title: Co-circulation of coxsackieviruses A6 and A10 in hand, foot and mouth disease outbreak in Finland.
abstract: BACKGROUND
  A nationwide outbreak of hand, foot and mouth disease (HFMD) occurred in Finland in autumn 2008. The outbreak was untypical since a considerable number of clinically diagnosed patients were adults. Furthermore, many of the patients suffered from onychomadesis several weeks after the acute phase of HFMD.
  
  
  OBJECTIVE
  Detection, identification and phylogenetic analysis of human enteroviruses (HEV) that caused the outbreak.
  
  
  METHODS
  A total of 420 clinical specimens were obtained from 317 HFMD cases all over the country. The presence of HEV in the specimens was analysed by virus isolation and/or direct real-time RT-PCR; selected HEV strains were further typed by molecular methods. The genetic similarities of HEV strains were assessed by phylogenetic analyses on partial VP1 sequences.
  
  
  RESULTS
  HEV were detected in 212 HFMD cases, including both children and adults, throughout Finland. Two HEV types, coxsackieviruses A6 (CV-A6) and A10 (CV-A10), were identified as the causative agents of the outbreak. One genetic variant of CV-A6 predominated, but, additionally, three other genetically distinct CV-A6 strains were found. All CV-A10 strains segregated into one genetic cluster distinct from previously reported CV-A10 sequences.
  
  
  CONCLUSIONS
  The Finnish 2008 HFMD outbreak was caused by two infrequently detected, co-circulating, coxsackie A viruses. Our data suggest endemic circulation of both CV-A types in Northern Europe and that the outbreak was due to the emergence of new genetic variants of these viruses.
authors.affiliation: National Institute for Health and Welfare (THL), Department of Infectious Disease Surveillance and Control, Gastrointestinal Infections Unit, PO Box 30, 00271 Helsinki, Finland. soile.blomqvist@thl.fi
authors.forename: Soile
authors.initials: S
authors.lastname: Blomqvist
authors.forename: Päivi
authors.initials: P
authors.lastname: Klemola
authors.forename: Svetlana
authors.initials: S
authors.lastname: Kaijalainen
authors.forename: Anja
authors.initials: A
authors.lastname: Paananen
authors.forename: Marja-Leena
authors.initials: ML
authors.lastname: Simonen
authors.forename: Tytti
authors.initials: T
authors.lastname: Vuorinen
authors.forename: Merja
authors.initials: M
authors.lastname: Roivainen
mesh_terms: D000328:Adult; D000818:Animals; D001483:Base Sequence; D002460:Cell Line; D002648:Child; D004196:Disease Outbreaks; D004770:Enterovirus / Q000145:classification / Q000235:genetics / Q000302:isolation & purification*; D005387:Finland / Q000453:epidemiology; D006232:Hand, Foot and Mouth Disease / Q000453:epidemiology* / Q000821:virology*; D006801:Humans; D051379:Mice; D008969:Molecular Sequence Data; D010802:Phylogeny