CDC Expects 2020 Outbreak of Life-Threatening Acute Flaccid Myelitis Transcript

Operator: Welcome, everyone, and thank you for standing by. At this time, I’d like to inform all participants that your lines are in a listen-only mode until the question and answer session of today’s conference call. If you would like to ask a question, please press star 1 on your phone. I will now turn the meeting over to our first speaker Ms. Michelle Bonds.

Thank you. You may begin.

Moderator: Thank you, Bridget. I’m Michelle Bonds, the Director of the Division of Public Affairs. Today’s telebriefing is in conjunction with the release of a “Vital Signs.” It’s about Acute Flaccid Myelitis, also known as AFM. AFM is a life-threatening neurologic condition that affects mostly children and is likely to be seen with other flu and infectious diseases.

We are joined today by CDC Director Dr. Robert Redfield and Dr. Tom Clark, a pediatrician and deputy director of the Division of Viral Diseases. They will discuss what CDC has learned about AFM and our continued work to better understand this condition. They will have opening remarks and then we will open up for questions.

I’ll turn the call over now to Dr. Redfield. Thank you.

Dr. Redfield: Thank you, Michelle, and good afternoon and thank you for joining us today to talk about CDC’s Vital Signs report on Acute Flaccid Myelitis or AFM – a serious paralytic condition affecting mostly children. As this report makes clear, AFM is a priority for CDC as we prepare for a possible outbreak this year. AFM affects the nervous system, specifically the area of the spinal cord called the gray matter. Most patients develop sudden arm or leg weakness. AFM can progress quickly and patients can become paralyzed over the course of hours or days and require ventilator to help them breathe. Some patients will be permanently disabled. One reason we wanted to do this report as a Vital Signs now is that the virus most commonly causing this condition, Enterovirus D68, tends to come in two-year cycles. This means it will be circulating at the same time as flu and other infectious diseases, including COVID-19, and could be another outbreak for clinicians, parents, and children to deal with. With this Vital Signs, CDC presents a more detailed view of the cases that happened two years ago in the 2018 outbreak. This has allowed us to learn more about AFM, better recognize the signs and symptoms, and respond faster. So today in collaboration with the Siegal Rare Neuroimmune Association  and other partners, we are tracking and sharing the latest information about AFM and CDC’s investigations. Before I go further, I want to thank the parents who have continuously advocated for AFM – and nd by doing so, helped to build a strong community to support the newly diagnosed. I know that even the threat of AFM is concerning, especially for parents of young children, and as a parent and a grandparent, my heart goes out to all the affected families. Since CDC began surveillance for AFM in 2014, a national outbreak has occurred every other year during August through November. Enteroviruses, particularly D68, have likely been the primary cause of these outbreaks. Since 2018, CDC has streamlined its systems for faster reporting and case classification leading to faster outbreak detection. We are pushing AFM information out far and wide to educate all clinicians, especially frontline providers, about AFM and to learn, alert, and prepare them for increased cases this year. Also, in November 2018, we established a task force made up of experts from a variety of scientific, medical, public health disciplines, including clinicians treating patients with AFM, to provide expert guidance and lessons learned.

Timing is critical for AFM. Delays in AFM recognition and care can put patients at risk. Clinicians should suspect AFM in patients with sudden limb weakness, especially during the months of August through November. Recent respiratory illness or fever, and the presence of neck or back pain or any neurological symptoms, should heighten the clinicians’ concern. When they recognize this, they can quickly hospitalize patients, monitor vital signs and pulmonary functions for signs of deterioration, collect specimens and order an MRI. We have seen that when this is done early, there’s a better chance of detecting the cause of AFM and distinguishing it from other conditions which could cause limb weakness. Clinicians need to remain vigilant for AFM and promptly evaluate patients even as frontline health care workers, family, physicians and other medical professionals continue to work under the constraints of the ongoing COVID-19 pandemic. While phone and telemedicine can be used for initial evaluations, AFM is a medical emergency that requires immediate medical care and monitoring, as this condition can progress rapidly to respiratory failure. Clinicians should not delay in hospitalizing patients when they suspect AFM. We do not know how the COVID-19 pandemic and the social distancing measures may affect the circulation of enteroviruses, or if COVID-19 will impact the health care system’s ability to promptly recognize and respond to AFM. AFM cases may be fewer this year, or the outbreak delayed. But we know this: AFM is a public health priority. Together with other public health agencies, clinicians and partners, including parent advocates, CDC is continuing to advance our knowledge of AFM, discover how best to prevent and to treat and improve patient outcomes. Now, I’d like to turn the briefing over to Dr. Thomas Clark, who will share the insights of the 2018 AFM outbreak described in our Vital Signs report.

Dr. Clark?

