Pathogen Safety Data Sheets: Infectious Substances – Coxsackievirus


NAME: Coxsackievirus

SYNONYM OR CROSS REFERENCE: Picornavirus, Enterovirus, Coxsackievirus Group A (serotypes 1-22 and 24), Coxsackievirus Group B (serotypes 1-6), enteroviral vesicular pharyngitis (herpangina), enteroviral vesicular stomatitis with exanthema (hand, foot and mouth disease), enteroviral lymphonodular pharyngitis (acute lymphonodular pharyngitis), Bornholm disease (Synonyms: epidemic myalgia, epidemic pleurodynia, Sylvest's disease, Bamble disease and Devil's grip) Footnote 1Footnote 2.

CHARACTERISTICS: Icosahedral, non-enveloped, linear single-stranded positive-sense RNA viruses of the Picornaviridaefamily and Enterovirus genusFootnote 1Footnote 3.


PATHOGENICITY/TOXICITY: Majority of infections are asymptomatic and self-limiting; however, infections may lead to a variety of rare conditions, some of which are life threatening Footnote 1Footnote 2. Clinical course can vary within and between strains of CoxsackievirusFootnote 1Footnote 2Footnote 4.

Coxsackievirus group A associated conditions: hand-foot-and-mouth disease, herpangina, acute lymphatic or nodular pharyngitis, aseptic meningitis, paralysis, exanthema, hand-foot-and-mouth disease (A10, A16), pneumonitis of infants, "common cold", hepatitis, infantile diarrhoea, acute hemorrhagic conjunctivitis (A24) Footnote 1Footnote 5.

Coxsackievirus group B associated conditions: diabetes, pleurodynia, aseptic meningitis, paralysis, severe systemic infection in infants, meningoencephalitis, myocarditis, pericarditis, upper respiratory illness and pneumonia, rash, hepatitis, and pancreatitis, Footnote 1Footnote 6-8. Undifferentiated febrile illness and viral parkinsonism may also be associated with Coxsackievirus group B infection; however, these are more controversial.

Most common conditions requiring hospitalization are:
Hand-foot-and-mouth disease: characterized by fever and vesicles on the mouth and extremities, sore throat, fever, and anorexia Footnote 5. Usually self limiting and requires only symptomatic treatment Footnote 5.

Aseptic meningitis/meningoencephalitis: Most common clinical syndrome associated with enteroviruses, resulting in medical attention Footnote 1. The virus causes nonbacterial inflammation of the meninges associated with fever, headache, photophobia, and with no apparent parenchymal involvement Footnote 1. The infection can progress to meningoencephalitis with infection of the parenchyma, characterized by disturbed state of consciousness, focal neurologic signs, and seizures Footnote 1. While severe meningeal disease is usually self limiting, deaths have been reported Footnote 1.

Myocarditis and dilated cardiomyopathy: Myocarditis is an inflammation of the myocardium associated with damage that is unrelated to ischemic injury, if infection/inflammation persist the syndrome may progress to dilated cardiomyopathy (in which the heart is enlarged), potentially leading to heart failure [very rare]Footnote 1Footnote 7.

EPIDEMIOLOGY: Coxsackieviruses are distributed worldwide and infections predominate in summer and fall, with sporadic cases year round Footnote 2Footnote 5. All age groups are infected but young children are more susceptible to infection. For example, viral meningitis occurs 5-8 times more often in infants than adults Footnote 2.

HOST RANGE: Human, monkey, mouse Footnote 1.

INFECTIOUS DOSE: Unknown; however, 15-50 TCID50 has been shown to be infective in adult volunteers Footnote 9.

MODE OF TRANSMISSION: Infection occurs through contact with infective secretions or excretions, and subsequent autoinoculation of mouth, nose, or eyes Footnote 1. It is possible that ingestion of contaminated water may contribute to infection Footnote 1. Intranasal and aerosol transmission are possible for some variants through contaminated respiratory secretions Footnote 1Footnote 9Footnote 10. Once inside the body, Coxsackievirusesreplicate in lymphoid tissues and then disseminate in blood Footnote 2.

INCUBATION PERIOD: Varies from days (eg. hand-foot-and-mouth disease) to years (eg. Myocarditis), depending on clinical course Footnote 5Footnote 7Footnote 8.

COMMUNICABILITY: Human-to-human transfer can occur readily through oral, ocular, respiratory, or faecal-oral routes Footnote 1Footnote 9Footnote 10.


RESERVOIR: HumanFootnote 1.




