Xunjie Cheng

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

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

Non-fatal injuries treated outside a hospital in Hunan, China: results from a household interview survey

Abstract Background: Injury morbidity data are collected through hospital-based surveillance in many countries. We assessed the extent of non-fatal injures treated outside a hospital. Methods: Data from the first provincial health household interview survey of Hunan, China, conducted in 2013, were used. Injury events were identified and included as medically significant when any of the following circumstances occurred in the prior 14 days: (i) receiving medical treatment from a doctor at a hospital following an injury; (ii) receiving medical treatment by self or others outside a hospital following an injury (e.g. taking medications, or receiving massage or hot compress); and/or (iii) being off work or school, or in bed for more than 1 day, following an injury. The 2-week prevalence of non-fatal injuries and 95% confidence intervals were calculated. We calculated the proportion of injury events treated outside a hospital and the reasons for not visiting a hospital for injury events occurring during the previous 2 weeks. Results: We captured 56 injury events during the previous 2 weeks. The weighted injury prevalence was 4.9 per 1000 persons during the last 2 weeks (95% confidence interval: 2.9–6.9 per 1000 persons). Of the 56 events, 14 (weighted proportion 41.2%) were treated outside a hospital. Primary explanations for skipping hospital visits included perceiving injuries were too minor and economic limitations to travel to hospitals or seek treatment. Conclusion: Results imply the burden of non-fatal injury may be underestimated by hospital-based surveillance systems such as that used in China.

Common traffic violations of bus drivers in urban China: an observational study

OBJECTIVE To report common traffic violations in bus drivers and the factors that influence those violations in urban China. METHODS We conducted an observational study to record three types of traffic violations among bus drivers in Changsha City, China: illegal stopping at bus stations, violating traffic light signals, and distracted driving. The behaviors of bus drivers on 32 routes (20% of bus routes in the city) were observed. A two-level Poisson regression examined factors that predicted bus driver violations. RESULTS The incidence of illegal stopping at bus stations was 20.2%. Illegal stopping was less frequent on weekends, sunny days, and at stations with cameras, with adjusted incidence rate ratios (IRRs) of 0.81, 0.65 and 0.89, respectively. The incidence of violating traffic light signals was 2.2%, and was lower on cloudy than sunny days (adjusted IRR: 0.60). The incidence of distracted driving was 3.3%. The incidence of distracted driving was less common on cloudy days, rainy or snowy days, and foggy/windy/dusty days compared to sunny days, with adjusted IRRs of 0.54, 0.55 and 0.07, respectively. CONCLUSION Traffic violations are common in bus drivers in urban China and they are associated with the date, weather, and presence of traffic cameras at bus station. Further studies are recommended to understand the behavioral mechanisms that may explain bus driver violations and to develop feasible prevention measures.

Child pedestrian street-crossing behaviors outside a primary school: Developing observational methodologies and data from a case study in Changsha, China

Background Child pedestrian injury is a significant global public health challenge, and prevention programming requires an understanding of the context children face when crossing the street. Methods to understand childrens behavior in real-world pedestrian settings are sparse in low- and middle-income countries. Methods Children in grades 1-6 were videotaped crossing a three-lane street outside their school in Changsha, China. Tapes were coded to collect: (1) extent of adult supervision, (2) whom children crossed the street with, and (3) safe behaviors exhibited by children. Results Observational videotape methods yielded data that could be reliably coded to understand Chinese childrens behavior crossing the street outside their primary school. In total, we observed 216 child pedestrians crossing the street, including 105 girls, 105 boys, and 6 for whom gender could not be determined. 51% of observations occurred in the morning before school and 49% in the afternoon after school. Children encountered a busy and somewhat-chaotic traffic environment. Adults were always present to help, but children appeared to heed adult advice concerning the crossing only about 70% of the time. Fewer than 1/3 of children looked at oncoming traffic before they entered a lane and over 1/3 entered a lane with moving traffic approaching. Conclusion Observational methods of coding videotaped behavior proved effective to understand and code childrens risk and safety while crossing the street outside their primary school. At the street environment we studied, we found that childrens pedestrian behavior involved significant risk.

