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Modifiable Risk Factors For Community-Acquired Pneumonia in Children Under 5 Years of Age in Resource-Poor Settings - A Case-Control Study

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Modifiable Risk Factors For Community-Acquired Pneumonia in Children Under 5 Years of Age in Resource-Poor Settings - A Case-Control Study

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Welisson Barbosa
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Tropical Medicine and International Health doi:10.1111/tmi.

13211

volume 24 no 4 pp 484–492 april 2019

Modifiable risk factors for community-acquired pneumonia in


children under 5 years of age in resource-poor settings: a
case–control study
James Samwel Ngocho1, Marien Isa€
ak de Jonge2, Linda Minja3, Gaudencia Alois Olomi4,
Michael Johnson Mahande , Sia Emmanueli Msuya1,5 and Blandina Theophile Mmbaga3
1

1 Institute of Public Health, Kilimanjaro Christian Medical University College, Moshi, Tanzania
2 Section of Pediatric Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
3 Kilimanjaro Clinical Research Institute, Moshi, Tanzania
4 Kilimanjaro Regional Health Management Team, Moshi, Tanzania
5 Community Health Department, Kilimanjaro Christian Medical Centre, Moshi, Tanzania

Abstract objective Despite the availability of vaccines and antibiotics, pneumonia remains the leading cause
of mortality among children under 5 years of age. The objective of this study was to identify
modifiable risk factors for community-acquired pneumonia (CAP) in children under 5 years of age in
a vaccinated population.
methods A case–control study was conducted between January and December 2017. The cases
included children aged 2–59 months with X-ray-confirmed pneumonia, whereas the controls were
children from the community with no history of respiratory infection. A multivariable logistic
regression model was used to determine the modifiable risk factors for CAP.
results A total of 113 children with X-ray-confirmed pneumonia and 350 healthy children were
enrolled in this study. The median ages for the cases and controls were 13.7 (IQR = 7.2–25.3) and
13.4 (IQR = 6.0–24.8) months respectively. One (0.9%) child died after the enrolment. The
independent predictors of CAP included a lack of exclusive breastfeeding for 6 months (aOR = 1.7,
95% CI = 1.0–2.9), underweight (aOR = 2.1, 95% CI = 1.0–4.5), unclean cooking fuel (aOR = 1.8,
95% CI = 1.0–3.3) and low income (aOR = 2.9, 95% CI = 1.6–5.4). No association was found
between vaccination status and CAP.
conclusion In addition to a lack of exclusive breastfeeding, children from families of low-
economic status were at risk of contracting CAP. Since the risk factors are complex, the study results
call for more concerted efforts by and collaboration among the health, agriculture and development
sectors to address mortality caused by CAP.

keywords community-acquired pneumonia, risk factors, children under 5 years of age, Tanzania

indoor air pollution, household crowding, malnutrition,


Introduction
vitamin A deficiency, zinc deficiency, birth order, and
Pneumonia remains the leading preventable cause of mother’s education level [3, 6–9]. Therefore, the higher
death among children under 5 years of age worldwide risk of death due to pneumonia among children in
[1]. In 2016 alone, the disease killed approximately 880 LMICs is not surprising. Other predictors of pneumonia
thousand children and contributed to 16% of all mortal- in children, such as a lack of exclusive breastfeeding,
ity among children under 5 years old [2]. Although pneu- low birth weight, human immunodeficiency virus (HIV)
monia affects children in all regions, the highest infection and incomplete immunisation, have also been
pneumonia-mediated mortality rates are found in low- reported to be common in LMICs [10].
and middle-income countries (LMICs) [3]. Most (82%) In response, similar to other countries, Tanzania has
of these deaths occur in sub-Saharan Africa and South adopted the WHO recommendation of including the
Asia, reflecting an increase from 77% in 2000 [3–5]. pneumococcal conjugate vaccine (PCV) and Haemophilus
Previous investigators have demonstrated a link influenzae type b vaccine (Hib) in the routine national
between pneumonia and poverty-related factors such as immunisation programme [11–13]. In addition, the

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Tropical Medicine and International Health volume 24 no 4 pp 484–492 april 2019

