Child health in China

SWP767 Child Health in China Mary E. Young Andre Prost WORLD BANK STAFF WORKING PAPERS Number 767   WORLD BANK STAFF WORKING PAPERS Number 767 Child Health in China INTERNATiONAL NIONETA1Y FUND JOINT L.BRARY JAN 198b Mary E. Young INTS11NATlOlJALhGi,.iF 1, Mary E. oung SsRECNSTRUCTION AND DZVZ^LOPP.IENT Andre Prost WASHINGTON, D.C. 20131 The World Bank Washington, D.C., U.S.A.  Copyright C) 1985 The International Bank for Reconstruction and Development/THE WORLD BANK 1818 H Street, N.W. Washington, D.C. 20433, U.S.A. All rights reservedI Manufactured in the United States of America First printing December 1985 This is a working document published informally by the World Bank. To present the results of research with the least possible delay, the typescript has not been prepared in accordance with the procedures appropriate to formal printed texts, and the World Bank accepts no responsibility for errors. The publication is supplied at a token charge to defray part of the cost of manufacture and distribution. The World Bank does not accept responsibility for the views expressed herein, which are those of the authors and should not be attributed to the World Bank or to its affiliated organizations. The findings, interpretations, and conclusions are the results of research supported by the Bank; they do not necessarily represent official policy of the Bank. The designations employed, the presentation of material, and any maps used in this document are solely for the convenience of the reader and do not imply the expression of any opinion whatsoever on the part of the World Bank or its affiliates concerning the legal status of any country, territory, city, area, or of its authorities, or concerning the delimitation of its boundaries, or national affiliation. The most recent World Bank publications are described in the annual spring and fall lists; the continuing research program is described in the annual Abstracts of Current Studies. The latest edition of each is available free of charge from the Publications Sales Unit, Department T, The World Bank, 1818 H Street, N.W., Washington, D.C. 20433, U.S.A., or from the European Office of the Bank, 66 avenue d'1ena, 75116 Paris, France. Mary E. Young is a consultant to, and Andre Prost a public health specialist in, the Population, Health, and Nutrition Department of the World Bank. Library of Congress Cataloging-in-Publication Data Young, Mary E., 1955- Child health in China. (World Bank staff working papers ; no. 767) Bibliography: p. 1. Children--Diseases--China. 2. Children--China-- Nutrition. 3. Child health services--China. 4. Maternal health services--China. 5. Family size--Government policy--China. 6. Preventive health services--China. I. Prost, Andre, 1944- II. Title. III. Series. [DNLM: 1. Child Health Services--China. 2. Health Surveys--in infancy & childhood--China. 3. Infant Mortality--China. 4. Maternal Health Services--China. 5. Perinatology-- China. WA 320 Y74c] RJ103.C6Y68 1985 362.1'9892'000951 85-26638 ISBN 0-8213-0676-1  ABSTRACT This paper reviews the existing data, mainly Chinese publications, on childhood diseases in order to assess the health status and morbidity patterns of Chinese children. China's infant mortality rate is among the very lowest in the developing world. The number of post-neonatal deaths as a proportion of total infant death has decreased to a level comparable to that of a developed country. The epidemiologic pattern of vaccine preventable diseases indicates that immunization activities have had a significant impact on the occurrence of these diseases. The overall prevalence of infectious diseases is decreasing and, relatively, the frequency of congenital defects is increasing as a major cause of childhood mortality. However, fecal-borne diseases such as dysentery, hepatitis, and ascariasis are still the predominant causes of morbidity. A secular improvement in the nutritional status of Chinese children is noted, but mild to moderate malnutrition still persists. This review sets out a series of issues: the impact of the one-child family policy, which is creating different demands on the maternal and child health care service network; technological shortcomings in immunization activities, which are affecting coverage; the lack of better technical training, which is influencing health reporting and surveillance systems; and the lack of corrective programs to further decrease malnutrition.  ACKNOWLEDGEMENTS We are indebted to Ms. Ann Van Aken for her editorial assistance, and for essential aid in the typing and organization of this paper. Her assistance was crucial to the completion of the work.  TABLE OF CONTENTS Page No. Acknowledgements Abstract Table of Contents List of Tables I. INTRODUCTION ........... .... ..... . ... * * * * * * * * * * * * 1 II. PERINATAL HEALTH .. .. ............. ......... . 3 A. Maternal Mortality. ................. ........ ........................ . 3 B. Infant Mortality . .................... ................ 5 C. Neonatal Mortality .. . * ............................ 9 D. Diseases of Infancy. .......... ..... ..... ..... .... 11 III. CHILD HEALTH ....................... ..% ..........................to.... 16 A. Acute Gastroenteritis ..... ........ ........... ..... 17 B. Acute Respiratory Infections .......... ................. 18 C. Vaccine Preventable Diseases ...................... . . 19 IV. NUTRITIONAL STATUS OF CHILDREN ........................... . 36 A. Diet and Food Supply ...*.*.. .... .o ........ .. . 36 B. Parameters of Child Growth ........* ................. ... 37 C. Micronutrient Deficiency Diseases ..................... 44 V. OTHER CHILDHOOD DISEASES ........................................... . . . . 48 A. Parasitic Infections ............... . ... . ....... . 48 B. FEndemic Diseases ... ................................... 50 C. Rheumatic Fever and Rheumatic Heart Disease .. . 50 VI. MATERNAL AND CHILD HEALTH CARE SERVICES ................... 54 A. Maternal Health Care .................... .. ..... 54 B. Child Health Care ......................... ....... ... . 59 VII. ISSUES ........................................ ..................... 61 A. The One Child Family Policy. . ......... ........ 61 B. Integration of MCH Services ................ ............ 64 C. Improvement of Immunization Coverage .................... 65 D. Additional Training .. .* . .. o o..o.. .....o. 67 E. Closing Network Service Gaps...oo .........o ........ 67  Page No. F. The Reporting System ............ ......... . 68 G. Continuing Presence of Malnutrition ................... 68 Annoted Bibliography Annex Tables Maps  LIST OF TABLES Page No. 1. Maternal Mortality Rate in Selected Urban and Rural Areas, 1975, 1980 and 1982 (per 10,000 live births).. .................. 3 2. International Comparison of Perinatal Mortality Rate ........... 5 3. Causes of Perinatal Mortality, by Rank Order, Several Countries ...................................................... 5 4. Infant Mortality Rates, 1926-1982 .............................. 7 5. Five Leading Causes of Infant Deaths as a Percentage of Total Infant Death ............................................. 9 6. Global Incidence of Low Birth-Weights .......................... 10 7. Proportions of Deliveries Using the "New Method" in China ...... 12 8. Disease Classification of Pediatric Admissions in Pediatrics Hospital Affiliated with Shanghai First Medical College, 1963 and 1978 ................................. 13 9. Percentage Distribution of Types of Congenital Defects ......... 13 10. Major Causes of Death at Ages 1 to 14, Beijing, 1979 .......... . 16 11. Five Most Common Diagnoses made by BFDs per day, by Age Listed in Rank Order, in Two Communes, Qufu County, September and October, 1982 ......... .. ......................... 17 12. Nationwide Incidence of Childhood Communicable Diseases, 1974-1981 (per 100,000 population) ............................. 20 13. Relationship between Vaccination Coverage in 1976 and the Incidence of Measles in 1977 in Shanghai County ................ 23 14. Comparison of Prevalence of Sequels of Poliomyelitis with Niger, Danfa (Ghana) and Ghana Surveys ............... .......... 25 15. Recent Distribution of Vaccination History of Cases of Paralytic Poliomyelitis, Changjian, 1981 ............ ............. 26 16. Urban-Rural Comparison of Rubella Serconversion, Lanzhou, 1980 ..............7..................................... 27 17. Rubella Serosurvey in Beijing, 198980............. 27  18. Number of Cases of Tuberculosis Meningitis Admitted to Shanghai Second Medical College Affiliated Pediatrics Hospital, 1950-1980 ............................................* * * * * * * * * * * 30 19. Morbidity and Mortality from Japanese B Encephalitis, Nationwide, 1974-1981 ........... .. .......... . 31 20. Morbidity and Mortality from Viral Hepatitis, Nationwide, 1974-1981 ........... ..... 31 21. Morbidity and Mortality from Epidemic Meningitis, Nationwide, 1974-1981 .......................... *............................. 34 22. Incidence of Epidemic Meningitis during 1953-1979, in Xuchang, Henan Province ............................................. . 34 23. Comparison of Energy (Calories) and Protein Availability ....... 37 24. Nutrient Sources and Ability, 1979 .................. ............. 38 25. Stunting Among Children in China and Selected Other Countries ....... ... .................. ..... 42 26. Weights and Heights of Schoolchildren in Z-scores, 1952-1980 .... .. .. .... ............... 43 27. Prevalence of Rickets in QiYi Commune in Children Under Age Three, Shanghai County .................. .. ............. . 45 28. Fluoride Content in Drinking Water and Prevalence of Dental Fluorosis (1979-1980) in Four Counties in Shangdong Province ................................................................... 51 29. Distribution of Total Health Facilities and Maternal Child Health Facilities, by Province, 1982 ........................... 56 30. Maternal Child Health Care Facilities, Beds, and Personnel, N ationwide, 1949-1982 time .ea.thCarePer.... ........... 57 31. Number of Part-time Health Care Personnel ................................................. 57  I. INTRODUCTION In China, one-third of the population is under 14 years old, i.e. 338.7 million people. The crude birth rate was highest in the mid-1950s, when it reached 45 per 1,000 population. Since then, the birth rate has declined to about 20 per 1,000 in 1982. According to the 1982 census, more than 20.7 million births occurred in 1981. The proportion of children in the total populati?7 in the 1982 census was lower than that in the 1953 and 1964 census. - This is in part a result of family planning and population control. At the same time, health policies have supported the improvement of environmental health standards and the provision of more adequate maternal and child health care in the community. These measures contributed to the decline in child mortality, particularly infant mortality. As the rate of child survival improves, the birth rate decreases. In China today, every child is a wanted child. Many visitors to China, especially those familiar with other developing countries, are surprised by the apparent good health of Chinese children. There is no acute malnutrition. Those children seen on the streets radiate cheerfulness and vitality. However, quantitative data, such as nationwide age-specific morbidity and mortality statistics for children in China, are scarce and difficult to obtain. Annex Table 1 presents an urban and rural comparison of age-specific mortality rates for 1957 and 1975. Death rates declined between 1957 and 1975 for every age group, most drastically for infant mortality. The rural infant mortality is about twice that of urban. Based on a two-year (1974-1976) review of infant mortality in 12 provinc 1q and cities, the rural infant mortality rate was 2 to 4 times that of urban. - The magnitude of the urban/rural difference in the age groups between 1 and 10 years is smaller; it varied between a factor of 1 and 2. The urban/rural difference in 1957 was greater than in 1975. Annex Table 2 and Annex Map 1 present the crude birth rate by province in 1982 based on the 10 percent sampling of the 1982 census. The percentage of infant deaths varied from 27 percent in Ningxia to 4 percent in Shanghai. Population age distribution data by province were not available to calculate the age-specific mortality rate. An alternative is to use an adjusted age-specific mortality rate. However, using a standard population, in this case, does not provide a better comparison because of the difference in population age distribution among the provinces. The Chinese population policy for minorities is different from its overall policy: minorities are exempted from policies on population 1/ "Age Distribution of China's Population," Beijing Review, No. 1 (1984): 20-22. 2/ "Rural Preschool Child Health Care Organization, Content and Methods," Chinese Medical Journal 95 (August, 1982): 551-6. This article cites a 2- year review (1974-1976) of infant mortality in 12 provinces and cities conducted by the Child Health Care Department, Institute of Pediatrics, Chinese Academy of Medical Science; data, however, were not presented.  -2- control. Ningxia, with a large minority population (54 percent are Hui), has a higher birth rate, and its population age distribution is different from other provinces, that is, it is younger. Thus, in addition to urban and rural differences within provinces, there is a regional difference in the mortality rate for both infants and children of age 1 to 10. The proportion of deaths for infants and children in Guizhou of the southwest region, and in Gansu and Ningxia of the northwest region are higher than that of other provinces. The major factors responsible for improvement in the health status of children in China should be attributed to the government's emphasis on prevention, on community mobilization in the organization of mass campaigns, on the improvement of environment sanitation, on the improvement of nutrition, and on organization of the basic network of maternal and child health care centers and personnel at each level, from province to brigade level. This paper reviews the existing literature on childhood diseases in order to assess the health status and morbidity pattern of Chinese children, and to discuss issues relating to their health care needs. Section II describes perinatal health, focusing on maternal and infant morbidity. Section III reviews the most prevalent childhood communicable diseases. Section IV presents available anthropometric surveys and micronutrient diseases. Section V describes other childhood diseases, such as parasitic and endemic diseases. Section VI describes the existing network of maternal and child health care services, and section VII sets out a series of relevant issues.  - 3 - II. PERINATAL HEALTH A. Maternal Mortality The maternal mortality rate is defined as the number of women who die as a result of child bearing in a given year per 100,000 births. Maternal deaths are those caused by complications of pregnancy and childbirth. Before liberation, the average maternal mortality rate in China was 3eported to be as high as 150 per 10,000 live births (range 32 to 171). Wray - cites an estimate that in preliberation North China, 2 to 3 percent of all women going into labor died of complications due to pelvic deformity from osteomalacia. In 1982, the reported national figure was 5 per 10,000 live births. The mortality rate has drastically declined over the last 30 years. However, urban and rural differences still exist, as shown in Table 1. The figures for Table 1: Maternal Mortality Rate in Selected Urban and Rural Areas 1975, 1980 and 1982 (per 10,000 live births) 1975 1980 1982 Urban a/ Beijing 2.8 1.3 2.2 Shanghai 0.8 1.1 1.0 Tienjin 2.6 1.3 1.8 Rural bt Heilongjiang 4.5 4.2 2.5 Shangdong 4.1 3.7 2.8 Sichuan 5.1 6.4 3.9 Ningxia 11.7 9.2 8.6 National Average 5.0 a/ Data were obtained from Statistical Data on National Health Care, 1982, provided by the Ministry of Public Health. b/ Data were obtained from the counties participating in this first World Bank health project; there were 10 counties from Heilongjiang, 15 counties from Shangdong, 16 counties from Sichuan, and 5 counties from Ningxia. 3/ Wray, J.D., "Child Care in the People's Republic of China - 1973: Part II." Pediatrics, 55 (May, 1975): 723-734.  - 4 - rural areas were calculated from data on 46 counties in 4 provinces (Shangdong, Heilongjiang, Sichuan and Ningxia) participating in the first World Rank health project. Regional differences in the mortality rate may be related to differences in the availability of health resources and cultural practices. Mortality in Ningxia was about 70 percent higher than the national average. The main causes of maternal deaths, as reported from a Shanghai hospital, but not in ranking order, were: eclamp 0a, ruptured uterus, pulmonary embolism, and amniotic fluid embolism. - This pattern is similar to other developed countries. Before liberation, postpartum fever, hemorrhage, and eclampsia were the major causes of maternal deaths. Postpartum fever is still a major cause of morbidity. Hemorrhage and infection are no longer the leading causes of death, which indicates that better standards of care are available, and a substantial proportion of "avoidable" deaths have been prevented. Perinatal mortality includes stillbirth from 28 weeks gestation and death of a live infant (of any gestation) up to one week after birth. Annex Table 3 provides information from selected sou qes in 17 provinces and cities between 1953 and 1979-on perinatal mortality. - The perinatal mortality rate varies among provinces. The average perinatal mortality was 20.48 per 1,000 live births (range 13.12 to 20.48). Within each province or city the rate also varies, which may be due to differences in reporting, differences in ascertainment of births and deaths, and bias in sample selection (see Table 2). The actual perinatal mortality rate is most likely higher, since these data were collected from major cities or provincial hospitals rather than from the entire province, including both rural and urban areas. There is also a difference in the reporting of deaths. In Shanghai data, abortions in late pregnancy (i.e. third trimester) and neonatal deaths within 7 days of birth occurring outside the hospital were not included in the nominator. The major causes of perinatal mortality were prematurity, difficult labor, eclampsia, congenital defects, and asphyxia. Clinicopathological correlation with autopsy of perinatal deaths showed that the causes of death were: first, respiratory (hemorrhage, hyaline membrane disease); second, asphyxia; and third, congenital malformation. Comparison with several countries is presented in Table 3. 4/ Chalmers, I. "Better Perinatal Health - Shanghai," The Lancet, No. 1 (1980): 138. 5/ Much information was lost as a result of the way the data was presented. The total number of perinatal deaths were reported by different time periods instead of by year. For instance, Nanjing Hospital reported a total number of 541 perinatal deaths from 1953 to 1978. Thus, the pattern of changes over the last 20 years is not obvious. Even so, the data do show that perinatal mortality varies among provinces.  -5- Table 2: International Comparison of Perinatal Mortality Rates Mortality Rate Year Country Perinatal Fetal Neonate 1974 Sweden 13.0 1974 Switzerland 15.0 1974 France 19.3 - - 1971 Holland 17.9 10.3 7.6 1971 Canada 20.3 9.4 10.9 1971 England 22.5 12.6 9.9 1971 Scotland 24.8 13.3 11.5 1974-77 Shanghai 14.2 7.8 6.5 Source: "Retrospective Analysis of Perinatal Mortality within 17 years, 1961-1977," Chinese Journal of Obstetrics and Gynecology, 13 (October, 1978): 121. Table 3: Causes of Perinatal Mortality, by Rank Order, Several Countries Cause of Death Shanghai Holland Canada England Scotland Asphyxia 1 2 1 2 2 Congenital defects 2 4 4 1 1 Placenta insufficiency 3 3 4 3 Cord abnormality 4 5 Difficult labor 5 Other 3 1 2 3 4 Toxemia 5 5 Birth injury 5 Source: "Retrospective Analysis of Perinatal Mortality within 17 years, 1961-1977," Chinese Journal of Obstetrics and Gynecology, 13 (October, 1978): 121. B. Infant Mortality The infant mortality rate (IMR) is the number of infant deaths under 1 year of age per 1,000 live births in a given year. The IMR has declined from 200 per 1,000 live births in 1949 to 53 per 1,000 live births in 1980. The pattern of decline is similar between the Beijing data and nationwide data, but the nationwide data indicated a drastic increase in the period 1960 to 1961. Major agricultural failure occurred during this period, in part due  - 6- to two successive years of bad weather, and in part due to economic mismanagement associated with the Great Leap Forward. Beijing, being the capital city, probably was less seriously affected by the famine and agricultural failure. Figures from Beijing from earlier years (1926-1934) are given in Table 4. These figures are not representative of rural China or of Chinese cities. The data was collected from the First Health Special Area established in 1926 in a northeastern section of Peking and covering a population of 55,000. The relatively high sex ratio for several years may reflect underreporting of female infanticides. One feature of infant mortality in old China was the predominance of female over male deaths. More recent infant mortality rates from various sources are also presented in Table 4; Figure 1 shows the trend over the last 30 years. The decline has been drastic; the reported IMR in China today has reached levels much lower than that of countries of comparable per capita gross national product. The official national estimate was 20.3 per 1,000 live births in 1982. The World Bank estimates of infant mortality rates are higher than the official figures. In order to fit the available data on age-specific mortality rates from China, the Bank used a modified "West" model life table which applies a different "West" mortality level for different age groups. This resulted in a higher infant mortality rate for given life expectancy than the unmodified "West" models. The official figures were obtained from reporting of selected urban and rural areas (which by no means are representative for China as a whole). Underreporting and the extent of underreporting vary from place to place, depending on the quality of the existing reporting system. Infant deaths might be reported as stillbirths and vice versa, or might not be reported at all. Infanticides may be reported as stillbirths. A verification survey of infant deaths was conducted in Chongqing coygty, Sichuan in 1981, and 33 percent of infant deaths were unreported. VI bother survey in Jingan County, Shanghai, found 5 percent underreporting. _ Age-specific death rates have declined for all ages, but the IMR still accounts for 50 percent of deaths for children less than 14 years of age. The major causes of deaths in Old China were diarrhea, malnutrition, tetanus, and birth injury. Today, infectious etiology is contributing to fewer deaths. Congenital defects, premature birth, and birth injury are taking up a greater share in the cause of deaths (see Table 5). In the urban areas, about 80 percent of infant deaths are due to pneumonia, congenital 6/ "Underreporting of Infant Deaths in Chongqing County," Chinese Journal of Epidemiology 4 (1983): 172-73. 