Risk Factors for Hand, Foot and Mouth Disease Transmission in the Kindergarten Setting, Zhejiang Province, China, 2010

Background: From 2008-2010, an epidemic of hand foot and mouth disease (HFMD) in China has reached 3,415,512 cases and 1,384 fatalities. Of 543 focal outbreaks reported, 82% occurred in kindergartens. The current practice to close kindergartens to control HFMD transmission is disruptive and unevaluated. We conducted a case-control study to identify modifiable risk factors for HFMD transmission in kindergarten.

Methods: We defined a case-class as one with 2 or more reported HFMD cases and a control-class as only one HFMD case within 3 days during May 1st to July 31, 2010 in any kindergarten in 2 counties. We compared layout, sanitary facilities, and hygienic practices between case and control classes.

Results: We identified 30 case-classes and 47 control-classes during the study period. The HFMD attack rate was 9.4% (80/853) in case-classes and 3.3% (47/1472) in control-classes. 17% of case-classes had no direct sunlight compared with 0% of control-classes (OR=∞, 95% CI: 1.6-∞). 20% of case-classes had no hand soap or sanitizer compared with 0% of control-classes (OR=∞; 95% CI 2.1-∞); 93% of case-classes had no disinfectant for drinking cups compared with 70% of control-classes ( OR=6.1; 95% CI: 1.2-59); in 13% of case-classes the first case was sent home > 1 day after onset of HMFD compared with 0% of control-classes (OR=∞; 95% CI: 1.1-∞) .

Conclusions: Increasing sunlight, improving hygiene, and promptly excluding HFMD affected children from classrooms may reduce HFMD transmission in kindergartens. The current strategy of closing kindergartens should be compared to a package of interventions as studied herein to determine which approach best minimizes both transmission and social disruption. 

Author (s): 

Jie Gao, J.C. Shen, Min Wu, H.L. Ma, J.F. Lin

Presenter (s): 
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