Parechovirus Genotype 3 Outbreakamong Infants, New South Wales,Australia, 2013–2014Germaine Cumming, 1 Ameneh Khatami, Brendan J. McMullan, Jennie Musto, Kit Leung,Oanh Nguyen, Mark J. Ferson, Georgina Papadakis, Vicky SheppeardMedscape, LLC is pleased to provide online continuing medical education (CME) for this journal article, allowingclinicians the opportunity to earn CME credit.This activity has been planned and implemented in accordance with the Essential Areas and policies of theAccreditation Council for Continuing Medical Education through the joint providership of Medscape, LLC andEmerging Infectious Diseases. Medscape, LLC is accredited by the ACCME to provide continuing medical educationfor physicians.Medscape, LLC designates this Journal-based CME activity for a maximum of 1.0 AMA PRA Category 1Credit(s) TM . Physicians should claim only the credit commensurate with the extent of their participation in the activity.All other clinicians completing this activity will be issued a certificate of participation. To participate in this journalCME activity: (1) review the learning objectives and author disclosures; (2) study the education content; (3) take thepost-test with a 75% minimum passing score and complete the evaluation at http://www.medscape.org/journal/eid; (4)view/print certificate.Learning ObjectivesUpon completion of this activity, participants will be able to:Release date: June 15, 2015; Expiration date: June 15, 20161. Describe the clinical and epidemiologic features of an HPeV3 outbreak among Australian infants2. Compare the presentation of the HPeV3 outbreak in Australia with that in the northern hemisphere3. Determine the efficacy of active surveillance in detecting and monitoring the HPeV3 outbreakamong Australian infants.CME EditorP. Lynne Stockton, VMD, MS, ELS(D), Technical Writer/Editor, Emerging Infectious Diseases. Disclosure: P. LynneStockton, VMD, MS, ELS(D), has disclosed no relevant financial relationships.CME AuthorLaurie Barclay, MD, freelance writer and reviewer, Medscape, LLC. Disclosure: Laurie Barclay, MD, has disclosedno relevant financial relationships.AuthorsDisclosures: Germaine Cumming, MPHN; Ameneh Khatami, BHB, MB ChB, DipPaeds, MD; Brendan J.McMullan, BMed(Hons), DTMH, DCH, FRACP, FRCPA; Jennie Musto, Dip.App.Sci (Nursing), Grad.Dip.ClinicalNursing, MPH; Kit Leung, MIPH; Oanh Nguyen, MD, MCH; Mark J. Ferson, MBBS, MPH, MD, FRACP, FAFPHM,FRSPH; Georgina Papadakis, BSc; and Vicky Sheppeard, MBBS, MPH(Hons), FAFPHM, have disclosed norelevant financial relationships.Author affiliations: Health Protection New South Wales, Sydney,New South Wales, Australia (G. Cumming, J. Musto,V. Sheppeard); New South Wales Ministry of Health, Sydney(G. Cumming, K. Leung); The Children’s Hospital at Westmead,Sydney (A. Khatami); Sydney Children’s Hospital, Sydney(B.J. McMullan); University of New South Wales, Sydney(B.J. McMullan, M.J. Ferson); Western Sydney Local HealthDistrict, Sydney (O. Nguyen); South Eastern Sydney Local HealthDistrict, Sydney (M.J. Ferson); Victorian Infectious DiseaseReference Laboratory, Melbourne, Victoria, Australia (G. Papadakis)DOI: http://dx.doi.org/10.3201/eid2107.1411491Current affiliation: Independent consultant, Freshwater, NewSouth Wales, Australia1144 Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 21, No. 7, July 2015
