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Abstrct A composite Air Health Index (AHI) is helpful for separately emphasizing the health risks of multiple stimuli and communicating the overall risks of an adverse atmospheric environment to the public. We aimed to establish a new AHI by integrating daily mortality risks due to air pollution with those due to non-optimum temperature in China. Based on the exposure-response (E-R) coefficients obtained from time-series models, the new AHI was constructed as the sum of excess mortality risk associated with air pollutants and non-optimum temperature in 272 Chinese cities from 2013 to 2015. We examined the association between the “total AHI” (based on total mortality) and total mortality, and further compared the ability of the “total AHI” to predict specific cardiopulmonary mortality with that of “specific AHIs” (based on specific mortalities). On average, air pollution and non-optimum temperature were associated with 28.23% of daily excess mortality, of which 23.47% was associated with non-optimum temperature while the remainder was associated with fine particulate matter (PM2.5) (1.12%), NO2 (2.29%,), and O3 (2.29%). The new AHI uses a 10-point scale and shows an average across all 272 cities of 6 points. The E-R curve for AHI and mortality is approximately linear, without any thresholds. Each one unit increase in “total AHI” is associated with a 0.84% increase in all-cause mortality and 1.01%, 0.98%, 1.02%, 1.66%, and 1.71% increases in cardiovascular disease, coronary heart disease, stroke, respiratory diseases, and chronic obstructive pulmonary disease mortality, respectively. Cause-specific mortality risk estimates using the “total AHI” are similar to those predicted by “specific AHIs”. In conclusion, the “total AHI” proposed herein could be a promising tool for communicating health risks related to exposure to the ambient environment to the public.

Objectives Cardiovascular disease (CVD) is leading cause of death in China. We aimed to provide national and subnational estimates and its change of premature mortality burden of CVD during 2005–2020. Methods Data from multi-source on the basis of national mortality surveillance system (NMSS) was used to estimate mortality and years of life lost (YLL) of total CVD and its subcategories in Chinese population across 31 provinces during 2005–2020. Results Estimated CVD deaths increased from 3.09 million in 2005 to 4.58 million in 2020; the age-standardized mortality rate (ASMR) decreased from 286.85 per 100,000 in 2005 to 245.39 per 100,000 in 2020. A substantial reduction of 19.27% of CVD premature mortality burden, as measured by age-standardized YLL rate, was observed. Ischemic heart disease (IHD), hemorrhagic stroke (HS) and ischemic stroke (IS) were leading 3 causes of CVD death. Marked differences were observed in geographical patterns for total CVD and its subcategories, and it appeared to be lower in areas with higher economic development. Population ageing was dominant driver contributed to CVD deaths increase, followed by population growth. And, age-specific mortality shifts contributed largely to CVD deaths decline in most provinces. Conclusion Substantial discrepancies were demonstrated in CVD premature mortality burden across China. Targeted considerations were needed to integrate primary care with clinical care through intensifying further strategies for reducing CVD mortality among specific subcategories, high risk population and regions with inadequate healthcare resources.

The distribution of temperature and temperature-health association varied largely across different regions in China, a region-specific definition for heatwave was therefore needed. We collected the data on daily mortality, meteorological factors and air pollution in 84 Chinese cities during 2013–2016, which was divided into seven regions. Based on the association between daily maximum temperature and mortality in each city in a threshold distributed lag non-linear model, where the threshold was defined as the temperature corresponding to the lowest mortality risk, we calculated the number of deaths that could be avoided for 1 °C decrease in maximum temperature under different thresholds, then a random-effect meta-analysis was used to generate regional results, in which the temperature with the highest avoidable mortality number for 1 °C decrease was considered as the most appropriate heatwave definition. We observed an immediate detrimental effect of high temperature within three lag days. Our analysis suggested to use 29.5 °C, 31.5 °C, 29.0 °C, 31.5 °C, 30.0 °C, and 28.5 °C as the heatwave standard for east, north, northeast, central, south, and southwest region, with the avoidable mortality number of 1.54 (95 % Confidence interval (CI): 0.88, 2.19), 0.55 (95 % CI: 0.16, 0.94), 0.59 (95 % CI: 0.32, 0.86), 1.14 (95 % CI: 0.68, 1.59), 1.22 (95 % CI: 0.54, 1.90), and 0.78 (95 % CI: 0.01, 1.55), respectively, while the estimated number 0.19 (95 % CI: −0.02, 0.40) in northwest region was not statistically significant. The concept of ‘avoidable mortality for 1 °C decrease’ was proposed to define the heatwave event, and varied maximum temperature between 28.5 and 31.5 °C was suggested for region-specific heatwave definition in China.

The burden of non-communicable diseases (NCDs) has increased in China. However, the contribution of dietary risks to the NCD burden has not been evaluated. This study aimed to estimate the burden of ischemic heart disease (IHD) and colorectal cancer (CRC) attributable to a diet low in fiber in China from 1990 to 2017. China data from the Global Burden of Disease Study (GBD) 2017 were used to assess the age-, sex-, and province-specific mortality and disability-adjusted life-years (DALYs) of IHD and CRC related to a diet low in fiber. In 2017, a diet low in fiber contributed 170,143 [95% uncertainty interval (UI): 99,623–256,806] IHD deaths and 25,561 (95% UI: 13,726–39,215) CRC deaths, with the population attributable fractions (PAFs) were 9.7 and 13.7%, respectively. Males had higher risk-attributable mortality and DALY rates for IHD and CRC than females. An upward trend with age in rates of mortality and DALY was observed. All-age risk-attributable mortality and DALY rates increased significantly by 111.4 and 53.2% for IHD, and 94.4 and 59.6% for CRC from 1990 to 2017, respectively; however, the corresponding age-standardized rates for IHD and CRC showed relatively stable trends. Heilongjiang, Xinjiang, and Inner Mongolia were ranked as the top three provinces in terms of total risk-attributable NCD burden in 2017. China has a large and growing NCD burden attributable to a diet low in fiber. Greater priority in disease prevention and control should be given to male and older adults throughout China, particularly in some western provinces.

The severe economic and disease burden caused by air pollution have become a public health concern. A great number of studies have proved that air pollution had an impact on mortality, but the association between air pollution and years of life lost (YLL) remains indistinct. The mortality data between January 1, 2008 to December 31, 2012 was collected from the China National Mortality Surveillance system to estimate the burden of disease attribute to air pollution. We used Distributed Lag Non-linear Model (DLNM) to analyze it, adjusting for long-term trend and weather confounders. Total 386,695 death was included in the study. 185,360 death was cardiovascular disease and 37,812 death was respiratory disease. The average value of air pollution index (API) was 84, average YLL for non-accidental death, cardiovascular disease, ischemic heart disease (IHD), stroke, respiratory disease, and chronic obstructive pulmonary disease (COPD) were 12.0, 9.8, 9.2, 9.7, 7.3 and 6.5, and daily YLL for non-accidental death, cardiovascular disease, IHD, stroke, respiratory disease, and COPD were 2540, 994, 428, 456, 150 and 60 respectively. The relative risk (RR) of API on YLL was 1.04 (95%CI, 1.00–1.07) at lag 0–2 days for non-accidental death, and 1.44 (95%CI, 1.02–2.02) at lag 0–7 days for cardiovascular disease. Air pollution had a more serious impact on the elderly and women. We found the positive association between API and YLL in Beijing. The study indicates that the government needs to develop public health policies to improve the quality of the air.

Summary Background Associations between high and low temperatures and increases in mortality and morbidity have been previously reported, yet no comprehensive assessment of disease burden has been done. Therefore, we aimed to estimate the global and regional burden due to non-optimal temperature exposure. Methods In part 1 of this study, we linked deaths to daily temperature estimates from the ERA5 reanalysis dataset. We modelled the cause-specific relative risks for 176 individual causes of death along daily temperature and 23 mean temperature zones using a two-dimensional spline within a Bayesian meta-regression framework. We then calculated the cause-specific and total temperature-attributable burden for the countries for which daily mortality data were available. In part 2, we applied cause-specific relative risks from part 1 to all locations globally. We combined exposure–response curves with daily gridded temperature and calculated the cause-specific burden based on the underlying burden of disease from the Global Burden of Diseases, Injuries, and Risk Factors Study, for the years 1990–2019. Uncertainty from all components of the modelling chain, including risks, temperature exposure, and theoretical minimum risk exposure levels, defined as the temperature of minimum mortality across all included causes, was propagated using posterior simulation of 1000 draws. Findings We included 64·9 million individual International Classification of Diseases-coded deaths from nine different countries, occurring between Jan 1, 1980, and Dec 31, 2016. 17 causes of death met the inclusion criteria. Ischaemic heart disease, stroke, cardiomyopathy and myocarditis, hypertensive heart disease, diabetes, chronic kidney disease, lower respiratory infection, and chronic obstructive pulmonary disease showed J-shaped relationships with daily temperature, whereas the risk of external causes (eg, homicide, suicide, drowning, and related to disasters, mechanical, transport, and other unintentional injuries) increased monotonically with temperature. The theoretical minimum risk exposure levels varied by location and year as a function of the underlying cause of death composition. Estimates for non-optimal temperature ranged from 7·98 deaths (95% uncertainty interval 7·10–8·85) per 100 000 and a population attributable fraction (PAF) of 1·2% (1·1–1·4) in Brazil to 35·1 deaths (29·9–40·3) per 100 000 and a PAF of 4·7% (4·3–5·1) in China. In 2019, the average cold-attributable mortality exceeded heat-attributable mortality in all countries for which data were available. Cold effects were most pronounced in China with PAFs of 4·3% (3·9–4·7) and attributable rates of 32·0 deaths (27·2–36·8) per 100 000 and in New Zealand with 3·4% (2·9–3·9) and 26·4 deaths (22·1–30·2). Heat effects were most pronounced in China with PAFs of 0·4% (0·3–0·6) and attributable rates of 3·25 deaths (2·39–4·24) per 100 000 and in Brazil with 0·4% (0·3–0·5) and 2·71 deaths (2·15–3·37). When applying our framework to all countries globally, we estimated that 1·69 million (1·52–1·83) deaths were attributable to non-optimal temperature globally in 2019. The highest heat-attributable burdens were observed in south and southeast Asia, sub-Saharan Africa, and North Africa and the Middle East, and the highest cold-attributable burdens in eastern and central Europe, and central Asia. Interpretation Acute heat and cold exposure can increase or decrease the risk of mortality for a diverse set of causes of death. Although in most regions cold effects dominate, locations with high prevailing temperatures can exhibit substantial heat effects far exceeding cold-attributable burden. Particularly, a high burden of external causes of death contributed to strong heat impacts, but cardiorespiratory diseases and metabolic diseases could also be substantial contributors. Changes in both exposures and the composition of causes of death drove changes in risk over time. Steady increases in exposure to the risk of high temperature are of increasing concern for health. Funding Bill & Melinda Gates Foundation.

