Morbidity and mortality in children in Northern India (Punjab)

INDIAN JOURNAL OF PEDIATRICS

October, 1962 Vol. 29 No. 177

M O R B I D I T Y AND M O R T A L I T Y IN CHILDREN IN N O R T H E R N INDIA

( P U N J A B ) *

Based o n an analys i s o f 1 0 , 9 9 0 a d m i s s i o n s

S. S. MANCIIANDA a n d K. K. SACHDEV

Amritsar

Since the creation of independent departments of pediatrics in most of the medical colleges in this country during the last decade or so, interest in child health and diseases of children has been inca'eased considerably. Pediatricians from all over the country are collecting data regarding ttle incidence of various ,diseases at different periods of childhood and also more and more statistical information on the mortality from various diseases in different age ,groups. There are, however, only a few reports from a vast country like India with cultural patterns varying flom one r egi'on to the other. M a n y more reports dealing as comprehensively as possible wilh childhood morbidity and mortality would be welcome. Such information would help, not only to understand the volume of illness and wastage of life at different age groups, but will also be of use in planning various health measures

* From the Department of Pediatrics, V. J. Hospital, Amritsar.

to improve the neonatal, infant and childhood morbidi ty and mortality. This paper presents facts on morbidity and mortality of children in Punjab.

'Fhe analysis is made from 10,990 children, their ages varying from 1 day to 14 years. These children were admitted to the children's w a r d of the V. J. Hospital, Amritsar, during the six year- perioc[ from 1956 to 1961. T h e Victoria Jubilee Hospital, Amritsar, is a Govern- ment hospital attached to the Medical College, Amritsar, impart ing both under- graduate and post-graduate medical training. Th e children's department started functioning independently in April !955 and the senior author registered the diagnosis in all cases. Only those cases which were either serious or rare disease entities were admitted. T h e cases include patients f rom the daily out- patient's depar tment and special weekly clinics, as well as patients from the casualty department. Children suffering from surgical, orthopaedic, ophthalmic,

334 INDIAN JOURNAl. OF PEDIATRICS VOL. 29 NO. 177"

T a b l e 1. Number of admissions and deaths per annum.

1955-56 1956-57 1957-58 1958 59 1959-60 1960 61

Total admissions 1521 1612 1930 1941 1959 2027

Total mortality 166 163 208 216 215 210

Mortality per cent. 10.9 10.9 10.7 11.07 10.9 10.3

T a b l e 2. The incidence o~ morbidity and mortality /rom systemic diseases.

Disease Total % Total Mortality admissions deaths %

Gastro-intmtinal disorders 2767 25.5 460 16.6

infections 2052 18.6 141 6.8

Respiratory system 18~0 17.1 118 6.4

Nervous system 1384 12.6 205 14.7

Diseases of blood 558 5.3 61 11.0

Nutritional deficiencies 452 4.1 22 5.0

Diseases of liver 365 3.0 85 23.2

Cardiovascular disease 346 3.1 30 8.6

Diseases of kidney 272 2.4 16 6.0

Accidental poisoning 172 1.6 5 2.2

Neoplasms 90 0.~ 8 8.8

Miscellaneous 603 5.8 27 4.5

E N T , skin and behav iour disorders etc.

are not r ep resen ted as they were Ireated

by the re levant depa r tmen t . T a b l e 1

shows the yearly admissions and deaths.

For the purpose of age-wise analysis

of the morb id i ty and mor ta l i ty data, the

per iod of c h i l d h o o d with an uppe r age

l imi t of 14 years was d iv ided in to the"

fo l lowing age groups, ,6 to 14 years, 1 to

5 )'ears, 1 m o n t h to 1 year, 7 to 30 days

avd below 1 week. All subsequen t

analysis is de ta i led systemwise accord ing

to these age groups. ( T a b l e 2).

Gastro.intestinal system. A total ot

2767 ch i ldren a m o u n t i n g to 25.5 per

cent. of the total admissions were admi t -

ted for var ious gastro- intes t inal disorders.

=The diseases inc luded unde r this h e a d -

M O R B I D I T Y AND MORTALITY IN PUNJAB--MANcI[ANDA AND SACHDEV 335

ing we re : acute gastro-enteritis, acute dysentery, chronic diarrhoea, hehninthia- sis, tuberculous abdomen, intestinal obstruction including intussusception, t t i rschsprung's disease, pancxeatitis, ulcerative colitis, constipation and chronic abdomen. Of these only the major diseases are comumnted on be low:

(a) Acute gastro-enteritis. There were 1846 cases of acute gastro-enteritis, amount ing to 66.6 per cent. of the gastro-intestinal diseases and 17.1 per cent. of the total admissions. T h e peak incidence was below the age of 1 year constituting 71 per cent. of the cases with gastro-enteritis. Only those cases present- ing with marked dehydrat ion and / o r electrolyte disturbances were admitted. Milder cases were treated at home through the out-patient depar tment ser- vices. Children from the urban areas and those f rom tile rural areas were found in the rat io of 4.7 to 1.

(b) In addit ion to the 184.6 cases of acute gastro-enteritis, another 183 cases were registered separately as acute dysentery since the stools contained blood and mucus in significant amounts and grip- ing was a very t roublesome complaint in the older children. Comparison bet- ween the age distr ibution of acute dysentery and acute gastro-enteritis revealed that the former was more common in the age group 1 to 5 years (54.4 per cent.) while the lat ter occurred more fre- quently in the younger age group 1 month to 1 year (64 per cent.).

(c) In addition to these two forms of acute bowel disturbances, 450 cases of dian'hoea, characterized by relapses and remissions, and associated with varying degrees and patterns of mal- and under- nutr i t ion constituted the second major group after acute gastro-enteritis, forming 16.2 per cent. of the gastro-intestinal disorders. T h e incidence was highest in the 1 to 5-year-old age gxoup.

