{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,16]],"date-time":"2026-10-16T13:21:47Z","timestamp":1792156907660,"version":"4.4.0"},"reference-count":31,"publisher":"JMIR Publications Inc.","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JMIR Public Health Surveill"],"abstract":"Abstract<\/jats:title>\n \n Background<\/jats:title>\n Hand, foot, and mouth disease (HFMD) is a highly contagious viral illness. Understanding the long-term trends of HFMD incidence and its epidemic characteristics under the circumstances of the enterovirus 71 (EV71) vaccination program and the outbreak of COVID-19 is crucial for effective disease surveillance and control.<\/jats:p>\n <\/jats:sec>\n \n Objective<\/jats:title>\n We aim to give an overview of the trends of HFMD over the past decades and evaluate the impact of the EV71 vaccination program and the COVID-19 pandemic on the epidemic trends of HFMD.<\/jats:p>\n <\/jats:sec>\n \n Methods<\/jats:title>\n Using official surveillance data from the Yunnan Province, China, we described long-term incidence trends and severity rates of HFMD as well as the variation of enterovirus proportions among cases. We conducted the autoregressive integrated moving average (ARIMA) of time series analyses to predict monthly incidences based on given subsets. The difference between the actual incidences and their counterfactual predictions was compared using absolute percentage errors (APEs) for periods after the EV71 vaccination program and the COVID-19 pandemic, respectively.<\/jats:p>\n <\/jats:sec>\n \n Results<\/jats:title>\n \n The annual incidence of HFMD fluctuated between 25.62 cases per 100,000 people in 2008 and 221.52 cases per 100,000 people in 2018. The incidence for men ranged from 30 to 250 cases per 100,000 people from 2008 to 2021, which was constantly higher than that for women. The annual incidence for children aged 1 to 2 years old ranged from 54.54 to 630.06 cases per 100,000 people, which was persistently higher than that for other age groups. For monthly incidences, semiannual peaks were observed for each year. All actual monthly incidences of 2014 to 2015 fell within the predicted 95% CI by the ARIMA(1,0,1)(1,1,0)[12] model. The average APE was 19% for a 2-year prediction. After the EV71 vaccination program, the actual monthly incidence of HFMD was consistently lower than the counterfactual predictions by ARIMA(1,0,1)(1,1,0)[12], with negative APEs ranging from \u221211% to \u2212229% from January 2017 to April 2018. In the meantime, the proportion of EV71 among the enteroviruses causing HFMD decreased significantly, and the proportion was highly correlated (\n r<\/jats:italic>\n =0.73,\n P<\/jats:italic>\n =.004) with the severity rate. After the onset of the COVID-19 pandemic in 2020, the actual monthly incidence of HFMD consistently maintained a lower magnitude compared to the counterfactual predictions\u2014ARIMA(1,0,1)(0,1,0)[12]\u2014from February to September 2020, with considerable negative APEs (ranging from \u221231% to \u22122248%).\n <\/jats:p>\n <\/jats:sec>\n \n Conclusions<\/jats:title>\n EV71 vaccination alleviated severe HFMD cases and altered epidemiological trends. The HFMD may also benefit from nonpharmaceutical interventions during outbreaks such as the COVID-19 pandemic. Further development of a multivalent virus vaccine is crucial for effectively controlling HFMD outbreaks. Policymakers should implement nonpharmaceutical interventions and emphasize personal hygiene for routine prevention when appropriate.