Enterovirus Outbreak — Hand, Foot and Mouth Disease

VADS CORNER — Enterovirus 71 · Echovirus 7 · Coxsackievirus · Adenovirus · Viral Myocarditis
Online since 6 June 1997 · Comprehensively revised 9 September 2026

This page covers the enterovirus family, with a focus on Enterovirus 71 (EV71), Echovirus 7, and the coxsackie group, as well as related material on adenoviruses and viral myocarditis. It began on 6 June 1997 in response to the Hand, Foot and Mouth Disease outbreak in Sarawak, Malaysia and was updated through the 1998–1999 Taiwan epidemic and subsequent outbreaks across the region. This was probably the first site dedicated specifically to EV71 outbreaks anywhere on the web.

For foot and mouth disease in animals, see the Foot and Mouth Disease page. For SARS, see the dedicated page.

Resource sites

• Centers for Disease Control and Prevention
  • Hand, Foot and Mouth Disease — CDC
  • Non-Polio Enterovirus — CDC NEW
• World Health Organization
  • Hand, Foot and Mouth Disease — WHO Western Pacific FIXED
• Hand, Foot and Mouth Disease — DermNet NZ
• Enterovirus 71 — Wikipedia
• Enterovirus 71 — MicrobeWiki

Updates — surveillance and outbreak reports

ProMED-mail

ProMED-mail electronic conference — search for Hand foot mouth, Enterovirus 71, Coxsackie, Echovirus. The individual post URLs from 1997–2008 in the original version of this page no longer resolve directly; ProMED’s own archive search is the reliable route to these records.

Hand, Foot and Mouth Disease — enteroviruses, coxsackieviruses and Enterovirus 71

• CDC: Hand, Foot and Mouth Disease
• DermNet NZ: Hand, foot and mouth disease
• Understanding the Coxsackie virus — Dr W.M. Chong, New Straits Times, 13 June 1997
• Hand, Foot and Mouth Disease — MedlinePlus FIXED (replaces dead NLM ency link)
• Emerging Viral Diseases of Southeast Asia and the Western Pacific — J.S. Mackenzie et al., Emerging Infectious Diseases Vol. 7 No. 3 Supplement, June 2001
• CDC Newsroom: Enterovirus outbreak in Taiwan — CDC Archive FIXED
  • Sequence AF119795; AF119796
  • Taiwanese EV71 isolate: AF136379

Clinical photographs

The original thumbnail images were hosted on nlm.nih.gov and healthcentral.com; both sources are now dead. The images are retained here by filename for any locally cached copies; the alt text describes each. The MedlinePlus article linked below contains current clinical photographs.

Source: MedlinePlus — Hand, Foot and Mouth Disease (current clinical images)

Picornaviridae background

• ICTV: International Committee on Taxonomy of Viruses
• Picornaviridae — ViralZone (ExPASy) FIXED (replaces dead Leicester University and virology.net links)
• Picornaviruses — archived Leicester University page ARCHIVE

Malaysia — outbreak pages, local updates and guidelines

• Hand, Foot and Mouth Update — Malaysia: Echovirus 7 (25 Oct 2000)
  • Press release (25 Oct 2000)
• Hand, Foot and Mouth — Malaysia (19 Oct 2000)
• Understanding the Coxsackie virus — Dr W.M. Chong, New Straits Times, 13 June 1997
• Neurogenic pulmonary oedema (NPE) (11 July 1998)
• EV71 brainstem encephalomyelitis: pathological findings in Malaysia (20 June 1998)
• Clinical presentation of 27 deaths in Sarawak, 14 April – 22 June 1997 (20 June 1998)
• Case history — Cases 1 & 2 posted to ProMED
• Case history — Cases 3 & 4
• Alert on HFM disease — The Star (14 June 1998)
• Letter to the editor: The Sarawak Sibu Story
• Letter to the editor: A New Coin Of The Same Value

EV71 brainstem encephalomyelitis — pathological findings

The histopathological findings from Malaysia during the 1997 outbreak, compiled by Dr Alan Teh and colleagues, are documented in the pathology page. For clinical context see also the viral encephalitis outbreak article in Berita MMA.

