Adenovirus Infection in Pediatric Populations

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Adenoviruses are not a nationally notifiable disease in the U.S. (not required to test or notify the CDC), and many outbreaks go undetected or unreported. An adenovirus infection can cause many illnesses in the pediatric population (5). In patients with weakened immune systems or with chronic medical diseases, certain care areas in addition to community members, especially the elderly, are at risk for severe complications, even death (2).  

Educating and empowering parents and children to engage in behaviors and develop habits that prevent the spread of an adenovirus infection is vital; as it can work toward decreasing the chance of serious infections, and outbreaks that can extend beyond pediatric patient care areas. 

As we start to feel some relief from the global COVID-19 pandemic, we must remember to remain mindful of and attentive to the prevention of a common year-round virus that causes a great deal of distress, discomfort, and potential harm. 

Introduction   

An adenovirus infection stems from a family of viruses, with each member affecting their host differently; additionally, they can cause many illnesses within the pediatric population (4). It is most common to see adenoviruses developing in children under the age of 10, but it can also arise in both teens and adults. The illnesses are generally mild and typically run their course within a few days, though certain patient populations can develop severe complications from adenovirus infections (2). 

This course explores the adenovirus, its associated illnesses, and their impact on pediatric patients and communities. We will also look at diagnosis, testing, treatment, prevention, and surveillance measures.  

What is an Adenovirus Infection? 

Adenoviruses are medium-sized (90-100nm), non-enveloped icosahedral viruses with double-stranded DNA. There are 100 serologically distinct adenoviruses, and 51 of them can cause human infections. Scientists first isolated the adenovirus in the adenoids, which gave rise to the name “adenovirus.” Unfortunately, the viruses are unusually stable and resistant, allowing them to survive outside the body for prolonged periods, thus being with us year-round (1, 3, 10).  

Associated Illness, Infection, and Symptoms of an Adenovirus Infection 

• Bronchitis: Cough, runny nose, fever, chills,  
• Colds and other respiratory infections: Stuffy and runny nose, cough, sore throats, and swollen glands 
• Croup: Barking cough, trouble breathing, high-pitched sound when breathing 
• Ear infection: Ear pain, irritability, and fever  
• Pink eye (conjunctivitis): Red discharge from eyes, tearing, feeling as if there is something in the patient’s eye 
• Pneumonia: Fever, cough, trouble breathing,  
• Stomach and intestinal infections: Diarrhea, vomiting, headaches, fever, stomach cramps, 
• Swelling of the brain and spinal meningitis and encephalitis: Headaches, fever, stiff neck, nausea, and vomiting (this event is rare) 
• Urinary tract infections: Burning and pain while urinating, frequent need to go, blood in urine (4) 
  

Spread and Prevention of Adenovirus Infections

Children gather in groups, daycare centers, schools, summer camps, and family units. Being in close contact with each other makes exposure and spread by coughing and sneezing (droplet spread) very easy. Kids touching contaminated objects and then touching their eyes, nose, and mouth can also result in the quick spreading of an adenovirus infection. For adults, changing a dirty diaper, eating food handled by someone who did not wash their hands properly, and swimming in lakes or pools are all situations that can lead to an adenovirus infection (4). Closed, crowded dormitories, military quarters, nursing homes, hospitals, and long-term pediatric facilities also create a higher contraction risk (11). 

Similarly to other pediatric viruses such as influenza or COVID-19, taking simple precautions can prevent the spread of an adenovirus infection. As healthcare providers working directly with sick patients, we need to ensure that we are practicing and reinforcing frequent hand washing with soap and warm water for at least 20 seconds. If a patient with an adenovirus infection is hospitalized, isolation protocols include personal protective equipment such as gowns, masks, and gloves (2).   

Lastly, some serotype adenoviruses can live on dry, inanimate surfaces for up to 3 months. Frequent cleaning of all environmental surfaces including shared equipment, toys, and touch-points such as telephones, doorknobs, and light switches, is essential in the prevention of spreading adenoviruses (9). 

Diagnosis, Testing, and Complications of Adenovirus Infections

Healthcare providers must recognize that upper and lower respiratory infections (i.e. pnuemonia) and conjunctivas are the most common adenovirus-associated illness for children, especially in those six months to two years of age who participate in daycare. Respiratory symptoms occur most often in the late winter, spring, and early summer and may start two to 14 days after exposure. Symptoms of respiratory infections include a runny nose, sore throat, fever, cough, swollen lymph nodes, headache, and pink eye (5). 

