|BRIEF RESEARCH ARTICLE
|Year : 2015 | Volume
| Issue : 2 | Page : 141-144
Clinical profile of hand, foot, and mouth disease and its associated complications among children in Shimoga City, southern Karnataka: A hospital-based study
Vikram S Kumar1, Sangeeta V Budur2, Girish H Odappa3, Shambulinga Y Bankolli4, Anand P Rao5
1 Assistant Professor, Department of Pediatrics, Subbaiah Institute of Medical Sciences and Research Centre, Purle, India
2 Assistant Professor, Department of Pediatrics, Raja Rajeshwari Institute of Medical Sciences, Bangalore, Karnataka, India
3 Assistant Professor, Department of Preventive and Social Medicine, Subbaiah Institute of Medical Sciences and Research Centre, Purle, India
4 Senior Resident, Department of Pediatrics, Subbaiah Institute of Medical Sciences and Research Centre, Purle, India
5 Department of Pediatrics, Honorary Assistant Professor, Indira Gandhi Institute of Child Health, Bangalore, Karnataka, India
|Date of Web Publication||25-May-2015|
Vikram S Kumar
Department of Pediatrics, Subbaiah Institute of Medical Sciences and Research Centre, Purle, HH Road, Shimoga - 577 222, Karnataka
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Hand, foot, and mouth disease (HFMD) is one of the important public health problems. It has become a common childhood illness in our part of the country. In most instances, this is a mild self-limiting illness. The affected children are often given outpatient care. However, over the last decade, HFMD has emerged as a growing health problem in Asian countries following frequent outbreaks of deaths associated with HFMD caused by a more virulent member of human enterovirus (HEV), namely, HEV71. A hospital-based descriptive study about the clinical presentations and complications of HFMD at the hospitals of Shimoga city between March 2013 and August 2013 is documented and presented here. HFMD was more common in the 1-3-year old age group, with aseptic meningitis being the most common complication. Surveillance of HFMD must be maintained as there is no effective chemoprophylaxis or vaccine available.
Keywords: Complications, human enterovirus 71 (HEV71), hand, foot, and mouth disease (HFMD), Shimoga
|How to cite this article:|
Kumar VS, Budur SV, Odappa GH, Bankolli SY, Rao AP. Clinical profile of hand, foot, and mouth disease and its associated complications among children in Shimoga City, southern Karnataka: A hospital-based study. Indian J Public Health 2015;59:141-4
|How to cite this URL:|
Kumar VS, Budur SV, Odappa GH, Bankolli SY, Rao AP. Clinical profile of hand, foot, and mouth disease and its associated complications among children in Shimoga City, southern Karnataka: A hospital-based study. Indian J Public Health [serial online] 2015 [cited 2020 Feb 18];59:141-4. Available from: http://www.ijph.in/text.asp?2015/59/2/141/157536
Hand, foot, and mouth disease (HFMD) typically affects children <10 years of age. The main signs and symptoms are fever, sore throat, general malaise, and often vesicular eruptions on the palms and soles, the oral mucosa, and the tongue. In most instances, this is a mild self-limiting illness. The affected children are often given outpatient care with symptomatic treatment. However, over the last decade, HFMD has emerged as a growing public health problem in Asia following frequent outbreaks of death-associated HFMD caused by a more virulent member of human enterovirus (HEV), namely, HEV71 in a number of countries in the region. 
This hospital-based descriptive study was conducted with an objective to know the clinical characteristics of HFMD patients presenting at the hospitals of Shimoga city. The study period was from March 1, 2013 to August 30, 2013, in five randomly selected leading private pediatric hospitals of Shimoga city. All the clinically diagnosed cases, diagnosed during the study period fulfilling the criteria of "case definition" of HFMD, were included in the study. Informed consent was taken from the parent/guardian of the child. Detailed medical histories, clinical examination findings, and laboratory test results of the children admitted with complications due to HFMD were extracted from the medical records.
The algorithm for case definitions [Figure 1] and classification of the disease severity were extrapolated from one of the studies.  These case definitions were used to diagnose and classify the children. Laboratory confirmation of the pathogen causing the disease was not done due to resource constraints.
On analyzing the results, [Table 1] shows that out of 276 patients included in the study, 145 (52.5%) were males showing a male preponderance. The reason for the differences observed in gender specific incidence rates is not known, as indicated in a study done by Ang et al.  HFMD was most commonly seen in the age group of 1-3-year-old children.
[Table 2] shows that among the clinical presentations, the most common presentation was vesicles on the hands or feet that were present in all the cases diagnosed followed by oral ulcer (89%), vesicles on the buttocks (65%), and fever (45%).
