https://orcid.org/0000-0001-5886-6630
Figures
Abstract
Background
Acute respiratory infection (ARI) is responsible for about 30–50 percent of visits to health facilities and for about 20–30 percent of admissions to hospitals in Nepal for children under 5 years old. Incidence of ARI in children among under-five years of age is 344 per 1000 in Nepal. Hence, the study aims to find out the prevalence and factors associated with acute respiratory infection among under-five children.
Methods
A cross-sectional study was conducted at Nepal Medical College and Teaching Hospital and International Friendship Children’s Hospital (IFCH) in Kathmandu among children of age 2–59 months attending Pediatric OPD. A total of 286 children were selected using the non-probability (convenient) sampling technique. Data were collected using pre-tested semi-structured tool through interview schedule, and descriptive and inferential statistical analyses were used.
Results
Out of 286 children, more than half of children (60.8%) had Acute Respiratory Infection (ARI). Nearly one-fifth of the children had severe or very severe pneumonia. Acute respiratory infection was significantly associated with religion followed by the family (p = 0.009, OR = 4.59 CI = 1.47–14.36), presence of the child in the kitchen while cooking (p = 0.001, OR = 2.03 CI = 1.17–3.51), and presence of respiratory tract infection in family (p = <0.001 OR = 2.83 CI = 1.59–5.05).
Citation: Ghimire P, Gachhadar R, Piya N, Shrestha K, Shrestha K (2022) Prevalence and factors associated with acute respiratory infection among under-five children in selected tertiary hospitals of Kathmandu Valley. PLoS ONE 17(4): e0265933. https://doi.org/10.1371/journal.pone.0265933
Editor: Sajid Bashir Soofi, Aga Khan University, PAKISTAN
Received: June 17, 2021; Accepted: March 11, 2022; Published: April 7, 2022
Copyright: © 2022 Ghimire et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: All relevant data are within the paper and its supporting information files.
Funding: This research was supported by Nepal Medical College-Institutional Review Committee (NMC-IRC): Ref.009-075/076 https://nmcth.edu/category/research/research_committee The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Competing interests: The authors have declared that no competing interests exist.
Introduction
Acute respiratory infections (ARIs) are infections of the airways from nostrils to the alveoli. ARIs can be categorized as upper respiratory tract infections (URIs) or lower respiratory tract infections (LRIs) [1]. Acute respiratory infection poses a major challenge to the health system, especially in developing countries and is the leading cause of mortality and morbidity among children under five years [2, 3].
According to the World Health Organization (WHO), respiratory infections account for 6% of the total global disease burden. Around 6.6 million, under-five aged children years of age die each year worldwide; 95 percent of them belong to low-income countries and one third of the total deaths is due to ARI [4]. It is estimated that Bangladesh, India, Indonesia and Nepal together account for 40% of the global ARI mortality. ARI is responsible for about 30–50% of visits to health facilities and for about 20–40% of admissions to hospitals for under-five children [3].
The Nepal Demographic and Health Survey (NDHS) 2016 revealed that 31% of the causes of neonatal mortality in Nepal were respiratory and cardiovascular disorders [5]. In fiscal year 2074/75, a total of 17, 50, 668 ARI cases among under-five were registered in Nepal, out of which 10.5% were categorized as pneumonia cases and 0.29% were severe pneumonia cases. ARI case fatality rate per thousand for under-five children at the health facility is 0.05 in Nepal [6].
Acute respiratory infection is linked to various modifiable risk factors including demographic, environmental, socio-economic, and nutritional factors [7]. Many studies have shown that comorbid illnesses especially HIV, malnutrition, prematurity or measles, family history of ARI, low socioeconomic status, inappropriate weaning time, pallor, severe malnutrition and cooking fuel other than liquefied petroleum gas, indoor air pollution, maternal illiteracy, parental smoking behavior male gender, rural residency and overcrowding associated with ARI [2, 7–9]. If the associated modifiable risk factors could be modified and/or avoided through the implementation of various intervention strategies then, the disease burden in the community could be reduced [7].
