title: Risk factors for hand, foot, and mouth disease and herpangina and the preventive effect of hand-washing.
abstract: BACKGROUND
  Hygiene and social distancing are recommended control measures for hand, foot, and mouth disease (HFMD) and herpangina. However, empirical data to support this recommendation are limited.
  
  
  METHODS
  During an outbreak of HFMD and herpangina due to infection by the human enterovirus 71, we defined a case as a vesicular papular rash on the hands, feet, buttocks, or oral mucosa and onset from April 30 to June 26, 2008. We selected 176 HFMD and herpangina case-children and a stratified random sample of 201 asymptomatic control-children; frequency matched according to residency status. We administered a questionnaire to the parents about their children's exposures and hygienic behaviors.
  
  
  RESULTS
  Risk factors for HFMD and herpangina included playing with neighborhood children (odds ratio [OR]: 11 [95% confidence interval (CI): 6.2-17]), visiting an outpatient clinic for another reason ≤ 1 week before onset (OR: 20 [95% CI: 5.0-88]), and community exposures to crowded places (OR: 7.3 [95% CI: 4.1-13]). By using a score summarizing responses to 4 hand-washing questions, we found that 50% of the case-children and 2.5% of control-children had a poor score of 1 to 3, whereas 12% of the case-children and 78% of control-children had a good score of ≥ 7 (OR: 0.00069 [95% CI: 0.0022-0.022]) after we adjusted for residency, age, and community exposures by using logistic regression.
  
  
  CONCLUSIONS
  Hand-washing by preschool-aged children and their caregivers had a significant protective effect against community-acquired HFMD and herpangina from the human enterovirus 71 infection.
authors.affiliation: Chinese Field Epidemiology Training Program, Chinese Center for Disease Control and Prevention, Beijing, China.
authors.forename: Feng
authors.initials: F
authors.lastname: Ruan
authors.forename: Tao
authors.initials: T
authors.lastname: Yang
authors.forename: Huilai
authors.initials: H
authors.lastname: Ma
authors.forename: Yan
authors.initials: Y
authors.lastname: Jin
authors.forename: Shili
authors.initials: S
authors.lastname: Song
authors.forename: Robert E
authors.initials: RE
authors.lastname: Fontaine
authors.forename: Bao-Ping
authors.initials: BP
authors.lastname: Zhu
mesh_terms: D000554:Ambulatory Care Facilities; D016022:Case-Control Studies; D002648:Child; D002675:Child, Preschool; D002681:China; D016000:Cluster Analysis; D017714:Community-Acquired Infections / Q000453:epidemiology / Q000517:prevention & control / Q000635:transmission; D003428:Cross Infection / Q000453:epidemiology / Q000517:prevention & control / Q000635:transmission; D003430:Cross-Sectional Studies; D003441:Crowding; D004196:Disease Outbreaks / Q000706:statistics & numerical data; D004203:Disinfection; D005260:Female; D006235:Hand Disinfection; D006232:Hand, Foot and Mouth Disease / Q000453:epidemiology / Q000517:prevention & control* / Q000635:transmission*; D015438:Health Behavior; D006266:Health Education; D006557:Herpangina / Q000453:epidemiology / Q000517:prevention & control* / Q000635:transmission*; D006801:Humans; D015994:Incidence; D007223:Infant; D008297:Male; D016017:Odds Ratio; D010988:Play and Playthings; D012111:Residence Characteristics; D012307:Risk Factors