Chronic Impairments that Lead to
Respiratory Diseases
Kartari DS., MD., MBBS., MPH
Non Communicable Disease Research Center, National Institute of
Health Research and Development, Jakarta
ABSTRACT
Disability study was carried, out in 1977 in 14 provinces of Indonesia; a sample of
22.568 individuals was obtained with a precentage distribution of 17.6% urban and
82.4% rural.
A special questionnaire was prepared and all members in a household were
interviewed. The data presented here are only for the respiratory diseases and the
diagnosis based on the ICU 9th Revision.
Diseases of the respiratory system ranks second among most important diseases
with prevalence rate of 64.02 per 1000. It is most prevalent in early infancy and
childhood age I to 9 years and again after 25 years.
Incidence among males show no differences in both urban and rural areas, while
females tend to be lower in rural area. In the age group 35 to 44 years both sexes show
no differences in the prevalence rates but in the age group 45 to 54, rate become very
high, with a marked difference female is lower than male.
Since respiratory diseases are largely controllable and reversible, early diagnosis
and prompt treatment are necessary so that chronic impairments and a loss of
manpower for economic development due to respiratory complications do not occur in
later life.
INTRODUCTION
Respiratory diseases have a widespread geographic
distribution occurring during infancy and childhood, and
repeated attacks of the upper respiratory infections is an
important cause of lower chronic respiratory disease in later
life. The most common respiratory infections are : adenovirus
infections, mycoplasmal infections, para influenza) viral
disease, influenza and rhinoviruses, common colds, respiratory
syncytial virus, and others.
CAUSES OF THE RESPIRATORY INFECTIONS
There is at the moment increasing awareness of the im-
portance of upper respiratory infections. They occur as a result
of ah interaction between 3 factors, the host, the infectious
agent and the environment.
The Host
In developing countries where nutrition plays an important
role, children who suffer from various kinds of infections like
respiratory infections may result in the impairment of natural
and acquired immunologic deficiences. This condition may
further impair the child's capacity to fight infection which has
already been reduced by malnutrition:
The Agent
Many agents are responsible for respiratory diseases,
varying from viruses, bacteria, fungal and parasitic infections.
Viruses are supposedly the most important initiators of minor
respiratory infections while bacteria most often cause severe
pneumonias.
Infants most commonly have adenovirus infections as coryzal
Cermin Dunia Kedokteran No. 62, 1990
20
symptoms, but occasionally causes fulminant bronchiolitis and
pneumonia. In older children, pharyngitis and tracheobronchitis
are most prevalent. Clinical manifestations such as abrupt
onset, fever, cough, pharyngitis, rhinorrhoea and pulmonary
rales are common. No antiviral chemotherapy is effective, only
symptomatic treatment is needed."
)
In mycoplasmal infections of the upper airways the onset is
insiduous, in contrast to the abrupt onset of adenoviral or
influenzal pneumonia. Pleural effusions, pericarditis and
myocarditis are most common complications. Acute
.
respiratory synctial virus infections are more common in
adults. Infections are usually asymptomatic but usually
associated with rhinorrhoe, pharyngitis, cough, headache,
fatigue and fever. In the elderly these infections is a cause of
bronchilitis and severe pneumonia.")
Para Influenza viral diseases have a widespread geographic
distribution and are an important cause of lower respiratory
tract disease during infancy and childhood, ranging from in-
apparent infection to life-threatening lower respiratory tract
disease.
Clinical manifestations in children, is usually consist of
rhinitis, pharyngitis and bronchitis, cough, hoarseness and fever
leading to bronchiolitis, bronchopneumonia and pneumonia.
(»
Influenza is usually a self-limiting febrile illness, with high
fever for one to five days with systemic signs and symptoms.
Later cough is most frequent.
The common cold is probably the most frequently occurring
illness in humans worldwide. The incidence is about 41.1 per
100 persons per year. More than 100 distinct common cold
viruses have been discovered and shown to be the major causa-
tive agents of the common cold. All these agents are named as
the rhinoviruses since they cause nasal symptoms. Shortly
thereafter another group of viruses, the corona viruses were
discovered and shown to be the second most important etio-
logic agents of the common cold and related diseases .1)
Rhino-viruses have emerged as the major known causative
agents of adult upper respiratory illnesses such as the common
colds and constitute from 15 to 40% of common cold in adults.
The corona viruses also constitute 10 to 20% of common colds
in adults."
Common cold represent 19,15% of all acute conditions and
estimated to cause over 261 million days of restricted activity.
