MEKELLE UNIVERSITY

COLLEGE OF HEALTH SCIENCE

DEPARTMENT OF NURSING
PREVALENCE OF PNEUMONIA IN UNDER FIVE CHILDREN IN
MEKELLE HEALTH CENTER MEKELLE TOWN TIGRAY ETHIOPIA

A PROPOSAL TO BE SUBMITTED TO THE DEPARTMENT OF

NURSING FOR THE PARITIAL FULFILMENT IN BSC NURSING

Investigators: Negus Mezgebu

Mohammed Awel

Advisor: Tsegalem H|Mariam

(BSC, MSC)
A THESIS PROPOSAL WILL BE SUBMITTED TO MEKELLE UNIVERSITY
COLLEGE OF HEALTH SCIENCES, DEPARTMENT OF NURSING ON PARTIAL
FULFILLMENT OF BSc IN NURSING.
Name of investigator Neguse mezgebu
Mohammed Awel
Address: PHONE 0914779324
0921225218
e-mail nmezgebu@gmail.com

Name of advisor Tsegalem H\Mariam

BSC,MSC
Full title of the research proposal prevalence of pneumonia in under five
children in Mekelle health center
Mekelle town Tigray-Ethiopia

Duration of the project From August - Sep 2015

Study area Mekelle health center Mekelle town
Tigray

Total cost of the project 4774

Address of the investigator Email address:- nmezgebu@gmail.com
Cell phone 0914779324
Acknowledgement

We would like to express our deepest gratitude to our adviser Kahsu for her
valuable help, unreserved guidance and constructive suggestions and comments
from the beginning of the course to the existence of this proposal.

Our genuine thanks also go to Mekelle University College of health science

Department of Nursing for the opportunity given to conduct this study.

We also extend our appreciation to Mekelle University College of health science

central library staff for their cooperation and support for internet use.
Table of Contents
Acknowledgement .......................................................... Error! Bookmark not defined.

Table of Contents .......................................................................................................... 4

Abbreviation /Acronym ................................................................................................ 6

List of tables ................................................................... Error! Bookmark not defined.

Summary ........................................................................ Error! Bookmark not defined.

1. Introduction ................................................................ Error! Bookmark not defined.

1.1. Back ground .......................................................... Error! Bookmark not defined.

1.2 Statement of the problem ........................................ Error! Bookmark not defined.

1.3. Significance of the study........................................ Error! Bookmark not defined.

2.Literature Review ........................................................ Error! Bookmark not defined.

3. Objectives of the study ............................................... Error! Bookmark not defined.

3.1.General objective ................................................... Error! Bookmark not defined.

3.2.Specific objectives .................................................. Error! Bookmark not defined.

4.Methodology and Materials ......................................... Error! Bookmark not defined.

4.1.Study area & period ............................................... Error! Bookmark not defined.

4.2 study design ........................................................... Error! Bookmark not defined.

4.3.Population ............................................................. Error! Bookmark not defined.

4.3.1 Source of population ........................................ Error! Bookmark not defined.

4.3.2 Study population .............................................. Error! Bookmark not defined.

4.4 Inclusion and Exclusion criteria ............................. Error! Bookmark not defined.
 4.4.1Inclusion criteria ............................................... Error! Bookmark not defined.

4.4.2 Exclusion criteria .............................................. Error! Bookmark not defined.

4.5.Sampling Technique and procedures ...................... Error! Bookmark not defined.

4.5.1.Sampling procedure ......................................... Error! Bookmark not defined.

4.6 Sample size and Technique .................................... Error! Bookmark not defined.

4.6. Data collection ...................................................... Error! Bookmark not defined.

4.6.1. Procedure of data collection ............................... Error! Bookmark not defined.

4.7 Data quality assurance ........................................... Error! Bookmark not defined.

4.8. Data management and analysis ............................. Error! Bookmark not defined.

4.9. Study Variables ..................................................... Error! Bookmark not defined.

4.9.1 Independent variable ........................................ Error! Bookmark not defined.

4.9.2.Dependent variable .......................................... Error! Bookmark not defined.

4.10.Operational definition of terms ............................ Error! Bookmark not defined.

