To examine the association between temperature and cause specific mortality, and to quantify the corresponding disease burden attributable to non-optimum ambient temperatures.
Time series analysis.
...272 main cities in China.
Non-accidental deaths in 272 cities covered by the Disease Surveillance Point System of China, from January 2013 to December 2015.
Daily numbers of deaths from all non-accidental causes and main cardiorespiratory diseases. Potential effect modifiers included demographic, climatic, geographical, and socioeconomic characteristics. The analysis used distributed lag non-linear models to estimate city specific associations, and multivariate meta-regression analysis to obtain the effect estimates at national and regional levels.
1 826 186 non-accidental deaths from total causes were recorded in the study period. Temperature and mortality consistently showed inversely J shaped associations. At the national average level, relative to the minimum mortality temperature (22.8°C, 79.1st centile), the mortality risk of extreme cold temperature (at -1.4°C, the 2.5th centile) lasted for more than 14 days, whereas the risk of extreme hot temperature (at 29.0°C, the 97.5th centile) appeared immediately and lasted for two to three days. 14.33% of non-accidental total mortality was attributable to non-optimum temperatures, of which moderate cold (ranging from -1.4 to 22.8°C), moderate heat (22.8 to 29.0°C), extreme cold (-6.4 to -1.4°C), and extreme heat (29.0 to 31.6°C) temperatures corresponded to attributable fractions of 10.49%, 2.08%, 1.14%, and 0.63%, respectively. The attributable fractions were 17.48% for overall cardiovascular disease, 18.76% for coronary heart disease, 16.11% for overall stroke, 14.09% for ischaemic stroke, 18.10% for haemorrhagic stroke, 10.57% for overall respiratory disease, and 12.57% for chronic obstructive pulmonary diseases. The mortality risk and burden were more prominent in the temperate monsoon and subtropical monsoon climatic zones, in specific subgroups (female sex, age ≥75 years, and ≤9 years spent in education), and in cities characterised by higher urbanisations rates and shorter durations of central heating.
This nationwide study provides a comprehensive picture of the non-linear associations between ambient temperature and mortality from all natural causes and main cardiorespiratory diseases, as well as the corresponding disease burden that is mainly attributable to moderate cold temperatures in China. The findings on vulnerability characteristics can help improve clinical and public health practices to reduce disease burden associated with current and future abnormal weather.
Public health is a priority for the Chinese Government. Evidence-based decision making for health at the province level in China, which is home to a fifth of the global population, is of paramount ...importance. This analysis uses data from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2017 to help inform decision making and monitor progress on health at the province level.
We used the methods in GBD 2017 to analyse health patterns in the 34 province-level administrative units in China from 1990 to 2017. We estimated all-cause and cause-specific mortality, years of life lost (YLLs), years lived with disability (YLDs), disability-adjusted life-years (DALYs), summary exposure values (SEVs), and attributable risk. We compared the observed results with expected values estimated based on the Socio-demographic Index (SDI).
Stroke and ischaemic heart disease were the leading causes of death and DALYs at the national level in China in 2017. Age-standardised DALYs per 100 000 population decreased by 33·1% (95% uncertainty interval UI 29·8 to 37·4) for stroke and increased by 4·6% (–3·3 to 10·7) for ischaemic heart disease from 1990 to 2017. Age-standardised stroke, ischaemic heart disease, lung cancer, chronic obstructive pulmonary disease, and liver cancer were the five leading causes of YLLs in 2017. Musculoskeletal disorders, mental health disorders, and sense organ diseases were the three leading causes of YLDs in 2017, and high systolic blood pressure, smoking, high-sodium diet, and ambient particulate matter pollution were among the leading four risk factors contributing to deaths and DALYs. All provinces had higher than expected DALYs per 100 000 population for liver cancer, with the observed to expected ratio ranging from 2·04 to 6·88. The all-cause age-standardised DALYs per 100 000 population were lower than expected in all provinces in 2017, and among the top 20 level 3 causes were lower than expected for ischaemic heart disease, Alzheimer's disease, headache disorder, and low back pain. The largest percentage change at the national level in age-standardised SEVs among the top ten leading risk factors was in high body-mass index (185%, 95% UI 113·1 to 247·7), followed by ambient particulate matter pollution (88·5%, 66·4 to 116·4).
China has made substantial progress in reducing the burden of many diseases and disabilities. Strategies targeting chronic diseases, particularly in the elderly, should be prioritised in the expanding Chinese health-care system.
China National Key Research and Development Program and Bill & Melinda Gates Foundation.
