Trend Analysis of Major Sexually Transmitted

Infections in China , 1999-2018

Research article

Keywords: sexually transmitted infections, JoinPoint regression, Annual percentage change (APC),
Average annual percentage Change (AAPC), hierarchical clustering analysis

DOI: https://doi.org/10.21203/rs.3.rs-55956/v2

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Abstract
Background The aim of our study was to analyze the trend changes and region distribution changes of
three sexually transmitted infections (STIs) in China and provided a scienti c basis for the government to
make prevention and control measures.

Methods This study used Joinpoint regression model to t the morbidity data of three STIs in China from
1999 to 2018. Annual percentage change (APC) and Average annual percentage Change (AAPC) were
calculated to evaluate the trend changes of three STIs. We also used hierarchical clustering analysis to
analyze the region distribution of three STIs in China from 2003-2018.

Results We analyzed the morbidity data of three STIs in 1999-2018 derived from China Health Statistics
Yearbook. The nal model of AIDS was the 3 Joinpoint model (P = 0.01) with an annual average percent
change (AAPC) of 33.7 (95% CI: 26.1-41.8, P < 0.001). The nal model of gonorrhea was the 1 Joinpoint
model (P= 0.0025) with an annual average percent change (AAPC) of -4.9 (95% CI: -6.2- -3.6, P < 0.001).
The nal model of gonorrhea was the 1 Joinpoint model (P < 0.05) with an annual average percent
change (AAPC) of 9.1 (95% CI:6.9-11.4, P < 0.001). The region distribution of the morbidity of three STIs
mainly concentrated in the southeast coastal areas and Xinjiang, other areas showed low epidemic
levels.

Conclusions: In a word, the morbidity of three STIs in China is still increasing slowly, the form of
prevention and control for STIs is still very severe, especially in coastal provinces and Xinjiang. Therefore,
it is necessary to actively popularize knowledge related to STIDs, and carry out large-scale peer education,
further reduce epidemic of sexually transmitted infections in China.

Background
Sexually transmitted infections are among the most common communicable conditions and affect the
health and lives of people worldwide[1]. These mainly transmitted by sexual contact or similar sexual
contact and can cause diseases of genitourinary organs, accessory lymphatic system and major organs
of the whole body. The World Health Organization (WHO) reports that More than 1 million STIs are
acquired every day worldwide[2]. In China, our government has taken corresponding prevention and
control measures for AIDS, gonorrhea, syphilis and other sexually transmitted diseases, and achieved
good effect. But the China Health Statistics Yearbook (2019) showed that the reported morbidity of three
kinds of sexually transmitted infections were still in the forefront of the noti able infectious diseases[3] .

The JoinPoint regression model, also known as fragment regression, was proposed by Kim in
2000[4].The basic idea is to divide a long-term liner trend into several segments, each of which is
described by a continuous linear pattern. It mainly includes two models: linear data model and
logarithmic linear data model.

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The Autoregressive moving average (ARIMA) model is the most widely used time series analysis method
for infectious diseases[5, 6], but it has high requirements on the data sample size. The Joinpoint model
does not have strict requirements on distribution of data, and can describe the long-term trend in linear
model, which has been gradually paid attention to in recent years[7-9]. There is no model that assesses
the trend changes and region distribution changes of three STIs among the whole population in China
over 20 years.

The purpose of this study is to analyze the trend changes and region distribution changes of three STIs in
China from 1999-2018, and provided a scienti c basis for the government to make prevention and control
measures.

Methods
Source of data

The morbidity data came from China Health Statistics Yearbook 2003-2019, and it is derived from the
annual statistical report of infectious diseases[3]. Since exact morbidity was di cult to obtain, we
replaced the morbidity of the three STIs with reported incidence indicator. Population data came from the
website of the statistical yearbook of the National Bureau of Statistics
(http://www.stats.gov.cn/tjsj/ndsj/).

Statistical analysis

The Joinpoint regression model is used to t the morbidity of the three STIs, and annual percent Change
(APC) and average annual Percent Change (AAPC) are calculated to evaluate the trend changes of the
three STIs in China from 1999 to 2018. If APC<0, indicating that the morbidity rate is decreasing per year;
If APC>0, meaning that the morbidity rate is increasing per year; If APC=AAPC, indicating no Joinpoint
and data increases monotonously or decreases monotonously with the change of the years.

We use hierarchical clustering analysis to describe the regional distribution differences of the three major
STDs. This method clusters provinces with similar incidence into one group by taking 31 provinces as
independent samples and the incidence of three major in 2018 as cluster indicators.

The Joinpoint regression model and hierarchical clustering analysis are performed by the Joinpoint
Regression Software (4.8.1.0 version developed by the American cancer research center) and R software
version 4.0.2, respectively. A bilateral probability value of P < 0.05 was considered indicative of statistical
signi cance.

