Pertussis remains a global threat for infants, and recent increases in notifications have renewed interest in optimising vaccination strategies and improving vaccines. At the biological level, the rationale for maternal pertussis immunization extends beyond passive antibody transfer alone and may also involve broader maternal-infant immune interactions; however, at the population level these mechanisms are operationalized through policy adoption, timing recommendations, and coverage. We compared incidence constructs from WHO routine notifications and Global Burden of Disease (GBD) modelled estimates and assessed how associations with vaccination policy indicators change across outcome definitions. Trends were characterised with Joinpoint regression; policy associations were estimated using Bayesian hierarchical models fitted separately to each dataset with Universal Health Coverage stratified random intercepts. Incidence levels and trends differed markedly between WHO and GBD. Unadjusted analyses showed heterogeneous, sometimes opposing, associations for maternal immunization and schedule timing. After adjustment, most schedule parameters were small and imprecise, whereas DTP3 coverage remained strongly inversely associated with incidence in GBD but not in WHO. Surveillance and modelled estimates should not be interpreted interchangeably; harmonized constructs and routine implementation and ascertainment metadata are needed for robust cross-country inference.

Background The largest documented chikungunya fever (CF) outbreak in China occurred in Foshan, yet evidence on outbreak-wide epidemiological characteristics and intervention-associated effects has remained limited. Methods We conducted a longitudinal analysis from 16 June to 10 August 2025, integrating case and vector epidemiology, and generalised estimating equation (GEE) models. Results A total of 8,964 cases were reported, with no deaths. Females had a higher incidence than males (1,027.12 vs 919.71 per 100,000), and males had lower infection odds (OR 0.89, 95% CI = 0.86–0.93). Adults older than 60 years showed the highest incidence (2371.62 vs. <1402.00 per 100,000) and infection risk (OR < 1 in other age groups). Cases were concentrated in Shunde District (82.42%). The onset-to-diagnosis interval shortened after interventions. 2.60% were asymptomatic; fever, rash and arthralgia were the predominant symptoms. The effective reproduction number (\(\:{R}_{t}\)) rose rapidly (3.12, 95% CI = 0.08–11.51) and declined below 1 by 1 August (0.87, 95% CI = 0.80–0.94). Breteau index (BI) and adult mosquito density Index (ADI) were decreased and high in the border areas between districts. For non-lagged GEE, one-unit changes in ADI and BI were associated with 9.28% (95% CI= -13.40–37.92; P = 0.45) and 0.60% (95% CI =-1.48–2.73; p = 0.57) changes in case numbers. One-unit changes in ADI were associated with a 10.73% change in \(\:{R}_{t}\) (95% CI = 3.23–18.78; p = 0.004), and 7.50% in BI (95% CI =-5.15–21.84; p = 0.26). For lagged GEE, lagged ADI remained associated with \(\:{R}_{t}\) (8.74%, 95% CI = 1.14–16.91; p = 0.023), while lagged tOD showed no significant association with case numbers (2.68%, 95% =CI -8.21 to 14.86; p = 0.64) and \(\:{R}_{t}\) (2.17%, 95% CI= -1.70 to 6.20; p = 0.28). Conclusions This outbreak showed high transmissibility, concentration in Shunde, and elevated risk in females and older adults. The key area for vector control was the border of different districts. Prioritising routine and targeted adult-mosquito surveillance and control, while maintaining larval source management and accelerating case detection, not only for this outbreak but also for other non-endemic urban settings facing comparable arboviral threats.

Introduction The prevalence of carbapenem-resistant Enterobacteriaceae (CRE) infections is increasing worldwide. However, the evidence regarding the treatment of infections caused by CRE is either low or conditional.Methods and analysis This multicentre, investigator-initiated, open-label, randomised controlled, non-inferiority trial compares colistin-based combination therapy with the best available therapy for treating CRE infections. This study is being conducted at 15 centres in China. We include participants with hospital-acquired pneumonia (HAP) or bloodstream infections (BSI) caused by CRE. Participants will be randomly assigned to a colistin-based combination therapy group or the best available therapy group. The primary outcome is the 14-day all-cause mortality. Secondary outcomes include 14-day clinical cure rate, 14-day efficacy rate, intensive care unit (ICU)-free days within 28 days after randomisation, 14-day microbiological cure rate, incidence of adverse events (AEs) and serious AEs within the first 28 days, hospital mortality, 28-day all-cause mortality and ICU mortality. A target sample size of 404, with 322 evaluable patients (161 in each group) allowed for at least 80% power (one-sided significance level of 0.025), assuming a 15% non-inferiority margin and a 14-day all-cause mortality rate of 35% in both groups. Primary outcome will be assessed based on the microbiologically modified intent-to-treat, and one interim analysis is planned when 50% of the participants have been enrolled.Ethics and dissemination The study was approved by the Research Ethics Boards at Zhongda Hospital (file number: 2023ZDSYLL295-P03) and all participating centres. Informed consent will be obtained from all participants. The trial will be conducted under the oversight of an independent data and safety monitoring committee. Results will be disseminated in peer-reviewed journals.Trial registration number NCT06051513.

