Prevalence of Acute Respiratory Infections Before, During, and After the COVID-19 Pandemic among the Pediatric Population in the United Arab Emirates: a Cross-sectional Study

Prevalence of Acute Respiratory Infections Before, During, and After the COVID-19 Pandemic among the Pediatric Population in the United Arab Emirates: a Cross-sectional Study | Authorea try { document.documentElement.classList.add('js'); } catch (e) { } var _gaq = _gaq || []; _gaq.push(['_setAccount', 'G-8VDV14Y67G']); _gaq.push(['_trackPageview']); (function() { var ga = document.createElement('script'); ga.type = 'text/javascript'; ga.async = true; ga.src = ('https:' == document.location.protocol ? 'https://ssl' : 'http://www') + '.google-analytics.com/ga.js'; var s = document.getElementsByTagName('script')[0]; s.parentNode.insertBefore(ga, s); })(); Skip to main content Preprints Collections Wiley Open Research IET Open Research Ecological Society of Japan All Collections About About Authorea FAQs Contact Us Quick Search anywhere Search for preprint articles, keywords, etc. Search Search ADVANCED SEARCH SCROLL This is a preprint and has not been peer reviewed. Data may be preliminary. 9 July 2025 V1 Latest version Share on Prevalence of Acute Respiratory Infections Before, During, and After the COVID-19 Pandemic among the Pediatric Population in the United Arab Emirates: a Cross-sectional Study Authors : Mazen Alhaj Ahmad 0009-0001-2429-4176 , Saif Eddin Mansour 0009-0003-2939-8331 , Albara’ Alshalkhaty , Obada Al-Wawi 0009-0003-5867-4200 [email protected] , Mukram Jamour , Rabia Shah , Arun Thomas , and Omendra Narayan Authors Info & Affiliations https://doi.org/10.22541/au.175203561.12935335/v1 593 views 190 downloads Contents Abstract Introduction Methodology Results Seasonality and PICU stay Discussion Conclusion Acknowledgements Supplementary Material References Information & Authors Metrics & Citations View Options References Figures Tables Media Share Abstract Introduction: Acute respiratory infections (ARIs) represent a significant burden among children globally. The COVID-19 pandemic and its associated public health measures disrupted the transmission and detection of common respiratory pathogens, yet little is known about how these parameters have changed in the United Arab Emirates (UAE). Objectives: This study aims to describe the prevalence, causative pathogens, and seasonal patterns of pediatric ARIs in the UAE before, during, and after the COVID-19 pandemic. Methods: This retrospective electronic chart review included pediatric patients, aged 0–18 years, diagnosed with ARIs across the American Hospital Dubai network between 2019 and 2024. Statistical analysis was performed using SPSS 26.0, and compared through three distinct time periods. Results: A total of 20976 cases were included in the analysis. Of these, 11248 (53.6%) were male, with a median age of 5 (IQR = 2,9). Overall, the most frequently detected pathogens were Human Rhinovirus/Enterovirus (34.6%), COVID-19 (22.6%), and Influenza A (14.8%). Seasonal peaks of all pathogens except Adenovirus showed a more even distribution after the pandemic, rather than peaking in specific quarters. We observed a shift in the peak of Human Rhinovirus/Enterovirus , from Q1 pre-pandemic to Q4 post-pandemic. Conclusions: Pediatric ARI patterns in the UAE changed during the COVID-19 pandemic, as there was an increase in the number of cases after 2021, along with a shift in seasonality for many of the common causative pathogens. COVID-19 was predominant during the pandemic, yet Human Rhinovirus/Enterovirus remained the most common pathogen overall. Keywords: Child, Respiratory Tract Infections, COVID-19, United Arab Emirates, Cross-Sectional Studies Running Head: ACUTE RESPIRATORY INFECTIONS AMONG CHILDREN IN UAE Introduction Acute Respiratory Infections (ARIs) are a group of diseases that include both upper respiratory infections (URIs) and lower respiratory infections (LRIs) 1 . In the pediatric age group, ARIs present a significant burden in terms of morbidity and mortality. These infections are a leading cause of illness in children under five. Children experience an average of three episodes annually, regardless of economic status 2 . Globally, ARIs account for 15% of all deaths in children under five 3 . In the United Arab Emirates (UAE), ARIs account for 15% of clinical encounters, particularly in pediatric