NO STRUKTUR JURNAL PENJELASAN

1 Judul Merupakan informasi tentang variabel yang diukur oleh

peneliti serta informasi tentang tempat penelitian

ContohJudul
Jurnal 1
HubunganAntaraBeratBadanLahir, Status Gizi Dan Status
ImunisasiDenganKejadian Pneumonia PadaBalita Di Wilayah
KerjaPuskesmasPanikiBawah Kota Manado

Jurnal 2
Impact of Temperature Relative Humidity and Absolute
Humidity on the Incidence of Hospitalizations for Lower
Respiratory Tract Infections Due to Influenza, Rhinovirus,
and Respiratory Syncytial Virus: Results from Community-
Acquired Pneumonia Organization (CAPO) International
Cohort Study

2 Abstrak Abstrak di ibaratkan teaser pada sebuah film, sehingga

tergambar maksud dan tujuan peneliti sehingga orang
tertarik untuk membacanya. Abstrak berfungsi sebagai
cermin untuk mewaklii representatif sebuah jurnal.
Sebuah abstrak menyajikan sekitar 250 kata yang berisi
tentang variabel penelitian, tujuan penelitian, metode
penelitian, hasil penelitian, tempat penelitian dan
kesimpulan.

3 Pendahuluan Bagian ini menjelaskan mengapa masalah perlu diangkat

menjadi sebuah penelitian. Peneliti menguraikan ide
penelitian dari data umum menjadi data khusus. Serta
menguatkan ide tersebut dengan pendapat para ahli yang
dalam penulisannya disebut sitasi sebagai tanda
penghormatan terhadap penulis literatur pustaka. Disini
juga diuraikan jenis penelitian bisa berupa deskriptif,
analitik, eksperimental dan atau observasional

4 Metode Penelitian Bagian ini menguraikan tentang metode yang digunakan

peneliti dapat berupa metode cross sctional, quasi
eksperiment, dll . Jumlah sampel yang digunakan

5 Hasil Bagian ini menguraikan karakteristik sampel variabel

pnelitianmisal bila individu yang diteliti adalah perawat
berdasarkan pilihan usia, jenis kelamin, tingkat
pendidikan,dll. Digambarkan berupa tabel atau diagram.
Juga menjelaskan tentang analisa uji menggunakan sistem
1
 komputerisasi.

6 Diskusi Bagian ini menguraikan tentang hasil penelitian yang telah

dilakukan serta hasil penelitian lain yang mendukung
penelitian ini. Juga diperkuat oleh kutipan para pakar untuk
semakin menajamkan hasil penelitian.

7. Daftarpustaka Semua informasi (KUTIPAN) yang di dapat peneliti harus

ditulis sesuai abjad pada bagian ini. Hal tersebut berguna
untukpembaca yang ingin merujuk literature asli.
Perhatikan bahwa referensi yang dikuti benar-benar
disebutkan pada jurnal yang kita buat.

2
Jurnal 1
HUBUNGAN ANTARA BERAT BADAN LAHIR, STATUS GIZI DAN STATUS IMUNISASI DENGAN
KEJADIAN PNEUMONIA PADA BALITA DI WILAYAH KERJA PUSKESMAS PANIKI BAWAH
KOTA MANADO
Muhammad Kahfi*, Grace D. Kandou*, A.J.M Rattu*

*Fakultas Kesehatan Masyarakat Universitas Sam Ratulangi

ABSTRAK

Pneumonia adalah suatu penyakit saluran napas bawah (lower respiratory tract) akut yang
disebabkan oleh infeksi disertai demam. Menurut World Health Organitation (WHO), pada
tahun 2015 terjadi kasus kematian pada anak dibawah usia lima tahun akibat pneumonia
sebanyak 922.000 (15%). Tujuan penelitian ini adalah untuk mengetahui hubungan antara
berat badan lahir, status gizi dan status imunisasi dengan kejadian pneumonia pada balita
di wilayah kerja Puskesmas Paniki Bawah Kota Manado. Penelitian ini menggunakan
metode observasional analitik dengan pendekatan cross sectional. Populasi dalam penelitian
ini adalah anak berumur 12-59 bulan yang berada di wilayah kerja Puskesmas Paniki Bawah
Kota Manado. Pada Januari 2017, diperoleh data dari Puskesmas Paniki Bawah Kota
Manado yaitu sebanyak 2506 balita yang datang untuk berobat dan total sampel pada
penelitian ini yaitu sebanyak 96 balita. Analisis bivariat dilakukan dengan menggunakan uji
Chi Square (α=0, 05). Hasil penelitian menunjukkan bahwa sebanyak 19 (19,8%) balita
menderita pneumonia dan sebanyak 77 (80,2%) balita bukan menderita pneumonia. Hasil
analisa statistik menunjukkan bahwa terdapat hubungan yang bermakna antara status gizi
(p=0,001) dan status imunisasi (p=0,004) dengan kejadian pneumonia pada balita
sedangkan berat badan lahir (p=0,256) tidak terdapat hubungan yang bermakna dengan
kejadian pneumonia pada balita.

Kata Kunci: Pneumonia, Balita, Berat badan lahir, Status Gizi, Status Imunisasi.

ABSTRACT

Pneumonia is a disease of the lower respiratory tract (LRT) caused by acute infection
accompanied by fever. According to the World Health Organitation (WHO), by the year 2015
case of death in children under five years of age due to pneumonia as much 922,000 (15%).
The purpose of this research is to know the relation between birth weight, nutritional status
and the status of immunization with pneumonia on toddlers in the region Paniki Bawah
Manado city Clinics. This research use analytic observational method with cross sectional
approach. The population in this research is children from 12-59 month in the work of the
Paniki Bawah Manado city Clinics. In January 2017, obtained data from Clinics Paniki Bawah
Manado city that is as much as the 2506 toddlers who came for medical treatment and the
total sample in this research that is as much as 96 toddlers. Bivariat analysis performed
3
using Chi Square test (α = 0, 05). The results showed that as many as 19 (19.8%) toddlers
suffering from pneumonia and as much as 77 (80.2%) toddler is not suffering from
pneumonia. The results of the analysis of the statistics shows that there is a meaningful
relationship between the nutritional status (p = 0.001) and immunization status (p = 0,004)
with the incidence of pneumonia on toddlers while birth weight (p = 0,256) there is no
meaningful relationship with the incidence of pneumonia in toddlers. There are two
independent variables that are associated with the incidence of pneumonia in babies in the
region Paniki Bawah Manado city Clinics, namely nutritional status and immunization status
while variables unrelated is birth weight.

Key Words: Pneumonia, Toddler, Birth Weight, Nutritional Status, Immunization Status

4
PENDAHULUAN
Pneumonia merupakan akibat infeksi, menghirup cairan atau bahan kimia. Populasi yang
rentan terserang pneumonia yaitu anak - anak usia kurang dari 2 tahun, usia lanjut lebih dari
65 tahun dan orang yang memiliki masalah kesehatan malnutrisi dan gangguan imunologi
(Profil Kesehatan Indonesia, 2014).
Pneumonia terus menjadi masalah kesehatan yang terbesar di seluruh dunia pada
anak-anak di bawah usia lima tahun. Menurut World Health Organitation (WHO) sekitar
922.000 (15%) kematian anak di bawah 5 tahun akibat pneumonia. Infeksi saluran nafas
bawah termasuk pneumonia dan influensa masih menjadi masalah kesehatan di negara
berkembang maupun negara maju (WHO, 2015).
Menurut hasil Riset Kesehatan Dasar (RISKESDAS) tahun 2013 menunjukkan period
prevalence pneumonia yang tinggi terjadi pada kelompok umur 1 - 4 tahun, kemudian mulai
meningkat pada umur 45 - 54 tahun dan terus meninggi pada kelompok umur berikutnya. Di
Indonesia pada tahun 2014 penderita pneumonia 0 - 4 tahun sebanyak
657.490 sedangkan jumlah kematian balita akibat pneumonia umur 0 - 4 tahun sebanyak 496
balita. Angka kematian akibat pneumonia atau Case Fatality Rate (CFR) pneumonia pada
balita sebesar 0,08% sedangkan pada kelompok bayi angka kematian yaitu sebesar 0,11%
(Profil Kesehatan Indonesia, 2014).
Berdasarkan data Dinas Kesehatan Provinsi Sulawesi Utara tahun 2014 sampai tahun
2016 menunjukkan realisasi penemuan penderita pneumonia pada usia 0-4 tahun. Tahun
2014 jumlah penderita pneumonia sebanyak 673 kasus. Pada tahun 2015 terjadi peningkatan
penderita pneumonia yaitu sebanyak 812 kasus dan pada tahun 2016 penderita pneumonia
sebanyak 843 kasus. Dalam kurun waktu kurang lebih 2 tahun kematian balita karena
pneumonia yaitu 3 kasus (Dinkes Prov. Sulut, 2016).
Berdasarkan data yang diperoleh dari Dinas Kesehatan Kota Manado penderita
pneumonia pada balita pada tahun 2012 sebanyak 180 kasus dan pada tahun 2015 terjadi
peningkatan yang signifikan yaitu 499 kasus. Kasus yang tinggi dari 12 Puskesmas yang ada
di Kota Manado terdapat pada Puskesmas Paniki Bawah dan Puskesmas Tuminting. (Dinkes
Kota Manado, 2016).
Menurut data yang diperoleh dari Manajemen Terpadu Balita Sakit (MTBS)
Puskesmas Paniki Bawah pada tahun 2013 sampai dengan tahun 2016 yaitu pada tahun
2013 penderita pneumonia balita berjumlah 23 kasus, pada tahun 2014 terjadi peningkatan

5
penderita pneumonia balita yaitu berjumlah 60 kasus, tahun 2015 jumlah penderita
pneumonia pada balita menigkat yaitu 92 kasus, sedangkan pada tahun 2016 penderita
pneumonia balita terjadi penurunan kasus yaitu berjumlah 75 kasus (Puskesmas Paniki
Bawah, 2016).
Secara umum terdapat 3 (tiga) faktor yang berhubungan dengan kejadian
pneumonia terbagi atas faktor lingkungan, faktor individu anak serta faktor perilaku.
Beberapa Faktor individu anak yang menyebabkan terjadinya pneumonia pada balita yaitu
berat badan lahir, status gizi dan status imunisasi. Berdasarkan data di atas maka peneliti
tertarik untuk melakukan penelitian tentang kejadian pneumonia pada balita yang diduga
dipengaruhi oleh beberapa faktor yang terkait dengan berat badan lahir, status gizi dan
status imunisasi di Puskesmas Paniki Bawah.

METODE PENELITIAN
Jenis Penelitian yang digunakan merupakan penelitian survei analitik dengan
menggunakan rancangan penelitian cross sectional study atau studi potong lintang.
Penelitian dilaksanakan pada bulan Maret – Desember 2017 di Puskesmas Paniki Bawah Kota
Manado. Populasi pada penelitian ini adalah semua ibu yang mempunyai Balita dengan usia
12-59 bulan yang datang berobat ke unit Manajemen Terpadu Balita Sakit (MTBS) di wilayah
kerja Puskesmas Paniki Bawah pada tahun 2017 yaitu 2506 balita. Jumlah sampel yang akan
diteliti yaitu 96 orang balita. Teknik pengambilan sampel menggunakan accidental sampling.
Teknik pengambilan ini dilakukan pada saat kasus atau responden yang ada atau
tersedia di ruang MTBS Puskesmas Paniki Bawah Kota Manado. Dalam penelitian ini, variable
terikat pneumonia pada balita sedangkan variable bebas yaitu berat badan lahir, status gizi
dan status imunisasi. Instrumen penelitian dalam penelitian sebagai alat ukur. Data primer
dilakukan secara langsung dengan responden yang datang di Puskesmas sedangkan data
sekunder diperoleh dari data Manajemen Terpadu Balita Sakit (MTBS) di Puskesmas Paniki
Bawah. ini yaitu menggunakan alat pengukur badan manual, alat pengukur tinggi badan
(mikrotoa) dan kuesioner

6
HASIL DAN PEMBAHASAN
Karakteristik Balita

Tabel 1. Karakteristik Balita

Karakteristik n (96) %
balita
Jenis kelamin
Laki-laki 45 46,9
Perempuan 51 53,1
Umur (Bulan)
12-23 54 56,3
24-35 14 14,6
36-47 11 11,5
48-59 17 17,7

Hasil pengumpulan data mengenai karakteristik balita di wilayah kerja Puskesmas Paniki
Bawah Kota Manado yang ditampilkan pada tabel 1 didapatkan bahwa terdapat 96 orang
balita dengan dominasi jenis kelamin perempuan yaitu sebanyak 51 balita (53,1%). Untuk
kelompok umur yang paling banyak yaitu 12- 23 bulan sebanyak 54 balita (56,3%)
sedangkan yang paling sedikit pada kelompok umur 36-47 bulan sebanyak 11
balita (11,5%).

Analisis Univariat
Tabel 2. Distibusi frekuensi variabel penelitian

Variabel n (96) %
Terdiagnosis
Pneumonia 19 19,8
Bukan 77 80,2
pneumonia
Berat Badan Lahir 5 5,2
Rendah 91 94,8
Normal
Status Gizi 26 27,1
Tidak normal 70 72,9
Normal
38 39,6
Status Imunisasi
Tidak lengkap 58 60,4
Lengkap

Berdasarkan hasil penelitian terhadap 96 balita yang berada di wilayah kerja Puskesmas
Paniki Bawah Kota Manado didapatkan hasil angka pneumonia yaitu sebesar (19,8%)
7
 menderita pneumonia dan (80,2%) bukan penderita pneumonia.
Hasil penelitian menunjukkan bahwa sebanyak 5 orang balita (5,2%) berberat badan lahir
rendah sedangkan yang berberat badan lahir normal sebanyak 91orang balita (94,8%).
Semakin rendah berat badan lahir bayi, ukuran alveoli cenderung lebih kecil dan pembuluh
darah yang mengelilingi stroma seluler matur cenderung lebih sedikit sedangkan pada bayi
yang memiliki berat badan lebih besar, maka ukuran alveoli yang dimilkinya akan lebih besar
dan lebih banyak pembuluh darah pada stroma selulernya (Polack, 2009).

Hasil penelitian menunjukkan bahwa sebanyak 26 balita (27, 1%) memiliki status gizi
tidak normal sedangkan sebanyak 70 balita (72, 9%) memiliki status gizi normal. Keadaan
gizi yang buruk muncul sebagai faktor risiko yang penting untuk terjadinya pneumonia.
Beberapa penelitian telah membuktikan tentang adanya hubungan antara gizi buruk dan
infeksi paru, sehingga anak- anak yang bergizi buruk sering mendapat pneumonia. Penyakit
infeksi sendiri akan menyebabkan balita tidak mempunyai nafsu makan dan mengakibatkan
kekurangan gizi (Maryunani, 2010).
Hasil penelitian menunjukkan bahwa sebanyak 38 orang balita (39, 6%) memiliki status
imunisasi tidak lengkap sedangkan sebanyak 58 orang balita (60, 4%) memiliki status
imunisasi lengkap. Imunisasi dengan vaksin pneumokokus yang mengandung polisakarida
kapsular dari 23 serotipe yang paling sering memberikan perlindungan sebesar 60- 70%.
Imunitas berlangsung jangka panjang (Mandal, dkk, 2006).

Analisis Bivariat
Hubungan antara berat badan lahir,
status gizi dan status imunisasi dengan
kejadian pneumonia pada balita

8
Tabel 3. Analisis Hubungan antara berat badan lahir, status gizi dan status imunisasi dengan
kejadian pneumonia pada balita di wilayah kerja Puskesmas Paniki Bawah Kota Manado

Diagnosis medis
Variabel n p-
No Pneumonia % Bukan % %
Penelitian pneumoni (96) value
a
1 Berat
badan lahir
• Rendah 2 40,0 3 60,0 5 100 0,256
• Normal 17 18,7 74 81,3 91 100
2 Status gizi
• Tidak 11 42,3 15 57,7 26 100 0,001
norma
l 8 11,4 62 88,6 70 100
3 • Normal

Status 0,004
imunisasi 13 34,2 25 65,8 38 100
• Tidak
lengkap 6 10,3 52 89,7 58 100
• Lengkap

9
 Hasil analisis hubungan antara berat badan lahir dengan kejadian pneumonia pada balita yaitu sebanyak 2 dari 5
(40,0%) balita dengan berat badan lahir rendah dan balita mengalami pneumonia sedangkan sebanyak 74 dari 91 (81,3%)
balita dengan berat badan lahir normal
dan balita bukan mengalami pneumonia. Berdasarkan hasil uji chi square diperoleh nilai p=0,256 (p-value > 0,05)
dikarenakan ditemukannya cell yang mempunyai frekuensi harapan dibawah 5 yaitu 2 cell (50%) sehingga menggunakan
rumus fisher exact test dan dapat disimpulkan bahwa tidak ada hubungan yang bermakna antara berat badan lahir
dengan pneumonia pada balita di wilayah kerja Puskemas Paniki Bawah Kota Manado.
Penelitian ini sejalan dengan penelitian yang dilakukan Regina dkk (2013) di wilayah kerja Puskesmas Miroto
Semarang, menunjukkan tidak adanya hubungan antara berat badan lahir rendah dengan kejadian pneumonia pada balita
(p=0,191).
Berbeda dengan penelitian yang dilakukan oleh (Tambunan dkk, 2013) di wilayah kerja Kedungmundu Kota
Semarang menunjukkan bahwa terdapat hubungan yang bermakna antara berat badan lahir dengan kejadian pneumonia
pada balita p-0,061. Hasil observasi dilapangan sedikitnya balita yang berberat badan lahir normal dikarenakan ibu balita
saat mengandung kurang mengonsumsi makanan- makanan yang bergizi sehingga mempengaruhi berat badan anaknya
sewaktu dilahirkan.
Hasil analisis hubungan antara status gizi dengan kejadian pneumonia pada balita yaitu sebanyak 11 dari 26
(42,3%) balita dengan status gizi tdak normal dan balita mengalami pneumonia sedangkan sebanyak 62 dari 70 (88,6%)
balita mengalami status gizi normal dan balita bukan mengalami pneumonia.
Berdasarkan hasil uji chi square diperoleh nilai p=0,001 (p-value < 0, 05) sehingga disimpulkan bahwa ada
hubungan yang bermakna antara status gizi dengan pneumonia pada balita di wilayah kerja Puskemas Paniki Bawah Kota
Manado.
Penelitian ini sejalan dengan penelitian yang dilakukan Efni dkk (2016) di Kelurahan Airtawar Padang
menunjukkan adanya hubungan yang bermakna antara status gizi dengan kejadian pneumonia pada balita (p=0,022).
Penelitian yang dilakukan Hartati dkk (2012) didapatkan hasil nilai probabilitas 0,000 yang menyatakan ada hubungan
bermakna antara status gizi dengan kejadian pneumonia dengan nilai OR 6, 52 (CI 95% 2, 28-18, 63) maka
dapat dikatakan responden yang berstatus gizi kurang memiliki risiko 6, 52 kali menderita pneumonia dibandingkan
dengan responden yang berstatus gizi baik.
Berdasarkan hasil observasi dilapangan ibu balita setelah melahirkan mereka memberikan asupan makanan
bergizi yang baik sehingga tingginya balita dengan status gizi normal namun beberapa balita masih memiliki status gizi
yang tidak normal dikarenakan sebagian ibu balita masih kurang pengetahuannya mengenai kecukupan gizi kepada
anaknya.

