The whole-of-society approach of mass COVID-19 vaccination in China: a qualitative study

doi:10.21203/rs.3.rs-1975368/v1

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The whole-of-society approach of mass COVID-19 vaccination in China: a qualitative study

https://doi.org/10.21203/rs.3.rs-1975368/v1

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published 30 Dec, 2022

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Background It is vital to summarize the experiences of mass COVID-19 vaccination practice in countries with high vaccination coverage and provide implications for other countries. This study aimed to investigate COVID-19 vaccination system and summarize the implementation experiences from health system perspectives in China.

Methods We conducted a qualitative study to summarize the implementation experiences from health system perspectives in five representative cities in China late 2021. Semi-structured interviews and COVID-19 vaccination policy documents were collected and coded by thematic analysis approach. Interview guideline was developed according to six building blocks of health systems framework proposed by the WHO, including leadership and governance, health workforce, vaccination service delivery, financing, access to vaccines, and information system; and a new system building block, vaccination mobilization and communication, was added to the interview guideline.

Results Totally 61 participants (nine vaccination program directors of CDCs, four government staffs, and 48 vaccination service workers) were interviewed. We found that China adopted a whole-of-society approach with adequate government engagement and linked health and non-health sectors as a whole to promote COVID-19 vaccination. Key measures included the collaboration of multi-system and multi-department from the governance perspective, allocation of sufficient health workers and resources, large-scale vaccination mobilization and communication, expansion of vaccine financing channels, localized production, and digital information systems. With vaccination system strengthening, the two-doses vaccination coverage reached 89.5% as of July 2022.

Conclusions Our study stresses the importance of a government-led whole-of-society approach to promote mass vaccination, and the low vaccination coverage among the elderly should be paid the highest attention. The experiences and lessons from China may serve as a reference for other countries.

COVID-19 vaccine

mass vaccination

vaccination system

whole-of-society

qualitative study

Mass COVID-19 vaccination has been in progress globally since the approval of COVID-19 vaccines. High vaccination coverage can be achieved through both vaccine acceptance from the public and efficient vaccination services delivery system. Due to the enormously large population, there were universal challenges for each country to utilize the current vaccination system to support mass COVID-19 vaccination. These challenges included the shortage of health workforce^[1], lack of manufacturing scalability^{[1, 2]}, differentiated accessibility and affordability^{[1, 3]}, vaccine hesitancy^[4–6], etc. Low- and middle-income countries have faced greater challenges^[7] due to their inefficient vaccination system, with gaps such as poor infrastructures to transport vaccines^[8], limited funds and operational mechanisms for surveillance^[9]. Thus, it is of great importance to summarize the experiences of mass COVID-19 vaccination in countries with high vaccination coverage and help promote COVID-19 vaccination in other countries. However, most studies analyzed COVID-19 vaccination willingness and coverage from the recipient perspectives^[10], and few studies investigated vaccination service delivery system from the provider perspectives.

As of July 2022, 3.47 billion doses of COVID-19 vaccines had been administered in China, and 89.5% of Chinese had completed their initial two-doses vaccination protocol^[11]. The full vaccination rate in China was higher than that in many countries or regions such as the US (67.0%), the UK (74.7%), Canada (82.5%), Australia (83.7%), the European Union (73.2%), and the worldwide coverage (61.2%)^[12]. The high vaccination rate was fueled by the COVID-19 vaccination system in China, which was strengthened to meet the huge vaccination demands.

This study aimed to investigate COVID-19 vaccination system and summarize the implementation experiences from health system perspectives in China. China’s experiences and lessons may serve as a reference for other countries in the promotion of COVID-19 vaccination.