Introduction: Cardiovascular disease (CVD) is the leading cause of death and has caused a heavy burden in China. China has about 106 million CVD patients, including 33 million with stroke. This study presents the latest cardiovascular mortality in China in 2019 to provide evidence for disease control and prevention. Methods: Mortality data from the China Death Surveillance Point System (DSP System) was used for CVD mortality estimation. A descriptive analysis was conducted to demonstrate the results. Results: A total of 5.09 million CVD deaths were estimated in China in 2019, with a mortality rate and age-standardized mortality rate of 364.5 per 100,000 population and 276.0 per 100,000, respectively. Stroke is the leading cause of death, and the mortality rate and age-standardized mortality rate (ASMR) were 171.6 per 100,000 and 130.0 per 100,000, respectively. The second major cause was ischemic heart diseases, and the mortality rate and ASMR were 147.3 per 100,000 and 142.1 per 100,000, respectively. Stroke and ischemic heart diseases were the two major causes of CVD deaths, which accounted for over 87% of all CVD deaths. Conclusions: Although age-standardized mortality of CVD continues to decline in China, the number of deaths is still increasing. Therefore, prevention and control efforts for CVD should be maintained. In order to achieve the “Healthy China 2030” goal of reducing the mortality rate of CVD in China, it is necessary to further strengthen the prevention, control, and treatment capacity of stroke. Meanwhile, increases in ischemic heart disease deaths in highly developed areas should be monitored.

What is already known about this topic? Breast cancer is the most common cancer in women in China and around the world. By 2019, 121 countries have instituted a national screening program as a secondary prevention measure for breast cancer. What is added by this report? Breast cancer screening rates in China were 18.9% in women aged 20 years and above, and 25.7% in women aged 35–64 years in 2015. The screening rate for women aged 20 years and above was significantly higher in urban areas than in rural areas (24.6% vs. 15.0%), and in the eastern region than in the central and western regions (24.0% vs. 15.1% and 15.3%). What are the implications for public health practice? Continued efforts should be made to strengthen national and local policy initiatives and financial support for population-based, organized screening programs for breast cancer. Health education and accessibility of screening services to women across the country should be strengthened, especially for women aged 50 years and above.

Background Oral cancer is among the most common malignant tumors worldwide, and it has become an increasingly important public health problem in China. This study systematically assesses the current state of oral cancer in China from 1990 to 2017, providing new information and perspectives for oral health researchers and public health policy makers. Methods Based on the Global Burden of Disease, Injuries, and Risk Factors Study 2017 (GBD 2017), we evaluated the incidence rates, mortality and disability-adjusted life year (DALY) rates for oral cancer in China and their changing trends between 1990 and 2017, making comparisons by gender and age. We also assessed the DALY rates associated with oral cancer at the provincial level for 33 provinces and their trends over time. Results From 1990 to 2017, the number of new cases and the age-standardized incidence rate for oral cancer in China increased by 280.0% and 79.7%, respectively; the number of deaths and the age-standardized mortality rose by 196.8% and 29.0%, respectively; and the number of DALYs and the age-standardized DALY rate increased by 149.1% and 21.0%, respectively. The incidence rates for oral cancer rose after 30 years of age and peaked at 65–69 years; the mortality for oral cancer rose after 50 years of age and peaked at 65–69 years; and the DALY rates for oral cancer rose after 45 years of age and peaked at 65–69 years. The incidence rates, mortality and DALY rates for oral cancer in males were significantly higher than those in females and showed an upward trend, while there was a decrease or no significant change in females. The DALY rates increased in 21 provinces and decreased in 12 provinces, with the largest growth in Henan Province and the largest decline in Hong Kong Province. Conclusions The burden of oral cancer in China continues to increase continuously. More prevention, control and intervention measures should be taken and increased attention paid to common risk factors is essential for the prevention of oral cancer.

Summary Background Vision loss is an important public health issue in China, but a detailed understanding of national and regional trends in its prevalence and causes, which could inform health policy, has not been available. This study aimed to assess the prevalence, causes, and regional distribution of vision impairment and blindness in China in 1990 and 2019. Methods Data from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019 were used to estimate the prevalence of moderate and severe vision impairment and blindness in China and compare with other Group of 20 (G20) countries. We used GBD methodology to systematically analyse all available demographic and epidemiological data at the provincial level in China. We compared the age-standardised prevalences across provinces, and the changes in proportion of vision loss attributable to various eye diseases in 1990 and 2019. We used two different counterfactual scenarios with respect to population structure and age-specific prevalence to assess the contribution of population growth and ageing to trends in vision loss. Findings In 2019, the age-standardised prevalence was 2·57% (uncertainty interval [UI] 2·28–2·86) for moderate vision impairment, 0·25% (0·22–0·29) for severe vision impairment, and 0·48% (0·43–0·54) for blindness in China, which were all below the global average, but the prevalence of moderate and severe vision impairment had increased more rapidly than in other G20 countries from 1990 to 2019. The prevalence of vision loss increased with age, and the main causes of vision loss varied across age groups. The leading causes of vision impairment in China were uncorrected refractive error, cataract, and macular degeneration in both 1990 and 2019 in the overall population. From 1990 to 2019, the number of people with moderate vision impairment increased by 133·67% (from 19·65 to 45·92 million), those with severe vision impairment increased by 147·14% (from 1·89 to 4·67 million), and those with blindness increased by 64·35% (from 5·29 to 8·69 million); in each case, 20·16% of the increase could be explained by population growth. The contributions to these changes by population ageing were 87·22% for moderate vision impairment, 116·06% for severe vision impairment, and 99·22% for blindness, and the contributions by age-specific prevalence were 26·29% for moderate vision impairment, 10·91% for severe vision impairment, and −55·04% for blindness. The prevalence and specific causes of vision loss differed across provinces. Interpretation Although a comprehensive national policy to prevent blindness is in place, public awareness of visual health needs improving, and reducing the prevalence of moderate and severe vision impairment should be prioritised in future work. Funding China National Key Research and Development Programme and Beijing Municipal Special Funds for Medical Research on Public Welfare Development and Reform.

The aim of this study was to estimate the burden of ischemic heart disease (IHD) and type 2 diabetes mellitus (T2DM) attributable to a diet high in sugar-sweetened beverages (SSBs) in China from 1990 to 2017.Data from the Global Burden of Disease Study 2017 were used to assess all-age and age-standardized, risk-attributable mortality, years of life lost (YLL), years of life with disability (YLD), and disability-adjusted life years (DALYs) by age, sex, year, province, and sociodemographic index (SDI).For total noncommunicable diseases (NCDs), 12 523 (95% uncertainty interval 776-27 631) deaths, 305 288 (18 611-661 847) YLL, 142 051 (64 530-257 468) YLD, and 447 339 (132 677-858 838) DALYs were attributable to diet high in SSBs in 2017, particularly among males. Age-standardized, risk-attributable mortality, YLL, YLD, and DALY rates increased distinctly by 507.3%, 410.3%, 571.0%, and 453.3% from 1990 to 2017 respectively. Age-sex-specific, risk-attributable mortality and YLL rates for IHD in older adults (over 65 years) were higher than in young (between 25 and 39 years) and middle-aged adults (between 40 and 64 years) in 2017; however, the YLD and DALY rates for T2DM were higher in young and middle-aged males than in older males. The age-standardized, risk-attributable DALY rates for total NCDs increased substantially in high-SDI and high-middle-SDI provinces during the period.China has a huge and growing burden of IHD and T2DM attributable to diet high in SSBs, particularly among young and middle-aged male adults in wealthier provinces. Evidence-based public health policies at the provincial levels to reduce the consumption of SSBs should be prioritized in China.目的: 估计中国1990年至2017年高糖饮料所导致的缺血性心脏病和2型糖尿病的疾病负担。 方法: 使用2017年全球疾病负担研究的数据; 按年龄、性别、年份、省份和社会人口指数评估归因于高糖饮料的缺血性心脏病和2型糖尿病的死亡率、早死所致寿命损失(YLL)、伤残所致寿命损失(YLD)和伤残调整寿命年(DALY)数及标化率。 结果: 2017年归因于高糖饮料的慢性病总死亡人数12523人(776-27631); 早死所致寿命损失为305288人年(18611-661847); 伤残所致寿命损失为142051人年(64530-257468); 伤残调整寿命年为447339人年(132677-858838); 以男性为主。1990年至2017年; 年龄标化的死亡率、YLL、 YLD 和DALY率分别增加了507.3%、410.3%、571.0%和453.3%。2017年; 老年人群(65岁以上)缺血性心脏病的死亡率和YLL率高于年轻人(25-39岁)和中年人(40-64岁); 然而; 对2型糖尿病来说; 青年和中年男性的YLD率和DALY率高于老年男性。1990-2017年; 在高SDI和高-中SDI的省份; 慢性病的标化DALY率大大增加。 结论: 中国归因于高糖饮料的缺血性心脏病和2型糖尿病的疾病负担呈现增长趋势; 特别是在较富裕省份的年轻和中年男性人群中。基于这些证据; 应优先考虑减少高糖饮料消费的公共卫生决策。.

