Incidence and trends for notifiable infectious diseases in Shenyang, China, 2005-2024

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Evolving epidemiological patterns and considerable regional variation underscore the need for localized, real-time surveillance and assessment. This study examines the incidence and trends of notifiable infectious diseases (NIDs) in Shenyang from 2005 to 2024 to generate an evidence base for regional and national public health strategy formulation. Methods The data of NIDs in Shenyang from January 1, 2005 to December 31, 2024 were obtained from the National Notifiable Diseases Reporting System (NNDRS). Joinpoint regression analysis was used to determine the changing trend of annual incidence. Results Between 2005 and 2024, Shenyang reported 668,476 cases of 33 notifiable infectious diseases, all classified as Class B (58.8%) or C (41.2%). Respiratory infections were the most common (47.4%), followed by fecal-oral (29.8%) and blood-borne/sexual transmission (21.7%). The overall annual age-standardized incidence rate (ASIR) averaged 481.49 per 100,000 population, increasing significantly from 360.72 to 880.18 per 100,000 over the 20-year period (AAPC: 6.20%; 95%CI: 2.11%,10.04%), representing a 144% overall rise. Males exhibited a higher average annual ASIR (565.30 per 100,000) compared to females (393.35 per 100,000). A pronounced upward trend was observed in Class C diseases (AAPC: 12.75%; 95%CI: 7.47%,18.19%), whereas Class B diseases remained stable. Respiratory-transmitted diseases showed the strongest growth (AAPC: 12.75%; 95%CI: 7.47%,18.19%), followed by those transmitted via the fecal-oral route (AAPC: 4.79%; 95%CI: 0.42%,9.65%), while blood-borne/sexually transmitted diseases declined slightly (AAPC: -2.52%; 95%CI: -4.11%,-0.30%). Vaccine-preventable diseases (VPDs) declined markedly (AAPC: -6.98%; 95%CI: -8.62%,-5.30%), in contrast to a substantial increase in non-VPDs (AAPC: 13.66%; 95%CI: 10.04%,17.68%). Conclusions The overall incidence of NIDs in Shenyang was lower than the national average, however, the respiratory infections pose a relatively high disease burden and warrant focused control. It is noteworthy that the incidence of VPDs has declined significantly over the past two decades, demonstrating the marked success of immunization strategies. Notifiable infectious diseases Incidence Trends Shenyang Figures Figure 1 Background Infectious diseases continue to pose a major global public health threat, contributing to substantial morbidity, mortality, and economic losses each year [ 1 – 2 ] . Despite progress in medical technology and healthcare infrastructure, the recurrent emergence and re-emergence of pathogens such as SARS-CoV-2 underscore the ongoing vulnerability of human populations to infectious disease outbreaks [ 3 – 4 ] . According to the World Health Organization (WHO), millions of annual deaths are attributable to infectious diseases, with low- and middle-income countries carrying a disproportionately high burden [ 5 ] . In China, such diseases have long constituted a significant part of the national disease profile, leading to the implementation of robust surveillance mechanisms including the National Notifiable Diseases Reporting System (NNDRS) in 2004 [ 6 ] . Globally, the epidemiology of infectious diseases has undergone considerable changes over the past two decades [ 7 ] . The incidence of vaccine-preventable diseases (VPDs) including measles, poliomyelitis, and pulmonary tuberculosis (PTB) has declined in many parts of the world [ 8 – 12 ] , and the global burden of enteric infections also exhibited a downward trend between 1990 and 2021 [ 13 ] . In contrast, sexually transmitted infections have increased markedly, influenced by a combination of biological and socio-behavioral factors, with marginalized and high-risk groups-especially in resource-limited settings-being disproportionately affected [ 14 – 16 ] . Furthermore, growing international travel and migration have contributed to a modest resurgence of malaria in certain areas [ 17 ] . The COVID-19 pandemic disrupted longstanding seasonal influenza dynamics. After the relaxation of non-pharmaceutical interventions (NPIs) such as international travel restrictions, social distancing, mask mandates, and school closures, some countries witnessed a rapid rebound in influenza activity, whereas others reported delayed or off-season epidemics [ 18 – 19 ] . In China, the overall incidence of notifiable infectious diseases (NIDs) fell markedly between 1975 and 1995, largely attributable to expanded immunization coverage and improved public sanitation [ 20 ] . However, a gradual resurgence occurred from 1995 to 2008, fueled by increases in blood-borne/sexually transmitted diseases-such as hepatitis B and syphilis, as well as respiratory infections including PTB and influenza [ 20 ] . Recent studies covering data from 2005 to 2024 indicated an average annual incidence of 549.76 per 100,000 population, with an overall upward trajectory [ 21 – 22 ] . Regionally, China's vast territory contributes to distinct epidemiological characteristics of NIDs. For example, in Nanjing, Jiangsu Province, the average annual incidence of NIDs from 2004 to 2022 was 347.45 per 100,000 population, with fecal-oral transmission being the dominant route [ 23 ] . No significant temporal trend in annual incidence was observed over the past two decades [ 23 ] . However, during the same period, Henan Province recorded a significantly higher average annual incidence of 417.47 per 100,000, predominantly driven by blood-borne/sexual transmission [ 24 ] . Furthermore, the annual incidence in Henan exhibited a clear upward trend over the last 20 years [ 24 ] . Economic development has accelerated population mobility, amplifying the risks of infectious disease transmission, particularly for respiratory and blood-borne pathogens [ 25 – 26 ] . The dynamic nature of epidemiological trends necessitates continuous reinforcement of surveillance systems. China's substantial regional heterogeneity in disease epidemiology underscores the critical importance of localized research. Shenyang, a major city in Liaoning Province with a population exceeding eight million, acts as a vital surveillance sentinel for monitoring regional infectious disease patterns. However, a comprehensive analysis of long-term trends in this context remains lacking [ 27 ] . This study aims to address this gap by examining the epidemiological trends of NIDs from 2005 to 2024, thereby providing an evidence base to inform regional and national public health strategies. Methods Study Area Shenyang, the capital of Liaoning Province in China, is situated between latitudes 41°11′N and 43°02′N, and longitudes 122°25′E and 123°48′E. As a prefecture-level city, it covers an area of 12,860 square kilometers and comprises 13 districts. From 2005 to 2024, the average population of Shenyang was 8,151,603. Data Sources In China, the list of NIDs has undergone dynamic adjustments to address emerging public health threats. Foot and mouth disease (HFMD) was first incorporated in 2008, followed by influenza A(H1N1) in 2009, which was later integrated into seasonal influenza surveillance in 2014. Subsequently, H7N9 avian influenza was added in 2013 and reclassified as human infection with novel influenza subtype in 2018 to encompass other novel subtypes. More recently, COVID-19 and monkeypox (Mpox) were included as statutory notifiable diseases in 2020 and 2023, respectively. Currently, there are totaling 40 NIDs in China, which were classified into classes A, B and C [ 28 ] (Table 1 ). Table 1 Current NIDs and classification in China Classification No. of diseases NIDs A 2 Plague and cholera B 27 COVID-19, AFP, rabies, anthrax, meningococcal meningitis, scarlet fever, leptospirosis, SARS, human infection with a novel influenza A virus subtype, JE, bacillary and amebic dysentery § , HB, schistosomiasis, HIV/AIDS, measles, dengue fever, PTB, diphtheria, gonorrhea, malaria, viral hepatitis ∮ , HFRS, Mpox, typhoid and paratyphoid fevers $ , neonatal tetanus, syphilis C 11 Influenza, leprosy, filariasis, mumps, epidemic and endemic typhus, hand, HFMD, rubella, visceral leishmaniasis, other infectious diarrhea £ , AHC, echinococcosis AFP: acute flaccid paralysis; AHC: acute hemorrhagic conjunctivitis; HB: human brucellosis; HFMD: hand, foot and mouth disease; HFRS: hemorrhagic fever with renal syndrome; JE: Japanese encephalitis; Mpox: monkeypox; NIDs: notifiable infectious diseases; PTB: pulmonary tuberculosis; SARS: severe acute respiratory syndrome. Note § Bacillary and amebic dysentery comprises two distinct diseases: bacillary dysentery and amebic dysentery. ∮ Viral hepatitis comprises six distinct disease types: Hepatitis A, Hepatitis B, Hepatitis C, Hepatitis D, Hepatitis E, and hepatitis (untyped). $ Typhoid and paratyphoid fevers comprise two distinct diseases: typhoid fever and paratyphoid fever. £ Other infectious diarrhea refers to diarrhea other than that caused by cholera, dysentery or typhoid fever. The NNDRS was established and officially put into operation in April 2004.This study collected all reported cases (including time of onset, diagnosis, reporting date, as well as patient demographic details such as age and gender) with onset from January 1, 2005 to December 31, 2024, in Shenyang, China through this system which was used under license and not publicly available. All eligible cases were confirmed based on clinical manifestations and laboratory tests, and the following cases were excluded: not residing in Shenyang, duplicate reported and without a definitive diagnosis. The annual population data for the years 2005–2024 were retrieved from the Official Website of Shenyang Statistical Bureau ( http://tjj.shenyang.gov.cn/ ). The study protocol was approved by the Ethics Committees of Shenyang Center for Disease Control and Prevention. Definition Respiratory transmitted infectious diseases are defined as a category of illnesses acquired through exposure to respiratory droplets generated by infected individuals during coughing or sneezing, or via contact with contaminated surfaces (fomites) [ 29 ] . This category in the present study includes COVID-19, severe acute respiratory syndrome (SARS), influenza, meningococcal meningitis, scarlet fever, human infection with a novel influenza A virus subtype, pertussis, measles, PTB, leprosy, mumps, rubella, and diphtheria. Infectious diseases transmitted via the fecal-oral route are defined as those caused by pathogens that are shed in the feces of infected individuals and subsequently enter a new susceptible host through the mouth via intermediaries such as contaminated water, food, or hands [ 30 ] . This transmission group in our study covers acute flaccid paralysis (AFP), bacillary and amebic dysentery, typhoid and paratyphoid fevers, hepatitis A, hepatitis E, HFMD, and other infectious diarrhea. Blood-borne/sexually transmitted infectious diseases refer to a category of illnesses contracted through exposure to infected blood or body fluids during sexual contact, sharing of injection equipment, or other forms of direct exposure [ 31 ] . Diseases classified under this mode in the current analysis include HIV/AIDS, gonorrhea, syphilis, hepatitis B, hepatitis C, hepatitis D, and hepatitis (untyped). Zoonotic and vector-borne infectious diseases are caused by pathogens naturally transmitted between vertebrate animals and humans, either directly (zoonoses) or indirectly via arthropod vectors such as mosquitoes and ticks [ 32 – 33 ] . In this study, these include rabies, cutaneous anthrax, human brucellosis (HB), hemorrhagic fever with renal syndrome (HFRS), echinococcosis, Japanese encephalitis (JE), dengue fever, malaria, typhus, filariasis, and visceral leishmaniasis. VPDs are those targeted by national immunization programs for control through vaccination [ 8 ] . The VPDs considered here comprise measles, pertussis, meningococcal meningitis, JE, AFP, hepatitis A, hepatitis B, PTB, rubella, and mumps. All remaining diseases are categorized as non-VPDs. Statistical Analysis Disease incidence was measured using the age-standardized incidence rate (ASIR). The annual ASIR was computed as the sum of the products of age-specific incidence rates and the corresponding standard population weights for each age group in a certain year. In this study, the annual ASIR from 2005 to 2024 were calculated and the 2010 national population census of China was serving as the standard population. The changes in annual ASIR from 2005 to 2024 were calculated as the percentage change, using the formula: \(\:\frac{{ASIR}_{2024}-{ASIR}_{2005}}{{ASIR}_{2005}}\times\:100\%\) . The average annual ASIR was defined as the mean of the annual ASIR for each year during the observation period. The average annual percent change (AAPC) and its corresponding 95% confidence interval (CI) were calculated. The AAPC quantifies the average direction and magnitude of a trend over the entire study period. If the 95%CI for the AAPC did not include zero, the trend was considered statistically significant. In such cases, the trend was classified as "increasing" for a positive value or "decreasing" for a negative value. Conversely, if the 95%CI contained zero, the trend was deemed "stationary", indicating that the null hypothesis (AAPC = 0) could not be rejected. A two-sided P < 0.05 was considered statistically significant. Stata version 17.0 (Stata Corp, College Station, TX, USA) was used for data extraction, sorting, and cleaning. Microsoft Excel 2019 (Microsoft, Seattle WA, USA) was utilized to visualize the epidemic patterns. The Joinpoint Regression Program, version 4.8.0.1 (National Cancer Institute, Bethesda, MD, USA) was performed to analyze temporal trends. Results General characteristics A total of 1,018,131 cases of infectious diseases were reported from 2005 to 2024. Following the application of exclusion criteria, 184,033 cases were excluded due to non-residency in Shenyang. An additional 1,733 cases were identified as duplicate reports and were subsequently removed. Furthermore, 57,483 cases were diagnosed as other conditions, and 106,406 cases were categorized as non-NIDs. The latter category comprised 89,384 cases of varicella, 6,513 cases of condyloma acuminatum, 4,358 cases of genital chlamydia trachomatis infection, 3,453 cases of tuberculous pleurisy, 53 cases of clonorchiasis, 1,607 cases of genital herpes, 1,015 cases of non-gonococcal urethritis, 17 cases of severe fever with thrombocytopenia syndrome, 4 cases of extrapulmonary tuberculosis, 1 case of streptococcus suis infection, and 1 case of scrub typhus. Consequently, the final analytical dataset comprised a total of 668,476 cases. Proportion and Dynamics As summarized in Table 2 , 33 NIDs were reported in Shenyang from 2005 to 2024, consisting of 24 Category B and 9 Category C diseases. No Category A infections were documented, and no cases of leptospirosis, SARS, diphtheria, filariasis, or visceral leishmaniasis were recorded. Of all the reported NIDs, Category B diseases accounted for 393,215 cases (58.82%) and Category C diseases accounted for 275,261 cases (41.18%). As shown in Fig. 1 , with the exception of 2010 and 2024, Category B diseases consistently represented a higher proportion of annual cases than Category C diseases, exceeding 80% of the total in both 2005 and 2022. In terms of transmission routes, respiratory transmission was the most common (316,912 cases, 47.41%), followed by fecal-oral (199,230, 29.80%) and blood-borne/sexual transmission (145,094 cases, 21.71%). Zoonotic and vector-borne transmissions accounted for 7,186 cases (1.07%), with other routes comprising 54 cases (0.01%). As shown in Fig. 1 , the dominant transmission routes shifted considerably over this period. Blood-borne/sexual transmission predominated in 2005, followed by respiratory transmission during 2006–2011, and fecal-oral transmission during 2012–2019. Since 2020, respiratory transmission has reemerged as the primary route, comprising over 70% of cases in both 2023 and 2024. VPDs accounted for 209,962 cases (31.41%) during the 20-year period, while non-VPDs comprised 458,514 cases (68.59%). As shown in Fig. 1 , a pronounced decline in the proportion of VPDs was observed over time, falling from 72.02% in 2005 to just 8.14% in 2023 and 9.64% in 2024. PTB was the most reported disease (100,866 cases, 15.09%), followed by HFMD (94,466 cases, 13.98%), viral hepatitis (71,574 cases, 10.71%), and influenza (66,475 cases, 9.94%). Substantial case numbers were also noted for syphilis (62,635 cases, 9.37%), COVID-19 (58,633 cases, 8.77%), and other infectious diarrhea (57,464 cases, 8.60%). In contrast, neonatal tetanus, schistosomiasis, and leprosy were the least reported, with one case each. Other rarely reported diseases included hepatitis D, JE, and echinococcosis (5 cases each), human infection with a novel influenza A virus subtype and rabies (2 cases each), as well as typhoid and paratyphoid fever (115 cases), malaria (97 cases), AFP (82 cases), epidemic and endemic typhus (79 cases), meningococcal meningitis (78 cases), anthrax (75 cases), pertussis (60 cases), dengue fever (44 cases), AHC (42 cases), and Mpox (10 cases). Table 2 Proportion of NIDs reported in Shenyang, 2005–2024 Respiratory route No.of cases(%) Fecal-oral route No.of cases(%) Blood-borne/sexual route No.of cases(%) Zoonotic and vector-borne route No.of cases(%) Other route No.of cases(%) Total(%) Category B PTB 100,866(15.09%) Bacillary and amebic dysentery 38,848(5.81%) Syphilis 62,635(9.37%) HB 5299(0.79%) Mpox 10(0.00%) 393,215(58.82%) COVID-19 58,633(8.77%) Hepatitis E 6326(0.95%) Hepatitis B 43,951(6.57%) HFRS 1580(0.24%) Neonatal tetanus 1(0.00%) Scarlet fever 28,806(4.31%) Hepatitis A 2929(0.44%) Hepatitis C 12,701(1.90%) Malaria 97(0.01%) Schistosomiasis 1(0.00%) Measles 4262(0.64%) Typhoid and paratyphoid fever 115(0.02%) Hepatitis D 5(0.00%) Anthrax 75(0.01%) - - Meningococcal meningitis 78(0.01%) AFP 82(0.01%) Gonorrhea 10,255(1.53%) Dengue fever 44(0.01%) Pertussis 60(0.01%) - - HIV/AIDS 9885(1.48%) JE 5(0.00%) Human infection with a novel influenza A virus subtype 2(0.00%) Hepatitis (untyped) 5662(0.85%) Rabies 2(0.00%) Subtotal 192,707(28.83%) 48,300(7.23%) 145,094(21.71%) 7102(1.06%) 12(0.00%) Category C Influenza 66,475(9.94%) HFMD 93,466(13.98%) - - Epidemic and endemic typhus 79(0.01%) AHC 42(0.01%) 275,261(41.18%) Mumps 35,639(5.33%) Other infectious diarrhea 57,464(8.60%) Echinococcosis 5(0.00%) - - Rubella 22,090(3.30%) - - - - Leprosy 1(0.00%) Subtotal 124,205(18.58%) 150,930(22.58%) 84(0.01%) 42(0.01%) Total 316,912(47.41%) 199,230(29.80%) 145,094(21.71%) 7186(1.07%) 54(0.01%) 668,476(100%) AFP: acute flaccid paralysis; AHC: acute hemorrhagic conjunctivitis; HB: human brucellosis; HFMD: hand, foot and mouth disease; HFRS: hemorrhagic fever with renal syndrome; JE: Japanese encephalitis; Mpox: monkeypox; NIDs: notifiable infectious diseases; PTB: pulmonary tuberculosis. Note In this table, the subtypes of viral hepatitis are presented separately to allow for comparison based on their distinct transmission routes. Additionally, influenza A (H1N1) was grouped with seasonal influenza for analysis. Incidence and temporal trends Table 3 summarizes the incidence and trends of NIDs in Shenyang from 2005 to 2024. The overall average annual ASIR was 481.49 per 100,000 population, showing a significant upward trend with an AAPC of 6.20% (95% CI: 2.11%,10.04%). The ASIR increased substantially from 360.72 per 100,000 in 2005 to 880.18 per 100,000 in 2024, corresponding to an overall rise of 144.01% over the 20-year period. Sex-specific analysis The average annual ASIR was higher in males (565.30 per 100,000) than in females (393.35 per 100,000). Both sexes experienced significant increasing trends, with AAPCs of 5.27% (95%CI: 1.28%,8.95%) for males and 7.69% (95%CI: 3.36%,11.93%) for females. The annual ASIR in males increased by 110.73%, from 444.96 to 937.66 per 100,000, while females showed a more pronounced increase of 212.33%, from 268.92 to 839.93 per 100,000. Disease category analysis The average annual ASIRs for Category B and Category C diseases were 243.40 and 238.09 per 100,000, respectively. Category B diseases showed no significant temporal trend (AAPC: 2.41%; 95%CI: -1.45%,5.00%), whereas Category C diseases exhibited a marked upward trend (AAPC: 12.75%; 95%CI: 7.47%,18.19%). The annual ASIR of Category C diseases increased dramatically by 585.49%, from 85.72 to 587.60 per 100,000. VPDs and non-VPDs analysis VPDs and non-VPDs showed contrasting trends. The average annual ASIR was 138.66 per 100,000 for VPDs and 342.83 per 100,000 for non-VPDs. VPDs declined significantly (AAPC: -6.98%; 95%CI: -8.62%,-5.30%), with a decrease of 73.73% from 259.68 to 68.23 per 100,000. In contrast, non-VPDs increased substantially (AAPC: 13.66%; 95%CI: 10.04%,17.68%), rising by 703.59% from 101.04 to 811.95 per 100,000. Transmission route analysis The average annual ASIRs by transmission route were: respiratory route (218.14 per 100,000), fecal-oral route (176.24 per 100,000), blood-borne/sexual contact route (83.12 per 100,000), zoonotic and vector-borne route (3.96 per 100,000), and other routes (0.03 per 100,000). Diseases transmitted via respiratory and fecal-oral routes showed significant upward trends, with AAPCs of 12.75% (95%CI: 7.47%,18.19%) and 4.79% (95%CI: 0.42%,9.65%), respectively. Blood-borne/sexual contact diseases exhibited a declining trend (AAPC: -2.52%; 95%CI: -4.11%, -0.30%), while zoonotic and vector-borne diseases showed no statistically significant trend. Disease-specific analysis Among respiratory route infectious diseases, PTB exhibited the highest average annual ASIR (59.26 per 100,000), followed by influenza (48.94 per 100,000) and mumps (33.29 per 100,000). Significant declining trends were observed in the annual ASIRs of PTB, mumps, rubella, and measles, with AAPCs of -2.85% (95%CI: -4.75%,-0.49%), -10.85% (95%CI: -13.17%,-8.43%), -29.56% (95%CI: -42.68%,-13.90%), and − 31.41% (95%CI: -43.94%,-16.40%), respectively. In contrast, influenza showed a marked upward trend (AAPC: 31.18%; 95%CI: 16.23%,47.66%), while no significant temporal trend was detected for scarlet fever. For diseases transmitted via the fecal-oral route, HFMD had the highest average annual ASIR (92.97 per 100,000), followed by other infectious diarrhea (47.18 per 100,000) and bacillary and amebic dysentery (30.50 per 100,000). Declining trends were observed for dysentery and hepatitis E, with AAPCs of -5.61% (95%CI: -6.87%,-4.22%) and − 4.26% (95%CI: -6.11%,-3.09%), respectively. Other infectious diarrhea showed a substantial increase (AAPC: 21.81%; 95%CI: 13.60%,29.68%), whereas HFMD and hepatitis A exhibited no statistically significant trends. For diseases transmitted via blood-borne/sexual contact route, syphilis exhibited the highest average annual ASIR (35.93 per 100,000 population), followed by hepatitis B (25.49 per 100,000) and hepatitis C (6.94 per 100,000). Significant declining trends were observed in the annual ASIRs of hepatitis B, gonorrhea and hepatitis (untyped), with AAPCs of -7.44% (95%CI: -9.41%,-4.54%), -3.36% (95%CI: -4.96%,-1.80%) and − 12.88% (95%CI: -14.04%,-11.90%), respectively. In contrast, syphilis, hepatitis C and HIV/AIDS demonstrated significant increasing trends, with AAPCs of 7.75% (95%CI: 6.68%,8.75%), 7.91% (95%CI: 5.02%,10.68%) and 15.94% (95%CI: 14.77%,17.53%), respectively. Among zoonotic and vector-borne route infectious diseases, HB exhibited the highest average annual ASIR (2.85 per 100,000), followed by HFRS (0.93 per 100,000). A pronounced declining trend of annual ASIR was observed for HFRS (AAPC: -19.66%; 95%CI: -21.56%,-17.74%), whereas HB increased significantly (AAPC: 14.50%; 95%CI: 11.15%,19.29%). Table 3 Incidence and trends of NIDs in Shenyang, 2005–2024 ASIR(/100,000) Change of ASIR(%) AAPC(%,95%CI) average annual ASIR(/100,000) 2005 2024 All 360.72 880.18 144.01 6.20 * (2.11,10.04) 481.49 Male 444.96 937.66 110.73 5.27 * (1.28,8.95) 565.3 Female 268.92 839.93 212.33 7.69 * (3.36,11.93) 393.35 Category B 275 292.58 6.39 2.41(-1.45,5) 243.4 Category C 85.72 587.6 585.49 12.75 * (7.47,18.19) 238.09 VPDs 259.68 68.23 -73.73 -6.98 * (-8.62,-5.3) 138.66 non-VPDs 101.04 811.95 703.59 13.66 * (10.04,17.68) 342.83 Respiratory route 168.3 644.77 283.11 12.75 * (7.47,18.19) 218.14 PTB 56.08 31.58 -43.69 -2.85 * (-4.75,-0.49) 59.26 Influenza 1.39 449.4 32230.94 31.18 * (16.23,47.66) 48.94 Mumps 80.26 8.93 -88.87 -10.85 * (-13.17,-8.43) 33.29 Scarlet fever 23.91 32.32 35.17 2.38(-2.98,6.8) 29.28 Rubella 1.81 0.05 -97.24 -29.56 * (-42.68,-13.9) 15.63 Measles 4.39 0.01 -99.77 -31.41 * (-43.94,-16.4) 3.11 Fecal-oral route 48.3 148.02 206.46 4.79 * (0.42,9.65) 176.24 HFMD # 45.38 30.98 -31.73 -10.53(-20.93,1.09) 109.36 Other infectious diarrhea 1.97 98.18 4883.76 21.81 * (13.6,29.68) 47.18 Bacillary and amebic dysentery 37.44 13.83 -63.06 -5.61 * (-6.87,-4.22) 30.5 Hepatitis E 7.05 2.92 -58.58 -4.26 * (-6.11,-3.09) 3.75 Hepatitis A 1.81 1.72 -4.97 -2.06(-6.39,2.48) 1.69 Blood-borne/sexual contact route 139.21 83.06 -40.33 -2.52 * (-4.11,-0.3) 83.12 Syphilis 10.25 40.01 290.34 7.75 * (6.68,8.75) 35.93 Hepatitis B 114.86 24.94 -78.29 -7.44 * (-9.41,-4.54) 25.49 Hepatitis C 3.21 8.88 176.64 7.91 * (5.02,10.68) 6.94 Gonorrhea 5.13 3.16 -38.4 -3.36 * (-4.96,-1.8) 5.94 HIV/AIDS 0.36 5.71 1486.11 15.94 * (14.77,17.53) 5.45 Hepatitis (untyped) 5.41 0.36 -93.35 -12.88 * (-14.04,-11.9) 3.37 Zoonotic and vector-borne route 4.88 4.32 -11.48 -0.16(-2.39,1.67) 3.96 HB 0.31 4.09 1219.35 14.50 * (11.15,19.29) 2.85 HFRS 4.16 0.06 -98.56 -19.66 * (-21.56,-17.74) 0.93 HB: human brucellosis; HFMD: hand, foot and mouth disease; HFRS: hemorrhagic fever with renal syndrome; NIDs: notifiable infectious diseases; PTB: pulmonary tuberculosis; VPDs: vaccine-preventable diseases. Note # HFMD data were analyzed starting in 2008. * AAPC differs significantly from 0 at the alpha = 0.05 level. The following diseases occur only sporadically: neonatal tetanus, schistosomiasis, human infection with a novel influenza A virus subtype, rabies, hepatitis D, JE, echinococcosis leprosy, Mpox, AHC, dengue fever, pertussis, anthrax, meningococcal meningitis, typhus, AFP, malaria, typhoid and paratyphoid fever. Furthermore, COVID-19 data are limited to the period 2020–2024. As none of these are suitable for joinpoint trend analysis, they are not presented in this table. Discussion In this study, NNDRS data from January 1,2005 to December 31,2024 were extracted to describe the incidence and trends of NIDs in Shenyang, China. In our study, 1,733 duplicate case reports were identified, accounting for approximately 2.60‰ (1,733/668,476) of all reported cases, indicating potential over-reporting across healthcare facilities and underscoring the need for unique patient identifiers and real-time duplicate checks. Additionally, 57,483 initially reported cases were subsequently reclassified as other conditions, reflecting diagnostic discrepancies between preliminary clinical assessments and final confirmations that highlight challenges in the early recognition and differential diagnosis of infectious diseases. The study revealed that from 2005 to 2024, NIDs in Shenyang were predominantly Category B (58.82%), followed by Category C (41.18%), whereas Category C diseases were more common nationwide during the same period [ 22 – 23 ] . It was also found that in Shenyang, respiratory transmission was the primary route of infection (47.41%), in contrast to the national pattern where fecal-oral transmission predominated, accounting for 47.83% of total cases [ 22 – 23 ] . These findings indicate that the epidemiological profile of NIDs in Shenyang differs from the overall national pattern, particularly in the hierarchy of transmission routes. Therefore, while adhering to the national prevention and control framework, Shenyang should implement more targeted strategies to enhance surveillance and management of locally predominant NIDs. This study found that the spectrum of NIDs in Shenyang has undergone significant shifts over time. Between 2005 and 2019, the dominant transmission routes gradually shifted from primarily blood-borne/sexual and respiratory transmission to intestinal and respiratory transmission, a trend consistent with national findings [ 22 – 23 ] . Since 2020, the distribution of transmission routes has changed anew, with a rebound in the proportion of blood-borne/sexual and respiratory diseases. After 2022, the proportion of respiratory infectious diseases increased markedly, surpassing 70% in both 2023 and 2024. This shift is closely associated with three key factors: 1) the strict COVID-19 isolation and control measures implemented in China from 2020 onward, which constrained healthcare-seeking behaviors and altered the surveillance and reporting landscape for some diseases [ 34 – 35 ] ; 2) the inclusion of influenza antigen-positive cases as confirmed diagnoses in the Diagnosis and Treatment Protocol for Influenza (2020 Edition), which enhanced influenza surveillance sensitivity [ 36 ] ; and 3) the significant rise in reported COVID-19 cases following the discontinuation of isolation measures in late 2022. This study also observed that the decline in the proportion of Category B diseases and the sharp decrease in VPDs in 2023 and 2024 may also be related to the three factors mentioned above. These findings indicate that the changing composition of NIDs reflects both the natural evolution of epidemic patterns and the substantial influence of adjustments in control policies and updates to surveillance standards [ 37 ] . The study found that from 2005 to 2024, the average annual ASIRs of Category B and Category C infectious diseases in Shenyang were similar, at 243.40/100,000 and 238.09/100,000, respectively. The combined overall average annual ASIR was 481.49/100,000, which was lower than the national average for the same period [ 22 – 23 ] . By transmission route, the average annual ASIR of respiratory infectious diseases in Shenyang was 218.14/100,000, higher than the national level. In contrast, the rates for fecal-oral transmission diseases (176.24/100,000), blood-borne/sexually transmitted diseases (83.12/100,000), as well as zoonotic and vector-borne diseases (3.96/100,000), were all lower than the corresponding national averages [ 22 – 23 ] . These findings suggest that while the overall burden of NIDs in Shenyang is relatively low nationwide, the burden of respiratory infectious diseases remains substantial and warrants focused attention. In this study, the annual ASIR of NIDs in Shenyang showed an overall increasing trend from 2005 to 2024, primarily driven by a rise in Category C diseases, consistent with national observations from the same period [ 22 – 23 ] . The increase in Category C disease incidence was largely attributable to rising rates of influenza and other infectious diarrhea, which may also explain the concurrent upward trends observed for respiratory and fecal-oral transmission diseases in Shenyang. Distinct regional patterns emerged when comparing Shenyang to national data [ 22 – 23 ] . While Shenyang experienced a rising trend in the incidence of respiratory infectious diseases, no significant nationwide increase was observed. The incidence of fecal-oral transmission diseases in Shenyang showed an upward trend, consistent with the national pattern. In contrast, the incidence of blood-borne/sexually transmitted diseases exhibited a declining trend in Shenyang, whereas no clear decline was evident at the national level. The incidence of zoonotic and vector-borne diseases remained stable in Shenyang, mirroring the national trend. These comparisons suggest that Shenyang has achieved relatively significant success in controlling blood-borne/sexually transmitted diseases, yet underscores the need to strengthen prevention and control measures targeting respiratory transmission. Notably, the incidence of VPDs in Shenyang exhibited a marked decrease, largely attributable to significant declines in PTB, measles, rubella, mumps, and hepatitis B. This trend demonstrates the effectiveness of the national immunization program and is consistent with previous studies conducted both in China and globally [ 8 – 12 , 38 – 40 ] , underscoring the considerable impact of vaccination strategies on NIDs control. In this study, the top ten NIDs reported in Shenyang between 2005 and 2024 were, in descending order: PTB, HFMD, influenza, syphilis, COVID-19, other infectious diarrhea, hepatitis B, bacillary and amebic dysentery, mumps, and scarlet fever. Collectively, these diseases accounted for 88.62% of all reported cases in the city. Trend analysis revealed declining patterns for PTB, hepatitis B, bacillary and amebic dysentery, and mumps, while no clear upward trend was observed for HFMD or scarlet fever. The increase in reported influenza cases was largely attributed to a surge following updates in surveillance criteria [ 36 ] . The rise in other infectious diarrhea was concentrated between 2005 and 2007, and that of syphilis between 2005 and 2013; in each case, the annual ASIR plateaued thereafter. Although a substantial increase in COVID-19 cases was reported in 2023 and 2024, surveillance data from 2025 indicated a subsequent decline. Overall, the increase in the annual ASIR of NIDs in Shenyang is largely attributable to the increases observed during certain periods and modifications in surveillance criteria. Consequently, the overall epidemic situation of NIDs in the city remains within a manageable range. In spite of the above findings, the limitations in our study should be considered. First, not all NIDs cases were reported to NNDRS system, analysis based on the NIDRIS data may reflect the level of reported cases in Shenyang, but may not be fully representative of local NIDs incidence. Second, the isolation measures implemented during the COVID-19 pandemic may have disrupted routine healthcare-seeking behavior for other infectious diseases, which could interfere with the objective assessment of their epidemiological trends. Conclusions The overall incidence of NIDs in Shenyang was lower than the national average, however, the disease burden of respiratory infections is relatively prominent and should become a key focus for future prevention and control. The observed upward trend in overall incidence is largely attributable to the increases observed during certain periods and modifications in surveillance criteria, suggesting that the epidemic situation remains manageable. It is noteworthy that the significant decline in the incidence of VPDs underscores the critical role of immunization programs, and such interventions should be consolidated and strengthened. Abbreviations AAPC average annual percent change AFP acute flaccid paralysis AHC acute hemorrhagic conjunctivitis APC annual percent change ASIR age-standardized incidence rates HB: human brucellosis HFMD hand,foot and mouth disease HFRS hemorrhagic fever with renal syndrome JE Japanese encephalitis Mpox monkeypox NIDs notifiable infectious diseases NNDRS national notifiable diseases reporting system NPIs non-pharmaceutical interventions PTB pulmonary tuberculosis SARS severe acute respiratory syndrome VPDs vaccine-preventable diseases. Declarations Ethics approval and consent to participate This study was reviewed and approved by the Ethics Committee of the Shenyang Center for Disease Control and Prevention. The informed consent was waived as all patient data were anonymized, with no personally identifiable information retained. Consent for publication Not applicable. Competing Interests The authors declare that they have no conflict of interest. Funding This work was not supported by any funding. Author Contribution HC, ZJ and BZ designed the study. HC and HW extracted, collected, and analysed the data. HC and HW drafted the manuscript. YC and LW verified the data. HC and HW reviewed the results and revised the manuscript. All authors read and approved the final manuscript. Acknowledgments Not applicable. Data Availability The reported cases data that support the findings of this study were downloaded from China's NNDRS, a non-commercial national surveillance platform accessible only with authorization and not publicly available. The processed datasets necessary to reproduce the study’s findings are, however, available from the corresponding author upon reasonable request. 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Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 23 Mar, 2026 Reviews received at journal 10 Mar, 2026 Reviewers agreed at journal 10 Mar, 2026 Reviews received at journal 29 Jan, 2026 Reviewers agreed at journal 23 Jan, 2026 Reviewers agreed at journal 18 Jan, 2026 Reviewers invited by journal 18 Jan, 2026 Editor assigned by journal 13 Jan, 2026 Editor invited by journal 13 Jan, 2026 Submission checks completed at journal 12 Jan, 2026 First submitted to journal 12 Jan, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8552297","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":576504001,"identity":"73ba3f0d-dbee-4a01-ab78-e22124c75f4c","order_by":0,"name":"Huijie Chen","email":"","orcid":"","institution":"Shenyang Municipal Center for Disease Control and Prevention (Shenyang Municipal Health Supervision Institute)","correspondingAuthor":false,"prefix":"","firstName":"Huijie","middleName":"","lastName":"Chen","suffix":""},{"id":576504002,"identity":"a1b0a7c7-a025-4794-a3db-6c933abd518a","order_by":1,"name":"Huiyu 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06:49:53","extension":"html","order_by":6,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":143203,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8552297/v1/c9f24e6570f6221bfc44ca36.html"},{"id":100757361,"identity":"93d44c32-52c8-49f4-a6c2-3117fc81072b","added_by":"auto","created_at":"2026-01-21 06:48:57","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":181399,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eProportion of NIDs in Shenyang, China by different categories from 2005-2024.