Original Paper
- Shuli Ma1, PhD ;
- Jie Ge1, PhD ;
- Lei Qin2, PhD ;
- Xiaoting Chen2, MD ;
- Linlin Du1, PhD ;
- Yanbo Qi1, MD ;
- Li Bai1, PhD ;
- Yunfeng Han1, MPH ;
- Zhiping Xie1, MD ;
- Jiaxin Chen1, MD ;
- Yuehui Jia1, PhD
1School of Public Health, Qiqihar Medical University, Qiqihar, China
2Scientific Research Office, Qiqihar Medical University, Qiqihar, China
Corresponding Author:
Yuehui Jia, PhD
School of Public Health
Qiqihar Medical University
333 Bukui Street
Jianhua District
Qiqihar, 161000
China
Phone: 86 0452 2663409
Email: superyuehui@163.com
Abstract
Background: The World Health Organization declared mpox an international public health emergency. Since January 1, 2022, China has been ranked among the top 10 countries most affected by the mpox outbreak globally. However, there is a lack of spatial epidemiological studies on mpox, which are crucial for accurately mapping the spatial distribution and clustering of the disease.
Objective: This study aims to provide geographically accurate visual evidence to determine priority areas for mpox prevention and control.
Methods: Locally confirmed mpox cases were collected between June and November 2023 from 31 provinces of mainland China excluding Taiwan, Macao, and Hong Kong. Spatiotemporal epidemiological analyses, including spatial autocorrelation and regression analyses, were conducted to identify the spatiotemporal characteristics and clustering patterns of mpox attack rate and its spatial relationship with sociodemographic and socioeconomic factors.
Results: From June to November 2023, a total of 1610 locally confirmed mpox cases were reported in 30 provinces in mainland China, resulting in an attack rate of 11.40 per 10 million people. Global spatial autocorrelation analysis showed that in July (Moran I=0.0938; P=.08), August (Moran I=0.1276; P=.08), and September (Moran I=0.0934; P=.07), the attack rates of mpox exhibited a clustered pattern and positive spatial autocorrelation. The Getis-Ord Gi* statistics identified hot spots of mpox attack rates in Beijing, Tianjin, Shanghai, Jiangsu, and Hainan. Beijing and Tianjin were consistent hot spots from June to October. No cold spots with low mpox attack rates were detected by the Getis-Ord Gi* statistics. Local Moran I statistics identified a high-high (HH) clustering of mpox attack rates in Guangdong, Beijing, and Tianjin. Guangdong province consistently exhibited HH clustering from June to November, while Beijing and Tianjin were identified as HH clusters from July to September. Low-low clusters were mainly located in Inner Mongolia, Xinjiang, Xizang, Qinghai, and Gansu. Ordinary least squares regression models showed that the cumulative mpox attack rates were significantly and positively associated with the proportion of the urban population (t0.05/2,1=2.4041 P=.02), per capita gross domestic product (t0.05/2,1=2.6955; P=.01), per capita disposable income (t0.05/2,1=2.8303; P=.008), per capita consumption expenditure (PCCE; t0.05/2,1=2.7452; P=.01), and PCCE for health care (t0.05/2,1=2.5924; P=.01). The geographically weighted regression models indicated a positive association and spatial heterogeneity between cumulative mpox attack rates and the proportion of the urban population, per capita gross domestic product, per capita disposable income, and PCCE, with high R2 values in north and northeast China.
Conclusions: Hot spots and HH clustering of mpox attack rates identified by local spatial autocorrelation analysis should be considered key areas for precision prevention and control of mpox. Specifically, Guangdong, Beijing, and Tianjin provinces should be prioritized for mpox prevention and control. These findings provide geographically precise and visualized evidence to assist in identifying key areas for targeted prevention and control.
