Severe outcomes associated with respiratory viruses in newborns and infants: a prospective viral surveillance study in Jordan

Burden of viral respiratory infections in the pediatric intensive care unit: age, virus distribution, and the impact of the COVID-19 pandemic

Though usually self-limiting, viral respiratory infections can escalate to severe cases requiring admission to a pediatric intensive care unit (PICU). This study aims to examine the proportional incidence, affected age ranges, viral pathogens involved, associated severity measures, and the impact of the COVID-19 pandemic on their incidence and virus distribution. This retrospective cohort study conducted in a tertiary care center (2011-2021) reviewed all pediatric patients admitted to PICU with laboratory-confirmed viral respiratory infection. The study included 312 patients, comprising 5.5% of all PICU admissions; 45% were males; 52% had underlying conditions. The median age was 1.1 (IQR 0.3-2.8) years; 18% were born prematurely. The most common viruses were respiratory syncytial virus (35%), adenovirus (26%), influenza (10%), parainfluenza (11%), and human metapneumovirus (11%). All viruses displayed a seasonal pattern, except year-round occurrence in adenovirus. The seasonality pattern was disrupted by COVID-19 pandemic-related restrictions. Mechanical ventilation was required for 46% of patients; 27% required other non-invasive respiratory support. Thirty-day mortality was documented in 18 (5.8%) patients. Underlying conditions, particularly immunosuppression, neuromuscular diseases, and genetic/metabolic syndromes, were associated with increased mortality (p = 0.001, 0.006, and 0.001, respectively). Adenovirus was also linked to higher mortality (p = 0.04), hMPV to prolonged ventilation (p = 0.004) and prolonged PICU stay (p = 0.009), and SARS-CoV-2 to extended ventilation (p = 0.04). During COVID-19, patients were older (p = 0.001), RSV cases decreased (p = 0.006), ventilation duration increased (p = 0.03), and cardiologic complications rose (p = 0.02). No influenza A or B cases appeared post-pandemic.

CONCLUSION

Viral respiratory infections can lead to severe complications. Their high prevalence in infants and young children highlights the need to extend vaccination age ranges for vaccine-preventable viral infections, monitor uptake in at-risk children, and implement public health interventions in daycare settings.

WHAT IS KNOWN

• Viral respiratory infections in children are a significant cause of illness and mortality.

WHAT IS NEW

• Severe infections in children beyond current vaccine eligibility suggest the need to expand vaccination to broader age groups. • SARS-CoV-2 dominance during the COVID-19 pandemic altered disease characteristics of respiratory infections.

Molecular characterization of human respiratory syncytial virus strains circulating among hospitalized children in Jordan

BACKGROUND

Human Respiratory Syncytial Virus (HRSV) is a primary cause of severe pediatric respiratory infections, particularly in infants and young children, often resulting in hospitalization. The virus possesses a high degree of mutagenic potential, contributing to significant antigenic diversity, which complicates immune responses and poses challenges for vaccine development and disease management. This study was conducted in Jordan from 2022 to 2023 to epidemiologically determine the prevalence and molecular characteristics of RSV.

METHODS

A total of 288 nasopharyngeal (NP) swabs were collected from hospitalized children at Prince Hamza Hospital, Amman, Jordan. All samples were screened for common viral and bacterial respiratory pathogens using PCR. A partial segment of the G gene of RSV was amplified for molecular characterization and phylogenetic tree analysis.

RESULTS

Viral and/or bacterial infection was identified in 71.9% (207/288) of the tested specimens. Among these, 35 samples (12.2%, 35/288) tested positive for RSV. Specific subgroup PCR analysis identified (25, 71.4%) RSV-A, (4, 11.4%) RSV-B, and (6, 17.1%) could not be identified using our set of primers. Phylogenetic tree analysis revealed that RSV-A ON1 and RSV-B BA9 genotype strains predominate in Jordan. We observed multiple substitutions in our studied sample which would drive variation in the level of antigenicity and pathogenicity of RSV. Glycosylation sites identified were consistent with previously reported studies.

CONCLUSION

This study provides updated epidemiological data on the strains circulating in Amman, Jordan and their molecular characteristics. Continuous RSV surveillance informs vaccine development, guides public health interventions, and enables timely administration of prophylactic treatments, reducing the burden of RSV-related illness.

Respiratory syncytial virus burden in children under 2 years old in understudied areas worldwide: gap analysis of available evidence, 2012-2022

Background

We evaluated published evidence (2012-2022) on pediatric RSV burden in 149 countries within World Health Organization (WHO) regions of Africa (AFRO), Americas (AMRO, excluding Canada and the USA), Eastern Mediterranean (EMRO), Europe (EURO, excluding European Union countries and the UK), Southeast Asia (SEARO), and Western Pacific (WPRO, excluding Australia, China, Japan, New Zealand, and South Korea).

Methods

Gap analysis on RSV-associated disease (hospitalizations, hospital course, mortality or case fatality, detection, and incidence) in children ≤2 years old, where hospitalization rates, hospital course, mortality rate, case fatality rate (CFR), and postmortem detection rates were summarized, by region, for each country.

Results

Forty-two publications were identified covering 19% of included countries in AFRO, 18% in AMRO, 14% in EMRO, 15% in EURO, 18% in SEARO, and 13% in WPRO. Methods, case definitions, and age groups varied widely across studies. Of these 42 publications, 25 countries reported hospitalization rate, hospital course, mortality rate, CFR, and/or postmortem detection rate. RSV hospitalization rate (per 1,000 children per year/child-years) was higher among ≤3-month-olds (range, 38 in Nicaragua to 138 in the Philippines) and ≤6-month-olds (range, 2.6 in Singapore to 70 in South Africa) than in 1-2-year-olds (from 0.7 in Guatemala to 19 in Nicaragua). Based on 11 studies, in AFRO (South Africa), AMRO (Chile and Mexico), EMRO (Lebanon and Jordan), EURO (Israel and Turkey), and SEARO (India), hospitalized children ≤2 years old remained hospitalized for 3-8 days, with 9%-30% requiring intensive care and 4%-26% needing mechanical ventilation. Based on a study in India, community-based CFR was considerably higher than that in the hospital (9.1% vs. 0% in ≤3-month-olds; 7.1% vs. 2.8% in ≤6-month-olds).

