Notifiable Disease In China Research Articles

An Analytical Approach for Temporal Infection Mapping and Composite Index Development

Significant and composite indices for infectious disease can have implications for developing interventions and public health. This paper presents an investment for developing access to further analysis of the incidence of individual and multiple diseases. This research mainly comprises two steps: first, an automatic and reproducible procedure based on functional data analysis techniques was proposed for analyzing the dynamic properties of each disease; second, orthogonal transformation was adopted for the development of composite indices. Between 2000 and 2019, nineteen class B notifiable diseases in China were collected for this study from the National Bureau of Statistics of China. The study facilitates the probing of underlying information about the dynamics from discrete incidence rates of each disease through the procedure, and it is also possible to obtain similarities and differences about diseases in detail by combining the derivative features. There has been great success in intervening in the majority of notifiable diseases in China, like bacterial or amebic dysentery and epidemic cerebrospinal meningitis, while more efforts are required for some diseases, like AIDS and virus hepatitis. The composite indices were able to reflect a more complex concept by combining individual incidences into a single value, providing a simultaneous reflection for multiple objects, and facilitating disease comparisons accordingly. For the notifiable diseases included in this study, there was superior management of gastro-intestinal infectious diseases and respiratory infectious diseases from the perspective of composite indices. This study developed a methodology for exploring the prevalent properties of infectious diseases. The development of effective and reliable analytical methods provides special insight into infectious diseases’ common dynamics and properties and has implications for the effective intervention of infectious diseases.

Epidemiological Trends and Hotspots of Other Infectious Diarrhea (OID) in Mainland China: A Population-Based Surveillance Study From 2004 to 2017.

Background: The incidence of other infectious diarrhea (OID) ranked second in class C notifiable disease in China. It has posed a great threat to public health of all age groups. The aim of this study was to investigate the epidemiological trends and hotspots of OID in mainland China.Materials and Methods: Incidence and mortality data for OID stratified by date, age and region from 2004 to 2017 was extracted from the data-center of China public health science. Joinpoint regression and space-time analyses were performed to explore the epidemiological trends and hotspots of OID.Results: The average annual incidence of OID was 60.64/100,000 and it showed an increased trend in the mainland China especially after 2006 (APC = 4.12, 95 CI%: 2.06–6.21). Children of 0–4 year age group accounts for 60.00% (5,820,897/11,414,247) of all cases and its incidence continuously increased though 2004–2017 (APC = 6.65, 95 CI%: 4.39–8.96). The first-level spatial and temporal aggregation areas were located in Beijing and Tianjin, with the gathering time from 2005/1/1 to 2011/12/31 (RR = 5.52, LLR = 572893.59, P < 0.001). The secondary spatial and temporal aggregation areas covered Guangdong, Guangxi, Hainan and Guizhou from 2011/1/1 to 2017/12/31 (RR = 1.98, LLR = 242292.72, P < 0.001). OID of Tianjin and Beijing presented a decreased trend since 2006. However, the incidence of OID in Guangdong, Guangxi, Hainan and Guizhou showed increased trends through 2004–2017.Conclusion: Our study showed that OID showed a constantly increasing trend and brought considerable burden in China especially in the 0–4 age group. The high-risk periods and clusters of regions for OID were identified, which will help government develop disease-specific and location-specific interventive measures.

Changes in Notifiable Infectious Diseases in China During the COVID-19 Pandemic: A National Surveillance Study

