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Memorias do Instituto Oswaldo Cruz Vol. 90(6), Nov./Dec. 1995 Acute Respiratory Infections in Children Living in Two Low Income Communites of Rio de Janeiro, Brazil Frits Sutmoller/+, Paulo Ricardo Maia* Hospital Evandro Chagas, Instituto Oswaldo Cruz, Av. Brasil 4365, 21045-900 Rio de Janeiro, RJ, Brasil *Instituto Fernandes Figueira, Av. Rui Barbosa 716, 20250-020 Rio de Janeiro, RJ, Brasil
Code Number: OC95135
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No associated graphics filesCommunity studies of non-hospitalized children are essential to obtain a more thorough understanding of acute respiratory infections (ARI) and provide important information for public health authorities. This study identified a total ARI incidence rate (IR) of 4.5 per 100 child-weeks at risk and 0.78 for lower respiratory tract infections (LRI). Disease duration averaged less than one week and produced a total time ill with ARI of 5.8% and for LRI 1.2%. No clear seasonal variation was observed, the sex-specific IR showed a higher proportion of boys becoming ill with ARI and LRI and the peak age-specific IR occurred in infants of 6-11 months. Correlation with risk factors of the child (breastfeeding, vaccination, diarrheal disease, undernourishment) and the environment (crowding, living conditions, maternal age and education) showed marginal increases in the rate ratios, making it difficult to propose clear-cuts targets for action to lower the ARI and LRI morbidity. The importance of an integral maternal-child health care program and public education in the early recognition of LRI is discussed. Key words: acute respiratory infections - incidence - Brazil - low income population - risk factor Acute respiratory infections (ARI) continue to have a large impact on childhood health. It is important because of the large number of deaths as well as the impact of disease burden on growth and development in young children. This paper describes the results of a community study carried out between April 1987 and September 1989 in two low income populations within the city of Rio de Janeiro, Brazil. Our understanding of ARI in the community remains incomplete and the development of preventive strategies requires a more thorough assessment of risk factors (such as undernourishment, vaccine coverage, parental education level, etc.). This is essential for public health authorities who need information that can produce direct and efficacious control measures which would lower the disease morbidity and thus lessening the human suffering and costs due to this important disease group. Health center based studies may have selection bias and these findings can not often be generalized to the community population. MATERIALS AND METHODS Study population - Rio de Janeiro, a sub-tropical city had 5.7 million inhabitants according to the 1980 census (IBGE 1983) with an average winter temperature of 18 C and average summer temperature of 28 C. In 1981, Rio de Janeiro had 377 shanty towns with a total population of 1.7 million (IPLANRIO 1983), representing 34% of the city population. Two low income communities [Cruzada Sao Sebastiao (CZSB) and Santa Marta (SM)] were selected for active surveillance because of their location near the Instituto Fernandes Figueira (IFF) hospital. The SM community is a densely populated shanty town, housing over 4,800 people (in 1986) on a steep hill side in the Botafogo section of the city and is about 10 min by bus from the IFF hospital. Community access is via steep and narrow steps and walkways; sanitation is poor with an open sewage system. The CZSB community houses 3,600 people (in 1986) in seven story apartments located in ten blocks. It has a good water supply system and is directly connected to the city' sewage system. A census of the communities was undertaken, during the final months of 1986 and the beginning of 1987, to identify children under the age of two. Of the 337 children (63% under two years of age) identified, 229 (68%) were enrolled as the remainder were not at home during the daytime. New children were also recruited (mainly newborns) during the study period and a total of 262 children entered the study. The study was approved by the Research Committee of the IFF and followed guidelines of the Fundação Oswaldo Cruz on clinical research involving human subjects. Informed consent was obtained from the parents or guardians by means of a verbal explanation of the study and a written consent form. Sociodemographic and anthropometric monitoring - Health workers were trained to complete the risk factor questionnaires and recognize specific signs and symptoms of ARI, both explained in a Field Work Manual provided to each worker which defined each question and standardized approaches for data collection. One of the authors (PRM) supervised the field workers and their performance. Baseline sociodemographic data were obtained and included family structure, socioeconomic status, family health and living condition. Information about the child included gestation information, breast feeding, vaccinations and history of previous diseases. Weight and height were measured periodically during the home visits. The weight for age was compared to the National Center for Health Statistics/Centers for Disease Control (NCHS/CDC) reference population values and the mean values calculated with the use of the CDC Anthropro-metric Software Package 3.0 (CDC 1987). This reference data was used to make result comparable with other BOSTID studies. Person with < 80% of the population reference population were considered undernourished. Surveillance of ARI morbidity - Weekly home visits were made by health workers. Information on ARI was based on parental or guardian's recall with confirmation by the health worker's observation which included counting respiratory frequency. If the child was not at home this was recorded and the child not considered at risk. Case definition - Children were considered to have a respiratory infection if the child had a cough, throat pain, earache, difficulty breathing, stridor, and/or wheezing. Coryza was not considered for case definition of ARI. LRI were defined as cases having dyspnea, tachypnea (RF>50 ipm) or when a clinical diagnose of LRI was made by a physician. Weekly visits were initiated in June 1987 in the SM community, but interrupted temporarily (August and September) during that year because of community violence. Visits began in CZSB during October 1987. A child was considered at risk for ARI if he or she was present and did not have an ARI on any day of the previous week. The field surveillance was stopped in both communities in September of 1989. For purpose of data analysis the following points were considered: (1) only children that had been visited at least two weeks were included in the analysis; (2) a disease episode was considered new when the child had been symptom free for a week prior to the visit; (3) incidence rates were calculated by using a denominator of child-weeks at risk and a numerator of the sum of new ARI episodes. The data was transformed to represent the number of new cases per 100 child-weeks (IR). The child was considered at risk when it was not sick during the previous week and if they were sick before they were not eligible during that week. Weeks that the child was absent were not considered in the denominator. RESULTS The socioeconomic characteristics of the population under surveillance are summarized in Tables I and II. Homes in the SM community were mainly huts (76%) while in the CZSB they were all apartments. Crowding within the homes was higher in the CZSB. Employment rates of the guardians were similar in both communities but in the CZSB a larger proportion of other family members were economically active. Both communities had equal access to medical care through the Instituto Nacional de Seguridade Social (INSS), the national public health care system. Maternal educational levels were low with 34% being illiterate and 53% having gone to primary school (both incomplete and completed) and rates were higher in the SM community. The characteristics of the children under surveillance are reviewed in Table II. A small predominance of male children existed. The average child's age, at the study onset (first weekly visit), was 14 months and was slightly higher in the CZSB. The termination average age was 30 months and was similar in both communities. Parental information about prenatal care, type of delivery and child birth weight were compared and revealed that the prenatal care coverage was better and the number of overweight was higher in the CZSB community while the percentage of children born at term and those born by vaginal delivery was higher in the SM community. The birth order data showed, in the CZSB, that the study children were mainly (75%) the first or second child (74%) and this percentage (60%) was lower in the SM. Incomplete vaccination (based on vaccination records) percentage was higher (63%) in SM when compared (37%) to CZSB. Hospitalization, before the study in the SM children was higher [33 hospitalizations, mainly due to respiratory problems (48%) and diarrheal diseases (39%)] and contrasted to just seven hospitalizations in the CZSB. Nine of the SM children had been hospitalized (all diseases) at least twice, one child three times and two others had four hospitalizations The first weight for age determination identified 7% of the children to be undernourished and was similar in both communities. The distribution of weeks observed per child (Table III) during the study period showed that 44% of the children were observed for more than one