Alabama | Positive cases of Enterovirus D68 confirmed

The Alabama Department of Public Health is investigating clusters of children with suspected Enterovirus D68 (EV-D68).

As of Sept. 15, results show 4 of 6 specimens from Mobile County
sent to the Centers for Disease Control and Prevention are positive for EV-D68. One of the specimens was positive for Coxsackievirus B3 and the remaining one was negative.

Health care providers have been asked to report clusters of cases. While individual cases of EV-D68 do not require reporting, a cluster must be reported.

In general, enteroviruses have various symptoms, including mild respiratory, fever, rash and neurologic illness. EV-D68 has more severe respiratory symptoms. There is no vaccine; treatment depends on the symptoms, and prevention is very important.

To prevent EV-D68 and all other communicable viruses like influenza, people need to
• Wash their hands frequently
• Cover their cough
• Keep children home if ill
• Avoid touching eyes, nose and mouth with unwashed hands
• Avoid kissing, hugging, and sharing cups and eating utensils with sick people
• Disinfect frequently touched surfaces, such as toys and doorknobs

If you or a family member has severe respiratory symptoms, please contact your doctor and follow his/her advice.

British Columbia | Take Home Naloxone program saves more lives

BC’s pilot Take Home Naloxone (THN) program has reversed 125 opioid drug overdoses over the past two years, according to the BC Centre for Disease Control.

Naloxone is a safe medication that can reverse the effects of an overdose of an opioid drug, such as heroin, morphine, fentanyl or oxycodone. Without action, an overdose can cause a person’s breathing to slow or stop which can eventually lead to severe brain damage or death. In the event of an opioid overdose, naloxone restores normal breathing within 2-5 minutes.

Since the program began in August 2012, 1215 naloxone kits have been distributed in 51 sites throughout BC. In addition, the program has trained more than 2,200 people, including people who use drugs, friends, family members, and service providers, to recognize and respond to an opioid overdose using the kit and medication. Eligible participants are prescribed a naloxone kit.

“Illicit and prescription drug overdose deaths continue to be a preventable tragedy in British Columbia. The BC Take Home Naloxone program has proven that it saves lives by equipping people with training and a safe medication that can reverse the effects of opioids,” said Dr. Jane Buxton, harm reduction lead, BC Centre for Disease Control.

Royal Inland Hospital in Kamloops, a BCTHN site, recently became the first emergency department in Canada to provide overdose prevention and response training and naloxone kits to at-risk patients.

“Emergency departments often see opioid users who are at highest risk for overdose deaths. Royal Inland Hospital is at the cutting edge of harm reduction, integrating an effective prevention manoeuvre [THN] with acute care services. Staff have wholeheartedly embraced the program. I am struck by the leadership, pragmatism, and compassion of the RIH physicians and nurses who stop and take the time to offer a simple yet lifesaving tool to some of their most marginalized patients,” said Dr. Tevor Corneil, Medical Health Officer, Interior Health Authority.

The Inner City Youth Program at St. Paul’s Hospital in Vancouver began a research study this summer to understand the experience of youth with the THN program which will help to inform future programs for youth.

“The Take Home Naloxone initiative has seen a remarkable number of youth in the Inner City Youth Program participate in the training and apply this intervention in critical, life-saving situations. It has contributed to their personal sense of autonomy and fostered our dialogue with them,” said Dr. Steve Mathias, Medical Manager, Inner City Youth Program.

Naloxone is currently used in harm reduction programs in the U.K, Italy, Germany, Australia and 17 US states. In Canada, naloxone programs are also available in Alberta and Ontario.

Facts:

· In 2013, there were 308 deaths in BC due to illicit drug overdoses, the majority involving opioids.

· The BC Coroners Service has reported 27 deaths from January to April 2014 where fentanyl, a very strong opioid, was detected.

· Canada has the highest consumption of opioid prescription drug use in the world. Overdoses can occur with both prescription and illicit opioids.