J. S. Ngocho et al. Modifiable risk factors for CAP

rotavirus vaccine for diarrhoea prevention was imple- Procedures


mented during this period [14]. The vaccine may have
Trained research nurses based in these three facilities
indirectly contributed to the reduction in childhood pneu-
reviewed admission logs to identify children with poten-
monia, as diarrhoea is among the known risk factors for
tial pneumonia for enrolment. Cases were defined as hos-
pneumonia [15].
pitalised children aged 2–59 months who met the WHO
Despite the availability of vaccines and antibiotics,
case definition for pneumonia in this age category [21].
the incidence of pneumonia remains high among chil-
Briefly, children under 5 years of age who presented with
dren under 5 years of age, but the reason is unclear.
cough and/or breathing difficulty, fast breathing (ages 2
Up to 15% of hospitalised children in Tanzania have
to <12 months – breathing rate ≥50 breaths per minute,
pneumonia [16], 5–12% of whom have X-ray-con-
and for ages 12–59 months – breathing rate ≥40 breaths
firmed pneumonia [17, 18]. Previously, investigators in
per minute) and/or chest in-drawing, symptoms appearing
Tanzania examined the factors (lack of exclusive
within the last 14 days, and a chest X-ray film with
breastfeeding, undernutrition, type of cooking fuel, low
dense, fluffy consolidation of the entire lung or a portion
birth weight, and mother’s education level, among
of a lobe were considered. Children with wheezing were
others) associated with pneumonia [19]; however, these
excluded from the study, as the presence of this symptom
factors are not static, and the country has recently
signified the likelihood of bronchiolitis rather than pneu-
recorded some improvements in both social and eco-
monia [22]. The focus of this study was community-
nomic indicators [20]. Improvements in living standards
acquired pneumonia (CAP), or pneumonia in patients
and health services have had cumulative effects and
with little contact (not hospitalised or residing in a long-
may have therefore influenced such risk factors. Investi-
term-care facility for ≥14 days before symptom onset)
gating pneumonia risk factors is a potential step
with the healthcare system [23]. To meet the criteria for
towards ending preventable childhood deaths and
CAP, children with recently (within 14 days) reported
attaining sustainable development goal number three:
hospital admission were excluded. The parents of chil-
‘ensuring healthy lives and promoting well-being for all
dren with X-ray-confirmed pneumonia and meeting the
at all ages. Therefore, the current study aimed to
above eligibility criteria were invited to participate after
examine the risk factors associated with pneumonia
they provided consent. Eligible children were enrolled
among children under 5 years of age in the Kilimanjaro
within 48 h post-hospital admission.
region of Tanzania.
After enrolment of cases, controls matching the charac-
teristics (sex and age; 1 month) of the cases were identi-
fied and recruited from the community. Three wards in
Materials and methods Moshi municipality in the same region as the cases were
earmarked as a source of the controls. We obtained a list
Study design and settings
of children under 5 years old from the three wards. Chil-
We conducted a multicentre case–control study between dren matching the characteristics of the cases were ran-
January and December 2017 involving three health facil- domly selected from the list. Street leaders helped the
ities in Moshi municipality, Kilimanjaro region: Kiliman- research team identify houses where these children were
jaro Christian Medical Centre (KCMC), Mawenzi living, and then eligibility screening was conducted. The
Regional Hospital and St. Joseph Designated District controls were healthy children without signs or symptoms
Hospital. KCMC is a zonal consultant and teaching hos- of respiratory tract infection within 28 days preceding
pital that serves more than 15 million people living in the enrolment period as determined by the study physi-
the five regions of northern Tanzania. Mawenzi Regio- cian. Following the enrolment of incident cases, monthly
nal Hospital serves as a regional referral site for more frequency matching was performed. The parents provided
than 1.6 million residents in the seven districts of the written consent for their children’s participation in the
Kilimanjaro region. Furthermore, St. Joseph is a district- study (Figure 1).
designated hospital that serves Moshi municipality resi- The minimum sample size required for a case–control
dents (population over 184 thousand) and neighbouring study was estimated according to the method described
districts. Most children with pneumonia are admitted to by Kirkwood and Sterne [24]. We assumed that 20% of
these facilities, with more severe cases at KCMC and the controls were exposed, with 80% power to detect an
milder cases at St. Joseph. Most pneumonia cases in this odds ratio of 2.0 at a significance level of 5%. The final
setting will end up in these facilities, which was the rea- sample size was 449, with 112 cases and 337 controls
son for their selection. and a ratio of three controls per one case.

