Molecular epidemiology of human enterovirus 71 at the origin of an epidemic of fatal hand, foot and mouth disease cases in Cambodia

Abstract

Human enterovirus 71 (EV-A71) causes hand, foot and mouth disease (HFMD). EV-A71 circulates in many countries and has caused large epidemics, especially in the Asia-Pacific region, since 1997. In April 2012, an undiagnosed fatal disease with neurological involvement and respiratory distress occurred in young children admitted to the Kantha Bopha Children’s Hospital in Phnom Penh, Cambodia. Most died within a day of hospital admission, causing public panic and international concern. In this study, we describe the enterovirus (EV) genotypes that were isolated during the outbreak in 2012 and the following year. From June 2012 to November 2013, 312 specimens were collected from hospitalized and ambulatory patients and tested by generic EV and specific EV-A71 reverse transcription PCR. EV-A71 was detected in 208 clinical specimens while other EVs were found in 32 patients. The VP1 gene and/or the complete genome were generated. Our phylogenetic sequencing analysis demonstrated that 80 EV-A71 strains belonged to the C4a subgenotype and 3 EV-A71 strains belonged to the B5 genotype. Furthermore, some lineages of EV-A71 were found to have appeared in Cambodia following separate introductions from neighboring countries. Nineteen EV A (CV-A6 and CV-A16), 9 EV B (EV-B83, CV-B3, CV-B2, CV-A9, E-31, E-2 and EV-B80) and 4 EV C (EV-C116, EV-C96, CV-A20 and Vaccine-related PV-3) strains were also detected. We found no molecular markers of disease severity. We report here that EV-A71 genotype C4 was the main etiological agent of a large outbreak of HFMD and particularly of severe forms associated with central nervous system infections. The role played by other EVs in the epidemic could not be clearly established.

• Cambodia
• epidemic
• hand foot and mouth disease
• human enterovirus 71
• severe disease

We thank the Institut Pasteur in Shanghai (Ke Lan, Peijun Ren, Qianqian Zhu, Shanshan Xu, Jia Liu, Lili Wang, Qingwei Liu), Institut Pasteur in Cambodia (Vincent Deubel), Institut Pasteur in Paris (Anna-Maria Burgiere, Erika Muth, Marc Jouan, Magali Herrant, Jerome Salomon, Marie-Line Joffret and Romain Volle) and the J. Craig Venter Institute (Rebecca Halpin, Dana Busan, Wei Wang and Xudong Lin), as well as the patients and the health-care teams from Kantha Bopha Hospital. This study was financially supported by the Outbreak investigation funds of the International Division of the Institut Pasteur. The sequencing work performed by the J. Craig Venter Institute was funded in whole or part with federal funds from the National Institute of Allergy and Infectious Diseases, National Institutes of Health, Department of Health and Human Services under contract number HHSN272200900007C. The opinions expressed in this article are the authors’ own and do not reflect the view of the Centers for Disease Control and Prevention, the Department of Health and Human Services or the United States Government.

Supplementary Information for this article can be found on the Emerging Microbes & Infections website (http://www.nature.com/emi)