Cohort studies in North America and western Europe have reported increased risk of mortality associated with long-term exposure to fine particles (PM
), but to date, no such studies have been ...reported in China, where higher levels of exposure are experienced.
We estimated the association between long-term exposure to PM
with nonaccidental and cause-specific mortality in a cohort of Chinese men.
We conducted a prospective cohort study of 189,793 men 40 y old or older during 1990-91 from 45 areas in China. Annual average PM
levels for the years 1990, 1995, 2000, and 2005 were estimated for each cohort location using a combination of satellite-based estimates, chemical transport model simulations, and ground-level measurements developed for the Global Burden of Disease (GBD) 2013 study. A Cox proportional hazards regression model was used to estimate hazard ratios (HR) for nonaccidental cardiovascular disease (CVD), chronic obstructive pulmonary disease (COPD), and lung-cancer mortality. We also assessed the shape of the concentration-response relationship and compared the risk estimates with those predicted by Integrated Exposure-Response (IER) function, which incorporated estimates of mortality risk from previous cohort studies in western Europe and North America.
The mean level of PM
exposure during 2000-2005 was 43.7 μg/m
(ranging from 4.2 to 83.8 μg/m
). Mortality HRs (95% CI) per 10-μg/m
increase in PM
were 1.09 (1.08, 1.09) for nonaccidental causes; 1.09 (1.08, 1.10) for CVD, 1.12 (1.10, 1.13) for COPD; and 1.12 (1.07, 1.14) for lung cancer. The HR estimate from our cohort was consistently higher than IER predictions.
Long-term exposure to PM
was associated with nonaccidental, CVD, lung cancer, and COPD mortality in China. The IER estimator may underestimate the excess relative risk of cause-specific mortality due to long-term exposure to PM
over the exposure range experienced in China and other low- and middle-income countries. https://doi.org/10.1289/EHP1673.
Few large multicity studies have been conducted in developing countries to address the acute health effects of atmospheric ozone pollution.
We explored the associations between ozone and daily ...cause-specific mortality in China.
We performed a nationwide time-series analysis in 272 representative Chinese cities between 2013 and 2015. We used distributed lag models and over-dispersed generalized linear models to estimate the cumulative effects of ozone (lagged over 0-3 d) on mortality in each city, and we used hierarchical Bayesian models to combine the city-specific estimates. Regional, seasonal, and demographic heterogeneity were evaluated by meta-regression.
At the national-average level, a 10-μg/m
increase in 8-h maximum ozone concentration was associated with 0.24% 95% posterior interval (PI): 0.13%, 0.35%, 0.27% (95% PI: 0.10%, 0.44%), 0.60% (95% PI: 0.08%, 1.11%), 0.24% (95% PI: 0.02%, 0.46%), and 0.29% (95% PI: 0.07%, 0.50%) higher daily mortality from all nonaccidental causes, cardiovascular diseases, hypertension, coronary diseases, and stroke, respectively. Associations between ozone and daily mortality due to respiratory and chronic obstructive pulmonary disease specifically were positive but imprecise and nonsignificant. There were no statistically significant differences in associations between ozone and nonaccidental mortality according to region, season, age, sex, or educational attainment.
Our findings provide robust evidence of higher nonaccidental and cardiovascular mortality in association with short-term exposure to ambient ozone in China. https://doi.org/10.1289/EHP1849.
Coarse particulate matter with aerodynamic diameter between 2.5 and Formula: see text (Formula: see text) air pollution is a severe environmental problem in developing countries, but its challenges ...to public health were rarely evaluated.
We aimed to investigate the associations between day-to-day changes in Formula: see text and cause-specific mortality in China.
We conducted a nationwide daily time-series analysis in 272 main Chinese cities from 2013 to 2015. The associations between Formula: see text concentrations and mortality were analyzed in each city using overdispersed generalized additive models. Two-stage Bayesian hierarchical models were used to estimate national and regional average associations, and random-effect models were used to pool city-specific concentration-response curves. Two-pollutant models were adjusted for fine particles with aerodynamic diameter Formula: see text (Formula: see text) or gaseous pollutants.
Overall, we observed positive and approximately linear concentration-response associations between Formula: see text and daily mortality. A Formula: see text increase in Formula: see text was associated with higher mortality due to nonaccidental causes 0.23%; 95% posterior interval (PI): 0.13, 0.33, cardiovascular diseases (CVDs; 0.25%; 95% PI: 0.13, 0.37), coronary heart disease (CHD; 0.21%; 95% PI: 0.05, 0.36), stroke (0.21%; 95% PI: 0.08, 0.35), respiratory diseases (0.26%; 95% PI: 0.07, 0.46), and chronic obstructive pulmonary disease (COPD; 0.34%; 95% PI: 0.12, 0.57). Associations were stronger for cities in southern vs. northern China, with significant differences for total and cardiovascular mortality. Associations with Formula: see text were of similar magnitude to those for Formula: see text in both single- and two-pollutant models with mutual adjustment. Associations were robust to adjustment for gaseous pollutants other than nitrogen dioxide and sulfur dioxide. Meta-regression indicated that a larger positive correlation between Formula: see text and Formula: see text predicted stronger city-specific associations between Formula: see text and total mortality.
