Health technology assessment in China: challenges and opportunities

Objectives:Economic growth and rapid development of health technology in China have created opportunities to strengthen health technology assessment (HTA) capacity.Over the time,HTA institutions have been established to conduct HTA related work.This study reviewed the current status of HTA in China and analysed the challenges of HTA development in the context of health reform under'new normal'economy.Methods:Literature review and webpage searches were used to document the development of HTA in China.An institutional survey has also been conducted to collect information on the HTA research institutions in China.Results:The number of articles and research projects on HTA were rising and are continuing to rise.HTA development has made substantial progress in China in terms of growing number of research institutions and qualified HTA workforce.However,HTA has notable weaknesses such as low capacity for conducting HTA research,limited experience in HTA researchers,and lack of knowledge translation.Conclusion:Currently,the translation of HTA findings to policy-making is limited and the integration of HTA in the policy-making processes is still in its infancy.The HTA development in China has had opportunities due to demands of health care,health insurance,and health technology as a result of health reform.Capacity building and institutionalization of HTA are urgently needed for further development of HTA in China.

Health technology assessment in traditional Chinese medicine in China: current status, opportunities, and challenges

Objectives:The widespread usage of traditional Chinese medicine(TCM)and the government's emphasis on TCM in China have created a positive macro-environment and great opportunities to develop and strengthen health technology assessment(HTA)in TCM.Over the past ten years,a series of policies have been issued by the government to promote the application of HTA and the development of TCM in China.This study reviews the concepts and characteristics of TCM,summarizes the current status of HTA in TCM,and analyzes the opportunities and challenges faced by HTA development in TCM with respect to deepening of healthcare reforms.Methods:Literature review and website searches were used to acquire information regarding the basic theories of TCM and the current status,opportunities,and challenges for HTA in TCM.Results:The number of articles on HTA in TCM rose substantially,especially those published in China National Knowledge Infrastructure(CNKI).With the optimistic policy environment and huge market demand for TCM,the development of HTA in TCM is expected to flourish in China.However,HTA in TCM also faces numerous challenges such as the absence of a clinical efficacy evaluation system for TCM and insufficient basic research evidence and qualified personnel.Conclusions:TCM has unique characteristic that distinguishes it from Western medicine.Currently,it is important to take all measures to address the existing main challenges and thereby take advantage of the present opportunities to develop and improve HTA in TCM.

Why pregnant women delay to initiate and utilize free antenatal care r service:a qualitative study in the Southern District of Mzimba,Malawi

Aim:The study aimed to explore factors related to the initiation and utilization of focused antenatal care(FANC)in the Southern District of Mzimba,Malawi.Methods:This study used an exploratory qualitative design.Total of 22 in-depth interviews with pregnant women and community midwife assistants were conducted from December 2015 to January 2016 in Mzimba.Thematic analysis approach was adopted to identify the facilitator and harriers of the FANC initiation and utilization.Results:Facilitator of FANC initiation and utilization included seeking pregnancy confirmation,medical treatment for an existing health problem and the support by community health extension workers.Barriers included the additional cost to free FANC service,lack of essential equipment,unfriendly adolescent reproductive health service,and HIV stigma.Conclusion:Early initiation of FANC relies on both woman’s awareness and community support.Promoting the use of FANC should focus on creating an enabling environment,e.g.,increasing investment of essential medical equipment,reducing additional costs of FANC services,eliminating the discrimination against adolescent pregnancy and people living with HIV,and strengthening health personnel’s training.

A Genetic Susceptibility Study of Lung Cancer Risk Potentially Associated with Polycyclic Aromatic Hydrocarbon Inhalation Exposure

For lifetime non-smokers, lung cancer risk is mainly associated with inhalation exposure to air pollution. For the Chinese population, indoor air pollution due to solid fuel combustion has been the primary source of inhalation exposure for decades. Polycyclic aromatic hydrocarbons （PAHs） are the by-products of incomplete combustion.

