Acute respiratory infections (ARIs) and factors associated with their poor clinical outcome among children under-five years attending pediatric wards of public hospital in Southwest district of Ethiopia: A prospective observational cohort study

Abstract

This study was designed to assess the prevalence and factors associated with poor clinical outcome of acute respiratory infections (ARIs) among children less than five years of age at Mizan-Tepi university teaching public hospital in southwest district of Ethiopia. A prospective observational cohort study design was conducted from 01 June to August 30, 2020. Data related to socio-demographics, child nutritional status, clinical and environmental characteristics of patients were collected with structured questionnaire. Follow-up data were gathered from patient’s medical records using standard data collection tool. The data were analyzed using SPSS versions 25.0. In this study, 305 children of age less than five years were included. Of these, 124 (40.7%) of children were diagnosed with ARIs, of which 66 (53.2%) were female and 69 (55.6%) were age of 24–59 months. Of children diagnosed with ARIs, 21 (16.9%) were ended with poor clinical outcomes after completion of their treatment. In the multivariate analysis, age of children and presence of any other disease conditions (OR = 0.331; 95% CI: 0.123– 0.880; p= 0.024), exposure to indoor air pollution (OR = 0.344; 95% CI: 0.128– 0.925; p= 0.030), malnutrition (OR = 0.175; 95% CI: 0.058– 0.523; p= 0.002) and end point pneumonia (OR = 0.305; 95% CI: 0.113–0.821; p= 0.015) were found to be independent factors for poor outcome of under-five children with ARIs. Our findings highlight that timely detection, proper management and treatments as well as addressing other contributing factors are essentials in order to reduce prevalence and poor clinical outcomes of under five children with ARIs.

Keywords

Prevalence clinical outcome risk factors acute respiratory infections Southwestern Ethiopia

Introduction

For decades, acute respiratory infections (ARIs), such as pneumonia and bronchiolitis have been among the top three causes of death and disability among both in children under 5 years of age and adults. ARIs are the leading cause of illness and death among young children everywhere in the developing world. Inequities in child mortality due to ARIs between high-income and low-income countries remain large. According to recent estimates, every year about 120–156 million cases of ARIs occur globally with approximately 1.4 million death, of which more than 95% of these deaths occur in the developing world.^1–3

Acute respiratory infections are caused by a number of infective agents, with Streptococcus pneumoniae being generally the most frequently identified bacterial agent.^4–6 Being very young or elderly, crowded living conditions, malnutrition, HIV infection, lack of breastfeeding in infants, lack of immunization, chronic health conditions and exposure to tobacco smoke or indoor air pollutants are risk factors for ARIs, especially pneumonia.^7–9 For instance, close to 40 per cent of children less than 5 years of age in Africa are undernourished,⁹ up to three-quarters of all hospitalized pneumonia patients are HIV-positive and up to one-quarter tuberculosis (TB) positive,⁹ with lower ratios of health professionals to its population than other regions.

The current advances in scientific knowledge about ARIs disease entities are high yet there remains the challenge that many children continue to die from ARIs, especially from pneumonia.¹⁰ The appropriate diagnosis and treatment, and high uptake of new bacterial conjugate vaccines are one of the most effective public health strategies to prevent and reduce the burden of ARIs.^11,12 But widespread implementation of currently effective preventative and management strategies remains challenging in many low and middle income countries. For instance, in Ethiopia, the pooled prevalence of ARI was 17.75%,¹³ and in rural area of the country, 20% of the deaths of children aged less than 5 years and more than 30% of the infant deaths under 1 year are due to ARIs.

Although, it is limited in our setting, conducting continuous and high-quality surveillance on ARIs is crucial to determine the extent of the problem and to assess the impact of any existing prevention/management strategies. Therefore, the current study was designed to assess the prevalence of ARIs and factors associated with poor clinical outcomes among children under-5 years attending at a public hospital in Southwest district of Ethiopia. This sensitizes local institutions and policy makers as prioritizes the situation in designing strategies for prevention, management and treatment of patients with ARIs.

