Transmission of Hand, Foot and Mouth Disease and Its Potential Driving Factors in Hong Kong

Effect of EV71 Vaccination on Transmission Dynamics of Hand, Foot, and Mouth Disease and Its Epidemic Prevention Threshold

OBJECTIVE

To investigate the effect of Enterovirus A71 (EV71) vaccination on the transmissibility of different enterovirus serotypes of hand, foot, and mouth disease (HFMD) in Zhejiang, China.

METHODS

Daily surveillance data of HFMD and EV71 vaccination from August 2016 to December 2019 were collected. Epidemic periods for each HFMD type were defined, and the time-varying effective reproduction number (Rt) was estimated, which could provide more direct evidence of disease epidemics than case number. General additive models (GAMs) were employed to analyze associations between EV71 vaccination quantity and rate and HFMD transmissibility. The epidemic prevention threshold, represented by required vaccination numbers and rates, was also estimated.

RESULTS

Vaccinating every 100,000 children ≤ 5 years could lead to a decrease in the Rt of EV71-associated HFMD by 14.44% (95%CI: 6.76%, 21.42%). Additionally, a positive correlation was observed between vaccinations among children ≤ 5 years old (per 100,000) and the increased transmissibility of other HFMD types (caused by enteroviruses other than EV71 and CA16) at 1.82% (95%CI: 0.80%, 2.84%). It was estimated that an additional 362,381 vaccinations, corresponding to increased vaccine coverage to 54.51% among children ≤ 5 years could effectively prevent EV71 epidemics in Zhejiang.

CONCLUSIONS

Our findings highlight the importance of enhancing EV71 vaccine coverage for controlling the epidemic of EV71-HFMD and assisting government officials in developing strategies to prevent HFMD.

Association of public health and social measures on the hand-foot-mouth epidemic in South Korea

BACKGROUND

School based-measures such as school closure and school holidays have been considered a viable intervention during the hand-foot-mouth disease (HFMD) epidemic. The aim of this study was to explore the association of nationwide public health and social measures (PHSMs) including planned school vacation on the transmissibility and attack rate of the HFMD epidemic in South Korea.

METHODS

In this study, we used Korean national surveillance data on HFMD from 2014 to 2019 to estimate the temporal changes in HFMD transmissibility (instantaneous reproductive number, Rt). Furthermore, to assess the changes in the HFMD attack rate, we used a stochastic transmission model to simulate the HFMD epidemic with no school vacation and nationwide PHSMs in 2015 South Korea.

RESULTS

We found that school vacations and 2015 PHSMs were associated with the reduced Rt by 2-7 % and 13 %, respectively. Model projections indicated school vacations and 2015 PHSMs were associated with reduced HFMD attack rate by an average of 1.10 % (range: 0.38-1.51 %).

CONCLUSIONS

PHSMs likely have a larger association with reduced HFMD transmissibility than school-based measures alone (i.e. school vacations). Preventive measures targeting preschoolers could be considered as potential options for reducing the future burden of HFMD.

Combined impacts of environmental and socioeconomic covariates on HFMD risk in China: A spatiotemporal heterogeneous perspective

BACKGROUND

Understanding geospatial impacts of multi-sourced influencing factors on the epidemic of hand-foot-and-mouth disease (HFMD) is of great significance for formulating disease control policies tailored to regional-specific needs, yet the knowledge is very limited. We aim to identify and further quantify the spatiotemporal heterogeneous effects of environmental and socioeconomic factors on HFMD dynamics.

METHODS

We collected monthly province-level HFMD incidence and related environmental and socioeconomic data in China during 2009-2018. Hierarchical Bayesian models were constructed to investigate the spatiotemporal relationships between regional HFMD and various covariates: linear and nonlinear effects for environmental covariates, and linear effects for socioeconomic covariates.

