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Abstract The COVID-19 pandemic has caused staggering human and economic costs. We outline four key lessons learned from efforts to address the pandemic in China and the US. First, effective surveillance, reporting, and contact tracing are needed to contain an epidemic at its emergence and to mitigate its impact at a later stage. Second, multi-sectoral efforts to offer incentives for those with no or minor symptoms to seek care and to quarantine themselves are critical, which would need concerted efforts from payers, providers, and public health. Third, sustained and routine prevention efforts involving both the public and the health systems will prove to be useful in times of a pandemic. Fourth, a strong public health system is essential and will be appreciated at times of urgency. Concerted multi-sectoral efforts are required to address COVID-19 pandemic with strong leadership from the public health sector.

Abstract Background In China, the spatiotemporal variations in cardiovascular disease (CVD) mortality are seldom characterized to understand their epidemiological features. It would be helpful to evaluate the performance of CVD-related interventions for subsequent adjustments. Methods The 2010 Census data as well as the coronary heart disease (CHD) and stroke mortality data from the Disease Surveillance Points (DSPs) were used to calculate the age standardized death rates (ASDRs) of CVD in the DSP counties during 1991–1995, 1996–2000, 2004–2005, and 2006–2009. The ordinary kriging (OK) method was used to estimate the county-level death rates of CHD and stroke and achieved satisfactory results. Results The goodness-of-fit between measured and estimated values of CVD mortality was significant at the 0.01 level (0.34 75 per 105) were located in the Northwest, North, and Northeast in 1991–2000 and then extended toward the North, Central, and South, yielding an inverted-triangle-shaped area in 2004–2009. The counties with a CHD death rate increase greater than 100% were concentrated in the Northeast and South. The Northeast-Southwest regions with a high stroke death rate gradient (> 150 per 105) narrowed in1991–2000, was followed by a slight expansion during 2004–2005, finally reducing in 2006–2009. The counties with a stroke mortality increase greater than 100% were scattered across the Northeast, Northwest, Central, and South. Conclusion The epidemiological characteristics of both CHD and stroke mortality in China was spatiotemporally featured on the county level during 1991–2009.

Background and objective Since 1970s, Xuanwei in Yunnan province has been one of the towns with highest lung cancer mortality in China. Moreover, the characters of high female lung cancer mortality and sub-regional clustering high lung cancer mortality have not changed. In this study, we further described the exposure situation of risk factors of lung cancer in Xuanwei nowadays, in order to explore the trend of the distribution of lung cancer there. Methods Firstly we divided the 26 towns of Xuanwei city to high-, median- and low- lung cancer areas by the lung cancer mortality in 2010-2012. We chose 2 towns within each area according to topography and orientation, and randomly picked 4 villages in each town to be our study area. We did a questionnaire about lung cancer related risk factors upon the sample population in the study area. We calculated the exposure percentages of each risk factor, in whole sample population and subgroups, for nowadays and for 10 years ago (only living environmental risk factors), and compared them between areas or time points using standardized rates and the statistical test of standardized rate comparison, or chi-square test. Results 65%-80% male in the study area has a history of smoking; 60%-90% non-smoker has been exposed to second hand smoke. These situations are worse in high and median lung cancer areas. 50% male in median lung cancer area have coal mining work experience, which is 2 times of the percentages in the other two areas; while 15%-25% people in high lung cancer area have other occupational exposure history to particulate air pollution, which is 3-5 times of the percentages in the other two areas. From ten years ago until nowadays, 80% families in median lung cancer area use 2 tons or more smoky coal per year; more than 90% families burn coal for household heating; more than 60% families suffer from smog in the kitchen during cook; 60% families most frequently use stove in the ground with chimney. Only 20% families in high lung cancer area now use 2 tons or more smoky coal per year. Now 50%-75% families in the study area use 700 kilowatt-hours of electricity per year, much more than ten years ago. 80% residents in low lung cancer area eat fatty or pickled or smoked food at least 3 days per week; while in high and median lung cancer areas the percentages are 50%-60%. Conclusion According to data obtained in this survey, current distribution of smoky coal use has differed from the distribution of high-, median- and low- lung cancer areas. Tobacco use and second hand smoke, the use of smoky coal and occupational exposure to particulate matters could be the main risk factors for lung cancer in Xuanwei now. The relations between lung cancer and stove type, dietary habit and so on deserve further study.

Abstract Esophageal and gastric cancers share some risk factors. This study aimed to compare the long-term trends in mortality rates of esophageal and gastric cancers in China to provide evidence for cancer prevention and control. Mortality data were derived from 103 continuous points of the Disease Surveillance Points system during 1991–2009, stratified by gender and urban-rural locations. Age-period-cohort models were used to disentangle the time trends of esophageal and gastric cancer mortality. The downward slope of the period effect for esophageal cancer was steeper than that for gastric cancer in rural areas. Cohort effect patterns were similar between esophageal and gastric cancers, with an inverse U-shape peaking around the late 1920s and early 1930s. A second peak, appearing around the 1950s, was weaker than the first but apparent in males, especially for esophageal cancer. The more marked changes in period effect for esophageal cancer in rural areas suggest esophageal cancer screening practices are effective in reducing mortality, and similar programs targeting gastric cancer should be implemented. The similarities of the cohort effects in these two cancers support the implication of nutrition deficiency in early childhood in the development of upper gastrointestinal cancer.

