title: Best practices to prevent transmission and control outbreaks of hand, foot, and mouth disease in childcare facilities: a systematic review.
abstract: BACKGROUND
  Hand, foot, and mouth disease continues to cause seasonal epidemics in the Asia-Pacific Region. Since the current Enterovirus 71 vaccines do not provide cross-protection for all Enterovirus species that cause hand, foot, and mouth disease, there is an urgent need to identify appropriate detection tools and best practice to prevent its transmission and to effectively control its outbreaks. This systematic review aimed to identify characteristics of outbreak and assess the impact and effectiveness of detection tools and public health preventive measures to interrupt transmission. The findings will be used to recommend policy on the most effective responses and interventions in Hong Kong to effectively minimise and contain the spread of the disease within childcare facilities.
  
  
  METHODS
  We searched the following databases for primary studies written in Chinese or English: MEDLINE, EMBASE, Global Health, WHO Western Pacific Region Index Medicus database, China National Knowledge Infrastructure Databases, and Chinese Scientific Journals Database. Studies conducted during or retrospective to outbreaks of hand, foot, and mouth disease caused by Enterovirus 71 from 1980 to 2012 within childcare facilities and with a study population of 0 to 6 years old were included.
  
  
  RESULTS
  Sixteen studies conducted on outbreaks in China showed that hand, foot, and mouth disease spread rapidly within the facility, with an outbreak length of 4 to 46 days, especially in those with delayed notification (after 24 hours) of clustered outbreak (with five or more cases discovered within the facility) to the local Center for Disease Control and Prevention and delayed implementation of a control response. The number of classes affected ranged from 1 to 13, and the attack rate for children ranged from 0.97% to 28.18%.
  
  
  CONCLUSIONS
  Communication between key stakeholders about outbreak confirmation, risk assessment, and surveillance should be improved. Effective communication facilitates timely notification (within 24 hours) of clustered outbreaks to a local Center for Disease Control and Prevention. Timely implementation of a control response is effective in minimising incidence and length of an outbreak in childcare facilities. The government should provide incentives for childcare facilities to train infection control specialists who can serve as the first contact, knowledge, and communication points, as well as facilitate exchange of information and provision of support across stakeholders during a communicable disease epidemic.
authors.affiliation: The Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Shatin, Hong Kong.
authors.forename: J Hy
authors.initials: JH
authors.lastname: Chan
authors.affiliation: The Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Shatin, Hong Kong.
authors.forename: C K
authors.initials: CK
authors.lastname: Law
authors.affiliation: Independent Consultant Epidemiologist, London, United Kingdom.
authors.forename: E
authors.initials: E
authors.lastname: Hamblion
authors.affiliation: The Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Shatin, Hong Kong.
authors.forename: H
authors.initials: H
authors.lastname: Fung
authors.affiliation: Communicable Diseases Policy Research Group, Department of Global Health and Development, London School of Hygiene and Tropical Medicine, Bangkok Office, Thailand.
authors.forename: J
authors.initials: J
authors.lastname: Rudge
mesh_terms: D001208:Asia; D002656:Child Day Care Centers / Q000592:standards; D002675:Child, Preschool; D004196:Disease Outbreaks / Q000517:prevention & control; D004770:Enterovirus / Q000302:isolation & purification*; D006232:Hand, Foot and Mouth Disease / Q000175:diagnosis* / Q000517:prevention & control* / Q000628:therapy*; D006801:Humans; D007223:Infant; D017053:Infection Control / Q000379:methods*
keywords: Disease outbreaks/prevention & control; Enterovirus infections; Hand, foot and mouth disease