Purpose

The paper aims to provide members with the background information on enterovirus infection and explain the preventive measures taken by the Administration.

Background

2. Hand Foot Mouth Disease (HFMD) is a common and mild infectious disease which mainly affects children under the age of five, although cases in adults are also possible. Affected patients would develop fever, mouth ulcers and rash on the limbs but they usually recover without complications. Complications affecting the brain and the heart are rare. The disease is more common in the summer months. It is mainly transmitted by the faecal oral route. There is no specific treatment for HFMD/enterovirus 71, nor is there a vaccine against the infection. The best way of prevention is to practise good personal hygiene.

3. HFMD can be caused by a number of enteroviruses, one of which is enterovirus 71. Recently, there has been much public concern on HFMD and infection caused by enterovirus 71. A recent outbreak of HFMD occurred in Taiwan and affected some 500,000 people, reportedly causing over 50 deaths. Enterovirus 71 was isolated in some of the fatal cases.

Local Situation

4. Enterovirus infection is not new to Hong Kong. Government Virus Unit and hospitals diagnose such infection every year.

5. The Department of Health (DH) has kept a close watch on the progress of outbreak in Taiwan. Communication with the National Quarantine Service has been established through phone calls, fax and E mail. Our Consultant Microbiologist went to Taiwan last week to get the most updated first hand information on virus isolation and disease control.

6. A sentinel surveillance network has been established and as at 15.7.98, we have had 7 confirmed and 14 suspected cases of enterovirus 71. All these are uncomplicated HFMD. The patients have fully recovered and were discharged.

Actions taken

(I) Setting up a sentinel surveillance system to monitor the trend of HFMD

Since 14.6.98, all the 63 General Outpatient Clinics of DH and 16 General Practitioners have been reporting the number of HFMD seen in their clinics to the DH Headquarters on a weekly basis. At about the same time, the Hospital Authority (HA) has stepped up monitoring of the numbers of HFMD admissions into their hospitals. The figures so far collected are shown below :

Quick tests enable a result to be obtained within an average of 1 to 4 days, whereas conventional tube culture with confirmatory test averages 2 weeks. While quick tests may be of help to the clinical management of serious cases, some quick tests are still under development. Their sensitivity and specificity are yet to be determined. However, the conventional tube culture together with the confirmatory test used by DH is generally known to be ‘gold standard’ in enterovirus diagnosis. Hence, DH and HA have agreed that all results on quick tests obtained in HA hospitals should be advised to DH, and confirmatory tests will continue to be undertaken by DH. By means of such close liaison, there will be a clear picture of the total number of cases both in and outside hospital.

(II) Case Investigation

Upon receiving notification of infectious diseases from child care centres or schools, the health team of DH would liaise with the principal or child care centre supervisor, visit the institution, inspect the environment and facilities, deliver health education and advise on measures to prevent spread of the disease.

(III) Stepping up inspections of Child Care Centres and kindergartens

All along, DH staff have been regularly inspecting child care centres and kindergartens. Since June, inspections have been stepped up with special attention to enhance hygiene practices and giving health advice targeted to the prevention of diseases transmitted in faecal-oral route. By now, we have nearly finished inspecting all child care centres and about 15% of a total of over 700 kindergartens.

In late June, Education Department issued a letter to all kindergartens, primary and secondary schools on "Observing Personal and Environmental Hygiene". The Department’s district officers were also reminded to pay special attention to the standard of hygiene maintained by schools during school visits.

In mid June, Social Welfare Department issued a circular letter on "Hygiene Practices" targeted at the prevention of enterovirus infection to all child care centres. Inspection visits to the child care centres have also been stepped up by the Department’s staff, with special attention paid to advise on precautionary measures as suggested by DH.

If clusters of HFMD infections are notified, DH would carry out investigation, and advise on the control and preventive measures. Only if the situation warrants, closure of the individual institution may be considered.