T h e three allied conditions, namely, acute gastro-enteritis, acute dysentery and chronic diarrhoea constituted 89.4 per cent. of the gastro-intestinal disorders. They are essentially manifesta- tions of the same pathological process and the vast majori ty are the result of mult iple aetiology, namely, specific and nonspeeific enteral and parenteral infections, and dietetic indiscretion. This is n o t ditficult to appreciate in tile light of the poor socio-economic conditions and unheal thy envi ronment of the children seeking admission. From the preventive health point of view, one might say that much of the morbidi ty could be prevent- ed when the general s tandard of envi- ronmental and personal hygiene is im- proved. Hehnin th ic infestations of the al imentary tract formed 4.5 per cent. of tile series with a total of 124 cases. T h e highest incidence was in the age group 5 to 14 years, which constituted 64.5 per cent. w h i l e ' t h e age group 1 to 5 years accou.~_ted for 35.5 per cent. T h e hel- minths encountered were mostly hook- worm and round-worm. Cases of thread- worm were not admit ted unless there were complications.

T h e incidence of abdominal tuberculosis was 3 per cent. (81 cases); intestinal obstruction 0.54 per cent. (15 cases); and chronic abdomen 2.06 per cent. (56 cases) of the cases with gastro- intestinal disorders. A total of 11 cases of Hirschsprung's disease were admit ted dur ing the past six years.

Against this background of morbidi ty the following statistics concerning mortality would be informative.

Deaths f rom acute gastro-enteritis accounted for 82.3 per cent. of tile total deaths due to gastro-intestinal disorders and the mortal i ty rate of 21.6 per cent. as against 8.2 per cent. in acute dysentery cases. T h e mortal i ty rate of acute

3 3 6 I N D I A N J O U R N A L O E P E D I & T R I C $ VOI.. 2 9 N o . 1 7 7

T a b l e 3 . Morbidity and mortality from gastrointestinal disorders and urban, rural and sex distribution.

Disease T o t a l % U r b a n M a l e T o t a l M o r t a l i t y

a d m i s s i o n s R u r a l F e m a l e d e a t h s %

A c u t e g a s t r o - e n t e r i t i s 1846 66.6 4.7 : 1 2.6 : 1 401 21.6

Acu te d y s e n t e r y 183 6.6 2 .8 :1 2 .0 :1 15 8.2

C h r o n i c d i a r r h o e a 450 16.2 2.8 : 1 1.9 : 1 40 8.8

H e h n i n t h i c i n f e s t a t i ons 124 4.5 1.7:1 2.5 : 1 - - - -

A b d o m i n a l t ube rcu lo s i s 81 3.0 1.5 : 1 1.0 : 1 4 4.9

I n t e s t i n a l o b s t r u c t i o n 15 {).5 6 . 5 : 1 1.0:1 - - - -

M i s c e l l a n e o u s 57 2.1 2.6 : 1 1.1 : 1 - - - -

H i r s c h s p r u n g ' s d isease 11 0.4 . . . .

T a b l e 4 . Showing morbidity and mortality from various diseases of the gastro- intestinal system, in different age groups.

5 ~ 1 4 1 - - 5 7 - - 3 0 Disease years years 1 m o n t h - - 1 yr . days

Mr. Mb. Mt . Mb. Mt . M-t-). Mt .

Acu te g a s t r o - e n t e r i t i s 108 16 426 95 1210 257 102 33

A c u t e d y s e n t e r y 51 4 9q 9 33 2 - - - -

( ' h r o n i c d i a r r h o e a 46 9 271 25 {33 6 - - - -

H e l m i n t h i c i n f e s t a t i ons 80 - - - 1 . t . . . . . . . .

A b d o m i n a l t u b e r c u l o s i s 71 3 7 1 3 . . . .

l n l e s t i n a l o b s t r u c t i o n 7 - - .t " - - 4 - - - - - -

H i s c h s p r u n g ' s d isease 3 - - 4 --- 3 - - 1 - -

O t h e r s 22 - - 2 ~ - - 12 . . . .

M b - -Mor l ) id i ty hit- - M o r t a l i t y

g a s t r o e n t e r i t i s a t v a r i o u s a g e g T o u p s i s

s h o w n b e l o w : -

Age group Moatality % B e l o w 1 m o n t h 3 3 . 0

1 m o n t h t o 1 y e a r 2 1 . 2

1 t o 5 y e a r s 2 2 . 3

5 t o 14 ,, 14 .8

T a b l e ~ 3 a n d 4 s u m m a r i s e t h e i n c i -

d e n c e o f v a r i o u s g a s t r o i n t e s t i n a l d i s2

o r d e r s r e f e r r e d t o a b o v e .

Nutritional deficiency diseases. T h e r e w e r e 4.52 c a s e s , T r o u p e d u n d e r t h i s

h e a d i n g c o n s t i t u t i n g 4 .1 p e r c e n t . o f

t h e t o t a l a d m i s s i o n s .

~ t O R B m I r g AND IVIORTALITY IN PUNJAB---MANCItANI)A AND NACHDEV 337

T a b l e 5 . Mort)idity and mortality from various nutritional deficiency diseases and urban, rural and sex distribution.

Total Urban Male Total l~Ior tality Disease admissions % deaths %

Rural Female

Malnutrition (including kwashiorkor) 187 41.4 1.3 : 1 1.5:1 14 7.4

Marasmus 82 18.1 2.3:1 1.0:1 8 11.1

Rickets 114 25.2 4.7 : 1 1 . 2 : 1 - - - -

S c u r v y 60 13.3 1 : 1.9 2.1 : 1 - - - -

P e l l a g r a ~ 0 . 9 . . . .

Vitamin A deficiency 5 1.1 . . . .

T a b l e 6 . Morbidity and mortality in dil~e~e~t age groups with nutritional deficiency diseases.

Disease 5-14 years 1-5 years 1 momh-- I yr. 7-30 days

Mb. Mt. Mb. Mt. Mb. Mt. Mb. Mt.

