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BACKGROUND: Few multicity studies have evaluated the association between cold spells and mortality risk and burden. OBJECTIVES: We aimed to estimate the association between cold spells and cause-specific mortality and to evaluate the mortality burden in China. METHODS: We conducted a time-series analysis with a nationally representative Disease Surveillance Points System database during the cool seasons spanning from 2013 to 2015 in 272 Chinese cities. We used 12 cold-spell definitions and overdispersed generalized additive models with distributed lag models to estimate the city-specific cumulative association of cold spells over lags of 0–28 d. We controlled for the nonlinear and lagged effects of cold temperature over 0–28 d to evaluate the added effect estimates of cold spell. We also quantified the nationwide mortality burden and pooled the estimated association at national and different climatic levels with meta-regression models. RESULTS: For the cold-spell definition of daily mean temperatures of ≤5th percentile of city-specific daily mean temperature and duration of ≥4 consecutive d, the relative risks (i.e., risk ratios) associated with cold spells were 1.39 [95% confidence interval (CI): 1.15, 1.69] for non-accidental mortality, 1.66 (95% CI: 1.20, 2.31) for coronary heart disease mortality, 1.49 (95% CI: 1.12, 1.97) for stroke mortality, and 1.26 (95% CI: 0.85, 1.87) for chronic obstructive pulmonary disease mortality. Cold spells showed a maximal lagged association of 28 d with the risks peaked at 10-15 d. A statistically significant attributable fraction (AF) of non-accidental mortality [2.10% (95% CI: 0.94%, 3.04%)] was estimated. The risks were higher in the temperate continental and the temperate monsoon zones than in the subtropical monsoon zone. The elderly population was especially vulnerable to cold spells. DISCUSSION: Our study provides evidence for the significant relative risks of non-accidental, cardiovascular, and respiratory mortality associated with cold spells. The findings on vulnerable populations and differential risks in different climatic zones may help establish region-specific forecasting systems against the hazardous impact of cold spells. [ABSTRACT FROM AUTHOR]

Background We used nationally representative data to examine trends in under-five unintentional suffocation mortality from 2006 to 2016 in China and mortality differences across age groups, sexes, rural vs urban locations and injury mechanisms. Methods Mortality data came from 161 surveillance points of China's disease surveillance points (DSPs) system. Unintentional suffocation deaths were identified through the 10th International Classification of Disease (ICD-10 codes: w75-w84). Negative binomial regression tested the significance of change in overall and subgroup mortality between 2006 and 2016. Results Despite minor fluctuations, a steady trend in overall age-adjusted unintentional suffocation mortality was observed from 2006 to 2016 in Chinese children under 5 years of age. Infants (<1 year), boys and rural children had higher mortality rates than children aged 1-4 years, girls and urban children, respectively. Strangulation and suffocation in bed was the most common cause of mortality for infants, accounting for 66% of deaths. Children aged 1-4 years suffered more often from inhalation suffocation (55% of deaths). Conclusions Unintentional suffocation mortality rates in under- five children remained fairly stable in China over the past decade but remained at high levels. We discuss actions that might be implemented to reduce pediatric suffocation rates in China. [ABSTRACT FROM AUTHOR]

Objective: To inform interventions targeted towards reducing mortality from acute myocardial infarction (AMI) and sudden cardiac arrest in three megacities in China and India, a baseline assessment of public knowledge, attitudes and practices was performed.Methods: A household survey, supplemented by focus group and individual interviews, was used to assess public understanding of cardiovascular disease (CVD) risk factors, AMI symptoms, cardiopulmonary resuscitation (CPR) and automated external defibrillators (AEDs). Additionally, information was collected on emergency service utilisation and associated barriers to care.Results: 5456 household surveys were completed. Hypertension was most commonly recognised among CVD risk factors in Beijing and Shanghai (68% and 67%, respectively), while behavioural risk factors were most commonly identified in Bangalore (smoking 91%; excessive alcohol consumption 64%). Chest pain/discomfort was reported by at least 60% of respondents in all cities as a symptom of AMI, but 21% of individuals in Bangalore could not name a single symptom. In Beijing, Shanghai and Bangalore, 26%, 15% and 3% of respondents were trained in CPR, respectively. Less than one-quarter of participants in all cities recognised an AED. Finally, emergency service utilisation rates were low, and many individuals expressed concern about the quality of prehospital care.Conclusions: Overall, we found low to modest knowledge of CVD risk factors and AMI symptoms, infrequent CPR training and little understanding of AEDs. Interventions will need to focus on basic principles of CVD and its complications in order for patients to receive timely and appropriate care for acute cardiac events. [ABSTRACT FROM AUTHOR]