\u003c/strong\u003e (A) Percentage of category B and category C. (B) Percentage of five transmission routes. (C) Percentage of VPDs and non-VPDs. The colors of the bars denote different categories, while their length indicates each category’s percentage share of the total.\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-8552297/v1/5c02cb90c35f1eaa7a2e6bb8.png"},{"id":100757812,"identity":"e54a097f-eda9-4360-b7fa-2642c8011b1f","added_by":"auto","created_at":"2026-01-21 06:53:56","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1062789,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8552297/v1/bea45cfe-b888-4af1-bdac-f44b85115234.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Incidence and trends for notifiable infectious diseases in Shenyang, China, 2005-2024","fulltext":[{"header":"Background","content":"\u003cp\u003eInfectious diseases continue to pose a major global public health threat, contributing to substantial morbidity, mortality, and economic losses each year \u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/sup\u003e. Despite progress in medical technology and healthcare infrastructure, the recurrent emergence and re-emergence of pathogens such as SARS-CoV-2 underscore the ongoing vulnerability of human populations to infectious disease outbreaks \u003csup\u003e[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/sup\u003e. According to the World Health Organization (WHO), millions of annual deaths are attributable to infectious diseases, with low- and middle-income countries carrying a disproportionately high burden \u003csup\u003e[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/sup\u003e. In China, such diseases have long constituted a significant part of the national disease profile, leading to the implementation of robust surveillance mechanisms including the National Notifiable Diseases Reporting System (NNDRS) in 2004 \u003csup\u003e[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eGlobally, the epidemiology of infectious diseases has undergone considerable changes over the past two decades \u003csup\u003e[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/sup\u003e. The incidence of vaccine-preventable diseases (VPDs) including measles, poliomyelitis, and pulmonary tuberculosis (PTB) has declined in many parts of the world \u003csup\u003e[\u003cspan additionalcitationids=\"CR9 CR10 CR11\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/sup\u003e, and the global burden of enteric infections also exhibited a downward trend between 1990 and 2021 \u003csup\u003e[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/sup\u003e. In contrast, sexually transmitted infections have increased markedly, influenced by a combination of biological and socio-behavioral factors, with marginalized and high-risk groups-especially in resource-limited settings-being disproportionately affected \u003csup\u003e[\u003cspan additionalcitationids=\"CR15\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/sup\u003e. Furthermore, growing international travel and migration have contributed to a modest resurgence of malaria in certain areas \u003csup\u003e[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]\u003c/sup\u003e. The COVID-19 pandemic disrupted longstanding seasonal influenza dynamics. After the relaxation of non-pharmaceutical interventions (NPIs) such as international travel restrictions, social distancing, mask mandates, and school closures, some countries witnessed a rapid rebound in influenza activity, whereas others reported delayed or off-season epidemics \u003csup\u003e[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eIn China, the overall incidence of notifiable infectious diseases (NIDs) fell markedly between 1975 and 1995, largely attributable to expanded immunization coverage and improved public sanitation \u003csup\u003e[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]\u003c/sup\u003e. However, a gradual resurgence occurred from 1995 to 2008, fueled by increases in blood-borne/sexually transmitted diseases-such as hepatitis B and syphilis, as well as respiratory infections including PTB and influenza \u003csup\u003e[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]\u003c/sup\u003e. Recent studies covering data from 2005 to 2024 indicated an average annual incidence of 549.76 per 100,000 population, with an overall upward trajectory \u003csup\u003e[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eRegionally, China's vast territory contributes to distinct epidemiological characteristics of NIDs. For example, in Nanjing, Jiangsu Province, the average annual incidence of NIDs from 2004 to 2022 was 347.45 per 100,000 population, with fecal-oral transmission being the dominant route \u003csup\u003e[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]\u003c/sup\u003e. No significant temporal trend in annual incidence was observed over the past two decades \u003csup\u003e[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]\u003c/sup\u003e. However, during the same period, Henan Province recorded a significantly higher average annual incidence of 417.47 per 100,000, predominantly driven by blood-borne/sexual transmission \u003csup\u003e[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]\u003c/sup\u003e. Furthermore, the annual incidence in Henan exhibited a clear upward trend over the last 20 years \u003csup\u003e[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eEconomic development has accelerated population mobility, amplifying the risks of infectious disease transmission, particularly for respiratory and blood-borne pathogens \u003csup\u003e[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]\u003c/sup\u003e. The dynamic nature of epidemiological trends necessitates continuous reinforcement of surveillance systems. China's substantial regional heterogeneity in disease epidemiology underscores the critical importance of localized research. Shenyang, a major city in Liaoning Province with a population exceeding eight million, acts as a vital surveillance sentinel for monitoring regional infectious disease patterns. However, a comprehensive analysis of long-term trends in this context remains lacking \u003csup\u003e[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]\u003c/sup\u003e. This study aims to address this gap by examining the epidemiological trends of NIDs from 2005 to 2024, thereby providing an evidence base to inform regional and national public health strategies.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Area\u003c/h2\u003e \u003cp\u003eShenyang, the capital of Liaoning Province in China, is situated between latitudes 41\u0026deg;11\u0026prime;N and 43\u0026deg;02\u0026prime;N, and longitudes 122\u0026deg;25\u0026prime;E and 123\u0026deg;48\u0026prime;E. As a prefecture-level city, it covers an area of 12,860 square kilometers and comprises 13 districts. From 2005 to 2024, the average population of Shenyang was 8,151,603.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eData Sources\u003c/h3\u003e\n\u003cp\u003eIn China, the list of NIDs has undergone dynamic adjustments to address emerging public health threats. Foot and mouth disease (HFMD) was first incorporated in 2008, followed by influenza A(H1N1) in 2009, which was later integrated into seasonal influenza surveillance in 2014. Subsequently, H7N9 avian influenza was added in 2013 and reclassified as human infection with novel influenza subtype in 2018 to encompass other novel subtypes. More recently, COVID-19 and monkeypox (Mpox) were included as statutory notifiable diseases in 2020 and 2023, respectively. Currently, there are totaling 40 NIDs in China, which were classified into classes A, B and C \u003csup\u003e[\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]\u003c/sup\u003e (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCurrent NIDs and classification in China\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClassification\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo. of diseases\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNIDs\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePlague and cholera\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCOVID-19, AFP, rabies, anthrax, meningococcal meningitis, scarlet fever, leptospirosis, SARS, human infection with a novel influenza A virus subtype, JE, bacillary and amebic dysentery\u003csup\u003e\u0026sect;\u003c/sup\u003e, HB, schistosomiasis, HIV/AIDS, measles, dengue fever, PTB, diphtheria, gonorrhea, malaria, viral hepatitis\u003csup\u003e∮\u003c/sup\u003e, HFRS, Mpox, typhoid and paratyphoid fevers\u003csup\u003e$\u003c/sup\u003e, neonatal tetanus, syphilis\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eInfluenza, leprosy, filariasis, mumps, epidemic and endemic typhus, hand, HFMD, rubella, visceral leishmaniasis, other infectious diarrhea\u003csup\u003e\u0026pound;\u003c/sup\u003e, AHC, echinococcosis\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eAFP: acute flaccid paralysis; AHC: acute hemorrhagic conjunctivitis; HB: human brucellosis; HFMD: hand, foot and mouth disease; HFRS: hemorrhagic fever with renal syndrome; JE: Japanese encephalitis; Mpox: monkeypox; NIDs: notifiable infectious diseases; PTB: pulmonary tuberculosis; SARS: severe acute respiratory syndrome.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eNote\u003c/strong\u003e \u003cp\u003e \u003csup\u003e\u0026sect;\u003c/sup\u003eBacillary and amebic dysentery comprises two distinct diseases: bacillary dysentery and amebic dysentery. \u003csup\u003e∮\u003c/sup\u003eViral hepatitis comprises six distinct disease types: Hepatitis A, Hepatitis B, Hepatitis C, Hepatitis D, Hepatitis E, and hepatitis (untyped). \u003csup\u003e$\u003c/sup\u003eTyphoid and paratyphoid fevers comprise two distinct diseases: typhoid fever and paratyphoid fever. \u003csup\u003e\u0026pound;\u003c/sup\u003eOther infectious diarrhea refers to diarrhea other than that caused by cholera, dysentery or typhoid fever.\u003c/p\u003e \u003c/p\u003e \u003cp\u003eThe NNDRS was established and officially put into operation in April 2004.This study collected all reported cases (including time of onset, diagnosis, reporting date, as well as patient demographic details such as age and gender) with onset from January 1, 2005 to December 31, 2024, in Shenyang, China through this system which was used under license and not publicly available. All eligible cases were confirmed based on clinical manifestations and laboratory tests, and the following cases were excluded: not residing in Shenyang, duplicate reported and without a definitive diagnosis.\u003c/p\u003e \u003cp\u003eThe annual population data for the years 2005\u0026ndash;2024 were retrieved from the Official Website of Shenyang Statistical Bureau (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://tjj.shenyang.gov.cn/\u003c/span\u003e\u003cspan address=\"http://tjj.shenyang.gov.cn/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e). The study protocol was approved by the Ethics Committees of Shenyang Center for Disease Control and Prevention.\u003c/p\u003e\n\u003ch3\u003eDefinition\u003c/h3\u003e\n\u003cp\u003eRespiratory transmitted infectious diseases are defined as a category of illnesses acquired through exposure to respiratory droplets generated by infected individuals during coughing or sneezing, or via contact with contaminated surfaces (fomites) \u003csup\u003e[\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]\u003c/sup\u003e. This category in the present study includes COVID-19, severe acute respiratory syndrome (SARS), influenza, meningococcal meningitis, scarlet fever, human infection with a novel influenza A virus subtype, pertussis, measles, PTB, leprosy, mumps, rubella, and diphtheria.\u003c/p\u003e \u003cp\u003eInfectious diseases transmitted via the fecal-oral route are defined as those caused by pathogens that are shed in the feces of infected individuals and subsequently enter a new susceptible host through the mouth via intermediaries such as contaminated water, food, or hands \u003csup\u003e[\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]\u003c/sup\u003e. This transmission group in our study covers acute flaccid paralysis (AFP), bacillary and amebic dysentery, typhoid and paratyphoid fevers, hepatitis A, hepatitis E, HFMD, and other infectious diarrhea.