Dr. Clark: Thank you, Dr. Redfield. And thank you again, everyone, for joining us today. In 2018, the United States experienced its third and largest outbreak of AFM since CDC started surveillance in 2014. CDC confirmed 238 cases in 42 states in this outbreak. Most cases were in young children; the average age was five years. Most patients developed AFM during the months of August through November. We examined the medical records of patients confirmed to have AFM in 2018, reviewing their symptoms, physical exam findings, lab test and imaging results, and hospitalization data. Most patients with AFM had fever or respiratory illness about six days before limb weakness onset. Once they developed limb weakness, it was common for them also to have difficulty walking, neck or back pain, limb pain, and fever. Most patients sought medical care within one day, with most going to the emergency department. Overall, 98% of patients were hospitalized; 54% were admitted to intensive care units; and  23% required ventilation or the use of machines to help them breathe. Most patients were hospitalized within one day of limb weakness onset. However, 10% were not hospitalized until four or more days after developing limb weakness. This could indicate delays in recognition of AFM and present an opportunity for improvement in patient outcomes. One type of enterovirus, EV-D68, was the most common virus identified among specimens we tested from patients. Poliovirus, a vaccine preventable cause of paralysis, was not detected in any cases. Patients who tested positive for EV-D68 typically had more severe AFM, and were more likely to require intensive care and ventilation. This Vital Signs report provides a more detailed view of the clinical picture of AFM, which we hope will help clinicians better recognize signs and symptoms, evaluate patients, and provide optimal medical management and rehabilitation. CDC urges clinicians to consider and promptly recognize AFM symptoms, to hospitalize patients immediately, to collect specimens early, and to report all suspected cases to their state or local health department. CDC is prepared to respond if an outbreak develops this year, and we will continue to learn about AFM, its risk factors, treatment, and patient outcomes. I thank you for your attention, and we are ready to take questions, please.

Operator: Thank you. Our first question will come from Eric Strauss of ABC. Your line is open.

Reporter: Hello. Thanks for having this call. It’s amazing to hear the development in what you’ve learned in the last two years getting ready for this year. I’m just wondering if you could talk, if you’ve made any progress in understanding why certain children might get this and other children don’t, and any tips for families to try and prevent getting AFM.

Dr. Redfield: Dr. Clark, why don’t you answer the question.

Dr. Clark: Sure. You know, we’ve learned a lot, but we have a lot to learn about AFM. We don’t yet know why certain kids develop AFM when the great majority who have a respiratory illness recover with no neurologic symptoms. We are working at CDC, and collaborating with the National Institutes of Health on a couple of large studies prospectively this outbreak season, which we hope will help us understand risk factors for AFM. You know, not understanding risk factors means I also can’t tell parents anything specific they can do to prevent AFM. But it’s important to remember the usual hygiene measures we recommend in respiratory virus season. That means careful handwashing, covering your cough, cleaning and sanitizing areas of the house that are high-touch surfaces. And this year especially, it is going to be more important than ever for everyone to get flu vaccinations as recommended.

Moderator: Next question, please.

Operator: Thank you. Our next question will be from Ivan Caronne of AFP. Your line is open.

Reporter: Thank you. How many of the 238 patients of 2018 are paralyzed today? Do we know, and how many have recovered?

Dr. Redfield: Dr. Clark?

Dr. Clark: Sure. Unfortunately, many kids with AFM will have permanent disability. We don’t know exactly from this outbreak, but we’re going back to all the families of kids who were affected in 2018 and assessing their neurologic function as late as 12 months afterwards. So we will have a good understanding of how they’re functioning. We’re also working to collect similar data from the previous outbreak years. One thing that we want to make sure everyone understands is that it’s really important that kids get into rehabilitation so early and aggressive physical therapy, occupational therapy, can help strengthen the function that they do retain, and help them go about their lives with the best functioning possible.

Moderator: Next question.

Operator: Thank you. Our next question will be from Brenda Goodman of WebMD. Your line is open.

Reporter: Hi. Thanks for doing this call. I’m just curious if there’s been any progress made toward a vaccine or especially for Enterovirus D68 to prevent this. And would it make sense to have a vaccine for this, given the small number of cases? And then a second question, if I could, is given that you’re expecting this outbreak this year during the pandemic and that there seems to be at least some overlap in symptoms that kids might have, are you worried these cases might be missed?

Moderator: Dr. Redfield?

Dr. Redfield: So the first part, there has been preclinical work that has been begun at NIAID under Dr. Fauci on looking at some prototype candidate vaccine approaching D68. So it’s begun at that level, what we call the preclinical level. And that was actually begun in the fall of 2018. And I would refer you to NIAID or follow up to where that is right now. But they have instituted a preclinical program in that regard. And the second question, maybe Dr. Clark?