Background Colorectal cancer (CRC) has emerged as a major public health concern. However, little is known about the burden attributable to specific risk factors. The present study aimed to estimate the temporal trends and geographical variation of CRC burden attributable to a diet low in milk in China. Methods Following the general analytic strategy used in the 2017 Global Burden of Disease study, we assessed the age-, sex-, and province-specific mortality and disability-adjusted life-years (DALYs) of CRC caused by a diet low in milk in China from 1990 to 2017. Results In 2017, a diet low in milk contributed 32 032 [95% uncertainty interval (UI) = 11 350-53 806] deaths and 726 710 (95% UI = 256 651-1 218 153) DALYs for CRC with a population attributable fraction of 17.1%. The age-standardised mortality and DALY rates per 100 000 were 1.7 (95% UI = 0.6-2.9) and 36.8 (95% UI = 13.0-61.7), respectively. An upward trend with age in rates of mortality and DALYs was observed. Males had higher age-standardised rates than females. The number of deaths and DALYs increased significantly from 1990 to 2017, whereas the corresponding age-standardised rates showed relatively stable trends. In 2017, Hunan and Liaoning were ranked as the top two provinces in terms of disease burden. Socio-demographic index had a weak correlation with the age-standardised mortality (r = 0.348, P = 0.047). Conclusions The present study shows a substantial increase in the CRC burden attributable to a diet low in milk over the past three decades. Greater priority in CRC prevention should be given to males and the elderly population throughout China, particularly in less-developed provinces.

Purpose China has a heavy cancer burden. We aimed to quantitatively estimate the secular trend of cancer mortality and incidence in China. Methods We extracted numbers, age-specific and age-standardized rates of 29 cancer groups (from 1990 to 2017) from the Global Burden of Disease (GBD) study in 2017. We estimated rates of major cancer types for annual percent change by Joinpoint regression, and for age, period, and cohort effect by an age-period-cohort model. Results In 2017, breast cancer had the highest incidence rate in females. Lung cancer had the highest mortality and incidence rates in males. Although the age-standardized incidence rate of prostate cancer ranked second highest in males, it increased by 112% from 1990 to 2017. Individuals aged over 50 years were at high risk of developing cancer, and the number of deaths at this age accounted for over 89% of all cancers in all age groups. When compared with the global average level, the age-standardized mortality and incidence rates of both liver and esophageal cancers were 2.1 times higher in China, and stomach, lung and nasopharyngeal cancers in China also had high levels (more than 1.5 times higher). During 1990-2017, most of the 29 cancers exhibited an increasing incidence trend, and Joinpoint regression demonstrated increasing mortality of some major cancers. The period effect indicated that the risk of mortality and incidence due to the main cancers generally increased during 1992-2017. Conclusion Trend analysis provided information on the effects of prevention strategies and targeted interventions on the occurrence of different cancers. Etiological studies need to be conducted on some major cancers in the Chinese population.

Background Death registration completeness has never been assessed at the county level in China. Such analyses would provide critical intelligence to monitor the performance of the vital registration system and yield adjustment factors to correct death registration data, thereby increasing their policy utility. Methods We estimated the completeness of death registration for 31 provinces and 2844 counties of China in 2018 based on death data from the China Cause of Death Reporting System (CDRS) by using the empirical completeness method. We computed the root mean square difference (RMSD) of county-level completeness compared with provincial-level completeness to study intra-provincial variations. A two-level (province and county) logistic regression model was fitted to explore the association between county-level registration completeness and a set of covariates reflecting socioeconomic status, healthcare quality, and specific strategies and regulations designed to improve registration. Results In 2018, the overall death registration completeness for the CDRS in China was 74.2% (95% uncertainty interval [UI] 66.2–80.4), with very little difference for males and females. Geographical differences in completeness were higher across counties than across provinces. The county-level completeness ranged from 2.4% (95% UI 1.0–5.0%) in Burang County, Tibet, to 100.0% (95% UI 99.9–100.0%) in Guandu District, Yunnan. The coastal provinces of Jiangsu, Guangdong, and Fujian, with higher overall completeness, contained counties with low completeness; conversely, the underdeveloped provinces of Guangxi and Guizhou, with lower overall completeness, included some counties with high completeness. GDP, education, population density, minority population, healthcare access, and registration strategies were important drivers of the geographical differences in registration completeness. Conclusions There are marked inequalities in registration completeness at the county level and within provinces in China. The socioeconomic condition, the implementation of specific registration-enhancing initiatives, and the availability and quality of medical care were the primary drivers of the observed geographical variation. A more strategic approach, with more research, is required to identify the main reasons for death under-reporting, especially in the poorer performing counties, to guide remedial action.

Background Depression in China has risen from the 15th leading cause of all-cause disability-adjusted life years (DALYs) in 1990 to the 10th in 2017. However, the burden of depression and the epidemiological trend in Chinese provinces remain unclear. This study aimed to estimate the prevalence and burden of depression among different sexes, ages, disease types and provincial administrative units in China. Methods Based on a general analysis of the Global Burden of Disease study (GBD) in 2017, we analyzed the age- sex- and province-specific prevalence and DALYs of depression in China from 1990 to 2017. Results From 1990 to 2017, the all-age prevalence rate of depression per 100,000 rose from 3224.6 (95% UI:2976.6–3509.1) to 3990.5 (95% UI: 3667.8–4353.0), and the DALY rate per 100,000 rose from 525.1 (95% UI: 373.5–719.0) to 607.4 (95% UI: 427.7–820.2). The prevalence rate decreased in the population aged 5–54 years, and increased in the population aged over 55 years. In 2017, the prevalence rate of females (5039.6, 95% UI: 4630.0–5502.8) was significantly higher than that of males (2984.9, 95% UI: 2736.0–3265.3). The prevalence and DALY rate increased in all provinces. However, the age-standardized prevalence and DALYs rate decreased in 31 provinces. Conclusions Depression has gradually become a major public health issue in China. The government should take measures to prevent the development of depression immediately. Women and the elderly are at high risk for depression.

Ambient air pollution may be associated with diabetes mellitus. However, evidence from developing countries is limited although the concentrations of air pollution are disproportionably higher in these countries. We collected daily data on diabetes mortality, air pollution, and weather conditions from 16 Chinese provincial cities during 2007–2013. A quasi-Poisson regression combined with a distributed lag model was used to quantify the city-specific mortality risk of PM10 (particulate matter with aerodynamic diameter

Summary Background China has seen a remarkable epidemiological and demographic transition during the past three decades. We aimed to describe the prevalence of osteoarthritis as well as years lived with disability (YLDs) due to osteoarthritis in China, according to age, sex, and geographical location, from 1990 to 2017. Methods Data were obtained from systematic reviews of symptomatic osteoarthritis of the knee and hip in the Global Burden of Diseases, Injuries, and Risk Factors Study 2017 (GBD 2017). Three categories of sequelae (mild, moderate, and severe) of osteoarthritis were defined to indicate the degrees of severity and functional loss associated with the condition. A Bayesian meta-regression tool was applied to estimate the prevalence of osteoarthritis and the distribution of its severity. YLDs were calculated by multiplying the prevalence of osteoarthritis sequelae by their corresponding disability weights. All data were analysed by age–sex–province–year groups in China. Findings Around 26·1 million individuals in China had osteoarthritis in 1990, and this number rose to 61·2 million in 2017. The age-standardised prevalence of osteoarthritis increased from 2·9% (95% uncertainty interval 2·5–3·3) in 1990 to 3·1% (2·7–3·4) in 2017. The total YLDs due to osteoarthritis increased from 0·84 million (0·42–1·69) in 1990 to 1·97 million (0·98–3·94) in 2017, while the age-standardised YLD rate increased from 92·5 (45·7–185·6) per 100 000 people to 98·8 (49·4–197·6) per 100 000. Osteoarthritis prevalence and YLDs were higher in females than in males, and YLD rate increased with age. Osteoarthritis was the 24th most common cause of YLDs in China in 2017, accounting for 1·08% (0·64–2·02) of all YLDs. Interpretation Osteoarthritis is prevalent in China. Between 1990 and 2017, disease burden increased and varied greatly according to geographical location. Appropriate prevention and treatment strategies, predominantly those targeted at women, older people, and underdeveloped areas, must be developed to reduce the burden of the disease. Funding National Natural Science Foundation of China, China National Key Research and Development Programme.

