Previously we talked about and gave you the facts about Ebola Hemorrhagic Fever in this article we are going to talk about a virus that you, or more specifically your kids, are far more likely to contract than Ebola, Enterovirus D-68.
Enteroviruses cause two main types of human disease, polio, and non-polio disease. In this article, the focus will be on the non-polio disease-causing enteroviruses. The polio-viruses that cause paralysis and other symptoms have been extensively covered in other articles. Non-polio enteroviruses may cause a wide range of infections that overlap:
- Enterovirus: aseptic meningitis with rash, conjunctivitis, hand, foot, and mouth disease (EV-71), paralysis (EV-71), myopericarditis
- Group A Coxsackie virus: flaccid paralysis, hand, foot, and mouth disease, hemorrhagic conjunctivitis, herpangina, aseptic meningitis (with or without rash)
- Group B Coxsackie virus: spastic paralysis, herpangina, pleurodynia, myocarditis, pericarditis, and meningoencephalitis
- Echovirus: common cold, rash, aseptic meningitis, myopericarditis, paralysis, hemorrhagic conjunctivitis
rhinovirus: the common cold (over 100 different stereotypes)
The causes for enterovirus infections are simply the passage of one of the many enteroviruses from one person directly to another, usually by contact with respiratory secretions and/or stool from infected people.
Occasionally, environmental sources such as water may be contaminated with enteroviruses that can infect people. The most common risk factor for getting an enterovirus infection is direct contact with any bodily secretions (especially respiratory and/or fecal) from an infected person.
Individuals with immature (neonates) or compromised immune systems (HIV/AIDS, Hepatitis, etc.) are at higher risk for enterovirus infections. Pregnant women and people with respiratory problems like asthma are also at higher risk. You, and your children, are at highest risk during the fall and summer months.
Signs and Symptoms of Enterovirus Infection
Many people who become infected with enteroviruses have no or only mild symptoms (fever, headache, sore throat, loss of appetite, and abdominal discomfort) of infection that may last about a week and resolve with no further problems. However, those people at higher risk may develop one or more of the following symptoms:
- Common cold: nasal discharge, cough, mild fever, mild malaise
- Hypoxia (low oxygen in the blood):shortness of breath, wheezing, coughing, rapid breathing, skin coloration change (bluish to cherry red), rapid heart rate
- Aseptic meningitis: most common among infants and children; may also occur with a rash (on face, neck, and extremities), fever, painful headache,stiff neck, body aches, sensitivity to light, nausea and vomiting, irritability
- Conjunctivitis (hemorrhagic): eye pain, bleeding seen in the whites of the eyes,photo-phobia (avoidance of light due to discomfort)
- Myopericarditis: shortness of breath, chest pain, fever, weakness
- Herpangina: small flat sores on the oral mucosa (tonsils and soft palate) that may produce blisters and ulcerate
- Pleurodynia: intermittent chest pain usually over the lower part of the rib cage; some people may have a plural friction rub that can be heard when the doctor examines the chest with a stethoscope
- Hand, foot, and mouth disease (HFMD): small nodules and blisters that are tender and appear gray that occur on the hands, feet, and in the oral cavity
- Encephalitis: Symptoms range from lethargy and drowsiness to personality changes, seizures, and coma.
- Paralysis (infrequent in both polio and non-polio intro viral infections): flaccid paralysis that is often asymmetric with proximal extremity muscles affected; lower extremities affected more commonly than upper extremities (polio virus, enterovirus 71, and coxsackievirus A7); other non-polio enteroviruses usually have less severe symptoms (muscle weakness and oculomotor palsy) if paralysis develops
As noted above, some strains of enteroviruses produce different symptoms, some of which are much more severe than others. In addition, some strains occasionally appear to be more transmissible and cause more intense or severe symptoms. Two recent examples are enterovirus 71 (EV-71) and EV-D68.
Diagnosis and Treatment
In general, enterovirus infections are most often diagnosed by clinical symptoms. Blood tests are done infrequently; the best test is polymerase chain reaction (PCR) that is available from specialized laboratories and used most often during outbreaks of viral infections.
