| [Background]Hand,Foot and Mouth Disease(HFMD)is a common infectious disease occurring mainly in children younger than 5 years,which is caused by various enteroviruses.Most patients would be self-limiting with typical presence of fever,skin eruptions on hands and feet,and vesicles in the mouth.However,some patients rapidly develop neurological and systemic complications such as aseptic meningitis,encephalitis,acute flaccid paralysis,respiratory tract infections and myocarditis and other complications that can result in death.EnterovirusA71(EV-A71)and Coxsackievirus A16(CV-A16)are the two major causative agents of HFMD that rarely cause acute neurological symptoms,accounted for about 60%to 80%of laboratory-confirmed cases each year.HFMD is a global epidemicand has been reported in most parts of the world.Since the beginning of the 21st century,the prevalence of HFMD in Asia has increased,and regular outbreaks occur regularly in many countries.HFMD has become an important public health problem in Asia that harms children's health.China began its report in Shanghai in 1981 and later reported in dozens of provinces and cities including Beijing,Hebei,Tianjin,Fujian,Jilin,Shandong,Hubei,Xining,Guangdong and Taiwan.In 2007,an outbreak of HFMD occurred in Linyi City,Shandong Province,and the joint investigation and study of China Center for Disease Control and Prevention and ShandongCenter for Disease Control and Prevention prevealed that it was caused by EV-A71,which was the firstrelatively large EV-A71-infected HFMD epidemic in our country's history.Subsequently,in 2008,EV-A71-infected HFMD broke out in the Fuyang area of Anhui Province.Eventually,on May 2rd,2008,the former The Ministry of Health classified HFMD in the category C infectious diseases managed by the Statutory Report of the "Infectious Diseases Control and Prevention Law of the People's Republic of China".Since then,the incidence and deaths of HFMD in China have been increasing year by year,which has become an important public health issue in China,and has also brought a huge disease burden and economic burden.After the former Ministry of Health classified HFMD in the category C infectious diseases,some scholars have used the monitoring data to analyse the economic burden of HFMD.However,HFMD is caused by different enterovirus infections.The clinical manifestations are quite different.The differences in the economic burden between HFMD patients with different types of HFMD,such as EV-A71,CV-A16,and other enteroviruses were still unknown.There was also a lack of use of sample survey data combined with epidemiological and virological monitoring data to analyze the overall economic burden of HFMD in a populous province and related influencing factors.Therefore,based on epidemiological and virological surveillance data of HFMD in Shandong Province from 2009 to 2016 and hospitalsampling investigation in Shandong Province in 2014,a more in-depth study of the economic burden of HFMD in Shandong Province and its influencing factors should be conducted,and the economic burden of HFMD patients in different regions,different clinical types,and different enteroviruses in Shandong Province should becalculated,and the overall economic burden of HFMD in Shandong Province in recent years should be estimated.This will have important theoretical and practical significance for helping Shandong Province to prevent and control HFMD,reduce the economic burden on HFMD patients.In addition,at present,China has successfully developed EV-A71 vaccine,the cost-effectiveness of the vaccine will be based on the assessment of the economic burden of HFMD in ShandongProvince,and this study should play an important role in providing data and theoretical support for improving the immune strategy.[Objectives]1.To conduct a comprehensive and systematic analysis of the epidemic characteristics of HFMD in Shandong Province from 2009 to 2016.2.To analyse economic burden of HFMD based on sampling surveys of selected hospitals in Shandong Province.3.To assess the total economic burden of HFMD in Shandong Province and analyze the influencing factors of the economic burden,therefore proposing policy and suggestions to prevent and control HFMD in Shandong Province and reduce economic burden of HFMD.[Methods]1.Epidemiological characteristics of HFMD in Shandong province from 2009 to 2016.The data of HFMD in Shandong province come from "Infectious Diseases Reporting Information Management System" in "China Disease Prevention and Control Information System".And part of the data come from epidemiological survey data of individual cases provided by Shandong Center for Disease Control and Prevention.We used the descriptive epidemiological methods to describe the epidemiological characteristics of HFMD in Shandong Province,and to find out the epidemiological characteristics of HFMD in Shandong Province.Meanwhile we figured out the characteristics and regional variations of the prevalence of HFMD in HFMD,and analyzed the influence of climatic factors on HFMD epidemic season by using boosted regression tree(BRT)model.The main analysis indicators were incidence,composition ratio and related indicators for statistical tests.2.Study on the economic burden of HFMD in Shandong Province.The hospital selectionwas based on the per capital GDP of Shandong Province in 2013,and thus all 17cities in Shandong Province were categorized as high,medium or low level of prosperity.Then two or three hospitals were randomly selected from cities of each level of prosperity.Eventually a total of 28 hospitals from eight cities were selected to participate in the survey.From January 1st,2014,the HFMD cases,including outpatients(mild