<\/jats:p>\n <\/jats:sec>","DOI":"10.2196\/63146","type":"journal-article","created":{"date-parts":[[2024,12,18]],"date-time":"2024-12-18T08:31:06Z","timestamp":1734510666000},"page":"e63146-e63146","source":"Crossref","is-referenced-by-count":8,"title":["Influence of the Enterovirus 71 Vaccine and the COVID-19 Pandemic on Hand, Foot, and Mouth Disease in China Based on Counterfactual Models: Observational Study"],"prefix":"10.2196","volume":"10","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-9393-482X","authenticated-orcid":false,"given":"Jia","family":"Nie","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0512-6791","authenticated-orcid":false,"given":"Tian","family":"Huang","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0002-2401-5920","authenticated-orcid":false,"given":"Yuhong","family":"Sun","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0002-0804-3921","authenticated-orcid":false,"given":"Zutong","family":"Peng","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0004-3547-7914","authenticated-orcid":false,"given":"Wenlong","family":"Dong","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0004-7297-7037","authenticated-orcid":false,"given":"Jiancheng","family":"Chen","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0002-4905-4176","authenticated-orcid":false,"given":"Di","family":"Zheng","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0009-1847-4099","authenticated-orcid":false,"given":"Fuyin","family":"Guo","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0006-0009-8820","authenticated-orcid":false,"given":"Wenhui","family":"Shi","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-7724-5370","authenticated-orcid":false,"given":"Yuewei","family":"Ling","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0005-3461-3037","authenticated-orcid":false,"given":"Weijia","family":"Zhao","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0007-0327-4532","authenticated-orcid":false,"given":"Haijun","family":"Yang","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-2224-0545","authenticated-orcid":false,"given":"Tiejun","family":"Shui","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-1496-0358","authenticated-orcid":false,"given":"Xiangyu","family":"Yan","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1010","published-online":{"date-parts":[[2024,12,17]]},"reference":[{"issue":"1","key":"R1","doi-asserted-by":"publisher","first-page":"15","DOI":"10.1186\/s12929-023-00908-4","article-title":"Current status of hand-foot-and-mouth disease","volume":"30","author":"Zhu","journal-title":"J Biomed Sci"},{"issue":"5","key":"R2","doi-asserted-by":"publisher","first-page":"599","DOI":"10.1586\/14760584.2016.1138862","article-title":"EV71 vaccine, a new tool to control outbreaks of hand, foot and mouth disease (HFMD)","volume":"15","author":"Mao","journal-title":"Expert Rev Vaccines"},{"issue":"50","key":"R3","doi-asserted-by":"publisher","DOI":"10.2807\/1560-7917.ES.2017.22.50.16-00824","article-title":"Epidemiology of hand, foot and mouth disease in China, 2008 to 2015 prior to the introduction of EV-A71 vaccine","volume":"22","author":"Yang","journal-title":"Euro Surveill"},{"issue":"25","key":"R4","doi-asserted-by":"publisher","first-page":"3319","DOI":"10.1016\/j.vaccine.2021.05.009","article-title":"The changes in the epidemiology of hand, foot, and mouth disease after the introduction of the EV-A71 vaccine","volume":"39","author":"Wang","journal-title":"Vaccine"},{"key":"R5","doi-asserted-by":"publisher","DOI":"10.2196\/47626","article-title":"Persistence and variation of the indirect effects of COVID-19 restrictions on the spectrum of notifiable infectious diseases in China: analysis of national surveillance among children and adolescents from 2018 to 2021","volume":"10","author":"Chen","journal-title":"JMIR Public Health Surveill"},{"key":"R6","doi-asserted-by":"publisher","DOI":"10.1136\/bmj-2024-080528","article-title":"Non-pharmaceutical interventions: evaluating challenges and priorities for future health