Retrospective Study of the Upsurge of Enterovirus D68 Clade D1 among Adults (2014–2018)

Enterovirus D68 (EV-D68) has emerged as an agent of epidemic respiratory illness and acute flaccid myelitis in the paediatric population but data are lacking in adult patients. We performed a 4.5-year single-centre retrospective study of all patients who tested positive for EV-D68 and analysed full-length EV-D68 genomes of the predominant clades B3 and D1. Between 1 June 2014, and 31 December 2018, 73 of the 11,365 patients investigated for respiratory pathogens tested positive for EV-D68, of whom 20 (27%) were adults (median age 53.7 years [IQR 34.0–65.7]) and 53 (73%) were children (median age 1.9 years [IQR 0.2–4.0]). The proportion of adults increased from 12% in 2014 to 48% in 2018 (p = 0.01). All adults had an underlying comorbidity factor, including chronic lung disease in 12 (60%), diabetes mellitus in six (30%), and chronic heart disease in five (25%). Clade D1 infected a higher proportion of adults than clades B3 and B2 (p = 0.001). Clade D1 was more divergent than clade B3: 5 of 19 amino acid changes in the capsid proteins were located in putative antigenic sites. Adult patients with underlying conditions are more likely to present with severe complications associated with EV-D68, notably the emergent clade D1.

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Genetic analysis of Enterovirus D68 associated with pneumonia in children from South India

Journal of Medical Microbiology ◽

10.1099/jmm.0.001356 ◽

2021 ◽

Vol 70 (5) ◽

Author(s):

Ramachandran Erathodi Sanjay ◽

Sasidharanpillai Sabeena ◽

Sudandiradas Robin ◽

John T. Shaji ◽

M. P. Jayakrishnan ◽

...

Keyword(s):

South India ◽

Single Case ◽

Respiratory Illness ◽

Neurological Complications ◽

The Novel ◽

Acute Flaccid Myelitis ◽

Sporadic Cases ◽

Enterovirus D68 ◽

Kerala State ◽

Unique Amino Acid

EV-D68 is an emerging enterovirus infection associated with severe acute respiratory illness (SARI), acute flaccid myelitis (AFM) and acute flaccid paralysis (AFP). While EV-D68 outbreaks and sporadic cases are reported globally, a single case has been reported from India. The present study aims to investigate the molecular epidemiology and clinical characteristics of EV-D68-associated SARI cases from South India. We screened influenza-negative archived throat swab specimens from Influenza-Like Illness (ILI) and SARI cases (n=959; 2016 to 2018 period) for enteroviruses by pan-enterovirus real-time RT-PCR. Thirteen samples positive for enteroviruses were typed by PCR and sequencing based on VPI, VP2 and/or 5′NCR regions. One EV-D68 RNA sample was subjected to next-generation sequencing for whole genome characterisation. Among 13 enterovirus cases, four were ECHO-11, three EV-D68, two CV-A16 and one each EV-71, CV-B1, CV-B2 and CV-A9. All three cases of EV-D68 infection were reported in children below 2 years of age from Kerala state of South India during June and July 2017. The patients developed pneumonia without any neurological complications. Sequencing based on VPI and 5′NCR regions showed that EV-D68 strains belong to the novel subclade B3. The EV-D68 complete genome identified with two unique amino acid substitutions in VP1 (T-246-I) and 3D (K-344-R) regions. This study reiterates the EV-D68 novel subclade B3 circulation in India and indicates the urgent need for structured EV-D68 surveillance in the country to describe the epidemiology.

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2854. Enterovirus D68 Infections in Pediatric Patients in Central Ohio: Clinical Characteristics of a New Outbreak in 2018

Open Forum Infectious Diseases ◽

10.1093/ofid/ofz359.159 ◽

2019 ◽

Vol 6 (Supplement_2) ◽

pp. S74-S74

Author(s):

Alejandro Diaz ◽

Huanyu Wang ◽

Isabel Torrus ◽

Fatima Ara Montojo ◽

Maria Mele-Casas ◽

...