Malnutrition 2-5 2 1 ()5 10 57 2 - - - -

Marasmus I - - 25 3 49 2 7 - -

Rickets 12 - - 85 - - 17 . . . .

Scurvy 4 - - ,88 - - 18 . . . .

Pellagra 4 . . . . . . . . . . .

Vit. A deficiency - - - - 2 - - 3 - - - - - -

Mb--Morhidity Mt--Mortali~y

T a b l e 5 a n d 6 s h o w t h e m o r b i d i t y

a n d m o r t a l i t y of t h e v a r i o u s n u t r i t i o n a l

def ic ienc ies .

Cases w i t h v a r i o u s types of m a l n u t r i -

t i on a re d i s c u s s e d s e p a r a t e l y t o e m p h a -

size t h e m a i n c l i n i ca l p a t t e r n s . Ae t io -

logical ly , c h r o n i c r e p e a t e d i n f e c t i o n s a n d

d i a r r h o e a w e r e bas i ca l ly r e s p o n s i b l e fo r

these m a n i f e s t a t i o n s in a vas t m a j o r i t y

of cases. T h e a p p a r e n t l y l ow i n c i d e n c e

r e s u l t s f r o m the g r o u p i n g of c h r o n i c in-

f ec t ions , d i a r r h o e a a n d d y s e n t e r y u n d e r

s e p a r a t e h e a d i n g s .

Malnutrition. ( ) f t h e 183 cases

g r o u p e d u n d e r ' m a l n u t r i t i o n ' , 73

cases h a d c lass ical k w a s h i o r k o r . N i n e t y -

s ix cases p r e s e n t e d w i t h g e n e r a l i z e d

h y p o p r o t e i n a e m i c o e d e m a , b u t w i t h o u t

338 INDIAN JOURNAL O.F_ PEDIATRICS

T a b l e 7 . Morbidity and mortality from liver diseases and distribution.

urban,

VOL. 29 r,'O. 177

rural and s'ex

Total Urban Male Total Mortality Disease admissions % --- deaths %

Rural Female

Cirrhosis 161 44.1 1.I : 1_ 4.3 : I 35 22.0

Viral hepatitis 98 26.8 3.2 : 1. 3.9 : ;1 7 7.2

Acute hepatic failure 22 6.0 1.7 : 1 3.1 : I 20 90.9

llepatosplenomegaly and portal hypertension 57 15.9 1.8 : 1 2.7 : 1 10 27.0

Jaundice 27 7.4 3. I : 1 5.0:1 3 12.0

T a b l e 8 . Morbidity and mortality from liver diseases in different age groups.

5-14 years 1-5 years l month--1 yr. Disease - --

Mb. Mt. Mb. Mt. Mb. Mt.

7-30 days

Mb. Mt.

Cirrhosis 35 5 94 21 31 9 1

Viral hepatitis 31 3 59 4 8 - - - -

Acute hepatic failure 4 4 13 11 5 3 - -

Hepatosplenomegaly 8,: portal hypertension 31 3 22 5 4 2 . -

Jaundice . . . . 8 13 5 6

Mb--.Morhidity Mt--MortaI[ty

t he o t h e r cha rac te r i s t i c s of k w a s h i o r k o r

c o m p r i s i n g skin, h a i r a n d m e n t a l

changes . E i g h t y - t w o (18.1 p e r cent . )

c h i l d r e n w e r e gross ly m a r a s m i c (ga'ade 3).

T h e over -a l l n m r t a l i t y i n the nu t r i -

t i o n a l de f ic iency states was 5 p e r cent . ,

7.4 p e r cent . fo r m a l n u t r i t i o n a n d

I1.1 p e r cent . for m a r a s m u s cases. Be-

sides t h e v e r y p o o r n u t r i t i o n a l s ta tus ,

e l e c t r o l y t e i m b a l a n c e a n d v a r i o u s infec-

t ions p l a y e d a v a r y i n g ro l e in t i le mor -

ta l i ty .

R icke t s , scurvy, v i t a m i n A def i c i ency

a n d p e l l a g r a cases a c c o u n t e d for 25.2,

13.2, 1.1 a n d 0.83 p e r cent . r e spec t ive ly .

E v i d e n c e of v i t a m i n B c o m p l e x defici-

ency, such as glossi t is a n d a n g u l a r s t oma-

t i t is was n o t r e c o r d e d sepa ra t e ly . T h e r e

was, h o w e v e r , n o case o f f r a n k be r i -be r i .

Liver diseases. A to t a l o f 365 cases

of l i ve r d i so rde r s f o r m i n g 3 pe r cent . o f

t he t o t a l admi s s ions w e r e seen. T h e

diseases i n c l u d e d u n d e r th is h e a d i n g

w e r e v i r a l h e p a t i t i s , a c u t e f a i lu re , c i r rho -

sis o f the l iver , h e p a t o m e g a l y a n d p o r t a l

h ) ~ e r t e n s i o n o f an o b s c u r e n a t u r e , j a u n -

d ice a n d a m o e b i c abscess. T h e s e a re de-

t a i l e d in T a b l e s 7 a n d 8.

MORBIDITY AND MORTALITY IN P U N J A B - - M A N C I I A N D A AND SACtlDEV

T a b l e 9 . Morbidity and mortality from diseases of. infective nature rural and sex distribuiwn.

and

~ 3 9

urban,

T o t a l U r b a n M a l e T o t a l M o r t a l i t y Disease admiss ions % . . . . . d e a t h s %

R u r a l F e m a l e

P. u . o . 1112 54.6 3 . 5 : 1 1.7 : 1 9.i 8.5

En t e r i c f eve r 585 28.5 2.6 : 1 2.2 : 1 47 8.3

W h o o p i n g cough 66 3.2 2 .4 :1 2.3 : 1 - - - -

Ac u t e p y o g e n i c l y m p h a d e n o p a t h y 65 3.2 2.3 : 1 1.3 : 1. - - - -

Skin infec t ions 66 3.2 3 .0 :1 1 .4 :1 - - - -

Acu t e r h e u m a t i c f eve r a n d c h o r e a 91 4.4 3 .0 :1 2 .5 :1 - - - -

Measles 39 1 . 9 6 . 2 : 1 1 . 6 : 1 - - - -

Misce l laueous 28 1.3 . . . . .

