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<record><TEI><teiHeader><fileDesc><titleStmt><title xml:lang="en">Influenza is more common than Middle East Respiratory Syndrome Coronavirus (MERS-CoV) among hospitalized adult Saudi patients</title><author><name sortKey="Al Tawfiq, Jaffar A" sort="Al Tawfiq, Jaffar A" uniqKey="Al Tawfiq J" first="Jaffar A." last="Al-Tawfiq">Jaffar A. Al-Tawfiq</name><affiliation><nlm:aff id="aff1">Specialty Internal Medicine, Johns Hopkins Aramco Healthcare, Dhahran, Saudi Arabia</nlm:aff></affiliation><affiliation><nlm:aff id="aff2">Indiana University School of Medicine, Indianapolis, IN, USA</nlm:aff></affiliation></author><author><name sortKey="Rabaan, Ali A" sort="Rabaan, Ali A" uniqKey="Rabaan A" first="Ali A." last="Rabaan">Ali A. Rabaan</name><affiliation><nlm:aff id="aff3">Molecular Diagnostic Laboratory, Johns Hopkins Aramco Healthcare, Dhahran, Saudi Arabia</nlm:aff></affiliation></author><author><name sortKey="Hinedi, Kareem" sort="Hinedi, Kareem" uniqKey="Hinedi K" first="Kareem" last="Hinedi">Kareem Hinedi</name><affiliation><nlm:aff id="aff4">Division of Hospital Medicine, Johns Hopkins Aramco Healthcare, Dhahran, Saudi Arabia</nlm:aff></affiliation></author></titleStmt><publicationStmt><idno type="wicri:source">PMC</idno><idno type="pmid">29031867</idno><idno type="pmc">7110697</idno><idno type="url">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7110697</idno><idno type="RBID">PMC:7110697</idno><idno type="doi">10.1016/j.tmaid.2017.10.004</idno><date when="2017">2017</date><idno type="wicri:Area/Pmc/Corpus">001156</idno><idno type="wicri:explorRef" wicri:stream="Pmc" wicri:step="Corpus" wicri:corpus="PMC">001156</idno></publicationStmt><sourceDesc><biblStruct><analytic><title xml:lang="en" level="a" type="main">Influenza is more common than Middle East Respiratory Syndrome Coronavirus (MERS-CoV) among hospitalized adult Saudi patients</title><author><name sortKey="Al Tawfiq, Jaffar A" sort="Al Tawfiq, Jaffar A" uniqKey="Al Tawfiq J" first="Jaffar A." last="Al-Tawfiq">Jaffar A. Al-Tawfiq</name><affiliation><nlm:aff id="aff1">Specialty Internal Medicine, Johns Hopkins Aramco Healthcare, Dhahran, Saudi Arabia</nlm:aff></affiliation><affiliation><nlm:aff id="aff2">Indiana University School of Medicine, Indianapolis, IN, USA</nlm:aff></affiliation></author><author><name sortKey="Rabaan, Ali A" sort="Rabaan, Ali A" uniqKey="Rabaan A" first="Ali A." last="Rabaan">Ali A. Rabaan</name><affiliation><nlm:aff id="aff3">Molecular Diagnostic Laboratory, Johns Hopkins Aramco Healthcare, Dhahran, Saudi Arabia</nlm:aff></affiliation></author><author><name sortKey="Hinedi, Kareem" sort="Hinedi, Kareem" uniqKey="Hinedi K" first="Kareem" last="Hinedi">Kareem Hinedi</name><affiliation><nlm:aff id="aff4">Division of Hospital Medicine, Johns Hopkins Aramco Healthcare, Dhahran, Saudi Arabia</nlm:aff></affiliation></author></analytic><series><title level="j">Travel Medicine and Infectious Disease</title><idno type="ISSN">1477-8939</idno><idno type="eISSN">1873-0442</idno><imprint><date when="2017">2017</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><front><div type="abstract" xml:lang="en"><sec><title>Background</title><p>Since the initial description of Middle East Respiratory Syndrome Coronavirus (MERS-CoV), we adopted a systematic process of screening patients admitted with community acquired pneumonia. Here, we report the result of the surveillance activity in a general hospital in Saudi Arabia over a four year period.</p></sec><sec><title>Materials and methods</title><p>All admitted patients with community acquired pneumonia from 2012 to 2016 were tested for MERS-CoV. In addition, testing for influenza viruses was carried out starting April 2015.