Acute Flaccid Myelitis

"AFM [acute flaccid myelitis] is a priority for the CDC [Centers for Disease Control and Prevention], as we expect an outbreak this year."                                            "The virus comes in two-year cycles, it will be circulating the same time as flu and COVID-19."                                                                                                               "We do not know how the COVID 19 pandemic and social distancing measures will affect AFM; cases may be fewer, or outbreak could be delayed."                               Robert Redfield, MD, director, Centers for Disease Control and Prevention (CDC)

Kari Hoglund / iStock

What are the symptoms of acute flaccid myelitis (AFM)?

Most people with AFM will suddenly have

• Arm or leg weakness
• A loss of muscle tone and reflexes

Some people also have other symptoms, including

• Facial drooping/weakness
• Trouble moving the eyes
• Drooping eyelids
• Trouble swallowing
• Slurred speech

 

The word has gone out from the U.S. Centers for Disease Control and Prevention for parents and pediatricians to be on special alert for the appearance of a rare neurological condition afflicting children. The condition is capable of leading to long-term paralysis and even, albeit infrequently, death. Acute flaccid myelitis has been known to strike children at low levels for years, and then in 2014 serious outbreaks of the condition occurred in the U.S. when 120 children were struck by it. Since that time, the condition has appeared in steadily increased numbers every other year, late summer and fall.

This year has seen its emergence with sixteen American children diagnosed and one death resulting, to the end of July while another 38 cases are under investigation. Though the precise cause of the condition is not yet known, AFM is thought to result from a complication of a viral infection, the likeliest culprit identified as an outbreak strain of enterovirus D68. 

The most immediate symptom of its onset is muscular weakness. Once identified, children who develop the symptoms should be taken immediately to hospital. "AFM is a medical emergency that requires immediate care", cautioned CDC director Robert Redfield, explaining it to be a serious condition of the spinal cord where paralysis can develop in a matter of hours.

The concern within the agency is that in the atmosphere prevailing with the coronavirus outbreak, parents may tend to hesitate before rushing children to a doctor, choosing to wait instead to see whether the symptoms will pass and the child will recover at home. Early and aggressive physical therapy, explained Dr.Redfield, may help strengthen the muscular function retained to help avoid permanent weakness or paralysis.

Fever or respiratory difficulties may present as the initial symptoms, so common that they can readily be mistaken for preliminary symptoms of any number of oncoming illnesses. Because of the general presence of COVID-19 and fears of contracting the coronavirus there are hopes that vigilance for unusual symptoms may spike greater awareness leading to an abundance of caution. Yet fears have arisen that cautions taken to avoid coronavirus may also serve to avert, reduce or delay attention to AFM outbreaks in 2020, the year when the focus is entirely on the SARS-CoV-2 virus.

Sharing some of the same symptoms of polio, which has been eliminated from the dire conditions pool threatening humanity through a concerted vaccine eradication of the disease, patients with AFM test negative to the poliovirus. The medical community is bracing for the possibility that 2020 will turn out to be the worst year ever, given a rising number of cases with each outbreak. 

In 2018 over half of the 238 children affected required intensive care. A quarter of those children were placed on ventilators. This is a condition for which there is no cure. And which on average strikes children at age five.

How is acute flaccid myelitis (AFM) diagnosed?

AFM causes many of the same symptoms as other neurologic diseases, such as transverse myelitis and Guillain-Barre syndrome. This can make it difficult to diagnose. To make a diagnosis, a doctor

• Will do a neurologic exam, including looking at where there is weakness, poor muscle tone, and decreased reflexes
• Will look at pictures of the spinal cord and brain. This may include images from an MRI.
• May do lab tests on the cerebrospinal fluid (the fluid around the brain and spinal cord)
• May check nerve speed (nerve conduction velocity) and the response of muscles to the messages from the nerves (electromyography)

It is important that the tests are done as soon as possible after the symptoms start.

What are the treatments for acute flaccid myelitis (AFM)?

There is no specific treatment for AFM. A doctor who specializes in treating brain and spinal cord illnesses (neurologist) may recommend treatments for specific symptoms. For example, physical and/or occupational therapy may help with arm or leg weakness. Researchers do not know the long-term outcomes of people with AFM.

