EV-D68

Lately, there has been a lot of media coverage about a respiratory virus outbreak that has now spread to 22 states: EV-D68. On Twitter, I’ve been seeing a lot of extreme comments to CNN Breaking News‘ post about the virus, such as “the world is coming to an end,” “zombie apocalypse,” and a lot of unnecessary blaming of President Obama. Despite stirring up a lot of panic, according to the CDC the respiratory virus is actually “not commonly severe.” 

As a parent and nurse, I figured I should post an entry about the virus, how it affects your family, and what you can expect if you find that your child(ren) come down with symptoms that may alert you to this infection. So here’s the scoop:

What is EV-D68?

EV-D68 is a non-polio enterovirus, which is a very common class of virus that causes dozens of other illnesses, which generally are not severe. D68 is a virus that mostly affects infants, children, and teens, due to a more vulnerable immune system.  It usually manifests as a mild infection, like the common cold. However, the more severe cases of EV-D68 infections are in infants, children, teens, and immune compromised people who have a history of asthma or wheezing.

Why am I hearing about EV-D68 just now?

Most cases of EV-D68 weren’t found in the US. It originally was discovered in California in the 60s, but is rarely reported here until recently. The Centers for Disease Control and Prevention (CDC) doesn’t generally gather information about this virus if children are becoming sick from it, because it often presents like a cold/flu and is treated similarly. However, on August 19, 2014, the CDC was alerted to a sudden increase in severe respiratory illnesses in infants, children, and teens, along with pediatric intensive care unit hospitalizations. What is alarming about it is the increased number of children requiring hospitalization.

With the school season back in full swing, rates of sickness are also increasing as expected. Additionally, rates of those with asthma have increased over the years. What makes EV-D68 bad for some kids over others, is the combination of a history of a respiratory condition (wheezing, asthma) and catching the virus. And hospitals are seeing more and more children hospitalized for respiratory illnesses, both with and without prior respiratory histories, moreso than in previous years. 

How many kids have been affected by this?

As of September 19, 2014, 160 confirmed cases have been reported to the CDC (an up-to-date count of cases in the link below). The CDC requests that hospitals send samples (throat and nose cultures) from suspected cases to be sent to them for confirmation. In the grand scheme of things this is not an alarming number. For instance, for the same class of viruses, enteroviruses are responsible for 10 to 15 million infections per year. However, the fact that a significant number of children hospitalized do not even have a history of respiratory illness and are requiring aggressive critical care is causing greater concern. 

The CDC reports that people are more likely to become infected by this type of enterovirus in the summer and fall seasons, and they expect EV-D68 to follow a similar pattern.

How is the virus spread?

Much like the common cold and flu, EV-D68 is spread from person to person. Close contact with an infected person, touching objects or surfaces that an infected person has made contact with then touching the eyes, mouth, or nose will spread it.  The key, like many viruses, is to wash hands in warm water for 20 seconds while scrubbing vigorously and disinfect surfaces with which your children have frequent contact. Avoid kissing, hugging, and sharing of eating utensils with sick people.  Wash hands after diaper changes, since the virus is shed through stool, too (CDC, APHA). 

With infants, keep them away from sick people, and make sure you are washing your own hands after contact with surfaces and people who are infected. Check with your child’s daycare to see what they are doing in response to this infection: how often are they disinfecting toys and other surfaces, are they enforcing rules to prevent sick children from coming to daycare, are they educating families about the importance of keeping sick children at home to prevent further spread of illness, are they staying alert to symptoms, etc. Hopefully they are hypervigilant all the time, but sometimes it takes a big scare like this to establish or enforce measures. 

People who are infected are contagious for 1-3 weeks through coughing, sneezing, and saliva, and the virus is still contagious through stool for “several weeks or longer,” after the person feels better. The term “entero” means it exists in the GI tract.

If my child gets sick from EV-D68, what symptoms should I expect? 

Symptoms are much like the common cold or flu, so it’s hard to tell if they are sick from EV-D68: fever, runny nose, sneezing, cough, muscle aches. If it is serious, your child may experience wheezing or difficulty breathing.  If your child has a history of wheezing or asthma, they are more susceptible to getting sick from this virus and their symptoms (like their ability to breathe) are likely to be more severe. The CDC recommends bringing your child to the ER if they are having any signs of trouble breathing (their breathing rate seems abnormally fast, they appear they are using a lot of effort to breathe).

The CDC recommends that those with less severe symptoms should be managed with over-the-counter pain and fever medications. (Remember, NO Aspirin for children!) Ask your child’s pediatrician what fever to treat, what dosage is appropriate, and at what fever to report to them or the Emergency Room.

Generally, call the doctor if your child’s rectal temperature is 100.4 F or higher. Ask them to teach you how to take a rectal temperature if you don’t know how, or check an armpit temperature. The temperature under the armpit is lower than rectal by about 1 degree F, so if you see an armpit temp of 99 F, call the doctor. 

What treatments are available if my child gets infected?

