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.

Full text

Original Research Article
European Journal of Inflammation
Volume 20: 1–8
© The Author(s) 2022
Article reuse guidelines:
sagepub.com/journals-permissions
DOI: 10.1177/1721727X221139266
journals.sagepub.com/home/eji
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
Mengistu Abayneh
1
, Dassaleng Muleta
1
, Asnake Simieneh
1
, Tadesse Duguma
1
,
Molla Asnake
2
, Murtii Teressa
2
, Biruk Endalkachew
3
and Milkiyas Toru
4
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
Date received: 16 March 2022; accepted: 30 September 2022
1
College of Medicine and Health Science, Department of Medical Laboratory Sciences, Mizan-Tepi University, Mizan-Aman, Ethiopia
2
College of Medicine and Health Science, Department of Medicine, Mizan-Tepi University, Mizan-Aman, Ethiopia
3
College of Medicine and Health Science, Department of Biomedical Science, Mizan-Tepi University, Mizan-Aman, Ethiopia
4
College of Health Science, Department of Medical Laboratory Sciences, Debre Markos University, Debre Marqos, Ethiopia
Corresponding author:
Mengistu Abayneh, College of Medicine and Health Science, Department of Medical Laboratory Sciences, Mizan-Tepi University, Mizan-Aman 16,
Ethiopia.
Email: menge.abay@gmail.com
Creative Commons Non Commercial CC BY-NC: This article is distributed under the terms of the Creative Commons
Attribution-NonCommercial 4.0 License (https://creativecommons.org/licenses/by-nc/4.0/) which permits non-commercial use,
reproduction and distribution of the work without further permission provided the original work is attributed as specified on the
SAGE and Open Access pages (https://us.sagepub.com/en-us/nam/open-access-at-sage).

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 es-
timates, 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 de-
veloping 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 breast-
feeding 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 under-
nourished,
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 chal-
lenging 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 out-
come 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 investi-
gations 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 im-
proved or cured after completing their treatment and were
not referred to other health institutions for further inves-
tigations 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 ¼ðZα=2Þ2pð1pÞ
d2
Therefore: n ¼ð1:96Þ2×0:2731ð10:273Þ
ð0:05Þ2¼305 was the final
sample size for this study.
2European Journal of Inflammation

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 ques-
tionnaires 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 definition
15
and other study done else-
where,
16
evidence of ARI included fever (≥38°C), hypo-
thermia (<36.5°C), white blood cell count <4000WBC/mm
3
or ≥15,000 WBC/mm
3
, 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, bra-
dycardia, and difficulty eating, drinking, or breastfeeding.
Statistical analysis
The data was analysed using Statistical Package for Social
Science (SPSS) window versions 25.0. Frequency distribu-
tions and descriptive statistics such as the number and percent
of patients were identified and calculated. To determine var-
iables 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 charac-
teristics 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’tcom-
pleted 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 ).
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/
mm
3
or ≥15,000 WBC/mm
3
). 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).
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
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
Abayneh et al. 3

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).
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 dif-
ferences 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
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
4European Journal of Inflammation

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 pre-
ventions, 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,
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-valueGood (n= 103) Poor (n= 21)
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%)
Sex of child
Male 48 (46.6%) 10 (47.6%) - .285
Female 55 (53.4%) 11 (52.4%)
Residences
Urban 51 (49.5%) 9 (42.8%) - .710
Rural 52 (50.5%) 12 (57.2%)
Crowding index (>3/room)
Yes 43 (41.7%) 10 (47.6%) - .380
No 60 (58.3%) 11 (52.4%)
Mother completed primary school
Yes 40 (38.8%) 11 (52.4%) - .452
No 63 (61.2%) 10 (47.6%)
Presence of smoker in the household
Yes 22 (21.4%) 12 (57.1%) - .453
No 81 (78.6%) 9 (42.9%)
Breastfed in first 2 years of life
Yes 48 (46.6%) 11 (52.4%) - .775
No 55 (53.4%) 10 (47.6%)
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%)
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%)
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%)
End point pneumonia
Yes 39 (37.9%) 14 (66.7%) 0.305 (0.113–0.821) .015*
No 64 (62.1%) 7 (33.3%)
NB: *: those variables showed statistical significant differences.
Abayneh et al. 5

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 comprehensive-
ness 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 out-
come, in this study age of children, presence of any other
disease conditions, exposure to indoor air pollution, mal-
nutrition, and endpoint pneumonia was found to be in-
dependent 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.
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 re-
spect 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 https://orcid.org/0000-0003-2700-8216
Supplemental Material
Supplemental material for this article is available online
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