BACKGROUND: Few large multicity studies have been conducted in developing countries to address the acute health effects of atmospheric ozone pollution. OBJECTIVE: We explored the associations between ozone and daily cause-specific mortality in China. METHODS: We performed a nationwide time-series analysis in 272 representative Chinese cities between 2013 and 2015. We used distributed lag models and over-dispersed generalized linear models to estimate the cumulative effects of ozone (lagged over 0-3 d) on mortality in each city, and we used hierarchical Bayesian models to combine the city-specific estimates. Regional, seasonal, and demographic heterogeneity were evaluated by meta-regression. RESULTS: At the national-average level, a 10-μg/m3 increase in 8-h maximum ozone concentration was associated with 0.24% [95% posterior interval (PI): 0.13%, 0.35%], 0.27% (95% PI: 0.10%, 0.44%), 0.60% (95% PI: 0.08%, 1.11%), 0.24% (95% PI: 0.02%, 0.46%), and 0.29% (95% PI: 0.07%, 0.50%) higher daily mortality from all nonaccidental causes, cardiovascular diseases, hypertension, coronary diseases, and stroke, respectively. Associations between ozone and daily mortality due to respiratory and chronic obstructive pulmonary disease specifically were positive but imprecise and nonsignificant. There were no statistically significant differences in associations between ozone and nonaccidental mortality according to region, season, age, sex, or educational attainment. CONCLUSIONS: Our findings provide robust evidence of higher nonaccidental and cardiovascular mortality in association with short-term exposure to ambient ozone in China. [ABSTRACT FROM AUTHOR]

BACKGROUND: Cohort studies in North America and western Europe have reported increased risk of mortality associated with long-term exposure to fine particles (PM2:5), but to date, no such studies have been reported in China, where higher levels of exposure are experienced. OBJECTIVES: We estimated the association between long-term exposure to PM2:5 with nonaccidental and cause-specific mortality in a cohort of Chinese men. METHODS: We conducted a prospective cohort study of 189,793 men 40 y old or older during 1990-91 from 45 areas in China. Annual average PM2:5 levels for the years 1990, 1995, 2000, and 2005 were estimated for each cohort location using a combination of satellite-based estimates, chemical transport model simulations, and ground-level measurements developed for the Global Burden of Disease (GBD) 2013 study. A Cox proportional hazards regression model was used to estimate hazard ratios (HR) for nonaccidental cardiovascular disease (CVD), chronic obstructive pulmonary disease (COPD), and lung-cancer mortality. We also assessed the shape of the concentration-response relationship and compared the risk estimates with those predicted by Integrated Exposure-Response (IER) function, which incorporated estimates of mortality risk from previous cohort studies in western Europe and North America. RESULTS: The mean level of PM2:5 exposure during 2000-2005 was 43:7 µg/m3 (ranging from 4.2 to 83:8 µg/m3). Mortality HRs (95% CI) per 10µg/m3 increase in PM2:5 were 1.09 (1.08, 1.09) for nonaccidental causes; 1.09 (1.08, 1.10) for CVD, 1.12 (1.10, 1.13) for COPD; and 1.12 (1.07, 1.14) for lung cancer. The HR estimate from our cohort was consistently higher than IER predictions. CONCLUSIONS: Long-term exposure to PM2:5 was associated with nonaccidental, CVD, lung cancer, and COPD mortality in China. The IER estimator may underestimate the excess relative risk of cause-specific mortality due to long-term exposure to PM2:5 over the exposure range experienced in China and other low- and middle-income countries. [ABSTRACT FROM AUTHOR]

Health insurance holds the promise of improving population health and survival and protecting people from catastrophic health spending. Yet evidence from lower- and middle-income countries on the impact of health insurance is limited. We investigated whether insurance expansion reduced adult mortality in rural China, taking advantage of differences across Chinese counties in the timing of the introduction of the New Cooperative Medical Scheme (NCMS). We assembled and analyzed newly collected data on NCMS implementation, linked to data from the Chinese Center for Disease Control and Prevention on cause-specific, age-standardized death rates and variables specific to county-year combinations for seventy-two counties in the period 2004-12. While mortality rates declined among rural residents during this period, we found little evidence that the expansion of health insurance through the NCMS contributed to this decline. However, our relatively large standard errors leave open the possibility that the NCMS had effects on mortality that we could not detect. Moreover, mortality benefits might arise only after many years of accumulated coverage. [ABSTRACT FROM AUTHOR]

