Key Pints Entervirus D68 in the United States, 2014 Nte: Newly added infrmatin is in red. The United States is currently experiencing a natinwide utbreak f entervirus D68 (EV-D68) assciated with severe respiratry illness. Frm mid-august t Octber 21, 2014, CDC r state public health labratries have cnfirmed a ttal f 938* peple in 46 states and the District f Clumbia (AL, AR, CA, CO, CT, DC, DE, FL, GA, IL, IN, IA, ID, KS, KY, LA, MA, ME, MD, MI, MN, MO, MS, MT, NC, NE, NH, NJ, NM, NY, ND, OH, OK, OR, PA, RI, SC, SD, TN, TX, UT, VA, VT, WA, WV, WI, WY) with respiratry illness caused by EV-D68. This indicates that at least ne case has been detected in each state listed but des nt indicate hw widespread infectins are in each state. CDC expects, as with ther enterviruses, that EV-D68 infectins will likely begin t decline by late fall. CDC has received infrmal reprts frm sme hspitals and states that are seeing signs f decreasing EV-D68 infectins. CDC is gathering mre infrmatin frm states and assessing whether this represents a natinal trend. Fr up-t-date infrmatin and a map f entervirus D68-like illness activity in states, see http://www.cdc.gv/nn-pli-entervirus/utbreaks/ev-d68-activity.html. Every year, enterviruses and rhinviruses cause millins f respiratry illnesses in children. This year, EV-D68 has been the mst cmmn type f entervirus identified, leading t increases in illnesses amng children and affecting thse with asthma mst severely. Other rhinviruses and enterviruses cntinue t be detected as well. CDC has received substantially mre specimens fr entervirus lab testing than usual this year, due t the large utbreak f EV-D68 and related hspitalizatins. CDC has priritized testing fr the mst severe cases since the utbreak began in August t get a better understanding f the disease. Of the mre than 1,400 specimens tested by the CDC lab, abut half have tested psitive fr EV-D68. Abut ne third have tested psitive fr a rhinvirus r entervirus ther than EV-D68. Almst all f the CDC-cnfirmed cases this year f EV-D68 infectin have been amng children. Many f the children had asthma r a histry f wheezing. CDC develped, and started using n Octber 14, a new, faster lab test fr detecting EV-D68, allwing CDC t rapidly prcess the remaining specimens received since mid-september. As a result, the number f cnfirmed EV-D68 cases has increased substantially and will likely cntinue t increase in the cming days. These increases will nt reflect actual changes r mean the situatin is getting wrse. Faster testing will help t better shw the trends f this utbreak since August and t mnitr changes ccurring in real time. Once we have finished testing the remaining specimens, we will then be able t test and reprt results fr new specimens within a few days f receiving them. EV-D68 has been detected in specimens frm seven** patients wh died and had samples submitted fr testing. CDC is reprting the test results t state health departments as we btain them. State and lcal fficials have the authrity t determine the cause f death, including whether EV-D68 infectin may have played a rle. They als have the authrity t determine the apprpriate infrmatin t release, and the time t release it. CDC will defer t states t prvide this infrmatin. S far, state and lcal fficials have reprted that tw f these deaths were caused by EV-D68. CDC understands that Americans may be cncerned abut these severe respiratry illnesses. Severe illness is always a cncern t us, especially when infants and children are affected. We will share infrmatin as sn as we have it, and pst updates n ur website (http://www.cdc.gv/nn-pli-entervirus/utbreaks/ev-d68- utbreaks.html). *Ttal cnfirmed case cunt includes results frm State Public Health Labratries that can d testing t determine type f entervirus. **CDC will review and update data every Thursday frm patients wh died and had samples submitted fr testing. 1
General Key Pints Enterviruses and Entervirus D68 FOR EXTERNAL DISTRIBUTION 10/21/2014 11:30 AM Backgrund Enterviruses Enterviruses are very cmmn viruses; there are mre than 100 types. It is estimated that 10 t 15 millin entervirus infectins ccur in the United States each year. Tens f thusands f peple are hspitalized each year fr illnesses caused by enterviruses. Different enterviruses can cause different illnesses, such as respiratry, febrile rash, and neurlgic [e.g., aseptic meningitis (swelling f the tissue cvering the brain and spinal crd) and encephalitis (swelling f the brain)]. In general, the spread f enterviruses is ften quite unpredictable. A mix f enterviruses circulates every year, and different types f enterviruses can be cmmn in different years. In the United States, peple are mre likely t get infected with enterviruses in the summer and fall. Entervirus D68 EV-D68 was first recgnized in Califrnia in 1962. Small numbers f EV-D68 have been reprted regularly t CDC since 1987. Hwever, this year the number f peple with cnfirmed EV-D68 infectins is much greater than that reprted in previus years. The strains f EV-D68 circulating this year are nt new. CDC, wrking with state health departments, has identified at least three separate strains