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Volume 17, Number 8—August 2011

Circulating Coxsackievirus A16 Identified as Recombinant Type A Human Enterovirus, China

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Ke Zhao, Xue Han, Guanjun Wang, Wei Hu, Wenyan Zhang, and Xiao-Fang YuComments to Author 
Author affiliations: Author affiliations: First Hospital of Jilin University, Changchun, People’s Republic of China (K. Zhao, X. Han, G. Wang, W. Hu, W. Zhang, X.-F. Yu); Johns Hopkins University, Baltimore, Maryland, USA (K. Zhao, X.-F. Yu)

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To determine the relationship of coxsackievirus A16 (CA16) to prototype CA16-G10, we conducted a phylogenetic analysis of circulating CA16 strains in China. Complex recombinant forms of CA16-related viruses involving multiple human enteroviruses, subgroup A (CA4, CA16, and enterovirus 71), are prevalent among patients with hand, foot, and mouth disease.

Coxsackievirus A16 (CA16) is a member of the family Picornaviridae, genus Human enterovirus (HEV). These viruses can be further divided into 4 subgroups on the basis of molecular typing: HEV-A, HEV-B, HEV-C, and HEV-D. The first, and prototype, CA16 strain, CA16-G10, was isolated in South Africa almost 60 years ago (1) and was subsequently sequenced in 1994 (2). CA16, along with enterovirus71 (EV71), CA2, and CA4, is a member of the HEV-A subgroup. CA16 is commonly associated with hand, foot, and mouth disease (HFMD) in children and sometimes causes aseptic meningitis, encephalitis, myocarditis, and poliomyelitis-like paralysis (3).

Enteroviruses related to HFMD have been endemic to Southeast Asia and the Pacific region for decades (47). Recently, a dramatic increase in HFMD prevalence has been reported in the People’s Republic of China (810). Partial viral sequencing (e.g., of the viral protein [VP] 1 region), serologic characterization, or both, have shown that 10%–50% of viruses from HFMD patients are related to prototype CA16-G10, and thus they have been classified as CA16 strains (11). The relationship of circulating CA16-related viruses to CA16-G10 has not been well studied. Therefore, we conducted a serial phylogenetic analysis of existing and new CA16 sequences from northern, central, and southern China to examine whether CA16–G10 truly is the parental strain of circulating CA16 strains. As a result, we found that current CA16 strains in China, although still related to CA16–G10, are recombinant HEV-A.

The Study

Figure 1

Thumbnail of Classification of coxsackievirus 16A (CA16) sequences from the People’s Republic of China into human enterovirus (HEV) groups. A) Phylogenetic analysis performed by using all HEV reference samples from China classified as HEV-A but not as CA16. All sequences were retrieved from GenBank. The sequences used corresponded to positions 2–7,407 bp in shzh00-1. MEGA4 software (12) was used as the analytic program and Kimura 2-parameter as the model. The phylogenetic tree was determined for

Figure 1. Classification of coxsackievirus 16A (CA16) sequences from the People’s Republic of China into human enterovirus (HEV) groups. A) Phylogenetic analysis performed by using all HEV reference samples from China classified as...

Twenty-four enterovirus sequences, mainly from HEV-A group were retrieved from the National Center for Biotechnology Information website. Phylogenetic analysis, performed with the MEGA4 program (12), indicated that CA16 strains shzh00-1, shzh05-1, and GZ08 did not cluster with CA16-G10 (Figure 1, panel A), although they indeed belonged to HEV-A and clustered with EV71A (BrCr), EV71B (EV71/9/97/SHA89), and EV71C (S10862-SAR-98) (Table). Thus, the so-called CA16 full-length sequences (shzh00-1, shzh05-1, and GZ08) from China are distinct from CA16-G10 full-length sequences.

Because the shzh00-1, shzh05-1, and GZ08 sequences clustered within the HEV-A group and were determined to be CA16 on the basis of the VP1 region (data not shown), we examined these 3 sequences for evidence of recombination. Shzh00-1 was chosen as representative because it was isolated earlier. It has 7,410 nt in its genome, including the 5′ untranslated region (UTR) (1–745), structural protein (746–3331), and nonstructural proteins P2 (3332–5065) and P3 (5066–7327), with the rest of its genome as 3′ UTR (7328–7410). Bootscanning with a sliding window of 500 nt, overlapping by 20 nt, was performed with the SimPlot program (version 3.5.1) (14) to investigate the possibility of recombination within the shzh00-1 sequence. Various HEV-A sequences were used as reference sequences. The results indicated that the 5′ UTR of the shzh00-1 sequence had relatively high similarity to CA4 (Figure 1, panel B). The P1 (VP4, VP2, VP3, and VP1) region was more similar to that of CA16-G10. However, part of the P2/P3 region of the shzh00-1 sequence (2C, 3A, 3B, and 3C) had relatively high similarity to EV71A but not to CA16-G10 (Figure 1, panel B). Similar results were obtained for the shzh05-1 and GZ08 sequences (data not shown). Thus, shzh00-1, shzh05-1, and GZ08 are recombinant type A HEVs that contain CA4, CA16, and EV71.

