CDC Telebriefing update on respiratory illness affecting children in multiple states

OPERATOR:  I would like to turn the meeting over to Mr. Tom Skinner. You may begin.

TOM SKINNER:  Hi, Operator. Thank you all for joining us today for this update today on CDC's investigation into some clusters of Enterorvirus D68 here in the United States, 2014. With us today is Dr. Ann Schuchat. She's the director of CDC’s national center for immunization and respiratory diseases. She'll provide some opening remarks and then we'll get to your questions. Doctor Schuchat?

ANN SCHUCHAT: Thank you, tom. Thanks, everybody, for joining us today. We know that media reports over the weekend and this morning have raised concerns about clusters of severe respiratory illness among children. I wanted to update you and provide an opportunity to answer the questions that you have. We understand the concern about this situation. Severe respiratory illness is always a concern to us, especially when children are affected. Our thoughts go to the families that have been impacted this season. Later this afternoon we're going to be releasing an mmwr report that describes recent clusters of severe respiratory illness associated with Enterorvirus 68 in Missouri and Illinois. I'm going to talk a little bit about those clusters and then some general background information and then have a chance for questions. In august 2014, hospital officials in Kansas City, Missouri and in Chicago, Illinois notified CDC of an increase in severe respiratory illness among children seen in the emergency rooms and admitted to the hospitals in those two cities. Specimens initially tested positive for rhinovirus and Enterorvirus. The CDC did further testing and identified Enterorvirus 68 in specimens from patients in hospitals in both Kansas City and Chicago. EV- D68 was identified in 19 of 22 specimens from Kansas City and 11 of 14 specimens from Chicago. Ages ranged from six weeks to 16 years with a median of four to five years. Well over half of the children in those two clusters had a previous history of asthma or wheezing. CDC is working closely with Missouri, Illinois and other state health departments as they continue to investigate suspected clusters of respiratory illness in other facilities. Our laboratory staff here at CDC have had a chance to sequence some of the recent specimens, and I can tell that you it's not a new strain. It's the same based on the sequencing results we have as EV- D68 strains identified in the United States last year and in previous specimens from other countries. So this isn't a new virus, but EV- D68 is fairly uncommon and we don't know as much about it as we do about some of the other common Enteroviruses. Hospital admissions for severe respiratory illness among children in the Kansas City and Chicago hospitals have been higher than expected for this time of year. Several other states are also investigating similar clusters of severe respiratory illness that might be due to EV- D68. Testing is ongoing in a number of these other instances. I need to say that the situation is evolving quickly. CDC and our colleagues are gathering information to better understand EV- D68 and the illness caused by this virus, how widespread infections may be and which populations are most affected, and whether other states are experiencing severe respiratory illness perhaps due to this virus. CDC is communicating often with state health departments that are investigating the suspect clusters of respiratory illness, and we have received specimens for lab testing from other states. That testing is in progress. I need to provide a little bit more background because Enterorvirus 68 is not something that we talk about very often. Enter viruses in general are very common. There are more than 100 different types of Enteroviruses, and it's estimated that 10 to 15 million Enterorvirus infections occur in the united states each year. Enteroviruses can cause respiratory illness, but they can also cause rash and neurologic illnesses as well as aseptic meningitis. Most infected people have no symptoms or only mild symptoms but some infections with different Enteroviruses can be serious. Infants, children and teenagers are most likely to get infected with Enteroviruses and become sick, as opposed to adults with exposure to this virus. Most Enterorvirus infections in the U.S. occur in the summer and fall, so this is the right time of year for Enterorvirus infection. EV- D68 is less common than the other Enteroviruses. EV- D68 was first identified in California in 1962. But compared with the other Enteroviruses, it has been very rarely reported here in the United States. What we know about it though is that it can cause mild or severe respiratory illness, yet the full spectrum of all of the illnesses that it can cause are not well defined, and that's something that people are looking into with these clusters. We don't know as much as we would like to know about this virus, but we believe it spreads similar to ways that other Enteroviruses are spread, through respiratory secretions like saliva and mucous. The virus likely spreads from person to person when an infected person coughs sneezes or touches surfaces. There's no specific treatment for this, and many illnesses that are mild will resolve on their own. But others who have more severe illness may need to be hospitalized and require supportive care. Importantly, since we have identified asthma as a factor in some of the illnesses, we think it's very important for asthma to be well treated and controlled. What can people do to protect themselves and their families from this virus? Based on how we think it's spreading, we think that it's important to follow those common sense steps -- washing your hands often with soap and water for 20 seconds, disinfecting frequently-touched surfaces like toys and doorknobs, especially if someone in the home is ill. While Enterorvirus doesn't have any vaccine that will prevent these respiratory infections at this point, remember that flu vaccination is going to be available very soon and preventing other respiratory infections can be important to protect people from the many other infections that are likely to be spreading.
We want healthcare professionals to be aware that these clusters are occurring and to be aware that EV- D68 may be a potential cause of clusters of severe respiratory illness, particularly affecting young children.  We would like healthcare professionals, doctors and nurses, to consider laboratory testing of respiratory specimens for Enteroviruses when the cause of infection in severely ill patients is unclear. State health departments or CDC can be approached for help with the typing of the viruses and we are keen for clinicians and hospitals to go through their state and local health departments as they're evaluating possible increases.  This is a dynamic situation, unusual virus. On a backdrop of very common of respiratory viruses and we are just beginning to understand the clusters in Kansas City and Chicago. I'm sure that you have some questions and I’d be happy to take them at this time.