year. Incidence rates comparison between children that were visited more or less than one year showed no significant difference. Disease duration analysis showed that most of ARI cases resolved within one week and in 87% lasted less than or equal to two weeks. Very few cases (1%) lasted longer then one month. Of the LRI, 59% resolved within a week, 25% in two weeks, 14% lasted three weeks and 2% lasted for four weeks. Incidence rates - During the two year period 262 children had a total of 12,283 home visits of observation. The child weeks at risk equaled 11,646. During these visits 522 ARI cases were identified (IR of 4.5 per 100 child weeks or 2.5 episodes per child-year). In SM community 333 cases and an IR of 3.9 was obtained, while in CZSB community 189 cases were identified and an IR of 6.0. The number of weeks that these children were sick was 678 weeks (percent time ill of 5.7%). LRI were seen in 73 cases in SM (IR= 0.87) and was lower in CZSB where 12 cases produced an IR of 0.38. ARI incidence varied over the study period but no seasonal pattern was detected, yet an overall decrease in IR was observed over the study time. There was an initial relatively high ARI incidence rate in the months of May through July of 1987 (winter months) and was followed by a second increase during spring (October 1987 through January 1988). ARI rates were low in the autumn of 1988 and increased slowly during the first semester and reached the highest level in the spring (September/ October) of that year, after which the rates remained at the same level through the first semester of 1989. The analysis of certain risk factors of ARI is shown in Table IV. Gender-specific ARI incidence rate for males was slightly higher than females with RR of 1.1 and increased to 1.8 for LRI. Age-specific ARI and LRI incidence were higher in the 6-11 month age bracket, followed by the children in the first semester of life and the second year of life. The lowest ARI rates were encountered in children above the age of three years. Children weaned at study onset and who had breastfed less than three months were at small increased risk of developing ARI and LRI. Vaccinations which were not complete at study onset showed an increased RR for LRI. The nutritional status evaluation showed an ARI ratio rate of 1.3 for children who were undernourished (<80% of reference population). Children who had been hospitalized (all reasons) prior to the study showed an increased risk of acquiring ARI, but not LRI. The evaluation of the individual child having diarrhea or other diseases showed that the RR is less than one. The risk of LRI is 2.9 times higher in children with diarrhea, and identical for other diseases. Characteristics of the family and housing as risk factors related to the incidence of ARI were investigated (Table V). Living conditions showed that the children that lived in crowded (>3 person/room) conditions and those living in houses/apartments were at increased risk of developing ARI. Children living in huts had greater risk (RR=1.2) of LRI, but the data on crowding was not conclusive. Having other young (<5 years old) children in the house was also a risk of increasing ARI and LRI. Maternal age specific ARI and LRI incidence rates were lower in the younger mother (less than 25 years of age) with the exception of those who were under 17 years old where the ARI incidence was higher. Maternal education level was not associated with ARI or LRI incidence but paternal education was associated with an increased RR in fathers with secondary or tertiary level education, specially when LRI (RR=3.1) is concerned. In the SM community 11 children were hospitalized, two of them had two hospitalizations. Of the 13 episodes, two (15%) had pneumonia, four (30%) had bronchitis and one child was hospitalized twice for tuberculosis. The other hospitalizations were due to gastroenteritis (two episodes), convulsion, hepatitis and a hernia operation. Two deaths occurred in this community, both at home. One child died after a high fever (suspected by attending physician to be dengue) and the mother left the community after this episode, so no further information could be obtained. The other child had cranial trauma and died from its' consequences. In CZSB one child was hospitalized with meningitis (no sequalae) while another child had pneumonia in another hospital and died after being transferred to IFF. DISCUSSION Many problems in performing this study, caused by factors beyond the control of the study design, were encountered. A government hiring freeze, community related problems (drug gang wars, many social projects being done at the same time, mud slides with fatalities), difficult community access, social concepts (parents hiding information about pneumonias which neighbors could consider as tuberculosis, etc.) and ignorance about ARI (Sutmoller, unpublished data). These factors have to be considered when interpreting the results. ARI studies in urban areas have shown an annual incidence rate of 5-8 per child-year (Sutton 1965, Kamath et al. 1969, Monto et al. 1971, Berman et al. 1983, Pio et al. 1985, Lang et al. 1986), and were higher than the rate reported in this study. Yet the 4.5 episodes per 100 child-weeks in this study compares with other community studies done in developing countries (Table VI). It was lower than the other BOSTID studies (Selwyn 1990) where the rates varied from 12.7 to 16.8 and in a previous study in another Rio community (Sutmoller & Nascimento 1983) but was similar to studies in the Philippines (Tupasi et al. 1990) and Mexico (Datta et al. 1982), India (Delgado et al. 1988), Guatemala (Vathanophas et al. 1990). The selection of URI with cough in Guatamala, the moderate or severe URI criteria in the Thailand study and the study in Trinidad (Sutton 1965) with febrile cases, produced similar rates as in the present study. ARI incidence rates varied among these two communities, being 1.5 times more frequent in CZSB community. The reason for this may be that poor parental recognition of ARI symptoms, specially in SM community, played a role and possibly caused an underestimation to occur in this study for overall ARI rates. As mentioned, the information was based on parental or guardian's recall and only recorded as an episode if confirmed by the health worker's observations with the BOSTID criteria. This was different from a previous study (Sutmoller, unpublished data) in which the child was examined by health workers and included if mild ARI signs, such as coryza, was observed. Indirect data collection about disease from persons, who may not have known everything that happened within the family, or the lack of knowledge about the symptoms of ARI, can also be a possible explanation. Other diseases, especially frequent diarrhea and cutaneous infections in SM community, may possibly have overriden the mild ARI symptoms and thus not reported. The LRI incidence of 0.73 per 100 child-weeks was similar to the rates found in the BOSTID studies (Selwyn 1990) which varied from 0.2 to 8.1 and other studies in developing countries which ranged from 1.1 to 4.9. This result was slightly higher than the 0.5 rate found in a previous study in Rio de Janeiro (Sutmoller & Nascimento 1983). In an outpatient study in a well defined community in Colombia (Berman et al. 1983) estimated 0.48 LRI episodes per 100 children were seen and similar to estimates made in Panama (Ngalikpima 1983). The wide range of incidence rates probably reflect methodological differences, but these rates are higher than observed in developed countries where the rates vary from .06 to 0.17 LRI per 100 child-weeks (0.03 to 0.09 per child year; Pio et al. 1985). Children with no ARI symptoms during the study period represented 28% of the study group. This was lower (18%) in SM community where the children were studied for a longer period. In the other BOSTID studies (Selwyn 1990) the percentage ranged from 5-20%. Average ARI disease duration was less than one week in this study but was slightly longer (<2 weeks) in CZSB community. In a few cases lasted longer than three weeks and the total time ill with ARI (5.8%). This disease duration is similar to those found in the other studies (Selwyn 1990) where disease duration ranged from < 1 week to > 10 weeks, but the total time ill was lower than reported. The shorter disease duration may possibly confirm that guardians did not recognize all ARI symptoms, so ARI episode was finalized sooner. Total disease duration of LRI was 1.2% and compares to 0.3% to 14.4% of observed weeks in the BOSTID studies (Selwyn 1990). Although the incidence rates varied over the study period no clear seasonal pattern was observed for ARI during the two years which concurs with other BOSTID community studies (Selwyn 1990) and the previous study in Rio (Sutmoller, unpublished data). A decrease in IR was observed in the second study year and was also observed in other BOSTID studies. Sex-specific incidence rates for both ARI and LRI were higher for boys. The ARI ratio rate was 1.1 and was similar to the other BOSTID studies (Selwyn 1990, Vathanophas et al. 1990) that showed a predominance of males and an RR value of 1.0-1.1. For LRI the proportion of sick boys was much higher (RR=1.8) and this rate was higher than in other studies where the RR varied from less than 1.0 to 1.4. In the developing countries, studies (Berman et al. 1983, Hortal et al. 1990) done in health care settings, often show higher proportion of males being consulted for ARI. This was also found in hospital component of the present study. Peak incidence of ARI in the 6-11 month age bracket show 8.0 episodes per 100 child-weeks and occurs when most