Preamble

Expert Consensus on Health Promotion Strategies for Adult Vaccination in China

Keywords: Adult vaccination; Health promotion; Expert consensus; Public health; China

CLC Number: R186 Document Code: A

Affiliations: Institute for Healthy China, Tsinghua University; School of Public Health, Peking University; Southern University of Science and Technology; Public Health Security and Health Professional Committee of the Public Safety Science and Technology Society.

Introduction

Vaccination is recognized as one of the most successful and cost-effective public health interventions in human history. While China has made significant strides in pediatric immunization through the National Immunization Program (NIP), adult vaccination remains a critical yet underdeveloped component of the national preventive healthcare strategy. As the population ages and the burden of chronic diseases increases, the importance of establishing robust health promotion strategies for adult vaccination has become increasingly urgent.

1. The Current Landscape of Adult Vaccination in China

Currently, adult vaccination in China faces several challenges, including low awareness among the general public, varying levels of recommendation from healthcare providers, and disparities in vaccine accessibility and affordability. Unlike the mandatory and well-funded pediatric program, most adult vaccines are categorized as non-immunization program vaccines (formerly Category 2 vaccines), requiring out-of-pocket payment and proactive health-seeking behavior.

[TABLE:1]

2. Objectives of the Health Promotion Strategy

The primary objective of this consensus is to provide a framework for improving adult vaccination rates through comprehensive health promotion. This involves:
- Enhancing public literacy regarding vaccine-preventable diseases (VPDs).
- Strengthening the role of primary care physicians and general practitioners in vaccine advocacy.
- Optimizing the service delivery system to ensure convenience and safety.
- Promoting policy integration to reduce financial barriers for high-risk populations.

3. Key Strategies for Implementation

3.1 Enhancing Public Awareness and Education

Health education should be tailored to different adult demographics, focusing on the safety, efficacy, and necessity of vaccines such as the influenza vaccine, pneumococcal vaccine, herpes zoster vaccine, and HPV vaccine. Utilizing digital media alongside traditional community outreach is essential to combat vaccine hesitancy and misinformation.

3.2 Strengthening the Role of Healthcare Professionals

General practitioners (GPs) and community health workers serve as the "gatekeepers" of public health. This consensus emphasizes the need for systematic training of healthcare providers to ensure they can provide evidence-based recommendations. Every clinical encounter should be viewed as an opportunity to assess vaccination status.

Abstract

Vaccine-preventable diseases impose a significant health burden on adults in China, highlighting urgent needs to address gaps in the current adult immunization program. The Expert Consensus on Health Promotion Strategies for Adult Vaccination in China was developed through collaboration among experts from multiple institutions, led by the Institute for Healthy China at Tsinghua University, the School of Public Health at Peking University, the School of General Practice and Health Management at the Southern University of Science and Technology, and the Public Health Security and Health Committee of the China Society of Public Security Science and Technology. Integrating evidence-based scientific research and practical insights from multidisciplinary experts in immunization promotion, this consensus addresses the necessity and health value of adult vaccination, the current status and challenges of adult vaccination services in China, and expert recommendations for advancing strategies such as integrating medical and preventive care, promoting vaccine prescriptions by general practitioners, and developing a national adult immunization strategy. The consensus aims to provide scientific, systematic, and actionable guidance for government policymakers, public health agencies, healthcare providers, and health promotion practitioners to facilitate vaccination efforts for key adult groups from a life-cycle perspective.

Key words: Adult vaccination; Health promotion; Expert consensus; Immunization program

1 Consensus Development Methodology

Institute for Healthy China, Tsinghua University; School of Public Health, Peking University; Southern University of Science and Technology, et al. Expert consensus on health promotion strategies for adult vaccination in China [J]. Chinese General Practice, 2026. [Epub ahead of print].