Background China has more than 18% of the global population and over 770 million workers. However, the burden of disease attributable to occupational risks is unavailable in China. We aimed to estimate the burden of disease attributable to occupational exposures at provincial levels from 1990 to 2017. Methods We estimated the summary exposure values (SEVs), deaths and disability-adjusted life years (DALYs) attributable to occupational risk factors in China from 1990 to 2017, based on Global Burden of Disease Study (GBD) 2017. There were 18 occupational risks, 22 related causes, and 35 risk-outcome pairs included in this study. Meanwhile, we compared age-standardized death rates attributable to occupational risk factors in provinces of China by socio-demographic index (SDI). Results The SEVs of most occupational risks increased from 1990 to 2017. There were 323,833 (95% UI 283,780 - 369,061) deaths and 14,060,210 (12,022,974 - 16,125,763) DALYs attributable to total occupational risks in China, which were 27.9 and 22.1% of corresponding global levels, respectively. For attributable deaths, major risks came from occupational particulate matter, gases, and fumes (PGFs), and for the attributable DALYs, from occupational injuries. The attributable burden was higher in males than in females. Compared with high SDI provinces, low SDI provinces, especially Western China, had higher death rates attributable to total occupational risks, occupational PGFs, and occupational injuries. Conclusion Occupational risks contribute to a huge disease burden in China. The attributable burden is higher in males, and in less developed provinces of Western China, reflecting differences in risk exposure, socioeconomic conditions, and type of jobs. Our study highlights the need for further research and focused policy interventions on the health of workers especially for less developed provinces in China to reduce occupational health losses effectively.

IntroductionCancer is an important public health concern with heavy disease burden in China. In 2017, cancer is the leading cause of death, with around 2.60 million deaths, which accounts for 26.07% of all deaths. This study aims to present cancer mortality in China in 2018 to provide evidence for cancer control and prevention. MethodsMortality data from China Cause of Death Reporting System (CDRS) and population data from National Bureau of Statistics are used for cancer mortality estimation. A descriptive analysis was conducted to demonstrate the results. ResultsA total of 2,557,297 cancer deaths were estimated in China in 2018 with a mortality rate and age-standardized mortality rate of 183.89 and 145.60 per 100,000, respectively. Lung, liver, and stomach cancer were the three leading causes of cancer death and accounted for around 56.75% of all cancer deaths. The age-standardized mortality rate was higher in men (194.37 per 100,000) than in women (99.47 per 100,000), in urban areas (148.25 per 100,000) than in rural areas (144.62 per 100,000), and in eastern regions (150.57 per 100,000) than in central (142.09 per 100,000)/western regions (141.54 per 100,000). The age-specific mortality rate remains low for the population younger than 44 years old and reaches its peak after 80 years old. Leukemia is the leading cause of cancer death among those aged 0–14 years in both sexes, while breast cancer is the leading cause of cancer death in women aged 15–44 years. Conclusions and Implications for Public Health PracticeThe cancer mortality patterns show substantial disparities among sexes, age groups, areas, and regions. Healthy lifestyle promotion, active vaccination uptake, and environmental governance are essential to eliminate cancer-related risk factors in the overall population. Tailored strategies for the early screening and diagnosis, therapeutic management, and palliative care should be a top priority for enforcement among target populations and regions.

What is already known about this topic? The World Health Organization’s (WHO) Global Health Estimates (GHE) reported that acute hepatitis caused 9,213 deaths and 307,720 person years of disability-adjusted life years (DALYs) in 2016, and acute hepatitis B accounted for 85.81% of all DALYs among acute hepatitis types A, B, C, and E in China. What is added by this report? In China, the percent changes in years lived with disability (YLDs) due to acute hepatitis A, B, and E in groups aged 50–69 years and 70 years or more and in all age groups for acute hepatitis C were increased from 2000 to 2019. What are the implications for public health practices? Effective vaccines, interventions, and treatments are key approaches to achieve the WHO’s goal of reducing new hepatitis infections by 90% and deaths by 65% between 2016 and 2030.

What is already known about this topic? Cervical cancer is the fourth most common cancer of women around the world. Age-adjusted incidence and mortality rates of cervical cancer were 11.78 and 3.29 per 100,000, respectively, in China in 2015. What is added by this report? Cervical cancer screening rates were 25.7% for women aged 20–64 years old and 31.4% for women aged 35–64 years old in China in 2015. Screening rates were lower in rural areas than in urban areas and varied across provinces. What are the implications for public health practice? Efforts should be made to continue to strengthen national and local policy initiatives, financial support, health education, and accessibility to women in rural areas for cervical cancer screening coverage.

What is already known about this topic? Mental and substance use disorders have notable contributions to the disease burden in China. What is added by this report? In China, mental disorders and substance use disorders accounted for 20.29 million and 5.76 million disability-adjusted life years (DALYs) in 2019, respectively; depressive disorders were the leading cause of DALYs. For mental disorders, the numbers of DALYs increased 12.06% from 2000 to 2019 while the standardized rates declined 5.24%; for substance use disorders, both the numbers and standardized rates of DALYs decreased 8.52% and 18.52%, respectively. What are the implications for public health practices? Mental and substance use disorders pose a challenge to the healthcare system in China. The government should take action and decrease the associated burden of disease.

What is already known about this topic? Hypertension has become a major public health problem worldwide because of its high prevalence and various complications, and it ranks the most important risk factor for cardiovascular diseases (CVDs). What is added by this report? The prevalence, awareness, treatment, and control of hypertension in the labor force population in 2015 in China were 21.4%, 26.1%, 19.6%, and 6.3%, respectively. Hypertension prevalence in the labor force population remains high and the control of hypertension is still very low. What are the implications for public health practice? Effective public health strategies targeting the labor force population, especially older adults, males, and overweight and obese participants are needed for hypertension prevention and control.

What is already known about this topic? There were approximately 1.23 million deaths reported among individuals aged 5–19 years worldwide in 2017. Limited attention has been paid to current mortality among primary and secondary school students aged 6–18 years in China. What is added by this report? In 2018, an estimated 28,519 deaths occurred among primary and secondary school students aged 6–18 years in China with an age-standardized mortality rate (ASMR) of 17.66 per 100,000. Substantial disparities existed among sexes, age groups, areas, and regions for different causes of death. Drowning, road traffic injuries, and leukemia were three leading causes of death. What are the implications for public health practice? Government support, legislation enforcement, multisectoral cooperation, and stakeholder engagement should be initiated to reduce premature deaths among primary and secondary school students in China, especially those due to injuries.

Background In China, chronic obstructive pulmonary disease (COPD) was accounted for a quarter of the global COPD population and has become a large economic burden. However, the comprehensive picture of the COPD burden, which could inform health policy, is not readily available for all of the provinces of China. Here, we aimed to describe the burden of COPD in China, providing an up-to-date and comprehensive analysis at the national and provincial levels, and time trends from 1990 to 2019.Methods Following the methodology framework and general analytical strategies used in the GBD 2019, we analyzed the incidence, prevalence, mortality, and disability-adjusted life years (DALYs) attributable to COPD across China and the corresponding time trends from 1990 to 2019, stratified by age and province. We also presented the contribution of risk factors (e.g., smoking, ambient particulate matter, and occupational risks) to COPD-related mortality and DALYs. The association between COPD burden and socio-demographic index (SDI) were also evaluated. Results From 1990 to 2019, the incidence and prevalence of COPD increased by 61.2% and 67.8%, respectively, whereas the number of deaths and DALYs owing to COPD decreased. The age-standardized rates (ASRs) of COPD burden continuously decreased from 1990 to 2019. The crude rates of COPD burden dramatically increased with age and reached a peak in the older than 95 years age group. In 2019, the leading risk factor for COPD mortality and DALYs was tobacco use in the whole population, but ambient particulate matter pollution was the most significant risk factor in females. At the provincial level, the ASRs of COPD burden was significantly associated with the SDIs, with the highest ASRs in the western provinces with low SDIs. ConclusionsAlthough the ASRs of COPD burden in China substantially decreased at the national and provincial levels from 1990 to 2019, absolute numbers of COPD incidence and prevalence are still rising, indicating that COPD remains an important public health problem in China. Geographically targeted considerations should be developed to enhance COPD health and reduce the COPD burden throughout China and in specific provinces.

In 2009, China launched an ambitious health system reform that combined extending social health insurance scheme with improving efficiency, access and quality of care in the country. To assess the impact of the policy on efficiency and productivity change, we investigated the country’s health system performance at provincial levels during pre- and post-reform period. Outputs were measured using multiple health outcomes (namely, non-communicable diseases free healthy life years and infant and maternal survival rates), while health expenditure, number of medical personnel and hospital beds per 1000 residents were used as proxy measures for health inputs. Changes in productivity were quantified using a bootstrap Malmquist productivity index (MPI). The analysis focused on the period between 2004 and 2015. This was to capture pre- and post-policy implementation experience and to ensure that enough time was allowed for the policy to work through. Finally, a bootstrap Tobit regression model for panel data was applied to examine the potential effects of contextual factors on productivity change. The result showed that the reform has had negative effects on productivity. Only scale efficiency had improved steadily, but the decline in the scale of technological change observed during the same period meant that the progress in scale efficiency had been masked. Better economic performance (as measured by per capita Gross Domestic Product (GDP)) and higher human resource to capital investment ratio (as measured by density of medical staff per hospital beds) tended to boost productivity growth, while population aging, low educational attainment and higher percentage of out-of-pocket (OOP) payments had adverse effects. Improving health system productivity in China requires improving financial risk protection and maintaining proper balance between human and capital investment in the country.