Conclusions

National and regional heterogeneity of evidence limits estimates of RSV burden in ≤2-year-olds in many WHO region countries, where further country-specific epidemiology is needed to guide prioritization, implementation, and impact assessment of RSV prevention strategies.

Respiratory Syncytial Vaccination: Parents' Willingness to Vaccinate Their Children

BACKGROUND

This study was conducted to assess parents' willingness to vaccinate their children with the RSV vaccine and the key predictors of this intention among parents in Italy.

METHODS

Data were collected using an anonymous self-administered questionnaire from April to November 2023, targeting parents in public kindergartens and nursery schools in southern Italy. The survey assessed parents' socio-demographic characteristics, health-related details, their child's health status, attitudes toward RSV infection and its vaccine, and their source(s) of information.

RESULTS

A total of 404 parents agreed to participate in the study. Only 18.2% of participants were very concerned that their children could get infected by RSV, and this concern was more likely among parents whose child had been diagnosed with bronchiolitis, those who received information from HCWs, those who had heard of RSV, and those who needed additional information. Almost half (51.3%) were willing to vaccinate their child, and this inclination was more likely among fathers, employed parents, those with daughters, those who had heard of RSV, those who received information from HCWs, and those who needed additional information.

CONCLUSIONS

An educational campaign regarding a future RSV vaccine, especially about its safety and efficacy, is needed in order to improve parents' willingness.

Pretransplant ribavirin and interferon-α therapy for rhinovirus interstitial pneumonia in a RAG1-deficient infant

Severe combined immunodeficiency (SCID) is one of the most serious inborn errors of immunity leading to a fatal infection in early infancy. Allogeneic hematopoietic cell transplantation (HCT) or elective gene therapy prior to infection or live-attenuated vaccination is the current standard of curative treatment. Even in the era of newborn screening for SCID, pretransplant control of severe infection is challenging for SCID. Multiple pathogens are often isolated from immunocompromised patients, and limited information is available regarding antiviral strategies to facilitate curative HCT. We herein present a case of successfully controlled pretransplant pneumonia after ribavirin and interferon-α therapy in an infant with RAG1-deficiency. A four-month-old infant presented with severe interstitial pneumonia due to a co-infection of rhinovirus and Pneumocystis jirovecii. The tentative diagnosis of SCID prompted to start antibiotics and trimethoprim-sulfamethoxazole on ventilatory support. Because of the progressive respiratory failure four days after treatment, ribavirin and then pegylated interferon-α were started. He showed a drastic response to the treatment that led to a curative HCT 32 days after admission. This patient received the genetic diagnosis of RAG1-deficiency. Currently, he is an active 3-year-old boy with normal growth and development. The review of literature indicated that rhinovirus had a comparable or rather greater impact on the mortality of pediatric patients than respiratory syncytial virus. Considered the turn-around time to the genetic diagnosis of SCID, prompt ribavirin plus interferon-α therapy may help to control severe rhinovirus pneumonia and led to the early curative HCT for the affected infants.

Etiology of Acute Lower Respiratory Illness Hospitalizations Among Infants in 4 Countries

Background

Recent studies explored which pathogens drive the global burden of pneumonia hospitalizations among young children. However, the etiology of broader acute lower respiratory tract infections (ALRIs) remains unclear.

Methods

Using a multicountry study (Albania, Jordan, Nicaragua, and the Philippines) of hospitalized infants and non-ill community controls between 2015 and 2017, we assessed the prevalence and severity of viral infections and coinfections. We also estimated the proportion of ALRI hospitalizations caused by 21 respiratory pathogens identified via multiplex real-time reverse transcription polymerase chain reaction with bayesian nested partially latent class models.

Results

An overall 3632 hospitalized infants and 1068 non-ill community controls participated in the study and had specimens tested. Among hospitalized infants, 1743 (48.0%) met the ALRI case definition for the etiology analysis. After accounting for the prevalence in non-ill controls, respiratory syncytial virus (RSV) was responsible for the largest proportion of ALRI hospitalizations, although the magnitude varied across sites-ranging from 65.2% (95% credible interval, 46.3%-79.6%) in Albania to 34.9% (95% credible interval, 20.0%-49.0%) in the Philippines. While the fraction of ALRI hospitalizations caused by RSV decreased as age increased, it remained the greatest driver. After RSV, rhinovirus/enterovirus (range, 13.4%-27.1%) and human metapneumovirus (range, 6.3%-12.0%) were the next-highest contributors to ALRI hospitalizations.

Conclusions

We observed substantial numbers of ALRI hospitalizations, with RSV as the largest source, particularly in infants aged <3 months. This underscores the potential for vaccines and long-lasting monoclonal antibodies on the horizon to reduce the burden of ALRI in infants worldwide.

