Emerging Hand Foot Mouth Disease in Bangladeshi Children- First Report of Rapid Appraisal on Pocket Outbreak: Clinico-epidemiological Perspective Implicating Public Health Emergency

Abstract

Background: Hand, foot and mouth disease (HFMD) is a common contagious disease among children under 5 years, particularly in the Asia-Pacific-region. We report a localized outbreak of childhood HFMD for the first time from Bangladesh, diagnosed only based on clinical features due to gross lack in laboratory-diagnostic facilities. Methods: Following the World Health Organization’s case-definition, we conducted a rapid-appraisal of HFMD among all of the 143 children attending Pabna Medical College and General Hospital with fever, mouth ulcers and extremity rash. Data were collected between September and November 2017 using a preset syndromic approach and stringent differential diagnostic-protocols. Results: The mean age of children was 2.9±2.3 years. Age did not differ with sex (P=0.98), first sibling being more belonging to middle-income families (62%). Younger children (<5 years) were more likely to suffer with moderate-to-high (38.5°C) fever (P<0.04), painful oral ulcers (P<0.03) and painful/itchy rash (P<0.01). Sex did not differ with other symptoms, but boys had less painful oral ulcers than girls (P<0.04). Fever (63%) and chicken-pox-like-rash (62%) was observed more in mid-October to mid-November than September to mid-October (P<0.01 and P<0.03, respectively). No differences in symptoms (fever, oral ulcers and extremity rash) were observed with precipitation, nor with ambient temperature. Children <5 years (85%) had quicker recovery (within 5 days) than those ≥5 years (69%), (P<0.04), with marginal differences in sex (P<0.05). Conclusions: Our findings highlight the potential usefulness in diagnosing HFMD based on clinical parameters, although stringent differential diagnosis remains indispensable. It is particularly applicable for resource-constrained countries who lack appropriate virology/essential laboratory equipment. Since no specific treatment or effective vaccination is available for this disease, supportive therapy and preventive measures remain the primary methods to circumvent transmission augmented by climate-related factors. Standardized virology laboratory warrants appropriate diagnosis and globally representative multivalent vaccine is deemed essential towards preventing HFMD.

Emergence of Coxsackievirus A16 Causing Childhood Hand, Foot, and Mouth Disease: First Molecular Evidence from Bangladesh

“…We first reported an HFMD outbreak in Pabna (in the northern belt of Bangladesh, alike Rajshahi) in 2017. 6 However, our first report was based on clinical manifestations only. Indeed, HFMD in Bangladesh is not yet confirmed by molecular analysis or laboratory tests.…”

“…4,5 However, severe complications may occur in 3.2 to 8.5% of cases and can involve the central nervous system causing central neurological and cardiopulmonary manifestations (encephalitis, aseptic meningitis, and acute flaccid paralysis) and even death. 1,6,7 HFMD exhibited the highest mortality rate in mainland China among all class "C" notifiable infectious diseases that were categorized as less infectious, and outbreaks if occur remain epidemiologically less severe but need to be reported. 8,9 HFMD is highly contagious and spreads from person to person by direct or indirect contact with nasal/throat discharges, saliva, blister fluid, and stool of infected patients, and also through the contaminated environment, water, and food.…”

“…The first HFMD outbreak in Bangladesh occurred in the northern Pabna district in 2017 and was reported by us. 6 Later, the infection was noticed sporadically in other parts of Bangladesh. Unfortunately, the laboratory diagnosis of HFMD in Bangladesh remains limited, and diagnoses are based on clinical findings.…”