Method and materials

Study area and period

A study was conducted from 01 June to 30 August 2020 at Mizan-Tepi university teaching hospital, Southwest of Ethiopia. This hospital was found in the Mizan-Aman town, which is located at 561 Kms from Addis Ababa, capital city of Ethiopia. Currently it is the second more than 139 bedded teaching hospital in the Southwestern part of the country, providing services for approximately 8000 inpatient, 57,184 outpatient attendants, 14,508 emergency cases and 4080 deliveries in a year coming to the hospital from the catchment population of more than five million people.

Study design and subjects

A prospective observational cohort study design involving interviewing of patient’s family and review of patient’s medical chart was conducted. Children of less than 5 years of age and diagnosed at pediatric and emergency outpatient department at time of data collection period were included. During their hospital stay, those children diagnosed with ARIs were followed and their diagnosis and clinical outcome information was captured. Children whose mothers or legal care takers were not willing to participate in the study were excluded.

Operational definitions of the variables

Poor outcome: If the children with ARIs were not showed improvement after completed their treatment, or were referred to other health institutions for further investigations or died in-hospital or were discharged home in a moribund condition were classified as poor clinical outcomes.

Good outcome: If the children with ARIs were improved or cured after completing their treatment and were not referred to other health institutions for further investigations or not died in-hospital or were discharged home not in a moribund condition were classified as good clinical outcomes.

Sampling size determination

The required sample size was calculated using single population proportion formula by assuming that confidence interval of 95%, margin error of 5%, and the prevalence of ARIs (p) as 27.3%,¹⁴ which is reported in previous study in Ethiopia.

Therefore: $n = \frac{{(Z α / 2)}^{2} p (1 - p)}{d^{2}}$

Therefore: $n = \frac{{(1.96)}^{2} \times 0.2731 (1 - 0.273)}{{(0.05)}^{2}} = 305$ was the final sample size for this study.

Data collection

The trained data collectors reviewed patients’ log books at pediatric and emergency department to identify all diagnosed children of less than 5 years of age. Risk factors related data were collected using interviewer administered pre-tested structured questionnaire and using standard data collection tools. Before conducting the actual study 5% of the questionnaires were pre-tested for their consistency at Mizan health center. Those children diagnosed with ARIs were followed during their hospital stay, and their clinical data such as discharged alive with improvement, died, referred with complications and was discharged home in a moribund condition were captured. Physicians have undertaken all the clinical evaluation of patients with ARIs. According to CDC/NHSN surveillance definition¹⁵ and other study done elsewhere,¹⁶ evidence of ARI included fever (≥38°C), hypothermia (<36.5°C), white blood cell count <4000WBC/mm³ or ≥15,000 WBC/mm³, tachypnea, cough, pleuritic chest pain, difficulty breathing, and sore throat; in addition, for children <2 years old, has at least two of the following signs or symptoms with no other recognized cause: signs included chest indrawing, nasal flaring, noisy breathing, apnea, bradycardia, and difficulty eating, drinking, or breastfeeding.

Statistical analysis

The data was analysed using Statistical Package for Social Science (SPSS) window versions 25.0. Frequency distributions and descriptive statistics such as the number and percent of patients were identified and calculated. To determine variables associated with poor outcome of ARIs, a multivariate logistic regression model was fitted and variables found to be significant at a p-value < .05 were declared as predictors, and odds ratios with 95% confidence interval were reported.

Results

Prevalence of ARIs and characteristics of children with ARIs

In this study, a total of 305 children of less than 5 years were included to assess the prevalence of ARIs clinical characteristics and their clinical outcomes. Of these, only 124 (40.7%) of children were diagnosed with ARIs, included in the analysis and were followed during their hospital stay to see their clinical outcomes. About 66 (53.2%) of them were female, and 69 (55.6%) were age of 24–59 months. Most children 73 (58.9%) were from mothers who didn’t completed their primary school, and 64 (51.6%) were rural residents. About 53 (42.7%) of children come from a family with high crowding index (>3 persons/room) and 56 (45.2%) were from households that had cooking inside their house and 34 (27.4%) comes from a family who had smokers in their house in the last 12 months. Sixty five (52.4%) children were not breastfeed in first 2 years of life (Table 1).

