Q & A about Enterovirus-D68 with infectious disease expert Yvonne Maldonado, MD and Keith Van Haren, MD, pediatric neurologist

On Sept. 18, the California Department of Public Health confirmed that the season’s first four cases of enterovirus-D68 respiratory illness had been found in the state, three in San Diego County and one in Ventura County, with more expected to surface. As of Sept. 29, this makes California one of 40 states across the nation to be affected by EV-D68.

Health officials in Colorado are now investigating a handful of cases of paralysis in children there. The paralysis began a few weeks after respiratory illness and appears to be connected to EV-D68. Since the same virus was tentatively linked to paralysis cases in California children earlier this year, California officials are monitoring the situation closely.

Below, Yvonne Maldonado, MD, service chief of pediatric infectious disease at Lucile Packard Children’s Hospital Stanford, answers questions about the respiratory symptoms caused by this virus. In addition, Keith Van Haren, MD, a pediatric neurologist who has been assisting closely with the California Department of Public Health’s investigation, comments on neurologic symptoms that might be associated with the virus:

Enteroviruses are not unusual. Why is there so much focus from health officials on this one, EV-D68?

Maldonado: The good news is that this virus comes from a very common family of viruses that cause most fever-producing illnesses in childhood. But it’s been more severe than other enteroviruses. Some hospitals in other parts of the country have had hundreds of children coming to their emergency departments with really bad respiratory symptoms. The fact that it’s been so highly symptomatic and that there has been a large volume of cases is why it has gotten so much attention.

Van Haren: It’s important to remember that most children and adults who are exposed to enteroviruses don’t get sick at all. A smaller percentage come down with fever and/or respiratory symptoms, as Dr. Maldonado has described. And as far as we can tell, it’s only a very, very small number of children, if any, who get paralysis, typically affecting one arm or leg. The Centers for Disease Control and the California Department of Public Health are still investigating to try to determine conclusively whether EV-D68 is causing neurologic symptoms, such as paralysis.

Is there a vaccine for EV-D68?

Van Haren: There is no vaccine for EV-D68, and as far as I know, none is under development. Interestingly, a vaccine was just approved for a different enterovirus, EV-71, that has caused recurrent epidemics of paralysis in Southeast Asia and Australia. However, that virus hasn’t made it to California in a prominent way.

Have any patients at Lucile Packard Children’s Hospital Stanford been affected with EV-D68?

Maldonado: Enterovirus season extends through the summer and fall. As of Sept. 30, we have not yet had a confirmed case of EV-D68 among children hospitalized for respiratory illness during the summer and fall of 2014. However, there have been a total of 443 confirmed cases in 40 states across the country. Some children who have this virus are probably not being tested, so the real number of cases nationwide is likely to be higher.

Van Haren: It’s been several months since our hospital or clinics had any new cases of paralysis in which we suspected an enterovirus as a cause, though that could change. From late 2012 through early 2014, we had about 8 such cases total in our hospital and clinics. The typical pattern in these cases was that the child’s neurologic symptoms began a few days or weeks after the respiratory symptoms.

If your child has respiratory symptoms and you suspect EV-D68, what should you do?

Maldonado: The virus causes symptoms such as coughing, sneezing and runny nose. In some cases but not all, kids also have a fever. If your child has respiratory symptoms with or without a fever, especially if he or she also has a history of asthma, monitor your child at home. If you feel that he or she has been sick for a long period, is getting worse or is experiencing worsening of asthma or difficulty breathing, go see your pediatrician.

If your child suddenly develops weakness or paralysis in a limb or elsewhere, what should you do?

Van Haren: Most children we’ve evaluated for neurologic symptoms developed paralysis in the setting of, or soon after, an acute illness that included fever, headache or back pain. If your child develops weakness or paralysis, take him or her to the pediatrician right away. It’s important to note that this illness is not the only possible cause of paralysis, and we do not want to alarm families unnecessarily, but it is important to seek medical help promptly.

Which groups are most at risk?

Maldonado: Children with a history of asthma have been reported to have especially bad respiratory symptoms with this virus. It can affect kids of all ages, from infants to teens. So far, only one case has been reported in an adult, which makes sense because adults are more likely to have immunity to enteroviruses. We do worry more about young infants than older children, just because they probably haven’t seen the virus before and can get worse respiratory symptoms with these viral infections.

Van Haren: We don’t yet know who is most at risk for paralysis or other neurologic symptoms, but we are studying this carefully to find out why some children get sick and some do not. So far, it seems that the children who have been affected by paralysis were generally healthy prior to their illness.

How can the illness be prevented?

Maldonado: This virus is spread by contact with secretions such as saliva. If your children are sick, they should stay home from school to avoid spreading the illness to others. To avoid getting sick, stay at least three feet from people with symptoms such as coughing and runny nose, wash your hands frequently, and make sure your kids wash their hands often, too.

What is the treatment for EV-D68 respiratory illness?

Maldonado: There is no treatment that is specific to the virus. At home, parents can manage children’s fevers with over-the-counter medications, make sure they drink lots of fluids to avoid dehydration, and help them get plenty of rest. For children who are very ill, doctors will check for secondary illnesses such as bacterial pneumonia, which would be treated with antibiotics, and may hospitalize children who need oxygen or IV hydration to help them recover.

What do we know about the course of possible neurologic symptoms of EV-D68 and their potential treatments?

Van Haren: We’re still learning about the possible neurologic symptoms and how we might treat them. To start, we have a growing suspicion that EV-D68 may be associated with paralysis. In the patients we’ve seen with paralysis, progression of weakness appears to stop on its own, and recovery of strength is very slow and usually incomplete.

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