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

Economic evaluation on meningococcal vaccination strategies among children under nine years of age in Zhejiang province, China

Meningococcal vaccination in Chinese national immunization program (NIP) includes polysaccharide vaccine against Neisseria meningitidis serogroup A (MPV-A) and polysaccharide vaccine against Neisseria meningitidis serogroup A and C(MPV-AC). This study aimed to assess the cost-effectiveness of an alternative strategy using polysaccharide conjugate vaccine against Neisseria meningitidis serogroup A,C,W,Y(MCV-ACWY) and polysaccharide vaccine against Neisseria meningitidis serogroup A,C,W,Y(MPV-ACWY). From a societal perspective, we constructed a decision tree-Markov model to simulate the economic and health consequences of meningococcal disease in a 2023 birth cohort with the current meningococcal vaccination strategy and the alternative. Parameters of epidemiology, vaccine efficacy, cost, and utility were extracted from database and previous literatures. The sensitivity analysis was implemented to evaluate the robustness of the model. Compared to the current practice, the alternative strategy could avoid 513 meningococcal disease cases, 53 sequelae and 47 deaths. The ICER was estimated at $16899.81 /QALY, under the threshold of one time of the GDP per capita of Zhejiang province in 2023. The incidence of meningococcemia, the incidence of meningococcal meningitis, the case fatality of meningococcemia, the vaccine efficacy of MCV-ACWY and the price of MCV-ACWY would influence the cost-effectiveness of the meningococcal vaccination strategies. At the threshold, the probability of cost-effectiveness was 14.76% for the current strategy and 55.98% for the alternative strategy, respectively. The current meningococcal vaccination strategy had effectively prevented meningococcal disease at a low cost, but with limited serogroup coverage. Strategy using MCV-ACWY and MPV-ACWY could increase health benefits at a substantial cost at a cost-effective manner.

Mortality Burden of Liver Cancer in China: An Observational Study From 2008 to 2020

Background and Aims

China accounts for nearly half of liver cancer deaths globally. A better understanding of the current liver cancer mortality will be helpful to establishing priorities for intervention and to decreasing the disease burden of liver cancer. The study aimed to explore and predict the mortality burden of liver cancer in China.

Methods

Data were extracted from the Disease Surveillance Point system of the Chinese Center for Disease Control and Prevention from 2008 to 2020. Crude and age-standardized liver cancer mortality rates were reported by sex, urban or rural residence, and region. Trends in liver cancer mortality rates from 2008 to 2020 were estimated as average annual percentage change (AAPC). The changing trend of live cancer mortality in the future is also predicted.

Results

In 2020, the crude mortality of liver cancer was 25.57/100,000, and males and people lived in rural areas had higher age-standardized liver cancer mortality rates than females and people lived in people in urban areas. Crude mortality and age-standardized mortality rates in southwest provinces (Guangxi, Sichuan, Tibet) and in a northeast province (Heilongjiang) were higher than that in other provinces, and age-specific mortality rates increased with age. From 2008 to 2020, liver cancer mortality rates decreased, but people under 50 years of age had a higher AAPC than those over 50 years of age, possibly because of the adoption of hepatitis B virus vaccination in newborns and children. Furthermore, the mortality of liver cancer in 2021-2030 is predicted to have a downward trend.

Conclusions

Liver cancer mortality rates declined in China from 2008 to 2020. Future interventions to control liver cancer mortality need to focus on people of male sex, older age, and living in rural areas or less developed provinces.

Life expectancy, long-term care demand and dynamic financing mechanism simulation: an empirical study of Zhejiang Pilot, China

BACKGROUND

China has piloted Long-Term Care Insurance (LTCI) to address increasing care demand. However, many cities neglected adjusting LTCI premiums since the pilot, risking the long-term sustainability of LTCI. Therefore, using Zhejiang Province as a case, this study simulated mortality-adjusted long-term care demand and the balance of LTCI funds through dynamic financing mechanism under diverse life expectancy and disability scenarios.

METHODS

Three-parameter log-quadratic model was used to estimate the mortality from 1990 to 2020. Mortality with predicted interval from 2020 to 2080 was projected by Lee-Carter method extended with rotation. Cohort-component projection model was used to simulate the number of older population with different degrees of disability. Disability data of the older people is sourced from China Health and Retirement Longitudinal Study 2018. The balance of LTCI fund was simulated by dynamic financing actuarial model.

RESULTS

Life expectancy of Zhejiang for male (female) is from 80.46 (84.66) years in 2020 to 89.39 [86.61, 91.74] (91.24 [88.90, 93.25]) years in 2080. The number of long-term care demand with severe disability in Zhejiang demonstrates an increasing trend from 285 [276, 295] thousand in 2023 to 1027 [634, 1657] thousand in 2080 under predicted mean of life expectancy. LTCI fund in Zhejiang will become accumulated surplus from 2024 to 2080 when annual premium growth rate is 5.25% [4.20%, 6.25%] under various disability scenarios, which is much higher than the annual growth of unit cost of long-term care services (2.25%). The accumulated balance of LTCI fund is sensitive with life expectancy.

CONCLUSIONS

Dynamic growth of LTCI premium is essential in dealing with current deficit around 2050 and realizing Zhejiang's LTCI sustainability in the long-run. The importance of dynamic monitoring disability and mortality information is emphasized to respond immediately to the increase of premiums. LTCI should strike a balance between expanding coverage and controlling financing scale. This study provides implications for developing countries to establish or pilot LTCI schemes.

Spatial-temporal distribution of preterm birth in China, 1990-2020: A systematic review and modelling analysis

BACKGROUND

Little is known about the long-term trends of preterm birth rates in China and their geographic variation by province.

OBJECTIVES

To estimate the annual spatial-temporal distribution of preterm birth rates in China by province from 1990 to 2020.

DATA SOURCES

We searched PubMed, EMBASE, Web of Science, CNKI, WANFANG and VIP from January 1990 to September 2023.

STUDY SELECTION AND DATA EXTRACTION

Studies that provided data on preterm births in China after 1990 were included. Data were extracted following the Guidelines for Accurate and Transparent Health Estimates Reporting.

SYNTHESIS

We assessed the quality of each survey using a 9-point checklist. We estimated the annual preterm birth risk by province using Bayesian multilevel logistic regression models considering potential socioeconomic, environmental, and sanitary predictors.

RESULTS

Based on 634 survey data from 343 included studies, we found a gradual increase in the preterm birth risk in most provinces in China since 1990, with an average annual increase of 0.7% nationally. However, the preterm birth rates in Inner Mongolia, Hubei, and Fujian Province showed a decline, while those in Sichuan were quite stable since 1990. In 2020, the estimates of preterm birth rates ranged from 2.9% (95% Bayesian credible interval [BCI] 2.1, 3.8) in Inner Mongolia to 8.5% (95% BCI 6.6, 10.9) in Jiangxi, with the national estimate of 5.9% (95% BCI 4.3, 8.1). Specifically, some provinces were identified as high-risk provinces for either consistently high preterm birth rates (e.g. Jiangxi) or relatively large increases (e.g. Shanxi) since 1990.

CONCLUSIONS

This study provides annual information on the preterm birth risk in China since 1990 and identifies high-risk provinces to assist in targeted control and intervention for this health issue.

Maximising the potential of Chinese birth cohort studies: a systematic review of mother-baby cohorts in mainland China

OBJECTIVES

There is now a growing interest in early-life influences on adult diseases in China. A number of birth cohorts have been established. This systematic review provided a better understanding of the development of mother-baby cohorts in China.

STUDY DESIGN

Systematic review.

METHODS

We conducted a systematic review for research or profile papers in English/Chinese that reported data from mother-baby cohorts in mainland China, with ≥1y follow-up after birth. We identified 315 papers, corresponding to 31 cohorts from 19 provinces/megacities.

RESULTS

All cohorts started in 1999-2017 (21 after 2010) and were set up with broad objectives or specific scientific focus. The baseline sample size varied, from <500 to >300,000 mothers. A majority of cohorts were initiated during pregnancy and followed children to <10y, only six to adolescence and none into adulthood. These cohorts mostly collected samples from mothers and babies, in addition to using interviews/questionnaires to collect information about pregnancy, birth and child health. Most cohorts were recruited from a single province/city. The large western region was understudied.

CONCLUSIONS

Mother-baby cohorts have developed rapidly in China, but usually with a short follow-up duration. Extending the follow-up of children and developing cross-cohort collaboration will increase the diversity, size and coverage of the sample, allow studying early influences on life-course health and identify targets for early intervention in the Chinese population.

Under-5, infant, and neonatal mortality trends and causes of death, 1991-2022: Findings from death surveillance in Xicheng district of Beijing, China

Overall, China has made substantial progress in improving child survival over the past few decades, but a detailed understanding of child mortality trend at local level is limited. This study aimed to present a comprehensive analysis of under-5, infant, and neonatal mortality rates and its trend in Xicheng district of Beijing, China. We used the surveillance data of under-5 children reported by Preventive Health Department of Xicheng District Community Health Service Center from 1991 to 2022. The data was collected based on the Child Death Reporting Card of the Beijing Under-5 Mortality Rate Surveillance Network. Data check was performed by each community health service center and related medical institutions. We extracted data included maternal age, date of death, date of birth, gender, census register, classification of any causes of death, and utilization of healthcare services before death and doubly input it in the Excel 2016 program. Categorization of the causes of death was adapted by the International Categorization of Diseases (ICD-10). Mortality rates and distribution of the leading causes of death were analyzed with descriptive statistics and the Pearson's Chi-square test using SAS 14.0 software. The Chi-square trend test was used to explore the trends in mortality. Interrupted time series analysis (ITSA) was conducted to assess the impact of the two-child policy on mortality using STATA statistical packages. From 1991 to 2022, totally, there were 166,061 live births and 793 (4.78 ‰) under-5 deaths. The mortality rates of under-5 children, infants and neonates in Xicheng district decreased from 14.75 ‰, 11.25 ‰ and 8.00 ‰ to 1.03 ‰, 0.83 ‰ and 0.41 ‰ respectively. All mortality rates showed an overall significant decline trend (χ2 trend for neonatal = -15.8136, P trend for neonatal < 0.001; χ2 trend for infant = -17.6652, P trend for infant < 0.001; χ2 trend for under-5 = -18.9103, P trend for under-5 < 0.001). The leading causes of death among under-5 children were congenital heart disease (1.65 ‰), birth asphyxia (1.44 ‰), and other congenital abnormalities (except congenital heart disease and down's syndrome) (1.36 ‰). ITSA results showed that the two-child policy did not change the overall decreased trend of child mortality rates. Future preventive measures for child healthcare should give a priority for congenital heart disease, birth asphyxia, and other congenital abnormalities.