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Tropical Medicine and International Health volume 24 no 4 pp 484–492 april 2019

J. S. Ngocho et al. Modifiable risk factors for CAP

Screened Screened
n = 217 n = 387

Excluded:
Excluded:
n = 3 denied consent
n = 7 denied consent
n = 13 not healthy
n = 5 critically ill
n = 12 inappropriate
n = 20 wheezing
age

Clinically diagnosed with Healthy


pneumonia n = 359
n = 185

Excluded from the analysis


Excluded in
n = 60 X-ray not performed
data cleaning
n = 11 no pneumonia
n=9
n = 1 not eligible

X-ray-confirmed CAP Healthy controls


n = 113 included in the analysis
n = 350

Figure 1 Participant screening and enrolment flow diagram.

A brief description of the study aims was provided to without an immunisation card were included in the study
the parents, and a further detailed discussion was held but were excluded from the analysis of birth weight and
with interested parents. In addition to general characteris- vaccination status. Finally, households in which children
tics (e.g. age of the child, sex of the child, age of the par- under 5 years of age shared a bedroom with more than
ent and education level of the parent), the following two other people were considered overcrowded.
explanatory variables were also collected. Breastfeeding After the interviews, weight was measured using a Seca
status was considered, and exclusive breastfeeding was Digital Baby Scale Model 354 (Seca GmbH & Co. KG,
defined according to the WHO recommendation of Hamburg, Germany), and the weight was recorded to the
6 months [25]. Families using gas or electricity to cook nearest 0.1 kg. The weight-for-age Z-score was derived
were considered to use clean cooking fuel, while biomass, from the WHO child growth standards, and underweight
firewood, charcoal and kerosene were considered was defined as a Z-score below 2 SDs [26]. Finally, for
unclean. A prior history of medications used was col- participants with an unknown HIV status, initial HIV
lected, particularly antibiotics and zinc tablets. Vaccina- screening was conducted by SD bioline HIV-1/2 3.0, a
tion status and birth weight were extracted from child lateral flow immunochromatographic assay (SD STAN-
growth monitoring and vaccination cards. Children DARD DIAGNOSTICS, INC. 65, Borahagal-ro,

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Tropical Medicine and International Health volume 24 no 4 pp 484–492 april 2019

J. S. Ngocho et al. Modifiable risk factors for CAP

Giheung-gu, Yongin-si, Gyeonggi-do, Korea), followed by age- and sex-matched healthy controls (Table 1). Half
confirmation with Uni-Gold HIV, a lateral flow (51.6%) of the controls were exclusively breastfed com-
immunochromatographic assay (TRINITY BIOTECH pared to 36.7% of the cases. Approximately one-quarter
PLC, Bray, Co. Wicklow, Ireland). Pre- and post-test (20.7%) of the children with CAP had a low weight per
counselling was offered to all participants’ parents prior age compared with 6.6% of the healthy controls.
to HIV testing. None of the children tested were found to A total of 77 cases (68.1%) were self-referral patients,
be positive; those enrolled in the study who were already with approximately one-quarter (23.9%) of all cases
infected had a known HIV status. Eighty (22.9%) parents given antibiotics at home prior to admission. Most cases
of the controls declined the HIV test, while all cases were (72.6%) had severe CAP, and one (0.9%) patient died in
either tested or had a known HIV status. When compar- the ward.
ing the proportions of HIV status among the cases and According to the bivariate analysis, we found several
controls, those with an unknown HIV status were factors that were significantly associated with CAP
excluded. among children under 5 years of age. These factors
included low birth weight, lack of exclusive breastfeed-
ing, incomplete vaccination and undernutrition (Table 1).
Data analysis
In addition, income-generating activities, type of cooking
Data processing and analysis were performed in STATA fuel, and type of house were significant risk factors for
version 14 (StataCorp. 2016. Stata Statistical Software: CAP (Table 2).
Release 14. College Station, TX, USA: StataCorp LLC). According to the multivariate logistic regression, only a
A logistic regression analysis was carried out to examine lack of exclusive breastfeeding, underweight, unclean
the risk factors associated with CAP. Since the matching cooking fuel and poverty remained significantly associ-
was considered weak, the crude odds ratios (cORs) and ated with CAP (Table 3). Children with CAP had almost
corresponding 95% CIs were calculated using uncondi- twice the odds of not being breastfed exclusively for
tional logistic regression. In the bivariate analysis, factors 6 months compared with healthy control children
with a P-value ≤0.2 were included in the final multivari- (aOR = 1.7, 95% CI = 1.0–2.8). Furthermore, the odds
able model. Additionally, several other variables were of being underweight were 2.5-times higher in children
selected a priori based on previous studies. Collinearity with CAP than in the healthy controls (aOR = 2.5, 95%
was identified between the type of house and income-gen- CI = 1.3–5.1). Additionally, children with CAP were
erating activities; therefore, the model with income-gener- more likely to be from a household that used unclean
ating activities was selected. The final model included cooking fuel compared with the healthy controls
both child characteristics and socio-demographic infor- (aOR = 1.7, 95% CI = 1.0–2.8). Lastly, the odds that
mation. Differences with a P-value <0.05 were considered parents of CAP patients were involved in farming or per-
statistically significant. formed unskilled labour, resulting in a low income, were
three times higher than the odds for parents of healthy
controls (aOR = 3.1, 95% CI = 1.7–5.5).
Ethical consideration
The study was approved by the Kilimanjaro Christian
Discussion
Medical University College Research Ethics Review Com-
mittee under certificate number 948 and the Tanzanian This case–control study examined risk factors for CAP
National Health Research Ethics Committee under certifi- among children under 5 years of age in a resource-limited
cate NIMR/HQ/R.8a/Vol.IX/2422. The participants’ par- setting. The main findings of this study support some of
ents or legal guardians were fully informed of the risks the WHO/UNICEF pneumonia risk factors in children,
and the benefits of participating in the study and under- which include lack of exclusive breastfeeding, poor nutri-
stood that participation was voluntary. Before enrolment, tion, indoor air pollution, and poverty. However, some
the parents or legal guardians of the eligible children of the factors previously reported to influence the risk of
signed a written consent form. developing CAP, such as lack of immunisation and over-
crowding, were not found to play a significant role. The
use of antibiotics and zinc tablets offered significant pro-
Results
tection against CAP.
A total of 463 children between 2 and 59 months of age Consistent with previous knowledge from a systematic
were eligible and were enrolled in this study, 113 of review [27], we found that a lack of exclusive breastfeed-
whom had X-ray-confirmed pneumonia, and 350 were ing for at least the first 6 months of life was associated

