The effect of war and siege on children with diabetes admitted to ayder comprehensive specialized hospital in mekelle, tigray, ethiopia: a cross-sectional study – Nature.com 04:42 

The effect of war and siege on children with diabetes admitted to ayder comprehensive specialized hospital in mekelle, tigray, ethiopia: a cross-sectional study

Scientific Reports volume 14, Article number: 25007 (2024) Cite this article

Abstract

The armed conflict in Tigray, which spanned from November 2020 to November 2022, along with the accompanying siege, led to the near-total collapse of Tigray’s healthcare system. Type 1 Diabetes Mellitus, the most common chronic condition in children, requires significant lifestyle adjustments, including daily insulin injections, regular glucose monitoring, and dietary modifications; all of which are severely impacted by war and siege. This study compared Type 1 diabetes care for children at the Ayder Comprehensive Specialized Hospital, Tigray, during the conflict and siege period with that of the pre-war period. We conducted a retrospective cross-sectional survey, analyzing data from September 2019 to August 2020 (pre-war period) and comparing it with data from September 2021 to August 2022 (war and siege period). Descriptive statistics, including frequencies and percentages, were employed, and Pearson’s or Spearman’s correlation analyses were used to evaluate correlations where appropriate. We identified 143 pediatric patients admitted (56 during the pre-war period and 87 during the war and siege period), with a mean age of 109 months in both periods. During the war and siege, a higher proportion of diabetes admissions were due to diabetic ketoacidosis (DKA) (90%) compared to the pre-war period (75%). In the pre-war period, the most common trigger for DKA was infections (35%), while in the war and siege period, it shifted to malnutrition (47%), infections (46%), lack of access to healthcare facilities (31%), and running out of medicines (24%). Complications such as death, renal failure, cerebral edema, and shock were more prevalent during the war and siege periods. The case fatality rate was significantly higher during the war and siege (9%) compared to the pre-war period (0%), correlating strongly with the severity of DKA, the degree of hypokalemia, the presence of complications, and admission during the war and siege. Our study showed the negative impact of war and siege on diabetes care in children demonstrating a high rate of DKA admissions with increased severity, complications, malnutrition, and case fatality rates. People with diabetes especially type 1 deserve great attention during such a crisis as the lack of insulin could lead to severe complications including death.

Introduction

The war which started in November 2020 between the Tigray regional government in northern Ethiopia on one side and the Ethiopian federal government and its allies, on the other side led to the near total collapse of the Tigray region’s health care system once touted as one of the best performing in the country1,2,3. In addition, a complete siege was also imposed on Tigray by the Ethiopian federal government and its allies until the formal signing of the cessation of hostilities by both sides in November 20224. Tigray’s health facilities were looted, damaged, and vandalized resulting in only 3.6% of all health facilities being fully functional during the war and siege5,6,7.

According to a WHO report, only 3% of Tigray’s health facilities remained fully functional due to the two-year blockade and destruction. The conflict and siege led to the suspension of immunization services, an increase in infectious disease outbreaks, decreased treatment for communicable and non-communicable diseases (NCDs) such as HIV and diabetes mellitus, and worsening food insecurity and malnutrition, which in turn increased complications and mortality8. Coupled with the siege, patients with chronic conditions were among those who suffered the most. A study by Abraha et al. conducted in 46 health facilities in Tigray reported a more than 50% reduction in hypertension follow-up visits, resulting in a rise in acute and chronic complications and mortality9. Another recent study by Gebrehiwet et al. highlighted critical disruptions in healthcare services and high rates of loss to follow-up among NCD patients, potentially leading to increased morbidity and mortality10.

