Anyone who has been following the outbreaks of Acute Flaccid Myelitis the last few years will likely think the following report is long overdue.
The report, Enterovirus D68–Associated Acute Respiratory Illness — New Vaccine Surveillance Network, United States, July–October,2017 and 2018, is especially welcome by those folks who are already convinced that AFM is associated with EV D68.
The New Vaccine Surveillance Network Report on Enterovirus D68 Infections
But wait, why was surveillance done through the New Vaccine Surveillance Network?
And for that matter, what is the New Vaccine Surveillance Network?
“The New Vaccine Surveillance Network (NVSN) includes study sites that focus on population-based surveillance and data collection on the use and impact of vaccines and the impact of vaccine policies. Since 2006, NVSN sites have conducted active, population-based surveillance for hospitalizations and outpatient visits associated with acute gastroenteritis (AGE) in children (2006-present). NVSN sites have conducted surveillance for acute respiratory illness (ARI) from 2000 to 2009, and again beginning in 2015.”
New Vaccine Surveillance Network (NVSN)
Before you start thinking that this means a new Enterovirus D68 vaccine is coming out soon, many NVSN studies have nothing to do with vaccines…
“NVSN supports broad-based surveillance and research projects for acute gastroenteritis and acute respiratory infections in areas with a population base of at least 500,000.”
New Vaccine Surveillance Network (NVSN) Overview
In addition to studies on the flu and pneumococcal disease, they have done studies on norovirus, coronavirus, human metapneumovirus, HPIV, RSV, and rhinovirus infections.
So what did they find out about Enterovirus D68 infections?
“Based on preliminary data, test results were positive for EV-D68 for two (0.08%) of 2,433 patients with ARI who were tested during 2017 and 358 (13.9%) of 2,579 tested during 2018. “
Enterovirus D68–Associated Acute Respiratory Illness — New Vaccine Surveillance Network, United States, July–October, 2017 and 2018
There were a lot more EV D68 infecions in 2018 than there were in 2017
“Although AFM is rare in the United States, these AFM surveillance data, along with the EV-D68 activity documented through NVSN, provide additional supporting evidence for a temporal association between EV-D68 respiratory illness and AFM. “
Enterovirus D68–Associated Acute Respiratory Illness — New Vaccine Surveillance Network, United States, July–October, 2017 and 2018
Again, few people are going to be surprised by this news…
Fortunately, the recall is limited to just 3 lots of Infants’ Ibuprofen Concentrated Oral Suspension that were made by Tris Pharma, Inc. and sold under the Equate, CVS Health, and Family Wellness brands and sold at Wal-Mart, CVS, and Family Dollar stores.
If you have the recalled Ibuprofen, don’t use it. Contact Tris Pharma for a refund.
And seek medical attention if you think your child got too much Ibuprofen and is having any symptoms, especially nausea, vomiting, epigastric pain, or more rarely, diarrhea.
Fortunately, getting extra Ibuprofen is not usually as dangerous as getting extra Acetaminophen.
Although, of course, neither is good! Be careful when dosing your kids and be sure they need it first.
Oh, and yes, at least in this case, store brand Ibuprofen at Family Dollar and Wal-Mart is the same as store brand Ibuprofen at CVS…
More on Infants’ Ibuprofen Concentrated Oral Suspension Recall
While you may want to seek medical attention, depending on your child’s age and how sick they are, believe it or not, you don’t need a flu test to get diagnosed with the flu.
“If your doctor needs to know for sure whether you have the flu, there are laboratory tests that can be done.”
CDC on Diagnosing Flu
A flu test is an option though.
Is it a good option?
A necessary option?
“Most people with flu symptoms are not tested because the test results usually do not change how you are treated.”
CDC on Diagnosing Flu
While a diagnosis of the flu can be made clinically, based on your symptoms, a flu test can be a good idea:
to help determine the cause of an outbreak (mostly if there aren’t already a lot of flu cases in your area)
if someone is at high risk for flu complications
In general though, most people do not need a flu test, especially during the active part of flu season.