Expert Consensus on Health Promotion Strategies for Adult Vaccination in China

Initiated by the Professional Committee and launched in April 2025, this consensus was developed through the collaborative efforts of the Institute for Healthy China at Tsinghua University, the School of Public Health at Peking University, the Southern University of Science and Technology, and other participating institutions.

Abstract

Vaccination is one of the most effective and cost-efficient public health interventions for preventing infectious diseases. While China has achieved significant success in pediatric immunization through the National Immunization Program, adult vaccination coverage remains suboptimal, facing challenges such as low public awareness, insufficient professional guidance, and systemic barriers to access. To address these issues and align with the "Healthy China 2030" initiative, this expert consensus outlines comprehensive health promotion strategies tailored to the Chinese context. The consensus focuses on enhancing health literacy, optimizing service delivery, strengthening the role of healthcare professionals, and leveraging digital health technologies to improve adult vaccine uptake and safeguard public health across the life course.

Editorial Office of Chinese General Practice. This is an open access article under the CC BY-NC-ND 4.0 license.

Chinese General Practice: The review period is 5 months, with the external review scheduled for September 2025 and the final manuscript finalization set for September 2025.

Intended Users and Target Population

1.2 Consensus Development Group

The consensus expert group consisted of 47 members. The inclusion criteria required participants to possess extensive experience in vaccine administration and clinical research, as well as a deep understanding of the relevant immunological principles and public health policies. These experts were drawn from diverse professional backgrounds, including clinical medicine, epidemiology, and immunology, ensuring a comprehensive and multidisciplinary perspective during the development of these guidelines.

1.3 Literature Search

A systematic search was conducted across databases including PubMed, Web of Science, Embase, Scopus, China National Knowledge Infrastructure (CNKI), and Wanfang Data Knowledge Service Platform. The search utilized keywords such as "adult vaccination," "adult immunization," "immunization program," "immunization service system," "vaccination in adults," "adult vaccine uptake," "vaccine uptake among adults," "vaccines for adults," "immunization policy," "immunization strategy," "vaccination policy," "vaccination program," "immunization delivery system," "vaccination infrastructure," and "immunization service provision."

The search period spanned from the inception of each database to July 30, 2025, with no restrictions placed on the language of publication. To determine the quality of evidence and the strength of recommendations, experts rated each recommendation using a 5-point Likert scale. On this scale, 5 points represented "strongly agree," 4 points "agree," 3 points "neutral," 2 points "disagree," and 1 point "strongly disagree." Consensus was defined as the proportion of experts (out of 43 total voters) who assigned a score of 5. A recommendation was considered to have reached consensus if the consensus rate exceeded 80%. Ultimately, consensus was achieved for all 18 proposed recommendations.

Declaration of Conflict of Interest

1.6 Publication, Dissemination, and Updating of the Consensus

Literature searches, evidence updates, and evaluations will be conducted regularly, with plans to update the consensus every 3 to 5 years.

2 Necessity and Health Value of Adult Vaccination

[Recommendation: 95.7% Agreement] Vaccination measures can prevent more than 30 life-threatening diseases and infections, averting 3.5 to 5 million deaths annually from diphtheria, tetanus, and pertussis. Vaccination is associated with a 45% and 38% reduction in mortality rates, respectively, and is linked to a decreased risk of cardiovascular death. Compared to those who are unvaccinated or have unknown status, individuals receiving the 23-valent pneumococcal polysaccharide vaccine (PPV23) experience shorter hospital stays and fewer serious in-hospital adverse events. Furthermore, influenza vaccination during specific periods can improve survival rates and reduce risks over the subsequent 12 months. Despite these benefits, "vaccine hesitancy" persists among some professionals. The World Health Organization's (WHO) Immunization Agenda 2030 (IA2030) emphasizes life-course immunization and the goal of "leaving no one behind," while the "Healthy China 2030" Planning Outline explicitly states the need for a strategic shift.