MOH Malaysia guidelines

• MOH: Integrated Action Plan for the Prevention and Control of HFMD ARCHIVE (original PDF link dead; see MOH Malaysia for current guidelines)
• MOH: HFMD Guidelines 2007 (PDF) ARCHIVE

Cybermed Archive — Berita MMA

• Berita MMA, June 1997
  • Cybermed: Information Online
• Berita MMA, July 1997
  • Cybermed: Outbreak in Sarawak
• Berita MMA, February 1998
  • Cybermed: Review
• Berita MMA, June 1998
  • Cybermed: Outbreak (Enterovirus) Revisited — Taiwan
• Berita MMA, July 1998
  • Cybermed: Interview with Prof Lam Sai Kit
• Berita MMA Vol.29 No.6, June 1999
  • Cybermed: Enterovirus, Haze, Nipah and Dioxin. What’s Next?
• Berita MMA Vol.29 No.10, October 1999
  • Cybermed: Publications on recent Malaysian Outbreaks
• Berita MMA Vol.30 No.5, May 2000
  • Cybermed: Sites for the month — May 2000
  • EV71 or Adenovirus? Hypothesis arising from two epidemics spanning 1997/98 — Dr T.G. Yap (HTML) and PDF format

IASR — Japan (contributed data on Malaysia and Taiwan)

• Molecular Epidemiology of Enterovirus 71 Isolated in Malaysia and Japan — IASR Vol.19 No.7, July 1998
• An Outbreak of Hand-Foot-and-Mouth Disease and Sudden Deaths Among Children in Malaysia — IASR Vol.19 No.7, July 1998

Emerging Infectious Diseases

• Molecular Epidemiology of Human Enterovirus 71 Strains and Recent Outbreaks in the Asia-Pacific Region — Cardosa MJ, Perera D, Brown BA et al. Vol. 9 No. 4, April 2003

Malaysia news archive (2000)

Direct links to Bernama and The Star search results from 2000 no longer resolve. Headlines retained as a historical record of coverage during the October 2000 outbreak.

Singapore — outbreak coverage 1998 and 2000

• Singapore Ministry of Health FIXED
  • Press releases on HFMD (Oct 2000 series) — original MOH archive links dead ARCHIVE
  • HFMD Advisory to Parents (PDF) ARCHIVE
  • Clinical Guidelines on Hand-Foot-Mouth Disease ARCHIVE
• The Straits Times Interactive — Singapore coverage series (Sept 2000 – Jan 2001) ARCHIVE
  • All childcare centres shut as 2 more die (30 Sept 2000)
  • 2 siblings die, a third still in intensive care (1 Oct 2000)
  • Outbreak virus identified (20 Oct 2000)
  • Siblings who died may have had genes that allow virus to slip through body’s defence (20 Oct 2000)
  • Hand, foot and mouth disease kills toddler (27 June 1998)
• Singapore Ministry of Environment (NEA predecessor) — press release series (Sept 2000 – March 2001) ARCHIVE

Taiwan — outbreak 1998

• News from Taiwan (contributed by Dr Chong Hoi Hee and friends)
• Enterovirus Epidemic, Taiwan, 1998 (contributed by Dr C.L. Wong)
• Communications regarding the outbreak in Taiwan
• Taiwan Ministry of Health and Welfare FIXED
• Taiwan Centers for Disease Control FIXED
• Enterovirus 71 Outbreaks, Taiwan — Occurrence and Recognition — Lin TY et al., Emerging Infectious Diseases Vol. 9 No. 3, March 2003
• Sentinel Surveillance for Enterovirus 71, Taiwan, 1998 — Wu TN et al., Emerging Infectious Diseases Vol. 5 No. 3, May–June 1999

MMWR — Taiwan 1998

• Deaths Among Children During an Outbreak of Hand, Foot, and Mouth Disease — Taiwan, April–July 1998 — MMWR Vol. 47 No. 30, 7 August 1998 FIXED

WHO Disease Outbreak News and CDI reports — Taiwan 1998

• WHO Disease Outbreak News: Enterovirus Outbreak in Taiwan, China — 4 July 1998 FIXED
• WHO Disease Outbreak News: Enterovirus Outbreak in Taiwan, China — 17 June 1998 FIXED
• Enterovirus outbreak in Asia — CDI Vol. 22 No. 8, August 1998 FIXED (compiled from WHO, CDC US, and Hong Kong DOH data)

APEC Enteroviral Watch Program symposium (March 2000)

Abstracts from the APEC Symposium on Enteroviral Watch Program for Children, 26–27 March 2000 — Taiwan CDC. Original links dead; abstracts listed for historical reference.

China Medical College Hospital materials (contributed by Wu-Chung Shen)

• MRI findings in Enterovirus Encephalitis in HFMD
• MRI findings in Enterovirus Encephalitis
• Outbreaks of Enterovirus 71 Around the World
• Translated articles (contributed by Dr Wong C.L.)