</p></sec><sec><title>Results</title><p>During the study period, a total of 2657 patients were screened for MERS-CoV and only 20 (0.74%) tested positive. From January 2015 to December 2016, a total of 1644 patients were tested for both MERS-CoV and influenza. None of the patients tested positive for MERS-CoV and 271 (16.4%) were positive for influenza. The detected influenza viruses were Influenza A (107, 6.5%), pandemic 2009 H1N1 (n = 120, 7.3%), and Influenza B (n = 44, 2.7%). Pandemic H1N1 was the most common influenza in 2015 with a peak in peaked October to December and influenza A other than H1N1 was more common in 2016 with a peak in August and then October to December.</p></sec><sec><title>Conclusions</title><p>MERS-CoV was a rare cause of community acquired pneumonia and other viral causes including influenza were much more common. Thus, admitted patients are potentially manageable with Oseltamivir or Zanamivir therapy.</p></sec></div></front><back><div1 type="bibliography"><listBibl><biblStruct><analytic><author><name sortKey="Zaki, A M" uniqKey="Zaki A">A.M. Zaki</name></author><author><name sortKey="Van Boheemen, S" uniqKey="Van Boheemen S">S. van Boheemen</name></author><author><name sortKey="Bestebroer, T M" uniqKey="Bestebroer T">T.M. Bestebroer</name></author><author><name sortKey="Osterhaus, A D M E" uniqKey="Osterhaus A">A.D.M.E. Osterhaus</name></author><author><name sortKey="Fouchier, R A M" uniqKey="Fouchier R">R.A.M. 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<front><journal-meta><journal-id journal-id-type="nlm-ta">Travel Med Infect Dis</journal-id><journal-id journal-id-type="iso-abbrev">Travel Med Infect Dis</journal-id><journal-title-group><journal-title>Travel Medicine and Infectious Disease</journal-title></journal-title-group><issn pub-type="ppub">1477-8939</issn><issn pub-type="epub">1873-0442</issn><publisher><publisher-name>Elsevier Ltd.</publisher-name></publisher></journal-meta><article-meta><article-id pub-id-type="pmid">29031867</article-id><article-id pub-id-type="pmc">7110697</article-id><article-id pub-id-type="publisher-id">S1477-8939(17)30159-X</article-id><article-id pub-id-type="doi">10.1016/j.tmaid.2017.10.004</article-id><article-categories><subj-group subj-group-type="heading"><subject>Article</subject></subj-group></article-categories><title-group><article-title>Influenza is more common than Middle East Respiratory Syndrome Coronavirus (MERS-CoV) among hospitalized adult Saudi patients</article-title></title-group><contrib-group><contrib contrib-type="author" id="au1"><name><surname>Al-Tawfiq</surname><given-names>Jaffar A.</given-names></name><email>jaffar.tawfiq@jhah.com</email><email>jaltawfi@yahoo.com</email><xref rid="aff1" ref-type="aff">a</xref><xref rid="aff2" ref-type="aff">b</xref><xref rid="cor1" ref-type="corresp">∗</xref></contrib><contrib contrib-type="author" id="au2"><name><surname>Rabaan</surname><given-names>Ali A.</given-names></name><xref rid="aff3" ref-type="aff">c</xref></contrib><contrib contrib-type="author" id="au3"><name><surname>Hinedi</surname><given-names>Kareem</given-names></name><xref rid="aff4" ref-type="aff">d</xref></contrib></contrib-group><aff id="aff1"><label>a</label>Specialty Internal Medicine, Johns Hopkins Aramco Healthcare, Dhahran, Saudi Arabia</aff><aff id="aff2"><label>b</label>Indiana University School of Medicine, Indianapolis, IN, USA</aff><aff id="aff3"><label>c</label>Molecular Diagnostic Laboratory, Johns Hopkins Aramco Healthcare, Dhahran, Saudi Arabia</aff><aff id="aff4"><label>d</label>Division of Hospital Medicine, Johns Hopkins Aramco Healthcare, Dhahran, Saudi Arabia</aff><author-notes><corresp id="cor1"><label>∗</label>Corresponding author. P.O. Box 76, Room A-428-2, Building 61, Dhahran Health Center, Saudi Aramco, Dhahran 31311, Saudi Arabia. <email>jaffar.tawfiq@jhah.com</email><email>jaltawfi@yahoo.com</email></corresp></author-notes><pub-date pub-type="pmc-release"><day>12</day><month>10</month><year>2017</year></pub-date><pmc-comment> PMC Release delay is 0 months and 0 days and was based on .</pmc-comment>
