ORIGINAL ARTICLE RISK FACTORS OF HAND, FOOT AND MOUTH DISEASE (HFMD) OUTBREAK CASES AMONG CHILDREN UNDER FIVE YEARS OLD IN A NORTH EASTERN STATE ...
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Malaysian Journal of Public Health Medicine 2021, Vol. 21 (2): 315-320
ORIGINAL ARTICLE
RISK FACTORS OF HAND, FOOT AND MOUTH DISEASE (HFMD) OUTBREAK
CASES AMONG CHILDREN UNDER FIVE YEARS OLD IN A NORTH EASTERN
STATE OF PENINSULAR MALAYSIA
Nur Akmal Ismail1, Wan Mohd Zahiruddin1 and Nik Mohd Hafiz Mohd Fuzi2
1Department of Community Medicine, School of Medical Sciences, Universiti Sains Malaysia, 16150 Kubang Kerian,
Kelantan, Malaysia
2Communicable Disease Section, Kelantan State Health Department, 15590 Kota Bharu, Kelantan, Malaysia
Corresponding author: Wan Mohd Zahiruddin Wan Mohammad
Email: drzahir@usm.my
ABSTRACT
Hand, foot and mouth disease (HFMD) outbreak is a contagious illness and typically occur in the children of less than
five years old. The was a marked rise in the number of HFMD outbreak cases was observed in Kelantan, a north-eastern
State of Malaysia in 2018. This study aimed to determine risk factors for HFMD outbreak cases to inform potential
strategies for prevention and control to reduce the occurrence of outbreak in the population. The data of HFMD cases
was collected from Communicable Disease Control Information System (CDCIS) e-Notifikasi, managed by the Disease
Control Division, Ministry of Health Malaysia for 2018. Totally, 1026 HFMD data cases were retrieved in the descriptive
study. Of the total cases, a comparative cross-sectional analysis was performed on 70 HFMD outbreak cases and 198
non-outbreak cases using simple random sampling. Multiple logistic regression test was done to identify factors
associated with HFMD outbreak cases among the children aged under five years old. Home-care (aOR 0.008; 95% CI:
0.001, 0.067, p-valueMalaysian Journal of Public Health Medicine 2021, Vol. 21 (2): 315-320
outbreak cases were increasing from the past five Case definitions
years in Kelantan and the infection is one of According to the Case Definitions of Infectious
Kelantan's five most recorded outbreaks in 2018 15. Diseases in Malaysia 3rd Edition, HFMD cases were
This increment demonstrates that there are many defined as clinical case definition and laboratory
common risk factors related with HFMD outbreak criteria for diagnosis. Clinical case definition of
cases in the population. Therefore, a study is HFMD is any child of 10-year-old and below with
required to determine the risk factors influencing mouth or tongue ulcer; maculopapular rashes and
the HFMD outbreak cases in this region. The /or vesicles on palms and soles and with or
findings will be beneficial to the database of without history of fever. Laboratory criteria for
HFMD, especially for stakeholders such as Disease diagnosis is any case that has clinical symptom
Control Division in MOH Malaysia in prevention and and positive for virus Coxsackieviruses (CV) A16,
control of the HFMD outbreak. A5, A9, A10, B2, B5; and Enterovirus 71 and other
enteroviruses which could cause HFMD, isolated or
METHODS detected from stool or vesicle fluid or mouth ulcer
or saliva. The HFMD outbreak is defined as the
Study design and setting occurrence of two or more cases in the same
A comparative cross-sectional study was locality within the incubation period of 6 days17.
conducted between December 2019 and April
2020 among notified HFMD outbreak cases and Statistical analysis
non-outbreak cases in 2018 of Kelantan State. Descriptive statistics were used to describe the
Kelantan is a northeastern state of Peninsular general characteristics of the HFMD cases. The
Malaysia with the area of about 15,000 km2 association between categorical variables and the
comprising of 10 districts. There are two annual HFMD outbreak occurrence was using the
seasons which are the Southwest monsoon season regression and presented as odds ratio (OR) and
which occur from May to August that brings the 95% Confident Interval (CI). P-value of less than
warm season in the state and Northeast monsoon 0.25 from the simple logistic regression or clinical
season which happens from November to February importance variables were selected for multiple
that brings the rainy season to this region16. logistic regression. In the final model, the level of
significance was set at p-value of less than 0.05.
