Coxsackie virus

Coxsackie viruses are non-enveloped RNA viruses belonging to the genus Enterovirus within the family Picornaviridae. Numerous Coxsackie virus serotypes have been described and are found worldwide. They are of particular medical significance as one of the main causes of hand, foot and mouth disease (HFMD), a highly contagious viral illness that primarily affects young children. The disease must not be confused with foot-and-mouth disease, which affects livestock and is unrelated to human hand, foot and mouth disease [1, 2].

Hand, foot and mouth disease occurs worldwide and particularly affects children under the age of five. However, adolescents and adults can also become infected. The disease is usually mild and self-limiting; however, due to the high transmissibility of the causative enteroviruses, outbreaks regularly occur in nurseries, schools and other communal settings [3].

The most common causative agents of HFMD are Coxsackievirus A16 and Coxsackievirus A6. Other enteroviruses can also cause the disease. Whilst most infections are uncomplicated, infections with enterovirus A71 (EV-A71) in particular are associated with severe neurological complications [1, 2].

Symptoms

The incubation period for hand, foot and mouth disease caused by Coxsackie viruses is usually three to ten days after exposure. Initially, non-specific symptoms such as fever, a sore throat, loss of appetite, a general feeling of being unwell and tiredness often occur [4].

One to two days after the onset of fever, painful lesions or blisters may develop on the oral mucosa, particularly on the tongue, gums and the insides of the cheeks. Shortly afterwards, a characteristic rash typically develops on the palms of the hands and soles of the feet. This may also spread to the buttocks, knees, elbows or genital area. The skin lesions usually appear as red patches, papules or small blisters [3,4].

More than 80% of infections are asymptomatic or cause only mild symptoms. Most affected individuals make a full recovery within five to ten days without specific treatment [3, 4].

In rare cases, serious complications may occur. These are most commonly associated with enterovirus A71 and include aseptic meningitis, encephalitis, acute flaccid paralysis and other neurological manifestations. Severe cases may require hospitalisation and intensive care [5, 6].

Infected individuals are most contagious during the first week of illness. However, the virus can still be shed in the stools for several weeks after symptoms have subsided, meaning transmission remains possible even after apparent recovery [2, 4].

Routes of transmission

Humans are the only known reservoir for the viruses that cause hand, foot and mouth disease. Transmission occurs mainly through direct contact with saliva, nasal secretions, respiratory droplets, the contents of blisters, and contaminated surfaces or objects. Toys, door handles, changing tables and other frequently touched objects can contribute to the spread of the disease, particularly in childcare centres. Transmission via contaminated hands plays a significant role in this. The pathogen can also be transmitted via the stools of infected individuals (faecal-oral) [1, 2, 4].

Since many infections are asymptomatic, transmission can occur unnoticed within families, schools and healthcare settings [2, 4].

Distribution

Coxsackie virus infections occur worldwide and are among the most common viral infections in childhood. Hand, foot and mouth disease is endemic in many countries and regularly causes seasonal outbreaks. In temperate climates, infections tend to be particularly prevalent in late summer and autumn, though they can occur at any time of year [1].

Children under the age of five are the most commonly affected age group. However, during outbreaks, older children and adults may also fall ill. Community outbreaks are particularly common in nurseries, childcare centres and schools [1, 3].

Large outbreaks have been reported repeatedly in the Western Pacific Region and parts of Asia, over the past few decades. Some outbreaks involving enterovirus A71 have been associated with increased rates of neurological complications and severe illness [5].

Measures to prevent infection

Effective prevention relies primarily on consistent hygiene measures. Regular handwashing with soap and water is particularly important after using the toilet, after changing nappies, after handling potentially contaminated materials, and before preparing food [1, 3, 4].

Frequently touched surfaces, shared objects, toys and sanitary facilities should be cleaned and disinfected regularly, particularly in childcare centres and healthcare settings where transmission can occur easily [3].

During the acute phase of the illness, close contact with infected individuals should be avoided where possible. Good respiratory hygiene, including covering the mouth and nose when coughing or sneezing, can also help to reduce transmission [3, 4].

There is currently no widely used vaccine available in Europe and North America against Coxsackie viruses, which cause hand, foot and mouth disease. Several vaccines against EV-A71 are available in the Western Pacific region [1, 3].

As Coxsackie viruses are non-enveloped viruses, they are more resistant to many disinfectants than enveloped viruses. Products with proven virucidal efficacy should therefore be used for hand and surface disinfection [1].

Sources

1. Robert Koch Institute (RKI). RKI Guide to Hand, Foot and Mouth Disease (HFMD). Updated 2025.
   https://www.rki.de/DE/Aktuelles/Publikationen/Epidemiologisches-Bulletin/2025/11_25.pdf
2. Centres for Disease Control and Prevention (CDC). HFMD: Causes and How It Spreads. Updated 2024.
   https://www.cdc.gov/hand-foot-mouth/causes/
3. Centres for Disease Control and Prevention (CDC). About Hand, Foot and Mouth Disease. Updated 2024.
   https://www.cdc.gov/hand-foot-mouth/about/
4. Federal Centre for Health Education (BZgA). Hand, Foot and Mouth Disease.
   https://www.infektionsschutz.de/infektionen/erregersteckbriefe/hand-fuss-mund-krankheit/
5. World Health Organisation (WHO). Enterovirus 71.
   https://www.who.int/teams/health-product-policy-and-standards/standards-and-specifications/norms-and-standards/vaccine-standardization/enterovirus-71
6. Pan American Health Organisation (PAHO/WHO). Epidemiological Alert: Hand, Foot and Mouth Disease. 2025.
   https://www.paho.org/sites/default/files/2025-03/2025-mar-26-phe-epidemiological-alert-hand-foot-mouth-disease.pdf