hfmd presentation

HFMDHFMD(Hand-Foot-Mouth (Hand-Foot-Mouth

Disease)Disease)An emerging diseaseAn emerging disease

Wong Ann ChengWong Ann Cheng

MD (UKM) MRCPCH (UK)MD (UKM) MRCPCH (UK)

Wednesday October 8, 2008Sarawak on high alert for HFM disease

KUCHING: Sarawak is on high alert for hand, foot and mouth disease following the detection of the EV71 virus, which causes a more severe form of the disease.Deputy Chief Minister Tan Sri Dr George Chan said the situation was under control and steps were being taken to prevent an outbreak.“We monitor for hand, foot and mouth disease all the time. “As soon as we detected EV71 in the state, we went on high alert because we know this virus can cause death,” he told a press conference at his office here yesterday.A total of 5,686 cases have been reported in Sarawak as of Saturday, compared with 6,286 in the same period last year.On Sept 30, a four-year-old child in Sibu died from suspected hand, foot On Sept 30, a four-year-old child in Sibu died from suspected hand, foot and mouth disease.and mouth disease.

SPOT DIAGNOSIS ?

MythMyth

Foot and mouth disease Hand, foot and mouth disease

Returning Coxsackie Virus Threatens

Sarawak The Star, March 30,

2000

Kuala Lumpur (Malaysia) - All hospitals and clinics in Sarawak have been directed to step up surveillance following the death of two children from symptoms similar to the Coxsackie outbreak three years ago. A Coxsackie outbreak in Sarawak in early 1997 killed 29 children, mostly below five years old.

Media insistence of using “Coxsackie

Outbreak” had misled the public. Virus later

identified as EV71. Subsequent lots of effort

to correct this misconception

The factsThe facts HFMD is typically a benign and HFMD is typically a benign and

common illness of infants and common illness of infants and children children

It caused by human enterovirus. It caused by human enterovirus. Often in children under 10 years old. Often in children under 10 years old. It also affect older children and adult It also affect older children and adult

but with milder symptomsbut with milder symptoms

http://www.cdc.gov/ncidod/dvrd/revb/enterovirus/hfhf.htm

Symptoms (Symptoms (case case definitiondefinition))

Usually begins withUsually begins with fever fever, poor appetite , poor appetite and malaise, often with sore throatand malaise, often with sore throat

After 1-2 days after onset of fever, After 1-2 days after onset of fever, sores/ulcerssores/ulcers develop in the mouth, side of develop in the mouth, side of cheek, gum and tonguecheek, gum and tongue

The The non-itchy skin rash/ maculopapular or non-itchy skin rash/ maculopapular or vesicularvesicular appears on palms of the hands appears on palms of the hands and soles of the feet. and soles of the feet.

The rashes may also appear on buttocks The rashes may also appear on buttocks and on the legs and arms. and on the legs and arms.

http://www.cdc.gov/ncidod/dvrd/revb/enterovirus/hfhf.htm

DifferentialsDifferentials

Aphthous ulcersHerpetic gingivostomatitis

Herpangina

EnterovirusEnterovirus Human enteroviruses comprise one Human enteroviruses comprise one

genus in the family of Picornaviridaegenus in the family of Picornaviridae Enterovirus genus that infect humans:Enterovirus genus that infect humans:

PoliovirusPoliovirus Coxsackievirus ACoxsackievirus A Coxsackievirus BCoxsackievirus B EchovirusEchovirus Enterovirus 68-71Enterovirus 68-71

HFMD are due to coxsackie virus A16, HFMD are due to coxsackie virus A16, A5, A9, A10, B2, B5 and EV71A5, A9, A10, B2, B5 and EV71

Coxsackie virusCoxsackie virus Coxsackie A16 is a frequently encountered Coxsackie A16 is a frequently encountered

pathogen in cases of HFMD occurring throughout pathogen in cases of HFMD occurring throughout the yearthe year