Study design and data collection

We conducted a qualitative study in five representative cities in China during late September to early November 2021. One megacity, two prefectural-level cities, and two county-level cities were selected to represent different socio-economic layers in China. The five cities covered the eastern, central, and western regions, and urban and rural areas of China as well. In each city, we interviewed 1 ~ 2 immunization program directors of local Center for Disease Control and Prevention (CDC), one government staff at community level who participated in COVID-19 vaccination campaign, and 9 ~ 12 vaccination service workers from three community health centers where vaccination sites are located. In each community health center, we interviewed one director of health center, one director of vaccination site, one vaccination physician or nurse, and one pediatrician for pre-screening and response to side effects following vaccination.

Semi-structured interviews, which lasted between 30 and 60 minutes, were conducted with all participants mentioned above. Each participant was informed of the purpose of this study and voluntary participation and was assured of the confidentiality of the interviews. Written consents were obtained from participants, and interviews were digitally recorded and then transcribed verbatim. Among 63 individuals invited, 61 agreed to participate in this study, including 9 vaccination program directors, 4 government staff at community level, and 48 vaccination service workers (9 directors of community health centers, 13 directors of vaccination sites, 15 vaccination physicians or nurses, and 11 pediatricians) (Table 1).

Table 1

Characteristics of study participants (N = 61)
Characteristics	n (%)
City levels and locations
Megacity in eastern region	12(19.7)
Prefectural-level city in central region	8(13.1)
Prefectural-level city in western region	14(23.0)
County-level city in central region	13(21.3)
County-level city in western region	14(23.0)
Occupation
Immunization program director at CDC	9(14.8)
Government staff at community level	4(6.6)
Community health center
Director	9(14.8)
Vaccination clinic director	13(21.3)
Vaccination physician or nurse	15(24.6)
Pediatrician	11(18.0)
Sex
Male	16(26.2)
Female	45(74.8)
Age (years)
< 30	4(6.6)
30–40	27(44.3)
40–50	23(37.7)
≥ 50	7(11.5)
Education
High school or below	4(6.6)
College	17(27.9)
Bachelor’s degree	37(60.7)
Postgraduate	3(4.9)

In addition to qualitative review, we collected COVID-19 vaccination policy documents at national, provincial, and city levels. We also collected the numbers of daily doses and cumulative doses administered per 100 people starting from COVID-19 vaccination rollout in China.

Interview guidelines

Our interview guideline was developed according to six building blocks of health systems framework proposed by the World Health Organization (WHO)^[13], including leadership and governance, health workforce, vaccination service delivery, financing, access to vaccines, and information system. Different from medical services, it is necessary to promote the awareness and acceptance of vaccination as a preventive measure^[14]. Therefore, we added a new building block to the original health systems framework - vaccination mobilization and communication.

We investigated how to strengthen the vaccination system and improve these seven building blocks of health system to meet the massive demands for COVID-19 vaccination in China. Leadership and governance involve ensuring the existence of policy frameworks combined with effective oversight, coalition building, regulation, attention to system design and accountability. We focused on the overall strategy and the design of COVID-19 vaccination system, oversight of the vaccination campaign, and cross-departmental accountability and collaboration for the vaccination process. For health workforce, we investigated how health workers were efficiently allocated and trained in response to vaccination demand and subsequent side effect monitoring. For vaccination service delivery, we investigated how to deliver vaccination services to meet the needs of diverse populations, such as community residents, internal migrants, and company staff. For vaccination mobilization and communication, we investigated how to inform the public of knowledge on COVID-19 vaccines and mitigate vaccine misinformation to address vaccine hesitancy. For financing, we investigated how to raise adequate funds, and who paid for the COVID-19 vaccines and vaccination. For access to vaccines, we investigated the production, procurement and distribution of COVID-19 vaccines and consumables. For information system, we asked about how vaccine circulation and vaccination records were tracked, and how side effects were monitored. In each system building block, we investigated the difficulties and solutions in COVID-19 vaccination campaign.

