| Open Peer Review | Clinical Microbiology | Research Article

Epidemiological characteristics of respiratory viruses in children

during the COVID-19 epidemic in Chengdu, China
Zheng-Xiang Gao,1,2 Ya Wang,1,2 Ling-Yi Yan,1,2 Ting Liu,1,2 Lei-Wen Peng1,2

AUTHOR AFFILIATIONS See affiliation list on p. 9.

ABSTRACT The purpose of this retrospective study was to analyze the prevalence
of respiratory viruses among children with acute respiratory tract infections (ARTIs)
during the coronavirus disease 2019 epidemic (1 March 2020–28 February 2022). This
study investigated respiratory viral specimens from children with ARTIs. A total of 7,092
children (<14 years) with ARTIs were included in this study, with a boy-to-girl ratio of
1.43. The median age was 1 year and 5 months. The average age of the patients was 2.7
± 3.1 years. Patients < 3 years of age were the main population with ARTIs (67%). The
predominant viruses were respiratory syncytial virus (RSV) (10.1%) and influenza virus
(A and B 9.7%) during the 2 years of the pandemic (1 March 2020–28 February 2022).
The proportion of positive viral test results among patients with ARTIs < 6 years of age
was higher than that among patients with ARTIs aged 6–14 years (17.3% vs. 5.7%, P <

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0.01). RSV infections were more common among patients < 3 years of age (P < 0.01).
Influenza A infections were more common among patients aged 3–6 years (P < 0.01).
Influenza B infections were more common among patients aged 6–14 years (P < 0.01).
The positive proportion among boys was higher than that among girls (14.4% vs. 8.6%,
P < 0.01). Peak virus infections occurred in the autumn and winter seasons, and the
lowest activity level occurred in the spring and summer of the 2 years. Compared with
that before the epidemic, the number of samples and positive proportion of respiratory
viruses decreased significantly.

IMPORTANCE During the coronavirus disease 2019 epidemic, the Chinese govern­
ment launched and used a series of nonpharmaceutical interventions (NPIs), includ­
ing banning social gatherings, wearing face masks, home isolation, and maintaining
hand hygiene, to control the disease spread. Whether and how NPIs influence other
respiratory viruses in children remain unclear. In this article, we analyzed relative data
and found that the number of samples and positive proportion of respiratory viruses
decreased significantly compared with that before the epidemic. Clinicians and public
health policymakers should pay attention to changes in the epidemic trends and types Editor Tulip A. Jhaveri, University of Mississippi
of respiratory viruses and maintain monitoring of respiratory-related viruses to avoid Medical Center, Jackson, Mississippi, USA
possible abnormal rebounds and epidemic outbreaks of these viruses. Ad Hoc Peer Reviewer Nazly Shafagati, Quest
Diagnostics, Chantilly, Virginia, USA
KEYWORDS epidemiology, COVID-19, respiratory infection, virus Address correspondence to Lei-Wen Peng,
[email protected].

A cute respiratory tract infections (ARTIs) are the most common disease in children
and adults (1, 2). ARTIs can occur regardless of age, sex, season, and region and
are the main cause of infectious disease morbidity and mortality in China and world­
The authors declare no conflict of interest.

See the funding table on p. 9.

wide (1, 2). Pathogens, including bacteria, mycoplasma, chlamydia, fungi and parasites, Received 22 June 2023
and viruses (such as influenza viruses, respiratory viruses, and rhinoviruses), have been Accepted 31 October 2023
Published 5 December 2023
identified as major causes of ARTIs in children (3–5). Studies have shown that acute
viral respiratory tract infection is the leading cause of hospitalization among infants and Copyright © 2023 Gao et al. This is an open-access
article distributed under the terms of the Creative
children in developed countries (6) and is the leading cause of death in developing
Commons Attribution 4.0 International license.