Table 1.

Characteristics of under-5 year’s children admitted with ARIs (n = 124).

Characteristics of patients	Frequency	Percents
Age in month
<24 months	55	44.4
24–59 months	69	55.6
Sex
Male	58	46.8
Female	66	53.2
Residence
Urban	60	48.4
Rural	64	51.6
High crowding index (>3/room)
Yes	53	42.7
No	71	57.3
Mother completed primary school
Yes	51	41.1
No	73	58.9
Presence of smoker in the household in the last 12 months
Yes	34	27.4
No	90	72.6
Breastfed in first 2 years of life
Yes	59	47.6
No	65	52.4
Cooking inside the house
Yes	56	45.2
No	68	54.8

Clinical characteristics of children with ARIs

In this study, 92 (74.2%) children present with fever ≥ 38°C and 84 (67.7%) with abnormal WBC count (<4000WBC/mm³ or ≥15,000 WBC/mm³). Moreover, 110 (88.7%) children present with more than two ARIs sign/ symptoms. As shown in table −2, the ARIs diseases diagnosed by physicians were: Pneumonia 53 (38.4%), rhinitis 23 (18.5%), pharyngitis 16 (12.9%), bronchiolitis 12 (9.7%), tonsillitis 11 (8.9%) and acute otitis media 9 (7.3%). Of the 124 children who had ARIs, 55 (44.4%) of them were also found to have other disease conditions like: malnutrition 18 (14.5%), diarrheal disease 13 (10.5%), malaria 12 (9.7%), any chronic disease 7 (5.4%) and HIV infection 5 (4.0%). Ninety two (74.2%) children showed antibiotics responses after 3–5 days of administration (Table 2).

Table 2.

Clinical features of under-5 year’s children admitted with ARIs (n = 124).

Clinical features of the patients with ARIs	Frequency	Percent
Fever ≥ 38°C
Yes	92	74.2
No	32	25.8
Abnormal WBC count
Yes	84	67.7
No	40	32.3
More than two ARIs sign/ symptoms
Yes	110	88.7
No	14	11.3
Disease diagnosed by physicians
End point pneumonia	53	38.4
Rhinitis	23	18.5
Pharyngitis	16	12.9
Bronchiolitis	12	9.7
Tonsillitis	11	8.9
Acute otitis media	9	7.3
Presence of co-morbidities (n = 55)
Any chronic disease	7	5.6
Malnutrition	18	14.5
HIV infection	5	4.0
Diarrhea	13	10.5
Malaria	12	9.7
Antibiotics responses after 3–5 days
Yes	92	74.2
Not	32	25.8
Final patients outcome
Discharged with improvement	103	83.1
Died or was discharged home in a moribund condition	11	8.9
Referred for further investigations	9	7.3

Prevalence and factors associated with poor clinical outcomes

Accordingly, 21 (16.9%) children with ARIs ended with poor clinical outcomes after completion of their treatment regimens. Of these, 11 (8.9%) were died or were discharged home in a moribund condition and 9 (7.3%) were referred for further investigations (Table 2). In the multivariate analysis, age of children, presence of any other disease conditions, malnutrition, exposure to indoor air pollution and end point pneumonia were found to be independent predictors for poor outcome of under-five children with ARIs. Children with age group of <24 months and with any other disease conditions were 67% (OR = 0.331; 95% CI: 0.123–0.880; p =.024) more likely to end up with poor ARIs outcome than patients with age group of 24–59 months and without any other disease conditions. Those under-five children with exposure to indoor air pollution were 66% (OR = 0.344; 95% CI: 0.128–0.925; p =.030) more likely to end up with poor ARI outcome than under-five children without exposure to indoor air pollution. Those under-five children with malnutrition (MUAC< 12.5 mm) were 82% (OR = 0.175; 95% CI: 0.058–0.523; p = .002) more likely to end up with poor ARI outcome than under-five children without malnutrition. Those under-five children diagnosed with end point pneumonia were 70% (OR = 0.305; 95% CI: 0.113–0.821; p = .015) more likely to end up with poor ARI outcome than those diagnosed with other respiratory tract infections (Table 3).

