Trends in incidence and DALYs of infectious disease from 2000 to 2023 and the attributable risk factors in China: an analysis of the Global Burden of Disease Study 2023.

Background: Infectious diseases remain a major source of health loss, yet long-term, cause-comparable assessments that jointly integrate incidence, disability-adjusted life-years (DALYs), age patterns, and risk attribution for China are fragmented and not comprehensively synthesized within a unified framework. We aimed to evaluate the trends in incidence and DALYs of infectious diseases in China from 2000 to 2023 to inform current priority setting by clarifying long-term trends and changes observed during the COVID-19 pandemic. Methods: Data on the number and rate of incidence and DALYs of five major infectious-disease cause groups (HIV/AIDS and sexually transmitted infections, respiratory infections and tuberculosis, enteric infections, neglected tropical diseases and malaria, and other infectious diseases) and 40 specific infectious diseases in China were obtained from the Global Burden of Disease Study (GBD) 2023. Estimated annual percentage changes (EAPCs) in age-standardized incidence rates (ASIRs) and age-standardized DALY rates (ASDRs) were calculated overall and by sex and age group to quantify temporal trends from 2000 to 2023. We conducted comparative risk assessment using population attributable fractions (PAFs) to quantify risk-attributable DALYs, and decomposition analyses to assess the contributions of population growth, population ageing and epidemiologic change to changes in incident cases, deaths, and DALYs. Sensitivity analyses were also conducted to examine the robustness of the results. Findings: From 2000 to 2023, age-standardized DALY rates declined in four of the five major infectious disease cause groups in China. The largest decrease was observed for enteric infections, with DALY rates falling from 365.4 to 43.8 per 100,000 (EAPC -11.0% [95% CI -12.2 to -9.7]). Among all groups, respiratory infections and tuberculosis had the highest DALY burden throughout the study period, while their DALY rates decreased from 2559.5 to 688.1 per 100,000 (EAPC -8.1% [-9.2 to -7.0]). It's estimated that HIV/AIDS and sexually transmitted infections were the only cause group with an increasing DALY rate, rising from 79.7 to 103.7 per 100,000 (EAPC 1.0% [0.6 to 1.4]). The increase was greatest among adults aged 20-54 years, in whom DALY rates rose from 71.1 to 152.0 per 100,000 (EAPC 3.3% [2.7 to 3.9]). Risk attribution varied by cause and age group. Unsafe sex accounted for most DALYs for sexually transmitted infections excluding HIV and more than 70% of HIV/AIDS DALYs. For lower respiratory infections, child and maternal malnutrition accounted for 42.2% of DALYs in those aged < 20 years, whereas tobacco use accounted for 38.1% in adults aged 20-54 years. Enteric infection DALYs were mainly attributable to unsafe water, sanitation, and handwashing, accounting for more than 70% across age groups. Decomposition analysis showed that epidemiologic change was the main driver of changes in infectious disease burden from 2000 to 2023. Interpretation: China's infectious disease DALY burden declined from 2000 to 2023, but progress was uneven across causes and increasingly concentrated in older adults. Persistent incidence-DALY discordance and heterogeneous age-specific risk profiles indicate that current priority setting should move beyond incidence-led targets towards reducing preventable disability and premature mortality through age- and mechanism-tailored prevention and care. Funding: Prevention and Control of Emerging and Major Infectious Diseases-National Science and Technology Major Project.