Background: Nationwide nonpharmaceutical interventions (NPI) were used to combat the novel coronavirus disease (COVID-19) during 2020 in the mainland of China. These NPIs have proven effective on mitigating the spread of COVID-19, but their broad impact on other diseases remains under-investigated. In this study, we aim to assess whether such broad impact exists on notifiable diseases in China.Methods: Weekly incidence and mortality data for 31 major notifiable infectious diseases at the province level were extracted from the China Information System for Disease Control and Prevention from 2014 to 2020. We assessed the impact of NPIs by contrasting the incidences of each infectious disease in predefined COVID-19 phases during 2020 to the average incidences in the corresponding time intervals during 2014-2019.Findings: We observed decreased incidences of most diseases during the phases after the lockdown of Wuhan. In general, respiratory diseases and gastrointestinal or enteroviral diseases were more affected than sexually transmitted or bloodborne diseases and vector-borne or zoonotic diseases. Seasonal flu and rubella were the most sensitive to the NPIs, with reductions of 67-99% in incidence rates throughout the NPI-implemented phases in China (Jan 27-Dec 31, 2020). Among gastrointestinal or enteroviral diseases, the hand, foot and mouth disease (HFMD) was subject to the largest declines during Jan 27-Aug 31, 2020, with >90% reduction in incidence rate. Phases with more stringent NPIs were associated with more reductions. Non-respiratory diseases, particularly HFMD, gonorrhea and brucellosis, rebounded towards the end of the year as the NPIs were relaxed.Interpretation: NPIs are broadly effective in containing infectious diseases. Less disruptive NPIs such as wearing face masks are still effective in mitigating respiratory diseases but are not adequate for containing non-respiratory diseases.Funding Statement: This work was supported by grants from the National Natural Science Funds [91846302, 81825019], the China Mega-Project on Infectious Disease Prevention [2018ZX10713001, 2018ZX10713002, 2018ZX10201001 and 2017ZX10103004], and the US National Institutes of Health [R56 AI148284].Declaration of Interests: All authors declare no competing interests.Ethics Approval Statement: Missing.

Impact of Immunization Programs on 11 Vaccine-Preventable Diseases in China: 1950-2018

Background: China’s immunization program has determined dramatic declines in morbidity and mortality of vaccine-preventable diseases (VPDs) in the past decades. To evaluate the program’s achievements, we explored the changes in morbidity and mortality of VPDs in China. Methods: 11 diseases were chosen as representative notifiable diseases in China, and annual surveillance data obtained between 1950 and 2018 were used to derive trends in morbidity and mortality for each stage. Quasi-Poisson regression models and Polynomial regression models were used to estimate the impacts of specific vaccine programs, and life-table methods were used to calculate the loss of life expectancy, years of life lost (YLLs) and loss of working years. Results: The total notification number for the 11 VPDs was 211,866,000 from 1950 to 2018. The greatest number occurred in 1959, with around 12 million cases and a total incidence rate of 1,723 per 100,000 persons. The quasi-Poisson regression models showed that most of the 11 diseases revealed dramatic declines in morbidity after integrating into Expanded Program on Immunization (EPI), while varicella, and paratyphoid fever showed an increased morbidity, which did not integrate into EPI in China. From 1978 to 2018, the incidence rate of pertussis fell 98% from 126.35 to 1.58 per million, that of measles fell 99% from 249.76 to 0.28 per 100,000, that of meningococcal meningitis fell 99% from 32.23 to 0.01 per million, that of JE fell 98% from 5.39 to 0.13 per million, and diphtheria and polio were eradicated, with the last cases being reported in 2006 and 1994, respectively. From 1978 to 2018, the total life expectancy for the 11 VPDs increased by 0.79 years. Interpretation: China had great success in controlling VPDs in recent decades, and the burden of major diseases has been declining. The implementation of the National Immunization Program (NIP) accelerated the decreases in morbidity and mortality rates. Improving vaccination coverage is a key aspect of controlling VPDs in China. Funding Statement: This study was funded by the “Evaluation project on national immunization program of China” Declaration of Interests: The authors declare that they have no competing interest.

