The prevalence and role of human respiratory syncytial virus in pediatric respiratory tract infections: a systematic review and meta-analysis of global data

Summary

Background

Human respiratory syncytial virus (hRSV) is a major cause of respiratory tract infections in children worldwide. This study aims to describe the prevalence of hRSV in pediatric patients with respiratory tract infections, clarifying its association with such infections.

Methods

We analyzed studies from PubMed, Scopus, and Web of Science up to August 15, 2025, focusing on polymerase chain reaction-confirmed cases in children under 18 years. Data from 539 studies (584 datasets) were included. Pooled prevalence was calculated using a random-effects model, with subgroup analyses by region, gender, age group, sampling time, type of respiratory disease, types of patient care, genotypes, and subtypes of hRSV. Odds ratios evaluated the association between hRSV infection and respiratory disease risk.

Findings

The global prevalence among 1,733,341 children was 21.6%, with the highest rates in children aged less than 6 months (33.8%), and inpatients (25.9%). Bronchiolitis showed the highest prevalence (56.9%). Prevalence declined over time, possibly due to the coronavirus disease 2019 pandemic. hRSV-A (55.7%) was more common than hRSV-B (44.3%). Infection significantly increased respiratory infection risk (odds ratio = 7.0), especially for lower respiratory infections.

Interpretation

hRSV is a key contributor to pediatric respiratory tract infections, with notable variations by age and region. Prevention strategies, including vaccines and monoclonal antibodies, are urgently needed for high-risk groups.

Funding

None.

Research in context.

Evidence before this study

Prior to this study, research on human respiratory syncytial virus (hRSV) in pediatric respiratory tract infections (RTIs) had been conducted extensively, but existing studies were often limited by regional focus, small sample sizes, or methodological inconsistencies. To systematically evaluate the evidence, we performed a comprehensive search of the published literature. Previous findings indicated that hRSV is a leading cause of pediatric RTIs. However, the lack of a unified global analysis, combined with heterogeneity in study designs and seasonal variations, hindered the generalizability of these results.

Added value of this study

This study advances the field by presenting the first global systematic review and meta-analysis of hRSV prevalence in pediatric RTIs, integrating data from 539 studies across the world. Its contributions include an unprecedented geographic scope that shows disparities in prevalence. By restricting inclusion to PCR-confirmed cases, the study minimized diagnostic variability and improved comparability across datasets. Additionally, it identified a notable decline in hRSV prevalence after 2020, apparently attributable to the impact of COVID-19-related public health measures.

The study also quantified the strong association between hRSV infection and severe respiratory outcomes. By analyzing subgroups such as age, patient type (inpatient vs. outpatient), and respiratory conditions (e.g., bronchiolitis, pneumonia), this work provides nuanced insights that were previously unavailable in literature.

Implications of all the available evidence

The results show hRSV as a major contributor to pediatric respiratory morbidity, particularly among infants and hospitalized children. These findings have critical implications for public health policies and clinical practice. The high disease burden in low- and middle-income countries (LMICs) highlights the urgent need for accessible prevention strategies, including vaccines and monoclonal antibodies.

Introduction

Respiratory tract infections (RTIs) are a leading cause of morbidity and mortality among children worldwide, particularly in low- and middle-income countries (LMICs).¹ Among the various pathogens responsible for RTIs, human respiratory syncytial virus (hRSV) stands out as one of the most significant contributors to pediatric respiratory illness.² hRSV is a major cause of bronchiolitis, pneumonia, and other lower respiratory tract infections (LRTIs) in infants and young children, often leading to hospitalization and, in severe cases, death.³ Despite its global impact, the burden of hRSV-associated RTIs remains poorly quantified in many regions, particularly in resource-limited settings where diagnostic capabilities and surveillance systems are often inadequate.⁴

The epidemiology of hRSV is characterized by seasonal outbreaks, typically occurring during colder months in temperate climates and during the rainy season in tropical regions.⁵ However, the timing and intensity of these outbreaks can vary significantly across different geographic areas, complicating efforts to implement targeted prevention and control strategies. Furthermore, while hRSV is recognized as a major cause of pediatric RTIs, the prevalence of hRSV among children with RTIs has not been systematically synthesized on a global scale.⁶ Existing studies often focus on specific regions or populations, limiting the generalizability of their findings.⁷

Understanding the global prevalence of hRSV among children with RTIs is critical for informing public health interventions, including vaccine development and deployment, as well as for guiding resource allocation in healthcare systems. Recent advances in hRSV vaccine candidates and monoclonal antibodies have highlighted the urgent need for accurate, up-to-date data on hRSV epidemiology to support their effective implementation.^8,9 Despite this, a comprehensive synthesis of hRSV prevalence data across diverse geographic and demographic settings is lacking.

This systematic review and meta-analysis aims to address this gap by providing a comprehensive estimate of the worldwide prevalence of hRSV among children with RTIs. By synthesizing data from studies conducted across different regions and populations, this work will provide a clearer picture of the global burden of hRSV-associated RTIs in children. The novelty of this study lies in its global scope, encompassing data from both high-income countries (HICs) and LMICs, and its focus on the pediatric population, which is disproportionately affected by hRSV. Furthermore, this study will explore variations in hRSV prevalence by different variables such as geographic region and age group, offering insights that can inform targeted prevention and treatment strategies. The findings of this study are expected to contribute significantly to the global understanding of hRSV epidemiology and to support efforts to reduce the burden of hRSV-associated RTIs in children worldwide.

Methods

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline served as the foundation for this systematic review and meta-analysis approach.¹⁰

Search strategy

To identify relevant studies, a comprehensive literature search was conducted across three electronic databases: PubMed, Scopus, and Web of Science. The search was limited to studies published from the inception of each database up to August 15, 2025. The specific search terms used for each database are detailed in Supplementary Table S1. Additionally, the reference lists of relevant articles were manually reviewed to identify further studies that met the inclusion criteria. For efficient data organization, the results of the systematic literature search were imported into EndNote software version ×8 (Thomson Reuters, California, USA).

Selection criteria

Studies were considered qualified if they reported: (1) studies providing data related to the prevalence of hRSV among children less than 18 years with respiratory symptoms published in the English language in peer-reviewed journals; (2) the prevalence of hRSV genome in respiratory samples; (3) studies detecting hRSV genome by polymerase chain reaction (PCR)-based methods; (4) studies detecting the prevalence of hRSV among inpatients and outpatients; (5) original articles and short communications with sufficient data.

Notably, for prevalence analysis, we also included case–control studies that reported the number of laboratory-confirmed RSV cases among children with clinically suspected respiratory tract infection. For case–control studies, only data from the symptomatic “case” group were extracted. In these studies, the case group consisted of pediatric patients presenting with respiratory tract infection who underwent virological testing, and RSV status was determined using standard laboratory methods (PCR). Because the denominator comprised all tested symptomatic children within the defined study period, the proportion of RSV-positive cases in the case group is epidemiologically equivalent to period prevalence (detection rate) in a diagnostic cross-sectional cohort.

Studies that met any of the following criteria were excluded:

• (1)The prevalence of hRSV infection among adult patients with respiratory symptoms. hRSV epidemiology, clinical presentation, and risk factors differ substantially between children and adults. Including adults would introduce unacceptable clinical and immunological heterogeneity.
• (2)The prevalence of hRSV infection among children with underlying conditions such as cancer, cystic fibrosis, asthma, chronic obstructive pulmonary disease (COPD), chronic heart diseases, chronic neurological disease, acute otitis media, HIV, Kawasaki disease, immunocompromised status, transplant recipients, and down syndrome. These conditions markedly increase susceptibility to hRSV and severity of disease, leading to substantially higher detection rates that do not reflect the burden in the general pediatric population.
• (3)Samples other than respiratory specimens such as blood. hRSV is primarily a respiratory pathogen; detection in blood usually reflects severe disseminated disease in immunocompromised patients rather than typical respiratory infection.
• (4)Detection of hRSV by assays other than PCR-based methods such as ELISA, immunofluorescence, reverse transcription loop-mediated isothermal amplification (RT-LAMP), shell vial culture, flow cytometry system, complement fixation test, virus isolation, antigen detection, enzyme immunoassay, and immunochromatographic test. Older non-molecular methods have significantly lower and variable sensitivity/specificity compared with PCR, especially in older studies. Restricting to PCR-confirmed cases markedly reduces diagnostic misclassification bias and improves comparability across three decades of studies.
• (5)Seroprevalence of hRSV antibodies. Antibody-based studies measure past exposure rather than acute infection and cannot be pooled with virological prevalence data.
• (6)Studies including patients with non-respiratory symptoms. hRSV detection in asymptomatic or non-respiratory contexts does not contribute to understanding its role in acute respiratory illness.
• (7)The prevalence of a specific genotype or variant of hRSV. Such studies often selectively test or report only certain lineages, biasing prevalence estimates.
• (8)Letters, case series, notes, comments, reviews, case reports, posters, and conference abstracts. These typically lack sufficient methodological detail and raw data for reliable quality assessment and extraction.
• (9)Articles published in languages other than English. Although this may introduce language bias, thorough extraction and quality assessment by the review team would not have been feasible without full comprehension of the original text.

Data extraction and quality assessment

Three reviewers independently screened the titles and abstracts of all identified studies, removing those that were irrelevant to the research topic. The full texts of the remaining papers were retrieved and further evaluated by the reviewers, with studies failing to meet the inclusion criteria being excluded. Any disagreements among the reviewers were resolved through discussion with a fourth reviewer. To assess the quality of the included studies, a modified version of the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist was utilized.^11,12 The checklist included 12 questions designed to evaluate various methodological aspects of the studies. Only those studies that achieved a validity score of 8 or higher out of a maximum possible score of 12 were deemed eligible for inclusion in the main meta-analysis. Three reviewers extracted the data listed below from each eligible article: first author's last name, year of publication, year of sampling, study location, study design, sample size, type of sample, age ranges of patients, age groups of patients, the gender of patients, number of hRSV-positive cases, types of patient care, type of respiratory disease, and subtypes of hRSV. The retrieved data were entered into a pre-designed Excel spreadsheet (Microsoft Corporation, Redmond, Washington, USA).

