EPIDEMIOLOGICAL STUDY ON COMMUNITY ACQUIRED PNEUMONIA

AMONG HOSPITAL TREATED ADULTS IN TIGRAY, ETHIOPIA.

HAFTU BERHE GEBRU

PhD DISSERTATION FOR THE DEGREE OF DOCTOR OF

PHILOSOPHY (PhD)
ADDIS ABABA UNIVERSITY, ETHIOPIA
December, 2017
 ADDIS ABABA UNIVERSITY SCHOOL OF
GRADUATE STUDIES

EPIDEMIOLOGICAL STUDY ON COMMUNITY ACQUIRED PNEUMONIA AMONG

HOSPITAL TREATED ADULTS IN TIGRAY, ETHIOPIA.

A DISSERTATION SUBMITTED TO THE SCHOOL OF GRADUATE STUDIES OF

ADDIS ABABA UNIVERSITY IN PARTIAL FULFILLMENT OF THE REQUIREMENTS
FOR THE DEGREE OF DOCTOR OF PHILOSOPHY (PhD) IN PUBLIC HEALTH

BY
Haftu Berhe Gebru

Advisors: Professor Fikre Enqueselassie (PhD)

Dr.Alemayehu Bayray (Assoc.Prof)

ADDIS ABABA UNIVERSITY, COLLEGE OF

HEALTH SCIENCES, SCHOOL OF PUBLIC
HEALTH

Dec/2017
 DISSERTATION APPROVAL

ADDIS ABABA UNIVERSITY SCHOOL OF

GRADUATE STUDIES

EPIDEMIOLOGICAL STUDY ON COMMUNITY ACQUIRED PNEUMONIA AMONG

HOSPITAL TREATED ADULTS IN TIGRAY, ETHIOPIA.

BY

Haftu Berhe Gebru

SCHOOL OF PUBLIC HEALTH, ADDIS ABABA UNIVERSITY APPROVED

BY THE EXAMINING BOARD

Chairman, Examining Board Signature and date

Supervisor (Primary) Signature and date

Supervisor (Secondary) Signature and date

External Examiner Signature and date

Internal Examiner Signature and date

Internal Examiner Signature and date

III
Original Papers

This dissertation is based on the following three papers, which will be referred to in the text
by their roman numbers:

I. Magnitude of Community Acquired Pneumonia among Hospital Treated Adults in Tigray,

Ethiopia: A Hospital Based Retrospective Study........published in Journal of Health, Medicine

and Nursing; ISSN 2422-8419 : An InternationalPeer-reviewedJournal ,Vol.33, 2016

II. Risk factors of community acquired pneumonia among adults in Tigray, Ethiopia: A case
control study. Journal of clinical and diagnostic research : in press

III. Cost of illness among hospital treated adults for community acquired pneumonia in Tigray,
Ethiopia, Annals ofAfrican Medicine. in press

IV
Acronyms and Abbreviations
AAU Addis Ababa University
AOR Adjusted Odds Ratio
ATS American Thoracic Society
BTS British Thoracic Society
BMI Body Mass Index
CAP Community Acquired Pneumonia
CDC Center for Disease Prevention and Control
CI Confidence Interval
COR Crude Odds Ratio
COI Cost of Illness
COPD Chronic Obstructive Pulmonary Disease
CSA Central Statistical Agency
DHS Demographic Heath Survey
EAT Empiric broad-spectrum antibiotic treatment
EDHS Ethiopia Demographic and Health Survey
EPI info Epidemiological information
ETB Ethiopian Birr
FMOH Federal Ministry of Health
GDP Gross Domestic Product
HAP Hospital Aquired Pneumonia
HCAP Health Care Associated Pneumonia
HDSS Health and Demographic Surveillance System
HIV Human Immunodeficiency Virus
ICU Intensive Care Unit
IPD Invasive Pneumococcal Disease
USA United States of America
USD United States' Dollar
LRTIs Lower respiratory tract infections
NHAP Nursing Home Associated Pneumonia
V
OR Odds Ratio
PDT Pathogen Directed Treatment
PI Principal Investigator
PSI Pneumonia Severity Index
SATS South African Thoracic Society
SD Standard Devation
SPSS Statistical Package for Social Sciences
SSA Sub-Saharan Africa
TB Tuberculosis
VAP Ventilator Associated Pneumonia
WHO World Health Organization

VI
Glossary of operational definitions and concepts

Direct costs- medical costs like diagnostics, medications, laboratory and cost of
hospitalization.

Indirect costs -earnings lost because of hospital stay related to community acquired
pneumonia.

Productive age group-those who are between the age group of 18-64 Years

VII
Table of Contents

Acronyms and Abbreviations .......................................................................................................................V

Glossary of operational definitions and concepts .......................................................................................VII

Table of Contents.......................................................................................................................................VIII

List of Tables ...............................................................................................................................................XI

List of Figures .............................................................................................................................................XII

Abstract......................................................................................................................................................XIII

I. INTRODUCTION.......................................................................................................................................... 1

1.1 Background ......................................................................................................................................... 1

1.2 Statement of the Problem .................................................................................................................. 2

1.3. Rationale of the study........................................................................................................................ 4

II. Literature Review ...................................................................................................................................... 5

2.1. The Biology of Community-Acquired Pneumonia.............................................................................. 5

2.1.1. Definition of Community-Acquired Pneumonia ........................................................................... 5

2.1.2. Pathogenesis of Community-Acquired Pneumonia ...................................................................... 5

2.1.3. Etiology of Community-Acquired Pneumonia............................................................................... 7

2.1.4 Transmission mechanisms and clinical course of CAP ................................................................... 8

2.1.5. Diagnosis of CAP............................................................................................................................. 8

2.1.6. Treatment of Community Acquired Pneumonia......................................................................... 10

2.2. The Epidemiology of CAP .................................................................................................................11

2.2.1. Magnitude and burden of Community-Acquired Pneumonia ......................................................11

2.2.2. Risk factors of Community-Acquired Pneumonia....................................................................... 13

2.3. Economic Burden of CAP .................................................................................................................15

2.4 Conceptual frame work.....................................................................................................................18

VIII
III. Objectives...............................................................................................................................................20

3.1. General objective:............................................................................................................................20

3.2. Specific objectives............................................................................................................................20

IV. Material and Methods ...........................................................................................................................21

4.1. Study Area:....................................................................................................................................... 21

4.2 Study Design...................................................................................................................................... 21

4.3 Source and Study population............................................................................................................ 22

4.3.1 Source population ........................................................................................................................22

4.3.2 Study Population............................................................................................................................22

4.3.3. Eigibiity criteria ............................................................................................................................23

4.3.4.1 Sample size determination ........................................................................................................ 24

4.3.4.2 Sampling Methods .....................................................................................................................25

4.4 Data collection .................................................................................................................................. 25

4.4.3 Variables of the study ...................................................................................................................26

4.5 Data management and Analysis ....................................................................................................... 27

4.6 Data quality Assurance .....................................................................................................................28

4.7 Ethical Considerations.......................................................................................................................29

V. Tabular Summary of the Methods Applied in the Dissertation ..............................................................30

VI. Results (Review of Main Findings in the Manuscripts I–III) ................................................................... 32

6.1. Magnitude of Community Acquired Pneumonia ............................................................................. 35

6.2. Clinical characterstics of the study participants .............................................................................. 37

6.3. Risk factors of community acquired pneumonia ............................................................................. 38

6.4. Cost of illness among hospital treated adults..................................................................................47

VII. Discussion ..................................................................................................................................... 51

7.1. Magnitude of community acquired pneumonia.............................................................................. 51

IX
 7.2. Risk factors of community acquired pneumonia ............................................................................. 52

7.3. Cost of illness for community acquired pneumonia ........................................................................ 53

VIII. Validity and Generalizability ................................................................................................................56

IX. Strengths and Limitations ......................................................................................................................57

X. Conclusion...............................................................................................................................................58

XI. Recommendation................................................................................................................................... 59

XI-Acknowledgment.................................................................................................................................... 60

References ..................................................................................................................................................61

Annex ..........................................................................................................................................................72

Annex 1: Original Papers .........................................................................................................................72

ANNEX2:DATA COLLECTION TOOLS ...................................................................................................... 114

ANNEX 3: Declaration ...........................................................................................................................148

X
List of Tables

Table 1: Summary of methods based on objectives of the study.................................................. 30

Table 2: Summary of main findings from the three manuscripts ..................................................32

Table 3.Socio-demographic characteristics of the study participants versus site of treatment,

Tigray,2016 ...................................................................................................................................36

Table 4. Clinical characteristics of the study participants versus site of treatment, Tigray,2016
..................................................................................................................................................37

Table 5.Community Acquired Pneumonia by socio-demographic characteristics,

Tigray,2016...................................................39

Table 6. Community Acquired Pneumonia by lifestyle and habits of study participants,

Tigray,2016..............................................................................................................................41

Table 7. Community Acquired Pneumonia by medical history of study participants,

Tigray,2016..............................................................................................................................43

Table 8. Community Acquired Pneumonia by environmental factors of study participants,

Tigray,2016....................................................................................................................................44

Table 9. Potential risk factors for Community Acquired Pneumonia,

Tigray,2016.........................................................................................................................46

Table 10. Socio-demographic and clinical characteristics of the study participants versus site of
treatment, Tigray, 2016
.................................................................................................................................................48

Table 11. Cost of treatment among patients with community acquired pneumonia according to
site of care,Tigray,2016................................................................................................................49

XI
List of Figures
Figure-1- conceptual frame work of the determinants of community accquired
pneumonia.............................................................................................................19

XII
Abstract
Background: - Lower respiratory tract infections are a leading cause of mortality worldwide,
causing 1.6 million deaths annually in adults. Excluding tuberculosis they are the third most
common cause of death worldwide and the most common cause of death in low-income
countries. Community acquired pneumonia is responsible for a large proportion of these deaths.
Globally, it is the leading cause of death from an infectious disease and the sixth leading cause of
death overall. Studies in different settings of the world, attest to the fact that community acquired
pneumonia has a substantial clinical and economic burden. Despite its high morbidity and
mortality globally and specifically in Ethiopia, community acquired pneumonia is not adequately
researched.

Objective:-The aim of this study was to assess the epidemiology of community acquired
pneumonia among hospital treated adults in Tigray, Ethiopia.

Methods:-The study was conducted in Tigray Region, north Ethiopia. A retrospective patient
record review and case control study designs were used. The source population for the case
control study design were both men and women aged 18 years and above who have been
attending their treatment in all zonal hospitals and Ayder Tertiary Hospital. Charts of all types of
pneumonia patients treated from July, 2013 to July, 2015 in all zonal hospitals of Tigray and
Ayder Tertiary Hospital were the source population for the retrospective record review. In this
study cases were patients of community acquired pneumonia who had been on treatment and
fulfilled the definition for community acquired pneumonia, while controls were clients who
came for some other purposes to the hospitals but without community acquired pneumonia. To
assess the magnitude of community acquired pneumonia all medical records from the selected
hospitals of the period 2013 to 2015 were retrieved and the cost estimation was made from the
records of the period 2014 to 2015.The sample size for the case control study was calculated
using two proportion formula with a case to control ration of 1 to 2.To collect the data semi-
structured interviewer-administrated questionnaire and check list were adapted from different
literatures .Once the data were collected, it was entered into Epi info 2002 and exported to SPSS
Version 20 statistical program for analysis. Ethical clearance was obtained from Institutional
Review Board of the Addis Ababa University College of Health Sciences. Letter of agreement

XIII
was secured from the Regional Health Bureau. Individual written informed consent was solicited
from the respondents at the time of data collection and examination.

Finally measures of central tendency & proportion were calculated. The association between the
exposure and outcome variables were also determined using bivariate and multivariable analysis.
Data for cost was analyzed using descriptive statistics, numerical summary measures, and simple
linear regression analysis. The method of cost estimation employed, included a bottom-up
approach in order to estimate direct patient side medical cost, whereas the indirect cost was
calculated using a human capital approach.

Results: During the study period, there were 36,005 patients of all types of pneumonia with
5877 cases of community acquired pneumonia, making the magnitude of community acquired
pneumonia to be 16%, with proportions for males (16%) and females (17%). The proportion of
admitted patients due to community acquired pneumonia was 9.8%, with a mean admission
length of 6 (+5.59) days.

History of contact with pets, working in dusty environment, history of pulmonary tuberculosis,
history of pneumonia, having contact with people who had respiratory infection, history of
respiratory infection, history of tonsillectomy, history of upper airway problem, age and
educational status had significant association with community acquired pneumonia in the
bivariate logistic regression analysis, while working in dusty environment [OR (95%
CI);2(1.1,4.1)], history of respiratory infection [OR (95% CI); 2.3(1.5,5.7) ], contact with people
who had respiratory infection [OR (95% CI);2.5(1.2,5.3)] and previous history of pneumonia
confirmed by radiograph [OR (95% CI); 39(19.4,78,6)] were significantly associated in the
multivariate analysis.

The total amount of money incurred over the study year was 319,056.52 Ethiopian Birr
($15,193.2). The direct medical expenditure was 242889.60 Eth.B ($11,566.20) and the cost of
lost working days by the patients due to community acquired pneumonia was 76166.92
Ethiopian Birr ($3627). From the cost of direct medical expense, 47.6 % was used for
medication, 18% for imaging (X-ray), 15% for laboratory, 16% for bed and 3% for registration.

XIV
Conclusion: The study revealed that the magnitude of community acquired pneumonia in the
study area was 16% and most prevalent among younger population. Working in dusty
environment, having history of pneumonia, history of respiratory infection and having contact
with people who had respiratory infections are the risk factors of community acquired
pneumonia confirmed in this study.

The cost of illness among adult patients of community acquired pneumonia in the study area was
substantially high. Of the total cost incurred, 76 % was due to direct medical expense and 24 %
for the lost working days.

Hence, appropriate prevention strategies should be designed and implemented so that the
magnitude of community acquired pneumonia would be minimized and terminally the treatment
cost incur by the community acquired pneumonia will be reduced. Besides, Treatment guideline
has to be developed and proper management should be offered to prevent the re-occurrences of
previous pneumonia and other respiratory infections as a result the development of community
acquired pneumonia would be minimized. Moreover, safety measures like personal protective
equipments should be used when there is contact with patients having respiratory tract infections.

More so, further prospective studies should be conducted to estimate the magnitude and
comprehensive costs of community acquired pneumonia. Larger studies are also needed to assess
the effect of some risk factors in the general population.

Keywords: Community acquired Pneumonia, Magnitude, Risk factors, Cost, Adults, Ethiopia

XV
I. INTRODUCTION

1.1 Background
Pneumonia is a disease in the lungs and it is a common cause of infection related to the mortality
that challenges most of health care providers and the community(1). When an individual has
pneumonia, the alveoli in the lungs are filled with pus and fluid, which makes breathing painful
and limits oxygen intake ( 2).

Currently accepted classifications of pneumonia include community acquired pneumonia (CAP),

hospital-acquired pneumonia (HAP), ventilator-associated pneumonia (VAP), and nursing
home–associated pneumonia (NHAP). Healthcare-associated pneumonia (HCAP) was recently
introduced to describe a non hospitalized population of nursing home residents, long-term care
patients, those undergoing same-day procedures, patients receiving home or hospital-based
intravenous therapy, dialysis patients, and patients recently discharged from the hospital(3,4).

CAP is the most common type of pneumonia that occurs either in the community setting or
within the first 48 hours after hospitalization and is defined as a lower respiratory tract infection
characterized by cough, fever, chills, fatigue, dyspnea, rigors, and pleuritic chest pain with or
without new infiltrate on chest radiography (1,5, 6).

CAP is widely recognized as a disease common for the elderly (age ≥65 years) and the very
young (age <5 years) (7). However, it can be potentially life threatening in the adult patients
with other co-morbid diseases, and with poor therapeutic intervention. Its clinical spectrum
ranges from rapid resolution of symptoms to severe medical complications and death. In
addition, Community-acquired pneumonia (CAP) is an acute disease which represents a common
cause of hospital admission and mortality in developed and developing countries and hence
consumes a great proportion of health care budgets (8).

A study from Utah, USA revealed that about 600,000 persons with pneumonia are hospitalized
each year and there are 64 million days of restricted activity due to this illness (9). Another study
in the Netherlands showed that clinical and economic burden of CAP is particularly high in older
adults (10). Although the number of pneumonia hospitalizations was more than twice greater in

1
elderly adults than in nonelderly adults, the mean lengths of hospital stay—5.6 and 5.5 days,
respectively were remarkably similar in USA (11). Like in elderly adults, the presence of
pneumonia in younger individuals (ages 18-64 years) who are still actively employed has an
impact on employers most notably, lost productivity costs associated with workplace sick time
and short-term disability (12).

Currently, there are many studies on CAP from developed countries but the studies focus on
elderly people and it is known that the incidence, risk factors and cost of illness of CAP varies
widely between countries. In addition robust national epidemiological study on CAP among
adults is largely missing across many countries, including Ethiopia and other sub-Saharan Africa.

1.2 Statement of the Problem

A study in Italy reported that the number of physician consultation accounts for 25% due to
respiratory system infections. Pneumonia accounts for 2-3%, of which the majority of these
cases are community-acquired pneumonia (13). The estimated incidence of community acquired
pneumonia varies between countries, by age and gender. The rate is higher among male
individuals aged more than 65 years. In the United States, 4 million adults are affected each year
of which 20% need hospitalization for management (14). Furthermore, about 50,000 adults in the
US die from Pneumonia disease every year (15).

In the United Kingdom, 345 people for every 100,000 had one or more episodes of pneumonia in
2012. Around 220,000 people receive diagnosis of pneumonia each year and 28,952 deaths
occurred from pneumonia in 2012 (5.1 per cent of all deaths and 25.3 per cent of deaths from
lung disease) (16)

In Latin America, a population weighted average incidence of hospitalized pneumonia in persons

over 50 years of age was 519.6 hospitalizations per 100 000 person years, with an average
fatality rate of 19.0 per 100 hospitalizations, representing 436,402 hospitalizations and 82,852
deaths in 2009. Extrapolating forward to 2020, with a projected adult population of 1.49 billion,
pneumonia could account for up to 617,993 hospitalizations and 112,680 deaths in a single year
(17)

Pneumonia ranks among the top three diagnoses in hospital admissions in sub-Saharan Africa
(18) and the fifth largest killer in South Africa, accounting for 3.9% of all deaths (19). Likewise,
2
,CAP is the leading cause of hospitalization and mortality among adult patients accounting for
10% in Kenya (8), 11.9% in Nigeria (20), 8.3% in Botswana, and 51,000 admissions per year
with 10,000 deaths per year in Malawi (21).

According to a study at Jimma University by Ali and Woldie infectious diseases are major
reasons for admission and a high mortality rate accounting for 12.3% and respiratory illness of
15.9% (22). Parallel to a report from sub-Saharan Africa (SSA) by Etyang and Scot, respiratory
diseases remained the leading causes of admission, accounting for 27.4% of all admissions (23).

Several risk factors are recognized for the development of community acquired pneumonia,
including older age, smoking, alcoholism, immunosuppressive conditions, and condition such as
COPD, cardiovascular disease, chronic liver or renal disease, diabetes mellitus and dementia
(24).

Pneumonia is a huge burden on healthcare systems. As reported by a study in the US, Pneumonia
expenses accounted for $16.2 billion in 2013 only (25).Likewise, in Europe, pneumonia costs
nearly € 10.1 billion annually (26). CAP has an effect towards the patient’s recovery to return to
a full range of daily activity of about 7 to 43 days. However, the length of stay in the hospitals is
variable primarily affecting the cost of care (27).

In a study from Spain, the cost of inpatient care for community-acquired pneumonia was €
1,553, whereas the mean cost of treating pneumonia in outpatient was € 196 (28). Another study
reported that hospitalization represents over 90% of the direct costs of treatment in Czech
Republic, Hungary, Poland and Slovakia in which adults aged 65 years and above accounting for
73% of the costs (29).

Being among the leading cause for hospitalization, mortality and costly, little is known about it
in Ethiopia and no available literature shows the magnitude, determinants and the cost of hospital
expenditure regarding CAP in Ethiopia and other sub-Saharan Africa countries.

Hence, the aim of this research was to determine the epidemiology of CAP among adults in
Tigray hospitals including the magnitude, risk factors and measure the cost of illness that can
have a consequence for the well-being of patients affecting the life of a whole populace.
3
1.3. Rationale of the study
Community-acquired pneumonia is a global disease that is an acute disease which represents a
common cause of hospital admission and mortality in developed as well as developing countries.

Nonetheless, Pneumonia does not have effective advocacy. It is not the subject of fund-raising
walks or runs. It does not have a ribbon or other symbol around which people rally. It does not
get the attention it needs from biomedical scientists or from research funders. Hence, more effort
is needed now(15).

Moreover, the burden of community acquired pneumonia will be felt even more acutely in the
years to come due to environmental pollution, climate change and increment of the proportion of
older adults worldwide. This problem will also hold true for Ethiopia. Hence, conducting
research on the epidemiology of community-acquired pneumonia in adults in Ethiopia where
little is known can provide a baseline information on the burden, risk factors and cost of illness
pertaining community acquired pneumonia.

The study will benefit policy makers to develop treatment guideline, design prevention and
control mechanisms for community acquired pneumonia. Likewise, it will be important for
health institutions to improve the quality of service being provided for community acquired
pneumonia.

Moreover, health care professionals will gain a good knowledge on the magnitude, risk factors
and cost of illness on community acquired pneumonia in Ethiopia and will enable them provide
health education on the area which can contribute for the improvement of health seeking
behavior of patients, early treatment and prevention. In addition, the research would help health
care providers to improve quality of care, design appropriate treatment, prevention and
promotional approaches.

4
II. Literature Review

2.1. The Biology of Community-Acquired Pneumonia

2.1.1. Definition of Community-Acquired Pneumonia
Pneumonia is an infection of the alveolar area where gas exchanging takes place in the
respiratory tract. The clinical symptoms of pneumonia include, but not limited to cough, fever,
sputum production and pleuritic chest pain accompanied with presence of infiltrates on chest
radiography (30)

Suspected community-acquired pneumonia (CAP) is defined as, an acute illness with cough and
at least one of new focal chest signs, fever >4 days or dyspnoea/tachypnoea, and without other
obvious cause. A definite community-acquired pneumonia (CAP) is same as suspected CAP, but
supported by chest radiograph findings of lung shadowing that is likely to be new. In the elderly,
the presence of chest radiograph shadowing accompanied by acute clinical illness (unspecified)
without other obvious cause (31).

Patients with typical community acquired pneumonia classically present with fever, a productive
cough with purulent sputum, dyspnea, and pleuritic chest pain. Characteristic pulmonary findings
on physical examination include tachypnea, rales heard over the involved lobe or segment,
increased tactile fremitus, bronchial breath sounds, and egophony may be present if
consolidation has occurred (32).

2.1.2. Pathogenesis of Community-Acquired Pneumonia

The underlying mechanism in all cases of pneumonia is constant exposure to contaminated air
and common aspiration of nasopharyngeal flora that makes lung parenchyma susceptible to
virulent microorganisms.Most microorganisms reach lower respiratory tract as inhaled and
contaminated micro droplets.Complex interactions exist between virulence and quantum of
aspirated or inhaled microorganisms that arrive at lower respiratory tract, the integrity of defense
barriers and host immunity status (33). Once pathogens have successfully passed the first line of
defense like the surface boundaries, the host initiates an immune reaction in an attempt to
eliminate the invading microorganisms, beginning with the local release of a vast number of
inflammatory mediators, such as cytokines and chemokines (34).These mediators also induce
resting neutrophils to transition to cells primed for enhanced responses and finally to fully

5
activate cells. Activated neutrophils engulf and sequester microorganisms through phagocytosis
and kill ingested bacteria by a combination of the production of toxic oxygen radicals,
proteolytic enzymes, myeloperoxidase, defensins, and other bactericidal peptides (35)

There are series of immune and nonimmune respiratory defense mechanisms working effectively
at different levels to keep the lung a bacterial free zone. Failure of these defense mechanisms and
presence of certain predisposing factors render the person susceptible to infection causing CAP.
As a consequence of the failure of defense mechanism, this can lead to alteration of normal
oropharyngeal flora which is common in late adult and elderly patient having diabetes mellitus,
malnutrition, chronic disorder alcoholism and other chronic systemic diseases reduce the levels
of salivary fibronectin. As an outcome, this can result to increase colonization by gram-negative
bacilli. Next is depression of a cough and glottis reflexes causing aspiration of gastric aspirate in
old age patients. Furthermore, healthy adults have 10 to 100 million bacteria per milliliter of
oropharyngeal secretions and up to 50% of healthy adults aspirate small volumes of pharyngeal
secretions during deep sleep. Oropharyngeal contents may be aspirated more often in situations
like alcoholism wherein it is an associated risk factor of CAP (36).

Moreover, effective mucociliary clearance is dependent on substantial ciliary motion and

physical properties of mucus. The protection offered by the slime covered ciliated epithelium
from the larynx to the terminal bronchioles is impaired in many situations like chronic cigarette
smoking, exposure to hot/cold air of other harmful gasses and old age(36).

Lastly, is immune dysfunction, wherein the immune response is the primary mode of defense
against infection by pathogenic microorganisms. Such case will include those that come through
and dwell in the respiratory tract. On the other hand, such immune responses depend on the
specific recognition of antigens by T and B lymphocytes. These reactions are regulated and
supplemented by nonspecific inflammatory cells of the immune system, such as pulmonary
dendritic cells, macrophages, neutrophils, eosinophils and mast cells. Disorders of granulocytes,
lymphocytes, acquired immunodeficiency and immunosuppressive therapy predispose to
pneumonia (37).

6
 2.1.3. Etiology of Community-Acquired Pneumonia
Sir William Osler proclaimed Streptococcus pneumonia (or pneumococcus) as “the captain of all
deaths of men” (38). This statement remains true today. Severe community-acquired pneumonia
is the most common cause of death from infection in developed and developing countries, where
pneumococcus is the most frequent cause of lower respiratory tract infection (39). Pertinent
history can sometimes point to the etiology of pneumonia. Travel to endemic areas, sick
contacts, exposure to specific pathogens and risk factors may help point to an etiology. However,
the clinical features and history cannot reliably tell the precise etiology of CAP or separate viral
from bacterial infection.

Although there are many pathogens that are associated with CAP, pneumonia is usually caused
by bacteria or viruses in which the exact proportions of each microorganism may vary between
countries. A review article from North America showed that the organisms responsible for CAP
in hospitalized patients are Streptococcus pneumonia ( 20-60%), Haemophilus influenza (3-
10%), Mycoplasma pneumoniae (1-6%), Chlamydia pneumonia (4%), Legionellae sp. (2-8%)
viruses (2%), Aspiration (6-10%), Staphylococcus aureus (3%), Gram-negative bacilli (3-5%)
and the other identified organisms ( 10-20%) (39).

A study in Finland showed that S. pneumonia occurrence is 41%, followed by chlamydiae 12%,
Mycoplasma pneumoniae 10%, viruses 9%, Haemophilus Influenza infection 4% and Moraxella
catarrhalis 3% (36). The etiology of CAP according to age and sex revealed that pneumococcal,
chlamydial and viral infections were consistent with the distribution of all cases of age, with a
peak at 60 to 75 years. The pneumococcal disease was significantly more frequent among
patients aged above 60 years (48%) than among patients aged <60 years (35%). In contrast,
Mycoplasma infection accounted for 24% in patients aged 15 to 44 years, compared only to 3%
of older adults. The pneumococcal disease was significantly more frequent among men aged
above 60 years than women of the same age group. Streptococcus pneumoniae was the most
common (51%) in predefined patients with chronic conditions; Mycoplasma infection is frequent
among outpatients accounting for 14% (50% pneumococcus infection, 23% M. pneumonia and
37%. unidentified organism). For admitted patients aged more than 60 years, the most common
ethiologic agent was chlamydiae accounting for 89% (36).

7
A study in Kenya, on the etiologic agents of CAP among 225 patients showed that Streptococcus
pneumonia was the most common causative microorganism, accounting for 46% and
Mycobacterium pneumoniae 9% (8). In a study at the intensive care unit in South Africa, it was
reported that there was a high incidence of Klebsiella pneumoniae (40). In Uganda, the most
common bacterial etiologies were S. pneumoniae, H. influenza, Moraxella catarrhalis,
Staphylococcus aureus and Klebsiella pneumoniae (41).

2.1.4 Transmission mechanisms and clinical course of CAP

Most CAP is of bacterial origin and often follow brief viral upper respiratory tract infection. In
the upright position, lower lobes are best ventilated therefore, deposition of inhaled
microorganisms is higher in these lobes. Inhalation pneumonia is most often due to
microorganisms (a) that can remain suspended in air so as to be transported far away, (b) survive
long enough while in transit, (c) have a size less than 5 μm (d) carry a high inoculum, and (e)
evade local host defence mechanisms. Infection by intracellular bacteria such as Mycoplasma
pneumoniae, Chlamydophila and Coxiella burnetii occurs through a contaminated aerosol
inhalation route. CAP due to Streptococcus pneumoniae, Haemophilus and gram-negative bacilli
occurs through microaspiration (42).

In a study of the time course of community-acquired pneumonia in ambulatory patients with

CAP, the median time to resolution of fever was three days, five days for myalgia, six days for
dyspnoea, and 14 days for both cough and fatigue. Symptoms can last even longer in critically ill
patients (43).Fine and colleagues in their study on the process and outcomes of CAP have noted
that 86% of patients had at least one persisting pneumonia-related symptom at 30 days (44).

2.1.5. Diagnosis of CAP

The American Thoracic Society (ATS) on its guideline for the management of CAP
recommendes : 1) Patients should be investigated for specific pathogens that would significantly
alter standard management decisions when the presence of such pathogens is suspected on the
basis of clinical, epidemiologic clues; 2) Routine diagnostic test to identify etiologic diagnosis
are optional for outpatient with CAP; 3) Pre-treatment blood samples for culture and
expectorated sputum sample for stain and culture(in patients with a productive cough) should be
obtained from hospitalized patients with the clinical indications; 4) Pre-treatment gram stain and
culture of expectorated sputum should be performed only if a high-quality specimen can be
8
obtained and quality performance measures for collection, transport and processing of samples
can be met; 5) Patients with severe CAP should at least have blood samples drawn for culture,
urinary antigen test for Legionella pneumophilia and Streptococcus pneumonia performed and
expectorated sputum samples collected for culture. For intubated patients, an endotracheal
aspirate should be obtained (39).

