Hand, foot and mouth disease (HFMD)

HFMD infects children in particular and is often caused by a group of Enteroviruses, Coxsackie and Enterovirus 71 being the most common. Outbreaks associated with Enterovirus 71 infection have been reported globally since the 1970s, predominantly in the Asia-Pacific region and largely affecting children. Clinical manifestation of cases has been mostly typical of HFMD, with fever, skin eruptions on hands and feet, and vesicles in the mouth. Rarely, HFMD can lead to serious complications including viral meningitis and other central nervous system conditions such as encephalitis and paralysis and/or fluid in the lungs (pulmonary oedema).

The following are standard case definitions to allow national health authorities to interpret data in an international context. However, during an outbreak case definitions may be adapted to the local context and the Red Cross Red Crescent should use those agreed/established by national health authorities. NB: Consider that during community surveillance, volunteers should use broad (simplified) case definitions to recognize most or all possible cases and to encourage them to seek care. Other actors such as healthcare workers or investigators studying the cause of a disease, on the other hand, can use more specific case definitions that may require laboratory confirmation.

Given the endemicity of this illness, it is not necessary to report every single case of detected HFMD. Instead, the objective should be to detect events that indicate an outbreak, clusters of cases, severe cases or deaths.

The standard case definition is: febrile illness with papulovesicular rash on palms and soles, with or without vesicles/ulcers in the mouth. Rash may occasionally be without vesicular lesion, and may also involve the buttocks, knees or elbows, particularly in younger children and infants.

WHO case definition source of information: https://www.who.int

The number of cases reaches two standard deviations above the normal baseline OR two or more cases occur within an institution, indicating transmission within a cohort.

• Taking care of infants and children who have the disease (parents, day carers, teachers).
• Poor personal hygiene.
• Close contact with infectious people in a same household or overcrowded areas where a person-to-person spread is easily possible.
• No proper sanitation and hygiene measures.
• Not properly treated recreational water, such as water in swimming pools.

Possibly high among close contacts, but only a small proportion with the disease present symptoms. Attack rates have varied from one country to another.

• Infants.
• Patients with Enterovirus 71 (EV71) infection.
• Patients who are immunosuppressed.

Coxsackievirus A16 and other coxsackieviruses, Enterovirus 71 (EV71).

Humans.

• Contact transmission: Contact with the nose and throat secretion fluid from blisters or scabs of an infected person by touching the person or through other types of close contact like kissing and hugging.
• Faecal oral transmission: Viruses in faecal particles pass from one person to the mouth of another person; for example, while changing diapers without appropriate hand hygiene.
• Droplet spread: Especially at the beginning of the infection, the viral load in the throat is high and can spread through coughing, sneezing or sharing eating utensils.
• Vehicle-borne transmission: Swallowing recreational water (e.g. in swimming pools) that is not properly treated with chlorine.

Three to ten days.

People with HFMD are usually most contagious during the first week of illness. For EV71, viral shedding from the throat can occur up to two weeks after an acute EV71 infection, and virus can be isolated from stools for up to 11 weeks.

• Fever, reduced appetite, fatigue, sore throat, and after a few days sores in the mouth.
• A skin rash with red spots, and sometimes with blisters, may also develop over one or two days on the palms of the hands and soles of the feet. It may also appear on the knees, elbows, buttocks or genital area.
• Some people, especially young children, are at increased risk of  dehydration because of painful mouth sores.
• Typically symptoms of HFMD resolve on their own within 7—10 days
• Most cases of the disease are harmless. But complications may occur with neurological symptoms such as meningitis, encephalitis and polio-like paralysis.
• In rare cases it can be fatal in children, particularly those aged less than five years. These cases may experience a brief febrile illness and present with only subtle neurological signs before developing acute heart failure and pulmonary oedema.

Herpetic gingivostomatitis, aphthous stomatitis, scabies infestation, chickenpox (varicella), measles and rubella.

• Typically HFMD is a clinical diagnosis from signs and symptoms
• Virus isolation from cell cultures.
• Virus identification (neutralization test, reverse transcriptase polymerase chain reaction (RT-PCR), immunofluorescence assay).
• Rapid diagnostic tests for clinical purposes.

Please refer to the appropriate local or international guidelines for clinical management. All clinical management including the administration of a treatment or vaccine should be conducted by a health professional.

• There is no specific treatment for HFMD and no vaccine.
• People who are unwell can take over-the-counter medications to relieve pain and fever and use mouthwashes or sprays that numb mouth pain.
• Sick people should drink enough liquids to stay hydrated.

When someone gets HFMD, they develop immunity to the specific virus that caused their infection. However, because HFMD is caused by several different viruses, people can get the disease again.