Gonorrhea in China, 2018

Abstract Objective: Gonorrhea is a globally widespread sexually transmitted infection caused by Neisseria gonorrhoeae. This study is aimed to analyze the epidemiological characteristics of gonorrhea cases reported in China in 2018 and provide evidence for strategies making in the gonorrhea prevention and control programme. Methods: Gonorrhea cases were extracted from National Notifiable Disease Report System (NNDRS) covering 31 provinces, autonomous regions, and municipalities in the mainland of China. The overall incidence rate was calculated, as were rate per province, sex, age group, and occupation group. Results: In 2018, 133,156 new cases of gonorrhea were reported in China, corresponding to an incidence rate of 9.59 cases per 100,000 population and having a 36.03% increase from 2014 (7.05 cases per 100,000 population). Zhejiang, Hainan, Guangdong, Fujian provinces, and Shanghai city had a higher reported rate (14.05-28.00 per 100,000 population). Hebei, Tianjin, Tibet, Heilongjiang, and Jilin provinces had a lower reported rate (1.56-5.19 per 100,000 population). The males had a much higher incidence than the females (15.81 per 100,000 vs. 3.08 per 100,000) and a faster rising rate (38.32% vs. 27.27%). The highest rate was detected in the aged 25–29 years both of male and female (46.37 and 6.60 per 100,000, respectively), followed by those aged 30–34 years (41.12 and 6.39 per 100,000, respectively). The largest proportion of gonorrhea cases was among the farmers accounting for 27.74%, followed by the unemployed persons (24.67%), business persons (17.02%) and industrial workers (9.50%). Conclusion: In general, gonorrhea has an increasing trend from 2014 and remains a common notifiable disease in China in 2018. Young males who are sexually active are high risk populations for gonococcal infection. The southeast coastal areas with developed economy have a higher rate of gonorrhea reported. Corresponding strategies on disease prevention and control should be performed on the high risk populations and regions.

Isolation and Characterization of Clinical Listeria monocytogenes in Beijing, China, 2014-2016.

Listeria monocytogenes is an important foodborne pathogen with a significant impact on public health worldwide. A great number of outbreaks caused by L. monocytogenes has been reported, especially in the United States, and European countries. However, listeriosis has not yet been included in notifiable disease in China, and thus information on this infection has been scarce among the Chinese population. In this study, we described a 3-year surveillance of listeriosis in Beijing, China. Fifty-six L. monocytogenes strains isolated from 49 clinical infectious cases (27 pregnancy-associated infections and 22 non-pregnancy-associated infections) were analyzed by serotyping, pulsed field gel electrophoresis (PFGE), multilocus sequence typing (MLST), and antimicrobial susceptibility testing between 2014 and 2016 in Beijing. The predominant serogroups were 1/2a,3a and 1/2b,3b,7 which accounted for 92% of the overall isolates. Four strains were serogroup 4b,4d,4e, isolated from patients with pregnancy-associated infections. Based on PFGE, these isolates were divided into 32 pulsotypes (PTs) and 3 clusters associated with serogroups. Ten PTs were represented by more than one isolate with PT09 containing the most number of isolates. MLST differentiated the isolates into 18 STs, without new ST designated. The three most common STs were ST8 (18.4%), ST5 (16.3%), and ST87 (12.2%), accounting for 46.9% of the isolates. STs prevalent in other parts of the world were also present in China such as ST1, ST2, ST5, ST8, and ST9 which caused maternal fetal infections or outbreaks. However, the STs and serogroup distribution of clinical L. monocytogenes in Beijing, China was different from those in other countries. Strains of ST1 and ST2 were isolated from patients with pregnancy-associated infection, whereas none of ST155 isolates caused pregnancy-associated cases. Surveillance of molecular characterization will provide important information for prevention of listeriosis. This study also enhances our understanding of genetic diversity of clinical L. monocytogenes in China.

Surveillance, epidemiology, and pathogen spectrum of hand, foot, and mouth disease in mainland of China from 2008 to 2017

Hand, foot and mouth disease (HFMD) was reported in May 2, 2008 to be the 38th legally notifiable disease in China's National Notifiable Disease Reporting and Surveillance System. In order to solve the infection, an extensive three-level HFMD surveillance laboratory network was established. In this study, the framework of that network is assessed and the incidence of HFMD in China from 2008 to 2017 is reported using a descriptive epidemiologic method. During these 10 years, a series of techniques have been widely applied in all the network laboratories. Using information and material obtained from the network, a virus bank and database containing 18,238 viruses were established. Nationally, 18,184,834 HFMD cases, including 152,436 severe cases and 3633 fatal cases, were reported in mainland of China. The average annual incidence in the population was 133.99/100,000 people, with a maximum incidence of 205.06/100,000 people in 2014. The incidence and mortality rates of HFMD were the highest in children aged 1–2 years. The numbers of reported cases fluctuated, with a high incidence observed every 2 years. An overall increase in the number of reported cases was also observed throughout the study period. Despite this, the incidence of severe cases and the mortality rate have been decreasing. High-risk regions are located in southern, eastern, and central China. Two peaks of HFMD infection cases were observed annually except for Northeast China. Different proportions of enterovirus serotypes were observed during the studied years. The predominant enterovirus varies from year to year, but the disease severity is always closely related to the specific serotype. EV-A71 is the dominant serotype associated with severe and fatal cases, with constituent ratios of 70.03% and 92.23%, respectively. The studied highly sensitive and efficient surveillance network provides information that is critical for prevention and control of the disease. It is extremely necessary and important to continuously conduct extensive virological surveillance for HFMD.

