The Enterovirus D68 Outbreak: A Public Health Concern

Tammie Lee Demler, BS, PharmD, MBA, BCPP


US Pharmacist. 2015;40(5):22-26. 

In This Article

Role of the Pharmacist

Pharmacists are in a good position to provide public education about EV-D68. All patients should be vaccinated to prevent influenza early in the season, and those at risk should receive the pneumococcal vaccine. This will reduce the chance of acquiring the influenza virus and, although not 100% effective against all possible strains, vaccination will assist in triage of the diagnosis of possible respiratory illness.

Patients should not insist on getting an antibiotic when discussing treatment options with their prescribing provider. Antibiotics are not effective against the EV-D68 or any other viral illnesses, and overuse or misuse of antibiotics contributes to resistance. Each year in the U.S., at least 2 million people become infected with bacteria that are resistant to antibiotics, and at least 23,000 people die each year as a direct result of these infections.[12]

Proper hand hygiene is important in the prevention of viral transmission. Patients should wash hands frequently with soap and water after using the bathroom, after changing diapers, and before and after touching their eyes, nose, or mouth. Patients should also avoid touching their eyes, nose, and mouth with unwashed hands, sharing utensils or drinking cups with people who are sick, having close contact with others (e.g., hugging and kissing), and attending work or school if sick. Frequently touched surfaces such as doorknobs and toys should be disinfected if someone is sick.

Supportive Care

Supportive care is also an important element of treatment and plays a role in providing comfort to patients, even for mild cases. Antipyretics and pain relievers, such as acetaminophen and nonsteroidal antiinflammatory drugs (NSAIDs; e.g., ibuprofen) can be used for adults and children. In order to improve safe and effective use of these products, parents and caregivers should be instructed to use a calibrated oral syringe (or measuring cup) when administering these products to children. Measuring devices are often included with the product, and those administering medication should be reminded to always read and follow the directions provided on the label before giving a dosage, regardless of the brand used. The FDA notified the public in 2011 that an additional concentration of liquid acetaminophen marketed for infants (160 mg/5 mL) is now available OTC. Prior to this release, liquid acetaminophen marketed for infants was only available in 80 mg/0.8 mL or 80 mg/mL concentrated drops.[13]

That same year, the FDA announced a joint meeting of the Nonprescription Drugs Advisory Committee and the Pediatric Advisory Committee to discuss the OTC use of acetaminophen in children. Based on recommendations made by this joint committee, the Consumer Healthcare Products Association (CPHA), a national trade association representing the leading manufacturers and distributors of OTC medication, took further action by voluntarily discontinuing the concentrated drops and only supplying the standard liquid strength available to children aged ≥2 years (180 mg/5 mL).[14] OTC dosing guidelines recommend confirming appropriate doses for those <2 years of age and limiting the total number of doses to no more than 5 in a 24-hour period.[13] However, if providers seek pharmacist recommendation for dosing in other age groups, the following dosing guidelines can be provided (Table 1).[15] Parents and caregivers should be reminded not to use acetaminophen for children for longer than 5 days and not use it for extremely high fevers (defined as temperature >39.5°C, or 103.1°F), fever persisting longer than 3 days, or recurrent fever, unless directed by a prescriber.

Aspirin and combinations containing aspirin or aspirinlike products, including Pepto-Bismol and Kaopectate, should be avoided in pediatric patients due to the increased risk of Reye syndrome. Although a causal relationship has not been entirely defined, this risk is associated with aspirin administration to children with viral illness.[15]

Nasal saline spray 0.65% (e.g., Ocean Saline Nasal Spray) can be used as often as needed or as directed by a prescriber to loosen congestion. Commercially available dispensing squeeze bottles can be used as a drop for infants and a spray for older children.[16] Oral nasal decongestants are not recommended for patients with hypertension, and topical decongestant sprays can cause rebound congestion when used for prolonged periods. Multipurpose products often contain ingredients that are unnecessary and may not be appropriate for children; only single-ingredient products, which are symptom-specific and appropriate, should be used.

The management of severe cases should be conducted only under the direct care of a prescriber, and often requires hospitalization. Any patient who presents with severe symptoms, including wheezing and difficulty breathing, should be referred for emergency care immediately.[17]