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SKEPTOID BLOG:

Ebola and Enterovirus D68, Pandemic or Panic Part I

by Stephen Propatier

October 5, 2014

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Donate American news media outlets love a good scary story. If a scary story involves deadly diseases and children, you have media gold. Media outlets tap into the primal fear of infectious disease to draw your eyes to their screens. Recently, the fear of infectious disease has become a constant drumbeat on the Internet, in print, and on television. This is primarily due to two viral diseases. Disease one is the deadly West African Ebola Virus. Disease two is Enterovirus D68. Mike Rothschild did a nice post about the enterovirus on September 16th titled "EV-D68: The (Not) New Disease to (Not) Panic About." Events this week seem to have pique an obsessive interest around both diseases: the first-ever case of Ebola diagnosed in the US in Dallas, Texas, and the recent news reports linking the death of a healthy child with the enterovirus.

There is a steadily rising level of concern about these illnesses from my patients in the office. Out of the office I hear a lot of speculative misinformation and disinformation related to these two diseases from the press, institutions charged with informing and educating.

Fear of Ebola and Enterovirus has hit hard especially close to my home. Rhode Island is the state I live and practice in. Fear related to the enterovirus has neared hysterical panic in Rhode Island because of a 10-year-old girl that recently died in Hasbro Children's Hospital here. Factually she died from a bacterial infection but she did test positive for the EV-D68 virus. Ebola fear is also running rampant locally due to the Texas case. The fear of Ebola cases in Rhode Island is not entirely unfounded according to the local newspaper, which reports that:
...some health officials say a case of Ebola in Rhode Island is inevitable because of the state's sizable West African population, including a large Liberian population and travel to and from countries affected by the disease.
My son is a student in the Rhode Island school system. When my child's level-headed school principal asked me if I was concerned about the recent enterovirus-related death, it really brought home the impact of the news media and the disproportional fear related to these health issues.

Infectious disease is worthy of fear, but what is justified precaution, and what is panic? Let's take a skeptical look at what is truly known about these diseases, and the current outbreaks. Let's try to inform people rather than panic, teach rather than terrify.

The discussion is nuanced and complicated for both diseases, far too much for one post so I've divided them into two discussions. Part I will focus on the Enterovirus, and Part II will focus on the Ebola epidemic.

Enterovirus D68 (the Basics)

* Warning Technical Jargon!*

The enteroviruses and parechoviruses are distinct genera within the Picornavirus family. The enteroviruses are divided into four species designated A through D based on homology within the RNA region coding for the VP1 capsid protein. Isolates of the same serotype characteristically diverge in the VP1 region by less than 25 percent and 12 percent, respectively, within corresponding nucleotide and amino acid sequences.

An older, traditional classification separates the enteroviruses into five sub-genera based on differences in host range and pathogenic potential. Each sub-genus contains a variable number of unique serotypes distinguished from one another on the basis of neutralization by specific antisera. A total of 72 serotypes were originally identified by conventional methods, of which 64 remain after recognition of redundant serotypes and reclassification of others.
  • Polioviruses — serotypes 1-3

  • Group A coxsackieviruses — serotypes 1-22, 24

  • Group B coxsackieviruses — serotypes 1-6

  • Echoviruses — serotypes 1-9, 11-21, 24-27, 29-33

  • Enteroviruses — serotypes 68-71

Enterovirus D68 has been reported to cause clusters of respiratory disease in the United States and other countries since 2008, and more recently in many states throughout the United States in the late summer/early autumn of 2014. Rare cases of central nervous system disease attributed to enterovirus D68 and associated with acute motor neuron disease similar to poliomyelitis have also occurred in New Hampshire in 2011, in California between 2012 and 2013, and in Colorado in the 2014 surge of respiratory infections. There has been an overall jump in the number of cases of EV-D68 in the United States. This was first reported in Missouri and Illinois, but has affected other states, too. Some children have had so much trouble breathing that they have needed to be treated in the hospital. These cases have occurred predominantly in children with a prior history of asthma and are characterized by low-grade or absent fever, wheezing, dyspnea, hypoxia, and perihilar infiltrates. Some cases have been severe enough to warrant mechanical ventilation.

Is there a test for EV-D68? Yes. There is a test for the EV-D68 virus. But most hospitals are not able to run the test themselves. Instead, they have to send samples (of mucus or saliva) to government-run labs for testing. As a result, it might take a little while to know for sure what the results are.

How is EV-D68 treated? Usually, EV-D68 is treated like a regular cold, and goes away on its own. There is no specific medicine used to treat it, and antibiotics do not help. In serious cases where the child is having trouble breathing, he or she might need treatment in the hospital. This can include giving the child extra oxygen, or using machines to help him or her to breathe.

Can EV-D68 be prevented? Yes. You can do the following to help prevent the spread of this infection:


  • Make sure your child washes his or her hands often with soap and water, especially after using the bathroom.

  • Keep your home clean and disinfect tabletops, toys, and other things that a child might touch.

  • If you think your child might have EV-D68 or another contagious illness, keep him or her away from other people. Teach your child to cover his or her sneezes and coughs.

  • Avoid touching people who are sick, and do not share cups or eating utensils.

  • If your child has asthma, follow his or her doctor's instructions carefully. Be sure to give your child all the medicines the doctor prescribes. Children with asthma might be more likely to have breathing problems if they get infected with EV-D68.