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Tropical Medicine and International Health volume 24 no 4 pp 484–492 april 2019

J. S. Ngocho et al. Modifiable risk factors for CAP

Table 1 Distribution of the child-related factors and bivariate analysis for the risk of acquiring community-acquired pneumonia (CAP;
n = 463)

Case (n = 113) Control (n = 350)


Variable n (%) n (%) cOR (95% CI) P-value

Age in months* 13.7 (7.2–25.3) 13.4 (6.0–25.0) 1.0 (0.98–1.0) 0.618


Sex
Male 66 (58.4) 207 (59.1) 1.0 (0.6–1.5) 0.890
Female 47 (41.6) 143 (40.9)
Birth weight (kg)
<2.5 17 (15.2) 25 (7.1) 2.3 (1.2–4.5) 0.012
≥2.5 95 (84.8) 325 (92.9)
Exclusive breastfeeding (n = 450)
Yes 40 (36.7) 176 (51.6)
No 69 (63.3) 165 (48.4) 1.8 (1.2–2.9) 0.007
Continued breastfeeding* 15.5 (9–20) 18 (12–24) 0.9 (0.9–1.0) 0.075
Attending day care/school (n = 440)
Yes 13 (11.7) 21 (6.4) 1.9 (0.9–4.0) 0.073
No 98 (88.3) 308 (93.6)
Completed immunisation (n = 460)
Yes 97 (87.4) 328 (94.0)
No 14 (12.6) 21 (6.0) 2.2 (1.1–4.6) 0.025
WAZ score (n = 445)
Underweight 23 (20.7) 22 (6.6) 3.5 (1.9–6.9) <0.001
Normal 82 (73.9) 278 (83.2)
Overweight 6 (5.4) 34 (10.2) 0.6 (0.2–1.5) 0.264
HIV status (n = 382)
Negative 111 (99.1) 268 (99.3)
Positive 1 (0.9) 2 (0.7) 1.2 (0.1–13.4) 0.878
Prior use of antibiotics/Pedzinc (n = 441)
Yes 8 (7.1) 42 (12.8) 0.5 (0.2–1.1) 0.110
No 104 (92.9) 287 (87.2)

CI, confidence interval; cOR, crude odds ratio; Pedzinc, zinc tablet; WAZ score, weight-for-age Z-score.
*Variables expressed as the median (IQR).

