Saturday, September 06, 2014

Enterovirus D-68 (HEV-D68) Update


States reporting suspected or confirmed HEV-D68



# 9045


Although lab confirmation is still awaited in some areas, the outbreak of severe respiratory illness in kids that we saw pop up N.W. Missouri a little over a week ago (see Kansas City Outbreak Identified As HEV 68), and then a few days later in St. Louis (see Missouri Health Alert On Enterovirus 68), has now been reported in at least four more states.

This week we’ve seen media reports of hospitals being slammed with (mostly young) patients with respiratory infections in Ohio, Illinois, Kansas, Missouri, and most recently Colorado.  While test results haven’t come back for all of these locations, local doctors are pointing their fingers at the emerging EV 68 virus.


A sampling of some of the media coverage overnight includes:


Severe respiratory virus impacting hundreds of kids reaches Colorado - ‎15 hours ago‎

DENVER — A potentially severe virus that has plagued hundreds of children across a 900-mile stretch in the Midwest in recent weeks has made its way to Colorado.

Colorado children's hospitals see spike in severe respiratory illness

The Denver Post - ‎12 hours ago‎

Children's hospitals in Denver are experiencing an alarming spike in a severe respiratory illness — especially among very young children and those with asthma — that may be caused by an uncommon viral pathogen.

Hospitals across Denver are on alert for a respiratory illness that can leave ...

The Denver Channel - ‎4 hours ago‎

At Rocky Mountain Hospital for Children, physicians report about 10 of the 20 beds in their pediatric intensive care unit are young people battling the virus. "Our pediatric floor is full of patients with pretty severe respiratory distress," said Dr.Raju Meyappan

Denver hospitals see virus spike in kids - ‎10 hours ago‎

DENVER - Denver hospitals and pediatricians offices are seeing a spike in a respiratory virus that is hitting kids hard who have histories of asthma and wheezing. ... "It seems to be what's happening with this virus which is more severe than other viruses.".


Often called EV 68, this virus is primarily known for producing respiratory symptoms - similar to that seen with rhinoviruses - although in some cases it can be severe enough to require hospitalization. There are reports of a number of children ending up in intensive care, some requiring ventilatory assistance, over the past week.


While children are usually the hardest hit, adults are not immune. Co-morbidities – such as asthma – can exacerbate the symptoms.


The virus (genus Enterovirus - family Picornaviridae – species HEV-D) –  is just one of a large family of small RNA viruses that include the three Polioviruses, along with myriad non-polio serotypes of Human Rhinovirus, Coxsackievirus, echovirus, and human, porcine, and simian enteroviruses.


HEV-D68  was first indentified in 1962, but until about 5 years ago, had not been often reported. The CDC called attention to its emergence several years ago - (see MMWR: Clusters Of HEV68 Respiratory Infections 2008-2010) – which looked at a half dozen  HEV 68 associated clusters that occurred in Asia, Europe, and the United States during 2008--2010.


EV 68’s rarity up until now in North America likely equates to very low levels of community immunity, which probably explains its rapid dissemination over the past couple of weeks, spurred on by the start of the school year.


For most kids (and adults) this will likely prove little more than a nasty `cold’ or virus.  But in a small percentage of cases, it can turn severe, and so parents need to pay particular attention this fall.  This virus appears to have `legs’, and so we could see a busy start to the winter respiratory illness season. 


While rarely seen in the United States, over the past 10 years we’ve seen this virus on the ascendant in China, The Netherlands, Japan, and the Philippines, sometimes producing significant outbreaks. 


A few recent studies include:


J Med Microbiol. 2014 Mar;63(Pt 3):408-14. doi: 10.1099/jmm.0.068247-0. Epub 2013 Dec 9.

Detection of enterovirus 68 as one of the commonest types of enterovirus found in patients with acute respiratory tract infection in China.

Lu QB1, Wo Y, Wang HY, Wei MT, Zhang L, Yang H, Liu EM, Li TY, Zhao ZT, Liu W, Cao WC.

Author information

Human enterovirus 68 (HEV-68) is an enterovirus associated with respiratory illness. In China, no information about HEV-68 is available for children yet. This study aimed to investigate the presence of HEV-68 in mainland China between 2009 and 2012 and to explore the migration events of HEV-68 across the world.

