Enterovirus D68: Good News, Bad News, What To Do

Pick your viral anxiety: Do you want to focus your media-fueled jitters on Ebola or on enterovirus D68?

Personally, even with today's news of the first U.S. death from Ebola, I pick the enterovirus every time. For one thing, it's actually around; it's not a single case in Texas. But I'd prefer no anxiety at all, and the best antidote tends to be knowledge. So here are some data points:

The Massachusetts Department of Public Health fact sheet on enterovirus D68 is here and the CDC's here. At a news conference last week, Dr. Alfred DeMaria, the department's medical director for the Bureau of Infectious Disease, told reporters that enterovirus D68 had probably been "the predominant cause of respiratory illness over the last four weeks."

Mostly, that meant colds, he said, and he thinks he even had the bug himself. But reports of lung ailments have "decreased significantly over the past couple of weeks," he said, so "enterovirus 68 seems to be going away."

Let's hope. But what the heck? Here & Now reports that the enterovirus has been connected to five deaths nationwide, most recently of a 4-year-old in New Jersey. Of course, we know that viruses can sometimes lead to deaths by unleashing bacterial infections; flu has been known to kill dozens of American children in a bad year. But still, what to make of all the coverage of this unfamiliar virus?

I asked Dr. Ben Kruskal, chief of infectious diseases at Harvard Vanguard Medical Associates. My takeaway: Yes, this is quite a bit like flu, only it's drawing attention because it's a virus that's acting atypically, surprisingly. Our conversation, edited:

There are so many viruses around; why are we even hearing about this one and what should we make of the coverage?

We’re hearing about it because it is not just a strain of a virus we don’t see very often but because it’s causing unusual manifestations, and manifestations that have enough impact for us to pay attention to. It’s actually in 30 or 40 states now, and we don’t really know how widespread it is because it’s clinically not terribly distinctive. It’s a respiratory virus that looks like a lot of other respiratory viruses, including the flu and the cold viruses and a whole bunch of others. And the reason we’re paying attention is not just the fact that it’s an unusual strain — then it would be a sort of laboratory curiosity — but because it's actually on a more severe end of the spectrum for some people.

So it's been confirmed that it's here in Massachusetts, and it sounds like we have had more kids being hospitalized for respiratory trouble than usual in recent weeks, right? For example, Tufts Medical Center tells us that they've had 54 hospital admissions of kids with repiratory problems this year, compared to 27 admissions by this date last year, and they're tending to stay in longer and need more treatment.

I understand from Dan Slater, who's the director of pediatrics here at Harvard Vanguard, that we went months without having to admit any kids with asthma to the hospital, and in the last few weeks we've had quite a few admissions.

So what’s your public health message then at this point? What do you say to parents?

It’s reasonable to think of this outbreak in most respects as being like a sort of a nastier flu season. The timing is different from the flu season but in terms of how it manifests itself, it’s pretty similar to a severe flu. Remember that the flu and this virus — like any infectious agent — have a spectrum of severity. So even though this one is on average more severe, there are still lots of people who will get just a regular old cold. And there are some people who will get kind of a nasty cold. And there are some people who will get more severe things, including asthma-like illness in people who don’t have pre-existing asthma or an exacerbation of underlying asthma in people who do.

So are there telltale symptoms to watch for?

There really isn’t anything terribly distinctive. The good and the bad news is that it’s really not very different from any other respiratory virus in terms of how it presents itself or what we do about it. So we don’t need to diagnose it specifically because the treatment is the same treatment we provide for any respiratory illness.

Which is?

Symptom relief for people with relatively mild illness, who can stay at home; and supportive care, including asthma medications, for people who have constriction of their airways. This may be done either at home or in the hospital depending on how severe it is.

And make sure to call your doctor if…

It’s all the same things you would call your doctor for ordinarily. The more severe end of the spectrum is if you have difficulty breathing.

And do you think all this is the shape of the future in any way?

Joshua Lederberg, who was a Nobel laureate, coined a term some years ago, “emerging infection,” to describe an accelerating pace of recognizing new infections. We had had this idea that we knew about all the infections there were, but all of a sudden new infections were emerging. And of course this was correct; we were recognizing new infections, most of which were probably emerging because of changes in the world — human changes, mostly, but sometimes environmental changes.

So in this case…

This particular virus has been seen before; this strain — enterovirus D68 — is well-characterized. It has not been as big a problem in the recorded past and it’s probably because this is a slightly different substrain of that strain, if you will. We’re now characterizing and recognizing infections like this that in the past might have been all lumped together under ‘some respiratory virus’ because we have better technologies for recognizing and diagnosing them.

And then it gets out in the media and it’s all scary —

Exactly, but on the other hand, there are benefits to the recognition too. So with the early recognition of this new strain, and with the benefit of the experience of the bad things that were happening in the midwest, we were able to prepare our asthma patients for this.

So that’s an upside.

There is definitely anxiety, but there’s also some upside to the recognition as well….

They’re not really comparable, but I must say, given the media landscape of viruses over recent weeks, I felt much more scared of EV-D68 than I did of Ebola — though it’s ridiculous to compare them.

That’s in fact an obvious comparison. There are a lot of contrasts and I think where you landed is not ridiculous. Remember, all infections have a spectrum of severity, and the spectrum of EV-D68 is not nearly as bad on average as the spectrum of Ebola. So that’s one important distinction. On the other hand, there’s only one case of Ebola in the US and there’s not likely to be a lot more, whereas there are hundreds of confirmed cases of EV-D68, and likely many more not officially diagnosed.

One way Ebola is different from EV-D68 is that Ebola is very distinctive clinically beyond it’s earliest stages, so it’s easy to recognize, and it’s pretty much only in western Africa. Those two things will likely enable us to keep it corralled, whereas EV-D68 is like so many other infections, and it’s already widespread in the US. At base, it’s infinitely more likely your child will get EV-D68 than that he or she will get Ebola. But fortunately, if he or she does get EV-D68, it’s likely to be mild.

Still, needless to say, I’d rather prevent it. The Department of Public Health offers these tips.

EV-D68 behaves like a cold virus (rhinovirus). Like other enteroviruses, EV-D68 spreads through close contact with infected people, most likely when an infected person coughs, sneezes, or when an uninfected person touches contaminated surfaces. You can help protect yourself from respiratory illnesses by following these steps:

Wash hands often with soap and water for 20 seconds, especially after coming in contact with respiratory secretions or when changing diapers (enteroviruses also infect the bowel).
Avoid touching eyes, nose and mouth with unwashed hands.
Avoid kissing, hugging, and sharing cups or eating utensils with people who are sick.
Clean and disinfect frequently touched surfaces, such as toys and doorknobs, especially if someone is sick.