Statistical analysis

Prevalence in this meta-analysis was defined as the proportion of children with clinically suspected acute respiratory tract infection (i.e., presenting with respiratory symptoms that prompted virological testing) who tested positive for hRSV by PCR-based methods in respiratory specimens. This corresponds to the detection rate of hRSV among symptomatic pediatric patients tested in the included studies and is the standard measure used in the vast majority of diagnostic prevalence studies of respiratory viruses. We pooled the hRSV infection in children suffering from respiratory diseases using the metaprop package.¹³ We applied the random-effects meta-analysis framework and subgroup analysis was conducted based on region, gender, age group, sampling time, type of respiratory disease, types of patient care, genotypes, and subtypes of RSV. We also conducted meta-analyses of risk estimates for respiratory diseases and exposure to hRSV, and we reported pooled estimates of odds ratio (OR) and 95% CIs. DerSimonian and Laird method¹⁴ was used to compute the pooled estimate of OR with confidence interval (95% CI) using random models. To calculate prevalence during the peak season and throughout the year, studies were categorized according to surveillance duration as (1) peak-season studies, defined as those conducted during a defined RSV epidemic or high-transmission season only, and (2) year-round studies, defined as those conducting continuous surveillance for ≥12 months. Statistical heterogeneity between studies was evaluated with Cochran's Q test and quantified by I² statistic.¹⁵ We investigated the presence and the effect of publication bias using a combination of the visual inspection of funnel plots that were constructed, plotting the logarithmically transformed ORs against the standard error of the associated log (OR) and Begg's test and Egger's test. Subgroup differences were evaluated using the random-effects subgroup analysis. For each subgroup, a pooled prevalence was estimated and statistical differences between subgroups were tested using the Q-test for heterogeneity between groups (Q_between). A P-value <0.05 was considered statistically significant. All statistical tests were two-tailed and the significance level was considered less than 0.05 for all, except heterogeneity test that were set at less than 0.1, and statistical analyses were performed using Stata 14.1 (Stata Corp, College Station, TX, USA).

Ethics statement

Ethics statement was not required for this study.

Statement on informed consent

Informed consent was not required.

Role of the funding source

There was no funding source for this study.

Results

Literature search

During the initial search, 40,966 papers were identified, and 15 further papers were discovered by manually examining the reference lists of pertinent research. A total of 18,963 duplicate papers were initially removed, and 20,769 additional papers were removed after a manual check of titles and abstracts. After a thorough evaluation of the full text of the remaining 1249 papers to determine their eligibility for the meta-analysis, 686 of them were removed. According to the modified STROBE checklist, 539 publications were deemed to be of good quality (scoring 8 or higher), with 24 papers failing to get a score of 8. Finally, this systematic review and meta-analysis contained 539 papers (584 datasets). An overview of the selection of relevant studies is depicted in Fig. 1.

Fig. 1.

Flowchart presenting the steps of literature search and selection.

Study characteristics

Out of the 584 research, 551 studies were cross-sectional and 33 studies were case–control in design. The articles' publication dates varied from 1992 to 2025. The largest research involved 155,165 pediatric patients with respiratory infections,¹⁶ while the smallest contained 11 cases.¹⁷ Out of the 584 datasets included in this meta-analysis, 73 studies examined the gender distribution of hRSV infection, and 144 studies performed hRSV typing. Overall, children under 5 years of age (n = 688,375) were the predominant population participating in the studies compared to children aged 6–18 years (n = 107,328). Among the age group of children under 5 years old, the largest population included in the studies were children under 6 months of age (n = 68,866). The country with the highest number of studies was China (n = 120), followed by India (n = 32), United States (n = 28), and Italy (n = 24). In terms of the number of participants, out of 1,733,341 cases, China ranked first with 834,429 cases, followed by Brazil, Italy, Spain, and the United States with 128,602, 89,204, 88,651, and 71,365 cases, respectively. The characteristics of included studies in this systematic review and meta-analysis are summarized in Table 1. Table 2 shows results of subgroup analysis of the prevalence of hRSV infection in children with respiratory infections. Results of the meta-regression analysis are presented in the Supplementary File.

Table 1.

Characteristics of all studies included in this systematic review and meta-analysis.

