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Abstract Background There are significant geographic inequities in COVID-19 case fatality rates (CFRs), and comprehensive understanding its country-level determinants in a global perspective is necessary. This study aims to quantify the country-specific risk of COVID-19 CFR and propose tailored response strategies, including vaccination strategies, in 156 countries. Methods Cross-temporal and cross-country variations in COVID-19 CFR was identified using extreme gradient boosting (XGBoost) including 35 factors from seven dimensions in 156 countries from 28 January, 2020 to 31 January, 2022. SHapley Additive exPlanations (SHAP) was used to further clarify the clustering of countries by the key factors driving CFR and the effect of concurrent risk factors for each country. Increases in vaccination rates was simulated to illustrate the reduction of CFR in different classes of countries. Findings Overall COVID-19 CFRs varied across countries from 28 Jan 2020 to 31 Jan 31 2022, ranging from 68 to 6373 per 100,000 population. During the COVID-19 pandemic, the determinants of CFRs first changed from health conditions to universal health coverage, and then to a multifactorial mixed effect dominated by vaccination. In the Omicron period, countries were divided into five classes according to risk determinants. Low vaccination-driven class (70 countries) mainly distributed in sub-Saharan Africa and Latin America, and include the majority of low-income countries (95.7%) with many concurrent risk factors. Aging-driven class (26 countries) mainly distributed in high-income European countries. High disease burden-driven class (32 countries) mainly distributed in Asia and North America. Low GDP-driven class (14 countries) are scattered across continents. Simulating a 5% increase in vaccination rate resulted in CFR reductions of 31.2% and 15.0% for the low vaccination-driven class and the high disease burden-driven class, respectively, with greater CFR reductions for countries with high overall risk (SHAP value > 0.1), but only 3.1% for the ageing-driven class. Conclusions Evidence from this study suggests that geographic inequities in COVID-19 CFR is jointly determined by key and concurrent risks, and achieving a decreasing COVID-19 CFR requires more than increasing vaccination coverage, but rather targeted intervention strategies based on country-specific risks.

ObjectivesHealth policy attention (HPA) refers to the extent of attention given by governments to health issues in public policy and is generally influenced by socioeconomic development. This study aimed to examine the spatiotemporal heterogeneity and clustering of the associations between socioeconomic factors and HPA.Study designLongitudinal study.MethodsThis study examined the spatiotemporal heterogeneity of the association between public and provincial government attention, economic development, and demographic transition and HPA by using geographically and temporally weighted regression (GTWR). Word2Vec machine learning technology was utilized to calculate HPA data in 323 cities and independent variable data was collected in each city in China over the period of 2018–2021.ResultsThe results showed that there is a substantial overall rise in HPA levels throughout China following the COVID-19 pandemic. Furthermore, the GTWR results revealed significant spatiotemporal heterogeneity in the associations between HPA and public and provincial government attention, economic development, and demographic transition, particularly in the context of COVID-19. The impact of provincial government attention on HPA decreased from the capital of the political center outward, while the impact of public financial investment decreased in less developed cities during the pandemic. It was only cities with high levels of aging are more likely to receive greater HPA.ConclusionThe finding highlighted the remarkable spatial and temporal variations in the associations between the variables and HPA across different regions in China, emphasizing the need for region-specific policies to strengthen the focus on health by municipal governments.

Background: In Wuhan, China, a stringent lockdown was implemented to contain the spread of COVID-19, transitioning later to normalised prevention and control strategy. This study examines the trends in hospital visits for acute and chronic respiratory diseases, with a focus on outpatient, inpatient, and severe condition visits. Methods: The study used administrative health insurance data spanning from January 2018 to August 2021, an interrupted time series analysis was conducted to assess the trend in hospital visits per million population for respiratory diseases. To confirm whether the change was exclusive to respiratory diseases, neoplasms and intracerebral haemorrhage were used as controls. The impact of the pandemic was estimated by comparing by weekly admissions to pre-pandemic levels. Subgroup analyses dissected variations by disease and visit types. Results: Hospital visits for respiratory diseases declined significantly during the lockdown and exhibited a slower recovery in the later normalised prevention and control period compared to the control conditions. As of August 2021, outpatient visits increased by over 22.2% above the pre-pandemic level, while inpatient and severe condition visits witnessed significant reductions, falling to 46.7% and 80.6% of pre-pandemic levels, respectively. Compared to three other subgroups, visits for acute lower respiratory infections experienced the most significant decline, with inpatient and severe visits dropping to 23.9% and 25.7% of pre-pandemic levels. Interpretation: Our study revealed a persistent reduction in inpatient and severe case visits for respiratory diseases throughout the ongoing pandemic. These findings suggested the possible role of non-pharmaceutical interventions in mitigating acute and chronic non-COVID respiratory diseases.

