Burden of Pneumococcal infections among under five children

Assistant professor, Department of Community Medicine, East-West Medical College. Associate professor & Head of the Department of Community Medicine, East-West Medical College. Assistant professor, Department of Dental Public Health, UpdateDental College. Assistant professor, Department of Oral Anatomy & physiology UpdateDental College. assistant professor, Department of Dental Public Health, Update Dental College.


INTRODUCTION
Streptococcus pneumoniae (pneumococcus) causes a variety of respiratory illnesses.More than 25% of community acquired bacterial pneumonia in children is attributable to S. pneumonia in developing countries 1 .Pneumococcal disease probably causes 1-2 million deaths in children < 5 years of age every year, mostly in developing countries 2 .Most deaths are associated with meningitis 3,4 or pneumonia 5,6 which also result in other serious complications, chronic sequelae and substantial direct and indirect costs 7 .Acute Respiratory Infection (ARI) has been shown to be the important known cause of death in children in Bangladesh 8 .
Pneumonia is the leading cause of death for children under 5 years of age in Bangladesh 9 .While Streptococcus pneumonia is likely the cause of at least 30% of episodes of severe pneumonia, S. pneumoniae is not widely recognized as a priority public health problem in Bangladesh.Blood cultures are not done routinely, so the importance of pneumococcus may not be consistently recognized. 10With the advent and availability of a highly effective vaccine to prevent pneumococcal diseases, this knowledge gap will serve as a substantial barrier to optimal use of this prevention mortality.Therefore, the study aimed to explore the burden of illness related to Streptococcus pneumoniae in a tertiary level hospital among under 5 children.The findings would address the knowledge gap and provide a means to define the impact of Streptococcus pneumoniae in ways that will be important to decision makers and stakeholders

METHODOLOGY
The present study utilized a descriptive, crosssectional research design involving self-report questionnaires (focused on socio-demographic information, location of kitchen, physical and nature of fuel using for cooking) filled by the attendants of the patients.Since different medical and demographic terms can have multiple-layered meanings -operational definition of important research variables like Pneumonia, Severe Pneumonia, Meningitis, Sepsis, Illness episode, Illiteracy, Monthly family income was postulated.
Under 5 children who were admitted in Dhaka Shishu Hospital with respiratory infections were selected as the study population by using purposive sampling mechanism.The researchers of the study explained the purpose of the study to the parents of the admitted children and asked them to join into the study.Parents of 101 children with respiratory infections were agreed to participate in the study and, therefore, the purposive sampling strategy was utilized to select the sample for this study.The period of data collect was between March 2006 and June 2006.For collecting data, the researchers had used a structured questionnaire and a structured check list.The questionnaire had no open-ended question and face to face interview with parents were done.In order to check out the effectiveness of the questionnaire a pre-testing of the questionnaire was conducted.Blood and Cerebrospinal Fluid (CSF) culture were done to confirm the streptococcal infection.
Apart from using descriptive statistics, t-test was used to see whether the mean difference between two groups (Pneumococcal and nonpneumococcal disease patients) was statistically significant or not.The differences were considered as significant at a p value of <0.05.The SPSS-12 software was used for the analysis of the data.Tables were prepared by using the Microsoft Windows 2007 software.

RESULTS
A total of 101 children aged under 5 were included in this study.Out of 101 participants around 30% of the sample respondents had Pneumonia, 17% had Severe Pneumonia, 26% had been affected by Meningitis and the rest had been suffering from Sepsis.As per the laboratory findings, 23 children had blood culture positive and 18 children had CSF culture positive.The age distribution of the under 5 children with respiratory infections was very symmetric and the mean age of the children was 27.8 months.The gender distribution of the under 5 children with respiratory infections was also very symmetrica depiction that the chosen sample was adequately representative.Around 70% of the mother (of the under 5 children with respiratory infections) was below 25 years of age and for the fathers the representative cluster was between 25-39 years.The occupational distribution of the fathers was very symmetric, even though majority of them belonged to the impoverished segment (around 70% having monthly income of less than taka 5000 per month) and all the mothers were housewives.
The distribution of the respondent's number of living children (under 5 years and above 5 years) was very symmetric.Finally, as per the nutritional status, only 25.32% of the children were well nourished.
There was no statistical difference between father's education level and pneumococcal infection between Pneumococcal and Non Pneumococcal group.However, it was evident from the statistical analysis that there was a strong statistical difference between mother's education level and pneumococcal infection between Pneumococcal and Non Pneumococcal group (p < .05).Mother's education exerts greater role in preventing children's Pneumonia than the case with other respiratory infections (Table 1).There was no statistical difference of pneumococcal infection and location of kitchen in the household.However, nature of fuel used for cooking differed among the pneumococcal and non pneumococcal groups.Almost half (47.8%) of the children's family in pneumococcal group used different sources of fuel other than gas where as in non pneumococcal group, 80.8% used gas for household cooking.The statistical test found strong correlation between nature of fuel using for cooking and pneumococcal status among the children (p= .005)(Table 3).Majority of children who are under weight (≤ 6.0 kg), 13 out of 16 children, were suffering from pneumococcal infection.The mean weight, weight for age between Pneumococcal and Non Pneumococcal groups found to be statistically significant (Table 6).

DISCUSSION
Streptococcal infection is a problem affecting the hospitalized patients both in many developing countries.In developing countries like Bangladesh no emphasis has yet been given in this field. 10In the present study, an attempt was made to explore the pattern of pneumonic infections caused by Streptococcus Pneumonia in large hospitals of Dhaka city.
Mother's education had been linked up with the reduction of Pneumoniaeducational status of the parents should be improved regarding overcrowding, smoke particularly during cooking and the nature of fuel.Greater weight, weight for age plays greater role in preventing children's pneumonia than the case with other respiratory infections.Similarly, higher age and lower respiratory rate plays more significant role in preventing children's Pneumonia than the case with other respiratory infections and vice versa.Therefore, intervention towards improved weight, weight for age and nutritional status under 5 children should be considered at a priority basis.The case management protocol of respiratory infection and pneumonia in particular needs to be implemented more effectively in secondary and primary level hospitals to minimize its burden in tertiary level.
The study was limited to only one tertiary level hospital; the findings may not be generalized for the entire population of Bangladesh.The relatively small sample size and purposeful selection of the study place is expected to produce few biases in the results of the study undertaken.Despite the limitations of this study, the findings will provide opportunities to define burden of pneumococcal diseases more precisely within communities among under 5 children.It will be useful for reliably extrapolating to larger populations within Bangladesh and for comparing with other settings.The findings of this study can, also, be considered as a basis towards tertiary care management of pneumonia to understand the burden of pneumococcal infections among under 5 children.