Among 1565 samples tested from children, 41 (2.6%) were positive for HEV and 223 (14.3%) for human rhinovirus (HRV). Seven (17.1%) of 41 HEVs were HEV-68. Two HEV-68- and five HRV-positive samples were detected in 585 adult samples. HEV-68 is the predominant type of enterovirus in children with acute respiratory tract infection (ARTI), followed by HEV-71 and coxsackievirus A6. Three HEV-68-infected children presented with severe pneumonia and one presented with a severe asthma attack.

The viruses were attributed to two novel distinct sublineages of HEV-68 based on phylogenetic analysis of partial VP1 gene sequences. Migration events analysis showed that the USA and the Netherlands were possible geographical sources of HEV-68, from where three strains migrated to China.

In conclusion, HEV-68 may play a predominant role among the enteroviruses associated with ARTI in children. Additional surveillance is needed to clarify the reason why HEV-68 causes such a wide spectrum of disease, from asymptomatic to severe respiratory disease and even death.

Virology. 2012 Feb 5;423(1):49-57. doi: 10.1016/j.virol.2011.11.021. Epub 2011 Dec 15.

Emergence and epidemic occurrence of enterovirus 68 respiratory infections in The Netherlands in 2010

Meijer A1, van der Sanden S, Snijders BE, Jaramillo-Gutierrez G, Bont L, van der Ent CK, Overduin P, Jenny SL, Jusic E, van der Avoort HG, Smith GJ, Donker GA, Koopmans MP.

Author information

Following an increase in detection of enterovirus 68 (EV68) in community surveillance of respiratory infections in The Netherlands in 2010, epidemiological and virological analyses were performed to investigate the possible public health impact of EV68 infections.

We retrospectively tested specimens collected from acute respiratory infections surveillance and through three children cohort studies conducted in The Netherlands from 1994 through 2010. A total of 71 of 13,310 (0.5%) specimens were positive for EV68, of which 67 (94%) were from symptomatic persons. Twenty-four (34%) of the EV68 positive specimens were collected during 2010. EV68-positive patients with respiratory symptoms showed significantly more dyspnea, cough and bronchitis than EV68-negative patients with respiratory symptoms. Phylogenetic analysis showed an increased VP1 gene diversity in 2010, suggesting that the increased number of EV68 detections in 2010 reflects a real epidemic.

Clinical laboratories should consider enterovirus diagnostics in the differential diagnosis of patients presenting with respiratory symptoms.

J Clin Virol. 2011 Oct;52(2):103-6. doi: 10.1016/j.jcv.2011.06.019. Epub 2011 Jul 29.

Upsurge of human enterovirus 68 infections in patients with severe respiratory tract infections

Rahamat-Langendoen J1, Riezebos-Brilman A, Borger R, van der Heide R, Brandenburg A, Schölvinck E, Niesters HG.



Enterovirus 68 (EV68) belongs to species Human enterovirus D. It is unique among enteroviruses because it shares properties with human rhinoviruses. After the first isolation in 1962 from four children with respiratory illness, reports of (clusters of) EV68 infections have been rare. During the autumn of 2010, we noticed an upsurge of EV68 infections in the Northern part of the Netherlands in patients with severe respiratory illness.


To give a detailed description of the clinical and virological data of patients with EV68 infection identified in 2010, and compare these with data collected in 2009.


We systematically collected clinical data from patients with an EV68 infection detected in 2010. We added four patients with an EV68 infection from 2009. Further characterization of EV68 was performed by partial sequence analysis of the VP1 genomic region.


In 2010, EV68 was identified as the only cause of respiratory illness in 24 patients, of which 5 had to be admitted to the intensive care unit. Sequence analysis revealed different lineages in the majority of EV68 detected in 2010 as compared to the 2009 isolates.


We noticed an increase of EV68 infections and present clinical as well as sequence data, in which two distinct phylogenetic clusters could be identified.

The advice being given this year is pretty standard, but worth repeating:

  • Get your flu shot (no, it won’t prevent EV 68, but it could help prevent a dual flu - Enterovirus infection)
  • stay home if you are sick & obtain consultation from your health care provider 
  • avoid contact with those who are sick
  • practice good `flu hygiene’  (cover coughs & sneezes)
  • Avoid touching your face, mouth, and eyes with unwashed hands
  • and wash your hands often





jeff said...

