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Yanqing Ye,1,2,* Ze-Lin Yan,3,* Yuanshou Huang,2,* Li Li,3 Shiming Wang,1 Xiaoxing Huang,1 Jingmeng Zhou,1 Liyi Chen,4 Chun-Quan Ou,3 Huaihong Chen1 1Department of Otorhinolaryngology-Head and Neck Surgery, Nan Fang Hospital, Southern Medical University, Guangzhou, People’s Republic of China; 2Otolaryngology Department, Foshan Nan Hai District People’s Hospital, Foshan, People’s Republic of China; 3State Key Laboratory of Organ Failure Research, Department of Biostatistics, Guangdong Provincial Key Laboratory of Tropical Disease Research, School of Public Health, Southern Medical University, Guangzhou, People’s Republic of China; 4Yidu Cloud Technology Ltd, Beijing, People’s Republic of China*These authors contributed equally to this workCorrespondence: Huaihong Chen, Department of Otorhinolaryngology Head and Neck Surgery, Nan fang Hospital, Southern Medical University, 1838 Guangzhou Avenue, Bai-Yun District, Guangzhou, People’s Republic of China, Email chh19760306@163.com Chun-Quan Ou, Department of Biostatistics, Guangdong Provincial Key Laboratory of Tropical Disease Research, School of Public Health, Southern Medical University, 1838 Guangzhou Avenue, Bai-Yun District, Guangzhou, People’s Republic of China, Email ouchunquan@hotmail.comPurpose: Obstructive sleep apnea (OSA) is a disease with high morbidity and is associated with adverse health outcomes. Screening potential severe OSA patients will improve the quality of patient management and prognosis, while the accuracy and feasibility of existing screening tools are not so satisfactory. The purpose of this study is to develop and validate a well-feasible clinical predictive model for screening potential severe OSA patients.Patients and Methods: We performed a retrospective cohort study including 1920 adults with overnight polysomnography among which 979 cases were diagnosed with severe OSA. Based on demography, symptoms, and hematological data, a multivariate logistic regression model was constructed and cross-validated and then a nomogram was developed to identify severe OSA. Moreover, we compared the performance of our model with the most commonly used screening tool, Stop-Bang Questionnaire (SBQ), among patients who completed the questionnaires.Results: Severe OSA was associated with male, BMI≥ 28 kg/m2, high blood pressure, choke, sleepiness, apnea, white blood cell count ≥ 9.5× 109/L, hemoglobin ≥ 175g/L, triglycerides ≥ 1.7 mmol/L. The AUC of the final model was 0.76 (95% CI: 0.74– 0.78), with sensitivity and specificity under the optimal threshold selected by maximizing Youden Index of 73% and 66%. Among patients having the information of SBQ, the AUC of our model was statistically significantly greater than that of SBQ (0.78 vs 0.66, P = 0.002).Conclusion: Based on common clinical examination of admission, we develop a novel model and a nomogram for identifying severe OSA from inpatient with suspected OSA, which provides physicians with a visual and easy-to-use tool for screening severe OSA.Plain Language Summary: Question: How to build a more efficient screening model for severe OSA using some common variables for community physicians or non-sleep physicians?Findings: It was found that severe OSA was associated with male, BMI≥ 28 kg/m2, high blood pressure, choke, sleepiness, apnea, white blood cell count ≥ 9.5× 109/L, hemoglobin ≥ 175g/L, and triglycerides ≥ 1.7 mmol/L. The nomogram based on these variables was developed and validated. It seemed that our model outperformed the SBQ.Meaning: A clinically easy-to-use nomogram was provided for the screening of severe OSA in both non-sleep departments and community hospitals.Keywords: severe obstructive sleep apnea, clinical prediction model, nomogram

Zhi-Ying Zhan,1,2,* Qi Tian,3,* Ting-Ting Chen,1,* Yunshao Ye,3 Qiaoxuan Lin,3 Dong Han,1 Chun-Quan Ou1 1State Key Laboratory of Organ Failure Research, Department of Biostatistics, Guangdong Provincial Key Laboratory of Tropical Disease Research, School of Public Health, Southern Medical University, Guangzhou, People’s Republic of China; 2Department of Health Care Management and Social Medicine, School of Public Health, Fujian Medical University, Fuzhou, People’s Republic of China; 3Department of Information Resources, Guangzhou Health Information Center, Guangzhou, People’s Republic of China*These authors contributed equally to this workCorrespondence: Chun-Quan Ou Email ocq@smu.edu.cnPurpose: Chronic obstructive pulmonary disease (COPD) is a major cause of chronic diseases causing considerable social and economic burden globally. Despite substantial evidence on temperature-COPD association, few studies have investigated the acute effect of temperature variability (TV), a potential trigger of exacerbation of COPD disease, and it remains unknown what fraction of the disease burden of COPD is attributable to TV.Patients and Methods: Based on 71,070 COPD hospitalizations during 2013– 2015 in Guangzhou, China, we conducted a time-series analysis using quasi-Poisson regression to assess the association between TV and hospital admission for COPD after adjusting for daily mean temperature. Short-term TV was captured by the standard deviation of hourly or daily temperatures across various exposure days. We also provided the fraction (total number) of COPD attributable to TV. Stratified analyses by admission route, sex, age, occupation, marital status and season were performed to identify vulnerable subpopulations.Results: We found a linear relationship between TV and COPD hospitalization, with a 1°C increase in hourly TV and daily TV associated with 4.3% (95%CI: 2.2– 6.4) and 4.0% (2.3– 5.8) increases in COPD, respectively. The greater relative risks of TV identified males, people aged 0– 64 years, blue collar, and divorced/widowed people as vulnerable population. There were 12.0% (8500 cases) of COPD hospitalization attributable to hourly TV during the study period. Daily TV produced similar estimates of relative effects (relative risk) but grater estimates of absolute effects (attributable fraction) than hourly TV.Conclusion: We concluded that TV was an independent risk factor of COPD morbidity, especially among the susceptible subgroups. These findings would be helpful to guide the development of targeted public intervention.Keywords: epidemiology, COPD hospitalization, distributed lag non-linear model, time-series analysis, China

Yu-He Hu,1,* Zhen-Yu Liang,2,* Li-Mei Xu,1,* Wen-Hui Xu,1 Hao Liao,1 Rui Li,1 Kai Wang,1 Ying Xu,1 Chun-Quan Ou,3 Xin Chen1 1Department of Respiratory Medicine, Zhujiang Hospital, Southern Medical University, Guangzhou, China; 2State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China; 3State Key Laboratory of Organ Failure Research, Department of Biostatistics, Guangdong Provincial Key Laboratory of Tropical Disease Research, School of Public Health, Southern Medical University, Guangzhou, China *These authors contributed equally to this work Objective: Compared with the 2011 Global Initiative for Chronic Obstructive Lung Disease (GOLD), there have been significant changes in the 2017 GOLD classification. The purpose of this study was to analyze the changes in clinical characteristics of the new A-B-C-D system and to explore its role in comprehensive assessment of COPD.Subjects and methods: A total of 631 stable COPD patients were included in a cross-sectional survey. Data collected included baseline data and pulmonary function testing results, respiratory muscle strength, symptoms and quality of life, exercise capacity, nutritional status, and anxiety and depression as a comprehensive assessment. Based on the 2011 GOLD and 2017 GOLD classifications, patients were divided into Groups A1–D1 and Groups A2–D2, respectively.Results: In the 2011 GOLD, 64 subjects in Group C1 were reclassified into Group A2 (41.6%), while 77 subjects in Group D1 were reclassified into Group B2 (27.1%). The old and new grading systems were somewhat consistent (Cohen’s kappa=0.6963, P

Background: Air pollutants are important exogenous stimulants to eye diseases, but knowledge of associations between long-term exposure to air pollutants and the risk of primary open-angle glaucoma (POAG) is limited. This study aimed to determine whether long-term exposure to air pollutants, genetic susceptibility, and their joint effects lead to an elevated risk of incident POAG., Methods: This is a population-based prospective cohort study from UK Biobank participants with complete measures of air pollution exposure and polygenetic risk scores. Cox proportional hazard models were fitted to assess the individual and joint effects of long-term exposure to air pollutants and genetics on the risk of POAG. In addition, the effect modification of genetic susceptibility was examined on an additive or multiplicative scale., Results: Among 434,290 participants with a mean (SD) age of 56.5 (8.1) years, 6651 (1.53 %) were diagnosed with POAG during a median follow-up of 13.7 years. Long-term exposure to air pollutants was associated with an increased risk of POAG. The hazard ratios associated with per interquartile range increase in PM 2.5 , PM 2.5 absorbance, PM 10 , NO 2 , and NO X individually ranged from 1.027 (95 % CI: 1.001-1.054) to 1.067 (95 % CI: 1.035-1.099). Compared with individuals residing in low-pollution areas and having low polygenic risk scores, the risk of incident POAG increased by 105.5 % (95 % CI: 78.3 %-136.9 %), 79.7 % (95 % CI: 56.5 %-106.5 %), 103.2 % (95 % CI: 76.9 %-133.4 %), 89.4 % (95 % CI: 63.9 %-118.9 %), and 90.2 % (95 % CI: 64.8 %-119.5 %) among those simultaneously exposed to high air pollutants levels and high genetic risk, respectively. Genetic susceptibility interacted with PM 2.5 absorbance and NO 2 in an additive manner, while no evidence of multiplicative interaction was found in this study. Stratification analyses revealed stronger effects in Black people and the elderly., Conclusion: Long-term air pollutant exposure was associated with an increased risk of POAG incidence, particularly in the population with high genetic predisposition., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Background: Identifying mediators between obesity-related traits and lower respiratory tract infections (LRTIs) would inform preventive and therapeutic strategies to reduce the burden of LRITs. We aimed to recognize whether lung function and inflammatory factors mediate their associations., Methods: We conducted a two-step, two-sample Mendelian randomization (MR) analysis. Two-sample MR was performed on (1) obesity-related traits (i.e., body mass index [BMI], waist circumference [WC], and waist-to-hip ratio [WHR]) and LRTIs (i.e., acute bronchitis, acute bronchiolitis, bronchiectasis, influenza, and pneumonia), (2) obesity-related traits and potential mediators, and (3) potential mediators and LRTIs. Next, two-step MR was applied to infer whether the mediation effects exist., Results: We found that C-reactive protein (CRP), interleukin-6 (IL-6), and forced expiratory volume in the first second (FEV1) mediated 32.59% (95% CI: 17.90%, 47.27%), 7.96% (95% CI: 1.79%, 14.14%), and 4.04% (95% CI: 0.34%, 7.74%) of the effect of BMI on pneumonia, and they mediated 26.90% (95% CI: 13.98%, 39.83%), 10.23% (95% CI: 2.72%, 17.73%), and 4.67% (95% CI: 0.25%, 9.09%) of the effect of WC on pneumonia, respectively. Additionally, CRP, forced vital capacity (FVC), and FEV1 mediated 18.66% (95% CI: 8.70%, 28.62%), 8.72% (95% CI: 1.86%, 15.58%), and 8.41% (95% CI: 2.77%, 14.06%) of the effect of BMI on acute bronchitis, and they mediated 19.96% (95% CI: 7.44%, 32.48%), 12.19% (95% CI: 2.00%, 22.39%), and 12.61% (95% CI: 2.94%, 22.29%) of the effect of WC on acute bronchitis, respectively., Conclusions: Health interventions linked to reducing inflammation and maintaining normal lung function could help mitigate the risk of obesity-related LRTIs.

