An editorial in The Lancet Infectious Diseases: Cambodian outbreak tests International Health Regulations. Excerpt:
The news that emerged from Cambodia in the first week of July of an unknown fatal illness that had killed at least 60 children in the previous 3 months, and the subsequent interagency response, shows how the International Health Regulations (IHRs) can work in practice. The event also serves as a timely reminder of the progress that still needs to be made to implement the IHR provisions in all WHO member states.
On June 20, Beat Richner from the Kantha Popha Children's Hospital, Phnom Penh, wrote to the Cambodian Ministry of Health to alert it to the unusual number of cases of children presenting with a syndrome of fever, encephalitis, and respiratory distress. Most children died within a day of being admitted to hospital.
In news reports, Richner has been quoted as saying that all the fatalities occurred among children first treated in private clinics. Initial investigation by the Ministry of Health identified 57 children admitted to hospital between April and July 5, 2012, with the common syndrome of fever and respiratory and neurological signs, which proved fatal in 56 cases (as of July 9, numbers had been revised to 59 cases with 52 fatalities). Affected children are aged 3 months to 11 years, with most younger than 3 years. The male to female ratio of cases is 1·3 to 1.
By the end of June, the Ministry of Health notified WHO of the outbreak because it met the IHR criterion for notification “of any event where the underlying agent of disease or mode of transmission is not formally identified”. To identify the source of the outbreak, the ministry and WHO are working with the Institut Pasteur du Cambodge, Phnom Penh, and the US Centers for Diseases Control and Prevention.
Unfortunately, samples are not available from most of the affected children; however, of the 24 samples tested, 15 have proved positive for enterovirus 71, which is best known as a cause of hand, foot, and mouth disease (HFMD).
HFMD is usually a mild, self-limiting illness among children that presents with mouth ulcers and a rash with blisters on hands, feet, and buttocks, but occasionally children can have fever, respiratory and neurological symptoms, and die quickly. The virus is spread by contact with respiratory secretions, fluid from blisters, or faeces of infected people.
There is no specific treatment for HFMD. Vaccines against enterovirus 71 are being developed in China, Singapore, and Taiwan, but might not be available for routine use for several years.
Vietnam, Cambodia's neighbour, reported 110 000 HFMD cases in 2011 with 166 deaths, with more cases and deaths reported this year. China reported 1·62 million HFMD cases and 509 deaths in 2011, with another 240 deaths in the first 5 months of 2012.
If the cause of the Cambodian outbreak is confirmed, it will count as a success for the IHRs. June 15 this year was an important date for the IHRs: when enacted in June, 2007, all WHO member countries were required to develop and implement a core set of public health capacities by the regulations’ 5 year anniversary. Perhaps unsurprisingly, at a time when government budgets are under pressure, many countries have not met the deadline and have requested a 2 year extension.