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Vol. Vol. XI No. 10 ~EINet News Brief ~ 16 May 2008 ~ EINet News Briefs ~ May 16, 2008
*****A free service of the APEC Emerging Infections Network*****
APEC EINet News Briefs offers the latest news, journal articles, and notifications for emerging infections affecting the APEC member economies. It was created to foster transparency, communication, and collaboration in emerging infectious diseases among health professionals, international business and commerce leaders, and policy makers in the Asia-Pacific region.
In this edition:
1. Influenza News
- Global: Cumulative number of human cases of avian influenza A/(H5N1)
- India (Darjeeling): Officials frustrated over slow culling operations in Northeastern India
- Indonesia (Jakarta): Two siblings die of suspected H5N1 avian influenza infection
- Viet Nam (Can Tho City): H5N1 avian influenza resurfaces in poultry flocks
- South Korea (Seoul): Officials claim to have culled all poultry in the capital city
2. Infectious Disease News
- Russia (Stavropol): Officials declare Crimean-Congo hemorrhagic fever situation “serious”
- Russia: Officials report two cases of botulism infection during the first quarter of 2008
- Singapore: Officials report an imported case of chikungunya
- Peru: Epidemiology officials confirm three cases of cutaneous anthrax
- Peru: Two more probable yellow fever cases
- Peru: Officials confident in control of imported measles case
- Peru: Toxins suspected in death of two sailors, quarantine lifted
- USA (South Carolina): 33 people possibly exposed to rabid baby raccoon
- USA (Colorado): Kiowa county man dies from hantavirus infection
- USA (New York): Health officials attempt to raise awareness of shigellosis
- USA (Washington): Measles outbreak continues in Grant County, possible exposure in King County
- Canada: Health authorities worry as measles outbreak continues
- AVIAN/PANDEMIC INFLUENZA
- Hand, foot and mouth disease – *Major International Outbreak*
- Enterovirus Déjà Vu
- An eight-year study of epidemiologic features of enterovirus 71 infection in Taiwan
- Salmonellosis Outcomes Differ Substantially by Serotype
- Crystal structures of oseltamivir-resistant influenza virus neuraminidase
- Cross-Recognition of Avian H5N1 Influenza Virus by Human Cytotoxic T-Lymphocyte
- Multi-antigen vaccines based on complex adenovirus vectors induce protective
- APEC EINet Pandemic Influenza Preparedness Virtual
- Critical care panel tackles disaster preparation, surge capacity, rationing
- Proposed Guidance on Workplace Stockpiling of Respirators and Facemasks
- CDC guide to hand, foot, and mouth disease
1. Influenza News
Global: Cumulative number of human cases of avian influenza A/(H5N1)
Economy / Cases (Deaths)
India (Darjeeling): Officials frustrated over slow culling operations in Northeastern India
Amidst a slow culling operation in avian flu-affected Darjeeling district due to noncooperation by owners of fowl, a fresh report of bird deaths worsened the situation. District magistrate Rajesh Pandey on 12 May 2008 said that the deadline was extended, as only 9,500 birds were culled against the target of culling 18,000 birds by 11 May 2008. Animal Resources Development department sources said that the progress of culling was not as expected because of noncooperation by poultry owners in some areas. The target was increased to 20,000 and was expected to be completed by 13 May 2008. To encourage poultry owners, the department announced revised compensation for birds culled: Rs 75 (USD 1.77) for a duck, Rs 50 (USD 1.18) for a layer, Rs 40 (USD 0.94) for a broiler, Rs 35 (USD 0.83) for a duckling, Rs 20 (USD 0.47]) for a chick and Rs 2 (USD 0.05) for an egg.
The situation, however, turned worse following reports of the deaths of a crow, two swallows and seven fowl from Bijanbari area in Darjeeling on 11 May 2008. Unofficial reports, however, claimed the deaths of 100 birds. The outbreak of avian influenza at Bagdogra, Matigara, Naxalbari in Siliguri and Sukna in Kurseong sub-division was confirmed by High Security Animal Disease Laboratory, Bhopal. The administration has banned trading on chicken and poultry products in the affected areas. Meanwhile, there were allegations that the administration, under pressure from the business community, was not banning the sale of poultry products in this commercial hub. The relaxation could cause problems, as there was every possibility that a supply of chickens and poultry products could come from the affected areas, which were within 15 km of this town.
