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Abstract Cancer is a major cause of death and morbidity in China. We aimed to analyze the trends in cancer mortality in six provinces in northwest China (Xinjiang Uyghur Autonomous Region, Qinghai Province, Shaanxi Province, Gansu Province, Ningxia Hui Autonomous Region, and Inner Mongolia Autonomous Region) from 2013 to 2021 and to explore the effect of cancer on life expectancy and the years of life lost. Based on cancer mortality data and demographic data from national surveillance units in six northwestern provinces from 2013 to 2021 in the National Cause-of-Death Surveillance, we calculated crude mortality rates, age-standardized mortality rates, life expectancy, cause-eliminated life expectancy, potential gains in life expectancy (PGLEs), years of life lost (YLL), YLL rates, and average years of life lost. Joinpoint software was used to calculate the average annual percentage change and annual percentage change (APC) for cancer mortality. Arriaga’s decomposition method was used to estimate the contribution of cancer to life expectancy in each age group. The age-standardized mortality rate for cancer in the six provinces in northwest China was stable overall from 2013 to 2021 but exhibited a decreasing trend from 2017 to 2021 (APC = − 5.64%, p = 0.047), male cancer age-standardized mortality rates were consistently higher than those of women and plateaued, women exhibited a decreasing trend after 2017 (APC = − 5.56%, p = 0.032), and the standardized mortality rate was higher and stable for those aged ≥ 65 years. Compared with the study area population in 2013, that in 2021 increased by 1.01 years in life expectancy, and changes in cancer mortality contributed positively to the increase in life expectancy, contributing 0.217 years or 21.38% of the increase in life expectancy. The greatest positive effect was in the 0–1 year age group (0.066 years, 6.48%), and the greatest negative effect was in the ≥ 85 years age group (− 0.026 years, − 2.56%). At a 1.06-year increase in cancer cause-eliminated life expectancy, PGLEs increased by 0.047 years, with the highest increase in PGLEs in urban areas (0.091 years) and an upward trend in YLL rates in the study area population from 2013 to 2021 (average annual percentage change = 2.16, p = 0.001). Average years of life lost presented a stable trend. Cancer age-standardized mortality rate in the study region from 2013 to 2021 was stable overall but has exhibited a decline in recent years. However, the disease burden of YLL has continued to increase. Preventive interventions targeting male groups and the elderly population need to be strengthened.

Abstract. Background:. China is one of the countries with the highest burdens of stomach cancer. The objective of this study was to analyze long-term trends in the incidence and mortality of stomach cancer in Chinese mainland from 1990 to 2019 and to make projections until 2030. Methods:. Data on stomach cancer were extracted from the Global Burden of Diseases Study 2019. Population data were extracted from the Global Burden of Diseases Study 2019 and World Population Prospects 2019. An age–period–cohort framework and decomposition analysis were used in this study. Results:. The net drift for the incidence of stomach cancer was 0.2% (95% confidence interval [CI]: 0, 0.4%) per year for men and –1.8% (95% CI: –2.0%, –1.6%) for women. The net drift for mortality was –1.6% (95% CI: –1.8%, –1.3%) per year for men and –3.3% (95% CI: –3.5%, –3.1%) for women. In the last 10–15 years, the risk of stomach cancer occurrence and death has continued to decline for both sexes. Regarding birth cohorts, although the risk of stomach cancer death decreased in general among women and men born after 1920, the risk of occurrence increased in recent birth cohorts (men born after 1970 and women born after 1985). It is expected that the age-standardized incidence will increase among men and decrease among women, and age-standardized mortality will decrease for both sexes. The largest contributor to the projected increase in incident cases and deaths is population aging, and elderly individuals are projected to have an increased proportion of occurrence and death. Conclusions:. In the past three decades, the incidence of stomach cancer among men has increased in Chinese mainland, and this trend is projected to continue. Aging will be the main contributor to future increased stomach cancer occurrence and deaths. To reduce the health impact of stomach cancer, more efforts are needed.

Carbapenem-resistant Pseudomonas aeruginosa (CRPA) has become a serious global health concern due to the limited treatment options. The primary resistance mechanism in CRPA involves the production of metallo-β-lactamases (MBLs), making MBL-producing P. aeruginosa a significant component of CRPA cases. To understand the prevalence of CRPA in hospitals in northern China, we conducted a preliminary screening and identification of CRPA in 143 clinical isolates of P. aeruginosa collected from various departments of a tertiary hospital between 2021 and 2023, analyzing CRPA resistance trends in certain regions of northern China during this period. We identified 71 CRPA isolates that exhibited high carbapenem resistance and phylogenetic tree analysis revealed that ST244 CRPA isolates had widely spread across various departments of the same hospital over three consecutive years. We also identified two VIM-producing isolates, PJK40 and PJK43, both of which carried the same novel VIM-type metallo-β-lactamase, VIM-92, encoded by a newly identified gene, blaVIM-92, closely related to blaVIM-24. blaVIM-92 was embedded in class 1 integrons within the Tn1403 transposon. The blaVIM-92-carrying plasmid, pPJK40, was found to resemble the pJB37 megaplasmid. The expression of VIM-92 and VIM-24 in DH5α and PAO1 revealed similar effects of the MICs of β-lactams, except for aztreonam. The high prevalence of CRPA in clinical settings, and the identification of VIM-92, highlights the urgent need for ongoing surveillance of CRPA and emerging MBL variants in P. aeruginosa.