<pub-date pub-type="ppub" iso-8601-date="2017-12-01"><season>November-December</season><year>2017</year></pub-date><pub-date pub-type="epub"><day>12</day><month>10</month><year>2017</year></pub-date><volume>20</volume><fpage>56</fpage><lpage>60</lpage><history><date date-type="received"><day>30</day><month>8</month><year>2017</year></date><date date-type="rev-recd"><day>8</day><month>10</month><year>2017</year></date><date date-type="accepted"><day>9</day><month>10</month><year>2017</year></date></history><permissions><copyright-statement>© 2017 Elsevier Ltd. All rights reserved.</copyright-statement><copyright-year>2017</copyright-year><copyright-holder>Elsevier Ltd</copyright-holder><license><license-p>Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active.</license-p></license></permissions><abstract id="abs0010"><sec><title>Background</title><p>Since the initial description of Middle East Respiratory Syndrome Coronavirus (MERS-CoV), we adopted a systematic process of screening patients admitted with community acquired pneumonia. Here, we report the result of the surveillance activity in a general hospital in Saudi Arabia over a four year period.</p></sec><sec><title>Materials and methods</title><p>All admitted patients with community acquired pneumonia from 2012 to 2016 were tested for MERS-CoV. In addition, testing for influenza viruses was carried out starting April 2015.</p></sec><sec><title>Results</title><p>During the study period, a total of 2657 patients were screened for MERS-CoV and only 20 (0.74%) tested positive. From January 2015 to December 2016, a total of 1644 patients were tested for both MERS-CoV and influenza. None of the patients tested positive for MERS-CoV and 271 (16.4%) were positive for influenza. The detected influenza viruses were Influenza A (107, 6.5%), pandemic 2009 H1N1 (n = 120, 7.3%), and Influenza B (n = 44, 2.7%). Pandemic H1N1 was the most common influenza in 2015 with a peak in peaked October to December and influenza A other than H1N1 was more common in 2016 with a peak in August and then October to December.</p></sec><sec><title>Conclusions</title><p>MERS-CoV was a rare cause of community acquired pneumonia and other viral causes including influenza were much more common. Thus, admitted patients are potentially manageable with Oseltamivir or Zanamivir therapy.</p></sec></abstract><kwd-group id="kwrds0010"><title>Keywords</title><kwd>MERS-CoV</kwd><kwd>Surveillance</kwd><kwd>Middle east respiratory syndrome coronavirus</kwd><kwd>Influenza</kwd><kwd>Community acquired pneumonia</kwd><kwd>CAP</kwd></kwd-group></article-meta></front><body><sec id="sec1"><label>1</label><title>Introduction</title><p id="p0010">The emergence of the Middle East respiratory Syndrome Coronavirus (MERS-CoV) in September 2012 had attracted international attention. The virus was initially isolated from a patient with a fatal community acquired pneumonia (CAP) in Saudi Arabia <xref rid="bib1" ref-type="bibr">[1]</xref>. Since then, multiple hospital outbreaks occurred within <xref rid="bib2" ref-type="bibr">[2]</xref>, <xref rid="bib3" ref-type="bibr">[3]</xref>, <xref rid="bib4" ref-type="bibr">[4]</xref>, <xref rid="bib5" ref-type="bibr">[5]</xref>, <xref rid="bib6" ref-type="bibr">[6]</xref>, <xref rid="bib7" ref-type="bibr">[7]</xref> and outside Saudi Arabia <xref rid="bib8" ref-type="bibr">[8]</xref>, <xref rid="bib9" ref-type="bibr">[9]</xref>, <xref rid="bib10" ref-type="bibr">[10]</xref>, <xref rid="bib11" ref-type="bibr">[11]</xref>. As of May 1st, 2017, the World Health Organization reported 1952 laboratory-confirmed cases worldwide and at least 693 related deaths <xref rid="bib12" ref-type="bibr">[12]</xref>. A wide-spectrum of MERS-CoV infection was described and ranges from mild to severe and fulminant infections leading to severe acute respiratory disease <xref rid="bib2" ref-type="bibr">[2]</xref>, <xref rid="bib13" ref-type="bibr">[13]</xref>, <xref rid="bib14" ref-type="bibr">[14]</xref>, <xref rid="bib15" ref-type="bibr">[15]</xref>. In the Kingdom of Saudi Arabia, the number of MERS-CoV cases was 1601 as of May 6th, 2017 <xref rid="bib16" ref-type="bibr">[16]</xref>. Since most of the cases of MERS-CoV in Saudi Arabia occurred due to intra- and inter-hospital transmissions, there was an increased amplification of the transmission <xref rid="bib2" ref-type="bibr">[2]</xref>, <xref rid="bib3" ref-type="bibr">[3]</xref>, <xref rid="bib4" ref-type="bibr">[4]</xref>, <xref rid="bib9" ref-type="bibr">[9]</xref>, <xref rid="bib10" ref-type="bibr">[10]</xref>, <xref rid="bib11" ref-type="bibr">[11]</xref>, <xref rid="bib17" ref-type="bibr">[17]</xref>. Early detection and isolation of patients with MERS-CoV infection remains an important factor for the control of MERS-CoV transmission <xref rid="bib18" ref-type="bibr">[18]</xref>, <xref rid="bib19" ref-type="bibr">[19]</xref>. One of the goals of the surveillance of emerging respiratory viruses is the rapid and early identification and placement of control measures <xref rid="bib20" ref-type="bibr">[20]</xref>. Following the initial description of the disease <xref rid="bib1" ref-type="bibr">[1]</xref>, the ministry of health in the Kingdom of Saudi Arabia put in place a surveillance and screening program for patients admitted with respiratory illness <xref rid="bib21" ref-type="bibr">[21]</xref>. Similarly, we adopted universal screening of admitted patients with community acquired pneumonia. Here, we report the result of the surveillance activity in a general hospital in Saudi Arabia over a four year period.</p></sec><sec id="sec2"><label>2</label><title>Materials and methods</title><p id="p0015">The study was conducted at a 350-bed general hospital, which also accepts referred patients. The hospital provides medical care for about 160,000 individuals eligible for medical care. The hospital has 5 intensive care units (cardiac, medical, surgical, pediatric, and neonatal) <xref rid="bib22" ref-type="bibr">[22]</xref>. All admitted patients with community acquired pneumonia from 2012 to 2016 were tested for MERS-CoV. The case definition of suspected MERS-CoV was an acute febrile respiratory illness (fever, cough, or dyspnea) with radiographic evidence of pneumonia <xref rid="bib22" ref-type="bibr">[22]</xref>. We collected data for all suspected patients using a standard Microsoft Excel data collection sheet. Both electronic and paper medical records were reviewed. We recorded the age and the date of admission and the MERS-CoV and influenza results. The study was approved by the Johns Hopkins Aramco Healthcare Institutional Review Board (IRB).