Enterovirus D68

Enterovirus D68 (EV-D68) causes respiratory illness, primarily in children; symptoms usually resemble those of a cold (eg, rhinorrhea, cough, malaise, fever in a few children). Some children, particularly those with asthma, have more serious symptoms involving the lower respiratory tract (eg, wheezing, respiratory distress).

Enterovirus is a term for viruses that live in the human digestive tract and cause a range of different symptoms, from mild to serious. Most cases do not cause serious harm and go away in just a few days.

Healthy adults can be infected, but they tend to have few or no symptoms. Immunocompromised adults may have severe respiratory disease.

Every year, respiratory infections caused by EV-D68 are identified in a few children, and small outbreaks tend to occur every other year. However, in the late summer and fall of 2014, over 1000 cases were confirmed in a large outbreak across the US. Severe respiratory distress developed in a significant number of children, and a few children died.

At the same time, case clusters of children with focal limb weakness or paralysis with spinal cord lesions (seen on MRI) consistent with acute flaccid myelitis (AFM) after a respiratory illness also were reported; EV-D68 was identified in respiratory specimens in two-thirds of cases in two distinct outbreak clusters and in the blood of one child during the progression of the paralysis.

Sequenced viruses were nearly identical and shared homology with poliovirus and enterovirus D70, which are known to be associated with AFM and support a potential causal role of EV-D68 in AFM paralysis. Ongoing surveillance by the Centers for Disease Control and Prevention (CDC) detected 120 cases of AFM in the fall of 2014, coinciding with the EV-D68 outbreak. Continued surveillance in 2015 detected 16 cases of AFM for the entire year, with no cases of EV-D68 reported that year.

Another large outbreak of EV-D68-associated respiratory illness peaked in the US in September 2018. Active CDC surveillance detected the virus in 13.9% of pediatric patients with acute respiratory illness at several large US medical centers, compared to only 0.08% of similar patients in 2017.

Two-thirds of the patients with EV-D68 required hospitalization, highlighting the severity of illness. There was also a contemporaneous increase in reported AFM with over 200 CDC-confirmed cases in 2018 compared to only 35 in 2017, which further supports an association between EV-D68 infection and AFM.

EV-D68 should be considered as an etiology for otherwise unexplained severe respiratory infection, particularly if associated with a cluster of cases in late summer to fall. Specific testing in potential outbreaks is recommended and can be arranged through public health officials.

What Is Enterovirus D68? (EV-D68)

EV-D68 belongs to a group of viruses called enteroviruses. Enteroviruses are similar to the common cold virus and can spread from person to person through coughing and sneezing, close contact with an infected person, or touching a contaminated surface. There are more than 100 types of enteroviruses. Most circulate and peak in the summer and autumn.

Enterovirus D68 (EV-D68) is one of the more than 100 types of enteroviruses which can cause 10 – 15 million infections in the US each year. EV-D68 was first identified in California in 1962 and until recently has caused very few infections in the United States. However, this strain of virus began an outbreak in the Midwest and has now reached coast-to-coast causing children respiratory problems.

Enterovirus D68 is a virus that can make you feel like you have a cold. If it’s severe, it could also make you wheeze or have trouble breathing, especially if you have asthma or other respiratory problems.

Most cases are mild and last about a week, but if it’s severe, you may need to go to the hospital. Babies, children, and teens are the most likely to get it. People with weak immune systems and those with severe chronic medical conditions have the biggest risk for severe complications.

This virus isn’t new. Experts first identified it in 1962. In the decades since then, it only seemed to impact a very small number of people. That changed in 2014 when the CDC reported a national outbreak.

EV-D68 causes mild to severe respiratory illness, sometimes even requiring ventilator support. 

It has also been associated with cases and clusters of polio-like neurological symptoms including acute flaccid paralysis (AFP) (i.e. when you are unable to move due to sudden onset of muscle weakness and paralysis), and meningoencephalitis (i.e. brain and spinal cord infection).

Medical Definition of Enterovirus

Infections caused by entering viruses are most likely to occur during the summer and fall. Most people who are infected with an enterovirus have no disease at all. Infected people who become ill usually develop either mild upper respiratory symptoms (a “cold”), a flu-like illness with fever, and muscle aches, or illness with rash. Less commonly, some people have aseptic or viral meningitis. Rarely, a person may develop an illness that affects the heart (myocarditis) or the brain (encephalitis) or causes paralysis.

In early fall 2014, an outbreak of infection with a non-polio enterovirus known as enterovirus D68, or EV-D68, sickened many children across multiple U.S. states, many of whom required care in a hospital intensive-care unit. Enterovirus infections have been suspected to play some role in the development of type 1 diabetes, although they do not directly cause the condition. Newborns who become infected with an enterovirus may rarely develop an overwhelming infection of many organs, including the liver and heart, and die from the infection.

Symptoms 

Most children that get enterovirus D68 infections have mild to moderate symptoms that include a runny nose, coughing and sneezing, fever (mild) and body aches. For some children, especially those with a history of any respiratory problem such as asthma, the viral infection can be more severe and cause wheezing and difficulty breathing.

