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Giguere R, Balán IC, Kutner BA, Choi SK, Tingler R, Johnson S, Macagna N, Webster J, Liu A, Chariyalertsak S, Hoesley C, Gonzales P, Ho K, Kayange N, Palanee-Phillips T, Brown E, Zemanek J, Jacobson CE, Doncel GF, Piper J, Bauermeister JA. History of Rectal Product Use and Country of Residence Influence Preference for Rectal Microbicide Dosage Forms Among Young Sexual and Gender Minorities: A Multi-country Trial Comparing Placebo Douche, Suppository, and Insert Products. AIDS Behav 2024; 28:2577-2589. [PMID: 38740628 DOI: 10.1007/s10461-024-04360-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/26/2024] [Indexed: 05/16/2024]
Abstract
The DESIRE Study (MTN-035) explored product preference among three placebo rectal microbicide (RM) formulations, a rectal douche (RD), a suppository, and an insert, among 210 sexually active transgender people and men who have sex with men in five counties: the United States, Peru, Thailand, South Africa, and Malawi. Participants used each product prior to receptive anal sex (RAS) for 1 month, following a randomly assigned sequence, then selected their preferred product via computer assisted self-interview. In-depth interviews examined reasons for preference. We compared product preference and prior product use by country to explore whether geographic location and experience with the similar products impacted preference. A majority in the United States (56%) and Peru (58%) and nearly half in South Africa (48%) preferred the douche. Most in Malawi (59%) preferred the suppository, while half in Thailand (50%) and nearly half in South Africa (47%) preferred the insert. Participants who preferred the douche described it as quick and easy, already routinized, and serving a dual purpose of cleansing and protecting. Those who preferred the insert found it small, portable, discreet, with quick dissolution. Those who preferred the suppository found the size and shape acceptable and liked the added lubrication it provided. Experience with product use varied by country. Participants with RD experience were significantly more likely to prefer the douche (p = 0.03). Diversifying availability of multiple RM dosage forms can increase uptake and improve HIV prevention efforts globally.
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Affiliation(s)
- Rebecca Giguere
- Division of Gender, Sexuality and Health, HIV Center for Clinical and Behavioral Research, New York State Psychiatric Institute and Columbia University, New York, NY, USA.
- Center for Translational Behavioral Science, College of Medicine, Florida State University, Tallahassee, FL, USA.
| | - Iván C Balán
- Center for Translational Behavioral Science, College of Medicine, Florida State University, Tallahassee, FL, USA
| | - Bryan A Kutner
- Division of Gender, Sexuality and Health, HIV Center for Clinical and Behavioral Research, New York State Psychiatric Institute and Columbia University, New York, NY, USA
- Psychiatry Research Institute at Montefiore Einstein (PRIME), Albert Einstein College of Medicine, Bronx, NY, USA
| | - Seul Ki Choi
- University of Pennsylvania, Philadelphia, PA, USA
| | - Ryan Tingler
- University of Pennsylvania, Philadelphia, PA, USA
| | | | | | | | - Al Liu
- Bridge HIV at the San Francisco Department of Public Health, San Francisco, CA, USA
| | - Suwat Chariyalertsak
- Research Institute for Health Sciences, Chiang Mai University, Chiang Mai, Thailand
| | - Craig Hoesley
- University of Alabama at Birmingham, Birmingham, AL, USA
| | - Pedro Gonzales
- IMPACTA Asociación Civil, Impacta Salud y Educación, San Miguel CES, Lima, Peru
| | - Ken Ho
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Noel Kayange
- Blanytre CRS, Johns Hopkins University Research Project, Blantyre, Malawi
| | - Thesla Palanee-Phillips
- Wits RHI, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
- Department of Epidemiology, School of Public Health, University of Washington, Seattle, WA, USA
| | - Elizabeth Brown
- Statistical Center for HIV/AIDS Research & Prevention, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Jillian Zemanek
- Statistical Center for HIV/AIDS Research & Prevention, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | | | | | - Jeanna Piper
- Division of AIDS, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
