Study On The Intervention Strategies Of Severe Cases Of Hand Foot And Mouth Disease

Background Hand Foot and Mouth Disease (HFMD), a common infectious disease of children, is caused mainly by the infection of EV71 and Cox A16 virus, with fever, skin symptoms and herpes of the hands, feet and mouth being the main clinical feature. From March to May in 2008, a HFMD outbreak occurred in Fuyang City of Anhui Province. Later on, it struck many areas of China. On May 2rd,2008, HFMD was classified as anotifiable infectious diseases, and till the end of 2014,11807 330 cases were reported countrywide, with an annual incidence rate of 1/1000 to 2/1000. The incidence rate of children in the 1-2 years old was up to 30/1000～40/1000.Most of the patients are self-limiting. However some cases may progress to develop fatal complications such as brainstem encephalitis, aseptic meningitis, acute flaccid paralysis and pulmonary edema, and even death. There were more than 120 000 of severe cases nationwide from 2008 to 2014, with the case-severity rate being 1.1%. A total of 3 210 death cases were reported, and the mortality was 0.03%. Therefore, HFMD is a fatal infectious disease for children, especially for children under three, which inflicts pains and financial burden on average families and society, so we must take effective measures to reduce severe cases of HFMD.Because of a lot of transmission and no vaccines on the market, there are no effective measures to reduce the incidence of HFMD currently. Thus, the key to reducing the severity and mortality of HFMD is to find out the risk factors and intervene timely. Scholars both at home and abroad have done research on the influencing factors of severe cases.They found undiagnosis in the first visit, delayed diagnosis and irrational use of antipyretics are the risk factors. However, because of many missing value of pathogenic results, pathogenic results failed to be taken into the multivariate analysis in some studies, thus affecting the reliability of the results. Meanwhile, most of the studies were conducted in some prosperous cities such as Shenzhen, with the floating population falling into the highest-risk group. The "left-behind" children in less developed provinces may be the riskiest. Just as the feature of mobile population differs from that of the guardians of the "left behind" children, the processes of treatment are different. Because risk factors of severe case aren’t very clear, we still need carry out relevant research.Children under 5 in rural areas are the key population of the intervention of HFMD, accounting for over 80% of the severe cases. Delay in seeing a doctor or diagnosis is the risk factor of severe case for rual children. Their guardians and the medical workers at basic units are very essential in that their knowledge of HFMD has a direct impact on the timeliness of the treatment and the diagnosis of the disease as well as the referral of the patients. There are conflicting reports about the levels of the guardians’ knowledge, ranging from 58.71% to 82.75%. Grassroots medical workers’ knowledge of HFMD has not been reported in literature. Therefore, we need carry out a investigation about gurdians’ and grassroots medical workers’ knowledge.Fever is the common clinical feature. The unreasonable use of antipyretics at an earlier phase of the disease can increase the risk of severe. The rational use of hormone during the critical period can slow the disease, which has an anti-inflammatory, immune-suppressing and anti-shock effect. But using hormone to bring down the fever during the early stage may mask the symptoms and facilitate the multiplication of pathogenic bacteria, thus worsening the condition. Pyrazole ketones antifebrile can lead to various adverse reactions, therefore most of the developed countries forbid children to take such medicines. During the period of HFMD treatment, using such medicines may increase the risk of severe.This study was to carry out the case-control study to analyze the risk factors leading to severe conditions according to etiology, individual physical conditions, process of treatment and medication taken on initial stage. At the same time, it was to survey the knowledge level of guardians of children under 5 and that of medical workers at basic units, and it was also to investigate the usage of antipyretics in some medical organizations at grass-roots level. Basing on the findings of risk factor analysis and field investigation, the study aimed to map out some intervention strategies to reduce the occurrence of severe cases of HFMD by employing the Delphi method.Part Ⅰ A Case Control Study on Risk Factors of Severe Cases of Hand Foot and Mouth DiseaseObjectives To explore the risk factors of severe cases of HFMD by carrying out a case-control study among severe and mild cases of HFMD, in order to provide some references to map out intervention strategies to reduce the occurrence of severe cases by expert consulting.Methods 213 severe cases of HFMD diagnosed in laboratories from March to November in 2014 were taken as a case group, and were compared with 213 mild cases taken from the same city. By using the method of univariate and multivariate non-conditional logistic regression, the subjects’ demography information, process of treatment, medication at early stage and results of pathogen were collected to analyze the risk factors leading to severe cases of HFMD. At the same time, the virus isolation and the VP1 gene sequence analysis of EV71 positive cases were conducted to draw distinctions between the sequences of VP1 of severe cases and mild cases.Results(1) According to the univariate analysis, the risk factors of severe cases of HFMD were as follows:age, guardians and their educational background, whether the patient’s respiratory system is infected one month before the onset, the interval between onset and first visit, the interval between first visit and diagnosis, the levels of medical organization in the first visit, the body temperature>39℃, taking antipyretics by injection, taking antipyretics orally, taking pyrazole ketonesantipyretics, bringing down the fever by using hormone in hospitals at basic units and the infection of EV71. The patient is diagnosed HFMD in the first visit, breast feeding were protection factor.