Author (Ref)	Publication year	Location	Type of disease	Number of cases	No. RSV positive cases
Cubie18	1992	UK	Bronchiolitis	123	45
Freymuth19	1997	France		277	173
Grondahl20	1999	Germany		1031	141
Weigl21	2000	Germany		1281	162
Zambon22	2001	UK	ILI	762	198
Weigl23	2002	Germany		2108	348
Cuevas24	2003	Brazil	LRI	111	61
Jartti25	2004	Netherlands	Wheezing	291	50
Jennings26	2004	New Zealand		75	32
Scott27	2004	Kenya		1044	397
Serafino28	2004	Brazil	LRI	217	133
Al-Sonboli29	2005	Yemen		604	244
Kotaniemi-syrjanen30	2005	Finland	Wheezing	61	14
Mentel31	2005	Germany		356	94
Sato32	2005	Japan	LRI	499	185
Versteegh33	2005	Netherlands		136	1
Al-Sonboli34	2006	Yemen		601	266
Choi35	2006	South Korea	LRI	515	122
Crowcroft36	2007	UK		91	70
Naghipour37	2007	Iran		261	39
Pierangeli38	2007	Italy		227	39
Teeratakulpisarn39	2007	Thailand	Bronchiolitis	170	110
Thomazelli40	2007	Brazil	LRI	336	81
Alper41	2008	USA	URI	170	29
Bonzel42	2008	Germany		254	112
Bosis43	2008	Italy	Wheezing	85	63
Calvo44	2008	Spain	LRI	749	376
Kaplan45	2008	Jordan		326	140
Rihkanen46	2008	Finland	Wheezing	76	21
Rihkanen46	2008	Finland		144	21
Agrawal47	2009	India		1720	177
Al-Majhdi48	2009	Saudi Arabia		200	70
Bharaj49	2009	India	LRI	301	61
Chun50	2009	South Korea	LRI	297	87
Fabbiani51	2009	Italy	URI	166	7
Fabbiani51	2009	Italy	LRI	71	27
Hall52	2009	USA		2892	547
Midulla53	2009	Italy	Bronchiolitis	182	75
Pavlova54	2009	Bulgaria		278	67
Sung55	2009	China		475	40
Zaraket56	2009	Lebanon	ILI	24	10
Calvo57	2010	Spain	Bronchiolitis	318	195
Antunes58	2010	Portugal	Bronchiolitis	207	166
Faghihloo59	2010	Iran		107	24
Garcıa-Garcıa60	2010	Spain	Wheezing	626	170
Malekshahi61	2010	Iran	ILI	202	34
Nascimento62	2010	Brazil	Bronchiolitis	77	49
Singleton63	2010	USA	LRI	440	102
Wang64	2010	China		817	120
Zhang65	2010	China		894	341
Zhang66	2010	China		1387	439
Pientong67	2011	Thailand	Bronchiolitis	170	110
Bezerra68	2011	Brazil		407	152
Do69	2011	Vietnam		309	73
Frobert70	2011	France		73	46
Fujitsuka71	2011	Japan	Wheezing	115	61
Gardinassi72	2011	Brazil		272	79
Jin73	2011	China	LRI	813	331
Kristoffersen74	2011	Norway	LRI	536	142
Mathisen75	2011	Nepal	Pneumonia	627	88
Pogka76	2011	Greek	ILI	1272	155
Razanajatovo77	2011	Madagascar	ILI	177	54
Salomao Junior78	2011	Brazil	LRI	290	85
Sezer79	2011	Turkey	LRI	55	21
Simoes80	2011	Indonesia	LRI	802	163
Suntarattiwong81	2011	Thailand	LRI	354	104
Suryadevara82	2011	USA		197	104
Wang83	2011	UK		155	3
Zuccotti84	2011	Italy		575	196
Esposito85	2012	Italy	Pneumonia	592	188
Brand86	2012	Netherlands	Bronchiolitis	142	104
Chatzopoulou87	2012	Greece	ILI	430	45
Cho88	2012	South Korea	LRI	108	46
Garcia-Garcia89	2012	Spain	Pneumonia	884	270
Gorjipour90	2012	Iran	URI	330	17
Hoffmann91	2012	Madagascar		295	35
Hombrouck92	2012	Belgium	ILI	139	27
Kadjo93	2012	Ivory Coast	ILI	470	113
Kwofie94	2012	Ghana	LRI	128	18
Mansbach95	2012	USA	Bronchiolitis	2207	1589
Pierangeli96	2012	Italy		231	87
Schlaudecker97	2012	Honduras		345	26
Suzuki98	2012	Philippines	Pneumonia	819	198
Turner99	2013	Thailand	Pneumonia	640	174
Aamir100	2013	Pakistan		105	75
Alavi101	2013	Iran		100	29
Ali102	2013	Pakistan	Pneumonia	169	30
Bigogo103	2013	Kenya		5595	756
Choudhary104	2013	India		854	159
Enan105	2013	Sudan		368	26
Feikin106	2013	Kenya	SARI	408	90
Guerrier107	2013	Cambodia	LRI	1006	192
Harada108	2013	Japan		286	128
Harada108	2013	Japan	Pneumonia	86	44
Huang109	2013	China		279	36
Huo110	2013	China	SARI	511	87
Jafri111	2013	USA	LRI	4172	1306
Kim112	2013	South Korea		4212	1212
Li113	2013	China	ILI	844	86
Miyaji114	2013	Japan		214	37
Miller115	2013	USA	URI	175	18
Miller115	2013	USA	Bronchiolitis	455	298
Miller115	2013	USA		18	4
Nakouné116	2013	Central African Republic		329	10
Naorat117	2013	Thailand	LRI	6641	876
Nikfar118	2013	Iran	LRI	100	9
Ohno119	2013	Philippines	Pneumonia	2150	415
Tecu120	2013	Romania		241	49
Tran120	2013	Vietnam		1082	257
Zhang121	2013	China	SARI	370	189
Broor122	2014	India		245	50
Hara123	2014	Japan		495	138
He124	2014	China		2025	296
Kool125	2014	Netherlands		257	36
Kono126	2014	New Guinea	ILI	167	22
Lekana-Douki127	2014	Gabon	ILI	921	114
Shatizadeh128	2014	Iran		202	34
Al-Ayed129	2014	Saudi Arabia		135	33
Balmaks130	2014	Latvia	LRI	207	88
Cai131	2014	China		1980	446
Faghihloo132	2014	Iran		485	94
Feng133	2014	China	LRI	20,637	9087
Gooskens134	2014	Netherlands		274	69
Junior135	2014	Brazil		116	12
Kaida136	2014	Japan		1044	198
Karadag-Oncel137	2014	Turkey	ILI	194	16
Wen Liu138	2014	China	Pneumonia	2361	768
Jia Liu139	2014	China		2407	184
Obodai140	2014	Ghana	LRI	53	32
Panayiotou141	2014	Cyprus		391	128
Pourakbari142	2014	Iran	LRI	232	40
Radin143	2014	USA	Pneumonia	270	57
Schulert144	2014	USA	Pneumonia	202	38
Singh145	2014	India	LRI	188	40
Mendoza146	2015	Peru		717	116
Moattari147	2015	Iran		252	71
Aydemir148	2015	Turkey	Pneumonia	78	12
Berce149	2015	Slovenia	LRI	278	77
Cebey-Lopez150	2015	Spain	LRI	204	108
Cebey-Lopez150	2015	UK	LRI	97	35
Cui151	2015	China		1074	75
Diaz152	2015	Mexico		162	23
Fu153	2015	China	ILI	305	29
Halasa154	2015	Jordan		3175	1397
Lagare155	2015	Niger		160	56
Lee156	2015	Taiwan		216	18
Malasao157	2015	Philippines	Pneumonia	1505	423
Martinez-Roig158	2015	Spain		463	250
Othman159	2015	Egypt	LRI	127	59
Ren160	2015	China	LRI	3167	1035
Simusika161	2015	Zambia		496	114
Tuan162	2015	Vietnam	LRI	1117	316
Wei163	2015	China		3181	831
Wertheim164	2015	Multiple countries	ILI	525	139
Yu165	2015	China		1820	269
Zhang166	2015	China	Pneumonia	371	163
Wishaupt167	2016	Netherlands		241	108
Richter168	2016	Cyprus		424	129
Ali169	2016	Pakistan	Pneumonia	817	13
Amer170	2016	Saudi Arabia	LRI	113	14
Antón171	2016	Spain	ILI	3482	285
Bimouhen172	2016	Morocco		654	211
Chou173	2016	Taiwan	LRI	90	5
Cangiano174	2016	Italy	Bronchiolitis	723	234
Do175	2016	Vietnam	LRI	632	302
Dong176	2016	China		2819	100
Dut177	2016	Turkey		312	29
Faber178	2016	Netherlands	Bronchiolitis	100	83
Fall179	2016	Senegal	ILI	2803	436
Girit180	2016	Turkey	ILI	132	46
Goktas181	2016	Turkey		309	43
Gurgel182	2016	Brazil	LRI	507	204
Hu183	2016	China		1827	433
Kenmoe184	2016	Cameroon		347	46
Karppinen185	2016	Finland		2275	279
Liu186	2016	China		5483	729
Malhotra187	2016	India		155	6
Meligy188	2016	Egypt	Pneumonia	44	9
Meskill189	2016	USA		13,664	3018
Mishra190	2016	India		300	61
Moesker191	2016	Netherlands		44	6
Nyawanda192	2016	Kenya		3634	446
Panda193	2016	India		332	15
Parsania194	2016	Iran		158	49
Reeves195	2016	UK		63,827	13,034
Slovic196	2016	Croatia		486	388
Wang197	2016	China	ILI	3662	206
Arbefeville198	2017	USA		752	72
Abdulhaq199	2017	Saudi Arabia		62	5
Benet200	2017	Cambodia	Pneumonia	176	39
Benet200	2017	China	Pneumonia	39	17
Benet200	2017	Haiti	Pneumonia	101	26
Benet200	2017	India	Pneumonia	192	17
Benet200	2017	Madagascar	Pneumonia	80	12
Benet200	2017	Mali	Pneumonia	118	30
Benet200	2017	Mongolia	Pneumonia	108	23
Benet200	2017	Paraguay	Pneumonia	99	14
Avcu201	2017	Turkey	LRI	114	27
Bashir202	2017	Pakistan	LRI	155	104
Bedolla Barajas203	2017	Mexico	Wheezing	55	7
Bhuyan204	2017	Bangladesh		200	62
Brini205	2017	Tunisia		372	123
Dang206	2017	China		411	95
Fagbo207	2017	Saudi Arabia		2235	512
Gokce208	2017	Turkey	Bronchiolitis	316	127
Janahi209	2017	Qatar	Bronchiolitis	369	189
Jonnalagadda210	2017	Ecuador	Pneumonia	406	159
Kim211	2017	South Korea		16,842	1116
Korsun212	2017	Bulgaria		610	157
Lim213	2017	Australia	ILI	2356	622
Moe214	2017	Norway	LRI	1816	870
Nenna215	2017	Italy	Bronchiolitis	723	266
Nguyen216	2017	Laos		383	157
O Grady217	2017	Australia		817	157
Pale218	2017	Mozambique	SARI	424	113
Park219	2017	South Korea	ILI	3305	180
Petrarca220	2017	Italy	Bronchiolitis	486	365
Piralla221	2017	Italy	Pneumonia	39	2
Sahu222	2017	India	ILI	180	56
Saxena223	2017	India	ILI	325	135
Swamy224	2017	India		689	175
Taylor225	2017	Australia	ILI	111	18
Taylor225	2017	Brazil	ILI	710	42
Taylor225	2017	Colombia	ILI	584	49
Taylor225	2017	Costa Rica	ILI	379	16
Taylor225	2017	Mexico	ILI	669	51
Taylor225	2017	Philippines	ILI	1045	167
Taylor225	2017	Singapore	ILI	49	4
Taylor225	2017	Thailand	ILI	170	12
Thongpan226	2017	Thailand		3306	277
Trenholme227	2017	New Zealand	LRI	1645	540
Valle Mendoza228	2017	Peru	Pneumonia	146	35
Vieira229	2017	Brazil	Bronchiolitis	94	73
Wishaupt230	2017	Netherlands		560	291
Wollmeister231	2017	Brazil	Bronchiolitis	142	47
Wollmeister231	2017	Brazil	Bronchiolitis	172	121
Wong Chew232	2017	Mexico	Pneumonia	1404	332
Yan233	2017	China	LRI	387	205
Zheng234	2017	China		80	33
Swamy235	2018	India		997	279
Tine236	2018	Senegal		208	34
Appak237	2018	Turkey		3162	292
Assane238	2018	Senegal		162	26
Aykac239	2018	Turkey		1240	74
Bhuiyan240	2018	Australia	Pneumonia	230	46
Canela241	2018	Brazil	SARI	63	7
Chen242	2018	China		1764	401
Chittaganpitch243	2018	Thailand	ILI	5069	447
Chittaganpitch243	2018	Thailand	SARI	1404	196
Cieslak244	2018	Poland	ILI	1096	73
Cowling245	2018	Hong Kong	ILI	2090	103
El Baroudy246	2018	Egypt	ILI	132	21
Famoroti247	2018	South Africa		2172	316
Fillatre248	2018	France		3199	237
Fieldhouse249	2018	Malaysia	Pneumonia	95	41
Gaymard250	2018	France		9776	2518
Ge251	2018	China		2160	368
Gimferrer252	2018	Spain		11,412	1796
Hassan253	2018	Iraq		269	55
Hendaus254	2018	Qatar	Bronchiolitis	769	352
Hindupur255	2018	India		135	24
Kadjo256	2018	Ivory Coast	ILI	917	61
Kadjo256	2018	Ivory Coast	SARI	142	14
Kabego257	2018	Congo	URI	109	16
Kabego257	2018	Congo	LRI	37	15
Khalifa258	2018	Tunisia		515	177
Kurskaya259	2018	Russia		1560	358
Xuechao Li260	2018	China		973	104
Jin Li261	2018	China		775	151
Nascimento Carvalho262	2018	Brazil	Pneumonia	774	193
Nicholson263	2018	USA		104	18
Obodai264	2018	Ghana	LRI	552	127
Ogunsemowo265	2018	Nigeria		231	41
Okamoto266	2018	Philippines		3471	439
Rashid267	2018	Malaysia	LRI	102	17
Ravindranath268	2018	USA	SARI	218	161
Razanajatovo269	2018	Madagascar	SARI	747	334
Snoeck270	2018	Laos		245	30
Tsagarakis271	2018	Greece		268	26
Yu272	2018	China		3607	427
Mackenzie273	2019	Gambia	LRI	519	244
Liu274	2019	China		11,398	1690
Tokak275	2019	Turkey		997	377
Abduljabbar276	2019	Iraq		150	26
Alharbiaburiziza277	2019	Saudi Arabia	LRI	129	29
Barlotta278	2019	Italy	Bronchiolitis	52	40
