Magnitude and factors associated with upper respiratory tract infection among under-five children in public health institutions of Aksum town, Tigray, Northern Ethiopia: an institutional based cross-sectional study

Introduction upper respiratory tract infection is a leading cause of morbidity among under-five, particularly in the developing countries. Delays in the identification and treatment of under-fives are among the main contributors to the complication. The aim of this study was to assess the magnitude and to identify factors associated with upper respiratory tract infection among under-five children, in public health institutions of Aksum City, Tigray Region, North Ethiopia, 2016. Methods institutional based cross-sectional study was done. Cases were under-five children who had get service. The study participants were selected using Systematic random sampling technique. Data were entered, using Epi-info version 7 and analyzed using SPSS version 22.0. Clinical data from the chart were used to diagnose upper respiratory tract infection types. The binary logistic regression model was used to test the association between dependent and independent variables and multivariable logistic regression was used to identify the associated factors to upper respiratory tract infections. Results out of 213 study participants 52.6% identified as having at least one type of upper respiratory tract infection, i.e. sinusitis 22 (10.3%), 37 (17.4%) otitis media, 39 (18.3%) tonsillitis and common cold 83 (39.0%). Multivariable logistic regression analysis shows that rural residence 7.6 [AOR (95%CI) (2.49, 23.58)], civil servant father's children 4.49 [AOR (95%CI) (1.57, 12.83)], non-immunization 6.0 [AOR(95%CI) (1.38, 26.8)], mud house wall 4.58 [AOR (95%CI) (1.74, 12.0)], rental house 5.1 [AOC (95% CI) (1.82, 14.6] and large family size 5.3 [AOC (95%CI) (2.3, 12.1 )], were found to be statistically associated. Conclusion socioeconomic, maternal and environmental factors had contributed to the upper respiratory tract infection. Strengthening of the existing disease prevention policy as well as improvement of institutional health service behavior is crucial.


Introduction
World Health Organization (WHO) has classified diseases of the respiratory system in the International Classification of Diseases (ICD). Respiratory diseases are categorized according to whether they affect the upper or lower part of the respiratory system [1,2]. Upper respiratory tract infections are the most common and frequently occurring infections in the pediatric population [3]. A strong confirmation for the prevention of the disease is rather inadequate, and thus, the patients take preventive measures on the basis of their own experience or preferences. However, an upper respiratory tract infection is referred to as a viral infection causing inflammation and infection in the nose and throat. Upper respiratory tract infection has been regarded as a nonspecific term that is used to describe acute infections involving the nose, Paranasal sinuses, pharynx, larynx, trachea, and bronchi [4,5]. The common physical factors which can contribute to the infection were urban living area, open waste disposal, exposure to cold, same sickness (URTI) in the family, smoking inside the house and irregular intake of fruits by the child [6]. There is a worldwide increase in antibiotic resistance, largely related to inappropriate use of antibiotics; studies suggest that inappropriate use of antibiotics for upper respiratory tract infection (URTIs) adds to the burden according study in India since 2013 [7].
Childhood upper respiratory tract infections also define as the acute inflammation of nasal or pharyngeal mucosa in the absence of other specifically defined respiratory infection [8]. Housing condition like day care attendance is a well-established risk factor for URTIs in preschool children [9,10]. Uncomplicated URTIs account for 25 million visit to family physicians and under-five children experience six to eight upper respiratory tract infections per year in the United States [11]. Upper respiratory tract infections are common and important, although rarely fatal; they are a source of significant morbidity and carry a considerable economic burden. Each year in the US, $2 billion is spent on over-the-counter preparations to relieve cold symptoms, predominantly in children. Children experience 3-8 colds per year and 10-15% has at least 12 per year, usually associated with overcrowding like attendance at day-care centres or nurseries. In infants, onset is more likely to be associated with a high fever, irritability and nasal obstruction affecting feeding and sleep [12]. A yearly acute upper respiratory infection in underfive children is responsible for an estimated 4.1 million deaths worldwide [13]. Under five years represent about 12% of general population in India, large majority of these children live in rural, tribal areas and in urban slums 30% of the mortality rate shows due to URTIs since 2014 [14]. Upper respiratory tract infections are highly prevalent, especially in children between the ages of two and four years. Children less than six months old are relatively protected against community based respiratory tract infections. The frequency of URTIs increases and becomes high during the second year of a child´s life, and may increase again during childbearing years [15].
Under-five children are risky population to get an upper respiratory tract infection due to lack of immune power. The important risk factor associated with respiratory diseases include malnutrition, low birth weight, climatic variations, overcrowding house, air pollution, poor ventilation and lack of environmental sanitation [16]. The preventive measures of respiratory infections includes hygienic practices related to personal and environmental hygiene, appropriate disposal of respiratory secretions, isolation infected patients, maintenance of nutritional status, immunization to be completed as per schedule and special protection of children during weather variations to prevent cold [17]. In addition prevention and controls of URTI through health education, environmental sanitation, good nutrition and avoid overcrowding is one of the component of primary health care listed since 1978; but this problem is still reported from health facilities. Taking into consideration this study is expected contribute on this problem in the study area as well as Tigray region. Therefore the aim of this study was to assess the magnitude and factors associated with upper respiratory tract infection among under-five children in public health institutions of Aksum town, Tigray, Ethiopia.

