Expression and clinical significance of pattern recognition receptor-associated genes in hand, foot and mouth disease

Objective:To explore which pattern recognition receptors(PRRs)play a key role in the development of hand,foot,and mouth disease(HFMD)by analyzing PRR-associated genes.Methods:We conducted a comparative analysis of PRR-associated gene expression in human peripheral blood mononuclear cells(PBMCs)infected with enterovirus 71(EV-A71)which were derived from patients with HFMD of different severities and at different stages.A total of 30 PRR-associated genes were identified as significantly upregulated both over time and across different EV-A71 isolates.Subsequently,ELISA was employed to quantify the expression of the six most prominent genes among these 30 identified genes,specifically,BST2,IRF7,IFI16,TRIM21,MX1,and DDX58.Results:Compared with those at the recovery stage,the expression levels of BST2(P=0.027),IFI16(P=0.016),MX1(P=0.046)and DDX58(P=0.008)in the acute stage of infection were significantly upregulated,while no significant difference in the expression levels of IRF7(P=0.495)and TRIM21(P=0.071)was found between different stages of the disease.The expression levels of BST2,IRF7,IFI16 and MX1 were significantly higher in children infected with single pathogen than those infected with mixed pathogens,and BST2,IRF7,IFI16 and MX1 expression levels were significantly lower in coxsackie B virus(COXB)positive patients than the negative patients.Expression levels of one or more of BST2,IRF7,IFI16,TRIM21,MX1 and DDX58 genes were correlated with PCT levels,various white blood cell counts,and serum antibody levels that reflect disease course of HFMD.Aspartate aminotransferase was correlated with BST2,MX1 and DDX58 expression levels.Conclusions:PRR-associated genes likely initiate the immune response in patients at the acute stage of HFMD.

Hand Foot and Mouth Disease Due to Enterovirus 71 in Malaysia

Hand foot and mouth disease is a febrile sickness complex characterized by cutaneous eruption (exanthem) on the palms and soles with simultaneous occurrence of muco-cutanous vesiculo-ulcerative lesions (enanthem) affecting the mouth. The illness is caused by a number of enteroviruses with coxsackievirus A16 and enterovirus 71 as the main causative agents. Human enterovirus 71 (EV71) belongs to the species Human enterovirus A under the genus Enterovirus within the family Picornaviridae. EV71 has been associated with an array of clinical diseases including hand foot and mouth disease (HFMD), aseptic meningitis, encephalitis and poliomyelitis-like acute flaccid paralysis. A large outbreak of HFMD due to highly neurovirulent EV71 emerged in Malaysia in 1997, and caused 41 deaths amongst young children. In late 2000, a recurrence of an outbreak of HFMD occurred in Malaysia with 8 fatalities in peninsular Malaysia. Outbreak of HFMD due to EV71 recurred in 2003 with an unknown number of cases and mortalities. A similar outbreak of HFMD with 2 recorded deaths in young children occurred in peninsular Malaysia in late 2005 and this was followed by a larger outbreak in Sarawak (Malaysian Borneo) with 6 reported fatalities in the early part of 2006. The current on-going outbreak of HFMD started in peninsular Malaysia in epidemiological week 12 of 2010. As with other HFMD outbreaks in Malaysia, both EV71 and CA16 were the main aetiological viruses isolated. In similarity with the HFMD outbreak in 2005, the isolation of CA16 preceded the appearance of EV71. Based on the VP1 gene nucleotide sequences, 4 sub-genogroups of EV71 (C1, C2, B3 and B4) co-circulated and caused the outbreak of hand, foot and mouth disease in peninsular Malaysia in 1997. Two sub-genogroups (C1 and B4) were noted to cause the outbreak in 2000 in both peninsular Malaysia and Sarawak. EV71 of sub-genogroup B5 with smaller contribution from sub-genogroup C1 caused the outbreak in 2003. In the 2005 outbreak, besides the EV71 strains of sub-genogroup C1, EV71 strains belonging to sub-genogroup B5 were isolated but formed a cluster which was distinct from the EV71 strains from the sub-genogroup B5 isolated in 2003. The four EV71 strains isolated from clinical specimens of patients with hand, foot and mouth disease in the Sarawak outbreak in early 2006 also belonged to sub-genogroup B5. Phylogenetic analysis of the VP1 gene suggests that the EV71 strains causing the outbreak in Sarawak could have originated from peninsular Malaysia. Epidemiological and molecular data since 1997 show the recurrence of HFMD due to EV71 in Malaysia every 2 to 4 years. In each of the past outbreaks, more than one sub-genogroup of the virus co-circulate.

