Archives of Virology

, Volume 156, Issue 6, pp 945–953 | Cite as

A large outbreak of hand, foot, and mouth disease caused by EV71 and CAV16 in Guangdong, China, 2009

  • Wu De
  • Ke Changwen
  • Li Wei
  • Corina Monagin
  • Yan Jin
  • Ma Cong
  • Zen Hanri
  • Su Jun
Original Article


A large outbreak of hand, foot and mouth disease (HFMD) occurred in Guangdong, China, in 2009. A total of 92,749 cases were officially reported to the Center for Disease Control and Prevention of Guangdong (GDCDC). To clarify the pathogen causing the outbreak, 600 specimens, including stool, rectal swabs, vesicular swabs, cerebrospinal fluid, and throat swabs, were collected from 541 patients and subjected to one-step RT-PCR. Four hundred eighty-nine of 541 patient samples were positive for enterovirus. All positive samples were cultured on RD and Hep2 cells; 307 specimens displayed CPE. Sequence analysis of PCR fragment and typing real-time PCR indicated that these isolates included EV71 (56%), CAV16 (35.5%), CAV6 (2.0%), CAV10 (1.0%), CAV2 (0.7%), CAV4 (1.3%), Echo30 (0.7%), Echo25 (1.0%), Echo4 (0.3%), CBV5 (1.0%) and human rhinovirus (0.7%). 100% (12/12) of fatal cases and 97.2% (140/144) of severe cases carried EV71 and CAV16. The results implied that EV71 and CAV16 were mainly responsible for the outbreak. Comparison with the three global types of EV71 and the five clusters of genotype C showed that the sequences from mainland China (not including the Hong Kong region) are located in subgenogroup C-4 and originate from isolates from the Shenzhen area of Guangdong Province. Results from this study show that the C-4 genotype has been a prevalent pathogen in mainland China since 1998.


