Acceptance of Influenza Vaccination in Asthmatic Children: What Does the Evidence Show?

Influenza remains a major public health concern worldwide and is associated with a substantial burden in children, particularly in those with chronic respiratory diseases such as asthma. This brief overview aimed to provide a preliminary examination of the available evidence on parental knowledge, attitudes, and acceptance of influenza vaccination, with a specific focus on children with asthma. The literature showed substantial variability in vaccination uptake, but overall rates were consistently suboptimal. Several factors were associated with higher vaccine acceptance, including healthcare professionals’ recommendations, greater parental awareness of influenza-related risks, trust in vaccine effectiveness, and increased perception of asthma severity. In contrast, poor knowledge, safety concerns, misconceptions about vaccines, and lack of medical advice were the main barriers to vaccination. Some studies also suggested a role for socioeconomic and healthcare access factors, although findings were not always consistent. Overall, parental acceptance of influenza vaccination in children with asthma appears to depend on a combination of clinical, social, and perceptual factors. Enhanced research efforts and targeted educational interventions may help improve vaccine uptake in this high-risk population; however, the current evidence remains limited, and further studies using validated methods are needed to better characterize the determinants of vaccine hesitancy and acceptance over time in this specific context.

BACKGROUND

Influenza poses a major public health issue ¹, with 4-50 million symptomatic cases occur annually in Europe ². While all age groups are affected, children, pregnant women, older adults, and individuals with chronic conditions are particularly vulnerable ². In Italy, a retrospective study of 10 influenza seasons (2010-2020) found an average of 8,892 influenza cases among 1,432,384 children aged 0-14 years ³, with higher incidence observed in children with at least two risk factors. In the 2023-2024 season, the Italian epidemiological surveillance system reported a peak weekly incidence of 46.91 cases per 1,000 in children aged 0-4 years and 21.83 per 1,000 in those aged 5-14 years ⁴. These data highlight the pediatric burden, contributing to school absenteeism and parental work loss ^5,6; moreover, children’s frequent close-contact settings and prolonged high viral shedding support their key role in transmission ^6,7. Annual influenza vaccination is a cornerstone of public health ⁸ and in recent years Italy has expanded pediatric influenza vaccination from high-risk children to include healthy children ⁹. Since the 2020-2021 season, the Italian Ministry of Health has recommended the annual vaccination for all children aged 6 months to 6 years, regardless of underlying health status ¹⁰. Moreover, the Italian National Immunization Prevention Plan 2023-2025 recognizes pediatric influenza vaccination as an “essential level of care” ¹¹. Among those at increased risk of influenza-related complications are children with chronic conditions, particularly respiratory diseases ^12,13. Asthma is a major chronic disease in childhood, is frequently associated with comorbidities ^14-16, and respiratory viruses are well-recognized triggers of exacerbations ^17,18. Considering this, we sought to preliminarily explore evidence on parental knowledge and perceptions of influenza and its vaccination in children with asthma, a subgroup warranting targeted assessment despite extensive literature on parental vaccine hesitancy (VH) ^19,20.

SUMMARY OF THE REVIEWED ARTICLE

The scientific evidence we reviewed shows that influenza vaccination coverage in children with asthma varies widely by country, time period, and study design, yet overall rates consistently fall short of international recommendations, with data mainly collected through self-reported survey. Jiménez-García et al. ²¹ reported an overall coverage of only 18.8% in the latest campaign analyzed; higher rates were later observed by Soyer et al. ²², where 69.5% of children had received at least one vaccine dose during their lifetime, although only 51.8% had been vaccinated during the most recent influenza season. In contrast, another study ²³ documented that only 11.7% of children received the annual vaccination, whereas Al-Qerem et al. ²⁴ reported that 60.4% of children had never been vaccinated, and only 10.5% received the vaccine annually. An intermediate pattern emerged elsewhere ²⁵, with a 43% vaccination rate during the 2003-2004 season. Notably, data collected during the COVID-19 pandemic highlighted a significant increase in vaccination uptake, suggesting a strong situation-specific influence. A Turkish study ²⁶ reported a rise from 29.5% before the pandemic to 71.8% during the pandemic, while another survey ²⁷ described an increase from 35.7% to 47.2%, with a substantial proportion of children receiving vaccination for the first time during this period. These findings point to the role of heightened risk perception, increased medical attention, and targeted recommendations ²⁸. However, concerns remain that this surge may not be sustained, as suggested by post-pandemic declines in coverage reported in Italy and elsewhere ^29,30. Beyond the pandemic, media communication and public health campaigns may also shape vaccination behaviors. The widespread media coverage of fatal paediatric influenza cases in 2003-2004 season was associated with higher parental acceptance ²⁵. Additionally, the key role of healthcare workers (HCWs) emerged – as well recognized in the literature ^28,31; a physician’s recommendation was found to more than double the likelihood of vaccination ²⁵, while Kaya et al. ²³ identified lack of medical advice as one of the major reasons for refusal. Again, HWCs are pivotal in shaping parental decisions: future research should determine which professionals – physicians, specialists, or nurses – exert the greatest influence, particularly for chronic diseases involving multiple providers.