Background: The United Nation's Sustainable Development Goals for 2030 include reducing premature mortality from non-communicable diseases (NCDs) by one third. To assess the feasibility of this goal in China, we projected premature mortality in 2030 of NCDs under different risk factor reduction scenarios.Methods: We used China results from the Global Burden of Disease Study 2013 as empirical data for projections. Deaths between 1990 and 2013 for cardiovascular disease (CVD), diabetes, chronic respiratory disease, cancer, and other NCDs were extracted, along with population numbers. We disaggregated deaths into parts attributable and unattributable to high systolic blood pressure (SBP), smoking, high body mass index (BMI), high total cholesterol, physical inactivity, and high fasting glucose. Risk factor exposure and deaths by NCD category were projected to 2030. Eight simulated scenarios were also constructed to explore how premature mortality will be affected if the World Health Organization's targets for risk factors reduction are achieved by 2030.Results: If current trends for each risk factor continued to 2030, the total premature deaths from NCDs would increase from 3.11 million to 3.52 million, but the premature mortality rate would decrease by 13.1%. In the combined scenario in which all risk factor reduction targets are achieved, nearly one million deaths among persons 30 to 70 years old due to NCDs would be avoided, and the one-third reduction goal would be achieved for all NCDs combined. More specifically, the goal would be achieved for CVD and chronic respiratory diseases, but not for cancer and diabetes. Reduction in the prevalence of high SBP, smoking, and high BMI played an important role in achieving the goals.Conclusions: Reaching the goal of a one-third reduction in premature mortality from NCDs is possible by 2030 if certain targets for risk factor intervention are reached, but more efforts are required to achieve risk factor reduction. [ABSTRACT FROM AUTHOR]

Importance: Previous studies have shown increasing prevalence of diabetes in China, which now has the world's largest diabetes epidemic.Objectives: To estimate the recent prevalence and to investigate the ethnic variation of diabetes and prediabetes in the Chinese adult population.Design, Setting, and Participants: A nationally representative cross-sectional survey in 2013 in mainland China, which consisted of 170 287 participants.Exposures: Fasting plasma glucose and hemoglobin A1c levels were measured for all participants. A 2-hour oral glucose tolerance test was conducted for all participants without diagnosed diabetes.Main Outcomes and Measures: Primary outcomes were total diabetes and prediabetes defined according to the 2010 American Diabetes Association criteria. Awareness and treatment were also evaluated. Hemoglobin A1c concentration of less than 7.0% among treated diabetes patients was considered adequate glycemic control. Minority ethnic groups in China with at least 1000 participants (Tibetan, Zhuang, Manchu, Uyghur, and Muslim) were compared with Han participants.Results: Among the Chinese adult population, the estimated standardized prevalence of total diagnosed and undiagnosed diabetes was 10.9% (95% CI, 10.4%-11.5%); that of diagnosed diabetes, 4.0% (95% CI, 3.6%-4.3%); and that of prediabetes, 35.7% (95% CI, 34.1%-37.4%). Among persons with diabetes, 36.5% (95% CI, 34.3%-38.6%) were aware of their diagnosis and 32.2% (95% CI, 30.1%-34.2%) were treated; 49.2% (95% CI, 46.9%-51.5%) of patients treated had adequate glycemic control. Tibetan and Muslim Chinese had significantly lower crude prevalence of diabetes than Han participants (14.7% [95% CI, 14.6%-14.9%] for Han, 4.3% [95% CI, 3.5%-5.0%] for Tibetan, and 10.6% [95% CI, 9.3%-11.9%] for Muslim; P < .001 for Tibetan and Muslim compared with Han). In the multivariable logistic models, the adjusted odds ratios compared with Han participants were 0.42 (95% CI, 0.35-0.50) for diabetes and 0.77 (95% CI, 0.71-0.84) for prediabetes for Tibetan Chinese and 0.73 (95% CI, 0.63-0.85) for diabetes and 0.78 (95% CI, 0.71-0.86) for prediabetes in Muslim Chinese.Conclusions and Relevance: Among adults in China, the estimated overall prevalence of diabetes was 10.9%, and that for prediabetes was 35.7%. Differences from previous estimates for 2010 may be due to an alternate method of measuring hemoglobin A1c. [ABSTRACT FROM AUTHOR]