BackgroundThe worldwide human monkeypox (mpox) outbreak in 2022 mainly affected men who have sex with men (MSM). In China, young men who have sex with men (YMSM) were at a potential high risk of mpox infection due to their sexual activeness and the eased COVID-19 restrictions at the end of 2022. ObjectiveThis study aimed to investigate the behavioral intention of receiving mpox vaccination and undergoing mpox testing in 4 different scenarios and explore their associations with background and behavioral theory–related factors among Chinese YMSM. MethodsAn online cross-sectional survey was conducted among YMSM aged 18-29 years from 6 representative provinces of China in September 2022. Participants recruited (recruitment rate=2918/4342, 67.2%) were asked to self-administer an anonymous questionnaire designed based on prior knowledge about mpox and classic health behavior theories. Data on the participants’ background, mpox knowledge and cognition, mpox vaccination and testing cognition, and the behavioral intention of receiving mpox vaccination and undergoing mpox testing were collected. Descriptive analysis and univariate and multivariate linear regressions were performed. Geodetector was used to measure the stratified heterogeneity of behavioral intention. ResultsA total of 2493 YMSM with a mean age of 24.6 (SD 2.9) years were included. The prevalence of having a behavioral intention of receiving mpox vaccination ranged from 66.2% to 88.4% by scenario, varying in epidemic status and cost. The prevalence of having an mpox testing intention was above 90% in all scenarios regardless of the presence of symptoms and the cost. The positive factors related to vaccination intention included mpox knowledge (ba=0.060, 95% CI 0.016-0.103), perceived susceptibility of mpox (ba=0.091, 95% CI 0.035-0.146), perceived severity of mpox (ba=0.230, 95% CI 0.164-0.296), emotional distress caused by mpox (ba=0.270, 95% CI 0.160-0.380), perceived benefits of mpox vaccination (ba=0.455, 95% CI 0.411-0.498), self-efficacy of mpox vaccination (ba=0.586, 95% CI 0.504-0.668), and having 1 male sex partner (ba=0.452, 95% CI 0.098-0.806), while the negative factor was perceived barriers to vaccination (ba=–0.056, 95% CI –0.090 to –0.022). The positive factors related to testing intention were perceived severity of mpox (ba=0.283, 95% CI 0.241-0.325), perceived benefits of mpox testing (ba=0.679, 95% CI 0.636-0.721), self-efficacy of mpox testing (ba=0.195, 95% CI 0.146-0.245), having 1 male sex partner (ba=0.290, 95% CI 0.070-0.510), and having in-person gatherings with MSM (ba=0.219, 95% CI 0.072-0.366), while the negative factor was emotional distress caused by mpox (ba=–0.069, 95% CI –0.137 to –0.001). ConclusionsAmong Chinese YMSM, the intention of undergoing mpox testing is optimal, while the mpox vaccination intention has room for improvement. A future national response should raise YMSM’s mpox knowledge, disseminate updated information about mpox and preventive measures, improve preventive service accessibility and privacy, and provide advice on positively coping with the associated emotional distress.

Abstract The incidence of plague has rebounded in the Americas, Asia, and Africa alongside rapid globalization and climate change. Previous studies have shown local climate to have significant nonlinear effects on plague dynamics among rodent communities. We analyzed an 18-year database of plague, spanning 1998 to 2015, in the foci of Mongolia and China to trace the associations between marmot plague and climate factors. Our results suggested a density-dependent effect of precipitation and a geographic location-dependent effect of temperature on marmot plague. That is, a significantly positive relationship was evident between risk of plague and precipitation only when the marmot density exceeded a certain threshold. The geographical heterogeneity of the temperature effect and the contrasting slopes of influence for the Qinghai-Tibet Plateau (QTP) and other regions in the study (nQTP) were primarily related to diversity of climate and landscape types.

IntroductionRespiratory viral infection (RVI) is of very concern after the outbreak of COVID-19, especially in pediatric departments. Learning pathogen spectrum of RVI in children previous the epidemic of COVID-19 could provide another perspective for understanding RVI under current situation and help to prepare for the post COVID-19 infection control.MethodsA nucleic acid sequence-based amplification (NASBA) assay, with 19 pairs of primers targeting various respiratory viruses, was used for multi-pathogen screening of viral infections in children presenting influenza-like illness (ILI) symptoms. Children with ILI at the outpatient department of Beijing Tsinghua Changgung Hospital during the influenza epidemic from 12/2018 to 01/2019 were included. Throat swabs were obtained for both the influenza rapid diagnostic test (IRDT) based on the colloidal gold immunochromatographic assay and the NASBA assay, targeting various respiratory viruses with an integrated chip technology.Results and discussionOf 519 patients, 430 (82.9%) were positive in the NASBA assay. The predominant viral pathogens were influenza A H1N1 pdm1/2009 (pH1N1) (48.4%) and influenza A (H3N2) (18.1%), followed by human metapneumovirus (hMPV) (8.8%) and respiratory syncytial virus (RSV) (6.1%). Of the 320 cases identified with influenza A by NASBA, only 128 (40.0%) were positive in the IRDT. The IRDT missed pH1N1 significantly more frequently than A (H3N2) (P

Abstract Background Multimorbidity of non-communicable diseases (NCDs) is increasingly prevalent among older adults around the world, leading a higher risk of household catastrophic health expenditure (CHE). As current powerful evidence was insufficient, we aimed to estimate the association between multimorbidity of NCDs and the risk of CHE in China. Methods We designed a cohort study using data investigated in 2011–2018 from the China Health and Retirement Longitudinal Study, which is a nationally-representative study covering 150 counties of 28 provinces in China. We used mean ± standard deviation (SD) and frequencies and percentages to describe baseline characteristics. Person χ2 test was employed to compare the differences of baseline characteristics between households with and without multimorbidity. Lorenz curve and concentration index were used to measure the socioeconomic inequalities of CHE incidence. Cox proportional hazards models were applied to estimate adjusted hazard ratios (aHRs) and 95% confidence intervals (CIs) for the association between multimorbidity and CHE. Results Among 17,708 participants, 17,182 individuals were included for the descriptive analysis of the prevalence of multimorbidity in 2011, and 13,299 individuals (8029 households) met inclusion criteria and were included in the final analysis with a median of 83 (interquartile range: 25–84) person-months of follow-up. 45.1% (7752/17,182) individuals and 56.9% (4571/8029) households had multimorbidity at baseline. Participants with higher family economic level (aOR = 0.91, 95% CI: 0.86–0.97) had lower multimorbidity prevalence than those with lowest family economic level. 82.1% of participants with multimorbidity did not make use of outpatient care. The CHE incidence was more concentrated among participants with higher socioeconomic status (SES) with a concentration index of 0.059. The risk of CHE was 19% (aHR = 1.19, 95% CI: 1.16–1.22) higher for each additional NCD. Conclusions Approximately half of middle-aged and older adults in China had multimorbidity, causing a 19% higher risk of CHE for each additional NCD. Early interventions for preventing multimorbidity among people with low SES could be intensified to protect older adults from financial hardship. In addition, concerted efforts are needed to increase patients’ rational healthcare utilization and strengthen current medical security for people with high SES to reduce economic disparities in CHE.

