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. 2025 Jul 2;25:886. doi: 10.1186/s12879-025-11281-y

Epidemiological trends of hand, foot, and mouth disease in children under age 10, Jiangning District, Jiangsu, China (2009–2023)

Baiqun Wu 1,#, Xiangnan Zhang 2,#, Minhui Fu 1, Xiaoming Ji 2,✉
PMCID: PMC12220131  PMID: 40604541

Abstract

Purpose

This study aimed to analyse the epidemiological characteristics of hand, foot, and mouth disease (HFMD) among children under age 10 in Jiangning District, Jiangsu Province, from 2009 to 2023, explore its changing trends, and provide a scientific basis for optimizing public health prevention and control strategies.

Methods

HFMD case data were obtained from the “Notifiable Infectious Disease Reporting Information Management System”. Descriptive statistical analysis was used to assess HFMD incidence, joinpoint regression analysis was applied to analyse long-term trends, and wavelet analysis was used to explore seasonality and periodicity.

Results

A total of 50,645 HFMD cases in children under 10 years of age were reported during the study period, with an average annual incidence rate of 3,136.01 per 100,000 people. The annual incidence rate fluctuated between 544.39 per 100,000 (in 2022) and 6,260.63 per 100,000 (in 2018), showing an initial steady increase, followed by a sharp decline and a rapid rebound. HFMD showed a pronounced incidence peak during summer and autumn, with periodic fluctuations at intervals of 6 months, 12 months, and 24 months. Boys had a higher incidence rate, with an average annual rate of 3588.07 per 100,000, compared with 2646.00 per 100,000 in girls. Children aged 1 and 3 years had the highest incidence rates. The dominant serotypes shifted, with an overall decline in the proportions of EV-A71 and CVA16, whereas CVA6 emerged as the predominant circulating serotype. Moreover, the proportion of severe cases has continued to decrease.

Conclusion

The incidence of HFMD among children under age 10 in Jiangning District remains high, and the predominant serotypes have changed in recent years. The decline in incidence during the COVID-19 pandemic and its subsequent recovery may be linked to non-pharmacological interventions and the “immune debt” phenomenon, a relationship that warrants further validation. The EV-A71 vaccine and improved public health interventions have contributed to a steady decline in the severity rate. Strengthening surveillance, developing vaccines targeting predominant serotypes, and optimizing prevention and control strategies are essential for the precise prevention and control of HFMD in children.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-025-11281-y.

Keywords: Hand, foot, and mouth disease; Human enterovirus; Children; Epidemiological characteristics; Incidence trends; Pathogen detection

Introduction

Hand, foot, and mouth disease (HFMD) is an acute infectious disease caused by multiple serogroups of enteroviruses and predominantly affects children under the age of five [1]. The clinical manifestations are fever and rashes, with most cases presenting mild symptoms that typically resolve spontaneously within 7–10 days of onset, resulting in a favourable prognosis. However, a minority of cases may progress to severe illness, potentially leading to complications such as encephalitis, meningitis, and heart failure [2, 3], with severe cases potentially resulting in death.

HFMD is highly contagious and is transmitted primarily through the fecal‒oral route, direct contact, and respiratory droplets. Close contact among children in kindergartens and schools accelerates virus transmission, while poor hygiene practices and environmental contamination further exacerbate the risk of spread. Therefore, outbreaks are common in densely populated places such as kindergartens and primary schools [4]. Owing to its widespread prevalence and frequent outbreaks, HFMD has become a prominent public health issue among children, particularly in East Asia and Southeast Asia. A study targeting eight high-burden areas in East Asia and Southeast Asia estimated that HFMD accounts for approximately 96,900 age-weighted disability adjusted life years (DALYs) annually, with a case fatality rate of 52.3 per 100,000 symptomatic infections [5].

