Transcript for CDC Telebriefing: Update on Acute Flaccid Myelitis (AFM) in the U.S. (11/13/2018)

Press Briefing Transcript

Tuesday, November 13, 2018

Please Note: This transcript is not edited and may contain errors.

OPERATOR: Welcome.  And thank you for standing by.  Today’s conference will begin momentarily.  Please continue to hold.  Once again, today’s conference will begin momentarily.  Please continue to hold.  Thank you.

OPERATOR:  Welcome.  And thank you for standing by.  All participants will be on a listen-only mode until the question and answer session of today’s conference.  At that time, you may press star, then 1, to ask a question from the phone lines.  Also, today’s conference is being recorded.  If you have any objections, you may disconnect at this time.  I would now like to turn the conference over to your host, Ms. Kathy Harben.  Thank you, ma’am.  You may now begin.

KATHY HARBEN: Thank you, Katie.  And thank you everyone for joining us today for an update on acute flaccid myelitis, also called AFM, the current outbreak in the United States. We are joined by Dr. Nancy Messonnier, director for the National Center for Immunizations and Respiratory Diseases. She will have opening remarks and then we’ll open up the line for Q & A.

NANCY MESSONNIER: Great.  Good afternoon, and thank you for joining us today to talk about acute flaccid myelitis or AFM.  It’s been about a month since my last telebriefing with you.  I want to give you an update on what we know about this year’s  cases, which is being released today in an MMWR early release.  Also I want to update you on what CDC is doing to understand what triggers AFM in some children.  I’ll start by talking about the early release.  The report details the 80 confirmed cases as of Monday, November 5: Most were children; particularly between 2 and 8 years old; about half were male; almost all reported fever and/or respiratory illness in the three to 10 days before limb weakness.  In almost all patients, an upper limb was involved. About half had only upper limb involvement. CDC has tested 125 spinal cord fluid respiratory and stool specimens from 71 of the 80 confirmed AFM cases.  Of the respiratory and stool specimens tested, about half were positive for enterovirus or rhinovirus, including EVA-71 and EVD-68.  The spinal cord fluid was positive in two cases.  One had evidence of EVA-71, and one had evidence of EVD-68.  One of the cases was in an adult who was on immune-suppressive medication and the other was in a child who had very rapid progression of paralysis.  It is important to put these two cases in context.  Since 2014, we have tested spinal cord fluid of most AFM cases, and in only a few have we identified a pathogen.  When a pathogen is found in the spinal fluid, it is good evidence that it was the cause of a patient’s illness.  However, oftentimes, despite extensive testing, no pathogens are found in the spinal fluid.  This may be because the pathogen has been cleared by the body or it is in hiding in tissues that make it difficult to detect.  Another possibility is that the pathogen triggers an immune response in the body that causes damage to the spinal cord.  We know that most patients with AFM have fever and/or respiratory symptoms before developing AFM.  However, at this time of year, many children have fever and respiratory symptoms.  Most of them do not go on to develop AFM.  We’re trying to figure out what the triggers are that would cause someone to develop AFM.  Later today, we also plan to update our website with the latest case counts.  As of today, we have 252 patients under investigation, which is an increase of 33 patients under investigation since last week.  We have confirmed an additional 10 cases to bring the total confirmed AFM case count to 90 in 27 states.  So far there have been no deaths among AFM patients reported to CDC in 2018.  We’ve gotten a lot of questions in the past few weeks about how cases are confirmed and if we’re catching all AFM cases.  Later today, the Council of State and Territorial Epidemiologists or CSTE, is releasing a statementpdf iconexternal icon about this that reiterates that all states consider AFM to be reportable and they’re working closely with CDC to detect and track patients.  I also think it’s helpful to understand how we classify a new case, meaning how a patient goes from being a patient under investigation to a confirmed case.  After a doctor suspects a patient has AFM, the doctor sends the patient’s medical information and radiological images to their health department.  The health department sends that information to CDC.  And then CDC staff and a network of AFM expert neurologists classify patients and confirm a case.  This process for confirming new AFM cases can take a week to a few weeks to complete.  Classifying cases is important, as we try to figure out what triggers AFM, and we’re working to expedite the process.  But taking care of the patient is the number one priority for doctors and the health department.  We want doctors to treat their patients and consult medical experts if necessary without waiting for the classification results.  Lastly, I want to talk about some of the things CDC has been doing to address AFM.  We have funded state health departments to increase physician awareness in identifying tracked cases.  We have increased our network of neurologists to assist with and confirm cases.  We’re working with health departments to cross-reference their list of AFM cases with their death registry, even from previous years, to see if patients from previous years have died.  We have established an AFM task force of national experts in multiple disciplines to help us develop a comprehensive research agenda to further understand why AFM affects some children.  This task force includes multiple academic researchers and other partners who are looking into the trigger for AFM.  We have collaborated closely with these researchers since 2014 and will continue to do so.  Finally, since 2014, we have been working with clinicians treating AFM patients.  In the next day or two, we are posting updated considerations for clinical management that reflect the significant experience of those clinicians.  Unfortunately, because we don’t yet know the cause of all AFM cases, these considerations are not as specific as we would like.  There are currently no targeted therapies or interventions with enough evidence to endorse or discover their use.  We recommend clinicians expedite neurology and infectious disease consultations to discuss treatment and management considerations.  As a mom, I know what it’s like to be scared for your child, and I understand parents want answers.  CDC is a science-driven agency.  Right now the science doesn’t give us an answer.  That’s why we at CDC, along with all our partners, will keep looking for answers.  Thank you.  I would be happy to take questions.

