Prevalence of Pneumonia in Children’S Under Five Years in Al Sabbah Hospital Juba – South Sudan

Background: Each year, pneumonia affects about 450 million people globally; it is a major cause of death among all age groups resulting in 4 million deaths (7% of the world’s total death) yearly. Pneumonia is dened as the presence of fever, acute respiratory symptoms, or both, plus evidence of parenchymal inltration chest radiography. Although, in the past decade the incidence of the disease was reported to have declined by half percent, that alone was considered to be the slowest decline in comparison to other diseases The objective of the study is to determine the prevalence of pneumonia in Al Sabah Children Hospital and to assess the risk factor associated. Method: A cross-sectional study design was used to determine the prevalence of pneumonia in children under-ve years in Al Sabah hospital, Juba South Sudan. The study ran from 18 th September to 5 th of October 2021. 241 participants were randomly selected for the study and primary data were obtained through questionnaires. Results: The prevalence of pneumonia in children under-ve years was found to be 22.4.7%. The incidence is highest in males 23 (57.5%) compared to females17 (42.5%). The ethnicity of the patients from Dinka (37.5%) and Bari (30%), Shilluk (7.5%), Mundari (2.5%), Madi (5%) Nuer (7.5%), Murli (5%), Lolobo (2.5%) latoka and the leading ethnicity high morbidity pneumonia was found to be in Dinka. Conclusion: The prevalence pneumonia Sabah high in 2019 with the 21%


Background
Pneumonia is an in ammation of the Lungs' parenchymal structure 1 . It is also de ned as an in ammatory Condition of lung primarily affecting small air sacs known as alveoli 2 . Each year, pneumonia affects about 450 million people globally; it is a major cause of death among all age groups resulting in 4 million deaths (7% of the world's total death) yearly. Rates are greatest in children less than ve, and adults less than 75 years 3 Pneumonia kills more children than any other infectious disease, claiming the lives of over 800,000 children under ve every year, or around 2,200 every day. This includes over 153,000 newborns 4 . Almost all of these deaths are preventable. Globally, there are over 1,400 cases of pneumonia per 100,000 children, or 1 case per 71 children every year, with the greatest incidence occurring in South Asia (2,500 cases per 100,000 children) and West and Central Africa (1,620 cases per 100,000 children). 5 In South Sudan, pneumonia is one of the top diseases causing morbidity and mortality among young children. It was reported that the disease was responsible for one-fth of deaths of children under ve years in 2018 6 A report by the UN children's agency UNICEF and charity groups Save the Children and Every Breath Counts Coalition, said pneumonia claimed 7,640 lives of children under the age of ve in 2018 in the country, causing 20 percent of under-ve deaths due to poverty and lack of access to health services. 6 Children immune compromised by malnutrition, and those living in areas with high levels of air pollution and unsafe water, are at far greater risk, the aid agencies said in a joint statement. 6 Clinically, pneumonia is de ned as the presence of fever, acute respiratory symptoms, or both, plus evidence of parenchymal in ltration chest radiography. 7 In the worst situation, it can affect the lung where the alveoli are lled with pus and uid, which makes breathing painful and limits oxygen intake. 7 There are a large number of microorganisms that can cause pneumonia, such as bacteria which is the most common cause of community acquired pneumonia, with streptococcus pneumonia isolated in nearly 50%, homophiles in uenza in 20%, chlamydophila pneumonia in 13% Mycoplasma pneumonia in 3% of cases and viruses which account for about one third of pneumonia cases in adults, and in children for about 15% of them. 8 Commonly implicated agents include rhinoviruses, corona viruses, in uenza virus respiratory syncytial virus, and adenovirus and Para in uenza. Fungal pneumonia is uncommon but occurs more commonly in individual with weakened immune 8