doi:10.2196/57807
Keywords
Introduction
Mpox is a zoonotic viral disease caused by the mpox virus, primarily circulating in animals but also transmissible to humans [Mitjà O, Ogoina D, Titanji BK, Galvan C, Muyembe JJ, Marks M, et al. Monkeypox. Lancet. 2023;401(10370):60-74. [FREE Full text] [CrossRef] [Medline]1,Thornton I, Gandhi G. Monkeypox: balancing response and future preparedness during a global public health emergency. BMJ Glob Health. 2022;7(10):e010644. [FREE Full text] [CrossRef] [Medline]2]. The main reservoir of the mpox virus is believed to be rodents and primates such as squirrels, kangaroos, dormice, monkeys, and apes [Diagnosis and treatment guidelines for monkeypox (2022 edition). National Health Commission of the People's Republic of China. 2022. URL: http://www.nhc.gov.cn/yzygj/s7653p/202206/d687b12fe8b84bbfaede2c7a5ca596ec.shtml [accessed 2023-12-20] 3,Technical guidelines for monkeypox prevention and control (2022 edition). National Health Commission of the People's Republic of China. 2022. URL: http://www.nhc.gov.cn/yjb/s3577/202207/acd6016aaca543e29c16deb9b5ea3303.shtml [accessed 2023-12-20] 4]. Mpox can be transmitted to humans through direct contact with infected animals, their bodily fluids, or contaminated materials [Technical guidelines for monkeypox prevention and control (2022 edition). National Health Commission of the People's Republic of China. 2022. URL: http://www.nhc.gov.cn/yjb/s3577/202207/acd6016aaca543e29c16deb9b5ea3303.shtml [accessed 2023-12-20] 4]. While human-to-human transmission of mpox is less common, it can occur through respiratory droplets, close physical contact, or contact with skin lesions or bodily fluids of an infected individual [Technical guidelines for monkeypox prevention and control (2022 edition). National Health Commission of the People's Republic of China. 2022. URL: http://www.nhc.gov.cn/yjb/s3577/202207/acd6016aaca543e29c16deb9b5ea3303.shtml [accessed 2023-12-20] 4]. An ongoing outbreak of mpox since January 1, 2022, has primarily affected men who have sex with men in countries outside of West and Central Africa, with cases reported to the World Health Organization (WHO) [2022-24 Mpox (Monkeypox) outbreak: global trends. World Health Organization. 2023. URL: https://worldhealthorg.shinyapps.io/mpx_global/ [accessed 2024-01-14] 5].
Historically, mpox has been mainly observed in Central and West Africa, with mortality rates ranging from 1% to 10% [Nakoune E, Olliaro P. Waking up to monkeypox. BMJ. 2022;377:o1321. [CrossRef] [Medline]6,Lane HC, Fauci AS. Monkeypox - past as prologue. N Engl J Med. 2022;387(8):749-750. [FREE Full text] [CrossRef] [Medline]7]. Since 2022, person-to-person transmission of mpox has been significantly increasing, thereby resulting in its widespread occurrence in other countries [Gessain A, Nakoune E, Yazdanpanah Y. Monkeypox. N Engl J Med. 2022;387(19):1783-1793. [FREE Full text] [CrossRef] [Medline]8-Hatmal MM, Al-Hatamleh MAI, Olaimat AN, Ahmad S, Hasan H, Suhaimi NAA, et al. Comprehensive literature review of monkeypox. Emerg Microbes Infect. 2022;11(1):2600-2631. [FREE Full text] [CrossRef] [Medline]10]. As of the end of February 2024, 94,707 confirmed cases of mpox, including 181 deaths, have been reported to the WHO from 117 countries and regions worldwide since January 1, 2022 [2022-24 Mpox (Monkeypox) outbreak: global trends. World Health Organization. 2023. URL: https://worldhealthorg.shinyapps.io/mpx_global/ [accessed 2024-01-14] 5]. In September 2022, the first imported case of mpox was reported in Chongqing, China. In June 2023, a local mpox epidemic occurred in China. As of November 30, 2023, 1611 confirmed cases of mpox have been reported from 30 (96.8%) provinces in mainland China, except Xizang, which included 1610 local cases [Monkeypox pandemic. Chinese Center for Disease Control and Prevention. 2023. URL: https://www.chinacdc.cn/jkzt/crb/zl/szkb_13037/gnyq/ [accessed 2024-01-16] 11].
The WHO declared mpox an international public health emergency on July 23, 2022 [Second meeting of the International Health Regulations (2005) (IHR) emergency committee regarding the multi-country outbreak of monkeypox. World Health Organization. 2022. URL: https://www.who.int/news/item/23-07-2022-second-meeting-of-the-international-health-regulations-(2005)-(ihr)-emergency-committee-regarding-the-multi-country-outbreak-of-monkeypox [accessed 2024-01-16] 12], which was reaffirmed on February 15, 2023 [Fourth meeting of the International Health Regulations (2005) (IHR) emergency committee on the multi-country outbreak of monkeypox (mpox). World Health Organization. 2023. URL: https://www.who.int/zh/news/item/15-02-2023-fourth-meeting-of-the-international-health-regulations-(2005)-(ihr)-emergency-committee-on-the-multi-country-outbreak-of-monkeypox-(mpox) [accessed 2024-01-16] 13]. A public health emergency of international concern is described in the International Health Regulations (2005) as an extraordinary event that poses a public health risk to other countries through the international spread of a disease, potentially requiring a coordinated global response [Emergencies: international health regulations and emergency committees. World Health Organization. 2019. URL: https://www.who.int/zh/news-room/questions-and-answers/item/what-are-the-international-health-regulations-and-emergency-committees [accessed 2024-03-31] 14]. On September 15, 2023, mpox was classified as a category B infectious disease for management by the National Health Commission of China, effective September 20, 2023 [Announcement of the national health commission of the People's Republic of China. National Health Commission of the People's Republic of China. 2023. URL: http://www.nhc.gov.cn/ylyjs/pqt/202309/3680634893d341e1b933726c206c20f6.shtml [accessed 2024-01-16] 15]. In accordance with the Law of Infectious Disease Prevention and Control of the People’s Republic of China, statutory infectious diseases are identified by their transmission, epidemic intensity, and hazard degree. These diseases are classified into 3 categories, totaling 40 types: 2 types in category A, 27 types in category B, and 11 types in category C. Category A infectious diseases are considered compulsory for management, while category B infectious diseases are strictly regulated [Law of infectious disease prevention and control of the People’s Republic of China. The State Council of the People’s Republic of China. 2004. URL: https://www.gov.cn/gongbao/content/2004/content_62975.htm [accessed 2024-03-31] 16]. According to the WHO, the confirmation of a single case of mpox in a country is considered an outbreak [2022-24 Mpox (Monkeypox) outbreak: global trends. World Health Organization. 2023. URL: https://worldhealthorg.shinyapps.io/mpx_global/ [accessed 2024-01-14] 5]. Therefore, it is crucial to prioritize the mpox pandemic owing to its potentially disastrous consequences for public health, socioeconomic factors, and overall health care systems. Experiences from previous pandemics, such as SARS, Middle East respiratory syndrome coronavirus, and COVID-19, highlight the roles of health administrators and policymakers to promptly develop comprehensive prevention and control strategies in all countries.
