Prevalence and factors associated with acute respiratory infection among under-five children in selected tertiary hospitals of Kathmandu Valley.

BACKGROUND: Acute respiratory infection (ARI) is responsible for about 30-50 percent of visits to health facilities and for about 20-30 percent of admissions to hospitals in Nepal for children under 5 years old. Incidence of ARI in children among under-five years of age is 344 per 1000 in Nepal. Hence, the study aims to find out the prevalence and factors associated with acute respiratory infection among under-five children.
METHODS: A cross-sectional study was conducted at Nepal Medical College and Teaching Hospital and International Friendship Children's Hospital (IFCH) in Kathmandu among children of age 2-59 months attending Pediatric OPD. A total of 286 children were selected using the non-probability (convenient) sampling technique. Data were collected using pre-tested semi-structured tool through interview schedule, and descriptive and inferential statistical analyses were used.
RESULTS: Out of 286 children, more than half of children (60.8%) had Acute Respiratory Infection (ARI). Nearly one-fifth of the children had severe or very severe pneumonia. Acute respiratory infection was significantly associated with religion followed by the family (p = 0.009, OR = 4.59 CI = 1.47-14.36), presence of the child in the kitchen while cooking (p = 0.001, OR = 2.03 CI = 1.17-3.51), and presence of respiratory tract infection in family (p = <0.001 OR = 2.83 CI = 1.59-5.05).
CONCLUSION: The study concluded that male children are more susceptible to acute respiratory infection than female children. Parents and family members should be aware of the prevention of acute respiratory infection by addressing and minimizing the factors contributing to ARI.

Introduction

Acute respiratory infections (ARIs) are infections of the airways from nostrils to the alveoli. ARIs can be categorized as upper respiratory tract infections (URIs) or lower respiratory tract infections (LRIs) [1]. Acute respiratory infection poses a major challenge to the health system, especially in developing countries and is the leading cause of mortality and morbidity among children under five years [2, 3].

According to the World Health Organization (WHO), respiratory infections account for 6% of the total global disease burden. Around 6.6 million, under-five aged children years of age die each year worldwide; 95 percent of them belong to low-income countries and one third of the total deaths is due to ARI [4]. It is estimated that Bangladesh, India, Indonesia and Nepal together account for 40% of the global ARI mortality. ARI is responsible for about 30–50% of visits to health facilities and for about 20–40% of admissions to hospitals for under-five children [3].

The Nepal Demographic and Health Survey (NDHS) 2016 revealed that 31% of the causes of neonatal mortality in Nepal were respiratory and cardiovascular disorders [5]. In fiscal year 2074/75, a total of 17, 50, 668 ARI cases among under-five were registered in Nepal, out of which 10.5% were categorized as pneumonia cases and 0.29% were severe pneumonia cases. ARI case fatality rate per thousand for under-five children at the health facility is 0.05 in Nepal [6].

Acute respiratory infection is linked to various modifiable risk factors including demographic, environmental, socio-economic, and nutritional factors [7]. Many studies have shown that comorbid illnesses especially HIV, malnutrition, prematurity or measles, family history of ARI, low socioeconomic status, inappropriate weaning time, pallor, severe malnutrition and cooking fuel other than liquefied petroleum gas, indoor air pollution, maternal illiteracy, parental smoking behavior male gender, rural residency and overcrowding associated with ARI [2, 7–9]. If the associated modifiable risk factors could be modified and/or avoided through the implementation of various intervention strategies then, the disease burden in the community could be reduced [7].

Despite the burden of acute respiratory infection on morbidity and mortality in children under-five children in the world, there is limited data to evaluate the problem in Nepal. The availability of data on the prevalence and risk factors of ARIs is vital because achieving Sustainable Development Goal on improving health and wellbeing will depend on the existing efforts to prevent and control ARIs in all WHO regions. Many socio-cultural, demographic, and environmental risk factors predispose children less than 5 years to acquire Respiratory Tract Infections (RTIs) [4].