There is no vaccine to prevent enterovirus D68. For most up-to-date information about EV-D68, visit the Centers for Disease Control and Prevention (CDC) Web site at: www.cdc.gov/non-polio-enterovirus/about/EV-D68.html.

Compared to Ebola the Enterovirus is a fairly banal disease. What brought it to the media's attention during an Ebola outbreak was some cases in Denver, related to a Colorado outbreak. The outbreak was associated with polio-like symptoms in a small group of children. Since then the story has taken on a life of its own. There are five deaths that have been associated with ev-D68. The Virus has not been causally linked to the deaths in any of those cases. The FDA has indicated that in three of the cases they will not release specific details but have indicated that the children had preexisting health issues. It is not terribly surprising that a respiratory illness contributed to their death. The fourth was a healthy 10-year-old, which is of course concerning. The fifth died approximately one week ago in New Jersey, although the details of that case are unclear.

This raises panicky questions: Is it turning deadly? Why did a healthy young girl die? Will there be more deaths?

These are all valid questions. Try to remember that testing positive for ev-D68 does not automatically mean that it must be the cause. In my home state the 10-year-old didn't die from enterovirus, as far as anyone can tell. This young, otherwise-healthy child seems to have died from Staphylococcal sepsis. In layman's terms she developed a bacterial infection that produced a system-wide breakdown and organ failure.

*Warning Technical Jargon!*

Sepsis occurs when the release of proinflammatory mediators in response to an infection exceeds the boundaries of the local environment, leading to a more generalized response. Sepsis can be conceptualized as malignant intravascular inflammation.
  • Malignant because it is uncontrolled, unregulated, and self-sustaining

  • Intravascular because the blood spreads mediators that are usually confined to cell-to-cell interactions within the interstitial space

  • Inflammatory because all characteristics of the septic response are exaggerations of the normal inflammatory response

  • It happens quickly in a short period of time.

  • Antibiotics can cause bacterial cell death and the release of inflammatory triggers, worsening the problem.

It is uncertain why immune responses that usually remain localized sometimes spread beyond the local environment, causing sepsis. The cause is likely multifactorial and may include the direct effects of the invading microorganisms or their toxic products, release of large quantities of proinflammatory mediators, and complement activation. In addition, some individuals may be genetically susceptible to developing sepsis, according to the paper "Advances in pathogenesis and management of sepsis."

Bottom Line: This 10-year-old died from a bacterial infection that triggered a massive immune response resulting in the body attacking itself, in addition to a cascade of damage with organ failure and death.

People often mistake that to mean that the organism is somehow different or "more deadly" than other strains. NO: that does not appear to be the case (there are many different strains of staphylococcus living on/in you right now). Rather, it is a combination of factors that have to do with the organism, the individual, their immune system, and a preexisting susceptibility that they seem to have.

How do we know that? In this case we don't have all the specifics. What we do know about almost all septic shock cases is that it doesn't seem to infect others who live and work with the affected. That leads us to believe that the individual is the critical factor not the organism.

In this case it is false to directly link the enterovirus infection to the bacterial infection. It may have played a role. There are historical precedents for Staphylococcal sepsis and influenza. EV-D68 may have been part of the reason her immune system overreacted to the bacterial infection. It may be completely coincidental. Most likely we will never know.

One thing is known: staph sepsis has so many interacting factors that there is little chance that this will become a wide-spread problem. Our immune systems are as individuated as our fingerprints. Like our fingerprints, the conditions leading to this child's unfortunate death are unlikely to be duplicated.

The number of cases of Ev-D68 that have produced nerve paralysis symptoms is tiny compared to the number of children infected. They have not been properly evaluated and we still are not sure what caused those symptoms in those children. This is not a new or unusual problem with this type of virus. There is a history of polio-type symptoms rarely from other members of this viral family (excluding polio, of course—its main sequelae is paralysis). Again, these are rare and exceptionally small numbers.

Overview: This infection is a benign cold in adults. It can cause respiratory distress in some children who have a history of respiratory disease. There does not appear to be any real deviation from what normally happens with this illness. The sepsis was a unique and rare circumstance, thankfully. Enterovirus is extremely unlikely to be causally related to the 10-year-old's death, even partially. Despite that one unfortunate death, the data does not give cause for concern. The other four deaths at this time are murky. Given the thousands of mild cases suffered, and the fact that this is a common and recurrent seasonal viral infection, there is little cause for serious concern at this time. That doesn't mean ignore it. Just remember: the flu is a proven-deadly infection that needs preventative vaccination. It killed 105 children in 2012. At this point even if this becomes causally related, EV-D68 is less deadly than seasonal influenza, which people dismiss (unfortunately) as benign.

Remember: TV, Internet, and the radio need your attention and they love everything that draws your attention. Don't get your medical information from sources that make money from scaring you. Ask your physician, call your nurse, check in with your department of health and CDC websites. DO use the diligent, prudent recommendations for this disease. But above all, take a page from Douglas Adams and the Hitchhiker's Guide: Don't panic.

Disclaimer: This post is my personal opinion, it is not a substitute for medical care. It is for informational purposes only. The information on Skeptoid blog is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. This post does not reflect the opinion of my partners, professional affiliates, or academic affiliations. I have no financial conflicts of interest to disclose.

by Stephen Propatier

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