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Rectal Douching and Anal Human Papillomavirus Among Young Men Who Have Sex With Men in China. Sex Transm Dis 2021; 48:550-556. [PMID: 34110748 DOI: 10.1097/olq.0000000000001392] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Young men who have sex with men (YMSM) are particularly at increased risk for human papillomavirus (HPV) infection and related malignancies. Rectal douching, commonly practiced among MSM, has been associated with HIV, chlamydia, gonorrhea, and viral hepatitis in cross-sectional studies. We conducted this study to understand the association between self-reported rectal douching and anal HPV among YMSM in China. METHODS Between September 2018 and March 2019, MSM aged 15 to 24 years who ever engaged in receptive anal intercourse over the last 3 months were recruited via community-based organizations and centers for disease control located in 4 cities in China. Participants were asked to complete an online survey. We performed multivariate logistic regression adjusted for potential confounders to examine the association between self-reported rectal douching and anal HPV. RESULTS Among 273 MSM with a median age of 20 years (interquartile range, 19-21 years) included in this study, 130 (47.6%) practiced rectal douching during the preceding 3 months and 96 (36.2%) were infected with anal HPV. Self-reported rectal douching was found to be associated with increased odds of anal HPV infection (odds ratio, 2.16; 95% confidence interval, 1.22-3.82) among YMSM, after adjusting for age, sexual debut, sex with alcohol or drugs, and HIV testing history. CONCLUSIONS Self-reported rectal douching is associated with higher odds of anal HPV infection independent of sexual behaviors among YMSM. More prospective studies to ascertain this association are needed. Health education materials should inform men of the potential risk of rectal douching. Research on safer rectal douching procedures is warranted.
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Chu ZX, Shen G, Hu Q, Wang H, Zhang J, Dong W, Jiang Y, Geng W, Shang H, Xu J. The use of inappropriate anal douching tool associates with increased HIV infection among men who have sex with men: a cross-sectional study in Shenyang, China. BMC Public Health 2021; 21:235. [PMID: 33509136 PMCID: PMC7844917 DOI: 10.1186/s12889-021-10276-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 01/19/2021] [Indexed: 11/10/2022] Open
Abstract
Background Rectal douching (RD) is widely practiced by men who have sex with men (MSM), and is associated with increased risk of HIV infection. However, the mechanism of how RD increases the risk of HIV infection is not well understood, and there is limited data on RD behavior in MSM practicing anal sex in China. We examine the purpose of RD, its timing in relation to anal sex, the types of RD products used, and risky sexual behaviors among MSM reporting anal sex. Methods Between August 2017 and December 2018, a cross-sectional study was conducted among adult MSM in Shenyang, China. Data were collected on demographics, sexual behaviors, and RD for the most recent sexual intercourse by means of interviewer-administered face-to-face questionnaires. Blood samples were collected to test for antibodies to HIV and syphilis. Multivariable logistic regression models were used to assess the risk factors associated with HIV infection. Results A total of 515 eligible MSM participated in this survey (median age: 31 years). During the most recent anal intercourse, 28.3% (146/515) had condomless receptive anal intercourse (CRAI), 21.4% (110/515) practiced serosorting, and more than half (61.6%, 317/515) reported RD before or after anal sex. Of those practicing RD, 96.8% (307/317) conducted RD before sex, while 62.5% (198/317) conducted RD after sex. The douching devices used were primarily shower hoses (85.3%, 262/307), and relatively few MSM used commercial RD products (8.1%, 25/307) before sex. The prevalence of HIV-1 and syphilis was 11.7% and 13.2%, respectively. HIV infection was positively associated with RD, practicing RD before sex, the interaction between RD and CRAI using a shower hose for RD and other risk factors, practicing RD after sex, CRAI, using nitrite inhalants, main sexual role with males as bottom and syphilis infection. Conclusions RD is popular among Chinese MSM. Improper noncommercial RD tools use (such as shower hose), the interaction effect between RD and CRAI associated with HIV infection. Public health workers and the MSM community should publicize scientific knowledge and prevention approaches relating to RD and HIV transmission to MSM. We recommend that further studies should be conducted to understand the detailed mechanism between RD and increased HIV prevalence. Supplementary Information The online version contains supplementary material available at 10.1186/s12889-021-10276-z.