Table 3.

Factors associated with poor outcome of under-5 year’s children admitted with ARIs (n = 124).

Variables	Outcome of patients with ARIs (n = 124; 40.7%)		Or [95% CI]	P-value
Variables	Good (n = 103)	Poor (n = 21)	Or [95% CI]	P-value
Age of child
<24 months	41 (39.8%)	14 (66.7%)	0.331 (0.123–0.880)	.024*
24–59 months	62 (60.2%)	7 (33.3%)	0.331 (0.123–0.880)	.024*
Sex of child
Male	48 (46.6%)	10 (47.6%)	‐	.285
Female	55 (53.4%)	11 (52.4%)	‐	.285
Residences
Urban	51 (49.5%)	9 (42.8%)	‐	.710
Rural	52 (50.5%)	12 (57.2%)	‐	.710
Crowding index (>3/room)
Yes	43 (41.7%)	10 (47.6%)	‐	.380
No	60 (58.3%)	11 (52.4%)	‐	.380
Mother completed primary school
Yes	40 (38.8%)	11 (52.4%)	‐	.452
No	63 (61.2%)	10 (47.6%)	‐	.452
Presence of smoker in the household
Yes	22 (21.4%)	12 (57.1%)	‐	.453
No	81 (78.6%)	9 (42.9%)	‐	.453
Breastfed in first 2 years of life
Yes	48 (46.6%)	11 (52.4%)	‐	.775
No	55 (53.4%)	10 (47.6%)	‐	.775
Cooking inside the house
Yes	42 (40.8%)	14 (66.7%)	0.344 (0.128–0.925)	.030*
No	61 (59.2%)	7 (33.3%)	0.344 (0.128–0.925)	.030*
Presence of co-morbidities
Yes	41 (39.8%)	14 (66.7%)	0.331 (0.123–0.889)	.024*
No	62 (60.2%)	7 (33.3%)	0.331 (0.123–0.889)	.024*
Malnutrition (MUAC<12.5 mm)
Yes	10 (9.7%)	8 (38.1%)	0.175 (0.058–0.523)	.002*
No	93 (90.3%)	13 (61.9%)	0.175 (0.058–0.523)	.002*
End point pneumonia
Yes	39 (37.9%)	14 (66.7%)	0.305 (0.113–0.821)	.015*
No	64 (62.1%)	7 (33.3%)	0.305 (0.113–0.821)	.015*

NB: *: those variables showed statistical significant differences.

Discussion

This study was conducted to assess prevalence of ARIs and factors associated with poor clinical outcomes in southwest of Ethiopia. The overall prevalence of ARIs in this study was 40.7%. This result is higher than a study finding in Ethiopia, in which the average prevalence of ARIs was 25.8%.^14,17,18 However, our finding is lower than a finding in other African countries, such as Nigeria and Cameroon, in which the average prevalence of ARIs was 59.8%.^19,20 This difference in the proportions of ARIs might be as a result of different in study settings, differences in sampling strategies and differences in the enrollment of patients with ARIs. This study used mainly clinical definitions for the ARIs cases which are more sensitive than laboratory confirmed cases.