Application of autoregressive integrated moving average model in predicting the reported notifiable communicable diseases in China

Objective: To develop the models for predicting the reported legally notifiable diseases in China. Autoregressive integrated moving average (ARIMA) model was applied to forecast the trend of diseases. Methods: Cases used for building the model were from of the records of Notifiable Infectious Diseases in China from May 2009 to July 2016 with R software and the model's predictive ability was tested by the data from August 2016 to January 2017. Results: A strong seasonal nature was seen in the reported cases of notifiable communicable diseases, with the lowest point in February and highest peak in June. ARIMA (4, 1, 0) (1, 1, 1)(12) model was established by the team to forecast the notifiable communicable diseases. Data showed that the biggest and lowest relative errors appeared as 9.78% and 2.21%, respectively, with the mean of the relative error as 5.39%. Conclusion: Based on the results of this study, the ARIMA (4, 1, 0) (1, 1, 1)(12) model seemed to have had the sound prediction of notifiable communicable diseases in China.

Multivariate time series analysis on the dynamic relationship between Class B notifiable diseases and gross domestic product (GDP) in China.

The surveillance of infectious diseases is of great importance for disease control and prevention, and more attention should be paid to the Class B notifiable diseases in China. Meanwhile, according to the International Monetary Fund (IMF), the annual growth of Chinese gross domestic product (GDP) would decelerate below 7% after many years of soaring. Under such circumstances, this study aimed to answer what will happen to the incidence rates of infectious diseases in China if Chinese GDP growth remained below 7% in the next five years. Firstly, time plots and cross-correlation matrices were presented to illustrate the characteristics of data. Then, the multivariate time series (MTS) models were proposed to explore the dynamic relationship between incidence rates and GDP. Three kinds of MTS models, i.e., vector auto-regressive (VAR) model for original series, VAR model for differenced series and error-correction model (ECM), were considered in this study. The rank of error-correction term was taken as an indicator for model selection. Finally, our results suggested that four kinds of infectious diseases (epidemic hemorrhagic fever, pertussis, scarlet fever and syphilis) might need attention in China because their incidence rates have increased since the year 2010.

Temporal and long-term trend analysis of class C notifiable diseases in China from 2009 to 2014

ObjectivesTime series models are effective tools for disease forecasting. This study aims to explore the time series behaviour of 11 notifiable diseases in China and to predict their incidence through...

Study of surveillance data for class B notifiable disease in China from 2005 to 2014.

SummaryBackgroundThe surveillance of infection is very important for public health management and disease control. It has been 10 years since China implemented its new web-based infection surveillance system, which covers the largest population in the world.MethodsIn this study, time series data were collected for 28 infectious diseases reported from 2005 to 2014 . Seasonality and long-term trends were explored using decomposition methods. Seasonality was expressed by calculating the seasonal indices. Long-term trends in the diseases were assessed using a linear regression model on the deseasonalized series.ResultsDuring the 10-year period, 38 982 567 cases and 126 372 deaths were reported in the system. The proportion of deaths caused by AIDS increased from 12% in 2005 to 78% in 2014. There were six diseases for which the seasonal index range was greater than 2: dengue fever, Japanese encephalitis, leptospirosis, anthrax, cerebrospinal meningitis, and measles . Among the 28 diseases, the incidence of syphilis increased fastest, with an average increase of 0.018626/100 000 every month after adjustment for seasonality.ConclusionsEffective surveillance is helpful in gaining a better understanding of the infection behaviour of infectious diseases; this will greatly facilitate disease control and management.

The changing epidemiology of dengue in China, 1990-2014: a descriptive analysis of 25 years of nationwide surveillance data.