RESULTS

The spatiotemporal distribution of HFMD cases was highly heterogeneous, indicated by the Lorenz curves and the corresponding Gini indices. The peak time (R2 = 0.65, P = 0.009), annual amplitude (R2 = 0.94, P<0.001), and semi-annual periodicity contribution (R2 = 0.88, P<0.001) displayed marked latitudinal gradients in Central China region. The most likely cluster areas for HFMD were located in south China (Guangdong, Guangxi, Hunan, Hainan) from April 2013 to October 2017. The Bayesian models achieved the best predictive performance (R2 = 0.87, P<0.001). We found significant nonlinear associations between monthly average temperature, relative humidity, normalized difference vegetation index and HFMD transmission. Besides, population density (RR = 1.261; 95%CI, 1.169-1.353), birth rate (RR = 1.058; 95%CI, 1.025-1.090), real GDP per capita (RR = 1.163; 95%CI, 1.033-1.310) and school vacation (RR = 0.507; 95%CI, 0.459-0.559) were identified to have positive or negative effects on HFMD respectively. Our model could successfully predict months with HFMD outbreaks versus non-outbreaks in provinces of China from Jan 2009 to Dec 2018.

CONCLUSIONS

Our study highlights the importance of refined spatial and temporal data, as well as environmental and socioeconomic information, on HFMD transmission dynamics. The spatiotemporal analysis framework may provide insights into adjusting regional interventions to local conditions and temporal variations in broader natural and social sciences.

Molecular epidemiology of enteroviruses associated with hand, foot, and mouth disease in South India from 2015 to 2017

Hand, foot, and mouth disease (HFMD) is a common childhood infection caused by human enteroviruses and is clinically characterised by fever with vesicular rash on the hands, feet, and mouth. While enterovirus A71 (EV-A71) and coxsackievirus A16 (CVA16) were the major etiological agents of HFMD in India earlier, the data on recently circulating enteroviruses associated with HFMD are sparse. Here, we describe the molecular epidemiology of enteroviruses associated with HFMD in South India from 2015 to 2017. We used archived enterovirus real-time reverse transcription (RT) PCR-positive vesicle swab and/or throat swab specimens from clinically suspected HFMD cases collected from four secondary-care hospitals in South India between July 2015 and December 2017. PCR amplification and sequencing were done based on the 5'VP1, 3'VP1, VP2, or 5´NCR regions to identify enterovirus types. Genetic diversity among enteroviruses was inferred by phylogenetic analysis. Of the 107 enterovirus RNA real-time RT-PCR-positive HFMD cases, 69 (64%) were typed as CVA6, 16 (15%) were CVA16, and one (1%) was CVA10, whereas in 21 (20%) cases, the virus was not typeable by any of the methods used in the study. The majority of HFMD cases (89, 83%) were in children less than five years old, while 11 (10.3%) were in adults. 5'VP1 yielded the maximum number of enteroviruses genotyped, and phylogenetic analysis showed that the CVA6 strains belonged to subclade D3, while the subclades of CVA16 and CVA10 were B1c and D, respectively. The predominant etiological agent of HFMD in South India during 2015-2017 was CVA6, followed by CVA16 and CVA10.

Decreased patient visits for ankle sprain during the COVID-19 pandemic in South Korea: A nationwide retrospective study

Social distancing measures including school closure and the cancelation of sports activity were enforced during the early phase of the coronavirus disease 2019 (COVID-19) pandemic to reduce the spread of severe acute respiratory syndrome coronavirus 2 in South Korea. To assess the impact of the COVID-19 pandemic on the nationwide burden of musculoskeletal injury in 2020, we analyzed data on the number of patient visits for ankle sprain in South Korea. We collected national reimbursement data on the number of patient visits for ankle sprain between August 2010 and July 2020. To quantify the impact of the COVID-19 pandemic on the number of reductions in patient visits for ankle sprain, we developed a regression model adjusting for the annual cycle of the patient visit during 2016/17-2018/19. During the COVID-19 pandemic in South Korea, the overall number of patient visits for ankle sprain dropped by 7.9%. The number of patient visits for ankle sprain substantially reduced by 23.4% among school-aged children (6-19 years) during the COVID-19 pandemic in South Korea. Our findings suggest that the social distancing measure has had a positive impact on reducing the burden of medical usages for ankle sprain.

