Cambodia EV 71 outbreak: Did children die from the use of steroids?

By Clothilde Le Coz Jul 16, 2012 

The World Health Organization (WHO) says yes. The Kantha Bopha Hospital says no. Since April, 78 cases of the so called “hand-foot-mouth” disease have been reported in Cambodia according to WHO and the Cambodian Ministry of Health (MoH). It is the first time the disease has been reported in the country, causing the death of 64 children  between 3 and 11 years old and sparking debate in medical circles.

Cambodian villagers line up to wait for a medical check-up for children outside Kuntha Bopha children's hospital in Phnom Penh, Cambodia earlier this month. Pic: AP.

According to data released on July 12 by the World Health Organization (WHO) and the Cambodian Ministry of Health (MoH), 79% of the children who died from HFMD syndrom were treated with steroids. This could be seen as the cause for aggravation of the disease, leading to death. Asked about this possibility, Dr. Nima Asgari, in charge of the investigation for the WHO, told Asian Correspondent that “patients who have this syndrome should not be treated with steroïds, in any case. Since fatal cases were observed in China and Vietnam, it is known that steroïds can be “fatal” when used to treat the disease.

The virus causing the HFMD disease in Cambodia is the Enterovirus 71 (EV 71), also known in Thailand, China and Vietnam to have caused millions of cases  of the HFMD in the past few years. The Pasteur Institute based in Phnom Penh just started to research if the EV 71 observed in Cambodia has the same strain observed elsewhere in the region.

According to Dr. Philippe Buchy director of the Virology unit at the Pasteur Institute, “a few days ago, the disease  was somewhat mysterious”, although the proper term would be “borne illness to be determined”. In a CNN report published on July 11, the Pasteur Institute seems to declare that the virulence of the disease was caused by a slight alteration of EV71,  as well as the fact that the Cambodian population has not been exposed to the disease for years, and the use of steroïds, which weakened the body condition of the children. In conclusion, Dr. Buchy states that “the case is closed”. Two days later, these information was confirmed by the WHO and the MoH in a press briefing. Dr. Asgari said that the steroids treatments  ”aggravated” the disease, which led to the death of the children.

The mystery remains unsolved

This weekend, Dr. Beat Richner, founder and director of the Kantha Bopha hospital, that admitted 68 cases since April, told the Cambodia Daily that concluding steroids caused an aggravation was “an absolute nonsense” since none of the children admitted to his hospital had shown symptoms of HFMD. The 68 children admitted were submitted to the same treatment, including steroids. 4 survived.  He continued telling the Daily that, if the disease is not new, “we could define this evolution of this development as maybe a first in the world. This is new.” During his investigation in Cambodia, Chief Medical Correspondent Sanjay Gupta, told CNN that it will be hard to know the exact cause of the virulence of the disease since there is not medical record of the disease in the country and also 34 children died less than 4 hours after being admitted at the hospital.  There are therefore a limited number of samples to be tested.

After he was interviewed by CNN, Dr. Buchy told Asian Correspondent that “the press took over this debate, which is not a new one and has been discussed in medical journals for years. In the CNN report, I only close the debate over the origin of the disease [i.e : EV71]. I never formulated an opinion on the role of steroids in the aggravation of the disease”.

It thus remains to be explained how these cases were fatal. According to Dr. Denis Laurent, deputy director of the Kuntha Bopha Hospital, one preferred explanation for the virulence of the disease is that of drug intoxication, “among the 68 children admitted with similar symptoms, the ones who survived were admitted to the hospital, without being treated by another clinic before. The 64 deaths could be linked to a combination with another drug administered before admission to hospital Kantha Bopha”.

Dr Buchy adds to this that “the debate seems  pointless because the children who already died in Cambodia were all admitted at Kantha Bopha while they were at a critical state. Although they received intensive care, they died really quickly. It is very likely that at his stage of the disease, none of the drugs can make the difference for such young children. Even more, there is no antiviral treatment that has ever be efficient in EV71 infections”. In other countries where this infection exists, medical experts are divided on the use of steroids on this virulent form of the disease.

In their joint investigation, the MoH and the WHO concluded that other pathogens were also detected. It includes the Hib, known to cause meningits and pneumonias, as well as other bacteria developing with any contact with pigs.

The first death occured on April 20. Twenty-three deaths  were reported a month later and there were 44 dead by June 20. The WHO and the MoH published a press release on July 4 to qualify the disease as “mysterious”. According to Dr. Philippe Buchy director of the Virology unit at the Pasteur Institute, “what is a mystery is in fact that EV 71 has been detected in fatal cases, which should have been only rare and unusual complications of the EV 71 infection”. Dr. Laurent added that the July 4 WHO’s alarming tone was “stupid” and created panic. According to the Bangkok Post, Thailand is now seeing a real exodus from Cambodian parents willing to have their children treated in Thailand.

Thousands of children have suffered and still suffer from the same disease in Vietnam, China and Thaïland. In 2011, Vietnam has recorded 169 deaths from a virulent form of the disease Hand, foot and mouth over 110,000 reported cases. Yang Jiechi, Chinese foreign minister, confirmed to the Cambodia Daily and Phnom Penh Post that Chinese specialists will come to Cambodia to help identify the disease more precisely. The Thai Public Health ministry also said specialists will be sent to Cambodia to help prevent the spread of the disease. In 2011, China has reported more than one and a half million cases, killing 500 of them. Thailand is now starting to see fatal cases.