Infectious diseases in children and adolescents in China: analysis of national surveillance data from 2008 to 2017

Abstract

Objectives: To outline which infectious diseases in the pre-covid-19 era persist in children and adolescents in China and to describe recent trends and variations by age, sex, season, and province.

Design: National surveillance studies, 2008-17.

Setting: 31 provinces in mainland China.

Participants: 4 959 790 Chinese students aged 6 to 22 years with a diagnosis of any of 44 notifiable infectious diseases. The diseases were categorised into seven groups: quarantinable; vaccine preventable; gastrointestinal and enteroviral; vectorborne; zoonotic; bacterial; and sexually transmitted and bloodborne.

Main outcome measures: Diagnosis of, and deaths from, 44 notifiable infectious diseases.

Results: From 2008 to 2017, 44 notifiable infectious diseases were diagnosed in 4 959 790 participants (3 045 905 males, 1 913 885 females) and there were 2532 deaths (1663 males, 869 females). The leading causes of death among infectious diseases shifted from rabies and tuberculosis to HIV/AIDS, particularly in males. Mortality from infectious diseases decreased steadily from 0.21 per 100 000 population in 2008 to 0.07 per 100 000 in 2017. Quarantinable conditions with high mortality have effectively disappeared. The incidence of notifiable infectious diseases in children and adolescents decreased from 280 per 100 000 in 2008 to 162 per 100 000 in 2015, but rose again to 242 per 100 000 in 2017, largely related to mumps and seasonal influenza. Excluding mumps and influenza, the incidence of vaccine preventable diseases fell from 96 per 100 000 in 2008 to 7 per 100 000 in 2017. The incidence of gastrointestinal and enterovirus diseases remained constant, but typhoid, paratyphoid, and dysentery continued to decline. Vectorborne diseases all declined, with a particularly noticeable reduction in malaria. Zoonotic infections remained at low incidence, but there were still unpredictable outbreaks, such as pandemic A/H1N1 2009 influenza. Tuberculosis remained the most common bacterial infection, although cases of scarlet fever doubled between 2008 and 2017. Sexually transmitted diseases and bloodborne infections increased significantly, particularly from 2011 to 2017, among which HIV/AIDS increased fivefold, particularly in males. Difference was noticeable between regions, with children and adolescents in western China continuing to carry a disproportionate burden from infectious diseases.

Conclusions: China's success in infectious disease control in the pre-covid-19 era was notable, with deaths due to infectious diseases in children and adolescents aged 6-22 years becoming rare. Many challenges remain around reducing regional inequalities, scaling-up of vaccination, prevention of further escalation of HIV/AIDS, renewed efforts for persisting diseases, and undertaking early and effective response to highly transmissible seasonal and unpredictable diseases such as that caused by the novel SARS-CoV-2 virus.

Fig 1

Trends in incidence of and mortality from 44 notifiable infectious diseases and joinpoints, 2008-17. *Statistically significant trends. APC=annual percentage change

Fig 2

Trends in incidence and proportions of 44 notifiable infectious diseases by categories, 2008-17. Top panels are based on seven categories of infectious diseases. Bottom panels are based on all 44 current notifiable infectious diseases. TB=tuberculosis; ID=infectious diarrhoea diseases; HFMD=hand, foot, and mouth disease; SI=seasonal influenza; SF=scarlet fever; AHC=acute haemorrhagic conjunctivitis; T/P=typhoid and paratyphoid; JE=Japanese encephalitis; HF=haemorrhagic fever; MM=meningococcal meningitis; HD=hydatid diseases; H5N=avian influenza H5N1; H7N9=avian influenza H7N9; H1N1=influenza A H1N1; SARS=severe acute respiratory syndrome

Fig 3

10 year trends in (a) incidence, (b) number of cases, and (c) number of deaths for 44 notifiable infectious diseases, arranged by seven categories, by year from 2008 to 2017. Each concentric circle represents one year starting from 2008 in the centre to 2017, and each vertical row represents one infectious disease. Different colours represent the extent of incidence, number of cases, and number of deaths. Pale blue boxes represent zero for each infectious disease

Fig 4

Ranking of incidence of each of the 44 notifiable infectious diseases by year, from 2008 to 2017. Annual percentage change (APC) in incidence of each infectious disease is listed with 95% confidence intervals. In the APC column, arrows pointing upwards (red) represent overall increased trends, arrows pointing downwards (green) represent decreased trends, whereas arrows pointing to the right (purple) represent stable trends for incidence of each infectious disease from 2008 to 2017

Fig 5

Infectious diseases with greatest incidence and mortality by age, 2008-17

Fig 6

Subnational distribution of 44 notifiable infectious diseases in 2017, according to seven categories but excluding quarantinable diseases. The keys vary owing to large difference in incidence of 44 notifiable infectious diseases by category. Quarantinable diseases are not presented because haemorrhagic fever dominated all the provinces without regional variations. Lines indicate the leading infectious disease in each province