age groups 4 . Studies before the COVID-19 pandemic identified Human Rhinovirus/Enterovirus, Influenza, and Respiratory Syncytial Virus (RSV) as the most prevalent causative agents of ARIs in children in the UAE 5,6 . The COVID-19 pandemic, officially declared a global pandemic on March 11, 2020, prompted widespread implementation of non-pharmacologic interventions (NPIs) worldwide. In the UAE, a full lockdown was imposed on April 4, 2020, accompanied by NPIs such as mandatory face masks, quarantine protocols, social distancing measures, and enhanced hygiene practices. These interventions effectively curbed the transmission of the virus 7,8 . While these measures were primarily aimed at controlling COVID-19 transmission, they also disrupted the spread of other respiratory pathogens, resulting in altered prevalence and seasonality patterns worldwide 9,10 . We hypothesize that such interventions may have similarly influenced the epidemiology of ARI-causative pathogens in the UAE. Understanding the change in epidemiology of ARIs after the pandemic can influence public health policies, including vaccination strategies and the targeted use of NPIs during future seasonal outbreaks. Despite global studies highlighting these changes, data remains scarce, specifically examining shifts in the prevalence, severity, or seasonality of respiratory pathogens in the UAE during and after the pandemic. The UAE, particularly cities like Dubai, offers a unique environment for studying ARIs, given its diverse demographics, high population density, and significant international travel. This study aims to describe the causative pathogens and seasonality patterns of pediatric respiratory infections in the UAE, with a focus on identifying key trends and their implications for pediatric health care. Methodology Study Design & Population A retrospective cross-sectional study was conducted within the American Hospital network, which includes one tertiary care hospital and seven clinics located throughout Dubai, UAE. Electronic Medical Records (EMRs) of pediatric patients diagnosed with ARIs from January 2019 to December 2024 were retrospectively reviewed. This time frame was selected to cover the COVID-19 pandemic as well as pre- and post-pandemic periods. This study was reviewed and approved by the Dubai Scientific Research Ethics Committee (DSREC), Dubai Health Authority (DSREC-08/2024_22). The requirement for informed consent was waived due to the retrospective nature of the EMR analysis. The study included all pediatric patients aged 0–18 years who presented to the American Hospital Network and were diagnosed with ARIs based on a positive respiratory pathogen test. Patients without positive laboratory testing or with incomplete data were excluded. Eligible participants were identified using ICD-10 codes. Variables and Data Sources EMRs were reviewed to collect demographics such as age, sex, length of stay, and PICU admission. Furthermore, molecular data regarding the identification of the pathogen, date of testing, and co-infection were identified. Nasopharyngeal swabs were collected from patients and analyzed using the BioFire® FilmArray® system with the Comprehensive Respiratory Panel. This system enables simultaneous extraction, amplification, and detection of nucleic acids from a broad range of respiratory pathogens including Adenovirus, Bordetella parapertussis, Bordetella pertussis, Chlamydia pneumoniae, Seasonal Coronaviruses (HCoV-229E, HCoV-OC43, HCoV-NL63, HCoV-HKU1), Human Metapneumovirus (hMPV), Human Rhinovirus/Enterovirus, Influenza A, Influenza B, Mycoplasma pneumoniae, Parainfluenza viruses (PIV) types 1, 2, 3, and 4, and Respiratory Syncytial Virus (RSV), using a single specimen. COVID-19 PCR testing was performed using the Zybio Extraction Kit (Zybio Inc., China) for RNA extraction, the DiaPlexQ™ SARS-CoV-2 Kit (Fujirebio, Japan) for amplification, and the Bio-Rad CF96 machine (Bio-Rad, USA) for amplification and detection of the virus. For influenza, the Sofia Influenza A+B Fluorescent Immunoassay was occasionally used for targeted detection of Influenza A and B. Quantitative variables The quantitative variables analyzed in this study included the total number of cases per year and quarter. Moreover, the number and percentage of identified pathogens in each case and the PICU admission rate were analyzed. The pre-COVID-19 pandemic period was