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We report a large-scale outbreak of hand, foot and mouth disease (HFMD) in France. As at 28 September 2021, 3,403 cases have been reported (47% higher than in 2018–19). We prospectively analysed 210 clinical samples; 190 (90.5%) were enterovirus-positive. Most children presented with atypical HFMD. Coxsackievirus (CV)A6 (49.5%; 94/190) was predominant; no enterovirus A71 was detected. Dermatological and neurological complications of HFMD justify prospective syndromic and virological surveillance for early detection of HFMD outbreaks and identification of associated types.


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  1. Solomon T, Lewthwaite P, Perera D, Cardosa MJ, McMinn P, Ooi MH. Virology, epidemiology, pathogenesis, and control of enterovirus 71. Lancet Infect Dis. 2010;10(11):778-90.  https://doi.org/10.1016/S1473-3099(10)70194-8  PMID: 20961813 
  2. Xing W, Liao Q, Viboud C, Zhang J, Sun J, Wu JT, et al. Hand, foot, and mouth disease in China, 2008-12: an epidemiological study. Lancet Infect Dis. 2014;14(4):308-18.  https://doi.org/10.1016/S1473-3099(13)70342-6  PMID: 24485991 
  3. 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 
  4. Cohen R, Béchet S, Gelbert N, Frandji B, Vié Le Sage F, Thiebault G, et al. New approach to the surveillance of Pediatric infectious diseases from ambulatory pediatricians in the digital era. Pediatr Infect Dis J. 2021;40(7):674-80.  https://doi.org/10.1097/INF.0000000000003116  PMID: 33657594 
  5. World Health Organization (WHO). International statistical classification of diseases and related health problems, 10th revision, fifth edition, 2016. Geneva: WHO; 2015. Available from: https://apps.who.int/iris/handle/10665/246208
  6. Mirand A, le Sage FV, Pereira B, Cohen R, Levy C, Archimbaud C, et al. Ambulatory pediatric surveillance of hand, foot and mouth disease as signal of an outbreak of coxsakievirus A6 infections, France, 2014-2015. Emerg Infect Dis. 2016;22(11):1884-93.  https://doi.org/10.3201/eid2211.160590  PMID: 27767012 
  7. 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 
  8. Centre National de Référence des entérovirus et parechovirus. Rapport d’activités 2019-2020. [Activity report 2019–2020]. Clermont-Ferrand: CHU Clermont-Ferrand. [Accessed: 6 Oct 2021]. French. Available from: http://cnr.chu-clermontferrand.fr/CNR
  9. Cohen R, Ashman M, Taha MK, Varon E, Angoulvant F, Lévy C, et al. Pediatric Infectious Disease Group (GPIP) position paper on the immune debt of the COVID-19 pandemic in childhood, how can we fill the immunity gap? Infect Dis Now. 2021;51(5):418-23.  https://doi.org/10.1016/j.idnow.2021.05.004  PMID: 33991720 
  10. Ujiie M, Tsuzuki S, Nakamoto T, Iwamoto N. Resurgence of respiratory syncytial virus infections during COVID-19 pandemic, Tokyo, Japan. Emerg Infect Dis. 2021;27(11):2969-70.  https://doi.org/10.3201/eid2711.211565  PMID: 34388086 
  11. van Summeren J, Meijer A, Aspelund G, Casalegno JS, Erna G, Hoang U, et al. Low levels of respiratory syncytial virus activity in Europe during the 2020/21 season: what can we expect in the coming summer and autumn/winter? Euro Surveill. 2021;26(29):2100639.  https://doi.org/10.2807/1560-7917.ES.2021.26.29.2100639  PMID: 34296672 
  12. Harvala H, Jasir A, Penttinen P, Pastore Celentano L, Greco D, Broberg E. Surveillance and laboratory detection for non-polio enteroviruses in the European Union/European Economic Area, 2016. Euro Surveill. 2017;22(45).  https://doi.org/10.2807/1560-7917.ES.2017.22.45.16-00807  PMID: 29162204 
  13. Huang WC, Huang LM, Lu CY, Cheng AL, Chang LY. Atypical hand-foot-mouth disease in children: a hospital-based prospective cohort study. Virol J. 2013;10(1):209.  https://doi.org/10.1186/1743-422X-10-209  PMID: 23800163 
  14. Mathes EF, Oza V, Frieden IJ, Cordoro KM, Yagi S, Howard R, et al. "Eczema coxsackium" and unusual cutaneous findings in an enterovirus outbreak. Pediatrics. 2013;132(1):e149-57.  https://doi.org/10.1542/peds.2012-3175  PMID: 23776120 
  15. Blomqvist S, Klemola P, Kaijalainen S, Paananen A, Simonen ML, Vuorinen T, et al. Co-circulation of coxsackieviruses A6 and A10 in hand, foot and mouth disease outbreak in Finland. J Clin Virol. 2010;48(1):49-54.  https://doi.org/10.1016/j.jcv.2010.02.002  PMID: 20189452 
  16. Ben-Chetrit E, Wiener-Well Y, Shulman LM, Cohen MJ, Elinav H, Sofer D, et al. Coxsackievirus A6-related hand foot and mouth disease: skin manifestations in a cluster of adult patients. J Clin Virol. 2014;59(3):201-3.  https://doi.org/10.1016/j.jcv.2013.12.012  PMID: 24457116 
  17. Harvala H, Benschop KSM, Berginc N, Midgley S, Wolthers K, Simmonds P, et al. European non-polio enterovirus network: introduction of hospital-based surveillance network to understand the true disease burden of non-polio enterovirus and parechovirus infections in Europe. Microorganisms. 2021;9(9):1827.  https://doi.org/10.3390/microorganisms9091827  PMID: 34576722 
  18. Fischer TK, Simmonds P, Harvala H. The importance of enterovirus surveillance in a post-polio world. Lancet Infect Dis. 2021;S1473-3099(20):30852-5.  https://doi.org/10.1016/S1473-3099(20)30852-5  PMID: 34265258 
  19. Tamura K, Stecher G, Peterson D, Filipski A, Kumar S. MEGA6: Molecular Evolutionary Genetics Analysis version 6.0. Mol Biol Evol. 2013;30(12):2725-9.  https://doi.org/10.1093/molbev/mst197  PMID: 24132122 
  20. Song Y, Zhang Y, Ji T, Gu X, Yang Q, Zhu S, et al. Persistent circulation of Coxsackievirus A6 of genotype D3 in mainland of China between 2008 and 2015. Sci Rep. 2017;7(1):5491.  https://doi.org/10.1038/s41598-017-05618-0  PMID: 28710474 

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