key: cord-0937899-yqfjtt1c
authors: Dong, Shuaibing; Ren, Xiang; Zhang, Cuihong; Geng, Mengjie; Zhu, Yuliang; Shi, Lusha; Zhang, Lijie; Li, Zhongjie; Wang, Liping
title: Morbidity Analysis of the Notifiable Infectious Diseases in China, 2018
date: 2019-12-03
journal: China CDC Wkly
DOI: nan
sha: 5048bcaffcd44a938dd3ce117fdd72fef9d82c7c
doc_id: 937899
cord_uid: yqfjtt1c

What is already known about this topic? Annual morbidity analysis reports that summarized trends and changing epidemiology for notifiable diseases were published in 2013 and 2015 (1,2). What is added by this report? In 2018, the morbidity of national notifiable diseases was 559.41 per 100,000 population, an increase of 12.88% compared with the average rate between 2015–2017. The five notifiable diseases with the highest reported morbidity were hand, foot, and mouth disease (HFMD), infectious diarrhea, hepatitis B, tuberculosis, and influenza. The five regions with the highest reported morbidity of infectious diseases were Zhejiang Province, Guangxi Autonomous Region, Guangdong Province, Beijing Municipality, and Xinjiang Autonomous Region. What are the implications for public health practice? Evidence on notifiable disease morbidity trends and changing epidemiology should help disease control and prevention agencies and medical institutions direct their response and prevention efforts. In addition, this report demonstrates the continued need for surveillance systems and high-quality data to identify focal points for disease control.

The National Notifiable Disease Reporting System (NNDRS) in China was established in the 1950s, and since 2004, compulsory guidelines mandate that medical and health institutions at all levels must report infectious diseases to the NNDRS in real time (3) . The NNDRS is the most important infectious disease surveillance system in China and has played an important role in infectious disease prevention and control. Timely analysis of outbreak surveillance data and understanding the relevant trends and characteristics are the foundation for the prevention and control of infectious diseases (4) . Therefore, a descriptive analysis of notifiable diseases in 2018 based on data from NNDRS is invaluable to Chinese public health efforts.

Data on clinical and laboratory diagnoses between January 1 and December 31 in 2018 were collected from NNDRS. Data from certain regions of China (Taiwan, Hong Kong, and Macau) and cases of foreign travelers are not included in the analysis. A total of 39 notifiable diseases (shown in Supplementary Table S1, available in http://weekly.chinacdc.cn/) are required to be reported under the regulations and management of the Law of the People's Republic of China on the Prevention and Treatment of Infectious Diseases (5), These diseases are divided into three categories: Class A, B, and C. Descriptive analysis was conducted by Microsoft Excel 2010, and ArcGIS 10.2 was used for geo-analysis.

Overall, 7,770,749 notifiable diseases cases were reported through the NNDRS, and the morbidity of notifiable diseases was 559.41 cases per 100,000 population, with an increase of 12.88% compared with the average of the recent three years. There were no cases of plague, severe acute respiratory syndrome associated coronavirus disease (SARS), poliomyelitis, avian influenza (H5N1), diphtheria, and filariasis reported in China in 2018. The morbidity of Class A and B notifiable diseases was 220.51 cases per 100,000 population, which was relatively stable in the recent years with only 0.03% higher than that of the recent three years. However, the morbidity of Class C was 338.90 cases per 100,000 population, with a remarkable increase of 23.18% compared with the recent three-year average. The top five notifiable diseases with the highest reported morbidity were HFMD, infectious diarrhea, hepatitis B, tuberculosis, and influenza, accounting for 80.10% of the total morbidity and HFMD alone accounting for 30.28%. Compared to the average of 2015-2017, the diseases with the highest increase in reported morbidity were pertussis, influenza, and Japanese encephalitis, while the diseases with the highest decline in morbidity were human infection with H7N9, schistosomiasis, and measles (Table 1) . In 2018, 73.78% of all national notifiable disease cases were attributable to viral diseases. The morbidity of viral infectious diseases was 344.63 cases per 100,000 population with an increase of 17.50% compared with the average of 2015-2017. Bacterial pathogens were responsible for 26.10% of all national notifiable disease cases. The morbidity of bacterial diseases was 121.89 cases per 100,000 population, which was nearly same as that of the recent three years. Parasitosis represented 0.12% of the total cases, and the corresponding morbidity was 0.58 cases per 100,000 population, which was a decrease of 39.21% compared with average of 2015-2017. The reported morbidity of schistosomiasis and visceral leishmaniasis has significantly decreased.