What’s the problem with doing a flu test?
“In January 2017, the FDA reclassified antigen-based RIDT systems into class II. This reclassification was to help improve the overall quality of flu testing. The reclassification was prompted, in part, by recognition that the poor sensitivity of some of antigen-based RIDTs resulted in misdiagnosed cases, and, according to anecdotal reports, even death.”
FDA on CLIA-Waived Rapid Flu Test Facts
Mostly, they are neither as accurate nor as easy to interpret as most folks think, even the newer versions of these tests.
Have you ever heard someone say that they tested positive for both flu A and flu B?
When a flu tests is positive for both A and B flu strains, it invalidates the test. They may have had either flu A or flu B or neither, but they almost certainly didn’t have both.
The antigen-based rapid flu tests that most doctors and clinics use, which give results in 10 or 15 minutes, are also prone to both false positive (you don’t really have the flu, even though your test was positive), and more commonly, false negative (you actually do have the flu, even though your test was negative) results, depending if flu is active at the time.
Other flu tests are available, but are more expensive and take longer to get results, so aren’t used as often. These include “rapid” nucleic acid detection based tests that can be done in a doctor’s office, rapid nucleic acid detection based tests and rapid influenza diagnostic tests that are done in a central lab, PCR tests, and viral cultures.
So why do so many people rush to the doctor to get a flu test?
Many think that if they are positive, then they can take Tamiflu or another flu medicine and get better faster.
The problem with thinking like that is that few people actually need to take Tamiflu, as at best, it only helps you get better about a day quicker than if you didn’t take it. That’s why the recommendations for Tamiflu say to reserve it for children under two to five years of age and others who might be at high risk for flu complications.
Since most other people don’t need to take Tamiflu, they don’t necessarily need a flu test or a definitive diagnosis of the flu. Again, even if they did need Tamiflu, the diagnosis of the flu could be made clinically.
And even more importantly, a negative flu test doesn’t necessarily mean that you don’t really have the flu, especially if you have classic flu symptoms in the middle of flu season. Again, a negative flu test could be a false negative.
“RIDTs may be used to help with diagnostic and treatment decisions for patients in clinical settings, such as whether to prescribe antiviral medications. However, due to the limited sensitivities and predictive values of RIDTs , negative results of RIDTs do not exclude influenza virus infection in patients with signs and symptoms suggestive of influenza. Therefore, antiviral treatment should not be withheld from patients with suspected influenza, even if they test negative.”
CDC on Guidance for Clinicians on the Use of Rapid Influenza Diagnostic Tests
Have you ever had a negative flu test and the doctor still gave you Tamiflu? Then why did they do the test?
Diagnosing the Flu Without a Flu Test
If the results of flu testing aren’t going to change how you are treated, then you probably don’t need to have the flu test done in the first place.
Plus it saves you from having a swab stuck up your nose.
But kids should have flu tests, right?
Although rapid flu tests might be a little more accurate in kids than adults, it is not by much, so you are left with the same issues.
A positive test might reassure you that it really is the flu, but your child could still have the flu if their test is negative. A diagnosis and treatment decision can be made clinically, without a flu test, remembering that most older, healthy kids don’t need to be treated with Tamiflu.
We can’t skip flu season (although we sure can try if we get vaccinated and protected), but we can try and skip flu testing season.
We continue to get regular updates from the CDC about AFM.
Unfortunately, we aren’t getting the real answer we were looking for – how to stop the outbreak.
Acute Flaccid Myelitis Update
Since the last update, we have learned that:
the case count is up to 223 confirmed cases among 374 reports, with most cases being confirmed at this point (2018)
cases have been reported in 41 states (2018)
there have been 2 confirmed cases (NC and UT) among 15 reported cases so far this year (2019)
That means that we have clearly exceeded the last record of 149 cases in 2016.
There are also 49 confirmed cases and 28 cases under investigation in Canada since January 2018.
In other news:
the CSTE will be issuing issued a new statement on AFM reporting reaffirming that they “are confident state and local health departments are working closely with doctors to ensure suspected cases are reported.”