In addition, it is useful to distinguish between enterovirus infections and other viral infections like rota-virus and influenza viruses. Infrequently, the infecting enterovirus will be isolated by cell cultures taken from the blood, feces, or cerebrospinal fluid and then identified by further immunologic tests. Other tests such as chest X-rays, electrocardiogram, lumbar puncture, and ECG’s may help decide the extent of infection.
The best treatment for an enterovirus infection is prevention. For poliovirus, an effective vaccine is available; unfortunately, for non-polio enteroviruses the treatment is supportive and is designed to alleviate the symptoms because there are no antiviral medications currently approved for the treatment of these types of enterovirus infections.
Immunoglobulins have been used in infected neonates and immunocompromised hosts to both treat and prevent non-polio enterovirus central nervous system infections, but these immunoglobulin treatments are not always very effective.
Consequently, supportive measures such as fever control, assisted-breathing methods (ranging from inhaled steroids to intubation), pain-control medications, and topical skin and oral mucosal medications to alleviate symptoms are given.
Recent Outbreaks of Enterovirus D-68
The recent outbreaks of various non-polio enteroviruses are listed below; (the data is modified from reports from the U.S. Centers for Disease Control and Prevention (CDC).
According to the CDC, to date hundreds of children across the U.S. Midwest have been stricken by this virus that is causing serious respiratory illnesses, paralysis, and in at least two cases, death.
Particularly hard hit has been the state of Missouri, where more than 400 cases of the respiratory illness have been reported in a Kansas City hospital; about 15% of those children with the infection needed treatment in an intensive-care unit. Since mid-August 2014, other states such as Kansas, Kentucky, Iowa, Colorado, Ohio, Oklahoma, North Carolina, and Georgia have seen an outbreak of this severe respiratory illness caused mainly by EV-D68 (about 75% of patients were confirmed to be infected by EV-D68 in a single Colorado hospital).
To date, there have been two deaths attributed to this virus outbreak. Major symptoms include:
- difficulty breathing; some patients develop wheezing.
The virus has been found mainly in children and those children who have any respiratory compromise (patients with asthma) often get more severe symptoms. The CDC is concerned that the large numbers of people infected with this virus only represent “the tip of the iceberg,” suggesting this outbreak may be very large while pediatricians at some hospitals consider the outbreak to be “unprecedented.”
Currently, the CDC does not have an exact count of infected people; there is no vaccine available to prevent EV-D68 infections, and treatment is mainly supportive care.
Prognosis of Enterovirus D-68
The prognosis of most enterovirus infections is good; most people will spontaneously resolve their infection in about seven to 10 days and have no complications.
Some patients, especially those who are immunocompromised in any way, may develop more severe infections. The more severe infections can have a prognosis that can range from good to poor, depending upon the severity of the viral strain causing the infection and the strength (or weakness) of the individual’s immune response. Consultation with an appropriate specialist (cardiologist, pulmonologist or others, depending on the particular complications) is recommended.
You can cut the chance of getting an enterovirus infection simply by avoiding direct contact with people who are infected with enteroviruses and by using such techniques as good hand washing and cleaning or disinfecting items that come in contact with infected people.
People are routinely vaccinated against certain enteroviruses (polio-viruses); as a result, polio is rarely seen in developing countries. Unfortunately, no vaccines are available for non-polio enteroviruses. Part of the reason there are no vaccines for these viruses is that there is a very large number of sub-types of non-polio enteroviruses.
Latest News on Enterovirus D-68
New findings and other information about EV-D68 is changing rapidly and to keep readers updated, we’ve added the most pertinent news about this outbreak.
Oct. 7, 2014: The 4-year-old boy who died in his sleep on Sept. 24 in New Jersey died from an EV-D68 viral infection. This death has worried many more parents because the child had only symptoms of pinkeye but no other symptoms of EV-D68 disease. When doctors were interviewed about this child’s death, they suggest there were no interventions that they or anyone else could have done to prevent the child’s death. The concern is that the child showed almost no symptoms yet the virus was lethal for the child. It is not known if the child was uniquely susceptible to EV-D68 infection or if the virus has changed in some way.