Thus, this study aims to determine the prevalence and factors associated with acute respiratory infection among under-five children in selected tertiary hospitals of Kathmandu Valley.

Materials and methods

Aim, design, and setting

A cross sectional study was carried to assess the prevalence of Acute Respiratory Infection (ARI) and to identify the factors associated with ARI at two tertiary level hospitals of Kathmandu Valley; Nepal Medical College Teaching Hospital and International Friendship Children’s Hospital.

Study participants

Children attending the Pediatric Out Patient Department (OPD) of Nepal Medical College Teaching Hospital and International Friendship Children’s Hospital were selected as study participants. The inclusion criteria included: children aged ≥2–59 months visiting the hospital OPD for either respiratory or any other problems. The exclusion criteria were; children with clinically diagnosed bronchial asthma (history of repeated episodes of wheeze with rapid response to bronchodilator and children with any co-morbidity or any other physical and/or intellectual disabilities.

Sampling technique and sample size

A convenient sampling technique was adopted for this study. A similar study conducted in Gorkha Municipality of Nepal reported the overall prevalence of ARI to be 21.5% [10]. So, using this prevalence with an allowable error of 5% at a confidence level of 95%, the sample size was estimated to be 286 participants after adding a non-response rate of 10%.

Instruments

Pretested semi-structured questionnaire was used which was developed after extensive literature review and consulting with subject expert.

The tool was translated into Nepali language and back translated into English; then Nepali version of tool was pretested among 29 participants (10.14% of the total participants) for validation before the final administration. The reliability of the tool was calculated using Cronbach’s alpha, which was 0.85.

The research instrument consists of the following parts:

Part I: Socio-demographic characteristics of the child’s family

It includes information as age of the attendee, gender of the attendee, caste/ethnicity and religion of children’s family; information on the type of family, family size, and socio-economic status (as per modified Kuppuswamy scale) [11].

Part II: Environmental Characteristics

It includes information as the type of house, number of family members per room, cross-ventilation, place of cooking, presence of a child in kitchen while cooking and history of smoking in a family within the living areas.

Part III: Child related Information

It includes information on child as age and sex of the child, birth status, birth weight, anthropometric measurement (height and weight), exclusive breast-feeding, the month of weaning, and immunization status

Part IV: Prevalence of ARI

The prevalence of ARI was assessed using revised WHO classification of childhood pneumonia at health facilities [12] which is classified as no pneumonia, pneumonia and severe or very severe pneumonia where, children with cough and cold were classified as no pneumonia, children with fast breathing and/or chest wall indrawing were classified as pneumonia, and children with cough and difficult breathing and/or chest wall indrawing and presence of general danger signs, such as history of convulsions, inability to feed, incessant vomiting and lethargy or unconsciousness were classified as severe or very severe pneumonia.

Variables under the study

Dependent variable: Acute Respiratory Infection (ARI). Independent variables: age and sex of the child, birth status, birth weight, caste/ethnicity, religion, type of family, family size and socio-economic status, type of house, number of family member per room, cross-ventilation, place of cooking, presence of child in kitchen while cooking, history of smoking in family, exclusive breast-feeding, month of weaning, immunization status and nutritional status

Procedure of data collection

The data was collected from March, 2019 to June, 2019 in the OPD of Nepal Medical College Teaching Hospital and International Friendship Children’s Hospital through interview schedule after obtaining formal permission from the respective hospitals. The attendees of the children were asked about the general information about the child and child’s family. The attendees were either mother or father of the child. The procedure and purpose of the study were explained to the attendees and were recruited based on inclusion and exclusion criteria. Those willing to participate were interviewed in the waiting area of OPD. Informed consent was read to the attendees and once signed, a face to face interview was conducted using the pretested semi-structured questionnaires by the researchers themselves. After obtaining general information, anthropometric measurement i.e. height and weight of the child was taken and finally the child was assessed for the presence of ARI as per WHO criteria. Children were recruited until the sample size was met.

