Enterovirus

Consistent with O. Reg. 671/92 of the French Language Services Act, laboratory testing information on this page is only available in English because it is scientific or technical in nature and is for use only by qualified health care providers and not by members of the public.

Background

This page provides testing information for Enterovirus detection and molecular serotyping, including those associated with acute flaccid paralysis (AFP)/acute flaccid myelitis (AFM) (e.g. serotypes D68 and A71) accepted at Public Health Ontario (PHO). For information regarding other testing options, refer to the following PHO webpages: Poliovirus

Updates

Added clarification that blood samples submitted for Molecular serotyping requires Microbiologist approval

*Uncontrolled print copy. Valid only on day of print: 21 Nov 2024.

Testing Indications

Laboratory testing for Enterovirus should be considered for patients with severe respiratory illness, neurologic symptoms suspected to be associated with viral illness (e.g. meningitis/encephalitis or AFP/AFM) or myocarditis.

Testing of skin or mucosal lesions in patients with suspected Enterovirus illness, such as hand, foot, and mouth disease, is not recommended, as this is usually a self-limiting illness. However testing is available if clinically required.

Molecular serotyping is available at PHO and should be requested on Enterovirus positive from cases with complicated or atypical illness, such as severe respiratory infection (e.g. requiring ICU admission or fatal infection), neurological complications such as AFP/AFM, or myocarditis. If Enterovirus is suspected, and serotyping is required, please clearly indicate this on the requisition.

For any suspected cases of Polio, contact Public Health Ontario to discuss testing guidelines and provide notification. Please refer to Poliovirus webpage for laboratory testing of suspected cases of polio or other causes of acute flaccid paralysis.

In addition, PHO may conduct molecular serotyping on a selection of Enterovirus-positive specimens to assist with Enterovirus molecular surveillance

Additional Testing Guideline for AFP/AFM at PHO’S Laboratory

Persons of any age presenting with AFM, or any child less than 15 years of age with AFP should have laboratory investigations to detect an infectious cause. Screening for viral pathogens may also be indicated for other neurological presentations where viral infection is on the differential diagnosis.

Testing should include enterovirus detection, followed by enterovirus molecular serotyping if positive. See below for specimen collection instructions for stool, respiratory, and cerebrospinal fluid (CSF) specimens and testing information.

Additionally, testing for Campylobacter should be performed if Guillain-Barre syndrome is suspected. Please refer to Enteric – Bacterial Culture Test Information Sheet for specimen collection instructions and testing information. Indicate on the test requisition “Campylobacter testing” in the Test(s) Requested field.

When submitting specimens from patients with neurological presentation, it is important to document the neurological symptoms on the laboratory requisition form, so the appropriate testing can be ordered.

Specimen Collection and Handling

Specimen Requirements

Test Requested	Required Requisition(s)	Specimen Type	Minimum Volume	Collection Kit
Any of the following: Enterovirus PCR EV-D68 Enterovirus molecular subtyping	General Test Requisition	Unpreserved stool	1.0 gram	Virus – Enteric Kit order#: 390087
Any of the following: Enterovirus PCR EV-D68 Enterovirus molecular subtyping	General Test Requisition	Nasal, nasopharyngeal or throat swabs.	1 swab in transport media provided in the kit	Virus Respiratory Kit order#: 390082
Any of the following: Enterovirus PCR EV-D68 Enterovirus molecular subtyping	General Test Requisition	Bronchoalveolar lavage (BAL)/bronchial wash (BW), pleural fluid, sputum	2.0 ml	Sterile container
Any of the following: Enterovirus PCR EV-D68 Enterovirus molecular subtyping	General Test Requisition	Skin lesion swabs	1 swab in transport media provided in the kit	Virus Culture Kit order#: 390081

Submission and Collection Notes

Label the specimen container with the patient’s full name, date of collection and one other unique identifier such as the patient’s date of birth or health card number. For additional information see: Criteria for Acceptance of Patient Specimens. Failure to provide this information may result in rejection or testing delay.

Complete the following fields of the General Test Requisition Form if diagnostic testing is requested:

Patient setting
Relevant clinical findings including severe respiratory illness, neurological complication [e.g. acute flaccid paralysis (AFP)/myelitis (AFM)]
Symptom onset date
Travel history
Sick contacts
Outbreak number if applicable

If specific testing for EV-D68 is required this must be indicated on PHO’s requisition form.

Testing blood and tissue specimens for Enterovirus testing requires approval from a PHO Microbiologist. Prior to specimen submission, contact PHO’s laboratory Customer Service Center at 416-235-6556 or 1-877-604-4567 for approval.

Storage and Transport

Specimens should be stored at 2-8°C following collection and shipped to PHO on ice packs. Freeze the specimen at -70°C if more than 72 hours are expected between the time of specimen collection and testing.

Requisitions and Kit Ordering

Test Frequency and Turnaround Time (TAT)

Enterovirus testing is performed Monday to Friday.

Turnaround times (TAT) are listed for each of the following:

TAT for Enterovirus PCR and EV-D68 is up to 3 days after receipt at PHO’s laboratory, Toronto location.

Test Methods

Enterovirus real-time PCR methodology: this assay, developed by the Centre for Disease Control (CDC) amplifies a target in the 5’ untranslated region (5’UTR) of Enteroviruses. It may also cross react with rhinoviruses due to genetic similarity.

Enterovirus molecular serotyping methodology: Enterovirus-positive primary specimens will undergo molecular serotyping using gene sequencing of VP1, a viral capsid protein. The molecular serotyping methods were developed by the CDC. The Enterovirus molecular serotyping protocol involves amplification of a fragment (350 to 400 nucleotides) of the viral capsid protein 1 (VP1) by semi-nested PCR, followed by Sanger sequencing of the resulting amplicon.

Interpretation

Results will be reported as DETECTED/NOT DETECTED/INDETERMINATE/INVALID for Enterovirus PCR.

Result	Interpretation	Comments
Not Detected	Enterovirus Not Detected	Enterovirus not detected by real-time PCR.
Detected	Enterovirus Detected	Enterovirus detected by real-time PCR.
Indeterminate	Enterovirus Indeterminate	An indeterminate PCR test result may be due to a low level of target genetic material in the specimen, inadequate specimen content, or a non-specific signal. Please resubmit another specimen for testing if clinically indicated.
Invalid	Invalid	Test results are invalid due to the failed amplification of the extraction control. Amplification failure may be due to inadequate specimen content, extraction failure, or PCR inhibition. Please resubmit another specimen for testing if clinically indicated.

Reporting

Results are reported to the ordering physician, authorized health care provider (General O. Reg 45/22, s.18), or submitter as indicated on the requisition.

Additional Information

For any suspected cases of Polio, contact the Medical Microbiologist or your local Public Health Laboratory. Please refer toPoliovirus for laboratory testing of suspected cases of polio or other causes of acute flaccid paralysis.

*Uncontrolled print copy. Valid only on day of print: 21 Nov 2024.

Contact Laboratory Customer Service

Microbiology and Laboratory Services

customerservicecentre@oahpp.ca

Updated 20 July 2020