Analysis of the Complete Genomes of Enterovirus 71 Subtypes in China

Enterovirus 71 (EV-A71) is one of the most pathogens to hand, foot, and mouth disease (HFMD) as well as neurological complications in young children. Molecular characteristic of EV-A71 is important to prevent the virus outbreak. Here, the complete genomes of EV-A71 from China between 1998 and 2019 were downloaded from GenBank. The phylogenetic trees were developed by MEGA7.0 software, and the complete genetic epidemiological characteristics and amino acid mutations of EV-A71 from China were also analysed. The results showed that major epidemic EV-A71 subtype was C4b before 2004, while it turned to C4a after 2004 in mainland China, and C4 and B5 were major subtypes in Taiwan. VP1, VP4, 2C, 3C, 3D, and complete genome sequence can be used for virus genotyping, and VP1, VP4, and complete genomes have obvious advantages over other segments. There were many significant mutations in the viral complete genome sequence. This study indicated that the major C4 and B5 subtypes will contribute to the development of vaccines and drugs of EV-A71 for prevention and monitoring of EV-A71-associated HFMD in China.

Spatial and Temporal Characteristics of Hand-Foot-and-Mouth Disease and Their Influencing Factors in Urumqi, China

Hand, foot, and mouth disease (HFMD) remains a serious health threat to young children. Urumqi is one of the most severely affected cities in northwestern China. This study aims to identify the spatiotemporal distribution characteristics of HFMD, and explore the relationships between driving factors and HFMD in Urumqi, Xinjiang.

METHODS

HFMD surveillance data from 2014 to 2018 were obtained from the China Center for Disease Control and Prevention. The center of gravity and geographical detector model were used to analyze the spatiotemporal distribution characteristics of HFMD and identify the association between these characteristics and socioeconomic and meteorological factors.

RESULTS

A total of 10,725 HFMD cases were reported in Urumqi during the study period. Spatially, the morbidity number of HFMD differed regionally and the density was higher in urban districts than in rural districts. Overall, the development of HFMD in Urumqi expanded toward the southeast. Temporally, we observed that the risk of HFMD peaked from June to July. Furthermore, socioeconomic and meteorological factors, including population density, road density, GDP, temperature and precipitation were significantly associated with the occurrence of HFMD.

CONCLUSIONS

HFMD cases occurred in spatiotemporal clusters. Our findings showed strong associations between HFMD and socioeconomic and meteorological factors. We comprehensively considered the spatiotemporal distribution characteristics and influencing factors of HFMD, and proposed some intervention strategies that may assist in predicting the morbidity number of HFMD.

Hand, Foot, and Mouth Disease in Thailand: A Comprehensive Modelling of Epidemic Dynamics

Hand, foot, and mouth disease (HFMD) is a highly contagious disease with several outbreaks in Asian-Pacific countries, including Thailand. With such epidemic characteristics and potential economic impact, HFMD is a significant public health issue in Thailand. Generally, contagious/infectious diseases' transmission dynamics vary across geolocations due to different socioeconomic situations, demography, and lifestyles. Hence, a nationwide comprehensive model of the disease's epidemic dynamics can provide information to understand better and predict a potential outbreak of this disease and efficiently and effectively manage its impact. However, there is no nationwide and comprehensive (i.e., the inclusion of reinfections in the model) model of HFDM dynamics for Thailand. This paper has endeavoured to promote nationwide comprehensive modelling of HFMD's epidemic dynamics and comprehend the reinfection cases. We have formulated the SEIRS epidemiological model with dynamic vitals, including reinfections, to explore this disease's prevalence. We also introduced periodic seasonality to reproduce the seasonal effect. The pattern of spread of this disease is uneven across the provinces in Thailand, so we used K-means clustering algorithm to cluster those provinces into three groups (i.e., highly, moderately, and least affected levels). We also analysed health records collected from district hospitals, which suggest significant reinfection cases. For example, we found that 11% (approximately) of infectious patients return for repeat treatment within the study period. We also performed sensitivity analysis which indicates that the basic reproduction number (R 0) is sensitive to the rate of transmission (β) and the rate at which infected people recover (γ). By fitting the model with HFMD confirmed data for the provinces in each cluster, the basic reproduction number (R 0) was estimated to be 2.643, 1.91, and 3.246 which are greater than 1. Based on this high R 0, this study recommends that this disease will persist in the coming years under identical cultural and environmental conditions.