Despite the burden of acute respiratory infection on morbidity and mortality in children under-five children in the world, there is limited data to evaluate the problem in Nepal. The availability of data on the prevalence and risk factors of ARIs is vital because achieving Sustainable Development Goal on improving health and wellbeing will depend on the existing efforts to prevent and control ARIs in all WHO regions. Many socio-cultural, demographic, and environmental risk factors predispose children less than 5 years to acquire Respiratory Tract Infections (RTIs) [4].
Thus, this study aims to determine the prevalence and factors associated with acute respiratory infection among under-five children in selected tertiary hospitals of Kathmandu Valley.
Materials and methods
Aim, design, and setting
A cross sectional study was carried to assess the prevalence of Acute Respiratory Infection (ARI) and to identify the factors associated with ARI at two tertiary level hospitals of Kathmandu Valley; Nepal Medical College Teaching Hospital and International Friendship Children’s Hospital.
Study participants
Children attending the Pediatric Out Patient Department (OPD) of Nepal Medical College Teaching Hospital and International Friendship Children’s Hospital were selected as study participants. The inclusion criteria included: children aged ≥2–59 months visiting the hospital OPD for either respiratory or any other problems. The exclusion criteria were; children with clinically diagnosed bronchial asthma (history of repeated episodes of wheeze with rapid response to bronchodilator and children with any co-morbidity or any other physical and/or intellectual disabilities.
Sampling technique and sample size
A convenient sampling technique was adopted for this study. A similar study conducted in Gorkha Municipality of Nepal reported the overall prevalence of ARI to be 21.5% [10]. So, using this prevalence with an allowable error of 5% at a confidence level of 95%, the sample size was estimated to be 286 participants after adding a non-response rate of 10%.
Instruments
Pretested semi-structured questionnaire was used which was developed after extensive literature review and consulting with subject expert.
The tool was translated into Nepali language and back translated into English; then Nepali version of tool was pretested among 29 participants (10.14% of the total participants) for validation before the final administration. The reliability of the tool was calculated using Cronbach’s alpha, which was 0.85.
The research instrument consists of the following parts:
Part I: Socio-demographic characteristics of the child’s family
It includes information as age of the attendee, gender of the attendee, caste/ethnicity and religion of children’s family; information on the type of family, family size, and socio-economic status (as per modified Kuppuswamy scale) [11].
Part II: Environmental Characteristics
It includes information as the type of house, number of family members per room, cross-ventilation, place of cooking, presence of a child in kitchen while cooking and history of smoking in a family within the living areas.
Part III: Child related Information
It includes information on child as age and sex of the child, birth status, birth weight, anthropometric measurement (height and weight), exclusive breast-feeding, the month of weaning, and immunization status
Part IV: Prevalence of ARI
The prevalence of ARI was assessed using revised WHO classification of childhood pneumonia at health facilities [12] which is classified as no pneumonia, pneumonia and severe or very severe pneumonia where, children with cough and cold were classified as no pneumonia, children with fast breathing and/or chest wall indrawing were classified as pneumonia, and children with cough and difficult breathing and/or chest wall indrawing and presence of general danger signs, such as history of convulsions, inability to feed, incessant vomiting and lethargy or unconsciousness were classified as severe or very severe pneumonia.
Variables under the study.