In this study, we compared the humoral immune characteristics of children, elderly individuals, and pregnant women in Guangzhou, China, who had been infected with the SARS-CoV-2 strains BA.5 and XBB against the currently predominant strains EG.5 and JN.1. It was discovered that the neutralizing antibody titers in children, elderly individuals, and pregnant women against strains EG.5 and JN.1 were low in individuals who had been infected with strain BA.5, irrespective of their vaccination status. There was a significant positive correlation between the neutralization titers against JN.1 and EG.5 in both the acute and convalescent phases of BA.5 infection. For XBB-infected patients, the sera in the acute stage exhibited a low neutralizing titer against EG.5 and JN.1, whereas the convalescent sera demonstrated a significantly higher neutralizing titer against the two viruses, particularly in infected individuals who had been vaccinated. For XBB-infected patients, there was a strong positive correlation between the serum neutralizing antibody titers against EG.5 and JN.1 in both the acute and recovery phases. This finding provides crucial information for judging the epidemic trend of COVID-19 and the development of vaccines, especially for developing customized vaccines and immune strategies for different populations.

Exploring the relative role of different indoor environments in respiratory infections transmission remains unclear, which is crucial for developing targeted nonpharmaceutical interventions. In this study, a total of 2,583,441 influenza-like illness cases tested from 2010 to 2017 in China were identified. An agent-based model was built and calibrated with the surveillance data, to assess the roles of 3 age groups (children <19 years, younger adults 19-60 years, older adults >60 years) and 4 types of indoor environments (home, schools, workplaces, and community areas) in influenza transmission by province with varying urbanization rates. When the urbanization rates increased from 35% to 90%, the proportion of children aged <19 years among influenza cases decreased from 76% to 45%. Additionally, we estimated that infections originating from children decreased from 95.1% (95% confidence interval (CI): 92.7, 97.5) to 59.3% (95% CI: 49.8, 68.7). Influenza transmission in schools decreased from 80.4% (95% CI: 76.5, 84.3) to 36.6% (95% CI: 20.6, 52.5), while transmission in the community increased from 2.4% (95% CI: 1.9, 2.8) to 45.4% (95% CI: 35.9, 54.8). With increasing urbanization rates, community areas and younger adults contributed more to infection transmission. These findings could help the development of targeted public health policies. This article is part of a Special Collection on Environmental Epidemiology. This article is part of a Special Collection on Environmental Epidemiology.

Respiratory infectious diseases (RID) are the major public health problems threatening the people's lives and health.Infection control (IC) is one of the effective tools to contain the occurrence and spread of RID.We collected the articles and data on IC published since January 1,2018 and summarized the achievements,problems,and challenges of IC from administrative control,management control,environment and engineering control,and personal protection in the medical institutions and public places in China.The efforts for IC vary in different regions and medical institutions of different levels.There are still links to be improved for IC from administrative control,management control,environment and engineering control,and personal protection,especially in community-level medical institutions and public areas.It is urgent to strengthen the implementation of IC policies and conduct IC precisely according to local situations.We proposed the following suggestions.First,the existing IC products and tools should be applied to precisely implement the IC measures;second,modern high technology should be employed to develop efficient and convenient IC products and tools;finally,a digital or intelligent IC platform should be built for monitoring infections,so as to contain the occurrence and spread of RID.

