The Enterovirus D68 Outbreak: A Public Health Concern

Tammie Lee Demler, BS, PharmD, MBA, BCPP

US Pharmacist. 2015;40(5):22-26.

High-risk Groups

Pharmacists should be aware of the specific groups, especially children, who are at high risk for contracting EV-D68, including:^[7]

Children aged ≤4 years
Children with a history of respiratory disease (e.g., wheezing, asthma, bronchiolitis), especially those with more severe illness
Both children and adults with immunocompromising conditions.

Children with asthma are particularly at risk for severe symptoms from EV-D68 infection. Therefore, if a child has asthma, parents must take steps to prepare in case the child becomes ill with EV-D68. The CDC recommends the following to control a child's asthma during this time:^[1]

Discuss options to develop and update the child's asthma action plan with his or her physician
Educate parents about the importance of adhering to treatment and ensuring the child takes his or her prescribed asthma medications as directed, especially long-term control medications for persistent asthma Children with less severe persistent asthma may require medications such as low-dose inhaled corticosteroids, mast cell stabilizers (cromolyn), and/or an oral leukotriene receptor antagonist such as montelukast (Singulair). More severe illness requires more intense steroidal intervention, and often includes oral therapy. Children with intermittent asthma may be controlled with short-acting bronchodilators used only when needed; however, overall use should be monitored and increased use should be promptly reported to the pediatrician to rule out a more serious respiratory exacerbation^[11]
Remind parents that the child should receive the annual influenza vaccine, since flu and other respiratory infections can trigger an asthma attack
Refer parents and families to their healthcare provider immediately if the child develops new or worsening asthma symptoms
Educate caregivers and/or teachers so that they are aware of the child's condition and know how to help if the child experiences any symptoms related to asthma.

1 2 3 4 5 6 7

Next Section

Table 1. Acetaminophen Dosing Recommendations ^a
Age	Oral or Rectal Dosage^b
Adults, adolescents, and children ≥12 y	325–650 mg PO or PR q4–6 h, as needed Alternatively, 1,000 mg PO or PR, 2–4 times per day; do not exceed 1 g/dose or 4 g/day
Infants and children <12 y	10–15 mg/kg PO or PR q4–6 h; do not exceed 5 doses in 24 h
Neonates	10–15 mg/kg PO or PR q6–8 h, as needed

^aFor the treatment of mild pain or fever, or for the temporary relief of headache and/or minor aches and pains associated with the common cold or flu.
^bRegular-release formulations.
Source: Reference 15.

Sidebar

Interview With Susan Gerber, MD

Additional questions answered by Dr. Gerber, team lead of the CDC's Respiratory Viruses and Picornavirus Team

Question: You mentioned that not all labs can test for this illness easily. Is this based on expense, or is the test not easily accessible by all? On October 14, 2014, the CDC press release stated it had developed and started using a new, faster lab test for detecting EV-D68 in specimens from people in the U.S.^[5] This was reported to be a real-time lab test that uses a reverse transcription polymerase chain reaction, or rRT-PCR, and is expected to identify all strains of EV-D68 that have been reported and documented in the U.S. this summer and fall. Have any additional tests been developed since then?

Answer: Many hospitals and some doctors' 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. The CDC and some state health departments can do this sort of testing. There have been no new tests to identify EV-D68 since the CDC developed and starting using the new rRT-PCR test on October 14, 2014. The CDC has made the protocols for this lab test publicly available on its website [www.cdc.gov/nonpolio-enterovirus/hcp/EV-D68-hcp.html]^[6] and is exploring options for providing test kits to state public health labs.

Question: This new test was expected to increase the total number of cases confirmed, from the 1,000 remaining samples collected and stored from September. Did this occur?

Answer: Yes, the CDC was able to test the remaining specimens in the backlog, which resulted in an increase in confirmed cases.

Question: Do we know anything more now compared to October 2014 when the story first broke?

Answer: Pharmacists can check the CDC's EV-D68 website [www.cdc.gov/non-polio-enterovirus/about/ev-d68.html]^[1] and stay tuned for summary information about the outbreak on our website soon. We know that basically the entire country was affected by the outbreak (at least one person from 49 out of 50 states tested positive for EV-D68). The CDC, working with state health departments, identified at least three separate strains of EV-D68 that caused infections in the U.S. in 2014. It is common for multiple strains of one enterovirus type to cocirculate in the same year. We also know that the strains of EV-D68 circulating this season are not new. The most prominent strain has been in the U.S. since 2012; it was not a recent introduction. It is also related to strains of EV-D68 detected in previous years in countries in Europe and Asia.

Question: The current EV-D68 strain is genetically related to strains from previous years, but do you agree with the Tokarz group,^[3] who have reported protein deletions that could have contributed to viral fitness and efficiency?

Answer: We generally do not comment on studies done by others. We attribute the increase in cases this year to increased surveillance and awareness, and more testing.

Question: According to the CDC, 1,121 cases of this virus have been lab-confirmed in 47 states from the middle of August to November 20, 2014. Is this different now?

Answer: The data you have in the body of your story through December 18th are correct and the most current. There are continual updates visible on the EV-D68 website.^[1]

Question: The CDC has collected and tested over 2,500 specimens—40% have been positive for EV-D68, 30% have been rhinovirus or enterovirus other than EV-D68. What was the other 30%?

Answer: The other 30% was negative for EV-D68 and any other enterovirus or rhinovirus.

Question: Is the severity of this outbreak greater than in the past?

Answer: 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 U.S. Also, the CDC does not have a surveillance system that specifically collects information on EV-D68 infections; no data are currently available regarding the overall burden of morbidity or mortality from EV-D68 in the U.S. In essence, we don't have data to compare this season with previous years. However, infections were widespread with confirmed EV-D68 infection among severe cases in 49 out of 50 states, as of December 18, 2014.

Source: References 1–3, 5, 6.