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Affiliation(s)
- Zhen Xing Chu
- NHC Key Laboratory of AIDS Immunology (China Medical University), National Clinical Research Center for Laboratory Medicine, The First Affiliated Hospital of China Medical University, No. 155, Nanjingbei Street, Heping District, Shenyang, 110001, Liaoning Province, China.,Key Laboratory of AIDS Immunology of Liaoning Province, The First Affiliated Hospital of China Medical University, Shenyang, 110001, China.,Key Laboratory of AIDS Immunology, Chinese Academy of Medical Sciences, Shenyang, 110001, China.,Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, 79 Qingchun Street, Hangzhou, 310003, China
| | - Guangquan Shen
- The Southern Medical University Institute for Global Health and Sexually Transmitted Diseases, Guangzhou, China.,SESH Global, Guangzhou, China.,University of North Carolina Project-China, Guangzhou, China
| | - Qinghai Hu
- NHC Key Laboratory of AIDS Immunology (China Medical University), National Clinical Research Center for Laboratory Medicine, The First Affiliated Hospital of China Medical University, No. 155, Nanjingbei Street, Heping District, Shenyang, 110001, Liaoning Province, China.,Key Laboratory of AIDS Immunology of Liaoning Province, The First Affiliated Hospital of China Medical University, Shenyang, 110001, China.,Key Laboratory of AIDS Immunology, Chinese Academy of Medical Sciences, Shenyang, 110001, China.,Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, 79 Qingchun Street, Hangzhou, 310003, China
| | - Hongyi Wang
- NHC Key Laboratory of AIDS Immunology (China Medical University), National Clinical Research Center for Laboratory Medicine, The First Affiliated Hospital of China Medical University, No. 155, Nanjingbei Street, Heping District, Shenyang, 110001, Liaoning Province, China.,Key Laboratory of AIDS Immunology of Liaoning Province, The First Affiliated Hospital of China Medical University, Shenyang, 110001, China.,Key Laboratory of AIDS Immunology, Chinese Academy of Medical Sciences, Shenyang, 110001, China.,Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, 79 Qingchun Street, Hangzhou, 310003, China
| | - Jing Zhang
- NHC Key Laboratory of AIDS Immunology (China Medical University), National Clinical Research Center for Laboratory Medicine, The First Affiliated Hospital of China Medical University, No. 155, Nanjingbei Street, Heping District, Shenyang, 110001, Liaoning Province, China.,Key Laboratory of AIDS Immunology of Liaoning Province, The First Affiliated Hospital of China Medical University, Shenyang, 110001, China.,Key Laboratory of AIDS Immunology, Chinese Academy of Medical Sciences, Shenyang, 110001, China.,Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, 79 Qingchun Street, Hangzhou, 310003, China
| | - Willa Dong
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Yongjun Jiang
- NHC Key Laboratory of AIDS Immunology (China Medical University), National Clinical Research Center for Laboratory Medicine, The First Affiliated Hospital of China Medical University, No. 155, Nanjingbei Street, Heping District, Shenyang, 110001, Liaoning Province, China.,Key Laboratory of AIDS Immunology of Liaoning Province, The First Affiliated Hospital of China Medical University, Shenyang, 110001, China.,Key Laboratory of AIDS Immunology, Chinese Academy of Medical Sciences, Shenyang, 110001, China.,Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, 79 Qingchun Street, Hangzhou, 310003, China
| | - Wenqing Geng
- NHC Key Laboratory of AIDS Immunology (China Medical University), National Clinical Research Center for Laboratory Medicine, The First Affiliated Hospital of China Medical University, No. 155, Nanjingbei Street, Heping District, Shenyang, 110001, Liaoning Province, China.,Key Laboratory of AIDS Immunology of Liaoning Province, The First Affiliated Hospital of China Medical University, Shenyang, 110001, China.,Key Laboratory of AIDS Immunology, Chinese Academy of Medical Sciences, Shenyang, 110001, China.,Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, 79 Qingchun Street, Hangzhou, 310003, China
| | - Hong Shang
- NHC Key Laboratory of AIDS Immunology (China Medical University), National Clinical Research Center for Laboratory Medicine, The First Affiliated Hospital of China Medical University, No. 155, Nanjingbei Street, Heping District, Shenyang, 110001, Liaoning Province, China. .,Key Laboratory of AIDS Immunology of Liaoning Province, The First Affiliated Hospital of China Medical University, Shenyang, 110001, China. .,Key Laboratory of AIDS Immunology, Chinese Academy of Medical Sciences, Shenyang, 110001, China. .,Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, 79 Qingchun Street, Hangzhou, 310003, China.
