2. WHAT IS HFMD
• Caused by a group of
enteroviruses, including
Coxsackieviruses (CA6, CVA16)
and Enterovirus 71 (EV71)
• Usually mild and self-limiting,
however:
• VERY contagious
• Some strains may cause more
severe illness, complications
and death
3. HOW IS IT TRANSMITTED?
• From infected person’s
• Nose and throat secretions,
such as saliva, drool, or nasal
mucus
• Fluid from blisters or scabs
• Feces
• Most contagious during the
first week of illness
4. ENTEROVIRUS 71 (EV71)
• Outbreaks in children in East and Southeast Asia
• Severe Infection/disease, death
• Complications – meningitis, encephalitis, neurogenic pulmonary
edema and cardiac pulmonary hemorrhage
5. NATIONAL HFMD SURVEILLANCE
• Began in 2012 – RITM
• RT-PCR
• 77% CA6
• 9% CA16
• 3% EV71
• E71 was isolated in 3% of the samples collected from year 2000-2017
• Ongoing, uninterrupted transmission of native E71 C2 strain in the Philippines
6. CLINICAL ASSESSMENT
• Most are self-limiting,
recover with supportive
and symptomatic
treatment (Pain control,
fever control, hydration)
• Small portion –
complications (neurologic)
or death
• E71
7. SEVERE ENTROVIRUS 71 INFECTION STAGES
• Stage 1 – Herpangina
(Oral ulcers over
anterior tonsillar pillars,
soft palate, buccal
mucosa and uvula),
vesicular rash on
hands, feet, knees
and/or buttocks
9. SEVERE ENTROVIRUS 71 INFECTION STAGES
• Stage 2 – CNS involvement
• Aseptic meningitis
• Encephalitis
• poliomyelitis-like
syndrome with acute
limb weakness and
decreased reflexes and
muscle strength
• AFP is a differential
• Encephalomyelitis
10. SEVERE ENTROVIRUS 71 INFECTION STAGES
• Stage 3 – Cardiopulmonary failure, pulmonary edema or hemorrhage
with decreased EF of left ventricle (2Decho) needing inotropic
support
• Stage 4 – Convalescence
• Recovery from CP failure
11. SEVERE ENTROVIRUS 71 INFECTION STAGES
Hand, Foot,
Mouth Disease;
Herpangina
CNS
involvement
ANS
dysregulation
CP failure
12. Clinical
Management
1. Mild
• Most cases
• Symptomatic
management
• Fever control
• Relief of symptoms
(pain, itchiness,
discomfort)
• Hydration
• Rest
13. Clinical Management
• Severe
• With Neurological, Respiratory,
circulatory complications, death
• Criteria for Admission
• Signs of dehydration and cannot feed
• Clinically very ill or toxic-looking
• Persistent hyperpyrexia (more than
38°C) for more than 48 hours
• Suspicion of neurologic complications
1. Lethargy
2. Increased drowsiness
3. Myoclonus
4. Change in sensorium
5. Seizures
• Suspicion of cardiac complications
1. Low blood pressure
2. Weak Pulse
3. Heart rhythm abnormalities
14. Prevention and Control
• Transmission
• Coughing, sneezing
• Contact with blister fluid
• Contact with feces
15. Prevention and Control
• Community Setting
• Hygiene and Regular handwashing
• Handwashing before and after using toilet
• Disinfect dirty surfaces and soiled items
• Avoid close contact (kissing, hugging, sharing of utensils or cups with infected
people
• Proper waste disposal (diapers, wipes)
• QUARANTINE AND ISOLATION: stay home until afebrile for 24 hours AND all
mouth sores and open lesions have healed
• VACCINE: There is no HFMD vaccine
• VIRAL: Antibiotics is not indicated
17. Prevention and Control
• Proper hygiene
• Mandatory handwashing after contact with patient
• Appropriate cleanliness during diaper change
• No sharing of personal items – utensils, cups
• Properly wash personal items after use
• Use gowns
• Isolate patient using standard contact and droplet precautions
22. Specimen Collection, Handling and Transport
Patient