Clinical course usually uneventful, with full Clinical course usually uneventful, with full recoveryrecovery

Fatal cases of Cox A16 rareFatal cases of Cox A16 rare Literature search only revealed 3 fatal cases since Literature search only revealed 3 fatal cases since

1963. All the cases were infant1963. All the cases were infant Wright et al: 10-month-old with respiratory infectionWright et al: 10-month-old with respiratory infection Goldberg et al: 7-month-old with grunting and tongue Goldberg et al: 7-month-old with grunting and tongue

ulcerulcer Wang et al: 15-month-old with HFMD complicated with Wang et al: 15-month-old with HFMD complicated with

myocarditis and intractable shockmyocarditis and intractable shock

Enterovirus 71 (EV71)Enterovirus 71 (EV71)

Responsible for sporadic outbreakResponsible for sporadic outbreak More severe courseMore severe course Maybe complicated by meningitis, Maybe complicated by meningitis,

encephalitis and neurogenic encephalitis and neurogenic pulmonary oedemapulmonary oedema

In Taiwan, based on 1998 epidemic, In Taiwan, based on 1998 epidemic, significant difference between Cox significant difference between Cox A16 and EV71 are the higher fever A16 and EV71 are the higher fever >39ºC and >3 days in EV71>39ºC and >3 days in EV71

Phylogenetic study of Phylogenetic study of EV71EV71

EV71 strains divided into genogroup A, B, EV71 strains divided into genogroup A, B, CC

Further subdivided to (4, 8-10)Further subdivided to (4, 8-10) four genetic lineages of EV71 have been

prevalent in the Asia-Pacific region since 1997, including two previously undescribed genogroups (B3 and B4).

Genogroups of EV71 isolatedGenogroups of EV71 isolated during each during each major outbreak are major outbreak are genetically distinctgenetically distinct from each otherfrom each other

Molecular Epidemiology

Epidemiological dataEpidemiological data

Most HFMD patients were very young Most HFMD patients were very young children (<4 years old) with a peak children (<4 years old) with a peak incidence at incidence at 1 year1 year..

MaleMale outnumber female 1.7 to 1 outnumber female 1.7 to 1 Predominance has also been observed Predominance has also been observed

in other enteroviral infectionin other enteroviral infection Suggest possible susceptibility at Suggest possible susceptibility at host host

genetic levelgenetic level

Emerging Infectious Diseases • Vol. 9, No. 1, January 2003

Epidemiological dataEpidemiological data Large outbreak maybe due to changes in the Large outbreak maybe due to changes in the

viral factorsviral factors Different strain of EV71 were obtained from Different strain of EV71 were obtained from

the each outbreak the each outbreak Genetic determinant of virulence still unclearGenetic determinant of virulence still unclear Co-infection with second virus had been Co-infection with second virus had been

suggested as possible pathogenic factor, suggested as possible pathogenic factor, supported by concomitant isolation of supported by concomitant isolation of subgenus B adenovirus from 3 fatal cases in subgenus B adenovirus from 3 fatal cases in Sarawak.Sarawak.

Consideration of unusual medications, Consideration of unusual medications, treatment or dietary exposure contributed to treatment or dietary exposure contributed to fatality found no conclusive evidence.fatality found no conclusive evidence.

Emerging Infectious Diseases • Vol. 9, No. 1, January 2003

Global EpidemiologyGlobal Epidemiology

Enterovirus 71 (EV71) infection was Enterovirus 71 (EV71) infection was first reported in 1969 in California, first reported in 1969 in California, United States; United States;

subsequent outbreaks were reported subsequent outbreaks were reported in worldwide distributionin worldwide distribution

Mainly during summer and early Mainly during summer and early autumn months in temperate autumn months in temperate countries while prevalent year round countries while prevalent year round in tropical climatesin tropical climates

Recorded outbreak of EV7120082008 ChinaChina 27 500 HFMD, 34 died27 500 HFMD, 34 died