| | - Junjie Xu
- NHC Key Laboratory of AIDS Immunology (China Medical University), National Clinical Research Center for Laboratory Medicine, The First Affiliated Hospital of China Medical University, No. 155, Nanjingbei Street, Heping District, Shenyang, 110001, Liaoning Province, China. .,Key Laboratory of AIDS Immunology of Liaoning Province, The First Affiliated Hospital of China Medical University, Shenyang, 110001, China. .,Key Laboratory of AIDS Immunology, Chinese Academy of Medical Sciences, Shenyang, 110001, China. .,Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, 79 Qingchun Street, Hangzhou, 310003, China.
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Li P, Yuan T, Wang Z, Huang R, Meng X, Zhang K, Wang G, Zhou Y, Luo D, Wang Y, Cai Y, Zou H. Rectal douching among men who have sex with men in six cities in China: a cross-sectional study. Sex Health 2021; 17:437-443. [PMID: 33497599 DOI: 10.1071/sh19239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2019] [Accepted: 07/28/2020] [Indexed: 11/23/2022]
Abstract
Background Rectal douching, which is a common practice among men who have sex men (MSM) as a preparation for anal sex, may potentially increase the risk of HIV infection. However, little is known about the practice of rectal douching among Chinese MSM. This study investigated the characteristics of rectal douching and factors associated with rectal douching. METHODS Between January and March 2019, MSM aged ≥18 years in six cities in China were recruited to the study. Participants were asked to complete a self-administered online questionnaire. Chi-squared tests and multivariable logistic regression were used to examine factors associated with rectal douching by calculating odds ratios (ORs) and 95% confidence intervals (CIs). RESULTS Of 485 MSM in this study, 278 (57.3%) practiced rectal douching in the preceding 6 months. The most common reasons for douching before and after anal sex were hygiene/cleanliness (78.6% and 66.1% respectively) and HIV/STI prevention (8.5% and 17.4% respectively). The most used enemas and equipment before and after anal sex were tap water (73.5% and 70.2% respectively) and showerhead hoses (76.1% and 75.2% respectively). Men who engaged in both insertive and receptive anal sex (OR 8.84; 95% CI 4.52-17.30), exclusively receptive anal sex (OR 6.56; 95% CI 3.55-12.13), condom-less anal intercourse (OR 1.64; 95% CI 1.03-2.63) and anal sex after alcohol use (OR 1.54; 95% CI 1.00-2.35) were more likely to perform douching. CONCLUSION Rectal douching is common in MSM, some of whom may not realise the potential risks associated with douching. The co-occurrence of douching and other high-risk behaviours would make MSM more vulnerable to HIV. Health education aimed at informing MSM of the potential risks and addressing the high prevalence of douching are urgently needed.
