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The U.S. is experiencing increased circulation of enterovirus D68 (EV-D68), a virus linked with a rare neurologic complication that can cause paralysis in children, according to CDC surveillance data.

Alongside increasing cases of rhinovirus (RV) and EV, mounting emergency department visits for acute respiratory illness have been reported in children and adolescents, and EV-D68 is turning up in more and more of these cases, reported Kevin C. Ma, PhD, of the CDC's Epidemic Intelligence Service, and colleagues.

"Health care facilities should be prepared for possible increases in pediatric health care use associated with severe EV-D68-associated respiratory illness," the group warned in the .

The findings follow recent reports from providers about rising pediatric hospitalizations potentially linked with the virus, and of particular concern is that biennial outbreaks of EV-D68 -- typically falling on even years (2014, 2016, 2018) -- have been linked to increasing cases of acute flaccid myelitis (AFM).

"Providers should have a high index of clinical suspicion for AFM in patients with acute flaccid limb weakness, neurologic signs and symptoms, or neck or back pain who have a recent history of respiratory illness or fever," wrote Ma and colleagues. "Children with AFM can experience rapid progression of weakness and should be promptly hospitalized and referred to specialty care."

So far this year, 15 cases of AFM have been confirmed (of 45 under investigation), but the circulation of EV-D68 is currently similar to peak levels observed in 2018, when 238 cases of the rare neurologic complication were recorded. The year 2020 was an exception, at 33 cases, with the lower number attributed to increased precautions due to COVID-19. AFM cases in years ending in odd numbers (2015, 2017, 2019) ranged from 22 to 47.

Acute respiratory illness from EV-D68 typically affects young children, the group explained, and severity varies.

While "typical signs and symptoms include cough, nasal congestion, wheezing, and dyspnea," infections with EV-D68 can also exacerbate asthma or reactive airway disease (RAD), and "children with a history of asthma/RAD might be more likely to require medical care," according to Ma and co-authors.

To assess EV-D68 trends, the CDC investigators gathered and analyzed data from three sources: emergency department visits for acute respiratory illness or asthma/RAD in the National Syndromic Surveillance Program; positive RV/EV test results from the National Respiratory and Enteric Virus Surveillance System (NREVSS); and the detection of EV-D68 in children hospitalized or visiting emergency department for acute respiratory illness in the New Vaccine Surveillance Network (NVSN).

NREVSS data showed that the weekly positive RV/EV results in 2022 appeared to be increasing at a rate comparable to that of past EV-D68 outbreak years, doubling from 15.8% to 31.4% from week 32 to week 35. This marked the fourth highest proportion when compared to prior years (31.7% in 2015 to 41.5% in 2014, for example).

Of 5,633 children in the NVSN presenting to emergency departments with acute respiratory illness from March to September 2022, RV/EV was detected in 26.4%. Overall, EV-D68 was identified in 17.4% of these RV/EV cases, but that number surged to 56% by the end of the surveillance period.

In addition to looking out for AFM, the CDC advised that clinicians should also consider and test for polio, due to the clinical similarity of acute flaccid paralysis from poliovirus, and "given the detection of a paralytic polio case and wastewater samples positive for poliovirus in New York during summer 2022."

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