Meteorological Factors and the Transmissibility of Hand, Foot, and Mouth Disease in Xiamen City, China

Background: As an emerging infectious disease, the prevention and control of hand, foot, and mouth disease (HFMD) poses a significant challenge to the development of public health in China. In this study, we aimed to explore the mechanism of the seasonal transmission characteristics of HFMD and to reveal the correlation and potential path between key meteorological factors and the transmissibility of HFMD. Methods: Combined with daily meteorological data such as average temperature, average relative humidity, average wind velocity, amount of precipitation, average air pressure, evaporation capacity, and sunshine duration, a database of HFMD incidence and meteorological factors was established. Spearman rank correlation was used to calculate the correlation between the various meteorological factors and the incidence of HFMD. The effective reproduction number (R eff ) of HFMD was used as an intermediate variable to further quantify the dynamic relationship between the average temperature and R eff . Results: A total of 43,659 cases of HFMD were reported in Xiamen from 2014 to 2018. There was a significantly positive correlation between the average temperature and the incidence of HFMD (r = 0.596, p < 0.001), and a significantly negative correlation between the average air pressure and the incidence of HFMD (r = -0.511, p < 0.001). There was no correlation between the average wind velocity (r = 0.045, p > 0.05) or amount of precipitation (r = 0.043, p > 0.05) and incidence. There was a temperature threshold for HFMD's transmissibility. Owing to the seasonal transmission characteristics of HFMD in Xiamen, the temperature threshold of HFMD's transmissibility was 13.4-18.4°C and 14.5-29.3°C in spring and summer and in autumn and winter, respectively. Conclusions: HFMD's transmissibility may be affected by the average temperature; the temperature threshold range of transmissibility in autumn and winter is slightly wider than that in spring and summer. Based on our findings, we suggest that the relevant epidemic prevention departments should pay close attention to temperature changes in Xiamen to formulate timely prevention strategies before the arrival of the high-risk period.

Trend analysis and forecast of daily reported incidence of hand, foot and mouth disease in Hubei, China by Prophet model

Hand, foot, and mouth disease (HFMD) is common among children below 5 years. HFMD has a high incidence in Hubei Province, China. In this study, the Prophet model was used to forecast the incidence of HFMD in comparison with the autoregressive-integrated moving average (ARIMA) model, and HFMD incidence was decomposed into trends, yearly, weekly seasonality and holiday effect. The Prophet model fitted better than the ARIMA model in daily reported incidence of HFMD. The HFMD incidence forecast by the Prophet model showed that two peaks occurred in 2019, with the higher peak in May and the lower peak in December. Periodically changing patterns of HFMD incidence were observed after decomposing the time-series into its major components. In specific, multi-year variability of HFMD incidence was found, and the slow-down increasing point of HFMD incidence was identified. Relatively high HFMD incidences appeared in May and on Mondays. The effect of Spring Festival on HFMD incidence was much stronger than that of other holidays. This study showed the potential of the Prophet model to detect seasonality in HFMD incidence. Our next goal is to incorporate climate variables into the Prophet model to produce an accurate forecast of HFMD incidence.

Forecast and early warning of hand, foot, and mouth disease based on meteorological factors: Evidence from a multicity study of 11 meteorological geographical divisions in mainland China

BACKGROUND

Hand, foot, and mouth disease (HFMD) is a significant public health issue in China. Early warning and forecasting are one of the most cost-effective ways for HFMD control and prevention. However, relevant research is limited, especially in China with a large population and diverse climatic characteristics. This study aims to identify local specific HFMD epidemic thresholds and construct a weather-based early warning model for HFMD control and prevention across China.