Spatial Trend of Foot and Mouth Disease Virus (FMDV) Serotypes in Cattle and Buffaloes, Pakistan

The present study describes the frequency of Foot and Mouth Disease （FMD） virus serotypes （O, A and Asia-l） in major regions （all provinces） of Pakistan using Indirect Sandwich ELISA. Also, spatial distribution of various FMD serotypes and their comparison is discussed. A total of 590 samples （Epithelial tissue） have been analyzed during a period of five years （2005-2009）. Out of 590 samples, 180 were found positive, giving an overall confirmation of FMDV about 33.2 %. Of the prevalent serotypes, FMDV ＇O＇ serotype caused most outbreaks （20.7 %）, followed by serotype A （6.6 %） and serotype Asia-1 （4.6 %） while there was no positive case of type ＇C＇. The study clearly showed that the disease was more frequent in the agro-climatic zones than in hilly areas. Based on the data of 590 samples （〉50 outbreaks）, the overall prevalence of FMDV in cattle and buffaloes in Pakistan was 33.2 %, while in cattle alone, it was 37.1%, higher than in buffalo （28.7 %）. There were eight cases of mixed serotypes infection, indicating the presence of endemic state of disease. Another significant feature was the change over time. In phase-I （2005-2007）, there was an overall prevalence of 29.4 %, while the occurrence of the serotype O, A and Asia-1 was 20.4 %, 2.9 % and 4.7 %, respectively. During phase-II （2008-2009）, the overall prevalence was 59.21%, while those of serotype O, A and Asia-1 were 22.4 %, 31.6 % and 4.0 %, respectively. This clearly indicated a shift from serotype O to A, which may help to explain the occurrence of more severe outbreaks, despite vaccination.

Establishment of Indirect ELISA Diagnosis Technique based on the VP1 Protein of Foot and Mouth Disease Virus Serotype A

The VP1 protein of foot-and-mouth disease virus serotype A was prokaryotically expressed and purified to replace the traditional virus antigen for estab- lishing a fast, safe, effective indirect ELISA method, so as to detecting antibody of foot-and-mouth disease virus serotype A. Western-Blot test showed that the VP1 recombinant protein could be used as detective antigen as it can be specifically recognized by bovine positive serum of FMDV serotype A. By employing matrix titra- tion method, the optimal parameters were obtained as follows： 1 mg/L VP1 protein as coating antigen, Vserum：Vblocking solution = 1：50 dilution for serum and Vsecondary enzyme-linked antibedies：Vblocking solution ---1：2 000 for enzyme combined antibodies. The results showod that the sensitivity and specificity of this method were 94.32% and 99.09% respectively, the coefficients of variations in intra-assay and inter-assay reproducibility tests was lower than 8%. Compared with liquid phase blocking ELISA kits, the agreement of 201 serum samples reached 92.54%. The VP1-ELISA method established here is specific, sensitive, stable and simple, which can be used to monitor the antibody level of FMD serotype A.

Evaluation on Common Hand, Foot and Mouth Disease Treated by Integrative Traditional Chinese Medicine and Western Medicine

Objective To evaluate the efifcacy and safety of traditional Chinese medicine (TCM) combined with Western medicine in the treatment of patients with common hand, foot and mouth disease (HFMD) by conducting a prospective, controlled, and randomized trial. Methods A total of 452 patients with common HFMD were randomly assigned to receive Western medicine alone (n=220) or combined with TCM (Reduning or Xiyanping injections) (n=232). The primary outcome was the incidence rate of rash/herpes disappearance within 5 days, while secondary outcomes included the incidence rate for fever, cough, lethargy, agitation, and vomiting clearance within 5 days. Results The rash/herpes disappearance rate was 45.5% (100/220) in Western medicine therapy group, and 67.2% (156/232) in TCM and Western medicine combined therapy group, with significant difference (P<0.001). Moreover, TCM remarkably increased the incidence rate of secondary disappearance, which was 56.4%in Western medicine therapy group and 71.4%in TCM and Western medicine combined therapy group (P=0.001). No drug-related adverse events were observed. Conclusions It’s suggested that the integrative TCM and Western medicine therapy achieved a better therapeutic efficacy. TCM may become an important complementary therapy on relieving the symptoms of HFMD.