Gastrointestinal illnesses are most common in children under five years of age and can start three to ten days after exposure.  Symptoms of digestive tract infections include watery diarrhea that starts suddenly, fever, belly pain, and vomiting (5). 

Children who are very sick or have serious underlying health problems are tested for the presence of an adenovirus. These tests include blood, urine, stool, ears, nose, throat, and chest X-rays (5). 

Healthcare providers must educate parents and children on serious symptoms that may require a call or visit to the doctor; these include: 

• Labored or trouble breathing (pneumonia).

• Swelling or drainage around the eyes (conjunctivitis).

• Pain or drainage from ears (ear infection).

• A fever that doesn’t go away in few days.

• A headache, fever, or stiff neck (meningitis).

• Dehydration, for infants; fewer tears and fewer wet diapers.  

• More severe complications include: 

– Chronic lung disease.

– A severe infection of those noted above.

– Intussusception (intestinal blockage) (5). 

Treatment of Adenovirus Infection 

The current treatment for an adenovirus infection is palliative in nature. 

However, for the more serious cases (especially patients with weakened immune systems), the use of antivirals may be a choice. Antivirals such as Cidofovir 1-5mg/kg/day until blood PCR tests are negative x2 and Ribavirin. Both antivirals used as the first line of defense, though not FDA approved.  

Another medication in line with use for those with an underlying disease or illness is Immunoglobulin, at a dose of 500mg/kg/day over 3 weeks (6, 8). 

Hospitals provide treatments such as IV fluids, bronchodilators, extra oxygen, and mechanical ventilation (5). 

There is a vaccine available against serotypes 4 and 7, approved by the FDA but only accessible to the military and not the general public (11).

Otherwise, healthcare providers must educate the parents and children alike on treatments that can relieve symptoms, these include: 

• Drinking plenty of water and clear liquids (popsicles). 
• Washing hands often. 
• Bed rest. 
• Staying away from other members of the family and school mates. 
• Pain relievers such as Acetaminophen or Ibuprofen for fever and headaches. Current practice contraindicates the use of aspirin with viral illnesses, especially for those less than 12 years of age (6). 
• Saline nasal drops, humidifiers, and lozenges. 

Surveillance  

The National Respiratory and Enteric Virus Surveillance System (NREVSS) is a laboratory-based surveillance system developed in 1989 to monitor circulation patterns and trends for: 

• Influenza 
• Seasonal respiratory syncytial virus (RSV) 
• Human parainfluenza virus (HPIV) 
• Respiratory Adenovirus 
• Enterovirus 
• Human metapneumovirus (HMPV) 
• Respiratory adenovirus 
• Human coronavirus, rotavirus, and norovirus.  

Participating U.S. laboratories, university and community hospitals, and public health departments voluntarily report testing and positive results (7). The CDC makes this information available to healthcare providers and the public. The information can is found in periodic summaries, alerts, weekly reports, and peer-reviewed journals (7). 

In 2014, the U.S. National Adenovirus Type Reporting System (NATRS) became active and has been collecting data on human types of adenoviruses. Collected data from clinical laboratories are developed for quarterly reports and based on the following information: species and human adenovirus type, specimen type, collection date, age, and sex.  

The reports generated recognize type-specific human adenovirus circulation, trends, and outbreaks. Each surveillance system mentioned above plays a crucial role in alerting health care professionals to incidence trends and outbreaks across the country and in their region (7). 

Outbreak: Sudden increases in the number of cases of a disease above normal for that specific patient population, often localized to a geographic area. Healthcare providers should notify the infectious control personnel at their facility or contact the local and state health departments for suspected outbreaks (1). Please visit the CDC for more information on outbreaks, reporting, and current surveillance information.

Conclusion 

Although illnesses caused by the adenovirus are commonplace in the pediatric population, as healthcare providers, it is extremely important to recognize the associated infections and possible outbreaks that can develop. We must be adamant about the prevention, spread, and potential complications in clinics, hospitals, schools, homes, and long-term pediatric facilities (4). 

Keeping up to date through the CDC surveillance system and knowing how, when and to whom to talk about suspected outbreaks can make a difference in outcomes, infection rates, and complications. 

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