{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,6]],"date-time":"2026-10-06T17:36:09Z","timestamp":1791308169982,"version":"4.3.1"},"reference-count":80,"publisher":"BMJ","issue":"1","funder":[{"name":"Singapore\u2019s Ministry of Health Health Services Research"},{"name":"President\u2019s Graduate Fellowship, National University of Singapore"},{"name":"Communicable Disease Public Health Research"},{"name":"Centre for Infectious Disease Epidemiology and Research"}],"content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["BMJ Glob Health"],"accepted":{"date-parts":[[2017,10,11]]},"published-print":{"date-parts":[[2018,1]]},"abstract":"<jats:sec>\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>Hand, foot and mouth disease (HFMD) affects millions of children across Asia annually, leading to an increase in implemented control policies such as surveillance, isolation and social distancing in affected jurisdictions. However, limited knowledge of disease burden and severity causes difficulty in policy optimisation as the associated economic cost cannot be easily estimated. We use a data synthesis approach to provide a comprehensive picture of HFMD disease burden, estimating infection risk, symptomatic rates, the risk of complications and death, and overall disability-adjusted life-year (DALY) losses, along with associated uncertainties.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>Complementary data from a variety of sources were synthesised with mathematical models to obtain estimates of severity of HFMD. This includes serological and other data extracted through a systematic review of HFMD epidemiology previously published by the authors, and laboratory investigations and sentinel reports from Singapore\u2019s surveillance system.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>HFMD is estimated to cause 96\u2009900 (95% CI 40\u2009600 to 259\u2009000) age-weighted DALYs per annum in eight high-burden countries in East and Southeast Asia, with the majority of DALYs attributed to years of life lost. The symptomatic case hospitalisation rate of HFMD is 6% (2.8%\u201314.9%), of which 18.7% (6.7%\u201331.5%) are expected to develop complications. 5% (2.9%\u20137.4%) of such cases are fatal, bringing the overall case fatality ratio to be 52.3 (24.4\u201392.7) per 100\u2009000 symptomatic infections. In contrast, the EV-A71 case fatality ratio is estimated to be at least 229.7 (75.4\u2013672.1) per 100\u2009000 symptomatic cases. Asymptomatic rate for EV-A71 is 71.4% (68.3%\u201374.3%) for ages 1\u20134, the years of greatest incidence.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>Despite the high incidence rate of HFMD, total DALY due to HFMD is limited in comparison to other endemic diseases in the region, such as dengue and upper respiratory tract infection. With the majority of DALY caused by years of life lost, it is possible to mitigate most with increased EV-A71 vaccine coverage.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1136\/bmjgh-2017-000442","type":"journal-article","created":{"date-parts":[[2018,1,26]],"date-time":"2018-01-26T20:10:23Z","timestamp":1516997423000},"page":"e000442","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":101,"title":["Severity and burden of hand, foot and mouth disease in Asia: a modelling study"],"prefix":"10.1136","volume":"3","author":[{"given":"Wee Ming","family":"Koh","sequence":"first","affiliation":[{"name":"Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Hishamuddin","family":"Badaruddin","sequence":"additional","affiliation":[{"name":"Ministry of