Investigation on Factors Associated with Severe Hand, Foot and Mouth Disease

Objective To analyze the clinical and laboratory features of patients with mild and severe HFMD to identify early predictive or diagnostic markers for severe cases. Methods Samples of feces, nasopharyngeal-swab specimens, peripheral blood, serum and cerebral spinal fluid were collected. Postmortem pathological examination was conducted on 2 dead patients with complication due to neurogenic pulmonary edema. Reverse transcription-polymerase chain-reaction(RT-PCR), culture and isolation of enterovirus 71(EV71) were performed to detect EV71 infection. Both univariate and multivariate logistic analysis were used to identify factors associated with severe cases. Results EV71 was mainly responsible for HFMD. In this study, 5 isolated EV71 strains belonged to C4 gene subtype. Compared with mild patients, EV71-RNA detection rate was higher and Cox A16 detection rate was lower among severe patients(P < 0.01). Inflammatory cell infiltration in the lung, cardiac and liver tissues were mild by postmortem pathological examination. It was found that body temperature, vomitting, limb tremor, neutrophil, blood glucose and EV71 infection were significantly related to the severe cases by univariate logistic analysis. However, after multivariate logistic regression analysis, only vomiting(OR 16.1, CI 2.3-110.5, P < 0.01) and limb tremor(OR 117.6, CI 13.8-1004.5, P < 0.01) were significantly and independently correlated with the severe cases.Conclusions EV71 was mainly responsible for HFMD, particularly for severe cases. Vomiting and limb tremor were predictive markers for severe cases.

The Comparative Study on Two Models of Syndrome Differentiation of the Hand, Foot and Mouth Disease: An Investigation Analysis of the Signs and Symptoms on 2325 Cases

Objective To realize the characteristics of "zheng" differentiation-treatment for hand, foot and mouth disease(HFMD), a new methodology of syndrome differentiation for different stages of HFMD has been explored. Methods Total of 2 325 cases with HFMD were recorded by distributing them into exterior syndrome stage, interior syndrome stage, severe syndrome stage and recovered syndrome stage, respectively, and the main symptoms and subsidiary symptoms of different stages of HFMD have been observed. The major and minor pathogenesis of HFMD in different stages were obtained, and compared with the "2010 Guideline for the Diagnosis and Treatment of HFMD". Results It was found that the major pathogenesis of exterior stage was defined as "the invation of the wenevil to the defender of the body with the collaterals got involved ", and the minor as "qi deficiency"; in interior stage, "the fury of Gan-Yang" was the main pathogenesis, and "qi in chaos and qi deficiency" was the minor; in severe syndrome stage, "the damage of heart, liver and lung" was the main pathogenesis, and "qi in chaos" was the minor; and the pathogenesis of recovered stage was "qi-yin deficiency". Compared with the "2010 Guideline for the Diagnosis and Treatment of HFMD", it showed that "the obstruction of the fei-pi qi by the mixture of shi-re evil" and "the mixture of shi-re" in vivo was quite difficult to be explained in completely different context in the general situation; in the severe stage, the TCM clinical characteristics of syndrome differentiation might lose; in the early acute severe cases, the phenomenon that xin-yang and fei-qi almost ran out was difficult to be observed, then, the line between the severe and the acute severe became vague.Conclusions The theory of syndrome differentiation by stages of HFMD was reasonable in the actual situation of clinical description on HFMD which was expected to be further tested and widely applied in the "zheng" differentiation-treatment of HFMD in the future.