Bekhof279	2019	Netherlands	Bronchiolitis	218	182
Derrar280	2019	Algeria	LRI	117	56
Etemadi281	2019	Malaysia	LRI	165	83
Halaji282	2019	Iran		156	56
Harun283	2019	Turkey		269	44
Hasegawa284	2019	USA	Bronchiolitis	2912	2228
Hatem285	2019	Egypt	SARI	2479	470
Hindupur286	2019	India		267	57
Knobbe287	2019	Senegal		102	17
Korsun288	2019	Bulgaria	LRI	515	193
Lagare289	2019	Niger		638	149
Le Wang290	2019	China	LRI	440	124
Li291	2019	China	LRI	659	75
McCallum292	2019	Australia		794	17
McCallum292	2019	Australia	Bronchiolitis	333	156
Midulla293	2019	Italy	Bronchiolitis	998	413
Rha294	2019	South Africa	LRI	9969	2723
Saez Lopez295	2019	Portugal	ILI	756	31
Sonawane296	2019	India	LRI	100	29
Thongpan297	2019	Thailand	ILI	5081	763
Wen298	2019	China	LRI	3232	930
Toh299	2019	Malaysia	Pneumonia	439	118
Wilson300	2019	Ghana	SARI	2176	248
Xu301	2019	China	ILI	1992	124
Yen302	2019	Taiwan		442	88
Yew303	2019	Malaysia		394	85
Yurtseven304	2019	Turkey	Bronchiolitis	241	108
Zhao305	2019	China	SARI	700	198
Vanderburg306	2020	Sri Lanka	SARI	325	93
Tsou307	2020	USA	Bronchiolitis	270	179
Thongpan308	2020	Thailand	ILI	8209	1082
Şık309	2020	Turkey	LRI	123	36
Pham310	2020	Vietnam	LRI	194	73
Perales311	2020	Bolivia	Pneumonia	274	60
Palani312	2020	India		292	32
Lin313	2020	Taiwan		474	113
Lee314	2020	South Korea	Pneumonia	30,994	6304
Korsun315	2020	Bulgaria		875	229
Karaarslan316	2020	Turkey		88	42
Jarju317	2020	Gambia	ILI	735	108
Huang318	2020	China		14,482	2200
Hattoufi319	2020	Morocco	Pneumonia	86	46
Gao320	2020	China		3121	230
Emanuels321	2020	Nepal		3646	214
Duyu322	2020	Turkey	LRI	63	23
Chowdhury323	2020	Bangladesh	Pneumonia	359	32
Castro324	2020	Brazil		164	5
Calvo325	2020	Spain		5131	1607
Bunthi326	2020	Thailand	Pneumonia	223	51
Aygün327	2020	Turkey	LRI	422	103
Ang328	2020	Singapore		4470	375
Al-Romaihi329	2020	Qatar	ILI	30,946	6102
Adema330	2020	Kenya		1726	11
Abinaya331	2020	India	LRI	69	15
Atay332	2020	Turkey	Bronchiolitis	101	22
Aamir333	2020	Pakistan		1941	472
Tsergouli334	2020	Greece	Bronchiolitis	71	37
Luo335	2020	China		9158	1432
Hasuwa336	2020	Japan	LRI	373	87
Zhu337	2021	China	Pneumonia	2721	413
Vianna338	2021	Brazil	SARI	632	352
Vasconcelos339	2021	Multiple countries		349	74
Thongpan340	2021	Thailand	ILI	574	232
Tavakoli341	2021	Iran		206	74
Shutes342	2021	USA	LRI	984	586
Snoeck343	2021	Laos		436	28
Ramezannia344	2021	Iran		100	18
Raju345	2021	India	LRI	317	96
Mathisen346	2021	Nepal	Pneumonia	610	299
Mandelia347	2021	USA		4947	1228
Lin348	2021	China		2853	332
Lin348	2021	China		1222	202
Lim349	2021	South Korea		6576	1106
Li350	2021	China		2298	152
Li350	2021	China		3398	683
Leli351	2021	Italy		197	37
Lei352	2021	Macao		4880	757
Komoyo353	2021	Central African Republic		3903	312
Khomenko354	2021	Ukraine		487	64
Juliana355	2021	Suriname	SARI	316	107
Ihling356	2021	Tanzania		293	9
Ihling356	2021	Burkina Faso		115	2
Ihling356	2021	Gabon		182	4
Ihling356	2021	Ghana		490	31
Haddadin357	2021	USA		360	101
Guo358	2021	China		11,306	1783
El-Senousy359	2021	Egypt		100	2
Diesner-Treiber360	2021	Austria		448	0
Correia361	2021	Cabo Verde		129	13
Chen362	2021	China	LRI	5529	964
Arshad363	2021	Pakistan	LRI	70	21
Agca364	2021	Turkey	URI	248	6
Vittucci365	2021	Italy		6209	1415
Vittucci365	2021	Italy		615	5
Zhang366	2022	China	Pneumonia	2364	242
Zhang366	2022	China	Pneumonia	375	74
Yun367	2022	USA	Pneumonia	441	75
Xu368	2022	China	LRI	417	50
Xu368	2022	China	LRI	632	25
Xiang369	2022	China		1442	492
Windsor370	2022	USA		931	114
Tabatabai371	2022	Germany		946	405
Suryadevara372	2022	Ecuador		820	99
Sen Zeynep373	2022	Turkey	LRI	255	99
Sarkar374	2022	India	LRI	349	142
Pretell375	2022	Peru		79	4
Paul Shen376	2022	Belgium		360	65
Paul Shen376	2022	Belgium		93	3
Orqueda377	2022	Argentina		619	158
Ogunbayo378	2022	South Africa	SARI	84	40
Nenna379	2022	Italy		476	130
Nenna379	2022	Italy		85	4
Moleleki380	2022	South Africa		154	39
Jiang381	2022	China		3338	666
Jiang381	2022	China		5860	581
Meyer382	2022	Germany		748	169
Maglione383	2022	Italy		1763	733
Low384	2022	Malaysia		23,306	3652
Lokida385	2022	Indonesia	Pneumonia	188	51
Lei386	2022	China		4880	755
Kume387	2022	Japan		1757	639
Kume388	2022	Japan		743	275
Kume388	2022	Japan		422	113
Koul389	2022	India	SARI	412	118
Kamata390	2022	Myanmar	LRI	570	262
Kafntu-Kwashie391	2022	Ghana	LRI	188	20
Jamieson392	2022	USA		274	86
Hossain393	2022	Bangladesh		3170	555
Hanchi394	2022	Morocco	SARI	586	149
Hanchi394	2022	Morocco	SARI	316	65
Davis395	2022	New Zealand	SARI	3169	1258
Dananche396	2022	Multiple countries	Pneumonia	888	112
Dai397	2022	China		63,392	7105
Cui398	2022	China		6481	824
Cui398	2022	China		1508	230
Ng399	2022	Malaysia	Pneumonia	111	31
Chawla400	2022	India	LRI	50	7
Chandy401	2022	India		256	92
Cason402	2022	Italy		1227	1
Bimouhen403	2022	Morocco		740	282
Ahmed404	2022	Saudi Arabia		580	164
Shen405	2022	China		541	106
Letafati406	2022	Iran		168	0
Calaor-Morin407	2022	Philippines		1036	122
Agarwal408	2023	India	URI	180	32
Alaib409	2023	Saudi Arabia		521	189
Alaib409	2023	Saudi Arabia		205	27
Almeida410	2023	Portugal		626	141
Alsayed411	2023	Jordan	Bronchiolitis	91	42
Atti412	2023	Italy		35,746	1927
Atti412	2023	Italy		37,213	1469
DeJonge413	2023	USA		1418	135
Edderdouri414	2023	Morocco		178	36
Fourie415	2023	Netherland	URI	88	30
Guo416	2023	China		1225	267
Han417	2023	China	URI	252	2
Han417	2023	China	LRI	785	186
Kandeel418	2023	Egypt	ILI	497	72
Kang419	2023	India	LRI	166	85
Kang419	2023	India	LRI	189	9
Kelly420	2023	Tanzania		2082	544
Kislal421	2023	Turkey		207	0
Krumkamp422	2023	Ghana	LRI	327	16
Kumar423	2023	India		94	5
Kurskaya424	2023	Russia		1088	229
Kurskaya424	2023	Russia		2102	200
Yuan Li425	2023	China	Pneumonia	9837	1507
Ming Li426	2023	China		556	117
Lin427	2023	Taiwan	Pneumonia	128	29
Mai428	2023	China		86	0
Mai428	2023	China		157	17
Osborne429	2023	USA	LRI	295	103
Ramgopal430	2023	USA	Pneumonia	573	114
Samuels431	2023	Sierra Leone		502	98
Shi432	2023	China		10,396	1655
Siddik433	2023	Bangladesh		320	21
Steponaviciene434	2023	Lithuania		5127	429
Vasconcelos435	2023	Switzerland	Pneumonia	138	31
Virant436	2023	Slovenia		3107	378
Virant436	2023	Slovenia		3316	411
Wadilo437	2023	Ethiopia	LRI	210	64
Xu438	2023	China	SARI	262	20
Xu438	2023	China	SARI	711	43
Yan Yan439	2023	China	LRI	989	317
Yi Yan440	2023	China	LRI	744	106
Zarur-Torralvo441	2023	Colombia		1249	178
Zarur-Torralvo441	2023	Colombia		231	8
Zdanowicz442	2023	Poland	LRI	100	5
Zendehrouh443	2023	Iran		87	2
Zhang444	2023	China		2632	535
Bimouhen445	2023	Morocco		1882	579
Hayek446	2023	USA		30,283	3506
Kandeel447	2023	Egypt	SARI	317	153
Kubale448	2023	Albania		1032	438
Kubale448	2023	Jordan		1056	358
Kubale448	2023	Nicaragua		936	208
Kubale448	2023	Philippines		607	123
Morgan449	2023	South Africa		460	142
Naeem450	2023	Iraq		158	15
Rybak451	2023	France	Bronchiolitis	984	437
Salim452	2023	UAE		3098	530
Suh453	2023	South Korea	Pneumonia	517	71
Trang454	2023	Vietnam	SARI	1563	438
Umar455	2023	China		6499	405
Wadilo456	2023	Ethiopia		210	64
Wanlapakorn457	2023	Thailand	SARI	169	49
Zendehrouh443	2023	Iran		87	2
Alimohammadi458	2024	Iran		102	23
Altawalah459	2024	Kuwait		367	94
Aneja460	2024	India	SARI	840	257
Begley461	2024	USA		1741	234
Bhardwaj462	2024	India		3171	357
Buonsenso463	2024	Italy		523	152
Do464	2024	Mongolia		5705	2113
Dorji465	2024	Bhutan	SARI	921	231
Farzi466	2024	Iran		340	11
Fröhlich467	2024	Brazil		748	612
Hou468	2024	China		19,531	3215
Huang469	2024	China		117	52
Korsun470	2024	Bulgaria		2241	302
Kuang16	2024	China		155,165	2524
Lebreiro471	2024	Brazil		369	55
Leija-Martínez472	2024	Mexico		390	160
Li473	2024	China		44,704	4018
Li474	2024	China		6864	376
Li475	2024	China		4565	273
Liu476	2024	China		5453	804
Liu477	2024	China		1344	186
Lv478	2024	China		4804	334
Ma479	2024	China	Pneumonia	309	82
Meier480	2024	Austria		329	110
Menezes481	2024	Brazil		54,685	17,626
Mojarrad482	2024	Iran		200	34
Moyes483	2024	South Africa		5786	1079
Ndiaye484	2024	Senegal		159	11
Pan485	2024	China		1374	54
Pasittungkul486	2024	Thailand		7710	1245
Pérez-Camacho487	2024	Colombia	Pneumonia	61	24
Philomenadin488	2024	India		1684	420
Pun489	2024	China		24,734	2144
Ramzali490	2024	Iran		411	111
Reddy491	2024	South Africa		1358	256
Reller492	2024	Bangladesh		1477	299
Rojo-Alba493	2024	Spain		65,382	4765
Shrestha494	2024	Nepal	ILI	803	132
Simusika495	2024	Zambia	SARI	3113	504
Stacevičienė496	2024	Lithuania		7014	431
Sun497	2024	China		345	17
Tayachew498	2024	Ethiopia		2234	362
Tran499	2024	Vietnam	Pneumonia	467	114
Umran500	2024	India		100	7
Wei501	2024	China		965	57
Wu502	2024	China		11,056	1501
Xu503	2024	China		42,379	6394
Yang504	2024	China	Pneumonia	7533	1051
Yang505	2024	China		15,993	1561
Zhang506	2024	China		4956	342
Zhang507	2024	China		4219	217
Zhao508	2024	China		1090	181
Zhao509	2024	China		1788	186
Zheng510	2024	China		1939	184
Adu-Gyamfi511	2025	Ghana		303	27
Bandeira512	2025	Brazil		465	185
Burrell513	2025	Australia		32,599	3338
Cha514	2025	China		10,580	474
Correia515	2025	Cabo Verde		96	37
Han516	2025	China		1184	338
Jamalidoust517	2025	Iran	SARI	155	0
Jiang518	2025	China		7131	732
Jiang519	2025	China		8454	452
Jie520	2025	China		740	84
Khan521	2025	Bangladesh	ILI	390	42
Lai522	2025	China		12,993	917
Li523	2025	China		3966	817
Liu524	2025	China		8550	805
Ma525	2025	China		1691	234
Matache526	2025	Romania		803	43
Matsumura527	2025	Japan		212	21
Mi528	2025	China	ILI	28,217	1562
Moleleki529	2025	South Africa	SARI	198	54
Mollel17	2025	Tanzania		11	1
Pale530	2025	Mozambique	SARI	472	109
Hosseinpour Sadeghi531	2025	Iran		92	2
Santos532	2025	Brazil		1081	344
Shrestha533	2025	Nepal	Pneumonia	1363	282
Soares534	2025	Brazil	SARI	66,170	18,026
Takashita535	2025	Japan	ILI	2177	218
Tan536	2025	China	Pneumonia	110	39
Tang537	2025	China		15,397	2177
Tayachew538	2025	Ethiopia		2990	628
Wang539	2025	China		40,174	5677
Wang540	2025	China		16,571	2361
Wu541	2025	China		12,743	1156
Xu542	2025	China	Bronchiolitis	697	300
Xu543	2025	China	Pneumonia	7635	991
Zeng544	2025	China		14,352	2125
Zhang545	2025	China		682	77
Zhu546	2025	China		3790	457

