Dr. Greene, the state of Borneo, Sarawak, is now facing a critical situation in which the coxsackievirus has claimed 14 children. Doctors are at a loss and seeking help through the internet. I hope you might help and provide whatever information you can regarding the virus.
Teh Seng Chai Kuching, Sarawak, Malaysia

Dr. Greene, there is currently an epidemic of viral myocarditis in Malaysia resulting in 21 deaths -- all children. The causative agent has not been identified, but there is currently also a large outbreak of hand-foot-and-mouth disease. Is it possible that the two are related?
Tarat, Malaysia

Dr. Greene, my 15 month old son recently was exposed to a child who had hand-foot-and-mouth disease. It was after the 4 day contagious period. He broke into a rash on his hips and his penis. It does not seem to be anywhere else though. It looks like little red blisters. If this is hand-foot-and-mouth disease, what can be done?
Jerri Thomas, Houston, Texas

How terrifying to live where a deadly virus runs unchecked through the children! In the modern world of international airplane travel, this terror could happen anywhere. Anytime.

Coxsackieviruses are the major cause of hand-foot-and-mouth syndrome, an illness common in children around the world -- especially in the summer and early fall. Classically, this results in painful blisters in the mouth, on the palms and fingers of the hands, on the soles of the feet, and/or in the diaper area, appearing 3 to 6 days after exposure. Ouch! These blisters are filled with active virus and usually last for 7 to 10 days. Treatments (such as Tylenol, Motrin, and/or Benadryl) are given only to alleviate discomfort. Some children need stronger pain medicines (such as Tylenol with codeine) to help them eat. Children often tolerate soft, cool treats like Jell-O or milkshakes. Most of the time the children's immune systems rally to defeat the virus, and the infection goes away without any serious complications. There is, however, a wide spectrum of other possibilities.

Many, if not most, children with coxsackievirus have no symptoms at all. Even so, the virus may be present in the saliva for 7 to 10 days and in the stool for months (making them contagious for months). Respiratory spread (others getting sick from breathing the same air) is usually limited to one week or less. However you look at it, though, I'm sorry to report that the contagious period is longer than 4 days, Jerri.

The most common route of spread is from child to child via stool-to-skin-to-mouth (or less commonly, saliva-to-hand-to-mouth). Houseflies help spread coxsackievirus by carrying it on their feet and mouthparts. Coxsackieviruses survive long enough on toys and other objects to make these agents of spread as well.

The Centers for Disease Control and Prevention (CDC) in the United States has made recommendations for hand-foot-and-mouth disease in the child care setting:

• "Make sure that all children and adults use good handwashing technique." (I would add -- especially after toileting and diaper changing and before eating!)
• "Do not exclude ill persons, because exclusion may not prevent additional cases since the virus may continue to be excreted for weeks after the symptoms have disappeared. Also, some persons excreting the virus may have no symptoms. However, some benefit may be gained by excluding children who have blisters in their mouths and drool or who have weeping lesions on their hands." (I would add that the rare child who is hospitalized with coxsackievirus should be isolated -- with contact precautions.)

Coxsackieviruses belong to a large family called the enteroviruses (named for their tendency to thrive in the human intestine). The most famous member of this family is polio, which has caused childhood paralysis dating back from at least 1350 B.C. (Pediatric Infectious Diseases, Saunders 1992). There are more than two dozen specific species of coxsackieviruses, each causing a wide variety of symptoms.

The most common sickness caused by coxsackieviruses is a nonspecific febrile illness. Children have a fever which lasts an average of 3 days. Sometimes the fever leaves for 2 or 3 days and then returns. Sometimes this is the only symptom, but sometimes children also have a headache or a sore throat.