Risk Factors of Acute Respiratory Infections in Children Living in Underserved Areas of Africa
Acute respiratory infections (ARIs) are among the leading causes of child mortality in the world, especially in underserved and underdeveloped areas. ARIs have a viral or bacterial origin, and the common cold, influenza, pneumonia, TB, and bronchitis are some specific examples of common ARIs. Most child ARI mortality cases are due to preventable causes and/or are related to country inequalities. Understanding the risk factors of developing ARIs is crucial in taking next steps to treating and preventing child mortality. This paper reviews multiple research studies that focus on identifying risk factors of ARIs, specifically for children living in underserved Africa. The most common risk factors identified were malnutrition, severe disease, comorbidities, disease clustering, low maternal education, high household density, and lack of or delayed access to health services. Overall, these results reveal a need to improve nutrition, sanitation, and maternal education as well as primary prevention and healthcare services to children in underserved African communities.
- Briefly discuss a background of ARIs, including signs and symptoms
- Briefly discuss prevalence and child mortality rates of ARIs in underserved/underdeveloped countries of the world
- Briefly discuss diagnostic tests and gold standard treatment for ARIs
- Discuss current strategies of treating and preventing child mortality from ARIs
- Identify risk factors of ARIs
- Discuss future plans and research to improve child mortality from ARIs
- Acute respiratory infections (ARIs) are infections of the respiratory system caused by bacteria or viruses.16
- ARIs are the most common cause of mortality and morbidity in children less than five years old worldwide. Children under five get approximately three to six ARIs every year, regardless of risk factors. However, the severity and mortality rates are significantly higher in underserved or underdeveloped countries than in developed countries. Differences in risk factors heavily contribute to these differences.16, 18, 19
- Nearly 11 million children in the world die every year. Of these, almost two million of them die from an ARI, and 70% of these children are from Africa and Southeast Asia, two underdeveloped countries with large populations of underserved communities.15, 17 However, these numbers are thought to be much higher than reported due to the likely high number of children who go undiagnosed.13
- Everyone is at risk for an ARI. The viruses and bacteria that cause ARIs are unavoidable. However, children are especially at high risk, primarily because of their developing immune systems and high likelihood of disease contact and transmission.
- ARIs are usually caused by viruses and bacteria. Common bacterial pathogens are Streptococcus pneumoniae and Haemophilus influenzae type b (Hib). Viral causes are more common than bacterial and include respiratory syncytial virus, rhinovirus, influenza, parainfluenza, coronavirus, and adenovirus.16,17
- ARIs infect either the upper respiratory tract or the lower respiratory tract. The upper respiratory tract consists of the structures from the nose to the vocal cords, whereas the lower respiratory tract starts at the end of the upper respiratory tract and ends at the alveoli in the lungs.16
- Most commonly, the upper respiratory tract is infected. Examples of upper respiratory infections (URIs) are rhinitis, sinusitis, pharyngitis, epiglottitis, and laryngitis.16
- The most common lower respiratory infections (LRIs) are pneumonia and bronchiolitis.16 Pneumonia is the most common ARI affecting children under five years.5, 17
- Clinical Presentation
- Table (ARI signs and symptoms)
- Pneumonia clinical signs and symptoms: severe vs. non-severe (table)1
- Pneumonia is among one of the most common ARIs that affects the lower respiratory tract, and it is the leading causes of death in children less than five years.4, 12, 15, 19
- Pneumonia clinical signs and symptoms: severe vs. non-severe (table)1
- Table (ARI signs and symptoms)
- Most commonly, the diagnosis of an ARI is clinical. It is usually based on the symptoms reported by the patient and the signs observed by the clinician (see clinical presentation table). A clinician will perform a physical exam, which will include auscultating the lungs for any abnormal breath sounds that could indicate an ARI. Work of breathing and vital signs should also be assessed.
- Sometimes, an x-ray or a CT scan may be used if a lower respiratory tract, such as pneumonia, is suspected and the lungs need to be assessed.
- Lung function tests can also be useful diagnostic tests to assess how effectively the lungs are functioning.
- If oxygen saturation needs to be assessed, pulse oximetry may be performed, which will identify how much oxygen is in the lungs.
- A nasopharyngeal swab may be used to identify the specific virus or bacteria causing the infection.
