Enterovirus D68 (EV-D68) is a specific enterovirus that causes respiratory illness. Symptoms range from a mild cold-like illness with coughing and wheezing to severe infections that require hospitalization.
Public Health Ontario has been working with the Ontario Ministry of Health and Long-Term Care, the Public Health Agency of Canada and other partners to monitor for and provide timely guidance regarding the circulation of EV-D68 in the United States and Canada, including laboratory testing and infection prevention and control measures.
Enterovirus infection is more common during the late summer and fall and the PHO Laboratories (PHOL) do not routinely test for EV-D68 outside of this period.
In 2014, EV-D68 was last detected at PHOL in late October. Testing was ceased on December 1, 2014 and recommenced on August 3, 2015.
Please contact PHOL Customer Service for more information or if you are requesting testing outside of the specified period: Telephone 416-235-6556 or toll free 1-877-604-4567.
What is EV-D68?
Enteroviruses are a group of viruses that can cause a range of symptoms including: no symptoms at all, mild cold-like symptoms, illnesses with fever and rashes, and neurologic problems. Infections with enteroviruses are very common and most people have mild symptoms. There are about 100 types of enteroviruses.
EV-D68 is a specific enterovirus that causes respiratory illness ranging from mild to severe. Symptoms can include a cold-like illness with coughing and wheezing to severe infections requiring admission to a hospital or possibly to an intensive care unit because of breathing difficulties.
Children and teenagers appear to be at increased risk of infection from EV-D68 because they may lack protection from previous exposures to the virus, although the virus can infect adults as well. Children with asthma seem to have a higher risk for severe respiratory illness.
When do infections from enteroviruses usually occur?
Enteroviruses usually circulate in the late summer and fall, although this can vary depending on the type of enterovirus.
How is EV-D68 spread?
EV-D68 can be present in respiratory secretions from the nose and throat and can spread from an infected person when they cough or sneeze. Touching surfaces or objects contaminated with these secretions may also result in infection if the virus then gets into the body by touching the mouth, nose or eyes.
Is there a vaccine or specific treatment for EV-D68?
There is no vaccine or specific antiviral treatment for EV-D68. Most people don’t require any treatment and will get better on their own, but symptoms like wheezing and fever can be treated (aspirin should be avoided in children). Patients who have difficulty breathing may require hospital admission and those with severe breathing problems may require treatment in an intensive care unit which may involve being placed on a ventilator.
What is happening with EV-D68?
In mid-August 2014, the US Centers for Disease Control and Prevention (CDC) began investigating clusters of children with severe respiratory illness in Missouri and Illinois. Laboratory testing indicated that EV-D68 was the cause of these illnesses. From mid-August 2014 to January 15, 2015 CDC or state public health laboratories reported a total of 1,153 people with EV-D68. EV-D68 was primarily identified in children, many of whom had asthma or a history of wheezing. CDC also stated that there were likely millions of individuals with mild EV-D68 infections who did not seek medical care thus were not tested for the virus. During the late summer and early fall of 2014, several provinces in Canada also reported laboratory confirmed cases of EV-D68.
As noted above, the actual number of cases of EV-D68 is not known as people with viral infections often don’t seek medical care. As well, when care is sought, swabs to test for viral infections are not routinely done and not all laboratories test for EV-D68 or other respiratory viruses. Furthermore, most respiratory infections, including EV-D68, are not reportable to public health unless they are identified as part of an institutional outbreak of respiratory illness. For most viruses, knowing the specific type of virus does not change patient care.
What is the history of EV-D68?
EV-D68 was first identified in 1962. It has occurred infrequently from then until 2014, although from 2008-2010, the Centers for Disease Control and Prevention reported on six clusters of EV-D68 in the Philippines, Japan, the Netherlands, and three US states (Georgia, Pennsylvania and Arizona). The clusters appeared to be concentrated in the fall. Four of the six outbreaks only reported infected children, one outbreak reported only infected adults and one outbreak involved both adults and children. Patients in these clusters often had new onset or worsening wheezing. Hospitalizations and admissions to intensive care units were noted and three individuals died.
What precautions can be taken regarding EV-D68?