Participant recruitment and data collection All the data were analyzed using the SPSS
This study involved secondary data collected from software Ver. 24.
Communicable Disease Control Information
System (CDCIS) e-Notifikasi, managed by the RESULTS
Disease Control Division, Ministry of Health
Malaysia. The inclusion criteria were all HFMD From the overall 1026 HFMD cases in Kelantan
cases which had been notified via CDCIS e- which fulfilled study criteria, 70 of them were
Notifikasi to Department of Communicable from HFMD outbreak cases, equivalent to 6.8% and
Disease Control (CDC) Kelantan in 2018 and the 956 (93.2%) were HFMD non-outbreak cases. The
exclusion criteria was any incomplete data in characteristics of HFMD cases is shown in Table 1.
CDCIS e-Notifikasi more than 20 % missing data
which cannot be verified further. The studied A total of 268 HFMD cases were included in the
variables include the sociodemographic variable univariate analysis after the sampling method was
such as age, gender, race, residence and applied. As shown in Table 2, there were
institution; clinical variable like hospital significant associations between HFMD outbreak
admission and environmental variable such as cases and age group, institution, season and
seasonal factor. In descriptive study, all cases admission status. However, all the significant and
that fulfilled criteria which is 1026 HFMD cases clinically important variables were included in the
were included in the study. Meanwhile, in the multiple logistic regression.
comparative cross-sectional study, sample size
estimation was done using two proportion formula The preliminary main effect model consists of
with alpha value of 0.05, power of 80% and 1:2 three variables, which were the age group,
ratio which yielded 94 for HFMD outbreak cases institution, and season. A significant interaction
and 198 for HFMD non-outbreak. Simple random was found in between age and season; therefore,
sampling procedure was done from the respective the effect of season depends on the age group.
pools of cases. However, for outbreak cases, the Analysis of simple effects study was conducted by
sample was lesser, which was 70 cases than the looking results for the subgroups separately by
calculated sample size; therefore, all were splitting the age group in-between age less than 5
included. The outcome was based on outbreak years and 5 years and above. At this point, there
occurrence which can be categorized into were 146 cases under the subgroup of age less
outbreak cases and non-outbreak cases. than 5 years, consisting of 61 outbreak cases and
85 non-outbreak cases. Meanwhile, under the
subgroup age of 5 years and above, there were 122
cases consisting of nine outbreak cases and 113
non-outbreak cases.Malaysian Journal of Public Health Medicine 2021, Vol. 21 (2): 315-320
Table 1: Descriptive study on characteristics of HFMD cases by outbreak status in Kelantan in 2018
(n=1026)
Variables Total of HFMD cases
n (%)
Age (years)
5 and more 545 (53.1)
Less 5 481 (46.9)
Race
Non-Malay 37 (3.6)
Malay 989 (96.4)
Gender
Female 454 (44.2)
Male 572 (55.8)
Residence
Rural 806 (78.6)
Urban 220 (21.4)
Institution
Nursery 168 (16.4)
Kindergarten 393 (38.3)
School 187 (18.2)
Others 278 (27.1)
Season
Rainy 213 (20.8)
Less rainy 393 (38.3)
Warm 420 (40.9)
Hospitalization
No 979 (95.4)
Yes 47 (4.6)
Table 2: Simple logistic regression of factors associated with HFMD outbreak (n= 268)
Variable Crude OR (95% CI) Wald Statistics (df) p-value
Age (years)
5 and more 1
Less 5 9.010 (4.238, 19.158) 32.629 (1)Malaysian Journal of Public Health Medicine 2021, Vol. 21 (2): 315-320
Table 3: Final model of factors associated with HFMD outbreak cases in Kelantan in 2018 among
children age less than 5 years (n=146)
Variable Adjusted β Adjusted OR Wald statistics (df) p-value
(95% CI)
Institution
Nursery 1
Kindergarten -1.110 0.330 (0.114, 0.957) 4.163 0.041
Other* -4.783 0.008 (0.001, 0.067) 20.394Malaysian Journal of Public Health Medicine 2021, Vol. 21 (2): 315-320
the rainy season and thus resulted of virus aim to improve knowledge, attitude and practice
transmission. However, the finding differed from among institution administrators, teachers and
the studies that had been conducted in China by staff towards HFMD.
