The Ohio State University Helps Us Understand and Treat Acute Flaccid Myelitis
Infection Control Can Prevent Paralysis
When the curriculum for my advanced degree in preventive medicine was first offered at The Ohio State University, the material was highly focused on infection control, including in hospitals and the general public health realm.
The material has saved many individuals from serious infections and even death, but it may also help prevent the paralysis caused by a mysterious condition known to us as acute flaccid myelitis.
Acute means "sudden onset" and "severe", flaccid means "unmoving and limp", and myelitis means "infection of nerves" like the spinal cord.
A Troubling Paralytic Disease
Throughout the month of October 2018, media outlets reported a troubling increase in U.S. cases of acute flaccid myelitis (AFM).
This condition is similar to poliomyelitis, which was once called “infantile paralysis.” Polio was eradicated fully from America in the 1979, but AFM produces a similar paralysis in children and a few adults, although it is not caused by the same virus (poliovirus).
While medical experts and the news media reported a scrambling among professionals to find the causes of AFM, The Ohio State University looked more closely, as did the Centers for Disease Control and Prevention (CDC).
Until a Cause and Cure are Found
To date, the paralytic symptoms of AFM are treated with such methods as blood plasma replacement and immunoglobulin IV administration. Some patients recover to varying degrees, but others do not. Until better methods are discovered, it is best to practice infection control, including:
- Wash your hands often and avoid people who are ill with respiratory illnesses. If you or children you have are sick, stay/keep them home. When sick around others, please cover your coughs and sneezes and wash your hands afterward. Use disinfectant wipes as well. Use disposable tissues instead of cloth handkerchiefs and discard them quickly.
- If you change diapers of either children or adults, please wash your hands thoroughly before touching anything else, including your own face, eyes, nose, or mouth. In the bathroom, keep the toilet bowl lid closed when not in use and clean the toilet regularly, followed by thorough hand washing.
- Do not lick your fingers and use them to turn pages in books in libraries and other public venues - even at home; do not use saliva-covered fingers to open plastic grocery store bags or money when you are a check-our cashier.; do not use saliva covered fingers to smooth out a anyone's hair, etc. Remember that you may not be sick, but may be a carrier of infection, in the manner of Typhoid Mary.
- Do not sit on, allow anyone else to sit on, or change diapers on kitchen counters, dining room table tops, etc. Infectious elements pass (are shed through) one's clothing onto these surfaces. Use different cloths or paper towels to clean chair seats and table tops/counter tops. In fact, in one of my local suburbs, this is the law for restaurants and other eating/drinking places.
- Do not drink from the same glass or cup or eat off the plate of another person, even a communal cup at church communion.
- Do not taste dishes you are cooking and put the spoon back into the food. Do not dunk food into a dip at a party and stick the same piece of food back into the dip.
- Instead of shaking hands with anyone, use the "fist bump." This includes friends and relatives.
- Do not purchase wood or plastic cutting boards from thrift stores and flea markets. They may be already-used and harbor infectious elements in the accumulated cuts on the surface - even bleach will not eradicate them all. After purchasing new boards, make sure to prevent cross contamination by reserving one board for vegetables (and possibly beef or pork, but to be safe I have another board for those two) and a separate board for chicken (all fowls).
- If you are pregnant, a senior citizen, or immuno-compromised, ask your doctor how best to be safe from infections.
If you have other useful advice in this vein, please list it for us in "Comments" below.
What Does Acute Flaccid Myelitis Do?
AFM affects the spinal cord, a bit in the manner of multiple sclerosis, which causes scarring in spots in the spinal cord and the brain. AFM causes inflammation of motor nerves (neurons) and usually within gray matter, which can lead to partial or full paralysis. It may be an autoimmune disease like MS, and associated with some trigger stimulus, but that idea is still in debate.
While it occurs most frequently in young children, largely per-schoolers, a few adults succumb.
Resulting paralysis is said to be "quick-evolving", developing in about four to seven days.However, in 2018, we are hearing from distraught mothers telling us that their child goes to bed with a cold and awakens with paralysis of at least one limb and in one case, the entire body below the neck.
Although AFM may mimic other infections of the central nervous system, it is different in that the infection seems to occur cyclically with spikes in even-numbered years. To date, we do not know why, but because the infection rate is only about 1/1,000,000 people overall, government and private funding for related research are not likely to increase.
Explaining the Cyclical Nature of the Disease
No research has been done as of Autumn 2018 into the two-year life cycle of insects that might somehow be associated with AFM disease. These insects may be the vectors that carry infectious organisms like bacteria and viruses and include:
- Two-year-cycle budworm: Choristoneura biennis, native to Eurasia. This insect eats pine trees in Western Canada and is not likely to be at fault.
- Two-year cicada: This is a possibility. In addition, many cicadas have a one-year life cycle but appear in massive quantities at intervals, such as two years or longer.
- Species Heteroptera: Aradus cinnamomea. This insect looks like a tick and some ticks carry diseases. This one is called the "pine flat bug", native to the Eastern Hemisphere at least from the UK across northern Europe to Siberia. It eats wood and spreads quickly if an infested woodpile is moved.
- Species Lepidoptera: Dozens of different insects like butterflies and moths. A few are native to North America and some are native to both North America and Siberia. Could butterflies carry disease(s) that harm our children?
Species Diptera: Chironomus anthracinus. This is a fly native to the Eastern Hemisphere. Some flies carry diseases.
- Species Hymenoptera: Neodiprion sertifer, the pine sawfly found in North America since 1925.
- Species Coleopter: Saperda populnea, a beetle found in North America and elsewhere.
Insect related spread of infections is an ongoing research concern at the Ohio State University and we may see some work there in the area of AFM in the future.
