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doi:10.1111/jpc.12708
ANNOTATION
Outbreak of variant hand-foot-and-mouth disease caused by coxsackievirus A6 in Auckland, New Zealand Rebecca Hayman,1 Michael Shepherd,1 Claire Tarring2 and Emma Best3,4 1
Children’s Emergency Department and 4Department of Infectious Disease, Auckland District Health Board, Starship Hospital, 2Auckland District Health Board Laboratory, Auckland City Hospital and 3Department of Paediatrics, University of Auckland, Auckland, New Zealand
Abstract: Hand-foot-and-mouth disease is a common, usually mild childhood illness caused by enteroviruses. Over the last five years, coxsackievirus A6 has been identified as a causative agent in outbreaks in Europe, South-East Asia and America. It has an atypical presentation compared with other enteroviruses, with more widespread rash, larger blisters and subsequent skin peeling and/or nail shedding. We give the first description of an outbreak of coxsackievirus A6 in New Zealand and how health-care communication networks enabled detection of and dissemination of information about this emergent strain. Key words:
coxsackievirus infection; disease outbreak; hand-foot-and-mouth disease.
Hand-foot-and-mouth disease (HFMD) is a common childhood illness caused by enteroviruses, most commonly enterovirus 71 and coxsackievirus A16. The disease is characterised by a mild febrile illness associated with the development of pink macules on the hands, feet and oral mucosa, which rapidly become small, elongated grey blisters. The rash resolves spontaneously after 7–10 days, with incidence peaks in the summer and autumn months. HFMD is very infectious and is associated with outbreaks. Due to a mild or subclinical picture, HFMD is predominantly seen in primary care. Management includes symptomatic relief of painful mouth ulcers, which aids in the secondary
Key Points 1 Hand-foot-and-mouth disease is usually a mild childhood illness, but some serotypes, such as enterovirus 71, can cause severe neurological complications and death. 2 Coxsackievirus A6 is an emerging cause of hand-foot-andmouth disease. It is responsible for a widespread rash that can become bullous and crusted, can affect adults and is responsible for nail shedding after resolution of the rash; rarely, it can also cause neurological and cardiac complications. More commonly it is responsible for dehydration. 3 Management of hand-foot-and-mouth disease caused by coxsackievirus A6 is primarily supportive care, such as pain relief for mouth ulcers and ensuring adequate hydration. Careful observation for more serious effects is warranted. Correspondence: Dr Emma Best, Department of Paediatrics: Child and Youth Health, Faculty of Medical & Health Sciences, University of Auckland, PO Box 92019, Auckland 1142, New Zealand. Fax: + 64 9 3078977; email: [email protected] Conflict of interest: The authors have no conflicts of interests to declare. Accepted for publication 11 July 2014.
management of maintaining hydration and fluid balance. Adults rarely present with HFMD, presumably due to protective immunity from other enterovirus serotypes and exposure in childhood. Although HFMD is typically a mild clinical disease, enterovirus 71 has been associated with neurological and cardiorespiratory complications including encephalitis, myocarditis and death.1 Outbreaks have been reported, particularly in the AsiaPacific region, over the last 15 years, including in Australia.2 In the summer/autumn months of 2012–2013, Sydney reported an increase of up to 30 cases of enterovirus 71 with severe neurological presentations in children.3 A marked increase in presentations with HFMD to the Starship Children’s Emergency Department (CED), Auckland, New Zealand, occurred at the same time, leading to concern that Auckland may be seeing an outbreak of enterovirus 71 infections. The presentations were also causing diagnostic uncertainty due to atypical features of HFMD. To determine the predominant enterovirus strain causing HFMD in Auckland, surveillance serotyping was undertaken. This report outlines the outbreak experience and summarises features of the causative agent, coxsackievirus A6 (CVA6).
