Abstract
.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.
Highlights
Hand, foot, and mouth disease (HFMD) is a common pediatric disease that is endemic in East and Southeast Asia[1,2] and increasingly found in North America[3,4] and Europe.[5]
HFMD caused by human enterovirus 71 may lead to complications involving the nervous system and result in reduced cognitive function, delayed neurodevelopment, and motor impairment, or death[7,8,9]; in China, an estimated 350–900 children die of HFMD annually.[10]
Weekly number of cases were modeled to be reduced to 93% relative to nonschool holidays for all children less than 12 years of age: 94% for age 0–2 years, 93% for age 3–5 years, and 90% for age 6–11 years
Summary
Foot, and mouth disease (HFMD) is a common pediatric disease that is endemic in East and Southeast Asia[1,2] and increasingly found in North America[3,4] and Europe.[5]. Daily routine health checks for all children and isolation of suspected cases are implemented for early detection and control of outbreaks.[11] Should transmission continue within an outbreak, school closure is enforced.[12] This policy was implemented following an outbreak in 2000 in which several children died from enterovirus 71 complications[13,14]; the details have evolved over time, but until recently, if a school has more than 16 cases or an attack rate more than 23% with a transmission period more than 24 days, the school will be required to close for a period of 10 days.[15] In the most updated guideline, the policy has been relaxed somewhat, and Ministry of Health will consider the predominant circulating strain when assessing closure in addition to the trigger. This change provides an avenue to assess the impact of this policy
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