OPERATOR: Thank you.  If you would like to ask a question from the phone lines, please press star, then 1, unmute your phone and record your name when prompted.  If you need to withdraw your question, please press star, then 2.  Once again, if you would like to ask a question from the phone lines, please press star, then 1, and record your name when prompted.  One moment, please, while questions queue up.  The first question today comes from Helen Branswell with STAT, your line is now open.

>> Hi, thanks for taking my question.  Doctor, I was wondering if you could give us more of a sense of why it is you think — or the CDC thinks you don’t have the answer yet on this one.  I mean, I know you just said that you only found enteroviruses in the cerebral spinal fluid in two of the patients.  But after your last press conference, a lot of experts came forward to say they thought that, you know, it was pretty clear that EVA-71 were the cause of this problem.  Why is it that you guys feel that that’s really not the case?  Or at least not proven at this point?

NANCY MESSONNIER: We have learned a lot about AFM since 2014, but there are things that we still don’t understand.  In 2014, when we first found the peak in AFM, there was a large outbreak of EVD-68, enterovirus D-68 occurring.  That outbreak was really severe.  Emergency rooms, intensive care units were flooded.  So, of course, in 2014, we really focused on EVD-68 as the cause of AFM.  But in 2016, when we saw the next peak of AFM, we weren’t having a large outbreak of EVD-68 or of EVA-71.  And now in 2018, we’re also not seeing an increase in EVD-68 or EVA-71.  That’s why we think that it’s important to continue to evaluate EVD-68, but we also think we need to be looking more broadly to figure out what’s triggering AFM.

OPERATOR: Our next question comes from Betsy Mckay with the “Wall Street Journal.”  your line is now open.

>> Hi.  Thanks, Dr. Messonnier.  I wanted to follow up on Helen’s question.  Is it pretty clear, at least, that the cause is viral?  I mean, are you — is CDC, you know, confident about that?  Or do you think there’s still — are you still, you know, casting a pretty wide net?  And then secondly, I just wanted to ask in regards to the update, it seems like quite a large number of cases you’ve been investigating recently.  So is there an uptick from October, or, you know, where are things in the kind of — the curve this season?

NANCY MESSONNIER:  Right.  So let me start with that first question.  As I said, we’ve learned a lot about AFM since 2014.  As we report in the MMWR, most of these patients have a fever or — and/or respiratory infection three to 10 days before the onset of limb weakness.  And fever and respiratory infections are certainly classic symptoms of respiratory viral disease.  At this time of year, lots of kids have fever and respiratory infection.  What we don’t know is what’s triggering AFM.  It may be one of the viruses that we’ve already detected.  It may be a virus that we haven’t yet detected.  Or it could be that the virus is kicking off another process and it’s actually triggering through an autoimmune process, AFM.  Those are all hypotheses that we’re looking closely at.  In terms of the curve, it would certainly be premature to project how many cases we’re going to see this season.  But so far, the curve from 2018 looks similar to 2016 and to 2014.  We’ve been working really hard this year to make sure that clinicians know about AFM so they can detect it and report it to the health department.  And certainly we know that that kind of increase awareness sometimes can increase the reporting of cases and result in increased case numbers.

OPERATOR: our next question comes from Mike Stobbe with the associated press.  Your line is now open.

>> Hi.  Thank you for taking my call.  Doctor, the children that had the confirmed cases, how long has their paralysis lasted?  And is that different than they experienced in 2014, 2016?  And also, could you just clarify for us — you made a point of talking about the spinal fluid.  Why is that more important than finding it in other fluids in the body?  Thank you.

NANCY MESSONNIER: Let me take the second one first.  In spinal fluid in a healthy person, you don’t find a pathogen.  So certainly finding a pathogen in the spinal fluid points to that pathogen as causing the disease.  But other fluids, for example, nasal pharyngeal swabs can harbor lots of pathogens, even in children that are mostly healthy.  So we do look more closely at things like spinal fluid, because if we took a swab and looked at lots of healthy people in the united states, we would find other things that they’re carrying that aren’t making them sick.  And the first question — can you repeat the first question?

