Effectiveness of Multivitamin on Malaria Child Nutrition: Analysis

Background:

Children are the group age malaria which affects lymphocyte levels and decreases in hemoglobin as measured by the erythrocyte index.

Objective:

To find out the effectiveness of multivitamins on the biochemical nutritional status of malaria sufferers in Sanggeng Health Center, Manokwari Regency.

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Research Methods:

The experiment with two group case-control. The population was 61 children with malaria and a sample of 15 children in the case group (giving vitamin B complex and vitamin C) and a control group that was not treated. Data were obtained using a questionnaire for respondents' identities and laboratory tests using the hematology analyzer Sysmex 300 to determine lymphocytes, MCV levels, MCH, and MCHC.

Results:

Respondents with malaria in children aged 6-9 years as many as 15 people (50%) and at the age of 10-12 years as many as 15 people (50%). Male sex as many as 16 people (53.3%) and women as many as 14 people (46.7%). There were no differences in lymphocyte levels before and after administration of vitamin B complex and Vitamin C in children with malaria sufferers in Sanggeng Community Health Center, Manokwari Regency (p-value = 0.318) with differences in average lymphocyte levels of -0.6133. There were differences in MCV levels before and after administration of vitamin B complex and Vitamin C in children with malaria sufferers in Sanggeng Health Center, Manokwari Regency (p-value = 0.044) with an average value in the jerseys and controls group of -2.27000. There were differences in MCH levels before and after administration of vitamin B complex and vitamin C in children with malaria sufferers in Sanggeng Health Center, Manokwari Regency (p-value = 0,000) with an average value in the case group of -2.12000. There are differences in MCH levels before and after administration of vitamin B complex and vitamin C in children with malaria sufferers in Sanggeng Community Health Center, Manokwari Regency (p-value = 0.001) with an average value in the case and control groups of -1.06333Malaria is a global health problem which is still a concern for governments and world health agencies with a high prevalence rate in 106 tropical and subtropical countries. The estimated incidence of malaria in 2017 ranges from 227 - 670 million cases, with the number of deaths from malaria reaching 4.3 million cases per year and affecting the quality of health for infants, toddlers, and pregnant women (WHO, 2017). Malaria cases in Indonesia until 2016 there were 374 malaria-endemic districts/cities including Papua, NTT, Maluku, and North Maluku. Nationally, malaria incidence in 2014 was 256,592 cases with annual parasitic incidence (API) of 1.94, in 2015 as many as 417,819 cases with API amounting to 1.69, and in 2016 as many as 343,527 with APIs of 1.38. This shows that nationally from 2014 to 2016, API fell 0.56% (Indonesian Ministry of Health, 2016). The incidence of malaria in West Papua Province in 2014 was 141,670 with API 64, 2015 as many as 168,530 (API = 58), 2016 as many as 241,450 (API = 77). The malaria incidence in Manokwari Regency in 2014 Annual Malaria Incidence (AMI) was 18.6 per 1000 and API 84.6, 2015 AMI was 27.9 per 1000 and API = 12.7 and in 2016 AMI was 26 per 1000 and API = 10.3. This shows an increase in the incidence of malaria in West Papua Province and the Manokwari Regency.

Tropical malaria is a parasitic infectious disease caused by Plasmodium falciparum which attacks young erythrocytes and is only characterized by the discovery of asexual forms in red blood caused by Plasmodium falciparum protozoa which are transmitted to humans through mosquito saliva (Sucipto, 2015).

Plasmodium infection causes an increase in lymphocytes due to the presence of lymphocyte cells played by helper 1 T cells that are specific to Plasmodium antigens which overproduce and changes in hematological status include the erythrocyte index (changes in hemoglobin level), thrombocytopenia and leukopenia to leukocytosis which causes lymphocyte changes due to the process hemolysis by malaria parasites (Van, 2013).