Background: Previous studies have indicated that reduced kidney function and albuminuria are associated with increased risk of mortality and adverse cardiovascular outcomes, however, the evidence from the Asian population is limited. We investigated the association between the indicators of chronic kidney disease (CKD) and all-cause mortality, as well as cardiovascular mortality among a general population in China.Methods: We conducted an observational study among 47,204 Chinese adults, from a cross-sectional survey, whose survival status is identified through December 31, 2013. Estimated glomerular filtration rate (eGFR) and urinary albumin-to-creatinine ratio (ACR) were used as indicators of CKD. We determined the rates of all-cause and cardiovascular mortality.Results: The incidence rates for both all-cause and cardiovascular mortality increased with the advanced stages of reduced eGFR or elevated ACR. Elevated ACR levels were found to be significantly associated with increased risk of both all-cause and cardiovascular mortality, as shown in the Cox proportional hazards regression model. The multivariable adjusted hazard ratios (HR) associated with all-cause mortality were 1.26 (95% confidence interval [CI]: 1.04-1.53) for those with ACR 30-299 mg/g and 2.07 (95% CI: 1.40-3.04) with ACR ≥ 300 mg/g, compared to those with ACR <30 mg/g. The corresponding HRs for the above ACR levels associated with cardiovascular mortality were 1.08 (95% CI: 0.77-1.50) and 2.32 (95% CI: 1.31-4.12), respectively. We did not identify reduced eGFR as a risk predictor in the multivariable adjusted model for the adverse outcomes in the population, however, an interaction between eGFR and age were detected. Stratified analyses revealed that the associations of reduced eGFR (<60 mL/min/1.73 m2) with all-cause mortality were prominent among participants aged less than 65 years.Conclusions: Albuminuria was associated with an elevated risk of all-cause and cardiovascular mortality among the Chinese population, however, the association of reduced kidney function with all-cause mortality was not clear. [ABSTRACT FROM AUTHOR]

Background: China has undergone a rapid demographic and epidemiological transition with fast ecomonic development since the 1980s. Oral health is becoming a major public health problem as the prevalence of non- communicable diseases has greatly increased. Periodontal disease (PD) and caries are among the most prevalent oral diseases. PD accounts for the majority of tooth loss and increases with age. China's third national epidemiological investigation on oral diseases (2005) revealed that periodontitis affected >50% of the adult population. The Global Burden of Disease Study 2013 (GBD2013) have been used to estimate DALYs for 301 acute and chronic diseases and injuries in 188 countries for 1990-2013. The estimation of burden of PD between 1990 and 2013 will provide a unique perspective for planning interventions and developing public health policies for PD even chronic diseases in China. Methods: We used the GBD 2013 results for Years of Life Lost (YLLs) and Years Lived with Disability (YLDs) to calculate Disability Adjusted Life Years (DALYs) for PD in China. PD standardized DALYs rate (SDR) per 100,000 persons, the percentage of PD standardized DALYs rate (% PD SDR) in all diseases DALYs, and variance ratio of these two indexes between the years of 1990 and 2013 were compared by province, gender and age groups. Results: Nationwide, compared to 1990, the SDR in 2013 increased slightly from 24.7 to 25.7, while the variance ratio of SDR for provinces in the middle, west and south of China showed a greater variation (4.8-6.2%). The % PD SDR in all disease DALYs increased from 0.06 to 0.11% for all groups. The four highest variance ratios % PD SDR in all diseases DALYs between 1990 and 2013 occurred in the west of China (97, 98.6, 108.4 and 112.8%). The PD SDR changed slightly in the women (20.3 to 21.7), meanwhile the variance ratio of PD SDR and % PD SDR in all diseases DALYs for the women (6.7 and 94.5%) was also higher than for men (2.1 and 60.6%). The highest variance ratio % PD SDR in all oral diseases DALYs occurred between 1990 and 2013 in ages 20 to 24 (50.7%) and 25 to 29 years (50.5%). Conclusion: The PD standardized DALYs rate and % PD SDR in all diseases DALYs in China in 2013 has increased from 1990. Especially, the variance ratio of % PD SDR in all disease DALYs among Young population and women, in the west provinces of China have been becoming the highest in all age groups and national wide. Future intervention measurements should include young women of child-bearing age because women's health impacts infant health. Periodontal disease has risk factors in common with a number of other non-communicable diseases (NCD) and conditions, and focusing on the common behavioral and environmental risk factors would be instrumental in the effective prevention of periodontal disease. [ABSTRACT FROM AUTHOR]

Background: China has experienced a remarkable epidemiological and demographic transition during the past three decades. Far less is known about this transition at the subnational level. Timely and accurate assessment of the provincial burden of disease is needed for evidence-based priority setting at the local level in China.Methods: Following the methods of the Global Burden of Disease Study 2013 (GBD 2013), we have systematically analysed all available demographic and epidemiological data sources for China at the provincial level. We developed methods to aggregate county-level surveillance data to inform provincial-level analysis, and we used local data to develop specific garbage code redistribution procedures for China. We assessed levels of and trends in all-cause mortality, causes of death, and years of life lost (YLL) in all 33 province-level administrative units in mainland China, all of which we refer to as provinces, for the years between 1990 and 2013.Findings: All provinces in mainland China have made substantial strides to improve life expectancy at birth between 1990 and 2013. Increases ranged from 4.0 years in Hebei province to 14.2 years in Tibet. Improvements in female life expectancy exceeded those in male life expectancy in all provinces except Shanghai, Macao, and Hong Kong. We saw significant heterogeneity among provinces in life expectancy at birth and probability of death at ages 0-14, 15-49, and 50-74 years. Such heterogeneity is also present in cause of death structures between sexes and provinces. From 1990 to 2013, leading causes of YLLs changed substantially. In 1990, 16 of 33 provinces had lower respiratory infections or preterm birth complications as the leading causes of YLLs. 15 provinces had cerebrovascular disease and two (Hong Kong and Macao) had ischaemic heart disease. By 2013, 27 provinces had cerebrovascular disease as the leading cause, five had ischaemic heart disease, and one had lung cancer (Hong Kong). Road injuries have become a top ten cause of death in all provinces in mainland China. The most common non-communicable diseases, including ischaemic heart disease, stroke, chronic obstructive pulmonary disease, and cancers (liver, stomach, and lung), contributed much more to YLLs in 2013 compared with 1990.Interpretation: Rapid transitions are occurring across China, but the leading health problems and the challenges imposed on the health system by epidemiological and demographic change differ between groups of Chinese provinces. Localised health policies need to be implemented to tackle the diverse challenges faced by local health-care systems.Funding: China National Science & Technology Pillar Program 2013 (2013BAI04B02) and Bill & Melinda Gates Foundation. [ABSTRACT FROM AUTHOR]