METHODS

Monthly notified HFMD cases and meteorological data for 22 cities selected from different climate zones from 2014 to 2018 were extracted from the National Notifiable Disease Surveillance System and the Meteorological Data Sharing Service System, respectively. A generalized additive model (GAM) based on meteorological factors was conducted to forecast HFMD epidemics. The receiver operator characteristic curve (ROC) was generated to determine the value of optimal warning threshold.

RESULTS

The developed model was solid in forecasting the epidemic of HFMD with all R square (R²) in the 22 cities above 85%, and mean absolute percentage error (MAPE) less than 1%. The warning thresholds varied by cities with the highest threshold observed in Shenzhen (n = 7195) and the lowest threshold in Liaoyang (n = 12). The areas under the curve (AUC) was greater than 0.9 for all regions, indicating a satisfied discriminating ability in epidemics detection.

CONCLUSIONS

The weather-based HFMD forecasting and early warning model we developed for different climate zones provides needed information on occurrence time and size of HFMD epidemics. An effective early warning system for HFMD could provide sufficient time for local authorities to implement timely interventions to minimize the HFMD morbidity and mortality.

Seasonality of the transmissibility of hand, foot and mouth disease: a modelling study in Xiamen City, China

This study attempts to figure out the seasonality of the transmissibility of hand, foot and mouth disease (HFMD). A mathematical model was established to calculate the transmissibility based on the reported data for HFMD in Xiamen City, China from 2014 to 2018. The transmissibility was measured by effective reproduction number (R_eff) in order to evaluate the seasonal characteristics of HFMD. A total of 43 659 HFMD cases were reported in Xiamen, for the period 2014 to 2018. The median of annual incidence was 221.87 per 100 000 persons (range: 167.98/100,000–283.34/100 000). The reported data had a great fitting effect with the model (R² = 0.9212, P < 0.0001), it has been shown that there are two epidemic peaks of HFMD in Xiamen every year. Both incidence and effective reproduction number had seasonal characteristics. The peak of incidence, 1–2 months later than the effective reproduction number, occurred in Summer and Autumn, that is, June and October each year. Both the incidence and transmissibility of HFMD have obvious seasonal characteristics, and two annual epidemic peaks as well. The peak of incidence is 1–2 months later than R_eff.

Spatial-temporal heterogeneity of hand, foot and mouth disease and impact of meteorological factors in arid/ semi-arid regions: a case study in Ningxia, China

Background

The incidence of hand, foot and mouth disease (HFMD) varies over space and time and this variability is related to climate and social-economic factors. Majority of studies on HFMD were carried out in humid regions while few have focused on the disease in arid/semi-arid regions, more research in such climates would potentially make the mechanism of HFMD transmission clearer under different climate conditions.

Methods

In this paper, we explore spatial-temporal distribution of HFMD in Ningxia province, which has an arid/semi-arid climate in northwest China. We first employed a Bayesian space-time hierarchy model (BSTHM) to assess the spatial-temporal heterogeneity of the HFMD cases and its relationship with meteorological factors in Ningxia from 2009 to 2013, then used a novel spatial statistical software package GeoDetector to test the spatial-temporal heterogeneity of HFMD risk.

Results

The results showed that the spatial relative risks in northern part of Ningxia were higher than those in the south. The highest temporal risk of HFMD incidence was in fall season, with a secondary peak in spring. Meteorological factors, such as average temperature, relative humidity, and wind speed played significant roles in the spatial-temporal distribution of HFMD risk.

Conclusions

The study provide valuable information on HFMD distribution in arid/semi-arid areas in northwest China and facilitate understanding of the concentration of HFMD.

Estimation of the reproduction number and identification of periodicity for HFMD infections in northwest China

