Gastrointestinal tract and viral pathogens

Viral gastroenteritis is the most common viral illness that affects the gastrointestinal (GI) tract, causing inflammation and irritation of the lining of the stomach and intestines. Common signs and symptoms associated with this condition include abdominal pain, diarrhea, and dehydration. The infections commonly involved in viral gastroenteritis are rotavirus, norovirus, and adenovirus, which spread through the fecal-oral and contact routes and cause non-bloody diarrhea. These infections can affect both immunocompetent and immunocompromised individuals. Since the pandemic in 2019, coronavirus gastroenteritis has increased in incidence and prevalence. Morbidity and mortality rates from viral gastroenteritis have declined significantly over the years due to early recognition, treatment with oral rehydration salts, and prompt vaccination. Improved sanitation measures have also played a key role in reducing the transmission of infection. In addition to viral hepatitis causing liver disease, herpes virus, and cytomegalovirus are responsible for ulcerative GI disease. They are associated with bloody diarrhea and commonly occur in im-munocompromised individuals. Hepatitis viruses, Epstein-Barr virus, herpesvirus 8, and human papillomavirus have been involved in benign and malignant diseases. This mini review aims to list different viruses affecting the GI tract. It will cover common symptoms aiding in diagnosis and various important aspects of each viral infection that can aid diagnosis and management. This will help primary care physicians and hospitalists diagnose and treat patients more easily.     

Emergence of Norovirus GII.4 variants in acute gastroenteritis outbreaks in South Korea between 2006 and 2013

BackgroundNew emerging strains of noroviruses (NoVs) often increase acute gastroenteritis (AGE) outbreaks worldwide.ObjectiveWe analyzed the epidemiological features and genotypic patterns of NoVs in AGE outbreaks.Study designTo elucidate the public health impact of NoVs during AGE outbreaks in South Korea, a molecular and epidemiological investigation was performed with 318 AGE outbreaks reported from the Gyeonggi province of South Korea during the period from 2006 to 2013.ResultsNoVs were associated with 102 (32.1%) of the AGE outbreaks. Epidemiological data revealed that the majority of NoV outbreaks were in the student group (47.1%), and the majority of AGE patients were identified in schools (68.8%). NoV genogroup (G) II strains were associated with 94 (92.2%) of the NoV outbreaks, and GII.4 strains were predominantly associated with 57.6% (n = 49) of NoV GII outbreaks. Four GII.4 variants (2006b, 2007, 2009 and 2012 variants) emerged and showed different contributions to NoV outbreak activity. The 2006b variant was predominantly associated with NoV outbreaks during the early years of the study period, and was subsequently displaced by the New Orleans 2009 variant, and most recently by the Sydney 2012 variant. In addition, the GII.2, GII.14, and GII.17 strains have recently been often associated with NoV AGE outbreaks.ConclusionsThe emergence of new NoV GII.4 variants significantly affected the NoV outbreak activity in South Korea during the period from 2006 to 2013. The surveillance for new emerging strains affecting NoV outbreak activity should be intensified to develop an adequate policy to prevent further NoV outbreaks.     

Comparative murine norovirus studies reveal a lack of correlation between intestinal virus titers and enteric pathology

Human noroviruses are significant emerging pathogens, causing the majority of non-bacterial gastroenteritis outbreaks worldwide. The recent discovery of 30 murine norovirus strains is beginning to facilitate a detailed investigation of norovirus pathogenesis. Here, we have performed an in vivo comparative analysis of two murine norovirus strains, MNV-1 and MNV-3. In immunocompetent mice, MNV-1 caused modest intestinal pathology whereas MNV-3 was attenuated compared to MNV-1. Surprisingly though, MNV-3 reached higher titers in intestinal tissue than MNV-1. MNV-3 also displayed attenuation in mice deficient in the critical interferon signaling molecule STAT-1, demonstrating that MNV-3 attenuation is not a result of increased interferon sensitivity. Importantly, MNV-3-infected mice lost weight and developed gastric bloating and diarrhea in STAT1^−/− mice, from which all animals recovered. This disease profile recapitulates several key features of acute gastroenteritis experienced by people infected with a human norovirus.     