The research conducted by Mau (2017) in positive patients with Plasmodium falciparum found 84% increased lymphocyte cells from reference values. The average number of P. falciparum 39.7200 lymphocytes with statistical test results showed that there was a significant difference between the number of lymphocytes in P.falciparum. Whereas Muslim research (2015) found changes in hemoglobin levels in tropical malaria patients between 7-14 g / dL with an average of 8.96 g / dL due to a decrease in hemoglobin levels affecting the erythrocyte index value. Research conducted by Sofiyetti (2016) reveals that administration of zinc supplementation with zinc and vitamin B12 can increase hemoglobin levels and erythrocyte index in malaria vivax. Research conducted by Fitri (2013), that the administration of vitamin C can reduce high lymphocyte levels to normal on the third and seventh day and Mizoc's (2011) study of giving vitamin B contributed to lymphocyte proliferation, lymphoid tissue formation, and in the antibody response.

The Malari incident in Manokwari district from the Manokwari District Health Office report data amounted to 4,127 with API values of 22.17 (Manokwari District Health Office, 2018). The incidence of malaria in Sanggeng Manokwari Community Health Center in 2018 had malaria cases with 1,717 cases, tropical malaria with 115 cases, and malaria mix in 3 cases. In January 2019, there were 61 cases of malignant malaria, 11 cases of tropical malaria, and 1 case of malaria mix.

Sanggeng Health Center was used as a place for sampling and research because there were many malaria sufferers with hemoglobin results below the normal range. In addition, there are many cases of tropical malaria in the Sanggeng Health Center using an examination of the number of lymphocytes and erythrocyte indices using automatic tools using the Hematology Analyzer (Sysmex XP 300). Sanggeng Health Center is a health center located in the center of Manokwari and covers a wide area. The treatment process for Malaria sufferers in the puskesmas is a dilemma because there are two methods of treatment that are equally believed to produce good results. The first treatment to provide multivitamins in malaria patients and the second treatment does not provide multivitamins in malaria sufferers. Looking for the truth of the two methods of treatment for malaria sufferers, a research is needed to do a research entitled 'Effectiveness of Multivitamins Giving Against the Biochemical Nutritional Status of Malaria Patients in Children in Sanggeng Health Center, Manokwari Regency'. Malaria is one of the public health problems because it affects high rates of morbidity and mortality. High-risk groups who are prone to malaria infection are toddlers, children, pregnant women, and nursing mothers. Other high-risk groups are residents who visit malaria endemic areas such as refugees, transmigrants, and tourists (Harijanto, 2012).

Malaria can cause blood deficiency because many destroyed blood cells are damaged or eaten by plasmodium. Malaria also causes splenomegaly, which is an enlarged spleen which is a symptom of a typical malaria clinic. Anemia occurs mainly due to the rupture of infected red blood cells, plasmodium falciparum infects all stages of red blood cells until a decrease in hemoglobin levels below normal can occur in acute and chronic infections. Anemia is a state of decreased hemoglobin levels, hematocrit, and rupture of red blood cells below the normal value added for individuals (MOH, 2007). Experiments carried out on 30 respondents in children who were divided into case groups and controls by giving a multivitamin, namely the administration of vitamin B complex and vitamin C are described as follows:

4.1. Provision of multivitamins (vitamin B complex and vitamin C) in the age of malaria sufferers in children

The results showed that of 30 respondents at the age of 6-9 years as many as 15 people (50%) and at the age of 10-12 years as many as 15 people (50%). In children who are given vitamin B complex and vitamin C occurs changes in lymphocyte, MCC, MCH, and MCHC levels in normal levels. Research is in line with previous research conducted by

Jannah that giving vitamin B complex syrup and vitamin C to anemic elementary school child in Sayung Subdistrict, Demak Regency, given once a week for three months can increase Hemoglobin levels by 2.2 g / dL (Jannah, 2009). Research by Subandi (1998) revealed that phagocytosis is very evident when parasitemia falls, this is because the presence of circulating antigens is also caused by the presence of vitamin B 12 and vitamin C which act as prooxins that can attract all circulating macrophage cells into peritoneal fluid and activate it.

