Enterovirus D68: What families need to know

With Enterovirus D68 making headlines across the nation, a group of our pediatric experts collaborated on a list of frequently asked questions, assuring families with reliable information about the virus that has hospitalized hundreds of children throughout the U.S.

Enterovirus D68: What families need to know click to enlarge This transmission electron micrograph (TEM) revealed some of the ultrastructural morphology exhibited by a grouping of Enterovirus virions. Source: CDC
  • The Enterovirus family consists of more than 70 different kinds of viruses. They are a common cause of infections in healthy adults and children and usually peak in the summer and fall months. They are most often associated with fever illnesses in children, summer colds, the “hand-foot and mouth” illness, the “herpangina” soft palate ulcers, and diarrheal illnesses. Much less frequently, they can be more severe and cause meningitis, hepatitis and a severe illness for newborn infants.
  • The Enterovirus D68 (EV-D68) strain circulating around the country now is unique in that it appears to cause more severe respiratory symptoms than other viruses in the family. There also appears to be less fever.

    Reports thus far have shown that the vast majority of the patients with severe illness caused by Enterovirus D68 have underlying asthma. This seems consistent with other respiratory viruses, which tend to cause the most severe symptoms in those patients who already have lung diseases.

    UPDATE: On September 30, 2014, media outlets started circulating reports of sudden onset muscle weakness or paralysis in some patients that have tested positive for EV-D68. Although much less common than severe respiratory symptoms (which, in themselves, are rare), the CDC and others are investigating the potential link between the neurological complications and EV-D68. More >>
  • Most labs, including ours at UNC Hospitals, are able to test patients to determine if they have an infection caused by a member of the Enterovirus family. Determining the specific type of Enterovirus, however, requires advance testing of the viral genetic material. The laboratory at UNC is in the process of establishing on-site testing, but for now, all official determination of virus subtype will be performed by the Centers for Disease Control (CDC).
  • Most Enteroviruses are spread by contact with an infected person or their secretions. For Enterovirus D68, contact with infectious respiratory secretions are the highest risk.

    Good hand hygiene is the best method of protection. Soap and water is best, but alcohol foams and sanitizers are better than nothing. Coughing or sneezing into your sleeve and not your hands is helpful, as is avoiding direct contact with someone who is known to have a respiratory illness.

    The CDC has also recommended wiping down frequently touched surfaces like door knobs and toys if someone in the house is sick. Enterovirus on surfaces can be killed with standard disinfectants.
  • None of our current antiviral medicines work against any of the Enteroviruses, nor do we have a vaccine that would protect patients from future infections.
  • We recommend families focus most of their attention on the child's physical symptoms and not worrying about which virus may be causing them. If the child has a mild runny nose, cough, and low-grade fever, the family can continue to treat the child as they would if he or she had a common cold.

    If the child is wheezing, having difficulty breathing, has trouble drinking fluids, appears distressed, or exhibits other worrisome symptoms, the family should contact their pediatrician or, if indicated, take the child to an emergency room. Seek immediate medical attention if the child can't catch his or her breath, is coughing so long and hard that it is difficult to talk, or seems “out of it.”

    Parents know their children better than anyone else, so focusing on how sick their child appears to them is the key action.
  • Children who have underlying lung or respiratory problems, such as asthma, or other chronic medical problems seem to be at higher risk for severe symptoms with this type of infection. Right now there are no special precautions for those children except vigilant hand hygiene. The child and his or her caregivers and other close contacts should be instructed to wash their hands carefully and often. They should also, when possible, avoid close contact with people who are sneezing or coughing.

    If the child has a chronic condition that requires medication (e.g., asthma needing a controller medication), the family should also ensure the child is getting all scheduled doses of the prescribed medication.
  • We understand that new outbreaks like this cause families to worry, but there is little cause for concern.

    Similar to influenza virus varying in severity from year to year, this strain of Enterovirus appears to cause more severe illness than some other strains. Families should know that, even with this virus, the majority of infections are very mild, and the small minority of children who develop severe disease seem to be fully recovering when given appropriate support in a hospital.

    Medical professionals throughout the state, including our own, are closely monitoring the situation and will communicate important new information to the media as it develops. Beyond implementing prevention measures and paying close attention to worsening respiratory symptoms, families do not need to change their children’s usual routines at this point.

    UPDATE: On October 1, 2014, the Centers for Disease Control and Prevention (CDC) announced that it is investigating four deaths in people who tested positive for Enterovirus D68. It is unclear if there is any connection between the virus and these fatalities. More >>
  • Clinicians at N.C. Children’s Hospital and many other hospitals throughout the state are being vigilant in their preparations and collaboratively looking for trends in admissions that might indicate the arrival of Enterovirus D68. Cross-communication with other hospitals, including those at the epicenter of this outbreak in the Midwest, is helping identify risk factors in patients and ascertain effective therapies.

    UNC Children’s team includes some of the world’s leading experts in pediatric infectious diseases and pediatric pulmonary medicine and an array of highly skilled pediatric intensivists. When needed, our pediatric intensive care unit (PICU) is equipped with a wide variety of respiratory therapies and support for potential patients who present with severe infection, including:

    • The appropriate medications for treating the spectrum of respiratory symptoms described;
    • Access and expertise in all modalities of respiratory support; and
    • The latest technology in mechanical ventilation and extracorporeal membrane oxygenation (ECMO/ECLS) in extreme cases of respiratory failure. (Respiratory failure is the condition in which patients can no longer breathe on their own and require mechanical support, either ventilation or ECMO.)

    To date, there has not been a confirmed case of Enterovirus D68 in North Carolina, but UNC Children’s care teams are prepared and closely monitoring the situation.

    UPDATE: On September 22, 2014, the N.C. Department of Health and Human Services confirmed the presence of Enterovirus D68 in six patients from North Carolina, all children 6 months to 10 years of age with respiratory illnesses. Two of those cases were later confirmed to be patients at N.C. Children's Hospital.

    Our care teams use appropriate contact precautions when caring for these patients. Children with known or suspected Enterovirus D68 are placed on enteric contact precautions (gowns, gloves for entering the room; use of soap and water or an antimicrobial soap for hand hygiene) and droplet precautions (use of mask by all persons entering the room) to prevent transmission to healthcare personnel and others.

    As of September 30, 2014, N.C. Children's Hospital has admitted 13 children with enterovirus respiratory infections (not all of them confirmed the EV-D68 strain, though viral panels take some time). As has been reported elsewhere, patients appear to be recovering fully given the appropriate medical interventions.

UPDATE: Upon getting reports of four deaths and cases of sudden onset paralysis in patients with Enterovirus D68 elsewhere in the country, UNC Children's issued this statement >>

A collaboration of:

Kevin Kelly, MD 
Pediatrician-in-Chief, N.C. Children's Hospital
Professor of Pediatrics, Division of Pediatric Allergy, Immunology and Rheumatology (AIR)

Ravi Jhaveri, MD 
Associate Professor of Pediatrics, Division of Pediatric Infectious Diseases

Benny Joyner, MD 
Division Chief, Pediatric Critical Care Medicine
Assistant Professor of Pediatrics

Michael Steiner, MD, MPH 
Division Chief, General Pediatrics and Adolescent Medicine
Associate Professor of Pediatrics

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