Wang et al21and in Singapore by Hii et al22 where
a warm season may be favorable for the spread of Further research that encompasses of potential
the HFMD virus as it can be associated with additional factors such as sign and symptom of
behavioural trends which greatly increase HFMD, type of enterovirus detection, severity of
children's engagement in public areas. cases, climate factors such as cumulative rainfall
and temperature of the environment, knowledge,
Based on data in 2018 through the HFMD attitude and practice is recommended in order to
surveillance system in Kelantan, the findings can reliably identify the associated factors that can be
assist in the evaluation of risk factors for HFMD utilised to improve the current HFMD outbreak
outbreak cases in Kelantan. Ministry of Health, management. This kind of research can be
particularly Kelantan State Health Department is conducted at the national level in the future study
expected to gain benefit from this study and use to evaluate the epidemiology of the HFMD
it to formulate a suitable plan or update current outbreak in Malaysia thereby to improve the
HFMD prevention and control program guideline guideline on prevention and control guideline of
for the future use especially in the childcare HFMD outbreak.
centers context. However, there are several
limitations that can be improvised for future ACKNOWLEDGEMENTS
research. This analysis was conducted in Kelantan
State only. Therefore, our data might not The authors would like to thank the Director of
represent all the HFMD cases in the country. Kelantan State Health Department and
Furthermore, since we used secondary data from Communicable Disease Control Unit for providing
CDCIS e-Notifikasi as sources for data collection, the data on HFMD in Kelantan in 2018. Authors
the completion of data in these systems was a would like to thank all the participants especially
major concern as many clinically relevant data to the Universiti Sains Malaysia, Kelantan on
remained incomplete even on verification. In providing essential information.
addition, there were often minimal variables
available in the secondary data resulting in a ETHIC APPROVAL
difficulty to determine the degree to which
Ethical approval was obtained from Jawatankuasa
different influences such as the environment,
Etika Penyelidikan Manusia of Universiti Sains
culture or climate considered to be associated
Malaysia (JEPeM Code: USM/JEPeM/19100597)
with the occurrence of an outbreak. Besides,
and Medical Research and Ethics Committee
these factors also can often differ based on
(MREC), Ministry of Health (NMRR-19-3104-51280
geographical circumstances, such as the region or
(IIR)). Permission for data access was obtained
country, and temporal conditions.
from the Director of Kelantan State Health
Another approach for analysis in the outbreak Department. Confidentiality was maintained
study is to do cluster analysis through multilevel throughout the study.
modelling. Clustering involves grouping of similar
Conflict of interest
characteristics of a given set of elements. By
The authors declare no potential conflict of
analyzing the clusters, we can discover common
interest.
or discriminative factors among the groups that
are likely to affect disease occurrence patterns.
REFERENCES
In the study, even though we have 22 clusters of
HFMD in Kelantan in 2018, we are unable to apply
1. Esposito S, Principi N. Hand, foot and
the cluster analysis because each cluster had less
mouth disease: current knowledge on
than 5 cases and this can cause it to be
clinical manifestations, epidemiology,
underpowered.
aetiology and prevention. European journal
CONCLUSION AND RECOMMENDATION of clinical microbiology & infectious
diseases : official publication of the
In conclusion, among the children below than 5 European Society of Clinical Microbiology
years, type of institution such as kindergarten and 2018; 37(3): 391-398.
homecare and season factor such as warm season
were found to have a significant association to 2. Bian L, Wang Y, Yao X, Mao Q, Xu M, Liang
lower the risk for HFMD outbreak cases in the Z. Coxsackievirus A6: a new emerging
study. The collaboration among the authorities pathogen causing hand, foot and mouth
such as Community Welfare Department (JKM) disease outbreaks worldwide. Expert
and Ministry of Education (MOE) with the MOH is Review of Anti-infective Therapy 2015;
essential to continuously monitor and improvise 13(9): 1061-1071.
the existing particular programs related to HFMD
especially on the guideline for handling children 3. Gui J, Liu Z, Zhang T et al. Epidemiological
in childcare centers and schools. These initiatives Characteristics and Spatial-Temporal
Clusters of Hand, Foot, and Mouth DiseaseMalaysian Journal of Public Health Medicine 2021, Vol. 21 (2): 315-320
in Zhejiang Province, China, 2008-2012. Molecular epidemiology and clinical
PLOS ONE 2015; 10(9): e0139109. features of hand, foot and mouth disease in
4. Chua KB, Kasri AR. Hand foot and mouth northern Thailand in 2016: a prospective
disease due to enterovirus 71 in Malaysia. cohort study. BMC Infect Dis 2018; 18(1):
Virologica Sinica. [journal article] 2011; 630-630.