In addition, researchers are concerned about EV-D68 becoming the new version of polio; they are looking for links between this viral infection and the development of paralysis in dozens of children nationwide. To date, a link is suspected but not yet proven.
Health officials think that many more children have enterovirus infections than are reported, and most children will develop only runny nose, mild fever, and/or a cough; some people will have no symptoms and most will recover completely. These people often seek no care and are not tested for viral infections and thus are not reported in the statistics. The time for concern is when the person is wheezing, having trouble breathing, or if there’s a bluish tinge to a child’s lips. These are markers that suggest the person is having difficulty breathing and should be seen by a doctor as quickly as possible. Investigators suggest these are the people whose cases are being reported and represented in the statistics because they are being seen by medical staff and being tested for viral infections.
Some researchers have suggested that if the incidence of paralysis being reported in the last few weeks is directly linked to the enterovirus infections (especially EV-D68), there should be an urgent push to develop both vaccines and antiviral drugs that would be effective in stopping these viral infections. Currently, there is no effective antiviral drug or vaccine available to treat EV-D68 or other non-polio enterovirus infections.
Oct. 6, 2014: More information was made available today about the child who died from EV-D68 virus infection. Apparently, the only symptom the child had was pinkeye and none of the more classic symptoms of fever, runny nose, sneezing, cough, body aches, or the more severe symptoms of wheezing and shortness of breath were observed. He essentially went to sleep and never woke up. EV-D68 viruses were isolated from the child’s brain and spinal cord fluid. What caused the virus to infect the child yet cause little or no symptoms is not clearly understood. To date, 594 people have been infected with the virus, almost exclusively young children. There is no vaccine or antiviral treatment for EV-D68.
Oct. 5, 2014: Yesterday the New Jersey Department of Health confirmed that a child (4 years old) died last week and tested positive for EV-D68. The viral infection was the major contributor to the death of the child. This is the first reported death linked to EV-D68 virus infection. An additional four patients who have died may also have been infected with this virus, but tests have not been yet completed one these people. The CDC says over 500 people, almost all children, in 43 states and in Washington, D.C., have been confirmed to be infected with EV-D68.
Oct. 1, 2014: Reports of the death of a 10-year-old girl in Rhode Island originally thought possibly due to EV-D68 have been changed to state that her death occurred as a result of Staphylococcus aureus sepsis associated with EV-D68. Although the CDC has detected EV-D68 in a few patients who have died, the role EV-D68 played in these few patients is still unclear according to the CDC. To date, there are 472 confirmed EV-D68 infections in 41 states and Washington, DC.
Sept. 30, 2014: Some physicians believe EV-D68 infections are getting too much press; Dr. Paul Checchia of Texas Children’s Hospital suggests the reaction to EV-D68 is “hysterical.” He says the real problem viruses for children (and some adults) are RSV and influenza viruses. Because infections with RSV and influenza commonly occur every year, they don’t get the same press coverage even though RSV may cause 200 deaths and influenza may cause about 100 deaths per year in the U.S. No deaths have been attributed to EV-D68. However, EV-D68’s link with children with prior respiratory problems and some people with post-infection muscle problems is still under investigation.
Sept. 29, 2014: The CDC reported that EV-D68 confirmed infections jumped to 443 today. Currently, there is no confirmed link to neurological problems (limb weakness or paralysis) and EV-D68 infections.
The CDC, state officials, and doctors at Children’s Hospital in Colorado are investigating if nine children who have developed muscle weakness and/or paralysis may be linked to an EV-D68 infection they may have acquired about two weeks before their current neurological problems. Eight have been tested, and four were EV-D68 positive. Eight of nine children were up to date on polio vaccinations. Currently, the doctors are trying to decide if the symptoms are due to EV-D68 or if these children’s symptoms are coincidental occurrences.
Sept. 27, 2014: This evening, another state, Texas, has reported its first 11 patients infected with EV-D68. Ten children in Dallas County and one child in Denton County were confirmed to be infected. More children have symptoms, but the test results have not been available. In addition, two children in Ohio have confirmed infections. These results now show the virus has spread to 40 states in the U.S. and Washington, DC.
