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Premature death among primary and secondary school students aged 6–18 years is an important public health issue in China. In this study, we used data from China’s Cause-of-Death Reporting System (CDRS) to estimate students’ mortality. In 2018, it was estimated that there were 28,519 student deaths between the ages of 6–18 years, with age-standardized mortality rate (ASMR) of 17.66 per 100,000. Substantial disparities existed among different sexes, age groups, areas, and regions. Drowning, road traffic injuries, and leukemia were three leading causes of death. Multisectoral efforts should be initiated to reduce premature death among students, especially those due to injuries.
Deaths in older children (5–9 years) and younger adolescents (10–14 years) have received little attention. The neglect of these groups are presumably associated with the fact that this is the age range during which human mortality risks reach their minimum but are not insubstantial (1). It was reported that there were approximately 1.23 million deaths among individuals aged 5–19 years worldwide in 2017 (2). Primary and secondary school students aged 6–18 years mostly consist of older children and adolescents. Estimating their mortality is of great necessity to identify health priorities for reducing premature death.
This report used deaths in 2018 as collected by CDRS. Detailed descriptions of CDRS have been reported elsewhere (3). After primary quality control, 512 out of 605 were identified as eligible disease surveillance points, with 1,822 thousand reported deaths, covering 272 million population. Individuals aged 6–18 years were extracted and stratified by sex, age group, occupation, area, and region. National data of total population and current students in primary and secondary schools were obtained from National Bureau of Statistics (4). International Classification of Disease, 10th revision (ICD-10) was used to re-classify cause-of-death.
Crude mortality rate was calculated by using deaths and the respective populations. In consideration of CDRS under-reporting, mortality rate was adjusted for under-reporting through following formula: mortality rate=crude morality rate/(1–under-reporting rate) (5). The Sixth National Population Census in 2010 was used for age-standardized mortality rate (ASMR) estimation (4). Estimated death count nationwide was generated through scaled-up aggregation data in each stratum acquired. Years of life lost (YLLs) is a measure of premature death calculated as the sum of each death multiplied by the standard life expectancy at each age (2). Software R (version 3.6.2, The R foundation for Statistical Computing) was applied for statistical analysis.
In 2018, a total of 45,385 deaths among individuals aged 6–18 years nationwide were estimated with 28,519 students and 16,867 non-students. The ASMR for those aged 6–18 years was 23.55 per 100,000 with students estimated at 17.66 and non-students at 54.13 per 100,000. Non-students showed higher ASMR compared with its counterpart in all age groups, especially for those aged 6–12 years (136.25 vs. 14.12 per 100,000). Deaths occurring in those aged 6–18 years were estimated to occupy 0.47% of total population and calculated YLLs constituted 2.19% of total YLLs in all age. (Table 1)
Age (Years) Education level* Age-standardized mortality rate
(per 100,000)Total population
(10,000)Estimated deaths Age-specific deaths/All-age deaths (%) Age-specific YLLs/All-age YLLs (%) Total Students Non-students Total Students Non-students Total Students Non-students 6−12 Primary school 19.61 14.12 136.25 10,568.86 10,093.70 475.16 20,730 14,256 6,474 0.21 1.02 13−15 Junior high school 27.03 22.46 55.51 4,386.04 3,780.05 605.99 11,855 8,491 3,364 0.12 0.54 16−18 Senior high school 28.88 25.78 32.35 4,314.39 2,279.49 2,034.91 12,458 5,876 6,583 0.14 0.63 Total 23.55 17.66 54.13 19,269.30 16,153.24 3,116.06 45,385 28,519 16,867 0.47 2.19 Abreviation: YLLs=Years of life lost.
* Education level for school students aged 6–18 years only.Table 1. Age-standardized mortality rate, estimated deaths in students and non-students aged 6–18 years in China, 2018.
