The last article on Information Online could not have been written at a better time. My involvement in the outbreak in Sarawak would not have occurred if I did not plan to write that article. I decided to place it on the web rather than make it a major part of the previous article as I felt the information would be useful then and not a month later when the article is published.

I have been busy, trying to get as much information as possible and ensuring the information linked are valid. The credit, of course, goes to all those who had maintained these web pages of information and my role was more of a coordinator. I never realised that the outbreak site would be so well received. I met many people who shared their views and concern over the outbreak and I hope this relationship will be maintained. Many had sent me email messages and a number had signed the outbreak guestbook and guestbook1. Many were concerned Malaysians wanting to know more about the disease. Not surprisingly, many were from Sarawak and Sabah. The counter at the outbreak site registered 6000 hits during this one-month period. The majority were from Malaysia(3965), followed by USA(531), Singapore(186), Australia(145), Netherlands(89), Brunei(63), Japan(38), Canada(33), New Zealand(24), UK and Germany(22), and the rest from over 24 countries. This just illustrates that we are not alone, there are no borders, and information is accessible if you look hard enough. I did not know much about the disease but managed to "collect" many links that had this information. Information is available but one has to be careful, as some information may be wrong or misleading. You have to decide what is right! I tried my best to moderate the links at my site so as to ensure the information that I had linked to are genuine, reliable and accurate.

Starting from this article I have excluded the URL and instead underlined the hyperlinks that can be accessed. This is to allow easier reading without the "http,colon,slash,slash,www,dot…". The URL for this article is given at the end of the page.

Two sites have to be commended for their effort in keeping the Internet community informed. The first, is the Sarawak Health Department, (Down) MOH which maintained a statistics on the number admitted or succumbed to the disease, press releases and useful links for more information. The second is comments(Down) from Enterovirus Research Laboratory, University of Nebraska Medical Center,(Down) Omaha NE, USA. They gave a very pragmatic and objective overview of the sequence of events(Down) that unfolded over the period of the outbreak. The other sites that had periodic updates were at ProMED-mail and news reported to WHO.

Information from WHO web site.

For the benefit of non-surfers (just to show what you are missing) I have included the following information from the World Health Organization, Emerging and other Communicable Diseases (EMC) - news reported to WHO site.

6 June 1997

Outbreak of fatal myocarditis in Malaysia

In an outbreak of, as yet, undetermined etiology 17 children aged from 5 months to 4 years have died in cardiogenic shock due to myocarditis since 14 April. The cases were from Sibu, Sarikei and Kuching Divisions at the western end of Sarawak with most cases coming from Sibu. The clinical condition as described by the Sarawak Health Department comprises fever of 2-3 days duration, nervous system involvement manifested as seizures and unilateral paralysis of one side of the upper limbs, poor systemic perfusion and at the end stage cardiogenic shock due to myocarditis with echocardiogram showing decreased contractability of left ventricle. The presence in some cases of pulmonary oedema and/or exanthema and lesions of the buccal mucosa and the palms could suggest the diagnosis of foot and mouth disease as a possibility but this awaits laboratory confirmation (coxsackie virus investigations are under way).

A variety of diagnostic specimens, including stools, respiratory swabs and cerebrospinal fluid, are being investigated at the University of Malaya and serological specimens at the Institute of Medical Research in Kuala Lumpur. So far tests for Japanese encephalitis, dengue, yellow fever and rickettsia have been negative.

A team of investigators from the Ministry of Health, consisting of paediatricians, cardiologists, epidemiologists, virologists and public health officers has been to Sibu to study the situation, assist in management and to prevent the spread of the infection.

Sarawak has a very well developed public health infrastructure. The local health authorities and the public have been alerted. Control measures in place emphasize good personal hygiene, especially hand washing, and avoidance of sharing baby pacifiers. Active case finding among family members of all cases reported has been instigated.

10 June 1997

The number of deaths in the outbreak of myocarditis increased to 21 on 9 June. Three of the 21 deaths occurred in the second half of April, 10 during May and the remaining 8 occurred in June. Most children had fever for 2-3 days and were admitted to hospital when their condition deteriorated. The clinical picture indicated viral involvement with coxsackie virus as a possible agent. Coxsackie virus was also suspected in a concurrent outbreak of hand, foot, and mouth disease in Sibu. Antibody to coxsackie B virus has been detected in specimens taken from four children who had died of viral myocarditis and three who had hand, foot and mouth disease. The laboratory results were from a team of clinical virologists and scientists at the Institute for Medical Research, Malaysia.

Coxsackie virus is mainly transmitted by the oral-faecal route and the public has been advised to maintain good personal hygiene, hand washing after defaecation and before handling food, avoid sharing baby pacifiers, avoid overcrowding. Public health measures include increased control of flies and cockroaches, and closures of nurseries, playschools, kindergartens and public swimming pools in Kuching and Sibu where most deaths have occurred. Surveillance of hand, foot and mouth disease has been established in cooperation with private doctors. All health facilities and hospitals in the State are on the alert and an observation ward has been established in Sibu Hospital. A similar facility is planned in Sarawak General Hospital in Kuching. Active case finding has been instituted among the family members of all the cases reported.