Scope of Problem
Pneumonia is responsible for the deaths of more than 800,000 young children worldwide each year, according to the United Nations Children's Fund (UNICEF) 4 . These deaths occur almost exclusively in children with underlying conditions, such as chronic lung disease of prematurity, congenital heart disease, and immunosuppressant. Pneumonia accounts for 15% of all deaths of children under 5 years old, killing 808 694 children in 2017. Globally, there are over 1,400 cases of pneumonia per 100,000 children, or 1 case per 71 children every year, with the greatest incidence occurring in South Asia (2,500 cases per 100,000 children) and West and Central Africa (1,620 cases per 100,000 children).
The disease is one of the leading killers of children in South Sudan. Causing 20% of fewer than ve deaths in 2018 due to poverty, and lack of access to health. 9

knowledge Gap
Health facilities in South Sudan are overwhelmed with pneumonia cases with more than 7,000 deaths in 2018. Pneumonia in South Sudan complicated with other childhood diseases like anemia and malaria, and a lack of access to health services makes things more dangerous

Problem Statement
Page 4/20 The prevalence of pneumonia in children under ve is assumed increasing. However, there is no clear data supporting this increment in South Sudan.

Research Question
What is the prevalence of pneumonia in children under ve years in Al Sabah Hospital? 1.5 Objectives

Overall Objective
The overall objectives of this study is to determine the environmental, social-economic and nutritional risk factors associated with children less than ve years of age hospitalized with pneumonia in Al Sabah Hospital .

Speci c Objectives
To identify the major risk factors of pneumonia in children under-ve years Al Sabah Hospital.
To determine the prevalence of pneumonia in children under ve years in Al Sabah Hospital.

To Reduce the prevalence of Pneumonia in children under ve years in Al Sabah
Hospital by providing evidence based information's to policy makers that would help them take correct decisions

Public Health Signi cance
In the world where numerous etiological and risk factors had already been identi ed, leading to the availability of preventive and curative measures, pneumonia still remains a major challenge to child health and survival in South Sudan 9 . Hence the signi cance of this research aimed at various levels including the community and the health policy makers are as follows: The research is also of profound value in planning, adopting and promoting policies that prevent and reduce morbidity and mortality by increasing the understanding to the need for vaccine coverage, antibiotics and other medication to all parts of the country.
Lack of awareness and education of the mothers may adversely have an impact on the outcome of the illness which may be amenable to public health intervention.
Educated mothers recognize the signs and symptoms of pneumonia early and so access health care earlier and so their children have a better outcome than others.
A study conducted in Nigeria reveals that poor parental educational status is signi cantly associated with ARI.
Study has found signi cant association of prelacteal feeding with childhood pneumonia. Age at onset of complementary feeding may also be associated with pneumonia occurrence 9 .
Occurrence is 21.3% when feeding was started at 4 months, 13.7% at six months and 30.7% beyond six months of age. 9 Our study too shows statistical association of complementary feeding in time with pneumonia occurrence.
Immunization of children with two doses of measles vaccine through routine immunization, immunization with three doses of pentavalent vaccine and also booster doses of DPT vaccine during childhood can go a long way for prevention of pneumonia occurrence.
Reductions in occurrence of pneumonia have been observed in completely immunized child as according to age.
In this chapter, we have focused on hypothesis, research question, objective and public health signi cance of pneumonia. In the next chapter therefore, we shall discuss about the mortality rate, classi cations, risk factors associated with it and managements of pneumonia.

Study Design
This was a descriptive cross-sectional study. Although cause and effect cannot be established by this study design, we chose it because it can determine the prevalence, less expensive and take short duration.

Site of the Study
The study was conducted in Al -Sabah Children Hospital in Central Equatoria State, Juba South Sudan.
The hospital is located at Hai Cinema next to Jerusalem House.
It is the main children hospital in Juba, with an outpatient capacity of 250_300 per day and admits about 25_40 patients per day and a capacity of seven wards.
The hospital is served by 200 staff both classi ed (doctors, nurses and lab technical and public health o cers) and unclassi ed (cleaners etc).

Population of the Study
The study is done in Al -Sabah Children Hospital population of children under the age of ve years from January to June 2021.

Sample Size
The Sample size was 241.

Variables
The study of mortality rate and risk factors of pneumonia was done. Patient and Parents or maternal related risk factors, Environment related risk factors, Malnutrition and Vitamin A de ciency, Low birth weight, Air pollution, viral infections and level of management were also analysed.