Abstract Background In the past 20 years, the trends of ischemic heart disease (IHD) mortality in China have been described in divergent claims. This research analyzes mortality trends for IHD by using the data from 102 continuous Disease Surveillance Points (DSP) from 1991 to 2009. Method The 102 continuous DSP covered 7.3 million people during the period 1991–2000, and then were expanded to a population of 52 million in the same areas for 2004–2009. The data were adjusted by using garbage code redistribution and underreporting rate, mapped from international classification of diseases ICD-9 to ICD-10. The mortality rates for IHD were further adjusted by the crude death proportion multiplied by the total number of deaths in the mortality envelope, which was calculated by using logrt = a + bt. Age-standard death rates (ASDRs) were computed using China’s 2010 census population structure. Trend in IHD was calculated from ASDRs by using a joinpoint regression model. Results The IHD ASDRs increased in total in regions with an average annual percentage change (AAPC) 4.96%, especially for the Southwest (AAPC = 7.97%) and Northeast areas (AAPC = 7.10%), and for male and female subjects (with 5% AAPC) as well. In rural areas, the year 2000 was a cut-off point for mortality rate with annual percentage change increasing from 3.52% in 1991–2000 to 9.02% in 2000–2009, which was much higher than in urban areas (AAPC = 1.05%). And the proportion of deaths increased in older adults, and more male deaths occurred before age 60 compared to female deaths. Conclusion By observing a wide range of areas across China from 1991 to 2009, this paper concludes that the ASDR trend for IHD increased. These trends reflect changes in the Chinese standard of living and lifestyle with diets higher in fat, higher blood lipids and increased body weight.

Background Xuanwei is one of the towns with highest lung cancer mortality in China. Residents there frequently use smoky coal for domestic cooking and heating. The smoking prevalence there is also high. Methods We conducted a population-based case-control study. 388 lung cancer cases and 388 gender-age-area-matched controls were surveyed. The exposure levels to potential lung cancer risk factors of multi-aspects 10 years ago were collected. After checking Spearman correlations between variables and referring to previous studies, we built conditional logistic regression model adjusting education, family history of malignancy, diet, alcohol consumption, occupational history, housing type and exposure to second hand smoke. We then introduced household annual consumption of smoky coal and total consumption of cigarettes from born to 10 years ago to the model in the form of ordered categorical variable (coal level 1-3: never use, less than 3 tons per year, 3 tons or more per year; tobacco level 1-3: never use, less than 130 thousands cigarettes, 130 thousands or more cigarettes). Results There were 27% and 31.2% ever-smokers in case and control group, respectively. Without interactive item, the effect of tobacco use on lung cancer was (all comparing with level 1, with 95% confidence intervals) level 2: OR=0.90(0.22, 3.67), level 3: OR=1.59(0.45, 5.70). After adding interactive item of coal and tobacco in the model, the effect of tobacco use among people never used smoky coal was level2: OR=1.09(0.09, 13.78), level3: OR=2.20(0.16, 29.44); among people using relatively small amount of coal was level2: OR=0.59(0.03, 11.37), level3: OR=0.18(0.01, 4.82); among people using large amount of coal was level2: OR=0.93(0.32, 2.72), level3: OR=1.78(0.30, 10.67). Household annual amount of smoky coal used, 10 years ago Total consumption of cigarettes from born to 10 years ago (reference group: never smoker) β SE OR(95%CI) Never

Background China is the largest producer and consumer of tobacco products worldwide, with 16.5% of all deaths attributed to tobacco use in 2010. While direct marketing and advertisement of tobacco products has been restricted, indirect marketing still exists under the guise of sponsorship and corporate social responsibility (CSR). This case study is focused on tobacco industry-sponsored elementary schools in Chinese rural areas and discusses the success story of a major tobacco control campaign to remove tobacco-related branding and logos from school buildings. Methods Field visits were undertaken to 3 tobacco industry-sponsored elementary schools in Yunnan in 2012, and semi-structured interviews were conducted with students, teachers, school principals and parents to understand their perceptions of the tobacco industry and its sponsorship of schools. In 2016, semi-structured interviews with tobacco control activists were conducted in Beijing, where respondents discussed the outcome of those field visits and the resulting work in petitioning government sectors to remove tobacco-related branding from school buildings. Interview data was transcribed and coded, and key themes were developed using thematic analysis. Results While health consequences of smoking were generally known, attitudes towards the tobacco industry and its CSR activities remained positive among the general public. Educators and parents did not perceive any impacts on schoolchildren from exposure to “pro-tobacco propaganda” created by the industry's CSR activities. Attitudes among tobacco control activists were drastically different, with consensus that CSR activities constitute indirect marketing attempts that should be banned. Conclusions The successful removal of branding from tobacco industry-sponsored schools shows that meaningful action is possible even in the absence of relevant legislation, and can be achieved through the mobilization of stakeholders, including academics and civil society organizations. National tobacco control legislation banning all forms of indirect marketing including sponsorship and CSR activities is needed in order to protect the health of the future generations.

Background Comprehensive smoke-free legislation is an effective way to protect the population from the harms of secondhand smoke (SHS) and has been implemented in many countries. Tianjin is one of the few cities in China that have passed smoke-free legislation. We investigated the impact of smoke-free legislation on acute myocardial infarction (AMI) and stroke in Tianjin. Methods An interrupted time series design adjusting for underlying secular trend, seasonal pattern, population size changes and meteorology factors was conducted to analyze the impact of the smoking free law on the weekly incidence and mortality of AMI and stroke. The study period was from January 1, 2007, to December 31, 2015, with a post-ban follow-up of 3.5 years. Results Following the smoke-free law implementation, there was a decline in the annual proportional change for AMI and stroke mortality. A gradual 16% (RR:0.84; 95% CI: 0.83-0.85) decrease per year in AMI mortality among in population ages ≥ 35 years and a gradual 4% (RR:0.96; 95% CI: 0.95-0.98) decrease per year in stroke mortality among 35-64 age group in Tianjin was observed. Post-ban stroke incidence immediate reductions were found in in stroke in 35-64 age group (RR:0.96; 95% CI: 0.95-0.98). AMI incidence immediate reductions were only found in females aged 35-64 (RR:0.71; 95% CI: 0.65-0.78). Conclusions The smoke-free law in Tianjin was associated with gradual reductions in AMI and stroke mortality and immediate reductions in AMI and stroke incidence. The considerably modest and inconsistent effect on AMI and stroke incidence probably reflects the weak law enforcement and limitation of incidence surveillance data in Tianjin. This study reinforces the need for large-scale, effective and comprehensive smoke-free law in China. Funding: This research was supported by China Medical Board (15-208)