Spatial epidemiological studies have accurately visualized the spatial distribution and clustering of diseases via mapping [Banerjee S. Spatial data analysis. Annu Rev Public Health. 2016;37:47-60. [FREE Full text] [CrossRef] [Medline]17-Nurjannah N, Baker KM, Mashinini DP. Spatiotemporal trends in diabetes-related mortality by school district in the state of Michigan, United States. Epidemiol Health. 2021;43:e2021098. [FREE Full text] [CrossRef] [Medline]20]. Using geographically precise and visual evidence, priorities for disease prevention and control could be identified, and their effectiveness could be evaluated [Tang H, Peng J, Jiang H, Lin Y, Dong J, Liu M, et al. Spatial analysis enables priority selection in conservation practices for landscapes that need ecological security. J Environ Manage. 2023;345:118888. [FREE Full text] [CrossRef] [Medline]21-Konstantinoudis G, Padellini T, Bennett J, Davies B, Ezzati M, Blangiardo M. Long-term exposure to air-pollution and COVID-19 mortality in England: a hierarchical spatial analysis. Environ Int. 2021;146:106316. [FREE Full text] [CrossRef] [Medline]24]. Various factors can influence the occurrence and prevalence of infectious diseases: natural factors (climate and geography) and social factors (economy and population density). The existing evidence emphasizes the spatial heterogeneity in mpox distribution, indicating complexity and unevenness in the spatial patterns of mpox cases [Walter K, Malani PN. What is monkeypox? JAMA. 2022;328(2):222. [FREE Full text] [CrossRef] [Medline]25-Arotolu TE, Afe AE, Wang H, Lv J, Shi K, Huang L, et al. Spatial modeling and ecological suitability of monkeypox disease in southern Nigeria. PLoS One. 2022;17(9):e0274325. [FREE Full text] [CrossRef] [Medline]27]. This highlights the significance of conducting spatial analyses in mpox studies. However, there is a scarcity of reports on spatial analyses of mpox.
The attack rate is a crucial indicator for measuring the frequency and intensity of disease occurrence and for evaluating the effectiveness of disease prevention and control within a short period. Therefore, we conducted a spatial epidemiological analysis to comprehensively and accurately describe and analyze the mpox attack rate. Our analysis aimed to identify spatial distribution characteristics and spatial clustering patterns and to determine the presence of cold and hot spots of spatial clustering. Furthermore, we examined the spatial regression relationship between the mpox attack rate and sociodemographic and socioeconomic factors.
Methods
Study Design
A spatial ecological comparison study was designed to conduct a spatiotemporal epidemiological analysis of mpox attack rates in mainland China at a provincial level, focusing on spatiotemporal distribution characteristics and clustering patterns of the mpox attack rate and its spatial relationship with sociodemographic and socioeconomic factors.
Study Area
This study was conducted in 31 provinces of mainland China, excluding Taiwan, Macao, and Hong Kong (Table S1 in Supplementary Tables S1-S10. Spatial distribution of the study areas (A) and administrative divisions (B).Multimedia Appendix 1
Multimedia Appendix 2
Study Population
This study analyzed all the locally confirmed cases of mpox in mainland China that occurred between June and November 2023. As of November 30, 2023, a total of 1610 locally confirmed cases of mpox have been reported by the National Health Commission of China [Monkeypox pandemic. Chinese Center for Disease Control and Prevention. 2023. URL: https://www.chinacdc.cn/jkzt/crb/zl/szkb_13037/gnyq/ [accessed 2024-01-16] 11].
Mpox Attack Rate
The provincial-level crude mpox attack rates per 10 million people were calculated by dividing the total number of confirmed mpox cases in each province by its total population. This rate was multiplied by 10 million to obtain the rate per 10 million people.
