# Epidemiological Characteristics and Trends of Scarlet Fever in Zhejiang Province of China: Population-Based Surveillance during 2004–2022

## TL;DR

This study examines how scarlet fever incidence in Zhejiang, China, changed during and after the COVID-19 pandemic, showing a significant drop in 2020 followed by a rebound.

## Contribution

The study provides new insights into how nonpharmaceutical interventions during the pandemic impacted scarlet fever trends and seasonal patterns.

## Key findings

- Scarlet fever incidence dropped sharply in 2020 in Zhejiang, especially among children under 5 years old.
- The seasonal pattern of scarlet fever shifted during the pandemic, with a peak in January 2020 instead of the usual April–June and November–January pattern.
- Relaxation of pandemic restrictions led to a rebound in scarlet fever cases in 2021 and 2022.

## Abstract

Over the past two decades, scarlet fever has resurged in some countries or areas. Nationwide nonpharmaceutical interventions changed the patterns of other infectious diseases, but its effects on the spread of scarlet fever were rarely studied. This study aimed to evaluate the changes in scarlet fever incidence in Zhejiang Province, China, before and during the COVID-19 pandemic periods and to provide references for scarlet fever prevention and control.

Scarlet fever surveillance data in Zhejiang, China (2004–2022), were analyzed in three stages. Two-sample z test, ANOVA, and Tukey's test were used to compare and analyze the characteristics of disease spread at different stages. The ARIMA model was used to predict the overall trend. The data were obtained from the National Infectious Disease Reporting Information System.

A total of 28,652 cases of scarlet fever were reported across Zhejiang Province during the study period, with the lowest average monthly incidences in 2020 (0.111/100,000). The predominant areas affected were the northern and central regions of Zhejiang, and all regions of Zhejiang experienced a decrease in incidence in 2020. The steepest decline in incidence in 2020 was found in children aged 0–4 years (67.3% decrease from 23.8/100,000 to 7.8/100,000). The seasonal pattern changed, with peak occurrences in April to June and November to January during 2004–2019 and 2021 and a peak in January in 2020. The median duration from diagnosis to confirmation was highest before COVID-19 (4 days); however, it decreased to 1 day in 2020–2022, matching the other two medians.

In 2020, Zhejiang experienced an unprecedented decrease in scarlet fever, with the lowest incidence in nearly 18 years, but it rebounded in 2021 and 2022. The seasonal epidemiologic characteristics of scarlet fever also changed with the COVID-19 outbreaks. This suggested that nationwide nonpharmaceutical interventions greatly depressed the spread of scarlet fever. With the relaxation of non-pharmaceutical intervention restrictions, scarlet fever may reappear. Government policymakers should prioritize the control of future scarlet fever outbreaks for public health.