Indonesia (Jakarta): Two siblings die of suspected H5N1 avian influenza infection
A 16-year-old girl died four days after being admitted to the Persahabatan Hospital in the Indonesian capital on 8 May 2008 with laboratory test later confirming she had the avian flu virus. She had been treated at the isolated room exclusively for bird flu patients but doctors failed to save her life. Ten days before her death, her 15-year-old brother died after a brief treatment at another hospital with symptoms similar to bird flu.
“The symptoms were just the same: high fever, cough and faint. We thought it was the common (seasonal) flu so he didn't stay at the hospital, but then he died,” the father of the ill-fated teenagers, said. But it cannot be confirmed that bird flu had caused the boy's death as he didn't take a blood test. The family lives in a densely populated neighborhood where a nearby house rears chickens.
Apart from the two cases, Indonesia has so far confirmed 133 bird flu cases in human with 107 deaths since the virus was first reported in 2003.
Viet Nam (Can Tho City): H5N1 avian influenza resurfaces in poultry flocks
South Korea (Seoul): Officials claim to have culled all poultry in the capital city
The slaughter began on 11 May 2008, hours after authorities confirmed Seoul's second outbreak of bird flu in less than a week. The slaughter did not affect parrots, parakeets, and canaries because they have little chance of spreading the disease, Kim said. On 12 May 2008, government tests confirmed the H5N1 viruscaused the latest outbreak in Seoul, said Yoon Young-ku, a spokesman at the Agriculture Ministry. The tests also confirmed two additional outbreaks of the virus in Busan, bringing to 31 the total number of outbreaks in South Korea, he said. Bird flu began sweeping southern parts of the country in April 2008 for the first time in more than a year, forcing the slaughter of about 6.8 million birds.
2. Infectious Disease News
Russia (Stavropol): Officials declare Crimean-Congo hemorrhagic fever situation “serious”
The administration of Rospotrebnadzor (Federal Trade and Public Health Inspection Authority) for Stavropol Krai considers that the Crimean-Congo hemorrhagic fever (CCHF) situation in the region is serious. One patient died on 13 May 2008. The agency reports that so far there are nine other patients with CCHF registered in 2008. These patients are from eight regions of the Stavropol Krai. Only three patients were registered during the same period in 2007.
Russia: Officials report two cases of botulism infection during the first quarter of 2008
Singapore: Officials report an imported case of chikungunya
Singapore's Health Ministry confirmed the 17th case of the mosquito-borne chikungunya disease here on 8 May 2008. The ministry revealed that the latest victim was a man that caught the disease overseas recently. He believed he caught the virus while playing golf at Jakarta's Jagorawi Golf and Economy Club a month ago. Since the first locally transmitted case was detected on 14 Jan 2008, so far 13 people have been infected locally, while another four caught the virus overseas, the ministry said. Its spokesman said: “The virus can be carried into Singapore, and the presence of the Aedes mosquito means the threat will remain.”
Like the dengue virus, the chikungunya virus is spread by the Aedes mosquito. Currently, there is no vaccine to prevent chikungunya fever, which is characterized by fever, joint pains, chills and nausea. The ministry said the best way to prevent chikungunya fever is to take precautionary measures to prevent mosquito breeding around the house and to protect oneself against mosquito bites.
Peru: Epidemiology officials confirm three cases of cutaneous anthrax
On 23 Apr 2008 the Lima District Health Unit (DIRESA) notified the General Directorate for Epidemiology of three confirmed cases of cutaneous anthrax from the Caudevilla locality, Supe District.
Case 1: 29-year-old, male worker in the Supe slaughterhouse, who went to the hospital on 16 Apr 2008, presented with an ulceronecrotic skin lesion in the right forearm, with perilesional edema, accompanying fever, and with a Gram-positive smear of the lesion compatible with Bacillus anthracis.
Case 2: 26-year-old female who went to the same hospital on 19 Apr 2008 with a ulceronecrotic skin lesion on the second finger of the left hand, and a Gram-positive swab of the lesion compatible with B. anthracis. On 10 Apr 2008 both patients had participated in a clandestine butchering of a bovine (animal) in Caudevilla, Supe district.
