As if frontline health care providers don’t have enough to worry about with the first case of Ebola diagnosed in the United States and concerns that the disease could spread further, now another rarely seen virus has been sending children to the ED with breathing difficulties. The virus, which has been identified by the Centers for Disease Control and Prevention (CDC) as enterovirus D68 (EV-D68), first began filling up pediatric EDs in the Midwest, but at press time, the virus had been detected in at least 40 states, causing long waits and administrative nightmares in more than a few hospitals.
Further, the CDC is investigating whether a few cases involving young patients with muscle weakness or paralysis are related to the EV-D68 outbreak. Nine of these patients are hospitalized in Colorado, and four additional cases have been identified in Massachusetts. The CDC reports that at least some of them have tested positive for EV-D68, although it is not clear whether the virus is responsible for the neurologic symptoms. Reports indicate that the nine patients all had fevers and respiratory illness about two weeks before they began experiencing varying amounts of weakness in their limbs.
Health officials confirm that paralysis is a rare complication of EV-D68, but with so many cases being reported this year, it is possible that the problem could surface.
Cases surge in Midwest
Infectious disease specialists at Children’s Mercy Hospital in Kansas City, MO, were the first to alert the CDC that they were experiencing an unusual trend in early August. "We noticed that we were seeing a lot more asthma patients than normal, and it seemed like they were a bit sicker than is usually the case," explains Lisa Schroeder, MD, associate division director, Emergency Medicine, Children’s Mercy Hospital. "Several of the children coming in appeared like they were having a bad asthma attack, but they had no history of asthma."
Emergency providers alerted the hospital’s infectious disease experts, who then began testing specimens from each of the patients admitted with the respiratory symptoms. "What they were finding is that almost all of these patients were showing up positive on the viral screening panel for enterovirus/rhinovirus," says Schroeder. However, she adds that the screening panel only indicates whether a patient has one of those two types of viruses, and there are several hundred strains between the two.
This is when the hospital turned to the CDC for more sensitive testing. "[Investigators from the CDC] took back samples from several of our patients, tested them, and were able to identify the culprit as enterovirus D68," says Schroeder.
By this time, the hospital was seeing a huge influx of patients with the hallmark respiratory symptoms, putting a big strain on both the ED and inpatient floors. Schroeder recalls one particularly difficult night early on during the outbreak. "We ended up with a very long wait in the ED for the patients who weren’t having trouble breathing. One patient who came in with a rash ended up waiting more than six hours to be seen," she recalls. "At one point, we had 10 patients in our department who were all receiving continuous albuterol treatments, and that night, the hospital became completely full. We ended up boarding nine patients in the ED all night."
To cope with the influx, administrative leaders ordered extra supplies of oxygen and masks, and they put plans in place to ensure the health system was adequately staffed. "By [mid-September] we had seen more than 500 confirmed cases, and 60 of those were admitted to our pediatric intensive care unit," notes Schroeder, adding that this number only includes the admitted patients because they are the only ones being tested. "Overall, between our main ED, our satellite, and our urgent care centers, we are seeing about, on average, 100 more patients per day than normal for this time of year, which is about a 20% to 25% increase in our volume."
Further, the average length-of-stay (LOS) for children hospitalized with the illness is running longer than usual. "Normally when we admit someone from the ED with an asthma exacerbation, typically they end up in the hospital overnight or maybe for a couple of days. But one of the things we found is that these children are responding to asthma treatment, but much more slowly than usual, so at one point, our average length-of-stay was about three days instead of one or two," offers Schroeder.
Recovery takes time
In addition to adding staff, the hospital has taken added precautions to minimize transmission of the respiratory virus. For example, administrators have communicated to all staff that they are to wear masks when entering the rooms of patients who are experiencing respiratory problems. "If a patient has respiratory symptoms, we are putting a sign on the door to remind everyone to please wear masks in those rooms at all times," says Schroeder.
Also, on the inpatient floors, staff are wearing masks and gowns, and hospital administrators have significantly reduced visitation. "Right now, we are on a no sibling visitation policy, which is hard for families, but we have to protect the kids," says Schroeder. "There are signs at all the entrances stating the new policy, and everyone is screened — even the adults. If a person is ill, we are not going to stop them from seeing their child, but they will be required to wear a mask when they are in the hospital at all times."
As of late September, all of the children treated for EV-D68 at Children’s Mercy Hospital had improved with treatment, but Schroeder notes that there is really no way to predict which cases are going to be the most severe. "The virus is not terribly common. When the CDC initially identified it this past summer, the agency had only identified 68 cases in the last few years, and at that point, we had already had about 70 cases here," she says.