Abstract Background Respiratory infectious diseases (RIDs) remain a pressing public health concern, posing a significant threat to the well-being and lives of individuals. This study delves into the incidence of seven primary RIDs during the period 2017–2021, aiming to gain deeper insights into their epidemiological characteristics for the purpose of enhancing control and prevention strategies. Methods Data pertaining to seven notifiable RIDs, namely, seasonal influenza, pulmonary tuberculosis (PTB), mumps, scarlet fever, pertussis, rubella and measles, in the mainland of China between 2017 and 2021 were obtained from the National Notifiable Disease Reporting System (NNDRS). Joinpoint regression software was utilized to analyze temporal trends, while SaTScan software with a Poisson probability model was used to assess seasonal and spatial patterns. Results A total of 11,963,886 cases of the seven RIDs were reported during 2017–2021, and yielding a five-year average incidence rate of 170.73 per 100,000 individuals. Among these RIDs, seasonal influenza exhibited the highest average incidence rate (94.14 per 100,000), followed by PTB (55.52 per 100,000), mumps (15.16 per 100,000), scarlet fever (4.02 per 100,000), pertussis (1.10 per 100,000), rubella (0.59 per 100,000), and measles (0.21 per 100,000). Males experienced higher incidence rates across all seven RIDs. PTB incidence was notably elevated among farmers and individuals aged over 65, whereas the other RIDs primarily affected children and students under 15 years of age. The incidences of PTB and measles exhibited a declining trend from 2017 to 2021 (APC = −7.53%, P = 0.009; APC = −40.87%, P = 0.02), while the other five RIDs peaked in 2019. Concerning seasonal and spatial distribution, the seven RIDs displayed distinct characteristics, with variations observed for the same RIDs across different regions. The proportion of laboratory-confirmed cases fluctuated among the seven RIDs from 2017 to 2021, with measles and rubella exhibiting higher proportions and mumps and scarlet fever showing lower proportions. Conclusions The incidence of PTB and measles demonstrated a decrease in the mainland of China between 2017 and 2021, while the remaining five RIDs reached a peak in 2019. Overall, RIDs continue to pose a significant public health challenge. Urgent action is required to bolster capacity-building efforts and enhance control and prevention strategies for RIDs, taking into account regional disparities and epidemiological nuances. With the rapid advancement of high-tech solutions, the development and effective implementation of a digital/intelligent RIDs control and prevention system are imperative to facilitate precise surveillance, early warnings, and swift responses. Graphical Abstract

目的 分析2010-2016监测年度中国流感监测网络质量评估得分趋势,探讨质量评估方案在"全面提升我国流感监测网络整体工作质量,促进监测网络整体能力建设"方面的作用.方法 对中国流感监测信息系统、突发公共卫生事件管理信息系统和中国国家流感中心实验室数据库中相关信息,以及各省提交的基于评估指标的流感监测年度工作总结等资料进行统计分析,评估各监测单位流感监测工作的综合管理能力水平(监测网络管理、检测能力考核和暴发疫情监测)和每个省流感监测网络工作质量(网络实验室和国家级哨点医院)的量化评分结果.结果 2010-2016监测全国31个省、直辖市、自治区及新疆生产建设兵团得分平均分为73.55分.2015-2016年度得分均数最高,为81.04分;80分以上的省份有22个,远高于2010-2011年度的3个省份.6个监测年度中,各项得分均得到不同程度的提升.广义估计方程结果显示,随着时间增加,暴发疫情得分、省级管理得分、哨点医院得分、实验室得分与总分的变化有统计学意义(P＜0.05),即每增加一个监测年得分各增加1.6分、3.3分、1.4分、1.8分和3.4分.交互检验结果显示,南方省份和北方省份各项得分随时间的变化趋势基本一致,二者没有交互效应(P＞0.05).结论 中国流感监测网络的工作质量逐年提升,质量评估方案对于整个网络的流感监测工作质量提升有促进作用,且对于所有监测单位也是公平的.

We conducted environmental surveillance to detect avian influenza viruses circulating at live poultry markets (LPMs) and poultry farms in Guangxi Autonomous Region, China, where near the China-Vietnam border. From November through April 2017–2018 and 2018–2019, we collected environmental samples from 14 LPMs, 4 poultry farms, and 5 households with backyard poultry in two counties of Guangxi and tested for avian influenza A, H5, H7, and H9 by real-time reverse transcription-polymerase chain reaction (rRT-PCR). In addition, we conducted four cross-sectional questionnaire surveys among stall owners on biosecurity practices in LPMs of two study sites. Among 16,713 environmental specimens collected and tested, the median weekly positive rate for avian influenza A was 53.6% (range = 33.5% − 66.0%), including 25.2% for H9, 4.9% for H5, and 21.2% for other avian influenza viruses A subtypes, whereas a total of two H7 positive samples were detected. Among the 189 LPM stalls investigated, most stall owners (73.0%) sold chickens and ducks. Therefore, continued surveillance of the avian influenza virus is necessary for detecting and responding to emerging trends in avian influenza virus epidemiology.

