Middle East respiratory syndrome coronavirus disease is rare in children: An update from Saudi Arabia
Identifieur interne : 001226 ( Pmc/Corpus ); précédent : 001225; suivant : 001227Middle East respiratory syndrome coronavirus disease is rare in children: An update from Saudi Arabia
Auteurs : Jaffar A. Al-Tawfiq ; Rana F. Kattan ; Ziad A. MemishSource :
- World Journal of Clinical Pediatrics [ 2219-2808 ] ; 2016.
Abstract
To summarize the reported Middle East respiratory syndrome-coronavirus (MERS-CoV) cases, the associated clinical presentations and the outcomes.
We searched the Saudi Ministry of Health website, the World Health Organization website, and the Flutracker website. We also searched MEDLINE and PubMed for the keywords: Middle East respiratory syndrome-coronavirus, MERS-CoV in combination with pediatric, children, childhood, infancy and pregnancy from the initial discovery of the virus in 2012 to 2016. The retrieved articles were also read to further find other articles. Relevant data were placed into an excel sheet and analyzed accordingly. Descriptive analytic statistics were used in the final analysis as deemed necessary.
From June 2012 to April 19, 2016, there were a total of 31 pediatric MERS-CoV cases. Of these cases 13 (42%) were asymptomatic and the male to female ratio was 1.7:1. The mean age of patients was 9.8 ± 5.4 years. Twenty-five (80.6%) of the cases were reported from the Kingdom of Saudi Arabia. The most common source of infection was household contact (10 of 15 with reported source) and 5 patients acquired infection within a health care facility. Using real time reverse transcriptase polymerase chain reaction of pediatric patients revealed that 9 out of 552 (1.6%) was positive in the Kingdom of Saudi Arabia.
Utilizing serology for MERS-CoV infection in Jordan and Saudi Arabia did not reveal any positive patients. Thus, the number of the pediatric MERS-CoV is low; the exact reason for the low prevalence of the disease in children is not known.
Url:
DOI: 10.5409/wjcp.v5.i4.391
PubMed: 27872828
PubMed Central: 5099592
Links to Exploration step
PMC:5099592Le document en format XML
<record><TEI><teiHeader><fileDesc><titleStmt><title xml:lang="en">Middle East respiratory syndrome coronavirus disease is rare in children: An update from Saudi Arabia</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></author><author><name sortKey="Kattan, Rana F" sort="Kattan, Rana F" uniqKey="Kattan R" first="Rana F" last="Kattan">Rana F. Kattan</name></author><author><name sortKey="Memish, Ziad A" sort="Memish, Ziad A" uniqKey="Memish Z" first="Ziad A" last="Memish">Ziad A. Memish</name></author></titleStmt><publicationStmt><idno type="wicri:source">PMC</idno><idno type="pmid">27872828</idno><idno type="pmc">5099592</idno><idno type="url">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5099592</idno><idno type="RBID">PMC:5099592</idno><idno type="doi">10.5409/wjcp.v5.i4.391</idno><date when="2016">2016</date><idno type="wicri:Area/Pmc/Corpus">001226</idno><idno type="wicri:explorRef" wicri:stream="Pmc" wicri:step="Corpus" wicri:corpus="PMC">001226</idno></publicationStmt><sourceDesc><biblStruct><analytic><title xml:lang="en" level="a" type="main">Middle East respiratory syndrome coronavirus disease is rare in children: An update from Saudi Arabia</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></author><author><name sortKey="Kattan, Rana F" sort="Kattan, Rana F" uniqKey="Kattan R" first="Rana F" last="Kattan">Rana F. Kattan</name></author><author><name sortKey="Memish, Ziad A" sort="Memish, Ziad A" uniqKey="Memish Z" first="Ziad A" last="Memish">Ziad A. Memish</name></author></analytic><series><title level="j">World Journal of Clinical Pediatrics</title><idno type="eISSN">2219-2808</idno><imprint><date when="2016">2016</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><front><div type="abstract" xml:lang="en"><sec><title>AIM</title><p>To summarize the reported Middle East respiratory syndrome-coronavirus (MERS-CoV) cases, the associated clinical presentations and the outcomes.</p></sec><sec><title>METHODS</title><p>We searched the Saudi Ministry of Health website, the World Health Organization website, and the Flutracker website. We also searched MEDLINE and PubMed for the keywords: Middle East respiratory syndrome-coronavirus, MERS-CoV in combination with pediatric, children, childhood, infancy and pregnancy from the initial discovery of the virus in 2012 to 2016. The retrieved articles were also read to further find other articles. Relevant data were placed into an excel sheet and analyzed accordingly. Descriptive analytic statistics were used in the final analysis as deemed necessary.</p></sec><sec><title>RESULTS</title><p>From June 2012 to April 19, 2016, there were a total of 31 pediatric MERS-CoV cases. Of these cases 13 (42%) were asymptomatic and the male to female ratio was 1.7:1. The mean age of patients was 9.8 ± 5.4 years. Twenty-five (80.6%) of the cases were reported from the Kingdom of Saudi Arabia. The most common source of infection was household contact (10 of 15 with reported source) and 5 patients acquired infection within a health care facility. Using real time reverse transcriptase polymerase chain reaction of pediatric patients revealed that 9 out of 552 (1.6%) was positive in the Kingdom of Saudi Arabia.</p></sec><sec><title>CONCLUSION</title><p>Utilizing serology for MERS-CoV infection in Jordan and Saudi Arabia did not reveal any positive patients. 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<front><journal-meta><journal-id journal-id-type="nlm-ta">World J Clin Pediatr</journal-id><journal-id journal-id-type="publisher-id">WJCP</journal-id><journal-title-group><journal-title>World Journal of Clinical Pediatrics</journal-title></journal-title-group><issn pub-type="epub">2219-2808</issn><publisher><publisher-name>Baishideng Publishing Group Inc</publisher-name></publisher></journal-meta><article-meta><article-id pub-id-type="pmid">27872828</article-id><article-id pub-id-type="pmc">5099592</article-id><article-id pub-id-type="other">jWJCP.v5.i4.pg391</article-id><article-id pub-id-type="doi">10.5409/wjcp.v5.i4.391</article-id><article-categories><subj-group subj-group-type="heading"><subject>Systematic Reviews</subject></subj-group></article-categories><title-group><article-title>Middle East respiratory syndrome coronavirus disease is rare in children: An update from Saudi Arabia</article-title></title-group><contrib-group><contrib contrib-type="author"><name><surname>Al-Tawfiq</surname><given-names>Jaffar A</given-names></name></contrib><contrib