Objective: To examine cardiovascular disease (CVD) mortality burden attributable to ambient temperature; to estimate effect modification of this burden by gender, age and education level.Methods: We obtained daily data on temperature and CVD mortality from 15 Chinese megacities during 2007-2013, including 1,936,116 CVD deaths. A quasi-Poisson regression combined with a distributed lag non-linear model was used to estimate the temperature-mortality association for each city. Then, a multivariate meta-analysis was used to derive the overall effect estimates of temperature at the national level. Attributable fraction of deaths were calculated for cold and heat (ie, temperature below and above minimum-mortality temperatures, MMTs), respectively. The MMT was defined as the specific temperature associated to the lowest mortality risk.Results: The MMT varied from the 70th percentile to the 99th percentile of temperature in 15 cities, centring at 78 at the national level. In total, 17.1% (95% empirical CI 14.4% to 19.1%) of CVD mortality (330,352 deaths) was attributable to ambient temperature, with substantial differences among cities, from 10.1% in Shanghai to 23.7% in Guangzhou. Most of the attributable deaths were due to cold, with a fraction of 15.8% (13.1% to 17.9%) corresponding to 305,902 deaths, compared with 1.3% (1.0% to 1.6%) and 24,450 deaths for heat.Conclusions: This study emphasises how cold weather is responsible for most part of the temperature-related CVD death burden. Our results may have important implications for the development of policies to reduce CVD mortality from extreme temperatures. [ABSTRACT FROM AUTHOR]

Background: Despite previous studies reporting spatial in equality in diabetes prevalence across China, potential geographic variations in diabetes mortality have not been explored. Methods: Age and gender stratified annual diabetes mortality counts for 161 counties were extracted from the China Mortality Surveillance System and interrogated using multilevel negative binomial regression. Random slopes were used to investigate spatiotemporal variation and the proportion of variance explained was used to assess the relative importance of geographical region, urbanization, mean temperature, local diabetes prevalence, behavioral risk factors and relevant biomarkers. Results: Diabetes mortality tended to reduce between 2006 and 2012, though there appeared to be an increase in diabetes mortality in urban (age standardized rate (ASR) 2006-2012: 10.5-13.6) and rural (ASR 10.8-13.0) areas in the Southwest region. A Median Rate Ratio of 1.47, slope variance of 0.006 (SE 0.001) and covariance of 0.268 (SE 0.007) indicated spatiotemporal variation. Fully adjusted models accounted for 37 % of this geographical variation, with diabetes mortality higher in the Northwest (RR 2.55, 95 % CI 1.74, 3.73) and Northeast (RR 2.68, 95 % CI 1.70, 4.21) compared with the South. Diabetes mortality was higher in urbanized areas (RR tertile 3 versus tertile 1 ('RRt3vs1') 1.39, 95 % CI 1.17, 1.66), with higher mean body mass index (RRt3vs1 1.46, 95 % CI 1.18, 1.80) and with higher average temperatures (RR 1.05 95 % CI 1.03, 1.08). Diabetes mortality was lower where consumption of alcohol was excessive (RRt3vs1 0.84, 95 % CI 0.72, 0.99). No association was observed with smoking, overconsumption of red meat, high mean sedentary time, systolic blood pressure, cholesterol, and diabetes prevalence. Conclusions: Declines in diabetes mortality between 2006 and 2012 have been unequally distributed across China, which may imply differentials in diagnosis, management, and the provision of services that warrant further investigation. [ABSTRACT FROM AUTHOR]