f EV-D68 that are causing infectins in the United States this year. It is cmmn fr multiple strains f the same entervirus type t be c-circulating in the same year. CDC extensively cmpared the strains circulating in this year t strains frm previus years. We fund that the mst prminent strain has been in the United States fr the last three years and is nt a recent intrductin. It is als related t strains f EV-D68 detected in previus years in cuntries in Eurpe and Asia. There is n evidence that unaccmpanied children brught EV-D68 t the United States; we are nt aware f any f these children testing psitive fr the virus. Respiratry illnesses can be caused by many different viruses and have similar symptms. Nt all respiratry illnesses ccurring nw are due t EV-D68. EV-D68 has been previusly referred t as human entervirus 68 (r HEV-68) and human rhinvirus 87 (r HRV- 87). They are all the same virus. The D stands fr entervirus species D. Symptms EV-D68 infectins can cause mild t severe respiratry illness, r n symptms at all. Mild symptms may include fever, runny nse, sneezing, cugh, and bdy and muscle aches. Severe symptms may include wheezing and difficulty breathing. Anyne with respiratry illness shuld cntact their dctr if they are having difficulty breathing, r if their symptms are getting wrse. Enterviruses are knwn t be ne f the causes f acute neurlgic disease in children. They mst cmmnly cause aseptic meningitis, less cmmnly encephalitis, and rarely, acute myelitis and paralysis. CDC is aware f tw published reprts f children with neurlgic illnesses cnfirmed as EV-D68 infectin frm cerebrspinal fluid (CSF) testing. Peple at risk In general, infants, children, and teenagers are mst likely t get infected with enterviruses and becme sick. That's because they d nt yet have immunity (prtectin) frm previus expsures t these viruses. We believe this is als true fr EV-D68. Adults can get infected with enterviruses, but they are mre likely t have n symptms r mild symptms. Children with asthma may have a higher risk fr severe respiratry illness caused by EV-D68 infectin. Transmissin Since EV-D68 causes respiratry illness, the virus can be fund in an infected persn s respiratry secretins, such as saliva, nasal mucus, r sputum. The virus likely spreads frm persn t persn when an infected persn cughs, sneezes, r tuches a surface that is then tuched by thers. Diagnsis EV-D68 can nly be diagnsed by ding specific lab tests n specimens frm a persn s nse and thrat. 2
Many hspitals and sme dctr s ffices can test sick patients t see if they have entervirus infectin. Hwever, mst cannt d specific testing t determine the type f entervirus, like EV-D68. CDC and sme state health departments can d this srt f testing. CDC recmmends that clinicians nly cnsider EV-D68 testing fr patients with severe respiratry illness and when the cause is unclear. Treatment There is n specific treatment fr peple with respiratry illness caused by EV-D68 infectin. Talk t yur child s dctr abut the best way t cntrl his r her symptms. Sme peple with severe respiratry illness caused by EV-D68 may need t be hspitalized and receive intensive supprtive therapy. There are n antiviral medicatins are currently available fr peple wh becme infected with EV-D68. Preventin Yu can help prtect yurself frm getting and spreading EV-D68 by fllwing these steps: Wash hands ften with sap and water fr 20 secnds Avid tuching eyes, nse and muth with unwashed hands Avid clse cntact such as kissing, hugging, and sharing cups r eating utensils with peple wh are sick, r when yu are sick Cver yur cughs and sneezes with a tissue r shirt sleeve, nt yur hands Clean and disinfect frequently tuched surfaces, such as tys and drknbs, especially if smene is sick Stay hme when yu are sick There are n vaccines fr preventing EV-D68 infectins. Children with asthma are at risk fr severe symptms frm EV-D68 and ther respiratry illnesses. They shuld fllw CDC s guidance t maintain cntrl f their illness during this time: Discuss and update yur asthma actin plan with yur primary care prvider. Take yur prescribed asthma medicatins as directed, especially lng term cntrl medicatin(s). Be sure t keep yur reliever medicatin with yu. Get a flu vaccine when available. If yu develp new r wrsening asthma symptms, fllw the steps f yur asthma actin plan. If yur symptms d nt g away, call yur dctr right away. Parents shuld make sure the child s caregiver and/r teacher is aware f his/her cnditin, and that they knw hw t help if the child experiences any symptms related t asthma. What CDC is ding CDC cntinues t cllect infrmatin frm states and assess the situatin t better understand EV-D68 and the illness caused by this virus and hw widespread EV-D68 infectins may be within states and the ppulatins affected. CDC is helping states with diagnstic and mlecular typing fr EV-D68. We are wrking with state and lcal health departments and clinical and state labratries t enhance their capacity t identify and investigate utbreaks, and perfrm diagnstic and mlecular typing tests t imprve detectin f enterviruses and enhance surveillance. CDC has develped, and started using n Octber 14, a new, faster