Health, Singapore"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Hanh","family":"La","sequence":"additional","affiliation":[{"name":"Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mark I-Cheng","family":"Chen","sequence":"additional","affiliation":[{"name":"Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore"},{"name":"Communicable Disease Centre, Tan Tock Seng Hospital, Singapore"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Alex R","family":"Cook","sequence":"additional","affiliation":[{"name":"Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"239","published-online":{"date-parts":[[2018,1,26]]},"reference":[{"key":"2025072913024852000_3.1.e000442.1","doi-asserted-by":"publisher","DOI":"10.1542\/peds.2006-1547"},{"key":"2025072913024852000_3.1.e000442.2","doi-asserted-by":"publisher","DOI":"10.1056\/NEJMoa065954"},{"key":"2025072913024852000_3.1.e000442.3","doi-asserted-by":"publisher","DOI":"10.1016\/S1473-3099(13)70342-6"},{"key":"2025072913024852000_3.1.e000442.4","doi-asserted-by":"publisher","DOI":"10.1086\/314032"},{"key":"2025072913024852000_3.1.e000442.5","doi-asserted-by":"crossref","first-page":"341","DOI":"10.1186\/1471-2334-14-341","article-title":"Epidemiological and clinical characteristics of children who died from hand, foot and mouth disease in Vietnam, 2011","volume":"14","author":"Nguyen","year":"2014","journal-title":"BMC Infect Dis"},{"key":"2025072913024852000_3.1.e000442.6","doi-asserted-by":"crossref","first-page":"e104","DOI":"10.1038\/emi.2016.101","article-title":"Molecular epidemiology of human enterovirus 71 at the origin of an epidemic of fatal hand, foot and mouth disease cases in Cambodia","volume":"5","author":"Duong","year":"2016","journal-title":"Emerg Microbes Infect"},{"key":"2025072913024852000_3.1.e000442.7","doi-asserted-by":"crossref","unstructured":"Siegel K , Cook AR , La H . The impact of hand, foot and mouth disease control policies in Singapore: a qualitative analysis of public perceptions. J Public Health Policy 2017:271\u201387.doi:10.1057\/s41271-017-0066-z","DOI":"10.1057\/s41271-017-0066-z"},{"key":"2025072913024852000_3.1.e000442.8","doi-asserted-by":"publisher","DOI":"10.1056\/NEJMoa1304923"},{"key":"2025072913024852000_3.1.e000442.9","doi-asserted-by":"crossref","first-page":"1209","DOI":"10.1016\/S0140-6736(09)61377-5","article-title":"How to maintain surveillance for novel influenza A H1N1 when there are too many cases to count","volume":"374","author":"Lipsitch","year":"2009","journal-title":"The Lancet"},{"key":"2025072913024852000_3.1.e000442.10","doi-asserted-by":"crossref","first-page":"929","DOI":"10.1056\/NEJM199909233411301","article-title":"An epidemic of enterovirus 71 infection in Taiwan","volume":"341","author":"Ho","year":"1999","journal-title":"N Engl J Med Overseas Ed"},{"key":"2025072913024852000_3.1.e000442.11","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pmed.1000207","article-title":"The severity of pandemic H1N1 influenza in the United States, from April to July 2009: a Bayesian analysis","volume":"6","author":"Presanis","year":"2009","journal-title":"PLoS Med"},{"key":"2025072913024852000_3.1.e000442.12","doi-asserted-by":"publisher","DOI":"10.1093\/aje\/kwr113"},{"key":"2025072913024852000_3.1.e000442.13","doi-asserted-by":"crossref","first-page":"541","DOI":"10.1111\/j.1467-985X.2007.00537.x","article-title":"Estimates of human immunodeficiency virus prevalence and proportion diagnosed based on Bayesian multiparameter synthesis of surveillance data","volume":"171","author":"Goubar","year":"2008","journal-title":"J R Stat Soc Ser A Stat