shocks","volume":"387","author":"Majeed","journal-title":"BMJ"},{"issue":"1","key":"R7","doi-asserted-by":"publisher","first-page":"1","DOI":"10.1016\/j.jinf.2020.11.039","article-title":"Impact of non-pharmaceutical interventions targeted at COVID-19 pandemic on influenza burden - a systematic review","volume":"82","author":"Fricke","journal-title":"J Infect"},{"issue":"2","key":"R8","doi-asserted-by":"publisher","first-page":"e13","DOI":"10.1016\/j.jinf.2021.12.023","article-title":"Impact of non-pharmaceutical interventions during COVID-19 pandemic on pertussis, scarlet fever and hand-foot-mouth disease in China","volume":"84","author":"Geng","journal-title":"J Infect"},{"issue":"7","key":"R9","doi-asserted-by":"publisher","first-page":"3121","DOI":"10.1002\/jmv.27715","article-title":"The impact of anti-COVID-19 nonpharmaceutical interventions on hand, foot, and mouth disease-a spatiotemporal perspective in Xi\u2019an, northwestern China","volume":"94","author":"Shen","journal-title":"J Med Virol"},{"issue":"1","key":"R10","doi-asserted-by":"publisher","DOI":"10.1186\/s12889-022-14850-x","article-title":"Effects of different levels of non-pharmaceutical interventions on hand, foot and mouth disease in Guangzhou, China","volume":"22","author":"Wu","journal-title":"BMC Public Health"},{"key":"R11","doi-asserted-by":"publisher","DOI":"10.3389\/fmicb.2021.811553","article-title":"Surveillance, epidemiology and impact of EV-A71 vaccination on hand, foot, and mouth disease in Nanchang, China, 2010-2019","volume":"12","author":"He","journal-title":"Front Microbiol"},{"issue":"10","key":"R12","doi-asserted-by":"publisher","first-page":"969","DOI":"10.1097\/INF.0000000000002745","article-title":"Epidemiology of hand, foot, and mouth disease before and after the introduction of enterovirus 71 vaccines in Chengdu, China, 2009-2018","volume":"39","author":"Han","journal-title":"Pediatr Infect Dis J"},{"key":"R13","unstructured":"Government information disclosure [Webpage in Chinese]. Yunnan Provincial Bureau of Statistics. URL: http:\/\/stats.yn.gov.cn\/List22.aspx [Accessed 04-12-2024]"},{"key":"R14","unstructured":"Thirty years of cooperation. Greater Mekong Subregion. URL: https:\/\/greatermekong.org [Accessed 01-12-2024]"},{"issue":"1","key":"R15","doi-asserted-by":"publisher","DOI":"10.1371\/journal.pone.0262589","article-title":"Cholangiocarcinoma protective factors in Greater Mekong Subregion: critical issues for joint planning to sustainably solve regional public health problems","volume":"17","author":"Songserm","journal-title":"PLoS One"},{"issue":"1","key":"R16","doi-asserted-by":"publisher","DOI":"10.5210\/ojphi.v11i1.9897","article-title":"Systematic review: National Notifiable Infectious Disease Surveillance System in China","volume":"11","author":"Ren","journal-title":"OJPHI"},{"issue":"5","key":"R17","doi-asserted-by":"publisher","first-page":"437","DOI":"10.1007\/s12519-018-0189-8","article-title":"Chinese guidelines for the diagnosis and treatment of hand, foot and mouth disease (2018 edition)","volume":"14","author":"Li","journal-title":"World J Pediatr"},{"key":"R18","unstructured":"The Ministry of Health Office issued the hand, foot, and mouth disease diagnosis and treatment guidelines (2008 edition) [Article in Chinese]. The State Council of the People\u2019s Republic of China. 