Ch i cken p o x 3 . . . . . . . .

M u m p s 2 . . . . . . .

l ) i ph t he r i a 5 . . . . .

T a b l e 1 0 . Morbidity and mortality from infective diseases in dii~erent age groups.

Digease 5-14 years 1-5 years 1 m o n t h - - 1 yr . 7-30 days 1 w e e k

Mb. Mr. Mb. Mr. Mb. Mt . Mb. Mt. Mb . Mt .

P. U . O . 468

E n t e r i c f eve r 375

W h o o p i n g cough 7

A c u t e r h e u m a - tic f eve r a n d cho rea 88

Acu te l y m p h a - d e n o p a t h y 43

Skin infec t ions 12

Measles 20

Misce l laneous 6

20 419 51 198 21 27 2

25 200 21 10 I . . . .

m

33 - - 26 - -

3 - -

21 - - l . . . . .

23 - - 12 - - 16 - - 3 - -

15 - - 4 . . . . .

7 - - 2 - - 9 - - 4 - -

M b - - - M o r b i d i t y M t ~ M o r t a l i t y

340 INDIAN JOURNAL OE PI~OIA'IRIC~ VOL. 29 NO. 177

T h e peak incidence of cirrhosis, viral hepatitis and acute hepatic failure was in the age group 1 to 5 years, accounting for 58.4, 60.2 and 59 per cent. respectively of the total. The cases with hepatosplenomegaly of obscure origin were mostly in the age groups of 5 to 14 years and 1 to 5 years forming 54.4 and 38.6 per cent. respectively.

The mortal i ty of tile ~ o u p as a whole was 23.8 per cent. constituting 6.5 per cent. of the total yearly deaths. Cir- rhosis, viral hepatitis and acute hepatic failure accounted for 53.9 per cent. of the deaths due to liver diseases. Jaun- dice accounted for 7.4 per cent. of the total group with a mortal i ty rate of 11.I per cent.

Diseases ~j an injective nature. Diseases included under this heading arc shown in Tab l e 9 which summarises the incidence of various infections and their mortality.

T h e total number of admissions m this group were 2052 comprising 18.6 per cent. of the total admissions.

Enteric fever (confirmed by WidaFs agglutination test a n d / o r positive blood culture) constituted 28.5 _per cent. of the series and 5.3 per cent. of the total ad- m.issions. T h o u g h the peak incidence was in age group 5 to 14 years (66 per cent.) 10 cases (1.7 per cent.) were, however, seen below the age of one year'.

Besides the cases of enteric fever con- finned by laboratory examinations, 54.6 per cent. of the cases with prolonged fever were grouped as pyrexias of obscure origin, even though many of them were highly suggestive of enteric fever clini- cally, and respomted to chloromycetin. T h e mortal i ty in this series was 8.5 per cent.

Infections of the skin including scabies, impetigo and other pyodermas formed 3.2 per cent. of the series.

T h e common diseases of childhood, namely, whoo.ping cough, measles, lnumps, diphtheria and ctlicken pox for:ned only 5.6 per cent. of tile cases. Whooping cough consti tuted 3.2 per cent. of the series, 50 per cent. of the cases being in the age ,group of 1 to 5 years and 39.1 per cent. in the 1 to 12- month age group. These were admit ted invariably in the second stage with paroxysms and were complicated by chest infections, encephalitis or mal- nutrit ion. T h e cases with measles were also admit ted because of complications and the m a x i m u m number (51.3 per cent) was in the age group 5 to 14 years. (Table I0).

The incidence of these infectious diseases collectively and individually is, of course, highly fallacious as only the complicated cases were admitted, the non- complicated ones at tended either the infectious diseases' hospital direcdy or as referred cases, and a large majori ty were treated either in the outpat ient 's department or at home without any consulta- tion.

Tuberculosis of various systems is discussed under tile respective systems. Collectively, however, these cases formed 6.5 per cent. 0f the total yearly admissions with a tota_l of 712 cases. T h e mortal i ty from tuberculosis formed 7.2 per cent. of the total deaths with a mortality rate of 12.5 per cent. Tuberculo- sis of the skeletal and genito-urinary systems, skin, eye, larynx, etc. is not included in the series.

Respiratory system. Various diseases of the respiratory systems arc tabu- lated in Tables 11 and 12.

Respiratory diseases constituted 17.1 per cent. of the total admissions. Br0ncho-pnemnonia formed 28.5 per cent .of the series with a peak incidence of 48.4 per cent. in the 1 to 12 month

M O R B I D I T Y A N D M O R T A L I T Y I N P U N J A B - - M A N C H A N D A A N D S A C H D E V 341

Table 11. Morbidity and mortality from respiratory diseases and urban, rural and

sex distribution.

T o t a l U r b a n M a l e T o t a l M o r t a l i t y - d e a t h s % Disease admiss ions % R u r a l F e m a l e

B r o n c h o - p n e u m o n i a 530 28.5 3.6 : 1 2.6 :I 85 16

U R T in fec t ion 489 26.3 4 . 0 : 1 3 . 0 : 1 - - - -

P u l m o n a r y t ube rcu los i s 291 15.2 3 . 9 : 1 1 . 8 : 1 12 4.2

A s t h m a t i c b r o n c h i t i s 163 8.7 3.0 : I 2 . 3 : 1 3 1 . 8

Bronch iec ta s i s 135 7.2 1 . 3 : 1 4 . 0 : 1 6 4.7

Ix)bar p n e u m o n i a 129 7 2.0 : 1 2.0 : 1 10 7.6

Acu l e b r o n c h i t i s 76 4.7 4.1 : 1 3 .9 :1 - - - -

P lcura l effusion 42 2.2 1.4 : 1 3.0 : 1 2 9.5

O t h e r s 6 . . . . . . .

