EV-D68

7 10 2014

We were writing an update on EV-D68 when this email arrived from CDC. We think the points are important for parents to know, so we’re going to share this with you and will provide future updates as warranted.

As parents, we’re all concerned about this virus which isn’t really new, but has captured the nation’s attention. If you have questions, please ask them in the comments and we’ll get answers for you.

[This information is current as of 23 October, 2014 and has been slightly edited for length (believe it or not). The bold text includes the latest updates]:

The United States is currently experiencing a nationwide outbreak of enterovirus D68 (EV-D68) associated with severe respiratory illness.

From mid-August to October 23, 2014, CDC or state public health laboratories have confirmed a total of 973* people in 47 states and the District of Columbia with respiratory illness caused by EV-D68.** This indicates that at least one case has been detected in each of those states but does not indicate how widespread infections are in each state.

In the United States, people are more likely to get infected with enteroviruses in the summer and fall. We are currently in the middle of the enterovirus season. EV-D68 infections are likely to decline later in fall.

For the week of October 8-12, 34 states reported to CDC that EV-D68-like illness activity is low or declining; 8 still have elevated activity, and only 1 has increasing activity.

Many state health departments are currently investigating reported increases in cases of severe respiratory illness in children. This increase could be caused by many different viruses that are common during this time of year. EV-D68 appears to be the predominant type of enterovirus this year and is likely contributing to the increases in severe respiratory illnesses.

Due to increasing knowledge about the nationwide EV-D68 outbreak, there has been a very large increase in the number of specimens tested from patients with severe respiratory illness. Awareness of these initial results is also contributing to increased recognition of new cases.

CDC is prioritizing testing of specimens from children with severe respiratory illness. There are likely many children affected with milder forms of illness.

Of the more than 1,700 specimens tested by the CDC lab, about half have tested positive for EV-D68. About one third have tested positive for an enterovirus or rhinovirus other than EV-D68. Almost all of the CDC-confirmed cases this year of EV-D68 infection have been among children. Many of the children had asthma or a history of wheezing.

CDC has developed, and started using on October 14, a new, faster lab test for detecting EV-D68, allowing CDC to rapidly process in about seven to 10 days the more than 1,000 remaining specimens received since mid-September. As a result, the number of confirmed EV-D68 cases will likely increase substantially in the coming days. These increases will not reflect changes in real time or mean the situation is getting worse.

As a result, confirmed cases increased today and will likely continue to increase in coming days. This does not mean the situation is getting worse.

Faster testing will help to better show the trends of this outbreak since August and to monitor changes occurring in real time.

EV-D68 has been detected in specimens from eight*** patients who died and had samples submitted for testing.

CDC is reporting the test results to state health departments as we obtain them. State and local officials have the authority to determine the cause of death, the appropriate information to release, and the time to release it. CDC will defer to states to provide this information.

So far, state and local officials have reported that two of these deaths were caused by EV-D68.

CDC will post updated data to the website every Thursday.

CDC understands that Americans may be concerned about these severe respiratory illnesses and the new reports of neurological illness. Severe illness is always a concern to us, especially when infants and children are affected. We will share information as soon as we have it, and post updates on our website (http://www.cdc.gov/non-polio-enterovirus/outbreaks/EV-D68-outbreaks.html).

Clinicians should consider EV-D68 as a possible cause of severe respiratory illness, particularly in children, and report unusual increases in the number of patients with severe respiratory illness to their health department.

The general public can help protect themselves from respiratory illnesses by washing hands with soap and water, avoiding close contact with sick people, and disinfecting frequently touched surfaces. Anyone with respiratory illness should contact their doctor if they are having difficulty breathing, or if their symptoms are getting worse.

*Total confirmed case count includes results from State Public Health Laboratories that can do testing to determine type of enterovirus.
**The primary reason for current increases in cases is that a backlog of specimens is being processed from several states that are investigating clusters of people with severe respiratory illness. It can take a while to test specimens and obtain lab results because the testing is complex and slow, and can only be done by CDC and a small number of state public health laboratories. These increases will not necessarily reflect changes in real time, or mean that the situation is getting worse.
***Investigations are ongoing; CDC will review and update available data every Wednesday.