This analysis showed significant associations between short-term Formula: see text exposure and daily nonaccidental and cardiopulmonary mortality based on data from 272 cities located throughout China. Associations appeared to be independent of exposure to Formula: see text, carbon monoxide, and ozone. https://doi.org/10.1289/EHP2711.
Summary Background China has experienced a remarkable epidemiological and demographic transition during the past three decades. Far less is known about this transition at the subnational level. ...Timely and accurate assessment of the provincial burden of disease is needed for evidence-based priority setting at the local level in China. Methods Following the methods of the Global Burden of Disease Study 2013 (GBD 2013), we have systematically analysed all available demographic and epidemiological data sources for China at the provincial level. We developed methods to aggregate county-level surveillance data to inform provincial-level analysis, and we used local data to develop specific garbage code redistribution procedures for China. We assessed levels of and trends in all-cause mortality, causes of death, and years of life lost (YLL) in all 33 province-level administrative units in mainland China, all of which we refer to as provinces, for the years between 1990 and 2013. Findings All provinces in mainland China have made substantial strides to improve life expectancy at birth between 1990 and 2013. Increases ranged from 4·0 years in Hebei province to 14·2 years in Tibet. Improvements in female life expectancy exceeded those in male life expectancy in all provinces except Shanghai, Macao, and Hong Kong. We saw significant heterogeneity among provinces in life expectancy at birth and probability of death at ages 0–14, 15–49, and 50–74 years. Such heterogeneity is also present in cause of death structures between sexes and provinces. From 1990 to 2013, leading causes of YLLs changed substantially. In 1990, 16 of 33 provinces had lower respiratory infections or preterm birth complications as the leading causes of YLLs. 15 provinces had cerebrovascular disease and two (Hong Kong and Macao) had ischaemic heart disease. By 2013, 27 provinces had cerebrovascular disease as the leading cause, five had ischaemic heart disease, and one had lung cancer (Hong Kong). Road injuries have become a top ten cause of death in all provinces in mainland China. The most common non-communicable diseases, including ischaemic heart disease, stroke, chronic obstructive pulmonary disease, and cancers (liver, stomach, and lung), contributed much more to YLLs in 2013 compared with 1990. Interpretation Rapid transitions are occurring across China, but the leading health problems and the challenges imposed on the health system by epidemiological and demographic change differ between groups of Chinese provinces. Localised health policies need to be implemented to tackle the diverse challenges faced by local health-care systems. Funding China National Science & Technology Pillar Program 2013 (2013BAI04B02) and Bill & Melinda Gates Foundation.
Few prior cohort studies exist in developing countries examining the association of ambient particulate matter (PM) with mortality. We examined the association of particulate air pollution with ...mortality in a prospective cohort study of 71,431 middle-aged Chinese men. Baseline data were obtained during 1990–1991. The follow-up evaluation was completed in January, 2006. Annual average PM exposure between 1990 and 2005, including TSP and PM10, were estimated by linking fixed-site monitoring data with residential communities. We found significant associations between PM10 and mortality from cardiopulmonary diseases; each 10 μg/m3 PM10 was associated with a 1.6% (95%CI: 0.7%, 2.6%), 1.8% (95%CI: 0.8%, 2.9%) and 1.7% (95%CI: 0.3%, 3.2%) increased risk of total, cardiovascular and respiratory mortality, respectively. For TSP, we observed significant associations only for cardiovascular morality. These data contribute to the scientific literature on long-term effects of particulate air pollution for high exposure settings typical in developing countries.
•There have been few air pollution cohort studies in developing countries.•PM10 was associated with increased cardiorespiratory mortality in 71,431 Chinese men.•PM was not significantly associated with lung cancer mortality.
PM10 was associated with increased cardiorespiratory mortality in a cohort of 71,431 Chinese men.
Ambient sulfur dioxide (SO2) remains a major air pollutant in developing countries, but epidemiological evidence about its health effects was not abundant and inconsistent.
To evaluate the ...associations between short-term exposure to SO2 and cause-specific mortality in China.