The consequence of incorrect diagnosis can be severe. In the case of a false negative
classification, there will be a delay in treatment; this can occur in young and middle-aged
patients, who are otherwise healthy, or in elderly patients without typical signs of pneumonia.
Due to unfavorable consequences of misleading diagnosis, a chest radiographic test ought to be
performed, to have a definitive diagnosis of pneumonia. The classical microbiological methods,
such as gram staining and culture have a low sensitivity and there is a delay before results from
culture are available. Isolation of pneumococci from blood provides a specific aetiological
diagnosis that does not only allow effective treatment to be given to the patient but can also be
used for surveillance of the epidemiology of pneumococcal infections. Unfortunately, a blood
culture method only detects pneumococci in about 10 to 20% of pneumococcal pneumonia cases,
and this detection rate can be lower (45).

The diagnosis of pneumonia in developing countries varies according to the patient's access to
medical care. Often the diagnosis is made simply by cough and fever. For patients with access to
a hospital, the likelihood of obtaining a chest x-ray increases; the infection is bacteriologically
confirmed only in the most sophisticated medical centers (46).S. pneumoniae is invariably found
more frequently than any other pathogen in etiological series of pneumonia in Africa. However,
the clinical evidence is scarce, not same, as the USA and United Kingdom (47).

Diagnosis is hampered by lack of a gold standard. Although blood and lung aspirate cultures are
regarded as highly accurate, they typically lack sensitivity (48). Thus antimicrobial treatment
makes the evaluation of culture-based diagnostic tests yet more complicated. In a study in
Nigeria, majority of the patients did not have thorough laboratory workup that would have been
useful both in severity assessment and the holistic management of these patients (39).

The diagnosis of respiratory symptoms in Africa is hampered by lack of available diagnostic

facilities, particularly at the level of primary care. Likewise, this is supported in Ethiopia, though

9
there is no literature that points out what particular microorganism predominate as well as
accurate diagnostic test among CAP infected patients.

2.1.6. Treatment of Community Acquired Pneumonia

Initial treatment of CAP is based on physical examination findings, laboratory results and patient
characteristics (e.g., age, chronic illnesses, history of smoking, history of the disease). Physicians
should begin their treatment decisions by assessing the need for hospitalization, using a
prediction tool for increased mortality, such as the Pneumonia Severity Index combined with
clinical judgment. Likewise, patients are treated for pneumonia depending upon what organism
triggered the disease. The majority of patients are managed out of the hospital. Of those who are
hospitalized, no more than 10 to 20% require intensive care unit. The decision to admit a patient
with CAP depends on many variables, including severity of illness, associated disease, adequacy
of home support, and the probability of adherence to treatment. Although guidelines vary on the
emphasis placed on obtaining a chest radiograph for ambulatory patients is necessary to
differentiate it from another respiratory disease (49).

The preliminary management of CAP depends on the patient's severity of illness, underlying
medical conditions and risk factors, such as smoking and ability to adhere to a treatment plan.
Over the past two decades, hospitalization with pneumonia has increased by 20 – 50% of aging
European and US population (50).

The primary treatment for a patient with CAP is antibiotic therapy. The main goals of
pharmacotherapy for patients with CAP include eradicating the causative pathogens, resolving
the clinical signs and symptoms, minimizing hospitalization and preventing reinfection.
Physicians should choose a medication based on the pharmacokinetic profile, adverse reactions,
drug interactions and cost-effectiveness (51). Further, patient evaluation should focus on the
severity of illness, patient age, comorbidities, clinical presentation, epidemiologic setting and
previous exposure (52).

The majority of patients with CAP are treated empirically based on the most common pathogen
associated with the condition. It has long been used as a management of CAP, antibiotic therapy
like Penicillin had been the treatment of choice since 1940, but resistance to this and other
antibiotics has grown (53). A study in Brazil revealed that substantial increases in penicillin

10
resistance in strains of S. pneumonia to 300% increase in strength and 61% increase in moderate
resistance from 1998 to 2003 (54).

A study showed doxycycline to be comparable to levofloxacin (Levaquin) in effectiveness,

length of hospital stay and failure rate for empiric treatment of CAP. Doxycycline is also a less
expensive option for hospitalized patients who are not admitted to the ICU (55). In a recently
completed study of severe CAP, it was reported that an increase the value of adding
hydrocortisone to antibiotic therapy in severe CAP.In this study, hydrocortisone was
administered for seven days in a placebo-controlled trial, and led to a delay in the onset of septic
shock and improved oxygenation, as well as reduced length of stay and improved mortality(56).
Although the role of steroids in severe CAP is still uncertain, it reminds the audience that this
therapy is valuable when patients with pneumococcal pneumonia have associated meningitis. As
a conclusion the role of steroids should be explored and not overlooked, because antibiotics have
limitations in efficacy, and there are no very promising new drugs in development (57).

Another form of treatment is the pathogen-directed approach which is particularly used for
moderate to severe CAP, where more sensitive diagnostic tests become more widely available.
However, there has been some concern that narrowing the coverage spectrum of antibiotics when
a specific pathogen is identified may undertreat patients who have a concurrent infection with
atypical organisms. This concern was not borne out in a prospective randomized trial comparing
pathogen-directed treatment (PDT) and empiric broad-spectrum antibiotic treatment (EAT) in
262 hospitalized patients with CAP.PDT was based upon microbiologic studies (rapid diagnostic
tests) or clinical presentation; EAT patients received a beta-lactam/beta-lactamase inhibitor plus
erythromycin or if admitted to the intensive care unit (ICU), ceftazidime and erythromycin .
Overall, clinical outcomes (length of stay, 30-day mortality, fever resolution, and clinical failure)
were the same for both groups. Adverse events were more frequent in the EAT group but were
primarily related to the particular antimicrobial choice (i.e., erythromycin) (58,59).

2.2. The Epidemiology of CAP

2.2.1. Magnitude and burden of Community-Acquired Pneumonia

The 2010 Global Burden of Disease Study reported that lower respiratory tract infections
(LRTIs), including pneumonia, are the fourth most common cause of death globally, exceeded

11
only by ischaemic heart disease, strokes and chronic obstructive pulmonary disease (COPD) and
second most common frequent reason for loss of life (60). Another study showed that lower
respiratory tract infections (LRTIs), which include community-acquired pneumonia (CAP), are a
leading cause of mortality worldwide, causing 1.6 million deaths annually in adults aged 60
years and above (61). In developed regions of the world, LRTIs have been reported to account
for 4% of overall deaths; while in Latin America, mortality due to LRTIs has been reported as
6% (62). LRTIs in persons aged 65 years and above were the third most frequent cause of death
in 31 Latin American Countries, during the period 2001 to 2003 (63). In comparison, pneumonia
was found to be the 8th leading cause of death in the USA (64). In aging adults, the burden of
CAP is a greater concern when considering that the number of persons aged 60 years and above
globally is projected to triple, from 673 million in 2005 to 2 billion by 2050(65). This will be
most apparent in developed regions of the world, where this age group is projected to increase
from 64% (2005) to 80% (2050) of the total population. The 50 least developed countries will
realize more than 200% increase in their population, from 0.8 billion in 2007 to 1.7 billion by
2050 compared with developed regions, which are projected to remain stable at a population of
1.2 billion (65).

CAP was the second most frequent reason for hospital admission in Brazil in 2003 (66). A
prospective study of 84 patients in five Latin American countries (Argentina, Brazil, Chile,
Mexico and Uruguay) showed that 50-52.8% of CAP patients were admitted to hospitals (67).
This high rate of hospitalization increased the economic burden of CAP through utilization of
more expensive health care resources in contrasts with the rest of the world, where 80% of CAP
patients are treated as outpatients (68). In a retrospective study in Argentina that assessed 436
patients admitted to 12 hospitals, 30% were admitted to the intensive care unit (ICU) (69). The
clinical burden associated with CAP is in part related to its bacteremic and invasive potential.
The clinical and economic burden of invasive pneumococcal disease (IPD) like CAP is
particularly high in older adults. This is usually observed in more than 50 years old patients in
the U.S. that it represent only 6% of all pneumococcal pneumonia. But the case fatality rate was
24.4% comparing to 9.7% for nonbacteremic pneumonia. Pneumococcal disease remains a
substantial burden for American adults aged more than 50 years (70)

12
In Nigeria, community-acquired pneumonia (CAP) is a leading infectious disease requiring
hospital admission, and it is a common cause of illness and death that constitutes a significant
burden on health care resources (71). Although, data on the specific diseases that indicate
reasons for admission to hospitals in Ethiopia and their outcomes is scarce, a study revealed that
in Addis Ababa, Ethiopia mortality among admitted patients with CAP was found to be 11.5%
(72).

Furthermore, the magnitude of community acquired pneumonia differs in different settings.

Studies from Canada showed that the proportion of community acquired pneumonia was 63%
(73). Likewise, a study conducted in 55 hospitals in Italy concluded that 61.6% of all pneumonia
patients admitted in the hospitals had community-acquired pneumonia (74). Another study from
Japanese community hospital revealed almost similar results of 62% of community acquired
pneumonia among the total pneumonia patients (75). On the other hand, a study in USA showed
lower proportion of CAP (32.6%) than reported from the studies mentioned above (76).
However, there are no available literatures that show the level of community acquired
pneumonia among hospital treated adults in Ethiopian and other sub-Saharan Africa countries.

2.2.2. Risk factors of Community-Acquired Pneumonia

In general, there are different factors identified in different countries as risks for the
development of community acquired pneumonia albeit contradicting findings are documented.
Different studies showed that the primary risk factor is age, specifically for children below 2
years old and adults 65 years and above. Findings of a study based on a nationwide database in
Germany showed a clear relationship between age and hospital fatality rates for adult patients
hospitalized with CAP (77). Another study showed that incidence of CAP is increased
dramatically with aging, achieving the highest rate in people aged 85 years or more, where 29
cases per1,000 person-years were observed(78). According to sex and age strata, elderly men are
at the greatest risk considering that one episode of CAP can be expected every year for every 25
people aged 85 years or older. Similar trends in the incidence rates stratified by age have been
reported in most prior epidemiological studies, considering that the frequent association between
increasing age and presence of underlying diseases accounts for a greater morbid-mortality due
to CAP in the oldest adults . In a study of 30-days case-fatality rate, it was reported that CAP has
a threefold increment among patients 85 years or older than in patients aged 65–74 years, which

13
supports the particularly important role of age as a predictor of 30-days mortality among patients
with CAP (79).

A study in Finland showed that the incidence of CAP rose dramatically with age, with a six-fold
increase in incidence between ages 30–44 & 75 years and above (80). In Portugal, case fatality
rates were 4.5% for patients aged 18–50 years, 19.4% for those aged 50 years & above and
24.8% for those aged 75 years and above (81). A UK study reported case-fatality rates of 5.6% in
those aged lower than 65 years and 47.2% for those aged 85 years and above. That study also
found a 12-fold higher for death within 30 days of hospital admission for adults aged 85 years
and above compared to those aged below 65 years (82);with the projected increase of those aged
65 years and above to 20% of the adult population in developed regions of the world by 2025
(83).

The incidence of primary medical condition such as chronic heart, lung (including asthma), renal
and liver disease are reported to be risk factors for potential pneumococcal disease resulting in a
poorer outcome (84). Cigarette smoking is reported to be the strongest independent risk factor
for invasive pneumococcal disease in immune-compromised non-elderly adults (85). On the
other hand, underlying malignancy, cardiovascular disease and smoking are believed to be risk
factors for Gram-negative pneumonia (85).

Studies showed that modifiable risk factors such as smoking, high alcohol intake, underweight,
living in a large household or having regular contact with children were associated with an
increased risk of CAP (77). Smoking is an established risk factor for CAP, due to its adverse
effects on the respiratory epithelium and the clearance of bacteria from the respiratory tract (86).
Being underweight may predispose patients to CAP due to the consequences of under nutrition
or underlying conditions on immune function (87). Regular contact with children has also been
identified as a risk factor for CAP, possibly due to the high carriage of Streptococcus
pneumoniae by children (88). Studies also reported that heart disease and history of diabetes as
being risk factors for CAP (81, 89, 90,). However, other studies failed to conclude that history of
diabetes and heart disease to be associated with CAP (90-93).

14
According to different studies globally, community acquired pneumonia is associated with upper
repeated respiratory infections (81,89,91,94,95,96). Likewise, chronic bronchitis, diagnosed
asthma and Pulmonary TB were identified as risk factors for community acquired pneumonia
among adults (89-91,94). Findings also showed that patients with history of previous pneumonia
confirmed by radiograph had higher risk of a subsequent community acquired pneumonia
(90,91,96,97,98).

A different prototype of CAP as an acute respiratory infection has been recognized primarily in
sub-Saharan Africa, where there is a high seroprevalence of HIV infection (99). Although the
incidence of opportunistic infection in HIV-positive individuals decrease in industrialized
countries following the initiation of antiretroviral therapy, the social and medical situation of
HIV-infected persons in Sub-Saharan Africa remains unchanged (100). Thus the high HIV
infection rate among patients with pneumonia on acute respiratory illness supports that HIV
infection is an important risk factor (101). A study estimated that the proportion of bacterial
pneumonia attributable to HIV in Sub-Saharan Africa is approximately 73% (102).

Concerning exposure to dusty environment, contradictory findings were reported from different
countries. A hospital based study from Great Britain showed that working in a dusty
environment as one of the major risk factors for the development of community acquired
pneumonia (90). In contrary a recent community based study confirmed that working in a dusty
environment is not a risk for community acquired pneumonia (89).

The risk factors observed among Malawian adults also included, alcohol abuse, cigarette
smoking, and other use of biomass fuel(103). Cigarette smoking men and smoky cooking fuel in
women are significantly related to a chronic cough in southern Africa (104).

2.3. Economic Burden of CAP

Pneumonia places a considerable burden on healthcare resources and society mainly due to
hospitalization and loss of working days (105).It is well established that older adults carry a
disproportionately higher epidemiologic burden of CAP than their younger counterparts, with
increased incidence, hospitalization and mortality rates with advancing age (106). Given the
strong correlation between older age and the presence of CAP, it is perhaps not surprising that
the bulk of epidemiologic data focuses on older adults, and that there is a widely acknowledged

15
lack of contemporary information in the nonelderly adult population. Nonetheless, limited
information is available on working-age adults in the United States (106).

Over the past several years, CAP has become a difficult condition to manage. Drugs used for the
treatment of CAP are launching to get more awareness and are increasing gradually in quantity.
Some new drugs emerge in the market for the treatments of CAP that are projected to become
the prime cost contributors, as a result of its expected increased use. For those reasons,
medications for the treatment of patients with CAP have to turn out to be a major concern for
patients, including health insurance companies. Fortunately, much is recognized about CAP in
the young and in the elderly populations that can allow further efficient healthcare strategies to
be implemented in the working-age population. Further, it has been estimated that, in Europe,
pneumonia direct costs (inpatient care, outpatient care, and drugs) account for €6.2 billion and
indirect (working days lost) for €3.6 billion (10 7). A study also showed that CAP remains as
under-recognized burden among employers, payers, healthcare providers and the nonelderly
adult population (108).

In a study in the countries including Czech Republic, Hungary and Poland, hospitalization
represents over 90% of the direct costs of treatment(109).Adults aged 65 years and above , who
represent 41% of the combined population, account for 73% of the expenses. The costs per case
remain relatively stable both for inpatient and outpatient of CAP across all age groups. By
contrast, the overall cost of outpatient care declined with age since the incidence was steady and
population sizes were larger in the younger groups (109).

The variability of indirect cost is explained principally by the length of stay (110), and there is a
general agreement that a substantial number of patients with community-acquired pneumonia
that could be treated as outpatients are hospitalized (111). A study indicated that 14% of hospital
admissions could be avoided with a reduction in the total cost of community-acquired
pneumonia attributable to hospitalized patient. Patients that are hospitalized for a shorter period
of time may be associated with an increase in the number of readmissions. Thus, the cost of CAP
expenditure will increase with readmission (112). Furthermore, readmission of patients
diagnosed with CAP aged 65 years or older is associated with greater investment in the acute
care setting (113). Readmission to hospital occurs when a patient returns to either the same or

16
different acute facility with a similar diagnosis (78).Readmission is costly both from the
healthcare system and patient perspective (114).

Several studies have evaluated the economic burden of CAP on the elderly population, but data
are scarce on the working –age population (108).A recent study from USA showed that CAP is a
common and costly infection in the working-age population, especially in adults with
comorbidities, with estimated social, direct and indirect cost of $8.5 billion and $2.1. Billion
respectively (115).

Moreover, a study from Italy showed that the mean cost per episode of community acquired
pneumonia (CAP) was Euro 1586 (116). Likewise a study from France revealed that the pooled
cost of ambulatory and hospitalized patients was Euro 357.1 (117). Another study from New
Zealand concluded that the annual cost (a societal perspective for the adult population aged 15
years and over) estimated to be 63 million Newzland’s dollars, (direct medical costs of 29
million dollars; direct non-medical costs of 1 million dollars; lost productivity of 33 million
dollars) (118). Similarly, a study from China confirmed that the median total hospital cost was
US$556.50 (mean US$705.60) (119). Another study from USA showed that the mean cost of
hospitalization per admission (excluding physician cost) was $US3490±3058 (median $US2430)
(120).

17
2.4 Conceptual frame work
In order to show the link between determinant factors and CAP, a conceptual framework was
developed based on findings of the literature review (Figure 1). The framework broadly explains
the determinants of CAP and the link among them by classifying them in to four groups namely
Socio-demographic factors, Health related factors, Environmental factors, Behavioural and
Lifestyle factors.

Socio-demographic factors include age, sex, educational status, residence, marital status,
occupation, number of people living with, income, height and weight.

Health related factors include Diabetes, cardiovascular problem, renal problem, mental problem,
dental problem, Gastro intestinal problem, cancer and liver problem

Environmental factors include working and /or living environment, contact with children, pets,
birds and animals

Lifestyle & behavioural factors include alcoholism, tobacco smoking and physical exercise

18
Figure -1- Conceptual frame work of the determinants of community acquired pneumonia
(Developed by PI).

19
III. Objectives

3.1. General objective:

To assess the epidemiology of community acquired pneumonia among hospital treated adults in
Tigray, Ethiopia.

3.2. Specific objectives

1. To determine the magnitude of community acquired pneumonia among hospital treated adults
in Tigray

2. To identify risk factors of community acquired pneumonia among hospital treated adults in
Tigray

3. To estimate the cost of illness of community acquired pneumonia among hospital treated
adults in Tigray

20
IV. Material and Methods

4.1. Study Area:

The study was conducted in Tigray Region. Based on the 2007 Census conducted by the Central
Statistical Agency of Ethiopia (CSA), the Region has an estimated total population of 4,314,456,
of whom 2,124,853 are males and 2,189,603 females; urban inhabitants account for 842,723
(19.53%) of the population. With an estimated area of 50,078.64 square kilometers, the region
has an estimated population density of 86.15 people per square kilometer. For the entire Region
985,654 households were counted, which results in an average family size for the region of 4.4
persons to a household, with urban households having on average 3.4 and rural households 4.6
people. The Region is predominantly Tigrian people at 96.55% of the population; other ethnic
groups include Amhara (1.63%), Irob or Saho (0.71%), Afar (0.29%), Agaw (0.19%), Oromo
(0.17%), and Kunama people (0.07%). About 95.6% of the population are followers of the
Ethiopian Orthodox Christianity, 4.0% Islam, 0.4% Roman Catholic and 0.1% P'ent'ay. There
are 712 health posts, 201 health centres and 15 hospitals (6 zonal or general hospitals, 1 referral
and the remaining are primary hospitals) in the Region. There are 3, 4, 77, 60, and 50 Hospitals,
Health centres, Medium clinics, Primary clinics and Specialty clinics respectively owned by
private and nongovernmental organizations (121,122). The study was conducted from August to
October, 2016

4.2 Study Design

To determine the magnitude of community acquired pneumonia retrospective hospital based
medical-record review was used.

To identify the risk factors of CAP unmatched case control study design was employed.

Cases- were patients of community acquired pneumonia (patients having a new pulmonary
infiltrate on chest radiograph plus at least one of: cough, fever, leukocytosis, or leukopenia).

Controls- were patients without community acquired pneumonia that have been attending their
treatments in the same hospitals with the cases in Tigray Region.

21
The cases and controls were ascertained by two internists in consultation with a radiologist after
taking history of the patients and undergone necessary diagnostic procedures (Sputum, blood and
X-ray examinations).

To estimate the cost of illness of the study, retrospective hospital based medical-record review
was used.

4.3 Source and Study population

4.3.1 Source population
For Magnitude: All types of pneumonia patients that occurred in the period of July, 2013 to
July, 2015 and got medical services in all zonal hospitals of Tigray and Ayder Tertiary Hospital
were the source population.

For Risk factors: The source popultion for cases were both men and women patients with
community acquired pneumonia who were 18 years and above, visited the zonal hospitals and
Ayder Tertiary Hospital during the data collection period.

The source popultion for the controls were both men and women patients with out community
acquired pneumonia who were 18 years and above, visited the zonal hospitals and Ayder tertiary
Hospital during the data collection period to get medical services.

For Cost of illness: All community acquired pneumonia patients who had been treated in all
zonal hospitals of Tigray and Ayder Tertiary Hospital between the period of july,2014 to
July,2015 were the source population.

4.3.2 Study Population

For Magnitude: All community acquired pneumonia patients treated in the period of July, 2013
to July, 2015 in all zonal hospitals of Tigray and Ayder Tertiary Hospital.

For Risk factors: The study population for cases were sampled men and women patients with
community acquired pneumonia who were 18 years and above, treated in the zonal hospitals and
Ayder Tertiary Hospital during the data collection period. The study population for the controls
were selected men and women patients without community acquired pneumonia who were 18

22
years and above, treated in the zonal hospitals and Ayder Tertiary Hospital during the data
collection period.

For Cost of illness: All community acquired pneumonia patients who had been treated in all
zonal hospitals of Tigray and Ayder Tertiary Hospital between the period of july,2014 to
July,2015

4.3.3. Eigibiity criteria

4.3.3.1. Inclusion criteria

For magnitude: Charts of community acquired pneumonia patients that occurred during the
period of July, 2013 to July, 2015 aged 18 years and above, treated in all zonal hospitals of
Tigray and Ayder Tertiary Hospital were included in this study.

For case control: Patients with/without community acquired pneumonia aged 18 years and above
of both sexes and had been on treatment during the data collection period in the government
Zonal hospitals and Ayder Tertiary Hospital were included in the study.

For the cost: Charts of community acquired pneumonia patients that occurred during the period
of July, 2014 to July, 2015 aged 18 years and above, treated in all zonal hospitals of Tigray and
Ayder tertiary hospital were included in this study.

4.3.3.2. Exclusion criteria

For Magnitude: exclusion was done if the patients had history of hospital admission 14 days
before their current visit to the hospitals, if the pneumonia was developed 48 hrs following
admission, patients with tuberculosis (TB) or previous chest X-ray which may conflict with
diagnosis of CAP, chronically debilitated patients, patients with lung cancer and asthma .
Moreover, incomplete charts were also excluded.

For Risk factors: Patients who had history of hospital admission 14 days before the data
collection period, patients who developed pneumonia 48hrs following admission, patients with
tuberculosis (TB) or previous chest X-ray, which might conflict with diagnosis of CAP,
chronically debilitated patients and patients with lung cancer and asthma were excluded from
the study.

23
For cost: if the patients had history of hospital admission 14 days before their arrival in the
hospitals, if the pneumonia was developed 48 hrs following admission, patients with tuberculosis
(TB) or previous chest X-ray which may conflict with diagnosis of CAP, chronically debilitated
patients, patients with lung cancer and asthma were excluded from the study. Moreover,
incomplete charts were also excluded

4.3.4. Sample Size and Sampling Methods

4.3.4.1 Sample size determination

For the magnitude: considering 95% confidence interval, probability of 50% (as there is no
similar research), and 3% precision, the sample size was calculated to be 1056 using the
following single proportion formula.

N= z2 p(1-p)

d2

But finally all medical records (registers) of community acquired pneumonia cases that had been
diagnosed and treated, in the period of July, 2013 to July, 2015 from the six zonal hospitals and
Ayder Tertiary Hospital were included.

For the case control: Sample size was calculated using double population proportion formula
with the assumptions of 26 % exposure in controls (considering smoking as a risk factor) and
(123) (OR=2.0), power of 80%, a confidence interval of 95% and a ratio of cases to controls of
two.Then, the required sample size was 120 cases and 240 controls.

For the cost study: considering 95% confidence interval, probability of 50% (as there is no
similar research), and 3% precision, the sample size was calculated to be 1056 using the
following single proportion formula.

N= z2 p(1-p)

d2

24
Finally, to estimate the cost of illness all medical records (registers) of community acquired
pneumonia cases that had been diagnosed and treated during the period of July,2014 to July,2015
from the six zonal hospitals and Ayder Tertiary Hospital were included.

4.3.4.2 Sampling Methods

For Magnitude: all medical charts of CAP treated during the period of July,2013 to July,2015
were needed; First the eligible charts were identified then, reviewed from each study hospital.

For case control: cases were selected from CAP patients who came to the zonal hospitals and
Ayder tertiary hospital for treatment, whose age was 18 years and above, who consented to
participate in the study were selected for the interview and for diagnosis of CAP signs and other
examinations. Similar procedure was followed in selecting the controls. Since the number of
cases were rare all cases were included in the study until the required number was met and
controls were selected through systematic sampling method after proportional allocation to each
zonal hospital and Ayder Tertiary Hospital.

For the cost study: all medical charts of CAP treated during the period of July,2014 to July,2015
were needed; First the eligible charts were identified then reviewed from each hospital.

4.4 Data collection

4.4.1 Data collection tools

For magnitude: Data were collected using a checklist which was adapted from relevant
literatures (73-76). Socio-demographic characteristics of the patients, diagnosis, treatment given
and any other management provided were collected from the medical records in each hospital.

For risk factors: A semi-structured interviewer-administered questionnaire was adapted from

different literatures (81, 84, 89-98). The questionnaire included structured information on the
socio-demographic characteristics, life styles and habits, medical history and environmental
conditions of both cases and controls. The questionnaire was prepared in English and translated
into Tigrigna, and back-translated to English to ensure consistency in phrasing of questions.

25
For cost of illness: Data were collected using a checklist which was adapted from relevant
literatures(116-120) to explore the socio-demographic characteristics of the patients, diagnosis,
treatment given and cost of the illness.

4.4.2 Data collection procedures

Data collectors and supervisors were health care professionals (nurses and health officers). A
total of 21 data collectors and 7 supervisors were enrolled. Intensive training was given for the
data collectors and supervisors for three days on the objectives of the study, data collection tools
and procedures to ensure consistency of interviewing and generation of high-quality data.

For magnitude: first all patient charts with CAP that fulfilled the case definition, in both sexes
aged > 18 years and patients who had been treated in that particular hospital were screened. Then
all cards that fulfilled the eligibility criteria within the specified period were reviewed using the
developed checklist.

For risk factors: first the required number of questionnaire were distributed to each hospital
according to the calculated sample size and patients flow then data were collected using the
questionnaire within two months period.

For cost: first all patient charts with CAP that fulfilled the case definition, in both sexes and
aged > 18 years and patients who had been treated in that particular hospital were screened. Then
all cards that fulfilled the eligibility criteria within the specified period were reviewed using the
developed checklist.

4.4.3 Variables of the study

For the magnitude: Socio-demographic variables (age, sex, economic status, educational status,
marital status, etc) and clinical characteristics.

For the risk factors:

Outcome variable: Community acquired pneumonia

Exposure variables:

26
Socio-economic and demographic characteristics (age, sex, economic status, educational status,
marital status, etc)

Life styles and habits (smoking, alcohol use, physical exercise, etc)

Environmental variables ( living/working environment, history of contact with animals and birds,
etc.)

Variables of medical history ( diabetes, cardiovascular, dental, renal, mental, cancer, liver and
gastrointestinal problems)

For the cost: Socio-demographic variables, clinical characteristics and cost of illness related
variables (cost spent for drugs, hospital admissions, radiograph and laboratory etc)

4.5 Data management and Analysis

Once the data were collected it was handled confidentially, code book was prepared, the data
were coded and double entered into Epi info 2002 on a daily basis. Data checking was done to
verify the consistency and backups were saved. Data cleaning were conducted for errors.

Data analysis for the magnitude: after exporting the data from EPI INFO 2002 to SPSS Version
20 frequency distributions, proportions and measures of central tendency had been calculated.

Data analysis for the risk factors: after exporting the data from EPI INFO 2002 to SPSS Version
20 frequency tables and proportions were used to present the descriptive part of the results. In
addition, the associations between the exposure and outcome variables were determined using
bivariate and multivariable logistic regression analysis. Odds ratios with 95% confidence
intervals and p-value were calculated to measure the strength of associations.

Data analysis for the cost was conducted using descriptive statistics, numerical summary
measures, and simple linear regression analysis. The methods of cost estimation employed in this
study included a bottom-up approach in order to estimate direct patient side medical cost of
Community acquired pneumonia whereas the indirect cost was calculated in terms of
productivity time losses (work days) due to hospitalization, using a human capital approach.

The direct costs estimated were medical costs, like diagnostics, medications and cost of
hospitalization. Indirect costs were defined as work days lost due to the illness. The indirect cost
27
estimates constitute earnings lost because of hospital stay related to community acquired
pneumonia.

Individual cost items were summed up to the categories of medical costs and lost income
because of hospitalization. The total cost of community acquired pneumonia for each patient was
calculated as the sum of the direct costs and the indirect costs. All costs were first calculated in
Ethiopian Birr and then converted into US dollars.

4.6 Data quality Assurance

For the magnitude: To assure the quality of data/research pre-test was conducted on 10% of the
total charts to evaluate the completeness and consistency of the checklist. Accordingly,
appropriate modifications and adjustments were made. Data were collected using trained
nurses/health officers, with at least some years of work experience on data collection and
research with supervision. At the end of every data collection day, each questionnaire was
examined and pertinent feedback was given to the data collectors and supervisors. Data entry
were carried out by an experienced data entry clerk with close supervision by the principal
investigator. Data cleaning were conducted exclusively by the principal investigator, and
finalized check list was stored in a well secured cabinet.

For the case control: To assure the quality of the data/research the adapted questionnaire was
prepared using a simple and easily understandable Tigrigna Language. Standardization on
translation was given emphasis during training. Pre-test was conducted on 10% of study subjects
to evaluate the completeness and consistency of the tools. Accordingly, appropriate modification
and corrections were made. At the end of every data collection day, each questionnaire was
examined and pertinent feedback was given to the data collectors and supervisors. Data entry
were carried out by an experienced data entry clerk with close supervision by the principal
investigator. Data cleaning were conducted out exclusively by the principal investigator,
finalized questionnaires and the data were stored in a well secured cabinet.

