H5N1

'Powerful piece of circumstantial evidence' that virus causes paralyzing illness in kids

Via CBC News, an AP report: 'Powerful piece of circumstantial evidence' that virus causes paralyzing illness in kids. Excerpt:

Scientists have found the strongest evidence yet that a virus is to blame for a mysterious illness that can start like the sniffles but quickly paralyze children.  

The poliolike syndrome, called acute flaccid myelitis or AFM, is very rare. Since the first reports from California in 2012, the U.S. has experienced an increasingly bigger outbreak every other year, from late summer into fall.  

Doctors have a chief suspect but proof that it's the culprit germ has been frustratingly elusive. 

So researchers tried a new trick: They checked patients' spinal fluid for signs the immune system had fought an invading virus. Sure enough, kids who got sick harboured antibodies that target enteroviruses, just the viral family specialists believe is to blame. 

"This is circumstantial evidence that this is what's going on, but it's a powerful piece of circumstantial evidence," said Dr. Michael Wilson of the University of California, San Francisco, who helped lead the research. His team reported the findings Monday in Nature Medicine. 

Nailing down a suspect is key to better diagnosis and eventually finding a way to prevent or treat the illness, said study co-author Dr. Riley Bove, a neurologist at the university whose own son developed AFM at age 4. 

"If you don't have a cause, you can't have a vaccine," Bove noted. Wilson developed "a good enough microscope, in a sense, to find things they suspected were there."  

Some 590 cases of the ailment have been confirmed in the U.S. since the Centers for Disease Control and Prevention began counting in 2014. Cases spiked that year and in 2016 and last year, with just a few in the intervening years. So far, there have been 22 this year.  

As of June 6, four cases of AFM have been reported in Canada, compared with 59 last year.

Vital Signs: Surveillance for acute flaccid myelitis — United States, 2018

Via MMWR, the CDC has published Vital Signs: Surveillance for Acute Flaccid Myelitis — United States, 2018 | MMWR. The summary and abstract:

Summary 

What is already known about this topic?  

Biennial U.S. outbreaks of acute flaccid myelitis (AFM) have been recognized since 2014. Most cases occur in children during late summer and early fall. 

What is added by this report?  

During 2018, 233 confirmed AFM cases were reported, the largest number since surveillance began in 2014. Upper limb involvement only was more prevalent in confirmed cases (42%), as was report of respiratory symptoms or fever (92%) within 4 weeks preceding limb weakness onset. Median intervals from onset of limb weakness to hospitalization, magnetic resonance imaging, and reporting to CDC were 1, 2, and 18 days, respectively.  

What are the implications for public health practice? 

Prompt recognition, early specimen collection, and rapid reporting will expedite public health investigations and help characterize AFM.

Abstract 

Background: 

Acute flaccid myelitis (AFM), a serious paralytic illness, was first recognized as a distinct condition in 2014, when cases were reported concurrent with a large U.S. outbreak of severe respiratory illness caused by enterovirus D-68 (EV-D68). Since 2014, nationwide outbreaks of AFM have occurred every 2 years in the United States; the cause for the recent change in the epidemiology of AFM in the United States, including the occurrence of outbreaks and a biennial periodicity since 2014, is under investigation. This report updates clinical, laboratory, and outcome data for cases reported to CDC during 2018.  

Methods: 

Clinical data and specimens from persons in the United States who met the clinical criterion for AFM (acute onset of flaccid limb weakness) with onset in 2018 were submitted to CDC for classification of the illnesses as confirmed, probable, or non-AFM cases. Enterovirus/rhinovirus (EV/RV) testing was performed on available specimens from persons meeting the clinical criterion. Descriptive analyses, laboratory results, and indicators of early recognition and reporting are summarized.  

Results: 

From January through December 2018, among 374 reported cases of AFM, 233 (62%) (from 41 states) were classified as confirmed, 26 (7%) as probable, and 115 (31%) as non-AFM cases. Median ages of patients with confirmed, probable, and non-AFM cases were 5.3, 2.9, and 8.8 years, respectively. Laboratory testing identified multiple EV/RV types, primarily in respiratory and stool specimens, in 44% of confirmed cases. Among confirmed cases, the interval from onset of limb weakness until specimen collection ranged from 2 to 7 days, depending on specimen type. Interval from onset of limb weakness until reporting to CDC during 2018 ranged from 18 to 36 days, with confirmed and probable cases reported earlier than non-AFM cases. 

Conclusion: 

Identification of risk factors leading to outbreaks of AFM remains a public health priority. Prompt recognition of signs and symptoms, early specimen collection, and complete and rapid reporting will expedite public health investigations and research studies to elucidate the recent epidemiology of AFM and subsequently inform treatment and prevention recommendations.