Evaluation of rectal swab use for the determination of enteric pathogens: a prospective study of diarrhoea in adults

ObjectivesA stool sample is the sample of choice for microbiological testing of enteric pathogens causing diarrhoea, but a rectal swab can be a more practical alternative. A prospective observational study was performed to evaluate the diagnostic performance of flocked rectal swab specimens using the syndromic molecular approach to determine the aetiology of diarrhoea in adults.MethodsWe compared the performance of rectal swabs with stool samples as the reference standard in determining viral, bacterial and protozoal pathogens using real-time multiplex PCR as well as standard stool culture. Paired samples of stool and rectal swab specimens were collected from 304 adult patients with diarrhoea, presented at the Department of Infectious Diseases, University Medical Centre Ljubljana, between June 2016 and August 2017.ResultsOverall sensitivity of rectal swab samples in the syndromic molecular approach was 83.2% (95% CI 77.2%–88.1%). Pathogen group-specific analysis of rectal swabs showed sensitivity of 65.6% (95% CI 52.7%–77.1%) for viruses and 57.1% (95% CI 28.9%–82.3%) for parasites. For bacteria, sensitivity was 86.5% (95% CI 79.5%–91.8%) when PCR was performed and 61.4% (95% CI 52.4%–69.9%) when culture for bacteria was performed. Mean threshold cycle (Ct) values for most pathogens were higher in rectal swab specimens than in stool specimens.ConclusionsOur results indicate that rectal swabs can be used in the diagnosis of diarrhoea in adults when stool specimens are not available or when rapid aetiological determination is needed. However, rectal swabs should be analysed using a molecular approach. The mean Ct value for most pathogens is higher in rectal swab specimens than in stool specimens.     

Rotavirus vaccine effectiveness in preventing hospitalizations due to gastroenteritis: a descriptive epidemiological study from Germany

Objectives

Rotavirus infections are common causes of infant hospitalization. The present study examined the effectiveness of anti-rotavirus vaccination in preventing rotavirus-related hospitalizations in Germany, following its state and nationwide introductions in 2008 and 2013, respectively.

Pediatric Sedation in the Emergency Department: Trends from a Nationwide Population-based Study in Korea, 2007–2018

BackgroundPediatric sedation in the emergency department (ED) is widely performed in Korea; thus exploring the trends of its use is necessary. This study aimed to investigate the characteristics of patients and sedatives use in the ED and verify their changes over recent years.MethodsA nationwide population-based retrospective study was conducted including pediatric patients aged ≤ 15 years who received sedative medication in the ED and were discharged during 2007–2018, using the Korean Health Insurance Review and Assessment Service database. Patient characteristics (age, sex, level of ED, and diagnosis) and type of sedative used were analyzed.ResultsSedation was performed in total 468,221 visits during 2007–2018 (399,320 visits, at least 3.8% of overall ED visits during 2009–2018). Among these, 71.0% were children aged 1–3 years and 93.5% were sedated to support diagnosis of injury. An increase in total sedation was observed in patients aged 4–6 years during the study period (from 13.8% to 21.8%). A gradual decrease in the use of chloral hydrate (CH) compared with an increase in ketamine use was observed (CH, from 70.6% to 28.6%; ketamine, from 23.8% to 60.7%). Therefore, ketamine was the most used sedative since 2014. The most frequently used sedatives over the study period differed according to age groups (CH in <1 year and 1–3 years; ketamine in 4–6 years and 7–10 years; and midazolam in 11–15 years).ConclusionsThe characteristics of patients related to sedatives use in the ED have changed over time. These changes should be considered in the development of future Korean guidelines regarding pediatric sedation in the ED.     

Community-acquired pathogens associated with prolonged coughing in children: a prospective cohort study

A 2-year prospective study was performed of children with prolonged coughing to investigate the frequency of different respiratory pathogens, the rate of mixed infections, and possible differences in severity of disease between single and mixed infections. Sera from 135 children (136 episodes of prolonged coughing lasting 1-6 weeks) were tested for antibodies to different viruses and bacteria. Swabs were taken for culture and PCR to detect different viral and bacterial pathogens. One or more pathogens were found in 91 (67%) patients. One infectious agent was found in 49 (36%) patients, two agents in 35 (26%) patients, and more than two agents in seven (5%) patients. The most frequent pathogens encountered were rhinovirus (n = 43; 32%), Bordetella pertussis (n = 23; 17%) and respiratory syncytial virus (n = 15; 11%). The most frequent mixed infection was B. pertussis and rhinovirus (n = 14; 10%). No significant differences in clinical symptoms were observed between patients with or without pathogens; however, patients with mixed infections were significantly older. There was a strong seasonal influence on the number of infections, but not on the number of mixed infections. In children with prolonged coughing, there was a high frequency of mixed infections regardless of the season. However, mixed infection was not associated with increased disease severity. No clinical symptoms were found that allowed discrimination between specific pathogens.     