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countries (7, 8). At present, respiratory tract viruses, including human parainfluenza virus,
respiratory syncytial virus (RSV), rhinovirus, coronavirus, adenovirus (ADV), and influenza
virus, are the most common pathogens associated with ARTIs in children (9). Relevant
studies have shown that controlling the spread of respiratory viruses is conducive to
the growth and development of children. Since the immune and respiratory systems of
infants and preschool children are not yet mature, early viral respiratory tract infections
may have an adverse effect on lung development and increase the risk of incident
asthma (10). ARTIs caused by viruses are the major cause of death and illness among
children under 5 years of age (11). Therefore, the prevalence of respiratory viruses that
cause ARTIs in children deserves our attention and continuous monitoring.
Coronavirus disease 2019 (COVID-19) is caused by severe acute respiratory syndrome
coronavirus 2 (SARS-CoV-2). Since December 2019, COVID-19 has spread rapidly and
subsequently become a pandemic. The World Health Organization declared COVID-19
a public health emergency of international concern on 30 January 2020. To control the
spread of SARS-CoV-2, a series of nonpharmaceutical interventions (NPIs) were rapidly
launched and used to control the spread of the disease worldwide. The categories
of NPIs included banning social gatherings, wearing face masks, home isolation, and
maintaining hand hygiene, which played an important role in controlling the spread of
SARS-CoV-2 (12). By the end of March 2020, China had successfully controlled the first
wave of the COVID-19 epidemic peak (13). In addition, studies have shown that NPIs
affect the epidemic trends and transmission patterns of infectious diseases transmitted
by air or feces, such as the common cold, gastroenteritis, bronchiolitis, and acute otitis
media (14).
Our research group collected relevant data and analyzed the epidemiological
characteristics of ARTIs caused by respiratory viruses in children before the outbreak

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of COVID-19 (10). At present, few studies have shown the epidemiology of respiratory
viruses in children during the COVID-19 epidemic, and the incidence, age of onset,
and seasonal changes in respiratory viruses in children remain unclear. Therefore, we
retrospectively analyzed respiratory virus test data among children with ARTIs during the
COVID-19 pandemic. Through the analysis of the positive proportion of seven respiratory
viruses, common virus types, epidemic season, and age of onset, we aimed to clarify the
impact of NPIs on non-COVID respiratory viruses among children during the COVID-19
pandemic. This could prevent antibiotic abuse and guide the effective treatment and
prevention of ARTIs.

MATERIALS AND METHODS

Study population
To continue our previous research, we chose and retrospectively analyzed children with
suspected ARTIs who visited pediatricians at West China Second University Hospital of
Sichuan University from 1 March 2020 to 28 February 2022. The West China Second
University Hospital of Sichuan University is located in Chengdu Sichuan province. The
hospital was one of the first national top tertiary hospitals and serves as a medical
center for women and children in southwestern China. It plays an important role in
medical services, education, research, disease prevention, and healthcare. The hospital
has 24 clinical departments/divisions and 7 medical supporting departments. As a
referral center in Southwest China, we provide medical services to women and children
with critical diseases. In 2022, we had 3.54 million outpatient and emergency visits,
discharged 90,000 patients, performed 125,000 operations, and delivered 22,000 infants.
Chengdu’s resident population was 21.26 million, and the number of 0–14-year-old
children was 2.78 million at the end of 2022. The inclusion criteria were as follows:
(i) patients younger than 14 years of age (as in China, the children visiting pediatric
clinics are mainly aged 0–14 years.); (ii) patients with at least the following two signs or
symptoms: fever (>38.0°C), sore throat, cough, hoarseness, runny nose, nasal conges­
tion/pharyngeal purulent exudate, increased respiratory rate, or moist rales; and (iii)

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ARTIs mentioned in the outpatient or discharge diagnosis. The exclusion criterion was
the lack of information on ARTIs in the top three outpatient or discharge diagnoses. All
patients were examined and diagnosed by clinicians.

Sample evaluation
Nasopharyngeal swabs were collected from patients (n = 7092) in the outpatient or
inpatient ward and sent to the hospital laboratory for testing. After receiving the
nasopharyngeal swabs, the laboratory technicians immediately processed and tested
the samples. Seven respiratory viruses, including RSV; influenza A and B; parainfluenza
viruses (PIV) I, II, and III; and ADV, were detected by a direct immunofluorescence assay
(Diagnostic Hybrids Inc., Athens, OH, USA) using nasopharyngeal swabs. The direct
immunofluorescence assay is relatively simple and inexpensive and is widely used in
clinical respiratory virus testing. Quality control will be performed in each test to ensure
that the results are reliable. At the same time, if the sample test results were suspicious,
they needed to be verified by PCR before inclusion in this study. The direct immunofluor­
escence assay kit did not contain metapneumovirus; to ensure the consistency of the
results, there was no metapneumovirus testing. The clinician tested for metapneumovi­
rus by PCR.

