Enterovirus D68–Associated Acute Respiratory Illness — New Vaccine Surveillance Network, United States, July–October, 2017 and 2018

Stephanie A. Kujawski, PhD; Claire M. Midgley, PhD; Brian Rha, MD; Joana Y. Lively, MPH; W. Allan Nix; Aaron T. Curns, MPH; Daniel C. Payne, PhD; Janet A. Englund, MD; Julie A. Boom, MD; John V. Williams, MD; Geoffrey A. Weinberg, MD; Mary A. Staat, MD; Rangaraj Selvarangan, PhD; Natasha B. Halasa, MD; Eileen J. Klein, MD; Leila C. Sahni, PhD; Marian G. Michaels, MD; Lynne Shelley; Monica McNeal, MS; Christopher J. Harrison, MD; Laura S. Stewart, PhD; Adriana S. Lopez, MHS; Janell A. Routh, MD; Manisha Patel, MD; M. Steven Oberste, PhD; John T. Watson, MD; Susan I. Gerber, MD


Morbidity and Mortality Weekly Report. 2019;68(12):277-280. 

In This Article

Abstract and Introduction


In the fall of 2014, an outbreak of enterovirus D68 (EV-D68)–associated acute respiratory illness (ARI) occurred in the United States;[1,2] before 2014, EV-D68 was rarely reported to CDC.[2,3] In the United States, reported EV-D68 detections typically peak during late summer and early fall.[3] EV-D68 epidemiology is not fully understood because testing in clinical settings seldom has been available and detections are not notifiable to CDC. To better understand EV-D68 epidemiology, CDC recently established active, prospective EV-D68 surveillance among pediatric patients at seven U.S. medical centers through the New Vaccine Surveillance Network (NVSN).[4] This report details a preliminary characterization of EV-D68 testing and detections among emergency department (ED) and hospitalized patients with ARI at all NVSN sites during July 1–October 31, 2017, and the same period in 2018. Among patients with ARI who were tested, EV-D68 was detected in two patients (0.8%) in 2017 and 358 (13.9%) in 2018. Continued active, prospective surveillance of EV-D68–associated ARI is needed to better understand EV-D68 epidemiology in the United States.

NVSN conducts active, prospective, population-based surveillance for ARI* among children and teens aged <18 years at seven U.S. medical centers at Cincinnati, Ohio; Houston, Texas; Kansas City, Missouri; Nashville, Tennessee; Pittsburgh, Pennsylvania; Rochester, New York; and Seattle, Washington.[4] Respiratory specimens (mid-turbinate nasal, oropharyngeal swabs, or both) from patients with ARI were tested at each site for EV-D68 using a validated real-time reverse transcription–polymerase chain reaction assay. Two NVSN sites (Nashville and Pittsburgh) tested all ARI specimens for EV-D68 directly. Five sites (Cincinnati, Houston, Kansas City, Rochester, and Seattle) used a two-step algorithm, wherein all ARI specimens were first tested for enterovirus/rhinovirus (EV/RV) using molecular diagnostic assays approved by the Food and Drug Administration or CDC; all EV-positive or RV-positive specimens were subsequently tested for EV-D68. Demographic and admission status information were collected from medical charts. EV-D68 detections were analyzed by year, month, site, admission status, and patient sex and age.

Based on preliminary data, test results were positive for EV-D68 for two (0.08%) of 2,433 patients with ARI who were tested during 2017 and 358 (13.9%) of 2,579 tested during 2018. In 2017, one patient whose test result was positive for EV-D68 was hospitalized in Houston, and one was evaluated in the ED in Rochester. In 2018, patients with EV-D68-positive test results were identified at all seven sites, and 242 of 358 patients (67.6%) were hospitalized (range by site = 53.3%–76.8%) (Table). EV-D68 was detected in 9.2% of patients with ED visits for ARI and 18.3% of hospitalized patients with ARI. Approximately half (169; 47.2%) of the 2018 EV-D68 detections occurred in September (Figure). The peak of detections varied by site, with Cincinnati and Kansas City peaking in late August through September; Houston, Pittsburgh, and Rochester in mid-September; and Nashville and Seattle in October. The median age of patients testing positive for EV-D68 was 3 years (range = 1 month–17 years; interquartile range = 1.5–5 years), and 211 (58.9%) were male. Among 42 EV-D68–positive specimens from 2018 sequenced at CDC, all were lineage B3.


Enterovirus-D68 (EV-D68) detections, by date of specimen collection and surveillance network site (N = 358) — New Vaccine Surveillance Network, United States, July 1–October 31, 2018

* A child (aged <18 years) was eligible for inclusion in NVSN ARI surveillance if he or she visited the emergency department or were admitted to the hospital in the 48 hours preceding enrollment, with one or more of the following symptoms/events: fever; cough; earache; nasal congestion; runny nose; sore throat; vomiting after coughing; wheezing; shortness of breath/rapid or shallow breathing; apnea; apparent life-threatening event or brief resolved unexplained event; or myalgias and the duration of illness at the time of enrollment was <14 days. Children with a known nonrespiratory cause for hospitalization/ED visit were excluded from enrollment, as were children residing outside the surveillance area.