Background: Low temperatures are adverse contributors to cardiovascular diseases, but the associations between short-term exposure to cold and the risk of death from aortic dissection and aneurysm remain unclear, particularly in tropical regions., Objective: This study was conducted based on 123,951 records of deaths caused by aortic dissection and aneurysms extracted from the national Mortality Information System in Brazil between 2000 and 2019., Methods: Relative risks and 95 % confidence intervals (CI) for the aortic-related deaths associated with low ambient temperatures were estimated using the conditional logistic model combined with the distributed lag nonlinear model. Subgroup analyses were performed by age group, sex, race, education level, and residential region. Furthermore, this study calculated the number and fraction of aortic-related deaths attributed to temperatures below the temperature threshold to quantify the cold-related mortality burden of aortic diseases., Results: During the study period, aortic-related deaths and mortality rates in Brazil exhibited a steady increase, rising from 4419 (2.66/100,000) in 2000 to 8152 (3.88/100,000) in 2019. Under the identified temperature threshold (26 °C), per 1 °C decrease in daily mean temperature was associated with a 4.77 % (95 % CI: 4.35, 5.19) increase in mortality risk of aortic-related diseases over lag 0-3 days. Females, individuals aged 50 years or older, Asian and Black race, and northern residents were more susceptible to low temperatures. Low temperatures were responsible for 19.10 % (95 % CI: 17.71, 20.45) of aortic-related deaths in Brazil., Conclusion: This study highlights that low temperatures were associated with an increased risk of aortic-related deaths, with a remarkable burden even in this predominantly tropical country., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: Meteorological factors are associated with various health outcomes. However, it remains uncertain whether ambient temperature affects animal aggressive behaviors and causes mammalian-related injuries (MRI) in humans. The study aimed to examine the effect of daily mean temperature on MRI in Guangzhou, China., Methods: Individual cases of MRI were obtained from Guangzhou Injury Surveillance System during 2014-2019. A combination of a distributed lag nonlinear model and conditional quasi-Poisson regression, implemented within a time-stratified case-crossover design, was employed to evaluate the association between temperature and MRI. Subgroup analyses were conducted by sex, age group, education level, and types of mammals., Result: This study included 24,206 MRI cases among which 89.7 % were caused by cats or dogs. We observed a nonlinear relationship between daily mean temperature and MRI. The impact of high temperatures was most pronounced on the current day and remained statistically significant on the next day. Compared with the reference temperature with a minimum risk of injuries (9.3 °C, approximately 2nd percentile of temperature), 75th percentile of temperature (27.4 °C) exerted the greatest relative risk (RR) of injuries (RR = 1.45, 95 % CI: 1.25-1.68) over lag 0-1 days. In subgroup analyses, the effects of high temperatures among males and females were similar. Individuals aged 15-34 years and 35-59 years were more susceptible to MRI at high temperatures compared to other age groups. The risk of injuries caused by cats or dogs consistently increased with high temperatures. We did not find significant impacts of low temperatures., Conclusion: Short-term heat exposure plays an important role in the occurrence of MRI. The findings highlight the importance of enhancing public awareness regarding the high temperature-associated hazards posed by mammals. There is a need for enhanced regulations and measures on the management for cats and dogs to mitigate the harm caused in hot seasons., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Background: This study aimed to examine the prevalence and associated factors of malnutrition in older community-dwellers and explore the interaction between associated factors., Methods: A total of 474,467 older community-dwellers aged 65 or above were selected in Guangzhou, China. We used a two-step methodology to detect the associated factors of malnutrition and constructed logistic regression models to explore the influencing factors and interactive effects on three patterns of malnutrition., Results: The prevalence of malnutrition was 22.28%. Older adults with both hypertension and diabetes (RERI = 0.13), both meat or fish diet and hypertension (RERI = 0.79), and both meat or fish diet and diabetes (RERI = 0.81) had positive additive interaction effects on the risk of obesity, whereas those on a vegetarian diet with hypertension (RERI = -0.25) or diabetes (RERI = -0.19) had negative additive interaction effects. Moreover, the interactions of physical activity with a meat or fish diet (RERI = -0.84) or dyslipidemia (RERI = -0.09) could lower the risk of obesity., Conclusions: Malnutrition was influenced by different health factors, and there were interactions between these influencing factors. Pertinent dietary instruction should be given according to different nutritional status indexes and the prevalence of metabolic diseases to avoid the occurrences of malnutrition among older adults.

Background: Previous studies on the effect of global warming on the global burden of disease have mainly focussed on the impact of high temperatures, thereby providing limited evidence of the effect of lower temperatures., Methods: We adopted a three-stage analysis approach using data from the Global Burden of Disease 2019 study. First, we explored the global burden of disease attributable to low temperatures, examining variations by gender, age, cause, region, and country. Second, we analysed temporal trends in low-temperature-related disease burdens from 1990 to 2019 by meta-regression. Finally, we fitted a mixed-effects meta-regression model to explore the effect modification of country-level characteristics., Results: In 2019, low temperatures were responsible for 2.92% of global deaths and 1.03% of disability-adjusted life years (DALYs), corresponding to a death rate of 21.36 (95% uncertainty interval (UI) = 18.26, 24.73) and a DALY rate of 335 (95% UI = 280, 399) per 100 000 population. Most of the deaths (85.12%) and DALYs (94.38%) attributable to low temperatures were associated with ischaemic heart disease, stroke, and chronic obstructive pulmonary disease. In the last three decades, we observed an upward trend for the annual number of attributable deaths (P < 0.001) and a downward trend for the rates of death (P < 0.001) and DALYs (P < 0.001). The disease burden associated with low temperatures varied considerably among regions and countries, with higher burdens observed in regions with middle or high-middle socio-demographic indices, as well as countries with higher gross domestic product per capita and a larger proportion of ageing population., Conclusions: Our findings emphasise the significance of raising public awareness and prioritising policies to protect global population health from the adverse effects of low temperatures, even in the face of global warming. Particular efforts should be targeted towards individuals with underlying diseases (e.g. cardiovascular diseases) and vulnerable countries or regions (e.g. Central Asia and central Europe)., Competing Interests: Disclosure of interest: The authors completed the ICMJE Disclosure of Interest Form (available upon request from the corresponding author) and disclose no relevant interests., (Copyright © 2024 by the Journal of Global Health. All rights reserved.)

Background: Count time series (e.g., daily deaths) are a very common type of data in environmental health research. The series is generally autocorrelated, while the widely used generalized linear model is based on the assumption of independent outcomes. None of the existing methods for modelling parameter-driven count time series can obtain consistent and reliable standard error of parameter estimates, causing potential inflation of type I error rate., Methods: We proposed a new maximum significant ρ correction (MSRC) method that utilizes information of significant autocorrelation coefficient ρ estimate within 5 orders by moment estimation. A Monte Carlo simulation was conducted to evaluate and compare the finite sample performance of the MSRC and classical unbiased correction (UB-corrected) method. We demonstrated a real-data analysis for assessing the effect of drunk driving regulations on the incidence of road traffic injuries (RTIs) using MSRC in Shenzhen, China. Moreover, there is no previous paper assessing the time-varying intervention effect and considering autocorrelation based on daily data of RTIs., Results: Both methods had a small bias in the regression coefficients. The autocorrelation coefficient estimated by UB-corrected is slightly underestimated at high autocorrelation (≥ 0.6), leading to the inflation of the type I error rate. The new method well controlled the type I error rate when the sample size reached 340. Moreover, the power of MSRC increased with increasing sample size and effect size and decreasing nuisance parameters, and it approached UB-corrected when ρ was small (≤ 0.4), but became more reliable as autocorrelation increased further. The daily data of RTIs exhibited significant autocorrelation after controlling for potential confounding, and therefore the MSRC was preferable to the UB-corrected. The intervention contributed to a decrease in the incidence of RTIs by 8.34% (95% CI, -5.69-20.51%), 45.07% (95% CI, 25.86-59.30%) and 42.94% (95% CI, 9.56-64.00%) at 1, 3 and 5 years after the implementation of the intervention, respectively., Conclusions: The proposed MSRC method provides a reliable and consistent approach for modelling parameter-driven time series with autocorrelated count data. It offers improved estimation compared to existing methods. The strict drunk driving regulations can reduce the risk of RTIs., (© 2024. The Author(s).)

Haze weather, characterized by low visibility due to severe air pollution, has aroused great public concern. However, haze definitions are inconclusive, and multicentre studies on the health impacts of haze are scarce. We collected data on the daily number of deaths and environmental factors in 190 Chinese cities from 2014 to 2020. The city-specific association was estimated using quasi-Poisson regression and then pooled using meta-analysis. We found a negative association between daily visibility and non-accidental deaths, and mortality risk sharply increased when visibility was < 10 km. Haze weather, defined as a daily average visibility of < 10 km without a limit for humidity, produced the best model fitness and greatest effect on mortality. A haze day was associated with an increase of 2.53% (95% confidence interval [CI]:1.96, 3.10), 2.84 (95% CI: 2.13, 3.56), and 2.99% (95% CI: 1.94, 4.04) in all non-accident, cardiovascular and respiratory mortality, respectively. Haze had the greatest effect on lung cancer mortality. The haze-associated risk of mortality increased with age. Severe haze (visibility <2 km) and damp haze (haze with relative humidity >90%) had greater health impacts. Our findings can help in the development of early warning systems and effective public health interventions for haze., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Background: The high prevalence of hepatitis A delivered a blow to public health decades ago. The World Health Organization (WHO) set a goal to eliminate viral hepatitis including hepatitis A by 2030. In 2008, hepatitis A vaccines were integrated into the Expanded Program on Immunization (EPI) in China to alleviate the burden of hepatitis A, although the effectiveness of the EPI has not been well investigated., Objective: We aimed to evaluate the intervention effect at both provincial and national levels on the incidence of hepatitis A in the Chinese mainland from 2005 to 2019., Methods: Based on the monthly reported number of hepatitis A cases from 2005 to 2019 in each provincial-level administrative division, we adopted generalized additive models with an interrupted time-series design to estimate province-specific effects of the EPI on the incidence of hepatitis A among the target population (children aged 2-9 years) from 2005 to 2019. We then pooled province-specific effect estimates using random-effects meta-analyses. We also assessed the effect among the nontarget population and the whole population., Results: A total of 98,275 hepatitis A cases among children aged 2-9 years were reported in the Chinese mainland from 2005 to 2019, with an average annual incidence of 5.33 cases per 100,000 persons. Nationally, the EPI decreased the hepatitis A incidence by 80.77% (excess risk [ER] -80.77%, 95% CI -85.86% to -72.92%) during the study period, guarding an annual average of 28.52 (95% empirical CI [eCI] 27.37-29.00) cases per 100,000 persons among the target children against hepatitis A. Western China saw a more significant effect of the EPI on the decrease in the incidence of hepatitis A among the target children. A greater number of target children were protected from onset in Northwest and Southwest China, with an excess incidence rate of -129.72 (95% eCI -135.67 to -117.86) and -66.61 (95% eCI -67.63 to -64.22) cases per 100,000 persons on average, respectively. Intervention effects among nontarget (ER -32.88%, 95% CI -39.76% to -25.21%) and whole populations (ER -31.97%, 95% CI -39.61% to -23.37%) were relatively small., Conclusions: The EPI has presented a lasting positive effect on the containment of hepatitis A in the target population in China. The EPI's effect on the target children also provided a degree of indirect protection for unvaccinated individuals. The continuous surveillance of hepatitis A and the maintenance of mass vaccination should shore up the accomplishment in the decline of hepatitis A incidence to ultimately achieve the goal set by the WHO., (©Bo-Wen Ming, Li Li, Hao-Neng Huang, Jia-Jun Ma, Chen Shi, Xiao-Han Xu, Zhou Yang, Chun-Quan Ou. Originally published in JMIR Public Health and Surveillance (https://publichealth.jmir.org), 28.02.2024.)

