Epidemiological update - Increase in Echovirus 30 detections in Denmark, Germany, the Netherlands, Norway and Sweden, June to July 2018
In 2018, Norway  and the Netherlands  published reports from national public health institutes on increased Echovirus 30 (E30) detections associated with an increase in the number of meningitis or meningoencephalitis cases. Since the beginning of 2018, 407 E30 cases have been reported to ECDC in 10 EU/EEA countries based on an Epidemic Intelligence Information System–Vaccine Preventable Diseases (EPIS-VPD) data call.
Since the beginning of 2018, 407 E30 cases have been reported to ECDC in 10 EU/EEA countries based on an Epidemic Intelligence Information System–Vaccine Preventable Diseases (EPIS-VPD) data call: Austria (6), Belgium (5), Denmark (65), Germany (44), Iceland (1), Latvia (1), Netherlands (122), Norway (37), Sweden (32) and United Kingdom (England, Scotland and Wales, 94) (Figure 1). This is an increase of 148 patients from the previous update on 3 August 2018. The figures are based on available preliminary data from 1 January to 31 July 2018. An update was also received from Croatia, Czech Republic, Finland and Slovenia, who did not detect any E30 detections in 2018. Certain typing results for enteropositive detections were still pending for July specimens in these countries.
Denmark reported that 41 out of their 65 E30 detections (63%) were from cerebrospinal fluid (CSF) specimens, which can be used as a proxy for severe infection. Germany collected specimens only from aseptic meningitis, encephalitis or acute flaccid paralysis cases, therefore their 44 E30 patients all had central nervous system (CNS) symptoms. A total of 94 out of 132 patients (71%) were reported with central nervous system symptoms from the Netherlands, Norway and the United Kingdom. For 68 patients, further symptom categories were reported and classified as meningitis (n=36, 53%), meningoencephalitis (n=26, 38%) or other CNS symptoms (n=5, 7%; one additional patient reported with sepsis, fever, tachycardia and groaning respiration). For the other patients, the specific symptoms were unknown. Up until now, age information was available for 361 of the patients and the epidemic has mostly affected individuals under 3 months (n=86, 24%) and 26–45 years of age (n=145, 40%). Based on available preliminary data, the male (n=208) to female (n=148) ratio was 1.4.
E30 is a non-polio enterovirus that causes aseptic meningitis outbreaks worldwide. Such outbreaks have been detected earlier in Europe [3–10] and occur usually at five- to six-year intervals . The exact transmission route of current infections is unknown. However, non-polio enteroviruses usually transmit through faecal-oral or oral-oral routes. Unfortunately, specific prevention or control measures are not available for E30 and symptomatic treatment should be applied. Good hygienic practices such as frequent hand washing, avoidance of shared utensils, bottles or glasses and disinfection of contaminated surfaces (e.g. with diluted bleach solution) are recommended to prevent the spread of E30 from person to person. In affected countries, further transmission of E30 cannot be excluded and all EU/EEA Member States should remain vigilant for the continuing E30 epidemic. Where relevant, national public health authorities should consider informing clinicians of increased numbers of aseptic meningitis cases related to E30 infections and the importance of collecting respiratory, stool and CSF specimens even if white blood cell count is normal, as well as adhering to recommendations on detection of non-polio enteroviruses in laboratories .
Data are as reported to ECDC as of 29 August 2018. Belgium did not report the months of detection and the data are therefore not displayed.
Member State contributors
Birgit Prochazka (National Polio Reference Laboratory/AGES, Vienna, Austria), Chloé Wyndham-Thomas, Nele Boon and Marc Van Ranst (Epidemiology of infectious diseases, Epidemiology and public health, Sciensano, Brussels, Belgium), Katerina Fabianova (NIPH, Prague, Czech Republic), Irena Tabain (Virology Department Croatian Institute of Public Health, Croatia), Sofie Midgley and Thea Kølsen Fischer (Statens Serum Institut, Copenhagen, Denmark), Soile Blomqvist (National Institute for Health and Welfare, Helsinki, Finland), Sabine Diedrich, Sindy Böttcher, Kathrin Keeren (Robert Koch Institute, Berlin, Germany), Guðrún Erna Baldvinsdóttir (Virology, Landspitali University Hospital, Reykjavik, Iceland), Jelena Storozenko, Gatis Pakarna, Natālija Zamjatina and Tatjana Kolupajeva (Riga East University Hospital, Latvian Centre of Infectious Diseases, National Microbiology Reference Laboratory, Riga, Latvia), Kimberley Benschop (on behalf of VIRO-TypeNed, National Institute for Public Health and the Environment, Bilthoven, the Netherlands), (Eric Claas (Leiden University Medical Center, the Netherlands), Bert Niesters (University Medical Center Groningen, the Netherlands), Jaco Verweij (Elisabeth Ziekenhuis, the Netherlands), Katja Wolthers (VU University Medical Center Amsterdam, the Netherlands), Suzan Pas (Microvida, the Netherlands), Sylvia Bruisten (Amsterdam Municipal Health Center, the Netherlands), Rob Schuurman (University Medical Center Utrecht, the Netherlands), Richard Molenkamp (Erasmus University Medical Center, the Netherlands), Lieuwe Roorda (Maasstad Ziekenhuis, the Netherlands), Susanne Gjeruldsen Dudman, Sanela Numanovic and Refah Al-Samarrai (Norwegian Institute of Public Health, Norway), Katherina Zakikhany and Tiia Lepp (Public Health Agency of Sweden, Sweden), Natasa Berginc (National Laboratory of Health, Environment and Food - Laboratory for Public Health Virology, Slovenia), Richard Pebody and Jake Dunning (Public Health England, the United Kingdom), Alison Smith-Palmer (Health Protection Scotland, the United Kingdom) and Catherine Moore (Molecular Infection Services/Wales Specialist Virology Centre, Public Health Wales Microbiology Cardiff, the United Kingdom).