Respiratory virus surveillance in hospitalized children less than two-years of age in Kenema, Sierra Leone during the COVID-19 pandemic (October 2020- October 2021)

Globally, viral pathogens are the leading cause of acute respiratory infection in children under-five years. We aim to describe the epidemiology of viral respiratory pathogens in hospitalized children under-two years of age in Eastern Province of Sierra Leone, during the second year of the SARS-CoV-2 pandemic. We conducted a prospective study of children hospitalized with respiratory symptoms between October 2020 and October 2021. We collected demographic and clinical characteristics and calculated each participant´s respiratory symptom severity. Nose and throat swabs were collected at enrollment. Total nucleic acid was purified and tested for multiple respiratory viruses. Statistical analysis was performed using R version 4.2.0 software. 502 children less than two-years of age were enrolled. 376 (74.9%) had at least one respiratory virus detected. The most common viruses isolated were HRV/EV (28.2%), RSV (19.5%) and PIV (13.1%). Influenza and SARS-CoV-2 were identified in only 9.2% and 3.9% of children, respectively. Viral co-detection was common. Human metapneumovirus and RSV had more than two-fold higher odds of requiring O2 therapy while hospitalized. Viral pathogen prevalence was high (74.9%) in our study population. Despite this, 100% of children received antibiotics, underscoring a need to expand laboratory diagnostic capacity and to revisit clinical guidelines implementation in these children. Continuous surveillance and serologic studies among more diverse age groups, with greater geographic breadth, are needed in Sierra Leone to better characterize the long-term impact of COVID-19 on respiratory virus prevalence and to better characterize the seasonality of respiratory viruses in Sierra Leone.

Prospective Attitudes towards Respiratory Syncytial Virus (RSV) Vaccination: Validation of a Survey Instrument among Young Females in Jordan Pending Vaccine Authorization

In May 2023, the U.S. FDA advisors endorsed Pfizer's pregnancy-administered vaccine (branded ABRYSVO) to protect infants from respiratory syncytial virus (RSV) infection. Vaccination can reduce the burden of RSV-related respiratory disease, with previous studies showing its substantial medical and financial burden in Jordan. However, pregnant women may exhibit hesitancy to get vaccinated due to concerns about potential risks to themselves or their fetuses. This study aimed to assess the acceptance of the RSV vaccine among young females and identify the determinants influencing their decision using a newly constructed instrument. A survey instrument was developed and validated, comprising 26 items to measure RSV vaccine acceptance. A cross-sectional study design was employed, with data collection from a sample of females aged 18 to 45 residing in Jordan during 5-6 July 2023, using a convenient approach via an online distributed questionnaire. The final study sample comprised 315 respondents, with 67.6% who have heard of RSV before the study. If the vaccine was safe, effective, and provided freely, 70.2% showed willingness to get the RSV vaccine, 15.2% resisted, and 14.6% were hesitant. Principal component analysis identified six internally consistent sub-scales with the following suggested themes: Advice, Burden, Conspiracy, Dangers, Efficiency, and Fear, comprising 21 items collectively as assigned as the "ABCDEF" scale for RSV vaccine acceptance. RSV vaccine acceptance in this study was associated with the advice and fear constructs. The validated survey instrument successfully captured important determinants of RSV vaccine acceptance among young females. RSV vaccine promotion efforts should focus on the following: enhancing vaccine education, improving trust in healthcare institutions and providers, reducing burdens through resolving cost issues and focusing on the role of social support, addressing safety concerns, and tailoring communication strategies to effectively promote the benefits of the vaccine. These insights can inform public health policies and interventions aiming to promote RSV vaccination and mitigate the burden of RSV-related diseases among infants. Follow-up studies are recommended with pregnant women as the target group to assess their attitude towards RSV vaccination and to confirm the validity of the conceived ABCDEF survey instrument.

Viral and Atypical Pathogen's Epidemiology of a Large Cohort of Patients with Acute Respiratory Tract Infections in Shaanxi Province, Northwest China

Purpose

To analyze and summarize the etiological and epidemiological characteristics of acute respiratory tract infections (ARIs) in northwest China to improve the clinical management and prevention of local ARIs.

Methods

Patients with ARIs in Shaanxi Province, from January 2014 to December 2018, were retrospectively analyzed. Indirect immunofluorescence assay (IFA) was used to detect the IgM antibody of eight respiratory pathogens.

Results

A total of 15,543 eligible patients were included in this study. Overall, 36.01% of the patients (5597/15543) were positive for at least one of eight pathogens, among which single and mixed infections accounted for 74.65% (4178/5597) and 25.35% (1419/5597), respectively. Mycoplasma (MP) showed the highest detection rate (18.12%), followed by influenza virus B (Flu B, 11.65%), chlamydia (CP, 7.00%), respiratory syncytial virus (RSV, 4.18%), parainfluenza virus (PIV, 2.83%), influenza virus A (Flu A, 1.69%), legionella (LP, 1.00%) and adenovirus (ADV, 0.70%). Flu B (17.54%, 759/4327) was the most prevalent virus in patients aged less than 18 years. In addition, common respiratory infections with higher detection rates were found in autumn (39.65%), followed by winter (37.37%), summer (36.21%) and spring (30.91%). There were significant differences in the detection rates of pathogens in different seasons (P < 0.001).

Conclusion

These findings serve as a reference for local health authorities to develop further plans for the prevention and control of ARIs.

Severe bronchiolitis profiling as the first step towards prevention of asthma

Bronchiolitis is the most common respiratory infection leading to hospitalization and constitutes a significant healthcare burden. The two main viral agents causing bronchiolitis, respiratory syncytial virus (RSV) and rhinovirus (RV), have distinct cytopathic, immune response, and clinical characteristics. Different approaches have been suggested for subtyping bronchiolitis based on viral etiology, atopic status, transcriptome profiles in blood, airway metabolome, lipidomic data, and airway microbiota. The highest risk of asthma at school age has been in a subgroup of bronchiolitis characterized by older age, high prevalence of RV infection, previous breathing problems, and/or eczema. Regarding solely viral etiology, RV-bronchiolitis in infancy has been linked to a nearly three times higher risk of developing asthma than RSV-bronchiolitis. Although treatment with betamimetics and systemic corticosteroids has been found ineffective in bronchiolitis overall, it can be beneficial for infants with severe RV bronchiolitis. Thus, there is a need to develop a more individualized therapeutic approach for bronchiolitis and follow-up strategies for infants at higher risk of asthma in the future perspective.