Background: Quantitative evidence on the impact of meteorological factors on influenza transmissibility across different virus types/subtypes is scarce, and no previous studies have reported the effect of hourly temperature variability (HTV) on influenza transmissibility. Herein, we explored the associations between meteorological factors and influenza transmissibility according to the influenza type and subtype in Guangzhou, a subtropical city in China., Methods: We collected influenza surveillance and meteorological data of Guangzhou between October 2010 and December 2019. Influenza transmissibility was measured using the instantaneous effective reproductive number (R t ). A gamma regression with a log link combined with a distributed lag non-linear model was used to assess the associations of daily meteorological factors with R t by influenza types/subtypes., Results: The exposure-response relationship between ambient temperature and R t was non-linear, with elevated transmissibility at low and high temperatures. Influenza transmissibility increased as HTV increased when HTV < around 4.5 °C. A non-linear association was observed between absolute humidity and R t , with increased transmissibility at low absolute humidity and at around 19 g/m 3 . Relative humidity had a U-shaped association with influenza transmissibility. The associations between meteorological factors and influenza transmissibility varied according to the influenza type and subtype: elevated transmissibility was observed at high ambient temperatures for influenza A(H3N2), but not for influenza A(H1N1)pdm09; transmissibility of influenza A(H1N1)pdm09 increased as HTV increased when HTV < around 4.5 °C, but the transmissibility decreased with HTV when HTV < 2.5 °C and 3.0 °C for influenza A(H3N2) and B, respectively; positive association of R t with absolute humidity was witnessed for influenza A(H3N2) even when absolute humidity was larger than 19 g/m 3 , which was different from that for influenza A(H1N1)pdm09 and influenza B., Conclusions: Temperature variability has an impact on influenza transmissibility. Ambient temperature, temperature variability, and humidity influence the transmissibility of different influenza types/subtypes discrepantly. Our findings have important implications for improving preparedness for influenza epidemics, especially under climate change conditions., (© 2024. The Author(s).)

Objectives: Neonatologists and obstetricians are crucial decision-makers regarding the resuscitation of extremely preterm infants (EPIs). However, there is a scarcity of research regarding the differing perspectives on EPI resuscitation between these medical professionals. We aim to determine the differences and influential factors of their attitudes towards EPIs resuscitation in China., Methods: This cross-sectional study was conducted in public hospitals of 31 provinces in Chinese mainland from June to July 2021. Influential factors of binary variables and those of ordinal variables were analyzed by modified Poisson regression models and multinomial logistic regression models due to the invalid parallel line assumption of ordinal logistic regression models., Results: A total of 832 neonatologists and 1,478 obstetricians who were deputy chief physicians or chief physicians participated. Compared with obstetricians, neonatologists delivered a larger proportion of infants of <28-week gestational age (87.74% vs. 84.91%) and were inclined to think it inappropriate to use 28 weeks as the cutoff of gestational age for providing full care to premature infants [63.34% vs. 31.60%, adjusted prevalence ratio = 1.61 (95% CI: 1.46-1.77)], and to suggest smaller cutoffs of gestational age and birth weight for providing EPIs resuscitation. Notably, 46.49% of the neonatologists and 19.01% of the obstetricians believed infants ≤24 weeks' gestation should receive resuscitation., Conclusions: In China, notable disparities exist in attitudes of neonatologists and obstetricians towards resuscitating EPIs. Strengthening collaboration between these two groups and revising the pertinent guidelines as soon as possible would be instrumental in elevating the resuscitation rate of EPIs., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (© 2023 Wang, Li, Ming, Ou, Han, Cao, Xie, Liu, Feng and Li.)

Importance: High-risk human papillomavirus (hrHPV) is recognized as an etiologic agent for cervical cancer, and hrHPV DNA testing is recommended as the preferred method of cervical cancer screening in recent World Health Organization guidelines. Cervical cancer prediction models may be useful for screening and monitoring, particularly in low-resource settings with unavailable cytological and colposcopic examination results, but previous studies did not include women infected with hrHPV., Objectives: To develop and validate a cervical cancer prediction model that includes women positive for hrHPV infection and examine whether the inclusion of HPV genotypes improves the cervical cancer prediction ability., Design, Setting, and Participants: This diagnostic study included diagnostic data from 314 587 women collected from 136 primary care centers in China between January 15, 2017, and February 28, 2018. The data set was separated geographically into data from 100 primary care centers in 6 districts for model development (training data set) and 36 centers in 3 districts for model validation. A total of 24 391 women identified with positive hrHPV test results in the cervical cancer screening program were included in the study. Data were analyzed from January 1, 2022, to July 14, 2022., Main Outcomes and Measures: Cervical intraepithelial neoplasia grade 3 or worse (CIN3+) was the primary outcome, and cervical intraepithelial neoplasia grade 2 or worse (CIN2+) was the secondary outcome. The ability of the prediction models to discriminate CIN3+ and CIN2+ was evaluated using the area under the receiver operating characteristic curve (AUROC), sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio. The calibration and clinical utility of the models were assessed using calibration plots and decision curves, respectively., Results: After excluding women without screening outcomes, the study included 21 720 women (median [IQR] age, 50 [44-55] years). Of 14 553 women in the training data set, 349 (2.4%) received a diagnosis of CIN3+ and 673 (4.6%) of CIN2+. Of 7167 women in the validation set, 167 (2.3%) received a diagnosis of CIN3+ and 228 (3.2%) of CIN2+. Including HPV genotype in the model improved the AUROC by 35.9% for CIN3+ and 41.7% for CIN2+. With HPV genotype, epidemiological factors, and pelvic examination as predictors, the stacking model had an AUROC of 0.87 (95% CI, 0.84-0.90) for predicting CIN3+. The sensitivity was 80.1%, specificity was 83.4%, positive likelihood ratio was 4.83, and negative likelihood ratio was 0.24. The model for predicting CIN2+ had an AUROC of 0.85 (95% CI, 0.82-0.88), with a sensitivity of 80.4%, specificity of 81.0%, positive likelihood ratio of 4.23, and negative likelihood ratio of 0.24. The decision curve analysis indicated that the stacking model provided a superior standardized net benefit when the threshold probability for clinical decision was lower than 23% for CIN3+ and lower than 17% for CIN2+., Conclusions and Relevance: This diagnostic study found that inclusion of HPV genotypes markedly improved the ability of a stacking model to predict cervical cancer among women who tested positive for hrHPV infection. This prediction model may be an important tool for screening and monitoring cervical cancer, particularly in low-resource settings.

Some studies have investigated the effects of PM 2.5 on cardiovascular diseases based on the population-average exposure data from several monitoring stations. No one has explored the short-term effect of PM 2.5 on cardiovascular hospitalizations using individual-level exposure data. We assessed the short-term effects of individual exposure to PM 2.5 on hospitalizations for myocardial infarction (MI) and stroke in Guangzhou, China, during 2014-2019. The population-based data on cardio-cerebrovascular events were provided by Guangzhou Center for Disease Control and Prevention. Average annual percent changes (AAPCs) were used to describe trends in the hospitalization rates of MI and stroke. The conditional logistic regression model with a time-stratified case-crossover design was applied to estimate the effects of satellite-retrieved PM 2.5 with 1-km resolution as individual-level exposure. Furthermore, we performed stratified analyses by demographic characteristics and season. There were 28,346 cases of MI, 188,611, and 36,850 cases of ischemic stroke (IS) and hemorrhagic stroke (HS), respectively, with an annual average hospitalization rate of 37.2, 247, and 48.4 per 100,000 people. Over the six-year study period, significant increasing trends in the hospitalization rates were observed with AAPCs of 12.3% (95% confidence interval [CI]: 7.24%, 17.6%), 13.1% (95% CI: 9.54%, 16.7%), and 9.57% (95% CI: 6.27%, 13.0%) for MI, IS, and HS, respectively. A 10 μg/m 3 increase in PM 2.5 was associated with an increase of 1.15% (95% CI: 0.308%, 1.99%) in MI hospitalization and 1.29% (95% CI: 0.882%, 1.70%) in IS hospitalization. A PM 2.5 -associated reduction of 1.17% (95% CI: 0.298%, 2.03%) was found for HS hospitalization. The impact of PM 2.5 was greater in males than in females for MI hospitalization, and greater effects were observed in the elderly (≥ 65 years) and in cold seasons for IS hospitalization. Our study added important evidence on the adverse effect of PM 2.5 based on satellite-retrieved individual-level exposure data., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: The effect of urbanization on the morbidity of hepatitis A remains unclear. We aimed to estimate the association between various urbanization-related indices and hepatitis A morbidity in China., Methods: Data on the annual morbidity of hepatitis A, urbanization-related measures (i.e., gross domestic product per capita, the number of hospitalization beds per 1000 persons, illiteracy rate, tap water coverage, motor vehicles per 100 persons, population density, and the proportion of arable land), and meteorological factors in 31 provincial-level administrative divisions of Chinese mainland during 2005-2018 were collected from the National Population and Health Science Data Sharing Platform, China Statistical Yearbooks, and the China Meteorological Data Sharing Service System, respectively. Generalized linear mixed models were applied to quantify the impacts of different urbanization-related indices on the morbidity of hepatitis A in China after adjusting for covariates., Results: A total of 537,466 hepatitis A cases were reported in China during 2005-2018. The annual morbidity had a decline of 79.4% from 5.64 cases to 1.16 cases per 100,000 people. There were obvious spatial variations with higher morbidity in western China. Nationally, gross domestic product per capita and the number of hospitalization beds per 1000 persons increased from 14,040 to 64,644 CNY and from 2.45 to 6.03 during 2005-2018, respectively. The illiteracy rate decreased from 11.0 to 4.9%. Gross domestic product per capita [relative risk (RR) = 0.96, 95% confidence interval (CI): 0.92-0.99], and the number of hospitalization beds per 1000 persons (RR = 0.79, 95% CI: 0.75-0.83) were associated with the declined morbidity of hepatitis A. By contrast, the increased morbidity of hepatitis A was linked to the illiteracy rate (RR = 1.04, 95% CI: 1.02-1.06). Similar influential factors were detected for children and adults, with greater effects witnessed for children., Conclusions: People in the western region suffered the heaviest burden of hepatitis A in Chinese mainland. Nationally, there was a sharp decline in the morbidity of hepatitis A. The urbanization process was associated with the reduction of hepatitis A morbidity in China during 2005-2018., (© 2023. The Author(s).)

