Magnitude of acute respiratory infections in 6 months- 6 years in a rural hospital in B G Nagara: a cross-sectional study

Background: ARI is a major cause for morbidity and mortality in under five children and is responsible for 30-50% of all outpatients and 20-40% of in-patients. The overall incidence may be 5 episodes/child/year accounting for about 238 million attacks. Objectives: To study the prevalence of ARI in 6 months6 years children in a rural hospital in B G Nagara. Methods: A cross-sectional study was conducted for a period of one year in a rural hospital. Symptoms of cough, cold, fever, refusal of feeds and hurried breathing were considered to assess an ARI episode. Respiratory rate >60/minute (<2 month infants), >50(2-12 months) and >40(1-5 years) in a child with cough, cold or fever singly or in combination was considered the criteria for recognition of pneumonia. Other parameters like previous episodes, family history of ARI and immunization status were also taken into account. Results: Out of the 145 children with ARI surveyed, 69.7% had LRTI while 30.3% had URTI. 63.4% male children and 36.6% female children had ARI; male: female ratio being 1.7:1. It was more predominant in the age group of 6-12 months (46.2%). Out of the 32 children not breast fed, 75% had LRTI and 25% had URTI. 31.7% of the children had previous episodes of ARI while 11% of the children had positive family history of ARI. Conclusion: An understanding of ARI prevalence and the associated risk factors is essential. There is a significant association between ARI and low socioeconomic status, overcrowding, low birth weight, delay in the initiation of breast feeding, lack of exclusive breast feeding, prelacteal feeding, timely given complementary feeding and immunization status. The importance of basic health promotional measures like proper infant feeding practices, proper nutrition, immunization and improvement in the socioeconomic status help in the control and prevention of ARI.


Introduction
Acute respiratory infections are a major cause of morbidity and mortality in children and of particular significance in developing countries like India [1]. ARI is responsible for an estimated 3.9 million deaths worldwide every year [2]. ARI is responsible for 30-50% of all outpatients and 20-40% of in-patients. The overall incidence of acute respiratory infection in the under-5 may be 5 episodes/child/year accounting for about 238 million attacks [2].
In India, in the year 2013, about 31.7 million cases of ARI were reported [3]. Worldwide (AURI) while the remaining are Acute Lower Respiratory Infections (ALRI) [4,5]. 90% of ARI deaths are due to Pneumonia which is mostly bacterial cause. The incidence of Pneumonia in developed countries is 3-4% while in developing countries is 20-30% [2]. Pneumonia is responsible for about 18% of all under five deaths in India [3].
ARI can be classified into 2 types, based on the site of infection, into Acute upper respiratory tract infection (AURI) that includes common cold, pharyngitis, tonsillitis, sinusitis and otitis media while epiglottitis, laryngitis, croup syndrome (acute laryngotracheobronchitis), bronchiolitis and pneumonia are Acute Lower respiratory tract infection (ALRI). The common organisms responsible for causing respiratory infections include bacteria and viruses. The most common organism identified is Streptococcus pneumoniae accounting for 30-50% of pneumonia cases. The second most common organism is being Hemophilus influenza accounting for 10-30% cases.
The other organisms isolated are Staphylococcus aureus, Klebsiella pneumoniae and Mycobacterium tuberculosis [1]. Among viruses, respiratory syncytial virus is the leading cause, identified in 15-40% of cases, followed by influenza A and B, parainfluenza, human metapneumovirus and adenovirus [1,6,7].
Various risk factors identified for ARI are malnutrition, lack of immunization, poor breast feeding practices, overcrowding, low birth weight, exposure to air pollution, young age, vitamin A deficiency, passive smoking, family history of respiratory diseases [6,8].

Management of AURI ( No Pneumonia)[9]:
Many children with symptoms of cough, cold or fever do not have pneumonia and do not require antibiotics. Majority is caused by viruses and hence antibiotics are not recommended. Symptomatic treatment and home care is sufficient for such cases.
The importance of basic health promotional measures like proper infant feeding practices, proper nutrition, immunization and improvement in the socioeconomic status help in the control and prevention of ARI [10].

Aims and Objectives of the Study:
To study about the prevalence of acute respiratory infections (ARI) in 6 months-6 years children in a rural hospital in B G Nagara.