Diabetic care was one of the most compromised services due to the prolonged interruption of insulin supplies, leading to acute complications such as diabetic ketoacidosis (DKA). Type 1 Diabetes Mellitus (DM), the most common chronic disease in children, requires significant lifestyle changes, including daily insulin injections, regular glucose monitoring, and dietary modifications11. Effective diabetes management depends on functional insulin storage (e.g., refrigeration), a steady supply of insulin, essential materials like glucometers, test strips, and syringes, as well as adequate dietary access. However, during the conflict, these needs were nearly impossible to meet in Tigray due to power outages and the complete siege7,8. A recent study from 44 rural and semi-urban healthcare facilities in Tigray found that only 15% of previously registered Type 2 diabetes patients continued to seek treatment during the war and siege10. Similar challenges in managing diabetes have been reported in other conflict zones such as Yemen12, Syria13, and Iraq14. The increase in refugees and internally displaced persons (IDPs) has exacerbated outbreaks of infections and malnutrition, further complicating diabetes management and increasing mortality and morbidity15.

Tigray’s healthcare service which had registered significant improvement in the management of acute and chronic illness before the war, collapsed almost entirely after the war and siege. Patients were suffering due to lack of medications such as insulin which is vital and lifesaving for Type 1 DM. Insulin was out of stock for a prolonged time and inaccessible for many diabetic patients leading to complications and mortality. The international Diabetic Federation16 released an appalling report on 14 January 2022 citing an eye witness of an internist in Ayder referral Hospital:

“As one of two doctors responsible for the management of people with diabetes at Ayder Hospital, I would like to highlight the plight of people with diabetes, particularly with type 1, who are now at serious risk of death due to lack of insulin.”

However, such personal appeals should be supported by data documenting the impact of the war and siege on patients with diabetes compared to the pre-war & siege period in Tigray. This study aims to do just that by focusing on children with diabetes at Ayder Comprehensive Specialized Hospital, Mekelle as a case study. The findings from the study will contribute to better understanding of the impact of war on diabetes care and assist in rebuilding of the diabetic care infrastructure in Tigray.

Methods

Study design, population, and setting

We conducted a retrospective cross-sectional survey comparing data from two distinct periods: September 1, 2019, to August 30, 2020 (pre-war period) and September 1, 2021, to August 30, 2022 (war and siege period) at Ayder Comprehensive Specialized Hospital (ACSH). Data extraction was done in November 2022. ACSH, Tigray’s flagship healthcare institution located in Mekelle, was established in 2008. Before the onset of the war, ACSH was serving as the tertiary referral centre to more than 8 million populations in the catchment areas of Tigray, and parts of neighbouring regional states in Ethiopia such as Afar, and Amhara. During the war and siege, the hospital was partially functioning with very limited resources and serving parts of Tigray only. Prior to the war, child health care was one of the major departments serving both inpatient and outpatient departments with a total of 162 beds, and six wards and was staffed up with more than 20 specialists and 5 subspecialists. Although Ayder Comprehensive Specialized Hospital was a teaching hospital for both under and post-graduates before the war, but during the war and siege it was serving as a teaching institution for limited postgraduate programs only.

Sampling and eligibility criteria

We included all children aged ≤ 18 years admitted to the pediatric wards with a diagnosis of diabetes mellitus (DM) who had complete medical records, including admission history, physical examination, investigations, and treatment details. Children with incomplete or missing data were excluded. Data were extracted from the records of all diabetic children admitted to the pediatric ward at Ayder Comprehensive Specialized Hospital between September 1, 2019, and August 30, 2020 (pre-war and siege period) and between September 1, 2021, and August 30, 2022 (war and siege period).

Study variables, measurements, and data extraction process

We collected data on age, sex, area of residency, malnutrition status and severity, outcomes of diabetic ketoacidosis (DKA), and other complications. All methods adhered to relevant guidelines and regulations. Malnutrition was identified by the presence of bilateral pitting edema or wasting, as indicated by low Mid-Upper Arm Circumference (MUAC), low Weight-for-Height (WFH) or Weight-for-Length (WFL), or low Body Mass Index (BMI). Measurements were interpreted using WHO growth curves17 with normal values being above − 2 Z-score, moderate malnutrition between − 3 and − 2 Z-score, and severe malnutrition below − 3 Z-score.

DKA was defined by random blood sugar (RBS) > 200 mg/dL and positive urine ketones, or positive urine ketones in known DM patients (to address euglycemic DKA). This definition was based on the latest International Society for Pediatric and Adolescent Diabetes (ISPAD) guidelines18,but due to the absence of venous pH and bicarbonate measurements, these were not used for classification. The severity of DKA was classified clinically11 based on the patients degree of dehydration, mental status and presence or absence of acidotic breathing (Kussmaul breathing) as:-.

