What do we know about hand, foot, and mouth disease, and are we prepared for future outbreaks in South Africa?
Hand, foot, and mouth disease (HFMD) is a common viral infection that mainly affects young children. HFMD is caused by several enteroviruses, including Coxsackievirus A6, A10, A16 and Enterovirus A71 (EV-A71). It usually causes a fever, mouth sores, and a rash or small blisters on the hands and feet. Most children recover without serious complications, but in some cases, particularly those caused by certain enteroviruses, the disease can become severe.
HFMD occurs in many parts of the world, with large outbreaks reported regularly in the Asia-Pacific region. In Africa, fewer outbreaks have been documented, but this may be partly because the disease is not routinely monitored and may go unrecognised.
In South Africa, HFMD is not currently a notifiable medical condition. This means there is limited information on how often it occurs, where it occurs, and which viruses are responsible. The 2025 outbreak in KwaZulu-Natal highlighted these gaps and raised important questions about the country’s ability to detect and respond to future outbreaks.
The following report provides a global overview of HFMD, examines the South African context, and highlights opportunities to strengthen surveillance and preparedness while recognising that most infections remain mild.
Background
Global epidemiology
The Asia-Pacific region has experienced the largest HFMD outbreaks. Cases have also been reported in Africa, Europe and the Americas. In Africa, documented outbreaks remain uncommon, but this may reflect under-recognition and limited diagnostic capacity.
Transmission and risk factors
HFMD spreads through close contact, respiratory droplets, contaminated surfaces and the faecal-oral route. Children in crèches, preschools and early-grade classrooms are at greatest risk. Overcrowding, unreliable water supplies and poor sanitation can further increase transmission.
HFMD in South Africa: the 2025 outbreak
The 2025 outbreak in KwaZulu-Natal was the first HFMD event recognised nationally. Rapid spread and anxiety highlighted surveillance gaps. Because HFMD is not currently a notifiable condition, South Africa has limited baseline information on its burden, seasonality and transmission patterns.
Discussion
Public health significance and improved HFMD surveillance
Without routine surveillance, changes in disease patterns or unusual strains may go undetected. Strengthening surveillance would improve situational awareness, support timely communication and inform preparedness.
Surveillance approaches for South Africa
A practical approach could combine clinical and sentinel surveillance, laboratory testing and sequencing, and wastewater monitoring. Schools and childcare centres could also report unusual clusters. Integration into broader surveillance systems would strengthen detection and response.
Limitations and operational challenges
Implementation will require improved clinician awareness, laboratory capacity and clear reporting pathways. Public communication must provide reassurance while ensuring severe or unusual cases receive appropriate attention.
Recommendations
South Africa should integrate HFMD into routine surveillance, expand testing and wastewater monitoring, strengthen clinician training, and improve public communication. Monitoring vaccine developments will support preparedness.
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