How long is hand, foot, and mouth disease (HFMD) contagious and when can a child return to school?

Hand, Foot, and Mouth Disease: Contagious Period and School Return Guidelines

Children with hand, foot, and mouth disease (HFMD) should be excluded from school until fever resolves and all lesions have dried and crusted, typically 3-5 days after symptom onset.

Understanding HFMD Transmission

Hand, foot, and mouth disease is a highly contagious viral illness primarily caused by enteroviruses, particularly coxsackieviruses A6, A10, A16, and enterovirus 71. The disease spreads through:

• Direct contact with nasal and throat secretions
• Contact with fluid from blisters/vesicles
• Fecal-oral route
• Respiratory droplets

Contagious Period

• Incubation period: 3-10 days after exposure 1
• Most contagious: During the first week of illness
• Virus shedding can continue in stool for weeks after symptoms resolve

Clinical Course and Return to School Criteria

HFMD typically follows this pattern:

1. Initial symptoms: Fever and sore throat
2. Within 1-2 days: Development of painful oral ulcerations
3. Shortly after: Appearance of maculopapular or vesicular rashes on hands, feet, and sometimes buttocks
4. Resolution: Lesions typically resolve in 7-10 days 2

School Exclusion Guidelines

Based on the available evidence, children with HFMD should be excluded from school or childcare settings until:

1. They are fever-free for at least 24 hours without fever-reducing medications
2. Mouth sores have healed enough that the child can eat and drink comfortably
3. Skin lesions have dried and crusted over (no active weeping or oozing)

This approach aligns with general principles for managing contagious diseases in pediatric settings 3. While specific HFMD exclusion guidelines aren't explicitly stated in the provided evidence, the recommendation follows the pattern established for similar viral illnesses with vesicular lesions, such as varicella (chickenpox), which requires exclusion until lesions have crusted 3.

Prevention Measures

To prevent transmission of HFMD:

• Frequent handwashing, especially after diaper changes and using the bathroom
• Proper disposal of tissues and diapers
• Regular disinfection of frequently touched surfaces and toys 4
• Avoiding close contact (kissing, hugging, sharing utensils) with infected individuals
• Teaching children to cover coughs and sneezes

Important Considerations

• HFMD is usually self-limiting with symptoms resolving within 7-10 days 2
• Rare complications can include neurological issues like meningitis, encephalitis, or acute flaccid paralysis, particularly with enterovirus 71 infections 1, 5
• Treatment is supportive, focusing on hydration and pain relief with acetaminophen or ibuprofen as needed 2
• No specific antiviral treatment or vaccine is widely available for HFMD in most countries 6

Key Takeaway

The decision to allow a child to return to school should balance the risk of disease transmission with the child's comfort and ability to participate in school activities. Generally, children can return to school when they feel well enough to participate, have no fever, and their lesions are no longer actively weeping or oozing.