#17,537
Just over a week ago, in WHO: DON On Enterovirus (Echovirus-11 (E-11)) Uptick In France, we looked at report from the World Health Organization on an apparent new lineage of Echovirus-11 affecting neonates in France.
The WHO reported at least 9 severe infections in neonatal patients (including 7 deaths) over the past year.
That DON was followed up by a few hours later by a report in Eurosurveillance: Severe and fatal neonatal infections linked to a new variant of echovirus 11, France, July 2022 to April 2023, that suggested ` a new variant of E-11 is currently circulating and associated with a high risk of severe neonatal infection and death at least in France.'
Enteroviruses encompass a large family of small RNA viruses that include the three Polioviruses, along with myriad non-polio serotypes (NPEVs) of Human Rhinovirus, Coxsackievirus, echovirus, and human, porcine, and simian enteroviruses.
Most NPEV infections are mild, or asymptomatic, but they can occasionally lead to severe illness, paralysis, or even death. As the chart below indicates, EV-D68 was the most reported NPEV reported in the United States between 2014-2016, but it was joined by a number of other enteroviruses, including Echovirus 11.
Surveillance and reporting is sketchy, both here in the United States and around the world. Some data is submitted by laboratories, and clusters of cases in one or more hospitals may spark an alert or an investigation, but for the most part non-polio enteroviruses are not `reportable' in the United States, or most European countries.
Last week I closed my blog on the WHO report by saying `Hopefully, if today's report is more than a transient, localized, outbreak we'll hear from other countries in the days and weeks ahead.'
Now that the alarm has been sounded, that has begun to happen.
Yesterday the WHO confirmed that this spike in Echovirus-11 extends far beyond France, with cases reported in Croatia, Italy, Spain, Sweden and the UK.
Given limited surveillance, this likely represents only a subset of the actual number of severe cases.
First some excerpts from a lengthy WHO Update (follow the link for country-specific information), after which I'll have a bit more.
Enterovirus-Echovirus 11 Infection - the European Region
7 July 2023
Situation at a glance
Since the Disease Outbreak News published on 31 May 2023 which reported enterovirus, Echovirus 11 (E-11) infection in France, additional Member States in the European Region have notified WHO of cases of E-11 among newborns.
As of 26 June 2023, Croatia, Italy, Spain, Sweden, and the United Kingdom of Great Britain and Northern Ireland have reported cases of E-11 infection confirmed in newborns. Further investigations and public health responses are being implemented in each of these Member States.
This Disease Outbreak News provides updates on the event and the public health response implemented in the reporting and non-reporting countries in the European Region.
Based on the limited information available, WHO assesses the public health risk for the general population to be low, while we continue to encourage countries to monitor for and report on cases. Health facilities caring for newborns should familiarize themselves with the signs and symptoms of echovirus and maintain vigilance for potential healthcare-associated infections and outbreaks.
Description of the cases
On 5 May 2023, France reported an increase in cases of severe neonatal sepsis associated with Enterovirus (Echovirus-11 (E-11)). A total of nine cases of neonatal sepsis with hepatic impairment and multi-organ failure with seven deaths were reported between July 2022 and April 2023 from four hospitals in three regions of France.
As of 26 June 2023, Croatia reported one confirmed case of E-11 infection from a cluster of enterovirus diseases in neonates detected in June 2023, Italy has reported seven cases of E-11 infection confirmed in neonates between April and June 2023, Spain reported two cases of E-11 infection in 2023, Sweden reported five E-11 cases with four cases of meningoencephalitis among infants due to E-11 infection between 2022 and 15 June 2023, and the United Kingdom of Great Britain and Northern Ireland (the UK) reported two cases in March 2023.
(SNIP)
WHO risk assessment
Between 2022 and June 2023, a few Member States in the European Region reported the detection of positive enterovirus, especially Echovirus 11 (E-11) cases. These include Croatia, France, Italy, Spain, Sweden and the UK. So far, Austria, Belgium, Denmark, the Netherlands, and Norway have reported no increase of E-11 associated with cases of neonatal sepsis has been observed in 2022 and 2023.