There are a lot of different rules that dictate when kids can go to daycare or school when they are sick.
The actual rules of your daycare or school are the ones that you are likely most familiar with, but there are also recommendations from the American Academy of Pediatrics and the CDC, in addition to state-specific regulations.
Can Your Sick Child Still Go to Daycare or School?
Most people know to stay home when they are sick.
“Stay home when you are sick. If possible, stay home from work, school, and errands when you are sick. You will help prevent others from catching your illness. Avoid close contact with people who are sick.”
CDC on Information for Schools & Childcare Providers
But what exactly does it mean to be “sick” and how long are you supposed to stay home and avoid other people?
“Most minor illnesses do not constitute a reason for excluding a child from child care, unless the illness prevents the child from participating in normal activities, as determined by the child care staff, or the illness requires a need for care that is greater than staff can provide.”
Recommendations for Inclusion or Exclusion (Red Book)
In general, your child does not need to be kept home and out of daycare or school if they are able to participate in routine activities, do not need extra care, and have:
a cold (unless they have a fever) or other upper respiratory infection, even if they have a green or yellow runny nose
diarrhea that can be contained in a diaper or the child can make it to the bathroom without having an accident, as long as they aren’t having more than 2 stools above their usual or stools that contain blood or mucus
a rash without fever – most skin rashes won’t keep your kids out of school, like if they have poison ivy, hives, or even molluscum contagiosum and warts
Fifth disease – interestingly, you aren’t contagious once you have the characteristic Fifth disease rash
head lice – why not keep kids out of school if they have lice? It doesn’t stop them from spreading. They can get them treated at the end of the day.
pinworms – like lice, keeping kids out of school with pinworms isn’t going to stop them from spreading, although kids should be treated
pink eye – if caused by an infection, in general, should be able to stay or return if is improving, but keep in mind that most experts now think that kids with pink eye do not need to be excluded from daycare or school at all
oral lesions and are able to contain their drool (unless they have a fever), which would include hand foot mouth disease
skin lesions that can be covered, and if they can’t, then they can return after they have been on antibiotics for 24 hours (impetigo) or have started treatment (ringworm)
strep throat and have been fever free and on antibiotics for 24 hours
scabies – if you have started treatment
a sore throat (unless they have a fever)
Why don’t you have to keep your kids home when they have RSV or many of these other common childhood diseases?
In addition to the fact that some kids would never get to go to daycare or school, since these diseases are so common, many kids continue to be contagious even after their symptoms have gone away. So excluding them doesn’t really keep the illnesses from spreading through the daycare or school.
So why not just send them when they have a fever or really don’t feel well?
In addition to the possibility that they might be a little more contagious at those times, it is because the typical daycare or school isn’t able to provide the one-on-one care that your child would likely need when feeling that sick, as your child probably isn’t going to want to participate in typical group activities.
Policies that are overly strict at excluding children from daycare and school may also lead to antibiotic overuse, as parents rush their kids to the doctor for and push for a quick cure because they need to go back to work.
Exclusion Criteria for Vaccine Preventable Diseases
While the exclusion criteria for many diseases simply extends to when your child is fever free, starts treatment, or feels well enough to return to daycare or school, for many now vaccine-preventable diseases, you will be excluded (quarantined) for much longer:
hepatitis A virus infection – exclusion for one week after illness starts
measles – exclusion until four days after start of rash
mumps – exclusion until five days after start of parotid gland swelling
pertussis – exclusion until completes five days of antibiotics or has had cough for at least 21 days
rubella – exclusion until seven days after start of rash
diphtheria – if survives having respiratory diphtheria, would likely be excluded until finishes treatment and has two negative cultures at least 24 hours apart
rotavirus – as with other diseases that causes diarrhea, children should be excluded until “stool frequency becomes no more than 2 stools above that child’s normal frequency” as diarrhea is contained in the child’s diaper or they aren’t having accidents
tetanus – if survives having tetanus, wouldn’t be excluded, as tetanus is not contagious
Unfortunately, kids are often contagious with many of these diseases, especially measles and chicken pox, even before they have obvious symptoms, which is why large outbreaks used to be so common.