7/ "Correctness of Infant Mortality Statistics," Chinese Journal of Pediatrics, 21 (1983): 213-14.  -7- :a]LjL: Infant Mortality Rates, 1926-1982 Estimated infant mortality rate (per '000) Both Sexes Iale Female Beijing - First Special Health Area a/ 1926 183.2 172.5 194.8 1927 176.4 174.0 179.1 1928 197.2 197.6 198.7 1929 172.7 165.6 189.5 1930 142.2 163.6 119.7 1931 199.3 179.1 203.0 1932 179.3 185.4 172.3 1933 134.0 137.6 129.0 1934 126.2 138.6 113.1 Ting Hsien b/ 1931 - 1933 199.0 1934 163.1 1935 185.2 1936 145.0 FArm Areas - 22 provinces, 1929-1931 All areas 160.0 152.0 North China 152.0 159.0 South China 166.0 147.0 4 provinces, 1924-1925 129.4 Chen-Kung c/ 2/1940 - 6/1944 212.1 211.1 China, overall - 1949 250-300 Beijing. city proper 1949 117.6 1950 95.5 1951 86.6 1952 65.7 1953 59.3 1954 46.1 1955 44.5 24 provinces, rural areas,1955 110.0 Beijing, city proper 1960 29.8 1972 15.0 China, most of the countrv 1973-75 53-63 1978-79 56 1982 22 (?) a/ First Special Health Area was established in 1926 in a northeastern section of Beijing with a population of 55.000. b/ Ting Haien, is a rural area situated 170 miles south of Beijing, with a population of 397,000. c/ Chen-Kung is a county located in Yunan province, with a population of 71,723. Sources: 1. Data for First Special Health Area. Ting Haien, Farm Areas, Four Provinces, Chen-Kung arnd Beijing City Proper are presenced in Table 2, and Table 11 of China - Facts and Figures Annual, Volume 6, 1983, by H. King and F.S. Locke. 2. The figures for 1973-75 and 1978-79 for China as a whole are presented in Table A.27 of China. Socialist Economic Development, Volume lII, World Bank Country Study, 1983.  -8- 300 - 250 .* X,\ ~~~I '\ NATIONWIDF 100 - . . . < . ._ > ~~BEIJING.---~~~ 50 55 60 65 70 75 80 82 Figure 1. Infant Mortality Rate, 1950-1982, Nationwide, and Beijing Sources: The nationwide figures were obtained from Table A-2, "Health Sector Report on China," Population, Health and Nutrition Department, World Bank, April, 1984. The Beijing figures were obtained from Lin, Y.Z., "China's 30 Year Mortality Rate," Chinese Journal of Preventive Medicine, 15 (1981).  Table 5: Five Leading Causes of Infant Deaths as a Percentage of Total Infant Death Shanghai County - Beijing 2/ Causes (1980) (1979) Congenital anomalies 20 19 Premature births 18 15 Asphyxia 15 8 Pneumonia 14 24 Congenital heart disease 11 11 Sources: 1/ Hu, X.J., et.al., "Child Health Care," American Journal of Public Health, 72 (September, 1982): 37. 2/ Table A.23 of China Socialist Economic Development, Vol. III, a World Bank Country Study, 1983. defects, premature birth, and birth injury. The incidence of tetanus has declined to negligible levels in the cities. In the rural areas, tetanus and pneumonia still account for about 40 percent of infant deaths. In Ningxia, the neonatal tetanus mortality rate was as high as 51 per 100,000 live births in some counties. The factors underlying improvement in infant health are complex. Aside from a general rise in living standards and better sanitary conditions, progress in prenatal, intrapartum, and neonatal care also contribute significantly to improved pregnancy outcome and reduced neonatal mortality. C. Neonatal Mortality It is important to note that the neonatal mortality rate, that is, deaths in the first 28 days of life per 1,000 live births, is now about 50 to 70 percent of infant deaths (see Annex Table 4). This is the pattern seen in industrialized countries where most infant deaths occur in the first month of life. The mortality rate secondary to diseases of newborns from 28 rural surveillance points was 6.26 per 100,000 population; it ranks 11th in the total causes of death for all ages, and accounts for 1 percent of total deaths for all age groups. 8/ In 1949, the neonatal mortality rate ranged between 56.5 to 188.0 per 1,000 live births. The major causes of death were congenital syphilis (26 percent) and neonatal tetanus (5 percent). The causes of neonatal mortality today are prematurity (26 percent), asphyxia (22 percent), congenital malformation (13 percent), and infections (14 percent). 8/ Data from Institute for Epidemiology and Microbiology, Chinese Academy of Medical Sciences.  - 10 - This pattern is similar to developed countries, whereas in many developing countries of China's level of economic development, malnutrition and infection are still the predominant causes of infant death. Although published neonatal data from China are limited, those that exist report a low incidence of low birth-weight (LBW) births. China's incidence of low birthweight is lower when compared to other developed and developing countries (see Table 6). Its incidence of LBW was about 6 percent in 1981.. The incidence of low birth weights reported by the International Peace Maternity Hospital, Shanghai, was 4.7 percent, compared with an overall rate of 6.8 percent in the United States (5.7 percent for whites, 12.5 percent for blacks in 1982). This low incidence may be due to underreporting of the births of very small babies and sampling bias (that is, hospital data underrepresent the population). But se ral factors give evidence of internal consistency within the data. Chalmers - compared some risk factors of low birth weight at the maternal hospital in Shanghai and Cardiff (Wales), and the prevalence rate of these risk factors was generally lower in Shanghai. The rate of multiple pregnancy is 7.2 per 1,000 in Shanghai, with 11.1 per 1,000 in Cardiff; the incidence of hypertensive disorder is 12 per 1,000 women in Shanghai and 45 per 1,000 women in Cardiff; the prevalence of congenital malformation is lower in Shanghai than in Cardiff (see Annex Table 5). In addition, teenage pregnancies and smoking are rare among Chinese women. Table 6: Global Incidence of Low Birth-Weights Percentage of Live Births Asia 20 Africa 15 Oceania 12 Latin America 11 USSR 8 Europe 8 North America 7 China 6 Source: WHO, World Health Statistics Quarterly. "The Incidence of Low Birth- Weight: A Critical Review of Available Information," Vol. 33, No. 3, Geneva, 1980. It is possible that genetic influence plays a role in the favorable distribution of birthweight. A vital statistics report from the U.S. National 9/ Chalmers, I. "Better Perinatal Health-Shanghai," The Lancet, No. 1 (1980): 137-39.  Center of Health Statistics, 1982, reported that 4.9 percent of Chinese babies born in the U.S. weighed less than NO0 grams, whereas the incidence of LBW is 5.7 percent among white babies. The differential in the low birth weight between these races was the same when controlled for the duration of mother's education. Another possible explanation may relate to certain traditional Chinese values and living habits that might be conducive to favorable fetal and perinatal development. The incidence of LBW is a powerful determinant of mortality risk in fetal, neonatal, and postneonatal life. The apparent low incidence of LBW deserves a closer investigation. Comparison of national statistics could provide a better understanding of nationwide variation in the incidence of LBW. If the incidence is consistently low, further research could be carried out to analyze possible contributing factors to the low incidence. D. Diseases of Infancy As discussed in the previous section, at least 50 percent of infant deaths occur during the neonatal period. The prevalence of morbidity among neonates is 30 percent. Low birth weight neonates have a high morbidity rate; the incidence is 50 percent, versus 29 percent in neonates of birth weight over 2,500 gm. The frequency of the morbidity pattern is as follows: communicable diseases, 30 percent; birth injury, 14 percent; congenital defects, 8 percent; hematologic diseases, 6 percent; respiratory diseases, 5 percent; digestive diseases, 4 percent; and others (such as apnea, diarrhea and dehydration, hydrocephalus, heart failure, craniotabes, etc.), account for 33 percent. Neonatal tetanus and congenital defects will be discussed in this section. Neonatal Tetanus The World Health Organization estimates that neonatal tetanus is responsible for 90 percent of the 1 million annual deaths related to tetanus in the world. Before liberation, neonatal tetanus was one of the causes of infant death; about 5 percent of neonatal deaths were due to tetanus. The incidence of death from neonatal tetanus has drastically declined over the last 30 years. The average incidence was 6 per 10,000 births in 1982 for the 46 above mentioned counties in 4 provinces (Heilongjiang, Shangdong, Sichuan, and Ningxia), with a range from 0 to 51. Tetanus bacterial spores are common in soil, especially when manure is used as a fertilizer, a common practice in China. Thus, there is no hope of eliminating the reservoir of infection. Even with accessible health services, the disease has a case fatality ranging from 40 to 90 percent in China. 10/ Taffel, S. "Characteristics of Asian Births: United States, 1980," Monthly Vital Statistics Report, Vol. 32, No. 10, February 10, 1984, U.S. Department of Health and Human Services.  - 12 - The disease is preventable at low cost with cord hygiene and maternal vaccination during pregnancy. A major contributing factor to the reduction of neonatal tetanus mortality may be the increased availability of maternal and child health services. Between 1949 and 1952, the national total of maternal and child health stations and centers increased from 9 to 2,379. The number of registered midwives increased from 13,900 in 1969 to 73,305 in 1982. In addition, there are 549,659 part-time midwives, and about 1 midwife per 1,600 population (or 6 midwives per 10,000 population). MCH services are accessible at every level, and at least 90 percent of deliveries are conducted with the "scientific method" of using sterile tools (see Table 7). Table 7: Proportion of Deliveries Using the "Scientific Method" in China Year Total Urban Rural 1977 88.5 98.2 87.6 1980 91.4 98.7 90.3 1982 92.7 98.6 91.6 Source: Statistical Data on National Health Care, 1982, Ministry of Public Health, March, 1983. Congenital Defects Congenital mal ormation among infants has been estimated as high as 20 per 1,000 births. - The overall prevalence based on Shanghai hospital data was 6.4 per 1,000 live births. As the prevalence of communicable diseases gradually declines, the relative prevalence of hereditary disorders increases. In the U.S., approximately 30 percent of children in hospitals are there because of genetically determined or influenced disorders. Data from Beijing also shows similar proportions. About 20 percent of total deaths for infants were due to congenital defects in 1979. During 1974-1976, 30 percent of death causes for chil ren aged less than 15 were due to congenital or hereditary disorders. 1 A comparison of hospital admissions between 1963 and 1978 in Shanghai illustrated that increasing proportions of admissions were due to genetic disorders or congenital malformations compared to infections and general pediatric ailments (see Table 8). 11/ Tien, H.Y. "China: Demographic Billionnaire," Population Bulletin 38, (April, 1983): 25. 12/ Li, C.D. and C.T. Zu, "Prevalence of Patients with Congenital Defects, 1963 and 1978", Chinese Journal of Pediatrics, 18 (1980): 210-13.  - 13 - Table 8: Disease Classification of Pediatric Admissions in Pediatrics Hospital Affiliated with Shanghai First Medical College, 1963 and 1978 Number of Admissions Disease Classification 1963 1978 Hereditary 237 (5.3) 435 (10.0) Congenital defects 131 (2.9) 202 (4.7) Malignancies 50 (1.1) 74 (1.7) Infections and other 4,058 (90.7) 3,612 (83.6) Total 4,476 (100.0) 4,323 (100.0) Source: Li, C.D. and C.T. Zu, "Prevalence of Patients with Congenital Defects, 1963 and 1978," Chinese Journal of Pediatrics, 18 (1980): 210. Of the congenital defects among newborns, 74 percent are of the nervoyi,system, 11 percent of the skeletal system, and 8 percent of cleft lips - (see Table 9). Table 9: Percentage Distribution of Types of Congenital Defects Percent Nervous system 74 Skeletal system 11 Cleft lip 8 Gastrointestinal 3 Endocrine/reproductive 2 Cardiovascular 2 Source: "Analysis of Congenital Defects," National Medical Journal of China, 62 (1982): 141. Congenital defects are becoming an increasingly important issue, especially under the one-child-per-family policy. Couples restricted to one 13/ Chen, Y.C. "Analysis of Congenital Defects", Medical Journal of China, 62 (1982): 141.  - 14 - child want reassurance that their child will be healthy. Although Article 6 of the 1980 Marriage Law specifically prohibits marriage among persons who are direct blood relations or collateral relatives within three generations, marriages among relatives are still prevalent among the minority population and people in the geographically distant areas. A survey of the percentages and types of consanguineous marriage in the Hans and 10 national minorities was carried out from May 1980 to January 1981. Marriage was considered to be consanguineous when husband and wife have a common ancestor within five generations. The percentages of consanguineous marriages were: 1 percent for Hans in Beijing and Hubei, 14 percent for Yi minority in Sichuan and Gansu, 10 percent for the Hui minority in Gansu, 3 percent for the Dongyang minority in Gansu, 3 percent for the Ewenki minority in Inner Mongolia, 2 percent for the Eroqen minority in Heilongjiang and Inner Mongolia, 1 percent for the Li minority and 1 percent for the Miao minority on Hainan Islands, a4n 0 percent for both the Korean and Tibetan minorities in Jilin and Xizang. - It is estimated that 3 to 9 percent of infants born to couples who are first cousins are affected by hereditary disease, compared tol?7e-tenth of a percent among offsprings of marriages of nonrelated persons. - Health education and marriage policies play an important role in preventing the 'avoidable' factor which increases the risk of congenital defects. However, restrictions in urban and rural population mobility may inadvently result in higher frequency of inter-marriage in a village with the same family name for populations residing in very remote areas. Genetic services, such as prenatal diagnosis by amniocentesis with biochemical or karyotype analysis of fetal cells or amniotic fluid, are the best available strategies for most genetic disorders, which are now under great demand in the counties and provincial health facilities. Many county level MCH centers are attempting to set up genetic screening. Neonatal Ophthalmia After liberation, the government carried out an extensive program to eradicate venereal disease. This program included the closing down of prostitute houses, prohibition of prostitution, establishment of prevention and treatment centers, organization of medical personnel for venereal disease eradication, mass screening, and active treatment with special emphasis on syphilis in pregnant women. As a result, venereal disease was eradicated. Statistics from the Peking Medical College show that the incidence of congenital syphilis dropped from 10 percent in 1949 to 0.7 percent in 1955. 14/ Du, R.F., et. al., "Percentage and Types of Consanguineous Marriage in Different Nationalities in China," National Medical Journal of China, 61 (1984): 723. 15/ Tien, H.Y. "China: Demographic Rillionnaire," Population Bulletin, 38 (April, 1983): 25.  - 15 - Today, such cases are not encountered.-L Neonatal ophthalmia, an acute purulent conjunctivitis occurring in infants within the first 3 weeks of birth and associated with maternal gonorrhea infections, has not been reported. Topical prophylaxis with solutions such as silver nitrate applied immediately postpartum is an effective preventive measure which should be continued, even though venereal disease has been eradicated. The increased influx of travellers to China in recent years will inevitably reintroduce sexually transmitted diseases. 16/ "Child Health Care in New China," Americal Journal of Chinese Medicine, 2 (1974): 149-158.  - 16 - III. CHILD HEALTH In relation to other age groups, mortality rates for children are very low. The rate for children aged 1 to 3 is one-half that for infants, and the rate for children aged 3 to 7 is one-tenth that for infants. About 50 percent of the deaths among children aged 1 to 4 were due to cancer, respiratory diseases, and congenital defects mainly of nervous system (see Table 10). Malnutrition was still among the 7 leading causes of death for infants under age 1 and children aged 1 to 4. The leading causes of death for urban children 1 to 4 years of age is becoming similar to the pattern in the United States. In the U.S., accidents, cancer, congenital anomalies, and pneumonia are the 4 major causes of deaths. Table 10: Major Causes of Death at Ages 1 to 14, Beijing, 1979 Age Cause % of total deaths Under 1 year Respiratory disease 23.5 Genetic deformity 19.1 Premature birth 15.0 Heart disease 10.6 Trauma or asphyxia at birth 8.2 1 to 14 years Malignant tumors 20.4 Respiratory disease 16.3 Nervous system disease 14.3 Heart disease 12.2 Digestive system disease 8.2 5 to 14 years Nervous system disease 15.3 Malignant tumors 14.1 Accidents, trauma 10.6 Heart disease 9.4 Respiratory disease 7.1 Source: From Table A.23 of China, Socialist Economic Development, Vol. III, a World Bank Country Study, 1983. The pattern of childhood morbidity resembles that of other developing countries. The most frequent illnesses for children less than 10 are respiratory diseases, acute gastroenteritis, external injuries and skin diseases. Table 11 shows the morbidity pattern for children in Qufu County, Shangdong province, during September and October, 1982.  - 17 - Table 11: Five Most Common Diagnoses made by Barefoot Doctors per day, by Age, Listed in Rank Order, in Two Communes, Qufu County, September and October, 1982 Diagnosis Up to 1 year 1-5 years 6-14 years Common cold 5 1 1 Bronchitis, pneumonia, asthma 2 3 5 Enteritis 3 4 3 Other gastrointestinal diseases 1 2 4 External injury 2 Skin disease 4 5 Source: Young, M., "Study of Barefoot Doctor's Activities," Johns Hopkins University, Baltimore, unpublished thesis for Dr.P.H., 1984. A. Acute Gastroenteritis Acute gastroenteritis is a group of clinical enterities, mainly of infectious origin, consisting of dysentery, typhoid and paratyphoid fevers, cholera, infantile diarrhea, food poisoning, and indigestive diarrhea. Reporting is based largely on clinical criteria. Bacterial culture or stool microscopic examination are seldom made at the commune and brigade level. Among the 24 notifiable diseases, dysentery ranks second, after influenza. Of all diarrheal deseases, dysentery heads the list of reported cases. Bacillary dysentery implies shigellosis. Shigella flexneri, followed by Shigella sonnei, are the predominant isolates. Shigella infection is most frequent in preschool children but may occur at any age. It is considered by the Ministry of Public Health to be China's most serious diarrheal disease problem. June, July, August, and September are the months of highest incidence. Based on hospital admissions for diarrheal diseases at Shanghai First Medical College, dysentery is an overwhelming childhood disease; 65 percent of admissions of children below 2 years of age were due to dysentery. About 90 percent of pediatric outpatient visits with acute gastroenteritis were diagnosed as dysentery. This may be a selection bias. Only patients with severe symptoms are taken to hospitals. The incidence of dysentery has not reduced drastically over the last 30 years. In 1935, the dysentery-specific death rate in Tingxien, a district southwest of Beijing, was 250 per 100,000. The reported incidence rate from 1939-44 in 19 provinces was 25.9 per 100,000. In 1981, the national incidence was 349 per 100,000. However, underreporting in the earlier years may be the main reason for the continuing high incidence rate over the recent years.  - 18 - Similarly, the reported incidence of acute gastroenteritis for Shanghai in 1979 was 1,000 per 100,000, and Guandong was 264 per 100,000; this is one-fourth the rate of Shanghai. The differences reflect the relative completeness of reporting in Shanghai rather than an actual lower incidence in Guangdong (Annex Table 6). A diarrhea morbidity and mortality survey on 5,789 households was conducted in Shanxi province in 1982. Of the 2,527 children less than 5 years old, 45 percent developed a new episode of diarrhea during the prior 2-week period. If based on the assumption that the surveys were representative of the entire year, the annual diarrhea incidence in children under 5 years of age would be 1.2 episodes per child per year. This most likely is an underrepresentation due to sampling bias and selection of populations. The incidence is lower than the mean annual incjt,nce of the U.S., which was 1.9 in the under-5-year olds (Tecumseh study). - A number of viral pathogens, such as rotavirus and parvovirus-like agents, are associated with clinical symptoms in children below the age 5. Dehydration is a typical feature of these illnesses. Very few studies have estimated the incidence of diarrhea associated with rotavirus or parvo-like agents due to lack of diagnostic tools in general clinical settings. In developed countries, close to 50 percent of children aged 1-3 years who are hospitalized for severe diarrhea are infected with rotavirus; a similar frequency of rotavirus in severg dehydrating diarrhea has been found in several developing countries. 