Clinical characteristics, outcomes, and seasonality of acute respiratory infection associated with single and codetected rhinovirus species among hospitalized children in Amman, Jordan

Rhinovirus (RV)-specific surveillance studies in the Middle East are limited. Therefore, we aimed to study the clinical characteristics, outcomes, and seasonality of RV-associated acute respiratory infection among hospitalized young children in Jordan. We conducted a prospective viral surveillance study and enrolled children <2 years old admitted to a large public hospital in Amman, Jordan (2010-2013). Demographic and clinical data were collected by structured interviews and chart abstractions. Nasal and/or throat swabs were collected and tested for a panel of respiratory viruses, and RV genotyping and speciation was performed. At least one virus was detected in 2641/3168 children (83.4%). RV was the second most common virus detected (n = 1238; 46.9%) and was codetected with another respiratory virus in 730 cases (59.0%). Children with RV codetection were more likely than those with RV-only detection to have respiratory distress but had similar outcomes. RV-A accounted for about half of RV-positive cases (54.7%), while children with RV-C had a higher frequency of wheezing and reactive airway disease. RV was detected year-round and peaked during winter. In conclusion, though children with RV codetection had worse clinical findings, neither codetection nor species affected most clinical outcomes.

Adenovirus Infection in Hospitalized Children with Acute Respiratory Infection in Jordan

BACKGROUND

The most common clinical manifestation of adenovirus (AdV) infection is acute respiratory illness (ARI). Specific AdV species associated with ARI hospitalizations are not well defined in the Middle East.

METHODS

A viral surveillance study was conducted among children <2 years hospitalized in Amman, Jordan, from March 2010 to March 2013. Nasal and throat respiratory specimens were obtained from enrolled children and tested for viruses using a real-time reverse-transcription quantitative polymerase chain reaction. AdV-positive specimens were typed by partial hexon gene sequencing. Demographic and clinical features were compared between AdV detected as single pathogen versus co-detected with other respiratory viruses, and between AdV-B and AdV-C species.

RESULTS

AdV was detected in 475/3168 (15%) children hospitalized with ARI; of these, 216 (45%) specimens were successfully typed with AdV-C as the most common species detected (140/216; 65%). Children with AdV-single detection (88/475; 19%) had a higher frequency of fever (71% vs. 56%; P=0.015), diarrhea (18% vs. 11%; p=0.048), and/or seizures/abnormal movements (14% vs. 5%; p=0.003). Children with AdV co-detected with other viruses more likely required oxygen support [adjusted odds ratio (aOR) 1.91 (95% CI: 1.08, 3.39), P = 0.027] than those with AdV-single detection. Children with AdV-C had higher odds of co-detections with other viruses compared with those with AdV-B [aOR 4.00 (95% CI: 1.91, 8.44), P < 0.001].

CONCLUSION

Clinical differences were identified between AdV-single and AdV co-detected with other viruses, and between AdV-B and AdV-C. Larger studies with AdV typing are needed to determine additional epidemiological and clinical differences between specific AdV species and types.

Antibiotic use for respiratory syncytial virus in the Middle East: A surveillance study in hospitalized Jordanian children

Introduction

In developing countries where point-of-care testing is limited, providers rely on clinical judgement to discriminate between viral and bacterial respiratory infections. We performed a cross-sectional cohort study of hospitalized Jordanian children to evaluate antibiotic use for respiratory syncytial virus (RSV) infections.

Materials and methods

Admitting diagnoses from a prior viral surveillance cohort of hospitalized Jordanian children were dichotomized into suspected viral-like, non-pulmonary bacterial-like, and pulmonary bacterial-like infection. Stratifying by sex, we performed a polytomous logistic regression adjusting for age, underlying medical condition, maternal education, and region of residence to estimate prevalence odds ratios (PORs) for antibiotic use during hospitalization. Sensitivity and specificity of admission diagnoses and research laboratory results were compared.

Results

Children with a suspected viral-like admission diagnosis, compared to those with suspected non-pulmonary bacterial-like, were 88% and 86% less likely to be administered an empiric/first-line antibiotic (male, aPOR: 0.12; female, aPOR: 0.14; p-value = <0.001). There were slight differences by sex with males having a lower prevalence than females in being administered an expanded coverage antibiotic; but they had a higher prevalence of macrolide administration than males with non-pulmonary bacterial-like infection. Overall, children with RSV had a 34% probability (sensitivity) of being assigned to a suspected viral-like diagnosis; whereas RSV-negative children had a 76% probability (specificity) of being assigned to a suspected pulmonary bacterial-like diagnosis.

Conclusions

Hospitalized children with a suspected viral-like admission diagnosis were less likely to receive an empiric/first-line and expanded coverage antibiotic compared to suspected non-pulmonary and pulmonary infections; however, when evaluating the accuracy of admission diagnosis to RSV-laboratory results there were considerable misclassifications. These results highlight the need for developing antibiotic interventions for Jordan and the rest of the Middle East.

The Clinical Characteristics, Severity, and Seasonality of RSV Subtypes Among Hospitalized Children in Jordan

BACKGROUND

Respiratory syncytial virus (RSV) is a leading cause of acute respiratory infection (ARI) in young children worldwide. Multiple factors affect RSV disease severity, and data regarding differences between RSV subtypes severity are controversial. This study aimed to evaluate the clinical characteristics, seasonality and severity of RSV subtypes in children.

METHODS

As part of a prospective ARI surveillance study conducted from March 2010 to March 2013 in Amman, Jordan, children less than 2 years with fever and/or respiratory symptoms were enrolled. Demographic and clinical characteristics were collected through parental interviews and medical chart review. The treating physician collected severity score data at admission. Nasal and throat swabs were collected and tested. Multivariable regression models were used to compare the odds of increased disease severity across a priori selected predictors of interest.