with CAP in this population. Available evidence suggests Children with undernutrition have impaired immune
that exclusive breastfeeding offers protection against gas- function, which predisposes them to persistent and recur-
trointestinal infection and pneumonia [28]. This protec- rent colonisation and subsequent pneumonia infection;
tion arises through the transfer of immunoglobulins, however, infections also predispose children to malnutri-
primarily IgA, to the mucosal surfaces of the child [29]; tion [33]. This concept of reverse causality is unlikely in
since IgA is the predominant immunoglobulin in the lung our study because of the short duration of illness (a med-
mucosa, it is part of the first-line response to infection ian of 3 days), suggesting that being underweight pre-
[30]. Children not exclusively breastfed for 6 months are ceded CAP infection. These children are not only more
more likely to be vulnerable to respiratory tract infections vulnerable to the development of pneumonia but also at
due to a lack of sufficient mucosal immunoglobulins [31]. risk for other infectious diseases, such as gastrointestinal
Most women feeding other foods to their infants before tract infection and tuberculosis [33]. More importantly,
the recommended 6 months believe that breast milk is malnutrition impacts growth and development, especially
not sufficient for older infants [32]. This finding reflects in younger children [34]. While several risk factors lead
the need for improved health education and awareness of to undernutrition in children, poverty tends to predomi-
the importance of exclusive breastfeeding and the need to nate [35]. Since undernutrition in children is complex,
address community myths surrounding this subject. holistic approaches are likely to produce good outcomes.
In this study, underweight children had a higher risk of As mentioned previously, the association found
CAP, which is consistent with available evidence demon- between the income of the parents and CAP is not sur-
strating a link between malnutrition and CAP [33]. prising. In this study, the income-generating activities of

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Tropical Medicine and International Health volume 24 no 4 pp 484–492 april 2019

J. S. Ngocho et al. Modifiable risk factors for CAP

Table 2 Bivariate analysis of socio-economic, demographic and environmental risk factors for community-acquired pneumonia (CAP)
among children under 5 years of age (n = 463)

Cases (n = 113) Controls (n = 350)


Variable n (%) n (%) cOR (95% CI) P-value

Age of mother in years* 29 (24–35) 28 (24–33) 1.0 (0.98–1.04) 0.377


Marital status (n = 457)
Married 95 (84.1) 289 (84.0)
Single 18 (15.9) 55 (16.0) 1.0 (0.5–1.8) 0.988
Level of education of mother (n = 457)
Primary education 47 (41.6) 173 (50.3) 0.7 (0.4–1.1) 0.109
Secondary and above 66 (58.4) 171 (49.7)
Income activities (n = 447)
None 22 (20.2) 80 (23.7) 1.2 (0.7–2.1) 0.538
Employed/business 50 (45.9) 217 (64.2)
Farming 37 (33.9) 41 (12.1) 3.9 (2.3–6.7) <0.001
Medical insurance (n = 460)
Yes 22 (19.6) 71 (20.6)
No 90 (80.4) 277 (79.4) 1.0 (0.6–1.8) 0.862
Household crowding (n = 458)
No 44 (38.9) 122 (35.4)
Yes 69 (61.1) 223 (64.6) 0.8 (0.5–1.3) 0.493
Other children under 5 years of age (n = 454)
0 74 (66.1) 252 (73.7)
≥1 38 (33.9) 90 (26.3) 1.4 (0.9–2.3) 0.121
Smoking by household members (n = 452)
Yes 7 (6.2) 39 (11.5) 0.5 (0.2–1.2) 0.112
No 106 (93.8) 300 (88.5)
Cooking fuel (n = 454)
Clean 32 (28.8) 154 (44.8)
Unclean 79 (71.2) 189 (55.1) 2.0 (1.3–3.2) 0.003
Type of house (n = 458)
Formal 102 (90.3) 337 (97.7)
Informal 11 (9.7) 8 (2.3) 4.5 (1.8–11.6) 0.002
Baby sharing bed (n = 459)
Yes 109 (97.3) 339 (97.4) 0.8 (0.2–3.3) 0.823
No 3 (2.7) 8 (2.3)

CI, confidence interval; cOR, crude odds ratio.