Comparing U.S. Injury Death Estimates from GBD 2015 and CDC WONDER

Objective: The purpose of the present study was to examine consistency in injury death statistics from the United States CDC Wide-ranging Online Data for Epidemiologic Research (CDC WONDER) with those from GBD 2015 estimates. Methods: Differences in deaths and the percent difference in deaths between GBD 2015 and CDC WONDER were assessed, as were changes in deaths between 2000 and 2015 for the two datasets. Results: From 2000 to 2015, GBD 2015 estimates for the U.S. injury deaths were somewhat higher than CDC WONDER estimates in most categories, with the exception of deaths from falls and from forces of nature, war, and legal intervention in 2015. Encouragingly, the difference in total injury deaths between the two data sources narrowed from 44,897 (percent difference in deaths = 41%) in 2000 to 34,877 (percent difference in deaths = 25%) in 2015. Differences in deaths and percent difference in deaths between the two data sources varied greatly across injury cause and over the assessment years. The two data sources present consistent changes in direction from 2000 to 2015 for all injury causes except for forces of nature, war, and legal intervention, and adverse effects of medical treatment. Conclusions: We conclude that further studies are warranted to interpret the inconsistencies in data and develop estimation approaches that increase the consistency of the two datasets.

Mortality from unspecified unintentional injury among individuals aged 65 years and older by U.S. state, 1999-2013

Introduction: Recent changes in unspecified unintentional injury mortality for the elderly by U.S. state remain unreported. This study aims to examine U.S. state variations in mortality from unspecified unintentional injury among Americans aged 65+, 1999–2013; Methods: Using mortality rates from the U.S. CDC’s Web-based Injury Statistics Query and Reporting System (WISQARS™), we examined unspecified unintentional injury mortality for older adults aged 65+ from 1999 to 2013 by state. Specifically, the proportion of unintentional injury deaths with unspecified external cause in the data was considered. Linear regression examined the statistical significance of changes in proportion of unspecified unintentional injury from 1999 to 2013; Results: Of the 36 U.S. states with stable mortality rates, over 8-fold differences were observed for both the mortality rates and the proportions of unspecified unintentional injury for Americans aged 65+ during 1999–2013. Twenty-nine of the 36 states showed reductions in the proportion of unspecified unintentional injury cause, with Oklahoma (−89%), Massachusetts (−86%) and Oregon (−81%) displaying the largest changes. As unspecified unintentional injury mortality decreased, mortality from falls in 28 states and poisoning in 3 states increased significantly. Mortality from suffocation in 15 states, motor vehicle traffic crashes in 12 states, and fire/burn in 8 states also decreased; Conclusions: The proportion of unintentional injuries among older adults with unspecified cause decreased significantly for many states in the United States from 1999 to 2013. The reduced proportion of unspecified injury has implications for research and practice. It should be considered in state-level trend analysis during 1999–2013. It also suggests comparisons between states for specific injury mortality should be conducted with caution, as large differences in unspecified injury mortality across states and over time could create bias for specified injury mortality comparisons.

Using an innovative method to develop the threshold of seasonal influenza epidemic in China

Background Proper early warning thresholds for defining seasonal influenza epidemics are crucial for timely engagement of intervention strategies, but are currently not well established in China. We propose a novel moving logistic regression method (MLRM) to determine epidemic thresholds and validate them with the Chinese influenza surveillance data. Methods For each province, historical epidemic waves are formed as weekly percentages of laboratory-confirmed patients among all clinically diagnosed influenza cases. For each epidemic curve that is approximately symmetric, a series of logistic curves are fitted to increasing temporal range of the epidemic, and the threshold is determined based on the best-fitting logistic curve. Results Using surveillance data of seasonal influenza collected during 2010–2014 in 30 provinces of China, we screened 153 epidemic waves and identified 100 as approximately symmetric; and 85 of the 100 waves were satisfactorily fitted. Compared to two published approaches, the MLRM identified lower thresholds of seasonal influenza epidemics, leading to about three weeks earlier detection of onset and about four weeks later detection of closure of the epidemics. The potential misclassification proportion of influenza epidemic waves was 6% for the MLRM, comparable to that for the two published approaches. Conclusions The MLRM offers an alternative to existing methods for defining early warning thresholds for the surveillance of seasonal influenza, and can be readily generalized to other countries and other infectious agents. The thresholds we identified can be used for early detection of future influenza epidemics in China.