Case 3: 9-year-old female with an ulceronecrotic skin lesion on the dorsum of the right hand and beginning of illness on 21 Apr 2008. This girl participated in washing the viscera of the same animal as in the cases above.
Peru: Two more probable yellow fever cases
During EW 1-17 of 2008, there were 13 reported cases in Peru, including three confirmed cases, six probable cases, and four discarded cases. All of the confirmed cases died.
Peru: Officials confident in control of imported measles case
The case is a 19-year-old male patient coming from India who departed on 19 Apr 2008 from Bombay heading to Guayaquil, with stops in London and Miami. On 21 Apr 2008, he arrived in Guayaquil and the same day went to Puerto Bolivar, where he boarded a tanker, Berge Nantong. The vessel set sail to Callao on 28 Apr 2008 and arrived there on 30 Apr 2008. Symptoms began on 28 Apr 2008 with malaise, cough, and sore throat. On 30 Apr 2008, he became febrile, with a rash on 1 May 2008, so it was decided to send the patient to a private clinic in Lima (Vesalio clinic), where it was determined that it was a probable case of measles, and they notified the case to the General Direction of Epidemiology. The patient did not leave the ship from 21 Apr to 1 May 2008, when he was taken to Vesalio clinic. On 2 May 2008, the Peruvian National Institute of Health reported the results of ELISA tests, positive IgM and negative IgG for measles in serum. When the case was confirmed, a multidisciplinary team was brought together in order to assess and control the risk for measles transmission from this imported case already identified. After the patient was notified as a probable case of measles, he was isolated for one week. International Maritime Sanitation stated on 1 May 2008 that the crew and every person on the ship had to stay in quarantine while investigations were carried out to determine their immune status for measles and their risk is assessed as a preventive measure against possible transmission of measles through contact.
Two places were identified in which the patient had contact with different persons whose immune status for measles was not initially known: Berge Nantong vessel and Vesalio Clinic, where the patient was initially seen. Thirty-eight contacts were identified in the vessel, including the crew members and persons who boarded the ship after she arrived to Callao. One hundred ninety one persons were identified and vaccinated in Vesalio clinic, including health care personnel who took care of the patient and other patients who were in the clinic while the measles case was hospitalized there.
On 2 May 2008, a clinical examination of all crew of Berge Nantong ship was performed. No febrile cases were found; nobody with a rash was found, so everybody was considered to be in an apparent good health condition. On 2 May 2008, blood samples were taken from 24 persons in the ship (20 crew members and four Peruvian citizens who boarded the ship). The samples were processed by the Peruvian National Institute of Health, and all of them were negative for measles IgM and positive for IgG, so it was interpreted that this population is immune for measles and that the quarantine period should be terminated.
Peru: Toxins suspected in death of two sailors, quarantine lifted
USA (South Carolina): 33 people possibly exposed to rabid baby raccoon
The people who found the raccoon in the woods at Wexford passed it around to many of their friends and relatives, Boatwright said. “They found it, took it to somebody else who kept it for a few days, and thought someone else would want it,” she said. “It was the pass-around-pack for a while from what we understand.”
USA (Colorado): Kiowa county man dies from hantavirus infection
Infection occurs when the virus becomes airborne and is inhaled, or by direct contact with rodents, their droppings, or nests. Vacuuming an area without first wetting it down does not provide protection. Little said the disease cannot be transmitted from person to person. No effective treatment exists for the disease, Little said, so prevention is the key to avoiding hantavirus (infection).
“When hantavirus infection is suspected or confirmed, early admission to a hospital where careful monitoring, treatment of symptoms, and supportive therapy can be provided is most important,” Little said. Homes can be rodent-proofed by eliminating food sources for rodents and removing abandoned vehicles, wood, brush, and junk piles where rodents hide, Little said. She urged caution around mouse droppings and other evidence of mice. A large, rapid increase in the number of mice around a home often precedes a human case of the virus.
USA (New York): Health officials attempt to raise awareness of shigellosis
Shigellosis spreads easily among young children in day care and preschool environments. Parents, teachers and caregivers should help young children wash their hands thoroughly and should make sure it is done properly. It takes very few Shigella bacteria to cause illness.