Data management and statistical analysis

The collected data was entered into Microsoft Excel and coded with alphanumerical codes which were finally converted into Statistical Package for Social Sciences (SPSS) for statistical analysis. Continuous variables were categorized using their mean value. Bi-variate analysis (Simple Logistic regression) was used to show relationship between the categorical variables. Variables which had p<0.2 were subsequently put on stepwise multiple logistic regression model to determine the significant independent risk factor of ARI.

Ethical consideration

The study was approved by the Institutional Review Committee of Nepal Medical College. Permission for data collection was obtained from the Hospital Director and Head of the Department of Pediatric OPD of the respective hospitals. Written informed consent was taken from the parent (Mother or Father) of children attending pediatric OPD prior to data collection and all the information were kept confidential.

Results

A total of 286 children were recruited in the study. Interview was carried with the parents, of which most of them were mothers or fathers of the child, while some of them were caregivers. More than half of the children (64%) were aged 24 months and above and relatively similar percentage of the children (62.2%) were male, 11.5% of the child were born preterm while 7.3% them were child with low birth weight. Regarding nutritional status, most of the children (97.9%) were of normal nutritional status and 60.5% of the children were exclusively breastfed. More than half of the children (59.4%) were weaned after six months of age while, most of them (96.2%) had completed immunization as per their age. Majority of the children’s family (73.4%) followed Hindu religion and more than 3/4th of the children belong to middle class family. Majority (86%) of the children lived in pucca house, 24.1% lived in over-crowded house and 23.1% had poor ventilation in their house. More than one fourth of the family had their kitchen within living room or same room, 54.2% of the children were carried on back by their mother during cooking and 32.2% of the children’s family member were involved in smoking.

More than half of the children (60.8%) of the children were found to be have acute respiratory infection including 14.3% being diagnosed as severe or very severe pneumonia. [Table 1]

Table 1

Prevalence of ARI.

n = 286.

Characteristics	Frequency(n)	Percentage (%)
No pneumonia	87	30.4
Pneumonia	46	16.1
Severe or very severe pneumonia	41	14.3
Overall prevalence of ARI	174	60.8

Bivariate analysis of the factors shows that the variables like religion followed by the family, presence of child in the kitchen while cooking and presence of respiratory tract infection were significantly associated with ARI. [Table 2]

Table 2

Bivariate analysis of the factors associated with ARI.

n = 286.