Results on Pathogen Detection of Foot and Mouth Disease in Guangxi China and Analysis on Its Popular Spectrum

Objective: The study aims to understand the characteristics and epidemic trend of the pathogen of hand, foot and mouth disease (HFMD) in Guangxi regions, China. Besides, it aims to analyze the differences of intestinal virus detection rate between anal swab and pharyngeal swab samples. Methods: Anal swab and pharyngeal swabs of suspected HFMD children were collected in our hospital from 2012 to 2015. Real-time fluorescent PCR (Polymerase Chain Reaction) was used to detect enterovirus 71 (EV71), coxsackie virus type 16 (CA16), and universal intestinal virus nucleic acid (EV). Composition and conversion of predominant pathogens were analyzed, and paired samples’ test results of swabs anal and pharyngeal swab were statistically analyzed. Results: There are 681 cases with enterovirus in 2351 cases of patients. Among those who got enterovirus, there are 501 cases of EV71, 102 cases of CA16 and 79 cases of EV. From 2012 to 2015, the total proportion of the virus detection is 46.47%, 16.23%, 41.02% and 15.33% respectively in each year, while the proportion of predominant epidemic virus is 93.93% of EV71, 66.12% of CA16, 89.30% of EV71 and 98.73% of EV, non-EV71, non-CA16 EV (from October to December in 2015). It’s obvious that the total virus detection rate in 2012 and 2014 is significantly higher than that in 2013 and 2015. There is statistical significance. Conclusion: The main HFMD pathogens are EV71 from 2012 to 2015 in Guangxi regions. In 2012 and 2014, the predominant epidemic pathogens were EV71, while in 2013 and 2015, the predominant epidemic pathogens turn to be CA16 and non-EV71, non-CA16 EV respectively. What’s more, collecting anal swab and pharyngeal swab virus at the same time for nucleic acid detection is of great significance to improve the HFMD laboratory diagnostic.

The non-stationary and spatially varying associations between hand,foot and mouth disease and multiple environmental factors:A Bayesian spatiotemporal mapping model study

The transmission and prevalence of Hand,Foot and Mouth Disease(HFMD)are affected by a variety of natural and socio-economic environmental factors.This study aims to quantitatively investigate the non-stationary and spatially varying associations between various environmental factors and HFMD risk.We collected HFMD surveillance cases and a series of relevant environmental data from 2013 to 2021 in Xi'an,Northwest China.By controlling the spatial and temporal mixture effects of HFMD,we constructed a Bayesian spatiotemporal mapping model and characterized the impacts of different driving factors into global linear,non-stationary and spatially varying effects.The results showed that the impact of meteorological conditions on HFMD risk varies in both type and magnitude above certain thresholds(temperature:30°C,precipitation:70 mm,solar radiation:13000 kJ/m^(2),pressure:945 hPa,humidity:69%).Air pollutants(PM_(2.5),PM_(10),NO_(2))showed an inverted U-shaped relationship with the risk of HFMD,while other air pollutants(O_(3),SO_(2))showed nonlinear fluctuations.Moreover,the driving effect of increasing temperature on HFMD was significant in the 3-year period,while the inhibitory effect of increasing precipitation appeared evident in the 5-year period.In addition,the proportion of urban/suburban/rural area had a strong influence on HFMD,indicating that the incidence of HFMD firstly increased and then decreased during the rapid urbanization process.The influence of population density on HFMD was not only limited by spatial location,but also varied between high and low intervals.Higher road density inhibited the risk of HFMD,but higher night light index promoted the occurrence of HFMD.Our findings further demonstrated that both ecological and socioeconomic environmental factors can pose multiple driving effects on increasing the spatiotemporal risk of HFMD,which is of great significance for effectively responding to the changes in HFMD epidemic outbreaks.

Diagnostic performance of different specimens in detecting enterovirus A71 in children with hand,foot and mouth disease

Hand,foot and mouth disease(HFMD)is a major public health problem among children in the Asia-Pacific region.The optimal specimen for HFMD virological diagnosis remains unclear.Enterovirus A71(EV-A71)neutralizing antibody titres detected in paired sera were considered the reference standard for calculating the sensitivity,specificity,positive and negative predictive value of throat swabs,rectal swabs,stool,blood samples and cerebrospinal fluid(CSF)by RT-PCR or ELISA assay.In this study,clinical samples from 276 HFMD patients were collected for analysing the sensitivity of different kind of specimens.Our results showed that stool had the highest sensitivity(88%,95%CI:74%–96%)and agreement with the reference standard(91%).The order of diagnostic yield for EV-A71 infection was stool samplerectal swab>throat swab>blood sample>CSF sample,and using a combination of clinical samples improved sensitivity for enterovirus detection.The sensitivity of ELISA for IgM antibody detection in sterile-site specimens was significantly higher than that of RT-PCR(serum/plasma:62%vs.2%,CSF:47%vs.0%)(P<0.002).In conclusion,our results suggest that stool has the highest diagnostic yield for EV-A71-infected HFMD.If stool is unavailable,rectal swabs can be collected to achieve a similar diagnostic yield.Otherwise,throat swabs may be useful in detecting positive samples.Although IgM in blood or CSF is diagnostically accurate,it lacks sensitivity,missing 40%–50%of cases.The higher proportion of severe cases and shorter interval between onset and sampling contributed to the increase in congruency between clinical testing and the serological reference standard.

