Health professionals' perceptions of hemorrhagic fever with renal syndrome and climate change in China
Introduction
Hemorrhagic fever with renal syndrome (HFRS) is a dangerous zoonotic disease caused by hantaviruses and is a serious public health problem in China in past decades (Zhang et al., 2010b, Liu et al., 2012). The disease is transmitted to humans via rodents and symptoms include fever, hemorrhage, hypotension and renal dysfunction (Xiao et al., 2014b, Zhang et al., 2011). About 90% of the world's cases are reported in China (Xiao et al., 2014b). Two species of hantavirus – Hantaan virus (HTNV) and Seoul virus (SEOV) are predominant in China (Zhang et al., 2011). The hosts for these viruses are Apodemus agrarius and Rattus norvegicus respectively. Humans can be infected by inhaling aerosols that are contaminated with the virus shed in excreta, saliva and urine of infected animals or by contact with contaminated food, water, and infected rodent hosts (Bi et al., 2002, Hansen et al., 2015). Apodemus agrarius is prevalent in agricultural regions of China while Rattus norvegicus is prevalent in urban areas (Xiao et al., 2013a).
There were > 1 million HFRS cases reported between 1931 and 1995 in China (Bi et al., 2002). Male farmers aged 30–50 years were the most vulnerable population (Liu et al., 2012). The incidence of HFRS peaked in 1986 (115,807 cases) and then declined in the late 1990s (about 20,000–50,000 cases annually) (Zhang et al., 2014a, Zhang et al., 2014b). This reduction could be due to numerous control measures such as deratization strategies, an introduced vaccination program, better health care access and health education. However, the incidence once again rebounded after 2008 (Zhang et al., 2014b). The majority of these cases in China are concentrated in north-eastern, central and eastern China, in the provinces of Liaoning, Heilongjiang, Shanxi, and Anhui (Zhang et al., 2014b, Bi et al., 2005, Liu et al., 2011). During 2004 and 2005, Liaoning had the highest incidence of HFRS in China, and is still one of the high-risk areas (Liu et al., 2011). Before that period, the incidence rate of HFRS was very high in Anhui - > 10 per 100,000 population during the 1980s and 1990s, and nowadays there are still a number of cases reported annually (Zou et al., 2016). Fig. 1 shows the annual incidence of HFRS from 2002 to 2013 in Liaoning and Anhui (National Health and Family Planning Commission of the PRC, 2016). In both provinces, the incidence of HFRS reduced gradually after 2004. However, there has been an increasing trend of HFRS cases in those regions since 2008. In Liaoning, for example, the incidence increased from 1.71/100,000 in 2008 to 2.96/100,000 in 2013. In Anhui the incidence of HFRS rose from 0.17/100,000 in 2008 to 0.32/100,000 in 2013. Although continuous control and prevention measures have been implemented in these provinces, there are still about 30,000 to 60,000 HFRS cases reported annually in China (Hansen et al., 2015, Xiao et al., 2013a).
There are a number of studies indicating the increasing number of HFRS cases is associated with climatic variables and possibly climate change, such as increasing temperature, precipitation and relative humidity (Hansen et al., 2015, Liu et al., 2011, Li et al., 2013, Zhang et al., 2010a, Guan et al., 2009, Bi et al., 2005). According to the most recent Intergovernmental Panel on Climate Change report (IPCC Fifth Assessment Report) in 2014, the average global land and ocean surface temperature is predicted to increase 1.1–6.4 °C from 1990 to 2100 (Intergovernmental Panel on Climate Change, 2013). This may have an influence on the ecology of the rodents, and increase the reproduction rate, and thus contribute to rodent-borne disease transmission (Xiao et al., 2014b, Hansen et al., 2015, Li et al., 2013, Liu et al., 2013).
In China, the Centers for Disease Control and Prevention (CDC) work to protect and improve population health and safety, and to control and prevent potential infectious disease threats (Chinese Center for Disease Control and Prevention, 2015). Although CDC health professionals are likely to be knowledgeable about HFRS and possible associations with climate change, to our knowledge there are no studies investigating health professionals' perceptions of this disease under the climate change scenario, which would contribute to our understanding of the relationship between climate change and HFRS.
The aim of this study was to gauge the perceptions of CDC health professionals in China concerning HFRS control and climate change. An examination of CDC professionals' understanding of the association between HFRS and climate change, and the main reasons responsible for HFRS emergence and re-emergence, will enhance understanding of this phenomenon, while providing policy makers and stakeholders with an evidence-base on which to formulate effective and feasible adaptation strategies for the control and prevention of HFRS in the future.
Section snippets
Study areas
A CDC-based cross-sectional survey was conducted in Liaoning and Anhui Provinces. These provinces were chosen as they historically have been high-risk areas for HFRS. They are also located in two different geographical areas of China and are in different climate zones.
Liaoning Province, located in Northeast China (Fig. 2), has a total area of 145,800 km2, a population of 42.7 million (The People's Government of Liaoning Province, 2016b). There are 4.09 million hectares of agricultural areas and
Demographic information
In this study, 381 participants who undertook duties such as communicable disease control and prevention, public health, medical laboratory testing and emergency response completed the questionnaires. Table 1 shows the demographic characteristics of participants. Of the total cohort, 59.6% were from Liaoning CDCs and 40.4% were from Anhui CDCs. More than half of the participants were from provincial CDCs, and others were from CDC in counties and prefectures within the provinces. Participants
Discussion
To our best knowledge, this is the first study to gauge the perceptions of CDC staff about the transmission of HFRS in relation to climate change in China. Results will provide scientific evidence to inform the capacity for improvement in control and prevention measures of HFRS in the face of climate change.
Most participants (> 80%) considered that climate change would have a negative effect on population health, and indicated that increasing temperature and precipitation would influence
Conclusions
Most CDC staff endorsed the statement that climate change would have an influence on population health and infectious disease transmission. However, many participants either did not think climate change would have an influence on rodent-borne diseases including hantavirus infections, or were undecided about the issue, indicating the uncertainties and lack of evidence that exists in this area. Further climate change related research concerning rodent-borne disease transmission is required to aid
Competing interests
The authors declare that they have no competing interests.
- HFRS
Hemorrhagic fever with renal syndrome
- CDC
Center for Disease Control and Prevention
- HTVN
Hantaan virus
- SEOV
Seoul virus
- IPCC
Intergovernmental Panel on Climate Change
Abbreviations
Acknowledgements
This study has been funded by the Department of Foreign Affairs and Trade through the Australian Development Research Awards Scheme under an award titled ‘How best to curb the public health impact of emerging and re-emerging infectious diseases due to climate change in China’ (Project ID: 66888) and the National Basic Research Program of China (973 Program) (Grant No. 2012CB955504). The views expressed in the publication are those of the authors and not necessarily those of the Department of
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