For the cost: To assure the quality of the data/research pre-test was conducted on 10% of the
total charts to evaluate the completeness and consistency of the checklist. Accordingly,
appropriate modifications and adjustments were made. Data were collected using trained
nurses/health officers with at least some years of work experience on data collection and research

28
with supervision. At the end of every data collection day, each questionnaire was examined and
pertinent feedback was given to the data collectors and supervisors. Data entry were carried out
by an experienced data entry clerk with close supervision by the principal investigator. Data
cleaning was conducted exclusively by the principal investigator, and finalized check list was
stored in a well secured cabinet.

4.7 Ethical Considerations

Ethical clearance was obtained from Institutional Review Board (IRB) of the Addis-Ababa
University, College of Health Sciences. Letter of agreement was secured from Tigray Regional
Health Bureau.

For the record review of the study, waiver of consent was obtained from IRB of AAU and
additional consent was obtained from the hospital administrators after explaining the purpose of
the study and they were informed that every patient record would be kept confidential at any
time.

All documents used in this research were kept private and confidential (data were password
protected and filled questionnaire and check lists were kept locked in a cabinet). No information
other than for the purpose of this study was collected from the patients charts. Moreover,
respondents were not identified by names or any other identifiers.

For the case control study: all participants were informed about the purpose of the study and
individual written informed consent was solicited to the selected respondents at the time of data
collection and examination, the data collectors and the principal investigator were blinded about
the cases and controls of CAP, only the physicians in charge were aware because they were in
charge of providing all necessary management in relation to CAP. Respondents were not
identified by name; they were also informed that they had the right to participate, not to totally
participate and to withdraw any time they like during the study. Furthermore, health education
about prevention and treatment of CAP had been provided.

The beneficiaries of this research will be primarily CAP patients, the scientific society, the
government, and the public in general.

29
V. Tabular Summary of the Methods Applied in the Dissertation
Table 1: Summary of methods based on objectives of the study

S/no Objectives Study design Study subjects Sample size Data collection Data analysis
utilized tools

1 To determine the magnitude A retrospective Medical records of All Charts (5877) Check list Descriptive
of CAP among hospital hospital based community acquired adapted from analysis
(Frequency
treated adults in medical-record pneumonia patients different distributions
Tigray,Ethiopia review aged > 18 years that literatures , proportions
occurred in the years and
July,2013 to July, measures of
central
2015 in all zonal tendency)
hospitals and Ayder
Teritary Hospital

2 To identify risk factors of A case control Sampled men and 360 (120 cases Semi structured Descriptive
CAP among hospital treated study design women with/without and 240 controls) Interviewer analysis and
adults in Tigray,Ethiopia Community acquired administered logistic regression
pneumonia, age > 18 questionnaire analysis
years and who had (adapted from
been treated at different (Bivariate and
Ayder Teritary literatures) multi variable)
Hospital and all
zonal hospitals of
Tigray region.

3 To estimate the cost of A retrospective Medical records of All charts (1174) Check list Descriptive
illness of CAP among hospital based community acquired adapted from analysis, Bottom-
30
hospital treated adults in medical-record pneumonia patients, different Up approach,
Tigray,Ethiopia review aged > 18 years that literatures human capital
occurred in the year approaches and
July,2014-July,2015 simple linear
in all the zonal regression analysis
hospitals and Ayder
Teritary Hospital

31
VI. Results (Review of Main Findings in the Manuscripts I–III)
In this section, main findings from the three manuscripts are outlined and reviewed.
Table 2: Summary of main findings from the three manuscripts

MS Objective Main findings

I To determine the magnitude of  There were a total of 36,005 patients (20,764 males and 15,241
CAP among hospital treated adults females) with all types of pneumonia treated during the study period
in Tigray,Ethiopia (July, 2013 to July, 2015) in the six zonal hospitals and one teritiary
hospital of Tigray regional state.

 During the study, there were 5877 medical records of adult

community acquired pneumonia cases

 The proportion of community acquired pneumonia was 16%, with

male to female ratio of 0.94 to 1 (16 and 17% for males and females,
respectively).

 Overall, patients treated at inpatient department accounted for 9.8%.

 For the total 574 admitted patients due to community acquired

pneumonia, the mean length of hospital stay was 6 days with SD of
5.59 days.

II To identify risk factors of community  Only 7(5.8%) of the cases and 12(5%) of the controls were current
acquired pneumonia among hospital smokers of any tobacco products, such as cigarettes.
treated adults
 In the last 30 days, 18 of cases and 34 of controls consumed 2
glasses of alcohol drink on average in one drinking occasion

 Only 15(12.5%) cases and 34(14.2%) controls were involved in

32
 vigorous-intensity sports, fitness or recreational (leisure) activities
that cause large increases in breathing or heart rate

 Fifty one (42.5%) cases and 86(35.8%) controls were ever admitted
in the last five years.

 Twenty six (21.7%) cases and 43(18%) controls were ever

bedridden for the last three months.

 In the last one year, 71(59.2%) cases and 98(40.8%) controls had
upper airway problem

 Eighty five (70.1%) cases and 16(6.7%) of the controls had previous
history of pneumonia confirmed by radiography

 Seventy (58.3%) of the cases and 107 (44.6%) of the controls had a
history of contact with pets,

 Thirty two (26.7%) cases and 51(21.2%) controls had history of

contact with birds. About 61% of the cases and 46% of the controls
had been exposed to dusty environment

 Only four of the variables, namely working in a dusty environment

[OR=2.0, 95% CI 1.1-4.1)], history of respiratory infection in the
last year[OR=2.5, 95% CI 1. 2-5.3], contact with people who had
respiratory infection [OR=2.3, 95% CI 1.5-5.7] and previous
history of pneumonia confirmed by radiograph [OR=39, 95% CI
19.4-78.6] had statistically significant association with CAP.

33
III To estimate the cost of illness of  The mean hospital stay for participants treated at the inpatient
CAP among hospital treated adults department was 7.43 (+7.7) days.
in Tigray,Ethiopia
 The hospital bed occupancy rate for the admitted patients of
community acquired pneumonia over the study year was 0.3%

 The total amount of money incurred over the study year was
319,056.52 Ethiopian Birr ($15,193.2)

 The mean cost of illness per episode of community acquired

pneumonia was 168 Eth.Birr ($8) for out pts and 775 ($37) for in
patients respectively.

 About 76% (242889.60 Ethiopian Birr (US$11,566.20)) of the total

money was attributed for direct medical expenditure

 The work related cost lost by the patients because of the community
acquired pneumonia was 76166.92 Eth B ($3627)

 Using linear regression model, we obtained a regression equation

Y= 454.95X+22 indicating that for every single day increment in
inpatient hospital stay there is an equivalent increment of ETB 22
($1.05).

34
6.1. Magnitude of Community Acquired Pneumonia
There were a total of 36,005 patients (20764 males and 15241 females) aged 15 years and above

with all types of pneumonia treated during the study period between July, 2013 and July, 2015 in

the six zonal hospitals and one referral hospital of Tigray Regional State. In this study, a total of

6477 charts were registered on the health information management system of the study hospitals

as community aquired pneumonia but 600 charts were excluded during the reviewing process

because of misclassification and misdagnosis. Finally only 5877 medical records of adult

community acquired pneumonia cases fulfilled the case definition for the study, making the

proportion of community acquired pneumonia 16%, with male to female ratio of 0.94 to 1 (16

and 17% for males and females, respectively) (Table 3).

The mean age of community acquired pneumonia cases treated in all the study hospitals was

37.5 (+16.65) ranging from 18 to 92 years. Of the total patients aged below 65 years 504 (9.5%)

were treated at inpatient department and 70 (12%) of patients aged 65 years and above were

treated at the inpatient department.Atotal of 3322(56.5%) were males among which 399(11.8%)

were treated at inpatient, while 181(7.1%) of females were inpatient. Farmers constitute higher

proportion (51.5%) of the total cases of CAP, of whom 326(10.8%) were treated at inpatient.

Overall 9.8 % of patients were treated at inpatient (Table 3).

35
Table 3. Socio-demographic characteristics of the study participants versus site of treatment, 2016

(n=5877)

Characteristics Department patients treated Total

Inpatient Outpatient
No (%) No (%) No (%)
Age
Below 65 504 (9.5) 4789 (90.5) 5293 (90.1)
65 and above 70 (12.0) 514 (84.0) 584 (9.9)
Mean (SD) 37.5(+16.65)
Sex
Male 393(11.8) 2929(88.2) 3322(56.5)
Female 181(7.1) 2374(92.9) 2555(43.5)

Occupation
Farmer 326(10.8) 2703(89.2) 3029(51.5)
Student 121(8,5) 1297(91.5) 1420(24.2)
Civil Servant 44(6,7) 606(93.3) 653(11.1)
House wife 56(11.6) 428(88.4) 484(8.2)
Private employee 25(8.6) 266(91.4) 291(5.0)

Total 574(9.8) 4603(90.2) 5877

No (%)

36
6.2. Clinical characterstics of the study participants
One thousand four hundred eleven (24%) community acquired pneumonia patients were treated

in Adigrat hospital, of whom 91% were treated as outpatients. Higher proportion of cases were

treated at the inpatient departments of Suhul and Kahsay Abera hospitals (29 and 18%,

respectively) as compared to the other public hospitals which had less than 10% of inpatient

treatments. Of the total 574 admitted patients due to community acquired pneumonia, the mean

length of hospital stay was 6 days with SD of 5.59 days. (Table_4).

Table 4. Clinical characteristics of the study participants versus site of treatment, 2016 (n=5877)

Characteristics Department patients treated Total

Inpatient Outpatient
No (%) No (%) No(%)
Treatment
Hospital
Adigrat 124 (8.8) 1287 (91.2) 1411 (24.0)
Ayder 47 (10.9) 385 (89.1) 432 (7.4)
Kahsay Abera 39 (18.4) 173 (81.6) 212 (3.6)
L.Karl 57 (6.3) 887 (83.7) 944 (16.1)
Mekelle Hospital 50 (4.0) 1269 (96.0) 1319 (22.4)
St.Marry 57 (6.5) 811 (93.5) 873 (14.9)
Suhul 200 (29.2) 486 (71.8) 686 (11.7)
Referal status
Reffered 204 (61.8) 126 (38.2) 330 (5.6)
Not referred 370 (6.7) 5177 (93.3) 5547 (94.4)

Length of
hospital stay
1-6 Days 424(74) 1
> 7 Days 150(26)
Mean(SD) 6(+5.59)

Total 574 (9.8) 4603(90.2) 5877

No (%)

37
6.3. Risk factors of community acquired pneumonia
6.3.1. Community acquired pneumonia by Socio-demographic characteristics

Among the socio -demographic factors, age and education were significantly associated with

CAP. The mean age of the cases and controls was 37.2 (+14.4) and 33.8(+13.6), respectively.

Fifty six (46.7%) of the cases and 130 (54.2%) of the controls were males. Forty nine (40.8%)

cases and 67(27.9%) controls had no formal education. One hundred eleven (92.5%) cases and

222(92.5 %) controls were Tegaru by ethnicity. One hundred twelve (50%) of the controls and

62(51.7%) cases were married. Forty seven (39.2%) of the cases and 88(36.7%) controls were

self employed. Two or more persons sleep in one room in 43 (35.8%) of cases and 72(30%) of

controls. Only one window was available in 86 (71.7%) of cases and 183(76.25%) controls. The

mean BMI of the cases and controls was 20.99 (Min 12, Max 30) and 21.45(Min 15, Max 30)

respectively (Table 5).

38
Table 5. Community Acquired Pneumonia by socio-demographic characteristics, 2016
(n=360)
Characteristics Cases Controls COR[95%CI],
n=120(%), n=240(%), t(df), p
Mean(SD) Mean(SD)

Age Uncategorized 37.2(14.4) 33.8(13.6) t(358)= -2.2

P=0.03

Sex Male 56(46.7) 130(54.2) 1.3(0.87,2.1)

Female 64(53.3) 110(45.8) 1

Level of No formal education 49(40.8) 67(27.9) 1.8(1.1,2.8)

education
Educated 71(59.2) 173(72.1) 1

Marital status Never married 41(34.2) 99(41.3) 2.4(0.93, 6.23)

Currently married 62(51.7) 120(50) 1.9(0.76, 4.89)
Divorced 7(5.8) 11(4.6) 1.5(0.43, 5.71)
Widowed 10(8.3) 10(4.2) 1
Number of One 13(10.8) 32(13.3) 0.79(0.39,1.5)
people live in a Greater than one 107(89.2) 208(86.7) 1
household
Number of One 17(14.2) 49(20.4) 0.64(0.35,1.2)
people use/sleep Two and above 103(85.8) 191(79.6) 1
in a single room
Number of No 7(5.8) 13(5.42) 1.1(0.42, 2.8)
windows in a Yes 113(94.2) 227(94.58) 1
room
BMI Uncategorized 20.99(2.965) 21.45( 2.782) t(358)= 1.5
P=0.15

39
6.3.2. Community acquired pneumonia by Life style and Habits

None of the life style or habit related variables were associated with CAP. Only 7(5.8%) of the
cases and 12(5%) of the controls were current smokers of any tobacco products, such as
cigarettes. All, 12(100%) of the smokers from the control group and 4 (57.1%) of the smokers
from the case group smoke 1-9 cigarettes per day where as 3(42.9%) of the smokers from the
cases did not know how many cigarette they smoke daily (Table-6).

Ninety two (76.7%) of the cases and 179(74.6%) of the controls ever consumed alcohol. Of the
alcohol consumers, 41(44.5%) cases and 111(62%) controls consumed alcohol in the last thirty
days,among whom 26 (63.4%) of cases and 59(53.1%) of controls consumed alcohol 1-3 days
per month. In the last 30 days 18 of cases and 34 of controls consumed 2 glasses of alcohol drink
on average in one drinking occasion. The largest alcohol intake they had in one occasion in the
last 30 days was 3 and 5 by most cases and controls (Table 6).

Regarding involvement in vigorous-intensity activity, 32 (26.7%) cases and 68(28.3%) controls

were involved in vigorous intensity activity.Twelve (37.5%) of the cases and 18(26.5%) of
controls spent 5 days each in vigorous intensity activities, respectively (Table 6).

About half(49.5%) of the cases and 46.4% of the controls walk or use bicycles for at least 10
minutes continuously to get to and from places for seven days a week. Forty (36%) cases and
79(35.6%) controls spent in walking or using a bicycle for thirty minutes per day.

Only 15(12.5%) cases and 34(14.2%) controls were involved in vigorous-intensity sports, fitness
or recreational (leisure) activities that cause large increases in breathing or heart rate. Six (40%)
of those cases and 10(29.4%) controls were involved for 1 day per week. From the cases
4(26.7%) and controls 9(26.5%) were involved in vigorous-intensity sports, fitness or
recreational (leisure) activities that cause large increases in breathing or heart rate for 30 minutes
in a typical day ( Table 6).

40
Table 6. Community Acquired Pneumonia by lifestyle and habits of study participants,
2016 (n=360)
Life style/Habit Category Cases Controls COR[95%CI]
n=120 (%) n=240 (%)
Currently smoke tobacco product Yes 7(5.8) 12(5) 0.85(0.32,2.22)
No 113(94.2) 228(95) 1
Ever consumed alcohol drink Yes 92(76.7) 179(74.6) 0.89(0.53, 1.49)
No 28(23.3) 61(25.4) 1
Involve vigorous-intensity activity Yes 32(26.7) 68(28.3) 1.08(0.66, 1.78)
that causes large increases in No 88(73.3) 172(71.7) 1
breathing or heart rate
Involve moderate-intensity activity, Yes 42(35) 85(35.4) 1.02(0.64, 1.61)
that causes small increases in No 78(65) 155(64.6) 1
breathing or heart rate
Walk or use a bicycle (pedal cycle) Yes 111(92.5) 222(92.5) 1.0(0.43, 2.29)
for at least 10minutes continuously No 9(7.5) 18(7.5) 1
to get to and from places
Do any vigorous-intensity sports, Yes 15(12.5) 34(14.2) 1.15(0.60, 2.22)
fitness or recreational (leisure) No 105(87.5) 206(85.8) 1
activities that cause large increases
in breathing or heart rate
Do any moderate-intensity sports, Yes 12(10) 43(18) 0.51(0.26, 1.0)
fitness or recreational (leisure) No 108(90) 197(82) 1
activities that causes a small
increase in breathing or heart rate

41
6.3.3. Community acquired pneumonia by Medical History

Among previous medical histories, history of upper airway problem, tonsillectomy, contact with
persons who had respiratory infection, confirmed pneumonia and history of pulmonary
tuberculosis were significantly associated with CAP. As shown in Table 7 , 51 (42.5%) cases
and 86(35.8%) controls were ever admitted in the last five years. In addition, 26(21.7%) cases
and 43(18%) controls were ever bedridden for the last three months. In the last one year,
71(59.2%) cases and 98(40.8%) controls had upper airway problem. Only 8(6.7%) cases and
5(2.1%) controls had history of tonsillectomy. None of the cases were vaccinated for influenza
in the last year where as only 1(0.4%) control was vaccinated for influenza last year. In the last
year, 59(49.2%) of the cases and 51(21.3%) of controls had any infection of the respiratory
system. Thirty two (26.7%) cases and 29(12.1%) controls had history of contact with people who
had respiratory infection. 85(70.1%) cases and 16(6.7%) of the controls had previous history of
pneumonia confirmed by radiography (Table-7 ).

42
Table 7. Community Acquired Pneumonia by medical history of study participants,
2016(n=360)
History Category Cases Controls COR[95%CI]
n=120(%) n=240(%)
Ever admitted in the last five yearsYes 51(42.5) 86(35.8) 0.75(0.48,1.18)
No 69(57.7) 154(64.2) 1
Ever bedridden in the last three Yes 26(21.7) 43(18) 0.78(.45, 1.36)
months No 94(78.3) 197(82) 1
Had upper air way problem last year Yes 71(59.2) 98(40.8) 2.1(1.3,3.3)
No 49(40.8) 142(59.2)
Had history of tonsillectomy Yes 8(6.7) 5(2.1) 3.4(1.1,10.5)
No 112((93.3) 235(97.9) 1

Had history of dental visit last month Yes 11(9.2) 30(12.5) 1.41 (0.68, 2.93)
No 109(90.8) 210(87.5) 1
Get vaccinated for influenza last Yes 0(0) 1(0.4) .0(0)
year No 120(100) 239(99.6) 1

Get vaccinated for any respiratory Yes 2(1.7) 6(2.5) 0.6(0.1,3)

infection last year No 118(98.3) 234(97.5) 1

Had any respiratory infection last Yes 59(49.2) 51(21.3) 3.6 (2.2,5.8)
year No 61(50.8) 189(78.7) 1

Had contact with people who had Yes 32(26.7) 29(12.1) 2.6(1.5,4.6)
respiratory infection No 88(73.3) 211(87.9) 1
Previous history of pneumonia Yes 85(70.8) 16(6.7) 34(17.9,64.6)
confirmed by radiograph No 34(29.2) 224(93.3) 1

History of diabetes Yes 8(6.7) 18(7.5) 1.13(0.48, 2.69)

No 112(93.3) 222(92.5) 1
History of cardiopathy Yes 9(7.5) 23(9.6) 1.3(0.58, 2.92)
No 111(92.5) 217(90.4) 1
History of chronic bronchitis Yes 4(3.3) 13(5.4) 0.6(0.2,1.9)
No 116(96.7) 227(94.6) 1

History of diagnosed asthma Yes 5(4.2) 18(7.5) 1.86(0.67,5.15)

No 115(95.8) 222(92.5) 1
History of pulmonary TB Yes 18(15) 18(7.5) 2.2 (1.1,4.4)
No 102(85) 222(92.5) 1
History of gastric Diseases Yes 61(50.8) 129(53.8) 0.9(0.6,1.4)
No 59(49.2) 111(46.2) 1
History of CLD Yes 4(3.3) 7(2.9) 1.1(0.3,4.0)
No 116(96.6) 233(97.1) 1

43
6.3.4. Community acquired pneumonia by Environmental factors

History of contact with pets and history of working in dusty environments were significantly
associated with CAP. Seventy (58.3%) of the cases and 107 (44.6%) of the controls had a history
of contact with pets, while (26.7%) cases and 51(21.2%) controls had history of contact with
birds. About 61% of the cases and 46% of the controls had been exposed to dusty environment
(Table 8).

Table 8. Community Acquired Pneumonia by environmental factors of study participants,

2016(n=360)
Variable Category Cases Controls COR[95%CI]
n=120(%) n=240(%)
History of contact Yes 93(77.5) 175(73) 1.2(0.8, 2.1)
with children No 27(22.5) 65(27) 1
History of contact Yes 32(26.7) 51(21.2) 1.4(0.8, 2.2)
with birds No 88(73.3) 189(78.8) 1
History of contact Yes 42(35) 82(34.2) 1(0.7, 1.6)
with Animals No 78(65) 158(65.8) 1
History of contact Yes 70(58.3) 107(44.6) 1.7(1.1, 2.7)
with pets No 50(41.7) 133(55.4) 1
History of working in Yes 73(60.8) 111(46.3) 1.8(1.2,2.8)
a dusty environment No 47(39.2) 129(53.7) 1

Electric stove 16(13.3) 48(20) 1

Cooking fuel Wood 67(55.8) 118(49.2) 1.3(0.62,2.74)
Electric, coal &
wood 1310.8) 19(7.9) 0.76(0.43, 1.35)
Electric, coal&
kerosene 24(20) 55(22.9) 0.64(0.27, 1.49)

44
In the final logistic regression model, we included variables that were significantly associated

with CAP at the univariate analysis, and found that only four of the variables, namely working in

a dusty environment, history of respiratory infection in the last year, contact with people who

had respiratory infection and previous history of pneumonia confirmed by radiograph having

statistically significant association with CAP. As shown in Table 9, the odds of developing

community acquired pneumonia among those working in a dusty environment was two times

higher as compared to their counterparts [OR=2.0, 95% CI 1.1-4.1)], the odds of developing

CAP among those who had history of contact with people who had respiratory infection was 2.5

times higher as compared to those who did not have history of contact [OR=2.5, 95% CI 1. 2-

5.3], those who had history of respiratory infection were about twice more likely to develop

community acquired pneumonia than those who did not have the same history [OR=2.3, 95% CI

1.5-5.7] and the odds of developing pneumonia among those who had history of pneumonia

confirmed by radiography was 39 times higher compared to those who had not [OR=39, 95% CI

19.4-78.6](Table 9)

45
Table 9. Potential risk factors for Community Acquired Pneumonia among the study
participants, 2016 (n=360)

Variable Category Cases Controls AOR[95%CI]

n=120(%) n=240(%)
Age Uncategorized 0.9(0.9,1.0)
Educational level No formal edu 49(40.8) 67(27.9) 1.7(0.8,3.9)
Educated 71(59.2) 173(72.1) 1
Contact with pets Yes 70(58.3) 107(44.6) 1.3(0.7,2.4)
No 50(39.2) 133(55.4) 1
Working in dusty Yes 73(60.8) 111(46.3) 2.0(1.1,4.1)
environment No 47(39.2) 129(53.7) 1
Had upper air way Yes 71(59.2) 98(40.8) 1.6(0.8,3.2)
problem last year No 49(40.8) 142(59.2) 1
Had history of Yes 8(6.7) 5(2.1) 0.7(0.14, 3.3)
tonsillectomy No 112((93.3) 235(97.9) 1

Had any respiratory Yes 59(49.2) 51(21.3) 2.3(1.5,5.7)

infection last year No 61(50.8) 189(78.7) 1

Had contact with Yes 32(26.7) 29(12.1) 2.5(1.2,5.3)

people who had No 88(73.3) 211(87.9) 1
respiratory infection
History of pneumonia Yes 85(70.8) 16(6.7) 39(19.4,78.6)
confirmed by No 34(29.2) 224(93.3) 1
radiograph
History of pulmonary Yes 18(15) 18(7.5) 0.9(0.3,2.6)
TB No 102(85) 222(92.5) 1

46
6.4. Cost of illness among hospital treated adults
6.4.1 Socio-demographic and clinical characteristics

In this study, we reviewed one thousand and one hundred seventy four medical records of

community acquired pneumonia adult patients treated in Tigray Zonal and tertiary hospitals.

Two hundred twenty three (19%) and 951(81%) patients were treated at inpatient and outpatient

departments, respectively. One hundred ninety one (17.8%) and 881(82.2%) patients treated at

inpatient and outpatient departments, respectively were below the age of 65 years. From the total

patients 663(56.5%) were males of whom 530(79.9%) were treated at outpatient department.

One thousand and twenty eight patients (87.6%) were treated in the hospitals without being

referred, of whom 147(14.3) patients were treated at inpatient department (Table 10).

Higher proportion (about 73.5%) of patients were treated at three zonal hospitals namely

Suhul(27%), Adigrat (24%) and Mekelle (22.5%). Mekelle hospital had highest (60) number of

patients treated at inpatient department while no patient had been treated at inpatient department

of Ayder referral hospital. Moreover, the mean hospital stay for participants treated at the

inpatient department was 7.4 (+7.7) (Table-10).

Furthermore, the hospital bed occupancy rate for the admitted patients of community acquired

pneumonia over the study year was 0.3% ; there were a total of 1522 beds in the study hospitals

and a total of 1657 inpatient days were observed.

47
Table 10. Socio-demographic and clinical characteristics of the study participants versus site of

treatment, 2016 (n=1174)

Characteristics Department patients treated Total

Inpatient Outpatient
No (%) No (%) No (%)
Age
Below65 191(17.8) 881(82.2) 1072(91.3)
65 and above 32 (31.4) 70(68.6) 102(8.7)
Sex
Male 133(20.1) 530(79.9) 663(56.5)
Female 90(17.6) 421(82.4) 511(43.5)

Occupation
Farmer 133(21.5) 485(78.5) 618(52.6)
Student 38(12.3) 270(87.7) 308(26.2)
Civil Servant 19(18.8) 82(81.2) 101(8.6)
House wife 15(15.5) 82(84.5) 97(8.3)
Private employee 18(36.0) 32(64.0) 50(4.3)

Referral Status
Referred 76(52.1) 70(47.8) 146(12.4)
Not referred 147(14.3) 881(85.5) 1028(87.6)
Treatment Hospital
Sihul 37(27.0) 100(73.0) 137(11.7)
St.Marry 21(12.1) 153(87.9) 174(14.8)
Kahsay Abera 21(50.0) 21(50.0) 42(3.6)
Adigrat 49(17.4) 233(82.6) 282(24)
Mekelle 60(22.7) 204(77.3) 264(22.5)
Ayder 0 86(100) 86(7.3)
Lemlem Karl 35(18.5) 154(81.5) 189(16.1)
Length of hospital stay
7.4 days or lower 161(72.2)
More than 7.4days 62(28)
Mean(SD) 7.43 (7.7)
Total 223(19.0) 951(81.0) 1174

48
6.4.2 Cost of treatment for community acquired pneumonia

The total amount of money incurred over the study year was 319,056.52 Birr ($15,193.2) with

the mean cost per episode of community acquired pneumonia of 168($8) Birr for outpatients and

775 Birr ($37) for in patients, respectively. About 76% (242889.60(11,566.20)) of the money

was attributed for direct medical expenditure of which 126,415.8(6,019.8) was incurred by

outpatients and 116473.8 (5546.4) by the inpatients. The work related cost lost by the patients

due to the community acquired pneumonia was 76166.92 Eth B ($3627) (Table-11).

Table 11. Cost of treatment among patients with community acquired pneumonia
according to site of care, 2016(n=1174)

Expenditure Inpatient Outpatient Sub Total

category
EthB(USD) EthB(USD)

Registration Fee 1554(74) 6430(306.2) 7984(380.2)

Bed stay 38634.75(1839.75) - 38634.75(1839.75)
Blood Test 9804 (466.85) 22847.34(1087.96) 32651.34(1554.8)
Other Tests 1183(8.7) 2368.6(112.8) 3551.6(169)
X-Ray 11925(567.85) 32606.5(1552.7) 44531.5(2120.5)
Antibiotic 50361.24(2398.15) 60153.66(2864.46) 110514.9(5262.6)
Anti Pain 755.7 (36) 1105.5 (52.6) 1861.2(88.10)
Other drugs 2256.1(107.4) 904.2 (43) 3160.3(150.5)
Sub-total 116473.8 (5546.4) 126,415.8(6,019.8) 242889.60(11,566.20)
Grand total of patient side cost: Medical expenditure cost (242889.60(11,566.20))
+ Loss of productivity cost (76166.92 Eth B($3627)) =
319,056.52 Birr ($15,193.2)

49
Using simple linear regression model, we obtained a regression equation Y= 454.95X+22

indicating that for every single day increment in inpatient hospital stay there is an equivalent

increment of ETB 22 ($1.05).

Though the regression equation had a poor fit, describing only 28 % of the variance in total cost

of illness due to community acquired pneumonia ( R2adj = 28%), the overall relationship helped

us to understand whether the model that we used is appropriate to predict the cost for each

inpatient hospital stay was statistically significant( F = 86 , p= 0.00).

50
VII. Discussion
This study was conducted for the first time in Ethiopia and other sub-Saharan Africa countries
that attempted to assess the magnitude, risk factors and cost of illness among hospital treated
adult patients (aged >18 years) of community acquired pneumonia in Tigray zonal and tertiary
hospitals.

7.1. Magnitude of community acquired pneumonia

The mean age of the treated patients for CAP in the current study was 37.5 (+16.65) years ,
which is much lower than compared to studies conducted in Canada and Switzerland with mean
ages of 64.4 years and 70.4 years respectively (73,124). Likewise, a study from Germany
confirmed that the median age of community acquired pneumonia patients was 76 years (125).
Similar study from USA concluded that the median age of CAP patients was 57 years (126).
Moreover, another study from USA confirmed that the mean age of admitted patients with
pneumonia was 58.9 years (76). This difference could be because of the small number of elderly
adults participated in our study and higher proportion of elderly adults in the developed nations
in general.

The proportion of community acquired pneumonia in our study was 16% (16 and 17% for males
and females, respectively). Our finding was much lower than previously conducted studies.
Studies conducted in Canada, Italy and Japan reported that the proportion of community
acquired pneumonia ranging between 62 and 63% (73-75),while a study in USA among
community acquired and health care associated pneumonia patients requiring hospital admission
showed that the proportion of CAP was lower (32.6%) than the above reports (76).

The variation might be justified as the difference in environmental condition and diagnosis of
community acquired pneumonia and b.c we didn't adjust age also.Moreover, it could be due to
biological difference of the study participants where most of our participants were young,
physically active, probably have better immunity and health.

