Importation and circulation of rubella virus lineages 1E-L2 and 2B-L2c between 2018 and 2021 in China: Virus evolution and spatial-temporal transmission characteristics.

To better understand the importation and circulation patterns of rubella virus lineages 1E-L2 and 2B-L2c circulating in China since 2018, 3,312 viral strains collected from 27 out of 31 provinces in China between 2018 and 2021 were sequenced and analyzed with the representative international strains of lineages 1E-L2 and 2B-L2c based on genotyping region. Time-scale phylogenetic analysis revealed that the global lineages 1E-L2 and 2B-L2c presented distinct evolutionary patterns. Lineage 1E-L2 circulated in relatively limited geographical areas (mainly Asia) and showed geographical and temporal clustering, while lineage 2B-L2c strains circulated widely throughout the world and exhibited a complicated topology with several independently evolved branches. Furthermore, both lineages showed extensive international transmission activities, and phylogeographic inference provided evidence that lineage 1E-L2 strains circulating in China possibly originated from Japan, while the source of lineage 2B-L2c isolated since 2018 is still unclear. After importation into China in 2018, the spread of lineage 1E-L2 presented a three-stage transmission pattern from southern to northern China, whereas lineage 2B-L2c spread from a single point in western China to all the other four regions. These two transmission patterns allowed both imported lineages to spread rapidly across China during the 2018-9 rubella epidemic and eventually established endemic circulations. This study provides critical scientific data for rubella control and elimination in China and worldwide.

Maternal mortality ratios in 2852 Chinese counties, 1996-2015, and achievement of Millennium Development Goal 5 in China: a subnational analysis of the Global Burden of Disease Study 2016.

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

Use of contraceptives and uptake of long-acting reversible contraception among postpartum women in rural China.

BACKGROUND: Pregnancies have been increasing since the universal two-child policy in China was announced and thus the prevention of short inter-pregnancy intervals has become more important. However, little is known about contraceptive use among postpartum women in rural areas of China. This study investigated the current situation and factors associated with contraceptive use, especially long-acting reversible contraception (LARC) practice among postpartum women. STUDY DESIGN: A cross-sectional study was conducted with a probability proportionate to size (PPS) sampling method in Shimen County of Hunan province with 423 mothers whose youngest child was aged under 2 years. A questionnaire was used to collect information on participants' demographics, reproductive history and contraceptive use. RESULTS: The rate of using all contraceptive methods was 66.4% in the study group and the rate of using LARC was 9.9%. Statistically significant predictors of contraceptive use were: no breastfeeding, no intention of having another child, and education beyond high school. Statistically significant predictors of LARC utilisation were: vaginal delivery, at least one child before the index delivery, and no breastfeeding. CONCLUSIONS: The utilisation rate of postpartum contraception, especially LARC, was relatively low in rural China. The benefits of LARC have not been realised and breastfeeding is still incorrectly believed to be a definitely reliable method of contraception. Thus, health education and contraceptive knowledge and regulations need to be updated and enhanced based on research evidence, for increased adoption of postpartum contraception in rural China.

Prevalence of Oral Clefts among Live Births in Gansu Province, China.

Background: Oral clefts (OCs) are common human birth defects. Children with OCs in underdeveloped regions are more likely to suffer from poverty and hardship in their future lives. Here, we attempted to estimate the prevalence of OCs among live births in Gansu Province in 2008 to understand the epidemiologic pattern of the disease. Methods: A cross-sectional study was conducted from January 2008 to December 2008 in Gansu Province. The live births delivered between January and December 2008 with OCs were investigated through face-to-face questionnaire survey. Results: A total of 468 infants with OCs were identified among 347,137 live births in 2008 in Gansu Province, which yielded a prevalence of 1.35 per 1000 live births. The majority of these cases were CL (cleft lip) (prevalence = 0.85 per 1000 live births), and the prevalence of CLP (cleft lip and palate) and CP (cleft palate) was 0.34 and 0.11 per 1000 live births, respectively. We also found that the prevalence of OCs in Jiayuguan (3.39 per 1000 live births) and Dingxi (2.71 per 1000 live births) was higher than those of other cities in Gansu Province. Additionally, we failed to detect significant correlation between economic conditions of the cities and the prevalence of OCs in our study. Conclusions: The prevalence of OCs among live births in Gansu Province in 2008 was higher than the prevalence of OCs in other provinces in China. The high prevalence may reflect the need for further etiological studies to explore the potential risk factors in this region. In addition, more subtype information needs to be collected in future prevalence studies for better understanding of the epidemiologic pattern of the disease.

