Hand, Foot & Mouth Disease What is hand, foot, and mouth disease (HFMD)? Hand, foot, and mouth disease (HFMD) is a common illness of infants and children caused by a virus. It most often occurs in children under 10 years old. It is characterized by fever, sores/ulcers in the mouth, and a rash with blisters. The blisters may appear in the mouth, palms of the hands and soles of the feet. The rashes may also appear on buttocks and on the legs and arms. The ulcers in the mouth usually appear on the tongue, the sides of the cheeks, gums or near the throat. What causes HFMD? The most common causes of Hand, Foot and Mouth disease are coxsackie virus A16, enterovirus 71 (EV71) and other enteroviruses. The enterovirus group includes polioviruses, coxsackieviruses, echoviruses and other enteroviruses. When and where does HFMD occur? Individual cases and outbreaks of HFMD occur worldwide, more frequently in summer and early autumn (in temperate countries). In the recent past, major outbreaks of HFMD attributable to enterovirus EV71 have been reported in Malaysia in 1997 and in Taiwan in 1998. HFMD is endemic in Malaysia and occurs every year. In Sarawak, the number of cases of HFMD tends to increase from February to June. Is HFMD serious? HFMD caused by coxsackie virus A16 infection is a mild disease and nearly all patients recover within 7 to 10 days. Complications are uncommon. HFMD caused by Enterovirus EV71 may be associated with neurological complications such as aseptic meningitis and encephalitis. Cases of fatal encephalitis which occurred during outbreaks of HFMD in Malaysia in 1997 and in Taiwan in 1998 were caused by EV71. Is HFMD contagious? Yes, HFMD is moderately contagious. A person is 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. How soon will someone become ill after getting infected? The usual period from infection to onset of symptoms (incubation period) is 3 to 7 days. Fever is often the first symptom of HFMD followed by blister/rash. 1 What are the clinical signs and symptoms? HFMD begins with a mild fever, poor appetite, malaise ("feeling sick"), and frequently a sore throat. One or 2 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 1 to 2 days with flat or raised red spots, some with blisters on the palms of the hand and the soles of the feet. A person with HFMD may have only the rash or the mouth ulcers. Blister on the palms of the hands Blister on the soles of the feet. Blister then become ulcer on the inner gums Blister on the dorsum of the feet Source of pictures: http//:tray.dermatology,uiowa.edu/Coxsack01.htm How is hand, foot and mouth disease diagnosed? Hand, foot and mouth disease is usually diagnosed based on a complete history and physical examination of your child. It is generally suspected on the appearance of blister-like rash on hands, feet and mouth in children with a mild febrile illness. Usually, the 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. A throat and/or blister swab collected preferably within 2 days of onset of HFMD may be sent to a laboratory to determine which enterovirus caused the illness. 2 How is HFMD treated? Presently, there is no specific effective antiviral drugs and vaccine available for the treatment of HFMD. Symptomatic treatment is given to provide relief from fever, aches, or pain from the mouth ulcers. Dehydration is a concern because the mouth sores may make it difficult and painful for children to eat and drink. Should their affected children be having fever, the parents are advised to dress their children in light, thin clothing, to do tepid sponging with water (room temperature) as often as necessary, and to expose them under the fan. Taking enough liquids is very important apart from body temperature monitoring. Who is at risk for 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 virus belonging to 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 the virus as well. 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. Strict adherence to generally recommended good hygienic practices by the pregnant woman might help to decrease the risk of infection during pregnancy and around the time of delivery. HMFD in childcare facilities HFMD outbreaks occurring in childcare facilities usually coincide with an increased number of cases in the community. Additional cases may occur since the virus may be excreted in the stools of infected person for weeks after the symptoms subsided. There is no specific recommendation regarding the exclusion of children with HFMD from childcare programs, schools, or other group settings. If there is an evidence of transmission in any childcare setting (2 or more cases detected within a period of 7 days), Sarawak Health Department will close the premise for a period of 14 days. 3 During an outbreak, everyone is advised: • To always practise good hand washing technique and good personal hygiene, • Thoroughly wash and disinfect contaminated items and surfaces using diluted solution of chlorine-containing bleach (10% concentration). • Daily examination of children for HFMD; if positive, call parents to bring child home and don’t bring child back to childcare center till recover. • Disinfect premises • Proper handwashing demo to children Can HFMD be prevented? Specific prevention for HFMD or other non-polio