Table 12. Morbidity and morgality irom di~Ierent age groups with respiratory diseases.

5-1_4 years I-5 years 1 m o n t h - - 1 w'. 7-30 days Disease . . . . . . . . . .

Mb. .M~. Mb. Mt . Mb. MI. Mb. Mr.

B r o n c h o - p n e u m o n i a 11 1 228 31 256 41 32 12

U-RT infec t ion 99 -- 235 - - 152 .-- 3 -

P t ; I m o n a r v tube l , ,u los i s 146 5 118 4 27 3 . . . . .

A s t h m a t i c b r o n c h i t i s 36 - - 74 1 52 2 1 - -

B:'onchiecLasi~ 90 2 39 3 6 1 . . . .

I .obar l~nemnon ia 63 4 39 5 25 l . . . .

Acute b ronch i tis 13 - -- 26 - - 3 ~ .-- 3 - -

P ! c m a l effusion 18 17 1 8 I . . . .

Mb----M'orbidity M t - - - M o r t a l i t y

342 INDIAN JOI.JRNAL OJ:; PEDIATRICS VOL, 2 9 NO. 177

T a b l e 13. Morbidity and mortality from blood diseases and urban, rural and sex

distribution.

Total Disease admissions %

l_rban Male Total Mortality . . . . . . . deaths %

Rural Female

Anaemias 410 74 2.2 : 1 2.4 : 1 43 11.5

Leukaemia 33 6 2.0 : i 5.6 : 1 5 15.1

l'urpuras 77 14 2.6 : 1 3.2:1 3 3.9

IIaemophilia 33 6 1.1 : 1 - - 2 5.4

T a b l e 14. Morbidity and mortality from blood diseases in different age groups.

Disease 5-14 years 1-5 years 1 month -1 yr. 7-30 days

Mb. Mr. Mb. Mt. Mb. Mt. Mb. Mt.

A n a e m i a s 118 6 157 22 129 80 6 3

Leukaemia 21 3 11 2 1 - - - - - -

Purpuras 30 2 24 - - 13 1 1 - -

H a e m o p h i l i a 17 1 12 1 4 . . . .

Mb---Morbidity Mr- -Mortality

age group , fo l lowed by 43 per cent. in

tile 1 to 5 year-age group, thus account-

ing for 97.4 per cent. of the cases below

the age of 5 years. T h e mor t a l i t y ra te

was 16 per cent. be ing highest in the age

,group 1 week to 1 m o n t h (37.5 per cent.).

Labor p n e u m o n i a cases cons t i tu ted 7 per

cent. and 50 per cent. of these were in

the 5 to l,t year age group. T h e morta-

l i ty of the g r o u p was 7.6 per cent.

R e s p i r a t o r y tract infect ions account-

ed for 26.3 per cent., allergies for

8.7 per cent. and acute bronchi t i s for 4.7

per cent. of the series. T h e mor t a l i t y in

these groups was negl igible .

T u b e r c u l o u s infec t ion of the l u n g

and p leura fo rmed 15.6 per cent. of

this gwoup, wi th the highest inc idence of

50.2 per cent. in the 5 to 14 y e a r age

group .

Bronchiectas is accounted for 7.2 per

cent. of the series and the m a x i m u m in-

c idence was in the 5 to 14 year age

group , accoun t ing for 67.1 per cent. o[

the total cases.

Deaths due to resp i ra tory tract dis-

eases cons t i tu ted 10.5 per cent. of tile

total deaths, the mor t a l i t y ra te of the

system concerned be ing 6.3 per cent. and

80.5 per cent. of these deaths were due to

pneum on ia .

Diseases o] blood. T h e diseases re-

M O R B I D I T Y AND M O R T A I . I T Y I N P U N J A B - - M A N C H A N D A AND SA_CHDEV 343

T a b l e 15. Morbidity and mortality from nervous system diseases and urban, rural and sex distribution.

Total Urban Male Total Mortality Disease admissions % deaths %

R u r a l F e m a l e

Convulsive disordels 320 23.1 2.7 : 1

Viral encephalitis 235 17.0 1.9:1

TB meningitis 226 16.1 3.4 : I

Septic ,, 135 9.9 2.6:1

Poliomyelitis 117 8.4 1.3 : 1

Mental retardation and cerebral palsy 123 8.8 1.5 : 1

Hemiplegias 91 6.5 1.1 : 1

Myopathies 47 3.4 1:1.2

Hydrocephalus 36 2.6 1 : 1.2

Paraplegia 6 0.4 1.0 : 4

Infective polyneuritis 7 0.5 2 : 1 . 5

Intracranial space occupying lesions 16 1.1 2.6 : I

Others 25 1.8 2.3 : 1

2.7:1 - -

1.9:1 87 86.7

2.7 : 1 71 32.2

3.3 : 1 41 30.6

2.2 : 1 6 5.1

5.8:1 - - - -

2.0:i - -

1 . 5 : 1 - -

5 . 0 : 1 - -

6 . 0 : 1 - -

4 . 5 : 1 ~

4 . 0 : 1 ~ - -

gis tered u n d e r this h e a d i n g were m a i n l y anaemia , l e u k a e m i a a n d b l e e d i n g disorders , f o r m i n g a to ta l of 553 cases a n d a c c o u n t i n g for 5.3 pe r cent. of the to ta l year ly admiss ions . ( T a b l e s 13 a n d 14).

T h e a n a e m i a cases cons t i t u t ed 74 per cent. of the g r o u p (410 cases); leukaemia , 6 per cent. a n d h a e m o r r h a g i c d isorders 20 pe r cent.