Source of Data:
Al -Sabbah Children Hospital will be the source of data collection for this study.

Collection of Data:
The activity designed to collect data took 18 days from 18 of September to 5th of October 2021. A Questionnaire was also developed for interviewing the different care givers in population of children under ve years in addition; the study also applied focus group discussion and observation as some of scienti c methodologies for data collection.

Data Management and Statistical Analysis:
The collected data will be rst reassessed for compatibility and accomplishment, and so will be arranged, presented or displayed in the form of graphs, charts and frequency tables using Microsoft Excel and word 2013.

Limitations
In the search for up to date information about the prevalence of pneumonia in Central Equatoria State, the lack of medical data in the country has forced us to entirely depend on primary data. The burden doesn't start and end only with the cost for the data collection techniques which included: Printing of the questionnaires. Transport to and from the hospital.
In nity in terms of language barrier.

Time consumption.
Has a potential for response bias (e.g. level of literacy) Can't establish whether an exposure will be followed by outcome (temporality) Not cooperative parents 3. Results

Analysis of Results
Our sample size comprises of 241 under-ve years children of which male was 116 (48%) and the remaining is female which 152 is (52%). The results in gure 3.3 showed that the risk of pneumonia was higher among female under-ve children 13 children than among male under-ve children 8 children.
Surprisingly, the results in gure 3.4 showed that the risk of pneumonia was higher among under-ve children who were born at hospital 17 children, while lower among those under-ve children who were born at home 4 children.  Table 3.2 showed that type of family was positively and insigni cantly linked with under-ve children at 95% con dence level.
Type of home was positively and insigni cantly allied with under-ve children at the 95% con dence level. As expected, the risk of pneumonia among under-ve children who were living in local building was about 1.463 times higher than those who lived in modern building.
Overcrowding was negatively and insigni cantly associated with under-ve children at 95% con dence level.
Method of cooking was negatively and insigni cantly associated with under-ve children at 95% con dence level..
Baby care taker was positively and insigni cantly associated with under-ve children at the 95% con dence level. Home treatment tried was positively and signi cantly associated with under-ve children at 95% con dence level. The results in Table 3.4 showed that born premature was negatively and insigni cantly associated with under-ve children at the 95% con dence level.
Mother's education was positively and insigni cantly associated with under-ve children at 95% con dence level Father's educational status was negatively and insigni cantly linked with under-ve children.
Mother's occupation was negatively and signi cantly associated with under-ve children at the 95% con dence level.
Father's occupation was negatively and signi cantly associated with under-ve children.
Poor ventilation was positively and insigni cantly related to under-ve children.
Smoking at home was negatively and insigni cantly connected to under-ve children at 95% con dence level.
Drinking water Source was negatively and insigni cantly associated to under-ve children Open defecation was positively and insigni cantly associated with pneumonia in under-ve children at the 95% con dence level.
Challenges of this Study:

Focus Group Discussion
In order to obtain more information to strengthen our research, we also opted to FGD as one of the scienti c methodologies. The aim was to discuss the risk factors associated with pneumonia, the current available intervention measure and to get idea on what can be done to prevent pneumonia in Al Sabbah Children Hospital.
According to 40 cases of children with pneumonia, the main risk factor was cold weather and rainy season. Other risk factors that were identi ed include; smoking, dust, and Air pollution. One of the participants highlighted that when a child Ss not breast fed exclusively for more than six months and not vaccinated it can become sick with pneumonia and other related diseases.
Other women said that they were not aware of any intervention measures put in place to prevent and control pneumonia in Al-Sabah children hospital. However, according to Christina one of the mothers, who brought her child for treatment in Al Sabah hospital, noted that the time she brought her child, the child was screened for pneumonia. She also added that a seminar for managing pneumonia at home was conducted. Most participants believed that creating public awareness about risk factor associated with Pneumonia, the prevalence of pneumonia would be reduced.
A pediatrician categorized the risk factors such as the air pollution, coldness, infected person and the dust. However, she also added that the following risk factors play a signi cant role in predisposing to pneumonia particularly among the children, getting coldness and smoking history of spouses. She noted that exposing a child to cold environment is very potential risk factor.