enterovirus infections is not available, but the risk of infection can be lowered by good hygienic practices. Preventive measures include: a. Frequent hand washing, especially after diaper changes, after using toilet and before preparing food, b. Maintain cleanliness of house, child care center, kindergartens or schools and its surrounding, c. Cleaning of contaminated surfaces and soiled items with soap and water, and then disinfecting them with diluted solution of chlorine-containing bleach (10% concentration), d. Parents are advised not to bring young children to crowded public places such as shopping centers, cinemas, swimming pools, markets or bus stations, e. Bring children to the nearest clinic if they show signs and symptoms. Refrain from sending them to child care centers, kindergartens or schools. f. Avoidance of close contact (kissing, hugging, sharing utensils, etc.) with children having HFMD illness to reduce of the risk of infection. HFMD In Sarawak Hand-foot-mouth disease (HFMD) is endemic in Sarawak. Prior to 1997, there was no baseline data on the epidemiology of HFMD in Sarawak. This is due to the fact that HFMD is not a notifiable disease in Malaysia and in Sarawak. Between 15 April and 30 June 1997, 31 previously healthy infants and young children in Sarawak died after a short febrile illness against a background of an outbreak of HFMD in the State. Sibu was badly affected during this outbreak as 11 of the death cases were reported from Sibu followed by Sarikei with 7 death cases. Surveillance of HFMD was initiated by Sarawak Health Department during this outbreak of sudden deaths among young children in Sarawak from 6 June 1997. The surveillance was stopped in December 1997. However, in 1998, following a report of increased cases of HFMD seen in private paediatrician clinics, sentinel surveillance of HFMD in collaboration with UNIMAS was re-started in the State involving urban public and private clinics in Kuching, Sibu and Miri and 3 government hospitals in Sarawak. When the enterovirus outbreak was reported in Taiwan in May 1998, the surveillance of outpatient and inpatient HFMD was extended to all government health facilicities in the state in June 1998. 4 Epidemiological data from the sentinel surveillance conducted by Sarawak Health Department and UNIMAS shows a three yearly EV71 epidemic cycle and predicted the occurrence in 2006. Hence, a reminder was sent to our division/district health offices in 2005 to intensify surveillance for HFMD and increase health promotion and education activities particularly at children care centers and institutions. In 2006, the surveillance data does not depict any unusual increase in the number of HFMD cases in the State. However, in Sibu, the cases reported by week are; week 1 (no case), week 2 (3 cases), week 3 (10 cases), week 4 (57 cases), week 5 (54 cases), week 6 (26 cases) and week 7 (24 cases). As of 2 March 2006, there are four notified HFMD deaths in Sibu Hospital. Out of that, only 2 cases found to be positive for EV71. Epidemic Curve HFMD IN SARAWAK IN 1998 0 10 20 30 40 50 60 1 4 7 10 13 16 19 22 25 28 31 34 37 40 43 46 49 52 EPID WEEK NUMBER OF CASES HFMD IN SARAWAK IN 2000 0 20 40 60 80 100 120 140 160 180 200 1 5 9 13 17 21 25 29 33 37 41 45 49 EPID WEEK NUMBER OF CASES Chart 1 : HFMD Cases in 1998 Chart 2 : HFMD Cases in 2000 HFMD IN SARAWAK IN 2003 0 50 100 150 200 250 300 350 400 1 4 7 10 13 16 19 22 25 28 31 34 37 40 43 46 49 52 EPID WEEK NUMBER OF CASES HFMD IN SARAWAK IN 2005 0 50 100 150 200 250 300 1 4 7 10 13 16 19 22 25 28 31 34 37 40 43 46 49 52 EPID WEEK NUMBER OF CASES Chart 3 : HFMD Cases in 2003 Chart 4 : HFMD Cases in 2005 5 Areas affected by HFMD. HFMD is endemic in Sarawak with yearly occurrence. Kuching, Sibu, Miri and Bintulu have been noted to be “hotspots” for HFMD. Age Group Affected by HFMD In Sarawak. HFMD mainly affect children of below 10 years old. Deaths associated with HFMD mostly occur among children below 6 years old. What Sarawak Health Department Have Done? The activities carried out by the department are: Reduction of Transmission  Initially every department are advised voluntary closure by the operators of child care centers and kindergartens as well as advise them to carry out cleaning, disinfection of their premises, furniture, equipment, toys etc. As of 24 February 2006 issue closure orders to operators of childcare centers, kindergartens and primary schools it they found to have 2 or more cases within 7 days. On 3 March 2006, Ministry of Health Malaysia announce directive for statewide closure for childcare centers (TASKA, TADIKA, TABIKA etc) or similar premises for 2 week with immediate effect.  Advise child care centre operators to do daily inspection of hands, feet and mouth of their enrolled children for rashes and ulcers  Advise parents with affected children to bring them to see a doctor immediately  Issuance of instruction to all Divisional Health Officers to conduct HFMD briefing to all medical practitioners in the public and private sectors on or before 6 March 2006, with emphasize on the importance of immediate notification, early referral and criteria for admission of potentially severe HFMD so as to minimize the scale and duration of the current HFMD outbreak.  