Background Anemia or low hemoglobin can increase the risk of stroke. However, the association between hemoglobin and outcomes after stroke is uncertain. In this study, we aimed to investigate the association between hemoglobin and clinical outcomes, including mortality, poor functional outcome, stroke recurrence, and composite vascular events at 1 year. Methods and Results We included the patients diagnosed with acute ischemic stroke or transient ischemic attack from the Third China National Stroke Registry. We used the Cox model for mortality, stroke recurrence, and composite vascular events and the logistic model for the poor functional outcome to examine the relationship between hemoglobin and clinical outcomes. In addition, we used the restricted cubic spline to evaluate the nonlinear relationship. This study included 14 159 patients with acute ischemic stroke or transient ischemic attack. After adjusted for potential cofounders, both anemia and high hemoglobin were associated with the higher risk of mortality (hazard ratio [HR], 1.73; 95% CI, 1.39–2.15; HR, 2.71; 95% CI, 1.95–3.76) and poor functional outcome (odds ratio [OR], 1.36; 95% CI, 1.18–1.57; OR, 1.42; 95% CI, 1.07–1.87). High hemoglobin, but not anemia, increased the risk of stroke recurrence (HR, 1.37; 95% CI, 1.05–1.79) and composite vascular events (HR, 1.41; 95% CI, 1.08–1.83). There was a U‐shaped relationship between hemoglobin and mortality and poor functional outcome. Conclusions Abnormal hemoglobin was associated with a higher risk of all‐cause mortality, poor functional outcome, stroke recurrence, and composite vascular events. More well‐designed clinical studies are needed to confirm the relationship between hemoglobin and clinical outcomes after stroke.

Wei Liu,* Wei Wang,* Jiangmei Liu, Yunning Liu, Shidi Meng, Feixue Wang, Zheng Long, Jinlei Qi, Jinling You, Lin Lin, Lijun Wang, Maigeng Zhou, Peng Yin National Center for Chronic and Noncommunicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, People’s Republic of China*These authors contributed equally to this workCorrespondence: Peng YinNational Center for Chronic and Noncommunicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention, No. 27 Nanwei Road, Beijing, 100050, People’s Republic of ChinaTel +86 010-63015058Email yinpeng@ncncd.chinacdc.cnBackground: To examine trends in chronic obstructive pulmonary disease (COPD) mortality and years of life lost (YLL) due to COPD for all provinces in China during 2005– 2020.Methods: Data for COPD mortality were derived from China National Mortality Surveillance System (NMSS). We analyzed the numbers and age-standardized rates of death and YLL due to COPD in China, during 2005– 2020. We carried out decomposition analysis to analyze the drivers of change in COPD deaths during the study period.Results: The age-standardized mortality rate of COPD in China decreased significantly from 99.5/100,000 in 2005 to 50.5/100,000 in 2020. Similar trend was seen in the age-standardized YLL rate. The mortality rate increased with age. During 2005– 2020, the age-standardized mortality rate decreased in all provinces (except for Tibet) with the largest decline in Jilin (− 77.8%), Henan (− 68.4%) and Fujian (− 67.1%). The decreased number of deaths was decomposed as population growth (8.5%) and population ageing (69.7%) with offset by decline of age-specific mortality (− 87.5%).Conclusion: COPD remains an important public health problem in China, though significant reductions of COPD mortality and YLL rate were observed. Vigorous prevention and control strategies should be enhanced to improve the quality of life of COPD patients and reduce the premature death caused by COPD in Chinese population.Keywords: COPD, mortality, YLL

Background Functional recovery is an important clinical outcome for patients with stroke. Hospital-level variation occurs in functional outcome after stroke. However, the extent to which patient characteristics, hospital characteristics, process of care, and medication persistence contribute to the hospital variation in poor functional outcome after ischemic stroke is unknown in China. Methods We retrospectively analyzed patients enrolled in the Third China National Stroke Registry from 2015 to 2018. The outcome was poor functional outcome (modified Rankin Scale score of 3-6) at 3 months and 1 year. We used the median odds ratio to quantify the hospital-level variation in rates of poor functional outcome. A series of hierarchical logistic models were constructed to assess the extent to which patient characteristics, hospital characteristics, process of care, and medication persistence contributed to the hospital variation. Results A total of 13,218 patients with acute ischemic stroke from 159 hospitals were included. The riskadjusted rates of the poor functional outcome at 3 months and 1 year after ischemic stroke varied across hospitals, ranging from 6.0% to 26.0% and 6.8% to 24.0%, respectively. The median odds ratio was 1.78 at 3 months and 1.67 at 1 year. Hierarchical logistic models indicated that the patient characteristics, hospital characteristics, process of care, and the medication persistence explained 27.5%, 7.0%, 6.5%, and 5.0% of the variation at 1 year. Altogether, 36.8% and 46.1% of the hospital variation in 3-month and 1-year poor functional outcome, respectively, was explained. Conclusions There was a wide variation in rates of functional outcomes across hospitals. Approximately half of the variation at 1 year can be explained by patient characteristics, hospital characteristics, process of care, and medication persistence. Approximately 11.5% of the variation can be modified through improvements in the process of care and medication persistence. More studies are needed to explore the contribution of post-discharge care in the future.

Background Efforts to quantify the burden of maternal disorders at the national and provincial levels are valuable for resource allocation and for development and adoption of public health policies. Methods Following the methods of the Global Burden of Diseases, Injuries, and Risk Factors Study 2019, the prevalence of maternal disorders and the resulting disability-adjusted life years (DALYs), years lived with disability(YLD), deaths, and years of life lost (YLL) at the national and provincial levels in China were examined for the 1990–2019 period. Estimated annual percentage changes (EAPCs) were calculated to estimate the trends of age-standardized rate (ASR) of prevalence, DALYs, death, and YLD due to maternal disorders and its main subcategories from 1990 to 2019. Findings In 2019, China had an estimated 0.85 million cases of maternal disorders (95% uncertainty interval: 0.65–1.08 million), with a 73% decline in absolute numbers from 1990 to 2019. The ASR of prevalence, DALYs and death for overall maternal disorders showed decreasing trends in China from 1990 to 2019 with the EAPCs being −3.25(95% confidence interval [CI] = −3.86 to −2.64), −8.07 (95% CI= −9.14 to −6.98), and −7.04 (95% CI= −7.99 to −6.07), respectively. The most pronounced decreases in trends in ASR of prevalence, DALYs and death were observed for maternal hemorrhage. Shandong, Hong Kong, Macao showed no significant trends in ASR of prevalence. Notably, the trends in ASR of prevalence due to maternal hypertensive disorders had been stable in China and most provinces. The trends in ASR of DALYs and death decreased the most in Jiangxi province. Interpretation The disease burden of prevalence, DALYs and death for overall maternal disorders decreased significantly in China from 1990 to 2019, however, the trends in ASR of prevalence due to maternal hypertensive disorders had been stable in China and most provinces. Funding The study is supported by grants from the Innovative Talent Support Plan of the Medical and Health Technology Project in Zhejiang Province (2021422878), Ningbo Science and Technology Project (202002N3152), Ningbo Health Branding Subject Fund (PPXK2018–02), Sanming Project of Medicine in Shen-zhen (SZSM201803080).

Background: There was lack of data on the burdens and trends of upper and lower respiratory infections (URIs and LRIs) over the past three decades in China. Methods: We estimated the incidence, mortality, and disability-adjusted life years (DALYs) due to upper and lower respiratory infections (URIs and LRIs) and attributable risk factors in China by a systematic analysis of the Global Burden of Disease 2019 study. Incidence, mortality, and DALYs were stratified by sex, age, and province. Risk factors for respiratory infections were analyzed from exposure data. Findings: The age-standardized incidence rates of URIs and LRIs were 179,077 and 3926 per 100,000 persons in 2019, with a 7•52% and 35•07% decrease from 1990, respectively. Moreover, 2801 and 185,264 persons died of URIs and LRIs in 2019, respectively. DALYs for URIs and LRIs also decreased from 1,516,727 in 1990 to 928,617 in 2019 and from 38,278,504 in 1990 to 4,020,676 in 2019. The burden of URIs and LRIs were generally similar in males and females, but relatively higher in the new-borns and the elderly. Child malnutrition and low birth weight were the most important cause of age-standardized DALYs of LRIs and URIs, respectively. Interpretation: Future URI and LRI prevention strategies should focus on the maternal and child health, air pollution, and tobacco control, especially in young children and the elderly population. Funding: National Key R&D Program of China (2018YFA0606200); National Natural Science Foundation of China (82041021); Fundamental Research Funds for the Central Universities (20ykpy86) and Guangdong Basic and Applied Basic Research Foundation (2019A1515110003); Bill & Melinda Gates Foundation (No.: INV-006371).

Background : This study aimed to identify changing spatial and temporal trends of lung cancer mortality rates (LCMRs) among subpopulations in China (according to region, age, and sex). Methods : Data on LCMRs from 2006 to 2015 were extracted from the Chinese National Death Surveillance. Joinpoint regression and seasonal decomposition were used to assess the temporal trends. A geographic information system and spatial kriging interpolation were used to examine the spatial trends. Results : LCMRs in men aged 30 to 49 years significantly declined nationally from 2009 to 2015 (annual percentage change, –2.7%; P < .05), but they continued to rise in men aged ≥ 70 years and women aged ≥ 50 years in the east, people aged 50 to 69 years in the south, and most groups in the southwest. Among provincial capital cities, Shenyang, Changsha, and Hohhot had the highest 10-year average LCMR for men aged 30 to 49 years, 50 to 69 years, and ≥ 70 years, respectively; among all ages of women, Harbin had the highest average LCMR. Over the 10 years, the odds of the increases in LCMRs in men and women aged 30 to 69 years decreased by 3% to 7% with the longitudes or latitudes increasing by 1° (ORs ranged from 0.93 [95% CI, 0.90-0.95) to 0.97 [95% CI, 0.95-0.99]). Conclusions : Disparities in the spatial and temporal trends of LCMRs among subpopulations highlight the need for investigation into potential drivers, especially for the east, south, and southwest of China. These findings may help health authorities target interventions to those most in need to reduce the lung cancer burden in China.