Mortality statistics systems provide basic information on the levels and causes of mortality in populations. Only a third of the world's countries have complete civil registration systems that yield adequate cause-specific mortality data for health policy-making and monitoring. This paper describes the development of a set of criteria for evaluating the quality of national mortality statistics and applies them to China as an example. The criteria cover a range of structural, statistical and technical aspects of national mortality data. Little is known about cause-of-death data in China, which is home to roughly one-fifth of the world's population. These criteria were used to evaluate the utility of data from two mortality statistics systems in use in China, namely the Ministry of Health-Vital Registration (MOH-VR) system and the Disease Surveillance Point (DSP) system. We concluded that mortality registration was incomplete in both. No statistics were available for geographical subdivisions of the country to inform resource allocation or for the monitoring of health programmes. Compilation and publication of statistics is irregular in the case of the DSP, and they are not made publicly available at all by the MOH-VR. More research is required to measure the content validity of cause-of-death attribution in the two systems, especially due to the use of verbal autopsy methods in rural areas. This framework of criteria-based evaluation is recommended for the evaluation of national mortality data in developing countries to determine their utility and to guide efforts to improve their value for guiding policy.

Rural-to-urban migrant women may be vulnerable to smoking initiation as they are newly exposed to risk factors in the urban environment. We sought to identify correlates of smoking among rural-to-urban migrant women in China.A cross-sectional survey of rural-to-urban migrant women working in restaurants and hotels (RHW) and those working as commercial sex workers (CSW) was conducted in ten provincial capital cities in China. Multiple logistic regression was conducted to identify correlates of smoking. We enrolled 2229 rural-to-urban migrant women (1697 RHWs aged 18-24 years and 532 CSWs aged 18-30 years). Of these, 18.4% RHWs and 58.3% CSWs reported ever tried smoking and 3.2% RHWs and 41.9% CSWs reported current smoking. Participants who first tried smoking after moving to the city were more likely to be current smokers compared to participants who first tried smoking before moving to the city (25.3% vs. 13.8% among RHWs, p = 0.02; 83.6% vs. 58.6% among CSWs, p =

Cause of death data are a critical input to formulating good public health policy. In the absence of reliable vital registration data, information collected after death from household members, called verbal autopsy (VA), is commonly used to study causes of death. VA data are usually analyzed by physician-coded verbal autopsy (PCVA). PCVA is expensive and its comparability across regions is questionable. Nearly all validation studies of PCVA have allowed physicians access to information collected from the household members' recall of medical records or contact with health services, thus exaggerating accuracy of PCVA in communities where few deaths had any interaction with the health system. In this study we develop and validate a statistical strategy for analyzing VA data that overcomes the limitations of PCVA.We propose and validate a method that combines the advantages of methods proposed by King and Lu, and Byass, which we term the symptom pattern (SP) method. The SP method uses two sources of VA data. First, it requires a dataset for which we know the true cause of death, but which need not be representative of the population of interest; this dataset might come from deaths that occur in a hospital. The SP method can then be applied to a second VA sample that is representative of the population of interest. From the hospital data we compute the properties of each symptom; that is, the probability of responding yes to each symptom, given the true cause of death. These symptom properties allow us first to estimate the population-level cause-specific mortality fractions (CSMFs), and to then use the CSMFs as an input in assigning a cause of death to each individual VA response. Finally, we use our individual cause-of-death assignments to refine our population-level CSMF estimates. The results from applying our method to data collected in China are promising. At the population level, SP estimates the CSMFs with 16% average relative error and 0.7% average absolute error, while PCVA results in 27% average relative error and 1.1% average absolute error. At the individual level, SP assigns the correct cause of death in 83% of the cases, while PCVA does so for 69% of the cases. We also compare the results of SP and PCVA when both methods have restricted access to the information from the medical record recall section of the VA instrument. At the population level, without medical record recall, the SP method estimates the CSMFs with 14% average relative error and 0.6% average absolute error, while PCVA results in 70% average relative error and 3.2% average absolute error. For individual estimates without medical record recall, SP assigns the correct cause of death in 78% of cases, while PCVA does so for 38% of cases.Our results from the data collected in China suggest that the SP method outperforms PCVA, both at the population and especially at the individual level. Further study is needed on additional VA datasets in order to continue validation of the method, and to understand how the symptom properties vary as a function of culture, language, and other factors. Our results also suggest that PCVA relies heavily on household recall of medical records and related information, limiting its applicability in low-resource settings. SP does not require that additional information to adequately estimate causes of death.

BackgroundCause-specific mortality statistics remain scarce for the majority of low-income countries, where the highest disease burdens are experienced. Neither facility-based information systems nor vital registration provide adequate or representative data. The expansion of sample vital registration with verbal autopsy procedures represents the most promising interim solution for this problem. The development and validation of core verbal autopsy forms and suitable coding and tabulation procedures are an essential first step to extending the benefits of this method.Methods and findingsCore forms for peri- and neonatal, child, and adult deaths were developed and revised over 12 y through a project of the Tanzanian Ministry of Health and were applied to over 50,000 deaths. The contents of the core forms draw upon and are generally comparable with previously proposed verbal autopsy procedures. The core forms and coding procedures based on the International Statistical Classification of Diseases (ICD) were further adapted for use in China. These forms, the ICD tabulation list, the summary validation protocol, and the summary validation results from Tanzania and China are presented here.ConclusionsThe procedures are capable of providing reasonable mortality estimates as adjudged against stated performance criteria for several common causes of death in two countries with radically different cause structures of mortality. However, the specific causes for which the procedures perform well varied between the two settings because of differences in the underlying prevalence of the main causes of death. These differences serve to emphasize the need to undertake validation studies of verbal autopsy procedures when they are applied in new epidemiological settings.