Parechovirus Outbreak among Infants, AustraliaFrom October 2013 through February 2014, humanparechovirus genotype 3 infection was identified in 183infants in New South Wales, Australia. Of those infants,57% were male and 95% required hospitalization. Commonsigns and symptoms were fever >38°C (86%), irritability(80%), tachycardia (68%), and rash (62%). Comparedwith affected infants in the Northern Hemisphere,infants in New South Wales were slightly older, bothsexes were affected more equally, and rash occurred withconsiderably higher frequency. The New South Walessyndromic surveillance system, which uses near real-timeemergency department and ambulance data, was usefulfor monitoring the outbreak. An alert distributed to cliniciansreduced unnecessary hospitalization for patientswith suspected sepsis.The clinical manifestations of infection with humanparechoviruses (HPeVs), members of the family Picornaviridiae,are often indistinguishable from those causedby human enterovirus infections. Over the past decade, outbreaksof human parechovirus genotype 3 (HPeV3) havebeen reported from the Northern Hemisphere and are particularlywell documented in Japan (where the virus wasdiscovered), Canada, the United Kingdom, Denmark, andthe Netherlands (1–4). Of the 16 HPeV genotypes, HPeV3is the most aggressive and causes a sepsis-like syndromein neonates (5). HPeV infection seems to follow a seasonalpattern; incidence is higher in summer and autumn (2,3). Itcan be spread by the fecal–oral and respiratory routes (4).On November 22, 2013, Health Protection New SouthWales (NSW), Australia, was notified of a possible clusterof HPeV cases at The Children’s Hospital at Westmeadin Sydney. At that time, 7 neonates had experienced rapidonset of acute sepsis-like illness with fever >38°C and acombination of irritability/pain, diarrhea, confluent erythematousrash, tachycardia, tachypnea, encephalitis, myoclonicjerks, and hepatitis. Inquiries revealed that neonatesdescribed as “red, hot, angry” had also been admitted toother tertiary children’s hospitals in NSW (6). An expertadvisory group comprising staff from the NSW Ministryof Health, Health Protection NSW, public health units, andthe Sydney Children’s Hospital Network was convened tocoordinate the investigation.On November 25, 2013, PCR detection of HPeV RNAconfirmed HPeV infection in 2 of the children. The NSWpublic health network and clinicians agreed that a surveillanceprogram should be initiated to gather information onthe epidemiologic and clinical characteristics and outcomesof children with HPeV infection.In addition to the public health response, Health ProtectionNSW issued a media release to alert members ofthe public to the outbreak. On November 29, 2013, HPeV3information including a case definition, instructions foraccessing diagnostic testing, and recommended clinicalmanagement was distributed to all emergency departments,pediatricians, and early childhood health servicesin NSW. During the outbreak, the expert advisory groupmet regularly via teleconference to discuss and address anyemerging issues. HPeV3 active surveillance activities wereconcluded on January 31, 2014, while other forms of surveillancecontinued into February 2014. We describe theepidemiology of the outbreak as observed through severalsurveillance mechanisms.MethodsHPeV infection is not a notifiable disease under the PublicHealth Act 2010 (NSW). This HPeV3 outbreak was detectedand reported by clinicians alert to unusual clusters and patternsof disease. Other forms of surveillance were developedas a result of this alert. Surveillance consisted of 3 components:1) active surveillance (case finding at the sentinelsites); 2) passive surveillance (laboratory reporting of allpositive HPeV specimens from sentinel sites and elsewherein NSW to Health Protection NSW); and 3) syndromic surveillance(reporting of infants seen in emergency departmentsby the NSW