cases)and inpatient cases(mild cases,severe cases)that treated at the hospitals in these cities would be investigated in time.Patients were surveyed using the self-administered handbook of disease analysis of HFMD.According to the survey results,the economic burden of HFMD from different regions,different clinical types and different virus types were calculated respectively,and the related indicators were statistically tested.3.Statistical analysis methods.Data was double entered using EpiDatav.3.1(EpiDataAssociation,Denmark).This study uses Microsoft Excel 2010 and SPSS 19.0 statistical software for analysis.Descriptive statistics were used to characterize all patients in the study.Individual categories of categorical variables are expressed in terms of frequency and percentage,and continuous variables are represented in median and quartile.One-way ANOVA for Kruskal-Wallis tests for normally distributed continuous or normal distribution variables.Multivariate analysis used binary logistic regression for statistical analysis.P values<0.05 were considered statistically significant.[Results]1.Epidemiological studies:A total of 839,483 cases of HFMD were reported to the surveillance system from 2009 to 2016 in Shandong Province,of which 48,133(5.73%)were confirmed by laboratory tests,and 13,732(1.64%)developed serious complications,75 died(case fatality 0.01%)and severe case fatality 0.55%.In terms of population distribution,the majority of HFMD patients were under the age of 5(90.15%),and the median age was 2.4 years.Men reported more cases than women,with a male-to-female ratio of about 1.6:1.In terms of geographical distribution,the top 5 cities were Qingdao,Jinan,Heze,Weifang,Tai'an.The average annual reported incidence rate of 17 cities was between 500-2200/1 million.The reported incidence rate in urban areas was about 2-4 times higher than that reported in rural areas.In terms of time distribution,the average peak arrival times in the southwestern Shandong Province,Luzhong and the northern regions,and the central and eastern coastal regions of Shandong Province were respectively 20th week,25th week and 27th week;BRT analysis shown that the average daily temperature is an outbreak of hand-foot-mouth disease The major predictors of the epidemic intensity.2.Shandong Province hand foot and mouth disease etiology changes:Shandong Province HFMD epidemic dominant virus is changing every year,but overall,the prevalence of predominant viruses every year mainly EV-A71,CV-A16,other enterovirus.A considerable proportion.The EV-A71 presented a preponderance of popularity in 2009,2011 and 2013-2014.The CV-A16 presented a prevailing epidemic(epidemic peak)every 2 years in 2010,2012,2014 and 2016,Other enteroviruses also showed prevalent popularity in the summer of 2013 and summer of 2015.EV-A71,CV-A16 basically showed the trend of alternate prevalence every 1-2 years.3.Study on the economic burden of HFMD(1)the characteristics of the participants.A total of 1,553 patients were enrolled in this study,with mild cases 1435(mild out-patient cases 573,mild in-patient cases),severe cases 118,and none fatal cases.(2)A survey of economic burden of HFMD.According to studies on the economic burden of different clinical types,the direct economic burden and indirect economic burden of severe cases were 11,899.97 yuan per case and 680.00 yuan per case respectively,which were greater than the direct economic burden and indirect economic burden of mild in-patientcases(3,250.29 yuan per case,390.73 yuan per case)and mild out-patient cases(307.15 yuan per case,65.13 yuan per case);the economic burden of mild out-patient cases,mild in-patient cases,and severe cases were 414.06 yuan per cases,3,913.06 yuan per case and 12,847.73 yuan per case(P<0.01),respectively.According to studies on the economic burden of different economic development regions,different clinical types,and different viral types,the economic burden of mild out-patient cases in high,medium and low level development regions were 520.03 yuan per case,340.00 yuan per case,and 405.62 yuan per case,respectively;the economic burden of mild in-patient cases in high,medium and low level development regions were 2,578.37 yuan per case,4,270.15 yuan per case,and 4,313.28 yuan per case,respectively;the economic burden of mild out-patient cases in high and low level development regions were 14,111.08 yuan per case and 9,351.55 yuan per case(P<0.01),respectively.According to studies on the economic burden of different viral types,the direct medical cost and economic burden of the severe cases of HFMD caused by CV-A16 infection were the most serious,which were 10,795.93 yuan per case and 14,340.93 yuan per case(P<0.01),followed by EV-A71 caused-cases(10,431.13 yuan per case,12,847.79 yuan per case).(3)The overall economic burden of HFMD in Shandong Province.The total economicburden of HFMD in Shandong Province in 2014 was estimated at 310 million yuan.