Fine particulate matter and cardiorespiratory health in China:A systematic review and meta-analysis of epidemiological studies

This review aimed to systematically summarize the epidemiological literature on the cardiorespiratory effects of PM_(2.5)published during the 13^(th) Five-Year Plan period(2016-2020)in China.Original articles published between January 1,2016 and June 30,2021 were searched in PubMed,Web of Science,the China National Knowledge Internet Database and Wanfang Database.Random-or fixed-effects models were used to pool effect estimates where appropriate.Of 8558 records identified,145 met the full eligibility criteria.A 10μg/m^(3) increase in short-term PM_(2.5)exposure was significantly associated with increases of 0.70%,0.86%,0.38%and 0.96%in cardiovascular mortality,respiratory mortality,cardiovascular morbidity,and respiratory morbidity,respectively.The specific diseases with significant associations included stroke,ischemic heart disease,heart failure,arrhythmia,chronic obstructive pulmonary disease,pneumonia and allergic rhinitis.The pooled estimates per 10μg/m^(3) increase in long-term PM_(2.5)exposure were 15.1%,11.9%and 21.0%increases in cardiovascular,stroke and lung cancer mortality,and 17.4%,11.0%and 4.88%increases in cardiovascular,hypertension and lung cancer incidence respectively.Adverse changes in blood pressure,heart rate variability,systemic infiammation,blood lipids,lung function and airway infiammation were observed for either short-term or long-term PM_(2.5)exposure,or both.Collectively,we summarized representative exposure-response relationships between short-and long-term PM_(2.5)exposure and a wide range of cardiorespiratory outcomes applicable to China.The magnitudes of estimates were generally smaller in short-term associations and comparable in long-term associations compared with those in developed countries.Ourfindings are helpful for future standard revisions and policy formulation.There are still some notable gaps that merit further investigation in China.

Subclinical atherosclerosis in northern and southern China： the Chinese paradox

背景冠的心疾病(CHD ) 的发生是更高的在北比在南部的中国，然而，在传统的 CHD 的差别冒险的，解释这。没有学习在可以帮助在发生解释差别的无临床症状的动脉粥样硬化检验了差别。这研究为在北、南部的中国之间的石灰化用冠的计算断层摄影术(CT ) 在无临床症状的动脉粥样硬化检验了这些差别。我们在一个大多中心选择了参加者的一件随机的样品的方法为冠的钙在一个北城市(诺思) 里扫描的进行中的流行病的学习(北京， n = 49 ) 并且在二个南部的城市(南方) 里(上海， n = 50，并且广州， n = 50 ) 。从三个领域中心的参加者(意味着年龄 67 年) 经历了用动脉粥样硬化扫描的多种族的学习为冠的钙测量扫描的冠的风险因素评估和心脏的 CT 协议。结果调整了在诺思中国(北京) 的转变木头的冠的动脉钙 20 是 3.1 +/-0.4 并且在华南(上海和广州) 是 2.2 +/- 0.3 (P = 0.04 ) 。为北京的北城市的吝啬的钙分数比广州的南部的城市的高三倍(P = 0.01 ) 并且比为上海的南部的城市高 2.5 倍(P = 0.03 ) 。结论无临床症状的动脉粥样硬化的程度在广州和上海的二个南部的城市里比那在北京的北城市里是显著地更高的，甚至在为标准心脏的风险因素调整以后。这发现建议标准风险因素充分不在临床的 CHD 发生解释北方南方差别。

Overview of particulate air pollution and human health in China: Evidence, challenges, and opportunities

Ambient particulate matter(PM)pollution in China continues to be a major public health challenge.With the release of the new WHO air quality guidelines in 2021,there is an urgent need for China to contemplate a revision of air quality standards(AQS).In the recent decade,there has been an increase in epidemiological studies on PM in China.A comprehensive evaluation of such epidemiological evidence among the Chinese population is central for revision of the AQS in China and in other developing countries with similar air pollution problems.We thus conducted a systematic review on the epidemiological literature of PM published in the recent decade.

