“Tip of the Iceberg”
Public health officials and physicians are scrambling to keep up with hospital admissions and Emergency Department (ED) visits in 10 states across the country as an epidemic of children presenting with severe respiratory symptoms spreads across the US. Mark Pallansch, the director of CDC’s Division of Viral Diseases has said that these increased hospitalizations could represent, “just the tip of the iceberg in terms of severe cases” and have prompted health officials in Colorado, North Carolina, Georgia, Ohio, Iowa, Illinois, Missouri, Kansas, Oklahoma, and Kentucky to reach out to the CDC for further assistance.
The first cases of an increase in severe respiratory illness in children were reported by the Children’s Mercy Hospital in Kansas City, Missouri on August 19th; some of these children required admission to the hospital’s pediatric intensive care unit (ICU). A total of 450 children have been treated there since these initial reports with 60 of them requiring ICU-level care. On August 23, the CDC was contacted by the Chicago Medicine Comer Children’s Hospital in Illinois because the healthcare providers there, too, were seeing an increase in children with similar respiratory symptoms as those reported by the hospital in Missouri. Since then officials in various states have reported a spike in the number of children with respiratory distress presenting to emergency departments and urgent care locations and in those requiring hospitalizations – more than 900 children have been seen at the Children’s Hospital Colorado ED and its surrounding urgent care locations since August 18; Blessing Hospital in Quincy Illinois reported more than 70 cases in a single weekend; and Cincinnati Children’s Hospital Medical Center are reporting a record 540 pediatric admissions over a single weekend due to the respiratory virus.
Dr. Mary Anne Jackson, Children’s Mercy Hospital’s division director for Infectious Diseases told CNN that, “I would call it unprecedented. I’ve practiced for 30 years in pediatrics, and I’ve never seen anything quite like this.”
The Source: Enterovirus D68
Sophisticated polymerase chain reaction assays conducted on nasopharngeal specimens collected from affected children in Kansas and Chicago by the CDC has revealed the most likely culprit – Enterovirus D68 (EV-D68). It belongs to a family of non-polio enteroviruses, and even after being first identified in California in 1960s it has rarely been reported in the United States. Though considered less infectious than other enteroviruses, it can cause respiratory illness with the most likely disease vector being an infected person’s respiratory secretions. In its Morbidity and Mortality Weekly Report published on Sept. 8, 2014 the CDC describes the signs and symptoms common to many of the young patients with confirmed cases of EV-D68:
– difficulty breathing and hypoxemia
– wheezing on auscultatory exam
– requirement of an advanced form of respiratory support either with bilevel positive airway pressure ventilation (BiPAP) or mechanical ventilation
– chest radiographs with perihilar infiltrates with some accompanying atelectasis
Interestingly, the CDC report also noted that a majority of these young patients also had some form of previous history of asthma or wheezing indicating that chronic lung injury can make children more susceptible to EV-D68. In all cases, the CDC recommends that clinical care consist of supportive measures with escalation of ventilatory support as deemed appropriate
Vaccination and Prevention
There is currently no vaccine available for EV-D68 – the many subgroups and serotypes of this virus and its error-prone replication process leading to numerous mutations makes that process extremely difficult. The CDC recommends standard precautions to reduce the risk of infection including:
– hand-washing with soap and water for at least 20 seconds
– avoiding kissing or sharing cups or eating utensils with affected individuals (given the virus’s spread through respiratory secretions)
– frequent use of disinfectant on surfaces such as toys and doorknobs and even school supplies like pens and pencils
– keeping affected children and individuals with active symptoms away from public places like schools or playgrounds
Please refer to the CDC website for further information about Enterovirus D68 and to stay updated about its efforts across the nation with this current outbreak: EV- D68.
Report written by Saadiyah Bilal, MD