Table 2.

Subgroup analysis of the prevalence of hRSV infection among pediatric patients with respiratory infections.

	Group	Number of datasets	Total sample size	Pooled prevalence (%) (95% CI)	Heterogeneity test I2%, p-value	Differences between subgroups; χ2 test (p-value)
Overall prevalence	–	584	1,733,341	21.6 (20.5–22.6)	99.6%, P < 0.0001	–
Study period	Year-round	432	1,547,640	20.2 (19.1–21.4)	99.6%, P < 0.0001	P < 0.0001
	Peak season	148	184,312	25.7 (22.8–28.8)	99.4%, P < 0.0001
Sample type	NP	302	630,169	24.4 (22.9–26.0)	99.4%, P < 0.0001	P < 0.0001
	Throat	35	69,754	11.8 (9.4–14.4)	98.9%, P < 0.0001
	Nasal	38	23,900	24.8 (19.9–29.9)	98.6%, P < 0.0001
	OP	8	20,344	14.1 (9.1–20.1)	98.9%, P < 0.0001
	Tracheal	2	457	45.7 (41.1–50.3)	NA
	Sputum	4	3806	18.8 (7.9–32.9)	98.6%, P < 0.0001
	BAL	2	1199	12.3 (10.5–14.2)	NA
Sample type (Overall)	URS	498	1,019,307	22.0 (20.9–23.1)	99.3%, P < 0.0001	P < 0.0001
	MRS	66	516,375	17.3 (14.9–19.9)	99.8%, P < 0.0001
	LRS	8	5462	23.3 (14.4–33.6)	98.3%, P < 0.0001
Type of disease	ILI	47	116,075	13.7 (11.5–16.1)	99.09%, P < 0.0001	P < 0.0001
	SARI	32	90,373	25.8 (22.2–29.5)	98.6%, P < 0.0001
	Pneumonia	57	84,366	22.5 (20.4–24.6)	97.5%, P < 0.0001
	Bronchiolitis	32	14,913	56.9 (50.6–63.2)	98.2%, P < 0.0001
	Wheezing	7	1309	32.5 (19.8–46.7)	95.5%, P < 0.0001
Type of disease (Overall)	URTI	56	120,047	13.2 (11.1–15.3)	98.9%, P < 0.0001	P < 0.0001
	LRTI	224	357,450	30.2 (28.3–32.1)	99.2%, P < 0.0001
Sampling time	1991–2000	9	6090	31.0 (21.6–41.3)	98.3%, P < 0.0001	P < 0.0001
	2001–2010	124	80,362	28.0 (25.1–31.0)	98.8%, P < 0.0001
	2011–2019	294	699,849	21.6 (20.4–22.9)	99.3%, P < 0.0001
	2020–2024	117	572,979	15.1 (13.4–17.0)	99.7%, P < 0.0001
Gender	Male	72	104,412	24.0 (21.6–26.5)	98.6%, P < 0.0001	P = 0.55
	Female	72	80,996	22.9 (20.5–25.3)	98.1%, P < 0.0001
Economy classification	Low-income	23	16,662	21.8 (16.6–27.5)	98.5%, P < 0.0001	P < 0.0001
	Middle-income	374	1,175,838	19.6 (18.3–20.9)	99.6%, P < 0.0001
	High-income	184	539,079	25.8 (23.8–27.9)	99.6%, P < 0.0001
Age (month)	0–6	60	68,866	33.8 (30.3–37.4)	98.6%, P < 0.0001	P < 0.0001
	7–12	42	29,509	23.8 (19.5–28.3)	98.3%, P < 0.0001
	13–24	60	30,945	17.3 (14.4–20.4)	97.3%, P < 0.0001
	25–36	17	7329	10.4 (7.8–13.3)	80.7%, P < 0.0001
	37–48	13	5311	4.9 (2.1–8.5)	85.9%, P < 0.0001
	49–60	14	4232	1.8 (0.1–4.5)	77.7%, P < 0.0001
Age (year)	0–5	369	688,375	25.2 (23.9–26.6)	99.3%, P < 0.0001	P < 0.0001
	6–18	94	107,328	4.6 (3.7–5.6)	97.4%, P < 0.0001
Patient type	Outpatients	61	50,112	11.1 (9.2–13.2)	97.8%, P < 0.0001	P < 0.0001
	Inpatients	339	920,717	25.9 (24.2–27.7)	99.7%, P < 0.0001

Prevalence of hRSV infection among children with respiratory infections

The overall pooled prevalence of hRSV infection among 1,733,341 pediatric patients with respiratory infections was 21.6% (95% CI: 20.5%–22.6%; I² = 99.6%, P < 0.0001). The prevalence of hRSV varied significantly across different respiratory conditions (P < 0.0001). The highest prevalence of hRSV was observed in bronchiolitis (56.9%, 95% CI: 50.6%–63.2%), followed by wheezing (32.5%, 95% CI: 19.8%–46.7%), severe acute respiratory infection (SARI) (25.8%, 95% CI: 22.2%–29.5%), and pneumonia (22.5%, 95% CI: 20.4%–24.6%).

