An Introduction to Hand, Foot, Mouth Disease (HFMD)

Hand, foot and mouth disease (HFMD) is a contagious infection. Infants and young children who do not yet have immunity to the viruses that cause HFMD are vulnerable to it. HFMD is caused by Enterovirus family, most commonly the Coxsackievirus A16 (CA16) and Enterovirus 71 (EV71). It is mainly transmitted through the fecal-oral route and respiratory droplets. Direct contact with open and weeping skin vesicles or contaminated objects may also transmit the virus. The incubation period for HFMD is 3 to 10 days. Painful ulcers in the mouth may impact on food and drink intake, resulting in dehydration eventually. Over the last decade, numerous outbreaks of HFMD have been reported in the Asia Pacific regions including Malaysia and Singapore, and across China. The first HFMD case reported in Malaysia was in Sarawak in 1997. From 1 June to 30 August 1997, a total of 2628 cases of HFMD primarily caused by EV71, were reported to the Sarawak state health department. During the outbreak, 889 children were hospitalized including 39 with aseptic meningitis or acute flaccid paralysis. A total of 29 previously healthy children younger than six years of age died of rapidly progressive cardiorespiratory failure.


HFMD is commonly a mild disease and nearly all patients recover in 7 to 10 days without medical treatment. In rare cases, chronic HFMD can lead to severe neurological disorders, including encephalitis, acute flaccid paralysis, pulmonary edema (PE) and hemorrhaging, resulting in fatality particularly in EV71-infected children under 5 years old. Younger children are more susceptible to the infection because they do not have immunity against the viruses that cause HFMD. In general, fever and sore throat are usually the first symptoms of HFMD. Other associated symptoms such blisters and rashes show up later, usually one or two days after the fever begins. Common symptoms of HFMD for children under age of 5:

Day 1 to day 2

  1. Fever (lasting 24-48 hours, is often the first symptom)

  2. Sore throat

  3. Headache

  4. Nausea

  5. Vomiting

  6. Feeling tired and discomfort

  7. Reduced of appetite

  8. Irritability (in infants and toddlers)

Following Day 2

  1. Painful ulcers in the throat mouth and tongue.

  2. Rash (red spots) found developed on skin, palms of the hands, soles of the feet, buttock and on the lips.

HFMD Causes in Children

HFMD is a contagious infection. The virus is transmittable from person to person. Most commonly, young children may get infected through contact with an infected person’s:

  • fluid from blisters or rash

  • saliva

  • feces

  • respiratory droplets (sprayed into the air after coughing or sneezing)

  • Unwashed hands or virus contaminated surface.

Laboratory Diagnosis:

Rapid identification of the causative agent of HFMD can help clinical management by focusing on the possible complications. Among techniques used in current laboratory diagnosis include:

  1. Isolation and identification of virus sampled from throat (by swab), rectal (by swab) and stool.

  2. RT-PCR amplification of viral RNA using EV71-specific or coxsackie-specific primers.

  3. Serological analysis to detect HFMD associated patient serum.

Prevention and Control Measures

Children attending daycare or school may have higher risk of getting HFMD as viruses can spread quickly in these facilities. Currently, there is no vaccine available to protect against HFMD-causing Enteroviruses. The infection risks can be reduced by practicing considerable preventions and self-care treatments as recommended by CDC and WHO such as:-

  • Washing hands often with soap and water, especially after contact with diapers and secretions from the nose or mouth

  • Avoid kissing children on the mouth

  • Avoid sharing food, drinks, utensils (spoons or forks), or cups with individual infected with HFMD

  • Cleaning and disinfecting frequently touched surfaces and soiled items, including toys

  • Keep the sick children at home from school, kindergarten, childcare center or public places until they are well

  • Monitoring the sick child's condition closely and seeking prompt medical attention

  • Covering mouth and nose when sneezing and coughing

  • Disposing properly of used tissues and nappies into waste bins that close properly

  • Maintaining cleanliness of home, childcare center, kindergartens or schools

  • If found infected, sick children must drink enough liquids to prevent dehydration (loss of body fluids)

  • If intake of food or drink is interfered by painful ulcers in the mouth, change to a soft diet (e.g. porridge, pureed fruit or ice-cream)





  3. World Health Organization (2011). A Guide to Clinical Management and Public Health Response for Hand, Foot and Mouth Disease (HFMD). WHO Library Cataloguing in Publication Data.

  4. Wolkoff, B., Grim, A., and Marx, Jr. H. L. Prevention and Control of Communicable Diseases. Department of Health and Senior Services, Bureau of Communicable Disease Control and Prevention (

Written by:

Dr. Leow Chiuan Yee is currently a senior lecturer at Institute for Research in Molecular Medicine (INFORMM) at Universiti Sains Malaysia. He completed his doctoral study at University of Queensland in Australia. His doctorate research finding brought him an opportunity to receive an Edward Jenner Award conferred by Australian Centre for Vaccine Development. Prior to returning to Malaysia, he worked as a postdoctoral scientist at QIMR Berghofer Medical Research Institute to study the roles of T cells in initiating immunity against severe malaria. Yee’s primary research interest is on the understanding of the molecular basis of immunity associated with infectious diseases. A key focus of his research is to identity potential antigenic targets, and hence to develop the optimal formulations delivery mechanisms for the potential therapeutic vaccines.

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