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ORIGINAL ARTICLE  
Year : 2015  |  Volume : 8  |  Issue : 6  |  Page : 276-279
An epidemiological study concerning pneumococcal LRTI in rural parts of Bengal and influence of socioenvironmental parameters on it


1 Department of Microbiology, Calcutta Medical College, Kolkata, India
2 Department of Microbiology, Calcutta National Medical College, Kolkata, India
3 Department of Health and Family Welfare, BMOH-LB Dutta Hospital, West Bengal, India
4 Department of Preventive and Social Medicine, RG Kar Medical College, Kolkata, West Bengal, India

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Date of Web Publication20-Nov-2015
 

   Abstract 

Background: Lower respiratory tract infection (LRTI) is a major public health problem. One of the major agents causing community acquired pneumonia is Streptococcus pneumoniae, or pneumococcus. This study was aimed to correlate between socio-environmental parameters and incidence of LRTI (by s0 pneumoniae ) in rural parts of West Bengal. Materials and Methods: A house to house survey was made in a rural community and sputum samples were collected from persons having features of lower respiratory tract infection. The socio-environmental background of the patients were taken in detail. The pneumococci isolated from the samples were tested for antibiotic susceptibility. Results: Out of 947 samples collected, 70 (4.77%) were positive for S pneumoniae. 15.71% were found to be resistant to penicillin. Highest incidence was found to occur in summer months, and in persons living in narrow spaces and in houses polluted with smoke. Conclusion: Although a low percentage of pneumococci were found among the community acquired pneumonia in rural parts of Bengal, many of the strains showed resistance to penicillin and erythromycin. That is a thing for concern in itself. Better living conditions regarding household with proper smoke outlet facility would have a good impact in bringing down the incidence in this area, where people are already burdened with lack of proper facilities for living.

Keywords: LRTI, pneumococci, socioenvironmental parameters

How to cite this article:
Dopthapa YP, Banerjee D, Chakraborty B, Chakraborty B, Ghosh I, Halder D. An epidemiological study concerning pneumococcal LRTI in rural parts of Bengal and influence of socioenvironmental parameters on it. Ann Trop Med Public Health 2015;8:276-9

How to cite this URL:
Dopthapa YP, Banerjee D, Chakraborty B, Chakraborty B, Ghosh I, Halder D. An epidemiological study concerning pneumococcal LRTI in rural parts of Bengal and influence of socioenvironmental parameters on it. Ann Trop Med Public Health [serial online] 2015 [cited 2019 Oct 20];8:276-9. Available from: http://www.atmph.org/text.asp?2015/8/6/276/162671

   Introduction Top


Acute respiratory tract infection (ARTI) is considered to be one of the major public health problems and is a leading cause of morbidity and mortality in many developing countries. It is known that community-acquired respiratory tract infection (RTI) is one of the most common reasons for physician visits and antibiotic prescription. [1],[2] Lower RTI (LRTI) includes community-acquired pneumonia and acute exacerbation of chronic obstructive pulmonary disease (COPD). The World Health Organization (WHO) health statistics (2013) show that pneumonia accounts for a whopping 18% of the causes of death in children below 5 years of age. [3] According to WHO, "for every 100 respiratory infections, only 20% require antibiotic treatment - the remaining 80 infections most likely have a viral origin." [3] Thus, antibacterial therapy should be avoided unless a bacterial cause has been confirmed or is deemed likely. The etiology of LRTI, thereby, plays a significant role in making decisions regarding the treatment. Streptococcus pneumoniae (S. pneumonia) is the most common cause of community-acquired RTI such as otitis media, sinusitis, and pneumonia. [1] Globally, pneumococcal diseases account for one-two million deaths annually in both extremes of age. [2]

Our main aim was to find out the incidence of this pathogen among LRTI cases who reside in rural parts of West Bengal, where the scarcity of money and medicine remains a scourge and poor living conditions prevail. We also wanted to find out the influence of different socioenvironmental parameters, if any, on the occurrence of this disease, and to check the antibiotic susceptibility patterns of the pneumococcal isolates found here.


