Enterovirus 71–associated Hand, Foot, and Mouth Disease, Southern Vietnam, 2011 - - Emerging Infectious Disease journal - CDC

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Enterovirus 71–associated Hand, Foot, and Mouth Disease, Southern Vietnam, 2011 - - Emerging Infectious Disease journal - CDC

CME ACTIVITY

Enterovirus 71–associated Hand, Foot, and Mouth Disease, Southern Vietnam, 2011

Article Contents

• Medscape CME Activity
• The Study
• Conclusions
• Acknowledgments
• References
• Figure 1
• Figure 2
• Table 1
• Table 2
• Suggested Citation

Truong Huu Khanh, Saraswathy Sabanathan, Tran Tan Thanh, Le Phan Kim Thoa, Tang Chi Thuong, Vu thi Ty Hang, Jeremy Farrar, Tran Tinh Hien, Nguyen van Vinh Chau, and H. Rogier van Doorn 

Author affiliations: Author affiliations: Children’s Hospital 1, Ho Chi Minh City, Vietnam (T.H. Khanh, L.P.K. Thoa, T.C. Thuong); Oxford University Clinical Research Unit, Oxford, UK (S. Sabanathan, T.T. Thanh, V.t.T. Hang, J. Farrar, T.T. Hien, H.R. van Doorn); Oxford University (S. Sabanathan, J. Farrar, T.T. Hien, H.R. van Doorn); Hospital for Tropical Diseases, Ho Chi Minh City (N.v.V. Chau)

Suggested citation for this article

Abstract

We prospectively studied 3,791 children hospitalized during 2011 during a large outbreak of enterovirus 71–associated hand, foot, and mouth disease in Vietnam. Formal assessment of public health interventions, use of intravenous immunoglobulin and other therapies, and factors predisposing for progression of disease is needed to improve clinical management.

In Southeast Asia, human enterovirus 71 (EV71) is a frequent cause of hand, foot, and mouth disease (HFMD) in Southeast Asia and resulting neurologic and cardiopulmonary complications. Children <5 age="age" and="and" are="are" at="at" but="but" disease="disease" factors="factors" for="for" largely="largely" of="of" p="p" predisposing="predisposing" risk="risk" severe="severe" severity="severity" symptomatic="symptomatic" the="the" unknown.="unknown." years="years"> In Vietnam, EV71 was first isolated in 2003. In 2005, an outbreak of HFMD was caused by an early peak of coxsackievirus A16 (CVA16), followed by a peak of EV71, associated with severe disease (1).
HFMD outbreaks occurring every 3 years have been reported from countries in the region to which it is endemic (2,3), but Vietnam had a high number of cases during February 2011–July 2012: a total of 174,677 cases (110,897 during 2011; 63,780 during the first 6 months of 2012) and 200 deaths were reported from Vietnam during this period. The outbreak peaked in week 38 (September 18–24, 2011, with ≈2,500 reported hospital admissions countrywide. Reported case-patients were mainly from southern Vietnam in 2011; in 2012, the outbreak spread to the northern provinces of Vietnam (4).
The Vietnamese Ministry of Health has implemented a clinical grading system to guide disease management. It is based on a grading system from Taiwan (5) and is a consensus of experienced physicians; it describes 4 grades of disease. Grade 1 is uncomplicated disease with fever and vesicles or papules on hands, feet, buttocks, and oral mucosa. In grade 2 disease, the central nervous system is involved, usually as myoclonus starting in the fingers. Grade 2 is further divided into grade 2a disease, when myoclonus is reported by the caregiver, and grade 2b disease, when myoclonus is observed by a physician. In grade 3 disease, autonomic dysfunction occurs with fever that is unresponsive to antipyretics and with hypertension and persistent tachycardia. Patients with grade 4 disease exhibit cardiopulmonary compromise with pulmonary edema or hemorrhage. Grades 2b, 3, and 4 describe severe disease and are indicators for hospital admission and treatment. Patients with grade 2a disease (reported myoclonus) also usually are admitted, and a small proportion of patients seeking care in the outpatient clinic with grade 1 disease are admitted for observation, on the basis of clinical judgment.
Myoclonus and more severe neurologic complications are treated with oral or intravenous phenobarbital. Heart rate, respiratory rate, blood pressure, and saturations are recorded to monitor progress of disease. When persistent tachycardia, fever unresponsive to antipyretics, irregular breathing, or persistent hypertension occur, intravenous immunoglobulin (IVIg) is administered. Children have arterial lines inserted for close observation of blood pressure. Hypertension is treated with milrinone, a phosphodiesterase inhibitor. When a child’s condition does not improve, hemofiltration is used in conjunction with full intensive care support as needed.