Differential associations of fine and coarse particulate air pollution with cause-specific pneumonia mortality: A nationwide, individual-level, case-crossover study.

BACKGROUND: The connections between fine particulate matter (PM2.5) and coarse particulate matter (PM2.5-10) and daily mortality of viral pneumonia and bacterial pneumonia were unclear. OBJECTIVES: To distinguish the connections between PM2.5 and PM2.5-10 and daily mortality due to viral pneumonia and bacterial pneumonia. METHODS: Using a comprehensive national death registry encompassing all areas of mainland China, we conducted a case-crossover investigation from 2013 to 2019 at an individual level. Residential daily particle concentrations were evaluated using satellite-based models with a spatial resolution of 1 km. To analyze the data, we employed the conditional logistic regression model in conjunction with polynomial distributed lag models. RESULTS: We included 221,507 pneumonia deaths in China. Every interquartile range (IQR) elevation in concentrations of PM2.5 (lag 0-2 d, 37.6 µg/m3) was associated with higher magnitude of mortality for viral pneumonia (3.03%) than bacterial pneumonia (2.14%), whereas the difference was not significant (p-value for difference = 0.38). An IQR increase in concentrations of PM2.5-10 (lag 0-2 d, 28.4 µg/m3) was also linked to higher magnitude of mortality from viral pneumonia (3.06%) compared to bacterial pneumonia (2.31%), whereas the difference was not significant (p-value for difference = 0.52). After controlling for gaseous pollutants, their effects were all stable; however, with mutual adjustment, the associations of PM2.5 remained, and those of PM2.5-10 were no longer statistically significant. Greater magnitude of associations was noted in individuals aged 75 years and above, as well as during the cold season. CONCLUSION: This nationwide study presents compelling evidence that both PM2.5 and PM2.5-10 exposures could increase pneumonia mortality of viral and bacterial causes, highlighting the more robust effects of PM2.5 and somewhat higher sensitivity of viral pneumonia.

Effect of vegetable consumption on risk of gastric cancer: a systematic review and multi-level meta-analysis of prospective studies.

Vegetables are known to be beneficial to human health, but the association between vegetable consumption and gastric cancer remains uncertain. To synthesise knowledge about the relationship between vegetable group consumption and gastric cancer risk, update present meta-analyses and estimate associations between vegetable consumption and gastric cancer risk based solely on prospective studies, we perform a PRISMA-compliant three-level meta-analysis. Systematic search identified thirteen prospective studies with fifty-two effect sizes that met all inclusion criteria and no exclusion criteria for our meta-analysis. Pooled risk ratios (RRs) showed a positive association between high vegetable consumption and low gastric cancer risk (pooled RR 0·93, 95% confidence interval 0·90-0·97, P = 0·06). In moderator analyses for indicators of gender, region and quantity of vegetable intake, there was no significant difference between subgroups. However, the effect became significant in populations with lower than the minimum risk exposure level (TMREL) of vegetable consumption (P < 0·05). Higher vegetable intake is associated with a decreased risk of gastric cancer. This effect may be limited to specific populations, such as ones with lower vegetable consumption. Evidence from our study has important public health implications for dietary recommendations.

Can global or national disability weights represent provincial level?

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.

Trend of nasopharyngeal carcinoma mortality and years of life lost in China and its provinces from 2005 to 2020.

To examine the trends of nasopharyngeal carcinoma (NPC) mortality and years of life lost (YLL) in China and its provinces from 2005 to 2020, our study used data from China National Mortality Surveillance System (NMSS) to estimate the number and rate of mortality and YLL of NPC by age and sex. We calculated average annual percent change (AAPC) to describe the trend of NPC mortality and YLL over time. We also analyzed the proportion of NPC deaths in all cancer deaths and explored the drivers of change in NPC deaths by decomposition analysis. The age-standardized mortality rate (ASMR) of NPC in China had a significant downward trend from 2.0/100 000 in 2005 to 1.4/100 000 in 2020 (AAPC = -2.4, P < .05). Age-standardized YLL rate also showed the similar trends (AAPC = -2.8, P < .05). Southern provinces including Guangdong (163.9/100 000), Guangxi (130.5/100 000), and Hainan (105.6/100 000) had the highest YLL rate in 2020. The mortality and YLL rate increased with age and males were higher than females. From 2005 to 2020, the proportion of NPC deaths in all cancer deaths remained stable at around 1.0% in China. The total number of deaths of NPC increased by 7.3%, of which age-specific mortality, population growth, and population aging accounted for -46.2%, 8.5% and 45.0%, respectively. NPC remains a significant public health issue in China southern provinces and tailored prevention and control strategies should be strengthened to reduce the burden of premature mortality of NPC in high risk areas.