Hasil penelitian ini sesuai dengan teori yang menyatakan adanya hubungan antara gizi buruk dan infeksi paru.
Keadaan gizi buruk muncul sebagai faktor penyebab yang penting untuk terjadinya pneumonia sehingga anak-anak yang
bergizi buruk sering mendapatkan pneumonia. Balita dengan gizi kurang akan lebih mudah terserang pneumonia
dibandingkan balita dengan gizi normal karena faktor daya tahan tubuh yang kurang.
Hasil analisis hubungan antara status imunisasi dengan kejadian pneumonia pada balita yaitu sebanyak 13 dari 38 (40,
0%) balita tidak mendapatkan imunisasi secara lengkap dan balita mengalami pneumonia sedangkan sebanyak 52 dari 58
© ULJRI 2017 Vol 1, (3) 27–35 | 27
(89,7%) balita yang sudah mendapatkan imunisasi lengkap dan balita bukan mengalami pneumonia. Berdasarkan
hasil uji chi square diperoleh nilai p=0,004 (p-value < 0, 05) sehingga disimpulkan bahwa ada hubungan yang bermakna
antara status imunisasi dengan pneumonia pada balita di wilayah kerja Puskemas Paniki Bawah Kota Manado
Hasil yang sama juga diperoleh dari penelitian yang dilakukan Oktaviani dan Maesaroh (2017) di Puskesmas Teluknaga
Kabupaten Tangerang menunjukkan adanya hubungan antara status imunisasi dengan kejadian pneumonia pada balita
dengan nilai (p=0,034).
Berdasarkan hasil observasi yang dilakukan dilapangan bahwa hampir setengah jumlah responden yang diteliti
memiliki status imunisasi tidak lengkap hal ini dikarenakan sebagian ibu balita sibuk dengan pekerjaannya dirumah
ataupun di kantor dan kurangnya pengetahuan sehingga banyaknya balita tidak mendapatkan imunisasi secara lengkap.
Hasil penelitian ini didukung oleh teori yang menyatakan bahwa bayi dan balita yang mempunyai status imunisasi
lengkap bila menderita pneumonia dapat diharapkan perkembangan penyakitnya tidak akan menjadi lebih berat.
Cara yang terbukti paling efektif saat ini adalah dengan pemberian imunisasi campak dan pertusis (DPT) dengan imunisasi
campak yang efektif sekitar 11% kematian pneumonia balita dapat dicegah dan dengan imunisasi pertusis (DPT) 6%
kematian pneumonia dapat dicegah (Maryunani, 2010).

© ULJRI 2017 Vol 1, (3) 27–35 | 28

KESIMPULAN
1. Tidak terdapat hubungan antara berat badan lahir dengan kejadian pneumonia pada balita di wilayah kerja
Puskesmas Paniki Bawah Kota Manado.

2. Terdapat hubungan antara status gizi dengan kejadian pneumonia pada balita di wilayah kerja Puskesmas Paniki
Bawah Kota Manado.
3. Terdapat hubungan antara status imunisasi dengan kejadian pneumonia pada balita di wilayah kerja Puskesmas Paniki
Bawah Kota Manado.
4.
SARAN
1. Bagi Puskesmas
a. Melakukan upaya penanggulangan penyakit pneumonia berdasarkan faktor risiko yang ada yaitu dengan
meningkatkan kegiatan edukasi kepada masyarakat khususnya bagi orangtua yang memiliki balita mengenai
pemenuhan gizi yang optimal guna meningkatkan status gizi balita dan memberikan informasi kepada masyarakat
tentang pentingnya pemberian imunisasi sesuai dengan jadwal imunisasi.
b. Memberikan penyuluhan atau sosialisasi mengenai imunisasi dan gizi kepada masyarakat untuk meningkatkan
pengetahuan dan kaitannya dengan pencegahan pneumonia.

2. Bagi masyarakat
a. Pemberian imunisasi pada bayi dengan membawa bayi untuk diimunisasi sesuai dengan jadwal pemberian
imunisasi.
b. Diharapkan untuk meningkatkan upaya peningkatan status gizi balita dengan pemberian variasi makanan pada
anak balita.

© ULJRI 2017 Vol 1, (3) 27–35 | 29

DAFTAR PUSTAKA
Dinas Kesehatan Provinsi Sulawesi Utara 2015. Profil Kesehatan Provinsi Sulawesi Utara. Sulawesi Utara

Efni, Y, Machmud, R, Pertiwi, D. 2016. Faktor risiko yang berhubungan dengan kejadian pneumonia pada balita di
Kelurahan Airtawar Barat. Padang. FK Unand (online), Vol. 5, No. 2. (http://jurnal.fk.unand.ac.id/index.
php/jka/article/view/523 diakses 22 Agustus 2017)
Hartati, S, Nurhaeni, N, Gayatri, D. 2012. Faktor risiko terjadinya pneumonia pada anak balita. Jakarta. (Online), Jurnal
Keperawatan Indonesia, Vol. 15, No.1 hal. 13-20
(http://jki.ui.ac.id/index.php/jki/ar ticle/view/42 diakses 27 Juni 2017)
Kemenkes RI. 2013. Profil Kesehatan Indonesia Tahun 2014. Jakarta

Kemenkes RI. 2013. Riset Kesehatan Dasar (RISKESDAS), (Online), (www.depkes.go.id/resources/dow

nload/general/Hasil%20Riskesdas

%202013.pdf. diakses 10 Agustus 2016).

Mandal, B.K., Wilkins, E.G.L., Dunbar, E.M., Mayon, R.T. dan White. 2006. Penyakit Infeksi. Jakarta: Erlangga
Maryunani, A., 2010. Ilmu Kesehatan Anak dalam Kebidanan. Jakarta: Trans Info Media

Oktaviani, I, dan Maesaroh, S. 2017. Faktor-faktor yang berhubungan dengan kejadian pneumonia pada balita di
Puskesmas Kecamatan Teluknaga. Tangerang.

Puskesmas Paniki Bawah. 2016. Laporan Bulanan Manajemen Terpadu Balita Sakit (MTBS). Manado

Polack, Fernando. 2009. Pemberian Asi Mengurangi Risiko Pneumonia Pada Bayi Perempuan. (The Pediatric Infectious
Disease Journal haros.co.id/ news-a- media/53-beritake diakses 15

Oktober 2017).

© ULJRI 2017 Vol 1, (3) 27–35 | 30

Jurnal 2

University of Louisville
Journal of Respiratory Infections

ORIGINAL RESEARCH

Impact of Temperature Relative Humidity and Absolute Humidity on the

Incidence of Hospitalizations for Lower Respiratory Tract Infections Due
to Influenza, Rhinovirus, and Respiratory Syncytial Virus: Results from
Community-Acquired Pneumonia Organization (CAPO) International Co-
hort Study

Timothy L. Wiemken,† William A. Mattingly, Stephen P. Furmanek, Brian E. Guinn, Connor L. English, Ruth M. Carrico,
Paula Peyrani, Julio A. Ramirez

Abstract

Background: Transmissibility of several etiologies of lower respiratory tract outbreaks and facilitate the
infections (LRTI) may vary based on outdoor climate factors. The objective of development of transmission
this study was to evaluate the impact of outdoor temperature, relative humidity, prevention interventions.
and absolute humidity on the incidence of hospitalizations for lower respiratory
tract infections due to influenza, rhinovirus, and respiratory syncytial virus
(RSV).
Methods: This was a secondary analysis of an ancillary study of the
Community Acquired Pneu- monia Organization (CAPO) database.
Respiratory viruses were detected using the Luminex xTAG respiratory viral
panel. Climate factors were obtained from the National Weather Service.
Adjusted Poisson regression models with robust error variance were used to
model the incidence of hospitalization with a LRTI due to: 1) influenza, 2)
rhinovirus, and 3) RSV (A and/or B), sepa- rately.
Results: A total of 467 hospitalized patients with LRTI were included in the
study; 135 (29%) with influenza, 41 (9%) with rhinovirus, and 27 (6%) with
RSV (20 RSV A, 7 RSV B). The aver- age, minimum, and maximum absolute
humidity and temperature variables were associated with hospitalization due to
influenza LRTI, while the relative humidity variables were not. None of the
climate variables were associated with hospitalization due to rhinovirus or
RSV.
Conclusions: This study suggests that outdoor absolute humidity and
temperature are asso- ciated with hospitalizations due to influenza LRTIs, but
not with LRTIs due to rhinovirus or RSV. Understanding factors contributing to
the transmission of respiratory viruses may assist in the pre- diction of future
© ULJRI 2017 Vol 1, (3) 27–35 | 31

DOI: 10.18297/jri/vol1/iss3/7/
Received Date: February 16, 2017
Accepted Date: April 6, 2017 Website: https://www.louisville.edu/jri Affiliations:
Department of Medicine, Division of Infectious
1Introduction
Lower respiratory tract infections are the third leading
cause of death worldwide 1. Data suggest that influenza
and other respi- ratory viruses are major causes of many
of these infections 2,3.
† Correspondence To: Timothy Wiemken, PhD MPH CIC
Assistant Professor of Medicine
Director, Healthcare Epidemiology and Data Science Program
University of Louisville Division of Infectious Diseases
501 E. Broadway Suite 120; Louisville, KY 40202
Office Phone: 502-852-4627; Fax: 502-852-1147
Email: tim.wiemken@louisville.edu
Diseases, University of Louisville, Louisville, KY:
(TLW, WAM, SPF, BEG, CLE, RC, PP, JAR)
Several of these pathogens are transmitted from person to
person or from the environment to person, but a clear
understanding of the transmission dynamics of influenza
and other respiratory viruses is still evolving. Due to this,
predicting transmission and epidemics of these viruses is
challenging 4. Climate factors such as temperature,
relative humidity and absolute humidity have been shown
to impact the transmission of respiratory viruses. How-
ever, the influence of each of these factors is still
controversial. Some studies suggest that low humidity
increases viral stability and transmission of influenza 5,6
and respiratory syncytial virus (RSV) 7. Lowen and
colleagues have also documented varied
© ULJRI 2017 Vol 1, (3) 27–35 | 32
transmission efficiencies of influenza viruses at different approximately 30◦F, and average precipitation of 3-4 inches per
temper- atures and relative humidities 8. Conversely, month during the same season.
other studies sug- gest that high humidity may increase
the stability of rhinovirus and adenovirus, favoring Inclusion Criteria
transmission 9. Most of the data re- lated to climate
factors and transmission dynamics of respiratory viruses Consecutive adult patients with the diagnosis of a lower respira-
has been generated from basic science research, ecologi- tory tract infection were approached by a study coordinator for
cal studies, and passive disease surveillance (e.g. viral inclusion in the study. Upon signing of the consent form, the pa-
specimens obtained for clinical practice). tient was enrolled and prospectively followed. Over 95% of the
The Community-Acquired Pneumonia Organization residents of Louisville, KY sought care in these nine hospitals un-
(CAPO) co- hort study is a multicenter, international der study during the third year of the study (Kentucky Hospital
study of adult hospi- talized patients with lower Association, unpublished data), therefore only patients from the
respiratory tract infections (LRTIs), which began in third year (2012/2013 influenza season) were included in the
2001. The database for the CAPO study con- tains
information on over 15,000 patients with CAP from over
40 countries. As part of this ancillary study, consecutive
hospi- talized patients with LRTIs from all nine adult
acute care hospi- tals in Louisville, KY during three
consecutive influenza seasons were enrolled. Each of
these patients underwent active surveil- lance for 12
respiratory viruses upon admission. Combining this
dataset with data from the National Weather Service
allowed us the unique opportunity to evaluate the role of
climate factors at the patient level using active
respiratory virus surveillance.
The objective of this study was to evaluate the impact of
outdoor temperature, relative humidity, and absolute
humidity on the in- cidence of hospitalizations for lower
respiratory tract infections due to influenza, rhinovirus,
and RSV.

2Methods
Study Design
This was a secondary analysis of the CAPO database. As
men- tioned previously, this ancillary study of CAPO was
a 3-year, prospective study, enrolling consecutive adult
hospitalized pa- tients with lower respiratory tract
infections (LRTIs) due to in- fluenza during three
consecutive influenza seasons. Consecu- tive adult
hospitalized patients with a diagnosis of LRTI were
evaluated prospectively from 4 adult hospitals in
Louisville, Ken- tucky during the influenza season
2010/2011, from 8 hospitals during the 2011/2012
season, and in all 9 adult care hospitals in Louisville,
Kentucky, during the influenza season 2012/2013. After
informed consent was obtained, a nasopharyngeal swab
was obtained from each patient for respiratory virus
detection. The normal climate of Louisville is classified
as a warm, humid, and temperate, with average
temperatures during the influenza season of
© ULJRI 2017 Vol 1, (3) 27–35 | 33
present analysis. Influenza LRTI was defined if the patient had a Luminex
xTAG res- piratory viral panel positive for any influenza
Exclusion Criteria virus via nasopha- ryngeal swab.
Patients with more than one respiratory virus Respiratory syncytial virus LRTI was defined if the
identified from the nasopharyngeal swab were patient had a Luminex xTAG respiratory viral panel
excluded from the analysis. positive for any respiratory syncytial virus via
nasopharyngeal swab.
Human Subjects Protection
Rhinovirus LRTI was defined if the patient had a
Institutional Review Board approval was Luminex xTAG respiratory viral panel positive for
obtained at all partici- pating CAPO institutions rhinovirus via nasopharyngeal swab.
prior to data collection.
Date of Acquisition of LRTI: To calculate the incidence
Study Definitions of each virus by week, the following formula was used:
Lower respiratory tract infection (LRTI) was ([date of admis- sion to the hospital] − ([number of days
with respiratory symp- toms prior to hospitalization]
defined as a one sign of acute infection (e.g.
+1)). This formula allowed us to approximate the date of
subjective/objective fever and/or chills) and 2
acquisition of the etiology of LRTI.
new respiratory symptoms (e.g. cough, shortness
of breath, change ins sputum production).
LRTI was further stratified as community-
acquired pneumonia (CAP), acute exacerbation
of chronic obstructive pulmonary dis- ease (AE-
COPD), or acute bronchitis (AB).
Community-Acquired Pneumonia (CAP) was
defined as the pres- ence of a new pulmonary
infiltrate on chest radiograph at the time of
hospitalization that was associated with at least
one of the following three criteria:
1. New or increased cough

2. An abnormal temperature ( < 35.6◦C

or > 37◦C) 3.Leukocytosis, leukopenia, or

left shift

Acute Exacerbation of Chronic Obstructive

Pulmonary Disease (AE-COPD) was defined as
the lack of pulmonary infiltrate on chest
radiograph at the time of hospitalization that
was associated with at least one of the above
three criteria PLUS a history of COPD.
Acute Bronchitis (AB) was defined as the lack
of pulmonary infil- trate on chest radiograph at
the time of hospitalization that was associated
with at least one of the above three criteria,
without a history of COPD.
© ULJRI 2017 Vol 1, (3) 27–35 | 34
Table 1 Baseline Patient Characteristics and Climate Data Of Those With And Without Influenza Lower Respiratory Tract Infections

Variable Influenza No Influenza P-Value

n=135 n=332
Age, Median (IQR) 64 (19.5) 63 (20.2) 0.254
Male Gender, n (%) 79 (59) 186 (56) 0.680
COPD, n (%) 66 (49) 194 (58) 0.065
Diabetes, n (%) 48 (36) 123 (37) 0.832
Obese (BMI ≥30kg/m2 ), n (%) 53 (39) 149 (45) 0.259
Risk Factors for Healthcare-Associated Pneumonia (HCAP), n (%) 38 (28) 126 (38) 0.054
Congestive Heart Failure, n (%) 27 (20) 102 (31) 0.022

Liver Disease, n (%) 6 (4) 21 (6) 0.517

Cancer, n (%) 16 (12) 29 (9) 0.303

Renal Disease, n (%) 25 (19) 64 (19) 0.897

Days with Respiratory Symptoms Prior to Hospitalization, Median (IQR) 3 (4) 4 (5) 0.209

