The climate and terrain in Hu is suitable for the survival and reproduction of the rat and mouse, which are important host and transmission media of HFRS. Most farmlands and rural dwellings of Hu County are located in this plain, as is the A. agrarius mice and R. norvegicus Wnt pathway rats. Therefore, farm-working and other outdoor activities may increase people’s exposure to infected rodents and their excrements and increase the risk for HFRS infection in this area. During 1994 to 2003, an HTNV-inactive vaccine was given to people between 16 and 60 years of age in Hu County as a series of four doses at 0 days, 7 days, 28 days and 12 months. After 1994,

an inactive bivalent vaccine that consisted of HTNV and SEOV was provided as a series of three doses at 0 days, 14 days and 6 months. Both regimens were carried out according to the instructions of the commercial vaccine. The vaccine was provided to people aged 16–60 because the number of these people accounted for more than 80% of the total cases in China [21] and [22], and because the Pharmacopeia of People’s Republic of China (2005) [23] specified that the vaccines

could only be used in persons between 16 and 60 years of age. This vaccination program may decrease Microbiology inhibitor the proportion of HFRS cases among the targeted population and increase that in the non-vaccinated population. HFRS is a class B notifiable communicable disease in China and Hu County is one of the monitor sentinels for HFRS in China [24]. The annual records of HFRS cases and deaths in Hu during 1971–2011 and vaccination compliance during 1994–2011 were obtained from the Hu Center for Disease Control and Prevention (CDC). The

HFRS cases were diagnosed using the national standard clinical criteria before 1982 [1]. After 1982, the HFRS cases were first diagnosed in the medical and health units of the county and then were laboratory-confirmed at the Hu CDC. Only a few sudden death cases were not laboratory confirmed. Both the annual population of all ages and those 16–60 years of age in Hu during 1971–2011 were collected from the Hu Bureau of Statistics in Hu. Population data was estimated using the annual records of household registration isothipendyl maintained by the local police departments. The vaccination compliance (VC) was calculated as follows: VC=nNwhere n is the number of people that received the HFRS vaccination and N is the number of people between 16 and 60 years of age. The annual mortality and HFRS incidence rates between 1971 and 2011 as well as the annual HFRS vaccination compliance between 1994 and 2011 in Hu were calculated and plotted to show their annual fluctuations. The Cochran–Armitage trend test was employed to examine the temporal trends in the annual HFRS incidence, mortality rate and annual vaccination compliance. The index Z > 0 denoted an increasing trend, while Z < 0 denoted a declining trend.