MIKE STOBBE: Sure.  Paralysis.  How long are kids suffering this paralysis?  Are they all recovering?  And is the timing of that different than what you all saw in 2014 and 2016?

NANCY MESSONNIER: Yeah, thank you for that question.  We generally know that some patients recover fully from AFM.  But at least half of the patients don’t recover.  And some of those patients have actually really serious swelling.  Unfortunately, we have not been following every AFM patient.  It’s a gap in our understanding of AFM that we don’t understand the long-term consequences in every patient.  And it’s something we’re going to be really looking at really closely, both for the patients this year and also to follow up the patients that have gotten AFM in previous years.

OPERATOR: Our next question comes from Tom Avril with “Philadelphia Inquirer.”  Your line is now open.

>> Hi.  Thank you so much.  I was wondering if you could comment on — they did those mouse studies out of colorado, i’m sure you’re familiar with, where they took the EVD-68 virus and they injected it into the animals, and they suffered limb paralysis.  So isn’t that a fairly — I know a mouse is not a human, but isn’t that a fairly strong piece of evidence?

NANCY MESSONNIER: As you said, a mouse is not a human.  We know that EVD-68, as well as other enteroviruses can cause limb weakness.  What we don’t know is what is triggering AFM in the majority of these patients.  There’s lots of great research that’s been going on by CDC as well as its many partners, and we want to take advantage of all of that research to understand what’s triggering AFM in every one of these patients.

OPERATOR: Once again, if you would like to ask a question from the phone lines, please press star, then 1 and record your name when prompted.  Our next question comes from Maggie Fox with nbc news.  Your line is now open.

>> Hi.  Thanks.  Can you talk a little bit more about the process that might underlie an immune response to a viral infection?  And does that mean something like polio is also an immune response, or are there two different ways viruses can cause AFM?  And I also have a follow-up.  Thank you.

NANCY MESSONNIER:  There are more than one way that a virus can cause limb weakness.  Polio virus is more a direct impact of the virus.  With AFM, one of the things we don’t completely understand is what is triggering the AFM.  It’s possible it’s a direct effect of one of the viruses we’ve already found.  It’s possible it’s a virus we haven’t found yet.  It’s also possible that the infection is triggering the body’s own immune response, and it’s actually the immune response that’s causing the AFM.  These are a variety of the hypothesis that we are considering, and certainly one of the things we’re going to be asking our AFM task force to help us think through, what are the possible triggers for AFM, and what science should we be doing to try to answer the question of what’s triggering AFM.

MAGGIE FOX: And can I also ask what’s not triggering AFM?  There is still a lot of discussion on social media about vaccines.  And I’ve noticed you’ve dropped the word “toxin.”

NANCY MESSONNIER: yep.  So we’re working really hard to investigate every one of the cases from this year as well as in the previous years.  In general, we have a list of hypotheses, and based on the epidemiology, the fact that most states in the United States have had cases of AFM, toxins are certainly lower on our list of causes.  But we’re not ruling anything out at this point.  In terms of vaccination, many of these kids have been vaccinated.  It’s certainly something we’re going to be investigating.  But for now, we continue to recommend that all children get their childhood vaccines, as CDC recommends.

OPERATOR: Our next question comes from Elizabeth Cohen with CNN.  Your line is now open.

>>Hi. Dr. Messonnier, I have two quick questions.  And then a larger question.  Of the 252 PUIs and 90 confirmed, is it 252 plus 90 or are 90 a part of the 252?

NANCY MESSONNIER:  90 is part of the 252.

ELIZABETH COHEN: okay, perfect.  And did you say there were two deaths in 2018 or did you say there were no deaths in 2018?

NANCY MESSONNIER: So far in 2018, among the patients reported to CDC, we have not had any reported deaths.

Elizabeth Cohen: Okay.  Have you had any deaths among patients — deaths in 2018 from patients who were diagnosed in previous years?

NANCY MESSONNIER: So as I said, one of the gaps in our program is that we don’t have long-term follow up on every one of these patients.  It’s something that we’re working to correct.  And one of the things that we’re asking our health departments to do is to match their list of AFM patients against their death registries to make sure that we’re identifying any deaths that have been the result of AFM.  We’re going to be looking really closely at these patients to try to understand what the long-term consequences are of this illness.

OPERATOR: Our next question comes from lena sun with the “Washington Post.”  your line is now open.

>> Thanks, Dr. Messonnier, for taking the question.  I actually have a couple things I just want to clarify.  So how strongly are you looking at the autoimmune response hypothesis?  When we spoke not that long ago, you said that that’s what CDC was homing in on.  And today I was wondering whether you were backing off of that a little bit and making the possibility that it was more viral.  That’s one question.  The second question is, if there’s no presence of the EVD in the spinal fluid, and that’s what we’re using for sort of causation, then polio virus has — is also not very easily isolated in spinal fluid, but yet that is known to be, you know, the virus is what causes the paralysis.  And the third question is, i just want to clarify.  So is now CDC going to be following up every single confirmed EVD — AFM case to determine what is going on with recovery and when people get better or not?

