Risk Factors for Severe Enteroviral Infections in Children.

OBJECTIVE: To study the risk factors associated with severe enterovirus infection among hospitalized pediatric patients with hand, foot, and mouth disease (HFMD) at King Narai Hospital, Lopburi, Thailand. MATERIAL AND METHOD: We reviewed all of the suspected enterovirus infection cases aged less than 15 years admitted to King Narai Hospital between 2011 and 2013. Cases were classified into mild and severe enterovirus infection. Risk factors for severe enterovirus infection were analyzed using univariate and multivariate logistic regressions. RESULTS: During the study period, 156 patients met the case definition for further analysis. Of those 156 patients, 131 (84.0%) were classifed as mild cases, and 25 (16.0%) as severe cases with five (3.2%) deaths. The most common manifestations among the severe cases were seizures, pneumonia, meningoencephalitis, meningitis, and hyperglycemia. Of the 31 identifiable cases, 12 were caused by enterovirus 71 (EV71), 12 by coxsackievirus A16 (CA16), four by both, and three by other enterovirus. The clinical manifestations that were significantly related to severe enterovirus infection in univariate analysis were age of less than one year, highest body temperature greater than 39.0 degrees C, duration of fever greater than three days, absence of skin lesions, diarrhea, dyspnea, and hyperglycemia. The clinical manifestations that were significantly related to severe enterovirus infection by both univariate and multivariate analyses were absence of oral lesions, seizures, and drowsiness/lethargy. CONCLUSION: The major pathogens of severe disease were EV71 and CA16. High-risk factors significantly related to severe enterovirus infection in both univariate and multivariate analyses were absence of oral lesions, seizures, and drowsiness/lethargy. Early recognition of children at risk and prompt treatment is important to mitigate the deterioration of patients with enterovirus infection.

RISK FACTORS FOR SEVERE HAND, FOOT AND MOUTH DISEASE.

We studied risk factors associated with severe hand, foot and mouth disease (HFMD) caused by enteroviruses among patients aged less than 15 years admitted to King Narai Hospital, Lopburi, Thailand during 2011-2013. Cases were divided into either mild or severe. Severe cases were those with encephalitis, meningitis, myocarditis, pneumonia, pulmonary edema or respiratory failure. Risk factors for severe infection were evaluated using univariate and multivariate logistic regression analysis. One hundred eighteen patients met the case definition of HFMD. Of these, 95 (80.5%) were classified as mild cases, and 23 (19.5%) as severe cases; there were 5 deaths (4.2%). Of the 23 severe cases, 9 were infected with coxsackievirus A16 (CA16), 8 with enterovirus 71 (EV71) and 4 with both EV71 and CA16. The most common presentations among the severe caseswere: seizures (74%), pneumonia (39%), encephalitis (39%), and meningitis (13%). The clinical manifestations significantly related to severe HFMD on univariate analysis were highest body temperature 39.00C, duration of fever 23 days, absence of skin lesions, diarrhea, dyspnea, seizures and hyperglycemia. The clinical manifestations significantly related to severe HFMD on both univariate and multivariate analyses were age less than 1 year, absence of oral lesions and drowsiness/lethargy. Clinicians should be aware of these factors. Early recognition of severe cases is important to increase the rates of successful outcomes and reduce mortality.

Review of fatal and severe cases of box jellyfish envenomation in Thailand.

The study aimed to describe severe and fatal cases of box jellyfish stings in Thailand. Medical records were reviewed and patients, relatives, health staffs, and witnesses were interviewed. The pictures of suspected box jellyfish were sent via e-mail to experts in the toxic jellyfish network for further identification. There were at least 8 cases of box jellyfish envenomation, with 4 fatal and 4 near-fatal cases. There were an equal number of male and female patients from 4 to 26 years of age. In each case, there was immediate severe pain followed by systemic reactions. Immediately after exposure to the sting, 7 victims collapsed experiencing severe pain at the tentacle marks, respiratory failure, and cardiac arrest. All patients had tentacle marks on their bodies. In none of the fatal cases was vinegar applied to the tentacle marks as first aid, but 3 out of the 4 near-fatal cases were treated with a vinegar application.

