Facts About Hand, Foot And Mouth Disease (HFMD) | Coxsackie

Hand, foot and mouth disease (HFMD) is a human syndrome caused by intestinal viruses of the Picornaviridae family. The most common strains causing HFMD are Coxsackie A virus and Enterovirus 71 (EV71).

HFMD usually affects infants and children, and is quite common. It is moderately contagious and is spread through direct contact with the mucus, saliva, or feces of an infected person. It typically occurs in small epidemics in nursery schools or kindergartens, usually during the summer and autumn months. The usual incubation period is 3-7 days.

It is extremely uncommon in adults; however, still a possibility. Most adults have strong enough immune systems to defeat the virus, but those with immune deficiencies are very susceptible. HFMD is not to be confused with foot-and-mouth disease (also called hoof-and-mouth disease), which is a disease affecting sheep, cattle, and swine, and which is unrelated to HFMD (but also caused by a member of the Picornaviridae family).

What is hand, foot, and mouth disease (HFMD)?

Not to be confused with foot and mouth disease, a fatal condition known to affect livestock (also called hoof-and-mouth), HFM is basically a common viral infection caused by the Coxsackie virus A16, enterovirus EV 71 and other enteroviruses.

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 skin 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.



HFMD Illness

* The disease usually begins with a fever, poor appetite, malaise (feeling vaguely unwell), and often with a sore throat.

* One or 2 days after fever onset, painful sores usually develop in the mouth. They begin as small red spots that blister and then often become ulcers. The sores are usually located on the tongue, gums, and inside of the cheeks.

* A non-itchy skin rash develops over 1–2 days. The rash has flat or raised red spots, sometimes with blisters. The rash is usually located on the palms of the hands and soles of the feet; it may also appear on the buttocks and/or genitalia.

* A person with HFMD may have only the rash or only the mouth sores.

What causes hand, foot, and mouth disease (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.

Coxsackievirus A16 is the most common cause of HFMD, but other coxsackieviruses have been associated with the illness.

Enteroviruses, including enterovirus 71, have also been associated with HFMD and with outbreaks of the disease.



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 (How it is spread)?

Yes, HFMD is moderately contagious. A person is most contagious during the first week of the illness.

* Infection is spread from person to person by direct contact with infectious virus. Infectious virus is found in the nose and throat secretions, saliva, blister fluid, and stool of infected persons (The virus may continue to be excreted in the stools of infected persons up till 1 month). The virus is most often spread by persons with unwashed, virus-contaminated hands and by contact with virus-contaminated surfaces.

* Infected persons are most contagious during the first week of the illness.

* The viruses that cause HFMD can remain in the body for weeks after a patient's symptoms have gone away. This means that the infected person can still pass the infection to other people even though he/she appears well. Also, some persons who are infected and excreting the virus, including most adults, may have no symptoms.

* HFMD is not transmitted to or from pets or other animals.

How does HFM disease spread?

The disease spreads through person-to-person contact with nose and throat discharges, saliva, fluid from blisters or the stool of a person with the infection.

It can also be transmitted through shared items such as toys and utensils. That’s why outbreaks frequently take place in childcare centres, nurseries and pre-schools as these places are packed with young children in close proximity and sharing various items. It may also spread from playgrounds and shopping malls.

Children with HFMD disease are most contagious when they have mouth ulcers during the first week of the illness.

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.

Factors That Increase the Chance for Infection or Disease

* Everyone who has not already been infected with an enterovirus that causes HFMD is at risk of infection, but not everyone who is infected with an enterovirus becomes ill with HFMD.

* HFMD occurs mainly in children under 10 years old but can also occur in adults. Children are more likely to be at risk for infection and illness because they are less likely than adults to have antibodies to protect them. Such antibodies develop in the body during a person’s first exposure to the enteroviruses that cause HFMD.

* Infection results in immunity to (protection against) the specific virus that caused HFMD. A second case of HFMD may occur following infection with a different member of the enterovirus group.

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.

What are the symptoms of HFMD disease?

The symptoms include:

# Ulcers in a child’s mouth, especially on the tongue, gums and inside of the cheeks. These ulcers can be painful and may last seven to 10 days.

# Blisters or rashes on the hands and feet, although they may appear on the trunk and other parts of the body as well. Unlike chickenpox, these rashes rarely itch.

# Low grade fever (38° C to 39°C).

Though it may be life-threatening in a few cases, HFMD disease is generally a self-limiting illness.

Presently, there is no specific treatment for it. Often, symptomatic treatments such as fluids, painkillers and fever relievers are used to ease a patient’s discomfort until the disease goes away on its own.

Prompt medical care is required if you suspect your child has been infected.

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.

How is HFMD treated?

Presently, there is no specific effective antivirul 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.

Prevention For Parents

* A specific preventive for HFMD is not available, but the risk of infection can be lowered by following good hygiene practices.

* Good hygiene practices that can lower the risk of infection include
o Washing hands frequently and correctly and especially after changing diapers and after using the toilet
o Cleaning dirty surfaces and soiled items, including toys, first with soap and water and then disinfecting them by cleansing with a solution of chlorine bleach (made by adding 1 tablespoon of bleach to 4 cups of water)
o Avoiding close contact (kissing, hugging, sharing eating utensils or cups, etc.) with persons with HFMD

Vaccination Recommendations

* No vaccine is available to protect against the enteroviruses that cause HFMD.

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.

Read also Hand, Foot, Mouth Disease - HFMD And Pregnancy

Complications

* Complications from the virus infections that cause HFMD are not common, but if they do occur, medical care should be sought.

* Viral or "aseptic meningitis can rarely occur with HFMD. Viral meningitis causes fever, headache, stiff neck, or back pain. The condition is usually mild and clears without treatment; however, some patients may need to be hospitalized for a short time.

* Other more serious diseases, such as encephalitis (swelling of the brain) or a polio-like paralysis, result even more rarely. Encephalitis can be fatal.

* There have been reports of fingernail and toenail loss occurring mostly in children within 4 weeks of their having hand, foot, and mouth disease (HFMD). At this time, it is not known whether the reported nail loss is or is not a result of the infection. However, in the reports reviewed, the nail loss has been temporary and nail growth resumed without medical treatment.

Trends and Statistics

* Individual cases and outbreaks of HFMD occur worldwide. In temperate climates, cases occur more often in summer and early autumn.

* Since 1997, outbreaks of HFMD caused by enterovirus 71 have been reported in Asia and Australia.

* HFMD caused by coxsackievirus A16 infection is a mild disease. Nearly all patients recover in 7 to 10 days without medical treatment.

* HFMD caused by enterovirus 71 has shown a higher incidence of neurologic (nervous system) involvement.

* Fatal cases of encephalitis (swelling of the brain) caused by enterovirus 71 have occurred during outbreaks.

References:
Centers for Disease Control and Prevention
Sarawak Health Department