Prognostic factors of asthma severity: a 9-year international prospective cohort study

BACKGROUND: The natural history of asthma severity is poorly known. OBJECTIVE: To investigate prognostic factors of asthma severity. METHODS: All current patients with asthma identified in 1991 to 1993 in the European Community Respiratory Health Survey were followed up, and their severity was assessed in 2002 by using the Global Initiative for Asthma categorization (n = 856). Asthma severity (remittent, intermittent, mild, moderate, severe) was related to potential determinants evaluated at baseline and during the follow-up by a multinomial logistic model, using the intermittent group as the reference category for relative risk ratios (RRRs). RESULTS: Asthma severity measured at baseline was a determinant of a patient's severity at the end of the follow-up. At baseline, severe persistent had a poorer FEV1% predicted, a poorer symptom control, higher IgE levels (RRR, 2.06; 95% CI, 1.38-3.06), and a higher prevalence of chronic cough/mucus hypersecretion (RRR, 4.90; 95% CI, 2.18-11.02) than patients with intermittent asthma. Moderate persistent showed the same prognostic factors as severe persistent, even if the associations were weaker. Mild persistent had a distribution of prognostic factors that was similar to patients with intermittent asthma, although the former showed a poorer symptom control than the latter. Remission mainly occurred in patients with less severe asthma and was negatively associated with a change in body mass index (RRR, 0.86; 95% CI, 0.75-0.97). Allergic rhinitis, smoking, and respiratory infections in childhood were not associated with asthma severity. CONCLUSION: Patients with moderate and severe persistent asthma are characterized by early deterioration of lung function. High IgE levels and persistent cough/mucus hypersecretion are strong markers of moderate/severe asthma, which seems to be a different phenotype from mild persistent or intermittent asthma. CLINICAL IMPLICATIONS: Our results suggest that the evolution of asthma severity is to a large extent predictable.     

Interleukin-22 predicts severity and death in advanced liver cirrhosis: a prospective cohort study

ABSTRACT: BACKGROUND: Interleukin-22 (IL-22), recently identified as a crucial parameter of pathology in experimental liver damage, may determine survival in clinical end-stage liver disease. Systematic analysis of serum IL-22 in relation to morbidity and mortality of patients with advanced liver cirrhosis has not been performed so far. METHODS: This is a prospective cohort study including 120 liver cirrhosis patients and 40 healthy donors to analyze systemic levels of IL-22 in relation to survival and hepatic complications. RESULTS: A total of 71% of patients displayed liver cirrhosis-related complications at study inclusion. A total of 23% of the patients died during a mean follow-up of 196 +/- 165 days. Systemic IL-22 was detectable in 74% of patients but only in 10% of healthy donors (P <0.001). Elevated levels of IL-22 were associated with ascites (P = 0.006), hepatorenal syndrome (P <0.0001), and spontaneous bacterial peritonitis (P = 0.001). Patients with elevated IL-22 (>18 pg/ml, n = 57) showed significantly reduced survival compared to patients with regular ([less than or equal to]18 pg/ml) levels of IL-22 (321 days versus 526 days, P = 0.003). Other factors associated with overall survival were high CRP ([greater than or equal to]2.9 mg/dl, P = 0.005, hazard ratio (HR) 0.314, confidence interval (CI) (0.141 to 0.702)), elevated serum creatinine (P = 0.05, HR 0.453, CI (0.203 to 1.012)), presence of liver-related complications (P = 0.028, HR 0.258 CI (0.077 to 0.862)), model of end stage liver disease (MELD) score [greater than or equal to]20 (P = 0.017, HR 0.364, CI (0.159 to 0.835)) and age (P = 0.011, HR 1.047, CI (1.011 to 1.085)). Adjusted multivariate Cox proportional-hazards analysis identified elevated systemic IL-22 levels as independent predictors of reduced survival (P = 0.007, HR 0.218, CI (0.072 to 0.662)). CONCLUSIONS: In patients with liver cirrhosis, elevated systemic IL-22 levels are predictive for reduced survival independently from age, liver-related complications, CRP, creatinine and the MELD score. Thus, processes that lead to a rise in systemic interleukin-22 may be relevant for prognosis of advanced liver cirrhosis.     

