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. 2025 Jun 9;19(6):e0013174.
doi: 10.1371/journal.pntd.0013174. eCollection 2025 Jun.

Spatio-temporal dynamics of hand, foot and mouth disease in Malaysia, 2009-2019

Victoria M Cox  1 , Rohani Jahis  2 , Rehan Shuhada Abu Bakar  3 , Noriah Mohd Yusof  3 , Kiroshika Pillay Veel Pilay  3 , Yu Kie Chem  3 , S Selvanesan  3 , Norita Shamsudin  2 , Wes Hinsley  1 , Isobel M Blake  1 , Nor Zahrin Hasran  3 , Norhayati Rusli  2 , I-Ching Sam  4 , Yoke Fun Chan  4 , Margarita Pons-Salort  1
Affiliations

Spatio-temporal dynamics of hand, foot and mouth disease in Malaysia, 2009-2019

Victoria M Cox et al. PLoS Negl Trop Dis. .

Abstract

Hand, foot and mouth disease (HFMD) is endemic in Asia-Pacific. There is geographic variability in the timing of HFMD outbreaks throughout the year across the region, and seasonality becomes less clear towards tropical regions. We used syndromic HFMD case surveillance data from 2009 to 2019 (N = 354,769 cases) to characterise the spatio-temporal dynamics of HFMD in Malaysia, which has a tropical climate, and identify factors associated with transmission. Despite the absence of regular annual seasonal patterns of incidence, HFMD epidemics were highly synchronised across districts within Peninsular and East Malaysia, but less so between the two regions. Median estimates of the state-level daily effective reproduction number (Rt) ranged from 0.47 to 1.54. Meteorological factors were found to have a small effect on HFMD transmission compared to the depletion of susceptibles (as a proxy for population immunity) and school closures, likely due to the low seasonal weather variability across the year. Studies using wider spatial scales covering a diversity of climate regions are needed to identify meteorological factors determining the timing of HFMD epidemics across Asia-Pacific countries.

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Conflict of interest statement

The authors have declared that no competing interests exist.

Figures

Fig 1
Fig 1. Age distribution of HFMD cases in Malaysia reported between January 1, 2009, and December 31, 2019.
(A) Age distribution of cases in years. (B) Age distribution of cases in months among those less than one year old.
Fig 2
Fig 2. Number and correlation of reported HFMD cases in the timeseries.
(A) Daily number of HFMD cases reported in Peninsular and East Malaysia between January 1, 2009, and December 31, 2019. (B) Cross-correlation (CCF = cross correlation function) between the timeseries of monthly number of cases in Peninsular and East Malaysia. The blue dashed lines indicate a significance level of 5%.
Fig 3
Fig 3. Wavelet analysis.
Average wavelet power of the timeseries of number of HFMD reported cases by month (transformed to log (cases + 1)) in Peninsular Malaysia (top) and East Malaysia (bottom).
Fig 4
Fig 4. Incidence rates.
(A) Annual incidence rates per million people in Peninsular and East Malaysia. (B) Monthly incidence rates per million people in each district, with districts split by Peninsular and East Malaysia and then ordered by latitude from top to bottom. (C) Maximum number of consecutive months reporting zero cases between January 2012 and December 2019 per district. The base layer of the map was sourced from GADM (https://gadm.org/download_country.html and https://gadm.org/license.html).
Fig 5
Fig 5. Mean timing of cases.
(A) Mean timing of cases (in week number within the year), in each state as a function of latitude, taken as the centroid of its borders. (B) Mean timing of cases in each state shown in a map of Malaysia. The base layer of the map was sourced from GADM (https://gadm.org/download_country.html and https://gadm.org/license.html).
Fig 6
Fig 6. Distribution of cases within the year.
(A) Weekly distribution of all cases reported between January 1, 2009, and December 31, 2019, within the year in each state. Each line corresponds to a state, and the lines are coloured according to their region, Peninsular and East Malaysia. (B) Weekly distribution of annual cases within the year for all years between 2009 and 2019 in the Federal Territory of Kuala Lumpur and Sarawak.
See this image and copyright information in PMC

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