defined as all cases between January 2019 and March 2020, during which schools and universities in the UAE were suspended, quarantine measures were implemented for suspected cases, and a night curfew policy was enforced. The COVID-19 pandemic period was defined as the period between April 2020 and December 2022, when all restrictions and precautionary measures were lifted in the UAE. All cases between January 2023 and December 2024 were considered the post-COVID-19 pandemic period. Statistical analysis The data was initially cleaned using Microsoft Excel (Microsoft, USA). Statistical analyses were performed using SPSS (IBM SPSS Statistics for Windows, IBM Corp., Version 26, Armonk, NY). Descriptive statistics using frequencies and percentages were used to analyze demographics, PICU admission rates, distribution of pathogens, co-infections, and seasonal trends. Associations between categorical variables were assessed using the chi-square test. p < 0.05 was considered a statistically significant difference. Plotting was performed using GraphPad Prism 8.0 (GraphPad Software Inc., USA). During the COVID-19 period, testing and retesting were being done frequently for patients. Hence, if COVID-19 was detected multiple times from the same patient within a time period of 14 days, only the first result was included. Otherwise, all other detected pathogens were included. Potential confounding variables were not adjusted for in the analysis. Results General characteristics of the study population A total of 20976 cases were included in this study. Of these cases, 11248 (53.6%) were male. The median age was 5 (IQR = 2, 9). PICU admission was required for 2161 (10.3%) cases. A notable increase in PICU admissions in the post-pandemic period was observed (p<.001). Regarding the number of organisms identified per hospital encounter, 17555 (83.7%) cases had single organism infections, while 3025 (14.4%) had co-infection involving two organisms and 396 (1.9%) had co-infection involving three or more organisms. There was a significant decline in the co-infection rate (p<.001) during the pandemic (n=773; 9.1%) which increased in the post-pandemic period (n=2052; 21.0%), nearly matching the pre-pandemic rate (n=596; 21.8%). The most affected age group overall was 2-3 years with 5127 (24.4%) cases, followed by the 4-6 years age group with 4622 (22.0%) cases. A shift in the most commonly affected age group was observed across time. Before and during the pandemic, children aged 4-6 years were the most affected; however, after the pandemic, children aged 2-3 years became the most affected, followed by those aged 4-6 years (p<.001). Other characteristics of the sample are shown in Table 1. Distribution of pathogens Overall, the most common pathogen reported was Human Rhinovirus/Enterovirus (n=7251; 34.6%), followed by COVID-19 (n=4735; 22.6%), and Influenza A (n=3094; 14.8%). The least common pathogens were Bordetella parapertussis (n=95; 0.5%), Chlamydia pneumoniae (n=78; 0.4%), and Bordetella pertussis (n=33; 0.2%). Comparing the pre-pandemic to the post-pandemic periods reveals notable shifts in respiratory pathogen distribution. Human Rhinovirus/Enterovirus significantly increased to 44.2% in the post-pandemic period in comparison to 40.7% in the pre-pandemic period (p=.001). In contrast, a sharp decline was observed in Influenza A from 27.1% to 12.1% (p<.001), alongside Influenza B from 11.3% to 6.8% (p<.001). Several pathogens increased significantly after the pandemic, including RSV (9.9% vs. 11.6%, p=.012) and hMPV (4.7% vs. 6.0%, p=.011). Meanwhile, Parainfluenza, Adenovirus, and Seasonal Coronaviruses did not show significant changes between the two periods. The distribution of other pathogens can be found in Table 2. Changes in the detection rate of respiratory pathogens per quarter are depicted in Figure 1. Human Rhino/Enterovirus notably peaked during the third quarter of 2019, whereas in the fourth quarter of 2019, Influenza A spiked, becoming the most commonly identified pathogen. In the first quarter of 2020, Influenza A detection rate declined, with Human Rhino/Enterovirus becoming predominant again. Starting from the second quarter of 2020, COVID-19 became predominant with fluctuations in its detection rate. A notable spike occurred in the first quarter of 2022, followed by a steady decline. By the fourth quarter of 2022, COVID-19 had reached its lowest