Data collection
The laboratory test results and patient demographic data (name, sex, age, clinical
diagnosis, and sampling time) were extracted from the laboratory information system
(LIS) of West China Second Hospital of Sichuan University. The study protocol was
approved by the Ethics Committee of West China Second University Hospital, Sichuan
University.

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Statistical analysis
The data were analyzed by SPSS Statistics 19 (SPSS Inc., Chicago, IL). All variables,
including age and sex, were tested for a normal distribution. Age was compared by
the Mann‒Whitney U test. Due to the unequal population size and data differences, the
χ2 test or Fisher’s exact test was used to analyze the association between age and sex
with positivity for respiratory viruses. P < 0.05 was considered statistically significant.

RESULTS
From 1 March 2020 to 28 February 2022, 7,092 patients who came to the hospital and
were diagnosed with ARTIs were included in this study. A total of 638 patients were
excluded. The sociodemographic variables associated with all samples are summarized
in Table 1. Regarding the age distribution of patients, patients aged 6 months to 3
years were the main population with ARTIs (35.3%), followed by patients aged 28 days
to 6 months (20.3%). The median age was 1 year and 5 months (range: 0 days to 14
years). The average age of the patients was 2.7 ± 3.1 years. Patients < 3 years of age
were the main population with ARTIs (67%). There were significantly more boys than
girls (58.9% vs. 41.1%, P < 0.01). The number of inpatients was significantly higher than
that of outpatients (61.2% vs. 38.8%, P < 0.01). However, the positive proportion of virus
detection among inpatients was significantly lower than that among outpatients (3.8%
vs. 19.3%, P < 0.01).
Regarding the prevalence of respiratory viruses among children with ARTIs, of the
7,092 patients, 1,635 patients (23.1%) had respiratory viruses. The positive proportions of
influenza A, influenza B, PIV I, PIV II, PIV III, ADV, and RSV were 4.1%, 5.6%, 0.7%, 0.1%,
1.1%, 1.3%, and 10.1%, respectively (Table 1). The predominant viruses were RSV (10.1%,
P < 0.01) and influenza (A and B 9.7%, P < 0.01) during the study period, followed by PIV
(I, II, and III, 1.9%) and ADV (1.3%). Among patients of different ages, the proportion of
positive viral test results among patients < 6 years of age was significantly higher than
that among patients aged 6–14 years (17.3% vs. 5.7%, P < 0.01). RSV infections were
more common among patients < 3 years of age (9.4%, 667/7,092, P < 0.001). The positive

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TABLE 1 Characteristics of included children

Characteristic Age Sex Category Total

0–28 d 28 d–6 mo 6 mo–3 yr 3–6 yr 6–14 yr Boy Girl Outpatient Inpatient
Samples (% of total samples received)
Total samples received 808 (11.4) 1,440 (20.3) 2,505 (35.3) 1,232 (17.4) 1,107 (15.6) 4,175 (58.9) 2,917 (41.1) 2,749 (38.8) 4,343 (61.2) 7,092 (100)
Positive samples 34 (0.5) 364 (5.1) 516 (7.3) 314 (4.4) 407 (5.7) 1,024 (14.4) 611 (8.6) 1,368 (19.3) 267 (3.8) 1,635 (23.1)
Respiratory virus identified (% of total positive samples based on age/sex)
Influenza A 0 (0.0) 2 (0.5) 36 (7.0) 152 (48.4) 104 (25.6) 202 (19.7) 92 (15.1) 282 (20.6) 12 (4.5) 294 (4.1)
Influenza B 0 (0.0) 4 (1.1) 50 (9.7) 65 (20.7) 277 (68.1) 230 (22.5) 166 (27.2) 389 (28.4) 7 (2.6) 396 (5.6)
Parainfluenza virus I 2 (5.9) 1 (0.3) 29 (5.6) 16 (5.1) 0 (0.0) 24 (2.3) 24 (3.9) 34 (2.5) 14 (5.2) 48 (0.7)
Parainfluenza virus II 0 (0.0) 0 (0.0) 2 (0.4) 2 (0.6) 2 (0.5) 2 (0.2) 4 (0.7) 5 (0.4) 1 (0.4) 6 (0.1)
Parainfluenza virus III 1 (2.9) 21 (5.8) 45 (8.7) 10 (3.2) 3 (0.7) 50 (4.9) 30 (4.9) 46 (3.4) 34 (12.7) 80 (1.1)
Adenovirus 0 (0.0) 15 (4.1) 39 (7.6) 23 (7.3) 17 (4.2) 62 (6.1) 32 (5.2) 77 (5.6) 17 (6.4) 94 (1.3)
Respiratory syncytial 31 (91.2) 321 (88.2) 315 (61.0) 46 (14.6) 4 (1.0) 454 (44.3) 263 (43.0) 535 (39.1) 182 (68.2) 717 (10.1)
virus

