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.