Sept. 25, 2014: With five new confirmed cases of EV-D68 in Saginaw County, Mich., the CDC now reports a total of 220 people from 32 states confirmed to have infections with this virus. So far, the CDC reports that all but one of the confirmed infections occurred in children.
Canada now reports at least 102 children have been reported to be infected with EV-D68 in Ontario; the health officials also report only a “few” required hospitalization while the majority of children were recovering at home. One health official suggested that they’re seeing a decrease in the number of samples to test for the virus, suggesting that perhaps EV-D68 infections have peaked and are starting to decline in Ontario.
Sept. 24, 2014: Apparently, the U.S. is not the only place being hard hit by EV-D68 virus. Infections have been reported in Canada, specifically in Alberta, British Columbia, and in Ontario. At least 18 infections have been confirmed and today, two others were confirmed, one in Windsor and another in Toronto. The children all developed similar symptoms.
Sept. 23, 2014: A Massachusetts pediatric hospital reported only one case of EV-D68, but state health officials have concerns that several more hospitalized children will test positive for the virus. Health officials are cautioning parents to be sure their asthmatic children stay on their maintenance medications and keep sick children home from school to reduce viral spread.
Sept. 22, 2014: Because of the EV-D68 outbreak, some hospitals are modifying their visitation rules. The following is an example of the changes that may be in place for a few months (perhaps until March 2015) until the EV-D68 (and other enterovirus-caused infections) seasonal risk for infection decreases:
- Someone should not visit the hospital, as a visitor, if he or she has a fever, cough, diarrhea, or has vomited.
- There should be no visitors under the age of 13.
- Siblings, who do not have cold and flu symptoms, may visit a new baby on the obstetrics unit but may be screened for illness by staff before being allowed to visit.
- Children 12 and under must be supervised by an adult in pubic waiting areas and cafeterias.
- People should wash or sanitize their hands frequently while at the hospital.
Sept. 19, 2014: The CDC reports that from about mid-August until Sept. 19, 2014, 22 states now have reported a combined total of 160 confirmed EV-D68 infections. None has been fatal, but some children with severe respiratory distress require hospitalization and a few have required respiratory support. Currently, the CDC reports that complete recovery has occurred in most children to date.
Sept. 18, 2014: The first four people (children ages 2-13) reported in California infected with EV-D68 occurred in San Diego (three people) and Ventura (one person). Three of the four children had a history of asthma; children with any respiratory compromise seem at higher risk to get a more severe EV-D68 infection. Health officials in California predict more people with EV-D68 will be identified.
Sept. 17, 2014: The CDC reports 18 states have reported a total of 153 confirmed EV-D68 infections, mainly in children.
As you can see the Enterovirus D-68 (EV-D68) is a far bigger threat than Ebola Hemorrhagic Fever, especially to kids. While there is no conclusive evidence just yet, many believe that this outbreak can be traced to the massive influx of illegal aliens through the southern border in recent months.
Enterovirus D-68 is very prevalent in the Central and South American countries where the majority of these illegal aliens come from. The CDC has denied any connection to this outbreak and the influx, yet the evidence is mounting that there is a connection.
Keep a close watch on your children, especially if you live in the Mid-Western states that are the hardest hit by this outbreak. Practice good hand-washing techniques and make sure your children follow your lead.
Thank you for reading! A special thanks to ETMC Health System in Tyler TX for the use of the rash photo, I look forward to seeing your comments and as always, Train to Survive!
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Schwartz, Robert A. “Enteroviruses Treatment & Management.” May 2, 2014.<http://emedicine.medscape.com/article/217146-treatment>.
United States. Centers for Disease Control and Prevention. “Non-Polio Enteroviruses.” Sept. 11, 2014. <http://www.cdc.gov/non-polio-enterovirus/>.
United States. Centers for Disease Control and Prevention. “Severe Respiratory Illness Associated with Enterovirus D68 — Missouri and Illinois, 2014.” MMWR 63.36 Sept. 12, 2014: 798-799. <http://www.cdc.gov/mmwr/preview/mmwrhtml/mm63e0908a1.htm>.