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Enterovirus D68 And Influenza Far More Dangerous Than Ebola In U.S., Say Top Infectious Diseases Physicians

This article is more than 9 years old.

A panel of infectious diseases experts this morning expressed far more grave concerns for Americans about the risks of flu and enterovirus D68 than for Ebola virus disease. That's noteworthy because the group included Bruce Ribner, MD, MPH, the Emory University Hospital doctor who led the team that successfully treated two Ebola-infected medical missionaries, Dr. Kent Brantly and Nancy Writebol.

Infectious diseases caregivers and public health professionals are gathered in Philadelphia through the weekend for the annual meeting of the Infectious Diseases Society of America (IDSA), more commonly known as IDWeek 2014. (You can also follow attendees in real-time on Twitter at the hashtag, #IDweek.) The Society organized the press conference because of the very timely news about Ebola here, Europe, and West Africa, as well as children with respiratory disease caused by enterovirus D68.

Of these three diseases, one kills 3,000 to 49,000 Americans each year, yet is preventable: Influenza.

As a result, all Americans are urged to take advantage of access to this year's flu vaccine, a sentiment strongly expressed by panel moderator, Jeff Duchin, MD, University of Washington associate professor of allergy and infectious diseases and chief of communicable disease control for the Seattle & King County Public Health Department.

And even if the vaccine is not 100% effective for a given person, the severity of the disease is reduced significantly, if you still get it.

Listen to sick children for wheezing, a major enterovirus D68 sign

The vast majority of today's panel discussion focused on enterovirus D68, or EV-D68 for short, a virus that's causing particularly severe respiratory illness in children nationwide. The Centers for Disease Control and Prevention (CDC) reported yesterday that EV-D68 infections have been confirmed in 45 states. Five children with the virus have died thus far and some children, especially in the Denver area, are experiencing muscle paralysis.

Neurology experts are still not certain if it's EV-D68 is causing the paralysis and muscle weakness but enteroviruses have occasionally been associated with nervous system effects such as meningitis and brain stem and spinal cord inflammation, said Mary Anne Jackson, MD, director of infectious diseases at Children's Mercy Hospital in Kansas City, the first institution to report this current outbreak of EV-D68.

Jackson also said that it's not clear if the paralysis is unique to the currently-circulating strain of EV-D68 virus or whether the sheer number of patients with the infection is just larger than usual, allowing rare complications to be seen in more patients.

"At this point, it's very clear that this is the largest national outbreak of the virus that's ever been recorded," said Jackson.

The virus was first discovered in 1962 but not seen again in the U.S. for 36 years. Over 100 types of enterovirus are known, but they are distinct from polioviruses, stressed Aaron M. Milstone, MD, an assistant professor of infectious diseases at the Johns Hopkins Children's Center.

In the current outbreak, Jackson said that EV-D68 is primarily affecting children. No cases have been identified in adults, suggesting that some previous exposure to EV-D68 conferred immunity to the currently-circulating virus.

Jackson said that the more severe form of the disease is more prevalent in the Midwest than either coast. At the peak of the Kansas City-area outbreak, from August 19 through September 2, their 354-bed hospital was filled. At one point, Children's Mercy had 100 patients in their pediatric intensive care unit (PICU), three times the number this time of the last two years. Most often, patients end up on the PICU because of unusually severe bronchospasms. The treatment is generally supportive because antiviral drugs lack effectiveness against EV-D68.

The children start with a typical "cold," exhibiting fever, runny nose, and body aches. The important sign of concern is if the child begins wheezing, a usually high-pitched squeaking or squeezing sound when exhaling. The video below plays the sound of wheezing (hat-tip to Amy Hubbard at the Los Angeles Times). This is the YouTube link in case your browser doesn't play the clip.

Jackson noted that the infection can sometimes show a positive result for rhinovirus, a less-worrisome family of viruses most often responsible for the common cold. Most hospital laboratories can do the rhinovirus test but the confirmatory D68 test must be sent out to state reference labs or the CDC. The lack of a real-time, rapid test is a problem.

Another risk factor for EV-D68 infection is a history of asthma. Jackson says that about one-third of patients have a history of asthma that requires medication, one-third had previously experienced wheezing but weren't on medications, and one-third have no previous asthma history.

Jackson notes that the CDC now has two specific efforts to monitor eneterovirus-D68 infections, one focusing on the severe respiratory effects and the other on the muscle paralysis and its cause.

Ebola physician offers lessons learned

Dr. Ribner gave a lecture last night at IDWeek 2014 debriefing on their experience in treating patients with Ebola. At the peak of Ebola infection, the patients were losing as much as five to 10 liters of fluid each day.

"All of our patients have gone through a phase where they experience fluid loss that rival that which we see in cholera," said Ribner. "We were able to maintain intravascular volume primarily by just keeping up with the fluid losses they sustained."

The problem in West Africa is the lack of enough staff and supplies to safely administer intravenous fluids, requiring that patients take electrolyte solutions orally. But Ribner said that with all the nausea and vomiting, his colleagues say that a good day is if they can get one or two liters into the patient.

Related: Ebola Victim Thomas Eric Duncan Passes Away -- But Not Because Drugs Failed

Ribner also addressed the seeming dichotomy with television images of health care workers in West Africa wearing full body protective suits and other personal protective devices, while we're now treating patients in hospital that lack biocontainment facilities like those at Emory and the University of Nebraska Medical Center.

"We have to appreciate that because of the health care infrastructure in West Africa, conditions in those facilities are quite different than those we experience in the United States. When you have 50 to 60 patients and maybe one nurse and maybe two doctors, the ability to keep the environment clean is substantially degraded," said Ribner. "My colleagues there tell me that you have gross contamination of the entire environment."

In contrast, while caring for the patients at Emory, Ribner said that lab tests showed no virus on the patients' bedsheets or surfaces in the bathrooms, "a phenomenal tribute to our professionals."

Travel history important beyond Ebola

Every community hospital in the U.S. is aware of contact precautions, said Ribner, an important point given the scope of the West Africa outbreak. With predictions of tens of thousands of West Africans becoming infected, "it's not going to be possible for a select group of institutions to care for all Ebola patients that come here."

But while we can treat Ebola-infected patients here safely and without any health care worker exposures, we have to be on guard in identifying patients when they present. Dr. Ribner therefore urges that we make taking a travel history screening part of any entry into our health care system.

"It's an easy, five-second question: 'Have you traveled in the last month?'

"We have to be much more aware that we don't only have patients coming back from West Africa with potentially Ebola virus disease, we have travelers coming back from Saudi Arabia potentially with MERS [Middle East Respiratory Syndrome]," said Ribner. "And we have other travelers coming back from other parts of the world where other infectious diseases not common in the United States are being seen."

But he expects that a renewed effort toward taking complete travel histories of patients entering health care facilities will be emboldened, "courtesy of recent events," referring to Texas Health Presbyterian Hospital initially turning away Thomas Eric Duncan, the Liberian man who succumbed yesterday to Ebola.

"The best way to control the threat of Ebola virus in the U.S. is to control the outbreak in West Africa," added Dr. Duchin.

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