False Vaccine Contraindications in Pediatric Practice: A Nationwide Survey and European Comparison

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Although there are European data on the practices of false known vaccine contraindications that may contribute to increasing vaccine hesitancy and refusal in recent years, there is no comprehensive study in this area in Türkiye and similar countries. Methods A survey study with the participation of the members of the European Society of Pediatric Infectious Diseases was taken as an example and an attempt was made to determine the practical practices of pediatricians regarding vaccine contraindications and precautions with more expanded themes of vaccine practices. The study was conducted as a survey study with the members of the National Pediatric Workshop called Pediatric Atelier. Results A total of 126 pediatricians completed the survey, yielding 1,638 responses across 13 clinical scenarios. In scenarios where there were no real precautions or contraindications to vaccination, 96.4% (1060/1100) of pediatricians made the correct decision to vaccinate. In the chemotherapy scenario requiring postpone, only 44.4% (56/126) pediatricians appropriately postponed live attenuated vaccine. 93.6% (118/126) of pediatricians correctly contraindicated vaccines in anaphylaxis scenario. For the other total scenarios, 33.3% (59/177) of pediatricians’ responses demonstrated false contraindication tendencies. Conclusion False contraindication patterns in Türkiye mirror Europe but reveal country-specific gaps, particularly in critical conditions such as chemotherapy scenario and false anaphylaxis indications. These findings highlight the need for targeted education on vaccine contraindications in pediatric training programs. False contraindications immunization pediatrics vaccine hesitancy What is Known Immunization has been recognized as one of the most cost-effective public health interventions. The misconceptions contribute to missed opportunities for immunization. What is New: There is insufficient information on pediatricians' misconceptions and false contraindications about the vaccines, and the results of this study may contribute to closing this gap in the literature. Data from the study can be used to update pediatric education and public health interventions on immunization. INTRODUCTION Vaccination remains one of the most effective and cost-efficient public health interventions to prevent infectious diseases in children. Despite the availability of safe and efficacious vaccines, global immunization coverage has plateaued or even declined in certain regions due to increasing vaccine hesitancy, misinformation, and missed opportunities for immunization. Among these contributing factors, false contraindications, misjudgments by healthcare providers that lead to unnecessary postponement or refusal of vaccines, are a particularly insidious barrier to optimal immunization rates ( 1 ). Healthcare professionals, especially pediatricians, play a pivotal role in ensuring vaccine uptake through evidence-based recommendations. However, multiple studies have shown that even trained physicians sometimes delay or withhold vaccines in the absence of valid clinical contraindications, either due to insufficient knowledge, fear of adverse events, or overly cautious interpretation of ambiguous symptoms. This phenomenon not only reduces vaccination coverage but may also unintentionally reinforce parental doubts and vaccine hesitancy ( 2 ). A recent study conducted by the European Society of Pediatric Infectious Diseases (ESPID) highlighted this issue by demonstrating that approximately one in five European pediatricians would either delay or contraindicate vaccines based on incorrect clinical assumptions. Scenarios involving mild fever, antibiotic use, steroid treatment, or post-chemotherapy status were frequently misinterpreted as reasons to withhold vaccines, despite contrary recommendations from international guidelines such as those of the World Health Organization (WHO) and the Advisory Committee on Immunization Practices (ACIP) ( 2 – 5 ). Although similar issues are suspected to occur in Türkiye, to date, no nationwide study has systematically examined how Turkish pediatricians interpret and apply vaccine contraindication guidelines in daily practice. Considering Türkiye's strong national immunization program and broad geographic and socioeconomic diversity, understanding these provider-level decision-making processes is critical for addressing missed vaccination opportunities and optimizing immunization strategies. This study aims to assess the knowledge and attitudes of pediatricians in Türkiye regarding vaccine contraindications and precautions, using clinical case-based scenarios modeled on the ESPID study ( 2 ). By comparing the Turkish results to European data, we hope to identify shared trends as well as country-specific gaps that could inform future pediatric training, policy updates, and public health interventions. MATERIALS AND METHODS Study Design and Setting This study was designed as a descriptive, cross-sectional survey to assess the practical knowledge and decision-making behavior of pediatricians in Türkiye regarding vaccine contraindications and precautions. The survey was inspired by and partially adapted from a prior European study conducted by the ESPID, with modifications to reflect national vaccination practices and to include additional scenarios relevant to the Turkish healthcare context ( 2 ). Study