proportion of influenza A among patients aged 3–6 years was significantly higher than
that of other viruses (P < 0.01). Influenza B infections were more common in patients
aged 6–14 years (P < 0.01) (Fig. S1). The positive proportion among boys was higher
than that among girls (14.4% vs. 8.6%, P < 0.01). The seasonal distribution of the sample
positive proportion during the study period is shown in Fig. 1. The positive proportions
of boys, girls, and total in the autumn and winter seasons were significantly higher than
those in the spring and summer seasons during the study period. In the first year, the
positive proportion of boys was highest in January (24.4%) and lowest in July (2.2%) (Fig.

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1A). The positive proportion of girls was highest in January (11.5%) and lowest in May
(1.4%) (Fig. 1B). The total positive proportion was highest in January (36.0%) and lowest
in July (3.9%) in this year (Fig. 1C). In the second year, the positive proportion of boys was
highest in October (44.1%) and lowest in June (5.0%) (Fig. 1A). The positive proportion of
girls was highest in October (30.5%) and lowest in April to June (3.2%–3.3%) (Fig. 1B). The
total positive proportion was highest in October (74.6%) and lowest in June (8.3%) in this
year (Fig. 1C). Meanwhile, the positive proportion of boys was higher than that of girls.
The seasonal distributions of each respiratory virus in the first and second years are
shown in Fig. 2 and 3, respectively. As shown in Fig. 2A, the peak infection period of
influenza A and RSV occurred in the autumn and winter seasons (from October 2020 to
February 2021), and the lowest activity level occurred in spring and summer (from March
to August). The positivity of other viruses was low, but their peak infection periods were
also in the autumn and winter seasons (from September to December). The number of
positive samples in the first year was 643, and the predominant virus was RSV, account­
ing for 53.5% of the positive samples, followed by influenza A, accounting for 23.3% of
the positive samples. The third major viruses were ADV (8.2%) and PIV III (6.7%). The
positive proportion of the other three viruses was low (Fig. 2B). Among the positive
samples, 64.9% and 35.2% were isolated from boys and girls, respectively (Fig. 2C). The
main positive proportion of virus detection among boys was RSV and influenza A, and
the main positive proportion of virus detection among girls was RSV and influenza A (Fig.
2D). A total of 77.9% of the positive samples were from outpatients and 22.0% were from
inpatients (Fig. 2E). The age distribution of positive patients was as follows: most patients
were aged 6 months to 3 years (n = 270), followed by those aged 28 days to 6 months (n
= 151) and 3–6 years (n = 140) (Fig. 2F).
The number of positive samples was 992 in the second year, and the number of
positive samples for influenza A and RSV was similar to that in the first year. However, the
number of positive cases of influenza B increased significantly, and there was an obvious
epidemic peak in the autumn and winter seasons (Fig. 3A). The predominant viruses in
2021 were influenza B and RSV, accounting for 38.6% and 37.6%, respectively. The third
most predominant virus was influenza A, with a 14.5% positivity rate, and the positive

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FIG 1 Monthly activity patterns of the positive proportion of respiratory viruses. (A) Monthly activity patterns of the positive proportion of respiratory viruses

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from March 1, 2020, to February 28, 2021. (B) Monthly activity patterns of the positive proportion of respiratory viruses from 1 March 2021 to 28 February 2022.
(C) The different monthly activity patterns of the positive proportion of respiratory viruses between the 2 years.