Methods
Institutional based cross-sectional study was conducted in Aksum town which is found in the central zone of Tigray located at 1024 km away from Addis Ababa the capital city of Ethiopia as well as 241 km from the capital city of the Tigray region Mekelle since December 2015 up to June 2. The study was carried out among under-five who were attentive to public health institution of the city. The required Sample size was determined using the single population proportion formula. The following assumptions were made during calculating the sample; 95% confidence interval with a 5% margin of error, the expected proportion of upper respiratory tract infection (P) is 30% in Addis Ababa. Monthly estimated total patient flow of health facilities are 480, use correction formula to calculate the final sample size using the following formula, since total population is <10000; nf = 193 By adding 10% Non-Response rate, the total required sample size = 213 The sample size was proportionally distributed to three health institution based on the number of patients. Systematic random sampling technique by dividing the total number of eligible patient (P) by the required sample size(s), the number "K" obtained by dividing P/s=K was used to identify the interval among under-five from the sampling frame. Different K th interval was calculated for each health facility. Finally since the sampling fraction was '2', every 2 th children was included in the study and to select the first child from 480/213 =2 were used.
A structured questionnaire was used and all the variables of interest were assessed accordingly. The questionnaire comprises four parts; sociodemographic and socio-economic factors, child factors, checklist from clinical data and environmental factors. Four diploma nurse data collectors and two BSc nurses supervisors were trained for three days. Initially the questionnaire was prepared in English and it translated to the local language Tigrigna and translated back to English by different individuals to ensure understandability, and check for its consistency. The data was collected for about two months. Participants who were not interested to provide information at the time of data collection was consider as non-response. As a whole data was checked for completeness and after coding for each questionnaire and checklist data was entered into Epi-Info version 7 and the data was cleaned for inconsistencies and missing values and important amendment were done. Final data were exported to window based statistical package for social sciences (SPSS) version 22.0 Odds Ratio at 95% Confidence Interval was used to ascertain the association between dependent and independent variables as appropriate. Bivariate regression analysis was run to assess the association between the dependent and independent variable, then variable which have a P-value of <0.3 was entered to multiple logistic regression analysis to see the independent effect of predictor variables over the outcome variables. During the multivariable analysis the cut-off point for level of significance was P-value < 0.05 from the model. The strength of statically association was measured by adjusted odds ratios and 95% confidence intervals. The goodness of fit the final logistic model was tested by using Hosmer and Lemeshow test at a P-value of > 0.05. The multicollinearity was checked using VIF <2.5/tolerance test near to 1. Finally the result was summarized and presented using text, graph, frequency tables and other summary statistics.
Ethical approval and consent to participate: ethical clearance were secured from the Mekelle University, College of Health Science Institution Review Board (IRB) with IRB Number 21/03/2016. Since the data is from staff Nurses permission from Tigray Regional health bureau (TRHB) and woreda offices was taken. Furthermore, written consent was taken from TRHB officer and verbal consent was agreed by all participants. However, data was recorded anonymously and confidentially
Child-related variables: study subjects were asked about their caretaker of children; one hundred sixty (75.1%) of them had both parents and only 7(3.3%) of them with other guardians. Regarding of their age group 112(52.6%) of them were 6-35 months and 39(18.3%) were less than 6 months old. Two hundred three (95.5%) were delivered in health facilities out of the 171 (80.3%) were normal weight immediately after delivery ( Table 2).