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Affiliation(s)
- Peiyang Li
- School of Public Health, Sun Yat-sen University, Guangzhou 510080, PR China
| | - Tanwei Yuan
- School of Public Health (Shenzhen), Sun Yat-sen University, Shenzhen 510006, PR China
| | - Zhenyu Wang
- School of Public Health, Sun Yat-sen University, Guangzhou 510080, PR China
| | - Ruonan Huang
- School of Public Health, Sun Yat-sen University, Guangzhou 510080, PR China
| | - Xiaojun Meng
- Wuxi Municipal Center for Disease Control and Prevention, Wuxi 214000, PR China
| | - Kechun Zhang
- Shenzhen Longhua District Center for Disease Control and Prevention, Shenzhen 518000, PR China
| | - Guanghui Wang
- Qingdao Qingtong AIDS Prevention Volunteer Service Center, Qingdao 266000, PR China
| | - Yepeng Zhou
- Foshan Friends Care Center for AIDS/HIV Control, Foshan 528000, PR China
| | - Danyang Luo
- Zhitong Guangzhou LGBT Center, Guangzhou 510000, PR China
| | - Ying Wang
- School of Public Health, Shanghai Jiao Tong University School of Medicine, Shanghai 200000, PR China
| | - Yong Cai
- School of Public Health, Shanghai Jiao Tong University School of Medicine, Shanghai 200000, PR China
| | - Huachun Zou
- School of Public Health (Shenzhen), Sun Yat-sen University, Shenzhen 510006, PR China; and Kirby Institute, UNSW Sydney, Sydney, NSW 2052, Australia; and Corresponding author.
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Tingler RC, Connochie D, Bauermeister JA. Rectal Douching and Microbicide Acceptability among Young Men who Have Sex with Men. AIDS Behav 2020; 24:1414-1421. [PMID: 31473846 DOI: 10.1007/s10461-019-02662-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Men who have sex with men (MSM) commonly report engaging in rectal douching (RD) practices prior to receptive anal intercourse. Researchers are interested in the possibility of designing a RD with a microbicide component. In our analyses, we examined whether YMSM who engaged in RD behaviors differ in HIV prevention behaviors from their non-RD peers. We then examined whether RD frequency was associated with rectal microbicide acceptability. Half the participants (47.8%) reported having ever douched. Participants were more likely to douche if they were racial/ethnic minorities (AOR = 2.24, p = 0.02) and had recently tested for HIV (AOR = 1.96, p = 0.04). Greater douching frequency was associated with racial/ethnic minorities (β = 0.20, p = 0.009) and recent HIV testing (β = 0.19, p < 0.01). Participants who reported frequently douching indicated greater microbicide acceptability (β = 0.32, p < 0.001). Designing behaviorally congruent products remains a priority in next generation Pre-Exposure Prophylaxis (PrEP) and a rectal douche might be an additional tool if found to be efficacious.
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Abstract
BACKGROUND Among men who have sex with men (MSM), rectal douching (RD) has been associated with increased prevalence of human immunodeficiency virus and other sexually transmitted infections. Substances commonly used for RD, especially water-based solutions, could disrupt the rectal epithelium and increase susceptibility to infection. The few existing reports on RD among MSM are primarily in middle- and high-income settings, and to date, no study has focused on RD among MSM in Africa. METHODS We conducted a secondary data analysis of programmatic data from key population service centers in western Kenya. Data were extracted from records of clients who identified as MSM and accessed services between January 1, 2014, and September 1, 2016. We compared demographic and behavioral characteristics of men who did and did not practice RD. Logistic regression assessed associations with RD. RESULTS Of the 202 MSM in this analysis, 63% engaged in RD. All who engaged in RD used water-based substances. Those who engaged in receptive anal intercourse in the last 3 months were more likely to report RD (odds ratio, 3.19; 95% confidence interval, 1.67-6.07). Among MSM who engaged in sex work, those who practiced RD reported more regular clients per week (2.8 clients vs. 1.3 clients, P = 0.01). Rectal douching practices did not vary by other sexual risk practices. CONCLUSIONS Rectal douching is common in this population of Kenyan MSM, especially among those who have recently engaged in receptive anal intercourse, suggesting that a rectal douche that delivers microbicides could be a potential intervention to reduce human immunodeficiency virus/sexually transmitted infection within this population.
