Hand, Foot, and Mouth Disease Outbreak | HFMD: Clinical features, complications, and management 

While HFMD cases are currently being reported  across Srinagar, Greater Kashmir’s Senior Editor, Nazir Ganaie, speaks to several doctors and flu experts to know more about the disease

 While Hand, Foot, and Mouth Disease (HMFD) cases are currently being reported in the summer capital, Srinagar, experts today say that the disease outbreak should be kept in check by adhering to the advisories issued by concerned line departments.

   

The experts told Greater Kashmir that the colloquial name of the HFMD flu is misleading and may create panic among people. Medical professionals have called ‘tomato fever’ a misleading and unscientific name for HFMD. Head, Department of Paediatrics, Government Medical College, Srinagar, Dr Muzaffar Jan, told Greater Kashmir, that hand-foot-and-mouth disease is a mild, contagious viral infection common in young children under five years old, but anyone can get it. “It spreads quickly at schools and day-care centers. It is one of the more distinctive rash syndromes most frequently caused by CoxsachieA16, sometimes in large outbreaks, and can also be caused by Enterovirus A 71. Symptoms include sores in the mouth and a rash on the hands and feet.

He said that the symptoms usually start three to seven days after becoming infected, and can last from seven to 10 days. “Hand-foot-and-mouth disease may cause all of the following symptoms or only some of them. They include fever, sore throat, feeling sick, painful, blister-like lesions on the tongue, gums, and inside of the cheeks.”

He reported a rash on the palms, soles, and sometimes the buttocks. The rash is not itchy, but sometimes it has blisters. “Depending on skin tone, the rash may appear red, white, gray, or only show as tiny bumps. Fussiness in infants and toddlers. Dr Jan advised that the blisters should not be itchy like chickenpox blisters. If the child has eczema, the HFMD can cause eczema to worsen and potentially become infected with bacteria.

Diagnosis

Dr Jan said that the child’s health care provider would decide if the child has hand-foot-and-mouth disease or other types of viral infections by evaluating the child’s age, child’s symptoms, and child’s rash or sores. “The most common cause of hand-foot-and-mouth disease is infection from coxsackievirus 16. This coxsackievirus belongs to a group of viruses called non-polio enteroviruses,” he said.

Former Deputy Director of Epidemiology, Directorate of Health Services, Kashmir, Dr SM Qadri said that “there shouldn’t be any confusion among people about tomato flu and HFMD. These are two different variants. Both have their incubation period and are self-limiting diseases,” Dr told Greater Kashmir. “There is no need to panic,” he said. He said HFMD is caused by a virus, most often one of the enteroviruses belonging to serotypes EV-A. Enterovirus EV-A71 infections more often result in severe complications or death than other serotypes. Recently, a variant of the CV-A16 serotype has caused outbreaks across India of a disease that was initially mistakenly assumed to be novel and dubbed tomato flu in the media.

“This highlights the need to increase awareness and understanding of the disease,” he said.

According to the experts the emergence of the EV-A71 epidemic in the Asia-Paci?c region, and the more recent emergence of the CV-A16 variant responsible for tomato flu has been associated with the transmission of viruses with different genetic lines and there is concern that the virus may be undergoing rapid genetic changes, increasing the need for robust surveillance to ensure early diagnosis, treatment, and intervention in affected regions, particularly regions where the experience of the disease is lower.

MAJOR HMFD OUTBREAK IN 2018

According to medical professionals, the major HMFD outbreak was reported in Jammu in Kashmir in 2018 in which 465 cases were reported, majorly from Leh in the Ladakh region. They say the outbreak occurred in a far-flung Chuglamsar village in the Leh district. According to doctors, all the cases recovered on their own with no mortality rate. Later in 2019, the HMFD outbreak occurred in Shopian and 2019 in north Kashmir’s Baramulla areas—with no mortality, again.

CAN’T PUT AN END TO VIRUSES

 “You can’t put an end to viruses. They are there. They are endemic. Outbreaks have happened, and they will keep happening,” Influenza expert and Associate Professor, Government Medical College, Srinagar, Dr Nisar Ul Hassan, said.

“It is not COVID. We don’t need an alarm on this. There are thousands of viruses like this. There are so many viruses which keep on happening, especially at this time,” he said, adding the kind of outbreak that we have witnessed at the local School is yet to be clinically testified.