Possible Causes of Acute Flaccid Myelitis
A lot of static from speculation has surrounded AFM since medical concern arose in 2012. Proposed causes for the disease have included:
- Poliovirus (quickly eliminated as a possibility)
- Various childhood vaccines (eliminated quickly as a cause)
- Avian flu
- Bed bugs as carriers. This suggestion came from some in the non-medical population of Central Ohio and no resulting research has involved bed bugs.
- Coxsackievirus A16: Found by CDC in only four out of 430 cases. This is not enough to prove a correlation.
- Non-Polio Enterovirus Type EV-A71: Found in only four out of 430 cases.
- Non-Polio Enterovirus Type EV-D68: Found in only four out of 430 cases. However a large outbreak of enteroviral respiratory infections in America occurred during the time that AFM hit hard in 2014. We may or may not have a cause in EV-D68, although some researchers at OSU believe so, pending further investigation.
- West Nile Virus: Believed to be a cause by the California Department of Public Health.
- An as-yet unknown virus or bacteria carried by mosquitoes or other vectors (insects, mammals, birds, fish, etc).
Note: From 2014 though 2018, at least 90% of patients suffered cold-like symptoms before acquiring AFM—either a respiratory infection, a fever, or both.
CDC will conduct routine testing and typing of CSF (cerebrospinal fluid), respiratory specimens and stool for enterovirus/rhinovirus, and poliovirus testing of stool specimens to rule out the presence of poliovirus. Additional testing protocols are being developed...— CDC, as of November 20, 2018
Few Markers Found for Causes
Whatever the cause(s) of the disease, a consensus among researchers at CDC, OSU, and other sites seems to be that AMF can be passed through feces and/or blood, and can be detected in sputum and spinal fluid.Tears, nasal mucus, saliva, and blister fluids may also contain a related infectious element. However the infectious elements for which these tissues are tested has turned up little evidence for a cause.
Additional tissue specimens for testing included flash-frozen sections of brain/spinal cord tissues (including gray and white matter), heart, lung, liver, kidney, and other organ tissues. New testing may be developed.
Most cases of this disease occur during three months from August - October and spike during even-numbered years.
Infection Statistics for AFM
Number of U.S. Cases
Number of Deaths
10 cases in California
Unknown, but a total of 59 from 2012 through 2015 in California
2014: August 1 - December 31
2 adults, ages 55 and 73
At least one child, acknowledged by CDC.
2018 to November 20
At least two children, reported by parents on social media.
Facebook group for parents of children with AFM: "A.F.M.-Acute Flaccid Myelitis Awareness, Our Generation's Polio" https://www.facebook.com/groups/afmawareness/
"The incidence of EV-D68 infections is increasing world-wide...Application of the Bradford Hill criteria supported a causal relationship between EV-D68 and AFM."
-- A. Dyda, et.al.; 2018
While this is true, not many cases support this evidence yet. We look for corroboration in the next few years.
Hope for a Cause and Cure From Government Health Agencies
The U.S. Epidemic Intelligence Service (EIS) has been called onto the AFM case by the CDC in 2018.
Concerned parents of children who have died from AFM or are suffering the debilitating symptoms of the disease may feel led to contact new personnel assigned to work on infections transmitted from animals to humans.
The EIS Class of 2018 includes new two-year fellowship personnel who may find themselves investigating the condition or stumbling across pertinent information in the course of other investigations. These people are:
National Center for Emerging and Zoonotic Infectious Diseases
- Emily McDonald, MD, MPH:
- Ana Bardossy, MD
- Danica Gomes, MD, MSc
- Alexandra Medley, DVM, MPH
Division of Foodborne, Waterborne, and Environmental Diseases
- Erin Conners, PhD, MPH
- Radhika Gharpure, DVM, MPH
- Mary Pomeroy, MSN
- Pryanka Relan, MD, MPH
- John Rossow, DVM, MPH
Division of Vector-Borne Diseases
- Christopher Prestel, MD: Division of Healthcare Quality Promotion
- Maya Ramaswamy, PhD, MS: Division of Preparedness and Emerging Infections
- Sukarma Tanwar, MBBS, MScPH, MMED: Division of Healthcare Quality Promotion
- Erin Whitehouse, PhD, MPH: Division of High-Consequence Pathogens and Pathology
National Center for Immunization and Respiratory Diseases
- Nicole Brown, PhD:, Division of Bacterial Diseases
- Eric Chow, MD, MPH, MS: Influenza Division
- Benjamin Hallowell, PhD, MPH Division of Viral Diseases
- Osato Idubor, MD, MHS: Division of Bacterial Diseases
- Chandresh Ladva, PhD, MPH: Influenza Division
- Olivia McGovern, PhD, MS: Division of Bacterial Diseases
- Heather Reese, PhD, MPH: Division of Bacterial Diseases
Center for Global Health, Division of Vector-Borne Diseases
- Velma Lopez, PhD, MPH
- Cohen, E. 13 November 2018. Parents accuse CDC of not reporting children's deaths from polio-like AFM. CNN. Retrieved November 19, 2018.
- Dyda, A. et.al. (2018). The association between acute flaccid myelitis (AFM) and Enterovirus D68 (EV-D68) - what is the evidence for causation? Euro Surveillance 23(3).
- Messacar, K., M.D. et.al. (2018). Enterovirus D68 and acute flaccid myelitis—evaluating the evidence for causality. The Lancet 18(8), e239-e247.
- Schwab, J., MD, PhD. 18 October 2018. What is acute flaccid myelitis (AFM)? The Ohio State University Wexner Medical Center Blog. Retrieved November 16, 2018.
- Tinker, B. 5 October 2016. What is the polio-like illness paralyzing US children? CNN Health. Retrieved November 16, 2018.
© 2018 Patty Inglish MS