Background The world is undergoing an unprecedented wave of urbanization. However, the effect of rapid urbanization during the early or middle stages of urbanization on seasonal influenza transmission remains unknown. Since about 70% of the world population live in low-income countries, exploring the impact of urbanization on influenza transmission in urbanized countries is significant for global infection prediction and prevention. Objective The aim of this study was to explore the effect of rapid urbanization on influenza transmission in China. Methods We performed spatiotemporal analyses of province-level influenza surveillance data collected in Mainland China from April 1, 2010, to March 31, 2017. An agent-based model based on hourly human contact–related behaviors was built to simulate the influenza transmission dynamics and to explore the potential mechanism of the impact of urbanization on influenza transmission. Results We observed persistent differences in the influenza epidemic attack rates among the provinces of Mainland China across the 7-year study period, and the attack rate in the winter waves exhibited a U-shaped relationship with the urbanization rates, with a turning point at 50%-60% urbanization across Mainland China. Rapid Chinese urbanization has led to increases in the urban population density and percentage of the workforce but decreases in household size and the percentage of student population. The net effect of increased influenza transmission in the community and workplaces but decreased transmission in households and schools yielded the observed U-shaped relationship. Conclusions Our results highlight the complicated effects of urbanization on the seasonal influenza epidemic in China. As the current urbanization rate in China is approximately 59%, further urbanization with no relevant interventions suggests a worrisome increasing future trend in the influenza epidemic attack rate.

The recent rise in the frequency of influenza A(H5N6) infections in China has raised serious concerns about whether the risk for human infection has increased. We surveyed epidemiologic, clinical, and genetic data of human infections with A(H5N6) viruses. Severe disease occurred in 93.8% of cases, and the fatality rate was 55.4%. Median patient age was 51 years. Most H5N6 hemagglutinin (HA) genes in human isolates in 2021 originated from subclade 2.3.4.4b; we estimated the time to most recent common ancestor as June 16, 2020. A total of 13 genotypes with HA genes from multiple subclades in clade 2.3.4.4 were identified in human isolates. Of note, 4 new genotypes detected in 2021 were the major causes of increased H5N6 virus infections. Mammalian-adapted mutations were found in HA and internal genes. Although we found no evidence of human-to-human transmission, continuous evolution of H5N6 viruses may increase the risk for human infections.

Understanding the role of meteorological factors in the transmission dynamics of respiratory infectious diseases remains challenging. Our study was to comprehensively investigate the nonlinear effects of environmental factors on influenza transmission, based on multi-region surveillance data from mainland China. An approach related to time-varying reproduction number (Rt) was proposed, which extracts the environment-related components from Rt to estimate the relationship between environmental factors and influenza transmission based on a mixed-effects regression model. Nonlinear relationships for absolute humidity (the lowest transmission was observed at absolute humidity of 12 g/m3) and mean temperature (the lowest transmission was observed at the mean temperature of 18 °C) with influenza transmission were observed. Influenza transmission holds almost constant with the average precipitation below 1 mm or sunshine hour below 9 h/day, but increases for the precipitation and decreases for the sunshine hour afterward. The environmental dependence varies across subtypes: A(H3N2) maintains relatively higher transmission in high temperature and humidity conditions, compared with other influenza subtypes. Overall, the subtypes specified environmental dependence of influenza transmission could explain 23.1 %, 29.2 % and 27.1 % of the variations for A(H1N1)pdm09, A(H3N2) and B-lineage in China. The projected seasonal transmission rates based on our approach could be used as a valuable seasonal proxy to model the influenza dynamics under various meteorological spaces. Finally, our approach is also applicable to obtain novel insights into the impact of environmental factors on other respiratory infectious diseases.

Objectives: The aim of this study was to explore whether indoor or outdoor relative humidity (RH) modulates the influenza epidemic transmission in temperate and subtropical climates. Methods: In this study, the daily temperature and RH in 1558 households from March 2017 to January 2019 in five cities across both temperate and subtropical regions in China were collected. City-level outdoor temperature and RH from 2013 to 2019 were collected from the weather stations. We first estimated the effective reproduction number (Rt) of influenza and then used time-series analyses to explore the relationship between indoor/outdoor RH/absolute humidity and the Rt of influenza. Furthermore, we expanded the measured 1-year indoor temperature and the RH data into 5 years and used the same method to examine the relationship between indoor/outdoor RH and the Rt of influenza. Results: Indoor RH displayed a seasonal pattern, with highs during the summer months and lows during the winter months, whereas outdoor RH fluctuated with no consistent pattern in subtropical regions. The Rt of influenza followed a U-shaped relationship with indoor RH in both temperate and subtropical regions, whereas a U-shaped relationship was not observed between outdoor RH and Rt. In addition, indoor RH may be a better indicator for Rt of influenza than indoor absolute humidity. Conclusion: The findings indicated that indoor RH may be the driver of influenza seasonality in both temperate and subtropical locations in China.