Learn more:
http://towardtheheart.com/naloxone/
Recently published evaluation of Take Home Naloxone program

Michigan | Community health officials receiving reports of increase in severe respiratory illness in children

The Michigan Department of Community Health (MDCH) is receiving reports indicating an increase in severe respiratory illness in children ages 5-17 across the state. MDCH is working with local health departments and hospitals to investigate these cases.

At this time, Michigan has no confirmed cases of Enterovirus D68 (EV-D68) associated with the national outbreak, but MDCH is forwarding samples to the Centers for Disease Control and Prevention (CDC) for testing.

Nationally, clusters of EV-D68 infections have recently impacted the pediatric population in multiple states. Original reports described clusters of illness in Missouri and most recently Illinois. The majority of those cases had a previous medical history of asthma or prior wheezing. Currently, suspected cases are also being investigated in Alabama, Colorado, Georgia, Iowa, Kansas, Kentucky, Michigan, Ohio, Oklahoma and Utah.

Enteroviruses are very common viruses; there are more than 100 types. It is estimated that 10 to 15 million enterovirus infections occur in the United States each year. Symptoms of EV-D68 infection can include wheezing, difficulty breathing, fever and racing heart rate. Most people infected with enteroviruses have no symptoms or only mild symptoms, but some infections can be serious requiring hospitalization. Enteroviruses are transmitted through close contact with an infected person, or by touching objects or surfaces that are contaminated with the virus and then touching the mouth, nose, or eyes. There is no specific treatment for EV-D68 infections but supportive care can be provided.

Young residents with asthma are encouraged to be vigilant in taking their asthma controlling medications. Further, Michiganders can protect themselves from enterovirus by taking general hygiene precautions:

  • Wash hands often with soap and water for 20 seconds, especially after changing diapers.
  • Avoid touching eyes, nose and mouth with unwashed hands.
  • Avoid kissing, hugging, and sharing cups or eating utensils with people who are sick.
  • Disinfect frequently touched surfaces, such as doorknobs, especially if someone is sick.

Additional information about human EV-D68 can be found in today’s CDC Morbidity and Mortality Weekly Report: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6038a1.htm.

Massachusetts | Second human case of West Nile virus announced

The Massachusetts Department of Public Health (DPH) today announced the second human case of West Nile virus (WNV) in the state this year. The woman is a resident of Middlesex County in her 40’s who was hospitalized, but has been released and is recovering.

This finding raises the risk level to “Moderate” in the following communities: Melrose, Reading, Saugus, Stoneham, Wakefield, Winchester and Woburn.

“While cooler weather reduces mosquito activity, risk for mosquito-borne illness remains a concern until the first hard overnight frost,” said State Public Health Veterinarian Dr. Catherine Brown. “Residents need to continue to take steps to protect themselves against mosquito bites: use insect repellant, cover up, and avoid outdoor activities at dusk and after nightfall when mosquitoes are at their most active.”

This is the second human case of WNV in the state this year. In 2013, there were eight human cases of WNV infection identified in Massachusetts. While WNV can infect people of all ages, people over the age of 50 are at higher risk for severe disease. WNV is usually transmitted to humans through the bite of an infected mosquito. Most people infected with WNV will have no symptoms. When present, WNV symptoms tend to include fever and flu-like illness. In rare cases, more severe illness can occur.

People have an important role to play in protecting themselves and their loved ones from illnesses caused by mosquitoes.

Avoid Mosquito Bites

Apply Insect Repellent when Outdoors. Use a repellent with DEET (N, N-diethyl-m-toluamide), permethrin, picaridin (KBR 3023), oil of lemon eucalyptus [p-methane 3, 8-diol (PMD)] or IR3535 according to the instructions on the product label. DEET products should not be used on infants under two months of age and should be used in concentrations of 30% or less on older children. Oil of lemon eucalyptus should not be used on children under three years of age.

Be Aware of Peak Mosquito Hours. The hours from dusk to dawn are peak biting times for many mosquitoes. Consider rescheduling outdoor activities that occur during evening or early morning.

