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Targeting an epidemic before it hurts

By Shan Juan (China Daily)
Updated: 2008-06-27 07:38

A child gets a mouthwash at a kindergarten in Fuyang, Anhui province, on June 2.

Five years ago, an epidemic of the Severe Acute Respiratory Syndrome, better known as SARS, showed the authorities the benefits of transparency in reporting and handling a health crisis.

In a similar vein, this year's outbreak of hand, foot and mouth disease (HFMD) - which peaked at 11,501 daily reported cases on May 14 - has forced both central and local health authorities to find and plug loopholes in their surveillance of and response to epidemics.

HFMD can be caused by a host of intestinal viruses, but enterovirus 71 (EV71) is considered one of the more common ones that can cause a severe form of the disease.

The disease usually starts with a slight fever followed by blisters and ulcers in the mouth, and rashes on the hands and feet. Those affected by the EV71 often have serious symptoms, which can lead to meningitis, encephalitis, pulmonary edema and paralysis in some children.

HFMD itself is spread through direct contact with the mucus, saliva, or feces of an infected person.

EV71 is a frequent cause of HFMD epidemics associated with neurological disease in a small proportion of cases, the World Health Organization (WHO) has said.

HFMD cases, with a number having EV71 as the causative agent, hit 176,321 and including 40 fatalities - mostly involving children - on the Chinese mainland in May alone, the Ministry of Health reported.

Local Beijing health officials also warned this week that summer remains a peak season for HFMD.

The deaths of children from pneumonia-like symptoms first occurred in Fuyang, Anhui province, in late March.

The HFMD outbreak was confirmed and made public nationwide about a month later on April 27 - four days after the EV71 was identified in the cases.

By then, the number of recorded HFMD infections soared to more than 1,000 in Fuyang alone, including 20 fatalities.

The virus also spread to neighboring Henan province.

The sharp rise in the number of infections was mainly due to the fact that the virus spreads via routine contact, medical experts have explained. Infected adults can also pass on the virus to others, particularly children, even though they develop no serious symptoms other than rashes on hands.

"The longer people are kept in dark, the more likely they will get infected," said Yang Weizhong, the deputy chief of the Chinese Center for Disease Control and Prevention (CDC), adding that people can be caught unawares and not take any preventive measures.

Questions have been raised as to why it took so long for the public to be informed of the infectious disease. Although there is currently no vaccine available for the disease, measures such as hand washing and other ways of keeping personal hygiene have been known to be effective in guarding against the infection.

A number of contributing factors have been cited for the delay.

Before May 2, HFMD was not listed as an infection that had to be reported.

"It was beyond our scope to publicize the epidemic without accreditation from higher authority," said Wang Hao, spokesman for the Fuyang government.

Procedural delays were also cited.

The doctor who raised the alarm for the epidemic was pediatrician Liu Xiaolin, of Fuyang No 1 Hospital, after she saw two youngsters die "in front of my eyes, within hours", on the night of March 28.

Liu first attributed the deaths to lung infection, although the HFMD caused by EV71 is associated with neurological disease.

Upon receiving the death report from Liu on March 29, experts from the local Fuyang health bureau and the CDC immediately started lab work, discussions, and other research, to find out the definite cause of the deadly disease, said Yan Wei, deputy director of the Fuyang health bureau.

Meanwhile, the alert on what was known of the infection was sent out, but only to local hospitals to strengthen surveillance.

Yan and his colleagues had little to work on. Last year, a total of eight HFMD cases, including one adult, was reported in Fuyang.

"It must have been underreported, as the infection was not listed as one that had to be reported before May," said Ni Daxin, a leading researcher at the CDC.

Ni said no lab test had ever been taken in Fuyang to figure out the specific virus behind the disease.

Unable to pin down the cause of the latest outbreak in three days, Yan and his colleagues immediately turned to the provincial health authority, reporting the epidemic on March 31.

However, it took the provincial health authority another 14 days to report the outbreak to the Ministry of Health.

Above all, there was the difficulty of verifying the virus for a public dissemination of the health threat that was already overdue, said Yang from the CDC.

Feng Zijian, director of the emergency response department of the CDC, attributed the challenging verification process to complicated lab tests, which could take up a lot of time.

"In the initial stages of the probe, efforts were expended to rule out serious viral diseases like SARS, bird flu and meningitis," he said.

At that time, the CDC labs in most provinces already had the capacity for EV71 testing and confirmation.

"If you know you are looking for the EV71 virus, it takes a very short time to verify the virus; if you don't know and have a case in front of you of an unknown disease, of course it can take a month, or even longer," said WHO China Representative Hans Troedsson.

Yang Hui, who lives in the suburb of Fuyang and has a 4-year-old daughter and 2-year-old boy, still laments why it took so long for people like her to learn about ways to prevent HFMD.

"My boy was in the intensive care unit of the People's Hospital of Fuyang for nearly a week," she told China Daily on May 2, as she waited for the doctor to see her daughter who developed rashes on her hands at the hospital.

"If we were told earlier about the problem, even if the information was not accurate and detailed, I would not have delayed treatment for my boy and my girl might not have been infected," she said.

When Yang first learnt about EV71 on April 27 through a radio program, she received from the village clinic a thermometer, a bottle of disinfectant, and a brochure explaining how the viral disease can be transmitted simply through the sharing of eating utensils and how, in most cases, it can be prevented.

"That knowledge came too late," she said.

The early deaths from the viral infection were largely caused by delayed and improper treatment, themselves a result of ignorance of the illness, pediatrician Liu Xiaolin said.

HFMD is now listed with 37 other contagious diseases, including SARS, tuberculosis and HIV/AIDS, as a notifiable infection.

Cheng Xiaodong, a public health professor with Wuhan University, said that government agencies should learn to become more media savvy to publicize issues closely related to people's life and health, without delay and in a mutually accepted way.

A doctor treats a boy infected with hand, foot and mouth disease at the No 2 People's Hospital in Fuyang on May 8.