Results
The morbidity of AIDS, syphilis and gonorrhea in China

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Our study analyzed the data about AIDS, syphilis and gonorrhea reported publicly by the Chinese
government. The results showed that morbidity of AIDS and syphilis (1/100000) ranged from 0.02 to
4.62 and from 6.50 to 35.63, which indicated the morbidity of both showed a trend of increasing per year.
On the contrary, the morbidity of gonorrhea (1/100000) ranged from 27.54 to 9.59 with continually
decreased per year. The differences among the three major STIs were statistically signi cant (P <0.001).
All results can be seen in Table1.

Time trends of AIDS, syphilis and gonorrhea

Time trends of AIDS The Joinpoint model showed that the morbidity of AIDS increased at an average
annual rate of 33.7%, with a statistically signi cant change trend (P <0.001). There were three turning
points:2002, 2005, 2011, respectively (Table2 and Fig1). From 1999 to 2002, the morbidity of AIDS had a
clear upward trend (1999-2002: APC=42.62; 2002-2005: APC=102.52; 2005-2011: APC=38.25; P<0.001).
The upward trend from 2011 to 2018 began to slow down (APC=5.74, P<0.001).

Time trends of gonorrhea The results showed that the nal model of gonorrhea was the 1 Joinpoint
model (P <0.05) (Fig2). The annual average percent change (AAPC) was -4.9 (95CI%: -6.2 to -3.6, P
<0.001), indicating a downward trend in the gonorrhea morbidity (Table3). The gonorrhea morbidity
decreased at an average rate of 9.57% per year from 1999 to 2012, and reached the lowest in 2012.From
2012-2018, the upward trend of gonorrhea morbidity began to appear (APC=5.96, 95%CI: 1.8-10.3)

Time trends of syphilis The Joinpoint model showed that the morbidity of syphilis increased at an
average annual rate of 9.1%, with a statistically signi cant change trend (P <0.001) (Fig3). The nal
model of syphilis was the 3 Joinpoints model (Table4). The syphilis morbidity decreased at an average
rate of 3.65% per year from 1999-2003, and reached the lowest in 2003. From 2003 to 2010, it had an
outstanding upward trend, with APC of 36.62 and 20.33 (P <0.001). The upward trend began to slow
down in 2010-2018 (APC=1.68, 95%CI:0.4-3.0, P <0.001)

Regional distribution of AIDS, syphilis and gonorrhea

The results of hierarchical clustering analysis indicated that the provinces with the highest morbidity of
the three STDs were mainly Shanghai and Zhejiang province in 2003-2010, Xinjiang and more southern
provinces also began to be classi ed as high-prevalence regions after 2010 (Fig4). The 2018 cluster plot
showed that the current three STIs high morbidity areas are mainly in Guangdong, Zhejiang and Hainan
provinces, followed by Chongqing and Xinjiang.

Discussion
Our study showed that the morbidity of AIDS in Chinese population increased from 1999 to 2018, which
were consistent with the results of Yong-Chao and Zun-you Wu's study[10, 11]. The rising tendency was
the most pronounced during 2002-2005. The possible reasons are the abuse of intravenous drug, the
increase in the number of homosexual men and infection occurred after irregular blood collection[12].

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Since the implementation of the blood donation law in 1998, the transmission of HIV through blood
collection and supply has been controlled in China. At present, the transmission of HIV is mainly through
sexual transmission[13-15]. The introduction of "four exemptions and one care" policy in 2006 and the
implementation of the "six expansion and ve strengthening" prevention and control measures in 2011
have also effectively slowed down the rising tendency of AIDS morbidity, which is consistent with our
study results[16-18]. In addition, a research report on the global AIDS epidemic showed that compared
with other countries, the current AIDS epidemic in China is at a low epidemic level[19].

Previous study indicated that the epidemic of gonorrhea in China rose rapidly in the 1970s, reached its
peak in 1999, and then declined, which was consistent with our study results[20]. But our study showed
that the morbidity of gonorrhea began to rising in 2012-2018, which was similar to that of the United
States and the United Kingdom in the same years[21]. This phenomenon may be due to the expanded
coverage of gonorrhea screening, the increased sensitivity of diagnostic methods and the increase in the
number of MSM patients[22, 23]. Although our study indicated that the morbidity of gonorrhea in China
from 1999 to 2018 had an overall trend of decline, it is still in the forefront of the noti able infectious
diseases, especially in 2018 its morbidity reached 9.58%, ranking fourth. Additionally, many studies found
neisseria gonorrhoeae was resistant to many antibiotics, making the treatment of gonorrhea become a
major challenge for clinicians in recent years[14, 24-26].

