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Friday, September 12, 2014

Severe Respiratory Illness in Illinois and Missouri

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 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.
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.

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