Summary: Background: Understanding the disease burden of mental disorders in children and adolescents in China, especially at the sub-national level, is important for effective prevention and intervention. This study aims to assess the prevalence and related health burden of mental disorders in children and adolescents in China. Methods: Following the same approach as the Global Burden of Disease Study 2021, we systematically analyze epidemiological and demographic information for mental disorders, and assess the prevalence, disability-adjusted life-years (DALYs), and years lived with disability (YLDs) in the children and adolescents for mental disorders and their ten subtypes across national and provinces in China from 1990 to 2021. Findings: In 2021, the age-standardized prevalence of mental disorders in children and adolescents was 8.9% (uncertainty intervals [UI]: 8.1, 9.8) in China, accounting for 30.8 million cases (26.0, 36.3) and 2.8 million DALYs (2.0, 3.7). Among mental disorders, attention-deficit/hyperactivity disorder had the highest age-standardized prevalence, at 3.6% (3.0, 4.5). From 1990 to 2021, the age-standardized prevalence increased by 4.8%, but the number of mental disorders cases decreased by 21.9%. DALYs for mental disorders are higher in boys than in girls across all age groups. At the provincial level, the age-standardized prevalence of mental disorders in some provinces was much greater than that in other provinces (e.g., bipolar disorder in Hebei was more than two times greater than that in other provinces). Although disparities in the distribution of mental disorder burden were observed across provinces, there was a reduction in income-related inequality, where the gap in the age-standardized DALY rates between the highest and lowest income provinces decreased by 61.7% between 1990 and 2021. In 2021, among 22 health condition groups in China, mental disorders accounted for the largest proportion of health life lost. Interpretation: Mental disorders are the leading causes of disability in children and adolescents in China, and the disease burden varies geographically. Careful planning of health services, including consideration of the local situation, is needed. Funding: China National Natural Science Foundation (Grant No. 72104113, 72204112), Social Science Fund of Jiangsu Province (Grant No. 21GLD008), ShuangChuang Doctor Program of Jiangsu Province (Grant No. JSSCBS20210359), and the Fundamental Research Funds for the Central Universities (Grant No. 30923011101).

Abstract. Background:. Studies that comprehensively address the characteristics of centenarian deaths are rare. The present study aimed to depict the characteristics of centenarian deaths in China and their changing trends. Methods:. Data on centenarian deaths between 2013 and 2020 were obtained from the national mortality surveillance system of China, including date, place of death (PoD), and underlying cause of death (CoD). Descriptive analyses were performed to understand the epidemiological characteristics, and a joinpoint regression model was adopted to examine the changing trends in the proportions of different PoDs, CoDs among centenarians, and centenarian deaths accounting for all deaths and deaths among people aged 65 years and older. Results:. There were 46,938 registered centenarian deaths between 2013 and 2020 that included 34,311 females (73.10%) and 12,627 males (26.90%). January (12.05%), February (9.99%), and December (9.74%) were the top three months with the highest number of deaths. The proportions of deaths that occurred in homes, hospitals, and nursing homes were 81.71%, 13.63%, and 2.68%, respectively. The proportion of deaths in nursing homes increased by 9.60% (95% confidence intervals [CIs], 6.4–12.9%) from 2014 to 2020. Heart disease (35.72%) was the leading cause of death, followed by respiratory diseases (17.63%), cerebrovascular disease (15.60%), and old age (11.22%). The proportion of respiratory diseases decreased by 4.8% (95% CI, –8.8 to –0.7%), and the proportion of deaths from old age decreased by 2.3% (95% CI, –4.4 to –0.1%) per year. Shanghai had the highest proportions of deaths in hospitals (39.38%) and nursing homes (14.68%). Sichuan had the highest proportion of deaths attributed to respiratory diseases (32.30%), while Jiangsu (26.58%) and Zhejiang (23.61%) had the highest proportions of deaths from old age. Conclusion:. Unlike other countries, centenarian deaths in China are characterized by a higher proportion of home and heart disease deaths, and this death pattern differs across provinces.

Abstract BackgroundChina has the highest number of liver cancers worldwide, and liver cancer is at the forefront of all cancers in China. However, current research on liver cancer in China primarily relies on extrapolated data or relatively lagging data, with limited focus on subregions and specific population groups. ObjectiveThe purpose of this study is to identify geographic disparities in liver cancer by exploring the spatial and temporal trends of liver cancer mortality and the years of life lost (YLL) caused by it within distinct geographical regions, climate zones, and population groups in China. MethodsData from the National Death Surveillance System between 2013 and 2020 were used to calculate the age-standardized mortality rate of liver cancer (LASMR) and YLL from liver cancer in China. The spatial distribution and temporal trends of liver cancer were analyzed in subgroups by sex, age, region, and climate classification. Estimated annual percentage change was used to describe liver cancer trends in various regions, and partial correlation was applied to explore associations between LASMR and latitude. ResultsIn China, the average LASMR decreased from 28.79 in 2013 to 26.38 per 100,000 in 2020 among men and 11.09 to 9.83 per 100,000 among women. This decline in mortality was consistent across all age groups. Geographically, Guangxi had the highest LASMR for men in China, with a rate of 50.15 per 100,000, while for women, it was Heilongjiang, with a rate of 16.64 per 100,000. Within these regions, the LASMR among men in most parts of Guangxi ranged from 32.32 to 74.98 per 100,000, whereas the LASMR among women in the majority of Heilongjiang ranged from 13.72 to 21.86 per 100,000. The trend of LASMR varied among regions. For both men and women, Guizhou showed an increasing trend in LASMR from 2013 to 2020, with estimated annual percentage changes ranging from 10.05% to 29.07% and from 10.09% to 21.71%, respectively. Both men and women observed an increase in LASMR with increasing latitude below the 40th parallel. However, overall, LASMR in men was positively correlated with latitude (RPRP ConclusionsDespite the declining overall trend of liver cancer in China, there are still marked disparities between regions and populations. Future prevention and control should focus on high-risk regions and populations to further reduce the burden of liver cancer in China.