  1. 1.Mild DKA: – The patient has no signs of dehydration, oriented, alert but fatigued.
  2. 2.Moderate DKA: – The patient has some dehydration, Kussmaul respirations; oriented but sleepy; arousable.
  3. 3.Severe DKA: – The patient has severe dehydration to shock, Kussmaul or depressed respirations; sleepy to depressed sensorium to coma.

Hypokalemia was defined as serum potassium level of less than 3.5 mmol/L and farther categorized as mild when the serum potassium level is 3 to 3.4 mmol/L, moderate when the serum potassium level is 2.5 to 3 mmol/L, and severe when the serum potassium level is less than 2.5 mmol/L.19,20.

Data extraction was performed using a checklist developed in ODK software. Two pediatric residents were trained to collect the data from medical charts, and the principal investigator reviewed the completeness of the data daily.

Data analysis

The extracted data were exported to Excel and then imported into SPSS for analysis. Descriptive statistics were used to assess frequencies, percentages, ratios, and measures of dispersion. Categorical data were compared using Pearson’s Chi-square test or Fisher’s exact test. Correlations were assessed using Pearson’s or Spearman’s correlation analyses, as appropriate. A p-value of < 0.05 was considered statistically significant.

Results

Sociodemographic characteristics

A total of 143 children with diabetes were admitted to Ayder Comprehensive Specialized Hospital (ACSH) across two-time intervals: pre-war and during the war and siege. All patient records from these admissions were included in the analysis. Of these 143 patients, 56 were admitted during the pre-war period, and 87 during the war and siege period. The mean age of the patients was approximately 109 months in both periods. Detailed demographic characteristics of the study participants are presented (Table 1).

Clinical presentation and complications

Table 1 also presents the detailed clinical and nutritional characteristics of children admitted for diabetes. The proportion of newly diagnosed diabetes patients was similar across both periods, with 47% during the pre-war period and 45% during the war and siege. Diabetic ketoacidosis (DKA) was the primary reason for hospital admission, affecting 120 patients (84%) overall. A significantly higher percentage of admissions during the war and siege were due to DKA (78 patients, or 90%) compared to the pre-war period (42 patients, or 75%) (p = 0.020). Furthermore, patients admitted during the war and siege experienced more severe complications of DKA, including cerebral edema, renal failure, shock, and hypokalemia, compared to those admitted before the war.

The proportion of patients with moderate to severe malnutrition increased significantly from 14 patients (25%) during the pre-war period to 54 patients (62%) during the war and siege (p < 0.001). Severe malnutrition alone more than doubled from 8 patients (14%) pre-war to 27 patients (31%) during the war and siege. Additionally, nearly half of the patients admitted during the war and siege (41 patients, or 47%) reported inadequate dietary access, in contrast to only 2 patients (4%) who reported such issues during the pre-war period.Table 1 Sociodemographic, clinical and nutritional characteristics of children admitted for diabetes (N = 143).

Full size table

Diabetic Ketoacidosis (DKA)

As detailed in Table 1, DKA was responsible for a higher proportion of admissions among children with diabetes during the war and siege (90%) compared to the pre-war period (75%). The severity of DKA was significantly greater during the war and siege, with a higher percentage of cases classified as moderate to severe (p = 0.002). Notably, the incidence of severe complications of DKA increased during the war and siege period: cerebral edema rose from 0 to 11% (p < 0.001), and shock increased from 2 to 7% (p < 0.001) compared to the pre-war period.

Table 2 outlines the clinical features and precipitating factors for children with DKA. The percentage of patients admitted for DKA two or more times within a year was higher during the war and siege (20%) than in the pre-war period (14%) (p = 0.03). Additionally, the proportion of DKA patients presenting with coma doubled from 14 to 28% during the war and siege (p < 0.001). New precipitating factors for DKA emerged during the war and siege period, including intentional rationing of insulin, lack of access to healthcare facilities due to war-related damage and transportation disruptions, and inadequate access to appropriate food for diabetes management.Table 2 Clinical features and precipitating factors for children with DKA, n = 120.