detection rate, with Human Rhino/Enterovirus surpassing it and becoming the most commonly detected pathogen. During the COVID-19 pandemic period, the detection rates of most respiratory pathogens declined, excluding COVID-19 and Human Rhino/Enterovirus. Influenza A detection rate, in particular, declined markedly during the COVID-19 pandemic, which then re-emerged after the national lockdown measures were lifted. After the pandemic, Influenza A was the most prevalent in the fourth quarter of 2022. It then declined and spiked again in the fourth quarter of 2023. Seasonality and PICU stay Table 3 demonstrates the impact of the COVID-19 pandemic on the seasonal distribution of respiratory pathogens and their association with PICU admissions. A significant shift in seasonality was observed for most viruses after the pandemic. Several pathogens, including Human rhinovirus/enterovirus, Influenza A, RSV, Parainfluenza, Seasonal Coronaviruses, and Mycoplasma pneumoniae, demonstrated a more even distribution throughout the year compared to the pre-pandemic period, with statistically significant changes observed (p<0.001 for all). Specifically, Human rhinovirus/enterovirus, which was most prevalent in Q1 before the pandemic (41.0%), shifted its peak to Q4 (31.5%) after the pandemic. Influenza A remained most frequent in Q4 but with less pronounced variability between quarters. RSV, which usually peaks in Q4 (67.4%), showed increased activity in Q3, but remained most prevalent in Q4. Mycoplasma pneumoniae, which previously had its peak in Q1 (53.8%), peaked in Q2 after the pandemic (37.8%). In contrast, Adenovirus showed no significant changes in seasonal distribution (p=0.223). PICU admissions increased significantly for several pathogens in the post-pandemic period. This increase was observed for Human Rhinovirus/Enterovirus (p<0.001), Influenza A (p<0.001), RSV (p=0.036), Adenovirus (p=0.016), and Influenza B (p=0.032). However, PICU admissions remained unchanged for Parainfluenza (p=0.121), Seasonal Coronaviruses (p=0.053), hMPV (p=0.277), and Mycoplasma pneumoniae (p=0.614). Discussion This study provided insight into the causative pathogens, seasonality changes, and PICU admission rates of pediatric ARIs before, during, and after the pandemic period. The findings revealed that after the initial reduction in ARIs during the COVID-19 period, the detection of pathogens other than COVID-19 rose near the end of the pandemic and remained a burden afterward. After the pandemic, the seasonality of most pathogens showed significant changes. While still rising and peaking in approximately the same quarters of the year, it was observed that the increases were less steep and the peaks were more gradually distributed throughout the year. PICU admission rates significantly increased in the post-pandemic period. Before the pandemic, the most commonly detected pathogens were Human Rhinovirus/Enterovirus, Influenza A, Influenza B, Adenovirus, and RSV, which is similar to the prevalence reported in the UAE by Salim et al. 2023 5 . However, other studies in the region found RSV or Influenza to be the most common pathogen, which could be because these studies had a relatively smaller sample size or looked at hospitalized cases only, which may overestimate more virulent pathogens such as RSV 6,11,12 . During the pandemic, detection rates of all viruses declined except for COVID-19. Other studies in the region 11,12 and worldwide 13–15 reported similar findings. NPIs aimed at stopping COVID-19 transmission may be the reason behind this rapid decline, as they are effective against the transmission of other respiratory pathogens too 16 . After the pandemic, the number of ARIs detected increased in comparison to the pandemic period, a finding that is supported by other studies in the region and internationally 17 . Several theories were proposed to explain this observation such as the suspension of most NPIs, people returning to their normal lives, as well as the increased testing for people with ARI symptoms 17–19 . Another theory is that a prior COVID-19 infection may cause affected individuals to become more susceptible to infection by other pathogens 20 . The respiratory pathogens described in this study typically peaked during the winter seasons of the pre-pandemic period, corresponding to the first and fourth quarters of the year. However, during the winter