Spatiotemporal trends and ecological determinants of cardiovascular mortality among 2844 counties in mainland China, 2006-2020: a Bayesian modeling study of national mortality registries.

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.

The burden of pneumoconiosis in China: an analysis from the Global Burden of Disease Study 2019.

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.

Estimating causes of out-of-hospital deaths in China: application of SmartVA methods.

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.

Metformin regulates the Th17/Treg balance by glycolysis with TIGAR in hepatic ischemia-reperfusion injury.

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.

Improvement in life expectancy for ischemic heart diseases by achieving daily ambient PM2.5 standards in China.

BACKGROUND: The potential impacts of daily ambient fine particulate pollution (PM2.5) exposure on year of life lost (YLL) due to ischemic heart diseases (IHD) remain uncertain. We aimed to estimate the improvement in IHD-related life expectancy by attaining the daily air quality standards of ambient PM2.5 in China. METHODS AND RESULTS: This study was based on daily mortality data covering 96 Chinese cities from 2013 to 2016. Regional- and national-associations between IHD-related YLLs and daily PM2.5 were estimated by generalized additive models. We further evaluated the IHD-related avoidable YLLs with an assumption that the daily PM2.5 was below the ambient air quality standards of World Health Organization (WHO) and China, and calculated the improvement of life expectancy by dividing the avoidable YLLs by the overall number of IHD mortality. We totally recorded 1,485,140 IHD deaths from 2013 to 2016. At the national level, we found a positive association between IHD-related YLLs and daily PM2.5. Per 10 µg/m3 increment of four-day averaged ambient PM2.5 related to an increase of 0.40 IHD-related YLLs (95% CI: 0.28, 0.51). By achieving the WHO's air quality guideline, we estimated that an averaged number of 1346.94 (95% CI: 932.61, 1761.27) YLLs can be avoided for the IHD deaths in each city. On average, the life expectancy can be improved by 0.15 years (95% CI: 0.11, 0.19) for each death. CONCLUSIONS: Our study provides a nationwide picture of the life expectancy improvements by reaching the daily PM2.5 standards in China, indicating that people can live longer in an environment with higher air quality.

Mortality, morbidity, and risk factors in China and its provinces, 1990-2017: a systematic analysis for the Global Burden of Disease Study 2017.

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

Measuring the completeness of death registration in 2844 Chinese counties in 2018.

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.

The disease burden attributable to 18 occupational risks in China: an analysis for the global burden of disease study 2017.

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.

Unintentional drowning mortality in China, 2006-2013.

BACKGROUND: Epidemiological characteristics and recent trends in unintentional drowning at the national level in China are unreported. METHODS: Using data from the Disease Surveillance Points system, the overall, sex-, location-, age- and cause-specific age-standardised mortality from unintentional drowning in China were calculated and compared. Linear regression was used to examine the significance of mortality trend changes over time. RESULTS: The average mortality was 4.05 per 100 000 persons between 2006 and 2013. Men and rural residents had much higher drowning mortality rates than women and urban residents at all time points. Drowning following a fall into natural water was the most common mechanism (46% of all drowning deaths). The overall drowning mortality rate remained stable for all subgroups except for distinct decreases in urban residents, children aged 5-9 years, and other specified and unspecified drowning (-10%, -36% and -25%, respectively). CONCLUSIONS: The overall drowning mortality rate remained high and stable in China between 2006 and 2013. Effective prevention measures like removing or covering water hazards, wearing personal floatation devices, supervision of children, and teaching survival swimming and resuscitation skills should be implemented nationwide.

Burden of headache disorders in China, 1990-2017: findings from the Global Burden of Disease Study 2017.