Full size table

*A patient may have > 1 one precipitating factors, hence the sum of the percentages on the columns may be > 100%.

Table 3 presents the determinant factors affecting patient outcomes for children with diabetes admitted with DKA. During the war and siege period, the mortality rate associated with DKA was 9%, compared to 0% in the pre-war period (p = 0.003). Factors significantly associated with mortality included the severity of DKA, degree of hypokalemia, admission during the war and siege period, and the presence of complications.

All seven diabetes patients who died during the war and siege had DKA. The immediate causes of death were multi-organ failure in five patients and respiratory failure in two. Among the survivors of DKA, 4.2% (5 out of 120) developed sequelae such as chronic renal failure and seizure disorders, all of which occurred during the war and siege period.Table 3 Determinant factors of patient outcome in children with diabetes admitted with DKA (n = 120).

Full size table

Discussion

Our study highlights the profound impact of the Tigray conflict and siege (2020–2022) on the care of children with diabetes. The significant increase in diabetes admissions at Ayder Comprehensive Specialized Hospital (ACSH) during the war and siege compared to the pre-war period is likely due to the widespread collapse of health services in the region. With only 27.5% of hospitals and 17.5% of health centers fully functional and most facilities operating with severely limited resources including insulin3many patients from across Tigray were compelled to seek care at ACSH, which remained relatively operational with some medical supplies. Additionally, Mekelle, the location of ACSH, became a major hub for internally displaced people21 further increasing the patient load at the hospital.

Our study found a higher percentage of children admitted with DKA during the war and siege compared to the pre-war period. Although infections such as pneumonia and urinary tract infections were common precipitating factors for DKA, their incidence increased during the conflict (35% pre-war vs. 46% during the war and siege). This rise in infections may be attributed to the collapse of infection prevention services, decreased access to water and sanitation, and inadequate nutrition3. New precipitating factors, including intentional insulin rationing and lack of access to healthcare facilities and appropriate food, emerged during the war and siege due to the disruption of the healthcare system.

The study also revealed a significant increase in severe complications associated with DKA, such as cerebral edema, renal failure, and hypokalemia, during the war and siege. The DKA-related mortality rate during the conflict was double that reported in a previous study conducted at ACSH in 2019 (pre-war)22. Delayed presentation to health care as result of disrupted transportation, lack of security, damage to diabetic care services in other parts of Tigray, and lack of access to food and clean water during the war and siege period in the region contributed to negative outcomes in our patients. Similar findings were reported by Gesesew H et al., who highlighted the broader impacts of the conflict on health and humanitarian conditions3.

The study also found a dramatic increase in malnutrition among diabetic children during the war and siege. While 25% of patients were malnourished pre-war, this figure surged to 62% (2.5 fold) during the conflict. The high food insecurity in Tigray due to the war and siege likely contributed to this raise in malnutrition in diabetic children. For example, World Food Program reported that 91% of the population in Tigray required emergency assistance2,6. Gesesew H et al. also reported fateful humanitarian crises including the use of food, medicine as a tool of war during the Tigray war3. A case report from a refugee camp in Cameroon corroborates our findings, indicating that conflict-related insecurity exacerbates severe acute malnutrition among patients with type-1 DM15. In contrast, a study from Yemen reported that 74.7% of patients adhered to their diabetic diet and 98% did not change their dietary habits, highlighting differences in the impact of conflict on diabetes care across regions12.

Whilst our study attempted to demonstrate the impact of the war and siege on children with diabetes and their care, it has its own limitations. First, the study was conducted in a single hospital which affects the generalizability of the findings to the entire Tigray. That said, given that Ayder Comprehensive Specialized Hospital was the most well equipped, we feel outcomes elsewhere could even be worse. Second, the sample size was small where we were not able to apply inferential statistics (regression analysis). This deters from reporting independent predictors affecting the main diabetic outcomes among children in our study. Third, data were extracted using chart review only and were not collected prospectively. Though Ayder Hospital sustained limited physical damage, it is very difficult to ascertain the completeness of all the data gathered from paper charts. Fourth, the demographic characteristics of the patients studied prewar versus during the war & siege are not the same (including gender and age), and making statistical adjustments is difficult due to the small sample size. That said, the reason the demographics are different might also be indicative of the selective effect of the war and siege on who goes to the hospital and who doesn’t.

