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Children with medical conditions are defined as those possessing specific physiological or disease states that may increase their risk of infection or exacerbate the severity of vaccine-preventable diseases. Such conditions can also impact the safety and effectiveness of vaccinations, often necessitating evaluations prior to immunization (1). A strategic objective of Immunization Agenda 2030 (IA2030) is to extend immunization services to “zero dose” and under-immunized children, ensuring that all children receive full benefits from vaccines (2).
In China, vaccination rates for the National Immunization Program (NIP) vaccines have reached 99% among age-eligible children (3). However, delayed and missed vaccinations are common among children with medical conditions for various reasons. These factors include a lack of awareness of vaccine-preventable diseases, uncertainty surrounding vaccination safety, restrictions stated in vaccine package inserts, difficulties in assessing medical condition severity, misperceptions regarding contraindications and precautions, and barriers related to operations and systems (1).
Immunization services are critical for maintaining and enhancing high vaccination coverage levels. Nevertheless, the current state of immunization service support for children with medical conditions in China remains unclear. In order to address this knowledge gap and lay the groundwork for potential improvements in immunization services, we conducted a study examining immunization service patterns for children with medical conditions across 31 provincial-level administrative divisions (PLADs) in China.
Between August 3 and 16, 2022, we conducted a cross-sectional, questionnaire-based survey targeting provincial-level CDC immunization program departments responsible for implementing immunization services for children with medical conditions in China. Questionnaires were electronically disseminated and collected, including questions about relevant immunization policies, development of recommendations or expert consensus statements, utilization of vaccination evaluation clinics, the structure and processes of such clinics, and the availability of relevant training programs. Additionally, we inquired about perceived barriers to and urgent demands for the provision of immunization services. The question addressing urgent demands featured eight items ranked from zero to seven, with higher scores indicating higher demand. Definitions and meanings of each question were clarified through online face-to-face interviews.
The 31 PLADs surveyed were divided into 3 distinct socioeconomic regions in China: Eastern (Beijing, Tianjin, Hebei, Liaoning, Shanghai, Jiangsu, Zhejiang, Fujian, Shandong, Guangdong, and Hainan), Central (Shanxi, Jilin, Heilongjiang, Anhui, Jiangxi, Henan, Hubei, and Hunan), and Western (Inner Mongolia, Guangxi, Chongqing, Sichuan, Guizhou, Yunnan, Tibet, Shaanxi, Gansu, Qinghai, Ningxia, and Xinjiang). Categorical variables are presented as frequencies and proportions. Analyses were conducted using R software (version 4.1.3, R Foundation for Statistical Computing, Vienna, Austria).
All 31 PLADs completed the survey. Table 1 shows specific immunization services support for children with medical conditions by region. In general, supporting services were more numerous in eastern PLADs than in central and western PLADs, especially in the use of expert consensus statements and use of vaccination evaluation clinics for certain medical conditions. There were 74 vaccination evaluation clinics in pediatric hospitals nationwide, distributed in 16 PLADs.
Indicator Eastern
(11 PLADs)Central
(8 PLADs)Western
(12 PLADs)Nationwide
(31 PLADs)P value** Local vaccination recommendations*, n (%) 1 (9.1) 0 (0.0) 0 (0.0) 1 (3.2) >0.999 Local expert consensus statements†, n (%) 5 (45.5) 1 (12.5) 0 (0.0) 6 (19.4) 0.009 Specialized training programs§, n (%) 5 (45.5) 3 (37.5) 2 (16.7) 10 (32.3) 0.353 Presence of vaccination evaluation clinics¶, n (%) 9 (81.8) 2 (25.0) 5 (41.6) 16 (51.6) 0.036 Number of vaccination evaluation clinics, n 56 6 12 74 − Defined structures and processes for evaluation clinics, n (%) 2 (18.2) 0 (0.0) 2 (16.7) 4 (12.9) 0.530 Abbreviation: PLADs=provincial-level administrative divisions; NIP=National Immunization Program. * Local vaccination recommendations represent the official guidelines, which NIP providers must adhere to when vaccinating children with medical conditions. † Local expert consensus statements, developed by expert teams, are not considered official standards. However, they serve as a foundation for NIP providers to enhance their scientific understanding of vaccination necessity, as well as to investigate the safety and efficacy of vaccinations in children with medical conditions. § Specialized training programs aim to enhance the vaccination of children with medical conditions by offering education on fundamental knowledge, professional skills, and relevant case studies. ¶ Vaccination evaluation clinics have been established to provide counseling and assessment for children with medical conditions, addressing safety concerns and the necessity of vaccination. ** The comparison of indicator rates between regions was conducted using Fisher's exact test, as the small sample size of one cell (<5) necessitated this statistical approach. “−” means data not available. Table 1. Support for immunization services among children with medical conditions by region, China, 2022.
