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A dispatch from the front lines of acute flaccid myelitis | STAT.

[NOVEMBER 28, 2018]


Although enterovirus D68 has been linked to acute flaccid myelitis, a single definitive cause hasn't yet been identified.CYNTHIA S. GOLDSMITH, YITING ZHANG/CDC

Roberta L. Debiasi, Elizabeth M. Wells, and Jessica Carpenter write:

To parents and the press, the “new” disease that is paralyzing kids is a mystery. Media coverage of acute flaccid myelitis (AFM), which causes sudden limb weakness and paralysis in children, has given families the impression that health care providers and public health officials are sitting quietly and helplessly, flummoxed in the face of a disease that threatens children’s health.

That just isn’t so.

Parents have a right to be concerned about this illness. But they should also know that AFM is rare, a one-in-a-million event. It does not spread within families, hospitals, or towns. Although a virus called enterovirus D68, along with other viruses that cause respiratory and diarrheal illness, has been linked to the disease, a single definitive cause hasn’t yet been identified. This isn’t because we aren’t looking: Physicians, scientists, and public health officials are working tirelessly to find answers and the best treatments.

Progress has been made on multiple fronts since 2014, when acute flaccid myelitis first emerged in news headlines and the public consciousness. In the clinical arena, multidisciplinary and multicenter collaborations have been tapping the collective wisdom of experts in infectious disease, neurology, neuroradiology, and rehabilitation, leading to the development of best practices for clinical care. Epidemiologic and research data on the disease are being shared across centers to optimize and standardize the approach to how children afflicted with this condition are cared for at any center across the country.

At Children’s National Health System in Washington, D.C., where we work, specialized programs have long been in place to combat emerging infections and neuroinflammatory disorders. Both of these are relevant to acute flaccid myelitis due to its association with viruses and the nerve inflammation it causes. Thanks to our program and similar programs in place at other pediatric medical centers, evidence-based, standardized clinical pathways now guide the evaluation and treatment of every child suspected to have acute flaccid myelitis.

As with other types of brain and spinal cord injury, the best results often come with early mobilization, so rehabilitation begins early, sometimes even while a child with AFM is in the intensive care unit. Pediatric physical therapists are trained to make children with weak limbs feel like they are champions, whether they are infants, toddlers, or older children.

On the epidemiologic and public health fronts, the Centers for Disease Control and Prevention has standardized and publicized case definitions so children with AFM can be identified. And the CDC recently announced a new task force on acute flaccid myelitis. Its work, which will be coordinated by the Office of the Director, aims to make its first report public in early December.

Multiple medical centers and surveillance networks have begun more intense and broad efforts to look at patterns of specific respiratory and diarrhea virus circulation in communities and have initiated targeted viral surveillance to detect spikes in frequency that might be associated with a subsequent spike in AFM cases.

On the scientific front, investigators have applied advanced molecular techniques, including whole exome genetic sequencing, to better understand enterovirus D68, as well as to exclude other agents that might contribute to AFM.

Investigators have also successfully developed laboratory and animal models of acute flaccid myelitis that closely mimic the human disease. These preclinical models provide a deeper understanding of how AFM injures the spinal cord and have helped identify possible treatment targets. Researchers are also screening off-the-shelf drugs and compounds that might work for these targets, and have already tested and reported on the safety and effectiveness of promising treatments.

Our health system has established a research biobank for blood and spinal fluid samples from children with neuroinflammatory diseases. Studying these specimens could lead to discoveries about AFM and new insights into how it affects individuals. Through a unique research partnership between Children’s National and the National Institute of Allergy and Infectious Diseases, we are engineering antiviral treatments tailored to the individual patient that target the exact virus he or she has been infected with. That approach can be lifesaving in potentially fatal viral infections among patients with defects in their immune systems. In the future, this targeted cell therapy technology could potentially be applied to viruses that target and disable the nervous system, including enteroviruses.

The first polio epidemic in the U.S. began in 1894; Franklin Delano Roosevelt got polio in 1921; Dr. Jonas Salk gave his vaccine to his family in 1953; and the vaccine developed by Dr. Albert Sabin was licensed in 1960. That’s a span of 66 years. Sabin’s highly effective and routinely used polio vaccine is often underappreciated for its essential role in safeguarding health and preventing a disease that paralyzed up to 20,000 children a year in the pre-vaccination era.


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Viewpoint: How physicians are fighting the polio-like illness sickening kids | Becker's Hospital Review.

[November 28, 2018]

Megan Knowles writes:

After the CDC reported 286 cases of possible and confirmed acute flaccid myelitis, the polio-like illness affecting children, physicians want the public to know they are working to find the best treatments, three physicians with Washington, D.C.-based Children's National Health System write in a STAT op-ed.

Five insights from the op-ed, written by Roberta DeBiasi MD, chief of the division of pediatric infectious diseases, Elizabeth Wells, MD, medical director of the neurosciences unit, and Jessica Carpenter, MD, associate professor of pediatrics and neurology:  

1. "Parents have a right to be concerned about this illness. But they should also know that AFM is rare, a one-in-a-million event," the physicians wrote. "It does not spread within families, hospitals or towns.

A virus called enterovirus D68, along with other viruses that cause respiratory and diarrheal illness, has been connected to AFM, but a definitive cause has not been found, the authors said.

"This isn't because we aren't looking: Physicians, scientists, and public health officials are working tirelessly to find answers and the best treatments," said the authors.

2. Since AFM first appeared in news headlines in 2014, progress has been made in epidemiologic and research data, which is shared across centers to standardize how children with the illness are treated.

3. Children's National Health System has long had specialized programs to fight emerging infections and neuroinflammatory disorders, which includes AFM.

"Thanks to our program and similar programs in place at other pediatric medical centers, evidence-based, standardized clinical pathways now guide the evaluation and treatment of every child suspected to have acute flaccid myelitis," the physicians wrote.

4. Additionally, the CDC recently standardized and publicized case definitions to help identify children with AFM and announced a new task force on the disease. The task force aims to publicize its first report in early December.

5. "Clinicians in our program and similar ones at other pediatric centers across the country apply continually updated information to guide a standardized approach to evaluate and treat children with acute flaccid myelitis and help them achieve the best possible chance of full recovery," the physicians concluded.


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Communicable Diseases in the Mediterranean Region | eJIFCC via Pubmed.

[2018 Nov 7;29(3):164-170]

Abstract.

Communicable diseases still pose a health hazard and are a major cause of death in many parts of the world. Tuberculosis is one of the top 10 causes of death worldwide with an annual burden of 1.7 million. Global deaths in 2016 for other communicable diseases included 1.34 million from hepatitis; 1.0 million from HIV-related causes; and almost half a million from malaria. Outbreaks of vaccine-preventable diseases like polio, measles, rubella and other life-threatening diseases also pose a significant threat to various communities around the world. In this paper, we shed some light on the epidemiology of communicable diseases in the Mediterranean Region and conclude that socioeconomic differences between the north and the south Mediterranean lead to differences in the epidemiology of communicable diseases.

Open Access PDF : http://www.ifcc.org/media/477476/ejifcc2018vol29no3pp164-170.pdf


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