Children will often be excluded from daycare or school if they are unvaccinated or not completely vaccinated and they are exposed to a vaccine-preventable disease.
More on Sending Your Sick Child to Daycare or School
Your toddler has a cough and runny nose and there is a notice that RSV is going around at daycare…
Do you need to rush to your pediatrician?
Does your child need an RSV test?
Like many things, it depends on who you ask.
For example, the folks at your child’s daycare might push for a visit and an RSV test, thinking it will help them keep the virus from spreading to other kids.
Does Your Child Need an RSV Test?
If an RSV test is available, why not do it?
“Our study showed that a simple nasal swab, while less painful for infants than NPA, failed to detect about one third of cases that were RSV positive by nasopharyngeal aspirate.”
Macfarlane et al on RSV testing in bronchiolitis: which nasal sampling method is best?
For one thing, the test isn’t that accurate, especially when done with a nasal swab, the most commonly used method. And while less invasive than a nasopharyngeal aspirate, if done correctly, sticking a nasal swab up your child’s nose, rotating it around a few times, and then getting a sample isn’t exactly something kids enjoy.
Mostly though, since there is no treatment for RSV, what are you going to do with those test results, whether or not they are positive?
Remember, RSV is a very common respiratory virus that can cause a cold, bronchiolitis, or pneumonia. But testing positive for RSV doesn’t mean that your child has bronchiolitis or pneumonia. Those are typically diagnosed clinically, based on the signs and symptoms that your child has, such as wheezing and trouble breathing.
Similarly, testing negative for RSV doesn’t mean that your child doesn’t have bronchiolitis or pneumonia.
“Clinicians should diagnose bronchiolitis and assess disease severity on the basis of history and physical exam.
When clinicians diagnose bronchiolitis on the basis of history and physical examination, radiographic or laboratory studies should not be obtained routinely.”
AAP on the Clinical Practice Guideline: The Diagnosis, Management, and Prevention of Bronchiolitis
Is there ever a role for RSV testing?
RSV testing might be a good idea when an infant has apnea or other uncommon symptoms.
And if a child is getting monthly Synagis injections and has a suspected case of RSV, it is a good idea to confirm that they actually have RSV.
If they really do, then you can stop getting Synagis injections, as they are unlikely to get RSV again in the same season.
“In the event an infant receiving monthly prophylaxis is hospitalized with bronchiolitis, testing should performed to determine if RSV is the etiologic agent. If a breakthrough RSV infection is determined to be present based on antigen detection or other assay, monthly palivizumab prophylaxis should be discontinued because of the very low likelihood of a second RSV infection in the same year. Apart from this setting, routine virologic testing is not recommended.”
AAP on the Clinical Practice Guideline: The Diagnosis, Management, and Prevention of Bronchiolitis
That’s pretty clear.
The American Academy of Pediatrics guidelines say that routine RSV testing is not recommended.
Need another good reason to avoid routine RSV testing?
Do you know how long kids with RSV shed the virus or can test positive after having an RSV infection?
“People infected with RSV are usually contagious for 3 to 8 days. However, some infants, and people with weakened immune systems, can continue to spread the virus even after they stop showing symptoms, for as long as 4 weeks.”
CDC on RSV Transmission
Apparently, it is a long time, which means that your child might have a new respiratory infection, but still test positive for RSV because they had it a month ago.
You might actually be “diagnosing” an old infection and not the virus that is causing your child’s current symptoms.
Do you still want an RSV test anyway? Talk to your pediatrician.
Did someone order an RSV test, but you are now wondering if it was necessary? Talk to your pediatrician.
Remember that an RSV test won’t change your child’s treatment (breathing treatments and steroids are no longer routinely recommended when infants have RSV), won’t help predict how sick your child might get, and won’t tell you if your child can return to daycare.