Chinese General Practice points out that the focus must transition from being "child-centered" to covering the entire population across the full life course \cite{13-14}. While the general population stands to benefit from vaccines that prevent death, the "anti-vaccine phenomenon" remains a long-term challenge. Indeed, "vaccine hesitancy" has been listed by the WHO as one of the top ten threats to global health.

Despite these frameworks \cite{16}, adult vaccination coverage remains at an extremely low level. In 2021, the vaccination rates for PPSV23 among individuals aged 18–59 and those aged $\ge 60$ were only 0.06% and 1%, respectively. For adult women, the first-dose coverage of the Human Papillomavirus (HPV) vaccine was 2.34%, with the full-course completion rate falling below 1%. Similarly, influenza vaccination rates were recorded at 0.52% for the 18–59 age group and 4.63% for those aged $\ge 60$.

On September 26, 2025, the Epidemic Prevention and Control Group of the State Council's Joint Prevention and Control Mechanism issued guidelines regarding health measures for the National Day and Mid-Autumn Festival period and the autumn/winter season. Internationally, while the pneumonia vaccination rate among people aged 65 and older in the United States reached 64% in 2022, the comprehensive coverage rate for all adults completing age-appropriate vaccinations remained only 22.8%. Some countries have designated 18 vaccines as statutory "routine immunizations"; for instance, varicella vaccine coverage rapidly rose to over 95% after its inclusion, whereas the coverage for the elderly pneumonia vaccine (which requires partial out-of-pocket payment) was only 33.5%. Although European Union countries generally recommend free influenza and pneumonia vaccinations for those aged $\ge 65$, the average influenza vaccination rate in 2018 was only 45%, falling far short of the 75% policy target. While some regions report higher rates of approximately 60%, the influenza vaccination rate among patients with heart failure in China is estimated to be less than 1%.

3 Current Status and Challenges of the Adult Vaccination Service System in China

[Recommendation: 93.6% Agreement] It is recommended to promote the use of non-immunization program vaccines, such as those for influenza, pneumococcal disease, and HPV, particularly through initiatives like free influenza vaccinations for the elderly, children, and healthcare workers. Efforts should be made to explore and broaden financing channels. During 2020–2021, the national mobilization for COVID-19 vaccination led to the rapid establishment of a disease management workflow covering national, provincial (municipal/autonomous region), city, and county levels. For instance, piloting a "vaccine prescription" model allows general practitioners to play a more active role.

[Recommendation: 85.1% Agreement] Factors influencing vaccination include trust, complacency, and convenience. (1) Trust: Concerns regarding the safety, efficacy, and health impact of vaccines are primary drivers of "vaccine hesitancy." (2) Complacency: This refers to a low perceived risk of disease. (3) Convenience: This encompasses vaccine supply capacity, price affordability, and accessibility.

Chinese General Practice identifies several key challenges: (1) Low vaccination rates: Non-immunization program vaccines require out-of-pocket payment, leading to low public willingness to vaccinate. (2) Inadequate payment mechanisms: While some adult vaccines (such as the 23-valent pneumococcal vaccine) are covered by medical insurance in certain regions, the coverage remains limited and lacks sustainability. (3) Fragmented service systems: Vaccination sites are scarce in some rural areas. (4) Shortage of professional vaccination teams: Existing personnel face heavy workloads and insufficient investment in specialized training. (5) Insufficient public awareness: General awareness regarding adult vaccination is low, with many individuals underestimating their risk of infection and the benefits of immunization. (6) Low recommendation rates: Some medical professionals do not prioritize adult immunization, leading to infrequent recommendations to patients. (7) Lack of standardized protocols: Vaccination standards vary significantly across different regions. (8) Difficulties in medical institution development: Resource constraints, a clinical-heavy focus over prevention, and "vaccine hesitancy" among staff hinder the integration of vaccination services.

4 Integration of Medical and Preventive Care for Adult Immunization

[Recommendation: 85.1% Agreement] It is recommended to share the vaccination history of key populations between Hospital Information Systems (HIS) and Immunization Program Information Systems.