Fantastic information! Thanks for the hard work that surely went into gathering and organizing all of this info. :)


I am suppose to be traveling to Denver in October for a conference, how long do these outbreaks last and should I consider not going?

Michael Coston said...


I don't think anyone can give you a firm answer as to the duration, but some of the media reports suggest the number of new cases have already started to level off in some areas.

I would make two points.

First, for most people, this is no worse than a bad cold.

Second, its doing a pretty good job of spreading.So there are no guarantees it won't come to you wherever you live.

While we each must make decisions regarding what we consider `acceptable risks', personally, I wouldn't cancel any of my travel plans because of it.


Thanks, I am not worried so much about me, I am disabled and the person that was going to escort me has asthma. I will go with or without her.

Anonymous said...

I too thank you for your detail, explination & especially your closing notes. I did several quick searches before finding your page (nothing was as through) & hoped I was correct in my conclusion. After reading this I feel very informed & encouraged.

Anonymous said...

how do the doctors test someone for this virus? What makes this virus different from a bad respiratory cold in someone who has asthma? I only ask because I am fighting a bad respiratory cold and I have asthma and am now on my second dose of steroids just to breathe. It has really been a very bad respiratory cold. I am having a hard time with recovering from this one. What is treatment?

Michael Coston said...


This is a seldom seen virus, and most local labs cannot reliably detect it. Samples are generally sent to the CDC for testing - which can take several days to get back.

Many patients won't be tested, since treatment is the same regardless of the viral type, and the time delay in getting results.

Based on average symptoms, most patients (and their doctors) would assume they just had ordinary cold (rhinovirus). Why it is worse - particularly for asthmatics - isn't known yet. We don't have a long track record dealing with it.

This virus was detected because someone became suspicious over seeing a large volume of `out of season' respiratory cases showing up at local hospitals.

Health officials are extra vigilant these days about respiratory outbreaks given concerns over MERS, H7N9, and a host of other novel viruses that could show up.

Your doctor will treat you essentially the same as for any other severe respiratory virus (except - there are no specific antivirals for this virus).

Kevin said...

I have Asthma and I stopped getting the Flu shot back when I turned 18, yet now I am 33 years old. When I did get the Flu Shot I would get the Flu at least 2 times. The smallest cold or virus I usually get really sick. What other things can one person do to help prevent getting anything bad besides washing your hands and covering when you sneeze?

Michael Coston said...


The flu shot only protects against 3 pre-selected flu strains, and offers no protection against rhinoviruses, enteroviruses, adenoviruses, and other common respiratory ailments.

Even against influenza, it may only be 50% to 60% effective.

Which means you still have a pretty good chance to catch a respiratory virus (or two) each year, even if you get the flu shot.

Influenza tends to be the most severe of these viruses, so it still makes sense to get the shot, even though there are no guarantees.

Aside from hand washing and covering sneezes:

Stay home if you are sick & call your health care provider

Avoid crowds & contact with those who are sick

Avoid touching your face, mouth, and eyes with unwashed hands

Anonymous said...

Our son had open heart surgery when he was a week old he is now 2 but when he gets sick he gets really sick he doesnt have to have anymore surgerys that we know of but I am concerned now we live in Nebraska and yesterday he was fine today he has a runny nose a very horse cough and is sneezing we have a 2 month old baby whom he loves to kiss a lot any suggestions?

Michael Coston said...


I'm sorry, I can't offer any advice other than for you to call your pediatrician.

Kristin said...

Do you we know how long the cold like symptoms go on before severe symptoms would begin? My son is 9 and is former asthmatic, being as he hasn't had any issues in over 2 years. He currently has a cough and runny nose, but has had them for 4 days now.. Do you think it would have turned severe by now?

Michael Coston said...


I'm sorry, It ethical for me to offer offer any medical advice.

All I can say is keep an eye on him and call your doctor if you are concerned.

Anonymous said...