Keyword(s):

Clinical Characteristics ◽

Clinical Presentation ◽

Gastrointestinal Symptoms ◽

Respiratory Illness ◽

Neurologic Manifestations ◽

Asthmatic Children ◽

Acute Flaccid Myelitis ◽

Enterovirus D68 ◽

Co Detection ◽

Opsoclonus Myoclonus Syndrome

Abstract Background Many aspects of EV-D68 pathogenesis in children are not fully understood. In 2014, we experienced an outbreak of EV-D68-associated acute respiratory illness affecting mostly asthmatic children with no cases of acute flaccid myelitis identified. Late in 2018, a new outbreak occurred. The objective of this study was to describe the differences in clinical presentation in children diagnosed with EV-D68 infection during the 2018 outbreak. Methods This is a single-center, observational study. Nasopharyngeal (NP) samples from patients <21 years of age that tested positive for rhinovirus/enterovirus (RV/EV) by the FilmArray respiratory panel v1.7 were prospectively collected. EV-D68 was confirmed using a laboratory-developed RT-PCR. Demographic, clinical characteristics, and semiquantitative EV-D68 loads were analyzed according to the clinical presentation. Results From May to October 2018, 1,987/3,633 (55%) samples were RV/EV positive. Of those 399/1,028 (39%) tested positive for EV-D68 (121 outpatients; 278 inpatients). Inpatients were older (3.1 vs. 1.8 year olds; P < 0.01) with no differences in sex or EV-D68 loads (P > 0.05). Within the inpatient cohort, 67 (1.4 year olds) children were previously healthy, 146 (4.1 year olds) had underlying asthma and 65 (2.5 year olds) had chronic medical conditions (24% vs. 53% vs. 23%, respectively). Most patients presented with respiratory symptoms (>95%), followed by fever (51%) or gastrointestinal symptoms (28%). Eleven children (4%) presented with neurologic manifestations including: acute flaccid myelitis in two children, opsoclonus myoclonus syndrome in one child, and seizures in the remaining eight. Rates of viral co-detection were low (8%) and none of the children with neurologic manifestations had another respiratory virus identified. Patients with neurologic findings had lower EV-D68 loads than those who did not (29 vs. 25 Ct values; P = 0.03). Conclusion EV-D68 infection was associated with significant morbidity, affecting children with underlying asthma at greater rates. It was associated with severe neurologic manifestations despite these children having lower EV-D68 loads. Active surveillance for EV-D68 should be routine to allow a better understanding of the epidemiology and severity of disease. Disclosures All Authors: No reported Disclosures.

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A surveillance method to identify patients with sepsis from electronic health records in Hong Kong: a single centre retrospective study

BMC Infectious Diseases ◽

10.1186/s12879-020-05330-x ◽

2020 ◽

Vol 20 (1) ◽

Cited By ~ 1

Author(s):

Ying Zhi Liu ◽

Raymond Chu ◽

Anna Lee ◽

Charles David Gomersall ◽

Lin Zhang ◽

...

Keyword(s):

