Five years ago, SARS, showed the authorities the benefits of transparency in reporting and handling a health crisis. In a similar vein¹, this year's outbreak of hand, foot and mouth disease (HFMD) has forced both central and local health authorities to find and plug loopholes in their surveillance of and response to epidemics³.

HFMD can be caused by a host of intestinal⁴ viruses, but enterovirus 71 (EV71) is the most common one that can cause a severe form of the disease. HFMD cases, with a number having EV71 as the causative agent, hit 176,321, including 40 fatalities⁵ - mostly children - in China in May alone, the Ministry⁶ of Health reported.

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 due to the fact that the virus spreads via routine contact, medical experts 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 the dark, the more likely they will get infected," said Yang Weizhong, the deputy chief of the Chinese Center for Disease Control and Prevention (CDC).

Questions have been raised as to why it took so long for the public to be informed of the disease. 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 epidemic² without accreditation⁷ 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 provincial⁸ 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 dissemination⁹ of the health threat that was already overdue¹⁰, 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 expended¹¹ to rule out serious viral diseases like SARS, bird flu and meningitis," he said.

"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.

The early deaths from the viral infection were largely caused by delayed and improper¹² treatment, themselves a result of ignorance of the illness, according to pediatrician Liu Xiaolin.

Cheng Xiaodong, a public health professor with Wuhan University, said that government agencies should also learn to become more media savvy¹³ to publicize issues closely related to people's life and health, without delay and in a mutually accepted way.

Local Beijing health officials warned this week that summer remains¹⁴ a peak season for HFMD.
 

Questions:

1. How many fatalities resulted from the recent outbreak of HFMD in China?

2. List two reasons why it took a long time to raise the alert about the virus.

3. When is the peak time for HFMD in Beijing?

Answers:

1. 40.

2. Doctors were not sure what virus they were looking for and the response time by the authorities was less than rapid due to structural¹⁵ constraints¹⁶.