Clothing Can Help Reduce Mosquito Bites. Wearing long-sleeves, long pants and socks when outdoors will help keep mosquitoes away from your skin.

Mosquito-Proof Your Home

Drain Standing Water. Mosquitoes lay their eggs in standing water. Limit the number of places around your home for mosquitoes to breed by either draining or discarding items that hold water. Check rain gutters and drains. Empty any unused flowerpots and wading pools, and change water in birdbaths frequently.

Install or Repair Screens. Keep mosquitoes outside by having tightly-fitting screens on all of your windows and doors.

Protect Your Animals

Animal owners should reduce potential mosquito breeding sites on their property by eliminating standing water from containers such as buckets, tires, and wading pools — especially after heavy rains. Water troughs provide excellent mosquito breeding habitats and should be flushed out at least once a week during the summer months to reduce mosquitoes near paddock areas. Horse owners should keep horses in indoor stalls at night to reduce their risk of exposure to mosquitoes. Owners should also speak with their veterinarian about mosquito repellents approved for use in animals and vaccinations to prevent WNV and EEE. If an animal is diagnosed with WNV or EEE, owners are required to report to DAR, Division of Animal Health by calling 617-626-1795 and to the Department of Public Health (DPH) by calling 617-983-6800.

More information, including all WNV and EEE positive results from 2013, can be found on the Arbovirus Surveillance Information web page at www.mass.gov/dph/mosquito or by calling the DPH Epidemiology Program at 617-983-6800.

DPH has produced a series of 30-second videos on how to prevent mosquito and tick bites and the illnesses that can result. All videos can be found at www.mass.gov/MosquitoesAndTicks. Media outlets are encouraged to share these videos on their websites. Instructions on how to embed the videos into external websites are included on this webpage.

Louisiana | DHH testing confirms presence of Naegleria Fowleri ameba in St John Water District 1 water system

The Louisiana Department of Health and Hospitals (DHH) announced that its testing confirmed the presence of the Naegleria fowleri ameba in the St. John Water District 1 water system. This water system serves 12,577 people in the towns of Reserve, Garyville and Mt. Airy. There are no known cases of illness related to the ameba in St. John the Baptist Parish or elsewhere in the state currently.

The water system was sampled as part of DHH’s surveillance program that just launched earlier this month. During the ameba testing, DHH discovered the system was not in compliance with the State’s emergency rule, which requires water systems to maintain a minimum disinfectant residual level of 0.5 milligrams per liter throughout all of their distribution lines. This 0.5 mg/L level is known to control the Naegleria fowleri ameba.

DHH has issued an emergency order requiring St. John Water District 1 to perform a free-chlorine burn (maintain 1.0 mg/l of free chlorine throughout the system for 60 days) to kill the amebae within the water system.  The water will remain safe to drink during this time.  At the end of 60 days, DHH will sample the system again for presence of the ameba.  In previous cases in Louisiana, this action has been effective in controlling the ameba. The emergency order also requires the system to achieve and maintain compliance with the state’s minimum chlorine residual of 0.5 mg/l throughout their system.

St. John Water District 1 is the third water system in Louisiana to test positive for the ameba. Last year, testing by the Centers for Disease Control and Prevention (CDC) confirmed the presence of the ameba in the St. Bernard Parish Water System and DeSoto Parish Waterworks District No. 1. The testing followed last summer’s death of a child in St. Bernard Parish and the 2011 deaths of two individuals in DeSoto and St. Bernard parishes. At the time of the 2011 deaths in DeSoto and St. Bernard parishes, health officials could only confirm the presence of the ameba in the homes of the deceased, but not in the water systems. In 2013, following the DeSoto and St. Bernard parish incidents, more advanced sampling technology was developed, which DHH used in this case. No known additional infections have occurred in DeSoto or St. Bernard parishes, as incidences of infection are extremely rare. Testing in May on DeSoto Parish Waterworks District No. 1 and St. Bernard Parish Water System did not detect the ameba.

