Abstract
Severe outbreaks of hand, foot and mouth disease (HFMD) have occurred in China for decades. Our understanding of the HFMD transmission process and its determinants is still limited. In this paper, factors that affect the local variation of HFMD transmission process were studied. Three classes of factors, including meteorological, demographic and public health intervention factors, were carefully selected and their effects on HFMD transmission were investigated with Pearson's correlation coefficient and multiple linear regression models. The determining factors for the variation of HFMD transmission were different for the southeastern and the northwestern regions of China. In the northwest, fadeouts occurred yearly, and the average age at infection and the fadeout were negatively correlated with the population density. In the southeast, HFMD transmission was governed by the combined effects of the birth rate, the relative humidity and the interaction of the Health System Performance and the log of the population density. When the Health System Performance was low, HFMD transmission increased with the population density, but when the Health System Performance was high, the better health performance counteracted the transmission increase due to the higher population density.