BackgroundDespite the release of updated metrics for Life’s Essential 8 (LE8), key indicators for assessing cardiovascular health (CVH) status, there is currently no report on their distribution among Chinese children. ObjectiveThis study aimed to assess the nationwide distribution of CVH in Chinese school-aged children using LE8 scores and analyze temporal changes in these scores over time. MethodsParticipants aged 7 to 19 years from 11 waves (between 1989 and 2018) of the China Health and Nutrition Survey were included in this study. LE8 components were grouped into 2 domains of health behaviors (diet, physical activity, nicotine exposure, sleep) and health factors (BMI, blood lipids, blood glucose, blood pressure). Scores of overall CVH and each LE8 metric were calculated individually. Temporal changes were assessed with joint point regression models by rural and urban living residence. The causal relationships between health behaviors and health factors that changed the most over time were built with cross-lagged panel models. ResultsA total of 21,921 participants, 52.6% (n=11,537) of whom were male, who had data for at least 4 CVH components were included in the analysis. The mean age was 13 (SD 3.6) years. The overall CVH score remained stable in most regions, with the lowest found in Shandong from East China, which had a mean between 67 (SD 10.9) and 67.2 (SD 12.4). In contrast, the highest score was found in Guizhou from Southwest China, with a mean between 71.4 (SD 10.8) and 74.3 (SD 10.3). In rural areas, the diet score decreased significantly from 1997 onward with a speed of 0.18 (95% CI: 0.15-0.21; P

Background: Natural flood disasters have a devastating effect on society, but the comprehensive assessment of their association with infectious diseases is lacking. We aimed to comprehensively assess the association of natural flood disasters with new cases and deaths of different infectious disease globally from 1990 to 2019, and provide scientific evidence for early warning and measures for the prevention and control of outbreaks and endemic of potential infectious disease following natural flood disasters. Methods: We used data on natural flood disasters from international disaster database from 1990 to 2019. Data on infectious diseases were from the Global Burden of Disease Study 2019. Quasi-Poisson generalized linear models (quasi-Poisson GLM) were used to calculate the effects size, after controlling other confounders. Results: From 1990 to 2019, natural flood disasters occurred on 47,368 cumulative days in 168 countries and territories, resulting in a total of 242,516 deaths and affecting 3.55 billion people. The duration of floods showed a trend of increase, with an average increased rate of 5.14% per year (Estimated annual percentage change [EAPC] =5.14%, 95% CI: 3.57%-7.16%; p < 0.05). The incidence rates of most infectious diseases showed decreasing trends in the past 30 years (all p

Newly emerging infectious diseases are vital issues that impact global health, social stability, economic development, and national security. While infectious disease prevention and control is a highly practical discipline, effective theoretical guidance remains indispensable in infectious disease prevention and control practices. During the past three years of responding to the Coronavirus Disease 2019 (COVID-19) pandemic, we have observed that the traditional “Three-Step Two-Factor” theory is not sufficient to meet the contemporary societal needs for newly emerging infectious disease prevention and control. Building upon years of experience in responding to infectious diseases, we have innovatively developed the “Triangle Model” theory for the prevention and control of infectious diseases. This model has been successfully applied in China's practices and management decisions during the COVID-19 pandemic. We introduce the definition, characteristics of the “Triangle Model” theory, as well as shared practical experience in China, to provide a theoretical reference for future prevention and control of newly emerging infectious diseases in China and other countries.

To more fully assess the far-reaching effects of fossil fuel combustion on humanity, it is necessary to gain an in-depth understanding of the full impact of fossil fuels on human health and lifetime potential. However, current knowledge of the long-term consequences of fossil fuel use on health damage in early life, such as human capital impacts in adulthood, is still insufficient. This paper aims to summarize the current evidence on the health effects of fossil fuel-driven air pollution and climate change on children and the consequent effect on human capital stemming from these early health damages. Evidence indicates that climate change and air pollution not only deteriorate children's health but also affect the entire human capital in their adulthood and can be deeply affected through damaged early-life health. Fossil fuel combustion can significantly impact the lifelong health and human capital for generations. We call for a more holistic assessment of the full range of impacts borne by children, including direct damages to children's health, losses of human capital, and associated economic costs. Cross-disciplinary collaboration is vital to facilitate research on such assessments, thereby enriching our understanding of the multifaceted impact of fossil fuel combustion on the early life and its long-term implications on human capital and economic potential.

Background: Long-term impact of the COVID-19 pandemic on health services utilization is unknown. We aim to assess the long-term effect of the COVID-19 pandemic on health services utilization in China. Methods: Between Jan 2017 and Dec 2021, we conducted a nationwide longitudinal study using routinely collected data on health services utilization in the National Health Information System of China. We extracted national and provincial data of demographic characteristics, socio-economic characteristics, and health resources. Interrupted time-series segmented negative binominal regression models were used. Results: A total of 34.2 billion health facilities visits and 1.1 billion inpatients discharged were included. The largest negative impact of COVID-19 pandemic on the health services utilization was during containment period, that health facility visits were observed 32% reduction in hospitals (adjusted incidence risk ratios [aRRs] 0.68, 95%CI: 0.50–0.92), 27% reduction in community health centers (aRR 0.73, 95%CI: 0.57–0.93), and 22% reduction township centers (aRR 0.78, 95%CI: 0.67–0.91), respectively. The impact on health facility visits and inpatients discharged were reduced and eliminated over time (all p>0.05). However, the negative impact on utilization rate of beds, average length of stay, average inpatient costs, and average outpatient costs in different level of health facilities still existed two years later (all p

Frequent heatwaves caused by global warming can lead to an increased risk of preterm birth, however, what remains unknown is the extent to which anthropogenic climate change has contributed to such burdens. Here, the authors combine health impact and economic assessment methods to comprehensively evaluate the entire preterm birth burden of heatwave exposure.