A b o u t 90 pe r cent. of the cases of a n a e m i a were of the n u t r i t i o n a l dyshae- m o p o i e t i c type a n d th ree- four ths of these were severely anaemic wi th h a e m o g l o b i n levels be low 6 gm. pe r cent. a n d as low as 1.5 to 2 gm. p e r cent. in a l a rge m a j o r i t y of cases. T h e o the r types of

anaemias were m a i n l y of the h a e m o l y t i c

var ie ty a n d in ra re ins tances of the ap las t i c type. Cases of a n a e m i a due to h o o k w o r m in fes t a t ion were discussed u n d e r h e l m i n t h i c in fes ta t ions of the in- testines. Bu t of the 33 cases of l eukaemia . 31 cases were of the acu te va r ie ty a n d there were on ly two cases of ch ron ic mye lo id l eukaemia . Of the 110 cases wi th h a e m o r r h a g i c d isorders , 33 h a d classical, f ami l ia l , sex l i n k e d h a e m o p h i - l ia .

Nervous system diseases. T a b l e s 15 a n d 16 give an analysis of 1384 cases in- c luded u n d e r ne rvous system diseases.

Dise~tses of an i n f l a m m a t o r y n a t u r e were reg i s t e red as encepha l i t i s , t ube rcu- lous men ing i t i s , sept ic me n ing i t i s a n d

344 I N D I & N J O U R I ~ A L O F PF, A ) I A T R I C f i

T a b l e 16. Morbidity and mortality from nervous system disease

groups.

VOL. 29 NO. 177

in different age

D i s e a s e 5-14 y e a r s 1-5 y e a r s 1 m o n t h - - 1 y r . % 3 0 d a y s

M b . M t . M b . M t . M b . M t . M b . M t .

C o n v u l s i v e d i s o r d e r s 151 - - 89 - - 48 - -

V i r a l e n c e p h a l i t i s 81 40 119 37 35 10

T B m e n i n g i t i s 54 11 134 48 41 12

S e p t i c , , 52 9 43 18 38 I0

P o l i o m y e l i t i s 20 2 66 4 31 - -

M e n t a l r e t a r d a t i o n a n d c e r e b r a l p a l s y 43 - - 50 - - 29 - -

H c m i p l e g i a s 52 - - 35 - - 3 - -

M y o p a t h i e s 45 - - 2 - - - - - -

H y d r o c e p h a l u s 4 - - 15 - - 17 - -

P a r a p l e g i a 5 - - 16 . . . .

h f f e c t i v e p o l y n e u r i t i s 5 --:" 2 . . . . .

I n t r a c r a n i a l s p a c e o c c u p y i n g l e s i o n s 13 - - 3 . . . .

O t h e r s 10 - - 12 - - 3 - -

28

4

1

1

M b ~ M o r b i d i t y M t - - M o r t a l i t y

acute poliomyelitis and amounted to 17.0, 16.0, 9.9 and 8.4 per cent. of the series respectively and 51.3 per cent. collectively. (Table 15).

Convulsive seizures and epilepsy accounted for 23.1 per cent. of the nervous system diseases. Encephalitis and tuberculous meningitis predominated in the 1 to 5 year age g'roup, constituting 50.6 and 59.7 per cent. respectively, while septic meningitis was 38.5 per cent. in 5 to 14- year-old pat ients ; 31.9 in those 1 to 5

yea r s o ld , and 28.1 per cent. in those 1 month to 1 year o l d . T h e overa l l mor-

t a l i t y rate of diseases of the nervous sys-

tem was 14.7 per cent. and formed 18.7 per cent. of the total deaths. Th e mortality from encephalitis was 36.7, tuberculous meningitis 32.2, purulent meningitis 30.4 and acute poliomyelitis 5.1 per cent. (Table 16).

Other diseases like hemiplegia, paraplegia, hydrocephalus, infective polyneu- riffs, intra-cranial space occupying lesions, myopathies, mental retardation and cerebral palsy, hereditary ataxias, op- tic atrophy of the obscure type, head in- jury etc. formed 25.5 per cent. of the cases admitted. This figure is, however,

. fa!lacious, as most o f these cases were ad-

MORBIDITY AND MORTALITY IN PUNJAB--MANCHANDA AND SACIIDEV 345

T a b l e 17. Morbidity and mortality from cardio-vascular diseases and urban, rural

and sex distribution.

Tota l Urban Male To ta l Mor ta l i ty Disease admissions % deaths %

Rural Female

Rheumatic heart disease 199 57.4 1.0:4 1:7 13 6.4

Congenital . . . . 137 40.0 2.0:1 2:1 16 11.6

Others 10 2.6 2.5 : 1 1 : 1 I 14.2

T a b l e 18. Morbidity and mortality fromcardio-vascular diseases in different age

groups.

5-14 years 1-5 years 1 m o n t h - - 1 yr. 7-30 days Disease . . . .

Mb. Mt. Mb. Mt. Mb. Mt. Mh. Mt.

R h e u m a t i c hea r t disease 196 13 3 . . . . .

Congeni ta l . . . . 49 5 53 6 32 4 4 1

Others 6 - - 4 1 . . . . . .

Mb--Morbidity Mt--Mortality

mit ted for academic reasons or for complications with acute infection. In the menta l re ta rda t ion group, there were 94 mongols, six gargoyles, two cases of amauro t ie famil iar idiocy and three cases of epiloia.

Diseases o] the cardiovascular system. A total of 346 cases account ing for 3.1 per cent. of the total admissions were seen. Ou t of these 199 cases forming 57.5 per cent. were due to chronic rheumat ic valvular hear t disease. In addition, there were 50 cases of acute rheumatic fever and 41 cases of rheumat i c chorea m e n t i o n e d elsewhere. T h e r e were 137 cases (40 per cent.) of co~genital

hear t disease of which 2.5 per cent. were due to diseases l ike pericarditis and hear t failure of obscure or igin inc lud ing one case of f ibrosarcoma of the hear t (proved at autopsy). T h e morta l i ty in rheumat i c hear t disease cases was 6.4 per cent. T h e r e was only one case of subacute bac- terial endocardi t is (blood cul ture positive) compl ica t ing pa tent duc tus arterio- sus in a chi ld aged six years. (Tables 17 and 18).