Data analysis

Interviews were audio-recorded and transcribed. Thematic analysis approach^[15] was applied to analyze the interview transcripts and vaccination policy documents by NVivo, version 12. Transcripts were coded for general topics used to guide the interviews and codes were continually refined during the coding process. We then derived common themes based on the respective codes across participants and synthesized them according to the above-mentioned seven system building blocks. One researcher coded all of the data and a second researcher reviewed a subset of the coding, with discrepancies discussed until reaching consensus. When necessary, we reviewed the raw data and took the context into consideration, to make sure that the themes were consistent and coherent. We also described the trends of daily doses and cumulative doses administered per 100 people.

Leadership and governance

Efficient leadership and clearly positioned responsibility are priorities to mass COVID-19 vaccination. In each interviewed city, a specific leading group of COVID-19 vaccination was established to develop local strategies and coordinate the implementation of COVID-19 vaccination. With effective governance, responsibilities were clearly defined for different government departments. First, the governments’ community committees shouldered the main responsibility for vaccination mobilization and communication for community residents. Each ministry such as health ministry, education ministry, and transportation ministry, was responsible for vaccination mobilization and communication for workers in the responding industry. Second, the local CDCs were responsible for supply and distribution of COVID-19 vaccines, training of vaccination service workers, and technical guidance for vaccination. Third, community health centers and general hospitals undertook the main responsibility of vaccine injection work. Vaccination sites at health centers and hospitals needed to check the number of target vaccination individuals with community committees and report the vaccination progress to local CDCs every day (Table 2).

Table 2

Seven building blocks of COVID-19 vaccination system strengthening in China
Building blocks	Practices for strengthening vaccination system
Leadership and governance: how to guarantee efficient leadership and clearly positioned responsibility?
Leading body	Establish a leading group to oversee the implementation of mass vaccination, including workforce, mobilization and communication, service delivery, vaccine supply, etc.
Cross-departmental accountability	Governments’ community committees and ministries responsible for vaccination mobilization and communication; CDCs for vaccine supply, staff training, and technical guidance; community health centers and hospitals responsible for vaccination, and daily update vaccination demand data from governments and report vaccinated amounts to CDCs.
Vaccination strategy	Two-step vaccination strategy with the priority orders of key groups maintaining social functions first, followed by the public.
Health workforce: how to address the shortage of vaccination workforce?
Workforce allocation	Health workers are allocated to participate in vaccination services after training and qualification exam; each vaccination site is equipped with government personnel, security, and volunteers.
Training	CDCs are responsible for COVID-19 vaccination training and capacity assessment for medical workers.
Responsibility	Doctors for pre-check, registration, and medical emergency at vaccination sites, while nurses for injection and vaccine management.
Incentive	Economic and non-economic incentives for medical workers to engage in the additional vaccination work.
Vaccination service delivery: how to improve the availability of COVID-19 vaccination services?
Vaccination sites	Traditional vaccination sites, new vaccination sites in hospitals, and temporary vaccination sites as needed.
Flexible services	Vaccination in health centers or hospitals for residents, door-to-door vaccination for enterprise institutions and schools, and vaccination at airport and railway stations for migrant population.
Appointment	Online appointment through various platforms, appointment through community or the employer, and on-site appointment.
Treatment of side effects	Doctors from hospitals shoulder the medical emergency and treatment of side effects following vaccination.
Vaccination mobilization and communication: how to address COVID-19 vaccine hesitancy?
Propaganda and mobilization	Rapid, largescale, and accessible publicity of COVID-19 vaccination on the internet and TV; publicity within institutions and industries by the corresponding government departments; notification by phone call and message, flyers and brochures; household screening by grassroots government staffs to find the unvaccinated.
Incentive	Incentives for the vaccinated such as living necessities for free or cash.
Fight misinformation	Health departments identified and timely refuted vaccine misinformation through the official websites, traditional media, and social media platforms.
Vaccine financing: how to raise adequate funds for the COVID-19 vaccines and vaccination?
Free of charge	COVID-19 vaccination is free for the public. The 70% of fees for COVID-19 vaccines and vaccination was directly covered by social health insurance, while the remaining was funded through reallocated general taxation.
Incentive for workers	Vaccination service fees for workers as incentives.
Access to vaccines: how to ensure adequate supply and distribution of COVID-19 vaccines?
Procurement and distribution	Provincial CDCs responsible for unified procurement and coordinated distribution of COVID-19 vaccines.
Management and inventory	Digital tracking of vaccines by scanning code for each in and out of storehouse. Daily report of the vaccinated amount and inventory for each vaccination site.
Supply of consumables	Vaccination sites responsible for purchasing syringes and other vaccination consumables which are paid by medical insurance funds.
Information system: how to track COVID-19 vaccine circulation and side effects?
Vaccination tracking	Establish vaccine circulation and vaccination management information system. Each vaccine dose is tracked from production to vaccination by digital tracking code, and individual vaccination records are recorded and stored in this system.
Side effect record	Information system for recording and reporting side effects following immunization.

