Impact of immunization programs on 11 childhood vaccine-preventable diseases in China: 1950–2018

•11 vaccine-preventable diseases (VPDs) were examined to measure the impact of national immunization program•Most 11 VPDs exhibited dramatic declines in morbidity rate after their integration into Expanded Program on Immunization (EPI)•From 1978 2018, total life expectancy for increased by 0.79 years, and similar results obtained different age groups•Improving vaccination coverage is a key aspect controlling China To evaluate achievements China's program between 1950 we chose as representative notifiable used annual surveillance data 2018 derive disease incidence mortality trends. Quasi-Poisson polynomial regression models estimate impacts specific vaccine programs, life-table methods calculate loss expectancy, years lost, working years. The notification number was 211,866,000 from 2018. greatest occurred 1959, with 1,723 per million persons. From substantial decline observed major infectious diseases. pertussis fell 98% 126.35 1.58 million, incidences measles, meningococcal meningitis, Japanese encephalitis 99%, 98%, respectively. showed that most (EPI), while varicella paratyphoid fever, which not integrated EPI, morbidity. groups. has had great success recent decades, improving China. Vaccination been one successful cost-effective public health interventions last century saved millions people various diseases.1Ehreth J. global value vaccination.Vaccine. 2003; 21: 596-600Crossref PubMed Scopus (187) Google Scholar, 2Greenwood B. Salisbury D. Hill A.V. Vaccines health.Philos. Trans. R. Soc. Lond. B Biol. Sci. 2011; 366: 2733-2742Crossref (17) 3Piot P. Larson H.J. O'Brien K.L. et al.Immunization: vital progress, unfinished agenda.Nature. 2019; 575: 119-129Crossref (39) Scholar benefits include eradication deadly disease, smallpox,4Weiss R.A. Esparza prevention smallpox: commentary Sloane (1755) 'An account inoculation'.Philos. 2015; 370: 20140378Crossref (25) near another, poliomyelitis.5Duclos Okwo-Bele J.M. Gacic-Dobo M. al.Global immunization: status, challenges future.BMC Int. Health Hum. Rights. 2009; 9: S2Crossref Scholar,6Nathanson N. Kew O.M. emergence eradication: epidemiology poliomyelitis deconstructed.Am. Epidemiol. 2010; 172: 1213-1229Crossref (245) In 1974, World Organization (WHO) established (EPI) goal increasing among children throughout world.7Kim-Farley R.J. EPI 1990s. Programme Team.Vaccine. 1992; 10: 940-948Crossref (11) Scholar,8Schreuder Arentsen H. Matosse How important are airfreight rates packaging cost-saving efforts Immunization?.Bull. Organ. 1997; 75: 315-321PubMed contributed significantly reducing burden over past decades.9World OrganizationImmunization, vaccines biologicals.http://apps.who.int/immunization_monitoring/globalsummaryDate: 2014Google Scholar,10Muloiwa Kagina B.M. Engel M.E. al.The laboratory-confirmed low- middle-income countries since inception Immunisation 1974: systematic review meta-analysis.BMC Med. 2020; 18: 233Crossref (3) largest oldest programs world, 16 infants vaccinated each year.11Wang G. A 60-Year History Disease Prevention Control Population Publishing House, 2015Google Scholar,12Wang al.Achievements control seven targeted National across 70 years.Chin. Vacc. Immun. 25: 359-367Google Work began earnest soon People's Republic founded 1949.13Yu W. Lee L.A. Liu Y. al.Vaccine-preventable China: 1949-2016.Vaccine. 2018; 36: 8131-8137Crossref (14) Based strategies, policy requirements, implementation plan can be divided four stages first stage pre-planned (1950–1977), during main strategy implement seasonal assault vaccinations diphtheria vaccine,14Zhang Q. Han F. Nie al.Seroprevalence antibodies healthy adults China.J. Infect. 