BackgroundDengue has been a notifiable disease in China since 1 September 1989. Cases have been reported each year during the past 25 years of dramatic socio-economic changes in China, and reached a historical high in 2014. This study describes the changing epidemiology of dengue in China during this period, to identify high-risk areas and seasons and to inform dengue prevention and control activities.MethodsWe describe the incidence and distribution of dengue in mainland China using notifiable surveillance data from 1990-2014, which includes classification of imported and indigenous cases from 2005-2014.ResultsFrom 1990-2014, 69,321 cases of dengue including 11 deaths were reported in mainland China, equating to 2.2 cases per one million residents. The highest number was recorded in 2014 (47,056 cases). The number of provinces affected has increased, from a median of three provinces per year (range: 1 to 5 provinces) during 1990-2000 to a median of 14.5 provinces per year (range: 5 to 26 provinces) during 2001-2014. During 2005-2014, imported cases were reported almost every month and 28 provinces (90.3%) were affected. However, 99.8% of indigenous cases occurred between July and November. The regions reporting indigenous cases have expanded from the coastal provinces of southern China and provinces adjacent to Southeast Asia to the central part of China. Dengue virus serotypes 1, 2, 3, and 4 were all detected from 2009-2014.ConclusionsIn China, the area affected by dengue has expanded since 2000 and the incidence has increased steadily since 2012, for both imported and indigenous dengue. Surveillance and control strategies should be adjusted to account for these changes, and further research should explore the drivers of these trends.Please see related article: http://dx.doi.org/10.1186/s12916-015-0345-0Electronic supplementary materialThe online version of this article (doi:10.1186/s12916-015-0336-1) contains supplementary material, which is available to authorized users.

Analysis of morbidity and mortality characteristics of the notifiable diseases reported in 2013 in China

To learn the characteristics of morbidity and mortality of notifiable diseases reported in China in 2013. Descriptive analysis method was used to analyze the morbidity and mortality of notifiable diseases in China in 2013, with Microsoft Excel 2010 and ArcGIS 10.0 used to develop statistical charts. In 2013, the morbidity of the nationwide notifiable diseases was 473.87/100 000, a decrease of 3% below the average of the recent 3 years, while the mortality was 1.23/100 000, an increase of 2% over the average of the recent 3 years. The rate of laboratory diagnosis of the reported cases was 38.4%. Top 5 diseases of the reported incidence were hand foot and mouth disease, other infectious diarrhea, hepatitis B, tuberculosis and syphilis. The death cases reported were mainly AIDS, tuberculosis and rabies. As classified by the transmission route analysis, intestinal infectious diseases accounted for 49% of the total incidence reported for the year, followed by the blood and sexually transmitted infectious diseases, respiratory infectious diseases, animal and vector borne infectious diseases. According to the pathogenic analysis, virus infectious diseases accounted for 68% of the total cases, higher than bacterial infectious diseases and animal-borne/vector-borne infectious diseases. In Shanghai, Zhejiang and Jiangsu, human infection with avian influenza A (H7N9) virus was emerging, as epidemic situation of measles, dengue fever and brucellosis were on the rise significantly nationwide, while the morbidity of infectious diseases decreased, namely pulmonary tuberculosis, hepatitis B among others. Morbidity of the top 5 provinces for notifiable infectious diseases were Hainan, Guangxi, Guangdong, Xinjiang and Zhejiang, respectively. The proportion of laboratory confirmed cases among totals was still low in 2013. The morbidity of the infectious diseases was higher in western provinces and parts of south-eastern province, the mortality was higher in western provinces. The emerging human infection with avian influenza A (H7N9) virus, and the high epidemic of measles, dengue fever and brucellosis in some areas had caught the society concerns.

Application of a novel grey self-memory coupling model to forecast the incidence rates of two notifiable diseases in China: dysentery and gonorrhea.