Acute flaccid myelitis associated with enterovirus D68 in children, Argentina, 2016

Via Emerging Infectious Diseases: Acute Flaccid Myelitis Associated with Enterovirus D68 in Children, Argentina, 2016. The abstract:

After a 2014 outbreak of severe respiratory illness caused by enterovirus D68 in the United States, sporadic cases of acute flaccid myelitis have been reported worldwide. We describe a cluster of acute flaccid myelitis cases in Argentina in 2016, adding data to the evidence of association between enterovirus D68 and this polio-like illness.

AFM, the polio-like illness, will be back

Via The Atlantic, a must-read by Ed Yong: AFM, the Polio-Like Illness, Will Be Back. Excerpt:

AFM isn’t new, but it rose to prominence (and gained its name) in 2014 when it afflicted 120 people in the United States—a record number. Doctors wondered whether that was a freak occurrence, but the condition came back in 2016, affecting 149 additional patients. And this year, it returned again, with 158 confirmed cases and more under investigation. The disease now seems to run on a biennial schedule, and although the third wave peaked in mid-fall, scientists, clinicians, and parents are anxiously looking ahead to a likely fourth surge in 2020.

Unlike many seasonal illnesses, which come, sicken, and leave without long-term consequences, AFM means lasting (if not lifelong) disability for those it touches. And that community grows with every new wave: A Facebook group for parents of children with AFM, which formed in January 2015, has swelled to more than 600 members. 

“We dread late summer,” wrote Bove in a recent opinion piece, co-authored with two other parents of children with AFM. “We grieve those final days when our still-normal children climbed their last playground structures or took their last runs down the block or their last independent breaths. We relive the trauma of the hospitalization, when at night we kissed our brave children, not knowing whether they would awaken stable, intubated, or unable to ever walk again. In addition, we fear the coming wave of new bewildered parents.” 

But Bove says that something was different this year. In 2014 and 2016, the affected families were still getting to grips with this strange and unfamiliar condition.

 “This year, when we saw many new parents join the Facebook group, it was like: Not this time!” she says. “It really galvanized the parent community to become more outspoken in their advocacy. They’ve plastered the news with stories.” 

In no small part because of their efforts, awareness of AFM has soared, including within the medical community. “We’re seeing a very appropriate amount of increased attention,” says Kevin Messacar, a pediatrician at Children’s Hospital Colorado.

CIDRAP: With 18 more cases, CDC says AFM may have peaked

Via CIDRAP, Stephanie Soucheray writes: With 18 more cases, CDC says AFM may have peaked. Excerpt:

The Centers for Disease Control and Prevention (CDC) reported 18 more cases of the mysterious acute flaccid myelitis (AFM) in the week ending on Nov 30, bringing this year's total to 134 cases confirmed in 33 states, among 299 cases reported, and the agency says the outbreak "appears to have peaked." 

AFM, which can cause limb weakness and paralysis, usually affects children who develop symptoms 1 to 2 weeks following a non-specific viral infection. Though AFM has sometimes been associated with enteroviruses, little is known about the cause of the polio-like condition. 

Pattern similar to previous years 

Since 2014, officials have detected higher levels of AFM every 2 years in the fall throughout the United States. This year, Texas has reported the most cases, with 16, followed by Colorado (15), Ohio (10), and 9 each in Illinois, New Jersey, and Washington. 

According to a CDC news release, "Most cases are reported between August and October, and a marked reduction in cases is seen in November. That pattern appears to be repeating in 2018 because states have reported fewer PUIs [persons under investigation] over the past couple of weeks. CDC expects this decline to continue." 

This year's case totals are nearing 2016's, which saw 149 confirmed cases of AFM in 39 states. In 2014, the first ear CDC began tracking case counts, officials confirmed 120 cases. 2015 and 2017 saw lower case totals. 

According to a practice article today in the Canadian Medical Association Journal (CMAJ), most patients have ongoing deficits 4 to 6 months post-diagnosis, with full recovery at that point in only 8% to 18% of cases. The article also notes that 8% to 14% of patients require either assistive devices for ambulation or complete dependence on caregivers. 

There is no known treatment for AFM at this time.

Polio and vaccination: A memoir of what we’ve forgotten

The Tyee has published my article Polio and Vaccination: A Memoir of What We’ve Forgotten. Excerpt:

We’re seeing reports of a “polio-like” disease turning up in Canada and especially in the U.S. Acute flaccid paralysis is leaving kids partially or completely paralyzed, and parents are understandably scared. The U.S. reportedly has 60 cases so far this year, and Canada has perhaps 30.  

AFP and its subtype, acute flaccid myelitis, are even becoming a political issue: the right-wing American Association of Physicians and Surgeons warns about the “public health threat from uncontrolled immigration” and suggesting that the “caravan” of asylum seekers might be bringing AFP with them. 