Dependent variable: Acute Respiratory Infection (ARI). Independent variables: age and sex of the child, birth status, birth weight, caste/ethnicity, religion, type of family, family size and socio-economic status, type of house, number of family member per room, cross-ventilation, place of cooking, presence of child in kitchen while cooking, history of smoking in family, exclusive breast-feeding, month of weaning, immunization status and nutritional status
Procedure of data collection
The data was collected from March, 2019 to June, 2019 in the OPD of Nepal Medical College Teaching Hospital and International Friendship Children’s Hospital through interview schedule after obtaining formal permission from the respective hospitals. The attendees of the children were asked about the general information about the child and child’s family. The attendees were either mother or father of the child. The procedure and purpose of the study were explained to the attendees and were recruited based on inclusion and exclusion criteria. Those willing to participate were interviewed in the waiting area of OPD. Informed consent was read to the attendees and once signed, a face to face interview was conducted using the pretested semi-structured questionnaires by the researchers themselves. After obtaining general information, anthropometric measurement i.e. height and weight of the child was taken and finally the child was assessed for the presence of ARI as per WHO criteria. Children were recruited until the sample size was met.
Data management and statistical analysis
The collected data was entered into Microsoft Excel and coded with alphanumerical codes which were finally converted into Statistical Package for Social Sciences (SPSS) for statistical analysis. Continuous variables were categorized using their mean value. Bi-variate analysis (Simple Logistic regression) was used to show relationship between the categorical variables. Variables which had p<0.2 were subsequently put on stepwise multiple logistic regression model to determine the significant independent risk factor of ARI.
Ethical consideration
The study was approved by the Institutional Review Committee of Nepal Medical College. Permission for data collection was obtained from the Hospital Director and Head of the Department of Pediatric OPD of the respective hospitals. Written informed consent was taken from the parent (Mother or Father) of children attending pediatric OPD prior to data collection and all the information were kept confidential.
Results
A total of 286 children were recruited in the study. Interview was carried with the parents, of which most of them were mothers or fathers of the child, while some of them were caregivers. More than half of the children (64%) were aged 24 months and above and relatively similar percentage of the children (62.2%) were male, 11.5% of the child were born preterm while 7.3% them were child with low birth weight. Regarding nutritional status, most of the children (97.9%) were of normal nutritional status and 60.5% of the children were exclusively breastfed. More than half of the children (59.4%) were weaned after six months of age while, most of them (96.2%) had completed immunization as per their age. Majority of the children’s family (73.4%) followed Hindu religion and more than 3/4th of the children belong to middle class family. Majority (86%) of the children lived in pucca house, 24.1% lived in over-crowded house and 23.1% had poor ventilation in their house. More than one fourth of the family had their kitchen within living room or same room, 54.2% of the children were carried on back by their mother during cooking and 32.2% of the children’s family member were involved in smoking.
More than half of the children (60.8%) of the children were found to be have acute respiratory infection including 14.3% being diagnosed as severe or very severe pneumonia. [Table 1]
n = 286.
Bivariate analysis of the factors shows that the variables like religion followed by the family, presence of child in the kitchen while cooking and presence of respiratory tract infection were significantly associated with ARI. [Table 2]
n = 286.
Table 3 shows the multivariable model where the variables significantly associated were religion, presence of the child in kitchen while cooking and presence of RTI in family. From the odds ratio evaluation, the odds of having ARI among Buddhist and others were higher (4.59 times and 6.12 times respectively) than the Hindu. The probability of ARI was 2.83 times higher among the children whose family members had history of RTI. Similarly, the probability of ARI was double in the children if they were present inside kitchen while cooking. [Table 3]
n = 286.
Discussion
Prevalence of Acute Respiratory Infection (ARI)
The overall prevalence of ARI was 60.8%. The finding of this study is higher than the national data i.e. 2% of under-five children are affected with ARI in Nepal [13]. The prevalence is also higher than a study done in Gorkha Municipality, Nepal which showed 21.5% prevalence of ARI among under-five children [10]. While, one of the study conducted in Pokhara, Nepal showed 63% of the under-five children had ARI which is higher than the prevalence of current study [14]. Various studies conducted in India found lower prevalence (22%-52%) of ARI [7–8, 15–19]. On the contrary, study done in Shivrajpur, India showed higher prevalence i.e. 79.02% than the current study [3]. The findings are also higher than the studies done in Cameron (54.7%), Ethiopia (27.3%-33.5%) and Swat (29%) [4, 20–22].
