Enterovirus D68 (EV-D68) infections are associated with severe respiratory disease and acute flaccid myelitis (AFM). The European Non-Polio Enterovirus Network (ENPEN) aimed to investigate the epidemiological and genetic characteristics of EV-D68 infections and its clinical impact during the fall-winter season of 2021-2022. From 19 European countries, 58 institutes reported 10 481 (6.8%) EV-positive samples of which 1004 (9.6%) were identified as EV-D68 (including 852 respiratory samples). Clinical data were reported for 969 cases; 78.9% of infections were reported in children (0-5 years); and 37.9% of cases were hospitalized. Acute respiratory distress was commonly noted (93.1%) followed by fever (49.4%). Neurological problems were observed in 6.4% of cases including 6 diagnosed with AFM. Phylodynamic/Nextstrain and phylogenetic analyses based on 694 sequences showed the emergence of 2 novel B3-derived lineages, with no regional clustering. In conclusion, we describe a large-scale European EV-D68 upsurge with severe clinical impact and the emergence of B3-derived lineages.

Austrian Agency for Health and Food Safety National Reference Laboratory for Poliomyelitis Vienna Austria

Center for Public Health Research Generalitat Valenciana Valencia Spain and the Spanish Research Networks Consortium of Epidemiology and Public Health Instituto de Salud Carlos 3 Madrid Spain

Centre for Infectious Disease Control Dutch National Public Health Institute Bilthoven The Netherlands

Clinic of Infectious Diseases University Hospital Prof Dr Stoyan Kirkovich AD Stara Zagora Bulgaria

Clinical and Epidemiological Virology Rega Institute Katholieke Universiteit Leuven Leuven Belgium

Clinical Microbiology Nottingham University Hospitals National Health Service Trust Nottingham United Kingdom

Commission for Polio Eradication in Germany Robert Koch Institute Berlin Germany

Danish World Health Organization National Reference Laboratory for Poliovirus Statens Serum Institut Copenhagen Denmark

Department of Biomedical Sciences for Health University of Milan Milan Italy

Department of Clinical and Molecular Medicine Norwegian University of Science and Technology Trondheim Norway

Department of Clinical Microbiology Karolinska University Hospital Stockholm Sweden

Department of Clinical Research Nordsjællands Hospital Hilleroed Denmark

Department of Clinical Surgical Diagnostic and Pediatric Sciences Università Degli Studi di Pavia Pavia Italy

Department of Health Security Expert Microbiology Unit Finnish Institute for Health and Welfare Helsinki Finland

Department of Medical Microbiology and Immunology Meander Medical Center Amersfoort The Netherlands

Department of Medical Microbiology Maasstad Hospital Rotterdam The Netherlands

Department of Medical Microbiology OrganoVIR Labs Amsterdam University Medical Centers Amsterdam The Netherlands

Department of Medical Microbiology Reinier Haga Medical Diagnostic Center Delft The Netherlands

Department of Medical Microbiology St Jansdal Hospital Harderwijk The Netherlands

Department of Medical Microbiology St Olavs Hospital Trondheim University Hospital Trondheim Norway

Department of Microbiology Oslo University Hospital Oslo Norway

Department of Microbiology Public Health Agency of Sweden Solna Sweden

Department of Microbiology Tumor and Cell Biology Karolinska Institutet Stockholm Sweden

Department of Public Health University of Copenhagen Copenhagen Denmark

Department of Virology Croatian Institute of Public Health Zagreb Croatia

Department of Virology Norwegian Institute of Public Health Oslo Norway

Department of Viroscience Erasmus Medical Center Rotterdam The Netherlands

Enteric Virus Unit UK Health Security Agency London United Kingdom

Enterovirus and Viral Gastroenteritis Lab National Centre for Microbiology Instituto de Salud Carlos 3 and the Spanish Research Networks Consortium of Epidemiology and Public Health Madrid Spain

European Non Polio Enterovirus Network

European Program for Public Health Microbiology Training European Centre for Disease Prevention and Control Stockholm Sweden

Geneva Center of Emerging Viral Diseases Geneva University Hospital and University of Geneva Geneva Switzerland