What To Know About RSV Tests
You likely won’t be able to avoid RSV season, especially if your kids are in daycare, but you can avoid RSV testing season.
Although you may just now be hearing about acute flaccid myelitis, it is important to understand that it isn’t new.
It wasn’t even new when we started to see an increased number of cases a few years ago.
What is new, is that we are seeing an increased number of cases.
Acute Flaccid Myelitis Timeline
AFM refers to acute (sudden onset) flaccid (droopy or loose muscles) myelitis (inflammation of the spinal cord) and it is a subtype of acute flaccid paralysis.
If that explanation doesn’t really help you, it might help to understand that paralytic polio, like AFM, is another subtype of acute flaccid paralysis.
“In August 2012, the California Department of Public Health (CDPH) was contacted by a San Francisco Bay area clinician who requested poliovirus testing for an unvaccinated man aged 29 years with acute flaccid paralysis (AFP) associated with anterior myelitis (i.e., evidence of inflammation of the spinal cord involving the grey matter including anterior horn cell bodies) and no history of international travel during the month before symptom onset. Within 2 weeks, CDPH had received reports of two additional cases of AFP with anterior myelitis of unknown etiology.”
Acute Flaccid Paralysis with Anterior Myelitis — California, June 2012–June 2014
That seems to be about when this started, in 2012.
Unfortunately, they didn’t figure out what was causing the paralysis in these three patients, despite extensive testing and more cases followed.
“To identify other cases of AFP with anterior myelitis and elucidate possible common etiologies, CDPH posted alerts in official communications for California local health departments during December 2012, July 2013, and February 2014.”
Among 23 cases, California health officials found that the median age of the patients was 10 years old, only two tested positive for EV-D68, although most did have a recent “an upper respiratory or gastrointestinal prodrome.”
“Acute flaccid paralysis (AFP) with anterior myelitis is not a reportable condition, and baseline rates of disease are unknown but are likely quite low. Data from 1992–1998 on children aged <15 years in California indicated an incidence of 1.4 AFP cases per 100,000 children per year and did not identify a single case of AFP with anterior myelitis.”
California wasn’t the only state with cases.
In 2014, there were at least 12 cases in Colorado and 11 in Utah.
“In response to the CDPH and CHCO reports, the CDC established a case definition for enhanced nationwide surveillance of AFM, which included individuals less than 21 years of age with acute flaccid limb weakness and MRI involvement of predominantly the gray matter of the spinal cord without identified etiology presenting after August 1, 2014.”
Messacar et al on Acute Flaccid Myelitis: A Clinical Review of US Cases 2012–2015
All together though, in 2014, once the CDC began actively investigating cases, at least 120 cases were discovered in 34 states. The cases were associated with a large outbreak of EV-D68-associated respiratory illness, although they weren’t able to conclusively link those respiratory illnesses to the AFM cases.
Is there any evidence that there were a lot of cases before 2012?
Or that the CDC has dropped the ball and hasn’t been doing enough to investigate cases?
CDC activities include… using multiple research methods to further explore the potential association of AFM with possible causes as well as risk factors for AFM. This includes collaborating with experts to review MRI scans of people from the past 10 years to determine how many AFM cases occurred before 2014, updating treatment and management protocols, and engaging with several academic centers to conduct active surveillance simultaneously for both AFM and respiratory viruses.
CDC on the AFM Investigation
And if the first cases in California and Colorado triggered so much attention, isn’t it likely that any cases anywhere else would have done the same thing?
That makes it very unlikely that many cases were missed in earlier years.