Blood Serology Swab
Mouth Ulcer
Viral transport
Media
Rectal
Viral Transport
media
Basal Scraping
of Vesicle
Viral Transport
media
Smear on slide
CSF
Send Clinical samples to respective
laboratory within 24 hours of collection
at 4°C (on ice), do not store at -20°C
23. HAND FOOT MOUTH DISEASE
SURVEILLANCE DATA
As of Morbidity Week 4 (January 29, 2023)
24. HAND FOOT MOUTH DISEASE
CASE DEFINITION
• Suspected case of HFMD: Any individual, regardless of age, who
develop acute febrile illness with papulovesicular or maculopapular
rash on palms and soles, with or without vesicular lesion/ulcers in the
mouth
• Probable case of HFMD: A suspected case that has not been
confirmed by a laboratory, but is geographically and temporally
related to a laboratory-confirmed case
• Confirmed case of HFMD: A suspected case with positive laboratory
result for Human Enteroviruses that cause HFMD
25. HAND FOOT MOUTH DISEASE
CASE DEFINITION
• Suspected case of Severe Enteroviral Disease: Any child less than ten
(10) years of age: with fever plus any severe signs and symptoms
referable to central nervous system involvement, autonomic nervous
system dysregulation or cardiopulmonary failure;
• OR a suspect or probable HFMD case with complications
• OR who died < 48hours after presenting with fever and CNS involvement;
• Confirmed case of Severe Enteroviral Disease: A suspected Severe
Enteroviral Disease that has positive laboratory results for
Enteroviruses
26. SUMMARY FOR MORBIDITY 4
(JAN 1– JAN 29, 2023)
• 76 cases of Hand, Foot and Mouth Disease with 0 deaths
• 24 (32%) were hospitalized
• Municipality with most reported number of cases is
KIDAPAWAN CITY (18 cases [24%])
• Ages ranged from 4 days to 22 years (Median 2 years)
• Majority of the cases were males (58%)
27. DISTRIBUTION OF HFMD CASES BY MORBIDITY
WEEK, COTABATO PROVINCE
As of January 29, 2023
33. h
• 45 SPECIMENS COLLECTED
• 30 SPECIMENS
SUBMITTED TO RITM
• 15 SPECIMENS FOR
TRANSPORT TO RITM
(Currently at PHO)
• RESULTS
• 3 – CV A16
• 1 – Binoligan, Kidapawan
• 1- Poblacion, Kidapawan
• 1 –Kalaisan, Kidapawan
• 1 – Negative
• 1 – Malanduague,
Kabacan
• 26 RESULTS PENDING
AS OF FEBRUARY 03, 2023
34. DATA FOR ACTION
• HFMD is increasing and has exceeded the alert and epidemic thresholds
• Once the alert threshold has been reached, actions must be taken
• Pediatric Age Group is the main target with a median age of 2 years old
• Pediatric age group – vulnerable because more of transmission are through droplet,
contact with bodily fluids (including feces)
• Differential diagnosis that are significant - scabies infestation, chickenpox
(varicella), measles and rubella, and AFP
• EV71 Surveillance
• CV A16 is currently the dominant strain
• 32% Hospitalization rate and 100% discharged alive
• No mortalities
36. Sources
• DOH DM 2020-0097 Guidelines on the implementation of Hand, Foot
and Mouth Disease Surveillance, Clinical management and Preventive
Measures
• CDC
• Nationwidechildrens.org
• Disclaimer: Some pictures presented in this were taken from the
internet with no intention of claiming them. All information are for
educational purposes only with no intention of copyright
infringement
• RITM
Editor's Notes
Aseptic meningitis: headache, irritability, or myoclonal jerk and CSF pleocytosis (>5x106 leaukocytes/litre) but without altrered levels of consciousness
Encephalitis with altered levels of consciousness plus CSF pleocytosis or poliomyelitis-like syndrome with acute limb weakness and decreased reflexes and muscle strength
Encephalomyelitis