Among the children who had symptoms of ARI, half of them had no pneumonia, 26.44% had pneumonia and 23.56% had severe or very severe pneumonia, while one of the study done in India found pneumonia among 23.3%, severe pneumonia among 47.7% and very severe pneumonia among 29% of the children and the study carried out in Cameron found 59% prevalence of no pneumonia, 25% pneumonia and 16% severe pneumonia [4, 7].
Factors associated with ARI among under-five children
The multivariate analysis showed, the variables significantly associated were again religion, presence of the child in kitchen while cooking and presence of RTI in family. From the odds ratio evaluation, the odds of having ARI among children following Buddhism and others were higher (p = 0.009, OR = 4.59 CI = 1.47–14.36) and (p = 0.004, OR = 6.12 CI = 1.77–21.15) respectively than the children following Hinduism. Therefore, children whose family was following buddhism religion were 4.5 times and other than hinduism and buddhism were 6 times likely to have ARI. The reason behind this might be the genetic inheritance. Children who were exposed to the family members (other than sibling) with RTI had 2.8 times probability of developing the symptoms of ARI. Similar finding have been identified by the studies done in Nepal (children are 7 times more likely to develop ARI when exposed to family member with symptoms of RTI), India (children are 5.32 times likely to develop ARI when exposed to family member with symptoms of ARI), Cameron (children are 3.37 times likely to develop ARI when exposed to family member with symptoms of ARI) and Zambia (children are 2.3 times likely to develop ARI when exposed to family member with symptoms of ARI) [2, 5, 9, 20]. A hospital based case-control study carried in India also found children whose mother had presence of Upper Respiratory Tract Infection (URTI) had 6.5 times were more likely to have ARI and presence of Lower Respiratory Tract Infection (LRTI) among family members were 5.15 times more likely to have ARI [23]. Children who were present in the kitchen during the time of cooking tend to develop symptoms of ARI double then those who were not present. A study carried in Bamenda Regional Hospital, Cameron also found children were 1.85 times more prone to ARI if they were exposed to wood smoke [4].
The present study shows no significant association of age, sex, birth weight, immunization status, nutritional status, exclusive breastfeeding, number of siblings, presence of ARI in sibling, type of family, parental education and occupation, socio-economic status, overcrowding, cross-ventilation and type of house. In contrast to this finding, various studies have identified these factors to be significantly associated with ARI among under-five children [2–4, 7–10, 14–22, 24–27].
Conclusions
Acute Respiratory Infection (ARI) is a major problem among under-five children. The prevalence of ARI among the male child is more than that of female child. The prevalence was higher among the children of age less than 24 months. Children when get exposed to smoking while cooking have greater chance of acquiring ARI. Similarly, when the family members have respiratory tract infections, it could double the risk of ARI among the children. Larger studies with case-control design in the community settings are recommended to find out the major factors of ARI. Children should not be exposed to fuel smoking unnecessarily and parents need to be more cautious when any of the family members have respiratory tract infection.
Supporting information
S1 Table. Socio-demographic information of the child.
n = 286.
https://doi.org/10.1371/journal.pone.0265933.s001
(TIF)
S2 Table. Distribution of child related environmental characteristics.
n = 286.
https://doi.org/10.1371/journal.pone.0265933.s002
(TIF)
S3 Table. Health information of the child.
n = 286.
https://doi.org/10.1371/journal.pone.0265933.s003
(TIF)
Acknowledgments
Researcher would like to thank the parents of children who shared their valuable experiences, spent precious time and for their participation and the faculties of Pediatric Department of Nepal Medical College and Teaching Hospital.
References
- 1.
Simones EAF, Cherian T, Chow J, Shahid-Salles SA, Laxminarayan R, John TJ, et.al. Acute Respiratory Infections in Children. Disease Control Priorities in Developing Countries. 2nd edition. Washington (DC): The International Bank for Reconstruction and Development / The World Bank. 2006. Chapter 25. pmid:21250360.
