Research ArticleEpidemiology

Epidemiological dynamics of enterovirus D68 in the United States and implications for acute flaccid myelitis

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Science Translational Medicine  10 Mar 2021:
Vol. 13, Issue 584, eabd2400
DOI: 10.1126/scitranslmed.abd2400

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When respiratory illness meets neurological symptoms

Enterovirus D68 (EV-D68) has been increasingly linked with the neurological condition acute flaccid myelitis (AFM) in the United States within the past decade, although the reason for their coincidence is not clear. Park et al. used recent surveillance data from a national repository of respiratory virus panels to predict the incidence of EV-D68. They then examined the dynamics of the spatiotemporal association between the predicted incidence of EV-D68 and reported AFM cases on regional and national scales. The authors also found evidence that the extent of EV-D68 and AFM transmission in the United States in 2020 was likely kept in check by current social distancing practices.


Acute flaccid myelitis (AFM) recently emerged in the United States as a rare but serious neurological condition since 2012. Enterovirus D68 (EV-D68) is thought to be a main causative agent, but limited surveillance of EV-D68 in the United States has hampered the ability to assess their causal relationship. Using surveillance data from the BioFire Syndromic Trends epidemiology network in the United States from January 2014 to September 2019, we characterized the epidemiological dynamics of EV-D68 and found latitudinal gradient in the mean timing of EV-D68 cases, which are likely climate driven. We also demonstrated a strong spatiotemporal association of EV-D68 with AFM. Mathematical modeling suggested that the recent dominant biennial cycles of EV-D68 dynamics may not be stable. Nonetheless, we predicted that a major EV-D68 outbreak, and hence an AFM outbreak, would have still been possible in 2020 under normal epidemiological conditions. Nonpharmaceutical intervention efforts due to the ongoing COVID-19 pandemic are likely to have reduced the sizes of EV-D68 and AFM outbreaks in 2020, illustrating the broader epidemiological impact of the pandemic.

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