You could have a fever, a runny nose, sneezing, and coughing. You might feel achy, too. The virus can also lead to wheezing and trouble breathing, especially in children who have asthma or other respiratory problems. It can cause bronchiolitis in babies and toddlers leading to wheezing and difficulty in breathing.

It’s very rare, but enteroviruses may cause other serious problems, such as muscle paralysis or inflammation of the brain or heart.

Most people with EV-D68 infection will likely have no symptoms. However, some will have mild to severe respiratory illness.

Mild symptoms may include:

• Body and muscle aches,
• Fever,
• Coughing,
• Runny nose,
• Sneezing
• Mouth blisters, and
• Skin rash.

Severe symptoms may include:

• Wheezing, and
• Difficulty breathing.

In rare cases, some people may develop:

• Heart infection (i.e. endocarditis),
• Brain and spinal cord infection (i.e. meningoencephalitis), and
• Inability to move due to muscle weakness and paralysis (i.e. acute flaccid paralysis).

How Dangerous Is Enterovirus D68?

EV-D68 can be very dangerous to some individuals. However, for most individuals, it is usually not serious. Young children with asthma or other breathing problems can have serious breathing problems develop when infected with this enterovirus. Some of these children will need to be hospitalized and given supportive care.

Although the more serious disease usually occurs in children with breathing problems, children without these problems may also develop serious breathing problems.

Cause 

EV-D68 may, in a few children, cause death. In addition in a few others, muscle weakness and paralysis have been noted. This may occur rarely with enteroviral infections. However, the infrequent role non-polio enterovirus plays in the development of these paralysis symptoms is not well understood. Although enteroviruses infrequently may cause weakness in the muscles and even paralysis, enterovirus D68, and many other enteroviruses are still considered as “non-polio” enteroviruses.

Who’s At Risk?

Anyone can get it, but children age 6 weeks to 16 years may be especially vulnerable.

Infants and people who have immune system disorders are the most likely to develop severe complications.

Common Myths

As stated previously, enterovirus D68 was first identified in California in 1962; it is not a new virus and previous outbreaks of EV-D68 were small and not characterized by serious complications. Even with this outbreak, most children that become infected with EV-D68 have symptoms they considered to be only a common cold.

Enterovirus D68 or the Flu?

Unfortunately, the symptoms of the flu (influenza) and EV-D68 are initially similar and in mild cases of both infections, clinically indistinguishable. Specific lab tests can distinguish these two viruses. Such tests are usually not done unless the person develops more severe symptoms. 

There is no vaccine to protect against EV-D68 but there are vaccines available to protect against flu. Since the flu every year usually causes many more complications and deaths than EV-D68 or other non-polio enteroviruses, everyone is encouraged to get their yearly flu vaccine.

How Does Enterovirus D68 Spread?

EV-D68 spreads easily from person to person through the air with coughs, sneezes, or other secretions like saliva, nasal mucus or sputum. If these particles that contain live viruses touch surfaces that are then handled by uninfected individuals, the viruses can be transferred and infect the individual.

You can catch this virus the same way you would catch a common cold: by having close contact with someone who’s infected — especially if that person coughs or sneezes on you — or by touching a contaminated surface.

You can lower your chances of getting it by following these tips:

• Wash your hands often. Scrub with soap for 20 seconds. (especially before eating)
• Don’t touch your eyes, nose, or mouth unless you’ve just washed your hands.
• Don’t hug, kiss, or share food with anyone who’s sick.
• If someone in your house is ill, it’s a good idea to regularly disinfect surfaces that are touched a lot, such as toys and doorknobs.

A person who is ill should always cover their mouth when coughing/sneezing, wear a mask and wash hands often. Staying in a separate room in the house helps contain the infection.

EV-D68 Infection

What is the incubation period for EV-D68 infection?

 The incubation period is three to five days (although it can be as long as 10 days). The incubation period is the time between catching an infection and symptoms appearing.

How do you get EV-D68 infection?

 EV-D68 can spread when an infected person coughs or sneezes. Touching surfaces or objects contaminated with the virus may also result in infection if the virus then gets into your body by touching the mouth, nose or eyes.

Is a person with EV-D68 infection infectious?

 Yes, EV-D68 is very infectious.

Who gets EV-D68 infection?

 Anyone can get sick with EV-D68 infection. In Ireland, the risk of getting sick usually occurs in the summer and autumn. Anyone who comes in close contact with infected people or with surfaces contaminated with the virus may get sick with EV-D68.

Who is at risk of EV-D68 infection?

 Infants, children, and teenagers are at most risk of infection. This might be because they do not yet have immunity (i.e. protection) from previous exposures to these viruses. People with asthma or who have weakened immune systems (immunocompromised) due to treatment or disease are at greater risk for severe disease. Adults can get infected, but they are more likely to have no symptoms or mild symptoms.

How is EV-D68 infection diagnosed?

 EV-D68 can only be diagnosed by doing specific laboratory tests on specimens from a person’s nose and throat, or blood.

How is EV-D68 infection treated?