- 2. Yadav S, Khinchi Y, Pan A, Gupta S, Shah G, Baral D, et al. Risk Factors for Acute Respiratory Infections in Hospitalized Under Five Children in Central Nepal. J Nepal Paediatr Soc. 2013 Jun; 33(1):39–44. doi: https://doi.org/http://dx.doi.org/10.3126/jnps.v33i1.7358.
- 3. Gahlot A, Kumar S, Som Nath M, Mahajan P. ARI in underfive children with associated risk factors. Rama University Journal of Medical Sciences. 2015;1(1):1–5. pmid:34307256
- 4. Tazinya AA, Halle-Ekane GE, Mbuagbaw LT, Abanda M, Atashili J, Obama MT. Risk factors for acute respiratory infections in children under five years attending the Bamenda Regional Hospital in Cameroon. BMC Pulm Med. 2018 Jan; 18(1):7. pmid:29338717
- 5. Singh S, Shrestha G, Joshi D, Gebreselassie T. Childhood Illness and Mortality in Nepal: Trends and Determinants. DHS Further Analysis Reports No. 120. Rockville, Maryland, USA. 2019 Jan. Available From: https://dhsprogram.com/pubs/pdf/FA120/FA120.pdf.
- 6.
Annual Report. Department of Health Services (DoHS). Ministry of Health and Population, Government of Nepal: 2017/18. 2019. Available From: https://dohs.gov.np/wp-content/uploads/2019/07/DoHS-Annual-Report-FY-2074-75-date-22-Ashad-2076-for-web-1.pdf.
- 7. Bhat RY, Manjunath N. Correlates of acute lower respiratory tract infections in children under 5 years of age in India. Int J Tuberc Lung Dis. 2013 Mar; 17(3):418–22. pmid:23407233
- 8. Goel K, Ahmad S, Agarwal G, Goel P, Kumar V. A Cross Sectional Study on Prevalence of Acute Respiratory Infections (ARI) in Under-Five Children of Meerut District, India. J Community Med Health Educ. 2012 Oct; 2(9):1–4. doi: https://doi.org/https://dx.doi.org/10.4172/2161-0711.1000176.
- 9. Selvaraj K, Chinnakali P, Majumdar A, Krishnan I. Acute respiratory infections among under-5 children in India: A situational analysis. J Nat Sci Biol Med. 2014 Jan; 5(1):15–20. pmid:24678190
- 10. Maharjan PL, Sharma Y. prevalence and determinants of ARI among children under Age five in Gorkha Municipality. Glob J Pharmaceu Sci. 2017;2(3).
- 11. Saleem S.M. Modified Kuppuswyami socioeconomic scale updated for the year 2019. Indian J Forensic Community Med. 2019; 6(1): 1–3.
- 12.
Revised WHO classification and treatment of childhood pneumonia at health facilities: Evidence Summaries. 2014. Department of Maternal, Newborn, Child and Adolescent Health (MCA), World Health Organization. [Cited 15 April, 2021]. Available from: https://apps.who.int/iris/bitstream/handle/10665/137319/9789241507813_eng.pdf.
- 13.
Ministry of Health, Nepal; New ERA; and ICF. Nepal Demographic and Health Survey 2016. Kathmandu, Nepal: Ministry of Health, Nepal. 2017. Available From: https://www.dhsprogram.com/pubs/pdf/fr336/fr336.pdf.
- 14. Koirala R. Risk Factors of Acute Respiratory Infections in Children under Five Years Attending the Fishtail Hospital, Pokhara, Nepal. Journal of Gandaki Medical College-Nepal. 2019; 12(02):74–79. doi: https://doi.org/https://doi.org/10.3126/jgmcn.v12i2.27214.
- 15. Ranganatha D, Redy P, Kokiwar PR, An appraisal of ARI among under-five children in an urban slum area. International Journal of Pharmaceutical and Medical Research. 2015;3:3. Available From: https://www.woarjournals.org/admin/vol_issue2/upload%20Image/IJPMR031301.pdf.