National and subnational trends in cancer burden in China, 2005-20: an analysis of national mortality surveillance data

BACKGROUND

Cancer has been the leading cause of death since 2010 in China, with increasing incidence, mortality, and burden. We aimed to assess national and subnational changes in the cancer burden from 2005 to 2020 in China using data from the National Mortality Surveillance System.

METHODS

We extracted data on cancer-related deaths from the National Mortality Surveillance System, which accounts for 24·3% of the country's population with national and provincial representativeness. Data for the surveillance population stratified by age and sex were extracted from the National Bureau of Statistics of China. We estimated mortality and years of life lost (YLLs) for all cancers and for 23 cancer groups by age and sex, nationally, and for 31 provinces in China between 2005 and 2020. We calculated age-standardised mortality and YLL rates using the China 2020 census as the reference population. Average annual percent changes in age-standardised rates for mortality and YLLs were calculated to assess trends over the study period. Decomposition analysis was used to assess the drivers of changes in cancer-related death due to three explanatory components: population growth, population ageing, and age-specific mortality rates in China.

FINDINGS

The total number of cancer-related deaths increased by 21·6% to 2 397 772 and YLLs increased by 5·0% to 56 598 975 between 2005 and 2020. The three leading fatal cancer types remained stable for both sexes over the study period: tracheal, bronchus, and lung cancer; liver cancer; and stomach cancer. The fourth and fifth leading cancers also remained stable among males (oesophageal, and colon and rectum), while colon and rectum cancer replaced oesophageal cancer as the fourth and breast cancer replaced colon and rectum cancer as the fifth leading cause of cancer-related death among females. Age-standardised mortality rates and age-standardised YLL rates for almost all cancer types (except for prostate for male and multiple myeloma for female) decreased significantly in both sexes in urban areas. Age-standardised YLL rates increased for about half of all cancers for both sexes in rural areas. Leading fatal types were leukaemia and brain and nervous system cancer in younger groups (aged 0-19 years); liver, tracheal, bronchus, and lung, or breast cancers in middle-aged groups (aged 40-59 years); and tracheal, bronchus, and lung, liver, or stomach cancers in older adults (aged ≥60 years) in 2020. The leading causes of cancer-related mortality varied for each province, with tracheal, bronchus, and lung or liver cancer at the top in 30 provinces.

INTERPRETATION

The cancer burden in China appeared to be shifting towards that in high-income countries from 2005 to 2020. Adjustments to existing health plans and actions are needed to reduce the burdens of tracheal, bronchus, and lung cancer or other leading and emerging cancers.

FUNDING

National Key Research and Development Program of China.

Tracking progress towards equitable maternal and child health in Yunnan: a systematic assessment for the Health Programme for Poverty Alleviation in China during 2015-2020

OBJECTIVES

To inform the impacts of health programmes which aimed at preventing women and children from being trapped in or returning to poverty because of illness in Yunnan, the main battlefield against poverty in China.

DESIGN

The longitudinal comparative evaluation design.

DATA COLLECTION AND ANALYSIS

National and Yunnan policy documents related to maternal and child health programmes for poverty alleviation during 2015-2020 were analysed. The changes in disparities in maternal and child health system inputs, service coverage, and health outcomes between poor and non-poor areas, as well as out-of-pocket payments between poor and non-poor populations were assessed before and after 2017.

RESULTS

In total 12 policies and 15 programmes related to poverty alleviation for poor women and children in Yunnan were summarised. As a result of health system strengthening in Yunnan, the densities of licensed doctors, nurses, obstetricians, midwives, township health workers and female village doctors had been increased substantially in poor areas, with the annual rates of 14.3%, 22.5%, 21.8%, 23.9%, 14.1% and 7.1% separately. Although disparities existed in some of service coverage between poor and non-poor areas, the health programmes had narrowed the gaps in utilisation of facility birth, caesarean section, prenatal screening and newborn screening across Yunnan (p<0.01). The out-of-pocket payments for inpatient care for serious illnesses among women and children with poverty registration had been considerably decreased to 10.0%. Paralleling the universal coverage, maternal deaths per 100 000 livebirths and child deaths per 1000 livebirths had further declined in both poor and non-poor areas, and the impacts of health programmes on closing the gaps in child survivals across Yunnan were significant (p<0.01).

CONCLUSIONS

Remarkable progress in equitable maternal and child survival has been achieved in Yunnan. The practices in Yunnan have shown the Chinese model in ending poverty by strengthening health system and implementing universal coverage with firm commitment, determined leadership, detailed blueprint and social participation.

Socioeconomic inequalities in dementia burden related to high body mass index, 2005-2018: findings from 1.25 million Chinese adults

Background

Dementia has become a major public health concern worldwide, but comprehensive assessments of dementia burden attributable to high body mass index (BMI) in China have not been done.

Methods

We used a temporal-spatial Bayesian hierarchical model to estimated BMI levels based on 1.25 million Chinese. We estimated dementia burden attributable to high BMI by age, sex, year, and socioeconomic development in terms of deaths and years of life lost (YLLs) and assessed the effect of population ageing.

Findings

The average age-standardised BMI was 24.58 kg/m2 and 24.15 kg/m2 for men and women in 2018, respectively. 12,901 (95% UI, 10,617-15,420) dementia deaths were attributable to high BMI in China in 2018, with 5417 deaths from man and 7421 deaths from woman. The attributable age-standardised YLL rates for dementia increased 27% from 2005 to 2018. The attributable age-standardised mortality rates increased with human development index. People aged 80 years and older had the highest attributable mortality rate, and the rate decreased with decreasing age. Population ageing was an important component of the increase in dementia death.

Interpretation

The rapid increase and large inequality highlighted the urgent need for evidence-based policies and interventions. We therefore call for establishing stronger anti-dementia strategies to promote the healthy ageing.

Funding

China National Key Research and Development Program, China National Science & Technology Pillar Program, and National Health Commission of the People's Republic of China.

Loss of life expectancy due to stroke and its subtypes in urban and rural areas in China, 2005-2020

Stroke is characterised by high mortality and disability rate in China. This study aimed to explore the temporal trends in years of life lost (YLL) and loss of life expectancy due to stroke and its subtypes in urban and rural areas in China during 2005-2020. Data were obtained from China National Mortality Surveillance System. Abbreviated life and stroke-eliminated life tables were generated to calculate loss of life expectancy. The YLL and loss of life expectancy due to stroke in urban and rural areas at both national and provincial level during 2005-2020 were estimated. In China, the age-standardised YLL rate due to stroke and its subtypes were higher in rural areas than in urban areas. The YLL rate due to stroke showed a downward trend in both urban and rural residents from 2005 to 2020, decreased by 39.9% and 21.5%, respectively. Loss of life expectancy caused by stroke decreased from 1.75 years to 1.70 years from 2005 to 2020. During which, loss of life expectancy due to intracerebral haemorrhage (ICH) decreased from 0.94 years to 0.65 years, while that of ischaemic stroke (IS) increased from 0.62 years to 0.86 years. A slightly upward trend was observed in loss of life expectancy caused by subarachnoid haemorrhage (SAH), from 0.05 years to 0.06 years. Loss of life expectancy due to ICH and SAH was always higher in rural areas than in urban areas, whereas that of IS was higher in urban areas than in rural areas. Rural males suffered the greatest loss of life expectancy due to ICH and SAH, while the highest loss of life expectancy caused by IS was found in urban females. Furthermore, Heilongjiang (2.25 years), Tibet (2.17 years) and Jilin (2.16 years) were found to have the highest loss of life expectancy caused by stroke in 2020. Loss of life expectancy caused by ICH and SAH was higher in western China, while the disease burden of IS was heavier in northeast China. Stroke remains a major public health problem in China, although the age-standardised YLL rate and loss of life expectancy due to stroke decreased. Evidence-based strategies should be conducted to reduce the premature death burden caused by stroke and prolong life expectancy in Chinese population.

Mortality and years of life lost due to pancreatic cancer in China, its provinces, urban and rural areas from 2005 to 2020: results from the national mortality surveillance system

BACKGROUND

Pancreatic cancer is a growing public health concern in China, and depicting it from different perspectives would provide a comprehensive understanding of its epidemiological characteristics.

METHODS

Data from the National Mortality Surveillance System (NMSS) in China was used to estimate the number of deaths, years of life lost (YLL), age-standardized mortality rate (ASMR) and age-standardized YLL rate in China, its provinces and urban-rural areas from 2005 to 2020. Joinpoint regression analysis was employed to explore the temporal trends of ASMR and age-standardized YLL rate. Decomposition analysis was conducted to assess the contribution of population growth, population aging and cause-specific mortality rate to the increment of pancreatic cancer deaths.

