Advancing the National Immunization Program in an era of achieving universal vaccine coverage in China and beyond.

Immunization is a cornerstone of public health. Despite great success, China's National Immunization Program (NIP) faces challenges, such as the integration of several World Health Organization-recommended vaccines and other systemic issues. The Innovation Laboratory for Vaccine Delivery Research (VaxLab), supported by the Bill & Melinda Gates Foundation and established in 2021 at Duke Kunshan University, focuses on enhancing China's NIP through research and policy advocacy. This editorial aims to summarize the key findings of the manuscripts published in the collection contributed by VaxLab team and set the future research agenda. The collection contains eleven manuscripts discussing China's immunization landscape and strategies to improve coverage, particularly for non-NIP vaccines like human papillomavirus vaccine (HPV), pneumococcal conjugate vaccine (PCV), Haemophilus influenzae type b vaccine (Hib), and rotavirus vaccines. Key findings include: (i) The COVID-19 vaccination campaign demonstrated China's capacity for rapid, large-scale immunization efforts, suggesting potential for broader vaccine coverage improvements; (ii) Efforts in combating cervical cancer through the HPV vaccine indicate progress but also highlight challenges like vaccine supply and equitable access; (iii) The lag in adopting higher-valent paediatric combination vaccines in China needs attention to address regulatory and health system hurdles; (iv) Disparities in access to non-NIP vaccines underscore the need for government initiatives to improve vaccine coverage, especially for remote areas and marginalized populations; (v) Original studies emphasize the influence of caregivers' knowledge, health workers' financial incentives, and concerns about vaccine efficacy on immunization rates; (vi) Case studies from the Weifang City of China and Indonesia to introduce PCV offer insights on successful vaccine introduction strategies and the impact of innovative financing and government support. The articles emphasize the need for government leadership, strategic policymaking, and public awareness to enhance vaccine coverage and equity. The VaxLab will continue strengthening China's NIP by focusing on vaccine financing, emphasizing diversity, equity, and inclusion, and improving maternal vaccination coverage. Research will extend to Southeast Asian and Western Pacific regions, especially in middle-income countries facing challenges in vaccine financing and delivery. The collective efforts outlined in this collection show a commitment to evolving and adapting immunization strategies to meet global health goals and to provide equitable access to vaccines for all.

Chen S ，Rodewald LE ，Du AH ，Tang S ... -  《-》

The coverage and challenges of increasing uptake of non-National Immunization Program vaccines in China: a scoping review.

Jiang M ，Chen S ，Yan X ，Ying X ，Tang S ... -  《-》

Vaccine preventable diseases and vaccination coverage in Aboriginal and Torres Strait Islander people, Australia 2006-2010.