Variable	Total	ARI present	ARI absent	p-value	Unadjusted Odds Ratio with 95% C. I.
Age of the child
≤24 months	183	114	69	0.502	0.85 (0.52–1.38)
>24 months	103	60	43
Sex of the child
Male	178	111	67	0.499	0.85 (0.52–1.38)
Female	108	63	45
Birth weight of the child
Normal or above	265	163	102	0.412	0.69 (0.28–1.68)
Low birth weight	21	11	10
Birth status of the child
Term	253	155	98	0.683	1.17 (0.56–2.43)
Pre-term	33	19	14
Immunization status of the child
Complete as per age	275	168	107	0.664	0.76 (0.23–2.57)
Incomplete as per age	11	6	5
Nutritional status (W/A)
Normal	280	172	108	0.185	0.31 (0.06–1.74)
Under-nutrition	6	2	4
Exclusive Breastfeeding
Exclusively breastfed	173	101	72	0.293	1.30 (0.79–2.12)
Non-exclusively breastfed	113	73	40
Month of weaning
After six months	170	98	72	0.181	1.39 (0.86–2.28)
Before six months	116	76	40
Number of siblings
≤1	183	117	66	0.154	0.69 (0.43–1.14)
>1	103	57	46
Religion followed by family
Hindu	210	127	83	0.047*
Buddhist	59	41	18	0.050	2.81 (0.99–7.88)
Others	17	6	11	0.014*	4.18 (1.34–13.04)
Type of family
Nuclear	142	91	51	0.265	0.76 (0.47–1.23)
Joint or extended	144	83	61
Educational status of the mother
Iliiterate	13	8	5	0.802	0.96 (0.69–1.33)
Literate	273	166	107
Educational status of the father
Illiterate	6	4	2	0.968	1.01 (0.71–1.43)
Literate	280	170	110
Occupational status of the mother
Unemployed	223	135	88	0.884	1.06 (0.59–1.88)
Employed	63	39	24
Occupational status of the father
Unemployed	10	5	5	0.254	1.30 (0.83–2.05)
Employed	276	169	107
Socio-economic status of the family
Upper class	20	15	5	0.260	0.75 (0.45–1.24)
Middle class	219	132	87
Lower class	47	27	20
Type of house
Kutcha and semi-pucca	40	24	16	0.907	1.04 (0.53–2.06)
Pucca	246	150	96
Place of cooking (Kitchen)
Within bedroom or sitting room	74	49	25	0.272	0.73 (0.42–1.28)
Separated	212	125	87
Type of cooking fuel used
LPG	226	164	102	0.307	0.62 (0.25–1.55)
Firewood and others	20	10	10
Presence of the child in kitchen while cooking
Yes	155	108	47	0.001*	0.44 (0.27–0.72)
No	131	66	65
Parental smoking
Yes	92	57	35	0.790	0.93 (0.56–1.55)
No	194	77	117
Adequacy of cross-ventilation
Adequate	220	129	91	0.165	1.51 (0.84–2.71)
Inadequate	66	45	21
Over-crowding
Yes	69	45	24	0.393	0.78 (0.44–1.38)
No	217	129	88
Presence of RTI in family
Yes	100	77	23	<0.001*	3.07 (1.78–5.31)
No	186	97	89
Presence of RTI in siblings
Yes	60	39	21	0.458	0.79 (0.44–1.45)
No	226	135	91

(RTI = Respiratory Tract Infection; W/A = Weight per Age of the child)

*p-value significant at 95%

Table 3 shows the multivariable model where the variables significantly associated were religion, presence of the child in kitchen while cooking and presence of RTI in family. From the odds ratio evaluation, the odds of having ARI among Buddhist and others were higher (4.59 times and 6.12 times respectively) than the Hindu. The probability of ARI was 2.83 times higher among the children whose family members had history of RTI. Similarly, the probability of ARI was double in the children if they were present inside kitchen while cooking. [Table 3]

Table 3

Multivariate analysis of the factors associated with ARI.

n = 286.

Variables	β Coefficient	p-value	Odds Ratio with 95% C. I.
Religion
Hindu		0.016	Ref
Buddhist	1.526	0.009	4.59 (1.47–14.36)
Others	1.812	0.004	6.12 (1.77–21.15)
Number of siblings
≤1			Ref
>1	0.429	0.119	1.54 (0.89–2.63)
Presence of RTI in family
No			Ref
Yes	1.042	<0.001	2.83 (1.59–5.05)
Adequacy of cross-ventilation
Inadeqaute			Ref
Adequate	-0.146	0.665	0.86 (0.45–1.68)
Presence of the child in kitchen while cooking
No			Ref
Yes	0.71	0.012	2.03 (1.17–3.51)
Month at weaning
Six months or before			Ref
After six months	-0.344	0.204	0.71 (0.42–1.21)
Nutritional Status
Normal			Ref
Underweight or overweight	0.905	0.371	2.47 (0.34–17.95)

Discussion

Prevalence of Acute Respiratory Infection (ARI)

The overall prevalence of ARI was 60.8%. The finding of this study is higher than the national data i.e. 2% of under-five children are affected with ARI in Nepal [13]. The prevalence is also higher than a study done in Gorkha Municipality, Nepal which showed 21.5% prevalence of ARI among under-five children [10]. While, one of the study conducted in Pokhara, Nepal showed 63% of the under-five children had ARI which is higher than the prevalence of current study [14]. Various studies conducted in India found lower prevalence (22%-52%) of ARI [7–8, 15–19]. On the contrary, study done in Shivrajpur, India showed higher prevalence i.e. 79.02% than the current study [3]. The findings are also higher than the studies done in Cameron (54.7%), Ethiopia (27.3%-33.5%) and Swat (29%) [4, 20–22].