children are weaned, when nutritional deficiencies may commence and the maternal antibodies have decreased. This makes the child susceptible to infections and if associated to other risk factors may make them more susceptible to severe LRI. This was also found in most of the BOSTID studies (Selwyn 1990). For LRI the highest rate was also in the 6-11 month year old bracket (2.9/100 child-weeks) slightly different from most of the BOSTID studies, which showed higher or equal rate in the 0-5 month old, but was similar to the Philippines study. The higher rates in infants was also observed in studies from the developed (Berman & McIntoch 1985) and in developing countries (Tupasi et al. 1990). Good prenatal care, which can possibly avoid premature deliveries, was shown to be important specially to diminish the risk of LRI. Other studies did not mention this as a risk factor but observed the low birth weight. In our study this was also increased for ARI (RR=1.4) and LRI (RR=3.7) in children with very low birth weights (less than 1500 grams). If children under 2500 grams were considered, no difference was found and this is compatible with the findings in the Uruguay study (Hortal et al. 1990). Breast feeding practices are believed by most health professionals to diminish ARI morbidity. In our study the longer breast fed children had a lower ARI incidence rate. Few authors (Grulee et al. 1934, Stevenson 1947, Frank et al. 1982) have investigated morbi-mortality, and although varying in results, they showed a lower incidence in breast fed children. Other studies (Mohs 1983, Barros Filho et al. 1985) showed no clear difference in ARI incidence, but Frank et al. (1982) noted a possible diminished frequency of severe cases in the breast fed children. Vaccination coverage was not and important factor for ARI and compares with the Uruguay study (Hortal et al. 1990) which found no increased ARI risk, but the RR for LRI was 1.5. Diarrhea was observed as a possible risk factor in this study and specially related to LRI. This was also observed in other BOSTID studies and specially in Bangladesh. This may also be an explanation for a possible underestimation of ARI in the SM community where diarrhea disease was very frequent. Guardians of the children know about diarrheal disease through the media coverage (oral rehydration solution, early recognition of dehydration) and its frequency. Undernourishment was associated with a small increased (RR=1.3) risk for ARI in these children but they were not at greater risk for LRI. This is in accordance with the BOSTID studies (Selwyn 1990) that produced variable results. This observation is interesting, as although most pediatricians consider this relationship important, it is not apparent in these studies. It may be that only when the child has a pronounced dystrophy combined with other nutrition related complication such as dehydration, hypovitaminosis may the correlation of increased ARI and LRI become more apparent. Living conditions showed that the children that lived in crowded conditions and having other young children in the home increased the risk of ARI, and corresponds studies of day care settings. Most of the crowding occurred in the apartments of the CZSB and may explain the higher rate encountered. LRI results for crowding was inconclusive but children having other siblings in the home or living in huts had a slightly higher risk. Maternal age was a risk in the very young (<17 years) mothers and was lowest in the 18-25 year old bracket and is comparable with the other BOSTID (Selwyn 1990) studies the mothers under 20 were considered at risk. This could possibly be due to less crowding in these homes. Maternal education level in this study showed no disease incidence and in the BOSTID studies (Selwyn 1990) these findings were inconclusive difference but paternal education level did show a difference (secondary or tertiary level education the RR was 1.4 and increased for LRI to 3.1). Reasons for this need to be studied further. The Brazilian Ministry of Health has a health care program for women (prenatal and obstetrical care) and children (breastfeeding, growth and development follow-up, vaccination, diarrheal diseases and respiratory infections). The RR for LRI for these items are shown in Table VII and it can be observed that the proposed program actions would, in conjunction, possibly decrease the ARI and LRI incidence. An example of this would be the Costa Rica (Mata 1978) experience which made large headway in improving the general condition of life (increased the individual resistance to infectious agents), better coverage of primary health care to the population with diverse but systematic action in the diagnosis, prevention and treatment of infectious diseases and better norms and application of health care in hospitals and health centers with a better institutional health system. This study is relevant for planning future ARI studies and give tools for government agencies to plan efficacious public health programs that can support the UNICEF plans to reduce by half the childhood mortality before the turn of the century.