The impact of EV71 vaccination program on hand,foot and mouth disease in Zhejiang Province,China:A negative control study

Objective:To estimate the potential causal impact of Enterovirus A71(EV71)vaccination program on the reduction of EV71-infected hand,foot,and mouth disease(HFMD)in Zhejiang Province.Methods:We utilized the longitudinal surveillance dataset of HFMD and EV71 vaccination in Zhejiang Province during 2010-2019.We estimated vaccine efficacy using a Bayesian structured time series(BSTS)model,and employed a negative control outcome(NCO)model to detect unmeasured confounding and reveal potential causal association.Results:We estimated that 20,132 EV71 cases(95%CI:16,733,23,532)were prevented by vaccination program during 2017-2019,corresponding to a reduction of 29%(95%CI:24%,34%).The effectiveness of vaccination increased annually,with reductions of 11%(95%CI:6%,16%)in 2017 and 66%(95%CI:61%,71%)in 2019.Children under 5 years old obtained greater benefits compared to those over 5 years.Cities with higher vaccination coverage experienced a sharper EV71 reduction compared to those with lower coverage.The NCO model detected no confounding factors in the association between vaccination and EV71 cases reduction.

Construction of Plant Expression Vector for Hand,Foot and Mouth Virus EV71-VP1 Gene and Its Expression in Tomato

EV71-type virus is one of the main pathogens causing the occurrence of hand,foot and mouth disease(HFMD),and VP1 protein,a factor that directly determines the antigenicity of the virus,has been isolated.The tomato was selected as a bioreactor for the production of an edible EV71 vaccine designed for the VP1 capsid protein.Using molecular biology techniques,the fusion gene EV71-VP1 was cut from vector PGEX-4T-2,a vector containing the p2300-EV71 gene with CaMV35S promoter and TL regulatory elements was constructed,and the hypocotyl and cotyledons of tomato were transformed using Agrobacterium(EHA105)-mediated method,screened,elongated and rooted,and finally 20 resistant tomato plants were obtained.Five transgenic positive seedlings were obtained by digestion and PCR assay,among which three plants were detected by RT-PCR to be capable of transcriptional translation at the RNA level.The experimental results aimed to explore new material support for the preparation of transgenic plant oral vaccines against EV71 infection and provide a theoretical basis for accelerating the development of transgenic plant vaccines in the future.

Genetic Variation of Multiple Serotypes of Enteroviruses Associated with Hand, Foot and Mouth Disease in Southern China

Enteroviruses(EVs)species A are a major public health issue in the Asia–Pacific region and cause frequent epidemics of hand,foot and mouth disease(HFMD)in China.Mild infections are common in children;however,HFMD can also cause severe illness that affects the central nervous system.To molecularly characterize EVs,a prospective HFMD virological surveillance program was performed in China between 2013 and 2016.Throat swabs,rectal swabs and stool samples were collected from suspected HFMD patients at participating hospitals.EVs were detected using generic real-time and nested reverse transcription-polymerase chain reactions(RT-PCRs).Then,the complete VP1 regions of enterovirus A71(EV-A71),coxsackievirus A16(CVA16)and CVA6 were sequenced to analyze amino acid changes and construct a viral molecular phylogeny.Of the 2836 enrolled HFMD patients,2,517(89%)were EV positive.The most frequently detected EVs were CVA16(32.5%,819),CVA6(31.2%,785),and EV-A71(20.4%,514).The subgenogroups CVA16B1 b,CVA6D3 a and EV-A71C4 a were predominant in China and recombination was not observed in the VP1 region.Sequence analysis revealed amino acid variations at the 30,29 and 44 positions in the VP1 region of EV-A71,CVA16 and CVA6(compared to the respective prototype strains Br Cr,G10 and Gdula),respectively.Furthermore,in 21 of 24(87.5%)identified EV-A71 samples,a known amino acid substitution(D31 N)that may enhance neurovirulence was detected.Our study provides insights about the genetic characteristics of common HFMD-associated EVs.However,the emergence and virulence of the described mutations require further investigation.