Thirty four (12.3%) children were hospitalized because of complications. The most common complication was aseptic meningitis seen in 30 (10.86%) children, followed by acute encephalitis syndrome in 22 (8%) children, and bronchopneumonia in 10 (3.6%) children. Pulmonary edema, pain in the abdomen and vomiting, and acute cerebellar ataxia were seen in three (1.08%) children, one (0.36%) child, and one (0.36%) child, respectively. A few children had overlapping complications. There was no mortality among the cases.
There have been outbreaks of HFMD in large parts of India;  however, no reports of complications can be found in any of the medical literatures. Following the large outbreaks in 2008 and 2009, the incidence of HFMD continued to rise during 2010 in the Western Pacific region, particularly in China, Japan, South Korea, and Singapore. ,, The largest and most severe HFMD outbreak associated with HEV71 took place in Taiwan in 1998, when 405 pediatric HFMD patients developed severe neurological complications and pulmonary edema and 78 children died.  In mainland China, there were about a million cases with 228 deaths reported up to the end of July in 2013. , Clinical observations revealed that severe HFMD occurred in only a small percentage of HFMD patients, and HEV71 was identified as the major agent. 
In a study conducted in Japan, the definition of complicated cases was "hospitalization over 24 h or fatality." HFMD cases were divided into the following two groups: "more severe" (if fatal, involving sequelae, or involving hospitalization for 7 days or longer) and "less severe." Meningitis was the most common final diagnosis in both groups, but encephalitis was more frequent in the more severe cases. There are a few studies that also analyzed the risk factors associated with complications. The characteristics of HFMD and other EV infections include long-term secretion of the virus. One study of HEV71 secretion in children showed that some patients shed the virus for 11 weeks. When an HFMD epidemic occurred due to HEV71, there was a statistically significant association between attending child care centers and severe HFMD in Japan. 
The primary care doctors are confronted with the clinical challenge of identifying a small fraction of children who are at risk of neurological complications from an overwhelmingly large number of children who would have an uncomplicated course of HFMD. For this reason, it is important to find clinical predictors for neurological involvement that can guide primary care doctors to perform a proper patient triage aimed to admit high-risk children into hospitals early for close observation and further management, while those at low risk of neurological complications may be given outpatient care after parental education and advice. Only a few studies (none in India) have systemically examined how to identify children at risk at an early stage before they develop cardiorespiratory failure, particularly at the primary care setting where the majority of children with HFMD would first seek treatment during a community outbreak of HFMD. A study conducted in Sarawak in Borneo, Malaysia by researchers  validated that history of lethargy, mean peak temperature ≥38.5°C, and total duration of fever ≥3 days were important risk factors for neurological involvement. The study also showed that neurological involvement occurs in the early course of complicated HFMD, and may be detectable within the first 2 days of the febrile illness. Hyperglycemia and leukocytosis have been shown as risk factors for the fatal HEV71 disease.  HEV71 was significantly associated with severe HFMD patients. Co-detection of HEV71 with norovirus and rotavirus was also significantly associated with patients with severe HFMD. 
In 2012, an investigation from India highlighted the cocirculation of coxsackievirus (CV)-A16, CV-A6, CV-A10, HEV-71, and E-9 serotypes causing HFMD. These results emphasize the need for continuous monitoring of HFMD in India and facilitation of the diagnosis of the associated HEV infections using molecular and/or serological approaches.  Many authors have proposed the development of vaccines for the control of HFMD. It is proposed that improved hand-washing and related hygienic improvement be incorporated in the community, nursery schools and kindergartens, and hospital outpatient and inpatient services. 
Surveillance for HFMD must be maintained as there is no effective chemoprophylaxis or vaccine available. Social distancing or in other words avoiding contact with HFMD patients, maintaining good personal hygiene, and disinfection of the environment are probably the most effective prevention measures. A cohort study using direct measures of disease severity with complete reporting of risk factors, such as day care attendance, should be strongly considered. Epidemiological knowledge of HFMD should enable public health personnel to predict outbreaks of the disease and implement effective interventions to reduce the burden of disease.
The following were limitations of the study: A laboratory isolate of the offending pathogen was not possible and a large number of hospitals were not included. Inclusion of a large number of hospitals and the hospitals from rural areas would give better knowledge about the disease proper.
| Acknowledgement|| |
The authors deeply acknowledge the contributions of Dr. D.Y. Baddi, consultant pediatrician in Chirayush Children's Hospital, Shimoga; Dr. H.V. Kotturesha Rasthapuramath, consultant pediatrician, Kotturesha Maternity and Children's Nursing Home, Shimoga; and Dr. Yateesha B.L., consultant pediatrician, Vaatsalya Multispeciality Hospital, Shimoga.
| References|| |
Ooi MH, Wong SC, Mohan A, Podin Y, Perera D, Clear D, et al
. Identification and validation of clinical predictors for the risk of neurological involvement in children with hand, foot, and mouth disease in Sarawak. BMC Infect Dis 2009;9:3.
