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PLoS One. 2013 May 21;8(5):e63447. doi: 10.1371/journal.pone.0063447. Print 2013.

Detecting spatial-temporal clusters of HFMD from 2007 to 2011 in Shandong Province, China.

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Department of Epidemiology and Biostatistics, School of Public Health, Shandong University, Jinan, China.



Hand, foot, and mouth disease (HFMD) has caused major public health concerns worldwide, and has become one of the leading causes of children death. China is the most serious epidemic area with a total of 3,419,149 reported cases just from 2008 to 2010, and its different geographic areas might have different spatial epidemiology characteristics at different spatial-temporal scale levels. We conducted spatial and spatial-temporal epidemiology analysis to HFMD at county level in Shandong Province, China.


Based on the China National Disease Surveillance Reporting and Management System, the spatial-temporal database of HFMD from 2007 to 2011 was built. The global autocorrelation statistic (Moran's I) was first used to detect the spatial autocorrelation of HFMD cases in each year. Purely Spatial scan statistics combined with Space-time scan statistic were used to detect epidemic clusters.


The annual average incidence rate was 93.70 per 100,000 in Shandong Province. Most HFMD cases (93.94%) were aged within 0-5 years old with an average male-to-female sex ratio 1.71, and the incidence seasonal peak was between April and July. The dominant pathogen was EV71 (47.35%), and CoxA16 (26.59%). HFMD had positive spatial autocorrelation at medium spatial scale level (county level) with higher Moran's I from 0.31 to 0.62 (P<0.001). Seven spatial-temporal clusters were detected from 2007 to 2011 in the landscape of the whole Shandong, with EV71 or CoxA16 as the dominant pathogen for most hotspots areas.


The spatial-temporal clusters of HFMD wandered around the whole Shandong Province during 2007 to 2011, with EV71 or CoxA16 as the dominant pathogen. These findings suggested that a real-time spatial-temporal surveillance system should be established for identifying high incidence region and conducting prevention to HFMD timely.

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