EV-D68 first identified as a cause of respiratory tract infections – 1962
the first reports that EV-D68 could cause severe, even fatal respiratory disease – 2008
first AFM cases are discovered in California – August 2012
the Colorado Department of Public Health and Environment notifies the CDC about a cluster of AFM cases at Children’s Hospital Colorado and a joint investigation begins between the CDPH, CDC, and the physicians caring for the patients – September 2014
the CDC issues a health advisory on Acute Neurologic Illness with Focal Limb Weakness of Unknown Etiology in Children and calls on local and state health departments to report patients to the CDC – September 2014
the CDC conducts a conference call on Neurologic Illness with Limb Weakness in Children, so that clinicians could learn about the latest situation, surveillance, and CDC clinical guidance for AFM testing, patient evaluation and case reporting – October 2014
the CDC posts Interim Considerations for Clinical Management – November 2014
120 AFM cases in 34 states – 2014
Council of State and Territorial Epidemiologists AFM case definition adopted – June 2015
33 AFM cases in 16 states, including one death – 2017
CDC Telebriefing on Acute Flaccid Myelitis in the US with Dr. Nancy Messonnier, director of CDC’s National Center for Immunization and Respiratory Diseases – August 2018
158 AFM cases confirmed in 36 states among 311 reported cases that are being investigated – 2018
The other issue that concerns many parents is why a definitive cause hasn’t yet been identified. And why don’t we have treatments or a cure yet?
“To date, no pathogen (germ) has been consistently detected in the patients’ spinal fluid; a pathogen detected in the spinal fluid would be good evidence to indicate the cause of AFM since this condition affects the spinal cord.”
CDC on AFM Investigation
Although enteroviruses can be difficult to detect in spinal fluid, it is important to keep in mind that isn’t the only thing that is keeping experts from declaring the investigation over and naming a cause, such as EV-D68.
“Among 41 patients whose upper respiratory tract samples were available for enterovirus/rhinovirus testing at CDC, 17 (41%) tested positive: eight (20%) for EV-D68 and nine (22%) for eight other enterovirus/rhinovirus types.”
Eyal Leshem on Notes from the Field: Acute Flaccid Myelitis Among Persons Aged ≤21 Years — United States, August 1–November 13, 2014
Another big issue is that EV-D68 has not been detected in every, or even most AMF patients, and many others have been found to have other enteroviral infections, including EV-A71.
Could it be a coincidence that investigators are finding these enteroviruses simply because it is the season for them to appear? That would mean something else is causing these kids to have AFM.
“During September–November 2016, 10 confirmed cases of AFM were reported in Washington. No common etiology or source of exposure was identified. Enterovirus-A71 was detected in one patient and EV-D68 in two patients, one of whom also tested positive for adenovirus.”
Acute Flaccid Myelitis Among Children — Washington, September–November 2016
While the focus is on EV-D68 as a cause and everyone wants an answer, no one wants the CDC or other investigators to be wrong.
That doesn’t mean that they should be overly cautious and waste time or resources once an answer is evident, but just that they should follow sound epidemiological principles, get the right answer, and help stop kids from getting AFM.
What’s Next for AFM?
There are still a lot of unknowns about AFM, but this is likely what we can expect in the coming months:
the CDC will continue to investigate all unconfirmed cases that have occurred this year, which can take about four weeks after a case is reported and all necessary information is sent in. Keep in mind that since we don’t know if the CDC has already received all of the information on the cases they are investigating, we don’t know when they will finish investigating any pending cases.
local or state health departments will likely reach out to treating physicians to get followup about AFM patients about two months after they developed limb weakness and then report this short-term follow-up data to the CDC. In general, the CDC does not seem to contact patients directly.
From the current investigation, information from outbreaks and cases over the previous years, and cases in other countries, we will hopefully get the answers we need soon to prevent and treat AFM.
Maybe some of those answers will come during a Clinician Outreach and Communication Activity (COCA) Call on November 13, when members from the CDC Acute Flaccid Myelitis Surveillance Team discuss the “activities the CDC is conducting as part of its investigation into AFM.”
The fact that the CDC has an Acute Flaccid Myelitis Surveillance Team will be news and is hopefully reassuring to some folks…
This is also probably a good time to remind folks that funding for public health has been declining in recent years, even as we expect our public health officials to respond to more things and react more quickly to keep us all safe and healthy. Let’s make sure we fund our public health programs, including the CDC and NIH, so that they have all of the resources they need to address all of today’s public health challenges.