This report outlines the major positive impacts of vaccines on the health of Aboriginal and Torres Strait Islander people from 2007 to 2010, as well as highlighting areas that require further attention. Hepatitis A disease is now less common in Aboriginal and Torres Strait Islander children than in their non-Indigenous counterparts. Hepatitis A vaccination for Aboriginal and Torres Strait Islander children was introduced in 2005 in the high incidence jurisdictions of the Northern Territory, Queensland, South Australia and Western Australia. In 2002–2005, there were 20 hospitalisations for hepatitis A in Aboriginal and Torres Strait Islander children aged<5 years--over 100 times more common than in other children--compared to none in 2006/07–2009/10. With respect to invasive pneumococcal disease (IPD), there has been a reduction of 87% in notifications of IPD caused by serotypes contained in 7-valent pneumococcal conjugate vaccine (7vPCV) since the introduction of the childhood 7vPCV program among Aboriginal and Torres Strait Islander children. However, due to a lower proportion of IPD caused by 7vPCV types prior to vaccine introduction, the decline in total IPD notifications has been less marked in Aboriginal and Torres Strait Islander children than in other children. Higher valency vaccines (10vPCV and 13vPCV) which replaced 7vPCV from 2011 are likely to result in a greater impact on IPD and potentially also non-invasive disease, although disease caused by non-vaccine serotypes appears likely to be an ongoing problem. Among Aboriginal and Torres Strait Islander people aged ≥50 years, there have been recent increases in IPD, which appear related to low vaccination coverage and highlight the need for improved coverage in this high-risk target group. Since routine meningococcal C vaccination for infants and the high-school catch-up program were implemented in 2003, there has been a significant decrease in cases caused by serogroup C. However, the predominant serogroup responsible for disease remains serogroup B, and Aboriginal and Torres Strait Islander children have significantly higher incidence of serogroup B disease than other children. A vaccine against meningococcus type B has now been licensed in Australia. The decline in severe rotavirus disease after vaccine introduction in 2007 was less marked in Aboriginal and Torres Strait Islander children than in other children. By far the highest hospitalisation rates continue to occur among Aboriginal and Torres Strait Islander children in the Northern Territory. Consideration of the role of age cut-offs and 2-dose versus 3-dose schedules may be necessary. Genotype surveillance is critically important to allow detection of any possible emergence of genotypes for which there is lower vaccine-derived immunity. Although Haemophilus influenzae type b disease rates have decreased significantly since the introduction of vaccines in 1993, the plateauing of rates in Aboriginal and Torres Strait Islander children, and increasing disparity with other children, are concerning. While it is possible that higher disease rates in young infants could be associated with the later age of protection from the newer 4-dose schedule, it is also possible that higher vaccine immunogenicity will result in reduced carriage. Close monitoring is important to detect any re-emergence of Hib disease as soon as possible. Pandemic and seasonal influenza and pneumonia are other diseases with comparatively higher rates in Aboriginal and Torres Strait Islander people. For Aboriginal and Torres Strait Islander people aged≥50 years, it is unclear whether or not there has been a decline in influenza hospitalisations since the start of the National Indigenous Pneumococcal and Influenza Immunisation Program in 1999, but hospitalisation rates are still higher in Aboriginal and Torres Strait Islander people. Achieving high coverage in those aged≥15 years should now be a priority. A prolonged mumps outbreak occurred in 2007/2008 predominantly affecting Aboriginal and Torres Strait Islander adolescents and young adults in north-western Australia. A potential contributor to this mumps outbreak was greater waning of immunity after receipt of the first dose of mumps-containing vaccine at 9, rather than 12, months of age in the Northern Territory in the 1980s and 1990s. However, outbreaks in Australia and overseas have subsided without additional boosters being routinely implemented. Pertussis epidemics continue to occur in Australia and affect both Aboriginal and Torres Strait Islander and other people. Parents are now encouraged to have their infant’s first vaccination given at 6 weeks of age, instead of the usual 2 months, and this is being successfully implemented for Aboriginal and Torres Strait Islander and other infants. Timely provision of the 4- and 6-month doses remains very important. High coverage for standard vaccines, poor timeliness of vaccination and lower coverage for ‘Indigenous only’ vaccines are continuing features of vaccination programs for Aboriginal and Torres Strait Islander people. There have been some improvements in vaccination timeliness in recent years for all children, but disparities remain between Aboriginal and Torres Strait Islander and other children. Poor timeliness reduces the potential benefits of vaccination, most importantly for pneumococcal, Hib and rotavirus vaccines in infants. The age cut-offs for rotavirus vaccines present a particular challenge for timely vaccination, limiting the capacity for catching up on late vaccination and resulting in lower overall coverage. This is more pronounced for the 3-dose than for the 2-dose rotavirus schedule. Coverage for vaccines recommended only for Aboriginal and Torres Strait Islander children continues to remain substantially lower than that for universal vaccines. This underlines the importance of immunisation providers establishing the Indigenous status of their clients, so that additional vaccines are offered as appropriate. The absence of any coverage data for Aboriginal and Torres Strait Islander adolescents, or for adults since 2004/2005, is a substantial obstacle to implementing and improving programs in these age groups.

Naidu L ，Chiu C ，Habig A ，Lowbridge C ，Jayasinghe S ，Wang H ，McIntyre P ，Menzies R ... -  《-》

Qualitative evidence synthesis informing our understanding of people's perceptions and experiences of targeted digital communication.