proportion of the other four viruses was low (Fig. 3B). Among all positive samples, 61.2%
came from boys and 38.9% came from girls (Fig. 3C). The main positive proportion of
virus detection among boys was RSV and influenza A and B, and the main positive
proportion of virus detection among girls was RSV and influenza A and B (Fig. 3D). A total
of 87.4% were outpatients and 12.6% were inpatients (Fig. 3E). Compared with the
previous year, there was no statistically significant difference in the proportion of boys
and girls or inpatients and outpatients (P > 0.05). The age distribution of positive patients
was as follows: most patients were 6–14 years old (n = 340), followed by 6 months to 3
years old (n = 246) and 28 days to 6 months old (n = 213) (Fig. 3F).

DISCUSSION
ARTIs account for a large proportion of infectious diseases in children, and respiratory
viruses are the most common cause of ARTIs in children and infants (15, 16). Although
the clinical characteristics of children and infants infected with different kinds of
respiratory viruses are different, their transmission routes are nearly the same, mainly
through droplets and aerosols and direct or indirect contact with infected secretions.
This study focused on the prevalence of respiratory virus infections in Southwest China
during the COVID-19 pandemic, aiming to investigate the impact of NPIs on the preva­
lence of respiratory viruses among children and infants.
In this study, we first counted the number of children with ARTIs who were tested for
viral antigens during the COVID-19 pandemic. The total number of children tested was
7,092 from March 2020 to March 2022. Compared with the related data published by our
research group from March 2018 to March 2020, the number of patients decreased
substantially (7,092 vs. 11,813), and the positive proportion also decreased to 3/5 of that
before the outbreak of COVID-19 (10). Studies have shown that the number of pediatric
outpatients and inpatients in many countries decreased substantially in 2020, when the
COVID-19 pandemic began (17–19). A study showed that the number of children

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FIG 2 The epidemic trend and demographic characteristics of respiratory viruses in the first year. (A) Monthly activity patterns of viruses. (B) The proportions of

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different viruses in the first year. (C) The proportions of different sexes among positive children. (D) The proportions of different viruses among positive children.
(E, F) The proportions of different categories and ages of positive children. Flu A, influenza A; Flu B, influenza B; PIV I, parainfluenza virus I; PIV II, parainfluenza
virus II; PIV III, parainfluenza virus III; ADV, adenovirus; RSV, respiratory syncytial virus; D, day; M, month; Y, year.

hospitalized for infectious diseases decreased by 37%, among whom the number of
children with respiratory infections decreased by 33% (20). Similar reductions were
observed in this study, with decreases of 31% for inpatients. At the same time, the study
found that the relevant reasons may be related to the adoption of serious intervention
measures, i.e., social distancing and especially school closures, leading to a sharp
reduction in contact between children, which may have reduced the risk of ARTI
transmission. On the other hand, parents’ concerns about sick children and their seeking
of timely clinical care may not play an important role (20). Moreover, the Chinese
government implemented similar public preventive measures after the outbreak of
COVID-19. Our results showed that the number and positive proportion of respiratory
viruses among children of all ages decreased significantly. This finding indicates that NPIs
to control SARS-CoV-2 transmission were also effective in reducing the transmission of
respiratory viruses among children during the COVID-19 pandemic.
During the study period, the number of boys infected with ARTIs and the positive
proportion of virus detection were significantly higher than those of girls, which is
consistent with previous studies, and it is reported that boys may be more susceptible to
ARTIs than girls (10, 21). The study revealed that the genetic susceptibility of children to
respiratory diseases is related to the type of virus and specific respiratory diseases of
patients. There are few studies indicating that the genetic susceptibility of children to
respiratory infectious diseases is related to sex (22–24). Meanwhile, in the gender
composition of children in Chengdu, boys accounted for 50.26%, girls accounted for
49.74%, and the proportion of boys and girls was basically the same. Therefore, we did
not normalize the ratio of virally infected boys vs. girls to an uninfected population.
Children under 3 years of age were the main population with ARTIs (67%). The
possible reason is the waning of maternal antibodies after 6 months and the fact that the
immune system gradually matures after 3 years of age. At this age stage, children lack

