Going Viral – Enterovirus Spreads Sickness, Worry Across Country

Viral epidemics — especially those spread as rapidly through the media as they are through the air — can be scary. But Dr. Michael Klatte is offering reassurance — for now.

After weeks of stories detailing the spread of enterovirus in other parts of the country, Baystate Children’s Hospital began seeing an increase of young patients presenting with respiratory illness possibly related to enterovirus.

However, said Klatte, a pediatric infectious-disease specialist at Baystate, most of the children with these symptoms have been treated and discharged soon after from the Emergency Department, with a small number of patients being admitted to the hospital. Most of those have been going home within a day or two, and the cases seen thus far at Baystate are generally less severe than those observed in the Midwest, where a troublesome strain of enterovirus first emerged in August.

“While increased concern exists for some children with predisposing conditions such as asthma,” he said, “the majority of these infections will not be serious, and will require only treatment of the symptoms.”

According to Klatte, enteroviruses mainly affect the respiratory system and gastrointestinal tract, causing symptoms such as fever, upper-respiratory issues — including cough, runny nose, and nasal congestion — as well as diarrhea and stomach pain. Depending on the specific type of enterovirus — the current strain spreading across the U.S. is known as EV-D68 — patients may also experience rashes (including hand, foot, and mouth disease), conjunctivitis (redness of the whites of the eyes), and neurologic illnesses, such as aseptic meningitis and encephalitis.

“EV-D68 appears to cause symptoms primarily affecting the airways, including wheezing, increased difficulty breathing, and the need for more oxygen,” he noted. “Given these symptoms, this infection is, therefore, more of a concern for children who have underlying respiratory issues, such as asthma, or for premature babies with respiratory airway difficulties, which would make them more predisposed to severe infection with this virus.”

From mid-August through Sept. 23, when HCN went to press, a total of 213 people from 30 states were confirmed to have respiratory illness caused by EV-D68, including Massachusetts, Connecticut, and New York. State health officials verified the first confirmed case in Massachusetts on Sept. 23, at Boston Children’s Hospital, while incidents at other hospitals continue to be tested. The strain mainly affects children, although adult cases are not unheard of.

The Centers for Disease Control and Prevention (CDC) says more states will have confirmed cases in the upcoming weeks, because several states are currently investigating clusters of people with severe respiratory illness, and specimens are still being tested for EV-D68; that process that can take time because the testing is complex and can only be done by the CDC and a small number of state public-health laboratories.

“As the backlog of specimens is processed, the number of states and confirmed cases will likely increase. These increases will not necessarily reflect changes in real time, or mean that the situation is getting worse,” the agency notes.

However, the number of new infections is also likely to increase, because early fall is the middle of the enterovirus season, so the threat to non-infected children is far from over. “As investigations progress, we will have a better understanding of the trends for EV-D68 infections.”

The virus had been detected in only a handful of Midwestern states when the Mass. Department of Public Health advised hospitals and other care providers that the virus was likely on its way here, and to consider it a potential cause of illness in children, as well as adults.

Enterovirus infections, Klatte explained, occur most often during the late spring through early autumn, with the highest numbers of infections routinely occurring in the summer months. But this is not a typical year.

The EV-D68 strain, which is causing the current outbreak, can be traced back to 1962, when it was first identified in California. Since then, however, its occurrence in the U.S. has been relatively rare, with only 79 confirmed cases reported by the CDC from 2009 through 2013. The current situation is, in fact, the first widespread outbreak of EV-D68 the country has seen.

Kipaya Kapiga, who blogs for Boston Children’s Hospital, noted that most enteroviruses, which cause colds, fever, headaches, vomiting, and rashes, are common, causing roughly 10 to 15 million mostly uneventful infections every year.

“D68 is an unusual strain, however,” he continued. “Not only is it much less common than other enteroviruses, it can cause especially bad respiratory illnesses, including a bad cough and difficulty breathing. In some cases, children and other patients with D68 have needed ICU-level care and the assistance of a mechanical ventilator. D68 can be especially dangerous for children with existing lung problems, like asthma, or who have weaker immune systems, like newborns.”

There are currently no antiviral medications for treating the EV-D68 infection, and no vaccines are available to protect against it. But there are ways to minimize the risk of contracting it, tips that apply to any viral threat. Because enteroviruses are spread by contact with infected bodily fluids, such as mucous and stool, Klatte said, prevention involves:

• Good hand hygiene — washing often with soap and water for 20 seconds, especially before and after changing a baby’s diaper;

• Avoiding touching the eyes, nose, or mouth with unwashed hands;

• Covering one’s nose when sneezing;

• Avoiding kissing, hugging, and sharing cups or utensils with those who are sick; and

• Disinfecting frequently touched surfaces, such as toys and doorknobs, especially if someone in the household is sick.

The onset of flu season isn’t making the enterovirus threat easier to manage, Klatte said, as multiple studies show that children who have co-infections with more than one respiratory virus are more likely to have significant symptoms requiring hospitalization and intensive medical management.

“As influenza season is rapidly approaching, now is the perfect time for you and your loved ones to receive influenza vaccine in order to be protected,” he said.

Meanwhile, to protect its patients and staff, Baystate Health has adopted a temporary change to its visitor policy to ensure the safest environment possible during the enterovirus threat. Specifically, anyone visiting a child or new mother in the hospital must be 14 years or older. The policy applies to Baystate Medical Center and Baystate Children’s Hospital in Springfield, Baystate Franklin Medical Center in Greenfield, Baystate Mary Lane Hospital in Ware, and Baystate Wing Hospital in Palmer. At press time, no other regional hospital had adopted a similar change.

“There are no vaccines or antiviral therapies for D68, and care is supportive, meaning that all hospitals can do is provide relief for the symptoms,” Kapiga said. “So it’s important that adults who are around children take precautions to minimize the risk of spreading the virus.”