RESULTS

Overall, 1397/3168 (44%) children were RSV positive, with a mean age of 5.3 months (±4.8 SD), 59.7% were male, 6.4% had an underlying medical condition (UMC), 63.6% were RSV-A positive, 25.2% were RSV-B positive, 0.6% were positive for both, and 10.6% could not be typed. Both RSV subtypes peaked in January-March of each year. RSV A-positive children were more likely to present with decreased appetite but less likely to have viral co-detection than RSV B-positive children. Independent factors associated with RSV disease severity included cycle threshold value, vitamin D level, age, UMC, prematurity and severity score, but not RSV subtypes.

CONCLUSION

RSV subtypes co-circulated and had similar severity profiles; future preventive and treatment measures should target both subtypes.

Acute Respiratory Illnesses in Children in the SARS-CoV-2 Pandemic: Prospective Multicenter Study

OBJECTIVES

Nonpharmaceutical interventions against coronavirus disease 2019 likely have a role in decreasing viral acute respiratory illnesses (ARIs). We aimed to assess the frequency of respiratory syncytial virus (RSV) and influenza ARIs before and during the coronavirus disease 2019 pandemic.

METHODS

This study was a prospective, multicenter, population-based ARI surveillance, including children seen in the emergency departments and inpatient settings in 7 US cities for ARI. Respiratory samples were collected and evaluated by molecular testing. Generalized linear mixed-effects models were used to evaluate the association between community mitigation and number of eligible and proportion of RSV and influenza cases.

RESULTS

Overall, 45 759 children were eligible; 25 415 were enrolled and tested; 25% and 14% were RSV-positive and influenza-positive, respectively. In 2020, we noted a decrease in eligible and enrolled ARI subjects after community mitigation measures were introduced, with no RSV or influenza detection from April 5, 2020, to April 30, 2020. Compared with 2016-2019, there was an average of 10.6 fewer eligible ARI cases per week per site and 63.9% and 45.8% lower odds of patients testing positive for RSV and influenza, respectively, during the 2020 community mitigation period. In all sites except Seattle, the proportions of positive tests for RSV and influenza in the 2020 community mitigation period were lower than predicted.

CONCLUSIONS

Between March and April 2020, rapid declines in ARI cases and the proportions of RSV and influenza in children were consistently noted across 7 US cities, which could be attributable to community mitigation measures against severe acute respiratory syndrome coronavirus 2.

Respiratory Virus Surveillance in Infants across Different Clinical Settings

OBJECTIVES

We aimed to evaluate the distribution, clinical presentations and severity of common acute respiratory infections (ARI) viruses in infants across 3 clinical settings.

STUDY DESIGN

In a prospective virus surveillance study, infants under 1 year with fever and/or respiratory symptoms were enrolled from outpatient, emergency department, and inpatient settings from December 16, 2019 through April 30, 2020. Demographic and clinical characteristics were collected through parent/guardian interviews, medical chart abstractions, and follow-up surveys. Nasal swabs were collected and tested for viruses using quantitative reverse-transcription polymerase chain reaction.

RESULTS

We enrolled 366 infants and tested nasal swabs on 360 (98%); median age was 6.3 months, 50% male. In total, 295 (82%) had at least 1 virus detected; rhinovirus/enterovirus (RV/EV; 42%), respiratory syncytial virus (RSV; 34%), and influenza (15%) were the most common. RSV was the most frequently detected virus in the inpatient (63%) and emergency department (37%) settings, and RV/EV was most frequently detected virus in the outpatient setting (54%). RSV-positive infants had a lower median age (4.9 months) and were more likely to have respiratory distress, and RV/EV-positive infants were less likely to have respiratory distress. Influenza-positive infants had a higher median age (8 months) and were more likely to have systemic symptoms. RSV infection and younger age were associated with higher odds of hospitalization in multivariable logistic regression.

CONCLUSIONS

Across 3 clinical settings, and combining virologic, patient, and health-system information, our results highlight the burden of viral ARI among infants. Overall, RSV, RV/EV, and influenza were most commonly detected, with RSV having the highest disease severity.

The burden of Respiratory Syncytial Virus (RSV) infection in the Middle East and North Africa (MENA) region across age groups: A systematic review

Respiratory Syncytial Virus (RSV) is a common respiratory virus that generally causes a mild illness in children and adults or severe symptoms with complications in infants and the elderly, particularly in the presence of underlying comorbidities. While epidemiological data about this virus are available globally, data from the Middle East and North Africa (MENA) region are still scarce. For this reason, we conducted a systematic review to determine the burden of RSV disease in the MENA region by searching the available literature up until September 2018. A total of 1242 studies were retrieved of which 90 were included in the review. Most of the included studies were conducted in subjects aged 0-18 years with the majority being in children below 3 years of age, while only 2 studies included exclusively adults above 18 years of age. RSV infection rates varied greatly between different studies on hospitalized subjects and ranged between 4% and 82%, while the range was smaller in studies on outpatient subjects (between 6% and 36%). When calculating the RSV infection rates in the hospitalized subjects with different inclusion criteria, we found that it was 19%, 70%, and 33% among subjects admitted with Acute Respiratory Infections (ARIs), Acute Lower Respiratory Infections (ALRIs), and bronchiolitis, respectively. RSV infections were most common during the winter season. With regards to complications, intensive care unit admissions ranged between 1% and 15%, while the need for mechanical ventilation ranged between 1% and 10%. The overall RSV related mortality rate across all age groups in studies included in our review was 1.9%. This review identifies several limitations in the existing data and under-representation of the adult population. Future studies should be providing more evidence on the RSV burden in adults and children with comorbidities in order to better assess the potential impact of future preventive strategies in the MENA region.