Repeated outbreaks of Hand, foot and mouth disease (HFMD) infections have been observed in recent decades and dominated by various enteroviral serotypes. In particular, enterovirus 71 (EV-A71), coxsackievirus A16 (CV-A16) and coxsackievirus A6 (CV-A6) dominated the prevalence of HFMD infections alternatively in recent years with various outbreak sizes in Baoji, a city of Shaanxi Province in Northwest China. Estimating the reproduction number for various enteroviruses serotypes in northwest China (north temperate zone) and identification of cyclicity of HFMD infections are therefore an issue of great importance for future epidemics prediction and control. The basic/effective reproduction numbers for EV-A71, CV-A16 and CV-A6 were estimated based on daily new cases in 2010, 2011 and 2018, respectively, in which the corresponding pathogen dominated the epidemic. Two different methods based on serial interval were adopted and the basic reproduction number were estimated to be in the range of (1.33, 1.46) for CV-A16, (1.20, 1.29) for EV-A71, and (1.38, 1.59) for CV-A6, respectively. The estimated daily effective reproduction numbers significantly fluctuated before June or after July but varied mildly in (0.5,2) in around June to July for three serotypes. The weekly effective reproduction number for HFMD was estimated based on weekly new cases from year 2010 to 2018, and in most years it peaked in the range of (1.6,2.0) in February to March as well as in the range of (1.0,1.2) in September to October. The wavelet analysis based on the time series of HFMD cases from 2008 to 2018 showed obvious annual and semi-annual cyclicity, while the inter-annual cycles are infeasible. In this study we found that CV-A6 shows the greatest transmission ability among these three pathogens while EV-A71 exhibits the weakest ability of transmission, and moreover, the estimated values of basic reproduction number in northwest China are lower than those in Singapore, Hongkong and Guangdong, which may be due to different climatic circumstances.

The Effect of School Closure on Hand, Foot, and Mouth Disease Transmission in Singapore: A Modeling Approach

Singapore implements a school closure policy for institutional hand, foot, and mouth disease (HFMD) outbreaks, but there is a lack of empirical evidence on the effect of closure on HFMD transmission. We conducted a retrospective analysis of 197,207 cases of HFMD over the period 2003–2012 at the national level and of 57,502 cases in 10,080 institutional outbreaks over the period 2011–2016 in Singapore. The effects of school closure due to 1) institutional outbreaks, 2) public holidays, and 3) school vacations were assessed using a Bayesian time series modeling approach. School closure was associated with a reduction in HFMD transmission rate. During public holidays, average numbers of secondary cases having onset the week after dropped by 53% (95% credible interval 44–62%), and during school vacations, the number of secondary cases dropped by 7% (95% credible interval 3–10%). Schools being temporarily closed in response to an institutional outbreak reduced the average number of new cases by 1,204 (95% credible interval 1,140–1,297). Despite the positive effect in reducing transmission, the effect of school closure is relatively small and may not justify the routine use of this measure.

The complex transmission seasonality of hand, foot, and mouth disease and its driving factors

Background

The transmission rate seasonality is an important index for transmission dynamics in many childhood infections, and has been widely studied in industrialized countries. However, it has been neglected in the study of pathogens in China.

Methods

To understand the transmission dynamics of hand, foot and mouth disease (HFMD), we examined the transmission rate seasonality of HFMD in three provinces, Henan, Anhui and Chongqing, in China, using a dynamical stochastic SIR model. We investigated potential driving factors, including school terms, the Chinese Spring Festival period, meteorological factors and population flux for their effects on the HFMD transmission seasonality using multiple regression models.

Results

The transmission rate of HFMD had complex seasonality with one large major peak in March and one small peak in autumn. School terms, the Chinese Spring Festival period, population flux and meteorological factors had combined effects on the HFMD transmission seasonality in mainland China. The school terms reflects the seasonal contact rate in Children, while the population flux and the Chinese Spring Festival period reflect the seasonal contact rate in population. They drove HFMD transmission rate seasonality in different time periods of the year in China. Contact rate seasonality in population dominated effects on HFMD transmission in February and March. The dramatic increase in transmission rate during February coincides with the Chinese Spring Festival period and high population flux in this month. The contact rate seasonality in children dominated effects on the transmission in the other months of the year in Chongqing. Meteorological factors can not solely explain the seasonality in HFMD transmission in mainland China; however, they may have combined effects with school terms and the highway passenger traffic on the transmission rate in Anhui during the fall semester.

Conclusion

The transmission rate of HFMD in three provinces in China had complex seasonality. The Chinese Spring Festival period, population flux and (or) school terms explained the majority of the transmission rate seasonality of HFMD, and they drove HFMD transmission rate seasonality in different time periods of the year. The Chinese Spring Festival period dominantly caused the dramatic increase of the HFMD transmission rate during February.