Health communication is an area where changing technologies, particularly digital technologies, have a growing role to play in delivering and exchanging health information between individuals, communities, health systems, and governments.[1] Such innovation has the potential to strengthen health systems and services, with substantial investments in digital health already taking place, particularly in low‐ and middle‐income countries. Communication using mobile phones is an important way of contacting individual people and the public more generally to deliver and exchange health information. Such technologies are used increasingly in this capacity, but poor planning and short‐term projects may be limiting their potential for health improvement. The assumption that mobile devices will solve problems that other forms of communication have not is also prevalent. In this context, understanding people's views and experiences may lead to firmer knowledge on which to build better programs. A qualitative evidence synthesis by Heather Ames and colleagues on clients' perceptions and experiences of targeted digital communication focuses on a particular type of messaging – targeted messages from health services delivered to particular group(s) via mobile devices, in this case looking at communicating with pregnant women and parents of young children, and with adults and teenagers about sexual health and family planning.[2] These areas of reproductive, maternal, newborn, child, and adolescent health (RMNCAH) are where important gains have been made worldwide, but there remains room for improvement. Ames and colleagues sought to examine and understand people's perceptions and experiences of using digital targeted client communication. This might include communication in different formats and with a range of purposes related to RMNCAH – for example, receiving text message reminders to take medicines (e.g. HIV medicines) or go to appointments (such as childhood vaccination appointments), or phone calls offering information or education (such as about breastfeeding or childhood illnesses), support (e.g. providing encouragement to change behaviours) or advice (such as advising about local healthcare services). These communication strategies have the potential to improve health outcomes by communicating with people or by supporting behaviour change. However, changing people's health behaviours to a significant and meaningful degree is notoriously challenging and seldom very effective across the board. There are a multitude of systematic reviews of interventions aiming to change behaviours of both patients and providers, with the overall objective of improving health outcomes – many of which show little or no average effects across groups of people.[3] This evidence synthesis is therefore important as it may help to understand why communicating with people around their health might (or might not) change behaviours and improve consequent health outcomes. By examining the experiences and perspectives of those receiving the interventions, this qualitative evidence synthesis allows us to better understand the interventions' acceptability and usefulness, barriers to their uptake, and factors to be considered when planning implementation. The synthesis looked at 35 studies from countries around the world, focussing on communication related to RMNCAH. Of the 35 studies, 16 were from high‐income countries, mainly the United States, and 19 were from low‐ or middle‐income countries, mainly African countries. Many of the studies presented hypothetical scenarios. The findings from the synthesis are mixed and give us a more nuanced picture of the role of targeted digital communication. People receiving targeted digital communications from health services often liked and valued these contacts, feeling supported and connected by them. However, some also reported problems with the use of these technologies, which may represent barriers to their use. These included practical or technical barriers like poor network or Internet access, as well as cost, language, technical literacy, reading or issues around confidentiality, especially where personal health conditions were involved. Access to mobile phones may also be a barrier, particularly for women and adolescents who may have to share or borrow a phone or who have access controlled by others. In such situations it may be difficult to receive communications or to maintain privacy of content. The synthesis also shows that people's experiences of these interventions are influenced by factors such as the timing of messages, their frequency and content, and their trust in the sender. Identifying key features of such communications by the people who use them might therefore help to inform future choices about how and when such messaging is used. The authors used their knowledge from 25 separate findings to list ten implications for practice. This section of the review is hugely valuable, making a practical contribution to assist governments and public health agencies wishing to develop or improve their delivery of digital health. The implications serve as a list of points to consider, including issues of access (seven different aspects are considered), privacy and confidentiality, reliability, credibility and trust, and responsiveness to the needs and preferences of users. In this way, qualitative evidence is building a picture of how to better communicate with people about health. For example, an earlier 2017 Cochrane qualitative evidence synthesis by Ames, Glenton and Lewin on parents' and informal caregivers' views and experiences of communication about routine childhood vaccination provides ample evidence that may help program managers to deliver or plan communication interventions in ways that are responsive to and acceptable to parents.[4] The qualitative synthesis method, therefore, puts a spotlight on how people's experiences of health and health care in the context of their lives may lead to the design of better interventions, as well as to experimental studies which take more account of the diversity that exists in people's attitudes and decision‐making experiences.[5] In the case of this qualitative evidence synthesis by Ames and colleagues, the method pulled together a substantial body of research (35 data‐rich studies were sampled from 48 studies identified, with the high‐to‐moderate confidence in the evidence for 13 of the synthesized findings). The evidence from this review can inform the development of interventions, and the design of trials and their implementation. While waiting for such new trials or trial evidence on effects to emerge, decision‐makers can build their programs on the highly informative base developed by this review. This qualitative evidence synthesis, alongside other reviews, has informed development by the World Health Organization of its first guideline for using digital technologies for health systems strengthening,[1, 6] part of a comprehensive program of work to better understand and support implementation of such new technologies.

Ryan R ，Hill S 《Cochrane Database of Systematic Reviews》

Public Preference and Priorities for Including Vaccines in China's National Immunization Program: Discrete Choice Experiment.

Several important vaccines, such as the Haemophilus influenzae type b vaccine, rotavirus vaccine, pneumococcal conjugate vaccine, and influenza vaccine, have not been included in China's National Immunization Program (NIP) due to a prolonged absence of updates and limited resources. Public engagement could identify concerns that require attention and foster trust to ensure continuous support for immunization. This study aimed to identify public preferences for vaccine inclusion in the NIP and to determine the desired vaccine funding priorities in the Chinese population. A dual-response discrete choice experiment was utilized to estimate the relative importance of 6 attributes, including incidence of vaccine-preventable diseases, mortality of vaccine-preventable diseases, vaccine effectiveness, vaccine cost, vaccinated group, and vaccine coverage. Participants were recruited through the Wenjuanxing platform using a census-based quota sample of the nationwide population aged 18 years and older. A mixed logit model was used to estimate the coefficient of attribute preferences and predict the selection probability. Subgroups and interaction effects were analyzed to examine the heterogeneity in preferences. In total, 1258 participants completed the survey, of which 880 were involved in the main analysis and 1166 in the sensitivity analysis. The relative importance and model estimates of 2 attributes, vaccine cost and vaccination group, varied between the unforced- and forced-choice settings. All 6 vaccine attributes significantly influenced the preferences for vaccine inclusion, with vaccine effectiveness and coverage as the most important factors, followed by the vaccinated group and mortality of vaccine-preventable diseases in the unforced-choice settings. The top vaccines recommended for China's NIP included the varicella vaccine, Haemophilus influenzae type b vaccine, enterovirus 71 vaccine, and influenza vaccine for preschoolers and school-aged children. The current analysis also revealed distinct preference patterns among different subgroups, such as gender, age, education, and income. The interaction analysis indicated that the region and health status of participants contribute to preference heterogeneity. Public preferences for including vaccines in the NIP were primarily influenced by vaccine effectiveness and coverage. The varicella vaccine should be prioritized for inclusion in the NIP. The public preferences could provide valuable insights when incorporating new vaccines in the NIP.

Zhang L ，Li X ，Chen J ，Wang X ，Sun Y ... -  《-》