Atlanta—Pharmacists and other healthcare professionals should be on the lookout for cases of enterovirus D68 (EV-D68) infections as a possible cause of severe respiratory illness in children and adolescents, according to the CDC.

Wheezing or need for respiratory support are indicators, according to the early-release article in the Morbidity & Mortality Weekly Report (MMWR), which adds that past upsurges in EV-D68 circulation were associated with increased reports of acute flaccid myelitis (AFM), which presents with acute flaccid limb weakness, neurologic signs and symptoms, or neck or back pain in children and adolescents who have a recent history of respiratory illness or fever. The condition requires prompt hospitalization.

Because of the detection of a paralytic polio case and wastewater samples positive for poliovirus in New York this summer, testing for poliovirus infection also is urged because of clinical similarity to acute flaccid paralysis caused by the poliovirus.

"After an extended period of low EV-D68 circulation during the COVID-19 pandemic, surveillance data suggest increased detection of rhinovirus/enterovirus and EV-D68, concurrent with increased emergency department visits by children and adolescents with acute respiratory illness and asthma/reactive airway disease during summer 2022," the CDC authors note, adding, "Clinicians should consider EV-D68 as a possible cause of acute respiratory illness and AFM in children and adolescents this fall and be aware of guidance for prompt testing and referral for patients with suspected AFM."

EV-D68 occurred biennially in the United States during 2014, 2016, and 2018, primarily in late summer and fall, and were accompanied by some AFM cases. "Although EV-D68 annual trends are not fully understood, EV-D68 levels were lower than expected in 2020, potentially because of implementation of COVID-19 mitigation measures (e.g., wearing face masks, enhanced hand hygiene, and physical distancing)," the study notes. Public-health officials point out that, in August 2022, clinicians in several geographic areas notified the CDC of an increase in hospitalizations of pediatric patients with severe respiratory illness and positive rhinovirus/enterovirus (RV/EV) test results. They analyzed surveillance data from national data sources to compile reported trends in acute respiratory illness (ARI), asthma/reactive airway disease (RAD) exacerbations, and the percentage of positive RV/EV and EV-D68 test results during 2022 compared with previous years.

"These data demonstrated an increase in emergency department (ED) visits by children and adolescents with ARI and asthma/RAD in late summer 2022," the MMWR article states. "The percentage of positive RV/EV test results in national laboratory-based surveillance and the percentage of positive EV-D68 test results in pediatric sentinel surveillance also increased during this time."

Young children with ARI caused by EV-D68 can present with varying severity. Usual signs and symptoms include cough, nasal congestion, wheezing, and dyspnea; infection can exacerbate asthma or RAD. "Children with a history of asthma/RAD might be more likely to require medical care, although any child with ARI caused by EV-D68 can have severe illness," the CDC authors add. "Importantly, EV-D68 is associated with AFM, a severe condition that can lead to muscle weakness and paralysis. Standard multiplex respiratory panels cannot distinguish between RVs and EVs or identify specific virus types. Thus, EV-D68 cases are likely undercounted because type identification is not routinely performed, and reporting is not mandatory."

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