What is hand, foot, and mouth disease?Hand, foot, and mouth disease (HFMD) is a common illness among infants and children, but it may also be seen in adults. Most cases occur in the summer and early fall in temperate climate. In tropical country like Brunei, it is found all year round. Outbreaks may occur among groups of children, especially in childcare centres or nursery schools. Symptoms usually appear three to five days after exposure. HFMD begins with a mild fever, poor appetite, malaise (“feeling sick”), and frequently a sore throat. One or two days after the fever begins, painful sores develop in the mouth. They begin as small red spots that blister and then often become ulcers. They are usually located on the tongue, gums, and inside of the cheeks. The skin rash develops over one to two days with flat or raised red spots, some with blisters. The rash does not itch, and it is usually located on the palms of the hands and soles of the feet. It may also appear on the buttocks. A person with HFMD may have only the rash or the mouth ulcers (also called herpangina).
Is HFMD the same as foot-and-mouth disease?No. HFMD is often confused with foot-and-mouth disease of cattle, sheep, and swine. Although the names are similar, the two diseases are not related at all and are caused by different viruses.
What causes HFMD?Viruses from the group called enteroviruses cause HFMD. The most common cause is coxsackievirus A16; sometimes, HFMD is caused by enterovirus 71 or other enteroviruses like coxsackievirus types A4-A7, A9, A10, B1-B3, and B5. Infections usually occur as isolated events, but epidemics occur regularly. Recently, a large outbreak of HFMD in Malaysia, Singapore and Taiwan was caused by enterovirus 71.
Is HFMD serious?Usually not. HFMD caused by coxsackievirus A16 infection is a mild disease and nearly all patients recover without medical treatment in seven to 10 days. Complications are uncommon.
Rarely, the patient with coxsackievirus A16 infection may also develop “aseptic” or viral meningitis (an infection and inflammation of the membranes and cerebrospinal fluid surrounding the brain and spinal cord), in which the person has fever, headache, stiff neck, or back pain, and may need to be hospitalised for a few days. More serious diseases, such as encephalitis (brain inflammation) caused by enterovirus 71 may be fatal. Cases of fatal encephalitis occurred during outbreaks of HFMD in Malaysia in 1997 and in Taiwan in 1998.
Is HFMD contagious?Yes, HFMD is moderately contagious. Infection is spread from person to person by direct contact with nose and throat discharges, saliva, fluid from blisters, or the stool of infected persons. A person is most contagious during the first week of the illness. HFMD is not transmitted to or from pets or other animals.
How soon will someone become ill after getting infected?The usual period from infection to onset of symptoms (“incubation period”) is three to seven days. Fever is often the first symptom of HFMD.
Who is at risk from HFMD?HFMD occurs mainly in children under 10 years old, but may also occur in adults, too. Everyone is at risk of infection, but not everyone who is infected becomes ill. Infants, children, and adolescents are more likely to be susceptible to infection and illness from these viruses, because they are less likely than adults to have antibodies and be immune from previous exposures to them. Infection results in immunity to the specific virus, but a second episode may occur following infection with a different member of the enterovirus group.
What are the risks to pregnant women exposed to children with HFMD?Because enteroviruses, including those causing HFMD, are very common, pregnant women are frequently exposed to them. As for any other adults, the risk of infection is higher for pregnant women who do not have antibodies from earlier exposures to these viruses, and who are exposed to young children – the primary spreaders of enteroviruses.
Most enterovirus infections during pregnancy cause mild or no illness in the mother. Although the available information is limited, currently there is no clear evidence that maternal enteroviral infection causes adverse outcomes of pregnancy such as abortion, stillbirth, or congenital defects. However, mothers infected shortly before delivery may pass the virus to the newborn. Babies born to mothers who have symptoms of enteroviral illness around the time of delivery are more likely to be infected. Most newborns infected with an enterovirus have mild illness, but, in rare cases, they may develop an overwhelming infection of many organs, including liver and heart, and die from the infection. The risk of this severe illness in newborns is higher during the first two weeks of life. Strict adherence to generally recommended good hygienic practices by the pregnant woman may help to decrease the risk of infection during pregnancy and around the time of delivery.
When and where does HFMD occur?Individual cases and outbreaks of HFMD occur worldwide. In the recent past, major outbreaks of HFMD attributable to enterovirus 71 have been reported in some Southeast Asian countries (Malaysia, 1997; Taiwan, 1998).
How is HFMD diagnosed?Usually the diagnosis is made based on the history and physical examination. Lab tests are available for the coxsackieviruses and other enteroviruses, but they are not usually necessary.
Your doctor can distinguish between HFMD and other causes of mouth sores based on the age of the patient, the pattern of symptoms reported by the patient or parent, and the appearance of the rash and sores on examination. Hand-foot-and-mouth disease is sometimes confused with strep throat, which can also begin with a fever and sore throat. It is sometimes mistaken for chickenpox because they both have blisters. It might be confused with any of the childhood exanthems (rash). Also, many children with hand-foot-and-mouth disease are diagnosed with ear infections because the eardrums may appear red.
How is HFMD treated?No specific treatment is available for this or other enterovirus infections. Symptomatic treatment is given to provide relief from fever, aches, or pain from the mouth ulcers. Paracetamol (panadol) or ibuprofen (brufen) will relieve fever and discomfort. Antibiotics do not help with hand-foot-and-mouth disease. Salt water mouth rinses (1/2 teaspoon of salt to one glass of warm water) may be soothing if the child is able to rinse without swallowing. Ensure an adequate fluid intake because swallowing may be painful. Dehydration can occur because the mouth lesions can cause pain with swallowing. Extra fluid is needed when a fever is present. The best fluids are cold milk products, especially ice cream. Many children refuse juices and sodas, for example, because their acidity causes burning pain in the ulcers.
Expectations (prognosis)Generally, complete recovery occurs in five to seven days.
How can it be prevented?Good hygiene is the best protection: wash hands with soap and water after going to the toilet, before eating, after wiping noses, and after changing nappies or soiled clothing. Avoid sharing cups, eating utensils, items of personal hygiene (for example: towels and toothbrushes). Thoroughly wash any soiled clothing. Ensure the mouth and nose are covered when coughing and sneezing. Wipe the nose and mouth with tissues, dispose of used tissues and then wash your hands.
How can spread of the disease be controlled?Children with hand-foot-and-mouth disease should be excluded from school or childcare facilities until their blisters have dried.
What should parents do if their child has HFMD?Parents are advised to consult a doctor early if their child has symptoms of HFMD. They should also be alert to any change in their child’s normal behaviour, for example, irritation and sleepiness. Should they refuse to eat or drink, have persistent vomiting or drowsiness, parents should bring their child immediately to the A&E Departments or nearest health clinic whichever is closer to their home. – (Ministry of Health Public Awareness Programme)
Datin Paduka Dr Lim Meng Keang and Dr Yew Teik Guan Specialist Paediatricians – RIPAS