\u003c/p\u003e \u003cp\u003eBlood-borne/sexually transmitted infectious diseases refer to a category of illnesses contracted through exposure to infected blood or body fluids during sexual contact, sharing of injection equipment, or other forms of direct exposure \u003csup\u003e[\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]\u003c/sup\u003e. Diseases classified under this mode in the current analysis include HIV/AIDS, gonorrhea, syphilis, hepatitis B, hepatitis C, hepatitis D, and hepatitis (untyped).\u003c/p\u003e \u003cp\u003eZoonotic and vector-borne infectious diseases are caused by pathogens naturally transmitted between vertebrate animals and humans, either directly (zoonoses) or indirectly via arthropod vectors such as mosquitoes and ticks \u003csup\u003e[\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]\u003c/sup\u003e. In this study, these include rabies, cutaneous anthrax, human brucellosis (HB), hemorrhagic fever with renal syndrome (HFRS), echinococcosis, Japanese encephalitis (JE), dengue fever, malaria, typhus, filariasis, and visceral leishmaniasis.\u003c/p\u003e \u003cp\u003eVPDs are those targeted by national immunization programs for control through vaccination \u003csup\u003e[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/sup\u003e. The VPDs considered here comprise measles, pertussis, meningococcal meningitis, JE, AFP, hepatitis A, hepatitis B, PTB, rubella, and mumps. All remaining diseases are categorized as non-VPDs.\u003c/p\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eDisease incidence was measured using the age-standardized incidence rate (ASIR). The annual ASIR was computed as the sum of the products of age-specific incidence rates and the corresponding standard population weights for each age group in a certain year. In this study, the annual ASIR from 2005 to 2024 were calculated and the 2010 national population census of China was serving as the standard population. The changes in annual ASIR from 2005 to 2024 were calculated as the percentage change, using the formula: \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\frac{{ASIR}_{2024}-{ASIR}_{2005}}{{ASIR}_{2005}}\\times\\:100\\%\\)\u003c/span\u003e\u003c/span\u003e. The average annual ASIR was defined as the mean of the annual ASIR for each year during the observation period. The average annual percent change (AAPC) and its corresponding 95% confidence interval (CI) were calculated. The AAPC quantifies the average direction and magnitude of a trend over the entire study period. If the 95%CI for the AAPC did not include zero, the trend was considered statistically significant. In such cases, the trend was classified as \"increasing\" for a positive value or \"decreasing\" for a negative value. Conversely, if the 95%CI contained zero, the trend was deemed \"stationary\", indicating that the null hypothesis (AAPC\u0026thinsp;=\u0026thinsp;0) could not be rejected. A two-sided \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant.\u003c/p\u003e \u003cp\u003eStata version 17.0 (Stata Corp, College Station, TX, USA) was used for data extraction, sorting, and cleaning. Microsoft Excel 2019 (Microsoft, Seattle WA, USA) was utilized to visualize the epidemic patterns. The Joinpoint Regression Program, version 4.8.0.1 (National Cancer Institute, Bethesda, MD, USA) was performed to analyze temporal trends.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eGeneral characteristics\u003c/h2\u003e \u003cp\u003eA total of 1,018,131 cases of infectious diseases were reported from 2005 to 2024. Following the application of exclusion criteria, 184,033 cases were excluded due to non-residency in Shenyang. An additional 1,733 cases were identified as duplicate reports and were subsequently removed. Furthermore, 57,483 cases were diagnosed as other conditions, and 106,406 cases were categorized as non-NIDs. The latter category comprised 89,384 cases of varicella, 6,513 cases of condyloma acuminatum, 4,358 cases of genital chlamydia trachomatis infection, 3,453 cases of tuberculous pleurisy, 53 cases of clonorchiasis, 1,607 cases of genital herpes, 1,015 cases of non-gonococcal urethritis, 17 cases of severe fever with thrombocytopenia syndrome, 4 cases of extrapulmonary tuberculosis, 1 case of streptococcus suis infection, and 1 case of scrub typhus. Consequently, the final analytical dataset comprised a total of 668,476 cases.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eProportion and Dynamics\u003c/h3\u003e\n\u003cp\u003eAs summarized in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, 33 NIDs were reported in Shenyang from 2005 to 2024, consisting of 24 Category B and 9 Category C diseases. No Category A infections were documented, and no cases of leptospirosis, SARS, diphtheria, filariasis, or visceral leishmaniasis were recorded. Of all the reported NIDs, Category B diseases accounted for 393,215 cases (58.82%) and Category C diseases accounted for 275,261 cases (41.18%). As shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, with the exception of 2010 and 2024, Category B diseases consistently represented a higher proportion of annual cases than Category C diseases, exceeding 80% of the total in both 2005 and 2022.\u003c/p\u003e \u003cp\u003eIn terms of transmission routes, respiratory transmission was the most common (316,912 cases, 47.41%), followed by fecal-oral (199,230, 29.80%) and blood-borne/sexual transmission (145,094 cases, 21.71%). Zoonotic and vector-borne transmissions accounted for 7,186 cases (1.07%), with other routes comprising 54 cases (0.01%). As shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, the dominant transmission routes shifted considerably over this period. Blood-borne/sexual transmission predominated in 2005, followed by respiratory transmission during 2006\u0026ndash;2011, and fecal-oral transmission during 2012\u0026ndash;2019. Since 2020, respiratory transmission has reemerged as the primary route, comprising over 70% of cases in both 2023 and 2024.\u003c/p\u003e \u003cp\u003eVPDs accounted for 209,962 cases (31.41%) during the 20-year period, while non-VPDs comprised 458,514 cases (68.59%). As shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, a pronounced decline in the proportion of VPDs was observed over time, falling from 72.02% in 2005 to just 8.14% in 2023 and 9.64% in 2024.\u003c/p\u003e \u003cp\u003ePTB was the most reported disease (100,866 cases, 15.09%), followed by HFMD (94,466 cases, 13.98%), viral hepatitis (71,574 cases, 10.71%), and influenza (66,475 cases, 9.94%). Substantial case numbers were also noted for syphilis (62,635 cases, 9.37%), COVID-19 (58,633 cases, 8.77%), and other infectious diarrhea (57,464 cases, 8.60%). In contrast, neonatal tetanus, schistosomiasis, and leprosy were the least reported, with one case each. Other rarely reported diseases included hepatitis D, JE, and echinococcosis (5 cases each), human infection with a novel influenza A virus subtype and rabies (2 cases each), as well as typhoid and paratyphoid fever (115 cases), malaria (97 cases), AFP (82 cases), epidemic and endemic typhus (79 cases), meningococcal meningitis (78 cases), anthrax (75 cases), pertussis (60 cases), dengue fever (44 cases), AHC (42 cases), and Mpox (10 cases).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eProportion of NIDs reported in Shenyang, 2005\u0026ndash;2024\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"12\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c12\" colnum=\"12\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRespiratory route\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo.of cases(%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFecal-oral route\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNo.of cases(%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eBlood-borne/sexual route\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNo.of cases(%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eZoonotic and vector-borne route\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eNo.of cases(%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cp\u003eOther route\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c11\"\u003e \u003cp\u003eNo.of cases(%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c12\"\u003e \u003cp\u003eTotal(%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"6\" rowspan=\"7\"\u003e \u003cp\u003eCategory B\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePTB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e100,866(15.09%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eBacillary and amebic dysentery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e38,848(5.81%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSyphilis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e62,635(9.37%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eHB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e5299(0.79%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eMpox\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e10(0.00%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\" morerows=\"6\" rowspan=\"7\"\u003e \u003cp\u003e393,215(58.82%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCOVID-19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e58,633(8.77%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eHepatitis E\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6326(0.95%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eHepatitis B\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e43,951(6.57%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eHFRS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e1580(0.24%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eNeonatal tetanus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e1(0.00%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eScarlet fever\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e28,806(4.31%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eHepatitis A\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2929(0.44%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eHepatitis C\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e12,701(1.90%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eMalaria\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e97(0.01%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eSchistosomiasis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e1(0.00%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMeasles\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4262(0.64%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTyphoid and paratyphoid fever\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e115(0.02%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eHepatitis D\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e5(0.00%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAnthrax\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e75(0.01%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMeningococcal meningitis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e78(0.01%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAFP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e82(0.01%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eGonorrhea\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e10,255(1.53%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eDengue fever\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e44(0.01%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePertussis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e60(0.01%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eHIV/AIDS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e9885(1.48%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eJE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e5(0.00%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHuman infection with a novel influenza A virus subtype\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2(0.00%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eHepatitis (untyped)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e5662(0.85%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eRabies\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e2(0.00%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSubtotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e192,707(28.83%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e48,300(7.23%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e145,094(21.71%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e7102(1.06%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e12(0.00%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eCategory