RESULTS

A total of 100,427 pancreatic cancer deaths and 2,166,355 pancreatic cancer related YLL were estimated in China in 2020. The overall ASMR significantly increased from 6.6/100 000 in 2005 to 7.4/100 000 in 2020, and was higher in men than that in women. Age-standardized YLL rate showed a similar trend. The mortality rates of pancreatic cancer were generally higher in northeast China than in southwest China. The highest ASMRs were found in Jilin, Zhejiang, Inner Mongolia and Anhui, and the lowest ones in Guangxi, Yunnan, Tibet, and Hainan. The disease burden due to pancreatic cancer presented a significant upward trend in rural areas and a downward trend in urban areas.

CONCLUSIONS

The burden associated with pancreatic cancer had been increasing in China from 2005 to 2020. The escalating disease burden of pancreatic cancer in rural areas necessitates the implementation of effective control and prevention measures. Relevant provinces should pay greater attention to the prevailing of pancreatic cancer, particularly those exhibiting higher mortality rates.

Estimating the exposure-response function between long-term ozone exposure and under-5 mortality in 55 low-income and middle-income countries: a retrospective, multicentre, epidemiological study

BACKGROUND

In 2021, WHO suggested new target concentration limits for long-term exposure to ambient ozone. However, the harmful effects of ozone on vulnerable children have not been sufficiently studied. We aimed to evaluate the association between long-term ozone exposure and mortality in children younger than 5 years (hereafter denoted under-5 mortality) in low-income and middle-income countries (LMICs) and to estimate this mortality burden for 97 LMICs.

METHODS

By combining information from 128 Demographic and Health Surveys, we evaluated the association between the survival status of more than 1·2 million children younger than 5 years from 2457 sampling strata in 55 LMICs and the average peak-season ozone concentration during the life course, using a fixed-effects Cox model. A non-linear exposure-response function was developed by integrating the marginal effects of within-strata variation in exposure. We extrapolated the function obtained from the 55 LMICs to estimate the under-5 mortality burden attributable to ozone exposure in 97 LMICs, in which more than 95% of global deaths in this age group occur.

FINDINGS

The fixed-effects model showed a robust association between ozone and under-5 mortality. According to the fully adjusted linear model, an increment of 10 ppb in the life-course average peak-season ozone concentration was associated with a 6·4% (95% CI 2·4-10·7) increase in the risk of under-5 mortality. The non-linear exposure-response function showed a sublinear curvature with a threshold, suggesting that the effect of ozone exposure was non-significant at concentrations lower than the first-stage interim target (100 μg/m3) recommended by WHO. Using this function, we estimate that, in 2010, long-term ozone exposure contributed to 153 361 (95% CI 17 077-276 768; 2·3% [0·3-4·1]) deaths of children younger than 5 years in 97 LMICs, which is equivalent to 56·8% of all ozone-related deaths in adults (269 785) in these countries. From 2003 to 2017, the ozone-related under-5 mortality burden decreased in most of the 97 LMICs.

INTERPRETATION

Long-term exposure to ozone concentrations higher than the WHO first-stage interim target is a risk factor for under-5 mortality, and ozone exposure contributes substantially to mortality in this age group in LMICs. Increased efforts should be made to control ambient ozone pollution as this will lead to positive health benefits.

FUNDING

Ministry of Science and Technology of the People's Republic of China and China National Natural Science Foundation.

Rapid increasing burden of diabetes and cardiovascular disease caused by high body mass index in 1.25 million Chinese adults, 2005-2018

BACKGROUND

Temporal trends and geographical variations in disease burden for diabetes mellitus (DM) and cardiovascular disease (CVD) attributable to high body mass index (BMI) in China have not been fully elucidated.

METHODS

We estimated deaths and years of life lost (YLLs) for DM and CVD attributable to high BMI by age, sex, year, and region from 2005 to 2018 based on pooled data of 1.25 million adults.

FINDINGS

Approximately 497,430 (95% uncertainty interval [UI], 470,520-525,720) deaths for DM and CVD were attributable to high BMI in China in 2018, with 453,750 deaths from CVD and 43,700 deaths from DM. Between 2005 and 2018, there was a 17.35% increase in age-standardized mortality rate for DM and CVD attributable to high BMI. The high BMI-related DM and CVD YLL rates increased from 127.46 (95% UI 108.70-148.62) per 100,000 people aged 20-24 years to 5,735.54 (95% UI 4,844.16-6,713.53) per 100,000 people aged ≥80 years, respectively. The highest age-standardized mortality rate for high BMI-related DM and CVD in northeast, northwest, and circum-Bohai Sea regions of China.

CONCLUSION

The disease burden for DM and CVD attributable to high BMI increased substantially between 2005 and 2018. Urgent measures are required at both national and regional levels for resource mobilization to slow the growing burden.

FUNDING

The work was supported by the National Key Research and Development Program of China, China National Science & Technology Pillar Program, and National Health Commission of the People's Republic of China.

The burden of cardiovascular disease attributable to dietary risk factors in the provinces of China, 2002-2018: a nationwide population-based study

Background

The burden of cardiovascular diseases (CVDs) is on the rise in China, yet a comprehensive and systematic understanding of the temporal trends and distribution of CVD burden attributable to dietary factors across the provinces remains elusive. This study endeavors to provide a comprehensive depiction of the burden of CVDs attributable to dietary risk factors across China's geographical regions from 2002 to 2018.

Methods

Data from the China National Nutrition Surveys, the China Chronic Disease and Risk Factor Surveillance, the Hypertension Survey, and the Chinese Centre for Disease Control and Prevention cause-of-death reporting system were used to estimate the intake of dietary factor, the number of deaths, and disability-adjusted life years (DALYs), mortality rate, for ischemic heart disease (IHD), ischemic stroke (IS), hemorrhage and other stroke (HOS) attributable to dietary factors at national and provincial levels in China from 2002 to 2018. Using a comparative risk assessment approach, we estimated the proportion of CVDs burden attributable to suboptimal intake of seven dietary factors, both individually and collectively, among Chinese citizens aged 20 years or older.

Finding

The mean consumption of whole grains, soybeans, nuts, vegetables, fruits, red meat, and sugar-sweetened beverages (SSBs) exhibited an upward trend from 2002 to 2018. However, with the exception of red meat and SSBs, the average intake remained below the levels recommended levels outlined in the Chinese national dietary guidelines. Inadequate fruit, whole grain, and vegetables intake were the leading dietary risk factors for IHD, IS and HOS in China, while nuts, soybean and SSB were only associated with IHD mortality. From 2002 to 2018, the number of deaths and mortality rate for CVDs attributable to suboptimal diet among Chinese males were greater than that of females. With increasing age, the diet-related mortality rate for CVDs increased substantially. In 2018, the nationwide mortality rate attributable to diet was found to be 77.9 (95% UI, 77.5-78.1) per 100,000 population for IHD, 34.1 (95% UI, 33.8-34.2) for IS, and 32.8 (95% UI, 32.4-32.8) for HOS. Suboptimal diet was responsible for 16.0 million (95% UI, 13.8-18.4) DALYs and 1137.1 (95% UI, 980.4-1312.3) DALYs per 100,000 population for stroke, and 13.9 million (95% UI, 11.8-16.3) DALYs and 990.2 (95% UI, 841.2-1158.6) DALYs for IHD. Across the provinces of China, in 2018, the highest age-standardized mortality rates of all diet-related deaths were observed in Shandong (92.8 [95% UI, 89.9-93.3]) for IHD, Heilongjiang (38.1 [95% UI, 36.2-38.8]) for IS, and Tibet (68.3 [95% UI, 65.0-70.1]) for HOS. The highest diet related DALYs were observed in Henan (1.4 million [95% UI, 1.2-1.6] for IS, and 1.3 million [95% UI, 1.1-1.5] for IHD).

Interpretation

This study provides a comprehensive picture of the geographic variation and temporal trends of the burden of CVDs attributable to dietary risk factors at the national and provincial levels from 2002 to 2018 in China, highlighting the need for geographically targeted intervention strategies to improve the quality of diet and reduce the diet-related burden of CVDs.

Funding

National Key Research and Development Program of China (2018YFC1315303), National Natural Science Foundation of China (82103966).

Current status and challenges in prenatal and neonatal screening, diagnosis, and management of congenital heart disease in China

Congenital heart disease (CHD), a wide spectrum of diseases with varied outcomes, is the most common congenital malformation worldwide. In this Series of three papers, we describe the burden of CHD in China; the development of screening, diagnosis, treatment, and follow-up strategies; and challenges associated with the disease. We also propose solutions and recommendations for policies and actions to improve the outcomes of CHD. In the first paper in this Series, we focus on prenatal and neonatal screening, diagnosis, and management of CHD. Based on advanced international knowledge, the Chinese Government has developed a network system comprising prenatal screening, diagnosis of CHD subtypes, specialist consultation appointments, and treatment centres for CHD. A new professional discipline, fetal cardiology, has been formed and rapidly developed. Consequently, the overall coverage of prenatal and neonatal screening and the accuracy of CHD diagnoses have gradually improved, and the neonatal CHD mortality rate has decreased substantially. However, China still faces several challenges in the prevention and treatment of CHD, such as insufficient diagnostic capabilities and unqualified consultation services in some regions and rural areas. TRANSLATION: For the Chinese translation of the abstract see Supplementary Materials section.

Growing old in China in socioeconomic and epidemiological context: systematic review of social care policy for older people

BACKGROUND

From 2020 to 2050, China's population aged ≥65 years old is estimated to more than double from 172 million (12·0%) to 366 million (26·0%). Some 10 million have Alzheimer's disease and related dementias, to approach 40 million by 2050. Critically, the population is ageing fast while China is still a middle-income country.

METHODS

Using official and population-level statistics, we summarise China's demographic and epidemiological trends relevant to ageing and health from 1970 to present, before examining key determinants of China's improving population health in a socioecological framework. We then explore how China is responding to the care needs of its older population by carrying out a systematic review to answer the question: 'what are the key policy challenges to China achieving an equitable nationwide long-term care system for older people?'. Databases were screened for records published between 1st June 2020 and 1st June 2022 in Mandarin Chinese or English, reflecting our focus on evidence published since introduction of China's second long-term care insurance pilot phase in 2020.