As with many viral infections, simple precautions can reduce the chances of getting EV-D68:
- Clean your hands frequently with soap and water or an alcohol-based hand rub, including after touching commonly touched objects and surfaces, before touching your face, before preparing food and before eating;
- Avoid touching your face as much as possible;
- Stay at least two metres (six feet) away from people who are ill;
- 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;
- Cough and sneeze into your elbow and not your hand;
- Clean your hands frequently with soap and water or an alcohol-based hand rub.
People with asthma should ensure that they have their puffers readily available and know how to use them properly. Seek medical attention right away if wheezing does not respond to puffers or if you are having difficulty breathing.
CENTERS FOR DISEASE CONTROL AND PREVENTION
Centers for Disease Control and Prevention, Enterovirus D-68
Centers for Disease Control and Prevention. Severe Respiratory Illness Associated with Enterovirus D68 — Missouri and Illinois, 2014 Morbidity and Mortality Weekly Report, September 12, 2014 / 63(36);798-799
Centers for Disease Control and Prevention (CDC). Clusters of Acute Respiratory Illness Associated with Human Enterovirus 68 -Asia, Europe, and United States, 2008—2010 Morbidity and Mortality Weekly Report, September 30, 2011 / 60(38);1301-1304
Centers for Disease Control and Prevention (CDC), Notes from the Field: Acute Flaccid Myelitis Among Persons Aged ≤21 Years — United States, August 1–November 13, 2014. Morbidity and Mortality Weekly Report January 9, 2015 63(53) 1243-1244.
Centers for Disease Control and Prevention (CDC), Summary of Findings: Investigation of Acute Flaccid Myelitis in U.S. Children, 2014-15
Centers for Disease Control and Prevention (CDC) Acute Neurology Illness of Unknown Etiology in Children – Colorado, August –September Morbidity and Mortality Weekly Report October 3, 2014 / 63; 1-2
Centers for Disease Control and Prevention (CDC) Acute Flaccid Paralysis with Anterior Myelitis, California, June 2012 – June 2014 Morbidity and Mortality Weekly Report October 3, 2014 / 63; 1-4
PHO PROVINCIAL INFECTIOUS DISEASES ADVISORY COMMITTEE BEST PRACTICES DOCUMENTS
Annex B: Best Practices for Prevention of Transmission of Acute Respiratory Infection In All Health Care Settings
Best Practices for Environmental Cleaning for Prevention and Control of Infections In All Health Care Settings - 2nd edition
National Collaborating Center for Infectious Diseases Disease Debrief: EV-D68
Edwin JJ, Domingo Reyes F et al. CCDR Surveillance Summary of Hospitalized Pediatric Enterovirus D 68 cases in Canada, September 2014 Volume 41 S-1, February 20, 2015
In 2014, EV-D68 was last detected at PHOL in late October. Testing was ceased on December 1, 2014 and recommenced on August 3, 2015.
Please contact PHOL Customer Service for more information or if requesting testing outside of the specified period. Telephone 416-235-6556 or toll free 1-877-604-4567.
When is EV-D68 testing recommended?
Laboratory testing should be considered during the late summer and early fall season for patients with severe respiratory illness, especially children, among whom symptomatic enterovirus infections, including EV-D68, are more common. Testing can also be considered if clusters of severe respiratory illness are identified. Testing patients with mild illness, or outside of the late summer/early fall season, is of limited clinical utility.
In order to investigate the epidemiology and clinical features of EV-D68 in Ontario, the PHO Laboratories are conducting enhanced surveillance on a subset of patients based on recent respiratory specimens submitted for testing from a range of clinical settings, including physicians’ offices and clinics, hospitals and outbreak settings. In addition to PHOL’s general laboratory requisition, clinicians are asked to submit the Enterovirus D68 (EV-D68) Patient Clinical Summary Form when submitting samples for EV-D68 testing. Please note submission of this form is voluntary and will not affect your request for laboratory testing. This form contains basic risk factor and clinical information. Thank you in advance for contributing to this enhanced surveillance initiative. A link to the CDC protocol is available here.
What is the EV-D68 testing process?
EV-D68 testing will take place at the PHO Laboratories. Currently, PHOL is verifying a realtime polymerase chain reaction (PCR) assay for EV-D68 testing. Once the test is verified this assay will be used on specimens for which EV-D68 testing is requested; this will allow for faster turnaround times. In the meantime, any specimens that are specifically requested to undergo EV-D68 testing will be tested for enterovirus using a realtime panenterovirus PCR (CDC protocol; detects all enterovirus serotypes) and sequenced to determine its specific serotype.