Table 2 shows barriers to immunization service provision as perceived by PLADs. More than half of the PLADs identified the following barriers: lack of comprehensive vaccination recommendations for specific medical conditions (74.2%); absence of standardized procedures to assess the appropriateness of vaccination in certain medical conditions (74.2%); inconsistencies between official recommendations, vaccine package inserts, and published expert consensus statements (61.3%); and limited authority of expert consensus statements (54.8%).
Barrier Eastern
(11 PLADs)Central
(8 PLADs)Western
(12 PLADs)Nationwide
(31 PLADs)P value* Lack of detailed vaccination recommendations for certain conditions, n (%) 9 (81.8) 7 (87.5) 7 (58.3) 23 (74.2) 0.339 Lack of standardized procedures for evaluation of specific conditions, n (%) 7 (63.6) 7 (87.5) 9 (75.0) 23 (74.2) 0.451 Inconsistency between official recommendations, vaccine package inserts, and expert consensus statements, n (%) 10 (90.9) 3 (37.5) 6 (50.0) 19 (61.3) 0.041 Insufficient authority of vaccination expert consensus statements, n (%) 6 (54.5) 4 (50.0) 7 (58.3) 17 (54.8) >0.999 Insufficient official policy support, n (%) 3 (27.3) 3 (37.5) 3 (25.0) 9 (29.0) 0.887 Unwillingness to vaccinate children with medical conditions due to fear of adverse events, n (%) 2 (18.2) 2 (25.0) 6 (50.0) 10 (32.3) 0.239 Sustainability of services in vaccination evaluation clinics due to high operational costs, n (%) 4 (36.4) 2 (25.0) 4 (33.3) 10 (32.3) 0.897 * The rates for the barriers between regions were compared using Fisher’s exact test, due to the small sample size of one cell (<5). Table 2. Barriers to delivery of immunization services for children with medical conditions by region, China, 2022.
Table 3 shows scores and rankings of urgent demands for immunization services for children with medical conditions. All three regions indicated that the top priority is to develop detailed official vaccination recommendations for children with medical conditions.
Demand Eastern Central Western Nationwide Score Rank Score Rank Score Rank Score Rank Detailed official vaccination recommendations 6.00 1 5.50 1 5.75 1 5.77 1 Technical guidelines for vaccination evaluation 4.73 2 4.00 3 4.42 2 4.42 2 Official policy support 4.00 3 4.50 2 3.25 3 3.84 3 Use of vaccination evaluation clinics for certain medical conditions 3.55 4 2.50 5 3.25 3 3.16 4 Developing Standard Operating Procedures for Counseling, Vaccination,
and Managing Adverse Events2.82 5 3.13 4 2.75 5 2.87 5 Establishing a multidisciplinary consultation team 2.73 6 1.63 7 2.08 6 2.19 6 Training with case studies for healthcare workers 1.27 7 1.75 6 2.00 7 1.68 7 Developing public education materials 0.64 8 0.63 8 0.67 8 0.65 8 Table 3. Demands for immunization services support for children with medical conditions by region, China, 2022.
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