Risk factors for illness severity in patients with COVID-19 pneumonia: a prospective cohort study

Background: Although COVID-19 pneumonia is spreading internationally, knowledge regarding the factors associated with the illness severity of patients remains limited. We aimed to identify the factors associated with the disease severity of patients with COVID-19 pneumonia induced by a novel coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).Methods: We prospectively enrolled a single-center case series of adult patients with COVID-19 admitted to the Infectious Disease Hospital of Jining, Jining City, Shandong Province, China, from January 24 to March 1, 2020. Demographics, clinical characteristics, and laboratory findings were compared to investigate the risk factors related with the disease severity of COVID-19 pneumonia patients.Results: We included a total of 78 patients with COVID-19 pneumonia, of whom 6 had the severe type. As compared to a moderately ill cohort, our analysis showed that shortness of breath, fatigue, longer days from illness onset to diagnosis confirmed, neutrophil percentages > 70%, neutrophil counts > 6.3 × 10⁹/L, lymphocyte percentages < 20%, lymphocyte counts < 1.0 × 10⁹/L, platelet < 100 × 10⁹/L, C-reactive protein (CRP) > 10 mg/L, neutrophil to platelet ratio (NPR) > 2.3, neutrophil to lymphocyte ratio (NLR) > 3.9, aspartate aminotransferase (AST) > 40 U/L, albumin < 40 g/L, lactate dehydrogenase (LDH) > 245 U/L, and glucose > 6.1 mmol/L were predictors of disease severity in COVID-19 pneumonia. In the sex-, age-, and comorbid illness-matched case-control study, neutrophil percentages > 70%, neutrophil counts > 6.3 × 10⁹/L, lymphocyte percentages < 20%, NPR > 2.3, NLR > 3.9, albumin < 40 g/L, and LDH > 245 U/L remained associated with the early detection and identification of severe patients.Conclusion: We demonstrated that neutrophil percentages > 70%, neutrophil counts > 6.3 × 10⁹/L, lymphocyte percentages < 20%, NPR > 2.3, NLR > 3.9, albumin < 40 g/L, and LDH > 245 U/L might predict the severity of illness in patients with COVID-19 pneumonia.     

Chest pain and subsequent consultation for coronary heart disease: a prospective cohort study

BACKGROUND: Chest pain may not be reported to general practice but could be an important first sign of coronary heart disease (CHD). AIMS: To determine whether self-reported chest pain predicts future consultation for CHD in those with no history of consultation for CHD. DESIGN OF STUDY: Population-based study, with 7 year's follow up by GP record linkage. SETTING: General practice in North Staffordshire. METHOD: A survey, including the Rose angina questionnaire, was mailed to 4002 adults. Linked GP records used to identify responders with no record of CHD (G3 Read code or British National Formulary code for nitrate use) in the 32 months before the survey to form the sample for a 7-year prospective study. 'Survival' was compared in those with and without self-reported chest pain up to the earliest date of GP diagnosis of CHD, death, or end of the study period. RESULTS: The survey response was 65% and 2348 participants gave permission to access their GP records. Of these, 2229 had no prior consultation for CHD. From the questionnaire, 558 reported chest pain of which 186 reported exertional pain and 103 met the criteria for angina. When followed prospectively, incidence of CHD consultations was higher in those with any chest pain definition, compared with no pain, and continued to be so for 7 years subsequently. Although these associations were strongly age related, self-reported symptoms were found to be an independent risk factor for future consultation for CHD. CONCLUSION: This study highlighted that self-reported chest pain is a marker of future CHD. The usefulness of early identification of people with this symptom remains to be established.     

