Monday, February 13, 2012

HFMD: An Old Illness With A New Cause



 Thumbnail of Vesicular eruptions in A) hand, B) foot, and C) mouth of a 6.5-year-old boy from Turku, Finland, with coxsackievirus (CV) A6 infection. Several of his fingernails shed 2 months after the pictures were taken. D) Onychomadesis in a 10-year-old boy from Seinäjoki, Finland, 2 months after hand, foot and mouth disease with CVA6 infection. Photographs courtesy of H. Kujari (A–C) and M. Linna (D).

Vesicular eruptions in A) hand, B) foot, and C) mouth of a 6.5-year-old boy from Turku, Finland, with coxsackievirus (CV) A6 infection.  Credit - CDC EID Journal 


# 6138


Since late in January the newshounds on FluTrackers  have been following a story out of Alabama, where public health authorities have been dealing with an offseason outbreak of Hand Foot and Mouth Disease (HFMD).


Hand Foot and Mouth Disease is often confused by the public with Foot and Mouth Disease (FMD) seen in cattle, swine, and sheep.  Despite the similar name, the diseases are in no way related.


HFMD is a very common viral infection, usually peaking late summer or early fall, and mainly seen among children under the age of 10 (although adults may be vulnerable as well).


It is caused by several of the non-polio enteroviruses.


While this virus classification may be unfamiliar to a lot of people, the 60+ viruses that fall into this category are among the most prevalent viral infections in the world, probably only second to the myriad and ubiquitous variants of Rhinovirus (`common cold’) that circulate every year.



The two most common causes of HFMD have been the Coxsackie A16 virus, and the Enterovirus-71 (EV-71), and rarely, the Coxsackie A10 virus.


The disease in the United States is commonly caused by the Coxsackie A16 virus and is generally mild. Outbreaks are not uncommon in schools and childcare facilities.


Over the past decade we've seen outbreaks - particularly in the Far East  - caused by the more pathogenic EV-71 virus, and this version of the HFMD can occasionally be quite serious.


Last year, Vietnam reported more than 90,000 cases of HFMD and reported more than 150 deaths, mostly among young children.


And two years ago , the Virology Journal, published an analysis of an EV-71 HFMD virus that caused a major disease outbreak in Fuyang City, China in 2008 that showed it was due to an emerging recombinant virus (see China: A Recombinant EV-71).


In 2008, the CDC’s EID Journal carried a dispatch describing an outbreak of HFMD in Finland due to an unusual, and apparently emerging, viral cause; the Coxsackie A6 virus.



Coxsackievirus A6 and Hand, Foot, and Mouth Disease, Finland

Riikka Österback, Tytti Vuorinen, Mervi Linna, Petri Susi, Timo Hyypiä, and Matti Waris

During fall 2008, an outbreak of hand, foot, and mouth disease (HFMD) with onychomadesis (nail shedding) as a common feature occurred in Finland. We identified an unusual enterovirus type, coxsackievirus A6 (CVA6), as the causative agent. CVA6 infections may be emerging as a new and major cause of epidemic HFMD.


This dispatch describe a prolonged nationwide outbreak of HFMD starting in 2008, in Finland:


During fall 2008, a nationwide outbreak of HFMD occurred in daycare centers and schools in Finland, starting in August and continuing at least until the end of the year and possibly into the following year. From vesicle fluid specimens of hospitalized children, we identified the etiologic agent as coxsackievirus A6.


Since then, we’ve seen a growing number of reports of HFMD outbreaks around the world due to this particular coxsackievirus, including:



An outbreak of coxsackievirus A6 hand, foot, and mouth disease associated with onychomadesis in Taiwan, 2010

Sung-Hsi Wei, Yuan-Pin Huang, Ming-Chih Liu, Tsung-Pei Tsou, Hui-Chen Lin, Tsuey-Li Lin, Chen-Yen Tsai, Yen-Nan Chao, Luan-Yin Chang and Chun-Ming Hsu

BMC Infectious Diseases 2011, 11:346 doi:10.1186/1471-2334-11-346

Published: 14 December 2011

Hand, Foot, and Mouth Disease Caused by Coxsackievirus A6, Japan, 2011

Fujimoto T, Iizuka S, Enomoto M, Abe K, Yamashita K, Hanaoka N, et al.

Emerg Infect Dis [serial on the Internet]. 2012 Feb



Until now, this A6 virus has not been associated with HFMD outbreaks in the United States. This from the Alabama Health Department’s website:



Alabama Department of Public Health monitors new cases of hand, foot and mouth disease

CONTACT:  Mary McIntyre, M.D.
(334) 206-5325

The Alabama Department of Public Health asks the public to be aware that cases of the contagious viral illness called hand, foot and mouth disease are more numerous and severe than normal in Alabama this winter. No known deaths have resulted from the virus, although there have been hospitalizations and there can be some rare, severe complications.


As of Feb. 10, the ADPH has interviewed patients and collected and submitted specimens to the Centers for Disease Control and Prevention for individuals with febrile illnesses and rash. Based on the results of testing done by the CDC, the Coxsackie A6 virus has been identified.


This  specific type of virus has been identified in other countries but has not previously been
associated with an outbreak in the U.S. There is no specific treatment for hand, foot and mouth


“As this is a new virus for our population, we can expect more cases and are monitoring for any change in the clinical presentation,” Dr. Donald Williamson, state health officer, said. “We will continue statewide surveillance on severe cases of this emerging disease and ask physicians and infection control specialists to make notifications to us.”

The public should not be unduly alarmed at this time; however, individuals diagnosed with hand, foot and mouth disease need to follow the recommendations of their health care provider to remain at home until they have no fever, all lesions have scabbed over, and no lesions have appeared for two days.  

The viral disease affects the hands, feet and mouth and usually infects infants and children younger than 5 years old in summer and early autumn. There is no vaccine to protect against it, but learning about the disease and following these recommendations can reduce the risk of illness.

Hand, foot and mouth disease spreads: 

  • Person-to-person: Direct contact with saliva, sputum or nasal mucus from the infected person’s nose and throat or with fluid in blisters, or with stool.
  • Surface-to-person: Touching objects and surfaces touched by infected persons.
  • Infected persons are most contagious during the first week of the illness, but can still pass the virus for weeks after symptoms have gone away.

These are the symptoms:


  • Fever, rash, sores, poor appetite, a vague feeling of illness and sore throat.
  • Painful sores in the mouth may blister and become ulcers.
  • Skin rash, flat or raised red spots, develops over 1 to 2 days.
  • Rash usually on the palms of the hands and soles of the feet and may appear on the knees, elbows, bottom or genital area.
  • Dehydration may occur because of painful mouth sores.


Recommendations to protect yourself and prevent its spread:

  • Wash hands with soap and water carefully and frequently, especially after going to the bathroom, after changing diapers, and before preparing foods or beverages.
  • Disinfect surfaces and items, including toys. First wash the items with soap and water; then disinfect them with a solution of 1 tablespoon of bleach and 4 cups of water.
  • Avoid close contact such as kissing, hugging or sharing eating utensils or cups with infected people.

Health care providers are being asked to notify the Alabama Department of Public Health if higher than normal numbers of cases are being hospitalized with hand, foot and mouth disease symptoms. Please call (800) 338-8374 immediately for hospitalized cases.





While apparently a bit more serious than the garden variety of HFMD we are used to seeing in the United States, this A6 virus doesn’t appear to be as pathogenic as the EV-71 virus seen in Asia.


But its arrival in the United States serves as a reminder that well adapted emerging viruses are very good at spreading, and that with today’s highly mobile society, oceans and borders provide little in the way of protection.