Background: Accurate estimation of the influenza death burden is of great significance for influenza prevention and control. However, few studies have considered the short-term harvesting effects of influenza on mortality when estimating influenza-associated excess deaths by cause of death, age, sex, and subtype/lineage., Objective: This study aimed to estimate the cause-, age-, and sex-specific excess mortality associated with influenza and its subtypes and lineages in Guangzhou from 2015 to 2018., Methods: Distributed-lag nonlinear models were fitted to estimate the excess mortality related to influenza subtypes or lineages for different causes of death, age groups, and sex based on daily time-series data for mortality, influenza, and meteorological factors., Results: A total of 199,777 death certificates were included in the study. The average annual influenza-associated excess mortality rate (EMR) was 25.06 (95% empirical CI [eCI] 19.85-30.16) per 100,000 persons; 7142 of 8791 (81.2%) deaths were due to respiratory or cardiovascular mortality (EMR 20.36, 95% eCI 16.75-23.74). Excess respiratory and cardiovascular deaths in people aged 60 to 79 years and those aged ≥80 years accounted for 32.9% (2346/7142) and 63.7% (4549/7142) of deaths, respectively. The male to female ratio (MFR) of excess death from respiratory diseases was 1.34 (95% CI 1.17-1.54), while the MFR for excess death from cardiovascular disease was 0.72 (95% CI 0.63-0.82). The average annual excess respiratory and cardiovascular mortality rates attributed to influenza A (H3N2), B/Yamagata, B/Victoria, and A (H1N1) were 8.47 (95% eCI 6.60-10.30), 5.81 (95% eCI 3.35-8.25), 3.68 (95% eCI 0.81-6.49), and 2.83 (95% eCI -1.26 to 6.71), respectively. Among these influenza subtypes/lineages, A (H3N2) had the highest excess respiratory and cardiovascular mortality rates for people aged 60 to 79 years (20.22, 95% eCI 14.56-25.63) and ≥80 years (180.15, 95% eCI 130.75-227.38), while younger people were more affected by A (H1N1), with an EMR of 1.29 (95% eCI 0.07-2.32). The mortality displacement of influenza A (H1N1), A (H3N2), and B/Yamagata was 2 to 5 days, but 5 to 13 days for B/Victoria., Conclusions: Influenza was associated with substantial mortality in Guangzhou, occurring predominantly in the elderly, even after considering mortality displacement. The mortality burden of influenza B, particularly B/Yamagata, cannot be ignored. Contrasting sex differences were found in influenza-associated excess mortality from respiratory diseases and from cardiovascular diseases; the underlying mechanisms need to be investigated in future studies. Our findings can help us better understand the magnitude and time-course of the effect of influenza on mortality and inform targeted interventions for mitigating the influenza mortality burden, such as immunizations with quadrivalent vaccines (especially for older people), behavioral campaigns, and treatment strategies., (©Li Li, Ze-Lin Yan, Lei Luo, Wenhui Liu, Zhou Yang, Chen Shi, Bo-Wen Ming, Jun Yang, Peihua Cao, Chun-Quan Ou. Originally published in JMIR Public Health and Surveillance (https://publichealth.jmir.org), 11.01.2023.)

Background: Evidence concerning effects of air pollution on influenza-like illness (ILI) from multi-center is limited and little is known about how regional factors might modify this relationship., Methods: In this ecological study, ILI cases defined as outpatients with temperature ≥38 °C, accompanied by cough or sore throat, were collected from National Influenza Surveillance Network in China. We adopted generalized additive model with quasi-Poisson to estimate province-specific association between air pollution and ILI in 30 Chinese provinces during 2015-2019, after adjusting for time trend and meteorological factors. We then pooled province-specific association by using random-effect meta-analysis. Potential effect modifications of season and regional characteristics were explored., Findings: A total of 26, 004, 853 ILI cases and 777, 223, 877 hospital outpatients were collected. In general, effects of air pollutants were acute. An inter-quartile range increase of PM 2.5 , SO 2 , PM 10 , NO 2 and CO at lag0, and O 3 at lag0-2 was associated with 3.08% (95% CI: 1.91%, 4.27%), 3.00% (1.86%, 4.16%), 6.46% (4.71%, 8.25%), 7.21% (5.73%, 8.71%), 4.37% (3.05%, 5.70%), and -9.26% (-11.32%, -7.14%) change of ILI at national level, respectively. Associations between air pollutants and ILI varied by season and regions, with higher effect estimates in cold season, eastern and central regions and provinces with more humid condition and larger population., Interpretation: This study indicated that most air pollutants increased the risk of ILI in China. Our findings might provide implications for the development of policies to protect public health from air pollution and influenza., Funding: National Natural Science Foundation of China and Chongqing Health Commission Program., Competing Interests: Declaration of interests The authors declare that they have no competing interests., (Copyright © 2022 The Author(s). Published by Elsevier B.V. All rights reserved.)

Background: High-risk human papillomavirus (hrHPV) infection is a necessary cause of almost all cervical cancers. Relative to hrHPV 16/18 infection, non-16/18 hrHPV infection is of less concern. However, the increasing prevalence of non-16/18 hrHPV infections has become an important public health issue. The early identification and treatment of cervical cytological abnormalities in women infected with non-16/18 hrHPV reduces the incidence of cervical cancer. To date, no study has examined the risk factors for cytological abnormalities in this high-risk population., Objective: This population-based, cross-sectional study aimed to identify the risk factors for cervical cytological abnormalities in women infected with non-16/18 hrHPV., Methods: A total of 314,587 women from the general population were recruited for cervical cancer screening at 136 primary care hospitals in Xiangyang, China. Of these, 311,604 women underwent HPV genotyping, and 17,523 non-16/18 hrHPV-positive women were referred for cytological screening according to the screening program. A logistic regression model was used to assess the risk factors for cytological abnormalities among these non-16/18 hrHPV-positive women. A separate analysis was performed to determine the factors influencing high-grade cytological abnormalities., Results: The non-16/18 hrHPV infection rate was 5.88% (18,323/311,604), which was 3-fold higher than that of hrHPV 16/18 (6068/311,604, 1.95%). Among the non-16/18 hrHPV-positive women who underwent ThinPrep cytologic test, the overall prevalence rates of cervical cytological abnormalities and high-grade cytological abnormalities were 13.46% (2359/17,523) and 1.18% (206/17,523), respectively. Multivariate logistic regression analysis revealed that women with middle or high school educational attainment were at a higher risk of having cytological abnormalities than those who received primary education (odds ratio [OR] 1.31, 95% CI 1.17-1.45; P<.001, and OR 1.32, 95% CI 1.14-1.53; P<.001, respectively). Living in rural areas (OR 2.58, 95% CI 2.29-2.90; P<.001), gravidity ≥3 (OR 2.77, 95% CI 1.19-6.45; P=.02), cervix abnormalities detected in pelvic examination (OR 1.22, 95% CI 1.11-1.34; P<.001), and having a cervical cancer screening 3 years ago (OR 0.79, 95% CI 0.62-1.00; P=.048) were associated with cytological abnormalities. The risk factors for high-grade cytological abnormalities included middle school education (OR 1.45, 95% CI 1.07-1.98; P=.02), living in rural regions (OR 1.52, 95% CI 1.10-2.10; P=.01), and cervix abnormality (OR 1.72, 95% CI 1.30-2.26; P<.001)., Conclusions: The dominant epidemic of non-16/18 hrHPV infection is revealed in Chinese women. Multiple risk factors for cervical cytological abnormalities have been identified in women infected with non-16/18 hrHPV. These findings can provide important information for clinically actionable decisions for the screening, early diagnosis, intervention, and prevention of cervical cancer in non-16/18 hrHPV-positive women., (©Ting Xiao, Chun-Quan Ou, Jun Yang, Chunhua Wang, Mei Yang, Tingyu Yu, Liang Shen, Xiaohan Xu, Hui Xing. Originally published in JMIR Public Health and Surveillance (https://publichealth.jmir.org), 08.12.2022.)

Background: The global spread of infectious diseases is currently a prominent threat to public health, with the accelerating pace of globalization and frequent international personnel intercourse. The present study examined the epidemiological characteristics of overseas imported cases of acute infectious diseases in Guangzhou, China., Methods: We retrospectively investigated the distribution of diseases, demographic characteristics, and temporal and spatial variations of imported cases of acute infectious diseases in Guangzhou based on the surveillance data of notifiable infectious diseases from 2005 to 2019, provided by Guangzhou center for Disease Control and Prevention. The Cochran-Armitage trend test was applied to examine the trend in the number of imported cases over time., Results: A total of 1,025 overseas imported cases of acute infectious diseases were identified during the study period. The top three diseases were dengue (67.12%), malaria (12.39%), and influenza A (H1N1) pdm09 (4.10%). Imported cases were predominantly males, with a sex ratio of 2.6: 1 and 75.22% of the cases were those aged 20-49 years. Businessmen, workers, students and unemployed persons accounted for a large proportion of the cases (68.49%) and many of the cases came from Southeast Asia (59.02%). The number of imported cases of acute infectious diseases increased during the study period and hit 318 in 2019. A clear seasonal pattern was observed in the number of imported cases with a peak period between June and November. Imported cases were reported in all of the 11 districts in Guangzhou and the central districts were more seriously affected compared with other districts., Conclusions: The burden of dengue imported from overseas was substantial and increasing in Guangzhou, China, with the peak period from June to November. Dengue was the most common imported disease. Most imported cases were males aged 20-49 years and businessmen. Further efforts, such as strengthening surveillance of imported cases, paying close attention to the epidemics in hotspots, and improving the ability to detect the imported cases from overseas, are warranted to control infectious diseases especially in the center of the city with a higher population density highly affected by imported cases., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2022 Liu et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

The traditional campaign-style enforcement in environmental governance has been debated whether its rebound effect is likely to eat away the short-term environmental benefits and subsequently bring about severer pollution. There are methodological challenges in assessing the effect of temporary environmental intervention. By applying the generalized synthetic control method (GSCM), we quantified and characterized the effectiveness of environmental regulations implemented for the G20 Hangzhou Summit held on 4-5 September, 2016. The summit was successful in reducing Air Quality Composite Index by 17.40% (95% CI: 9.53%, 24.60%), 13.30% (95% CI: 4.23%, 21.50%), and 10.09% (95% CI: 2.01%, 17.51%) in the core, strictly-regulated and regulated areas respectively, comparing with the index expected under a "No-G20" scenario during the preparatory period and the summit period (July-September 2016), and the reduction of the levels in specific pollutants (PM 10 , PM 2.5 , NO 2 , and CO) was also observed. Besides, the environmental benefits lasted for at least 3 months after the summit. This study demonstrates that the pollution control measures during the G20 Hangzhou Summit improved air quality immediately and continuously, and the GSCM provides a useful tool for evaluating the intervention effects of environmental regulations., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Huang, Yang, Wang, Ou and Guan.)

