School Exclusion for Hand, Foot, and Mouth Disease
Children with hand, foot, and mouth disease (HFMD) do not need to stay home from school or childcare, as exclusion is not practical or effective for controlling transmission.
Key Recommendation
- School exclusion is not recommended because children remain infectious for several weeks through fecal shedding, making any exclusion period ineffective at preventing transmission 1
- Children are most contagious until blisters disappear, but the virus persists in feces for weeks after symptoms resolve, rendering short-term exclusion futile 1
Rationale for No Exclusion Policy
The evidence supporting no exclusion is based on the following:
- Extended viral shedding: The virus can be present in feces for several weeks after clinical recovery, making it impossible to determine when a child is truly non-infectious 1
- Asymptomatic transmission: Most HFMD infections are asymptomatic, meaning many infectious children would never be identified or excluded 2
- Incubation period variability: The incubation period ranges from 3-7 days typically, but can extend beyond 10 days in 8.8-23.2% of cases depending on age group, meaning exposure has already occurred before diagnosis 3
Clinical Management Approach
When HFMD is diagnosed:
- Children can remain in school but should practice enhanced hand hygiene 1
- Parents should be notified to monitor for symptoms in household contacts 1
- The illness is typically self-limited, lasting less than 1 week 4
- Treatment is symptomatic only, as no specific pharmaceutical intervention exists 5
Important Caveats
Exceptions requiring home care (not school exclusion per se):
- Children with fever should stay home until fever-free for 24 hours for comfort and general illness policy 4
- Severe cases with neurological or cardiopulmonary complications require medical attention and hospitalization 5
- Children too ill or uncomfortable to participate in normal activities should remain home for their own comfort 4
Infection Control Measures
Focus should be on hygiene rather than exclusion:
- Enhanced handwashing practices, particularly after toileting and before eating 1
- Disinfection of frequently touched surfaces and toys 3
- These measures should continue for an extended period during outbreaks, given the prolonged incubation period 3
This approach parallels the evidence-based recommendations against "no-nit" policies for head lice, where exclusion causes unnecessary school absence without meaningful reduction in transmission 6.