2008. URL: https:\/\/www.gov.cn\/gzdt\/2008-12\/12\/content_1176057.htm [Accessed 02-12-2024]"},{"issue":"1","key":"R19","doi-asserted-by":"publisher","first-page":"128","DOI":"10.1590\/s1679-45082013000100024","article-title":"Disease management with ARIMA model in time series","volume":"11","author":"Sato","journal-title":"Einstein (Sao Paulo)"},{"issue":"1","key":"R20","doi-asserted-by":"publisher","first-page":"58","DOI":"10.1186\/s12874-021-01235-8","article-title":"Interrupted time series analysis using autoregressive integrated moving average (ARIMA) models: a guide for evaluating large-scale health interventions","volume":"21","author":"Schaffer","journal-title":"BMC Med Res Methodol"},{"issue":"3","key":"R21","doi-asserted-by":"publisher","DOI":"10.18637\/jss.v027.i03","article-title":"Automatic time series forecasting: the forecast package for R","volume":"27","author":"Hyndman","journal-title":"J Stat Soft"},{"key":"R22","doi-asserted-by":"publisher","DOI":"10.3389\/fpubh.2021.737817","article-title":"The epidemic of sexually transmitted diseases under the influence of COVID-19 in China","volume":"9","author":"Yan","journal-title":"Front Public Health"},{"issue":"20","key":"R23","doi-asserted-by":"publisher","DOI":"10.1097\/MD.0000000000025930","article-title":"Epidemiological characteristics of hand, foot, and mouth disease in China: a meta-analysis","volume":"100","author":"Chen","journal-title":"Medicine (Baltimore)"},{"issue":"5","key":"R24","doi-asserted-by":"publisher","DOI":"10.1080\/21645515.2022.2049168","article-title":"Disease burden in patients with severe hand, foot, and mouth disease in Jiangsu Province: a cross-sectional study","volume":"18","author":"Han","journal-title":"Hum Vaccin Immunother"},{"issue":"52","key":"R25","doi-asserted-by":"publisher","first-page":"8273","DOI":"10.1016\/j.vaccine.2020.11.031","article-title":"Coxsackieviruses A6 and A16 associated with hand, foot, and mouth disease in Vietnam, 2008-2017: essential information for rational vaccine design","volume":"38","author":"Hoa-Tran","journal-title":"Vaccine"},{"issue":"4","key":"R26","doi-asserted-by":"publisher","first-page":"398","DOI":"10.1093\/jpids\/piaa111","article-title":"A different epidemiology of enterovirus A and enterovirus B co-circulating in Korea, 2012-2019","volume":"10","author":"Kang","journal-title":"J Pediatr Infect Dis Soc"},{"issue":"7825","key":"R27","doi-asserted-by":"publisher","first-page":"410","DOI":"10.1038\/s41586-020-2293-x","article-title":"Effect of non-pharmaceutical interventions to contain COVID-19 in China","volume":"585","author":"Lai","journal-title":"Nature"},{"key":"R28","doi-asserted-by":"publisher","DOI":"10.1016\/j.lanwpc.2023.100755","article-title":"The influence of the COVID-19 pandemic on identifying HIV\/AIDS cases in China: an interrupted time series study","volume":"36","author":"Zhao","journal-title":"Lancet Reg Health West Pac"},{"issue":"1","key":"R29","doi-asserted-by":"publisher","DOI":"10.1186\/s12889-023-15081-4","article-title":"Trends in respiratory diseases before and after the COVID-19 pandemic in China from 2010 to 2021","volume":"23","author":"Zuo","journal-title":"BMC Public Health"},{"issue":"4","key":"R30","doi-asserted-by":"publisher","first-page":"239","DOI":"10.3760\/cma.j.cn112137-20211205-02710","article-title":"The dynamic COVID-zero strategy on prevention and control of COVID-19 in China [Article in Chinese]","volume":"102","author":"Liang","journal-title":"Zhonghua Yi Xue Za Zhi"},{"issue":"4","key":"R31","doi-asserted-by":"publisher","first-page":"74","DOI":"10.46234\/ccdcw2022.015","article-title":"The dynamic COVID-zero strategy in China","volume":"4","author":"Liu","journal-title":"China CDC Wkly"}],"container-title":["JMIR Public Health and Surveillance"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/publichealth.jmir.org\/2024\/1\/e63146","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,7,31]],"date-time":"2026-07-31T22:31:14Z","timestamp":1785537074000},"score":1,"resource":{"primary":{"URL":"https:\/\/publichealth.jmir.org\/2024\/1\/e63146"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2024,12,17]]},"references-count":31,"URL":"https:\/\/doi.org\/10.2196\/63146","relation":{},"ISSN":["2369-2960"],"issn-type":[{"value":"2369-2960","type":"electronic"}],"subject":[],"published":{"date-parts":[[2024,12,17]]},"article-number":"v10i1e63146"}}