19 June 1997

The WHO Collaborating Centre at the University of Malaya in Kuala Lumpur reported on 12 June that 13 virus strains had been isolated from 15 cases, 8 of which were fatal. Six of the 13 isolates were from CSF, three from serum samples and four from rectal and/or throat swabs. Preliminary results on nine of the isolates sent to the Centers for Disease Control and Prevention, Atlanta, Georgia, USA and to the Department of Microbiology, Queen Mary Hospital, University of Hong Kong confirmed that two were positive for enterovirus by RT-PCR, of which one was an isolate from serum of a fatal case. Further identification results will be available soon. The WHO Collaborating Centre in Kuala Lumpur is working closely with the Institute for Medical Research and the University of Malaysia Sarawak in a joint effort to identify the causative virus of this outbreak.

Up to 17 June 1997 the outbreak had caused 26 fatal cases.

26 June 1997

Two more deaths from acute viral myocarditits occurred on 24 June bringing the total number of deaths to 29, all in children aged from 5 months to 6 years. A total of over 600 children has been admitted to the observation wards in hospitals in Sarawak State and 66 remained under observation on 26 June. The number of cases being admitted to hospital for observation has declined since 20 June.

Teams from WHO and the Centers for Disease Control and Prevention are working with the Ministry of Health and national laboratories to establish the cause of the outbreak which may be an enterovirus. Laboratory investigations on specimens from fatal cases of myocarditis and from cases of hand, foot and mouth disease have been collected for virus isolation in tissue culture, for PCR and other techniques. Preliminary results from the virological studies should be available shortly.

Update 30 June

The Sarawak Health Department informed of an additional fatal case in a 2-year-old boy from Sarikei Division who died from viral myocarditis in Sarawak General Hospital on 30 June. Update posted on the web site of Sarawak Health Department at http://www.jaring.my/jkns/outbreak/virus1.htm (Down)

3 July 1997

Report from the Ministry of Health, Malaysia, dated 28 June 1997 regarding the cluster of deaths among infants and young children during an outbreak of hand, foot and mouth disease in Sarawak, Malaysia.

On 14 April 1997, a 19-month old boy was admitted to the Sibu Hospital Sibu, Sarawak, Malaysia, with a 3-day history of fever and oral ulcers. On examination, he showed poor peripheral perfusion and tachycardia, subsequently developed cardiac failure, and died on 15 April 1997. Since then, 26 more children in several cities in Sarawak have died of heart failure, and 2 others who were brought in dead are suspected to have died of similar cause. Eighteen (62%) of the 29 children were male. Their mean age was 1.6 years (range 7 months to 6 years); 23 (79.3%) of 29 were less than 2 years old.

The 27 children who were admitted alive presented with or soon thereafter developed signs of shock, including pallor, cold extremities, delayed capillary refill, and weak peripheral pulses. Pulmonary oedema was present in many cases; intravenous fluids often exacerbated the oedema. Nearly all the children had sinus tachycardia on electrocardiogram; no rhythm disturbances were noted. Echocardiograms obtained on most patients uniformly showed a poorly contractile globular left ventricle with low output (ejection fraction <60%). In most instances, children died within 7 days of onset of illness, and death usually ensued within 24 hours of admission. Postmortem examinations have been performed on 3 children; results are pending. The most recent fatal case to date had onset on 21 June 1997 and died on 24 June 1997.

Many of these children had a maculopapular or vesicular rash on the palms or soles and vesicles or ulcers in the oral cavity, characteristic of hand, foot, and mouth disease. Several children had signs of central nervous system infection [3 (15%) of 20 had acute flaccid paralysis, and 9 (45%) of 20 had histories of seizures]. Examination of the cerebrospinal fluid showed a lymphocytosis, consistent with viral meningitis. In several cases, family members reported that the children who died had been in contact with other children with hand, foot, and mouth disease two to five days prior to onset of their own illness.

Since April 1997, private practitioners in Sarawak have reported seeing a large number of children with hand, foot and mouth disease, who presented with fever, mouth ulcers and maculopapular or vesicular rash on the palms and soles. Since 6 June 1997, private physicians and government clinics have reported 2 113 cases of hand, foot, and mouth disease in young children in Sarawak (population 1.9 million).

During June 1997, almost 2140 children with hand, foot and mouth disease have been admitted to private or government hospitals in peninsular Malaysia (population 21 million). No fatalities have yet been reported among those children hospitalized.

Epidemiological and laboratory investigations are underway. Several enteroviruses have been isolated from clinical specimens obtained both from children who died and those with uncomplicated hand, foot and mouth disease. Two isolates have been identified as enterovirus 71; further identification of the remaining isolates is in progress.


The media insistence on using the term "Coxsackievirus outbreak" when the organism had yet to be identified, should be dropped. The closest is probably to call it enterovirus outbreak, (positive PCR for enterovirus 71 and ?serology for coxsackie) since enterovirus 71(EV 71) and coxsackie group of viruses comes under the group called enteroviruses. Both of these are known to cause (Hand, Foot and Mouth) HFM disease. (Down)

Coxsackie B group (Down)of viruses have been known to cause viral myocarditis whereas EV 71 although mainly known to cause neurological symptoms, the Bulgarian strain (outbreak in 1975) was also found to cause encephalo-myocarditis.

More links can be found at the outbreak site.


Mars Pathfinder

The latest information and photographs from the red planet through NASA Spacelink. Choose one of the mirror sites or go directly to Silicon Graphics mirror site.

Till next month, "Happy Surfing".

M.Vadivale (vadivale@geocities.com) aka Cyberdoc

Web www.vadscorner.com
Locations of visitors to this page

The links to URL mentioned above are valid at the time of writing (9 July 1997).

This page can be accessed at http://www.vadcorner.com/internet5.html or at http://www.vadscorner.com/mma_internet.html.

Links last updated 17 April 2005