Abstract Background A universal set of disability weights(DWs) is mainly based on the survey of North America, Australia and Europe, whereas the participants in Asia was limited. The debate hasn’t yet settled whether a universal DW is desirable or useful.The focus of the debate is its representativenes-s.After all, the DWs come from people's subjective evaluation of pain, and they may vary according to cultural background.The differences of the DWs could have implications for the magnitude or ranking of disease burdens.The DWs of Anhui Province has not been completely presented.This paper aims to obtain the DWs suitable for the general population of Anhui Province of China, and attempts to explore the differences between different DWs by comparing the DWs with the similar-cultural background and the DWs with cross-cultural background. Methods A web-based survey was conducted to estimate the DWs for 206 health states of Anhui province in 2020. Paired comparison (PC) data were analyzed and anchored by probit regression and fitting loess model. We compared the DWs in Anhui with other provinces in China and those in Global burden of disease (GBD) and Japan. Results Compared with Anhui province, the proportion of health states which showed 2 times or more differences ranged from 1.94% (Henan) to 11.17% (Sichuan) in China and domestic provinces. It was 19.88% in Japan and 21.51% in GBD 2013 respectively. In Asian countries or regions, most of the health states with top 15 DWs belonged to the category of mental, behavioral, and substance use disorders. But in GBD, most were infectious diseases and cancer. The differences of DWs in neighboring provinces were smaller than other geographically distant provinces or countries. Conclusion PC responses were largely consistent across very distinct settings,but the exceptions do need to be faced squarely.The differences of DWs among similar-cultural regions were smaller than cross-cultural regions. There is an urgent need for relevant gold standards.

Summary: Background: It remains unknown how ambient temperature impact pneumonia of various infectious causes. Methods: Based on the national death registry covering all counties in Chinese mainland, we conducted an individual-level case-crossover study in China from 2013 to 2019. Exposures were assigned at residential addresses for each decedent. Conditional logistic regression model combined with distributed lag non-linear models were used to estimate the exposure-response associations. The attributable fractions due to non-optimum temperature were calculated after accounting for spatial and temporal patterns for the excess risks. Findings: The exposure-response curves were inversely J-shaped with both low and high temperature increasing the risks, and the effect of low temperature was stronger. Extremely low temperature was associated with higher magnitude of influenza-related pneumonia [relative risk (RR): 2.46, 95% confidence interval (CI): 1.62–3.74], than viral pneumonia (RR: 1.89, 95% CI: 1.55–2.30) and bacterial pneumonia (RR: 1.81, 95% CI: 1.56–2.09). The magnitudes of RRs associated with extremely high temperature were similar among the three categories of pneumonia. The mortality attributable fraction for influenza-related pneumonia (29.78%) was the highest. The effects were stronger in people of low education level or residence in the north. Interpretation: This nationwide study presents findings on the varied risk and burden of pneumonia mortality of various infectious causes, and highlights the susceptibility of influenza-related pneumonia to ambient low temperature. Funding: This study is supported by the National Key Research and Development Program (2022YFC3702701), the Shanghai Municipal Science and Technology Commission (21TQ015) and Shanghai International Science and Technology Partnership Project (21230780200).

Abstract Background Cardiovascular disease (CVD) is the leading cause of death in China. No previous study has reported CVD mortality at county-level, and little was known about the nonmedical ecological factors of CVD mortality at such small scale in mainland China. Understanding the spatiotemporal variations of CVD mortality and examining its nonmedical ecological factors would be of great importance to tailor local public health policies. Methods By using national mortality registration data in China, this study used hierarchical spatiotemporal Bayesian model to demonstrate spatiotemporal distribution of CVD mortality in 2844 counties during 2006 to 2020 and investigate how nonmedical ecological determinants have affected CVD mortality inequities from the spatial perspectives. Results During 2006–2020, the age-standardized mortality rate (ASMR) of CVD decreased from 284.77 per 100,000 in 2006 to 241.34 per 100,000 in 2020. Among 2844 counties, 1144 (40.22%) were hot spots counties with a higher CVD mortality risk compared to the national average and located mostly in northeast, north central, and westernmost regions; on the contrary, 1551 (54.53%) were cold spots counties and located mostly in south and southeast coastal counties. CVD mortality risk decreased from 2006 to 2020 was larger in counties where CVD mortality rate had been higher in 2006 in most of the counties, vice versa. Nationwide, nighttime light intensity (NTL) was the major influencing factor of CVD mortality, a higher NTL appeared to be negatively associated with a lower CVD mortality, with one unit increase in NTL, and the CVD mortality risk will decrease 11% (relative risk of NTL was estimated as 0.89 with 95% confidence interval of 0.83–0.94). Conclusions Substantial between-county discrepancies of CVD mortality distribution were observed during past 15 years in mainland China. Nonmedical ecological determinants were estimated to significantly explain the overall and local spatiotemporal patterns of this CVD mortality risk. Targeted considerations are needed to integrate primary care with clinical care through intensifying further strategies to narrow unequally distribution of CVD mortality at local scale. The approach to county-level analysis with small area models has the potential to provide novel insights into Chinese disease-specific mortality burden.

Abstract Background Pneumoconiosis refers to a class of serious diseases threatening the health of workers exposed to coal or silicosis dust. However, the burden of pneumoconiosis is unavailable in China. Methods Incident cases, deaths, and disability-adjusted life years (DALYs) from pneumoconiosis and its subtypes in China were estimated from the Global Burden of Disease Study 2019 using a Bayesian meta-regression method. The trend of the burden from pneumoconiosis was analyzed using percentage change and annualized rate of change (ARC) during the period 1990–2019. The relationship between subnational socio-demographic index (SDI) and the ARC of age-standardised death rate was measured using Spearman’s Rank-Order Correlation. Results In 2019, there were 136.8 (95% uncertainty interval [UI] 113.7–162.5) thousand new cases, 10.2 (8.1–13.6) thousand deaths, and 608.7 (473.6–779.4) thousand DALYs from pneumoconiosis in China. Of the global burdens from pneumoconiosis, more than 60% were in China. Both the total number of new cases and DALYs from pneumoconiosis was keeping increasing from 1990 to 2019. In contrast, the age-standardised incidence, death, and DALY rates from pneumoconiosis and its subtypes, except for the age-standardised incidence rate of silicosis, and age-standardised death rate of asbestosis, experienced a significant decline during the same period. The subnational age-standardised death rates were higher in western China than in eastern China. Meanwhile, the subnational ARC of age-standardised death rates due to pneumoconiosis and its subtypes were significantly negatively correlated with SDI in 2019. Conclusion China suffers the largest health loss from pneumoconiosis in the world. Reducing the burden of pneumoconiosis is still an urgent task in China.