Sociodemographic and Socioeconomic Variables
Sociodemographic variables included the proportion of the urban population (PUP), natural population growth rate (NPGR), percentage of the illiterate population older than 15 years (PIP), aging rate older than 65 years (AR), and per capita road area (PCRA) [The China statistical yearbook from national bureau of statistics of the People's Republic of China. National Bureau of Statistics of China. 2023. URL: https://www.stats.gov.cn/sj/ndsj/2023/indexch.htm [accessed 2023-12-17] 28]. Socioeconomic variables included the PCGDP, PCDI, per capita consumption expenditure (PCCE), and PCCE for health care (PCCEH) [The China statistical yearbook from national bureau of statistics of the People's Republic of China. National Bureau of Statistics of China. 2023. URL: https://www.stats.gov.cn/sj/ndsj/2023/indexch.htm [accessed 2023-12-17] 28].
Spatial Analysis
Spatial description and analysis were conducted using ArcGIS (version 9.0; Environmental Systems Research Institute, Inc), with the province as the spatial analysis unit. Thematic maps were created to visually and intuitively display the spatial distribution of the confirmed cases and attack rates of mpox.
Global spatial autocorrelation analysis was conducted to probe the presence of spatial clustering in mpox attack rates at a broader level [Wang Q, Dong W, Yang K, Ren Z, Huang D, Zhang P, et al. Temporal and spatial analysis of COVID-19 transmission in China and its influencing factors. Int J Infect Dis. 2021;105:675-685. [FREE Full text] [CrossRef] [Medline]22]. This analysis used the global Moran I statistic (–1 ≤ values ≤ +1). Spatial autocorrelation was considered to be present if the P value was below .10, with a test level α of .10. The values of Moran I indicate whether the spatial distribution of the mpox attack rates was random (Moran I=0), dispersed (Moran I<0), or clustered (Moran I>0). However, it is important to note that global spatial autocorrelation analysis does not provide information on specific local locations and patterns of spatial clustering.
To accurately identify the geographic locations and patterns of spatial clustering at the provincial level of mpox attack rates within the study area, a local spatial autocorrelation analysis was conducted. The analysis used Getis-Ord-Gi* and local Moran I statistics, which are commonly used spatial techniques for assessing local spatial autocorrelation [Wang Q, Dong W, Yang K, Ren Z, Huang D, Zhang P, et al. Temporal and spatial analysis of COVID-19 transmission in China and its influencing factors. Int J Infect Dis. 2021;105:675-685. [FREE Full text] [CrossRef] [Medline]22]. The Getis-Ord Gi* statistics identified 2 types of clustering: hot spots and cold spots. Hot spots are identified by positive z values, indicating that high values of mpox attack rates are clustered among neighboring provinces, while cold spots are identified by negative z values, indicating that low values of mpox attack rates are clustered among neighboring provinces. The corresponding z values for the Getis-Ord Gi* statistic at 90%, 95%, and 99% CIs are ±1.65, ±1.96, and ±2.58, respectively. The local Moran I statistic was used to verify and complement the Getis-Ord Gi* analysis, as it allows the detection of areas where spatial outliers exist. The results of the local Moran I highlighted aspects that may have been overlooked in the Getis-Ord Gi* analysis. Local Moran I examines 4 patterns of spatial clustering: high-high (HH) clustering (positive correlation; high values of mpox attack rates clustered among neighboring provinces), high-low (HL) outlier (negative correlation; provinces with high values of mpox attack rates surrounded by those with low values), low-high (LH) outlier (negative correlation; provinces with low values surrounded by those with high values), and low-low clustering (positive correlation; low values clustered among neighboring provinces).
This study used ordinary least squares (OLS) and geographically weighted regression (GWR) models to examine the spatial regression relationship between the mpox attack rates and sociodemographic and socioeconomic factors. The dependent variable was the cumulative mpox attack rate between June 1 and November 30, 2023, and sociodemographic and socioeconomic factors were considered independent variables. The OLS model was used to estimate the global parameters, whereas the GWR model was used to estimate the local parameters, considering the spatial autocorrelation and spatial heterogeneity of the research factors [Rahnama MR, Shaddel L. Urban green space is spatially associated with cardiovascular disease occurrence in women of Mashhad: a spatial analysis of influential factors on their presence in urban green spaces. J Urban Health. 2019;96(5):653-668. [FREE Full text] [CrossRef] [Medline]29,Fotheringham AS, Brunsdon C, Charlton M. Geographically Weighted Regression: The Analysis of Spatially Varying Relationships. Hoboken, NJ. John Wiley & Sons; 2002. 30]. The GWR model was constructed using the weighted least squares method, with the selection criterion and kernel function playing essential roles. The selection criterion determined the adaptive bandwidth size, while the kernel function calculated the weight matrix. This study used the fixed Gaussian and Akaike information criterion as the kernel function and selection criterion, respectively [Fotheringham AS, Brunsdon C, Charlton M. Geographically Weighted Regression: The Analysis of Spatially Varying Relationships. Hoboken, NJ. John Wiley & Sons; 2002. 30].
