The recent unfolding of a five year old story of two million doses of vaccines illegally procured and sold across China is a confidence breaker. Worse, it is not a new episode of abusing a public health good for personal financial gain, but the latest of a series of public health incidents in China.
Twenty nine companies have been implicated in the current saga, 202 individuals arrested, and 357 civil servants “dismissed or demoted” according to the official government report.  The value of the improperly stored and distributed vaccines (some about to expire), has been estimated at over $40 million. The former pharmacist who choreographed the scandal, along with her daughter, were arrested nearly a year before the story became public. However, little was done about the crisis then.
Once the story went public, WHO was quick to announce that the public should not worry about harm due to improperly stored or expired vaccines.  They acknowledged that there was a risk that the vaccines would not provide the protection individuals had personally paid for. These vaccines were Category 2 self-financed vaccines, but some also protected against childhood infections mainly targeted by Category 1 vaccines in the national immunization programme. Whether category 1 or 2, public trust around all vaccines has been broken. While the WHO statement aimed to calm the public, it was perceived by some as a gesture to protect the government. The public is angry, and not without reason.
Chinese authorities responded by aligning agencies to track the flow of the vaccines and rectify supply chain flaws. However, widespread public distrust over vaccine safety still loomed large. As other vaccine incidents in history have shown, there are often long term impacts on vaccine confidence with consequent declines in vaccine uptake.  Following the Chinese hepatitis B vaccine scare in December 2013, for instance, despite the fact that reported childhood deaths following vaccination were found to be unrelated to the vaccine, vaccination rates of hepatitis B dropped by 30% in ten provinces, and the national immunization programme reported a 15% decline in overall vaccine acceptance. 
This recent episode should be a wake-up call for more rigorous restrictions on entrenched bribery and corruptions that undermined public confidence for health systems and products.  Already in the 1990s there were reports of public distrust towards healthcare professionals and the health system, stemming from perceptions of financial motives.  Public protests erupted as well as individual attacks on health professionals, who were physically abused, some fatally, by distrusting and angry citizens. In a survey conducted by the Chinese Hospital Association among 312 hospitals between late 2012 and early 2013, the number of assaults on doctors increased from 20.6 to 27.3 per hospital between 2008 and 2012. 
What can be done to mitigate the negative consequences of this recent incident, as well as rebuild and protect public trust moving forward?
First, prompt, clear, and honest communication with the public is needed about what is being done to address not only this recent incident but, more importantly, the underlying weaknesses in the system. Because these deeper issues will not have a “quick fix” solution, regular updates on progress in implementing any promised actions are critical for restoring public confidence.
Second, listening to the public and identifying particular vaccine concerns will be essential to inform appropriate responses and build trust.  This can be done through systematic media surveillance to detect emerging rumours and concerns, combined with public perception surveys and focus group discussions.
Third, health authorities should monitor and publicly share the effects (or lack thereof) of the illegal vaccines on individuals who received them. The public should be encouraged to report suspected use of illegal vaccines and suspected adverse effects, and any evidence of harm should be reported in an honest and transparent manner. Fourth, vaccination points at hospitals and local centers for disease control and prevention will need to provide transparent information about the sources of their vaccines. Such transparency is important for dismissing skepticism, particularly among parents of young children.
Fifth, health authorities need to prepare for short-term and long-lasting negative impacts on vaccination. The uptake of Measles, Mumps and Rubella vaccination in the UK, for instance, declined drastically after the publication of Wakefield’s now-retracted Lancet publication, which suggested links between the vaccine and autism, prompting public panic. The decline in vaccine acceptance continued for years, and only reached its lowest point five years following Wakefield’s publication.  Health authorities need to closely monitor the vaccine uptake trends of vaccines and impacts on disease dynamics.
Last but not least, health agencies with other government agencies should consistently and strictly enforce health laws, regulations, policies, and standard operating procedures regarding the production, supply, and use of all vaccines to prevent similar vaccine incidents in future.
The public deserves it.
Heidi J. Larson is director of The Vaccine Confidence Project and Senior Lecturer, Department of Infectious Disease Epidemiology at the London School of Hygiene & Tropical Medicine, and Associate Clinical Professor, Department of Global Health at the University of Washington, Seattle.
Ruoran Li is a doctoral student in the Department of Epidemiology, Harvard T.H. Chan School of Public Health.
Xiong-Fei Pan is a PhD student in Epidemiology at Sichuan University, and is also affiliated with the Chinese Evidence-based Medicine Center at West China Hospital.
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Competing Interests: Heidi Larson serves on the Merck Vaccines Global Strategy Advisory Board and is a consultant to GSK on vaccine confidence. XP and RL have no conflicts.