 

BACKGROUND

Enteroviruses are very common viruses; there are more than 100 types.

It is estimated that 10 to 15 million enterovirus infections occur in the United States each year. Tens of thousands of people are hospitalized each year for illnesses caused by enteroviruses.

Different enteroviruses can cause different illnesses, such as respiratory, febrile rash, and neurologic [e.g., aseptic meningitis (swelling of the tissue covering the brain and spinal cord) and encephalitis (swelling of the brain)].

In general, the spread of enteroviruses is often quite unpredictable. A mix of enteroviruses circulates every year, and different types of enteroviruses can be common in different years.

In the United States, people are more likely to get infected with enteroviruses in the summer and fall.

 

Enterovirus D68

EV-D68 was first recognized in California in 1962. Small numbers of EV-D68 have been reported regularly to CDC since 1987. However, this year the number of people with confirmed EV-D68 infections is much greater than that reported in previous years.

The strains of EV-D68 circulating this year are not new.

CDC, working with state health departments, has identified at least three separate strains of EV-D68 that are causing infections in the United States this year; the most prominent strain is related to the strains of EV-D68 that were detected in the United States in 2012 and 2013.

There is no evidence that unaccompanied children brought EV-D68 to the United States; we are not aware of any of these children testing positive for the virus.

It is common for multiple strains of the same enterovirus type to be co-circulating in the same year.

Respiratory illnesses can be caused by many different viruses and have similar symptoms. Not all respiratory illnesses occurring now are due to EV-D68.

EV-D68 has been previously referred to as human enterovirus 68 (or HEV-68) and human rhinovirus 87 (or HRV-87). They are all the same virus. The D stands for enterovirus species D.

 

SYMPTOMS

EV-D68 infections can cause mild to severe respiratory illness, or no symptoms at all.

Mild symptoms may include fever, runny nose, sneezing, cough, and body and muscle aches.

Severe symptoms may include wheezing and difficulty breathing.
Anyone with respiratory illness should contact their doctor if they are having difficulty breathing, or if their symptoms are getting worse.

Enteroviruses are known to be one of the causes of acute neurologic disease in children. They most commonly cause aseptic meningitis, less commonly encephalitis, and rarely, acute myelitis and paralysis.

CDC is aware of two published reports of children with neurologic illnesses confirmed as EV-D68 infection from cerebrospinal fluid (CSF) testing.

 

PEOPLE AT RISK

In general, infants, children, and teenagers are most likely to get infected with enteroviruses and become sick. That’s because they do not yet have immunity (protection) from previous exposures to these viruses. We believe this is also true for EV-D68. Adults can get infected with enteroviruses, but they are more likely to have no symptoms or mild symptoms.

Children with asthma may have a higher risk for severe respiratory illness caused by EV-D68 infection.

 

TRANSMISSION

Since EV-D68 causes respiratory illness, the virus can be found in an infected person’s respiratory secretions, such as saliva, nasal mucus, or sputum.

The virus likely spreads from person to person when an infected person coughs, sneezes, or touches a surface that is then touched by others.

Diagnosis

EV-D68 can only be diagnosed by doing specific lab tests on specimens from a person’s nose and throat.

Many hospitals and some doctor’s offices can test sick patients to see if they have enterovirus infection. However, most cannot do specific testing to determine the type of enterovirus, like EV-D68. CDC and some state health departments can do this sort of testing.

CDC recommends that clinicians only consider EV-D68 testing for patients with severe respiratory illness and when the cause is unclear.

 

TREATMENT

There is no specific treatment for people with respiratory illness caused by EV-D68 infection.

For mild respiratory illness, you can help relieve symptoms by taking over-the-counter medications for pain and fever. Aspirin should not be given to children.

Some people with severe respiratory illness caused by EV-D68 may need to be hospitalized and receive intensive supportive therapy.