Population Participants were pediatricians who are members of the Pediatric Atelier, a nationwide professional network that includes over 2,500 pediatricians practicing in diverse settings across almost all provinces of Türkiye. This group was chosen due to its comprehensive representation of frontline pediatric healthcare providers. All practicing pediatricians within the network were eligible to participate, regardless of subspecialty or institutional affiliation. Survey Instrument A structured questionnaire was developed based on existing clinical guidelines from WHO and national immunization protocols. The questionnaire consisted of 13 clinical case scenarios, each describing a pediatric patient with a condition that may or may not require postponement or contraindication of vaccination. The themes included: fever, epilepsy, cerebral palsy, antibiotic therapy, prematurity, recent chemotherapy, history of anaphylaxis, breastfeeding, steroid use, recovery from meningococcal infection, administration of live attenuated vaccines, monoclonal antibody, and chronic diseases. For each scenario, participants were asked to choose one of three options: Vaccinate, Delay vaccination (Precaution), or Do not vaccinate (Contraindicated). Scenarios were selected to reflect real-life ambiguity in clinical decision-making and to assess provider knowledge in both common and complex cases. Data Collection The survey was distributed electronically via the Pediatric Atelier’s communication platform. Participation was voluntary and anonymous. No personal identifiers were collected. Participants were informed about the purpose of the study, and consent was implied upon completion of the survey. The data collection period lasted four weeks (March-April 2024) All responses were entered into a secure, password-protected database and analyzed using SPSS. Descriptive statistics were used to summarize participants’ choices for each scenario. Responses were categorized as: Correct, False precaution, and False contraindication. Comparisons were made with data from the ESPID study to identify similarities and differences in decision-making patterns between Turkish and European pediatricians. This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Ethics Committee of Memorial Hospital (No: 2025.0616). RESULTS A total of 126 pediatricians completed the survey, yielding 1,638 responses across 13 clinical scenarios. Of these, 1.234 responses (75.3%, n = 1234/1638) were consistent with current immunization guidelines and were categorized as correct. The remaining responses consisted of 305 instances (18.6%, n = 305/1638) in which vaccination was unnecessarily delayed ( false precautions ) and 59 instances (3.6%, n = 59/1638) where vaccines were incorrectly contraindicated ( false contraindications ) (Table 1 ). Table 1 Summary of pediatricians’ responses by scenario No. Clinical scenario Theme Vaccinate (n, %) Delay (n, %) Contraindicated (n, %) TOTAL (n, %) 1 Fever (38.3°C) and mild diarrhea Fever 28 (22.2%) 97 (77.0%) 1 (0.8%) 126 (100%) 2 Stable epilepsy on antiepileptic drugs Epilepsy 117 (92.9%) 8 (6.3%) 1 (0.8%) 126 (100%) 3 Cerebral palsy Cerebral palsy 126 (100%) 0 (0%) 0 (0%) 126 (100%) 4 Acute tonsillitis on Day 3 of amoxicillin-clavulanate therapy Antibiotic usage 68 (54.0%) 58 (46.0%) 0 (0%) 126 (100%) 5 Prematurity (33 weeks gestation), now four months of age Prematurity 104 (82.5%) 20 (15.9%) 2 (1.6%) 126 (100%) 6 Post-chemotherapy (2 months ago), varicella vaccination Chemotherapy 36 (28.6%) 56 (44.4%) 34 (27.0%) 126 (100%) 7 Anaphylaxis after first dose of Hepatitis A vaccine Anaphylaxis 4 (3.2%) 4 (3.2%) 118 (93.6%) 126 (100%) 8 Exclusive breastfeeding Breastfeeding 122 (96.8%) 3 (2.4%) 1 (0.8%) 126 (100%) 9 Asthma, recently completed 3-day course of 2 mg/kg/day oral steroids Steroid usage 86 (68.3%) 40 (31.7%) 0 (0%) 126 (100%) 10 Recovery from meningococcal septicemia (4 weeks ago) Convalescence 72 (57.1%) 50 (39.7%) 4 (3.2%) 126 (100%) 11 Administration of rotavirus vaccine after BCG Live attenuated vaccines 112 (88.9%) 14 (11.1%) 0 (0%) 126 (100%) 12 Congenital heart disease, recently received palivizumab and MMR vaccination Monoclonal antibody 110 (87.3%) 14 (11.1%) 2 (1.6%) 126 (100%) 13 Chronic liver disease (biliary atresia) Chronic disease 122 (96.8%) 2 (1.6%) 2 (1.6%) 126 (100%) Total Total number of responses [ True (n ) and False (n)] 1100 [ 1060 + 40] 361 [ 56 + 305] 177 [ 118 + 59] 1638 (100%) [ 1234 + 404] The highest level of correct responses was observed in scenarios involving clinical conditions commonly mistaken for contraindications by the public, such as cerebral palsy, breastfeeding, and chronic diseases. All participants (100%) correctly chose to vaccinate a child with cerebral palsy. Similarly, 96.8% correctly proceeded with vaccination in the case of an exclusively breastfed 6-month-old infant and in a child diagnosed with chronic diseases (biliary atresia). These results suggest a strong level of familiarity with national and international guidelines in these more straightforward scenarios. In contrast, scenarios involving mild acute illness or common medical treatments such as low-grade fever, antibiotic use, and recent steroid therapy were often misinterpreted. In the scenario of a 6-month-old infant with a body temperature of 38.3°C and mild diarrhea, only 22.2% of respondents chose to vaccinate, while the remaining 77% opted to delay immunization. This closely mirrors the European ESPID data, in which 23.0% of pediatricians vaccinated under similar circumstances. A similar hesitancy was noted for children receiving antibiotics: only 54% chose to vaccinate a child on high-dose amoxicillin-clavulanate therapy for tonsillitis, despite evidence that antibiotics are not a contraindication. Likewise, 68.3% correctly vaccinated a child recently treated with short-term systemic steroids for an asthma exacerbation, though 31.7% still chose to delay immunization unnecessarily (Table 1 ). Complex clinical contexts, particularly those involving immunosuppression or recovery from serious illness, demonstrated even greater variability in responses. In a case describing a child who had completed chemotherapy for Hodgkin lymphoma two months prior and presented for a varicella vaccination, only 44.4% of pediatricians correctly postponed the vaccine. 