key: cord-0835994-slvw3dsg authors: Zhang, Tiegang; Ren, Lili; Luo, Ming; Li, Aihua; Gong, Cheng; Chen, Meng; Yu, Xiali; Wu, Jiang; Deng, Ying; Huang, Fang title: Enterovirus D68–Associated Severe Pneumonia, China, 2014 date: 2015-05-03 journal: Emerg Infect Dis DOI: 10.3201/eid2105.150036 sha: 52894c8c3006787a931905740904eee2c915989b doc_id: 835994 cord_uid: slvw3dsg nan DOI: http://dx.doi.org/10.3201/eid2105.150036 To the Editor: Over the past 4 years, outbreaks caused by enterovirus type D68 (EV-D68) infection have occurred in many parts of the world (1); this virus can cause severe respiratory tract infections (RTIs) in children. This public health concern has been boosted by the recent outbreaks of EV-D68 infection in the United States (http://www.cdc. gov/non-polio-enterovirus/outbreaks/EV-D68-outbreaks. html). Outbreaks associated with novel EV-D68 have also been reported during 2006-2012 in China (2, 3) . However, since 2012, no EV-D68 infections in China have been reported. Whether the EV-D68 outbreaks in the United States affected those in China is unclear. Continuous characterization of EV-D68 epidemics is therefore necessary for purposes of early alert and for facilitating control measure decisions. To determine EV-D68 prevalence in China, we screened for EV-D68 infections in 2014 in Beijing, China. We tested patients with RTI during August-November 2014, reported by the Respiratory Virus Surveillance System, established by Beijing Center for Disease Prevention and Control. The System covers 30 sentinel hospitals in all 16 districts of Beijing. We obtained 1,478 clinical specimens (1,034 nasopharyngeal swab and 444 sputum). Patient ages ranged from 8 months to 93 years (median 33.5 years, mean 37.9 years). Enteroviruses and other known respiratory viruses were detected by real-time PCR (4) . A total of 70 enterovirus-positive samples were identified. Other respiratory viruses detected were 89 rhinoviruses, 87 influenza viruses, 70 human parainfluenza viruses (types 1-4), 43 human coronaviruses, 26 respiratory syncytial viruses, 29 adenoviruses, 9 bocaviruses, and 2 metapneumoviruses. Among the EV-positive samples, 1 was positive for EV-D68 according to PCR amplification of the viral protein 1 (VP1) gene (5) ; no other respiratory viruses were detected in this patient. The EV-D68-positive patient was a 5-year-old girl with no underlying disease. On August 5, 2014, she had fever (highest temperature 40°C), cough, breathing difficulty, abdominal pain, diarrhea, and vomiting. Her condition deteriorated, and on August 11, she was hospitalized in Beijing Children's Hospital with a diagnosis of severe pneumonia. A nasopharyngeal swab sample was collected at the time of admission. She was released on August 16, after receiving symptomatic supportive treatment in the general ward; she had not required mechanical ventilation. She and her family had no history of travel in the months before she became ill. To further characterize this virus strain, Beijing-R0132, we amplified the genome sequence directly from a nasopharyngeal swab sample by using overlapping primers designed according to the reference sequence We then used MEGA software version 6.06 (http:// www.megasoftware.net) to analyze the phylogeny of the whole genome and the VP1 gene with EV-D68 sequences available in GenBank (Figure) . Beijing-R0132 was clustered with most of the EV-D68 strains that circulated throughout the United States during 2014. The strains identified from Beijing in 2008, represented by BCH895A/2008, belong to another distinct lineage according to genome phylogeny ( Figure, panel A) . Similar relationships were observed in the phylogenic tree of the VP1 gene (Figure, panel B) . Beijing-R0132 and some EV-D68 strains from China identified in 2011 grouped with most of the strains obtained from the United States in 2014. These findings demonstrate that the EV-D68 strain circulating in Beijing was closely related to strains circulating in the United States. The origin of the 2014 EV-D68 outbreaks in the United States is unclear. This Beijing-R0132 genome sequence provides information for tracking EV-D68 as it spreads throughout the world and for evaluating the sequence diversity in circulating EV-D68 strains. In contrast to EV-D68 detection during the outbreaks in the United States, positive detection of EV-D68 in this study was limited, although the circulating virus strains were closely related. The reason for this disparity warrants further investigation. However, the severe pneumonia caused by EV-D68 reported here underlies the need for intensive attention to surveillance and control of EV-D68 in vulnerable populations, such as young children. In addition, for a megacity with very high population density and mobility, such as Beijing, the citywide implementation of the Respiratory Virus Surveillance System is critical for monitoring the epidemic or potential outbreaks of EV-D68 and other respiratory viruses and for enabling early warning. Nonpolio enterovirus and human parechovirus surveillance-United States Non-polio enterovirus: enterovirus D68 in the United States Severe respiratory illness associated with enterovirus D68-Missouri and Illinois The American-European Consensus Conference on ARDS: definitions, mechanisms, relevant outcomes, and clinical trial coordination Evaluation of the FilmArray® Respiratory Panel for clinical use in a large children's hospital Genome sequence of enterovirus D68 from Salvage microbiology': detection of bacteria directly from clinical specimens following initiation of antimicrobial treatment Initial identification and characterization of an emerging zoonotic influenza virus prior to pandemic spread Analytical characterization of an assay designed to detect and identify diverse agents of disseminated viral infection Enterovirus 68 in pediatric patients hospitalized for acute airway diseases Coxsackievirus A21, enterovirus 68, and acute respiratory tract infection Detection of enterovirus 68 as one of the commonest types of enterovirus found in patients with acute respiratory tract infection in China A comparison of three methods for detecting respiratory viruses Worldwide emergence of multiple clades of enterovirus 68 We thank the staff at Washington University in St. Louis, MO, USA, particularly Anthony Orvedahl, for assistance with EV-D68-specific PCR. We thank sentinel hospitals of the Respiratory Virus Surveillance System in Beijing for collecting samples and investigating cases. The Continuing Medical Education quizzes for 2 articles were inadvertently omitted from the April issue. The quizzes are printed at the back of this issue, and the complete articles and quizzes are available online (http://wwwnc.cdc.gov/eid/article/21/4/14-1479_intro and http://wwwnc.cdc.gov/eid/article/21/4/14-1033_intro).