ObjectiveIn this study, a novel grey self-memory coupling model was developed to forecast the incidence rates of two notifiable infectious diseases (dysentery and gonorrhea); the effectiveness and applicability of this model was assessed based on its ability to predict the epidemiological trend of infectious diseases in China.MethodsThe linear model, the conventional GM(1,1) model and the GM(1,1) model with self-memory principle (SMGM(1,1) model) were used to predict the incidence rates of the two notifiable infectious diseases based on statistical incidence data. Both simulation accuracy and prediction accuracy were assessed to compare the predictive performances of the three models. The best-fit model was applied to predict future incidence rates.ResultsSimulation results show that the SMGM(1,1) model can take full advantage of the systematic multi-time historical data and possesses superior predictive performance compared with the linear model and the conventional GM(1,1) model. By applying the novel SMGM(1,1) model, we obtained the possible incidence rates of the two representative notifiable infectious diseases in China.ConclusionThe disadvantages of the conventional grey prediction model, such as sensitivity to initial value, can be overcome by the self-memory principle. The novel grey self-memory coupling model can predict the incidence rates of infectious diseases more accurately than the conventional model, and may provide useful references for making decisions involving infectious disease prevention and control.

Systematic review of human listeriosis in China, 1964–2010

Listeria is an important foodborne pathogen with severe manifestations and high case-fatality rate. However, listeriosis is not yet a notifiable disease in China, and there is no national monitoring system for cases. We conducted a systematic review to better understand the clinical and epidemiologic features of listeriosis in China. Both electronic and manual retrieval systems were used to search Chinese literature for cases and isolates of human listeriosis reported between 1964 and 2010. We recorded and analysed demographic, clinical and laboratory information available for reported cases. A total of 147 clinical cases, 479 Listeria isolates and 82 outbreak-related cases were reported in 28 (90%) provinces in China from January 1964 to December 2010. Of the clinical cases, 45 (31%) were central nervous system infections, 68 (46%) were septicaemia and 34 (23%) were focal infections or gastroenteritis. The overall case-fatality rate was 26% (34/130) among clinical cases with known outcomes and 46% (21/46) among neonatal cases. Listeriosis cases occurred in China throughout the study period between 1964 and 2010. Case-fatality was similar to published data from other countries. China should consider requiring notification of listeriosis cases to improve estimates of incidence, identification of risk factors and design of preventive measures.

Characterization of Hand, Foot, and Mouth Disease in China between 2008 and 2009

Objective To investigate the epidemiological and clinical features of hand, foot and mouth disease (HFMD) since several outbreaks of HFMD caused by enteroviruses were documented in China between 2007 and 2008. Methods HFMD cases reported to the National Infectious Disease Information Management System database between May 2008 and April 2009 were assessed. Clinical features in some of the severe and fatal cases were analyzed the etiology of the outbreaks was investigated. Results 89.1% of reported HFMD cases were found in children<5 year-old with an age-specific incidence rate of 834.1/100 000 in the first year as the notifiable disease in China from May 2008 to April 2009. The incidence, mortality and percentage of severe cases were studied for three regions of China and found to be highest in the central region. The incidence of severe cases and mortality in rural population were significantly higher than those in urban population. Among the laboratory confirmed EV17 positive cases there were 52.6% mild, 83.5% severe, and 96.1% fatal cases. More myoclonic jerks were found in the severe case group than in group that died. Tachypnea, lip purpling, pink foaming and low limb temperature occurred more frequently in the fatal cases than in the severe cases. Conclusion The epidemic of HFMD in China was characterized predominantly by EV71 infections, had relatively high mortality rates especially in the central region, and was most prevalent in young, rural populations.

Controlling SARS: a review on China's response compared with other SARS-affected countries.

Summary Objective To summarise the major control measures implemented by severe acute respiratory syndrome (SARS)‐affected countries and to compare distinctive features of the Chinese approach to other affected Asian countries and Canada. Method Literature review. Results The realisation in March 2003 that SARS was spreading led affected countries to introduce measures such as rapid dissemination of information, early case detection and isolation, tracing and quarantining of SARS contacts, traveller screening, raising public awareness of risk and institution of stricter infection control in health care settings. SARS became a notifiable disease in China in mid‐April 2003, after which introduction of efficient nationwide control measures led to containment within 2 months. Countries differed in the timeliness of implementing control measures, the mode and extent to which these were enforced and in the resources available to do so. Conclusion SARS challenged the political and public health systems of all affected countries. It demanded rapid and decisive action to be taken, yet the comparison shows how difficult this was for an unknown new disease. Guangdong reacted rapidly but this pace was not continued by China for some time, which facilitated national and international spread. Once the Chinese government changed its policy, it developed an impressive control strategy involving the public which culminated in containment. The significance of timely information was perhaps the main lesson which the SARS epidemic taught.