   Materials and Methods Top


Study area

The study was based on a house-to-house survey as well as patients attending the outpatient department (OPD) in a rural community of Budge Budge II block and LB Dutta Hospital of the block in the district of South 24 Parganas, West Bengal, India. There are 65 villages in the block with a total population of 190,000. Majority of the residents were engaged as daily wage laborers in the government or private sectors and lived in unhygienic and overcrowded conditions.

Sampling and sample size

The multistage random sampling technique was adopted in the study. Out of the 947 study subjects, 22%, i.e., 208 patients were selected from the OPD of LB Dutta Hospital. The rest of the patients, i.e., 739 were selected at the community level through the cluster sampling method. The visits were divided into four phases and in each visit, 10 study subjects from each cluster were selected. Starting in an unbiased manner, households were approached until the desired number of subjects was included/selected from each cluster.

Inclusion criteria

People of all age groups and from both the sexes suffering from acute RTI presented with sore throat, cough with expectoration fever, fast breathing, chest pain, breathing difficulty, and pneumonia for <7 days.

Exclusion criteria

Patients with dry cough due to URTI/tuberculosis (TB)/asthma/COPD/ARTI, patients with comorbidity of diabetes mellitus, patients with human immunodeficiency virus (HIV)/acquired immune deficiency syndrome (AIDS), patients getting steroid, patients with other immune compromised states, patients with any other chronic debilitating illness like congestive cardiac failure (CCF), etc., and the patients receiving antibiotics were excluded from the study.

Data collection

A household list was prepared with the help of accredited social health activist (ASHA) volunteers. Demographic, socioeconomic as well as environmental data, obtained by interviewing the head of each household, were recorded on that structured pro forma. Data were collected for a period of 1 year from September 2012 to August 2013, thus covering all the seasons, i.e., autumn (September to November), winter (December to February), summer (March to May), and rainy (June to August).

Collection and transport of samples

Sputum samples were collected in a disposable, wide-mouthed, screw-capped plastic container. The patient was instructed to spit the coughed material directly into the opened container without spilling over the rim. The cap of the container was screwed up tightly. A thick portion of the sputum was taken in a cotton swab from the container and put into Amies transport medium (M651-500G. HiMedia, Mumbai-400 086, India). The specimen was then taken into the vaccine box at room temperature and transported to the laboratory within 2-3 h.

Laboratory investigation

The samples were processed on the same day. The sputum samples were selected to be cultured by Gram staining [following the rejection criteria of sputum ≥10 squamous epithelial cells (SECs)/ low power field (LPF) and/or acceptance of the specimen if polymorphonuclear leukocyte (PMN): SEC = 10:1] (Lynne S. Garcia. "Clinical Microbiology Procedures Handbook" - Volume 1, 3rd Edition, page 3.2.1.20). The selected sputum samples were homogenized by shaking with sterile water and glass beads for 20-30 min and inoculated in sheep blood agar, chocolate agar (with 5-10% CO 2 ), and MacConkey agar, and after overnight incubation at 37΀C, identification of the organism was done by its colony character, and by hemolysis, Gram stain morphology, and standard biochemical tests.

Identification of microorganisms

Microorganisms were identified by standard methods and antimicrobial susceptibility testing was performed using disk diffusion by Kirby-Bauer method (Bauer et al. 1966) in the same reference laboratory.

Identification of pathogens of S. pneumoniae

Gram stain identification: Gram-positive elongated cocci in pairs or in short chain

Culture media: Blood agar or chocolate agar

Colony: On a blood agar plate, colonies of S. pneumoniae appeared as small, grey, moist (sometimes mucoidal) colonies and characteristically produced a zone of alpha-hemolysis. When the culture aged 24-48 h, the colonies became flattened and the central portion became depressed.

S. pneumoniae was identified by using Gram stain from the colony, catalase (negative), and optochin tests [optochin susceptible (≥14 mm in diameter) with bile (10% sodium deoxycholate) solubility positive].

