Table of Contents  
ORIGINAL ARTICLE
Year : 2012  |  Volume : 5  |  Issue : 2  |  Page : 125-128  

Clinical and epidemiological study of acute respiratory infection cases in children below twelve years of age in a tertiary care teaching hospital in Pune, India


1 Department of Community Medicine, Smt. Kashibai Navale Medical College, Narhe, Pune, India
2 Department of Community Medicine, R D Gardi Medical College, Ujjain, Madhya Pradesh, India
3 Department of Community Medicine, S R T R Medical College, Ambejogai, Maharashtra, India

Date of Web Publication10-Nov-2012

Correspondence Address:
Dhrubajyoti Debnath
Department of Community Medicine, Smt. Kashibai Navale Medical College, Narhe, Pune - 411041, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0975-2870.103337

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  Abstract 

Context: Pneumonia is the leading killer of children worldwide. AIMS: To study clinical and epidemiological factors associated with Acute Respiratory Infection (ARI) cases and find the case fatality rate. Setting and Design: Hospital-based cross-sectional study. Materials And Methods: Detailed clinical examination of all ARI cases were done in children below 12 years of age. The relevant socio-demographic and epidemiological information of the cases were collected by interviewing the parents/guardians of the children through a pre-tested proforma. Duration of the study was one year. Statistical Analysis Used: χ² test, P < 0.05 was considered as statistically significant. Results: There were 539 (11.3%) ARI cases from a total of 4,764 admissions. There were 317 males and 222 females. Out of 539 ARI cases, 455 (84.4%) were in the age group of 0-5 years. Malnutrition was associated with 360 (79.1%) of the 455 under-five cases. A total of 283 (62.2%) cases were incompletely immunized for age. Case fatality rate was 3.8% in males and 8.1% in females. Conclusion: Children who were incompletely immunized for age suffered from severe forms of ARI, and this was statistically significant. The case fatality rate was much higher in females, and this was statistically significant. The comorbid factors/illnesses with ARI, which were statistically significantly associated with mortality, were malnutrition, acute diarrheal illness, septicemia, meningitis, and congenital anomaly.

Keywords: Acute respiratory infection, mortality, under-five


How to cite this article:
Debnath D, Wanjpe A, Kakrani V, Singru S. Clinical and epidemiological study of acute respiratory infection cases in children below twelve years of age in a tertiary care teaching hospital in Pune, India. Med J DY Patil Univ 2012;5:125-8

How to cite this URL:
Debnath D, Wanjpe A, Kakrani V, Singru S. Clinical and epidemiological study of acute respiratory infection cases in children below twelve years of age in a tertiary care teaching hospital in Pune, India. Med J DY Patil Univ [serial online] 2012 [cited 2024 Mar 29];5:125-8. Available from: https://journals.lww.com/mjdy/pages/default.aspx/text.asp?2012/5/2/125/103337


  Introduction Top


Pneumonia kills more children than any other illness does, and it accounts for 19 per cent of all under-five deaths. This figure, however, does not include deaths due to pneumonia during the first four weeks of life, ie, the neonatal period. It has been estimated that 26 per cent of neonatal deaths, or 10 per cent of all under-five deaths, are caused by severe infections during the neonatal period. Further, a significant proportion of these infections is caused by pneumonia/sepsis (sepsis is a serious blood-borne bacterial infection that is also treated with antibiotics). If these deaths were included in the overall estimate, pneumonia would account for up to three million, or as many as one-third (29 per cent), of under-five deaths each year. [1]

The objective was to study the clinical and epidemiological factors associated with the Acute Respiratory Infection (ARI) cases and find the Case Fatality Rate (CFR).


  Materials and Methods Top


Ethical approval was taken from the Institutional Ethics Committee. The study was conducted in Pediatric Indoor Patient Department (IPD) of tertiary care teaching hospital in Pune, India. The study included all children below 12 years of age who were suffering from ARI and were admitted in the Pediatric IPD. Acute respiratory infection in children below five years of age was classified as per the standard case definition. [2] The purpose of the study was explained to the parent/guardian of all children and informed consent was obtained. The relevant socio-demographic and epidemiological information of the cases were collected by interviewing the parents/guardians of the children by using a pre-tested proforma. A detailed clinical review was done, including history and clinical examination. Malnutrition was classified as per Indian Academy of Pediatrics Classification. The study was conducted for an entire year to study the seasonal variation in the admission of ARI cases.


