National and provincial burden of varicella disease and cost-effectiveness of childhood varicella vaccination in China from 2019 to 2049: a modelling analysis.

Background: In China, varicella is the third most frequently reported vaccine-preventable infectious disease after tuberculosis and influenza, and imposes a heavy burden on families and society. To inform future immunization policy, we investigated disease burden of varicella in China and explored cost-effectiveness of different varicella vaccination strategies at national and provincial levels. Methods: A dynamic transmission model was developed to assess disease burden of varicella and the impact of varicella vaccination in China. A cost-effectiveness analysis of three alternative vaccination strategies in China's National Immunization Program (NIP) compared with no vaccination was conducted. Scenario analyses and sensitivity analyses were performed to check the robustness of the results. Findings: It was estimated that 3.35 million new varicella cases occurred in 2019, more than three times of 982 thousand cases officially reported from National Notifiable Infectious Disease Surveillance System (NNIDSS). The under-reported rate was approximately 71%. The economic analysis revealed that from the societal perspective, the incremental cost-effectiveness ratio (ICER) for one dose of varicella vaccination in NIP was US$ 2357 per QALY at the national level and it was cost-effective in 22 of 31 provinces. The ICER for one dose varicella vaccination plus a mass catch-up for unvaccinated children aged 2-11 years old would be US$ -5260 per QALY, cost-saving at the national level. The one dose plus mass catch-up NIP strategy was also cost-saving in 24 of the 31 provinces. Interpretation: Varicella incident cases were substantially under-reported in China. Varicella vaccination in the NIP could significantly contribute to reducing the burden of varicella disease. From the societal perspective, including varicella vaccination into China's NIP was highly cost-effective at the national level and in most provinces. Funding: Bill & Melinda Gates Foundation.

Cost-effectiveness of pneumococcal vaccines among adults aged 65 years and older in China: A comparative study.

We aimed to assess the cost-effectiveness and health benefits of 23-valent pneumococcal polysaccharide vaccine (PPSV23), 13-valent pneumococcal conjunctive vaccine (PCV13), and PCV13-PPSV23 sequential vaccination strategies in preventing pneumonia and other pneumococcal diseases among the senior citizens (≥ 65 years) in China. The cost-effectiveness of pneumococcal vaccines compared to no vaccination was estimated using a decision-tree Markov model from a societal perspective. Parameters including epidemiological data, vaccine efficacy and cost data were obtained from previous studies. Cases and deaths averted, quality-adjusted life years (QALYs) gained, and incremental cost-effectiveness ratios (ICERs) were presented as outcomes. Sensitivity analyses were performed to explore the uncertainty in the model. In the base-case analysis, compared with no pneumococcal vaccination, the ICERs of PPSV23, PCV13 and PCV13-PPSV23 are US$10,776.7/QALY, $9,193.2/QALY, and $15,080.0/QALY, respectively. PCV13 is the most cost-effective strategy and the only cost-effective strategy based on a threshold of the one-time national GDP per capita, whereas PPSV23 vaccine strategy is provided with the lowest cost, and PCV13-PPSV23 demonstrates the greatest impact on pneumococcal disease burden. Sensitivity analyses reveal that the results are greatly influenced by serotype coverage, vaccine efficacy, CAP incidence and vaccine prices. The PCV13 vaccination for Chinese seniors is more cost-effective than PPSV23 vaccination and PCV13-PPSV23 sequential vaccination.

PPSV-23 recommendation and vaccination coverage in China: a cross-sectional survey among healthcare workers, older adults and chronic disease patients.

BACKGROUND: 23-valent pneumococcal polysaccharide vaccine (PPSV-23) is crucial to protecting high-risk groups. This study aimed to investigate the influencing factors of PPSV-23 recommendation among healthcare workers, and PPSV-23 coverage among Chinese older adults and chronic disease patients. RESEARCH DESIGN AND METHODS: In 2019, a cross-sectional questionnaire survey was conducted in ten provinces in China among older adults aged ≥65 years, chronic disease patients aged 18-64 years, and primary healthcare workers. Multiple logistic regression model was adopted to identify the influencing factors of PPSV-23 recommendation and vaccination uptake. RESULTS: Of the 1138 healthcare workers, 46.75% often recommended PPSV-23 to target groups, and public health workers were more likely to recommend than general practitioners. PPSV-23 vaccination rate was 3.29% among chronic disease patients aged <65 years, 6.69% among older adults without chronic disease(s), and 8.87% among chronic disease patients aged ≥65 years. Multiple logistic regression revealed that only general practitioners' recommendation was associated with increased PPSV-23 coverage (p < 0.05). CONCLUSIONS: The findings highlighted the suboptimal PPSV-23 coverage rate in China and the strong association between healthcare workers' recommendation and residents' vaccination uptake. Targeted and coherent PPSV-23-related training is suggested for general practitioners to encourage effective health promotion in clinical practices.

From COVID-19 Vaccination Intention to Actual Vaccine Uptake: A Longitudinal Study Among Chinese Adults After Six Months of a National Vaccination Campaign.

BACKGROUND: Mass COVID-19 vaccination campaigns have been launched globally, but the translation from vaccination intention to actual vaccine uptake by the public remains unknown, hindering the evaluation of present promotion strategies. METHODS: Six months after the national vaccination campaign in China, a longitudinal study was conducted among the Chinese adult population, whose vaccination intention has been previously surveyed, to examine the vaccine uptake, the relationship between intention and actual vaccination, and factors associated with actual vaccination behaviors with multiplelogistic models. RESULTS: Among the total 1047 participants, 81.8% (834/936) of those who had a prior COVID-19 vaccination intention before the campaign actually received the vaccine, while 61.3% (68/111) of those without a prior intention got vaccinated. Having a prior vaccination intention, believing in vaccine safety and receiving frequent recommendations from community sources were significant predictors of vaccine uptake, while the shortage of vaccine supply would reduce the likelihood of getting vaccinated. CONCLUSIONS: Promotion interventions for vaccination intentions need to be launched well before the availability of the vaccine. Sustaining vaccination attitudes and intentions, reducing barriers (e.g. vaccine safety concerns, accessibility, affordability) and shaping vaccination behavior would be effective in closing the intention-action gap and motivating vaccine uptake.

The Acceptance of COVID-19 Vaccination Under Different Methods of Investigation: Based on Online and On-Site Surveys in China.

As Coronavirus Disease-2019 (COVID-19) vaccines became available in December 2020, increasingly more surveys were organized to examine the acceptance of vaccination, while most of them were conducted online. This study aimed to explore the difference between online and traditional on-site surveys in terms of COVID-19 vaccine acceptance. From November to December 2020, an online survey (n = 2013) and an on-site survey (n = 4,316) were conducted simultaneously in China. Multivariate logistic regression was used to identify influencing factors of acceptance, and propensity score matching (PSM) was adopted to balance the outcomes. As a result, 90.0% of the online respondents accepted COVID-19 vaccination, while it was only 82.1% in the on-site survey. After applying PSM, the acceptance rate of the on-site survey was declined to 78.6%. The age structure, residence location, education, and health status were observed as important factors in addressing vaccination acceptance, which needed to be specifically considered when designing online surveys.

Public Perceptions and Acceptance of COVID-19 Booster Vaccination in China: A Cross-Sectional Study.

Coronavirus disease 2019 (COVID-19) booster vaccination has been proposed in response to the new challenges of highly contagious variants, yet few studies have examined public acceptance of boosters. This study examined public acceptance of COVID-19 booster vaccination and its influencing factors by using the data from a self-administered online cross-sectional survey conducted in June 2021 in China. Multiple logistic analysis was used to examine the influencing factors of booster acceptance based on the health belief model (HBM). Among 1145 respondents, 84.80% reported to accept COVID-19 booster vaccination. Having COVID-19 vaccination history, perceiving high benefits and low barriers to booster vaccination, being younger (18-30 vs. 41-50), having a lower education level, being employed, and belonging to priority groups for vaccination were associated with increased odds of booster acceptance. The primary reason for refusing booster vaccination was concern about vaccine safety. The vast majority (92.8%) of respondents reported an annual willingness to pay between 0 and 300 CNY (0-46.29 USD) if the booster was not free. Our findings suggest that the acceptance rate of booster vaccination is relatively high in China, and the HBM-based analysis reveals that more efforts are needed to increase perceived benefits and reduce perceived barriers of vaccination to design effective and proper vaccination extension strategies when boosters become widely recommended.

