Building Parental Trust in Childhood Vaccination: Lessons From Iran’s COVID-19 Response

Abstract

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Since the 18th century, when Edward Jenner introduced vaccination to control smallpox, humanity has mitigated numerous pandemics through this method.^1^ Vaccines, comprising pathogen components or weakened/inactivated forms, stimulate the immune system to generate memory for future pathogen responses. Pandemic experiences underscore that safe, effective, affordable vaccines with equitable distribution are vital for societal health and well-being.^2^

Achieving herd immunity to halt infectious disease spread requires policy-makers to provide vaccines cost-effectively and equitably while fostering public trust and acceptance. Factors like social, economic, cultural, religious influences, misinformation, and health literacy impact vaccine uptake.^3^ Vaccinating all, including children, is crucial; it prevents child hospitalizations and deaths, reduces social isolation and educational disruptions, and curbs transmission to vulnerable individuals.^4^

COVID-19 emerged in Iran with confirmed cases reported on February 19, 2020, in Qom, though evidence indicates an earlier start in January 2020. By August 2020, official figures exceeded 350 000 cases and 20 000 deaths. As of 2022, cumulative cases reached over 7.2 million with approximately 141 000 deaths.^5^

Iran faced multifaceted challenges in managing the COVID-19 pandemic, exacerbated by international sanctions that impeded imports of essential medical supplies, leading to shortages and heightened mortality.^6^ Governance flaws in the National Headquarters Against COVID-19, including poor coordination and contradictory policies, eroded public trust and compliance, with adherence dropping below 40%. Health system strains involved inadequate physical structures, human resource shortages, fatigue, and financial constraints, necessitating inter-sectoral reforms.^7^ Additionally, influential clerics sometimes propagated misinformation and opposed quarantines, hindering prevention efforts despite their potential as social assets.^8^

Iran’s COVID-19 vaccination began in February 2021, with 155 million doses administered by year-end using inactivated (eg, Sinopharm), adenoviral (eg, Sputnik V), and recombinant platforms mortality.^5^ Despite challenges—including initial delays, distrust of Western vaccines, slow procurement, US/UK vaccine prohibitions, economic sanctions, lack of confidence in Chinese/Russian vaccines, financial/resource shortages for procurement, and inadequate production due to insufficient scientific/economic infrastructure^9^—coverage reached 75% for one dose and 65% fully vaccinated, reducing hospitalizations and mortality.^5^

In the United States, three COVID-19 vaccines are available for children: Pfizer-BioNTech, Moderna, and Novavax. However, as a developing country, Iran could not access these and instead used the indigenous PastoCovac and Chinese Sinopharm vaccines for children aged 5-12 years. COVID-19 vaccine uptake among Iranian children was low (29%-60%). Parental hesitancy mainly arises from concerns about side effects, potential effects on growth and fertility, and perceived ineffectiveness (50.9% doubt protection).^10^ Other barriers include beliefs that the pandemic has ended, insufficient information, overcrowded vaccination sites, limited vaccine availability, and distrust in primary health care.^11,12^ Our study in Bojnourd, Iran, found over 60% of parents of children aged 5–12 years unwilling to vaccinate due to health system distrust, misinformation, and vaccine safety fears.^13^ Younger children, boys, those with pre-existing conditions, lower socioeconomic status, and children of hesitant mothers are less likely vaccinated, while older children, those with prior COVID-19 infection, and higher socioeconomic families show greater acceptance.^14^ In a systematic review and meta-analysis, we assessed global parental acceptance of COVID-19 vaccination for children, revealing a low rate of 57%. Influencing factors included country income level, WHO region, vaccine side effects, efficacy and benefit doubts, cost, accessibility, and trust in government and health systems.^15^

A primary reason for parental hesitancy toward pediatric COVID-19 vaccination in Iran is uncertainty about vaccine safety and fear of adverse effects; over 81% of hesitant or unwilling parents in a Tabriz study cited side effect concerns.^11^ An Iranian study of PastoCovac and Sinopharm vaccines in children aged 5-12 years reported side effect incidences of 24%-37%, varying by type and dose. Most were localized and mild, resolving within days without treatment; no severe effects occurred.^16^

Drawing upon findings from our previous studies and Iran’s unique COVID-19 experiences, we propose evidence-based policy recommendations to enhance parental acceptance of childhood vaccination in future pandemics:

Acknowledgements

We gratefully acknowledge the contributions of all authors whose articles informed and enriched this manuscript.

Ethical issues

Since the data were extracted from a public database, there was not necessary to get an ethics approval.

Conflicts of interest

Authors declare that they have no conflicts of interest.

Declaration of Generative Artificial Intelligence (AI)

While preparing this work, the authors used the GPT-4o service developed by OpenAI to improve the English language and remove grammar and spelling errors. After using this service, the authors reviewed and edited the content if needed and took full responsibility for the publication’s content.