C\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInfluenza\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e66,475(9.94%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eHFMD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e93,466(13.98%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eEpidemic and endemic typhus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e79(0.01%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eAHC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e42(0.01%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e275,261(41.18%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMumps\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e35,639(5.33%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eOther infectious diarrhea\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e57,464(8.60%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eEchinococcosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e5(0.00%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRubella\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e22,090(3.30%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLeprosy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1(0.00%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSubtotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e124,205(18.58%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e150,930(22.58%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e84(0.01%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e42(0.01%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e316,912(47.41%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e199,230(29.80%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e145,094(21.71%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e7186(1.07%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e54(0.01%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e668,476(100%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eAFP: acute flaccid paralysis; AHC: acute hemorrhagic conjunctivitis; HB: human brucellosis; HFMD: hand, foot and mouth disease; HFRS: hemorrhagic fever with renal syndrome; JE: Japanese encephalitis; Mpox: monkeypox; NIDs: notifiable infectious diseases; PTB: pulmonary tuberculosis.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eNote\u003c/strong\u003e \u003cp\u003eIn this table, the subtypes of viral hepatitis are presented separately to allow for comparison based on their distinct transmission routes. Additionally, influenza A (H1N1) was grouped with seasonal influenza for analysis.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e\n\u003ch3\u003eIncidence and temporal trends\u003c/h3\u003e\n\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e summarizes the incidence and trends of NIDs in Shenyang from 2005 to 2024. The overall average annual ASIR was 481.49 per 100,000 population, showing a significant upward trend with an AAPC of 6.20% (95% CI: 2.11%,10.04%). The ASIR increased substantially from 360.72 per 100,000 in 2005 to 880.18 per 100,000 in 2024, corresponding to an overall rise of 144.01% over the 20-year period.\u003c/p\u003e \u003cp\u003eSex-specific analysis\u003c/p\u003e \u003cp\u003eThe average annual ASIR was higher in males (565.30 per 100,000) than in females (393.35 per 100,000). Both sexes experienced significant increasing trends, with AAPCs of 5.27% (95%CI: 1.28%,8.95%) for males and 7.69% (95%CI: 3.36%,11.93%) for females. The annual ASIR in males increased by 110.73%, from 444.96 to 937.66 per 100,000, while females showed a more pronounced increase of 212.33%, from 268.92 to 839.93 per 100,000.\u003c/p\u003e \u003cp\u003eDisease category analysis\u003c/p\u003e \u003cp\u003eThe average annual ASIRs for Category B and Category C diseases were 243.40 and 238.09 per 100,000, respectively. Category B diseases showed no significant temporal trend (AAPC: 2.41%; 95%CI: -1.45%,5.00%), whereas Category C diseases exhibited a marked upward trend (AAPC: 12.75%; 95%CI: 7.47%,18.19%). The annual ASIR of Category C diseases increased dramatically by 585.49%, from 85.72 to 587.60 per 100,000.\u003c/p\u003e \u003cp\u003eVPDs and non-VPDs analysis\u003c/p\u003e \u003cp\u003eVPDs and non-VPDs showed contrasting trends. The average annual ASIR was 138.66 per 100,000 for VPDs and 342.83 per 100,000 for non-VPDs. VPDs declined significantly (AAPC: -6.98%; 95%CI: -8.62%,-5.30%), with a decrease of 73.73% from 259.68 to 68.23 per 100,000. In contrast, non-VPDs increased substantially (AAPC: 13.66%; 95%CI: 10.04%,17.68%), rising by 703.59% from 101.04 to 811.95 per 100,000.\u003c/p\u003e \u003cp\u003eTransmission route analysis\u003c/p\u003e \u003cp\u003eThe average annual ASIRs by transmission route were: respiratory route (218.14 per 100,000), fecal-oral route (176.24 per 100,000), blood-borne/sexual contact route (83.12 per 100,000), zoonotic and vector-borne route (3.96 per 100,000), and other routes (0.03 per 100,000). Diseases transmitted via respiratory and fecal-oral routes showed significant upward trends, with AAPCs of 12.75% (95%CI: 7.47%,18.19%) and 4.79% (95%CI: 0.42%,9.65%), respectively. Blood-borne/sexual contact diseases exhibited a declining trend (AAPC: -2.52%; 95%CI: -4.11%, -0.30%), while zoonotic and vector-borne diseases showed no statistically significant trend.\u003c/p\u003e \u003cp\u003eDisease-specific analysis\u003c/p\u003e \u003cp\u003eAmong respiratory route infectious diseases, PTB exhibited the highest average annual ASIR (59.26 per 100,000), followed by influenza (48.94 per 100,000) and mumps (33.29 per 100,000). Significant declining trends were observed in the annual ASIRs of PTB, mumps, rubella, and measles, with AAPCs of -2.85% (95%CI: -4.75%,-0.49%), -10.85% (95%CI: -13.17%,-8.43%), -29.56% (95%CI: -42.68%,-13.90%), and \u0026minus;\u0026thinsp;31.41% (95%CI: -43.94%,-16.40%), respectively. In contrast, influenza showed a marked upward trend (AAPC: 31.18%; 95%CI: 16.23%,47.66%), while no significant temporal trend was detected for scarlet fever.\u003c/p\u003e \u003cp\u003eFor diseases transmitted via the fecal-oral route, HFMD had the highest average annual ASIR (92.97 per 100,000), followed by other infectious diarrhea (47.18 per 100,000) and bacillary and amebic dysentery (30.50 per 100,000). Declining trends were observed for dysentery and hepatitis E, with AAPCs of -5.61% (95%CI: -6.87%,-4.22%) and \u0026minus;\u0026thinsp;4.26% (95%CI: -6.11%,-3.09%), respectively. Other infectious diarrhea showed a substantial increase (AAPC: 21.81%; 95%CI: 13.60%,29.68%), whereas HFMD and hepatitis A exhibited no statistically significant trends.\u003c/p\u003e \u003cp\u003eFor diseases transmitted via blood-borne/sexual contact route, syphilis exhibited the highest average annual ASIR (35.93 per 100,000 population), followed by hepatitis B (25.49 per 100,000) and hepatitis C (6.94 per 100,000). Significant declining trends were observed in the annual ASIRs of hepatitis B, gonorrhea and hepatitis (untyped), with AAPCs of -7.44% (95%CI: -9.41%,-4.54%), -3.36% (95%CI: -4.96%,-1.80%) and \u0026minus;\u0026thinsp;12.88% (95%CI: -14.04%,-11.90%), respectively. In contrast, syphilis, hepatitis C and HIV/AIDS demonstrated significant increasing trends, with AAPCs of 7.75% (95%CI: 6.68%,8.75%), 7.91% (95%CI: 5.02%,10.68%) and 15.94% (95%CI: 14.77%,17.53%), respectively.\u003c/p\u003e \u003cp\u003eAmong zoonotic and vector-borne route infectious diseases, HB exhibited the highest average annual ASIR (2.85 per 100,000), followed by HFRS (0.93 per 100,000). A pronounced declining trend of annual ASIR was observed for HFRS (AAPC: -19.66%; 95%CI: -21.56%,-17.74%), whereas HB increased significantly (AAPC: 14.50%; 95%CI: 11.15%,19.29%).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eIncidence and trends of NIDs in Shenyang, 2005\u0026ndash;2024\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eASIR(/100,000)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eChange of\u003c/p\u003e \u003cp\u003eASIR(%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eAAPC(%,95%CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eaverage annual ASIR(/100,000)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2005\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2024\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAll\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e360.72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e880.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e144.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e6.20\u003csup\u003e*\u003c/sup\u003e(2.11,10.04)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e481.49\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e444.96\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e937.66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e110.73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e5.27\u003csup\u003e*\u003c/sup\u003e(1.28,8.95)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e565.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e268.92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e839.93\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e212.33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e7.69\u003csup\u003e*\u003c/sup\u003e(3.36,11.93)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e393.35\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCategory B\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e275\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e292.58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e6.39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2.41(-1.45,5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e243.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCategory C\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e85.72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e587.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e585.49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e12.75\u003csup\u003e*\u003c/sup\u003e(7.47,18.19)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e238.09\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVPDs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e259.68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e68.23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-73.73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e-6.98\u003csup\u003e*\u003c/sup\u003e(-8.62,-5.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e138.66\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003enon-VPDs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e101.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e811.95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e703.59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e13.66\u003csup\u003e*\u003c/sup\u003e(10.04,17.68)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e342.83\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRespiratory route\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e168.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e644.77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e283.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e12.75\u003csup\u003e*\u003c/sup\u003e(7.47,18.19)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e218.14\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePTB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e56.08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e31.58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-43.69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e-2.85\u003csup\u003e*\u003c/sup\u003e(-4.75,-0.49)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e59.26\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInfluenza\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e449.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e32230.94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e31.18\u003csup\u003e*\u003c/sup\u003e(16.23,47.66)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e48.94\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMumps\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e80.26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8.93\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-88.87\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e-10.85\u003csup\u003e*\u003c/sup\u003e(-13.17,-8.43)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e33.29\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eScarlet fever\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23.91\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e32.32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e35.