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Enterovirus 71 & HFMD

Microbecide® Special Report

Enterovirus 71 and Hand, Foot, and Mouth Disease

The most common cause of Hand, Foot, and Mouth Disease (HFMD) is coxsackievirus A16; coxsackieviruses are a member of the enterovirus group which includes polioviruses, echoviruses and other enteroviruses.

Many enteroviruses are associated with specific syndromes. For example, the Human enterovirus A species more commonly causes hand-foot-mouth disease (rash especially on the palms and soles with vesicular eruption and inflammation of the mouth). Those within the Human enterovirus B species more commonly cause meningitis or myopericarditis. Non-polio enteroviruses are common and distributed worldwide.

Today more and more cases that appear to be HFMD are actually being caused by a virus identified as enterovirus 71 (EV71). Replication of the enterovirus begins in the gastrointestinal or respiratory tract and once the virus is present in the blood stream, infection may affect various tissues and organs, causing a variety of diseases.

The majority of infections are symptomless or mild in nature, the most common effect being a non-specific illness, with fever.

However, more sinister manifestations include rashes, vesicular eruption and inflammation of the throat, acute respiratory disease, conjunctivitis, aseptic meningitis, encephalitis (inflammation of the brain), myopericarditis (inflammation of the heart tissue), and, occasionally, paralytic diseases.

EV71 may cause viral meningitis and, rarely, more serious diseases, such as encephalitis, or a poliomyelitis-like paralysis. EV71 encephalitis may be fatal. Cases of fatal encephalitis occurred during outbreaks of HFMD in Malaysia in 1997.

A major enterovirus outbreak hit Taiwan in 1998, infecting up to 300,000 children with HFMD and killing at least 55, according to the World Health Organization.

Outbreaks of aseptic meningitis associated with enterovirus infection have previously been reported from the Gaza Strip (1997) and Cyprus (1996).

HFMD is characterized by fever, sores in the mouth, and a rash with blisters. It begins with a mild fever, poor appetite, malaise ("feeling sick"), and frequently a sore throat.

One or two days after the fever begins, painful sores develop in the mouth. They begin as small red spots that blister and then often become ulcers. They are usually located on the tongue, gums, and inside of the cheeks. The skin rash develops over 1 to 2 days with flat or raised red spots, some with blisters.

The rash does not itch, and it is usually located on the palms of the hands and soles of the feet. It may also appear on the buttocks. A person with HFMD may have only the rash or the mouth ulcers.

HFMD is NOT the same as foot-and-mouth disease. Foot-and-mouth is a disease of cattle, sheep, and swine. Although the names are similar, the two diseases are not related at all and are caused by different viruses.

Highly Contagious

EV71 is highly contagious, HFMD is moderately contagious. Infection is spread from person to person by direct contact with nose and throat discharges, saliva, fluid from blisters, or the stool of infected persons. A person is most contagious during the first week of the illness. HFMD is not transmitted to or from pets or other animals.

There are no known specific preventions for HFMD or other non-polio enterovirus infections, but the risk of infection can be lowered by good hygienic practices.

Preventive measures include frequent hand washing, especially after diaper changes, cleaning of contaminated surfaces and soiled items first with soap and water, and then disinfecting them with Microbecide® silver ion complex.

Avoidance of close contact (kissing, hugging, sharing utensils, etc.) with children with HFMD may also help to reduce the risk of infection to caregivers.

HMFD In Childcare Setting

HFMD caused by coxsackievirus A16 infection is a mild disease and nearly all patients recover without medical treatment in 7 to 10 days. Complications are uncommon.

There are no specific recommendations regarding the exclusion of children with HFMD from child care programs, schools, or other group settings.

Exclusion of ill persons may not prevent additional cases since the virus may be excreted for weeks after the symptoms have disappeared. Also, some persons excreting the virus, including most adults, may have no symptoms.