28.6% chose to vaccination (which is inappropriate), and 27% incorrectly classified the situation as a permanent contraindication (Table 1 ). Compared to ESPID data, which showed 4.6% opting to vaccinate, 61% delaying, and 34.4% contraindicating, Turkish pediatricians showed a slightly better understanding of temporary immunosuppression but still revealed a significant knowledge gap regarding the timing of live vaccines post-chemotherapy. On the other hand, pediatricians demonstrated excellent judgment in the anaphylaxis scenario. Following a clear-cut case of vaccine-related anaphylaxis after a previous Hepatitis A dose, 93.6% of participants correctly contraindicated further administration, a figure nearly identical to that reported in the ESPID survey (91.2%) ( 2 ). Other scenarios also reflected moderate levels of confusion. For instance, in the case of a child recovering from meningococcal septic shock four weeks earlier, only 57.1% proceeded with vaccination, while 39.7% chose to delay unnecessarily. In a scenario involving the simultaneous administration of live vaccines (e.g., BCG and rotavirus), 88.9% responded correctly, indicating high familiarity with co-administration principles. Similarly, most pediatricians (87.3%) correctly chose to vaccinate a child with congenital heart disease who had recently received passive immunization with palivizumab (Table 1 ). Overall, the results demonstrate that while pediatricians in Türkiye generally follow established immunization practices, notable gaps persist—particularly in scenarios involving mild illness, immunosuppression, and recovery from severe infection. These trends closely mirror those observed in the ESPID study, suggesting that misinterpretation of vaccine contraindications is a widespread challenge across regions and healthcare systems. DISCUSSION This study provides insight into the clinical reasoning of Turkish pediatricians regarding vaccination decisions and their interpretation of contraindications in real-life scenarios. Our findings highlight that while the majority of pediatricians demonstrate appropriate knowledge of vaccine safety in straightforward clinical conditions, notable misconceptions persist in more nuanced or ambiguous situations, particularly regarding mild illness, recent chemotherapy, and concurrent medication use. The patterns observed in our study closely mirror those identified in the European Society of Pediatric Infectious Diseases (ESPID) survey, suggesting that false contraindications are a pervasive and international challenge. In both the Turkish and ESPID cohorts, mild fever was one of the most frequently misinterpreted conditions, with over 75% of physicians choosing to delay immunization unnecessarily. This trend contradicts well-established guidelines by the World Health Organization (WHO) and Advisory Committee on Immunization Practices (ACIP), which explicitly state that mild acute illness, with or without low-grade fever, is not a valid reason to defer vaccination ( 3 ). Similarly, antibiotic therapy and recent steroid use were commonly associated with unnecessary precautionary delays, despite evidence that neither affects vaccine immunogenicity nor increases adverse outcomes ( 4 ). This suggests a persistent gap between theoretical knowledge and clinical application, possibly driven by over cautiousness or outdated education. One of the most concerning findings was the handling of the post-chemotherapy scenario, which requires nuanced interpretation based on the type of vaccine and timing post-treatment. Only 44.4% of Turkish pediatricians answered correctly by appropriately delaying the administration of live vaccines. A significant proportion (27%) incorrectly considered this an absolute contraindication. This pattern was similarly reflected in the ESPID data and points to a critical need for better education on vaccine use in immunocompromised patients. Studies have shown that live vaccines can be safely administered two years after chemotherapy in patients with hematologic malignancies in remission ( 5 , 6 ). The scenario involving anaphylaxis was the most accurately interpreted among all participants in both studies, reflecting widespread recognition of this as a definitive contraindication. This suggests that when guidelines are clear and consistent, provider adherence is high. In contrast, ambiguous or complex scenarios are more prone to misinterpretation. Our findings align with prior literature suggesting that healthcare providers, while often supportive of immunization in principle, may lack detailed knowledge about vaccine contraindications ( 7 ). Verger et al. demonstrated a similar disconnect among French general practitioners during