  Results Top


The total number of admissions in the Pediatric IPD during the one-year study period was 4,764, out of which 539 (11.3%) suffered from ARI. There were 317 males and 222 females, with the male-to-female ratio being 1.4:1.

The clinical severity of ARI in under-five children i.e. pneumonia and severe pneumonia/very severe illness was statistically significantly associated with incomplete immunization for age as seen in [Table 1], however the clinical severity was not statistically significantly associated with grades of malnutrition and age of the child as seen in [Table 2] and [Table 3] respectively. [Table 4] shows highest case fatality rate (CFR) of 12.1% in young infants (age 0-2 months) and high CFR in female children as compared to male children. [Table 5] shows that highest CFR of 11.3% was observed in under-five children with severe pneumonia/very severe illness. [Table 6] shows that the associated illnesses which were statistically significantly associated with case fatality were malnutrition, acute diarrheal disease, septicemia, meningitis, and congenital anomaly.
Table 1: Relationship between immunization status and severity of ARI cases under-five

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Table 2: Relationship between grades of malnutrition and severity of ARI cases under-five

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Table 3: Relationship between age of the child and severity of ARI cases under-five

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Table 4: Age-and Gender-specific case-fatality rate in ARI cases in age group of 0-12 years

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Table 5: Relationship between severity of ARI cases and mortality in age group of 0-5 years

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Table 6: Associated illnesses in ARI cases who died (age group, 0-12 years)

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Among 539 cases of ARI, overcrowding was associated in 445 (82.6%), pollution from biomass fuel in 412 (76.4%), history of ARI in family member in preceding two weeks in 205 (38%), and history of tobacco smokers in family in 110 (20.4%).

After pooling the data season-wise, it was found that the largest number of cases occurred during the rainy season (38.8%), followed by summer season (34.7%), and then winter season (26.5%).


  Discussion Top


In the present study, 539 cases of ARI were in the age group of 0-12 years, out of which 455 cases (84.4%) were under-five and only 84 cases (15.6%) were in the 5-12 years of age. There were 317 males and 222 females, and the male to female ratio was 1.4:1. Similar findings were seen by other investigators in India. [3],[4] The gender difference may partly be due to preferential treatment to male children, who when sick are more likely to be brought to hospital or a healthcare unit. [5]

In the present study, children suffering from episodes of severe pneumonia/very severe illness are comparatively less in the under-five who had complete immunization for age as compared to those children who were incompletely immunized for age, and the difference is statistically highly significant. These findings were observed in other studies as well. [6],[7] The findings of these studies suggest that mothers utilizing the immunization services are better aware of healthcare facilities and probably seek early consultation for illness of their children. Awareness of mothers leading to early identification of illness probably avoids severe illness. [7]

Cases of severe pneumonia/very severe illness were seen more frequently with severe malnutrition, but when we pooled the cases of 'pneumonia' and 'severe pneumonia/very severe illness' for analysis, the difference was not statistically significant. Synergistic action between malnutrition and infection is well recognized, as the presence of one predisposes and aggravates the other. In a malnourished child, there is significant impairment in immunity, particularly of cellular type, which increases the susceptibility to ARI and secondary infection. [5]

The proportion of cases suffering from severe pneumonia/very severe illness was highest (78.8%) in children 0-2 months of age, followed by 38.2% in the age group of 2-12 months, and was least (29.9%) in the age group of 12- 60 months. Thus, the proportion of ARI cases with severe pneumonia/very severe illness decreased as age advanced, but again when we pooled the cases of 'pneumonia' and 'Severe pneumonia/very severe illness' for analysis, the difference was not statistically significant.

The case-fatality rate in ARI cases decreased as age advanced up to 5 years, but increased in the age group of 5-12 years. This may be due to three deaths (out of 5 deaths in the age group of 5-12 years) that were associated with septicemia, congenital heart disease with congestive cardiac failure, and one case was HIV positive. In the present study, the mortality was inversely related to age. This was also observed by Sehgal et al. [8]

Among children below 5 years of age, the mortality was much higher in those with severe pneumonia/very severe illness, but for analysis, when the cases with 'pneumonia' and 'severe pneumonia/very severe illness were pooled together, the difference was not statistically significant.