The morbidity analysis by the main route of transmission and the reservoir of the organism showed that diseases transmitted by direct contact/fecal-oral transmission are the largest proportion 49.37% of the total cases, and the related morbidity was 276.16 cases per 100,000 population, which was an increase of 11.41% compared with the average of 2015-2017. The major contributors were HFMD and infectious diarrhea.

Respiratory transmitted diseases contributed 25.18% of total cases, and the morbidity of respiratory transmitted diseases was 140.86 cases per 100,000 population, which was an increase of 31.13% compared with 3-year average. The largest contributors in this category were tuberculosis and influenza.

Blood-borne/sexually transmitted diseases accounted for 24.60% of the totals, and the morbidity was 137.64 cases per 100,000 population, which was an increase of 5.38% compared with the 3-year average. Hepatitis B and syphilis were the major contributors.

The smallest contributor for total cases was zoonotic and vector-borne diseases, which accounted for 0.85%, and the morbidity was 4.74 cases per 100,000 population, which was a decrease of 24.48% compared with the 3-year average. These diseases include brucellosis and epidemic hemorrhagic fever (Table 1, Figure 1 ).

Zhejiang Province, Guangxi Autonomous Region, Guangdong Province, Beijing Municipality, and Xinjiang Autonomous Region are the five regions with the highest reported morbidity of infectious diseases, and the morbidities were 986.47, 981.61, 932.64, 840.72, and 813.49 cases per 100,000 population, respectively. For the top four regions, the leading diseases were mainly HFMD, infectious diarrhea, influenza, all of which belong to Class C. However, hepatitis B, syphilis, and infectious diarrhea were the three leading diseases in Xinjiang Autonomous Region of western China. Combining the regional distribution of infectious diseases with different transmission routes, Guangxi Autonomous Region and Zhejiang Province had higher morbidity of direct contact/fecaloral transmitted diseases than other regions in China including HFMD and infectious diarrhea diseases. Beijing Municipality, Xinjiang Autonomous Region, and Tibet Autonomous Region reported more morbidity of respiratory infectious diseases like tuberculosis and influenza than other provinces. The morbidity of zoonotic infectious diseases was higher in Figure 2 ). In 2018, 36.22% of national notifiable disease cases were laboratory diagnosed, 4.03% lower than the average rate between 2015-2017. The proportion of bacterial pathogens with laboratory confirmation was 57.26%, an increase of 8.14% compared to the 3-year average. However, the proportion of viral disease cases with laboratory confirmation was 32.15%, a decrease of 8.56% compared with the average of 2015-2017. The proportion of parasitic cases with laboratory confirmation was 54.17%, an increase of 110.78% compared with the average of 2015-2017. All cases of cholera, H7N9, gonorrhea, and syphilis were laboratory confirmed, but the proportions of scarlet fever, neonatal tetanus, mumps, and acute hemorrhagic conjunctivitis with laboratory confirmation were less than 5% (Table 1 ).

The national morbidity of notifiable infectious diseases showed an increase in 2018 compared with the average of 2015-2017, and all the morbidities of direct contact/fecal-oral transmitted diseases, respiratory transmitted diseases, and blood-borne/sexually transmitted diseases increased, which can be attributed primarily to the higher morbidity of category C diseases, such as HFMD, infectious diarrhea, and influenza. There was 2,353,310 HFMD cases reported in 2018, an increase over 230,000 cases compared with the average of 2015-2017, and this was the largest contributor of direct contact/fecal-oral transmission cases. The HFMD morbidity is higher in eastern and southern provinces of China, and children less than three years old should be the primary targets for interventions (6) .

There Tuberculosis morbidity was reported as 59.27 cases per 100,000 population and contributes the most to the burden of respiratory transmitted diseases. The World Health Organization (WHO) reported over 10 million new tuberculosis cases globally in 2018, and China was one of 20 countries with the highest tuberculosis burden (7) .

Hepatitis B morbidity was reported as 71.99 cases per 100,000 population, an increase of 2.87% compared with the average of the recent three years, which accounted for the largest proportion of blood/sexually transmitted diseases. The most costeffective way to control hepatitis B is to prevent a susceptible person from acquiring Hepatitis B virus infection by the interruption of the transmission route and by immunization of susceptible hosts (8) .

