31 JOURNAL OF SCIENCE, Hue University, N 0 61, 2010 SOME DETERMINANTS OF URINARY TRACT INFECTION IN CHILDREN FROM 2 MONTHS TO 6 YEARS OLD IN HAI PHONG VIETNAM IN 2008 Dang Van Chuc, Nguyen Ngoc Sang, Dang Viet Linh SUMMARY This research was conducted to establish some determinants of urinary tract infections (UTI) in children from 2 months to 6 years old in some areas of Haiphong in 2008. Method: Cross-sectional study. Results and Conclusions: “Poverty”, “Underweight weight malnutrition”, “Phimosis” and incorrect washing method after children have passed stools were statistically significant with the presence of UTI using a logistic regression analysis. There was a relationship between UTI development, poverty and poor knowledge of child hygiene. Keyword: Urinary Tract Infection, Determinant. 1. Introduction Urinary Tract Infections (UTI) are of interest to scientists because they can lead to renal scarring, which causes dangerous complications when children grow up such as: anemia, hypertension (7-17%), preeclampsia, eclampsia, renal failure and end stage nephropathologies. Most research has been conducted in hospitals to determine the incidence of UTI, type of bacteria and treatment effectiveness. In Vietnam, no studies have been conducted in the community to evaluate the Prevalence rate, In particular, to determine some risk factors of UTI. Therefore, this study was conducted with the following objectives: Determine some risk factors of UTI in children from 2 months to 6 years old in some areas of Haiphong, Vietnam. 2. Methodology 2.1. Population and study time All children from 2 months to 6 years old in some areas of Haiphong. Study duration: 7/2007-10/2007. Criteria of UTI: Leucocyturia ≥ 30/mm 3 and bacteriuria ≥ 10 5 /ml urine. 2.2. Method Study location 32 3 districts representative of Haiphong district, which were coastal, rural and urban. Study design Cross-sectional and descriptive study. Sample size was calculated according to the following formula:   2 2 2/1 1 d pp Zn     n: Sample size Z 2 1-α/2 = (1, 96) 2 (confidence 95%) p = 0, 04 (UTI rate in children of Haiphong after Nguyen Ngoc Sang et al in one commune in 2005) d= (p*  ) or 20% of p So approximately 4610 children were needed for the study. Sampling process: Multistage sampling was used. The 3 districts chosen were Kien An (urban), Kien Thuy (coastal) and Thuy Nguyen (rural). The 9 communes/ quarters selected were Nam son, Trang Minh and Van Dau (Kien An), Dai Ha, Tan Trao and Ngu Doan (Kien Thuy), Phuc Le, Lap Le and Pha Le (Thuy Nguyen). Data collection: + Identification of UTI: We carried out screening of midstream urine of children in the morning to detect UTIs. In the previous night and in the morning the child’s genitals were cleaned using safe water and soap. The first urine was eliminated and 5 ml of midstream urine was collected in a neutral tube. If the urine sample has leucocyturia ≥ 30/mm 3 , it was cultured to identify bacteriuria. A UTI was identified if urine sample had both leucocyturia ≥ 30/mm 3 and bacteriuria ≥10 5 /ml. + Parental interview: Parental interview of socio-economic conditions, and the child’s history of disease. + Complete examination: Pediatricians examined children for diseases, particularly genitor-urinary diseases. Anthropometry was completed to evaluate children’s nutritional status. 33 Data treatment: SPSS version 13.0 was used for entering and analyzing data, determining UTI rate and risk factors. Cases were dependent variables and socio-economic conditions, child’s diseases were independent variables. UTI and risk factors were associated when OR>1, p<0.05 or OR<1 and p<0.05. Confounding was eliminated by Logistics Regression. 