MEDICAL ADVISORY: Enterovirus D68 and Acute Flaccid Paralysis 

Issued by: M. Mustafa Hirji, MD, MPH, FRCPC, Medical Officer of Health & Commissioner (Acting)

On Sept. 9, 2022, the Center for Diseases Control (CDC) in the United States issued a health advisory on increases in pediatric hospitalizations in patients with severe respiratory illness who also tested positive for rhinovirus (RV) and/or enterovirus (EV). Some specimens have been positive for enterovirus D68 (EV-D68). Concurrently, surveillance reports from the United States show a higher proportion of EV-D68 positivity in children who are RV/EV positive compared to previous years. 

EV-D68 primarily causes acute respiratory illness, which can range in severity. However, EV-D68 has also been associated with acute flaccid myelitis (AFM), a rare but serious neurologic complication involving limb weakness. AFM is a subset of acute flaccid paralysis (AFP).

Public Health Ontario labs have now confirmed that EV-D68 is present in Ontario. However, the overall cases of EV does not seem to be higher than baseline thus far. Nonetheless, health care providers are reminded of the importance of EV testing; particularly now as EV infections tend to be more common in the fall.

Testing for Enterovirus

• Laboratory testing for EV should be considered for patients with severe respiratory illness, or neurologic symptoms suspected to be associated with viral illness (e.g. meningitis/encephalitis or AFP/AFM)
• Persons of any age presenting with AFM, or any child less than 15 years of age with AFP should have laboratory investigations to detect a viral cause
• For more information on Enterovirus testing, refer to Enterovirus Test Information Index – Public Health Ontario

Reporting Requirements for Health Care Providers 

• Cases of AFP in children less than 15 years of age must be reported to the Medical Officer of Health under Ontario Regulation 135/18 and amendments of the Health Protection and Promotion Act
  • AFP is defined as: acute onset of focal weakness or paralysis characterized as flaccid (reduced tone) without other obvious cause (e.g. trauma) in children <15 years of age
    • Cases of Guillain-Barre Syndrome (GBS) should be included as cases of AFP
    • Transient weakness (e.g. post-ictal) should not be reported
• To report a disease of public health significance, contact the Infectious Disease Program at
  • 905-688-8248 at ext. 7330
  • Toll free: 1-888-505-6074
  • Emergency after-hours: 905-984-3690

More Information

• Enterovirus D68 – Public Health Ontario
• Case Definitions and Disease Specific Information: Acute Flaccid Paralysis – Ministry of Health