Average Absolute Humidity the Day Before Symptom Onset, Median (IQR) 4.1 (1.6) 4.3 (1.8) 0.010

Average Relative Humidity the Day Before Symptom Onset, Median (IQR) 70.9 (9.1) 70.9 (9.2) 0.367

Average Temperature the Day Before Symptom Onset, Median (IQR) 3.3 (4.5) 3.8 (3.8) 0.003

Table 2 Baseline Patient Characteristics and Climate Data Of Those With And Without Rhinovirus Lower Respiratory Tract Infections

Variable Rhinovirus No Rhinovirus P-Value

n=41 n=426
Age, Median (IQR) 64 (22) 63 (20.8) 0.822
Male Gender, n (%) 25 (61) 240 (56) 0.623
COPD, n (%) 23 (56) 237 (56) 1.000
Diabetes, n (%) 11 (27) 160 (38) 0.234
Obese (BMI ≥30kg/m2 ), n (%) 16 (39) 186 (44) 0.622
Risk Factors for Healthcare-Associated Pneumonia (HCAP), n (%) 11 (27) 153 (36) 0.305
Congestive Heart Failure, n (%) 7 (17) 122 (29) 0.143

Liver Disease, n (%) 3 (7) 24 (6) 0.722

Cancer, n (%) 8 (20) 37 (9) 0.045

Renal Disease, n (%) 6 (15) 83 (19) 0.537

Days with Respiratory Symptoms Prior to Hospitalization, Median (IQR) 4 (5) 4 (5) 0.784

Average Absolute Humidity the Day Before Symptom Onset, Median (IQR) 4.3 (1.4) 4.3 (1.8) 0.680

Average Relative Humidity the Day Before Symptom Onset, Median (IQR) 69 (9.1) 70.9 (9.3) 0.970

Average Temperature the Day Before Symptom Onset, Median (IQR) 3.8 (3.8) 3.8 (4.2) 0.612

Study Variables
Predictor Variable - The primary predictor variables for
the present study were as follows: 1) average absolute
humidity per week, 2) minimum absolute humidity per
week, 3) maximum ab- solute humidity per week, 4)
average relative humidity per week,
5) minimum relative humidity per week, 6) maximum
relative humidity per week, 7) average temperature
(degrees Celsius) per week, 8) minimum temperature
(degrees Celsius) per week, and
9) maximum temperature (degrees Celsius) per week.
Data were gathered from the national weather service, and the
absolute hu- midity in grams/meters3 was calculated with the
following for-
mula (T =temperature in degrees Celsius, rh= percent relative
humidity):
(6.112 × e(17.67xT )/(T +243.5) × 2.1674 × rh) \ (273.15 + T )
Each of these variables was assigned to a particular patient based
on the formula described above for the date of acquisition of LRTI.
Confounding Variables - We evaluated the following potentially
confounding variables: age, gender, obesity, risk factors for HCAP,
the number of days with respiratory symptoms prior to hospital-
ization, as well as a history of: COPD, liver disease, renal disease,
diabetes, congestive heart failure, and cancer.
© ULJRI 2017 Vol 1, (3) 27–35 | 35
Quality Control/Data Management Plan - Trained study
coordina- tors or research associates collected data both
from patient inter- views/questionnaires, and from
entered, trained study coordinators and research
medical records. All data were collected on a paper case
associates ex- amined each case for abnormal data. Any
report form and were subsequently entered into an online
queries were sent back to the coordinator collecting data
case report form. The online system in- cluded validators
for remedy. Once all queries were answered, the data
to limit data entry error. Once the case was
were corrected and finally entered into the online
database.

Statistical Analysis

Categorical variables were expressed as frequencies and

percent- ages and were compared between those with and
without in- fluenza, with and without rhinovirus, and
with and without RSV using Chi-squared or Fisher’s
exact tests. Continuous variables were expressed as
medians and interquartile ranges or means and standard
deviations and were compared between groups using the
Mann-Whitney U test or the student’s t-test. P-values
≤0.05 were considered statistically significant in all
analyses unless oth- erwise specified.

Poisson regression models with robust error variance were

used to model the incidence of hospitalization with a
LRTI due to either:
1) influenza, 2) rhinovirus, and 3) respiratory syncytial
virus (A and/or B), separately 10. For each of those three
outcomes, nine separate models were run, using each of
the nine predictor vari-
ables listed in the Study Variables section. All models
were ad- justed for the confounding variables described
previously.

P-values of ≤0.05 were considered statistically

significant, and R v3.0 was used for all analyses.

© ULJRI 2017 Vol 1, (3) 27–35 | 36

Table 3 Baseline Patient Characteristics and Climate Data Of Those With And Without Respiratory Syncytial Virus Lower Respiratory Tract Infections

Respiratory No Respiratory
Variable Syncytial Virus Syncytial Virus P-Value
n=27 n=440
Age, Median (IQR) 60 (17) 63 (21) 0.824
Male Gender, n (%) 19 (70) 246 (56) 0.164
COPD, n (%) 16 (59) 244 (55) 0.842
Diabetes, n (%) 9 (33) 162 (37) 0.838
Obese (BMI≥30kg/m2 ), n (%) 14 (52) 188 (43) 0.425
Risk Factors for Healthcare-Associated Pneumonia (HCAP), n (%) 9 (33) 155 (35) 1.000
Congestive Heart Failure, n (%) 13 (48) 116 (26) 0.024

Liver Disease, n (%) 1 (4) 26 (6) 1.000

Cancer, n (%) 0 (0) 45 (10) 0.095

Renal Disease, n (%) 6 (22) 83 (19) 0.619

Days with Respiratory Symptoms Prior to Hospitalization, Median (IQR) 4 (2.5) 4 (5) 0.379

Average Absolute Humidity the Day Before Symptom Onset, Median (IQR) 4.1 (1.9) 4.3 (1.8) 0.824

Average Relative Humidity the Day Before Symptom Onset, Median (IQR) 70.9 (14.2) 70.9 (9.3) 0.686

Average Temperature the Day Before Symptom Onset, Median (IQR) 3.3 (3.4) 3.8 (3.8) 0.307

RR=0.95, 95% CI=0.92,0.98, P−value=0.001

Max Temp 
RR=0.94, 95% CI=0.90,0.97, P−value=0.001

Min Temp RR=0.94, 95% CI=0.91,0.97, P−value=0.001

RR=1.00, 95% CI=0.98,1.02, P−value=0.895
Avg Temp 
Meteorological Parameter

RR=0.99, 95% CI=0.98,1, P−value=0.202


Max RH RR=0.99, 95% CI=0.98,1.01, P−value=0.344

RR=0.86, 95% CI=0.78,0.95, P−value=0.004

Min RH

RR=0.87, 95% CI=0.79,0.96, P−value=0.004


Avg RH RR=0.86, 95% CI=0.78,0.95, P−value=0.004



0.75 0.80 0.85 0.90 0.95 1.00 1.05 1.10 1.15 1.20
Max AH
Risk Ratio (RR) for Influenza Infection

Min AH

Avg AH

Fig. 1 Adjusted impact of climate factors on hospitalizations due to influenza virus lower respiratory tract infections (Avg = average; Min = minimum;

Max = maximum; AH = absolute humidity; RH = relative humidity; Temp = temperature in degrees Celsius)

3Results influenza, 41 (9%) had rhinovirus, and 27 (6%) had RSV (20 RSV
A, 7 RSV B). Baseline patient char- acteristics and baseline climate
A total of 467 hospitalized patients with LRTI were data on the day before symptom onset of hospitalized patients with
included in the study, 293 with CAP, 126 with AECOPD, and without LRTIs due to in- fluenza, rhinovirus, and RSV can be
and 48 with AB. A to- tal of 135 (29%) patients had found in Tables 1, 2, and 3, respectively.
© ULJRI 2017 Vol 1, (3) 27–35 | 37
During the three seasons, the average weekly absolute
humidity was 4.7 grams/m3 (min=2.3 grams/m3;
max=9.2 grams/m3), the average weekly relative
humidity was 71.1% (min=42.3%; max=85.7%), and
the average weekly temperature was 4.3◦C (min=-
2.3◦C ; max=12.7◦C).
The adjusted impact of each of the nine climate factors
for in- fluenza infection, rhinovirus infection, and RSV
infection can be seen in Figures 1, 2, and 3, respectively.
The average, minimum, and maximum absolute humidity
and temperature variables were
associated with hospitalization due to influenza LRTI,
while the relative humidity variables were not.
Correlations between each of the nine climate factors and
the weekly influenza incidence rates are depicted in
Figure 4. None of the nine predictor vari- ables were
associated with hospitalization due to rhinovirus or RSV.
4Discussion
This study suggests that absolute humidity and
temperature on the day before symptom onset are
associated with hospitaliza- tions due to influenza LRTIs,
but not with LRTIs due to rhinovirus or respiratory
syncytial virus during the influenza season. Fur-
thermore, the relative humidity on the day before
symptom onset was not associated with hospitalizations
due to any of the eti- ologies evaluated. Although
temperature was associated with in- fluenza LRTIs, the
protective effects were small compared to those related to
relative humidity.
The relationships between climate factors and respiratory
virus infection incidence are documented in the literature
but most
© ULJRI 2017 Vol 1, (3) 27–35 | 38
 0.75 0.80 0.85 0.90 0.95 1.00 1.05 1.10 1.15 1.20
Max Temp
Risk Ratio (RR) for Rhinovirus Infection

Min Temp

Avg Temp
Meteorological Parameter

Max RH

Min RH

Avg RH

Max AH

Min AH

Avg AH

RR=1.03, 95% CI=0.96,1.11, P−value=0.424


RR=1.02, 95% CI=0.94,1.12, P−value=0.588

RR=1.03, 95% CI=0.95,1.12, P−value=0.472

RR=0.99, 95% CI=0.94,1.04, P−value=0.75

RR=1.00, 95% CI=0.97,1.03, P−value=0.81

RR=0.99, 95% CI=0.95,1.04, P−value=0.753

RR=1.01, 95% CI=0.85,1.2, P−value=0.92

RR=1.01, 95% CI=0.85,1.2, P−value=0.909

RR=1.01, 95% CI=0.85,1.2, P−value=0.914


Fig. 2 Adjusted impact of climate factors on hospitalizations due to rhinovirus lower respiratory tract infections (Avg = average; Min = minimum; Max =

maximum; AH = absolute humidity; RH = relative humidity; Temp = temperature in degrees Celsius)

published studies are somewhat limited in their methods humidity Rhinovirus has been shown to survive more readily in
and scope 5,11–43. For example, there are no true incidence aerosols as well as on surfaces in the pres- ence of high relative
studies evaluating this correlation enrolling all humidity 9,47. Since droplet and contact are known modes of
hospitalized patients with lower respiratory tract transmission of this organism, it has been sug- gested that high
infections in a defined population during a defined time humidity may prevent the virus from desiccating thereby
period in the literature. Available clinical data do suggest prolonging survival on environmental surfaces and sub- sequently
that influenza virus infections are related to absolute hu- facilitating transmission. 6. Increases in the incidence of RSV
midity 29, relative humidity 44, and temperature 45. infections have been correlated with both low and high relative
Interestingly, contact transmission of the influenza virus, humidity levels 48,49. However, rainfall has been associ- ated with
but not aerosol trans- mission, may be facilitated in times RSV incidence in multiple studies, both negatively and positively
of high temperature 46 and in the presence of high 7,50–54.

© ULJRI 2017 Vol 1, (3) 27–35 | 39


Various theories behind the association between climate
fac- tors and the incidence of respiratory viruses have
been pro- posed. Most of the theories have focused on
the low tempera- ture/humidity correlations with
influenza virus 8,42. Both inter- host factors such as viral
stability changes, respiratory droplet size, and airflow, as
well as host factors such as respiratory secre- tion
production and composition, viral clearance, seasonal
nutri- tion changes, ultraviolet light, and socio-behavioral
changes (e.g. close indoor contact) have been described
as potential mecha- nisms 8,55. Our results suggest that
host factors, including socio- behavioral factors may not
be primary drivers of respiratory vi- ral epidemics during
winter seasons. The climate certainly influ- ences droplet
size, host and socio-behavioral factors, but if those
factors were related to respiratory viral transmission,
similar pat- terns of association between climate factors
and different viruses should be seen. Since only the
influenza virus was associated with climate factors, our
data suggest that absolute humidity and temperature may
affect influenza virus stability, pathogenesis or virulence.
This study has a number of limitations. First, we did not
account for indoor climate, which may be different than
outdoor climate and could modify viral survival and
transmission during the win- ter months. Second,
although we made an attempt to define the date of
infection with each virus, it is possible that we have not ac-
curately defined this date, leading to misclassification of
climate factors to each patient. Third, we had a relatively
small sam- ple size, which makes it difficult to make
accurate assessments. Since we enrolled patients only
during the influenza season, it is possible that we missed
a number of cases of viral lower respira- tory tract
infections. For example, RSV and rhinovirus may have
been circulating at different times of the year leading to
biased estimates during the winter season. It is also
possible that some patients were misclassified as not
having an LRTI due to one of these viruses due to the
diagnostic technique used. It is possi- ble that patients
arriving to the hospital may already have reduce their
respiratory virus to an undetectable level, resulting in
mis- classification. Finally, since this study was
ecological in nature, it is not possible to confirm that each
patient was truly exposed to a particular temperature or
humidity level, particularly indoor tem- perature and
humidity values, where an individual may spend the
majority of their day. Another limitation of this study is
the fact that there are no accepted gold standard
definitions of any of the LRTIs we evaluated. Because of
this, we may have misclassified patients based on various
definitions. Due to the relatively small sample size, we
were not able to evaluate differences among the three
influenza seasons. This could possibly induce bias in the
re-
© ULJRI 2017 Vol 1, (3) 27–35 | 40
 0.75 0.80 0.85 0.90 0.95 1.00 1.05 1.10 1.15 1.20
Max Temp
Risk Ratio (RR) for RSV Infection

Min Temp

Avg Temp
Meteorological Parameter

Max RH

Min RH

Avg RH

Max AH

Min AH

Avg AH

RR=0.95, 95% CI=0.88,1.03, P−value=0.213


RR=0.93, 95% CI=0.85,1.02, P−value=0.119

RR=0.94, 95% CI=0.86,1.03, P−value=0.159

RR=1.00, 95% CI=0.97,1.04, P−value=0.856

RR=1.01, 95% CI=0.98,1.05, P−value=0.435

RR=1.02, 95% CI=0.97,1.06, P−value=0.534

RR=1.00, 95% CI=0.97,1.04, P−value=0.856

RR=0.96, 95% CI=0.77,1.18, P−value=0.678

RR=0.95, 95% CI=0.77,1.19, P−value=0.671


Fig. 3 Adjusted impact of climate factors on hospitalizations due to respiratory syncytial virus lower respiratory tract infections (Avg = average; Min =

minimum; Max = maximum; AH = absolute humidity; RH = relative humidity; Temp = temperature in degrees Celsius)

sults. We were also not able to evaluate the role of asthma and/or
use of inhaled corticosteroids in COPD patients. This may
bias the results due to residual confounding.
The major strength of this study is that it is a population-
based incidence study of nearly all residents of
Louisville, Kentucky re- quiring hospitalization for a
LRTI using active respiratory virus surveillance. Most
prior studies largely relied on a patient sam- ple or
passive surveillance and attempted to correlate population
based climate data with the patient sample. Since we were able to
enroll nearly all hospitalized patients with lower respiratory tract
infections in Louisville, we are able to reduce the bias inherent in
some other studies.
Future studies may consider the both the role of the outdoor and
indoor climate on the incidence of respiratory virus infections. The
indoor climate, humidity in particular, has been suggested as an
important factor in respiratory virus transmission 56. Com- bining
the indoor and outdoor temperature may facilitate the de-
© ULJRI 2017 Vol 1, (3) 27–35 | 41
velopment of more robust predictive models for
respiratory virus infections. Furthermore, results of these
studies may lead to the development of climate
modification interventions to limit viral transmission.
Finally, there is a need to further elucidate the
mechanisms behind the correlation between low absolute
humid- ity and the pathogenesis and/or virulence of the
influenza virus but not other respiratory viruses.
In conclusion, this study adds to the body of evidence
that the outdoor climate factors, particularly absolute
humidity, are asso- ciated with influenza incidence.
However, we were not able to demonstrate any impact of
climate on the incidence of rhinovirus or respiratory
syncytial virus. Understanding factors contributing to the
transmission of respiratory viruses may assist in the
predic- tion of future outbreaks and facilitate the
development of novel interventions for preventing
respiratory viral transmission.
References
1World Health Organization, “The top 10 causes of
death,” 2015 [updated January 2017]. [Online].
Available: http:
//www.who.int/mediacentre/factsheets/fs310/en/
2B. Müller-Pebody, N. S. Crowcroft, M. C. Zambon, and
W. J. Edmunds, “Modelling hospital admissions for
lower respira- tory tract infections in the elderly in
england,” Epidemiology and Infection, vol. 134, no. 06,
pp. 1150–1157, 2006.
3T. Wiemken, P. Peyrani, K. Bryant, R. R. Kelley, J.
Summers- gill, F. Arnold et al., “Incidence of
respiratory viruses in pa- tients with community-
acquired pneumonia admitted to the intensive care
unit: results from the severe influenza pneu- monia
surveillance (sips) project,” European journal of clinical
microbiology & infectious diseases, vol. 32, no. 5, pp.
705–710, 2013.
4J. A. Ramirez, “The challenge of predicting influenza,” Fron- tiers in
microbiology, vol. 2, 2011.
5J. Shaman and M. Kohn, “Absolute humidity modulates in- fluenza
survival, transmission, and seasonality,” Proceedings of the
National Academy of Sciences, vol. 106, no. 9, pp. 3243– 3248,
2009.
6J. D. Noti, F. M. Blachere, C. M. McMillen, W. G. Lindsley,
M. L. Kashon, D. R. Slaughter et al., “High humidity
leads to loss of infectious influenza virus from
simulated coughs,” PLoS One, vol. 8, no. 2, p.
e57485, 2013.
7S. B. Omer, A. Sutanto, H. Sarwo, M. Linehan, I. G. Djelantik,
D. Mercer et al., “Climatic, temporal, and geographic
charac- teristics of respiratory syncytial virus disease
in a tropical is- land population,” Epidemiology and
infection, vol. 136, no. 10, pp. 1319–1327, 2008.
8A. C. Lowen and J. Steel, “Roles of humidity and temperature
© ULJRI 2017 Vol 1, (3) 27–35 | 42
 40 9 40 50 40 20