Unintentional drowning mortality in China, 2006–2013

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

Trends in injury morbidity in China, 1993–2013: A longitudinal analysis of population-based survey data

Understanding long-term trends in injury morbidity is critical to prevention and intervention planning. The aim of this study was to assess long-term trends in injury morbidity rates in China from 1993 to 2013. Using data from the National Health Service Survey (NHSS), which is conducted every five years, crude and age-standardized prevalence during the previous two weeks and hospitalization rates in the last 12 months with 95% confidence intervals (CI) were calculated. The Rao-Scott Chi-square test examined injury morbidity differences across the five survey years by location (urban/rural), sex, age group, and household income. Percent changes in morbidity rate were approximated using logistic regressions. Sampling weights were applied to all analyses. In 2013, crude two-week injury prevalence in China was 0.46% (95% CI: 0.40%, 0.52%) and 12-month crude hospitalization rate was 0.70% (95% CI: 0.63%, 0.77%). Age-standardized injury prevalence increased 31.4% (95% CI: 7.6%, 60.6%) between 1993 and 2013 (29.4%, 95% CI: 6.7%, 56.9% from 1993-2003; 1.6%, 95% CI: -14.8%, 21.0% from 2003-2013), and age-standardized hospitalization rates rose 107.2% (95% CI: 75.1%, 145.2%) from 1993 to 2013 (-9.5%, 95% CI: -24.6%, 8.6% from 1993-2003 and 129.0%, 95% CI: 93.9%, 170.4% from 2003-2013). Subgroup analyses showed similar trends over time. The leading cause of injury was dislocation, sprain or strain for prevalence, and fractures for hospitalization. In conclusion, injury morbidity increased substantially from 1993 to 2013 in China. Inconsistent changes in two-week prevalence and 12-month hospitalization rate merit attention from researchers and policy-makers.

Comparing road safety performance across countries: Do data source and type of mortality indicator matter?

This study examined the impact of data source estimates (World Health Organization (WHO) versus Global Burden of Disease (GBD)) and the type of mortality indicator (population-based versus exposure-based mortality) on road safety performance evaluation. Data were derived from WHO publications and the GBD results tool, and we calculated mortality rate ratio (MRR) and differences in country ranking between the two data sources, plus differences in country rankings and in mortality changes between 2010 and 2013 for population-based and vehicle-based mortality. Of 172 countries in both datasets, 32 countries (19%) had low consistency across the two data sources (MRR ≤ 0.49 or ≥1.51). Using population-based mortality data to rank the 172 countries, 77 (45%) had ≥ 20 position difference between the two data sources. Population-based vs. vehicle-based mortality data yielded ≥ 20 position difference in 33 countries for WHO estimates and 42 for GBD estimates. Among the 80 countries having comparable population-based and vehicle-based GBD mortality rates over time, 9 countries displayed opposite changing directions - that is, the change increased in one mortality indicator but decreased in the other indicator between 2010 and 2013. Data source and type of mortality indicators yield a substantial impact on ranking road safety performance across countries, as they are widely used for decision-making by global and national policy-makers and injury researchers. The differences between WHO and GBD estimates may arise from inconsistencies in data input and estimation models. Exposure-based indicators should be preferred in road safety evaluation when data are available. Advanced research is needed to interpret large country variations in road traffic mortality and mortality progress and to develop strategies to narrow the gaps across countries.