syndromic surveillance system that usesnear real-time emergency department and ambulance data[7]) (Figure 1). The sentinel sites were 3 tertiary children’shospitals in NSW: The Children’s Hospital at Westmead,The Sydney Children’s Hospital Randwick, and John HunterChildren’s Hospital Newcastle. Passive and syndromicsurveillance continued into February 2014. In addition tosurveillance, public health communication in the form ofan HPeV information sheet for clinicians was distributed onNovember 29, 2013, alerting emergency department staff,pediatricians, and early childhood health service staff ofcurrent HPeV activity in NSW, providing a description ofHPeV infection, and recommending management options(i.e., early laboratory testing and provision of supportive careafter receipt of confirmation of HPeV infection).Active SurveillanceActive surveillance activities commenced at the 3 hospitals(sentinel sites) on November 25, 2013, and continuedthrough January 19, 2014; however, some retrospectivecase finding was included for cases with onset dating backto October 1, 2013, when the outbreak was thought to havestarted. A patient with a suspected case of HPeV was definedas a neonate or young infant 38.0°C and >2 of the following:irritability/pain, rash, diarrhea, tachycardia, tachypnea,encephalitis, myoclonic jerks, or hepatitis. A patient witha confirmed case of HPeV was a suspected case-patientfor whom PCR was positive for HPeV. Clinicians at thesentinel sites collected case information by using an HPeVcase investigation form and PCR testing of patient stool,cerebrospinal fluid (CSF), nasopharyngeal aspirate, throatEmerging Infectious Diseases • www.cdc.gov/eid • Vol. 21, No. 7, July 2015 1145
- Page 3 and 4: July 2015SynopsisOn the CoverMarian
- Page 5 and 6: 1240 Gastroenteritis OutbreaksCause
- Page 7 and 8: SYNOPSISDisseminated Infections wit
- Page 9 and 10: Disseminated Infections with Talaro
- Page 11 and 12: Disseminated Infections with Talaro
- Page 13 and 14: Macacine Herpesvirus 1 inLong-Taile
- Page 15 and 16: Macacine Herpesvirus 1 in Macaques,
- Page 17 and 18: Macacine Herpesvirus 1 in Macaques,
- Page 19: Macacine Herpesvirus 1 in Macaques,
- Page 23: Malaria among Young Infants, Africa
- Page 26 and 27: RESEARCHFigure 3. Dynamics of 19-kD
- Page 28 and 29: Transdermal Diagnosis of MalariaUsi
- Page 30 and 31: RESEARCHFigure 2. A) Acoustic trace
- Page 32 and 33: RESEARCHof malaria-infected mosquit
- Page 34 and 35: Lack of Transmission amongClose Con
- Page 36 and 37: RESEARCH(IFA) and microneutralizati
- Page 38 and 39: RESEARCHoropharyngeal, and serum sa
- Page 40 and 41: RESEARCH6. Assiri A, McGeer A, Perl
- Page 42 and 43: RESEARCHadvanced genomic sequencing
- Page 44 and 45: RESEARCHTable 2. Next-generation se
- Page 46 and 47: RESEARCHTable 3. Mutation analysis
- Page 48 and 49: RESEARCHReferences1. Baize S, Panne
- Page 52 and 53: RESEARCHFigure 1. Venn diagramshowi
- Page 54 and 55: RESEARCHTable 2. HPeV testing of sp
- Page 56 and 57: RESEARCHFigure 5. Distribution of h
- Page 58 and 59: RESEARCHReferences1. Selvarangan R,
- Page 60 and 61: RESEARCHthe left lobe was sampled b
- Page 62 and 63: RESEARCHTable 2. Middle East respir
- Page 64 and 65: RESEARCHseroprevalence in domestic
- Page 66 and 67: RESEARCHmeasure their current surve
- Page 68 and 69: RESEARCHTable 2. States with labora
- Page 70 and 71: RESEARCHFigure 2. Comparison of sur
- Page 72 and 73: RESEARCH9. Centers for Disease Cont
- Page 74 and 75: RESEARCHthe analyses. Cases in pers
- Page 76 and 77: RESEARCHTable 3. Sampling results (
- Page 78 and 79: RESEARCHpresence of Legionella spp.