periods of public vaccine controversy ( 8 ). Agrinier et al. further highlighted inconsistencies between physicians’ recommendations to patients and the vaccination decisions they make for their own children, underscoring the influence of underlying uncertainty and personal bias ( 9 ). Importantly, Sridhar et al. emphasized that missed opportunities for vaccination, often due to false contraindications, remain one of the most frequent and preventable causes of under-immunization globally ( 7 ). Our data support this conclusion and demonstrate that even in a country with a well-established national immunization program like Türkiye, there is a critical need for ongoing education of pediatricians on vaccine safety and contraindications. One strength of our study is the use of realistic, case-based scenarios that reflect the complexity of day-to-day pediatric practice. However, our study is not without limitations. The survey was conducted among members of a professional pediatric network, which may include more academically engaged practitioners than the general pediatric population. Therefore, the true prevalence of misinterpretations may be even higher in the broader clinical community. Furthermore, the study did not assess participants' prior training, access to guidelines, or confidence levels in vaccine decision-making, all of which may influence clinical judgment. In light of these findings, we recommend that national health authorities and pediatric associations integrate focused, scenario-based training on vaccine contraindications into residency programs and continuing medical education. Developing concise, accessible guidance—perhaps via mobile apps, flowcharts, or quick-reference tools—may also improve confidence and reduce the frequency of missed opportunities to vaccinate. This nationwide survey highlights that Turkish pediatricians, while generally knowledgeable and aligned with immunization guidelines in straightforward scenarios, continue to exhibit significant rates of false vaccine contraindications in more complex clinical situations. Similar to findings reported in European studies, conditions such as mild fever, antibiotic use, and recent chemotherapy are frequently misinterpreted as valid reasons to delay or avoid vaccination. Conclusion The misconceptions contribute to missed opportunities for immunization, potentially undermining national vaccination coverage and public confidence in vaccines. Of particular concern is the misjudgment surrounding temporary immunosuppressive states, such as post-chemotherapy, where confusion over live vaccine safety persists despite clear international recommendations. To address these gaps, targeted education strategies focusing on practical, scenario-based training in vaccine safety and contraindications should be incorporated into both undergraduate medical curricula and continuing professional development for pediatricians. Strengthening the confidence and consistency of healthcare providers is a critical step toward improving vaccine uptake and combating hesitancy in Türkiye and beyond. Declarations Funding: The authors declare that no funds, grants, or other support were received during the preparation of this manuscript. Competing Interests: The authors have no relevant financial or non-financial interests to disclose. Author Contributions: All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by Serkan Atıcı, and Ahmet Soysal. The first draft of the manuscript was written by Serkan Atıcı and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript. Ethics approval: This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Ethics Committee of Memorial Hospital (Decision no: 2025.0616). Consent to participate: Informed consent was obtained from all individual participants included in the study. References Gentile Á, Castellano VE, Juárez MDV, Diana Menéndez S, Degiuseppe JI, Lución MF, Moreno RP. National survey for pediatricians in Argentina: Vaccination in daily practice, perception of knowledge and barriers. Arch Argent Pediatr. 2024; 1:122(3):e202310204. Rivero I, Raguindin PF, Buttler R, Martinon-Torres F. False vaccine contraindications among healthcare providers in Europe: A short survey among members of the European Society of Pediatric Infectious Diseases. Pediatr Infect Dis J. 2019;38(9):974–6. Kroger AT, Duchin J, Vázquez M. General Best Practice Guidelines for Immunization: Best Practices Guidance of the Advisory Committee on Immunization Practices (ACIP). Centers for Disease Control and Prevention; 2018. Available from: https://www.cdc.gov/vaccines/hcp/acip-recs/general-recs/index.html Lopez AL, Harris JB, Raguindin PF, et al. Introduction of inactivated poliovirus vaccine in the Philippines: effect on healthcare provider and infant caregiver attitudes and practices. Vaccine. 2018;36(52):7399–7407. doi:10.1016/j.vaccine.2018.10.090 Martinon-Torres F, Rivero-Calle I. Vaccine Safety and False Contraindication to Vaccination: Training Manual. Copenhagen: WHO Regional Office for Europe; 2017. Einarsson J, Wilkinson AN. Vaccination considerations for patients receiving cancer therapy. Can Fam Physician. 2022;68(10):751-2. Sridhar S, Maleq N, Guillermet E, Colombini A, Gessner BD. A systematic literature review of missed opportunities for immunization in low- and middle-income countries. Vaccine. 2014;32(51):6870–9. doi:10.1016/j.vaccine.2014.10.063 Verger P, Fressard L, Collange F, Gautier A, Jestin C, Launay O, et al. Vaccine hesitancy among general practitioners and its determinants during controversies: a National Cross-Sectional Survey in France. EBioMedicine. 