Interview
We interviewed 15 participants who comprised of 3 care givers, 5 from department of Nutrition and other 7 from staff within Al-Sabah Children Hospital. The aim of the interview was to access the level of awareness, the associated risk factors and intervention measures that had been or can be put in place to prevent and control the prevalence of pneumonia in Al-Sabah Children Hospital.
Generally the level of awareness was moderate among the participants 15 of participant (5 care givers, 7 staffs and 5 nutrition o cers) said they had heard about pneumonia. And these, only 5participants (1 care giver, 4 staff and 2 nutrition o cers) were capable of giving clear cut explanation about pneumonia.
The following measures were suggested by subjects in order to prevent and control the prevalence of pneumonia, The government must provide drugs for pneumonia in different health centers Improvement of health care facility across the country, Pneumonia awareness programs should be carried out in communities

Observation
The level of awareness about pneumonia among mothers in Al-Sabah children hospital varies. It appeared to be highest in children of educated and employed mothers. However, mothers who are not educated had the lowest level of awareness.
From our observation, no intervention measures had been put in place to prevent and control pneumonia. However, mothers were eager to learn more about the prevention and control of pneumonia. We also noted that there were increased new cases. This is from the statistics. Possibly it may be because of changes in the season.

Discussion
The nding shows that the prevalence of pneumonia in children under-ve years in Al Sabah hospital is 22.4%. This is higher compared to the previous research done by the students of Upper Nile University and Juba University in 2019 with the prevalence of 21%. The increase in prevalence can be best explained by taking into consideration the discussion of the commonly associated risk factors in context with the country.
This study shown earlier in chapter four indicates that the incidence of pneumonia is highest in children under ve years .This shows that children less than one year of age are at more risk to pneumonia compared to the other age groups of less than ve years. This can be linked to the combination of multiple factors including nonexclusive breastfeeding, the behavior of the children as they begin to move, getting exposed to different environmental factors and more importantly is that, most of these children might have not yet completed the recommended childhood vaccines at that age group.
Of total 40 pneumonia cases, 23 were males that make 57.5%% and 17 were females making 42.5%. Moreover, this study con rms with the other studies that males were more susceptible to contract the disease compared to the females. This fact is more within the age group under ve years.
In accordance with this study, the ethnicity of the patients from Dinka (37.5%) and Bari (30%), Shilluk (7.5%), Mundari (2.5%), Madi (5%) Nuer (7.5%), Murli (5%), Lolobo (2.5%) and latoka (2.5%) are the leading ethnicities with high morbidity of pneumonia the highest was found in Dinka. This can be related to the factors such as population density and socioeconomic status. Dinka is known to be one of the highest population in Juba city. On the other hand, Lolobo, Mundari and Latoko are one of few ethnic groups in Juba city .
The data showed that premature birth was negatively and insigni cantly associated with under-ve children at the 95% con dence level. The risk of pneumonia was 0.652 times lower among under-ve children who have not been born premature than those under-ve children who have born premature.
Similarly, low birth weight was negatively and not signi cantly connected with under-ve children. The risk of pneumonia was 0.626 times lower among under-ve children who had been born with lower weight than those under-ve children who had been born with higher birth weight.
Mother education was positively and insigni cantly associated with under-ve children at 95% con dence level. As expected, the risk of pneumonia among under-ve children whose mothers were illiterate was about 1.220 times higher than those under-ve children whose mothers with primary education and below. Father education was negatively and insigni cantly linked with under-ve children.
The risk of pneumonia among under-ve children whose fathers had primary education and above was around 0.740 times lower than among those under-ve children whose fathers were illiterate.
Mother's occupation was negatively and signi cantly associated with under-ve children at the 95% con dence level. As expected, the risk of pneumonia among under-ve children whose mothers were working was about 0.233 times lower as compared to those under-ve children whose mothers were not working. Similarly, father occupation was negatively and signi cantly associated with under-ve children.
The risk of pneumonia among under-ve children whose fathers were working was about 0.864 times lower than those under-ve children whose fathers were not working.
Poor ventilation was positively and insigni cantly related to under-ve children. The risk of pneumonia was about 1.283 times higher in households with poor ventilation. Besides that, contact with TB was positively and signi cantly associated with pneumonia in under-ve children at the 95% con dence level.
Smoking at home was negatively and insigni cantly connected to under-ve children at 95% con dence level. The risk of pneumonia among under-ve children in homes with no smoking was around 0.305 times lower than those in homes with smoking.
Drinking water source was negatively and insigni cantly associated with under-ve children. The risk of pneumonia was about 0.749 times lower among under-ve children living in households whose source of drinking water is tap water than those under-ve children living in households their source of drinking water is underground water. Open defecation was positively and insigni cantly associated with pneumonia in under-ve children at the 95% con dence level.
Type of family was positively and insigni cantly linked with under-ve children at 95% con dence level.
The risk of pneumonia for under-ve children who living in joint family was about 1.983 times higher compared with under-ve children who were living in nuclear family.
Number of family members was negatively and insigni cantly associated with under-ve children at 95% con dence level. As expected, the risk of pneumonia for under-ve children who were living in family with members up to 5 persons was about 0.967 times lower as compared to those children who were living in family their members more than 5 persons.
Type of home was positively and insigni cantly allied with under-ve children at the 95% con dence level. As expected, the risk of pneumonia among under-ve children living in local building was about 1.463 times higher than those in modern building.
Overcrowding was negatively and insigni cantly associated with under-ve children at 95% con dence level. As expected, the risk of pneumonia for under-ve children living in uncrowded houses was about 0.591 times lower than those under-ve children living in crowded houses.
Method of cooking was negatively and insigni cantly associated with under-ve children at 95% con dence level. As expected, the risk of pneumonia for under-ve children whose mothers were cooking with gas was about 0.508 times lower than those under-ve children whose mothers were cooking with rewood and charcoal.