Geographic Variations and Temporal Trends in Cesarean Delivery Rates in China, 2008-2014.

Importance: The increasing use of cesarean delivery is an emerging global health issue. Prior estimates of China's cesarean rate have been based on surveys with limited geographic coverage. Objective: To provide updated information about cesarean rates and geographic variation in cesarean use in China. Design, Setting, and Data Sources: Descriptive study, covering every county (n = 2865) in mainland China's 31 provinces, using county-level aggregated information on the number of live births, cesarean deliveries, maternal deaths, and perinatal deaths, collected by the Office for National Maternal & Child Health Statistics of China, from 2008 through 2014. Exposures: Live births. Main Outcomes and Measures: Annual rate of cesarean deliveries. Results: Over the study period, there were 100 873 051 live births, of which 32 947 229 (32.7%) were by cesarean delivery. In 2008, there were 13 160 634 live births, of which 3 788 029 (28.8%) were by cesarean delivery and in 2014 there were 15 123 276 live births, of which 5 280 124 (34.9%) were by cesarean delivery. Rates varied markedly by province, from 4.0% to 62.5% in 2014. Despite the overall increase, by 2014 rates of cesarean delieries in 14 of the nation's 17 "super cities" had declined by 4.1 to 17.5 percentage points from their earlier peak values (median, 11.4; interquartile range, 6.3-15.4). In 4 super cities with the largest decreases, there was no increase in maternal or perinatal mortality. Conclusions and Relevance: Between 2008 and 2014, the overall annual rate of cesarean deliveries increased in China, reaching 34.9%. There was major geographic variation in rates and trends over time, with rates declining in some of the largest urban areas.

Barriers to Hospital Deliveries among Ethnic Minority Women with Religious Beliefs in China: A Descriptive Study Using Interviews and Survey Data.

BACKGROUND: China has made great progress in improving hospital delivery-the coverage of hospital delivery has increased to above 95% in most regions- some regions lag behind owing to geographic and economic inequality, particularly the poor ethnic minority areas of the Sichuan Province. This study explores factors which may influence hospital delivery from multiple perspectives, with implications for practice and policy. METHODS: A framework analysis approach was used to identify and categorize the main barriers and levers to hospital delivery. Our analysis draws on basic information from the sampled counties (Butuo and Daofu). RESULTS: The hospital delivery rate was below 50% in the two sampled areas. In both areas, the "New Rural Cooperative Medical Scheme" and "Rural hospital delivery subsidy" were introduced, but only Butuo county had a transportation subsidy policy. Socioeconomically disadvantaged women in both counties who delivered their babies in hospitals could also apply for financial assistance. A lack of transport was among the main reasons for low hospital delivery rates in these two counties. Furthermore, while the hospital delivery costs could be mostly covered by "New Rural Cooperative Medical Scheme" or "Rural Hospital Delivery Subsidy", reimbursement was not guaranteed. People in Daofu county might be affected by their Buddhism religion for hospital delivery. Women in Butuo following the Animism religion would refuse delivery in hospitals because of language barriers. Traditional lay beliefs were the main factor that influenced hospital delivery; their understandings of reproductive health varied, and many believed that childbirth should not be watched by strangers and that a home delivery was safe. CONCLUSIONS: This study has highlighted a number of barriers and levers to hospital delivery in rural poor ethnic minority areas which could inform and improve the access and rate of hospital delivery rate; thereby reducing health inequalities in maternal and child health in China.

