Table 1.

Current status of key issues affecting influenza vaccination coverage among pregnant women in China.

Technical Guidance	China CDC has recommended influenza vaccination for pregnant women since 2014	Feng L, Hum Vaccine Immunother. 2015 Feng LZ, Zhonghua LiuXing Bing Xue Za Zhi, 2018
Regulatory Barriers
Classification of vaccination	Influenza vaccination designated as a Category 2 vaccine, which is voluntary, and typically paid out-of-pocket and not covered by government health insurance Vaccine manufacturer is required to pay compensation or Category 2 vaccine injuries	Yu W, Vaccine 2018 Fei L, Med La Rev, 2017
Designation in Chinese Pharmacopeia	Pregnancy listed as an absolute contraindication to seasonal influenza vaccination	Chinese Pharmacopoeia Commission, 2017
Opportunities and strengths
Domestic influenza vaccination production capacity	China’s first influenza vaccine licensed in 1997 China has eight influenza vaccine manufacturers as of 2017 One manufacturer produces seasonal influenzas vaccination meeting WHO-prequalification standards	Zheng Y, BMC Infec Dis, 2018 World Health Organization. WHO Prequalified Vaccines
National Immunization Advisory Committee	Established by the National Health Commission in 2017 Authorized China CDC to establish technical working groups to review evidence in support of making recommendations to the National Health Commission, which has the authority to make establish national vaccine policy As has been done in other countries, influenza working group of the National Immunization Advisory Committee can serve as a platform to address specific maternal immunization issues	Chinese Center for Disease Control and Prevention, 2017 Beiji RH, Vaccine, 2018
National Health Commission	Issued a notice in October 2018 requiring healthcare workers to promote influenza vaccination among patients*	National Health Commission, 2018
Antenatal care system	97% of women utilize services from the antenatal care system at least once during pregnancy System has been used successfully for public health vaccinations initiatives as part of the preconception program	National Health Commission, Chinese Health Statistics Yearbook, 2018 National Health Commission, 2017
Challenges
Off-label vaccine usage	National Immunization Advisory Committee has yet to make an “off-label” vaccine recommendations that differs from the Chinese Pharmacopeia Off-label recommendations are specific to a country’s legal landscape, and a legal pathway for authorizing maternal influenza immunization will need to be identified for China	Neels P, Vaccine, 2017
Vaccine supply	From 2004–2014, China had an estimated annual influenza vaccination supply up to 58.8 million doses From 2004–2014, 426 million were considered recommended for influenza vaccination Assuming increased demand for influenza vaccination in the future, current supply is insufficient for recommended population, expanding vaccine access in the future may require developing priority recipient groups among high risk populations recommended for influenza vaccination	Yang J, Vaccine, 2016
Healthcare worker knowledge and behaviors	Healthcare workers have low awareness of the safety and benefit of influenza vaccine Few healthcare workers have been received an influenza vaccination Few pregnant women reported receiving recommendations to be vaccinated from healthcare workers	Bu L, Chinese Health Service Management, 2017 Song Y, Vaccine, 2017
Patient hesitancy	Recent nationwide vaccine safety scandals involving vaccines other than influenza have shaken public trust Pregnant women have declined influenza vaccination citing concerns about potential harm to fetus and harm to self	Cao L, Hum Vaccine Immunother, 2018 Song Y, Vaccine, 2017

*The issuance does not mention specific patient populations to whom health-care workers should recommend influenza vaccination.