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Enterovirus A71 (EV-A71) is an emerging pathogen that causes a wide range of disorders including severe neurological manifestations. In the past 20 years, this virus has been associated with large outbreaks of hand, foot and mouth disease with neurological complications in the Asia-Pacific region, while in Europe mainly sporadic cases have been reported. In spring 2016, however, an EV-A71 outbreak associated with severe neurological cases was reported in Catalonia and spread further to other Spanish regions.


Our objective was to investigate the epidemiology and clinical characteristics of the outbreak.


We carried out a retrospective study which included 233 EV-A71-positive samples collected during 2016 from hospitalised patients. We analysed the clinical manifestations associated with EV-A71 infections and performed phylogenetic analyses of the 3’-VP1 and 3Dpol regions from all Spanish strains and a set of EV-A71 from other countries.


Most EV-A71 infections were reported in children (mean age: 2.6 years) and the highest incidence was between May and July 2016 (83%). Most isolates (218/233) were classified as subgenogroup C1 and 217 of them were grouped in one cluster phylogenetically related to a new recombinant variant strain associated with severe neurological diseases in Germany and France in 2015 and 2016. Moreover, we found a clear association of EV-A71-C1 infection with severe neurological disorders, brainstem encephalitis being the most commonly reported.


An emerging recombinant variant of EV-A71-C1 was responsible for the large outbreak in 2016 in Spain that was associated with many severe neurological cases.