We conducted a nationwide time-series analysis in 272 major Chinese cities (2013–2015). We used the over-dispersed generalized linear model together with the Bayesian hierarchical model to analyze the data. Two-pollutant models were fitted to test the robustness of the associations. We conducted stratification analyses to examine potential effect modifications by age, sex and educational level.
On average, the annual-mean SO2 concentrations was 29.8 μg/m3 in 272 cities. We observed positive and associations of SO2 with total and cardiorespiratory mortality. A 10 μg/m3 increase in two-day average concentrations of SO2 was associated with increments of 0.59% in mortality from total non-accidental causes, 0.70% from total cardiovascular diseases, 0.55% from total respiratory diseases, 0.64% from hypertension disease, 0.65% from coronary heart disease, 0.58% from stroke, and 0.69% from chronic obstructive pulmonary disease. In two-pollutant models, there were no significant differences between single-pollutant model and two-pollutant model estimates with fine particulate matter, carbon monoxide and ozone, but the estimates decreased substantially after adjusting for nitrogen dioxide, especially in South China. The associations were stronger in warmer cities, in older people and in less-educated subgroups.
This nationwide study demonstrated associations of daily SO2 concentrations with increased total and cardiorespiratory mortality, but the associations might not be independent from NO2.
•There was limited evidence on SO2-mortality associations in developing countries.•This is the largest epidemiological study of SO2 in the world.•Daily SO2 was associated with increased total and cardiorespiratory mortality.•The associations were robust to the adjustment of PM2.5, CO and O3, but not to NO2.
•No multisite studies have been conducted to examine the link between ozone and YLL.•Ozone was associated with YLL from nonaccidental causes and cardiopulmonary diseases.•Associations were stronger ...in cities with low CO or northern ones with low temperature.•A 0.055 year would be gained per deceased people if ozone fell to 100 μg/m3.
Ozone is one of the dominant air pollutants due to its impact on disease burden and increasing trend in concentration. However, evidence regarding short-term effect of ozone on years of life lost (YLL) is scarce.
A national time-series study was conducted in 48 large Chinese cities from 2013 to 2017. Generalized additive model coupled with random effects model were used to estimate national-average associations of ozone with YLL. Potential modifiers and additional life gain due to avoidable YLL under certain scenario were also evaluated.
The average annual mean ozone concentration of these cities was 86.9 μg/m3. For 10 μg/m3 increase in 3-day moving average ozone concentration, we estimated 0.37% 95% confidence interval (CI): 0.29%, 0.46% increase in YLL from nonaccidental causes, 0.38% (95% CI: 0.30%, 0.46%) increase in YLL from cardiovascular diseases, and 0.36% (95% CI: 0.16%, 0.56%) increase in YLL from respiratory diseases. Moreover, the associations were more evident in people with less education and in cities with lower carbon monoxide concentration or those located at north region with lower mean temperature. Finally, an estimated life of 0.055 (95% CI: 0.043, 0.068) years would be gained per deceased people if ozone concentration could fall to 100 μg/m3.
Our findings indicated robust associations between short-term exposure to ozone and YLL from nonaccidental causes and cardiopulmonary diseases. Relevant intervention design should take the heterogeneity of both individual- and city-level characteristics into account. Implementation of more stringent standard is beneficial for alleviating YLL caused by ozone.
To examine cardiovascular disease (CVD) mortality burden attributable to ambient temperature; to estimate effect modification of this burden by gender, age and education level.
We obtained daily data ...on temperature and CVD mortality from 15 Chinese megacities during 2007-2013, including 1,936,116 CVD deaths. A quasi-Poisson regression combined with a distributed lag non-linear model was used to estimate the temperature-mortality association for each city. Then, a multivariate meta-analysis was used to derive the overall effect estimates of temperature at the national level. Attributable fraction of deaths were calculated for cold and heat (ie, temperature below and above minimum-mortality temperatures, MMTs), respectively. The MMT was defined as the specific temperature associated to the lowest mortality risk.
The MMT varied from the 70th percentile to the 99th percentile of temperature in 15 cities, centring at 78 at the national level. In total, 17.1% (95% empirical CI 14.4% to 19.1%) of CVD mortality (330,352 deaths) was attributable to ambient temperature, with substantial differences among cities, from 10.1% in Shanghai to 23.7% in Guangzhou. Most of the attributable deaths were due to cold, with a fraction of 15.8% (13.1% to 17.9%) corresponding to 305,902 deaths, compared with 1.3% (1.0% to 1.6%) and 24,450 deaths for heat.
This study emphasises how cold weather is responsible for most part of the temperature-related CVD death burden. Our results may have important implications for the development of policies to reduce CVD mortality from extreme temperatures.
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