Rapid Risk Assessment: Outbreak of enterovirus A71 with severe neurological symptoms among children in Catalonia, Spain, 16 June 2016

risk assessment
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European Centre for Disease Prevention and Control. Outbreak of enterovirus A71 with severe neurological symptoms among children in Catalonia, Spain 14 June 2016. Stockholm: ECDC; 2016.

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​ECDC has published a rapid risk assessment due to a localised outbreak of neurological symptoms associated with enterovirus A71 (EV-A71) in Catalonia, Spain.
Most EV infections, including EV-A71, result in asymptomatic infection. Most symptomatic EV-A71 infections manifest as a self-limiting hand, foot and mouth disease and only a very small proportion of patients develop severe and life-threatening disease. The current outbreak is notable in terms of its magnitude and the severity of symptoms of the reported cases.

Executive summary

The outbreak with neurological complications caused by enterovirus has been ongoing in Catalonia since mid-April 2016, affecting children up to ten years of age. As of 7 June, 87 cases of enterovirus infection with neurological complications have been reported, most of which have evolved favourably, but 22 of the cases remain in hospital, including seven in intensive care units. According to the information received from regional authorities, there are no deaths related to this outbreak. The cases are widespread in Catalonia.

Other EU Member States have not reported concomitant enterovirus outbreaks and ECDC is not aware of signals of other unusual enterovirus outbreaks in the EU.

There is evidence to suggest that the epidemiological pattern of EV-A71 in Europe is going through a change, both due to virus molecular evolution, as well as an increasing likelihood of importation of new virus strains from outside the EU. The full characterisation of the isolates from the Spanish outbreak, and comparison of these to virus sequences from other countries and continents, should contribute to a better understanding of the changing pattern of EV-A71 epidemiology in Europe.

This outbreak of EV-A71 together with the previously reported clusters of EV-D68 reinforces the need for vigilance for enterovirus infections presenting with hand, foot and mouth disease and more severe clinical syndromes. Paediatricians should be encouraged to obtain specimens for enterovirus detection and characterisation from all patients presenting with symptoms suggestive of meningitis, encephalitis or acute flaccid paralysis (AFP), as well as hand, foot and mouth disease. In addition to non-polio enterovirus laboratory surveillance, AFP surveillance for purposes of polio surveillance or surveillance of meningoencephalitis are likely to be the most sensitive clinical surveillance systems to pick up such signals.

As a general precaution, children residing in or travelling to Catalonia should avoid contact with symptomatically ill children and follow strict hygiene in personal contacts.

Most EV infections, including EV-A71, result in asymptomatic infection. Most symptomatic EV-A71 infections manifest as a self-limiting hand, foot and mouth disease and only a very small proportion of patients develop severe and life-threatening disease