RESULTS

Rapid economic development and improved access to education has led to widescale internal migration. Changing fertility policies and household structures also pose considerable challenges to the traditional family care model. To deal with increasing need, China has piloted 49 alternative long-term care insurance systems. Our findings from 42 studies (n = 16 in Mandarin) highlight significant challenges in the provision of quality and quantity of care which suits the preference of users, varying eligibility for long-term care insurance and an inequitable distribution of cost burden. Key recommendations include increasing salaries to attract and retain staff, introduction of mandatory financial contributions from employees and a unified standard of disability with regular assessment. Strengthening support for family caregivers and improving smart old age care capacity can also support preferences to age at home.

CONCLUSIONS

China has yet to establish a sustainable funding mechanism, standardised eligibility criteria and a high-quality service delivery system. Its long-term care insurance pilot studies provide useful lessons for other middle-income countries facing similar challenges in terms of meeting the long-term care needs of their rapidly growing older populations.

Global biomass fires and infant mortality

Global outdoor biomass burning is a major contributor to air pollution, especially in low- and middle-income countries. Recent years have witnessed substantial changes in the extent of biomass burning, including large declines in Africa. However, direct evidence of the contribution of biomass burning to global health outcomes remains limited. Here, we use georeferenced data on more than 2 million births matched to satellite-derived burned area exposure to estimate the burden of biomass fires on infant mortality. We find that each additional square kilometer of burning is associated with nearly 2% higher infant mortality in nearby downwind locations. The share of infant deaths attributable to biomass fires has increased over time due to the rapid decline in other important causes of infant death. Applying our model estimates across harmonized district-level data covering 98% of global infant deaths, we find that exposure to outdoor biomass burning was associated with nearly 130,000 additional infant deaths per year globally over our 2004 to 2018 study period. Despite the observed decline in biomass burning in Africa, nearly 75% of global infant deaths due to burning still occur in Africa. While fully eliminating biomass burning is unlikely, we estimate that even achievable reductions-equivalent to the lowest observed annual burning in each location during our study period-could have avoided more than 70,000 infant deaths per year globally since 2004.

The association between parental risks and childhood development: findings from a community-based survey in East China

BACKGROUND

Nurturing care is necessary for optimal early childhood development. This study aimed to investigate the prevalence of parental risks in rural East China and assess their impacts on early development in children younger than three years old.

METHODS

This community-based cross-sectional survey was conducted among 3852 caregiver-child pairs in Zhejiang Province from December 2019 to January 2020. Children aged 0 to 3 years were recruited from China's Early Childhood Development Program (ECD). Local child health care providers conducted face-to-face interviews with the primary caregivers. Demographic information of the participants was collected by questionnaire. Each child was screened for parental risk through the Parental Risk Checklist designed by the ECD program. The Ages and Stages Questionnaire (ASQ) was used to identify children with potential developmental delays. Multinomial logistic regression model and linear trend test were applied to assess the association between parental risks and suspected developmental delays.

RESULTS

Among the 3852 children included in the analyses, 46.70% had at least one parental risk and 9.01% presented suspected developmental delays in any domain of ASQ. Parental risk was statistically associated with the overall suspected developmental delay in young children (Relative Risk Ratio (RRR): 1.36; 95% confidence interval (CI): 1.08, 1.72; P = 0.010) after adjusting potential confounders. Compared with children with no parental risk, children exposed to 3 or more parental risks had 2.59, 5.76, 3.95, and 2.84 times higher risk of the suspected developmental delay in overall ASQ, communication, problem-solving, and personal-social domain, respectively (P values < 0.05). The linear trend tests found that the more parental risks, the higher possibility of developmental delay (P values < 0.05).

CONCLUSIONS

Parental risks are prevalent among children under three years in rural East China, which may increase the risk of developmental delays in children. Meanwhile, parental risk screening can be used to recognize poor nurturing care in primary health care settings. Targeted interventions are warranted to improve nurturing care for optimal early childhood development.

The Pediatrician Workforce in the United States and China

From 2019 to 2022, the For Our Children project gathered a team of Chinese and American pediatricians to explore the readiness of the pediatric workforce in each country to address pressing child health concerns. The teams compared existing data on child health outcomes, the pediatric workforce, and education and combined qualitative and quantitative comparisons centered on themes of effective health care delivery outlined in the World Health Organization Workforce 2030 Report. This article describes key findings about pediatric workload, career satisfaction, and systems to assure competency. We discuss pediatrician accessibility, including geographic distribution, practice locations, trends in pediatric hospitalizations, and payment mechanisms. Pediatric roles differed in the context of each country's child health systems and varied teams. We identified strengths we could learn from one another, such as the US Medical Home Model with continuity of care and robust numbers of skilled clinicians working alongside pediatricians, as well as China's Maternal Child Health system with broad community accessibility and health workers who provide preventive care.In both countries, notable inequities in child health outcomes, evolving epidemiology, and increasing complexity of care require new approaches to the pediatric workforce and education. Although child health systems in the United States and China have significant differences, in both countries, a way forward is to develop a more inclusive and broad view of the child health team to provide truly integrated care that reaches every child. Training competencies must evolve with changing epidemiology as well as changing health system structures and pediatrician roles.

Trends of Incidence, Mortality, and Risk Factors for Lower Respiratory Infections among Children under 5 Years in China from 2000 to 2019

BACKGROUND

Understanding the temporal trends in the burden of lower respiratory tract infections (LRI) and their attributable risk factors in children under 5 years is important for effective prevention strategies.

METHODS

We used incidence, mortality, and attributable risk factors of LRI among children under 5 years from the Global Burden of Diseases database to analyze health patterns in 33 provincial administrative units in China from 2000 to 2019. Trends were examined using the annual average percentage change (AAPC) by the joinpoint regression method.

RESULTS

The rates of incidence and mortality for under-5 LRI in China were 18.1 and 4134.3 per 100,000 children in 2019, with an AAPC decrease of 4.1% and 11.0% from 2000, respectively. In recent years, the under-5 LRI incidence rate has decreased significantly in 11 provinces (Guangdong, Guangxi, Guizhou, Hainan, Heilongjiang, Jiangxi, Qinghai, Sichuan, Xinjiang, Xizang, and Zhejiang) and remained stable in the other 22 provinces. The case fatality ratio was associated with the Human Development Index and the Health Resource Density Index. The largest decline in risk factors of deaths was household air pollution from solid fuels.

CONCLUSIONS

The burden of under-5 LRI in China and the provinces has declined significantly, with variation across provinces. Further efforts are needed to promote child health through the development of measures to control major risk factors.

Association of perinatal factors with suspected developmental delay in urban children aged 1-36 months - a large-scale cross-sectional study in China

BACKGROUND

Studies on perinatal risk factors and the developmental delay of children have been inconclusive and few studies have assessed the association between infants and toddlers' body mass index (BMI) and developmental outcomes.

METHODS

We conducted a cross-sectional study of children aged 1-36 months who had a routine physical examination in the child health departments of hospitals from March 2018 to November 2021 in 16 provinces, 4 autonomous regions and 2 municipalities directly under the central government by using the Infant Toddler Growth Development Screening Test (ITGDST). Normal children were defined as those with scores ≥ mean - 2 standard deviations (SD), while children with developmental delay were those with scores < mean-2SD in terms of overall development, gross motor, fine motor and language development. Binary logistic regression was used to analyze the risk factors of gross motor, fine motor, language and overall neurodevelopment.

RESULTS

After removing some provinces with a small sample size and children with incomplete data, 178,235 children with 12 complete variables were included in the final analysis. The rate of overall developmental delay was 4.5%, while 12.5% of children had at least one developmental delay aspect. Boys, parity, advanced maternal age, multiple birth, cesarean section, neonatal injury, family heredity history, microcephaly, abnormal BMI at birth and at physical examination after controlling the confounding of other factors had a significant effect on development delay (overall neurodevelopment, gross motor, fine motor or language development). Per capita gross domestic product was a protective factor for the children's neuropsychological development.

CONCLUSIONS

This study reveals significant associations of perinatal factors and BMI with developmental delay in the Chinese children aged 1-36 months, which may be crucial for early intervention.

Burden and trend of cardiovascular diseases among people under 20 years in China, Western Pacific region, and the world: An analysis of the global burden of disease study in 2019

Objectives

Cardiovascular disease (CVD) is a global public health concern, but its disease burden and trend have been poorly studied in people younger than 20 years. This study aimed to fill this gap by evaluating the CVD burden and trend in China, Western Pacific Region, and the world from 1990 to 2019.

Methods

We applied the 2019 Global Burden of Diseases (GBD) analytical tools to compare the incidence, mortality, and prevalence of CVD, years lived with disability (YLDs), years of life lost (YLLs), and disability-adjusted life years (DALYs) among people younger than 20 years from 1990 to 2019 in China, the Western Pacific Region, and the world. The trends of disease burden between 1990 and 2019 evaluated using the average annual percent change (AAPC) and the 95% uncertainty interval (UI) were reported.

Results

Globally, in 2019, there were 2.37 (95% UI: 1.82 to 3.05) million incidence of CVD, 16.85 (95% UI: 12.56 to 22.03) million prevalence of CVD, and 74386.73 (95% UI: 64543.82 to 86310.24) deaths due to CVD among people under 20 years of age. The trends for DALYs decreased among children and adolescents in China, Western Pacific Region, and the world (AAPC = -4.29, 95% CI: -4.38% to -4.20%; AAPC = -3.37, 95% CI: -3.48% to -3.26%; AAPC = -2.17, 95% CI: -2.24% to -2.09%; p < 0.001, respectively) between 1990 and 2019. With the increase in age, the AAPC values of mortality, YLLs, and DALYs showed a notable downward trend. The AAPC values of mortality, YLLs, and DALYs in female patients were significantly greater than those in male patients. For all subtypes of CVD, the AAPC values showed a downward trend, with the largest reduction observed for stroke. From 1990 to 2019, a decline in the DALY rate for all CVD risk factors was observed, with a significant decrease in environmental/occupational risk factors.