Hong Kong ◽

Retrospective Study ◽

Predictive Value ◽

Adult Patients ◽

Single Centre ◽

Study Objective ◽

Suspected Infection ◽

Link Type ◽

Surveillance Method ◽

Electronic Health

Abstract Background Currently there are only two population studies on sepsis incidence in Asia. The burden of sepsis in Hong Kong is unknown. We developed a sepsis surveillance method to estimate sepsis incidence from a population electronic health record (EHR) in Hong Kong using objective clinical data. The study objective was to assess our method’s performance in identifying sepsis using a retrospective cohort. We compared its accuracy to administrative sepsis surveillance methods such as Angus’ and Martin’s methods. Method In this single centre retrospective study we applied our sepsis surveillance method on adult patients admitted to a tertiary hospital in Hong Kong. Two clinicians independently reviewed the clinical notes to determine which patients had sepsis. Performance was assessed by sensitivity, specificity, positive predictive value, negative predictive value and area under the curve (AUC) of Angus’, Martin’s and our surveillance methods using clinical review as “gold standard.” Results Between January 1 and February 28, 2018, our sepsis surveillance method identified 1352 adult patients hospitalised with suspected infection. We found that 38.9% (95%CI 36.3–41.5) of these patients had sepsis. Using a 490 patient validation cohort, two clinicians had good agreement with weighted kappa of 0.75 (95% CI 0.69–0.81) before coming to consensus on diagnosis of uncomplicated infection or sepsis for all patients. Our method had sensitivity 0.93 (95%CI 0.89–0.96), specificity 0.86 (95%CI 0.82–0.90) and an AUC 0.90 (95%CI 0.87–0.92) when validated against clinician review. In contrast, Angus’ and Martin’s methods had AUCs 0.56 (95%CI 0.53–0.58) and 0.56 (95%CI 0.52–0.59), respectively. Conclusions A sepsis surveillance method based on objective data from a population EHR in Hong Kong was more accurate than administrative methods. It may be used to estimate sepsis population incidence and outcomes in Hong Kong. Trial registration This study was retrospectively registered at clinicaltrials.gov on October 3, 2019 (NCT04114214).

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Genomic Analyses of Acute Flaccid Myelitis Cases among a Cluster in Arizona Provide Further Evidence of Enterovirus D68 Role

mBio ◽

10.1128/mbio.02262-18 ◽

2019 ◽

Vol 10 (1) ◽

Cited By ~ 6

Author(s):

Jolene R. Bowers ◽

Michael Valentine ◽

Veronica Harrison ◽

Viacheslav Y. Fofanov ◽

John Gillece ◽

...

Keyword(s):

Real Time ◽

Real Time Pcr ◽

Respiratory Illness ◽

Amplicon Sequencing ◽

Gastrointestinal Illness ◽

Metagenomic Sequencing ◽

Neurologic Disease ◽

Acute Flaccid Myelitis ◽

Genomic Analyses ◽

Enterovirus D68

ABSTRACTEnteroviruses are a common cause of respiratory and gastrointestinal illness, and multiple subtypes, including poliovirus, can cause neurologic disease. In recent years, enterovirus D68 (EV-D68) has been associated with serious neurologic illnesses, including acute flaccid myelitis (AFM), frequently preceded by respiratory disease. A cluster of 11 suspect cases of pediatric AFM was identified in September 2016 in Phoenix, AZ. To determine if these cases were associated with EV-D68, we performed multiple genomic analyses of nasopharyngeal (NP) swabs and cerebrospinal fluid (CSF) material from the patients, including real-time PCR and amplicon sequencing targeting the EV-D68 VP1 gene and unbiased microbiome and metagenomic sequencing. Four of the 11 patients were classified as confirmed cases of AFM, and an additional case was classified as probable AFM. Real-time PCR and amplicon sequencing detected EV-D68 virus RNA in the three AFM patients from which NP swabs were collected, as well as in a fourth patient diagnosed with acute disseminated encephalomyelitis, a disease that commonly follows bacterial or viral infections, including enterovirus. No other obvious etiological causes for AFM were identified by 16S or RNA and DNA metagenomic sequencing in these cases, strengthening the likelihood that EV-D68 is an etiological factor. Herpes simplex viral DNA was detected in the CSF of the fourth case of AFM and in one additional suspect case from the cluster. Multiple genomic techniques, such as those described here, can be used to diagnose patients with suspected EV-D68 respiratory illness, to aid in AFM diagnosis, and for future EV-D68 surveillance and epidemiology.IMPORTANCEEnteroviruses frequently result in respiratory and gastrointestinal illness; however, multiple subtypes, including poliovirus, can cause severe neurologic disease. Recent biennial increases (i.e., 2014, 2016, and 2018) in cases of non-polio acute flaccid paralysis have led to speculations that other enteroviruses, specifically enterovirus D68 (EV-D68), are emerging to fill the niche that was left from poliovirus eradication. A cluster of 11 suspect cases of pediatric acute flaccid myelitis (AFM) was identified in 2016 in Phoenix, AZ. Multiple genomic analyses identified the presence of EV-D68 in the majority of clinical AFM cases. Beyond limited detection of herpesvirus, no other likely etiologies were found in the cluster. These findings strengthen the likelihood that EV-D68 is a cause of AFM and show that the rapid molecular assays developed for this study are useful for investigations of AFM and EV-D68.