I think I just had this. I was sick for two months. Avoid perfumes and dust the first week or two nothing helped then I got better than days later I got worse. Then I went back for a second round of antibiotics by then I had sinusitis. Bronchitis and throat infection. After two weeks I improved and am still congested and cough but finally after two months I do not feel sick. Used Zpac antibiotic. And benadryl

Anonymous said...

Mine was severe by day 2.

And even worse on day 3

Anonymous said...

Would the RSV vaccine offer any protection or lessen the severity?

Michael Coston said...


There isn't a currently available RSV vaccine, so I'm assuming you are talking about the prophylactic administration of Palivizumab.

Palivizumab is a monoclonal antibody directed against a very specific epitope in the RSV virus.

I'm no expert in this field, but I suspect it would be quite the long shot for it to protect against EV-D68.

As always, you should consult your family doctor when considering any medical course of action.

Anonymous said...

I am in Vancouver Canada. I am a retired nurse, 51 years old and have always had a history of bronchitis and chest infections since my childhood. I have a 7 year old who was very ill (cold and respiratory distress) at the end of Aug and early Sept (before the recent media awarensess of Enterovirus 68). He has a strong immune system and rarely gets sick but this was a LONG bad one! I fought and fought it off with lots of sleep and eating healthy and with lots of immune boosters and still ended up sick, and I believe it to be Enterovirus 68. I am so upset that the media is NOT warning vulnerable Seniors and those with lower immune systems! Four years ago when my son was a toddler in daycare alot, I had "walking pnenomia" THREE times in 18 months, so I KNOW what that is and feels like, and this is soooo much different! The coughing and not being able to breathe and it hanging on now past a week, even after a full dose of Biaxin XL for 7 days. I dont want to go back to the Doctor just to confirm my breathing struggle and get 'quarantined' as there is no one else to look after my family! I just want it KNOWN in this recent media blast that ADULTS can get it tooo, and Please Please Please get this out there that it is NOT just a 'children's' virus so others can protect themselves in advance and do ALL they can to NOT get this sick! I just called my father who has had a laryngectomy and throat cancer survivor for 8 years and THIS coughing would be sooo hard on him and being a "neck breather" through a HOLE! I am going to do ALLL I can to help him from being exposed and keep him out of the public; he is 80 years old and people like this DESERVE to be warned that this could affect them also! Wearing a mask if needed and just not going out if not needed! All I have read is just that it is a "children and young teens virus". Here in Vancouver one recent confirmed case was a 19 year old, so please do anything to help us "old peeps" with weak lungs and tired immune systems KNOW to be super cautious and that is CAN affect us to we can be more aware of trying not to get it too! Going to the hospital tomm, if not better to help my breathing and will give in to hospitalization now if I have to, now it is that bad! thanks for reading and for all the help you can hopefully give:)

Anonymous said...

I am 43 years old and believe I have this virus. Last Monday I woke up with a sore throat, cough, runny/stuffy nose and mild fever. By Tuesday I was wheezing and short of breath. I do have asthma, but it has always been very mild. I have never had an illness before where I struggled to breathe. A week and a half later, I am doing much better, but am still not back to 100%. I did not get tested for the virus, so I can't say for sure that's what it is, but it sure sounds like it.

Anonymous said...

I got sick on Sept 9th. But not with the breathing and coughing issue. I have burning in my legs from the waist down. After I had bad diarrhia. Then several days later I got a severe stabbing headache on the left side of my head and it has not gone away. Now it is October 4th. I heard that this enterovirus takes 2 forms the respirtory and on that has neurological. I have been to several doctors already and they do not know why but this have not tested me for the Enterovirus. I think the doctors don't know enough about this virus or they don't want to get the CDC involved. Anybody know if this is how it is effecting adults?

Cherie said...

I too am sure I have it. I am 67 years old and have mild asthma. I started out coughing and coughed for now six weeks. The doctor out me on Antibiotics and steriods because I could not breathe. I am using inhalers and reacting to anything in the air like perfumes, cleaning at restrooms, or least little exercise. I am using cough syrup and it only helps a little. I use my,inhalers several times a day. I am wore out and frustrated to tears. The doctor says I now have asthmaic bronchitis. I had to,go,in to,the doctors twice for a breathing treatment because I,could not breathe. How long does it last?