Among the children who had symptoms of ARI, half of them had no pneumonia, 26.44% had pneumonia and 23.56% had severe or very severe pneumonia, while one of the study done in India found pneumonia among 23.3%, severe pneumonia among 47.7% and very severe pneumonia among 29% of the children and the study carried out in Cameron found 59% prevalence of no pneumonia, 25% pneumonia and 16% severe pneumonia [4, 7].

Factors associated with ARI among under-five children

The multivariate analysis showed, the variables significantly associated were again religion, presence of the child in kitchen while cooking and presence of RTI in family. From the odds ratio evaluation, the odds of having ARI among children following Buddhism and others were higher (p = 0.009, OR = 4.59 CI = 1.47–14.36) and (p = 0.004, OR = 6.12 CI = 1.77–21.15) respectively than the children following Hinduism. Therefore, children whose family was following buddhism religion were 4.5 times and other than hinduism and buddhism were 6 times likely to have ARI. The reason behind this might be the genetic inheritance. Children who were exposed to the family members (other than sibling) with RTI had 2.8 times probability of developing the symptoms of ARI. Similar finding have been identified by the studies done in Nepal (children are 7 times more likely to develop ARI when exposed to family member with symptoms of RTI), India (children are 5.32 times likely to develop ARI when exposed to family member with symptoms of ARI), Cameron (children are 3.37 times likely to develop ARI when exposed to family member with symptoms of ARI) and Zambia (children are 2.3 times likely to develop ARI when exposed to family member with symptoms of ARI) [2, 5, 9, 20]. A hospital based case-control study carried in India also found children whose mother had presence of Upper Respiratory Tract Infection (URTI) had 6.5 times were more likely to have ARI and presence of Lower Respiratory Tract Infection (LRTI) among family members were 5.15 times more likely to have ARI [23]. Children who were present in the kitchen during the time of cooking tend to develop symptoms of ARI double then those who were not present. A study carried in Bamenda Regional Hospital, Cameron also found children were 1.85 times more prone to ARI if they were exposed to wood smoke [4].

The present study shows no significant association of age, sex, birth weight, immunization status, nutritional status, exclusive breastfeeding, number of siblings, presence of ARI in sibling, type of family, parental education and occupation, socio-economic status, overcrowding, cross-ventilation and type of house. In contrast to this finding, various studies have identified these factors to be significantly associated with ARI among under-five children [2–4, 7–10, 14–22, 24–27].

Conclusions

Acute Respiratory Infection (ARI) is a major problem among under-five children. The prevalence of ARI among the male child is more than that of female child. The prevalence was higher among the children of age less than 24 months. Children when get exposed to smoking while cooking have greater chance of acquiring ARI. Similarly, when the family members have respiratory tract infections, it could double the risk of ARI among the children. Larger studies with case-control design in the community settings are recommended to find out the major factors of ARI. Children should not be exposed to fuel smoking unnecessarily and parents need to be more cautious when any of the family members have respiratory tract infection.

Socio-demographic information of the child.

(TIF)

Click here for additional data file.

Distribution of child related environmental characteristics.

(TIF)

Click here for additional data file.

Health information of the child.

(TIF)

Click here for additional data file.

26 Nov 2021

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.

A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.

An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Prof Sajid Bashir Soofi

Academic Editor

PLOS ONE

Journal Requirements:

When submitting your revision, we need you to address these additional requirements.

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at

https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf.

2. In your Data Availability statement, you have not specified where the minimal data set underlying the results described in your manuscript can be found. PLOS defines a study's minimal data set as the underlying data used to reach the conclusions drawn in the manuscript and any additional data required to replicate the reported study findings in their entirety. All PLOS journals require that the minimal data set be made fully available. For more information about our data policy, please see http://journals.plos.org/plosone/s/data-availability.

