title: Spatial, temporal and spatio-temporal clusters of measles incidence at the county level in Guangxi, China during 2004-2014: flexibly shaped scan statistics.
abstract: Outbreaks of measles re-emerged in Guangxi province during 2013-2014, where measles again became a major public health concern. A better understanding of the patterns of measles cases would help in identifying high-risk areas and periods for optimizing preventive strategies, yet these patterns remain largely unknown. Thus, this study aimed to determine the patterns of measles clusters in space, time and space-time at the county level over the period 2004-2014 in Guangxi.
  
  
  
  Annual data on measles cases and population sizes for each county were obtained from Guangxi CDC and Guangxi Bureau of Statistics, respectively. Epidemic curves and Kulldorff's temporal scan statistics were used to identify seasonal peaks and high-risk periods. Tango's flexible scan statistics were implemented to determine irregular spatial clusters. Spatio-temporal clusters in elliptical cylinder shapes were detected by Kulldorff's scan statistics. Population attributable risk percent (PAR%) of children aged ≤24 months was used to identify regions with a heavy burden of measles.
  
  
  
  Seasonal peaks occurred between April and June, and a temporal measles cluster was detected in 2014. Spatial clusters were identified in West, Southwest and North Central Guangxi. Three phases of spatio-temporal clusters with high relative risk were detected: Central Guangxi during 2004-2005, Midwest Guangxi in 2007, and West and Southwest Guangxi during 2013-2014. Regions with high PAR% were mainly clustered in West, Southwest, North and Central Guangxi.
  
  
  
  A temporal uptrend of measles incidence existed in Guangxi between 2010 and 2014, while downtrend during 2004-2009. The hotspots shifted from Central to West and Southwest Guangxi, regions overburdened with measles. Thus, intensifying surveillance of timeliness and completeness of routine vaccination and implementing supplementary immunization activities for measles should prioritized in these regions.
authors.affiliation: Department of Epidemiology and Biostatistics, School of Public Health, Guangxi Medical University, Guangxi Zhuang Autonomous Region, China. tangxianyan0746@163.com.|Epidemiology Unit, Faculty of Medicine, Prince of Songkla University, Hat Yai, Thailand. tangxianyan0746@163.com.
authors.forename: Xianyan
authors.initials: X
authors.lastname: Tang
authors.affiliation: Epidemiology Unit, Faculty of Medicine, Prince of Songkla University, Hat Yai, Thailand.
authors.forename: Alan
authors.initials: A
authors.lastname: Geater
authors.affiliation: Epidemiology Unit, Faculty of Medicine, Prince of Songkla University, Hat Yai, Thailand.
authors.forename: Edward
authors.initials: E
authors.lastname: McNeil
authors.affiliation: Guangxi Center for Disease Control and Prevention, Institute of Vaccination, Guangxi Zhuang Autonomous Region, China.
authors.forename: Qiuyun
authors.initials: Q
authors.lastname: Deng
authors.affiliation: Guangxi Center for Disease Control and Prevention, Institute of Vaccination, Guangxi Zhuang Autonomous Region, China.
authors.forename: Aihu
authors.initials: A
authors.lastname: Dong
authors.affiliation: Guangxi Center for Disease Control and Prevention, Institute of Vaccination, Guangxi Zhuang Autonomous Region, China. gxzhongge@163.com.
authors.forename: Ge
authors.initials: G
authors.lastname: Zhong
mesh_terms: D002648:Child; D002681:China / Q000453:epidemiology; D016000:Cluster Analysis; D004196:Disease Outbreaks; D058872:Epidemics; D006801:Humans; D015994:Incidence; D007223:Infant; D008457:Measles / Q000453:epidemiology*; D008458:Measles Vaccine / Q000008:administration & dosage; D011156:Population Density; D018570:Risk Assessment; D062211:Spatio-Temporal Analysis
chemical_list: D008458:Measles Vaccine
keywords: Irregular cluster; Measles; Scan statistics; Spatial; Spatio-temporal; Temporal