Potential health benefits of controlling dust emissions in Beijing.

Although the adverse impact of fine particulate matter (i.e., PM2.5) on human health has been well acknowledged, little is known of the health effects of its specific constituents. Over the past decade, the annual average dust concentrations in Beijing were approximately ∼14 µg m(-3), a value that poses a great threat to the city's 20 million residents. In this study, we quantify the potential long-term health damages in Beijing resulting from the dust exposure that occurred from 2000 to 2011. Each year in Beijing, nearly 4000 (95% CI: 1000-7000) premature deaths may be associated with long-term dust exposure, and ∼20% of these deaths are attributed to lung cancer. A decomposition analysis of the inter-annual variability of premature deaths in Beijing indicates that dust concentrations determine the year-to-year tendency, whereas population growth and lung cancer mortality rates drive the increasing tendency of premature death. We suggest that if Beijing takes effective measures towards reducing dust concentrations (e.g., controlling the resuspension of road dust and the fugitive dust from construction sites) to a level comparable to that of New York City's, the associated premature deaths will be significantly reduced. This recommendation offers "low-hanging fruit" suggestions for pollution control that would greatly benefit the public health in Beijing.

Under-5 mortality in 2851 Chinese counties, 1996-2012: a subnational assessment of achieving MDG 4 goals in China.

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

Factors associated with the use of prenatal corticosteroids in the management of preterm delivery in Chinese hospitals.

OBJECTIVE: To assess the prevalence of the use of prenatal corticosteroids (PCS) in the management of preterm delivery and the factors associated with PCS administration. METHODS: A secondary analysis was performed of a cross-sectional study conducted in 21 Chinese healthcare facilities between November 2010 and January 2011. The medical records of women who delivered preterm were reviewed. Associations between PCS administration and individual and organizational-level factors were determined. RESULTS: The study population comprised 659 women who delivered at 20 facilities. PCS were given to 158 (68.1%) of 232 women delivering after 27-34 weeks of pregnancy and 119 (27.9%) of 427 delivering after 35-36 weeks. Teenaged girls were less likely to receive PCS after 27-34 weeks than were women aged 20-35 years (odds ratio [OR] 0.22; 95% confidence interval [CI] 0.07-0.70). Among women who delivered after 35-36 weeks, the odds of receiving PCS were lower in urban hospitals than in periurban or rural hospitals (OR 0.04; 95% CI 0.00-0.44), and there was significant hospital-level variance with regard to the administration of PCS (P<0.05). CONCLUSION: Generally, PCS were underprescribed to women at risk of preterm delivery and many women received the treatment after 35-36 weeks of pregnancy, when it might not have been effective.

[Status of mother's KAP on child immunization in minority areas, Guizhou Province].

OBJECTIVE: To evaluate the status of mothers' knowledge, attitudes and practices (KAP) and its related factors and provide evidences for further effective implementation on childhood immunization in Guizhou Province. METHODS: This study was a cross-sectional study, in which 591 mothers of children under 2 years were surveyed with structured questionnaires in six selected counties of Qiandongnan Canton. RESULTS: Mothers' knowledge, attitudes and practices on childhood immunization were at a low level and influenced by educational background, county's economical level, mother's age, household size and ethnic groups. The childhood immunization was also at a low level. Among the 290 youngest children in a household survey, the coverage rate of all five vaccines (including HBV, BCG, OPV, DTP and measles vaccine) was 35.2%, and 12.3% of the surveyed children had never been immunized since birth. The main source of knowledge on immunization was interpersonal communication. CONCLUSION: Considering mothers' poor KAP status and low education level, health education on immunization should be implemented though interpersonal communication via assistant media, and educating emphases should be laid on some special-characteristics targets.