contrib-type="author"><name><surname>Kattan</surname><given-names>Rana F</given-names></name></contrib><contrib contrib-type="author"><name><surname>Memish</surname><given-names>Ziad A</given-names></name></contrib><aff>Jaffar A Al-Tawfiq, Johns Hopkins Aramco Healthcare, Dhahran 31311, Kingdom of Saudi Arabia</aff><aff>Jaffar A Al-Tawfiq, Indiana University School of Medicine, Indianapolis, IN 46202, United States</aff><aff>Rana F Kattan, Department of Pediatric, King Saud bin Abdulaziz University for Health Sciences, King Abdullah Specialist Children’s Hospital, Riyadh 11514, Kingdom of Saudi Arabia</aff><aff>Ziad A Memish, Ministry of Health, Riyadh 1151, Kingdom of Saudi Arabia</aff><aff>Ziad A Memish, College of Medicine, Alfaisal University, Riyadh 11514, Kingdom of Saudi Arabia</aff></contrib-group><author-notes><fn><p>Author contributions: Al-Tawfiq JA developed the research protocol, performed the research and data analysis; Al-Tawfiq JA, Kattan RF and Memish ZA authored and approved the article.</p><p>Correspondence to: Ziad A Memish, Professor, College of Medicine, Alfaisal University, P.O. Box 54146, Riyadh 11514, Kingdom of Saudi Arabia. <email>zmemish@yahoo.com</email></p><p>Telephone: +966-50-5483515 Fax: +966-11-2616464</p></fn></author-notes><pub-date pub-type="collection"><day>8</day><month>11</month><year>2016</year></pub-date><pub-date pub-type="epub"><day>8</day><month>11</month><year>2016</year></pub-date><volume>5</volume><issue>4</issue><fpage>391</fpage><lpage>396</lpage><history><date date-type="received"><day>27</day><month>5</month><year>2016</year></date><date date-type="rev-recd"><day>16</day><month>8</month><year>2016</year></date><date date-type="accepted"><day>27</day><month>8</month><year>2016</year></date></history><permissions><copyright-statement>©The Author(s) 2016. Published by Baishideng Publishing Group Inc. All rights reserved.</copyright-statement><copyright-year>2016</copyright-year><license license-type="open-access" xlink:href="http://creativecommons.org/licenses/by-nc/4.0/"><license-p>This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial.</license-p></license></permissions><abstract><sec><title>AIM</title><p>To summarize the reported Middle East respiratory syndrome-coronavirus (MERS-CoV) cases, the associated clinical presentations and the outcomes.</p></sec><sec><title>METHODS</title><p>We searched the Saudi Ministry of Health website, the World Health Organization website, and the Flutracker website. We also searched MEDLINE and PubMed for the keywords: Middle East respiratory syndrome-coronavirus, MERS-CoV in combination with pediatric, children, childhood, infancy and pregnancy from the initial discovery of the virus in 2012 to 2016. The retrieved articles were also read to further find other articles. Relevant data were placed into an excel sheet and analyzed accordingly. Descriptive analytic statistics were used in the final analysis as deemed necessary.</p></sec><sec><title>RESULTS</title><p>From June 2012 to April 19, 2016, there were a total of 31 pediatric MERS-CoV cases. Of these cases 13 (42%) were asymptomatic and the male to female ratio was 1.7:1. The mean age of patients was 9.8 ± 5.4 years. Twenty-five (80.6%) of the cases were reported from the Kingdom of Saudi Arabia. The most common source of infection was household contact (10 of 15 with reported source) and 5 patients acquired infection within a health care facility. Using real time reverse transcriptase polymerase chain reaction of pediatric patients revealed that 9 out of 552 (1.6%) was positive in the Kingdom of Saudi Arabia.</p></sec><sec><title>CONCLUSION</title><p>Utilizing serology for MERS-CoV infection in Jordan and Saudi Arabia did not reveal any positive patients. Thus, the number of the pediatric MERS-CoV is low; the exact reason for the low prevalence of the disease in children is not known.</p></sec></abstract><kwd-group><kwd>Pediatric</kwd><kwd>Middle East respiratory syndrome-coronavirus</kwd><kwd>Children</kwd><kwd>Respiratory tract infection</kwd></kwd-group></article-meta></front><body><p><bold>Core tip:</bold> The number of the pediatric Middle East respiratory syndrome-coronavirus (MERS-CoV) is low and the exact reason for the low prevalence is not known. A total of 31 pediatric MERS-CoV cases were reported since June 2012. Of all the cases 13 (42%) were asymptomatic and the male to female ratio was 1.7:1. The mean age of patients was 9.8 ± 5.4 years.The most common source of infection was household contact followed by infection within a health care facility. Using real time reverse transcriptase polymerase chain reaction of pediatric patients revealed that 9 out of 552 (1.6%) was positive in the Kingdom of Saudi Arabia.</p><sec><title>INTRODUCTION</title><p>Middle East respiratory syndrome-coronavirus (MERS-CoV) was first isolated in 2012 from a patient in the Kingdom of Saudi Arabia (KSA)[<xref rid="B1" ref-type="bibr">1</xref>]. As more cases were reported, the case fatality rate changed to 40% from 60%[<xref rid="B2" ref-type="bibr">2</xref>-<xref rid="B5" ref-type="bibr">5</xref>]. In addition, initially there was a predominance of males; later this ratio decreased[<xref rid="B2" ref-type="bibr">2</xref>,<xref rid="B6" ref-type="bibr">6</xref>]. MERS-CoV is characterized by three different patterns of disease: Sporadic cases, intra-familial transmission[<xref rid="B7" ref-type="bibr">7</xref>-<xref rid="B9" ref-type="bibr">9</xref>] and health care associated infection[<xref rid="B2" ref-type="bibr">2</xref>,<xref rid="B3" ref-type="bibr">3</xref>,<xref rid="B10" ref-type="bibr">10</xref>-<xref rid="B16" ref-type="bibr">16</xref>]. Despite the increased number overtime and the multiple health care associated outbreaks[<xref rid="B17" ref-type="bibr">17</xref>], the number of pediatric cases remained low during the study period[<xref rid="B18" ref-type="bibr">18</xref>]. The initial description of 47 cases included only a 14-year-old child[<xref rid="B4" ref-type="bibr">4</xref>]. The first pediatric case was a 2-year-old child reported from Jeddah, KSA on June 28, 2013[<xref rid="B19" ref-type="bibr">19</xref>]. Later an additional three asymptomatic children were reported[<xref rid="B4" ref-type="bibr">4</xref>]. The largest report of childhood MERS-CoV cases included eleven, of which two patients were symptomatic and nine were asymptomatic[<xref rid="B18" ref-type="bibr">18</xref>]. The exact reason for this low prevalence of the disease in children is not known. In this study, we summarize the reported MERS-CoV cases and the associated clinical presentation and the outcome.