The national Expanded Program on Immunization (EPI) in China has covered vaccines for measles, mumps, and rubella, among children aged 18-24 months since September 2008. However, no previous studies have quantified the effectiveness of the EPI on mumps incidence. There are methodological challenges in assessing the effect of an intervention that targets a subpopulation but finally influences the whole population. In this study, monthly data on mumps incidence were collected in Guangzhou, China, during 2005-2019. We proposed a multi-age-group interrupted time-series design, setting the starting time of exerting effect separately for 14 different age groups. A mixed-effects quasi-Poisson regression was applied to analyze the effectiveness of the EPI on mumps incidence, after controlling for long-term and seasonal trends, and meteorological factors. The model also accounted for the first-order autocorrelation within each age group. Between-age-group correlations were expressed using the contact matrix of age groups. We found that 70,682 mumps cases were reported during 2005-2019, with an annual incidence rate of 37.91 cases per 100,000 population. The effect of EPI strengthened over time, resulting in a decrease in the incidence of mumps by 16.6% (EPI-associated excess risk% = -16.6%, 95% CI: -27.0% to -4.7%) in September 2009 to 40.1% (EPI-associated excess risk% = -40.1%, 95% CI: -46.1% to -33.3%) in September 2019. A reverse U-shape pattern was found in age-specific effect estimates, with the largest reduction of 129 cases per 100,000 population (95% CI: 14 to 1173) in those aged 4-5 years. The EPI is effective in reducing the mumps incidence in Guangzhou. The proposed modeling strategy can be applied for simultaneous assessment of the effectiveness of public health interventions across different age groups, with adequate adjustment for within- and between-group correlations.

Background: The sex difference trend of short-term mortality in coronary artery disease (CAD) is narrowing, which has been reported in the previous studies. However, no studies assess the sex difference temporal trends of CAD mortality in China especially long-term mortality trend., Methods: Based on the registry at Guangdong Provincial People's Hospital which is the largest cardiovascular center in South China, this retrospective cohort study included 24,432 hospitalized patients with CAD confirmed by coronary angiography from January 2007 to December 2014. Women and men were followed for 1-year and 5-year all-cause mortality., Results: From 2007 to 2014, 5-year age-standardized mortality increased from 10.0 to 11.7% in men ( p for trend < 0.001) and from 11.5 to 8.1% in women ( p for trend = 0.99). The multivariable-adjusted hazard ratios (95% CI), which compare women with men, were from 1.02 (0.39-2.67) to 0.66 (0.39-1.12) for 1-year all-cause mortality and 1.23 (0.64-2.36) to 0.59 (0.44-0.79) for 5-year all-cause mortality ( p for trend = 0.04)., Conclusion: Our study found that the mortality risk among men and women was similar in the 1-year prognosis of CAD, and there was no significant downward trend. In the 5-year long-term prognosis of CAD, the mortality risk among men continued to rise, while women had reached the peak, which means that the mortality risk continues to be higher among men than women., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Huang, Lai, Li, Wei, Remutula, Tuersun, Yang, Bao, Yan, Wang, He, Chen, Ou, Yang, Chen, Liu and Liu.)

Few studies have evaluated the short-term association between hospital admissions and individual exposure to ambient particulate matter (PM 2.5 ). Particularly, no studies focused on hospital admissions for chronic obstructive pulmonary disease (COPD) at the individual level. We assessed the short-term effects of PM 2.5 on hospitalization admissions for COPD in Guangzhou, China, during 2014-2015, based on satellite-derived estimates of ambient PM 2.5 concentrations at a 1-km resolution near the residential address as individual-level exposure for each patient. Around 40,002 patients with COPD admitted to 110 hospitals were included in this study. A time-stratified case-crossover design with conditional logistic regression models was applied to assess the effects of PM 2.5 based on a 1-km grid data of aerosol optical depth provided by the National Aeronautics and Space Administration on hospital admissions for COPD. Further, we performed stratified analyses by individual demographic characteristics and season of hospital admission. Around 10 μg/m 3 increase in individual-level PM 2.5 was associated with an increase of 1.6% (95% confidence interval [CI]: 0.6%, 2.7%) in hospitalization for COPD at a lag of 0-5 days. The impact of PM 2.5 on hospitalization for COPD was greater significantly in males and patients admitted in summer. Our study strengthened the evidence for the adverse effect of PM 2.5 based on satellite-based individual-level exposure data., (© 2021. The Author(s).)

Background: The first community transmission of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) Delta variant of concern (VOC) in Guangzhou, China occurred between May and June 2021. Herein, we describe the epidemiological characteristics of this outbreak and evaluate the implemented containment measures against this outbreak., Methodology/principal Findings: Guangzhou Center for Disease Control and Prevention provided the data on SARS-CoV-2 infections reported between 21 May and 24 June 2021. We estimated the incubation period distribution by fitting a gamma distribution to the data, while the serial interval distribution was estimated by fitting a normal distribution. The instantaneous effective reproductive number (Rt) was estimated to reflect the transmissibility of SARS-CoV-2. Clinical severity was compared for cases with different vaccination statuses using an ordinal regression model after controlling for age. Of the reported local cases, 7/153 (4.6%) were asymptomatic. The median incubation period was 6.02 (95% confidence interval [CI]: 5.42-6.71) days and the means of serial intervals decreased from 5.19 (95% CI: 4.29-6.11) to 3.78 (95% CI: 2.74-4.81) days. The incubation period increased with age (P<0.001). A hierarchical prevention and control strategy against COVID-19 was implemented in Guangzhou, with Rt decreasing from 6.83 (95% credible interval [CrI]: 3.98-10.44) for the 7-day time window ending on 27 May 2021 to below 1 for the time window ending on 8 June and thereafter. Individuals with partial or full vaccination schedules with BBIBP-CorV or CoronaVac accounted for 15.3% of the COVID-19 cases. Clinical symptoms were milder in partially or fully vaccinated cases than in unvaccinated cases (odds ratio [OR] = 0.26 [95% CI: 0.07-0.94])., Conclusions/significance: The hierarchical prevention and control strategy against COVID-19 in Guangzhou was timely and effective. Authorised inactivated vaccines are likely to contribute to reducing the probability of developing severe disease. Our findings have important implications for the containment of COVID-19., Competing Interests: The authors have declared that no competing interests exist.

Aims: The aims of this study were to describe the characteristics and outcomes of the universal new definition of heart failure with improved ejection fraction (HFimpEF) and to identify predictors for HFimpEF among patients with coronary artery disease (CAD). Methods: CAD subjects with heart failure with reduced ejection fraction (HFrEF) (EF ≤ 40%) at baseline were enrolled from the real-world registry of the Cardiorenal ImprovemeNt study from January 2007 to December 2018. The new definition of HFimpEF was defined as left ventricular EF (LVEF) of≤40% at baseline and with improvement of up to 40% and at least a ≥ 10% increase during 1 month to 1 year after discharge. Results: Of the 747 CAD patients with HFrEF (86.7% males, mean age: 61.4 ± 11 years), 267 (35.7%) patients conformed to the new HFimpEF definition. Patients with HFimpEF were younger (adjusted odds ratio [aOR]: 0.98 [0.97-0.99]) and had a higher rate of hypertension (aOR:1.43 [1.04-1.98]), lower rate of percutaneous coronary intervention (PCI) treatment at the time of detection of HFrEF (aOR: 0.48 [0.34-0.69]), history of PCI (aOR: 0.51 [0.28-0.88]), history of acute myocardial infarction (aOR: 0.40 [0.21-0.70]), and lower left ventricular end diastolic diameter (aOR: 0.92 [0.90-0.95]). During 3.3-year follow-up, patients with HFimpEF demonstrated lower rates of long-term all-cause mortality (13.1% vs. 20.8%, aHR: 0.61[0.41-0.90]). Conclusion: In our study, CAD patients with HFimpEF achieved a better prognosis compared to those with persistent HFrEF. Patients with CAD meeting the criteria for the universal definition of HFimpEF tended to be younger, presented fewer clinical comorbidities, and had lower left ventricular end diastolic diameter., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Huang, Liu, Lei, Yang, Bao, Li, Lai, Wang, He, Chen, Ou, Abudukerimu, Hu, Tan, Chen and Liu.)

Background: In the context of ongoing climate change, temperature variability (TV) has been considered as an important trigger of death. However, evidence of association between mortality and hourly temperature variability (HTV) is scarce at the multi-city level, and the time window of health effects of HTV is lack of investigation. This study aims at quantifying the mortality risk and burden of HTV and exploring subpopulations susceptible to HTV from a large-scale multi-city perspective., Methods: Data on daily number of deaths and meteorology were collected for 31 Chinese major cities during 2007-2013. HTV was calculated as the standard deviation of hourly temperature within a few days. The optimal exposure period of HTV was chosen according to multiple scientific criteria. A quasi-Poisson regression combined with distributed lag nonlinear model was used to assess the city-specific HTV-mortality associations. Then, meta-analysis was further applied to pool city-specific effect estimates. Finally, we calculated the fraction of mortality attributable to HTV. Stratification analyses were conducted by individual characteristics (i.e. age, sex, and educational attainment), season, and region., Results: HTV calculated in a relatively long-time window like 18 d (HTV 0-17 ) could capture the impact of HTV adequately. Per 1 °C raise of HTV 0-17 associated with 1.38% (95%CI: 0.77, 1.99) increase of non-accidental mortality. During the study period, 5.47% (95%CI: 1.06, 9.64) of non-accidental mortality could be attributed to HTV. The females, the elderly, and individuals with low education level were more susceptible to HTV than their counterparts, respectively. Moreover, a stronger HTV-mortality association was observed in individuals who live in warmer season and temperature zone., Conclusion: HTV is associated with a considerable mortality burden, which may be modified by season, geographic and individual-level factors. Our findings highlight the practical importance of establishing early warning systems and promoting health education to mitigate the impacts of temperature variability., (Copyright © 2021 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: China has introduced a series of stricter policies to criminalize drunk driving and increase penalties since May 2011. However, there is no previous study examining the time-varying impacts of drunk driving regulations on road traffic fatalities based on daily data., Methods: We collected 6536 individual data of road traffic deaths (RTDs) in Guangzhou from 2008 to 2018. The quasi-Poisson regression models with an inclusion of the intervention variable and the interaction of intervention variable and a function of time were used to quantify the time-varying effects of these regulations., Results: During the 11-year study period, the number of population and motor vehicles showed a steady upward trend. However, the population- and motor vehicles- standardized RTDs rose steadily before May 2011, the criminalizing drunk driving intervention was implemented and gradually declined after that. The new drunk driving intervention were associated with an average risk reduction of RTDs (ER = -9.01, 95% eCI: - 10.05% to - 7.62%) during the 7.7 years after May 2011. On average, 75.82 (95% eCI, 54.06 to 92.04) RTDs per 1 million population annually were prevented due to the drunk driving intervention., Conclusion: These findings would provide important implications for the development of integrated intervention measures in China and other countries attempting to reduce traffic fatalities by stricter regulations on drunk driving., (© 2021. The Author(s).)