BackgroundDepression is one of the most common mental illnesses, and it may have a lasting effect on one’s whole life. As a form of financial hardship, catastrophic health expenditure (CHE) may be associated with depression. However, current evidence about the relationship between CHE and the risk of depression is insufficient. ObjectiveThis study aimed to explore the relationship between CHE and the risk of depression among Chinese adults. MethodsIn this study, we used 3 waves of the China Family Panel Studies (CFPS) from 2012, 2016, and 2018. The CFPS are a nationally representative study covering 25 of 31 provinces in Chinese mainland and representing nearly 94.5% of the total population. We selected eligible household heads as participants, divided them into 2 groups by CHE events at baseline (exposed group: with CHE; unexposed group: without CHE), and followed them up. Households with CHE were defined as having out-of-pocket medical expenditures exceeding 40% of the total household nonfood expenditure, and people with depression were identified by the 8-item Centre for Epidemiological Studies Depression Scale (CES-D). We first described the baseline characteristics and used logistical regression to estimate their effects on CHE events. Then, we used Cox proportional hazard models to estimate adjusted hazard ratios and 95% CIs of depression among participants with CHE compared with those without CHE. Finally, we analyzed the subgroup difference in the association between CHE and depression. ResultsOf a total of 13,315 households, 9629 were eligible for analysis. Among them, 6824 (70.9%) were men. The mean age was 50.15 (SD 12.84) years. Only 987 (10.3%) participants had no medical insurance. The prevalence of CHE at baseline was 12.9% (1393/9629). Participants with a higher family economic level (adjusted odds ratio [aOR] 1.15, 95% CI 1.02-1.31) and with the highest socioeconomic development level (aOR 1.18, 95% CI 1.04-1.34) had a higher prevalence of CHE than reference groups. During a median of 71 (IQR 69-72) person-months of follow-up, the depression incidence of participants with CHE (1.41 per 1000 person-months) was higher than those without CHE (0.73 per 1000 person-months). Multivariable models revealed that the adjusted hazard ratio for the incidence of depression in participants with CHE was 1.33 (95% CI 1.08-1.64), and this association appeared to be greater in participants without outpatient services (for interaction, P=.048). ConclusionsCHE was significantly associated with increased risk of depression among Chinese adults. Concentrated work should be done to monitor CHE, and more efforts to ensure financial protection need to be made to prevent depression, especially for people with high health care needs.

BackgroundResearch assessing trends in online search activity related to mpox in China is scarce. ObjectiveWe aimed to provide evidence for an overview of online information searching during an infectious disease outbreak by analyzing trends in online search activity related to mpox at geographical and economic levels in China and explore influencing factors. MethodsWe used the Baidu index to present online search activity related to mpox from May 19 to September 19, 2022. Segmented interrupted time-series analysis was used to estimate trends in online search activity. Factors influencing these trends were analyzed using a general linear regression (GLM) model. We calculated the concentration index to measure economic-related inequality in online search activity and related trends. ResultsOnline search activity was highest on the day the first imported case of mpox appeared in Chongqing compared to 3 other cutoff time points. After the day of the first imported mpox case in Taiwan, the declaration of a public health emergency of international concern, the first imported mpox case in Hong Kong, and the first imported mpox case in Chongqing, national online search activity increased by 0.642%, 1.035%, 1.199%, and 2.023%, respectively. The eastern regions had higher increases than the central and western regions. Across 31 provinces, municipalities, and autonomous regions, the top 3 areas with higher increases were Beijing, Shanghai, and Tianjin at 3 time points, with the exception of the day of the first imported mpox case in Chongqing (Chongqing replaced Tianjin on that day). When AIDS incidence increased by 1 per 100,000 people, there was an increase after the day of the first imported mpox case in Chongqing of 36.22% (95% CI 3.29%-69.15%; P=.04) after controlling for other covariates. Online search activity (concentration index=0.18; P

OBJECTIVES The long-term trends of cognitive function and its associations with physical performance remain unclear, particularly in Asian populations. The study objectives were to determine cognitive trajectories in middle-aged and elderly Chinese individuals, as well as to examine differences in physical performance across cognitive trajectory groups. METHODS Data were extracted from the China Health and Retirement Longitudinal Study. A total of 5,701 participants (47.7% male) with a mean age of 57.8 (standard deviation, 8.4) years at enrollment were included. A group-based trajectory model was used to identify cognitive trajectory groups for each sex. Grip strength, repeated chair stand, and standing balance tests were used to evaluate physical performance. An ordered logistic regression model was employed to analyze differences in physical performance across cognitive trajectory groups. RESULTS Three cognitive trajectory groups were identified for each sex: low, middle, and high. For both sexes, higher cognitive trajectory groups exhibited smaller declines with age. In the fully adjusted model, relative to the low trajectory group, the odds ratios (ORs) of better physical performance in the middle cognitive group were 1.37 (95% confidence interval [CI], 1.17 to 1.59; p

ObjectivesNon-pharmaceutical interventions (NPIs) implemented on China-bound travel have successfully mitigated cross-regional transmission of COVID-19 but made the country face ripple effects. Thus, adjusting these interventions to reduce interruptions to individuals’ daily life while minimizing transmission risk was urgent.MethodsAn improved Susceptible-Infected-Recovered (SIR) model was built to evaluate the Delta variant’s epidemiological characteristics and the impact of NPIs. To explore the risk associated with inbound travelers and the occurrence of domestic traceable outbreaks, we developed an association parameter that combined inbound traveler counts with a time-varying initial value. In addition, multiple time-varying functions were used to model changes in the implementation of NPIs. Related parameters of functions were run by the MCSS method with 1,000 iterations to derive the probability distribution. Initial values, estimated parameters, and corresponding 95% CI were obtained. Reported existing symptomatic, suspected, and asymptomatic case counts were used as the training datasets. Reported cumulative recovered individual data were used to verify the reliability of relevant parameters. Lastly, we used the value of the ratio (Bias2/Variance) to verify the stability of the mathematical model, and the effects of the NPIs on the infected cases to analyze the sensitivity of input parameters.ResultsThe quantitative findings indicated that this improved model was highly compatible with publicly reported data collected from July 21 to August 30, 2021. The number of inbound travelers was associated with the occurrence of domestic outbreaks. A proportional relationship between the Delta variant incubation period and PCR test validity period was found. The model also predicted that restoration of pre-pandemic travel schedules while adhering to NPIs requirements would cause shortages in health resources. The maximum demand for hospital beds would reach 25,000/day, the volume of PCR tests would be 8,000/day, and the number of isolation rooms would reach 800,000/day within 30 days.ConclusionWith the pandemic approaching the end, reexamining it carefully helps better address future outbreaks. This predictive model has provided scientific evidence for NPIs’ effectiveness and quantifiable evidence of health resource allocation. It could guide the design of future epidemic prevention and control policies, and provide strategic recommendations on scarce health resource allocation.

