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Published Date: 2012-03-29 19:01:01
Subject: PRO/EDR> Hand-foot & mouth disease - USA: (multistate) Coxsackievirus A6
Archive Number: 20120329.1084829

HAND, FOOT AND MOUTH DISEASE - USA: (MULTISTATE), COXSACKIEVIRUS A6
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Date: Thu 29 Mar 2012
Source: Morbidity and Mortality Weekly Report (MMWR), Weekly, Notes from the Field, March 30, 2012 / 61(12);213-214 [edited]
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6112a5.htm?s_cid=mm6112a5_e

Severe Hand, Foot, and Mouth Disease Associated with Coxsackievirus A6 -- Alabama, Connecticut, California, and Nevada, November 2011 to February 2012
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Hand, foot, and mouth disease (HFMD) is a common viral illness caused by enteroviruses that predominantly affect children aged under 5 years. In the United States, outbreaks of HFMD typically occur during summer and autumn months. The most common cause of HFMD in the United States has been enterovirus serotype coxsackievirus A16. Most infections are asymptomatic; persons with signs and symptoms typically have a mild febrile illness with rash on the palms of the hands and soles of the feet, and sores in the mouth. HFMD also has been associated, often weeks after initial symptom onset, with nail dystrophies (e.g., Beau's lines or nail shedding).

From 7 Nov 2011, to 29 Feb 2012, CDC received reports of 63 persons with signs and symptoms of HFMD or with fever and atypical rash in Alabama (38 cases), California (7), Connecticut (1), and Nevada (17). HFMD is not a reportable disease in the United States; the cases were identified as unusual by health-care providers or by a department of health that contacted CDC for diagnostic assistance. Clinical specimens were collected from patients in 34 of the 63 cases. Coxsackievirus A6 (CVA6) was detected in 25 (74 percent) of those 34 patients by reverse transcriptase-polymerase chain reaction and partial sequencing of the VP1 gene at CDC or at the California Department of Public Health. No enteroviruses were detected in the other 9 patients.

Of the 63 patients, 40 (63 percent) were aged under 2 years, and 15 (24 percent) were adults aged 18 years or older; 44 (70 percent) of the patients had exposure to a child care facility or school, and 8 (53 percent) of the 15 adults had contact with children in childcare where cases of HFMD [hand, foot and mouth disease] were reported, or provided medical care, or were related to a child with HFMD.

Rash and fever were more severe, and hospitalization was more common than with typical HFMD. Signs of HFMD included fever (48 patients [76 percent]); rash on the hands or feet, or in the mouth (42 [67 percent]); and rash on the arms or legs (29 [46 percent]), face (26 [41 percent]), buttocks (22 [35 percent]), and trunk (12 [19 percent]). Of 46 patients with rash variables reported, the rash typically was maculopapular; vesicles were reported in 32 (70 percent) patients and scabs in 30 (65 percent) patients. Shedding of nails [onychomadesis] occurred after initial infection in 2 (4 percent) patients. Of the 63 patients, 51 (81 percent) sought care from a clinician, and 12 (19 percent) were hospitalized. Reasons for hospitalization varied and included dehydration and/or severe pain. No deaths were reported.

The age ranges of patients, severity of illness, seasonality of disease, and identification of CVA6 [Coxsackievirus A6] in these cases were unusual for HFMD in the United States. CVA6 has been associated with more severe and extensive rash than HFMD caused by other enteroviruses (1). Since 2008, international outbreaks of CVA6 HFMD in children and adults have been described (1-4), but no outbreaks had been reported in the United States previously. Although all 25 of the CVA6 strains identified in the U.S. cases were genetically closely related (based on partial VP1 gene sequences) to CVA6 strains identified in recent international outbreaks, no epidemiologic evidence (e.g., travel history) has directly linked any of the U.S. cases to importation.

HFMD is spread from person to person by contact with saliva, respiratory secretions, fluid in vesicles, and feces. Transmission of HFMD can be reduced by maintaining good hygiene, including handwashing and disinfection of surfaces in child care settings (5). CDC continues to receive reports of CVA6-associated HFMD. Persons who suspect a severe case of HFMD should contact their health-care provider. Local or state health departments may contact CDC for assistance with enterovirus laboratory diagnosis.

References:
1. Wei SH, Huang YP, Liu MC, et al. An outbreak of coxsackievirus A6 hand, foot, and mouth disease associated with onychomadesis in Taiwan, 2010. BMC Infect Dis 2011;11:346.
2. Blomqvist S, Klemola P, Kaijalainen S, et al. Co-circulation of coxsackievirus A6 and A10 in hand, foot and mouth disease outbreak in Finland. J Clin Virol 2010;48:49-54.
3. Fujimoto T, Iizuka S, Enomoto M, et al. Hand, foot and mouth disease caused by coxsackievirus A6, Japan, 2011. Emerg Infect Dis 2012;18:337-9.
4. Wu Y, Yeo A, Phoon MC, et al. The largest outbreak of hand, foot and mouth disease in Singapore in 2008: the role of enterovirus 71 and coxsackievirus A strains. Int J Infect Dis 2010;14:e1076-81.
5. Ruan F, Yang T, Ma H, et al. Risk factors for hand, foot, and mouth disease and herpangina and the preventative effect of hand-washing. Pediatrics 2011;127:e898-904.

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[This is a fuller account of the outbreak of hand, foot and mouth disease caused by Coxsackievirus A6 infection described initially in Alabama and now known to have involved the states of Connecticut, California, and Nevada. Hand, foot and mouth disease occurs globally. In developed countries, hand, foot and mouth disease is generally mild and often associated with outbreaks of Coxsackie A16 virus infection. In east Asian countries in recent years, the disease has been associated with outbreaks of Enterovirus 71 infection and can be more severe, with a small proportion of children experiencing neurological complications, occasionally with fatal outcomes. Coxsackievirus A6 infection as a cause of the hand, foot and mouth disease currently observed in Alabama and other states appears to be intermediate in severity. - Mod.CP

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