The double diseases burdens trends in Ethiopia: COVID-19 aggravate the burdens of diseases and health system


The relevance of the study included that scarcity of evidence about the burdens of diseases in Ethiopia, in particular to non-communicable diseases along with the impact of COVID-19.Materials and methods. The systematic analysis and content analysis using GBD 2019 database and health metrics datasets of 2020 was used to analyze diseases burdens trends of Ethiopia. The descriptive retrospective analysis has been performed, and reported in text and charts method.Results. The result of the study showed increment of crude death and premature death due to both communicable and non-communicable diseases such as enteric infections, cardiovascular, neoplasm, others.Conclusion. COVID-19 would be the headache of Ethiopia health systems due to double burdens of diseases have steadily been shooting at ground. Hence, the nation should incite local based innovation work proactively and integrate all health services to fight with COVID-19 based on the experience of Russia.

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Introduction Globally, COVID-19 pandemic becomes the main catastrophic event and crisis touching all parts of the world, directly and indirectly, and creating enormous disruption to lives and livelihoods as well as social and economic systems in addition to the growing existing disease burdens. The disease is highly contagious and has spread with geometric progression to every corner of the world. Elderly and old population groups are more likelihood to die, but communicability is more seen in young people. Multidimensional crisis’s of COVID-19 is short-term and long-term, particularly in health systems in developing countries. For instance, it has short-term economic contraction, thrown tens of millions out of work, disrupted global supply chains, severely strained health services, decreased fiscal capacity, impaired safety nets, and eroded global solidarity and multilateralism, leading to the social unrest [1, 2]. According to the 2019 revision of the World Population Prospects, Ethiopia is the 11th rank, and second in population comparison to the world, and Africa respectively, with an estimated total population was 109,224,414 in 2018, compared to 18,434,000 in 1950 (nearly 83% gross population growth rate, and 2.83% growth rate in 2018). Thus, female sex took 51%, and the remained 49% is men, this due to total fertility rate become nearly five children per reproductive women (the 15th in the world rank). The median age is 18 years, this makes Ethiopia the youngest population which took two-third of total population, in particular six in ten persons are under productive age 15-65 years. Last year, the second EMDHS (Ethiopian Mini Demographic and Health Survey) provides valuable information on trends in key demographic and health indicators over time. The Health Development plans emphasizes the prioritized disease prevention, decentralization of the delivery of health services, strengthening partnerships between the government and non-governmental organizations to accesses basic health care packages and achieve universal primary health care coverage. But, after the endorsement of Sustainable Developmental Goals (SDGs) ensure healthy lives and promote well-being for all at all ages Ethiopia Gross transformational plan II was developed by considering the issues of quality and equity of health care services [3]. Ethiopia faced the onset of the crisis with clear strengths. Ethiopia has taken strict preventive measures against COVID-19 to control its spread, to protect citizens, and ensure their wellbeing and waiting for vaccinating and preparing for the first round COVID-9 vaccine [4]. Literatures review From situational and content review follows for the last four decades the global population health burden has fluctuated and was heterogeneous across the regions. If in 1990 the first, second and third levels of the disease burden were occupied by diseases such as lower respiratory tract infections, diarrhea and conditions occurring in the prenatal period, then in 2020 coronary heart disease, unipolar major depression and road traffic accidents came to the fore. Also the death rate due to NCDs increased dramatically by 77% and due to injury slightly from 1990 to 2020, but decrement has reported death due to communicable diseases, prenatal, maternal and nutritional conditions in the same period [2]. The non-communicable diseases (NCDs) has still been largely affecting the high and middle income countries, for instance in European region 9 of 10 death recorded due to NCD. However, more than half could be prevented by tacking their risk factors like stopping high alcohol consumption, regular physical exercises, healthy diet, and ceasing smoking. Africa confronts the world's most dramatic public health crisis where infectious diseases have still taken predominate cause of death nearly took 75%. Over the past years, measures to combat HIV/AIDS and tuberculosis