| Abstract|| |
Background: Acute respiratory infection (ARI) is a major public health problem worldwide. It is a significant cause of morbidity and mortality and main reason for utilization of health services among children. Identification and intervention of major risk factors can reduce the burden of ARI among children. Objective: To determine the prevalence of ARI and its risk factors among under five children in urban and rural areas of Kancheepuram district, South India. Materials and Methods: A community-based, cross-sectional study was done in urban and rural field practice areas of Melmaruvathur Adhiparasakthi Institute of Medical Sciences and Research (MAPIMS), Melmaruvathur, Kancheepuram (District) Tamil Nadu, south India, during the period of October 2009-February 2010, covering a study population of 500 under five children. Descriptive statistics was done and chi-square was used as test of significance. Results : Overall, prevalence of ARI was found to be 27%. ARI was noticed more among low social class (79.3%), illiterate mothers (37.8%), those living in kutcha houses (52.6%), overcrowded houses (63.7%), use of smoky fuel for cooking (67.4%), inadequate cross ventilation (70.4%), history of parental smoking (55.6%), low birth weight children (54.8%), and malnourished children (57.8%). Rural children (62.2%) were more affected than urban children. Conclusion: The present study had identified low socioeconomic status, poor housing conditions, cooking fuel used, birth weight, and nutritional status as important determinants for ARI. Interventions to improve these modifiable risk factors can significantly reduce the ARI burden among children.
Keywords: Acute respiratory infection, environment, nutrition, risk factors, under five children
|How to cite this article:|
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
|How to cite this URL:|
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 [serial online] 2013 [cited 2020 Jan 27];6:513-8. Available from: http://www.atmph.org/text.asp?2013/6/5/513/133700
| Introduction|| |
Acute respiratory infections (ARIs) are a substantial cause of morbidity and mortality in young children,  and it is a major public health problem in both developed and developing countries. ARI is an acute infection of any part of respiratory tract and related structures including paranasal sinuses, middle ear, and pleural cavity. ARIs include a diverse group of diseases ranging from self-limiting illnesses to bronchiolitis and pneumonia that may require medical care. It includes all infections of less than 30 days duration except those of the middle ear where the duration of an acute episode is less than 14 days. 
In young children, ARI is responsible for an estimated 3.9 million deaths worldwide, with 90% deaths due to bacterial pneumonia. In the developing countries, seven out of 10 deaths happen due to ARI in under 5-year age group.  In India, about 26.3 million cases of ARI were reported in 2011, with an incidence rate of about 2,173 cases per lakh population. 
ARI contributes to 15-30% of all under five deaths in India and most of these deaths are preventable.  National Family Health Survey (NFHS-3) revealed that 2 weeks before the survey, 5.8% of under five children had symptoms of an ARI and out of these, 69% were taken to a health facility or health provider for treatment. 
Hospital records from states with high infant mortality rate shows that up to 13% of inpatient deaths in pediatric wards are due to ARI. On an average, children below 5 years of age suffer about five episodes of ARI per child per year, thus accounting for about 238 million attacks. Although most of the attacks are mild and self-limiting episodes, ARI is responsible for about 30-50% visits to health facilities and for about 20-40% admissions to hospital.  The disability-adjusted life years (DALYs) lost due to ARI in southeast Asia region are about 33 million.
A multiple of social and environmental factors are associated with ARI morbidity and mortality in childhood. Various risk factors associated with ARI are poverty, malnutrition, low birth weight, inadequate breast feeding, complementary foods initiation, overcrowding, poor housing conditions, indoor and outdoor air pollution, seasonality, and lack of access to preventive (including immunization) and curative services. ,
With this background, the present study was conducted to study the prevalence of ARIs and their major determinants in under five children in the field practice area of a medical college in south India.
| Materials and Methods|| |
The present community-based, cross-sectional study was carried out among children under 5 years of age, residing in urban and rural field practice areas covered under Department of Community Medicine, Melmaruvathur Adhiparasakthi Institute of Medical Sciences and Research (MAPIMS), Melmaruvathur, Kancheepuram (District), Tamil Nadu, south India, during the period of October 2009-February 2010.
The study population consisted of 500 under five children. Cluster sampling method was used. A total of 10 clusters with 50 children in each cluster were selected. In urban field practice area (Madhurantakam), five out of 14 wards were selected as clusters by simple random sampling method. By the same method, five villages were selected as clusters from 32 villages in rural field practice area (Venmalagaram). Data collection started from a first house in a selected street and then consecutive houses were surveyed moving clockwise, until the desired number were reached in each cluster for both urban and rural areas.
