The collection features eleven articles. Ten provide different perspectives on China's immunization landscape, with particular focus on improving coverage levels of four key non-program vaccines: HPV, PCV, Hib, and rotavirus. One of the articles shares experiences and lessons learnt from Indonesia’s introduction of PCV. The collection has a diversity of manuscripts, including three commentaries, four original studies, one scoping review, and three case studies.

Commentaries

The three commentaries address pivotal aspects of vaccination efforts in China, encompassing the COVID-19 vaccination campaign, HPV vaccination initiatives, and the adoption of higher-valent paediatric combination vaccines. Dr. Lance Rodewald highlights China’s swift mobilization of resources to achieve widespread COVID-19 vaccine coverage, advocating for the application of this infrastructure and experience to sustain high immunization rates as per IA2030 objectives, across all age groups for all WHO-recommended vaccines [7]. Prof. Fanghui Zhao and colleagues discuss the advances and challenges in China’s approach to HPV vaccination as a measure against cervical cancer, acknowledging significant progress but also calling attention to the need for stable vaccine supply, fair pricing, and a focus on marginalized populations to ensure equitable vaccine access [8]. A collaborative analysis by Prof. Shenglan Tang’s Duke Kunshan University team and Prof. Fuqiang Cui’s Peking University team examines the sluggish uptake of higher-valent paediatric combination vaccines in China, citing legislative and public awareness barriers while recommending a comprehensive promotion strategy that includes stricter vaccination law enforcement, schedule alignment, and enhanced vaccine research and development [9]. Together, these commentaries underscore the necessity of a concerted effort to enhance vaccine financing, services, access, and regulatory environment to stimulate vaccine innovation, so as to improve vaccine coverage in China.

Scoping review

The collection includes one scoping review led by Prof. Xiaohua Ying from Fudan University on coverage of the four underutilized non-NIP vaccines in China mentioned above—HPV, PCV, Hib, and Rotavirus—that are not part of China’s NIP but are primarily financed through out-of-pocket payment by families [4]. The authors identify gaps in coverage and the need to tackle issues related to access, affordability, acceptance, awareness, and activation. They advocate for a strategic government initiative to methodically incorporate these vaccines into China’s NIP and emphasize the importance of addressing disparities in vaccine access, particularly focusing on marginalized populations and less developed areas [4].

Original studies

The collection includes four original studies focusing on different immunization topics among diverse populations and regions, with a common aim to improve non-NIP vaccines coverage in China. These topics include vaccine coverage among the migrant and left-behind families, pentavalent vaccination coverage, Streptococcus pneumoniae nasopharyngeal carriage among children under five, and public health workers’ recommendations for non-NIP vaccines.

Original evidence on the low coverage of non-NIP vaccines has been generated. The lower vaccination coverage of non-NIP vaccines among migrant and left-behind families reported in the study led by Dr. Xiaolin Xu shows that factors such as the ages of children and caregivers, family roles, and caregivers’ knowledge about vaccines significantly influence vaccination rates [10]. It calls for specific interventions to enhance immunization information dissemination and satisfaction among these vulnerable groups, aiming to bridge the coverage gap with local urban families. The study led by Prof. Guohong Li focuses on pentavalent vaccine, analyzing its low coverage in Southern China. They identified key factors influencing caregiver decisions to vaccinate, including concerns about vaccine efficacy, manufacturer reputation, and the complexity of immunization schedules [12]. They show that urban–rural disparities exist, with urban caregivers displaying more concern about cost and convenience.

Consistent with the low coverage of PCV vaccine, evidence shows the carriage rate of Streptococcus pneumoniae is not low. The study led by Dr. Jiang Wu obtained nasopharyngeal swab samples from 2333 children in Hainan and found Streptococcus pneumoniae in 30.4% of the samples, spanning 29 serotypes. PCV13 vaccine covered 60.9% of the serotypes found in their study, and PCV13-vaccinated children had lower carriage rates [13]. Risk factors for carriage included attending day-care and having siblings, whereas children of more educated mothers, those living in urban areas and fully vaccinated with PCV13 had lower carriage rates, suggesting that the vaccine’s introduction could markedly reduce pneumococcal infections.

As medical and public health doctors’ recommendations may play a pivotal role in increasing the uptake of non-NIP vaccines, the study led by Prof. Hai Fang further provides insight into the behaviours of public health workers in recommending non-NIP vaccines, revealing a direct correlation between their recommending practices and financial incentives [11]. In addition, perceptions of vaccine safety play a significant role. Their study underscores the need for policies that encourage health workers to advocate for vaccinations, potentially through financial motivation, to achieve broader public health goals.