Recent studies have reported a variety of health consequences of climate change. However, the vulnerability of individuals and cities to climate change remains to be evaluated. We project the excess cause-, age-, region-, and education-specific mortality attributable to future high temperatures in 161 Chinese districts/counties using 28 global climate models (GCMs) under two representative concentration pathways (RCPs). To assess the influence of population ageing on the projection of future heat-related mortality, we further project the age-specific effect estimates under five shared socioeconomic pathways (SSPs). Heat-related excess mortality is projected to increase from 1.9% (95% eCI: 0.2-3.3%) in the 2010s to 2.4% (0.4-4.1%) in the 2030 s and 5.5% (0.5-9.9%) in the 2090 s under RCP8.5, with corresponding relative changes of 0.5% (0.0-1.2%) and 3.6% (-0.5-7.5%). The projected slopes are steeper in southern, eastern, central and northern China. People with cardiorespiratory diseases, females, the elderly and those with low educational attainment could be more affected. Population ageing amplifies future heat-related excess deaths 2.3- to 5.8-fold under different SSPs, particularly for the northeast region. Our findings can help guide public health responses to ameliorate the risk of climate change.

Background: Aedes albopictus is the primary vector of mosquito-borne diseases, including dengue and chikungunya, in China. The management of vector mosquitoes is the primary strategy for the control of such infectious diseases. The gravid Ae. albopictus prefers to skip-oviposit its eggs into different small water containers, and the management of these breeding places is critical for mosquito control. Bacillus thuringiensis subspecies Israelensis (Bti) is a useful biological larvicide, but the effective period of the currently available commercial product is relatively short. This study aimed to develop a long-lasting formulation of Bti to control the dengue vector mosquito Ae. albopictus., Results: Water-soluble polyethylene glycols and water-insoluble hexadecanol were mixed with Bti to develop the long-lasting formulation Bti-BLOCK, based on the solid dispersion technique. The controlled release of Bti-BLOCK and its effect on Ae. albopictus were assayed in the laboratory and in the field. The results showed that Bti toxins were slowly released from Bti-BLOCK into the water and maintained at an effective dose for at least 6 months. Bti-BLOCK caused high mortality during the immature stage (>90%) and achieved full inhibition during pupation (100%). The efficacy lasted at least 12 weeks in the laboratory and 6 weeks in the field. Furthermore, we confirmed an 89% reduction in Ae. albopictus density and a reduction in the R 0 of dengue to a low-risk level after 6 months of open-field interventions., Conclusions: We developed a long-lasting biological larvicide, Bti-BLOCK, which displayed very good efficacy in the control of the dengue vector mosquito Ae. albopictus., (© 2020 Society of Chemical Industry.)

We examined characteristics of chest CT across different time periods for patients with COVID-19 pneumonia in Huizhou, China. This study included 56 COVID-19 patients with abnormal CT acquired between January 22 and March 3, 2020. The 141 scans of 56 patients were classified into four groups (Groups 1-4) based on dates on which scans were obtained at the 1st, 2nd, 3rd week or longer than three weeks after illness onset. Forty-five patients with follow-up scans were categorized into four groups (Groups A-D) according to extent that lesions reduced (≥ 75%, 50-75%, 25-50% and < 25%). Ground-glass opacities (GGO) was prevalent in Groups 1-4 (58.1-82.6%), while percentages of consolidation ranged between 9.7% in Group 4 and 26.2% in Group 2. The highest frequency of fibrous stripes occurred in Group 3 (46.7%). Total CT scores were on average higher in Groups 2-3. Among 45 follow-up patients, 11 (24.4%) of them recovered with lesions reducing ≥ 75%, with the lowest median age and total CT scores on admission. There are temporal patterns of lung abnormalities in COVID-19 patients, with higher extent of lesion involvement occurring in the 2nd and 3rd week. Persisting lung changes indicate some patients may need isolation after discharge from hospital.

Background: Individualized prediction of mortality risk can inform the treatment strategy for patients with COVID-19 and solid tumors and potentially improve patient outcomes. We aimed to develop a nomogram for predicting in-hospital mortality of patients with COVID-19 with solid tumors., Methods: We enrolled patients with COVID-19 with solid tumors admitted to 32 hospitals in China between December 17, 2020, and March 18, 2020. A multivariate logistic regression model was constructed via stepwise regression analysis, and a nomogram was subsequently developed based on the fitted multivariate logistic regression model. Discrimination and calibration of the nomogram were evaluated by estimating the area under the receiver operator characteristic curve (AUC) for the model and by bootstrap resampling, a Hosmer-Lemeshow test, and visual inspection of the calibration curve., Results: There were 216 patients with COVID-19 with solid tumors included in the present study, of whom 37 (17%) died and the other 179 all recovered from COVID-19 and were discharged. The median age of the enrolled patients was 63.0 years and 113 (52.3%) were men. Multivariate logistic regression revealed that increasing age (OR=1.08, 95% CI 1.00 to 1.16), receipt of antitumor treatment within 3 months before COVID-19 (OR=28.65, 95% CI 3.54 to 231.97), peripheral white blood cell (WBC) count ≥6.93 ×10 9 /L (OR=14.52, 95% CI 2.45 to 86.14), derived neutrophil-to-lymphocyte ratio (dNLR; neutrophil count/(WBC count minus neutrophil count)) ≥4.19 (OR=18.99, 95% CI 3.58 to 100.65), and dyspnea on admission (OR=20.38, 95% CI 3.55 to 117.02) were associated with elevated mortality risk. The performance of the established nomogram was satisfactory, with an AUC of 0.953 (95% CI 0.908 to 0.997) for the model, non-significant findings on the Hosmer-Lemeshow test, and rough agreement between predicted and observed probabilities as suggested in calibration curves. The sensitivity and specificity of the model were 86.4% and 92.5%., Conclusion: Increasing age, receipt of antitumor treatment within 3 months before COVID-19 diagnosis, elevated WBC count and dNLR, and having dyspnea on admission were independent risk factors for mortality among patients with COVID-19 and solid tumors. The nomogram based on these factors accurately predicted mortality risk for individual patients., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

In 2019, dengue incidences increased dramatically in many countries. However, the prospective growth in dengue incidence did not occur in Guangzhou, China. We examined the effectiveness of early start of Grade III response to dengue in Guangzhou. We extracted the data on daily number of dengue cases during 2017-2019 in Guangzhou and weekly data for Foshan and Zhongshan from the China National Notifiable Disease Reporting System, while the data on weekly number of positive ovitraps for adult and larval Aedes albopictus were obtained from Guangzhou Center for Disease Control and Prevention. We estimated the number of dengue cases prevented by bringing forward the starting time of Grade III response from September in 2017-2018 to August in 2019 in Guangzhou using a quasi-Poisson regression model and applied the Baron and Kenny's approach to explore whether mosquito vector density was a mediator of the protective benefit. In Guangzhou, early start of Grade III response was associated with a decline in dengue incidence (relative risk [RR]: 0.54, 95% confidence interval [CI]: 0.43-0.70), with 987 (95% CI: 521-1,593) cases averted in 2019. The rate of positive ovitraps also significantly declined (RR: 0.64, 95% CI: 0.53-0.77). Moreover, both mosquito vector density and early start of Grade III response was significantly associated with dengue incidence after adjustment for each other. By comparing with the incidence in Foshan and Zhongshan where the Grade III response has not been taken, benefits from the response starting in August were confirmed but not if starting from September. Early start of Grade III response has effectively mitigated the dengue burden in Guangzhou, China, which might be partially through reducing the mosquito vector density. Our findings have important public health implications for development and implementation of dengue control interventions for Guangzhou and other locations with dengue epidemics., Competing Interests: The authors have declared that no competing interests exist.

Background: This study analyzed the trends and seasonality in mortality among children aged 0-14 years in Guangzhou, China during 2008-2018. Understanding the epidemiology of this public health problem can guide policy development for children mortality prevention., Methods: A population-based epidemiological retrospective study was conducted. Seven thousand two hundred sixty-five individual data of children mortality were obtained from the Guangzhou Center for Disease Control and Prevention (CDC). The Poisson regression was used to quantify the annual average reduction rate and the difference in mortality rate between sex and age groups. Incidence ratio with 95% confidence interval (CI) was estimated to determine the temperaol variations in mortality by month, season, school term, day of the week and between holidays and other days., Results: Between 2008 and 2018, the children mortality rate in Guangzhou decreased from 54.0 to 34.3 per 100,000 children, with an annual reduction rate of 4.6% (95% CI: 1.1%-8.1%), especially the under-5 mortality rate decreased by 8.3% (95% CI: 4.8%-11.6%) per year. Decline trends varied by causes of death, even with an upward trend for the mortality of asphyxia and neurological diseases. The risk of death among males children was 1.33 times (95% CI: 1.20-1.47) of that of females. The distribution of causes of death differed by age group. Maternal and perinatal, congenital and pneumonia were the top three causes of death in infants and cancer accounted for 17% of deaths in children aged 1-14 years. Moreover, the injury-related mortality showed significant temporal variations with higher risk during the weekend. And there was a summer peak for drowning and a winter peak for asphyxia., Conclusions: Guangzhou has made considerable progress in reducing mortality over the last decade. The findings of characteristics of children mortality would provide important information for the development and implementation of integrated interventions targeted specific age groups and causes of death.

Some researches have shown the associations between air pollution and hospital-based emergency department visits, while the evidence about the acute effects of air pollution on emergency ambulance dispatches for the whole population is rarely available, especially on an hourly time scale. This paper aimed to investigate the effects of hourly concentrations of ambient air pollution on hourly number of ambulance emergency call-outs (AECOs) in Shenzhen, China. AECO data were collected from Shenzhen Emergency Center from January 2013 to December 2016. A time-stratified case-crossover design with conditional Poisson regression was performed to fit the relationship between hourly air pollution and AECOs. The distributed lag model was applied to determine lag structure of the effects of air pollutants. There were a total of 502,862 AECOs during the study period. The significant detrimental effects of SO 2 , PM 2.5 , and PM 10 appeared immediately with a following harvesting effect after 5 h and the effects lasted for about 96 h. The cumulative effect estimates of four pollutants over 0-96 h were 13.99% (95% CI 7.52-20.85%), 2.07% (95% CI 0.72-3.43%), 1.20% (95% CI 0.54-1.87%), and 2.46% (95% CI 1.63-3.29%), respectively. We did not observe significant effects of O 3 . This population-based study quantifies the adverse effects of air pollution on ambulance dispatches and provides evidence of the lag structure of the effects on an hourly time scale.

