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Research Letter |

Resource Burden During the 2014 Enterovirus D68 Respiratory Disease Outbreak at Children’s Hospital Colorado An Unexpected Strain

Kevin Messacar, MD1,2,3; Stephen M. M. Hawkins, MD2,4; Joyce Baker, MBA, RRT-NPS, AE-C2; Kelly Pearce, BA2,5; Suhong Tong, MS2; Samuel R. Dominguez, MD, PhD2,3,5; Sarah Parker, MD2,3,5
[+] Author Affiliations
1Section of Hospital Medicine, Children’s Hospital Colorado, University of Colorado, Aurora
2Department of Pediatrics, Children’s Hospital Colorado, University of Colorado, Aurora
3Section of Infectious Diseases, Children’s Hospital Colorado, University of Colorado, Aurora
4Section of Pulmonary Medicine, Children’s Hospital Colorado, University of Colorado, Aurora
5Department of Epidemiology, Children’s Hospital Colorado, University of Colorado, Aurora
JAMA Pediatr. 2016;170(3):294-297. doi:10.1001/jamapediatrics.2015.3879.
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This study describes the resource burden of the 2014 outbreak of enterovirus D68 respiratory disease at a children’s hospital.

Enterovirus D68 (EV-D68) is a unique enterovirus that shares biological properties with human rhinoviruses.1 It primarily causes respiratory disease, particularly in children with asthma. Although rarely reported from 1970 to 2005, small clusters of EV-D68 respiratory disease have been increasingly reported since 2008.2,3 From August to November 2014, an outbreak of EV-D68 respiratory disease occurred throughout the United States, with 1153 microbiologically confirmed infections in 49 states.4,5 However, owing to marked underascertainment of cases, the true magnitude and impact of this outbreak are difficult to estimate. The objective of this study is to characterize and quantify the resource burden at a tertiary care children’s hospital during the 2014 EV-D68 respiratory disease outbreak.

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Figure 1.
Respiratory Virus Testing at Children’s Hospital Colorado in 2014

The numbers of respiratory specimens testing positive for viral pathogens on multiplex respiratory pathogen panel polymerase chain reaction testing (Biofire Diagnostics) at Children’s Hospital Colorado by week in 2014 are depicted by colored lines corresponding to the left axis. Of note, this technology detects rhinoviruses and enteroviruses but cannot differentiate the two. For pediatric intensive care unit (PICU) patients, the numbers of rhinovirus/enterovirus-positive respiratory specimens typed as enterovirus D68 by real-time reverse transcription–polymerase chain reaction at the Centers for Disease Control and Prevention Polio and Picornavirus Laboratory by week are depicted by bars corresponding to the right axis. During this period, 564 of 971 children (58%) tested by multiplex respiratory pathogen panel polymerase chain reaction testing at Children’s Hospital Colorado had results positive for rhinoviruses/enteroviruses. Among 156 rhinovirus/enterovirus-positive specimens from PICU patients tested with real-time enterovirus D68 reverse transcription–polymerase chain reaction, 98 (63%) were positive during this period.

aThe defined outbreak period from August 1 to September 30, 2014.

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Figure 2.
Observed vs Expected Resource Utilization at Children’s Hospital Colorado During the 2014 Enterovirus D68 Outbreak

Expected monthly resource utilization at Children’s Hospital Colorado, forecasted by seasonal autoregressive integrated moving average (SARIMA) time series analysis with 95% CIs compared with actual observed values from January 2011 to November 2014. The shaded area indicates the defined outbreak period from August 1 to September 30, 2014. A-C, Respiratory patient volumes, including emergency department visits (A), hospital admissions (B), and pediatric intensive care unit admissions (C) with International Classification of Diseases, Ninth Revision codes within major diagnostic category 4 (diseases and disorders of the respiratory system). D-F, Rates of medication use, including albuterol sulfate (D), steroids (E), and secondary asthma medications (parenteral terbutaline sulfate, parenteral magnesium sulfate, and parenteral or oral aminophylline) (F). G-I, Rates of respiratory equipment use, including ventilator days (G), noninvasive positive airway pressure ventilation days (H), and intermittent positive airway pressure therapy administrations (I). J-L, Staffing demands, including inhaled medication administrations (J), respiratory therapist units of service (K), and respiratory therapist units of service per hour worked (L).

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