BackgroundThe global COVID-19 pandemic is still ongoing, and cross-country and cross-period variation in COVID-19 age-adjusted case fatality rates (CFRs) has not been clarified. Here, we aimed to identify the country-specific effects of booster vaccination and other features that may affect heterogeneity in age-adjusted CFRs with a worldwide scope, and to predict the benefit of increasing booster vaccination rate on future CFR.MethodCross-temporal and cross-country variations in CFR were identified in 32 countries using the latest available database, with multi-feature (vaccination coverage, demographic characteristics, disease burden, behavioral risks, environmental risks, health services and trust) using Extreme Gradient Boosting (XGBoost) algorithm and SHapley Additive exPlanations (SHAP). After that, country-specific risk features that affect age-adjusted CFRs were identified. The benefit of booster on age-adjusted CFR was simulated by increasing booster vaccination by 1–30% in each country.ResultsOverall COVID-19 age-adjusted CFRs across 32 countries ranged from 110 deaths per 100,000 cases to 5,112 deaths per 100,000 cases from February 4, 2020 to Jan 31, 2022, which were divided into countries with age-adjusted CFRs higher than the crude CFRs and countries with age-adjusted CFRs lower than the crude CFRs (n = 9 and n = 23) when compared with the crude CFR. The effect of booster vaccination on age-adjusted CFRs becomes more important from Alpha to Omicron period (importance scores: 0.03–0.23). The Omicron period model showed that the key risk factors for countries with higher age-adjusted CFR than crude CFR are low GDP per capita and low booster vaccination rates, while the key risk factors for countries with higher age-adjusted CFR than crude CFR were high dietary risks and low physical activity. Increasing booster vaccination rates by 7% would reduce CFRs in all countries with age-adjusted CFRs higher than the crude CFRs.ConclusionBooster vaccination still plays an important role in reducing age-adjusted CFRs, while there are multidimensional concurrent risk factors and precise joint intervention strategies and preparations based on country-specific risks are also essential.

This study investigates collaborative route mapping for a collection of connected automated vehicles (CAVs) traversing multi-lane pathways, with a particular emphasis on intersections without traffic signals. A distinctive feature of our research is the prioritization of emergency vehicles, such as ambulances and fire engines, according to their velocity demands. Additionally, a comprehensive analysis of the ethical ramifications of implementing such a prioritised system is engaged, while it is notable that in most of the existing studies, the ethical evaluation of intelligent transportation modalities is neglected. From a technical aspect, trajectories for CAVs in current models tend to be either inflexible or congruent with the collective formation of the fleet. Concurrently, the pre-set velocities for CAVs frequently demonstrate a lack of adaptability, which impedes cohesive operation. Moreover, there exists a pronounced deficiency in catering to the prioritization needs of emergency vehicles within these models. The current research endeavours to address these shortcomings by formulating the intersection management as an optimal control problem (OCP). This formulation enables CAVs to modulate their velocities in response to practical objectives, sidestepping fixed lane regulations at junctions. The control framework also encompasses autonomous vehicles of diverse sizes and velocities. An Adaptive Stepwise Optimization (ASO) methodology is proposed to augment the efficacy of the OCP resolution.

BackgroundNinety-eight percent of documented cases of the zoonotic disease human monkeypox (MPX) were reported after 2001, with especially dramatic global spread in 2022. This longitudinal study aimed to assess spatiotemporal risk factors of MPX infection and predict global epidemiological trends.MethodTwenty-one potential risk factors were evaluated by correlation-based network analysis and multivariate regression. Country-level risk was assessed using a modified Susceptible-Exposed-Infectious-Removed (SEIR) model and a risk-factor-driven k-means clustering analysis.ResultsBetween historical cases and the 2022 outbreak, MPX infection risk factors changed from relatively simple [human immunodeficiency virus (HIV) infection and population density] to multiple [human mobility, population of men who have sex with men, coronavirus disease 2019 (COVID-19) infection, and socioeconomic factors], with human mobility in the context of COVID-19 being especially key. The 141 included countries classified into three risk clusters: 24 high-risk countries mainly in West Europe and Northern America, 70 medium-risk countries mainly in Latin America and Asia, and 47 low-risk countries mainly in Africa and South Asia. The modified SEIR model predicted declining transmission rates, with basic reproduction numbers ranging 1.61–7.84 in the early stage and 0.70–4.13 in the current stage. The estimated cumulative cases in Northern and Latin America may overtake the number in Europe in autumn 2022.ConclusionsIn the current outbreak, risk factors for MPX infection have changed and expanded. Forecasts of epidemiological trends from our modified SEIR models suggest that Northern America and Latin America are at greater risk of MPX infection in the future.