Abstract Background Most deaths in China occur at home, making it difficult to collect reliable cause of death (CoD) information. Verbal autopsy (VA) was applied using the SmartVA tool to a sample of home deaths in China to explore its feasibility as a means of improving the quality of CoD data. Methods The study was carried out in 22 districts in 9 provinces, located in north-east, central, and western areas of China during 2017 and 2018. Trained interviewers selected suitable respondents in each household to collect information using the Population Health Metrics Research Consortium (PHMRC) shortened and validated electronic VA questionnaire on tablets. The CoD was diagnosed from the interview data using the SmartVA-Analyze 2.0 software (Tariff 2.0). Results Non-communicable diseases (NCDs) dominated the leading causes of death in all age groups and for both sexes. After redistribution of undetermined causes, stroke (24%), ischemic heart diseases (IHD) (21%), chronic respiratory diseases (11%), and lung cancer (6%) were the leading causes of death. The cause fractions for level-one cause categories and ranking of specific causes were similar between SmartVA and results from the Global Burden of Disease (GBD) study. Conclusion Evidence from this large pilot study suggests that SmartVA is a feasible and plausible tool and could be a valuable tool to improve the quality and standardization of CoD information across China.

The balance of Th17/Treg plays an important role in hepatic ischemia–reperfusion (I/R) injury. Glycolysis and glutaminolysis for energy metabolism governs the differentiate of CD 4+ T-cells to Th17/Treg. Metformin can regulate glucose metabolism in the liver, but its protective effect on I/R liver injury and its effect on Th17/Treg balancestill unknown. In this study, the I/R liver injury rat model and the primary hepatocyte hypoxia/reoxygenation injury model were established. The biochemical indexes, inflammatory factor indexes, Th17/Treg balance and energy metabolism were evaluated. RNA-seq and gene knockout cells were used to investigated the target protein of metformin. The results showed that metformin could effectively improve liver injury caused by I/R, significantly inhibit the glycolysis, improve the Th17/Treg balance, and inhibit the expression of inflammatory factors. RNA-seq results showed that TIGAR was a possible regulatory site of metformin. However, the protective effect and the regulating effect of Th17/Treg balance by metformin in TIGAR knock-out cells were disappeared. In conclusion, metformin could regulate TIGAR inhibit glycolysis then regulate Th17/Treg balance, inhibit the release of liver inflammatory factors, and finally play a role in inhibiting the occurrence of liver injury caused by ischemia-reperfusion.

Summary: Background: The disability weight (DW) quantifies the severity of health states from disease sequela and is a pivotal parameter for disease burden calculation. We conducted a national and subnational DW measurement in China. Methods: In 2020–2021, we conducted a web-based survey to assess DWs for 206 health states in 31 Chinese provinces targeting health workers via professional networks. We fielded questions of paired comparison (PC) and population health equivalence (PHE). The PC data were analysed by probit regression analysis, and the regression results were anchored by results from the PHE responses on the DW scale between 0 (no loss of health) and 1 (health loss equivalent to death). Findings: We used PC responses from 468,541 respondents to estimate DWs of health states. Eight of 11 domains of health had significantly negative coefficients in the regression of the difference between Chinese and Global Burden of Disease (GBD) DWs, suggesting lower DW values for health states with mention of these domains in their lay description. We noted considerable heterogeneity within domains, however. After applying these Chinese DWs to the 2019 GBD estimates for China, total years lived with disability (YLDs) increased by 14·9% to 177 million despite lower estimates for musculoskeletal disorders, cardiovascular diseases, mental disorders, diabetes and chronic kidney disease. The lower estimates of YLDs for these conditions were more than offset by higher estimates of common, low-severity conditions. Interpretation: The differences between the GBD and Chinese DWs suggest that there might be some contextual factors influencing the valuation of health states. While the reduced estimates for mental disorders, alcohol use disorder, and dementia could hint at a culturally different valuation of these conditions in China, the much greater shifts in YLDs from low-severity conditions more likely reflects methodological difficulty to distinguish between health states that vary a little in absolute DW value but a lot in relative terms. Funding: This work was supported by the National Natural Science Foundation of China [grant number 82173626], the National Key Research and Development Program of China [grant numbers 2018YFC1315302], Wuhan Medical Research Program of Joint Fund of Hubei Health Committee [grant number WJ2019H304], and Ningxia Natural Science Foundation Project [grant number 2020AAC03436].

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

Summary: Background: Social determinants of health (SDOH) produce a broad range of life expectancy (LE) disparities. In China, limited literatures were found to report association between SDOH and LE at ecological level during a consecutive period of time from the spatial perspectives. This study aimed to determine the existence, quantify the magnitude, and interpret the association between SDOH and LE in China. Methods: Provincial-level LE were estimated from mortality records during 2005–2020 from National Mortality Surveillance System in China. A spatial panel Durbin model was used to investigate LE associated SDOH proxies. Spatial spillover effects were introduced to interpret direct and indirect effects caused by SDOH during long-term and short-term period on LE disparities. Findings: Nationwide, LE increased from 73.1 (95% confidence interval (CI): 71.3, 74.4) years to 77.7 (95%CI: 76.5, 78.7) years from 2005 to 2020. Unequally spatial distribution of LE with High-High clustering in coastal areas and Low-Low clustering in western regions were observed. Locally, it was estimated that SDOH proxies statistically significant related to an increase of LE, including GDP (coefficient: 0.02, 95%CI: 0.00, 0.03), Gini index (coefficient: 2.35, 95%CI: 1.82, 2.88), number of beds in health care institutions (coefficient: 0.02, 95%CI: 0.00, 0.05) and natural growth rate of resident population (coefficient: 0.02, 95%CI: 0.01, 0.02). Direct and indirect effects decomposition during long-term and short-term of LE associated SDOH proxies demonstrated that GDP, urbanization rate, unemployment rate, education attainment, Gini index, number of beds in health care institutions, sex ratio, gross dependence ratio and natural growth rate of resident population not only affected local LE, but also exerted spatial spillover effects towards geographical neighbors. Interpretation: Spatial variations of LE existed at provincial-level in China. SDOH regarding socioeconomic development and equity, healthcare resources, as well as population characteristics not only affected LE disparities at local scale but also among nearby provinces. Externalities of policy of those SDOH proxies should be took into consideration to promote health equity nationally. Comprehensive approaches on the basis of population strategy should be consolidated to optimize supportive socioeconomic environment and narrow the regional gap to reduce health disparities and increase LE. Funding: National Key Research & Development Program of China (Grant No.2018YFC1315301); Ministry of Education of China Humanities and Social Science General Program (Grant No.18YJC790138).