Clinical characteristics of hand, foot and mouth disease in Harbin and the prediction of severe cases

Background Hand, foot and mouth disease （HFMD） is an emerging public health problem in China, not only threatening the health of children, but also causing tremendous loss and burden to both families and society. The aim of this study was to characterize the epidemiology and clinical features of HFMD, and to understand the key factors affecting HFMD in the Harbin region to provide scientific evidence for effective prevention and control strategies. Methods Epidemiological and clinical information from 2379 randomly chosen cases of HFMD treated at the Harbin Center for Disease Control and Prevention from May 2008 to November 2011 were analyzed. All cases were separated into common and severe HFMD, with key factors for severe HFMD analyzed using multivariable Logistic regression. Results Among the 2379 patients, 1798 were common cases and 581 severe cases, 14 of which resulted in death. Most cases were in children younger than 5 years. Morbidity peaked in July and was higher in the surrounding country and cities than in Harbin proper. Medical expenses were significantly higher for severe than for common cases （P 〈0.001）. The primary clinical symptoms were fever and erythema; laboratory examination showed leucocytosis together with pneumonia, carditis, and abnormal electrocardiogram and electroencephalogram in severe cases. Multivariabie Logistic regression analysis showed that the key factors for severe HFMD were age, morbidity location, morbidity area, fever duration, mouth mucosal symptoms, and abnormal serum levels of neutrophils （NEUT）, hemoglobin and glucose （P 〈0.05）. Conclusions To improve prognosis, reduce medical expense and prevent the development of severe cases, we should improve the epidemiological detection of HFMD to treat patients quickly. We should also closely monitor children with the EV71 virus, who present with continuous fever as well as abnormal laboratory results, from areas highly susceptible to

A randomized controlled clinical study on treatment of hand, foot and mouth disease in children with Reduning injection

