Echovirus Type 11: Outbreak of Hand-Foot-and-Mouth Disease in a Thai Hospital Nursery

SirHand-foot-and-mouth disease (HFMD) is a mild exanthematous illness seen worldwide. The causative agents of HFMD include various serotypes of coxsackievirus, echovirus, and enterovirus [2]. In recent decades, HFMD caused by enterovirus serotype 71 has undergone a transformation from a minor, self-limited illness to the cause of major epidemics with high associated morbidity and mortality. This has been particularly so in Asian-Pacific countries [3–7]. In Thailand, the annual incidence of HFMD was estimated to be 5.65 cases per 100,000 population, with no associated deaths, in 2003 [8]. We reported the first outbreak of HFMD caused by echovirus type 11 in a Thai hospital nursery. On 16 March 2005, we were contacted by a staff member at the nursery unit of Thammasart University Hospital regarding a cluster of HFMD infections. The index case had been diagnosed on 10 March 2005. Over the next 6 days, 12 (20%) of 60 children subsequently developed painful vesicular lesions on the palms of their hands, the soles of their feet, and on their oral mucosa. The median age of the patients was 2.1 years (range, 1.12.9 years), and 6 (50%) were boys. All 12 children with HFMD had contact with the index case through shared toys and utensils. HFMD was confirmed, and the epidemiologic curve was created (figure 1). No children infected with HFMD developed any complications, and all care providers were without evidence of infection. Epidemiologic curve of a hand-foot-and-mouth disease outbreak in a Thai hospital nursery. Stool samples for viral culture were obtained from 6 children infected with HFMD, 6 children not infected with HFMD, and all care providers. Cultures of environmental samples, including samples from activity and play room surfaces, tables, the computer, door handles, and the bathroom, were also performed. Multiple observations of pediatric care revealed modifiable breaches in infection control practices: towel-sharing, an irregular and unmonitored environmental cleaning schedule (for the nursery, toys, playroom, door handles, computer, and telephones), and poor compliance with hand hygiene. After extensive discussion with the hospital administration, the nursery was closed within 24 h after the infection control evaluation. During the 14-day unit closure, all soiled articles and clothing were cleaned, all surfaces were exposed to 1 : 10 sodium hypochlorite solution with 10-min dwell times, and a revised routine cleaning schedule for the nursery and an improved hand hygiene program were initiated. Stool cultures from 4 (66.6%) of 6 screened children infected with HFMD subsequently yielded echovirus type 11. No subsequent cases were identified in the 4 months after the nursery unit reopened. Within the recognized limitations of retrospective study design, we report the first nosocomial outbreak of HFMD due to echovirus type 11. A definitive diagnosis of echovirus type 11 infection was made for the majority (66.6%) of symptomatic children with available stool for viral cultures. A presumptive diagnosis of echovirus type 11 infection was made for the other 6 symptomatic children who did not have stool culture performed. Our investigation supports the need for ongoing epidemiological surveillance and the rapid involvement of infection control specialists in Asian-Pacific outbreaks, to target prevention and control of emerging and reemerging infectious pathogens. Furthermore, our data emphasize the importance of compliance with infection control practices, especially hand hygiene, to help limit the transmission of communicable diseases. Potential conflicts of interest. All authors: no conflicts.