In China, HFMD was classified as a notifiable infectious disease starting on July 1, 2008. A national HFMD surveillance system and a laboratory network for pathogen monitoring were established across mainland China to better address the growing threat of HFMD to children’s health. Data released by the National Administration of Disease Prevention and Control in China show that millions of HFMD cases are reported annually nationwide, making it one of the most prevalent infectious diseases in China [6]. This imposes significant pressure on healthcare resources and places a heavy economic burden on families and society. Ying et al. estimated that the economic loss caused by HFMD in Beijing is between 7.03 and 13.31 million USD annually [7]. In recent years, with the strengthening of vaccination and prevention measures, the number of severe and fatal cases has decreased [8, 9], although cases of mild HFMD remain prevalent. Moreover, the epidemiological characteristics of HFMD in China have undergone significant changes, with more frequent clustering and outbreaks and a wider geographical distribution [10]. Newly identified enterovirus serotypes, such as Coxsackievirus A6 (CVA6) and Coxsackievirus A10 (CVA10), have replaced enterovirus A71 (EV-A71) as the dominant strains [11].

The Jiangning District, located in the central part of Jiangsu Province, is a manufacturing base, transportation and logistics hub, and air transport hub in Eastern China. It covers an area of approximately 1,563 km2, with a resident population of 1.99 million (2024). The subtropical climate of this region, characterized by warm and humid weather for most of the year, makes it a traditional endemic area for HFMD. In recent years, frequent outbreaks of HFMD in primary schools and kindergartens have severely impacted children’s health and disrupted the normal educational activities of schools. This study aims to conduct a detailed analysis of the epidemiological characteristics of HFMD among children under the age of 10 in Jiangning District from 2009 to 2023 to provide scientific evidence for community-level public health strategies, reduce the disease burden, and offer precise guidance for future epidemic control.

Materials and methods

Data sources

The data on HFMD incidence and case information used in this study were obtained from the “Notifiable Infectious Disease Reporting Information Management System” of the Chinese Center for Disease Control and Prevention. The cases included in the study had onset dates ranging from January 1, 2009, to December 31, 2023. Individual case information included demographic characteristics, illness onset details, clinical classification, and laboratory test results. The diagnosis and clinical classification of HFMD were based on the updated hand, foot, and mouth disease diagnostic criteria (WS588) [12], and the definition of severe cases is provided in Supplementary File 1. The population data of Jiangning District were extracted from the Jiangning District Statistical Yearbooks.

Pathogen detection

As a sentinel surveillance site for HFMD, samples (pharyngeal swabs and/or anal swabs) of children with HFMD were collected from hospitals in Jiangning District during the epidemic season each year. Total RNA was extracted from 50µL of the clinical specimens using the Viral Isolation Kit (Ambion, USA), following the manufacturer’s protocol. Real-time RT-PCR was conducted to detect the universal sequence of enteroviruses, and samples with a cycle threshold (Ct) value ≤ 37 were considered positive. Positive samples were subsequently subjected to serotype-specific RT-PCR assays targeting EV-A71, CV-A16, CV-A6, and CV-A10, using detection kits provided by Jiangsu Shuoshi Biotechnology Co., Ltd. Samples positive for the universal enterovirus sequence but negative for specific sequences of EV-A71, CV-A16, CV-A6, and CV-A10 were categorized as other enterovirus serotypes.

From 2009 to 2016, typing was limited to two serotypes, namely, EV-A71 and CVA16. Cases that tested positive for enterovirus universal primers but negative for EV-A71 and CVA16 were reported as other enterovirus serotypes. Since 2017, the scope of detection has been expanded to include four serotypes: EV-A71, CVA16, CVA10, and CVA6.

Statistical analysis

Descriptive statistics were used to calculate the number of cases, incidence rates, and proportions. Comparisons of categorical data were performed via the χ² test. joinpoint regression analysis was used to assess the long-term trends in incidence rates, whereas wavelet analysis was performed to explore the periodicity and seasonality of the disease. Statistical analyses and data visualization were conducted via excel, joinpoint 0, MATLAB 2024a (30-day free trial version), and R 4.3.3. A P value < 0.05 was considered statistically significant.