Male students showed higher ASMR than female students (21.50 vs. 13.30 per 100,000). Rural areas showed a higher value than urban areas (19.72 vs. 14.28 per 100,000). Western regions showed the highest ASMR (22.07 per 100,000), followed by central regions (18.23 per 100,000) and eastern regions (14.07 per 100,000). Injury (52.87%) and non-communicable diseases (NCDs) (38.71%) contributed over 90% deaths to overall mortality in students. Drowning (2.93 per 100,000, 16.59%), road traffic injuries (2.74 per 100,000, 15.51%), and leukemia (1.37 per 100,000, 7.75%) were the three leading causes of death. (Table 2)
Item Sex Urban Rural Eastern Central Western Total Male Female Total Male Female Total Male Female Total Male Female Total Male Female Total Male Female All-cause 17.66 21.50 13.30 14.28 16.91 11.34 19.72 24.27 14.51 14.07 16.76 11.00 18.23 22.62 13.16 22.07 27.07 16.59 Injury 9.33 12.14 6.15 7.29 9.30 5.04 10.58 13.86 6.83 6.60 8.61 4.30 9.72 12.85 6.11 12.75 16.43 8.71 Drowning 2.93 4.34 1.33 1.92 2.93 0.78 3.55 5.20 1.67 1.86 2.76 0.82 3.20 4.56 1.63 4.16 6.37 1.73 Road traffic injuries 2.74 3.46 1.93 2.19 2.60 1.74 3.07 3.98 2.04 2.03 2.48 1.52 2.93 3.80 1.94 3.53 4.49 2.47 Suicide 1.10 1.31 0.86 1.11 1.24 0.96 1.09 1.35 0.79 0.86 1.23 0.43 1.05 1.21 0.86 1.49 1.54 1.44 Falls 0.91 1.10 0.69 0.83 1.07 0.56 0.95 1.12 0.76 0.62 0.73 0.50 1.08 1.43 0.67 1.13 1.28 0.96 Poisoning 0.50 0.53 0.47 0.30 0.29 0.30 0.62 0.68 0.56 0.37 0.36 0.37 0.43 0.48 0.37 0.76 0.82 0.70 Other injuries 1.15 1.40 0.88 0.95 1.18 0.69 1.28 1.53 0.99 0.87 1.05 0.67 1.03 1.36 0.65 1.68 1.94 1.40 Non-communicable diseases 6.83 7.79 5.75 5.72 6.28 5.09 7.52 8.70 6.16 6.21 6.91 5.42 7.01 8.12 5.72 7.53 8.70 6.24 Leukemia 1.37 1.61 1.11 1.17 1.31 1.00 1.50 1.78 1.17 1.39 1.60 1.14 1.47 1.73 1.16 1.25 1.48 1.01 Cardiovascular diseases 1.05 1.24 0.83 0.94 1.00 0.88 1.11 1.38 0.81 1.01 1.24 0.74 1.03 1.10 0.95 1.13 1.38 0.85 Congenital abnormality 0.82 0.90 0.74 0.81 0.77 0.86 0.83 0.98 0.66 0.57 0.63 0.50 1.03 1.19 0.84 0.97 0.98 0.96 Nervous systems diseases 0.76 0.87 0.63 0.48 0.59 0.36 0.93 1.04 0.79 0.62 0.73 0.50 0.77 0.93 0.58 0.94 1.02 0.85 Respiratory diseases 0.50 0.50 0.50 0.33 0.36 0.29 0.61 0.59 0.64 0.39 0.43 0.35 0.42 0.35 0.49 0.74 0.76 0.72 Immune system diseases 0.26 0.25 0.27 0.19 0.15 0.24 0.30 0.30 0.29 0.25 0.15 0.35 0.28 0.30 0.26 0.25 0.32 0.18 Digestive system diseases 0.17 0.15 0.19 0.10 0.09 0.10 0.22 0.19 0.25 0.13 0.08 0.19 0.10 0.15 0.04 0.30 0.26 0.35 Other malignant tumor 1.90 2.27 1.48 1.71 2.01 1.37 2.02 2.43 1.55 1.86 2.04 1.66 1.92 2.36 1.40 1.94 2.52 1.31 Communicable diseases 0.31 0.32 0.30 0.20 0.21 0.19 0.38 0.39 0.37 0.22 0.20 0.24 0.29 0.35 0.22 0.47 0.48 0.46 Infectious & parasitic diseases 0.31 0.32 0.30 0.20 0.21 0.19 0.38 0.39 0.37 0.22 0.20 0.24 0.29 0.35 0.22 0.47 0.48 0.46 Others 1.18 1.24 1.11 1.07 1.12 1.02 1.24 1.32 1.16 1.04 1.05 1.04 1.22 1.30 1.12 1.33 1.46 1.18 Table 2. The age-standardized mortality rate (per 100,000) of primary and secondary school students aged 6–18 years in China, 2018.
The ASMR of students varied as age changed. The ASMR of drowning reached its peak in primary school students with downward trends in junior high school students. Following a similar trend as age increased, suicide mortality came reached its peak in secondary school students aged 15 years and older. For other conditions, a comparatively stable trend was observed in adjacent ages such as road traffic injuries, falls, poisonings, and most NCDs. Female students showed more frequent mortality fluctuations in comparison with male students, especially for malignant tumor after 13 years. (Figure 1)
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