 There is no specific treatment for EV-D68 infection, so the illness has to run its course. Talk to a medical doctor or general practitioner (GP) about your symptoms and the best way to control them. Most people with mild symptoms recover completely; however, some people with severe symptoms need to be hospitalized.

How can EV-D68 infection be prevented?

There is no specific treatment against non-polio enterovirus infections, including EV-D68. However, as with many viral infections, there are simple steps you can take that can reduce the chances of getting EV-D68:

• Clean hands frequently with soap and water or an alcohol-based hand rub, including after touching commonly used objects and surfaces, before touching your face, before preparing food and before eating, when around someone who is sick. Also, clean your hands with soap and water or an alcohol-based hand rub before and after changing the nappies of sick children;
• Avoid touching your face as much as possible;
• Stay at least one meter (three feet) away from people who are ill (i.e. avoid close contact such as kissing, hugging, and sharing cups or eating utensils with people who are sick, and when you are sick); and
• Frequently clean surfaces and objects that are commonly touched.

To avoid spreading viral infections:

• Stay home from work, school, and other activities if you are ill;
• Covering your nose and mouth with a tissue (if you have no tissue use your sleeve) when you cough and sneeze (catch it), disposing of the tissue as soon as possible (bin it) and cleaning your hands as soon as you can (kill it) are important measures in helping prevent the spread of viruses to others. See the poster on HPSC website and
• Clean your hands frequently with soap and water or an alcohol-based hand rub.

How Long Does Enterovirus D68 Last?

Most people (children) will have mild to moderate symptoms for about a week. Those with severe symptoms may have infection last longer (about 10 – 14 days). Unfortunately, the virus may be shed from the body for several weeks so that an infected child, even though they clinically recover in a week, may still shed viruses that can infect others for several weeks.

Treatment

There are no specific treatments for children with respiratory illness caused by EV-D68; in general, treatment is supportive to help relieve symptoms such as fever, discomfort, and cough. Aspirin should not be given to children. There are no vaccines or antiviral medications currently available for EV-D68 treatment. Infrequently, children with severe symptoms may require hospitalization and more intensive supportive help such as assistance in breathing.

Severe symptoms of EV-D68 often need more immediate medical care or they need to be taken to an emergency department. Severe symptoms include wheezing, shortness of breath and a bluish coloration of the lips.

No medicines target this virus. Antibiotics won’t help since the illness is not caused by bacteria.

You can take an over-the-counter pain/fever reliever, which might help you feel a little better, just like with a normal cold. If your symptoms are severe, you should call your doctor or go to the emergency room.

If it’s an emergency — for instance, you’re having trouble breathing — call 911. You may need to be hospitalized.

Prevention

Avoiding contact with a person that has an infection with enterovirus D68 is one of the good ways to protect you from infection. Avoiding close contact with bodily fluids, including nasal secretions, mucous secretions, spit, and staying about 6 feet away from someone who is coughing are precautions that reduce the chance of infection.

In addition, good hand washing techniques, avoiding touching your eyes or mucous membranes with your hands and avoiding physical contact such as kissing or hugging individuals that might be infected can reduce your risk. There is no vaccine or antiviral available to prevent EV-D68 infections.

Asthma

Children with asthma are the most likely individuals to develop more severe symptoms. If your child has asthma, one of the best things to do is to make sure that asthma symptoms are well controlled with the child’s medication. This can help reduce the severity of symptoms if the child develops the infection.

 If a child with a history of asthma develops any respiratory decline with the early symptoms of EV-D68, they should seek medical evaluation immediately.

More to Know

There are many kinds of enteroviruses, including coxsackieviruses, echoviruses, polioviruses, hepatitis a virus, and others, such as enterovirus D68. These viruses are common and infect millions of Americans every year. They can infect anyone but are more likely to cause illnesses in infants, children, and teens who haven’t developed immunity against the virus yet (from not being previously exposed to it), and people with weakened immune systems.

Most people who get infected with an enterovirus don’t get sick. When someone does get sick, symptoms include:

• fever
• runny nose
• sneezing
• cough
• breathing difficulty
• muscle aches

Infections that spread beyond the digestive tract can cause hand, foot, and mouth disease, hemorrhagic conjunctivitis (an infection of the eye), and viral meningitis (an infection of the membranes surrounding the brain and spinal cord).

Recent outbreaks of enterovirus D68 in the United States have caused severe respiratory illness in some children and teens. In rare cases, enterovirus infections can lead to paralysis and infections of the brain (encephalitis) and heart (myocarditis).

Enteroviruses spread easily from person to person, usually on unwashed hands and surfaces contaminated by feces (poop), where they can live for several days.

There is no specific treatment for enterovirus infection other than relieving symptoms until the infection has run its course, which is usually not more than a few days.

Keep in Mind

Although enteroviruses can cause serious illness, enterovirus infections usually are mild. Most cause no symptoms at all. If symptoms are severe or lasts more than a few days, call a doctor right away.

Many enterovirus infections can be prevented by washing hands often, avoiding contact with sick people, and keeping household surfaces clean and disinfected.

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