Future research needs for environmental science in China

Environmental science is an interdisciplinary science developed in the process of understanding and solving ecolog-ical and environmental problems.In order to tackle these problems,environmental science research is expected to reveal the source,behavior,fate,exposure,and risks of pollutants in the environment and develop potential solutions to control pollution.It provides the scientific basis for decision-makers to establish environmental and economic poli-cies,and promote concerted efforts for the sustainable development of society.Here,we articulate the development patterns,challenges,and future research needs of environmental science in China based on literature review and expert panel discussion.Environmental science research has evolved significantly in the past decade with an increas-ing diversity of environmental pollutants and health impacts,new technologies and methods,deepening fusion of multiple disciplines,and emerging solutions for pollution control.Its future development relies on the advances in our knowledge on the fate and transport of pollutants,regional environmental processes,ecotoxicological effects,environmental exposure and health effects,environmental analysis and monitoring,source control and reduction,environmental remediation,as well as environmental risk management.For each of these fields,we summarize the significant challenges and highlight the research demands for China.Based on the status quo of China’s environmen-tal science research and future needs,we provide recommendations to promote its future development,including encouraging innovation and interdisciplinary research,providing decision support for national needs,encouraging international collaboration,and improving collaboration mechanisms.

Air pollution may increase the sleep apnea severity:A nationwide analysis of smart device-based monitoring

Obstructive sleep apnea(OSA)can lead to sleep deprivation,accidents,and cardiovascular diseases.However,research on the short-term effects of air pollutants on OSA severity is limited and inconsistent.We conducted a novel case time series analysis using a nationwide dataset among Huawei smart device users to assess the association between air pollution and OSA severity in a population at moderate-to-severe risk of OSA.Fixed-effects regression models were used to assess the associations between air pollution and the risk of OSA exacerbation,apnea-hypopnea index(AH),and oxygen saturation.A total of 51,842 participants who were at moder-ate-tosevere risk of OSA(mean age[SD]:45.4[11.0],95.5%male)were included,with 6,232,056 person-days of monitoring.The as sociations of fine particulate matter,nitrogen dioxide,carbon monoxide,and sulfur dioxide with OSA severity could occur during the sleep period,and last for 2 days.An increase of 1 interquartile range in the moving average concentrations of air pollution during the sleep period and the 2 previous days was associated with a 1.14%-4.31%increase in the risk of OSA exacerbation,an increase in AHI by 0.05-0.17 events/h,and a decrease in oxygen saturation(%)by 0.003-0.014.The exposure-response curves were almost linear.The associations between air pollutants and OSA were consistently stronger in participants aged 45 years or older.By virtue of the smart device-based technology,this largescale,nationwide,longitudinal study provides compelling evidence that short-term exposure to air pollution may worsen sleep apnea.Our findings highlight the significance of ongoing efforts to improve air quality in mitigating OSA severity and the relevant disease burden in an aging era.

Ambient Nitrogen Dioxide and Hospitalizations of Full-Spectrum Respiratory Diseases:A National Case-Crossover Study

Few multicity studies have examined the acute effects of nitrogen dioxide(NO_(2))on respiratory disease(RD),especially its specific causes.This study aimed to investigate the associations between short-term exposure to NO_(2)and hospitalization of full-spectrum RDs in China.Hospitalization of 10 major categories and 40 cause-specific RDs were obtained from 20 provinces over the study period of 2013−2020.A time-stratified case-crossover study was conducted at the individual level to explore the associations between NO_(2)and RDs.NO_(2)was significantly associated with increased hospitalization of eight major RDs(acute upper respiratory infections,influenza and pneumonia,acute lower respiratory infections,upper respiratory tract diseases,chronic lower respiratory diseases,respiratory interstitium diseases,pleura diseases,and other respiratory diseases)and 18 specific causes of RDs,with the largest associations observed on lag 0−1 day.The effect estimates ranged from 0.75 to 4.09%per 10μg/m^(3)of NO_(2)exposure.The associations remained robust after controlling for copollutants.The concentration−response curves were mostly positive and linear.This nationwide study provides comprehensive information on the acute effects of NO_(2)on respiratory morbidity across the full spectrum,highlighting the need for caution with regard to this important traffic-related air pollutant in current pollution control programs.

