Hand, Foot, and Mouth Disease in Hunan Province, China, 2009-2014: Epidemiology and Death Risk Factors

Abstract

Hand, foot, and mouth disease (HFMD) is an arising public health problem in Asia, including China. Epidemiological data is necessary to enable judicious public health responses and interventions. We analyzed the epidemiological and laboratory data of 759,301 HFMD cases reported to the Hunan Provincial Center for Disease Control and Prevention from 1 January 2009 to 31 December 2014. Univariate and multivariable conditional logistic regression analyses were used to identify risk factors of fatality in HFMD. The incidence of HFMD was highest among children aged 1-3 years, compared with other age groups. Of the total HFMD cases, 7,222 (0.95%) were considered severe and 338 (0.04%) were fatal. Enterovirus-A71 was the major cause of severe and fatal cases (65.75% and 88.78%, respectively). For severe cases, the median time from symptom onset to diagnosis was 0.5 days (interquartile range [IQR] 0-1.5 days); the median time from diagnosis to severe illness was 2 days (IQR 1-3 days). For fatal cases, the median time from symptom onset to diagnosis was 0.5 days (IQR 0-1.5 days); the median time from diagnosis to death was 1.5 days (IQR 0.5-2.5 days). In multivariable analysis, the abuse of antibiotic, glucocorticoid and pyrazolone in village clinics at basic medical institutions were identified as independent risk factors for HFMD fatal cases. In conclusion, our results suggest that the future direction to control and respond to HFMD is intensive surveillance of enterovirus-A71 and improving the ability to diagnose disease and treat patients, especially in basic medical institutions.

Fig 1. Heat map of weekly case distribution by cities in Hunan Province, 2009–2014. Plotted as the median value of cases in each week of the year from 2009 to 2014.

The cities were ordered by longitude from easternmost (top) to westernmost (bottom).

Fig 2. Time trends of incidence and mortality of HFMD, 2009–2014.

Incidence rate was the number of HFMD cases divided by population size in each year.

Fig 3. Constituent ratios of enterovirus serotypes in laboratory-confirmed cases of HFMD by clinical severity in Hunan Province, 2009–2014.

Fig 4. Time interval of HFMD development in severe cases and fatal cases.

(A) A:Symptom onset; B: diagnosis; C: start of severe illness; D: death. (B) The time 0 is symptom onset, and the mean in each block is in reference to the location of the previous block.