- 16. Sharma D, Kuppusamy K, Bhoorasamy A. Prevalence of acute respiratory infections (ari) and their determinants in under five children in urban and rural areas of Kancheepuram district, South India. Ann Trop Med Public Health. 2013;6:513–8. doi: https://doi.org/https://dx.doi.org/10.4103/1755-6783.133700.
- 17. Prajapati B, Talsania N. A study on prevalence of acute respiratory tract infections(ari) in under five children in urban and rural communities of Ahmedabad district, Gujarat National Journ of Com Med. 2011;1 2: 2. Available from: http://www.njcmindia.org/home/view/135/.
- 18. Asghar SA, Srivastava MR, Srivastava JP, Gupta P and Zaidi ZH. Prevalence of acute respiratory infections among children under five years of age attending rural health training centre of Era’s Lucknow Medical College and Hospital. Int J Community Med Public Health. 2017;4(10):3752–3756. doi: https://doi.org/http://dx.doi.org/10.18203/2394-6040.ijcmph20174245.
- 19. Kumar SG, Majumdar A, Kumar V, Naik NB, Selvaraj K, Balajee K. Prevalence of acute respiratory infection among under-five children in urban and rural areas. J Nat Sci Biol Med. 2015 Jan-Jun; 6:3–6. pmid:25810626
- 20. Abuka T. Prevalence of pneumonia and factors associated among children 2–59 months old in Wondo Genet district, Sidama zone, SNNPR, Ethiopia. Curr Pediatr Res. 2017; 21:19–25. Available from: http://www.currentpediatrics.com/articles/prevalence-of-pneumonia-and-factors-associated-among-children-259-months-old-in-wondo-genet-district-sidama-zone-snnpr-ethiopia.html.
- 21. Rehman MU, Ishaq M. Prevalence of acute respiratory infections (ARI) and its risk factors in under five children in urban and rural areas of Matta, district Swat. Int J Infect Dis. 2018 1;73:230. doi: https://doi.org/https://doi.org/10.1016/j.ijid.2018.04.3937.
- 22. Dagne H, Andualem Z, Dagnew B and Taddese AD. Acute respiratory infection and its associated factors among children under- five years attending pediatrics ward at University of Gondar Comprehensive Specialized Hospital, Northwest Ethiopia: institution-based cross-sectional study. BMC Pediatrics. 2020; 20:93. pmid:32111196
- 23. Broor S, Pandey RM, Ghosh M et.al. Risk factors for severe acute lower respiratory tract infection in under-five children. Indian Pediatr. 2001; 38:1361–9. pmid:11752733.
- 24. Banda W, Mazaba LM, Mulenga D, Siziya S. Risk factors associated with acute respiratory infections among under-five children admitted to Arthur’s Children Hospital, Ndola, Zambia. Asian Pac. J. Health Sci. 2016; 3 (3):153–159. Available From: https://www.apjhs.com/index.php/apjhs/article/view/378/327.
- 25. Yaya S and Bishwajit G. Burden of Acute Respiratory Infections Among Under-Five Children in Relation to Household Wealth and Socioeconomic Status in Bangladesh. Trop Med Infect Dis. 2019; 4(1):36. pmid:30759811
- 26. Leung DT, Das SK, Malek MAet.al. Concurrent Pneumonia in Children under 5 Years of Age Presenting to a Diarrheal Hospital in Dhaka, Bangladesh. Am J Trop Med Hyg. 2015; 93: 831–835. pmid:26149863
- 27. Geberetsadik A, Worku A, Berhane Y. Factors associated with acute respiratory infection in children under the age of 5 years: evidence from the 2011 Ethiopia Demographic and Health Survey. J Pedia Health Med Therapeutics. 2015; 6: 9–13. Available From: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5683277/pdf/phmt-6-009.pdf. pmid:29388598