Treatments for EV-D68 are supportive measures – fluids, oxygen, etc. There is no vaccine and there are no specific antiviral medications for treating it. Read the section below for more information on what to expect when you bring your child to the hospital.

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Since I am not a Pediatric Nurse, I asked Sarah Hickle, a nurse with almost 10 years of Emergency Room experience,  who most recently worked in the Emergency Room at Rady Children’s Hospital in San Diego about the impact of EV-D68 and advice for concerned parents. Emergency Room nurses, after all, are the first ones to assess and treat your child. Here’s what she had to say:

As an ER RN at a Children’s Hospital, what have you been seeing re: EV-D68?

For probably the past month or so, we’ve definitely seen an huge increase in what we originally thought was just asthma, mostly children 12 and under. What was also interesting was we were getting a lot of kids that really had no huge respiratory problems. In our ER, we aren’t diagnosing the virus specifically because it’s really not going to change how we treat the illness. We started applying isolation precautions [wearing disposable gowns and protective masks] since information emerged about the virus.

What can parents expect if they bring their baby or child into the ER with a possible infection with EV-D68?

We typically would start off with [asthma therapy] nebulizer treatments: albuterol or duo-neb. Some kids would improve with 3 back-to-back treatments and starting steroid therapy. However, some needed more advanced care [like needing a breathing mask that pushes air into the lungs with two different levels of pressure to improve breathing, or a breathing tube if other methods are ineffective]. Along with the above mentioned, [they may need] IV steroids vs oral [for difficulty breathing due to inflammation in the lungs], continuous albuterol respiratory treatments, additional oxygen, magnesium infusions. Some required the use of helix [a breathing gas of helium and oxygen to help breathing].

Labs [bloodwork] that are being done are CBC, BMP, VBG, and blood culture if fever, possible influenza or RSV [tests] to rule those out as root causes. Chest X-rays are [also] done. (look below for description of these tests)

What advice would you give to scared parents bringing their kids into the ER?

To parents, I want them to be aware but don’t panic. Give [your children their] prescribed breathing treatments if they have a prior history and follow up with their [Primary Care Physician]. Come to the emergency room if they have labored breathing. Have your child lift up their shirt and look at their chest. If you see them using their abdominal muscles, sucking in between the ribs, or sucking in the throat, they need to be seen in the emergency room. If they are running a fever, Tylenol and Motrin are always appropriate except children under 6 months of age can only receive Tylenol. Don’t worry that we won’t believe you that they had a fever [if you treated it with motrin or Tylenol], it is always appropriate to treat. But, remember that fever is just a number. High fever doesn’t necessarily mean they are sicker. Look at how well your child is taking oral fluids, playing, and responding medications.

Explanation of Tests: 

A CBC is a Complete Blood Count which checks a white blood cell count for infection, hemoglobin and hematocrit to check for if your baby/child is experiencing anemia or if their blood volume and oxygen in the blood is low.

A BMP is a Basic Metabolic Panel that checks for electrolytes.

VBG is a Venous Blood Gas to check to see if your baby/child is breathing well enough (if not breathing well, it will show an imbalance of carbon dioxide and oxygen).

A blood culture means a sample of blood is taken and put on a slide and in a lab container to see what kind of kind of bug grows. This also is done to help decide which kind of antibiotic or antiviral will treat the infection.

A chest x-ray is a picture that’s taken to see how clear the lungs are. The doctors will be able to see if the airways are very tight, if the lungs are well-inflated, and if there is “junk” in your baby’s lungs.

Knowledge is power, so I hope you feel comforted in knowing a little more about this. It’s still always super scary when your little one gets sick, and when it involves their breathing it is even scarier. However, it’s good to know what to expect and not buy into some of the hype out there. The world isn’t over because of EV-D68, but hopefully this virus will be, soon!

Sources:

Non-Polio Enterovirus Infection – About: http://www.cdc.gov/non-polio-enterovirus/about/index.html

Transmission of EV-D68: http://www.cdc.gov/non-polio-enterovirus/about/transmission.html

Entervirus D68 CDC: http://www.cdc.gov/non-polio-enterovirus/about/EV-D68.html?s_cid=cdc_homepage_whatsnew_001

Trends in Asthma Prevalence: http://www.cdc.gov/nchs/data/databriefs/db94.pdf

Up-to-date prevalence: http://www.cdc.gov/non-polio-enterovirus/about/EV-D68-states.html

Symptoms of Non-Polio Enterovirus Infections from the CDC: http://www.cdc.gov/non-polio-enterovirus/about/symptoms.html

CNN – Enterovirus D68 in 19 States, Canada: http://www.cnn.com/2014/09/17/health/enterovirus-outbreak/index.html

American Academy of Pediatrics: Advice on Managing Fevers in Children: http://www.aap.org/en-us/about-the-aap/aap-press-room/Pages/AAP-Issues-Advice-on-Managing-Fevers-in-Children.aspx

American Public Health Association’s Get Ready Blog on EV-D68: http://getreadyforflu.blogspot.com/2014/09/ev-d68-whats-that-what-you-need-to-know.html