Electronic supplementary material

The online version of this article (10.1186/s12879-019-4153-6) contains supplementary material, which is available to authorized users.

Development and evaluation of a deep learning approach for modeling seasonality and trends in hand-foot-mouth disease incidence in mainland China

The high incidence, seasonal pattern and frequent outbreaks of hand, foot, and mouth disease (HFMD) represent a threat for millions of children in mainland China. And advanced response is being used to address this. Here, we aimed to model time series with a long short-term memory (LSTM) based on the HFMD notified data from June 2008 to June 2018 and the ultimate performance was compared with the autoregressive integrated moving average (ARIMA) and nonlinear auto-regressive neural network (NAR). The results indicated that the identified best-fitting LSTM with the better superiority, be it in modeling dataset or two robustness tests dataset, than the best-conducting NAR and seasonal ARIMA (SARIMA) methods in forecasting performances, including the minimum indices of root mean square error, mean absolute error and mean absolute percentage error. The epidemic trends of HFMD remained stable during the study period, but the reported cases were even at significantly high levels with a notable high-risk seasonality in summer, and the incident cases projected by the LSTM would still be fairly high with a slightly upward trend in the future. In this regard, the LSTM approach should be highlighted in forecasting the epidemics of HFMD, and therefore assisting decision makers in making efficient decisions derived from the early detection of the disease incidents.

Temperature and humidity affect the incidence of hand, foot, and mouth disease: a systematic review of the literature - a report from the International Society of Dermatology Climate Change Committee

Hand, foot, and mouth disease (HFMD) is an enterovirus-mediated condition that predominantly affects children under 5 years of age. The tendency for outbreaks to peak in warmer summer months suggests a relationship between HFMD and weather patterns. We reviewed the English-language literature for articles describing a relationship between meteorological variables and HFMD. Seventy-two studies meeting criteria were identified. A positive, statistically significant relationship was identified between HFMD cases and both temperature (61 of 67 studies, or 91.0%, reported a positive relationship) [CI 81.8-95.8%, P = 0.0001] and relative humidity (41 of 54 studies, or 75.9%) [CI 63.1-85.4%, P = 0.0001]. No significant relationship was identified between HFMD and precipitation, wind speed, and/or sunshine. Most countries reported a single peak of disease each year (most commonly early Summer), but subtropical and tropical climate zones were significantly more likely to experience a bimodal distribution of cases throughout the year (two peaks a year; most commonly late spring/early summer, with a smaller peak in autumn). The rising global incidence of HFMD, particularly in Pacific Asia, may be related to climate change. Weather forecasting might be used effectively in the future to indicate the risk of HFMD outbreaks and the need for targeted public health interventions.

Case report: Features of hand, foot and mouth disease in neonates

RATIONALE

Hand, foot and mouth disease (HFMD) is caused by enterovirus. The virus may exist in secretions.

PATIENT CONCERNS

Five neonates had symptoms of fever and maculopapular rashes involving face, trunk, breech, arms, and legs, especially scattering on palms and feet. Blood, oropharyngeal fluid, urine, and cerebrospinal fluid (CSF) samples were collected and detected for further diagnoses with the consent of the infants' parents. Some of them suffered aseptic meningitis.

DIAGNOSES

They were diagnosed as HFMD with CSF enterovirus positive.

INTERVENTIONS

All of them continued breastfeed. Water bag was used during the pyrogenic stage. Antibiotics were administrated at first and withdrawn as soon as possible.

OUTCOMES

None of them developed into brainstem encephalitis or pulmonary edema and they all recovered well.

LESSONS

HFMD is more common in neonates than it has been thought. Enterovirus may exist in neonatal CSF and cause CSF cell to increase similar to purulent meningitis. Medical history, physical examination, and CSF enterovirus detection are important in making correct diagnosis. Unlike bacterial infection, HFMD is a self-limited disease. Once HFMD is determined and bacterial infection is ruled out, antibiotics should be avoided.