2015;2(8):891–7. doi:10.1016/j.ebiom.2015.06.018 Agrinier N, Le Maréchal M, Fressard L, Verger P, Pulcini C. Discrepancies between general practitioners’ vaccination recommendations for their patients and practices for their own children. Clin Microbiol Infect. 2017;23(5):311–7. doi:10.1016/j.cmi.2016.12.006 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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The misconceptions contribute to missed opportunities for immunization.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eWhat is New:\u0026nbsp;\u003c/strong\u003eThere is insufficient information on pediatricians\u0026apos; misconceptions and false contraindications about the vaccines, and the results of this study may contribute to closing this gap in the literature. Data from the study can be used to update pediatric education and public health interventions on immunization.\u003c/p\u003e"},{"header":"INTRODUCTION","content":"\u003cp\u003eVaccination remains one of the most effective and cost-efficient public health interventions to prevent infectious diseases in children. Despite the availability of safe and efficacious vaccines, global immunization coverage has plateaued or even declined in certain regions due to increasing vaccine hesitancy, misinformation, and missed opportunities for immunization. Among these contributing factors, false contraindications, misjudgments by healthcare providers that lead to unnecessary postponement or refusal of vaccines, are a particularly insidious barrier to optimal immunization rates (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eHealthcare professionals, especially pediatricians, play a pivotal role in ensuring vaccine uptake through evidence-based recommendations. However, multiple studies have shown that even trained physicians sometimes delay or withhold vaccines in the absence of valid clinical contraindications, either due to insufficient knowledge, fear of adverse events, or overly cautious interpretation of ambiguous symptoms. This phenomenon not only reduces vaccination coverage but may also unintentionally reinforce parental doubts and vaccine hesitancy (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eA recent study conducted by the European Society of Pediatric Infectious Diseases (ESPID) highlighted this issue by demonstrating that approximately one in five European pediatricians would either delay or contraindicate vaccines based on incorrect clinical assumptions. Scenarios involving mild fever, antibiotic use, steroid treatment, or post-chemotherapy status were frequently misinterpreted as reasons to withhold vaccines, despite contrary recommendations from international guidelines such as those of the World Health Organization (WHO) and the Advisory Committee on Immunization Practices (ACIP) (\u003cspan additionalcitationids=\"CR3 CR4\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e Although similar issues are suspected to occur in T\u0026uuml;rkiye, to date, no nationwide study has systematically examined how Turkish pediatricians interpret and apply vaccine contraindication guidelines in daily practice. Considering T\u0026uuml;rkiye's strong national immunization program and broad geographic and socioeconomic diversity, understanding these provider-level decision-making processes is critical for addressing missed vaccination opportunities and optimizing immunization strategies. This study aims to assess the knowledge and attitudes of pediatricians in T\u0026uuml;rkiye regarding vaccine contraindications and precautions, using clinical case-based scenarios modeled on the ESPID study (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). By comparing the Turkish results to European data, we hope to identify shared trends as well as country-specific gaps that could inform future pediatric training, policy updates, and public health interventions.\u003c/p\u003e"},{"header":"MATERIALS AND METHODS","content":"\u003cp\u003e\u003cb\u003eStudy Design and Setting\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThis study was designed as a descriptive, cross-sectional survey to assess the practical knowledge and decision-making behavior of pediatricians in T\u0026uuml;rkiye regarding vaccine contraindications and precautions. The survey was inspired by and partially adapted from a prior European study conducted by the ESPID, with modifications to reflect national vaccination practices and to include additional scenarios relevant to the Turkish healthcare context (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cb\u003eStudy Population\u003c/b\u003e\u003c/p\u003e\u003cp\u003e Participants were pediatricians who are members of the Pediatric Atelier, a nationwide professional network that includes over 2,500 pediatricians practicing in diverse settings across almost all provinces of T\u0026uuml;rkiye. This group was chosen due to its comprehensive representation of frontline pediatric healthcare providers. All practicing pediatricians within the network were eligible to participate, regardless of subspecialty or institutional affiliation.