TABLE 1 Socioeconomic characteristics of the study children registered in the community study on acute respirator), infections - Rio de Janeiro, Brazil
Environmental Community
characteristics Santa Maria Cruzada Sao Sebastiao Total
No. (%) No. (%) value No. (%)
--------------------------------------------------------------
Housing
hut 141 (76) 0 ( - ) 141 (43)
brick house 44 (24) 0 ( - ) 44 (13)
apartament 0 ( - ) 143 (100) 143 (44)
Crowding
< 3 persons/room 80 (48) 30 (21) 110 (61)
> 3 persons/room 88 (52) 111 (79) 191 (63)
Employment of guardians
employed 217 (61) 154 (59) 371 (61)
unemployed 31 (9) 16 (6) 47 (8)
housewife/retired 108 (30) 82 (31) 190 (31)
Other family members
economically active 42 (24) 66 (46) 108 (34)
Family income in
minimum salaries^a
+/< IMS 62(43) 15 (11) 77 (28) 1 - 3 MS
73 (51) 77 (57) 150 (54)
> 3 MS 9 (6) 42 (31 ) 51 (18)
Maternal education
iliterate 85 (52) 14 (11) 99 (34)
primary level 72 (44) 80 (66) 152 (53)
secondary level 7 (4) 28 (23) 35 (12)
university level 1 (1) 2 (2) 3 (1)
--------------------------------------------------------------
a: approximately USS 50.00
TABLE 11
Characteristics of the study children registered in the acute respiratory
infection community study
Child's risk Santa Maria No. (%) Community
factors Cruzada Sao Total
Sebastiao No.(%)
No. (%) value
------------------------------------------------------------
Sex
male 80 (42) 71 (50) 151 (46)
female 109 (58) 71 (50) 180 (54)
Age at first visit
(months)
0-5 30 (19) 16 (13) 46 (17)
6-11 48 (31) 29 (24) 77 (28)
12-23 55 (35) 50 (41) 105 (38)
24-35 20 (13) 24 (20) 44 (16)
36-47 2(-) 3(-) 5(-)
48-59 0(-) 0(-) 0(-)
Age at last visit
(months)
0-5 3(2) 2 (2) 5 (2)
6-11 15 (10) 9 (7) 24 (9)
12-23 30 (19) 22 (18) 52 (19)
24-35 42 (27) 45 (37) 87 (31)
36-47 46 (30) 32 (26) 78 (28)
48-59 19 (12) 12 (10) 31 (11)
Pregnancy
normal gestation 170 (90) 113 (84) 238 (88)
w/prenatal care 151 (80) 122 (90) 273 (85)
at term delivery 171 (92) 109 (80) 280 (87)
vaginal delivery 144 (77) 94 (68) 238 (73)
hospital 181 (96) 136 (99) 317 (97)
Birth weight
< 2.5 kg 30 (16) 21 (15) 51 (16)
2.6 - 4.0 kg 144 (77) 100 (71) 244 (74)
4.0 kg 14 (7) 19 (14) 33 (10)
Birth order
1-2 110 (60) 101 (74) 311 (74)
3-4 40 (22) 30 (22) 70 (17)
> 5 33 (18) 6 (4) 39 (9)
Breastfeeding
only breast 23 (12) 23 (17) 46 (14)
mixed 85 (45) 48 (32) 133 (41)
weened
0-1 months 72 (58) 47 (48) 119 (54)
2-3 months 29 (23) 31 (32) 60 (27)
4-5 months 11 (9) 9 (9) 20 (9)
6-11 months 12 (10) 10 (10) 22 (10)
Vaccines
complete 57 (37) 81 (63) 138 (48)
incomplete 99 (63) 48 (37) 147 (52)
Hospitalizations 33 7 40
diarrhea 13 (39) 3 (43) 16 (40)
respiratory infection 16 (48) 1 (14) 17 (42)
other 4 (12) 3 (43) 7 (18)
Malnutrition
normal 51 (92) 115 (93) 167 (93)
undemourished 4 (8) 8 (7) 12 (7)
TABLE III
Time distribution of surveillance in the acute respiratory
infection community study
Number of weeks Santa Marta Community Cruzada Total
observed No. (%) Silo Sebastiao No. (%)
No. (%) value
----------------------------------------------------------------
01-10 weeks 12 (8) 24 (20) 36 (14)
11- 20 weeks 18 (12) 41 (35) 59 (23)
21- 30 weeks 6 (4) 11 (9) 17 (6)
31- 40 weeks 9 (6) 3(3) 12 (5)
41- 50 weeks 14 (10) 10(8) 24 (9)
51- 60 weeks 12 (8) 13 (11) 25 (10)
61- 70 weeks 4 (3) 10 (8) 14 (5)
71- 80 weeks 6 (4) 6(5) 12 (5)
81- 90 weeks 33 (23) 0(-) 33 (13)
91-100 weeks 30 (21) 0(-) 30 (11)
----------------------------------------------------------
Total 114 118 262
TABLE IV
Incidence rates according to epidemiologic characteristics in the accute
respiratory infection (ARI) community study
Risk Total No. Total No. ARI incid. Total LRI
factor child-weeks ARI epi- rate (100/ No. LRI incid-
sodes ch-wk) episodes ence
of ARI RR rate
(100/ch-wk)
RR
----- ----------- ---------- ----------- ------- -----------
Sex
male 5076 239 4.7 1.1 48 0.95 1.8
female 6570 283 4.3 ... 35 0.53 ...
Age (months)
0-5 317 17 5.4 2.1 2 0.63 1.2
6-11 1003 80 8.0 3.1 15 1.50 2.9
12-23 3634 189 5.2 2.0 31 0.85 1.6
24-35 4400 177 4.0 ... 26 0.59 ...
36-47 1944 50 2.6 ... 6 0.30 ...
48-59 348 9 2.6 ... 3 0.86 ...
Pregnancy
gestation
abnormal 1249 61 4.9 1.1 11 0.88 1.3
normal 10305 456 4.4 ... 71 0.69 ...
prenatal care
no 1249 61 4.9 1.1 11 0.88 1.3
yes 9539 412 4.3 ... 62 0.65 ...
delivery
premature 877 46 5.2 1.2 9 1.03 1.5
at term 10281 449 4.4 ... 71 0.69 ...
Birth weight gr.
<1500 259 16 6.2 1.4 6 2.32 3.7
1600-2400 1202 50 4.2 ... 5 0.42 ...
>-- 2500 9810 428 4.4 ... 65 0.66 ...
Breast feeding^a
2 month 1619 81 5.0 1.2 0 - -
2-3 months 1234 65 5.3 1.3 14 1.13 1.2
4-6 months 1129 48 4.3 ... 11 0.97 ...