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Molecular epidemiological study of enterovirus D68 in hospitalised children in Hong Kong in 2014–2015 and their complete coding sequences

BMJ Open Respiratory Research ◽

10.1136/bmjresp-2019-000437 ◽

2019 ◽

Vol 6 (1) ◽

pp. e000437

Author(s):

Haichao Wang ◽

Kinpong Tao ◽

Cheuk Yin Leung ◽

Kam Lun Hon ◽

C M Apple Yeung ◽

...

Keyword(s):

Hong Kong ◽

Vaccine Development ◽

Public Awareness ◽

Respiratory Illness ◽

Molecular Classification ◽

Human Enterovirus ◽

Coding Sequences ◽

Acute Flaccid Myelitis ◽

Hospitalised Patients ◽

Enterovirus D68

BackgroundHuman enterovirus D68 (EV-D68) was first isolated in 1962 and has aroused public concern recently because of a nationwide outbreak among children in 2014–2015 in the USA. The symptoms include fever, runny nose, sneezing, cough and muscle pains. It might be associated with severe respiratory illness in individuals with pre-existing respiratory conditions and its potential association with acute flaccid myelitis is under investigation. In Asia, EV-D68 cases have been reported in several countries.The studyWe aimed to understand the EV-D68 prevalence and their genetic diversity in Hong Kong children.MethodsA total of 10 695 nasopharyngeal aspirate (NPA) samples from hospitalised patients aged <18 years were collected from September 2014 to December 2015 in two regional hospitals. NPAs tested positive for enterovirus/rhinovirus (EV/RV) were selected for genotyping. For those identified as EV-D68, their complete coding sequences (CDSs) were obtained by Sanger sequencing. A maximum-likelihood phylogeny was constructed using all EV-D68 complete coding sequences available in GenBank (n=482).Results2662/10 695 (24.9%) were tested positive with EV/RV and 882/2662 (33.1%) were selected randomly and subjected to molecular classification. EV-D68 was detected in 15 (1.70%) samples from patients with clinical presentations ranging from wheezing to pneumonia and belonged to subclade B3. Eight CDSs were successfully obtained. A total of 10 amino acid residue polymorphisms were detected in the viral capsid proteins, proteases, ATPase and RNA polymerase.ConclusionB3 subclade was the only subclade found locally. Surveillance of EV-D68 raises public awareness and provides the information to determine the most relevant genotypes for vaccine development.

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Respiratory and intestinal epithelial cells exhibit differential susceptibility and innate immune responses to EV-D68

eLife ◽

10.7554/elife.66687 ◽

2021 ◽

Vol 10 ◽

Author(s):

Megan Culler Freeman ◽

Alexandra I Wells ◽

Jessica Ciomperlik-Patton ◽

Michael M Myerburg ◽

Liheng Yang ◽

...

Keyword(s):

Intestinal Epithelium ◽

Differential Susceptibility ◽

Respiratory Illness ◽

Intestinal Epithelial ◽

Innate Immune Responses ◽

Human Airway ◽

Acute Flaccid Myelitis ◽

Enterovirus D68 ◽

Type Iii Interferon ◽

Severe Respiratory Illness

Enterovirus D68 (EV-D68) has been implicated in outbreaks of severe respiratory illness and is associated with acute flaccid myelitis (AFM). EV-D68 is often detected in patient respiratory samples but has also been detected in stool and wastewater, suggesting the potential for both respiratory and enteric routes of transmission. Here, we used a panel of EV-D68 isolates, including a historical pre-2014 isolate and multiple contemporary isolates from AFM outbreak years, to define the dynamics of viral replication and the host response to infection in primary human airway cells and stem cell-derived enteroids. We show that some recent EV-D68 isolates have decreased sensitivity to acid and temperature compared with earlier isolates and that the respiratory, but not intestinal, epithelium induces a robust type III interferon (IFN) response that restricts infection. Our findings define the differential responses of the respiratory and intestinal epithelium to contemporary EV-D68 isolates and suggest that a subset of isolates have the potential to target both the human airway and gastrointestinal tracts.