Magnitude and types of upper respiratory tract infections:
this study revealed that from the total respondents, 122 (57.3%) had a history of upper respiratory tract infection, 80 (37.6%) were acquired 1-2 times per year and only 2(0.9%) were above seven times per year. One hundred thirty seven (64.3%) of the children were taken intervention and 78(36.6%) of them were treated by antibiotics. Among the total participants 112 (52.6%) of were presented with at least one type of upper respiratory tract infections. Regarding of upper respiratory tract types rate, sinusitis 22 (10.3%), otitis media 37 (17.4%), tonsillitis 39(18.3%) Figure 1 and common cold 83(39.0%) ( Table 3).
Environmental related factors: all the study subjects were also asked about the living house, 169(79.3%) were non rental house and only 44(20.7%) rental house. One hundred sixty (81.8%) had windows (Table 4).  (Table 5).

Discussion
The purpose of this study was to assess the magnitude and factors associated with upper respiratory tract infection among under-five children in public health institutions of Aksum town. The prevalence of upper respiratory tract infection is clearly recognized and over the years more evident that; it is the most common problem among under-five even in developed countries. In this study, it was found that 52.6% of visited the study participant under-five children were identified as presence of upper respiratory tract infection. This result is higher than a study in Atlanta 24%, (2015) [18]. The difference is due to low economic standard of the population shortage of basic needs like basic sanitation and balance diet. It is also higher than the study conducted In Malaysia 35.8%), 1996 [19]; because of large number of family size and most of the live in rental house. In Uganda 37.4%), (2004) [20]; the difference is due to enough public health professionals create an awareness on prevention and control respiratory infection. But it is less than with the study conducted in Iran Mofid (62%) 2012. The important risk factor associated with respiratory diseases, climatic variations, overcrowding house, air pollution, poor ventilation and lack of environmental sanitation more than Ethiopia; So that, the finding of this study had a good argument back ground and evidence based to find out more or less prevalence rate compared to other studies. In this study the predominant type of respiratory tract infection was common cold (39%), tonsillitis (18.3%), otitis media (17.4%) and sinusitis (10.3%). Although the predominant was common cold; compared with the study conducted in Iraq Mofid this study was relatively smaller since finding were common cold 54%, sinusitis 17.5% but higher than otitis media 8.3% and tonsillitis 5.1% [21]. The possible reason for the predominance could be due to the different species of virus, bacterial infections even normal floral caused infection since immature immunity system of the children.
In this study 80 (37.6%) were infected 1-2 times per year compared with study conducted in America which was 6-8 in a year [18,22]. This may be the health policy of the country and traditionally most people considered as upper respiratory tract infections are self-limited while in developed country like America give value even mild problem of upper respiratory tract infection needed immediate treatment and follow up. In this study residence was found to be a significant factor of upper respiratory tract infection (p< 0.001). The odds having URTI in rural area 7.6 compared to those urban area 7. 6 [21,26]. Which revealed rental house were independent predictors of upper respiratory tract infection. This difference by house could be explained that most of the people living in the area were low economic status; lack of basic sanitation may not focus on the cleaning of room regularly and proper ventilation because of unstable house. This study showed that the odds of URTI in large family size 5.3 compared with small 5.3 [AOR (95%CI) (2.3, 12.1)]. Similar observations are also shown in the studies conducted in Atlanta (2015), Pakistan (1999) and Malaysian family size were significantly associated (1995), [21,27,28]. This may be due to overcrowding is implicated risk factor for acquiring of upper respiratory tract infection exposure with infected individuals day and night time in a single room and spend long.

Conclusion
Based on the findings of the current study, it can be concluded that the majority of respondents, 52.6% identified as having upper respiratory tract infection and most of them were acquired 1-2 times per year. It was found that most of rural residents were acquired upper respiratory tract infection. Civil servant father children's was statistically associated with upper respiratory tract infection. Immunization is one prevention measure of upper respiratory tract infection. Overcrowding were risk factor of upper respiratory tract infection.

Competing interests
The authors declare no competing interests.

Authors' contributions
TZ and HB: Developed the proposal, analyzed data, and wrote the report and the manuscript. TZ: Organized the overall process. GB, HG and MZ: Contributed in proposal writing, data collection and analysis. All authors has checked and accepted the final manuscript.

Acknowledgments
We would like to acknowledge all of Aksum town governmental health facility staff for their kind support and permission in getting references and data about the population's profile. We are also grateful to the Department of Nursing, College of Health Sciences, Mekelle University, and Mekelle, Ethiopia for giving us this opportunity to do this research. Table 1: socio-demographic characteristics of participants attending public health institutions, Aksum town, Northern Ethiopia, 2016(n=213)