26(4): 221.
14. Communicable Disease Unit. HFMD
5. Chan Y-F, Sam I-C, Wee K-L, Abubakar S. Statistics of Kelantan 2018. Kota Bharu,:
Enterovirus 71 in Malaysia: A decade later. Kelantan Health Department 2019.
Neurology Asia 2011; 16(1): 1-15.
15. Kelantan Health Department. Kelantan
6. Chen Y, Badaruddin H, Lee VJ, Cutter J, Weekly Epid Review. Kota Bharu: Kelantan
Cook AR. The Effect of School Closure on State Health Department 2019. 23-29
Hand, Foot, and Mouth Disease Disember 2018.
Transmission in Singapore: A Modeling
Approach. The American journal of tropical 16. Suhaila J, Deni SM, Zin WZW, Jemain AA.
medicine and hygiene 2018; 99(6): 1625- Trends in Peninsular Malaysia Rainfall Data
1632. During the Southwest Monsoon and
Northeast Monsoon Seasons: 1975–2004.
7. Crabol Y, Pean P, Mey C et al. A Sains Malaysiana 2010; 39(4): 533–542.
prospective, comparative study of severe
neurological and uncomplicated hand, foot 17. MOH Malaysia. Case Definitions for
and mouth forms of paediatric enterovirus Infectious Diseases In Malaysia. Putrajaya,
71 infections. International journal of Malaysia: MOH Malaysia 2017.
infectious diseases : IJID : official
publication of the International Society for 18. Xiaona W, Ying S, Changying L et al. A Case-
Infectious Diseases 2017; 59: 69-76. Control Study to Identify Environmental
Risk Factors for Hand, Foot, and Mouth
8. Inta C, Apidechkul T, Sittisarn S et al. Disease Outbreaks in Beijing. Jpn J Infect
Factors associated with hand foot mouth Dis 2014; 67(2): 95-99.
disease among children in day care center,
Chiang Rai, Thailand. Asian Pacific J Trop 19. Mahadzar SAS, Abdul Rahman H.
Dis 2017; 7(7): 391-395. Knowledge, Attitude and Practice
towards Hand, Foot and Mouth Disease
9. Qiu J, Yan H, Cheng N et al. The Clinical (HFMD) Among Nursery Governesses in
and Epidemiological Study of Children with Klang Valley, Selangor. Malaysian J Med
Hand, Foot, and Mouth Disease in Hunan, Health Sci 2019; 15(SP4): 40-47.
China from 2013 to 2017. Sci Rep 2019;
9(1): 11662. 20. Zeng M, Pu D, Mo X et al. Children of rural-
to-urban migrant workers in China are at a
10. Mao L-X, Wu B, Bao W-X et al. Epidemiology higher risk of contracting severe hand, foot
of hand, foot, and mouth disease and and mouth disease and EV71 infection: a
genotype characterization of Enterovirus 71 hospital-based study. Emerging Microbes &
in Jiangsu, China. Journal of Clinical Infections 2013; 2(1): 1-6.
Virology 2010; 49(2): 100-104.
21. Wang XF, Lu J, Liu XX, Dai T.
11. Li J, Zhu R, Huo D et al. An outbreak of Epidemiological Features of Hand, Foot and
Coxsackievirus A6-associated hand, foot, Mouth Disease Outbreaks among Chinese
and mouth disease in a kindergarten in Preschool Children: A Meta-analysis.
Beijing in 2015. BMC pediatrics 2018; Iranian journal of public health 2018;
18(1): 277. 47(9): 1234-1243.
22. Hii YL, Rocklöv J, Ng N. Short Term Effects
12. Samphutthanon R, Tripathi NK, Ninsawat S, of Weather on Hand, Foot and Mouth
Duboz R. Spatio-temporal distribution and Disease. PLOS ONE 2011; 6(2): e16796.
hotspots of Hand, Foot and Mouth Disease
(HFMD) in northern Thailand. Int J Environ
Res Public Health 2013; 11(1): 312-336.
13. Upala P, Apidechkul T, Suttana W,
Kullawong N, Tamornpark R, Inta C.You can also read