63: 441-446Abstract Full Text PDF (24) vaccine,15Zhang L. Xu Zhao al.Effect Bordetella strains, China.Emerg. Dis. 16: 1695-1701Crossref vaccine,16Gao X. Li al.Vaccine strategies Mainland China, 1951-2011.PLoS Negl. Trop. 2014; 8: e3015Crossref (45) bacillus Calmette-Guerin (BCG) tuberculosis.17Chen Z.R. Wei X.H. Zhu Z.Y. BCG China.Chin. (Engl). 1982; 95: 437-442PubMed 1978, response call WHO, Ministry proposed concept Planned suitable conditions,18Wang Z. Yang B.P. expanded immunization.Chin. 105: 443-445PubMed thereby moving work planned (1978–2000).19Lance E.R. China’s successes, challenges, healthier children.Chin. 2013; 19: 473-479Google Rapid progress made (2001–2007). During this period, cold chain system improved, controlled low level. 2001, reorganized renamed (NIP) reflect expansion its remit growing range programmatic issues introduction new vaccines.20Wang Practice Management. Medical 2006Google While five prevent diseases, NIP 14 15 including routine 12 diseases.21Chinese Center PreventionNational Program.2015http://nip.chinacdc.cn/zstd/mycx/201807/t20180731_189375.htmGoogle fourth early 2008 “Implementation Plan Expanding Plan” (hereafter referred “the Plan”).22National Committee PRCAnnouncement Implementation Plan.2008http://www.nhc.gov.cn/bgt/pw10803/200805/06e538cad856458bba92730b81e0f29c.shtmlGoogle overall comprehensively an NIP, continue maintain polio-free state, eliminate hepatitis B, further reduce VPDs. According Plan, against tuberculosis, polio, diphtheria/pertussis/tetanus (DPT), measles/DPT, A, mumps included school-age undergo regular vaccination.23National PRCNational Children. Procedures Instructions.2016http://www.nhc.gov.cn/jkj/s3581/201701/a91fa2f3f9264cc186e1dee4b1f24084.shtmlGoogle developed rapidly comprehensively, making significant contributions protecting population, VPDs, capita expectancy. Recently, although some studies have reported there no publication burdens associated Here, quantify evaluated patterns based data. We also estimated decrease caused these vaccines. when more than 11.5 cases 100,000 persons (Figure 1); about 95.25% up measles pertussis, accounting large infected patients 1960s. As gradually progressed, declined 1980s until it reached nadir 13 1989. establishment Notifiable Diseases Network Direct Reporting System (NNDNDRS) 2004 led discovery cases. general, downward trend three periods, especially periods 1). basically stable at relatively addition our analysis separately long-term trends subset six continuously monitored study period (Japanese encephalitis, diphtheria, poliomyelitis, pertussis; here called “long-studied” or VPDs). long-studied same before 1990, because other collected 1990. Unlike 1990 remained then. Similar data, highest 1959 (during period), deaths exceeded 335,700 49.96/100,000 1959; lowest 0.038/100,000 2017, represented 99.92% compared 1959. (nearly 100%) seen relevant 2). Similarly, separate revealed prior those After slowly eventually approached zero. 3) (9 11) peaked 2000, exceptions being year. Moreover, tuberculosis consistently high many areas. 1977, studied numbers meningitis 4), consistent (95.25%). top encephalitis. came group program. With realization 85% provinces, counties, townships types causing hazards changed. (in 2002) 2008) NIP. Thus, unsurprising fallen out Chinese government carried series immunization-strengthening activities; nationwide activities, put place 2010 toward eliminating measles. result, ranked sixth Figure·S1 shows whereby overall, respective increases. provincial administrative districts 2016 calculated province stages. shown Figure 5, all stage, newly initiated planning mainly vaccinations. Thereafter, took shape, did child framework. Since children's implemented nationwide, timely effective administered accordance prescribed procedures. DTP, It therefore much lower second stage. Interestingly, midwestern provinces eastern provinces. third stages, continued decline; particularly notable central regions, where dropped less 5/100,000 2016. Table 1, (for lacked epidemic 