In this study, 16.9% children with ARIs ended with poor clinical outcomes after completion of their treatment. This result is in agreement with other study finding; in which unfavorable outcomes of patients with ARIs were exceed 15% in many cases.^21,22 This finding is also higher than a finding in India, in which cases fatality rates related to ARIs was 1.1%–1.43%^23,24 and in Guatemala,¹⁶ in which 4% of patients <2 years old and 12% of adult patients dying during hospitalization or discharged in a moribund state. However, the finding is slightly lower than a finding in Morocco, in which (27.2%) children were classified as having a poor prognosis.²⁵ The observed differences in favorable and unfavorable outcomes due to ARIs may be related with differences in the definition used for poor outcomes, the progress exerted towards delivering appropriate health care management in reducing ARIs mortality and population awareness on health care seeking behaviors.

The possible factor that could be contributing for poor outcomes of ARIs in this study may be related with the quality of care providing activity of a hospital and disease management of healthcare workers. The success of preventions, management or treatment of many respiratory infections is dependent on the quality of the healthcare system. Although there was an improvement in access to and the quality of hospital cares as well as care-seeking behavior of the patients, still it is questionable in resource limited setting, including our study area.^26,27 For instance, in our setting, ICU room and mechanical ventilators were started to give functions very recently. Sometimes health workers may not have supportive, continuous training on ARIs and may miss timely detection and management of patients with ARIs. A better knowledge of ARIs will enable physicians to detect children with ARIs more quickly and give appropriate management and treatment, or refer them if the disease is severe. In addition, physicians now face situations in which infected patients cannot be treated adequately because the responsible bacterium is totally resistant to available antibiotics.^8,26 A descriptive FRESH AIR study concluded that, duration and comprehensiveness of clinical consultations and appropriate treatment options to guide respiratory diagnosis in young children is insufficient and not available in certain low-, middle-, and high-income countries.²⁸ These might be contributed for unfavorable and poor outcome of patients with ARIs. Although, we didn’t included information about the actual disease management for the children in the study area, substantial effrts need to be made, if further improvements in quality of hospital care and reductions in ARIs mortality are to be achieved.

Regarding factors associated with poor clinical outcome, in this study age of children, presence of any other disease conditions, exposure to indoor air pollution, malnutrition, and endpoint pneumonia was found to be independent predictors for poor outcomes of under-five children with ARIs. Our finding is similar to another study finding, in which the above risk factors were found to be independent risk factors for poor outcomes of children with ARIs.^29–32 This could be because as children get older, their immunity grows stronger and becomes better able to resist infection. Nutrition and co-morbidity conditions may also hinder the immune status of children and becomes susceptible to infections. Therefore, a combination of public health and clinical strategies is required to prevent and control the poor outcome of ARIs. The efforts should be focused not only on the prevention of ARIs but also on the other contributing risk factors.

Limitations of this study

This is a hospital-based study, which may missed those didn’t visit the hospital for medical care despite they were with ARIs so the finding may not be a true reflection of what is in the community.

Conclusion

As a conclusion, the prevalence and poor clinical outcome of under five children with ARIs was still high. This study also revealed that, age of children, malnutrition, exposure to indoor air pollution, presence of any other disease conditions, and end point pneumonia were associated with increased risk of poor outcome of children with ARIs. Therefore, to improve outcome of patients with ARIs timely detection and proper management and treatment as well as reducing other contributing factors are essentials.

Supplemental Material

Supplemental Material - Acute respiratory infections (ARIs) and factors associated with their poor clinical outcome among children under-five years attending pediatric wards of public hospital in Southwest district of Ethiopia: A prospective observational cohort study

Supplemental Material for Acute respiratory infections (ARIs) and factors associated with their poor clinical outcome among children under-five years attending pediatric wards of public hospital in Southwest district of Ethiopia: A prospective observational cohort study by Mengistu Abayneh, Dassaleng Muleta, Asnake Simieneh, Tadesse Duguma, Molla A Kebede, Murtii Teressa, Biruk Endalkachew and Milkiyas Toru in European Journal of Inflammation

Footnotes

Acknowledgements

First, we would like to thanks Mizan-Tepi University, Institute of Research and Community Support Coordinating Office. Thanks to all data collectors for their willingness during data collection.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Ethical approval

Ethical approval for this study was obtained from Mizan- Tepi University Ethical Review committee (Approval Number/ID: Rf/253/2020).