Based on the limited information available, WHO assesses the public health risk for the general population to be low. However, asymptomatic carriage and shedding of infectious viruses are a feature of enterovirus infection.
Although some countries have enterovirus surveillance, there is no systematic European-wide enterovirus surveillance in place in the European Region. It is therefore difficult to estimate the extent of the current severe neonatal E-11 infections or background rates for circulation of E-11 viruses in the population. Without enterovirus surveillance, only the most severe cases will probably be detected through active efforts to test and type specimens from such cases. As non-polio enterovirus infection is often not a notifiable disease in Member States, additional cases of severe neonatal enterovirus infection may have gone undiagnosed and/or unreported.
WHO advice
Non-polio enteroviruses are common and distributed worldwide. Although infections often are asymptomatic, some may present with respiratory tract infections. Some of the reported cases had fever and apnoea and progressed to hepatocellular and renal failure within the neonatal sepsis presentation. These viruses are also associated with occasional outbreaks in which an unusually high proportion of patients develop clinical disease, sometimes with serious and fatal consequences. Clinicians managing neonates and young infants presenting with circulatory shock should consider an underlying diagnosis of sepsis and perform appropriate diagnostic investigations, including testing for enteroviruses.
Health-care staff working with samples suspicious of non-polio enteroviruses should be properly trained to collect, store, and transport various samples. If samples are referred domestically and/or internationally for confirmation, typing, or sequencing purposes, appropriate national and international regulations on the transport of infectious substances should be strictly followed. Laboratories that perform sequencing should consider sharing genetic sequence data through publicly accessible databases.
No specific antiviral therapy for echovirus infection is available, and treatment focuses on preventing complications. Health facilities caring for obstetric and neonate populations should familiarize themselves with the signs and symptoms of echovirus infection and maintain vigilance for potential healthcare-associated infection cases and outbreaks in hospital units providing neonatal care. Health facilities and healthcare workers should implement infection prevention and control measures with a focus on adherence to WHO “Your 5 Moments for Hand Hygiene”, visitor restriction, re-enforcing the importance of cleaning and disinfecting the environment and use of contact precautions when caring for neonates suspected or confirmed to have E-11. For suspected and confirmed neonatal cases consider isolation, ensure utensils (e.g., cup, spoon, syringe) for supplemental feeding are not shared and educate mothers and caregivers on personal hygiene and handwashing during care of newborn including diaper change. WHO provides training for health and care workers on preventing maternal and neonatal infections in health facilities, which can be accessed on Open WHO.
A little over a year ago, when reports of an unusual increase in hepatitis in children began to emerge from UK, it didn't take long before other European nations began to report cases (see WHO Update On Acute Hepatitis Of Unknown Aetiology In Children), as well as the United States (see CDC Technical Report: Acute Hepatitis of Unknown Cause).
Similarly, in 2014 - when an unusual outbreak of EV-D68 began in the American Midwest (with accompanying reports of Acute Flaccid Paralysis) - it wasn't long before cases began turning up in Europe (see Eurosurveillance: Acute Flaccid Paralysis Following EV-D68 Infection – France).
Prevention & Treatment
Prevention
Many people who get infected with non-polio enteroviruses do not have symptoms but can still spread the virus to other people. This makes it is difficult to prevent them from spreading. The best way to help protect yourself and others from non-polio enterovirus infections is to:
- wash your hands often with soap and water for 20 seconds, especially after using the toilet or changing diapers
- avoid close contact, such as touching and shaking hands, with people who are sick
- clean and disinfecting frequently touched surfaces
Learn the Right Way to Wash Your Hands
See this infographic on prevention steps: Keep Your Child from Getting and Spreading Enterovirus D68.
There is no vaccine to protect you from non-polio enterovirus infection.Treatment
There is no specific treatment for non-polio enterovirus infection. People with mild illness caused by non-polio enterovirus infection typically only need to treat their symptoms. This includes drinking enough water to stay hydrated and taking over-the-counter cold medications as needed. Most people recover completely. However, some illnesses caused by non-polio enteroviruses can be severe enough to require hospitalization.
If you are concerned about your symptoms, you should contact your health care provider.