Conclusion

Our study shows a decline in the burden and trend of CVD among people younger than 20 years, which reflects the success in reducing disability, premature death, and the early incidence of CVD. More effective and targeted preventive policies and interventions aimed at mitigating preventable CVD burden and addressing risk factors from childhood are urgently needed.

Effectiveness of early essential newborn care implementation in four counties of western China

Background

Neonatal survival is a public health concern globally. However, the regional disparity in neonatal mortality between rural counties of western China and urban areas of eastern provinces remains high. Early essential newborn care (EENC), recommended by World Health Organization, refers to a set of cost-effective interventions to improve neonatal health and development outcomes. In this study, we aimed to explore the effectiveness of EENC implementation in four counties of western China.

Methods

Pre- and post-intervention investigations were conducted in four selected EENC intervention counties and four control counties of four western provinces of China, from June to August 2017 and from December 2020 to April 2021 respectively. A mixed quantitative and qualitative approach was used for data collection and analysis. Data on the coverage of EENC practices were collected via a post-intervention face-to-face questionnaire survey with postpartum mothers before hospital discharge. Hospital-reported data on neonatal health indicators were obtained through mail surveys in both investigations. We also performed semi-structured interviews with policymakers, health staff and postpartum mothers to understand their perceptions about the usefulness of EENC implementation.

Results

Overall, 599 mother-newborn pairs in the intervention group and 699 pairs in the control group participated in the post-intervention survey. Controlling for the confounding factor of province, the proportion of newborns receiving EENC interventions was higher in the intervention group than in the control group (P < 0.05). Intervention groups in four provinces had higher coverage of: any skin-to-skin contact (99.50% vs. 49.07%); early breastfeeding initiation (within 60 min of birth) (90.84% vs. 80.35%); no medicine applied to the umbilical cord (98.50% vs. 9.73%); routine eye care (93.16% vs. 8.73%); and vitamin K₁ administration (98.33% vs. 88.98%). EENC implementation was associated with decreased risk of neonatal diarrhea (OR: 0.326, 95% CI: 0.123, 0.865) and eye infection (OR: 0.147, 95% CI: 0.045, 0.483). Policymakers, health staff and postpartum mothers expressed satisfaction with the EENC interventions, noting a willingness among staff and policymakers to implement and sustain these interventions; the promotion of these interventions within hospital policy; the positive emotions experienced by postpartum mothers; perceived improvements in health; and improvements in support for health workers.

Conclusion

EENC-recommended core practices (except kangaroo mother care) have been successfully introduced in pilot hospitals. The efficacy of EENC implementation should be highly recognized to accelerate the progress towards its national roll out.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08570-6.

Outcome of neonatal hypoxemic respiratory failure: a livebirth population-based retrospective survey

Background

To explore the prevalence, outcome and perinatal risks of neonatal hypoxemic respiratory failure (NRF) in a survey of all livebirths from a regional network of perinatal-neonatal care during the transition period after 5-year universal health insurance implemented in China.

Methods

Clinical data of all neonatal respiratory morbidities in Huai’an were retrospectively collected in the regional perinatal network database of all livebirths as vital statistics in 2015. NRF was defined as hypoxemia requiring continuous positive airway pressure (CPAP) and/or mechanical ventilation (MV) for at least 24 h. Mortality risks of antenatal and perinatal morbidities, major respiratory therapies and complications were analyzed by multivariable logistic regression model.

Results

There were 788 NRF cases identified in 9.9% (7960) hospitalized, or 13.3‰ (59056) livebirths, in which 6.7% received intensive care and 93.0% critical care. The major underlying morbidities were respiratory distress syndrome (RDS, 36.4%) and pneumonia/sepsis (35.3%), treated mainly by CPAP, MV and surfactant. Significantly improved outcomes by surfactant in RDS were in patients with birthweight (BW) < 1500 g or gestational age (GA) < 32 weeks. The overall mortality rate in NRF was 18.4% whereas for those of BW < 1000 g and GA < 28 weeks, 70% and 54%, respectively. The multivariable regression analysis showed the highest odds for NRF death among meconium aspiration syndrome, congenital anomalies, BW < 1500 g and necrotizing enterocolitis, whereas born in level III hospitals, cesarean delivery, CPAP and MV were associated with markedly reduced death odds.

Conclusions

The salient findings with associated risk estimates reflected efficiency of respiratory support as critical care in a prefectural regional network infrastructure for annual livebirths in 5.6 million inhabitants. It implicated the representativeness of contemporaneous perinatal-neonatal care standard at medium to medium-high level, in one/fourth of the population of China, aiming at saving more life of very critical and preterm infants for better survival.

Spatial variations and social determinants of life expectancy in China, 2005-2020: A population-based spatial panel modelling study

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).

Empirical dynamic modeling of the association between ambient PM2.5 and under-five mortality across 2851 counties in Mainland China, 1999-2012

BACKGROUND

Ambient fine particulate matter (PM_2.5) pollution has been associated with mortality from various diseases, however, its association with under-five mortality rate (U5MR) has remained largely unknown.

METHODS

Based on the U5MR data across 2851 counties in Mainland China from 1999 to 2012, we employed approximate Bayesian latent Gaussian models to assess the association between ambient PM_2.5 and U5MR at the county level for the whole nation and sub-regions. GDP growth rate, normalized difference vegetation index (NDVI), temperature, and night-time light were included as covariates using a smoothing function. We further implemented an empirical dynamic model (EDM) to explore the potential causal relationship between PM_2.5 and U5MR.

RESULTS

We observed a declining trend in U5MR in most counties throughout the study period. Spatial heterogeneity in U5MR was observed. Nationwide analysis suggested that each 10 µg/m³ increase in annual concentration of PM_2.5 was associated with an increase of 1.2 (95% CI: 1.0 - 1.3) per 1000 live births in U5MR. Regional analyses showed that the strongest positive association was located in the Northeastern part of China [1.8 (95% CI: 1.4 - 2.1)]. The EDM showed a significant causal association between PM_2.5 and U5MR, with an embedding dimension of 5 and 7, and nonlinear values θ of 4 and 6, respectively.

CONCLUSION

China exhibited a downward trend in U5MR from 1999 to 2012, with spatial heterogeneity observed across the country. Our analysis reveals a positive association between PM_2.5 and U5MR, which may support a causal relationship.

Cohort profile: the Taicang and Wuqiang mother-child cohort study (TAWS) in China

PURPOSE

The Taicang and Wuqiang cohort study (TAWS) was established to examine the association between early-life nutrition and children's health, and to explore the potential roles of maternal health, metabolites and microbiota in children's health in two different regions of China.

PARTICIPANTS

A total of 7041 mother-child pairs were recruited during early pregnancy (n=4035, 57.3%) or delivery phase (n=3006, 42.7%) from health centres or hospitals in Taicang and Wuqiang. Mother-child pairs were followed up three times during pregnancy, once during delivery, and 7-10 times in the 3 years after delivery. Questionnaires were used to collect data on diet, supplementary intake, physical activity, depression scale, disease occurrence, feeding practice and development quotient of children. Anthropometric measurements of mothers and their children were assessed at each visit. Pregnancy outcomes were extracted from medical records. Biospecimens were collected and stored, including venous blood, cord blood, urine, stool, breast milk, cord and placenta.

FINDINGS TO DATE

Data from the TAWS cohort showed different baseline characteristics of participants at the two sites of TAWS. Abnormal metabolism occurred among newborns whose mothers were diagnosed with gestational diabetes mellitus. Maternal serum folic acid above 14.5 ng/mL at early pregnancy was associated with a reduced risk of delivering small-for-gestational-age newborns.

FUTURE PLANS

The association between maternal nutrition and the health of offspring will be examined at various follow-up visits. Biomarkers will be analysed to assess the associations between early-life nutrition and child development, immunity and health. Strategic recommendations for optimal infant feeding practices, obesity prevention and routine healthcare items will be developed and proposed based on the findings from the study. Children in this prospective cohort study will be followed up once a year until age 12 years to further examine the relationships between early-life nutrition and children's long-term development and health.

Preterm delivery rate in China: a systematic review and meta-analysis

BACKGROUND

Preterm delivery rate is a crucial public health indicator, yet reliable statistic is currently not available in China. In this systematic review and meta-analysis, we aimed to review studies on preterm delivery rate in China, explore sources of heterogeneity, and estimate the preterm delivery rate in China.

METHODS

Published studies on preterm delivery rate in China since 2010 were electronically searched from PubMed, Embase, Web of Science, China National Knowledge Infrastructure, China Science and Technology Journal Database, and Wanfang Database, and complemented by manual search. Study selection, data extraction, and quality and bias assessment (using the Joanna Briggs Institute Critical Appraisal Checklist) were conducted by two reviewers independently. Random-effects meta-analysis was performed to estimate the pooled preterm delivery rate, and prespecified stratified analysis was conducted to explore sources of heterogeneity.

RESULTS

The database search returned 4494 articles and manual search identified 10 additional studies. In total, 162 studies were eligible, of which 124 were hospital-based and 38 population-based. The pooled preterm delivery rate of hospital-based studies (7.2%; 95% CI: 6.9% to 7.6%) was significantly higher than that of population-based studies (4.9%; 95% CI: 4.5% to 5.4%) (P for subgroup difference < 0.001). Among population-based studies, the rate tended to differ by geography (P for subgroup difference = 0.07): 5.3% for Eastern, 4.6% for Central, and 3.8% for Western.