Data collection was done using a pretested, semistructured questionnaire, designed for the study purpose. The questionnaire elicited information about sociodemographic profile, housing conditions, cooking fuel used, parental smoking, immunization status, breast feeding, and nutritional status. Anthropometric measurements and clinical examination were also done. History of episodes of ARI (cough, cold, breathing difficulty, fever, etc.) during the last 1 month was enquired for calculating the prevalence. Standard operational definitions were used for the study variables. Socioeconomic classification is done on the basis of Modified BG Prasad's classification revised according to All India Consumer Price Index for the year 2009-2010.
Prior to the interview, the parents or guardians or any other members available in the family were addressed regarding the purpose of study and informed consent was taken from them. Before the start of the study, approval from institutional ethics committee was obtained.
The data was analyzed using Statistical Package for Social Sciences (SPSS) v16. Descriptive statistics were performed for various variables. The chi-square test for association was used and P < 0.05 was considered as statistically significant.
| Results|| |
Sociodemographic and other characteristics
A total of 500 under five children were surveyed for the study. It was observed that majority (247, 49.4%) were in the age group 1-4 years followed by infants (198, 39.6%). Male children constituted 257 (51.4%) and female children 243 (48.6%). Majority were Hindu families 480 (96%). Regarding social classification, 345 (69%) was in lower class (III, IV, V) and rest 31% in upper class (I, II). About 217 (42.8%) of mothers were educated up to high school, while 150 (30%) had no formal education. The distribution of subjects according to sociodemographic features is given in [Table 1].
|Table 1: Distribution of subjects according to sociodemographic variables|
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About 159 (31.8%) were living in kutcha houses and rest 341 (68.2%) in pucca and semi-pucca houses. Overcrowding was present in 209 (41.8%) of the houses and cross-ventilation was inadequate in 235 (47%) of the households. Fifty percent of the households use smokeless fuel for cooking purposes and history of parental smoking was present in 240 (48%) of the households.
About 22.8% (147) of children were in low birth weight category (<2.5 kg). Regarding initiation of breast feeding, 65.6% infants were initiated within 1 h of delivery and rest of infants in 1-24 h. Majority, 460 (92%) of children were completely immunized according to their age. Malnutrition was noticed in 137 (27.4%) of the children (Grade I-10.8%, II-7.6%, III/IV-9%). Distribution of subjects according to various environmental and nutritional characteristics is depicted in [Table 2].
Prevalence of ARI and its determinants
Overall, ARI was found in 135 children with a prevalence rate of 27% (95% CI 23.1-31.1). ARI was found to be more in 1-4 year age group (62, 45.6%), followed by infant age group (54, 40%). Male children were affected more than female children, but the difference was not statistically significant. Occurrence of ARI was higher in the lower social class 107 (79.3%) than the upper class 28 (20.7%) and was found to be statistically significant (P = 0.031, odds ratio (OR) = 2.04). ARI occurrence risk was highest in children of illiterate mothers (51, 37.8%) and who had primary schooling (29, 21.5%) and least in mothers who had more than 12 years of schooling (12, 8.9%). This difference was not statistically significant [Table 1].
ARI was present more among children residing in kutcha houses (71, 52.6%) than semi-pucca and pucca houses 64 (47.4%) and was found to highly significant (P < 0.001, OR = 3.49). Overcrowding was present in 86 (63.7%) of households of ARI children and this was also found to be statistically significant (P < 0.001, OR = 3.45). Type of fuel used for cooking had a strong significant association with ARI occurrence (P < 0.001, OR = 2.65), since majority 91 (67.4%) of the households use some type of smoky fuel for cooking purposes. Cross-ventilation was inadequate in 95 (70.4%) of the households among ARI children and was found to be highly significant (P < 0.001, OR = 3.82). Among ARI children, history of parental smoking was present in 75 (55.6%) and this was also found to be statistically significant (P = 0.039, OR = 1.52).
Birth weight was also found to be a significant risk factor, where ARI was noticed more, 74 (54.8%) among children with low birth weight (<2.5 kg) than normal birth weight (P < 0.0001, OR = 9.86). Regarding immunization status of the children, ARI is less among who are completely immunized according to age than children with incomplete immunization and found to be statistically significant (P = 0.021, OR = 0.47). Nutritional status of the children had a strong relationship with ARI susceptibility, since prevalence was more among malnourished children (Grade I-IV - 78 (57.8%)) than children with normal weight for age and this difference was highly statistically significant (P < 0.0001, OR = 7.10). The distribution of subjects according to various risk correlates and their association is given in [Table 2].