To maintain the society and economic development, China adopted a two-step strategy for COVID-19 vaccination rollout (Fig. 1). The first step was to implement emergency vaccination for key population groups: one group is people at high risk of occupational exposure including health workers, community care workers, and those at risk of overseas infection such as airport staffs; the other group is workers in essential positions of maintaining the basic society operation including workers engaged in national security, production and supply of daily essentials. With the improvement of vaccine supply capacity and the update of the clinical trials data of COVID-19 vaccines, the vaccination strategy moved to the second step. Vaccination expanded to the public and high-risk groups with a priority order of 18–59 age group, high-risk groups (individuals aged 60 + or with health conditions), 12–17 age group, and 3–11 age group. People aged 60 + and / or with multiple chronic conditions were given the lower priority than people aged 18–59, partially due to lack of inactivated vaccine trial evidence among the elderly.

Health workforce

Herd immunity means a widescale targeted population for COVID-19 vaccination, which requires a large number of vaccination workers to handle the work of pre-check, registration, injection, medical emergency, vaccine management, etc. To address the shortage of vaccination workforce, health workers in community health centers and general hospitals who had never engaged in vaccination services were allocated to participate in COVID-19 vaccination. All of them were required to attend online or on-site COVID-19 vaccination trainings organized by local CDCs. The COVID-19 vaccination trainings included preparation and implementation, operation, treatment to suspected side effects following vaccination, information reporting, COVID-19 vaccines management, etc. A specific qualified vaccination certificate would be offered to them after passing the qualification exam.

Those health workers needed to undertake both COVID-19 vaccination and their routine work. Therefore, almost all the qualified doctors and nurses participated in the mass COVID-19 vaccination and worked in shifts, and they would receive subsidies and incentives for this additional responsibility. The doctors mainly took responsibility for pre-check, registration, and medical emergency, while nurses were mainly responsible for injection and vaccine management. Medical emergency and treatment to side effects following vaccination were undertaken by doctors from general hospitals for security purposes. The amount of vaccination workforce in each vaccination site would be adjusted according to the vaccination demands. Usually, there were 15–20 vaccination workers for 3–5 vaccination units in community health center and around 30 vaccination workers for 8–10 vaccination units in the large temporary vaccination site to meet the great demands (Table 3). A vaccination unit includes pre-check, registration, injection, and medical emergency. In addition to vaccination workers, each vaccination site would also be equipped with government staff at community level, security personnel, and volunteers as assistance.