Materials and Methods
A cross-sectional hospital based study conducted on the children of age group 6 months-6 years with ARTI attending a rural hospital in Karnataka from December 1 st 2014-November 30 th 2015. The study was approved by the Institutional Ethical Review Committee. A predesigned proforma has aided in the enrollment of children into the study.
All children between 6 months-6years of age group were included. Exclusion criteria included cases with chronic respiratory ailments, any congenital defects in the lung, a known case of Pulmonay Tuberculosis and non consenting parents.
The diagnostic criteria included:  History of nasal discharge, cough, fever, hurried breathing, chest indrawing, refusal of feeds was used to assess an episode of ARI [9];  Respiratory rate >60/minute (among <2 month infants), >50 (2-11 months) and >40 (1-5 years) in a child with cough, cold or fever, singly or in combination are the criteria for recognition of pneumonia [9];  Previous history of ARI episodes, history of ARI in the family members, the immunization status and diet history was also considered.
 Nutritional status was assessed with parameters like weight, height and mid-arm circumference.
The children with common respiratory symptoms and signs were admitted for further evaluation and treatment. Routine blood investigations were sent like complete blood counts that included Hb, total counts, differential counts, platelet counts, haematocrit values. Absolute Eosinophil Count (AEC) were done for relevant cases. Chest x-ray was done for all cases. Pulmonary function tests were conducted for diagnosed bronchial asthma cases. Oxygen saturation was checked for all cases.
All the cases over a period of one year were included that comprised of 145 children. Data collection was done using a predesigned proforma.
The data collected was transferred to a master chart and the inference made separately. Data was entered in MS Excel and analysed using SPSS version 20. The data was analysed using the statistical test of significance (Chi-square test). Data was presented in the form of percentage, mean and standard deviation, graphs and figures. P value of <0.05 was considered to be statistically significant at 95% confidence interval.  The prevalence studied in different age groups. The higher incidence of respiratory infections was observed in the age group of 6-12 months (67, 46.2%). The mean age is 2.71 years + 2.42.    In both cases, male children had higher incidence of ARI (LRTI and URTI) compared to female children.
This could be compared with studies done by Rahman and Rahman et al who observed 14.9% incidence in male children and 14.4% incidence in female children [14]. Anand Krishnan et al observed that boys had higher hospitalization rate due to ARI than girls [15]. While studies by Chabra et al and Islam et al observed the ARI incidence to be higher in girls than boys [12,16]. The probable reason could be that boys are more susceptible for the infection than girls because they are more exposed to the cross infections.

ARI and Age:
Our study showed 46.2% children of the age group 6-12 months with the highest incidence of ARI and lowest in the age group of 37-48 months and 61-72 months (6.2%). The highest incidence in relation to ARI control programme was observed in the age group of 13-72 months and least among 6 months. This could be compared with a study done by Islam et al who observed the incidence to be 26.2% and more common among infants and females [16]. Chabra et al and Mathew J L et al showed the highest incidence among infants less than 2 months [12,17]. Tambe MP et al observed a higher incidence in the age group of 6 months-2 years [18]. Vanthanopas K et al observed the highest ARI incidence among 6-11 months and lowest among 48-59 months [19].
Since the breast fed children are protective against some viral or bacterial agents due to maternal antibodies in the first 6 months of life. Concurrent initiation of weaning may predispose nutritional deficiencies and subsequent susceptibility to most infections, including ARI. The high ARI incidence found in children of 2-3 year age group may be due to their greater exposure to environmental factors.

ARI and Immunization Status:
In the present study, 20.7% children were either partially immunized or not immunized. In such children LRTI was more common than URTI. Immunization status was inappropriate in male children than female children.
Studies that have shown association between immunization status and ARI were done by Savitha M R et al [20], Mathew J L et al [17], Broor S et al [21] and Prajapati B et al [22].  [21,25]. In a study by Biswas et al [26], Nafstad P et al [27] and Peat J K et al [28], an association of ARI with parenteral smoking habit has been observed.

ARI and
Children tend to stay in close contact with the family members, which makes them more vulnerable to contract communicable diseases.

Limitations
 Not all the risk factors associated with ARI could be assessed.  Follow up was not proper in the admitted children.  Exclusive breast feeding was not followed by the mother and early weaning was done.

Conclusion
 Breast fed children have a lower incidence of ARI.  Better nutritional status reduce the ARI incidence.  Regular and complete immunization lower the ARI incidence.  Family history of ARI can predispose to the disease in children.  There has a been a relation to previous episodes of ARI found in this study.
Increased global awareness regarding ARI has culminated in the initiation of a standard strategy of case identification using simple clinical signs and symptoms, and empiric antibiotic treatment and this approach has been organized by the WHO [29].
Thus community organizations must promote and make efforts to improve the nutritional status, encourage mothers for proper breast feeding practices and give complete immunization in children.
Funding: Nil, Conflict of interest: None initiated, Perission from IRB: Yes