There are no antiviral medications are currently available for people who become infected with EV-D68.

 

PREVENTION

You can help protect yourself from getting and spreading EV-D68 by following these steps:

  • Wash hands often with soap and water for 20 seconds
  • Avoid touching eyes, nose and mouth with unwashed hands
  • Avoid close contact such as kissing, hugging, and sharing cups or eating utensils with people who are sick, or when you are sick
  • Cover your coughs and sneezes with a tissue or shirt sleeve, not your hands
  • Clean and disinfect frequently touched surfaces, such as toys and doorknobs, especially if someone is sick
  • Stay home when you are sick
  • There are no vaccines for preventing EV-D68 infections.

Children with asthma are at risk for severe symptoms from EV-D68 and other respiratory illnesses. They should follow CDC’s guidance to maintain control of their illness during this time:

  • Discuss and update your asthma action plan with your primary care provider.
  • Take your prescribed asthma medications as directed, especially long term control medication(s).
  • Be sure to keep your reliever medication with you.
  • Get a flu vaccine when available.
  • If you develop new or worsening asthma symptoms, follow the steps of your asthma action plan. If your symptoms do not go away, call your doctor right away.
  • Parents should make sure the child’s caregiver and/or teacher is aware of his/her condition, and that they know how to help if the child experiences any symptoms related to asthma.

 

WHAT IS CDC DOING

CDC continues to collect information from states and assess the situation to better understand  EV-D68 and the illness caused by this virus and how widespread EV-D68 infections may be within states and the populations affected.

CDC is helping states with diagnostic and molecular typing for EV-D68.

We are working with state and local health departments and clinical and state laboratories to enhance their capacity to identify and investigate outbreaks, and perform diagnostic and molecular typing tests to improve detection of enteroviruses and enhance surveillance.

CDC has developed, and started using on October 14, a new, faster lab test for detecting EV-D68 in specimens from people in the United States with respiratory illness. CDC will provide protocols to state public health labs and explore options for providing test kits.

CDC’s new lab test is a “real-time” reverse transcription polymerase chain reaction, or rRT-PCR, and it identifies all strains of EV-D68 that we have been seeing this summer and fall. The new test has fewer and shorter steps than the test that CDC and some states were using previously during this EV-D68 outbreak. This will allow CDC to test and report results for new specimens within a few days of receiving them.

The previous test, which CDC used for about nine years,  is very sensitive and can be used to detect and identify almost all enteroviruses; however, it requires multiple, labor-intensive processing steps and cannot be easily scaled up to support testing of large numbers of specimens in real time that is needed for the current EV-D68 outbreak.

We are providing information to healthcare professionals, policymakers, general public, and partners in numerous formats, including Morbidity and Mortality Weekly Reports (MMWRs), health alerts, websites, social media, podcasts, infographics, and presentations.

CDC has obtained one complete genomic sequence and six partial genomic sequences from viruses, representing the three known strains of EV-D68 that are causing infection at this time.

Comparison of these sequences to sequences from previous years shows they are genetically related to strains of EV-D68 that were detected in previous years in the United States, Europe, and Asia.

CDC has submitted the sequences to GenBank to make them available to the scientific community for further testing and analysis.

 

GUIDANCE FOR CLINICIANS

Clinicians should:

  • consider EV-D68 as a possible cause of acute, unexplained severe respiratory illness, even if the patient does not have fever.
  • report suspected clusters of severe respiratory illness to local and state health departments. EV-D68 is not nationally notifiable, but state and local health departments may have additional guidance on reporting.
  • consider laboratory testing of respiratory specimens for enteroviruses when the cause of respiratory illness in severely ill patients is unclear.
  • consider testing to confirm the presence of EV-D68. State health departments can be approached for diagnostic and molecular typing for enteroviruses.
  • contact your state or local health department before sending specimens for diagnostic and molecular typing.
  • follow standard, contact, and droplet infection control measures

The antiviral drugs pleconaril, pocapavir, and vapendavir, have significant activity against a wide range of enteroviruses and rhinoviruses. CDC has tested these drugs for activity against currently circulating strains of enterovirus D68 (EV-D68), and none of them has activity against EV-D68 at clinically relevant concentrations.

