Parent/carers' opinions about COVID‐19 vaccination for children with chronic lung diseases

Discipline of Paediatrics, School of Women's and Children's Health, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia Respiratory Department, Sydney Children's Hospital, Randwick, New South Wales, Australia School of Population Health, University of New South Wales, Sydney, New South Wales, Australia Clinical Management Group, Woolcock Institute of Medical Research, University of Sydney, Sydney, New South Wales, Australia

Therefore, we conducted a survey among parents/carers of children with CLDs to determine their reasons for accepting or rejecting COVID-19 vaccines for their children.

| Study design and population
During November 2020 to February 2021, we conducted an online survey at Sydney Children's Hospital (SCH), Randwick. The SCH is one of Australia's leading tertiary pediatric healthcare entities and cares for more than 600 children with CLDs including asthma, CF, congenital diaphragmatic hernia (CDH), tracheo-esophageal fistula (TOF), non-CF bronchiectasis, primary ciliary dyskinesia (PCD), and other respiratory conditions. We reviewed the electronic medical records to collate a list of all children with CLDs who received care from SCH during 2015 to 2020. Parents/carers of all children with CLDs identified from the medical records were eligible to participate in the study. Parents/carers of children without chronic lung disease or who did not speak English were not included in the survey.
An email with the URL link and QR code to the online survey was sent to all eligible participants who had valid email addresses. Mails with the study URL address and QR code were posted to residential  (Table 1). Similarly, respondents who were unlikely to vaccinate responded to questions associated with reasons for refusing COVID-19 vaccine for their children with CLDs (Table 2). Respondents who responded unsure to whether they would get their child vaccinated against COVID-19 responded to both questions around reasons for accepting the vaccine and for refusing the vaccine.

| Statistical analysis
We used descriptive statistics such as frequency and proportions where appropriate. For purpose of analysis responses such as agree/ strongly agree and disagree/strongly disagree were grouped as agree or disagree, respectively. Area-level socioeconomic status (SES) was assessed using the Australian Bureau of Statistics Socio-Economic Indexes for Areas (SEIFA) Index of Relative Socioeconomic Advantage and Disadvantage (IRSAD), based on the child's residential postcode.
SES was according to the postcode's NSW percentiles. 4 All analyses were performed in STATA version 15.0, StataCorp.

| Ethics approval and consent
The study was approved by the ethics committee of the Sydney Children's Hospitals Network (2020/ETH02556). Information about the study including nature, purpose, and duration of the study was displayed on the front page of the online survey and included in the emails and the letters.
Participants consented by checking the "YES" button in the survey.

| RESULTS
We sent out 230 emails and 90 mails to 320 parents/carers of children with CLDs who had valid email and residential addresses listed in the medical records. Parents/carers of children with CLDs who came  6 Risk perception is a major driver in health behavior and the fact that more than 80% of parents/carers in our study believed that children with CLDs are at greater risk of COVID-19 infection than children without CLD may act as a key factor in increasing vaccine coverage in high-risk children 7 when a COVID-19 vaccine will be rolled to wider pediatric populations.
However, one-third of the parents (30%) who were likely to get their child vaccinated were unsure if the vaccine would be safe for the child. Concerns around the safety and side effects of the vaccine were also some of the major reasons cited by parents/carers who were not likely to get their child with CLD vaccinated and have been reported previously as well. 6 In addition, half of the parents/carers who were not likely to get their child vaccinated were concerned about their child getting an illness other than COVID-19 from the vaccine and one-third of them were willing to keep their children at home to protect than from COVID-19 rather than getting them vaccinated.
These lines of evidence suggest that while there is consensus among parents/carers of children with CLDs regarding the severity of COVID-19, the major issue around uptake of COVID-19 vaccine for children with CLDs is probably around safety issues. 7 These concerns might be further enhanced by the recent reports of unusual blood clots associated with COVID-19 vaccine. 8 The majority of the parents/carers reported that advice from the child's specialist/pediatricians or GP will positively impact their decision to get their child vaccinated. Healthcare worker's recommendation has been consistently identified as a major predictor of vaccine uptake for other diseases as well. 9 Children with CLDs require ongoing follow-up visits with their pediatricians/specialists or GPs. GPs and pediatricians could use scheduled follow-up visits of children with CLDs to promote COVID-19 vaccine and explain to their parents/ carers how the rare side effects outweigh the benefits of the vaccine. 10 One of the major limitations of our study is that the survey participants were recruited from one hospital; however, SCH is one of the largest tertiary hospitals in Sydney with a large diverse catchment population. Also, we do not know the characteristics of the parents/ carers who did not participate in the survey and can be very different from those who did. Nevertheless, our study has identified important factors that can be used in designing public health messages to improve COVID-19 vaccine uptake in this specific high-risk group of children.