Registration of births, recording deaths by age, sex and cause, and calculating mortality levels and differentials are fundamental to evidence-based health policy, monitoring and evaluation. Yet few of the countries with the greatest need for these data have functioning systems to produce them despite legislation providing for the establishment and maintenance of vital registration. Sample vital registration (SVR), when applied in conjunction with validated verbal autopsy procedures and implemented in a nationally representative sample of population clusters represents an affordable, cost-effective, and sustainable short- and medium-term solution to this problem. SVR complements other information sources by producing age-, sex-, and cause-specific mortality data that are more complete and continuous than those currently available. The tools and methods employed in an SVR system, however, are imperfect and require rigorous validation and continuous quality assurance; sampling strategies for SVR are also still evolving. Nonetheless, interest in establishing SVR is rapidly growing in Africa and Asia. Better systems for reporting and recording data on vital events will be sustainable only if developed hand-in-hand with existing health information strategies at the national and district levels; governance structures; and agendas for social research and development monitoring. If the global community wishes to have mortality measurements 5 or 10 years hence, the foundation stones of SVR must be laid today. Keywords Vital statistics; Sample size; Mortality; Cause of death; Autopsy; Interviews; Data collection/methods; Information systems (source: MeSH, NLM). Mots cles Statistique demographique; Taille echantillon; Mortalite; Cause deces; Autopsie; Entretien; Collecte donnees/methodes; Systeme information (source: MeSH, INSERM). Palabras clave Estadisticas vitales; Tamano de la muestra; Mortalidad; Causa de muerte; Autopsia; Entrevistas; Recoleccion de datos/metodos; Sistemas de informacion (fuente: DeCS, BIREME)., Making people count Registration of births, recording deaths by age, sex and cause, and calculating mortality levels and differentials are fundamental to evidence-based health policy, monitoring and evaluation. Yet few [...]

The non-communicable disease burden in China is enormous, with tobacco use a leading risk factor for the major non-communicable diseases. The prevalence of tobacco use in men is one of the highest in the world, with more than 300 million smokers and 740 million non-smokers exposed to second-hand smoke. In the past decade public awareness of the health hazards of tobacco use and exposure to second-hand smoke has grown, social customs and habits have changed, aggressive tactics used by the tobacco industry have been revealed, and serious tobacco control policies have been actively promoted. In 2014, national legislators in China began actively considering national bans on smoking in public and work places and tobacco advertising. However, tobacco control in China has remained particularly difficult because of interference by the tobacco industry. Changes to the interministerial coordinating mechanism for implementation of the WHO Framework Convention on Tobacco Control are now crucial. Progress towards a tobacco-free world will be dependent on more rapid action in China. [ABSTRACT FROM AUTHOR]

Objective To develop an approach for rapid assessment of tobacco control interventions in China. We examined the correlation between components of the Strength of Tobacco Control (SOTC) index and a proposed rapid evaluation indicator, the Policy Performance Indicator (PPI), which is based on protection of non-smokers from secondhand smoke (SHS). The PPI was used to assess the implementation of policies related to SHS at the provincial/municipal level in China. Methods Stratified random sampling was used to select five types of organisational and household respondents in two municipalities and five provinces in China (Shanghai and Tianjin, Heilongjiang, Henan, Guangdong, Zhejiang and Jiangxi, respectively). Data collection methods included key informant interviews, observation and intercept surveys (organisations), and a modified Global Adult Tobacco Survey (GATS) questionnaire (households). SOTC scores (SHS policy, capacity and efforts), PPI (no smoking in designated smoke-free places) and mid-term to long-term impact (knowledge, attitude and reduced exposure to SHS) were measured, and correlations among them were calculated. Results The PPI varied across the seven locations. Shanghai led in the component indicators (at 56.5% for indoor workplaces and 49.1% for indoor public places, respectively), followed by Guangdong, Tianjin and Zhejiang (at 30-35% for these two indicators), and finally, Henan and Jiangxi (at 20-25%). Smoke-free policies were more effectively implemented at indoor workplaces than indoor public places. The PPI correlated well with certain components of the SOTC but not with the long-term indicators. Conclusions The PPI is useful for evaluating implementation of smoke-free policies. As tobacco control programmes are implemented, the PPI offers an indicator to track success and change strategies, without collecting data for a full SOTC index. [ABSTRACT FROM AUTHOR]

Background: Handheld computers for data collection (HCDC) and management have become increasingly common in health research. However, current knowledge about the use of HCDC in health research in China is very limited. In this study, we administered a survey to a hard-to-reach population in China using HCDC and assessed the acceptability and adoption of HCDC in China. Methods: Handheld computers operating Windows Mobile and Questionnaire Development Studio (QDS) software (Nova Research Company) were used for this survey. Questions on tobacco use and susceptibility were drawn from the Global Adult Tobacco Survey (GATS) and other validated instruments, and these were programmed in Chinese characters by local staff. We conducted a half-day training session for survey supervisors and a three-day training session for 20 interviewers and 9 supervisors. After the training, all trainees completed a self-assessment of their skill level using HCDC. The main study was implemented in fall 2010 in 10 sites, with data managed centrally in Beijing. Study interviewers completed a post-survey evaluation questionnaire on the acceptability and utility of HCDC in survey research. Results: Twenty-nine trainees completed post-training surveys, and 20 interviewers completed post-data collection questionnaires. After training, more than 90% felt confident about their ability to collect survey data using HCDC, to transfer study data from a handheld computer to a laptop, and to encrypt the survey data file. After data collection, 80% of the interviewers thought data collection and management were easy and 60% of staff felt confident they could solve problems they might encounter. Overall, after data collection, nearly 70% of interviewers reported that they would prefer to use handheld computers for future surveys. More than half (55%) felt the HCDC was a particularly useful data collection tool for studies conducted in China. Conclusions: We successfully conducted a health-related survey using HCDC. Using handheld computers for data collection was a feasible, acceptable, and preferred method by Chinese interviewers. Despite minor technical issues that occurred during data collection, HCDC is a promising methodology to be used in survey-based research in China. [ABSTRACT FROM AUTHOR]