3. Results 3.1. Common information: - The urine of 4631 children was screened, of whom 2268 were boys (49%); and 2363 were girls (51%); there were children in rural were 1603 (34.6%) children in rural areas, 1568 (33.9%)in coastal, and 1460 (31.5%) in urban arras. The Common UTI rate was 2.8%. 3.2. Some risk factors of UTI: Table 1. The relationship of socio-economic conditions and UTIS Risk factors Exposure n Rate % OR Bi variables 95%CI OR Multi variables 95%CI Maternal education < secondary* 105 3.1 1.7 1.1-2.7 ≥ secondary 23 1.8 Paternal education < secondary * 109 3.3 2.2 1.3-3.7 ≥ secondary 19 1.5 Economy Poverty* 29 5.8 2.5 1.6-3.8 2.9 1.3-6.5 Non poverty 99 2.4 Water Unsafe water 31 2.6 0.9 0.6-1.3 Safe water 97 2.8 Ware of UTI Unware of UTI 115 2.8 1.2 0.7-2.2 Ware 13 2.3 Paternal Indirect 84 3.6 1.9 1.3-2.8 34 care of child paternal care of child* Direct care 44 1.9 Remarks: Significant factors with asterisk included “maternal education level less than secondary school”, “poverty”, “indirect paternal care of the child”. With multivariable analysis, only “poverty” remained significant. Table 2. The relationship of socio-economic conditions and UTIs (continued). Risk factors Exposure n Rate % OR Bi variables 95%CI OR Multi variables 95%CI Maternal care of child Indirect maternal care of child* 71 3.9 1.9 1.4-2.8 Direct care 57 2.0 House Stable 73 2.5 0.7 0.5-1.1 Unstable 55 3.3 Lavatory Unhygienic lavatory 58 2.3 0.65 0.4-0.9 Hygienic lavatory 70 3.4 House’s square < 20 m 2 98 2.5 0.5 0.3-0.8 ≥ 20 m 2 30 4.3 Remarks: “Indirect maternal care of the child” had a statistically significant association with UTI in bivariate analysis but it was not significant in multivariable analysis. Others were not significantly associated with UTI. Table 3. The relationship between hygienic factors and UTI. Risk factors Exposure n Rate % OR Bi variables 95% CI OR Multi variables 95%CI Hygiene after urination Clean* 102 3.3 1.9 1.3- 3.0 Clean and 26 1.8 35 washing Diaper Yes* 23 5.8 2.4 1.5- 3.8 No 105 2.5 Hygiene after stool Clean * 99 3.2 1.7 1.1- 2.6 Clean and washing 29 1.9 Remark: Factors such as “Incorrect washing method after urination and Passing stools”, and “diapers”, were significantly associated with UTI in bivariate analysis but they were not significantly associated in the multivariable one. Table 4. The relationship of hygienic factors with UTI (continued). Risk factors Exposure n Rate % OR Bi variables 95%CI OR Multi variables 95%CI Way of washing after stool Back- ward* 123 2.9 2.6 1.1-6.3 1.9 1.2-3.9 Back- ward, in place 5 1.2 Kinder- garten Yes 94 2.6 0.9 0.5-1.1 No 34 3.3 Preschool Yes 16 2.5 0.8 0.5-1.4 No 112 2.8 Remark: Factors such as “incorrect washing method after urination and passing stools” were statistically significant in bivariate and multivariable analysis. Others were not significant. Table 5. The relationship of child’s diseases and UTIS. Risk factors Exposure n Rate % OR Bi variables 95%CI OR Multi variables 95%CI Stunting Yes * 49 3.5 1.4 1.0-2.1 36 No 79 2.4 Under weight Yes * 41 4.0 1.6 1.1-2.4 1.7 1.1-3.3 No 87 2.4 Wasting Yes * 26 4.7 1.97 1.3-3.3 No 102 2.5 Phimosis Yes * 30 6.6 6.6 3.7- 11.9 6.7 3.7- 12.2 No 19 1.0 Consti pation Yes * 44 4.6 2.0 1.4-2.9 No 84 2.3 Enuresis Yes * 81 3.3 1.5 1.1-2.3 No 45 2.1 Remark: Factors marked with an asterisk were significant in bivariate analysis, including “Malnutrition of all kinds”, “phimosis”, “constipation” and “enuresis”. In multivariable analysis, only “phimosis and “low weight malnutrition” were significantly associated with UTIS. 4. Discussion 4.1. Socio-economic conditions and maternal education level: Table 1, 2 showed that “poverty”, paternal education level under secondary school”, and “indirect paternal care of child” were significantly associated with UTI. The results revealed the relationship between poverty, ignorance and disease. People with low education levels generally do not earn a high income later in life. Once being poor, parents have to work hard and so they do not have enough time to take care of their child, they are not able to get access to medical services and their child’s disease makes them become poorer. In multivariable analysis, only “poverty” remained significantly associated with UTI (OR = 2, 9). 