Table 3

Setting-up and services delivery of COVID-19 vaccination sites
Type of vaccination site	Location	Responsible organization	Vaccination unit^#	Allocation of workers
Traditional or mobile vaccination site	Community health center or community	Community health center	3–5 units	1) Around 15 health workers: 2 for overall administration, 3 for pre-check, 2 for registration, 4 for injection, 2 for medical emergency^*, and 2 for vaccine management. 2) Around 2 government staffs at community level for the collaboration between vaccination site and community and organizing the vaccinated individuals. 3) Around 2 security personnel or volunteers for maintaining the order of the vaccination site.
Large temporary vaccination site	Giant stadium, outdoor square, airport and railway station, hospital, etc.	General hospital	8–10 units	1) Around 30 health workers from hospitals: 3 for overall administration, 7 for pre-check, 6 for registration, 9 for injection, 3 for medical emergency, and 2 for vaccine management. 2) Around 2 government staffs at community level for the collaboration between vaccination site and community and organizing the vaccinated individuals. 3) Around 5 security personnel or volunteers for maintaining the order of the vaccination site.
* Doctors from general hospital are dispatched to vaccination sites for medical emergency and treatment of side effects following vaccination.
# A vaccination unit includes pre-check, registration, injection, and medical emergency.

Vaccination service delivery

To improve the availability of COVID-19 vaccination services, new vaccination sites based in hospitals and other temporary vaccination sites were established apart from the traditional vaccination sites at health centers to practice COVID-19 vaccination (Table 3). Temporary vaccination sites were set up as needed, usually located in areas with convenient transportation and concentrated population, and were staffed by qualified vaccination facilities. In urban areas, COVID-19 vaccination sites mainly located in community health centers, hospitals, and varieties of temporary sites. Some temporary vaccination sites were set up in giant stadiums or outdoor squares and were equipped with more than ten vaccination units, which improved capacity of mass vaccination and created convenience for the citizens. And some community health centers, as mobile vaccination sites, started COVID-19 vaccination when vaccination demands were large. For enterprise institutions and schools with high population concentration, door-to-door vaccination services were provided. For migrant population, temporary vaccination sites were set in airports and railway stations. In rural areas, vaccination sites mainly located in county hospitals, township health centers, and temporary sites. Temporary vaccination sites were applied for villages far from township health centers, and transportation services were provided to the elderly with mobility impairment.

Most vaccination sites adopted an appointment-based approach to guarantee availability of COVID-19 vaccination services and stagger timing of vaccination. Individuals can apply for reservation online, make an appointment through their employer or community, or directly go to vaccination sites. Vaccination sites also extended working hours and even during holidays.

To ensure the vaccination safety, each vaccination site was equipped with vaccination area, observation area, and area for treating side effects following vaccination, which met the requirements of emergent treatment to side effects as well as vaccination. The medical emergency was shouldered by doctors from general hospitals, and emergency medicine and equipment were also available at each vaccination site. Symptomatic management was performed for mild reactions, while emergent first aid was performed for some severe cases like acute allergy.

Vaccination mobilization and communication

Since COVID-19 vaccines were newly developed in a rapid speed, COVID-19 vaccine hesitancy was prevalent across the world, causing barriers to mass vaccination. To address vaccine hesitancy, the public needs to be informed knowledge on this new vaccine, and fights vaccine misinformation. In China, government agencies such as community committees and different departments were responsible for vaccination mobilization and communication through various propaganda. First, all kinds of publicity were used to promote COVID19 vaccines, including the official websites of health ministry and CDC, TV news, social media platforms, all-media matrix linkages, online and offline multiform and multichannel promotions. Second, flyers, brochures, posters, audios, and videos were placed at high-traffic places to popularize knowledge on COVID-19 vaccination. Third, household screening was conducted by grassroots government staff to find the unvaccinated, and vaccination details were introduced to the unvaccinated to address vaccine refusal. In addition, incentive measures were also adopted to increase the public willingness of vaccination. Daily necessities like rice, edible oil, towels, washbasin, or cash were provided for free if vaccinated.

Vaccination information was communicated to every corner of the society based on the above-mentioned vaccination mobilization and communication. Besides effective communication on vaccination knowledge, health departments also identified and timely refuted misinformation and disinformation around COVID-19 vaccines through their official websites, traditional media, and social media platforms.