20062006 MalaysiaMalaysia 14 253 HFMD, 13 died14 253 HFMD, 13 died

20052005 ThailandThailand 4646 HFMD4646 HFMD

20032003 MalaysiaMalaysia Most self limited, few neurological deathMost self limited, few neurological death

20002000 SingaporeSingapore

Malaysia, Malaysia, TaiwanTaiwan

3526 cases 83% EV71 4 died of 3526 cases 83% EV71 4 died of pneumonia, encephalitispneumonia, encephalitis

Also outbreakAlso outbreak

19981998 TaiwanTaiwan >300 000 HFMD, 386 ICU due to >300 000 HFMD, 386 ICU due to encephalitis, 78 diedencephalitis, 78 died

19971997 MalaysiaMalaysia 2140 patients 31 died2140 patients 31 died

19871987 USUS 45 patients high rate of meningitis and 45 patients high rate of meningitis and paralysisparalysis

19871987 PhiladelphiaPhiladelphia 5 polio-like disease, 1 brain stem 5 polio-like disease, 1 brain stem encephalitisencephalitis

19861986 AustraliaAustralia 140 cases, 61 HFMD, 34 meningitis and 140 cases, 61 HFMD, 34 meningitis and encephalitisencephalitis

19861986 Hong KongHong Kong 5 HFMD with flaccid monoplegia5 HFMD with flaccid monoplegia

19791979 FranceFrance 5 cases with CNS signs5 cases with CNS signs

19781978 HungaryHungary 1550 HFMD, 826 meningitis, 724 1550 HFMD, 826 meningitis, 724 encephalitis, 45 deathencephalitis, 45 death

19781978 JapanJapan 692 HFMD, meningitis, encephalitis692 HFMD, meningitis, encephalitis

19771977 New YorkNew York 29 HFMD, meningitis, encephalitis, 29 HFMD, meningitis, encephalitis, monoparesismonoparesis

19751975 BulgariaBulgaria 705 cases, 149 paralysis, 44 died705 cases, 149 paralysis, 44 died

Large Outbreaks of HFMD in Large Outbreaks of HFMD in AsiaAsia

Japan 1978

36,301/ ?

Taiwan 1998

129,106/ 78

Malaysia1997

5,999/ 31

Singapore 2000

> 4,000/ 7

Thailand2005

4,646/ 0

Malaysia 2006

14,253/ 13

China2008

27,500/34

An emerging infectious An emerging infectious diseasedisease

Dengue

Typhoid

JE

Malaria

HFMD

Melioidosis

Hepatitis

HIV

Tuberculosis

Leptospirosis

Chikungunya

Malaysia top five notifiable Malaysia top five notifiable diseases in 2006diseases in 2006

1.1. TuberculosisTuberculosis

2.2. Food poisoningFood poisoning

3.3. Dengue feverDengue fever

4.4. Hand, foot and mouth diseaseHand, foot and mouth disease

5.5. MalariaMalaria

HFMD in SarawakHFMD in Sarawak HFMD is endemic in Sarawak.HFMD is endemic in Sarawak. Prior to 1997, no baseline data on the Prior to 1997, no baseline data on the

epidemiology of HFMD in Sarawak as it is not a epidemiology of HFMD in Sarawak as it is not a notifiable disease. notifiable disease.

Between 15 April and 30 June 1997, 31 Between 15 April and 30 June 1997, 31 previously healthy infants and young children in previously healthy infants and young children in Sarawak died after a short febrile illness Sarawak died after a short febrile illness against a background of an outbreak of HFMD against a background of an outbreak of HFMD in the State. in the State.

Sibu was badly affected during this outbreak as Sibu was badly affected during this outbreak as 11 of the death cases were reported from Sibu 11 of the death cases were reported from Sibu followed by Sarikei with 7 death cases. followed by Sarikei with 7 death cases.

http://www.sarawak.health.gov.my/hfmd.htm

HFMD in SarawakHFMD in Sarawak Surveillance of HFMD was initiated by Sarawak Surveillance of HFMD was initiated by Sarawak

Health Department from 6 June 1997 till Health Department from 6 June 1997 till December 1997. December 1997.