In the current study, of all the community acquired pneumonia patients in the study years, only
9.8% patients have been treated as in patients with a mean hospitalization of 6 days, which was
shorter than studies conducted in different countries. A study from Canada confirmed that the
average length of hospitalization in community acquired pneumonia patients was 17 days, a
study from British hospitals revealed that hospital stay in survivors of community acquired
patients averaged 10.8 days (73,127). Likewise, study from Switzerland concluded that the mean
51
treatment duration of community acquired pneumonia patients was 12.1 days (124), However,
the mean length of stay in our study was longer than a study conducted in one community and
three university teaching hospitals in USA which showed that the adjusted inter hospital
differences in mean length of stay ranged from 0.9 to 2.3 days (128). This difference could be
explained by the difference of the severity of the problem,small number of our participants with
comorbidity diseases and pathogenic difference of the admitted patients.On the other hand due
to the low availability of beds admission rates which might differ from place to place in general
and from hospital to hospital in particular.

7.2. Risk factors of community acquired pneumonia

This finding has showed no significant association between smoking and community acquired
pneumonia, while other studies conducted in different countries reported that smoking as one
risk factor for the development of community acquired pneumonia (89-91, 81,92,94,129).
Perhaps only few (19) of our study participants reported to have been smokers which may be a
small number to give a significant information.

Although, some studies have reported that alcohol consumption as being a risk factor for
developing community acquired pneumonia (84,93,130), our study showed no significant
association between alcohol consumption and CAP. Similar to the current study there are
findings which indicated that alcohol consumption is not a risk factor for community acquired
pneumonia (90, 91, 94, 129 ).This could be justified by difference in the number of users, type,
amount and frequency of the alcohol consumption.

Having history of respiratory infections and contact with people who had respiratory infection

were found to be risk factors for the development of community acquired pneumonia which was

also reported by different studies globally (81,89, 91, 94- 96). Similar to previous findings our

study showed that patients with history of pneumonia confirmed by radiograph had higher risk

of a subsequent CAP (89, 91, 96, 97, 98).

In line with a study from Great Britain (90), working in a dusty environment was identified in

our study as one of the major risk factors of community acquired pneumonia. However, contrary

result was also reported by others (89). This dissimilarity could be because of different working

environment, difference in the number of exposure and the nature of the dust.
52
History of diabetes and heart disease were not significantly associated with CAP in this study,

which was also reported by many other studies (90-93), however, studies from different

countries reported that heart disease and diabetes being significant risk factors for CAP

(89,90,93). These differences may be due to that many of our respondents might have not known

their status or not diagnosed for diabetes and heart diseases.

Chronic bronchitis, diagnosed asthma and Pulmonary TB were not associated with CAP in the

current study, as was also reported by others (91, 92). Unlike this, findings showed that chronic

bronchitis, diagnosed asthma and Pulmonary TB are risk factors for community acquired

pneumonia among adults (89-91, 94).

Similar to a finding by Schnoor et al, contact with birds and pets were not significantly

associated with community acquired pneumonia when adjusted for other variables in the current

study(96), but Almirall et al reported that contact with birds and pets as being a risk factor for

the development of community acquired pneumonia (89).

7.3. Cost of illness for community acquired pneumonia

This study attempted to address cost of illness of adult CAP patients which is rarely considered

in Ethiopia and Africa by in large.

In the present study, it is confirmed that the total amount of money incurred over the study year

was 319,056.52 Birr ($15,193.2) and the mean cost of illness per episode of community acquired

pneumonia was 168 Eth.Birr ($8) for out pts and 775 ($37) for in patients respectively which is

much lower than a study from Italy that showed the mean cost per episode of CAP was Euro

1586 (116). Likewise, a study from France showed that the pooled cost of ambulatory and

hospitalized patients was Euro 357.1 (117). The difference may be due to variations in prices of

the treatment packages and resources used.

53
The mean direct medical expense per episode (of the patients) was 522.3 Ethiopian Birr ($25.9)

for inpatients and 132.9 ($6.3) for outpatients. Our finding was not in line with studies from

developed countries, such as a study from France revealed that the mean direct medical cost of a

disease episode of CAP was EU 118.8 for strictly ambulatory patients with an equal weight for

medical time, drugs, diagnostic procedures and tests. This direct cost was EU102.1 before

admission for patients who were finally hospitalized. The mean cost of hospital admissions was

EU 3522.9 (117). Another study from New Zealand concluded that the annual cost (of a societal

perspective for the adult population aged 15 years and over) was estimated to be 63 million

dollars, (direct medical costs of 29 million dollars; direct non-medical costs of 1 million dollars;

lost productivity of 33 million dollars) (118). Furthermore, a study from USA showed that the

mean cost of hospitalization per admission (excluding physician cost) was $US3490 ± $US3058

(median $US2430) (120). Likewise, a study from China confirmed that the median total hospital

cost was $556.50 (mean $705.60) (119). The discrepancies could be because of differences in

severity of the problem, length of the treatment, service consumption and price variations among

the countries.

In the current study the mean working days lost due to CAP for the productive age group of

inpatients (18-64years) was 7.43+7.7 days. As a result the mean amount of money incurred per

episode due to work loss by the in patients and out patients was 256 Eth.Birr (US$12.2) and

34.4 (US$1.6) respectively. Our finding was much lower than the study from France which

showed that the mean number of non-worked days was 10.8 (SD 8.0) for ambulatory patients

and 31.0 (SD 27.2) days for patients who were hospitalized: the impact of the disease episode on

productivity was EU 1980 (SD 1400) per ambulatory episode and EU 5425 (SD 4760) per

episode leading to hospital admission (117).

54
From the total patients in this study, 72% undergone X-ray examination, 98.4% got medication

prescription with the most common being antibiotics and 83.2% undergone laboratory tests.

Unlike ours, a study from France showed that one hundred and seventy-two (19%) patients were

managed without X-rays. White blood cell count was measured in 316 (36%) patients; C-

reactive protein (CRP) and pro-calcitonin levels were respectively assessed in 314 (35%) and

13(1%) patients. Microbiological tests were rarely prescribed (1%), antibiotics were prescribed

medications for most (94%) patients at the inclusion visit (117). Similarly, a study from

Australia confirmed that at least one medication was prescribed (or provided) for 63% of

pneumonia problems, with the most common being antibiotics. Imaging was requested for 29%

of pneumonia contacts, with chest radiology (92%) the most common form. Pathology testing

was sought for 10%, with chemistry, hematology and microbiology, the most common

categories recorded (131). The variations could be because of the availability of different

diagnostic options, knowledge & skill gap of the professionals and lack of standardized

management guideline for community acquired pneumonia in our country.

Of the total direct medical expense, 47.6 % was used for medication, 18% for imaging (X-ray),

15% for laboratory, 16% for bed and 3% for registration which is different from a study

conducted in USA that confirmed bed costs accounted for 55.6% of total costs, followed by

laboratory (9.9%) and pharmacy (9.8%) costs (132). Another study from USA indicated that

from the cost of hospitalization per admission (excluding physician cost) hospital room/board

accounted for the largest percentage (83.7%), followed by laboratory (8.1%), antibacterial

(4.6%), radiology (2.6%) and respiratory (0.9%) cost centers (120). Likewise, a study from

Australia showed that of the total costs of community acquired pneumonia, 60% was used for

medication and 23% for imaging cost (131). Similar study in China revealed that from the total

hospital cost 48.9% was used for drugs, 21.9% for laboratory tests, 8.6% for radiology, 6.3% for

hospital beds and 5.3% for examination (119). The explanation for the discrepancy could be

because of differences in diagnostic and treatment standards among the countries.

55
VIII. Validity
In quantitative research, validity (internal validity) refers to ability to measure correctly what is
supposed to measure (getting the true value). It needs the evaluation of chance, bias and
confounding as alternative explanations for research findings.

In this dissertation, the role of chance was addressed by having adequate and representative
samples to answer each specific objective. Its effect was also detected using the confidence
intervals. In some of the categories of independent variables, small sample sizes were observed
during multivariate analysis. In such situations, re-categorizing by merging or excluding very
small categories were done.

Various actions, starting from questionnaire designing to data analysis, were taken to reduce the
role of bias as alternative explanations for research findings. Use of questionnaires adapted from
standard data collection instruments, use of educated and experienced data collectors, presence
of intensive trainings and close supervision were among the major inputs to reduce
interviewer and other measurement biases.

To control the effect of potential confounders for the case control study, Binary logistic
regression was applied when assessing the associations.

Generalizability (external validity) refers whether results are applicable to other populations.
Since the health care system organizations in the country are similar, the findings can
reasonably be informative about the magnitude, risk factors and cost of illness for community
acquired pneumonia in other health institutions of the country.

56
IX. Strengths and Limitations
This study had a number of strengths. First, in two of the study objectives the study utilized
all medical records of patients who had been treated over the study years which gave us the true
image of the target population and can avoid selection bias .Secondly, the strong side of this
research is that the ascertainment of the cases and controls i.e similar procedures were
undertaken to identify cases and controls by experienced physicians in fully equipped hospitals.
Moreover, data collectors and supervisors were kept blinded from knowing who is a case and
who is a control during interviewing the study participants.

There were also a number of limitations throughout the process of the study. The issue of
incompleteness was one of the limitations of the medical record review design, but the
potential limitation was minimized by cross checking the charts with electronic medical
record. Besides, since the current study is hospital based, it might not be generalized to the
whole community in the region and the country.

In addition, comparison of our findings with previous Ethiopian and/or other sub-saharan Africa
countries data were not possible for there have been no studies examining the cost, magnitude
and risk factors of community acquired pneumonia. Hence, some of the comparisons made with
studies conducted in the advanced countries would be of limited value because of the difference
in the categories of cost, the methods used, the pattern of health services utilization and the
health care system.

Moreover, as the data collected to estimate the cost of illness were from medical records, all
patient side expenses might not be recorded in the charts of the patients. Furthermore, direct non
medical costs and care giver's costs were not studied. Hence, the cost of illness for the study
might be under estimated.

Furthermore, the Adj.R2 value for the linear regression was small (28% ) which is because of
that we didn't include multiple variables which could be one of the limitations of this
study.Besides,since we used convenient sampling technique to select the cases of community
acquired pneumonia (for the case control study) selection bias might have been introduced.

57
X. Conclusion
In conclusion, the current study revealed that the magnitude of community acquired pneumonia

among adults in Tigray zonal and tertiary hospitals was 16%, Community acquired pneumonia

was higher among younger population.

Working in dusty environment, history of pneumonia, history of respiratory infection and having

contact with people who had respiratory infections are confirmed as the risk factors of

community acquired pneumonia in the current study.

The cost incurred among adult patients of community acquired pneumonia in Tigray hospitals is

significant. During the one year period, of the total cost incurred, 76 % was due to direct medical

expense and 24 % was for non-worked days.

58
XI. Recommendation
Tigrai Regional Health Bureau/Federal Ministry of Health

 It is good if Prevention strategies for adults are introduced in the region/country.

 Management guideline has to be developed and uniformly used for the treatment of

CAP.

Health care professionals

 Should provide health education on prevention and promotion strategies of CAP

 Should not undermine the prevalence of community acquired pneumonia and get

appropriate trainings that enable them diagnose and manage the problem properly

 Whenever respiratory tract infections including pneumonia are occurred proper

management should be given so that subsequent infections or complications would be

minimized

 To minimize the risk of developing CAP, health professionals/health care institutions

should promote the use of safety measures like PPE when there is contact with patients

having respiratory tract infections including pneumonia.

Research institutions/ Researchers

 Larger prospective studies are needed:

• to minimize the problem and improve the prevention, promotion and treatment

modalities

• to estimate the comprehensive cost of CAP illness

• to assess the effect of some risk factors in the general population

59
XI-Acknowledgment
I am deeply grateful to e x t e n d my sinces thanks to my supervisors, Professor Fikre

Enqeselassie a n d Dr. Alemayehu Bayray for their unreserved support, continoues

encouragement and immense knowledge they shared me throughout my study. I am very

grateful to Mekelle University, Addis Ababa University and Korea international cooperation

agency for their financial support. I would like to extend my heartfelt thanks to the staffs of

Tigray health bureau, Zonal hospitals and Ayder tertiary hospital for their cooperation to access

their documents and support during data collection processes. Finally, yet importantly, I also

want to acknowledge the study participants, data collectors and supervisors.

60
References

1. Nair GB, Niederman MS. Community-acquired pneumonia: an unfinished battle. Med Clin
North Am. 2011;95:1143-1161.

2. Nga Tong: Priority Medicines for Europe and the World "A Public Health Approach to
Innovation", back ground paper of pneumonia, May 2013

3. Kollef MH, Shorr A, Tabak YP, Gupta V, Liu LZ, Johannes RS. Epidemiology and
outcomes of healthcare-associated pneumonia: results from a large US database of culture
positive pneumonia. Chest 2005;128:3854–3862

4. American Thoracic Society; Infectious Diseases Society. Guidelines for the management of
adults with hospitalacquired, ventilator-associated, and healthcare-associated pneumonia.
Am J Respir Crit Care Med 2005;171:388–416

5. National institute of health- U.S. Department of Health & Human Services available at
https://www.nhlbi.nih.gov/health/health-topics/topics/pnu/types

6. Polverino E, Torres Marti A. Community-acquired pneumonia. Minerva Anestesiol.

2011;77:196-211

7. Center for disease Control and Prevention., Trends in aging United States and Worldwide,
MMWR Morb Mortal Wkly Rep 2003:52:101-4.
8. Jokinen J, Scott JA, Estimating the proportion of pneumonia attributable to pneumococcus
in Kenyan adults: Latent class analysis. Doi 2010: 21(5): 719–725
9. Dean NC,Silver MP. Bateman KA. Frequency of subspecialty physician care for elderly
patients with community acquired pneumonia, Cest 2000, 117: 393-7
10. Jansen AG, Rondenburg GD, de Greef SC, et. al. Invasive pneumococcal infection in
Netherlands: Sundrome, outcome and potential vaccine benefits. Vaccine 2009; 27: 2394-
2401
11. Centers for Disease Control and Prevention. National Hospital Discharge Survey. Number of
discharges from short-stay hospitals, by first-listed diagnosis and age: United States, 2010.
Updates August 22, 2013
12. Bonafede MM, Suaya JA, Wilson KL, et al. Incidence and cost of CAP in a large working-
age population. Am J Manag Care. 2012;18:380-387.

61
13. Giorgi Rossi P,Agabiti N,Faustini et al. The burden of hospitalized pneumonia in Lazio,
Italy, 1997-1998. Int J Tuberc Lung Dis. 2004; 8:528

14. Deshpande A. Epidemiology of Community Acquired Pneumonia Supp Japi 2012;60: 6

15. American Thoracic society, Top 20 Pneumonia facts,2015.

16. British Lung Foundation, pneumonia statistics, 2016
17. Alfonso Rosado Buzzo, Craig Roberts, Lourdes Garcı´a Mollinedo etal. Morbidity and
mortality of pneumonia in adults in six Latin American countries, International Journal of
Infectious Diseases 17 (2013) e673–e677)

18. Woodhead M, Blasi F, Ewig S, Garau J, Huchon G, et al. (2011) Guidelines for the
management of adult lower respiratory tract infections-summary. Clin Microbiol Infect 17
Suppl 61–24.

19. Van der Pol T, Opal SM. Pathogenesis, treatment, and prevention of pneumococcal
pneumonia. Lancet 2009;374(9700);1543-1556.

20. Onyedum C, Chukwuka JC. Admission profile and management of community acquired
pneumonia in Nigeria-5 year experience in a tertiary hospital.
21. Gordon S, Graham S. Epidemiology of Respiratory disease in Malawi. Malawi Med J 2006;
18(3); 134-145.
22. Ali E. Woldie M. Reasons and Outcomes of Admissions to the Medical Wards of Jimma
University Specialized Hospital, Southwest Ethiopia. Ethiop J Health Sci. Jul 2010; 20(2):
113–120.
23. Etyang AO, Scott JA. Medica; causes of admission to hospital among adults in Africa: a
systematic review. Global Health Action; Glob Health Action 2013;6: 6-14.
24. Pneumonia. In:Europran Lung white book, 2nd edn. Sheffield, UK: European Respiratory
Society/ European Lung Foundation, 2003:55-65.
25. American lung association, Trends in Pneumonia and Influenza Morbidity and Mortality,
November 2015
26. Nathwani D, Welte T, Torres A. Clinical and economic burden of community acquired
pneumonia among adults Doi 2012; 67: 71–79.

27. Siegel RE. How long a stay in hospital is needed for patient with community acquired
pneumonia in hospital? Am J Med 2000; 109; 434-436.

28. Bartolome M. Almirall J, Morera J, Pera G, Ortun V, et al. A population-based study of the
cost of care for community acquired pneumonia. Euro Respir J 2004; 23: 610-616. ....30
62
29. Tichopad mail A, Roberts C, Gembula I, Hajek P, et al. Clinical and Economic Burden of
Community-Acquired Pneumonia among Adults in the Czech Republic, Hungary, Poland
and Slovakia. DOI; 2013: 10.1371; 837.
30. Welsh D, Mason C: Host defence in respiratory infections. Med Clin North Am 2001;
85:1329-13-45.

31. Woodhead,F. Blasi,S. Ewig,J. etal. Guidelines for the management of adult lower respiratory
tract infections, Clin Microbiol Infect 2011; 17(Suppl. 6): E1–E59..

32. Stephanie L Baer, Rhonda E Colombo, Jose A Vazquez. Community-Acquired Pneumonia

(CAP), Medscape, Jul 25, 2016.

33. Kadioglu A, Weiser JN, Paton JC, Andrew PW. The role of Streptococcus pneumoniae
virulence factors in host respiratory colonization and disease. Nature Rev Microbiol 2008; 6:
288-301.

34. Watson DA, Musher DM, Jacobson JW, Verhoef J. A brief history of the pneumococcus in
biomedical research: a panoply of scientific discovery. Clin Infect Dis 1993; 17: 913-924.

35. Jose Bordona, Stefano Alibertib, Rafael Fernandez-Botranc. Etal. Understanding the roles of
cytokines and neutrophil activity and neutrophil apoptosis in the protective versus deleterious
inflammatory response in pneumonia, International Journal of Infectious Diseases,Volume
17, Issue 2, February 2013, Pages e76–e83

36. Jokinen, C.Heiskanen L, Juvonen H, et. al.Microbial etiology of community acquired

pneumonia in the adult population of 4 Municipalities in Eastern Finland . CID 2001;32:
1141-1154.

37. Park DR, Sherbin VL., Goodman MS, et. al.the aetiology of community acquired
pneumonia at an urban public hospital of immunodeficiency virus infection and initial
severity of illness. Infect Disease 2001: 84: 268-277

38. Niederman MS, Mandell LA, Anzueto A, et al. Guidelines for the management of adults
with community-acquired lower respiratory tract infections: diagnosis, assessment of
severity, antimicrobial therapy and prevention. Am J Respir Crit Care Med. 2001;163:1730-
1754

39. Mandel LM, Wunderink RG, Anzueto A. et al.Infectious Diseases Society of

American/American Thoracic Society Consensus Guidelines on the Management of
Community Acquired Pneumonis in Adults. CID 2007:44: S28-S29
63
40. Black AD. The atypical pneumonias: The South African context. SA Fam Pract
2006;48(2):20-27

41. Yoshimine, H, Oishi K, Mubiru F ,et. al. Community Acquired pneumonia in Ugandan adult:
short-term parenteral ampicillin therapy for bacterial pneumonia Am j. Trop Med hyg. 64

(3,4) 2001; 172-177

42. Yudh Dev Singh, pathophysiology of CAP, Association of physicians,india, SUPPLEMENT

TO JAPI • JANUARY 2012 • VOL. 60

43. Metlay JP, Atlas SJ, Borowsky LH, Singer DE. Time course of symptom resolution in
patients with community-acquired pneumonia. Resp Med 1998; 92: 1137–42

44. Fine MJ, Stone RA, Singer DE, et al. Processes and outcomes of care for patients with
community-acquired pneumonia: results from the Pneumonia Patient Outcomes Research
Team (PORT) cohort study. Arch Intern Med 1999; 159: 970–80.

45. Aronsky D, Dean NC, How should we make admission decision in community acquired
pneumonia? Med Clin N America 2001;85: 1397-1411

46. Chan SS, Yuen EH, Kew J, Cheung WL, Cock RA. Community Acquired pneumonia
implementation of prediction rule to guide selection of patients for outpatient treatment. Euro
Emerg Med 2001; 8:279-86

47. Metlay JP, Fine MJ. Testing strategies in the initial management of patients with community-
acquired pneumonia. Ann Intern Med 2003;138; 109-118.

48. Mandel LA, marie TJ, Grossman RF, et al. Canadian guidelines for the initial management
of community acquired pneumonia on evidence based update by the Canadian Infectious
Society and the Canadian Thoracic Society. The Canadian community Acquired Pneumonia
working Group. Clin Infect Dis 2000;31:383-421.

49. Fry AM, Shay DK, Holman RC, et al. Trends in hospitalization for pneumonia among
persons aged 65 years and older in the United States 1998-2002/AMA2005;294:2712-2719.

50. Mokabberi R, Haftbaradaran A, Ravakhah K. Doxycycline vs. levofloxacin in the treatment

of community-acquired pneumonia. J Clin Pharm Ther. 2010;35(2):195–200.

64
51. Confalonieri M, Urbino R, Potena A, et al. Hydrocortisone infusion for severe community-
acquired pneumonia: a preliminary randomized study. Am J Respir Crit Care Med.
2005;171:242-248.

52. De Gans J, van de Beek D; European Dexamethasone in Adulthood Bacterial Meningitis

Study Investigators. Dexamethasone in adults with bacterial meningitis. N Engl J Med.
2002;347:1549-1556.

53. Van der Eerden MM, Vlaspolder F, de Graaff CS, et al. Comparison between pathogen
directed antibiotic treatment and empirical broad spectrum antibiotic treatment in patients
with community acquired pneumonia: a prospective randomised study. Thorax 2005; 60:672.

54. Johansson N, Kalin M, Hedlund J. Clinical impact of combined viral and bacterial infection
in patients with community-acquired pneumonia. Scand J Infect Dis 2011; 43:609.

55. Black AD. Community acquired pneumonia- a clinical approach to assessment and
management. SA Fam Pract 2008; 50(3):15-23

56. Niederman MS. Recent advances in community-acquired pneumonia inpatient and

outpatient 2007;131(4):1205-1215

57. Lim WS, Van der Eerden MM, Laing R, et.al. Defining community acquired pneumonia
severity on presentation to hospital:An international derivation and validation study. Thorax
2003;58:377-382

58. Meelan TP. Quality of care, process, and outcomes in elderly patients with pneumonia.
JAMA 1997;273(23):2080-2084

59. Yan Man S, Lee N, Ip M, et.al. Prospective comparison of three predictive rules for
assessing severity of community acquired pneumonia in Hongkong. Thorax;62(4);348-353

60. Lozano R, Naghavi M, Foreman K, et al. Global and regional mortality from 235 causes of
death for 20 age groups in1990 and 2010:a systematic analysis for the Global Burden of
Disease Study 2010. Lancet 2012:380: 2095 -128

61. World Health Organization. The global burden of disease:2004 update, Geneva Switzerland:
World Health Organization;2008

62. Murray CJ, Lopez AD. Mortality by cause for eight regions of the world: Global burden of
disease study. Lancet 1997;349:1269-1276

65
63. Pan American Organization. The ten leading causes of death in countries of the Americas.
2006 ed. Washington, DC:PAHO;2006

64. Kung HC, Hoyet DL, Xu J, Murphy SL. Death: final data for 2005. Natl Vital Sat Rep
2008;56:1-120

65. United Nations. World population prospects:the 2006 revision. Report No.
ST/ESA/SERA/261/ES. New York, NY: United Nations:2007

66. Diretriz para pneumonias adquiridas na comunidade (PAC) em adultos imunocompetentes. J

Bras Pneumol 2004; 30(Suppl 4): S1-24

67. Carlotto OJ, Cadario ME, Garay JE, Copacastro CA, Cabo A, Savy VL. Community-
acquired pneumonia in patients from two different hospitals. Medicina (B Aires) 2003;63:1-8

68. Sociedad Brasileira de Pneumologia e Tisologia. Conseso brasileiro de pneumonias em

individuos adultos imunocompetentes. Part 1: Community-acquired pneumonia (CAP). J
Pneumologia 2001; 27 (Suppl 1): S3-21

69. Christensen D, Luna CM, Martinez J, Rodriguez E, Marzoratti L, Gonzales J, et.al.

Adherence with national guidelines in hospitalized patients with community acquired
pneumonia: results of the CAPO study in Argentina. Medicina (B Aires) 2007;67(6 pt
2):709-713

70. Weycker D, Strutton D, Edelsberg J, et. al. Clinical and economic burden of pneumococcal
disease in older US adults. Vaccine 2010;28:4955-4960

71. Sow O, Freche Mt, Diallo AA, Soumah S, Conde MK, Diot P, Boissinot E, Lemarie E.
Community acquired pneumonia in adults: a study comparing clinical features and outcome
in Africa (Republic of Guinea) and Europe (France) Thorax 1996;51:385-388

72. Aderaye G. Community acquired pneumonia in adults in Addis Abeba: etiologic agents,
clinical and radiographic presentation.. Ethiop Med J. 1994 Apr; 32(2):115-23

73. Chow C, Lee-Pack L, Senathiragah N etal, Community acquired, nursing home acquired and
hospital acquired pneumonia: A five-year review of the clinical, bacteriological and
radiological characteristics, Department of Medicine, The Wellesley Hospital and The
Toronto Hospital, University of Toronto, Toronto, Ontario, available at Pubmed. com and
accessed on March,25/2016.

66
74. Mario Venditti,Marco Falcone, Salvatore Corrao etal. Outcomes of Patients Hospitalized
With Community-Acquired, Health Care Associated, and Hospital-Acquired Pneumonia,
University of Rome, Rome, Italy, Ann Intern Med. 2009;150(1):19-26

75. Yuichiro Shindo,Shinji Sato,Eiichi Maruyama etal. Health-Care–Associated Pneumonia

Among Hospitalized Patients in a Japanese Community Hospital, CHEST 2009; 135:633–
640

76. Scott T. Micek, Katherine E. Kollef etal. Health Care-Associated Pneumonia and
Community-Acquired Pneumonia: a Single-Center Experience, American Society for
Microbiology, antimicrobial agents and chemotherapy, 2007, 51(10), 3568–3573

77. Vinogradova Y, Hppisley-Cox J, Coupland C. Identification of new risk factors for

pneumonia:population based cased-control study. Br J Gen Pract 2009; 59: e329-e338

78. Kaplan V, Angus DC, Griffin MF, Clermont G, Scott Watson R, Linde Zwirble WT:
Hospitalized community-acquired pneumonia in the elderly: age- and sex- related patterns of
care and outcome in the United States. Am J Respir Crit Care Med 2002, 165:766-772

79. World Health organization, Department of Mental Health and Subsequent Abuse. Global
Status Report on Alcohol 2004. Geneva World Health Organization.

80. Jokinen C, Heiskanen L, Juvonen H, et al. Incidence of community-acquired pneumonia in

the population of four municipalities in eastern Finland. Am J Epidemiol 1993;137:977–88

81. Froes F. Community-acquired pneumonia in adults in mainland Portugal—incidence and

mortality in hospital inpatients between 1998 and 2000. Rev Port Pneumol 2003:187–94

82. Trotter CL, Stuart JM, George R, et al. Increasing hospital admissions for pneumonia,
England. Emerg Infect Dis 2008;14:727–33

83. United Nations, Department of Economic and Social Affairs, Population Division. World
Population Prospects: The Revision, Highlights, Working Paper No. ESA/P/WP.202, 2006

84. Fine MJ, Auble TE, Yealy DM, et al.: A prediction rule to identify low-risk patients with
community-acquired pneumonia. N Engl J Med 1997, 336:243-50

85. Torres A, Peetermans WE, Veigi G, et. al. Risk factors for community-acquired pneumonia
in adults in Europe: a literature. Thorax 2013;68: 1057-106.

86. Nuorti JP, Butler JC, Farley MM, et al. Cigarette smoking and invasive pneumococcal
disease. N Engl J Med 2000;342:681–689

67
87. Hedlund J, Hansson LO, Ortqvist A . Short- and long-term prognosis for middle-aged and
elderly patients hospitalised with community-acquired pneumonia: impact of nutritional and
inflammatory factors. Scand J Infect Dis 1995;27:32–37

88. Schnoor M, Klante T, Beckmann M, et al. Risk factors for community-acquired pneumonia
in German adults: the impact of children in the household. Epidemiol Infect 2007;135:1389–
97

89. Almirall J, Bolibar I, Seera-Prat M, Roid J, et.al. New evidence of risk factors for
community-acquired pneumonia: a population based study. Eu Repir J 2008; 31: 1274-1284.
90. Farr BM, Woodhead MA, Macfarlane JT, et al. Risk factors for community –acquired
pneumonia diagnosed by general practitioners in the community. Repir med 2000; 94; 422-
427.
91. Almirall J, Bolibar I, Balanzo X, Gonzales CA. Risk factors for community-acquired
pneumonia in adults: a population based case-control study: Eur Respi J 1999; 13;349-355.
92. Aykut Çilli,Tülay Özdemir,Ömer Özbudak, etal, Risk Factors for the Development of
Community-Acquired Pneumonia in Young Adults, Turkish Respiratory Journal, 2001;2
(1):3-7
93. Koivula I, Sten M, MaÈkela È PH. Risk factors for pneumonia in the elderly. Am J Med
1994; 96: 313-320

94. J. Teepe, L. Grigoryan and T.J.M. Verheij , Determinants of community-acquired

pneumonia in children and young adults in primary care, Eur Respir J, 2010; 35: 1113–1117

95. Rose RM, Pinkston P, O'Donnell C, Jensen WA. Viral infection in the lower respiratory tract. Clin
Chest Med 1987; 8: 405-418
96. M. Schnoor, T. Klante, M. Beckmann etal, Risk factors for community-acquired pneumonia in
German adults: the impact of children in the household, Epidemiol. Infect. (2007), 135, 1389–1397.
2007 , Cambridge University Press.
97. Hedlund JU, Ortqvist AB, Kalin M, Scalia-Tomba G, Giesecke J. Risk of pneumonia in patients
previously treated in hospital for pneumonia. Lancet 1992; 340: 396-397.

98. Hedlund J. Community-acquired pneumonia requiring hospitalisation: factors of importance for the
short-and long term prognosis. Scand J Infect Dis 1995; 97: 11-60

99. Kaplan JE, Hu DJ, Holmes KK, Jaffe HW, Measure H, et. al. Preventing opportunistic
infections in human immunodeficiency virus-infected persons: implications for the
developing world. Am J Trop med Hyg 1996;55: 1-11.