*Variables expressed as the median (IQR).

the parents were linked to other environmental risk fac- especially those of a younger age, tend to be more exposed
tors for pneumonia. Parents who were less educated were because they are carried by or on the back of their mothers
more likely to be involved in small-scale farming and during the preparation of the family’s food [38]. This contin-
unskilled labour compared to those with a high level of uous and longer exposure to polluted air results in impaired
education. These parents have limited resources to sustain pulmonary alveolar macrophages and epithelial cells [39].
their families; therefore, they ultimately live in houses These findings are consistent with the current body of
with poor ventilation and use unclean cooking fuels. knowledge supporting the association between unclean
Additionally, with food insecurity in the family, these cooking fuel and childhood pneumonia [6, 8]. The use of
children are likely to suffer poor nutrition, which is a clean cooking fuel has not yet received substantial attention
potential risk factor for pneumonia. Consistent with our in the health sector, especially in Tanzania. However, there
findings, several previous studies have reported an associ- are several efforts advocating the use of clean energy as a
ation between family income and the risk of pneumonia strategy to combat climate change. These efforts have a mul-
in children [36, 37]. tiplier effect, including a reduced risk of pneumonia.
Lastly, the use of unclean cooking fuel was the main con- The above-mentioned risk factors for childhood pneu-
tributor to indoor air pollution in the resource-limited set- monia have been suggested to have decreased [40],
tings of this study and increased the risk of CAP. Children, although the trend is different in this resource-poor

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Tropical Medicine and International Health volume 24 no 4 pp 484–492 april 2019

J. S. Ngocho et al. Modifiable risk factors for CAP

Table 3 Multivariate analysis of risk factors associated with community-acquired pneumonia (CAP) among children under 5 years of
age

First model Final model

Variable aOR (95% CI) P-value aOR (95% CI) P-value

Age in months 1.0 (0.98–1.01) 0.673


Sex
Male 1.1 (0.6–1.8) 0.708
Female
Birth weight
<2.5 2.2 (1.0–4.9) 0.056
≥2.5 1
Exclusive BF
Yes 1
No 1.7 (1.0–2.9) 0.038 1.7 (1.0–2.8) 0.039
Completed immunisation
Yes 1
No 1.7 (0.7–4.0) 0.229
Prior antibiotics/zinc tablets
Yes 0.4 (0.1–0.9) 0.036 0.4 (0.2–1.0) 0.056
No 1
WAZ
Underweight 2.1 (1.0–4.5) 0.046 2.5 (1.3–5.1) 0.009
Normal 1
Overweight 0.6 (0.2–1.5) 0.277 0.5 (0.2–1.4) 0.224
Income activities
None 1.0 (0.5–1.8) 0.656 1.0 (0.6–1.9) 0.889
Employed/business 1
Farming/unskilled employment 2.9 (1.6–5.4) 0.001 3.1 (1.7–5.5) <0.001
Cooking fuel
Clean 1
Unclean 1.8 (1.0–3.3) 0.043 1.7 (1.0–2.8) 0.046
Other children under 5 years of age at home
Yes 1.3 (0.8–2.3) 0.271
No 1
Education of parent/guardian
Primary or lower 1.0 (0.6–1.8) 0.934
Secondary or higher 1
Cigarette smoking
Yes 0.4 (0.2–1.0) 0.050
No 1

aOR, adjusted odds ratio; CI, confidence interval.

setting, and a lack of exclusive breastfeeding, indoor air proportion of children had not completed vaccinations
pollution, and malnutrition are the key pneumonia risk per their age. Additionally, with this high-vaccine cover-
factors. The pooled global estimates sometimes mask dis- age, herd immunity is possible for unvaccinated chil-
parities between regions. Therefore, continued monitoring dren. Evidence from numerous studies shows that the
of improvements in nutrition and living standards in dif- PCV offers protection even to unvaccinated children
ferent regions is warranted. [41–43].
Notably, some of the known risk factors for CAP, such Lastly, no significant association was found between
as immunisation and parental cigarette smoking, were parental smoking and the risk of CAP. This finding dif-
not found to be significantly associated with pneumonia fers from that of a recent review that found that parental
in this population. Several factors might have contributed smoking was a strong predictor of lower respiratory tract
to these conflicting findings, such as the high vaccination infection [44]; however, in this population, only a small
coverage in the population. For example, only a small proportion of parents were smokers.

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Tropical Medicine and International Health volume 24 no 4 pp 484–492 april 2019

J. S. Ngocho et al. Modifiable risk factors for CAP

The most important strength of this study is that inci- Exchange Service (DAAD). The funding bodies had no
dent cases were used, and all cases were confirmed by X- role in the design of the study, collection, analysis, and
ray, thus preventing the inclusion of non-pneumonia interpretation of the data or in writing the manuscript.
cases with infection-related respiratory tract diseases. Sec-
ond, the enrolled cases were derived from different types
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Corresponding Author James Samwel Ngocho, Institute of Public Health, Kilimanjaro Christian Medical University College,
Box 2240 Moshi, Tanzania. E-mail: [email protected]

492 © 2019 John Wiley & Sons Ltd

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