have been steadily improved: from case detection to cure. Despite this, in the African region, there are still problems of unsanitary conditions, the availability of safe sources of water. In other hand, one-in four cause of death in the Region is among one of NCDs like cardiovascular disease, cancer, diabetes, and injury; 80% of NCDs burden contributed for the global burden. This and the aforementioned communicable diseases burden called the Region as “Double Burden threaten Region” in the world [8, 9]. By 2030, Ethiopia is planning to decrease the age-standardized mortality rate of 509 per 100,000 populations due to NCDs, decreased rates for HIV by 5%, tuberculosis (TB) by 3%, and malaria to 0%. The collection of statistical information is an additional obstacle in Ethiopia. For example, the civil registration system was launched only in 2006 and is not yet functioning in all parts of the country with full potential due to limited resources and lack of autopsy. Hence, limited verbal autopsy (VA) studies from demographic to show major public health problems and the emerging challenges of NCDs in the country [5]. Furthermore, all the aforementioned burdens have been leveraging by impact of COVID-19 pandemic [6, 7]. Globally, as of 9 February 2021, there have been 106,008,943 confirmed cases of COVID-19, including 2,316,389 deaths, which is an unprecedented crisis. In Africa, South Africa (cases: 14,7,6135; death: 46,290 death) still leading, and followed by Ethiopia (cases: 142,338; deaths: 2,148). Whereas in East Africa 6,668 deaths were due to due to COVID-19, of this 34% accounted to Ethiopia and the made the leading position in the East Africa. The world communities have been feared about Africa that the spread to be worsen that other regions due to continuing of unresolved socio-economical constrains, and fragile health system, and instability; but still is as not as expected and the second wave is hitting much other regions in comparison, except in South Africa [1, 2]. Various studies and reports show that unless additional resources are implemented or reform mechanisms are introduced in all sectors, the long-term impact of COVID-19 will end in crisis due to worsening poverty. Health care services will be reduced compared with the current state, all diseases are a burden of borrowed funds and paralyzed sectors of the economy. Thus, the analysis trends of diseases burdens and predicating the impact of COVID-19 on other diseases burdens to met SDGs 2030 targets is a vital forwards step in public health action [2]. Materials and methods GBD 2019 data and World Healthmeters database were used to analyze burdens of diseases of GBD, and COVID-19 trends for Ethiopia. A global burden of diseases applies 195 countries data that meet inclusion criteria and rigorous analysis to determine the patterns of mortality along with their specific cause. Data quality and potential biases resolved before asserting analysis. Garbage data were coded to rule out the confounding effect due to causes of death. The Global Burden of Disease Study 2019 (GBD 2019) synthesizes a large number of input sources to estimate mortality, causes of death and illness, and risk factors. 69 dataset were used from GBD 2019 of cause of death; these sources were used to produce national estimates for Ethiopia. The sources of data collected from diseased persons, sibling history and verbal autopsy data collection method. Eight COVID-19 articles and impacts were reviewed to predict the impacts on the existing major diseases burdens such as cardiovascular disorders (CVDS) from NCDs, and TB from communicable diseases. EndnoteX7 software for references management and citation was used. A different test processed such as spatiotemporal Gaussian process regression and mixed effects linear models, and constructs an ensemble model. The study revealed mortality rates rate with 95% uncertainty intervals, COVID-19 cases and death trends, and how COVID-19 leverage both NCDs and communicable diseases such as TB, directly and indirectly in 2020. Results Crude mortality rate of Ethiopia was 520.48 (95% UI: 409.12-691.6) in 2019 and the crude mortality rate has declined by 18.71% in 2019 from 2015. The top 10 causes of mortality changed from 2015 to 2019. Still, this study reported that predominate cause of death is communicable diseases, maternal and neonatal diseases, nutritional diseases (CMNNDs), followed by NCDs and injuries. Females are more likely dyed than male due to communicable diseases, and NCDs. In this study the maternal and neonatal deaths has declined by 18.71% in 2019 with 79.07 (95% UI: 63.25-100.06), HIV/AIDS&STIs death has declined by 1/4th. On one hand, respiratory infections and TB, and enteric infections were the 3rd and the 4th causes of death but decreased by 17.7%, and other infectious diseases death rate has declined much by 41.72%. On other hand, NCDs death rate has steadily raised, in particular to CVDs mortality rate has increased by 2.06% and took the 2nd rank, and diabetes and chronic kidney