Background: Although road traffic casualty (RTC) is preventable, it remains the eighth leading cause of death globally, especially in developing countries. Previous studies suggested the association between RTC and monthly or daily weather conditions, while the acute effects of weather conditions on an hourly timescale remains unknown. This study aims to quantify hourly effects of precipitation and temperature on RTC., Methods: Using ambulance records on RTC during 2010-2016 for the whole population in Shenzhen, China, we conducted a time-stratified case-crossover design which can inherently control for hour of the day, day of the week, seasonality, time trends and potential time-invariant confounders. Conditional quasi-Poisson regression with distributed lag nonlinear model was used to determine the effects of hourly precipitation and temperature on RTC., Results: Light and heavy precipitation increased RTC in current and following 2 h by 8.09% (95% CI: 4.20-12.12%) and 11.62% (95% CI: 5.93-17.62%), respectively. A J-shaped temperature-RTC curve revealed that each 1 °C increment above 17 °C were associated with a 0.87% (0.52-1.22%) increase in RTC. High temperature accounted for 6.44% (95% CI: 3.95-8.91%) of all RTC, with a high fraction of 10.64% (95% CI: 4.33-15.96%) during warm season and 8.30% (95% CI: 4.26-12.66%) in traffic peak hours. Precipitation contributed to 0.68% (95% CI: 0.44-0.92%) of RTC within 3 h. The middle-aged and female suffered more from precipitation-associated RTC, and the younger suffered more from high temperature-associated RTC., Conclusions: High temperature increased substantially hourly RTC. Precipitation was also a risk factor of RTC and the adverse effect lasted for 3 h. The findings would be helpful to guide the development of targeted intervention to accelerate progress in road traffic safety., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Background: The coronavirus disease 2019 (COVID-19) outbreak is evolving rapidly worldwide., Objective: To evaluate the risk of serious adverse outcomes in patients with COVID-19 by stratifying the comorbidity status., Methods: We analysed data from 1590 laboratory confirmed hospitalised patients from 575 hospitals in 31 provinces/autonomous regions/provincial municipalities across mainland China between 11 December 2019 and 31 January 2020. We analysed the composite end-points, which consisted of admission to an intensive care unit, invasive ventilation or death. The risk of reaching the composite end-points was compared according to the presence and number of comorbidities., Results: The mean age was 48.9 years and 686 (42.7%) patients were female. Severe cases accounted for 16.0% of the study population. 131 (8.2%) patients reached the composite end-points. 399 (25.1%) reported having at least one comorbidity. The most prevalent comorbidity was hypertension (16.9%), followed by diabetes (8.2%). 130 (8.2%) patients reported having two or more comorbidities. After adjusting for age and smoking status, COPD (HR (95% CI) 2.681 (1.424-5.048)), diabetes (1.59 (1.03-2.45)), hypertension (1.58 (1.07-2.32)) and malignancy (3.50 (1.60-7.64)) were risk factors of reaching the composite end-points. The hazard ratio (95% CI) was 1.79 (1.16-2.77) among patients with at least one comorbidity and 2.59 (1.61-4.17) among patients with two or more comorbidities., Conclusion: Among laboratory confirmed cases of COVID-19, patients with any comorbidity yielded poorer clinical outcomes than those without. A greater number of comorbidities also correlated with poorer clinical outcomes., Competing Interests: Conflict of interest: Wei-jie Guan has nothing to disclose. Conflict of interest: Wen-hua Liang has nothing to disclose. Conflict of interest: Yi Zhao has nothing to disclose. Conflict of interest: Heng-rui Liang has nothing to disclose. Conflict of interest: Zi-sheng Chen has nothing to disclose. Conflict of interest: Yi-min Li has nothing to disclose. Conflict of interest: Xiao-qing Liu has nothing to disclose. Conflict of interest: Ru-chong Chen has nothing to disclose. Conflict of interest: Chun-li Tang has nothing to disclose. Conflict of interest: Tao Wang has nothing to disclose. Conflict of interest: Chun-quan Ou has nothing to disclose. Conflict of interest: Li has nothing to disclose. Conflict of interest: Ping-yan Chen has nothing to disclose. Conflict of interest: Ling Sang has nothing to disclose. Conflict of interest: Wei Wang has nothing to disclose. Conflict of interest: Jian-fu Li has nothing to disclose. Conflict of interest: Cai-chen Li has nothing to disclose. Conflict of interest: Li-min Ou has nothing to disclose. Conflict of interest: Bo Cheng has nothing to disclose. Conflict of interest: Shan Xiong has nothing to disclose. Conflict of interest: Zheng-yi Ni has nothing to disclose. Conflict of interest: Jie Xiang has nothing to disclose. Conflict of interest: Yu Hu has nothing to disclose. Conflict of interest: Lei Liu has nothing to disclose. Conflict of interest: Hong Shan has nothing to disclose. Conflict of interest: Chun-liang Lei has nothing to disclose. Conflict of interest: Yi-xiang Peng has nothing to disclose. Conflict of interest: Li Wei has nothing to disclose. Conflict of interest: Yong Liu has nothing to disclose. Conflict of interest: Ya-hua Hu has nothing to disclose. Conflict of interest: Peng has nothing to disclose. Conflict of interest: Jian-ming Wang has nothing to disclose. Conflict of interest: Ji-yang Liu has nothing to disclose. Conflict of interest: Zhong Chen has nothing to disclose. Conflict of interest: Gang Li has nothing to disclose. Conflict of interest: Zhi-jian Zheng has nothing to disclose. Conflict of interest: Shao-qin Qiu has nothing to disclose. Conflict of interest: Jie Luo has nothing to disclose. Conflict of interest: Chang-jiang Ye has nothing to disclose. Conflict of interest: Shao-yong Zhu has nothing to disclose. Conflict of interest: Lin-ling Cheng has nothing to disclose. Conflict of interest: Feng Ye has nothing to disclose. Conflict of interest: Shi-yue Li has nothing to disclose. Conflict of interest: Jin-ping Zheng has nothing to disclose. Conflict of interest: Nuo-fu Zhang has nothing to disclose. Conflict of interest: Nan-shan Zhong reports grants from the National Health Commission and Dept of Science and Technology of Guangdong Province, during the conduct of the study. Conflict of interest: Jian-xing He has nothing to disclose., (Copyright ©ERS 2020.)

Background: Since December 2019, when coronavirus disease 2019 (Covid-19) emerged in Wuhan city and rapidly spread throughout China, data have been needed on the clinical characteristics of the affected patients., Methods: We extracted data regarding 1099 patients with laboratory-confirmed Covid-19 from 552 hospitals in 30 provinces, autonomous regions, and municipalities in mainland China through January 29, 2020. The primary composite end point was admission to an intensive care unit (ICU), the use of mechanical ventilation, or death., Results: The median age of the patients was 47 years; 41.9% of the patients were female. The primary composite end point occurred in 67 patients (6.1%), including 5.0% who were admitted to the ICU, 2.3% who underwent invasive mechanical ventilation, and 1.4% who died. Only 1.9% of the patients had a history of direct contact with wildlife. Among nonresidents of Wuhan, 72.3% had contact with residents of Wuhan, including 31.3% who had visited the city. The most common symptoms were fever (43.8% on admission and 88.7% during hospitalization) and cough (67.8%). Diarrhea was uncommon (3.8%). The median incubation period was 4 days (interquartile range, 2 to 7). On admission, ground-glass opacity was the most common radiologic finding on chest computed tomography (CT) (56.4%). No radiographic or CT abnormality was found in 157 of 877 patients (17.9%) with nonsevere disease and in 5 of 173 patients (2.9%) with severe disease. Lymphocytopenia was present in 83.2% of the patients on admission., Conclusions: During the first 2 months of the current outbreak, Covid-19 spread rapidly throughout China and caused varying degrees of illness. Patients often presented without fever, and many did not have abnormal radiologic findings. (Funded by the National Health Commission of China and others.)., (Copyright © 2020 Massachusetts Medical Society.)

Background: Longer ambulance response time (ART) delaying treatment would worsen conditions of seriously ill or injured patients, but limited evidence is available on the effects of weather factors on ART. This study aims to assess precipitation- and temperature-ART associations and their potential lagged effects using a novel modeling strategy., Methods: Based on 779,156 emergency records during 2010-2016 from the whole population in Shenzhen, China, we creatively combined quantile regression with distributed-lag nonlinear models to examine the non-linear and lagged effects of hourly precipitation and temperature on ART at the 50th and 90th percentiles., Results: A linear precipitation-ART association with a delay of 9.01 (95%CI, 7.82-10.20) seconds at median ART for a 1 mm increase in hourly precipitation, and the effects lasted for 5 h with the greatest effect at the current hour. A two linear thresholds temperature-ART association revealed 1 °C decrease below 19 °C caused 1.68 (95%CI, 0.92-2.44) seconds delay in total ART over lag 0-7 h, and 1 °C increase above 24 °C caused 2.44 (95%CI, 1.55-3.33) seconds delay. The hourly call volumes exceeding 54 calls caused 8.79 (95%CI, 8.71-8.86) seconds delay in total ART for 1 more call, but not affected the effects of weather factors. The internal ART suffered more from the hourly call volumes, while the external ART suffered more from precipitation and temperature. The effects were apparently greater on ART at the 90th percentile than median., Conclusions: Precipitation and temperature are independent risk factors for ambulance services performance, and their lagged effects are notable. The external ART and patients with long ART are vulnerable. More attention should be paid to weather and ART, and these findings may have implications for effective policies to reduce ART to protect public health., Competing Interests: Declaration of competing interest The authors declare they have no actual or potential competing financial interests., (Copyright © 2019 Elsevier Inc. All rights reserved.)