100. Jones JL, Hanson DL, Dworkin MS, Kaplan JE, et. al. Trends in AIDS-related
opportunistic infections among men who have sex with men and among injecting drug users.
Clin Infect Dis 178; 114 -120

68
101. Daley CL, Mugusi F, Chen LL, Schmidt DM, Small PM, et.al. Pulmonary complications
of HIV infection in Dar es Salaam, Tanzania: Role of bronchoscopy and bronchoalveolar
lavag. Am J Respir Crit Care Med 1996;154:105-110

102. French N. Community acquired pneumonia in Africa the contribution of HIV.

International Journal of Tuberculosis and Lung Disease 2003; 7(11): S133-S132

103. Steptoe A, Wardle J, Cui W, et. al. An international comparison of tobacco smoking,
beliefs and risk awareness in university students from 23 countries. Addiction
2002;97(12):1561-1571

104. Fullerton DG, Gordon SB. Hidden risks of pneumonia in Malawi. Med J 2004;15(2):68-
70

105. Kothe H, Bauer T, Marre R, et al. Outcome of community-acquired pneumonia:

influence age, residence status and antimicrobial treatment. Eur Respir J 2008; 32:139-146

106. Broulette J, Yu H, Pyenson B, Iwasaki K, Sato R. The incidence rate and economic
burden of community-acquired pneumonia in a working-age population. Am Health Drug
Benefits. 2013;6(8):494-503

107. Bonafede MM, Suaya JA, Wilson KL, et al. Incidence and cost of CAP in alarge
working-age population. Am J Manag Care. 2012; 18: 380 -387

108. Polsky D, Bonafede M, Suaya JA. Comorbidities as a driver of the excess cost of
community-acquired pneumonia in U.S. commercially- insured working age adults. BMC
Health Serv Res. 2012;12: 379

109. Tichopad mail A, Roberts C, Gembula I, Hajek P, et al. Clinical and Economic Burden
of Community-Acquired Pneumonia among Adults in the Czech Republic, Hungary, Poland
and Slovakia. DOI; 2013: 10.1371; 837

110. Siegel RE. How long a stay in the hospital is needed for patients with community
acquired pneumonia? Am J Med 2000;109:434-436

111. Fine MJ, Pratt HM, Obrosky DS, et. al. Relation between length of hospital stay and cost
of care for patients with community acquired pneumonia. Am J Med 2000; 109:378-385

112. Birnbaum HG, Morley M, Greenberg PE, et.al. Economic burden of pneumonia in an
employed population Arch Intern Med 2001; 161:2725 -2731

69
113. Khanzada Z, Rodriguez E, Cosentini R, et. al. Discrepancies between physicians’
clinical diagnosis of community acquired pneumonia and diagnosis based on objective
criteria: results from community-acquired pneumonia organization (CAPO). Proceedings
from the international American Thoracic Society Conference ; 2004 p.A654

114. Jericks SK, William MB, Coleman EA. Rehospitalization among patients in the
Medicare fee for service programs. New England Journal of Medicine 2011; 302:1418-1428

115. Colice GL, Morley MA, Asche C, et.al. Treatment cost of community acquired
pneumonia in an employed population. Chest 2004;125:2140-2145

116. Dal Negro R, Berto P, Tognella S, Quareni L; Cost-of-illness of lung disease in the
TriVeneto Region, Italy: the GOLD Study, Monaldi Arch Chest Dis. 2002 Feb;57(1):3-9.

117. V. Personne, J. Chevalier C. Buffel du Vaure etal, CAPECO: Cost evaluation of

community acquired pneumonia managed in primary care. Vaccine (2016),
http://dx.doi.org/10.1016/j.

118. Scott G, Scott H, Turley M, Baker M, Economic cost of community-acquired pneumonia

in New Zealand adults, N Z Med J. 2004 Jun 18;117(1196):U933.

119. Qing-tao Zhou, MD, Bei He, BSMed, Hong Zhu, BSMed, Potential for Cost-Savings in
the Care of Hospitalized Low-Risk Community-Acquired Pneumonia Patients in China,
value in health,2009, 12;1.

120. Orrick JJ, Segal R, Johns TE etal. resource use and cost of care for patients hospitalised
with community acquired pneumonia: impact of adherence to infectious diseases society of
america guidelines,available at www. Pubmed. com and accessed on April 10/2016.

121. The 2007 Census by the Central Statistical Agency of Ethiopia (CSA)

122. Federal ministry of health Ethiopia: health and health related indicators, 2007

123. Gerald Yonga, case kenya study:-NCD situation, Kenya NCD Alliance, Kenya Cardiac Society,
Aga Khan University, East Africa,2009

124. Garbino J, Sommer R, Gerber A J etal. Prospective epidemiologic survey of patients

with community-acquired pneumonia requiring hospitalization in Switzerland, Division of
Infectious Diseases, Department of Internal Medicine, University Hospitals of Geneva,
Geneva, Accessed from Pubmed and accessed on March,25/2016.

125. S Ewig, N Birkner,R Strauss etal. New perspectives on community-acquired pneumonia

in 388,406 patients. Results from a nationwide mandatory performance measurement
programme in healthcare quality, Thorax 2009;64:1062–1069. doi:10.1136/thx.2008.109785

70
126. S. Jain, W.H. Self, R.G. etal. Community-Acquired Pneumonia Requiring
Hospitalization among U.S. Adults, N Engl J Med 2015;373:415-27

127. Community-acquired pneumonia in adults in British hospitals in 1982-1983: a survey of

aetiology, mortality, prognostic factors and outcome. The British Thoracic Society and the
Public Health Laboratory Service, available on Pubmed, accessed on March 25/2016.

128. Danny McCormick, Michael J Fine, Christopher M Coley etal, Variation in length of
hospital stay in patients with community-acquired pneumonia: are shorter stays associated
with worse medical outcomes? Department of Medicine, Cambridge Hospital, Massachusetts
, available at Pubmed, accessed on March 26/2016

129. Baik I, Curhan GC, Rimm EB etal. A Prospective Study of Age and Lifestyle Factors in
Relation to Community-Acquired Pneumonia in US Men and Women, Arch Intern Med.
2000;160(20):3082-3088.

130. Irma Koivula, Marja Sten, Pirjo Helena Makela, Risk factors for pneumonia in the
elderly, The American Journal of Medicine, Volume 96, Issue 4, April 1994, Pages 313–320.

131. Ambrose Li , Anthony T. Newalla, Helena Britt , C. Raina MacIntyre, The cost and
disease burden of pneumonia in general practice in Australia, Vaccine 30 (2012) 830– 831
132. Sun HK, Nicolau DP, Kuti JL., Resource utilization of adults admitted to a large urban
hospital with community-acquired pneumonia caused by Streptococcus pneumoniae, Chest.
2006 Sep;130(3):807-14.

71
Annex

Annex 1: Original Papers

72
Original Paper-One

73
 Journal of Health,MedicineandNursing
ISSN 2422-8419 AnInternationalPeer-reviewedJournal
Vol.33, 2016

Magnitude ofCommunity AcquiredPneumonia amongHospital

Treated AdultsinTigray,Ethiopia:AHospitalBased Retrospective
Study
HaftuBerheGebru.MSc1 Prof.FikreEnqueselassiePhD2 Dr.AlemayehuBayrayPhD 3
1. CollegeofHealthSciences,SchoolofNursing,MekelleUniversity,Ethiopia
2. CollegeofHealthSciences,SchoolofPublicHealth,AddisAbabaUniversity,Ethiopia
3. CollegeofHealthSciences,SchoolofPublicHealth,MekelleUniversity,Ethiopia

Abstract
Background: Of thetotalrespiratory system infectionsworldwide,pneumoniaaccounts2-3%andcommunity-
acquiredpneumoniatakesthemajorityalbeitlittleisknownabouttheproblemamongadultsinEthiopia.
Objective:Todeterminethemagnitudeofcommunity acquiredpneumoniaamonghospitaltreatedadultsin
Tigray,Ethiopia.Methods: Aretrospectivepatientrecordreviewwasused.Chartsofallpneumoniapatients treatedfrom
July,2013to June,2015inzonalandtertiary hospitalsofTigraywereincludedinthestudy. Data
werecollectedusingachecklistandenteredintoEpiinfo2002andanalysedusingSPSSVersion20.Results:
Duringthestudyperiod,therewere36,005patientsofalltypesofpneumonia&5877communityacquired
pneumoniacases.Hence,themagnitudeofcommunityacquiredpneumoniawas16%,withproportionsformales
(16%)andfemales(17%).Themean ageofthestudy participantswas37.5 (+16.65).Theproportionofadmitted
patientsduetocommunityacquiredpneumoniawas9.8%with amean admissionlength of6(+5.59) days.Conclusion:
Thestudyrevealedthatthemagnitudeofcommunityacquiredpneumoniaamongthestudy participants inthestudy
areawassignificant andmostprevalent amongyoungerpopulation.Hence,prevention
strategiesshouldbedesignedandimplementedtominimizetheproblem.
Keywords: Magnitude,CAP,Adults,Tigray,Ethiopia

Introduction
Respiratorysysteminfectionsarewidelyspreadaroundtheworld,accountingfor25%ofthetotalnumberof
physicianconsultations,ofwhichpneumoniaaccountsfor2-3%;andmajority ofthesearecasesofcommunity-
acquiredpneumonia(RossiGPetal,1998).Itsestimatedincidencevariesbetweencountriesandby ageand gender. In
theUnitedStatesalone,4million adults areaffectedeachyearofwhich 20%needhospitalizationfor
management(DeshpandeA,2012).
Community-acquiredpneumonia(CAP)isanacutediseasewhich representsacommon causeof
hospitaladmission andmortality indevelopedanddevelopingcountriesandhenceconsumesagreatproportion
ofhealthcarebudgets((CDC,2003),(JokinenJ, ScottJA,2010)).
Themagnitude ofcommunity acquiredpneumonia differs in differentcountries.Resultsfrom Canada
showedthatthe proportion ofcommunity acquiredpneumoniawas 63%(ChowC etal,1995).Likewise,astudy
conductedin55hospitalsin Italyconcludedthat61.6%of allpneumoniapatientsadmittedinthehospitalshad
community-acquiredpneumonia(MarioVendittietal,2009).Anotherstudyfrom Japanesecommunityhospital
revealedalmostsimilarresults of 62%of communityacquiredpneumoniaamongthetotalpneumoniapatients
(YuichiroShindo etal.2009).On theotherhand,astudy inUSAshowed lower proportionofCAP(32.6%) than
reportedfromthestudiesmentionedabove(ScottT.Miceketal.2007).However,therearenoavailableliterature
thatshowsthelevelofcommunityacquiredpneumoniaamonghospitaltreatedadultsinEthiopianandothersub-
SaharanAfricacountries.
Thus,theaim ofthisstudywastodeterminethemagnitudeofcommunityacquiredpneumoniaamong
hospitaltreatedadultsof18 yearsandaboveinTigray,Ethiopiathatcanbeimportantfordecisionsofprevention,
treatmentandpromotion.

Methods
InstitutionalbasedmedicalrecordsreviewwasconductedinTigrayregion.Theregionhasanestimatedtotal
populationof 4,314,456, of which 2,124,853 malesand2,189,603females.Theregion is predominantly of
Tigrianethinicgroup accountingfor96.55% of thepopulation.About 95.6% of thepopulation arefollowersof
EthiopianOrthodox Christianity.Thereare 712health posts,201healthcentresand15hospitals (6zonalor
generalhospitals,onereferralandtheremainingareprimary hospitals)intheregion((CSA,2007), (FMoH,2007)).
Allpneumoniapatientsthatoccurredduringtheperiod July,2013andJune,2015aged18yearsand
abovetreatedin allzonalhospitals of TigrayandAyderreferralhospitalwereincludedin thisstudy.If
pneumoniawasnotthemain reasonforadmission,ifthepatientshadhistoryofhospitaladmissioninthelast 14

74
ISSN 2422-8419 AnInternationalPeer-reviewedJournal
Vol.33, 2016

days,ifthepneumoniawasdeveloped48hrsfollowingadmission,patientswithtuberculosis(TB)orprevious chestX-
raywhichmayconflictwithdiagnosisofCAP,chronicallydebilitatedpatients,patientswithlungcancer
andasthmawereexcludedfromthestudy.
Datawerecollectedusingachecklistwhichwasadaptedfrom relevantliteratures.Socio-demographic
characteristicsofthepatients,diagnosis,treatmentgiven andany othermanagement providedwerecollected
fromthemedicalrecordsineachhospital.
A totalof 21datacollectorsand7supervisors(nursesandhealth officers)wererecruitedfordata collection.
Trainingwasgiven forthedatacollectorsandsupervisorsforthreedays on theobjectiveof thestudy,
datacollectionchecklistandproceduretoensureconsistencyofthedatacollectionandhigh-qualitydata.
Oncethe datawas collecteditwas handledconfidentially,coded,anddoubleenteredintoEpi info2002.
Datacheckingwasdonetoverifytheconsistencyand backup was saved.Datacleaningwasconductedforerrors
andimplausiblevalues andexported toSPSSVersion20.Frequency distributions,proportionsandmeasuresof
centraltendencyhadbeencalculated.
Pre-testwasconductedon10%ofthetotalchartstoevaluatethecompletenessandconsistency of the
checklist.Accordingly,appropriatemodifications andadjustmentswasmade.Datawascollectedusing trained
nurses/health officerswith atleastsomeyears ofworkexperienceon datacollectionandresearchwith
supervision.Attheendofeverydatacollectiondayeachquestionnairewasexaminedandpertinentfeedback
wasgiventothedatacollectorsandsupervisors.Dataentrywascarriedoutby anexperienceddataentry clerk
withclosesupervisionbythe principalinvestigator.Data cleaningwasconductedout exclusivelybythe
principalinvestigator,and finalizedchecklist was storedinawell securedcabinet.
Ethicalclearancewasobtainedfrom InstitutionalReviewBoardofAddis-AbabaUniversity,Collegeof
HealthSciences.LetterofagreementwassecuredfromTigrayregionalhealthbureau.andadditionalconsent
wasobtainedfromthe hospitaladministratorsafterexplainingthepurposeofthe study.
Anydocumentused inthisresearchwas keptprivateandconfidential(datawaspasswordprotectedand
filledchecklistwaskeptlockedinacabinet).Noinformationotherthanforthepurposeofthisstudywas
collectedfromthepatients’charts.

Results
Therewereatotalof36,005 patients(20764 malesand15241females)aged15yearsandabovewithalltypes
ofpneumoniatreatedduring thestudy periodbetween July,2013andJune,2015inthesixzonalhospitalsand
onereferralhospitalofTigray regionalstate.Inthisstudy,wereviewed5877medicalrecordsofadult
communityacquiredpneumoniacases,makingtheproportionofcommunityacquiredpneumonia16%,with
maletofemaleratioof 0.94to1 (16and17%formalesandfemales,respectively).Themeanageof community
acquiredpneumoniacases treated inthehospitalswas37.5(+16.65)rangingfrom18 to92years.Five
hundredfour(9.5%)ofthepatientstreatedatinpatientdepartmentwereagedbelow 65yearsandofthepatients
treatedasinpatient,70(12%)wereabove65yearsold.About3322(56.5%)weremalesamongwhich
393(11.8%)wereinpatients.About3029(51.5%)werefarmers,ofwhom326(10.8%)treatedattheinpatient
department.Overall,patientstreatedatinpatientdepartmentaccountedfor9.8%(Table1).
Table 1. Socio-demographic characteristics of the study participants versus site of treatment, 2016 (n=5877)
Characteristics Departmentpatientstreated Total
Inpatient Outpatient No(%)
No(%) No(%)
Age
Below65 504 (9.5) 4789(90.5) 5293(90.1)
65andabove 70(12.0) 514 (84.0) 584 (9.9)
Mean(SD) 37.5(+16.65)
Sex
Male 393(11.8) 2929(88.2) 3322(56.5)
Female 181(7.1) 2374(92.9) 2555(43.5)
Occupation
Farmer 326(10.8) 2703(89.2) 3029(51.5)
StudentCivil 121(8,5) 1297(91.5) 1420(24.2)
ServantHousewif 44(6,7) 606(93.3) 653(11.1)
ePrivateemployee 56(11.6) 428(88.4) 484(8.2)
25(8.6) 266(91.4) 291(5.0)
TotalNo(%) 574(9.8) 4603(90.2) 5877
Onethousandfourhundredeleven(24%)communityacquiredpneumoniapatientsweretreatedin
Adigrathospital,ofwhom91%weretreatedasoutpatients.Higherproportionofcasesweretreatedatthe

75
ISSN 2422-8419 AnInternationalPeer-reviewedJournal
Vol.33, 2016

inpatient departmentsofSuhulandKahsayAberahospitals(29and18%, respectively)ascomparedtotheother

publichospitalswhichhadlessthan10%ofinpatienttreatments.Forthetotal574admittedpatientsdueto
communityacquiredpneumonia,themeanlengthof hospitalstaywas6 days withSDof 5.59days.(Table_2). Table2.
Clinicalcharacteristicsofthestudyparticipantsversussiteoftreatment,2016(n=5877)
Characteristics Departmentpatientstreated Total
Inpatient Outpatient No(%)
No(%) No(%)
TreatmentHospital
Adigrat 124 (8.8) 1287(91.2) 1411(24.0)
AyderKahsay 47(10.9) 385 (89.1) 432 (7.4)
AberaL.Karl 39(18.4) 173 (81.6) 212 (3.6)
MekelleHospital 57(6.3) 887 (83.7) 944 (16.1)
St.MarrySuhul 50(4.0) 1269(96.0) 1319(22.4)
57(6.5) 811 (93.5) 873 (14.9)
200 (29.2) 486 (71.8) 686 (11.7)
Referalstatus
Reffered 204(61.8) 126(38.2) 330(5.6)
Notreferred 370(6.7) 5177(93.3) 5547(94.4)
Lengthofhospitalstay
1-6Days 424(74) 1
>7 Days 150(26)
Mean(SD) 6(+5.59)
Total 574(9.8) 4603(90.2) 5877
No(%)

Discussion
Thisstudyattemptedtoassessthemagnitudeofcommunityacquiredpneumoniaamonghospitaltreatedadults
(aged>18years)inTigrayzonalandtertiaryhospitals.
Themean ageof thetreatedpatients forCAPin thecurrentstudy was 37.5 (+16.65) years ,which is
muchlowerthancomparedtostudiesconductedinCanadaandSwitzerlandwithmeanagesof 64.4yearsand
70.4years respectively((ChowCetal,1995),(GarbinoJetal,2002)).Likewise,astudyfrom Germany confirmed
thatthemedianageofcommunity acquiredpneumoniapatientswas76years(SEwigetal,2009).Similarstudy from
USAconcludedthatthemedian ageofCAPpatientswas57years(S.Jainetal.2015).Moreover,another
studyfromUSAconfirmedthatthemeanageofadmittedpatientswithpneumoniawas58.9years(ScottT.
Miceketal.2007).Thisdifferencecouldbebecauseofthesmallnumberof elderlyadultsparticipatedinour
studyandhigherproportionofelderlyadultsinthedevelopednations ingeneral.
Theproportion of community acquiredpneumonia in ourstudy was 16% (16and17%formalesand
females,respectively).Ourfindingwasmuchlowerthanpreviously conductedresearches. Studiesconductedin
Canada, Italy andJapanreportedthattheproportionofcommunityacquiredpneumoniarangingbetween62and
63%((Chow Cetal,1995),(MarioVendittietal,2009),(YuichiroShindoetal.2009)),whileastudyinUSA among
community acquired andhealth careassociatedpneumoniapatientsrequiringhospitaladmissionshowedthatthe
proportion of CAPwaslower(32.6%)thantheabovereports (ScottT. Miceketal.2007). Thevariationmight be
justifiedasthedifferenceinprevalence/distributionand/ordifferenceinthediagnosisofcommunityacquired pneumonia.
Inthecurrentstudy,ofallthecommunity acquiredpneumoniapatientsin thestudyyears,only 9.8%
patientshavebeentreatedasin patientswithameanhospitalizationof 6days,whichwas shorterthanstudies
conductedindifferentcountries.Astudyfrom Canadaconfirmedthattheaveragelengthofhospitalization in
communityacquiredpneumoniapatientswas17days,astudyfromBritishhospitalsrevealedthathospitalstay
insurvivorsofcommunityacquiredpatientsaveraged10.8 days((Chow Cetal,1995),(BTS,1982)). Likewise,
studyfrom Switzerlandconcludedthatthemeantreatmentdurationofcommunityacquiredpneumoniapatients
was12.1days(GarbinoJetal,2002),However,themeanlemgthofstay inourstudywaslongerthanastudy
conductedinonecommunityandthreeuniversityteachinghospitalsinUSAwhichshowed thattheadjusted inter
hospitaldifferencesinmeanlengthof stayrangedfrom0.9to2.3days(DannyMcCormicketal,1999).This
differencecouldbeexplainedby thedifferenceoftheseverity oftheproblem andpathogenicdifferenceofthe
admittedpatients.Ontheotherhandduetothelowavailabilityofbedsadmission ratesmightdifferfromplace
toplaceingeneraland fromhospitalto hospitalinparticular.
Inconclusion,thestudyrevealedthatthemagnitudeofcommunityacquiredpneumoniaamongadults in
Tigrayzonalandtertiaryhospitalswas16%,Community acquiredpneumoniawashigheramongyounger
population.Healthcareprofessionalsshouldnotunderminetheprevalenceofcommunityacquiredpneumonia

76
ISSN 2422-8419 AnInternationalPeer-reviewedJournal
Vol.33, 2016

andgetappropriatetrainingsthatenablethem diagnoseandmanagetheproblem properly.Moreover,prevention

strategies likehealth education and immunization shouldbedesignedand implementedtominimizethe
magnitudeofcommunityacquiredpneumoniaamongadultsinTigray,Ethiopia.

Abbreviations
CAP:CommunityAcquiredPneumonia,EDHS,Ethiopiandemographichealthsurvey,
SPSS,statisticalpackageforsocialscience,TB-Tuberculosis,

Acknowledgements
We expressourgratitudetoTigrayRegionalHealthBureau,the participatingzonal hospitals,data collectorsand
supervisorsfortheircollaborationinthisstudy&toMekelleandAddisAbabaUniversitiesforsupportingthe
studyfinancially.

Competinginterests
Theauthorsdeclarethat we havenocompetinginterests.

Reference
1.CenterfordiseaseControlandPrevention(2003),TrendsinagingUnitedStatesandWorldwide,MMWR
MorbMortalWklyRep2003:52:101-4.
2.Community-acquiredpneumonia inadultsin Britishhospitalsin 1982-1983:asurvey of aetiology,mortality,
prognosticfactorsandoutcome.TheBritishThoracicSocietyandthePublicHealthLaboratoryService,
availableonPubmed,accessedonMarch25/2016.
3.ChowCetal(1995).Community acquired,nursinghomeacquiredandhospitalacquiredpneumonia:Afive-
yearreviewoftheclinical,bacteriologicalandradiologicalcharacteristics,DepartmentofMedicine,The Wellesley
HospitalandTheTorontoHospital,UniversityofToronto,Toronto,Ontario,availableat
Pubmed.comandaccessedonMarch,25/2016.
4.ScottT,Miceketal.(2007).HealthCare-AssociatedPneumoniaandCommunity-AcquiredPneumonia:a
Single-CenterExperience,AmericanSocietyforMicrobiology,availableathttp://aac.asm.org/onMarch26,
2016
5.S. Jainetal.(2015)Community-AcquiredPneumoniaRequiringHospitalizationamongU.S.Adults,NEnglJ
Med2015;373:415-27
6.The2007Censusbythe CentralStatisticalAgencyofEthiopia(CSA)
7.DannyMcCormicketal,(1999)Variationinlengthofhospitalstay inpatientswithcommunity-acquired pneumonia:
are shorter stays associated with worse medical outcomes? Department ofMedicine,
CambridgeHospital,Massachusetts, availableatPubmed,accessedonMarch26/2016
8. DeshpandeA.(2012)EpidemiologyofCommunityAcquiredPneumoniaSuppJapi2012;60:6
9. Federalministryof healthEthiopia(2007).healthandhealthrelatedindicators
10.GarbinoJetal.(2002) Prospectiveepidemiologicsurvey ofpatientswithcommunity-acquiredpneumonia
requiringhospitalizationinSwitzerland,Division of InfectiousDiseases,Departmentof InternalMedicine,
UniversityHospitalsofGeneva,Geneva,AccessedfromPubmedandaccessedonMarch,25/2016.
11.JokinenJ,ScottJA,(2010)Estimatingtheproportion ofpneumoniaattributabletopneumococcusin Kenyan
adults:Latentclassanalysis.Doi2010:21(5):719–725.
12.MarioVendittietal.(2009)OutcomesofPatientsHospitalizedWithCommunity-Acquired,HealthCare
Associated,andHospital-AcquiredPneumonia,UniversityofRome,Rome,Italy,availableatPubmed,
accessedonMarch26/20016
13.RossiGP,etal.(1998)Theburdenofhospitalized pneumoniainLazio,Italy,1997-1998.IntJTubercLung
Dis.2004;8:528
14.SEwigetal.(2009)New perspectivesoncommunity-acquiredpneumoniain388,406patients.Resultsfroma
nationwidemandatoryperformancemeasurementprogrammeinhealthcarequality,Thorax2009;64:1062–
1069.doi:10.1136/thx.2008.109785
15.YuichiroShindoetal(2009).Health-Care–AssociatedPneumoniaAmong HospitalizedPatientsinaJapanese
CommunityHospital,availableathttp://journal.publications.chestnet.org,accessedon03/26/2016

77
Original Paper-Two

78
RISK FACTORS OF COMMUNITY ACQUIRED PNEUMONIA AMONG ADULTS IN
TIGRAY, ETHIOPIA: A CASE CONTROL STUDY,

2
Haftu Berhe Gebru MSc1, Prof.Fikre Enqueselassie PhD , Alemayehu Bayray Kahsay PhD3

1.Mekelle University, College of Health Sciences, School of Nursing

2. Addis Ababa University, College of Health Sciences, School of Public Health

3. Mekelle University, College of Health Sciences, School of Public Health

Corresponding author: Haftu Berhe Gebru

Email:[email protected]

79
 Abstract

Background : Community acquired pneumonia is a worldwide major health problem that varies
among countries. Though several studies have been conducted to determine its risk factors they
have been clearly established in middle aged or elderly people. Hence, little is known on the risk
factors among adults globally including Ethiopia.

Objective: To identify risk factors of community acquired pneumonia among adults treated in
Tigray hospitals, Ethiopia

Methods : A case control study was conducted on 120 cases and 240 controls in Tigray region,
north Ethiopia. Cases were patients with community acquired pneumonia while controls were
patients without the problem. A structured questionnaire was used to collect the data and entered
using EPI Info version 2002 and exported to SPSS version 20. Associations between the
exposure and outcome variables were determined using bivariate and multivariable logistic
regression analysis. Odds ratios with 95% confidence interval were calculated to measure the
strength of associations.

Result: History of contact with pets, working in dusty environment, history of pulmonary
tuberculosis, history of pneumonia, having contact with people who had respiratory infection,
history of respiratory infection, history of tonsillectomy, history of upper airway problem, age
and educational status had significant association with community acquired pneumonia in the
bivariable analysis While working in dusty environment [OR (95% CI);2(1.1,4.1)], history of
respiratory infection [OR (95% CI); 2.3(1.5,5.7) ] , contact with people who had respiratory
infection [OR (95% CI);2.5(1.2,5.3)] and previous history of pneumonia confirmed by
radiograph [OR (95% CI); 39(19.4,78,6)] were significantly associated in the multivariate
analysis.

Conclusion: Working in dusty environment, having history of pneumonia, history of respiratory

infection and having contact with people who had respiratory infections are the risk factors of
community acquired pneumonia confirmed in this study. Hence much has to be done to prevent
and properly treat the problem.

Key words: Community acquired pneumonia, risk factors, adults, Tigray, Ethiopia

80
Introduction

Community acquired pneumonia (CAP) is a worldwide major health problem that is associated
with considerable morbidity and mortality. It is a global problem with multi facet of risks and
outcomes. A study in Finland showed that the incidence of CAP rose dramatically with age, with
a six-fold increase in incidence between ages 30–44 years and ≥75 years(1).

Studies conducted in different countries globally showed that smoking is a risk factor for the
development of community acquired pneumonia (2-8). Some findings confirmed that alcohol is a
risk factor for the development of community acquired pneumonia (8,9,10), But also other
studies showed that alcohol is not a risk factor for the development of community acquired
pneumonia (2,3,6,7).

Concerning exposure to dusty environment, contradictory findings were reported fro different
studies. A hospital based study from Great Britain showed that working in a dusty environment
as one of the major risk factors for the development of community acquired pneumonia(3). In
contrary a recent community based study confirmed that working in a dusty environment is not a
risk for community acquired pneumonia (5).

Studies from different countries reported that heart disease and history of diabetes as being risk
factors for CAP (3,5,8). However, other studies failed to conclude that history of diabetes and
heart disease to be associated with CAP (2,3, 4,9).

According to different studies globally, community acquired pneumonia is associated with

upper repeated respiratory infections (2,5,6,8,11,12). Likewise, Chronic bronchitis, diagnosed
asthma and Pulmonary TB were identified in different studies as risk factors for community
acquired pneumonia among adults (2,3,5,6). Studies also showed that patients with history of
Previous pneumonia confirmed by radiograph had higher risk of a subsequent community
acquired pneumonia (2, 5,13,14,12).

81
In summary, contradicting findings are documented concerning the risk factors of CAP. Besides
there is no available literature on risk factors of community acquired pneumonia generally in all
age groups and specifically among adults aged 18 years and above in Ethiopia. Thus, the aim of
this research was to identify the potential risk factors of community acquired pneumonia among
adults in Tigray, Ethiopia.

Methods

The study was conducted in Tigray region. Based on the 2007 Census conducted by the Central
Statistical Agency of Ethiopia (CSA), the region has an estimated total population of 4,314,456
(2,124,853 males and 2,189,603 females), urban inhabitants account, 842,723 (19.53%) of the
population. With an estimated area of 50,078.64 square kilometers, the region has an estimated
population density of 86.15 people per square kilometer. The region is predominantly Tegaru
people at 96.55% of the population; other ethnic groups include Amhara (1.63%), Irob or Saho
(0.71%), Afar (0.29%), Agaw (0.19%), Oromo (0.17%), and Kunama (0.07%). About 95.6% of
the population are followers of Ethiopian Orthodox Christian, 4.0% Islam, 0.4% Roman Catholic
and 0.1% P'ent'ay. In the region there are 712 health posts, 201 health centres and 15 hospitals (6
Zonal or general hospitals, one referral/tertiary and the remaining are primary hospitals). There
are 3, 4, 77, 60, and 50 Hospitals, Health centres, Medium clinics, Primary clinics and Specialty
clinic respectively owned by private and nongovernmental organizations (15 and 16).

