By the end of the second week of August, China has recorded 55,286 confirmed influenza cases, followed by Japan (7,046) and Singapore (800), according to data from the World Health Organisation (WHO)’s Western Pacific Regional Office.

In view of the possibility that China may face even worse influenza seasons in the coming years, the China-branch of the WHO has been urging China’s State Council to expand its childhood immunisation programme to include flu vaccines as part of the core vaccines that are provided at free of charge. The aim of this move is to reduce the number of severe influenza cases and influenza-related deaths among the population, especially children.

Currently, flu vaccine falls under Category 2 in China, making it an optional vaccine used in the private sector, and parents would have to pay out of pocket if they want their children to receive an annual jab. With the WHO’s new recommendation, Lance Rodewald, team leader of the Expanded Program on Immunisation of WHO China, hopes that it can highlight the importance of flu vaccine in the current medical climate. "It [flu vaccine] is an important vaccine. However, as a Category 2 vaccine, it is widely available; but not used as much as it is in other countries. It is of vital interest in the scientific community for the epidemiology in China to get influenza vaccine to be of much higher [uptake] but there's a way to go,” he said.

Fortunately, there is hope for the implementation of free flu vaccines as they have now become more readily available and affordable. In fact, Beijing city already provides free flu vaccines to children and people over the age of 60. While epidemiological evidence is sparse, Rodewald is confident of pushing for change. "You will see some cities moving forward and when they see the benefits of influenza vaccines; for example, having fewer outbreaks in schools, that will help provide good evidence for moving the vaccines into the program,” elaborated Rodewald.

The landscape of influenza vaccination across China

Spurred by the need for a reconsideration of influenza vaccination programmes, the landscape of China’s influenza vaccination has not been without its hurdles.

Between 2004 and 2014, average national vaccination coverage for influenza was just 1.5 – 2.0% with no concrete data present on age-specific coverage rates throughout the country. Even in areas where free influenza vaccination is provided, namely Beijing, the vaccination rates for the elderly in 2010 was only 43.1%, which fell far below the World Health Assembly’s target. These statistics served to highlight that financial barriers were not the only hurdles in place rather, a lack of awareness among the public about the influenza pandemic served to hamper the nation’s efforts.

Vaccination is the most effective way of preventing influenza – but, it has to be administered annually and may incur a high cost as a government-funded programme.
Vaccination is the most effective way of preventing influenza – but, it has to be administered annually and may incur a high cost as a government-funded programme.

Had population awareness not been a problem, there is still the matter of cost. According to a study conducted across provincial Centers for Disease Control and Prevention (CDC) in 2014 and 2016, it is estimated that a national programme on influenza vaccination would cost USD757 million. This figure alone accounts for close to 5% of the nation’s government health expenditures. Despite the high cost, implementing a national influenza vaccination policy has the potential to reduce influenza-related morbidity and mortality which would then help offset the cost of implementing the programme.

Current government efforts to spread influenza vaccination comprise of regular reimbursement policies provided by the local governmental Financial Department of Basic Social Medical Insurance (BSMI). Eligible groups include subgroups at a certain age, school children, health-care works and insured persons under the BSMI. But, even then, the coverage is only limited to certain regions and is not available nationwide. As appraised by the study, such small-scale policy approaches failed to increase the national uptake of influenza vaccination.

The importance of increasing national uptake

While it is easy to dismiss the importance of vaccine immunisation – partly due to its seasonal nature and relatively harmless effects on adults – the influenza pandemic is only going to continue growing and together with it, the threat on vulnerable populations.

Annually, seasonal influenza epidemics cause 3 – 5 million cases of severe illness that result in over a quarter of a million deaths every year. Worldwide, over 40% of countries have listed seasonal influenza vaccination on their National Immunisation Schedule, including several countries in the South-East Asia region. Despite that, influenza vaccination is not included on the National Immunisation Programme in China, which has led to one of the lowest national uptake levels of the vaccine in the region.

Future directions and improvements

Moving forward into the future, the need for China to have a nationwide influenza vaccination programme is greater than ever, despite the substantial financial investment required.

Earlier in February, the State Council released a new guideline governing the development, management and recommendation of vaccines for use in China. The guideline highlights the importance of consulting experts and evidenced-based medicine for new and existing vaccines to be implemented as part of the government’s Expanded Programme on Immunisation.

Identifying the challenges faced by the government, the Chinese Centre for Disease Control and Prevention (China CDC) has suggested several directions and improvements towards implementing a national influenza vaccination programme. This includes keeping a closer watch at the rate of influenza vaccination in people over the age of 60, and aiming for a vaccination rate above 75% – as they are the most vulnerable to severe influenza cases. While transitioning towards a national programme, the government can also work towards expanding its regional subsidisation programmes by increasing the number of individual and groups eligible for reimbursement.

In order to ensure the success of the national programme, careful cost-effectiveness analysis is required to identify the most efficient way for the government to implement such a sweeping change in policy. More than finances, the government also has to ensure that the implemented program is able to cover the vast area of the state, improve national uptake and community awareness. MIMS

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