7-11 months 505 19 3.8 ... 0 - ...
Vaccines^a
incomplete 5521 272 5.1 1.2 49 0.89 1.5
complete 4660 196 4.2 ... 28 0.60 ...
Nutritional status
malnourished 1083 61 5.6 1.3 8 0.74 1.0
normal 9411 395 4.2 ... 72 0.77 ...
Prev. hospitalized
yes 837 43 5.1 1.2 6 0.72 1.0
no 10614 471 4.4 ... 73 0.69 ...
Diarrheal disease
yes 8846 360 4.1 0.7 75 0.85 2.9
no 2714 159 5.9 ... 8 0.29
Other diseases
yes 6660 248 3.7 0.6 44 0.66 1.0
no 3810 224 5.9 ... 26 0.68
a: status at study entry; ch-wks: child-weeks; RR: relative
risk; LRI: lower respiratory infections
TABLE V
Incidence rates according to environmental characteristics in the accute
respiratory infection (ARI) community study
Risk Total No. Total No. ARI incidence Total LRI incid.
child-weeks of ARI rate(100/ch-wk) No. rate (100/
at risk episodes LRI ch-wk)
RR
----- -------- ------- --------------- ---- ------------
Housing
hut 6438 261 4.0 0.8 50 0.78 1.2
house/apart.
4983 252 5.1 ... 32 0.64 ...
Crowding (persons/room)
3 persons
4869 246 5.1 1.4 31 0.64 0.9
2-3 persons
2265 95 4.2 1.2 23 1.02 1.5
2 persons
3943 143 3.6 ... 27 0.68 ...
Siblings under 5 y
3 others 1244 47 3.8 1.0 0 - ...
2 others 934 59 6.1 1.6 10 1.07 1.4
1 other 3679 188 5.1 1.3 32 0.87 1.1
study child
5695 223 3.9 ... 43 0.76 ...
Family income in
minimum salaries^a
+/< 1 MS 3144 137 4.4 0.9 31 0.99 2.4
1-3 MS 4910 233 4.7 0.9 33 0.67 1.6
3 MS 1189 57 5.0 ... 5 0.42 ...
Maternal age years
17 14 1 7.1 1.4 0 - ...
17-19 1831 59 32 0.6 6 0.33 0.4
20-24 2399 95 4.0 0.8 11 0.46 0.5
25-29 2714 151 5.6 ... 30 1.11 ...
30-34 2050 104 5.1 ... 21 1.02 ...
35-39 1138 52 4.6 ... 21 0.44 ...
40-45 192 8 4.2 ... 0 - ...
Maternal education
=/< prim. level
9257 420 4.5 1.0 37 0.40 0.1
+/> sec. level
1112 52 4.7 ... 37 3.33 ...
Paternal education
=/< prim. level
6495 277 4.3 0.7 38 0.59 0.3
=/> sec. level
1158 68 5.9 ... 21 1.81 ...
a: minimum salarie aprox. USS 50.00; h-wks: child weeks;
R.R: relative risk; LRI: lower respiratory infections
TABLE VI
Comparison of acute respiratory infection incidence
rates in community studies in children less than 5
years age
Author Country ARI LRI
------------------------------------
Selwyn Kenya 12.7 0.4
Nigeria 15.5 ...
Nigeria 15.5
Papua New Guinea
2.6 ...
Phillipines 13.3 3.4
Thailand 27.5 0.2
Colombia 13.2 3.4
Uruguay 15.4 8.1
Guatemala 16.8 0.6
Tupasi Phillipines 5.0-7.7
Mata Costa Riea 12.4 4.9
Gomes Mexico 5.4-5.0) 1.2-1.1
Delgado Guatemala 8.5(3.8) 1.5
Datta India 4.6 ...