Cases were patients of community acquired pneumonia (having a new pulmonary infiltrate on
chest radiograph plus at least one of cough, fever, leukocytosis, or leukopenia). The cases were
labelled by two internists in consultation with radiologists after taking history of the patients and
undergone necessary diagnostic procedures (Sputum, blood and X-ray examinations). Controls
were patients who visited the hospitals for any other reason but without community acquired
pneumonia.

All CAP patients aged 18 years and above in both sexes and had been on treatment during the
data collection period in the government Zonal hospitals and Ayder referral hospital were
included in the study. Patients who had history of hospital admission 14 days before the data
collection period, patients who developed pneumonia 48hrs following admission, patients with
tuberculosis (TB) or previous chest X-ray which might conflict with diagnosis of CAP,
82
chronically debilitated patients and patients with lung cancer and asthma were excluded from
the study.

The sample size for the study was calculated using two proportion formula. Assuming 26%
exposure to smoking has twice risk (OR=2) for CAP (17), with power of 80% and significance
level of 5%, a case control ratio of 1 to 2, the required sample size was 120 cases and 240
controls.

A semi-structured interviewer-administered questionnaire was adapted from different literatures.

The questionnaire included structured information on the socio-demographic characteristics, life
styles and habits, medical history and environmental conditions of both cases and controls. The
questionnaire was prepared in English and translated into Tigrigna, and back-translated to ensure
consistency in phrasing of questions.

Data collectors and supervisors were Nurses and health officers. Training was given for the data
collectors and supervisors for three days on the objective of the study, data collection tools and
procedures to ensure consistency of interviewing and high-quality data.

Once the data were collected,it was handled confidentially, code book was prepared, the data
were coded, and be double entered into Epi info 2002 on a daily basis. Data checking were done
to verify the consistency and backups were saved. Data cleaning were conducted for errors and
implausible values that might result from incorrect reading, incorrect reporting, incorrect filling,
and incorrect sensing, incorrect coding, and incorrect typing.

After cleaning the data, frequency tables, graphs and proportions were used to present the results.
In addition, the associations between the exposure and outcome variables were determined using
bivariable and multivariate logistic regression analysis.Odds ratios with 95% confidence
intervals and p-value were calculated to measure the strength of associations.

To assure the quality of the data/research the adapted questionnaire and check list was prepared
using a simple and easily understandable Tigrigna language. Standardization on translation was
given emphasis during training. Pre-test was conducted on 10% study subjects to evaluate the
completeness and consistency of the tools. Accordingly, appropriate modification and
corrections were made. At the end of every data collection day each questionnaire was examined
and pertinent feedback was given to the data collectors and supervisor. Data entry was carried
83
out by an experienced data entry clerk with close supervision by the principal investigator. Data
cleaning was conducted out exclusively by the principal investigator, and finalized
questionnaires/check lists and the data were stored in a well secured cabinet.

Ethical clearance was obtained from Institutional Review Board (IRB) of the Addis-Ababa
University, College of Health Sciences. Letter of agreement was secured from Tigray regional
health bureau. All participants were informed about the purpose of the study and individual
written informed consent was solicited from the selected respondents at the time of data
collection, the data collectors and the principal investigator were blinded about the cases and
controls of CAP, only the physicians in charge were aware because they were to provide all
necessary management in relation to CAP. Respondents were not identified by name; they were
also informed that they had the right to participate, totally not to participate and to withdraw any
time they like during the study. Furthermore, health education about prevention and treatment of
CAP had been provided. The beneficiaries of this research will be primarily CAP patients, the
scientific society, the government, and the public in general.

84
Results
CAP by Socio-demographic characteristics factors

Among the socio -demographic factors, age and education were significantly associated with
CAP. The mean age of the cases and controls was 37.2 (+14.4) and 33.8(+13.6) respectively.
Fifty six (46.7%) of the cases and 130 (54.2%) of the controls were males. Forty nine (40.8%)
cases and 67(27.9%) controls had no formal education. One hundred eleven (92.5%) cases and
222(92.5 %) controls were Tegaru by ethnicity. One hundred twelve (50%) of the controls and
62(51.7%) cases were married. Forty seven (39.2%) of the cases and 88(36.7%) controls were
self employed. Two or more persons sleep in one room in 43 (35.8%) of cases and 72(30%) of
controls. Only one window was available in 86 (71.7%) of cases and 183(76.25%) controls. The
mean BMI of the cases and controls was 20.99 (Min 12, Max 30) and 21.45(Min 15, Max 30)
respectively (Table 1).

Table 1. Community Acquired Pneumonia by socio-demographic characteristics of study

participants, 2016(n=360)
Characteristics Cases Controls COR[95%CI],
n=120(%), n=240(%), t(df), p
Mean(SD) Mean(SD)

Age Uncategorized 37.2(14.4) 33.8(13.6) t(358)= -2.2

P=0.03

Sex Male 56(46.7) 130(54.2) 1.3(0.87,2.1)

Female 64(53.3) 110(45.8) 1

Level of No formal education 49(40.8) 67(27.9) 1.8(1.1,2.8)

education
Educated 71(59.2) 173(72.1) 1

Marital status Never married 41(34.2) 99(41.3) 2.4(0.93, 6.23)

Currently married 62(51.7) 120(50) 1.9(0.76, 4.89)
Divorced 7(5.8) 11(4.6) 1.5(0.43, 5.71)
Widowed 10(8.3) 10(4.2) 1
Number of One 13(10.8) 32(13.3) 0.79(0.39,1.5)
people live in a Greater than one 107(89.2) 208(86.7) 1
household
85
Number of One 17(14.2) 49(20.4) 0.64(0.35,1.2)
people use/sleep Two and above 103(85.8) 191(79.6) 1
in a single room
Number of No 7(5.8) 13(5.42) 1.1(0.42, 2.8)
windows in a Yes 113(94.2) 227(94.58) 1
room
BMI Uncategorized 20.99(2.965) 21.45( 2.782) t(358)= 1.5
P=0.15

CAP by Life style and Habits

None of the life style or habit variables were associated with CAP. Only 7(5.8%) of the cases
and 12(5%) of the controls were current smokers of any tobacco products, such as cigarettes. All,
12(100%) of the smokers from the control group and 4 (57.1%) of the smokers from the case
group smoke 1-9 cigarettes per day where as 3(42.9%) of the smokers from the cases did not
know how many cigarette they smoke daily (Table-2).

Ninety two (76.7%) of the cases and 179(74.6%) of the controls ever consumed alcohol. From
the alcohol consumers, 41(44.5%) cases and 111(62%) controls consumed alcohol in the last
thirty days. Among this 26 (63.4%) of cases and 59(53.1%) of controls consumed alcohol 1-3
days per month. In the last 30 days 18(43.9%) of cases and 34(30.6 %) of controls consumed 2
glasses of alcohol drink on average in one drinking occasion. The largest alcohol intake they had
in one occasion in the last 30 days was 3 and 5 by most cases and controls (Table 2).

Regarding involvement in vigorous-intensity activity,32(26.7%) cases and 68(28.3%) controls

were involved in vigorous intensity activity.Twelve(37.5%) of the cases and 18(26.5%) of
controls spent 5 days each in vigorous intensity activities, respectively.

About half(49.5%) of the cases and 46.4% of the controls walk or use bicycles for at least 10
minutes continuously to get to and from places for seven days a week. Forty (36%) cases and
79(35.6%) controls spent in walking or using a bicycle for thirty minutes per day.

Only 15(12.5%) cases and 34(14.2%) controls were involved in vigorous-intensity sports, fitness
or recreational (leisure) activities that cause large increases in breathing or heart rate. Six (40%)
86
of those cases and 10(29.4%) controls were involved for 1 day per week. From the cases
4(26.7%) and controls 9(26.5%) were involved in vigorous-intensity sports, fitness or
recreational (leisure) activities that cause large increases in breathing or heart rate for 30 minutes
in a typical day ( Table 2).

Table 2. Community Acquired Pneumonia by lifestyle and habits of of study participants,

2016(n=360)

Life style/Habit category Cases Controls COR[95%CI]

n=120 (%) n=240 (%)
Currently smoke tobacco product Yes 7(5.8) 12(5) 0.85(0.32,2.22)
No 113(94.2) 228(95) 1
Ever consumed alcohol drink Yes 92(76.7) 179(74.6) 0.89(0.53, 1.49)
No 28(23.3) 61(25.4) 1
Involve vigorous-intensity activity Yes 32(26.7) 68(28.3) 1.08(0.66, 1.78)
that causes large increases in No 88(73.3) 172(71.7) 1
breathing or heart rate
involve moderate-intensity activity, Yes 42(35) 85(35.4) 1.02(0.64, 1.61)
that causes small increases in No 78(65) 155(64.6) 1
breathing or heart rate
Walk or use a bicycle (pedal cycle) Yes 111(92.5) 222(92.5) 1.0(0.43, 2.29)
for at least 10minutes continuously No 9(7.5) 18(7.5) 1
to get to and from places
Do any vigorous-intensity sports, Yes 15(12.5) 34(14.2) 1.15(0.60, 2.22)
fitness or recreational (leisure) No 105(87.5) 206(85.8) 1
activities that cause large increases
in breathing or heart rate
Do any moderate-intensity sports, Yes 12(10) 43(18) 0.51(0.26, 1.0)
fitness or recreational (leisure) No 108(90) 197(82) 1
activities that causes a small increase
in breathing or heart rate

87
CAP by Medical History

Among previous medical histories, history of upper airway problem, tonsillectomy, contact with
persons who had respiratory infection, confirmed pneumonia and history of pulmonary
tuberculosis were significantly associated with CAP. As shown in Table 3, 51 (42.5%) cases and
86(35.8%) controls were ever admitted in the last five years. In addition, 26(21.7%) cases and
43(18%) controls were ever bedridden for the last three months. In the last one year, 71(59.2%)
cases and 98(40.8%) controls had upper airway problem. Only 8(6.7%) cases and 5(2.1%)
controls had history of tonsillectomy. None of the cases were vaccinated for influenza in the last
year where as only 1(0.4%) control was vaccinated for influenza last year. In the last year,
59(49.2%) of the cases and 51(21.3%) of controls had any infection of the respiratory system.
Thirty two (26.7%) cases and 29(12.1%) controls had history of contact with people who had
respiratory infection. 85(70.1%) cases and 16(6.7%) of the controls had previous history of
pneumonia confirmed by radiography. (Table-3)

Table 3. Community Acquired Pneumonia by medical history of study participants,

2016(n=360)

History Category Cases Controls COR[95%CI]

n=120(%) n=240(%)
Ever admitted in the last five Yes 51(42.5) 86(35.8) 0.75(0.48,1.18)
years No 69(57.7) 154(64.2) 1
Ever bedridden in the last three Yes 26(21.7) 43(18) 0.78(.45, 1.36)
months No 94(78.3) 197(82) 1
Had upper air way problem last Yes 71(59.2) 98(40.8) 2.1(1.3,3.3)
year No 49(40.8) 142(59.2)
Had history of tonsillectomy Yes 8(6.7) 5(2.1) 3.4(1.1,10.5)
No 112((93.3) 235(97.9) 1

Had history of dental visit last Yes 11(9.2) 30(12.5) 1.41 (0.68, 2.93)
month No 109(90.8) 210(87.5) 1
Get vaccinated for influenza last Yes 0(0) 1(0.4) .0(.0,)
year No 120(100) 239(99.6) 1

Get vaccinated for any respiratory Yes 2(1.7) 6(2.5) 0.6(0.1,3)

infection last year No 118(98.3) 234(97.5) 1

Had any respiratory infection last Yes 59(49.2) 51(21.3) 3.6 (2.2,5.8)
year No 61(50.8) 189(78.7) 1
88
 Had contact with people who had Yes 32(26.7) 29(12.1) 2.6(1.5,4.6)
respiratory infection No 88(73.3) 211(87.9) 1
Previous history of pneumonia Yes 85(70.8) 16(6.7) 34(17.9,64.6)
confirmed by radiograph No 34(29.2) 224(93.3) 1

History of diabetes Yes 8(6.7) 18(7.5) 1.13(0.48, 2.69)

No 112(93.3) 222(92.5) 1
History of cardiopathy Yes 9(7.5) 23(9.6) 1.3(0.58, 2.92)
No 111(92.5) 217(90.4) 1
History of chronic bronchitis Yes 4(3.3) 13(5.4) 0.6(0.2,1.9)
No 116(96.7) 227(94.6) 1

History of diagnosed asthma Yes 5(4.2) 18(7.5) 1.86(0.67,5.15)

No 115(95.8) 222(92.5) 1
History of pulmonary TB Yes 18(15) 18(7.5) 2.2 (1.1,4.4)
No 102(85) 222(92.5) 1
History of gastric Diseases Yes 61(50.8) 129(53.8) 0.9(0.6,1.4)
No 59(49.2) 111(46.2) 1
History of CLD Yes 4(3.3) 7(2.9) 1.1(0.3,4.0)
No 116(96.6) 233(97.1) 1

CAP by Environmental factors

History of contact with pets and history of working in dusty environments were significantly
associated with CAP. Seventy (58.3%) of the cases and 107 (44.6%) of the controls had a history
of contact with pets, while (26.7%) cases and 51(21.2%) controls had history of contact with
birds. About 61% of the cases and 46% of the controls had been exposed to dusty environment
(Table 4).

89
Table 4 Community Acquired Pneumonia by environmental factors of study participants,
2016(n=360)

Variable Category Cases Controls COR[95%CI]

n=120(%) n=240(%)
History of contact Yes 93(77.5) 175(73) 1.2(0.8, 2.1)
with children No 27(22.5) 65(27) 1
History of contact Yes 32(26.7) 51(21.2) 1.4(0.8, 2.2)
with birds No 88(73.3) 189(78.8) 1
History of contact Yes 42(35) 82(34.2) 1(0.7, 1.6)
with Animals No 78(65) 158(65.8) 1
History of contact Yes 70(58.3) 107(44.6) 1.7(1.1, 2.7)
with pets No 50(41.7) 133(55.4) 1
History of working in Yes 73(60.8) 111(46.3) 1.8(1.2,2.8)
a dusty environment No 47(39.2) 129(53.7) 1

Electric stove 16(13.3) 48(20) 1

Cooking fuel Wood 67(55.8) 118(49.2) 1.3(0.62,2.74)
Electric, coal &
wood 1310.8) 19(7.9) 0.76(0.43, 1.35)
Electric, coal&
kerosene 24(20) 55(22.9) 0.64(0.27, 1.49)

In the final logistic regression model, we included variables that were significantly associated
with CAP at the univariate analysis, and found that only four of the variables, namely working in
a dusty environment, history of respiratory infection in the last year, contact with people who had
respiratory infection and previous history of pneumonia confirmed by radiograph having
statistically significant association with CAP. As shown in Table 5, the odds of developing
community acquired pneumonia among those working in a dusty environment was two times
higher as compared to their counterparts [OR=2.0, 95% CI 1.1-4.1)], the odds of developing
CAP among those who had history of contact with people who had respiratory infection was 2.5
times higher as compared to those who did not have history of contact [OR=2.5, 95% CI 1. 2-
5.3], those who had history of respiratory infection were about twice more likely to develop
community acquired pneumonia than those who did not have the same history [OR=2.3, 95% CI
1.5-5.7] and the odds of developing pneumonia among those who had history of pneumonia
confirmed by radiography was 39 times higher compared to those who had not [OR=39, 95% CI
19.4-78.6](Table 5)

90
Table 5. Potential risk factors for Community Acquired Pneumonia among study
participants, 2016(n=360)

Variable category Cases Controls AOR[95%CI]

n=120(%) n=240(%)
Age Uncategorized 0.9(0.9,1.0)
Educational level No formal edu 49(40.8) 67(27.9) 1.7(0.8,3.9)
Educated 71(59.2) 173(72.1) 1
Contact with pets Yes 70(58.3) 107(44.6) 1.3(0.7,2.4)
No 50(39.2) 133(55.4) 1
Working in dusty Yes 73(60.8) 111(46.3) 2.0(1.1,4.1)
environment No 47(39.2) 129(53.7) 1
Had upper air way Yes 71(59.2) 98(40.8) 1.6(0.8,3.2)
problem last year No 49(40.8) 142(59.2) 1
Had history of Yes 8(6.7) 5(2.1) 0.7(0.14, 3.3)
tonsillectomy No 112((93.3) 235(97.9) 1

Had any respiratory Yes 59(49.2) 51(21.3) 2.3(1.5,5.7)

infection last year No 61(50.8) 189(78.7) 1

Had contact with Yes 32(26.7) 29(12.1) 2.5(1.2,5.3)

people who had No 88(73.3) 211(87.9) 1
respiratory infection
History of pneumonia Yes 85(70.8) 16(6.7) 39(19.4,78.6)
confirmed by No 34(29.2) 224(93.3) 1
radiograph
History of pulmonary Yes 18(15) 18(7.5) 0.9(0.3,2.6)
TB No 102(85) 222(92.5) 1

91
Discussion

The study has attempted to determine potential risk factors for Community Acquired Pneumonia
in the hospital setting of Tigray region in Ethiopia.
Our finding showed no significant association between smoking and community acquired
pneumonia, while other studies conducted in different countries reported that smoking as one
risk factor for the development of community acquired pneumonia (2-8). Perhaps only few (19)
of our study participants reported to have been smokers which may be a small number to give a
significant information.

Although, some studies have reported that alcohol consumption as being a risk factor for
developing CAP (8-10), our study showed no significant association between alcohol
consumption and CAP. Similar to our study there are findings revealed alcohol consumption is
not a risk factor for community acquired pneumonia (2,3,6,7). This could be justified by
difference in the type, amount and frequency of the alcohol consumption.

Having history of respiratory infections and contact with people who had respiratory infection
were found to be risk factors for the development of community acquired pneumonia which was
also reported by different studies globally (2,5,6,8,11,12). Similar to previous findings our study
showed that patients with history of pneumonia confirmed by radiograph had higher risk of a
subsequent CAP (2,5,12-14).

In line with a study from Great Britain (3), working in a dusty environment was identified in our
study as one of the major risk factors of community acquired pneumonia. However, contrary
results were also reported by others (5). This dissimilarity could be because of different working
environment, difference in exposure and the nature of the dust.

History of diabetes and heart disease were not significantly associated with CAP in this study,
which was also reported by many other studies (2,3, 9, 4), however, other studies from different
countries reported that heart disease and diabetes being significant risk factors for CAP (3,5, 8).
These differences may be due to that many of our respondents might have not known their status
or not diagnosed for diabetes and heart diseases.

Chronic bronchitis, diagnosed asthma and Pulmonary TB were not associated with CAP in the
current study as was also reported by others (2,4). Unlike to this, findings showed that chronic
bronchitis, diagnosed asthma and Pulmonary TB are risk factors for community acquired
pneumonia among adults (2,3,5,6).

92
Similar to a finding by Schnoor et al, contact with birds and pets were not significantly
associated with CAP when adjusted by other variables in the current study(12) but Almirall et al
reported that contact with birds and pets as being a risk factor for the development of CAP (5).

Since the current study is hospital based it might not be generalized to the whole community in
the region. In addition there might be selection bias as the cases in the study had been enrolled
continuously until the required sample size was met.

In conclusion working in dusty environment, history of pneumonia, history of respiratory

infection and having contact with people who had respiratory infections are confirmed as the risk
factors of community acquired pneumonia in the current study.

Hence, much has to be done to prevent community acquired pneumonia through health education
and awareness raising interventions. On the other hand, to minimize the risk of developing
community acquired pneumonia safety measures like personal protective equipments should be
used when there is contact with patients having respiratory tract infections. Whenever respiratory
tract infections including pneumonia are occurred proper management using standardized
treatment guideline should be given so that subsequent infections or complications would be
minimized . Moreover, Larger studies are also needed to assess the effect of some risk factors in
the general population.

Acknowledgement

We would like to extend our gratitude to Mekelle University and Addis Abeba university for
funding the study,Tiray health bureau and zonal hospitals administration bodies, the study
participants, data collectors, supervisors.

Competing interests

The authors declare that we have no competing interests.

93
References

1. Jokinen C, Heiskanen L, Juvonen H, et al. Incidence of community-acquired pneumonia in the

population of four municipalities in eastern Finland. Am J Epidemiol 1993;137:977–88.
2. Almirall J, Bolíbar I, Balanzó X, etal. Risk factors for community-acquired pneumonia in
adults: a population-based case control study. Eur Respir J 1999; 13: 349-355.

3. Farr BM, Bartlett CL, Wadsworth J, Miller DL etal, Risk factors for community-acquired
pneumonia diagnosed upon hospital admission, Harcourt Publishers Ltd , Respir. Med. (2000)
94, 954–963

4.Aykut Çilli,Tülay Özdemir,Ömer Özbudak, etal, Risk Factors for the Development of
Community-Acquired Pneumonia in Young Adults, Turkish Respiratory Journal, 2001;2 (1):3-7

5. Almirall J, Bolíbar I, Serra-Prat M etal, New evidence of risk factors for community acquired
pneumonia: a population-based study, Eur Respir J 2008; 31: 1274–84
6. J. Teepe, L. Grigoryan and T.J.M. Verheij , Determinants of community-acquired pneumonia
in children and young adults in primary care, Eur Respir J, 2010; 35: 1113–1117
7. Baik I, Curhan GC, Rimm EB etal. A Prospective Study of Age and Lifestyle Factors in Relation
to Community-Acquired Pneumonia in US Men and Women, Arch Intern Med.
2000;160(20):3082-3088.
8. Antoni Torres, Willy E Peetermans, Giovanni Viegi and Francesco Blasi,Risk factors for
community-acquired pneumonia in adults in Europe: a literature review, Thorax 2013;68:1057–
1065.

9. Koivula I, Sten M, MaÈkela È PH. Risk factors for pneumonia in the elderly. Am J Med 1994;
96: 313-320.
10. Irma Koivula, Marja Sten, Pirjo Helena Makela, Risk factors for pneumonia in the elderly,
The American Journal of Medicine, Volume 96, Issue 4, April 1994, Pages 313–320.
11. Rose RM, Pinkston P, O'Donnell C, Jensen WA. Viral infection in the lower respiratory tract. Clin
Chest Med 1987; 8: 405-418

12. M. Schnoor, T. Klante, M. Beckmann etal, Risk factors for community-acquired pneumonia in
German adults: the impact of children in the household, Epidemiol. Infect. (2007), 135, 1389–1397. 2007
, Cambridge University Press.

13. Hedlund JU, Ortqvist AB, Kalin M, Scalia-Tomba G, Giesecke J. Risk of pneumonia in patients
previously treated in hospital for pneumonia. Lancet 1992; 340: 396-397.

14. Hedlund J. Community-acquired pneumonia requiring hospitalisation: factors of importance for the
short-and long term prognosis. Scand J Infect Dis 1995; 97: 11-60.
94
15. The 2007 Census by the Central Statistical Agency of Ethiopia (CSA)

16. Federal Ministry of health Ethiopia,Health and health related indicators,2007

17. Gerald Yonga, case kenya study:-NCD situation, Kenya NCD Alliance, Kenya Cardiac Society, Aga
Khan University, East Africa,2009

95
Original Paper-Three

96
 Cost of illness among hospital treated adults for community acquired pneumonia in

Tigray, Ethiopia.

Haftu Berhe Gebru, MSc1, Prof. Fikre Enquselassie, PhD2 & Alemayehu Bayray ,PhD3

1. College of Health Sciences, School of Nursing, Mekelle University, Ethiopia

2. College of Health Sciences, School of Public Health, Addis Ababa University,

Ethiopia

3. College of Health Sciences, School of Public Health, Mekelle University, Ethiopia

Corresponding Author, Haftu Berhe Gebru

Email: [email protected]

97
Abstract

Background: Albeit pneumonia incurs a considerable burden on healthcare resources much is

not known yet about the cost of illness among hospital treated adult patients globally and in
Ethiopia specifically.

Objective: To estimate the cost of illness of community acquired pneumonia among hospital
treated adults in Tigray

Methods: The study was conducted in Tigray region, north Ethiopia. A retrospective patient
record review was used. Medical records of 1174 patients that had been diagnosed and treated
for community acquired pneumonia between July, 2014-July, 2015 at zonal hospitals and Ayder
referral hospital were reviewed. Cost of illness was estimated from individual database after
developing a check list. Descriptive analysis and linear regression was performed using SPSS
Version 20 statistical program.

Result: The total amount of money incurred over the study year was 319,056.52 Ethiopian Birr
($15,193.2) of which the direct medical expenditure was 242889.60 Ethiopian Birr
(US$11,566.20) and the cost of lost working days by the patients due to community acquired
pneumonia was 76166.92 Ethiopian Birr ($3627). From the cost of direct medical expense, 47.6
% was used for medication, 18% for imaging (X-ray), 15% for laboratory, 16% for bed and 3%
for registration.

Conclusion: The cost of illness among adult patients of community acquired pneumonia in the
study area was substantially high. Of the total cost incurred, 76 % was due to direct medical
expense and 24 % for the lost working days. Appropriate prevention strategies should be
implemented so that the magnitude would be minimized and terminally the treatment cost incur
by community acquired pneumonia will be reduced.

Key Words: Cost,CAP,Adults,Tigray

98
Introduction

Pneumonia is a disease in the lungs and it is a common cause of infection related to the mortality

that challenges most of health care providers and the community (1).

Community-acquired pneumonia (CAP) is an acute disease which represents a common cause of

hospital admission and mortality in developed and developing countries and hence consumes a
great proportion of health care budgets (2).

A study in Italy reported that the number of physician consultation accounts for 25% due to
respiratory system infections. Pneumonia accounts for 2-3%, of which the majority of these
cases are community-acquired pneumonia (3). In the United States, 4 million adults are affected
each year of which 20% need hospitalization for management (4). Furthermore, about 50,000
adults in the US die from Pneumonia disease every year (5). In the united kingdom around
220,000 people receive diagnosis of pneumonia each year and 28,952 deaths occurred from
pneumonia in 2012 (5.1 per cent of all deaths and 25.3 per cent of deaths from lung disease) (6)

Pneumonia is a common cause of hospitalization and mortality in adults in Latin America. A

population weighted average incidence of hospitalized pneumonia in persons over 50 years of
age was 519.6 hospitalizations per 100 000 person years, with an average fatality rate of 19.0 per
100 hospitalizations, representing 436,402 hospitalizations and 82,852 deaths in 2009.
Extrapolating forward to 2020, with a projected adult population of 1.49 billion, pneumonia
could account for up to 617,993 hospitalizations and 112,680 deaths in a single year (7).

Pneumonia ranks among the top three diagnoses in hospital admissions in sub-Saharan Africa (8)
and the fifth largest killer in South Africa, accounting for 3.9% of all deaths (9). Likewise, CAP
is the leading cause of hospitalization and mortality among adult patients accounting for 10% in
Kenya (2), 11.9% in Nigeria (10), 8.3% in Botswana, and 51,000 admissions per year with
10,000 deaths per year in Malawi (11).

Pneumonia is a huge burden on healthcare systems. As reported by a study in the US, Pneumonia
expenses accounted for $16.2 billion in 2013 only (12).Likewise, in Europe, pneumonia costs
nearly € 10.1 billion annually (13). Community acquired pneumonia has an effect towards the

99
patient’s recovery to return to a full range of daily activity of about 7 to 43 days. However, the
length of stay in the hospitals is variable primarily affecting the cost of care (14).

A study from Spain revealed that the cost of inpatient care for community-acquired pneumonia
was € 1,553, whereas the mean cost of treating pneumonia in outpatient was € 196 (15). Another
study reported that hospitalization represents over 90% of the direct costs of treatment in Czech
Republic, Hungary, Poland and Slovakia in which adults aged 65 years and above accounting for
73% of the costs (16).

A study from Italy showed that the mean cost per episode of community acquired pneumonia

was Euro 1586 (17). Likewise a study from France revealed that the pooled cost of ambulatory

and hospitalized patients was Euro 357.1 (18). Another study from New Zealand concluded that

the annual cost of (a societal perspective for the adult population aged 15 years and over) was

estimated to be 63 million Newzland’s dollars, (direct medical costs of 29 million dollars; direct

non-medical costs of 1 million dollars; lost productivity of 33 million dollars) (19). Similarly, a

study from China confirmed that the median total hospital cost was US$556.50 (mean

US$705.60) (20). Another study from USA showed that the mean cost of hospitalization per

admission (excluding physician cost) was $US3490±3058 (median $US2430) (21). Two recent

studies showed that CAP is common and costly infection in working age population in USA,

specially, adults with co-morbidities, with estimated national direct and indirect cost of US$8.5

billion and US$2.1 billion, respectively. Despite the data, CAP remains as under recognized

burden among employers, payers, healthcare providers, and the nonelderly adult population (22).

In a study by Tichopad Mail et. al., in countries including Czech Republic, Hungary and Poland

hospitalization represents over 90% of the direct costs of treatment. Adults aged 65 and above,

who represent 41% of the combined population, account for 73% of the costs. The costs per case

remain relatively stable both for inpatient and outpatient of CAP across all age groups. By
100
contrast, the overall cost of outpatient care declined with age since the incidence was generally

steady and population sizes were larger in the younger groups (16).

However there is no available literature that shows the cost of hospital expenditure regarding

CAP in Ethiopia and other sub-Saharan Africa countries. Hence, the aim of this research was to

estimate the cost of illness of community acquired pneumonia among hospital treated adults in

Tigray, Ethiopia.

Methods

The study was conducted in Tigray region. Based on the 2007 Census conducted by the Central

Statistical Agency of Ethiopia (CSA), the region has an estimated total population of 4,314,456,

of whom 2,124,853 males and 2,189,603 females; urban inhabitants account for 842,723

(19.53%) of the population. With an estimated area of 50,078.64 square kms, the region has an

estimated density of 86.15 people per square km. The region is predominantly Tigrian people at

96.55% of the population. About 95.6% of the population are followers of Ethiopian Orthodox

Christianity. There are 712 health posts, 201 health centres and 15 hospitals (six zonal or general

hospitals, one referral and the remaining are primary hospitals) in the region. There are 3, 4, 77,

60, and 50 Hospitals, Health centres, Medium clinics, Primary clinics and Specialty clinics,

respectively owned by private and nongovernmental organizations (23, 24).

Hospital based medical-record review design was used. All community acquired pneumonia

patients who had been treated in all zonal hospitals of Tigray and Ayder referral hospital

between the periods July, 2014-July, 2015 were the source population.