As literally a one-in-a-million disease, AFP is a faint echo of poliomyelitis itself. But it comes at a time when we’ve forgotten how deadly childhood diseases can be, and many have even begun to question the vaccines that saved both them and their parents from death or lifelong impairment.  

Seventy years ago this month, I was seven years old, running a fever, and unable to touch my chin to my chest. Every parent in 1948 knew those were likely symptoms of polio, and that same afternoon I was in a downtown hospital for tests. They showed I was indeed one of over 20,000 polio cases in the U.S. that year.  

My memories of the next two weeks are fragmentary but vivid. I’m carried on the shoulder of a tall black man to undergo a spinal tap — not a funny phony band, but my first experience of real pain. I’m in a ward with other kids, each of us in a crib — a crib! — learning to use bedpans and suffering the further indignity of having our temperatures taken rectally. Drop a comic book through the crib slats to the floor, and it’s gone forever.

Every day we lie on our stomachs in our cribs while “hot packs” — steaming-hot blankets — are piled on us. This is state-of-the-art therapy for polio patients.  

Toward the end of my hitch, I’m taken from my crib in a wheelchair, plunked into a bathtub and sloshed with green disinfectant soap. Then I’m taught how to walk again. After two weeks in a crib, it’s not easy.  

Finally back home, I begin to understand that I am really lucky. Other kids have died, or been trapped for life in iron lungs that keep them breathing. When I’m back in school, I see a girl with a brace on one leg from her own case of polio. She’s not the last.

Cases of rare, polio-like paralysis targeting kids appear in Canada

Via CBC News: Cases of rare, polio-like paralysis targeting kids appear in Canada. Excerpt:

Last week, the U.S. Centers for Disease Control reported a small surge in cases of a mysterious disease in children. More than 60 cases of the polio-like illness have been confirmed in 22 U.S. states in recent weeks. Now, doctors in Toronto say they're seeing cases appear in Canada.  

"I can confirm that since September, we have certainly seen an increase of patients with muscle weakness who also had a preceding viral illness," said Dr. Jeremy Friedman, associate pediatrician-in-chief at the Hospital for Sick Children. "These symptoms are typical of acute flaccid paralysis (AFP) and increases of similar cases have been reported by many other North American pediatric centres." 

Doctors do not know what causes the ailment, nor are they sure why more cases have been reported recently. Children are the victims in the vast majority of cases and doctors are not exactly sure why.

Dr. Friedman would not give an exact figure on the number of new cases in Canada, but did say SickKids has seen "fewer than 20 probable cases of AFP."  

Canada has systems in place, led by the Public Health Agency of Canada, to look for cases of sudden onset muscle weakness in children.  

Last Thursday, Public Health Agency of Canada spokesperson Anna Maddison said in an email there were fewer than five cases of acute flaccid myelitis (AFM), a subtype of AFP, reported from January to August 2018. 

On Monday, the agency provided an update based on the broader definition of AFP.   

"To date in 2018, 25 probable cases and five confirmed cases of sudden onset muscle weakness in children have been reported. This reporting includes a variety of conditions related to sudden onset muscle weakness in children," said Maddison, who also serves as a spokesperson for Health Canada, said in an email.  

"Currently, the surveillance data do not indicate an increase in the number of potential cases in Canada."  

The agency also said it is enhancing real-time surveillance of AFP based on the increase reported in the U.S. 

US: Parents of children with AFM warn about rare polio-like condition

Via The Washington Post: Parents of children with AFM warn about rare polio-like condition. Excerpt:

It started with a sinus infection. Then 4-year-old Camdyn Carr couldn’t move the right side of his face or lift his arm to scratch his nose. 

His parents decided to take him a couple of hours away to see doctors who might be able to figure out what had afflicted their young boy. But as they drove from their Roanoke home to the University of Virginia, Carr’s whole body seized up and he was suddenly paralyzed.  

Many tests later, Carr was diagnosed with the rare polio-like condition acute flaccid myelitis, or AFM. He is now a patient at Kennedy Krieger Institute, where his father, Christopher Carr, brought him for physical therapy and other treatment to try to get his son moving again.  

AFM affects the gray matter in the spinal cord and can lead to paralysis, but is so rare that fewer than 1 in 1 million people, mostly children, contract it. 

But a recent uptick in cases in the United States has put public health officials on alert and freaked out parents because of the severe symptoms that sometimes accompany it. Doctors don’t know exactly what is causing the mystery illness and there is no official treatment for it, raising the fear factor for some. 

“So much of this doesn’t make sense to me,” said Christopher Carr, who is staying with Camdyn at Kennedy Krieger while the rest of the family remains at home. “I am hoping the physical therapy can help improve my son’s condition.” 

The Centers for Disease Control held a teleconference Tuesday expressing concern about the disease, which has sickened 62 children this year and killed one. The CDC is investigating an additional 65 cases, including five children with the symptoms reported in Maryland. 