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Current Understanding of Human Enterovirus D68

Viruses ◽

10.3390/v11060490 ◽

2019 ◽

Vol 11 (6) ◽

pp. 490 ◽

Cited By ~ 16

Author(s):

Jing Sun ◽

Xiao-Yi Hu ◽

Xiao-Fang Yu

Keyword(s):

Treatment Options ◽

Antiviral Agents ◽

Respiratory Illness ◽

The United States ◽

Human Enterovirus ◽

Genetic Characteristics ◽

Host Interactions ◽

Acute Flaccid Myelitis ◽

Enterovirus D68 ◽

Neurogenic Disease

Human enterovirus D68 (EV-D68), a member of the species Enterovirus D of the Picornaviridae family, was first isolated in 1962 in the United States. EV-D68 infection was only infrequently reported until an outbreak occurred in 2014 in the US; since then, it has continued to increase worldwide. EV-D68 infection leads to severe respiratory illness and has recently been reported to be linked to the development of the neurogenic disease known as acute flaccid myelitis (AFM), mostly in children, seriously endangering public health. Hitherto, treatment options for EV-D68 infections were limited to supportive care, and as yet there are no approved, specific antiviral drugs or vaccines. Research on EV-D68 has mainly focused on its epidemiology, and its virologic characteristics and pathogenesis still need to be further explored. Here, we provide an overview of current research on EV-D68, including the genotypes and genetic characteristics of recent epidemics, the mechanism of infection and virus–host interactions, and its relationship to acute flaccid myelitis (AFM), in order to broaden our understanding of the biological features of EV-D68 and provide a basis for the development of effective antiviral agents.

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Human antibodies neutralize enterovirus D68 and protect against infection and paralytic disease

Science Immunology ◽

10.1126/sciimmunol.aba4902 ◽

2020 ◽

Vol 5 (49) ◽

pp. eaba4902 ◽

Cited By ~ 2

Author(s):

Matthew R. Vogt ◽

Jianing Fu ◽

Nurgun Kose ◽

Lauren E. Williamson ◽

Robin Bombardi ◽

...

Keyword(s):

Neutralizing Antibody ◽

Respiratory Illness ◽

High Potency ◽

Acute Flaccid Myelitis ◽

Cryo Electron Microscopy ◽

Enterovirus D68 ◽

Axes Of Symmetry ◽

Prior Infection ◽

Reactive Antibody

Enterovirus D68 (EV-D68) causes outbreaks of respiratory illness, and there is increasing evidence that it causes outbreaks of acute flaccid myelitis (AFM). There are no licensed therapies to prevent or treat EV-D68 infection or AFM disease. We isolated a panel of EV-D68–reactive human monoclonal antibodies that recognize diverse antigenic variants from participants with prior infection. One potently neutralizing cross-reactive antibody, EV68-228, protected mice from respiratory and neurologic disease when given either before or after infection. Cryo–electron microscopy studies revealed that EV68-228 and another potently neutralizing antibody (EV68-159) bound around the fivefold or threefold axes of symmetry on virion particles, respectively. The structures suggest diverse mechanisms of action by these antibodies. The high potency and effectiveness observed in vivo suggest that antibodies are a mechanistic correlate of protection against AFM disease and are candidates for clinical use in humans with EV-D68 infection.

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Biennial Upsurge and Molecular Epidemiology of Enterovirus D68 Infection in New York, USA, 2014 to 2018

Journal of Clinical Microbiology ◽

10.1128/jcm.00284-20 ◽

2020 ◽

Vol 58 (9) ◽

Author(s):

Victoria L. Gilrane ◽

Jian Zhuge ◽

Weihua Huang ◽

Sheila M. Nolan ◽

Abhay Dhand ◽

...