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

Summary: Background: Cardiovascular disease (CVD) is the leading cause of death (COD) in China. Understanding the characteristics of place of death (POD) among CVD deaths would be of great importance to evaluate the healthcare service utilization at the end stage of life. Limited studies have reported the POD distribution among CVD deaths, and little was known about the associated factors of hospital CVD deaths. Methods: By using data from National Mortality Surveillance System (NMSS) in China, this study presented the characteristics of POD distribution during 2008 and 2020. Afterwards, multilevel logistic regression was used to explore associated factors of hospital CVD deaths and quantify the magnitude to which the spatial variations of hospital CVD deaths could be explained by those associated factors. Findings: During 2008-2020, there was 7101871 CVD deaths collected by NMSS in China, with 77·13% home deaths and 18·49% hospital deaths. Shanghai (59·40%) had the highest percentage of hospital CVD deaths. Age, sex, ethnicity, marital status, education, occupation, underlying COD were significant influential factors of hospital CVD deaths. Spatial variations were shown at provincial level, with 33·88% of them being explained by factors at individual level. Interpretation: Home was the leading POD among CVD deaths in China, those CVD decedents characterized as the female, the youngest, Han population, the married, the retiree, lived in urban areas, with higher socioeconomic status and died of chronic CVDs had a higher probability of hospital deaths. Providing accessible and available healthcare services were priorities to improve quality of end-of-life care, significant variations among provinces and sub-population also reminded us of the requirements for equal healthcare resources allocation and multiple options for minorities of POD preference at the end stage of life. Funding: National Key Research & Development Program of China (grant number 2018YFC1315301)

BackgroundSchizophrenia is an important public health problem in China. This study aims to assess the long-term trends in the incidence and disability-adjusted life years (DALYs) rate of schizophrenia in China between 1990 and 2019.MethodsThe incidence and DALYs data were drawn from the Global Burden of Disease Study 2019, and an age–period–cohort model was used in the analysis.ResultsThe age-standardized incidence rate (ASIR) and age-standardized DALYs rate (ASDR) of schizophrenia increased by 0.3 and 3.7% for both sexes between 1990 and 2019. For males, the local drift for incidence was higher than 0 (P < 0.05) in those aged 10 to 29 years (local drifts, 0.01 to 0.26%) and lower than 0 (P < 0.05) in those aged 35 to 74 years (local drifts, −1.01 to −0.06%). For females, the local drift was higher than 0 (P < 0.05) in those aged 10 to 34 years (local drifts, 0.05 to 0.26%) and lower than 0 (P < 0.05) in those aged 40 to 74 years (local drifts, −0.86 to −0.11%). The local drift for DALYs rate was higher than 0 (P < 0.05) in the age group from 10 to 69 years (local drifts, 0.06 to 0.26% for males and 0.06 to 0.28% for females). The estimated period and cohort relative risks (RR) for DALYs rate of schizophrenia were found in monotonic upward patterns, and the cohort RR for the incidence increased as the birth cohort moved forward starting with those born in 1972.ConclusionAlthough the crude incidence of schizophrenia has decreased in China, the ASIR, ASDR, and crude DALYs rate all showed a general increasing trend over the last three decades. The DALYs rate continue to increase as the birth cohort moved forward, and the increasing trend of incidence was also found in individuals born after 1972. More efforts are needed to promote mental health in China.

Summary: Background: Fall in elderly is a major public health problem. Characterizing trends in fall mortality in different subpopulations could help identifying the needs and developing preventive program for target groups. Here we evaluated the trends of fall-related deaths in Chinese mainland among adults aged ≥60 years specific in sex, age, and provinces, to measure the change in this mortality rate between 2013 and 2020, and to explore the underlying factors influencing this change. Methods: Mortality data were retrieved from the National Disease Surveillance Points system(DSPs) of China, a national-level and provincial-level representative data source, to estimate the impact of elderly falls on mortality in the mainland of China and the specific provinces from 2013 to 2020. The joinpoint regression model was used to estimate the temporal trend of mortality in elderly fallen by calculating the annual percentage change (APC). Findings: The age-standardized falls mortality was 10·438 per 100 000 in 2020. The age-standardized mortality of elderly falls in total and female showed a steady increasing trend (APC=1·96%, p = 0·023 total; APC=3·42%, p = 0·003 female), with it was stable in males (APC=1.26%, p>0·05). Fall mortality among the elderly was more common in people over 70 years of age and increased sharply. The death rates and APCs were highest among the oldest age groups(aged≥85 years). The higher fall mortality was mainly focused in the southeast and central regions, and lower rates were in the northeast provinces and Tibet. Interpretation: Since 2013, the overall fall-related mortality trend among individuals aged ≥60 years has been consistently increasing in China, making it most critical public health challenge. Adherence interventions and increased social support for those at most risk should be considered. Funding: None.

Objectives. To analyze diabetes mellitus (DM) mortality and years of life lost (YLL) in different years and different subgroups at the national and regional levels in China from 2005 to 2020. Methods. We estimated mortality and YLL of DM and its subcategories for 31 provinces in China during 2005–2020 using multisource data from the National Mortality Surveillance System (NMSS). Results. The age standardized mortality rate (ASMR) of DM increased from 12.18 per 100,000 in 2005 to 13.62 per 100,000 in 2020, which was an increase of 11.86%. The ASMR of type 2 diabetes mellitus (T2DM) was much higher than that of type 1 diabetes mellitus (T1DM). The ASMR of T1DM remained stable, but the rate of T2DM increased, and the increase in male patients was higher than that in their female counterparts. At the same time, the burden of premature death was highest in the group≥80 years old, and ASMR increased from 236.02 per 100,000 in 2005 to 358.86 per 100,000 in 2020. In 2005, the eastern region had the highest ASMR of DM, but the western region’s ASMR grew faster and eventually became the highest in 2020. In addition, the YLL rate in the eastern region showed a downward trend; however, in the middle and western regions the YLL rate continued to rise, with that of the western region rapidly increasing. Conclusion. A dramatically upward trend in DM deaths can be seen in China from 2005 to 2020. DM remains a chronic disease in urgent need of prevention and control, especially in the elderly and people in less-affluent provinces. We must put forward more targeted policies to effectively allocate medical resources and focus on high-risk groups to reduce the premature-mortality burden of DM and its subcategories.