4.2. Paternal practice for UTI prevention: Table 3, 4 showed that “incorrect method of cleaning after urination”, “diapers”, “clean after stool”, and “incorrect washing methods after stools” were risk factors of UTIs. According to Gal and Steven Use of an incorrect hygiene method after urination and stools helps bacteria colonize on the perineal surface and then penetrate into urinary tract and cause UTI. In multivariable analysis, “incorrect washing method after stool 37 was significantly associated with UTI” OR =1.9. 4.3. Other accompanied diseases and genitor-urinary abnormalies: Table 5 indicated that “malnutrition of all kinds”, “phimosis”, “constipation” and “enuresis” was risk factors. When a child was malnourished, his immune status was reduced so they were more susceptible to bacterial infection. Phimosis was an anchor of bacteria that penetrated into the urinaty tract in favorable conditions. According to Gal and Steven, when children have constipation, the urinary tract is suppressed and this causes urinary stagnation contributing to bacterial development leading to UTI. Enuresis contributes to good colonization of bacteria on the perineal surface and then penetrates into the urinary tract. In multivariable analysis, “phimosis” with OR=6.7 and “low weight malnutrition” with OR=1.7 were associated with UTI. 5. Conclusion Risk factors such as “poverty”, “Under weight malnutrition”, “phimosis” and “incorrect washing method” were associated with UTI using multivariable analyze. The model revealed the relationship between UTI, poverty and a Poor knowledge of child hygiene. REFERENCES 1. Steven L et al. Pediatric Urinary Tract Infections. Pediatric Clin N Am 53. 2006; 379- 400. 2. Le Nam Tra et al. Malnutrition in children. Pediatric book, volume I. Hanoi Publish house. 2001; 199-207. 3. Braslavsky et al. Recurrence risk in infants with urinary tract infections and a negative radiographic evaluation. J Urol 172. 2004; (4 Pt2): 1610-3. 4. Yan A et al. Adequacy of urinary tract infections management among minority underserved children. Pediatric Nephrol 19.2004; (12): 1375-8. 5. Gal Finer et al. Pathogenesis of urinary tract infection with normal female anatomy. The Lancet Infect Dis 4. 2004; 631-635. 6. Le Nam Tra et al. Urinary tract infection in children. Pediatric book, volume II. Hanoi Publish house. 2001; 168-176. 7. Gram N et coll. L’infections urinaires Ðcidivantes de l’enfant. Rev Maghr PÐdiatr IX, 1. 1999; 3-14. 8. Zorc JJ et al. Clinical and demographic factors associated with urinary tract infection in infants in young febrile infants. Pediatrics. 2005; 116(3): 644-8. . 1.0 -2. 1 36 No 79 2. 4 Under weight Yes * 41 4.0 1 .6 1.1 -2. 4 1.7 1.1-3.3 No 87 2. 4 Wasting Yes * 26 4.7 1.97 1.3-3.3 No 1 02 2.5 Phimosis Yes * 30 6. 6 6. 6 3.7- 11.9 6. 7 3.7- 12. 2. Back- ward* 123 2. 9 2. 6 1.1 -6. 3 1.9 1 .2- 3.9 Back- ward, in place 5 1 .2 Kinder- garten Yes 94 2. 6 0.9 0.5-1.1 No 34 3.3 Preschool Yes 16 2. 5 0.8 0.5-1.4 No 1 12 2. 8 Remark: Factors. 2. 4 Water Unsafe water 31 2. 6 0.9 0 .6- 1.3 Safe water 97 2. 8 Ware of UTI Unware of UTI 115 2. 8 1 .2 0.7 -2. 2 Ware 13 2. 3 Paternal Indirect 84 3 .6 1.9 1.3 -2. 8 34 care of child paternal