1969. A Case Control Study of Acute Flaccid Myelitis (AFM) and Enterovirus-D68 (EV-D68), Colorado (CO), 2014
Session: Oral Abstract Session: Emerging Public Health Threats
Saturday, October 10, 2015: 2:45 PM
Room: 25--ABC


From August-October 2014, 11 AFM cases were identified in CO during a national outbreak of EV-D68 respiratory disease.  The significance of EV-D68 detection in the nasopharynx (NP) and development of AFM is unclear.


A case-control study design compared EV-D68 detection in NP specimens from AFM cases in Colorado to controls from the same location and time period. Cases were 1-18 years old with acute focal limb weakness and MRI findings of spinal cord lesions largely restricted to gray matter with no known etiology. Controls were children of the same age with NP specimens collected at outpatient visits at CHCO for (1) respiratory viruses (RV) or (2) Bordetella pertussis (BP) testing.  Cases and controls were classified as ‘EV-D68' if EV-D68 detected by real-time RT PCR; or ‘other enterovirus' if pan EV PCR positive and EV-D68 rRT-PCR negative in NP specimens. Multivariable logistic regression controlled for significant covariates.


Ten of 11 (91%) cases had respiratory symptoms, compared to 96/123 (80%, p=0.69) of RV and 264/275 (98%, p=0.25) of BP tested controls. Cases were older than RV controls (8 vs 5 median y, p=0.04) and had specimens collected later (10 vs 5 median d, p<0.01). Cases had fever more often than BP tested controls (91% vs 34%, p<0.01). EV-D68 was detected in NP specimens of 4/11 (36%) AFM cases compared to 5/123 (4%) of RV tested controls (p<0.01) and 21/275 (8%) of BP tested controls (p<0.01).  AFM cases had 12 times higher odds of EV-D68 compared to RV tested controls, and 9 times higher odds compared to BP tested controls in adjusted multivariable models (Table). Non-EVD68 enterovirus was not associated with AFM.


Odds of EV-D68 detection in AFM cases significantly exceeded those in outpatient controls with respiratory illness during the outbreak period in CO, supporting an epidemiologic association between EV-D68 and AFM.

Adjusted multivariable models testing the association of enterovirus with AFM


RV tested controls


OR (95%CI)2

BP tested controls


OR (95%CI)3



12.4 (2.1, 81.2)¹

9.3 (1.8, 50.5)¹

Other enteroviruses

4.6 (0.6, 38.6)

2.2 (0.4, 12.0)

¹ p<0.05; 2Adjusted for age, days between symptoms and specimen collection and specimen collection week;

3adjusted for fever, specimen type and collection week


Negar Aliabadi, MD MS1, Kevin Messacar, MD2, Daniel M Pastula, MD3, Eyal Leshem, MD4, Christine C. Robinson, PhD5, William A. Nix, BS6, M Steve Oberste, PhD7, James Sejvar, MD8, Daniel Feikin, MD4 and Samuel Dominguez, MD, PhD9, (1)National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA, (2)Pediatric Infectious Diseases, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, (3)Arboviral Disease Branch, CDC, Fort Collins, CO, (4)Centers for Disease Control and Prevention, Atlanta, GA, (5)Children's Hospital Colorado, Denver, CO, (6)Polio and Picornavirus Laboratory Branch, Division of Viral Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, Atlanta, GA, (7)Polio and Picornavirus Laboratory Branch, Centers for Disease Control and Prevention, Atlanta, GA, (8)Division of High-Consequence Pathogens and Pathology, Centers for Disease Control and Prevention, Atlanta, GA, (9)Childrens Hospital Colorado, Aurora, CO


N. Aliabadi, None

K. Messacar, None

D. M. Pastula, None

E. Leshem, None

C. C. Robinson, Biofire: Scientific Advisor , Consulting fee

W. A. Nix, None

M. S. Oberste, None

J. Sejvar, None

D. Feikin, None

S. Dominguez, None

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