 

SURVEILLANCE

U.S. healthcare professionals are not required to report known or suspected cases of EV-D68 infection to health departments because it is not a nationally notifiable disease in the United States. Also, CDC does not have a surveillance system that specifically collects information on EV-D68 infections.

No data is currently available regarding the overall burden of morbidity or mortality from EV-D68 in the United States. Any data CDC receives about EV-D68 infections or outbreaks are voluntarily provided by labs to CDC’s National Enterovirus Surveillance System (NESS). NESS collects limited data, focusing on circulating types of enteroviruses and parechoviruses.

For a large image and details of EV-D68-like illness activity in states, see http://www.cdc.gov/non-polio-enterovirus/outbreaks/EV-D68-activity.html.

MORE INFORMATION

CDC Enterovirus D68 in the United States, 2014 website: http://www.cdc.gov/non-polio-enterovirus/outbreaks/EV-D68-outbreaks.html

CDC Enterovirus D68 general website: http://www.cdc.gov/non-polio-enterovirus/about/EV-D68.html

CDC Enterovirus D68 for Health Care Professionals website: http://www.cdc.gov/non-polio-enterovirus/hcp/EV-D68-hcp.html

CDC Activity of Enterovirus D68-like Illness in States website: http://www.cdc.gov/non-polio-enterovirus/outbreaks/EV-D68-activity.html  

CDC What Parents Need to Know about Enterovirus D68 webpage: http://www.cdc.gov/features/evd68/

Enterovirus D68 in the United States: Epidemiology, Diagnosis & Treatment, COCA Call, September 16, 2014 (http://www.bt.cdc.gov/coca/calls/2014/callinfo_091614.asp)

Severe Respiratory Illness Associated with Enterovirus D68 – Multiple States, 2014, Health Alert Network, September 12, 2014 (http://emergency.cdc.gov/han/han00369.asp)

Severe Respiratory Illness Associated with Enterovirus D68 – Missouri and Illinois, 2014, MMWR, September 8, 2014 (http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6336a4.htm?s_cid=mm6336a4_w)

Clusters of Acute Respiratory Illness Associated with Human Enterovirus 68 — Asia, Europe, and United States, 2008–2010, MMWR, September 30, 2011 (http://www.cdc.gov/mmwR/preview/mmwrhtml/mm6038a1.htm)





Your Student Athlete

27 08 2013

Kids are back in school and signing up for sports.

Some parents wonder about their infected children playing sports and possibly infecting others in the process.  Parents also wonder how concerned they should be about their children becoming infected from other players living with undiagnosed or undisclosed infections.

Playing sports can be risky in many ways and part of that risk is the potential to become infected with all sorts of germs.

Parents of children living with diagnosed infectious diseases worry that they may be responsible for infecting another child.  They wonder if they should inform the coach or the school.  They worry that the adults in charge don’t really follow standard precautions, thereby increasing the risk of infections.  They want their kids to enjoy life and they want to do the right thing.

The American Academy of Pediatrics issued a policy statement on this dilemma in December, 1999: HIV and Other Blood-Borne Viral Pathogens in the Athletic Setting. In it, the Academy made clear, “Because of the low probability of transmission of their infection to other athletes, athletes infected with HIV, hepatitis B or hepatitis C should be allowed to participate in all sports.”

The AAP’s Redbook still supports this policy.

Participation, however, assumes all athletes and coaches will follow standard precautions to prevent and minimize exposure to bloodborne viruses.

There is no reason to exclude any student from sports if they’re infected with HIV, HBV or HCV.  Nor is there a reason to disclose the infection.  There are many people living with undiagnosed infections, so it is more prudent to ensure everyone is practicing standard precautions rather than simply excluding those with known infections and not properly protecting all athletes from undiagnosed infections.

