EV-D68 Warnings: Did they Help or Hurt?

Soon after she heard that hospitals in the Midwest were seeing a patient surge due to admissions with pediatric cases of Enterovirus-D68 (EV-D68), Jana Shaw, MD, MPH, sprang into action.

Shaw and colleagues say their preparedness plan is a playbook for future epidemics—but that testing backlogs were an unintended consequence in need of addressing.

“We mobilized the nursing staff, we got more asthma medications, and we even opened extra beds,” said Shaw, an associate professor of pediatrics at Upstate Medical University and an attending physician in pediatrics at Upstate Golisano Children’s Hospital in Syracuse, NY. Her specialty is pediatric infectious disease.

“We knew about the Midwest and we knew EV-D68 would come to us,” she said in an interview. The 71-bed hospital then began testing all cases of children who came into the emergency department with respiratory illness, not just the ones who needed to be admitted.

Shaw says this “syndromic surveillance” differs from testing people who are very ill, and had many benefits for public health. In an opinion piece in JAMA Pediatrics, Shaw and colleagues detail their response, its benefits, and drawbacks.

Knowing EV-D68 was coming enabled the hospital to get ready for a sudden increase in admissions, and gave its staff reliable information to forward to concerned primary care doctors and the public.

But the unintended consequence was that due to similar surveillance efforts at other hospitals across the US, the US Centers for Disease Control and Prevention (CDC) was soon overwhelmed with specimens, she said. Hospitals have been on high alert for epidemics for over a year with concerns over Middle East Respiratory Syndrome and Ebola. That has meant testing when they believe they are seeing something new or unusual, even if it turns out to be a relatively benign pathogen such as EV-D68.

The enterovirus is easily managed in a hospital setting, and usually goes undiagnosed because it can present with nothing worse than cold symptoms.

“There was a downside, and all the testing raises the question of cost, and who pays,” she said.

As it turned out, only 2 of the 8 extra beds the hospital added were needed, she said.

Another successful part of planning, Shaw said, was reaching out to the media to give the public accurate information about EV-D68, to avoid causing panic. So far there have been no deaths, though in New Jersey, the day after Shaw's piece appeared, a frontpage story in the Trenton Times citing a "CDC probe" said that the death of a 4-year-old boy with asthma may have been caused by the virus. The test results are due later this week. Meawhile, the story has spread nationally.

Earlier, at Shaw's hospital, the public relations' goal was to head off the “worried well” before they sought care unnecessarily at primary care offices and hospital emergency departments.

In its own testing, hospital staff used a simpler test than the PCR testing used at the NY State Department of Health’s Wadsworth Center or the CDC. Known as a multiplex polymerase chain reaction-based respiratory pathogen panel, the test can tell only if a specimen is enterovirus/rhinovirus—but not which one.

To get a final diagnosis, specimens must go to either a high-tech lab like Wadsworth, or to the CDC.

By mid-September, the CDC was already telling some hospitals not to send it more specimens. Shaw said she believes the public health approach her hospital used holds lessons for future outbreaks. It is always better for clinicians and their patients to know what they are dealing with, she said.

“If a new virus comes along, early detection is useful,” she said, “it has a calming effect on the public and providers.”