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Background  Rabies is a significant public health problem in China. Previous spatial epidemiological studies have helped understand the epidemiology of animal and human rabies in China. However, quantification of effects derived from relevant factors was insufficient and complex spatial interactions were not well articulated, which may lead to non-negligible bias. In this study, we aimed to quantify the role of socio-economic and climate factors in the spatial distribution of human rabies to support decision making pertaining to rabies control in China.    Methods  We conducted a multivariate analysis of human rabies in China with explicit consideration for spatial heterogeneity and spatial dependence effects. The panel of 20,368 cases reported between 2005 and 2013 and their socio-economic and climate factors was implemented in regression models. Several significant covariates were extracted, including the longitude, the average temperature, the distance to county center, the distance to the road network and the distance to the nearest rabies case. The GMM was adopted to provide unbiased estimation with respect to heterogeneity and spatial autocorrelation.    Results  The analysis explained the inferred relationships between the counts of cases aggregated to 271 spatially-defined cells and the explanatory variables. The results suggested that temperature, longitude, the distance to county centers and the distance to the road network are positively associated with the local incidence of human rabies while the distance to newly occurred rabies cases has a negative correlation. With heterogeneity and spatial autocorrelation taken into consideration, the estimation of regression models performed better.    Conclusions  It was found that climatic and socioeconomic factors have significant influence on the spread of human rabies in China as they continuously affect the living environments of humans and animals, which critically impacts on how timely local citizens can gain access to post-exposure prophylactic services. Moreover, through comparisons between traditional regression models and the aggregation model that allows for heterogeneity and spatial effects, we demonstrated the validity and advantage of the aggregation model. It outperformed the existing models and decreased the estimation bias brought by omission of the spatial heterogeneity and spatial dependence effects. Statistical results are readily translated into public health policy takeaways.

The role of socioeconomic and climatic factors in the spatio-temporal variation of human rabies in China