Ethical statement

This study was based on public health surveillance data and aimed to assess and improve disease prevention and control strategies. The data used in this study were aggregated surveillance data and did not include detailed personal information; therefore, individual informed consent was not needed. All data were deidentified and anonymized to ensure the protection of personal privacy. Throughout the data collection and analysis process, we strictly adhered to relevant data protection regulations and ethical guidelines.

Results

General incidence trends

From 2009 to 2023, a total of 50,645 HFMD cases among children under 10 years of age were reported in Jiangning District, accounting for 98.05% of all HFMD cases in the general population. Among these patients, 98.00% were clinically diagnosed, and 2.00% were laboratory-confirmed. No fatalities were reported. The annual number of reported cases ranged from 1,021 in 2022 to 6,588 in 2018. The average annual incidence rate of HFMD among children under 10 years of age was 3,136.01 per 100,000, exhibiting a biennial epidemic pattern, particularly since 2014. The annual incidence rate fluctuated between 544.39 per 100,000 in 2022 and 6,260.63 per 100,000 in 2018 (Fig. 1).

Fig. 1.

Fig. 1

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Incidence rate and number of HFMD cases among children under 10 years of age in Jiangning District, 2009-2023. The bar chart displays the annual number of HFMD cases, stratified into clinically diagnosed cases (blue) and laboratory confirmed cases (yellow). The line graph represents the incidence rate per 100,000 populations

Joinpoint regression analysis revealed two inflection points in the incidence rates in 2018 and 2021. Overall, the incidence rate showed an initial increase, followed by a sharp decline in the middle period, and a rapid rebound in the later period of the study (2009–2023). Detailed annual percentage change (APC) statistics for each segment and the average annual percentage change (AAPC) for the entire period are presented in Supplementary Table S1 and Figure S1.

Population distribution

Between 2009 and 2023 in Jiangning District, a total of 30,141 HFMD cases were reported among boys under 10 years of age, accounting for 59.51% of all cases, with an average annual incidence rate of 3,588.07 per 100,000. Moreover, 20,504 cases were reported among girls less than 10 years of age, accounting for 40.49% of all cases, with an average annual incidence rate of 2,646.00 per 100,000. The incidence rate among boys was consistently higher than that among girls across all study years. The age-specific incidence rates are shown in Fig. 2. The highest average annual incidence rates were observed in children aged 1 year (8,659.05 per 100,000) and 3 years (7,040.23 per 100,000). From age 4 onwards, the average annual incidence rate declined rapidly, reaching its lowest level at age 8 (272.00 per 100,000). Except for the 9-year-old group, the incidence rate in boys was higher than that in girls across all other age groups. The distribution of HFMD cases by population category is shown in Fig. 3, with 55.24% of cases occurring among children in the community (i.e., children not enrolled in formal education or childcare) and 39.41% among children in daycare or preschool.

Fig. 2.

Fig. 2

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Average annual incidence rate of HFMD among children of different ages in Jiangning District, 2009-2023. The line chart presents the average annual incidence rates of HFMD per 100,000 populations, stratified by sex

Fig. 3.

Fig. 3

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Proportion of HFMD cases among different groups of children in Jiangning District, 2009-2023. The stacked bar chart shows the annual proportion of HFMD cases occurring within distinct child populations: children in the community (blue), referring to those not enrolled in formal educational or care settings; children in daycare/preschool (orange), referring to those attending childcare centers or kindergartens; and children in primary school (yellow), representing school-aged children enrolled in primary education

Seasonal and periodic variations

HFMD exhibited distinct seasonal epidemic patterns (Fig. 4), with a significant increase in incidence during the summer months. In most years, two peaks in incidence were observed: the primary peak occurred from May to July, accounting for 46.59% of the total cases, whereas the secondary peak appeared from September to November, accounting for 25.28% of the total cases.