"Upon re-submitting your revised manuscript, please upload your study’s minimal underlying data set as either Supporting Information files or to a stable, public repository and include the relevant URLs, DOIs, or accession numbers within your revised cover letter. For a list of acceptable repositories, please see http://journals.plos.org/plosone/s/data-availability#loc-recommended-repositories. Any potentially identifying patient information must be fully anonymized.

Important: If there are ethical or legal restrictions to sharing your data publicly, please explain these restrictions in detail. Please see our guidelines for more information on what we consider unacceptable restrictions to publicly sharing data: http://journals.plos.org/plosone/s/data-availability#loc-unacceptable-data-access-restrictions. Note that it is not acceptable for the authors to be the sole named individuals responsible for ensuring data access.

We will update your Data Availability statement to reflect the information you provide in your cover letter.

Additional Editor Comments (if provided):

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands and need Major Revision. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process by the reviewers.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: No

Reviewer #2: Yes

**********

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

**********

3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: No

Reviewer #2: No

**********

4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: No

Reviewer #2: Yes

**********

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: The manuscript is not presented in an intelligible fashion and is written in standard English. Authors need to read this paper carefully and make all the necessary changes, as there are several errors while reporting this paper.

Reviewer #2: Abstract

A few clarifications needed. Please reword:

Acute respiratory infection (ARI) is responsible for 30-50 percent of visits to health facilty and 20-30 percent of admissions to hospital in Nepal. – is this for both adults and children or for children under 5 years old?

What does it mean, ‘incidence of ARI/1000 children < 5 years of age is 344 in Nepal’? Does this mean 344/1000? Please reword: The incidence of ARI in children < 5 years old is 344/1000.

The sentences are not clear. Please reword to make it clear.

Non-probability is not equivalent to purposive. Purposive is to target those with ARI. In this study, I believe it is convenient sampling – please stick to convenient sampling.

When you say out of the 286 children, half had ARI. What did the other children have?

Also, do not include conclusion that male children are not susceptible to ARI, because the results were insignificant.

Introduction

Line 60: ARI is responsible for about 30-50% of visits…. Question: is this in children under 5 years old? Please specify.

Line 64: The deaths due to ARI at health facility is 127. What does this mean? Any health facility or hospitals or primary care? Can remove this information as it is not clear.

Methodology

Line 91: Please specify the time and duration of the data collection period e.g. from month, year until month, year.

Line 106: Please add the Cronbach alpha for the pretesting that you have done, to show whether the questionnaire was reliable.

From paragraph 66-73 in the introduction, please add in the methodology the factors that was studied in your study.

Chi-squared test was done to show relationship between the categorical variables. My personal opinion is it is better to do simple logistic regression, and then move on to multiple logistic regression for the significant factors. Any reason why you use Chi-squared test rather than simple logistic?

Results – okay

Discussion

You are right to discuss in line 204 regarding the prevalence of ARI.

218: In the discussion, you do not need to mention twice but to just discuss about the three factors that were associated with increase risk of ARI in children, which are religion, presence of child in the kitchen while cooking and presence of respiratory tract infection in family member.

**********

6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: Yes: Associate Professor Dr. Farnaza Ariffin

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

6 Jan 2022

Response to Academic editor

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming.

Author Response: The manuscript has been revised and corrected as per the requirements of PLOS ONE.

2. In your Data Availability statement, you have not specified where the minimal data set underlying the results described in your manuscript can be found.

Author Response: All the data are with in the manuscript and under supporting information file.

Response to the reviewer’s comment

1. Comment 3: Have the authors made all data underlying the findings in their manuscript fully available?

Author Response: All the data are made available with in the manuscript except the one that are inside the supporting information file.

2. Comment 4: Is the manuscript presented in an intelligible fashion and written in standard English?

Author Response: The manuscript has been revised, and corrected based on the standard format.

3. Comment 5: Reviewer #1

- The manuscript is not presented in an intelligible fashion and is written in standard English. Authors need to read this paper carefully and make all the necessary changes, as there are several errors while reporting this paper.

Author Response: The manuscript has been revised and corrected making all the necessary changes.