In the present study, the overall CFR in ARI cases (0-12 years of age) is 5.6%. The ARI-associated CFR among hospitalized patients in developing countries is as high as 5-10%. [5] The case-fatality rate of ARI cases in males was 3.8% and, in females, it was 8.1%, with the difference being statistically significant. Similar findings were also reported by other studies. [4],[9]

In a study by Rudan, [10] malnutrition (weight-for-age z score < -2) and lack of measles immunization (within the first 12 months of life) are among the definite risk factors that affect the incidence of childhood clinical pneumonia in the community in developing countries.

The comorbid factors/illnesses with ARI, which were statistically significantly associated with mortality, were malnutrition, acute diarrheal illness, septicemia, meningitis, and congenital anomaly.

In the present study, the maximum number of cases (38.8%) were recorded in the rainy season, followed by (34.7%) in summer season, and (26.5%) in winter.

To summarize, children who were incompletely immunized for age suffered from severe forms of ARI, and this was statistically significant. Although the male to female ratio was 1.4:1, the CFR was much higher in females, and this was statistically significant. This reflects the gender inequality wherein female children are neglected and brought late to a healthcare facility during her illness. The comorbid factors/illnesses with ARI, which were statistically significantly associated with mortality, included malnutrition, acute diarrheal illness, septicemia, meningitis, and congenital anomaly. The Integrated Management of Childhood Illness IMCI (Integrated Management of Neonatal and Childhood Illness IMNCI in India) guidelines were developed keeping in mind that millions of under-five children die in developing countries due to pneumonia, acute diarrheal disease, measles, malaria, and often due to a combination of these illnesses. Malnutrition is associated in a large proportion of these deaths. Hence, case management in under-five should be as per IMNCI guidelines that assess the possible bacterial infection/jaundice in 0-2 months and general danger signs in the age group of 2 months to 5 years. The IMNCI guidelines also assess the clinical presentation of these infectious diseases to classify the severity. These infectious diseases are the common causes of deaths in children under five. The IMNCI guidelines assess feeding, nutritional, and immunization status of the child. Thus, as seen in our study, the overall health of the child has to be assessed. Therefore, there is a definite role of early diagnosis and case management in children aged below 5 years as per IMCI (IMNCI in India) guidelines.


  Limitations Top


This being a cross-sectional study done in a tertiary care teaching hospital, the severe forms of ARI seen may be much higher than in community-based studies.

 
  References Top

1.UNICEF/WHO, Pneumonia: The forgotten killer of children, 2006 ISBN-13: 978-92-806-4048-9 ISBN-10: 92-806-4048-8.  Back to cited text no. 1
    
2.WHO. The management of acute respiratory infections in children, practical guidelines for outpatient care. Geneva: World Health Organization; 1995.  Back to cited text no. 2
    
3.Patwari A, Aneja S, Mandal R, Mullick D. Acute respiratory infections in children: A hospital based report. Indian Pediatr 1998;25:613-7.  Back to cited text no. 3
    
4.Agarwal P, Shendurnikar N, Shastri NJ. Host factors and pneumonia in hospitalized children. J Indian Med Assoc 1995;93:271-2.  Back to cited text no. 4
    
5.Narain JP. Epidemiology of acute respiratory infections. Indian J Pediatr 1987;54:153-60.  Back to cited text no. 5
[PUBMED]    
6.Agarwal DK, Bhatia BD, Agarwal KN. Simple approach to acute respiratory infection in rural under-five children. Indian Pediatr 1993;30:629-35.  Back to cited text no. 6
[PUBMED]    
7.Broor S, Pandey RM, Ghosh M, Maitreyi RS, Lodha R, Singhal T. Risk factors for severe acute lower respiratory tract infection in under-five children. Indian Pediatr 2001;38:1361- 9.  Back to cited text no. 7
    
8.Sehgal V, Sethi GR, Sachdev HP, Satyanarayana L. Predictors of mortality in subjects hospitalized with acute lower respiratory tract infections. Indian Pediatr 1997;34:213-9.  Back to cited text no. 8
[PUBMED]    
9.Khan AJ, Khan JA, Akbar M, Addiss DG. Acute respiratory infections in children: A case management intervention in Abbottabad district, Pakistan. Bull World Health Organ 1990;68:577-85.  Back to cited text no. 9
[PUBMED]    
10.Rudan I, Boschi-Pinto C, Biloglav Z, Mulholland K, Campbell H. Epidemiology and etiology of childhood pneumonia. Bull World Health Organ 2008;86:408-16.  Back to cited text no. 10
[PUBMED]    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]


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[Pubmed] | [DOI]



 

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