Background China has undergone rapid demographic and epidemiological changes in the past few decades including striking declines in fertility and child mortality and increases in life expectancy at birth. Popular discontent with the health system has led to major reforms. To help inform these reforms, we did a comprehensive assessment of disease burden in China, how it changed between 1990 and 2010, and how China's health burden compares with other nations. Methods We used results of the Global Burden of Diseases, Injuries, and Risk Factors Study 2010 (GBD 2010) for 1990 and 2010 for China and 18 other countries in the G20 to assess rates and trends in mortality, causes of death, years of life lost (YLLs), years lived with disability (YLDs), disability-adjusted life-years (DALYs), and healthy life expectancy (HALE). Vie present results for 231 diseases and injuries and for 67 risk factors or clusters of risk factors relevant to China. Vie assessed relative performance of China against G20 countries (significantly better, worse, or indistinguishable from the G20 mean) with age-standardised rates and 95% uncertainty intervals. Findings The leading causes of death in China in 2010 were stroke (1.7 million deaths, 95% UI 1-5-1-8 million) ischaemic heart disease (948700 deaths, 774500-1024600), and chronic obstructive pulmonary disease (934 000 deaths, 846 600-1032 300). Age-standardised YLLs in China were lower in 2010 than all emerging economies in the G20, and only slightly higher than noted in the USA. China had the lowest age-standardised YLD rate in the G20 in 2010. China also ranked tenth (95% UI eighth to tenth) for HALE and 12th (11th to 13th) for life expectancy. YLLs from neonatal causes, infectious diseases, and injuries in children declined substantially between 1990 and 2010. Mental and behavioural disorders, substance use disorders, and musculoskeletal disorders were responsible for almost half of all YLDs. The fraction of DALYs from YLDs rose from 28.1% (95% UI 24.2-32.5) in 1990 to 39.4% (34.9-43.8) in 2010. Leading causes of DALYs in 2010 were cardiovascular diseases (stroke and ischaemic heart disease), cancers (lung and liver cancer), low back pain, and depression. Dietary risk factors, high blood pressure, and tobacco exposure are the risk factors that constituted the largest number of attributable DALYs in China. Ambient air pollution ranked fourth (third to fifth; the second highest in the G20) and household air pollution ranked fifth (fourth to sixth; the third highest in the G20) in terms of the age-standardised DALY rate in 2010. Interpretation The rapid rise of non-communicable diseases driven by urbanisation, rising incomes, and ageing poses major challenges for China's health system, as does a shift to chronic disability. Reduction of population exposures from poor diet, high blood pressure, tobacco use, cholesterol, and fasting blood glucose are public policy priorities for China, as are the control of ambient and household air pollution. These changes will require an integrated government response to improve primary care and undertake required multisectoral action to tackle key risks. Analyses of disease burden provide a useful framework to guide policy responses to the changing disease spectrum in China. Funding Bill & Melinda Gates Foundation. [ABSTRACT FROM AUTHOR]

Objective: To critically review the structure of tobacco control policy making in China, examine conflicts of interest within this structure, and consider how these affected the introduction of on-pack warnings. Methods: Government policy documents and warning labels were obtained and critically reviewed. Results: Few differences exist between the on-pack warnings formerly used in China and those introduced ostensibly to meet Framework Convention on Tobacco Control (FCTC) obligations. Comparison with tobacco manufactured for export or overseas consumption shows the new Chinese domestic on-pack warnings are demonstrably inferior to those required internationally. The inherent conflict of interest in the Chinese tobacco control agency structure, which must meet commercial and public health objectives, undermined the introduction of new health warnings. Conclusions To promote more effective tobacco control policies, the conflict of interest inhibiting the public health function of the State Tobacco Monopoly Administration (STMA) must be removed. Specifically, the public health function must be separated from oversight of commercial production, and packaging must be redesigned with pictorial warnings and messages compliant with Article 11 of the FCTC. [ABSTRACT FROM AUTHOR]

Background: The quality of routine data, such as the maternal mortality ratio (MMR), infant mortality rate (IMR), and under-five mortality rate (U5MR) is often questioned. The objective of this study was to compare routine and survey data on key maternal and child health indicators, including the MMR, IMR, and U5MR in the Guizhou Province of China. Methods: In 2008, an urban area and a rural area in the Guizhou Province were randomly selected. All households in the selected areas were included and, of the total 5466 households therein, 5459 were visited. The response rate was 99.9%. Survey data were collected from mothers (46.0%), fathers (32.5%), grandmothers (11.1%), grandfathers (9.0%), and other caregivers (1.4%). Data from routine records of the health bureaus in selected areas were reviewed for the same indicators. The Chi-square test was used to study the differences between routine data and survey data. Results: We found the differences between the routine and survey data live births in the survey data (68) was fewer than in the routine data (94) in the rural area, while live births in the survey data (106) was larger than in the routine data (96) in the urban area. The IMR was higher in the survey data (51.7 per thousand) as compared with routine data (31.6 per thousand). The U5MR was higher (69.0 per thousand) in the survey data than in the routine data (42.1 per thousand). Indicators related to the coverage of maternal and child health interventions were over-reported in routine data. Conclusion: Small differences were observed between routine data and survey data in Guizhou, one of the poorest areas of China. The quality of routine data in urban areas was better than in rural areas. [ABSTRACT FROM AUTHOR]