TOM SKINNER: Operator, I believe we're ready for questions, please.

OPERATOR: If you would like to ask a question, please press star one on your touchtone phone. Please unmute your phone and record your name clearly when prompted. One moment, please, for our first question. Our first question comes from Miriam Falco of CNN Medical News. Go ahead, ma'am. The line is open.

MIRIAM FALCO:  Hi, Dr. Schuchat. Thank you very much for taking questions. This is not a reportable disease, so how -- folks want to know how many cases are out there. I'm sure that's hard to answer, but can you specify what other states are reporting clusters and an approximate number on how many severe illness cases you think there are, and also should this now possibly be a reportable illness?

DR. SCHUCHAT: Thanks so much Miriam. There isn't routine reporting for this kind of Enterorvirus infection. We have a number of systems that track respiratory illness, usually at the syndromic level. I think many of you are familiar with our influenza reporting of providers around the country. That system tracks the percent of acute visits that are associated with an illness that is a respiratory or influenza-like illness. That system is not detecting any increase in the proportion of visits around the country, so we don't think that there's a national, generalized increase in people seeking care for respiratory illness in the outpatient setting. But that is not specific to Enterorvirus 68. We've been connecting with our state and local health departments. We issued an epi-x to try to ask them about clusters of respiratory illness and alert them to what was going on in the Kansas City area. Through that system we've been contacted by about a dozen states. Some of those states are still in the process of investigating their clusters and some of the laboratory testing -- in fact, pretty much all of the laboratory testing is still in process. In terms of numbers, unfortunately, I can't say exactly how much disease is out there. I can say that several dozen cases have been identified to be caused by the EV- D68, but even in some of these clusters, not all of the illness is caused by this particular virus. So we're in a stage where it's difficult to say just how big this is, how long it will go on for, and how widespread it will be. But we do plan to make sure that we update people and that we work closely with the state and local health departments as they support the clinical communities in understanding what's going on nearby. In terms of making this reportable, I think what we do have as a generally reportable condition is a severe illness that is unexplained or clusters of severe illness. So we get alerts for this kind of thing in the general way rather than the actual EV- D68. The testing is not simple and it's not widely available, so that would make the specific viral testing as a condition for reporting somewhat difficult. Next question?

OPERATOR: Again, if you would like to ask a question or if you pressed star one previously, please press star one again for a question. Our next question comes from Andrew Siff. Go ahead your line is open.

ANDREW SIFF: Hi there. I'm calling from New York City and wondering since there is so much travel here from some of the affected states so far, has any advice been communicated to hospitals in the New York area or doctors out here or is there any advice for folks in regions not yet affected by it?