Summary Background Public health is a priority for the Chinese Government. Evidence-based decision making for health at the province level in China, which is home to a fifth of the global population, is of paramount importance. This analysis uses data from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2017 to help inform decision making and monitor progress on health at the province level. Methods We used the methods in GBD 2017 to analyse health patterns in the 34 province-level administrative units in China from 1990 to 2017. We estimated all-cause and cause-specific mortality, years of life lost (YLLs), years lived with disability (YLDs), disability-adjusted life-years (DALYs), summary exposure values (SEVs), and attributable risk. We compared the observed results with expected values estimated based on the Socio-demographic Index (SDI). Findings Stroke and ischaemic heart disease were the leading causes of death and DALYs at the national level in China in 2017. Age-standardised DALYs per 100 000 population decreased by 33·1% (95% uncertainty interval [UI] 29·8 to 37·4) for stroke and increased by 4·6% (–3·3 to 10·7) for ischaemic heart disease from 1990 to 2017. Age-standardised stroke, ischaemic heart disease, lung cancer, chronic obstructive pulmonary disease, and liver cancer were the five leading causes of YLLs in 2017. Musculoskeletal disorders, mental health disorders, and sense organ diseases were the three leading causes of YLDs in 2017, and high systolic blood pressure, smoking, high-sodium diet, and ambient particulate matter pollution were among the leading four risk factors contributing to deaths and DALYs. All provinces had higher than expected DALYs per 100 000 population for liver cancer, with the observed to expected ratio ranging from 2·04 to 6·88. The all-cause age-standardised DALYs per 100 000 population were lower than expected in all provinces in 2017, and among the top 20 level 3 causes were lower than expected for ischaemic heart disease, Alzheimer's disease, headache disorder, and low back pain. The largest percentage change at the national level in age-standardised SEVs among the top ten leading risk factors was in high body-mass index (185%, 95% UI 113·1 to 247·7]), followed by ambient particulate matter pollution (88·5%, 66·4 to 116·4). Interpretation China has made substantial progress in reducing the burden of many diseases and disabilities. Strategies targeting chronic diseases, particularly in the elderly, should be prioritised in the expanding Chinese health-care system. Funding China National Key Research and Development Program and Bill & Melinda Gates Foundation.

Introduction Periodic population surveys of smoking behavior can inform development of effective tobacco control strategies. We investigated smoking patterns, cessation, and knowledge about smoking hazards in China. Methods A nationally representative cross-sectional survey recruited 176 318 people aged ≥18 years across 31 provinces of China in 2013–2014, using multi-stage stratified cluster sampling methods. The smoking patterns, cessation, and knowledge about smoking hazards were analyzed, overall and in population subgroups, adjusting for sample selection weight and post-stratification factors. Results Among men, 60.7% were ever-smokers, with proportions of regular, occasional and former smokers being 46.3%, 5.5%, and 8.8% respectively. Among women, only 2.8% had ever smoked. The prevalence of ever smoking in men was higher in rural than urban areas (63.2% vs. 57.6%) and varied from 39.5% to 67.4% across 31 provinces. Among male regular smokers, the mean daily number of cigarettes smoked was 17.8, with mean age at first starting to smoke daily being 20.1 years. Among current smokers, one-third (32.6% men, 32.1% women) had tried to quit before and 36.8% (36.8% men, 35.5% women) intended to quit in the future. Of the Chinese adults, 75.9% recognized that smoking was hazardous, with the proportions believing that smoking could cause lung cancer, heart attack or stroke being 67.0%, 33.2%, and 29.5%, respectively and with 26.0% reporting that smoking could cause all these conditions. Conclusion Among Chinese adults, the smoking prevalence remained high in men but was low in women. In both men and women, knowledge about smoking hazards was poor. Implications This study showed that tobacco smoking remained highly prevalent among adult men in China in 2013–2014. Moreover, men born in recent decades were more likely to start smoking at younger ages and to smoke more cigarettes than those born in previous generations. There was a large regional variation in male smoking prevalence, with the least economically developed regions having higher prevalence. In contrast, few women in China smoked, especially among those born in recent decades. The contrasting smoking patterns in men and women is likely to result in an increasingly large gender disparity in life expectancy in the coming decades.

Chronic respiratory diseases cause huge death burden worldwide, especially in developing countries. The influence of ambient temperature on respiratory mortality has attracted growing concerns in the background of climate change. Daily cause-specific respiratory deaths and meteorological variables were collected from 16 Chinese cities during 2007–2013. We first applied the distributed lag non-linear model for each city to calculate the percentage change in respiratory mortality risk with a 1 °C change in moderate and extreme temperature range. Then, random-effect meta-analytical approach was used to produce the pooled effects. Individual-level and city-level effect modifications were separately assessed by the stratified analysis and mixed effects meta-regression model. Both cold and heat effects were associated with respiratory mortality. The pooled excess risk was 4.40% (95%CI: 2.75–6.08%), 2.23% (1.19–3.28%), 2.64% (1.81–3.47%), and 4.21% (3.10–5.33%) for 1 °C change among extreme cold, moderate cold, moderate heat, and extreme heat, respectively. Positive heat and cold effects were found for COPD, asthma, and pneumonia, among which asthma was most vulnerable to extreme cold temperatures, with the effect estimate of 6.52% (2.73–10.46%). The heat effects were much higher in females than males. Slightly higher risks were also observed in the elderly during the heat, and those with lower education level during the heat and extreme cold. City-level modifiers included green coverage rates and diurnal temperature range. Ambient heat and cold temperatures are positively associated with respiratory mortality in China. Individual and city-specific effect modifiers should be taken into consideration in policy-making.

What is already known about this topic? The burden from chronic non-communicable diseases has become an important public health concern in China. What is added by this report? The most recent estimates on incidence, prevalence, and mortality for cancer, cardiovascular disease, chronic respiratory disease, and diabetes in China during 1990-2017 reveal that the accumulated prevalences of the four major NCDs are increasing, but the age-standardized mortality rates for CVD, cancer, and CRD have been on a decline during the period of 1990-2017. What are the implications for public health practice? More effective intervention strategies should be developed to deal with the continuously increasing burden caused by NCDs.

Background: The evidence was limited and inconclusive about the added effects of heatwaves, especially in developing countries. Objective: To evaluate the added effects of heatwaves on cause-specific mortality in China. Methods: We designed a nationwide time-series analysis based on daily data from 272 main Chinese cities to from 2013 to 2015. We adopted 12 definitions by combining 4 heat thresholds (90th, 92.5th, 95th, 97.5th percentile of city-specific daily mean temperature) and duration of ≥2, 3 and 4 days. We applied overdispersed generalized additive models with distributed lag models to estimate the city-specific cumulative effects of heatwaves over lags of 0–10 days after controlling for daily temperature. We then, used a meta-regression model to pool the effect estimates at national and regional levels. Results: Heatwaves could significantly increase risk for mortality from total and cardiopulmonary diseases, including coronary heart disease, ischemic stroke (rather than hemorrhagic stroke) and chronic obstructive pulmonary disease. The effects increased with higher thresholds, but were not appreciably influenced by the duration of heat. The risks generally occurred immediately and lasted for 3 to 5 days. The risks were much larger in the temperate continental zone and the temperate monsoon zones than in the subtropical monsoon zone where there was an evident mortality displacement. The elderly, females and less-educated people were more vulnerable. Conclusions: This analysis provided ample evidence for the added mortality risk associated with heatwaves, which had important implications for designing heatwave-warning systems and predicting the disease burden of future heatwaves. Keywords: Heat waves, Mortality, Cardiopulmonary diseases, Vulnerable subgroups, Climatic zones, China

What is already known about this topic? Previous studies have mainly focused on the relationship between temperature and mortality from stroke, but analysis on the effects on years of life lost (YLL) is limited. What is added by this report? YLLs were used as the health outcome, and cold and hot weather were found to be significantly associated with an increase in YLLs from stroke and for different groups, with a stronger effect found to be associated with low temperature. What are the implications for public health practice? These findings could help identify vulnerable regions and populations that have a more serious temperature-related burden and to guide the practical and effective measures for stroke control from a YLL perspective.

