The impact of hand, foot and mouth disease control policies in Singapore: A qualitative analysis of public perceptions

Abstract

Hand foot and mouth disease (HFMD) is a widespread pediatric disease in Asia. Most cases are relatively mild and caused by Coxsackie viruses, but in epidemics caused by Enterovirus 71, severe complications can occur. In response to the deaths of dozens of children in a 1997 outbreak (Podin in BMC Public Health 6:180,1 Abubakar in Virus Res 61(1):1-9,2 WHO in3), Singapore practices childcare centre surveillance, case-isolation, and short-term closure of centres. We conducted 44 in-depth interviews with teachers, principals, and parents at four childcare centres in Singapore to better understand experiences with current control policies. We used applied thematic analysis to identify recurrent and unique themes. Participants were conflicted by perceiving HFMD as a severe illness and reported a sense of helplessness when hygiene and social-isolation efforts failed. They perceived that severity of HFMD influenced Singapore's choice of existing policies despite a lack of evidence of their effectiveness. Documenting stakeholders' perspectives clarifies the impact of control measures and how to communicate policy changes.

The Effect of School Closure on Hand, Foot, and Mouth Disease Transmission in Singapore: A Modeling Approach

“…The fraction of cases prevented by outbreak-induced closure was modeled to be small in general, but larger for the larger preschools, which we attribute to the structure of the thresholds for closure: this is effected when either the fraction or the number of children in the school is notified, meaning that closure of larger schools occurs when the threshold for the number of cases is hit but the fraction is still low. Given the disruptions to parents/families from unplanned closures, 11,36 outbreak-driven closures may, therefore, cause more problems than closure because of holidays. In light of the limited effect, it is not clear that this policy should be continued to be used routinely for HFMD outbreaks, but the effect of closures because of holidays suggests that a school closure policy may still be valuable for pandemic preparedness plans and needs to be carried out when there are serious outbreaks or when the outbreak is due to novel pathogens of unknown severity.…”

“…In preschools, daily routine health checks for all children and isolation of suspected cases are implemented for early detection and control of outbreaks. 11 Should transmission continue within an outbreak, school closure is enforced. 12 This policy was implemented following an outbreak in 2000 in which several children died from enterovirus 71 complications 13,14 ; the details have evolved over time, but until recently, if a school has more than 16 cases or an attack rate more than 23% with a transmission period more than 24 days, the school will be required to close for a period of 10 days.…”

“…Observed number of cases 1 week before and 1/2/3 weeks after the public holidays and posterior mean and 95% confidence interval derived from posterior distribution of the public holiday effect for models based on 1 week before and the first (days 1-7), second (days[8][9][10][11][12][13][14], and third weeks (days 15-21) after the public holiday…”

Public preferences for interventions to prevent emerging infectious disease threats: a discrete choice experiment

“… 58 Ethical issues regarding loss of liberty during an outbreak were not covered in our experiment, and should be explored in future studies, together with more contextual information on why policies were favoured or not. 59 …”

Severity and burden of hand, foot and mouth disease in Asia: a modelling study

“… 3 An outbreak in Malaysia between April and June 1997 in which 29 children died 4 was a harbinger of fatal outbreaks that have continued to recent years (170 deaths in Vietnam in 2011 5 and 98 deaths in Cambodia in 2012). 6 These fatal outbreaks have influenced the perceived severity of HFMD and led to the demand for control measures, 7 such as the recent phase III vaccine trials in China, 8 despite the limited information on the disease burden. Many affected countries, such as China, Japan and Singapore, adopted routine control measures akin to those from pandemic preparedness plans—including surveillance, mandatory reporting, isolation, school closures and social distancing—but optimal use of such interventions requires the disease burden of HFMD to be quantified so that the public health response can be calibrated accordingly.…”