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The Population-Based Health Effect of Hand, Foot and Mouth Disease in Children in Shanghai

Xu, Zhiyin MS; Shen, Huiguo MS; Wang, Zhonglin MD, PhD*; Altmeyer, Ralf PhD; Xia, Aimei BS*; Mao, Shenghua MS§; Zhen, Yaxu MS§; Li, Weixi BS; Zhao, Yanping MS; Su, Hualin MS; Zhan, Longwen MS; Wang, Xiaohong MD*; Pan, Hao MD§; Hu, Jiayu MD§; Zeng, Mei MD, PhD*

The Pediatric Infectious Disease Journal: May 2014 - Volume 33 - Issue 5 - p 448–452
doi: 10.1097/INF.0000000000000136
Original Studies

Background: An effective enterovirus 71 (EV71) vaccine is needed to control the annual outbreaks of hand, foot and mouth disease (HFMD) in China. Adequate epidemiologic data relating to HFMD are needed to make decisions about appropriate public health interventions and implementation of the new EV71 vaccine.

Methods: We analyzed the population-based epidemiologic characteristics, clinical outcome and laboratory investigation of the 2011 HFMD outbreak in children based on the citywide surveillance system in Shanghai.

Results: The incidence rate of HFMD was 25.8 per 1000 in children <10 years of age in Shanghai in 2011, ranging from 2.5 per 1000 in the age group 7 to 9.9 years to 48.4 per 1000 in the age group 3 to 3.9 years. Children 1 to 1.9 years were at the highest risk of developing severe complications and most susceptible to HFMD. Boys and migrant children had significantly increased risks of contracting HFMD and developing severe disease. More institutional clusters/outbreaks occurred in the winter peak months than in the summer peak months. Migrant young children played a central role in the spread of HFMD in the community. EV71 was identified in 39.7% of mild HFMD outpatients, 47.4% of hospitalized patients, 92.1% of severe inpatients with complications, 50% of outbreaks and 38.8% of clusters in institutions.

Conclusion: HFMD and EV71 infections have a significant health effect on Shanghai children.

From the *Department of Infectious Diseases, Children’s Hospital of Fudan University; Department of Infectious Diseases, Minhang District Center For Disease Control and Prevention; Institut Pasteur Shanghai, Chinese Academy of Sciences; and §Department of Infectious Diseases and Control, Shanghai Municipal Center For Disease Control and Prevention, Shanghai, China.

Accepted for publication October 14, 2013.

Z.X., H.S. and Z.W. equally contributed to this work.

The authors have no funding or conflicts of interest to disclose.

Address for correspondence: Mei Zeng, MD, PhD, Department of Infectious Diseases, Children’s Hospital of Fudan University, 399 Wanyuan Road, Shanghai 201102, China. E-mail:; or Jiayu Hu, MD, Department of Infectious Diseases, Shanghai Municipal Center For Disease Control and Prevention, 1380 West Zhongshan Road, Shanghai 200336, China. Email:

© 2014 by Lippincott Williams & Wilkins, Inc.