Discussion
Key findings from this study that aimed to understand the perspectives of paediatricians and other healthcare providers working with children in India regarding paediatric COVID-19 vaccines within the first year of the rollout indicated that most respondents were supportive of paediatric vaccination, although half did not feel adequately informed. Concerns about vaccine hesitancy among caregivers were also highlighted.
Healthcare authorities globally continue to emphasise the importance that vaccinating adults alone cannot curb the pandemic without widespread vaccine uptake in children.12 Although adult vaccination rates are increasing around the globe, paediatric infections have become a significant source of burden in communities as infected children could serve as the primary drivers for disease transmission.13 As of May 2023, 21% of the reported COVID-19 cases were noted in children and adolescents, with many children requiring hospitalisation and critical care in Low-and-middle income countries (LMICs) every day.14 15 Data indicated that with the emergence of new variants worldwide, unvaccinated children may be at higher risk of infections due to increased transmission and virulence, changes in clinical manifestations of the disease, including conditions like MIS-C and long-COVID.15 16 Vaccinating children and adolescents might help reduce the indirect harms caused by quarantine, lockdowns, repeat testing, school exclusion and closures.17 In India, COVID-19 paediatric vaccines approved for emergency use authorisation, such as ZyCoV-D, Corbevax and Covaxin have shown 66.6%, >91% and >95% safety, efficacy and immunogenicity regarding vaccines, respectively.18–20 The successes of such scientific endeavours and subsequent availability of such efficacious vaccines in the arsenal against COVID-19 should motivate providers and recipients to advocate for and increase uptake rates, respectively.
One of the most described and researched reasons for low COVID-19 vaccine uptake has been vaccine hesitancy.21 In the context of paediatric COVID-19 vaccination, several studies conducted in diverse settings including Italy,22 Kuwait,23 Singapore,24 Saudi Arabia25 and the USA26 have indicated strong hesitancy among parents against the COVID-19 vaccination of their children. A major concern noted by these studies was that hesitancy was driven mostly by concerns about vaccine safety and efficacy, a pattern that is also noted in our study findings. Parental hesitancy was predominantly driven by the fear of vaccine side effects, adverse events following vaccination, parental trust in their child’s paediatrician and the healthcare system and the rapid development of COVID-19 vaccines and the label of ‘emergency use authorisations’. Several of these reasons can be successfully addressed by informed providers, and findings from these studies and ours call for concerted efforts from public health leaders and healthcare providers in raising awareness and providing sufficient information on the safety, efficacy and effectiveness of COVID-19 vaccines.
Paediatricians and other paediatric providers are recognised globally as highly trusted sources about providing vaccine education and safety.11 27 Parents often rely on their child’s paediatricians for alleviating questions and concerns regarding vaccines and enhancing vaccine acceptance. Most respondents in our survey did not feel adequately informed about details surrounding paediatric COVID-19 vaccination. Wide-spread dissemination of guidelines that were made available early in the rollout phase would be of vital importance to allay concerns. Additionally, tools such as those developed by the Centers for Disease Control28 and the Indian Academy of Pediatrics29 to be used during patient visits incorporating a series of motivational interviewing techniques, aimed toward increasing COVID-19 vaccination uptake should be made available to healthcare providers to provide additional support. Paediatricians are also encouraged to explore opportunities to partner with schools, and other academic institutions and/or organisations to advocate for COVID-19 vaccines. Public health leaders need to collaborate with paediatric providers, global organisations and local political leaders to build rapport and provide the targeted audience with educational resources and programmes, evidence-based communication and policies aimed toward the implementation of mass immunisation efforts.
In addition to demand side barriers to vaccination such as vaccine hesitancy, respondents alluded to concerns such as lack of efficient vaccine monitoring systems and enforcement guidelines, supply and cold chain issues, and low availability of HCWs for vaccination sessions as supply-side barriers to successful vaccine rollout. Studies have identified that during the pandemic in India, HCWs’ tasks shifted towards tackling the immediate challenges associated with the pandemic, with duties that included promoting COVID-19 preventive behaviours, contact tracing, mobilising testing, ensuring home quarantines, delivering medicines30; and thus, staffing at immunisation clinics was poor. Studies have also identified bottlenecks in the storage and transportation of COVID-19 vaccines; the government of India has been highly responsive and has taken special measures to ensure that a robust plan is in place for vaccine storage and distribution.31 Further, vigorous pharmacovigilance of vaccines is of paramount importance to promote the safe use of vaccines among their recipients.32 While India has a specific, passive AEFI reporting system for COVID-19 vaccines, inbuilt within the COWIN application, reporting rates are poor.33 A recent study from South India found that 76.5% of COVID-19 vaccine recipients who suffered an AEFI did not report it.34 There is a need for an active surveillance system to gather vaccine-related data which would help enhance vaccine confidence.
In our survey, a large majority of respondents suggested that school-based vaccination programmes (SBVPs) would be an effective strategy for the successful rollout and uptake of paediatric COVID-19 vaccines. SBVPs offer numerous advantages for vaccine delivery by eliminating many logistical barriers, including reducing travel and time demands.35 They can improve equity in vaccine access for children experiencing sociodemographic disadvantages. They are uniquely positioned to boost vaccine acceptability by normalising vaccination and providing access to trusted sources of information via school nurses or other officials, to meaningfully engage parents and address concerns.35 Historically, SBVPs have been instrumental in increasing uptake among adolescents for multiple routinely recommended vaccines, including meningococcal, hepatitis B and Human papillomavirus (HPV) vaccines.35 A Canadian study showed that first dose coverage of COVID-19 vaccines increased from 30.6% to 81.5% within 12 days of the launch of an SBVP.36 Innovative strategies such as these will need to be incorporated into rollout strategies in the Indian context as well.
Our study has some limitations that are worth noting. The survey was disseminated shortly after the initial rollout of the paediatric COVID-19 vaccines in India, a period when paediatric COVID-19 vaccine information, options and opinions were rapidly changing. We acknowledge the possibility of selection bias as mostly private-sector paediatricians had responded to the survey since a large part of dissemination occurred through the listservs of the Indian Academy of Pediatrics. Selection bias may have additionally arisen because the survey was administered in English on an internet-supported platform; non-English speaking healthcare providers and those without access to the internet would not have been able to participate in this survey. The snowball sampling strategy may have further added to the selection bias, since such a sampling methodology does not guarantee representativeness of a sample, and does not allow an estimation of the response rate, leading to an unknown denominator. Responses may have been affected by social desirability bias. Further, this was a cross-sectional survey with no longitudinal follow-up; the cross-sectional survey design was employed to understand healthcare providers’ perspectives towards paediatric COVID-19 vaccination, the rapid rollout of which precluded us from strengthening our sampling methodology.