Informed consent

Written informed consent was obtained from their family or from legally authorized parents before the study.

ORCID iD

Mengistu Abayneh

Supplemental Material

Supplemental material for this article is available online

References

GBD 2015, Eastern Mediterranean Region Lower Respiratory Infections Collaborators . Burden of lower respiratory infections in the eastern mediterranean region between 1990 and 2015: findings from the global burden of disease 2015 study. Int J Public Health 2018; 63: S97–S108. DOI: 10.1007/s00038-017-1007-0

GBD 2015, Mortality and Causes of Death Collaborators . Global, regional, and national life expectancy, all cause mortality and cause-specific mortality for 249 causes of death, 1980–2015: a systematic analysis for the global burden of disease study 2015. Lancet 2016; 388: 1459–1544.

Nair

Simoes

Rudan

, et al. Global and regional burden of hospital admissions for severe acute lower respiratory infections in young children in 2010: a systematic analysis. Lancet 2013; 381: 1380–1390. DOI: 10.1016/S0140-6736(12)61901-1

Lozano

Naghavi

Foreman

, et al. Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the global burden of disease study 2010. Lancet 2012; 380: 2095–2128. Available from: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(12)61728-0/abstract

Cilloniz

Martin-Loeches

Garcia-Vidal

, et al. Microbial etiology of pneumonia: epidemiology, diagnosis and resistance patterns. Int J Mol Sci 2016; 17: 2120. Available from: https://www.mdpi.com/1422-0067/17/12/2120

Ferkol

Schraufnagel

. The global burden of respiratory disease. Ann Am Thorac Soc 2014. 11(3):404–406.

WHO Regional Office for Africa, 2016 . Protocol for the investigation of acute respiratory illness outbreaks of unknown etiology. Brazzaville, Republic of Congo: World Health Organization Regional Office for Africa, 2015.

Forum of International Respiratory Societies . The global impact of respiratory disease – Second Edition. Sheffield, UK, European Respiratory Society, 2017.

Aston

. Pneumonia in the developing world: characteristic features and approach to management. Respirology 2017: 22, 1276–1287. DOI: 10.1111/resp.13112

10.

Zar

Madhi

Aston

, et al. Pneumonia in low and middle income countries: progress and challenges. Thorax 2013; 68:1052–1056. DOI:10.1136/thoraxjnl-2013204247

11.

SanJoaquin

Allain

Molyneux

, et al. Surveillance programme of in-patients and epidemiology (SPINE): implementation of an electronic data collection tool within a large hospital in Malawi. Plos Med 2013; 10(3): e1001400. DOI: 10.1371/journal.pmed.1001400

12.

Hirschtick

Glassroth

Jordan

, et al. Bacterial pneumonia in persons infected with the human immunodeficiency virus. Pulmonary Complications of HIV Infection Study Group. N Engl J Med 1995; 333: 845–851.

13.

Andualem

Nigussie Azene

Dessie

, et al. Acute respiratory infections among under-five children from households using biomass fuel in Ethiopia: systematic review and meta-analysis. Multidisciplinary Respir Med 2020; 15: 710. DOI: 10.4081/mrm.2020.710

14.

Dagne

Andualem

Dagnew

, et al. Acute respiratory infection and its associated factors among children under-five years attending pediatrics ward at university of gondar comprehensive specialized hospital, Northwest Ethiopia: institution-based cross-sectional study. BMC Pediatr 2020; 20:93. DOI: 10.1186/s12887-020-1997-2

15.

Horan

Andrus

Dudeck

. CDC/NHSN surveillance definition of health care-associated infection and criteria for specific types of infections in the acute care setting. Am J Infect Control 2008; 36 (5): 309–332.

16.

