The recent news regarding the death of two children in Malaysia due to a more severe form of hand foot and mouth disease (HFMD) from the enterovirus-71 (EV-71) strain, have set off alarm bells regarding this illness. I have had some parents who were absolutely dismayed about their child’s HFMD diagnosis and some who heaved a huge sigh of relief when their child, suspected of HFMD, was eventually not infected by the disease. Is this condition really as fearful as how people perceive it to be?
This article seeks to answer some practical questions often asked in the clinic setting, as much as possible, avoid repeating information that is already available on online. Detailed information about the transmission, treatment and prevention will be in the links provided at the end of the article.
What is HFMD?
For a start, HFMD is a condition commonly affecting young children (below the age of five, but can also occur to anyone of any age) that results in ulcers in the mouth, and rashes (most often with little blisters) over the palms, soles and buttocks. It is a viral infection caused by a group of viruses called enteroviruses, of which a subset named coxsackie virus is a common cause. The disease is usually spread by touching the mucous, saliva, stool or fluids from the rashes of someone with the disease. The most common problem that young children have with the condition is having a lot of difficulty eating and drinking during the illness due to the painful ulcers, and hence may require hospitalisation due to dehydration. Though rare, more severe effects of the virus may include inflammation of the brain / brain lining (meningitis / encephalitis), lungs (pneumonitis) or the heart (myocarditis).
HMFD: What You Should Know (By Raffles Medical Group)
Some common questions but lesser known facts about HFMD…
Does my child have HFMD?
Many times, parents visit the clinic on the first day of their child’s fever after being informed of HFMD cases in school. Does my child have HFMD? This will be the question that worries most parents. Truth be told, it is often very hard to give a clear answer unless there are definite signs of HFMD – rashes and oral ulcers. As such, on many occasions, the attending doctor would have to conclude that the child has a viral fever if none of these symptoms are found. However, that doesn’t always mean that the fever is not due to HFMD. Symptoms of HFMD take time to develop and fever is usually the first sign. The diagnosis will be clear only over the next three to four days, when more signs emerge. Hence, if there have been cases of HFMD in your child’s school and your child develops a fever, do keep him or her at home, avoid playdates and monitor for signs of HFMD over the next few days. An initial diagnosis of viral fever, especially on the first day or two of the illness does not always mean a clear “pass” of not having the infection.
How bad is the problem in Singapore? Should I be worried?
As of writing this article, 32,000 cases have been reported for 2018, compared to an estimate of 26,000 cases reported last year within the same period. HFMD, like stomach flu or the common cold, is a viral infection from which most healthy children recover on their own in time without any specific medications. The difference of course, would lie in the fact that children have to be out of school for a longer period and some may require hospitalisation because of the difficulty of eating from the pain of the ulcers. Do not be overly worried if your child catches the infection. As long as parents continue to keep up their child’s hydration during the period of illness, your child will most likely be fine. What parents should take note of is preventing the transmission of the infection to siblings or even to themselves at home. Despite so, there are rare complications of HFMD that can affect the heart, lungs and the brain with fatality as the most severe complication. EV71, the less common strain causing HFMD, was recently thrust into the spotlight because of the death of two young children in Malaysia. This strain has been known to have a higher rate of complication compared to the common coxsackie virus A16 strain. The exact occurrence of the EV71 strain in Singapore is not very clear because not every child diagnosed with HFMD is tested for the strain they are infected with. However, the occurrence of this particular strain is definitely not known to be high. In general, these severe complications are rare and more often than not, children recover well from the infection.
Must we do some tests / investigations at the clinic?
Generally, HFMD is a diagnosis based on examination. At the moment, testing via swabs taken from the rectum, throat or the fluid from the blisters of rashes is used in a hospital setting for specific cases. These swab tests may take awhile for the results to be out and are costly. As a result, they are not routinely done except in situations whereby the child is severely ill (eg. meningitis) and the cause is not certain. Additionally, routine testing is not done because there is no specific antiviral medication to target the infection even if tested positive. Currently, there is no test to predict whether the child will have complications from the infection. Tests and investigations (eg. blood tests or chest xray etc) are mainly done to look for evidence of complications when it is suspected.
Just how long does one usually have to stay out of school?
HFMD symptoms usually last about 7 to 10 days. However, some may have prolonged symptoms while others may go without symptoms for a week. HFMD is most contagious when the child has a fever and blister rashes are still present. Hence, children are only allowed to go back to school after the fever has settled and when there are no more blisters and oral ulcers noted in the child. As such, it is likely that your child has to be out of school for at least a week or longer. That being said, a lesser known fact is that the virus can continue to be present in the stools of infected children for up to three months after the infection, and in the saliva for up to one month after the infection. Of course, these children who have recovered are much less contagious. Thus, it is critical to maintain good environmental and personal hygiene at all times to prevent the spread of HFMD.
There are so many cases in my child’s school! Isn’t it time to close down the school?
There are strict criteria set by the Ministry of Health regarding the closure of schools. Before school closure is mandated, schools with a higher than usual number of cases of HFMD are listed so that parents can be made aware of the situation. Schools that are on the list have either more than 10 HFMD cases or have more than 13 per cent of all the school children affected by HFMD (attack rate), with a recorded period of cases being spread (transmission period) over more than 16 days. For school closure, the transmission period has to be more than 24 days with either more than 16 HFMD cases or an attack rate of more than 23 per cent. Parents can refer to the following website to check out the list of schools affected and the detailed criteria for each category – https://www.moh.gov.sg/diseases-updates/hand-foot-and-mouth-disease/hand-foot-mouth-disease-updates
The school hasn’t reached the closure criteria yet but there are still new cases… Should I take my child out of school? If so, for how long?
Parents often ask for advice regarding the need to take their child out of school due to HFMD cases. There is no absolute answer to this question, but it is a discussion of concerns and considerations. Going to school serves as a great stimulation to young children in their formative years as they pick up social skills and are challenged to learn something new each day. Taking them out of school removes them from these learning opportunities and hence avoiding school will have to be carefully balanced against the risk of actually catching the infection. Often, a discussion of how many cases have occurred in school and how close the cases are to the child would ensue. One other consideration is that there should be a logistical caretaking support at home should the child not be at school. A discussion with your child’s paediatrician would be useful as there may be more factors to consider as well. If your final decision is to keep your child at home, a suggestion (not an absolute answer) for the period to be away from school would be for about five days from the last case reported. This is because the incubation period (the time of infection to the time the symptoms appear) is usually three to five days for HFMD.
My child has had it once before, it is unlikely he will get it again?
Although there are many strains of enteroviruses that can cause HFMD, having been infected by one strain does not prevent you from being infected by another. Therefore, your child is not immune against HFMD after catching it once.
Is this preventable?
Strict hand hygiene measures are important and these include frequent and proper hand washing especially before meals, and covering the mouth and nose when coughing or sneezing. It also helps to separate the infected child’s toys, books, eating utensils, towels and clothes from others and avoid sharing food with, kissing or hugging the child with HFMD. Wiping down surfaces with wet wipes at home and in the childcare / school setting is important too. However, when a child contracts HFMD, prevention of severe complications can be difficult as there is no specific antiviral medication to stop the infection from spreading. As such, if a child develops complications like a heart or brain inflammation, current standards of treatment would mainly be to support the organ functions of the child until the infection resolves on its own. Hence, while contracting the infection may be preventable, the complications are hard to prevent. It is important for parents to recognise the danger signs of complications early and seek medical attention as soon as possible. Some of the danger signs would include extreme lethargy, repeated episodes of vomiting, looking ill, headache and neck stiffness.
What does the future hold? Will things get better?
Although a vaccine against EV71 has been developed and used in China, its overall effect in preventing HFMD is not certain. Despite the on-going research in developing a vaccine, it is still likely to be years away for public use. Apart from vaccines, research groups are also looking into modifying existing antiviral medications to work against enteroviruses. Additionally, researchers from the National University of Singapore have announced that they are working on a test kit that uses saliva to test for HFMD even before the symptoms appear. This would certainly be very effective in reducing the transmission of the virus in a school setting. However, this test kit is not likely to be out in the market and would perhaps take another year or two to undergo further rigorous testing.
Can probiotics prevent HFMD?
Although there is no clear evidence that probiotics help in preventing HFMD, a recent scientific research has indicated that certain strains of probiotics have been shown to have some antiviral activity against specific strains of enteroviruses (not all of them). That being said, consuming probiotics is not a foolproof way to prevent HFMD but it may still be taken regardless due to its other benefits
Useful Links
Raffles Medical Group Video (as above)
About Dr Christelle Tan
Specialist in Paediatric Medicine & Consultant
Raffles Specialists – Holland V
Dr Christelle Tan is a paediatrician and an avid volunteer who is passionate in paediatric global health. She had also been previously involved in conducting the global health and leadership workshop in the Saw Swee Hock School of Public Health, NUS. Dr Tan’s practice includes all area of general ambulatory paediatrics, including a wide range of common childhood conditions like asthma, childhood allergies, growth and developmental concerns. She is interested and experienced in developmental assessment and vaccinations.
About Raffles Holland V
Raffles Medical Group's second integrated multi-disciplinary medical centre at Raffles Holland V brings quality healthcare closer to where you live, work and play. Patients can expect a comprehensive range of healthcare services including specialist care such as women, children, skin and aesthetics; family medicine, dental, health screening and traditional Chinese medicine. You can have peace of mind when our specialists, physicians and allied health professionals work together for your complete healthcare needs.