- Page 80 and 81: Seroprevalence for Hepatitis Eand O
- Page 82 and 83: RESEARCHTable 1. Description of stu
- Page 84 and 85: RESEARCHTable 3. Crude and adjusted
- Page 86 and 87: RESEARCHrates by gender or HIV stat
- Page 88 and 89: RESEARCH25. Taha TE, Kumwenda N, Ka
- Page 90 and 91: POLICY REVIEWDutch Consensus Guidel
- Page 92 and 93: POLICY REVIEWTable 3. Comparison of
- Page 94 and 95: POLICY REVIEW6. Botelho-Nevers E, F
- Page 96 and 97: DISPATCHESFigure 1. Phylogenetic tr
- Page 98 and 99: DISPATCHESSevere Pediatric Adenovir
- Page 100 and 101:
DISPATCHESTable 1. Demographics and
- Page 102 and 103:
DISPATCHES13. Kim YJ, Hong JY, Lee
- Page 104 and 105:
DISPATCHESTable. Alignment of resid
- Page 106 and 107:
DISPATCHESFigure 2. Interaction of
- Page 108 and 109:
DISPATCHESSchmallenberg Virus Recur
- Page 110 and 111:
DISPATCHESFigure 2. Detection of Sc
- Page 112 and 113:
DISPATCHESFigure 1. Histopathologic
- Page 114:
DISPATCHESFigure 2. Detection of fo
- Page 117 and 118:
Influenza Virus Strains in the Amer
- Page 119 and 120:
Novel Arenavirus Isolates from Nama
- Page 121 and 122:
Novel Arenaviruses, Southern Africa
- Page 123 and 124:
Readability of Ebola Informationon
- Page 125 and 126:
Readability of Ebola Information on
- Page 127 and 128:
Patients under investigation for ME
- Page 129 and 130:
Patients under investigation for ME
- Page 131 and 132:
Wildlife Reservoir for Hepatitis E
- Page 133 and 134:
Asymptomatic Malaria and Other Infe
- Page 135 and 136:
Asymptomatic Malaria in Children fr
- Page 137 and 138:
Bufavirus in Wild Shrews and Nonhum
- Page 139 and 140:
Bufavirus in Wild Shrews and Nonhum
- Page 141 and 142:
Range Expansion for Rat Lungworm in
- Page 143 and 144:
Slow Clearance of Plasmodium falcip
- Page 145 and 146:
Slow Clearance of Plasmodium falcip
- Page 147 and 148:
Gastroenteritis Caused by Norovirus
- Page 149 and 150:
Ebola Virus Stability on Surfaces a
- Page 151 and 152:
Ebola Virus Stability on Surfaces a
- Page 153 and 154:
Outbreak of Ciprofloxacin-Resistant
- Page 155 and 156:
Outbreak of S. sonnei, South KoreaT
- Page 157 and 158:
Rapidly Expanding Range of Highly P
- Page 159 and 160:
Cluster of Ebola Virus Disease, Bon
- Page 161 and 162:
Cluster of Ebola Virus Disease, Lib
- Page 163 and 164:
ANOTHER DIMENSIONThe Past Is Never
- Page 165 and 166:
Measles Epidemic, Boston, Massachus
- Page 167 and 168:
LETTERSInfluenza A(H5N6)Virus Reass
- Page 169 and 170:
LETTERSsystem (8 kb-span paired-end
- Page 171 and 172:
LETTERS3. Van Hong N, Amambua-Ngwa
- Page 173 and 174:
LETTERSTable. Prevalence of Bartone
- Page 175 and 176:
LETTERSavian influenza A(H5N1) viru
- Page 177 and 178:
LETTERSprovinces and a total of 200
- Page 179 and 180:
LETTERS7. Manian FA. Bloodstream in
- Page 181 and 182:
LETTERSforward projections. N Engl
- Page 183 and 184:
LETTERS3. Guindon S, Gascuel OA. Si
- Page 185 and 186:
BOOKS AND MEDIAin the port cities o
- Page 187 and 188:
ABOUT THE COVERNorth was not intere
- Page 189 and 190:
Earning CME CreditTo obtain credit,
- Page 191:
Emerging Infectious Diseases is a p