4. Comment 5: Reviewer #2

- Abstract: A few clarifications needed. Please reword:

- Acute respiratory infection (ARI) is responsible for 30-50 percent of visits to health facility and 20-30 percent of admissions to hospital in Nepal. – is this for both adults and children or for children under 5 years old?

Author Response: The data is for under-five children.

- What does it mean, ‘incidence of ARI/1000 children < 5 years of age is 344 in Nepal’? Does this mean 344/1000? Please reword: The incidence of ARI in children < 5 years old is 344/1000. The sentences are not clear. Please reword to make it clear.

Author Response: The sentence has been reworded to “Incidence of ARI among under-5 years of age is 344 per 1000 children in Nepal.”

- Non-probability is not equivalent to purposive. Purposive is to target those with ARI. In this study, I believe it is convenient sampling – please stick to convenient sampling.

Author Response: Changed to convenient sampling.

- When you say out of the 286 children, half had ARI. What did the other children have?

Author Response: It means, out of the total participants, half of them had ARI while others were visiting OPD for other cause.

- Also, do not include conclusion that male children are not susceptible to ARI, because the results were insignificant.

Author Response: The sentence has been omitted.

• Introduction

- Line 60: ARI is responsible for about 30-50% of visits…. Question: is this in children under 5 years old? Please specify.

Author Response: The data is for under-five children. The sentence has been reworded.

- Line 64: The deaths due to ARI at health facility is 127. What does this mean? Any health facility or hospitals or primary care? Can remove this information as it is not clear.

Author Response: The sentence has been removed.

- Methodology

- Line 91: Please specify the time and duration of the data collection period e.g. from month, year until month, year.

Author Response: The duration for data collection has been specified.

- Line 106: Please add the Cronbach’s alpha for the pretesting that you have done, to show whether the questionnaire was reliable.

Author Response: The calculated value of Cronbach’s alpha was 0.85, which is mentioned in the “Instruments” section under methods.

- From paragraph 66-73 in the introduction, please add in the methodology the factors that was studied in your study.

Author Response: It has been mentioned as “variables under study” under methods.

- Chi-squared test was done to show relationship between the categorical variables. My personal opinion is it is better to do simple logistic regression, and then move on to multiple logistic regression for the significant factors. Any reason why you use Chi-squared test rather than simple logistic?

Author Response: Simple logistic regression has been carried for bivariate analysis.

- Discussion

- 218: In the discussion, you do not need to mention twice but to just discuss about the three factors that were associated with increase risk of ARI in children, which are religion, presence of child in the kitchen while cooking and presence of respiratory tract infection in family member.

Author Response: The factors has been discussed once.

Submitted filename: Response to Reviewers.docx

Click here for additional data file.

11 Mar 2022

Prevalence and Factors Associated with Acute Respiratory Infection among Under-five Children in Selected Tertiary Hospitals of Kathmandu Valley

PONE-D-21-19925R1

Dear Dr. Pratima Ghimire,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org.

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Sajid Bashir Soofi

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Congratulations, your paper is accepted for publication

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #2: All comments have been addressed

Reviewer #3: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #2: Yes

Reviewer #3: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #2: Yes

Reviewer #3: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #2: Yes

Reviewer #3: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #2: Yes

Reviewer #3: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #2: Thank you for addressing all of the comments. The manuscript could improve in its linguistic delivery. Otherwise, no other comments.

Reviewer #3: all the comments have been adequately addressed.

the paper is of significant public health importance and also opens the discussion on environmental health and impact .

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #2: No

Reviewer #3: Yes: Shabina Ariff Associate Professor ,Aga khan university Pakistan

29 Mar 2022

PONE-D-21-19925R1

Prevalence and factors associated with acute respiratory infection among under-five children in selected tertiary hospitals of Kathmandu Valley

Dear Dr. Ghimire:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

If we can help with anything else, please email us at plosone@plos.org.

Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Professor Sajid Bashir Soofi

Academic Editor

PLOS ONE