The prevalence of hRSV was the highest in studies conducted between 1991 and 2000 (31.0%, 95% CI: 21.6%–41.3%), followed by 2001–2010 (28.0%, 95% CI: 25.1%–31.0%). The differences between time periods were statistically significant (P < 0.0001). Additionally, the highest number of studies conducted (n = 294) and respiratory samples collected (n = 699,849) were recorded between 2011 and 2019.

The prevalence of hRSV was slightly higher in males (24.0%, 95% CI: 21.6%–26.5%) compared to females (22.9%, 95% CI: 20.5%–25.3%), but the difference was not statistically significant (P = 0.55). The highest prevalence of hRSV was observed in children aged 0–6 months (33.8%, 95% CI: 30.3%–37.4%), followed by 7–12 months (23.8%, 95% CI: 19.5%–28.3%). The differences between age groups were statistically significant (P < 0.0001). Overall, the prevalence of hRSV was significantly higher in children aged 0–5 years (25.2%, 95% CI: 23.9%–26.6%) compared to those aged 6–18 years (4.6%, 95% CI: 3.7%–5.6%) (P < 0.0001).

The prevalence of hRSV was higher among inpatients (25.9%, 95% CI: 24.2%–27.7%) compared to outpatients (11.1%, 95% CI: 9.2%–13.2%), with a statistically significant difference (P < 0.0001). In total, 37,536 hRSV positive samples were typed, among which 20,937 (55.7%) belonged to type A and 16,599 (44.3%) belonged to type B.

Geographic distribution of hRSV

Subgroup analysis of the prevalence of hRSV infection among pediatric patients with respiratory tract infection revealed considerable geographic variation in 97 countries, as shown in Table 3. Pooled estimates of prevalence varied greatly, ranging from 1.7% (95% CI: 0.2–6.1) in Burkina Faso to 79.8% (95% CI: 75.9–83.3) in Croatia, reflecting differing epidemiological patterns globally.

Table 3.

Subgroup analysis of the prevalence of hRSV infection among pediatric patients with respiratory tract infections based on geographic areas.

Country	No. of Studies	Total sample size	Pooled prevalence (%) (95% CI)	Heterogeneity test I2%, p-value
Albania	1	1032	42.4 (39.4–45.5)	NA
Algeria	1	117	47.8 (38.5–57.2)	NA
Argentina	1	619	25.5 (22.1–29.1)	NA
Australia	7	37,240	18.2 (10.2–27.9)	99.2%, P < 0.0001
Austria	2	777	7.2 (5.5–9.2)	NA
Bangladesh	6	5916	14.9 (10.5–20.0)	95.0%, P < 0.0001
Belgium	3	592	12.7 (4.8–23.6)	NA
Bhutan	1	921	25.0 (22.3–28.0)	NA
Bolivia	1	274	21.9 (17.1–27.2)	NA
Brazil	23	128,602	35.6 (31.8–39.5)	99.0%, P < 0.0001
Bulgaria	5	4519	24.9 (16.3–34.6)	97.7%, P < 0.0001
Burkina Faso	1	115	1.7 (0.2–6.1)	NA
Cambodia	2	1182	19.4 (17.2–21.8)	NA
Cameroon	1	347	13.2 (9.8–17.2)	NA
Cape Verde	2	225	20.6 (15.5–26.1)	NA
Central African Republic	2	4232	7.4 (6.7–8.3)	NA
China	120	834,429	15.1 (13.4–16.9)	99.7%, P < 0.0001
Colombia	4	2125	13.1 (6.3–21.9)	95.2%, P < 0.0001
Congo	2	146	20.2 (13.9–27.2)	NA
Costa Rica	1	379	4.2 (2.4–6.7)	NA
Croatia	1	486	79.8 (75.9–83.3)	NA
Cyprus	2	815	31.5 (28.3–34.7)	NA
Ecuador	2	1226	19.8 (17.6–22.0)	NA
Egypt	7	3696	21.8 (12.4–32.9)	97.1%, P < 0.0001
Ethiopia	4	5644	23.4 (18.3–29.0)	93.7%, P < 0.0001
Finland	4	2556	17.9 (11.3–25.4)	82.1%, P = 0.0008
France	5	14,309	38.3 (21.9–56.2)	99.6%, P < 0.0001
Gabon	2	1103	10.1 (8.4–12.0)	NA
Gambia	2	1254	26.7 (24.3–29.2)	NA
Germany	7	6724	24.5 (16.2–33.8)	98.5%, P < 0.0001
Ghana	8	4217	14.3 (9.1–20.6)	95.4%, P < 0.0001
Greece	4	2041	17.7 (9.7–27.4)	95.0%, P < 0.0001
Haiti	1	101	25.7 (17.5–35.4)	NA
Honduras	1	345	7.5 (4.9–10.8)	NA
India	32	16,146	20.3 (16.7–24.1)	97.0%, P < 0.0001
Indonesia	2	990	21.5 (19.0–24.1)	NA
Iran	22	4446	14.6 (9.7–20.2)	95.8%, P < 0.0001
Iraq	3	577	15.6 (9.5–22.8)	NA
Italy	24	89,204	25.5 (19.2–32.4)	99.7%, P < 0.0001
Ivory Coast	3	1529	12.7 (3.4–26.5)	NA
Japan	13	8423	29.0 (21.4–37.2)	98.3%, P < 0.0001
Jordan	4	4648	41.1 (34.8–47.6)	91.4%, P < 0.0001
Kenya	5	12,407	14.6 (5.9–26.5)	99.5%, P < 0.0001
Kuwait	1	367	25.6 (21.2–30.4)	NA
Laos	3	1064	17.8 (2.4–42.7)	NA
Latvia	1	207	42.5 (35.6–49.5)	NA
Lebanon	1	24	41.6 (22.1–63.3)	NA
Lithuania	2	12,141	7.0 (6.6–7.5)	NA
Madagascar	4	1299	24.6 (9.3–44.2)	97.8%, P < 0.0001
Malaysia	7	24,612	27.9 (19.3–37.4)	96.6%, P < 0.0001
Mali	1	118	25.4 (17.8–34.2)	NA
Mexico	5	2680	18.8 (8.7–31.7)	97.8%, P < 0.0001
Mozambique	2	896	24.7 (21.9–27.6)	NA
Mongolia	2	5813	36.6 (35.4–37.9)	NA
Morocco	7	4442	30.5 (25.4–35.8)	91.7%, P < 0.0001
Myanmar	1	570	45.9 (41.8–50.1)	NA
Nepal	5	7049	19.5 (8.1–34.4)	99.4%, P < 0.0001
Netherlands	11	2351	38.0 (21.4–56.2)	98.7%, P < 0.0001
New Guinea	1	167	13.1 (8.4–19.2)	NA
New Zealand	3	4889	37.3 (31.4–43.4)	NA
Nicaragua	1	936	22.2 (19.6–25.0)	NA
Niger	2	798	25.5 (22.5–28.6)	NA
Nigeria	1	231	17.7 (13.0–23.3)	NA
Norway	2	2352	42.8 (40.8–44.8)	NA
Pakistan	6	3257	32.0 (12.3–55.7)	99.2%, P < 0.0001
Paraguay	1	99	14.1 (7.9–22.5)	NA
Peru	3	942	14.6 (7.2–23.9)	NA
Philippines	7	10,633	18.5 (14.1–23.4)	97.2%, P < 0.0001
Poland	2	1196	6.3 (5.0–7.8)	NA
Portugal	3	1589	32.0 (2.9–73.4)	NA
Qatar	3	32,084	38.1 (16.9–62.0)	NA
Romania	2	1044	8.0 (6.4–9.7)	NA
Russia	3	4750	17.3 (9.0–27.6)	NA
Saudi Arabia	9	4180	22.5 (17.6–27.9)	91.3%, P < 0.0001
Senegal	5	3434	14.1 (11.0–17.6)	65.4%, P = 0.02
Sierra Leone	1	502	19.5 (16.1–23.2)	NA
Singapore	2	4519	7.9 (7.1–8.8)	NA
Slovenia	3	6701	16.0 (11.7–20.9)	NA
South Africa	8	20,181	24.8 (20.1–29.9)	97.8%, P < 0.0001
South Korea	9	63,366	19.2 (12.9–26.3)	99.7%, P < 0.0001
Spain	10	88,651	31.9 (22.3–42.3)	99.8%, P < 0.0001
Sri Lanka	1	325	28.6 (23.7–33.8)	NA
Sudan	1	368	7.0 (4.6–10.1)	NA
Suriname	1	316	33.8 (28.6–39.3)	NA
Switzerland	1	138	22.4 (15.8–30.3)	NA
Taiwan	5	1350	15.5 (9.3–22.9)	90.7%, P < 0.0001
Tanzania	3	2386	11.1 (0.0–36.3)	NA
Thailand	15	39,890	22.5 (18.7–26.5)	98.6%, P < 0.0001
Tunisia	2	887	33.8 (30.7–36.9)	NA
Turkey	21	8926	21.1 (14.6–28.4)	98.2%, P < 0.0001
United Arab Emirates	1	3098	17.1 (15.8–18.4)	NA
United Kingdom	6	65,055	29.9 (19.0–42.2)	97.8%, P < 0.0001
United States	28	71,365	30.1 (22.7–38.0)	99.7%, P < 0.0001
Ukraine	1	487	13.1 (10.2–16.4)	NA
Vietnam	7	5364	30.1 (24.4–36.2)	95.3%, P < 0.0001
Yemen	2	1205	42.3 (39.5–45.1)	NA
Zambia	2	3609	17.0 (15.8–18.2)	NA

In Africa, there was a range of prevalence of 1.7% (95% CI: 0.2–6.1) in Burkina Faso to 30.5% (95% CI: 25.4–35.8) in Morocco. Noteworthy is Algeria with 47.8% (95% CI: 38.5–57.2) with one study and sample of 117. In Senegal, it was more mid-range at a prevalence of 14.1% (95% CI: 11.0–17.6) with lower heterogeneity (I² = 65.4%, P = 0.02). This is in contrast to Kenya having a prevalence of 14.6% (95% CI: 5.9–26.5) and significant heterogeneity (I² = 99.5%, P < 0.0001), indicating that its five studies were different.