</p></sec><sec sec-type="methods"><title>MATERIALS AND METHODS</title><p>We searched the Saudi Ministry of Health website[<xref rid="B20" ref-type="bibr">20</xref>], the World Health Organization website[<xref rid="B21" ref-type="bibr">21</xref>], the Flutracker website[<xref rid="B22" ref-type="bibr">22</xref>], the medical literature and the retrieved published studies for any childhood MERS-CoV infections. We searched MEDLINE and PubMed for the keywords Middle East respiratory syndrome-coronavirus, MERS-CoV, in combination with pediatric, children, childhood, infancy and pregnancy from the initial discovery of the virus in June 2012 until April 19, 2016. The retrieved articles were also read to find other relevant articles.</p><sec><title>Statistical analysis</title><p>Relevant data were placed into an excel sheet and analyzed accordingly. Descriptive analytic statistics were used in the final analysis as deemed necessary, including mean and standard deviation when applicable and frequency. The statistical review of the study was performed by a biomedical statistician. Statistical review is performed before the submission of the manuscript.</p></sec></sec><sec><title>RESULTS</title><sec><title>Summary of pediatric cases</title><p>From June 2012, to April 19, 2016, there were a total of 31 pediatric MERS-CoV cases as shown in Table <xref ref-type="table" rid="T1">1</xref>. Of all the cases, thirteen (13) or 42% were asymptomatic, and there were 17 males, 10 females and 4 unreported (a male to female ratio of 1.7:1). The mean age of patients was 9.8 + 5.4 (0.75-17) years. Twenty-five cases (80.6%) were reported from KSA; the other patients were in Jordan, United Arab Emirates and the Republic of Korea (Table <xref ref-type="table" rid="T1">1</xref>). The most common source of the infection was household contact (10 of 15 with reported source), and 5 patients acquired the infection within a health care facility. About one half of the cases were reported in 2014, and 29% were reported in 2013 and 22.6% in 2015 (Table <xref ref-type="table" rid="T2">2</xref>).</p><table-wrap id="T1" position="float"><label>Table 1</label><caption><p>Summary of reported pediatric Middle East respiratory syndrome cases</p></caption><table frame="hsides" rules="groups"><thead align="center"><tr><td align="left" rowspan="1" colspan="1"><bold>Age</bold></td><td rowspan="1" colspan="1"><bold>Gender</bold></td><td rowspan="1" colspan="1"><bold>Country</bold></td><td rowspan="1" colspan="1"><bold>Sample source</bold></td><td rowspan="1" colspan="1"><bold>Year of reporting</bold></td><td rowspan="1" colspan="1"><bold>Symptoms</bold></td><td rowspan="1" colspan="1"><bold>Co-morbidity</bold></td><td rowspan="1" colspan="1"><bold>Signs</bold></td><td rowspan="1" colspan="1"><bold>Sample type</bold></td><td rowspan="1" colspan="1"><bold>Viral load ct value</bold></td><td rowspan="1" colspan="1"><bold>Imaging</bold></td><td rowspan="1" colspan="1"><bold>Intensive care</bold></td><td rowspan="1" colspan="1"><bold>Death</bold></td><td rowspan="1" colspan="1"><bold>Ref</bold>.</td></tr></thead><tbody align="center"><tr><td align="left" rowspan="1" colspan="1">2</td><td rowspan="1" colspan="1">Male</td><td rowspan="1" colspan="1">KSA</td><td rowspan="1" colspan="1">Hospital inpatient</td><td rowspan="1" colspan="1">2013</td><td rowspan="1" colspan="1">Fever, respiratory distress</td><td rowspan="1" colspan="1">Cystic fibrosis</td><td rowspan="1" colspan="1">Chest: Bilateral fine crepitation</td><td rowspan="1" colspan="1">NPS</td><td rowspan="1" colspan="1">36</td><td rowspan="1" colspan="1">Bilateral diffused infiltrate</td><td rowspan="1" colspan="1">+</td><td rowspan="1" colspan="1">Yes</td><td rowspan="1" colspan="1">[<xref rid="B18" ref-type="bibr">18</xref>]</td></tr><tr><td colspan="14" rowspan="1"></td></tr><tr><td align="left" rowspan="1" colspan="1">14</td><td rowspan="1" colspan="1">Female</td><td rowspan="1" colspan="1">KSA</td><td rowspan="1" colspan="1">Hospital inpatient</td><td rowspan="1" colspan="1">2013</td><td rowspan="1" colspan="1">Fever</td><td rowspan="1" colspan="1">Down’s syndrome</td><td rowspan="1" colspan="1"></td><td rowspan="1" colspan="1">NPS</td><td rowspan="1" colspan="1">37</td><td rowspan="1" colspan="1">Bilateral diffused infiltrate</td><td rowspan="1" colspan="1">No</td><td rowspan="1" colspan="1">No</td><td rowspan="1" colspan="1">[<xref rid="B18" ref-type="bibr">18</xref>]</td></tr><tr><td colspan="14" rowspan="1"></td></tr><tr><td align="left" rowspan="1" colspan="1">7</td><td rowspan="1" colspan="1">Female</td><td rowspan="1" colspan="1">KSA</td><td rowspan="1" colspan="1">Family contact</td><td rowspan="1" colspan="1">2013</td><td rowspan="1" colspan="1">Asymptomatic</td><td rowspan="1" colspan="1">None</td><td rowspan="1" colspan="1">None</td><td rowspan="1" colspan="1">N + T</td><td rowspan="1" colspan="1">37</td><td rowspan="1" colspan="1">ND</td><td rowspan="1" colspan="1">No</td><td rowspan="1" colspan="1">No</td><td rowspan="1" colspan="1">[<xref rid="B18" ref-type="bibr">18</xref>]</td></tr><tr><td colspan="14" rowspan="1"></td></tr><tr><td align="left" rowspan="1" colspan="1">15</td><td rowspan="1" colspan="1">Female</td><td rowspan="1" colspan="1">KSA</td><td rowspan="1" colspan="1">Family contact</td><td rowspan="1" colspan="1">2014</td><td rowspan="1" colspan="1">Asymptomatic</td><td rowspan="1" colspan="1">None</td><td rowspan="1" colspan="1">None</td><td rowspan="1" colspan="1">NPS</td><td rowspan="1" colspan="1">35</td><td rowspan="1" colspan="1">ND</td><td rowspan="1" colspan="1">No</td><td rowspan="1" colspan="1">No</td><td rowspan="1" colspan="1">[<xref rid="B18" ref-type="bibr">18</xref>]</td></tr><tr><td colspan="14" rowspan="1"></td></tr><tr><td align="left" rowspan="1" colspan="1">14</td><td rowspan="1" colspan="1">Male</td><td rowspan="1" colspan="1">KSA</td><td rowspan="1" colspan="1">Family contact</td><td rowspan="1" colspan="1">2014</td><td rowspan="1" colspan="1">Asymptomatic</td><td rowspan="1" colspan="1">None</td><td rowspan="1" colspan="1">None</td><td rowspan="1" colspan="1">NPS</td><td rowspan="1" colspan="1">34</td><td rowspan="1" colspan="1">ND</td><td rowspan="1" colspan="1">No</td><td rowspan="1" colspan="1">No</td><td rowspan="1" colspan="1">[<xref rid="B18" ref-type="bibr">18</xref>]</td></tr><tr><td colspan="14" rowspan="1"></td></tr><tr><td align="left" rowspan="1" colspan="1">12</td><td rowspan="1" colspan="1">Female</td><td rowspan="1" colspan="1">KSA</td><td rowspan="1" colspan="1">Family contact</td><td