\u003c/p\u003e\u003cp\u003e\u003cb\u003eSurvey Instrument\u003c/b\u003e\u003c/p\u003e\u003cp\u003e A structured questionnaire was developed based on existing clinical guidelines from WHO and national immunization protocols. The questionnaire consisted of 13 clinical case scenarios, each describing a pediatric patient with a condition that may or may not require postponement or contraindication of vaccination. The themes included: fever, epilepsy, cerebral palsy, antibiotic therapy, prematurity, recent chemotherapy, history of anaphylaxis, breastfeeding, steroid use, recovery from meningococcal infection, administration of live attenuated vaccines, monoclonal antibody, and chronic diseases. For each scenario, participants were asked to choose one of three options: Vaccinate, Delay vaccination (Precaution), or Do not vaccinate (Contraindicated). Scenarios were selected to reflect real-life ambiguity in clinical decision-making and to assess provider knowledge in both common and complex cases.\u003c/p\u003e\u003cp\u003e\u003cb\u003eData Collection\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe survey was distributed electronically via the Pediatric Atelier\u0026rsquo;s communication platform. Participation was voluntary and anonymous. No personal identifiers were collected. Participants were informed about the purpose of the study, and consent was implied upon completion of the survey. The data collection period lasted four weeks (March-April 2024)\u003c/p\u003e\u003cp\u003eAll responses were entered into a secure, password-protected database and analyzed using SPSS. Descriptive statistics were used to summarize participants\u0026rsquo; choices for each scenario. Responses were categorized as: Correct, False precaution, and False contraindication. Comparisons were made with data from the ESPID study to identify similarities and differences in decision-making patterns between Turkish and European pediatricians.\u003c/p\u003e\u003cp\u003e This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Ethics Committee of Memorial Hospital (No: 2025.0616).\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003eA total of 126 pediatricians completed the survey, yielding 1,638 responses across 13 clinical scenarios. Of these, 1.234 responses (75.3%, n\u0026thinsp;=\u0026thinsp;1234/1638) were consistent with current immunization guidelines and were categorized as correct. The remaining responses consisted of 305 instances (18.6%, n\u0026thinsp;=\u0026thinsp;305/1638) in which vaccination was unnecessarily delayed (\u003cem\u003efalse precautions\u003c/em\u003e) and 59 instances (3.6%, n\u0026thinsp;=\u0026thinsp;59/1638) where vaccines were incorrectly contraindicated (\u003cem\u003efalse contraindications\u003c/em\u003e) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eSummary of pediatricians\u0026rsquo; responses by scenario\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"7\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo.\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eClinical scenario\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eTheme\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eVaccinate\u003c/p\u003e\u003cp\u003e(n, %)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eDelay\u003c/p\u003e\u003cp\u003e(n, %)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eContraindicated\u003c/p\u003e\u003cp\u003e(n, %)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eTOTAL\u003c/p\u003e\u003cp\u003e(n, %)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFever (38.3\u0026deg;C) and mild diarrhea\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFever\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e28 (22.2%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e97 (77.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1 (0.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e126 (100%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eStable epilepsy on antiepileptic drugs\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eEpilepsy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e117 (92.9%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e8 (6.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1 (0.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e126 (100%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCerebral palsy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eCerebral palsy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e126 (100%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0 (0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0 (0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e126 (100%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAcute tonsillitis on Day 3 of amoxicillin-clavulanate therapy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eAntibiotic usage\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e68 (54.0%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e58 (46.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0 (0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e126 (100%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePrematurity (33 weeks gestation), now four months of age\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePrematurity\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e104 (82.5%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e20 (15.9%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e2 (1.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e126 (100%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePost-chemotherapy (2 months ago), varicella vaccination\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eChemotherapy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e36 (28.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e56 (44.4%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e34 (27.