Vitamin B complex is needed in the formation of blood cells red and is important in the final maturation of red blood cells for DNA synthesis (Deoxysio Nucleic Acid) because each vitamin in a different way is needed for the formation of thymidine triphosphate, which is one of the essential building blocks of DNA deficient in vitamin B12 or folic acid can cause DNA abnormalities and reduction and consequently are failure of core maturation and cell division (Guyton, and Hall, 2008). Vitamin B complex and vitamin C are known as anti-oxidant vitamins in the body, whose role is to help reduce free radicals simultaneously with endogenous antioxidants SOD (Super Oxide Dismutase), GPX (Glutathione Peroxidase), and catalase. In addition to functioning as an antioxidant, vitamin C has another important role, namely maintaining Se stability in the stomach (Suwondo, 2009).

4.2. Provision of multivitamins (vitamin B complex and vitamin C) in the sex of malaria sufferers in children

Respondents who were male were 16 people (53.3%) and women were 14 people (46.7%). This research is in line with Fitri's research (2013) that administration of vitamin B complex and Vitamin C is given to children with malaria regardless of sex.

Length of time given to children for 14 days, both route and frequency of giving vitamin B complex and vitamin C to children. The presence of parasites that persist in the human body can cause immunosuppressive reactions and can cause pathological tissue trauma. So that the main problem that occurs in the pathology of malaria is increased production of free radicals and decreased immune response (immunosuppression) in the final stages of the disease course. Immunosuppression that occurs in malaria turns out to be about cellular and humoral immune responses. The effects of immunosuppression occur on macrophage activity, antigen presentation, and secretion of immunoregulatory mediators (Fitri, 2013).

4.3. Effectiveness of giving multivitamins (vitamin B complex and vitamin C) to lymphocyte levels of malaria sufferers in children

Lymphocytes are cells that play a role in the immune response because they have the ability to recognize antigens through special surface receptors and divide themselves into a number of cells with identical specificity, with long life span of lymphocytes which makes the cell ideal for adaptive responses (Suparman, 2014). The results were obtained in children suffering from malaria with lymphocyte levels before the administration of vitamin B complex and Vitamin C in the case group as many as 11 people (73.3%) in the normal category and after administration of vitamin B complex and Vitamin C, there was an increase of 13 people ( 86.7%) in the normal category. In the control group before giving vitamin B complex and Vitamin C as many as 9 people (60%) in the normal category and after 2 weeks there was a decrease to as many as 8 people (53.3%) in the normal category.

Before giving vitamin B complex and vitamin C to lymphocyte levels, the average value in the case group was 25.7% and after giving vitamin B complex and vitamin C to lymphocyte levels, the average value in the case group was 27.6%, while in the control group it was 24.8% and after 2 weeks it decreased with an average of 24.1%.

The mean value is -0.6133 with a standard deviation value of 3.30420. The paired t-test results obtained a significance value at the significance level of 95% p-value = 0.318>  0.05 which means that there were no differences in lymphocyte levels before and after administration of vitamin B complex and Vitamin C in children with malaria in Sanggeng District Health Center Manokwari. This research is in line with that conducted by Fitri (2013), that administration of vitamin C can reduce high lymphocyte levels to normal on the third and seventh day. While in this study the researchers examined lymphocyte levels on day 14. This can cause changes in lymphocyte levels that are not significant. In addition, with the presence of the malaria drug which decreases the level of parasitemia, lymphocyte levels experience a significant insignificant decrease in normality.

Vitamin B consists of several forms, and those that are beneficial in the immune system are vitamin B12, vitamin B6, folic acid, and niacin. Vitamin B6 contributes to lymphocyte proliferation, lymphoid tissue formation, and in antibody responses. Vitamin B12 plays a role in the augmentation of phagocyte performance and T cell proliferation. Folic acid with vitamin B12 can affect NK cells (Mizoc, 2011). Giving vitamin C here can also be intended as an immunostimulator because vitamin C is a nutrient that is able to regulate the immune system because of its anti-viral and antioxidant abilities, has an important role in phagocytic function, and has the effect of stimulating lymphocyte cells. Giving vitamin C also caused a significant increase in phagocytic activity of peritoneal macrophages in mice. This is probably due to the immunostimulatory effect found in vitamin C, this has also been proven by (Fuente et al. 1997) who found that vitamin C can increase the proliferation and activity of immunocompetent cells, especially macrophages and T lymphocytes,