Utility of RSV rapid diagnostic assays in hospitalized children in Amman, Jordan

BACKGROUND

Respiratory syncytial virus (RSV) is the leading cause of acute respiratory infections in children worldwide and a frequent cause of hospitalization. Rapid diagnostic assays (RDAs) are available for RSV and they help guide management; however, they are underutilized in developing countries. We compared molecular diagnostics to RSV RDA in hospitalized children in Amman, Jordan.

MATERIALS AND METHODS

Children under 2 years of age, admitted with fever and/or respiratory symptoms were enrolled prospectively from March 2010 to 2012. Demographic and clinical data were collected through parent/guardian interviews and medical chart abstraction. RSV RDAs were performed, and nasal/throat swabs were tested for RSV using quantitative reverse transcription-polymerase chain reaction (qRT-PCR).

RESULTS

RSV RDA and PCR were performed on specimens from 1271 subjects. RSV RDA had a sensitivity of 26% and a specificity of 99%, with positive and negative predictive values of 98.6% and 43%, respectively. RDA-positive patients had fewer days of symptoms at presentation and were more likely to have a history of prematurity, lower birth weight, require supplemental oxygen, and a longer hospitalization as compared with subjects with negative RDA. Multivariate analysis showed only lower birth weight, lack of cyanosis on examination, and lower cycle threshold to be independently associated with positive RDA (p ≤ .001).

CONCLUSION

RSV RDAs had high specificity, but low sensitivity as compared with qRT-PCR. Positive RDA was associated with patients with a more severe disease, as indicated by oxygen use, longer length of stay, and higher viral load. Implementation of RDAs in developing countries could be an inexpensive and expedient method for predicting RSV disease severity and guiding management.

Molecular characterization of respiratory syncytial viruses circulating in a paediatric cohort in Amman, Jordan

Respiratory syncytial viruses (RSVs) are an important cause of mortality worldwide and a major cause of respiratory tract infections in children, driving development of vaccine candidates. However, there are large gaps in our knowledge of the local evolutionary and transmission dynamics of RSVs, particularly in understudied regions such as the Middle East. To address this gap, we sequenced the complete genomes of 58 RSVA and 27 RSVB samples collected in a paediatric cohort in Amman, Jordan, between 2010 and 2013. RSVA and RSVB co-circulated during each winter epidemic of RSV in Amman, and each epidemic comprised multiple independent viral introductions of RSVA and RSVB. However, RSVA and RSVB alternated in dominance across years, potential evidence of immunological interactions. Children infected with RSVA tended to be older than RSVB-infected children [30 months versus 22.4 months, respectively (P value = 0.02)], and tended to developed bronchopneumonia less frequently than those with RSVB, although the difference was not statistically significant (P value = 0.06). Differences in spatial patterns were investigated, and RSVA lineages were often identified in multiple regions in Amman, whereas RSVB introductions did not spread beyond a single region of the city, although these findings were based on small sample sizes. Multiple RSVA genotypes were identified in Amman, including GA2 viruses as well as three viruses from the ON1 sub-genotype that emerged in 2009 and are now the dominant genotype circulating worldwide. As vaccine development advances, further sequencing of RSV is needed to understand viral ecology and transmission, particularly in under-studied locations.

Clinical features of parainfluenza infections among young children hospitalized for acute respiratory illness in Amman, Jordan

Background

Parainfluenza virus (PIV) is a leading cause of acute respiratory illness (ARI) in children. However, few studies have characterized the clinical features and outcomes associated with PIV infections among young children in the Middle East.

Methods

We conducted hospital-based surveillance for ARI among children < 2 years of age in a large referral hospital in Amman, Jordan. We systematically collected clinical data and respiratory specimens for pathogen detection using reverse transcription polymerase chain reaction. We compared clinical features of PIV-associated ARI among individual serotypes 1, 2, 3, and 4 and among PIV infections compared with other viral ARI and ARI with no virus detected. We also compared the odds of supplemental oxygen use using logistic regression.

Results

PIV was detected in 221/3168 (7.0%) children hospitalized with ARI. PIV-3 was the most commonly detected serotype (125/221; 57%). Individual clinical features of PIV infections varied little by individual serotype, although admission diagnosis of ‘croup’ was only associated with PIV-1 and PIV-2. Children with PIV-associated ARI had lower frequency of cough (71% vs 83%; p < 0.001) and wheezing (53% vs 60% p < 0.001) than children with ARI associated with other viruses. We did not find a significant difference in supplemental oxygen use between children with PIV-associated infections (adjusted odds ratio [aOR] 1.12, 95% CI 0.66–1.89, p = 0.68) and infections in which no virus was detected.

Conclusions

PIV is frequently associated with ARI requiring hospitalization in young Jordanian children. Substantial overlap in clinical features may preclude distinguishing PIV infections from other viral infections at presentation.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-021-06001-1.

Indole-3-carboxaldehyde regulates RSV-induced inflammatory response in RAW264.7 cells by moderate inhibition of the TLR7 signaling pathway

Human respiratory syncytial virus (RSV) is highly contagious and the leading cause of severe respiratory tract illness in infants, elderly, and immunocompromised individuals. Toll-like receptor 7 (TLR7), a pattern recognition receptor recognising the ssRNA of RSV, activates proinflammatory pathways and triggers secretion of interferons (IFNs). On the one hand, the inflammatory responses help clear out virus. On the other hand, they lead to severe lung damage. Banlangen is a traditional Chinese herbal medicine commonly prescribed for respiratory virus infection treatment, but the mechanisms of action and active components remain largely unknown. In the present study, we investigated the effects of the main active components of total alkaloids from banlangen (epigoitrin, indole-3-carboxaldehyde, indole-3-acetonitrile and 4-methoxyindole-3-acetonitrile) on the RSV-induced inflammatory responses in mouse macrophage cells (RAW264.7). Our results demonstrated that RSV-induced IFN-α excessive secretion was moderately inhibited by indole-3-carboxaldehyde through downregulation of mRNA expression in a dose-dependent manner, in comparison, the inhibitory effects of ribavirin were too strong. Furthermore, we revealed that indole-3-carboxaldehyde suppressed transcription of IFN-α by inhibiting RSV-induced TLR7 expression in RAW264.7 cells. Additionally, indole-3-carboxaldehyde inhibited RSV-induced NF-κB signalling activation in a TLR7-MyD88-dependent manner. Together, our findings suggest that indole-3-carboxaldehyde inhibited RSV-induced inflammatory injury by moderate regulation of TLR7 signaling pathway and did not significantly affect the viral clearance competence of the innate immune system.