[Recommendation: 85.1% Agreement] Integrated services for diagnosis, treatment, and vaccination should be established to bridge the "last mile" of service delivery.

[Consensus: 89.4% Agreement] By addressing the "last mile" of vaccination services, we can better serve key populations such as the elderly and children.

[Recommendation: 91.5% Agreement] [Recommendation: 89.4% Agreement] [Recommendation: 86.0% Agreement] [Recommendation: 89.4% Agreement] Interpretation and Evidence: Within the closed-loop policy framework of "Prevention-Cost Control-Development," these measures are essential.

Chinese General Practice: As a form of "empowerment funding," these funds improve the cash flow of medical institutions and enhance service quality. [Recommendation: 85.1% Agreement] However, a contradiction exists between short-term cost control goals (annual totals) and the long-term returns on preventive investment (which typically manifest over 3 to 5 years). Furthermore, some regions currently include vaccine costs within the "drug-to-total revenue ratio" (drug percentage) calculations.

In terms of innovation, we should implement pilot programs for "capitation-based prepaid packages" or "pay-for-health-outcomes" models. We should explore multi-party co-payment models for vaccine costs involving "medical insurance + public finance + individuals." These efforts should be coordinated with Diagnosis-Related Group (DRG) and Diagnosis-Intervention Packet (DIP) reforms. By incorporating vaccination into disease-specific cost accounting, the expenditures for related DRG groups can be reduced, effectively utilizing medical insurance surpluses.

5 Promoting Vaccine Prescriptions by General Practitioners

[Recommendation: 87.2% Agreement] It is recommended to jointly establish vaccination areas within outpatient clinics for physical examinations and specialized care for high-risk groups, including patients with hypertension or diabetes, pregnant women, children aged 0–6, and the elderly. During peak influenza seasons, the construction of integrated "General Practice + Immunization" clinics should be promoted. This involves upgrading information systems to implement "vaccine prescriptions," allowing general practitioners (GPs) to include specific vaccine recommendations within comprehensive health prescriptions. Once a "vaccine prescription" is issued, patients can proceed directly to the vaccination clinic. Furthermore, "integrated medical-preventive practice courses," such as GP vaccine prescribing modules, should be added to the curriculum.

[Recommendation: 83.0% Agreement] For facilities providing disease diagnosis and treatment services with robust HIS systems and high-quality data, AI-assisted prescribing tools should be introduced. These tools will enable "intelligent GPs" to play a critical role in generating personalized "vaccine prescriptions."

[Recommendation: 87.2% Agreement] Vaccination against influenza, pneumonia, and HPV should be prioritized for high-risk populations.

[Recommendation: 85.1% Agreement] Special attention should also be given to the vaccination needs of mobile populations.

The "15th Five-Year Plan" for Chinese General Practice serves not only as a strategic extension of the "Healthy China 2030" initiative...

6 Constructing a Strategic Plan for Adult Immunization

Expert Consensus Group for the Development of the "Expert Consensus on Health Promotion Strategies for Adult Vaccination in China" [Recommendation: 85.1% Agreement] Consensus Group Leader, Consensus Lead Author, Consensus Expert Group; demonstrating the sustainability of "Vaccine Prescription" services.

[Recommendation: 87.2% Agreement] [Recommendation: 89.4% Agreement] Incorporate relevant content into the "15th Five-Year Plan" and strengthen continuous policy supervision and evaluation.

Chinese General Practice

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Immunization is one of the most successful and cost-effective interventions in the history of public health. To further advance global immunization efforts, the World Health Organization (WHO) and its partners have developed the "Global Strategy Framework for Vaccine Action 2021–2030" (IA2030). This framework aims to ensure that everyone, everywhere, at every age, fully benefits from vaccines for good health and well-being. This article analyzes the core components of IA2030 and explores its strategic implications for the development of China’s immunization programs over the coming decade.

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(Received: 2025-09-01; Revised: 2025-10-21)