Sex-specific effects of organophosphate ester exposure on child growth trajectories in the first two years

The connections between urinary organophosphate ester(OPE)metabolites and child growth have been identified in prior research,but there is currently a dearth of epidemiological evidence regarding the sex-specific impact of OPEs on child growth trajectories.This study enrolled 804 maternal-child pairs,and five OPE congeners were quantified in maternal serum during pregnancy.In this study,the impact of prenatal OPE exposure on child growth trajectories was assessed using linear mixed-effect models and a group-based trajectory model(GBTM),with consideration given to sex-specific effects.Fetuses were frequently exposed to OPEs in utero,and tris(2-butoxyethel)phosphate(TBEP)exhibited the highest concentration levels in maternal serum.Among male children,an increase of 2.72 ng/g lipid in TBEP concentration was associated with a 0.11-unit increase in head circumference-for-age z-score(HCAZ),and the effect was mainly concentrated at 1 and 2 months of age.Among female children,an increase of 2.72 ng/g lipid in tris(2-chloro-1-(chloromethyl)ethyl)phosphate(TDCPP)concentration was associated with a 0.15-unit increase in length-for-age z-score(LAZ)and a 0.14-unit increase in weight-for-age z-score(WAZ),and the effects were mainly concentrated at 9 months of age.For HCAZ trajectories,higher prenatal TBEP exposure was associated with higher odds for the fast growth group in male children.For the LAZ and WAZ trajectories,higher prenatal TDCPP exposure was associated with higher odds for the fast growth group in female children.The trajectory analysis approach provided insight into the complex associations between OPE exposure and child growth.

Rising challenge of multidrug-resistant tuberculosis in China:a predictive study using Markov modeling

Background:Multidrug-resistant tuberculosis(MDR-TB)is on the rise in China.This study used a dynamic Markov model to predict the longitudinal trends of MDR-TB in China by 2050 and to assess the effects of alternative control measures.Methods:Eight states of tuberculosis transmission were set up in the Markov model using a hypothetical cohort of 100000 people.The prevalence of MDR-TB and bacteriologically confirmed drug-susceptible tuberculosis(DS-TB+)were simulated and MDR-TB was stratified into whether the disease was treated with the recommended regimen or not.Results:Without any intervention changes to current conditions,the prevalence of DS-TB+was projected to decline 67.7%by 2050,decreasing to 20 per 100000 people,whereas that of MDR-TB was expected to triple to 58/100000.Furthermore,86.2%of the MDR-TB cases would be left untreated by the year of 2050.In the case where MDR-TB detection rate reaches 50%or 70%at 5%per year,the decline in prevalence of MDR-TB would be 25.9 and 36.2%respectively.In the case where treatment coverage was improved to 70%or 100%at 5%per year,MDR-TB prevalence in 2050 would decrease by 13.8 and 24.1%,respectively.If both detection rate and treatment coverage reach 70%,the prevalence of MDR-TB by 2050 would be reduced to 28/100000 by a 51.7%reduction.Conclusions:MDR-TB,especially untreated MDR-TB,would rise rapidly under China’s current MDR-TB control strategies.Interventions designed to promote effective detection and treatment of MDR-TB are imperative in the fights against MDR-TB epidemics.