Conclusions

The Tigray conflict and siege had a severe and detrimental impact on children with diabetes. There was a significant increase in the proportion of patients admitted with DKA, which led to greater complications and higher mortality rates. Key precipitating factors for DKA during the conflict included infections, insulin rationing, and inadequate access to food and medical supplies.

Our findings underscore the urgent need for special attention to children with type 1 diabetes during crises. The lack of insulin and other essential resources can lead to severe complications and death. We urge governments, international organizations, and humanitarian agencies to prioritize the needs of children with type 1 diabetes to prevent such crises from having devastating effects on their health during war and humanitarian disasters.

Data availability

The datasets analyzed during the current study are available from the corresponding author on reasonable request.

Abbreviations

ACSH:

Ayder comprehensive specialized hospitalDM:

diabetes mellitusDKA:

diabetic ketoacidosisMAM:

moderate acute malnutritionSAM:

severe acute malnutritionT1DM:

type one diabetes mellitusRBS:

Random blood sugarIRB:

Institutional Review BoardMU:

Mekelle University

References

  1. Plaut, M. The International Community Struggles to Address the Ethiopian Conflict – Martin Plaut (Royal United Services Institute for Defence and Security Studies, 2021). -04-23 2021.
  2. Gesesew, H. et al. The impact of war on the health system of the Tigray region in Ethiopia: an assessment. BMJ. Glob. Health. Nov. 6(11), 1–4 (2021).
  3. Gesesew, H., Kebede, H., Berhe, K., Fauk, N. & Ward, P. Perilous medicine in Tigray: a systematic review. Conflict and Health. /05/30 2023;17(1):26. (2023).
  4. Ethiopia, U. N. Peace Agreement between Government and Tigray (Guterres, 2022).
  5. Gebregziabher, M. et al. Geographical distribution of the health crisis of war in the Tigray region of Ethiopia. BMJ. Glob. Health. Apr. 7(4), 5–7 (2022).
  6. USAID. Ethiopian-Tigray crisis. https://www.usaid.gov/sites/default/files/2022-05/2021_09_30_USG_Tigray_Fact_Sheet_11.pdf
  7. insight E. The health crisis in Ethiopia’s war-ravaged Tigray. https://rusi.org/explore-our-research/publications/rusi-newsbrief/international-community-struggles-address-ethiopian-conflict
  8. WHO. Crisis in Northern Ethiopia https://www.who.int/emergencies/situations/crisis-in-tigray-ethiopia
  9. Hailu, A. et al. The Impact of the Northern Ethiopian Tigray War on Hypertensive Patients’ Follow-Up:. (2022).
  10. Gebrehiwet, T. G. et al. War and Health Care services utilization for chronic diseases in Rural and Semiurban areas of Tigray, Ethiopia. JAMA Netw. Open. Aug. 1 (8), e2331745 (2023).Article Google Scholar 
  11. Kliegman, M. R. III JWSG. Nelson Textbook Pediatr.21, 11814–11815 (2020).
  12. Al-Sharafi, B. A. & Al-Tahami, B. A. The Effect of War on the control of diabetes in patients with type 2 diabetes Mellitus in Yemen: a cross-sectional study. Endocrinol. Metab. 3–5 (2017).
  13. Alali, I. & Afandi, B. Challenges in Type-1 Diabetes Management during the Conflict in Syria. (2022).
  14. Mansour, A. A. Patients’ opinion on the barriers to diabetes control in areas of conflicts: the Iraqi example. Confl. Health Jun. 24, 2:7 (2008).Article Google Scholar 
  15. Sap, S. et al. A hidden face of migration: Diabetic ketoacidosis in a severely malnourished refugee. Clin. Case Rep. Dec.7 (12), 2425–2428 (2019).Article Google Scholar 
  16. Federetion, I. D. Call for urgent action to avert avoidable diabetes deaths in Tigray, Ethiopia. https://idf.org/news/call-for-urgent-action-to-avert-avoidable-diabetes-deaths-in-tigray-ethiopia/
  17. WHO. The WHO Child Growth Standards.
  18. Nicole Glaser, M. F. et al. ISPAD Clinical Practice Consensus Guidelines 2022: Diabetic ketoacidosis and hyperglycemic hyperosmolar state. (2022).
  19. Sharma, D. C. S. Hypokalemia; (2022).
  20. Kardalas, E. P. S., Anagnostis, P., Muscogiuri, G., Siasos, G. & Vryonidou, A. Hypokalemia: a clinical update. Endocr. Connect. 7 (4), R135–R146 (2018).Article CAS PubMed PubMed Central Google Scholar 
  21. NEWS-GLOBAL. Over 1.7 Million People Displaced Due to Conflict Need Urgent Assistance in Northern Ethiopia: IOM. https://eastandhornofafrica.iom.int/news/over-17-million-people-displaced-due-conflict-need-urgent-assistance-northern-ethiopia-iom
  22. Hadgu, F. B., Sibhat, G. G. & Gebretsadik, L. G. Diabetic ketoacidosis in children and adolescents with newly diagnosed type 1 diabetes in Tigray, Ethiopia: retrospective observational study. Pediatr. Health Med. Ther. 10, 49–55 (2019).Article Google Scholar 