The burden of influenza and other respiratory viruses in hospitalized infants and children in a university hospital, Jordan

Background

Acute lower respiratory infection (ALRI) is a major cause of morbidity and mortality worldwide in young children and is predominately caused by viral respiratory pathogens. This study aims to identify the viral etiologies of ALRI in hospitalized children in Jordan University Hospital and compare the clinical characteristics of influenza virus infection with other respiratory viruses.

Methods

A retrospective viral surveillance study that included 152 children below 15 years of age admitted with ALRI from December 2018 through April 2019 was conducted. We recorded results of real-time reverse transcriptasepolymerase chain reaction (RT-PCR) for common respiratory viruses. Clinical and demographic information of the study population was collected from patients' electronic medical records.

Results

152 patients were identified with a median age of 1 year (mean was 2.1 years). Ninety-five patients (62.5%) were males. One or more viral respiratory pathogens were detected in 145 (95.3%) children. Respiratory syncytial virus was the most detected virus in 68 patients (44.8%). Influenza virus was detected in 25 patients (16.4%). Children with influenza infection had more fever and lower leukocyte count compared to children infected with other viruses. The severity of the ALRI correlated significantly with several factors, including age less than six months and the presence of neuromuscular disease (p<0.05).

Conclusion

Viral detection was common among children admitted with ALRI. Viruses, including influenza, are recognized as significant contributors to the morbidity associated with ALRI. More attention is needed on strategies for the prevention and detection of viral ALRI in developing countries.

Coronavirus Surveillance in a Pediatric Population in Jordan From 2010 to 2013: A Prospective Viral Surveillance Study

BACKGROUND

Human coronaviruses (HCoVs) are a significant cause of acute respiratory illness (ARI) in children; however, the role of HCoVs in ARI among hospitalized children in the Middle East is not well defined.

METHODS

Children under 2 years admitted with fever and/or respiratory symptoms were enrolled from 2010 to 2013 in Amman, Jordan. Nasal/throat swabs were collected and stored for testing. Demographic and clinical characteristics were collected through parent/guardian interviews and medical chart abstractions. Prior stored specimens were tested for HCoVs (HKU1, OC43, 229E and NL63) by qRT-PCR.

RESULTS

Of the 3168 children enrolled, 6.7% were HCoVs-positive. Among HCoV-positive children, the median age was 3.8 (1.9-8.4) months, 59% were male, 14% were premature, 11% had underlying medical conditions and 76% had viral-codetection. The most common presenting symptoms were cough, fever, wheezing and shortness of breath. HCoVs were detected year-round, peaking in winter-spring months. Overall, 56%, 22%, 13% and 6% were OC43, NL63, HKU1 and 229E, respectively. There was no difference in disease severity between the species, except higher intensive care unit admission frequency in NL63-positive subjects.

CONCLUSIONS

HCoVs were detected in around 7% of children enrolled in our study. Despite HCoV detection in children with ARI with highest peaks in respiratory seasons, the actual burden and pathogenic role of HCoVs in ARI merits further evaluation given the high frequency of viral codetection.

Role of Respiratory Syncytial Virus in Pediatric Pneumonia

Respiratory viral infections represent the leading cause of hospitalization in infants and young children worldwide and the second leading cause of infant mortality. Among these, Respiratory Syncytial Virus (RSV) represents the main cause of lower respiratory tract infections (LRTIs) in young children worldwide. RSV manifestation can range widely from mild upper respiratory infections to severe respiratory infections, mainly bronchiolitis and pneumonia, leading to hospitalization, serious complications (such as respiratory failure), and relevant sequalae in childhood and adulthood (wheezing, asthma, and hyperreactive airways). There are no specific clinical signs or symptoms that can distinguish RSV infection from other respiratory pathogens. New multiplex platforms offer the possibility to simultaneously identify different pathogens, including RSV, with an accuracy similar to that of single polymerase chain reaction (PCR) in the majority of cases. At present, the treatment of RSV infection relies on supportive therapy, mainly consisting of oxygen and hydration. Palivizumab is the only prophylactic method available for RSV infection. Advances in technology and scientific knowledge have led to the creation of different kinds of vaccines and drugs to treat RSV infection. Despite the good level of these studies, there are currently few registered strategies to prevent or treat RSV due to difficulties related to the unpredictable nature of the disease and to the specific target population.

Respiratory Viruses Associated With Acute Wheezing in Hospitalized Young Children in Jordan

A cross-sectional viral surveillance study of hospitalized children less than 2 years of old in Amman, Jordan, noted that respiratory syncytial virus and human metapneumovirus, but not human rhinovirus, were associated with higher odds of acute wheezing. Future longitudinal studies are needed to evaluate the association between early childhood viral acute respiratory infections and recurrent wheezing later in childhood.

Challenges in the prevention or treatment of RSV with emerging new agents in children from low- and middle-income countries

INTRODUCTION

Respiratory syncytial virus (RSV) causes approximately 120,000 deaths annually in children <5 years, with 99% of fatalities occurring in low- and middle-income countries (LMICs).