1 / The incidence of cholera has decreased to 0.008 per 100,000 in 1981, and the cases are mainly imported, which means they occur along the southern border of China, such as Guandong and Fujian Provinces. The incidence of typhoid and paratyphoid was 7.6 per 100,000 in 1981. It has increased between 1974 and 1981. This increase, however, is due to improvement of the reporting system rather than actual higher incidence. Highest attack rates occur to the age group of 5 to 19. There is no data available on the prevalence of Amoebiasis, a severe parasitic dysentery. Annex Table 4 presents the incidence of cholera, dysentery, typhoid, and hepatitis by province in 1981. B. Acute Respiratory Infections The pathogens involved are multiple, such as the respiratory syncytial virus, parainfluenza viruses, rhinoviruses, coronaviruses, adenoviruses, and also measles, which produces respiratory manifestations as one component of a more generalized disease. A serological survey in Beijing 17/ Last, John M. Public Health and Preventive Medicine, New York: Appleton Century Crafts, 11th Edition, 1983. 18/ Ibid.  - 19 - on children under 14 showed that parainfluenza type I and III are the moa common, followed by influenza type A, then respiratory syncytial virus. It is not possible to determine etiology on clinical grounds; the illnesses are usually enumerated simply as common colds. The distribution of these illnesses is highest in younger children and decreases with increasing age. Respiratory syncytial virus is considered the most important agent of respiratory infection among infants and young children because of its capacity to cause life-threatening bronchiolitis and pneumonia. Major outbreaks occur in the winter of alternate years; then in the next year, a smaller outbreak takes place in the spring. Reinfection with the virus throughout life is common. About 30 percent of a sample of children under 14 in Beijing had antibodies to respiratory syncytial virus. Acute respiratory infections rank second as a cause of outpatient visits in brigade health stations. The prevalence of acute respiratory infections including pneumonia among children was 7 to 8 percent in Heilongjiang and Sichuan Province. Pneumonia, either viral or bacterial, is still a major cause of morbidity and mortality for infants and children. Respiratory diseases account for one-third to one-fourth of all causes of illness in neonates. The fatality rate of neonatal pneumonia can be as high as 20 percent. C. Vaccine-Preventable Diseases Immunization is one of the major contributing factors to China's remarkable improvement in the health condition of its population. Since liberation, a basic network for child health care was built up, and since the 1960s mass immunization campaigns for childhood diseases have been established and become routinely implemented. Five vaccines are administered to all children: Bacillus Calmette-Guerin (BCG) against tuberculosis, oral polio- myelitis vaccine, diphtheria and tetanus toxoids combined with pertussis (DPT), and live attenuated measles vaccine. Vaccines are administered by Barefoot Doctors and MCH services. The present schedule for routine immunization campaigns is shown in Annex Table 7. A modified schedule is progressively introduced with the implementation of the WHO sponsored Expanded Programme of Immunization (EPI). The impact of this activity is evident, as the incidence of vaccine-preventable diseases have decreased remarkably in both urban and rural areas. Vaccinations are given in organized campaigns because of lack of adequate cold chain resources in rural areas. Thus, vaccinations are given once a year for each type of vaccine, during campaigns of one to several days, organized at the county level. The dates for vaccination are arranged in 19/ Zhao, J.M. et.al. "Investigation on Antibodies Against Respiratory Tract Virus in Children," National Medical Journal of China, 62 (1982): 723-26.  - 20 - advance. Barefoot doctors notify the eligible children (that is, children who have attained the recommended age). Annex Table 8 indicates the number of children eligible and percentage coverage. Immunization coverage rates were well in excess of 90 percent for all the vaccines given. In the following sections we will discuss verification surveys for some of the diseases in an attempt to review the efficacy of the vaccination program. Table 12 gives nationwide incidence rates for the childhood communicable disease during 1974-1981, and Annex Table 9 gives incidences for East District in Beijing from 1958 to 1979. Both sets of data indicate that the incidence for childhood communicable diseases have decreased over the years. The reported rates are lower in the cities than in the rural areas, but there is a significant degree of underreporting, the extent of which varies by disease between urban and rural areas. Table 12: Nationwide Incidence of Childhood Communicable Diseases, 1974-1981 (per 100,000 population) Measles Poliomyelitis Diphtheria Pertussis incidence CFR incidence CFR incidence CFR incidence CFR 1974 110.9 0.5 1.2 2 2.6 9 73.3 0.1 1975 149.5 0.8 0.8 2 4.1 82.8 0.2 1976 119.0 0.6 0.5 3 2.6 9 66.7 0.1 1977 107.9 0.6 0.8 3 3.2 8 70.3 0.1 1978 116.1 0.6 1.1 2 2.1 8 62.1 0.2 1979 92.9 0.7 0.6 3 1.7 8 41.4 0.2 1980 299.9 0.02 0.8 2 1.0 9 32.3 0.1 1981 206.1 0.02 0.5 4 0.9 10 27.2 0.2 CFR = Case Fatality Rate = Number of deaths per 100 cases of a given disease. Source: Data provided by the Ministry of Public Health, October, 1982. A recent survey was carried out to assess the validity of the reporting system in several urban and rural surveillance points (Annex table 10). The comparison between reported cases versus discovered cases (retrospective survey based on household visits) seems to indicate that the accuracy and the reliability of reporting is greater in rural areas. Differ- ences are significant for hepatitis, but also for measles. It is surprising that reporting is less complete in urban areas, but it may be because the clinical symptoms are less severe in urban children, who have better nutritional status; hence, less frequent complications and less frequent health care services are sought.  - 21 - Incidence of Vaccine-Preventable Diseases Measles Measles is a highly contagious disease, which 90 percent of the unprotected population aged under 5 years contract in many countries. Poor nutritional status seems to be the main factor leading to the most severe consequences of measles. Death is caused by pneumonia, diarrhea or, in a small number of cases, encephalitis in association with the disease. Maternal antibodies transferred through the placenta protect the infant during the first months of life. If measles vaccine is given to the infant before nine months of age, these antibodies may prevent the vaccine from producing immunity in the child. Before the mass vaccination in China in 1965, epidemics of measles occurred in alternate years. During the epidemic years, the annual incidence was as high as 1,000 to 5,000 cases per 100,000 population, with a case fatality rate of 1 to 2 percent. In 1965, when an attenuated measles vaccine was developed in China, a vaccination campaign was launched throughout the country. In its early years, the immunization program was not implemented simultaneously at all places, and outbreaks continued to occur; however, the incidence of measles declined in some areas. Since the late 1970s, the coverage of vaccination of children younger than 7 years of age has increased to over 90 percent. The incidence had dropped to below 20 per 100,000 for major cities by 1980 (see Annex table 9 for East Beijing). Nationally, the incidence was about 200 per 100,000 in 1981, and the fatality-rate has decreased to less than 0.1 percent (Table 12). Figure 2 shows the decrease in the incidence of measles before and after vaccination. However, measles still account for an appreciable proportion of all cases of infectious disease. The epidemiologic characteristics of measles have changed substantially with widespread vaccination campaigns. The age-specific incidence of measles has shifted to older age groups. In the prevaccine era, the incidence was highest among preschool children, especially those up to 4 years of age. More than 95 percent of children had measles by the age of 6. After mass vaccination, the number of wsles cases in older age groups (5-14) represents two-thirds of total cases. - This shift is due to an increasing proportion of young children being protected by immunization. Before the vaccine era, the incidence of measles generally peaked in February and March, and fell in the winter or late spring. A change in this pattern has been observed in many places since the vaccination campaign was launched. The peak incidence occurs later in the year, shifting toward spring and summer. (See Figure 3.) 20/ Zhanq, Y.H. and W.N. Su. "A Review of the Current Impact of Measles in the People's Republic of China," Review of Infectious Diseases, 5 (1983): 415.  - 22 - 1950-1966 -7 - - ~ ~ 1966-1974 1974-1980 70 3- ~~ ''2 3\\5.. o~~~~~~mnh Figure 2. Average Monthly Incidences of Measles During the Three Epidemiologic Stages: (l) Prevaccination (-); (2) Early Vaccination (---;and (3) Scheduled Vaccination ( !CM * 00 es j ----------7.-- oe ----" A 'd.,a \_, /011 1tt *7 34 .1 67 69e Figure 2.Avrg Monthly Nu cidercef Reofte Measles DurngtheTre Epidemiologicd SftagWies:p(1)adrVaccination () in Ningbo City, Zheziang Province Source: Zhang, Y.H( and W.N. Su, "A Review of the Current Impact of Measles in the People's Republic of China," Review of InIfectious Diseases, 5 (1983): 414.  - 23 - The epidemic pattern of measles is dependent upon the proper use of measles vaccine. If a high-quality vaccine is used, and if both vaccination coverage and the rate of successful vaccination are high, there should be no epidemic at all. Table 13 presents data which shows that the incidence of measles decreases as percentage coverage by vaccination increases. A seroepidemiologic sryrey was conducted in Mengcun county, Hehei Province, of 130,000 population - in 1978 after a measles outbreak. The outbreak occurred after the introduction of measles cases from outside the county, which propagated to a total of 116 cases in the county. An investigation of the immunization history of these cases showed that 49 percent (57 cases) were not vaccinated, and 51 percent (59 cases) received vaccination, of which 16 cases had received measles vaccine at age less than 1. Six cases had received measles vaccination twice. Table 13: Relationship between Vaccination Coverage in 1976 and the Incidence of Measles in 1977 in Shanghai County Vaccination No. of No. of No. of Incidence Coverage in 1976 (7%) Communes Children Cases per 10,000 40-49 4 5,498 45 83.4 50-59 2 2,020 5 24.7 60-69 4 5,930 10 6.9 70-79 4 7,531 7 9.3 80-95 6 9,138 5 5.5 Total 20 30,017 72 24.0 Source: Zhang, Y.H. and W.N. Su, "A Review of the Current Impact of Measles in the People's Republic of China," Review of Infectious Diseases, 5 (1983): 413. The problems are in the quality of vaccine, in the cold chain and the timing of vaccination. Freeze-dried vaccine is not yet available in China, and the liquid form currently used has a short period of potency. Patients who were vaccinated but failed to elicit an immune response may have received a vaccine that had lost its potency. Since vaccines need to be stored between 40C to 80C during transport, lack of knowledge about vaccine storage or lack of equipment for proper storage contribute to the ineffectiveness of a vaccine. In Gansu, the health officials reported that 85 percent of measles vaccines have lost effectiveness by the time of vaccination. In certain areas in China, the measles vaccination schedule are set for infants to receive the 21/ Wu, Z.Y., et.al. "A Seroepidemiologic Analysis of Measles," Chinese Journal of Epidemiology, 4 (1983): 4-7.  - 24 - vaccine after 8 months of age. The optimal age for vaccination has been extensively researched. In developing countries, the risk of exposure to the infection at an earlier age versus the risk of failing to elicit an immune response when the vaccine is given too early (when maternal immunoglobulin is still present) in addition to the immature immune system, must be weighed in order to decide an optimal age for the vaccination. The consensus, therefore, is to administer measles vaccination after one year of age. Pertussis Pertussis is second to measles as a cause of morbidity and mortality among vaccine-preventable diseases in some developing countries and also in China. The World Health Organization estimates that up to 80 percent of unimmunized children will contract it. Pertussis, an acute bacterial infection affecting the respiratory tract, is very contagious in the first week or two of infection. The spasmodic coughing that characterizes the disease lasts one to two months. In very young children there is no characteristic whoop, so the disease may be difficult to recognize. Immunization requires three vaccinations which may begin as early as 2 months of age. The incidence of pertussis in China has gradually declined. The incidence was about 30 per 100,000 population in 1981 nationwide, which is an underestimate. A verification survey indicated that underreporting is impor- tant in several urban areas (see Annex Table 10). Poliomyelitis Poliomyelitis is a viral disease spread by contact with objects, food or water contaminated with excreta. Poliomyelitis infection is universal, but most persons have no symptoms. The older the child at the age of infection, the more likely the infection will lead to severe sequella. Prior to 1955 epidemics were common, with local outbreaks occurring every year. Hence, the incidence of poliomyelitis varied greatly across localities. For example, in 1959, in Nanning, the incidence of poliomyelitis was 151 per 100,000; in Shanghai, the incidence was 30; in Tsingtao, 54; and in Kunming, 62 per 100,000, while incomplete aggregates of statistics from 17 provinces, municipalities, and autonomous regions showed an overall incidence of 5 per 100,000. Live attenuated polio vaccine was introduced in China in 1960, and since 1964 oral polio vaccine has been extensively supplied to the entire country. In 1971 the average incidence of poliomyelitis for China was 2.12 per 100,000, which has declined to 0.5 per 100,000 in 1981. (The rate is lower in the urban areas - 0.22 per 100,000 versus the rural areas of 1.05 per 100,000.) Again, the incidence rate is likely an underestimate, since children affected may be asymptomatic. In 1981, a national survey on the evaluation of frequency of paralytic sequella of poliomyelitis was conducted in 12 provinces (which include a population of 3,521,373 under the age of 30). As a result, 4,241 cases of paralytic polio were detected; the average prevalence of paralytic poliomyelitis was 1.21 per 1,000 (see Annex Table 11). According to  - 25 - the results of recent surveys, WHO proposes to multiply the prevalence of paralytic sequella by 1.25 to account for paralysis of muscles other than lower limbs, and then again by 1.33 to account for clinical poliomyelitis cases who either die or fully recover. This calculation indicates that the prevalence of clinical poliomyelitis among the population surveyed had been about 2 per 1,000. The age-specific distribution of the prevalence rate in China indicates that there is an age shift of affected cases toward older age groups, which means that the mass campaigns have offered increasing coverage and protection among the younger age groups. The age shift is more markedly observed in urban areas: about 9 percent were of less than 15 years of age, whereas in the rural areas, 49 percent of the cases were still less than 15 years of age (see Annex Table 12). The prevalence of paralytic poliomyelitis is lower than the rates reported in selected surveys in Niger and Ghana (see Table 14). In both Niger and Ghana, the prevalence is about 0.7 percent, compared to 0.1 percent for rural children of comparable age in China. Table 14: Comparison of Prevalence of Sequels of Poliomyelitis with Niger and Ghana Surveys Place Age Prevalence % Niger 1-/ 5-9 0.69 10-14 0.57 5-14 0.64 Danfa (Ghana) 2/ school age 0.72 2/ school age 0.82 Ghana -scolae08 China 3/ 5-9 urban 0.02 rural 0.10 10-14 urban 0.08 rural 0.12 Sources: 1/ Thuriaux, M.C. and B. Getholamy, "Enquete sur la prevalence des sequelles de poliomyelite au niveau des membres inferieurs chez des enfants d'age scolaire dans les zones rurales du Departement de Niamey, Niger", Medecine Tropicale, 42 (1982): 547. 2/ "Comparison of Methods for Estimating the Frequency of Paralytic Polio- myelitis in Developing Countries," Bulletin of the World Health Organization, 57 (1979): 303. 3/ "Survey of Paralytic Sequella of Poliomyelitis," Chinese Journal of Epidemiology, 4 (1983): 142.  - 26 - A review of the immunization history of detected cases shows that among 4,241 cases, 40 percent occurred after the initiation of mass immunization campaigns. Among these cases, 72 percent had not received vaccination, 3 percent received the full course of vaccination, 5 percent received an incomplete course of vaccination, and 19 percent had an unclear history of vaccination (see Table 15). Table 15: Recent Distribution of Vaccination History of Cases of Paralytic Poliomyelitis, Changjian, 1981 Urban Changjian Rural Changjian Vaccination History North South Total North South Total Not vaccinated 68 57 63 72 86 75 Complete 3 5 4 3 2 3 Incomplete 5 8 6 6 1 5 Unclear 24 30 27 19 11 17 Source: "Report on the Survey of Paralytic Sequella of Poliomyelitis," Chinese Journal of Epidemiology, 4 (1983): 144. Possible reasons to explain the inapparent protection by vaccine were: (a) ineffective cold chain, resulting in the loss of vaccine efficacy during transport; (b) virulence from the live vaccine causing the infection, which is possible in China, although it has not been documented. (c) Inappropriate use, resulting in the loss of vaccine effectiveness at time of vaccination. Rubella Rubella is a common contagious disease of children and young adults. The illness itself is usually mild and self-limited. The real significance of rubella lies in its ability to cause congenital defects in infants of women who acquire rubella during pregnancy. Congenital rubella syndromes include congenital heart disease, cataracts, nerve deafness, and mental retardation. Rubella infection is universally endemic. Active immunity is acquired by natural infection or by active immunization. Routine rubella  - 27 - vaccination is not given in China. The incidence of the disease is high in children. A rubella serosurvey conducted in Lanzhou city in 1980 on 1,157 persons of different age groups (see Table 16) and in Beijing in 1980 (see Table 16: UJrban-Rural Comparison of Rubella Seroconversion, Lanzhou, 1980 Urban Rural Age No. x positive No. % Positive 1-5 55 70.9 26 80.8 6-10 131 98.5 118 98.3 11-15 141 99.3 59 96.6 16+ 352 95.5 211 94.8 Total 679 94.8 414 95.2 Source: Chang, W.Z. et.al., "Serological Survey of Rubella in Lanzhou," Chinese Journal of Epidemiology, 4 (1983): 90. Table 17) showed that hemaglutination inhibiting antibody level versus rubella was positive in 95 percent of the sample population tested in Lanzhou, and 89 percent of the sample population in Beijing. About 95 percent of the population after 10 years of age are seropositive in both places. Table 17: Rubella Serosurvey in Beijing, 1980 Age No. Surveyed % Positive less than 1 67 53.7 1-5 183 72.1 6-10 203 91.6 11-15 115 95.5 16-45 391 99.2 Total 959 88.8 Source: Lin, Z.M. et.al., "Serological Survey of Rubella in Beijing," Chinese Journal of Epidemiology, 4 (1983): 32. About 95 percent of the female population acquire an antibody to rubella by the time they reach childbearing age. Thus, 5 percent of women between ages 21 to 35 are susceptible to rubella infection. An important decision thus needs to be made: to identify and vaccinate susceptible women, and to incorporate the rubella vaccine in the routine vaccination schedule in  - 28 - order to avoid the risk of rubella infection during early pregnancy (when a mother is capable of infecting the fetus), resulting in congenital defects to the infant. Diphtheria Typically manifested as an acute infection of the throat, diphtheria toxin can affect the heart or brain of infants and young children. Death in diphtheria, however, is still mainly due to airway obstruction. The epi- demiologic characteristics of the disease has changed concomitant with a marked decrease in incidence since widespread vaccination campaigns. In 1981, the nationwide incidence was 0.9 per 100,000. In the past few years, no diphtheria cases were reported in 1,040 cities, prefectures, and counties. A review of the characteristics of the reported cases over a 30- year period between 1950 and 1979 in Guandong province showed that 60 to 78 percent of the cases occurred during the months between October and January. The age distribution of patients ranges from 19 days to 37 years of age. Overall, children less than 7 years old accounted for 84 percent of all the cases. However, over the last 10 years, the age distribution of patients has shifted toward older age groups. Between 1974-1975, about 11 percent of cases were of children less than 7 years of age, whereas in the 1950s and 1960s at least 70 percent occurred within the less than 7 year old group. This indicated that immunization has provided protection to an increasing proportion of the younger population which receives routine immunization. The incidence is higher in urban areas, probably due to crowding which increases the risk of exposure to contacts or carriers. Case fatality rates are still higher in rural areas. This is probably due to differences in access to health care between urban and the rural areas. The overall case fatality rate is about 10 percent, which has changed very little for the last 10 years. The virulence of the disease has decreased with widespread immunization campaigns. There are fewer cases of generalized toxemia and relatively more cases of cutaneous diphtheria. There are also possibilities of unapparent infections which may outnumber recognized cases. Cutaneous diphtheria is often indistinguishable from skin infections such as impetigo. Infections are more often localized to nasopharyngeal involvement (90 percent), and much less frequently laryngeal involvement. Tuberculosis Tuberculosis was the leading cause of death before liberation, responsible for an estimated 200 to 230 annual deaths per 100,000 population. After liberation, with improvements in living standards (housing and nutrition), immunization, and the availability of chemotherapy, tuberculosis prevalence declined. Tuberculosis mortality by 1979 ranged between 10 to 40 deaths per 100,000 population. In 1980, tuberculosis mortality had dropped to 9th rank among causes of mortality. Bivariate regression analysis seems to indicate that urbanization is associated with a lower prevalence of tuberculosis.  - 29 - A national tuberculosis morbidity survey was carried out in 1979. The average prevalence of the disease in China was then 717 per 100,000 population. Annex Table 13 and Map shows the tuberculosis prevalence by province. It was estimated from this survey that 2 million patients were actively infectious (i.e., excrete bacillus). Nationwide age-specific morbidity rates are not available; however, reports from some provinces and cities indicate that childhood tuberculosis is still a major concern. The overall prevalence for children less than 7 was estimated to be about 8 percent; the prevalence of pulmonary tuberculosis among primary school children decreased from 1,700 per 100,000 in 1940 to 40 per 100,000. The prevalence for children in middle school declined from 5,400 in 1940 to 200 per 100,000 population in 1979 in Beijing. But the prevalence for middle school children has remained at 200 per 100,000 for the last 10 years. 2-/ At present, in many regions in China, the prevalence of pulmonary tuberculosis is highest among the group between 15 to 29 years of age. In adults, pulmonary tuberculosis is the primary form of infection. The disease takes many forms in children, infecting the bones, kidneys, or brain. Often it may not be recognized as the same disease that affects adults. Distribution of the affected organ in a report on 743 cases of childhood tuberculosis showed that 44 percent were pulmonary, 22 percent extrapulmonary (of which 80 percent were meningitis), and 34 percent were combined pulmonary and extrapulmonary. Among these 743 cases, 85 percent apparently had a history of receiving BCG vaccination. Meningitis is the major cause of death in childhood tuberculosis. Jiamusi City Tuberculosis Control Center in Heilongjiang Province reported that between 1972 and 1979, about one-third of patients admitted had tuberculosis meningitis. Inner Mongolia Pediatrics Hospital had 74 cases of tuberculosis meningitis between 1978 and 1979, 51 percent of these patients were children less than 2 years of age. Among the tuberculosis patients admitted to a Sichuan Pediatric hospital, 62 percent were less than 5 years of age, 30 percent were between 5 and 10, and 8 percent were between 10 and 12. The prevalence of childhood tuberculosis is about the same for urban and rural populations. Where the infection rate is high, an effective vaccine could markedly decrease the risk of developing tuberculosis. In China, the level of infection rate is 1.1 percent among young children less than 7 years of age. The level of the infection rate above which vaccination is indicated varies with many factors. Most tuberculosis experts would place this level somewhere between 5.0 and 0.5 new infections per 100 persons per year. Meningitis is the first component of childhood tuberculosis that will disappear with adequate BCG coverage. Thus, effectiveness of BCG vaccination can be measured by decline or eradication of cases of tuberculosis meningi- tis. BCG vaccination is a relatively harmless procedure. At present, BCG vaccination is given to all newborns prior to discharge from hospitals, and 22/ "Summary Discussion on Pediatric Tuberculosis," Chinese Journal of Pediatrics, 20 (1982): 167-71.  - 30 - re-vaccination is given to children of 7 and 12 years of age, to newly enrolled college students, factory workers, and military recruits. The BCG vaccination campaign started in 1950 and was widely popularized. Shanghai Second Medical College Affiliated Pediatrics-Hospital showed that the incidence of tuberculosis meningitis has gradually declined (see Table 18). However, the problem is still not negligible and this is partially due to sub- optimal level of BCG coverage. More than 32 percent of the 1,295,000 persons surveyed in the national tuberculosis sample survey had never received BCG. Also, the effectiveness of BCG vaccination is questionable, since the liquid vaccine produced in China has a validity of only 43 days. Therefore, it is unlikely that all vaccinations throughout China are given with a potent vaccine. Physicians from the Tuberculosis Institute of Heilongjiang Province estimate that about 80 percent of the target population receives the vaccine, of which only 60 to 80 percent are effectively immunized. Consequently, the coverage of the target group is probably lower than 50 percent. Table 18: Number of Cases of Tuberculosis Meningitis Admitted to Shanghai Second Medical College Affiliated Pediatrics Hospital, 1950-1980 Year Cases of TB meningitis 1952-55 164 1956-60 194 1961-65 33 1966-70 15 1971-75 8 1976-1980 7 Total 1952-1980 421 Source: "Summary Discussions on Prevention and Management of Pediatric Meningitis," Chinese Journal of Pediatrics, 20 (1980): 170. Japanese B Encephalitis This is a mosquito transmitted viral disease which is seen throughout East Asia, including Japan and Korea. Large epidemics were frequently seen near Shanghai City until 1965, with the incidence approximately 54 per 100,000. Since 1965, the incidence in the Shanghai area has been around 2 to 3 per 100,000. From 1974 to 1981 it has ranged between 7 to 12 per 100,000 (see Table 19). Japanese B encephalitis is thought to be present in all of China except Tibet and Xinjiang. Human cases peak at 4-5 years of age; children are at higher risk of clinical infection than young adults. Neurological sequella are noted in as many as 75 percent of survivors, and are more severe in children under 10 years of age. About 80 million doses of inactivated vaccine are produced annually in China. The target population are children between the ages of 5 and 12, with the vaccination schedule being 2  - 31 - Table 19: Morbidy and Mortality from Japanese B Encephalitis, Nationwide, 1974-1981 Reported Incidence Cases Deaths CFR per 100,000 1974 98,445 2,899 29 10.8 1975 72,030 422 1 7.8 1976 115,964 4,380 4 12.4 1977 90,149 5,113 6 9.5 1978 107,337 4,313 4 11.2 1979 109,304 4,903 4 11.3 1980 108,774 4,590 4 11.1 1981 67,373 197 0.3 6.8 Source: Data provided by the Ministry of Public Health, October, 1982. initial doses, 2-3 weeks apart, and a single booster a month later. Since 1979, a booster every four years has been recommended. About 100,000 cases of Japanese B encepahlitis are still reported in China every year. Immunization and control of vector breeding either by application of larvicides or insecticides are available preventive measures of Japanese B encephalitis. Hepatitis The change in the prevalence of hepatitis in China is less dramatic than in other countries. A trend of a high prevalence of hepatitis continues. Table 20 reports on the total number of cases registered in China between 1974 and 1981. Table 20: Morbidity and Mortality from Viral Hepatitis, Nationwide, 1974-1981 Reported Incidence Cases Deaths CFR per 100,000 1974 241,597 1,276 0.5 26.5 1975 311,547 1,187 0.4 33.7 1976 258,960 1,113 0.4 27.7 1977 264,413 1,121 0.4 27.9 1978 411,312 1,068 0.3 42.9 1979 471,580 1,103 0.2 48.8 1980 474,601 1,153 0.2 48.4 1981 431,016 1,164 0.3 43.5 Source: Data provided by the Ministry of Public Health, October, 1982.  - 32 - Hepatitis A classically affects almost the entire population during childhood with a demonstrable effect of socioeconomic status and sanitary level on age-specific incidence pattern. The clinical disease in young children is usually mild and the incidence of subclinical infection is high. Infection results in clinical symptoms in 5 to 10 percent of infections only. Outbreaks of hepatitis A occur mainly in children, or collective units in primary and middle schools. The incidence has increased in the recent years due partially to improvements in reporting. However, reports do not usually identify A and B hepatitis and therefore the prevalence of the A form is largely unknown, except for specific surveys. In contrast to feco-oral transmission of hepatitis A, the mode of hepatitis B transmission is mainly, although not exclusively, parenteral, through inoculation by a contaminated needle, by infective serum or by blood products. Transmission of hepatitis B from carrier mothers to their babies during the perinatal period is an important determinant of the prevalence of the hepatitis B virus (HBV) in some regions. The risk of infection may reach 50 percent. A survey in Henan reported an incidence of 44 percent of such perinatal infections. Frequently, infected people become chronic carriers of HBV, and chronicity is more likely to follow infections acquired in childhood than those acquired in adult life. The highest prevalence of HBV is usually found in children aged 4-8 years, with steadily declining rates among older age groups. The main epidemiological feature is the association between the HBV infection and the development of primary liver carcinoma. The relative risk of developing liver cancer in HBV carriers as compared to non-carriers is estimated at about 150:1. Liver carcinoma is a fatal disease in almost 100 percent of cases. The coastal plain of China is one of the major world foci of liver carcinoma, responsible for more than 20 annual deaths per 100,000 males in Shanghai municipality, Fujian, Jiangsu, and Zhejiang provinces, and Guangxi Autonomous Region (age-adjusted rates to 1964 census population of China). Therefore, the prevention of hepatitis B through mass immunization in affected areas is a priority for action in southern China. The prevalence of clinical acute infectious hepatitis was 810 per 100,000 population for children less than 14 years of age in a Beijing survey in 1979. Fourty-four percent of acute hepatitis cases were positive for type A, 20 percent were positive for type B, 22 percent were negative for both (non-A, non-B types), and 14 percent were positive for both type A and B. In Zibo City, Shangdong, 30 percent of patients with acute viral hepatitis were HBV positive. Beijing and Shanghai reported 38 percent and 44 percent, respectivjjy, of hepatitis B among hospitalized hepatitis pediatric patients in 1980. -' 23/ Yan, Y.G., et. al., "Summary of National Symposium on Prevention and Treatment of Childhood Hepatitis," Chinese Journal of Pediatrics, 20 (May, 1982): 120-123.  - 33 - The prevalence of HBV in apparently healthy individuals varies from 0.1 to 0.5 percent in North America to as high as 20 percent in Asian and African endemic zones. The prevalence of HBV carriers in Wuhan city for children less than 2 years of age was 22 percent, and 20 percent for children 3 to 6 years of age. In Shanghai City, among children less than 4 years in day care centers surveyed, 30 percent were HBV carriers. In Guizhou provinie overall, the HBV carrier rate was 6 percent among 1,280 persons surveyed, - whereas in Zib ,Shangdong, 12 percent of apparently health individuals were HBV positive. _ Prevention of hepatitis B depends on minimizing risk of direct contact with contaminated blood, through testing of donor blood for HBV and proper sterilization of reusable needles or regular examinations of food handlers and day care personnel. Several vaccines are now available in Europe, United States and Japan. China is actively involved in the research on hepatitis B vaccines, and considers mass immunization as a priority for public health. Prevention of hepatitis A is a relatively difficult task, since it depends on improvement of agricultural sanitation and decreased frequency of fecal contamination to water supply and vegetables. Human and animal wastes are heavily utilized for fertilizer production. Environmental pollution is difficult to control until sanitary methods of fertilizer storage, processing and application are applied. In the rural areas, at least 50 percent of the population still uses surface water. Ground water is highly susceptible to fecal contamination when there is no strict standards in sewage disposal. Epidemic Meningitis Meningococci are found only in humans. They are spread from the nasopharynx of one person to that of another, probably by respiratory droplets. Transmission is most intense in closed, crowded conditions. Meningococcal disease occurs with a peak in late winter and early spring. Most large epidemics of menigococcal disease are caused by serogroup A. Table 21 presents the nationwide incidence rate for the period 1974 to 1981. A review of cases for all counties in Xuchang prefecture, Henan province, during 1953-1979 illustrated several epidemiologic characteristics of meningitis. The incidence was highest in February to April in either epidemic or non-epidemic years. A severe epidemic occurred every 8-10 years. The incidence was highest in children of 7 to 15 years of age. The fatality rate was highest among the 0-3 age group. In Xuchang prefecture, the average fatality rate was 9 percent and showed a gradual decline from year to year. The highest fatality rate was 37 percent in 1955, and the lowest was 4 24/ Zheng, Y.H., et. al., "Serological Investigation of Hepatitis B," Chinese Journal of Epidemiology, 2 (1981): 152-155. 25/ Hu, Z.L., et. al., "Epidemiology of Hepatitis in Zibo City," Chinese Journal of Epidemiology, 21 (1981): 243-246.  - 34 - Table 21: Morbidity and Mortality from Epidemic Meningitis, Nationwide, 1974-1981 Reported Incidence Cases Deaths CFR per 100,000 1974 30,914 4,996 3.4 16 1975 22,126 3,308 2.4 15 1976 14,861 1,964 1.6 13 1977 13,865 2,027 1.5 15 1978 18,082 2,578 1.9 14 1979 17,437 2,031 1.8 12 1980 14,192 1,793 1.4 13 1981 14,572 1,983 1.5 14 Source: Data provided by the Ministry of Public Health, October, 1982. percent in 1978. The fatality rate usually does not vary with the rise and fall of the incidence rate. The decrease in the fatality rate is closely associated with improvement of health care and hygienic conditions. In China overall, the fatality rate has been about 15 percent over the last 10 years without marked changes. Table 22 shows the range of incidence between 1953- 1979 in Xuchang prefecture. Table 22: Incidence of Epidemic Meningitis during 1953-1979 in Xuchang, Henan Province Period Range Average 1953-62 0.8 to 33.3 per 100,000 8.4 per 100,000 1963-72 0.8 to 653.0 per 100,000 98.9 per 100,000 1973-79 5.3 to 87.0 per 100,000 29.3 per 100,000 Source: "Epidemiological Analysis of Epidemic Meningitis in Xuchang Prefecture," Chinese Journal of Epidemiology, 1 (February, 1982): 8-11. Among groups of people, the incidence of the disease is directly related to the carrier rate. A survey of 2,359 persons in Xuchang prefecture indicated that 29 percent of people sampled were meningococcal carriers. The carrier rate in the epidemic region was about 62 percent, and was 13 percent  - 35 - in the non-epidemic region. The carrier rate of serogroup A in the epidemic region was 26 percent, and that of the non-epidemic region was 1 percent. Production and efficacy trials of different vaccines have been carried out since 1966 in China. In 1973, a purified vaccine was produced and a five-year trial was carried out which provided a protection rate of 80 percent. However, the vaccine had severe side reactions. Between 1980 and 1981, A4 strain polysaccharide vaccine was used, and the incidence rate of meningitis for the recipient group was 2.20 versus 43.16 for the placebo group. A four-fold rise of antibody was present in 88 percent of the vaccinated group; this was significantly higher than the placebo group (25 percent). This vaccine has been adopted for mass immunization.  - 36 - IV. NUTRITIONAL STATUS OF CHILDREN A. Diet and Food Supply Diet Human milk offers one of the best ways to close the "protein gap" in the developing world. A major problem encountered today in developing countries is very early weaning or substitution of breast-feeding with cow's milk. In China, both in the cities and in the countryside, breast-feeding is still the "method of choice". At least 90 percent (more in the range of 95-98 percent) of all infants are breastfed today. In urban families, an infant is breastfed for 8-9 months. In rural households, babies are usually breast-fed for at least 18 months. The measures taken by the Chinese health authorities to facilitate breast-feeding are noteworthy. All mothers employed in factories or working for the government are given 2 months maternity leave with pay, in order to allow for breast-feeding. Thereafter, mothers are provided 2 half-hour breaks during their work day to breastfeed their infants. In the rural areas, the daily schedule of nursing mothers is arranged so that they can feed their infants at regular intervals. A more recent study in Shanghai in 1981, however, showed that only 32 percent of infants in urban districts and 74 percent of infants in rural areas are breastfed for 6 months. The trend toward bottle feeding may unfavorably increase as people in the cities adopt it as a sign of westernization. In the cities, majority of the women are engaged in the labor force, hence the grandparents are the primary caretakers of the children. In rural areas, the change from collective to individual or household production may force mothers to give up the choice of breastfeeding in order to increase their time spent in the field for production. Supplementary feedings begin at six months of age (occasionally earlier), and consists of cereal porridge. Over the following months, pureed vegetables, fruits, and eggs are added. Finely chopped meat, chicken, pork or fish, rice, and noodles are added in the second year. After two years of age, the children begin to eat a diet which their parents eat. Vitamins are not given to all children regularly. Vitamin A and D are the only ones administered with any frequency, in the form of cod-liver oil capsules by some parents. Food Supply and Consumption China's food requirements are enormous. The per capita food energy availability in China changed very little during the period 1959 to 1977 (see Annex Table 14). Based on estimates from aggregate data, China has an adequate level of nutrient availability with respect to requirement. Its per capita daily availability of energy and protein is higher than that of low income countries, and is at a comparable level with many middle income countries (see Table 23). Grains and soya products are the main sources of  - 37 - Table 23: Comparison of Energy (Calories) and Protein Availability Per Capita Daily Availability of: Energy Protein % of % of require- Total require- % animal Country Calories ment (grams) ment and pulse China, 1979-81 2,531 107 64.9 169 19 Bangladesh 1,812 78 36.0 100 18 Brazil 2,562 107 62.7 161 56 Hong Kong 2,883 126 86.0 257 59 India 2,021 91 50.0 136 26 Indonesia 2,272 105 47.0 130 13 Korea, Rep. of 2,785 119 73.0 183 21 Mexico 2,654 114 66.0 173 41 Nepal 2,002 91 48.0 121 19 Pakistan 2,281 99 63.0 165 32 Sri Lanka 2,126 96 43.0 121 16 Low-income countries 2,052 91 n.a. n.a. n.a. Middle-income countries 2,590 108 n.a. n.a. n.a. Sources: A. Piazza, "Trends in Food and Nutrient Availability in China, 1950-1981," World Bank Staff Working Paper No. 607, 1983. protein and energy intake (see Table 24). The per capita nutrient availability varies by region. Nutrient availabilities in some provinces of the southwest and northwest regions are lower than the national average. However, the differences are not large (see Annex Tables 15 and 16). B. Parameters of Child Growth Children who are well nourished and relatively free of infection grow well. Their physical growth is one of the best indicators of the general health status of children.  - 38 - Table 24: Nutrient Sources and Availability, 1981 Annual per capita Daily Per Capita Consumption consumption Food energy Protein Fats Foodstuffs (kg) (calories) (grams) (grams) Vegetable Rice 90.0 902 15.6 2.0 Wheat 52.3 501 16.2 2.2 Other grains 47.7 468 12.0 4.3 Tubers 15.5 212 2.5 0.5 Pulses 6.8 62 4.4 0.2 Vegetable oil, 2.6 62 0 7.0 Soya products 4.6 56 4.0 3.2 Sugar 3.8 40 0 0 Vegetables 92.3 66 4.0 0.8 Fruits 5.7 8 0.1 0 Animal Pork, beef and mutton 12.1 100 3.9 9.2 Other meat 0.1 1 0.1 0 Poultry 0.9 5 0.4 0.4 Fish 4.3 7 1.2 0.2 Eggs 2.2 8 0.7 0.6 Milk 1.5 2 0.1 0.2 Animal fats 1.0 24 0 2.6 Total 343.0 2,524 65.1 33.4 of which vegetable 320.9 2,377 58.7 20.2 of which animal 22.1 147 6.4 13.2 Source: A. Piazza, "Trends in Food and Nutrient Availability in China, 1950-1981," World Bank Staff Working Paper No. 607, 1983. International comparisons of the growth of Chinese children have been made with ethnic Chinese children living in Hong Kong and Singapore. The studies show that Chinese infants have, on an average, heights and weights above the North American 58th percentile levels during the first six months of life. In the latter half of the first year of life, they begin to fall behind the North American standards. The mean values in Shanghai do not fall much  - 39 - below 25th percentile levels, and in the later preschool years they are consistently above that level, both for height and weight. The mean values of Chinese children in Hong Kong and Singapore fall below the 10th percentile levels for weight, 267d remain there throughout the preschool period (see Figures 4 and 5). 