1. Norwegian Institute of Public Health. Økning av enterovirus-infeksjoner i juni [Internet]. Oslo: Folkehelseinstituttet; 2018 [accessed 3 Aug 2018]. Available from: https://www.fhi.no/nettpub/smittevernveilederen/sykdommer-a-a/echovirusinfeksjon---veileder-for-h/.
2. Microvida – Medische Microbiologie West-Brabant en Zeeland. Start van het enterovirus seizoen [Internet]. Breda: Microvida; 2018 [accessed 3 Aug 2018]. Available from: http://www.microvida.nl/algemeen/start-van-het-enterovirus-seizoen.
3. Trallero G, Avellon A, Otero A, De Miguel T, Perez C, Rabella N, et al. Enteroviruses in Spain over the decade 1998-2007: Virological and epidemiological studies. J Clin Virol. 2010;47(2):170-6.
4. Leveque N, Jacques J, Renois F, Antona D, Abely M, Chomel JJ, et al. Phylogenetic analysis of Echovirus 30 isolated during the 2005 outbreak in France reveals existence of multiple lineages and suggests frequent recombination events. J Clin Virol. 2010;48(2):137-41.
5. Rudolph H, Prieto Dernbach R, Walka M, Rey-Hinterkopf P, Melichar V, Muschiol E, et al. Comparison of clinical and laboratory characteristics during two major paediatric meningitis outbreaks of echovirus 30 and other non-polio enteroviruses in Germany in 2008 and 2013. Eur J Clin Microbiol Infect Dis. 2017;36(9):1651-60.
6. Savolainen-Kopra C, Paananen A, Blomqvist S, Klemola P, Simonen ML, Lappalainen M, et al. A large Finnish echovirus 30 outbreak was preceded by silent circulation of the same genotype. Virus Genes. 2011;42(1):28-36.
7. Perevoscikovs J, Brila A, Firstova L, Komarova T, Lucenko I, Osmjana J, et al. Ongoing outbreak of aseptic meningitis in South-Eastern Latvia, June - August 2010. Euro Surveill. 2010;15(32).
8. Cosic G, Duric P, Milosevic V, Dekic J, Canak G, Turkulov V. Ongoing outbreak of aseptic meningitis associated with echovirus type 30 in the City of Novi Sad, Autonomous Province of Vojvodina, Serbia, June - July 2010. Euro Surveill. 2010;15(32).
9. Mantadakis E, Pogka V, Voulgari-Kokota A, Tsouvala E, Emmanouil M, Kremastinou J, et al. Echovirus 30 outbreak associated with a high meningitis attack rate in Thrace, Greece. Pediatr Infect Dis J. 2013;32(8):914-6.
10. Nougairede A, Bessaud M, Thiberville SD, Piorkowski G, Ninove L, Zandotti C, et al. Widespread circulation of a new echovirus 30 variant causing aseptic meningitis and non-specific viral illness, South-East France, 2013. J Clin Virol. 2014;61(1):118-24.
11. McWilliam Leitch EC, Cabrerizo M, Cardosa J, Harvala H, Ivanova OE, Kroes AC, et al. Evolutionary dynamics and temporal/geographical correlates of recombination in the human enterovirus echovirus types 9, 11, and 30. J Virol. 2010;84(18):9292-300.
12. Harvala H, Broberg E, Benschop K, Berginc N, Ladhani S, Susi P, et al. Recommendations for enterovirus diagnostics and characterisation within and beyond Europe. J Clin Virol. 2018;101:11-7.