Hand, foot and mouth disease （HFMD） has become a major public health problem in China since 2008,which has been widely prevalent in children under 5 years of age. According to the data of the Ministry of Health, the number of cases with HFMD exceeded 1 million during the recent 4 years. The major etiologic agent of HFMD is enterovirus 71 and coxsackievirus A 16. The main clinical manifestations of the disease include fever, maculopapular skin vesicles on the hand, foot and buttock, oral herpes, ulcer; ation severe cases there can be central nervous system infection and/or pulmonary hemorrhage, which are mostly caused by EV71 and may be life-threatening with a fatality rate of 0.3 to 0.5 per thousand cases. There are no specific antiviral drugs, nor vaccine against EV71.~ The difficult problem of the treatment is how to reduce the severe cases and mortality. Reduning injection is a preparation of traditional Chinese herbal medicine composed of Qinghao （Artemisiae annuae）, Jinyinhua （Flos lonicerae） and Zhizi （Gardenia jasminoides）, which was listed among the therapies for HFMD in the 2010 guidelines of the Ministry of Health for diagnosis and treatment of HFMD.2 We now reported the results of our study on the efficacy of Reduning injection in treatment of 81 patients with HFMD. We selected 81 cases who were inpatients treated in 2010 in the Department of Infectious Diseases of Quanzhou Chidren＇s Hospital. The inclusion criteria were as follows： 1. Patients who met either the clinical diagnostic criteria for HFMD ordinary clinical type or the clinical diagnostic criteria for confirmed cases of HFMD （etiologically confirmed cases must account for more than 1/3 of the cases）. 2. The axillary temperature is _〉37.5~C, within 48 hours after onset of the disease; 3. Skin changes such as the rashes and vesicles occurred in no more than 48 hours; 4. Range of age is between 1 and 13 years; 5. Patients or their parents or guardians are willing to participate in the study and sign the informed consent forms. The exclusion criteria were as follows： 1. Patients who are complicated with the following primary diseases： congenital heart disease, chronic hepatitis, acute or chronic nephritis, diseases of hematologic system; 2. Patients who have hypersensitivity with history of allergy to the study drugs or other drugs; 3. Patients who were treated with western or traditional Chinese medicines other than the study medicines for HFMD by the time of the visit to the hospital; 4. Patientswho have been participated in other clinical trial for HFMD. The patients were centrally randomized （the random numbers were obtained from the web version of the Randomization System of Clinical Studies, Clinical Evaluation Center of Chinese Academy of Traditional Chinese Medicine, No. 200907001-3） into the following 3 groups： Reduning group （group 1）, 28 cases with 21 men and 7 women; age 12-72 （mean 29.2＋18.8） months; 24 were positive for EV71, 2 were positive for CoxA16 and 2 were negative for both; treated with intravenous infusion of Reduning （Jiangsu Kangyuan Pharmaceutical Corporation, Ltd., 10 ml in each vial, Batch number 100122） at a dose of 0.5 ml.kg-＇.d＂ added into 10% glucose solution for injection, once a day. Symptomatic treatment group （group 2）, 27 cases with 19 male and 8 female; age 12-96 （mean 28.7＋20.4） months; 19 were positive for EV71, 3 were positive for CoxA16 and 5 were negative for both; these patients were treated with intravenous infusion of vitamin C （0.5-1.0 g/d） and B6 （50-100 mg/d） added into 10% glucose solution for injection and ibuprofen （5-10 mg/kg per day, 6-8 hours repeat p.r.n.） or Aspisol （15-25 mg＇kg＂.d1） was used for antipyretic purpose. Antibiotics were added for patients who had increased peripheral blood leukocyte count. And Reduning plus symptomatic treatment group （group 3）, had 26 cases with 17 male and 9 female; age 12-84 （mean 30.4＋16.6） months; 18 were positive for EV71, 4 were positive for CoxA16 and 5 were negative for both viruses; these cases were treated with both Reduning and symptomatic treatments. No significant difference was found among the 3 groups in age, sex and etiological characteristics compared using chi-square test （P 〉0.05）. The numbers of patients who were positive for EV7I or CoxA 16 accounted for 75.3% and 11.1% for each group.

Effect of Integrated Chinese and Western Medicine Therapy on Severe Hand, Foot and Mouth Disease: A Prospective, Randomized, Controlled Trial

Objective: To evaluate the efficacy and safety of Chinese medicine(CM) plus Western medicine(WM) in the treatment of pediatric patients with severe hand, foot and mouth disease(HFMD) by conducting a prospective, controlled, and randomized trial. Methods: A total of 451 pediatric patients with severe HFMD were randomly assigned to receive WM therapy alone(224 cases, WM therapy group) or CM [Reduning Injection(热毒宁注射液) or Xiyanping Injection(喜炎平注射液)] plus WM therapy(227 cases, CM plus WM therapy group) for 7–10 days, according to a web-based randomization system. The primary outcome was fever clearance time, which was presented as temperature decreased half-life time. The secondary outcomes included the rate of rash/herpes disappearance within 120 h, as well as the rate for cough, runny nose, lethargy and weakness, agitation or irritability, and vomiting clearance within 120 h. The drug-related adverse events were also recorded. Results: The temperature decreased half-life time was 40.4 h in the WM therapy group, significantly longer than 27.2 h in the CM plus WM therapy group(P<0.01). Moreover, the rate for rash/herpes disappearance within 120 h was 43.6%(99/227) in the CM plus WM therapy group, significantly higher than 29.5%(66/224) in the WM therapy group(P<0.01). In addition, the rate for cough, lethargy and weakness, agitation or irritability disappearance within 120 h was 32.6%(74/227) in the CM plus WM therapy group, significantly higher than 19.2%(43/224) in the WM therapy group(P<0.01). No drug-related adverse events were observed during the course of the study. Conclusions: The combined CM and WM therapy achieved a better therapeutic efficacy in treating severe HFMD than the WM therapy alone. Reduning or Xiyanping Injections may become an important complementary therapy to WM for relieving the symptoms of severe HFMD.