The Environment
Certain environmental circumstances favour the
transmission of Acute Respiratory Infection (ARI) agents from
one person to another, infection passed around within families,
often being brought from school.
Some agents are carried by droplets in the air, others passed
by touch from one person to another. In some places where
agents show a seasonal pattern, climate may also be a factor."
)
OTHER FACTORS
Cause in the host
Nutrition : A defective immune response is often associated
with malnutrition. In addition to impaired cellular immunity,
malnutrition is accompanied by other defects in the ability of
the white blood cells to fight disease and by low blood levels of
complement, a substance present in the blood serum of plasma
which is necessary to complete the destructive action of anti-
bodies against bacteria. In children with poor nutritional status
acute respiratory infections can become very serious, even
leading to death. (1)
Low birth weight (LBW) is known to be a risk factor;
infants with less than 2500 g body weight are much more prone
and die from serious acute respiratory infections.'
Vitamin A deficiency can cause xerophthalmia and is
closely linked with illnesses such as diarrhoea. Vitamin A is
known to have important effects i on the mucosal surfaces and
deficiency of this vitamin could impair defences in the
respiratory epithelium. (4)
Genetic and acquired defects can also make some children
abnormally vulnerable to acute respiratory infections. The
spleen plays a crucial role in bodily defences against some
respiratory pathogens : when it is removed or is not functioning
properly, children are especially susceptible to bacterial
pneumonia and overwhelming bacterial infections. Children
with defects in the immune system may suffer frequent bouts of
pneumonia. Cystic fibrosis is also pose a significant problem
because of their susceptibility to acute respiratory infections:"
)
Cause in the environment
Smoke increases the risk of acute respiratory infections.
This may come from traditional stoves burning firewood and
straw. Biomass fuels produce high nitrogen dioxide levels as
well as other toxic pollutants, and it is probable that these
pollutants have some adverse effects on the child's respiratory
defence mechanism.
0),
Tobacco smoke. Children who come from homes in which
neither parent smoke have fewer and less severe acute
respiratory infections than those who come from homes where
parents smoke, and it has been shown in some studies that
cotinine (metabolite of nicotine) was found in their urine and
saliva. It is possible that smoke inhalation causes paralysis of
the ciliae in the respiratory tract. (3)
Domestic cooking smoke. In a study that was carried out in
Nepal, it was found that children under one year of age, who
spent longer time close to the fire place each day, were more
likely to experience moderate and severe acute respiratory
infections.
The possible role of domestic cooking fuel in acute
respiratory infections has been investigated in Britain and
USA, and it seems that exposure to nitrogen dioxide from gas
cooking stoves may increase risk. Biomass fuels produce high
nitrogen dioxide levels as well as other toxic pollutants, and it
is probable that these pollutants have a range of effects on the
child's respiratory defence mechanisms.
(3)
In 1977 a study was carried out to collect information on
some aspects of the problems of disability as a whole in the
community and to determine the various types of impairments
that lead to disability.
METHOD AND MATERIAL
A five stage random sampling design was used for this
Cermin Dunia Kedokteran No. 62, 1990 21
survey, and the study population was based on the 1971 census.
Fourteen provinces were selected with a percentage distribution
of 17.6% urban and 82.4% rural, involving 93 rural and 24
urban regencies/municipalities respectively. A final sample of
22.568 individuals was obtained.
A special questionnaire form was prepared for each house-
hold, and all individuals in the household were listed. The
questionnaire was completed by the Health Centre doctors of
the area.
The main items included the following :
1)
Descriptive data such as name, age, sex, education, occupa-
tion, marital status, relation to the household, address, etc.
2)
Type of impairments in the house occurring during the last
3 months with more or less persistent symptoms of cough,
almost everyday with or without expectoration, such as chronic
bronchitis, asthma, emphysema, tuberculosis, or other lung
disease were recorded. The diagnoses were coded into the 4th
International Classification of Diseases (9th Rev).
RESULTS
Respiratory diseases rank second in order in the important
symptoms of chronic impairments for both sexes with a pre-
valence rate of 64.02 per 1000 (Table 1).