GFO Kliniken Bonn Betriebsstätte St Marien Bonn Germany

Insititute of Clinical Medicine University of Oslo Oslo Norway

Insitute of Virology Medical Faculty University Bonn Bonn Germany

Institute of Medical Microbiology and Virology University of Leipzig Leipzig Germany

Institute of Microbiology and Immunology Faculty of Medicine University of Ljubljana Ljubljana Slovenia

Institute of Microbiology and Immunology Laboratory for the Diagnosis of Viral Infections Faculty of Medicine University of Ljubljana Ljubljana Slovenia

Institute of Social and Preventive Medicine University of Bern Bern Switzerland

Institute of Virology Medical Center University of Freiburg Faculty of Medicine University of Freiburg Freiburg Germany

Labaratoire Microorganismes Génome Environnement Epidemiology and Physiopathology of Enterovirus Diseases LMGE EPIE Team Université Clermont Auvergne CNRS Clermont Ferrand France

Laboratoire de Virologie Département de Biologie des Agents Infectieux Centre Hospitalier Universitaire Angers Angers France

Laboratoire de Virologie INSERM U1259 Centre Hospitalier Régional Universitaire de Tours Tours France

Laboratoire de Virologie ULR Univ Lille Centre Hospitalier Universitaire de Lille Lille France

Laboratory for Medical Microbiology and Immunology Rijnstate Velp The Netherlands

Laboratory for Medical Microbiology and Public Health Hengelo The Netherlands

Laboratory for Medical Microbiology Eurofins PAMM Veldhoven The Netherlands

Laboratory Medical Microbiology and Immunology Admiraal de Ruijter Hospital Goes The Netherlands

Laboratory Medicine Molecular Microbiology AZ St Jan Brugge Oostende AV Bruges Belgium

Microbiology and Virology Department Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Policlinico San Matteo Pavia Italy

Microbiology and Virology Unit Department of Diagnostic Services Azienda Socio Sanitaria Territoriale della Brianza Vimercate Italy

Microbiology Department Complejo Hospitalario de Navarra Navarra Spain

Microbiology Department Donostia University Hospital and Biogipuzkoa Health Research Institute San Sebastián Spain

Microbiology Department Hospital Clínico Universitario Virgen de la Arrixaca Instituto Murciano De Investigación Biosanitaria Arrixaca Murcia University Murcia Spain

Microbiology Department Hospital Universitari de la Santa Creu i Sant Pau Universitat Autònoma de Barcelona Barcelona Spain

Microbiology Department Hospital Unviersitario La Paz Centro de Investigación Biomédica en Red de Enfermedades Infecciosas Instituto de Salud Carlos 3 Madrid Spain

Microvida Laboratory of Medical Microbiology and Immunology Elisabeth Tweesteden Hospital Tilburg The Netherlands

National Health Service Blood and Transplant Microbiology Services Colindale United Kingdom

National Laboratory of Health Environment and Food Laboratory for Public Health Virology Ljubljana Slovenia

National Public Health Center Budapest Hungary

National Reference Center for Enteroviruses and Parechoviruses Institut des Agents Infectieux Hospices Civils de Lyon Lyon France

National Reference Centre for Enteroviruses and Parechoviruses Associated Laboratory Centre Hospitalier Universitaire Clermont Ferrand Clermont Ferrand France

National Reference Centre for Gastroenteritis Viruses Laboratory of Virology Serology University Hospital of Dijon Bourgogne Dijon France

National Reference Laboratory for Enteroviruses National Center of Infectious and Parasitic Diseases Sofia Bulgaria

National Reference Laboratory for Enteroviruses National Institute of Public Health Prague Czech Republic

National Reference Laboratory for Influenza and Other Respiratory Viruses National Institute of Health Dr Ricardo Jorge Lisbon Portugal

National Reference Laboratory for Poliomyelitis and Enteroviruses Robert Koch Institute Berlin Germany

National Virus Reference Laboratory University College Dublin Dublin Ireland

Nuffield Department for Medicine University of Oxford Oxford United Kingdom

Nuffield Division of Clinical Laboratory Sciences Radcliffe Department of Medicine Oxford United Kingdom

