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Adenovirus: More than just another viral illness
The mother of three looked tired and little worried. She wasn’t one to bring her kids to the pediatrician’s office with every minor illness, but her youngest had 3 days of fever, runny nose, cough, and little of her normal energy.
The pediatrician entered the room and smiled sympathetically.
“We ran tests for flu and RSV [respiratory syncytial virus] and it’s neither of those so. ...”
“So it’s just a virus that we don’t routinely test for and it’s going to need to run its course,” the mother finished his sentence. She knew the drill.
Before the doctor could leave the room though, the mother had one more question. “You don’t think it could be adenovirus do you?”
Most years, influenza and RSV command center stage, and adenovirus is relegated to the wings. It is not so much lack of disease or morbidity, but rather lack of recognition. Yes, we all learned in medical school that it is a cause of epidemic keratoconjunctivitis, but many adenoviral infections are clinically indistinguishable from infections caused by other viruses. Common symptoms – fever, cough, sore throat, and malaise – overlap with those caused by influenza. Like rhinovirus, adenovirus can cause common cold symptoms. Like RSV, it can cause bronchiolitis. Just like parainfluenza, it can cause croup. It can cause a pertussislike syndrome with prolonged cough, and enteric adenoviruses, especially types 40 and 41, cause gastroenteritis that mimics norovirus or rotavirus infection.
Testing for adenovirus is not readily available or routine in most pediatricians’ offices, and while many hospitals and reference labs offer adenovirus polymerase chain reaction testing as part of a comprehensive respiratory virus panel, the test can be expensive and unlikely to change management in most ambulatory patients. This makes it difficult to count the number of adenoviruses annually.
This winter though, adenovirus was in the news ... repeatedly. In November 2018, CBS News reported that a University of Maryland freshman had died of an adenovirus-related illness. The family of Olivia Paregol told reporters that she was being treated for Crohn’s disease. Immune suppression is one recognized risk factor for more severe adenoviral disease; underlying heart and lung disease are others. Testing at the Centers for Disease Control and Prevention revealed that the student and several others on campus were infected with adenovirus type 7, a strain that has been associated with outbreaks of acute, severe respiratory illness in military recruits. As of Jan. 24, 2019, university officials reported 42 confirmed cases of adenovirus in University of Maryland students, 13 of which were confirmed as adenovirus 7.
Adenovirus type 7 also caused an outbreak at a pediatric long-term care facility in New Jersey late last year. Between Sept. 26 and Nov. 11, 2018, 36 residents and 1 staff member became ill. Eleven individuals died. In an unrelated outbreak at a second pediatric long-term care facility, 17 residents were affected between Oct. 20 and Dec. 10, 2018. Adenovirus 3 was identified and all children recovered.
Between October 2013 and July 2014, public health officials in Oregon identified an increase in adenoviral infections in people with respiratory illness. Sixty-nine percent were hospitalized (136/198), 31% needed intensive care, and 18% were mechanically ventilated. Multiple types of adenovirus were recovered but the most common was adenovirus 7 (Emerg Infect Dis. 2016. doi: 10.3201/eid2206.151898).
Depending on your perspective, measures to prevent the spread of adenovirus are elegantly simple, evidence-based, public health intervention or maddeningly little more than common sense. Wash your hands often with soap and water. Avoid touching your eyes, mouth, and nose with unwashed hands. Avoid close contact with people who are sick. The latter is easier if those who are sick stay home. Prior to the start of the most recent academic semester at the University of Maryland, university officials urged students who were sick not to return to campus but to stay at home to rest and recover. Those who fell ill on campus were urged to return home via nonpublic transportation if possible. Those who stayed on campus were advised to stay in their living spaces and clean high-touch surfaces with bleach. Like other nonenveloped viruses, adenovirus is not easily destroyed by many commonly used disinfectants. Under ideal conditions, it can survive on surfaces – remaining infectious – for up to 3 months.
Back at the pediatrician’s office, “We need an adenovirus vaccine,” the mother said as she picked up her child and headed for the door.