Cost-effectiveness analysis of malaria rapid diagnostic test in the elimination setting

Background:As more and more countries approaching the goal of malaria elimination,malaria rapid diagnostic tests(RDT)was recomendated to be a diagnostic strategy to achieve and maintain the statute of malaria free,as it’s less requirments on equipment and experitise than microscopic examination.But there are very few economic evaluations to confirm whether RDT was cost-effective in the setting of malaria elimination.This research aimed to offer evidence for helping decision making on malaria diagnosis strategy.Methods:A cost-effectiveness analysis was conducted to compare RDT with microscopy examination for malaria diagnosis,by using a decision tree model.There were three strategies of malaria diagnostic testing evaluated in the model,1)microscopy,2)RDT,3)RDT followed by microscopy.The effect indicator was defined as the number of malaria cases treated appropriately.Based on the joint perspective of health sector and patient,costs data were collected from hospital information systems,key informant interviews,and patient surveys.Data collection was conducted in Jiangsu from September 2018 to January 2019.Epidemiological data were obtained from local malaria surveillance reports.A hypothetical cohort of 300000 febrile patients were simulated to calculate the total cost and effect of each strategy.One-way,two-way,and probabilistic sensitivity analysis were performed to test the robustness of the result.Results:The results showed that RDT strategy was the most effective(245 cases)but also the most costly(United States Dollar[USD]4.47 million)compared to using microscopy alone(238 cases,USD 3.63 million),and RDT followed by microscopy(221 cases,USD 2.75 million).There was no strategy dominated.One-way sensitivity analysis reflected that the result was sensitive to the change in labor cost and two-way sensitivity analysis indicated that the result was not sensitive to the proportion of falciparum malaria.The result of Monte Carlo simulation showed that RDT strategy had higher effects and higher cost than other strategies with a high probability.Conclusions:Compared to microscopy and RDT followed by microscopy,RDT strategy had higher effects and higher cost in the setting of malaria elimination.

Effects of greenness on preterm birth: A national longitudinal study of 3.7 million singleton births

Exposure to greenness may lead to a wide range of beneficial health outcomes.However,the effects of greenness on preterm birth(PTB)are inconsistent,and limited studies have focused on the subcategories of PTB.A total of 3,751,672 singleton births from a national birth cohort in China's Mainland were included in this study.Greenness was estimated using the satellitebased Normalized Difference Vegetation Index(NDVI)and Enhanced Vegetation Index with 500-m and 1,000-m buffers around participants’addresses.The subcategories of PTB(20-36 weeks)included extremely PTB(EPTB,20-27 weeks).

World Health Organization air quality guidelines 2021:implication for air pollution control and climate goal in China

Air pollution is one of the biggest environmental threats to human health.In 2005,the World Health Organization(WHO)released its first global air quality guidelines(AQGs)for particulate matter(PM),ozone(O3),nitrogen dioxide(NO2),and sulfur dioxide.[1]On September 22,2021,the WHO updated its AQGs,providing clear evidence of the adverse health effects of air pollution,at even lower concentrations than previously understood.[2]For instance,the WHO AQGs 2021 recommend annual mean concentrations of PM2.5 not exceeding 5μg/m3 and NO2 not exceeding 10μg/m3 and the peak season mean 8-h O3 concentration not exceeding 60μg/m.[2,3]As a comparison,the corresponding WHO AQGs 2005 values were 10μg/m3 for PM2.5 and 40μg/m3 for NO2,with no recommendation for long-term O3 concentrations.

Evaluating the implementation of rapid diagnostic tests in a malaria elimination setting

