An outbreak of Kingella kingae infections associated with hand, foot and mouth disease/herpangina virus outbreak in Marseille, France, 2013.
BACKGROUND
Outbreaks of invasive Kingella kingae infections recently emerged as a new public health concern in daycare centers in Europe, USA and Israel. Despite this, no trigger factor has been yet identified, preventing the setting up of rational measures of control and prevention. We report an outbreak of K. kingae infections associated with hand, foot and mouth disease/herpangina outbreak, and we define the research and policy priorities.


METHODS
From April 22 to May 07, 2013, 5 toddlers presented successive osteo-articular infections in a daycare center in Marseille, France. Real-time polymerase chain reaction targeting the cpn60 gene of K. kingae was used to investigate suspected cases and the prevalence of oropharyngeal K. kingae carriage of their close contacts.


RESULTS
The attack rate of the K. kingae infections outbreak was 23.7% (5/21) with no fatality. Positive real-time polymerase chain reaction targeting the cpn60 gene of K. kingae confirmed the diagnosis in 3 cases and revealed a rate of K. kingae oropharynx carriage in the index classroom of 94.4% (17/18) among daycare attendees not given antibiotic during the previous month, and of 76.9% (10/13) among staff in close contact. The eradication rate of K. kingae was 21.4% (3/14) among classmates after oral administration of rifampicin, and eradication occurred spontaneously in 83.3% (5/6) of the staff. Clinical and epidemiological features of the herpangina outbreak were consistent with that of an emerging European Coxsackievirus-A6 outbreak.


CONCLUSIONS
Hand, foot and mouth disease/herpangina virus outbreak enables triggering a K. kingae infections outbreak. Our findings offer support for new guidelines of K. kingae infections outbreaks management and emphasize the need for further research.
From the *Department of Pediatric Orthopedics, University La Timone Children's Hospital, Aix-Marseille University, APHM Public Hospitals of Marseille, Marseille, France; †Department of Pediatrics, Emergency Medicine, University North Hospital, Aix-Marseille University, APHM Public Hospitals of Marseille, Marseille, France; ‡URMITE, UM63, CNRS 7278, IRD 198, Inserm 1095, Aix-Marseille University, APHM Public Hospitals of Marseille, Marseille, France; §Department of Pediatrics, Saint Joseph Hospital, Marseille, France; ¶Department of Safety and Health Monitoring, Regional Health Authority of Provence Alpes Côte d'Azur, Marseille, France; and ‖EPV UMR IRD 190 "Emergence des Pathologies Virales", Aix Marseille University, IRD French Institute of Research for Development, EHESP French School of Public Health & IHU Méditerranée Infection, APHM Public Hospitals of Marseille, Marseille, France.
Nawal
N
El Houmami
Philippe
P
Minodier
Grégory
G
Dubourg
Alain
A
Martin-Laval
Elisabeth
E
Lafont
Jean-Luc
JL
Jouve
Rémi
R
Charrel
Didier
D
Raoult
Pierre-Edouard
PE
Fournier
D002656:Child Day Care Centers; D060085:Coinfection; D004196:Disease Outbreaks; D029821:Enterovirus A, Human / Q000145:classification / Q000235:genetics; D005260:Female; D005602:France / Q000453:epidemiology; D006232:Hand, Foot and Mouth Disease / Q000453:epidemiology* / Q000266:history / Q000382:microbiology; D049674:History, 21st Century; D006801:Humans; D007223:Infant; D017882:Kingella kingae / Q000145:classification / Q000235:genetics; D008297:Male; D016870:Neisseriaceae Infections / Q000453:epidemiology* / Q000266:history / Q000382:microbiology; D011159:Population Surveillance; D012307:Risk Factors