Objective To determine the coverage of smoking restriction policies in indoor workplaces in China and to assess the relationships between these restrictive policies and secondhand smoke (SHS) exposure and smoking behaviours. Methods A cross-sectional household survey was conducted in six counties in Sichuan, Jiangxi and Henan provinces in 2004. Using a standardised questionnaire, information on demographic characteristics, knowledge, attitudes and behaviours related to smoking and SHS exposure was collected through face-to-face interviews by trained local investigators among 12 036 respondents. Of respondents, 2698 individuals worked mainly indoors and were included in data analysis. Results Only 28.5% of respondents reported that indoor workplaces had a smoke-free policy. Even when respondents reported smoke-free policies, 41.1% smokers reported that they were non-compliant with policies and smoked at work. In addition, 32.0% of nonsmokers reported being exposed to SHS at work despite smoke-free policies. Non-smokers who reported no smoking restriction policies were 3.7 times more likely to be exposed to SHS than those working in smoke-free workplaces (adjusted OR 3.7, 95% CI 1.3 to 10.1). On average, respondents complying with smoke-free policies smoked 3.8 fewer cigarettes than those reporting no policies in their workplaces at a marginally non-significant level (p=0.06) (adjusted mean difference --3.8, 95% CI --8.0 to 0.5). Conclusions In China, few workplaces have implemented policies to restrict smoking, and, even in workplaces that have policies, workers report exposure to SHS while at their places of employment. Many workers report a lack of compliance with smoke-free policies. China needs better implementation of SHS policies to promote compliance. Working to improve implementation of smoke-free policies would promote cessation since Chinese smokers who were compliant with these efforts reported smoking fewer cigarettes per day. [ABSTRACT FROM AUTHOR]

Background: Low body mass index (BMI) is associated with chronic obstructive pulmonary disease (COPD) in populations where many are overweight. Substantial uncertainty remains about the relationship in populations with lower mean BMI levels, and about the relevance to it of the effects of smoking or of reverse causality.Methods: A nationally representative prospective cohort study included 221,194 Chinese men aged 40-79 years in 1990-91, who were followed up for 15 years or to the age of 80 years. Hazard ratios for COPD-related mortality vs baseline BMI were adjusted for age, smoking, drinking and other factors. To reduce reverse causality, main analyses excluded all men with prior history of any respiratory diseases or abnormal lung function at baseline, leaving 2960 COPD-related deaths (16% of all deaths).Results: The mean baseline BMI was 21.7 kg/m(2). There was a highly significant inverse association between BMI and COPD-related mortality among men without any apparent impairment of lung function. Approximately 90% of men had a baseline BMI <25 kg/m(2), and among them, 5 kg/m(2) lower BMI was associated with 31% (95% confidence interval 18-45%) higher COPD-related mortality. The excess risk persisted after restricting the analysis to never-smokers or excluding the first 5 years of follow-up.Conclusions: Low BMI is associated with increased COPD mortality in a relatively lean adult male population in China where COPD is one of the most common causes of death. [ABSTRACT FROM AUTHOR]

The article presents a study which examines the claim made by the Chinese tobacco industry which states that herbal cigarettes are less harmful than regular cigarettes. It mentions that the researchers have used a cross-sectional survey which was participated in by 155 herbal cigarette smokers and 143 regular smokers in China. Findings showed that herbal cigarettes did not deliver less carcinogens than regular ones and affirms that there is a need for the public to be aware of such fact.

Objective: To assess airborne nicotine concentrations as an indicator of second-hand smoke (SHS) exposure in public places in both urban and rural areas of China. Design: Measurement of vapour-phase nicotine concentration using a common protocol in all locations. A total of 273 samplers were placed for 7 days in urban and rural areas of China, including Beijing and the capital city, and a county (rural) area of the following provinces: Sichuan (Chengdu/Mianzhu), Jiangxi (Nanchang/Anyi) and Henan (Zhengzhou/Xin'an). Setting: Samplers were placed in hospitals, secondary schools, city government buildings, train stations, restaurants and entertainment establishments (internet cafes, mahjong parlours and karaoke bars) in each location. Main outcome measure: The time-weighted average airborne concentration of nicotine (µg/m³) was measured by gas chromatography. Results: Airborne nicotine was detected in 91% of the locations sampled. Beijing had the highest nicotine concentrations in most indoor environments (median 3.01 µg/m³) and Chengdu had the lowest concentrations (median 0.11 µg/m³). Overall, restaurants and entertainment establishments had the highest nicotine concentrations (median 2.17 and 7.48 µg/m³, respectively). High nicotine concentrations were also found in government buildings and in train stations. Conclusions: The data collected in this study provide evidence that SHS exposure is frequent in public places in China. Environmental nicotine concentrations in China provide evidence for implementation and enforcement of smoke-free initiatives in public places in China and indicate the need for protecting the public from exposure to SHS. [ABSTRACT FROM AUTHOR]

Background: Death registration systems in rural China are in a developmental stage. The Disease Surveillance Points (DSP) system provides the only nationally representative information on causes of death. In this system, there are no standard procedures or instruments for ascertaining causes of death; hence available statistics require careful evaluation before use. Aim: To assess the reliability of data from the DSP. Methods: 14 DSP sites were selected through stratified sampling, enrolling 2482 deaths registered during June–November 2002. Defined verbal autopsy (VA) procedures were used to derive underlying causes of death. κ Measures of agreement between VA and registered diagnoses were computed. VA diagnoses were used as references to compute sensitivity and positive predictive values. Finally, patterns of cause-specific discordance between the two data sources were studied. Results: κ Scores indicate only moderate agreement for chronic obstructive pulmonary disease (COPD) and ischaemic heart disease (IHD). The results also suggest that COPD is undercounted in registration data. A significant degree of cross attribution of cause was found between the two data sources. Overall, the VA was successful in limiting deaths with ill-defined causes to <10%. Conclusions: Diagnoses based on structured symptom questionnaires in the VA approach seem plausible and reliable as compared with lay-reported diagnoses in registration data. Concerns with attribution of cause of death due to COPD, IHD and tuberculosis in registration data suggest caution in their use for research and health programme purposes. The VA methods tested in this study offer promise for implementation in the routine registration system. [ABSTRACT FROM AUTHOR]

AbstractObjectiveTo assess the impact of urbanisation on the prevalence of the metabolic syndrome in Chinese adults.DesignAs part of a community-based cross-sectional survey conducted in 2002, a sample from rural and urban populations in East China was obtained. The metabolic syndrome is defined by the National Cholesterol Education Program Adult Treatment Panel III criteria (ATP III) and the modified ATP III, which recommended a lower waist circumference cut-off for Asians.SettingField sites in Jiangxi and Anhui provinces and the Jing'an District of Shanghai, China.SubjectsA total of 529 non-pregnant, non-lactating urban and rural adults, aged 20?64 years without diagnosed diabetes.ResultsDwelling in urban areas was associated with higher dietary fat intake and slightly lower total energy intake, and with significantly lower occupational physical activity. Using the ATP III criteria, the prevalence of the metabolic syndrome was significantly higher for urban than rural men (12.7 vs. 1.7%, P?