Can acute flaccid myelitis (AFM) be prevented?

Since the cause of AFM is unknown, there is no there is no specific way to prevent it. However, viruses may play a role in AFM, and you can take steps to help prevent getting or spreading viral infections by

• Washing hands often with soap and water
• Avoiding touching your face with unwashed hands
• Avoiding close contact with people who are sick
• Cleaning and disinfecting surfaces that you frequently touch, including toys
• Covering coughs and sneezes with a tissue or upper shirt sleeve, not hands
• Staying home when sick

Centers for Disease Control and Prevention

 

The Health and Safety Vulnerabilities of Poverty

"Simply put, poorer children are at an increased risk of getting hit by cars. Child pedestrian injury is a public health and health equity issue."
"Although progress has been made in reducing preventable pedestrian motor vehicle collisions, more work remains to be done. Our streets should be safe for all children to walk to school, to the playground or to the park."
Dr. Linda Rothman, senior research associate in child health evaluative sciences, Sick Children's Hospital, Toronto

"While in some cities children in low-income areas are more likely to walk to school, this association has not been found in previous studies in Toronto. Another potential explanation is that children from low-income families are more likely to walk to school unescorted, which may put them at increased risk of injury."
"Recent research has found differences in road safety features in high-income versus low-income areas, with more lower speed roadways and traffic-calming measures in higher income areas. A request-based process in many cities in relation to installing traffic safety features such as speed bumps may favour communities with higher income levels."
Research study, ER visits/risks of children from vehicular accidents

A new study suggests children from poorer areas of Ontario face a greater risk of getting hit by vehicles than those from wealthier areas because they are more likely to walk to school alone.  (Codie McLachlan / Star Edmonton)

Researchers from Sick Children's Hospital, York University and the Institute for Clinical Evaluative Sciences in Toronto studied available data on emergency department visits involving children from the years 2008 to 2015 who presented with injuries sustained by car accidents. The number of emergency room trips for that type of incident -- children hit by vehicles -- while having decreased by 18 percent over those years, actually increased for children from low-income neighbourhoods.

Children who live in high-income areas had 22 percent fewer visits to hospital emergency rooms as a result of being hit by cars. Whereas children from low-income neighbourhoods saw their numbers increase by 14 percent for the same reason. Authors in the study concluded that the differential between children in the highest-income areas suffering fewer hits by vehicles necessitating fewer ER visits than those in the lowest-income areas, differed by 48 percent.

Reducing health disparities with linkage to socio-economic status, point out the researchers, represents an overall social policy objective. The purpose of the study was to determine whether progress in the issue -- children getting hit by cars -- had materially advanced. Published in the April 2019 edition of the journal Injury Prevention, the study posits several possible reasons for the phenomenon without reaching a final conclusion.

New York City study

Mandating the creation of safer roads toward a safer walking environment for middle- and high-school kids who frequently walk alone, accounting for most emergency department visits after getting hit by vehicles is one potential solution, the study points out. As for younger children, benefits could be seen with well-maintained playgrounds given that a lack of such facilities could lead children to play instead in the streets, leading to greater exposure to traffic.

Strategies for the reduction of vehicle-pedestrian collision rates in poorer areas might begin by installing simple traffic-slowing measures such as the installation of speed bumps and signage urging more awareness, along with lower-speed roadways alongside traffic calming measures that tend to be seen more frequently in higher-income areas, extended equally to their lower-income counterparts.

The examined data excluded children who died at the scene of collisions, so deaths appear under-represented in the study, which found teens and pre-teens at the highest risk of being hit in traffic in the period examined, accounting for 51 and 26 percent of ER visits respectively. Additionally, the bulk -- 73 percent of incidents -- took place in cities, while the suburbs accounted for 20 percent.

"Children who are the most disadvantaged ... often live in families that don’t have a car."
"They don’t have a choice about how they get to school, how they get to go grocery shopping, etc." "They have to take care of transit and they have to walk."
Dr. Alison Macpherson, professor, York University’s School of Kinesiology and Health Sciences