Wednesday, December 27, 2017

Taiwan Reports 5 More Severe Enterovirus Infections

Credit Taiwan CDC


Acute flaccid myelitis (AFM) is a rare polio-like illness that affects a person’s nervous system - specifically the spinal cord - and is characterized by sudden weakness in one or more arms or legs, along with loss of muscle tone and decreased or absent reflexes.

AFM is a subset of conditions that fall under a broader `umbrella' of syndromes called Acute Flaccid paralysis (AFP), which may include myelitis, peripheral neuropathy, myopathy, Guillain-Barré syndrome (GBS), toxic neuropathy, and other muscle disorders.
While the exact causes of Acute flaccid myelitis aren't fully understood, it has been linked to a number of viral infections, including West Nile Virus, Adenoviruses, and a number of (polio and non-polio) enteroviruses, including EV-71 and more recently, EV-D68
Non-polio Enteroviruses (NPEV's) - of which there are literally dozens - typically spread in the summer and early fall, and generally produce mild or asymptomatic infections, mostly in children under the age of 10. Two weeks ago we looked at a report from the Taiwan CDC: Of A Late Season Surge In EV-D68 Cases, which included a couple of severe (AFP) reports).

A nationwide outbreak of EV-D68 was linked to a concurrent spike in AFP cases across the United States in the fall of 2014, and while a pretty strong circumstantial case has been made over the past couple of years (see EID Journal Enterovirus D68 Infection in Children with Acute Flaccid Myelitis, Colorado, USA, 2014), no definitive causal link to EV-D68 has been established.
Some of these AFM cases have tested positive for EV-D68, while others have not. The CDC continues to investigate.
With seasonal flu rising in Taiwan, diagnosing EV-D68 (or other enterovirus) infections early on becomes more difficult.  With no vaccine, high transmissibility, and the potential for severe complications - particularly in children -  Taiwan's CDC issued the following advice to parents yesterday.

Press Releases
Public urged to pay attention to health of children as Taiwan CDC confirms 5 new cases of enterovirus infection with severe complications ( 2017-12-26 )

During December 17 and 23, 2017, the Taiwan Centers for Disease Control (Taiwan CDC) confirmed 5 new cases of enterovirus infection with severe complications. 
In light of the increasing number of cases of enterovirus infection with severe complications reported and the majority of these new cases are infected with enterovirus D68, Taiwan CDC invited the Pediatric Neurology professor from the Fu Jen Catholic University College of Medicine who is also Taiwan CDC’s Acute Flaccid Paralysis Surveillance Expert Northern Region Convener to discuss the symptoms induced by enterovirus D68, including acute flaccid paralysis and numbness, and urge parents to pay attention to the health of the children in their households and take the children to hospitals immediately when suspected symptoms develop.

Professor Hung Kun-long (洪焜隆) pointed out besides the common symptoms of enterovirus infection such as hand, foot and mouth disease (HFMD) and herpangina, the primary symptoms of enterovirus D68 infection include the symptoms of the upper respiratory tract infection such as fever, runny nose, and cough. A few infected individuals may develop complications such as encephalitis and myelitis. However, once limb weakness or numbness develops, patients might develop permanent sequelae that will require extensive physical therapy.
Professor Hung reminded the public that as there is no effective vaccine to prevent or drug to treat the infection, the most effective ways to prevent infection are to wash hands properly and frequently with soap and water and practice good personal hygiene. If a child in the household develops flaccid paralysis, he/she needs to be taken to a large hospital for treatment as soon as possible.

The 5 new cases of enterovirus infection with severe complications confirmed last week are respectively caused by enterovirus D68 (2 cases), CA9 (2 cases), and EV71 (1 case).   
Among them, the 2 cases caused by enterovirus D68 respectively are a 4-year-old boy who resides in northern Taiwan and 5-year-old boy who resides in southern Taiwan. Both of them developed symptoms, including cough, runny nose, fever and sudden onset of limb weakness in early December. As of now, both of them are still hospitalized for treatment.
The cases caused by CA9 respectively are a 5-year-old girl and a 3-year-old boy who reside in northern Taiwan. Both of them developed symptoms, including fever, vomiting, gait abnormality, limb weakness and encephalitis in early December and their infections were laboratory confirmed. As of now, both of them have recovered and been discharged from the hospital.
The case caused by EV71 is a 13-year-old boy who resides in southern Taiwan. He developed symptoms, including fever, oral ulcer, sore throat, nausea, dizziness, general weakness and gait abnormality in early December and his infection was laboratory confirmed. As of now, the case’s conditions have been improved and he has been discharged from the hospital.

Thus far this year, 20 cases of enterovirus infection with severe complications, including 1 death, respectively caused by enterovirus D68 (8 cases), CA 6 (3 cases), CB3 (2 cases), CA9 (2cases), echovirus 5 (2 cases), enterovirus 71 (2 cases), and CA 2 (1 case) have been confirmed. 

All enteroviruses are transmitted through the fecal-oral route, respiratory droplets and direct contact. The most effective ways to ward off enteroviruses are to practice good hand hygiene and cough etiquette, avoid visiting crowded public places, and rest at home when sick. When a child in a household develops symptoms of complications such as drowsiness, disturbed consciousness, inactivity, flaccid paralysis, myoclonic jerk, continuous vomiting, tachypnea, and tachycardia, please take the child to a large hospital for medical attention immediately in order to ensure prompt treatment. For more information, please visit the Taiwan CDC website at or call the toll-free Communicable Disease Reporting and Consultation Hotline, 1922 (or 0800-001922).

In August of 2016 Taiwan's CDC announced their 1st Case Of EV-D68 With Acute Flaccid Paralysis.   While not alone in causing severe Enterovirus-related illness in Taiwan, it sits in the lead this year in causing severe illness.  
EV-D68 is relative newcomer, however, as EV-71 has long been considered the biggest enterovirus threat in Asia. It remains to be seen whether this reversal in that trend continues.
 Some earlier blogs on EV-D68 and other NPEVs include:

MMWR: Cluster of Acute Flaccid Myelitis in Five Pediatric Patients - Arizona, 2016
CDC Acute Flaccid Myelitis Update - January 2017

EID Journal Upsurge In EV-D68 In The Netherlands, 2016

Taiwan CDC: 1st Case Of EV-D68 With Acute Flaccid Paralysis 

ECDC: Rapid Risk Assessment On Recent Enterovirus Outbreaks In Europe

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