(4)Analysis on the Influencing factors of economic burden in patients with HFMD inShandong Province.Univariate analysis of the economic burden of patients with HFMD showed that the economic burden among patients of different genders was comparable and there was no significant statistical difference.The older the age,the lower the economic burden of HFMD patients,and the correlation coefficients were significantly correlated(P<0.001).The economic burden of HFMD varied greatly among patients in different monitoring situations.It showed the trend of children>children from nursing school>students from primary school.The direct medical expenses,indirect non-medical expenses,indirect economic burden and economic burden had statistical differences in different occupations(P<0.01),which was,the economic burden of children was much higher than children from nursing school and students from primary school.Multivariate analysis of the economic burden of HFMD patients showed that regional economic status,case severity,pathogen examination results,case type,and place of residence were factors that affected the direct economic burden of HFMD cases,and were all risk factors;regional economic status,the severity of the case,the status of the child's supervision,the type of the case,and the place of residence were the influencing factors of the indirect economic burden of the case of HFMD cases.The severity of the case,the state of supervision of the child,the type of the case were risk factors,and the place of residence was a protective factor.[Conclusions]1.Shandong Province is one of the most stricken provinces of HFMD.The HFMD incidence rates of Shandong Province ranged from 754.14 in 2013 to 1454.67 in 2010 per million person-years with an annual average incidence rate of 1095 per million person-years.In summary,we describe the recent epidemiological characteristics of a large HFMD cohort.Our findings show that HFMD continued to cause annual epidemics since 2013 and,in addition,significantly higher case-severity and case-fatality rates were found in rural areas compared to urban centers.Therefore,enhanced support for rural hospitals to improve time to diagnosis and treatment would likely mitigate HFMD-associated disease.A dynamic change of the predominant HFMD causing agent was observed in Shandong Province and non-EV-A71/CV-A16 enteroviruses became dominant in recent years,which will potentially complicate efforts to administer multivalent HFMD vaccines.Our study sheds light on the latest epidemiological characteristics of HFMD in Shandong province and should prove helpful for the prevention and control of HFMD-associated disease of Shandong,as well as other Chinese provinces.In Shandong Province,when the average temperature was>21?(approximately corresponding to the maximum temperature of 28?),the HFMD incidence began to decrease.Therefore,these meteorological factors might contribute to the incidence rates of HFMD,however,they are clearly not the sole determinants of the incidence rates of HFMD.It is likely that yearly fluctuations in the rates of herd immunity against different enteroviruses in children would be the major determinant and that the decrease of the numbers of susceptible children-by targeted intervention with safe,well-tolerated and efficacious multivalent vaccines-would decrease HFMD-associated morbidity and mortality.2.BRT model analysis showed that daily average temperature,daily average atmospheric pressure,daily average precipitation,daily average wind speed,and daily average relative humidity were the influencing factors of the incidence of HFMD,and the daily average temperature was the main influencing factor.When the average temperature was higher than 21°C(the highest temperature reaches about 28 ° C),the incidence of HFMD was decreasing.3.The 2014 survey of economic burden of HFMD Studies have shown that the economic burden on in-patient cases and severe cases in rural households was even heavier,and it was prone to extreme cases that exceed household income by 100%.According to studies on the economic burden of different clinical types,the higher the severity of HFMD,the higher the costs associated with the disease and the greater the economic burden.According to studies on the economic burden of different economic development regions,different clinical types,in-patient cases,the level of regional economic development is inversely proportional to the economic burden of HFMD cases,that is,the more developed the economy,the lighter the economic burden of common inpatients with HFMD,the less developed the economy,and the more economic burden of common inpatients with HFMD;for severe cases,the more developed the regional economic level,the heavier the economic burden of HFMD patients.The direct medical cost and economic burden of the severe cases of HFMD caused by CV-A16 infection were the most serious,while the indirect medical cost of the severe cases of HFMD caused by other entervirouses was the most severe.4.The study on the factors affecting the economic burden of HFMD cases in Shandong Province in 2014 showed that the worse the regional economic situation was,the more serious the disease were,and the rural areas where the residents lived,the heavier the direct economic burden of HFMD cases were;severe cases,hospitalized cases,child care and the indirect economic burden of urban patients was heavier.[Suggestions]1.In addition to non-specific prevention and control measures such as prevention and control of health education,child care institutions and primary schools,relevant departments should consider adopting specific preventive and control measures such as vaccination for children under 5 years old before enrollment and after enrollment.Pay attention to the cultivation of good health habits of children from 6 months to 36 months of age,thus effectively reducing the incidence of hand,foot and mouth disease cases and reducing the incidence rate.Although the highest number of cases and severe cases reported in Shandong province from 2009 to 2016 is Qingdao,the highest mortality rate is in Heze and Liaocheng,which are relatively less developed area in Shandong Province.This requires health supervision and management departments and the Centers for Disease Control and Prevention to supervise and urge the daily reporting and treatment of HFMD in economically underdeveloped areas such as Heze City which has the largest number of deaths reported and carry