However, in 1998, following a report of increased However, in 1998, following a report of increased cases of HFMD seen in private paediatrician cases of HFMD seen in private paediatrician clinics, sentinel surveillance of HFMD in clinics, sentinel surveillance of HFMD in collaboration with UNIMAS was re-started in the collaboration with UNIMAS was re-started in the State involving urban public and private clinics State involving urban public and private clinics in Kuching, Sibu and Miri and 3 government in Kuching, Sibu and Miri and 3 government hospitals in Sarawak. hospitals in Sarawak.

When the enterovirus outbreak was reported in When the enterovirus outbreak was reported in Taiwan in May 1998, the surveillance of Taiwan in May 1998, the surveillance of outpatient and inpatient HFMD was extended to outpatient and inpatient HFMD was extended to all government health facilicities in the state in all government health facilicities in the state in June 1998. June 1998.


List of HFMD Sentinel Surveillance Clinics in Sarawak ( 2008 )

No. Clinic Location

1 T.Y Wee Specialist Clinic For Children Kuching

2 Bibiana Teo's Specialist Clinic Kuching

3 KK Jalan Masjid Kuching

4 KK Kota Sentosa Kota Sentosa

5 KK Tanah Puteh Pending, Kuching

6 KK Kota Samarahan Samarahan

7 Betty Kong's Clinic Sibu

8 K.T Ting Specialist Clinic For Children Sibu

9 Sibu Polyclinic Sibu

10 Sarikei Polyclinic Sarikei

11 Dr Chen WS Child Specialist Miri

Sarawak Surveillance Sarawak Surveillance programmeprogramme

EV71 outbreaks has occurred every 3 years EV71 outbreaks has occurred every 3 years in Sarawak – 1997, 2000, 2003, 2006( as in Sarawak – 1997, 2000, 2003, 2006( as predicted)predicted)

The shape of HFMD epidemiological curves The shape of HFMD epidemiological curves are influence by social factors such as media are influence by social factors such as media and people movements during major public and people movements during major public holidays (especially Gawai)holidays (especially Gawai)

Only EV71 causes large outbreakOnly EV71 causes large outbreak The genogroups of EV71 isolated during The genogroups of EV71 isolated during

major outbreak are genetically distinct from major outbreak are genetically distinct from each other, but all are first identified in each other, but all are first identified in Sarawak and some had spread to Peninsular Sarawak and some had spread to Peninsular Malaysia, Singapore and AustraliaMalaysia, Singapore and Australia

Podin et al; licensee BioMed Central Ltd.

Sarawak Surveilance Sarawak Surveilance programme programme

The transmission of EV71 in a The transmission of EV71 in a susceptible cohort is extremely rapid susceptible cohort is extremely rapid with only 4-6 weeks between first with only 4-6 weeks between first identification of an EV71 case in our identification of an EV71 case in our sentinel clinics to peaking. sentinel clinics to peaking.

These outbreaks can drag on for many These outbreaks can drag on for many months after they peaked, especially if months after they peaked, especially if the outbreak has not reached baseline the outbreak has not reached baseline before people start travelling or moving before people start travelling or moving about in the state (eg State elections in about in the state (eg State elections in 2006, followed by Gawai holidays). 2006, followed by Gawai holidays).

Podin et al; licensee BioMed Central Ltd.