1997), (the increased), mumps, rubella confidence interval zero), considerable reductions introduced Notably, category-2 vaccines, cutoff small, such model large; therefore, compare rubella. On hand, despite subsequent through 2000s, still rise; speculated may due under-reporting verify this, combined Global Burden (GBD) adjust possibly under-reported under-ascertained GBD S2), adjusted re-establish quasi-Poisson model. This generated conclusions, support conjecture. Given strides preventing infections newborns, changes neonatal separately. Although performed using yielded result ages, (−90.11; 95% −94.79 −82.95).Table 1Impact selected diseasesDiseaseYear EPITime periodaThe availability year EPI. (years)Change (%) (95% interval)dData system.Change interval)eData estimate.Measles197820 (1969–1988)−79.66 (−87.97, −67.43)−80.74 (−88.43, −69.60)Pertussis197820 (1969–1988)−82.6 (−89.26, −73.15)−80.80 (−87.61, −71.41)Diphtheria197820 (1969–1988)−81.39 (−89.42, −69.3)−81.29 (−89.39, −69.09)Polio197820 (1969–1988)−74.50 (−87.10, −53.53)NATuberculosisbTuberculosis: available 1997 onward.1978NANANAHepatitis B200220 (1993–2012)109.30 (78.33, 146.39)1.72 (−73.75, 296.22)Hepatitis newborns200220 (1993–2012)108.59 (55.75, 182.26)−90.11 (−94.79, −82.95)MumpscMumps rubella: onward.20078 (2004–2011)28.21 (0.19, 64.48)NARubellacMumps (2004–2011)82.49 (−9.50, 287.29)NAHepatitis A200710 (2003–2012)−54.21 (−66.18, −38.68)−66.47 (−96.16, 68.24)Meningococcal meningitis200710 (2003–2012)−78.21 (−89.11, −60.13)−76.25 (−98.12, 29.49)Japanese encephalitis200710 (2003–2012)−58.27 (−72.30, −38.50)−65.26 (−95.86, 72.19)Varicella200220 (1993–2012)NA0.27 (−0.24, 0.79)Varicella200420 (1995–2014)NA0.74 (0.24, 1.25)Varicella200720 (1998–2017)NA1.4 (1.16, 1.64)Paratyphoid fever200220 (1993–2012)NA1.17 (0.53, 1.83)Paratyphoid fever200420 (1995–2014)NA2.14 (1.17, 3.12)Paratyphoid fever200720 (1998–2017)NA4.36 (2.29, 6.47)NA, available.a EPI.b Tuberculosis: onward.c Mumps onward.d Data system.e estimate. Open table tab NA, available. increase death (about 9.25 months) 6). increases following: 2.86 months; 1.95 1.83 0.09 0.50 months. effects S1. For indicator 0.01 months 1.30 1978. By 1.29 6, excluding any decreased Compared 0.11, without cause 99.1% Our time older S3) well younger (Table S2). 2016, 1,182,322 person-years; exception 2012, time. 53,137 person-years, 81,593 person-years (a 37.5%). always efforts, metric guide development assess performance.13Yu explored effect 1970s. However, differed 1965 but largely 1966. slightly, perhaps improvement NNDNDRS. terms identified, proportions substantially Successful steep smallpox campaign 1949–1952 500 doses >90% country finally elimination Routine tetanus, 1960s larger cities later rural areas country, leading drops absolute VPD 1970s, substantially: million; 99% 249.76 0.28; 32.23 0.01; 5.39 0.13. conducted Yu al. reviewed department archives serosurvey China.13Yu They found vaccine, recommendation universal use children, vaccination. completely line present findings. countries, highlighted policies. Analysis captured Vietnam's suggested 1980 2010, 5.7 26,000 prevented extended immunization.24Jit Dang T.T. Friberg I. al.Thirty Vietnam: cost-effectiveness programme immunization.Vaccine. 33: A233-A239Crossref (19) addition, Iran demonstrated positive communicable diseases.25Mokhayeri Naderimagham S. Mohammadi al.Burden diseases-measles, whooping cough-in Iran: findings 2010.Arch. Iran. 2016; 382-387PubMed morbidities contrast, Also, rise. reflected earlier stages.26Cui Drobeniuc Hadler S.C. al.Review information frame future directions control.Vaccine. 