Dr. Steven J. Anderson, a pediatrics professor at the University of Washington and a team doctor for many high school athletic teams, ballet companies and the U.S. Olympic Diving Team, suggests children should have access to any sport, except boxing, which the Academy opposes for all youths because of its physical risks.

Pediatricians can avoid reporting a student’s infection, the Academy noted, by making it clear on any participation forms that they support the Academy’s position that all students can participate in all sports and that pediatricians must respect an athlete’s right to confidentiality.

But strict compliance with standard precautions is critical for this open embrace of all athletes, regardless of their infectious status.  Dr. Anderson notes that, as a parent, he would make sure that there is a plan in place to handle blood spills, including latex gloves, occlusive dressings, appropriate sterilizing solutions, disposal bags and even a printed protocol for coaches, athletes and officials.

Dr. Anderson does feel that students with infectious hepatitis A (spread through close physical contact with contaminated food, water or skin) or with liver or spleen enlargement should be restricted from contact or collision sports until the liver or spleen has returned to normal size, and the person is no longer contagious.

An article that ran in 2004 in the British Journal of Sports Medicine talked about possible methods of transmission in sports and reported incidents of transmission:

Bleeding or oozing injuries could, in theory, transmit the virus through the mucous membrane or injured skin of other athletes.  This risk is considered extremely low.  However, contact and collision sports like wrestling or boxing increase that risk.  The risk goes down a bit for those playing basketball or soccer, and those playing sports with little physical contact, such as tennis or baseball, are at the lowest risk.

It has been suggested that bloodborne infections may be transmitted through sharing a water container, because bleeding around the mouth is common in contact sport.  Therefore it is recommended that water containers should be available individually for each player in contact sports. Athletes should use squeeze water bottles which they do not put in their mouth.

Bloodborne infections can be transmitted through blood doping. There is also a risk from sharing needles which may be associated with drug abuse in sport. Injectable drugs used in sports include steroids, hormones, and vitamins.

Three separate cases of HIV infection associated with sharing needles among bodybuilders have been reported, two in the United States and one in France.  It has also been reported that three soccer players from one amateur club were infected with HCV as a result of sharing a syringe to inject intravenous vitamin complexes. Syringes have often been shared by athletes who inject vitamins minutes before a game.

A 1993 study estimated that, in the United States, there were one million people who were either current or past users of anabolic androgenic steroids. Of these, 50% were intramuscular drug users, and about 25% had shared needles. Therefore it seems that the risk of transmission in this way may be considerable among athletes, especially bodybuilders.

So, if your family is getting involved in sports, it would be worth your time to:

  • Get caught up on all vaccinations
  • Practice standard precautions
  • Wash your hands a lot or, if hands aren’t visibly soiled, use alcohol handrubs
  • Don’t share needles with anyone for any purpose




Sports and Infectious Diseases – Part 2 of 3

10 04 2013

bloodborneWhat risk does an athlete with a bloodborne pathogen pose?

The American Academy of Pediatrics tackled this difficult issue in December, 1999, with a policy statement on HIV and Other Bloodborne Viral Pathogens in the Athletic Setting.  In it, the Academy made clear, “Because of the low probability of transmission of their infection to other athletes, athletes infected with HIV, hepatitis B or hepatitis C should be allowed to participate in all sports.”

That participation, however, assumes all athletes and coaches will follow standard precautions to prevent and minimize exposure to bloodborne viruses.  The Academy tackled each infectious disease individually:

HIV: The risk of HIV infection via skin or mucous membrane exposure to blood or other infectious bodily fluids during sports participation is very low . . . such transmission appears to require, in addition to a portal of entry, prolonged exposure to large quantities of blood.  Transmission through intact skin has not been documented: no HIV infections occurred after 2,712 such exposures in 1 large prospective study.  Transmission of HIV in sports has not been documented.  One unsubstantiated report describes possible transmission during a collision between professional soccer players.