HFMD CASES FOR SARAWAK, 2006

4155398105

193

435

633

121212341345

1282

1017

567

332265232

156198228239220

274271253315

403412397431326310322

17411214785979563403133223729361426171723

0100200300400500600700800900

10001100120013001400

1 4 7 10 13 16 19 22 25 28 31 34 37 40 43 46 49 52

Epid Week

Cas

es

Sarawak centre for disease control (CDC)

HFMD CASES FOR SARAWAK, 2008

30

5869 75

121

88

139

183172175

11610410810598

78 81

516154484749

79 748795

154

197

252

315

385

428

320

254

192

245

189198

142

0

100

200

300

400

500

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 2021222324 2526 27282930 31323334 3536 37383940

EPID WEEK


HFMD CASES FOR KUCHING DIVISION 2008

3 6 6 7 11 7

26 28

49

2619 18 21 23

13 1219

11 15 9 7 210 16 17

28

49 51

83

131

181

251

270

193

143

99

113

8976

47

0

25

50

75

100

125

150

175

200

225

250

275

300

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40

EPID WEEK


HFMD Cases ( Death )

Year No.'s Cases No.'s Death

1997 2628 31

1998 455 0

1999 65 0

2000 3560 3

2001 667 0

2002 621 1

2003 2113 4

2004 56 0

2005 3558 0

2006 14875 13

2007 6571 0

20085716 ( Till 4th October

2008 )1

2009 ? ?

Total 40885 53


Deaths of children during an outbreak of HFMD in Sarawak, clinical and pathological characteristics

of the disease. April -June 1997, 29 previously healthy children

aged <6 years (median, 1.5 years) in Sarawak, died of rapidly progressive cardiorespiratory failure during an outbreak of HFMD caused primarily by EV71.

Hospitalized after a short illness (median duration, 2 days) that usually included fever (in 100% of case children), oral ulcers (66%), and extremity rashes (62%).

Illness rapidly progressed to include seizures (28%), flaccid limb weakness (17%), or cardiopulmonary symptoms (of 24 children, 17 had CXR showing pulmonary edema, and 24 had ECHO showing left ventricular dysfunction), resulting in cardiopulmonary arrest soon after hospitalization (median time, 9 h).

Chan et al, CID 2000; 31 (September)

Chan et al, CID 2000; 31 (September)

PathologyPathology CNS: CNS:

extensive inflammation of brain stem and extensive inflammation of brain stem and spinal cord. spinal cord.

Lung: Lung: marked pulmonary oedema with focal marked pulmonary oedema with focal

haemorrhagehaemorrhage Heart: Heart:

Normal myocardiumNormal myocardium Virus: Virus:

EV 71 isolated from fresh brain tissue EV 71 isolated from fresh brain tissue (brainstem, C-spinal cord, cerebrum)(brainstem, C-spinal cord, cerebrum)

NOT from heart, lung or other organsNOT from heart, lung or other organsHsueh C, et al. Modern Pathology 2000

suggesting that a central nervous system infection was responsible for the

disease, with the cardiopulmonary dysfunction being neurogenic in origin.

Postulated pathogenesis of severe EV71 infection

EV71 infection classified into EV71 infection classified into 4 stages4 stages

Stage 1Stage 1 Hand, foot and mouth diseaseHand, foot and mouth disease

Stage 2Stage 2 CNS involvementCNS involvement

Stage 3Stage 3 Cardiopulmonary failureCardiopulmonary failure

Stage 4Stage 4 ConvalescenceConvalescence

Malaysian Hand-Foot-Mouth disease guideline

FLOW CHART OF HFMD & HERPANGINA MANAGEMENTFLOW CHART OF HFMD & HERPANGINA MANAGEMENT

Hand,Foot & Mouth DiseaseHand,Foot & Mouth Disease

and Herpangina and Herpangina

Admit if have 1 or more following criteria Admit if have 1 or more following criteria Does not fit admission criteriaDoes not fit admission criteria

Discharge when criteria fulfilled (Page 8)Discharge when criteria fulfilled (Page 8)

<12 months

Vomiting or feeding poorly or dehydration

Fever>38.5C or history for fever >/48 hours

Toxic/ill looking

Inappropriate Tachycardia

Tachypnoea

Poor perfusion

Reduced level of consciousness

Seizures or history of seizures

Reduced motor activity

Increased startle during sleep or when awake

Neurological deficit (limb paralysis, cranial nerve palsy, cerebellar signs, nystagmas)