Ethical Considerations
This study was approved by the ethical committee of Qiqihar Medical University (approval number [2021] 31). This study adhered to the Helsinki Declaration.
Results
Spatiotemporal Distribution of Confirmed Cases and Attack Rates of Mpox
Between June 1 and November 30, 2023, a total of 1610 locally confirmed cases of mpox were reported in mainland China, resulting in an attack rate of 11.40 per 10 million people. The number of confirmed cases and the attack rate of mpox initially increased and then decreased during the study period, as depicted in Figure 1A-C. The peak period was observed between July and August, which accounted for 61.6% (n=992) of the total cases. In August 2023, mpox reached its highest level with 501 confirmed cases and an attack rate of 3.55 per 10 million people. However, by November, the number of confirmed cases and attack rate reached their lowest points and were even lower than the attack rate in June. There were 80 confirmed cases with an attack rate of 0.57 per 10 million people (
Figure 1A).

Between June 1 and November 30, 2023, a total of 30 provinces reported confirmed cases of mpox, with Xizang being the only province without any cases (Table S2 in Supplementary Tables S1-S10. Spatial distribution of the cumulative confirmed cases (A) and attack rates (B) of mpox. Supplementary Tables S1-S10. Spatial distribution of the cumulative confirmed cases (A) and attack rates (B) of mpox. Supplementary Tables S1-S10. Spatial distribution of the cumulative confirmed cases (A) and attack rates (B) of mpox.Multimedia Appendix 1
Multimedia Appendix 3
Multimedia Appendix 1
Multimedia Appendix 3
Multimedia Appendix 1
Multimedia Appendix 3
Figure 2A,B). Confirmed mpox cases were reported in 6 provinces in June, whereas in September, the number of regions reporting confirmed mpox cases rose to 28. However, from October to November 2023, there was a gradual decline in the number of regions reporting mpox cases (
Figure 2A,B). Beijing consistently exhibited the highest mpox attack rates (
Figure 2B). During July and August 2023, the number of confirmed cases and attack rates of mpox in various regions were particularly elevated, especially in Beijing, Guangdong, Shanghai, Sichuan, Tianjin, and Zhejiang provinces, when compared with other regions and months (
Figure 2A,B).

Multimedia Appendix 4
Higher resolution version of Figure 2.
PDF File (Adobe PDF File), 6887 KBMultimedia Appendix 4.Global Spatial Autocorrelation Analysis of Mpox Attack Rates
A global spatial autocorrelation analysis was conducted to examine the spatial patterns of mpox attack rates at the provincial level in mainland China (Table S3 in Supplementary Tables S1-S10.Multimedia Appendix 1
Figure 3).

Local Spatial Autocorrelation Analysis of Mpox Attack Rates
The Getis-Ord Gi* statistics revealed that Beijing and Tianjin consistently exhibited high mpox attack rates from June to October, categorizing them as hot spots. Shanghai was identified as a hot spot in August and October. Jiangsu and Hainan were identified as hot spots in October and November, respectively. No cold spots with low mpox attack rates were detected using the Getis-Ord Gi* statistics (Figure 4A).

Multimedia Appendix 5
Higher resolution version of Figure 4.
PDF File (Adobe PDF File), 5672 KBMultimedia Appendix 5.According to the results of the local Moran I statistics, Guangdong province consistently exhibited HH clustering in terms of spatial patterns of mpox attack rates from June to November. Beijing and Tianjin were identified as HH clusters from July to September. Beijing was identified as an HL outlier for June, October, and November. Sichuan was determined to be an HL outlier in July, August, and October. Tianjin was identified as an LH outlier in June and November. Jiangsu was identified as an LH outlier in October. Low-low clusters were mainly located in Inner Mongolia, Xinjiang, Xizang, Qinghai, and Gansu (Figure 4B). This implies that areas with low mpox attack rates are clustered in neighboring regions.
