NHS Lothian, NHS Fife

Transcription

1 Investigation of a cluster of cases of acute flaccid paralysis associated with Enterovirus D68 infection (EVD68) in children in South East Scotland, 2016 Catriona Waugh, Dr Kate Mark, Dr Janet Stevenson, NHS Lothian, NHS Fife Faculty of Public Health Conference, Aviemore, 2017

2 Enterovirus D68 was first discovered in 1962, previously one of the rarest enteroviruses with less than 700 confirmed cases golbally between 1962 and 2014 Single strand RNA virus most well known enterovirus is polio Transmission can occur by faeco-oral or respiratory spread Can cause a range of clinical syndromes from asymptomatic to acute respiratory infection requiring hospitalisation i Sporadically can cause neurological symptoms such as acute flaccid paralysis (AFP) AFP = a complex clinical syndrome: sudden onset of limb weakness in 1 or more limb or respiratory muscles due to disease of lower motor neurons. Background to EVD68

3 In mid August 2014, a large number of cases (1153) of EVD68 were detected in USA. 107 cases of AFP and 14 deaths A number of EU countries also reported an increase in severe enterovirus infections with a variety of different strains. Only 1 case of AFP in Europe (France). In a number of countries also reported sporadic cases of EVD68 with associated acute flaccid paralysis Wales reported a cluster of cases of EVD68 with atypical Guillain-Barré i type syndrome. Cluster included adults and children - 2 cases of confirmed EVD68 with AFP. Global context

4 A review of respiratory samples collected in South East Scotland in 2014 was carried out to determine an estimate of circulating EVD68. There was a marked increase in EVD68 compared to previous years with 74 cases of EVD68 identified in 8359 respiratory samples sent to Specialist Virology Centre in Edinburgh. Nearly 30% of of enteroviruses were identified as EVD68 61% of EVD68 were e in under 5 year olds, with majority male (68%) Cases of EVD68 had more severe markers of infection than other enteroviruses (admission to hospital, admission to ITU, length of admisison) Scotland context: 2014

5 Scotland context: September 2016

6 Between September and November 2016, 5 cases of confirmed EVD68 with associated acute flaccid paralysis were reported to the NHS Lothian Health Protection Team by the RHSC. 4 confirmed cases presented within a 2 week window in September th case presented in October 2016 Aged between 2-6 years 1 case in Fife, 3 in West Lothian, 1 in East Lothian All previously well with history of minor illness only The cluster

7 All presented with prodromal symptoms of coryza and fever. Neurological symptom onset was 1-6 days following prodrome. 2/5 children had bulbar symptoms and required ventilatory support in ITU (still required at 6 months) Asymmetrical limb weakness was a feature in all children Reflexes and tone were reduced in all children 4/5 children had facial signs such as facial droop 2/5 had autonomic dysfunction (high BP and low HR) Pain was a feature in all 5 children. Cognition was preserved in all children Clinical features

8 CSF MRI Nerve conduction IVI g Steroid s Gabapent in 1 High WCC, normal protein, 40% lymphocytes Abnormal signal pons, diffuse signal grey matter in cervical spinal cord 2 No Abnormal signal in pons, diffuse signal grey matter in cervical spinal cord 3 No Abnormal signal in midbrain, high signal grey matter cervical spinal cord 4 No Abnormal signal pons, high signal medulla, increased signal in grey matter of cervical cord 5 High WCC, normal protein, predominantly lymphocytes Abnormal signal medulla, through cervical spinal cord to T1/2, enhancement facial nerves bilaterally Suggestive acute motor neuropathy Suggestive acute motor neuropathy Yes Yes Yes Yes No Yes No No No Yes No Yes No Yes No Yes Yes Yes Investigations & management

9 NHS Lothian urgently formed an IMT with multi-disciplinary input when initial 2 cases confirmed and 2 cases suspected. Case definitions agreed Trawling questionnaires were carried out by NHS Lothian HPT Parents of cases were interviewed shortly after cases were confirmed. Questionnaire covered previous 4 weeks. Exposures vaccinations, travel, environmental, school/nursery, sick contacts were all explored - no common exposures identified Temporal and geographical link noted Surveillance data extracted for analysis Clinical alert letter sent to primary and secondary care Communications statement prepared Epidemiological i i l investigation i i

10 Map

11 6 Epicurve pcu eof EVD68 cases: South East Scotland Epicurve: 2014

12 4 Epicurve pcu eof EVD68 cases: South East Scotland 2016 Non-neurological 3 Neurological Epicurve: 2016

13 Emerging infection: significant distress for families uncertain outlook, poor prognosis, lack of information Long-term medical and psychological support for children and families HCW support lack of evidence base for management Media interest The new polio Challenges of infection control, including community Planning services ITU beds, isolation precautions, long term care Largest cluster of confirmed EVD68 in Europe Challenges for Public Health

14 Urgent need for an international collaborative working Role of surveillance of circulating EVD68 tip of the iceberg as seen in USA in 2014 Surveillance in Europe challenging not all countries have access to typing in laboratories. Missing data for Eastern Europe. Need to gain an understanding of of condition and risk factors for contracting EVD68, and developing eloping AFP Preparedness for emerging infection services, infection control and limiting anxiety Management of clinical condition Improving long-term outcomes Role for a vaccine? Future considerations

15 We would like to thank: Dr Kate Templeton and Virology team in NHS Lothian Dr Margaret Hanna and HPT in NHS Fife Dr Paul Eunson and Clinical team at RHSC Infection Control Team at RHSC HPS Acknowledgements

16 Questions?

17 Hay F, Horsley J, Guerendiain D, Hardie A, Harvala H, Templeton KE K.E. Enterovirus D-68 in Edinburgh, : 2015 Clinical i l and Epidemiological Features of Enterovirus D-68 in Comparison to Rhinovirus and Enterovirus Infection Holm-Hansen CC, et al. Global emergence of enterovirus D68: a systematic review. Lancet Infect Dis. 2016;16:e Lang M et al. Acute flaccid paralysis following enterovirus D68 associated pneumonia, France, Euro Surveill. 2014;19. Messacar, K. et al. (2016), 2014 outbreak of enterovirus D68 in North America. J. Med. Virol., 88: Pariani, E. Et al. (2017). Letter to the editor: Need for a European network for enterovirus D68 surveillance after detections ti of EV-D68 of the new B3 lineage in Sweden and Italy, Eurosurveillance, 22(2), Williams CJ et al. Cluster of atypical adult Guillain-Barré syndrome temporally associated with neurological illness due to EV-D68 in children, South Wales, United Kingdom, October 2015 to January Euro Surveill. 2016;21(4). References