Paediatric Hospital Medicine Department of Paediatrics Hospital Universitari Vall d'Hebron Barcelona Spain

Pediatric and Infectious Diseases Department Hospital Universtiario La Paz Fundación IdiPaz Centro de Investigación Biomédica en Red de Enfermedades Infecciosas Instituto de Salud Carlos 3 Madrid Spain

Pediatric Infectious Diseases Unit Hospital Universitario Virgen de la Arrixaca Murcia Spain

Regional Virus Laboratory Belfast Health and Social Care Trust Royal Victoria Hospital Belfast United Kingdom

Respiratory Viruses Unit Microbiology Department Vall d'Hebron Hospital Universitari Vall d'Hebron Institut of Research Vall d'Hebron Barcelona Hospital Campus Barcelona Spain

Service de Biologie Centre Hospitalier de Versailles Le Chesnay France

Swiss Institute of Bioinformatics Lausanne Switzerland

Unité de Virologie Département de Bactériologie Virologie Parasitologie Mycologie Hygiène Pôle de Biologie Pathologie Centre Hospitalier Régional et Universitaire de Brest Brest Cedex France

Virology Department Centre Hospitalier Universitaire Hôtel Dieu University Hospital Nantes France

Virology Department University Hospital of Bordeaux Bordeaux France

Virology Unit Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca' Granda Ospedale Maggiore Policlinico Milan Italy

Wolfson Centre for Global Virus Research School of Life Sciences University of Nottingham Nottingham United Kingdom

See more in PubMed

Hixon AM, Frost J, Rudy MJ, Messacar K, Clarke P, Tyler KL. Understanding enterovirus D68-induced neurologic disease: a basic science review. Viruses 2019; 11:821. PubMed PMC

Sooksawasdi Na Ayudhya S, Laksono BM, van Riel D. The pathogenesis and virulence of enterovirus-D68 infection. Virulence 2021; 12:2060–72. PubMed PMC

Elrick MJ, Pekosz A, Duggal P. Enterovirus D68 molecular and cellular biology and pathogenesis. J Biol Chem 2021; 296:100317. PubMed PMC

Zhang W, Luan R. Estimating the impact of non-pharmaceutical interventions against COVID-19 on mumps incidence in Sichuan, China. BMC Infect Dis 2021; 21:886. PubMed PMC

Larsson SB, Vracar D, Karlsson M, Ringlander J, Norder H. Epidemiology and clinical manifestations of different enterovirus and rhinovirus types show that EV-D68 may still have an impact on severity of respiratory infections. J Med Virol 2022; 94:3829–39. PubMed PMC

Zell R, Delwart E, Gorbalenya AE, et al. . ICTV virus taxonomy profile: Picornaviridae. J Gen Virol 2017; 98:2421–2. PubMed PMC

Harvala H, Broberg E, Benschop K, et al. . Recommendations for enterovirus diagnostics and characterisation within and beyond Europe. J Clin Virol 2018; 101:11–7. PubMed

Andres C, Vila J, Creus-Costa A, et al. . Enterovirus D68 in hospitalized children, Barcelona, Spain, 2014–2021. Emerg Infect Dis 2022; 28:1327–31. PubMed PMC

Meijer A, van der Sanden S, Snijders BE, et al. . Emergence and epidemic occurrence of enterovirus 68 respiratory infections in The Netherlands in 2010. Virology 2012; 423:49–57. PubMed

Piralla A, Lilleri D, Sarasini A, et al. . Human rhinovirus and human respiratory enterovirus (EV68 and EV104) infections in hospitalized patients in Italy, 2008–2009. Diagn Microbiol Infect Dis 2012; 73:162–7. PubMed

Poelman R, Schuffenecker I, Van Leer-Buter C, et al. . European surveillance for enterovirus D68 during the emerging North-American outbreak in 2014. J Clin Virol 2015; 71:1–9. PubMed