Willingness to accept COVID-19 vaccine among the elderly and the chronic disease population in China.

A cross-sectional field survey was conducted from November 2020 to January 2021 among 7259 participants to investigate the public perception, willingness, and information sources for COVID-19 vaccination, with the focus on the elderly and non-communicable chronic disease (NCD) population. Multiple logistic regressions were performed to identify associated factors of the vaccination willingness. The willingness rate of the elderly to accept the future COVID-19 vaccine (79.08%) was lower than that of the adults aged 18-59 (84.75%). The multiple analysis didn't identify significant relationship between NCD status and the vaccination intention. The main reasons for vaccine hesitancy by the public were: concern for vaccine safety, low infection risk, waiting and seeing others getting vaccinated, concern of vaccine effectiveness and price. Their relative importance differed between adults aged 18-59 and the elderly, and between adults aged 18-59 with or without NCD. Perception for vaccination importance, vaccine confidence, and trust in health workers were significant predictors of the vaccination intention in both age groups. The elderly who perceived high infection risk or had trust in governments were more likely to accept the vaccine. Compared with the adults aged 18-59, the elderly used fewer sources for COVID-19 vaccination information and more trusted in traditional media and family, relatives, and friends for getting vaccination recommendations. To promote vaccine uptake, the vaccination campaigns require comprehensive interventions to improve vaccination attitude, vaccine accessibility and affordability, and tailor strategies to address specific concerns among different population groups and conducted via their trusted sources, especially for the elderly.

Caregivers' intentions to COVID-19 vaccination for their children in China: a cross-sectional survey.

Chinese caregivers' intentions to allow their children to be vaccinated against coronavirus disease 2019 (COVID-19) is unknown. We explored the intention rate of Chinese caregivers to allow their children to be vaccinated and examined potential influencing factors and underlying reasons for their unwillingness or hesitation. From November 30, 2020, to January 31, 2021, we conducted a cross-sectional survey of 3703 caregivers in six representative provinces in China. We assessed intention rates and correlates of caregivers' intentions to vaccinate children against COVID-19, using descriptive analyses and a multiple logistic regression analysis, respectively. In the study sample, about 84.0% of caregivers intended to get their children vaccinated for COVID-19 if the vaccine was available. In particular, 92.2% of caregivers who were willing to be vaccinated themselves for COVID-19 intended to have their children vaccinated, yet among caregivers who were unwilling (or uncertain) whether to be vaccinated, only 41.1% intended to have their children vaccinated. Older age, lower education level, and perceived safety and effectiveness of the COVID-19 vaccine were associated with increased odds of caregivers intending to have their children vaccinated. Of the six provinces included in the study, residence in a province other than Hubei increased the likelihood that caregivers would choose not to have their children vaccinated. We found a relatively high vaccination rate (84.0%) among caregivers by using a cross-sectional sample in China. Concerted efforts are needed to address caregivers' concerns about vaccine safety, especially among caregivers who do not intend to be vaccinated themselves.

Plain Language Summary: Recently, COVID-19 infection in children has increased. Although most countries have not approved the COVID-19 vaccine for children, it is likely that they will do so. There is a clear need to explore caregivers' intentions and to understand potential hesitancy as means to inform vaccination policies. We found a relatively high caregivers' intention rate to have their children vaccinated against COVID-19, and caregivers' intentions to be vaccinated themselves was associated with their own decision to have their children vaccinated. In this study, older age, lower education level, belief that the COVID-19 vaccine was safe and effective, and residence in Hubei province were associated with increased odds of caregivers intending to have their children vaccinated. Policy makers should address caregivers' concerns about vaccine safety and encourage caregivers themselves to get vaccinated before they decide to have their children vaccinated.

The associations of geographic location and perceived risk of infection with the intentions to get vaccinated against COVID-19 in China.

