health facilities based involving on-going cases in the general population and likely to have higher value.
In the present study, the prevalence of diarrhea in Debre Berhan (24.7%) was greater than Addis Ababa (17.6%). This result agrees with study done in Uganda where high prevalence of 59.8% diarrheal diseases in under-five children reported for rural areas compared to urban areas with 42.6% (56).There are certain factors such as mother’s education, quality of housing, sharing of water sources, sanitation facilities and use of surface water that may influence childhood diarrhea outcomes in urban versus rural. For example in a study done in Uganda (56) found that rural homes without pit latrines registered 94.0% cases (p-value=0.0053) compared to 5.5% without latrines in urban area which could contribute to high prevalence of diarrhea in rural area. However, statistical analysis showed that the risk of getting diarrhea is 2 times in Addis Ababa greater than Debre Berhan (OR=1.903. 95% CI=1.717, 2.109).This contradiction may be due to difference in a mechanism influenced by population density and/or the built environment (57). The impact of environmental conditions such as dry condition which could result in water scarcity and/or increased accumulation of fecal contamination in the environment, and the high rainfall and flooding in urban may flush enteric pathogens into waterways used for drinking water, leading to greater exposure and in turn higher risk of diarrhea (57). In addition, the impact of COVID-19 may have more contributions in urban than rural (58).
Males children had greater prevalence (21%) of diarrhea as compared with female children (18.3%), statistically significant (p=0.000) in the present study. In the present study females found to be at greater risk of getting diarrhea than boys, it could be a cultural bias in care-seeking behaviour that favours boys and the finding agrees with other studies (44, 59). The prevalence of diarrhea was found to be associated with age less than 6 months (p<0.000) and 12-24 months (p<0.001) and agrees with study done in Cameroon (48). Children with age less than 6 months were 1.5 times at risk of getting diarrhea (AOR=1.474, 95% CI=1.240, 1.753) compared to age greater than 24 months. These children in age group 12-24 months were less likelihood to have diarrhea (AOR= 0.838, 95% CI=0.750, 0.932) compared to age greater than 24 months.
The prevalence of diarrhea before COVID-19 occurrence (20.2%) was greater than during COVID-19 (18.6%), not statistically significant (p=0.292) in the present study. The impact of COVID-19 pandemic on diarrhea might be negative (12, 31) or positive (32). It is better to characterize the aetiology of the diarrhea, particularly during the COVID-19 pandemic, and the community actual practice of the prevention measures of COVID-19 that helps in the prevention of diarrhea. The reduction of prevalence of diarrhea from 2019 (20.4%) to 2020 (18.6%) agrees with other reports (14-17). The Ethiopia DHS data showed that a decrement in diarrhea prevalence among under-five children over the study period, from 24% in 2000 to 18% in 2005 (14, 15), to 13% in 2011(16) and to 12% in 2016 (17). However, the rate of decrement in diarrhea prevalence was very slow, 6% from 2000-2005, 5% from 2005-2011, and 1% from 2011-2016. This tells us the diarrheal burden is still remaining high.
The greatest prevalence was in May (34%) and autumn season (26.0%) in 2019 in the present study. In the overall analysis, the prevalence of diarrhea was high in May (at the end of autumn), June and July (summer) in 2019 but fall during this time in 2020. The prevalence was increased from January to April in Addis Ababa (Figure 1) and from January to July in Debre Berhan (figure 2) during COVID-19. And the prevalence decreased from April to November in Addis Ababa and from July to November in Debre Berhan during Covid-19. This may be due to the campaign done against COVID-19 that includes proper hand washing. However, beginning on November in both study sites (Figure 1 and 2), the prevalence of diarrhea was getting higher and higher during COVID-19. It may be due to decrement in or back to the usual hand wash practices of the community. Overall prevalence of diarrhea was 12% in spring, 19.7% in winter, 26.0% in autumn and 24.5% in summer (figure 3). Diarrhea occurrence was more likely 3 times during spring (AOR=2.975, 95% CI=2.549, 3.473) and 1.5 times during winter (AOR=1.530, 95% CI=1.329, 1.762) compared to during summer. The finding agrees with study done in India (60) and Nepal (61). The variation across different months and seasons may be due to the season dependent pathogens. Like for example, in a study done in China showed that diarrhea was predominant due to bacteria in summer and virus in winter (62). Establishing active health facility based surveillance will allow clear understanding on occurrence of diarrhea with its aetiology and seasonality. The seasonal variation for prevalence of diarrhea may depends on pathogen spectrum and their seasonality (62) as well as actual community practice of COVID-19 prevention measures that help in the prevention of diarrhea.