“We encourage residents to be vigilant about hand-washing,” said Dr. Sharon Balter, Medical Epidemiologist in the Health Department's Bureau of Communicable Disease. Large outbreaks of shigellosis have occurred in recent decades in traditionally observant Jewish communities in Borough Park, Williamsburg and other parts of New York State, New Jersey, Illinois, Maryland and Canada. Some 274 cases of shigellosis were reported in New York City in 2006, a rate of 3.4 cases per 100,000 people.
USA (Washington): Measles outbreak continues in Grant County, possible exposure in King County
All activities at the school have been cancelled until further notice while officials work to identify students and school staff who may be at risk of infection. The girl traveled to western Washington on 29 Apr 2008 as part of a school trip and would have been contagious at the time. The other eight cases were in members of a family from Grant County who attended a “Generation Church Conference” in Kirkland in late March 2008 and developed symptoms afterwards.
In 2000, the Centers For Disease Control (CDC) declared measles had been eliminated in the United States, but now the CDC says 64 cases have been reported in nine states in 2008. The agency says that’s the highest number they’ve seen in seven years. All of the patients except one weren’t vaccinated. States most affected were Wisconsin, Arizona, Michigan and New York.
Canada: Health authorities worry as measles outbreak continues
But these new cases are more worrisome for authorities. Two of them were traced back to patients who had been at the Scotia and TD Towers, potentially leaving those who frequent the underground PATH system (a 27-kilometer network of pedestrian tunnels beneath the office towers of downtown Toronto) exposed.
“All of the new cases either live or work downtown,” reveals Dr. Barbara Yaffe, director of Communicable Disease Control for Toronto Public Health. “Anyone born before 1970 likely had measles in childhood, and is therefore protected. Everyone else should ensure they have had two doses of measles vaccine for full protection, especially as we know measles is circulating in Toronto.”
Toronto Public Health is recommending that those who received a single vaccination as children consider getting a second dose. “Complete and up-to-date vaccination remains the best way to protect yourself and your family from communicable diseases like measles,” Dr. Yaffe added. “Prior to universal immunization in the 1970s, Canada saw thousands of cases of measles each year.”
Hand, foot and mouth disease – *Major International Outbreak*
The number is expected to continue rising after the state Health Ministry ordered health care providers to report cases within 24 hours. The virus has been yet another major concern for Chinese authorities as they prepare for the Beijing Olympics in August 2008. Cases have been reported from Guangdong province in the south to Jilin province in the northeast, and in major cities including Beijing and Shanghai.
Most cases of hand, foot, and mouth disease in China this year have been blamed
on Enterovirus 71. The virus spreads through contact with saliva, feces, nose,
and throat mucus or fluid secreted from blisters. There is no vaccine or
specific treatment, but most children with mild forms of the illness recover
quickly after suffering little more than a fever and rash. The disease is
expected to peak in the hot months of June and July.
The first occurred at Universiti Malaysia Sarawak (Unimas) on 10-25 Mar 2008 involving 48 adults, the second in Kampung Pichin, Serian (4-22 Apr 2008) involving 24 children and the last at Al Hidayah Abim Nursery in Sarikei (9-24 Apr 2008) involving 10 children. Dr. Chan said none of the cases involved enterovirus 71 (EV71), which potentially causes a more severe form of the disease.
“The outbreaks were mild and no one was hospitalized. All the outbreaks have now
been controlled. However, because of the increased number of cases in Singapore
including a few with EV71, and also in Anhui, China. . .this is a good time to
warn the public, especially those looking after young children, to make sure
they follow hygienic practices,” he told a press conference at his office here
on 2 May 2008. Sarawak last experienced a major outbreak of HFMD in 2006, when
more than 14,000 cases and 13 deaths were reported.
Health officials at the CDC said that the number of confirmed serious cases of
enterovirus has reached 60 in 2008, and among them there have been two deaths;
seven other patients remain in intensive care, while one has been hospitalized
for about four months due to encephalitis complications.
Also, in Sukoharjo District, Central Java province during April 2008, two
children died of dengue fever. In the first quarter of 2008, there were a total
of 160 dengue fever cases and seven residents died of the disease in the
district, Agus Prihatmo of the Sukohardjo health service said on 1 May 2008.
Most of the victims were children and they lost their lives because they had
been admitted to the hospital in very critical condition, he said, (and added
that there is a) lack of awareness in the community on the eradication of
mosquito-nesting (breeding) grounds, making the areas prone to dengue fever
caused by Aedes aegypti mosquito bites.