  1. 1.
    Lin KH, Hwang KP, Ke GM et al (2006) Evolution of EV71 genogroup in Taiwan from 1998 to 2005: an emerging of subgenogroup C4 of EV71. J Med Virol 78(2):254–262PubMedCrossRefGoogle Scholar
  2. 2.
    Wu PC, Huang LM, Kao CL et al (2010) An outbreak of coxsackievirus A16 infection: comparison with other enteroviruses in a preschool in Taipei. J Microbiol Immunol Infect 43(4):271–277PubMedCrossRefGoogle Scholar
  3. 3.
    Yan JJ, Su IJ, Chen PF et al (2001) Complete genome analysis of enterovirus 71 isolated from an outbreak in Taiwan and rapid identification of enterovirus 71 and coxsackievirus A16 by RT-PCR. J Med Virol 65(2):331–339PubMedCrossRefGoogle Scholar
  4. 4.
    Hamaguchi T, Fujisawa H, Sakai K et al (2008) Acute encephalitis caused by intrafamilial transmission of enterovirus 71 in adult. Emerg Infect Dis 14:828–830PubMedCrossRefGoogle Scholar
  5. 5.
    Shahmahmoodi S, Mehrabi Z, Eshraghian MR et al (2008) First detection of enterovirus 71 from an acute flaccid paralysis case with residual paralysis in Iran. J Clin Virol 42:409–411PubMedCrossRefGoogle Scholar
  6. 6.
    Zhang Y, Zhu Z, Yang W et al (2010) An emerging recombinant human enterovirus 71 responsible for the 2008 outbreak of hand foot and mouth disease in Fuyang city of China. Virol J 7:94PubMedCrossRefGoogle Scholar
  7. 7.
    Qiu J (2008) Enterovirus 71 infection: a new threat to global public health? Lancet Neurol 7:868–869PubMedCrossRefGoogle Scholar
  8. 8.
    Chen QJ, Yan DS, Luo ZF (2008) Investigation of outbreak of HFMD caused by CA16 in a Kindergarten. Strait J Pre Med 14:45–47Google Scholar
  9. 9.
    Zhu LY, Ding ZT, Wan JF et al (2008) Epidemiology investigation of severe cases of HFMD infected with EV71 in FUYANG city. J Anhui Med 29:595–596Google Scholar
  10. 10.
    Ooi MH, Solomon T, Podin Y et al (2007) Evaluation of different clinical sample types in diagnosis of human enterovirus 71-associated hand-foot-and-mouth disease. J Clin Microbiol 45:1858–1866PubMedCrossRefGoogle Scholar
  11. 11.
    Oberste MS, Maher K, Flemister MR et al (2000) Comparison of classic and molecular approaches for the identification of untypeable enteroviruses. J Clin Microbiol 38(3):1170–1174PubMedGoogle Scholar
  12. 12.
    Ishiko H, Shimada Y, Yonaha M et al (2002) Molecular diagnosis of human enteroviruses by phylogeny-based classification by use of the VP4 sequence. J Infect Dis 185:744–754PubMedCrossRefGoogle Scholar
  13. 13.
    De W, Ke CW, Mo YL et al (2008) Multiple outbreaks of acute hemorrhagic conjunctivitis due to a variant of coxsackievirus A24:Guangdong, China, 2007. J Med Virol 80:1762–1768CrossRefGoogle Scholar
  14. 14.
    Tamura K, Dudley J, Nei M, Kumar S (2007) MEGA4: Molecular evolutionary genetics analysis (MEGA) software version 4.0. Mol Biol Evol 24:1596–1599PubMedCrossRefGoogle Scholar
  15. 15.
    Ho M, Chen ER, Hsu KH et al (1999) An epidemic of enterovirus 71 infection in Taiwan. Taiwan enterovirus epidemic working group. N Eng J Med 341:929–935CrossRefGoogle Scholar
  16. 16.
    Shah VA, Chong CY, Chan KP et al (2003) Clinical characteristics of an outbreak of hand, foot and mouth disease in Singapore. Ann Acad Med Singap 32:381–387PubMedGoogle Scholar
  17. 17.
    Russo DH, Luchs A, Machado BC et al (2006) Echovirus 4 associated to hand, foot and mouth disease. Rev Inst Med Trop Sao Paulo 48:197–199PubMedCrossRefGoogle Scholar
  18. 18.
    Chen TC, Chen GW, Hsiung CA et al (2006) Combining multiplex reverse transcription-PCR and a diagnostic microarray to detect and differentiate enterovirus 71 and coxsackievirus A16. J Clin Microbiol 44(6):2212–2219PubMedCrossRefGoogle Scholar
  19. 19.
    Chan KP, Goh KT, Chong CY et al (2003) Epidemic hand, foot and mouth disease caused by human enterovirus 71, Singapore. Emerg Infect Dis 9:78–85PubMedGoogle Scholar
  20. 20.
    Morens DM, Pallansch MA (1995) Epidemiology. In: Rotbart HA (ed) Human enterovirus infections. American Society for Microbiology, Washington, DC, pp 3–23Google Scholar
  21. 21.
    Itagaki A, Ishihara J, Mochida K et al (1983) A clustering outbreak of hand, foot, and mouth disease caused by Coxsackie virus A10. Microbiol Immunol 27:929–935PubMedGoogle Scholar
  22. 22.
    Liu JF, Zhang Y, Li H (2009) Genetic characterization of VP4-VP2 of two coxsackievirus A4 isolated from patients with hand, foot and mouth disease. Chinese. J Vac Immumol 15(4):345–349Google Scholar
  23. 23.
    Osterback R, Vuorinen T, Linna M et al (2009) Coxsackievirus A6 and hand, foot, and mouth disease, Finland. Emerg Infect Dis 15(9):1485–1488PubMedCrossRefGoogle Scholar
  24. 24.
    Lindenbaum JE, Van Dyck PC, Allen RG (1975) Hand, foot and mouth disease associated with coxsackievirus group B. Scand J Infect Dis 7:161–163PubMedGoogle Scholar
  25. 25.
    Guidotti MB (1983) An outbreak of skin rash by echovirus 25 in an infant home. J Infect 6(1):67–70PubMedCrossRefGoogle Scholar
  26. 26.
    Ortner B, Huang CW, Schmid D et al (2009) Epidemiology of enterovirus types causing neurological disease in Austria 1999–2007: detection of clusters of echovirus 30 and enterovirus 71 and analysis of prevalent genotypes. J Med Virol 81:317–324PubMedCrossRefGoogle Scholar
  27. 27.
    Kusel MM, de Klerk NH, Holt PG et al (2006) Role of respiratory viruses in acute upper and lower respiratory tract illness in the first year of life: a birth cohort study. Pediatr Infect Dis J 25:680–686PubMedCrossRefGoogle Scholar
  28. 28.
    Van Benten I, Koopman L, Niesters B et al (2003) Predominance of rhinovirus in the nose of symptomatic and asymptomatic infants. Pediatr Allergy Immunol 114:363–370CrossRefGoogle Scholar
  29. 29.
    Fujimoto T, Shinohara M, Ito M et al (2007) Detection of dual-infected cases of adenoviruses and coxsackieviruses type B by real-time PCR but not by the conventional viral culture technique. Clin Lab 53(9–12):605–609PubMedGoogle Scholar
  30. 30.
    Ooi MH, Wong SC, Podin Y et al (2007) Human enterovirus 71 disease in Sarawak, Malaysia: a prospective clinical, virological, and molecular epidemiological study. Clin Infect Dis 44(5):646–656PubMedCrossRefGoogle Scholar
  31. 31.
    Chu PY, Lin KH, Hwang KP et al (2001) Molecular epidemiology of enterovirus 71 in Taiwan. Arch Virol 146:589–600PubMedCrossRefGoogle Scholar
  32. 32.
    Shimizu H, Utama A, Onnimala N et al (2004) Molecular epidemiology of enterovirus 71 infection in the Western Pacific Region. Pediatr Int 46:231–235PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag 2011

Authors and Affiliations

  • Wu De
    • 1
  • Ke Changwen
    • 1
  • Li Wei
    • 1
  • Corina Monagin
    • 2
  • Yan Jin
    • 1
  • Ma Cong
    • 1
  • Zen Hanri
    • 1
  • Su Jun
    • 1
  1. 1.Institute of Microbiology, Center for Disease Control and Prevention of GuangdongGuangzhouPeople’s Republic of China
  2. 2.Global Viral Forecasting InitiativeSan FranciscoUSA

Personalised recommendations