4.11. Ethical consideration ........................................... Error! Bookmark not defined.

4.12.Dissemination and utilization ............................... Error! Bookmark not defined.

5.Project work plan ......................................................... Error! Bookmark not defined.

6. Budget ........................................................................ Error! Bookmark not defined.

7. References .................................................................. Error! Bookmark not defined.

Consent form .................................................................. Error! Bookmark not defined.

Dummy Tables ............................................................... Error! Bookmark not defined.

Abbreviation /Acronym

CAP –COMMUNITY AQUIRED PNEUMONIA

ARTI-Acute respiratory tract infection

PCV-pneumococcal polysaccharide vaccine

EDHS-Ethiopia Demographic and Health Survey

UNICEF – United Nation Children’s Fund

WHO - World Health Organization

IMNCI –Integrated management of neonatal and child hood illness

MDG-Millennium development goal

1. INTRODUCTION
1.1 BACK GROUND

Pneumonia is a general term that means inflammation of the lungs. It can affect
one or both of the lungs. If bacteria, a virus, a fungus, or other foreign matter
enters the lungs, the body’s natural immune response produces inflammation in the
affected area. When inflammation occurs in the lungs, fluid and pus (destroyed
white blood cells) can collect and interfere with normal lung function, which is to
provide oxygen to and remove carbon dioxide from the bloodstream.

Pneumonia ranges in severity from mild to severe, and it can be fatal. Very young
children, adults over 65, and patients who have a chronic illness are particularly
vulnerable to pneumonia. In patients who are at increased risk for this condition,
talking with a qualified health care provider about precautions and taking steps to
prevent pneumonia can help reduce the risk.

Incidence and Prevalence of Pneumonia

In the United States, about 3 million cases of pneumonia are reported each year
and about 60,000 people die as a result of the condition. About one-third of
pneumonia cases occur in people over age 65. Approximately 4 out of every 100
children in the United States develop pneumonia each year.

Pneumonia Causes and Risk Factors

There are many different types of pneumonia, and vaccines are available to
protect against some types. The most common types are caused by either a
bacterial or viral infection.
Bacterial pneumonia is usually transmitted from person to person through
coughing or sneezing. However, Legionnaires disease is a type of bacterial
pneumonia that is transmitted by breathing in water vapor contaminated with
Legionella bacteria. This strain of bacteria is sometimes found in the plumbing and
air conditioning systems of large buildings or in poorly maintained hot tubs. This
type of pneumonia does not spread from person to person.

Viruses, such as the influenza (flu) virus and the common cold virus, are the most
common cause of pneumonia in young children and the elderly. Measles and
chickenpox (i.e., varicella-zoster virus) also can develop into pneumonia.

Mycoplasma, which is a group of bacteria, is another type of organism that can

cause pneumonia. Because it is highly contagious, this type usually occurs in older
children and young adults in school or other group settings.

Breathing in (inhaling) dust, contaminated liquids, gases, or even food also can
cause pneumonia. Patients who require assisted breathing and are put on a
ventilator can accidentally inhale food or vomit into the lungs. This kind of
inhalation also occurs in people who pass out from drinking excessive amounts of
alcohol and in patients whose gag reflex is impaired (e.g., due to a brain injury).

People with weakened immune systems, such as patients who have HIV or other
chronic health conditions, and patients who have received an organ transplant, are
at increased risk for pneumonia. Patients with these conditions can develop
pneumonia from viruses that usually do not affect healthy people.

The following medical conditions increase the risk for pneumonia:

 Diabetes
  Emphysema
 Heart disease
 HIV/AIDS
 Sickle-cell disease

Others who are at increased risk include patients who are taking
immunosuppressant drugs, post-operative patients with an impaired ability to
cough or clear the lungs, patients in intensive care units (ICUs) who are on
breathing tubes, patients who have their spleen removed, and patients who are
undergoing chemotherapy.

The following people also are at increased risk for developing pneumonia:

 Adults over 65 years old

 Infants and very young children who have immature immune systems
 People who live in areas with high levels of air pollution
 Farm workers exposed to agricultural chemicals
 Construction workers and workers in industrial settings
 People who work near animals
 People who smoke or are addicted to alcohol

Patients who are at increased risk should talk with a qualified health care provider
about ways to reduce the risk for developing pneumonia.

