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Atypical strain of coxsackievirus caused outbreak of HFMD in four states
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An outbreak of hand, foot, and mouth disease primarily caused by coxsackievirus A6 occurred in four states between November 2011 and February 2012, according to a report from the CDC.
From Nov. 7, 2011, to Feb. 29, 2012, the CDC received reports of 63 patients with signs and symptoms of hand, foot and mouth disease (HFMD) or with fever and atypical rash. Reports came from Alabama (38 cases), California (seven), Connecticut (one) and Nevada (17).
The cases were identified as unusual by health care providers or by a department of health that contacted CDC for diagnostic assistance because HFMD is not a reportable disease in the United States.
Clinical specimens were collected from patients in 34 of the 63 cases. Coxsackievirus A6 (CVA6) was detected in 25 (74%) 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 nine patients, according to the CDC.
Forty (63%) of the 63 patients in the outbreak were aged 2 years or younger, and 15 (24%) were adults aged 18 years and older. Most of the patients had exposure to a child care facility or school; contact with children in child care where cases of HFMD were reported; provided medical care; or were related to a child with HFMD.
Rash and fever were more severe and hospitalization was more common with patients in this outbreak compared with typical HFMD. Signs of HFMD included fever (48 patients [76%]); rash on the hands or feet, or in the mouth (42 [67%]); and rash on the arms or legs (29 [46%]), face (26 [41%]), buttocks (22 [35%]), and trunk (12 [19%]). Of 46 patients with rash variables reported, the rash typically was maculopapular; vesicles were reported in 32 (70%) patients and scabs in 30 (65%) patients. Shedding of nails occurred after initial infection in two (4%) patients.
Of the 63 patients, 51 (81%) sought care from a clinician, and 12 (19%) were hospitalized. Reasons for hospitalization varied and included dehydration and/or severe pain. No deaths were reported, but CVA6-associated HFMD cases continue to be reported to CDC.
According to the CDC, the age ranges of patients, severity of illness, seasonality of disease, and identification of CVA6 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, and this is the first outbreak like this to be reported in the United States.
Perspective
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David W. Kimberlin, MD
This unusual outbreak of hand, foot, and mouth disease (HFMD) during the winter months in the United States was investigated thoroughly by the CDC and found to be caused by coxsackievirus A6. This virus has never before been documented to cause a US outbreak, and thus qualifies as an emerging infectious disease. The outbreak illustrates vividly how, in this global and interconnected world, infectious pathogens no longer remain isolated in one small area. Rather, they spread across regions, countries and continents with ease.
While the HFMD cases recognized so far have been more severe than would typically be seen, they have not resulted in death or lifelong disability. The same would not be the case if (or when) poliovirus, measles, rubella, diphtheria or Haemophilus influenzae type b is imported again – which could happen today if an infected person is en route to the US on an international airline flight. This outbreak serves as a strong warning to us that, until a disease is eradicated from the entire planet, we all remain at risk. The only way to protect your children is to have them fully vaccinated.
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