Recommendations for enterovirus diagnostics and characterisation within and beyond Europe

Abstract

Enteroviruses (EV) can cause severe neurological and respiratory infections, and occasionally lead to devastating outbreaks as previously demonstrated with EV-A71 and EV-D68 in Europe. However, these infections are still often underdiagnosed and EV typing data is not currently collected at European level. In order to improve EV diagnostics, collate data on severe EV infections and monitor the circulation of EV types, we have established European non-polio enterovirus network (ENPEN). First task of this cross-border network has been to ensure prompt and adequate diagnosis of these infections in Europe, and hence we present recommendations for non-polio EV detection and typing based on the consensus view of this multidisciplinary team including experts from over 20 European countries. We recommend that respiratory and stool samples in addition to cerebrospinal fluid (CSF) and blood samples are submitted for EV testing from patients with suspected neurological infections. This is vital since viruses like EV-D68 are rarely detectable in CSF or stool samples. Furthermore, reverse transcriptase PCR (RT-PCR) targeting the 5'noncoding regions (5'NCR) should be used for diagnosis of EVs due to their sensitivity, specificity and short turnaround time. Sequencing of the VP1 capsid protein gene is recommended for EV typing; EV typing cannot be based on the 5'NCR sequences due to frequent recombination events and should not rely on virus isolation. Effective and standardized laboratory diagnostics and characterisation of circulating virus strains are the first step towards effective and continuous surveillance activities, which in turn will be used to provide better estimation on EV disease burden.

Virus genotyping by massive parallel amplicon sequencing: adenovirus and enterovirus in the Norwegian MIDIA study

“…The virus type repertoire was similar to what had been previously found in other children of the same cohort, including the surprisingly high occurrence of EV‐A71 . Interestingly, although the detection primers anneal perfectly to deposited sequences of enterovirus D68, this type was not observed in our sample set—this may be related not only to the rarity of HEV‐D68 in stool, but also to the time of collection of the samples—most samples were collected between 2006 and 2009, long before the 2014‐2015 outbreaks in the USA and Europe …”

Assessment of blood enterovirus PCR testing in paediatric populations with fever without source, sepsis-like disease, or suspected meningitis: a prospective, multicentre, observational cohort study

“…1,2 Detection of enterovirus by RT-PCR from cerebrospinal fluid (CSF) specimens is recom mended for diagnosis of meningitis caused by entero virus. [3][4][5] Paediatricians are also confronted frequently with young infants with fever without source or sepsis-like diseases. These febrile illnesses account for 3·4-13·6% of cases seen in emergency departments.…”

“…Additional molecular tests are needed to speed up diagnosis of conditions asso ciated with enterovirus infections. 5 Several studies have evaluated testing blood specimens, [7][8][9][10][11][12] but as yet no assessment has been done in a large cohort of paediatric patients.…”

A fatal case of enterovirus infection with secondary hemophagocytosis—case report with review of literature

“…Serological tests are limited by the high prevalence of enteroviral infection and presence of cross‐reactivity . Molecular mechanism for enterovirus detection and serotyping by polymerase chain reaction remains a rapid, specific and sensitive method . The conserved 5′ untranslated region of the viral RNA is used to identify genus enterovirus .…”