Summary Background Understanding the temporal trend of the disease burden of stroke and its attributable risk factors in China, especially at provincial levels, is important for effective prevention strategies and improvement. The aim of this analysis from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) is to investigate the disease burden of stroke and its risk factors at national and provincial levels in China from 1990 to 2019. Methods Following the methodology in the GBD 2019, the incidence, prevalence, mortality, and disability-adjusted life-years (DALYs) of stroke cases in the Chinese population were estimated by sex, age, year, stroke subtypes (ischaemic stroke, intracerebral haemorrhage, and subarachnoid haemorrhage), and across 33 provincial administrative units in China from 1990 to 2019. Attributable mortality and DALYs of underlying risk factors were calculated by a comparative risk assessment. Findings In 2019, there were 3·94 million (95% uncertainty interval 3·43–4·58) new stroke cases in China. The incidence rate of stroke increased by 86·0% (73·2–99·0) from 1990, reaching 276·7 (241·3–322·0) per 100 000 population in 2019. The age-standardised incidence rate declined by 9·3% (3·3–15·5) from 1990 to 2019. Among 28·76 million (25·60–32·21) prevalent cases of stroke in 2019, 24·18 million (20·80–27·87) were ischaemic stroke, 4·36 million (3·69–5·05) were intracerebral haemorrhage, and 1·58 million (1·32–1·91) were subarachnoid haemorrhage. The prevalence rate increased by 106·0% (93·7–118·8) and age-standardised prevalence rate increased by 13·2% (7·7–19·1) from 1990 to 2019. In 2019, there were 2·19 million (1·89–2·51) deaths and 45·9 million (39·8–52·3) DALYs due to stroke. The mortality rate increased by 32·3% (8·6–59·0) from 1990 to 2019. Over the same period, the age-standardised mortality rate decreased by 39·8% (28·6–50·7) and the DALY rate decreased by 41·6% (30·7–50·9). High systolic blood pressure, ambient particulate matter pollution exposure, smoking, and diet high in sodium were four major risk factors for stroke burden in 2019. Moreover, we found marked differences of stroke burden and attributable risk factors across provinces in China from 1990 to 2019. Interpretation The disease burden of stroke is still severe in China, although the age-standardised incidence and mortality rates have decreased since 1990. The stroke burden in China might be reduced through blood pressure management, lifestyle interventions, and air pollution control. Moreover, because substantial heterogeneity of stroke burden existed in different provinces, improved health care is needed in provinces with heavy stroke burden. Funding National Key Research and Development Program of China and Taikang Yicai Public Health and Epidemic Control Fund.

Background Atopic dermatitis (AD) is a chronic disease with growing prevalence and has become a global public health problem. However, little is known about the burden caused by AD in China. Objective To access the prevalence and burden of AD in China. Methods We estimated the prevalence and year lived with disability (YLD) of AD in China, by different age and sex groups. We also compared the burden of AD in China with other countries in the Group of Twenty (G20). We analyzed the changes in the number of AD patients and their YLDs by cause decomposition from 1990 to 2019. Results AD was the twenty-fourth leading cause of the burden of 369 diseases in China in 2019. From 1990 to 2019, the age-standardized prevalence and YLD rate of AD in China increased by 1.04% and 1.43% respectively, which were the second and the largest increase among the G20 and both higher than the global average (−4.29% and −4.14%). The number of patients with AD increased by 25.65%, of which 20.16% was due to population growth, 3.85% due to population aging, and 1.64% due to age-specific prevalence. Both the prevalence and YLD rate of AD were higher in 1 to 4 year-olds and 95+ years age group. Before the age of 10, the prevalence and YLD rate of AD in males were higher than those in females, while there was a marked sex shift at the ages of 10 to 14. Conclusion AD is a serious public health problem in China. Substantial variations exist in burden due to AD between male and female, and in age groups. Considering these findings will be important for developing preventive strategies and treatments to reduce the burden of AD.

Summary Background In China, mean body-mass index (BMI) and obesity in adults have increased steadily since the early 1980s. However, to our knowledge, there has been no reliable assessment of recent trends, nationally, regionally, or in certain population subgroups. To address this evidence gap, we present detailed analyses of relevant data from six consecutive nationally representative health surveys done between 2004 and 2018. We aimed to examine the long-term and recent trends in mean BMI and prevalence of obesity among Chinese adults, with specific emphasis on changes before and after 2010 (when various national non-communicable disease prevention programmes were initiated), assess how these trends might vary by sex, age, urban–rural locality, and socioeconomic status, and estimate the number of people who were obese in 2018 compared with 2004. Methods We used data from the China Chronic Disease and Risk Factors Surveillance programme, which was established in 2004 with the aim to provide periodic nationwide data on the prevalence of major chronic diseases and the associated behavioural and metabolic risk factors in the general population. Between 2004 and 2018 six nationally representative surveys were done. 776 571 individuals were invited and 746 020 (96·1%) participated, including 33 051 in 2004, 51 050 in 2007, 98 174 in 2010, 189 115 in 2013, 189 754 in 2015, and 184 876 in 2018. After exclusions, 645 223 participants aged 18–69 years remained for the present analyses. The mean BMI and prevalence of obesity (BMI ≥30 kg/m2) were calculated and time trends compared by sex, age, urban–rural locality, geographical region, and socioeconomic status. Findings Standardised mean BMI levels rose from 22·7 kg/m2 (95% CI 22·5–22·9) in 2004 to 24·4 kg/m2 (24·3–24·6) in 2018 and obesity prevalence from 3·1% (2·5–3·7) to 8·1% (7·6–8·7). Between 2010 and 2018, mean BMI rose by 0·09 kg/m2 annually (0·06–0·11), which was half of that reported during 2004–10 (0·17 kg/m2, 95% CI 0·12–0·22). Similarly, the annual increase in obesity prevalence was somewhat smaller after 2010 than before 2010 (6·0% annual relative increase, 95% CI 4·4–7·6 vs 8·7% annual relative increase, 4·9–12·8; p=0·13). Since 2010, the rise in mean BMI and obesity prevalence has slowed down substantially in urban men and women, and moderately in rural men, but continued steadily in rural women. By 2018, mean BMI was higher in rural than urban women (24·3 kg/m2 vs 23·9 kg/m2; p=0·0045), but remained lower in rural than urban men (24·5 kg/m2 vs 25·1 kg/m2; p=0·0007). Across all six surveys, mean BMI was persistently lower in women with higher levels of education compared with women with lower levels of education, but the inverse was true among men. Overall, an estimated 85 million adults (95% CI 70 million–100 million; 48 million men [95% CI 39 million–57 million] and 37 million women [31 million–43 million]) aged 18–69 years in China were obese in 2018, which was three times as many as in 2004. Interpretation In China, the rise in mean BMI among the adult population appears to have slowed down over the past decade. However, we found divergent trends by sex, geographical area, and socioeconomic status, highlighting the need for a more targeted approach to prevent further increases in obesity in the Chinese general population. Funding China National Key Research and Development Program, China National Key Project of Public Health Program, and Youth Scientific Research Foundation of the National Center for Chronic and Noncommunicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention.

Smoking has a substantial impact on deaths from non-communicable chronic diseases (NCDs). Quantitatively measuring the impact of tobacco control on population health is of great theoretical and practical importance, for governments to make health policy decisions. Focusing on premature deaths, we predicted the deaths by 2030 from major NCDs caused by smoking among people aged 30–69 years in Sichuan Province, Southwest China. We extracted data for 1990–2015 from the Global Burden of Disease Study 2015 and calculated the population attributable fraction, to estimate the proportion of deaths caused by smoking. Four different tobacco control standards were used to estimate 2030 projections for the prevalence of smoking and premature mortality. If smoking prevalence were reduced by 30% from 2015 levels, premature mortality could be expected to decline by 24.4% in 2030, achieving 81.3% of the World Health Organization target for reducing premature mortality by 30%. Compared with the continuation of historical trends, the strongest tobacco control policy scenario would reduce premature mortality by 6.6%, prevent 23,600 deaths, reduce mortality by 7.8%, and increase life expectancy at birth by 0.3 years. Smoking bans represent an important action toward achieving national health goals.

Background: Lymphoma is a malignant disease that threatens human health and imposes a significant burden on the society burden; however, there are limited accurate mortality data on lymphoma in China. Methods: Mortality data of patients with lymphoma were extracted from the disease surveillance system of the Chinese Center for Disease Control and Prevention. Mortality was represented by the number of deaths, crude death rate, and age-standardized mortality rate. Temporal trends in mortality rates were examined using the fitting joinpoint models. Findings: Lymphoma accounted for 31,225 deaths in 2020, of which 1,838 and 29,387 were due to Hodgkin lymphoma (HL) and non-Hodgkin lymphoma (NHL), respectively. The age-standardized mortality rate per 100,000 population was 1·76 for lymphoma, 0·10 for HL, and 1·65 for NHL. The mortality rate increased with age, reaching a peak in the age group of 80–84 years for HL and over 85 years for NHL. Moreover, the death risk due to lymphoma was approximately 1·5–2 times greater in males than in females in all age groups. The mortality rate was higher in eastern China than in central and western China, indicating a heterogeneous distribution at the provincial level. During 2013–2020, the mortality rate of lymphoma decreased by 1·85% (−22·94% for HL and −0·14% for NHL). Interpretation: The mortality rate of lymphoma varied by sex, age, and region (provinces). A significant decrease in the mortality rate of HL was demonstrated. This highlights the need to establish a differentiated strategy for disease control and prevention. Funding Information: None. Declaration of Interests: We declare no competing interests.