The risk of blood transfusion-associated Chikungunya fever during the 2009 epidemic in Songkhla Province, Thailand.

BACKGROUND: Asymptomatic Chikungunya fever (CHIKF)-viremic blood donors could be a potential threat of spreading the disease unwittingly through contaminated blood transfusions. The relatively low prevalence of Chikungunya virus antibodies in the population and the records of more than 9000 suspected CHIKF cases raised concern about the potential transfusion-associated CHIKF during the 2009 epidemic. This study assessed the potential transfusion risk for CHIKF and the implementation of blood safety measures to mitigate this risk. STUDY DESIGN AND METHODS: A probabilistic model using key variables obtained from local information was used to estimate the weekly risk of transfusion-associated CHIKF during the 2009 epidemic. In addition, other blood safety measure-based strategies involving screening for donors at risk, donor tracing, and a 7-day quarantine of blood components at risk were implemented at the time of the epidemic. RESULTS: The risk of viremic donations per 100,000 ranged from 38.2 (95% confidence interval [CI], 36.5-39.8) to 52.3 (95% CI, 50.4-54.2). The potential risk of transfusion-associated CHIKF per 100,000 was estimated to be 1 in 2429 (0.04%; 95% CI, 1 in 6681 [0.02%]-1 in 1572 [0.06%]) to 1 in 1781 (0.06%; 95% CI, 1 in 3817 [0.03%]-1 in 1214 (0.08%]) donations. Among 26,722 donations, 11 (95% CI, 4-17) to 15 (95% CI, 7-22) donations were predicted to associate with transfusion risk. The implementation of blood safety measure-based strategies for this epidemic period suggested to deter 11 blood donations of transfusion risk. CONCLUSION: The interventions for blood safety measures applied in this study had mitigated the potential transfusion-associated CHIKF during the 2009 epidemic.

Viremic profiles in asymptomatic and symptomatic chikungunya fever: a blood transfusion threat?

BACKGROUND: The presence of a chikungunya virus (CHIKV) outbreak could have an impact on transfusion safety when there are a large number of infected persons during an epidemic. Serosurveys have found that 3% to 28% of infected persons remain asymptomatic and are potential disseminators of transfusion-associated chikungunya. However, the viremic profiles of asymptomatic chikungunya patients, the major determinant of the transfusion risk, are unknown. STUDY DESIGN AND METHODS: Data on CHIKV viremic profiles were obtained from a case-control study carried out in a chikungunya-affected area during the 2009 epidemic in Songkhla, Thailand. CHIKV-infected individuals were classified based on a combination of the patient's history and clinical and laboratory findings. RESULTS: There were 134 laboratory-proven CHIKV-infected cases, of whom 122 (91.0%) were symptomatic and 12 (9.0%) were asymptomatic. The viremic levels in the symptomatic infected individuals peaked on the first 3 days and lasted up to 8 days as defined by viral isolates. CHIKV genomic products were detected as late as Day 17 of illness. The viral loads observed in the symptomatic individuals (median, 5.6 × 10(5) plaque-forming units per milliliter [pfu/mL]; range, 1.3 × 10(1) -2.9 × 10(8) pfu/mL) were higher than but not significantly different from those observed in the viremic asymptomatic individuals (median, 3.4 × 10(3) pfu/mL; range, 8.4 × 10(1) -2.9 × 10(5) pfu/mL [p = 0.22, Wilcoxon test]). CONCLUSION: CHIKV infection is highly symptomatic and is associated with high-titred viremia. The viremic levels in asymptomatic CHIKV-infected individuals were in the range known to be capable of transmitting the disease to experimental animals. Asymptomatic CHIKV viremia individuals could be potential disseminators of transfusion-associated chikungunya.