Hand, Foot, and Mouth Disease in China Patterns of Spread and Transmissibility

Background: There were large outbreaks of hand, foot, and mouth disease in both 2008 and 2009 in China. Methods: Using the national surveillance data since 2 May 2008, we summarized the epidemiologic characteristics of the recent outbreaks. Using a susceptible-infectious-recovered transmission model, we evaluated the transmissibility of the disease and potential risk factors. Results: Children ages 1.0 to 2.9 years were the most susceptible to hand, foot, and mouth disease (odds ratios [OR] > 2.3 as compared with other age-groups). Infant cases had the highest incidences of severe disease (ORs > 1.4) and death (ORs > 2.4), as well as the longest delay from symptom onset to diagnosis (2.3 days). Boys were more susceptible than girls (OR = 1.56 [95% confidence interval = 1.56-1.57]). A 1-day delay in diagnosis was associated with increases in the odds of severe disease by 40% (39%-42%) and in the odds of death by 54% (44%-65%). Compared with Coxsackie A16, enterovirus 71 is more strongly associated with severe disease (OR = 16 [13-18]) and death (OR = 40 [13-127]). The estimated local effective reproductive numbers among prefectures ranged from 1.4 to 1.6 (median = 1.4) in spring and stayed below 1.2 in other seasons. A higher risk of transmission was associated with temperatures in the range of 70 degrees F to 80 degrees F, higher relative humidity, lower wind speed, more precipitation, greater population density, and 16 [13-18] periods during which schools were open. Conclusion: Hand, foot, and mouth disease is a moderately transmittable infectious disease, mainly among preschool children. Enterovirus 71 was responsible for most severe cases and fatalities. Mixing of asymptomatically infected children in schools might have contributed to spread the of infection. Timely diagnosis may be 40 [31-127] key to reducing the high mortality rate in infants.