While children with underlying asthma or other conditions may be more at risk, close to 40% of the patients being admitted with EV-D68 do not have a history of asthma, observes Schroeder. "They are previously healthy children. Several of them have never wheezed in their lives, and they are coming in in respiratory distress," she says. "People will say that it seemed as though [their child] just had a bad cold, and then all of a sudden he couldn’t breathe."
These patients are not necessarily having fevers, but many of them are requiring supplemental oxygen, says Schroeder. "We are treating them like we would treat someone with an asthma attack, with bronchodilators and steroids," she says. "They are not responding as quickly as a normal asthma exacerbation case does. Several of the patients are taking multiple hours of continuous breathing treatment to respond, which is quite unusual and goes along with the longer hospitalizations."
Another interesting aspect to the outbreak is that compared with the normal winter respiratory viruses that typically affect young babies, this virus seems to be impacting children who are a little bit older. "During the first two weeks [of the outbreak] the average age of the patients presenting with this was 4 or 5 years old," says Schroeder. "We have seen a lot of school-aged kids, and typically they handle their colds much better."
Thus far, EV-D68 doesn’t seem to be impacting adults as much or as harshly as it is young children. Schroeder notes that while some hospital staff members have developed respiratory problems, there haven’t been many off days attributed to these issues. Further, by the end of September, the severity of the illness appeared to lessen just a bit in patients. "We aren’t seeing as many of the really sick kids as we were in the first couple of weeks," she says.
Timing is unusual
The University of Chicago Medicine Comer Children’s Hospital in Chicago, IL, has also seen a spike in volume during the past few weeks from children presenting to the ED with respiratory problems. The influx began in August, gradually increasing until there was a sudden peak in mid-September, explains Allison Tothy, MD, the section chief of Pediatric Emergency Medicine at the hospital.
"Usually we see this sort of bronchiolitis pattern in the middle of winter, so this was an unusual time to see it, and then we were seeing it in very large volumes," says Tothy. "Our average volume is between 70 and 80 patients a day, and we have been up to 120 patients, so we have seen an increase of about 40 patients per day, and the majority of them have the viral respiratory type of symptoms."
Putting the numbers in more context, Tothy says that the hospital usually admits about 8% of the patients who come to the ED, but that number is closer to 15% now. "We have almost doubled our admissions, and not only are we doubling our admissions percentage, our volumes are higher," she says. "When you talk about wait times and overcrowding, it is almost always the adult side of the world that gets [the attention]. We forget that pediatric EDs can have that same experience."
The hospital alerted the CDC to what it was seeing in late August — not long after Children’s Mercy Hospital notified the agency. At this point, however, the hospital isn’t testing for the virus anymore because treatment is the same whether the patients have enterovirus D68 or another virus, explains Tothy. "What really matters is how we take care of them," she says. "It’s really affecting our asthmatic patients significantly, and our toddlers."
Handling the sustained surge in patient volume has been very challenging, observes Tothy. "We have a standing surge plan that we review regularly for disaster planning, but this required a very quick influx of resources for a longer period of time," she says.
Consequently, administrators from throughout the hospital evaluated how they could allocate resources appropriately for an extended period. "It has involved pulling our physicians in for more clinical time in the ED and we have had to increase our nursing staff, but it does not just involve doctors and nurses," says Tothy. "It includes environmental services staff, our techs who transport patients, and our coordinators who register patients. It includes a whole workforce that we have had to rapidly surge."
In fact, Tothy notes that the biggest challenge has been trying to make sure the hospital doesn’t burn out the resources it has. Her advice to other hospitals that have not yet seen a surge in patients with EV-D68 is to start planning now just in case. "Assume that you need resources and put those resources in place so that it doesn’t take you by surprise," she says.
Also, don’t just plan at your gateway point or entry point level, advises Tothy. "It is not just the ED that has to surge. It is the floors and the ICU," she says. "Consider how you will move patients throughout your system efficiently, rapidly, and — most important — safely while maintaining expert, experienced care."
To gain more information about the typical characteristics of this illness, investigators at Children’s Mercy Hospital plan to evaluate some of the cases retrospectively. "We’re looking at all of the patients that have been admitted at least to see if we can describe the virus a little bit better," says Schroeder. "We are looking at every patient that had this and was discharged and returned for any reason so we can see the natural course of the disease."
Editor’s Note: The CDC has issued guidance on EV-D68 at www.cdc.gov/non-polio-enterovirus/about/EV-D68.html.
- Lisa Schroeder, MD, Associate Division Director, Emergency Medicine, Children’s Mercy Hospital, Kansas City, MO. E-mail: firstname.lastname@example.org.
- Allison Tothy, MD, Section Chief, Pediatric Emergency Medicine, University of Chicago Medicine Comer Children’s Hospital, Chicago, IL. E-mail: email@example.com.