AREAS COVERED

There are numerous RSV interventions in development, including long-acting monoclonal antibodies, vaccines (maternal and child) and treatments which are expected to become available soon. We reviewed the key challenges and issues that need to be addressed to maximize the impact of these interventions in LMICs. The epidemiology of RSV in LMICs was reviewed (PubMed search to 30 June 2020 inclusive) and the need for more and better-quality data, encompassing hospital admissions, community contacts, and longer-term respiratory morbidity, emphasized. The requirement for an agreed clinical definition of RSV lower respiratory tract infection was proposed. The pros and cons of the new RSV interventions are reviewed from the perspective of LMICs.

EXPERT OPINION

We believe that a vaccine (or combination of vaccines, if practicable) is the only viable solution to the burden of RSV in LMICs. A coordinated program, analogous to that with polio, involving governments, non-governmental organizations, the World Health Organization, the manufacturers and the healthcare community is required to realize the full potential of vaccine(s) and end the devastation of RSV in LMICs.

Assessing the epidemiology and seasonality of influenza among children under two hospitalized in Amman, Jordan, 2010-2013

Background

The disease burden of influenza‐associated hospitalizations among children in Jordan is not well established. We aimed to characterize hospitalizations attributed to influenza in a pediatric population.

Methods

We conducted a cross‐sectional study from our viral surveillance cohort in children under 2 years hospitalized with acute respiratory symptoms and/or fever from March 2010 to March 2013. We collected demographic and clinical characteristics, and calculated the frequency of children who met the severe acute respiratory illness (SARI) criteria. Nasal specimens were tested using real‐time reverse transcriptase polymerase chain reaction to detect influenza A, B, or C. Further subtyping for influenza A‐positive isolates was conducted.

Results

Of the 3168 children enrolled in our study, 119 (4%) were influenza‐positive. Influenza types and subtypes varied by season but were predominantly detected between December and February. Codetection of multiple respiratory pathogens was identified in 58% of children with the majority occurring among those <6 months. Bronchopneumonia and rule‐out sepsis were the most common admission diagnoses, with influenza A accounting for over 2/3 of children with a rule‐out sepsis admission status. One‐third of children under 6 months compared to 3/4 of children 6‐23 months met the SARI criteria.

Conclusions

Influenza was an important cause of acute respiratory illness in children under 2 years. Children <6 months had the highest burden of influenza‐associated hospitalizations and were less likely to meet the SARI global surveillance case definition. Additional surveillance is needed in the Middle East to determine the true influenza burden on a global scale.

Clinical characteristics, predictors, and performance of case definition-Interim results from the WHO global respiratory syncytial virus surveillance pilot

Background

The lack of a uniform surveillance case definition poses a challenge to characterize the epidemiology, clinical features, and disease burden of the respiratory syncytial virus (RSV). Global standards for RSV surveillance will inform immunization policy when RSV vaccines become available.

Methods

The WHO RSV surveillance pilot leverages the capacities of the Global Influenza Surveillance and Response System (GISRS). Hospitalized and non‐hospitalized medically attended patients of any age were tested for RSV using standardized molecular diagnostics throughout the year in fourteen countries. An extended severe acute respiratory infection (extended SARI) or an acute respiratory infection (ARI) case definition was used that did not require fever as a criterion.

Results

Amongst 21 221 patients tested for RSV between January 2017 and September 2018, 15 428 (73%) were hospital admissions. Amongst hospitalized RSV‐positive patients, 50% were aged <6 months and 88% <2 years. The percentage of patients testing positive for RSV was 37% in children <6 months and 25% in those aged 6 months to 2 years. Patients with fever were less likely to be RSV positive compared to those without fever (OR 0.74; 95% CI: 0.63‐0.86). For infants <6 months, 29% of RSV ARI cases did not have fever.

Conclusion

Requiring fever in a case definition for RSV lowers the sensitivity to detect cases in young children. Countries should consider ways to leverage the GISRS platform to implement RSV surveillance with an augmented case definition amongst the young pediatric population.

Respiratory syncytial virus (RSV) infection in children with medical complexity

Children with medical complexity (CMC) are vulnerable to respiratory illness hospitalization (RIH) and respiratory syncytial virus (RSV)-related hospitalization (RSVH) due to multisystem disorders and compromised airways. It is unknown whether RSV prophylaxis is effective, or if RSVH is associated with significant morbidities in CMC. The study objectives were to (1) determine the incidence of RSV-related infection in prophylaxed CMC during the first 3 years of life and (2) assess the burden of illness following RSVH. A single tertiary center, retrospective study, was conducted of CMC who received palivizumab during the 2012-2016 RSV seasons. Fifty-four subjects were enrolled; most received one (38.9%, n = 21) or two (57.4%, n = 31) seasons of prophylaxis (mean = 4.2 [SD = 1.24], palivizumab doses per season). The cohort comprised children with multiple medical conditions (n = 22, 40.8%), tracheostomy (n = 18, 33.3%), and invasive (n = 10, 18.5%) or non-invasive (n = 4, 7.4%) ventilation. Of the CMC, 24 were hospitalized 47 times for a viral-related respiratory illness. RSV incidence in the first 3 years of life was 7.4%. Viral-related RIH and RSVH rates were 44.4% (n = 24/54) and 1.9% (n = 1/54), respectively. Of the four RSV-positive children, one was ventilated for 9 days, two acquired nosocomial RSV that was managed on the ward, and one was discharged home under close complex care supervision. All four RSV-positive cases required additional oxygen during their illness. CMC experience a high viral-related RIH rate and palivizumab likely minimizes RSV-related events and associated morbidities. The efficacy of palivizumab in CMC, especially in those ≤ 3 years, should be prospectively evaluated.