Public health officials have not identified a common link among cases, but there seems to be a surge every couple of years. 

The International Center for Spinal Cord Injury at Kennedy Krieger Institute has treated many cases from around the country, including six patients who are there now. 

“Until we figure out if this is an infection or if this is an autoimmune process, until we figure out how to prevent it, then the effort to bring awareness to it and develop timely interventions is appropriate even if it is 1 in a million,” said Cristina L. Sadowsky, the center’s clinical director.

The most recent mention of AFM on the website of the Public Health Agency of Canada is this note from early 2016, which lists it as a possible consequence of an EV-D68 infection. The Washington Post story cites enteroviruses but doesn't specify them.

CIDRAP: CDC, partners probe 127 polio-like cases in 22 states

Via CIDRAP, Lisa Schnirring writes: CDC, partners probe 127 polio-like cases in 22 states. Excerpt:

The US Centers for Disease Control and Prevention (CDC) said today that officials are investigating a spike in acute flaccid myelitis (AFM) cases, mostly in children, that looks similar to increases they saw in the late summer and fall of 2014 and 2016, with 127 cases under investigation in 22 states. 

So far 62 of the cases—marked by sudden onset of limb weakness and decreased muscle tone—have been confirmed, Nancy Messonnier, MD, director of the CDC's National Center for Immunization and Respiratory Diseases, said today at a media briefing. More than 90% have been in children, and the average age is 4 years.  

She emphasized the AFM cases are very rare, affecting 1 in 1 million people, and the condition is not caused by poliovirus, though symptoms can be similar to polio. In addition, unlike with polio, most children recover, though some require ongoing treatment. Only one death has been reported, which involved an AFM illness reported in 2017. 

Messonnier urged parents to seek care right away if children experience AFM symptoms.  

Cause still a mystery 

In 2014, a large AFM epidemic coincided with a national outbreak of severe respiratory illness caused by enterovirus D68 (EV-D68), but in-depth testing of patient samples hasn't consistently found a common cause. 

Messonnier said the search for a cause is frustrating, and so far, no particular pathogen or immune response has been identified that would explain the big AFM peaks. Some patients have tested positive for enterovirus or rhinovirus. 

Other countries have reported AFM cases, but not the same seasonal pattern the United States has experienced. Messonnier added that health officials are considering other potential causes, such as West Nile virus and environmental toxins, though none of the cases have involved them.  

So far, the CDC hasn't seen any geographic patterns based on reporting from states. 

And for now, it's hard to say if 2018 will equal or surpass spikes seen in 2014 and 2016, Messonnier said, adding that state and federal health officials haven't finished the whole diagnostic algorithm for many of the cases reported over the past several weeks. Also, she said there can be lags in reporting because of the time it takes to review a patient's clinical syndrome and radiographic findings. 

To give parents, healthcare workers, and public health officials a look at what to expect, she said the CDC will report suspected cases this year, as well as confirmed ones. The agency had a teleconference with health providers slated for later today, and it provided a toolkit for diagnosing AFM, along with instructions for reporting suspected cases.

US: Acute flaccid myelitis cases in children are investigated in at least five states

Via The New York Times, an October 10 report: Acute Flaccid Myelitis Cases in Children Are Investigated in at Least 5 States. Excerpt:

Health authorities in the United States said this week that they were investigating an unusual spike in cases of a rare condition that causes limb paralysis and severe muscle weakness in children.  

At least five states — Illinois, Washington, Colorado, Minnesota and Pennsylvania — reported that they were investigating the cause or trying to confirm new cases of the illness, known as acute flaccid myelitis. Some health authorities in those states have said the condition coincides with seasonal respiratory illnesses.  

A.F.M. affects the nervous system and causes, mostly in children, paralysis similar to polio. The signs include sudden weakness in the arms or legs; neck weakness or stiffness; a drooping face or eyelids; difficulty swallowing; and slurred speech, health officials say. 

Recent Cases 

Since mid-September, six cases of A.F.M. in children under 10 years old have been reported to the Minnesota Department of Health, the agency said. Another two possible cases are pending confirmation, officials said. 

The number of confirmed cases is the highest in the state since 2014, when there were three cases, the authorities said.  

On Tuesday, the health authorities said three children suspected to have A.F.M. were being treated at UPMC Children’s Hospital of Pittsburgh, and officials in Colorado said they were investigating 14 cases this year. 

On Wednesday, the Illinois Department of Public Health said it had received reports of nine A.F.M. cases in people younger than 18, all from Northern Illinois. The state had previously recorded only four cases since 2015.  

And in Washington State, officials said in a statement on Wednesday that they are working to confirm whether five children recently hospitalized with sudden paralysis of one or more limbs had A.F.M.