To examine the circulation status of recombinant CA16 in China, we characterized 24 additional CA16-related sequences from HFMD patients from central (Hangzhou, Zhejiang Province) and northeastern (Changchun, Jilin Province) China (Table). The break point around position 3555 interested us most because it not only roughly separated the P1 region from P2/P3 but also divided the open reading frame (746–7327) into CA16-like and non–CA16-like fragments. Thus, we selected this region spanning the recombination break point between the CA16 sequence and the downstream sequence.

Figure 2

Thumbnail of Phylogenetic analysis of Changchun and Hangzhou coxsackievirus 16A (CA16) sequences. A) Bootscanning results representing selected Changchun and Hangzhou sequences. changchun104 was shown for bootscanning analysis with human enterovirus A (HEV-A) sequences and shzh00-1 as references. The results suggested changchun104 was similar to shzh00-1. The red vertical line indicates position 3,555, which corresponded to shzh00-1. B) hangzhou212, hangzhou023, and all Changchun sequences clust

Figure 2. Phylogenetic analysis of Changchun and Hangzhou coxsackievirus 16A (CA16) sequences. A) Bootscanning results representing selected Changchun and Hangzhou sequences. changchun104 was shown for bootscanning analysis with human enterovirus A (HEV-A) sequences...

Bootscanning of these new sequences showed that the sequences from Changchun and Hangzhou have a recombination pattern similar to that of shzh00–1 (Figure 2, panel A; data not shown). Most Changchun and Hangzhou sequences changed from a CA16-like fragment into a non–CA16-like fragment at the break point around position 3555. However, when shzh00-1 was used as the reference sequence, bootscanning of these Changchun and Hangzhou sequences showed a high similarity to shzh00-1 through the entire sequenced region (data not shown). Phylogenetic analysis indicated that 23 of the Changchun and Hangzhou sequences formed a strong cluster with shzh00-1, shzh05-1, and GZ08 (Figure 2, panel B). Notably, 1 sequence clustered with the CA4 reference sequence, indicating that CA4-related viruses are also circulating among HFMD patients in China. These data suggest that shzh00-1 and these Changchun and Hangzhou sequences are likely derived from a common ancestor. New sequences identified in this study have been submitted to GenBank under accession nos. HQ450559–HQ450582.


As many as 40% of cases of HFMD in China have been attributed to CA16 infection on the basis of partial viral genome determination (11). In the current study, we demonstrated that circulating CA16 viruses in China are actually complex recombinant viruses involving multiple type A HEVs, including CA4, CA16, and EV71 (Figure 1). The 5′ UTR region (207–647 bp) of these viruses had the highest similarity to CA4. Most of the P1 region resembled that of the prototype CA16-G10 strain. The nonstructural protein domains (P2 and P3) had a 1.5-kb fragment (4,406–5,854 bp) that was most similar to EV71A. Several regions of shzh00-1 remain unclassified, including part of 2A, 2B, part of 2C, and 3D.

Over the past 30 years, numerous large outbreaks of CA16-associated HFMD, along with outbreaks caused by EV71, have been reported in China. However, full molecular characterization of circulating CA16 viruses in China had not been conducted. The current study provides evidence that circulating recombinant forms of the CA16-related viruses are prevalent among HFMD patients throughout China (Figure 2, panel C). The origin, including the place and date, of the current recombinant CA16 viruses is not clear. The exact parental viral strains involved in the generation of CA16 recombinant viruses are also unknown. Some of the parental virus strains of China CA16 could have become extinct or are yet to be discovered. Notably, CA4 was detected in 1 of our samples from Zhejiang Province (central China) and has also been reported in Gansu Province (northwestern China) (15). The identification of CA16-related HFMD, based mainly on VP1 sequences, has been widely reported in many parts of China, including Guangdong, Fujian, Jiangsu, and Inner Mongolia Provinces, and Beijing and Shanghai. Unfortunately, the sequences of other parts of these viral genomes, especially the regions spanning the recombination site, have not been determined. Further detailed characterization of HEV sequences from HFMD patients is still needed, but the information obtained thus far has implications for addressing the future emergence of new pathogenic HEVs and for vaccine development to manage the increasing prevalence of HFMD.

Mr Zhao is a visiting scholar at the Johns Hopkins Bloomberg School of Public Health, Baltimore. His research focuses on RNA viruses, primarily the molecular mechanisms of viral transmission and prevention.



We thank Juan Du, Xiaomei Wang, Haoran Guo, and Alan Templeton for advice and helpful discussions and Deborah McClellan for editorial assistance.