CONCLUSIONS

According to population-based studies, the preterm delivery rate in China is around 5%. This rate is substantially lower than estimates from hospital-based studies or estimates from a combination of both hospital-based and population-based studies as having been done in previous studies.

Preterm delivery rate in China: a systematic review and meta-analysis

BACKGROUND

Preterm delivery rate is a crucial public health indicator, yet reliable statistic is currently not available in China. In this systematic review and meta-analysis, we aimed to review studies on preterm delivery rate in China, explore sources of heterogeneity, and estimate the preterm delivery rate in China.

METHODS

Published studies on preterm delivery rate in China since 2010 were electronically searched from PubMed, Embase, Web of Science, China National Knowledge Infrastructure, China Science and Technology Journal Database, and Wanfang Database, and complemented by manual search. Study selection, data extraction, and quality and bias assessment (using the Joanna Briggs Institute Critical Appraisal Checklist) were conducted by two reviewers independently. Random-effects meta-analysis was performed to estimate the pooled preterm delivery rate, and prespecified stratified analysis was conducted to explore sources of heterogeneity.

RESULTS

The database search returned 4494 articles and manual search identified 10 additional studies. In total, 162 studies were eligible, of which 124 were hospital-based and 38 population-based. The pooled preterm delivery rate of hospital-based studies (7.2%; 95% CI: 6.9% to 7.6%) was significantly higher than that of population-based studies (4.9%; 95% CI: 4.5% to 5.4%) (P for subgroup difference < 0.001). Among population-based studies, the rate tended to differ by geography (P for subgroup difference = 0.07): 5.3% for Eastern, 4.6% for Central, and 3.8% for Western.

CONCLUSIONS

According to population-based studies, the preterm delivery rate in China is around 5%. This rate is substantially lower than estimates from hospital-based studies or estimates from a combination of both hospital-based and population-based studies as having been done in previous studies.

National, regional, and provincial disease burden attributed to Streptococcus pneumoniae and Haemophilus influenzae type b in children in China: Modelled estimates for 2010-17

Background

Vaccination against Streptococcus pneumoniae (pneumococcus) and Haemophilus influenzae type b (Hib) is not included in China's national immunization programme. To inform China's immunization polices, we estimated annual national, regional, and provincial childhood mortality and morbidity attributable to pneumococcus and Hib in 2010-17.

Methods

We estimated proportions of pneumonia and meningitis deaths and cases attributable to pneumococcus and Hib using evidence from vaccine clinical trials and surveillance studies of bacterial meningitis and pathogen-specific case fatality ratios (CFR). Then we applied the proportions to model provincial-level pneumonia cases and deaths, meningitis deaths and meningitis CFR in children aged 1-59 months, accounting for vaccine coverage. Non-pneumonia, non-meningitis (NPNM) invasive disease cases were derived by applying NPNM meningitis ratios to meningitis estimates.

Findings

In 2010-17, annual pneumococcal deaths fell by 49% from 15 600 (uncertainty range: 10 800-17 300) to 8 000 (5 500-8 900), and Hib deaths fell by 56% from 6 500 (4 500-8 800) to 2 900 (2 000-3 900). Severe pneumococcal and Hib cases decreased by 16% to 218 200 (161 500-252 200) in 2017 and 29% to 49 900 (29 000-99 100). Estimated 2017 national three-dose coverage in private market was 1·3% for PCV and 33·4% for Hib vaccine among children aged 1-59 months. Provinces in the west region had the highest disease burden.

Interpretation

Childhood mortality and morbidity attributable to pneumococcal and Hib has decreased in China, but still substantially varied by region and province. Higher vaccine coverage could further reduce disease burden.

Funding

Bill & Melinda Gates Foundation.

Perinatal Risks of Neonatal and Infant Mortalities in a Sub-provincial Region of China: A Livebirth Population-based Cohort Study

BACKGROUND

Current vital statistics of birth population and neonatal outcome in China lacked information and definition of deaths at delivery and during hospitalization, especially for extreme preterm (EPT) birth. This study aims to delineate the prevalence of neonatal hospitalization, neonatal and infant mortality rates (NMR, IMR) and associated perinatal risks based on all livebirths in Huai'an, an evolving sub-provincial region in eastern China.

METHODS

This retrospective cohort study established a comprehensive database linking information of whole regional livebirths and neonatal hospitalization in 2015, including deaths at delivery and EPT livebirths. The primary outcomes were NMR and IMR stratified by gestational age (GA) and birthweight (BW) with 95% confidence intervals. Causes of the neonatal and infant deaths were categorized according to the International Statistical Classification of Diseases 10th version, and population attributable fractions of GA and BW strata were analyzed. Perinatal risks of infant mortalities in continuum periods were estimated by Cox regression models.

RESULTS

Among the whole livebirth population (59056), 7960 were hospitalized (prevalence 13.5%), with 168 (2.8‰) in-hospital deaths. The NMR was 3.6 (3.2, 4.1)‰ and IMR 4.9 (1.4, 4.5)‰, with additionally 35 (0.6‰) deaths at delivery. The major causes of infant deaths were perinatal conditions (2.6‰, mainly preterm-related), congenital anomalies (1.5‰), sudden unexpected death in infancy (0.6‰) and other causes (0.2‰). The deaths caused by preterm and low BW (LBW) accounted for 50% and 40% of NMR and IMR, with 20-30% contributed by EPT or extremely LBW, respectively. Multivariable Cox regression analysis revealed that peripartum factors and LBW strata had strong association with early- and late-neonatal deaths, whereas those of GA < 28 weeks were highly associated with postneonatal deaths. Congenital anomalies and neonatal hospitalization remained high death risks over the entire infancy, whereas maternal co-morbidities/complications were modestly associated with neonatal but not postneonatal infant mortality.

CONCLUSIONS

The NMR, IMR, major causes of deaths and associated perinatal risks in continuum periods of infancy, denote the status and quality improvement of the regional perinatal-neonatal care associated with socioeconomic development. The study concept, applicability and representativeness may be validated in other evolving regions or countries for genuine comparison and better maternal-infant healthcare.

Prevalence of major morbidities and outcome of all hospitalized neonates. A retrospective cohort study of Huai'an neonatal survivals

BACKGROUND

Reliable data for causal implication of neonatal survival in China are lacking. We assumed that by analyzing surviving data of in-hospital neonatal care based on all livebirths in Huai'an, prevalence of neonatal morbidity, mortality and causal relations may be derived comprehensively.

MATERIALS AND METHODS

Data of all regionally hospitalized neonates were retrospectively linked with corresponding whole livebirths (59,056) in 2015 as a cohort. Diagnoses of diseases and causes of deaths were redefined and categorized. Disease patterns, prevalence of morbidities, case-fatality rate (CFR), and cause-specific mortality rate (CSMR) referring to livebirths were presented. Perinatal and disease-specific risks of death were estimated by multivariable logistic regression.

RESULTS

In 7,960 (134.8‰) hospitalized patients, 168 (2.1%) died in hospital (2.85‰ of livebirths). Prevalence of major morbidities were 76.8‰ hyperbilirubinemia, 57.4‰ pneumonia, 32.7‰ intraventricular hemorrhage, 20.7‰ sepsis, 20.2‰ birth asphyxia, 9.69‰ congenital anomalies (CA), and 5.30‰ respiratory distress syndrome (RDS). The CFR (CSMR) of major diseases were 30.4% (0.12‰) meconium aspiration syndrome, 17.6% (0.22‰) necrotizing enterocolitis, 14.1% (0.75‰) RDS, 9.09% (0.88‰) CA, 5.26% (0.07‰) bronchopulmonary dysplasia, 1.71% (0.36‰) sepsis and 1.51% (0.31‰) asphyxia. Overall mortality rates were 4.6% and 6.8% in the preterm and low birthweight, and >50% in those of <28 week gestation or <1000 g birthweight, respectively. Mortality risks associated with the perinatal and neonatal morbidities were markedly declined with variable magnitude by multivariable regression models.

CONCLUSIONS

The in-hospital neonatal survival datafile, depicted as the prevalence of major morbidities and CSMR of livebirth population in Huai'an, denoted overall and specific quality and efficiency of the perinatal-neonatal care system. Its concept and methodology should be relevant, and outcome extrapolated, to other countries or domestic regions, with similar socioeconomic development.

Reductions in under-5 mortality and public health improvements of the China Healthy Cities (Counties) initiative: a nationwide quasi-experimental study

INTRODUCTION

The China Healthy Cities (Counties) public health initiative has been at the forefront of China's efforts to counteract the growing challenges in the urban environment since the 1990s. It primarily focuses on improving the urban living environment. However, the nationwide health impacts of the initiative remain unexplored.

METHODS

We constructed nationwide county-level and city-level panel data from 1996 to 2012 using data on under-5 mortality rates (U5MR), the list of China healthy cities and counties and socioeconomic factors. We used a two-step staggered difference-in-differences approach that exploits variations in the timing of achieving the title of China Healthy City/County. Subgroup analyses by region were performed.

RESULTS

We included 707 cities in the China Healthy Cities study, and 1631 counties in the China Healthy Counties study. Our results indicate substantial and significant reductions in U5MR associated with the public health initiative in China. The association varies across regions with different socioeconomic statuses. China Healthy Cities were significantly associated with a reduction of 0.7/1000 (95% CI -1.2 to -0.2) in under-5 mortality 5 years after cities gained the title and a decrease of 1.4/1000 (95% CI -2.2 to -0.6) 10 years afterward. Cities from western China saw the largest statistically significant gains with 3.2/1000 and 7.2/1000 reductions in child mortality after 5 and 10 years, respectively. China Healthy Counties were also associated with significant reductions in under-5 mortality 8 years after achieving the title; it was associated with 2.6/1000 reductions in under-5 mortality nationwide and 3.8/1000 reductions in eastern China. Our results are robust to heterogeneous treatment effects across cities/counties over time and various model specifications.