Temperature (Degrees Celsius)

% of Positive Influenza Cases

% of Positive Influenza Cases

% of Positive Influenza Cases

Relative Humidity (Percent)

Absolute Humidity
35 35 35 18

(grams/cubic meter)
8 55

30 30 30 16

7
25 60 25
25 14

20 6 20 20 12
65
40 42 44 46 48 50 1 3 5 7 9 11 13 15 17 40 42 44 46 48 50 1 3 5 7 9 11 13 15 17 40 41 42 43 44 45 46 47 48 49 50 51 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
15 15 15 10
5
Weeks Weeks 70 Weeks
10 10 10 8

5 Weekly Flu Cases Average Weekly Absolute Humidity 4 5 Weekly Flu Cases Average Weekly Relative Humidity 5 Weekly Flu Cases Average Weekly Temperature 6
40 9 40 75
70 40 12

0 8 350 75 0 4

Temperature (Degrees Celsius)

% of Positive Influenza Cases

3 10

% of Positive Influenza Cases

% of Positive Influenza Cases

Relative Humidity (Percent)

35 80 35

Absolute Humidity
(grams/cubic meter)
80
7 2
30 8

30
25 6 30 0
85
90 6
25
95 -2
20 20 25 4
5
4
100
2
15 155 105 20
40 42 44 46 48 50 1 3 5 7 9 11 13 15 17 40 42 44 46 48 50 1 3 5 7 9 11 13 15 17 40 42 44 46 48 50 1 3 5 7 9 11 13 15 17
5 3 0

10 Weeks 100 15 Weeks

Weeks
-2
0

Weekly Flu Cases Minimum Weekly Absolute Humidity Weekly Flu Cases Minimum Weekly Relative Humidity 10 Weekly Flu Cases Minimum Weekly Temperature -4

35
40 9 35 30 35
40 25
8 40 25 -6
5 20
30 30 35
7

Temperature (Degrees Celsius)

30

% of Positive Influenza Cases

25
% of Positive Influenza Cases

25 40
% of Postive Influenza Cases

Relative Humidity (Percent)

0 15
Absolute Humidity
(grams/cubic meter)

25

20 6 20 45 20

10
15 15 50
5
15
10
10 10 55
5
4 5
5 60

5
0 3 0 65 0
40 42 44 46 48 50 1 3 5 7 9 11 13 15 17
© ULJRI 2017 Vol 1, (3)

40 42 44 46 48 50 1 3 5 7 9 11 13 15 17 40 42 44 46 48 50 1 3 5 7 9 11 13 15 17
0

Weeks Weeks Weeks

Weekly Flu Cases Maximum Weekly Absolute Humidity Weekly Flu Cases Maximum Weekly Relative Humidity Weekly Flu Cases Maximum Weekly Temperature

Fig. 4 Depiction of the correlation between nine climate variables and the weekly influenza incidence rate
27–35 | 33
 in shaping influenza seasonality,” Journal of virology, vol. 88, no.
14, pp. 7692–7695, 2014.
9Y. G. Karim, M. K. Ijaz, S. A. Sattar, and C. M.
Johnson- Lussenburg, “Effect of relative humidity on
the airborne sur- vival of rhinovirus-14,” Canadian
journal of microbiology, vol. 31, no. 11, pp. 1058–
1061, 1985.
10G. Zou, “A modified poisson regression approach to prospec- tive
studies with binary data,” American journal of epidemiol- ogy, vol.
159, no. 7, pp. 702–706, 2004.
11M. L. Bouzas, J. R. Oliveira, K. F. Fukutani, I. C.
Borges,
A. Barral, W. Van der Gucht et al., “Respiratory
syncytial virus a and b display different temporal
patterns in a 4-year prospective cross-sectional study
among children with acute respiratory infection in a
tropical city,” Medicine, vol. 95, no. 41, 2016.
12E. R. Deyle, M. C. Maher, R. D. Hernandez, S. Basu,
and
G. Sugihara, “Global environmental drivers of influenza,” Pro-
ceedings of the National Academy of Sciences, p. 201607747,
2016.
17T. Kamigaki, L. Chaw, A. G. Tan, R. Tamaki, P. P.
Alday, J. B. Javier, R. M. Olveda, H. Oshitani, and V. L.
Tallo, “Seasonality of influenza and respiratory
syncytial viruses and the effect of climate factors in
subtropical–tropical asia using influenza- like illness
surveillance data, 2010–2012,” PloS one, vol. 11, no.
12, p. e0167712, 2016.
18S. Morikawa, U. Kohdera, T. Hosaka, K. Ishii, S.
Akagawa,
S. Hiroi, and T. Kase, “Seasonal variations of
respiratory viruses and etiology of human rhinovirus
infection in chil- dren,” Journal of Clinical Virology,
vol. 73, pp. 14–19, 2015.
19P. D. Shaw Stewart, “Seasonality and selective trends in
viral acute respiratory tract infections,” Medical
hypotheses, vol. 86, pp. 104–119, 2016.
20N. Sirimi, M. Miligkos, F. Koutouzi, E. Petridou, T.
Sia- hanidou, and A. Michos, “Respiratory syncytial
virus activity and climate parameters during a 12-year
period,” Journal of medical virology, 2015.
21C. Sloan, M. Heaton, S. Kang, C. Berrett, P. Wu, T.
Gebret-

13P. Fagan, C. McLeod, and R. W. Baird, “Seasonal

variability of respiratory syncytial virus infection in
the top end of the northern territory (2012–2014),”
Journal of paediatrics and child health, vol. 53, no. 1,
pp. 43–46, 2017.
14A. R. R. Freitas and M. R. Donalisio, “Respiratory
syncytial virus seasonality in brazil: implications for
the immunisation policy for at-risk populations,”
Memórias do Instituto Oswaldo Cruz, vol. 111, no. 5,
pp. 294–301, 2016.
15R. Q. Gurgel, P. G. de Matos Bezerra, M. d. C. M. B.
Duarte,
A. Á. Moura, E. L. Souza, L. S. da Silveira Silva, C.
E. Suzuki, and R. B. Peixoto, “Relative frequency,
possible risk factors, vi- ral codetection rates, and
seasonality of respiratory syncytial virus among
children with lower respiratory tract infection in
northeastern brazil,” Medicine, vol. 95, no. 15, 2016.
16T. M. Ikäheimo, K. Jaakkola, J. Jokelainen, A.
Saukkoriipi,
M. Roivainen, R. Juvonen et al., “A decrease in
temperature and humidity precedes human rhinovirus
infections in a cold climate,” Viruses, vol. 8, no. 9, p.
244, 2016.
© ULJRI 2017 Vol 1, (3) 27–35 | 34
 sadik, N. Sicignano, A. Evans, R. Lee, and T.
Hartert, “The impact of temperature and relative
humidity on spatiotempo- ral patterns of infant
bronchiolitis epidemics in the contiguous united
states,” Health & Place, vol. 45, pp. 46–54, 2017.
22N. Sundell, L.-M. Andersson, R. Brittain-Long, M.
Lindh, and
J. Westin, “A four year seasonal survey of the
relationship be- tween outdoor climate and
epidemiology of viral respiratory tract infections in a
temperate climate,” Journal of Clinical Vi- rology,
vol. 84, pp. 59–63, 2016.
23N. Zhao, G. Cao, J. K. Vanos, and D. J. Vecellio,
“The effects of synoptic weather on influenza
infection incidences: a ret- rospective study utilizing
digital disease surveillance,” Inter- national Journal
of Biometeorology, pp. 1–16, 2017.
24S. F. Dowell and M. S. Ho, “Seasonality of infectious
diseases and severe acute respiratory syndrome–what
we don’t know can hurt us,” The Lancet infectious
diseases, vol. 4, no. 11, pp. 704–708, 2004.
25J. Shaman and A. Karspeck, “Forecasting seasonal outbreaks of
influenza,” Proceedings of the National Academy of Sciences, vol.
109, no. 50, pp. 20 425–20 430, 2012.
contamination of common house- hold surfaces during
the 2009 influenza a (h1n1) pandemic in bangkok,
thailand: Implications for contact transmission,”
Clinical Infectious Diseases, vol. 51, no. 9, pp. 1053–
1061,
2010.
31C. Sloan, M. L. Moore, and T. Hartert, “Impact of
pollution, climate, and sociodemographic factors on
spatiotemporal dy- namics of seasonal respiratory
viruses,” Clinical and transla- tional science, vol. 4,
no. 1, pp. 48–54, 2011.
32R. P. Soebiyanto, F. Adimi, and R. K. Kiang,
“Modeling and predicting seasonal influenza
transmission in warm regions using climatological
parameters,” PloS one, vol. 5, no. 3, p. e9450, 2010.
33H. Sooryanarain and S. Elankumaran, “Environmental
role in influenza virus outbreaks,” Annu. Rev. Anim.
Biosci., vol. 3, no. 1, pp. 347–373, 2015.
34V. L. Tallo, T. Kamigaki, A. G. Tan, R. R. Pamaran, P.
P. Alday,

26J. Shaman, V. Pitzer, C. Viboud, M. Lipsitch, and B.

Grenfell, “Absolute humidity and the seasonal onset
of influenza in the continental us,” PLoS currents, vol.
2.
27J. Shaman, V. E. Pitzer, C. Viboud, B. T. Grenfell, and
M. Lip- sitch, “Absolute humidity and the seasonal
onset of influenza in the continental united states,”
PLoS Biol, vol. 8, no. 2, p. e1000316, 2010.
28M. Shoji, K. Katayama, and K. Sano, “Absolute humidity as a
deterministic factor affecting seasonal influenza epidemics in
japan,” The Tohoku journal of experimental medicine, vol. 224, no. 4,
pp. 251–256, 2011.

29D. R. Silva, V. P. Viana, A. M. Müller, F. P. Livi, and

P. d. T. R. Dalcin, “Respiratory viral infections and
effects of meteoro- logical parameters and air
pollution in adults with respiratory symptoms
admitted to the emergency room,” Influenza and
other respiratory viruses, vol. 8, no. 1, pp. 42–52,
2014.
30J. M. Simmerman, P. Suntarattiwong, J. Levy, R. V.
Gib- bons, C. Cruz, J. Shaman, R. G. Jarman, and T.
Chotpitaya- sunondh, “Influenza a virus
© ULJRI 2017 Vol 1, (3) 27–35 | 35
 E. S. Mercado, J. B. Javier, H. Oshitani, and R. M.
Olveda, “Estimating influenza outpatients’ and
inpatients’ incidences from 2009 to 2011 in a tropical
urban setting in the philip- pines,” Influenza and other
respiratory viruses, vol. 8, no. 2, pp. 159–168, 2014.
35J. Tamerius, M. I. Nelson, S. Z. Zhou, C. Viboud, M.
A. Miller, and W. J. Alonso, “Global influenza
seasonality: reconciling patterns across temperate and
tropical regions,” Environmen- tal health perspectives,
vol. 119, no. 4, p. 439, 2011.
36J. D. Tamerius, J. Shaman, W. J. Alonso, K. Bloom-
Feshbach,
C. K. Uejio, A. Comrie, and C. Viboud,
“Environmental pre- dictors of seasonal influenza
epidemics across temperate and tropical climates,”
PLoS Pathog, vol. 9, no. 3, p. e1003194, 2013.
37J. W. Tang and T. P. Loh, “Correlations between
climate fac- tors and incidence-a contributor to rsv
seasonality,” Reviews in medical virology, vol. 24, no.
1, pp. 15–34, 2014.
38D. E. te Beest, M. van Boven, M. Hooiveld, C. van
den Dool, and J. Wallinga, “Driving factors of
influenza transmis- sion in the netherlands,” American
journal of epidemiology, p. kwt132, 2013.
39S. Towers, G. Chowell, R. Hameed, M. Jastrebski, M.
Khan,
J. Meeks, A. Mubayi, and G. Harris, “Climate change
and in- fluenza: the likelihood of early and severe
influenza seasons following warmer than average
winters,” PLOS Currents In- fluenza, 2013.
40S. P. van Noort, R. Águas, S. Ballesteros, and M. G. M.
Gomes, “The role of weather on the relation between
influenza and influenza-like illness,” Journal of
theoretical biology, vol. 298, pp. 131–137, 2012.
41W. Yang, S. Elankumaran, and L. C. Marr,
“Relationship be- tween humidity and influenza a
viability in droplets and im- plications for influenza’s
seasonality,” PloS one, vol. 7, no. 10, p. e46789, 2012.
42W. Yang and L. C. Marr, “Dynamics of airborne
influenza a viruses indoors and dependence on
humidity,” PloS one, vol. 6, no. 6, p. e21481, 2011.
43T Żuk, F. Rakowski, and J. P. Radomski, “Probabilistic
. model
2012.
46A. C. Lowen, J. Steel, S. Mubareka, and P. Palese,
“High tem- perature (30 c) blocks aerosol but not
contact transmission of influenza virus,” Journal of
virology, vol. 82, no. 11, pp. 5650–5652, 2008.
47S. A. Sattar, Y. G. Karim, V. S. Springthorpe, and C.
Johnson- Lussenburg, “Survival of human rhinovirus
type 14 dried onto nonporous inanimate surfaces:
effect of relative humidity and suspending medium,”
Canadian journal of microbiology, vol. 33, no. 9, pp.
802–806, 1987.
48C.-S. Khor, I.-C. Sam, P.-S. Hooi, K.-F. Quek, and Y.-
F. Chan, “Epidemiology and seasonality of respiratory
viral infections in hospitalized children in kuala
lumpur, malaysia: a retro- spective study of 27 years,”
BMC pediatrics, vol. 12, no. 1, p. 32, 2012.
49J. Rechsteiner, “Inactivation of respiratory syncytial
virus in air,” Antonie van Leeuwenhoek, vol. 35, no. 1,
pp. 238–238, 1969.
50P. W. Chan, F. T. Chew, T. N. Tan, K. B. Chua, and P.
S. Hooi, “Seasonal variation in respiratory syncytial
virus chest infec- tion in the tropics,” Pediatric
pulmonology, vol. 34, no. 1, pp. 47–51, 2002.
51M. P. Loscertales, A. Roca, P. J. Ventura, F.
Abacassamo,
F. Dos Santos, M. Sitaube, C. MenÉndez, B. M.
Greenwood,
J. C. Saiz, and P. L. Alonso, “Epidemiology and clinical
presen- tation of respiratory syncytial virus infection
in a rural area of southern mozambique,” The Pediatric
infectious disease jour- nal, vol. 21, no. 2, pp. 148–
155, 2002.
52P. E. Reese and N. J. Marchette, “Respiratory syncytial
virus infection and prevalence of subgroups a and b in
hawaii.” Journal of clinical microbiology, vol. 29, no.
11, pp. 2614– 2615, 1991.
53S. E. Robertson, A. Roca, P. Alonso, E. A. Simoes, C.
B. Kartasasmita, D. O. Olaleye, G. N. Odaibo, M.
Collinson,
M. Venter, Y. Zhu et al., “Respiratory syncytial virus infection:
denominator-based studies in indonesia, mozambique, nige- ria
and south africa,” Bulletin of the World Health Organiza-
tion, vol. 82, no. 12, pp. 914–922, 2004.
© ULJRI 2017 Vol 1, (3) 27–35 | 36
 of influenza virus transmissibility at various temperature and humidity conditions,” Computational biology and chemistry, vol.
33, no. 4, pp. 339–343, 2009.

44J. W. Tang, F. Y. Lai, P. Nymadawa, Y.-M. Deng, M. Ratnamo- han, M. Petric, T. P. Loh, N. W. Tee,
D. E. Dwyer, I. G. Barr et al., “Comparison of the incidence of influenza in relation to climate factors
during 2000–2007 in five countries,” Journal of medical virology, vol. 82, no. 11, pp. 1958–1965,
2010.
45S. M. Firestone, N. Cogger, M. P. Ward, J.-A. L. Toribio, B. J. Moloney, and N. K. Dhand, “The
influence of meteorology on the spread of influenza: survival analysis of an equine in- fluenza
(a/h3n8) outbreak,” PloS one, vol. 7, no. 4, p. e35284,

© ULJRI 2017 Vol 1, (3) 27–35 | 37

54M. W. Weber, E. K. Mulholland, and B. M. Greenwood, “Res- piratory syncytial virus infection in
tropical and developing countries,” Tropical Medicine & International Health, vol. 3, no. 4, pp.
268–280, 1998.
55N. Pica and N. M. Bouvier, “Environmental factors affecting the transmission of respiratory viruses,”
Current opinion in vi- rology, vol. 2, no. 1, pp. 90–95, 2012.
56T. H. Koep, F. T. Enders, C. Pierret, S. C. Ekker,
D. Krageschmidt, K. L. Neff, M. Lipsitch, J. Shaman, and W. C. Huskins, “Predictors of indoor
absolute humidity and esti- mated effects on influenza virus survival in grade schools,” BMC
infectious diseases, vol. 13, no. 1, p. 71, 2013.