4.4. Effectiveness of giving multivitamins (vitamin B complex and vitamin C) to MCV levels

Low MCV values indicate a small size of red blood cells (called microcytes), normal MCV

values indicate the normal size of red blood cells and high MCV values indicate large red blood cell size (or macrocytes). This value can determine the type of anemia (lack of red blood cells) based on the size of the red blood cell. Normal values of 80-97 fl / red blood cell MCV in adults. The range of normal values can be different in each laboratory and the age of the patient (Kurniawan, 2016). The results showed that MCV levels before administration of vitamin B complex and Vitamin C in the case group were 5 people (33.3%) in the normocytic category and after administration of vitamin B complex and Vitamin C there was an increase of 11 people (73.3%) in the normocytic category. In the control group before giving vitamin B complex and Vitamin C as many as 4 people (26.7%) in the normocytic category and after 2 weeks there was no increase of 4 people (26.7%) in the normocytic category. The mean value of MCV levels in the case group before administration of vitamin B complex and Vitamin C was 77.4 fl and after administration of vitamin B complex and Vitamin C was 82.1 fl. In the MCV level control group, a value of 75.8 fl and after 2 weeks was 75.7 fl.

MCV levels before and after administration of vitamin B complex and vitamin C at an average value of -2.27000 with a standard deviation value of 5.90716. The paired t-test results obtained a significance value at the significance level of 95% p-value = 0.044 The results of the research on the combination of vitamin B complex and vitamin C were able to reduce eritorist degrees and provide healing in mice infected with Plasmodium berghei. However, it turns out that the combination of vitamin B complex and vitamin C can reduce the degree of parasitemia faster. This is likely because in vitamin C there is an immunostimulator effect so that it can increase the proliferation and activity of peritoneal macrophages which in turn will cause the parasite elimination process to occur faster. In addition to the second possibility, the group treated with anti-malarial drugs has the effect of releasing free radicals so that the healing process from malaria infection is slower than the group treated with a combination of Chloroquine and vitamin C so that chlorokuin eliminates vitamin C. antioxidants will help prevent tissue damage from free radicals (Fitri, 2013).

4.5. Effectiveness of multivitamins (vitamin B complex and vitamin C) on MCH levels (mean corpuscular hemoglobin)

Patients who have low MCH have a tendency to have iron deficiency type anemia. Anemia that occurs in these patients usually occurs due to lack of iron nutrition or bleeding that occurs, such as in colon cancer and bleeding in other digestive tracts. High MCH can indicate a large size of red blood cells that can occur due to liver damage, vitamin B12 deficiency, and also lack of folic acid (Kurniawan, 2016). The results showed that the levels of MCH before administration of vitamin B complex and Vitamin C in the case group were 5 people (33.3%) in the normochromic category and after administration of vitamin B complex and Vitamin C there was an increase of 10 people (66.7%) in the normochromic category. In the control group before giving vitamin B complex and Vitamin C as many as 4 people (26.7%) in the normokromikk category and after 2 weeks there was an increase to as many as 7 people (46.7%) in the normochromic category. The mean value of the respondents' MCH levels before giving vitamin B complex and vitamin C was 25 pg and after the treatment was 28 pg or there was an increase in MCV levels in the normal direction. Whereas in the control group before treatment, 32.8 pg and after 2 weeks without treatment increased to 32.9 pg or 0.1 pg. this increase is lower than the provision of vitamin B complex and vitamin C.

The level of MCH before and after administration of vitamin B complex and vitamin C in the case and control groups with an average value of -2.12000 with a standard deviation value of 2.59634. The paired t-test results obtained a significance value at the significance level of 95% p-value = 0,000 This study is in line with Sofiyetti's research (2016) revealing that there are differences in MCH levels before zinc and vitamin b6 supplementation with hemoglobin, hematocrit and erythrocyte levels of anemia in vivax malaria patients.