DR. SCHUCHAT: Respiratory viruses can spread quite quickly across the U.S. we see a number of different respiratory viruses cycling each year or over a couple-year period. So we really do think that clinicians throughout the country need to be on the alert for increases in severe respiratory illness and consider this in the differential diagnosis. Geography isn't that helpful when it comes to respiratory viruses. We know that flu transits the country pretty quickly and the unusual increases in Kansas City and Chicago may be occurring elsewhere over the weeks ahead so we want people to be on the lookout. Next question.

OPERATOR: Our next question comes from Mike Stobbe from the Associated Press. Go ahead. Your line is open.

DR. SCHUCHAT: Are you there, Mike?

OPERATOR: One moment, please.

MIKE STOBBE: Thanks for taking the question. How many cases make a cluster, and then could you give a little more detail on how many clusters we're talking about and could you name the twelve states that have contacted the CDC about having cases? About twelve states have contacted -- I don't have the names, but I could probably get you that through our press office. It's very important when you're talking about respiratory illness to think about the background patterns. Respiratory infections are among the most common reason that people seek medical care either in doctor's offices or emergency departments. So it's not like measles where three cases make a cluster. What you're looking for is an increase over previous seasonal patterns. So in Kansas city and Chicago, they were looking at their emergency department visits and their admissions to their pediatric wards or pediatric intensive care units, and it's there that they saw more than they expected based on the usual late summer experience. So we don't have a numeric cutoff. We really are looking at background patterns and when that's larger than expected. We also will look at unusual presentations. So when you see, for instance, more severe disease in older children than usual, usually the severe diseases are in kids under two, so seeing several cases that are in 5-year-olds and 8-year-olds and 9-year-olds, that's unusual. So the clinicians and the state and local health departments really look at patterns rather than numbers?

MIKE STOBBE: Can you just say how many clusters then?

DR. SCHUCHAT: What I was saying was about twelve different states have contacted us to support them as they investigate. Now, I know that one or more of them have been shown to be caused by something else, not the EV- D68, but I think there's a lot of work that's ongoing.
And I wouldn't be surprised if there are many more. One thing to say about Enterorvirus 68 and other unusual viruses is that when we look we can find more. So as we put out an alert, we're not surprised when more people let us know that they're managing a situation. Also the lab testing wasn't really being done ten years ago or so, and as some of the them become a little more available when they find out about these kinds of occurrences.

TOM SKINNER: Next question Operator?

OPERATOR: Our next question comes from Richard Besser of ABC News. Go ahead sir, your line is open. Your line is open.

RICHARD BESSER: Thanks very much for taking the question. A couple questions. First, was there any adult disease in these clusters?

DR. SCHUCHAT: So far we don't have adult disease confirmed to be by EV- D68. We did look into a respiratory outbreak in a nursing home, and it turned out it did not -- was not caused by this. We were a little concerned because it happened geographically and temporally around the same time and place, but it was due to a different virus. I think it's important to say there are a lot of respiratory viruses circulating right now and the much more common ones are out there as well.

RICHARD BESSER:  Have there been any fatalities, and if this was the same strain seen in California, any neurologic findings such as paralysis?

DR. SCHUCHAT: There haven't been fatalities this year that we're aware of but of course that may happen and we need to be alert to that. One of the reasons to raise the alert is so that clinicians can prepare for the increasing numbers of children with severe illness. The clusters currently are focusing on the severe respiratory illness and so I’m not aware of new severe neurologic symptoms being linked with this strain as of this summer's investigation we haven't seen that.

OPERATOR: Our next question is from Robert Lowes of Medscape Medical News. Go ahead your line is open.

ROBERT LOWES: Thanks for taking my call. I guess this is part of your investigation, but in general, why does one particular strain of this Enterorvirus come to the forefront and cause outbreaks?

DR. SCHUCHAT: Thank you for that question. That's a really great question, and I don't have the answer to it. But we will be doing investigations in conjunction with the state and local health departments to understand who's getting sick and why they might be at higher risk than others. Exactly why different strains of the virus emerge and have an ability to spread well is a key question. Perhaps some of the additional study of this virus itself will elaborate some clues. Next question?

OPERATOR: Our next question comes from Michelle Cortez of Bloomberg News. Go ahead, your line is open.

MICHELLE CORTEZ: Thank you for taking the question. I'm wondering if you can tell us if there's anything that might highlight these particular cases versus normal cold and viruses that might be circulating at this time, if there's any way for parents to differentiate right away that this is something they might need to see their doctor about right away and also for the children who are being hospitalized, is that protectively or are these kids needing mechanical ventilation and the like?