(IV) Strengthening the Government Virus Unit

In view of the enhanced surveillance activity and heightened awareness of doctors, a sharp increase in the workload in Government Virus Unit is expected. In June alone, the unit received about 2000 specimens for enterovirus isolation as compared with around 850 specimens in June last year. Manpower & other resources have been redeployed to support the laboratory work.

(V) Establishing an interdepartmental working group to co-ordinate efforts on prevention and control of the disease

Education Department and Social Welfare Department have sent out circulars to the institutions under their care to remind their staff the information of hygiene practices. A meeting to co-ordinate policies and the surveillance and investigation of cases, collection of specimen for viral studies, and information exchange was also arranged with the Hospital Authority.

An interdepartmental working group was then set up to better co-ordinate efforts on prevention and control of enterovirus 71 infection. The first meeting was held on 7.7.98. It was chaired by the Deputy Director of Health and attended by representatives from DH, HA, Education Department, Social Welfare Department, Urban Services Department, Regional Services Department and Government Information Services. The co-ordination of monitoring of cases in hospitals and streamlining of information exchange between DH and HA were confirmed in the meeting. The HA would assist in the dissemination of information to the public through A&E Departments, and inpatient paediatric units. During the meeting, it was agreed that Education Department and Social Welfare Department would organise seminars with supervisors of child care centres, heads and teachers of kindergartens and primary schools on enterovirus infection. DH staff would be present to deliver health talks and answer questions from school masters and child care centre supervisors. The seminars to be held by Social Welfare Department for child care centres have been held on 14.7.98 and 16.7.98 respectively while the Education Department seminars are scheduled to be held on 28.7.1998, 5.8.1998 and in early September. The Urban Services Department and Regional Services Department have confirmed that the chlorine/ozone level of public swimming pools are up to international standard. The staff working in public swimming pools would strictly prohibit people with obvious skin lesions or other infectious diseases to enter the pool area. The 2 Municipal Services Departments would also maintain the cleanliness of their indoor recreation centres at all times. Play equipment will be thoroughly cleaned by soap and water and if necessary, diluted bleaching solution recognised by DH as an effective disinfectant. Information Services Department would help produce a poster and a leaflet to better inform the public about HFMD.

The working group will have its next meeting in late July to monitor and co-ordinate efforts of various departments.

(VI) Public Education

DH has taken proactive steps to disseminate the information on enterovirus infection to various target groups:

1. members of the medical profession in collaboration with the H.K. Medical Association and H.K. Dental Association.

2. to the public by
   1. information leaflets : More than 14,000 copies were distributed through our clinics. More will be available in public places like the A&E Departments of HA hospitals, the recreational facilities of the 2 Municipal Services Departments, and District offices of Home Affairs Department.

   2. telephone hotlines : Two automated hotlines were set up, one in Chinese and one in English (2833 0111). The public can also obtain information about HFMD by fax.

   3. Internet DH homepage : General information about HFMD and enterovirus 71 infection is available. Starting from last week, surveillance data from our sentinel surveillance system and HA hospitals will also be uploaded on our homepage on a weekly basis.

The public are reminded to observe good personal hygiene especially washing hands after toilets, changing napkins, and handling of articles soiled with respiratory secretions. A fact sheet on HFMD is at Annex.

The Outlook

7. Since HFMD usually peaks in summer, DH will work together with the Hospital Authority to remain vigilant and keep up with the surveillance on the disease. Moreover, DH together with other relevant departments would make every endeavour to disseminate timely health messages in order to prevent the spread of the disease in Hong Kong.

8. As regards the long term measures to combat communicable diseases, DH will strengthen the team responsible for communicable disease control, in particular, the field epidemiology and public health laboratory service. The surveillance activities for various communicable diseases would be enhanced. International liaison and networking with world health authorities would also be strengthened. In addition, more training for staff would be arranged in various formats including short term attachment and attending of courses in overseas institutions or inviting experts to train local staff.

Health and Welfare Bureau
July 1998