Table 1. Frequency of diagnosis for the most important symptoms of
chronic impairments for both sexes combined (No interviewed : 22568)
Diagnosis category
flank
Number of
individuals
Proportional
Prevalence
rate Pe
r
percent
1000
Diseases of oral cavity,
1
1663
22.6
73.68
salivary glands & jaw
Diseases of respiratory
2 1445 19.6 64.02
system
Diseases of circulatory
3 887 12.0 39.30
system/hypertension
Musculo-skeletal and
4 687 9.3 30.44
connective tissue
Skin & sub cutaneous
5 666 9.0 29.51
tissue
Disease of digestive
6 388 5.3 17.19
system
Diseases of eye 4c adnexa
7 369 5.0 16.35
Nutritional deficiencies/
8
350
4.7
15.50
underweight
Diseases of ear & adnexa
9 232 3.1 10.28
Fevers of unknown origin
10
118
1.6
5.23
Accidents, fractures
11
58
0.8
2.57
missing limb
Poliomyelitis, spastic
12 53 0.7 3.35
mucles
Others
13 457 6.2 20.25
Total
7373
100.0
Table 2. shows that below 34 years of age the prevalence
rate for male is 32.47 and that of 35 years and above is 174.16.
The' picture for female is also similar for those below 34 years
the prevalence rate is 33.32 while for those from 35 years and
Table 2. Total number of respiratory diseases by age and sex
Age Male
Female
Total
Prevalence
hate per 1000
Male
Female
< 1
6
6
12
1 - 4
50
53
103
5 - 9
57
68
125
10 -14
30
28
58
32.47
33.32
15 -24
46
50
96
25 -34
69
70
139
-
35 -44
127
82
209
45 -54
171
91
262
1
174.16
109.85
55 64
168
83 251
65 & above
115
75
190
Total 839 606
1445
above, it is 109.85. It can be seen that the prevalence rate for
both sexes below 34 years are almost the same, but above 35
years of age the rate are higher, especially in the male group.
This may be due to other causes, such as male smokes more,
and more in contact with industrial fumes and heavy metals
(Table 2).
Among all types of the respiratory diseases, especially in
the early infancy and childhood (age 1 to 9 years), the
prevalence of chronic bronchitis, is high in both sexes. There is
a slight decrease in the younger age group (10 - 24 years).
Beyond 25 years all respiratory diseases tend to rise with age
especially in male. Chronic pharyngitis, viral infections,
chronic common cold, chronic sinusitis, emphysema etc. are
included in 'others
'
category (Table 3)
Comparing between urban and rural areas for chronic
impairments, the incidence in male seem to be higher than
female in both areas. Factors that may be responsible will be
discussed later (Table 4).
Chronic impairments in the 35 - 44 age group year show no
difference between sexes, but chronic impairments in males
aged > 45 year seem to be higher than in female (Table 5).
DISCUSSION
This paper will discuss the figures of the respiratory
diseases, obtained from the Disability Study which was carried
out in 1976, from a sample of 22,568 individuals drawn from
14 provinces (whole population 1971: 98.950.904).
Chronic impairment is defined as a permanent or transitory
psychological, physiological or anatomical loss and/or abnor-
mality occurring in a household during the last three months
with more or less persistent symptoms. i.e : a missing or defec-
tive part of tissue organ or mechanism of the body, such as
amputated limb, paralysis after poliomyelitis, myocardial
infarction, cerebrovascular thrombosis, restricted pulmonary
function as in chronic bronchitis, asthma etc.
Rapid technological developments and urbanization has
created changes in the attitude, knowledge and behavior of the
Cermin Dunia Kedokteran No. 62, 1990
22
Table 3. Different types of respiratory diseases by age and sex
Age in
Males
Females
years
Chr. Asthma T B Others Total Chr. Asthma T B Others Total
bron
bron
< 1
6
6
4
1
1
6
1 4
18
13
7
12
50
28
15
2
8
53
5 9
24
17
6
10
57
32
23
5
8
68
10 14
17
4
2
7
30
12 =·
9
5
2
28
15 24
17
9
16
4
46
22
12
9
7
50
25 34
22
12
27
8
69
16
12
40
2
70
35 44
48
17
50
12
127
38
12
18
14
82
45 54
60
24
75
12
171
29
11
44
7
91
55 64
66
42
41
19
168
25
13
38
7
83
65 & above
53
19
32
11
115
19
5
39
12
75
Total 331
157
256
95
839
225
113
260
68
606
Chr
bron chronic
bronchitis
TB
pulmonary
tuberculosis
nutrition and a healthy living environment. Good
nutrition will increase the ability to produce the
defense mechanisms.
Accurate diagnosis, early and prompt treatment
will reduce the occurrence of the respiratory in-
fections.