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  1. Zell R, Delwart E, Gorbalenya AE, Hovi T, King AMQ, Knowles NJ, et al. ICTV virus taxonomy profile: Picornaviridae. J Gen Virol. 2017;98(10):2421-2.  https://doi.org/10.1099/jgv.0.000911  PMID: 28884666 
  2. Hassel C, Mirand A, Lukashev A, TerletskaiaLadwig E, Farkas A, Schuffenecker I, et al. Transmission patterns of human enterovirus 71 to, from and among European countries, 2003 to 2013. Euro Surveill. 2015;20(34):30005.  https://doi.org/10.2807/1560-7917.ES.2015.20.34.30005  PMID: 26530407 
  3. Ooi MH, Wong SC, Lewthwaite P, Cardosa MJ, Solomon T. Clinical features, diagnosis, and management of enterovirus 71. Lancet Neurol. 2010;9(11):1097-105.  https://doi.org/10.1016/S1474-4422(10)70209-X  PMID: 20965438 
  4. Lee KY. Enterovirus 71 infection and neurological complications. Korean J Pediatr. 2016;59(10):395-401.  https://doi.org/10.3345/kjp.2016.59.10.395  PMID: 27826325 
  5. Yip CC, Lau SK, Woo PC, Yuen KY. Human enterovirus 71 epidemics: what’s next? Emerg Health Threats J. 2013;6(1):19780.  https://doi.org/10.3402/ehtj.v6i0.19780  PMID: 24119538 
  6. McMinn PC. Recent advances in the molecular epidemiology and control of human enterovirus 71 infection. Curr Opin Virol. 2012;2(2):199-205.  https://doi.org/10.1016/j.coviro.2012.02.009  PMID: 22482716 
  7. Tee KK, Lam TT, Chan YF, Bible JM, Kamarulzaman A, Tong CY, et al. Evolutionary genetics of human enterovirus 71: origin, population dynamics, natural selection, and seasonal periodicity of the VP1 gene. J Virol. 2010;84(7):3339-50.  https://doi.org/10.1128/JVI.01019-09  PMID: 20089660 
  8. Cardosa MJ, Perera D, Brown BA, Cheon D, Chan HM, Chan KP, et al. Molecular epidemiology of human enterovirus 71 strains and recent outbreaks in the Asia-Pacific region: comparative analysis of the VP1 and VP4 genes. Emerg Infect Dis. 2003;9(4):461-8.  https://doi.org/10.3201/eid0904.020395  PMID: 12702227 
  9. Chan KP, Goh KT, Chong CY, Teo ES, Lau G, Ling AE. Epidemic hand, foot and mouth disease caused by human enterovirus 71, Singapore. Emerg Infect Dis. 2003;9(1):78-85.  https://doi.org/10.3201/eid1301.020112  PMID: 12533285 
  10. McMinn P, Lindsay K, Perera D, Chan HM, Chan KP, Cardosa MJ. Phylogenetic analysis of enterovirus 71 strains isolated during linked epidemics in Malaysia, Singapore, and Western Australia. J Virol. 2001;75(16):7732-8.  https://doi.org/10.1128/JVI.75.16.7732-7738.2001  PMID: 11462047 
  11. Donato C, Hoi T, Hoa NT, Hoa TM, Van Duyet L, Dieu Ngan TT, et al. Genetic characterization of Enterovirus 71 strains circulating in Vietnam in 2012. Virology. 2016;495:1-9.  https://doi.org/10.1016/j.virol.2016.04.026  PMID: 27148893 
  12. AbuBakar S, Sam IC, Yusof J, Lim MK, Misbah S, MatRahim N, et al. Enterovirus 71 outbreak, Brunei. Emerg Infect Dis. 2009;15(1):79-82.  https://doi.org/10.3201/eid1501.080264  PMID: 19116058 
  13. Fujimoto T, Chikahira M, Yoshida S, Ebira H, Hasegawa A, Totsuka A, et al. Outbreak of central nervous system disease associated with hand, foot, and mouth disease in Japan during the summer of 2000: detection and molecular epidemiology of enterovirus 71. Microbiol Immunol. 2002;46(9):621-7.  https://doi.org/10.1111/j.1348-0421.2002.tb02743.x  PMID: 12437029 
  14. Chang PC, Chen SC, Chen KT. The current status of the disease caused by enterovirus 71 infections: epidemiology, pathogenesis, molecular epidemiology, and vaccine development. Int J Environ Res Public Health. 2016;13(9):E890.  https://doi.org/10.3390/ijerph13090890  PMID: 27618078 
  15. Chumakov M, Voroshilova M, Shindarov L, Lavrova I, Gracheva L, Koroleva G, et al. Enterovirus 71 isolated from cases of epidemic poliomyelitis-like disease in Bulgaria. Arch Virol. 1979;60(3-4):329-40.  https://doi.org/10.1007/BF01317504  PMID: 228639 
  16. Nagy G, Takátsy S, Kukán E, Mihály I, Dömök I. Virological diagnosis of enterovirus type 71 infections: experiences gained during an epidemic of acute CNS diseases in Hungary in 1978. Arch Virol. 1982;71(3):217-27.  https://doi.org/10.1007/BF01314873  PMID: 6285858 
  17. Mirand A, Schuffenecker I, Henquell C, Billaud G, Jugie G, Falcon D, et al. Phylogenetic evidence for a recent spread of two populations of human enterovirus 71 in European countries. J Gen Virol. 2010;91(Pt 9):2263-77.  https://doi.org/10.1099/vir.0.021741-0  PMID: 20505012 
  18. Böttcher S, Obermeier PE, Neubauer K, Diedrich SLaboratory Network for Enterovirus Diagnostics. Recombinant Enterovirus A71 Subgenogroup C1 Strains, Germany, 2015. Emerg Infect Dis. 2016;22(10):1843-6.  https://doi.org/10.3201/eid2210.160357  PMID: 27439117 
  19. Karrasch M, Fischer E, Scholten M, Sauerbrei A, Henke A, Renz DM, et al. A severe pediatric infection with a novel enterovirus A71 strain, Thuringia, Germany. J Clin Virol. 2016;84:90-5.  https://doi.org/10.1016/j.jcv.2016.09.007  PMID: 27771495 
  20. Antona D, Kossorotoff M, Schuffenecker I, Mirand A, Leruez-Ville M, Bassi C, et al. Severe paediatric conditions linked with EV-A71 and EV-D68, France, May to October 2016. Euro Surveill. 2016;21(46):30402.  https://doi.org/10.2807/1560-7917.ES.2016.21.46.30402  PMID: 27918268 
  21. Wieczorek M, Purzyńska M, Krzysztoszek A, Ciąćka A, Figas A, Szenborn L. Genetic characterization of enterovirus A71 isolates from severe neurological cases in Poland. J Med Virol. 2018;90(2):372-6.  https://doi.org/10.1002/jmv.24958  PMID: 28960454 