BACKGROUND: Vaccines are a critical tool against coronavirus disease 2019 (COVID-19) pandemic, yet little is known regarding the associations of geographic location and perceived risk with the intentions to get vaccinated against COVID-19 in China. METHODS: An on-site survey of adults aged 18 or older (n = 7261) was conducted from November to December, 2020 in China, and this survey selected six provinces based on the geographic location. RESULTS: In the total sample, 82.5% reported that they would intend to get vaccinated against COVID-19. Compared with Hubei province, respondents' intentions to get vaccinated decreased by 70% in Zhejiang, 61% in Guangdong, 87% in Gansu, and 71% in Jilin, respectively. However, within Hubei province, compared with Wuhan city, respondents' intentions to get vaccinated in other cities were not significantly different. Respondents with higher perceived risk of infection were associated with increased odds of intentions to get vaccinated against COVID-19. CONCLUSION: Our study identified priority geographic regions that need to pay attention on the vaccination campaign and help design effective immunization strategies to increase the vaccine uptake against COVID-19. More attention should be paid to adults residing farther from the epicenter of the outbreak and having lower perceived risk of infection.

The Economic Burden of Influenza-Like Illness among Children, Chronic Disease Patients, and the Elderly in China: A National Cross-Sectional Survey.

Background: The disease burden of seasonal influenza is substantial in China, while there is still a lack of nationwide economic burden estimates. This study aims to examine influenza-like illness (ILI) prevalence, healthcare-seeking behaviors, economic impact of ILI, and its influencing factors among three priority groups during the 2018-19 influenza season. Methods: From August to October 2019, 6668 children's caregivers, 1735 chronic disease patients, and 3849 elderly people were recruited from 10 provinces in China to participate in an on-site survey. The economic burden of ILI consisted of direct (medical or non-medical) and indirect burdens, and a two-part model was adopted to predict the influencing factors of total economic burden. Results: There were 45.73% children, 16.77% chronic disease patients, and 12.70% elderly people reporting ILI, and most participants chose outpatient service or over-the-counter (OTC) medication after ILI. The average economic burden was CNY 1647 (USD 237.2) for children, CNY 951 (USD 136.9) for chronic disease patients, and CNY 1796 (USD 258.6) for the elderly. Two-part regression showed that age, gender, whether the only child in the family, region, and household income were important predictors of ILI economic burden among children, while age, region, place of residence, basic health insurance, and household income were significant predictors of ILI economic burden among chronic disease patients and the elderly. Conclusions: A large economic burden of ILI was highlighted, especially among the elderly with less income and larger medical burdens, as well as children, with higher prevalence and higher self-payment ratio. It is important to adopt targeted interventions for high-risk groups, and this study can help national-level decision-making on the introduction of influenza vaccination as a public health project.

Willingness to pay and financing preferences for COVID-19 vaccination in China.

BACKGROUND: The COVID-19 pandemic has caused significant diseases and economic burdens in the world. Vaccines are often considered as a cost-effective way to prevent and control infectious diseases, and the research and development of COVID-19 vaccines have been progressing unprecedently. It is needed to understand individuals' willingness to pay (WTP) among general population, which provides information about social demand, access and financing for future COVID-19 vaccination. OBJECTIVE: To investigate individuals' WTP and financing mechanism preference for COVID-19 vaccination during the pandemic period in China. METHODS: During March 1-18, 2020, we conducted a network stratified random sampling survey with 2058 respondents in China. The survey questionnaires included out-of-pocket WTP, financing mechanism preference as well as basic characteristics of the respondents; risk perception and impact of the COVID-19 pandemic; attitude for future COVID-19 vaccination. Multivariable Tobit regression was used to determine impact factors for respondents' out-of-pocket WTP. RESULTS: The individuals' mean WTP for full COVID-19 vaccination was CNY 254 (USD 36.8) with median of CNY 100 (USD 14.5). Most respondents believed that governments (90.9%) and health insurance (78.0%) needed to pay for some or full portions of COVID-19 vaccination, although 84.3% stated that individuals needed to pay. Annual family income, employee size in the workplace, and whether considering the COVID-19 pandemic in China in a declining trend affected respondents' WTP significantly. CONCLUSION: The findings demonstrated the individuals' WTP for COVID-19 vaccination in China and their preferences for financing sources from individuals, governments and health insurance. And to suggest an effective and optimal financing strategy, the public health perspective with equal access to COVID-19 vaccination should be prioritized to ensure a high vaccination rate.