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.

Associations Between Ambient Nitrogen Dioxide and Daily Cause-specific Mortality: Evidence from 272 Chinese Cities.

BACKGROUND: There has been a long history of debate regarding whether ambient nitrogen dioxide (NO2) directly affects human health. METHODS: We conducted a nationwide time-series analysis in 272 major Chinese cities (2013-2015) to evaluate the associations between short-term exposure to NO2 and cause-specific mortality. We used the overdispersed generalized linear model together with the Bayesian hierarchical model to estimate the associations between NO2 and mortality at the national and regional levels. We examined two-pollutant models with adjustment of fine particles, sulfur dioxide, carbon monoxide, and ozone to evaluate robustness for the effects of NO2. RESULTS: At the national-average level, we observed linear and positive associations between NO2 and mortality from all causes and main cardiorespiratory diseases. A 10 µg/m increase in 2-day average concentrations of NO2 would lead to increments of 0.9% (95% posterial interval [PI], 0.7%, 1.1%) in mortality from total nonaccidental causes, 0.9% (95% PI, 0.7%, 1.2%) from total cardiovascular disease, 1.4% (95% PI, 0.8%, 2.0%) from hypertension, 0.9% (95% PI, 0.6%, 1.2%) from coronary heart disease, 0.9% (95% PI, 0.5%, 1.2%) from stroke, 1.2% (95% PI, 0.9%, 1.5%) from total respiratory diseases, and 1.6% (95% PI, 1.1%, 2.0%) from chronic obstructive pulmonary disease. There were no appreciable differences in estimates from single-pollutant and two-pollutant models. The associations were stronger in the south of China, in the elderly, and in females. CONCLUSIONS: The present study provided robust epidemiologic evidence of associations between day-to-day NO2 and mortality from total natural causes and main cardiorespiratory diseases that might be independent of other criteria air pollutants.

Poisoning deaths in China, 2006-2016.

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

Diurnal temperature range in relation to death from stroke in China.

BACKGROUND: Stroke is the second leading cause of death in the world. It has multiple risk factors of which some, such as ambient temperature, are less well documented. OBJECTIVE: We aimed to examine the association between diurnal temperature range (DTR) and stroke mortality, and to test the possible effect modification of this association according to gender, age and educational level. METHODS: Daily data on weather and stroke mortality from 16 provincial capital cities in China for the years 2007-2013 were obtained, with a total of 788,783 deaths from stroke. A quasi-Poisson generalized linear regression combined with a distributed lag non-linear model was used to examine the city-specific DTR effect on stroke mortality. The pooled effects of DTR on stroke mortality were then obtained using a meta-analysis, which was based on restricted maximum likelihood estimation. RESULTS: The DTR impacts were generally limited to a period of eight days, while significant effects during lag 0-8 days were only found in the cities of Beijing, Zhengzhou, Nanjing, Hefei, Chongqing and Changsha. The DTR effects were significantly and negatively associated with latitudes at lag 0-10 days (rs = - 0.640, P = 0.008). An increase of 1 °C in DTR was associated with pooled estimate of 0.66% (95%CI: 0.28-1.05%), 0.12% (- 0.26% to 0.51%) and 0.67% (0.26-1.07%) increases in stroke mortality at lag 0-10 days during the total, hot and cold days, respectively. The impact of DTR was much higher in southern China than in northern China [1.02% (0.62% to 1.43%) versus 0.10% (-0.27% to 0.47%) ]. For the individual characteristics, only females, the elderly aged ≥ 65 years, and those with lower educational attainment were vulnerable to DTR. CONCLUSIONS: DTR has considerable effects on risk of mortality from stroke in various cities in China, especially among the elderly, females, those with low educational level, and people living in southern China. The results can inform decisions on developing programs to protect vulnerable subpopulations from adverse impacts of DTR.

Trends in traumatic brain injury mortality in China, 2006-2013: A population-based longitudinal study.

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.

Cause-specific mortality for 240 causes in China during 1990-2013: a systematic subnational analysis for the Global Burden of Disease Study 2013.

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

Can China achieve a one-third reduction in premature mortality from non-communicable diseases by 2030?

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.