Kidney" diseases. T h e r e were 272 cases of various diseases of the k idney cons t i tu t ing 2.4 per cent. of the total admissions. Acute nephri t is , nephro t i c syndrome and pyelonephri t is fo rmed

346 INDIAN JOURNAL OF PEDIATRICS VOL. 29 NO. 177

T a b l e 19 . Morbidity and mortality from kidney diseases and urban, rural and sex distribution.


Rural Female

Acute nephritis 63 23.0 1.8 :I 4.2 : 1 - -

Ncphrotic syndrome 125 45.9 1.0 : 1 3.0 : 1 4 3.2

Pyelonephritis 59 21.6 2.1 : 1 1.9 : l 6 10.9

Others 26 9.5 1.1 : I 1.3 : 1 7 27.0

T a b l e 20 , Morbidity and mortality from kidney diseases in different age groups.

Disease 5-14 years 1-5 years 1 month--1 yr. %30 days

Mb. Mt. Mb. Mr. Mb. Mr. Mb. Mt.

Acute nephritis 45 - - 18 . . . . . .

Nephrotic syndrome 65 3 60 1 . . . . .

Pyelonephritis 36 - - 2,0 3 3 3 - - - -

Others 12 3 8 3 2 - - 3 1

Mb--Morbidity Mt---Mortality

23.0, 45.9 a n d 21.6 pe r cent. respect ively . O t h e r diseases i n c l u d e d u n d e r the head-

ing were r e n a l fa i lure , h a e m o g l o b i n u r i a , h a e m a t u r i a , anur i a , ca lcul i and hydro- nephros is , a ccoun t i ng for on ly 9.5 pe r cent. T h e overa l l m o r t a l i t y of the g r o u p was 6.2 per cent., for n e p h r o t i c s y n d r o m e 3.2, for pye lonephr i t i s , 10.9 a n d for cases of r e n a l f a i lu re f rom all o t h e r causes 27 pe r cent. T h e inc idcnce o,f pye loneph r i - tis appea r s to be lower t h a n expec t ed since mar ly cases p r i m a r i l y suffer ing f rom o the r diseases b u t wi th s u p e r - a d d e d uri- na ry t ract infec t ion , a r e no t i n c l u d e d in the series. (Tab l e s I9 a n d 20).

Poisoning. T h e r e were 176 cases of po i son ing f o r m i n g 1.6 pe r cent . of the to ta l admiss ions , the c o m o n ones b e i n g ke rosene oil , corrosives, s po i son ing , seeds, p lan ts , crackers, m e d i c a m e n t s , o p i u m a n d r a t p i l l po i son ing , etc. T h e h ighes t inc idcnce was in the 1 to 5-year- o ld age g r o u p c o n s t i t u t i n g 73.3 pe r cent. ( T a b l e 21).

Neoplasms. T h e s e c o n s t i t u t e d 0.82 per cent. of the to ta l admiss ions com- p r i s ing on ly 90 cases i n c l u d i n g l y m p h o - sarcoma, H o d g k i n s disease, r e t ino - b las toma, W i l m s tumor , t e r a toma , tier- mo ld , n e u r o b l a s t o m a a n d gang l ioneu -

MORBIDITY" AND MORTALITY IN PUNJAB--MANCHANDA AND SACHDEy 347

T a b l e 21. Morbidity and mortality Fore poisoning and neoplasms and urban, rural

and sex distribution.


Rural Female

Poisoning 176 - - 9.0:1 2.3 : 1 5 2.8

Neoplasms 90 - - 1.4 : I 3.0 : 1 8 9.0

T a b l e 22. Morbidity and mortality frompoisoning and neoplasms in different age

g oups.

Disease 5-14 years 1-5 years 1 month--1 yr. 7-30 days

Mb. Mt. Mb. Mt. Mb. Mt. Mb. Me.

Poisoning 27 - - 129 3 19 2 I - -

'Neoplasms 47 4 30 3 10 - - 3 1

Ml~-Morbidity Mt---Mortality

roma etc. Cases of leukaemias have already been discussed under tile blood diseases. (Table 22).

Miscellaneous group. There were 603 cases ~ o u p e d under this heading forming 5.6 per cent. of the total admissions, comprising :

(1) Endocrinal and metabolic dis- ordccs, for example, hypo-and hyperthy- roidism, simple goitre, hypogonadism, adrenogenital syndrome, Laurence- Moon-Biedl syndrome, diabetes ,melli- tus, obesity, renal acidosis, hypocalcemia and lipo~dystrophica progxessiva.

(2) Skeletal disorders such as achon- droplasia, osteochondrodystrophy, osteo- genesis imperfecta, vertebral deformities including Klippel-Feil deformity, hemi- vertebrae and spina bifida, various types

of craniosynostoses, Albers-Schonberg's disease, Still's disease, arthrogryposis mult iplex congenita etc.

Non-infective dermatosis included cases of skin allergy (urticaria, drug, food and contact allergy), bullous cruptions and icthyosis.

In addition, there were six cases of trichobezoar and three of sclerema neo- natorum.

T h e other diseases included under this heading were behaviour disorders and diseases of a functional nature.

C o m m e n t

Further appraisal of these cases shows that 4100 (37.3 per cent.) children were in the age gr&ap 1 to 5 years; followed

3't8 INDIAN JOURNAL OF_ PgDIATRICS VOL. 29 NO. 177

by 3588 (32.6 per cent.) in the 5 to 14- year-old g roup ; 2978 (27.1 per cent.) in the 1 month to l-year-old g roup ; 273 (3 per cent.) in the l-week to 30-day-old group and only 31 cases during the first week of life. The last figure is fallacious as the newborn infants are still under the direct care of the obsterician in the institution and the pediatrician is called only for serious cases.

