The Duke Project Behind China’s Move to Expand Immunizations

For decades, China has had a gap in its efforts to immunize children against infectious diseases. Now, with the encouragement and support of a Duke research team, the world’s most populous country appears poised to fill it.

China’s National Immunization Program, which sets standards for childhood immunizations routinely given across the country, currently does not include a handful of vaccines considered essential by the World Health Organization, including vaccines for human papillomavirus (HPV), Haemophilus Influenzae Type B (Hib) and pneumococcal and rotavirus infections. Without government funding, those vaccines are expensive to consumers, creating huge disparities in disease protection, explains Shenglan Tang, M.D., a global health professor at Duke and Duke Kunshan Universities.

In 2020, Tang established the Innovation Lab for Vaccine Delivery Research, with support from the Bill & Melinda Gates Foundation, to study possible ways to further optimize China’s vaccine delivery. Housed at Duke Kunshan University and involving researchers with the Duke Global Health Institute, the lab has put out multiple papers and reports laying out the case for adding the four WHO-recommended vaccines to the national program.

Those arguments appear to be gaining traction. In December 2022, China’s government issued a strategic plan that calls for expansion of the NIP, which could signal the first addition of new vaccines to the program since 2008.

 “It’s the first-ever reference to NIP expansion in a top-level national strategic plan,” says Tang. The move “provides a great opportunity to advance vaccine development and delivery” in the country.

Expanding access to free or low-cost vaccines could help China address gaps in its protection against epidemic infections, especially for children in rural areas. One study led by researchers from Zhejiang University found that less than a third of children who remain in rural areas after their parents migrate to cities – so-called “left-behind” children – have been immunized with three or more of the WHO-recommended vaccines, compared to 72 percent of children in urban areas.

China’s endorsement of additional vaccines could also spur efforts to control the spread of HPV, the leading cause of cervical cancer. China accounts for about 17% of global cervical cancer deaths, and the country has taken steps to improve screening for the virus among women and young girls. Several local and provincial governments have already moved to include free HPV vaccines in local immunization programs, and inclusion in the NIP would certainly accelerate that change, notes Tang.

The Duke project, known as the VaxLab, has taken a unique approach, combining traditional academic research with a focus on outreach and policy advocacy, Tang says. Researchers have worked closely with Chinese universities and government think tanks to build evidence for vaccine expansion and work out technical details around how it can be accomplished.

Chao Ma, M.D., director of the evidence-based immunization policy branch of the National Immunization Program for China’s Centers for Disease Control and Prevention says that any decision concerning the introduction of new vaccines into the NIP must be rooted in science. “A number of studies and policy reviews supported by the VaxLab at DKU have filled in the gaps where the robust evidence is insufficient and badly needed for the Chinese policymakers,” he says.

The VaxLab has also enlisted a team with the Peking University School of New Media to engage with high-level journalists around the country to encourage understanding and support for vaccine expansion.

“Our impact especially concentrates on generating and compiling scientific evidence for advocacy, an area heavily neglected by other players in the field,” says Tang. “We believe the advocacy efforts have played an important role in making the change happen.”

With that landmark in sight, the VaxLab is continuing to evaluate barriers to scaling up all WHO-recommended vaccines in China, including potential shortfalls in government financing, supply chain and the healthcare workforce.  Tang also expects what the lab learns will be useful to other countries in Southeast Asia that are looking to bolster routine immunizations.