CDC Investigating Four Deaths Linked to Enterovirus D68

Troy Brown, RN

October 02, 2014

The Centers for Disease Control and Prevention (CDC) is investigating four deaths in people who had enterovirus D 68 (EV-D68) infection, but the role EV-D68 played in the deaths "is still unclear at this time," according to the CDC.

One of those deaths was confirmed yesterday by the Rhode Island Department of Health. A 10-year-old girl in that state died last week from Staphylococcus aureus sepsis associated with EV-D68.

"We are all heartbroken to hear about the death of one of Rhode Island's children," said Michael Fine, MD, director of the Rhode Island Department of Health. "Many of us will have EV-D68. Most of us will have very mild symptoms, and all but very few will recover quickly and completely. The vast majority of children exposed to EV-D68 recover completely."

The CDC has tested specimens from three other patients who died and had specimens available, and is also investigating the Rhode Island death. State and local health departments are also investigating all four deaths.

Nonpolio enteroviruses typically circulate in summer and fall. A total of 500 cases of EV-D68 in 42 states and the District of Columbia have been confirmed by the CDC from mid-August to October 1, 2014. EV-D68 infections are expected to decline later this fall, according to a CDC statement.

Most Cases Mild, but Some Serious

Severe respiratory illnesses have increased in children this year, first reported in hospitals in Missouri and Illinois. The infections were determined to be predominantly caused by EV-D68.

Most people who develop EV-D68 will only have mild symptoms, including a runny nose and low-grade fever. Sometimes after a disease outbreak certain people develop complications, and this appears to be what is happening with EV-D68. The disease begins with cold-like symptoms, which can then progress to wheezing and difficulty breathing. Some patients develop viral conjunctivitis (pinkeye); hand, foot, and mouth disease; and viral meningitis (infection of the spinal cord covering and/or brain).

More rarely, patients can develop myocarditis (infection of the heart), pericarditis (infection of the sac around the heart), encephalitis (infection of the brain), and paralysis.

The highest risk for severe symptoms is in babies, children, and teenagers, particularly those with asthma. "There are 9 recent case reports about acute neurologic illness-limb weakness and [magnetic resonance imaging] changes that have occurred at the same time as there has been an outbreak of EV-D68," the CDC statement notes.

There is currently no antiviral treatment and no vaccine to prevent it. The CDC continues to study the virus and its associated complications but does not entirely understand the reason for the current outbreak at this time.

US Senator Barbara Boxer (D-CA) wrote a letter yesterday to National Institutes of Health (NIH) Director Francis Collins, inquiring about what is being done to address this outbreak.

"We already know that EV-D68 is extremely dangerous to our children, particularly for those with asthma and other pre-existing respiratory conditions. Parents are wondering what more can be done to prevent their children from becoming infected," Senator Boxer wrote. "What is NIH doing to develop vaccines, diagnostics, and treatments for EV-D68 and other related enteroviruses? What are the prospects of developing effective interventions, and how can we overcome any existing challenges in reaching that critical goal?"

CDC Assisting With Investigation

Although many children are sick with milder forms of the illness, the CDC has made testing of specimens from children with severe respiratory illness a priority. About half of specimens tested in the CDC lab have tested positive for EV-D68. Approximately one third of specimens have tested positive for a rhinovirus or enterovirus different from EV-D68.

Virtually all confirmed cases of EV-D68 this year have occurred among children, particularly those with asthma or a history of wheezing.

The CDC is collecting information from states to better understand the extent of infection in each state, and it is also helping state and local health departments and clinical and state laboratories investigate outbreaks and conduct surveillance.

The CDC is also working with the Colorado health department to investigate the cases among children there who first developed respiratory symptoms and later developed neurologic illness.

Prevention Is Key

Clinicians may tell patients the following recommendations from the Rhode Island Department of Health to avoid contracting EV-D68:

  • Wash hands often with soap and warm water for at least 20 seconds, five or six times a day (some evidence suggests that soap and water is more effective at killing enteroviruses than alcohol rubs).

  • Avoid touching your eyes, nose, and mouth with unwashed hands, and remind children to keep their hands away from their faces.

  • Management of asthma is especially important at this time. Be sure your child is following instructions and taking medications as prescribed by their physician.

  • Clean often-used surfaces frequently, including doorknobs, telephone receivers, keyboards, and toys.

  • Don't kiss, hug, or share cups or eating utensils with sick people.

  • If you or your child have a fever, stay home while sick and for at least 1 day after the fever subsides without fever-reducing medicines.

  • Get medical help immediately for a child with asthma who is having difficulty breathing or whose respiratory symptoms get worse or do not improve after taking their usual medications.

It's also important for clinicians to recommend the influenza vaccine to their patients. "While we can't prevent EV-68 with a vaccine, it's important for everyone to get the flu shot — it is as bad as or worse than EV-68. And, we do have a shot to prevent the flu. The sooner you get the flu shot, the better," Dr. Fine explained.

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