Recommendations
The recommendations cover Health Information Education and Communication about preventive measures that target the Government, Health workers and Development partners. It also targets the entire population including women, men, youth and community leaders. There should be a development of community health programs that aim at promoting health education by creating awareness about the causes, risk factors and prevention of the disease via the radio, television, or health campaigns in the schools and churches and other social institutions: Educate parents to understand that local herbs, home prescribed medications can prevent a child from getting appropriate treatment at the right time which can lead to further complications of the disease.
Train health workers on GOBIFFF principles (Growth monitoring, oral rehydration, breastfeeding, Immunization, female education, family planning and food supplement) Provision of medical supplies and improve laboratory services Educate the parents and caretakers about child health care Training parents about the importance of good nutrition for both the child and mother in prevention of malnutrition, low birth weight and associated disease that can predispose to pneumonia.
Educate the caretakers on the importance of the completion of all the recommended vaccines for their children.
Mobilizing the parents on the importance of urgent medical intervention in preventing the complications of the disease.
Provision of clean and safe drinking water especially in displacement camps Provision of clean form of energy such as electricity and solar energy Provision of the required medications for the treatment of pneumonia in all the health facilities.
Provision of medications for other diseases that can predispose a child to pneumonia.
Continuous data collection, monitoring and evaluation of the disease progress.

Educating the community to build better ventilated houses
Educating the community about the dangers of smoking Advocating the government to develop a policy of managing smoking Advocating the development partners such UNICEF to support programs related to child health care.
Allocate budget for research and encourage young researchers to look more into disease dimensions

Conclusion
The Permission to carry out the study was granted by the ethical committee, faculty of medicine in Upper Nile University and Al -Sabah Children Hospital.

Consent for publication
Informed consent were obtained for the questioners from the participants prior to data collection.
Anybody who declined their data are not collected and they were excluded.
Patients' information that were obtained, were kept con dential and an effort was made to maintain the privacy and autonomy of the participants by encrypting all the information through the process of data analysis.
Availability of data and material Datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.