Doctor predicts spike in AFM cases for 2018
Children’s helps track illness throughout U.S.
The jump in cases of acute flaccid myelitis across the country in 2018 is likely to reach 250, even 300 cases of the paralyzing condition, according to John Williams, chief of pediatric infectious diseases at UPMC Children’s Hospital of Pittsburgh.
“Even though the final tally is not in, it’s clear there are a lot more confirmed cases this year than in 2016 and 2014,” he said, citing earlier years with spikes in AFM cases.
In 2014, there were 120 confirmed cases; in 2016 the condition was confirmed in 149 cases.
So far, for 2018, there are 210 confirmed cases and 367 potential cases, Dr. Williams said.
“More will be confirmed,” he said, predicting 40 to 90 additional cases, all from the summer and fall of 2018.
Despite the expected increase in confirmed cases, Dr. Williams said the odds of a child getting AFM are 1 in a million.
Children’s is one of seven pediatric hospitals across the U.S. that is part of a Centers for Disease Control and Prevention study tracking cases of acute respiratory and gastrointestinal illness and collecting samples for the CDC to test for various viruses. Called the New Vaccine Surveillance Network, the study will allow a comparison of AFM case counts with current circulating respiratory and gastrointestinal viruses in the seven locations.
The CDC is responding to spikes in AFM cases every two years since 2014, affecting mostly children, and reports it is looking for risk factors and causes. It is trying to understand why some people get AFM, keeping track of AFM cases around the country and looking for options to treat patients.
There have been six confirmed cases of AFM from the 2018 season at Children’s. There remain seven cases under investigation, Dr. Williams said.
The data from the sevensite study is expected to be released to the public through the CDC’s Morbidity and Mortality Weekly Report sometime soon, Dr. Williams said. All of the sites tested suspected cases for the presence of the enterovirus D68. D68 has been linked to many of the cases of paralysis, particularly during the summer of 2014, when there was an outbreak of AFM and D68 at the same time.
CDC is doing genomic sequencing of several strains of D68 and researching their connection to respiratory illness in children.
“Eventually the CDC will have a lot of data about EVD68 all around the country,” Dr. Williams said. “Hopefully, we’ll be able to figure out what is different about D68.”
He said there also is the question of why some are more susceptible to the infection.
“People never figured out why 1 out of 150 got polio,” he said. On the contrary, “anybody exposed to measles [who is unvaccinated] is going to get sick; the same is true with smallpox.”
The family of enteroviruses is everywhere in the summer, he said. When D68 cases spiked in 2014, there were 1,153 confirmed cases in 49 states, and many more cases weren’t tested.
Dr. Williams said research is looking into the two questions — what is different about D68 compared to all the other common enteroviruses and why some people get AFM.
“Out of all the kids who get EV-D68, how many would get AFM?” he asked. “We don’t know. After this year, we will have enough data. Our network of seven sites probably will be able to answer that. We have the number of kids with respiratory EV-D68 and we know the number of AFM cases.”
Children’s now has a protocol to follow when doctors suspect a patient may have AFM, according to Kavita Thakkar, co-director of the Clinical Neuro-Immunology Program. There is a neurological exam along with supplementary testing, including an MRI scan looking for specific abnormalities in the brain and spinal cord, as well as testing the fluid around them.
Dr. Thakkar said it’s not known if an earlier diagnosis means better outcomes.
“I don’t think we understand the cause or physiology as to the nature of this disorder,” Dr. Thakkar said. “In terms of early diagnosis, it will help not to miss these cases. We can provide them with appropriate supportive services.” She cited as examples respiratory support and hospital care, including the intensive care unit.
Because many of the cases came after respiratory infections, she said doctors believe EV-D68 is involved, although the virus wasn’t found in some of their patients.
Dr. Thakkar said Children’s is reviewing patient data back to 2012, studying the records, including MRIs, of similar cases — some may have been diagnosed as transverse myelitis, for example, caused by an inflammation of the spinal cord.
“It’s a work in progress,” she said. “A lot of things point to a virus: It’s happening in the pediatric age group, it follows a seasonal pattern, one nerve in the spinal cord is involved.”
Although some adults have been diagnosed with AFM, most patients are children — and paralysis can involve an arm or leg or much more, Dr. Thakkar said. By the time weakness is noticed, the nerve damage can be done, she said.
“Every case is not the same. That makes it hard,” she said. “Most of our patients are left with neurological disability; some are more functional than others.” None has recovered completely yet, she added.
Nerve transfer surgery for AFM patients, in which a damaged nerve is replaced with a functioning one, has not been done at Children’s, according to Dr. Thakkar.
“We’re in communication with groups here to see if it’s feasible. We just don’t have enough numbers to have this done, to know how it impacts the quality of life,” she said.
The best way to treat AFM is still uncertain, Dr. Williams said.
“Above all, do no harm,” he said. “We try to do things we think may modulate the immune system,” such as steroids and intravenous immunoglobulin. He said often doctors and patients will think the treatment works because of a rapid recovery.
“This is why you need research and studies,” he said. “Otherwise anecdotally, I could say I gave [a patient] chocolate ice cream and he got better.”
“At this time we don’t know if immunotherapy works, including IVIG,” Dr. Thakkar said.
Dr. Williams said the number of AFM cases may spike again in 2020, following the two-year pattern of virus outbreaks.
“AFM can be called a disease now. It appears to be triggered by viral infections,” he said. “What we don’t understand is how much the nerve damage is caused by the virus and how much is the immune system response — the friendly fire.”
The seven hospitals will be doing surveillance again in the summer and testing for EV-D68. Most of the cases will appear in September, he said.
In 2019, Dr. Williams advises children and adults to get their flu shots and use good handwashing habits.
Enteroviruses are spread through the stool (feces) and other secretions from the eye, nose and mouth, so that means not just washing your hands when they look dirty. It’s also always washing before fixing food or eating, treating wounds and taking care of a sick person. Also it’s always washing after preparing food, using the toilet or changing a diaper, and after touching a pet or its food or its waste. Hands need to be washed after blowing your nose, coughing or sneezing and after taking care of a wound or a sick person.
Despite the expected increase in confirmed cases, Dr. Williams said the odds of a child getting AFM are 1 in a million.