NANCY MESSONNIER: So let me take these one by one.  I guess I am sorry if there was a misunderstanding when I talked about the autoimmune hypothesis.  We certainly haven’t backed off on the idea that this is an infectious pathogen directly causing it.  But we’re broadening our hypotheses.  So, again, in 2014, we’re very focused on EVD-68.  In 2016, we were again focused very much on identifying a pathogen.  In 2018, we’re trying to think more broadly, both about whether it’s a pathogen directly or whether it also could be some kind of autoimmune disease.  And so we’re broadening the kind of tests we’re doing.  We’re also working with a variety of partners to make sure that our hypotheses are valid and also that we have the right kind of studies in place to make sure that we can evaluate these hypotheses.  In terms of spinal fluid, again, I’m sorry if I wasn’t clear.  Like I was asked about what the significance was of finding it in the spinal fluid versus finding it in a nonsterile site, I was trying to make the distinction it’s easier to interpret if it’s found in the spinal fluid versus found in a nonsterile site.  Most of these patients have a fever and respiratory illness three to 10 days before the onset of AFM.  But the specimens are being taken when they present with limb weakness.  So it is possible that we’re  missing the pathogen because we’re getting — they’re testing at the point when — for that limb weakness.  Not at the point when their illness occurs.  It’s possible that our testing is not sophisticated enough.  It’s possible that the pathogen is hiding somewhere.  And so that’s a distinction I was trying to make with spinal fluid.  Polio testing nowadays certainly doesn’t look at spinal fluid, because we know that finding polio in the gastrointestinal track tells us that a patient has polio.  We haven’t yet figured out AFM to understand completely what the significance is in finding it in respiratory specimens.  And finally, yes, we hope to be able to follow all of these patients — the patients that are having onset of disease in 2018, as well as the patients who had onset of disease in previous years to fully understand the consequences of their illness.

OPERATOR: our next question comes from Rob Stein with the National Public Radio.  Your line is now open.

>> Hi, thanks for taking my questions.  Two questions.  One is, can you just remind us what the total numbers of cases were in 2016 and 2018?  And also, just more broadly, how worried should, you know, people and parents be about this condition?

NANCY MESSONNIER: Let me do the second one first.  As a mom myself, I can certainly understand why parents are worried.  I am concerned about this increase in AFM.  It is important for parents to realize that this still is a relatively rare condition.  If parents have concerns about their child, they should reach out quickly to their physician and get their child evaluated.  In terms of the second — the first question, in 2014, there were 120 confirmed AFM cases.  In 2016, there were 149.  In 2015 there were 22.  I think we have time for one more question.

OPERATOR: Our final question today comes from Amy Brenburn with CBS News.  Your line is now open.

>> Hi.  Thanks for taking my call.  Could you just give us, again — you’ve touched on it, but some context to that 54% finding in the virus.  So you’re saying that not finding it is not indicative that it’s something health — that, you know, it just may mean that the virus is cleared or it’s difficult to find it?  That’s the first question.  And then is it similar to what you found in 2014 and 2016?  And then I also just want to ask if you could talk a little bit about the mechanism of the immune response.  Is it that — is one theory that you’re the — the immune system is finding something similar in the spinal system or in the spinal cord that — that is also present in the virus?

NANCY MESSONNIER: Right.  So let me take the last one first, and just say that it’s a really great question.  And that’s exactly what we’re trying to figure out.  How an autoimmune disease might cause these symptoms.  It’s one of the reasons we’ve convened this task force, to be able to have the right set of expertise to think broadly across all this hypothesis and make sure we’re doing the appropriate testing.  And you’re asking about the 54%.  And I think you said it correctly.  We’re not sure if the reason we’re not finding pathogens in all of these patients is because it’s cleared, is because it’s hiding, is it because it’s something we haven’t tested for.  Similarly, even in the patients that we’re finding a pathogen, we’re not sure yet if that pathogen is directly the cause of their AFM.  What we do know is that these patients have fever, respiratory symptoms, three to 10 days before their limb weakness.  And we know that it’s the season where lots of people have fever and respiratory symptoms.  What we need to sort out is what is the trigger for the AFM.

KATHY HARBEN: Okay.  Thank you, Dr. Messonnier, for joining us today.  Thank you also to the reporters who have joined.  If you have follow up questions, please call the CDC press office at 404-639-3286.  You can also e-mail us at  Thank you very much for joining us.  This concludes our call.

OPERATOR: That concludes today’s conference.  Thank you for your participation.  You may disconnect at this time.


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