Dr. Clark: Sure. That’s why we’re coming to you today to talk to clinicians and to parents, as we are concerned that in the midst of our COVID pandemic, that cases of AFM might not be recognized. We’re concerned that parents might be worried about taking their child to the doctor if they develop something as serious as limb weakness. So that’s why we’re here, re-emphasizing that we are prepared for an AFM outbreak this year, starting soon, if it’s consistent with previous years, and helping physicians think about and understand the signs and symptoms of AFM. We want parents to understand that many measures have been taken to provide health care online safely. AFM is a medical emergency, and any signs of limb weakness in their kids that develop suddenly, they need to get to the doctor.

Dr. Redfield: Part of what we were hoping with this Vital Signs and with obviously the outreach, is to really get this anticipatory alert, not just to health care professionals, but really even more importantly to parents. The situation is a parent may notice, or the child may complain, that their arm is a little weak or their leg is a little weak. And rather than sort of observe to see how that evolves over the next day or two, to see if it persists, as many parents – having been a parent for six kids and now 11 grandkids – kind of just hoping it will go away. What we really want is for parents to recognize that that can be a significant early sign, and we want them to have the security to go seek medical attention at that point in time.

Moderator: Next question, please.

Operator: Our next question will be from Molly Walker of MedPage Today. Your line is open.

Reporter: Hi. Thank you for taking my question. I was wondering how a potential AFM outbreak, (unintelligible) or do you anticipate it complicating school re-openings? Parents are concerned enough about sending their kids back to school in the middle of COVID-19. Does this add another wrinkle, and how would you plan to address it? Thank you so much.

Dr. Redfield: I would just say, and Dr. Clark may want to add, I just want to stress AFM is a very rare occurrence that we’ve had, as was mentioned, in 2014 and then 2016 and then 2018, where we’ve had those three outbreaks. But I want to stress it’s a very rare event. It’s a very serious event when it occurs in a family. But at the same time, it’s an extremely rare event. I don’t know if Dr. Clark wants to quantitate that more.

Dr. Clark: We understand, as Dr. Redfield says, AFM is scary for parents and it’s an uncommon outcome of what we think are very common respiratory illnesses. And so we encourage parents to follow the recommendations set forward by their schools and their local public health jurisdictions and especially to emphasize now more than ever, the careful handwashing, cough etiquette, sanitizing high-touch surfaces to help reduce the risk of all respiratory illnesses.

Moderator: Next question, please.

Operator: Our next question will be from Erika Edwards of NBC news. Your line is open.

Reporter: Hi. Thank you. I was wondering if there are multiple enteroviruses are still – (unintelligible) including A71. I noticed you’ve really only addressed D68. Have you narrowed it down?

Dr. Redfield: And Dr. Clark will add to this, but it’s important as we report in the MMWR, clearly D68 has been the most common one that we’ve associated. But as you noted, A71 is also — so I think we should keep an open mind that these are at least two of the enteroviruses that have been associated. And, in fact, there may be additional enteroviruses as we get further evaluation, particularly with the ability to get improved sampling and specimens with the cases that are current today. Dr. Clark, do you want to add?

Dr. Clark: So Enterovirus D68 has been the virus we find most commonly in specimens we test from kids with AFM. But it’s not the only one. This report includes a cluster of AFM cases caused by EV-A71 that occurred in Colorado. Those kids tended to be a little bit younger, seemed to recover more completely and more quickly. So we do think — we do know — that enteroviruses can cause AFM. But we have a lot to learn about exactly what’s causing and really driving these every-other-year outbreaks, and exactly how enteroviruses are causing the paralysis that we see in AFM.

Moderator: Next question, please.

Operator: Our next question will be from Nick Ballasy, Justthenews.com. Your line is open.

Reporter: Thanks so much for taking the question. Dr. Redfield, you spoke at the recent House hearing about the CDC reviewing COVID-19 death certificates. Based on your knowledge, have some hospitals been incorrectly reporting deaths as coronavirus death? And what are the consequences if a hospital or a physician does that?

Dr. Redfield: So you know, death certificates, the way death certificates are completed, they’re completed by the physician of record. And as a physician, we make our best assessment as to what we believe the primary cause of death was, and then frequently we’ll note if there was some contributory factors. And then those death certificates become part of the public health record. Eventually they make their way to our national health statistics center in Hyattsville. And that’s how we do report the death. So it really is a clinical decision that is made by the physician that is either of record or is the physician that is assigned to complete the death certificate. I think, in general, these physicians take this quite seriously and do this to the best of their capacity.

Reporter: Is the death count right now accurate?

Dr. Redfield: I think the death count — there’s no reason to suspect that the death count is not accurate. Obviously, there are individuals that may die that may not have been diagnosed with COVID. So there is that possibility. But I do think that the reporting that we do get from the state, local, tribal, territory health departments and our center for national health statistics is accurate.

Moderator: Thank you, Dr. Redfield and Dr. Clark for joining us today. And to all the reporters, thank you for participating. For follow-up questions, please call the press office at 404-639-3286 or send an email to Media@CDC.gov.

This concludes our call.

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