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2.38(-2.98,6.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e29.28\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRubella\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.81\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-97.24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e-29.56\u003csup\u003e*\u003c/sup\u003e(-42.68,-13.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e15.63\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMeasles\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-99.77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e-31.41\u003csup\u003e*\u003c/sup\u003e(-43.94,-16.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e3.11\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFecal-oral route\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e48.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e148.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e206.46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e4.79\u003csup\u003e*\u003c/sup\u003e(0.42,9.65)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e176.24\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHFMD\u003csup\u003e#\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e45.38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e30.98\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-31.73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e-10.53(-20.93,1.09)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e109.36\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther infectious diarrhea\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e98.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4883.76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e21.81\u003csup\u003e*\u003c/sup\u003e(13.6,29.68)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e47.18\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBacillary and amebic dysentery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e37.44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e13.83\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-63.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e-5.61\u003csup\u003e*\u003c/sup\u003e(-6.87,-4.22)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e30.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHepatitis E\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-58.58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e-4.26\u003csup\u003e*\u003c/sup\u003e(-6.11,-3.09)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e3.75\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHepatitis A\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.81\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-4.97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e-2.06(-6.39,2.48)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1.69\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBlood-borne/sexual contact route\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e139.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e83.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-40.33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e-2.52\u003csup\u003e*\u003c/sup\u003e(-4.11,-0.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e83.12\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSyphilis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e40.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e290.34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e7.75\u003csup\u003e*\u003c/sup\u003e(6.68,8.75)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e35.93\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHepatitis B\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e114.86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e24.94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-78.29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e-7.44\u003csup\u003e*\u003c/sup\u003e(-9.41,-4.54)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e25.49\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHepatitis C\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8.88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e176.64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e7.91\u003csup\u003e*\u003c/sup\u003e(5.02,10.68)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e6.94\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGonorrhea\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3.16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-38.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e-3.36\u003csup\u003e*\u003c/sup\u003e(-4.96,-1.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e5.94\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHIV/AIDS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5.71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1486.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e15.94\u003csup\u003e*\u003c/sup\u003e(14.77,17.53)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e5.45\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHepatitis (untyped)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-93.35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e-12.88\u003csup\u003e*\u003c/sup\u003e(-14.04,-11.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e3.37\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eZoonotic and vector-borne route\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4.32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-11.48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e-0.16(-2.39,1.67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e3.96\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4.09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1219.35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e14.50\u003csup\u003e*\u003c/sup\u003e(11.15,19.29)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e2.85\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHFRS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-98.56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e-19.66\u003csup\u003e*\u003c/sup\u003e(-21.56,-17.74)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.93\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eHB: human brucellosis; HFMD: hand, foot and mouth disease; HFRS: hemorrhagic fever with renal syndrome; NIDs: notifiable infectious diseases; PTB: pulmonary tuberculosis; VPDs: vaccine-preventable diseases.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eNote\u003c/strong\u003e \u003cp\u003e \u003csup\u003e#\u003c/sup\u003e HFMD data were analyzed starting in 2008. \u003csup\u003e*\u003c/sup\u003e AAPC differs significantly from 0 at the alpha\u0026thinsp;=\u0026thinsp;0.05 level. The following diseases occur only sporadically: neonatal tetanus, schistosomiasis, human infection with a novel influenza A virus subtype, rabies, hepatitis D, JE, echinococcosis leprosy, Mpox, AHC, dengue fever, pertussis, anthrax, meningococcal meningitis, typhus, AFP, malaria, typhoid and paratyphoid fever. Furthermore, COVID-19 data are limited to the period 2020\u0026ndash;2024. As none of these are suitable for joinpoint trend analysis, they are not presented in this table.\u003c/p\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this study, NNDRS data from January 1,2005 to December 31,2024 were extracted to describe the incidence and trends of NIDs in Shenyang, China. In our study, 1,733 duplicate case reports were identified, accounting for approximately 2.60\u0026permil; (1,733/668,476) of all reported cases, indicating potential over-reporting across healthcare facilities and underscoring the need for unique patient identifiers and real-time duplicate checks. Additionally, 57,483 initially reported cases were subsequently reclassified as other conditions, reflecting diagnostic discrepancies between preliminary clinical assessments and final confirmations that highlight challenges in the early recognition and differential diagnosis of infectious diseases.\u003c/p\u003e \u003cp\u003eThe study revealed that from 2005 to 2024, NIDs in Shenyang were predominantly Category B (58.82%), followed by Category C (41.18%), whereas Category C diseases were more common nationwide during the same period \u003csup\u003e[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]\u003c/sup\u003e. It was also found that in Shenyang, respiratory transmission was the primary route of infection (47.41%), in contrast to the national pattern where fecal-oral transmission predominated, accounting for 47.83% of total cases \u003csup\u003e[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]\u003c/sup\u003e. These findings indicate that the epidemiological profile of NIDs in Shenyang differs from the overall national pattern, particularly in the hierarchy of transmission routes. Therefore, while adhering to the national prevention and control framework, Shenyang should implement more targeted strategies to enhance surveillance and management of locally predominant NIDs.\u003c/p\u003e \u003cp\u003eThis study found that the spectrum of NIDs in Shenyang has undergone significant shifts over time. Between 2005 and 2019, the dominant transmission routes gradually shifted from primarily blood-borne/sexual and respiratory transmission to intestinal and respiratory transmission, a trend consistent with national findings \u003csup\u003e[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]\u003c/sup\u003e. Since 2020, the distribution of transmission routes has changed anew, with a rebound in the proportion of blood-borne/sexual and respiratory diseases. After 2022, the proportion of respiratory infectious diseases increased markedly, surpassing 70% in both 2023 and 2024. This shift is closely associated with three key factors: 1) the strict COVID-19 isolation and control measures implemented in China from 2020 onward, which constrained healthcare-seeking behaviors and altered the surveillance and reporting landscape for some diseases \u003csup\u003e[\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]\u003c/sup\u003e; 2) the inclusion of influenza antigen-positive cases as confirmed diagnoses in the Diagnosis and Treatment Protocol for Influenza (2020 Edition), which enhanced influenza surveillance sensitivity \u003csup\u003e[\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]\u003c/sup\u003e; and 3) the significant rise in reported COVID-19 cases following the discontinuation of isolation measures in late 2022.\u003c/p\u003e \u003cp\u003eThis study also observed that the decline in the proportion of Category B diseases and the sharp decrease in VPDs in 2023 and 2024 may also be related to the three factors mentioned above. These findings indicate that the changing composition of NIDs reflects both the natural evolution of epidemic patterns and the substantial influence of adjustments in control policies and updates to surveillance standards \u003csup\u003e[\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe study found that from 2005 to 2024, the average annual ASIRs of Category B and Category C infectious diseases in Shenyang were similar, at 243.40/100,000 and 238.09/100,000, respectively. The combined overall average annual ASIR was 481.49/100,000, which was lower than the national average for the same period \u003csup\u003e[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]\u003c/sup\u003e. By transmission route, the average annual ASIR of respiratory infectious diseases in Shenyang was 218.14/100,000, higher than the national level. In contrast, the rates for fecal-oral transmission diseases (176.24/100,000), blood-borne/sexually transmitted diseases (83.12/100,000), as well as zoonotic and vector-borne diseases (3.96/100,000), were all lower than the corresponding national averages \u003csup\u003e[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]\u003c/sup\u003e. These findings suggest that while the overall burden of NIDs in Shenyang is relatively low nationwide, the burden of respiratory infectious diseases remains substantial and warrants focused attention.\u003c/p\u003e \u003cp\u003eIn this study, the annual ASIR of NIDs in Shenyang showed an overall increasing trend from 2005 to 2024, primarily driven by a rise in Category C diseases, consistent with national observations from the same period \u003csup\u003e[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]\u003c/sup\u003e. The increase in Category C disease incidence was largely attributable to rising rates of influenza and other infectious diarrhea, which may also explain the concurrent upward trends observed for respiratory and fecal-oral transmission diseases in Shenyang.