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

Abstract Background Headache has emerged as a global public health concern. However, little is known about the burden from headache disorders in China. The aim of this work was to quantify the spatial patterns and temporal trends of burden from headache disorders in China. Methods Following the general analytic strategy used in the 2017 Global Burden of Disease study, we analyzed the prevalence and years lived with disability (YLDs) of headache and its main subcategories, including migraine and tension-type headache (TTH), by age, sex, year and 33 province-level administrative units in China from 1990 to 2017. Results Almost 112.4 million individuals were estimated to have headache disorders in 1990 in China, which rose to 482.7 million in 2017. The all-age YLDs increased by 36.2% from 1990 to 2017. Migraine caused 5.5 million YLDs, much higher than TTH (1.1 million) in 2017. The age-standardized prevalence and YLDs rate of headache remained stable and high in 2017 compared with 1990, respectively. The proportion of total headache YLDs in all diseases increased from 1990 to 2017 by 5.4%. A female preponderance was observed for YLDs and the YLDs were mainly in people aged 20~54 years. Conclusions Headache remains a huge health burden in China from 1990 to 2017, with prevalence and YLDs rates higher in eastern provinces than western provinces. The substantial increase in headache cases and YLDs represents an ongoing challenge in Chinese population. Our results can help shape and inform headache research and public policy throughout China, especially for females and middle-aged people.

Background: Both inhalable particles (PM10) and fine particles (PM2.5) are regulated in various countries mainly due to their adverse health effects. However, there is increasing evidence that PM2.5 might be responsible for these effects and coarse particles (PMc) plays little role in adverse health effects, if so, it might be not necessary to monitor PM10. Methods: In this study, we conducted a time-series analysis using a generalized additive model to explore the effects of PM2.5, PMc, and PM10 on mortality from ischemic heart disease (IHD) and chronic obstructive pulmonary disease (COPD) in 96 Chinese cities during 2013–2016. The mortality number and attributable fraction were further estimated using the national air quality standard and WHO’s guideline as the reference. Results: We observed significant effects of PM2.5 on IHD and COPD mortality; each 10 ug/m3 increase in lag01 PM2.5 was associated with a 0.26% (95% CI: 0.17%, 0.34%) increase in IHD mortality and a 0.19% (95% CI: 0.09%, 0.29%) increase in COPD mortality. We also found significant effects of PMc and PM10 on mortality from IHD and COPD, but the magnitudes of effects were weaker than those of PM2.5. The results were robust when adjusting for co-pollutants and altering model parameters. We further estimated that about 1.27% (95% CI: 0.29%, 2.30%) of IHD mortality and 1.25% (95% CI: 0.08%, 2.46%) of COPD mortality could be attributable to PM2.5 exposure using WHO’s guideline (25 ug/m3) as a reference, corresponding to 15,337 (95% CI: 3,375, 27,842) mortalities from IHD and 5,653 (95% CI: 379, 11,152) COPD mortalities in the 96 cities. Across all of China, almost fifty thousand cases of IHD mortality and twenty thousand cases of COPD mortality might be avoidable if the PM2.5 concentration declined to the WHO guideline. Conclusions: Our study indicates that short-term exposure to PM2.5 could be an important risk factor of mortality from IHD and COPD, and substantial cardiopulmonary mortality could be avoidable by reducing daily PM2.5 concentrations. It is nonnegligible to consider the role of PMc in triggering in cardiopulmonary mortality. And it could be necessary to continue monitoring PM10 in the study regions due to the adverse effects of PMc.

Summary: Although exposure to air pollution increases the risk of premature mortality and years of life lost (YLL), the effects of daily air quality improvement to the life expectancy of respiratory diseases remained unclear. We applied a generalized additive model (GAM) to assess the associations between daily PM2.5 exposure and YLL from respiratory diseases in 96 Chinese cities during 2013–2016. We further estimated the avoidable YLL, potential gains in life expectancy, and the attributable fraction by assuming daily PM2.5 concentration decrease to the air quality standards of China and World Health Organization. Regional and national results were generated by random-effects meta-analysis. A total of 861,494 total respiratory diseases and 586,962 chronic obstructive pulmonary disease (COPD) caused death from 96 Chinese cities were recorded during study period. Each 10 μg/m3 increase of PM2.5 in 3-day moving average (lag02) was associated with 0.16 (95% CI: 0.08, 0.24) years increment in life expectancy from total respiratory diseases. The highest effect was observed in Southwest region with 0.42 (95% CI: 0.22, 0.62) years increase in life expectancy. By attaining the WHO's Air Quality Guidelines, we estimated that an average of 782.09 (95% CI: 438.29, 1125.89) YLLs caused by total respiratory death in each city could be avoided, which corresponded to 1.15% (95% CI: 0.67%, 1.64%) of the overall YLLs, and 0.12 (95% CI: 0.07, 0.17) years increment in life expectancy. The results of COPD were generally consistent with total respiratory diseases. Our findings indicate that reduction in daily PM2.5 concentrations might lead to longer life expectancy from respiratory death.