1.2. STATEMENT OF THE PROBLEM

Pneumonia still constitutes a public health problem in the world, especially in

the developing countries pneumonia is found more among children less than
5 children. Many children do not develop their immunity at this age so they
are prone to different types of diseases especially to pneumonia. The effect of
pneumonia has been shown to be associated with an increased risk of under-
five morbidity and mortality. However, risk factors such as Exposure to indoor
air pollution has 2.3 (1.9-2.7) times increase risk of respiratory infections
(especially lower respiratory tract infections Hence, use of cleaner fuels or
improvised stoves have proven to be the cost-effective interventions to reduce
incidence of indoor air pollution Million deaths study has also reported increasing
prevalence ratio (PR = 1.54 among males, 1.94 among females) of respiratory
infections due to use of solid fuel.

1.3. SIGNIFICANCE OF THE STUDY

Incidence of respiratory infections cannot be reduced without an overall increase in
social and economic development. But enormous evidences have shown various
measures to reduce this disease mortality. Every reduction in death due to ARI
would give an incremental benefit towards achieving the Millennium Development
Goal (MDG 4). Final step towards control of ARI would be commitment to
implement these proven and evidence-based interventions. There is no previous
data about the prevalence of pneumonia in the study area. This study
attempted to assess prevalence of pneumonia in under five years of age at
Mekelle health center.
Information on this regard is necessary to know about the prevalence of
pneumonia so as to guide us towards alleviating the problem with an
appropriate care and this study will also be used as base line data to the study
area.
2. LITERATURE REVIEW
The fourth Millennium Development Goal calls for reducing child mortality by
two-thirds between 1990 and 2015, but about 29,000 children under-five die
worldwide every day, mainly from preventable causes [1, 2]. In 2007, 9.2 million
children died before age five globally. Asia and Africa together accounted for 92
percent of these deaths [3]. Sub-Saharan Africa had average under-five mortality
rate of 172 deaths per 1,000 live births [1}. Ethiopia ranks 27th in under-five
mortality with 119 deaths per 1,000 live births [4] and the prevalence of
pneumonia is 26% as national level. Almost one in every ten babies born in
Ethiopia does not survive to celebrate the first birthday [5]. Pneumonia, diarrhea,
malaria, measles and AIDS accounted for about 50 percent of under-five deaths
globally [1]. These and other neonatal diseases are major causes of death for 85%
of African and 90% of Ethiopian children [6, 7].
Approximately two million children under five die from pneumonia each year,
accounting for nearly one in five children deaths globally [8]. A study done by
Luis Huicho et al identified that pneumonia caused about 20% of all under-five
deaths in Peru [9]. Several studies done in different parts of Ethiopia showed that
pneumonia is major cause of mortality and morbidity among under-five children
(3, 10, 11, 12). A study done in New Delhi slums estimated the overall prevalence
of ARI among under-fives to be around 4.5 percent for a period of one month [13].
Azad found that 21.3% of children less than five years of age in Bangladesh
suffered from ARI during the two weeks preceding the survey [14]. Previous
studies done in Ethiopia showed varied and high levels of the prevalence of
pneumonia among this age group (5, 15, 16, 17]. In developing countries, low
socio-economic status, malnutrition, low birth weight, non-exclusive breastfeeding,
indoor air pollution, crowding, parental smoking, zinc deficiency, mother’s
experience as a caregiver, mother’s age, lack of education in the mother, humid
conditions, high altitude, vitamin A deficiency, birth order and outdoor air
pollution were found as possible risk factors associated with pneumonia among
children [11, 14, 17, 18, 19, 20, 21, 22,23}
In Ethiopia, there are studies showing causes of mortality among children aged
under-five years. However, little is known about the prevalence and determinants
of each cause of mortality. Severity and transmissibility of respiratory tract
infections by major pathogens, limited availability of laboratory diagnostics, and
antibiotic resistance to wide range of drugs makes vaccines as a potential
intervention against ARI. While conventional fatality due to pertussis, diphtheria,
and measles is reduced by routine immunization, infections due to other bacterial
organisms such as H. influenza, Streptococcus pneumonia remains responsible for
major burden of the disease. Despite the proven efficacy of vaccines and assistance
through Global Alliance for Vaccines and Immunization (GAVI), wide scale
implementation is lacking due to non availability of community-based studies to
establish the evidence of ARI/pneumonia due to above organisms.