</p><sec id="sec2.1"><label>2.1</label><title>MERS-CoV and influenza testing</title><p id="p0020">Suspected patients had either Dacron-flocked nasopharyngeal swabs, or sputum testing for MERS-CoV. The testing was done at the Saudi Ministry of Health MERS-CoV laboratory and at the main hospital. Clinical samples were screened with real-time reverse-transcriptase (RT)—PCR as described previously <xref rid="bib23" ref-type="bibr">[23]</xref>. The test amplified both the upstream E protein (upE gene) and ORF1a for MERS-CoV and if both assays were positive then the diagnosis of MERS-CoV was made, as described previously <xref rid="bib14" ref-type="bibr">[14]</xref>. The influenza test was carried out at the Johns Hopkins Aramco Healthcare Centre, Dhahran, using the Cepheid<sup>®</sup> Xpert Flu assay multiplex real-time PCR. The tested influenza viruses were pandemic 2009 H1N1, Influenza A (other than H1N1), and Influenza B. The test was systematically carried out starting April 2015.</p></sec><sec id="sec2.2"><label>2.2</label><title>Statistical analysis</title><p id="p0025">Statistical analysis was done using Excel and descriptive analyses were done for demographic, results of the tests and the monthly number of cases. Minitab<sup>®</sup> (Minitab Inc. Version 17, PA16801, USA; 2017) was used to calculate the mean age (±SD) of patients with influenza.</p></sec></sec><sec id="sec3"><label>3</label><title>Results</title><p id="p0030">During the study period from 2013 to 2016, a total of 2657 patients were screened for MERS-CoV and only 20 (0.74%) tested positive. During the first two years (April 2013–March 2015), a total of 1013 patients were screened for MERS-CoV. Only 1.8% of them were positive for MERS-CoV (<xref rid="tbl1" ref-type="table">Table 1</xref>) and unfortunately these were not systematically screened for influenza. There was an increased number of tests in November 2015–March 2016 (<xref rid="fig1" ref-type="fig">Fig. 1</xref>).<table-wrap position="float" id="tbl1"><label>Table 1</label><caption><p>Number of positive tests for influenza and MERS-CoV in relation to the study period.</p></caption><alt-text id="alttext0030">Table 1</alt-text><table frame="hsides" rules="groups"><thead><tr><th>Study Period</th><th>MERS-CoV</th><th>Influenza A</th><th>H1N1</th><th>Influenza B</th><th>Grand Total</th></tr></thead><tbody><tr><td>4/2013–3/2015</td><td>20 (1.8)</td><td>ND</td><td>ND</td><td>ND</td><td>1092</td></tr><tr><td>4/2015–12/2016</td><td>0 (0)</td><td>107 (6.5)</td><td>120 (7.2)</td><td>44 (2.6)</td><td>1644</td></tr><tr><td>Overall</td><td>20 (0.74)</td><td></td><td></td><td></td><td>2736</td></tr></tbody></table></table-wrap><fig id="fig1"><label>Fig. 1</label><caption><p>Monthly number of patients who were tested for MERS-CoV and the time of occurrence of major outbreaks.</p></caption><alt-text id="alttext0010">Fig. 1</alt-text><graphic xlink:href="gr1_lrg"></graphic></fig></p><p id="p0035">From April 2015 to December 2016, a total of 1644 patients were tested for both MERS-CoV and influenza. None of the patients tested positive for MERS-CoV and 271 (16.4%) were positive for influenza. The detected influenza viruses were Influenza A (107, 6.5%), pandemic 2009 H1N1 (n = 120, 7.3%), and Influenza B (n = 44, 2.7%) (<xref rid="tbl1" ref-type="table">Table 1</xref> and <xref rid="fig2" ref-type="fig">Fig. 2</xref>). It is interesting to note the pattern of the influenza in 2015 and 2016 (<xref rid="fig3" ref-type="fig">Fig. 3</xref>). Pandemic H1N1 was the most common influenza in 2015 and influenza A other than H1N1 was more common in 2016. The 2015 influenza season peaked October to December and the 2016 season had a peak in August and then October to December (<xref rid="fig3" ref-type="fig">Fig. 3</xref>). There was a significant difference in the mean age (±SD; 95% CI) of patients with H1N1 and other influenza (<xref rid="fig4" ref-type="fig">Fig. 4</xref>). The mean age (±SD; 95% CI) was 45.09 (±24.32; 40.85, 49.33) for H1N1, 63.70 (±20.34; 59.21, 68.19) for influenza A, 55.11 (±25.27; 48.11, 62.12) for Influenza B, and 61.28 (±23.82; 60.03, 62.54) for influenza negative patients (P < 0.0001).