Background: Ozone is one of the dominant air pollutants due to its impact on disease burden and increasing trend in concentration. However, evidence regarding short-term effect of ozone on years of life lost (YLL) is scarce. Methods: A national time-series study was conducted in 48 large Chinese cities from 2013 to 2017. Generalized additive model coupled with random effects model were used to estimate national-average associations of ozone with YLL. Potential modifiers and additional life gain due to avoidable YLL under certain scenario were also evaluated. Results: The average annual mean ozone concentration of these cities was 86.9 μg/m3. For 10 μg/m3 increase in 3-day moving average ozone concentration, we estimated 0.37% [95% confidence interval (CI): 0.29%, 0.46%] increase in YLL from nonaccidental causes, 0.38% (95% CI: 0.30%, 0.46%) increase in YLL from cardiovascular diseases, and 0.36% (95% CI: 0.16%, 0.56%) increase in YLL from respiratory diseases. Moreover, the associations were more evident in people with less education and in cities with lower carbon monoxide concentration or those located at north region with lower mean temperature. Finally, an estimated life of 0.055 (95% CI: 0.043, 0.068) years would be gained per deceased people if ozone concentration could fall to 100 μg/m3. Conclusions: Our findings indicated robust associations between short-term exposure to ozone and YLL from nonaccidental causes and cardiopulmonary diseases. Relevant intervention design should take the heterogeneity of both individual- and city-level characteristics into account. Implementation of more stringent standard is beneficial for alleviating YLL caused by ozone.

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

Abstract 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 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.

Objectives To investigate potential geographical and socioeconomic patterning of allostatic load (AL) in China.Design Multilevel longitudinal study of the 2010 Chronic Disease Risk Factor Surveillance linked to the National Death Surveillance up to 31 December 2015.Setting All 31 provinces in China, not including Hong Kong, Macao or Taiwan.Participants 96 466 ≥ 18 years old (women=54.3%).Exposures Person-level educational attainment and mean years of education in counties.Outcome AL was measured using clinical guidelines for nine biomarkers: body mass index; waist circumference; systolic blood pressure; diastolic blood pressure; fasting blood glucose; total cholesterol; triglycerides; high-density lipoprotein cholesterol; low-density lipoprotein cholesterol.Results Multilevel logistic regressions adjusted for sex, age, marital status, person-level education, county mean years of education and urban/rural reported ORs of 1.22 (95% CI 1.08 to 1.38) for 5-year all-cause mortality (n=3284) and 1.20 (1.04–1.37) for deaths from non-communicable diseases (n=2891) among people in AL quintile 5 (high) compared with quintile 1 (low). The median rate ratio estimated from unadjusted multilevel negative binomial regression showed AL clustered geographically (province=1.14; county=1.12; town=1.11; village=1.14). After adjusting for aforementioned confounders, AL remained higher with age (rate ratio 1.02, 95% CI 1.02 to 1.02), higher in women compared with men (1.17, 1.15 to 1.19), lower among singletons (0.83, 0.81 to 0.85) and widowers (0.96, 0.94 to 0.98). AL was lower among people with university-level compared with no education (0.92, 0.89 to 0.96), but higher in counties with higher mean education years (1.03, 1.01 to 1.05). A two-way interaction suggested AL was higher (1.04, 1.02 to 1.06) among those with university-level compared with no education within counties with higher mean years of education. Similar results were observed for alternative constructions of AL using 75th and 80th percentile cut-points.Conclusions AL in China is patterned geographically. The degree of association between AL and person-level education seems to be dependent on area-level education, which may be a proxy for other contextual factors that warrant investigation.

Summary: Background: The estimation of influenza-associated excess mortality in countries can help to improve estimates of the global mortality burden attributable to influenza virus infections. We did a study to estimate the influenza-associated excess respiratory mortality in mainland China for the 2010–11 through 2014–15 seasons. Methods: We obtained provincial weekly influenza surveillance data and population mortality data for 161 disease surveillance points in 31 provinces in mainland China from the Chinese Center for Disease Control and Prevention for the years 2005–15. Disease surveillance points with an annual average mortality rate of less than 0·4% between 2005 and 2015 or an annual mortality rate of less than 0·3% in any given years were excluded. We extracted data for respiratory deaths based on codes J00-J99 under the tenth edition of the International Classification of Diseases. Data on respiratory mortality and population were stratified by age group (age

Summary: Background: Sustainable Development Goal (SDG) 3.6 is to halve the number of global deaths and injuries from road traffic accidents by 2020. We aimed to investigate progress in reducing mortality rates from road traffic injury in China from 2006 to 2016. Methods: We obtained data from national disease surveillance points. Crude and age-standardised mortality were calculated, with SEs. Joinpoint regression analysis was used to examine and quantify trends in overall and subgroup road traffic mortality from 2006 to 2016. Subgroup analyses were done by place (urban and rural), sex, age group, geographical location (province), and road user, and by type of vehicle for motor vehicle occupant deaths. Findings: In 2016 in China, crude road traffic mortality was 11·0 (SE 0·11) deaths per 100 000 population. Overall age-adjusted road traffic mortality increased from 12·6 (SE 0·03) deaths per 100 000 population in 2006 to 15·5 (0·03) deaths per 100 000 population in 2011 then decreased to 10·4 (0·03) deaths per 100 000 population in 2016. Subgroup mortality rates generally followed similar trends. Males, older adults, and rural areas consistently had higher road traffic mortality rates than did females, younger people, and urban areas. Mortality changes varied across urban and rural areas and by sex, age group, and province between 2006 and 2016, revealing large urban–rural and provincial disparities and highlighting pedestrians as the most vulnerable road users. Deaths among occupants of cars and three-wheeled motor vehicles constituted 48% and 20%, respectively, of total occupant mortality from road traffic accidents between 2006 and 2016. Interpretation: Despite a substantial decrease in road traffic mortality since 2011, the SDG target to halve deaths and injuries from road traffic accidents by 2020 is unlikely to be reached in China. Systematic and sustainable efforts are needed to accelerate progress in road traffic safety in China. Funding: National Natural Science Foundation of China.