CONCLUSION

Our results suggest significant reductions in under-5 mortality associated with this public health intervention focusing on living environment conditions. Future research could explore differential effects across regions and clarify the underlying causal mechanisms.

Global trends in incidence and death of neonatal disorders and its specific causes in 204 countries/territories during 1990–2019

Background

Neonatal disorders (ND) are a significant global health issue. This article aimed to track the global trends of neonatal disorders in 204 countries/territories from 1990 to 2019.

Methods

Data was explored from the Global Burden of Disease study 2019. Estimated annual percentage change (EAPC) and age-standardized rate (ASR) were calculated to quantify the trends of neonatal disorders and their specific causes, mainly included neonatal preterm birth (NPB), neonatal encephalopathy due to birth asphyxia and trauma (NE), neonatal sepsis and other neonatal infections (NS), and hemolytic disease and other neonatal jaundice (HD).

Results

In 2019, there were 23,532.23 × 10³ incident cases of ND, and caused 1882.44 × 10³ death worldwide. During 1990–2019, trends in the overall age-standardized incidence rate (ASIR) of ND was relatively stable, but that of age-standardized death rate (ASDR) declined (EAPC = -1.51, 95% confidence interval [CI]: -1.66 to -1.36). Meanwhile, decreasing trends of ASDR were observed in most regions and countries, particularly Cook Islands and Estonia, in which the respective EAPCs were -9.04 (95%CI: -9.69 to -8.38) and -8.12 (95%CI: -8.46 to -7.77). Among the specific four causes, only the NPB showed decreasing trends in the ASIR globally (EAPC = -0.19, 95%CI: -0.26 to -0.11). Decreasing trends of ASDR caused by ND underlying specific causes were observed in most regions, particularly the HD in Armenia, with the EAPC was -13.08 (95%CI: -14.04 to -12.11).

Conclusions

Decreasing trends of death caused by neonatal disorders were observed worldwide from 1990 to 2019. However, the burden of neonatal disorders is still a considerable challenge, especially in low-resource settings, which need more effective health strategies.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-12765-1.

Epidemiology and region-specific risk factors for low Apgar scores in China: a nationwide study

BACKGROUND

Neonatal asphyxia is a serious public health issue. This study aimed to determine the epidemiology and region-specific risk factors for low Apgar scores, an important proxy for neonatal asphyxia, in China from 2015 to 2016.

METHODS

The China Labor and Delivery Survey was a multicenter cross-sectional study including 96 hospitals distributed in 24 (out of 34) provinces. Logistic regression analysis was performed to examine the risk factors for a low Apgar score (< 7). Correspondence analyses were performed among neonates with low Apgar scores to explore the relationship between risk factors and geographical regions. The population attributable risk percentage (PAR%) was calculated for each region-specific risk factor.

RESULTS

A total of 72,073 live births, including 320 births with low Apgar scores, were used for the analysis, giving a weighted rate of 3.9/1000 live births. There was a substantial difference in the incidence of low Apgar scores by geographic region, from 2.3/1000 live births in East China to 10.9/1000 live births in Northeast China. Maternal and obstetric factors are the major region-specific risk factors. In Southwest China, hypertensive disorders in pregnancy were more important contributors, with PAR% being 74.47%; in North and Northwest China, pre-pregnancy underweight was a more significant factor, with PAR% of 62.92%; in East China, infants born between 0:00 a.m. and 7:59 a.m. were a key factor, with PAR% of 80.44%.

CONCLUSION

Strategies based on region-specific risk factors should be considered to reduce the burden of low Apgar scores in China.

Fine particulate matter air pollution and under-5 children mortality in China: A national time-stratified case-crossover study

BACKGROUND

Under-5 mortality rate is an important indicator in Millennium Development Goals and Sustainable Development Goals. To date, no nationally representative studies have examined the effects of fine particulate matter (PM_2.5) air pollution on under-5 mortality.

OBJECTIVE

To investigate the association of short-term exposure to PM_2.5 with under-5 mortality from total and specific causes in China.

METHODS

We used the national Maternal and Child Health Surveillance System to identify under-5 mortality cases during the study period of 2009 to 2019. We adopted a time-stratified case-crossover study design at the individual level to capture the effect of short-term exposure to daily PM_2.5 on under-5 mortality, using conditional logistic regression models.

RESULTS

A total of 61,464 under-5 mortality cases were included. A 10 μg/m³ increase in concentrations of PM_2.5 on lag 0-1 d was significantly associated with a 1.15% (95%confidence interval: 0.65%, 1.65%) increase in under-5 mortality. Mortality from diarrhea, pneumonia, digestive diseases, and preterm birth were significantly associated with exposure to PM_2.5. The effect estimates were larger for neonatal mortality (<28 days), female children, and in warm seasons. We observed steeper slopes in lower ranges (<50 μg/m³) of the concentration-response curve between PM_2.5 and under-5 mortality, and positive associations remained below the 24-h PM_2.5 concentration limit recommended by WHO Air Quality Guidelines and China Air Quality Standards.

CONCLUSIONS

This nationwide case-crossover study in China demonstrated that acute exposure to PM_2.5 may significantly increase the risk of under-5 mortality, with larger effects for neonates, female children, and during warm seasons. Relevant control strategies are needed to remove this roadblock to achieving under-5 mortality targets in developing countries.

Mortality and Years of Life Lost in Diabetes Mellitus and Its Subcategories in China and Its Provinces, 2005-2020

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.

Trend of Mortality and Years of Life Lost Due to Chronic Obstructive Pulmonary Disease in China and Its Provinces, 2005-2020

Background

To examine trends in chronic obstructive pulmonary disease (COPD) mortality and years of life lost (YLL) due to COPD for all provinces in China during 2005–2020.

Methods

Data for COPD mortality were derived from China National Mortality Surveillance System (NMSS). We analyzed the numbers and age-standardized rates of death and YLL due to COPD in China, during 2005–2020. We carried out decomposition analysis to analyze the drivers of change in COPD deaths during the study period.

Results

The age-standardized mortality rate of COPD in China decreased significantly from 99.5/100,000 in 2005 to 50.5/100,000 in 2020. Similar trend was seen in the age-standardized YLL rate. The mortality rate increased with age. During 2005–2020, the age-standardized mortality rate decreased in all provinces (except for Tibet) with the largest decline in Jilin (−77.8%), Henan (−68.4%) and Fujian (−67.1%). The decreased number of deaths was decomposed as population growth (8.5%) and population ageing (69.7%) with offset by decline of age-specific mortality (−87.5%).

Conclusion

COPD remains an important public health problem in China, though significant reductions of COPD mortality and YLL rate were observed. Vigorous prevention and control strategies should be enhanced to improve the quality of life of COPD patients and reduce the premature death caused by COPD in Chinese population.

Assessing the Inequality of Early Child Development in China - A Population-Based Study

Background

As a country with the second largest child population in the world, China has little population-level evidence on who has been left behind in early childhood development (ECD). Knowledge of inequalities in ECD will inform the Chinese government in policies on promoting ECD and guide global-level monitoring on ECD progress.

Methods

Using data from the first wave of ECD surveys conducted in China at the least-developed region, most-developed region, and a megacity (Shanghai) in 2017 and 2018, we measured population-level ECD with early Human Capability Index for a total of 63,559 children aged 36-59 months old. A child was classified as developmentally on track if his/her overall development score was above the 20^th percentile of the pooled populations. We measured inequalities in ECD with the absolute inequality in five domains: gender/sex, family income, maternal schooling, residential Hukou, and migrant- or left-behind status. Besides observed inequalities, we used a multilevel logistic regression model to generate adjusted inequalities.

Findings

Children developmentally on track ranges from 71% (95% CI 70 to 72%) in the least-developed region, 82% (95% CI 81 to 83%) in the most-developed region, and 86% (95% CI 85 to 87%) in Shanghai. Significant unadjusted inequalities in ECD were observed in all five dimensions. After controlling for other socioeconomic factors, significant differences remained in three dimensions: those living in the poorest families, or with lower maternal schooling, or boys were less likely to be developmentally on track than their counterparts (lower by 10[95% CI 8 to 11]-15[95% CI 13 to 17], 7[95% CI 5 to 10]-10[95% CI 7 to 12], and 5[95% CI 4 to 6]-6[95% CI 5 to 8] percentage points respectively).

Interpretation

Efforts of reducing ECD inequalities in China shall focus primarily on reducing poverty and improving maternal education.

Funding

National Natural Science Foundation of China (81773443), Shanghai Committee of Science and Technology (2018SHZDZX05), Shanghai Municipal Health Commission (GWV-10.1-XK07; GDEK201708), Shanghai Education Committee, Chinese Social Science Foundation (BFA140046), Macao Tong Chai Charity Association, Beijing Sany Charitable Foundation, China Medical Board (#20-388), UNICEF, Faculty Grant of Brigham & Women's Hospital, Economic and Social Research Council [grant reference number ES/T003936/1’] as a UKRI Collective Fund Award “UKRI GCRF Harnessing the Power of Global Data to Support Young Children's Learning and Development Collaborative."

Ophthalmic services in Shanghai 2017: a cataract-centric city-wide government survey

Background

Demand for eye care has increased in recent decades in China due to rapid socioeconomic development and demographic shift. Knowledge of output and productivity of ophthalmic services would allow policymakers to optimize resource allocation, and is therefore essential. This study sought to map the landscape of ophthalmic services available in Shanghai, China.

Methods

In 2018, a government-led survey was conducted of all 86 tertiary/secondary hospitals and five major private hospitals providing eye care in Shanghai in the form of electronic questionnaire, which encompassed ophthalmic services (outpatient and emergency room [ER] visit, inpatient admissions, and surgical volume) and service productivity in terms of annual outpatient and ER visits per doctor, inpatient admissions per bed, and surgical volume per doctor. Comparisons were made among different levels of hospitals with categorical variables tested by Chi-square analysis.