“On the surface level, it appears it’s a form of hand, foot, mouth disease with additional symptoms of joint pains and high-grade fever. In any case, Hand, Foot, and Mouth Disease itself is a syndrome that can be caused by different enteroviruses. Symptoms vary from type of virus, age group, and immunity status of the patient. It’s not life-threatening and there shouldn’t be any panic on this,” he said.

He, however, said that sensitization is very important in such cases. “The government, especially DHSK, needs to launch a massive sensitization campaign and educate children, parents, and teachers on the various aspects of these viruses.

MOST RECOGNISABLE VIRAL ILLNESS

Assistant Professor, Department of Paediatrics, Government Medical College, Srinagar, Dr Suhail Naik, in an interview with Greater Kashmir, shared that HFMD is a clinical syndrome characterized by an oral eruption and maculopapular, or vesicular rash of the hands and feet (and other locations).

“HFMD is one of the most recognisable viral illnesses with rash and fever in children,” Dr Naik said.

Asked whether the government can have a proper monitoring mechanism for such situations, Dr Naik informed that the seasonal viruses usually spread like wildfire particularly when children are going to school. “Viruses don’t come with any warning and therefore can’t be predicted like weather, but still the government institutions keep a close vigil on all such infectious diseases through infectious diseases surveillance and take all precautionary and preventive measures whatsoever are required at the outset to safeguard their citizens.”

Pertinently HFMD was first described in a summer outbreak that occurred in Toronto, Canada in 1957 and was caused by coxsackievirus A16. Since then, at least 15 other enterovirus serotypes have been shown to cause HFMD, most commonly Coxsackievirus A serotypes. Coxsackievirus A16 and enterovirus A71 are the serotypes most frequently associated with HFMD and are responsible for the majority of large outbreaks. Enterovirus A71 has been associated with outbreaks involving thousands of persons in the Asia-Pacific region.

CLINICAL FEATURES

According to Dr Naik, the clinical features of typical HFMD include-Painful oral lesions on the tongue and buccal mucosa that may interfere with oral intake; oral lesions may occur in isolation. Macular, maculopapular, or vesicular nonpruritic, non-tender skin lesions on the hands, feet, buttocks, and extremities; skin lesions may occur in the isolation-When present, fever is below 38.3°C (101°F). He said that some children may have a higher fever and with wider distribution of lesions, Vesicobullous lesions, bullae, erosions, ulcerations, and eschar, longer duration, Plamar/plantar desquamation, Nail dystrophy

“Complications of HFMD and herpangina are rare and occur in 1 in million. They occur more commonly with enterovirus A71 than other types of enteroviruses,” Dr Naik said.

MANAGEMENT OF OUTBREAK

The experts said that most cases of uncomplicated HFMD and herpangina resolve spontaneously within seven days. Management is supportive. Pain and discomfort can be managed with ibuprofen or acetaminophen. “We suggest not routinely using topical oral therapies for children with HFMD,” they said.

HOW CONTAGIOUS IS HFMD?

HFMD is highly contagious. It can easily spread from human secretion (especially nose and throat), close contact, etc. A person who comes into contact with an infected person is likely to contract the infection. “It spreads from person to person just like a common cold, through contact with the patient’s secretions including stool, for example during a diaper change in child care facilities.

ADVISORY

Director, Health Services Kashmir, Dr Mushtaq Ahmad Rather told Greater Kashmir that an advisory has been issued and people have been advised not to panic due to the outbreak of Hand Foot and Mouth Disease (HFMD) instead of taking some precautionary measures. “HFMD is not a serious disease. It is a viral infection. Those children who have been infected should be isolated and their parents should follow the proper advice of doctors,” Dr Rather said.

In Srinagar, several schools have reported the HFMD outbreak prompting the management to shut down some classes to prevent its spread.

“Parents should ensure that proper hygiene is maintained for their children. Those who have been infected should be isolated. They should also ensure that clothes, food, and toys of infected children are not shared with others,” he said., adding that the Department of Health Services, Kashmir has also issued a detailed list of dos and don’ts and advised parents to adhere to the guidelines to prevent the spread of HFMD/Tomato Flu.

“Avoid immediate contact with the infected person. Educate your child about the signs and symptoms and their side effects. Tell your child not to hug or touch children having fever or rash symptoms. You should encourage your children about hygiene maintenance and stopping thumb-sucking habits.”

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