Antimicrobial susceptibility testing was performed using disk diffusion by Kirby-Bauer method [interpreted as per Clinical and Laboratory Standards Institute (CLSI) guidelines], which corroborates the finding of Etest for penicillin and erythromycin.


   Results Top


Of the 947 samples collected from patients having acute RTI on the day of the visit, 70 (4.77%) were culture positive for S. pneumoniae, 140 (9.54%) for Klebsiella, 71 (4.83%) for Staphylococcus aureus, 83 (5.74%) for  Moraxella More Details, 6 (0.4%) for Haemophilus influenzae) 9 (0.6%) for Enterococcous, 8 (0.67%) for Pseudomonas, 2 (0.13%) for Acinetobacter, 2 (0.13%) for  E.coli Scientific Name Search , and 1 (.06%) group B Streptococcus. The study population had complaints of RTI.


   Discussion Top


Regarding the housing conditions of the community, 50.36% were living in brick houses and separate kitchen facilities were available to 46.25% of the study population. Most families lived in overcrowded homes, with an average of 2.5 persons per room. Households with environmental factors present, e.g., indoor air pollution arising from the usage of chullah for cooking purpose and from a tobacco smoker being present in the family, exhibited a significantly higher incidence of pneumococcal infection (P < 0.01). Interestingly enough, overcrowding by itself did not show any relation to the incidence of RTI by S. pneumoniae as maximum number of pneumococcal RTI patients enjoyed an average of >4.65 m 2 area per person, the highest area parameter found in the study group selected.

Similarly, the maximum number of pneumococcal cases was in persons living in brick houses rather than the ones living in soil-made houses or unfinished brick houses. Having a toilet had no significance either.

On the contrary, as expected, persons living in narrow spaces showed a higher incidence of pneumococcal RTI (and LRTI due to other pathogens also) than those living in open airy rooms. Having a kitchen within the living room especially had a direct bearing on the disease, particularly when the indigenous method of cooking/chullah was used. Tobacco smoking in the house was also associated with higher incidence of the disease. Hence, a narrow, non-airy space with insufficient outlet for smoke, whether from the kitchen or from tobacco smoking seems to be the important socioenvironmental factor in the epidemiology of this disease [Table 1].
Table 1: Socio-environmental data of the study population

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The incidence of pneumococcal RTI among males was 55.71% and among females 44.28%. So, there was no significant difference in the incidence between males and females.

The most serious infections of S. pneumoniae occur in children who are less than 3 years and in adults who are over 65 years. [4],[5] In our study, the incidence of pneumococcal RTI varied according to age, being higher among the 0-18 years age group [Table 2].
Table 2: Age group wise distribution of LRTI cases caused by S pneumoniae

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The incidence of pneumococcal infection was highest in the summer months in our study. However, other studies have depicted a definite peak in pneumococcal disease incidence in the winter months. These studies were from developed countries, where a possible major risk factor for catching pneumococcal LRTI is a dip in mercury. In our country, especially in the area we took up for survey, the winter months are pleasant while the summer months are dusty with high levels of pollution, possibly leading to our finding of an increase in the incidence of the disease in the hot, sultry months of the year [Table 3].
Table 3: Seasonal variation over one year study period

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A major concern about S. pneumoniae is the emergence of antimicrobial resistance, especially to penicillin. [6],[7],[8] Recent studies by the Centre for Disease Control and Prevention (CDC) National Surveillance System indicated a decreased susceptibility pattern to penicillin ranging 15-35%. Apart from showing resistance to penicillin and cephalosporin, pneumococcal coresistance to several other antimicrobial agents, including macrolides, sulfonamides, and tetracyclines, have been reported. [9],[10],[11],[12] In an international study published in 2004, macrolide resistance was the highest in Asia (51.7%). We found a 15.71% resistance to penicillin and 20% resistance to erythromycin in our study [Table 4].
Table 4: Antibiotic resistance pattern of isolated Streptococcous pneumoniae

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   Conclusion Top


Our study in the rural parts of Bengal showed a 4.77% incidence of pneumococcal LRTI. The younger age group (0-18 years) was found to bear the maximum brunt. The definite environmental risk factors were found to be indoor air pollution (by smoke) and living in narrow spaces. Interestingly, the incidence of the infection, as found by us, was highest during the summer months, in clear contrast to other studies in which the incidence peaked in winter. Although a low percentage of pneumococci were found in community-acquired pneumonia in the rural parts of Bengal, many of the strains showed resistance to penicillin and erythromycin. That is a matter of concern in itself. Better living conditions regarding household with proper smoke outlet facility would have a good impact in bringing down the incidence in this area, where people are already burdened with the lack of proper facilities for living.