diseases death rate also has raised by 3.05% took 9th top cause in 2019 cause-specific mortality rate of Ethiopia. In this study looked age group cause of mortality rate, enteric infections (diarrhea), respiratory infections and TB, other infections, and NCDs were among the top five under 5 children death. HIV/AIDS&STIs, respiratory infections and TB, digestive diseases, neoplasm, and CVDs ranked in the top 5 adult cause of death in 2019. Of these, adult cause of death, were HIV/AIDS&STIs has declined by 1/3rd, and neoplasm specific death rate has rose by 3.99% and ranked the 4th top cause of adult death. In addition, neoplasm death rate has increased by 1.64 in age between 50-69 years which is less observed in age below 49 years, accounted 3.99% change rate. ps2021s1.4htm00095.jpg ps2021s1.4htm00097.jpg At the end of 2020, COVID-19 death in Ethiopia was 2,177 among 145,548 cases. At this time the top 10 causes of death were NCDs (coronary heart disease and stroke accounted 187.31 per 100,000), TB and others respiratory diseases (influenza, pneumonia, and lung diseases) took 154.58 per 100,000, neoplasm accounted, and HIV/AIDS death rate was 27.70 per 100,000 (see Table and Figure). A number of measurements have been taken in Ethiopia to curve these trends. Ethiopia underpinned establishment of 20 treatment centers decentralizing approach, providing multidimensional health education programmers, proclamation of law to stop collection of people and restrict number of passengers in public transport and banning on any services providing organization clients without wearing mask, has started experimenting treatment drug, and being ready for importing COVID-19 vaccine. Furthermore, economical and financial reforms have been done by the government of Ethiopia to do all these activities. Discussion In Ethiopia, CMNNDs age standardized death rate took nearly 55%, and the remained 45% accounted to NCDs and injury. The top 5 causes of death in Ethiopia are due to maternal and neonatal diseases, CVDs, TB and respiratory infections, enteric diseases, and neoplasm. Of these, reduction has looked on maternal and neonatal diseases by 18.71%, TB and other respiratory diseases by 17.7%, enteric infections nearly by 18%; but from NCDs; CVDs, and neoplasm cause death has enhanced by 2.06%, and 4.25%, respectively. But, the reduction of TB and respiratory diseases, enteric infectious diseases, and HIV/AIDS and STIs is comparable with Sub-Saharan Africa, but incomparable report has seen in CVDs and Neoplasm which rose by 2.06% and 4.25% in Ethiopia. CVDs and neoplasm death in Ethiopia changes indicated a similarity with East part of Sub-Saharan Africa. In Sub-Saharan Africa, the top causes of age-standardized death were TB and respiratory infections diseases (declined by 16.3%), CVDs (declined by 2.06%), maternal and neonatal diseases (declined by 14.15%), HIV/AIDS and STIs (declined by 24.17%), and enteric infection (declined by 18.58%). The possible reasons for similarity might be due to approaching standardized and several times reaffirmed international approaches based on the long run experiences sharing on these public health problems, implementing some community based intervention approaches, and proxy of socio-economic standard in lower-income country. In Ethiopia, MNDs cause of death followed by respiratory infections and TB diseases, enteric diseases, HIV/AIDS and STIs, NTDs and malaria, and nutritional diseases. This agreed with WHO reported that maternal and neonatal, malaria, TB, and HIV/AIDS as the main health problem of Ethiopia because inaccessible of basic health services both in prevention and curative cares, and unmet need of quality services, and rising of concomitant confection (HIV/AIDS and TB). Also, in particular to enteric diseases death, reasons might be still in Ethiopia 75% of the people lacked access to clean water and 80% of people use without proper sanitation condition [12]. Also 4 of 5 people died due to NCDs and injuries, of these CVDs and neoplasm related death took a lion share. Many studies reported NCDs have been steadily increasing in low-income countries; in particular to Ethiopia. The reasons behind could be adopting western lifestyles, increase urbanization, improvement of life expectancy, limited and lacked accesses to non-communicable prevention and curative services, and lacked quality of services. The study looked out the old age people have more likely lead to death due to NCDs which supported by as many studies have revealed. This might be the fact that at the biological level, ageing results from the impact of the accumulation of a wide variety of molecular and cellular damage over time. This leads to a gradual decrease in physical and mental capacity, a growing risk of disease, and ultimately, death. Moreover, we found COVID-19 impacts; global COVID-19 pandemic has reached many African countries that are already suffering from malnutrition and disease, under-resourced health systems, and limited economic funding. Sub-Saharan Africa, including