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e126 (100%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAnaphylaxis after first dose of Hepatitis A vaccine\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eAnaphylaxis\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e4 (3.2%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e4 (3.2%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cb\u003e118 (93.6%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e126 (100%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eExclusive breastfeeding\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eBreastfeeding\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e122 (96.8%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e3 (2.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1 (0.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e126 (100%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAsthma, recently completed 3-day course of 2 mg/kg/day oral steroids\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSteroid usage\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e86 (68.3%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e40 (31.7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0 (0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e126 (100%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRecovery from meningococcal septicemia (4 weeks ago)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eConvalescence\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e72 (57.1%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e50 (39.7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e4 (3.2%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e126 (100%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAdministration of rotavirus vaccine after BCG\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eLive attenuated vaccines\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e112 (88.9%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e14 (11.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0 (0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e126 (100%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCongenital heart disease, recently received palivizumab and MMR vaccination\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMonoclonal antibody\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e110 (87.3%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e14 (11.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e2 (1.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e126 (100%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eChronic liver disease (biliary atresia)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eChronic disease\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e122 (96.8%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2 (1.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e2 (1.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e126 (100%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTotal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTotal number of responses\u003c/p\u003e\u003cp\u003e\u003cb\u003e[\u003c/b\u003e\u003cb\u003eTrue (n\u003c/b\u003e\u003cb\u003e)\u003c/b\u003e and False (n)]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1100\u003c/p\u003e\u003cp\u003e[\u003cb\u003e1060\u003c/b\u003e\u0026thinsp;+\u0026thinsp;40]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e361\u003c/p\u003e\u003cp\u003e[\u003cb\u003e56\u003c/b\u003e\u0026thinsp;+\u0026thinsp;305]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e177\u003c/p\u003e\u003cp\u003e[\u003cb\u003e118\u003c/b\u003e\u0026thinsp;+\u0026thinsp;59]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e1638 (100%)\u003c/p\u003e\u003cp\u003e[\u003cb\u003e1234\u003c/b\u003e\u0026thinsp;+\u0026thinsp;404]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThe highest level of correct responses was observed in scenarios involving clinical conditions commonly mistaken for contraindications by the public, such as cerebral palsy, breastfeeding, and chronic diseases. All participants (100%) correctly chose to vaccinate a child with cerebral palsy. Similarly, 96.8% correctly proceeded with vaccination in the case of an exclusively breastfed 6-month-old infant and in a child diagnosed with chronic diseases (biliary atresia). These results suggest a strong level of familiarity with national and international guidelines in these more straightforward scenarios.\u003c/p\u003e\u003cp\u003eIn contrast, scenarios involving mild acute illness or common medical treatments such as low-grade fever, antibiotic use, and recent steroid therapy were often misinterpreted. In the scenario of a 6-month-old infant with a body temperature of 38.3\u0026deg;C and mild diarrhea, only 22.2% of respondents chose to vaccinate, while the remaining 77% opted to delay immunization. This closely mirrors the European ESPID data, in which 23.0% of pediatricians vaccinated under similar circumstances. A similar hesitancy was noted for children receiving antibiotics: only 54% chose to vaccinate a child on high-dose amoxicillin-clavulanate therapy for tonsillitis, despite evidence that antibiotics are not a contraindication. Likewise, 68.3% correctly vaccinated a child recently treated with short-term systemic steroids for an asthma exacerbation, though 31.7% still chose to delay immunization unnecessarily (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eComplex clinical contexts, particularly those involving immunosuppression or recovery from serious illness, demonstrated even greater variability in responses. In a case describing a child who had completed chemotherapy for Hodgkin lymphoma two months prior and presented for a varicella vaccination, only 44.4% of pediatricians correctly postponed the vaccine. 