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Acknowledgements

The authors would like to acknowledge the data collectors who extracted the data.

Author information

Author notes

  1. Hailay Abrha Gesesew and Elias S. Siraj contributed equally to this work.

Authors and Affiliations

  1. Department of Pediatrics College of Health Science, Mekelle University, Tigray, EthiopiaAtsede Gebrekidan, Hansa Haftu & Abadi Luel
  2. Department of Pharmacy, College of Health Science, Mekelle University, Tigray, EthiopiaBerhane Yohannes Hailu
  3. Department of Public Health, College of Health Science, Mekelle University, Tigray, EthiopiaDawit Zenebe
  4. Department of Internal Medicine, College of Health Science, Mekelle University, Tigray, EthiopiaMigbnesh Gebremedhin
  5. College of Health Science, Ayder Comprehensive Specialized Hospital, Quality Management Office, Tigray, EthiopiaHiluf Ebuy Abraha
  6. Research Centre for Public Health, Equity, and Human Flourishing, Torrens University Australia, Adelaide, SA, 5000, AustraliaHailay Abrha Gesesew
  7. Tigray Health Research Institute, Mekelle, Tigray, EthiopiaHailay Abrha Gesesew
  8. Division of Endocrine and Metabolic Disorders, Eastern Virginia Medical School, Norfolk, VA, 23510, USAElias S. Siraj

Contributions

AG and HH contributed to the conception and drafting of writing the manuscript. BY, HAG, ESS, DZ, MG, HEA and AL participated in the analysis, critical review, and edition of the manuscript. HAG and ESS contributed equally. All authors approved the final version of the manuscript.

Corresponding author

Correspondence to Atsede Gebrekidan.

Ethics declarations

Competing interests

The authors declare no competing interests.

Ethical consideration

Ethical clearance was obtained from the Institutional Review Board (IRB) of the College of Health Sciences of Mekelle University with IRB number MU-IRB2015/2022. Permission from Ayder Comprehensive Specialized Hospital clinical director offices and a support letter from the chief clinical director were obtained before the commencement of the study. Due to the retrospective nature of the study, Institutional Review Board (IRB) of the College of Health Sciences of Mekelle University waived the need of obtaining informed consent.”

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Gebrekidan, A., Haftu, H., Hailu, B.Y. et al. The effect of war and siege on children with diabetes admitted to ayder comprehensive specialized hospital in mekelle, tigray, ethiopia: a cross-sectional study. Sci Rep 14, 25007 (2024). https://doi.org/10.1038/s41598-024-76516-5

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