seasons of 2020 and 2021, amid the COVID-19 pandemic, there were no clear peaks. This finding is consistent with other studies worldwide 20–22 . This study found that, excluding Adenovirus, the seasonality of all pathogens changed to a more even distribution throughout the year while maintaining their respective seasonal peaks. Multiple studies showed a shift in seasonality of RSV, which came in the summer and peaked before winter with a reduced number of cases in its usual pre-pandemic season 20,22 . A study in Australia found that Influenza B had a delayed onset and a diminished peak in the seasons of 2023 and 2024, suggesting that the disruption of seasonality persisted after the pandemic 21 . One possible explanation is that due to the low number of cases and exposure to pathogens like RSV and Influenza, the population may have become immunologically naive to these pathogens, thus making them more susceptible to infection even in times where the pathogen is out of season 22,23 . We observed a significant rise in PICU admissions in the post-pandemic period for several pathogens. We theorize that this could be the result of the immunity debt incurred from limited exposure to respiratory infections and pathogens during the pandemic 23,24 . A study in Spain that focused on hospitalization for acute bronchiolitis showed that the PICU admission rate was significantly higher after lifting the NPIs and mandates in late 2021 25 . However, another study in Canada found no significant differences in PICU admission rates for all-cause pediatric respiratory diseases between pre- and post-pandemic years 26 . More studies are needed to explain this finding and explore the cause behind it. Primary prevention against ARIs with vaccination, against pathogens with available vaccines, should be recommended for all children to strengthen immunity and reduce disease severity and spread 27 . Since the prevalence of RSV and Influenza exceeded 10% in this study, we recommend the usage of Nirsevimab to prevent hospitalisation due to RSV infections as well as the usage of intranasal influenza vaccines as an adjunct to improve the efficacy of influenza vaccination 28,29 . NPIs proved to be an effective protective measure during the pandemic 30 , and these results supported this fact in showing the decrease in the incidence of all ARI-causative pathogens during the COVID-19 period. Tailored awareness campaigns educating parents about the symptoms of ARIs and the application of NPIs when their children are exhibiting these symptoms might help curb disease burden 31 . Additionally, educating parents on the correct implementation of NPIs, such as wearing masks, hand hygiene, and self-isolation during symptomatic periods, may reduce the spread of ARI-causative pathogens 16 . The use of short, interactive videos can effectively convey educational health messages, increasing the reach and accessibility of information, in addition to implementing recommendations published by the CDC 32,33 . It is important to note that the data used in this study was collected from a single hospital network system, potentially limiting this study’s representation of the general pediatric population in the country. The variation in socio-economic status among the UAE population may have influenced patients’ access to healthcare, leading to them avoiding medical care or potentially visiting other centers not included in this study. In addition, the inclusion of patients who sought medical care could lead to the indirect exclusion of milder ARI cases that recovered spontaneously without medical intervention. This selection bias may have led to overestimating detection and PICU admission rates. Another limitation is that we did not take into account possible confounding factors such as the socio-economic status of the family, existing comorbidities, and vaccination rates. Despite these limitations, the use of real-world hospital data across several years allowed for detailed analysis of ARI trends and disease patterns, along with the changes in their seasonality among different periods. Furthermore, the analysis of PICU admissions allowed for a unique perspective on disease severity and its changes across different time periods. Additionally, the study’s temporal analysis of ARI incidence before, during, and after the COVID-19 pandemic provides a unique perspective on the effectiveness of public