Seroprevalence of Toxoplasma gondii infection among patients with hand, foot and mouth disease in Henan, China: a hospital-based study

Background:The prevalence of infection with Toxoplasma gondii(T.gondii)in humans has been increasing in China due to the growing number of cats in the country.Hand,foot and mouth disease(HFMD)is a serious public health issue in China and still one of the leading causes of child mortality.However,little is known about the epidemiology of T.gondii infection among HFMD patients.Methods:A case–control study of 281 HFMD patients from the First People’s Hospital of Pingdingshan in Pingdingshan city,Henan province,central China,and 222 controls from Pingdingshan city was conducted.Anti-T.gondii antibodies were serologically detected using the enzyme-linked immunosorbent assay.Results:We found that the overall anti-T.gondii immunoglobulin G(IgG)antibody prevalence among HFMD patients was 12.46%,which was significantly higher than that in clinically healthy children(1.80%).The highest T.gondii seroprevalence was detected in critical cases(22.58%),followed by severe cases(11.50%),and the lowest was detected in mild cases(8.33%).Conclusion:The present study is the first survey of T.gondii seroprevalence among HFMD patients in China;12.46%were defined as seropositive.It is imperative that improved integrated measures are taken to prevent and control T.gondii infection among HFMD patients.

Xiyanping injection therapy for children with mild hand foot and mouth disease:a randomized controlled trial

OBJECTIVE: To evaluate the clinical effects of Xiyan-ping injection intervention in pediatric patients with mild hand foot and mouth disease(HFMD).METHODS: A total of 329 patients were stratified and block-randomized for symptomatic treatment of HFMD and assigned to one of the following groups: Western Medicine(group A, n = 103), Xiyanping injection(group B, n = 109), or Xiyanping injection and symptomatic treatment using Western Medicine(group C, n = 117). During the trial, fever,rash, ulcers of the mouth were observed among participants in each group before and after treatment, and conversion rates from mild to severe HFMD were measured.RESULTS: After 3-7 days' treatment, no significant differences in the conversion rates from mild to severe HFMD were observed among the three groups(P > 0.05). There was a significantly low number of patients with the onset time of antifebrile effect,vanished time of hand and foot rashes and cumulative time for the ulcers in the mouth vanished,among the three groups(P < 0.05, P < 0.01). The onset time of antifebrile effect of patients in groups B and C were markedly shorter compared with those in group A(P < 0.05, P < 0.01); there was no statically significant difference observed between groups B and C(P > 0.05). No significant differences were observed in the time for body temperature recovery among the three groups(P > 0.05). There were no significant differences in adverse effects among the three groups(P > 0.05).CONCLUSION: Xiyanping injection together with use of Western Medicine is most effective for symptomatic treatment of mild HFMD. No severe adverse reactions were observed.

Achievements, challenges and prospects for the development of broadly protective multivalent vaccines and therapeutic antibodies against hand, foot and mouth disease

Hand, foot and mouth disease(HFMD) is a significant health concern in the Asia–Pacific regions for infants and young children in recent years. However, no vaccines or therapeutics are available at present. The causative agents for HFMD include human enterovirus 71(EV71), coxsackievirus A16(CVA16) and some other viruses. Recently, tremendous progress has been made in the development of monovalent and bivalent vaccines against HFMD. A few neutralizing monoclonal antibodies against EV71 or CVA16 have been identified and characterized. Here, we reviewed some achievements for the development of broadly protective vaccines and neutralizing antibodies against HFMD, and discussed challenges and prospects toward broadly protective multivalent vaccines and therapeutic antibodies against HFMD.

Review of hand, foot and mouth disease

Hand,foot and mouth disease(HFMD)is an acute viral illness that primarily affects infants and young children,and often occurs in clusters or outbreaks.The major causative agents of HFMD are coxsackievirus A16(CVA16),human enterovirus 71(HEV71)and coxsack-ievirus A10(CVA10),of the genus Enterovirus in the family Picornaviridae.HFMD caused by EV71 is associated with severe neurological complications and death.Since the late 1990s,several major epidemics of EV71 HFMD have swept through the Asia-Pacific region,associated with a rapid fulminant course,severe neurolo-gical complications,and a large number of fatalities.Until now,little has been known about the genetics and transmission trends of the fast-mutation virus,and there is no effective and specific antiviral therapy or vaccine for HFMD.It is time to step up efforts to understand the molecular epidemics and pathogenesis so that we can develop effective management strategies and surveillance programs.