Summary: Background: In China, most previous projections of heat-related mortality have been based on modeling studies using global climate models (GCMs), which can help to elucidate the risks of extreme heat events in a changing climate. However, spatiotemporal changes in the health effects of climate change considering specific regional characteristics remain poorly understood. We aimed to use credible climate and population projections to estimate future heatwave-attributable deaths under different emission scenarios and to explore the drivers underlying these patterns of changes. Methods: We derived climate data from a regional climate model driven by three CMIP5 GCM models and calculated future heatwaves in China under Representative Concentration Pathway (RCP) 2.6, RCP4.5, and RCP8.5. The future gridded population data were based on Shared Socioeconomic Pathway 2 assumption with different fertility rates. By applying climate zone-specific exposure-response functions to mortality during heatwave events, we projected the scale of heatwave-attributable deaths under each RCP scenario. We further analyzed the factors driving changes in heatwave-related deaths and main sources of uncertainty using a decomposition method. We compared differences in death burden under the 1.5°C target, which is closely related to achieving carbon neutrality by mid-century. Findings: The number of heatwave-related deaths will increase continuously to the mid-century even under RCP2.6 and RCP4.5 scenarios, and will continue increasing throughout the century under RCP8.5. There will be 20,303 deaths caused by heatwaves in 2090 under RCP2.6, 35,025 under RCP4.5, and 72,260 under RCP8.5, with half of all heatwave-related deaths in any scenario concentrated in east and central China. Climate effects are the main driver for the increase in attributable deaths in the near future till 2060, explaining 78% of the total change. Subsequent population decline cannot offset the losses caused by higher incidence of heatwaves and an aging population under RCP8.5. Although health loss under the 1.5°C warming scenario is 1.6-fold higher than the baseline period 1986–2005, limiting the temperature rise to 1.5°C can reduce the annual mortality burden in China by 3,534 deaths in 2090 compared with RCP2.6 scenarios. Interpretation: With accelerating climate change and population aging, the effects of future heatwaves on human health in China are likely to increase continuously even under a low emission scenario. Significant health benefits are expected if the optimistic 1.5°C goal is achieved, suggesting that carbon neutrality by mid-century is a critical target for China's sustainable development. Policymakers need to tighten climate mitigation policies tailored to local conditions while enhancing climate resilience technically and infrastructurally, especially for vulnerable elderly people. Funding: National Key R&D Program of China (2018YFA0606200), Wellcome Trust (209734/Z/17/Z), Natural Science Foundation of China (41790471), and Guangdong Major Project of Basic and Applied Basic Research (2020B0301030004).

BackgroundChange in obesity risk could be related to shift in high blood pressure (HBP) risk, while individualized influence of weight change on high blood pressure is in need of exploration.MethodsA total of 16,446 children (53.47% boys) and 13,9021 effective annual measurements from 2006 to 2020 were recruited. Children's weight status, both at baseline and endpoint, was categorized as underweight, normal, overweight, and obese according to the age and sex-specific Body Mass Index z scores. HBP at late adolescence was defined with the last two measurements for each child. Populational attributable risk (PAR) of weight trait on HBP risk was calculated.ResultsCompared to children who maintained normal weight during follow-up, staying obese was associated with the highest HBP risk with OR of 6.39 (95% CI: 4.46, 9.15; p < 0.001) and PAR of 28.71% (95% CI: 21.58, 35.54) in boys, and OR of 6.12 (95% CI: 2.80, 13.37; p < 0.001) and PAR of 12.75% (95% CI: 4.29, 21.02) in girls. Returning from obese to normal weight was associated with lowered HBP risk, with ORs of 1.07 (95% CI: 0.69, 1.66; p = 0.771) in boys and 0.73 (95% CI: 0.25, 2.12; p = 0.566) in girls.ConclusionWeight loss program could be effective to reduce HBP risk during school age, while the underlying mechanism needs further exploration.

The traditional approach to evaluating dietary quality is based on the achievement of the recommended intakes for each food group, which may overlook the achievement of correct relative proportions between food groups. We propose a “Dietary Non-Adherence Score (DNAS)” to assess the degree of similarity between subjects’ diets and those recommended in the Chinese Dietary Guidelines (CDG). Furthermore, it is important to incorporate the time-dependent nature of dietary quality into mortality prediction. This study investigated the association between long-term changes in adherence to the CDG and all-cause mortality. This study included 4533 participants aged 30–60 from the China Health and Nutrition Survey study with a median follow-up of 6.9 years. Intakes from 10 food groups were collected in 5 survey rounds from 2004 to 2015. We calculated the Euclidean distance between the intake of each food and the CDG-recommended intake, and then summed all the food groups as DNAS. Mortality was assessed in 2015. Latent class trajectory modeling was used to identify three classes of participants with distinct longitudinal trajectories of DNAS during the follow-up period. The Cox proportional hazard model was used to assess the risk of all-cause mortality in the three classes of people. Risk factors for death and confounders for diets were sequentially adjusted in the models. There were 187 deaths overall. Participants in the first class identified had consistently low and decreasing DNAS levels (coefficient = −0.020) over their lifetime, compared with a hazard ratio (HR) of 4.4 (95% confidence interval [CI]: 1.5, 12.7) for participants with consistently high and increasing DNAS levels (coefficient = 0.008). Those with moderate DNAS had an HR of 3.0 (95% CI: 1.1, 8.4). In summary, we find that people with consistently high adherence to CDG-recommended dietary patterns had a significantly lower mortality risk. DNAS is a promising method to assess diet quality.

ObjectiveHealth dietary pattern is related with reduced risk of chronic metabolic disease, but the benefits were not fully clear in the Chinese population. The aim of this study was to explore the association between dietary patterns and multiple chronic metabolic diseases in middle-aged and elderly Chinese.MethodsA total of 718 Chinese adults aged ≥ 45 who lived in the Huairou regions of Beijing were included in the present cross-sectional analysis from 2019 to 2020. Dietary data were obtained by food frequency questionnaires (FFQs). Dietary patterns were identified by principal components analysis (PCA). Logistic regression analysis and hierarchical analysis were used to examine the relationship among dietary patterns, health management, and chronic diseases.ResultsFive dietary patterns were discovered in the subjects. The pattern with the higher percentage of energy supply by lipid was a risk factor for hypertension [odds ratio (OR) = 2.067, p = 0.013]. Lower energy intake (OR = 0.512, p = 0.012) and a reasonable ratio of dietary energy supply (OR = 0.506, p = 0.011) were beneficial to diabetes. The substitution of potato for grain might be an effective way of reducing diabetes (OR = 0.372, p < 0.001). The higher intake of high-quality protein was the protective factor for coronary heart disease (CHD; OR = 0.438, p = 0.008). Moderate intervention (OR = 0.185, p = 0.033) and appropriate health education (OR = 0.432, p = 0.016) could greatly subserve the prevention of chronic diseases, especially for hyperlipidemia. Men were more likely to be affected by health education, intervention, and follow-up than women. The prevalence of multimorbidity was higher in women (43.2%) than men (41.5%). The staple food intake and health management were also important factors to prevent multimorbidity.ConclusionDietary pattern with appropriate energy intake, a reasonable source of energy supply, high quality of macronutrients, and moderate management was associated with decreased risk of chronic metabolic diseases. Further studies are needed to clarify the cause–effect relationship between dietary patterns, health management, and chronic diseases and give suggestions to chronic metabolic disease prevention in middle-aged and elderly people in a rural area.