Spatial Regression Analysis Between Mpox Attack Rates and Sociodemographic and Socioeconomic Factors
The detailed values of the cumulative mpox attack rates and explanatory variables can be found in Tables S4 and S5 in Supplementary Tables S1-S10. Spatial distribution of the provincial-level values of explanatory variables. Correlation analysis between the cumulative mpox attack rates and explanatory variables.Multimedia Appendix 1
Multimedia Appendix 6
Multimedia Appendix 7
First, we used OLS regression models to explore the spatial regression relationship between the cumulative mpox attack rates from June 1 to November 30, 2023, as the dependent variable and sociodemographic and socioeconomic factors as independent variables. The cumulative mpox attack rates were not significantly correlated with the NPGR, PIP, AR, or PCRA; while they were significantly and positively associated with the PUP (t0.05/2,1=2.4041, P=.02), PCGDP (t0.05/2,1=2.6955, P=.01), PCDI (t0.05/2,1=2.8303, P=.008), PCCE (t0.05/2,1=2.7452, P=.01), and PCCEH (t0.05/2,1=2.5924, P=.01). The R2 values of the OLS models for the PUP, PCGDP, PCDI, PCCE, and PCCEH were 0.4190, 0.5743, 0.6469, 0.5583, and 0.5400, respectively; indicating that these 5 variables can explain the 41.90%, 57.43%, 64.69%, 55.83%, and 54% variance of cumulative mpox attack rates at the provincial level (Table S6 in Supplementary Tables S1-S10.Multimedia Appendix 1
The GWR regression models were created using only the statistically significant independent variables identified in the OLS regression models, along with the cumulative mpox attack rates. The coefficients and local R2 values of the explanatory variables in the GWR models are presented in Supplementary Tables S1-S10. Supplementary Tables S1-S10.Figure 5 and Tables S7-S10 in
Multimedia Appendix 1
Multimedia Appendix 1
Figure 5), with high R2 values in north and northeast China.

Multimedia Appendix 8
Higher resolution version of Figure 5.
PDF File (Adobe PDF File), 5597 KBMultimedia Appendix 8.Discussion
Principal Findings
This study is the first in mainland China to conduct a spatiotemporal epidemiological analysis to comprehensively identify the spatiotemporal characteristics and clustering patterns of confirmed cases and attack rates of mpox at the provincial level. The findings of this study are of great significance for improving the accuracy and effectiveness of mpox prevention and control.
Since June 2023, local cases of mpox have been reported in 30 of 31 provinces in mainland China, excluding Xizang [Monkeypox pandemic. Chinese Center for Disease Control and Prevention. 2023. URL: https://www.chinacdc.cn/jkzt/crb/zl/szkb_13037/gnyq/ [accessed 2024-01-16] 11]. In June, 6 provinces reported cases, which rose to 28 regions by September. However, from October to November 2023, there was a gradual decline in the number of regions reporting mpox cases. As of November 30, 2023, a total of 1610 locally confirmed cases of mpox have been reported [Monkeypox pandemic. Chinese Center for Disease Control and Prevention. 2023. URL: https://www.chinacdc.cn/jkzt/crb/zl/szkb_13037/gnyq/ [accessed 2024-01-16] 11]. The attack rate of mpox is 11.40 per 10 million. The number of confirmed cases and attack rate of mpox exhibited a pattern of increase from June to August, followed by a decrease from September to November. In November, both the number of confirmed cases and the attack rate reached their lowest points, even lower than the level observed in June. These findings highlight the importance of the implementation of preventive and control measures. On June 10, 2022, the National Health Commission of China formulated the “Diagnosis and Treatment Guidelines for Monkeypox (2022 edition)” [Diagnosis and treatment guidelines for monkeypox (2022 edition). National Health Commission of the People's Republic of China. 2022. URL: http://www.nhc.gov.cn/yzygj/s7653p/202206/d687b12fe8b84bbfaede2c7a5ca596ec.shtml [accessed 2023-12-20] 3]. Subsequently, on June 27, 2022, the National Health Commission of China released the Technical Guidelines for Monkeypox Prevention and Control (2022 edition) [Technical guidelines for monkeypox prevention and control (2022 edition). National Health Commission of the People's Republic of China. 2022. URL: http://www.nhc.gov.cn/yjb/s3577/202207/acd6016aaca543e29c16deb9b5ea3303.shtml [accessed 2023-12-20] 4]. The guidelines highlight 4 key areas for action: first, enhancing the evaluation of the mpox pandemic situation; second, intensifying quarantine and monitoring measures for mpox; third, enhancing the professional training of health care workers; and finally, ensuring the availability of diagnostic reagents, therapeutic drugs, and vaccines for mpox [State council prevention and control mechanism press conference. National Health Commission of the People's Republic of China. 2022. URL: http://www.nhc.gov.cn/xcs/s3574/202208/c2be77648c8640f0bf9c9dfbfb9c8430.shtml [accessed 2023-12-20] 31]. On July 26, 2023, the National Disease Control and Prevention Administration developed the Monkeypox Prevention and Control Plan [Monkeypox prevention and control plan. Chinese Center for Disease Control and Prevention. 2023. URL: https://www.chinacdc.cn/jkzt/crb/zl/szkb_13037/jswj/202307/t20230727_268170.html [accessed 2023-12-20] 32]. Subsequently, on August 2, 2023, the AIDS Prevention and Control Center of China created the Core Information of Monkeypox Prevention and Treatment for Key Populations, aiming to enhance awareness and prevention of mpox [Core information of monkeypox prevention and treatment for key populations. Chinese Center for Disease Control and Prevention. 2023. URL: https://www.chinacdc.cn/tzgg/202308/t20230802_268336.html [accessed 2023-12-20] 33]. On September 15, 2023, mpox was classified as a category B infectious disease for management by the National Health Commission of China, effective September 20, 2023 [Emergencies: international health regulations and emergency committees. World Health Organization. 2019. URL: https://www.who.int/zh/news-room/questions-and-answers/item/what-are-the-international-health-regulations-and-emergency-committees [accessed 2024-03-31] 14]. These guidelines provide guidance on the diagnosis, treatment, prevention, and control of mpox in various regions, which also emphasizes the need to strengthen prevention and control measures for mpox.