rowspan="1" colspan="1">2014</td><td rowspan="1" colspan="1">Asymptomatic</td><td rowspan="1" colspan="1">None</td><td rowspan="1" colspan="1">None</td><td rowspan="1" colspan="1">NPS</td><td rowspan="1" colspan="1">35</td><td rowspan="1" colspan="1">ND</td><td rowspan="1" colspan="1">No</td><td rowspan="1" colspan="1">No</td><td rowspan="1" colspan="1">[<xref rid="B18" ref-type="bibr">18</xref>]</td></tr><tr><td colspan="14" rowspan="1"></td></tr><tr><td align="left" rowspan="1" colspan="1">16</td><td rowspan="1" colspan="1">male</td><td rowspan="1" colspan="1">KSA</td><td rowspan="1" colspan="1">Family contact</td><td rowspan="1" colspan="1">2013</td><td rowspan="1" colspan="1">Asymptomatic</td><td rowspan="1" colspan="1">None</td><td rowspan="1" colspan="1">none</td><td rowspan="1" colspan="1">NPS</td><td rowspan="1" colspan="1">36</td><td rowspan="1" colspan="1">ND</td><td rowspan="1" colspan="1">No</td><td rowspan="1" colspan="1">No</td><td rowspan="1" colspan="1">[<xref rid="B18" ref-type="bibr">18</xref>]</td></tr><tr><td colspan="14" rowspan="1"></td></tr><tr><td align="left" rowspan="1" colspan="1">7</td><td rowspan="1" colspan="1">Female</td><td rowspan="1" colspan="1">KSA</td><td rowspan="1" colspan="1">Family contact</td><td rowspan="1" colspan="1">2014</td><td rowspan="1" colspan="1">Asymptomatic</td><td rowspan="1" colspan="1">None</td><td rowspan="1" colspan="1">none</td><td rowspan="1" colspan="1">NPS</td><td rowspan="1" colspan="1">37</td><td rowspan="1" colspan="1">ND</td><td rowspan="1" colspan="1">No</td><td rowspan="1" colspan="1">No</td><td rowspan="1" colspan="1">[<xref rid="B18" ref-type="bibr">18</xref>]</td></tr><tr><td colspan="14" rowspan="1"></td></tr><tr><td align="left" rowspan="1" colspan="1">3</td><td rowspan="1" colspan="1">Female</td><td rowspan="1" colspan="1">KSA</td><td rowspan="1" colspan="1">Family contact</td><td rowspan="1" colspan="1">2013</td><td rowspan="1" colspan="1">Asymptomatic</td><td rowspan="1" colspan="1">None</td><td rowspan="1" colspan="1">none</td><td rowspan="1" colspan="1">NPS</td><td rowspan="1" colspan="1">38</td><td rowspan="1" colspan="1">ND</td><td rowspan="1" colspan="1">No</td><td rowspan="1" colspan="1">No</td><td rowspan="1" colspan="1">[<xref rid="B18" ref-type="bibr">18</xref>]</td></tr><tr><td colspan="14" rowspan="1"></td></tr><tr><td align="left" rowspan="1" colspan="1">13</td><td rowspan="1" colspan="1">Female</td><td rowspan="1" colspan="1">KSA</td><td rowspan="1" colspan="1">Contact</td><td rowspan="1" colspan="1">2014</td><td rowspan="1" colspan="1">Asymptomatic</td><td rowspan="1" colspan="1">None</td><td rowspan="1" colspan="1">none</td><td rowspan="1" colspan="1">NPS</td><td rowspan="1" colspan="1">34</td><td rowspan="1" colspan="1">ND</td><td rowspan="1" colspan="1">No</td><td rowspan="1" colspan="1">No</td><td rowspan="1" colspan="1">[<xref rid="B18" ref-type="bibr">18</xref>]</td></tr><tr><td colspan="14" rowspan="1"></td></tr><tr><td align="left" rowspan="1" colspan="1">14</td><td rowspan="1" colspan="1">Female</td><td rowspan="1" colspan="1">KSA</td><td rowspan="1" colspan="1">Family contact</td><td rowspan="1" colspan="1">2013</td><td rowspan="1" colspan="1">Asymptomatic</td><td rowspan="1" colspan="1">None</td><td rowspan="1" colspan="1">none</td><td rowspan="1" colspan="1">NPS</td><td rowspan="1" colspan="1">36</td><td rowspan="1" colspan="1">ND</td><td rowspan="1" colspan="1">No</td><td rowspan="1" colspan="1">No</td><td rowspan="1" colspan="1">[<xref rid="B18" ref-type="bibr">18</xref>]</td></tr><tr><td colspan="14" rowspan="1"></td></tr><tr><td align="left" rowspan="1" colspan="1">0.75</td><td rowspan="1" colspan="1">Male</td><td rowspan="1" colspan="1">KSA</td><td rowspan="1" colspan="1">Not known</td><td rowspan="1" colspan="1">2014</td><td rowspan="1" colspan="1">ICU</td><td rowspan="1" colspan="1">Nephrotic syndrome</td><td rowspan="1" colspan="1">Respiratory distress</td><td rowspan="1" colspan="1">Tracheal aspirate</td><td rowspan="1" colspan="1">NA</td><td rowspan="1" colspan="1">Diffuse bilateral haziness</td><td rowspan="1" colspan="1">Yes</td><td rowspan="1" colspan="1">Yes</td><td rowspan="1" colspan="1">[<xref rid="B35" ref-type="bibr">35</xref>]</td></tr><tr><td colspan="14" rowspan="1"></td></tr><tr><td align="left" rowspan="1" colspan="1">4</td><td rowspan="1" colspan="1">Male</td><td rowspan="1" colspan="1">KSA</td><td rowspan="1" colspan="1">NA</td><td rowspan="1" colspan="1">2013</td><td rowspan="1" colspan="1">Mild respiratory symptoms</td><td rowspan="1" colspan="1">None</td><td rowspan="1" colspan="1">NA</td><td rowspan="1" colspan="1"></td><td rowspan="1" colspan="1">NA</td><td rowspan="1" colspan="1">ND</td><td rowspan="1" colspan="1">No</td><td rowspan="1" colspan="1">No</td><td rowspan="1" colspan="1">[<xref rid="B36" ref-type="bibr">36</xref>]</td></tr><tr><td colspan="14" rowspan="1"></td></tr><tr><td align="left" rowspan="1" colspan="1">8</td><td rowspan="1" colspan="1">Male</td><td rowspan="1" colspan="1">KSA</td><td rowspan="1" colspan="1">NA</td><td rowspan="1" colspan="1">2013</td><td rowspan="1" colspan="1">Mild respiratory symptoms</td><td rowspan="1" colspan="1">None</td><td rowspan="1" colspan="1">NA</td><td rowspan="1" colspan="1"></td><td rowspan="1" colspan="1">NA</td><td rowspan="1" colspan="1">ND</td><td rowspan="1" colspan="1">NA</td><td rowspan="1" colspan="1">No</td><td rowspan="1" colspan="1">[<xref rid="B37" ref-type="bibr">37</xref>]</td></tr><tr><td colspan="14" rowspan="1"></td></tr><tr><td align="left" rowspan="1" colspan="1">17</td><td rowspan="1" colspan="1">NA</td><td rowspan="1" colspan="1">KSA</td><td rowspan="1" colspan="1">Contact</td><td rowspan="1" colspan="1">2014</td><td rowspan="1" colspan="1">Asymptomatic</td><td rowspan="1" colspan="1">NA</td><td rowspan="1" colspan="1">NA</td><td rowspan="1" colspan="1">NA</td><td rowspan="1" colspan="1">NA</td><td rowspan="1" colspan="1">NA</td><td rowspan="1" colspan="1">NA</td><td rowspan="1" colspan="1">NA</td><td rowspan="1" colspan="1">[<xref rid="B22" ref-type="bibr">22</xref>]</td></tr><tr><td colspan="14" rowspan="1"></td></tr><tr><td align="left" rowspan="1" colspan="1">11</td><td rowspan="1" colspan="1">NA</td><td rowspan="1" colspan="1">KSA</td><td rowspan="1" colspan="1">Contact</td><td rowspan="1" colspan="1">2014</td><td rowspan="1" colspan="1">Asymptomatic</td><td rowspan="1" colspan="1">NA</td><td rowspan="1" colspan="1">NA</td><td rowspan="1" colspan="1">NA</td><td rowspan="1" colspan="1">NA</td><td rowspan="1" colspan="1">NA</td><td rowspan="1" colspan="1">NA</td><td rowspan="1" colspan="1">NA</td><td