Fig. 4.

Fig. 4

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Heatmap of the monthly incidence rates of HFMD in Jiangning District, 2009-2023.The x-axis shows months, and the y-axis shows years from 2009 to 2023. Color intensity reflects incidence rates per 100,000 populations, with darker red indicating higher rates

The real-part contour plot of the wavelet coefficients (Fig. 5) revealed multilevel periodic fluctuations in HFMD incidence across different time scales. Periodic fluctuations of 6 months and 12 months were observed at shorter and medium time scales, which coincided with the seasonal changes in HFMD incidence. At a longer time scale (35 months), a biennial cycle characterized by alternating peaks and troughs every two years was identified. Overall, the periodic fluctuations in HFMD were manifested primarily with cycles of 6 months, 12 months, and 24 months. However, from 2020 to 2022, a distinct pattern characterized by weakened amplitudes and durations of HFMD’s cyclical fluctuations was observed during the COVID-19 pandemic.

Fig. 5.

Fig. 5

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Real Part Contour Plot of the Wavelet Coefficients for Monthly HFMD Incidence Rates in Jiangning District, 2009-2023. The horizontal axis represents time in months, from January 2009 (Month 1) to December 2023 (Month 180). The vertical axis shows the wavelet time scale in months, indicating the oscillation period of the incidence data. Regions in red indicate strong positive wavelet coefficients (corresponding to higher HFMD incidence), while blue areas represent strong negative coefficients (corresponding to lower HFMD incidence)

Serotype distribution

Over the 14-year period, a total of 1,640 case samples were tested, with an overall enterovirus positivity rate of 62.01%. Among these, EV-A71 and CVA16 had positivity rates of 19.88% and 14.39%, respectively. Further analysis of the serotype composition in positive samples revealed distinct changes over time. From 2009 to 2016, the typing of enterovirus-positive specimens was limited to two serotypes (EV-A71 and CVA16). However, since 2017, the scope has expanded to include four serotypes (EV-A71, CVA16, CVA10, and CVA6).

As shown in Fig. 6, the serotype composition of the positive samples changed significantly over the study period. From 2009 to 2016, EV-A71 and CVA16 were the predominant circulating serotypes in most years. However, since 2018, the proportion of EV-A71 has decreased significantly, with CVA6 emerging as the dominant serotype. Moreover, the prevalence of CVA16 fluctuated across different years.

Fig. 6.

Fig. 6

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Serotype distribution of HFMD in Jiangning District, 2009-2023. The stacked bar chart shows the annual proportion of different enterovirus serotypes identified in laboratory-confirmed HFMD cases

Occurrence of severe cases

During the study period, a total of 388 cases were reported as severe HFMD, accounting for 0.77% of all cases. The proportion of severe cases was greater in boys than in girls (0.85% vs. 0.64%, P = 0.011). Since 2010, the severity rate has steadily declined, and notably, no severe HFMD cases have been reported for five consecutive years since 2019 (Fig. 7). Linear regression analysis revealed a significant downwards trend in the proportion of severe cases with increasing age (P < 0.001).

Fig. 7.

Fig. 7

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Severity rate of HFMD in Jiangning District, 2009-2023. A Annual severity rate. B Age-specific severity rate

Pathogen detection was conducted for all severe cases, with 170 enterovirus-positive cases detected (43.81%). Among the positive samples, the EV-A71 serotype accounted for the highest proportion (71.76%), followed by the other serotypes (21.18%), whereas CVA16 and CVA6 combined accounted for 7.06%.