Mobilisation and deployment of all public health staff within the state (intra and inter division) to conduct field investigation of all reported HFMD cases. To seek assistance from other states/MOH if necessary for additional health staff.  Screening clinics- all public and private health care practitioners are advised to notify all cases of HFMD seen to their respective Divisional Operations Room daily. They are also advised to segregate these patients from the general out- patient waiting area and wherever possible, to attend to these cases immediately. Health Education Activities  Supply HFMD health education pamphlets for distribution by the operators of the child care centers/kindergartens to every parent of their enrolled children 6  Carry out radio talks in Bahasa Melayu, English, Mandarin, Iban and Bidayuh through RTM for state-wide broadcast on HFMD  Print and disseminate health education pamphlets in 4 languages (English, Bahasa Melayu, Mandarin, Iban) Enforcement of Legislation  Statewide closure of all childcare centers/kindergartens was announced by the Minister of Health Malaysia on 3 rd March 2006.  Delegation of authority by the State Health Director, Sarawak to the Divisional Health Officers to close tadika/taska and kindergartens using Section 7(2) of the Protection of the Public Health Ordinance 1999 Sarawak. Interagency Assistance  Mobilisation of health teams at district and divisional level to conduct sanitary inspection, physical examination of all enrolled children at all registered child care centers as per list of child care centers furnished by the relevant agencies  Request for the assistance and co-operation of Hornbill Skyways to assign a standby helicopter in Kuching, Sibu and Miri to facilitate immediate medical evacuation of ill children with HFMD to any of the three designated hospitals (SGH, Kuching, Sibu and Miri)  Should the number of cases continue to increase in the State, to recommend to the Education Department for the immediate closure of all primary schools for 14 days Management Protocols  Observation and isolation facilities –instructions have been issued to all government hospitals to set up special isolation wards/cubicles to accommodate all admitted HFMD cases including referrals by private or health clinics.  Distribute the revised HFMD management protocols/guidelines to all practitioners throughout the state (Kuching Division done on 28 Feb. 2006)  Remind all hospital staff especially those working in the isolation wards/cubicles and out-patient clinics to observe strict universal precautions Is Sarawak Safe To Visit? Sarawak is still very safe to visit. The HFMD situation is very much under control. Nevertheless, visitors who bring along their young children to Sarawak are advised to take extra precautionary measures and to practise good personal hygiene at all time s especially good hand washing technique. 7 Case Notifications Anybody can notify the Sarawak Health Department about any case detected via phone call, fax or e-mail or report direct to the nearest Health Center within the community. Notification Form can be downloaded in PDF format as attached. Notification Form Further Inquiries on HFMD Information In Sarawak: Hotline : 60 82 246350 Fax : 60 82 247254 E-mail: opsroom@sarawak.health.gov.my 8 OPERATION ROOM CONTACT NUMBER FOR HFMD IN SARAWAK 2006 NO. DIVISION/ DISTRICT TEL. NUMBER FAX NUMBER E-MAIL 1 KUCHING +60 82 250037 +60 82 414542 opsroom_kch@health.gov.my 2 BAU +60 82 763116 +60 82 762381 3 LUNDU +60 82 735311 +60 82 734652 4 SAMARAHAN +60 82 673626 +60 82 673632 opsroom_shan@health.gov.my 5 SERIAN +60 82 874311 +60 82 876811 6 SIMUNJAN +60 82 803612 +60 82 803823 7 SRI AMAN +60 83 322176 +60 83 323220 opsroom_sriaman@health.gov.my 8 LUBOK ANTU +60 83 584105 +60 83 584080 9 BETONG +60 83 472116 +60 83 471870 opsroom_btong@health.gov.my 10 SARATOK +60 83 437379 +60 83 437886 11 SARIKEI +60 84 651077 +60 84 658598 opsroom_skei@health.gov.my 12 JULAU +60 84 734067 +60 84 734253 13 PAKAN +60 84 717225 +60 84 717225 14 MERADONG +60 84 693333 +60 84 693494 15 SIBU +60 84 345862 +60 84 348284 opsroom_sibu@health.gov.my 16 KANOWIT +60 84 752333 +60 84 752682 17 MUKAH +60 84 873201 +60 84 872459 opsroom_mkh@health.gov.my 18 DALAT +60 84 863087 +60 84 864269 19 MATU +60 84 832236 +60 84 832236 20 DARO +60 84 823744 +60 84 823886 21 KAPIT +60 84 796471 +60 84 796454 opsroom_kapit@health.gov.my 22 SONG +60 84 777634 +60 84 777514 23 BELAGA +60 86 461545 +60 86 461508 24 BINTULU +60 86 315235 +60 86 339094 opsroom_btu@health.gov.my 25 TATAU +60 86 584619 +60 86 584619 26 MIRI +60 85 824260 +60 85 424235 opsroom_miri@health.gov.my 27 MARUDI +60 85 755511 +60 85 755217 28 LIMBANG +60 85 211046 +60 85 214652 opsroom_lbg@health.gov.my 29 LAWAS +60 85 283781 +60 85 284807 9 . Hand, Foot & Mouth Disease What is hand, foot, and mouth disease (HFMD)? Hand, foot, and mouth disease (HFMD) is a common illness of infants. pictures: http//:tray.dermatology,uiowa.edu/Coxsack01.htm How is hand, foot and mouth disease diagnosed? Hand, foot and mouth disease is usually diagnosed based on a complete history and physical. The ulcers in the mouth usually appear on the tongue, the sides of the cheeks, gums or near the throat. What causes HFMD? The most common causes of Hand, Foot and Mouth disease are coxsackie