China’s poorest families pay out-of-pocket for vaccines that are free in many low-income countries, and a new research partnership aims to give policymakers the evidence they need to change that. The problem is stark: China divides its licensed vaccines into two categories. Category I vaccines are publicly funded nationwide, but Category II vaccines—including those for pneumococcal disease, influenza, and human papillomavirus—are not. Users pay for them directly, creating deep inequity. Roughly 150 million people in China live on less than $2 a day, and 180,000 children under five die each year. These are the people most underserved by current vaccine financing, despite carrying the highest health burden. The Chinese government is considering moving some Category II vaccines into Category I, but needs robust evidence on health benefits, budget impact, and cost-effectiveness before committing the vast financial and manufacturing resources required. The EPIC group—bringing together the London School of Hygiene & Tropical Medicine, Public Health England, Fudan University, and the China CDC—will generate that evidence. If successful, the research could directly reshape vaccine financing policy in China, making life-saving vaccines accessible to millions who currently cannot afford them. It will also help maintain public confidence in vaccines, a critical concern after recent scandals over improperly stored Category II vaccines sparked safety rumours.
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1) Institutional environment LSHTM hosts the largest group of epidemiologists in Europe. It has been one of the main academic providers of research to inform UK vaccination policy for decades, and was awarded a £4m 5-yr grant to run the NIHR HPRU in Immunisation with PHE. LSHTM’s Vaccine Centre has >100 staff working on all aspects of vaccine research. PHE collects and analyses surveillance data on vaccination in England, evaluates the programme’s outcomes and hosts the Secretariat of the Joint Committee on Vaccination and Immunisation (JCVI), the UK’s expert committee on vaccination. Many named EPIC applicants (Jit, Ramsay, Scott, Edmunds, Baguelin) are members and/or regular presenters on JCVI and its subgroups. Although LSHTM and PHE have tremendous strengths in UK vaccine research, they have developed links with China more recently, principally with China CDC and Fudan. These personal links are now sufficiently well-established to propose a collaborative platform to build capacity for evidence-based decision-making on immunisation. China CDC is responsible for infectious disease surveillance, implementing vaccination programmes, conducting research, developing evidence-based guidelines for infectious disease control, and providing scientific evidence to inform immunisation policy by China’s National Health and Family Planning Commission (NHFPC). Fudan is one of China’s top 5 universities, hosts the Laboratory of Public Health Safety of the Ministry of Education and is a main academic provider of applied health and health economics research to inform evidence-based policy. Both organisations seek to strengthen capacity in China for the evidence-to-policy pathway for immunisation. 2) Broad research programme and fit with global health agenda Access to new and underutilised vaccines in low-income countries has dramatically improved since Gavi, the Vaccine Alliance, was launched in 2000. Uptake in middle-income countries has lagged behind because they are mostly not eligible for Gavi support. The prime example is China, where vaccines with universal access in many low-income countries (eg. pneumococcal, influenza and human papillomavirus vaccines) are paid for by users out-of-pocket, leading to inequity in uptake (Hou et al., 2014). The rapid growth of China’s middle class in coastal cities hides huge socioeconomic and health disparities; 150m people live on <$2/day and 180,000 children <5y die each year. These people are underserved by the current vaccine financing policy despite having the highest health burden (Cortez et al., 2014). Licensed vaccines in China are divided into Category I (publicly funded nationwide) and Category II (licensed but not publicly funded). China is considering moving some Category II vaccines to Category I, to maximise health impact particularly for socioeconomically vulnerable people who cannot afford Category II vaccines. Such moves will vastly increase the financial and manufacturing resources needed to supply the large Chinese population. Hence a pre-requisite for funding is evidence of the potential health benefits, budget impact and cost-effectiveness of broader vaccine uptake. In addition, sufficient and reliable public demand for vaccines is needed so that local manufacturers will ensure a reliable vaccine supply. Maintaining public confidence in vaccines is vital in the wake of recent scandals about improperly stored Category II vaccines that have given rise to safety concerns and rumours (Qiu et al., 2016). The UK is a world leader in conducting applied vaccine research and using it in immunisation policy. Our proposed Evidence to Policy pathway to Immunisation in China (EPIC) is a Global Health Research Group that brings the two principal research actors in the UK pathway (LSHTM and PHE) in collaboration with their Chinese counterparts (Fudan and China CDC). EPIC will conduct research directly relevant to supporting policy-makers in making decisions to ensure a
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