  22. Cabrerizo M, Tarragó D, Muñoz-Almagro C, Del Amo E, Domínguez-Gil M, Eiros JM, et al. Molecular epidemiology of enterovirus 71, coxsackievirus A16 and A6 associated with hand, foot and mouth disease in Spain. Clin Microbiol Infect. 2014;20(3):O150-6.  https://doi.org/10.1111/1469-0691.12361  PMID: 24033818 
  23. Cabrerizo M, Díaz-Cerio M, Muñoz-Almagro C, Rabella N, Tarragó D, Romero MP, et al. Molecular epidemiology of enterovirus and parechovirus infections according to patient age over a 4-year period in Spain. J Med Virol. 2017;89(3):435-42.  https://doi.org/10.1002/jmv.24658  PMID: 27505281 
  24. Casas-Alba D, de Sevilla MF, Valero-Rello A, Fortuny C, García-García JJ, Ortez C, et al. Outbreak of brainstem encephalitis associated with enterovirus-A71 in Catalonia, Spain (2016): a clinical observational study in a children’s reference centre in Catalonia. Clin Microbiol Infect. 2017;23(11):874-81.  https://doi.org/10.1016/j.cmi.2017.03.016  PMID: 28344164 
  25. European Centre for Disease Prevention and Control (ECDC). Outbreak of enterovirus A71 with severe neurological symptoms among children in Catalonia, Spain. 14 June 2016. Stockholm: ECDC. 2016. Available from: http://ecdc.europa.eu/en/publications/Publications/07-06-2016-RRA-Enterovirus%2071-Spain.pdf
  26. European Centre for Disease Prevention and Control (ECDC). Rapid risk assessment. Enterovirus detection associated with severe neurological symptoms in children and adults in European countries. Stockholm: ECDC. 2016. Available from: http://ecdc.europa.eu/en/publications/Publications/01-08-2016-RRA-Enterovirus%2071-Spain,%20France,%20Netherlands.pdf
  27. Casas I, Tenorio A, Echevarría JM, Klapper PE, Cleator GM. Detection of enteroviral RNA and specific DNA of herpesviruses by multiplex genome amplification. J Virol Methods. 1997;66(1):39-50.  https://doi.org/10.1016/S0166-0934(97)00035-9  PMID: 9220389 
  28. McWilliam Leitch EC, Cabrerizo M, Cardosa J, Harvala H, Ivanova OE, Koike S, et al. The association of recombination events in the founding and emergence of subgenogroup evolutionary lineages of human enterovirus 71. J Virol. 2012;86(5):2676-85.  https://doi.org/10.1128/JVI.06065-11  PMID: 22205739 
  29. Harvala H, Broberg E, Benschop K, Berginc N, Ladhani S, Susi P, et al. Recommendations for enterovirus diagnostics and characterisation within and beyond Europe. J Clin Virol. 2018;101:11-7.  https://doi.org/10.1016/j.jcv.2018.01.008  PMID: 29414181 
  30. Trallero G, Avellon A, Otero A, De Miguel T, Pérez C, Rabella N, et al. Enteroviruses in Spain over the decade 1998-2007: virological and epidemiological studies. J Clin Virol. 2010;47(2):170-6.  https://doi.org/10.1016/j.jcv.2009.11.013  PMID: 20007023 
  31. Ho M, Chen ER, Hsu KH, Twu SJ, Chen KT, Tsai SF, et al. An epidemic of enterovirus 71 infection in Taiwan. N Engl J Med. 1999;341(13):929-35.  https://doi.org/10.1056/NEJM199909233411301  PMID: 10498487 
  32. Koh WM, Bogich T, Siegel K, Jin J, Chong EY, Tan CY, et al. The epidemiology of hand, foot and mouth disease in Asia: a systematic review and analysis. Pediatr Infect Dis J. 2016;35(10):e285-300.  https://doi.org/10.1097/INF.0000000000001242  PMID: 27273688 
  33. Zhu FC, Meng FY, Li JX, Li XL, Mao QY, Tao H, et al. Efficacy, safety, and immunology of an inactivated alum-adjuvant enterovirus 71 vaccine in children in China: a multicentre, randomised, double-blind, placebo-controlled, phase 3 trial. Lancet. 2013;381(9882):2024-32.  https://doi.org/10.1016/S0140-6736(13)61049-1  PMID: 23726161 
  34. Duong V, Mey C, Eloit M, Zhu H, Danet L, Huang Z, et al. Molecular epidemiology of human enterovirus 71 at the origin of an epidemic of fatal hand, foot and mouth disease cases in Cambodia. Emerg Microbes Infect. 2016;5(9):e104.  https://doi.org/10.1038/emi.2016.101  PMID: 27651091 
  35. Bible JM, Pantelidis P, Chan PK, Tong CY. Genetic evolution of enterovirus 71: epidemiological and pathological implications. Rev Med Virol. 2007;17(6):371-9.  https://doi.org/10.1002/rmv.538  PMID: 17487831 
  36. Solomon T, Willison H. Infectious causes of acute flaccid paralysis. Curr Opin Infect Dis. 2003;16(5):375-81.  https://doi.org/10.1097/00001432-200310000-00002  PMID: 14501988 
  37. NikNadia N, Sam IC, Rampal S, WanNorAmalina W, NurAtifah G, Verasahib K, et al. Cyclical patterns of hand, foot and mouth disease caused by enterovirus A71 in Malaysia. PLoS Negl Trop Dis. 2016;10(3):e0004562.  https://doi.org/10.1371/journal.pntd.0004562  PMID: 27010319 
  38. Rabenau HF, Richter M, Doerr HW. Hand, foot and mouth disease: seroprevalence of Coxsackie A16 and Enterovirus 71 in Germany. Med Microbiol Immunol (Berl). 2010;199(1):45-51.  https://doi.org/10.1007/s00430-009-0133-6  PMID: 19941005 
  39. Schuffenecker I, Mirand A, Antona D, Henquell C, Chomel JJ, Archimbaud C, et al. Epidemiology of human enterovirus 71 infections in France, 2000-2009. J Clin Virol. 2011;50(1):50-6.  https://doi.org/10.1016/j.jcv.2010.09.019  PMID: 21035387 
  40. Akhmadishina LV, Govorukhina MV, Kovalev EV, Nenadskaya SA, Ivanova OE, Lukashev AN. Enterovirus A71 meningoencephalitis outbreak, Rostov-on-Don, Russia, 2013. Emerg Infect Dis. 2015;21(8):1440-3.  https://doi.org/10.3201/eid2108.141084  PMID: 26196217 
  41. Worner N, Rodrigo R, Castellarnau E, Sanz-Santaeufemia FJ, Ferrer G, Rincón López E, et al. First outbreak of enterovirus related brainstem encephalitis in western Europe: characterization, management and evolution of the patients (ESP17-0352). Annual ESPID Meeting, Madrid, 2017.

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