Once St. John Water District 1 begins the chlorine burn, residents served by this water system may notice a change in the smell and taste of the water throughout the chlorine burn. However, the water will remain safe to drink. The St. John Water District 1 is one of several community water systems in the parish and services 12,577 customers. If residents are uncertain as to what water system they are served by, they should review their most recent water statement.

“We are working closely with the water system and parish officials to ensure that the chlorine levels are increased to a level that will reduce the risk of exposure to the ameba,” said DHH Public Health Assistant Secretary J.T. Lane. “Water from St. John Water District 1 remains safe to drink; however, we do have guidance for residents on steps they can take to reduce their risk.”

“Residents in Reserve, Garyville and Mt. Airy are advised to take all recommended pre-cautions to avoid having water enter their nose,” said St. John the Baptist Parish President Natalie Robottom.  “The parish Utilities Department is taking immediate actions to fully chlorinate the water system and eliminate the threat.  As more information becomes available, it will be released to the public.”

“Families can take simple steps to protect themselves from exposure to this ameba, the most important being to avoid allowing water to go up your nose while bathing or swimming in a pool,” said Louisiana State Health Officer Jimmy Guidry. “It is important to remember that the water is safe to drink; the ameba cannot infect an individual through the stomach.”

PRECAUTIONARY MEASURES FOR FAMILIES

According to the CDC, personal actions to reduce the risk of Naegleria fowleri infection should focus on limiting the amount of water going up a person’s nose and lowering the chances that Naegleria fowleri may be in the water. Preventative measures recommended by the CDC include the following:

  • DO NOT allow water to go up your nose or sniff water into your nose when bathing, showering, washing your face, or swimming in small hard plastic/blow-up pools.
  • DO NOT jump into or put your head under bathing water (bathtubs, small hard plastic/blow-up pools) – walk or lower yourself in.
  • DO NOT allow children to play unsupervised with hoses or sprinklers, as they may accidentally squirt water up their nose. Avoid slip-n-slides or other activities where it is difficult to prevent water going up the nose.
  • DO run bath and shower taps and hoses for five minutes before use to flush out the pipes. This is most important the first time you use the tap after the water utility raises the disinfectant level.
  • DO keep small hard plastic/blow-up pools clean by emptying, scrubbing, and allowing them to dry after each use.
  • DO use only boiled and cooled, distilled or sterile water for making sinus rinse solutions for neti pots or performing ritual ablutions.
  • DO keep your swimming pool adequately disinfected before and during use. Adequate disinfection means:
    • Pools: free chlorine at 1-3 parts per million (ppm) and pH 7.2-7.8, and
    • Hot tubs/spas: free chlorine 2-4 parts per million (ppm) or free bromine 4-6 ppm and pH 7.2-7.8.
  • If you need to top off the water in your swimming pool with tap water, place the hose directly into the skimmer box and ensure that the filter is running. Do not top off by placing the hose in the body of the pool.

Residents should continue these precautions until testing no longer confirms the presence of the ameba in the water system. Residents will be made aware when that occurs. For further information on preventative measures, please visit the CDC website here: http://www.cdc.gov/parasites/naegleria/prevention.html

FOR UPDATES

For more information on how to protect yourself and on the current status of testing, visit DHH’s Water Facts website at www.dhh.la.gov/WaterFacts. DHH launched the website to provide the public with accurate information about the ameba. DHH is also accepting questions from the public for using a form on this Website or via e-mail to DHHInfo@la.gov.

Louisiana | DHH testing confirms presence of Naegleria Fowleri ameba in Ebarb Water District 1 Aimwell area

The Louisiana Department of Health and Hospitals (DHH) announced that its testing confirmed the presence of the Naegleria fowleri ameba in the Ebarb Water District 1 Aimwell Area located in Sabine Parish.

This water system serves 5,529 people. There are no known cases of illness related to the ameba in Sabine Parish or elsewhere in the state currently.