Zoonotic and vector-borne disease morbidity decreased slightly. Brucellosis morbidity was reported China has the ability to achieve the WHO global goal of eliminating rabies transmission from dog to human by 2030 (9) .

Dengue fever morbidity increased by 28.86% in 2018, compared with the average of 2015-2017. In recent years, dengue outbreaks occurred frequently in coastal areas, such as Zhejiang Province and Guangdong Province, and most dengue cases in China were imported (10) .

Overall, the laboratory diagnosis rate of notifiable disease decreased 4.03% compared with the average of 2015-2017. The laboratory diagnosis rate of class C infectious diseases is still lower than that of class A and B infectious diseases. Parasitic infectious diseases had a significantly higher laboratory diagnostic rate in 2018 compared with the average of 2015-2017. However, there is still a big gap in terms of laboratory evidence of pathogen diagnosis between China and western countries (11) . Even though China has uniform diagnostic standards and reporting requirements for infectious diseases, unbalanced develpoment of laboratory diagnostic facilities and economic status within the country may limit the laboratory confirmation rates, which is reflected in the laboratory diagnosis rate of notifiable disease cases varies across the country. Thus, further strengthening the construction of infectious disease laboratory systems in China and the laboratory testing capabilities are major priorities.

Conflict of interest statement: The authors who have taken part in this study declared that they do not have any other potential conflicts of interest.

Financial support statement: This study was funded by grants from the National Science and Technology 

Analysis of morbidity and mortality characteristics of the notifiable diseases reported in 2013 in China

Morbidity and mortality of notifiable infectious diseases in 2015 in China

Quality analysis on the reports of notifiable diseases in 2004

Surveillance as an effective approach to infectious diseases control and prevention

The People's Republic of China National Health and Family Planning Commission. Notice of The People's Republic of China National Health and Family Planning Commission on adjusting the part of notifiable infectious diseases management

Trend of epidemics and variation of pathogens of hand, foot and mouth disease in China: a dynamic series analysis

NOhep: Toward Global Control of Hepatitis B Virus Infection-An Introduction

S749

World Health Organization, Zero by 30: the global strategic plan to end human deaths from dog-mediated rabies by 2030

The use of air travel data for predicting dengue importation to China: A modelling study

Speed up the development of laboratory diagnosis

A: plague, cholera Class B: SARS, AIDS, viral Hepatitis, Poliomyelitis, Human infection with H5N1 virus, Measles, Epidemic hemorrhagic fever, Rabies, Epidemic encephalitis B, Dengue fever, Anthrax, Dysentery, Tuberculosis, Typhoid fever, Pertussis, Diphtheria, Neonatal tetanus, Scarlet fever, Brucellosis, Gonorrhea, Syphilis, Leptospirosis, Schistosomiasis, Malaria, Human infection with H7N9 virus.7N9 virus, Meningococcal meningitis. Class C: Influenza, Mumps, Rubella, Acute hemorrhagic conjunctivitis, Lepriasis, Epidemic typhus, Kala-azar, Echinococcosis, Filariasis, Infectious diarrhea, HFMD Transmission routes Direct contact/fecal-oral transmitted diseases (cholera, Hepatitis A, Hepatitis E, Other hepatitis, poliomyelitis, Bacillary and Amebic dysentery, Typhoid and paratyphoid, Acute hemorrhagic con-junctivitis, Infectious diarrhea, HFMD)

Epidemic hemorrhagic fever, Rabies, Epidemic encephalitis B, Dengue fever, Anthrax, Brucellosis, Leptospirosis, Schistosomiasis, Malaria, Human infection with H7N9 virus, Epidemic and endemic typhus, Kala-azar, Echinococcosis, Filariasis, Anthrax); Blood and sexual transmitted type (AIDS, Hepatitis B, Hepatitis C, Gonorrhea, Syphilis); other infectious diseases (neonatal tetanus) Pathogens Bacterial diseases (Plague, Cholera, Anthrax, Bacterial dysentery, Tuberculosis, Typhoid fever and paratyphoid fever, Meningococcal meningitis, Pertussis, Diphtheria, Neonatal tetanus

Human infection with H5N1 virus, Measles, Mumps, Epidemic hemorrhagic fever, Rabies, Epidemic encephalitis B, Dengue fever, Human infections with H7N9 virus, influenza, Rubella, Acute hemorrhagic conjunctivitis, HFMD)