Taiwan news archive 1998 — original links dead

CNA Daily English News Wire, Reuters, CNN, BBC Asia-Pacific, China Times, and NandoTimes coverage of the 1998 Taiwan outbreak. None of these 1998 articles are accessible in open web archives. The scientific and official record of the outbreak is fully covered by the peer-reviewed and government sources above.

Cases in the region

Australia

• Communicable Diseases Intelligence Vol. 23 No. 7 — Enterovirus 71 outbreak in Western Australia associated with acute flaccid paralysis, preliminary report FIXED
• Australian Department of Health and Aged Care FIXED

Japan

• IASR (Infectious Agent Surveillance Report) — Enterovirus HFMD graphs and EV71/CVA16 by prefecture — JIHS/NIID FIXED (idsc.nih.go.jp moved to id-info.jihs.go.jp)
• National Institute of Infectious Diseases, Japan (NIID) / Japan Institute for Health Security (JIHS) FIXED

Hong Kong

• Hand, Foot and Mouth Disease — Centre for Health Protection, Department of Health Hong Kong NEW
• Enterovirus 71 Infection — Centre for Health Protection, Department of Health Hong Kong NEW

Viral Myocarditis

• Myocarditis — Merck Manual (Professional) FIXED

Adenoviruses — implicated in viral myocarditis in children

• ICTV — Adenoviridae
• Adenoviruses — CDC NEW

Echoviruses and Aseptic Meningitis

• Meningitis — CDC
• Aseptic Meningitis in the Newborn and Young Infant — American Family Physician, 15 May 1999 FIXED
• Outbreak of Aseptic Meningitis Associated with Multiple Enterovirus Serotypes — Romania, 1999 — MMWR Vol. 49 No. 29 (28 July 2000) FIXED
• Enterovirus Surveillance — United States, 1997–1999 — MMWR Vol. 49 No. 40 (13 Oct 2000) FIXED

Articles

• Role of Enterovirus 71 in Acute Flaccid Paralysis After the Eradication of Poliovirus in Brazil — da Silva EE et al., Emerging Infectious Diseases Vol. 2 No. 3, July–Sept 1996
• Enterovirus 71 — Emerging Infections and Emerging Questions — Dolin R. N Engl J Med. 1999 Sep 23;341(13):984–5 FIXED
• Principles of Immunisation — Wikipedia
• Pleconaril — activity against enteroviruses and rhinoviruses, Infect Med 17(7):488–494, 2000 ARCHIVE (Stanford virology link dead)
• A Clinical Trial of Immunosuppressive Therapy for Myocarditis — Mason JW et al., NEJM Vol. 333 No. 5, August 1995 ARCHIVE (NEJM paywall; search PubMed 7596370)
• Preventing Emerging Infectious Diseases: A Strategy for the 21st Century — Overview of the Updated CDC Plan FIXED

Journal abstracts — key literature

Malaysia — Sarawak 1997 and subsequent outbreaks

• Identification of enterovirus 71 isolates from an outbreak of HFMD with fatal cases of encephalomyelitis in Malaysia. Virus Res. 1999 May;61(1):1–9. AbuBakar S, Chee HY, Al-Kobaisi MF, Xiaoshan J, Chua KB, Lam SK. [PubMed]
• Isolation of subgenus B adenovirus during a fatal outbreak of enterovirus 71-associated hand, foot, and mouth disease in Sibu, Sarawak. Lancet. 1999 Sep 18;354(9183):987–91. Cardosa MJ, Krishnan S, Tio PH, Perera D, Wong SC. [PubMed]
• Fatal enterovirus 71 encephalomyelitis. J Pediatr. 1998 Dec;133(6):795–798. Lum LCS, Wong KT, Lam SK, Chua KB, Goh AYT, Lim WL, Ong BB, Paul G, AbuBakar S, Lambert M. [PubMed]
• Neurogenic pulmonary oedema and enterovirus 71 encephalomyelitis. Lancet. 1998 Oct 24;352(9137):1391. Lum LCS, Wong KT, Lam SK, Chua KB, Goh AYT. [PubMed]
• Enterovirus 71 from fatal and nonfatal cases of HFMD epidemics in Malaysia, Japan and Taiwan in 1997–1998. Jpn J Infect Dis. 1999 Feb;52(1):12–5. Shimizu H, Utama A, Yoshii K, Yoshida H, Yoneyama T, Sinniah M, Yusof MA, Okuno Y, Okabe N, Shih SR, Chen HY, Wang GR, Kao CL, Chang KS, Miyamura T, Hagiwara A. [PubMed]