2 Results of comparison with other countries, such as Nepal, Sri Lanka, Togo, and Liberia, indicate that there is less stunting among suburban Chinese children than among rural children from other countries (see Table 25). Within China, available data suggest a positive similar change in the growth of children. The improvement, however, is not uniform throughout China. The proportion of stunting in rural children is higher than in urban children (see Annex Tables 17, 18, 19 and 20). Data from 16 provinces in 1979 (see Annex Table 19) showed that about 13 percent of rural 7-year old boys are stunted compared with 3 percent of urban boys. The proportion of stunting in 1979 is less severe than the relatively comparable data of 1975. In 1975, 26 percent of 7 to 8 year old suburban boys and 4 percent of urban boys were stunted. There is a geographical variation in the extent of malnutrition, southern provinces more than northern provinces. Jamison 27/ reviewed anthropometric data sets from different time periods which included Guangzhou (1952-75); Beijing (1958-80); rural Shanghai (1959-79); 9 cities (1975); and 16 provinces survey (1979). A summary of some of the findings are presented in Table 26. The Z scores represent the number of standard deviations above (+) and below (-) the NCHS median. Again, the data show the urban and rural differences in height and weight. School children in rural Shanghai do better than their counterparts in rural Guangzhou. The rate of increase in height in China for the last 2 decades for 9-year olds was 1.55 cm. per decade in rural Shanghai, 2.49 cm. in Guangzhou City, 1.48 cm. for rural Guangdong, and 3.8 cm. for urban Beijing. Similar data from the 19 provinces of 1979, when compared to 1953-58, indicated an average height increase of 2.3 cm. for males and 2.1 cm. for females per decade for urban children and youths of 7 to 18 years of age, and an increase in weight of 1.35 kg. per decade for males and 0.92 kg. for females. The rate of growth over the last 25 years was slightly higher than the growth rate of European counterparts, which had an average of 1.5 cm. height increase per decade and 0.5 kg. weight increase per decade. The growth rate, however, was slower than for Japanese counterparts, which had an increase of 3.25 cm. in height per decade for males and 2.93 cm. for females, 26/ J.D. Wray, "Child Care in the People's Republic of China: 1973," Pediatrics, 55 (1975): 539-550. 27/ D.T. Jamison and F.C. Trowbridge, "The Nutritional Status of Children in China: A Review of the Anthropometric Evidence," Population, Health and Nutrition Technical Notes, GEN 17, World Bank, 1983.  _ 40 - 120- HEIGHT, BOYS 0-7 Years . v gy F~~~~m- HoNg 1Ko, 19631964 60N2 90- Figure 4. Height of Chinese Boys in Shanghai, Hong Kong, and Singapore from Birth to 7 Years of Age, Plotted against North American Percentile Values Source: Wray, J.D., "Child Care in the People's Republic of China - 1973: Part II."  - 41 - 22 WEIGHT, BOYS 0-7 Years 0~~~~~~~4 20 Percent/le * 1 E185 16 E.#x 0 10 X U. J t// ... XX ~~Sh"hal, 1967 6- *__ Hong Kong, 1963-19M g Singapor, 19704. N=2,270 Age In years Birth 1 2 3 4 5 6 7 Figure 5. Weight of Chinese Boys in Shanghai, Hong Kong, and Singapore from Birth to 7 Years of Age, Plotted against North American Percentile Values Source: Wray, J.D., "Child Care in the People's Republic of China - 1973: Part II."  - 42 - Table 25: Stunting Among Children in China and Selected Other Countries Percent Stunted Location Males Females Both Sexes China 1975 - 9-City Survey, Urban Age 3 years 1.8 1.8 1.8 Age 7 years 1.9 1.7 1.8 1975 - 9-City Survey, Suburban Age 3 years 12.3 13.6 13.0 Age 7 years 14.9 11.5 13.2 1980 - School Children (age 6-8 years) Urban Beijing (N = 136) 0.0 0.0 0.0 Urban Gansu-Lanzhou (N = 29) 0.0 20.0 10.3 Rural Gansu (N = 219) 37.1 23.0 29.2 Urban Jiangsu-Nanjing (N = 80) 0.0 7.3 3.8 Rural Jiangsu (N = 61) 14.3 9.1 11.5 1980 - School Children (age 6-14 years) Urban Beijing (N = 530) 0.3 1.6 0.9 Urban Gansu-Lanzhou (N = 154) 5.8 11.8 8.4 Rural Gansu (N = 1,691) 34.1 35.5 34.8 Urban Jiangsu-Nanjing (N = 348) 8.2 11.3 9.8 Rural Jiangsu (N = 426) 25.1 24.1 24.6 Other Countries Nepal Age 5 years (N = 1,202) 55.4 Age 0-5 years (N = 6,525) 51.9 Sri Lanka Age 5 years (N = 2,183) 46.2 Age 0-5 years (N = 13,450) 34.7 Togo Age 5 years (N = 700) 24.8 Age 0-5 years (N = 6,094) 19.0 Liberia Age 0-5 years (N = 3,377) 18.2 Source: Jamison, D.T. and F.L. Trowbridge, The World Bank, Population, Health and Nutrition Technical Note, No. GEN17, August 1983.  - 43 - Table 26: Weights and Heights of Schoolchildren in Z-scores -a, 1952-1980 Urban Areas Rural Areas Weight Height Weight Reight Male Female Male Female Male Female Male Female Guandong (1952) 7 -1.8 -1.6 -1.8 -2.3 10 -2.0 -1.9 -2.0 -2.4 13 -2.0 -1.7 -2.3 -2.6 Beijing (1958) 9 -0.8 -1.0 -1.2 -1.1 12 -1.4 -1.3 -1.6 -2.0 Shanghai (1959) 7 -1.6 -1.3 -1.3 -1.7 10 -1.7 -1.8 -1.9 -2.2 13 -1.8 -1.9 -2.0 -2.2 Shanghai (1964) 7 -1.3 -1.1 -1.6 -1.3 10 -1.5 -1.7 -1.9 -1.9 13 -2.0 -1.8 -2.4 -2.4 Shanghai (1973) 7 -1.2 -0.7 -0.9 -0.7 10 -1.2 -1.3 -0.8 -1.1 13 -1.5 -1.3 -1.4 -1.5 Beijing (1975) 9 -0.5 -0.7 -0.0 -0.2 12 -0.8 -0.7 -0.5 -0.4 Guangzhan (1975) 7 -1.1 -0.5 -1.7 -1.6 10 -1.2 -0.8 -1.5 -1.6 13 -1.3 -0.9 -1.8 -1.7 Shanghai (1979) 7 -0.9 -0.8 -0.7 -0.6 10 -1.1 -1.3 -1.1 -1.0 13 -1.4 -1.3 -1.4 -1.6 Beijing (1980) 9 0.0 -0.3 0.3 -0.1 12 -0.4 -0.3 -0.3 -0.1 a/ Z-scores represent the number of standard deviations above (+) or below (-) the NCHS median.  - 44 - and an avnpge weight increase of 2.5 kg. for males and 2.03 kg. for females. - In summary, despite the positive secular changes, moderate malnutrition still persists, more in rural than urban areas. The existing data for the rural areas are not representative for the entire rural population; we might expect an even higher prevalence of growth faltering in the more remote rural areas of China. However, the growth attainment achieved in China with the limited nutrient availability is greater in comparison with several developing countries where anthropometric data are available. C. Micronutrient Deficiency Diseases A review of nutrition publications to date does not provide additional information on the extent of micronutrient deficiencies in China. It is difficult to measure improvement in specific nutritional diseases. In general, micronutrient deficiency is no longer a major problem in China. There is relatively little vitamin A deficiency, which is commonly associated with protein-energy deficiency disease in many developing countries. Intake of B vitamins may be low, since their highest concentration is in eggs and meat. However, no data are available on the prevalence of vitamin B deficiency diseases. Lack of vitamin BI (thiamine) may have become less of a problem after elimination of polished rice. Pellagra (vitamin B6 deficiency) mainly occurs in adults. Prevalence of goiter, which also occurs almost exclusively in adults, has decreased over time with intensive efforts in health education in endemic areas. Local policies, such as the subsidy of production of iodinated salt, and licensing merchants to sell only iodinated salts, have widened the coverage of the population being protected from low iodine intakes. Anemia On average, about one-third of Chinese children suffer from anemia. Anemia is a sign, not a disease. Diseases that give rise to anemia in children are primarily malnutrition, malaria, hookworm, congenital defects of hemoglobin, and several other infections. Nutritional anemia, due to lack of nutrients (iron and protein) or loss of iron and protein from the bowel due to hookworm infestation, is still prevalent in China. A 1979 survey of children aged 1 month to 7 years of age in Beijing and Shanxi found 47 percent to be moderately anemic (hemoglobin of 9-12 gram percent) and 2.4 percent to be severely anemic (hemoglobin less than 9 gram percent). A nutritional survey was conducted in urban day care centers and nurseries in Beijing from 1979 to 1980. The percent of children aged 1.5 to 3 years with hemoglobin below 11 gram percent ranged from 10 to 27 percent, and for children aged 3-6 years it 28/ Research on Physical Shapes, Functions and Qualities of Chinese Children and Youth, Research Group in the Study of the Physique of Chinese Children and Youth, Beijing, 1982.  - 45 - ranged from 15 to 34 percent (see Annex Table 21). A special survey by staff from the medical college of 45 brigades in Lintong county, Shaanxi province, reported a 27 percent prevalence of anemia in children under 7. In Yangsuo county, Guangxi Autonomous Region, 69 percent of the children under 1 were anemic, and 43 percent of children between 1-2 years and 67 percent of children between 2-3 years had hemoglobin values less than 11 grams percent. A survey conducted in 16 provinceW9}n 1980 showed that overall, 50 percent of children had nutritional anemia. - Important variations exist between regions, between urban and rural areas, and between groups of population with different levels of income. Rickets - Vitamin D deficiency Rickets is a chronic nutritional disorder caused by vitamin D deficiency due to failure to expose the skin to the ultraviolet rays of the sun. It generally occurs during the first two years of life when growth is rapid. Rickets is responsible for bowed legs, knock-knees, flat feet and saber legs, and is associated with rachitic rosary and pigeon breast. The deformity of pelvic bones produced by rickets during childhood is one of the causes of difficult labor in pregnant women, and may result in fetal or maternal death. The overall prevalence rate of rickets in China is not available. In 1979, a sample survey of 10 provinces of over 70,000 children 3 years old and younger found a prevalence of rickets of 29 percent. About 9 percent of children younger than 3 years of age in QiYi Commune, Shanghai County, in annual surveys conducted from 1978 to 1980, was found to have rickets (see Table 27). In Rudong County, Jiangsu province, 30 percent of a sample of 674 children under the age of 7 had rickets. There is a regional difference in the prevalence rate; it is higher in the northern or mountainous regions in high altitudes, where rickets is associated with long winters and shorter hours of daylight. For example, clinical estimates from well-baby clinics of Table 27: Prevalence of Rickets in QiYi Commune in Children IJnder Age Three, Shanghai County Year Number Examined Number of Cases Percent Morbidity 1978 727 106 14.6 1979 698 81 11.6 1980 891 78 8.8 Source: X.J. Hu, X.Y. Zhu, and S.E. Xu, "Child Health Care," American Journal of Public Health, 72 (September, 1982): 37. 29/ Xue, 0.B. "Child Health Care Must be Strengthened," National Medical Journal of China, 62 (January, 1982): 1-3.  - 46 - Huaide County, Jilin province, indicate that 41 percent of children under age 7 had symptoms of rickets in 1982-83. Rickets has been historically and remains a problem of the northern provinces. Although there is no national policy, in some northern provinces vitamin D supplements, such as cod-liver oil, are given to children during winter months. Keshan Disease Keshan disease, a chronic cardiomyopathy which may result from selenium deficiency, has been prevalent in China for more than a hundred years. The disease was named after Keshan county in Heilongjiang province, where the first epidemiologic survey of this disease was carried out in 1935. Since then, cases have been reported from 206 counties located in 14 provinces and autonomous regions. Figure 6 presents the incidence of Keshan disease in Heilongjiang Province between 1955 and 1979, and the overall decline of reported cases in that province. The disease is distributed in a belt-like zone located between the coastal zone of south eastern China and the inland zone of northwestern China. The affected sites are usually distributed in hilly land, and are seldom seen in high mountains or plains. Ninety-five percent of cases occur in children between 2 and 7 years of age. Figures 7 and 8 indicate the age distribution of cases in children. The prevalence of the disease in endemic areas may reach 1 percent of children under 10 years of age. In recent years, the incidence has sharply decreased to less than 5 per 100,000 from the 3 peak years in 1959, 1964 and 1970, when the incidence was over 40 per 100,000. The case fatality rate has declined from about 5 deaths per 100,000 population in the peak years to less than 1 death per 100,000 population between 1978 to 1980. The alteration of diet to include high selenium food, such as maize and soybean, or sodium selenite supplements have been found to be effective preventive measures.  - 47 - 40 ~35 NY 30 Incidence l9 (per 100,000) - i.s 55 57 ) 53 i o3 63 6T 69 71 73 .; 77 T Year 'i) t 19979 70*.SWfi Figure 6. Incidence of Keshan Disease in Heilongjiang, 1955-1979 . a X Male -~13 Female Percent 10 0 1 2 3 4 5 6 t 8 9 10 1112 13 14 15 4:0(v) Age U4 tWiM)LWtO!t 6V*;*. tiVIlJidAt (1369-197SAW Figure 7. Age Distribution of Cases of Keshan Disease in Tengxian, Shangdong, 1969-1978 20 Percent I_ () *10 0 I 3 4 J 0 7 8 9 10( ) ASe US . W&:jIJfJLY3Wi$tglx ( 1950-197140) Figure 8. Age Distribution of Cases of Keshan Disease in Keshan County, Heilongjiang, 1950-1971 Source: Su, Y. and Yu, W.H. "Keshan Disease in Children and its Dietary Prevention," National Medical Journal of China, 61 (1981): 642.  - 48 - V. OTHER CHILDHOOD DISEASES A. Parasitic Infections Malaria In 1953, 11 percent of China's population lived in hyperendemic areas where malaria transmission occurs throughout the year as a result of the presence of all three malaria parasites: P. falciparum, P. vivax, and P. malariae. Fifty percent of the population in China lived in an area where malaria transmission was due to P. vivax, which occurs for six months out of the year, and 32 percent of China's 1953 population lived in areas where malaria is unstable as a result of P. vivax transmission during short periods only. About 8 percent of China's population lived in malaria-free areas. Sample surveys in 1953 reported a 70 percent infection rate among children in Guangdong. An extensive malaria control program was started in 1950 through mass treatment, mass chemoprophylaxis during the transmission period, extensive use of residual indoor insecticide spraying, and control of larval breeding sites. The incidence of malaria since that time has decreased steadily. Between 1950 and 1981, the total number of malaria cases decreased from an estimated 30 million cases to a reported 3 million cases. The number of counties endemic for malaria decreased from 70 percent of the total number of counties to 28 percent. Today, only about 6 percent of the 2,100 counties in China are in high risk areas. In 1979, 30 percent of China's population lived in malaria-free areas, and 35 percent lived in areas where malaria is sporadic (fewer than 5 cases per 10,000 population per year). Twenty-eight percent of China's population lived in areas of moderate risk (between 5 and 100 cases per 10,000 population per year), and 2 percent lived in high malaria risk areas (greater than 100 cases per 10,000). National statistics indicated an overall incidence of about 300 cases per 100,000 population in 1981. Cases reported from Jiangsu, Shandong, Henan, Anhui and Hubei provinces in 1981 accounted for 86 percent of the total number of cases in China. In these provinces, P. vivax is mostly prevalent and P. falciparum malaria, the only form that causes death, has a diffuse distribution. Age- specific morbidity and mortality figures for malaria in China are difficult to obtain. Mortality from malaria in children is probably limited to southern China in some parts of Guangdong, Guangxi, and Yunnan provinces, and Hainan Island, where falciparum malaria morbidity is still comparatively high and where resistance to chloroquine was recently documented. However, malaria is not an important factor of child mortality, since only 70 deaths due to malaria occurred in China in 1981 among the 3 million reported cases. Intestinal Parasites The intestinal worms which are most prevalent and are most debilitating are (i) Ascaris lumbricoides, (ii) Ancylostoma duodenale, and (iii) Trichiuris trichiura. One-third of the entire world population is estimated to be infected by one or more worm species. Ascaris, Ancylostoma and Trichiuris are often associated in the same patient.  - 49 - The clinical symptoms are usually inapparent; however, the two most damaging symptoms are malnutrition and anemia. Worms excrete toxins (roundworms (ascaris) in particular) which have an inhibiting effect on the digestive enzymes, and hence result in malabsorption syndromes. Ancylostomiasis is cited as a major cause of anemia. The anemia may be further exacerbated by undernutrition. Blood loss caused by any single Ancylostoma worm in an infected person can be as much as 0.67 ml. a day. With average worm loads of Ancylostoma ranging between 50 and 500 worms per infected person, the blood loss can be as high as 300 ml. per day. Ascaris infection in children retards growth. The percent of dietary calories lost per day due to average Ascaris worm burdens (+7 worms per person) is estimated at 2 to 3 percent. Winfield made an estimate in 1939 3 on the impact of ascaris infestation on nutrient intake. He estimated that about 336 million people (out of a total population of 400 million) in China were parasitized by 6 billion adult ascarids, which would weight about 24,300 metric tons and would cost about one and a half million pounds sterling annually for food (1939 prices). The cost to the country for treatment of patients, along with the additional indirect cost from loss of work produc- tivity in adults or growth faltering in children as result of decreased nutrition intake, are phenomenal. The recent documentation on intestinal parasites in China is poor. It does not seem that the disease is a priority for action, nor that surveillance is actively conducted. However, scattered information indicates that the magnitude of the problem probably did not change much since liberation (see Annex Table 22). A recent sample survey in Shaanxi province of 10,000 population showed that 71 percent has Ascaris, 10 percent has Trichiuris, 71 percent has Enterobius vermicularis, and 3 percent has Ancylostoma. Also in Shaanxi, a 1981 survey of 969 children in two schools in rural areas of Lintong county reported an 81 percent infection rate with Ascaris among children aged 7 to 12, and 65 percent among children aged 12 to 14. Another survey of a school sample in Zhangqin county, Shandong Province, showed in 1974 that ascaris was prevalent in 91 percent of children below 9 years of age, with an average number of 37,300 eggs per gram of feces. In Heilongjiang Province, ascaris was present in 37 percent of children in a sample survey in Suihua county in 1981 (personal communication). Kala Azar In 1949, there were 650,000 cases of Kala Azar, and the majority of its victims were children. The case fatality rate was about 5 percent. It is now reported that through the use of insecticides, antimony preparations, and the extermination of stray dogs, the disease has been almost completely eliminated. A few cases are still reported from regions where cattle herding is extensively practiced, such as Inner Mongolia and Xinjiang (Sinkiang). 30/ Winfield, G. "Studies on the Control of Fecal-borne Diseases in Northern China: Problems and Methods," Chinese Medical Journal, 51 (1937): 217-36.  - 50 - B. Endemic Diseases Endemic Fluorosis Fluoride is an essential micronutrient. The optimal level of fluoride for drinking water varies with temperature, but the range is usually between 0.5 to 1.0 mg/l. Excess consumption of fluoride in areas where potable water contains a higher concentration may result in fluorosis (mottling of teeth and damage of bone). Dental fluorosis occurs more frequently in children. Skeletal fluorosis occurs more frequently in adults with chronic exposure to excess fluoride content in drinking water. In China, the northeast and northwest regions and Shangdong Province are the endemic areas. Table 28 gives the result of a survey in 4 counties in Shangdong, which shows an increasing prevalence of dental fluorosis as the concentration of fluoride in drinking water increases. The data did not present the age-specific prevalence rate. Kaschin-Beck Disease (Osteoarthritis deformans) The onset of symptoms begins around age of 7, consisting of joint swelling, muscle atrophy, and limb deformity, which may result in stunting in children. The disease is common among children and adolescents in the areas of northeast, northwest, and north China. The provinces of Shaanxi, Heilongjiang, Gansu, and Sichuan are high incidence sites. A three-year study of Yangzhou County, Shaanxi Province, which has the highest incidence of Kaschin-Beck disease, indicated that the disease may be prevented by replacing a low selenium content maize diet with high selenium content wheat. Data on the age-specific prevalence rate for the endemic regions are not available. Figures for Heilongjiang show that there are about 600,000 cases concentrated in limited foci. For example, 402 cases are documented in Suihua County (which has a population of 719,000), but all of these cases occur among the 2,063 population of two production brigades. C. Rheumatic Fever and Rheumatic Heart Disease The incidence of Rheumatic Fever (RF) has declined markedly in developed countries, in contrast to the continuing high prevalence of the disease in developing countries. RF is a sequel of pharyngeal infection with group A Streptococcus. RF is rare in children less than four years of age. The peak incidence is age group 4-15, but both primary cases and recurrence cases are frequently seen in adults. The incidence of RF is declining in China. From a survey in Guandong  Table 28. Fluoride Content in Drinking Water and Prevalence of Dental Fluorosis (1979-1980) in Four Counties in Shangdong Province GAOHI JIAXIAN HUANTAI FEICHENG TOTAL Fluoride F Cases Percent I Cases Percent f Cases Percent I Cases Percent I Cases Percent (mg/1) Surveyed Prevalence Surveyed Prevalence Surveyed Prevalence Surveyed Prevalence Surveyed Prevalence _ 0.5 64 0 49 6.1 - - 42 7.1 155 3.9 0.5 152 3.9 50 28.0 56 35.7 50 54.0 308 21.8 1.01 167 56.3 51 88.2 53 79.2 47 85.1 318 69.5 2.01 122 46.4 51 92.2 55 80.0 49 83.7 267 68.9 3.01 103 56.3 49 83.7 52 82.7 50 90.0 254 73.6 4.01 52 78.8 51 100.0 53 83.0 - - 156 87.2 5.01 53 88.7 49 89.8 55 74.5 - - 157 84.1 S.Ol 53 88.7 50 98.0 53 88.7 - - 156 91.7 7.01 55 90.9 49 91.8 - - - - 104 91.3 ,3.01 78 76.9 45 88.9 - - - - 123 81.3 9.01 50 86.0 50 92.0 - - - - 100 89.0 no0.01 170 90.0 52 84.6 - - - - 222 88.7 Source: "Survey on the Epidemiology of Endemic Fluorosis in Shangdong Province," Chinese Journal of Preventive Medicine, 6 (1982): 366.  - 52 - in 1978, Sh7 incidence of RF among school children age 6-14 was 81 per 100,000. - Although this is higher than the incidence in the U.S. (3 per 100,000), it i 2} ower than other developing countries such as India (200-1,200 per 100,000). - The signs and symptoms of RF can vary greatly. Clinical manifestations can include varying combinations of polyarthritis, carditis, subcutaneous nodule, erythema marginatum and chorea. Carditis (Rheumatic Heart Disease) is the most debilitating manifestation. Episodes of carditis occurring with recurrent attacks of RF can result in permanent cardiac damage or death. Rheumatic Heart Disease (RHD) is the most common cause of chronic heart disease in children and young adults. It carries significant morbidity. One-fourth of hospitalized cardiac disease cases in the 1970s were still due to RHD, which has declined from 50 percent in the 1950s. The mortality rate of RHD is also high. In Tienjin Children's Hospital the mortality rate of hospitalized children with RHD was 30 perce3s, of which 75 percent of affected children were less than 15 years of age. - The prevalence rate of RHD reported from several mass surveys vary around 3 per 1000. Between 1976 and 1978, the prevalence rate was 3 per 1000 in Panyu Count 4/Guandong Province (a survey sample of 170,469 farmers of age 15 and over). - A province-wide survey in Guandong (sample of 312,848 people age 15 and over) showed a standardized prevalence rate of 2.89 per 1000. Groups over 45 years of age had a higher prevalence rate, 4 ger 1000, and age group 6-18 had the lowest prevalence rate, 1.1 per 1000. _ An aggregate prevalence rate was 1.83 per 1000 from a survey of 14 provinces (778,599 persons). The rate was 0.54 per 1000 for children aged 6-14 (sample of 262,317) and 2.48 per 1000 for adults. Southern provinces such as Guandong have a 86her prevalence rate than the northern provinces of Jilin and Heilongjiang. 31/ "Survey of Rheumatic Heart Disease and Rheumatic Fever in Guandong Province," (in Chinese) Chinese Journal of Cardiology, 10 (1982): 8-10. 32/ Weatherall, D.J., Oxford Textbook of Medicine, Oxford: Oxford University Press, 1983. 33/ "Report of a Symposium on Rheumatic Heart Disease," (in Chinese), Chinese Journal of Cardiology 10 (1982): 71-73. 34/ "Analysis of Epidemiology of Rheumatic Heart Disease of Natural Masses and Three Years' Follow-up Study in Rural Areas," Lecture in Conference of Epidemiology of Cardiovascular Diseases in China. 1981. 35/ "Survey of Rheumatic Heart Disease and Rheumatic Fever in Guandong Provinces," (in Chinese), Chinese Journal of Cardiology, 10 (1982): 8-10. 36/ "Report of a Symposium on Rheumatic Heart Disease," (in Chinese), Chinese Journal of Cardiology, 10 (1982): 71-73.  - 53 - The reported decline in the incidence of RF and prevalence of RHD is supported by the fact that there is a shift in the age groups of the affected population. Older age groups have the highest prevalence rates of RHD and active episodes of RF. In the 1950s the peak age group for the prevalence rate of RHD was 20-29; in the 1960s the peak age group was 30-39; and in the 1970s the peak age group shifted to 40-49. Initial and recurrent attacks of RF are preventable by treatment or prophylaxis of the antecedent streptococcal infection. Accurate diagnosis is required for primary prevention of RF. This is difficult to achieve because streptococcal pharyngitis occurs most frequently in children, who seldom come to medical attention, and in addition one-third or more cases of RF arise after clinical inapparent streptococcal infection. The most effective strategy for avoiding the mortality and chronic cardiac disability is 'secondary prevention', i.e. focus on persons who already suffered a rheumatic attack and who are susceptible to a recurrence following upper respiratory infection. Antibiotics should be given to all patients who have suffered a documented attack of RF. To ensure patient follow-up for continuing prophylaxis, patient education is important in addition to establishing ongoing service to provide antimicrobial prophylaxis in either the Maternal Child Health or the Epidemic Prevention Station.  - 54 - VI. MATERNAL AND CHILD HEALTH CARE SERVICES The Chinese primary health care system operates on three levels: brigade health station, commune health center, and the county hospital (Annex Chart 1). The brigade health station is the base of the pyramid of the three- tier system. Two or three Barefoot Doctors provide care for a population of 1000 to 3000. The commune health centers receive referrals from the brigade health stations and are responsible for technical supervision and training of Barefoot Doctors at the brigade level. At the county level, which is the top of the three-tiered system, there are three health care units: the county hospital, the county epidemic prevention station, and the county maternal and child health station. The county hospital serves as the referral center for the entire county (from approximately 400,000 to 1,300,000 population). The county epidemic prevention station, which is responsible for preventive activities, provides technical support and supervision to the commune health centers. The county maternal and child health station supervises and provides maternal child health activities. The MCH services are vertically organized from the ministry to the provincial, prefectural, and county levels. The MCH centers are responsible for providing maternal child health care services, including family planning, prenatal and obstetrical care, and surveillance of infants and children. The framework is shown in Figure 9. The distribution of MCH facilities by province in 1982 are set out in Table 29. A. Maternal Health Care The Maternal and Child Health service (MCH) is responsible for care for women at all stages of their reproductive cycle, the so-called 5 periods: menstrual, prenatal, intrapartum, postnatal, and menopausal. In 1949, there were only 80 maternal child health centers, with 1,762 beds for all of China (see Table 30). Women in rural areas relied entirely on traditional birth attendants (see Table 31). After liberation, the traditional birth attendants were retrained, in addition to the large increment of health workers trained for MCH services. The number of MCH stations increased 293-fold, and the number of beds in MCH centers increased 8-fold (see Table 30). However, nationwide, the MCH units only account for 1.4 percent of the total health care facilities. There is a wide variation among provinces. Xinjiang has less than half a percent of total health facilities as MCH units. Qinghai has almost 3 percent (see Table 29; Annex Table 23). At the county level, there is a maternal and child health station whose staff provides guidance, supervision, and administrative support to the maternal health services of the county. For example, Qufu county in Shandong Province (with 0.5 million inhabitants) is staffed by 4 senior physicians, 16 assistant physicians, and 10 mid-level nurses, who perform and organize the MCH activities in the county. The MCH staff organizes and participates in the county-wide screening programs, such as surveys of prevalence of gynecological diseases. In each brigade health station there is a female BFD in charge of  - 55 - County Public Health Bureau County Maternal Child Health Services Institute Commune Health Center Maternal-Child Division Brigade Health Station Barefoot Doctors and/or Midwives Figure 9. Vertical Organization of Maternal Child Health Services  - 56 - Table 29: Distribution of Total Health Facilities and Maternal Child Health Care Facilities, by Province, 1982 of which: Total number of Maternal-child Percent Province health facilities health facilities of Total Nationwide 193,438 2,645 1.4 Beijing 4,389 18 0.4 Tienjin 3,548 19 0.5 Hebei 10,227 178 1.7 Shanxi 5,627 129 2.3 NeiMongol 4,660 121 2.6 Liaoning 7,459 108 1.4 Jilin 4,494 75 1.7 Heilongjiang 9,455 149 1.6 Shanghai 6,445 22 0.3 Jiangsu 10,787 95 0.9 Zhejiang 7,895 73 0.9 Anhui 7,059 114 1.6 Fujian 4,533 31 0.7 Jiangxi 5,615 108 1.9 Shandong 9,830 141 1.4 Henan 8,513 137 1.6 Hubei 6,353 99 1.6 Hunan 10,262 124 1.2 Guangdong 11,990 84 0.7 Guanxi 5,822 88 1.5 Sichuan 18,830 227 1.2 Guizhan 6,595 88 1.3 Yunnan 6,293 147 2.3 Xizhang 958 2 0.2 Shaanxi 6,369 110 1.7 Gansu 3,979 91 2.3 Qinghai 1,208 34 2.8 Ningxia 1,073 21 2.0 Xinjiang 3,170 12 0.4 Source: Statistical Data on National Health Care, 1982, Ministry of Public Health, March, 1983.  - 57 - Table 30: Maternal Child Health Care Facilities, Reds, and Personnel, Nationwide, 1949-1982 % Increase 1949 1957 1965 1975 1980 1982 1949-19824 MCH centers - units 80 96 115 103 135 182 1.3 - beds 1,762 6,794 9,233 8,307 11,013 15,446 7.8 Children's hospitals units 5 16 28 23 24 24 3.8 beds 139 2,295 4,527 4,546 5,407 5,878 41.3 MCH clinics and stations 9 4,599 2,795 2,025 2,610 2,645 292.9 Western obstetricians and gynecologists - 4,194 9,218 22,295 - 42,982 - Western pediatricians - 4,539 10,281 19,433 - 31,991 - Midwives 13,900 35,774 45,639 64,875 70,843 73,305 4.3 Part-time midwives - 657,335 685,740 615,184 634,858 549,659 - Source: Statistical Data on National Health Care, 1982, Ministry of Public Health, March, 1983. Table 31: Number of Part-time Health Care Personnel 1970 1975 1980 1982 Barefoot doctors 1,218,266 1,559,214 1,463,406 1,348,784 of which female - 502,225 489,422 409,792 % female - 32.2 33.4 30.4 Rural midwives - 615,184 634,858 549,659 Source: Statistical Data on National Health Care, 1982, Ministry of Public Health, March, 1983.  - 58 - MCH. Prenatal services are provided to pregnant women once the pregnancy is diagnosed. The BFDs provide most of the routine prenatal care, such as measurement of blood pressure. Some pregnant women go to the commune health centers for check-ups. Pregnant women who develop complications such as hypertension or oedema, or have a family history of congenital defects are referred to the county level MCH centers. The quality of care, as measured by reported complications rates, has steadily improved. The frequency of postpartum hemorrhage and infections have declined. The coverage of midwives per population increased from 26,705 population per midwife to 13,828 per midwife, between 1952 and 1980. Nowadays, there is nearly complete coverage of deliveries by hospital or by rural birth attendants. Over 90 percent of deliveries are performed by the so-called "scientific method," i.e. using sterile instruments. On the average, there are 1.4 barefoot doctors per 1,000 rural population. As a result of increased access to health services, the incidence of neonatal tetanus and postpartum infection have drastically declined. Besides antenatal care, the BFTs and health personnels in the commune health centers and county MCH centers also provide postpartum care. The BFDs provide home visits to the mother and the infants within one week after discharge from the hospital. Gynecological services, such as treatment of common gynecological diseases, are provided in the commune and county MCH centers. Screening for gynecological diseases, such as cervicitis and cervical cancer, are conducted every two to three years. Women who have cervicitis, salpingitis, or vaginitis are treated. Those diagnosed with possible malignancy are referred to either commune or county level for further work-up. In Qufu county (Shandong Province), for example, the MCH health centers carry out systematic examination of all married women below 60 years of age every three years. The most common diseases are cervicitis, salpingitis, and menstrual disorders. The prevalence of these disorders among women in Qufu county was abut 20 percent. Contraceptives are dispensed at all levels of the health care system. Intrauterine devices are inserted at the commune hospitals or higher level medical centers. However, in some areas the BFDs are also trained to insert IUDs. Abortions are perfomed at the commune health centers or county level MCH health centers. A survey in 12 provinces reflected a steady increase in the percentage of births delivered by C-sections in recent years. The rate of C- sections ranges from 7 to 38 percent. The reasons attributed to the increase are (i) an increased proportion of primid gravidas, which in general have a higher prevalence of difficult deliveries, (ii) an increased frequency of intrapartum monitoring, resulting in earlier diagnosis of fetal distress, (iii) a relaxing of criteria for C-sections by health personnel under the one child family policy aimed at improving pregnancy outcome, and (iv) the demand by families for C-sections in order to decrease the risks associated with vaginal deliveries. In certain areas, the rate of C-section deliveries increased from 7 percent in 1976 to 29 percent in 1981. The associated maternal risks of C-sections are many, including bleeding, wound infection, and chronic endometritis. Thus, even under the pressure to optimize pregnancy  - 59 - outcome, the criteria for C-sections should be strictly medical, rather than letting socially related factors influence medical decisions. B. Child Health Care In 1949, China had only 5 children's hospitals, all in the urban cities, with a total of 139 beds. In 1980, there were 24 specialized children's hospitals with 5,407 beds, located in 18 of the 29 provinces, autonomous regions and municipalities. Annex Table 23 presents the distribution of children's hospitals by province. There is great inter- provincial variation, with 11 provinces and regions lacking this type of facility. However, many general hospitals encompass pediatrics departments and the availability of beds for child care exceeds by large the capacity of specialized children's facilities. Since 1949, a 3-level child health care service network, in conjuction with maternal health care, has been entensively developed. Child health services, which include home visits for care of newborns, routine physical examinations, mass screening of school age children, supervision of nurseries and kindergartens, and routine immunization, are carried out by health staff from all three levels, that is, (i) barefoot doctors, (ii) health personnel at the commune health centers who carry out activities under the supervision and guidance of staff from the county MCH centers, and (iii) pediatric staff from the county hospitals. The immunization services are usually done in collaboration with the county and commune epidemic prevention stations. The staff from the epidemic prevention station plan and organize the logistics for vaccine distribution. The BFDs and MCH staff are responsible for identifying the target group and giving the vaccination. Children in China have easy access to health care services. In 1982, there were 31,991 Western trained pediatricians, 24 malor pediatrics hospi- tals, and 18,091 MCH centers and clinics for the 339 million children under age 14. There is, however, a lack of integration of services. Curative services for children at different ages are provided by BFDs and health staff in commune health centers and county hospitals. Preventive services, such as growth monitoring of a well baby, mass surveys of school age children, and immunizations, are provided by the staff from maternal child health care centers and epidemic prevention stations. It is only at the brigade level that the services are integrated and continuity of care is provided. There are very little data on the assessment of the quality of staff. Coverage of immunization has attained a rate over 90 percent. However, efficacy of the vaccinations is handicapped by the poor quality of vaccines. From the available verification reports on immunization against preventable diseases, lack of knowledge of vaccine handling was still a common reason for patients contracting the disease despite having received the vaccination. A study of barefoot doctors' practice showed that there is heavy use of antibiotics for treatment of illnesses, such as common cold and acute gastroenteritis. In 335 cases of common cold, BFDs prescribed an average of 1.6 drugs per patient: 32 percent of the cases received antibiotics, 52 percent received traditional Chinese medicine, and 74 percent received an analgesic or antipyretic. Of the 108 patients who received antibiotics, 10  - 60 - percent received kanamycin, 20 percent received gentamycin, 48 percent received tetracyclJ57, 20 percent received penicillin, and 6 percent received sulfamethaxazole. For children affected with respiratory disease, timely use of penicillin is crucial to the reduction of morbidity from complications of pneumonia. However, casual use of antibiotics without appropriate indication on the severity of the illness may lead to the appearance of drug-resistant organisms. 37/ Young, M. "Study of Barefoot Doctors' Activities in China," Johns Hopkins School of Public Health and Hygiene, thesis for Dr.P.H., March, 1984.  - 61 - VII. ISSUES China over the last 30 years has established a sound infrastructure of maternal child health services. Under limited resources, it made a firm commitment to emphasize preventive health services, such as immunization against childhood communicable diseases, and prenatal, intrapartum, and postnatal services. In our review of the pattern of child mortality, we notice that the trend in infant mortality is steadily decreasing. As changes in the infant mortality rate are closely associated with the general economic development of the population, we observe that China's accomplishment has exceeded any expected level of improvement in health, considering its present level of economic development. The overall pattern of mortality in China is undergoing a gradual transition: the percentage of total deaths secondary to chronic diseases, such as cardiovascular disease and cancers, are increasing in the urbanized areas, and the percentage of total deaths secondary to infectious, parasitic diseases, although they still persist, are decreasing. Similarly, the mortality reduction is also observed among children. About two-thirds of infant deaths now occur during the neonatal period. The prevalence of chronic disease, such as congenital defects, is rising, although the magnitude of the problem is not comparable to the impact of respiratory diseases. The morbidity pattern, however, is still mainly due to infectious diseases. The improvement attained in child health care has been remarkable; however, these achievements are not satisfactory under the one child per family policy. The "one child is best" norm was approved by the State Council and formally endorsed in 1978 by the Central Committee of the Chinese Communist Party. The one child campaign was launched in early 1979. The call in 1979 for the "one child per family" was an attempt to avoid the potential resurgence of a second baby boom. The cohort of the "baby boom" of the late 1960s is now entering childbearing ages. The increase in the absolute numbers of couples as a result of the first baby boom would lead to a significant increase in the population, even with a population policy of two children per couple. A. The One Child Family Policy A major issue in child health care stems from the consequences of the one child family policy. Premier Hua Guofeng stated "The State demands that each couple should ideally have only one child and not more th8n two. To produce a third child is to violate the state regulations." _1 There are varied incentives and disincentives to encourage couples of child-bearing age to pledge to have only one child. As an incentive, couples who sign the "one child certificate" are entitled to benefits in health care, housing, food 38/ Hua Guofeng. Report to the Second Session of National People's Congress, Beijing, June 18, 1979.  - 62 - allowances, and work assignments. The disincentives for couples who have more than two children also vary from place to place. For example, in some areas the medical care cost of the first child is free (paid for by the state or the parent's workplace), and the medical care cost of any child beyond two children must be paid by the parents. Another form of disincentive is through restricting the number of children from a single family who can attend university simultaneously. Annex table 24 summarizes the incentives and the disincentives used in China's population strategy. The intensive campaign for population limitation in China is directed to the ethnic Chinese population, the Han people, who comprise 94 percent of the population (about 937 million people). The remaining 66 million people are 'national minorities'. For these minority groups the population policy is different. The policy encourages population increase; however, family planning is provided to those who want to limit the number of their children. Better health as part of an improved population policy has become important with the one child family program. Couples restricted to one child want and need extra reassurance that the child will be healthy. Guaranteeing healthy babies implies a need to improve prenatal as well as postnatal care. There is strong pressure at the county level to establish genetic screening services for early identification of congenital defects, in order to reassure the quality of the pregnancy outcome. Prenatal diagnosis and screening programmes at birth for treatable or preventable diseases become, therefore, essential components of maternal and child care services. The state of the fetus can be directly assessed from an anatomical viewpoint by ultrasonography, and at the cellular level by examining the amniotic fluid by biochemical and cytological techniques. An amniocentesis for the diagnosis of chromosomal and inherited biochemical ahnormalities is ideally undertaken during the sixteenth week of pregnancv, because the volume of fluid is then sufficiently large to reduce the risk of inducing the miscarriage of a normal fetus to about 1 percent. Amniotic fluid should be examined for diagnosis of inborn error of metabolism, for alpha-fetoprotein in order to diagnose an unsuspected open neural tube defect, and for chromosomal abnormalities. It should be aimed at a selective population which is at high risk for certain diseases based on genetic, geographical and clinical grounds. In many county level MCH centers, the health staff, under the increased demands of the community for eugenics screening, is attempting to set up genetics laboratories. With limited resources, uniform quality standards are difficult to achieve. Chromosomal mapping, cell culture, and detailed biochemical analysis techniques require advanced technical training and sophisticated laboratory tools. Such services can be most efficiently utilized if established at prefectural or provincial level, and if high-risk couples with family histories of congenital defects are referred from the counties for genetic screening at the regional centers. To divert the time of the health staff in the county MCH centers from direct patient care to laboratory analysis would be inefficient and non-efficacious.  - 63 - Similarly, improved screening for perinatal risks is needed. There is a need to use standard fetal monitoring to assist in the early detection of fetal distress and for timely management of high-risk infants. In order to reduce perinatal mortality, regular prenatal care should begin early in pregnancy. In the urban areas, prenatal care begins at 3 to 6 months of pregnancy, and the woman is examined once a month. After 7 months of pregnancy, she is examined every two weeks. In the rural areas, basic knowledge about prenatal care is becoming more widespread, and increasingly more pregnant women begin their care as soon as the pregnancy is confirmed. Most of the prenatal care is provided by BFDs; some pregnant women go to the commune health center for care. Pregnant women with high-risk conditions, such as eclampsia or intrauterine growth retardation, can be referred to the county level health care facilities for closer monitoring and prompt obstetrical management in collaboration with assistance from the pediatric staff who will provide care to the high-risk neonate. Extrauterine monitoring of the fetal heart rate can diagnose conditions leading to fetal distress such as placental insufficiency, nuchal umbilical cord, or prolapse of the umbilical cord. However, training of health staff is required to ensure competent interpretation of the diagnostic findings. Comprehensiveness of prenatal care activities may vary according to urban and rural conditions. The rural areas, based on the limitations of their resources, may aim to (a) strengthen health education on potential consequences of consanguineous marriage, benefits of prenatal care, and proper maternal dietary intakes; (b) strengthen outreach services to increase the coverage of prenatal care to pregnant women; and (c) increase coverage of 'scientific' deliveries. In Heilongjiang, the requirements of a 'scientific' delivery are to monitor stages of the labor, to use sterile tools and gloves, and to apply mercurichrome on the perineal area prior to delivery. Although in China the overall rate of 'scientific' delivery is over 90 percent, there is still a wide variation in rural areas. Many factors, such as different cultural practices among the national minorities, home deliveries, inadequate training of midwives or birth attendants, and lack of sterile tools, all contribute to the relatively higher maternal and neonatal morbidity rates in rural areas, especially in geographically remote or in poorer socioeconomic regions. There is also a need to strengthen neonatal care and to establish a high-risk neonatal transfer transport system. The perinatal mortality rate ranges from 9.3 to 122.5 deaths per 1,000 live births. Such a wide variation may be due to difference in reporting; however, they also reflect urban-rural differences in quality of health facilities. The best single indicator of the quality of perinatal care may be the risk of death among the heavier  - 64 - infants. The rate is higher in Shanghai than the rate in California. 39/ The county health centers lack equipment and staff to adequately manage high-risk infants. There is a need for monitoring and resuscitation of high-risk neonates during transport from local health centers to a regional health facility which is equipped with an intensive care unit. China has put her priorities in the past on prevention, with curative medical care universally available but basic. China has established a well- developed health care infrastructure; her next major task, especially under the one child policy, is to improve the sophistication in the technology of perinatal care, such as updating equipment and facilities for resuscitation and intensive care of sick infants. The rural counties have simple incubators, but more complex equipment is notably absent. B. Integration of MCH Services The lack of integration of curative and preventive services for mothers and children is another major issue. Under the three-tiered health care system, the obstetrics and gynecology and the pediatrics departments of the county general hospitals offer curative services. The county epidemic prevention station organizes immunization activities, and the county MCH station provides a mixture of preventive and curative services. As a result of this fragmentation, there is a duplication of services. MCH services at the county level provide obstetrical services in addition to preventive services such as prenatal care and well baby care. Therefore, MCH services increasingly duplicate curative services already available in the county hospital. This emphasis on curative activities inevitably reduces the MCH's allocation of financial and manpower resources for preventive services, and do not improve the quality of services available to the population. Furthermore, there is a possibility that the BFDs may abandon the preventive aspects of the MCH services. Before the introduction of the responsibility system, rural basic health care was mainly financed out of the collective welfare fund; at present, services are provided on a fee-for- service basis. Because preventive services yield few immediate results as compared to curative care, patients may be reluctant to pay for them, and BFDs may become less willing to provide these services because the monetary return is low, relative to curative services. The BFDs' activities in Qufu county, ShandoM Province, were measured quantitatively with work study techniques in 1982. - The results indicated that on a daily average, a BFD spent only 3 percent of his time, out of a six-hour observational period, on preventive 39/ Wegman, M.E. "Addendum: Some First Hand Observations", in M.E. Wegman, et.al. (eds.), Public Health in the PROC, New York: Mosiah Macy Jr. Foundation, 1973: 273-81. 40/ Young, M. "Study of Barefoot Doctors' Activities in China," Johns Hopkins University, Baltimore, thesis for Dr. P.H., 1984.  - 65 - activities. Only 5 minutes were devoted to maternal child care and family planning. The administrative organization of family planning services is branching off to become a new, independent vertical structure. This trend directly results from the promotion of the State Family Planning Commission in 1983 to a ministerial level authority, which indicates the high priority that is given by the State Council to the tasks of the population program. This new situation calls for the creation of independent delivery services under direct line authority. The Birth Planning Commission of the State Council sets population policies. The commission is backed up by the State Birth Planning Office, which supervises activities throughout the country. At the provincial level, a birth plannning committee sets implementation plans and organizes mass media campaigns. At the county level, county birth planning offices supply contraceptives to the rural communes and production brigades. There is also a birth planning leadership group at the commune level, and another at the brigade level, that supervises the BFDs who deliver contraceptives to brigade members. It is only at the brigade level that services are fully integrated. The separation of a different administrative hierarchy for family planning services, in addition to MCH services, duplicates many activities provided by health personnel. The resultant lack of continuity of care reduces the efficiency and efficacy of the services offered. There is a need to coordinate the existing fragmented services for mothers and children which are now provided from various sources: the county MCH center, the epidemic prevention station, the county hospital (pediatric, obstetrical, and gynecological departments), and the county birth planning office. The efficacy of these services could be greatly enhanced if they could be organized under one leading group with the responsibility of maintaining a balance of curative and preventive services provided by the different organizations. C. Improvement of Immunization Coverage A third major issue is the improvement of immunization coverage. A very high percentage of children are being immunized, and a sharp decrease in the incidence of communicable diseases is the best evidence for the tremendous administrative and manpower efforts dedicated to the immunization activities. Problems, however, do still exist. Remarkable efforts in the organization of mass campaigns, and prompt delivery of vaccines, have been invested to compensate for an inadequate cold chain system. However, the production of good quality vaccines is just as important as the issue of vaccine storage and transport, and the logistics of giving the vaccines to the target population. There are five important issues in immunization activities. First, the production of vaccines is ineffective and outdated. Measles and BCG are not available in freeze-dried form. The liquid product has a short potency duration (43 days), as compared with 2 years of the freeze-dried products. The equipment for vaccine production needs to be improved to reach  - 66 - international standards. There is a need for freeze drying equipment to enhance the life span of vaccine products now produced in China. There is a need for quality control during production to ensure safety of the vaccines, both in terms of avoiding contamination by microorganisms and in ensuring proper attenuation of live viruses; and there is also a need for improvement of the packaging of the final product form. For example, polio vaccine is presently encapsulated in candies, which are bulky and difficult to transport in ice boxes. Second, wastage is enormous. Recent surveys estimate that the wastage ratio is 2.5 to 3, which means that the amount of vaccine ordered is 3 times the number of actual planned doses. Some reasons for wastage are short duration of vaccine potency, poor cold chain, and inadequate product packaging. Vaccines are packaged in large vials (100 or more doses per vial), which inevitably leads to wastage in the decentralized delivery system. Vaccines could be optimally utilized if smaller vials (5 to 10 doses per vial) were distributed to the brigades, since the number of recipients per brigade is small. Third, the immunization schedules are inadequate. In general, mass vaccination campaigns are organized once a year. Those children who do not reach the eligible age at the time of the vaccination, or who are ill at the time of the campaign, or are absent for other reasons, will not receive the vaccination, and hence are susceptible to contracting the disease. For measles vaccination the annual interval is not desirable. A high proportion of infants who are too young at the time of the annual vaccination campaign will be at high risk, susceptible to contracting the infection before the next vaccination campaign. In order to further reduce morbidity, a more frequent vaccination schedule, such as quarterly campaigns, would be required to improve the coverage of infants and to reach the target group of infants of 9 to 12 month of age. Fourth, cold chain equipment is inadequate. There is a lack of equipment for a more effective cold chain, such as refrigerators, cold boxes, and vaccine temperature-monitoring devices. The problem of the cold chain is evidenced by the continuing high prevalence of diseases such as measles, despite high reported immunization coverage. Temperature monitoring is crucial during transport and storage of the vaccines. Fifth, the development of a recording, reporting, and feedback system for immunization activities, and morbidity and mortality data is needed. Training of personnel, such as those individuals involved in administering vaccines, maintaining the cold chain, or driving a vehicle for vaccine transport, and training of a new generation of technical staff in vaccine production and quality control are crucial to enhance further improvement in the outcome of the immunization activities.  - 67 - D. Additional Training There is a need to strengthen the technical skills of MCH staff at all levels. Appropriate diagnosis and management of illnesses is crucial to reducing morbidity and mortality. For example, pneumonia accounts for one- third of the causes of child morbidity. Childhood respiratory infections are mainly of viral etiology. However, complications with the development of bacterial pneumonia carry high fatality rates, especially in infants. The BFDs and the health staff at the commune level must be trained to recognize the severity of illnesses, and to be aware of indications for timely referral of patients to a higher level. Decision trees or flow charts are crucial in assisting BFDs to manage prevalent illnesses such as respiratory infections. Under the one child family policy, emphasis is placed on optimizing pregnancy outcome, and fetal monitoring can assist the early recognition of fetal distress. However, training of health staff to appropriately recognize signs of fetal distress is crucial to avoid the overzealous performance of invasive procedures such as C-section deliveries, which is a procedure not totally risk free. E. Closing Network Service Gaps There is also a need to fill the service gaps present in the health care network. There is no routine monitoring of growth and development. Special nutritional surveys indicate that moderate malnutrition still persists in China; however, monitoring of the nutritional status of children is not routinely performed. Early diagnosis of growth faltering and management of failure-to-thrive infants is crucial to maximize the full growth potential of each child. The BFDs should be trained to regularly weigh infants and to use weight charts for each child. At present, annual height and weight records are kept in the brigade health stations. However, the practice of recording weight and height is often a self-limited exercise. Actions are not taken to identify growth faltering in individual children. Assessments of children's development are seldom performed by the primary level health workers. This activity has been emphasized only since the launch of the one child policy. The basic techniques in development screening should be incorporated into the training curriculum of health workers to enable them to provide early identification of children with developmental delays and problems, and to refer them for more professional assessment. There is a decreasing emphasis on sanitation services. The current emphasis on improving quality of services applies largely to curative care. In the past 30 years, through community mobilization, a major effort has been placed on improvement of environmental hygiene. There has been drastic improvement in general sanitation . However, the emphasis seems not to have been maintained recently. The BFDs are spending only a very small proportion of their time on preventive activities. There is no longer a full-time staff at the commune health stations with responsibilities for sanitation. Environmental and water pollution are the key contributing factors to fecal- borne diseases, such as dysentery, ascaris, hookworm, and hepatitis, which are still major health problems in China. With the introduction of the  - 68 - responsibility system, individual households may intensify their use of human excreta as fertilizers. Concurrently, as the collective agricultural system collapses after the introduction of the responsibility system, the communal sanitation system for collection, conservation, and composting of excreta may also be collapsing. This may lead to a worsening of environmental pollution, which in turn may lead to higher prevalence of fecal-borne diseases. Public health officials need to allocate special resources to maintain environmental sanitation. Regular inspections of water should be strengthened . Health education should also be strengthened to increase the awareness of the peasants of agricultural sanitation. F. The Reporting System Another major issue is the strengthening of the reporting and surveillance system. The prospects for complete notification of diseases are excellent, since the organization of health services enables a complete coverage of the population, both rural and urban areas. Existing literature to date indicate that many surveys have been conducted by health institutions on the morbidity and mortality pattern of children; however, there is no indication on the representativeness of the population from the sample surveyed. Underreporting is a significant problem in the data on mortality and morbidity. There is a wide variation in the extent of underreporting from province to province. Poor validity in reporting is inevitable, since standardized case definitions have not been developed, and there is no evidence of a manual outlining surveillance and investigation procedures. In order to improve the validity and the quality of the data, there is a great need for training of those health staff at all levels who are involved in the reporting of deaths and diseases. G. Continuing Presence of Malnutrition The final issue is the strengthening of strategies to address the continuing presence of malnutrition. The assessment of the nutritional status of children is the ultimate test of health and food policies. Secular improvement in anthropometric status is noted, even though the caloric availability per capita in China increased by only about 1 percent between 1957 and 1977. The key contributing factors were the elimination of maldistribution of food and the health sector's promotion of a preventive approach to diseases. China's agriculture has progressed from mobilization of labor for increased production to increased use of fertilizer to mechanization. To ensure adequate dietary energy intake, efforts to increase production is complemented by a careful control on consumption, that is, equitable rationing, a process which has improved distribution and minimized food wastage. The effectiveness of the health care system in contributing to the improvement of nutrition is largely the result of its accessibility and an emphasis on prevention: sanitation, immunization, and prenatal and postnatal care. There has been a steady secular improvement in the nutritional status of children in China. A comparison of the growth of Chinese children with  - 69 - that of other developinng countries (such as Nepal, Sri Lanka, Togo, and Liberia) also showed that the rates of stunting in China are lower. The results of various nutritional assessments, however, indicate that there remains a substantial amount of mild to moderate malnutrition. Furthermore, there are distinct regional and urban-rural differences in the extent of malnutrition. Comprehensive surveys that link the anthropometric status of a child with his food consumption are not available in China. The results of a nutritional survey in urban nurseries in Beijing showed that the nutritional quality of the diet provided by these institutions seemed to be reasonable, since 13 percent of the total caloric intake was from protein and 25 percent of the total intake was from fat. The amount of animal and legume protein was about 55 percent of the total protein intake. However, the intake of calories and protein was only about 62 percent of.the standard quantity provided. The intake of micronutrients was also below standards; calcium was abwyl 34 percent, vitamin A was 59 percent, and vitamin C was 58 percent. - Although acute signs of protein deficiency (such as kwashiorkor) are not observed, there may be a substantial degree of subclinical protein deficiency. This is supported by observation of a high prevalence of anemia among children. Over the last 30 years, China has addressed aggressively the key issue of coverage, both in terms of food distribution and accessibility of health services. In addition to maintaining its political commitment to nutritional issues, the government needs to respond to the findings of the nutritional surveys by setting up corrective programs. It is not possible, however, to make recommendations with regard to the types of corrective programs that are needed without analyzing the underlying reasons. Malnutrition can be caused by many factors, some of them synergistic. The high prevalence of parasitism, acute respiratory or gastrointestinal infections, and dysfunction in family dynamics (an emerging problem as a result of the 'one child norm'), are only a few possible contributing factors. Improving the quality of nutrient intake, strengthening health surveillance, early detection of those at risk, and active diagnosis and treatment of malnourished children, all deserve to be high priority components of the health care service delivery system. Maximizing a child's growth is the most effective way to reassure the family and the society. A child that grows well closely determines the acceptance and the viability of the present one child family policy. 41/ Lui, D.S. et.al. "Nutritional Survey in Urban Nurseries and Kindergartens of Beijing During 1979-1980," National Medical Journal of China, 61 (1981): 585-590.  - 70 - Annoted Bibliography "Age Distribution of China's Population," Beijing Review, 3 (January, 1984): 20-22. "An Investigation on the Method, Content and Organization Pattern of Child Health Care in Rural Areas," (in Chinese), Chinese Medical Journal, 62 (January, 1982): 4-7. Child health services, organization and administration. Arena, J.M., "Nutritional Status of China's Children," Nutrition Review, 32 (October, 1974): 289-295. "A Survey of Unreported Cases of Infant Mortality, Chongqing County," (in Chinese), Chinese Journal of Epidemiology, 4 (1983): 172-173. Thirty-three percent of infant deaths were not reported. Belcher, D.W., et.al., "Comparison of Methods for Estimating the Frequency of Paralytic Poliomyelitis in Developing Countries," Bulletin of the World Health Organization, 57 (1929): 301-307. Chen, H.D., and Jiang, D.X., "A Clinico-Pathological Analysis of 645 Cases of Perinatal Infantile Death," Chinese Journal of Obstetrics and Gynecology, 15 (July, 1980): 150-152. Chen, S.Y., "Tuberculosis Meningitis in Children: A Comprehensive Report of 2757 Cases," (in Chinese), Chinese Journal of Pediatrics, 20 (August, 1982): 153-155. Summary data of patients with TB meningitis, including age, sex distribution, history of BCG vaccination, clinical features and laboratory analysis. Child Health Care in New China," American Journal of Chinese Medicine, 2 (1974): 149-158. China Socialist Economic Development, Volume III, A World Bank Country Study, 1983. "China's Birth Rate," Beijing Review, 26 (August, 1983). Dong, Y., and Chen, Y.Z., "Analysis of Congenital Defects," (in Chinese), National Medical Journal of China, 62 (March, 1982): 141. Prevalence of congenital defects was 2 percent among newborns, of which 73 percent was of neurological etiology.  - 71 - Du, C.Y., et.al., "Report of a Survey of Paralytic Poliomyelitis," (in Chinese), Chinese Journal of Epidemiology, 1 (1982): 42-48. Prevalence of paralytic poliomyelitis in a hyperendemic commune in Guangdong was 5.28 per 1,000 population under 30; prevalence was 1.18 per 1,000 children of age 5 to 9. Du, R.F., et.al., "Percentages and Types of Consanguineous Marriage in Different Nationalities of China," (in Chinese), National Medical Journal of China, 61 (1981): 723-726. Frequency distribution of consanguineous marriage among ten minority nationalities was surveyed within China. Chang, R.X., et.al., "Study on Viruses from Children with a Repiratory Infection in Guangzhou," Chinese Journal of Pediatrics, 21 (1983): 219. Respiratory syncytial virus, adenovirus and parainfluenza are the three leading pathogens found in a serological study conducted in Guangzhou Children's Hospital. "Epidemiological Analysis of Endemic Fluorosis in Some Districts of Shangdong Province," (in Chinese), Chinese Journal of Preventive Medicine, 16 (November, 1982): 353-356. Occurrence of fluoride poisoning, occurrence of mottled enamel and bone disease. Fan, P.L., "Prevention and Treatment of Tuberculosis in Childhood: Summary of Discussions," (in Chinese), Chinese Journal of Pediatrics, 20 (August, 1982): 167-171. Review of terminology and standards of management in perinatal medicine. Ge, K., et.al., "Keshan Disease - An Endemic Cardiomyopathy in China," Institute of Health, Chinese Academy of Medical Sciences, 401 (1983): 1- 15. Hu, Z.L., et.al., "Epidemiology of Hepatitis in Zibo City," (in Chinese), Chinese Journal of Epidemiology, 21 (1981): 243-246. One-third of apparently health population has HBV. Peak incidence occurs among children age 1-6. "Incidence of Hepatitis in China," Beijing Review, 4 (January, 1984): 34. Prevalence of hepatitis is as high as 31-61 percent in some areas.  - 72 - Jamison, D.T., and Trowbridge, F.L., "The Nutritional Status of Children in China: A Review of the Anthropometric Evidence," PHN Technical Note Number 17, August, 1983. Joseph, B., et.al., "Comparison of Techniques for the Estimation of the Prevalence of Poliomyelitis in Developing Countries," Bulletin of the World Health Organization, 61 (1983): 833-837. Jing, Q., et.al., "Familial Hepatitis B Infections," (in Chinese), Chinese Journal of Preventive Medicine, 14 (November, 1980): 235-237. Transmission of HBV from mother to infant is about 65 percent. Seventy-eight percent of children who are HBV positive have mothers who are HBV positive. Last, J.M., Public Health and Preventive Medicine, New York: Appleton Century Crofts, 1980. Li, X.Q., et.al., "Incidence of Genetic Disease Among Hospitalized Children in Children's Hospital of Shanghai First Medical College, 1963-1978," (in Chinese), Chinese Journal of Pediatrics, 18 (November, 1980): 210-213. Proportion of congenital defects as a cause of hospital admission has increased between 1963 and 1978. Classifications of hereditary disease are given in the paper. Li, J., "Survey of Japanese B Encephalitis, Eastern Regions Inner Mongolia," (in Chinese), Chinese Journal of Epidemiology, 2 (1981): 247-248. In the Eastern Region, Inner Mongolia. Sixty percent of cases are children and youths of age less than 20. Outbreaks occur every four years, in relatively higher temperature weathers. Lin, Z.M., et.al., "Rubella Serological Survey - Beijing City," (in Chinese), Chinese Journal of Preventive Medicine, 4 (1983): 32-33. Ninety-eight percent of women of childbearing age had antibody to rubella. Ling, R.Z., "A Brief Account of 30 Years' Mortality of Chinese Population," (in Chinese), Chinese Journal of Preventive Medicine, 15 (September, 1981): 259-262. Infant, newborn and child mortality rates. Liu, C.H., "Endemic Fluorosis," Popular Medicine, 6 (1983): 34-36. Clinical presentation of fluorosis and distribution of regions with high fluoride content in water and soil were discussed.  - 73 - Liu, D.S., et.al., "Nutritional Survey in Urban Nurseries and Kindergartens of Beijing During 1979-1980," National Medical Journal of China, 61 (1981): 585-590. Liu, W.W., et.al., "An Analysis of Diseases of the Newborn," (in Chinese), Chinese Journal of Obstetrics and Gynecology, 14 (October, 1979): 303-305. Prevalence of morbidity among newborns between 1973 and 1977. Peak prevalence occurs during September, the hottest month of the year. Communicable diseases still account for 31 percent of morbidity; birth injury, 14 percent; congenital defects, 8 percent; hematological system, 6 percent; respiratory disease, 5 percent; digestive system, 4 percent; and other, 33 percent. Liu, X.Y., and Zhao, H.X., "Investigation on Immunity Level Against Measles in Nanguan, Changchun," (in Chinese), Chinese Journal of Epidemiology, 4 (1983): 176-177. All 364 children of ages 2 to 15 were found to be positive for measles antibody. Revaccination of those who pre-vaccination antibody titer was less than 1:16 resulted in an increase of antibody in 33 percent of the recipients. Mao, W.H., "Clinical Features of Tuberculosis and Early Diagnosis in Infants," Chinese Journal of Pediatrics, 20 (August, 1982): 150-152. Mark, C.E., et.al., "Birthweight Distribution of Singapore Chinese, Malay and Indian Infants From 34 Weeks to 42 Weeks Gestation," The Journal of Obstetrics and Gynecology, 79 (February, 1972): 149-153. Meng, O.W., "Epidemiologic Characteristics of Diphtheria in Guandong Over the Last 30 Years," (in Chinese), Chinese Journal of Epidemiology, 2 (1981): 170-172. The article reviewed the clinical features of diphtheria cases, changes in incidence rate, age, and urban/rural distribution. Ofosu-Amaah, S., Kratzer, J., and Nicholas, D., "Is Poliomyelitis a Serious Problem in Developing Countries? - Lameness in Ghanaian Schools," British Medical Journal, 1 (1977): 1012-1014. Estimated annual incidence of paralytic poliomyelitis was 23 per 100,000 population, official reported incidence rate ranged from 0.1 to 2.1 per 100,000 population. The estimated prevalence of lameness attributable to poliomyelitis was 5.8 per 1,000 school age children. Piazza, A., "Trends in Food and Nutrient Availability in China, 1950-1981," World Bank Staff Working Paper No. 607, 1983.  - 74 - "Preliminary Report on Disease Surveillance in East City, Beijing," (in Chinese), Chinese Journal of Preventive Medicine, 15 (1981): 9-13. Data is presented on the age distribution of population, incidence of communicable diseases, and percentage of deaths by cause in East City, Beijing, 1979. Prost, A., et.al., "Health Sector Issues in Shandong Province," PHY Technical Notes, No. 18, World Bank, April, 1983. "Protective Effect of Live Attenuated Measles Vaccine," (in Chinese), Chinese Journal of Epidemiology, 4 (1983): 1-3. Protective rate within 2 years after primary immunication was 96 percent. Protective rate dropped to 86 percent by 3rd to 4th year, and to 71 percent in the 5th year. Qian, S.G., and Shaw, J.Y., "Distribution of Newborn Weights in Shanghai," (in Chinese), Chinese Journal of Obstetrics and Gynecology, 15 (October, 1980): 198-201. Ren, S.L., Dong, Y.W., and Liu, S.H., "Epidemiological Analysis of Epidemic Meningitis in Xuchang Prefecture," Chinese Journal of Epidemiology, 1 (February, 1982): 8-11. "Report of a Survey of Paralytic Poliomyelitis in Heilongjian Province," (in Chinese), Chinese Journal of Epidemiology, 4 (1983): 174-175. Prevalence of paralytic poliomyelitis was 2.84 per 1,000. Rate was 1.97 per 1,000 children age 5 to 9. "Report of a Survey of Paralytic Polimyelitis in Guangdong Province," (in Chinese), Chinese Journal of Epidemiology, 4 (1983): 161-163. Prevalence of paralytic poliomyelitis was 1.19 per 1,000. Eighty-six percent of the cases did not receive the vaccination. Prevalence was 0.33 per 1,000 children age 5 to 9. "Report of a Survey of Paralytic Poliomyelitis in Jilin Province," (in Chinese), Chinese Journal of Epidemiology, 4 (1983): 164-166. Prevalence of paralytic poliomyelitis was 0.76 per 1,000 population under age 30. The rate was 0.04 per 1,000 before vaccination, during 1950-1964, and 0.02 per 1,000 from 1965-1980. Prevalence was 0.30 per 1,000 children age 5 to 9. "Report of a Symposium on Rheumatic Heart Disease," (in Chinese), Chinese Journal of Cardiology, 10 (1982): 71-72.  - 75 - "Report on The Survey of Paralytic Poliomyelitis," (in Chinese), Chinese Journal of Epidemiology, 4 (March, 1983): 140-145. The national survey was conducted in 12 provinces, including both urban and rural areas, with a total population of 3.5 million. Prevalence of paralytic poliomyelitis was 0.22 in urban cities and 1.0 in rural areas per 100,000 children of age 5 to 9. Retrospect Analysis of Perinatal Mortality Within 17 Years (1961-1977)," (in Chinese), Chinese Journal of Obstetrics and Gynecology, 13 (October, 1978): 119-122. Comparison of perinatal mortality at Shanghai First Maternity Hospital with several developed countries. "Rural Preschool Child Health Care Organization Content and Methods," (in Chinese), Chinese Medical Journal, 95 (August, 1982): 551-556. Shang, C.M., "Clinical Features, Epidemiology and Control of Endemic Fluorosis," (in Chinese), Chinese Journal of Preventive Medicine, 14 (1980): 27-35. Shi, S.Z., et.al., "Correctness of Statistics: IMR," (in Chinese), Chinese Journal of Pediatrics, 21 (1983): 213-214. Jingan district, Shanghai underreports infant mortality by 5 percent. Song, M.T., "Push Forward Energetically Research on Hepatitis B in Children," (in Chinese), Chinese Journal of Pediatrics, 18 (May, 1980): 65-66. Among 'healthy' children in Hubei province, 5 percent are HBsAG carriers. Prevalence rate has not changed over the last 20 years. "Study on Vaccination Schedule of Inactivated Japanese Encephalitis Vaccine," (in Chinese), Chinese Journal of Preventive Medicine, 15 (November, 1981): 360-362. Su, Y., and Wei, H., "Keshan Disease in Children and its Dietary Prevention," (in Chinese), National Medical Journal of China, 61 (October, 1981): 641- 643. Review of the epidemiologic characteristics of the disease and discussion of dietary preventive measures. "Survey of Paralytic Poliomyelitis, Eastern District, Beijing," (in Chinese), Chinese Journal of Epidemiology, 3 (1982): 273-276. Prevalence of paralytic poliomyelitis was 0.06 per 1,000 children 5 to 9.  - 76 - "Survey of Rheumatic Heart Disease and Rheumatic Fever in Guandong Province," (in Chinese), Chinese Journal of Cardiology, 10 (1982): 8-10. "Survey on the Epidemiology of Endemic Fluorosis in Shangdong Province," (in Chinese), Chinese Journal of Preventive Medicine, 16 (1982): 359-363. Survey on distribution of fluoride contents of drinking water and dental and skeletal fluorosis was carried out in 4 counties. "The Health Sector in China," Population, Health and Nutrition Department, Report No. 4664-CHA, The World Bank, April, 1984. Thuriaux, M.C., and GBetholancy, B., "Enquete sur la Prevalence des Sequelles de Poliomyelite au niveau des Membres Inferieurs chez les Enfants d'age Scolaire dans les Zones Rurales du Department de Niamey, Niger," Medecine Tropicale, 42 (1982): 545-549. Extrapolated annual incidence rate for paralytic poliomyelitis was 45 per 100,000 population. Seven to ten higher than routine reported figure. Wang, N.J., et.al., "Perinatal Mortality and Causes of Death," (in Chinese), Chinese Journal of Obstetrics and Gynecology, 15 (October, 1980): 206-209. Summary perinatal deaths between 1953 to 1979 in various provinces; data, however, is not presented by year. Wray, J.D., "Child Care in the People's Republic of China - 1973, Part II," Pediatrics, 55 (May, 1975): 723-734. Wu, S.Y., et.al., "A Study on the Cause of Failure in Measles Vaccination During Early Infancy," (in Chinese), National Medical Journal of China, 61 (1981): 102-105. Residual maternal antibody was present in one-third of infants between 4-5 months of age. Seroconversion rates in susceptible infants after vaccination varied with their age, namely, 64 percent, 84 percent, 94 percent and 96 percent in age groups of 4-6, 7-8, 9-11, and over 12 months of age, respectively. Seroconversion rate in infants bearing maternal antibody varied by age. Wu, Z.Y., et.al., "A Sero Epidemiologic Surveillance of Measles," (in Chinese), Chinese Journal of Epidemiology, 4 (1983): 4-7. No outbreak of measles occurred among a population where seropositive rate was about 75 percent in patients who had measles with a positive history of previous vaccination. The patients either were under age of one when vaccinated or received a vaccine from a batch which was kept under improper storage.  - 77 - Xue, B.Q., "Child Health Care Must Be Strengthened," National Medical Journal of China, 62 (1982): 1-3. Overall prevalence of nutritional anemia in children was about 50 percent in 16 provinces. Yan, Y.G., et.al., "Summary of National Symposium on Prevention and Treatment of Childhood Hepatitis," (in Chinese), Chinese Journal of Pediatrics, 20 (May, 1982): 120-123. Prevalence of hepatitis among children less than 14 years of age in 2,089 cities was 810 per 100,000 population in 1979. Fourty-four percent was Hepatitis A; 19 percent, Type B; 23 percent, NANB; and 14 percent, combined Type A and B. In Wuhan city, among 'healthy' children, the prevalence rate was 22 percent for children under 2, and 20 percent for children between 3 to 6. In Shanghai city, the prevalence rate was 30 percent among children under 4 in various nurseries. Yuan, C.T., et.al., "Efficacy of Meningococcus Group A Polysaccharide Vaccine," (in Chinese), Chinese Journal of Epidemiology, 4 (1983): 207- 210. Group A polysaccharide vaccine was studied in placebo-controlled double blind trials in 274,725 children ages 1-15. Group A polysaccharide vaccine induced much higher antibody response and less side effect. Zhang, W.Z., et.al., "Rubella Serological Survey - Lonzhou," (in Chinese), Chinese Journal of Preventive Medicine, 4 (1983): 89-91. Serological conversion survey of population of childbearing age indicated that 98 percent of sample surveyed were positive antibody titer rubella. Zhang, Y.H., and Su, W.N., "A Review of the Current Impact of Measles in the People's Republic of China," Review of Infectious Disease, 5 (1983): 411- 416. Annual incidence of measles has declined since initiation of vaccination campaigns. Incidence was as high as 1000-5000 cases per 100,000 population before 1965. In 1980 the incidence was 57 per 100,000 population.  - 78 - Zhao, J.M., et.al., "Investigation on Antibodies Against Respiratory Tract Virus in Children," (in Chinese), National Medical Journal of China, 62 (1982): 723-726. Positive rate of antibody to Type I parainfluenza virus was 75 percent; to Type III parainfluenza virus, 73 percent; to Type A3 influenza, 42 percent; to respiratory syncytical virus, 29 percent; to Type B influenza firus, 21 percent; and to adenovirus, 23 percent. Zhao, Z.W., et.al., "Investigation of Immune Reponse to Meningococcal Polysaccharide Vaccine," (in Chinese), Chinese Journal of Epidemiology, 4 (1983): 12-14. The immune response of 172 children to meningococcal A polysaccharide vaccine was observed. Infants of 6-12 months had a poorer immune response to the vaccine compared with children of age 1-3. Zheng, Y.H., et.al., "Serological Investigation of Hepatitis B," (in Chinese), Chinese Journal of Epidemiology, 2 (1981): 152-155. In Guizhou Province, prevalence of HBsAg carriers among 'healthy' population was 6 percent. Ten percent of carriers are children under 10 years of age. Prevalence rate was higher in males (8 percent) than females (3 percent).  - 79 - ANNEX TABLES   - 81 - Annex Table 1: Comparison of Urban and Rural, Age-Specific Death Rates (%) by Sex, 1957 and 1975 in China Urban area Rural area 1957 1975 1957 1975 Age group Male Female Male Female Male Female Male Female - 1 35.01 35.73 10.23 9.72 75.71 76.62 20.53 19.79 1 - 2 21.42 24.32 5.80 5.62 34.55 37.94 9.20 9.36 3 - 6 5.25 6.44 1.39 1.31 10.65 12.49 3.02 3.27 7 - 9 1.77 1.87 0.84 0.57 3.74 3.68 1.34 1.19 10 - 14 1.31 1.33 0.64 0.40 2.32 2.53 0.85 0.70 15 - 24 1.08 1.66 0.98 0.75 2.37 2.91 1.06 0.91 25 - 29 1.34 2.37 1.14 1.10 2.91 3.69 1.47 1.48 30 - 34 1.85 3.00 1.44 1.38 3.77 4.70 1.82 1.74 35 - 39 2.84 4.19 1.94 1.75 5.12 5.18 2.56 2.39 40 - 49 5.67 6.27 3.76 3.19 8.38 7.04 4.52 4.09 50 - 59 14.65 12.40 10.92 8.88 15.96 12.33 11.79 9.55 60 - 69 34.93 25.73 32.38 23.61 35.85 27.52 31.55 25.14 70 & + 83.77 71.66 99.77 83.24 84.44 73.60 96.89 86.20 Total 8.03 9.21 5.70 5.40 13.28 13.56 7.08 6.63 Source: "Analysis of 30 Years Mortality of Chinese Population," Chinese Journal of Preventive Medicine, 5 (1981): 260.  Annex Table 2: Crude Death Rate of Selected Provinces- and Number and Percentage of Total Death by Age, 0-10, 1982 BMILJING TIENJIN LUONING SUANCAI FLUIEN IENA GUANDONG CUUIZHU CANSU hNGXLA AGE POPULAT1O4: 917,966 779,016 3,562,104 1,188,510 2,587,044 7,455,952 5,928,490 2,851,440 1,963,524 385,660 6 Deatba 51,659 46,168 186,877 74,356 148,825 441,173 323,144 237,960 110,348 23,031 CUa 56.3 5i.3 52.5 62.6 57.5 59.2 54.5 83.5 56.2 59.7 0 J Deaths 2,249 2,286 11,735 2,833 10,750 29,687 25,738 45,910 13,306 6,153 S 4.4 5.0 6.3 3.8 7.2 6.7 8.0 19.3 12.1 26.1 I 0 Deaths 202 200 1,744 351 2,425 5,901 6.248 14,280 2,419 1,192 Z 0.4 0.4 0.9 0.5 1.6 1.3 1.9 6.0 2.2 5.2 2 * Deaths 113 127 1,174 221 1,861 3,861 4,199 10,245 1,580 679 X 0.2 0.3 0.6 0.3 1.2 0.9 0.3 4.3 1.4 3.0 3 I Deaths 72 94 738 150 1,370 2,733 2,642 6,672 1,049 369 2 0.1 0.2 0.4 0.2 0.9 0.6 0.8 2.8 0.9 1.6 4 0 Deaths 54 71 503 106 1,019 1,936 1,782 4,360 738 253 2 0.1 0.2 0.3 0.1 0.7 0.4 0.6 1.8 0.7 1.1 5 * Deaths 64 82 415 78 816 1,728 1,531 3,244 547 227 2 0.1 0.2 0.2 0.1 0.6 0.4 0.5 1.4 0.5 1.0 6 * Deaths 58 84 444 47 b80 1,680 1,404 2,434 513 163 X 0.1 0.2 0.2 0.1 0.5 0.4 0.4 1.0 0.5 0.7 7 1 Deaths 68 77 386 54 623 1,625 1,191 1,956 506 117 z 0.1 0.2 0.2 0.1 0.4 0.4 0.4 0.8 0.5 0.5 8 J Deatba 64 65 382 72 591 1,495 1,046 1,494 472 109 2 - 0.1 0.1 0.2 0.1 0.4 0.3 0.3 0.6 0.4 0.5 9 * Deaths 57 67 380 49 496 1,222 918 1,212 394 72 2 0.1 0.2 0.2 0.1 0.3 0.3 0.3 0.5 0.4 0.3 10 I Deaths 71 57 376 69 498 1,290 945 1,262 429 88 2 0.1 0.1 0.2 0.1 0.3 0.3 0.3 0.5 0.4 0.4 Li The selected proviaces are of tkb 101 amplIng a< the 1982 census. Source: Ten percent sampling tabulation on the 1982 Population Census of the People's Republic of China, Population Census Office, State Statistical Bureau, October, 1983, Beijing.  Annex Table 3: Perinatal Mortality Rate, Neonatal Mortality Rate, 17 Reporting Units, Between 1953 and 1979 No. of Perinatal Dead Still- Neonatal Reporting Unit Total Births Deaths Fetus births Deaths Shanghai First Maternity Hospital 1974.1-1978.12 165,317 2,169 13.12 873 5.28 321 1.94 975 5.90 Nanjing Ba Yi Hospital 1953.1-1978.12 34,186 541 15.83 137 4.01 138 4.04 266 7.78 Hanzhou Fourth Hospital 1974.7-1979.6 4,242 71 16.74 24 5.66 22 5.19 25 5.90 Sichuan Medical College Hospital 1977.9-1979.8 2,194 37 16.86 16 7.29 8 3.65 13 5.92 Tienji Maternity Hospital 1974.1-1978.12 19,694 373 18.94 85 4.32 117 5.94 171 8.68 Liaoning Traditional Medicine Hospital 1970.6-1978.12 5,385 111 20.61 25 4.64 28 5.20 58 10.77 W Guangxi Medical College Hospital 1963.1-1979.12 36,214 768 21.21 386 10.66 112 3.09 270 7.46 Suzhou Perinstal Center 1979.1-1979.12 8,037 187 23.27 47 5.85 55 6.84 85 10.58 Fujian Maternity Hospital 1974.1-1978.12 13,649 359 26.30 166 12.16 106 7.77 87 6.37 Jinan Maternity Hospital 1976.1-1978.12 10,925 302 27.64 136 12.45 68 6.22 98 8.97 Wenzhou Third People's Hospital 1969.1-1978.12 19,889 665 33.44 234 11.77 129 6.49 302 15.18 Tienjin Medical College Affiliated Hospital 1969.1-1978.12 19,970 700 35.05 232 11.62 126 6.31 276 13.82 Chengdu Third Hospital 1964.1-1979.12 18,260 641 35.10 352 19.40 95 5.24 188 10.36 Kaifong Medical College 1977.9-1979.8 963 29 30.11 3 3.12 7 7.27 19 19.73 Wushun Mineral Enterprise Hospital 1976.1-1979.12 32,792 777 23.69 188 5.73 445 13.57 144 4.39 Hunan Maternity Hospital 1954.1-1978.12 48,395 1,077 22.23 - - 205 - - - Henan People's Hospital 1971.1-1978.12 11,827 450 38.05 162 13.70 74 6.27 62 5.24 Source: Wang, N.J. et.al., "Perinstal Mortality and Causes of Death," Chinese Journal cf Obstetrics and Gynecology, 15 (October, 1980): 206.  - 84 - Annex Table 4: Infant Mortality Rate, Neonatal Mortality Rate and Percent of Infant Deaths in Neonatal Period, 1949-1978, Beijing % infant deaths Year IMR Neonatal Mortality Rate in Neonatal Period 1949 117.6 -- 1950 95.5 -- __ 1951 86.6 44.0 51 1952 65.7 35.9 55 1953 59.3 31.5 53 1954 4b.1 27.3 59 1955 44.5 21.0 47 1956 35.1 18.0 51 1957 35.4 18.1 51 1958 37.9 17.0 45 1959 35.1 15.6 44 1960 29.8 14.2 48 1961 35.6 14.3 40 1962 21.7 11.3 52 1963 22.3 12.4 56 1964 27.9 11.3 40 1973 11.6 6.1 52 1974 12.5 6.6 53 1975 12.4 7.9 64 1976 10.4 5.2 50 1977 10.1 0.5 64 1978 10.3 7.4 72 Source: Lin, Y.Z., "China's 30 Year Mortality Rate," Chinese Journal of Preventive Medicine, 15 (1981).  - 85 - Annex Table 5: Prevalence of Anomalies at the Maternity Hospital in Shanghai and Cardiff Maternity Hospital, 1972-76 Shanghai Cardiff (rate/1000) (rate/1000) Anenencephaly 0.24 1.79 Spinabifida 0.35 2.28 Cardiac anomaly 1.07 5.26 Down's 0.64 1.28 Cleft palate 1.38 0.38 Cleft lip 1.25 0.41 hypospadias 0.58 2.90 Talipes 0.76 4.17 Hemangioma 1.29 2.18 accessory digits 1.05 1.17 accessory auricle 2.23 0.23 born with teeth 0.89 0.22 RH immunization 0.17 5.15 ABO incompatibility 5.20 2.56 Source: Chalmers, I., "Better Perinatal Health, Shanghai," The Lancet, No. 1 (1980): 138.  q:X'.1 tt'iq- So isi,oull *'ql