Knowledge, Attitude, and Current Practice of Primary Care Pediatricians Toward Immunization in Children With Rheumatic Diseases

Young boy receiving vaccination
A young Caucasian boy sits up on an exam table with his sleeve over his shoulder, as a female Latin nurse gives him his immunization needle. The boy is dressed casually in a t-shirt and the nurse is wearing blue scrubs and white medical gloves for protection, as she holds the young boys shoulder with one hand and gives the injection with the other.
Researchers aimed to describe the knowledge, attitude, and current practice of pediatricians toward immunizations in children with rheumatic diseases and identify barriers and facilitators that could promote uptake.

Primary care pediatricians in Greece typically agree that vaccination is essential in children with rheumatic diseases; however, half of the surveyed respondents felt hesitant to adhere to typical vaccination schedules without counsel from a rheumatology expert, according to survey data published in the Journal of Clinical Rheumatology. In addition, some pediatricians indicated that they felt hesitant to administer live-attenuated vaccines to children receiving immunosuppressive treatment.

Investigators administered an anonymous, online questionnaire to 400 pediatricians in Greece. The survey captured information on demographics, physician knowledge regarding vaccines, physician perception and opinions, and advice given to families. Three specific vaccine categories were addressed: live vaccines, nonlive vaccines, and annual influenza vaccines. The questionnaire also assessed physicians’ views on vaccines in the context of systemic treatment. Chi-square and Fisher exact tests were used to assess agreement across participants.

A total of 256 questionnaires were returned. The majority (83%) of participants agreed that vaccination in children with rheumatic diseases was of “pivotal importance.” A total of 75% of participants cited the use of existing guidelines to make vaccine-related decisions (eg, from the European League Against Rheumatism), and 35% were unaware of national guidelines. Half the number of participants indicated that they were hesitant to adhere to the national vaccination scheme without first consulting a rheumatic diseases expert, and 34% indicated that they would refer patients to a tertiary rheumatology unit for immunization. The majority (92%) of participants supported the use of an annual influenza vaccine, while the remaining percentage were against the administration of live vaccines even if their patients were not receiving immunosuppressive treatment. A total of 77% of survey participants indicated that they felt keener to administer a booster doses than primary doses of vaccines.

According to survey data, the primary source of reluctance to administer vaccines was the use of immunosuppressive treatment. Among physicians who cited noncompliance, primary reasons included the inability to deal with parental concerns/refusal (54%) and fear of causing disease flares in patients (43%).

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Sex, age, duration of experience, and possession of secondary certifications did not appear to influence vaccination approach. However, pediatricians employed in the private sector were significantly more aware of existing guidelines (P =.04) and were also more likely to be aware of which vaccines should be avoided in patients with rheumatic diseases under specific treatments (P =.05). There were no significant differences in terms of vaccine type, primary or booster doses, and immunization hesitancy among the participant groups.

These data suggest that although the majority of pediatricians in Greece understand the necessity of vaccines in children with rheumatic diseases, some variations in clinical practice exist. “Pediatric rheumatologists should advocate the adherence to the vaccination program,” the investigators wrote.


Papailiou S, Markade A, Eleftheriou I, Tsolia MN, Garoufi A, Maritsi DN. A national survey across primary care pediatricians regarding immunization views and practices in children with rheumatic diseases [published online January 15, 2020]. J Clin Rheumatol. doi:10.1097/RHU.0000000000001251