There is, in fact, a live oral vaccine that protects against adenovirus types 4 and 7. It is only approved for use in United States military personnel aged 17-50 years and it is given to all recruits as soon as they enter basic training. It works too. Before vaccine was available, up to 80% of recruits became infected during their initial training, half of those developing significant illness and a quarter being hospitalized. When the current vaccine was introduced in 2011, there was a 100-fold decrease in adenovirus-related disease burden (from 5.8 to 0.02 cases per 1,000 person-weeks, P less than .0001). That translates to 1 death, 1,100-2,700 hospitalizations and 13,000 febrile illnesses prevented each year (Clin Infect Dis. 2014 Oct 1. doi: 10.1093/cid/ciu507).
Some experts have suggested that adenovirus vaccine could be useful in civilian populations, too, but I question what the public reception would be. We have safe influenza vaccines that reduce the need for hospitalization and reduce mortality from influenza, but we still can’t convince some people to immunize themselves and their children. In the last 4 years, flu vaccination rates among children have remained just shy of 60% and adult rates are even lower. Collectively, we don’t seem to be ready to relinquish – or at least diminish – the annual suffering that goes with flu. I have to wonder if the same would be true for adenovirus.
Dr. Bryant is a pediatrician specializing in infectious diseases at the University of Louisville (Ky.) and Norton Children’s Hospital, also in Louisville. She said she had no relevant financial disclosures. Email her at pdnews@mdedge.com.
The mother of three looked tired and little worried. She wasn’t one to bring her kids to the pediatrician’s office with every minor illness, but her youngest had 3 days of fever, runny nose, cough, and little of her normal energy.
The pediatrician entered the room and smiled sympathetically.
“We ran tests for flu and RSV [respiratory syncytial virus] and it’s neither of those so. ...”
“So it’s just a virus that we don’t routinely test for and it’s going to need to run its course,” the mother finished his sentence. She knew the drill.
Before the doctor could leave the room though, the mother had one more question. “You don’t think it could be adenovirus do you?”
Most years, influenza and RSV command center stage, and adenovirus is relegated to the wings. It is not so much lack of disease or morbidity, but rather lack of recognition. Yes, we all learned in medical school that it is a cause of epidemic keratoconjunctivitis, but many adenoviral infections are clinically indistinguishable from infections caused by other viruses. Common symptoms – fever, cough, sore throat, and malaise – overlap with those caused by influenza. Like rhinovirus, adenovirus can cause common cold symptoms. Like RSV, it can cause bronchiolitis. Just like parainfluenza, it can cause croup. It can cause a pertussislike syndrome with prolonged cough, and enteric adenoviruses, especially types 40 and 41, cause gastroenteritis that mimics norovirus or rotavirus infection.
Testing for adenovirus is not readily available or routine in most pediatricians’ offices, and while many hospitals and reference labs offer adenovirus polymerase chain reaction testing as part of a comprehensive respiratory virus panel, the test can be expensive and unlikely to change management in most ambulatory patients. This makes it difficult to count the number of adenoviruses annually.
This winter though, adenovirus was in the news ... repeatedly. In November 2018, CBS News reported that a University of Maryland freshman had died of an adenovirus-related illness. The family of Olivia Paregol told reporters that she was being treated for Crohn’s disease. Immune suppression is one recognized risk factor for more severe adenoviral disease; underlying heart and lung disease are others. Testing at the Centers for Disease Control and Prevention revealed that the student and several others on campus were infected with adenovirus type 7, a strain that has been associated with outbreaks of acute, severe respiratory illness in military recruits. As of Jan. 24, 2019, university officials reported 42 confirmed cases of adenovirus in University of Maryland students, 13 of which were confirmed as adenovirus 7.
Adenovirus type 7 also caused an outbreak at a pediatric long-term care facility in New Jersey late last year. Between Sept. 26 and Nov. 11, 2018, 36 residents and 1 staff member became ill. Eleven individuals died. In an unrelated outbreak at a second pediatric long-term care facility, 17 residents were affected between Oct. 20 and Dec. 10, 2018. Adenovirus 3 was identified and all children recovered.
