Cause-specific mortality for 240 causes in China during 1990-2013: a systematic subnational analysis for the Global Burden of Disease Study 2013.
BACKGROUND
China has experienced a remarkable epidemiological and demographic transition during the past three decades. Far less is known about this transition at the subnational level. Timely and accurate assessment of the provincial burden of disease is needed for evidence-based priority setting at the local level in China.


METHODS
Following the methods of the Global Burden of Disease Study 2013 (GBD 2013), we have systematically analysed all available demographic and epidemiological data sources for China at the provincial level. We developed methods to aggregate county-level surveillance data to inform provincial-level analysis, and we used local data to develop specific garbage code redistribution procedures for China. We assessed levels of and trends in all-cause mortality, causes of death, and years of life lost (YLL) in all 33 province-level administrative units in mainland China, all of which we refer to as provinces, for the years between 1990 and 2013.


RESULTS
All provinces in mainland China have made substantial strides to improve life expectancy at birth between 1990 and 2013. Increases ranged from 4.0 years in Hebei province to 14.2 years in Tibet. Improvements in female life expectancy exceeded those in male life expectancy in all provinces except Shanghai, Macao, and Hong Kong. We saw significant heterogeneity among provinces in life expectancy at birth and probability of death at ages 0-14, 15-49, and 50-74 years. Such heterogeneity is also present in cause of death structures between sexes and provinces. From 1990 to 2013, leading causes of YLLs changed substantially. In 1990, 16 of 33 provinces had lower respiratory infections or preterm birth complications as the leading causes of YLLs. 15 provinces had cerebrovascular disease and two (Hong Kong and Macao) had ischaemic heart disease. By 2013, 27 provinces had cerebrovascular disease as the leading cause, five had ischaemic heart disease, and one had lung cancer (Hong Kong). Road injuries have become a top ten cause of death in all provinces in mainland China. The most common non-communicable diseases, including ischaemic heart disease, stroke, chronic obstructive pulmonary disease, and cancers (liver, stomach, and lung), contributed much more to YLLs in 2013 compared with 1990.


CONCLUSIONS
Rapid transitions are occurring across China, but the leading health problems and the challenges imposed on the health system by epidemiological and demographic change differ between groups of Chinese provinces. Localised health policies need to be implemented to tackle the diverse challenges faced by local health-care systems.


BACKGROUND
China National Science & Technology Pillar Program 2013 (2013BAI04B02) and Bill & Melinda Gates Foundation.
National Center for Chronic and Noncommunicable Disease Control and Prevention, Beijing, China; Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA.
Maigeng
M
Zhou
Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA.
Haidong
H
Wang
National Office of MCH Surveillance of China, Chengdu, China.
Jun
J
Zhu
Cancer Institute, Chinese Academy of Medical Sciences, Beijing, China.
Wanqing
W
Chen
National Center for Chronic and Noncommunicable Disease Control and Prevention, Beijing, China.
Linhong
L
Wang
National Center for Chronic and Noncommunicable Disease Control and Prevention, Beijing, China.
Shiwei
S
Liu
National Center for Chronic and Noncommunicable Disease Control and Prevention, Beijing, China.
Yichong
Y
Li
Chinese Center for Disease Control and Prevention, Beijing, China.
Lijun
L
Wang
National Center for Chronic and Noncommunicable Disease Control and Prevention, Beijing, China.
Yunning
Y
Liu
Chinese Center for Disease Control and Prevention, Beijing, China.
Peng
P
Yin
Chinese Center for Disease Control and Prevention, Beijing, China.
Jiangmei
J
Liu
Chinese Center for Disease Control and Prevention, Beijing, China.
Shicheng
S
Yu
National Institute of Occupational Health and Poison Control, Beijing, China.
Feng
F
Tan
Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA.
Ryan M
RM
Barber
Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA.
Matthew M
MM
Coates
Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA.
Daniel
D
Dicker
Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA.
Maya
M
Fraser
Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA.
Diego
D
González-Medina
Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA.
Hannah
H
Hamavid
School of Public Health, Sun Yat-sen University, Guangzhou, China.
Yuantao
Y
Hao
Department of Epidemiology and Health Statistics, School of Public Health, Central South University, Changsha, China.
Guoqing
G
Hu
Tianjin Centers for Disease Control and Prevention, Tianjin, China.
Guohong
G
Jiang
Fudan University, Shanghai, China.
Haidong
H
Kan
University of Melbourne, Melbourne, VIC, Australia.
Alan D
AD
Lopez
School of Medicine, Shanghai Jiao Tong University, Shanghai, China; Emory University, Atlanta, GA, USA.
Michael R
MR
Phillips
Zhongshan Hospital, Shanghai, China.
Jun
J
She
Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA.
Theo
T
Vos
Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences, Beijing, China.
Xia
X
Wan
Department of Neurology, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China.
Gelin
G
Xu
Duke Kunshan University, Kunshan, China.
Lijing L
LL
Yan
Department of Epidemiology and Biostatistics, School of Public Health, Wuhan University, Wuhan, China; Global Health Institute, Wuhan University, Wuhan, China.
Chuanhua
C
Yu
Chongqing Medical University, Chongqing, China.
Yong
Y
Zhao
Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China.
Yingfeng
Y
Zheng
Cancer Institute, Chinese Academy of Medical Sciences, Beijing, China.
Xiaonong
X
Zou
Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA.
Mohsen
M
Naghavi
Chinese Center for Disease Control and Prevention, Beijing, China.
Yu
Y
Wang
Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA. Electronic address: cjlm@uw.edu.
Christopher J L
CJ
Murray
Peking Union Medical College, Beijing, China. Electronic address: yangghuan@vip.sina.com.
Gonghuan
G
Yang
Chinese Center for Disease Control and Prevention, Beijing, China. Electronic address: liangxf@hotmail.com.
Xiaofeng
X
Liang
D000293:Adolescent; D000328:Adult; D000367:Age Factors; D000368:Aged; D002423:Cause of Death; D002648:Child; D002675:Child, Preschool; D002681:China / Q000453:epidemiology; D017281:Cost of Illness; D005260:Female; D049673:History, 20th Century; D049674:History, 21st Century; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008017:Life Expectancy; D008297:Male; D008875:Middle Aged; D009026:Mortality / Q000266:history; D055815:Young Adult