Discussion

This study conducted a detailed analysis of the incidence trends, epidemiological characteristics, and serotype distributions of HFMD among children under 10 years of age in Jiangning District from 2009 to 2023 while also exploring the characteristics and changes in severe cases. Over the 14-year period, a total of 50,645 HFMD cases were reported among children under 10 years of age in Jiangning District, accounting for 98.05% of all reported cases and indicating that children are the primary affected population. The incidence rate of HFMD among children under 10 years of age fluctuated between 544.39 per 100,000 (in 2022) and 6,260.63 per 100,000 (in 2018), which was higher than the national average during the same period. Liu et al. reported that the national incidence rate of HFMD among children under 10 years of age from 2009 to 2019 ranged from 716.02 per 100,000 (in 2009) to 1,704.83 per 100,000 (in 2014) [13]. The incidence rates in Jiangning District were significantly higher than the national average each year, suggesting a heavier disease burden of HFMD in this region. This may be related to the high population density, frequent population movement, well-established surveillance system, and climatic conditions conducive to enterovirus transmission.

In our study, age-specific incidence rates revealed that children aged 1 year had the highest incidence, whereas incidence rates were relatively lower in infants (0 years old) and children aged 2 years. This trend is consistent with findings from neighboring regions [14]. Liu et al. reported that among children under 10 years of age nationwide, the highest HFMD incidence occurred in the 1-year-old group, and the incidence rate decreased with age. The relative risk (RR) of HFMD decreased by 0.59 per additional year of age [13]. Several serological studies on HFMD [15, 16] have shown that infants (0 years old) typically have high levels of protective IgA antibodies, which confer strong resistance to HFMD. In contrast, 1-year-old children experience a decline in maternal IgA and other protective antibodies, while their own immune system remains immature, resulting in weaker resistance. As children grow older, their immune system matures, and better hygiene practices develop, both of which contribute to a lower risk of HFMD infection.

HFMD is highly contagious and is transmitted primarily through the fecal‒oral route, direct contact, and respiratory droplets. Close contact in daycare centers or preschools facilitates rapid viral spread, while poor hygiene practices and environmental contamination further increase the risk of transmission [4]. In the present study, a secondary peak in incidence was observed in 3-year-old children, which may be attributed to their entry into preschools. Group living increases exposure to infection sources, thus increasing the risk of HFMD transmission. Therefore, strengthening preventive measures in early childhood education institutions, such as enhanced hygiene management, health monitoring, regular environmental disinfection, and temporary class suspension when necessary, could be crucial in reducing the risk of HFMD [17, 18]. Additionally, we noted that the incidence rate among boys was significantly higher than that among girls in our study, a trend consistent across all years and age groups except for the 9-year-old group. This may be related to the behavioral patterns of boys (e.g., higher activity levels and contact rates). Liao et al. reported that HFMD transmission rates were higher among boys than girls and that cases among boys were more infectious [19]. These findings suggest that gender differences should be considered when implementing public health prevention interventions.

From 2009 to 2023, the incidence of HFMD among children under 10 years of age in Jiangning District exhibited distinct temporal trends. In terms of long-term trends, the incidence rate underwent three distinct phases. In early years, a continuous increase in incidence was observed, with an average annual increase of 12.28%, which was consistent with the national trend in China [13]. This increase may be associated with socioeconomic development, improvements in healthcare services, and environmental changes. From 2020 to 2022, the incidence rate of HFMD in Jiangning District remained low, likely due to the impact of COVID-19 prevention measures, such as social distancing, enhanced hand hygiene, mask wearing, and frequent cleaning and disinfection, which significantly reduced the transmission efficiency of HFMD [20, 21]. However, with the relaxation of COVID-19 prevention measures, the incidence rate rebounded sharply in 2023, increasing by 479.17% compared with that in 2022. Some studies suggest that the reduction in exposure to various pathogens during COVID-19 prevention efforts may have led to a decrease in immunity against common viruses and bacteria, resulting in an “immune debt” [22, 23]. As social distancing and other measures were lifted, individuals became re-exposed to pathogens, increasing susceptibility and leading to resurgence in the intensity of HFMD and other infectious diseases.