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Li P, Yuan T, Fitzpatrick T, Smith K, Zhao J, Wu G, Ouyang L, Wang Y, Zhang K, Zhou Y, Li M, Chen D, Li L, Cai W, Cai Y, Zou H. Association between rectal douching and HIV and other sexually transmitted infections among men who have sex with men: a systematic review and meta-analysis. Sex Transm Infect 2019; 95:428-436. [PMID: 31073094 DOI: 10.1136/sextrans-2019-053964] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Revised: 04/13/2019] [Accepted: 04/18/2019] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Men who have sex with men (MSM) are disproportionately affected by HIV and other STIs worldwide. Rectal douching, which is commonly used by MSM in preparation for anal sex, may increase the risk of HIV and other STIs by injuring the rectal mucosa. Results from individual studies reporting associations between rectal douching and HIV and other STIs among MSM are inconsistent. We performed a systematic review and meta-analysis to estimate the association between rectal douching and HIV and other STIs among MSM. METHODS We searched PubMed, Embase, Scopus and Web of Science for studies published from January 1970 to November 2018. Studies that reported ORs and 95% CIs of associations between rectal douching and infection with HIV/STIs, or reported enough data to calculate these estimates, were included. We assessed risk of bias using the Newcastle-Ottawa Scale. ORs were pooled using a random effects model. RESULTS Twenty-eight eligible studies were identified in our review, of which 24 (20 398 participants) were included in the meta-analysis. Rectal douching was associated with increased odds of infection with HIV (OR 2.80, 95% CI 2.32 to 3.39), and any STI other than HIV (including hepatitis B virus (HBV), hepatitis C virus (HCV), chlamydia, gonorrhoea, syphilis and human papillomavirus) (OR 2.46, 95% CI 1.95 to 3.11) among MSM. For specific STIs, douching was associated with increased odds of viral hepatitis (HBV, HCV) (OR 3.29, 95% CI 2.79 to 3.87), and chlamydia or gonorrhoea (OR 3.25, 95% CI 2.02 to 5.23). These associations remained significant in studies that adjusted for potential confounders. CONCLUSION Rectal douching may put MSM at increased risk for infection with HIV and other STIs. Longitudinal studies are needed to clarify this association, and health education materials should inform men of the potential for increased risk of infection with rectal douching.
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Affiliation(s)
- Peiyang Li
- School of Public Health, Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Tanwei Yuan
- School of Public Health (Shenzhen), Sun Yat-Sen University, Shenzhen, Guangdong, China
| | | | - Kumi Smith
- School of Public Health, University of Minnesota Twin Cities, Minneapolis, Minnesota, USA
| | - Jin Zhao
- Shenzhen Center for Disease Control and Prevention, Shenzhen, China
| | - Guohui Wu
- Institute for AIDS/STD Control and Prevention, Chongqing Center for Disease Control and Prevention, Chongqing, China
| | - Lin Ouyang
- Institute for AIDS/STD Control and Prevention, Chongqing Center for Disease Control and Prevention, Chongqing, China
| | - Ying Wang
- School of Public Health, Shanghai Jiao Tong University, School of Medicine, Shanghai, China
| | - Kechun Zhang
- Shenzhen Longhua District Center for Disease Control and Prevention, Shenzhen, China
| | - Yiguo Zhou
- School of Public Health (Shenzhen), Sun Yat-Sen University, Shenzhen, Guangdong, China
| | - Meijuan Li
- School of Public Health (Shenzhen), Sun Yat-Sen University, Shenzhen, Guangdong, China
| | - Dahui Chen
- School of Public Health (Shenzhen), Sun Yat-Sen University, Shenzhen, Guangdong, China
| | - Linghua Li
- Center for Infectious Diseases, Guangzhou Eighth People's Hospital, Guangzhou, Guangdong, China
| | - Weiping Cai
- Center for Infectious Diseases, Guangzhou Eighth People's Hospital, Guangzhou, Guangdong, China
| | - Yong Cai
- School of Public Health, Shanghai Jiao Tong University, School of Medicine, Shanghai, China
| | - Huachun Zou
- School of Public Health (Shenzhen), Sun Yat-Sen University, Shenzhen, Guangdong, China .,Kirby Institute, University of New South Wales, Sydney, New South Wales, Australia
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