Background Vital registration of causes of death in China is incomplete with poor coverage of medical certification. Information on the leading causes of mortality will continue to rely on verbal autopsy (VA) methods. A new international VA form is being considered for data collection in China, but it first needs to be validated to determine its operating characteristics.Methods Detailed medical records and clinical evidence for 3290 deaths (mostly adults) among residents of six cities representative of the urban Chinese population were reviewed by a panel of physicians and coded by experts to establish a reference underlying cause of death. Independently, families of the deceased were interviewed using a structured symptomatic questionnaire and a separate death certificate was prepared for each matching case (2102). Validity of the VA procedure was assessed using standard measurement criteria of sensitivity, specificity, and positive predictive value.Results VA methods perform reasonably well in identifying deaths from several leading causes of adult deaths including stroke, several major cancer sites (lung, liver, stomach, oesophagus, and colorectal), and transport accidents. Sensitivity was less satisfactory in detecting deaths from several causes of major public health concern in China including ischaemic heart disease, chronic obstructive pulmonary disease, diabetes, and tuberculosis, and was particularly poor in diagnosing deaths from viral hepatitis, hypertension, and kidney diseases.Conclusions VA is an imprecise tool for detecting leading causes of death among adults. However, much of the misclassification generally occurs within broad cause groups (e.g. CVD, respiratory diseases, and liver diseases). Moreover, compensating patterns of misclassification would appear to suggest that, in urban China at least, the method yields population-level cause-specific estimates that are reasonably reliable. These results suggest the possible utility of these methods in rural China, to back up the low coverage of medical certification of cause of death owing to poor access to health facilities there. [ABSTRACT FROM AUTHOR]

Background Increased body mass index (BMI) is known to be related to ischaemic heart disease (IHD) in populations where many are overweight (BMI ≥ 25 kg/m2) or obese (BMI ≥ 30). Substantial uncertainty remains, however, about the relationship between BMI and IHD in populations with lower BMI levels.Methods We examined the data from a population-based, prospective cohort study of 222 000 Chinese men aged 40–79. Relative and absolute risks of death from IHD by baseline BMI were calculated, standardized for age, smoking, and other potential confounding factors.Results The mean baseline BMI was 21.7 kg/m2, and 1942 IHD deaths were recorded during 10 years of follow-up (6.5% of all such deaths). Among men without prior vascular diseases at baseline, there was a J-shaped association between BMI and IHD mortality. Above 20 kg/m2 there was a positive association of BMI with risk, with each 2 kg/m2 higher in usual BMI associated with 12% (95% CI 6–19%, 2P = 0.0001) higher IHD mortality. Below this BMI range, however, the association appeared to be reversed, with risk ratios of 1.00, 1.09, and 1.15, respectively, for men with BMI 20–21.9, 18–19.9, and <18 kg/m2. The excess IHD risk observed at low BMI levels persisted after restricting analysis to never smokers or excluding the first 3 years of follow-up, and became about twice as great after allowing for blood pressure.Conclusions Lower BMI is associated with lower IHD risk among people in the so-called normal range of BMI values (20–25 kg/m2), but below that range the association may well be reversed. [ABSTRACT FROM AUTHOR]

Background. Acts of suicide differ widely in the amount of planning preceding the act. Correlates of completed suicide in China identified in a previous investigation were re-examined to identify those that may be especially relevant to low-planned (impulsive) and high-planned suicidal behavior. The association of planning and method in completed suicide was also assessed.Method. A psychological autopsy study of 505 suicide decedents aged 18 years sampled to be representative of suicides in China was conducted. Multinomial regression analyses compared three levels of suicide planning (low, intermediate, high).Results. Women and younger individuals were more likely to carry out low-planned and intermediate-planned than high-planned acts of suicide. Greater acute stress distinguished low-planned from high-planned suicides. Ingestion of pesticides stored in the home was a more commonly employed method in low-planned than high-planned suicides.Conclusions. Low-planned suicides are more common in women, in younger individuals, and among those who are experiencing acute stress. Prevention strategies targeted at restricting access to pesticides may preferentially lower the rate of low-planned suicides. [ABSTRACT FROM AUTHOR]

Background: Mortality statistics are key inputs for evidence based health policy at national level. Little is known of the empirical basis for mortality statistics in China, which accounts for roughly one-fifth of the world's population. An adequate description of the evolution of mortality registration in China and its current situation is important to evaluate the usability of the statistics derived from it for international epidemiology and health policy. Current situation: The Chinese vital registration system currently covers 41 urban and 85 rural centres, accounting for roughly 8 % of the national population. Quality of registration is better in urban than in rural areas, and eastern than in western regions, resulting in significant biases in the overall statistics. The Ministry of Health introduced the Disease Surveillance Point System in 1980, to generate cause specific mortality statistics from a nationally representative sample of sites. Currently, the sample consists of 145 urban and rural sites, covering populations from 30,000 - 70,000, and a total of about 1 % of the national population. Causes of death are derived through a mix of medical certification and 'verbal autopsy' procedures, applied according to standard guidelines in all sites. Periodic evaluations for completeness of registration are conducted, with subsequent corrections for under reporting of deaths. Conclusion: Results from the DSP have been used to inform health policy at national, regional and global levels. There remains a need to critically validate the information on causes of death, and a detailed validation exercise on these aspects is currently underway. In general, such sample based mortality registration systems hold much promise as models for rapidly improving knowledge about levels and causes of mortality in other low-income populations. [ABSTRACT FROM AUTHOR]