© ULJRI 2017 Vol 1, (3) 27–35 | 38

HUBUNGAN ANTARA BERAT BADAN LAHIR, STATUS GIZI DAN STATUS
IMUNISASI DENGAN KEJADIAN PNEUMONIA PADA BALITA DI WILAYAH
KERJA PUSKESMAS PANIKI BAWAH KOTA MANADO
Muhammad Kahfi*, Grace D. Kandou*, A.J.M Rattu*

*Fakultas Kesehatan Masyarakat Universitas Sam Ratulangi

ABSTRAK
Pneumonia adalah suatu penyakit saluran napas bawah (lower respiratory tract) akut yang
disebabkan oleh infeksi disertai demam. Menurut World Health Organitation (WHO), pada tahun
2015 terjadi kasus kematian pada anak dibawah usia lima tahun akibat pneumonia sebanyak 922.000
(15%). Tujuan penelitian ini adalah untuk mengetahui hubungan antara berat badan lahir, status gizi
dan status imunisasi dengan kejadian pneumonia pada balita di wilayah kerja Puskesmas Paniki
Bawah Kota Manado. Penelitian ini menggunakan metode observasional analitik dengan pendekatan
cross sectional. Populasi dalam penelitian ini adalah anak berumur 12-59 bulan yang berada di
wilayah kerja Puskesmas Paniki Bawah Kota Manado. Pada Januari 2017, diperoleh data dari
Puskesmas Paniki Bawah Kota Manado yaitu sebanyak 2506 balita yang datang untuk berobat dan
total sampel pada penelitian ini yaitu sebanyak 96 balita. Analisis bivariat dilakukan dengan
menggunakan uji Chi Square (α=0, 05). Hasil penelitian menunjukkan bahwa sebanyak 19 (19,8%)
balita menderita pneumonia dan sebanyak 77 (80,2%) balita bukan menderita pneumonia. Hasil
analisa statistik menunjukkan bahwa terdapat hubungan yang bermakna antara status gizi (p=0,001)
dan status imunisasi (p=0,004) dengan kejadian pneumonia pada balita sedangkan berat badan lahir
(p=0,256) tidak terdapat hubungan yang bermakna dengan kejadian pneumonia pada balita.

Kata Kunci: Pneumonia, Balita, Berat badan lahir, Status Gizi, Status Imunisasi.

ABSTRACT
Pneumonia is a disease of the lower respiratory tract (LRT) caused by acute infection accompanied by
fever. According to the World Health Organitation (WHO), by the year 2015 case of death in children
under five years of age due to pneumonia as much 922,000 (15%). The purpose of this research is to
know the relation between birth weight, nutritional status and the status of immunization with
pneumonia on toddlers in the region Paniki Bawah Manado city Clinics. This research use analytic
observational method with cross sectional approach. The population in this research is children from
12-59 month in the work of the Paniki Bawah Manado city Clinics. In January 2017, obtained data
from Clinics Paniki Bawah Manado city that is as much as the 2506 toddlers who came for medical
treatment and the total sample in this research that is as much as 96 toddlers. Bivariat analysis
performed using Chi Square test (α = 0, 05). The results showed that as many as 19 (19.8%) toddlers
suffering from pneumonia and as much as 77 (80.2%) toddler is not suffering from pneumonia. The
results of the analysis of the statistics shows that there is a meaningful relationship between the
nutritional status (p = 0.001) and immunization status (p = 0,004) with the incidence of pneumonia on
toddlers while birth weight (p = 0,256) there is no meaningful relationship with the incidence of
pneumonia in toddlers. There are two independent variables that are associated with the incidence of
pneumonia in babies in the region Paniki Bawah Manado city Clinics, namely nutritional status and
immunization status while variables unrelated is birth weight.
Key Words: Pneumonia, Toddler, Birth Weight, Nutritional Status, Immunization Status

PENDAHULUAN yaitu anak - anak usia kurang dari 2 tahun,

Pneumonia merupakan akibat infeksi, usia lanjut lebih dari 65 tahun dan orang
menghirup cairan atau bahan kimia. yang memiliki masalah kesehatan
Populasi yang rentan terserang pneumonia

1
malnutrisi dan gangguan imunologi (Profil
Kesehatan Indonesia, 2014).
Pneumonia terus menjadi masalah
kesehatan yang terbesar di seluruh dunia
pada anak-anak di bawah usia lima tahun.
Menurut World Health Organitation
(WHO) sekitar 922.000 (15%) kematian
anak di bawah 5 tahun akibat pneumonia.
Infeksi saluran nafas bawah termasuk
pneumonia dan influensa masih menjadi
masalah kesehatan di negara berkembang
maupun negara maju (WHO, 2015).
Menurut hasil Riset Kesehatan
Dasar (RISKESDAS) tahun 2013
menunjukkan period prevalence
pneumonia yang tinggi terjadi pada
kelompok umur 1 - 4 tahun, kemudian
mulai meningkat pada umur 45 - 54 tahun
dan terus meninggi pada kelompok umur
berikutnya. Di Indonesia pada tahun 2014
penderita pneumonia 0 - 4 tahun sebanyak
657.490 sedangkan jumlah kematian balita
akibat pneumonia umur 0 - 4 tahun
sebanyak 496 balita. Angka kematian
akibat pneumonia atau Case Fatality Rate
(CFR) pneumonia pada balita sebesar
0,08% sedangkan pada kelompok bayi
angka kematian yaitu sebesar 0,11%
(Profil Kesehatan Indonesia, 2014).
Berdasarkan data Dinas
Kesehatan Provinsi Sulawesi Utara tahun
2014 sampai tahun 2016 menunjukkan
realisasi penemuan penderita pneumonia
2
pada usia 0-4 tahun. Tahun 2014 jumlah
penderita pneumonia sebanyak 673 kasus.
Pada tahun 2015 terjadi peningkatan
penderita pneumonia yaitu sebanyak 812
kasus dan pada tahun 2016 penderita
pneumonia sebanyak 843 kasus. Dalam
kurun waktu kurang lebih 2 tahun
kematian balita karena pneumonia yaitu 3
kasus (Dinkes Prov. Sulut, 2016).
Berdasarkan data yang diperoleh
dari Dinas Kesehatan Kota Manado
penderita pneumonia pada balita pada
tahun 2012 sebanyak 180 kasus dan pada
tahun 2015 terjadi peningkatan yang
signifikan yaitu 499 kasus. Kasus yang
tinggi dari 12 Puskesmas yang ada di Kota
Manado terdapat pada Puskesmas Paniki
Bawah dan Puskesmas Tuminting.
(Dinkes Kota Manado, 2016).
Menurut data yang diperoleh dari
Manajemen Terpadu Balita Sakit (MTBS)
Puskesmas Paniki Bawah pada tahun 2013
sampai dengan tahun 2016 yaitu pada
tahun 2013 penderita pneumonia balita
berjumlah 23 kasus, pada tahun 2014
terjadi peningkatan penderita pneumonia
balita yaitu berjumlah 60 kasus, tahun
2015 jumlah penderita pneumonia pada
balita menigkat yaitu 92 kasus, sedangkan
pada tahun 2016 penderita pneumonia
balita terjadi penurunan kasus yaitu
berjumlah 75 kasus (Puskesmas Paniki
Bawah, 2016).
 Secara umum terdapat 3 (tiga) Teknik pengambilan ini dilakukan pada
faktor yang berhubungan dengan kejadian saat kasus atau responden yang ada atau
pneumonia terbagi atas faktor lingkungan, tersedia di ruang MTBS Puskesmas Paniki
faktor individu anak serta faktor perilaku. Bawah Kota Manado. Dalam penelitian
Beberapa Faktor individu anak yang ini, variable terikat pneumonia pada balita
menyebabkan terjadinya pneumonia pada sedangkan variable bebas yaitu berat
balita yaitu berat badan lahir, status gizi badan lahir, status gizi dan status
dan status imunisasi. Berdasarkan data di imunisasi. Instrumen penelitian dalam
atas maka peneliti tertarik untuk penelitian sebagai alat ukur. Data primer
melakukan penelitian tentang kejadian dilakukan secara langsung dengan
pneumonia pada balita yang diduga responden yang datang di Puskesmas
dipengaruhi oleh beberapa faktor yang sedangkan data sekunder diperoleh dari
terkait dengan berat badan lahir, status data Manajemen Terpadu Balita Sakit
gizi dan status imunisasi di Puskesmas (MTBS) di Puskesmas Paniki Bawah. ini
Paniki Bawah. yaitu menggunakan alat pengukur badan
manual, alat pengukur tinggi badan
METODE PENELITIAN
(mikrotoa) dan kuesioner
Jenis Penelitian yang digunakan
merupakan penelitian survei analitik
HASIL DAN PEMBAHASAN
dengan menggunakan rancangan
Karakteristik Balita
penelitian cross sectional study atau studi
Tabel 1. Karakteristik Balita
potong lintang. Penelitian dilaksanakan
pada bulan Maret – Desember 2017 di Karakteristik n (96) %
balita
Puskesmas Paniki Bawah Kota Manado. Jenis kelamin
Populasi pada penelitian ini adalah semua Laki-laki 45 46,9
Perempuan 51 53,1
ibu yang mempunyai Balita dengan usia Umur (Bulan)
12-59 bulan yang datang berobat ke unit 12-23 54 56,3
24-35 14 14,6
Manajemen Terpadu Balita Sakit (MTBS) 36-47 11 11,5
di wilayah kerja Puskesmas Paniki Bawah 48-59 17 17,7
pada tahun 2017 yaitu 2506 balita. Jumlah
Hasil pengumpulan data mengenai
sampel yang akan diteliti yaitu 96 orang
karakteristik balita di wilayah kerja
balita. Teknik pengambilan sampel
Puskesmas Paniki Bawah Kota Manado
menggunakan accidental sampling.
yang ditampilkan pada tabel 1 didapatkan

3
bahwa terdapat 96 orang balita dengan orang balita (94,8%). Semakin rendah
dominasi jenis kelamin perempuan yaitu berat badan lahir bayi, ukuran alveoli
sebanyak 51 balita (53,1%). Untuk cenderung lebih kecil dan pembuluh darah
kelompok umur yang paling banyak yaitu yang mengelilingi stroma seluler matur
12- 23 bulan sebanyak 54 balita (56,3%) cenderung lebih sedikit sedangkan pada
sedangkan yang paling sedikit pada bayi yang memiliki berat badan lebih
kelompok umur 36-47 bulan sebanyak 11 besar, maka ukuran alveoli yang
balita (11,5%). dimilkinya akan lebih besar dan lebih
banyak pembuluh darah pada stroma
Analisis Univariat selulernya (Polack, 2009).
Tabel 2. Distibusi frekuensi variabel
Hasil penelitian menunjukkan bahwa
penelitian
sebanyak 26 balita (27, 1%) memiliki
Variabel n (96) % status gizi tidak normal sedangkan
Terdiagnosis sebanyak 70 balita (72, 9%) memiliki
Pneumonia 19 19,8
Bukan pneumonia 77 80,2 status gizi normal. Keadaan gizi yang
Berat Badan Lahir buruk muncul sebagai faktor risiko yang
Rendah 5 5,2
Normal 91 94,8 penting untuk terjadinya pneumonia.
Status Gizi Beberapa penelitian telah membuktikan
Tidak normal 26 27,1
Normal 70 72,9 tentang adanya hubungan antara gizi
Status Imunisasi buruk dan infeksi paru, sehingga anak-
Tidak lengkap 38 39,6
anak yang bergizi buruk sering mendapat
Lengkap 58 60,4
pneumonia. Penyakit infeksi sendiri akan
Berdasarkan hasil penelitian terhadap menyebabkan balita tidak mempunyai
96 balita yang berada di wilayah kerja nafsu makan dan mengakibatkan
Puskesmas Paniki Bawah Kota Manado kekurangan gizi (Maryunani, 2010).
didapatkan hasil angka pneumonia yaitu Hasil penelitian menunjukkan bahwa
sebesar (19,8%) menderita pneumonia dan sebanyak 38 orang balita (39, 6%)
(80,2%) bukan penderita pneumonia. memiliki status imunisasi tidak lengkap
Hasil penelitian menunjukkan bahwa sedangkan sebanyak 58 orang balita (60,
sebanyak 5 orang balita (5,2%) berberat
4%) memiliki status imunisasi lengkap.
badan lahir rendah sedangkan yang
Imunisasi dengan vaksin pneumokokus
berberat badan lahir normal sebanyak 91

4
yang mengandung polisakarida kapsular
dari 23 serotipe yang paling sering
memberikan perlindungan sebesar 60-
70%. Imunitas berlangsung jangka
panjang (Mandal, dkk, 2006).

Analisis Bivariat
Hubungan antara berat badan lahir,
status gizi dan status imunisasi dengan
kejadian pneumonia pada balita
Tabel 3. Analisis Hubungan antara berat badan lahir, status gizi dan status imunisasi dengan
kejadian pneumonia pada balita di wilayah kerja Puskesmas Paniki Bawah Kota Manado

Diagnosis medis
Variabel n p-
No Pneumonia % Bukan % %
Penelitian (96) value
pneumonia
1 Berat badan
lahir
 Rendah 2 40,0 3 60,0 5 100 0,256
 Normal 17 18,7 74 81,3 91 100

2 Status gizi
 Tidak 11 42,3 15 57,7 26 100 0,001
normal
 Normal 8 11,4 62 88,6 70 100

3 Status
imunisasi
 Tidak 13 34,2 25 65,8 38 100 0,004
lengkap
 Lengkap 6 10,3 52 89,7 58 100

Hasil analisis hubungan antara berat dan balita bukan mengalami pneumonia.
badan lahir dengan kejadian pneumonia Berdasarkan hasil uji chi square diperoleh
pada balita yaitu sebanyak 2 dari 5 nilai p=0,256 (p-value > 0,05)
(40,0%) balita dengan berat badan lahir dikarenakan ditemukannya cell yang
rendah dan balita mengalami pneumonia mempunyai frekuensi harapan dibawah 5
sedangkan sebanyak 74 dari 91 (81,3%) yaitu 2 cell (50%) sehingga menggunakan
balita dengan berat badan lahir normal rumus fisher exact test dan dapat

5
disimpulkan bahwa tidak ada hubungan Berdasarkan hasil uji chi square diperoleh
yang bermakna antara berat badan lahir nilai p=0,001 (p-value < 0, 05) sehingga
dengan pneumonia pada balita di wilayah disimpulkan bahwa ada hubungan yang
kerja Puskemas Paniki Bawah Kota bermakna antara status gizi dengan
Manado. pneumonia pada balita di wilayah kerja
Penelitian ini sejalan dengan Puskemas Paniki Bawah Kota Manado.
penelitian yang dilakukan Regina dkk Penelitian ini sejalan dengan
(2013) di wilayah kerja Puskesmas Miroto penelitian yang dilakukan Efni dkk (2016)
Semarang, menunjukkan tidak adanya di Kelurahan Airtawar Padang
hubungan antara berat badan lahir rendah menunjukkan adanya hubungan yang
dengan kejadian pneumonia pada balita bermakna antara status gizi dengan
(p=0,191). kejadian pneumonia pada balita
Berbeda dengan penelitian yang (p=0,022). Penelitian yang dilakukan
dilakukan oleh (Tambunan dkk, 2013) di Hartati dkk (2012) didapatkan hasil nilai
wilayah kerja Kedungmundu Kota probabilitas 0,000 yang menyatakan ada
Semarang menunjukkan bahwa terdapat hubungan bermakna antara status gizi
hubungan yang bermakna antara berat dengan kejadian pneumonia dengan nilai
badan lahir dengan kejadian pneumonia OR 6, 52 (CI 95% 2, 28-18, 63) maka
pada balita p-0,061. Hasil observasi dapat dikatakan responden yang berstatus
dilapangan sedikitnya balita yang berberat gizi kurang memiliki risiko 6, 52 kali
badan lahir normal dikarenakan ibu balita menderita pneumonia dibandingkan
saat mengandung kurang mengonsumsi dengan responden yang berstatus gizi
makanan- makanan yang bergizi sehingga baik.
mempengaruhi berat badan anaknya Berdasarkan hasil observasi
sewaktu dilahirkan. dilapangan ibu balita setelah melahirkan
Hasil analisis hubungan antara mereka memberikan asupan makanan
status gizi dengan kejadian pneumonia bergizi yang baik sehingga tingginya
pada balita yaitu sebanyak 11 dari 26 balita dengan status gizi normal namun
(42,3%) balita dengan status gizi tdak beberapa balita masih memiliki status gizi
normal dan balita mengalami pneumonia yang tidak normal dikarenakan sebagian
sedangkan sebanyak 62 dari 70 (88,6%) ibu balita masih kurang pengetahuannya
balita mengalami status gizi normal dan mengenai kecukupan gizi kepada anaknya.
balita bukan mengalami pneumonia.