Soc"},{"key":"2025072913024852000_3.1.e000442.14","doi-asserted-by":"publisher","DOI":"10.1097\/INF.0000000000001242"},{"key":"2025072913024852000_3.1.e000442.15","first-page":"429","article-title":"Quantifying the burden of disease: the technical basis for disability-adjusted life years","volume":"72","author":"Murray","year":"1994","journal-title":"Bull World Health Organ"},{"key":"2025072913024852000_3.1.e000442.16","doi-asserted-by":"publisher","DOI":"10.1016\/S2214-109X(15)00069-8"},{"key":"2025072913024852000_3.1.e000442.17","doi-asserted-by":"publisher","DOI":"10.1136\/bmj.b2840"},{"key":"2025072913024852000_3.1.e000442.18","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pone.0080515","article-title":"Seroprevalence of human enterovirus 71 and coxsackievirus A16 in Guangdong, China, in pre- and post-2010 HFMD epidemic period","volume":"8","author":"Li","year":"2013","journal-title":"PLoS One"},{"key":"2025072913024852000_3.1.e000442.19","doi-asserted-by":"crossref","first-page":"528","DOI":"10.7883\/yoken.64.528","article-title":"Prevalence of antibodies against enterovirus 71 in children from Lu\u2019an City in Central China","volume":"64","author":"Yu","year":"2011","journal-title":"Jpn J Infect Dis"},{"key":"2025072913024852000_3.1.e000442.20","doi-asserted-by":"publisher","DOI":"10.1016\/j.jcv.2011.12.025"},{"key":"2025072913024852000_3.1.e000442.21","doi-asserted-by":"publisher","DOI":"10.3201\/eid0809.010397"},{"key":"2025072913024852000_3.1.e000442.22","doi-asserted-by":"publisher","DOI":"10.1186\/1471-2334-11-270"},{"key":"2025072913024852000_3.1.e000442.23","doi-asserted-by":"publisher","DOI":"10.1002\/jmv.2210"},{"key":"2025072913024852000_3.1.e000442.24","doi-asserted-by":"publisher","DOI":"10.1542\/peds.109.6.e88"},{"key":"2025072913024852000_3.1.e000442.25","doi-asserted-by":"publisher","DOI":"10.3201\/eid1504.081550"},{"key":"2025072913024852000_3.1.e000442.26","doi-asserted-by":"crossref","first-page":"1030-4","DOI":"10.1097\/INF.0b013e3181e52945","article-title":"An investigation of epidemic enterovirus 71 infection in Taiwan, 2008: clinical, virologic, and serologic features","volume":"29","author":"Lee","year":"2010","journal-title":"Pediatr Infect Dis J"},{"key":"2025072913024852000_3.1.e000442.27","doi-asserted-by":"publisher","DOI":"10.1186\/1423-0127-21-16"},{"key":"2025072913024852000_3.1.e000442.28","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pone.0021116","article-title":"The seroprevalence and seroincidence of enterovirus71 infection in infants and children in Ho Chi Minh City, Viet Nam","volume":"6","author":"Tran","year":"2011","journal-title":"PLoS One"},{"key":"2025072913024852000_3.1.e000442.29","doi-asserted-by":"publisher","DOI":"10.1186\/1743-422X-9-8"},{"key":"2025072913024852000_3.1.e000442.30","doi-asserted-by":"publisher","DOI":"10.1017\/S0950268811001622"},{"key":"2025072913024852000_3.1.e000442.31","doi-asserted-by":"crossref","first-page":"539","DOI":"10.1186\/1471-2334-13-539","article-title":"Epidemiology and clinical characteristics of hand foot, and mouth disease in a Shenzhen sentinel hospital from 2009 to 2011","volume":"13","author":"Wang","year":"2013","journal-title":"BMC Infect Dis"},{"key":"2025072913024852000_3.1.e000442.32","doi-asserted-by":"crossref","first-page":"422","DOI":"10.7883\/yoken.63.422","article-title":"Changing epidemiology of hand, foot, and mouth disease in Hong Kong, 2001-2009","volume":"63","author":"Ma","year":"2010","journal-title":"Jpn J Infect Dis"},{"key":"2025072913024852000_3.1.e000442.33","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pone.0100003","article-title":"Correlation analysis of EV71 detection and case severity in hand, foot, and mouth disease in the Hunan Province of China","volume":"9","author":"Gao","year":"2014","journal-title":"PLoS One"},{"key":"2025072913024852000_3.1.e000442.34","doi-asserted-by":"publisher","DOI":"10.1186\/1471-2334-9-3"},{"key":"2025072913024852000_3.1.e000442.35","first-page":"82","article-title":"Prognostic implications of myoclonic jerk in children with enterovirus infection","volume":"37","author":"Lu","year":"2004","journal-title":"J Microbiol Immunol Infect"},{"key":"2025072913024852000_3.1.e000442.36","doi-asserted-by":"crossref","first-page":"621","DOI":"10.1111\/j.1348-0421.2002.tb02743.x","article-title":"Outbreak of central nervous system disease associated with hand, foot, and mouth disease in Japan during the summer of 2000: detection and molecular epidemiology of enterovirus 71","volume":"46","author":"Fujimoto","year":"2002","journal-title":"Microbiol Immunol"},{"key":"2025072913024852000_3.1.e000442.37","doi-asserted-by":"publisher","DOI":"10.1542\/peds.2006-3331"},{"key":"2025072913024852000_3.1.e000442.38","first-page":"417","article-title":"Clinical features and factors of unfavorable outcomes for non-polio enterovirus infection of the central nervous system in northern Taiwan, 1994-2003","volume":"38","author":"Yang","year":"2005","journal-title":"J Microbiol Immunol Infect"},{"key":"2025072913024852000_3.1.e000442.39","doi-asserted-by":"crossref","first-page":"162","DOI":"10.1016\/j.diagmicrobio.2013.02.011","article-title":"A new factor influencing pathogen detection by molecular assay in children with both mild and severe hand, foot, and mouth disease","volume":"76","author":"Zhu","year":"2013","journal-title":"Diagn Microbiol Infect Dis"},{"key":"2025072913024852000_3.1.e000442.40","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pone.0025287","article-title":"Characterization of an outbreak of hand, foot, and mouth disease in Nanchang, China in 2010","volume":"6","author":"Liu","year":"2011","journal-title":"PLoS One"},{"key":"2025072913024852000_3.1.e000442.41","doi-asserted-by":"crossref","first-page":"355","DOI":"10.1159\/000334619","article-title":"Clinical features and management outcomes of severe hand, foot and mouth disease","volume":"21","author":"Tian","year":"2012","journal-title":"Med Princ Pract"},{"key":"2025072913024852000_3.1.e000442.42","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pone.0092745","article-title":"Epidemiological analysis, detection, and comparison of space-time patterns of Beijing hand-foot-mouth disease (2008-2012)","volume":"9","author":"Wang","year":"2014","journal-title":"PLoS One"},{"key":"2025072913024852000_3.1.e000442.43","doi-asserted-by":"crossref","first-page":"533","DOI":"10.1007\/s11434-013-0069-5","article-title":"Distribution and risk factors of hand, foot, and mouth disease in Changchun, northeastern China","volume":"59","author":"Yan","year":"2014","journal-title":"Chin Sci Bull"},{"key":"2025072913024852000_3.1.e000442.44","doi-asserted-by":"publisher","DOI":"10.1097\/EDE.0b013e318231d67a"},{"key":"2025072913024852000_3.1.e000442.45","doi-asserted-by":"publisher","DOI":"10.1007\/s00705-011-0929-8"},{"key":"2025072913024852000_3.1.e000442.46","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pone.0088065","article-title":"Spatio-temporal clustering of hand, foot, and mouth disease at the county level in Guangxi, China","volume":"9","author":"Xie","year":"2014","journal-title":"PLoS