rowspan="1" colspan="1">[<xref rid="B22" ref-type="bibr">22</xref>]</td></tr><tr><td colspan="14" rowspan="1"></td></tr><tr><td align="left" rowspan="1" colspan="1">16</td><td rowspan="1" colspan="1">NA</td><td rowspan="1" colspan="1">KSA</td><td rowspan="1" colspan="1">NA</td><td rowspan="1" colspan="1">2014</td><td rowspan="1" colspan="1">Symptomatic</td><td rowspan="1" colspan="1">NA</td><td rowspan="1" colspan="1">NA</td><td rowspan="1" colspan="1">NA</td><td rowspan="1" colspan="1">NA</td><td rowspan="1" colspan="1">NA</td><td rowspan="1" colspan="1">NA</td><td rowspan="1" colspan="1">NA</td><td rowspan="1" colspan="1">[<xref rid="B22" ref-type="bibr">22</xref>]</td></tr><tr><td colspan="14" rowspan="1"></td></tr><tr><td align="left" rowspan="1" colspan="1">13</td><td rowspan="1" colspan="1">M</td><td rowspan="1" colspan="1">KSA</td><td rowspan="1" colspan="1">NA</td><td rowspan="1" colspan="1">2014</td><td rowspan="1" colspan="1">Symptomatic</td><td rowspan="1" colspan="1">NA</td><td rowspan="1" colspan="1">NA</td><td rowspan="1" colspan="1">NA</td><td rowspan="1" colspan="1">NA</td><td rowspan="1" colspan="1">NA</td><td rowspan="1" colspan="1">NA</td><td rowspan="1" colspan="1">NA</td><td rowspan="1" colspan="1">[<xref rid="B22" ref-type="bibr">22</xref>]</td></tr><tr><td colspan="14" rowspan="1"></td></tr><tr><td align="left" rowspan="1" colspan="1">10</td><td rowspan="1" colspan="1">M</td><td rowspan="1" colspan="1">KSA</td><td rowspan="1" colspan="1">Hospital contact</td><td rowspan="1" colspan="1">2014</td><td rowspan="1" colspan="1">Symptomatic</td><td rowspan="1" colspan="1">NA</td><td rowspan="1" colspan="1">NA</td><td rowspan="1" colspan="1">NA</td><td rowspan="1" colspan="1">NA</td><td rowspan="1" colspan="1">NA</td><td rowspan="1" colspan="1">NA</td><td rowspan="1" colspan="1">NA</td><td rowspan="1" colspan="1">[<xref rid="B20" ref-type="bibr">20</xref>,<xref rid="B22" ref-type="bibr">22</xref>]</td></tr><tr><td colspan="14" rowspan="1"></td></tr><tr><td align="left" rowspan="1" colspan="1">2</td><td rowspan="1" colspan="1">NA</td><td rowspan="1" colspan="1">KSA</td><td rowspan="1" colspan="1">NA</td><td rowspan="1" colspan="1">2014</td><td rowspan="1" colspan="1">Symptomatic</td><td rowspan="1" colspan="1">Congenital anomalies</td><td rowspan="1" colspan="1">NA</td><td rowspan="1" colspan="1">NA</td><td rowspan="1" colspan="1">NA</td><td rowspan="1" colspan="1">NA</td><td rowspan="1" colspan="1">NA</td><td rowspan="1" colspan="1">NA</td><td rowspan="1" colspan="1">[<xref rid="B20" ref-type="bibr">20</xref>,<xref rid="B22" ref-type="bibr">22</xref>]</td></tr><tr><td colspan="14" rowspan="1"></td></tr><tr><td align="left" rowspan="1" colspan="1">11</td><td rowspan="1" colspan="1">M</td><td rowspan="1" colspan="1">KSA</td><td rowspan="1" colspan="1">Hospital contact</td><td rowspan="1" colspan="1">2014</td><td rowspan="1" colspan="1">Symptomatic</td><td rowspan="1" colspan="1">Brain tumor</td><td rowspan="1" colspan="1">NA</td><td rowspan="1" colspan="1">NA</td><td rowspan="1" colspan="1">NA</td><td rowspan="1" colspan="1">NA</td><td rowspan="1" colspan="1">NA</td><td rowspan="1" colspan="1">NA</td><td rowspan="1" colspan="1">[<xref rid="B20" ref-type="bibr">20</xref>,<xref rid="B22" ref-type="bibr">22</xref>]</td></tr><tr><td colspan="14" rowspan="1"></td></tr><tr><td align="left" rowspan="1" colspan="1">17</td><td rowspan="1" colspan="1">M</td><td rowspan="1" colspan="1">KSA</td><td rowspan="1" colspan="1">NA</td><td rowspan="1" colspan="1">2014</td><td rowspan="1" colspan="1">Symptomatic</td><td rowspan="1" colspan="1">NA</td><td rowspan="1" colspan="1">NA</td><td rowspan="1" colspan="1">NA</td><td rowspan="1" colspan="1">NA</td><td rowspan="1" colspan="1">NA</td><td rowspan="1" colspan="1">NA</td><td rowspan="1" colspan="1">NA</td><td rowspan="1" colspan="1">[<xref rid="B20" ref-type="bibr">20</xref>,<xref rid="B22" ref-type="bibr">22</xref>]</td></tr><tr><td colspan="14" rowspan="1"></td></tr><tr><td align="left" rowspan="1" colspan="1">16</td><td rowspan="1" colspan="1">M</td><td rowspan="1" colspan="1">South Korea</td><td rowspan="1" colspan="1">Hospital contact</td><td rowspan="1" colspan="1">2015</td><td rowspan="1" colspan="1">Symptomatic</td><td rowspan="1" colspan="1">NA</td><td rowspan="1" colspan="1">NA</td><td rowspan="1" colspan="1">NA</td><td rowspan="1" colspan="1">NA</td><td rowspan="1" colspan="1">NA</td><td rowspan="1" colspan="1">NA</td><td rowspan="1" colspan="1">NA</td><td rowspan="1" colspan="1">[<xref rid="B22" ref-type="bibr">22</xref>]</td></tr><tr><td colspan="14" rowspan="1"></td></tr><tr><td align="left" rowspan="1" colspan="1">2</td><td rowspan="1" colspan="1">M</td><td rowspan="1" colspan="1">KSA</td><td rowspan="1" colspan="1">Hospital contact</td><td rowspan="1" colspan="1">2015</td><td rowspan="1" colspan="1">Symptomatic</td><td rowspan="1" colspan="1">NA</td><td rowspan="1" colspan="1">NA</td><td rowspan="1" colspan="1">NA</td><td rowspan="1" colspan="1">NA</td><td rowspan="1" colspan="1">NA</td><td rowspan="1" colspan="1">NA</td><td rowspan="1" colspan="1">NA</td><td rowspan="1" colspan="1">[<xref rid="B20" ref-type="bibr">20</xref>,<xref rid="B22" ref-type="bibr">22</xref>]</td></tr><tr><td colspan="14" rowspan="1"></td></tr><tr><td align="left" rowspan="1" colspan="1">16</td><td rowspan="1" colspan="1">M</td><td rowspan="1" colspan="1">KSA</td><td rowspan="1" colspan="1">contact</td><td rowspan="1" colspan="1">2015</td><td rowspan="1" colspan="1">Symptomatic</td><td rowspan="1" colspan="1">NA</td><td rowspan="1" colspan="1">NA</td><td rowspan="1" colspan="1">NA</td><td rowspan="1" colspan="1">NA</td><td rowspan="1" colspan="1">NA</td><td rowspan="1" colspan="1">NA</td><td rowspan="1" colspan="1">NA</td><td rowspan="1" colspan="1">[<xref rid="B20" ref-type="bibr">20</xref>,<xref rid="B22" ref-type="bibr">22</xref>]</td></tr><tr><td colspan="14" rowspan="1"></td></tr><tr><td align="left" rowspan="1" colspan="1">7</td><td rowspan="1" colspan="1">F</td><td rowspan="1" colspan="1">Jordan</td><td rowspan="1" colspan="1">Contact</td><td rowspan="1" colspan="1">2015</td><td rowspan="1" colspan="1">Asymptomatic</td><td rowspan="1" colspan="1">None</td><td rowspan="1" colspan="1">NA</td><td rowspan="1" colspan="1">NA</td><td rowspan="1" colspan="1">NA</td><td rowspan="1" colspan="1">NA</td><td rowspan="1" colspan="1">NA</td><td rowspan="1" colspan="1">NA</td><td rowspan="1" colspan="1">[<xref rid="B22" ref-type="bibr">22</xref>]</td></tr><tr><td colspan="14" rowspan="1"></td></tr><tr><td align="left" rowspan="1" colspan="1">0.8</td><td