Environmental factors such as smoke from
various industries and congested traffic as well as
from smoking, can all lead to upper respiratory tract
diseases. In urban areas, (Table 4) more males from
rural areas migrated to the more densely populated
city, especially young adults who come to the cities
to find work. Also in the rural areas males seem to
have a higher prevalence of the chronic impairments.
Factors that might caused differences in males for
both urban and rural areas is because males smoke
more, poor nutritional status of health and ignorance
in healthy living. On the other hand females also do
not show much differences in both urban and rural
areas, which might be due to females who tend
Tabel 4. Number and percentage of cases of chronic impairments due to
respiratory diseases by area of residence and sex
Urban (614) Rural (3070) Total (3684)
Sex IMPAIRMENT
No "/o No % No %
Male Respiratory
158 25.7 681 22.2 839 22.8
disease
No respiratory
456 74.3 2389 77.8 2845 77.2
disease
Urban (701)
Rural (2988)
Total (3689)
Female
Respiratory
128 18.3 478 15.9 606 16.4
disease
No respiratory
573 81.7 2510 84.1 3083 83.6
disease
Urban (1315) Rural (6058)
Total (7373)
Total Respiratory
286 21.7 1159 19.1 1445 19.6
disease
No respiratory
1029 78.3 4899 80.9 5928 80.4
disease
population, many factors will increase the risk of chronic respi-
ratory diseases that lead to disabling impairments and
permanent damage of the lungs.
Since chronic impairments tend to increase with age (table
2) early steps to treat repeated attacks of upper respiratory fract
infections have to be taken on the young age group 5 to 9 years
and also those from 25 years and above, since repeated
respiratory tract infections during infancy and child-hood may
lead to chronic respiratory impairments.
Respiratory diseases are largely controllable diseases. There-
fore interaction between the host, the infectious agent and the
environment should be interrupted by early diagnosis and treat-
ment, preventive measures to prevent recurrent attacks, good
to try to hide their ailments, or neglect the symptoms.
Similarly,some of the above factors could be applied to males
who seem to show higher prevalence rate per 1000 population
in the age group of 34 to 44 years and 45 to 54 years being
92.76 and 165.69 respectively, in the age group 45 to 54 years
there is a difference between males and females (Table 5).
Cermin Dunia Kedokteran No. 62, 1990 23
Table 5. Total number of cases of chronic impairments due to respiratory diseases in two age
groups and sex
Male (No : 2401)
Female (No : 2053)
Age group
in
years
No
%
Age group
in
year
No
%
35 - 44
Respiratory
127
24.3
Respiratory
disease
disease 82
24.4
35 - 44
(No : 1369) No respiratory
1242
75
,
7
(No : 1357) No respiratory
disease
- disease
1275
75.6
45 - 54
Respiratory
171
32.5
Respiratory
disease
45
-54
disease
91
21.9
(No : 1032) No respiratory
861
67.5
(No : 869) No respiratory
disease
disease
778
78.1
the cycle of illness between the host, in-
fectious agent and the environment are
very important
.
as a basic requirement of
modem life. By the year 2000 large cities
will have a large proportion of urban
slums and low income groups in the
periphery. This condition will further
aggravate the precarious conditions of
health, garbage disposal problem and other
services that are necessary for the mainte-
nance of health.
Pollution of air, water, soil and the
whole environment will create even
greater challenges in the future. Most im-
portant is the effort to prevent or reduce
the negative effects and thereby mobi-
lize the community, which involves citizen
education especially the young so as to in-
It can be concluded that most of the respiratory diseases are
largely treatable and can be prevented from developing into
chronic impairments. Thus it is important to inform the public
regarding the awareness of the importance of the respiratory
diseases and that they shoud find help for every minor symptoms.
CONCLUSION
There is a need to improve the health of the whole population
which requires proper delivery of the services provided and the
process of dissemination of information, thus promoting effi-
ciency and efficacy in health intervention programs. Breaking
cure proper health concepts and that people will understand
their own essential contribution to the solution of health pro-
blems.
(6)
REFERENCES
1.
Robert M Chanock. Text Book of Medicine 17th Edition 1982.
2.
Tupasi Thelma. ARI News 4 April 1986.
3.
Pandey MR. ARI News 4 April 1986.
4.
Douglas Robert. ARI News 4 April 1986.
5.
Kumar Vijay. ARI News 4 April 1986.
6.
WHO Magazine October 1987.
Cermin Dunia Kedokteran No. 62, 1990
24