Outbreak Experience Presentations to Starship Children’s Emergency Department Between December 2012 and May 2013, clinicians at CED noted an increase in presentations with an atypical clinical picture of HFMD. CED is the only dedicated paediatric emergency department in New Zealand and sees 33 000 children a year from the Auckland region (estimated catchment population aged
doi:10.1111/jpc.12708
ANNOTATION
Outbreak of variant hand-foot-and-mouth disease caused by coxsackievirus A6 in Auckland, New Zealand Rebecca Hayman,1 Michael Shepherd,1 Claire Tarring2 and Emma Best3,4 1
Children’s Emergency Department and 4Department of Infectious Disease, Auckland District Health Board, Starship Hospital, 2Auckland District Health Board Laboratory, Auckland City Hospital and 3Department of Paediatrics, University of Auckland, Auckland, New Zealand
Abstract: Hand-foot-and-mouth disease is a common, usually mild childhood illness caused by enteroviruses. Over the last five years, coxsackievirus A6 has been identified as a causative agent in outbreaks in Europe, South-East Asia and America. It has an atypical presentation compared with other enteroviruses, with more widespread rash, larger blisters and subsequent skin peeling and/or nail shedding. We give the first description of an outbreak of coxsackievirus A6 in New Zealand and how health-care communication networks enabled detection of and dissemination of information about this emergent strain. Key words:
coxsackievirus infection; disease outbreak; hand-foot-and-mouth disease.
Hand-foot-and-mouth disease (HFMD) is a common childhood illness caused by enteroviruses, most commonly enterovirus 71 and coxsackievirus A16. The disease is characterised by a mild febrile illness associated with the development of pink macules on the hands, feet and oral mucosa, which rapidly become small, elongated grey blisters. The rash resolves spontaneously after 7–10 days, with incidence peaks in the summer and autumn months. HFMD is very infectious and is associated with outbreaks. Due to a mild or subclinical picture, HFMD is predominantly seen in primary care. Management includes symptomatic relief of painful mouth ulcers, which aids in the secondary
Key Points 1 Hand-foot-and-mouth disease is usually a mild childhood illness, but some serotypes, such as enterovirus 71, can cause severe neurological complications and death. 2 Coxsackievirus A6 is an emerging cause of hand-foot-andmouth disease. It is responsible for a widespread rash that can become bullous and crusted, can affect adults and is responsible for nail shedding after resolution of the rash; rarely, it can also cause neurological and cardiac complications. More commonly it is responsible for dehydration. 3 Management of hand-foot-and-mouth disease caused by coxsackievirus A6 is primarily supportive care, such as pain relief for mouth ulcers and ensuring adequate hydration. Careful observation for more serious effects is warranted. Correspondence: Dr Emma Best, Department of Paediatrics: Child and Youth Health, Faculty of Medical & Health Sciences, University of Auckland, PO Box 92019, Auckland 1142, New Zealand. Fax: + 64 9 3078977; email: [email protected] Conflict of interest: The authors have no conflicts of interests to declare. Accepted for publication 11 July 2014.
management of maintaining hydration and fluid balance. Adults rarely present with HFMD, presumably due to protective immunity from other enterovirus serotypes and exposure in childhood. Although HFMD is typically a mild clinical disease, enterovirus 71 has been associated with neurological and cardiorespiratory complications including encephalitis, myocarditis and death.1 Outbreaks have been reported, particularly in the AsiaPacific region, over the last 15 years, including in Australia.2 In the summer/autumn months of 2012–2013, Sydney reported an increase of up to 30 cases of enterovirus 71 with severe neurological presentations in children.3 A marked increase in presentations with HFMD to the Starship Children’s Emergency Department (CED), Auckland, New Zealand, occurred at the same time, leading to concern that Auckland may be seeing an outbreak of enterovirus 71 infections. The presentations were also causing diagnostic uncertainty due to atypical features of HFMD. To determine the predominant enterovirus strain causing HFMD in Auckland, surveillance serotyping was undertaken. This report outlines the outbreak experience and summarises features of the causative agent, coxsackievirus A6 (CVA6).
Outbreak Experience Presentations to Starship Children’s Emergency Department Between December 2012 and May 2013, clinicians at CED noted an increase in presentations with an atypical clinical picture of HFMD. CED is the only dedicated paediatric emergency department in New Zealand and sees 33 000 children a year from the Auckland region (estimated catchment population aged