DRUG SUSCEPTIBILITY/RESISTANCE: No antiviral medications are currently approved. Although Pleconaril® has been used in clinical trials to treat severe Coxsackievirus infections, these have shown no important effects on morbidity or mortality Footnote 4Footnote 11.

SUSCEPTIBILITY/RESISTANCE TO DISINFECTANTS: Sensitive to formaldehyde, gluteraldehyde, strong acids, sodium hypochlorite (bleach), and free residual chlorine Footnote 1Footnote 12. Sensitivity is dependent on sufficient concentration, pH, and contact time and is reduced in presence of extraneous organic materials Footnote 1.  Infectious viruses are usually resistant to many common laboratory disinfectants, including 70% ethanol, isopropanol, dilute Lysol, and quaternary ammonium compounds Footnote 1Footnote 13. Insensitive to lipid solvents, including ether and chloroform Footnote 1. Stable in many detergents at ambient temperatures Footnote 1.

PHYSICAL INACTIVATION: Sensitive to UV mediated inactivation Footnote 1. Drying conditions reduce viral titres, the degree of which is dependent on the porosity of the surface and presence of extraneous organic matter Footnote 1. Most are readily inactivated at 42 °C, but stability and heat resistance is increased in the presence of sulphydral reducing agents and magnesium cations Footnote 1.

SURVIVAL OUTSIDE HOST: Can survive for months under favourable conditions of neutral pH, moisture, and low temperature; enhanced by presence of organic matter Footnote 1. Survival has been documented in seafood from Coxsackievirus-positive water supplies for up to 3 weeks at temperatures of 1°C – 20°CFootnote 1Footnote 14.


SURVEILLANCE: Monitor for symptoms; confirm by serology, virus isolation, or PCR from lesions or nasopharyngeal and fecal specimens Footnote 2Footnote 11. The use of viral culture is declining as not all serotypes will grow well in culture. Molecular typing has largely replaced serotyping.

Note: All diagnostic methods are not necessarily available in all countries.

FIRST AID/TREATMENT: No specific treatment is available Footnote 1Footnote 11.

IMMUNIZATION: No general vaccine available; however, one is under development for Coxsackievirus induced heart diseaseFootnote 3Footnote 11.



LABORATORY-ACQUIRED INFECTIONS: Responsible for 39 reported cases up to 2006 Footnote 15-17.

SOURCES/SPECIMENS: Throat swabs, rectal swabs, stool samples, aseptic meningitis cerebrospinal fluids Footnote 2Footnote 16Footnote 17.

PRIMARY HAZARDS: Ingestion or inhalation of aerosols, contact of mucous membranes with infectious agents Footnote 1Footnote 2Footnote 9Footnote 10.



RISK GROUP CLASSIFICATION: Risk Group 2 Footnote 18.

CONTAINMENT REQUIREMENTS: Containment Level 2 facilities, equipment, and operational practices for work involving infectious or potentially infectious materials, animals, or cultures.

PROTECTIVE CLOTHING: Lab coat. Gloves when direct skin contact with infected materials or animals is unavoidable. Eye protection must be used where there is a known or potential risk of exposure to splashes Footnote 19.

OTHER PRECAUTIONS: All procedures that may produce aerosols, or involve high concentrations or large volumes should be conducted in a biological safety cabinet (BSC). The use of needles, syringes, and other sharp objects should be strictly limited. Additional precautions should be considered with work involving animals or large scale activities Footnote 19.


SPILLS: Allow aerosols to settle and, wearing protective clothing, gently cover spill with paper towels and apply an appropriate disinfectant, starting at the perimeter and working towards the centre.  Allow sufficient contact time before clean up Footnote 19.

DISPOSAL: Decontaminate all wastes that contain or have come in contact with the infectious organism by autoclave, chemical disinfection, gamma irradiation, or incineration before disposing Footnote 19.

STORAGE: The infectious agent should be stored in leak-proof containers that are appropriately labelled Footnote 19.


REGULATORY INFORMATION: The import, transport, and use of pathogens in Canada is regulated under many regulatory bodies, including the Public Health Agency of Canada, Health Canada, Canadian Food Inspection Agency, Environment Canada, and Transport Canada. Users are responsible for ensuring they are compliant with all relevant acts, regulations, guidelines, and standards.

UPDATED: November 2011

PREPARED BY: Pathogen Regulation Directorate, Public Health Agency of Canada

Although the information, opinions and recommendations contained in this Pathogen Safety Data Sheet are compiled from sources believed to be reliable, we accept no responsibility for the accuracy, sufficiency, or reliability or for any loss or injury resulting from the use of the information. Newly discovered hazards are frequent and this information may not be completely up to date.

Copyright © Public Health Agency of Canada, 2011

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