Tomczyk

McCracken

Contreras

, et al. Factors associated with fatal cases of acute respiratory infection (ARI) among hospitalized patients in Guatemala. BMC Public Health 2019; 19:499. DOI: 10.1186/s12889-019-6824-z

17.

Sanbata

Asfaw

Kumie

. Association of biomass fuel use with acute respiratory infections among under-five children in a slum urban of Addis Ababa, Ethiopia. BMC Public Health 2014; 14(1):1122.

18.

Alemayehu

Alemu

Sharma

, et al. Household fuel use and acute respiratory infections in children under five years of age in Gondar city of Ethiopia. J Environ Earth Sci 2014; 4(7): 77–85.

19.

Solomon

Odu

Amu

, et al. Prevalence and risk factors of acute respiratory infection among under-fives in rural communities of Ekiti state Nigeria. Glob J Med Public Health 2018; 7(1): 12.

20.

Tazinya

Halle-Ekane

Mbuagbaw

, et al. Risk factors for acute respiratory infections in children under five years attending the Bamenda regional Hospital in Cameroon. BMC Pulmon Med 2018; 18(1): 7.

21.

Walker

Rudan

Liu

, et al. Global burden of childhood pneumonia and diarrhea. Lancet 2013; 381: 1405–1416.

22.

World Health Organization . Pneumonia. Fact Sheet No. 331. World Health Organization, Geneva, Switzerland, 2013. https://www.who.int/mediacentre/factsheets/fs331/en/

23.

Sriram

Satyanarayana

. Study on clinical profile and risk factors associated with pneumonia. Int J Contemp Pediatr. 2019; 6: 2349–3291. https://www.ijpediatrics.com

24.

Antony

Celine

Chacko

. Case fatality of Pneumonia: a “5” year retrospective study. Int J Med Public Health. 2014; 4: 163–166. DOI: 10.4103/2230-8598.133121

25.

Jroundi

Mahraoui

Benmessaoud

, et al. Risk factors for a poor outcome among children admitted with clinically severe pneumonia to a university hospital in Rabat, Morocco. Int J Infect Dis. 2014; 28: 164–170. DOI: 10.1016/j.ijid.2014.07.027

26.

Lim

Steinhoff

Girosi

, et al. Reducing the global burden of acute lower respiratory infections in children: the contribution of new diagnostics. Nature. 2006; 444(Suppl 1): 9–18. DOI: 10.1038/nature05442

27.

Krüger

Heinzel-Gutenbrunner

Ali

. Adherence to the integrated management of childhood illness guidelines in Namibia, Kenya, Tanzania and Uganda: evidence from the national service provision assessment surveys. BMC Health Serv Res 2017; 17: 822. DOI: 10.1186/s12913-017-2781-3

28.

Kjærgaard

Anastasaki

Stubbe Østergaard

, et al. (2019) Diagnosis and treatment of acute respiratory illness in children under five in primary care in low-, middle-, and high-income countries: a descriptive FRESH AIR study. PLoS ONE 14(11): e0221389. DOI: 10.1371/journal.pone.0221389

29.

Sonego

Pellegrin

Becker

, et al. 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

30.

Geberetsadik

Worku

Berhane

. Factors associated with acute respiratory infection in children under the age of 5 years: evidence from the 2011 Ethiopia demographic and health survey. Pediatr Health Med Ther 2015; 6: 9–13.

31.

Alemayehu

Kidanu

Kahsay

, et al. Risk factors of acute respiratory infections among under five children attending public hospitals in southern Tigray, Ethiopia, 2016/2017. BMC Pediatr. 2019; 19: 380. DOI: 10.1186/s12887-019-1767-1

32.

Jackson

Mathews

Pulanić

, et al. Risk factors for severe acute lower respiratory infections in young children – a systematic review and meta-analysis. Croat Med J 2013; 54: 110–121. DOI: 10.3325/cmj.2013.54.110

Supplementary Material

Please find the following supplemental material available below.

For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.

For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.

0.00 MB

0.30 MB