Human Rabies in China

To the Editor: Rabies has occurred in China for >2,000 years and was first described in ≈56 BC (1). Since 1950, human rabies has been a class II notifiable disease in China, and the annual number and distribution of human rabies cases have been archived. We examined the archived data from 1950 to 2004 and analyzed epidemiologic characteristics. During the 55-year period, 108,412 human rabies cases were recorded in China. The Figure shows the number of annual cases from 1950 to 2004; 3 major epidemics of human rabies in China are apparent. In the early 1950s, only a few cases occurred; the first peak occurred from 1956 to 1957 with ≈,000 cases each year. Then the number of cases declined during subsequent years and was relatively constant throughout the 1960s. By 1969, the number of cases increased again to ≈,000. This ascending phase continued throughout the 1970s and 1980s. The second epidemic peaked in the early 1980s. In 1981, 7,037 cases were recorded, the largest number of cases in a single year during the 55-year period. During the 1980s, 55,367 cases were reported (>5,000 cases annually), representing >50% of the 108,412 cases seen during the entire period. In the early 1990s, the number of human cases decreased dramatically from 3,520 in 1990 to 159 in 1996. However, this downward trend reversed its course in 1998, and annual cases have increased gradually since then. In 2004, a total of 2,651 cases were reported, an increase of >16 fold when compared with the numbers in 1996. This third rabies epidemic apparently has not yet peaked. Figure Annual rabies cases reported in China from 1950 to 2004. The compiled data also showed substantially more rabies cases in the summer and autumn than in the spring and winter. Similar seasonality was reported in animals (2), indicating the pattern of transmission from animals to humans. Rabies patients range in age from infancy to >65 years of age. The ratio of male to female victims is 68 to 32. Although human rabies has been reported in almost all provinces, 15 provinces have had >1,000 cumulative cases each. These provinces are Hunan, Guangdong, Sichuan, Guangxi, Guizhou, Hubei, Jiangxi, Shandong, Henan, Anhui, Jiangsu, Hebei, Fujian, Yunnan, and Liaoning. These 15 provinces account for >93% of the total cases. Four provinces (Hunan, Guangdong, Sichuan, and Guangxi) have had >7,000 cumulative cases each. Most of the human patients were infected with rabies by dog bites. The number of dogs has increased gradually in China since the late 1970s. Now ≈0% of households in Guangxi, Guizhou, and Jiangsu, and Hunan, where the most cases were recorded in recent years, have >1 dog (data not shown). However, the rate of dog vaccination remains ≈%. The rabies epidemics in China since 1950 may be partially explained by dog population dynamics. The first major epidemic subsided at the end of the 1950s and the beginning of the 1960s, coinciding with pet reduction policy. The second major epidemic peaked in the late 1970s and early 1980s, when economic reforms were initiated in China and the dog population increased dramatically. Population immunity may also play a role in these cyclic epidemics. However, neither the dramatic decline of rabies cases in the early part of 1990s nor the initiation of the third epidemic around the turn of the millennium could be explained simply by dog population dynamics. Other factors may include untimely and inappropriate postexposure treatment (3,4) and the existence of healthy carrier dogs (5–7). Wounds of 118 of 178 patients were not treated; 60 of the patients washed the wounds with soap and water. A total of 129 (72%) patients did not receive vaccine. Of the remaining 49 (28%) patients, 35 received vaccination in a timely manner. Two of the 178 patients received antirabies serum intramuscularly. Among the 49 patients who received postexposure vaccination, 30 did not complete the immunization requirements. Healthy carriers have been detected, and rabies virus antigen was found in 25 (10%) of 248 brain specimens from healthy dogs collected from Guangxi, Guizhou, and Jiangsu (data not shown) in 1 study. Further investigation is needed to confirm these findings. In summary, rabies remains a public health problem in China. Strategies to control and prevent human rabies include public education and awareness about rabies, pet vaccination programs, elimination of stray animals, and enhanced postexposure management. In addition, the large number of rabies cases should encourage rabies prophylaxis for foreign travelers before they visit China, particularly those who might travel to rural areas.