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Pediatric Viral Respiratory Infections in Saudi Arabia: Narrative and Descriptive Revisits for the Etiology, Epidemiology and Cl June 2020 KUWAIT MEDICAL JOURNAL 118 Review Article Pediatric viral respiratory infections in Saudi Arabia: Narrative and descriptive revisits for the etiology, epidemiology and clinical phenotypes with diagnostic challenges highlights Ayed A Shati1, Abdelwahid S Ali2, Ahmed M Al-Hakami2, Ali A Asseri1, Saleh M Al-Qahatani1 1Department of Child Health, College of Medicine, King Khalid University, Abha, Saudi Arabia 2Department of Microbiology and Clinical Parasitology, College of Medicine, King Khalid University, Abha, Saudi Arabia Kuwait Medical Journal 2020; 52 (2): 118 - 128 ABSTRACT Objective: To review, describe and narrate the etiology, Up to 2019, 35 studies were published in the topic. The epidemiology and clinical phenotypes of pediatric viral highest number of reports was for respiratory syncytial respiratory infections (PVRIs) in Saudi Arabia (KSA) viruses (n=17, 48.6%), while bocaviruses are the least Design: A comprehensive electronic search of the reported viruses (n=3, 8.6%). Clinical presentations literature for PVRIs in KSA reported suggested both upper and lower respiratory Setting:An electronic search in PubMed, SCOPUS, Google tract infections. PVRIs were reported from Riyadh, Al- Scholar and MEDLINE Qassim, Jazan, Jeddah, Dammam, Najran, Taif and Subjects: Articles published up till 2019 and those that Abha. Immunofluorescence assays, enzyme-linked dealt with the detection of viruses from clinical specimens immunosorbent assay, polymerase chain reaction and Interventions: Retrieved articles were subtly studied. Data virus isolation were employed. obtained included the virus reported, year of publication, Conclusion(s): In this review communication, we diagnostics, region or city, research purpose, the season of described the etiology, epidemiology and clinical infection and hospital of admission (if any). phenotypes of PVRIs in KSA reported from 1988 through Main outcome measure(s): The etiology, epidemiological 2019. We also showed some challenges associated with features and clinical phenotypes associated with the PVRIs the diagnostic protocols employed. Directions for future in each study were recorded and analyzed. research in this topic, particularly towards diagnostics and Result(s): The first report for PVRIs in KSA was in 1988. preventive medicine, were also recommended. KEY WORDS: children, Middle East, respiratory infections, Saudi Arabia, viruses INTRODUCTION infections resulted in far higher mortality rates in It is well-established that respiratory tract children as compared to those in resource- rich infections are major causes of morbidities and countries. Inadequate data about the public health mortalities among children worldwide[1]. A recent impacts and economic losses of these infections in World Health Organization (WHO) report revealed developed countries are available[6-8]. These data that 18% of deaths among children under five years are always critically essential for the design and are attributable to pneumonia[2,3]. Among the different development of efficient protective measures and causes of respiratory infections, viruses were known treatment protocols. The viruses which are known to be to constitute the major etiological factor responsible responsible for ARIs in infants and children included for acute respiratory infections (ARIs) in pediatrics influenza viruses, human respiratory syncytial virus globally[4,5]. In poor and developing countries, these (HRSV), human metapneumovirus (HMPV), human Address correspondence to: Dr. Ayed Abdullah Shati, Department of Child Health, College of Medicine, King Khalid University, Abha, Saudi Arabia. Tel: +966555752063; Mob: +966172417750; E-mail: [email protected] 119 Pediatric viral respiratory infections in Saudi Arabia: Narrative and descriptive revisits for the etiology... June 2020 coronaviruses (HCoVs), human parainfluenza viruses from children suffering from ALRTIs. It has been (HPIV), human adenoviruses (HAdVs), and human suggested that the epidemiological parameters of bocaviruses (HBoVs). the infections including incidences, prevalences, Although the burden and public health implications morbidities and mortalities due to HAdVs are highly of influenza infections are yet to be known in many parts virus type dependent[30]. HPIVs were also recognized of the world, particularly in resource-poor countries, it to be associated with URT and LRT illnesses in has been shown that influenza is characterized by high children with their pathology, symptomatology and incidence rates and hospitalizations in the tropics and epidemiology dependent on the virus serotype, age and subtropics[8]. The global incidences and mortalities due season[31]. Among the four genotypes