Signs of meningism (neck stiffness, Kernig’s sign)

Hyperglycaemia > 8.5 mmol/L or total white cell count > 17 500/mL (Page1-2)

Discharge with advice (Page 8)

Clinical Staging (Page 3)• History taking• Physical examination To use standard clerking sheet for HFMD• Investigations (Page 3)

Notification by phone & written form

Stage I

Symptomatic treatmentEnsure adequate hydration

Stage 2

Admit acute cubicle/ HDUFrequent vital signs monitoringEnsure normal hydration statusEmpirical IV antibioticsAggressive control of seizureIntubation & mechanical ventilation when indicatedMeasures to ↓ ICP (adequate cerebral perfusion, IV Mannitol, hyperventilation)IVIG when indicated

(Page 5)

Stage 3

Admit HDU/ICUIntensive monitoringEnsure normal vascular filling pressureEmpirical IV antibioticsOxygenIntubation & mechanical ventilation when indicatedFluid restrictionIV FrusemideCorrection of metabolic acidosisUse of inotropes: Dobutamine, Dopamine, Milrinone, AdrenalineUse of vasodilator: Nitroglycerin

(Page 6 – 7)

Stage 4

Convalescence

Clinical sample typesClinical sample types

Establishing the actual cause of HFMD cases Establishing the actual cause of HFMD cases relies on laboratory identification of the virusrelies on laboratory identification of the virus

Diagnostic techniques include isolating virus Diagnostic techniques include isolating virus in continuous cell lines or detecting viral RNA in continuous cell lines or detecting viral RNA by PCR. by PCR.

Virus isolation remains gold standard; it is Virus isolation remains gold standard; it is cheaper than PCR and more widely used cheaper than PCR and more widely used method particularly in developing countriesmethod particularly in developing countries

Ranges of sample for virus isolation include Ranges of sample for virus isolation include throat and rectal swab, serum and CSF (when throat and rectal swab, serum and CSF (when taken), and vesicles and ulcers when presenttaken), and vesicles and ulcers when present

Ooi, et al. J. Clinical Microbiology, June 2007

Clinical sample typesClinical sample types

Throat swabs single most useful Throat swabs single most useful specimen (49%) specimen (49%)

Vesicles swab (48%) in patient with Vesicles swab (48%) in patient with vesicles; yield greater if 2 or more vesicles; yield greater if 2 or more vesicles swabvesicles swab

Combination of throat and vesicle swab Combination of throat and vesicle swab enable identification of virus (67%)enable identification of virus (67%)

Rectal and ulcer swab identified Rectal and ulcer swab identified additional (8%)additional (8%)


HFMD guidelines

TransmissionTransmission

Nose Throat discharge

Saliva

Fluid fromblisters

Stools

Mode of transmissionMode of transmission

HFMD is moderately contagious. HFMD is moderately contagious. Most contagious during the first week of the Most contagious during the first week of the

illness.illness. The virus can be transmitted from person to The virus can be transmitted from person to

person via person via direct contact with nose and throat discharges, direct contact with nose and throat discharges,

saliva, fluid from blisters, or the stool of infected saliva, fluid from blisters, or the stool of infected persons. persons.

The virus may continue to be excreted in the The virus may continue to be excreted in the stools of infected persons up till 1 month. HFMD is stools of infected persons up till 1 month. HFMD is not transmitted to or from pets or other animals.not transmitted to or from pets or other animals.

TransmissionTransmission

Infants in diapers appears to be the Infants in diapers appears to be the most efficient transmitter.most efficient transmitter.