BackgroundCurrent reference systems using body mass index (BMI) or BMI z-scores to estimate overweight and obesity risk in adolescents are complex to use. An easy and effective measure and cutoffs such as the tri-ponderal mass index (TMI) are in need for parents and grassroots health workers.ObjectiveThe aim of this study was to test whether cohort-derived TMI could be efficient for obesity prediction and to find out whether simplified TMI cutoffs could be used in the prediction.MethodsData were obtained from a 12-year retrospective growth cohort generated in Guangdong, China. A total of 17,815 children (53.9% were boys) with 151,879 follow-ups conducted annually between 2005 and 2016 were involved. Late adolescent overweight and obesity were defined based on the BMI z-score (WHO 2007 growth reference) of the last measurement, which happened at the mean age of 17.2 (SD: 0.7) for both sexes. Analysis of the area under the curve (AUC) of the receiver operating characteristic curves was used to find the most appropriate cutoff.ResultsIn total, 9,604 boys and 8,211 girls were included in the final analysis. TMI cutoffs performed better than WHO BMI cutoffs in the prediction of late adolescent overweight and obesity, with all corresponding AUCs

There is evidence of correlation between mild cognitive impairment (MCI) and sarcopenia (SA). However, the influencing factors and the mechanism, such as age-related lipid redistribution, remain unknown. This study aimed to clarify the role of dietary fats and erythrocyte lipids profile combined with basal metabolic rate (BMR) in the link between MCI and SA. A total of 1050 participants aged 65 to 85 were divided into control, MCI, SA and MCI and SA groups. Bioelectrical impedance analysis was used to evaluate appendicular lean mass and BMR. Cognition and dietary nutrition were detected by neuropsychological tests and food frequency questionnaires. UHPLC-QExactive-MS/MS and UHPLC-Qtrap-MS/MS were used to conduct the lipidomics analysis. Lower dietary intake of different phospholipids, unsaturated fatty acids and kinds of choline were significantly associated with MCI and SA. Least absolute shrinkage and selection operator, multivariate logistic regression, receiver operating characteristic curve and validation tests provided evidence that specific phospholipids, unsaturated fatty acids and BMR might be the critical factors in the processing of MCI and SA, as well as in their link. The lipidomic analysis observed a clear discrimination of the lipid profiles in the individuals who are in MCI, SA, or MCI and SA, compared with the control. Lower expressions in certain phospholipid species, such as sphingomyelin and phosphatidylethanolamines, decreased phosphatidylcholine with more unsaturated double bonds, lower level of lipids with C20:5 and C20:4, higher level of lipids with C18:2 and lipids with a remodeled length of acyl chain, might be closely related to the link between MCI and SA. Inadequate dietary intake and lower concentrations of the erythrocyte lipid profile of phospholipids and unsaturated fatty acids with a lower level of BMR might be the key points that lead to progress in MCI and SA, as well as in their link. They could be used as the prospective biomarkers for the higher risk of cognitive decline and/or SA in elderly population.

IntroductionTo ascertain the possible cut point of tri-ponderal mass index (TMI) in discriminating metabolic syndrome (MetS) and related cardio-metabolic risk factors in Chinese and American children and adolescents.MethodsA total of 57,201 Chinese children aged 7-18 recruited in 2012 and and 10,441 American children aged 12-18 from National Health and Nutrition Examination Survey (NHANES 2001-2014) were included to fit TMI percentiles. Participants were randomly assigned to a derivation set (75%) and validation set (25%). The cut points of TMI with the lowest misclassification rate under the premise of the highest area under curves (AUC) were selected for each sex, which were additionally examined in the validation set. All of data analysis was conducted between September and December in 2019.ResultsTMI showed good capacity on discriminating MetS, with AUC of 0.7658 (95% CI: 0.7544-0.7770) to 0.8445 (95% CI: 0.8349-0.8537) in Chinese and 0.8871 (95% CI: 0.8663-0.9056) to 0.9329 (95% CI: 0.9166-0.9469) in American children. The optimal cut points were 14.46 kg/m3 and 13.91 kg/m3 for Chinese boys and girls, and 17.08 kg/m3 and 18.89 kg/m3 for American boys and girls, respectively. The corresponding misclassification rates were 17.1% (95% CI: 16.4-17.8) and 11.2% (95% CI: 9.9-12.6), respectively. Performance of these cut points were also examined in the validation set (sensitivity 67.7%, specificity 82.4% in Chinese; sensitivity 84.4%, specificity 88.7% in American children).ConclusionsA sex- and ethnicity- specific single cut point of TMI could be used to distinguish MetS and elevated risk of cardio-metabolic factors in children and adolescents.

Inflammation is known as an important mechanism of cognitive dysfunction. Systemic immune inflammation index (SII) and system inflammation response index (SIRI) are two blood inflammatory markers, which are related to many chronic diseases including cognitive impairment. It is recognized that dietary inflammatory index (DII), which is used to estimate the overall inflammatory potential of diet, may be related to mild cognitive impairment (MCI) as well. This study aimed to explore the relationship between SII, SIRI and DII, as well as the role of these inflammatory indexes on MCI in elderly people. A total of 1050 participants from Beijing were included. Neuropsychological tests were used for cognitive evaluation. Energy-adjusted DII scores were calculated based on semi-quantitative food frequency questionnaire. Blood samples were tested for calculating SII and SIRI. Log-binomial regression models were used to estimate the correlation of indexes. After adjusting demographic characteristics, SII and SIRI in MCI individuals were higher than controls (p ≤ 0.001). DII, SII and SIRI had positive relationship with MoCA scores (p < 0.005). DII also correlated with SIRI in MCI (β = 0.11, p = 0.031). Higher DII and SIRI could definitely increase the risk of MCI, as well as DII and SII (p < 0.005). In conclusion, DII was positively correlated with blood inflammation. The elderly with higher level of DII and SIRI, or DII and SII could be considered as people with higher risk of developing MCI.

