Background

Enteroviruses

• 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.
    • 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 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 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 DHEC is doing

• Following CDC guidance regarding EV-D68 including sending patient specimens to the CDC laboratory for testing.
  • Working with healthcare providers to report cases of severe respiratory illness and facilitate testing at CDC
  • Providing information on preventive measures
  • The Bureau of Laboratories is getting ready to perform the screening test for D-68.

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 or required to be reported to DHEC, but clusters of
  • 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.
  • contact DHEC if you are interested in 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.

Additional information is provided in the CDC health alert released on September 12, 2014.

Surveillance

• Clinicians should report to the local or state health department: (i) unusual increase in the number of patients with severe respiratory illness (ii) patients ≤ 21 years of age with acute onset of focal limb weakness occurring on or after August 1, 2014 and an MRI showing a spinal cord lesion largely restricted to gray matter. Reporting of enterovirus infections is consistent with South Carolina Law requiring the reporting of diseases and conditions to your state or local public health department. (State Law # 44-29-10 and Regulation # 61-20) as per the DHEC 2014 List of Reportable Conditions available at: https://scdhec.gov/ReportableConditionsList
• Federal HIPAA legislation allows disclosure of protected health information, without consent of the individual, to public health authorities to collect and receive such information for the purpose of preventing or controlling disease. (HIPAA 45 CFR §164.512).
• 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.

More information

• CDC Enterovirus D68 in the United States, 2014 website: https://www.cdc.gov/amd/whats-new/enteroviruses.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
• 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
• 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 )