Together, these studies provide empirical evidence on the low coverage of non-NIP vaccines, especially among vulnerable population, and a comprehensive analysis of current challenges and factors affecting immunization service delivery in China. They highlight the need for nuanced strategies to address gaps in vaccine coverage and acceptance, and the potential impact of educational and policy interventions in improving public health outcomes.

Case studies

The collection presents three case studies detailing the experiences and insights gained from pilot programs aimed at introducing HPV and PCV vaccines in China and Indonesia, providing valuable experience and lessons for China and other middle-income countries (MICs).

China started to introduce free HPV vaccine in 2021 in selected pilot cities as part of the Healthy City Innovation Pilot Program. In contrast, few cities have tried to introduce PCV vaccine into the local immunization program. The two case studies on HPV vaccine introduction in Shenzhen City and PCV introduction in Weifang City are snapshots of the ongoing new vaccine introduction effort in China. A case study on the HPV vaccine pilot in Shenzhen City of China, led by Dr. Yueyun Wang, credits its success to strong government support, strategic funding, multi-sectoral effort, and effective communication, while also recognizing challenges such as vaccine hesitancy and service quality, suggesting that ongoing innovation and partnerships are essential for wider vaccine uptake [14]. The PCV case study, led by Prof. Luzhao Feng, showcases an innovative PCV13 vaccination initiative in Weifang City, Shandong Province, China, where offering the first dose for free to young children and using commercial insurance for older children led to increased vaccination rates. Despite improvements, the authors acknowledge the need to explore further innovative financing and possibly reduced-dose schedules to reach coverage levels comparable to developed countries [15].

Indonesia started to introduce PCV vaccine in 2017, with the support from the Clinton Health Access Initiatives (CHAI) team. This case study provides a comprehensive overview of the strategic approaches that overcame hurdles in the introduction of PCV vaccine in Indonesia from 2017 to 2022. Key to the program’s success were high-level political support, evidence-based decision-making, and a sustainable vaccine procurement and distribution system [16]. This case is particularly instructive for nations transitioning from The Vaccine Alliance (Gavi) support and grappling with similar challenges in vaccine finance and delivery.

Collectively, these studies underscore the critical role of governmental support, financial strategies, stakeholder collaboration, and communication in the successful introduction and scaling up of vaccination programs in MICs, while also highlighting the importance of addressing vaccine hesitancy and improving service quality to achieve broad and sustained coverage.

Lessons learned and the way forward

These eleven articles provide insight into successes and challenges of vaccine implementation across different regions and demographics. Several of the articles highlight the importance of government leadership, strategic policy making, financial incentives, and public awareness in improving vaccine coverage and equity in China. Considering the rapidly changing landscape of vaccine technology and public health policies globally and in China, supporting research on implementation strategies and practices from a system perspective is imperative. Hence, VaxLab will continue working to strengthen China’s NIP and accelerate the inclusion of WHO-recommended vaccines into the NIP. Specifically, VaxLab’s future research endeavours will focus on three key areas:

Improving vaccine financing. VaxLab will work to analyse and compare government investment in public health programs and will conduct modelling analyses to estimate saved costs if health insurance could pay for the four non-NIP vaccines—PCV, HPV, Hib, and rotavirus vaccines—and will analyze costs and prices of existing and potentially-included NIP vaccines for market shaping and business sustainability of NIP vaccine suppliers. VaxLab will also support a randomised control trial to evaluate the effect of a pay-it-forward strategy, which is an innovative vaccine financing technique designed to increase HPV vaccine coverage among school girls aged 15–18 years.

Emphasizing diversity, equity, and inclusion (DEI) in immunization. A focus on DEI is crucial for developing inclusive strategies that ensure equitable access to vaccines for all segments of the population. VaxLab will support several studies of access to vaccines in remote areas and low-income areas (such as western China) and among vulnerable populations (such as left-behind children), to explore effective ways to improve vaccine coverage and regional equity.

Maternal vaccination. Enhancing vaccine uptake among pregnant women is a vital component of maternal and neonatal health. However, awareness and acceptance of maternal vaccination are very low in China, resulting in very limited uptake of vaccines recommended for pregnant women. VaxLab will support a study led by Fudan University to map available evidence about maternal vaccination, including coverage and research gaps, that will explore effective ways to increase awareness and acceptance of maternal vaccination in China.

VaxLab will expand its geographic interest to include countries in the Southeast Asian and Western Pacific WHO regions, especially in those Gavi-ineligible MICs that face the greatest challenges in financing and delivering vaccines [17]. Research collaborations and capacity building activities will focus on strengthening the NIPs via a health system approach, and facilitating quality and accelerated new vaccine introduction. Good practices, challenges, and lessons learnt will be shared through joint efforts to improve vaccine coverage in China and other MICs.