Although the number of regions reporting mpox cases, confirmed cases, and attack rates declined from October to November 2023, the first confirmed case of mpox was reported in Gansu Province in November 2023. Since January 1, 2022, China, including Taiwan, Macau, and Hong Kong, has ranked 10th globally in the number of confirmed mpox cases reported by the WHO [2022-24 Mpox (Monkeypox) outbreak: global trends. World Health Organization. 2023. URL: https://worldhealthorg.shinyapps.io/mpx_global/ [accessed 2024-01-14] 5]. The number of confirmed mpox cases in China (n=2031) was lower than that in the United States (n=31,800), Brazil (n=10,967), Spain (n=7898), France (n=4195), Colombia (n=4090), Mexico (n=4081), the United Kingdom (n=3892), Germany (n=3816), and Peru (n=3812). Therefore, mpox has emerged as a major public health emergency in mainland China, necessitating the implementation of effective prevention and control measures to minimize its impact. This is crucial for safeguarding public health and safety, as well as maintaining a stable social environment.
From June to November, the number of confirmed cases and attack rates of mpox exhibited spatiotemporal heterogeneity. Through local spatial autocorrelation analysis, the geographic locations and patterns of spatial clustering at the provincial level of mpox attack rates within the study areas were identified. The Getis-Ord Gi* statistics identified hot spots with high mpox attack rates in Beijing, Tianjin, Shanghai, Jiangsu, and Hainan provinces. Beijing and Tianjin exhibited consistently high mpox attack rates from June to October. The local Moran I statistic was used to validate and supplement the Getis-Ord Gi* analysis. Local Moran I statistics identified HH clustering in Guangdong, Beijing, and Tianjin, indicating that areas with high mpox attack rates were clustered among neighboring provinces. Among these provinces, Guangdong consistently exhibited HH clustering in terms of spatial patterns of mpox attack rates from June to November, while Beijing and Tianjin were identified as HH clusters from July to September. In June, October, and November, Beijing was identified as an HL outlier, suggesting that the areas with high mpox attack rates in Beijing were surrounded by other areas with low values. Similarly, Tianjin was recognized as an LH outlier in June and November, indicating that the areas with low mpox attack rates in Tianjin were surrounded by other areas with high values. This finding aligns with the identification of Beijing as an HL outlier in June and November, emphasizing the consistently high mpox attack rates in Beijing. Further research is necessary to comprehend the reasons behind these high attack rates in Beijing, with possible reasons including Beijing’s status as the capital and most densely populated area in China, along with the presence of a large floating population that may contribute to virus transmission. Therefore, the results of the local Moran I highlighted an HH clustering in Guangdong Province that had been overlooked in the Getis-Ord Gi* analysis and verified the result that Beijing and Tianjin were consistent hot spots identified by the Getis-Ord Gi* analysis. Additionally, Sichuan was identified as an HL outlier in July, August, and October, whereas Jiangsu was identified as an LH outlier in October, suggesting that the surrounding Shanghai and Zhejiang provinces had high mpox attack rates. Therefore, all the hot spots and HH clustering of mpox attack rates identified through local spatial autocorrelation analysis should be considered key areas for precision prevention and control of mpox. Specifically, the Guangdong, Beijing, and Tianjin provinces, which consistently exhibited high-value clustering, should be given high priority for mpox prevention and control. These findings provide geographically precise and visual evidence to assist in identifying key areas for the targeted prevention and control of mpox.