Background: National mortality data are obtained routinely by the Disease Surveillance Points system (DSPs) in China and under-reporting is a big challenge in mortality surveillance. Methods: We carried out an under-reporting field survey in all 161 DSP sites to collect death cases during 2009-2011, using a multi-stage stratified sampling. To identify under-reporting, death data were matched between field survey system and the routine online surveillance system by an automatic computer checking followed by a thorough manual verification. We used a propensity score (PS) weighting method based on a logistic regression to calculate the under-reporting rate in different groups classified by age, gender, urban/rural residency, geographic locations and other mortality related variables. For comparison purposes, we also calculated the under-reporting rate by using capture-mark-recapture (CMR) method. Results: There were no significant differences between the field survey system and routine online surveillance system in terms of age group, causes of death, highest level of diagnosis and diagnostic basis. The overall under-reporting rate in the DSPs was 12.9 % (95%CI 11.2 %, 14.6 %) based on PS. The under-reporting rate was higher in the west (18.8 %, 95%CI 16.5 %, 21.0 %) than the east (10.1 %, 95%CI 8.6 %, 11.3 %) and central regions (11.2 %, 95%CI 9.6 %, 12.7 %). Among all age groups, the under-reporting rate was highest in the 0-5 year group (23.7 %, 95%CI 16.1 %, 35.5 %) and lowest in the 65 years and above group (12.4 %, 95%CI 10.9 %, 13.6 %). The under-reporting rates in each group by PS were similar to the results calculated by the CMR methods. Conclusions: The mortality data from the DSP system in China needs to be adjusted. Compared to the commonly used CMR method in the estimation of under-reporting rate, the results of propensity score weighting method are similar but more flexible when calculating the under-reporting rates in different groups. Propensity score weighting is suitable to adjust DSP data and can be used to address under-reporting in mortality surveillance in China. [ABSTRACT FROM AUTHOR]

OBJECTIVE To investigate the geographic variation in diabetes prevalence and detection in China. RESEARCH DESIGN AND METHODS Self-report and biomedical data were collected from98,058 adults aged ≥18 years (90.5% response) from 162 areas spanning mainland China. Diabetes status was assessed using American Diabetes Association criteria. Among those with diabetes, detection was defined by prior diagnosis. Choropleth maps were used to visually assess geographical variation in each outcome at the provincial level. The odds of each outcome were assessed using multilevel logistic regression, with adjustment for person- and area-level characteristics. RESULTS Geographic visualization at the provincial level indicated widespread variation in diabetes prevalence and detection across China. Regional prevalence adjusted for age, sex, and urban/rural socioeconomic circumstances (SECs) ranged from 8.3% (95% CI 7.2%, 9.7%) in the northeast to 12.7% (11.1%, 14.6%) in the north. A clear negative gradient in diabetes prevalence was observed from13.1%(12.0%, 14.4%) in the urban high-SEC to 8.7% (7.8%, 9.6%) in rural low-SEC counties/districts. Adjusting for health literacy and other person-level characteristics only partially attenuated these geographic variations. Only one-third of participants living with diabetes had been previously diagnosed, but this also varied substantively by geography. Regional detection adjusted for age, sex, and urban/rural SEC, for example, spanned from 40.4% (34.9%, 46.3%) in the north to 15.6% (11.7%, 20.5%) in the southwest. Compared with detection of 40.8% (37.3%, 44.4%) in urban high-SEC counties, detection was poorest among rural low-SEC counties at just 20.5% (17.7%, 23.7%). Person-level characteristics did not fully account for these geographic variations in diabetes detection. CONCLUSIONS Strategies for addressing diabetes risk and improving detection require geographical targeting. [ABSTRACT FROM AUTHOR]

Context: While road traffic mortality has been reported to be seriously undercounted by the police in China, non–police-reported data have not been explored previously to examine vulnerable road user mortality. Objective: To examine changes in bicyclist mortality between 2006 and 2010 in China, using the Disease Surveillance Points (DSP) data of China. Design, setting and data source: Mortality data of 2006–2010 from DSP data, covering 73 million population, was analysed. Poisson regression was used to examine the significance of year after controlling for sex, age and urban/rural location. Main outcome measure(s): Mortality rate and mortality rate ratio (MRR). Results: Between 2006 and 2010, the mortality rate for bicyclists increased from 1.1 to 1.6 per 100 000 population according to DSP data. Between 2006 and 2010, more than 90% of bicyclist deaths were undercounted by the police compared to the findings from DSP data. Contrary to the 34% increase between 2006 and 2010 reflected by DSP data (adjusted MRR: 1.34, 95% CI 1.23 to 1.46), police data revealed a 64% decrease in bicyclist mortality (unadjusted MRR: 0.36, 95% CI 0.32 to 0.40) in the study time period. Conclusions Health data should be used to assess the road traffic injuries in China. The recent increase in bicyclist mortality merits attention from policy makers and researchers. [ABSTRACT FROM AUTHOR]