   Acknowledgement Top


We thank the Indian Council of Medical Research (ICMR) for funding and other support to carry out this project.

 
   References Top

1.
Murray CJ, Lopez AD. Mortality by cause for eight regions of the world: Global Burden of Disease Study. Lancet 1997;349:1269-76.  Back to cited text no. 1
    
2.
Mogyoros M. Challenges of managed care organizations in treating respiratory tract infections in an age of antibiotic resistance. Am J Manag Care 2001;7(Suppl):S163-9.  Back to cited text no. 2
    
3.
World Health Organization. World Health Statistics 2013. World Health Organization Report on Infectious Diseases 2000. Overcoming Antimicrobial Resistance. Big Guns of Resistance. World Health Organization; 2013. p. 999.  Back to cited text no. 3
    
4.
Michelow JC, Olsen K, Lozano J, Rollins NK, Duffy LB, Ziegler T, et al. Epidemiology and clinical characteristics of ommunity-acquired pneumonia in hospitalized children. Pediatrics 2004;113:701-7.   Back to cited text no. 4
    
5.
Musher DM. Streptococcus pneumonia. In: Mandell GL, Bennett JE, Dolin R, editors. Mandell, Douglas and Bennett's Principles and Practice of Infectious Diseases. 5 th ed. New York: Churchill Livingstone; 1999. p. 2128-47.  Back to cited text no. 5
    
6.
Appelbaum PC. Antimicrobial resistance in Streptococcus pneumoniae: An overview. Clin Infect Dis 1992;15:77-83.  Back to cited text no. 6
    
7.
Caputo GM, Appelbaum PC, Liu HH. Infections due to penicillin-resistant pneumococci. Clinical, epidemiologic, and microbiologic features. Arch Intern med 1993;153:1301-10.  Back to cited text no. 7
    
8.
Klugman KP. Pneumococcal resistance to antibiotics. Clin Microbial Rev 1990;3:171-96.  Back to cited text no. 8
    
9.
Doern JV, Heilmann KP, Huynh HK, Rhomberg PR, Coffman SL, Brueggemann AB. Antimicrobial resistance among clinical isolates of Streptococcus pneumoniae in the United States during 1999-2000, including a comparison of resistance rates since 1994-1995. Antimicrob Agents Chemother 2001;45:1721-9.   Back to cited text no. 9
    
10.
Doern GV, Pfaller MA, Kugler K, Freeman J, Jones RN. Prevalence of antimicrobial resistance among respiratory tract isolates of streptococcus pneumoniae in North America: 1997 results from the SENTRY antimicrobial surveillance program. Clin Infect Dis 1998;27:764-70.  Back to cited text no. 10
    
11.
Jones RN, Pfaller MA. In vitro activity of newer fluoroquinolones for respiratory tract infections and emerging patterns of antimicrobial resistance. Data from the SENTRY antimicrobial surveillance program. Clin Infect Dis 2000;31(Suppl 2):S16-23.  Back to cited text no. 11
    
12.
Whitney CG, Farley MM, Hadler J, Harrison LH, Lexau C, Reingold A, et al.; Active Bacterial Core Surveillance Program of the Emerging Infections Program Network. Increased incidence of multidrug-resistant Streptococcus pneumonia in the United States. N Engl J Med 2000;343:1917-24.  Back to cited text no. 12
    

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Correspondence Address:
Banya Chakraborty
15/E Central Road, Jadavpur, Kolkata, PIN - 700 032, West Bengal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1755-6783.162671

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



 

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