The water system was sampled as part of DHH’s surveillance program that launched earlier in Aug. 2014. During the ameba testing, DHH discovered the system was not in compliance with the State’s emergency rule, which requires water systems to maintain a minimum disinfectant residual level of 0.5 milligrams per liter throughout all of their distribution lines. This 0.5 mg/L level is known to control the Naegleria fowleri ameba.

The Department’s new ameba sampling program is currently in its third round of testing. Thus far, eight systems have been tested, in addition to water systems in DeSoto and St. Bernard parishes. Of the eight, DHH has results for six; two of those six tested positive for Naegleria fowleri.

Of the six for which results were completed, none had the required level of chlorine residuals. For the two water system sampled this week, both had chlorine residuals above the required 0.5 mg/l. Next week, the fourth round of samples will be collected.

Test results take approximately 14 calendar days to process. Test results for the third week will be available the week of Sept. 22. The test results for the fourth round of samples will likely not be available until the end of the month.

DHH has issued an emergency order requiring Ebarb Water District 1 Aimwell Area to perform a free-chlorine burn (maintain 1.0 mg/l of free chlorine throughout the system for 60 days) to kill the amebae within the water system.  The water will remain safe to drink during this time. At the end of 60 days, DHH will sample the system again for presence of the ameba.  In previous cases in Louisiana, this action has been effective in controlling the ameba. The emergency order also requires the system to achieve and maintain compliance with the state’s minimum chlorine residual of 0.5 mg/l throughout their system.

Ebarb Water District 1 Aimwell Area is the fourth water system in Louisiana to test positive for the ameba. Last year, testing by the Centers for Disease Control and Prevention (CDC) confirmed the presence of the ameba in the St. Bernard Parish Water System and DeSoto Parish Waterworks District No. 1. The St. John the Baptist Water System also tested positive for the presence of the ameba late last month. It is currently undergoing the 60-day chlorine burn. No known additional infections have occurred in DeSoto, St. Bernard or St. John the Baptist parishes, as incidences of infection are extremely rare. Testing in May on DeSoto Parish Waterworks District No. 1 and St. Bernard Parish Water System did not detect the ameba.

Once Ebarb Water District 1 Aimwell Area begins the chlorine burn, residents served by this water system may notice a change in the smell and taste of the water throughout the chlorine burn. However, the water will remain safe to drink. If residents are uncertain as to what water system they are served by, they should review their most recent water statement.

“There are simple steps that residents in the Aimwell Area can take to avoid exposure to Naegeria Fowleri, but tap water is still safe to drink,” said DHH Public Health Assistant Secretary J.T. Lane. “We spoke with local officials in Sabine Parish and the water district; they are working quickly to implement a chlorine burn in order to eliminate any ameba that may exist through the water system.”

“Warm summer weather is ideal for swimming pools and outside with tap water, such as on a slip and slide, so it is important for families to take precautions, especially for small children,” said Louisiana State Health Officer Jimmy Guidry. “The ameba can only infect a person through very small holes in the top of the nose that lead to the brain, so it is an extremely rare infection in humans. Even still, it is so important for families in the area to take precautions.”

PRECAUTIONARY MEASURES FOR FAMILIES

According to the CDC, personal actions to reduce the risk of Naegleria fowleri infection should focus on limiting the amount of water going up a person’s nose and lowering the chances that Naegleria fowleri may be in the water. Preventative measures recommended by the CDC include the following:

  • DO NOT allow water to go up your nose or sniff water into your nose when bathing, showering, washing your face, or swimming in small hard plastic/blow-up pools.
  • DO NOT jump into or put your head under bathing water (bathtubs, small hard plastic/blow-up pools) – walk or lower yourself in.
  • DO NOT allow children to play unsupervised with hoses or sprinklers, as they may accidentally squirt water up their nose. Avoid slip-n-slides or other activities where it is difficult to prevent water going up the nose.
  • DO run bath and shower taps and hoses for five minutes before use to flush out the pipes. This is most important the first time you use the tap after the water utility raises the disinfectant level.
  • DO keep small hard plastic/blow-up pools clean by emptying, scrubbing, and allowing them to dry after each use.
  • DO use only boiled and cooled, distilled or sterile water for making sinus rinse solutions for neti pots or performing ritual ablutions.
  • DO keep your swimming pool adequately disinfected before and during use. Adequate disinfection means:
    • Pools: free chlorine at 1-3 parts per million (ppm) and pH 7.2-7.8, and
    • Hot tubs/spas: free chlorine 2-4 parts per million (ppm) or free bromine 4-6 ppm and pH 7.2-7.8.
  • If you need to top off the water in your swimming pool with tap water, place the hose directly into the skimmer box and ensure that the filter is running. Do not top off by placing the hose in the body of the pool.