Objective: Road traffic injury (RTI) has become one of the leading causes of deaths in China, yet numbers on road traffic deaths are often inconsistent. This study sought to systematically review 4 national-level data sources that can be used to estimate burdens of RTI, including mortality, injury, and crashes in China. Methods: We conducted structured literature reviews in PubMed, using combined key words of injury or fatality or injury surveillance and traffic and China in order to identify relevant studies (in both English and Chinese) and data sources. We also conducted interviews and hosted seminars with key researchers from the Chinese Center for Disease Control and Prevention ( Chinese CDC) to identify potential useful data sources for injury surveillance. We then extracted key information from publicly available reports of each data source. Results: Four national-level data sources were reviewed and compared: Ministry of Health-Vital Registration (MOH-VR) System, Chinese CDC-Disease Surveillance Points (DSP), Chinese CDC-National Injury Surveillance System (NISS), and police reports. Together they provide a complementary yet somewhat contradictory epidemiological profile of RTIs in China. Estimates on road traffic fatalities obtained from MOH-VR and police reports are often used by researchers and policymakers, whereas DSP and NISS, both with great merits, have virtually not been used for RTI research. Despite the well-documented problems of underreported deaths with both MOH- VR and DSP, estimated road traffic deaths from both systems were 3 times those reported by the police. Conclusions: As the foundation of injury prevention, national-level data sources and surveillance systems were reviewed in the study. Existing data infrastructures present the Chinese government a great opportunity to strengthen and integrate existing surveillance systems to better track road traffic injury and fatality and identify the population at risk. [ABSTRACT FROM AUTHOR]

Background: In the past two decades, the under-5 mortality rate in China has fallen substantially, but progress with regards to the Millennium Development Goal (MDG) 4 at the subnational level has not been quantified. We aimed to estimate under-5 mortality rates in mainland China for the years 1970 to 2012.Methods: We estimated the under-5 mortality rate for 31 provinces in mainland China between 1970 and 2013 with data from censuses, surveys, surveillance sites, and disease surveillance points. We estimated under-5 mortality rates for 2851 counties in China from 1996 to 2012 with the reported child mortality numbers from the Annual Report System on Maternal and Child Health. We used a small area mortality estimation model, spatiotemporal smoothing, and Gaussian process regression to synthesise data and generate consistent provincial and county-level estimates. We compared progress at the county level with what was expected on the basis of income and educational attainment using an econometric model. We computed Gini coefficients to study the inequality of under-5 mortality rates across counties.Findings: In 2012, the lowest provincial level under-5 mortality rate in China was about five per 1000 livebirths, lower than in Canada, New Zealand, and the USA. The highest provincial level under-5 mortality rate in China was higher than that of Bangladesh. 29 provinces achieved a decrease in under-5 mortality rates twice as fast as the MDG 4 target rate; only two provinces will not achieve MDG 4 by 2015. Although some counties in China have under-5 mortality rates similar to those in the most developed nations in 2012, some have similar rates to those recorded in Burkina Faso and Cameroon. Despite wide differences, the inter-county Gini coefficient has been decreasing. Improvement in maternal education and the economic boom have contributed to the fall in child mortality; more than 60% of the counties in China had rates of decline in under-5 mortality rates significantly faster than expected. Fast reduction in under-5 mortality rates have been recorded not only in the Han population, the dominant ethnic majority in China, but also in the minority populations. All top ten minority groups in terms of population sizes have experienced annual reductions in under-5 mortality rates faster than the MDG 4 target at 4.4%.Interpretation: The reduction of under-5 mortality rates in China at the country, provincial, and county level is an extraordinary success story. Reductions of under-5 mortality rates faster than 8.8% (twice MDG 4 pace) are possible. Extremely rapid declines seem to be related to public policy in addition to socioeconomic progress. Lessons from successful counties should prove valuable for China to intensify efforts for those with unacceptably high under-5 mortality rates.Funding: National "Twelfth Five-Year" Plan for Science and Technology Support, National Health and Family Planning Commission of The People's Republic of China, Program for Changjiang Scholars and Innovative Research Team in University, the National Institute on Aging, and the Bill & Melinda Gates Foundation. [ABSTRACT FROM AUTHOR]