Between October 2013 and July 2014, public health officials in Oregon identified an increase in adenoviral infections in people with respiratory illness. Sixty-nine percent were hospitalized (136/198), 31% needed intensive care, and 18% were mechanically ventilated. Multiple types of adenovirus were recovered but the most common was adenovirus 7 (Emerg Infect Dis. 2016. doi: 10.3201/eid2206.151898).
Depending on your perspective, measures to prevent the spread of adenovirus are elegantly simple, evidence-based, public health intervention or maddeningly little more than common sense. Wash your hands often with soap and water. Avoid touching your eyes, mouth, and nose with unwashed hands. Avoid close contact with people who are sick. The latter is easier if those who are sick stay home. Prior to the start of the most recent academic semester at the University of Maryland, university officials urged students who were sick not to return to campus but to stay at home to rest and recover. Those who fell ill on campus were urged to return home via nonpublic transportation if possible. Those who stayed on campus were advised to stay in their living spaces and clean high-touch surfaces with bleach. Like other nonenveloped viruses, adenovirus is not easily destroyed by many commonly used disinfectants. Under ideal conditions, it can survive on surfaces – remaining infectious – for up to 3 months.
Back at the pediatrician’s office, “We need an adenovirus vaccine,” the mother said as she picked up her child and headed for the door.
There is, in fact, a live oral vaccine that protects against adenovirus types 4 and 7. It is only approved for use in United States military personnel aged 17-50 years and it is given to all recruits as soon as they enter basic training. It works too. Before vaccine was available, up to 80% of recruits became infected during their initial training, half of those developing significant illness and a quarter being hospitalized. When the current vaccine was introduced in 2011, there was a 100-fold decrease in adenovirus-related disease burden (from 5.8 to 0.02 cases per 1,000 person-weeks, P less than .0001). That translates to 1 death, 1,100-2,700 hospitalizations and 13,000 febrile illnesses prevented each year (Clin Infect Dis. 2014 Oct 1. doi: 10.1093/cid/ciu507).
Some experts have suggested that adenovirus vaccine could be useful in civilian populations, too, but I question what the public reception would be. We have safe influenza vaccines that reduce the need for hospitalization and reduce mortality from influenza, but we still can’t convince some people to immunize themselves and their children. In the last 4 years, flu vaccination rates among children have remained just shy of 60% and adult rates are even lower. Collectively, we don’t seem to be ready to relinquish – or at least diminish – the annual suffering that goes with flu. I have to wonder if the same would be true for adenovirus.
Dr. Bryant is a pediatrician specializing in infectious diseases at the University of Louisville (Ky.) and Norton Children’s Hospital, also in Louisville. She said she had no relevant financial disclosures. Email her at pdnews@mdedge.com.
The mother of three looked tired and little worried. She wasn’t one to bring her kids to the pediatrician’s office with every minor illness, but her youngest had 3 days of fever, runny nose, cough, and little of her normal energy.
The pediatrician entered the room and smiled sympathetically.
“We ran tests for flu and RSV [respiratory syncytial virus] and it’s neither of those so. ...”
“So it’s just a virus that we don’t routinely test for and it’s going to need to run its course,” the mother finished his sentence. She knew the drill.
Before the doctor could leave the room though, the mother had one more question. “You don’t think it could be adenovirus do you?”
Most years, influenza and RSV command center stage, and adenovirus is relegated to the wings. It is not so much lack of disease or morbidity, but rather lack of recognition. Yes, we all learned in medical school that it is a cause of epidemic keratoconjunctivitis, but many adenoviral infections are clinically indistinguishable from infections caused by other viruses. Common symptoms – fever, cough, sore throat, and malaise – overlap with those caused by influenza. Like rhinovirus, adenovirus can cause common cold symptoms. Like RSV, it can cause bronchiolitis. Just like parainfluenza, it can cause croup. It can cause a pertussislike syndrome with prolonged cough, and enteric adenoviruses, especially types 40 and 41, cause gastroenteritis that mimics norovirus or rotavirus infection.
