Gert van der Hoek
In Memoriam - Editor, Senior Moderator
RAPID RISK ASSESSMENT
Enterovirus 68 detected in the USA, Canada and Europe
Second update, 25 November 2014
Main conclusions
? In November, France and the United Kingdom both reported sporadic cases of neurological disease involving enterovirus 68 (EV-D68)
detection. As a result, ECDC has updated its rapid risk assessment on EV-D68,first triggered by reports from North America. To date,
European acute flaccid paralysis (AFP)/enhanced enterovirus surveillance has not detected unusual clusters or unexpected trends. In
2014, EV-D68 has been detected in at least fifteen EU/EEA countries but no epidemic clusters of severe disease have been reported.
? Since mid-August 2014 and as of 20 November 2014, local health authorities in 47 States and the District of Columbia in the US have
notified the US Centers for Disease Control and Prevention (CDC) of 1 121 laboratory-confirmed EV-D68 infections. Some regions in
Canada have also been detecting respiratory illness associated with EV-D68 infection since September 2014 and, as of 4 November
2014, 214 cases of EV-D68 had been confirmed by the National Microbiology Laboratory at the Public Health Agency of Canada
(PHAC). Following two scientific reports detailing clusters of neurological illness including AFP cases, media in the USA have reported
several small clusters of neurological illness potentially associated with EV-D68 infection. Moreover, Canada has reported a small
number of children with some paralysis who also have EV-D68 infection.
? As yet, an epidemiological link has not been established between EV-D68 and the neurological illness clusters reported in several
States across the US, but the virus has been circulating independently at several locations.
? To date, EU/EEA countries have not reported any unusual increase in numbers of undiagnosed acute respiratory infections, clusters of
neurological disease or an increase in hospital admissions.
? The likelihood of cases of disease due to EV-D68 being laboratory-confirmed in EU/EEA countries is low because most countries do
not routinely screen for enteroviruses and/or EV-D68, and the disease is not notifiable since most of the infections are caused by
respiratory viruses.
? In cases of severe respiratory disease, if tests for all other respiratory pathogens are negative, or if rhino-/enterovirus is detected
initially, EV-D68 should be considered as a potential cause of the disease. More systematic testing of both severe respiratory illness
cases and surveys of respiratory illness in primary care/community settings for EV-D68 could be considered in EU/EEA countries to
better document the incidence of disease associated with respiratory viruses in general and with EV-D68 at present.
? EU/EEA countries need to remain vigilant and consider strengthening respiratory sample screening for enteroviruses and enterovirus
typing.
? EU/EEA countries should include testing for polio and other enteroviruses as part of the investigation of AFP cases, and consider
strengthening AFP surveillance and/or enhanced enterovirus meningitis/neurological surveillance in order to both enhance polio
surveillance and detect unusual clusters of neurological disease or trends among non-polio AFP cases.AFP cases should include the
collection of cerebrospinal fluid (CSF), respiratory and faecal specimens that are tested for polio and other enteroviruses.
? Hospitals should be alert to the possibility of nosocomial infections of EV-D68, especially in immunocompromised patients.
? Based on information currently available to ECDC, the risk of increased severe cases of EV-D68 in EU/EEA countries is assessed as
moderate, in light of recent reports of such cases and because the circulation of this strain in the population seems to be
geographically widespread in the EU.
More: ECDC
Enterovirus 68 detected in the USA, Canada and Europe
Second update, 25 November 2014
Main conclusions
? In November, France and the United Kingdom both reported sporadic cases of neurological disease involving enterovirus 68 (EV-D68)
detection. As a result, ECDC has updated its rapid risk assessment on EV-D68,first triggered by reports from North America. To date,
European acute flaccid paralysis (AFP)/enhanced enterovirus surveillance has not detected unusual clusters or unexpected trends. In
2014, EV-D68 has been detected in at least fifteen EU/EEA countries but no epidemic clusters of severe disease have been reported.
? Since mid-August 2014 and as of 20 November 2014, local health authorities in 47 States and the District of Columbia in the US have
notified the US Centers for Disease Control and Prevention (CDC) of 1 121 laboratory-confirmed EV-D68 infections. Some regions in
Canada have also been detecting respiratory illness associated with EV-D68 infection since September 2014 and, as of 4 November
2014, 214 cases of EV-D68 had been confirmed by the National Microbiology Laboratory at the Public Health Agency of Canada
(PHAC). Following two scientific reports detailing clusters of neurological illness including AFP cases, media in the USA have reported
several small clusters of neurological illness potentially associated with EV-D68 infection. Moreover, Canada has reported a small
number of children with some paralysis who also have EV-D68 infection.
? As yet, an epidemiological link has not been established between EV-D68 and the neurological illness clusters reported in several
States across the US, but the virus has been circulating independently at several locations.
? To date, EU/EEA countries have not reported any unusual increase in numbers of undiagnosed acute respiratory infections, clusters of
neurological disease or an increase in hospital admissions.
? The likelihood of cases of disease due to EV-D68 being laboratory-confirmed in EU/EEA countries is low because most countries do
not routinely screen for enteroviruses and/or EV-D68, and the disease is not notifiable since most of the infections are caused by
respiratory viruses.
? In cases of severe respiratory disease, if tests for all other respiratory pathogens are negative, or if rhino-/enterovirus is detected
initially, EV-D68 should be considered as a potential cause of the disease. More systematic testing of both severe respiratory illness
cases and surveys of respiratory illness in primary care/community settings for EV-D68 could be considered in EU/EEA countries to
better document the incidence of disease associated with respiratory viruses in general and with EV-D68 at present.
? EU/EEA countries need to remain vigilant and consider strengthening respiratory sample screening for enteroviruses and enterovirus
typing.
? EU/EEA countries should include testing for polio and other enteroviruses as part of the investigation of AFP cases, and consider
strengthening AFP surveillance and/or enhanced enterovirus meningitis/neurological surveillance in order to both enhance polio
surveillance and detect unusual clusters of neurological disease or trends among non-polio AFP cases.AFP cases should include the
collection of cerebrospinal fluid (CSF), respiratory and faecal specimens that are tested for polio and other enteroviruses.
? Hospitals should be alert to the possibility of nosocomial infections of EV-D68, especially in immunocompromised patients.
? Based on information currently available to ECDC, the risk of increased severe cases of EV-D68 in EU/EEA countries is assessed as
moderate, in light of recent reports of such cases and because the circulation of this strain in the population seems to be
geographically widespread in the EU.
More: ECDC