Hand, Foot and Mouth Disease

Hand,  foot,  and  mouth  disease,  or  HFMD,  is  a  contagious  illness  caused  by  different  viruses.  Infants  and  children  younger  than  5  years  are  more  likely  to  get  this  disease.  However, older children and adults can also get it.

Case definition

Clinical case definition Case of HFMD

Any child with

• Mouth / tongue ulcer and
• Maculopapular rashes and /or vesicles on palms and soles
• With OR without history of fever

Suspected

• A case that meets the clinical case definition.

Confirmed

• A suspected case in which laboratory investigation confirms the presence of virus OR when cases are epidemiologically linked to a laboratory confirmed case

Laboratory criteria

• Any case that has the clinical symptoms and positive for viruses (coxsackieviruses (Cox) A16, A5, A9, A10, B2, B5 and enterovirus (EV) 71) which could cause HFMD, isolated or detected from stool or vesicle fluid or mouth ulcer or saliva.

Clinical Presentation

Hand, foot, and mouth disease usually starts with a fever, poor appetite, a vague feeling of being unwell (malaise), and sore throat. One or 2 days after fever starts, painful sores usually develop in the mouth (herpangina).  They begin  as  small  red  spots that  blister  and  that  often  become  ulcers. The sores are often in the back of the mouth. A skin rash develops over 1 to 2 days. The rash has flat or raised red spots, sometimes with blisters. The rash is usually on the palms of the hands and soles of the feet; it may also appear on the knees, elbows, buttocks or genital area.

Persons  infected  with  the  viruses  that  cause  hand,  foot,  and  mouth  disease  may  not  get  all  the symptoms of the disease. They may only get mouth sores or skin rash. The  viruses  that  cause  hand,  foot,  and  mouth  disease  (HFMD)  can  be  found  in  an  infected person’s:

• Nose and throat secretions (such as saliva, sputum, or nasal mucus),
• Blister fluid, and
• Feces (stool).

An infected person may spread the viruses that cause hand, foot, and mouth disease through:

• Close personal contact,
• The air (through coughing or sneezing),
• Contact with feces,
• Contaminated objects and surfaces.

A person with hand, foot, and mouth disease is most contagious during the first week of illness.  People can sometimes be contagious for days or weeks after symptoms go away. Some people, especially adults, who get infected with the viruses that cause hand, foot, and mouth disease, may not develop any symptoms.  However, they may still be contagious.  This is why people should always try to maintain good hygiene (e.g.  Handwashing)  so they can minimize their chance of spreading or getting infections.

Complications

• Viral or "aseptic" meningitis can occur with hand, foot, and mouth disease but it is rare. It causes fever, headache, stiff neck, or back pain.
• Inflammation of the brain (encephalitis) can occur, but this is even rarer.
• Fingernail and  toenail  loss  have  been  reported,  occurring  mostly  in  children  within  4 weeks of their having hand, foot, and mouth disease.

Diagnosis

Depending on how severe the symptoms are samples from the throat or stool may be collected and sent to a laboratory to test for the virus.

Clinical Management

There  is  no  specific  treatment  for  hand,  foot  and  mouth  disease.  However, some things can be done to relieve symptoms, such as

• Taking over -the-counter medications to relieve pain and fever (Caution: Aspirin should not be given to children.)
• Using mouthwashes or sprays that numb mouth pain Mild HFMD cases only need symptomatic treatment. Treatment of fever and relief of symptoms, adequate hydration and rest are important. Parents and care takers should be educated on hygiene and measures that they should take to prevent transmission to other children.

Hospitalization

Criteria for admission

• When  the  child  is  unable  to  tolerate  oral  feeds  and  there  is  a  need  for  intravenous hydration;
• When the child is clinically very ill or toxic - looking
• When some other more serious disease cannot be excluded
• When there is persistent hyperpyrexia (e.g >38ºC) for >48 hours;
• When   there   is   a   suspicion   of   neurological   complications,   e.g.   Increased lethargy, myoclonus, increased drowsiness, and change in sensorium and/or seizures;
• When there is a suspicion of cardiac complications (myocarditis), e.g low blood pressure, low pulse  volume,  heart  rhythm  abnormalities,  murmurs, gallop  rhythm,  displaced  apex beat;
• When parents are unable to cope with child’s illness; and
• When there is inadequate family or social support in looking after the child at home.

Infection control

• Proper hygiene including mandatory hand washing after contact with patient, appropriate cleanliness during diaper changes is imperative
• Personal  items  such as  spoons,  cups  and  utensils  should  not  be  shared  and  should  be properly washed with detergent after use;
• The use of gowns may act as a useful protection for health personnel looking after these patients; and
• Patients with HFMD should be isolated and the usual isolation procedures followed for infection control.
• Articles  such  as  toys  contaminated  by  infected  cases  are  disinfected  with  0.5%  sodium hypochlorite solutions
• A high standard of food and personal hygiene is maintained by the institution involved which include proper waste and diapers disposal.

Advice Given upon Patient’s Discharge

Parents  and  guardians  should  be  advised  upon  patients  discharge  on  complications  that may occur; a statement as shown below can be given:

“Your child has been diagnosed to have hand -foot-mouth disease.  This disease is  normally  not  dangerous  but  in  the  light  of  recent  events,  we  advise  that  you  bring  back your child to this hospital if he / she has any of the following symptoms:

• High fever.
• Lethargy and weakness.
• Refusing feeds and passing less urine.
• Rapid breathing.
• Vomiting.
• Drowsiness or irritably.
• Fits.

Prevention

There is no vaccine to protect against the viruses that cause hand, foot and mouth disease.

A person can lower their risk of being infected by

• Washing hands often with soap and water, especially after changing diapers and using the toilet.  Cleaning and disinfecting frequently touched surfaces and soiled items, including toys.
• Avoiding close contact such as kissing, hugging, or sharing eating utensils or cups with people with hand, foot, and mouth disease.

If  a  person  has  mouth  sores,  it  might  be  painful  to  swallow.  However, drinking liquids is important to stay hydrated.  If  a  person  cannot  swallow  enough  liquids,  these  may  need  to  be given through an IV in their vein.

Right Method of Washing Hands

• Wet your hands with clean, running water (warm or cold) and apply soap.
• Rub your hands together to make lather and scrub them well; be sure to scrub the backs of your hands, between your fingers, and under your nails Continue rubbing your hands for at least 20 seconds.  Need a timer?  Hum the “Happy Birthday" song from beginning to end twice.
• Rinse your hands well under running water.
• Dry your hands using a clean towel or air dry them.

How do you use hand sanitizers?

• Apply the product to the palm of one hand.
• Rub your hands together.
• Rub the product over all surfaces of your hands and fingers until your hands are dry.

If the outbreak occurs in primary schools;

• Principals, teachers and supervisors shall be alerted to look out for children with fever, rash / blisters on palms and soles and to isolate them immediately. Screening before coming to class is recommended
• Ensure that the infected children remain away from the institution for at least ten days after onset of symptoms and must be certified free from infection by a registered medical practitioner prior to returning to school
• Health education to the students on the disease, mode of transmission, importance of good personal hygiene.
• If closure is necessary, just closed the affected class. Closure of the whole school is  unnecessary as HFMD in older children is usually very mild and so far no complication has been documented from this age group

Source: National Centre for Disease Control (NCDC)