Reemergence of increasing number of pertussis cases are evident. This has led to
the change in National Immunization Schedule to introduce Diphtheria, Pertussiss
and Tetanus, (DPT-booster) at 5 years of age instead of Diphtheria and Tetanus DT
and raising the upper age limit for DPT vaccine to 7 years of age.[31]

The recent multiyear strategic plan of India gives an opportunity for Indian
children to receive the second dose of measles vaccine. According to this plan,
Measles, Mumps and Rubella (MMR) at 15-18 months of age is suggested in states
with >80% immunization coverage, while catch up campaigns are suggested in
states where less than 80% routine coverage is reported.[31]

For children 6-23 months, two doses of trivalent influenza vaccine is

recommended if country can afford, make it feasible, and cost-effective analysis is
made in favor of vaccination. Children less than 6 months are exempted from
vaccination, but protection of mother during pregnancy is recommended as a
means to protect these young infants. However, for developing countries
appropriate target groups for influenza vaccination is not well-defined.[32]

More than 95% H. influenza infections occur only among children. According to
the recent estimates H. influenza contributes to annual burden of 8.13 million
serious illnesses and 371,000 deaths worldwide.[33] From the first H. influenza
vaccine trial conducted in 1973-74 showed the efficacy of vaccine against all types
of invasive pathogens.[2,34] Conjugated vaccines are shown to be more
immunogenic and less reactogenic.[35] Various vaccine trials reported efficacy in
the range of 98%-100% after three doses of vaccination, in contrast 35%-47% of
the children had low level of immunoglobulin G antibodies against this organism
when they did not receive any booster dose.[36] The estimated overall efficacy for
three doses of Polyribosylribitol Phosphate-Tetanus Conjugate (Hib) Vaccine was
98.1% (95% confidence interval 97.3%-98.7%).[37] Efficacy in infants aged 5-11
months was 99.1%, 12-23 months 97.3%, and 24-35 months 94.7%. This vaccine
not only protects against severe pneumonia but also prevents the colonization,
thereby helping in prevention of disease transmission.[38] In spite of its safety,
efficacy, feasibility to insert in routine immunization schedule and protection
against huge number of avertable deaths most of the developing countries are
hesitant to adopt this mode of intervention. Only impediment factor is cost and fear
of reactions. Despite financial and technical assistance offered by GAVI
introduction of this vaccine in National Immunization Schedule is slow due to
questionable affordability toward long-term commitment. A recent study has shed
some insight into vaccine safety wherein use of 1.25 μg dose of vaccine has given
equivalent sero conversion with less reaction compared to conventional 5 μg doses.
This dose reduction can further reduce cost of vaccination.[3]
Scope for inclusion under National Immunization Schedule: Pneumococcal
infections alone contribute to 11% of all deaths among children under 5 years of
age.[39] Randomized trial reports from nationwide Finish group of children had
proven 100% efficacy of vaccine against vaccine serotypes when the 3 + 1
schedule (6, 10, 14 weeks infant series and 1 year post toddler) was adopted.[40]
Vaccine efficacy against this 2 + 1 schedule was reported to be 92%.[41] Safety
profiles were confirmed from many trials including the recent trial reported from
12 sites in India.[41,42,43] Like Hib vaccines, this also prevents colonization
thereby facilitates the protection against the disease transmission.[44,45] While the
currently available PCV 7 gives protection against only seven serotypes, rest of the
serotypes are left out. Unfortunately, vaccine which covers all 23 serotypes cannot
be used among children under 2 years which is a most vulnerable period to get this
disease. To widen the protection against additional serotypes PCV-13 is suggested.
Trial reports from various countries again confirmed the safety profile and added
protection by PCV13 compared to PCV 7.[42] However, issues on revaccination of
children in 5 years age group remains a challenge. With these scientific evidences,
political commitment toward acceptance for inclusion under routine vaccination is
yet to be achieved.