Background With the progress of globalization, international mobility increases, greatly facilitating cross-border transmission of respiratory infectious diseases (RIDs). This study aimed to analyze the epidemiological characteristics and factors influencing imported RIDs, with the goal of providing evidence to support adoption of high-tech, intelligent methods to early find imported RIDs and prevent their spread in China. Methods We obtained data of imported RIDs cases from 2014 to 2018 from the Inbound Sentinel Network of Customs and the National Notifiable Diseases Reporting System in China. We analyzed spatial, temporal, and population distribution characteristics of the imported RIDs. We developed an index to describe seasonality. Pearson correlation coefficients were used to examine associations between independent variables and imported cases. Data analyses and visualizations were conducted with R software. Results From a total of 1 409 265 253 inbound travelers, 31 732 (2.25/100 000) imported RIDs cases were reported. RIDs cases were imported from 142 countries and five continents. The incidence of imported RIDs was nearly 5 times higher in 2018 (2.81/100 000) than in 2014 (0.58/100 000). Among foreigners, incidence rates were higher among males (5.32/100 000), 0–14-year-olds (15.15/100 000), and cases originating in Oceania (11.10/100 000). The vast majority (90.3%) of imported RIDs were influenza, with seasonality consistent with annual seasonality of influenza. The spatial distribution of imported RIDs was different between Chinese citizens and foreigners. Increases in inbound travel volume and the number of influenza cases in source countries were associated with the number of imported RIDs. Conclusions Our study documented importation of RIDs into China from 142 countries. Inbound travel poses a significant risks bringing important RIDs to China. It is urgent to strengthen surveillance at customs of inbound travelers and establish an intelligent surveillance and early warning system to prevent importation of RIDs to China for preventing further spread within China. Graphical Abstract

Background: Optimizing the timing of influenza vaccination based on regional temporal seasonal influenza illness patterns may make seasonal influenza vaccination more effective in China.Methods: We obtained provincial weekly influenza surveillance data for 30 of 31 provinces in mainland China from the Chinese Center for Disease Control and Prevention for the years 2010-2018. Influenza epidemiological regions were constructed by clustering analysis. For each region, we calculated onset date, end date, and duration of seasonal influenza epidemics by the modified mean threshold method. To help identify initial vaccination target populations, we acquired weekly influenza surveillance data for four age groups (0-4, 5-18, 19-59, ≥60 years) in each region and in 171 cities of wide-ranging size. We used linear regression analyses to explore the association of epidemic onset dates by age group, city, and epidemiological region and provide evidence for initial target populations for seasonal influenza vaccination.Findings: We determined that northern, mid, southwestern, southeast regions of mainland China have distinct seasonal influenza epidemic patterns. We found significant regional, temporal, and spatial heterogeneity of seasonal influenza epidemics. There were significant differences by age group and city size in the interval between epidemic onset in the city or age group and regional spread (epidemic lead time), with longer epidemic lead times for 5-18-year-old children and larger cities.Interpretation: Knowledge of influenza epidemic characteristics may help optimize local influenza vaccination timing and identify initial target groups for seasonal influenza vaccination in mainland China. Similar analyses may help inform seasonal influenza vaccination strategies in other regions and countries.Funding Information: National Natural Science Foundation of China (Grant No: 42171419 and 91846302). Declaration of Interests: We declare no competing interests.