Background In China, tobacco smoking accounts for approximately 800 000 deaths annually and evidence suggests that tobacco use is rising. To improve tobacco control initiatives directed at youth, we conducted a population-based survey of children ages 11–20 years, both in and out of school. While there have been previous school-based studies on smoking prevalence and smoking-related knowledge, attitudes, and behaviours among adolescents in China, including the Global Youth Tobacco Survey, this survey also describes smoking behaviour among non-student youth. This population is important as approximately 40% of Chinese youths aged 15–19 years have already discontinued their studies.Methods A survey of smoking behaviour and smoking-related knowledge and attitudes was administered to 24 000 youths (students and non-students of middle school age) in 24 disease surveillance points in China, selected to include equal numbers of urban and rural children.Results The prevalence rates of experimenting were 47.8% for boys and 12.8% for girls. The prevalence of regular smoking among non-students was higher (8.3%) compared with students (5.2%). The strongest predictor of regular smoking was peer influence with 44% reporting that they obtained their first cigarette from peers. The majority of youths were aware that smoking was a cause of several diseases and addictive; however, non-students were less aware than students.Conclusions The evidence highlights the need for tobacco control interventions aimed at youths in China including non-student youths. For males, prevention programmes should extend into young adulthood. [ABSTRACT FROM AUTHOR]

Summary: Background: Suicide is the fifth most important cause of death in China, but the reasons fo1 the high rate and unique pattern of characteristics of those who kill themselves are unknown. Methods: We pretested, and then administered a comprehensive interview to family members and close associates of 519 people who committed suicide and of 536 people who died from other injuries (controls) randomly selected from 23 geographically representative sites in China. Findings: After adjustment for sex, age, location of residence, and research site, eight significant predictors of suicide remained in the final unconditional logistic regression model. In order of importance they were: high depression symptom score, previous suicide attempt, acute stress at time of death, low quality of life, high chronic stress, severe interpersonal conflict in the 2 days before death, a blood relative with previous suicidal behaviour, and a friend or associate with previous suicidal behaviour. Suicide risk increased substantially with exposure to multiple risk factors: none of the 265 deceased people who were exposed to one or fewer of the eight risk factors died by suicide, but 30% (90/299) with two or three risk factors, 85% (320/377) with four or five risk factors, and 96% (109/114) with six or more risk factors died by suicide. Interpretation: Despite substantial differences between characteristics of people who commit suicide in China and the west, risk factors for suicide do not differ greatly. Suicide prevention programmes that concentrate on a single risk factor are unlikely to reduce suicide rates substantially; preventive efforts should focus on individuals exposed to multiple risk factors. [ABSTRACT FROM AUTHOR]

Objectives-To describe patterns of smoking and smoking cessation in China within the context of the stages of change model, in using data from the 1996 national prevalence survey. Design-A cross sectional survey was carried out using the 145 preselected disease surveillance points, which provide a pi representative sample for the entire country. A standardised questionnaire on smoking was interviewer administered. Setting-The country of China. Subjects-l22 220 people aged 15-69 years. Maintenance measures-Smoking cessation patterns, as defined by smoking status (current or former) and stage of change (precontemplation, contemplation, and ti action). Results-The sample included 45 995 ever smokers of whom 4336 had quit. About 72% of current smokers reported not intending to give up their smoking behaviour, and about 16% of current smokers said they intended to do so, but have not taken any action. Of all ever smokers, the percentage of former smokers was 9.5%, and 12% of current smokers had quit at least once, but relapsed by the time of the survey. The patterns were similar in men and women with regard to the stated intent to quit. Among males, the percentage of former smokers increased with age but the percentage intending to quit was constant at about 15% across age strata. The most common reason for quitting was illness. Participants with a university education were more likely to have made an attempt to quit. conclusions. The percentage of smokers contemplating quitting was low in China in 1996. The study shows that smokers in China must be mobilised to contemplate quitting and then to take action. [ABSTRACT FROM AUTHOR]

Background National vital registration systems are the principal source of cause specific mortality statistics, and require periodic validation to guide use of their outputs for health policy and programme purposes, and epidemiological research. We report results from a validation of cause of death statistics from health facilities in urban China. Methods 2917 deaths from health facilities located in six cities in China constituted the study sample. A reference diagnosis of the underlying cause was derived for each death, based on expert review of available medical records, and compared with that filed at registration. Sensitivity, specificity and positive predictive value were computed for specific causes/cause categories according to the International Classification of Diseases (ICD), including analyses based on quality of evidence scores for each cause. Patterns of misclassification by the registration system were studied for individual causes of death. Results The registration system had good sensitivity in diagnosing cerebrovascular disease and several site specific cancers (lung, liver, stomach, colorectal, breast and pancreas). Sensitivity was average (50–75%) for some major causes of adult death in China, namely ischaemic heart disease (IHD), chronic obstructive lung disease (COPD), diabetes, and liver and kidney diseases, with compensatory misclassification patterns observed between several of them. Sensitivity was particularly low for hypertensive disease. Conclusions Although diagnostic misclassification is not uncommon in urban death registration data, they appear to balance each other at the population level. Compensating misclassification errors suggest that caution is required when drawing conclusions about particular chronic causes of adult death in China. Investment is required to improve the quality of cause attribution for health facility deaths, and to assess the validity of cause attribution for home deaths. Periodic assessments of the quality of cause of death statistics will enhance their usability for health policy and epidemiological research. [ABSTRACT FROM AUTHOR]

The article discusses a study which examined global trends in neonatal, infant and under-5 mortality from 1990 to 2013. Topics discussed include a reduction in child mortality rate, an increase in the number of child births in 2013 as compared to 1990, and developing countries expected to achieve the Millennium Development Goal 4 (MDG 4).