- Most ARIs are self-limiting, and therefore, treatment is mostly supportive. For some cases, antibiotics may be given.16
- Vaccinations for Haemophilus influenzae type b (Hib), a bacterial cause of some serious forms of ARIs, and pneumonia may be given for those at high risk to provide immunization.9, 14
- All children less than five years are recommended for the Hib vaccine. 9
- There are two types of pneumonia vaccines, PCV13 and PPSV23. The PCV13 vaccine provides immunization against 13 types of pneumococcal bacteria, whereas the PPSV23 vaccine provides immunization against 23 types of pneumococcal bacteria. Both the PCV13 and PPSV23 are recommended for children under two years and older children with high risk of developing pneumonia, such as having comorbidities.14
- Risk factors
- The most common risk factor identified among all the studies was malnutrition. Over 80% of the studies reviewed found a significant association between malnourished children and their risk of developing an ARI.1, 2, 4, 5, 10, 12, 19 Further, many of the studies identified malnutrition as a significant independent risk factor for high morbidity and mortality in children under five years with an ARI.
- Low maternal education, which was defined as primary school or less, was associated with higher morbidity and mortality.5, 8, 10, 17, 18
- Severe disease, longer duration of symptoms, and poor access and availability to health services also increased child mortality of ARIs.1, 8, 10, 12, 17, 19
- Other risk factors commonly identified in the studies reviewed were high household density, lack of vaccinations, HIV and other comorbidities, and disease clustering.1, 4, 5, 8, 17, 18
- Table: most commonly identified risk factors
- Table: from one pivotal study
- Odds ratios of risk factors identified5
- ARIs in children under five years is an immense burden, especially for children living in underserved communities in underdeveloped countries. Due to the lack of easy healthcare access in these areas, many children go undiagnosed and untreated. Therefore, it is important for improvements in access and availability of health services to be made for morbidity and mortality rates of ARIs to decline. Primary prevention, including Hib and pneumonia vaccinations, can also help tackle the problem.
- Furthermore, as many of the studies identified, malnutrition not only increases the likelihood of developing an ARI, but it is an independent risk factor for high morbidity and mortality rates of ARIs in children. Therefore, better nutrition may help decrease the incidence of ARIs in children.
- Finally, disease clustering was identified as a risk factor in multiple studies, suggesting improvement in hygiene and sanitation can help reduce the spread of ARIs.
- Overall, to decrease the morbidity and mortality of children less than five years from underserved areas, it is important to improve healthcare services and prevention as well as nutrition and hygiene.
- Future research
- Future research should focus on the impact of interventions on the risk factors for children in underserved Africa.
- For example, the effectiveness of the Hib and pneumococcal vaccinations have been shown in research studies conducted in developed countries that they significantly decrease ARI prevalence, morbidity, and mortality rates in children. Moving forward, it should be researched how these ARI rates in children living in underdeveloped countries can be impacted if the vaccinations are made easily accessible to them and maternal education is given regarding the importance of the vaccines for the protection of their children.
- Furthermore, research on nutrition programs, maternal educational programs, and proper hygiene and sanitation programs should be studied for their impact on how they may help decrease risk factors in these high-risk African children and if a significant decrease in the prevalence, morbidity, and mortality rates of ARIs in children can be achieved.
- Agweyu A, Lilford RJ, English M; Clinical Information Network Author Group. Appropriateness of clinical severity classification of new WHO childhood pneumonia guidance: a multi-hospital, retrospective, cohort study. Lancet Glob Health. 2018;6(1):e74–e83. doi:10.1016/S2214-109X(17)30448-5
- Akosa, F, Biritwum, RB, Egbefome, A, Nartey, ET, Nyarko, MY, Tette, EMA. Under-five mortality pattern and associated risk factors: a case-control study at the Princess Marie Louise Children's Hospital in Accra, Ghana. BMC Pediatr. 2016;16(1):148. doi: 10.1186/s12887-016-0682-y.
- Armstrong Schellenberg, JR, de Francisco, A, Greenwood, BM, Hall, AJ, Morris, J. Risk factors for mortality from acute lower respiratory tract infections in young Gambian children. Int J Epidemiol. 1993;22(6):1174-82. https://doi.org/10.1093/ije/22.6.1174
- Ansermino, JM, Kabakyenga, J, Kissoon, N, Kiwanuka, J, Kumbakumba, E, Larson, CP, Lowlaavar, N, Ndamira, A, Singer, J, Wiens, MO, Wong, H, Zhou, G. Pediatric in-Hospital Death from Infectious Disease in Uganda: Derivation of Clinical Prediction Models. PLoS One. 2016;11(3):e0150683. doi: 10.1371/journal.pone.0150683.
