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Factsheet for health professionals on human non-polio enterovirus infections

Factsheet

Last review/update: 28 March 2025

Case definition 

Human non-polio enterovirus (NPEV) infections are not notifiable at the European Union level and there are no standard case definitions available for diseases caused by NPEVs [1-3].

The pathogens

NPEVs are small RNA non-enveloped viruses with a single positive sense RNA strand. They belong to the genus Enterovirus within the subfamily Ensavirinae of the family Picornaviridae.

There are 15 Enterovirus species known to date. Of these, enteroviruses within species A to D and rhinoviruses within species A to C are responsible for clinical infections in humans [4]. Within the Enterovirus species A to D there are over 100 enterovirus types known to infect humans, of which the most well-known is poliovirus (within Enterovirus species C). Other enterovirus types include coxsackieviruses (CV)-A and B, echoviruses, and enteroviruses identified by numbers and letters indicating their species. 

As RNA viruses, enteroviruses can rapidly evolve genetically, resulting in the circulation of new types and new variants or recombinants [5-9].

Genetic recombination events are common among many enterovirus types and typically occur within viruses of the same species. Recombination is frequent within species A to C, but rare or absent in species D. Common recombination breakpoints are found between the 5' untranslated region (5'UTR) and the structural protein coding region, as well as between the structural and non-structural protein coding regions [9,10].

Enteroviruses enter the body via gastrointestinal or respiratory routes, initially infecting the mucosal cell layer of the mouth, nose or throat. Within the first 2–10 days, the virus replicates in these cells and spreads further to the digestive and intestinal tracts (after oral infections) or to ciliated respiratory cells (after respiratory infections). After replication in the mucosal cells, the viruses can spread further, allowing them to infect tissues such as the central nervous system, liver, heart, skin, pancreas or muscles.

Clinical features and sequelae

Enterovirus infections are often asymptomatic and are usually mild and self-limiting. Clinical diagnosis can be challenging due to the wide range of clinical signs and symptoms, which can vary from mild to severe or even life-threatening. Different enterovirus types can cause the same disease, while a single type or variant may cause different diseases.

Serious clinical signs and symptoms include:

  • paralysis (including poliomyelitis);
  • acute meningitis;
  • encephalitis;
  • myocarditis;
  • neonatal sepsis-like syndrome;
  • hepatitis;
  • gastroenteritis;
  • respiratory disease;
  • herpangina;
  • hand, foot, and mouth disease;
  • and haemorrhagic conjunctivitis [11,12].

Clinical presentations and associated enterovirus types

Severe respiratory enterovirus infections can present as pneumonia or bronchitis and are often associated with EV-D68 (in case of paralysis, respiratory disease is identified as a prodromal syndrome) and high-numbered enterovirus C types such as EV-C104, EV-C105 and EV-C109 [13-16].

Many NPEVs can cause acute flaccid myelitis (AFM), but it is most often associated with EV-D68 and EV-A71. Patients with AFM present with acute flaccid paralysis (AFP), which has a broad differential diagnosis, including Guillain-Barré syndrome and other presentations of inflammation of the spinal chord. However, it is not currently known how frequently paralysis occurs in EV-D68 infections [17,18].

CV-A6, CV-A16 and EV-A71 are the dominant enterovirus types reported in hand, foot and mouth disease patients. This is a common childhood disease where most children present with fever, an uncomplicated skin eruption on the hands and feet, and blisters or ulcerations in the mouth [19-21]. However, fatal neurological complications – such as rhombencephalitis or cardiorespiratory failure – have also been associated with EV-A71 in Asia [22,23].

Myocarditis is often associated with CV-B viruses and can be fatal in neonatal cases [24]. Echovirus 11 is a notable type among neonatal cases with hepatitis, some of which may be fatal [25-27].

Risk of severe infection

There is an increased risk of severe infection among immune naive individuals, such as neonates and young children, as well as people with immune disorders or compromised immune systems due to other conditions (such as immunotherapy or underlying disease) [12,28,29].

Several reports have shown that NPEV infection during pregnancy, in particular in immune-naive individuals lacking maternal antibodies, may results in severe pregnancy complications, still birth or failure to thrive after birth [30,31]. Severe sequelae of delayed neurological development later in life have been reported, particularly when infections occur in the first three months of life [12,32,33].

 

Epidemiology 

Enteroviruses are very common and are among the most prevalent viruses worldwide. Circulation of several enterovirus types has been documented in Europe [1-3, 5, 6, 25, 41, 43, 56, 57, 59, 62]. As mild cases are not likely to seek care, severe clinical manifestations are reported in many of these documented instances [10, 13, 14, 28, 34-37].

In temperate climates, outbreaks often occur in the summer and early fall months, though different types can predominate from year to year. Winter outbreaks have also been reported, particularly for echovirus 30, CV-A6 and EV-D68 [34]. Specific types are known to cause outbreaks every year (e.g. CV-A6) or every three to five years (e.g. echovirus 30).

In Europe, viruses of the enterovirus C species are frequently found in sewage-related surveillance programmes but are not often reported among clinical cases. In contrast, C species enteroviruses are frequently found among clinical cases in Africa [35].