Background Understanding the transmission source, pattern, and mechanism of infectious diseases is essential for targeted prevention and control. Though it has been studied for many years, the detailed transmission patterns and drivers for the seasonal influenza epidemics in China remain elusive. Methods In this study, utilizing a suite of epidemiological and genetic approaches, we analyzed the updated province-level weekly influenza surveillance, sequence, climate, and demographic data between 1 April 2010 and 31 March 2018 from continental China, to characterize detailed transmission patterns and explore the potential initiating region and drivers of the seasonal influenza epidemics in China. Results An annual cycle for influenza A(H1N1)pdm09 and B and a semi-annual cycle for influenza A(H3N2) were confirmed. Overall, the seasonal influenza A(H3N2) virus caused more infection in China and dominated the summer season in the south. The summer season epidemics in southern China were likely initiated in the "Lingnan" region, which includes the three most southern provinces of Hainan, Guangxi, and Guangdong. Additionally, the regions in the south play more important seeding roles in maintaining the circulation of seasonal influenza in China. Though intense human mobility plays a role in the province-level transmission of influenza epidemics on a temporal scale, climate factors drive the spread of influenza epidemics on both the spatial and temporal scales. Conclusion The surveillance of seasonal influenza in the south, especially the "Lingnan" region in the summer, should be strengthened. More broadly, both the socioeconomic and climate factors contribute to the transmission of seasonal influenza in China. The patterns and mechanisms revealed in this study shed light on the precise forecasting, prevention, and control of seasonal influenza in China and worldwide.

Background During the coronavirus disease 2019 (COVID-19) pandemic, seasonal influenza activity declined globally and remained below previous seasonal levels, but intensified in China since 2021. Preventive measures to COVID-19 accompanied by different epidemic characteristics of influenza in different regions of the world. To better respond to influenza outbreaks under the COVID-19 pandemic, we analyzed the epidemiology, antigenic and genetic characteristics, and antiviral susceptibility of influenza viruses in the mainland of China during 2020-2021. Methods Respiratory specimens from influenza like illness cases were collected by sentinel hospitals and sent to network laboratories in Chinese National Influenza Surveillance Network. Antigenic mutation analysis of influenza virus isolates was performed by hemagglutination inhibition assay. Next-generation sequencing was used for genetic analyses. We also conducted molecular characterization and phylogenetic analysis of circulating influenza viruses. Viruses were tested for resistance to antiviral medications using phenotypic and/or sequence-based methods. Results In the mainland of China, influenza activity recovered in 2021 compared with that in 2020 and intensified during the traditional influenza winter season, but it did not exceed the peak in previous years. Almost all viruses isolated during the study period were of the B/Victoria lineage and were characterized by genetic diversity, with the subgroup 1A.3a.2 viruses currently predominated. 37.8% viruses tested were antigenically similar to reference viruses representing the components of the vaccine for the 2020-2021 and 2021-2022 Northern Hemisphere influenza seasons. In addition, China has a unique subgroup of 1A.3a.1 viruses. All viruses tested were sensitive to neuraminidase inhibitors and endonuclease inhibitors, except two B/Victoria lineage viruses identified to have reduced sensitivity to neuraminidase inhibitors. Conclusions Influenza activity increased in the mainland of China in 2021, and caused flu season in the winter of 2021-2022. Although the diversity of influenza (sub)type decreases, B/Victoria lineage viruses show increased genetic and antigenic diversity. The world needs to be fully prepared for the co-epidemic of influenza and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus globally.

Background: The estimation of influenza-associated excess mortality in developing countries can help improve the estimate of global mortality burden attributable to influenza virus infections. The present study estimates the influenza-associated excess respiratory mortality in mainland China for the 2010/11 through 2014/15 seasons. Methods: We collected the provincial weekly influenza surveillance data and population mortality data from the Chinese Center for Disease Control and Prevention for the analysis. The influenza-associated in the country were estimated using the linear regression models. Extrapolation of EMRs was performed using random-effect meta-regression models for provinces without valid data for a direct estimation of EMR. Findings: It was estimated that an annual average of 88,100 (95% confidence interval (CI): 84,200, 92,000) influenza-associated excess respiratory deaths occurred in China in the five years studied, corresponding to 8·2% (95% CI: 7·9%, 8·6%) of respiratory deaths. The mean EMRs per season for influenza A(H1N1)pdm09, A(H3N2), and B viruses were 1·6 (95% CI: 1·5, 1·7), 2·6 (95% CI: 2·4, 2·8), and 2·3 (95% CI: 2·1, 2·5) per 100,000 person-seasons, respectively. The estimated EMR was 1·5 (95% CI: 1.1, 1·9) for people <60 years of age, which was substantially smaller than the rate of 38·5 (95% CI: 36·8, 40·2) per 100,000 person-seasons for those ≥60 years of age. Approximately 80% of influenza-associated excess respiratory deaths occurred in people aged ≥60 years of age. estimates of which varied across whereas comparable to what has been previously Continuous and high-quality surveillance data across the whole country are needed to improve the estimation of the disease burden attributable to influenza in China.