The virus may be excreted in stools The virus may be excreted in stools for many weeksfor many weeks

The virus can survive for days on The virus can survive for days on formites at room temperatureformites at room temperature

Resistant to many disinfectants – use Resistant to many disinfectants – use chlorinated or iodinized disinfectantchlorinated or iodinized disinfectant

Transmission rateTransmission rate

To household contacts To household contacts 52%52% SiblingsSiblings 84%84% CousinsCousins 83%83% ParentsParents 41%41% GrandparentsGrandparents 28%28% Uncle and auntsUncle and aunts 26%26% Intrafamilial and kindergarden Intrafamilial and kindergarden

transmission major mode of transmission transmission major mode of transmission (both in Taiwan and Singapore)(both in Taiwan and Singapore)

JAMA 2004; 291: 222-7 Pediatr 2002; 109: e88

Risks factorsRisks factors

Children more susceptible due to lack Children more susceptible due to lack of immunityof immunity

Parents sending sick children to centreParents sending sick children to centre Cases not detected and isolatedCases not detected and isolated Close contact among classmates Close contact among classmates Asymptomatic casesAsymptomatic cases Poor personal hygienePoor personal hygiene Contamination of toys, furniture and Contamination of toys, furniture and

premisespremises

ImmunityImmunity

Infection results in immunity to Infection results in immunity to specific virusspecific virus

Second episode may occur following Second episode may occur following infection with other enterovirusinfection with other enterovirus

TreatmentTreatment

No specific antiviral treatment No specific antiviral treatment available for HFMDavailable for HFMD

Mainly supportive.Mainly supportive. ?immunoglobulin?immunoglobulin

Health screening for Health screening for HFMDHFMD

Early detection and prompt isolationEarly detection and prompt isolation Children should be monitored daily, Children should be monitored daily,

noting any unusual symptoms or noting any unusual symptoms or behaviourbehaviour

A child should not be allowed to A child should not be allowed to continue class if he/she appears continue class if he/she appears unwellunwell

Hygiene and sanitationHygiene and sanitation

Hand washing not emphasized Hand washing not emphasized enoughenough

One of the most important route of One of the most important route of transmission of infectiontransmission of infection

Single most effective practice to Single most effective practice to prevent spread of germsprevent spread of germs Practice itPractice it Teach itTeach it Monitor and enforcement of good Monitor and enforcement of good

handwashing practiceshandwashing practices

Outbreak control Outbreak control measuresmeasures

Continue health screeningContinue health screening Ensure high level of personal and Ensure high level of personal and

environmental hygieneenvironmental hygiene Eliminate communal activities where Eliminate communal activities where

all children congregateall children congregate Public educational effortPublic educational effort Closure of kindergarden and school Closure of kindergarden and school

for 10 days to break the chain of for 10 days to break the chain of transmissiontransmission

Poster

Pamphlets

Booklets

MessageMessage From Sarawak, since 1997, EV71 outbreak From Sarawak, since 1997, EV71 outbreak

had occurred every three yearshad occurred every three years Shape of epidemiological curve influence by Shape of epidemiological curve influence by

social factors such as media and people’s social factors such as media and people’s movement during public holidays movement during public holidays

Genogroups of EV71 isolated during each Genogroups of EV71 isolated during each major outbreak are genetically distinct from major outbreak are genetically distinct from each othereach other

Transmission of EV71 in susceptible cohort Transmission of EV71 in susceptible cohort extremely rapid with only 4-6 weeks between extremely rapid with only 4-6 weeks between first identification in sentinel clinics to first identification in sentinel clinics to peakingpeaking

MessageMessage From Singapore, transmission occur mainly From Singapore, transmission occur mainly

in places where preschool children in places where preschool children congregate, and public health measures to congregate, and public health measures to focus on these placesfocus on these places

From Taiwan 1998 outbreak showed that From Taiwan 1998 outbreak showed that HFMD spreads easily through contact HFMD spreads easily through contact leading to mostly symptomatic cases in leading to mostly symptomatic cases in children and mostly asymptomatic cases in children and mostly asymptomatic cases in adultadult

Proper surveillance system works showing Proper surveillance system works showing trends and the current circulating viruses trends and the current circulating viruses and predicting coming outbreak and predicting coming outbreak

ChallengesChallenges

Identify reservoir of EV71 in the Identify reservoir of EV71 in the inter-epidemic periodsinter-epidemic periods