Background It was recommended that malaria rapid diagnostic tests(RDTs)should be available in all epidemiological situations.But evidence was limited on the implementation of RDTs and its effectiveness in malaria elimination settings.This study examined the implementation of RDTs and how it affected the diagnosis of imported malaria patients in Jiangsu Province,China.Methods To scale up RDTs,this study developed an intervention package with four major elements covering the supply of RDT test,the training on RDTs,the monitoring and management of RDT use,and the advocacy of RDTs.By using a pretest-posttest control group design,we implemented the interventions in 4 cities in Jiangsu Province with the rest nine cities as controlled areas,from January 2017 to January 2018.Difference-in-Difference approach was used to evaluate the impact of the scale-up of RDTs on the identification of malaria cases.Three binary outcome measures were included to indicate delayed malaria diagnosis,malaria cases with confirmed malaria diagnosis at township-level institutions,and severe malaria cases,respectively.Linear probability regression was performed with time and group fixed effects and the interaction term between time and group.Results Intervention areas received sufficient RDT test supply,regular professional training programs,monthly tracking and management of RDT supply and use,and health education to targeted population.The implementation of interventions was associated with 10.8%(P=0.021)fewer patients with delayed diagnosis.But intervention areas did not see a higher likelihood of having confirmed diagnosis from township-level institutions(coefficient=-0.038,P=0.185)or reduced severe malaria cases(coef.=0.040,P=0.592).Conclusions The comprehensive package of RDT implementation in this study is promising in scaling up RDT use and improving access to care among malaria patients,especially in malaria elimination settings.

Acute Effects of Personal Ozone Exposure on Biomarkers of Inflammation,Oxidative Stress,and Mitochondrial Oxidative Damage-Shanghai Municipality,China,May-October 2016

Summary What is already known on this topic?It remains inconclusive whether short-term ozone exposure can cause an inflammatory response and oxidative damage in the circulatory system,particularly at low concentrations.What is added by this report?This study made an accurate exposure assessment by conducting personal ozone monitoring,thus minimizing the exposure misclassification commonly found in previous environmental epidemiological studies.

Criteria air pollutants and hospitalizations of a wide spectrum of cardiovascular diseases: A nationwide case-crossover study in China

Few national studies have systemically examined the effects of criteria air pollutants on cardiovascular morbidity.This study aimed to investigate the associations between all criteria air pollutants and hospitalization of causespecific cardiovascular diseases(CVD)in China.We obtained data on CVD hospitalization events of four major categories and 12 specific diseases from 153 hospitals distributed in 20 provincial-level regions from 2013 to 2020.We adopted a time-stratified case-crossover study design using individual cases to capture the effect of short-term exposure to six criteria air pollutants on CVD hospitalizations,using conditional logistic regression models.More than 1.1 million CVD hospitalization events were included.The lag pattern exploration demonstrated the largest effect for six air pollutants on lag 0–1 day.PM_(2.5),PM_(10),NO_(2),and CO were significantly associated with increased hospitalization from ischemic heart diseases,cerebrovascular diseases,other heart diseases,and five specific causes of CVD.The effect estimates of NO_(2)were the most robust when adjusting for copollutants.The concentration-response curves were positive and linear for most pollutant–endpoint pairs(except for O_(3)),and these positive associations remained even below the 24-h levels recommended by WHO Air Quality Guidelines and China Air Quality Standards.This nationwide case-crossover study in China demonstrated that short-term exposure to multiple ambient air pollutants may significantly increase the risk of cause-specific CVD hospitalizations even under the most stringent air quality regulations,striking an alert for potential CVD patients against these environmental risk factors.

2013~2017年中国空气质量改善与早产疾病负担改变

Preterm birth(PTB)is a leading cause of perinatal mortality and morbidity worldwide[1].Since maternal and fetal health protection has been included in the United Nations Sustainable Development Goals,identification of modifiable risk factors for PTB is particularly crucial.The Global Burden of Disease(GBD)Study 2019 recognized fine particulate matter(PM2.5)pollution as a risk factor for decreased gestational age and low birth weight.

Integrated Approaches for COVID-19 Case Finding and Their Impact on Timeliness for Disease Containment——Changning District,Shanghai Municipality,China,January-July,2020

Summary What is already known on this topic?The demand for containing the virus and protecting the economy is high on the agenda of policymakers during the coronavirus disease 2019(COVID-19)pandemic.Modelling studies indicated that highly effective contact tracing and case isolation were enough to contain the spread of COVID-19 at the early stages,but this has not been validated in real world contexts.