<fig id="fig2"><label>Fig. 2</label><caption><p>Monthly influenza type from April 2015 to December 2016.</p></caption><alt-text id="alttext0015">Fig. 2</alt-text><graphic xlink:href="gr2_lrg"></graphic></fig><fig id="fig3"><label>Fig. 3</label><caption><p>A Line graph showing the monthly number of isolated influenza by type.</p></caption><alt-text id="alttext0020">Fig. 3</alt-text><graphic xlink:href="gr3_lrg"></graphic></fig><fig id="fig4"><label>Fig. 4</label><caption><p>Interval plot of age and 95% confidence interval of age among influenza patients.</p></caption><alt-text id="alttext0025">Fig. 4</alt-text><graphic xlink:href="gr4_lrg"></graphic></fig></p></sec><sec id="sec4"><label>4</label><title>Discussion</title><p id="p0040">In this study, we presented the surveillance data on MERS-CoV over a four year period and the surveillance for influenza over a two year period. MERS-CoV was only detected in 20 (0.75%) from a total of 2657 patients as detailed in previous publication <xref rid="bib22" ref-type="bibr">[22]</xref>, <xref rid="bib24" ref-type="bibr">[24]</xref>. The earliest surveillance study from Saudi Arabia was done from 1 October 2012 to 30 September 2013 and tested a total of 5065 samples <xref rid="bib21" ref-type="bibr">[21]</xref>. In that study, the MERS positivity rate was 2% <xref rid="bib21" ref-type="bibr">[21]</xref>. A second surveillance of MERS-CoV in Saudi Arabia was conducted from April 1, 2015 to February 1, 2016 and included a total of 57,363 suspected MERS cases <xref rid="bib25" ref-type="bibr">[25]</xref>. The study showed only 384 (0.7%) MERS-CoV positive cases <xref rid="bib25" ref-type="bibr">[25]</xref>. In a study in the United States, two (0.4%) imported cases were detected among 490 patients-under investigation in 2013–2014 <xref rid="bib26" ref-type="bibr">[26]</xref>. In a surveillance study of 1586 unique persons from the United Arab Emirates between January 1, 2013and April 17, 2014, 41 (3%) tested positive for MERS-CoV infection <xref rid="bib27" ref-type="bibr">[27]</xref>. In the South Korea outbreak, 184 (1%) had MERS among 16,752 suspected cases <xref rid="bib28" ref-type="bibr">[28]</xref>. In a small study from Saudi Arabia, MERS-CoV was not detected in 182 cases tested November 2013 and January 2014 (winter time) <xref rid="bib29" ref-type="bibr">[29]</xref>. Thus, the overall positivity of MERS-CoV among a large cohort remains low. There is a need for a better tool to identify patients with high probability of MERS-CoV. However, a case control study and a large cohort study did not reveal significant predictor of MERS-CoV infection <xref rid="bib22" ref-type="bibr">[22]</xref>, <xref rid="bib30" ref-type="bibr">[30]</xref>.</p><p id="p0045">The monthly frequency of suspected MERS cases that were tested showed variation with an apparent increase in the tested number during November 2015–March 2016. This apparent increase likely represented an increased activity of influenza during that time. There was no relation to the Hajj season as it occurred during September 21–26, 2015 (<xref rid="fig1" ref-type="fig">Fig. 1</xref>). In addition at that time, there were no known outbreaks in the Kingdom of Saudi Arabia to account for such an increase in the testing. The 2015 outbreaks occurred in Al-Hasa in May 2015 <xref rid="bib31" ref-type="bibr">[31]</xref> and in Riyadh in August 2015 <xref rid="bib7" ref-type="bibr">[7]</xref>, <xref rid="bib32" ref-type="bibr">[32]</xref>, <xref rid="bib33" ref-type="bibr">[33]</xref>. Previous studies had shown increased testing of patients for MERS-CoV during outbreaks <xref rid="bib4" ref-type="bibr">[4]</xref>. In the current study, the 2015 season was predominated