DR. SCHUCHAT: Signs for parents to worry about are the usual ones in terms of difficulty breathing. That's a warning sign for parents. Runny nose and the sniffles are not unexpected and that can be caused by many different things, but it if looks like your child is having difficulty breathing, you absolutely want to seek medical help. In terms of the second part of the question, I’m just forgetting -- could you repeat the second part of your question?

MICHELLE CORTEZ: The second part of the question is what type of illness and treatments are the children who are hospitalized getting? Is it just a protective, we're going to keep them in the hospital to give them fluids and treat the symptoms, or is it severe like mechanical ventilation and what not?

DR. SCHUCHAT: Some have been more severe, particularly with the asthma background, getting the breathing stabilized. I think there has been some mechanical ventilation, but that's not been common. It's been more the need for the asthma to be treated. So it's really supportive care, sometimes in an intensive care unit, fluids as well as other oxygen support to help make the breathing a little bit easier. One of the signs that have been common among kids, even those without asthma history, has been wheezing. So there are some medicines we can give to children who are having difficulty wheezing, in addition to the oxygen, basically medicines that help open up the airways. That's been the kind of support. Again, this can be a scary thing to hear about for parents. Very important to say that if you're concerned that your child is having difficulty breathing, you want to make sure that you contact their healthcare provider. Most of the runny noses out there are not going to be turning into this. Next question?

OPERATOR: Our next question comes from Eben Brown of Fox News Radio. Go ahead. Your line is open.

EBEN BROWN: Thank you for taking the question. Doctor Schuchat, can you talk about prevention. When we talk about other diseases we talk about hygiene and things like that. Is this virus -- can it be prevented by good hygiene, or is someone just going to kind of get sick if they come into contact with it? And also, if you don't mind, I realize this is a bit off topic, but there has been an announcement -- I’m calling from Miami -- that a Miami area hospital has a potential Ebola case and I was wondering if you have information on that as well.

DR. SCHUCHAT: On the second question I don't have any information. I'm sorry about that. But in terms of the prevention and hygiene, we don't know as much as we would like to specifically about EV- D68. But for Enteroviruses and other respiratory viruses, we do think hygiene is important, that frequent hand washing can be helpful, that avoiding touching eyes, nose and mouth with unwashed hands can be helpful because you can have something on your hands and inoculate yourself through your eyes, nose or mouth. Avoiding sharing utensils with people who are sick, disinfecting frequently-touched surfaces, such as toys or doorknobs, especially if somebody is sick. There aren't any vaccines specific for EV - 68, but I want to remind everyone we do recommend influenza vaccines for anyone six months and over. And that will not prevent every respiratory virus out there and it certainly won’t prevent EV – 68, but it will be the best protection against the influenza viruses which will be circulating this year, too. Next question?

OPERATOR: Our next question comes from Deborah Kotz of Boston Globe. Go ahead, your line is open.

DEBORAH KOTZ: Hi, thanks for taking my question. I just wanted to verify something that was said by the doctor Schuchat when she was giving her opening remarks. Was it half of the kids who were hospitalized had asthma, and my follow-up question to that is, are there other children who have been identified as a higher risk as well like I’m thinking maybe children with certain allergies, seasonal allergies or other respiratory conditions, who are at risk of having a more severe reaction?

DR. SCHUCHAT: It was more than half of the children in these two clusters who had asthma or a history of wheezing, and we don't have other conditions that we have found to be more frequently recognized in children in these clusters than the general population. We will be working with the health departments to understand what kinds of illnesses they're seeing and whether there are particular age groups or other factors involved but as of now it's only been asthma that's been showing up. Another important feature is that if children have asthma you want to make sure they're well controlled, taking their medications regularly and seeing their healthcare professionals regularly. Keeping asthma in good control can keep you in better form if you come in contact with one of these respiratory viruses. Next question?

OPERATOR: Our next question comes from Anahad O’Conner with the New York Times. Go ahead sir, your line is open.