- Bailey, Robin, Cox, Miriam, Hart, John, Kalua, Khumbo, Rose, Louis, de Wildt, Gilles. The prevalence and risk factors for acute respiratory infections in children aged 0-59 months in rural Malawi: A cross-sectional study. Influenza Other Respir Viruses. 2017;11(6):489-496. doi: 10.1111/irv.12481
- Boschi-Pinto, C, Bryce, J, Dye, C, Gouws, E, Williams, BG. Estimates of world-wide distribution of child deaths from acute respiratory infections. Lancet Infect Dis. 2002;2(1):25-32. https://www.ncbi.nlm.nih.gov/pubmed/11892493
- Donkor, ES, Nartey, ET, Neizer, M, Nyarko, MY, Sifah, EK, Tette, EM. Changing Patterns of Disease and Mortality at the Children’s Hospital, Accra: Are Infections Rising? PLoS One. 2016;11(4):e0150387. doi: 10.1371/journal.pone.0150387.
- Gupta N, Hirschhorn LR, Rwabukwisi FC, et al. Causes of death and predictors of childhood mortality in Rwanda: a matched case-control study using verbal social autopsy. BMC Public Health. 2018;18(1):1378. doi:10.1186/s12889-018-6282-z
- “Hib (Haemophilus influenze type b) Vaccination.” Centers for Disease Control. 13 February 2018. https://www.cdc.gov/vaccines/vpd/hib/index.html.
- Hinderaker, SG, Kahabuka, C, Kvale, G. Factors associated with severe disease from malaria, pneumonia and diarrhea among children in rural Tanzania - a hospital-based cross-sectional study. BMC Infect Dis. 2012;12:219. doi: 10.1186/1471-2334-12-219.
- Kazaura, M, Kalokola, F, Lugangira, K. Morbidity and mortality of children aged 2-59 months admitted in the Tanzania Lake Zone's public hospitals: a cross-sectional study. BMC Res Notes. 2017;10(1):502. doi: 10.1186/s13104-017-2818-z.
- Lazzerini M, Seward N, Lufesi N, et al. Mortality and its risk factors in Malawian children admitted to hospital with clinical pneumonia, 2001-12: a retrospective observational study. Lancet Glob Health. 2016;4(1):e57–e68. doi:10.1016/S2214-109X(15)00215-6
- Mulholland, K. Global burden of acute respiratory infections in children: implications for interventions. Pediatr Pulmonol. 2003;36(6):469-74. DOI:10.1002/ppul.10344
- “Pneumococcal Vaccination.” Centers for Disease Control. 6 September 2017. https://www.cdc.gov/pneumococcal/vaccination.html.
- Rudan, I; Boschi-Pinto, C; Biloglav, Z; Mulholland, K; Campbell, H (2008) Epidemiology and etiology of childhood pneumonia. Bulletin of the World Health Organization, 86 (5). pp. 408-416. ISSN 0042- 9686 https://doi.org/10.2471/BLT.07.048769
- Simoes EAF, Cherian T, Chow J, et al. Acute Respiratory Infections in Children. In: Jamison DT, Breman JG, Measham AR, et al., editors. Disease Control Priorities in Developing Countries. 2nd edition. Washington (DC): The International Bank for Reconstruction and Development / The World Bank; 2006. Chapter 25. Available from: https://www.ncbi.nlm.nih.gov/books/NBK11786/ Co-published by Oxford University Press, New York
- Sonego M, Pellegrin MC, Becker G, Lazzerini M. Risk factors for mortality from acute lower respiratory infections (ALRI) in children under five years of age in low and middle-income countries: a systematic review and meta-analysis of observational studies. PLoS One. 2015;10(1):e0116380. doi:10.1371/journal.pone.0116380
- 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;18(1):7. doi:10.1186/s12890-018-0579-7
- Tuti T, Agweyu A, Mwaniki P, Peek N, English M; Clinical Information Network Author Group. An exploration of mortality risk factors in non-severe pneumonia in children using clinical data from Kenya [published correction appears in BMC Med. 2017 Dec 5;15(1):212]. BMC Med. 2017;15(1):201. doi:10.1186/s12916-017-0963-9
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