Background: Evidence of the acute health effects of ambient carbon monoxide air pollution in developing countries is scarce and mixed. We aimed to evaluate short-term associations between carbon monoxide and daily cardiovascular disease mortality in China. Methods: We did a nationwide time-series analysis in 272 major cities in China from January, 2013, to December, 2015. We extracted daily cardiovascular disease mortality data from China's Disease Surveillance Points system. Data on daily carbon monoxide concentrations for each city were obtained from the National Urban Air Quality Real-time Publishing Platform. City-specific associations between carbon monoxide concentrations and daily mortality from cardiovascular disease, coronary heart disease, and stroke were estimated with over-dispersed generalised linear models. Bayesian hierarchical models were used to obtain national and regional average associations. Exposure–response association curves and potential effect modifiers were evaluated. Two-pollutant models were fit to evaluate the robustness of the effects of carbon monoxide on cardiovascular mortality. Findings: The average annual mean carbon monoxide concentration in these cities from 2013 to 2015 was 1·20 mg/m3, ranging from 0·43 mg/m3 to 2·45 mg/m3. For a 1 mg/m3 increase in average carbon monoxide concentrations on the present day and previous day (lag 0–1), we observed significant increments in mortality of 1·12% (95% posterior interval [PI] 0·42–1·83) from cardiovascular disease, 1·75% (0·85–2·66) from coronary heart disease, and 0·88% (0·07–1·69) from stroke. These associations did not vary substantially by city, region, and demographic characteristics (age, sex, and level of education), and the associations for cardiovascular disease and coronary heart disease were robust to the adjustment of criteria co-pollutants. We did not find a threshold below which carbon monoxide exposure had no effect on cardiovascular disease mortality. Interpretation: This analysis is, to our knowledge, the largest study done in a developing country, and provides robust evidence of the association between short-term exposure to ambient carbon monoxide and increased cardiovascular disease mortality, especially coronary heart disease mortality. Funding: Public Welfare Research Program.

BACKGROUND:Traumatic brain injury (TBI) is a significant global public health problem, but has received minimal attention from researchers and policy-makers in low- and middle-income countries (LMICs). Epidemiological evidence of TBI morbidity and mortality is absent at the national level for most LMICs, including China. Using data from China's Disease Surveillance Points (DSPs) system, we conducted a population-based longitudinal analysis to examine TBI mortality, and mortality differences by sex, age group, location (urban/rural), and external cause of injury, from 1 January 2006 to 31 December 2013 in China. METHOD AND FINDINGS:Mortality data came from the national DSPs system of China, which has coded deaths using the International Classification of Diseases-10th Revision (ICD-10) since 2004. Crude and age-standardized mortality with 95% CIs were estimated using the census population in 2010 as a reference population. The Cochran-Armitage trend test was used to examine the significance of trends in mortality from 2006 to 2013. Negative binomial models were used to examine the associations of TBI mortality with location, sex, and age group. Subgroup analysis was performed by external cause of TBI. We found the following: (1) Age-adjusted TBI mortality increased from 13.23 per 100,000 population in 2006 to 17.06 per 100,000 population in 2008 and then began to fall slightly. In 2013, age-adjusted TBI mortality was 12.99 per 100,000 population (SE = 0.13). (2) Compared to females and urban residents, males and rural residents had higher TBI mortality risk, with adjusted mortality rate ratios of 2.57 and 1.71, respectively. TBI mortality increased substantially with older age. (3) Motor vehicle crashes and falls were the 2 leading causes of TBI mortality between 2006 and 2013. TBI deaths from motor vehicle crashes in children aged 0-14 years and adults aged 65 years and older were most often in pedestrians, and motorcyclists were the first or second leading category of road user for the other age groups. (4) TBI mortality attributed to motor vehicle crashes increased for pedestrians and motorcyclists in all 7 age groups from 2006 to 2013. Our analysis was limited by the availability and quality of data in the DSPs dataset, including lack of injury-related socio-economic factors, policy factors, and individual and behavioral factors. The dataset also may be incomplete in TBI death recording or contain misclassification of mortality data. CONCLUSIONS:TBI constitutes a serious public health threat in China. Further studies should explore the reasons for the particularly high risk of TBI mortality among particular populations, as well as the reasons for recent increases in certain subgroups, and should develop solutions to address these challenges. Interventions proven to work in other cultures should be introduced and implemented nationwide. Examples of these in the domain of motor vehicle crashes include policy change and enforcement of laws concerning helmet use for motorcyclists and bicyclists, car seat and booster seat use for child motor vehicle passengers, speed limit and drunk driving laws, and alcohol ignition interlock use. Examples to prevent falls, especially among elderly individuals, include exercise programs, home modification to reduce fall risk, and multifaceted interventions to prevent falls in all age groups.

BackgroundAs of 31(st) March 2010, more than 127,000 confirmed cases of 2009 pandemic influenza A (H1N1), including 800 deaths, were reported in mainland China. The distribution and characteristics of the confirmed cases in the initial phase of this pandemic in this country are largely unknown. The present study aimed to characterize the geographic distribution and patient characteristics of H1N1 infection in the 2009 pandemic as well as to identify potential risk factors associated with adverse patient outcome in China, through retrospective analyses of 885 hospitalized cases with confirmed H1N1 infection.Methodology/principal findingsThe proportional hazards model was employed to detect risk factors for adverse outcome; the geo-statistical maps were used to characterize the distribution of all 2668 confirmed H1N1 patients throughout mainland China. The number of new cases increased slowly in May, 2009, but rapidly between June and August of the year. Confirmed cases were reported in 26 provinces; Beijing, Guangdong, Shanghai, Zhejiang and Fujian were the top five regions of the incidence of the virus infection. After being adjusted for gender, age, chronic pulmonary disease and other general symptoms, delay for more than two days before hospital admission (HR: 0.6; 95%CI: 0.5-0.7) and delayed onset of the H1N1-specific respiratory symptoms (HR: 0.3; 95%CI: 0.2-0.4) were associated with adverse patient outcome.Conclusions/significanceThe 2009 pandemic influenza A affected east and southeast coastal provinces and most populous cities more severely than other regions in mainland China due to higher risk of high level traffic-, high population density-, and high population mobility-associated H1N1 transmission.The clinical symptoms were mild in the initial phase of infection. Delayed hospital admission and delayed appearance of respiratory symptoms were among the major risk factors for poor patient outcome. These findings may have significant implications in the future pandemic preparedness and response.