The results of our study showed that the morbidity of syphilis in China was on the rise during 1999 to
2018, which was contrary to the overall trend of gonorrhea incidence[20]. The trend changes in the both
SIDs were similar to developed countries. On the one hand, this phenomenon may be due to the increased
number of syphilis infection population in MSM; On the other hand, it mainly because the government
launched a national plan on expanding syphilis screening in 2010, which led to an increase in the number
of cases diagnosed as latent syphilis[27, 28]. And the related literature also suggested that syphilis
morbidity rate was higher than AIDS in Chinese MSM population[10]. Our study indicated that the
morbidity of syphilis had been increasing per year since it reached lowest level in 2003, and its morbidity
was higher than that of AIDS and gonorrhea. Moreover, previous studies also showed that the majority of
Chinese people's knowledge of syphilis is far lower than the standard of 10-year plan set by our
country[27, 29, 30].

We also used hierarchical clustering analysis to describe the region distribution of three STIs. Compared
with previous years, the current high incidence of the three STIs is mainly concentrated in the southeast
coastal areas and Xinjiang. The reason for the high morbidity of STIs in southern cities is mainly due to
the sexual disorder caused by the rapid increase of oating population in recent years. However, the
cause of the high morbidity of STIs in Xinjiang still needs further study. The above results suggest that
the government should strengthen the prevention and treatment of southeast coastal areas and Xinjiang.

Some limitations also need to be noted. First, the sample size of our study is very small. Second, the
study data comes from passive monitoring, exact morbidity rates are hard to obtain, and reported
morbidity rates may underestimate the true status of STIs. In nal, the morbidity of infectious diseases is

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related to the natural environment, social economy and personal hygiene habits, which may lead to
unstable prediction results.

Conclusion
In summary, the morbidity of three major STIs in China is still increasing slowly, the form of prevention
and control for STIs is still very severe, especially in coastal provinces and Xinjiang. Therefore, it is
necessary to actively popularize knowledge related to STIDs, and carry out large-scale peer education, so
as to further reduce epidemic of sexually transmitted infections in China.

Abbreviations
STIS: Sexually transmitted infections

HIV: Human immunode ciency virus

AIDS: Acquired immune de ciency syndrome

APC: Annual percentage change

AAPC: Average annual percentage change

Declarations
Acknowledgements

No Applicable.

Funding

None.

Author information

A liations

Tong Ji University School of Medicine, Shanghai 200092, China

Chunxia Han & Zisheng Ai

Contributions

All authors contributed to the manuscript proof. All authors read and approved the nal manuscript.

Corresponding author

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Correspondence to Zi sheng Ai

Ethics declarations

No Applicable.

Consent for publication

No Applicable.

Competing interests

The authors declare that they have no competing interests.

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Tables
Table1 Morbidity of AIDS, syphilis, gonorrhea in China in 1999-2018

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 year Number(million)  Morbidity of AIDS Morbidity of gonorrhea Morbidity of syphilis

1/100,000 (1/100,000) (1/100,000)

1999 125786 0.02 27.54 6.50

2000 126743 0.02 22.92 6.43

2001 127627 0.04 18.57 6.11

2002 128453 0.06 16.14 5.80

2003 129227 0.08 16.54 5.63

2004 129988 0.23 17.71 7.70

2005 130756 0.43 14.27 10.96

2006 131448 0.60 12.46 14.24

2007 132129 0.82 11.33 17.16

2008 132802 1.10 10.16 21.06

2009 133450 1.51 9.19 24.66

2010 134091 2.56 8.07 28.90

2011 134735 2.92 7.61 32.04

2012 135404 3.11 7.07 33.30

2013 136072 3.12 7.61 32.86

2014 136782 3.33 7.05 30.93

2015 137462 3.69 7.36 31.85

2016 138271 3.97 8.39 31.97

2017 139008 4.15 10.06 34.49

2018 139538 4.62 9.59 35.63

Table 2 APC and AAPC of AIDS morbidity in China ,1999-2018

Joinpoint (95%CI) year APC 95%CI AAPC 95%CI

_ 1999-2002 42.62* (20.0-69.4) 33.7*(26.1-41.8)

2002 (2001-2004) 2002-2005 102.52* (43.5-185.8)  

2005 (2004-2008) 2005-2011 38.25* (28-49.3)

2011 (2008-2013) 2011-2018 5.74* (1.0-10.7)

* P<0.05

Table 3 APC and AAPC of gonorrhea morbidity in China ,1999-2018

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 Joinpoint (95%CI) year APC (95%CI) AAPC (95%CI)

_ 1999-2012 -9.57* (-10.7--8.4) -4.9*(-6.2--3.6)

2012 (2011-2014) 2012-2018 5.96* (1.8-10.3)

* P<0.05

Table 4 APC and AAPC of syphilis morbidity in China ,1999-2018

Joinpoint (95%CI) year APC (95%CI) AAPC (95%CI)

- 1999-2003 -3.65* (-7.1--0.1) 9.1* (6.9-11.4)

2003 (2002-2004) 2003-2006 36.62* (21.9-53.2)

2006 (2005-2008) 2006-2010 20.33* (13.6-27.4)

2010 (2009-2018) 2010-2018 1.68* (0.4-3.0)

* P<0.05

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