By doing analysis for the children with ARI, according to their area of residence [Table 3], majority of the risk factors identified in the study were found to be more in the rural areas than compared to urban areas. Risk factors for ARI, like social class, mother's education, type of house and fuel used for cooking, overcrowding, cross-ventilation, parental smoking, birth weight, and nutritional status showed a statistically significant difference between children residing in urban and rural communities.
|Table 3: Distribution of ARI cases according to area of residence and association with major risk factors|
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| Discussion|| |
In the present study, prevalence of ARI was found to be 27%. The prevalence reported in our study is comparable to studies done by Islam et al.,  (26.2%), Prajapati et al.,  (22%), and Duarte and Botelho  (25.6%). Male children were more prone for ARI than females and it has been noticed in some studies. ,, Prevalence of ARI was higher among children residing in rural areas (62.2%) than urban areas (37.8%). Rural-urban differences were reported in some Indian studies done in Uttar Pradesh,  Gujarat,  and Tripura. 
Regarding social class, prevalence was more among lower class (79.3%) than the upper class and a statistically significant association was found between social class and ARI. Similar observations were also noted in studies done by Goel et al.,  Prajapati et al.,  Deb,  Gupta et al.,  Savitha et al.,  Biswas et al.,  and Mitra.  ARI occurrence was higher among illiterate mothers and with primary schooling, but was not significant. Similar findings were observed by Goel et al.,  Prajapati et al.,  and Mitra. 
The present study noted a strong significant association between ARI and type of house. ARI was more among children residing in kutcha houses (52.6%) than pucca/semi-pucca houses, mainly in rural areas. Studies done by Islam et al.,  and Singh and Nayar  also reported same findings. Overcrowding was present in 63.7% of households of ARI children, more in rural areas and this also had a strong statistically significant association with ARI. Similar observations were also noted in various studies by Goel et al.,  Prajapati et al.,  Gupta et al.,  Savitha et al.,  and Rahman and Rahman.  Regarding the type of fuel used for cooking and ARI, prevalence was higher (67.4%) among households using smoky fuel as compared to smokeless fuel (rural > urban). A strong significant association was found in this study and is comparable to studies done in Meerut,  Ahmedabad,  and Mysore. 
In our study, inadequate cross ventilation (70.4%) was found to be strongly associated with ARI. Our findings can be correlated with studies done by Goel et al.,  Prajapati et al.,  and Singh and Nayar  History of parental smoking (55.6%) has got significant association with occurrence of ARI. Studies done by Goel et al.,  in Meerut and Rahman and Rahman  in Bangladesh showed a similar association.
Prevalence of ARI was higher among low birth weight babies (55.6%) and showed a strong association, as compared to normal birth weight babies. Similar findings are reported by Prajapati et al.,  Mitra,  Fonseca et al.,  and Yadav and Yadav.  Immunization status had a direct relationship with occurrence of ARI. It is less among who are completely immunized according to age than children with incomplete immunization. Various studies by Prajapati et al.,  Deb,  Savitha et al.,  Mitra,  and Fonseca et al.,  reported similar findings.
In the current study, malnourished children (Grade I-IV-57.8%) are highly susceptible to ARI than normal children. A strong statistically significant association exists between ARI and nutritional status of the children. Many studies like Islam et al.,  Prajapati et al.,  Duarte and Botelho,  Deb,  Savitha et al.,  Mitra,  and Fonseca et al.,  also observed similar association.
| Conclusion|| |
The present study had highlighted the burden and public health problem of ARI among under five children. It has found various sociodemographic, socioeconomic, environmental, and nutritional factors as significant determinants for ARI, prevailing more in rural areas. ARI burden can be significantly reduced by improving the nutritional status of children, living environment and socioeconomic conditions, education of mothers, and by various health promotional measures. The study strongly implicates towards a major improvement of these various determinants and further research, which could be helpful for strengthening the policy and program activities needed for prevention and control of ARIs among children.
| Acknowledgement|| |
Authors are thankful to the management of the institution and the undergraduate students who were involved in the data collection. Also we thank the parents/guardians/caretakers of the children for their active participation in the study and sharing their valuable experiences.
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Department of Community Medicine, Melmaruvathur Adhiparasakthi Institute of Medical Sciences and Research, Melmaruvathur - 603 319, Tamil Nadu
Source of Support: None, Conflict of Interest: None
[Table 1], [Table 2], [Table 3]