T h e spectrum of morbidity at the different age periods broadly reveals that whereas infections are predominant in the age group 5 to 14 years, gastrointestinal disorders take the lead in the age groups 1 to 5 years, 1 month to 1 year and 7 to 30 days. Respiratory diseases and infections follow closely in the age groups 1 to 5 years, I month to 1 year and 7 to 30 days. In the 5 to 14 year- old-age group, infections are followed by nervous system diseases and then respiratory and gastro-intestinal diseases. Figs. 1 and 2 illustrate the total quan- tum of morbidity and mortality in various age groups and graphs 3 to 6 show the breakdown of these figures according to various systems at different age groups.

T h e above analysis is, howe~cr, not infallible and is open to criticism due to the selected nature of admissions. Never- theless, a broad comparison of the pat- tern of morbidity and mortali ty of children in India with that of the advanced countries reveals that a very large per- centage of the child population is wast- ed in the early years f rom causes which have been successfully controlled in the West and elsewhere and that the survi- vor's health is markedly jeopardized from suffering due to one illness or another. T h e Indian child, broadly speaking, is thus unhealthy, poor in physique and much below par as compared to the children of the developed countries.

I:rom the poin t of view of preven- tion, the various diseases grouped above may be broadly classified into preventable and non-preventable diseases.

T h e "preventable" group includes a large number of diseases of an infective nature such as diarrhoeas, dysenteries, tuberculosis, respiratory tract infections, exanthematous fevers, poliomyelitis, hel- minthic infestations, various nutri t ional deficiency states, accidents, etc.

Th e "non-preventable" group is mainly composed of congenital anoma- lies, allergic and various inheri ted metabolic disorders, for example, endocrinal and chromosonml disorders and neoplas- tic diseases. With fur ther rapid advan- ces in pediatrics, some of these conditions may also come to be included in the preventable group.

Whereas improvement in the general socio-economic standards of living of the huge populat ion of India rightly promi- ses an appreciable reduction of the morbidity and mortali ty in children, it is equally essential to train and equip a large number of doctors with basic know- ledge not only of children's diseases but of child health.

It is r e~e t t ab le that pediatrics is still regarded as a speciality like other organ specialities and accordingly the under- ga'aduate and postga'aduate training im- parted to the students is very inadequate. Neither tile Medical Council of India nor the university authorities seem to appreciate the basic fact that pediatrics is in- ternal medicine confined to a particular age group i.e. of the child. T h e importance of this comprehensive discipline is minilnized during the final qualif)dng examinat ion; yet after graduation and a short period of internship, it is the general practit ioner who sees in his private practice 40 to 50 per cent. of children. It is a strange paradox that while, on the

MORBIDITY AND M_OR'FAIATY IN PUNJAB--MANCHANDA 3a.NO S_ACHDEV ~49

1 A#ONTH "~o

Fig. I . - -Morb id i t y at various age groups.

\ +++.,,,+

Fig. 2 . - -Mor ta l i t y at various age groups.

~3

E

+100

IO00 -

~ O -

gt, o-

Tl~O-

~00 ~

frO0"

Ioo

I t o t lhlll't~l

,,+o+.,,-?'~.~I

o = ~ ~ o = ~ ~ ~ - u �9 "~. - - -o o

Fig. 3 - -Morb id i t y and morta l i ty in 5--14 year age group.

9 0 0

l $00-

70o" I

~ ~ I U

I

+ 1 ~ 4110- Z

9.00"

I iiin _~ ~ o

I ~ [1~ ~'~

o ~S ~ ~ --~

~ " ~ ~ " 2 - ; L~ c Z Z ~ 'n v U Z

Fig. 4 . - Morb id i ty and morta l i ty in I - 5 year age group.

350 INDIAN JOURNAL O~ I'~DIATRIC8 VOL. 29 NO. 177

I100"

IlOt.

tO00

lifO'

70O

~00

~OO

r

goo

"N

l iO l l r r l r ' ~

i,i o l Tllil,~l

Fig. 5.--Norbidity and mortality in one month to one year age group.

I10,

I ~

90

l ; o

u G0

fi qO

IO

zoli~l~v,f [, I

m

r~. { t. -41 a'

,d

Fig. 6 . - -Morb id i ty and mortality in 17--30 days age group.

one hand, international bodies like the UNICEF, W H O and our national lead- ers are stressing the importance of child- health and describe children as the "wealth of the nation", the universities and other authorities do practically nothing to improv e the training of doctors in child health. Such an att i tude is very disheartening. We hope that soon pediatrics will be given equal standing with general medic ine at the university level.

Our thanks are due to DR. HARBANS LAL, Assistant Registrar, for helping us in analysing the data.

References

1. CI[AKRAVAR'FY, A., I{ERLITZ, G. AND SURA, A. M.--Morbidity) ill children. Indian J. Chld. Hlth. , 6: 89, 1957.

2. ])ATrA, S. P. AND GUPTA, &--Child health in l~ondicherry. Indian J. Pediat., 2 8 : 16, 1961.

3. MEItTA, J. B.--Morbidity and mortality in children ; handicapped children. Indian J. Chld. Hlth. , 11: 258, 1962

4. PAUL, S. S.--A study of mortality rate i n Kalawati Saran Children's Hospital in Delhi. Indian J. Chld. Hlth. , 8: 365, 1959.

5. ][~DANI, P. M.--Morbidity and mortality. Indian f . Chld. Hlth. , 11: 239, 1962.

6. VVAS, K. J .--Morbidity and mortality in chihtren. Indian J. Chld. t t l th . , 11: 262, 1962.

Documents

Morbidity and mortality in children in Northern India (Punjab)