Results

The response rate was 85.7%. The Eye and Ear, Nose, and Throat (EENT) Hospital was the largest tertiary specialty hospital, and alone contributed to the highest 21.0% of annual ophthalmic outpatient and ER visits (visits per doctor: 5460), compared with other 26 tertiary hospitals, 46 secondary hospitals and five private hospitals (visits per doctor: 3683, 4651 and 1876). The annual inpatient admission was 20,103, 56,992, 14,090, and 52,047 for the EENT Hospital, all the other tertiary hospitals, secondary hospitals and five private hospitals, respectively. Turnover rates were highest for the EENT Hospital and private hospitals. The average surgical volume at the EENT Hospital was 72,666, exceeding that of private (15,874.8) and other tertiary hospitals (3366.7). The EENT Hospital and private hospitals performed 16,982 (14.2%) and 55,538 (46.6%) of all cataract surgeries. Proportions of both complicated cataractous cases and complicated cataract surgeries at the EENT Hospital was the highest, followed by other tertiary and secondary/private hospitals (P < 0.0001).

Conclusions

In Shanghai, public providers dominate ophthalmic services especially for complicated cases, with almost one fifth of services provided by the EENT Hospital alone, while private sectors, though not large in number, still effectively help meet large proportions of eye care demand. Optimization of hierarchical medical system is warranted to improve the efficiency and standardization of ophthalmic services.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-07048-1.

Mortality and years of life lost of cardiovascular diseases in China, 2005-2020: Empirical evidence from national mortality surveillance system

OBJECTIVES

Cardiovascular disease (CVD) is leading cause of death in China. We aimed to provide national and subnational estimates and its change of premature mortality burden of CVD during 2005-2020.

METHODS

Data from multi-source on the basis of national mortality surveillance system (NMSS) was used to estimate mortality and years of life lost (YLL) of total CVD and its subcategories in Chinese population across 31 provinces during 2005-2020.

RESULTS

Estimated CVD deaths increased from 3.09 million in 2005 to 4.58 million in 2020; the age-standardized mortality rate (ASMR) decreased from 286.85 per 100,000 in 2005 to 245.39 per 100,000 in 2020. A substantial reduction of 19.27% of CVD premature mortality burden, as measured by age-standardized YLL rate, was observed. Ischemic heart disease (IHD), hemorrhagic stroke (HS) and ischemic stroke (IS) were leading 3 causes of CVD death. Marked differences were observed in geographical patterns for total CVD and its subcategories, and it appeared to be lower in areas with higher economic development. Population ageing was dominant driver contributed to CVD deaths increase, followed by population growth. And, age-specific mortality shifts contributed largely to CVD deaths decline in most provinces.

CONCLUSION

Substantial discrepancies were demonstrated in CVD premature mortality burden across China. Targeted considerations were needed to integrate primary care with clinical care through intensifying further strategies for reducing CVD mortality among specific subcategories, high risk population and regions with inadequate healthcare resources.

What is an appropriate caesarean delivery rate for China: a multicentre survey

Objective

To assess the current status of caesarean delivery (CD) in China, propose reference CD rates for China overall, and by regions, investigate the main indications for CDs and identify possible areas for safe reduction.

Design

A multicentre cross‐sectional study.

Setting

A total of 94 hospitals across 23 provinces in China.

Population

A total of 73 977 randomly selected deliveries.

Methods

We used a modified Robson classification to characterise CDs in subgroups and by regions, and the World Health Organization (WHO) C‐Model to calculate reference CD rates.

Main outcome measures

CD rates in China.

Results

In 2015–2016, the overall CD rate in China was 38.9% (95% CI 38.6–39.3%). Considering the obstetric characteristics of the population, the multivariable model‐based reference CD rate was estimated at 28.5% (95% CI 28.3–28.8%). Accordingly, an absolute reduction of 10.4% (or 26.7% relative reduction) may be considered. The CD rate varied substantially by region. Previous CD was the most common indication in all regions, accounting for 38.2% of all CDs, followed by maternal request (9.8%), labour dystocia (8.3%), fetal distress (7.7%) and malpresentation (7.6%). Overall, 12.7% of women had prelabour CDs, contributing to 32.8% of the total CDs.

Conclusions

Nearly 39% of births were delivered by caesarean in China but a reduction of this rate by a quarter may be considered attainable. Repeat CD contributed more than one‐third of the total CDs. Given the large variation in maternal characteristics, region‐specific or even hospital‐specific reference CD rates are needed for precision management of CD.

Tweetable abstract

The caesarean rate in 2015–2016 in China was 38.9%, whereas the reference rate was 28.5%.

The caesarean rate in 2015–2016 in China was 38.9%, whereas the reference rate was 28.5%.

Linked article This article is commented on by M Varner, p. 148 in this issue. To view this mini commentary visit https://doi.org/10.1111/1471-0528.16953.

National and provincial impact and cost-effectiveness of Haemophilus influenzae type b conjugate vaccine in China: a modeling analysis

BACKGROUND

Globally, Haemophilus influenzae type b (Hib) vaccine has substantially reduced the burden of Hib invasive disease. However, China remains the only country not to include Hib vaccine into its national immunization program (NIP), although it accounts for 11% of global Hib deaths. We aimed to assess the cost-effectiveness of including Hib vaccine in China's NIP at the national and provincial levels.

METHODS

Using a decision-tree Markov state transition model, we estimated the cost-effectiveness of Hib vaccine in the NIP compared to the status quo of Hib vaccine in the private market for the 2017 birth cohort. Treatment costs and vaccine program costs were calculated from Chinese Center for Disease Control and Prevention (CDC) and national insurance databases. Epidemiological data and other model parameters were obtained from published literature. Cases and deaths averted, quality-adjusted life years (QALYs) gained, and incremental cost-effectiveness ratios (ICER) were predicted by province. Deterministic and probabilistic sensitivity analyses were performed to explore model uncertainty.

RESULTS

Including Hib vaccine in the NIP was projected to prevent approximately 2700 deaths (93% reduction) and 235,700 cases of Hib disease (92% reduction) for the 2017 birth cohort at the national level. Hib vaccine was cost-effective nationally (US$ 8001 per QALY gained) compared to the GDP per capita and cost-effective in 15 of 31 provinces. One-way and scenario sensitivity analyses indicated results were robust when varying model parameters, and in probabilistic sensitivity analysis, Hib vaccine had a 64% probability of being cost-effective nationally.

CONCLUSION

Introducing Hib vaccine in China's NIP is cost-effective nationally and in many provinces. Less socioeconomically developed provinces with high Hib disease burden and low access to Hib vaccine in the current private market, such as those in the west region, would benefit the most from adding Hib vaccine to the NIP. In the absence of a national policy decision on Hib vaccine, this analysis provides evidence for provincial governments to include Hib vaccine into local immunization programs to substantially reduce disease burden and treatment costs.

Mortality and years of life lost of colorectal cancer in China, 2005-2020: findings from the national mortality surveillance system

BACKGROUND

Colorectal cancer (CRC) is the fourth cause of cancer death in China. We aimed to provide national and subnational estimates and changes of CRC premature mortality burden during 2005-2020.

METHODS

Data from multi-source on the basis of the national surveillance mortality system were used to estimate mortality and years of life lost (YLL) of CRC in the Chinese population during 2005-2020. Estimates were generated and compared for 31 provincial-level administrative divisions in China.

RESULTS

Estimated CRC deaths increased from 111.41 thousand in 2005 to 178.02 thousand in 2020; age-standardized mortality rate decreased from 10.01 per 100,000 in 2005 to 9.68 per 100,000 in 2020. Substantial reduction in CRC premature mortality burden, as measured by age-standardized YLL rate, was observed with a reduction of 10.20% nationwide. Marked differences were observed in the geographical patterns of provincial units, and they appeared to be obvious in areas with higher economic development. Population aging was the dominant driver which contributed to the increase in CRC deaths, followed by population growth and age-specific mortality change.

CONCLUSIONS

Substantial discrepancies were observed in the premature mortality burden of CRC across China. Targeted considerations were needed to promote a healthy lifestyle, expand cost-effective CRC early screening and diagnosis, and improve medical treatment to reduce CRC mortality among high-risk populations and regions with inadequate healthcare resources.

Associations between measures of pediatric human resources and the under-five mortality rate: a nationwide study in China in 2014

BACKGROUND

To quantify the associations between the under-five mortality rate (U5MR) and measures of pediatric human resources, including pediatricians per thousand children (PPTC) and the geographical distribution of pediatricians.

METHODS

We analyzed data from a national survey in 2015-2016 in 2636 counties, accounting for 31 mainland provinces of China. We evaluated the associations between measures of pediatric human resources and the risk of a high U5MR (≥ 18 deaths per 1000 live births) using logistic regression and restricted cubic spline regression models with adjustments for potential confounders. PPTC and pediatricians per 10,000 km2 were categorized into quartiles. The highest quartiles were used as reference.

RESULTS

The median values of PPTC and pediatricians per 10,000 km2 were 0.35 (0.20-0.70) and 150 (50-500), respectively. Compared to the counties with the highest PPTC (≥ 0.7), those with the lowest PPTC (< 0.2) had a 52% higher risk of a high U5MR, with an L-shaped relationship. An inverted J-shaped relationship was found that the risk of a high U5MR was 3.74 [95% confidence interval (CI) 2.55-5.48], 3.07 (95% CI 2.11-4.47), and 2.25 times (95% CI 1.52-3.31) higher in counties with < 50, 50-149, and 150-499 pediatricians per 10,000 km2, respectively, than in counties with ≥ 500 physicians per 10,000 km2. The joint association analyses show a stronger association with the risk of a high U5MR in geographical pediatrician density than PPTC.

CONCLUSION

Both population and geographical pediatrician density should be considered when planning child health care services, even in areas with high numbers of PPTC.