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A Bachelor of Science in Enterovirus - Allen
1. Krisandra Allen, MPH
Foodborne Disease Epidemiology Assistant
Division of Surveillance and Investigation
Virginia Department of Health
Field Epidemiology Seminar: April 30, 2013
2. Understand symptoms, modes of
transmission, and epidemiology of hand,
foot, and mouth disease (HFMD)
Identify emerging strains of virus causing
severe HFMD outbreaks worldwide
Describe the unique epidemiological
characteristics of a local outbreak of
HFMD
4. Typical Symptoms include:
• Fever (often the first symptom)
• Malaise
• Painful sores in the mouth
• Skin rash with flat or raised red spots
and possibly blisters
Typically found on the palms of the hands and soles
of the feet
May also be found on the knees, elbows, buttocks and
genitals
5. Incubation period 3-7 days
Usually self-limiting and resolves in 7-10
days
Modes of transmission include:
• Respiratory secretions – contact and aerosol
• Contact with blister fluid
• Objects contaminated by feces from infected
individuals
6. Virus Characteristics
Coxsackie A16
(CVA16)
Common in the USA, typically causes classic HFMD and
rarely associated with complications, rash typically on the
palms of hands and soles of feet and in the mouth
Coxsackie A6
(CVA6)
Rash may be more widespread and severe, associated
with onychomadesis and desquamation of fingers and
toes, rash often on the back of the hands rather than
palms
Enterovirus 71
(EV71)
Has caused severe outbreaks and deaths in the Western
Pacific Region
10. Piedmont Health District notified in
September 2012 by the director of the
Student Health Clinic at College A of
several students diagnosed with HFMD
Literature review found no previous
HFMD outbreaks in a College setting
13. Mode of Transmission Recommendations for students
Respiratory Secretions •Avoid eating and/or drinking after
another person
•Do not share eating utensils or share
beverages/drinks with another
person
•Kissing may spread HFMD
Feces •Wash your hands often with soap
and water, especially after using the
toilet and before preparing food
•Always wash your hands after
diapering a child
Blister Fluid •Avoid close contact such as hugging
14. College A puts infection control
recommendations for students on the
school website
Nearby University B contacted to make
them aware of an increase in HFMD cases
among adults in the Health District
• Student Health Director reports one case
• Sample collection kits taken to University B
15. Samples from two University B students
sent to CDC
• Vesicle and throat swabs from one student both
tested positive for Coxsackievirus A6
• No virus detected in sample from second
student
• Sample from third student leaked in transport
and was unable to be tested
16. Outbreaks have been reported in
Finland,Taiwan, Japan, Spain, France
since 2008
First reported outbreak in USA occurred
November 2011- February 2012
• Alabama, Connecticut, California, and Nevada
reported cases of severe HFMD
• 25 cases tested positive at CDC for Coxsackie
A6
17. 0
1
2
3
4
5
6
7
8
9
10
9/10-9/14 9/17-9/21 9/24-9/28 10/1-10/5 10/8-10/12 10/15-10/19
NumberofReportedCases
Date of Diagnosis
Epidemic Curve for HFMD Outbreak at College A
and University B by week September – October 2012
University B
College A
18. University C, located less than 100 miles
from College A and University B
Outbreak not reported to Health
Department
HFMD outbreak reported in school
newspaper article October 17th
• Article reported 16 cases in September and 8
cases in October
19. College A University B University C Total
September 16 2 16 34
October 18 2 8 28
Total 34 4 24 62
Cases counts from College A and
University B were reported to health
department by student health centers
Case counts from University C obtained
from published newspaper article
Reported HFMD cases among Virginia College Students at three schools, 2012
20. HFMD is an emerging disease worldwide
with the potential for viruses to move
around the globe
College students are a population at risk
for outbreaks of HFMD
Lab testing is important to confirm HFMD
outbreaks and identify what strains are
circulating in the population
21. Angela West, Central Region
Epidemiologist,VDH
Dr. Alexander Samuel, Piedmont Health
District Director,VDH
Marilyn B. Freeman,
Immunology/Virology and Drug Testing
Group Manager, DCLS
JunYang, Senior Epidemiologist,VDH
Student Health Center Directors at
College A and University B
22. Österback R,Vuorinen T, Linna M, Susi P, Hyypiä,Waris M. Coxackievirus A6 and
hand, foot, and mouth disease, Finland. Emerg Infect Dis [serial on the Internet].
2009 Sep [04/18/2013]. Available from
http://wwwnc.cdc.gov/eid/article/15/9/09-0438.htm
Wei SH, HuangYP, 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.
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.
Mirand A, Henquell C, Archimbaud C, Ughetto S, Antona D, Bailly JL, etal.
Outbreak of hand, foot and mouth disease/herpangina associated with
coxsackievirus A6 and A10 infections in 2010, France: a large citywide,
prospective observational study. Clin Microbiol Infect. 2012;18:E110–8.
http://dx.doi.org/10.1111/j.1469-0691.2012.03789.x
Centers for Disease Control and Prevention. Notes from the field: Severe hand,
foot, and mouth disease associated with coxsackievirus a6 - Alabama,
Connecticut, California, and Nevada, November 2011-February 2012. MMWR
2012;61:213-4.