Vaccine financing

Positive externality of vaccines limits individual motivation to vaccinate, and the government usually internalizes externality by subsidizing products with positive externality. Government subsidies on COVID-19 vaccination are necessary to achieve herd immunity. In China, vaccines covered by the expanded programme on immunization (EPI) are free of charge and fully financed by general taxes, while non-EPI vaccines are fully paid by recipients. In early 2021, Chinese government stipulated that COVID-19 vaccines were not included in EPI but free for residents. The 70% of fees for COVID-19 vaccines and vaccination was directly covered by social health insurance, while the remaining was funded through reallocated general taxation. Vaccination fees were delivered to vaccination workers as incentives. This was the first time that social health insurance funds had been used to pay vaccine fees nationally.

The National Healthcare Security Administration adopted strategic purchasing of COVID-19 vaccines and negotiated the vaccine price with enterprises. Through several rounds of negotiations with domestic vaccine manufacturers, the purchasing price of inactivated COVID-19 vaccines was set up at no more than 14.2 US Dollars (1 Dollar = 6.36 Chinese Yuan) per dose in early 2021, and further dropped to around 6.3 US Dollars per dose and 3.1 US Dollars per dose in the consequent periods.

Access to vaccines

Sufficient supply and appropriate distribution of COVID-19 vaccines can ensure access to vaccines as prerequisites of mass vaccination. China had set up a special assurance group to promote the production and supply capacity of COVID-19 vaccines on various technical platforms and emphasized the localized production to ensure the supply and availability of COVID-19 vaccines. Given that China’s inactivated vaccines can be transported in room and implemented in room temperature, the logistics were easier and less costly than other vaccine technologies. There was a clear supply chain from producing and purchasing to vaccinating and tracking COVID-19 vaccines. In general, provincial CDCs took responsibility for both procurement and distribution of COVID-19 vaccines. Provincial CDCs collected vaccination demands and procurement plans from all cities in the province, centralized procurement from vaccine manufacturers, and distributed vaccines to each vaccination site through CDCs system. Circulation of COVID-19 vaccines was recorded by information system, and local CDCs could timely adjust the distribution plans of COVID-19 vaccines according to vaccination demands and daily reports of vaccinated amount and inventory, which helped optimize the distribution capacity and ensure the supply of COVID-19 vaccines. Moreover, syringes and other vaccination consumables were purchased by the vaccination sites themselves, and these were billed to vaccination fees and covered by medical insurance funds.

Information system

Well-functioned information systems recording vaccination and side effects are vital to keep abreast of mass COVID-19 vaccination. In China, digital tracking of COVID-19 vaccination was realized through Vaccine Circulation and Vaccination Management Information Systems. There was a tracking code on each package box of COVID-19 vaccine, and every in and out of storehouse was recorded by scanning the code. When vaccinating, the system automatically matched the vaccination information (e.g., type of vaccine, manufacturer, vaccination time) to the vaccinated person and recorded it by scanning the code. Meanwhile, every vaccination site checked the numbers of vaccinated doses and inventory and reported to local CDCs on a daily basis, which helped to fully track the real-time circulation of COVID-19 vaccines and timely optimize the procurement and distribution plans.

The side effects following COVID-19 vaccination also need to be treated to ensure vaccination safety. In China, side effects suspected to be related to COVID-19 vaccination must be recorded in the record book of Adverse Event Following Immunization (AEFI) by vaccination sites. Side effects and the treatments to AEFI must be timely reported to health administrations. For severe AFEI, it required a daily report of the detailed conditions like onset, symptom, and treatment of the case.

COVID-19 vaccination coverage

With the strengthening of vaccination system, a total of around 3.47 billion doses and 239 doses per 100 individuals had been administrated in China until early July 2022 (Fig. 1). As of 14th July, 89.5% of Chinese population had completed the initial two-doses vaccination protocol. However, up to 16% of the elderly (42.8 million) had not completed two-doses vaccination^[11].