All complete medical records of CAP patients aged 18 years and above were included in the

study. Exclusion was done if the patients had history of hospital admission 14 days before their

101
arrival in the hospitals, if the pneumonia was developed 48 hrs following admission, patients

with tuberculosis (TB) or previous chest X-ray which may conflict with diagnosis of CAP,

chronically debilitated patients, patients with lung cancer and asthma. Moreover, incomplete

charts were also excluded from the study.

First, all patient charts with CAP that fulfilled the case definition aged 18 years and above were

retrieved. Accordingly only 1174 charts fulfilled the eligibility criteria. Data was collected using

a checklist which was adapted from relevant literatures to explore the socio-demographic

characteristics of the patients, diagnosis, treatment given and cost of illness.

Pre-test was conducted on 10% of the total charts to check the completeness and consistency of

the checklist. Accordingly, appropriate modifications and adjustments were made. Data was

collected using trained nurses/health officers with at least some years of work experience. At the

end of every data collection day each questionnaire was examined and pertinent feedback was

given to the data collectors and supervisors.

Ethical clearance was obtained from Institutional Review Board (IRB) of Addis-Ababa

University, College of Health Sciences. Letter of agreement was secured from Tigray regional

health bureau. In addition, waiver of consent was obtained from IRB of AAU and additional

consent was obtained from the hospital administrators after explaining the purpose of the study

and they were informed that every patient record will be kept confidential at any time.

Any document used in this research was kept private and confidential (data was password

protected and filled checklist was kept locked in a cabinet). No information other than for the

purpose of this study was collected from the patients charts. Moreover, respondents were not

identified by names or any other indicators.

102
Data analysis was conducted using SPSS Version 20, descriptive statistics, numerical summary

measures, and simple linear regression analysis was carried out using SPSS.

The methods of cost estimation employed in this study included a micro-costing bottom-up
approach in order to estimate direct patient side medical cost of community acquired pneumonia.
Indirect cost was calculated in terms of productivity time losses (work days) due to
hospitalization using a human capital approach. This was applied only for the productive age
group participants (18-64 year old).
Valuation of costs was calculated as follows: costs due to community acquired pneumonia were
framed under direct and indirect cost components. The direct costs estimated were medical costs
like diagnostics, medications, laboratory and cost of hospitalization. Indirect costs were defined
as work days lost due to the illness.
The indirect cost estimates for the productive age participants constitute earnings lost because of
hospital stay related to community acquired pneumonia.These work days were changed into
monetary terms using a human capital approach. That is, considering the average daily income of
the cases to be ETB 34.4 ($1.64). The time foregone in seeking care (productive time lost due to
hospitalization) for the inpatients was converted into an indirect cost by multiplying the total
hospital bed days, i.e.1420 by the average daily wage ETB 34.4 ($1.64) while for the out patients
was one day(25).

Individual cost items were summed up to the categories of medical costs and lost income
because of hospitalization. The total cost of community acquired pneumonia for each patient was
calculated as the sum of the direct costs and the indirect costs. All costs were first calculated in
Ethiopian Birr and then converted into US dollars. The average currency exchange rate during
the period July, 2014 to July 01,2015 was used to convert ETB into US dollars (21 ETB=US $1).
Furthermore, simple linear regression analysis was run to predict the amount of cost incurred for
every increase in hospitalization day.

103
Results

In this study, we reviewed one thousand and one hundred seventy four medical records of

community acquired pneumonia adult patients treated in Tigray Zonal and tertiary hospitals.

Two hundred twenty three (19%) and 951(81%) patients were treated at inpatient and outpatient

departments, respectively. One hundred ninety one (16.3%) and 881(75%) patients treated at

inpatient and outpatient departments, respectively were below the age of 65 years. From the total

patients 663(56.5%) were males of whom 530(79.9%) were treated at outpatient department.

One thousand and twenty eight patients (87.6%) were treated in the hospitals without being

referred, of whom 147(14.3) patients were treated at inpatient department.

Higher proportion (about 63%) of patients were treated at three zonal hospitals namely Adigrat

(24%), Mekelle (22.5%) and Lemlem Karl (16%). Mekelle hospital had highest (60) proportion

of patients treated at inpatient department while no patient had been treated at inpatient

department of Ayder referral hospital. Moreover, the mean hospital stay for participants treated

at the inpatient department was 7.4 (+7.7) (Table-1).

Moreover, the hospital bed occupancy rate for the admitted patients of community acquired

pneumonia over the study year was 0.3% ; there were a total of 1522 beds in the study hospitals

and a total of 1657 inpatient days were observed.

104
Table 1. Socio-demographic and clinical characteristics of the study participants versus site of

treatment, 2016 (n=1174)

Characteristics Department patients treated Total

Inpatient Outpatient
No (%) No (%) No (%)
Age
Below65 191(17.8) 881(73.2) 1072(91.3)
65 and above 32 (31.4) 70(68.6) 102(8.7)
Sex
Male 133(20.1) 530(79.9) 663(56.5)
Female 90(17.6) 421(82.4) 511(43.5)

Occupation
Farmer 133(21.5) 485(78.5) 618(52.6)
Student 38(12.3) 270(87.7) 308(26.2)
Civil Servant 19(18.8) 82(81.2) 101(8.6)
House wife 15(15.5) 82(84.5) 97(8.3)
Private employee 18(36.0) 32(64.0) 50(4.3)

Referral Status
Referred 76(52.1) 70(47.8) 146(12.4)
Not referred 147(14.3) 881(85.5) 1028(87.6)
Treatment Hospital
Sihul 37(13.0) 100(73.0) 137(11.7)
St.Marry 21(12.1) 153(87.9) 174(14.8)
Kahsay Abera 21(50.0) 21(50.0) 42(3.6)
Adigrat 49(17.4) 233(82.6) 282(24)
Mekelle 60(22.7) 204(77.3) 264(22.5)
Ayder 0 86(100) 86(7.3)
Lemlem Karl 35(18.5) 154(81.5) 189(16.1)
Length of hospital stay
7.4 days or lower 161(72.2)
More than 7.4days 62(28)
Mean(SD) 7.43 (7.7)
Total 223(19.0) 951(81.0) 1174

105
Cost of treatment for community acquired pneumonia

The total amount of money incurred over the study year was 319,056.52 Birr ($15,193.2) with

the mean cost per episode of community acquired pneumonia of 168($8) Birr for outpatients and

775 Birr($37) for in patients, respectively. About 76% (242889.60(11,566.20)) of the money was

attributed for direct medical expenditure of which 126,415.8(6,019.8) was incurred by

outpatients and 116473.8 (5546.4) by the inpatients. The work related cost lost by the patients

due to the community acquired pneumonia was 76166.92 Eth B ($3627) (Table 2).

Table 2. Cost of treatment among patients with community acquired pneumonia according
to site of care,2016(n=1174)

Expenditure Inpatient Outpatient Sub Total

category
EthB(USD) EthB(USD)

Registration Fee 1554(74) 6430(306.2) 7984(380.2)

Bed stay 38634.75(1839.75) - 38634.75(1839.75)
Blood Test 9804 (466.85) 22847.34(1087.96) 32651.34(1554.8)
Other Tests 1183(8.7) 2368.6(112.8) 3551.6(169)
X-Ray 11925(567.85) 32606.5(1552.7) 44531.5(2120.5)
Antibiotic 50361.24(2398.15) 60153.66(2864.46) 110514.9(5262.6)
Anti Pain 755.7 (36) 1105.5 (52.6) 1861.2(88.10)
Other drugs 2256.1(107.4) 904.2 (43) 3160.3(150.5)
Sub-total 116473.8 (5546.4) 126,415.8(6,019.8) 242889.60(11,566.20)
Grand total of patient side cost: Medical expenditure cost 242889.60(11,566.20)
+ Loss of productivity cost (76166.92 Eth B($3627 ) =
319,056.52 Birr ($15,193.2)

106
Using simple linear regression model, we obtained a regression equation Y= 454.95+22

indicating that for every single day increment in inpatient hospital stay there is an equivalent

increment of ETB 22 ($1.05).

Though the regression equation had a poor fit, describing only 28 % of the variance in total cost

of illness due to community acquired pneumonia ( R2adj = 28%), the overall relationship help us

to understand whether the model that we used is appropriate to predict the cost for each inpatient

hospital stay was statistically significant( F = 86 , p= 0.00).

Discussion

This study attempted to address cost of illness of adult CAP patients which is rarely considered

in Ethiopia and Africa by in large.

In the present study it is confirmed that the total amount of money incurred over the study years

was 319,056.52 Birr ($15,193.2) and the mean cost of illness per episode of community acquired

pneumonia was 168 Eth.Birr ($8) for out pts and 775 ($37) for in patients respectively which is

much lower than a study from Italy that showed the mean cost per episode of CAP was Euro

1586 (17). Likewise a study from France showed that the pooled cost of ambulatory and

hospitalized patients was Euro 357.1 (18). The difference may be b due to variations in prices of

the treatment packages and resources used.

The mean direct medical expense per episode (of the patients) was 522.3 Ethiopian Birr ($25.9)

for inpatients and 132.9 ($6.3) for outpatients. Our finding was not in line with studies from

developed countries such as a study from France revealed that the mean direct medical cost of a

disease episode of CAP was EU 118.8 for strictly ambulatory patients with an equal weight for

medical time, drugs, diagnostic procedures and tests. This direct cost was EU102.1 before

admission for patients who were finally hospitalized. The mean cost of hospital admissions was
107
EU 3522.9 (18 ). Another study from New Zealand concluded that the annual cost (of a societal

perspective for the adult population aged 15 years and over) was estimated to be 63 million

dollars, (direct medical costs of 29 million dollars; direct non-medical costs of 1 million dollars;

lost productivity of 33 million dollars) (19). Furthermore, a study from USA showed that the

mean cost of hospitalization per admission (excluding physician cost) was $US3490 ± $US3058

(median $US2430) (21). Likewise, a study from China confirmed that the median total hospital

cost was $556.50 (mean $705.60) (20). The discrepancies could be because of differences in

severity of the problem, length of the treatment, service consumption and price variations among

the countries.

In the current study the mean working days lost due to CAP for the productive age group of

inpatients (18-65years) was 7.43+7.7 days. As a result the mean amount of money incurred per

episode due to work loss by the in patients and out patients was 256 Eth.Birr (US$12.2) and

34.4(US$1.6) respectively. Our finding was much lower than the study from France which

showed that the mean number of non-worked days was 10.8 (SD 8.0) days for ambulatory

patients and 31.0 (SD 27.2) days for patients who were hospitalized: the impact of the disease

episode on productivity was EU 1980 (SD 1400) per ambulatory episode and EU 5425 (SD

4760) per episode leading to hospital admission (18).

From the total patients in this study, 72% undergone X-ray examination, 98.4% got medication

prescription with the most common being antibiotics and 83.2% undergone laboratory tests.

Unlike to ours a study from France showed that one hundred and seventy-two (19%) patients

were managed without X-rays. White blood cell count was measured in 316 (36%) patients; C-

108
reactive protein (CRP) and pro-calcitonin levels were respectively assessed in 314 (35%) and

13(1%) patients. Microbiological tests were rarely prescribed (1%), antibiotics were prescribed

medications for most (94%) patients at the inclusion visit (18). Similarly, a study from Australia

confirmed that at least one medication was prescribed (or provided) for 63% of pneumonia

problems, with the most common being antibiotics. Imaging was requested for 29% of

pneumonia contacts, with chest radiology (92%) the most common form. Pathology testing was

sought for 10%, with chemistry, hematology and microbiology the most common categories

recorded (26). The variations could be because of the availability of different diagnostic options,

knowledge and skill gap of the professionals and lack of standardized management guideline for

community acquired pneumonia in our country.

Of the total direct medical expense, 47.6 % was used for medication, 18% for imaging (X-ray),

15% for laboratory, 16% for bed and 3% for registration which is different from a study

conducted in USA that confirmed bed costs accounted for 55.6% of total costs, followed by

laboratory (9.9%) and pharmacy (9.8%) costs (27). Another study from USA indicated that from

the cost of hospitalization per admission (excluding physician cost) hospital room/board

accounted for the largest percentage (83.7%), followed by laboratory (8.1%), antibacterial

(4.6%), radiology (2.6%) and respiratory (0.9%) cost centers (21). Likewise, a study from

Australia showed that of the total costs of community acquired pneumonia, 60% was used for

medication and 23% for imaging cost (26). Similar study in China revealed that from the total

hospital cost 48.9% was used for drugs, 21.9% for laboratory tests, 8.6% for radiology, 6.3% for

hospital beds and 5.3% for examination (20). The explanation for the discrepancy could be

because of differences in diagnostic and treatment standards among the countries.

109
Limitations

Since the current study is retrospective review all patient side expenses might not be recorded in

the charts of the patients. In addition, opportunity costs, direct non medical costs and care giver's

cost were not studied. Hence, the cost of illness for this study might be under estimated.

In addition, comparison of our findings with previous Ethiopian and/or other sub-saharan Africa

countries data was not possible for there have been no studies examining the cost of community

acquired pneumonia. Hence, some of the comparisons made with studies conducted in the

advanced countries would be of limited value because of the difference in the categories of cost,

the methods used, the pattern of health services utilization and the health care system.

In conclusion the cost incurred among adult patients of community acquired pneumonia in

Tigray hospitals is significant. During the two years period, of the total cost incurred 76 % was

due to direct medical expense. Hence, prevention strategies like immunization and other

interventions should be implemented so that the magnitude of the problem would be minimized

and terminally the treatment cost incur by community acquired pneumonia will be reduced.

Moreover, it is good if prospective studies are further conducted to estimate holistic costs of

community acquired pneumonia.

Acknowledgment

We would like to extend our gratitude to Mekelle and Addis Abeba universities,the data

collectors, supervisors, Zonal and tertiary hospitals in Tigray region.

110
References

1. Nair GB, Niederman MS. Community-acquired pneumonia: an unfinished battle. Med Clin
North Am. 2011;95:1143-1161.

2. Jokinen J, Scott JA, Estimating the proportion of pneumonia attributable to pneumococcus

in Kenyan adults: Latent class analysis. Doi 2010: 21(5): 719–725

3. Giorgi Rossi P,Agabiti N,Faustini et al. The burden of hospitalized pneumonia in Lazio,
Italy, 1997-1998. Int J Tuberc Lung Dis. 2004; 8:528

4. Deshpande A. Epidemiology of Community Acquired Pneumonia Supp Japi 2012;60: 6

5. American Thoracic society, Top 20 Pneumonia facts,2015.

6. British Lung Foundation, pneumonia statistics, 2016
7. Alfonso Rosado Buzzo, Craig Roberts, Lourdes Garcı´a Mollinedo etal. Morbidity and
mortality of pneumonia in adults in six Latin American countries, International Journal of
Infectious Diseases 17 (2013) e673–e677)

8. Woodhead M, Blasi F, Ewig S, Garau J, Huchon G, et al. (2011) Guidelines for the
management of adult lower respiratory tract infections-summary. Clin Microbiol Infect 17
Suppl 61–24.

9. Van der Pol T, Opal SM. Pathogenesis, treatment, and prevention of pneumococcal
pneumonia. Lancet 2009;374(9700);1543-1556.

10. Onyedum C, Chukwuka JC. Admission profile and management of community acquired
pneumonia in Nigeria-5 year experience in a tertiary hospital.
11. Gordon S, Graham S. Epidemiology of Respiratory disease in Malawi. Malawi Med J 2006;
18(3); 134-145.
12. American lung association, Trends in Pneumonia and Influenza Morbidity and Mortality,
November 2015
13. Nathwani D, Welte T, Torres A. Clinical and economic burden of community acquired
pneumonia among adults Doi 2012; 67: 71–79.

111
14. Siegel RE. How long a stay in hospital is needed for patient with community acquired
pneumonia in hospital? Am J Med 2000; 109; 434-436.

15. Bartolome M. Almirall J, Morera J, Pera G, Ortun V, et al. A population-based study of the
cost of care for community acquired pneumonia. Euro Respir J 2004; 23: 610-616. ....30
16. Tichopad mail A, Roberts C, Gembula I, Hajek P, et al. Clinical and Economic Burden of
Community-Acquired Pneumonia among Adults in the Czech Republic, Hungary, Poland and
Slovakia. DOI; 2013: 10.1371; 837

17. Dal Negro R, Berto P, Tognella S, Quareni L; Cost-of-illness of lung disease in the
TriVeneto Region, Italy: the GOLD Study, Monaldi Arch Chest Dis. 2002 Feb;57(1):3-9.

18. V. Personne, J. Chevalier C. Buffel du Vaure etal, CAPECO: Cost evaluation of community
acquired pneumonia managed in primary care. Vaccine (2016), http://dx.doi.org/10.1016/j.

19. Scott G, Scott H, Turley M, Baker M, Economic cost of community-acquired pneumonia in

New Zealand adults, N Z Med J. 2004 Jun 18;117(1196):U933.

20. Qing-tao Zhou, MD, Bei He, BSMed, Hong Zhu, BSMed, Potential for Cost-Savings in the
Care of Hospitalized Low-Risk Community-Acquired Pneumonia Patients in China, value in
health 12;1,2009 .

21. Orrick JJ, Segal R, Johns TE etal. resource use and cost of care for patients hospitalised with
community acquired pneumonia: impact of adherence to infectious diseases society of america
guidelines,available at www. Pubmed. com and accessed on April 10/2016.

22. Polsky D, Bonafede M, Suaya JA. Comorbidities as a driver of the excess cost of
community-acquired pneumonia in U.S. commercially- insured working age adults. BMC Health
Serv Res. 2012;12: 379

23. The 2007 Census by the Central Statistical Agency of Ethiopia (CSA).

112
24. Federal ministry of health Ethiopia: health and health related indicators 2007

25. International monetary fund (IMF) world economic outlook data base, October, 2014

26. Ambrose Li , Anthony T. Newalla, Helena Britt , C. Raina MacIntyre, The cost and disease
burden of pneumonia in general practice in Australia, Vaccine 30 (2012) 830– 831

27.Sun HK, Nicolau DP, Kuti JL., Resource utilization of adults admitted to a large urban
hospital with community-acquired pneumonia caused by Streptococcus pneumoniae, Chest. 2006
Sep;130(3):807-14.

113
 ANNEX2:DATA COLLECTION TOOLS
Annex 2.1 Checklist
ADDIS ABABA UNIVERSITY
COLLEGE OF HEALTH SCIENCES
SCHOOL OF PUBLIC HEALTH
General instruction for data collectors/supervisors
This is a checklist for collecting data from patient chart of community acquired pneumonia to be
filled by the respective nurses/health officers, you as part of research team are responsible to
adhere to the ethical issues in maintaining confidentiality and hand over the charts to the records
office immediately after taking the necessary information needed, and say thank you to the
record office staffs.

Name of the nurse/health officer: ______________________________

Name of hospital: _____________________
Zone/wereda: _________________
Identification information:
1. Registration no of the chart: __________________________________
2. Age of the patient in years: _________
3. Sex of the patient:___________
4. Address of the patient: zone__________wereda_______________
5. Occupation of the patient____________________
6. Referral (if any)___________________________
7. Outpatient visits (OPD)_________________________
8. Date of admission: _____________________
9. Date of discharge from hospital: _____________________

114
Resource utilized & costs for diagnosis and treatment of CAP
Resource utilized Utilization Unit cost/Birr Cost per resource
frequency
Total Hospital bed-days
Intensive care unit (ICU)

Laboratory tests
 Blood test
 Urine test
 Other tests

 X-ray/any imaging
(type)
 Ultra sound
Drugs
 Antibiotics
 Anti pains
 Others (please
specify)

Registration fee
N.B. Any special information
available from the chart
should be documented in this
check list

Suggestions after completing the checklist by the data collector (report any missing data,
vague sentences, spoiled or unreadable statements, etc below)

115
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

Data collector’s Supervisor’s

Signature____________________ Signature______________

116
ልጋብ I: ቃለ መሕትት ትግርኛ

ዩኒቨርሲቲ ኣዲስኣበባ
ኮሌጅ ጥዕና ሳይንስ
ክፍሊ ትምህርቲ ሓለዋ ጥዕና ማሕበረሰብ

ሓፈሻዊ መምርሒ ን ኣከብቲ መረዳእታን መራሕቲ ጉጅለን

እዚ ዝርዝር መረዳእታ ካብ ካርዲ ተሓከምቲ ሕብረተሰብ መንቀሊ ዝገበረ ሳንባ ምቺ ዝምላእ
ኾይኑ ብ ዝምልከቶም ነርስን ላዕለዎት ጥዕና መኮነንን ይምላእ፡፡ ንሶም/ሰን ከም ኣካቢ
መረዳእታ ኣብቲ መፅናዕቲ እዚ ኣገደስቲ ዝኾኑ መረዳእታ ብምእካብ ስነምግባር በዓል ሞያ
ብዝጠልቦ መሰረት ሚስጥር ናይ ምዕቃብን ኣድሌቲ ዝኾኑ ሓበሬታ ብምውሳድ መረዳእታ
ብእዋኑ ንዝምልከቶ ክፍሊ ማህደር ናይምርካብ ሓላፍነት ኣለዎም፡፡ ብተወሳኺ መረዳእታኹም
ምስ ኣረከብኹም ንሰራሕተኛ ክፍሊ ማህደር ኣመስግኑ፡፡

ሽም ሓኪም/ በዓል ሞያ ላዕለዋይ ጥዕና፡ __________________________________

ሽም ሆስፒታል፡ _____________________
ዞባ/ወረዳ፡ ____________________
መፍለዪ ሓበሬታ
1. መዝገብ ቁፅሪ፡ _______________
2. ዕድመ ተሓካማይ ብዓመት፡ _____
3. ፆታ፡ ______
4. ኣድራሻ ተሓካማይ፡ ዞባ_______________ወረዳ_______________
5. ዓይነት ስራሕ ተሓካማይ፡ _________________
6. ቅብብል ሕክምና /እንተልዩ/፡ _______________
7. ተመላለስቲ ሕክምና (OPD): _______________
8. ዝደቀሰሉ ዕለት ፡ _______________
9. ካብ ሆስፒታል ዝወፀሉ ዕለት፡ _______________
10.ብዘይካ ሕብረተሰብ መንቀሊ ዝገበረ ናይሳንባ ምቺ ካልእ ዓይነት ሕማም እንተሃልዩ፡
_______________________________________________________________
117
ንመነፀሪን ፤ ላብራቶሪን ሕብረተሰብ መንቀሊ ዝገበረ ናይሳንባ ምቺ ዝተኸፈለ ዋጋ
በዝሒ ናይ ሓደ ዋጋ ሓደ
ግልጋሎት ዋጋ/ብብር ዓይነት
ዝተጠቐመ ሃፍቲ ገንዘብ ሕክምና

ኣብ ሆስፒታል ዝደቀስሉ በዝሒዕለት

ክፍሊ ሕክምና ዝተፀንዑ ሑሙማት (ICU)
ምርመራ ላብራቶሪ
 ምርመራ ደም
 ምርምራ ሽንቲ
 ካልዕ ዓይነት ምርመራ
 ምርመራ ራጅን ምስልን
 ምርምራ ኣልትራሳውንድ
ኣፋውስ
 ፀረ ረኽሲ
 ፀረ ቃንዛ
 ካልእ እንተልዩ ይገለፅ
ክፍሊት መመዝገቢ
ኣብ ማህደር ተሓካማይ ዝርከብ ዝኾነ ኣድላዪ
ሓበሬታ እንተልዩ ኣብዚ ይመዝገብ

118
እዚ ቃለ መሕትት ምስተኻየደ ነዚ መረዳእታ ዝምዝግብ ኣካል ዘይበርሀሉ ዘይምዕሩይ ወይ
ብንፁር ዘይንበብ ቃል እንተሃልዩ ኣብዚ ይፀሓፍ፡፡
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
_________________________________________________________________

ኣካቢ መረዳእታ መራሒ ጉጅለ

ክታም _______________ ክታም _______________

119
Annex 2.2: A Semi-structured Questionnaire, to assess the risk of community acquired
pneumonia among hospital treated adults, Tigray, Ethiopia.

Subject Information Sheet

Dear respondent
Good morning/Good afternoon. Thank you for your interest in talking with me today. I am
_____________ who is a member of a team conducting a study to assess the risk of community
acquired pneumonia among hospital treated adults in your locality. The study is conducted as
part of a PhD research under college of health sciences, Addis Ababa University; you are
randomly selected to take part in this research interview.
The purpose of my visit today is to take information from you on the aforementioned issue. If
you are willing to participate in the study, I will ask you few questions lasting for 30 minutes. I
will also measure your body weight and height in order to assess your nutritional status. In
addition. The questionnaire will not be used for any other analysis apart from this study and
won’t be stored in anyway. In the study if you are found to have any infection or disease, you
will be referred for treatment and advice. However, no financial payment will be made for your
participation.
Your name will not be written on this form and will never be used in connection with any of
your information. You do not have to answer any question that you do not feel comfortable with,
and you may end this task any time you want to. However, your honest answers to these
questions and your continuous interest to participate in the study will help us in better
understanding of the risk factors of CAP in your locality, and will eventually help in designing
and implementing appropriate prevention and intervention programs to alleviate the problem.
Hence we would greatly appreciate your help in involving in the study. Your participation in the
study is fully based on your interest and choice. Your participation or non participation will not
be related with the health service that you will get from governmental and non governmental
institutions.
If you have any un-clarity on my visit you can ask me now so that I can elaborate it. If you come
across with any concern during my stay with you, you can stop me and raise it anytime you want.
It is also possible to communicate the principal investigator Haftu Berhe through the telephone
address +251914 725835 and Prof. Fikrie Enquselassie through +251912 45 97 07

120
Informed Consent Form
With due understanding of the aforementioned information, are you willing to participate in the
study?

Yes (Proceed with the interview)

No (Terminate the interview)

Signature of the interviewer

Name ________________ Signature ________________ date _______________

Supervisors/Researcher remark and signature

_________________________________________________________________________
Name ________________ Signature ________________ date _______________

121
Part I Demographic information

Question Response Code

1 Sex (Record Male / Female as Male 1 C1
observed) Female 2
2 What is your date of birth? C2
└─┴─┘ └─┴─┘ └─┴─┴─┴─┘
dd mm year
If known, Go to C4

3 C3
How old are you? Years └─┴─┘
4 What is the highest level of education No formal schooling 1 C4
you have completed? Less than primary school 2
Primary school completed 3
Secondary school completed 4
Preparatory school completed 5
College/University completed 6
Post graduate degree 7
Refused 88

5 What is your ethnic group / racial Tigraway/ti ....... 1 C5

group / ? Erop...................2
Amharay/ti ........3
Afar .............. .. 4
Other:---------------------------------
Refused 88

6 What is your marital status? Never married 1 C6

Currently married 2
Divorced 3
122
 Widowed 4
Cohabitating 5
7 Which of the following best describes Government employee 1 C7
your main work status over the past 12 Non-government employee 2
months? Self-employed 3
Student 4
Homemaker 5
Retired 6

8 How many people including yourself, C8

live in your household? Number of people
└─┴─┘
9 How many people do you use/sleep in a Number of people C9
single room? └─┴─┘
10 How many windows do you have in a Number of windows in a room C 10
room ? └─┴─┘
11 Taking the past year, can you tell me 11a
what the average earnings of the Per week
household have been?
(RECORD ONLY ONE, NOT ALL 3) └─┴─┴─┴─┴─┴─┴─┘
11b
OR per month

└─┴─┴─┴─┴─┴─┴─┘
11c
OR per year

└─┴─┴─┴─┴─┴─┴─┘
12 If you don’t know the amount, can you ≤ Quintile (Q) 1 1 12C
give an estimate of the annual More than Q 1, ≤ Q 2 2
household income if I read some More than Q 2, ≤ Q 3 3
123
 options to you? Is it More than Q 3, ≤ Q 4 4
[INSERT QUINTILE VALUES IN More than Q 4 5
LOCAL CURRENCY] Don't Know 77

13 Height of the respondent in CM

14 Weight of the respondent in KG

124
Part II . lifestyle and habits

Tobacco Use
Now I am going to ask you some questions about your lifestyle and habits. This includes things
like smoking, drinking alcohol, and physical activity. Let's start with tobacco.
Question Response Code
15 Do you currently smoke any tobacco Yes 1 T1
products, such as cigarettes, cigars No 2
or pipes?
16 Do you currently smoke tobacco Yes 1 T2
products daily? No 2
17 How old were you when you first Age in years_____ T3
started smoking daily? Don’t know 77_______
18 Do you remember how long ago it In years______ T4a
was? In months____ T4b
In weeks______ T4c

19 On average, How many cigarettes do T5a

you smoke each day? 1-9 cigarettes.day
T5b
10-20 cigarettes.day

T5c
>20 cigarettes.day

T5d

125
 Alcohol consumption
Question Response Code
20 Have you ever consumed an Yes 1 A1
alcoholic drink such as beer, wine, No 2
spirits, fermented cider or [add other
local examples]?
21 Have you consumed an alcoholic Yes 1 A2
drink within the past 30 days? No 2
22 During the past 30 days, on how Number A3
many occasions did you have at least Don't know 77 └─┴─┘
one alcoholic drink?
23 During the past 30 days, on average, Number A4
how many glass alcoholic drinks did Don't know 77 └─┴─┘
you have during one drinking
occasion?
24 During the past 30 days, what was the Largest number A5
largest number of alcoholic drinks Don't know 77 └─┴─┘
you had(glass, bottle and the like) on
a single occasion, counting all types
of alcoholic drinks together?

126
Physical Activity

Next I am going to ask you about the time you spend doing different types of physical activity in
a typical week. Please answer these questions even if you do not consider yourself to be a
physically active Person. There are various domains of activity which need to be included; work,
activities in and around the home and garden, to get from place-to-place (transport-related) and
recreation (discretionary or leisure-time) exercise or sports activities. This opening statement
should not be omitted.
Questions Response Code

Activity at work

25 Does your work involve vigorous- Yes 1 P1

intensity activity that causes Large
No 2
increases in breathing or heart rate like
[carrying or lifting heavy loads, If no go to P4
digging or Construction work] for at
least 10 minutes continuously?
26 In a typical week, on how many days Number of days P2
do you do vigorous intensity activities
└─┘
as part of your work?
27 How much time do you spend doing Hours : minutes P3
vigorous-intensity activities at work
└─┴─┘: └─┴─┘
on a typical day?
28 Does your work involve moderate- Yes 1 P4
intensity activity, that causes small
No 2
increases in breathing or heart rate
such as brisk walking [or carrying If no go to P7
light loads] for at least 10 minutes
continuously?