Disease severity and perceptions can also play a critical role. Soyer et al. ²² reported higher uptake among children with three or more healthcare contacts for asthma, while a study in Spain ²¹ found that a negative parental perception of the child’s health status was associated with increased adherence, likely reflecting greater disease severity. Similarly, a history of multiple exacerbations and higher treatment steps were reported as positively associated with vaccination ²⁷. Ozer et al. ²⁶, during the pandemic, observed that regular asthma medication use, atopy, and a family history of COVID-19 were strong predictors of vaccine uptake in children. Conversely, one study ²⁴ found that longer asthma duration was associated with higher hesitancy and rejection, although uncontrolled or partially controlled asthma was linked to lower odds of refusal than controlled asthma. Parental beliefs about influenza and its vaccination were also recurrently identified as crucial determinants. Parents of vaccinated children perceived the vaccine as effective in preventing asthma attacks, whereas those who did not consider influenza a significant illness were more likely to decline vaccination ²². Similarly, Gnanasekaran et al. ²⁵ showed that trust in vaccine efficacy and low concern about side effects were associated with higher uptake. Al-Qerem et al. ²⁴ demonstrated that higher parental attitude scores toward the influenza vaccine reduced hesitancy and rejection. Likewise, one survey ³² emphasized that perceived benefits – particularly the risk of influenza in unvaccinated children – predicted vaccine uptake among children with asthma, whereas the belief that the vaccine could cause influenza was negatively associated with uptake.

Finally, no important significant associations were observed for contextual factors. However, significant differences were reported in monthly household income between vaccinated and unvaccinated children ²⁷. In another study ³² significant differences were observed in parental education level and the perceived ease of access to healthcare services was found as a positive predictor of vaccination status. Additionally, Al-Qerem et al. ²⁴ identified low educational level as a determinant of reduced VH compared with higher-educated groups. These findings probably suggest that the role of socio-economic context, access to services, and trust in the healthcare system warrant further investigation in this setting.

CONCLUSIONS

For healthcare providers, particularly those caring for children with chronic conditions, understanding how parents approach vaccination is crucial to inform immunization strategies, especially where vaccines are provided free of charge to high-risk groups. This preliminary overview suggests the need to enhance and update evidence in asthmatic children, also drawing on studies in other chronic conditions, and finally address key gaps, including the use of validated data collection, accurate sample characterization, and more detailed identification of critical determinants. As parental attitudes and behaviors can influence both individual beliefs and social factors, it is essential to identify subgroups that face barriers, clarify misconceptions, and enhance awareness while reinforcing perceived benefits. Addressing these can improve vaccine uptake, strengthen preventive care, and improve data collection, ultimately protecting this vulnerable population.

Acknowledgements

The authors have no acknowledgements to declare.

Ethical consideration

Since this study analyzed previously published primary data, ethical approval was not required.

Funding

No funding to declare.

Conflict of interest statement

The authors declare that they have no competing interests.

Author’s contributions

MR conducted the literature search, analyzed the included articles, and drafted the main text. AMZ and MD reviewed and revised the manuscript.

History

Received: March 6, 2026

Published: March 27, 2026