(2) According to the multivariate analysis, the risk factors of severe cases of HFMD were as follows:age<3 (OR=3.011,95%CI:1.502-6.035), body temperature >39℃ (OR=7.283,95%CI:3.783-14.019), the interval between the outbreak of the disease and the patients’ going to the doctor’s(OR=1.362,95%CI:1.155-1.607), the interval between the patients’ going to the doctor’s and the patients’ getting diagnosed(OR=1.235,95%CI: 1.103-1.383), using pyrazole ketones antipyetics(OR=5.885,95%CI:1.454-23.812), bringing down the fever by using hormone in hospitals at basic units(OR=6.380,95%CI: 1.764-23.078), and the infection of EV71 (OR=12.653,95%CI:6.462-24.773), breast feeding(OR=0.471,95%CI:0.232-0.957) was protection factor.(3) According to the VP1 gene sequence analysis, both of the EV71 leading to severe cases and the EV71 leading to mild cases are be of C4a subtype. The homology of its nucleotides and amino acids are 97.30%～99.80% and 98.90%～100.00% respectively. There is statistical significance in the difference of 283 S/T sequence in VP1 Amino acid in severe and mild cases (χ2=4.904, P=0.027).Conclusion The risk factors leading to severe cases of HFMD were as follows:age<3, body temperature >39℃, delay in seeing a doctor and diagnosis, using hormone at early stage, and bringing down the fever by using pyrazole ketones antipyretics. In addition, the protection factor was breastfeeding. In order to reduce the occurrence of the severe cases, measures should be taken to promote timely treatment and timely diagnosis and conformity in using antipyetics in medical organizations at basic units. Meanwhile, special attention must be paid to patients who are under 3 and whose body temperature is higher than 39℃.Part Ⅱ The Gurdians’ and the Grassroots Medical Workers’ Knowledge of HFMD and the Medication of Feverish Children under 5 on Early StageObjectives This study aimed to get a better understanding of the guardians’and the medical workers’ knowledge of HFMD and the application of antipyretics in medical organizations in towns and villages, and to provide reference to map out intervention strategies to reduce the occurrence of severe cases by expert consulting.Methods Basing on the geographic location and the incidence of HFMD, investigation was carried out to get the picture of the medical workers’ knowledge of HFMD in 16 villages and towns in 8 counties chosen at random.6 medical workers in township hospitals and 9 in village clinics were selected in each town. Meanwhile,40 guardians of children under 5 were chosen from vaccination clinics of each town, and their knowledge of HFMD was tested. Moreover,40 prescriptions of feverish children under 5 in 72 hours of each town were copied. Statistical analysis was conducted by software SPSS 11.0. The t or F test was applied to comparisons of categorical variables and the χ2 test was used to comparison of numeration data. A P value of P<0.05 was considered statistically significant.Results(1) 250 medical workers were investigated,104 in township hospitals and 146 in village clinics. The knowledge rate of HFMD was 85.64%. The knowledge rate of medical workers in township hospitals was higher than that of medical workers in village clinics (χ2=30.220,P<0.001), and the knowledge rate of medical workers with qualifications of medical practitioners or assistant medical practitioners was higher than that of medical workers without the qualifications(χ2=13.859,P<0.001). They had less knowledge about the identification of symptoms on early stage. Only 19.60% of them knew that vomiting, persistent fever and limb shaking were the most identifiable symptoms on early stage of severe case.(2) 651 guardians of children under 5 were surveyed. Among them,412 were parents of children and 231 were grandparents of children. The guardians’ knowledge rate of HFMD was 55.89%, and the parents’ knowledge rate was higher than the grandparents’ (χ2=269.988, P<0.001). What was known by few people was where the skin rashes and the herpes were most likely to appear; only 15.51% of the guardians knew that the skin rashes and the herpes are commonly seen on the hands, feet and buttocks and in the mouths.(3) 626 prescriptions of feverish children under 5 were copied, including 297 in township hospitals and 329 in village clinics. According to the subscriptions, hormones were used in 179 cases, accounting for 28.59%, and pyrazole ketones antipyretics were used in 63 cases, accounting for 10.06%. Other commonly used antipyretics were ibuprofen, dl-lysine acetylsalicylate and Pediatric Paracetamol Atificial Cow-bezoar and Chl, accounting for 31.31%,25.08% and 13.74% respectively.Conclusion Effective intervention measures should be taken to propagate key knowledge to key population in order to raise the guardians’ and medical workers’ knowledge rate. Hormones and pyrazole ketones antipyetics were still used in medical organization at basic units. Therefore, relevant guidelines should be established or perfected to standardize the use of antipyetics at basic units.Part Ⅲ Mapping Out the Intervention Strategies by the Delphi Method to Reduce the Occurrence of Severe Cases of HFMDObjectives To develop intervention strategies for reducing the occurrence of severe cases of HFMD by applying the Delphi method and to provide evidence for the health administration departments.Methods Expert questionnaires were formed by former study results and the interviews of experts. A 2 rounds of Delphi method was adopted to form intervention strategies to reduce the occurrence of severe cases of HFMD. The data was analyzed statistically by SPSS 11.0. The numbers and percentages were calculated for categorical variables and median and standard deviation for continuous variables, Kendall’s coefficient was used to evaluate the coordination coefficient of each item evaluated by experts.Results(1) The results of the first round expert consultation:The positive coefficient of expert was 100%. All of the specialist authority coefficients were over 0.7. The harmony coefficient of the experts’importance judgment was 0.267 and that of the feasibility judgment was 0.243. Six first grade items and twenty-five second grade items were remained after the first round.(2) The results of the second round expert consultation:The positive coefficient of expert was 100%. The harmony coefficient of the experts’ importance judgment was 0.512 and that of the feasibility judgment was 0.490. Five first grade items and seventeen second grade items were remained after the second round.Conclusion According to the result of expert consultations,5 first grade items and 17 second grade items were included in the intervention strategies to reduce the occurrence of severe HFMD cases, providing reference for the health administrative department.