rowspan="1" colspan="1">F</td><td rowspan="1" colspan="1">Jordan</td><td rowspan="1" colspan="1">Contact</td><td rowspan="1" colspan="1">2015</td><td rowspan="1" colspan="1">Symptomatic</td><td rowspan="1" colspan="1">None</td><td rowspan="1" colspan="1">NA</td><td rowspan="1" colspan="1">NA</td><td rowspan="1" colspan="1">NA</td><td rowspan="1" colspan="1">NA</td><td rowspan="1" colspan="1">NA</td><td rowspan="1" colspan="1">NA</td><td rowspan="1" colspan="1">[<xref rid="B22" ref-type="bibr">22</xref>]</td></tr><tr><td colspan="14" rowspan="1"></td></tr><tr><td align="left" rowspan="1" colspan="1">14</td><td rowspan="1" colspan="1">M</td><td rowspan="1" colspan="1">KSA</td><td rowspan="1" colspan="1">Contact</td><td rowspan="1" colspan="1">2015</td><td rowspan="1" colspan="1">Symptomatic</td><td rowspan="1" colspan="1">None</td><td rowspan="1" colspan="1">NA</td><td rowspan="1" colspan="1">NA</td><td rowspan="1" colspan="1">NA</td><td rowspan="1" colspan="1">NA</td><td rowspan="1" colspan="1">NA</td><td rowspan="1" colspan="1">NA</td><td rowspan="1" colspan="1">[<xref rid="B20" ref-type="bibr">20</xref>,<xref rid="B22" ref-type="bibr">22</xref>]</td></tr><tr><td colspan="14" rowspan="1"></td></tr><tr><td align="left" rowspan="1" colspan="1">4</td><td rowspan="1" colspan="1">M</td><td rowspan="1" colspan="1">UAE</td><td rowspan="1" colspan="1">NA</td><td rowspan="1" colspan="1">2014</td><td rowspan="1" colspan="1">NA</td><td rowspan="1" colspan="1">NA</td><td rowspan="1" colspan="1">NA</td><td rowspan="1" colspan="1">NA</td><td rowspan="1" colspan="1">NA</td><td rowspan="1" colspan="1">NA</td><td rowspan="1" colspan="1">NA</td><td rowspan="1" colspan="1">NA</td><td rowspan="1" colspan="1">[<xref rid="B22" ref-type="bibr">22</xref>]</td></tr><tr><td colspan="14" rowspan="1"></td></tr><tr><td align="left" rowspan="1" colspan="1">8</td><td rowspan="1" colspan="1">M</td><td rowspan="1" colspan="1">UAE</td><td rowspan="1" colspan="1">Family contact</td><td rowspan="1" colspan="1">2013</td><td rowspan="1" colspan="1">NA</td><td rowspan="1" colspan="1">NA</td><td rowspan="1" colspan="1">NA</td><td rowspan="1" colspan="1">NA</td><td rowspan="1" colspan="1">NA</td><td rowspan="1" colspan="1">NA</td><td rowspan="1" colspan="1">NA</td><td rowspan="1" colspan="1">NA</td><td rowspan="1" colspan="1">[<xref rid="B22" ref-type="bibr">22</xref>]</td></tr><tr><td colspan="14" rowspan="1"></td></tr><tr><td align="left" rowspan="1" colspan="1">11</td><td rowspan="1" colspan="1">M</td><td rowspan="1" colspan="1">UAE</td><td rowspan="1" colspan="1">Family contact</td><td rowspan="1" colspan="1">2015</td><td rowspan="1" colspan="1">Asymptomatic</td><td rowspan="1" colspan="1">None</td><td rowspan="1" colspan="1">NA</td><td rowspan="1" colspan="1">NA</td><td rowspan="1" colspan="1">NA</td><td rowspan="1" colspan="1">NA</td><td rowspan="1" colspan="1">NA</td><td rowspan="1" colspan="1">NA</td><td rowspan="1" colspan="1">[<xref rid="B22" ref-type="bibr">22</xref>]</td></tr></tbody></table><table-wrap-foot><fn><p>NPS: Nasopharyngeal swab; N + T: Nasal and tracheal aspirate; ND: Not done; KSA: Kingdom of Saudi Arabia; UAE: United Arab Emirates; ICU: Intensive care unit; NA: Not available.</p></fn></table-wrap-foot></table-wrap><table-wrap id="T2" position="float"><label>Table 2</label><caption><p>Summary of the demographic characteristics of pediatric Middle East respiratory syndrome-coronavirus</p></caption><table frame="hsides" rules="groups"><thead align="center"><tr><td align="left" rowspan="1" colspan="1"></td><td rowspan="1" colspan="1"><bold>No</bold>.</td><td rowspan="1" colspan="1"><bold>%</bold></td></tr></thead><tbody align="center"><tr><td align="left" rowspan="1" colspan="1">Male:female</td><td rowspan="1" colspan="1">17:10 (1.7:1)</td><td rowspan="1" colspan="1">63 <italic>vs</italic> 37</td></tr><tr><td align="left" rowspan="1" colspan="1">Saudi</td><td rowspan="1" colspan="1">20</td><td rowspan="1" colspan="1">83.3</td></tr><tr><td align="left" rowspan="1" colspan="1">City</td><td rowspan="1" colspan="1"></td><td rowspan="1" colspan="1"></td></tr><tr><td align="left" rowspan="1" colspan="1">Jeddah</td><td rowspan="1" colspan="1">7</td><td rowspan="1" colspan="1">29.2</td></tr><tr><td align="left" rowspan="1" colspan="1">Riyadh</td><td rowspan="1" colspan="1">7</td><td rowspan="1" colspan="1">29.2</td></tr><tr><td align="left" rowspan="1" colspan="1">Hafr al-Batin</td><td rowspan="1" colspan="1">3</td><td rowspan="1" colspan="1">12.5</td></tr><tr><td align="left" rowspan="1" colspan="1">Symptomatic</td><td rowspan="1" colspan="1">12</td><td rowspan="1" colspan="1">50.0</td></tr><tr><td align="left" rowspan="1" colspan="1">Death</td><td rowspan="1" colspan="1">8</td><td rowspan="1" colspan="1">33.3</td></tr><tr><td align="left" rowspan="1" colspan="1">Year of report</td><td rowspan="1" colspan="1"></td><td rowspan="1" colspan="1"></td></tr><tr><td align="left" rowspan="1" colspan="1">2013</td><td rowspan="1" colspan="1">9</td><td rowspan="1" colspan="1">29</td></tr><tr><td align="left" rowspan="1" colspan="1">2014</td><td rowspan="1" colspan="1">15</td><td rowspan="1" colspan="1">48.4</td></tr><tr><td align="left" rowspan="1" colspan="1">2015</td><td rowspan="1" colspan="1">7</td><td rowspan="1" colspan="1">22.6</td></tr></tbody></table></table-wrap></sec><sec><title>Screening of pediatric patients for MERS-CoV</title><p>Screening of pediatric patients for MERS-CoV infection using real time reverse transcriptase polymerase chain reaction showed that only 9 out of 552 (1.6%) were positive in KSA[<xref rid="B23" ref-type="bibr">23</xref>]. However, serologic testing of pediatric patients admitted with lower respiratory tract infection in Jordan and Saudi Arabia revealed no positive tests[<xref rid="B24" ref-type="bibr">24</xref>,<xref rid="B25" ref-type="bibr">25</xref>] (Table <xref ref-type="table" rid="T3">3</xref>).</p><table-wrap id="T3" position="float"><label>Table 3</label><caption><p>Summary of different studies examining Middle East respiratory syndrome-coronavirus infection in children</p></caption><table frame="hsides" rules="groups"><thead align="center"><tr><td align="left" rowspan="1" colspan="1"><bold>Country</bold></td><td rowspan="1" colspan="1"><bold>Testing method</bold></td><td rowspan="1" colspan="1"><bold>Population</bold></td><td rowspan="1" colspan="1"><bold>Positive <italic>n</italic> (%)</bold></td><td rowspan="1" colspan="1"><bold>Yr</bold></td><td rowspan="1" colspan="1"><bold>Ref</bold>.