Enterovirus D-68 in children presenting for acute care in the hospital setting.

Timothy J. Savage,Jane Kuypers,Helen Y. Chu,Anne Marie Buccat,Janet A. Englund,Alpana Waghmare,Keith R. Jerome,Miranda C. Bradford,Eileen J. Klein,Xuan Qin

doi:10.1111/irv.12551

Timothy J. Savage, Jane Kuypers + Show 8 more

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https://doi.org/10.1111/irv.12551

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Abstract

BackgroundSevere respiratory disease associated with enterovirus D68 (EV‐D68) has been reported in hospitalized pediatric patients. Virologic and clinical characteristics of EV‐D68 infections exclusively in patients presenting to a hospital Emergency Department (ED) or urgent care have not been well defined.MethodsMid‐nasal swabs from pediatric patients with respiratory symptoms presenting to the ED or urgent care were evaluated using a commercial multiplex PCR platform. Specimens positive for rhinovirus/enterovirus (HRV/EV) were subsequently tested using real‐time reverse‐transcriptase PCR for EV‐D68. The PCR cycle threshold (CT) was used as a viral load proxy. Clinical outcomes were compared between patients with EV‐D68 and patients without EV‐D68 who tested positive for HRV/EV.ResultsFrom August to December 2014, 511 swabs from patients with HRV/EV were available. EV‐D68 was detected in 170 (33%) HRV/EV‐positive samples. In multivariable models adjusted for age and underlying asthma, patients with EV‐D68 were more likely to require hospitalization for respiratory reasons (odds ratio (OR): 3.11, CI: 1.85‐5.25), require respiratory support (OR: 1.69, CI: 1.09‐2.62), have confirmed/probable lower respiratory tract infection (LRTI; OR: 3.78, CI: 2.03‐7.04), and require continuous albuterol or steroids (OR: 3.91, CI: 2.22‐6.88 and OR: 4.73, CI: 2.65‐8.46, respectively). Higher EV‐D68 viral load was associated with need for respiratory support and LRTI in multivariate models.ConclusionsAmong pediatric patients presenting to the ED or urgent care, EV‐D68 causes more severe disease than non‐EV‐D68 HRV/EV independent of underlying asthma. High viral load was associated with worse clinical outcomes. Rapid and quantitative viral testing may help identify and risk stratify patients.

Highlights

Enterovirus D68 (EV-D68) is a non-polio enterovirus recently recognized as a significant cause of respiratory disease after decades of sporadic reported cases and small outbreaks.[1,2] A spike in nationwide pediatric admissions due to respiratory symptoms in summer 2014 prompted increased surveillance that led to the detection of EV-D68 as the likely responsible pathogen.[3,4,5,6] Initially, hospitals in the American Midwest reported increased burdens on emergency departments[7] and described severe respiratory illness caused by EV- D68 among children admitted to the pediatric intensive care unit.[8]
Our study aims to define the burden of EV-D68 in a large cohort of pediatric patients presenting for urgent or emergent care in the emergency department (ED) or urgent care clinic at a regional children’s hospital and to compare the clinical presentation, role of comorbidities, and outcomes between patients with EV-D68 and those with other strains of human rhinovirus/enterovirus (HRV/EV) during an outbreak
We describe a cohort of 511 patients with EV-D68 and non-EV-D68 HRV/EV who presented to the ED and urgent care at Seattle Children’s Hospital during the late summer and fall of 2014

Summary

Background

Severe respiratory disease associated with enterovirus D68 (EV-D68) has been reported in hospitalized pediatric patients. Virologic and clinical characteristics of EV-D68 infections exclusively in patients presenting to a hospital Emergency Department (ED) or urgent care have not been well defined. Methods: Mid-nasal swabs from pediatric patients with respiratory symptoms presenting to the ED or urgent care were evaluated using a commercial multiplex PCR platform. Clinical outcomes were compared between patients with EV-D68 and patients without EV-D68 who tested positive for HRV/EV. Higher EV-D68 viral load was associated with need for respiratory support and LRTI in multivariate models. Conclusions: Among pediatric patients presenting to the ED or urgent care, EV-D68 causes more severe disease than non-EV-D68 HRV/EV independent of underlying asthma. High viral load was associated with worse clinical outcomes.

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