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FIG 3 The epidemic trend and demographic characteristics of respiratory viruses in the second year. (A) Monthly activity patterns of viruses. (B) The proportions

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of different viruses in the first year. (C) The proportions of different sexes in positive children. (D) The proportions of different viruses in positive children. (E, F) The
proportions of different categories and ages of positive children. Flu A, influenza A; Flu B, influenza B; PIV I, parainfluenza virus I; PIV II, parainfluenza virus II; PIV III,
parainfluenza virus III; ADV, adenovirus; RSV, respiratory syncytial virus; D, day; M, month; Y, year.

antibodies against viral infections and are more easily infected by viruses (25). In this
study, the number of inpatients was significantly higher than that of outpatients. The
possible reason is that this testing requires a long time and outpatients hope to obtain
the test results as soon as possible to visit the doctor, resulting in a smaller number of
tests than those for inpatients. At the same time, the main positive proportion of virus
detection among outpatients involved RSV, influenza A and B, and the main positive
proportion of virus detection among inpatients involved RSV, which is consistent with
the relevant research reported (26, 27).
Our previous research revealed that children under 5 years of age were mainly
infected with RSV and influenza A, and children aged 5–10 years were mainly infected
with influenza A (10). During the pandemic, we found that children under 3 years
of age were mainly infected with RSV, children aged 3–6 years were mainly infected
with influenza A, and children aged 6–14 years were mainly infected with influenza
A. Relevant studies have also shown that the population susceptible to RSV is mainly
infants and young children and the detection rate of RSV decreased with age, owing
to the maturation of the immune system (28, 29). According to statistics, RSV causes at
least 3.4 million hospitalizations and between 66,000 and 199,000 deaths among young
children under 5 years of age every year (30). Meanwhile, the influenza virus prevalence
increased with age, which was similar to previous reports (31, 32). Based on the results
of this study, it is possible that there was no significant change in the population
susceptible to viruses after the COVID-19 pandemic. Our previous data showed that
influenza A was the most common virus in this area before the COVID-19 pandemic,
followed by RSV and influenza B (10). In this study, the most common virus detected in
children with ARTIs was RSV, followed by influenza A and B 2 years after the COVID-19
pandemic. This may have been due to NPIs applied during the COVID-19 pandemic,
during which student learning changed from traditional classroom teaching in schools to
online learning at home. School-age children are susceptible to influenza infection, and

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decentralized teaching reduces the risk of this infection. Combined with the increased
number of RSV infections, influenza A and B infections may be mainly transmitted
in schools, while RSV may be mainly transmitted within the family or community.
Additionally, influenza virus vaccination may not be a convincing factor. Under the
influence of COVID-19, the willingness to receive influenza vaccines has increased to
avoid double infection with influenza viruses and SARS-CoV-2 (33). Even so, compared
with other countries, China’s influenza vaccination coverage is very low, far from the
herd immunity threshold (34). The vaccination of COVID-19 vaccine in Chinese children
began in October 2021, and the first round of vaccination was completed at the end
of December 2021. We analyzed the rates of positivity for respiratory viruses in January
2022–February 2022. Compared with the positive proportion for respiratory viruses from
January to February 2021, there was no significant change in 2022. The observation time
after the new coronavirus vaccination in children was only 2 months, and a longer time is
needed in future studies.
The positive proportion of viral infections increased significantly between September
2021 and January 2022. Further analysis showed that the positive proportion of influenza
B was significantly higher than that of other viruses, thus increasing the total positive
proportion of the virus. At the same time, the data released by the National Influenza
Center of China showed that the number of cases of influenza B infection increased
substantially during this period (35). Therefore, we speculate that the increased positive
proportion of influenza B may be related to the influenza B epidemic. After excluding
cases of influenza B, the monthly trend of the positive proportion of respiratory virus
detection during the study period was generally consistent. Although the positive
proportions in the autumn and winter seasons were higher than those in the spring
and summer seasons, the degree of change in the positive proportion by seasonality was