It is unclear how to develop a model based on the combined satellite data and ground monitoring data to accurately estimate daily NO 2 levels. Furthermore, the conventional cross-validation (CV) results represent average levels but the model performance may vary greatly from grid to grid. It is an essential issue to evaluate model's prediction ability in different grids and determine the factors affecting model extrapolating ability, which have never been well examined to date. The aim of this study was to compare the ability of three different methods to estimate the daily NO 2 across mainland China during 2014-2016; and to develop a novel two-stage meta-analysis method for exploring the influence of the number and the distribution of nearby sites on grid-level prediction accuracy. For better estimating the daily NO 2 level, we developed and compared three methods, including universal kriging model, satellite-based method (Non-linear exposure-lag-response model & Extreme gradient boosting combined technique) and the kriging-calibrated satellite method. For exploring influencing factors, the two-stage meta-analysis method was purposed. The kriging-calibrated satellite method had an overall CV R-square and root mean square error (RMSE) of 0.85 and 7.87μg/m 3 , better than the Universal Kriging model and the satellite-based method (CV R 2  = 0.57 and 0.81). The two-stage meta-analysis method revealed that the model performance did decrease with the sparser distribution of nearby sites. And adding 5 sites within 50 km in the random mode can bring 17.51% improvement in model extrapolating ability. The kriging-calibration can help satellite-based machine learning to provide more accurate NO 2 prediction. Our novel evaluation method can provide the suggestion of adding new sites effectively within a limit budget., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Objective: Ambient particulate pollution, especially PM 2.5 , has adverse impacts on health and welfare. To manage and control PM 2.5 pollution, it is of great importance to determine the factors that affect PM 2.5 levels. Previous studies commonly focused on a single or several cities. This study aims to analyze the impacts of meteorological and socio-economic factors on daily concentrations of PM 2.5 in 109 Chinese cities from January 1, 2015 to December 31, 2015., Methods: To evaluate potential risk factors associated with the spatial and temporal variations in PM 2.5 levels, we developed a Bayesian spatio-temporal model in which the potential temporal autocorrelation and spatial autocorrelation of PM 2.5 levels were taken into account to ensure the independence of the error term of the model and hence the robustness of the estimated parameters., Results: Daily concentrations of PM 2.5 peaked in winter and troughed in summer. The annual average concentration reached its highest value (79 μg/m 3 ) in the Beijing-Tianjin-Hebei area. The city-level PM 2.5 was positively associated with the proportion of the secondary industry, the total consumption of liquefied petroleum gas and the total emissions of industrial sulfur dioxide (SO 2 ), but negatively associated with the proportion of the primary industry. A reverse U-shaped relationship between population density and PM 2.5 was found. The city-level and daily-level of weather conditions within a city were both associated with PM 2.5 ., Conclusion: PM 2.5 levels had significant spatio-temporal variations which were associated with socioeconomic and meteorological factors. Particularly, economic structure was a determinant factor of PM 2.5 pollution rather than per capita GDP. This finding will be helpful for the intervention planning of particulate pollution control when considering the environmental and social-economic factors as part of the strategies., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Background: In the context of global warming, most researches have been conducted on health influences of heat waves, with limited understanding of health impacts of cold spells, especially for developing countries., Methods: We collected daily mortality and meteorological data for 31 capital cities across China during the maximum period of 2007-2013. A quasi-Poisson regression model combined with a distributed lag non-linear model was used to estimate the short-term effects of cold spells on mortality in cold seasons (November to March). 19 definitions of cold spell were clearly compared, including three definitions from the China Meteorological Administration (CMA) and 16 definitions by combining two temperature indicators (daily minimum and mean temperature), two temperature thresholds (3rd and 5th percentile) and four durations of at least 2-5 days. Then, a random effect meta-analysis was applied to pool the effect estimates at national level. Furthermore, a stratified analysis was constructed to identify the vulnerable subpopulations to cold spells., Results: The definition, in which daily mean temperature falls below 5th percentile for at least two consecutive days, produced the optimum model fit performance. Generally, the mortality risk increased to the maximum after 3-6 days' exposure to cold spell and then leveled off in the next 3 weeks. The pooled relative risks (RR) of non-accidental mortality for cold spells were 1.03 (95% CI: 1.01-1.05), 1.27 (1.19-1.35) and 1.55 (1.40-1.70) at lag 0, lag 0-14 and lag 0-27 days, respectively. The greatest effect estimates of cold spells were found among total respiratory diseases and COPD, with RR of 1.88 (1.65-2.11) and 1.88 (1.58-2.19), respectively. The elderly, less-educated individuals and residents in southern China were more vulnerable to cold spells., Conclusion: There are remarkable mortality effects of cold spells, with effect estimates varying with the definition of cold spell and subpopulations. Using the official definition of cold spells may fail to capture the mortality risk associated with cold spells. These findings may facilitate the development of cold alert warning system and preventive actions to the vulnerable populations., (Copyright © 2019 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: Drought is a major natural disaster that causes severe social and economic losses. The prediction of regional droughts may provide important information for drought preparedness and farm irrigation. The existing drought prediction models are mainly based on a single weather station. Efforts need to be taken to develop a new multistation-based prediction model., Objectives: This study optimizes the predictor selection process and develops a new model to predict droughts using past drought index, meteorological measures and climate signals from 32 stations during 1961 to 2016 in Shaanxi province, China., Methods: We applied and compared two methods, including a cross-correlation function and a distributed lag nonlinear model (DLNM), in selecting the optimal predictors and specifying their lag time. Then, we built a DLNM, an artificial neural network model and an XGBoost model and compared their validations for predicting the Standardized Precipitation Evapotranspiration Index (SPEI) 1-6 months in advance., Results: The DLNM was better than the cross-correlation function in predictor selection and lag effect determination. The XGBoost model more accurately predicted SPEI with a lead time of 1-6 months than the DLNM and the artificial neural network, with cross-validation R 2 values of 0.68-0.82, 0.72-0.89, 0.81-0.92, and 0.84-0.95 at 3-, 6-, 9- and 12-month time scales, respectively. Moreover, the XGBoost model had the highest prediction accuracy for overall droughts (89%-97%) and for three specific drought categories (i.e., moderate, severe, and extreme) (76%-94%)., Conclusion: This study offers a new modeling strategy for drought predictions based on multistation data. The incorporation of nonlinear and lag effects of predictors into the XGBoost method can significantly improve prediction accuracy of SPEI and drought., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Background: People are exposed to mixtures of highly correlated gaseous, liquid and solid pollutants. However, in previous studies, the assessment of air pollution effects was mainly based on single-pollutant models or was simultaneously included as multiple pollutants in a model. It is essential to develop appropriate methods to accurately estimate the health effects of multiple pollutants in the presence of a high correlation between pollutants., Methods: The flexible tensor product smooths of multiple pollutants was applied for the first time in a quasi-Poisson model to estimate the health effects of SO 2 , NO 2 and PM 10 on daily all-cause deaths during 2005-2012 in Guangzhou, China. The results were compared with those from three other conventional models, including the single-pollutant model and the three-pollutant model with and without first-order interactions., Results: The tensor product model revealed a complex interaction among three pollutants and significant combined effects of PM 10 , NO 2 and SO 2 , which revealed a 2.53% (95%CI: 1.03-4.01%) increase in mortality associated with an interquartile-range (IQR) increase in the concentrations of all three pollutants. The combined effect estimated by the single-pollutant model was 5.63% (95% CI: 3.96-7.34%). Although the conventional three-pollutant models produced combined effect estimates (2.20, 95%CI, 1.18-3.23%; 2.78, 95%CI: 1.35-4.23%) similar to those of the tensor product model, they distorted the estimates and inflated the variances of the estimates when attributing the combined health effects to individual pollutants., Conclusions: The single-pollutant model or conventional multi-pollutant model may yield misleading results in the presence of collinearity. The tensor product quasi-Poisson regression provides a novel approach to the assessment of the health impacts of multiple pollutants by flexibly fitting the interaction effects and avoiding the collinearity problem.

Background: Major depressive disorder (MDD) is a common psychiatric disorder. With systematic antidepressant treatment, 50-75% of patients have a treatment response but require 4-6 weeks to have their symptoms alleviated. Therefore, researchers anticipate the development of novel fast-acting antidepressants. Previous studies have revealed that the decrease of bio-energetic metabolism may contribute to the occurrence of depression, while our team has found adenosine triphosphate (ATP) and phosphocreatine (PCr) to be fast-acting antidepressants in the depressed-animal model. ATP and PCr have already been widely prescribed clinically as energy supplements for cells. This will be the first clinical attempt of the intravenous administration of ATP and PCr combined with orally administered fluoxetine in MDD., Methods: This is a single-center, randomized, double-blind, placebo-controlled pilot study. A total of 42 patients will be divided randomly into three groups. Patients will receive an intravenous administration of ATP or PCr or saline twice daily combined with orally administered fluoxetine (20 mg/day) for the first 2 weeks and fluoxetine monotherapy for the following 4 weeks. Follow-up assessment will be completed at week 10. Feasibility outcomes will include percentages of patient eligibility, intention to use medication, willingness to participate, drug adherence, completion of the scheduled assessment, retention, drop-out, etc. Physical examination results, Side Effect Rating Scale, adverse events, results from blood tests, electroencephalogram, and electrocardiograph will be recorded for safety evaluation of the augmentation therapy. The trends of efficacy will be evaluated by the reduction rate of the Hamilton Depression Rating Scale, the mean change of the Clinical Global Impression Scale, and the Patients Health Questionaire-9 items., Discussion: In our study, ATP and PCr will be given by intravenous infusion. Thus patients will be hospitalized for the initial 2 weeks for safety concern. Hospitalization will be an impact factor for the recruitment, participation, drop-out, efficacy, results, etc. The evaluation of our feasibility outcomes, study setting, safety of augmentation therapy and possible efficacy trends among groups, will facilitate a full-scale trial design and sample size calculation., Trial Registration: NCT03138681 . Registered on 3 May 2017. First patient: 4 May 2017.

The associations between meteorological factors and mortality have been well documented worldwide, but limited evidence is available for the non-fatal health impacts of ambient temperature, particularly there are few population-based investigations on the impacts of emergency ambulance dispatches in Asia. In this study, based on 809,906 ambulance emergency call-outs (AECOs) for the total population from 2010-2016 in the subtropical city of Shenzhen, China, a Poisson regression combined with a distributed lag nonlinear model was used to simultaneously assess the nonlinear and lag effects of daily mean temperature on AECOs. Stratified analyses by age and sex were performed to identify vulnerable subpopulations. A U-shaped relationship was found between temperature and AECOs. Cold effects were delayed and persisted for 3-4 weeks, with a cumulative relative risk (RR) and 95% confidence interval (CI) of 1.23 (1.10-1.38) and 1.25 (1.16-1.35) over lag 0-28 when comparing the 1st and 5th percentile of the temperature distribution to the optimal (i.e. minimum AECOs) temperature, respectively. Hot effects were immediate and diminished quickly in 5 days, with an increase of 19% (RR = 1.19, 95%CI: 1.14-1.23) and 21% (RR = 1.21, 95%CI: 1.16-1.26) in AECOs over lag 0-5 when comparing the 95th and 99th percentile of temperature to the optimal temperature. Children and the elderly were more vulnerable to cold effects. The youth and middle-aged people suffered more from high temperature. The effects of temperature were similar between males and females. In summary, significant increases were observed in the frequency of AECOs during cold and hot days, and the weather-associated increases in AECOs are different among age groups. This information has valuable implications in ambulance demand prediction and service provision planning., Competing Interests: The authors have declared that no competing interests exist.