Background: As one of only a handful of countries that have achieved both Millennium Development Goals (MDGs) 4 and 5, China has substantially lowered maternal mortality in the past two decades. Little is known, however, about the levels and trends of maternal mortality at the county level in China.Methods: Using a national registration system of maternal mortality at the county level, we estimated the maternal mortality ratios for 2852 counties in China between 1996 and 2015. We used a state-of-the-art Bayesian small-area estimation hierarchical model with latent Gaussian layers to account for space and time correlations among neighbouring counties. Estimates at the county level were then scaled to be consistent with country-level estimates of maternal mortality for China, which were separately estimated from multiple data sources. We also assessed maternal mortality ratios among ethnic minorities in China and computed Gini coefficients of inequality of maternal mortality ratios at the country and provincial levels.Findings: China as a country has experienced fast decline in maternal mortality ratios, from 108·7 per 100 000 livebirths in 1996 to 21·8 per 100 000 livebirths in 2015, with an annualised rate of decline of 8·5% per year, which is much faster than the target pace in MDG 5. However, we found substantial heterogeneity in levels and trends at the county level. In 1996, the range of maternal mortality ratios by county was 16·8 per 100 000 livebirths in Shantou, Guangdong, to 3510·3 per 100 000 livebirths in Zanda County, Tibet. Almost all counties showed remarkable decline in maternal mortality ratios in the two decades regardless of those in 1996. The annualised rate of decline across counties from 1996 to 2015 ranges from 4·4% to 12·9%, and 2838 (99·5%) of the 2852 counties had achieved the MDG 5 pace of decline. Decline accelerated between 2005 and 2015 compared with between 1996 and 2005. In 2015, the lowest county-level maternal mortality ratio was 3·4 per 100 000 livebirths in Nanhu District, Zhejiang Province. The highest was still in Zanda County, Tibet, but the fall to 830·5 per 100 000 livebirths was only 76·3%. 26 ethnic groups had population majorities in at least one county in China, and all had achieved declines in maternal mortality ratios in line with the pace of MDG 5. Intercounty Gini coefficients for maternal mortality ratio have declined at the national level in China, indicating improved equality, whereas trends in inequality at the provincial level varied.Interpretation: In the past two decades, maternal mortality ratios have reduced rapidly and universally across China at the county level. Fast improvement in maternal mortality ratios is possible even in less economically developed places with resource constraints. This finding has important implications for improving maternal mortality ratios in developing countries in the Sustainable Development Goal era.Funding: National Health and Family Planning Commission of the People's Republic of China, China Medical Board, WHO, University of Washington Center for Demography and Economics of Aging, Bill & Melinda Gates Foundation. [ABSTRACT FROM AUTHOR]

Objective To provide a comprehensive overview of poisoning mortality patterns in China. Methods Using mortality data from the Chinese national disease surveillance points system, we examined trends in poisoning mortality by intent and substance from 2006 to 2016. Differences over time between urban and rural residents among different age groups and across external causes of poisoning were quantified using negative binomial models for males and females separately. Results In 2016, there were 4936 poisoning deaths in a sample of 84 060 559 people (5.9 per 100 000 people; 95% confidence interval: 5.6-6.2). Age-adjusted poisoning mortality dropped from 9.2 to 5.4 per 100 000 people between 2006 and 2016. Males, rural residents and older adults consistently had higher poisoning mortality than females, urban residents and children or young adults. Most pesticide-related deaths (34 996 out of 39 813) were suicides among persons older than 15 years, although such suicides decreased between 2006 and 2016 (from 6.1 per 100 000 people to 3.6 for males and from 5.8 to 3.0 for females). In 2016, alcohol caused 29.3% (600/2050) of unintentional poisoning deaths in men aged 25-64 years. During the study period, unintentional fatal drug poisoning by narcotics and psychodysleptics in individuals aged 25-44 years increased from 0.4 per 100 000 people to 0.7 for males and from 0.05 to 0.13 for females. Conclusion Despite substantial decreases in mortality, poisoning is still a public health threat in China. This warrants further research to explore causative factors and to develop and implement interventions targeting at-risk populations. [ABSTRACT FROM AUTHOR]

In China, sample-based mortality surveillance systems, such as the Chinese Center for Disease Control and Prevention's disease surveillance points system and the Ministry of Health's vital registration system, have been used for decades to provide nationally representative data on health status for health-care decision-making and performance evaluation. However, neither system provided representative mortality and cause-of-death data at the provincial level to inform regional health service needs and policy priorities. Moreover, the systems overlapped to a considerable extent, thereby entailing a duplication of effort. In 2013, the Chinese Government combined these two systems into an integrated national mortality surveillance system to provide a provincially representative picture of total and cause-specific mortality and to accelerate the development of a comprehensive vital registration and mortality surveillance system for the whole country. This new system increased the surveillance population from 6 to 24% of the Chinese population. The number of surveillance points, each of which covered a district or county, increased from 161 to 605. To ensure representativeness at the provincial level, the 605 surveillance points were selected to cover China's 31 provinces using an iterative method involving multistage stratification that took into account the sociodemographic characteristics of the population. This paper describes the development and operation of the new national mortality surveillance system, which is expected to yield representative provincial estimates of mortality in China for the first time. [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]

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]