Taiwan 1998 epidemic

• An epidemic of enterovirus 71 infection in Taiwan. Taiwan Enterovirus Epidemic Working Group. N Engl J Med. 1999 Sep 23;341(13):929–35. [PubMed]
• Neurologic complications in children with enterovirus 71 infection. N Engl J Med. 1999 Sep 23;341(13):936–42. Huang CC, Liu CC, Chang YC, Chen CY, Wang ST, Yeh TF. [PubMed]
• Clinical features and risk factors of pulmonary oedema after enterovirus-71-related HFMD. Lancet. 1999 Nov 13;354(9191):1682–6. Chang LY, Lin TY, Hsu KH et al. [PubMed]
• Fulminant neurogenic pulmonary oedema with hand, foot, and mouth disease. Lancet. 352(9125), 1 August 1998. Chang LY, Huang YC, Lin TY. [PubMed]
• Clinical spectrum of enterovirus 71 infection in children in southern Taiwan, with emphasis on neurological complications. Clin Infect Dis. 1999 Jul;29(1):184–90. Wang SM, Liu CC, Tseng HW et al. [PubMed]
• An outbreak of enterovirus 71 infection in Taiwan, 1998: epidemiologic and clinical manifestations. J Clin Virol. 2000 Jun;17(1):23–30. Liu C, Tseng H, Wang S, Wang J, Su I. [PubMed]
• An outbreak of enterovirus 71 infection in Taiwan 1998: a comprehensive pathological, virological, and molecular study. J Clin Virol. 2000 Jun;17(1):13–22. Yan J, Wang J, Liu C, Yang H, Su I. [PubMed]
• An outbreak of enterovirus 71 infection in Taiwan, 1998. II. Laboratory diagnosis and genetic analysis. J Clin Virol. 2000 Aug;17(2):91–9. Wang JR, Tsai HP, Chen PF et al. [PubMed]
• Genetic analysis of enterovirus 71 isolated from fatal and non-fatal cases during an epidemic in Taiwan, 1998. Virus Res. 2000 Jul;68(2):127–36. Shih SR, Ho MS, Lin KH et al. [PubMed]
• Sentinel surveillance for enterovirus 71, Taiwan, 1998. Emerg Infect Dis. 1999 May–Jun;5(3):458–60. Wu TN, Tsai SF, Li SF et al. [PubMed]
• Comparison of enterovirus 71 and coxsackievirus A16 clinical illnesses during the Taiwan enterovirus epidemic, 1998. Pediatr Infect Dis J. 1999 Dec;18(12):1092–6. Chang LY, Lin TY, Huang YC et al. [PubMed]
• Expression of capsid protein VP1 as antigen for diagnosis of enterovirus 71 infection. J Med Virol. 2000 Jun;61(2):228–34. Shih SR, Li YS, Chiou CC et al. [PubMed]
• Serotype-specific identification of enterovirus 71 by PCR. J Clin Virol. 2000 Apr;16(2):107–12. Brown BA, Kilpatrick DR, Oberste MS, Pallansch MA. [PubMed]
• Outbreaks of enterovirus 71 infection — Correspondence. N Engl J Med. 2000 Feb 3;342(5). [PubMed]
• Molecular epidemiology of enterovirus 71 in Taiwan. Arch Virol. 2001;146(3):589–600. Chu PY, Lin KH, Hwang KP et al. [PubMed]
• Pathologic studies of fatal cases in outbreak of HFMD, Taiwan. Emerg Infect Dis. 2001 Jan–Feb;7(1):146–8. Shieh WJ, Jung SM, Hsueh C et al. [PubMed]
• Neurologic involvement in an outbreak of enterovirus 71 infection: a hospital-based study. Acta Paediatr Taiwan. 2001 Jan–Feb;42(1):27–32. Liao HT, Hung KL. [PubMed]

Neuroimaging

• MRI of Enterovirus 71 myelitis with monoplegia. Neuroradiology. 2000 Feb;42(2):124–127. Shen WC, Tsai C, Chiu H, Chow K. [PubMed]
• MR imaging findings of enteroviral encephalomyelitis: an outbreak in Taiwan. AJNR Am J Neuroradiol. 1999 Nov–Dec;20(10):1889–95. Shen WC, Chiu HH, Chow KC, Tsai CH. [PubMed]
• Outbreak of severe neurologic involvement associated with enterovirus 71 infection. Pediatr Neurol. 1999 Jan;20(1):17–23. Komatsu H, Shimizu Y, Takeuchi Y, Ishiko H, Takada H. [PubMed]
• Emerging and re-emerging epidemic encephalitis: a tale of two viruses. Neuropathol Appl Neurobiol. 2000 Aug;26(4):313–8. Wong KT. [PubMed]