Hepatitis B: HBV [hepatitis B virus] is more easily transmitted via exposure to infected blood than is HIV . . . the risk of infection [is] greater if the blood [is] positive for HBV e antigen . . . transmission of infection by contamination of mucous membranes or broken skin with infected blood has been documented, but the magnitude of risk has not been quantified.

Although transmission of HBV is apparently rare in sports, 2 reports document such transmission.  An asymptomatic high school sumo wrestler who had a chronic infection transmitted HBV to other members of his team.  An epidemic of HBV infection occurred through unknown means among Swedish athletes participating in track finding (orienteering).  The epidemiologists concluded that the most likely route of infection was the use of water contaminated with infected blood to clean wounds caused by branches and thorns.

An effective way of preventing HBV transmission in the athletic setting is through immunization of athletes.  The American Academy of Pediatrics (AAP) recommends that all children and adolescents be immunized.  Clinicians and the staff of athletic programs should aggressively promote immunization.

Hepatitis C: Although the transmission risks of HCV infection are not completely understood, the risk of infection from percutaneous [through the skin] exposure to infected blood is estimated to be 10 times greater than that of HIV but lower than that of HBV.  Transmission via contamination of mucous membranes or broken skin also probably has a risk intermediate between that for blood infected with HIV and HBV.

“There is clearly no basis for excluding any student from sports if they are infected,” said Dr. Steven J. Anderson, who was chair of the Academy’s Committee on Sports Medicine and Fitness when it drafted the Academy’s policy, “and we should also try to protect the confidentiality of each athlete.”

Dr. Anderson, a pediatrics professor at the University of Washington and a team doctor for many high school athletic teams, ballet companies and the U.S. Olympic Diving Team, suggests students should have access to any sport, except boxing, which the Academy opposes for all youths because of its physical risks.

“I personally feel parents have no obligation to disclose the infectious status of their children to anyone,” said Dr. Anderson.  Strict compliance with standard precautions is critical for this open-embrace of all athletes, regardless of their infectious status.  Coaches and teachers must have a plan in place to handle blood spills, said Dr. Anderson, including latex [or non-permeable] gloves, occlusive dressings, appropriate sterilizing solutions, disposal bags and even a printed protocol for coaches, athletes and officials.

The following is an excerpt of a sample school policy, used by numerous public school districts and in compliance with ADA that addresses HIV infection:

“The privilege of participating in physical education classes, programs, competitive sports and recess is not conditional on a person’s HIV status.  School authorities will make reasonable accommodations to allow students living with HIV infection to participate in school-sponsored physical activities.

“All employees must consistently adhere to infection control guidelines in locker rooms and all play and athletic settings.  Rulebooks will reflect these guidelines.  First aid kits and standard precautions equipment must be on hand at every athletic event.

“All physical education teachers and athletic program staff will complete an approved first aid and injury prevention course that includes implementation of infection control guidelines.  Student orientation about safety on the playing field will include guidelines for avoiding HIV infection.”

In addition to the Academy, several sports and other health organizations have also weighed in on this issue.  According to the NCAA, National Football League (NFL) and World Health Organization, athletes with HIV should be permitted to participate in all competitive sports at all levels.

These organizations all endorse immunization against hepatitis B for all athletes.

The National Athletic Trainers’ Association (NATA) echoes Dr. Anderson’s suggestion that coaches, trainers, athletic directors, school officials and others take the lead in educating themselves, their teams, parents and their communities about the importance of effective disease prevention.

Trainers and coaches, they suggest, should provide the following information in age-appropriate terms to all participants before or during any competition :

  • The risk of transmission or infection during competition.
  • The risk of transmission or infection generally.
  • The availability of HIV testing (for teens and adults).
  • The availability of hepatitis B vaccination and testing (for parents, teens and adults).

“Athletic trainers who have educational program responsibility should extend educational efforts to include those, such as the athletes’ families and communities, who are directly or indirectly affected by the presence of bloodborne pathogens in athletic competitions,” the NATA stated in a position paper.

See PKIDs’ Infectious Disease Workshop for more information.

Photo courtesy of Lolie Smith