Vathanophas
Thailand (4.1)
ARI - acute respiratory infection with Cough or mod-
erate or severe upper respiratory infection
LRI - lower respiratory infection
ACKNOWLEDGMENTSTo Isis GB da Silva, Elizabete AP dos Santos, Lourdes MO Nascimento and Almira G do Nascimento (field workers) and Marcelo P Souza (computer assistant). To Drs Harris Pasitides and Steve Berman for their review and constructive comments of this manuscript. REFERENCES Barros Filho AA, Barbieri MA, Santoro R 1985. Influencia da duração do aleitamento materno na morbidade de lactentes. Bol Oficina San Panameri-cana 99: 594-604. Berman S, Duenas A, Bedoya A, Constain V, Leon S, Borrero I, Murphy J 1983. Acute Lower respiratory tract illnesses in Cali, Colombia: A two year ambulatory study. Pediatrics 71: 210-218. Berman S, McIntoch K 1985. Selective primary health care: strategies for control of disease in the developing world. XXI. Acute Respiratory infections. Rev Infect Dis 7: 674-691. CDC 1987. Center for Disease Control Anthropro-metric Software Package 3.0. Datta N, Kumar V, Kumar L, Singhi S 1982. Application of case management to control of acute respiratory infections in low-birth-weight infants: a feasablity study. Bull WHO 115: 305-314. Delgado HL, Giron EM, Ramirez HL, Hurtado 1988. Epideimiology of acute respiratory infections in preschool children of rural Guatemala. Bull PAHO 22: 383-393. IBGE 1983. Fundacao Instituto Brasileiro de Geografia e Estatistica. Censo Demografico do Rio de Janeiro: Recenseamento geral - 1980, 34 pp. Frank AL, Taber LH, Glezen WP, Kasel GL, Wells CR, Paredes A 1982. Breast Feeding and Respiratory Virus Infection. Pediatrics 70: 239-245. Grulee CG, Standford HN, Harron PH 1934. Breast and artifical feeding. J Am Med Assoc 103: 735-748. Hortal M, Benitez A, Contera M, Etorena P, Montano A, Meny M 1990. A community based study of acute respiratory tract infections in children in Uruguay. Rev Infect Dis 12: s966-s973. IPLANRIO 1983. Instituto de Planejamento do Rio de Janeiro. Cadastro de Favelas, Vol. I, Vol. III., 5 pp. Kamath KR, Feldman RA, Rao PSS 1969. Infection and disease in a group of south Indian families. II: general morbidity patterns in family members. Am J Epidemiol 89: 375-383. Lang T, Lafaix C, Fassin D, Arnaut I, Salmon B, Baudon D, Ezekiel J 1986. Acute respiratory infections: a longitudinal study of 151 children in Burkina-Faso. Int J Epidemiol 15: 553-560. Monto AS, Naspier JA, Metzner HL 1971. The Tecumsch study of respiratory illness. I. Plan of study and observations on syndromes of acute resiratory disease. Am J Epidmiol 94: 269-279. Mohs E 1983. Infecciones respiratorias agudas en Costa Rica, 1965-1980: Prevalencia, gravedad y letalidad. Bol Ofic San Panamericana 94: 535-545. Mata LJ 1978. The children of Santa Maria Cauque. A prospective field study of health and growth. Cambridge, The MIT Press. Ngalikpima VF 1983. Review of respiratory infections in a developing country. Euro J Resp Dis 64: 481-486. Pio A, Leowski J, ten Dam HG 1985. The magnitude of the problem of acute respiratory infections, p. 3-16. In RM Douglas, E Kerby-Eaton (eds). Acute respiratory infections in childhood. Proceedings of an international workshop, University of Adelaide, Sydney, Australia. Sutton RNP 1965. Minor illnesses in Trinidad: a longitudinal study. Trans R Soc Trop Med Hyg 59: 212-220. Selwyn BJ 1990. On behalf of the Coordianted Data group of BOSTID Researchers. The epidemiology of acute respiratory tract infection in young children: Comparison of findings from several developing countries. Rev Infect Dis 12: 870-888. Sutmoller F, Nascimento J 1983. Studies on Acute Respiratory Infections in Brazil. Ped Research 17: 1038-1040. Stevenson SS 1947. Comparison of breast and artifical feeding. J Am Diet Assoc 25: 752-756. Tupasi TE, Velmonte MA, Sanvictores MEG, Abraham I, De Leon LE, Tan SA, Miguel CA, Saniel MC 1990. Determinants of morbidity and mortality due to acute respiratory infections. Implications for interventions. J Infect Dis 157: 615-623. Vathanophas K, Sanfchai R, Raktham S, Pariyanonda A, Thangsuvan J, Bunyaratabhandu P, Athipanyakom S, Suwanjutha S, Jayanetra P, Wasi C, Vorachit M, Puthavathana P 1990. A community based study of acute respiratory infection in Thai children. Rev Infect Dis 12: 957-965. Financial support for this research was provided by the National Academy of Science/National Research Council by means of a grant from the U.S. Agency for International Development. +Corresponding author Received 12 September 1994 Accepted 29 June 1995 Copyright 1995 Fundacao Oswaldo Cruz FIOCRUZ
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