In terms of periodic trends, the incidence of HFMD in Jiangning District exhibited a biennial epidemic pattern, which may be related to the alternating circulation of dominant virus strains, changes in population immunity, and the accumulation of susceptible individuals. This cyclical fluctuation typically results in incidence peaks occurring every two or three years [24–27]. In terms of seasonal variations, the HFMD incidence in this study exhibited seasonal peaks, with two peaks in most years: the primary peak occurring from May-July and the secondary peak occurring from September-November. This pattern aligns with previous studies that identified similar high-incidence periods [28, 29]. The Jiangning District has a subtropical monsoon maritime climate with distinct seasons. The months from May to July are warm and humid, conditions that favour the proliferation and transmission of enteroviruses. However, in August, when the average temperature exceeds 30 °C and school vacations reduce children’s gathering activities, transmission pathways become limited, leading to a lower risk of infection. Several studies [30–32] have indicated that within an optimal temperature range, typically between 16 °C and 29 °C, the transmission of HFMD is increased, whereas excessively low or high temperatures are less conducive to HFMD outbreaks. During the COVID-19 pandemic (2020–2022), the seasonal and periodic patterns of HFMD weakened, suggesting that nonpharmaceutical interventions, such as social distancing and hand hygiene, may have reduced HFMD transmission.

In our study, 1,640 clinically diagnosed HFMD cases were tested for enteroviruses, with an overall positivity rate of 62.01%. This is consistent with surveillance data from other regions of China (e.g., 58–65% in national CDC reports [33] and 60.2% in a Nanchang cohort [34]). Globally, positivity rates vary widely. Lower rates have been observed in hospitalized HFMD cases in Thailand [35] (48.7%, 2019–2022), while higher rates were reported in a retrospective cohort in Singapore (81.0%, 2013–2018) [36] and during France’s 2021 HFMD epidemic (90.5%) [37]. Despite these broadly consistent findings, it is notable that a considerable proportion of samples tested negative for enteroviruses, even though all cases were clinically diagnosed. This may be due to low viral loads, improper sample types, or inappropriate timing of collection, which can lead to false-negative results. Clinical misdiagnosis is also possible, especially in the absence of laboratory confirmation. These findings underscore the limitations of clinical-based surveillance and highlight the need for improved testing protocols and standardized specimen collection.

In recent years, with the widespread use of the EV-A71 vaccine in China, the positivity rate of EV-A71 has significantly declined. Moreover, CVA16 has continued to circulate at a certain level alongside CVA6 and CVA10, forming the primary serotype combination of HFMD. This shift represents a transition from an EV-A71-dominant pattern to a scenario in which multiple enteroviruses cocirculate [11, 38]. EV-A71 is generally considered more likely to cause severe HFMD cases and complications in other systems, whereas infections with CVA16, CVA6, and other serotypes typically present as mild cases with a low proportion of severe disease [39, 40]. Since 2017, Jiangning District has implemented large-scale vaccination against EV-A71 among eligible children. Pathogen surveillance results have shown that the proportion of EV-A71 has rapidly decreased since 2018, with CVA6 emerging as the dominant circulating serotype. These changes have imposed new requirements for vaccine development, epidemic monitoring, and the formulation of public health strategies.

The severity rate of HFMD has always been a focus in the field of public health. In this study, we observed a declining trend in the proportion of severe HFMD cases with increasing age, which is consistent with the findings of previous studies [41–43]. This may be related to the maturation of the immune system, as younger children are more susceptible to complications following EV-A71 infection. Since 2010, despite fluctuations in the overall incidence of HFMD, the proportion of severe cases has shown a steady downwards trend. Notably, since 2019, no severe cases have been reported in Jiangning District for five consecutive years. This phenomenon can be attributed to two key factors. First, improvements in early diagnosis, timely treatment, and public health interventions have contributed to better disease management. Second, with the widespread administration of the EV-A71 vaccine, the number of EV-A71 infections among children has significantly decreased [8]. EV-A71 has been recognized as a major contributor to severe HFMD cases, as it is more likely to cause neurological, circulatory, and respiratory complications [44]. Vaccination has played a crucial role in reducing the number of severe HFMD cases [8].