How to order EV-D68 testing
Submit a nasopharyngeal (NP) swab or throat swab (NP swab preferred) in universal transport media (UTM), or bronchoalveolar lavage in a sterile dry container for EV-D68 testing with a completed PHOL General Test Requisition Form. Write “EV-D68 Testing” in the “Test(s) Requested” field. Include dates of onset and sample collection, symptoms, travel history if appropriate, patient setting and note any co-morbidities such as asthma. Clinicians requesting EV-D68 testing are also asked to submit an Enterovirus D68 (EV-D68) Patient Clinical Summary Form to assist in understanding the epidemiology and clinical features of EV-D68. This form can be submitted to the laboratory along with the requisition and specimen, or sent by confidential fax to 416-596-1799
The turnaround time for receiving results is approximately 10 days. Specimens submitted for EV-D68 testing will also be tested for other respiratory viruses.
Does EV-D68 cause neurologic problems?
The family of enteroviruses include types of viruses known to cause neurologic problems such as muscle weakness and acute flaccid paralysis (AFP). AFP is reportable in Ontario. For more information on AFP, visit here.
The CDC investigated a small cluster of children hospitalized in Colorado who developed acute neurologic illness in August and early September 2014. EV-D68 has been identified in respiratory specimens from some of the children. Most of the children had a respiratory illness with fever in the two weeks before the onset of their neurologic symptoms. From August 2, 2014 to April 14, 2015, CDC has checked reports from 118 children who developed acute flaccid myelitis. Some of these children had EV-D68 or other enteroviruses/rhinovirus identified from respiratory samples. A few children with acute muscle weakness or paralysis who have EV-D68 found in respiratory specimens have also been identified in Canada, including in Ontario. The connection between the virus and the neurological symptoms remains uncertain and is under investigation.
What testing should be done in someone with acute neurological symptoms?
Persons of any age presenting with acute neurological symptoms/signs should have laboratory investigations to detect a viral cause. Screening for enteroviruses will include laboratory testing for EV-D68 as well as other enteroviruses. When submitting specimens from patients with neurological presentation, it is important to document the neurological symptoms on the laboratory requisition form, so the appropriate testing can be ordered. Specimen collection should include:
Collect two sets of stool samples - each stool sample is divided into a sterile container for viral testing and a bacterial (Cary-Blair) transport media container for Campylobacter testing. The clinician should write “Enterovirus / EV-D68” in the “Test(s) Requested” field of one requisition, and “Campylobacter Testing” in the
“Test(s) Requested” of another requisition.
- Respiratory specimens:
Collect a nasopharyngeal (NP) swab and/or throat swab (NP swab preferred) in universal transport media (UTM), or bronchoalveolar lavage in a sterile dry container for EV-D68 testing. Always submit a throat swab from children under 15 years of age with acute flaccid paralysis. The clinician should write “Enterovirus / EV-D68 Testing" in the “Test(s) Requested” field of the requisition. The clinician is also requested to complete the Enterovirus D68 (EV-D68) Patient Clinical Summary Form and submit it to the laboratory along with the requisition and specimen, or fax it via confidential fax to 416-596-1799.
For all ages, collect CSF as appropriate for the investigation.
- Neurologic investigations:
For all ages, neurologic tests, such as electromyography, nerve conduction studies, Magnetic Resonance Imaging (MRI) and computerized axial tomography (CT) scans should be conducted as appropriate.
|Infection Prevention |
and Control Measures
Enteroviruses typically spread by fecal-oral route; however, EV-D68 appears to spread via droplet and direct contact like other respiratory viruses.
Patients with symptoms of acute respiratory infection should be placed on droplet and contact precautions as per the Annex B: Best Practices for Prevention of Transmission of Acute Respiratory Infection In All Health Care Settings guidance document that outlines risk assessment, hand hygiene, personal protective equipment, control of the environment and administrative controls.
Environmental disinfection of surfaces in healthcare settings should be performed using a hospital-grade disinfectant with a label claim of effectiveness against non-enveloped viruses.