out grassroots supervision,especially the number of annual reports.2.The southwestern Shandong Province is the earliest area where HFMD is the most popular,followed by middle and northern regions,and the middle and the eastern coastal areas.Therefore,it is recommended that the relevant departments develop the best EV-A71 vaccination time for HFMD for these three endemic areas,which would definitely improve the prevention and control effect of the vaccine,so as to effectively control incidence of HFMD in different regions.3.From the perspective of personalized health and poverty alleviation,policy research on HFMD in-patient cases,especially medical assistance for severe cases and fatal cases should be done.4.According to the results of the research on the factors affecting the economic burden of HFMD cases in Shandong Province in 2014,health policy makers and disease prevention and control workers should mobilize effective health and epidemic prevention resources to face economically underdeveloped areas,EV-A71 positive patients and hospitalized cases,severe cases and rural children have targeted prevention and treatment policies and means;more attention should be paid to health education and publicity work for child care institutions and parents,and to improve the awareness of patients with HFMD and their guardians to avoid aggravation.[Significance and innovation]1.The historical evolution of the epidemic of HFMD in Shandong province is of great significance for the study of the epidemic characteristics of HFMD in China.Since 2013,there has been no description of a large number of epidemiological data on HFMD at home and abroad.Although the size of Shandong Province is small,the level of social and economic development in the eastern and western regions can be regarded as a microcosm of the entire eastern and western parts of the Chinese mainland.In the present study,we described the HFMD burden and epidemiological patterns of Shandong Province during 2009-2016,which is the most comprehensive dataset describing the latest epidemiology information of HFMD in China.Analyzing and describing epidemic differences in different regions,seasonal differences and influencing factors in different regions,epidemiological characteristics of different age groups and different types of clinical cases,and finding out the inherent characteristics and laws of the epidemic of HFMD,and developing targeted prevention and control for our province have important theoretical and practical significance for our province to formulate targeted prevention and control strategies,scientifically prevent HFMD and protect the health of children.2.From the perspective of health resource management,analyzing the situation of high incidence of HFMD,analyzing and estimating its economic burden has important practical significance for the current work of deepening medical reform to reduce the burden of people's disease.As one of the provinces with the highest incidence of HFMD in China,HFMD has caused a huge threat to the health of patients in Shandong Province,and has also caused a heavy economic burden.Not only poses a threat to the health of patients,HFMD caused by EV-A71,CV-A16,and other enteroviruses also leads to increased medical costs,loss of productivity,and other social costs.However,there is no research on the economic burden of HFMD patients caused by EV-A71,CV-A16 and other enteroviruses.The difference in the economic burden of HFMD patients caused by these enteroviruses remains unclear.The results of this study could evaluate the health economics of existing fixed-point treatment strategies,and provide advice on classification and diagnosis in terms of how to rationally allocate limited medical resources,reduce service costs,and reduce the economic burden,in order to formulate medical security policies for HFMD.3.This study has comprehensively used a variety of multidisciplinary methods to analyze the epidemiological characteristics economic burden of HFMD,which has a certain degree of trial and exploration significance in the field of HFMD related research.In the study of the epidemiological characteristics of HFMD in Shandong Province from 2009 to 2016,a comprehensive system of investigations and studies was carried out using epidemiological and health statistics and other theories and methods.The sample size was higher than that of previous studies at home and abroad.This study not only analyzed the three distribution characteristics of HFMD cases,but also integrated laboratory diagnosis to study the etiological changes of enteroviruses in HFMD,and to prevent and control HFMD for disease control workers and public health policy makers.It provided theoretical support in epidemiology and laid a foundation for the investigation and research on the economic burden of HFMD in Shandong Province.The combination of the two mould provide a basis for formulating medical security policies for HFMD.In the survey of the economic burden of HFMD in Shandong Province in 2014,theories and methods of epidemiology,health statistics,and health economics were applied to combine the aforementioned studies on the epidemiological characteristics of HFMD in Shandong Province.The economic burden of disease has been systematically and comprehensively investigated.The differences in the economic burden of HFMD in different economic development areas and the economic burden characteristics of different clinical types and different types of viral infections had been analyzed,which had direct application value for the definition of the scope and proportion of urban medical insurance and new rural cooperative medical insurance reimbursement for HFMD. |
PDF Full Text Request