In the Americas, prevalence ranged from 4.2% (95% CI: 2.4–6.7) in Costa Rica to 35.6% (95% CI: 31.8–39.5) in Brazil. The United States had a combined prevalence of 30.1% (95% CI: 22.7–38.0) from 28 studies with high heterogeneity (I² = 99.7%, P < 0.0001). Brazil with 23 studies and 128,602 sample size also reported high heterogeneity (I² = 99.0%, P < 0.0001), which showed diverse infection rates within the country.

Among Asian countries included in the analysis, pooled prevalence rates varied widely, reflecting diverse epidemiological patterns. The highest pooled prevalence was observed in Myanmar at 45.9% (95% CI: 41.8–50.1), based on a single study with 570 participants, followed closely by Yemen at 42.3% (95% CI: 39.5–45.1) from two studies totaling 1205 individuals. In contrast, the lowest pooled prevalence was recorded in Singapore at 7.9% (95% CI: 7.1–8.8) across two studies with 4519 participants. Other notable high-prevalence countries included Jordan (41.1%, 95% CI: 34.8–47.6) and Mongolia (36.6%, 95% CI: 35.4–37.9), whereas relatively lower rates were seen in South Korea (19.2%, 95% CI: 12.9–26.3) and Taiwan (15.5%, 95% CI: 9.3–22.9), despite large sample sizes in some cases. High heterogeneity (I² > 90%, P < 0.0001) was common in countries with multiple studies, such as China, India, and Japan, underscoring significant variability in prevalence estimates across studies within the same nation.

Among European countries included in the analysis, pooled prevalence rates varied widely, reflecting diverse study populations and methodologies. Croatia reported the highest pooled prevalence at 79.8% (95% CI: 75.9–83.3) based on a single study of 486 participants, while Poland recorded the lowest at 6.3% (95% CI: 5.0–7.8) across two studies totaling 1196 individuals. High heterogeneity (I² > 95%, P < 0.0001) was observed in countries with multiple studies, such as France, Germany, Italy, and Spain, indicating substantial variation across individual studies within these nations.

Within Oceania, Australia's prevalence was reported at 18.2% (95% CI: 10.2–27.9) based on seven studies with high heterogeneity (I² = 99.2%, P < 0.0001) and New Zealand had a higher prevalence of 37.3% (95% CI: 31.4–43.4) based on three studies. Fig. 2 depicts the global distribution of hRSV infection among pediatric patients with respiratory infections.

Fig. 2.

The global map presents the geographical variations in the prevalence of hRSV infection among pediatric patients with respiratory infections in a period of 33 years.

The association between hRSV infection and respiratory infections among pediatric patients

The second meta-analysis, focusing on case–control studies, assessed the association between hRSV infection and the risk of respiratory infections among pediatric patients. A total of 33 datasets were included, comprising 18,345 pediatric patients with respiratory infections and 7975 controls. Using a random-effects model, the overall pooled odds ratio (OR) was calculated as 7.0 (95% CI: 5.1–9.6; I² = 77.4%, P < 0.0001), indicating a strong association between hRSV infection and increased risk of respiratory infections (Fig. 3).

Fig. 3.

Forest plot of the association between hRSV infection and respiratory infection risk in pediatric patients according to the random effect model using case case–control studies.

Subgroup analyses were conducted to explore this association further based on type of disease, economy classification, sample type, and sampling time. When stratified by type of disease, the pooled OR for SARI based on one dataset was 14.9 (95% CI: 8.2–27.0). For pneumonia, 13 datasets yielded a pooled OR of 7.6 (95% CI: 5.4–10.6; I² = 26.0%, P = 0.1).

When analyzed by sampling time, studies conducted between 2001 and 2010 (four datasets) had a pooled OR of 3.9 (95% CI: 1.3–11.9) with significant heterogeneity (I² = 88.3%, P < 0.0001). For the period of 2011–2019, 24 datasets yielded a pooled OR of 7.1 (95% CI: 5.5–9.1) with moderate heterogeneity (I² = 47.4%, P = 0.006). The most recent period, 2020 to 2024, based on five datasets, showed the highest pooled OR of 9.5 (95% CI: 3.9–23.1; I² = 69.7%, P = 0.01), suggesting a potentially stronger association in recent years, though limited by fewer studies. The subgroup analysis of the association between hRSV infection and the risk of respiratory infections among pediatric patients is presented in Table 4.

Table 4.

Subgroup analysis of association between hRSV infection and respiratory infections risk among pediatric patients.

Characteristics	Categories	No. of datasets	Pooled ORs (95% CI)	Heterogeneity: I2%, P value
Overall	–	33	7.0 (5.1–9.6)	77.4%, P < 0.0001
Economy classification	Low	4	9.5 (5.1–17.7)	34.7%, P = 0.2
	Middle	23	6.5 (4.3–9.7)	80.9%, P < 0.0001
	High	4	7.5 (3.1–18.1)	51.9%, P = 0.3
Sample type	NP	17	6.7 (4.8–9.3)	39.5%, P = 0.04
	Nasal	1	6.2 (1.4–27.2)	NA
	OP	2	6.7 (0.9–46.5)	87.4%, P = 0.005
	Throat	1	59.6 (3.5–996.6)	NA
Sample type (Overall)	URS	32	7.2 (5.2–9.9)	77.8%, P < 0.0001
	MRS	1	1.9 (0.4–8.3)	NA
Type of disease	Pneumonia	13	7.6 (5.4–10.6)	26.0%, P = 0.1
	SARI	1	14.9 (8.2–27.0)	NA
Sampling time	2001–2010	4	3.9 (1.3–11.9)	88.3%, P < 0.0001
	2011–2019	24	7.1 (5.5–9.1)	47.4%, P = 0.006
	2020–2024	5	9.5 (3.9–23.1)	69.7%, P = 0.01

We assessed publication bias with visual inspection of the funnel plot and statistical tests. The results showed evidence of publication bias for the association between hRSV infection and respiratory infection risk (P = 0.74, for Begg's adjusted rank correlation test and P = 0.014 for Egger's regression asymmetry test). Also, because of the potentially missing studies, the funnel plot looks fairly asymmetrical and strongly indicates publication bias. To identify and correct the publication bias, we used the trim-and-fill method, and 5 missing studies were identified (Fig. 4). After adjusting for missing studies with the ‘trim and fill’ method, the overall OR is estimated as 6.33 with a 95% confidence interval (CI) [4.65, 8.61]. Therefore, larger effects in the positive direction were likely favored in the publication process, and studies with smaller effects might be suppressed in the negative direction.

Fig. 4.

Funnel plots before (A) and after (B) applying the trim-and-fill method. The open dots indicate the observed studies, and the closed dots indicate the missing studies imputed by the trim-and-fill method.

Sensitivity analysis

In a sensitivity analysis by successively removing a particular study at a time to assess the influence of every single study on pooled results, a significant positive association [range of summary ORs 6.76–7.34] between hRSV infection and respiratory infections was observed consistently and did not alter the pooled results, which indicated that the meta-analysis model is robust.

Discussion

This systematic review and meta-analysis provide a comprehensive synthesis of the global prevalence of hRSV among pediatric patients with RTIs, drawing from 539 studies across 97 countries over a 33-year period (1992–2024). The findings reveal a significant global burden of hRSV, with pooled prevalence estimates varying widely from 1.7% in Burkina Faso to 79.8% in Croatia, highlighting substantial geographic heterogeneity. This variability aligns with previous research indicating that hRSV epidemiology is influenced by climatic, demographic, and healthcare-related factors.^3,5 The overall association between hRSV infection and increased risk of respiratory infections, with a pooled odds ratio (OR) of 7.0 (95% CI: 5.1–9.6), further underscores its role as a major contributor to pediatric respiratory morbidity worldwide.

The wide range of hRSV prevalence across countries underscores the complex interplay of environmental, demographic, and healthcare-related factors shaping its epidemiology. High prevalence rates in settings such as Croatia (79.8%), Algeria (47.8%), and Myanmar (45.9%) contrast sharply with low rates in Burkina Faso (1.7%), Costa Rica (4.2%), and Poland (6.3%). This variability aligns with established patterns of hRSV seasonality, where temperate regions experience peaks during colder months, and tropical areas see surges during rainy seasons.⁵ For instance, Myanmar's high prevalence may reflect increased transmission during monsoon periods, facilitated by indoor crowding and humidity, as noted in other tropical settings.⁴

Countries with multiple studies, such as China (15.1%, 120 studies), India (20.3%, 32 studies), and the United States (30.1%, 28 studies), exhibited extreme heterogeneity (I² > 97%), suggesting within-country variations driven by factors like urban-rural disparities, climate zones, or differences in diagnostic practices. For example, China's vast geographic and socioeconomic diversity likely contributes to its high heterogeneity, a pattern echoed in other large nations.⁸ These findings emphasize the need for region-specific data to inform targeted interventions, as blanket assumptions about hRSV prevalence may overlook critical local dynamics.

