Cambodia’s Outbreak Linked to Hand, Foot, Mouth Virus

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By Natasha Khan and Daniel Ten Kate on July 09, 2012

Researchers found a virus that causes hand, foot and mouth disease in patients who succumbed to an illness that has killed dozens of children in Cambodia.

The Institut Pasteur du Cambodge discovered enterovirus 71 in 15 of 24 children presenting with the symptoms since mid- June, Philippe Buchy, head of the Phnom Penh-based institute’s virology unit, said yesterday by phone. The virus may be linked to the deaths of more than 60 children across the country since April, he said.

“This information is valuable and will help the investigation tremendously,” said Nima Asgari, leader of the emerging diseases surveillance and response group at the World Health Organization in Cambodia, which is helping the local Ministry of Health find the cause of the illness.

Samples tested were negative for influenzas including H5N1, or bird flu, SARS and Nipah virus, the Ministry of Health and WHO said in a joint statement yesterday. If enterovirus 71 is further confirmed, “it is in a sense reassuring — at least we know it’s not a new virus that has stepped out of the woodwork,” said Malik Peiris, chair professor in virology at the University of Hong Kong’s School of Public Health.

The investigators are reviewing the records of cases in which hospitalized children died before the tests started to confirm they “at least clinically and epidemiologically” fit the hand, foot and mouth disease profile, Asgari said in an e- mailed response to questions.

‘Unknown Disease’

A total of 59 children were affected by this “unknown disease,” according to a review of suspected hospitalized cases, the Ministry of Health and WHO said.

The Southeast Asian kingdom’s health ministry announced July 4 that it was working with the WHO to actively investigate the cause of the deaths. The majority of the patients were hospitalized in the Kantha Bopha Children’s Hospital in Phnom Penh, the WHO said in a July 6 statement.

Children admitted to hospitals with symptoms including high fever, breathing difficulty and neurological problems had rapid deterioration of respiratory function, Joy Rivaca Caminade, a technical officer with WHO’s Regional Office for the Western Pacific in Manila, said July 6.

The affected children developed “in the last hours of their life a total destruction of the alveolas in the lungs,” Beat Richner, head of the hospital, said yesterday in an e- mailed statement. They also suffered encephalitis, he said.

Vorn Pov

Among the dead was Vorn Pov, whom his father said was 12 years old. In Cambodia, it’s common to add a year when counting ages. Vorn Pov died on June 23, about a week after he first became sick. His father, Khuth Vorn, 53, lives in a wooden thatched roof house next to lush green rice fields in Prey Veng province, southeast of Phnom Penh near the border with Vietnam.

When Vorn Pov first got sick, Khuth Vorn took him to a local clinic, where he stayed for three days. He was transferred to a private clinic in Prey Veng provincial town for four days when his condition worsened, after which he was taken to the Kantha Bopha hospital, Khuth Vorn said. His son arrived at 5 p.m. and was pronounced dead four hours later.

“The doctors said his lungs had burned,” Khuth Vorn said, sitting shirtless at a stone table as half-a-dozen barefooted small children played around him in dirt littered with plastic bags, empty soda bottles and discarded cigarette packages. “My wife was sobbing. We felt helpless.”

Provincial and district officials visited him yesterday to find out more details about his son’s illness, he said.

Iceberg Effect

“If EV-71 is the explanation, what very likely occurred is a massive outbreak of hand, mouth and foot disease, which might not have hit the radar because it’s generally a mild disease and lasts for a few days,” said Peiris.

Peiris explained that in epidemiology there is what is called the iceberg effect: where only a small percentage of the affected present as a serious disease. “What is different could be the host’s ability to combat the disease,” he said.

Hand, foot and mouth disease is a common infectious disease in infants and children, according to the joint release. It is spread from person to person by direct contact with nose or throat discharges, saliva, fluid from blisters, or the feces of the infected, according to the release.

The coxsackievirus A16 is the most common cause of hand, foot and mouth disease, according to the release, which usually results in a “mild, self-limited disease with few complications.” Enterovirus 71 “causes the same picture of the disease, and in some cases it has the predilection to hit the brain stem region, which may explain the complications seen in the Cambodian patients,” Peiris said.

The majority of the children affected by the illness were less than 3 years old, according to the joint statement.

“We hope to be able to conclude our investigation in the coming days,” Cambodia’s Minister of Health Mam BunHeng, said in the joint release.

To contact the reporters on this story: Natasha Khan in Hong Kong at; Daniel Ten Kate in Bangkok at

To contact the editors responsible for this story: Jason Gale at; Tony Jordan at


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