One"},{"key":"2025072913024852000_3.1.e000442.47","doi-asserted-by":"publisher","DOI":"10.1177\/1010539511430523"},{"key":"2025072913024852000_3.1.e000442.48","doi-asserted-by":"crossref","first-page":"776","DOI":"10.1017\/S0950268813001453","article-title":"Severe hand, foot and mouth disease in Shenzhen, South China: what matters most?","volume":"142","author":"Mou","year":"2014","journal-title":"Epidemiol Infect"},{"key":"2025072913024852000_3.1.e000442.49","first-page":"297","article-title":"Deaths in children during an outbreak of hand, foot and mouth disease in Peninsular Malaysia--clinical and pathological characteristics","volume":"60","author":"Shekhar","year":"2005","journal-title":"Med J Malaysia"},{"key":"2025072913024852000_3.1.e000442.50","doi-asserted-by":"publisher","DOI":"10.1080\/08035250310005242"},{"key":"2025072913024852000_3.1.e000442.51","doi-asserted-by":"publisher","DOI":"10.1016\/j.jcv.2009.02.002"},{"key":"2025072913024852000_3.1.e000442.52","doi-asserted-by":"crossref","first-page":"106","DOI":"10.47102\/annals-acadmedsg.V38N2p106","article-title":"Epidemiology and control of hand, foot and mouth disease in Singapore, 2001-2007","volume":"38","author":"Ang","year":"2009","journal-title":"Ann Acad Med Singapore"},{"key":"2025072913024852000_3.1.e000442.53","doi-asserted-by":"publisher","DOI":"10.1016\/j.ijid.2010.07.006"},{"key":"2025072913024852000_3.1.e000442.54","doi-asserted-by":"publisher","DOI":"10.1128\/JCM.40.1.10-15.2002"},{"key":"2025072913024852000_3.1.e000442.55","doi-asserted-by":"publisher","DOI":"10.1086\/511073"},{"key":"2025072913024852000_3.1.e000442.56","doi-asserted-by":"publisher","DOI":"10.1542\/peds.2007-3735"},{"key":"2025072913024852000_3.1.e000442.57","doi-asserted-by":"publisher","DOI":"10.1016\/S1386-6532(00)00068-8"},{"key":"2025072913024852000_3.1.e000442.58","doi-asserted-by":"publisher","DOI":"10.3201\/eid1311.070632"},{"key":"2025072913024852000_3.1.e000442.59","doi-asserted-by":"crossref","first-page":"1764","DOI":"10.3201\/eid1611.100104","article-title":"Enterovirus 71 infection with central nervous system involvement, South Korea","volume":"16","author":"Ryu","year":"2010","journal-title":"Emerg Infect Dis"},{"key":"2025072913024852000_3.1.e000442.60","doi-asserted-by":"publisher","DOI":"10.1007\/s10096-011-1432-6"},{"key":"2025072913024852000_3.1.e000442.61","doi-asserted-by":"publisher","DOI":"10.1086\/520149"},{"key":"2025072913024852000_3.1.e000442.62","doi-asserted-by":"crossref","first-page":"1679","DOI":"10.3760\/cma.j.issn.0366-6999.2010.13.012","article-title":"Dynamic change of mother-source neutralizing antibodies against enterovirus 71 and coxsackievirus A16 in infants","volume":"123","author":"Mao","year":"2010","journal-title":"Chin Med J"},{"key":"2025072913024852000_3.1.e000442.63","doi-asserted-by":"publisher","DOI":"10.1084\/jem.74.5.433"},{"key":"2025072913024852000_3.1.e000442.64","doi-asserted-by":"publisher","DOI":"10.1186\/1471-2334-14-414"},{"key":"2025072913024852000_3.1.e000442.65","unstructured":"R Core Team. R: A language and environment for statistical computing. R Foundation for Statistical Computing. 2016."},{"key":"2025072913024852000_3.1.e000442.66","doi-asserted-by":"publisher","DOI":"10.1111\/j.1467-9868.2005.00503.x"},{"key":"2025072913024852000_3.1.e000442.67","unstructured":"Ministry of Health. Hand, foot & mouth disease. https:\/\/www.moh.gov.sg\/content\/moh_web\/home\/diseases_and_conditions\/h\/hfmd.html (accessed 3 May 2016)."},{"key":"2025072913024852000_3.1.e000442.68","unstructured":"US Census Bureau. D. I. S. International programs, international data base. https:\/\/www.census.gov\/population\/international\/data\/idb\/informationGateway.php (accessed 1 Nov 2016)."