Molecular epidemiology

• Molecular epidemiology and evolution of enterovirus 71 strains isolated from 1970 to 1998. J Virol. 1999 Dec;73(12):9969–75. Brown BA, Oberste MS, Alexander JP Jr, Kennett ML, Pallansch MA. [PubMed]
• Enterovirus 71 isolated from China is serologically similar to the prototype E71 BrCr strain but differs in the 5′-noncoding region. J Med Virol. 47(2):161–167, 1995. Zheng ZM et al. [PubMed]
• Identification of Bulgarian strain 258 of enterovirus 71. Intervirology. 12(6):297–302, 1980. Melnick et al. [PubMed]
• Epidemiological, clinical, and pathomorphological characteristics of epidemic poliomyelitis-like disease caused by enterovirus 71. J Hyg Epidemiol Microbiol Immunol. 23(3):284–295, 1979. Shindarov LM et al. [PubMed]
• Enterovirus 71 isolated from cases of epidemic poliomyelitis-like disease in Bulgaria. Arch Virol. 60(3–4):329–340, 1979. Chumakov M et al. [PubMed]
• Enterovirus 71 infections: a varied clinical pattern sometimes mimicking paralytic poliomyelitis. Rev Infect Dis. 6:S387–S390, 1984. Milnick et al. [PubMed]
• Enterovirus type 71 infections: outbreak in Victoria, Australia, with a high incidence of neurologic involvement. Pediatr Infect Dis J. 7(7):484–488, 1988. Gilbert et al. [PubMed]

Viral myocarditis — key literature

• Etiology of mild acute infectious myocarditis — relation to clinical features. Acta Med Scand. 213(1):65–73, 1983. Karjalainen J et al. [PubMed]
• Extracorporeal membrane oxygenation: its role in the survival of a child with adenoviral pneumonia and myocarditis. South Med J. 76(9):1171–1173, 1983. Splaingard ML et al. [PubMed]
• Myocarditis: epidemiology, etiology and clinical aspects. Nord Med. 109(4):111–116, 1994. Friman G et al. [PubMed]
• Acute myocarditis: rapid diagnosis by PCR in children. Circulation. 90(1):330–339, 1994. Martin et al. [PubMed]
• Coxsackie viral myocarditis: a clinical and echocardiographic study. Indian Heart J. 42(6):441–444, 1990. Joy J et al. [PubMed]
• Clinical features of acute coxsackie B viral myocarditis. Jpn Circ J. 43(5):441–444, 1979. Toshima H et al. [PubMed]

PubMed searches

• Search PubMed: Enterovirus 71 FIXED
• Search PubMed: Echovirus 7 FIXED
• Search PubMed: Hand foot mouth disease enterovirus NEW

Virology sites

• ViralZone — ExPASy FIXED (replaces dead virology.net)
• ICTV: Virus taxonomy database
• Virus Reference Laboratory, University College Dublin

Communicable disease control, surveillance and other organisations

• Centers for Disease Control and Prevention (CDC)
• CDC MMWR — Morbidity and Mortality Weekly Report
• WHO Disease Outbreak News
• Emerging Infectious Diseases — peer-reviewed journal
• ProMED-mail
• Health advice for travellers — UK Government
• Travel Health Advisory — Health Canada
• Coxsackie, New York — where the name originated FIXED (replaces dead Yahoo Maps link)

Resource articles

• Guideline for Isolation Precautions in Hospitals — CDC
• Globalization, International Law, and Emerging Infectious Diseases — David P. Fidler, J.D. Emerging Infectious Diseases Vol. 2 No. 2, April–June 1996
• Viral Agents of Gastroenteritis: Public Health Importance and Outbreak Management — MMWR 39(RR-5);1–24, 1990 FIXED

Medline search and medical journals

• PubMed — NLM FIXED
• Medical Journal Sites — Vads Corner
• Google News — search coxsackie, enterovirus, hand foot mouth

First posted 6 June 1997 · Last updated 21 October 2017 · Comprehensively revised 9 September 2026 · Previous version · Disclaimer · Contact