Professional Documents
Culture Documents
(Hand-Foot-Mouth
Disease)
An emerging disease
Wong Ann Cheng
MD (UKM) MRCPCH (UK)
Wednesday October 8, 2008
Sarawak on high alert for HFM disease
KUCHING: Sarawak is on high alert for hand, foot and mouth disease
following the detection of the EV71 virus, which causes a more severe
form of the disease.
Deputy Chief Minister Tan Sri Dr George Chan said the situation was under
control and steps were being taken to prevent an outbreak.“We monitor
for hand, foot and mouth disease all the time. “As soon as we detected
EV71 in the state, we went on high alert because we know this virus can
cause death,” he told a press conference at his office here yesterday.
A total of 5,686 cases have been reported in Sarawak as of Saturday,
compared with 6,286 in the same period last year.
On Sept 30, a four-year-old child in Sibu died from suspected hand, foot
and mouth disease.
SPOT DIAGNOSIS ?
HFMD
Myth
http://www.cdc.gov/ncidod/dvrd/revb/enterovirus/hfhf.htm
Symptoms (case
definition)
Usually begins with fever, poor appetite
and malaise, often with sore throat
After 1-2 days after onset of fever,
sores/ulcers develop in the mouth, side of
cheek, gum and tongue
The non-itchy skin rash/ maculopapular or
vesicular appears on palms of the hands
and soles of the feet.
The rashes may also appear on buttocks
and on the legs and arms.
http://www.cdc.gov/ncidod/dvrd/revb/enterovirus/hfhf.htm
HAND
FOOT
MOUTH
Differentials
Herpangina
Coxsackievirus B
Echovirus
Enterovirus 68-71
Malaysia
1997
5,999/ 31 Malaysia
2006
14,253/ 13
Singapore
2000
> 4,000/ 7
An emerging infectious
disease
Malaria
Typhoid
Dengue Leptospirosis
Chikungunya Melioidosis
HIV JE
1345
1400 1282
1300 1234
1212
1200
1100 1017
1000
900
800
Cases
700 633
567
600
500 435 412
403 431
397
400 332 315 326 322
310
265
232 198 239 274
271
253
300 193 228 220
156 174 147
200 98105 112 859795
53 6340313322372936 26
100 4 15 14 171723
0
1
10
13
16
19
22
25
28
31
34
37
40
43
46
49
52
Epid Week
500
428
400 385
315 320
300
252 254
245
0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40
EPID WEEK
300
270
275
251
250
225
193
200
181
175
143
150
131
125 113
99
100 89
83
76
75
49 49 51 47
50
26 28 26 28
19 18 21 23 19 16 17
25
6 6 7 11 7
13 12 11 15 9 7 10
3 2
0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40
EP ID WEEK
Stage 4 Convalescence
Admit if have 1 or more following criteria Does not fit admission criteria
Saliva
Fluid from
blisters
Stools
Mode of transmission
HFMD is moderately contagious.
Most contagious during the first week of
the illness.
The virus can be transmitted from person
to person via
direct contact with nose and throat discharges,
saliva, fluid from blisters, or the stool of
infected persons.
The virus may continue to be excreted in the
stools of infected persons up till 1 month.
HFMD is not transmitted to or from pets or
other animals.
Transmission
Infants in diapers appears to be the
most efficient transmitter.
The virus may be excreted in stools
for many weeks
The virus can survive for days on
formites at room temperature
Resistant to many disinfectants – use
chlorinated or iodinized disinfectant
Transmission rate
To household contacts 52%
Siblings 84%
Cousins 83%
Parents 41%
Grandparents 28%
Uncle and aunts 26%
Intrafamilial and kindergarden
transmission major mode of transmission
(both in Taiwan and Singapore)
JAMA 2004; 291: 222-7 Pediatr 2002; 109: e88
Risks factors
Children more susceptible due to
lack of immunity
Parents sending sick children to
centre
Cases not detected and isolated
Close contact among classmates
Asymptomatic cases
Poor personal hygiene
Contamination of toys, furniture and
premises
Immunity
Infection results in immunity to
specific virus
Second episode may occur following
infection with other enterovirus
Treatment
No specific antiviral treatment
available for HFMD
Mainly supportive.
?immunoglobulin
Health screening for
HFMD
Early detection and prompt isolation
Children should be monitored daily,
noting any unusual symptoms or
behaviour
A child should not be allowed to
continue class if he/she appears
unwell
Hygiene and sanitation
Hand washing not emphasized
enough
One of the most important route of
transmission of infection
Single most effective practice to
prevent spread of germs
Practice it
Teach it
Monitor and enforcement of good
handwashing practices
Outbreak control
measures
Continue health screening
Ensure high level of personal and
environmental hygiene
Eliminate communal activities where
all children congregate
Public educational effort
Closure of kindergarden and school
for 10 days to break the chain of
transmission
Poster
Pamphlets
Booklets
Message
From Sarawak, since 1997, EV71 outbreak
had occurred every three years
Shape of epidemiological curve influence
by social factors such as media and
people’s movement during public holidays
Genogroups of EV71 isolated during each
major outbreak are genetically distinct
from each other
Transmission of EV71 in susceptible cohort
extremely rapid with only 4-6 weeks
between first identification in sentinel
clinics to peaking
Message
From Singapore, transmission occur
mainly in places where preschool children
congregate, and public health measures to
focus on these places
From Taiwan 1998 outbreak showed that
HFMD spreads easily through contact
leading to mostly symptomatic cases in
children and mostly asymptomatic cases
in adult
Proper surveillance system works showing
trends and the current circulating viruses
and predicting coming outbreak
Challenges
Identify reservoir of EV71 in the
inter-epidemic periods
Develop simple rapid diagnostic tests
that can be used to differentiate
EV71 from CA16
References
http://www.sarawak.health.gov.my/hfmd.htm
http://en.wikipedia.org/wiki/HFMD
Chan, L. G., U. D. Parashar, M. S. Lye, et al. 2000. Deaths of children during an
outbreak of hand, foot and mouth disease in Sarawak, Malaysia: clinical and
pathological characteristics of the disease. Clin. Infect. Dis. 31:678-683[Medline]
Cardosa, M. J., S. Krishnan, P. H. Tio, et al. 1999. Isolation of subgenus
B adenovirus during a fatal outbreak of enterovirus 71-associated
hand, foot and mouth disease in Sibu, Sarawak. Lancet 354:987-991
[Medline].
Chong CY, Chan KP, Shah VA, Ng WY, Lau G, Teo TE, et al. Hand, foot and mouth
disease in Singapore: a comparison of fatal and non-fatal cases. Acta
Paediatr. Oct 2003;92(10):1163-9. [Medline].
Ooi MH, Wong SC, Clear D, Perera D, Krishnan S, Preston T, et al. Adenovirus
type 21-associated acute flaccid paralysis during an outbreak of hand-foot-and-
mouth disease in Sarawak, Malaysia. Clin Infect Dis. Mar 1 2003;36(5):550-9.
[Medline].
Shekhar K, Lye MS, Norlijah O, Ong F, Looi LM, Khuzaiah R, et al. Deaths in
children during an outbreak of hand, foot and mouth disease in Peninsular
Malaysia--clinical and pathological characteristics. Med J
Malaysia. Aug 2005;60(3):297-304. [Medline].
Tseng FC, Huang HC, Chi CY, Lin TL, Liu CC, Jian JW, et al. Epidemiological survey
of enterovirus infections occurring in Taiwan between 2000 and 2005: Analysis
of sentinel physician surveillance data. J Med Virol. Dec 2007;79(12):1850-60.
[Medline].
THANK YOU