},{"key":"2025072913024852000_3.1.e000442.69","unstructured":"Ministry of Health, Singapore. Weekly infectious diseases bulletin. https:\/\/www.moh.gov.sg\/content\/moh_web\/home\/statistics\/infectiousDiseasesStatistics\/weekly_infectiousdiseasesbulletin.html (accessed 2 Feb 2017)."},{"key":"2025072913024852000_3.1.e000442.70","unstructured":"Ministry of Health, Labour and Welfare, Japan. The 21th life tables (2010). http:\/\/www.mhlw.go.jp\/english\/database\/db-hw\/lifetb21th\/dl\/tables.pdf (Accessed: 11 Jan 2016)."},{"key":"2025072913024852000_3.1.e000442.71","doi-asserted-by":"publisher","DOI":"10.1017\/S0950268815002137"},{"key":"2025072913024852000_3.1.e000442.72","doi-asserted-by":"publisher","DOI":"10.1371\/journal.pmed.1001958"},{"key":"2025072913024852000_3.1.e000442.73","doi-asserted-by":"crossref","first-page":"3108","DOI":"10.3390\/ijerph110303108","article-title":"Modeling and preventive measures of hand, foot and mouth disease (HFMD) in China","volume":"11","author":"Li","year":"2014","journal-title":"Int J Environ Res Public Health"},{"key":"2025072913024852000_3.1.e000442.74","first-page":"61","article-title":"The data fitting and optimal control of a hand, foot and mouth disease (HFMD) model with stage structure","volume":"276","author":"Li","year":"2016","journal-title":"Appl Math Comput"},{"key":"2025072913024852000_3.1.e000442.75","doi-asserted-by":"crossref","first-page":"99","DOI":"10.1007\/s12190-012-0597-1","article-title":"Stability analysis and optimal control of a hand-foot-mouth disease (HFMD) model","volume":"41","author":"Yang","year":"2013","journal-title":"J Appl Math Comput"},{"key":"2025072913024852000_3.1.e000442.76","doi-asserted-by":"publisher","DOI":"10.1097\/INF.0b013e3182116e95"},{"key":"2025072913024852000_3.1.e000442.77","doi-asserted-by":"crossref","first-page":"3094","DOI":"10.1017\/S095026881500028X","article-title":"Case-fatality of hand, foot and mouth disease associated with EV71: a systematic review and meta-analysis","volume":"143","author":"Zhao","year":"2015","journal-title":"Epidemiol Infect"},{"key":"2025072913024852000_3.1.e000442.78","doi-asserted-by":"publisher","DOI":"10.1097\/EDE.0b013e3182a67448"},{"key":"2025072913024852000_3.1.e000442.79","unstructured":"Global Burden of Disease Study. Global Burden of Disease Study 2015 (GBD 2015) Results.Seattle, United States: Institute for Health Metrics and Evaluation (IHME) (2016). 2015 http:\/\/ghdx.healthdata.org\/gbd-results-tool (accessed 6 Feb 2017)."},{"key":"2025072913024852000_3.1.e000442.80","first-page":"267","article-title":"Applying DALYs to the burden of infectious diseases","volume":"79","author":"Zou","year":"2001","journal-title":"Bull World Health Organ"}],"container-title":["BMJ Global Health"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/syndication.highwire.org\/content\/doi\/10.1136\/bmjgh-2017-000442","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,7,29]],"date-time":"2025-07-29T20:03:01Z","timestamp":1753819381000},"score":1,"resource":{"primary":{"URL":"https:\/\/gh.bmj.com\/lookup\/doi\/10.1136\/bmjgh-2017-000442"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2018,1]]},"references-count":80,"journal-issue":{"issue":"1","published-online":{"date-parts":[[2018,1,26]]},"published-print":{"date-parts":[[2018,1]]}},"alternative-id":["10.1136\/bmjgh-2017-000442"],"URL":"https:\/\/doi.org\/10.1136\/bmjgh-2017-000442","relation":{},"ISSN":["2059-7908"],"issn-type":[{"value":"2059-7908","type":"electronic"}],"subject":[],"published":{"date-parts":[[2018,1]]}}}