Ethiopia, is unlikely to escape effects of the pandemic. While the trajectory of COVID-19 is still at its initial stages in the region, the repercussions of developments elsewhere are already being felt strongly. Ethiopia is a one country has affected by pandemic COVID-19 despite the least affected globally and Africa level; but the leading in East Africa by nearly 32% contribution in terms of death rate, followed by Kenya and Somalia. The pandemic COVID-19 has being affecting the world socioeconomic activities when implementing prevention and control measures strictly. The slowing down of the economy due to COVID-19’s impact (in Ethiopia, GDP drop from 7.2 to 2.6) on key sectors for the country could, in the worst case, force the government to join its expenditure such as health and education could be highly harmful for the medium to long-term economic development of the country, potentially putting at risk development gains achieved recently by the country. In Ethiopia during COVID-19 year and when COVID-19 death were 1,709; age standardized death rate of TB was 43.14per 100,000, and other respiratory diseases was 86.94 per 100,000, diarrheal diseases was 86.94 per 100,000, coronary heart disease was 112.44 per 100,000, stork was 74.87 per 100,000, and HIV/AIDS was 27.60 per 100,000. To summarize these, total TB and other respiratory diseases death was 130.08 per 100,000, and CVDs or total coronary heart disease and stork was 187.13 per 100,000. This indicated that both communicable and non-communicable diseases have steadily increased in COVID-19 era than before COVID-19 begins. The discrepancy seen during COVID-19 era that an increment death due to CVDs in Ethiopia might be due to the limited accessibility, poor quality and disruption of services to at risk group of people, old age is at risk and have more likelihood of death due to COVID-19 than young age, restriction of movements ,and the chance of risk of hypertension is higher on COVID-19 positive people than negative one. Moreover, in Ethiopia, the health services readiness for routine service was not more than 45%. The possible reasons for the increment of both communicable diseases and NCDs looked due to COVID-19 were diversion of resources from routine basic health care services, postponing 17 million children immunization campaign, limits prevention and curative services and expected to rise malnutrition by 10-15%, only 1 in 10 person accessed to adequate safe drinking water, nearly 1/4th of people have practiced open defecation, and very low rate of hand wash practice after toilet. Also, one study revealed that as well as diverting a limited resource allotted for routine basic health care services, COVID 19 has affected on the reduction of detection rate of TB and health seeking behaviors on TB in Ethiopia. In specific to NCDs and COVID-19 correlation, death rate due to CVDs among COVID-19 positives was higher than not the counterpart. However, a limited studies point out that there is a positive relation between COVID-19 and cancers (neoplasm) by aggravating the death and high likelihood of exposure than the counter parts, but needs further research. Beyond the effects of the disease itself, the impact would be overwhelmed in multidimensional ways directly and indirectly, more are expecting lower-income countries like in Ethiopia, and even abroad in some case [1, 5]. Conclusion Ethiopia is still under epidemiological transition during COVID-19 era, and cause of death has turned the face to NCDs. COVID-19 has frozen the entire healthcare system, bringing double burden to triple burden. Taking timely measures in countries such as Ethiopia is hampered by limited and insufficiently reliable and stable data on the real situation on morbidity and mortality from all types of nosologies. This study is based on the experience of Russia and provides updated data and value for policymakers, and researchers to achieve the targeted SDG 2030 targets through health system reform and a health care approach with parallel integration with local social service sectors. Since COVID-19 has affected all sectors of the economy, joint planning and work to combat the pandemic is essential. In developing countries, which are most susceptible to infectious diseases, and also experiencing the oppression of other non-infectious diseases, scenario planning, the readiness to implement the necessary preventive measures are especially important. Источник финансирования. Исследование не имело спонсорской поддержки. Конфликт интересов. Авторы заявляют об отсутствии конфликта интересов.

About the authors

M. B. Selgado

Peoples' Friendship University of Russia (RUDN University), Medical Institution

A. Yu. Abramov

Peoples' Friendship University of Russia (RUDN University), Medical Institution

D. I. Kicha

Peoples' Friendship University of Russia (RUDN University), Medical Institution


J. A. Zuenkova

Peoples' Friendship University of Russia (RUDN University), Medical Institution


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