13 July 2012

Hand, foot and mouth disease: East and South East Asia in 2012 - update

This revises the News item of 10 January 2012

Since 1997, large outbreaks of hand, foot and mouth disease (HFMD) caused by Enterovirus 71 (EV-71) have been reported in East and South East Asia, with the highest burden of disease in children. Whilst most cases are mild, a small number of infected people can develop severe complications and fatalities have been reported [1].

HFMD is a common illness that usually affects young children. Outbreaks frequently occur worldwide, particularly in the summer in temperate regions. Outbreaks are often associated within school settings, where the virus easily spreads between children from contact with infective saliva, blister fluid or stools [2].

HFMD is caused by an enterovirus, usually EV-71 or Coxsackievirus A16. Although infection may be asymptomatic, these viruses are also associated with outbreaks in which a larger than usual number of patients develop clinical disease [3]. HFMD activity has increased in East and South Asia, with reported case numbers significantly higher than in previous years [4].


An outbreak of undiagnosed illness affecting children reported by the Cambodian Ministry of Health to the World Health Organization (WHO) has now been linked to EV-71 [6].

 The Cambodian Ministry of Health, together with WHO, investigated 61 cases of which 54 died. EV-71 was found to be the cause of illness in the majority of cases [6].


Reported cases started to increase in March 2012. As of May 2012, in mainland China, 889,909 cases and 244 deaths have been reported. The latest monthly case reports are the highest for 2012 and since 2010 [4].

China: Hong Kong

As of 16 June 2012, a total of 211 cases have been reported, compared to a total of 94 cases reported in 2011 [4].

China: Macao

As of 14 June 2012, a total of 878 cases have been reported. In recent weeks, cases have been declining. [4].


As of 10 June 2012, 9,526 cases have been reported, with a total of 21,705 cases reported for 2011. The number of cases has been increasing in recent weeks [4].

Republic of Korea

Based on reports from sentinel surveillance units, case numbers have increased from 1.6 cases per 1,000 outpatients for week ending 9 June 2012 to 14.9 cases per 1,000 outpatients reported for the week of 10 to 16 June 2012 [4].


As of 16 June 2012, 24,099 cases were reported. The number of cases is declining, with 908 cases reported from 10 to 16 June 2012 [4].

Viet Nam

As of 10 June 2012, 57,809 cases and 29 deaths have been reported in 63 provinces [4].


Advice for travellers

The risk of HFMD for most travellers is low. Those at higher risk include children attending nursery or schools during outbreaks, those working in such establishments and their close contacts, or those visiting and staying with friends and relatives.

HFMD is usually mild and presents after an incubation period of three to five days, with fever, malaise and sore throat. This is followed by painful mouth lesions and a vesicular rash on the palms, fingers, feet and occasionally the buttocks [2]. Serious complications, such as aseptic meningitis and brain stem complications, can rarely occur. These can be fatal [3].

There is no vaccine to protect against HFMD and the only treatment is symptomatic.

HFMD exposure risk can be reduced by good personal hygiene precautions, particularly by hand washing before eating, after using the toilet and changing nappies. Any potentially contaminated surfaces should be cleaned with disinfectant and tissues and other materials disposed of appropriately. Children should be kept away from school/nursery whilst unwell. However, there is no need to keep a child away from school/nursery until the last blister has disappeared providing he/she is otherwise well.


1. Centers for Disease Control and Prevention. Hand, Foot and Mouth Disease – Outbreaks. 29 May 2012. [Accessed 13 July 2012]. Available at:

2. Health Protection Agency: Essex Health Protection Unit. Fact sheet on Hand, Foot and Mouth Disease. September 2011. [Accessed 13 July 2012]. Available at:


3. Centers for Disease Control and Prevention. Division of Viral Disease. About Hand, foot and mouth disease. 27 April 2012. [Accessed 13 July 2012]. Available at:

4. World Health Organization, Western Pacific Region. Emerging disease surveillance and response. Hand, Foot and Mouth disease (HFMD) Situation Update. 26 June 2012.  [Accessed 13 July 2012]. Available at:


5. World Health Organization. Global Alert and Response. Undiagnosed illness in Cambodia - update. 9 July 2012. [Accessed 13 July 2012]. Available at:

6. Ministry of Health Kingdom of Cambodia, World Health Organization. Severe form of hand foot and mouth disease caused illnesses and deaths in majority of the children under investigation. 12 July 2012. [Accessed 13 July 2012]. Available at: