Newborn enteroviruses, seven cases in Italy, one in intensive care. WHO: “Increase surveillance”

The alarm had come from France and was released by the World Health Organization on May 31st. Beyond the Alps, doctors had detected an increase in cases of severe sepsis among newborns, associated with an enterovirus (Echovirus-11, E-11). In detail, the country had recorded 9 sepsis with liver impairment and multi-organ failure with 7 deaths, between July 2022 and April 2023 from 4 hospitals in three different regions. Since then other countries have checked and reported E-11, including Italy.

In the latest WHO report, released in recent days, it appears that as of June 26 “seven cases of neonatal E-11 infection were confirmed in Italy between April and June 2023”. Three of these young patients were admitted to the neonatal intensive care unit.

At the time of reporting, only one case of those intercepted by Italian doctors remained in intensive care, one was showing clinical improvement and one had already been discharged. Two other cases, who tested positive at screening, had no significant symptoms. Further investigations are ongoing and clinical and epidemiological data are awaited.

Together with Italy, other states of the European region have notified WHO of cases of E-11 among newborns: Croatia, Spain, Sweden, United Kingdom. “Based on the limited information available, WHO assesses the public health risk to the general population as low. We continue to encourage countries to monitor and report cases. Healthcare settings caring for newborns should familiarize themselves with the signs and symptoms of the echovirus and remain vigilant for potential healthcare-associated infections and epidemics,” urges the UN health agency.

In the report, WHO takes stock of the public health responses put in place. France was the first to alert itself on May 5th. Of the 9 documented cases, 6 occurred in 2022 (at a rate of 2 in July, October and December) and three cases in 2023 (1 in January and 2 in April). Eight cases were preterm infants (born before 37 weeks of gestation) in 4 sets of twins. With the dissemination of the WHO alert relating to France, the level of attention has risen throughout the European area.

The cases in Europe

From the last update, the details of the other infections detected by several countries emerge. There are 7 Italian cases (in addition to the 5 described, data on the remaining two cases was awaited). And then Croatia reported one confirmed case of E-11 infection within a cluster of enteroviral diseases detected in newborns in June 2023, Spain reported two cases intercepted in 2023, Sweden reported 5 with 4 newborns affected by E-11 meningoencephalitis between 2022 and 15 June 2023, the UK reported two cases in March 2023.

Instead they do not detect increases in neonatal sepsis from E-11 Austria, Belgium, Denmark, the Netherlands and Norway in 2022 and 2023.

Viruses and how the disease manifests itself

Enteroviruses are a group of viruses that can cause various infectious diseases and are responsible for annual epidemics. The disease is usually mild, but it has been found to affect infants differently and sometimes more severely than older children and adults.

Like other enteroviruses, E-11 infections are associated with a broad spectrum of disease, ranging from mild nonspecific symptoms and systemic disorders such as skin rashes, febrile illnesses, to severe neurological disorders, including meningitis, encephalitis, and acute flaccid paralysis . And it has been shown to lead to serious disease in newborns and infants – inflammatory diseases, including severe acute hepatitis with coagulopathies – with high morbidity and mortality. The virus can be transmitted vertically from mother to child, making it more difficult to control infections, WHO said.

After the alert, every country took action. Italy is monitoring and implementing response and prevention activities, investigations into confirmed and other probable cases are also continuing.

The problem of asymptomatics

WHO notes that a characteristic of enterovirus infection is that it can be carried by asymptomatic people. And, apart from a few countries, “there is no systematic surveillance of enteroviruses at the European level. It is therefore difficult to estimate the extent of current serious neonatal E-11 infections or circulation rates in the population. Without surveillance, only the most serious cases will likely be detected through active efforts to test and type specimens. Because non-polio enterovirus infection is often not a notifiable disease, additional cases may not have been diagnosed or reported.”

Recommendations to doctors and hospitals

Another invitation is to doctors who manage newborns and infants: in the presence of circulatory shock, WHO says, “they should consider an underlying diagnosis of sepsis and perform appropriate diagnostic investigations, including tests for enteroviruses”. Healthcare facilities serving obstetric and neonatal populations “should familiarize themselves with the signs and symptoms of echovirus infection and maintain vigilance for potential cases of nosocomial infection and outbreaks in hospital units providing neonatal care.”

Prevention and control

Another warning from the agency is that “healthcare facilities and healthcare workers should implement infection prevention and control measures”, on the hand hygiene front, and then with regard to visitors entering the wards, reinforcing the importance of cleanliness and disinfection of the environment and the use of contact precautions when caring for infants with suspected or confirmed E-11.”

Isolation should be considered for these virus-affected babies, ensure that utensils (cup, spoon, syringe) for supplementary feeding are not shared, and educate mothers and health workers on personal hygiene and hand washing during infant care, including diaper changes.