Fischer TK, Simmonds P, Harvala H. The importance of enterovirus surveillance in a post-polio world. Lancet Infect Dis 2022; 22:e35–40. PubMed

Kramer R, Sabatier M, Wirth T, et al. . Molecular diversity and biennial circulation of enterovirus D68: a systematic screening study in Lyon, France, 2010 to 2016. Euro Surveill 2018; 23:1700711. PubMed PMC

Cottrell S, Moore C, Perry M, Hilvers E, Williams C, Shankar AG. Prospective enterovirus D68 (EV-D68) surveillance from September 2015 to November 2018 indicates a current wave of activity in Wales. Euro Surveill 2018; 23:1800578. PubMed PMC

Hodcroft EB, Dyrdak R, Andres C, et al. . Evolution, geographic spreading, and demographic distribution of enterovirus D68. PLoS Pathog 2022; 18:e1010515. PubMed PMC

Holm-Hansen CC, Midgley SE, Fischer TK. Global emergence of enterovirus D68: a systematic review. Lancet Infect Dis 2016; 16:e64–75. PubMed

Xiang Z, Wang J. Enterovirus D68 and human respiratory infections. Semin Respir Crit Care Med 2016; 37:578–85. PubMed PMC

Messacar K, Tyler KL. Enterovirus D68-associated acute flaccid myelitis: rising to the clinical and research challenges. JAMA 2019; 321:831–2. PubMed PMC

Helfferich J, de Lange MM, Benschop KS, et al. . Epidemiology of acute flaccid myelitis in children in The Netherlands, 2014 to 2019. Euro Surveill 2022; 27:2200157. PubMed PMC

Lang M, Mirand A, Savy N, et al. . Acute flaccid paralysis following enterovirus D68 associated pneumonia, France, 2014. Euro Surveill 2014; 19:20952. PubMed

Pfeiffer HC, Bragstad K, Skram MK, et al. . Two cases of acute severe flaccid myelitis associated with enterovirus D68 infection in children, Norway, autumn 2014. Euro Surveill 2015; 20:21062. PubMed

Midgley SE, Benschop K, Dyrdak R, et al. . Co-circulation of multiple enterovirus D68 subclades, including a novel B3 cluster, across Europe in a season of expected low prevalence, 2019/20. Euro Surveill 2020; 25:1900749. PubMed PMC

Benschop KS, Albert J, Anton A, et al. . Re-emergence of enterovirus D68 in Europe after easing the COVID-19 lockdown, September 2021. Euro Surveill 2021; 26:2100998. PubMed PMC

Benschop KSM, Broberg EK, Hodcroft E, et al. . Molecular epidemiology and evolutionary trajectory of emerging echovirus 30, Europe. Emerg Infect Dis 2021; 27:1616–26. PubMed PMC

Huddleston J, Hadfield J, Sibley TR, et al. . Augur: a bioinformatics toolkit for phylogenetic analyses of human pathogens. J Open Source Softw 2021; 6:2906. PubMed PMC

Kumar S, Stecher G, Tamura K. MEGA7: molecular evolutionary genetics analysis version 7.0 for bigger datasets. Mol Biol Evol 2016; 33:1870–4. PubMed PMC

Simmonds P. SSE: a nucleotide and amino acid sequence analysis platform. BMC Res Notes 2012; 5:50. PubMed PMC

Tedcastle A, Wilton T, Pegg E, et al. . Detection of enterovirus D68 in wastewater samples from the UK between July and November 2021. Viruses 2022; 14:143. PubMed PMC

Park SW, Pons-Salort M, Messacar K, et al. . Epidemiological dynamics of enterovirus D68 in the United States and implications for acute flaccid myelitis. Sci Transl Med 2021; 13:eabd2400. PubMed

van Summeren J, Meijer A, Aspelund G, et al. . Low levels of respiratory syncytial virus activity in Europe during the 2020/21 season: what can we expect in the coming summer and autumn/winter? Euro Surveill 2021; 26:2100639. PubMed PMC

Wang LP, Han JY, Zhou SX, et al. . The changing pattern of enteric pathogen infections in China during the COVID-19 pandemic: a nation-wide observational study. Lancet Reg Health West Pac 2021; 16:100268. PubMed PMC