The prevalence of hRSV varied significantly across respiratory conditions (P < 0.0001), with bronchiolitis exhibiting the highest rate (56.9%, 95% CI: 50.6%–63.2%), followed by wheezing (32.5%, 95% CI: 19.8%–46.7%) and SARI (25.8%, 95% CI: 22.2%–29.5%). This pattern corroborates hRSV's well-established role as the primary cause of bronchiolitis in infants, often leading to hospitalization.² The elevated prevalence in wheezing and SARI further highlights its tropism for the lower respiratory tract, consistent with clinical observations of severe outcomes in young children.⁴ In contrast, lower rates in conditions like influenza-like illness (ILI; 13.7%, 95% CI: 11.5%–16.1%) suggest that hRSV is less dominant in milder or upper airway presentations, where other viruses like rhinovirus or influenza may predominate.¹ These differences underscore the need for disease-specific approaches in hRSV management, particularly targeting severe manifestations like bronchiolitis.

The temporal analysis revealed a declining trend in hRSV prevalence, from 31.0% (1991–2000) to 15.1% (2020–2024), with statistically significant differences (P < 0.0001). This decline may reflect several factors, including improved infection control measures, shifts in diagnostic practices, or changes in hRSV circulation patterns. The highest prevalence in the 1991–2000 period could be linked to less stringent public health interventions or limited awareness of hRSV's burden at the time, while the 2011–2019 period, with the most studies (n = 294) and samples (n = 699,849), likely benefits from enhanced surveillance and molecular diagnostics.⁵ The sharp drop in 2020–2024 aligns with the COVID-19 pandemic's impact, where non-pharmaceutical interventions (e.g., masking, social distancing) disrupted respiratory virus transmission, followed by altered resurgence patterns post-restrictions.⁶ This temporal shift warrants further investigation to distinguish between methodological artifacts and true epidemiological changes.

In the case of age-related differences, with the highest prevalence in children aged 0–6 months (33.8%, 95% CI: 30.3%–37.4%), decreasing progressively to 1.8% (95% CI: 0.1%–4.5%) by 49–60 months (P < 0.0001). The overall prevalence in children aged 0–5 years (25.2%, 95% CI: 23.9%–26.6%) far exceeded that in those aged 6–18 years (4.6%, 95% CI: 3.7%–5.6%), reflecting hRSV's disproportionate impact on infants and preschoolers. This age gradient is consistent with the virus's peak severity in early life, driven by immature immune responses and smaller airway diameters, which exacerbate disease progression.⁴

The prevalence was significantly higher among inpatients (25.9%, 95% CI: 24.2%–27.7%) than outpatients (11.1%, 95% CI: 9.2%–13.2%; P < 0.0001), highlighting hRSV's association with severe disease requiring hospitalization. This disparity underscores its role as a major driver of healthcare utilization, particularly in young children with LRIs or bronchiolitis.² Among typed samples, hRSV-A predominated (55.7%) over hRSV-B (44.3%), consistent with global patterns where subtype A often circulates more frequently, though subtype B can dominate in certain seasons or regions.⁶⁶ This distribution has implications for vaccine development, as antigenic differences between subtypes may influence efficacy.⁹

Separate pooled prevalence estimates were calculated for peak-season and year-round studies using random-effects models. As expected, pooled prevalence was higher among peak-season studies compared to year-round studies. This reflects concentration of RSV detection during epidemic periods rather than a true difference in underlying annual burden. Therefore, peak-season prevalence should not be interpreted as annual prevalence.

The 21.6% pooled prevalence and its variation across subgroups emphasize hRSV's global significance, particularly in early childhood. The high burden in infants and inpatients supports the prioritization of preventive strategies, such as the monoclonal antibody nirsevimab, which has demonstrated efficacy in reducing severe RSV outcomes.⁹ Vaccine candidates in late-stage trials further heighten the need for accurate prevalence data to guide deployment, especially in high-risk groups like those under 12 months.⁸ The declining prevalence in recent years suggests that public health measures can mitigate transmission, offering lessons for future respiratory virus control. However, the higher burden in low-resource settings, inferred from inpatient rates, calls for enhanced diagnostic and surveillance capacity in LMICs to address underreporting.⁴

The findings of this meta-analysis underscore a robust association between hRSV infection and an increased risk of respiratory infections among pediatric patients, with an overall pooled odds ratio (OR) of 7.0 (95% CI: 5.1–9.6). This result aligns with previous evidence demonstrating hRSV as a major cause of ARI, pneumonia, and LRI in children globally. The consistency of this association across various subgroup analyses, which were stratified by economy classification, sample type, type of disease, and sampling time. This further reinforces the critical role of hRSV in pediatric respiratory morbidity.

Subgroup analysis by disease type revealed varying degrees of association, with SARI exhibiting the highest pooled OR of 14.9 (95% CI: 8.2–27.0), followed by pneumonia (OR: 7.6, 95% CI: 5.4–10.6). These findings are consistent with recent studies, such as Li et al.,⁵ which reported hRSV as a predominant etiologic agent in severe LRI cases among children under five years of age, often necessitating hospitalization. The higher OR for LRI may reflect the virus's tropism for the lower respiratory tract, leading to more severe clinical outcomes such as bronchiolitis and pneumonia, which are well-documented complications of hRSV infection.²

This study has several important limitations that should be acknowledged when interpreting the findings. First, despite extensive subgroup analyses, substantial heterogeneity was observed across studies (overall I² > 99% for prevalence estimates), likely arising from differences in case definitions, testing indications, healthcare settings (inpatient vs. outpatient), seasonal timing, specimen types, and PCR assay performance. Although we restricted inclusion to PCR-confirmed cases to improve comparability, residual heterogeneity persists and may affect the precision of pooled estimates.

Second, although PCR is currently the gold-standard diagnostic method for hRSV, variability in assay sensitivity (primer targets, amplification platforms, and viral load thresholds) and differences in specimen collection (nasopharyngeal vs. nasal vs. throat swabs) across three decades of studies may have introduced modest detection bias. While restriction to molecular methods markedly reduced misclassification compared with older antigen-based tests, very early studies (pre-2010) using less sensitive first-generation PCR assays might slightly underestimate true prevalence, whereas recent multiplex panels could marginally overestimate it by detecting low-level or prolonged shedding.

Third, a large proportion of included studies were conducted in hospitalized children or those with severe disease, which likely overestimates hRSV prevalence and attributable risk in the broader community and outpatient settings. Conversely, in many low- and middle-income countries, especially in sub-Saharan Africa and parts of South Asia, access to PCR testing remains limited, leading to under-representation of these regions and potentially underestimating the true global burden in settings where hRSV mortality is highest.

Fourth, restriction to English-language publications and exclusion of gray literature and conference abstracts may have introduced language and publication bias, as suggested by funnel-plot asymmetry and statistical tests. Although trim-and-fill adjustment was applied, small studies with low or null prevalence may still be under-represented.

Fifth, the apparent temporal increase in the strength of association (pooled OR rising from 3.9 in 2001–2010 to 9.5 in 2020–2024) cannot be fully disentangled from improvements in diagnostic sensitivity over time vs. genuine epidemiological or virological changes. Similarly, the marked decline in hRSV detection during 2020–2024 and subsequent rebound reflect the profound impact of COVID-19 non-pharmaceutical interventions rather than long-term secular trends.

Additionally, due to inconsistent or incomplete reporting of the exact month/season of sample collection in many included studies, we were unable to perform a reliable subgroup analysis by season (e.g., winter vs. rainy season in tropical climates). This is an important limitation, as hRSV circulation is highly seasonal and prevalence can vary several-fold between peak and off-season periods, potentially masking true regional and climatic differences in our global pooled estimates.

In conclusion, this systematic review and meta-analysis, the first of its kind to comprehensively assess the global prevalence of hRSV among children with RTIs, reveals a pooled prevalence of 22.7% across 846,678 pediatric patients. The findings affirm hRSV as a major contributor to pediatric respiratory morbidity, with a pronounced burden in infants aged 0–6 months (35.3%) and inpatients (27.9%), particularly those with bronchiolitis (57.8%). The significant association with severe respiratory diseases, evidenced by a pooled odds ratio (OR) of 7.0, and up to 14.9 for SARI, underscores hRSV's role in driving hospitalization and healthcare utilization worldwide. The study highlights substantial regional, temporal, and demographic variations, with prevalence declining from 31.0% (1991–2000) to 15.1% (2020–2024), potentially reflecting the impact of improved diagnostics, public health measures, and the COVID-19 pandemic's disruption of viral transmission. The predominance of hRSV-A (55.7%) over hRSV-B (44.3%) informs vaccine and therapeutic design, while the higher burden in low- and middle-income countries (LMICs) signals a need for enhanced surveillance and resource allocation. These insights emphasize the urgency of advancing targeted prevention strategies, such as vaccines and monoclonal antibodies, particularly for high-risk groups like infants and hospitalized children.

Contributors

A.T designed and administrated the study. H.S and S.G performed all statistical analyses. P.K, M.H.R, Z.S, M.V, and S.G performed search strategy and data extraction and A.T and S.G verified the data. P.K and AT wrote the initial draft. M.H.R and H.S constructed all maps and graphs. A.M and A.T performed intellectual interpretation. All authors read and approved the final draft.

Data sharing statement

All data included in this study are available upon request from the corresponding author.

Editor note

The Lancet Group takes a neutral position with respect to territorial claims in published maps and institutional affiliations.

Declaration of interests

The authors have no competing interests.