Changing patterns of viral hepatitis mortality—China, 1987-2021

Viral hepatitis (VH) continues to pose a serious global health problem, causing approximately 1.34 million deaths annually. China, in particular, bears the heaviest VH burden in the world. To this end, we have implemented major strategies and made significant progress in VH prevention (1). However, significant gaps remain in the evidence regarding the effectiveness of these prevention efforts and the impact of age, period and cohort on changing VH patterns. To address these gaps, we conducted an extensive analysis of VH mortality from 1987 to 2021, investigating the impact of these three factors. Our analysis aims to provide policymakers with fundamental insights into developing strategic intervention plans. Our study demonstrated a significant decrease in VH mortality, suggesting a strong success of applicable prevention strategies. However, it also highlights a prominent new challenge unique to older adults that requires increased attention and the development of targeted intervention strategies.

This study obtained VH deaths by age, sex, and urban and rural sector from 1987 to 2021 from the Chinese Death Registration System National Health Commission (1954-2013, Ministry of Health; 2013-2018, National Health and Family Planning Commission) rate data. To calculate age-standardized mortality rates per 100,000 people, we used a direct standardization method based on the world standard population. To identify significant fluctuations and determine the independent effects of age, period, and cohort, we used junction regression and age-period-cohort (APC) models (age-standardized mortality rates per 100,000 people. We used a direct standardization approach using world standard population. To identify significant fluctuations and determine the independent effects of age, period and cohort, we used joinpoint regression and APC models (2).

This study explores changing patterns in urban and rural areas of China from 1987 to 2021 and evaluates the effects of age, period, and cohort on VH mortality.

figure 1 Evolving trends in VH mortality from 1987 to 2021 are highlighted. During this period, continued downward trends were observed in both urban and rural populations. More specifically, the VH mortality rate in the urban population decreased from 2.76 per 100,000 in 1988 to 1.36 per 100,000 in 2021. Likewise, in rural areas, these statistics dropped from 2.59 to 1.81. Detailed analysis showed that VH mortality showed a continuous downward trend until 2004, regardless of location, whether urban or rural. However, between 2004 and 2015, VH mortality rebounded, then subsided and resumed the initial downward trend until 2021. In terms of gender differences, VH mortality was higher in males than in females. The pattern was consistent in both urban and rural settings.

Table 1 The results of joinpoint regression analysis are presented, showing a decrease in VH mortality in both urban and rural areas, with higher rates of decline in urban areas. The table also shows trends over time and highlights gender differences, noting that VH mortality has declined more significantly in women than in men.

figure 2 The results of the APC model analysis are presented. VH mortality increased with age in both urban and rural parameters. This trend is more pronounced in rural areas than in cities. When stratified by sex, men consistently showed a higher risk than women regardless of geographic classification.

In terms of period effects, there was a general decline in urban and rural demographics throughout the study period. However, there was a clear recovery in urban areas from 2004 to 2009 and in rural areas from 2004 to 2015. These recoveries did not show significant gender differences.

Observation of cohort effects suggested a conservative pattern for urban and rural populations; both showed an initial increase in risk followed by a decrease in risk. Among urban populations, the year 1931 was the peak period of risk (hazard ratio (RR)=1.53, 95% confidence interval (I see): 1.37–1.70), with lower risk among those born after 1961. Before 1961, women were at higher risk, but this pattern was reversed among those born after 1961. In rural areas, those born in 1966 showed the greatest risk (RR=1.23, 95% I see:1.10–1.39). Specifically, the risk increases as the cohort approaches 1961, while the risk decreases for more distant cohorts. Similar to urban populations, risk rates were higher for women before 1961, but this trend reversed thereafter.