Hand, Foot, and Mouth Disease Outbreak and Coxsackievirus A6, Northern Spain, 2011 - Vol. 19 No. 4 - April 2013 - Emerging Infectious Disease journal - CDC
Volume 19, Number 4—April 2013
Letter
Hand, Foot, and Mouth Disease Outbreak and Coxsackievirus A6, Northern Spain, 2011
Article Contents
To the Editor: Hand, foot, and mouth disease (HFMD) is an acute, febrile viral infection characterized by vesicular exanthema on the palms of the hands, soles of the feet, and oral mucosa. The infection is transmitted through oral and respiratory secretions, vesicular fluid, and/or feces of affected persons. The most common etiologic agents are coxsackievirus (CV) A16 and human enterovirus (HEV) 71, but other HEVs, mainly belonging to species A, have also been associated with illness (1). HFMD mainly affects infants and children <5 age.="" of="" p="" years="">On May 10, 2011, an outbreak of HFMD was reported in a daycare center in the city of Irun in Basque Country, Spain. Monitoring subsequently was conducted for HFMD cases among children in the health district that contained the daycare center (a total of 4,540 children <14 37="" 5="" a="" age="" amplification="" amplified="" an="" and="" bio-m="" by="" children="" clinics.="" collected="" confirmation="" considered="" dermal="" described="" detected="" directly="" easy-mag="" enterovirus="" extracted="" exudate="" feces="" fever="" for="" fragment="" france="" from="" hfmd="" href="http://wwwnc.cdc.gov/eid/article/19/4/12-1589_article.htm#r2" in-house="" in="" marcy-l="" methods.="" mouth="" multiple="" of="" on="" or="" outpatient="" palms="" patients.="" patients="" pcr="" pediatricians="" pharyngeal="" primers="" rash="" real-time="" region="" representative="" rieux="" rna="" selected="" sentinel="" soles="" specimens="" that="" the="" title="2" toile="" uclisens="" untranslated="" used="" using="" vesicular="" viral="" virologic="" was="" were="" with="" within="" years="">214>5>
Our results suggest that CVA6 can cause HFMD outbreaks that develop rapidly and reach a high incidence in children. Despite the mildness of the disease, the high attack rate in the daycare center alarmed families and staff. HFMD is not subject to epidemiologic surveillance in Spain, and thus its real incidence cannot be identified.
Although CVA6 has long been known to cause HFMD (1), it has not usually been considered to play a major role in this disease. Except in a few countries, CVA6 has been infrequently detected until recent years. However, since 2008, this virus has caused major outbreaks of HFMD in some countries of eastern Asia and Europe and, more recently, in the United States (4–9); the CVA6 strains in this outbreak shared >97% of nucleotide identities in the viral protein 1 gene and showed sequence similarity >94% with the strains that caused these outbreaks. These strains segregated in a phylogenetic tree (Figure), supporting the recent international spread of emerging CVA6 genetic variants (4). In Taiwan and Japan, the emergence of these strains has been associated with a change in the predominant clinical expression of the infections produced by CVA6, from herpangina before 2009 to HFMD in 2010–2011 (7,8). The development of a perioral rash has also been associated to HFMD caused by CVA6 (10).
Although the course of HFMD is usually self-limiting, illness and death rates vary among outbreaks. Severe illness is more frequent in outbreaks caused by HEV71 (1); in outbreaks caused by CVA6 in Taiwan and the United States, the illness affected a broader spectrum of skin sites and was associated with more severe and extensive rash than was HFMD caused by other coxsackieviruses (7,9).
In conclusion, reports of HFMD outbreaks associated with CVA6 are increasing. Improved HFMD surveillance is required, with virus genotyping as a key element.
Acknowledgment
We thank María M. Yagüe, María J. Llorens, and Guido Castillo for help identifying cases and collecting samples from this outbreak.
References
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Suggested citation for this article: Montes M, Artieda J, Piñeiro LD, Gastesi M, Diez-Nieves I, Cilla G. Hand, foot, and mouth disease outbreak and coxsackievirus A6, northern Spain, 2011 [letter]. Emerg Infect Dis [Internet]. 2013 Apr [date cited]. http://dx.doi.org/10.3201/eid1904.121589
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