Background: Physical inactivity is an essential health-related behaviour and a significant risk factor for chronic non-communicable diseases. Temporal trends in physical inactivity in Chinese adults are unclear. Method: Four nationally representative cross-sectional surveys were conducted in 31 provinces in China between 2010 and 2018. Using a multi-stage, stratified, cluster-randomized sampling method, 669 919 Chinese adults were selected to participate in the surveys, and 645 903 adults were included in the analyses. Domain-specific (work-, transport-, and recreation-) moderate- to vigorous-intensity physical activity (MVPA) was measured using the Global Physical Activity Questionnaire. Physical activity was defined as not doing at least 150 minutes of moderate-intensity, 75 minutes of vigorous-intensity PA per week, or any equivalent combination of the two. Temporal changes in physical inactivity and no domain-specific PA were analyzed using linear regression methods. All analysis was accounted for the complex sampling design. Findings: From 2010 to 2018, the prevalence of physical inactivity among Chinese adults increased from 17·9% (95%CI, 16·3-19·5) to 22·3% (95%CI, 20·9-23·8) (Ptrend

Background: Recent studies have shown an increase in the prevalence of hyperuricemia (HUA) worldwide. However, representative national data suggesting national trends of HUA in China are lacking. Methods: Using a multi-stage, stratified, cluster-randomized sampling design, two cross-sectional surveys (representative of national and provincial information) were conducted in 31 provinces (autonomous regions and municipalities) in mainland China, with 166,861 Chinese adults in 2015–16 and 168,351 in 2018–19. Serum uric acid (SUA) levels of all participants were measured after a >10-hour overnight fast. HUA was defined when SUA was >420 μmol/L. Prevalence estimates were weighted to represent the total population considering the complex sampling design. Multivariable logistic regression models estimated factors associated with HUA. Findings: The overall HUA prevalence in the Chinese adult population was 11.1% (95% CI, 10.3–11.8%) in 2015–16 and 14.0% (95% CI, 13.1-14.8%) in 2018–19; an alarming rise was observed in the three years. HUA was more common in men with 19.3% (95% CI, 17.9–20.7%) in 2015–16 and 24.4% (95% CI, 23.0–25.8%) in 2018–19. The HUA prevalence also escalated from 2.8% (95% CI, 2.5-3.0%) in 2015–16 to 3.6% (95% CI, 3.2–4.0%) in 2018–19 in women. Various risk factors, including urban culture, settlement in the East, Zhuang descent, high education, heavy or frequent beer drinking, high red meat intake, physical inactivity, high BMI, central obesity, hypertension, hyperlipidemia, and low eGFR, were significantly associated with HUA. Interpretation: The estimated HUA prevalence among Chinese adults was 14.0% in 2018–19; significant escalating trends were observed between 2015 and 2019. Therefore, HUA is a public health problem in China. Funding: Chinese Central Government and National Key R&D Program of China. Declaration of Interest: We declare no competing interests. Ethical Approval: The ethical review committee of the Chinese Center for Disease Control and Prevention (China CDC) approved the 2015 CCDRFS (approval number 201519- A) and that of the National Center for Chronic and Noncommunicable Disease Control and Prevention, China CDC approved the 2018 CCDRFS (approval number 201819).

Background Cardiovascular diseases (CVDs) are the leading causes of death in China. Little is known about the CVD burden and risk factors in Henan Province, China. Objective To analyze the CVD burden and main risk factors between 1990 and 2017 in the Henan Province in China. Methods The methodological framework and analytical strategies adopted in the Global Burden of Disease Study 2017 were used. Results (1) Age-standardized mortality rate attributed to CVDs increased from 355.0 per 100,000 persons in 1990 to 364.1 per 100,000 persons in 2017 in Henan. (2) Age-standardized disability adjusted life years (DALYs) rate fell by 3.9% from 1990 to 2017. However, the number of DALYs attributed to CVDs increased by 75.9% from 4.2 million person-years in 1990 to 7.3 million person-years in 2017. (3) The age-standardized years lived with disability (YLDs) rate increased by 27.5% from 1990 to 2017. However, years of life lost (YLLs) rate decreased by 6.7% from 1990 to 2017. The contribution of YLLs to the DALYs decreased from 91.4% in 1990 to 89.2% in 2017. (4) Stroke (52.3%) and ischemic heart diseases (38.8%) accounted for 91.1% of total CVDs DALYs among adults in 2017. (5) Dietary factors such as high intake of sodium, alcohol use and low intake of fruits, high systolic blood pressure, and tobacco use were the top risk factors for CVDs, and the estimated population attributable fraction in 2017 was 69.4%, 56.7% and 25.2%, respectively. Conclusions The absolute burden of CVDs in Henan is still high, although age-standardized DALYs declined between 1990 and 2017. The prevention and control of stroke and ischemic heart diseases should focus on a few modifiable risk factors which mainly contributed to the burden of CVDs, such as dietary factors, high systolic blood pressure, and tobacco use.

Updated information on the burden of Alzheimer's disease and other forms of dementia are of great importance for evidence-based health care planning. However, such an estimate has been lacking in Chinese populations at both national and provincial levels.To estimate the temporal trends and the attributable burdens of selected risk factors of Alzheimer's disease and other forms of dementia in China.This is an observational description of the Global Burden of Diseases Study 2019 (GBD 2019). Data on incidence, mortality, prevalence, disability-adjusted life years (DALYs), years lived with disability (YLDs), and years of life lost (YLLs) of Alzheimer's disease and other forms of dementia were derived from the GBD 2019 study at both national and provincial levels in China.Six indicators were used: incidence, mortality, prevalence, DALYs, YLLs, and YLDs. Absolute numbers in detail by age, sex, region, and age-standardized rates (with 95% uncertainty intervals) were calculated.There were notable increasing trends in the number of deaths (247·9%), incidence (264·8%), prevalence (296·5%), DALYs (228·1%), YLDs (308·7%) and YLLs (201·7%) from 1990 to 2019, respectively. The corresponding age-standardized rates increased by 6·2%, 19·3%, 33·6%, 10·7%, 33·4% and 3·1%. Smoking, high body mass index, high fasting plasma glucose levels, and metabolic risks were the four leading risk factors. Higher burden was observed among females versus males and in the more developed regions.The disease burden in China were increasing substantially. Regional differences of the disease burden are accompanied by discrepancies of economic level and geographical location, as well as different levels of exposure to risk factors. Targeted prevention and control strategies are urgently needed to reduce the disease burden.

Background: Limited information exists on the temporal trend of the disease burden of stroke and its attributable risk factors in China, especially at provincial levels. The aim of this analysis from the Global Burden of Disease Study (GBD) 2019 is to investigate the disease burden of stroke and its risk factors at national and provincial levels of China from 1990 to 2019. Methods: Following the methodology in the GBD 2019, the incidence, prevalence, mortality, and disability-adjusted life years (DALYs) of stroke cases in the Chinese population were estimated by sex, age, year, three subcategories of stroke and across 33 province-level administrative units in China from 1990 to 2019. Attributable mortality and DALYs of underlying risk factors were calculated by a comparative risk assessment. Findings: The annual stroke incidence increased from 1.76 million in 1990 to 3.94 million in 2019; the age-standardised incidence rate declined from 221.5 per 100,000 population in 1990 to 200.8 per 100,000 population in 2019. Deaths due to stroke increased by 59.0%, reaching 2.19 million in 2019. The age-standardised mortality rate decreased by 39.8%, reaching 127.2 per 100,000 population in 2019. The number of stroke prevalence overall increased by 147.5% (from 11.62 million in 1990 to 28.76 million in 2019). From 1990 to 2019, the age-standardised prevalence rate increased by 13.2% for overall stroke and 33.5% for ischemic stroke, and decreased by 31.9% for intracerebral hemorrhage and 21.9% for subarachnoid hemorrhage. A substantial reduction was observed in the age-standardised DALYs rate (41.6%) of stroke from 1990 to 2019. Moreover, there were marked differences of these estimates stratified by sex, age, stroke subtype, and across province. High systolic blood pressure , high fasting blood glucose , p articulate matter pollution exposure , and smoking were four major risk factors for stroke burden in 2019. Interpretation: This study demonstrates that the disease burden of stroke is still severe for the Chinese population, although the age-standardised incidence and mortality rate have decreased since 1990. There was substantial variation of these estimates among different provinces which suggested the necessary of targeted stroke intervention. Blood pressure and blood glucose management through regular health care and air pollution control measures might help reduce the stroke burden in China. Funding Information: This work was supported by the National Key R&D Program of China (2018YFA0606200). The Global Burden of Disease Study is funded by the Bill and Melinda Gates Foundation. Declaration of Interests: The authors declare they have no actual or potential competing financial interests. Ethics Approval Statement: This study was approved by the Ethical Review Committee of the National Center for Chronic and Non-communicable Disease Control and Prevention of the Chinese Center for Disease Control and Prevention. No individual identifiable information was used in this study.

Background: Cardiovascular disease (CVD) is the leading cause of death (COD) in China. Understanding the characteristics of place of death (POD) among CVD deaths would be of great importance to improve quality of end-of-life care. Limited studies have reported the POD among CVD deaths, and little was known about the associated factors of hospital CVD deaths. Methods: By using data from National Mortality Surveillance System (NMSS) in China, this study presented the characteristics of POD distribution during 2008 and 2020. Afterwards, we used multilevel logistic regression to explore associated factors of hospital CVD deaths, quantify the magnitude to which the spatial variations of hospital CVD deaths could be explained by those associated factors. Findings: During 2008-2020, there were 7101871 CVD deaths collected by NMSS in China, with 77·13% home deaths and 18·49% hospital death. Shanghai (59·40%) had the highest percentage of hospital CVD deaths. Age, sex, ethnicity, marital status, education, occupation, underlying COD were significant influential factors of hospital CVD deaths. Spatial variations were shown at provincial level, with 33·88% of them were explained by factors at individual level. Interpretation: POD distribution among CVD patients remained stable and home was the leading POD. Demographics and socioeconomic status were important factors at individual level explained majority of spatial variations among hospital CVD deaths, and patients with acute CVD exacerbations tended to have lower probability dying in hospitals. A comprehensive approach of integrating clinical care and community- or home-based care to formulate long-term care system that supports informal care and provides care arrangement options concerning cultural background should be emphasized to improve the quality of end-of-life care in China. Funding Information: National Key Research & Development Program of China (grant number 2018YFC1315301). Declaration of Interests: We declare no competing interests.