6
 Hasil penelitian ini sesuai dengan dengan kejadian pneumonia pada balita
teori yang menyatakan adanya hubungan dengan nilai (p=0,034).
antara gizi buruk dan infeksi paru. Berdasarkan hasil observasi yang
Keadaan gizi buruk muncul sebagai faktor dilakukan dilapangan bahwa hampir
penyebab yang penting untuk terjadinya setengah jumlah responden yang diteliti
pneumonia sehingga anak-anak yang memiliki status imunisasi tidak lengkap
bergizi buruk sering mendapatkan hal ini dikarenakan sebagian ibu balita
pneumonia. Balita dengan gizi kurang sibuk dengan pekerjaannya dirumah
akan lebih mudah terserang pneumonia ataupun di kantor dan kurangnya
dibandingkan balita dengan gizi normal pengetahuan sehingga banyaknya balita
karena faktor daya tahan tubuh yang tidak mendapatkan imunisasi secara
kurang. lengkap. Hasil penelitian ini didukung
oleh teori yang menyatakan bahwa bayi
Hasil analisis hubungan antara status dan balita yang mempunyai status
imunisasi dengan kejadian pneumonia imunisasi lengkap bila menderita
pada balita yaitu sebanyak 13 dari 38 (40, pneumonia dapat diharapkan
0%) balita tidak mendapatkan imunisasi perkembangan penyakitnya tidak akan
secara lengkap dan balita mengalami menjadi lebih berat. Cara yang terbukti
pneumonia sedangkan sebanyak 52 dari paling efektif saat ini adalah dengan
58 (89,7%) balita yang sudah pemberian imunisasi campak dan pertusis
mendapatkan imunisasi lengkap dan balita (DPT) dengan imunisasi campak yang
bukan mengalami pneumonia. efektif sekitar 11% kematian pneumonia
Berdasarkan hasil uji chi square diperoleh balita dapat dicegah dan dengan imunisasi
nilai p=0,004 (p-value < 0, 05) sehingga pertusis (DPT) 6% kematian pneumonia
disimpulkan bahwa ada hubungan yang dapat dicegah (Maryunani, 2010).
bermakna antara status imunisasi dengan
pneumonia pada balita di wilayah kerja KESIMPULAN
Puskemas Paniki Bawah Kota Manado 1. Tidak terdapat hubungan antara berat
Hasil yang sama juga diperoleh dari badan lahir dengan kejadian
penelitian yang dilakukan Oktaviani dan pneumonia pada balita di wilayah kerja
Maesaroh (2017) di Puskesmas Teluknaga Puskesmas Paniki Bawah Kota
Kabupaten Tangerang menunjukkan Manado.
adanya hubungan antara status imunisasi

7
2. Terdapat hubungan antara status gizi 2. Bagi masyarakat
dengan kejadian pneumonia pada balita a. Pemberian imunisasi pada bayi
di wilayah kerja Puskesmas Paniki dengan membawa bayi untuk
Bawah Kota Manado. diimunisasi sesuai dengan jadwal
3. Terdapat hubungan antara status pemberian imunisasi.
imunisasi dengan kejadian pneumonia b. Diharapkan untuk meningkatkan
pada balita di wilayah kerja Puskesmas upaya peningkatan status gizi balita
Paniki Bawah Kota Manado. dengan pemberian variasi makanan
pada anak balita.
SARAN
1. Bagi Puskesmas DAFTAR PUSTAKA
a. Melakukan upaya penanggulangan Dinas Kesehatan Provinsi Sulawesi Utara
penyakit pneumonia berdasarkan 2015. Profil Kesehatan Provinsi
faktor risiko yang ada yaitu dengan Sulawesi Utara. Sulawesi Utara
meningkatkan kegiatan edukasi Efni, Y, Machmud, R, Pertiwi, D. 2016.
kepada masyarakat khususnya bagi Faktor risiko yang berhubungan
orangtua yang memiliki balita dengan kejadian pneumonia pada
mengenai pemenuhan gizi yang balita di Kelurahan Airtawar
optimal guna meningkatkan status Barat. Padang. FK Unand
gizi balita dan memberikan (online), Vol. 5, No. 2.
informasi kepada masyarakat (http://jurnal.fk.unand.ac.id/index.
tentang pentingnya pemberian php/jka/article/view/523 diakses
imunisasi sesuai dengan jadwal 22 Agustus 2017)
imunisasi. Hartati, S, Nurhaeni, N, Gayatri, D. 2012.
Faktor risiko terjadinya
b. Memberikan penyuluhan atau
pneumonia pada anak balita.
sosialisasi mengenai imunisasi dan Jakarta. (Online), Jurnal
Keperawatan Indonesia, Vol. 15,
gizi kepada masyarakat untuk
No.1 hal. 13-20
meningkatkan pengetahuan dan (http://jki.ui.ac.id/index.php/jki/ar
ticle/view/42 diakses 27 Juni
kaitannya dengan pencegahan
2017)
pneumonia. Kemenkes RI. 2013. Profil Kesehatan
Indonesia Tahun 2014. Jakarta
Kemenkes RI. 2013. Riset Kesehatan
Dasar (RISKESDAS), (Online),

8
 (www.depkes.go.id/resources/dow Universitas Muhammadiyah,
nload/general/Hasil%20Riskesdas (online), Vol. VIII, No. 1,
%202013.pdf. diakses 10 Agustus (http://e-journal.akbid-
2016). purworejo.ac.id/index.php/jkk14/a
Mandal, B.K., Wilkins, E.G.L., Dunbar, rticle/view/174 diakses 22
E.M., Mayon, R.T. dan White.
Agustus 2017)
2006. Penyakit Infeksi. Jakarta:
Erlangga Puskesmas Paniki Bawah. 2016. Laporan
Maryunani, A., 2010. Ilmu Kesehatan Bulanan Manajemen Terpadu
Balita Sakit (MTBS). Manado
Anak dalam Kebidanan. Jakarta:
Polack, Fernando. 2009. Pemberian Asi
Trans Info Media Mengurangi Risiko Pneumonia
Pada Bayi Perempuan. (The
Oktaviani, I, dan Maesaroh, S. 2017.
Pediatric Infectious Disease
Faktor-faktor yang berhubungan Journal haros.co.id/ news-a-
media/53-beritake diakses 15
dengan kejadian pneumonia pada
Oktober 2017).
balita di Puskesmas Kecamatan
Teluknaga. Tangerang.

9
The University of Louisville Journal of Respiratory Infections
Volume 1 | Issue 3 Article 7

5-22-2017

Impact of Temperature Relative Humidity and

Absolute Humidity on the Incidence of
Hospitalizations for Lower Respiratory Tract
Infections Due to Influenza, Rhinovirus, and
Respiratory Syncytial Virus: Results from
Community-Acquired Pneumonia Organization
(CAPO) International Cohort Study
Timothy L. Wiemken
University of Louisville, Louisville, KY

William A. Mattingly
University of Louisville, Louisville, KY

Stephen P. Furmanek
University of Louisville, Louisville, KY

Brian E. Guinn
University of Louisville, Louisville, KY

Recommended Citation
Wiemken, Timothy L.; Mattingly, William A.; Furmanek, Stephen P.; Guinn, Brian E.; English, Connor L.; Carrico, Ruth; Peyrani,
Paula; and Ramirez, Julio A. (2017) "Impact of Temperature Relative Humidity and Absolute Humidity on the Incidence of
Hospitalizations for Lower Respiratory Tract Infections Due to Influenza, Rhinovirus, and Respiratory Syncytial Virus: Results from
Community-Acquired Pneumonia Organization (CAPO) International Cohort Study," The University of Louisville Journal of
Respiratory Infections: Vol. 1 : Iss. 3 , Article 7.
DOI: 10.18297/jri/vol1/iss3/7/
Available at: http://ir.library.louisville.edu/jri/vol1/iss3/7

This Original Research is brought to you for free and open access by ThinkIR: The University of Louisville's Institutional Repository. It has been
accepted for inclusion in The University of Louisville Journal of Respiratory Infections by an authorized editor of ThinkIR: The University of
Louisville's Institutional Repository. For more information, please contact thinkir@louisville.edu.
Connor L. English
University of Louisville, Louisville, KY

See next page for additional authors

Follow this and additional works at: http://ir.library.louisville.edu/jri

Part of the Community Health and Preventive Medicine Commons, Epidemiology Commons,
Health Information Technology Commons, Influenza Humans Commons, Influenza Virus Vaccines
Commons, International Public Health Commons, and the Translational Medical Research
Commons
Impact of Temperature Relative Humidity and Absolute Humidity on the
Incidence of Hospitalizations for Lower Respiratory Tract Infections Due
to Influenza, Rhinovirus, and Respiratory Syncytial Virus: Results from
Community-Acquired Pneumonia Organization (CAPO) International
Cohort Study
Cover Page Footnote
CORRESPONDING AUTHOR: Timothy Wiemken, PhD MPH CIC Assistant Professor of Medicine
Director, Healthcare Epidemiology and Data Science Program University of Louisville Division of Infectious
Diseases 501 E Broadway Suite 120 Louisville, KY 40202 Office: 502-852-4627 Fax: 502-852-1147
tlwiem01@louisville.edu

Authors
Timothy L. Wiemken, William A. Mattingly, Stephen P. Furmanek, Brian E. Guinn, Connor L. English, Ruth
Carrico, Paula Peyrani, and Julio A. Ramirez

This original research is available in The University of Louisville Journal of Respiratory Infections: http://ir.library.louisville.edu/jri/
vol1/iss3/7
University of Louisville
Journal of Respiratory Infections
ORIGINAL RESEARCH

Impact of Temperature Relative Humidity and Absolute Humidity on the

Incidence of Hospitalizations for Lower Respiratory Tract Infections Due
to Influenza, Rhinovirus, and Respiratory Syncytial Virus: Results from
Community-Acquired Pneumonia Organization (CAPO) International Co-
hort Study

Timothy L. Wiemken,† William A. Mattingly, Stephen P. Furmanek, Brian E. Guinn, Connor L. English, Ruth M. Carrico,
Paula Peyrani, Julio A. Ramirez

Abstract

Background: Transmissibility of several etiologies of lower respiratory tract infections (LRTI) may DOI: 10.18297/jri/vol1/iss3/7/
Received Date: February 16, 2017
vary based on outdoor climate factors. The objective of this study was to evaluate the impact of
Accepted Date: April 6, 2017
outdoor temperature, relative humidity, and absolute humidity on the incidence of hospitalizations
Website: https://www.louisville.edu/jri
for lower respiratory tract infections due to influenza, rhinovirus, and respiratory syncytial virus
Affiliations:
(RSV). Department of Medicine, Division of Infectious
Methods: This was a secondary analysis of an ancillary study of the Community Acquired Pneu- Diseases, University of Louisville, Louisville, KY:
(TLW, WAM, SPF, BEG, CLE, RC, PP, JAR)
monia Organization (CAPO) database. Respiratory viruses were detected using the Luminex
xTAG respiratory viral panel. Climate factors were obtained from the National Weather Service.
Adjusted Poisson regression models with robust error variance were used to model the incidence
of hospitalization with a LRTI due to: 1) influenza, 2) rhinovirus, and 3) RSV (A and/or B), sepa-
rately.
Results: A total of 467 hospitalized patients with LRTI were included in the study; 135 (29%)
with influenza, 41 (9%) with rhinovirus, and 27 (6%) with RSV (20 RSV A, 7 RSV B). The aver-
age, minimum, and maximum absolute humidity and temperature variables were associated with
hospitalization due to influenza LRTI, while the relative humidity variables were not. None of the
climate variables were associated with hospitalization due to rhinovirus or RSV.
Conclusions: This study suggests that outdoor absolute humidity and temperature are asso-
ciated with hospitalizations due to influenza LRTIs, but not with LRTIs due to rhinovirus or RSV.
Understanding factors contributing to the transmission of respiratory viruses may assist in the pre-
diction of future outbreaks and facilitate the development of transmission prevention interventions.

1 Introduction
Lower respiratory tract infections are the third leading cause of
death worldwide 1 . Data suggest that influenza and other respi-
ratory viruses are major causes of many of these infections 2,3 .
†
Correspondence To: Timothy Wiemken, PhD MPH CIC
Assistant Professor of Medicine
Director, Healthcare Epidemiology and Data Science Program
University of Louisville Division of Infectious Diseases
501 E. Broadway Suite 120; Louisville, KY 40202
Office Phone: 502-852-4627; Fax: 502-852-1147
Email: tim.wiemken@louisville.edu
Several of these pathogens are transmitted from person to person
or from the environment to person, but a clear understanding
of the transmission dynamics of influenza and other respiratory
viruses is still evolving. Due to this, predicting transmission and
epidemics of these viruses is challenging 4 . Climate factors such as
temperature, relative humidity and absolute humidity have been
shown to impact the transmission of respiratory viruses. How-
ever, the influence of each of these factors is still controversial.
Some studies suggest that low humidity increases viral stability
and transmission of influenza 5,6 and respiratory syncytial virus
(RSV) 7 . Lowen and colleagues have also documented varied

© ULJRI 2017 Vol 1, (3) 27–35 | 27

transmission efficiencies of influenza viruses at different temper-
atures and relative humidities 8 . Conversely, other studies sug-
gest that high humidity may increase the stability of rhinovirus
and adenovirus, favoring transmission 9 . Most of the data re-
lated to climate factors and transmission dynamics of respiratory
viruses has been generated from basic science research, ecologi-
cal studies, and passive disease surveillance (e.g. viral specimens
obtained for clinical practice).
The Community-Acquired Pneumonia Organization (CAPO) co-
hort study is a multicenter, international study of adult hospi-
talized patients with lower respiratory tract infections (LRTIs),
which began in 2001. The database for the CAPO study con-
tains information on over 15,000 patients with CAP from over
40 countries. As part of this ancillary study, consecutive hospi-
talized patients with LRTIs from all nine adult acute care hospi-
tals in Louisville, KY during three consecutive influenza seasons
were enrolled. Each of these patients underwent active surveil-
lance for 12 respiratory viruses upon admission. Combining this
dataset with data from the National Weather Service allowed us
the unique opportunity to evaluate the role of climate factors at
the patient level using active respiratory virus surveillance.
The objective of this study was to evaluate the impact of outdoor
temperature, relative humidity, and absolute humidity on the in-
cidence of hospitalizations for lower respiratory tract infections
due to influenza, rhinovirus, and RSV.
2 Methods
2.1 Study Design
This was a secondary analysis of the CAPO database. As men-
tioned previously, this ancillary study of CAPO was a 3-year,
prospective study, enrolling consecutive adult hospitalized pa-
tients with lower respiratory tract infections (LRTIs) due to in-
fluenza during three consecutive influenza seasons. Consecu-
tive adult hospitalized patients with a diagnosis of LRTI were
evaluated prospectively from 4 adult hospitals in Louisville, Ken-
tucky during the influenza season 2010/2011, from 8 hospitals
during the 2011/2012 season, and in all 9 adult care hospitals
in Louisville, Kentucky, during the influenza season 2012/2013.
After informed consent was obtained, a nasopharyngeal swab
was obtained from each patient for respiratory virus detection.
The normal climate of Louisville is classified as a warm, humid,
and temperate, with average temperatures during the influenza
season of approximately 30◦ F, and average precipitation of 3-4
inches per month during the same season.
2.2 Inclusion Criteria
Consecutive adult patients with the diagnosis of a lower respira-
tory tract infection were approached by a study coordinator for
inclusion in the study. Upon signing of the consent form, the pa-
tient was enrolled and prospectively followed. Over 95% of the
residents of Louisville, KY sought care in these nine hospitals un-
der study during the third year of the study (Kentucky Hospital
Association, unpublished data), therefore only patients from the
third year (2012/2013 influenza season) were included in the
28 | © ULJRI 2017 Vol 1, (3) 27–35
present analysis.
2.3 Exclusion Criteria
Patients with more than one respiratory virus identified from the
nasopharyngeal swab were excluded from the analysis.
2.4 Human Subjects Protection
Institutional Review Board approval was obtained at all partici-
pating CAPO institutions prior to data collection.
2.5 Study Definitions
Lower respiratory tract infection (LRTI) was defined as a one sign
of acute infection (e.g. subjective/objective fever and/or chills)
and 2 new respiratory symptoms (e.g. cough, shortness of breath,
change ins sputum production).
LRTI was further stratified as community-acquired pneumonia
(CAP), acute exacerbation of chronic obstructive pulmonary dis-
ease (AE-COPD), or acute bronchitis (AB).
Community-Acquired Pneumonia (CAP) was defined as the pres-
ence of a new pulmonary infiltrate on chest radiograph at the
time of hospitalization that was associated with at least one of
the following three criteria:
1. New or increased cough
2. An abnormal temperature (< 35.6◦ C or > 37◦ C)
3. Leukocytosis, leukopenia, or left shift
Acute Exacerbation of Chronic Obstructive Pulmonary Disease
(AE-COPD) was defined as the lack of pulmonary infiltrate
on chest radiograph at the time of hospitalization that was
associated with at least one of the above three criteria PLUS a
history of COPD.
Acute Bronchitis (AB) was defined as the lack of pulmonary infil-
trate on chest radiograph at the time of hospitalization that was
associated with at least one of the above three criteria, without a
history of COPD.
Influenza LRTI was defined if the patient had a Luminex xTAG res-
piratory viral panel positive for any influenza virus via nasopha-
ryngeal swab.
Respiratory syncytial virus LRTI was defined if the patient had a
Luminex xTAG respiratory viral panel positive for any respiratory
syncytial virus via nasopharyngeal swab.
Rhinovirus LRTI was defined if the patient had a Luminex xTAG
respiratory viral panel positive for rhinovirus via nasopharyngeal
swab.
Date of Acquisition of LRTI: To calculate the incidence of each
virus by week, the following formula was used: ([date of admis-
sion to the hospital] − ([number of days with respiratory symp-
toms prior to hospitalization] +1)). This formula allowed us to
approximate the date of acquisition of the etiology of LRTI.
Table 1 Baseline Patient Characteristics and Climate Data Of Those With And Without Influenza Lower Respiratory Tract Infections

Variable Influenza No Influenza P-Value

n=135 n=332
Age, Median (IQR) 64 (19.5) 63 (20.2) 0.254
Male Gender, n (%) 79 (59) 186 (56) 0.680
COPD, n (%) 66 (49) 194 (58) 0.065
Diabetes, n (%) 48 (36) 123 (37) 0.832
Obese (BMI ≥30kg/m2 ), n (%) 53 (39) 149 (45) 0.259
Risk Factors for Healthcare-Associated Pneumonia (HCAP), n (%) 38 (28) 126 (38) 0.054
Congestive Heart Failure, n (%) 27 (20) 102 (31) 0.022
Liver Disease, n (%) 6 (4) 21 (6) 0.517
Cancer, n (%) 16 (12) 29 (9) 0.303
Renal Disease, n (%) 25 (19) 64 (19) 0.897
Days with Respiratory Symptoms Prior to Hospitalization, Median (IQR) 3 (4) 4 (5) 0.209
Average Absolute Humidity the Day Before Symptom Onset, Median (IQR) 4.1 (1.6) 4.3 (1.8) 0.010
Average Relative Humidity the Day Before Symptom Onset, Median (IQR) 70.9 (9.1) 70.9 (9.2) 0.367
Average Temperature the Day Before Symptom Onset, Median (IQR) 3.3 (4.5) 3.8 (3.8) 0.003