The GWR model was used to analyze the spatially varying relationships between independent and dependent variables while considering spatial autocorrelation [Ali S, Ran J, Luan Y, Khorrami B, Xiao Y, Tangdamrongsub N. The GWR model-based regional downscaling of GRACE/GRACE-FO derived groundwater storage to investigate local-scale variations in the North China Plain. Sci Total Environ. 2024;908:168239. [FREE Full text] [CrossRef] [Medline]34]. It used the weighted least squares method to estimate varying parameters locally, allowing for varied spatial relationships across different geographical regions. This localized approach facilitated the identification of spatial heterogeneity, revealing trends and distribution patterns of the spatial relationship between independent and dependent variables within specific spatial extents [Fotheringham AS, Brunsdon C, Charlton M. Geographically Weighted Regression: The Analysis of Spatially Varying Relationships. Hoboken, NJ. John Wiley & Sons; 2002. 30,Ali S, Ran J, Luan Y, Khorrami B, Xiao Y, Tangdamrongsub N. The GWR model-based regional downscaling of GRACE/GRACE-FO derived groundwater storage to investigate local-scale variations in the North China Plain. Sci Total Environ. 2024;908:168239. [FREE Full text] [CrossRef] [Medline]34]. In contrast, the OLS model estimated parameters using the OLS method, assuming that spatial relationships in the model were constant across space [Fotheringham AS, Brunsdon C, Charlton M. Geographically Weighted Regression: The Analysis of Spatially Varying Relationships. Hoboken, NJ. John Wiley & Sons; 2002. 30]. However, this global parameter estimation with constant parameters overlooks spatial heterogeneity in the data and fails to capture spatial variation trends [Fotheringham AS, Brunsdon C, Charlton M. Geographically Weighted Regression: The Analysis of Spatially Varying Relationships. Hoboken, NJ. John Wiley & Sons; 2002. 30]. In this study, the GWR model revealed a positive association and spatial heterogeneity between the cumulative mpox attack rates and the PUP, PCGDP, PCDI, and PCCE. This finding aligns with the results obtained from the application of the Getis-Ord Gi* statistics, which identified hot spots in the Beijing, Tianjin, Shanghai, Jiangsu, and Hainan provinces. Furthermore, the results of the Local Moran I statistics also supported this finding, indicating HH clustering in Guangdong, Beijing, and Tianjin and HL outliers in Sichuan. These areas, which were identified as key regions for the precise prevention and control of mpox through local autocorrelation analysis, are characterized by robust economic development [The China statistical yearbook from national bureau of statistics of the People's Republic of China. National Bureau of Statistics of China. 2023. URL: https://www.stats.gov.cn/sj/ndsj/2023/indexch.htm [accessed 2023-12-17] 28].
Limitations
This study had 2 limitations. First, the spatial analysis was conducted at the provincial level, and further studies should consider smaller geographic units for more accurate evidence. Second, this study focused solely on the relationship between cumulative mpox attack rates and sociodemographic and socioeconomic factors; future studies should also consider natural and environmental risk factors.
Conclusions
A total of 1610 locally confirmed mpox cases were reported in 30 provinces in mainland China from June to November 2023, resulting in an attack rate of 11.40 per 10 million people. The hot spots and HH clustering of mpox attack rates should be considered as key areas for precision prevention and control of mpox. Specifically, Guangdong, Beijing, and Tianjin should be given high priority for mpox prevention and control. These findings provide geographically precise and visual evidence for identifying key areas for targeted prevention and control.
Acknowledgments
The authors sincerely thank the workers at the Centers for Disease Prevention and Control for their efforts in collecting and managing data on confirmed cases of Mpox. The authors express their deepest gratitude to Editage (Cactus Communications Private Limited) for their assistance with language editing. This study was supported by the Doctorate Research Foundation of the Qiqihar Medical University (grant QMSI2023B-16). Generative artificial intelligence had no role in the study design and any portion of the manuscript writing.
Data Availability
The data sets used or analyzed during the current study are available from the corresponding author on reasonable request.
Authors' Contributions
YJ and JG did the conceptualization, formal analysis, funding acquisition, and methodology, wrote the original draft, and reviewed and edited the draft. LQ, LD, YQ, LB, and JG did the conceptualization, supervision, and project administration. XC, SM, YH, ZX, and JC did the data curation, software, and formal analysis. All authors read and approved the final manuscript.
Conflicts of Interest
None declared.
Multimedia Appendix 2
Spatial distribution of the study areas (A) and administrative divisions (B).
PNG File , 318 KBMultimedia Appendix 3
Spatial distribution of the cumulative confirmed cases (A) and attack rates (B) of mpox.
PNG File , 2007 KBMultimedia Appendix 6
Spatial distribution of the provincial-level values of explanatory variables.
PNG File , 472 KBMultimedia Appendix 7
Correlation analysis between the cumulative mpox attack rates and explanatory variables.
PNG File , 3527 KBReferences
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Abbreviations
AR: aging rate |
GWR: geographically weighted regression |
HH: high-high |
HL: high-low |
LH: low-high |
NPGR: natural population growth rate |
OLS: ordinary least square |
PCCE: per capita consumption expenditure |
PCCEH: per capita consumption expenditure for health care |
PCDI: per capita disposable income |
PCGDP: per capita gross domestic product |
PCRA: per capita road area |
PUP: proportion of the urban population |
WHO: World Health Organization |
Edited by A Mavragani; submitted 27.02.24; peer-reviewed by T Wang, JR Medina; comments to author 20.03.24; revised version received 08.04.24; accepted 29.04.24; published 19.06.24.
Copyright©Shuli Ma, Jie Ge, Lei Qin, Xiaoting Chen, Linlin Du, Yanbo Qi, Li Bai, Yunfeng Han, Zhiping Xie, Jiaxin Chen, Yuehui Jia. Originally published in JMIR Public Health and Surveillance (https://publichealth.jmir.org), 19.06.2024.
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