Residents should continue these precautions until testing no longer confirms the presence of the ameba in the water system. Residents will be made aware when that occurs. For further information on preventative measures, please visit the CDC website here: http://www.cdc.gov/parasites/naegleria/prevention.html

FOR UPDATES

For more information on how to protect yourself and on the current status of testing, visit DHH’s Water Facts website at www.dhh.la.gov/WaterFacts. DHH launched the website to provide the public with accurate information about the ameba. DHH is also accepting questions from the public for using a form on this Website or via e-mail to DHHInfo@la.gov.

Indiana | Lake County children confirmed as having EV-D68 respiratory illness

State health officials announced today that four Lake County children have been confirmed as having had enterovirus D68 (EV-D68), a respiratory illness which can be serious in individuals with underlying medical conditions, such as asthma.

The individuals were treated at University of Chicago Hospital and were previously thought to be residents of Illinois. All four children have been discharged from the hospital.

The Indiana State Department of Health is working with local health departments and hospitals to conduct surveillance for additional cases of EV-D68. Testing for EV-D68 is being conducted at the State Laboratory. On Tuesday, the State health officials announced a higher than expected level of respiratory illness statewide for this time of year.

Indiana joins several other states in this multi-state outbreak, including Missouri, Ohio, Illinois, Kentucky and others. Enteroviruses are very common, with between 10 to 15 million cases occurring in the United States each year. There are more than 100 types of enteroviruses.

Typically, EV-D68 causes upper respiratory illness, such as low-grade fever, cough, runny nose, sneezing and body/muscle aches. Infected individuals generally recover on their own without incident by treating symptoms.  However, some individuals, especially those with weakened immune systems or underlying medical conditions, such as asthma, may experience severe complications and require hospitalization with supportive therapy.

Enteroviruses, including EV-D68, are spread through close contact with infected people. Health officials recommend the following tips to prevent the spread of infection:

  • Clean: Wash your hands frequently with warm soap and water for at least 20 seconds. Alcohol-based hand sanitizer is not effective in preventing the spread of EV-D68.
  • Cover: Cover your cough with your sleeve or a tissue when you cough or sneeze.
  • Contain: Prevent spreading illness to others by staying home if you are sick.
  • Avoid close contact and sharing cups or eating utensils with those who are ill.
  • Disinfect frequently touched surfaces.

Individuals experiencing cold-like symptoms and trouble breathing should contact their healthcare provider right away.

Idaho | Public health officials closely monitor respiratory infections

Idaho Public Health officials are working closely with hospitals, public health districts, laboratories and healthcare providers to identify any possible clusters of respiratory illnesses caused by Enterovirus D68. More than a dozen other states are reporting increased hospitalizations of children due to possible Enterovirus D68 respiratory infections.

Enteroviruses are very common viruses that cause respiratory illnesses similar to common colds. Most people infected with an enterovirus have mild symptoms that do not require a doctor’s care. However, some states are reporting that children with underlying health issues, particularly with asthma or other lung conditions, are experiencing difficulty breathing and require supportive medical treatment.

Idaho epidemiologists contacted hospitals and healthcare providers on Monday, querying them on possible infections they may be treating. Private labs throughout the state also were surveyed on their test results and capacity to test for enteroviruses.