Develop simple rapid diagnostic Develop simple rapid diagnostic tests that can be used to tests that can be used to differentiate EV71 from CA16differentiate EV71 from CA16

ReferencesReferences http://www.sarawak.health.gov.my/hfmd.htmhttp://www.sarawak.health.gov.my/hfmd.htm http://en.wikipedia.org/wiki/HFMDhttp://en.wikipedia.org/wiki/HFMD Chan, L. G., U. D. Parashar, M. S. Lye, et al. 2000. Deaths of children during an Chan, L. G., U. D. Parashar, M. S. Lye, et al. 2000. Deaths of children during an

outbreak of hand, foot and mouth disease in Sarawak, Malaysia: clinical and outbreak of hand, foot and mouth disease in Sarawak, Malaysia: clinical and pathological characteristics of the disease. Clin. Infect. Dis. 31:678-683pathological characteristics of the disease. Clin. Infect. Dis. 31:678-683[Medline][Medline]

Cardosa, M. J., S. Krishnan, P. H. Tio, et al. 1999. Isolation of subgenus B Cardosa, M. J., S. Krishnan, P. H. Tio, et al. 1999. Isolation of subgenus B adenovirus during a fatal outbreak of enterovirus 71-associated hand, adenovirus during a fatal outbreak of enterovirus 71-associated hand, foot and mouth disease in Sibu, Sarawak. Lancet 354:987-991foot and mouth disease in Sibu, Sarawak. Lancet 354:987-991[Medline][Medline]. .

Chong CY, Chan KP, Shah VA, Ng WY, Lau G, Teo TE, et al. Hand, foot and mouth Chong CY, Chan KP, Shah VA, Ng WY, Lau G, Teo TE, et al. Hand, foot and mouth disease in Singapore: a comparison of fatal and non-fatal cases. disease in Singapore: a comparison of fatal and non-fatal cases. Acta Acta PaediatrPaediatr. Oct 2003;92(10):1163-9. . Oct 2003;92(10):1163-9. [Medline][Medline]. .

Ooi MH, Wong SC, Clear D, Perera D, Krishnan S, Preston T, et al. Adenovirus type Ooi MH, Wong SC, Clear D, Perera D, Krishnan S, Preston T, et al. Adenovirus type 21-associated acute flaccid paralysis during an outbreak of hand-foot-and-mouth 21-associated acute flaccid paralysis during an outbreak of hand-foot-and-mouth disease in Sarawak, Malaysia. disease in Sarawak, Malaysia. Clin Infect DisClin Infect Dis. Mar 1 2003;36(5):550-9. . Mar 1 2003;36(5):550-9. [Medline][Medline]. .

Shekhar K, Lye MS, Norlijah O, Ong F, Looi LM, Khuzaiah R, et al. Deaths in Shekhar K, Lye MS, Norlijah O, Ong F, Looi LM, Khuzaiah R, et al. Deaths in children during an outbreak of hand, foot and mouth disease in Peninsular children during an outbreak of hand, foot and mouth disease in Peninsular Malaysia--clinical and pathological characteristics. Malaysia--clinical and pathological characteristics. Med J Med J MalaysiaMalaysia. Aug 2005;60(3):297-304. . Aug 2005;60(3):297-304. [Medline][Medline]. .

Tseng FC, Huang HC, Chi CY, Lin TL, Liu CC, Jian JW, et al. Epidemiological survey Tseng FC, Huang HC, Chi CY, Lin TL, Liu CC, Jian JW, et al. Epidemiological survey of enterovirus infections occurring in Taiwan between 2000 and 2005: Analysis of of enterovirus infections occurring in Taiwan between 2000 and 2005: Analysis of sentinel physician surveillance data. sentinel physician surveillance data. J Med VirolJ Med Virol. Dec 2007;79(12):1850-60. . Dec 2007;79(12):1850-60. [Medline][Medline]. .

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