by 2009 pandemic H1N1 whereas influenza A was more common during 2016. Similarly, in the United States the 2014–2015 season was predominated by pandemic H1N1 and H3N2 was more common during the 2016–2017 season <xref rid="bib34" ref-type="bibr">[34]</xref>, <xref rid="bib35" ref-type="bibr">[35]</xref>.We found that influenza rather than MERS-CoV was more common among the tested patients. The findings are also consistent with other studies among travelers and pilgrims where influenza far exceeded MERS <xref rid="bib36" ref-type="bibr">[36]</xref>, <xref rid="bib37" ref-type="bibr">[37]</xref>, <xref rid="bib38" ref-type="bibr">[38]</xref>, <xref rid="bib39" ref-type="bibr">[39]</xref>, <xref rid="bib40" ref-type="bibr">[40]</xref>. Similarly, in a small study in Saudi Arabia, influenza viruses were detected in 16% of 182 patients <xref rid="bib29" ref-type="bibr">[29]</xref>. Similarly, among a small study of 52 suspected MERS cases in the United States of America, Influenza was the most commonly (35%) identified respiratory agent <xref rid="bib41" ref-type="bibr">[41]</xref> and another study found influenza A and B in 11% of 296 investigated patients <xref rid="bib26" ref-type="bibr">[26]</xref>. Thus, it is important to test for common respiratory pathogens such as influenza viruses and it should be noted that identification of a respiratory pathogen should not exclude MERS-CoV testing <xref rid="bib42" ref-type="bibr">[42]</xref>. One report indicated co-infection with influenza and MERS in four patients <xref rid="bib43" ref-type="bibr">[43]</xref>. However, epidemiologic differences between different countries should remain as an important predictor of the existence of MERS-CoV infection.</p><p id="p0050">The mean age of patients with H1N1 was younger than the other influenza patients of at least 10 years (45.09 vs. 63.70 for influenza A, 55.11 for Influenza B, and 61.28 for influenza negative patients (P < 0.0001). The inital cases of pandemic 2009 H1N1 were also younger than the influenza negative patients <xref rid="bib44" ref-type="bibr">[44]</xref>. In a small study of 196 patients, influenza B patients were younger than other influenza <xref rid="bib45" ref-type="bibr">[45]</xref> and in another study the mean age was lower for patients with influenza B (16.4 yr) than (H1N1) pdm09 influenza infection. However, these studies included children and thus are not comparable with the present study <xref rid="bib46" ref-type="bibr">[46]</xref>.</p><p id="p0055">Similar results were obtained in travelers returning from the Middle East. These studies showed the lack of MERS-CoV among travelers and that influenza was more common among French travelers <xref rid="bib47" ref-type="bibr">[47]</xref>, <xref rid="bib48" ref-type="bibr">[48]</xref>, Austrian returning pilgrims <xref rid="bib40" ref-type="bibr">[40]</xref>, British travelers <xref rid="bib49" ref-type="bibr">[49]</xref>, German travelers <xref rid="bib50" ref-type="bibr">[50]</xref>, and travelers to California, United States <xref rid="bib41" ref-type="bibr">[41]</xref>. The presence of influenza infection among those travelrs stress the need for influenza vaccination in travelers, notably tfor those going for the Hajj and Umrah in Saudi Arabia.</p><p id="p0060">In conclusion, MERS-CoV was a rare cause of community acquired pneumonia (CAP) and other viral causes including influenza are much more common. The epidemiology of influenza mirrored the epidemiology of influenza worldwide. The study highlights the importance of the surveillance system to elucidate the epidemiology of respiratory infections in order to formulate appropriate control measures. 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