3. OBJECTIVES
3.1 General objective:
 To assess prevalence of pneumonia in under five in Mekelle Health
center.
3.2 Specific objectives
 To determine the prevalence of pneumonia in under five children in
Mekelle Health center.
4. Methodology

4.1 Study area and period

The study will be conducted at Mekelle health center from August, 2015 to
September 2015. Mekelle is the capital city of Tigray Administrative regional
state. It is located in the north part of Ethiopia approximately783 kilometers from
Addis Ababa. The town is divided into seven sub administrative units; namely
Hawelty, Hadnet, Ayder, Semean, Kedamay weyane, Adihaki, and Quiha. Total
population of the Mekelle town is estimated to be 227; 505. Mekelle has one
referral hospital (Ayder) and three other governmental hospitals which are
Mekelle, Quiha and North command hospitals and six health centers which are
kasech, Mekelle, semen, Adyshimdhun adyha and Lachi health centers.we
randomly select Mekelle health center using lottery method

4.2 Study design

Facility based review of records will be conducted at Mekelle health center from
August, 2015 to September 2015
4.3 Source population
All unde five children who were treated by pneumonia inMekelle health
center in 2007
4.4 Study population
All Unde five years who were treated by pneumonia in Mekelle health center
in 2007.
4.5 Inclusion (eligibility) criteria
• Resident in the study area
• Under five years old
• Given consent to participate
4.6 Exclusion criteria
 Above five years old
4.7 Sample size determination
All under five children who were treated by pneumonia in the past year of
2007ec.
4.8 Data collection instruments/tools:
A structure check list was used to obtain the prevalence of pneumonia in
under five children according to the registration book of under five children.
The check list was developed in English. The data collectors will regularly be
supervised by the principal investigator for proper data collection.before data
collection they are given training how to collect the data.
4.9 Data Processing and Analysis
Data will enter, should be cleaned and edited using SPSS for Dependent
variable frequencies, percentage, mean, range and proportions will be
calculated.
4.10 Data Quality Control
Close follow up by the advisor during data collection process will be done.
4.11 Study variables
I. Independent variables
 Pneumonia in under five children.
II. Dependent variables
• Age
• Residence
• Place of birth
4.12 Ethical clearance
The research proposal will be approved by the Ethical Clearance Committee of
Mekelle University College of health science, department of nursing. Written
permission of the college will be secured in the study and; head of the clinics
will be informed about the objectives of the study. Confidentiality will be
ensured by making the check list anonymous. Personal identification of the
respondents will not be asked and would therefore be strictly anonymous and
Data will be entered as confidential and analyzed the reporting system will be
put secured and in place.
4.13 Plan for dissemination of Findings
Final findings of the study will be submitted to, Mekelle University, college of
health science, department of Nursing. It will be also disseminated to Mekelle
Health center. Finally the thesis will be presented to the department of
nursing.
 5. WORK PLAN:

Months, 2015
July Aug Sep
No. Activities wk wk Wk wk Wk. wk2 wk3 Wk4 Wk 1 Wk 2 Wk3
.1 2 3 4 1
1 Topic selection
Proposal
development and
2
Preparing tools for
data collection
Finalizing the
3
proposal
4 Data collection
Data entry and
5
Analysis
Report writing and
6
finalizing the report
7 Presentation
6. BUDGET

Resources and
Total
activities which needs Item Unit Unit cost Remark
cost
budget
1.Personal cost
1.1cost for 1 x70x3 210
Person each
communication
1.2cost for Person each 1x70x6 420
(Telephone )
Subtotal cost
transportation 630
2. Logistic cost
2.1. Pen 1Pack each 50 x 3 150.00
2.2 pencils Pack each 1.00 x10 10.00
2.3 Printing Print Eachpage 1.00 x 1500
1500
2.4.Clip board each 40 x25 1000.00
Subtotal cost 2660
3.Data collection cost
3.1 per diem for key Person each 3x70x5 1050
student council(s)
Total 4340
Total cost with 10% contingency 4774
: http://www.healthcommunities.com/pneumonia/overview-of-
pneumonia.shtml#sthash.7YrLF2NG.dpuf

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