Preventable drivers of acute respiratory infections among under-five children in India’s high-risk zones: application of population attributable fractions analyses

Background Acute respiratory infections (ARI) remain a major contributor to morbidity and mortality among under-five children in India. Although previous national studies have identified individual-level risk factors, evidence on the spatial distribution of ARI and the burden statistically attributable to selected exposures within hotspot regions remains limited. Methods We analysed data from the 2019–21 National Family Health Survey (NFHS-5) Children’s Recode file using a two-stage analytical framework. First, district-level ARI hotspots were identified among 221,849 under-five children across 707 districts. Second, analyses were restricted to children residing in hotspot districts (weighted n = 108,470). Survey-weighted prevalence, multivariable logistic regression, and population attributable fraction (PAF) analyses accounted for sampling weights, clustering, and stratification. Findings A total of 167 districts were identified as ARI hotspots, predominantly in central and eastern India. The unrestricted national weighted prevalence of ARI in the study dataset was 2.74%, compared with 7.23% (95% CI 7.08–7.39) within hotspot districts. Recent diarrhoeal illness (AOR 4.37, 95% CI 4.01–4.76) and maternal tobacco use (AOR 1.29, 95% CI 1.06–1.57) were independently associated with ARI. The PAF was 19.6% for recent diarrhoea and 0.7% for maternal tobacco use. Rural residence, interpreted as a contextual marker rather than a directly modifiable exposure, had a model-based PAF of 10.2%. The joint counterfactual scenario yielded a PAF of 28.7% (95% CI 20.4–36.1). Conclusions Under-five ARI is geographically concentrated in distinct hotspot districts. Integrated interventions addressing diarrhoeal disease and maternal tobacco exposure, together with improvements in rural child-health services and infrastructure, may reduce ARI burden in these districts. Because rural residence is not itself an intervention, its PAF should be interpreted as a priority-setting indicator of place-based disadvantage rather than as the effect of relocating rural populations.