</td></tr></thead><tbody align="center"><tr><td align="left" rowspan="1" colspan="1">KSA</td><td rowspan="1" colspan="1">rRT-PCR</td><td rowspan="1" colspan="1">Screening of children</td><td rowspan="1" colspan="1">9/552 (1.6)</td><td rowspan="1" colspan="1"></td><td rowspan="1" colspan="1">[<xref rid="B23" ref-type="bibr">23</xref>]</td></tr><tr><td align="left" rowspan="1" colspan="1">KSA</td><td rowspan="1" colspan="1">Neutralizing antibodies testing</td><td rowspan="1" colspan="1">Serum samples from children hospitalized for lower respiratory tract infections</td><td rowspan="1" colspan="1">0/158 (0)</td><td rowspan="1" colspan="1">May 2010-May 2011</td><td rowspan="1" colspan="1">[<xref rid="B25" ref-type="bibr">25</xref>]</td></tr><tr><td align="left" rowspan="1" colspan="1">Jordan</td><td rowspan="1" colspan="1">rRT-PCR</td><td rowspan="1" colspan="1">Hospitalized children < 2 yr of age</td><td rowspan="1" colspan="1">0/2427 (0)</td><td rowspan="1" colspan="1"></td><td rowspan="1" colspan="1">[<xref rid="B24" ref-type="bibr">24</xref>]</td></tr></tbody></table><table-wrap-foot><fn><p>rRT-PCR: Real time reverse transcriptase polymerase chain reaction; KSA: Kingdom of Saudi Arabia.</p></fn></table-wrap-foot></table-wrap></sec><sec><title>Pregnancy associated MERS-COV</title><p>The effect of MERS-CoV infection on the fetus was described in eight cases[<xref rid="B26" ref-type="bibr">26</xref>-<xref rid="B29" ref-type="bibr">29</xref>] as summarized in Table <xref ref-type="table" rid="T4">4</xref>. The mean age of the mothers was 32.25 + 3.4 years, and the mean gestational age was 28.4 + 6.3 wk. Death of the fetus was observed in 3 (37.5%) of the 8 fetuses.</p><table-wrap id="T4" position="float"><label>Table 4</label><caption><p>Summary of pregnancy associated Middle East respiratory syndrome-coronavirus infection</p></caption><table frame="hsides" rules="groups"><thead align="center"><tr><td align="left" rowspan="1" colspan="1"><bold>Age of the patient (yr)</bold></td><td rowspan="1" colspan="1"><bold>Gestational age</bold></td><td rowspan="1" colspan="1"><bold>Fetal outcome</bold></td><td rowspan="1" colspan="1"><bold>Diagnostic test</bold></td><td rowspan="1" colspan="1"><bold>Country</bold></td><td rowspan="1" colspan="1"><bold>Ref</bold>.</td></tr></thead><tbody align="center"><tr><td align="left" rowspan="1" colspan="1">39</td><td rowspan="1" colspan="1">5 mo</td><td rowspan="1" colspan="1">Still birth</td><td rowspan="1" colspan="1">Antibody by EIA</td><td rowspan="1" colspan="1">Jordan</td><td rowspan="1" colspan="1">[<xref rid="B26" ref-type="bibr">26</xref>]</td></tr><tr><td align="left" rowspan="1" colspan="1">33</td><td rowspan="1" colspan="1">32 wk</td><td rowspan="1" colspan="1">Healthy infant</td><td rowspan="1" colspan="1">PCR</td><td rowspan="1" colspan="1">Saudi Arabia</td><td rowspan="1" colspan="1">[<xref rid="B27" ref-type="bibr">27</xref>]</td></tr><tr><td align="left" rowspan="1" colspan="1">32</td><td rowspan="1" colspan="1">32 wk</td><td rowspan="1" colspan="1">Healthy</td><td rowspan="1" colspan="1">PCR</td><td rowspan="1" colspan="1">United Arab Emirates</td><td rowspan="1" colspan="1">[<xref rid="B28" ref-type="bibr">28</xref>]</td></tr><tr><td align="left" rowspan="1" colspan="1">34</td><td rowspan="1" colspan="1">34 wk</td><td rowspan="1" colspan="1">Died</td><td rowspan="1" colspan="1">PCR</td><td rowspan="1" colspan="1">Saudi Arabia</td><td rowspan="1" colspan="1">[<xref rid="B29" ref-type="bibr">29</xref>]</td></tr><tr><td align="left" rowspan="1" colspan="1">32</td><td rowspan="1" colspan="1">38 wk</td><td rowspan="1" colspan="1">Survived</td><td rowspan="1" colspan="1">PCR</td><td rowspan="1" colspan="1">Saudi Arabia</td><td rowspan="1" colspan="1">[<xref rid="B29" ref-type="bibr">29</xref>]</td></tr><tr><td align="left" rowspan="1" colspan="1">31</td><td rowspan="1" colspan="1">24 wk</td><td rowspan="1" colspan="1">Died</td><td rowspan="1" colspan="1">PCR</td><td rowspan="1" colspan="1">Saudi Arabia</td><td rowspan="1" colspan="1">[<xref rid="B29" ref-type="bibr">29</xref>]</td></tr><tr><td align="left" rowspan="1" colspan="1">27</td><td rowspan="1" colspan="1">22 wk</td><td rowspan="1" colspan="1">Survived</td><td rowspan="1" colspan="1">PCR</td><td rowspan="1" colspan="1">Saudi Arabia</td><td rowspan="1" colspan="1">[<xref rid="B29" ref-type="bibr">29</xref>]</td></tr><tr><td align="left" rowspan="1" colspan="1">30</td><td rowspan="1" colspan="1">23 wk</td><td rowspan="1" colspan="1">Survived</td><td rowspan="1" colspan="1">PCR</td><td rowspan="1" colspan="1">Saudi Arabia</td><td rowspan="1" colspan="1">[<xref rid="B29" ref-type="bibr">29</xref>]</td></tr></tbody></table><table-wrap-foot><fn><p>PCR: Polymerase chain reaction; EIA: Enzyme immunoassay.</p></fn></table-wrap-foot></table-wrap></sec></sec><sec><title>DISCUSSION</title><p>Despite the total number of MERS cases increasing, especially in KSA, the number of pediatric cases remained low during the study period. Initially, the testing in KSA was directed towards hospitalized patients with severe pneumonia. In 2015, the Saudi Ministry of Health added a specific case definition for MERS-CoV infection in children[<xref rid="B30" ref-type="bibr">30</xref>]. The definition includes those ≤ 14 years, meets the adult case definition and has either a history of exposure to a confirmed or suspected MERS-CoV in the proceeding 14 d or a history of contact with camels or camel products in the proceeding 14 d[<xref rid="B30" ref-type="bibr">30</xref>]. The case definition also includes children with unexplained severe pneumonia[<xref rid="B30" ref-type="bibr">30</xref>]. The 2015 change in the case definition does not account for the low rate of childhood MERS-CoV infection as 33% of the cases were reported in 2014 before the case definition was changed. One of the reasons for an increased number of cases in 2014 during the Jeddah outbreak was increased testing of asymptomatic and mildly symptomatic patients[<xref rid="B11" ref-type="bibr">11</xref>].</p><p>The pattern of MERS-CoV pediatric cases was similar to the 2003 SARS outbreak. Children were less affected than adults and children less than 2 years of age had milder disease[<xref rid="B31" ref-type="bibr">31</xref>]. In the largest screening of contacts, the rate of MERS-CoV positive children (1.6%, 9/616) compared to 2.2% (99/4440) in adults (<italic>P</italic> = 0.23)[<xref rid="B23" ref-type="bibr">23</xref>]. Thus, in this study utilizing MERS-CoV PCR the positivity rate did not differ in children and adults.