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significantly reduced compared with that before the COVID-19 epidemic (10). Related
studies have also shown that seasonal changes in the positive proportion of respiratory
viruses were due to NPIs preventing SARS-CoV-2 transmission (36, 37). The number of
RSV cases increased considerably after New Zealand partially relaxed its strict border
lockdown policy in April 2021 to five times the average peak level of 2015–2019 (38).
Meanwhile, the impact of non-NPIs may have had an effect on reducing the rate of
respiratory virus infection in children. Parents are not willing to take their sick children
to the hospital during the COVID-19 pandemic. They are worried about nosocomial
infections, unwilling to be isolated from their children, or reluctant to burden hospitals
during the COVID-19 pandemic. Consequently, they may choose to delay treatment or
seek medical help online. On the one hand, this reduces the spread of respiratory viruses;
on the other hand, it also reduces the number of respiratory viruses detected (39). At
the same time, due to isolation, less travel reduces air pollution, parents have more time
to take care of sick children at home, and children may recover faster, thus indirectly
reducing the probability of respiratory virus infection (40). The introduction of COVID-19
containment policies and public awareness campaigns may have reduced the transmis­
sion of Streptococcus pneumoniae, Haemophilus influenzae, and Neisseria meningitidis,
thereby greatly reducing life-threatening invasive diseases in many countries worldwide
(41). Studies have revealed that the number of admissions for respiratory infections in
children caused mainly by bacteria has decreased significantly. The number of admis­
sions for pneumonia decreased by 60%, that for otitis media decreased by 74%, and
that for tonsillitis decreased by 66% after the outbreak of the epidemic. The number of
bacterial and viral coinfections also decreased (42).
This study has some limitations. First, this was a single-center study. We only collected
data on children who visited our hospital for respiratory virus testing. These patients
were more likely to be seriously affected, which may have led to selection bias. In
the future, multicenter research trials and larger patient cohorts will provide a better
reference and support for the control, prevention, and treatment of respiratory virus
infections. Second, this was a retrospective analysis. We included only a limited number
of factors and investigated some viral respiratory antigens through the final serological

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positive proportion of the virus; therefore, further epidemiological monitoring of more

pathogens through molecular assays and their epidemic subtypes is needed to reveal
more detailed epidemiological information. Third, the comorbidities of patients were not
analyzed in this study; we will focus on this topic in future investigations.
In this study, we recruited more than 7,000 patients with ARTIs and analyzed the
prevalence of respiratory viruses during the COVID-19 pandemic in Chengdu, China.
Compared with that before the epidemic, the number of samples and positive propor­
tion of respiratory viruses decreased significantly (40% and 47%, respectively). Clinicians
and public health policymakers should pay attention to changes in the epidemic trends
and types of respiratory viruses and maintain monitoring of respiratory-related viruses to
avoid possible abnormal rebounds and epidemic outbreaks of these viruses.

ACKNOWLEDGMENTS

This work was supported by the Foundation (No. 21H1219 and No. 22H1407) and the
Science & Technology Department of Sichuan Province (No. 2023YFS0186). The funders
played no role in the study design, data collection and analyses, decision to publish, or
manuscript preparation.

AUTHOR AFFILIATIONS
1
Department of Laboratory Medicine, West China Second University Hospital, Sichuan
University, Chengdu, Sichuan, China
2
Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan
University, Ministry of Education, Chengdu, Sichuan, China

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AUTHOR ORCIDs

Zheng-Xiang Gao http://orcid.org/0000-0003-4042-8960

Lei-Wen Peng http://orcid.org/0000-0001-7800-7067

FUNDING

Funder Grant(s) Author(s)

Science and Technology Department of Sichuan Province No. 2023YFS0186 Ting Liu
(SPDST)

DATA AVAILABILITY

The raw data supporting the conclusions of this article will be made available by the
authors, without undue reservation.

ETHICS APPROVAL

The study protocol was approved by the Ethics Committee of West China Second
University Hospital of Sichuan University.

ADDITIONAL FILES

The following material is available online.

Supplemental Material

Supplemental Figure S1 (Spectrum02614-23-s0001.docx). The differences in age and

the different viral infections. Flu A = influenza A; Flu B = influenza B; PIV I = parainfluenza
virus I; PIV II = parainfluenza virus II; PIV III = parainfluenza virus III; ADV = adenovirus, RSV
= respiratory syncytial virus, D = Day, M = Month, Y = Year.

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Research Article Microbiology Spectrum

Open Peer Review

PEER REVIEW HISTORY (review-history.pdf). An accounting of the reviewer comments

and feedback.

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