31: J79-J84Crossref (7) under-ascertainment re-established supported conclusions original except change pre- post-vaccination supports idea serious alleviated only 0.28 even better rubella, cough improve 0.11 months.27Wright J.C. Weinstein M.C. Gains medical interventions--standardizing outcomes.N. Engl. 1998; 339: 380-386Crossref (277) Here report that, contribution newborns 0.16 span nearly 0.40 0.02 who joined 2007, 0.53 0.23 herein few limitations should noted. First, following surveillance, 1960, necessarily represent rise occurrence rather gradual (e.g., reporting years).28Yang Wu Ding C. al.Epidemiological features decade SARS outbreak: observational study.Lancet 2017; 17: 716-725Abstract (111) Second, passive nature could resulted and/or true burden.29Wang Y.S. W.L. T. al.Changes notified time-series data.Infect. Poverty. 2021; 16Crossref (1) Scholar,30Jiang Dou Yan characteristics 1986 2016.J. Glob. Health. 20803Crossref (4) massive political, social, economic chaos Cultural Revolution (1966–1976). Indeed, explain sudden drop late Aside societal changes, individual behavioral factors need taken consideration examine conclusion, declining decades. Fluctuations notifications transmission prevention, treatment. continues year, current spectrum differs Strengthening together enhancement informatization coverage, will facilitate future. constructed standardized dataset extracting GBD.31Global Collaborative NetworkGlobal Study 2019 (GBD 2019) Results. Institute Metrics Evaluation (IHME), 2020http://ghdx.healthdata.org/gbd-results-toolGoogle population natural Statistical Yearbook.32National Bureau Statisticshttp://www.stats.gov.cn/tjsj/Google compiled computed spanning surveys 1998–2018 All utilized multi-stage probability selection proportional size sampling WHO guidelines.33Danovaro-Holliday Dansereau E. Rhoda D.A. al.Collecting reliable survey estimates: summary recommendations “Meeting share lessons learnt roll-out updated Coverage Cluster Survey Reference Manual set operational research agenda around surveys”, Geneva, 18-21 April 2017.Vaccine. 5150-5159PubMed website (http://apps.who.int/gho/data/node.main.A824?lang=en). Eleven category-1 selected: Two (varicella fever). historical pattern denominator. Information related sources, reports Western Pacific Region Office published papers.34Parry enters market.Bull. 92: 626-627Crossref 35Lee K. Harmer A. Ten alliance immunisation.BMJ. 340: c2004Crossref (6) 36Zheng Rodewald landscape history, classification, supply, price.BMC 502Crossref (28) 37Kane M.A. inception, achievements, implications GAVI Alliance project J15-J20Crossref define pre-vaccination (i.e., 10 year) year). Therefore, ranged 8 20 depending Under assumption analyzed entirely attributable immunization, effectiveness previous studies.38Steens Vestrheim D.F. de Blasio B.F. Pneumococcal era childhood vaccination: insights Norwegian statistical prediction study.Epidemics. 11: 24-31Crossref 39Bellino Piovesan Bella al.Determinants uptake, influenza hospital admissions elderly population; Treviso, Italy, 2014/2015-2016/2017 seasons.Hum. Vaccin. Immunother. 301-312Crossref (5) 40Richter Schmid Kanitz E.E. al.Invasive pneumococcal 10-valent conjugate Austrian program.PLoS One. 14: e210081PubMed controls, (2002, 2004, 2007 chosen corrected Dismod.MR.41Barendregt J.J. Van Oortmarssen G.J. Vos al.A generic assessment epidemiology: computational basis DisMod II.Popul. Metr. 1: 4Crossref (239) efficacy post-vaccination, covered built GBD, predict possible 1989 abbreviated method distribution groups Details calculation potential lost premature presented supplemental information. R 3.5.1 (https://cran.r-project.org/bin/windows/base/old/3.5.1/) construct models, ArcGIS version 10.2 (ESRI, Redlands, CA, USA) draw thematic map funded “ .” J.P., Y.W., W.W. designed study. Z.L., Z.W., B.Z., L.C. J.P. Y.W. processed drafted manuscript. Q.Z., S.T., W.G., L.G., revised structure paper polished language. authors critically approved final declare competing interests. http://sph.fudan.edu.cn/t/14. Download .pdf (.69 MB) Help pdf files Document Supplemental materials methods, Figures S1–S3, Tables S1 S2