Serum IL-27 predicts the severity and prognosis in patients with community-acquired pneumonia: a prospective cohort study

Background: The previous studies have revealed that IL-27 was involved in the pathophysiology of pulmonary inflammatory diseases. However, the role of IL-27 in community-acquired pneumonia (CAP) was unclear. The goal of this research was to explore the associations of serum IL-27 with the severity and prognosis among CAP patients through a prospective cohort study.Methods: The whole of 239 healthy population and 239 CAP patients were enrolled. Fasting blood samples were collected. Inflammatory cytokines were detected using enzyme linked immunosorbent assay (ELISA). Demographic characteristics and clinical information were analyzed.Results: Serum IL-27 on admission was significantly risen in CAP patients compared with control subjects. Besides, serum IL-27 was gradually increased in line with CAP severity scores. Correlative analysis suggested that serum IL-27 was associated with blood routine indices, renal function, liver function, myocardial function and inflammatory cytokines. Linear and logistic regression analyses revealed that serum IL-27 was positively correlated with CAP severity scores. Logistic regression analysis demonstrated that serum higher IL-27 on admission elevated the risks of vasoactive agent usage and longer hospital stay during hospitalization among CAP patients.Conclusions: Serum IL-27 is markedly and positively associated with the severity and poor prognosis among CAP patients, indicating that IL-27 may involve in the pathophysiological process of CAP. Serum IL-27 may be used as a biomarker for diagnosis and prognosis in CAP patients.     

Surge Capacity and Mass Casualty Incidents Preparedness of Emergency Departments in a Metropolitan City: a Regional Survey Study

BackgroundEmergency departments (EDs) generally receive many casualties in disaster or mass casualty incidents (MCI). Some studies have conceptually suggested the surge capacity that ED should have; however, only few studies have investigated measurable numbers in one community. This study investigated the surge capacity of the specific number of accommodatable patients and overall preparedness at EDs in a metropolitan city.MethodsThis cross-sectional study officially surveyed surge capacity and disaster preparedness for all regional and local emergency medical centers (EMC) in Seoul with the Seoul Metropolitan Government''s public health division. This study developed survey items on space, staff, stuff, and systems, which are essential elements of surge capacity. The number of patients acceptable for each ED was investigated by triage level in ordinary and crisis situations. Multivariate linear regression analysis was performed on hospital resource variables related to surge capacity.ResultsIn the second half of 2018, a survey was conducted targeting 31 EMC directors in Seoul. It was found that all regional and local EMCs in Seoul can accommodate 848 emergency patients and 537 non-emergency patients in crisis conditions. In ordinary situations, one EMC could accommodate an average of 1.3 patients with Korean Triage and Acuity Scale (KTAS) level 1, 3.1 patients with KTAS level 2, and 5.7 patients with KTAS level 3. In situations of crisis, this number increased to 3.4, 7.8, and 16.2, respectively. There are significant differences in surge capacity between ordinary and crisis conditions. The difference in surge capacity between regional and local EMC was not significant. In both ordinary and crisis conditions, only the total number of hospital beds were significantly associated with surge capacity.ConclusionIf the hospital''s emergency transport system is ideally accomplished, patients arising from average MCI can be accommodated in Seoul. However, in a huge disaster, it may be challenging to handle the current surge capacity. More detailed follow-up studies are needed to prepare a surge capacity protocol in the community.     

Prevalence and severity of acute viral hepatitis and fulminant hepatitis during pregnancy: a prospective study from north India

The present study aimed to find out the prevalence and severity of acute viral hepatitis and fulminant hepatitis during pregnancy in North India. The study was conducted on 97 consecutive pregnant patients in third trimester with acute viral hepatitis (AVH) or fulminant hepatic failure (FHF). The patients were evaluated on the basis of history, examination, liver function profile and serological markers for hepatitis A,B,C and E viruses. Hepatitis E virus (HEV) was the causative agent in 47.4% of the cases of viral hepatitis and 52.6% were caused by non-E viruses(HAV-5.2%,HBV-7.2%,HCV-0%,non A-E 47.4%). HEV was responsible for 36.2% of the cases of AVH and 75% of the cases of FHF. The mortality was 24.7% (24/97). All of them had FHF. Eighteen of 24 cases (75%) who expired were HEV positive. The mortality rate was 39.1% in HEV group and 11.7% in non HEV group. Majority of patients (87.5%) who expired had died undelivered. Hepatitis E was the commonest etiological agent in those who had fulminant disease during pregnancy and was associated with high mortality rate.     

Relationship between prenatal anxiety and perinatal outcome in nulliparous women: a prospective study.