This study investigated the implementation experience of COVID-19 vaccination program in China according to the health systems framework proposed by the WHO^[13]. China adopted a Whole-of-Society (WoS) approach with adequate government engagement to promote mass vaccination. The key measures in this WoS approach included the collaboration of multi-system and multi-department from the governance perspective, allocation of sufficient health workers and resources, large-scale vaccination mobilization and communication, expansion of vaccine financing channels, localized production, and digital information system. These measures sped up and achieved mass vaccination in China and could provide evidence for promoting mass vaccination in countries with low vaccination coverage.

The WoS governance system is proposed by the WHO and provides guidance for pandemic preparedness and response^[16]. It contains three central entities as the entirety of society: government, civil society, and business with surrounding essential services such as health, defense, food, and transport^[17]. The WoS requires the cooperation of multi-systems and multi-sectors and has been widely used for public health policymaking^[18–21]. The WoS governance played an important role in China’s COVID-19 vaccination. China adopted the principle of "governments undertake mobilization and health sectors deliver injections", with all ministries jointly promoting COVID-19 vaccination. The COVID-19 vaccination system involved not only health sector, but also various essential service sectors like transport, security, publicity, volunteers, finance, and social organizations. These health and non-health sectors collaborated as a whole to engage in almost all parts of COVID-19 vaccination, including vaccination workforce mobilizing, access to vaccines, vaccination mobilization and communication, and health communication. The successful implementation of the WoS approach might be facilitated by the centralized national administration system in China^{[22, 23]}. It can enable a top-down leadership mechanism, multi-system collaboration, and the consistency of policy implementation from central to local. Studies also showed that the national government leadership might contribute to China’s containment of both SARS and COVID-19 pandemics^{[23, 24]}. Government-led Whole-of-Society governance had contributed to China’s COVID-19 vaccination program and provided an approach to coordinate various entities of society as a whole to promote mass vaccination.

Vaccination resources are in a heavy shortage when facing mass vaccination. To meet huge demands for COVID-19 vaccination, China adjusted its traditional vaccination system with dedicated vaccinators and vaccination sites. The adjustments included the allocation of enough health workers and resources, flexible vaccination services for diverse populations, and extended working hours. Before the COVID-19 vaccination campaign, vaccination services were only delivered by dedicated vaccinators at vaccination clinics held in community health centers^[25]. There were only 3–5 vaccinators in a community health center, and they cannot manage to serve tens of thousands of residents. Therefore, many health workers in community health centers and hospitals were widely mobilized to receive training and dispatched to undertake COVID-19 vaccination services. Temporary vaccination sites and door-to-door vaccination services were also provided besides the traditional vaccination system. These adjustments in China were consistent with Israel where thousands of healthcare workers were recruited and trained to deliver COVID-19 vaccination^[26]. Vaccine “pop-up” centers were established in large event halls and indoor sports stadiums throughout Israel to facilitate access to COVID-19 vaccination, without compromising the normal routine of the healthcare system^{[27, 28]}. The various expansions of vaccination services have greatly improved the convenience and accessibility of vaccination services. Extensive training and participation in vaccination could also enhance the prevention awareness of healthcare workers, which is beneficial to future vaccination.

COVID-19 vaccine misinformation and hesitancy were prevalent globally^{[6, 29]}, and as a result, vaccination mobilization and communication became the key to address vaccine hesitancy. As an important component of the government-led WoS governance, all departments and levels of government had engaged in mobilization and communication of COVID-19 vaccination in China. The safety, efficacy, and useful information of COVID-19 vaccines were informed to the public and misinformation was refuted through various communication channels, while the public were mobilized to get vaccination through telephone, social media, household screening, etc. The success of vaccination communication and mobilization depended on the public trust in government^[30]. Previous studies reported the high support of Chinese for COVID-19 mitigation measures^{[31, 32]}, which also occurred for mass vaccination. Note that the elderly had worse health literacy and were more hesitant towards general vaccines such as flu vaccine in China^[33]. Therefore, the elderly should become the priority group of vaccination mobilization and communication in the future. Overall, community-based publicity and mobilization could serve as an efficient strategy to decrease vaccine hesitancy and promote vaccination^[34].