127
29 In a typical week, on how many days Number of days └─┘ P5
do you do moderate intensity activities
as part of your work?
30 How much time do you spend doing Hours : minutes P6
moderate-intensity activities at work
└─┴─┘: └─┴─┘
on a typical day?
Travel to and from places

The next questions exclude the physical activities at work that you have already mentioned. Now
I would like to ask you about the usual way you travel to and from places. For example to work,
for shopping, to market, to place of worship. [insert other examples if needed]
31 Do you walk or use a bicycle (pedal Yes 1 P7
cycle) for at least 10minutes
No 2
continuously to get to and from
places? If no go to P10

33 In a typical week, on how many days Number of days └─┘ P8

do you walk or bicycle
for at least 10 minutes continuously to
get to and from places?
How much time do you spend walking Hours : minutes P9
or bicycling for travel └─┴─┘: └─┴─┘.
33
on a typical day? hrs mins

Recreational activities

The next questions exclude the work and transport activities that you have already
mentioned. Now I would like to ask you about sports, fitness and recreational activities
(leisure),[insert relevant terms].
34 Do you do any vigorous-intensity Yes 1 P10
sports, fitness or recreational (leisure)
No 2
activities that cause large increases in
breathing or heart rate like [running or If no go to P13

128
 football, ] for at least 10 minutes
continuously?
35 In a typical week, on how many days P11
do you do vigorous intensity sports,
Number of days └─┘
fitness or recreational (leisure)
activities?
36 How much time do you spend doing Hours : minutes P12
vigorous-intensity sports,fitness or
└─┴─┘: └─┴─┘
recreational activities on a typical
day?
37 Do you do any moderate-intensity Yes 1 P13
sports, fitness or recreational (leisure)
No 2
activities that causes a small increase
in breathing or heart rate such as brisk If no go to P16
walking,(cycling, swimming,
olleyball)for at least 10 minutes
continuously?
38 In a typical week, on how many days Number of days P14
do you do moderate intensity sports,
└─┘
fitness or recreational (leisure)
activities?
39 How much time do you spend doing Hours : minutes P15
moderate-intensity sports, fitness or
└─┴─┘: └─┴─┘
recreational (leisure) activities on a
typical day?
Sedentary behaviour

The following question is about sitting or reclining at work, at home, getting to and from
places, or with friends including time spent [sitting at a desk, sitting with friends, travelling
in car, bus, train, reading, playing cards or watching television], but do not include time
spent sleeping.

129
40 How much time do you usually spend Hours : minutes P16
sitting or reclining on a typical day?
└─┴─┘: └─┴─┘

130
Part -III. Medical history

I am going to ask you about your medical history and please provide me your response according
to the questions I will ask you.

S/no Question Yes(1) No(2) I don't

Know(3)

41 Have you ever been admitted to hospital in the last 5 yrs?

42 Have you ever been a bedridden for the last 3 months?

43 Did you have upper airway problem, last yr ?

44 Did you have Tonsillectomy ?

45 Did you visit to the dentist, last month ?

46 Did you get vaccinated for Influenza last yr ?

47 Did you get vaccinated for any respiratory vaccination, last yr ?

48 Did you have any respiratory infection, last month?

49 Have you had a contact with people who had respiratory infection?

50 Do you have Previous history of pneumonia confirmed by radiograph?

51 Do you have history of diabetes?

52 Do you have history of Cardiopathy ?

53 Do you have history of Chronic bronchitis?

54 Do you have history of Diagnosed asthma ?

55 Do you have history of Lung tuberculosis ?

56 Do you have history of Gastric disease/symptoms?

57 Do you have history of Chronic liver disease?

58 Do you have history of Renal failure ?

59 Do you have history of Depression/anxiety ?

131
60 Do you have history of Cancer?

Part-V- Environmental factors

I am going to ask you about your contact history with children, animals, birds and the like.
Kindly provide me your response according to the response options provided below.

S/no Question Yes No I don't know

61 Do you have history of contact with

children?

62 Do you have history of contact with

birds?

63 Do you have history of contact with

animals?

64 Do you have history of contact with

pets?

65 Do you have history of working in a

dusty environment?

66. Would you please tell me the type of cooking fuel you usually use at your home?

67. Usually, where do you go first if you have any health problem?

Thank you for giving us your time

132
LUB 2.2 ቃለ m?TT ¼BÌNÌ TGR¾ ZtÄlw¼

ˆbʬ

Z,bRk#M ˆbʬ w¦ÆY¿

kmY ˆÄ!Rk#M¼kmY ¨RðDk#M¼ kmY W›!Lk#M MúY KtêG;#N kt:Ll#N

Fªd¾ BMáNk#M ¨Zy ymSGnk#MÝÝ ¨n_________________________________ Zb¦LÝÝ
¨Bz! kÆb!,#M nz! m}Â:tE zµYD g#Jl ¨ÆL XyÝÝ Xz! m}Â:tE ¨B T?tE
†n!vRs!tE ¨Ä!S ¨bÆ ZRkB ÷l@J úYNS _: NmmLx! TMHRtE ìKTÊT
¼pEx@CÄ!¼ ZGbR X†ÝÝ Xz! ¨B ?¥M ?BrtsB mNql! Zgbr ÂY úNÆ McE ZGbR
ÄHúS kÆb!,#M Z-mt m}Â:tE X†ÝÝ Slz! ¨n ¨Bz! M}Â:tE kM :§¥ /!z× zl,#
B²:Æ,#M ZMLkT WLq ˆbʬ k#n¬Tk#M NMWúD _‰? X†ÝÝ ¨Bz! m}Â:tE
KTútû DLyT XNt¦LYk#M NkÆb! 30 dªYO ZwSD Gz ?è¬T Kˆtk#M XyÝÝ
k#n¬T Sn MGB,#M NMDHúS D¥ q$mTk#MN KBdTk#MN K:QN XyÝÝ W}x!T
Xz! ›‚N q$mTN KBdTN µB :§¥ Xz! m}Â:tE wÉx! Nµl!X ên!N ¨YW:LNÝÝ
D?¶ Xz! m}Â:tE D¥ ¨Y:qBNÝÝ ¨Bz! m}Â:tE tˆ¬tE ?¥M XNttgn!Yk#M
ÂB Kx!§ ˆk!M KTl¨,#N ?KMÂN GLUlÖT M<RN KTr<b# KGbR X†ÝÝ ¨Bz!
BtgBRã N_fTN túTæN BÑl#x# T,FLã KFl!T wYD¥ ZHLwk#M wÉx!
ylNÝÝ

SMk#M ¨Bz! m?TT ¨YiˆFN wYD¥ MSZ¦Bk#M ˆbʬ BZt¨úsrN

BZt²mdN k#n¬T BZën mNgÄ! NZón ›YnT ˆbʬ ¨YW:LNÝÝ
NzYts¥m:k#MN dS NzYblk#MN ?è zYMM§S Y<Xl# x!,#MÝÝ µBz! Btwú,!
D¥ ”? ¨BZblk#M XêN XWN nz! m?TT ktÌR}ã T<Xl# x!,#MÝÝ Y,#N
XMbR THb#Â Qn#:N T<Kl¾ mLS¬T kMx# XWN qÉl! túTæ NKHLwk#M
tRXYã DLyT nz! nµYì zl m}Â:tE BwúÂY mLK;# ˆU²Y X†ÝÝ BF§Y D¥
¨B kÆb!,#M MS ?BrtsB MNql! Zgbr ÂY úNÆ McE t²mDtE g#ÄÃTN
NZHLW ÄHúS ¨B mwÄX¬ XWN nz! ZtÄHss igM NMX§YN NMQ§LN Z?GZ
»§ NM?NÉ} ¨Z† ˆUz! X† Z,WNÝÝ nz! igM NMKLáLN NMq$}ÉRN z<XL
mdB _:Â NMO‰}N ¨tgÆBRx# NM?NÉ}N MT§MN wúÂY t‰ YHLã ¥lT
133
X†ÝÝ Slz! ¨Bz! m}Â:tE KúB mwÄX¬ BN_fT N<Tútû ¨z! N§ïÝÝ ¨Bz!
m}Â:tE ZHLwk#M túTæN N_fTN ¨B DLyTk#MN MRÅ,#MN ZtmSrt X†ÝÝ
Xz! túTæ,#M Y,#N zYMS¬Fk#M ¨BZón Y,#N ›YnT mNGS¬êE wYD¥
zYmNGS¬êE TµL _: MSTr<Bã GLUlÖT _: fÉ!Ñ Z²mDN Zt¨úsrN
¨Y÷nNÝÝ

ÂÆ,#M NMN¬Y kMZmÉ,#N NMN¬Y kMZˆtk#M zl,# BZMLkT KúB /z!

¨BZgl}k#Lk#M BMLx# zYtrĨk#M XNt¦L† ?z! KTˆt$n! T<Xl# x!,#MÝÝ ¨n
XWN twú,! mBR£ KHbk#M X<XLÝÝ ¨B XêN XNgBé MYY_N XnµYì zlÂ
?èN mLSN Zón ›YnT zgDsk#M g#ÄY ÂB ¨XMé,#M XNtmÉ!x# >;# N>;# --
W KtBl#NN dS ¨BZblk#M wYD¥ ¨BZ-›mk#M XêN KTˆTn#N kBRhLk#M
KTgB„ XWN T<Xl# x!,#MÝÝ µBz! ˆl!û D¥ B²:Æ zgDsk#M g#ÄY µÆY ˆl!û
nz! m}Â:tE BêÂnT NzµYD zlÖ ê tm‰¥‰Y Xz! m}Â:tE ¦Ft$ bRh B‚$}¶
SLk! +251914 725835 wY D¥ ì/ር FQÊ XNq$S§s@ B +251912 45 97 07
q$}¶ SLk! dêELk#M M?¬T T<Xl# MáNk#M KnrUGiLk#M Næt$ÝÝ

ናይ ስምምዕነት ቅጥዒ

Bmsrት ኣቐዲሙ ZtgllÖ#MlN :§¥ Xz! m}ÂLtE msrT ¨BtE ZµyD m}Â:tE
ZRZR ˆbʬ msrT BMGÆR Xz! YµyD zlÖ m}Â:tE BGb#X SltrÄX,#M ¨Bz!
m}Â:tE NMS¬F Fªd¾ Ä!,#M?

እወ (ናበቲ ቃለመሕትት ቀፅል)

ኣይፋሉን (ቃለ መሕትት ይቌረፅ)

ክታም ኣካባይ ሓበሬታ

ሽም ________________ ክታም ________________ ዕለት _______________

134
ሪኢቶን ክታምን ተመራማራይ/ሱፐረቫይዘር

____________________________________________________________________
_____
ሽም ________________ ክታም ________________ ዕለት _______________

135
ክፋል ሓደ ውልቓዊ ሓበሬታ

1 ፆታ ተባዕታይ 1 C1
ብምርኣይ ምላእ ኣንስታይ 2

2 ዝተወለድካሉ ዕለት C2
└─┴─┘└─┴─┘└─┴─┴─┴─┘
ዕለት ወርሒ
ዓመት
እንተደኣ መሊስዎ ናብ ኮድ C4
ስገር

3 C3
ዕድመኻ ክንደይ እዩ? ዓመታት └─┴─┘
4 ዝለዓለ ብርኪ ትምህርቶም/ ተን? ስሩዕ ትምህርቲ ኣይተምሃርኩን 1 C4
ትሕቲ ቀዳማይ ብርኪ 2
ቀዳማይ ብርኪ ኣጠናቂቀ 3
ትምህርቲ ካልኣይ ብርኪ
ኣጠናቂቀ 4
ትምህርቲ መሰናድኦ ዩኒቨርስቲ
ኣጠናቂቀ 5
ኮሌጅ/ዪኒቨርስቲ ኣጠናቂቀ 6
ትምህርቲ ድሕረ ምርቃ 7
ንምምላስ ፍቃደኛ ኣይኮንኩን 88

5 ድሕረባይታ ኻእንታይ ይመስል ትግራዋይ/ ቲ C5

[ከም ብሄር ዘርኢ]? 1
ኢሮፕ
136
 2
ኣምሓራይ/ ረይቲ 3
ዓፋር 4
ካልእ ይገለፅ
ንምምላስ ፍቃደኛ ኣይኮንኩን 88
6 ኩነታት ሓዳር ባሕተላይ/ለይቲ 1 C6
በዓል ሓዳር 2
ዝተፋተሐ/ት 3

በዓል/ቲ ገዛኣ ዝሞታ 4

ከይተመርዓዉ ብሓባረ ዝነብሩ 5
7 ካብዞም ዝስዕቡ ስራሕትታት ኣብ ዝሓለፉ 12 ሰራሕተኛ መንግስቲ 1 C7
ኣዋርሕ ካብ ዝሰራሕካዮ ኣውራ ስራሕ መኒኡ ሰራሕተኛ ዘይመንግስታዊ ትካል
ይገልፅ? 2

ዓርሰ ቁፃር 3
ተምሃሪ 5
ናይገዛ እመቤት 6
ጡረተኛ 7
8 ኣብ ገዛኹም ንአኦም አን ሓዊሱ ክንደይ ሰባት C8
ትነብሩ? በዝሒ ስድራ

└─┴─┘
9 ኣብ ሓንቲ ክፍሊ ገዛ ክንደይ ሰባት ትድቅሱ? በዝሒ ሰብ C9

└─┴─┘
1 ኣብታ ክፍሊ ክንደይ መሰኮት ኣሎ? በዝሒ መስኮት ብቂፅሪ C
0 10

└─┴─┘
137
1 ስኣብ ዝሓለፈ ዓመት ናይ ገዛኩም ማእኸላይ 11a
1 እቶት ክንደይ ነይሩ? ብሰሙን
(በሓዲኡ ጥራሕ መዝግብ)
└─┴─┴─┴─┴─┴─┴─┘
11b
ወይብወርሒ

└─┴─┴─┴─┴─┴─┴─┘
11c
ወይብዓመት

1 ናይ ገዛኩም ዓመታዊ ኣታዊ እንተደኣ ብዕሊ ≤ኩንታል (ኩ) 1 1 12

2 ዘይትፈልጦ ኮይንካ ዝተወሰኑ መማረፅታት ልዕሊሓደ ኩ, ≤ 2ኩ 2 C
እንተደኣ እንቢበልካ ተቀራራቢ ዝኮን መልሲ ዶ ልዕሊ 2ኩ, ≤ 3ኩ 3
ክትንግረኒ ምኸኣልካ? ልዕሊ 3ኩ, ≤ 4ኩ 4
[ናይ ኩንታል ዋጋ ብብር ኣቀምጥ] ልዕሊ 4ኩ 5
ኣይፈለጥኩን 77

1 ቁመት ወሃባይ ሓበሬታ ብሴሜ

3
1 ክብደት ወሃባይ ሓበሬታ ብ ኪሎግራም
4

138
ክፋል II. ስርዓት ኣነባብራን/ልምድን ባህሪታትን

ምጥቃም ትንባሆ
ሕዚ ምስ ኩነታት ጥዕናኻ ዝተኣሳሰሩ ሕቶታት ክሓተኩም እየ ÝÝ ምእዚ ድማ ከም ምትኻኽ
ሲጋራ ½ምፍራምረን ኣትክልቲ ምብላዕ½ምኣካላዊ ኩነታትን ወዘተ ዝሓወሰ እዩÝÝ
ብምትካኽ ሲጋራ ንጀምርÝÝ.
ሕቶ መልሲ ኮድ
15 ኣብዚ ሕዚ እዋን ዝኮነ ይኹን እወ 1 T1
ውፅኢታት ትንባሆ ከም ሲጋራ ፒፓ ኣይፋሉን 2
ዝኣምሰሉ ትጥቀም ዶ?
16 ኣብ ዚ ሐዚ እዋን ውፅኢታት እወ 1 T2
ትንባሆ በብመዓልቲ ዶ ትጥቀም? ኣይፋሉን 2
17 ፈለማ በቢመዓልቱ ሲጋራ ምትካኽ ዕድመ ብ ዓመት_____ T3
እንትትጅምር ከለኻ ዕድመኻ ክንደይ ኣይፈለጥኩን 77_______
ነይሩ?
18 እዋኑ መኣዝ ከምዝነበረ ትዝክሮዶ? ብዓመት______ T4a
ብኣዋርሕ____ T4b
ብሰሙን______ T4c

19 ብማእኸላይ ኣብ መዓልቲ ክንደይ T5a

ሲጋራ ተትክኽ? 1-9 ሲጋራ ብመዓልቲ
T5b
10-20 ሲጋራ ብመዓልቲ
T5c
>20 ሲጋራ ብመዓልቲ

T5d

139
 ምጥቃም መስተ/ኣልኮል
ሕቶ መልሲ ኮድ
20 ዝኾነ ይኹን ኣልኮላዊ መስተ ዶ እወ 1 A1a
ሰቲኻ ትፈልጥ/ከም ቢራ ወይኒ ስዋ ኣይፋሉን 2
ሜስ ኣረቂ ወዘተ/?
21 ኣብ ዝሓለፉ30 መዓልትታት እወ 1 A1b
ኣልኮል/መስተ/ሰቲኻ ኔርካ ዶ? ኣይፋሉን 2
22 ኣብ ዝሓለፉ 30 መዓልትታት ሓደ በቢ መዓልቲ 1 A2
ኣልኮል/1 ዋንጫ ስዋ 1 ቢራ 1 5-6 መዓልቲታት ብሰሙን 2
መለኪያ ዊስኪ ን ካልኦትን/ በቢ 1-4 መዓልቲታት ብሰሙን 3
ክንደይ ግዘ ትሰቲ? 1-3 መዓልቲታት ብወርሒ 4
ፅሕቲ ሓደ ግዘ ኣብ ወርሒሪ 5
23 ኣብ ዝሓለፉ 30 መዓልቲታት ሓደ ብቁፅሪ A4
ኣልኮል/1 ዋንጫ ስዋ 1 ቢራ 1 ኣይፈለጥኩን 77 └─┴─┘
መለኪያ ዊስኪ ን ካልኦትን/ ኣብ በቢ
ክንደይ እዋን ትሰቲ?
24 ኣብ ዝሓለፉ 30 መዓልትታት መስተ ብቁፅሪ A5
ክትሰቲ ከለኻ ብማእኸላይ ኣብ ናይ ኣይፈለጥኩን 77 └─┴─┘
ሓደ እዋን መስተ ክንደይ ትሰቲ/ቢራ
ዋንጫ መለኪያ ወዘተ/?
25 ኣብ ዝሓለፉ 30 መዓልትታት ኣብ A6
ሓደ እዋን እቲ ዝበዝሐ ዓቀን መሰተ ዝዓበየ ቁፅሪ
ዝሰተኻሉ ክንደይ/ጥርሙዝ ቢራ ኣይፈለጥኩን 77 └─┴─┘
ዋንጫ መለኪያ ወዘተ ኩሎም
ይቆፀሩ/ እዩ

140
ኣካላዊ እንቅስቃሴ

ብምቅፃል ድማ ብዛዕባ ኣብ እተፈላለዩ እዋናት እትገብሮ ም ኣብሰሙን ኣካላዊ

እንቅስቃሰታት ክሓተካ እየ ዋላ እካ ናይ ስፖርተኛ እየ ኢልካ እንተዘይ ሓሰብካ ኣብ ስራሕ
ዘጋጥሙካ ከበድቲ ስራሕቲን ካብ ቦታ ናብ ቦታ እትገብሮም እንቅስቃሴታት ስለ ዝሓውስ
ነተም ሕቶታት መልሰለይኢኻ .
ሕቶ መልሲ ኮድ

እንቅስቃሴ ኣብ ስራሕ

26 ስራሕካ ብውስን መልክዑ ፍጥነት እወ 1 P1

ስርዓት ምስትንፋስን ህርምት ልቢን
ኣይፋሉን 2
ዝውስኹ ኣድኸምቲ ከበድቲን ዝኾኑ
ስራሕትታት ከም ከበድቲ ነገራት መልሱ ኣይፋሉን እንተደኣ
ምሽካም ምኹዓት ዝኣምሰሉ ን ኮይኑ ናብ ኮድ P4 ስገር

ተኸታታሊ 10 ደቂቃ ምስራሕ

የካትት ዶ??
27 ከም ኣካል ስራምካ ኣብ ሰሙነ በዝሒ መዓልትታት P2
ንክንደይ መዓልቲታት ብጣዕሚ
ኣድኻሚ ዝኾኑ ስራሕትታት
└─┘
ትሰርሕ?
28 ከም ኣካል ስራምካ ኣብ መዓልቲ ሰዓት : ደቂቃ P3
ንክንደይ ሰዓታት ብጣዕሚ ኣድኻሚ
└─┴─┘: └─┴─┘
ዝኾኑ ስራሕትታት ትሰርሕ?
29 ስራሕካ ብውስን መልክዑ ፍጥነት እወ 1 P4
ስርዓት ምስትንፋስን ህርምት ልቢን
ኣይፋሉን 2
ዝውስኹ ማእኸላይ ክብደት ብዙሕ
ኣድኸምቲ ዘይዝኾኑ ስራሕትታት መልሱ ኣይፋሉን እንተደኣ

ከም ምሽካም ዝኣምሰሉ ን ኮይኑ ናብ ኮድ P7 ስገር

ተኸታታሊ 10 ደቂቃ ምስራሕ

141
 የካትት ዶ?
30 ከም ኣካል ስራምካ ኣብ ሰሙን በዝሒ መዓልትታት P5
ንክንደይ መዓልትታት ማእኸላይ
ክብደት ብዙሕ ኣድኸምቲ ዘይዝኾኑ
└─┘
ስራሕትታት ትሰርሕ?
31 ከም ኣካል ስራምካ ኣብ መዓልቲ ሰዓት : ደቂቃ P6
ንክንደይ ሰዓታት ማእኸላይ ክብደት
└─┴─┘: └─┴─┘
ብዙሕ ኣድኸምቲ ዘይዝኾኑ
ስራሕትታት ትሰርሕ?

ካብ ቦታ ናብ ቦታ ምጉዓዝ

ብምቅፃል ድማ ብዛዕባ ካብ ቦታ ናብ ቦታ እትገብሮም ጉዕዞታት ክሓተካ እየ ንኣብነት ናብ

ስራሕ ድኳን ዕዳጋ
32 ካብ ቦታ ናብ ቦታ ንምንቅስቃስ እወ 1 P7
እንተወሓደ ን10 ደቂቃ ብእግሪኻ
ኣይፋሉን 2
ወይ ብሳይክል ዶ ትጓዓዝ?
መልሱ ኣይፋሉን እንተደኣ
ኮይኑ ናብ ኮድ P10 ስገር

33 ኣብ ሰሙን ንክንደይ መዓልትታት በዝሒ መዓልትታት P8

እንተወሓደ ንተኸታታሊ 10
ደቂቃታተ ብእግሪ ወይ ብሳይክለ
└─┘
ትጓዓዝ?
ኣብ መዓልቲ ንኽንደይ ሰዓታት ሰዓት : ደቂቃ P9
እንተወሓደ ንተኸታታሊ 10
34 └─┴─┘: └─┴─┘
ደቂቃታተ ብእግሪ ወይ ብሳይክለ
ትጓዓዝ?
ዘዝናንዩ

142
እንቅስቃሴታት

ሕዚ ድማ ብዛዕባ ንመዝናነሪ እንጥቀመሎም እንቅስቃሴታትን ንሰብነት ጥንካረ እንሰርሖም

ስፖርትታት ክሓተካ እየ
35 ስርዓት ኣተነፋፍሳን ህርመት ልቢን እወ 1 P10
ዝውስኹ ዘዝናንዩን ኣድኸምቲ
ኣይፋሉን 2
ዝኾኑ ስፖረትታት ልተኸታታሊ
10 ደቂቃ ትሰረሕ ዶ /ከም ጉያ መልሱ ኣይፋሉን እንተደኣ

ፃወታ ኩዕሶ እግሪ /? ኮይኑ ናብ ኮድ P13 ስገር

36 ኣብ ሰሙን ንክንደይ መዓልትታት በዝሒ መዓልትታት P11

ኸቢድን ኣድካሚ ዝኾነ ናይ ኣካል
ብቅዓት እንቅስቃሴ ስፖርት
└─┘
ወይድማ ትገብር?
37 ኣብ መዓልቲ ንክንደይ ሰዓታት ኢኻ ሰዓት : ደቂቃ P12
ኸቢድን ኣድካሚ ናይ ኣካልበቅዓት
└─┴─┘: └─┴─┘
እንቅስቃሴ ትገብር?
38 ብዝተወሰነ መልክዑ ስርዓት እወ 1 P13
ኣተነፋፍሳን ህርመት ልቢን
ኣይፋሉን 2
ዝውስኹ ዘዝናንዩን ማእኸላይ
ክብደት ዘለዎም ስፖረት መልሱ ኣይፋሉን እንተደኣ

ልተኸታታሊ 10 ደቂቃ ትሰረሕ ዶ ኮይኑ ናብ ኮድ P16 ስገር

/ከም ሳይክል ሓመሳ /?

39 ኣብ ሰሙን ንክንደይ መዓልትታት በዝሒ መዓልትታት P14
ማእኸላይ ዝኾነ ናይ ኣካል ብቅዓት
እንቅስቃሴ ስፖርት ወይድማ
└─┘
ትገብር?
40 ኣብ መዓልቲ ንክንደይ ሰዓታት ኢኻ ሰዓት : ደቂቃ P15
ማእኸላይ ናይ ኣካልበቅዓት

143
 እንቅስቃሴ ትገብር? └─┴─┘: └─┴─┘

ናይዕረፍቲ ሰዓታት

ቀፂሎም ዘለዉ ሕቶታት ድማ ብዛዕባ ኣብ ስራሕ ምስ መሓዙትካ ንምዝንናይ ከፍ ዚልካ

እተሕልፎም ሰዓታት ዝሓዙ እዮም ብዛዕባ ደቂስካ ዘሕለፍካዮም ሰዓተት ግና ኣይትሕወስ
41 ኣብ መዓልቲ ንክንደይ ሰዓታት ኮፍ ሰዓት : ደቂቃ P16
ትብል?
└─┴─┘: └─┴─┘

144
ክፋል -III. ታሪክ ሕክምና

ሕዚ ድማ ብዛዕባ ታሪኽ ሕክምናታትኻ ክሓተካ እየ ብቶም ዝሓተካ ሕቶታተ መሰረት ምላሽ

ክትህበኒ ይላቦ .

ሪጋ ሕቶታት እወ ኣይፋሉን ኣይፈለጥኩን

1 ኣብ ዝሓለፈ 5 ዓመት ብሕማም ኣብ ሆስፒታል

ደቂስካ ዶ ነይርካ?
2 ንዝሓለፉ 3 ኣዋርሕ ብሰንኪ ሕማም ነዊሕ ግዘ
ደቂስኻ /ማእሲ ሒዝካ/ ኔርካ?
3 ኣብ ዝሓለፈ ሓደ ዓመት ሕማም ላዕለዋይ ክፍሊ
ስርዓት ምስትንፋስ ኣጓኒፍካ ዶ ነይሩ
4 መጥባሕታዊ ምውጋድ ሕማም ቶንሲል
/ኣዲኖዴክቶሚ/ ተጌርልካ ዶ ኔይሩ?
5 ኣብ ዝሓለፈ ወረሒ ናብ ናይ ስኒ ሓኪም
ክይድኻ ኔርካዶ?
7 ኣብ ዝሓለፈ ዓመት ክታበት ኢንፍሎንዛ ረኺብካ
ዶ?
8 ኣብ ዝሓለፈ ዓመት ክታበት ስርዓተ ምስትንፋስ
ረኺብካ ዶ?
9 ኣብ ዝሓለፈ ዓመት ረኽሲ ስርዓተ ምስትንፋስ
ኣጋጢሙካ ዶ ነይሩ?
10 ምስ ረኽሲ ስርዓተ ምስትንፋስ ዘለዎም ሰባት
ርክብ ኔርካ ዶ?
11 ብራጂ ዝተነፀረ ታሪኽ ሕማም ሳምባ ምቺ
ኣለካዶ?
12 ታሪኽ ሕማም ሽኮርያ ኣለካዶ

13 ታሪኽ ሕማም ልቢ ኣለካዶ?

14 ታሪኽ ሕማም ሕዱር ብሮንካይተስ ኣለካዶ

145
15 ታሪኽ ሕማም ብበዓል ሞያ ዝተነፀረ ኣስሚ
ኣለካዶ
16 ታሪኽ ሕማም ዓባይ ሰዓል ኣለካዶ

18 ታሪኽ ሕማም ጨጓራ ወይ ምልክታት ሕማም

ጨጓራ ኣለካዶ
19 ታሪኽ ሕዱር ሕማም ፀሊም ከብዲ/ጉበት/ ኣለካ
ዶ
20 ታሪኽ ናይ ኩላሊት ድኽመት/ ሬናል ፌለር/
ኣለካዶ
21 ናይ ሕማም ድብርትን ጭንቀትን ታሪኽ ኣለካዶ

22 ናይ ሕማም ካንሰር መንሽሮ ታሪኽ ኣለካዶ

146
ክፋል 5- ኣከባቢያዊ ፅልዋታት

ክፋሕዚ ድማ ምስ ህፃናት እንስሳታትን ኣዕዋፍን ዘለካ ታሪኽነ ርክብን ክሓተካ እየ እቶም

ሕቶተታት ምስ ተገንዘብካ ካብ ቶመ ዝህበካ መማረፅታት መሪፅካ ምላሽካ ትህበኒ ኢኻ

ሪጋ ሕቶታት እወ ኣይፋሉን ኣይፈለጥኩን

1 ምስ ህፃናት ቆልዑ ንክክእ ኣለካዶ /?

2 ምስ ኣዕዋፍ ንክክእ ኣለካ ዶ?

ከም ደርሆ ዛግራ

3 ምስ እንስሳታት ንክክእ ኣለካ ዶ/?

4 ምስ ድሙ ከልቢ ንክክእ ኣለካዶ?

5 ኣብ ደሮና ዝበዝሖ ከባቢ ስራሕ ናይ ምስራሕ ታሪክ

ኣለካዶ?

6. ኣብ ገዛኹም ንመብሰሊ ምግቢ እትጥቀምሉ ዓይነት ነዳዲ ክትነግረኒ ዶ ምኸኣልካ?

7. መብዛሕትኡ ግዘ ሕማም እንትስመዖም ናበይ ኣዘውቲሮም ይኸዱ

የቀንየለይ ንዝሃብካኒ ሓበሬታ ኣዝየ እየ ዘመስግን

147
ANNEX 3: Declaration

Letter for declaration

I, the under signed, declared that this is my original work, has never been presented in this
or any other University, and that all the resources and materials used for the dissertation,
have been fully acknowledged.
Name:
Signature:
Date:
Place:
Date of Submission:

This dissertation has been submitted for examination with my approval as

University Supervisor.
Name:
Signature:
Date:

148