This work was supported in part by funding from the Key Laboratory of Molecular Virology, Jilin Province (20102209), New Teacher Fund from the Ministry of Education of China and the Innovative Project of Jilin University. K.Z. was supported in part by R01DA026150 from the National Institute on Drug Abuse.



  1. Sickles  GM, Mutterer  M, Feorino  P, Plager  H. Recently classified types of Coxsackie virus, group A; behavior in tissue culture. Proc Soc Exp Biol Med. 1955;90:52931.PubMedGoogle Scholar
  2. Pöyry  T, Hyypiä  T, Horsnell  C, Kinnunen  L, Hovi  T, Stanway  G. Molecular analysis of coxsackievirus A16 reveals a new genetic group of enteroviruses. Virology. 1994;202:9827. DOIPubMedGoogle Scholar
  3. McMinn  PC. An overview of the evolution of enterovirus 71 and its clinical and public health significance. FEMS Microbiol Rev. 2002;26:91107. DOIPubMedGoogle Scholar
  4. Doraisingham  S, Goh  KT, Ling  AE. Epidemiology of viral infections in Singapore. Ann Acad Med Singapore. 1987;16:2439.PubMedGoogle Scholar
  5. Yan  JJ, Su  IJ, Chen  PF, Liu  CC, Yu  CK, Wang  JR. Complete genome analysis of enterovirus 71 isolated from an outbreak in Taiwan and rapid identification of enterovirus 71 and coxsackievirus A16 by RT-PCR. J Med Virol. 2001;65:3319. DOIPubMedGoogle Scholar
  6. Tu  PV, Thao  NT, Perera  D, Huu  TK, Tien  NT, Thuong  TC, Epidemiologic and virologic investigation of hand, foot, and mouth disease, southern Vietnam, 2005. Emerg Infect Dis. 2007;13:173341.PubMedGoogle Scholar
  7. Wu  Y, Yeo  A, Phoon  MC, Tan  EL, Poh  CL, Quak  SH, The largest outbreak of hand, foot and mouth disease in Singapore in 2008: the role of enterovirus 71 and coxsackievirus A strains. Int J Infect Dis. 2010;14:e107681. DOIPubMedGoogle Scholar
  8. Li  L, He  Y, Yang  H, Zhu  J, Xu  X, Dong  J, Genetic characteristics of human enterovirus 71 and coxsackievirus A16 circulating from 1999 to 2004 in Shenzhen, People’s Republic of China. J Clin Microbiol. 2005;43:38359. DOIPubMedGoogle Scholar
  9. Li  RQ, Chen  LJ, Zhang  HR, Wang  YM, He  X. Study on the etiology of hand-foot-mouth disease outbreaks in Beijing in 2007 [in Chinese]. Zhonghua Liu Xing Bing Xue Za Zhi. 2009;30:7847.PubMedGoogle Scholar
  10. Zhang  Y, Wang  D, Yan  D, Zhu  S, Liu  J, Wang  H, Molecular evidence of persistent epidemic and evolution of subgenotype B1 coxsackievirus A16–associated hand, foot, and mouth disease in China. J Clin Microbiol. 2010;48:61922. DOIPubMedGoogle Scholar
  11. Zhu  Z, Zhu  S, Guo  X, Wang  J, Wang  D, Yan  D, Retrospective seroepidemiology indicated that human enterovirus 71 and coxsackievirus A16 circulated wildly in central and southern China before large-scale outbreaks from 2008. Virol J. 2010;7:300. DOIPubMedGoogle Scholar
  12. Tamura  K, Dudley  J, Nei  M, Kumar  S. MEGA4: Molecular Evolutionary Genetics Analysis (MEGA) software version 4.0. Mol Biol Evol. 2007;24:15969. DOIPubMedGoogle Scholar
  13. Kosakovsky Pond  SL, Posada  D, Gravenor  MB, Woelk  CH, Frost  SD. Automated phylogenetic detection of recombination using a genetic algorithm. Mol Biol Evol. 2006;23:1891901. DOIPubMedGoogle Scholar
  14. Lole  KS, Bollinger  RC, Paranjape  RS, Gadkari  D, Kulkarni  SS, Novak  NG, Full-length human immunodeficiency virus type 1 genomes from subtype C–infected seroconverters in India, with evidence of intersubtype recombination. J Virol. 1999;73:15260.PubMedGoogle Scholar
  15. Liu  JF, Zhang  Y, Li  H. Genetic characterization of VP4–VP2 of 2 coxsackievirus A4 isolated from patients with hand, foot, and mouth disease [in Chinese]. Zhongguo Ji Hua Mian Yi. 2009;15:3459.PubMedGoogle Scholar




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DOI: 10.3201/eid1708.101719

Table of Contents – Volume 17, Number 8—August 2011

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Xiao-Fang Yu, Johns Hopkins University, Room E5148, 615 N Wolfe St, Baltimore, MD 21205-2103, USA

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