Nulliparous women with singleton gestation were assessed prospectively for anxiety levels with the State-Trait Anxiety Inventory, which measured state (situational and transitional) and trait (dispositional and stable) anxiety, with high scores indicating high anxiety. Bivariate and multivariate methods were used for data analysis. Anxiety assessments (n = 239) were obtained in 88 women at different stages of gestation. Mean anxiety scores were lowest at 22 to 26 weeks. A woman''s successive scores were highly correlated. The trait anxiety (A-T) scores were higher for married women. A positive correlation was present between anxiety scores and gestational age at delivery. Low A-T scores correlated with low birthweight, preterm delivery, and chorioamnionitis. High state anxiety (A-S) levels correlated with the presence of meconium in the amniotic fluid and neonatal congenital abnormalities. Postdate delivery also was associated with higher although statistically insignificant anxiety scores. Women who presented to the labor and delivery room for various complaints had higher A-S and A-T levels. Maternal anxiety level was associated with adverse perinatal outcome; specifically, prematurity and low birthweight correlated with low A-T levels.     

Postnatal depression and the original mother-child relationship: a prospective cohort study

BACKGROUND: Previous studies assessing the role of early mother-child relationship as a risk factor for postnatal depression have been cross-sectional and/or retrospective in nature. AIMS: To examine associations between early mother-child relationship (assessed prospectively and retrospectively) and later risk of postnatal depression. METHODS: Dataset from national 1946 birth cohort study; 1137 women at age 51, completed a modified version of the Bromley Postnatal Depression Scale. RESULTS: Compared with women who did not experience maternal separation or recalled moderate to best level of care, women who experienced maternal separation for 3.5 days or more in early childhood and who felt they received a low level of maternal care were at higher risk of postnatal depression (odds ratio (95% CI): 2.4 (1.51-3.79), p=0.001); this relationship was robust to adjustment for current psychological status. Regular enuresis at age of 6 years (2.2 (1.01-4.90), p=0.05), and lack of emotional closeness in current maternal relationship (1.6 (1.01-2.46), p=0.04) were also associated with increased postnatal depression risk. Insufficient evidence was found for a link between other indicators of early behaviour and temperament (anxious, antisocial, or neurotic behaviour) and reported postnatal depression. LIMITATIONS: Postnatal depression was assessed retrospectively using self-report, introducing potential bias in recall. CONCLUSION: Women who experienced early maternal separation and recalled the lowest level of maternal care had a particularly high risk of postnatal depression. In the treatment and management of postnatal depression, the results support health professionals in their consideration of the woman's past and current relationship with her mother; both actual events and the woman's perceptions of them.     

Epidemiological and clinical characteristics of children with acute respiratory viral infections in the Philippines: a prospective cohort study

ObjectivesViral acute respiratory infection (ARI) remains a major global health problem, especially among children in low- and middle-income countries. The study was conducted to reveal aetiological significance of respiratory viruses among both non-hospitalized and hospitalized children.MethodsA cohort study of children with ARI at the household, primary healthcare facility, and hospital levels was conducted alongside a hospital-based study including non-cohort children from 2014 to 2016 in the Philippines. The ARI cases were recorded at households and healthcare facilities, and a clinical investigation was performed. Nasopharyngeal swabs were collected from the symptomatic children and tested for respiratory viruses via polymerase chain reaction. Then, the association between healthcare facility utilization and viral detection was investigated.ResultsOverall, 18,514 ARI cases were enrolled in the cohort study, and samples were collected from 4735 of these cases. The hospital-based study detected 648 ARI cases, all of which were sampled. Rhinovirus (22.2%; 1052/4735) was most frequently detected followed by respiratory syncytial virus (12.0%; 566/4735). Enterovirus (adjusted odds ratio, 1.8; 95% confidence interval, 1.1–2.8), human metapneumovirus (2.1, 1.4–3.2), rhinovirus (2.1, 1.8–2.6), and respiratory syncytial virus (1.6, 1.2–1.9) were significantly more prevalent in the ARI cases at healthcare facilities than in those in households. Of all ARI cases, 0.6% required hospitalization while 1.8% were hospitalized among the respiratory syncytial virus-positive cases (3.8, 3.0–4.9).ConclusionsWe determined the prevalence of respiratory viruses among children with ARIs at the household, primary healthcare facility, and hospital levels and the association with clinical characteristics. In particular, we discovered a significant disease burden and impact of respiratory syncytial virus infections as well as a considerable aetiological implication of rhinovirus infections.