Dr Sazaly said Malaysians had grown complacent because the dengue problem had not been prevalent in the country for so long. For example, the current vector-controlling measures were adopted from an American model developed some 30 years ago, and it (fogging) was only effective in killing the adult mosquitoes but not the larvae, said Dr Sazaly, who also heads the Department of Medical Microbiology at Universiti Malaya. “No one knows the answers, because we have not done any studies. We need to study these factors and devise a strategy based on it.” Dr Sazaly said one of the more effective ways to control the problem was for the authorities to take daily and weekly samples of mosquitoes to find those carrying the dengue virus and reduce their population without disturbing the ecological system. “There should be continuous monitoring and surveillance, and only then can we predict and preempt an outbreak before it occurs. Right now, we do not even know the genetics of our mosquitoes here. The fire-fighting methods, such as fogging an area when a case is reported, are ineffective.”
In Malaysia, the number of dengue fever and dengue haemorrhagic fever cases has risen from 518 cases in 1973 to 45,856 suspected cases in 2007.
“The danger is that for every patient confirmed with dengue, three more go undetected because it is asymptomatic.” Dr Sazaly said there was a need to come up with a faster and more accurate method of diagnosing dengue. “We are still relying on old lab tests which require you to have a fever for at least five days before you are confirmed to be positive for dengue. By then, your condition may be severe, and by the time you go to hospital, it may be too late. We have to improve not only our vector-control methods but also ensure early detection of the infection, like coming up with a cheap self-diagnostic kit.” Dr Sazaly said although the technology was available now, it was expensive and could only be done at referral centers such as the University Malaya Medical Centre and the Kuala Lumpur Hospital. “We need to come up with our own diagnostic kit so that we can bring the cost down.”
He said of the 45,856 suspected dengue cases in 2007, only 14,354 were confirmed positive by laboratory test. “Because of the weaknesses in our detection system, we could not positively identify the remaining 33,000 as dengue cases. So, these people who are walking out there could have been infected and not know it. People need to know their dengue status. If you have had dengue fever before, then you have to be careful, because the second time you get it, the chances are high that it will develop into haemorrhagic fever. But then again, not everyone who has a second infection will die. We need to study the factors which contribute to dengue haemorrhagic fever and determine those who are more susceptible.”
Those who are obese, diabetic or over 60 years old are considered to be in the high-risk group, as they have a higher chance of developing dengue haemorrhagic fever. “We need to study why this group is predisposed to it, and, to do this, we need to study their genetic background. If we know that not everyone will die of dengue, at least we can focus on the type of patients we need to manage. If we can spend some money to research this, we can develop drugs to prevent these deaths. And if we have drugs to manage dengue, we won't have to vaccinate 29 million people.”
He said it was not cost-effective to develop a vaccine for a large number of
people when only a certain percentage of them were at real risk of dying from
dengue. Dr Sazaly said the proper management of dengue patients was another area
that was often overlooked by doctors. As there is no blanket treatment that is
suitable for all dengue patients, doctors need to treat each patient based on
the symptoms. Dr Sazaly said a multi-pronged approach was needed to tackle the
dengue problem, including funding more research by local scientists. “It is
hyper-endemic here, and yet we are not putting our research efforts into it.”
Enterovirus Déjà Vu
Modlin JF, et al. New England Journal of Medicine. 2007;356:1204-1205
Salmonellosis Outcomes Differ Substantially by Serotype
Crystal structures of oseltamivir-resistant influenza virus neuraminidase
Cross-Recognition of Avian H5N1 Influenza Virus by Human Cytotoxic T-Lymphocyte
There are legitimate concerns that the highly pathogenic H5N1 avian influenza
virus could adapt for human-to-human transmission and cause a pandemic similar
to the 1918 “Spanish flu” that killed 50 million people worldwide. We have
developed pandemic influenza vaccines by incorporating multiple antigens from
both avian and Spanish influenza viruses into complex recombinant adenovirus
vectors. In vaccinated mice, these vaccines induced strong humoral and cellular
immune responses against pandemic influenza virus antigens, and protected
vaccinated mice against lethal H5N1 virus challenge. These results indicate that
this multi-antigen, broadly protective vaccine may serve as a safer and more
effective approach than traditional methods for development of a pandemic
APEC EINet Pandemic Influenza Preparedness Virtual
APEC EINet is pleased to host a special videoconference on pandemic influenza preparedness. This videoconference is a follow-up to our first “virtual symposium”, which was conducted in January 2006 with great success (participating economies were Australia, Canada, China, Korea, Philippines, Singapore, Chinese Taipei, Thailand, USA, and Viet Nam). You can view a five-minute videoclip of our previous virtual symposium at: http://depts.washington.edu/einet/symposium.html. Our upcoming videoconference will be held in late May 2008. It will take place during the evening hours of 29 May in the Americas and in the morning hours of 30 May in Asia, for approximately 5 hours. Our objective is to describe how private and public sectors in the APEC region can cooperate and work effectively to prepare for and respond to an influenza pandemic.
