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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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  2. Patriarca PA, Onorato IM, Sklar VE, et al. Acute hemorrhagic conjunctivitis: investigation of a large-scale community outbreak in Dade County, Florida. JAMA 1983;249:1283-9.

  3. CDC. Acute hemorrhagic conjunctivitis--Latin America. MMWR 1981;30:450-1.

  4. CDC. Acute hemorrhagic conjunctivitis--Key West, Florida. MMWR 1981;30:463-4.

  5. CDC. Acute hemorrhagic conjunctivitis--Panama and Belize, 1981. MMWR 1981;30:497-500.

  6. World Health Organization. Enterovirus 70 surveillance: acute haemorrhagic conjunctivitis. Wkly Epidemiol Rec 1981;56:254.

  7. World Health Organization. Acute haemorrhagic conjunctivitis in the American region. Wkly Epidemiol Rec 1981;56:311.

  8. Mirkovic RR, Schmidt NJ, Yin-Murphy M, et al. Enterovirus etiology of the 1970 Singapore epidemic of acute conjunctivitis. Intervirology 1974;4:119-27.

  9. ICMR Centre of Virology. An outbreak of acute viral conjunctivitis in October-November 1986. North Arcot District (India) Health Information 1986;Dec:6-7.

  10. Wulff H, Anderson LJ, Pallansch MA, Carvalho RP. Diagnosis of enterovirus 70 infection by demonstration of IgM antibodies. J Med Virol 1987;21:321-7.

  11. Anderson LJ, Hatch MH, Flemister MR, Marchetti GE. Detection of enterovirus 70 with monoclonal antibodies. J Clin Microbiol 1984;20:405-8.

  12. Melnick JL. Enteroviruses: polioviruses, coxsackieviruses, echoviruses, and newer enteroviruses. In: Fields BN, Knipe DM, Chanock RM, Melnick JL, Roizman B, Shope RE, eds. Virology. New York: Raven Press, 1985:739-94.

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