Prevention and Control

Transmission of enterovirus infections is increased by poor hygiene and overcrowded living conditions. Improved sanitation and general hygiene are important preventive measures.

The viruses are resistant to many disinfectants so it is important to use an antimicrobal agent that is effective against viruses as well as bacteria. Many virucidal disinfectants are toxic and require special handling. Often, because of the toxicity of the disinfecting agent, the disinfection process can require the use of protective equipment and clothing and take several days to ventilate the area of toxic residue.

Microbecide® silver ion complex is an antimicrobial that is natural and non-toxic, safe for use around children and around food preparation areas. Non-flammable, non-caustic and non-corrosive, it also provides a 24 hour protective surface barrier to prevent recontamination.


During recognized epidemics, it may be advised to close certain institutions such as schools or child care facilities and throughly decontaminate them in order to reduce transmission especially among young children.

Decontamination Challenges

A particular challenge is dealing with large, contaminated areas such as schools or play centers. Decon Suited PersonnelThe closing of high usage facilities for extended periods of time disrupts operations, inconveniences customers and users, results in loss of revenue and increases costs. Safety and efficacy compounded by the length of time required to clear toxic residue often present conflicting demands.

Microbecide® Bio Decontamination System's ionic silver technology is tough enough to rapidly kill a broad range of dangerous pathogens, yet gentle enough for even daily use by personnel without masks or gloves.

The Microbecide® Bio Decontamination Service removes the need to close high usage facilities by rapidly (overnight for a large school), decontaminating large indoor or outdoor areas safely and without toxic residue or harm to the enviornment.

Humans Are Natural Hosts

Enteroviruses infecting humans are found worldwide and humans are the only known natural hosts. Young children are most susceptible to infection. In less developed areas, children may become infected during early infancy while in more socio-economically advanced areas, first infection may not occur until adolescence.

Males more often develop clinically-recognizable diseases than females. Transmission is usually by the feaco-oral or by the respiratory route when there is an associated respiratory illness. The virus may be excreted in the stool for many weeks.

Enteroviruses have been detected in water, soil, vegetables and shellfish and may possibly be transmitted in the community by contact with contaminated food or water. The epidemiological pattern varies by geographical region and climate, but the incidence of infection is higher in the summer and autumn months in temperate climates while remaining prevalent year-round in tropical climates.

Diagnosis Clinically

It is difficult to distinguish the specific cause of most enteroviral infections. Diagnostic testing for non-polio enteroviruses requires specialized laboratory facilities. Diagnosis is made by detecting virus in throat or fecal samples or, more convincingly, from specimens collected from the affected part of the body, for example, cerebrospinal fluid (CSF), biopsy material, and skin lesions.

Incubation Period

The usual period from infection to onset of symptoms ("incubation period") is 3 to 7 days. Fever is often the first symptom of HFMD.

HFMD occurs mainly in children under 10 years old, but may also occur in adults too. Everyone is at risk of infection, but not everyone who is infected becomes ill.

Infants, children, and adolescents are more likely to be susceptible to infection and illness from these viruses, because they are less likely than adults to have antibodies and be immune from previous exposures to them.

Infection results in immunity to the specific virus, but a second episode may occur following infection with a different member of the enterovirus group.

Risks to Pregnant Women

Because enteroviruses, including those causing HFMD, are very common, pregnant women are frequently exposed to them, especially during summer and fall months. As for any other adults, the risk of infection is higher for pregnant women who do not have antibodies from earlier exposures to these viruses, and who are exposed to young children - the primary spreaders of enteroviruses.

Strict adherence to generally recommended good hygienic practices by the pregnant woman may help to decrease the risk of infection during pregnancy and around the time of delivery.

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No specific antiviral agent is available for therapy of enterovirus infection. Treatment focuses on management of complications (for example, meningitis, abnormal cardiac rhythms, and heart failure). Intravenous administration of immune globulin may have a use in preventing severe disease in immunocompromised individuals or those with life-threatening disease.


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