ORIGINAL STUDIES High Prevalence of Acute Respiratory Tract Infections Among Warao Amerindian Children in Venezuela in Relation to Low Immunization Coverage and Chronic Malnutrition Lilly M. Verhagen, MD,*† Adilia Warris, MD, PhD,†‡ Peter W. M. Hermans, PhD,†‡ Berenice del Nogal, MD,§ Ronald de Groot, MD, PhD,†‡ and Jacobus H. de Waard, PhD* Background: Higher prevalence rates of acute respiratory tract infections (ARTIs) have been described in Australian and Canadian indigenous populations than in nonindigenous age-matched counterparts. Few studies on ARTIs in South American indigenous populations have been published. We performed a cross-sectional survey to describe the prevalence of upper respiratory tract infections and acute lower respiratory tract infections (ALRTIs) and associations with malnutrition and immunization status. Methods: From December 1, 2009 to May 31, 2010, 487 Warao Amer- indian children 0 to 59 months of age living in the Delta Amacuro in Venezuela were included in a cross-sectional survey. Data were obtained through parent questionnaires, vaccination cards, and physical examina- tions including anthropometric measurements. Results: Of the 487 children, 47% presented with an ARTI. Of these, 60% had upper respiratory tract infections and 40% were ALRTI. Immunization coverage was low, with only 27% of all children presenting a vaccination card being fully immunized. The prevalence of malnutrition was high (52%), with stunting (height-for-age -2 standard deviations) being the most frequent presentation affecting 45% of children. ARTI and ALRTI prevalence diminished with increasing age (odds ratio for ALRTI in children 25–59 months of age vs. children younger than 12 months, 0.49; 95% confidence interval, 0.26 – 0.93). Furthermore, significant differences in ARTI prevalence were seen between villages. No significant associa- tions between immunization status or malnutrition and ARTI or ALRTI prevalence were identified. Conclusions: A high prevalence of ARTIs and chronic malnutrition in combination with a low immunization status highlights the need for an integrated approach to improve the health status of indigenous Venezuelan children. Key Words: indigenous children, respiratory tract infections, otitis media, malnutrition, immunization coverage (Pediatr Infect Dis J 2012;31: 255–262) A cute respiratory tract infections (ARTIs) are among the leading causes of death in children younger than 5 years throughout the world. 1 Point prevalences of clinically diagnosed ARTI in Indian and Brazilian children 5 years of age varied from 11% to 24%, depending on demographic and environmental factors such as socioeconomic status and crowding. 2–5 In indigenous children, ARTIs are more common than among nonindigenous age-matched counterparts in the same region, 6 and high prev- alence rates of otitis media are described in Australian and Canadian indigenous children. 7,8 Malnutrition is also rampant in indigenous populations. It is not uncommon to find indigenous groups in which malnutrition affects more than a quarter of children 5 years of age. 9 –11 In Latin American indigenous populations, the coexistence of mal- nutrition and a high prevalence of infectious diseases leads to disproportionately high infant mortality rates and a low overall life expectancy at birth compared with nonindigenous populations. 12 Additionally, Latin America’s indigenous populations receive less medical care and have less access to preventive care such as vaccination programs than nonindigenous populations. 12 The Warao people residing in the Orinoco River delta along the eastern coast of Venezuela (Fig. 1) are the second largest Venezuelan indigenous population. They live in an estimated 300 villages consisting of a number of wooden houses raised on stilts along the river banks. We performed a cross-sectional survey to estimate the prevalence of clinically diagnosed upper respiratory tract infections (URTIs), acute lower respiratory tract infections (ALRTIs), and recurrent wheeze in Warao Amerindian children aged 0 to 59 months and studied the impact of nutritional and immunization status. METHODS Ethical Considerations The nature and objectives of the survey were explained to parents in Spanish and/or in their native language. Children were examined and vaccination cards were copied after obtaining oral informed parental consent. The ethical committee of the Instituto de Biomedicina, the Regional Health Services, and the Indigenous Health Committee of the Ministry of Health and Social Welfare approved this survey. Study Setting The Delta Amacuro or Orinoco Delta comprises 4 munici- palities. This survey was undertaken in 8 isolated Warao villages located in the largest of the 4 municipalities, Antonio Diaz, which has almost 19,000 inhabitants. In most villages, a small poorly equipped health post is present. The nearest hospital with radiol- ogy and laboratory facilities is located at an average sail distance of approximately 100 km, corresponding to a boat trip of 2 to 7 hours, depending on the material of which the boat is made, the horsepower of the engines, and how heavily the boat is loaded. Vaccination is carried out by regional mobile vaccination teams Accepted for publication October 25, 2011. From the *Laboratorio de Tuberculosis, Instituto de Biomedicina, Caracas, Venezuela; †Division of Pediatric Infectious Diseases, Department of Pe- diatrics, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands; ‡Nijmegen Institute for Infection, Inflammation and Immu- nity, Radboud University Nijmegen Medical Centre, Nijmegen, The Neth- erlands; and §Departamento de Pediatría, Hospital de Nin ˜os “J.M. de los Rios,” Caracas, Venezuela. Supported by LOCTI research grant from Total Venezuela SA. The authors have no other funding or conflicts of interest to disclose. Address for Correspondence: Lilly M. Verhagen, MD, Laboratory of Pediatric Infectious Diseases, Radboud University Nijmegen Medical Centre, PO Box 9101 (internal post 224), 6500 HB Nijmegen, The Netherlands. E-mail: lillyverhagen@hotmail.com. Copyright © 2012 by Lippincott Williams & Wilkins ISSN: 0891-3668/12/3103-0255 DOI: 10.1097/INF.0b013e31823eed8e The Pediatric Infectious Disease Journal • Volume 31, Number 3, March 2012 www.pidj.com | 255