Table 2 Baseline Patient Characteristics and Climate Data Of Those With And Without Rhinovirus Lower Respiratory Tract Infections

Variable Rhinovirus No Rhinovirus P-Value

n=41 n=426
Age, Median (IQR) 64 (22) 63 (20.8) 0.822
Male Gender, n (%) 25 (61) 240 (56) 0.623
COPD, n (%) 23 (56) 237 (56) 1.000
Diabetes, n (%) 11 (27) 160 (38) 0.234
Obese (BMI ≥30kg/m2 ), n (%) 16 (39) 186 (44) 0.622
Risk Factors for Healthcare-Associated Pneumonia (HCAP), n (%) 11 (27) 153 (36) 0.305
Congestive Heart Failure, n (%) 7 (17) 122 (29) 0.143
Liver Disease, n (%) 3 (7) 24 (6) 0.722
Cancer, n (%) 8 (20) 37 (9) 0.045
Renal Disease, n (%) 6 (15) 83 (19) 0.537
Days with Respiratory Symptoms Prior to Hospitalization, Median (IQR) 4 (5) 4 (5) 0.784
Average Absolute Humidity the Day Before Symptom Onset, Median (IQR) 4.3 (1.4) 4.3 (1.8) 0.680
Average Relative Humidity the Day Before Symptom Onset, Median (IQR) 69 (9.1) 70.9 (9.3) 0.970
Average Temperature the Day Before Symptom Onset, Median (IQR) 3.8 (3.8) 3.8 (4.2) 0.612

2.6 Study Variables
Predictor Variable - The primary predictor variables for the
present study were as follows: 1) average absolute humidity per
week, 2) minimum absolute humidity per week, 3) maximum ab-
solute humidity per week, 4) average relative humidity per week,
5) minimum relative humidity per week, 6) maximum relative
humidity per week, 7) average temperature (degrees Celsius) per
week, 8) minimum temperature (degrees Celsius) per week, and
9) maximum temperature (degrees Celsius) per week. Data were
gathered from the national weather service, and the absolute hu-
midity in grams/meters3 was calculated with the following for-
mula (T =temperature in degrees Celsius, rh= percent relative
humidity):
(6.112 × e(17.67xT )/(T +243.5) × 2.1674 × rh) \ (273.15 + T )
Each of these variables was assigned to a particular patient based
on the formula described above for the date of acquisition of LRTI.
Confounding Variables - We evaluated the following potentially
confounding variables: age, gender, obesity, risk factors for HCAP,
the number of days with respiratory symptoms prior to hospital-
ization, as well as a history of: COPD, liver disease, renal disease,
diabetes, congestive heart failure, and cancer.
Quality Control/Data Management Plan - Trained study coordina-
tors or research associates collected data both from patient inter-
views/questionnaires, and from medical records. All data were
collected on a paper case report form and were subsequently
entered into an online case report form. The online system in-
cluded validators to limit data entry error. Once the case was
entered, trained study coordinators and research associates ex-
amined each case for abnormal data. Any queries were sent back
to the coordinator collecting data for remedy. Once all queries
were answered, the data were corrected and finally entered into
the online database.
2.7 Statistical Analysis
Categorical variables were expressed as frequencies and percent-
ages and were compared between those with and without in-
fluenza, with and without rhinovirus, and with and without RSV
using Chi-squared or Fisher’s exact tests. Continuous variables
were expressed as medians and interquartile ranges or means and
standard deviations and were compared between groups using
the Mann-Whitney U test or the student’s t-test. P-values ≤0.05
were considered statistically significant in all analyses unless oth-
erwise specified.
Poisson regression models with robust error variance were used to
model the incidence of hospitalization with a LRTI due to either:
1) influenza, 2) rhinovirus, and 3) respiratory syncytial virus (A
and/or B), separately 10 . For each of those three outcomes, nine
separate models were run, using each of the nine predictor vari-
ables listed in the Study Variables section. All models were ad-
justed for the confounding variables described previously.
P-values of ≤0.05 were considered statistically significant, and R
v3.0 was used for all analyses.

© ULJRI 2017 Vol 1, (3) 27–35 | 29

Table 3 Baseline Patient Characteristics and Climate Data Of Those With And Without Respiratory Syncytial Virus Lower Respiratory Tract Infections

Respiratory No Respiratory
Variable Syncytial Virus Syncytial Virus P-Value
n=27 n=440
Age, Median (IQR) 60 (17) 63 (21) 0.824
Male Gender, n (%) 19 (70) 246 (56) 0.164
COPD, n (%) 16 (59) 244 (55) 0.842
Diabetes, n (%) 9 (33) 162 (37) 0.838
Obese (BMI≥30kg/m2 ), n (%) 14 (52) 188 (43) 0.425
Risk Factors for Healthcare-Associated Pneumonia (HCAP), n (%) 9 (33) 155 (35) 1.000
Congestive Heart Failure, n (%) 13 (48) 116 (26) 0.024
Liver Disease, n (%) 1 (4) 26 (6) 1.000
Cancer, n (%) 0 (0) 45 (10) 0.095
Renal Disease, n (%) 6 (22) 83 (19) 0.619
Days with Respiratory Symptoms Prior to Hospitalization, Median (IQR) 4 (2.5) 4 (5) 0.379
Average Absolute Humidity the Day Before Symptom Onset, Median (IQR) 4.1 (1.9) 4.3 (1.8) 0.824
Average Relative Humidity the Day Before Symptom Onset, Median (IQR) 70.9 (14.2) 70.9 (9.3) 0.686
Average Temperature the Day Before Symptom Onset, Median (IQR) 3.3 (3.4) 3.8 (3.8) 0.307

RR=0.95, 95% CI=0.92,0.98, P−value=0.001

Max Temp ●

RR=0.94, 95% CI=0.90,0.97, P−value=0.001

Min Temp ●

RR=0.94, 95% CI=0.91,0.97, P−value=0.001

Avg Temp ●
Meteorological Parameter

RR=1.00, 95% CI=0.98,1.02, P−value=0.895

Max RH ●

RR=0.99, 95% CI=0.98,1, P−value=0.202

Min RH ●

RR=0.99, 95% CI=0.98,1.01, P−value=0.344

Avg RH ●

RR=0.86, 95% CI=0.78,0.95, P−value=0.004

Max AH ●

RR=0.87, 95% CI=0.79,0.96, P−value=0.004

Min AH ●

RR=0.86, 95% CI=0.78,0.95, P−value=0.004

Avg AH ●

0.75 0.80 0.85 0.90 0.95 1.00 1.05 1.10 1.15 1.20
Risk Ratio (RR) for Influenza Infection

Fig. 1 Adjusted impact of climate factors on hospitalizations due to influenza virus lower respiratory tract infections (Avg = average; Min = minimum;
Max = maximum; AH = absolute humidity; RH = relative humidity; Temp = temperature in degrees Celsius)

3 Results associated with hospitalization due to influenza LRTI, while the

A total of 467 hospitalized patients with LRTI were included in
the study, 293 with CAP, 126 with AECOPD, and 48 with AB. A to-
tal of 135 (29%) patients had influenza, 41 (9%) had rhinovirus,
and 27 (6%) had RSV (20 RSV A, 7 RSV B). Baseline patient char-
acteristics and baseline climate data on the day before symptom
onset of hospitalized patients with and without LRTIs due to in-
fluenza, rhinovirus, and RSV can be found in Tables 1, 2, and 3,
respectively.
During the three seasons, the average weekly absolute humidity
was 4.7 grams/m3 (min=2.3 grams/m3 ; max=9.2 grams/m3 ),
the average weekly relative humidity was 71.1% (min=42.3%;
max=85.7%), and the average weekly temperature was 4.3◦ C
(min=-2.3◦ C ; max=12.7◦ C).
The adjusted impact of each of the nine climate factors for in-
fluenza infection, rhinovirus infection, and RSV infection can be
seen in Figures 1, 2, and 3, respectively. The average, minimum,
and maximum absolute humidity and temperature variables were
relative humidity variables were not. Correlations between each
of the nine climate factors and the weekly influenza incidence
rates are depicted in Figure 4. None of the nine predictor vari-
ables were associated with hospitalization due to rhinovirus or
RSV.
4 Discussion
This study suggests that absolute humidity and temperature on
the day before symptom onset are associated with hospitaliza-
tions due to influenza LRTIs, but not with LRTIs due to rhinovirus
or respiratory syncytial virus during the influenza season. Fur-
thermore, the relative humidity on the day before symptom onset
was not associated with hospitalizations due to any of the eti-
ologies evaluated. Although temperature was associated with in-
fluenza LRTIs, the protective effects were small compared to those
related to relative humidity.
The relationships between climate factors and respiratory virus
infection incidence are documented in the literature but most

30 | © ULJRI 2017 Vol 1, (3) 27–35


Max Temp
Min Temp
Avg Temp
Meteorological Parameter
Max RH
Min RH
Avg RH
Max AH
Min AH
Avg AH
0.75 0.80
Fig. 2 Adjusted impact of climate factors on hospitalizations due to rhinovirus lower respiratory tract infections (Avg = average; Min = minimum; Max =
maximum; AH = absolute humidity; RH = relative humidity; Temp = temperature in degrees Celsius)
published studies are somewhat limited in their methods and
scope 5,11–43 . For example, there are no true incidence studies
evaluating this correlation enrolling all hospitalized patients with
lower respiratory tract infections in a defined population during
a defined time period in the literature. Available clinical data do
suggest that influenza virus infections are related to absolute hu-
midity 29 , relative humidity 44 , and temperature 45 . Interestingly,
contact transmission of the influenza virus, but not aerosol trans-
mission, may be facilitated in times of high temperature 46 and
in the presence of high humidity Rhinovirus has been shown to
survive more readily in aerosols as well as on surfaces in the pres-
ence of high relative humidity 9,47 . Since droplet and contact are
known modes of transmission of this organism, it has been sug-
gested that high humidity may prevent the virus from desiccating
thereby prolonging survival on environmental surfaces and sub-
sequently facilitating transmission. 6 . Increases in the incidence
of RSV infections have been correlated with both low and high
relative humidity levels 48,49 . However, rainfall has been associ-
ated with RSV incidence in multiple studies, both negatively and
positively 7,50–54 .
Various theories behind the association between climate fac-
tors and the incidence of respiratory viruses have been pro-
posed. Most of the theories have focused on the low tempera-
ture/humidity correlations with influenza virus 8,42 . Both inter-
host factors such as viral stability changes, respiratory droplet
size, and airflow, as well as host factors such as respiratory secre-
tion production and composition, viral clearance, seasonal nutri-
tion changes, ultraviolet light, and socio-behavioral changes (e.g.
close indoor contact) have been described as potential mecha-
nisms 8,55 . Our results suggest that host factors, including socio-
behavioral factors may not be primary drivers of respiratory vi-
ral epidemics during winter seasons. The climate certainly influ-
ences droplet size, host and socio-behavioral factors, but if those
RR=1.03, 95% CI=0.96,1.11, P−value=0.424
●
RR=1.02, 95% CI=0.94,1.12, P−value=0.588
●
RR=1.03, 95% CI=0.95,1.12, P−value=0.472
●
RR=0.99, 95% CI=0.94,1.04, P−value=0.75
●
RR=1.00, 95% CI=0.97,1.03, P−value=0.81
●
RR=0.99, 95% CI=0.95,1.04, P−value=0.753
●
RR=1.01, 95% CI=0.85,1.2, P−value=0.92
●
RR=1.01, 95% CI=0.85,1.2, P−value=0.909
●
RR=1.01, 95% CI=0.85,1.2, P−value=0.914
●
0.85 0.90 0.95 1.00 1.05 1.10 1.15 1.20
Risk Ratio (RR) for Rhinovirus Infection
factors were related to respiratory viral transmission, similar pat-
terns of association between climate factors and different viruses
should be seen. Since only the influenza virus was associated
with climate factors, our data suggest that absolute humidity and
temperature may affect influenza virus stability, pathogenesis or
virulence.
This study has a number of limitations. First, we did not account
for indoor climate, which may be different than outdoor climate
and could modify viral survival and transmission during the win-
ter months. Second, although we made an attempt to define the
date of infection with each virus, it is possible that we have not ac-
curately defined this date, leading to misclassification of climate
factors to each patient. Third, we had a relatively small sam-
ple size, which makes it difficult to make accurate assessments.
Since we enrolled patients only during the influenza season, it is
possible that we missed a number of cases of viral lower respira-
tory tract infections. For example, RSV and rhinovirus may have
been circulating at different times of the year leading to biased
estimates during the winter season. It is also possible that some
patients were misclassified as not having an LRTI due to one of
these viruses due to the diagnostic technique used. It is possi-
ble that patients arriving to the hospital may already have reduce
their respiratory virus to an undetectable level, resulting in mis-
classification. Finally, since this study was ecological in nature, it
is not possible to confirm that each patient was truly exposed to a
particular temperature or humidity level, particularly indoor tem-
perature and humidity values, where an individual may spend the
majority of their day. Another limitation of this study is the fact
that there are no accepted gold standard definitions of any of the
LRTIs we evaluated. Because of this, we may have misclassified
patients based on various definitions. Due to the relatively small
sample size, we were not able to evaluate differences among the
three influenza seasons. This could possibly induce bias in the re-
© ULJRI 2017 Vol 1, (3) 27–35 | 31

Max Temp
Min Temp
Avg Temp
Meteorological Parameter
Max RH
Min RH
Avg RH
Max AH
Min AH
Avg AH
0.75
Fig. 3 Adjusted impact of climate factors on hospitalizations due to respiratory syncytial virus lower respiratory tract infections (Avg = average; Min =
minimum; Max = maximum; AH = absolute humidity; RH = relative humidity; Temp = temperature in degrees Celsius)
sults. We were also not able to evaluate the role of asthma and/or
use of inhaled corticosteroids in COPD patients. This may bias the
results due to residual confounding.
The major strength of this study is that it is a population-based
incidence study of nearly all residents of Louisville, Kentucky re-
quiring hospitalization for a LRTI using active respiratory virus
surveillance. Most prior studies largely relied on a patient sam-
ple or passive surveillance and attempted to correlate population
based climate data with the patient sample. Since we were able to
enroll nearly all hospitalized patients with lower respiratory tract
infections in Louisville, we are able to reduce the bias inherent in
some other studies.
Future studies may consider the both the role of the outdoor and
indoor climate on the incidence of respiratory virus infections.
The indoor climate, humidity in particular, has been suggested
as an important factor in respiratory virus transmission 56 . Com-
bining the indoor and outdoor temperature may facilitate the de-
velopment of more robust predictive models for respiratory virus
infections. Furthermore, results of these studies may lead to the
development of climate modification interventions to limit viral
transmission. Finally, there is a need to further elucidate the
mechanisms behind the correlation between low absolute humid-
ity and the pathogenesis and/or virulence of the influenza virus
but not other respiratory viruses.
In conclusion, this study adds to the body of evidence that the
outdoor climate factors, particularly absolute humidity, are asso-
ciated with influenza incidence. However, we were not able to
demonstrate any impact of climate on the incidence of rhinovirus
or respiratory syncytial virus. Understanding factors contributing
to the transmission of respiratory viruses may assist in the predic-
tion of future outbreaks and facilitate the development of novel
interventions for preventing respiratory viral transmission.
32 | © ULJRI 2017 Vol 1, (3) 27–35
RR=0.95, 95% CI=0.88,1.03, P−value=0.213
●
RR=0.93, 95% CI=0.85,1.02, P−value=0.119
●
RR=0.94, 95% CI=0.86,1.03, P−value=0.159
●
RR=1.00, 95% CI=0.97,1.04, P−value=0.856
●
RR=1.01, 95% CI=0.98,1.05, P−value=0.435
●
RR=1.02, 95% CI=0.97,1.06, P−value=0.534
●
RR=1.00, 95% CI=0.97,1.04, P−value=0.856
●
RR=0.96, 95% CI=0.77,1.18, P−value=0.678
●
RR=0.95, 95% CI=0.77,1.19, P−value=0.671
●
0.80 0.85 0.90 0.95 1.00 1.05 1.10 1.15 1.20
Risk Ratio (RR) for RSV Infection
References
1 World Health Organization, “The top 10 causes of death,”
2015 [updated January 2017]. [Online]. Available: http:
//www.who.int/mediacentre/factsheets/fs310/en/
2 B. Müller-Pebody, N. S. Crowcroft, M. C. Zambon, and W. J.
Edmunds, “Modelling hospital admissions for lower respira-
tory tract infections in the elderly in england,” Epidemiology
and Infection, vol. 134, no. 06, pp. 1150–1157, 2006.
3 T. Wiemken, P. Peyrani, K. Bryant, R. R. Kelley, J. Summers-
gill, F. Arnold et al., “Incidence of respiratory viruses in pa-
tients with community-acquired pneumonia admitted to the
intensive care unit: results from the severe influenza pneu-
monia surveillance (sips) project,” European journal of clinical
microbiology & infectious diseases, vol. 32, no. 5, pp. 705–710,
2013.
4 J. A. Ramirez, “The challenge of predicting influenza,” Fron-
tiers in microbiology, vol. 2, 2011.
5 J. Shaman and M. Kohn, “Absolute humidity modulates in-
fluenza survival, transmission, and seasonality,” Proceedings
of the National Academy of Sciences, vol. 106, no. 9, pp. 3243–
3248, 2009.
6 J. D. Noti, F. M. Blachere, C. M. McMillen, W. G. Lindsley,
M. L. Kashon, D. R. Slaughter et al., “High humidity leads
to loss of infectious influenza virus from simulated coughs,”
PLoS One, vol. 8, no. 2, p. e57485, 2013.
7 S. B. Omer, A. Sutanto, H. Sarwo, M. Linehan, I. G. Djelantik,
D. Mercer et al., “Climatic, temporal, and geographic charac-
teristics of respiratory syncytial virus disease in a tropical is-
land population,” Epidemiology and infection, vol. 136, no. 10,
pp. 1319–1327, 2008.
8 A. C. Lowen and J. Steel, “Roles of humidity and temperature
 40 9 40 50 40 20
18
35 35 35
8 55 16
30 30 30 14
7 60 12
25 25 25
10
20 6 20 65 20
8
15 15 15 6
5 70

Absolute Humidity
4

(grams/cubic meter)
10 10 10
4 2

Relative Humidity (Percent)

75

% of Positive Influenza Cases

% of Positive Influenza Cases

% of Positive Influenza Cases
5 5
Temperature (Degrees Celsius)

5 0
0 3 0 80 0 -2
40 42 44 46 48 50 1 3 5 7 9 11 13 15 17 40 42 44 46 48 50 1 3 5 7 9 11 13 15 17 40 41 42 43 44 45 46 47 48 49 50 51 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
Weeks Weeks Weeks

Weekly Flu Cases Average Weekly Absolute Humidity Weekly Flu Cases Average Weekly Relative Humidity Weekly Flu Cases Average Weekly Temperature

40 9 40 70 40 12
35 35 35 10
8 75
30 30 8
30
80
7 6
25 25 25
85 4
20 6 20 20
90 2
15 15 15
5

Absolute Humidity
0

(grams/cubic meter)
10 95
10 10
Relative Humidity (Percent)
-2

% of Positive Influenza Cases

% of Positive Influenza Cases

% of Positive Influenza Cases

Temperature (Degrees Celsius)

4
5 5 100 5 -4
0 3 0 105 0 -6
40 42 44 46 48 50 1 3 5 7 9 11 13 15 17 40 42 44 46 48 50 1 3 5 7 9 11 13 15 17 40 42 44 46 48 50 1 3 5 7 9 11 13 15 17
Weeks Weeks Weeks

Weekly Flu Cases Minimum Weekly Absolute Humidity Weekly Flu Cases Minimum Weekly Relative Humidity Weekly Flu Cases Minimum Weekly Temperature

40 9 40 25 40 25

35 35 30 35
8
20
30 30 35 30
7
25 25 40 25 15

20 6 20 45 20

15 10
15 15 50

Absolute Humidity
5

(grams/cubic meter)
10 55 10
Relative Humidity (Percent)

10
% of Positive Influenza Cases

% of Postive Influenza Cases

% of Positive Influenza Cases

Temperature (Degrees Celsius)

5
4 5
5 5 60

0 3 0 65 0 0
40 42 44 46 48 50 1 3 5 7 9 11 13 15 17 40 42 44 46 48 50 1 3 5 7 9 11 13 15 17 40 42 44 46 48 50 1 3 5 7 9 11 13 15 17
Weeks Weeks Weeks

Weekly Flu Cases Maximum Weekly Absolute Humidity Weekly Flu Cases Maximum Weekly Relative Humidity Weekly Flu Cases Maximum Weekly Temperature

Fig. 4 Depiction of the correlation between nine climate variables and the weekly influenza incidence rate

© ULJRI 2017 Vol 1, (3)

27–35 | 33
 in shaping influenza seasonality,” Journal of virology, vol. 88,
no. 14, pp. 7692–7695, 2014.
9 Y. G. Karim, M. K. Ijaz, S. A. Sattar, and C. M. Johnson-
Lussenburg, “Effect of relative humidity on the airborne sur-
vival of rhinovirus-14,” Canadian journal of microbiology,
vol. 31, no. 11, pp. 1058–1061, 1985.
10 G. Zou, “A modified poisson regression approach to prospec-
tive studies with binary data,” American journal of epidemiol-
ogy, vol. 159, no. 7, pp. 702–706, 2004.
11 M. L. Bouzas, J. R. Oliveira, K. F. Fukutani, I. C. Borges,
A. Barral, W. Van der Gucht et al., “Respiratory syncytial
virus a and b display different temporal patterns in a 4-year
prospective cross-sectional study among children with acute
respiratory infection in a tropical city,” Medicine, vol. 95,
no. 41, 2016.
12 E. R. Deyle, M. C. Maher, R. D. Hernandez, S. Basu, and
G. Sugihara, “Global environmental drivers of influenza,” Pro-
ceedings of the National Academy of Sciences, p. 201607747,
2016.
13 P. Fagan, C. McLeod, and R. W. Baird, “Seasonal variability
of respiratory syncytial virus infection in the top end of the
northern territory (2012–2014),” Journal of paediatrics and
child health, vol. 53, no. 1, pp. 43–46, 2017.
14 A. R. R. Freitas and M. R. Donalisio, “Respiratory syncytial
virus seasonality in brazil: implications for the immunisation
policy for at-risk populations,” Memórias do Instituto Oswaldo
Cruz, vol. 111, no. 5, pp. 294–301, 2016.
15 R. Q. Gurgel, P. G. de Matos Bezerra, M. d. C. M. B. Duarte,
A. Á. Moura, E. L. Souza, L. S. da Silveira Silva, C. E. Suzuki,
and R. B. Peixoto, “Relative frequency, possible risk factors, vi-
ral codetection rates, and seasonality of respiratory syncytial
virus among children with lower respiratory tract infection in
northeastern brazil,” Medicine, vol. 95, no. 15, 2016.
16 T. M. Ikäheimo, K. Jaakkola, J. Jokelainen, A. Saukkoriipi,
M. Roivainen, R. Juvonen et al., “A decrease in temperature
and humidity precedes human rhinovirus infections in a cold
climate,” Viruses, vol. 8, no. 9, p. 244, 2016.
17 T. Kamigaki, L. Chaw, A. G. Tan, R. Tamaki, P. P. Alday, J. B.
Javier, R. M. Olveda, H. Oshitani, and V. L. Tallo, “Seasonality
of influenza and respiratory syncytial viruses and the effect
of climate factors in subtropical–tropical asia using influenza-
like illness surveillance data, 2010–2012,” PloS one, vol. 11,
no. 12, p. e0167712, 2016.
18 S. Morikawa, U. Kohdera, T. Hosaka, K. Ishii, S. Akagawa,
S. Hiroi, and T. Kase, “Seasonal variations of respiratory
viruses and etiology of human rhinovirus infection in chil-
dren,” Journal of Clinical Virology, vol. 73, pp. 14–19, 2015.
19 P. D. Shaw Stewart, “Seasonality and selective trends in viral
acute respiratory tract infections,” Medical hypotheses, vol. 86,
pp. 104–119, 2016.
20 N. Sirimi, M. Miligkos, F. Koutouzi, E. Petridou, T. Sia-
hanidou, and A. Michos, “Respiratory syncytial virus activity
and climate parameters during a 12-year period,” Journal of
medical virology, 2015.
21 C. Sloan, M. Heaton, S. Kang, C. Berrett, P. Wu, T. Gebret-
34 | © ULJRI 2017 Vol 1, (3) 27–35
sadik, N. Sicignano, A. Evans, R. Lee, and T. Hartert, “The
impact of temperature and relative humidity on spatiotempo-
ral patterns of infant bronchiolitis epidemics in the contiguous
united states,” Health & Place, vol. 45, pp. 46–54, 2017.
22 N. Sundell, L.-M. Andersson, R. Brittain-Long, M. Lindh, and
J. Westin, “A four year seasonal survey of the relationship be-
tween outdoor climate and epidemiology of viral respiratory
tract infections in a temperate climate,” Journal of Clinical Vi-
rology, vol. 84, pp. 59–63, 2016.
23 N. Zhao, G. Cao, J. K. Vanos, and D. J. Vecellio, “The effects
of synoptic weather on influenza infection incidences: a ret-
rospective study utilizing digital disease surveillance,” Inter-
national Journal of Biometeorology, pp. 1–16, 2017.
24 S. F. Dowell and M. S. Ho, “Seasonality of infectious diseases
and severe acute respiratory syndrome–what we don’t know
can hurt us,” The Lancet infectious diseases, vol. 4, no. 11, pp.
704–708, 2004.
25 J. Shaman and A. Karspeck, “Forecasting seasonal outbreaks
of influenza,” Proceedings of the National Academy of Sciences,
vol. 109, no. 50, pp. 20 425–20 430, 2012.
26 J. Shaman, V. Pitzer, C. Viboud, M. Lipsitch, and B. Grenfell,
“Absolute humidity and the seasonal onset of influenza in the
continental us,” PLoS currents, vol. 2.
27 J. Shaman, V. E. Pitzer, C. Viboud, B. T. Grenfell, and M. Lip-
sitch, “Absolute humidity and the seasonal onset of influenza
in the continental united states,” PLoS Biol, vol. 8, no. 2, p.
e1000316, 2010.
28 M. Shoji, K. Katayama, and K. Sano, “Absolute humidity as a
deterministic factor affecting seasonal influenza epidemics in
japan,” The Tohoku journal of experimental medicine, vol. 224,
no. 4, pp. 251–256, 2011.
29 D. R. Silva, V. P. Viana, A. M. Müller, F. P. Livi, and P. d. T. R.
Dalcin, “Respiratory viral infections and effects of meteoro-
logical parameters and air pollution in adults with respiratory
symptoms admitted to the emergency room,” Influenza and
other respiratory viruses, vol. 8, no. 1, pp. 42–52, 2014.
30 J. M. Simmerman, P. Suntarattiwong, J. Levy, R. V. Gib-
bons, C. Cruz, J. Shaman, R. G. Jarman, and T. Chotpitaya-
sunondh, “Influenza a virus contamination of common house-
hold surfaces during the 2009 influenza a (h1n1) pandemic
in bangkok, thailand: Implications for contact transmission,”
Clinical Infectious Diseases, vol. 51, no. 9, pp. 1053–1061,
2010.
31 C. Sloan, M. L. Moore, and T. Hartert, “Impact of pollution,
climate, and sociodemographic factors on spatiotemporal dy-
namics of seasonal respiratory viruses,” Clinical and transla-
tional science, vol. 4, no. 1, pp. 48–54, 2011.
32 R. P. Soebiyanto, F. Adimi, and R. K. Kiang, “Modeling and
predicting seasonal influenza transmission in warm regions
using climatological parameters,” PloS one, vol. 5, no. 3, p.
e9450, 2010.
33 H. Sooryanarain and S. Elankumaran, “Environmental role in
influenza virus outbreaks,” Annu. Rev. Anim. Biosci., vol. 3,
no. 1, pp. 347–373, 2015.
34 V. L. Tallo, T. Kamigaki, A. G. Tan, R. R. Pamaran, P. P. Alday,
 E. S. Mercado, J. B. Javier, H. Oshitani, and R. M. Olveda,
“Estimating influenza outpatients’ and inpatients’ incidences
from 2009 to 2011 in a tropical urban setting in the philip-
pines,” Influenza and other respiratory viruses, vol. 8, no. 2,
pp. 159–168, 2014.
35 J. Tamerius, M. I. Nelson, S. Z. Zhou, C. Viboud, M. A. Miller,
and W. J. Alonso, “Global influenza seasonality: reconciling
patterns across temperate and tropical regions,” Environmen-
tal health perspectives, vol. 119, no. 4, p. 439, 2011.
36 J. D. Tamerius, J. Shaman, W. J. Alonso, K. Bloom-Feshbach,
C. K. Uejio, A. Comrie, and C. Viboud, “Environmental pre-
dictors of seasonal influenza epidemics across temperate and
tropical climates,” PLoS Pathog, vol. 9, no. 3, p. e1003194,
2013.
37 J. W. Tang and T. P. Loh, “Correlations between climate fac-
tors and incidence-a contributor to rsv seasonality,” Reviews in
medical virology, vol. 24, no. 1, pp. 15–34, 2014.
38 D. E. te Beest, M. van Boven, M. Hooiveld, C. van den
Dool, and J. Wallinga, “Driving factors of influenza transmis-
sion in the netherlands,” American journal of epidemiology, p.
kwt132, 2013.
39 S. Towers, G. Chowell, R. Hameed, M. Jastrebski, M. Khan,
J. Meeks, A. Mubayi, and G. Harris, “Climate change and in-
fluenza: the likelihood of early and severe influenza seasons
following warmer than average winters,” PLOS Currents In-
fluenza, 2013.
40 S. P. van Noort, R. Águas, S. Ballesteros, and M. G. M. Gomes,
“The role of weather on the relation between influenza and
influenza-like illness,” Journal of theoretical biology, vol. 298,
pp. 131–137, 2012.
41 W. Yang, S. Elankumaran, and L. C. Marr, “Relationship be-
tween humidity and influenza a viability in droplets and im-
plications for influenza’s seasonality,” PloS one, vol. 7, no. 10,
p. e46789, 2012.
42 W. Yang and L. C. Marr, “Dynamics of airborne influenza
a viruses indoors and dependence on humidity,” PloS one,
vol. 6, no. 6, p. e21481, 2011.
43 T. Żuk, F. Rakowski, and J. P. Radomski, “Probabilistic model
of influenza virus transmissibility at various temperature and
humidity conditions,” Computational biology and chemistry,
vol. 33, no. 4, pp. 339–343, 2009.
44 J. W. Tang, F. Y. Lai, P. Nymadawa, Y.-M. Deng, M. Ratnamo-
han, M. Petric, T. P. Loh, N. W. Tee, D. E. Dwyer, I. G. Barr
et al., “Comparison of the incidence of influenza in relation to
climate factors during 2000–2007 in five countries,” Journal
of medical virology, vol. 82, no. 11, pp. 1958–1965, 2010.
45 S. M. Firestone, N. Cogger, M. P. Ward, J.-A. L. Toribio, B. J.
Moloney, and N. K. Dhand, “The influence of meteorology on
the spread of influenza: survival analysis of an equine in-
fluenza (a/h3n8) outbreak,” PloS one, vol. 7, no. 4, p. e35284,
2012.
46 A. C. Lowen, J. Steel, S. Mubareka, and P. Palese, “High tem-
perature (30 c) blocks aerosol but not contact transmission
of influenza virus,” Journal of virology, vol. 82, no. 11, pp.
5650–5652, 2008.
47 S. A. Sattar, Y. G. Karim, V. S. Springthorpe, and C. Johnson-
Lussenburg, “Survival of human rhinovirus type 14 dried onto
nonporous inanimate surfaces: effect of relative humidity
and suspending medium,” Canadian journal of microbiology,
vol. 33, no. 9, pp. 802–806, 1987.
48 C.-S. Khor, I.-C. Sam, P.-S. Hooi, K.-F. Quek, and Y.-F. Chan,
“Epidemiology and seasonality of respiratory viral infections
in hospitalized children in kuala lumpur, malaysia: a retro-
spective study of 27 years,” BMC pediatrics, vol. 12, no. 1,
p. 32, 2012.
49 J. Rechsteiner, “Inactivation of respiratory syncytial virus in
air,” Antonie van Leeuwenhoek, vol. 35, no. 1, pp. 238–238,
1969.
50 P. W. Chan, F. T. Chew, T. N. Tan, K. B. Chua, and P. S. Hooi,
“Seasonal variation in respiratory syncytial virus chest infec-
tion in the tropics,” Pediatric pulmonology, vol. 34, no. 1, pp.
47–51, 2002.
51 M. P. Loscertales, A. Roca, P. J. Ventura, F. Abacassamo,
F. Dos Santos, M. Sitaube, C. MenÉndez, B. M. Greenwood,
J. C. Saiz, and P. L. Alonso, “Epidemiology and clinical presen-
tation of respiratory syncytial virus infection in a rural area of
southern mozambique,” The Pediatric infectious disease jour-
nal, vol. 21, no. 2, pp. 148–155, 2002.
52 P. E. Reese and N. J. Marchette, “Respiratory syncytial virus
infection and prevalence of subgroups a and b in hawaii.”
Journal of clinical microbiology, vol. 29, no. 11, pp. 2614–
2615, 1991.
53 S. E. Robertson, A. Roca, P. Alonso, E. A. Simoes, C. B.
Kartasasmita, D. O. Olaleye, G. N. Odaibo, M. Collinson,
M. Venter, Y. Zhu et al., “Respiratory syncytial virus infection:
denominator-based studies in indonesia, mozambique, nige-
ria and south africa,” Bulletin of the World Health Organiza-
tion, vol. 82, no. 12, pp. 914–922, 2004.
54 M. W. Weber, E. K. Mulholland, and B. M. Greenwood, “Res-
piratory syncytial virus infection in tropical and developing
countries,” Tropical Medicine & International Health, vol. 3,
no. 4, pp. 268–280, 1998.
55 N. Pica and N. M. Bouvier, “Environmental factors affecting
the transmission of respiratory viruses,” Current opinion in vi-
rology, vol. 2, no. 1, pp. 90–95, 2012.
56 T. H. Koep, F. T. Enders, C. Pierret, S. C. Ekker,
D. Krageschmidt, K. L. Neff, M. Lipsitch, J. Shaman, and W. C.
Huskins, “Predictors of indoor absolute humidity and esti-
mated effects on influenza virus survival in grade schools,”
BMC infectious diseases, vol. 13, no. 1, p. 71, 2013.
© ULJRI 2017 Vol 1, (3) 27–35 | 35