Through this videoconference, we hope to promote regional information sharing and collaboration to enhance pandemic preparedness. In order to improve preparedness regionally, it is vital to understand how each economy in the region is undertaking this task. In this process, EINet will:
Anticipating that a terrorist attack, influenza pandemic, or natural disaster will someday exhaust regional or national critical care systems, an expert task force recently issued a comprehensive series of reports that takes stock of current capabilities and recommends a surge framework that would care for as many patients as possible but would necessarily exclude some.
The series, from the Critical Care Collaborative Initiative's January 2007 Mass Critical Care Summit, appeared recently in a May supplement issue of the journal Chest. The five articles from the 37-member task force of American and Canadian experts include an executive summary and individual papers on current capabilities, a framework to optimize surge capacity, medical resource guidance, and recommendations for allocating scarce critical care resources in a mass critical care setting.
Task force member John Hick, MD, said that, although initial mainstream media focus was patient exclusion issues surrounding the task force’s ventilator triage criteria, the guidelines are so far receiving good support in the medical community. "It [the series] provides both a systems and facility-based approach to resource-poor situations," he said. "Whether the goals are reasonable or not, we'll have to see," added Hick, medical director of bioterrorism and disaster preparedness and an emergency medicine physician at Hennepin County Medical Center in Minneapolis and coauthor on three of the five articles.
Though the group covered an expansive array of controversial ethics and resource
topics related to critical care in a disaster scenario, they had few
disagreements on about 90% of the materials, Hick said. Not surprisingly, the
critical care inclusion-exclusion generated the most discussion and required a
great deal of compromise, he said. “It’s not exactly what we would do as
individuals, but it’s a good framework nonetheless,” Hick said. Perhaps the
biggest sticking point was the group’s recommendation for intensive care unit
(ICU) expansion, he said, adding that the group settled on 200% because of
pandemic concerns, though many advocated 100% ICU expansion as a more achievable
goal. “My only fear is that people will see that as unrealistic and not aim for
what they can achieve, and I think we tried to be clear to do at least what you
can,” Hick said.
Proposed Guidance on Workplace Stockpiling of Respirators and Facemasks
In the event of an influenza pandemic, employers will play a key role in protecting employees’ health and safety as well as in limiting the impact on the economy and society. Employers will likely experience employee absences, changes in patterns of commerce and interrupted supply and delivery schedules. To further preparedness efforts, the Department of Labor (DOL) proposes to publish this information on stockpiling respirators and facemasks in occupational settings as an appendix to the DOL and the Department of Health and Human Services (HHS) jointly issued Guidance on Preparing Workplaces for an Influenza Pandemic (February 2007). This proposed guidance is designed to encourage employers in the private and public sectors to purchase and stockpile facemasks and respirators in advance of an influenza pandemic, because manufacturing capacity at the time of an outbreak would not meet the expected demand for respiratory protection devices during the pandemic. Through advanced planning and stockpiling, employers will be able to better protect their employees as well as lessen the impact of a pandemic on their business, society, and the economy.
As is explained in more detail in this guidance, employers should consider
stockpiling facemasks and respirators. More specifically, it is recommended that
employees at very-high risk and high risk of exposure to pandemic influenza use
respirators, while employees at medium risk of exposure use facemasks. Neither
facemasks nor respirators are recommended for employees at lower risk of
exposure to pandemic influenza.
What is hand, foot, and mouth disease?
Is HFMD the same as foot-and-mouth disease?
What causes HFMD?
Is HFMD serious?