ANAHAD O’ CONNER: Thanks for hosting this call. Could you repeat for us the number of children that were in those two clusters that you mentioned earlier and then also whether there's an actual -- what the actual number of confirmed cases are. The numbers that I can share are the laboratory-confirmed clusters. Nineteen out of twenty-two specimens from Kansas City were confirmed to be due to the EV- D68. Eleven out of fourteen specimens from Chicago -- there were larger numbers of children in both of those clusters, some of whom didn't have laboratory testing, but those were the numbers that we have. The mmwr has a little bit more information, but what I can say is that the situations in those cities and elsewhere are evolving and so the day to day numbers are helpful as just knowing those specimens in those two clusters were EV- D68. Next question?

OPERATOR: Our next question is from Diane Estabrook from Al Jazeera America. Go ahead ma’am, your line is open.

 DIANE ESTABROOK: Hi there, I was wondering, I know you mentioned that there's really --you can't treat this with antibiotics, but what can parents give their children. Can they give them ibuprofen or aspirin to treat the symptoms?

DR. SCHUCHAT: We try to stay away from aspirin in children who have respiratory illnesses. There was a condition called rye syndrome associated with aspirin when given to children who had the flu. In general, we don’t want parents to give their kids aspirin for the respiratory illnesses. Fluids are always a good idea. Medications like ibuprofen are probably okay. Clearly, if the child as asthma you want to make sure that the asthma medicines are going in and they're working well. Many people with this kind of respiratory virus will do well with just time. Next question?

OPERATOR: Our next question comes from Pauline Dakin of CBC News. Go ahead, your line is open.

PAULINE DAKIN: Thanks very much. I'm wondering what the challenges are for testing. Are there state facilities for testing?

DR. SCHUCHAT: Some of the state health departments are able to do testing. It's a preliminary chain reaction test that's done. CDC can provide back-up or support, but the clinician's first line would be the state or local health department. There are commercial tests that will test for respiratory viral panels, but those will usually give you a result of a rhinovirus or Enterorvirus and they wouldn't be specific to this type. So if clinicians are seeing increases in cases, they may want to check with their state or local health department about being able to test for this virus to understand whether it's circulating. It could be helpful to know if it's circulating in the community to have a sense that there might be further increases coming. It wouldn't change the individual care that the child has, but it would be more for understanding the situation at the hospital or in the community.

PAULINE DAKIN: Thank you. What is the normal course of the illness in terms of length?

DR. SCHUCHAT: this is so relatively new, this particular EV that it would be hard for me to say. Probably about a week would be typical for most of the Enterorvirus illnesses that don't lead to longer term sequelae like some of the neurologic ones but that will be the information that will be gathered as these clusters are investigated.

OPERATOR: Our next question comes from Jill Macyshon of C- TV National News. Go ahead ma’am, your line is open.

JILL MACYSHON: Hi there, we're hearing about this in Canada. Is the international community being notified about the virus? And I also have another question. If there are few cases last year, what's causing the spread this year?

DR. SCHUCHAT: The respiratory virus spread is quite unpredictable. When new strains come in we usually see them for a few years and then other strains start to dominate. We haven't specifically targeted global communications, but I can say that reports a couple years ago were about clusters of the EV- D68 severe respiratory illness in other countries before we saw it here in the U.S. so japan and the Philippines had clusters in addition to the United States a couple places here. So we don't -- we think that respiratory viruses will circle the globe and they'll common and go, and whether we'll be seeing extended spread of the EV- D68 or it will just be a few cities affected this year, we just don't know at this time. Next question?

OPERATOR: Our next question comes from Alyson Wyckoff of AAP News. Go ahead, your line is open.

ALYSON WYCKCOFF: Hi Dr. Schuchat, you mentioned the specimens that you tested that were confirmed for EV- D68. What about the ones that were not confirmed to have that? What did those children have?

DR. SCHUCHAT: We see the usual spread. We've seen rhinovirus and echovirus for instance, other common respiratory viruses, so I think that as you know and as the AAP news readers know, there are so many different respiratory viruses and depending on the location and the time of year, they'll be coming and going. I don't believe we saw RSV in the samples we were looking at. It's a little early in the year for us to find that, but of course going forward that will become more common likely, as will influenza. But some were negative for anything, actually. Next question?