lab test fr detecting EV-D68 in specimens frm peple in the United States with respiratry illness. CDC will prvide prtcls t state public health labs and explre ptins fr prviding test kits. CDC s new lab test is a real-time reverse transcriptin plymerase chain reactin, r rrt-pcr, and it identifies all strains f EV-D68 that we have been seeing this summer and fall. The new test has fewer and shrter steps than the test that CDC and sme states were using previusly during this EV-D68 utbreak. Once we have finished testing the remaining specimens, we will then be able t test and reprt results fr new specimens within a few days f receiving them. The previus test, which CDC used fr abut nine years, is very sensitive and can be used t detect and identify almst all enterviruses; hwever, it requires multiple, labr-intensive prcessing steps and cannt 3
be easily scaled up t supprt testing f large numbers f specimens in real time that is needed fr the current EV-D68 utbreak. We are prviding infrmatin t healthcare prfessinals, plicymakers, general public, and partners in numerus frmats, including Mrbidity and Mrtality Weekly Reprts (MMWRs), health alerts, websites, scial media, pdcasts, infgraphics, and presentatins. CDC has btained ne cmplete genmic sequence and six nearly cmplete genmic sequences frm viruses representing the three knwn strains f EV-D68 that are causing infectin at this time. Cmparisn f these sequences t sequences frm previus years shws they are genetically related t strains f EV-D68 that were detected in previus years in the United States, Eurpe, and Asia. CDC has submitted the sequences t GenBank t make them available t the scientific cmmunity fr further testing and analysis. Guidance fr Clinicians Clinicians shuld cnsider EV-D68 as a pssible cause f acute, unexplained severe respiratry illness, even if the patient des nt have fever. reprt suspected clusters f severe respiratry illness t lcal and state health departments. EV-D68 is nt natinally ntifiable, but state and lcal health departments may have additinal guidance n reprting. cnsider labratry testing f respiratry specimens fr enterviruses when the cause f respiratry illness in severely ill patients is unclear. cnsider testing t cnfirm the presence f EV-D68. State health departments can be apprached fr diagnstic and mlecular typing fr enterviruses. cntact yur state r lcal health department befre sending specimens fr diagnstic and mlecular typing. fllw standard, cntact, and drplet infectin cntrl measures The antiviral drugs plecnaril, pcapavir, and vapendavir, have significant activity against a wide range f enterviruses and rhinviruses. CDC has tested these drugs fr activity against currently circulating strains f entervirus D68 (EV-D68), and nne f them has activity against EV-D68 at clinically relevant cncentratins. Surveillance U.S. healthcare prfessinals are nt required t reprt knwn r suspected cases f EV-D68 infectin t health departments because it is nt a natinally ntifiable disease in the United States. Als, CDC des nt have a surveillance system that specifically cllects infrmatin n EV-D68 infectins. N data is currently available regarding the verall burden f mrbidity r mrtality frm EV-D68 in the United States. Any data CDC receives abut EV-D68 infectins r utbreaks are vluntarily prvided by labs t CDC s Natinal Entervirus Surveillance System (NESS). NESS cllects limited data, fcusing n circulating types f enterviruses and parechviruses. Activity f Entervirus D68-like Illness in States Fr the week f Octber 5-11, 2014, 44 states and the District f Clumbia submitted assessments t CDC f activity f EV-D68-like illness. 32 states and the District f Clumbia reprted lw r declining activity 12 states reprting increasing r elevated activity Fr a larger image and details f EV-D68-like illness activity in states, see http://www.cdc.gv/nn-plientervirus/utbreaks/ev-d68-activity.html. 4
Mre infrmatin CDC Entervirus D68 in the United States, 2014 website: http://www.cdc.gv/nn-pli-entervirus/utbreaks/ev- D68-utbreaks.html CDC Entervirus D68 general website: http://www.cdc.gv/nn-pli-entervirus/abut/ev-d68.html CDC Entervirus D68 fr Health Care Prfessinals website: http://www.cdc.gv/nn-pli-entervirus/hcp/ev- D68-hcp.html CDC Activity f Entervirus D68-like Illness in States website: http://www.cdc.gv/nn-plientervirus/utbreaks/ev-d68-activity.html CDC What Parents Need t Knw abut Entervirus D68 webpage: http://www.cdc.gv/features/evd68/ Entervirus D68 in the United States: Epidemilgy, Diagnsis & Treatment, COCA Call, September 16, 2014 (http://www.bt.cdc.gv/cca/calls/2014/callinf_091614.asp) Severe Respiratry Illness Assciated with Entervirus D68 Multiple States, 2014, Health Alert Netwrk, September 12, 2014 (http://emergency.cdc.gv/han/han00369.asp) Severe Respiratry Illness Assciated with Entervirus D68 Missuri and Illinis, 2014, MMWR, September 8, 2014 (http://www.cdc.gv/mmwr/preview/mmwrhtml/mm6336a4.htm?s_cid=mm6336a4_w) Clusters f Acute Respiratry Illness Assciated with Human Entervirus 68 --- Asia, Eurpe, and United States, 2008--2010, MMWR, September 30, 2011 (http://www.cdc.gv/mmwr/preview/mmwrhtml/mm6038a1.htm) 5