China was affected by all four pandemics in the past century and the 1957 and 1968 pandemics were first identified in China (Table 1). The virus with the highest pandemic potential to date among all influenza viruses assessed, avian influenza A(H7N9), was also identified in China. With 20% of the world’s population and the world’s largest poultry production of 5 billion chickens and ducks per year, China plays a critical role in global influenza pandemic preparedness through continuous surveillance for early detection of novel viruses.
Pandemic Influenza A Virus Subtype Area of First Detection Estimated Mortality Worldwide Estimated Mortality in China Population in China 1918 H1N1 Unclear 20-100 million(1) 4-9.5 million(4) 460 million 1957 H2N2 Southern China Singapore/Hong Kong, China 1-4 million(7) 225,000-900,000* 646 million 1968 H3N2 Hong Kong, China 1-4 million(7) 220,000-881,000* 782 million 2009 H1N1pdm09 North America 100,000-400,000(13) 32,500(12) 1.33 billion * No published data available; mortality estimates in China for pandemics in 1957 and 1968 were extrapolated by multiplying the global mortality estimates and the proportions of China’s population size in the world.
Table 1. Estimated mortality of the past influenza pandemics.
In the past several decades, China has made significant progress in responding to influenza pandemics through public health investment and infrastructure development resulting in an influenza surveillance network covering most of the nation (Figure 1). China’s response to the H7N9 epidemics was notable for close public health collaborations with WHO and other international organizations in regular, joint risk assessments to enable the timely dissemination of data to the international community. Additionally, China has demonstrated interest in coordinating surveillance and response efforts with regional partners, and it has the capacity to implement sweeping measures with central government support, such as mass poultry vaccination.
Figure 1. Influenza pandemics, scientific discoveries and China’s influenza-related capacity milestones, 1918–2018.
Despite these advances, key challenges remain. Using WHO’s “Checklist for Pandemic Influenza Risk and Impact Management” and U.S. CDC’s “Preparedness and Response Framework for Influenza Pandemics”, China CDC influenza experts summarized recent progress, remaining challenges and proposed actions in five core components of pandemic preparedness (Table 2).
Subject Remaining Challenges Planned Actions Political Commitment - Underinvestment in CDC human resources contributing to difficulties in recruiting and retaining highly qualified public health professionals
- Inadequate emphasis on pandemic preparedness at higher government levels due to competing health priorities
- Increase financial investment in the public health system in China particularly with respect to recruiting and retaining highly qualified public health professionals
- Prioritize pandemic preparedness and develop an updated national influenza pandemic preparedness plan
Multisector Coordination - Inconsistent data sharing between animal and human health sectors
- Insufficient communication between clinicians and public health professionals
- Convene regular multi-sectoral systematic planning meetings during inter-pandemic periods to promote a One Health approach to influenza
- Disseminate key public health messages to clinicians through multiple approaches (e.g., medical education; continuing education; social media)
- Develop mechanism for clinicians to communicate with public health professionals (e.g., clinician hotlines; conferences on cross-cutting topics for both public health professionals and clinicians)
Influenza Vaccination - Significant underuse in all high-risk groups
- Inadequate awareness of the influenza vaccine in both health care workers and the public
- Conduct mass media campaigns and continuing education to increase awareness of influenza vaccine in both health care workers and the public
- Develop strategies to increase influenza vaccination in health care workers
- Develop strategies to encourage health care workers to recommend seasonal influenza vaccine to high risk patients
- Expand adult immunization services
- Develop free influenza vaccination policy for high risk groups
○ Explore whether insurance can be used to pay for the influenza vaccine for the general public
Medical Care and Countermeasures - Insufficient healthcare surge capacity
○ In the 2017-18 influenza season there were:
● Temporary antiviral shortages
● Hospitals overrun with patients
● Too few ventilators
- Insufficient knowledge of how to prevent, test for and treat seasonal influenza illness, including lack of knowledge about hospital acquired infections
- Improve infrastructure and operational standards at all hospital levels
- Improve preparedness and continuity of clinical capacity at all levels (through regular training, continuing education etc.)
- Implement early warning systems and develop plans for taskforce management to respond to unexpected surges in healthcare utilization during the influenza season
- Improve clinical practice for seasonal influenza prevention, testing and treatment (through regular training, continuing education etc.)
- Promote vaccination and PPE among healthcare workers
Risk Communication - Lack of an official technical framework to communicate seasonal influenza intensity, severity and risks - Develop an influenza intensity and severity framework based on data collected in recent influenza seasons
Table 2. Remaining challenges and recommended actions for influenza pandemic preparedness in China.
After the 2003 SARS outbreak, recent avian influenza outbreaks and the 2009 H1N1 pandemic, China increased political commitment and financial resources for preventing infectious diseases, enhancing influenza surveillance and response capacity, and expanding the CDC system. As of November 2017, China CDC consisted of 3,481 units and 877,000 public health professionals serving at all levels of government. In addition, a web-based national notifiable infectious disease reporting system was developed to increase timely case reporting.
Nevertheless, growing public health needs have stretched the still limited investments in China’s public health system. Low salaries are a significant barrier to the recruitment and retention of high quality professionals, and recently, CDC staffing at all levels has declined. In addition, competing health priorities potentially interfere with high level Chinese government commitment to pandemic preparedness. Improved CDC human resource development is essential, in addition to the government’s prompt endorsement of an updated national influenza pandemic preparedness plan.
As demonstrated during the recent H7N9 epidemics, China has the capacity to implement sweeping measures and coordinate actions across government levels, sectors, and agencies if prioritized by the central government. For example, mobilization of multiple sectors facilitated mass poultry vaccination, with >85% of all poultry receiving the bivalent H5/H7 vaccine annually since 2017. (16) Nevertheless, intergovernmental coordination challenges remain. Improving data sharing and coordination between human and animal health sectors will facilitate a One Health approach to influenza, while enhancing communication between clinicians and public health professionals will improve early detection and the use of influenza vaccine and antiviral medications.
Seasonal influenza immunization infrastructure is critical for pandemic preparedness to allow efficient, rapid vaccination with pandemic vaccine. Despite China’s domestic seasonal influenza vaccine production capacity, influenza vaccine coverage in China is low (<2%) (17), even among high risk populations recommended for vaccination by China CDC. National policy to encourage influenza vaccine use may increase healthcare worker and public awareness of the vaccine, promote adult immunization infrastructure development, and better prepare China for the next pandemic.
In the past decade, China has increased its capacity to diagnose, manage, and treat avian influenza infections. Gaps remain in testing and treating patients with seasonal influenza. Moreover, during the severe 2017–2018 influenza season, the healthcare system was overwhelmed due to insufficient clinical surge capacity, and several cities reported antiviral medication shortages. Improving preparedness will entail upgrading hospital infrastructures, expanding antiviral stockpiles, building logistical capacity, and improving staff surge capacity. In addition, increasing influenza vaccination coverage and use of personal protective equipment among healthcare workers may protect frontline staff and prevent nosocomial infections.
Risk communication has improved since the 2003 SARS outbreak. During the H7N9 epidemics, China’s key government ministries, led by the State Council, collaborated to develop and disseminate H7N9 prevention and control messages through traditional and social media platforms. Government spokespersons provided timely, transparent information-sharing. The 2017–18 influenza season, however, revealed the need to strengthen risk communication about the intensity and severity of influenza seasons using influenza surveillance data.
Progress and Remaining Challenges in Pandemic Preparedness and Response
Medical Care and Countermeasures