Cardiovascular disease (CVD) is the leading cause of death worldwide. Population aging is becoming the most important driver of the CVD epidemic. With the rapid increase in an aging population, the burden of CVD will continuously increase. Most old people also suffer multimorbidity, which is strongly associated with impaired quality of life, disability, dependence, and mortality. However, few reviews evaluated the CVD burden accompanied by population aging and the challenges of CVD care in elderly individuals with multimorbidity. This review identified and summarized the current status of the CVD epidemic associated with aging and highlighted the challenges and needs of CVD care for the elderly.

Community healthcare in mainland China is still at an early stage. The qualities of life (QOLs) of patients with psychotic disorders undergoing rehabilitation in hospitals or in the community, as well as those of their caregivers, may differ from each other.The study was performed to evaluate the QOL of patients with psychotic disorders and assess the differences in the QOLs between patients receiving care in diverse settings (hospital vs. the community).This study was a descriptive study, in which all cases were collected from two psychiatric hospitals and five communities. Patients (n = 43) and caregivers (n = 40) in the psychiatric hospitals were grouped according to the length of illness and areas of residence and these criteria were also used to group patients (n = 55) and caregivers (n = 59) in the community. All participants were assessed using the WHOQOL-BREF (Chinese version). ANOVA was adopted to compare the QOL scores among the four groups (cases and caregivers in two settings), while confounding factors, such as age and marital status, were adjusted.Among the four groups of participants, namely, hospitalised and community patients and their corresponding caregivers, community samples had a significantly lower QOL score. The QOL score for the social relationships domain of the hospitalised patients' caregivers was significantly higher than that of the caregivers of community patients (P = 0.019).Community patients and their caregivers tend to have lower QOL scores than their hospitalised counterparts. The support of family members is urgently needed to provide better care for patients.

Most cases of severe acute respiratory syndrome (SARS) have occurred in close contacts of SARS patients. However, in Beijing, a large proportion of SARS cases occurred in persons without such contact. We conducted a case-control study in Beijing that compared exposures of 94 unlinked, probable SARS patients with those of 281 community-based controls matched for age group and sex. Case-patients were more likely than controls to have chronic medical conditions or to have visited fever clinics (clinics at which possible SARS patients were separated from other patients), eaten outside the home, or taken taxis frequently. The use of masks was strongly protective. Among 31 case-patients for whom convalescent-phase (>21 days) sera were available, 26% had immunoglobulin G to SARS-associated coronavirus. Our finding that clinical SARS was associated with visits to fever clinics supports Beijing’s strategy of closing clinics with poor infection-control measures. Our finding that mask use lowered the risk for disease supports the community’s use of this strategy.

The largest outbreak of severe acute respiratory syndrome (SARS) struck Beijing in spring 2003. Multiple importations of SARS to Beijing initiated transmission in several healthcare facilities. Beijing’s outbreak began March 5; by late April, daily hospital admissions for SARS exceeded 100 for several days; 2,521 cases of probable SARS occurred. Attack rates were highest in those 20–39 years of age; 1% of cases occurred in children 65 years (27.7% vs. 4.8% for those 20–64 years, p < 0.001). Healthcare workers accounted for 16% of probable cases. The proportion of case-patients without known contact to a SARS patient increased significantly in May. Implementation of early detection, isolation, contact tracing, quarantine, triage of case-patients to designated SARS hospitals, and community mobilization ended the outbreak.

BACKGROUND AND PURPOSE: This study aimed to explore the possible association of plasma total homocysteine with carotid plaque stability. METHODS: A cross-sectional study was conducted from 2010 to 2011. A stratified random sample of 2,919 Chinese participants aged 40 years or older was enrolled. Plasma total homocysteine levels were measured and carotid plaques were evaluated by ultrasonography. Logistic regression model was used to analyze the association of homocysteine levels to the progression of carotid plaque development, while adjusting for demographics and vascular risk factors. RESULTS: The mean level of plasma homocysteine in the subjects was 14.9 µmol/l. Along with increase in homocysteine level, the risk of advanced carotid plaque elevated (odds ratio = 1.28; 95% confidence interval = 1.09-1.51) after adjusting for age, sex, and other potential confounders. Stratified by sex, higher homocysteine level was strongly associated with advanced carotid plaque in men (OR = 1.41; 95% confidence interval = 1.17-1.70), but not in women. CONCLUSION: The findings suggest that plasma level of homocysteine may be associated with advanced carotid plaque, which constitutes high risks of stroke, in male Chinese adults.

Abstract Background Primary care medical staffs’ knowledge, attitude and behavior about health emergency and the response capacity are directly related to the control and prevention of public health emergencies. Therefore, it is of great significance for improving primary care to gain in-depth knowledge about knowledge, attitude and behavior and the response capacity of primary care medical staffs. The main objective of this study is to explore knowledge, attitude and behavior, and the response capacity of primary care medical staffs of Guangdong Province, China. Methods Stratified clustered sample method was used in the anonymous questionnaire investigation about knowledge, attitude and behavior, and the response capacity of 3410 primary care medical staffs in 15 cities of Guangdong Province, China from July, 2010 to October 2010. The emergency response capacity was evaluated by 33 questions. The highest score of the response capacity was 100 points (full score), score of 70 was a standard. Results 62.4% primary care medical staffs believed that public health emergencies would happen. Influenza (3.86 ± 0.88), food poisoning (3.35 ± 0.75), and environmental pollution events (3.23 ± 0.80) (the total score was 5) were considered most likely to occur. Among the 7 public health emergency skills, the highest self-assessment score is “public health emergency prevention skills” (2.90 ± 0.68), the lowest is “public health emergency risk management (the total score was 5)” (1.81 ± 0.40). Attitude evaluation showed 66.1% of the medical staffs believed that the community awareness of risk management were ordinary. Evaluation of response capacity of health emergency showed that the score of primary care medical staffs was 67.23 ± 10.61, and the response capacity of senior physicians, public health physicians and physicians with relatively long-term practice were significantly better (P Conclusions The knowledge, attitude and behavior about public health emergencies and the response capacity of primary care medical staffs of Guangdong Province (China) were poor. Health administrative departments should strengthen the training of health emergency knowledge and skills of the primary care medical staffs to enhance their health emergency response capabilities.