WHO reported in July 2023 that Member States within the European Region had notified the organisation of cases of enterovirus Echovirus 11 (E-11) among newborns. The statement indicated that, on the 26th June 2023 cases had been confirmed in Croatia, Italy, Spain, Sweden, and the UK. Prior to these reports, France had notified WHO of cases as well. In each Member State investigations and public health responses are being implemented. Although working with “limited information”, WHO described the general population health risk as “low”. However, countries are encouraged to monitor for and report on cases. 

“Health facilities caring for newborns should familiarise themselves with the signs and symptoms of echovirus and maintain vigilance for potential healthcare-associated infections and outbreaks.”  
What is E-11? 

The European Centre for Disease Prevention and Control (ECDC) describes enteroviruses as a group that can cause several infectious illnesses, which are “usually mild”. However, if they infect the central nervous system, they can have severe consequences. The most common enteroviruses are echovirus and coxsackievirus. 

E-11 is a positive-strand RNA virus, associated with a “wide spectrum of illnesses” that range from mild symptoms to severe neurological disorders. It is particularly dangerous in neonates and infants and can be transmitted vertically from mother to child.  

The current situation 

On 5th May 2023 France reported an increase in cases of severe neonatal sepsis associated with E11. In total 9 cases of neonatal sepsis with hepatic impairment and multi-organ failure with 7 deaths were reported across 4 hospitals. Since France’s report, Croatia, Italy, Spain, Sweden, and the UK have reported cases.  

Several other countries, including Austria, the Netherlands, and Norway, have reported no increase in cases of E-11. The ECDC and WHO held a collaborative with Member States to assess the situation and encourage all Member States to collaborate on further information sharing.  

The risk assessment and advice 

With limited information WHO has assessed the public health risk for the general population to be low, yet asymptomatic carriage and shedding of infectious viruses are a feature of enterovirus infection. WHO also states that although some countries have enterovirus surveillance in place there is no systematic, European-wide enterovirus surveillance across the Region. Therefore, it is “difficult” to understand the extent of current infections or background rates in the population.  

WHO suggests that non-polio enteroviruses are “common and distributed worldwide”. Despite many infections being asymptomatic, some may present with respiratory tract infections. Some reported cases had fever and apnoea and progressed to hepatocellular and renal failure within neonatal sepsis presentation.  

The advice from WHO is that clinicians who manage neonates and young infants presenting with circulatory shock should “consider an underlying diagnosis of sepsis” and respond with “appropriate diagnostic investigations, including enterovirus testing.  

Health workers working with samples suspected to contain non-polio enteroviruses should be adequately trained, and appropriate regulations must be followed. Furthermore, laboratories that perform sequencing are encouraged to consider sharing genetic sequence data through publicly accessible databases.  

Although there is currently no specific antiviral therapy for echovirus infection, health facilities are reminded to familiarise staff with the signs and symptoms so that treatment, which focuses on “preventing complications”, can be delivered.  

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