To date, healthcare providers have reported several respiratory illnesses that may be due to enterovirus. Samples from these individuals are being sent to the Centers for Disease Control and Prevention (CDC) to identify if they are Enterovirus D68; the CDC can currently subtype enteroviruses and identify D68. At this time, no cases of Enterovirus D68 have been confirmed in Idaho.

“The Idaho Division of Public Health is closely monitoring respiratory illnesses in the state, especially in children and teens,” says Dr. Christine Hahn M.D., state epidemiologist. “Enterovirus infections are very common this time of year, but we want to be vigilant in identifying any clusters of illnesses to prevent the spread to vulnerable people, especially those with underlying health conditions.”

Enteroviruses are transmitted through close contact with an infected person or by touching surfaces that are contaminated by the virus and then touching your mouth, nose or eyes.  Symptoms of enterovirus illness include fever, runny nose, sneezing, coughing and body aches. There is no vaccine, but people can protect themselves and others by washing their hands frequently, covering their cough and staying home when sick.

Parents should be watchful of their children, especially if children have an underlying health condition such as asthma or a lung disease. If a child is ill and begins to have trouble breathing or is wheezing, parents should contact their healthcare provider immediately.

More information about Enterovirus D68 is available on the CDC website at: http://www.cdc.gov/non-polio-enterovirus/about/EV-D68.html?s_cid=cdc_homepage_whatsnew_001

USA | CDC Health Advisory – Severe Respiratory Illness Associated with Enterovirus D68 – Multiple States, 2014

Distributed via the CDC Health Alert Network
September 12, 2014, 17:00 ET (5:00 pm ET)
CDCHAN-00369

Summary

The Centers for Disease Control and Prevention (CDC) is working closely with hospitals and local and state health departments to investigate recent increases in hospitalizations of patients with severe respiratory illness. Enterovirus D68 (EV-D68) has been detected in specimens from children with severe illness in Missouri and Illinois. Investigations into suspected clusters in other jurisdictions are ongoing. The purpose of this HAN Advisory is to provide awareness of EV-D68 as a possible cause of acute unexplained respiratory illness, and to provide guidance to state health departments and health care providers. Please disseminate this information to infectious disease specialists, intensive care physicians, pediatricians, internists, infection preventionists, and primary care providers, as well as to emergency departments and microbiology laboratories.

Background

Enteroviruses are associated with various clinical symptoms, from mild to severe. EV-D68 causes primarily respiratory illness, although the full spectrum of disease remains unclear. EV-D68 was originally isolated in 1962 and, since then, has been reported rarely in the United States. Small clusters of EV-D68 associated with respiratory illness were reported in the United States during 2009–2010.There are no available vaccines or specific treatments for EV-D68, and clinical care is supportive.

In August 2014, a children’s hospital in Kansas City, Missouri, and one in Chicago, Illinois, notified CDC of increases in pediatric patients examined and hospitalized with severe respiratory illness, including some admitted to pediatric intensive care units. Both hospitals also reported recent increases in detection of rhinovirus/enterovirus, in initial screening with a respiratory virus panel. Nasopharyngeal specimens from patients with recent onset of severe symptoms from both facilities were sequenced by the CDC Picornavirus Laboratory. EV-D68 was identified in 19 of 22 specimens from Kansas City and in 11 of 14 specimens from Chicago. Admissions for severe respiratory illness have continued at both facilities at rates higher than expected for this time of year. CDC has been notified by various states of similar clusters of respiratory illness, though confirmation of EV-D68 in these potential clusters is still under way.

Of these severely ill patients who were confirmed positive for EV-D68 from both hospitals, all presented with difficulty breathing and hypoxemia, and some with wheezing. Notably, most patients were afebrile at presentation and throughout the hospital course. Approximately two thirds of cases had a previous medical history of asthma or wheezing, but both hospitals reported some patients with no known underlying respiratory illness. Ages ranged from 6 weeks through 16 years, with median ages of 4 and 5 years in Kansas City and Chicago, respectively. Most patients were admitted to the pediatric intensive care unit. Of the 30 patients who were positive for EV-D68, two required mechanical ventilation (one of whom also received extracorporeal membrane oxygenation) and six required bilevel positive airway pressure ventilation. It should be noted that specimens from only the most severe cases have been typed at this time, and so these findings may not reflect the full spectrum of disease.

