NCCID Disease Debriefs provide Canadian public health practitioners and clinicians with up-to-date reviews of essential information on prominent infectious diseases for Canadian public health practice. While not a formal literature review, information is gathered from key sources including the Public Health Agency of Canada (PHAC), the USA Centers for Disease Control and Prevention (CDC), the World Health Organization (WHO) and peer reviewed literature.
This disease debrief was prepared by Shyama Nanayakkara. Questions, comments, and suggestions regarding this disease brief are most welcome and can be sent to email@example.com.
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Questions Addressed in this debrief:
- What are important characteristics of Hand, Foot, and Mouth Disease?
- What is happening with current outbreaks of Hand, Foot, and Mouth Disease?
- What is the current risk for Canadians from Hand, Foot, and Mouth Disease?
What are important characteristics of Hand, Foot, and Mouth Disease?
Hand, Foot, and Mouth Disease (HFMD) is a highly contagious disease caused by a virus belonging to Enteroviruses including certain coxsackieviruses A16 (CA16), A6 (CA6) and Enterovirus 71 (EV71). These viruses are a member of the picornaviruses belonging to the Picornaviridae family which includes non-enveloped single-stranded RNA viruses. Coxsackievirus A16 is the most common cause of HFMD and usually causes less severe infection, while Coxsackievirus A6 rare and causes more severe infection. Enterovirus EV-A71 is a rarer cause of HFMD but is considered the most severe neurotoxic enterovirus and has been associated with severe outbreaks in Asia. EV71 has eight genogroups (A–H), with genogroups B and C commonly seen. Each two of these genogroups are sub-classified into five sub-genogroups (C1–C5 and B1–B5). In China, C4 is the major genogroup circulating, while in other Asian countries B4, B5 and C5 are found. Strains of genogroups C1 and C2 are predominantly found in Europe where the severe disease is uncommon.
Signs, Symptoms, and Severity
Symptoms usually include fever, mouth sores, and a skin rash commonly found on the hands and feet. The incubation period is 3-7 days, while the symptoms usually last 7 to 10 days.
- Fever and flu-like symptoms: Symptoms may include fever, eating or drinking less, sore throat and feeling unwell. These symptoms usually occur within 3 to 5 days of onset.
- Mouth Sores: Starting as small red spots on the tongue and inside of mouth, mouth sores can become painful, often making swallowing painful. Usually, the painful oral ulcers appear before typical skin lesions on palms and soles, which appear a day or two later.
- Not eating or drinking
- Drooling more than usual
- Only wanting to drink cold fluids
- Skin rash: Skin rash usually can be found on the palms and soles of the feet, but may also can see on the arms, legs and buttocks. The rash is generally not itchy, may be flat or have slightly raised red spots, local redness, and possibly blisters. Fluid and scabs can contain virus.
Rarely, more severe symptoms like meningitis, encephalitis and polio-like paralysis may occur, particularly when the illness results from infection with EV 71 and involve the central nervous system (CNS).
Complications include encephalitis, aseptic meningitis, acute flaccid paralysis, pulmonary edema or hemorrhage and myocarditis. Most deaths in HFMD occur as a result of pulmonary edema or hemorrhage.
The differential diagnoses for HFMD include herpetic gingivostomatitis, aphthous stomatitis, scabies infestation, chickenpox (varicella), measles and rubella.
HFMD is a primarily diagnosed clinically. However, a few laboratory tests are available if the diagnosis is uncertain or when severe disease is suspected. The virus can be shed from the oropharynx for up to 4 weeks and from the stool for up to 6 weeks. Confirmed diagnosis is based on cell culture, virus isolation and identification of enteroviruses. Light microscopy can be used to distinguish HFMD from other viruses like varicella or herpes simplex viruses. Polymerase chain reaction (PCR) assays are available to confirm presence of coxsackievirus and enterovirus. The specimens examined are usually scrapings or biopsies of the vesicle, upper respiratory tract or faecal specimens or from specimens of cerebrospinal fluid in case of suspected meningitis. Serology has limited use, although IgG levels can be measured to monitor recovery.