Testing for adenovirus is not readily available or routine in most pediatricians’ offices, and while many hospitals and reference labs offer adenovirus polymerase chain reaction testing as part of a comprehensive respiratory virus panel, the test can be expensive and unlikely to change management in most ambulatory patients. This makes it difficult to count the number of adenoviruses annually.
This winter though, adenovirus was in the news ... repeatedly. In November 2018, CBS News reported that a University of Maryland freshman had died of an adenovirus-related illness. The family of Olivia Paregol told reporters that she was being treated for Crohn’s disease. Immune suppression is one recognized risk factor for more severe adenoviral disease; underlying heart and lung disease are others. Testing at the Centers for Disease Control and Prevention revealed that the student and several others on campus were infected with adenovirus type 7, a strain that has been associated with outbreaks of acute, severe respiratory illness in military recruits. As of Jan. 24, 2019, university officials reported 42 confirmed cases of adenovirus in University of Maryland students, 13 of which were confirmed as adenovirus 7.
Adenovirus type 7 also caused an outbreak at a pediatric long-term care facility in New Jersey late last year. Between Sept. 26 and Nov. 11, 2018, 36 residents and 1 staff member became ill. Eleven individuals died. In an unrelated outbreak at a second pediatric long-term care facility, 17 residents were affected between Oct. 20 and Dec. 10, 2018. Adenovirus 3 was identified and all children recovered.
Between October 2013 and July 2014, public health officials in Oregon identified an increase in adenoviral infections in people with respiratory illness. Sixty-nine percent were hospitalized (136/198), 31% needed intensive care, and 18% were mechanically ventilated. Multiple types of adenovirus were recovered but the most common was adenovirus 7 (Emerg Infect Dis. 2016. doi: 10.3201/eid2206.151898).
Depending on your perspective, measures to prevent the spread of adenovirus are elegantly simple, evidence-based, public health intervention or maddeningly little more than common sense. Wash your hands often with soap and water. Avoid touching your eyes, mouth, and nose with unwashed hands. Avoid close contact with people who are sick. The latter is easier if those who are sick stay home. Prior to the start of the most recent academic semester at the University of Maryland, university officials urged students who were sick not to return to campus but to stay at home to rest and recover. Those who fell ill on campus were urged to return home via nonpublic transportation if possible. Those who stayed on campus were advised to stay in their living spaces and clean high-touch surfaces with bleach. Like other nonenveloped viruses, adenovirus is not easily destroyed by many commonly used disinfectants. Under ideal conditions, it can survive on surfaces – remaining infectious – for up to 3 months.
Back at the pediatrician’s office, “We need an adenovirus vaccine,” the mother said as she picked up her child and headed for the door.
There is, in fact, a live oral vaccine that protects against adenovirus types 4 and 7. It is only approved for use in United States military personnel aged 17-50 years and it is given to all recruits as soon as they enter basic training. It works too. Before vaccine was available, up to 80% of recruits became infected during their initial training, half of those developing significant illness and a quarter being hospitalized. When the current vaccine was introduced in 2011, there was a 100-fold decrease in adenovirus-related disease burden (from 5.8 to 0.02 cases per 1,000 person-weeks, P less than .0001). That translates to 1 death, 1,100-2,700 hospitalizations and 13,000 febrile illnesses prevented each year (Clin Infect Dis. 2014 Oct 1. doi: 10.1093/cid/ciu507).
Some experts have suggested that adenovirus vaccine could be useful in civilian populations, too, but I question what the public reception would be. We have safe influenza vaccines that reduce the need for hospitalization and reduce mortality from influenza, but we still can’t convince some people to immunize themselves and their children. In the last 4 years, flu vaccination rates among children have remained just shy of 60% and adult rates are even lower. Collectively, we don’t seem to be ready to relinquish – or at least diminish – the annual suffering that goes with flu. I have to wonder if the same would be true for adenovirus.
Dr. Bryant is a pediatrician specializing in infectious diseases at the University of Louisville (Ky.) and Norton Children’s Hospital, also in Louisville. She said she had no relevant financial disclosures. Email her at pdnews@mdedge.com.