Additional details about these EV-D68 clusters can be found in the September 8, 2014, MMWR Early Release: (http://www.cdc.gov/mmwr/preview/mmwrhtml/mm63e0908a1.htm?s_cid=mm63e0908a1_e)

Recommendations

Clinical Care:

  • Health care providers should consider EV-D68 as a possible cause of acute, unexplained severe respiratory illness, even in the absence of fever.
  • Although the findings to date have been in children, EV-D68 may also affect adults.

Laboratory Testing:

  • Providers should consider laboratory testing of respiratory specimens for enteroviruses when the cause of respiratory infection in severely ill patients is unclear.
  • Confirmation of the presence of EV-D68 requires typing by molecular sequencing.
  • Providers may contact state or local health departments for further enterovirus typing. CDC is available for consultation.
  • Health departments may contact CDC for further enterovirus typing.
  • CDC is currently prioritizing respiratory specimens from patients with severe respiratory illness who are known to be positive for rhinovirus/enterovirus from initial screening assays.
  • Please visit the CDC EV-D68 website (http://www.cdc.gov/non-polio-enterovirus/about/EV-D68.html) for information on specimen submission. Completion of a brief patient summary form is required with each specimen submission to CDC.

Infection Control:

  • Routes of transmission for EV-D68 are not fully understood.
  • Infection control guidelines for hospitalized patients with EV-D68 infection should include standard precautions, and contact precautions in certain situations, as is recommended for all enteroviruses (http://www.cdc.gov/hicpac/pdf/isolation/Isolation2007.pdf).
  • As EV-D68 is a cause of clusters of respiratory illness, similar to rhinoviruses, droplet precautions also should be considered as an interim recommendation until there is more definitive information available on appropriate infection control.
  • As EV-D68 is a non-enveloped virus, environmental disinfection of surfaces in healthcare settings should be performed using a hospital-grade disinfectant with an EPA label claim for any of several non-enveloped viruses (e.g. norovirus, poliovirus, rhinovirus). Disinfectant products should be used in accordance with the manufacturer’s instructions for the specific label claim and in a manner consistent with environmental infection control recommendations (http://www.cdc.gov/hicpac/pdf/guidelines/eic_in_HCF_03.pdf).

Reporting:

  • Providers should report suspected clusters of severe respiratory illness to local and state health departments.
  • EV-D68 is not nationally notifiable, but state and local health departments may have additional guidance on reporting.
  • Health departments may contact CDC for epidemiologic support. Please contact Dr. Claire Midgley (cmidgley@cdc.gov) with brief descriptions of possible clusters.

For more information:
For additional information, please consult the CDC enterovirus D68 website: (http://www.cdc.gov/non-polio-enterovirus/about/EV-D68.html)

Connecticut | Public health officials monitoring two clusters of severe respiratory illness among young children

The Connecticut Department of Public Health (DPH) has received reports from two hospitals in different parts of the state of clusters of severe respiratory illness among young children that could be due to enterovirus D68 (EV-D68).

They are working with the hospitals to facilitate testing for EV-D68 by the Centers for Disease Control and Prevention (CDC). When test results are available from the CDC, DPH will share a summary of that information with health care professionals and the public.

The CDC reports that from mid-August to September 12, 2014, a total of 97 people in Colorado, Illinois, Iowa, Kansas, Kentucky and Missouri have been confirmed to have respiratory illness caused by EV-D68. CDC is working with state health departments to track the spread of EV-D68.

On September 12, 2014, the New York State Department of Health has announced that EV-D68 has now been confirmed in more than a dozen children in New York State.

The Connecticut DPH has asked clinicians to consider laboratory testing of respiratory specimens for enteroviruses when the cause of infection in severely ill patients is unclear, and to report clusters of severe respiratory illnesses to their local public health agency and to DPH.

Be well. Practice big medicine.