Keyword(s):

New York ◽

Molecular Epidemiology ◽

Vaccine Development ◽

Genomic Analysis ◽

Respiratory Illness ◽

The United States ◽

Essential Information ◽

Hudson Valley ◽

Acute Flaccid Myelitis ◽

Enterovirus D68

ABSTRACT Enterovirus D68 (EV-D68) infection has been associated with outbreaks of severe respiratory illness and increased cases of nonpolio acute flaccid myelitis. The patterns of EV-D68 circulation and molecular epidemiology are not fully understood. In this study, nasopharyngeal (NP) specimens collected from patients in the Lower Hudson Valley, New York, from 2014 to 2018 were examined for rhinovirus/enterovirus (RhV/EV) by the FilmArray respiratory panel. Selected RhV/EV-positive NP specimens were analyzed using two EV-D68-specific real-time RT-PCR assays, Sanger sequencing and metatranscriptomic next-generation sequencing. A total of 2,398 NP specimens were examined. EV-D68 was detected in 348 patients with NP specimens collected in 2014 (n = 94), 2015 (n = 0), 2016 (n = 160), 2017 (n = 5), and 2018 (n = 89), demonstrating a biennial upsurge of EV-D68 infection in the study area. Ninety-one complete or nearly complete EV-D68 genome sequences were obtained. Genomic analysis of these EV-D68 strains revealed dynamics and evolution of circulating EV-D68 strains since 2014. The dominant EV-D68 strains causing the 2014 outbreak belonged to subclade B1, with a few belonging to subclade B2. New EV-D68 subclade B3 strains emerged in 2016 and continued in circulation in 2018. Clade D strains that are rarely detected in the United States also arose and spread in 2018. The establishment of distinct viral strains and their variable circulation patterns provide essential information for future surveillance, diagnosis, vaccine development, and prediction of EV-D68-associated disease prevalence and potential outbreaks.

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Transcriptomic Profiling Reveals a Role for TREM-1 Activation in Enterovirus D68 Infection-Induced Proinflammatory Responses

Frontiers in Immunology ◽

10.3389/fimmu.2021.749618 ◽

2021 ◽

Vol 12 ◽

Author(s):

Jinyu Li ◽

Shan Yang ◽

Sihua Liu ◽

Yulu Chen ◽

Hongyun Liu ◽

...

Keyword(s):

Inflammatory Responses ◽

Transcriptional Profiling ◽

Specific Inhibitor ◽

Respiratory Illness ◽

Mapk Signaling ◽

Mitogen Activated Protein Kinase ◽

Health Concern ◽

Necrosis Factor Alpha ◽

Acute Flaccid Myelitis ◽

Enterovirus D68

Increasing cases related to the pathogenicity of Enterovirus D68 (EV-D68) have made it a growing worldwide public health concern, especially due to increased severe respiratory illness and acute flaccid myelitis (AFM) in children. There are currently no vaccines or medicines to prevent or treat EV-D68 infections. Herein, we performed genome-wide transcriptional profiling of EV-D68-infected human rhabdomyosarcoma (RD) cells to investigate host-pathogen interplay. RNA sequencing and subsequent experiments revealed that EV-D68 infection induced a profound transcriptional dysregulation of host genes, causing significantly elevated inflammatory responses and altered antiviral immune responses. In particular, triggering receptor expressed on myeloid cells 1 (TREM-1) is involved in highly activated TREM-1 signaling processes, acting as an important mediator in EV-D68 infection, and it is related to upregulation of interleukin 8 (IL-8), IL-6, IL-12p70, IL-1β, and tumor necrosis factor alpha (TNF-α). Further results demonstrated that NF-κB p65 was essential for EV-D68-induced TREM-1 upregulation. Moreover, inhibition of the TREM1 signaling pathway by the specific inhibitor LP17 dampened activation of the p38 mitogen-activated protein kinase (MAPK) signaling cascade, suggesting that TREM-1 mainly transmits activation signals to phosphorylate p38 MAPK. Interestingly, treatment with LP17 to inhibit TREM-1 inhibited viral replication and infection. These findings imply the pathogenic mechanisms of EV-D68 and provide critical insight into therapeutic intervention in enterovirus diseases.

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