Liu P, Xu M, Lu L, et al. . The changing pattern of common respiratory and enteric viruses among outpatient children in Shanghai, China: two years of the COVID-19 pandemic. J Med Virol 2022; 94:4696–703. PubMed PMC

Olsen SJ, Winn AK, Budd AP, et al. . Changes in influenza and other respiratory virus activity during the COVID-19 pandemic-United States, 2020–2021. Am J Transplant 2021; 21:3481–6. PubMed PMC

Honemann M, Thiem S, Bergs S, et al. . In-depth analysis of the re-emergence of respiratory syncytial virus at a tertiary care hospital in Germany in the summer of 2021 after the alleviation of non-pharmaceutical interventions due to the SARS-CoV-2 pandemic. Viruses 2023; 15:877. PubMed PMC

Cassidy H, Poelman R, Knoester M, Van Leer-Buter CC, Niesters HGM. Enterovirus D68—the new polio? Front Microbiol 2018; 9:2677. PubMed PMC

Penela-Sanchez D, Gonzalez-de-Audicana J, Armero G, et al. . Lower respiratory tract infection and genus enterovirus in children requiring intensive care: clinical manifestations and impact of viral co-infections. Viruses 2021; 13:2059. PubMed PMC

Freeman MC, Wells AI, Ciomperlik-Patton J, et al. . Respiratory and intestinal epithelial cells exhibit differential susceptibility and innate immune responses to contemporary EV-D68 isolates. Elife 2021; 10:e66687. PubMed PMC

Giardina FAM, Piralla A, Ferrari G, Zavaglio F, Cassaniti I, Baldanti F. Molecular epidemiology of rhinovirus/enterovirus and their role on cause severe and prolonged infection in hospitalized patients. Microorganisms 2022; 10:755. PubMed PMC

Sinclair W, Omar M. Enterovirus. StatPearls. Treasure Island, FL: StatPearls Publishing, 2022. PubMed

Christy A, Messacar K. Acute flaccid myelitis associated with enterovirus D68: a review. J Child Neurol 2019; 34:511–6. PubMed

Knoester M, Helfferich J, Poelman R, et al. . Twenty-nine cases of enterovirus-D68-associated acute flaccid myelitis in Europe 2016: a case series and epidemiologic overview. Pediatr Infect Dis J 2019; 38:16–21. PubMed PMC

Helfferich J, Knoester M, Van Leer-Buter CC, et al. . Acute flaccid myelitis and enterovirus D68: lessons from the past and present. Eur J Pediatr 2019; 178:1305–15. PubMed PMC

Murphy OC, Messacar K, Benson L, et al. . Acute flaccid myelitis: cause, diagnosis, and management. Lancet 2021; 397:334–46. PubMed PMC

Rha B, Curns AT, Lively JY, et al. . Respiratory syncytial virus-associated hospitalizations among young children: 2015–2016. Pediatrics 2020; 146:e20193611. PubMed

Chen Z, Schiffman M, Herrero R, et al. . Classification and evolution of human papillomavirus genome variants: alpha-5 (HPV26, 51, 69, 82), alpha-6 (HPV30, 53, 56, 66), alpha-11 (HPV34, 73), alpha-13 (HPV54) and alpha-3 (HPV61). Virology 2018; 516:86–101. PubMed PMC

Graf T, Bello G, Venas TMM, et al. . Identification of a novel SARS-CoV-2 P.1 sub-lineage in Brazil provides new insights about the mechanisms of emergence of variants of concern. Virus Evol 2021; 7:veab091. PubMed PMC

Huang C, Yu J, Hause BM, et al. . Emergence of new phylogenetic lineage of influenza D virus with broad antigenicity in California, United States. Emerg Microbes Infect 2021; 10:739–42. PubMed PMC

Nix WA, Oberste MS, Pallansch MA. Sensitive, seminested PCR amplification of VP1 sequences for direct identification of all enterovirus serotypes from original clinical specimens. J Clin Microbiol 2006; 44:2698–704. PubMed PMC