</p><p>In adults with MERS-CoV infections, three patterns of transmissions were observed: Sporadic (primary) cases presumed to be due to animal exposure (mainly camels), household contacts or health care associated infections[<xref rid="B32" ref-type="bibr">32</xref>]. In KSA, the majority (45%) of cases were health care-associated infections, 38% were primary cases, and 13% were household contacts[<xref rid="B32" ref-type="bibr">32</xref>]. In contrast, in the majority of pediatric cases that reported source of acquisition (66.7% of the 15 with reported source), the disease was acquired through household contact. This pattern indicates a low exposure of children to animals and a higher rate of health care associated infections in adult wards. The male to female ratio (2.8:1 and 3.3:1) was initially high[<xref rid="B3" ref-type="bibr">3</xref>,<xref rid="B4" ref-type="bibr">4</xref>]. This apparent male predominance could be explained by the nature of hospital outbreaks[<xref rid="B2" ref-type="bibr">2</xref>]. Eventually the male to female ratio was reduced to 1.3:1 to 1.8:1[<xref rid="B5" ref-type="bibr">5</xref>,<xref rid="B6" ref-type="bibr">6</xref>]. Consistent with these studies, the male to female ratio in children with MERS-CoV was 1.7:1 and may indicate similar exposure of children to index cases in the household settings and differential host factors.</p><p>Possible explanations for the lower number of pediatric cases compared to adults include differential testing of adult patients and milder diseases in children; although, serologic testing of pediatric patients in KSA and Jordan did not reveal any positive cases[<xref rid="B24" ref-type="bibr">24</xref>,<xref rid="B25" ref-type="bibr">25</xref>]. In the largest sero-epidemiologic survey in KSA, the study did not include children and thus it is difficult to establish the rate of sero-positivity in children[<xref rid="B31" ref-type="bibr">31</xref>].</p><p>The MERS-CoV infection rate in children remains low and possible explanations include: A milder disease in children, asymptomatic infection, or the presence of yet to be identified factors. The development of a shorter duration of MERS in children is another possible explanation. If this is the case, it may limit the development of a positive serology. In one study, delayed antibody responses as measured with the neutralization test was associated with severe diseases[<xref rid="B33" ref-type="bibr">33</xref>]. The longevity of antibodies in MERS-CoV cases might be limited as was the case with SARS[<xref rid="B33" ref-type="bibr">33</xref>,<xref rid="B34" ref-type="bibr">34</xref>]. The only study of serology among children was done among hospitalized pediatric cases who presented with lower respiratory tract infections[<xref rid="B25" ref-type="bibr">25</xref>]. There is no systematic screening of exposed children using serologic testing; this limited the interpretation of available serologic studies.</p><p>Little data also exist regarding the effect and the likelihood of MERS-CoV in pregnancy. Eight cases were reported[<xref rid="B26" ref-type="bibr">26</xref>,<xref rid="B27" ref-type="bibr">27</xref>,<xref rid="B29" ref-type="bibr">29</xref>]. The outcome was favorable in the majority of cases. The exact prevalence of MERS-CoV antibodies and exposure of pregnant women to MERS-CoV is not known.</p><p>In conclusion, the number of MERS-CoV infections in pediatric patients remains low. Possible explanations include low exposure, presence of asymptomatic, mildly symptomatic patients or the presence of yet to be identified factors. The immune system predisposing to severe disease and to fatal outcome remains unknown. An exploration of the virus-host interaction may add to the understanding of the low prevalence in this age group.</p></sec><sec><title>COMMENTS</title><sec><title>Background</title><p>Middle East respiratory syndrome-coronavirus (MERS-CoV) was first isolated in 2012 from a patient in the Kingdom of Saudi Arabia (KSA). Despite the increased number of MERS-CoV cases overtime, the number of pediatric cases remained low. The exact reason for this low prevalence of the disease in children is not known. The aim of this study is to summarize the reported MERS-CoV cases and the associated clinical presentation and the outcome.</p></sec><sec><title>Research frontiers</title><p>The first pediatric case was a two-year-old child reported from Jeddah, KSA on June 28, 2013. Later an additional three asymptomatic children were reported. The largest report of childhood MERS-CoV cases included eleven, including nine asymptomatic cases.</p></sec><sec><title>Innovations and breakthroughs</title><p>The number of MERS-CoV infections in pediatric patients remains low. Possible explanations include low exposure, presence of asymptomatic, mildly symptomatic patients or the presence of yet to be identified factors. The immune system predisposing to severe disease and to fatal outcome remains unknown. An exploration of the virus-host interaction may add to the understanding of the low prevalence in this age group.</p></sec><sec><title>Applications</title><p>Despite the low number of pediatric MERS-CoV cases, it is important to continue to monitor the development of this disease in this age group and to understand the risk factors.</p></sec><sec><title>Terminology</title><p>MERS-CoV is a new emerging virus that was first isolated in 2012.</p></sec><sec><title>Peer-review</title><p>This complication of all known pediatric cases is a useful contribution to the medical literature, and knowing it is possible but rare is important.</p></sec></sec></body><back><fn-group><fn><p>Manuscript source: Invited manuscript</p></fn><fn><p>Specialty type: Pediatrics</p></fn><fn><p>Country of origin: Kingdom of Saudi Arabia</p></fn><fn><p>Peer-review report classification</p></fn><fn><p>Grade A (Excellent): 0</p></fn><fn><p>Grade B (Very good): 0</p></fn><fn><p>Grade C (Good): C, C</p></fn><fn><p>Grade D (Fair): 0</p></fn><fn><p>Grade E (Poor): 0</p></fn><fn fn-type="COI-statement"><p>Conflict-of-interest statement: All authors have no competing interests to declare.</p></fn><fn><p>Data sharing statement: The dataset as presented in tables is available upon request to the corresponding author.</p></fn><fn><p>Peer-review started: May 30, 2016</p></fn><fn><p>First decision: July 6, 2016</p></fn><fn><p>Article in press: August 29, 2016</p></fn><fn><p>P- Reviewer: Chen XL, Striker R S- Editor: Ji FF L- Editor: A E- Editor: Li D</p></fn></fn-group><ref-list><ref id="B1"><label>1</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Zaki</surname><given-names>AM</given-names></name><name><surname>van 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