OPERATOR: Our next question is from Sheila Eldred of Discovery News. Go ahead, the line is open.

SHEILA ELDRED: Hi. My question was just asked. Thanks.

DR. SCHUCHAT: Okay, great. Is there another question? Operator, anymore questions?

OPERATOR: Our next question is from Nicki Egan of People Magazine.
Go ahead, your line is open.

NICKI EGAN: Hi there. Earlier this year we did a story about the polio-like illness appearing in some children in California and a doctor there at Stanford had pinpointed Enterorvirus 68 as being in at least two of the five cases that they saw. Were you involved in that investigation at all? I think that's why someone was asking earlier about reports of paralysis. But they still had not come up with a cause for the paralysis but said they thought it was some sort of Enterorvirus and they tested and two of the five kids had 68 in their systems.

DR. SCHUCHAT: Let me say a few things. Enteroviruses can cause neurologic symptoms, including paralysis in children. The EV- D68 has been associated with neurologic conditions, not just with the severe respiratory illness. To my knowledge, we don't actually have those specimens that the clinician in California tested so aren't able to compare sequences, for instance, with the EV- D68 that we're seeing now. We haven't been contacted by health departments recently about paralytic disease such as we heard about last year with the California situation. So I can't comment on whether those two individuals that were reported by the neurology folks in California had a strain that was the same as what we're seeing now. What was reported this summer to us was severe respiratory illness and that's where we've been identifying EV- D68.

NICKI EGAN: How many different strains of 68 would there be?

DR. SCHUCHAT: 68 is fairly unusual in terms of our surveillance, but you would really need to compare the viruses. Since we didn't do that testing, it's hard for us to say exactly what those strains were. The specimens that we got from California didn't reveal that result.

TOM SKINNER: We have time for two more questions.

 OPERATOR: Thank you. Our next question comes from Isolda Peguero of Telemundo. Go ahead, your line is open.

ISOLDA PEGUERO: Yes, hi. I was just wondering, doctor -- thank you for taking my question. I know this is commonly or most common among children, but does that mean that the adults are exempt from becoming sick with this virus, and also do we have a rounded number among the states, like a random number, nine hundred, seven hundred, how many people in total, how many kids?

DR. SCHUCHAT: We don't have a rounded number. We have very small numbers of confirmed cases so far, so that's why I was saying dozens rather than rounded numbers. Adults don't tend to get enteroviral infections or get diagnosed with them as much as children and perhaps that's due to previous exposures. We really don't know. It's not something that we have a great awareness of. But what we're seeing right now is typical that we're seeing children with the Enterorvirus infections, even though the type involved is unusual. Operator, we have time for one last question if that's one.

OPERATOR: Thank you. Our last question comes from Fred Hiers of Star Banner. Go ahead, your line is open.

FRED HIERS: Thank you for taking my question. This was something that you addressed earlier before and I wanted to make sure I understood. Based on the number of clusters and the number of states that are contacting the CDC for assistance, I wanted to make sure I understood. What do you anticipate as far as the spread of the virus in additional states? Is there reason to believe that that's going to be seen in other states now, or might it very well stay relatively stagnant in where it's being seen now?

DR. SCHUCHAT: You know, it's just too soon to say. We, of course, want to make sure that clinicians around the country are on the lookout for this and health departments are ready to support clinicians. I can't say whether we'll be seeing this in many more states or not, but of course we want to be supporting the families involved and making sure that the state and hospitals are ready should more cases occur. Thank you all for calling in. I'm going to let Mr. Skinner wrap things up.

TOM SKINNER: Hi, thank you for joining us today. I did want to follow up on a question that a reporter asked of the doctor about a suspected case of Ebola in south Florida, particularly in Miami. I can tell that you there was a low risk patient, a person who is considered to be low risk for Ebola that was tested by the state laboratory response network there in Florida and tested negative. So we'll be receiving that specimen here to do confirmatory testing, and then we will provide results of those tests to the state health department in Florida, and they'll release that information to you. So I did want to follow up on that one question. So this concludes our call. If you have additional questions or need additional information, please call the CDC press office at 404-639-3286. Thank you.

OPERATOR: Thank you for your participation in today's conference. You may now disconnect.

###
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES