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NCID > For Healthcare Professionals > Diseases and Conditions > Hand, Foot and Mouth Disease

Hand, Foot and Mouth Disease

Hand, Foot and Mouth Disease

Causative Agent

Numerous members of the Enteroviruses group of the family Picornaviridae e.g. coxsackievirus, echovirus, enterovirus (EV) 71.

Incubation Period

3-5 days (range 2 days to 2 weeks)

Infectious Period

Few days before onset of prodromal symptoms to about 1 week from the onset of illness.

Maximum duration of excretion: nasopharynx (3-4 weeks), faeces (6-12 weeks).

Transmission

Faecal-oral route, direct contact with respiratory droplets, saliva, vesicular fluid or indirectly by articles/ fomites contaminated by secretions.

Epidemiology

Infection leads to specific immunity against the particular virus but can be reinfected by a different virus from the enterovirus group.

After an epidemic of HFMD in Sarawak in 1997 and Taiwan in 1998, a system of surveillance for the disease, based on notifications from child-care centres was implemented in April 1998. Singapore experienced an epidemic of HFMD in September–October 2000 during which 3790 cases were reported. The predominant virus was EV71. There were four EV71- related deaths in 2000 and three in 2001. Reporting the disease was made legally mandatory on October 1, 2000. The outbreak was finally interrupted by a swift coordinated inter-agency response that led to the closure of all preschools from 1 Oct – 15 Oct.

During the period 2005-2009, there were between 15,257 and 29,686 reported cases per year, including one death in 2008. Coxsackievirus A 16 was the predominant circulating virus in 2005, 2007 and 2009, and EV 71 in 2006 and 2008.


Children younger than 10 yrs of age have the highest risk but infection also occurs  in adults. The majority of the infections occur at the preschool ages.

  • 50-80% are asymptomatic
  • Fever lasts 2-3 days (up to 5 days) followed by a rash over the palms, soles, dorsum of the feet, shins and buttocks. Rash starts as papules and become vesicles. Resolves in 7-10 days
  • Mouth ulcers over the soft/ hard palate, uvula, buccal mucosa and tongue.
  • May also have cough or rhinitis.
  • May also have no rash but only ulcers in which case the patient is labelled as herpangina which is due to the same group of enteroviruses.

Complications:

Rarely myocarditis, pulmonary oedema, acute respiratory distress syndrome, viral pneumonitis, aseptic meningitis, brainstem encephalitis, acute flaccid paralysis, secondary bacterial infection

Differential diagnosis:

Herpes simplex stomatitis – ulcers more in the anterior mouth and visible externally.



  • Rapid diagnosis can be performed by sending a nasopharyngeal throat swab or stool sample for enterovirus PCR.
  • Stool/rectal swab, swab of vesicle fluid or oral ulcers can be sent for enterovirus isolation which takes 5-6 weeks. The yield of virus isolation is highest from the stool followed by vesicles and throat swabs.


A legally notifiable disease in Singapore. Notify Ministry of Health (Form MD 131 or electronically via CD-LENS) not later than 24 hours from the time of diagnosis.

Details of school/child-care centre should be provided for cases involving children.



  • Patients with signs and symptoms of severe disease should be referred to hospital for further management; e.g. prolonged hyperpyrexia, tachycardia, tachypnoea, poor feeding or severe vomiting, lethargy.
  • Symptomatic measures: anti-pyretics, tepid sponging, IV drip for rehydration.
  • Hospitalisation for treatment of complications.
  • Antibiotics (especially versus Staphylococcus) are used when there is evidence of secondary bacterial infection; e.g. raised total white counts.


  • No vaccines against enteroviruses are available. Good personal hygiene such as hand washing and isolation of infected cases are key to controlling an outbreak. No sharing of food and contaminated items.
  • HFMD cases should be given medical leave until 10 days (2 incubation periods) from the onset of illness in order to break the transmission in child-care centres and schools.
  • Parents should be advised that children with HFMD are to avoid contact with other children at home and to refrain from visiting crowded public places during the acute infection and not swim until 6 weeks later; and to disinfect articles contaminated by the droplets, saliva, vesicular fluid and excreta of infected cases.
  • MOH monitors the regional EV 71-associated HFMD situation and tracks the types of enteroviruses circulating in the community through a sentinel surveillance system.
  • MOH, together with MCYS and MOE, closely monitors the local disease incidence and trends and provides guidance to childcare centres and kindergartens to ensure that these institutions exercise a high level of vigilance in their management of HFMD.









References

  1. Chan KP, Goh KT, Chong CY et al. Epidemic hand, foot and mouth disease caused by human enterovirus 71, Singapore. Emerging Infect Dis 2003; 9:78-85.
  2. Chong CY, Chan KP, VA Shah VA et al. Hand,, foot and mouth disease in Singapore: a comparison of fatal and non-fatal cases. Acta Paediatrica 2003; 92: 1-8.
  3. Ooi EE, Phoon MC, Ishak B et al. Seroepidemiology of human enterovirus 71, Singapore. Emerg Infect Dis 2002;8:995-7.
  4. Ang LW, Koh BKW,Chan KP et al. Epidemiology and control of hand, foot and mouth disease in Singapore, 2001-2007. Ann Acad Med Singapore 2009;38:106-12.





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