Ang LW, Koh BK, Chan KP, Chua LT, James L, Goh KT. Epidemiology and control of hand, foot and mouth disease in Singapore, 2001-2007. Ann Acad Med Singapore 2009;38:106-12.
National Institute of Communicable Diseases. Directorate General of Health Services, Government of India. Hand, Foot and Mouth Disease. 2008. Available from: http://www.nicd.nic.in/writereaddata/linkimages/July08475966895.pdf. [Last accessed on 2014 Jul 7].
Emerging Disease Surveillance and Response. Hand, Foot and Mouth Disease (HFMD). 2013. Available from: http://www.wpro.who.int/emerging_diseases/HFMD/en/index.html. [Last accessed on 2013 Aug 7].
Arora S, Arora G, Tewari V. Hand foot and mouth disease: Emerging epidemics. Indian J Dermatol Venereol Leprol 2008;74:503-5.
Sarma N, Sarkar A, Mukherjee A, Ghosh A, Dhar S, Malakar R. Epidemic of hand, foot and mouth disease in West Bengal, India in August, 2007: A multicentric study. Indian J Dermatol 2009;54:26-30.
Liu LJ, Xu HM, Li XJ, Wang J, Wang XJ, Ding SJ, et al
. Co-detection in the pathogenesis of severe hand-foot-mouth disease. Arch Virol 2012;157:2219-22.
Suzuki Y, Taya K, Nakashima K, Ohyama T, Kobayashi JM, Ohkusa Y, et al.
Risk factors for severe hand foot and mouth disease. Pediatr Int 2010;52:203-7.
Gopalkrishna V, Patil PR, Patil GP, Chitambar SD. Circulation of multiple enterovirus serotypes causing hand, foot and mouth disease in India. J Med Microbiol 2012;61:420-5.
Ruan F, Yang T, Ma H, Jin Y, Song S, Fontaine RE, et al
. Risk factors for hand, foot, and mouth disease and herpangina and the preventive effect of hand-washing. Pediatrics 2011;127:e898-904.
[Table 1], [Table 2]
|This article has been cited by|
||The application of meteorological data and search index data in improving the prediction of HFMD: A study of two cities in Guangdong Province, China
| ||Shaoxing Chen,Xiaojian Liu,Yongsheng Wu,Guangxing Xu,Xubin Zhang,Shujiang Mei,Zhen Zhang,Michael OśMeara,Mary Clare OśGara,Xuerui Tan,Liping Li |
| ||Science of The Total Environment. 2019; 652: 1013 |
|[Pubmed] | [DOI]|
||Hand, Foot and Mouth Disease in the Andaman Islands, India
| ||Surya Palani,Muruganandam Nagarajan,Ashok Kumar Biswas,Rajesh Reesu,Vijayachari Paluru |
| ||Indian Pediatrics. 2018; 55(5): 408 |
|[Pubmed] | [DOI]|
||Epidemiological characteristics of severe cases of hand, foot, and mouth disease in Guangdong, China
| ||Zhicheng Du,Wangjian Zhang,Dingmei Zhang,Shicheng Yu,Yuantao Hao |
| ||Biostatistics & Epidemiology. 2018; : 1 |
|[Pubmed] | [DOI]|
||Genetic characterization of enterovirus strains identified in Hand, Foot and Mouth Disease (HFMD): Emergence of B1c, A, C1 subgenotypes of CVA16, CVA6, and EV71 strains in India
| ||Nital N. Ganorkar,Pooja P. Fulmali,Sanjay S. Tikute,Varanasi Gopalkrishna |
| ||Infection, Genetics and Evolution. 2017; |
|[Pubmed] | [DOI]|
||Quantifying the adverse effect of excessive heat on children: An elevated risk of hand, foot and mouth disease in hot days
| ||Wangjian Zhang,Zhicheng Du,Dingmei Zhang,Shicheng Yu,Yuantao Hao |
| ||Science of The Total Environment. 2016; 541: 194 |
|[Pubmed] | [DOI]|
||Epidemiological Features of Hand, Foot and Mouth Disease during the Period of 2008Ė14 in Wenzhou, China
| ||Zu-Mu Zhou,Yi Xu,Cai-Song Hu,Qiong-Jiao Pan,Jing-Jiao Wei |
| ||Journal of Tropical Pediatrics. 2016; : fmw070 |
|[Pubmed] | [DOI]|