The effective prevention and control of HFMD, particularly among young children, continues to be a public health priority. However, this study has several limitations. First, the incompleteness of case reporting is a concern. Owing to the asymptomatic and self-limiting nature of mild HFMD cases, many infections may not be diagnosed and reported, leading to an underestimation of the actual number of cases. Additionally, variations in diagnostic capacities and disease-reporting awareness across healthcare facilities may further impact case reporting. Second, the sample size for pathogen testing and the scope of serotype identification were limited, restricting a comprehensive assessment of enterovirus diversity and circulating trends. Finally, the factors influencing the incidence trends are complex and warrant further in-depth analysis in future studies.

Conclusions

In summary, this study revealed that the incidence of HFMD among children under 10 years of age is relatively high, with a substantial disease burden. The disease exhibits a biennial epidemic pattern, along with distinct seasonal and periodic variations. Nonpharmaceutical interventions during the COVID-19 pandemic were temporally associated with reduced HFMD transmission. However, following the relaxation of control measures, the incidence rebounded rapidly, reflecting the impact of “immune debt”. Owing to the widespread administration of the EV-A71 vaccine and improvements in public health interventions, the severity rate of HFMD has steadily declined. Moving forward, it is essential to strengthen the surveillance of young children and high-risk environments, conduct detailed analyses of disease risk factors, and optimize prevention and control strategies to further safeguard children’s health.

Supplementary Information

Supplementary Material 1. (285.5KB, docx)

Acknowledgements

We sincerely thank the Jiangning District Center for Disease Control and Prevention for providing the epidemiological data. We also appreciate the contributions of all healthcare workers involved in HFMD surveillance and control.

Clinical trial number

Not applicable.

Abbreviations

HFMD

Hand, Foot, and Mouth Disease

CVA6

Coxsackievirus A6

CVA10

Coxsackievirus A10

CVA16

Coxsackievirus A16

EV-A71

Enterovirus A71

Authors’ contributions

B.W. conceptualized and designed the study. X.Z. and B.W. conducted the data collection and statistical analysis. M.F. contributed to the interpretation of results. B.W. and X.J. drafted the manuscript. All authors reviewed and approved the final version.

Funding

No funding was received for this study.

Data availability

The datasets used and analyzed in this study are available from the corresponding author upon reasonable request. However, due to privacy concerns, we are unable to provide individual case data. Instead, we can provide aggregate data that summarize the overall findings.

Declarations

Ethics approval and consent to participate

This study was conducted using de-identified public health surveillance data obtained from the Notifiable Infectious Disease Reporting Information Management System of the Chinese Center for Disease Control and Prevention (China CDC). This study adhered to the ethical principles outlined in the World Medical Association (WMA) Declaration of Helsinki and approved by the Ethics and Human Subject Committee of Nanjing Medical University. When registration in the Notifiable Infectious Disease Reporting Information Management System in China, written informed consent was obtained from each adult patient and legally authorized representatives of patient who was under the age of 16. The data used in this study are de-identified and anonymized aggregated surveillance data. During the research process, we have fully considered the issue of data security and established a comprehensive data security management system. This includes restricting data access permissions, authorizing only the research team members to access the relevant data, and requiring them to sign confidentiality agreements.

Consent for publication

Not applicable. This manuscript does not include individual-level data requiring consent for publication.

Competing interests

The authors declare no competing interests.

Footnotes

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Baiqun Wu and Xiangnan Zhang contributed equally to this work.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Supplementary Material 1. (285.5KB, docx)

Data Availability Statement

The datasets used and analyzed in this study are available from the corresponding author upon reasonable request. However, due to privacy concerns, we are unable to provide individual case data. Instead, we can provide aggregate data that summarize the overall findings.

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