With vaccination system strengthening, the two-doses vaccination coverage had reached 89.5% as of July 2022. However, China still faced challenges in further improving COVID-19 vaccination, especially the low vaccination coverage among the elderly. Only 84% of the elderly had completed the initial two-doses vaccination protocol ^[11]. This might be related to China’s priority-group setting of COVID-19 vaccination strategy. In contrast to WHO recommendation and western countries which normally prioritize the elderly^[35], the elderly was ordered as the third priority following health care workers and adults in China. This priority order presented the key difference between China and western countries, which was partially explained by their priorities in the clinical trials that a smaller and less representative share of older populations were recruited in inactivated vaccine trials than mRNA vaccines trials. Additionally, the elderly is usually more vulnerable to vaccine misinformation, which in turn reduced their vaccination willingness^[33]. Insufficient vaccination among the elderly would be a disaster when facing the more contagious Omicron variant. Therefore, China’s vaccination system should step up to promote COVID-19 vaccination among the elderly as the highest priority.

Another challenge was the fatigue of vaccination workers. Extremely heavy workloads with extended working hours had caused fatigue, exhaustion, and psychological disturbances^[36]. It is important to take economic and non-economic incentives for vaccination workers to ensure their enthusiasm^[37]. Arranging reasonable working hours might be vital to their efficiency and mental status^[36].

We acknowledge that there may be limitations in our findings. First, qualitative interview introduced a degree of unavoidable subjectivity and limited extrapolation, although our study covered various social-economic regions in China. Second, the vaccination coverage data for the studied cities were unavailable, therefore we cannot differentiate the performance of their local vaccination campaign. Third, this study focused on the supply side of the vaccination campaign, which complements our understanding based on the previous studies on the demand side.

Our study summarized China’s experiences from seven building blocks of COVID-19 vaccination system according to the experiences of workers and stakeholders working in various organizations. It stresses the importance of a Whole-of-Society approach with adequate government engagement to promote mass vaccination, and the low vaccination coverage among the elderly should be paid the highest attention. The experiences and lessons from China may serve as a reference for other countries, especially for low- and middle-income countries, with adaptations to local contexts. Moreover, they could help strengthen vaccination systems over the long term.

Ethics approval and consent to participate: The Fudan University School of Public Health Ethics Committee approved the study protocol [FDU IRB#2018-10-0703]. Written consents were obtained from participants.

Consent for publication: Not applicable.

Availability of data and materials: The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Competing interests: The authors declare that they have no competing interests.

Funding: No.

Authors' contributions: ZH and ST designed the study. QW, ZH, and ST collected data. QW coded and analyzed data. ZQ and QW wrote the first draft of the manuscript. XC revised the manuscript. ZH intensively revised and prepared the final manuscript. All authors have read and approved the manuscript.

Acknowledgements: We thank for Kaiyi Han, Yuting Xing , Simeng Hu, Jing Du, Shujie Zang, Xu Zhang from Fudan School of Public Health for helping collect data, and for Kaiyi Han for helping code data.

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The whole-of-society approach of mass COVID-19 vaccination in China: a qualitative study

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Abstract

Figures

Introduction

Methods

Study design and data collection

Interview guidelines

Data analysis

Results

Leadership and governance

Health workforce

Vaccination service delivery

Vaccination mobilization and communication

Vaccine financing

Access to vaccines

Information system

COVID-19 vaccination coverage

Discussion

Conclusion

Declarations

References

Status:

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