There is no specific antiviral treatment for HFMD, and most patients will recover in 7-10 days. Over the counter medications formulated specifically for children can be given to reduce fever and mouth pain. Children should be encouraged to drink liquids to remain hydrated.
When to see a healthcare provider:
- Child becomes dehydrated
- Symptoms last more than 10 days
- Child has a weakened immune system
- Child is younger than 6 months
- Dehydrated, especially young children; due to a sore mouth they are not able to swallow enough liquids
- Severe symptoms are rare like loss of a fingernail or toenail, headache, stiff neck, or back pain (signs of meningitis), drowsy or paralysis (signs of encephalitis)
Pregnant women should contact their healthcare provider if they have been exposed to a HFMD patient.
If symptoms develop while travelling, the patient needs to contact a healthcare provider immediately after arrival.
HFMD was first reported in New Zealand in 1957. Outbreaks associated with EV71 infection have been reported throughout the world since the early 1970s. Humans are the only reservoir of the enterovirus family that causes HFMD. The virus can be passed to other people though contact with respiratory droplets, nose and throat secretions, saliva, fluid from the blisters, and from feces. It can be spread by close personal contact (kissing or hugging), touching an infected person, changing diapers, or touching a contaminated object or surface followed by touching eyes, nose or mouth. In rare cases, swallowing contaminated pool water can also transmit the virus.
Anyone can get HFMD at any time of the year in tropical climates; however, it occurs most commonly in the summer and fall in seasonal climates. The disease is most common in children younger than 5 years old.
WHO monitors HFMD in the region by the Regional Event Based Surveillance System, to detect any outbreaks.
Prevention and Control
HFMD can be prevented using the following simple steps.
Hand Washing: Wash your hands with soap and water for at least 20 seconds, or use an alcohol-based hand sanitizer. Ensure hands are washed thoroughly after using the toilet, changing diapers, blowing nose, coughing, sneezing, and before and after caring for a sick patient. Ensure children are following thorough hand washing practices as well.
Disinfect household surfaces: Ensure all touch surfaces such as doorknobs and toys are frequently cleaned with a proper disinfectant.
Avoid touching one’s eyes, nose, and mouth: Keep blisters clean and avoid touching; never touch your eyes, nose or mouth with unwashed hands.
Avoid close contact with sick people: Minimize unnecessary physical contact (hugging/kissing) with infected children.
To avoid community transmission, parents should speak with the family health care provider before sending a child to school.
The vaccine is only available for EV71 using C4 genogroup strains which is mainly used in Southeast Asia. Vaccines containing B4 and B5 genogroups are in development but not have reached the licensing stage. Researchers are working to develop multivalent vaccine against Coxsackie A16, A6 and A10. Vaccines are not in use in Canada.
What is happening with current outbreaks?
In each summer a spike in cases in seen in provinces. Individual outbreaks have occurred in childcare centers throughout Canada, and large-scale outbreaks are common in East and Southeast Asia.
According to the WHO Western Pacific Region HFMD Surveillance Summary report, last updated on 2018 in month of July 2018, a total of 377 629 cases of HFMD and four deaths were reported in China, which is a 27% increase from the same period in 2017. A consistent seasonal trend was seen from 2013–2017. Almost similar kinds of trends are seen in Republic of Korea, Hong Kong, Singapore and Vietnam.
What is the current risk for Canadians?
Although HFMD is not a notifiable disease in Canada, each summer, a spike in cases is seen in provinces. Individual outbreaks have occurred in childcare centres throughout Canada.
The Public Health Agency of Canada does not recommend any specific treatment for the condition, as it is self-limiting in most cases. Supportive treatment is recommended, and parents are advised to closely monitor their children for the development of complications such as dehydration.
The viruses that cause HFMD can be found worldwide. Young children are most at risk. Travelers are at increased risk, especially when visiting areas where many people are in proximity. Measures that can be taken to avoid getting infected include frequent handwashing, disinfection of contaminated surfaces with bleach, and washing soiled articles of clothing. The viruses are resistant to many disinfectants, so it is important to use chlorinated (bleach) or iodized disinfectants. During epidemics, the closure of schools or childcare facilities may be considered to reduce transmission, especially among young children. It is not necessary to restrict travel or trade.