\u003c/p\u003e \u003cp\u003eDistinct regional patterns emerged when comparing Shenyang to national data \u003csup\u003e[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]\u003c/sup\u003e. While Shenyang experienced a rising trend in the incidence of respiratory infectious diseases, no significant nationwide increase was observed. The incidence of fecal-oral transmission diseases in Shenyang showed an upward trend, consistent with the national pattern. In contrast, the incidence of blood-borne/sexually transmitted diseases exhibited a declining trend in Shenyang, whereas no clear decline was evident at the national level. The incidence of zoonotic and vector-borne diseases remained stable in Shenyang, mirroring the national trend. These comparisons suggest that Shenyang has achieved relatively significant success in controlling blood-borne/sexually transmitted diseases, yet underscores the need to strengthen prevention and control measures targeting respiratory transmission.\u003c/p\u003e \u003cp\u003eNotably, the incidence of VPDs in Shenyang exhibited a marked decrease, largely attributable to significant declines in PTB, measles, rubella, mumps, and hepatitis B. This trend demonstrates the effectiveness of the national immunization program and is consistent with previous studies conducted both in China and globally \u003csup\u003e[\u003cspan additionalcitationids=\"CR9 CR10 CR11\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan additionalcitationids=\"CR39\" citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]\u003c/sup\u003e, underscoring the considerable impact of vaccination strategies on NIDs control.\u003c/p\u003e \u003cp\u003eIn this study, the top ten NIDs reported in Shenyang between 2005 and 2024 were, in descending order: PTB, HFMD, influenza, syphilis, COVID-19, other infectious diarrhea, hepatitis B, bacillary and amebic dysentery, mumps, and scarlet fever. Collectively, these diseases accounted for 88.62% of all reported cases in the city. Trend analysis revealed declining patterns for PTB, hepatitis B, bacillary and amebic dysentery, and mumps, while no clear upward trend was observed for HFMD or scarlet fever. The increase in reported influenza cases was largely attributed to a surge following updates in surveillance criteria \u003csup\u003e[\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]\u003c/sup\u003e. The rise in other infectious diarrhea was concentrated between 2005 and 2007, and that of syphilis between 2005 and 2013; in each case, the annual ASIR plateaued thereafter. Although a substantial increase in COVID-19 cases was reported in 2023 and 2024, surveillance data from 2025 indicated a subsequent decline. Overall, the increase in the annual ASIR of NIDs in Shenyang is largely attributable to the increases observed during certain periods and modifications in surveillance criteria. Consequently, the overall epidemic situation of NIDs in the city remains within a manageable range.\u003c/p\u003e \u003cp\u003eIn spite of the above findings, the limitations in our study should be considered. First, not all NIDs cases were reported to NNDRS system, analysis based on the NIDRIS data may reflect the level of reported cases in Shenyang, but may not be fully representative of local NIDs incidence. Second, the isolation measures implemented during the COVID-19 pandemic may have disrupted routine healthcare-seeking behavior for other infectious diseases, which could interfere with the objective assessment of their epidemiological trends.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThe overall incidence of NIDs in Shenyang was lower than the national average, however, the disease burden of respiratory infections is relatively prominent and should become a key focus for future prevention and control. The observed upward trend in overall incidence is largely attributable to the increases observed during certain periods and modifications in surveillance criteria, suggesting that the epidemic situation remains manageable. It is noteworthy that the significant decline in the incidence of VPDs underscores the critical role of immunization programs, and such interventions should be consolidated and strengthened.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eAAPC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eaverage annual percent change\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eAFP\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eacute flaccid paralysis\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eAHC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eacute hemorrhagic conjunctivitis\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eAPC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eannual percent change\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eASIR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eage-standardized incidence rates\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eHB: human brucellosis\u003c/div\u003e \u003cdiv class=\"Description\"\u003e\u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eHFMD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ehand,foot and mouth disease\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eHFRS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ehemorrhagic fever with renal syndrome\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eJE\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eJapanese encephalitis\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMpox\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003emonkeypox\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eNIDs\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003enotifiable infectious diseases\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eNNDRS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003enational notifiable diseases reporting system\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eNPIs\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003enon-pharmaceutical interventions\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePTB\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003epulmonary tuberculosis\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSARS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003esevere acute respiratory syndrome\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eVPDs\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003evaccine-preventable diseases.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003ch2\u003eEthics approval and consent to participate\u003c/h2\u003e \u003cp\u003eThis study was reviewed and approved by the Ethics Committee of the Shenyang Center for Disease Control and Prevention. The informed consent was waived as all patient data were anonymized, with no personally identifiable information retained.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent for publication\u003c/strong\u003e \u003cp\u003eNot applicable.\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eCompeting Interests\u003c/h2\u003e \u003cp\u003eThe authors declare that they have no conflict of interest.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eThis work was not supported by any funding.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eHC, ZJ and BZ designed the study. HC and HW extracted, collected, and analysed the data. HC and HW drafted the manuscript. YC and LW verified the data. HC and HW reviewed the results and revised the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgments\u003c/h2\u003e \u003cp\u003eNot applicable.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe reported cases data that support the findings of this study were downloaded from China's NNDRS, a non-commercial national surveillance platform accessible only with authorization and not publicly available. The processed datasets necessary to reproduce the study\u0026rsquo;s findings are, however, available from the corresponding author upon reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eKeddy KH, Gobena T. The continuing challenge of infectious diseases[J]. 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Innovation. 2021;2(2):100113. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.xinn.2021.100113\u003c/span\u003e\u003cspan address=\"10.1016/j.xinn.2021.100113\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Notifiable infectious diseases, Incidence, Trends, Shenyang","lastPublishedDoi":"10.21203/rs.3.rs-8552297/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8552297/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eInfectious diseases remain a major global public health challenge. Evolving epidemiological patterns and considerable regional variation underscore the need for localized, real-time surveillance and assessment. This study examines the incidence and trends of notifiable infectious diseases (NIDs) in Shenyang from 2005 to 2024 to generate an evidence base for regional and national public health strategy formulation.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThe data of NIDs in Shenyang from January 1, 2005 to December 31, 2024 were obtained from the National Notifiable Diseases Reporting System (NNDRS). Joinpoint regression analysis was used to determine the changing trend of annual incidence.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eBetween 2005 and 2024, Shenyang reported 668,476 cases of 33 notifiable infectious diseases, all classified as Class B (58.8%) or C (41.2%). Respiratory infections were the most common (47.4%), followed by fecal-oral (29.8%) and blood-borne/sexual transmission (21.7%). The overall annual age-standardized incidence rate (ASIR) averaged 481.49 per 100,000 population, increasing significantly from 360.72 to 880.18 per 100,000 over the 20-year period (AAPC: 6.20%; 95%CI: 2.11%,10.04%), representing a 144% overall rise. Males exhibited a higher average annual ASIR (565.30 per 100,000) compared to females (393.35 per 100,000). A pronounced upward trend was observed in Class C diseases (AAPC: 12.75%; 95%CI: 7.47%,18.19%), whereas Class B diseases remained stable. Respiratory-transmitted diseases showed the strongest growth (AAPC: 12.75%; 95%CI: 7.47%,18.19%), followed by those transmitted via the fecal-oral route (AAPC: 4.79%; 95%CI: 0.42%,9.65%), while blood-borne/sexually transmitted diseases declined slightly (AAPC: -2.52%; 95%CI: -4.11%,-0.30%). Vaccine-preventable diseases (VPDs) declined markedly (AAPC: -6.98%; 95%CI: -8.62%,-5.30%), in contrast to a substantial increase in non-VPDs (AAPC: 13.66%; 95%CI: 10.04%,17.68%).\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThe overall incidence of NIDs in Shenyang was lower than the national average, however, the respiratory infections pose a relatively high disease burden and warrant focused control. It is noteworthy that the incidence of VPDs has declined significantly over the past two decades, demonstrating the marked success of immunization strategies.\u003c/p\u003e","manuscriptTitle":"Incidence and trends for notifiable infectious diseases in Shenyang, China, 2005-2024","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-21 06:38:45","doi":"10.21203/rs.3.rs-8552297/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-03-23T06:49:05+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-10T07:19:33+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"255260970305403683159556120524274001831","date":"2026-03-10T06:37:25+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-29T23:33:58+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"202844941244723077732499172558276690805","date":"2026-01-23T08:12:38+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"31318317129833525623664419080224208672","date":"2026-01-19T04:20:16+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-01-19T00:34:41+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-01-13T05:12:47+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-01-13T05:08:25+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-01-13T01:27:17+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2026-01-13T01:21:45+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"8ada4f6f-d122-4b76-bd53-7e6e166f22c2","owner":[],"postedDate":"January 21st, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-27T14:53:59+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-21 06:38:45","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8552297","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8552297","identity":"rs-8552297","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}