health measures in controlling respiratory infections. Conclusion This study highlighted the burden of ARIs among the pediatric population in the UAE. The analysis revealed that all pathogens causing ARIs, other than COVID-19, showed a decrease in prevalence during the lockdown period in the UAE. Despite this decline, detection rates of most pathogens rose significantly after the pandemic, surpassing pre-pandemic levels. Additionally, the seasonality of most ARI-causative pathogens was found to be less pronounced in comparison to their previous peaks during specific quarters. PICU admission rates were significantly higher in more recent years, indicating a possible rise in the severity of ARIs after lifting the national lockdown measures. In order to reduce the burden of ARIs, tailored awareness campaigns and educational tools, such as interactive videos, should be used to teach the population about symptoms of ARIs and proper use of NPIs. Additionally, promoting vaccination for preventable pathogens is essential to strengthen children’s immunity and decrease disease transmission and severity. Further research should focus on including a more representative study sample, as well as accounting for potential confounding factors to provide a more accurate understanding of the incidence and severity of ARIs in children. Acknowledgements We would like to thank the Information Technology (IT) department of the American Hospital Network, especially Ms. Manjusha Manda and Mr. Bhushan Voovayya, for their valuable technical support. Moreover, we gratefully thank the laboratory department of the American Hospital Network for their assistance throughout the project. Supplementary Material File (figure_1.docx) Download 102.12 KB File (tables.docx) Download 19.17 KB References 1. Simoes EAF, Cherian T, Chow J, Shahid-Salles SA, Laxminarayan R, John TJ. Acute respiratory infections in children. In: Jamison DT, Breman JG, Measham AR, Alleyne G, Claeson M, Evans DB, Jha P, Mills A, Musgrove P, editors. Disease control priorities in developing countries. 2nd ed. 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This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Google Scholar 36. The authors declare no conflicts of interest. Google Scholar 37. The study protocol was reviewed and approved by the Dubai Scientific Research Ethics Committee (DSREC), Dubai Health Authority (DSREC-08/2024_22). Google Scholar 38. This manuscript does not contain any material reproduced from other sources that requires permission. Google Scholar Information & Authors Information Version history V1 Version 1 09 July 2025 Copyright This work is licensed under a Non Exclusive No Reuse License. Keywords child covid-19 cross-sectional studies respiratory tract infections united arab emirates Authors Affiliations Mazen Alhaj Ahmad 0009-0001-2429-4176 University of Sharjah College of Medicine View all articles by this author Saif Eddin Mansour 0009-0003-2939-8331 University of Sharjah College of Medicine View all articles by this author Albara’ Alshalkhaty University of Sharjah College of Medicine View all articles by this author Obada Al-Wawi 0009-0003-5867-4200 [email protected] University of Sharjah College of Medicine View all articles by this author Mukram Jamour University of Sharjah College of Medicine View all articles by this author Rabia Shah American Hospital Dubai View all articles by this author Arun Thomas American Hospital Dubai View all articles by this author Omendra Narayan University of Sharjah College of Medicine American Hospital Dubai View all articles by this author Metrics & Citations Metrics Article Usage 593 views 190 downloads .FvxKWukQNSOunydq8rnd { width: 100px; } Citations Download citation Mazen Alhaj Ahmad, Saif Eddin Mansour, Albara’ Alshalkhaty, et al. Prevalence of Acute Respiratory Infections Before, During, and After the COVID-19 Pandemic among the Pediatric Population in the United Arab Emirates: a Cross-sectional Study. Authorea . 09 July 2025. DOI: https://doi.org/10.22541/au.175203561.12935335/v1 If you have the appropriate software installed, you can download article citation data to the citation manager of your choice. Simply select your manager software from the list below and click Download. For more information or tips please see 'Downloading to a citation manager' in the Help menu . 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