Epidemiologic Notes and Reports Acute Hemorrhagic
Conjunctivitis Caused by Coxsackievirus A24 -- Caribbean
In the fall of 1986, large outbreaks of acute hemorrhagic
conjunctivitis (AHC) occurred on the islands of Trinidad, Jamaica,
and
St. Croix. The outbreak on Trinidad was identified through a
public
health surveillance program for AHC initiated during the large
outbreak of AHC caused by enterovirus 70 (EV70) in 1981. Beginning
in
October 1986, reported physician-diagnosed cases of AHC increased
from
50-100 cases per 4-week period to 9,666 at the peak of the outbreak
(Figure 3). By January of 1987, the number of reported cases had
returned to background level. During the 3 outbreak months, a
total
of 15,396 cases of AHC were reported to the Ministry of Health.
Two
isolates were typed as coxsackievirus A24 variant (CA24v) by
strain-specific neutralizing antisera.
Between mid-October and late November, over 500 AHC patients
who
were self-referred and physician-diagnosed were seen at a hospital
and
ophthalmology clinic in Kingston, Jamaica. CA24v was isolated from
five of the 15 AHC patients for whom viral cultures were performed.
Three of four patients with acute- and convalescent-phase serum
pairs
available had a
16-fold rise in antibody titer (10 to
80) to the
outbreak virus. Over 500 patients with AHC were also seen on the
island of St. Croix in the Virgin Islands during October and
November,
but no isolates or serum specimens were obtained.
Reported by: R Doug-Deen, MD, R Paul, MD, Ministry of Health,
Welfare
and Status of Women, Trinidad and Tobago; B Watson, PhD, Trinidad
Public Health Laboratory; B Birju, SSO, National Surveillance Unit,
Trinidad and Tobago. B Hull, PhD, Caribbean Epidemiology Centre; D
King, MD, Univ of the West Indies, Kingston; H Vaughan, MD,
Kingston
Public Hospital; D Calder, MD, Kingston; P Figueroa, MD, Ministry
of
Health, Jamaica. A Anduze, MD, J Lewis, MD, St Croix Dept of
Health,
US Virgin Islands. Div of Viral Diseases, Center for Infectious
Diseases, CDC.
Editorial Note
Editorial Note: Both EV70 and CA24v have caused large outbreaks of
AHC, usually in tropical, coastal cities; however, this is the
first
report of an isolation of CA24v in the western hemisphere. AHC,
which
follows an incubation period of 18 to 48 hours, is characterized by
sudden onset of painful, swollen, red eyes with subconjunctival
hemorrhaging, palpebral follicles, and excessive tearing (1). The
symptoms usually persist for 3 to 5 days. The outbreaks have been
explosive in nature, often affecting 50% or more of the persons in
communities with a low socioeconomic status within a 1- to 2-month
period (1). Spread appears to be related to crowding, poor
hygiene,
and other conditions characteristic of such communities (2).
The first reports of AHC caused by EV70 were from western
Africa
in 1969; this virus has caused major pandemics since then (1). In
1981, during the last pandemic, EV70 was introduced into the
western
hemisphere and caused outbreaks in Central America, South America,
and
Florida (3-7). CA24v was first isolated during an outbreak in
Singapore in 1970 (8). Prior to 1986, CA24v had not been reported
outside of Southeast Asia and the Indian subcontinent (1). In
1986,
CA24v was isolated during outbreaks in Taiwan, American Samoa, and
India (CDC, unpublished data) (9). It is possible that CA24v, like
EV70, may spread to other areas in the western hemisphere.
EV70 and CA24v are antigenically unrelated, and infection with
one
virus does not induce neutralizing antibody against the other.
This
is particularly important in the diagnosis of AHC caused by EV70
because this virus is difficult to isolate. Attempts at viral
culture
of CA24v are more successful, with isolates often obtained from
40%
of specimens using human cell lines (HeLa, HEp-2, HLF). EV70
outbreaks have also been diagnosed using an IgM capture
enzyme-linked
immunosorbent assay (ELISA) (10).
Characterization of an isolate of either serotype usually is
accomplished by neutralization studies with type-specific antisera,
but it can also be accomplished by a monoclonal antibody ELISA as
has
been done with EV70 (11). Attempts to type CA24v isolates with
polyclonal serum can sometimes be confused by a one-way cross
reaction
with echovirus 34 antisera. Echovirus 34 antiserum neutralizes
CA24v,
but CA24v antiserum does not neutralize echovirus 34 (12).
Clinicians are encouraged to report cases of AHC caused by
CA24v
to their state or territorial health departments. They are also
encouraged to send isolates of CA24v through their state or
territorial laboratories to the Division of Viral Diseases, Center
for
Infectious Diseases, CDC.
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conjunctivitis: investigation of a large-scale community
outbreak
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1981.
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World Health Organization. Enterovirus 70 surveillance: acute
haemorrhagic conjunctivitis. Wkly Epidemiol Rec 1981;56:254.
World Health Organization. Acute haemorrhagic conjunctivitis
in
the American region. Wkly Epidemiol Rec 1981;56:311.
Mirkovic RR, Schmidt NJ, Yin-Murphy M, et al. Enterovirus
etiology of the 1970 Singapore epidemic of acute
conjunctivitis.
Intervirology 1974;4:119-27.
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conjunctivitis in October-November 1986. North Arcot District
(India) Health Information 1986;Dec:6-7.
Wulff H, Anderson LJ, Pallansch MA, Carvalho RP. Diagnosis of
enterovirus 70 infection by demonstration of IgM antibodies. J
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Anderson LJ, Hatch MH, Flemister MR, Marchetti GE. Detection
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enterovirus 70 with monoclonal antibodies. J Clin Microbiol
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Melnick JL. Enteroviruses: polioviruses, coxsackieviruses,
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