of HBoVs known to influenza in children less than five years was also so far, HBoV-1 is the predominant genotype known to estimated and noted to be significantly high in terms infect the respiratory tract of children[32,33]. Throughout of number of deaths, particularly in the developing the years, human rhinoviruses (HRVs), were known as countries[8-10]. In many epidemiological studies, a significant cause of the “common cold” in children HMPV were recognized as potential etiologic agents and adults worldwide, with considerable economic for acute lower respiratory tract infections (ALRTIs), burdens incurred due to medical visits, schooling and namely bronchopneumonia and bronchiolitis, in work absenteeism[34]. Other viruses causing respiratory children[11-16]. Although the life-threatening effects of infections in children and reported at various points of HMPV infections in children were known in some time include Nipah and Hindra viruses[35]. cases, the fatalities were usually seen associated with Taken all together, viral respiratory infections are other underlying chronic conditions such as chronic considered as major health concerns in pediatric practice lung disease of prematurity, asthma[17], cancer[18] in many parts of the world, particularly in developing and immunosuppression[19,20]. Following intensive and resource-poor countries. As diagnostic testing is literature revisits and personal communications, there improved, more respiratory viruses are expected to be were no obvious distinctions in the epidemiological explored. This review intended to focus on the clinical and clinical patterns between HRSV and HMPV phenotypes and epidemiological pictures of pediatric infections in pediatric patients. Both viruses cause viral respiratory infections (PVRIs) in Saudi Arabia severe and ALRTIs in infants and children, and both (KSA) concerning the previously published reports in represent primary reasons for emergency department that respect. We would also like to cast some light on visits and hospitalization[18,20]. However, HMPV the diagnostic and medical intervention challenges. infections were observed to occur in relatively older children, as compared to HRSV[17]. HCoVs were also METHODS noted, causing numerous seasonal clinical respiratory Search methodology infections in children since ancient times[21]. The In this study, we performed a comprehensive epidemiological patterns of these HCoVs-associated electronic search of the literature for PVRIs in KSA diseases were observed undergoing regular changes in PubMed, SCOPUS, Google Scholar and MEDLINE every time and the respiratory infections attributable databases. The keywords used in the search include to HCoVs were observed not only confined to upper Saudi Arabia, respiratory, children, infants and respiratory tract infections (URTIs), but they are also viruses (the word “virus” was used at times and the seen to cause pneumonia in infants and children[22]. virus name was specified at other times). The search Several reports describing the role of HCoVs in considered articles from ancient times up to 2019. The the lower respiratory tract infections (LRTIs) with retrieved articles were carefully read to help in further their clinical presentations and complications in the search for additional articles. The only considered pediatrics were also published[23-25]. HCoV-severe and documented studies are those that dealt with acute respiratory syndrome (HCoV-SARS) has the detection and/or isolation of viruses from clinical emerged as the first HCoV identified responsible for specimens of the patients and published in peer- severe, acute and fatal respiratory infection in children reviewed journals. in many parts of the world[26,27]. Recently, HCoV- Middle East Respiratory Syndrome (HCoV-MERS) Data retrieval and analysis has also emerged from KSA and proven as a potential The clinical and epidemiological features associated etiologic agent for severe URTIs and LRTIs in children with PVRIs in each study were recorded and analyzed. and young adults[28]. Although HAdVs were primarily The elements recorded included the author(s) who recognized to cause mild URT and LRT infections in conducted the research, year of publication, the virus young children, severe infections of HAdVs during reported to cause the infection, diagnostic technique epidemics were also noted in immunocompromised employed, region or city of the study, the research patients[29]. Several serotypes of HAdVs were isolated purpose, the season of the infection and the hospital June 2020 KUWAIT MEDICAL JOURNAL 120 Table 1: The reports of different respiratory viruses in Saudi Arabia among pediatric patients from 1988 - 2019 No. of reports Virus Regions of reports Years of reports References Single (%)a Combined (%)b Total (%)c Influenza 2 (28.6) 5 (71.4) 7 (20.0)
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