HEALTH ADVISORY #320
September 12, 2014
ENTEROVIRUS D68
Please distribute to Healthcare Facilities, Infection Control Department, Emergency Department, Infectious Disease Department, Director of Nursing, Medical Director, Laboratory Service, and all patient care areas.
SUMMARY
- Enterovirus D68 (EV-D68) is a type of non-polio enterovirus. Recently, infections in pediatric patients, including some severe infections, have been reported to the Centers for Disease Control and Prevention (CDC) from twelve states, most of them located in the Midwest.
- While providers are not required to report individual cases of suspected or confirmed enterovirus infection, including EV-D68 infection, existing New York State Department of Health (NYSDOH) surveillance systems maintain the capacity to identify unusual increases in the number of individuals seeking care in emergency departments for respiratory illness and outbreaks, unusual presentations or severity of communicable diseases.
- Testing for non-polio enteroviruses is commercially available. Public Health Laboratory testing at the NYSDOH Wadsworth Center is generally reserved for outbreaks.
- Thorough hand washing, respiratory etiquette, and surface disinfection can help reduce the risk of infection with EV-D68 and other respiratory and enteroviruses.
- NYSDOH encourages medical providers in Erie County to report outbreaks or unusual clusters or presentations of respiratory illness to the Erie County Department of Health (ECDOH) so that they may be investigated and their etiology confirmed.
BACKGROUND
In August 2014, hospitals in Kansas City, MO and Chicago, IL notified CDC of an increase in severe respiratory illness among children seen in their emergency departments and admitted to their facility. Testing by CDC identified EV-D68 in specimens from patients in both hospitals.
Since then, ten additional states have reported pediatric respiratory illness outbreaks to CDC. Results of specimen testing from these outbreaks are pending.
CDC, NYSDOH and other state public health departments are working together to gather information to better understand EV-D68 and the illness caused by this virus; how widespread EV-D68 infections may be and the populations impacted; and whether other states are noting an increased incidence of severe respiratory illness, possibly due to EV-D68.
EPIDEMIOLOGY
Non-polio enteroviruses are common, causing between 10 to 15 million infections in the U.S. each year. Most occur during the summer and fall and may cause respiratory illness, febrile rash, aseptic meningitis or encephalitis. The majority of individuals infected with non-polio enteroviruses do not become symptomatic or only have mild illness. However, infants, children, and teenagers are at increased risk because they have not yet acquired immunity from previous exposures.
EV-D68 is one of many non-polio enteroviruses and is thought to occur less commonly than other enteroviruses. The virus can be found in respiratory secretions such as saliva, nasal mucus, or sputum of ill persons. EV-D68 is less studied than other enteroviruses. While the ways it is transmitted is not well understood, the virus is thought to spread from person to person when an infected person coughs, sneezes, or touches contaminated surfaces.
CLINICAL INFORMATION
EV-D68 primarily causes respiratory illness, although the full spectrum of disease remains unclear. As with other non-polio enteroviruses, many infections will be mild and self-limited, requiring only symptomatic care. However, some people with severe respiratory illness may need to be hospitalized and receive intensive supportive therapy. There is no specific treatment for EV-D68 infections.
Providers should consider EV-D68 as a potential cause of clusters of severe respiratory illness, particularly in young children. Symptoms in severe cases reported from the recent clusters in Kansas City and Chicago included difficulty breathing, hypoxemia and wheezing. More than half of these severe cases occurred in patients with a previous history of asthma or wheezing. A majority of patients in these clusters were afebrile.
LABORATORY TESTING
Laboratory testing of respiratory specimens for enteroviruses should be considered when the cause of infection in severely ill patients is unclear. EV-D68 can be detected in respiratory specimens, such as nasopharyngeal swabs (NPS), oropharyngeal swabs (OPS) and sputum. Respiratory specimens should be referred for enterovirus testing via the usual internal route for laboratory test requests at each facility. Infection with enteroviruses can be identified by virus culture and immunofluorescent staining or other confirmation technique, or by reverse transcription-polymerase chain reaction (RT-PCR) directly on specimens. It should be noted that most molecular enterovirus assays available at hospital, clinical, and commercial laboratories do not distinguish the enterovirus type. Additionally, many cannot distinguish enteroviruses from rhinoviruses, and some are only FDA-approved or validated for non-respiratory specimen types. Further, some tests have been demonstrated to be insensitive for the detection of EV-D68. Information needed on the specific test characteristics of the assay used at a facility should be obtained from that laboratory. However, it should be noted that distinguishing EV-D68 from any other enterovirus or rhinovirus infection, will generally have no impact on patient management.
The NYSDOH Wadsworth Center (WC) Virology Laboratory is CLEP-approved to perform enterovirus molecular typing, including for EV-D68, by conventional RT-PCR and dideoxysequencing. In order to assist in monitoring the current outbreak, selected specimens are being accepted at the WC Virology Laboratory for testing.
Acceptable specimens are:
respiratory tract specimens or cultured viral isolates that have tested positive for enterovirus or enterovirus/rhinovirus OR
- If enterovirus typing is being requested, the name of the enterovirus screening assay must be indicated on the Wadsworth Infectious Disease Requisition form. Preferred sample volume is ≥ 1.0 mL, minimum required volume is .5 mL. Specimens must be accompanied by a completed Infectious Disease Requisition
- or requested by remote order for facilities with appropriate electronic access. Providers with questions regarding enterovirus typing can contact WC Virology laboratory at (518) 474-4177.
- Turnaround time for typing results is approximately one week.
PREVENTION
Vaccines against EV-D68 infections are not available. Providers should work with their asthmatic patients to help achieve optimal control of their condition. Additionally, the following actions can help protect patients from EV-D68 and other respiratory illnesses:
- Wash hands often with soap and water for 20 seconds, especially after changing diapers
- Avoid touching eyes, noses and mouths with unwashed hands
- Avoid kissing, hugging, and sharing cups or eating utensils with people who are ill
- Cover mouths and noses when coughing or sneezing
- Disinfect frequently commonly touched surfaces, such as toys and doorknobs, especially when someone is ill.
REPORTING
While providers are not required to report individual cases of suspected or confirmed EV-D68 infection, outbreaks or unusual presentations are reportable to the LHD where the patient resides. Providers can contact the Erie County Department of Health at 716-858-7697 during business hours or at 716-961-7898 evenings, weekends and holidays.
ADDITIONAL INFORMATION
Additional information and guidance about non-polio enteroviruses is available from CDC at http://www.cdc.gov/non-polio-enterovirus/about/EV-D68.html.
Health Category Definitions:
Health Alert FLASH: conveys the highest level of importance due to a large-scale, catastrophic public health emergency; warrants immediate action or attention
Health Alert Priority: conveys the highest level of importance; warrants immediate action or attention to a health problem or situation
Health Advisory: provides important information for a specific incident or situation; may not require immediate action
Health Update: provides updated information regarding an incident or situation; no immediate action necessary
The Erie County Department of Health does not provide medical advice. The information provided on the Erie County Department of
Health website is not an attempt to practice medicine and is not intended as a substitute for professional medical advice, diagnosis,
or treatment. It is for informational purposes only. Always seek the advice of your personal physician or other qualified health
provider with any questions you may have regarding a medical condition or issue. Never disregard professional medical advice or
delay in seeking it because of the content found on the Erie County Department of Health website or this correspondence.
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