Transmission

Human enteroviruses are spread from one person to the other through contact with infectious material such as faeces, fluid from blisters, or secretions (e.g. saliva, vomit, sputum or mucus), or through contaminated environmental water supplies, like swimming pools, recreational swimming areas and drinking water.

Immunocompetent individuals can shed the virus for three to six months after infection. Certain immunocompromised patients can shed the virus for years, possibly decades [29,36].

Although rare, infection of pregnant individuals can result in transmission to the baby during pregnancy or labour, or after delivery [37].

Diagnostics 

The current gold standard for enterovirus detection is real-time reverse transcription polymerase chain reaction (RT-PCR) based on the conserved 5’UTR. As detection by PCR does not distinguish between different enterovirus types, and some assays will also detect rhinoviruses due to their genetic relatedness, further characterisation is required by sequencing the capsid genes [38]. This is important to better define the disease burden of NPEVs such as EV-D68 and EV-A71.

The semi-nested CODEHOP partial VP1 assay [39] is recommended by the European non-polio enterovirus network (ENPEN) of the European Society for Clinical Virology and the Word Health Organization (WHO) [2,40]. Nowadays, next-generation sequencing methods such as Illumina and Nanopore sequencing are under continuous development and are increasingly used for enterovirus typing. Typing tools are available for rapid analysis of enterovirus sequence data generated from the VP1 gene [41]. VP2 and VP4 sequencing can also be conducted if VP1 typing fails. 

As recombination can underlie the emergence of new outbreaks, complete genome sequences can aid in defining these outbreaks and identifying the cause of increased transmission and pathogenicity [6,7,42-44].

For notable enterovirus types such as EV-D68, type-specific, real-time assays are available and allow for rapid virus identification to enable early warning and response, as well as possible emergence of cases with paralysis [45,46].

Molecular methods may fail to detect certain enterovirus types, such as EV-D68, EV-C105 and EV-C109 due to virus evolution and the primer mismatches this can cause. It is therefore important to evaluate the diagnostic methods frequently through external quality assessment (EQA) programmes and to evaluate primers and probes when new variants or types are identified [14,38,47].

Sample collection for testing

The sample type collected for testing should be selected based on the clinical presentation, diagnosis and time of disease onset. Appropriate samples for detection of enterovirus are:

  • faeces (swab);
  • respiratory samples (e.g. throat or nasopharyngeal swab and bronchoalveolar lavage (BAL));
  • vesicle fluid;
  • blood/serum;
  • cerebral spinal fluid (CSF);
  • pericardial fluid;
  • conjunctival fluid or eye swab;
  • pleura fluid;
  • urine;
  • biopsy material [2].

In cases of neurological infections, faeces and respiratory sampling should be collected in addition to a CSF sample and blood sample. While enterovirus RNA can be detected in CSF of individuals with meningitis, this is often inconsistent in encephalitis cases.

In paralysis cases, CSF is often negative and additional samples may be needed. Nasopharyngeal swab is required to detect EV-D68; however, timing the nasopharyngeal swab with the onset of paralysis is crucial.

Vesicle fluid sample is recommended in cases of hand, foot and mouth disease or other lesions [2].

Virus detection and isolation

As these viruses can be shed for long periods of time in faeces and respiratory samples, detection of the virus may not always define the aetiological link.

Enteroviruses can be cultured on enterovirus permissive cell lines, such as rhabdomyosarcoma cells (RD), HT29, monkey kidney cells and human fibroblasts.

Samples such as faeces and throat swabs are recommended for culture, but other samples – such as vesicle fluid and CSF – have also been shown to be applicable for culture. However, not all sample types can be readily cultured on these cell lines. WHO recommends that any RD-positive stool sample be further cultured on polio-permissive L20B cells [40].

ENPEN does not recommend virus isolation through cell culture for enterovirus diagnostics. However, they indicate that it can be used for certain virus types that culture well when the viral load in the sample is too low for virus typing. 

Case management and treatment 

There are no specific treatments available for NPEV infection. Supportive treatments aim to relieve symptoms. Rapid enterovirus diagnostics can reduce antibiotic use when a bacterial infection is excluded, helping to avoid unnecessary antimicrobial use [48].

Public health prevention and control measures and considerations for the authorities

Recommendations to reduce transmission:

  • Ensure access to clean water and sanitation to reduce transmission.
  • Raise awareness of the importance of good hygiene practices.

There are currently no licenced vaccines against disease caused by NPEV infection in the EU. In China, three inactivated monovalent EV-A71 vaccines have been licenced. However, the vaccines are not cross-protective to other EV types [49-51].

Infection prevention and control, and personal protective measures for healthcare facilities

Recommendations to reduce transmission in healthcare facilities include:

  • Encourage all staff, patients and visitors to the facility to maintain good hand and cough hygiene, e.g. frequent, proper handwashing and using a tissue, elbow or upper arm to cover the nose and mouth when coughing;
  • If respiratory enterovirus cases are identified, individuals with the infection and potentially susceptible individuals should use face masks to reduce airborne transmission;
  • Enure that frequently touched surfaces are properly disinfected.

References

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