28.6% chose to vaccination (which is inappropriate), and 27% incorrectly classified the situation as a permanent contraindication (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Compared to ESPID data, which showed 4.6% opting to vaccinate, 61% delaying, and 34.4% contraindicating, Turkish pediatricians showed a slightly better understanding of temporary immunosuppression but still revealed a significant knowledge gap regarding the timing of live vaccines post-chemotherapy. On the other hand, pediatricians demonstrated excellent judgment in the anaphylaxis scenario. Following a clear-cut case of vaccine-related anaphylaxis after a previous Hepatitis A dose, 93.6% of participants correctly contraindicated further administration, a figure nearly identical to that reported in the ESPID survey (91.2%) (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eOther scenarios also reflected moderate levels of confusion. For instance, in the case of a child recovering from meningococcal septic shock four weeks earlier, only 57.1% proceeded with vaccination, while 39.7% chose to delay unnecessarily. In a scenario involving the simultaneous administration of live vaccines (e.g., BCG and rotavirus), 88.9% responded correctly, indicating high familiarity with co-administration principles. Similarly, most pediatricians (87.3%) correctly chose to vaccinate a child with congenital heart disease who had recently received passive immunization with palivizumab (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eOverall, the results demonstrate that while pediatricians in T\u0026uuml;rkiye generally follow established immunization practices, notable gaps persist\u0026mdash;particularly in scenarios involving mild illness, immunosuppression, and recovery from severe infection. These trends closely mirror those observed in the ESPID study, suggesting that misinterpretation of vaccine contraindications is a widespread challenge across regions and healthcare systems.\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThis study provides insight into the clinical reasoning of Turkish pediatricians regarding vaccination decisions and their interpretation of contraindications in real-life scenarios. Our findings highlight that while the majority of pediatricians demonstrate appropriate knowledge of vaccine safety in straightforward clinical conditions, notable misconceptions persist in more nuanced or ambiguous situations, particularly regarding mild illness, recent chemotherapy, and concurrent medication use.\u003c/p\u003e\u003cp\u003eThe patterns observed in our study closely mirror those identified in the European Society of Pediatric Infectious Diseases (ESPID) survey, suggesting that false contraindications are a pervasive and international challenge. In both the Turkish and ESPID cohorts, mild fever was one of the most frequently misinterpreted conditions, with over 75% of physicians choosing to delay immunization unnecessarily. This trend contradicts well-established guidelines by the World Health Organization (WHO) and Advisory Committee on Immunization Practices (ACIP), which explicitly state that mild acute illness, with or without low-grade fever, is not a valid reason to defer vaccination (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eSimilarly, antibiotic therapy and recent steroid use were commonly associated with unnecessary precautionary delays, despite evidence that neither affects vaccine immunogenicity nor increases adverse outcomes (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). This suggests a persistent gap between theoretical knowledge and clinical application, possibly driven by over cautiousness or outdated education.\u003c/p\u003e\u003cp\u003eOne of the most concerning findings was the handling of the post-chemotherapy scenario, which requires nuanced interpretation based on the type of vaccine and timing post-treatment. Only 44.4% of Turkish pediatricians answered correctly by appropriately delaying the administration of live vaccines. A significant proportion (27%) incorrectly considered this an absolute contraindication. This pattern was similarly reflected in the ESPID data and points to a critical need for better education on vaccine use in immunocompromised patients. Studies have shown that live vaccines can be safely administered two years after chemotherapy in patients with hematologic malignancies in remission (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe scenario involving anaphylaxis was the most accurately interpreted among all participants in both studies, reflecting widespread recognition of this as a definitive contraindication. This suggests that when guidelines are clear and consistent, provider adherence is high. In contrast, ambiguous or complex scenarios are more prone to misinterpretation.\u003c/p\u003e\u003cp\u003eOur findings align with prior literature suggesting that healthcare providers, while often supportive of immunization in principle, may lack detailed knowledge about vaccine contraindications (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Verger et al. demonstrated a similar disconnect among French general practitioners during periods of public vaccine controversy (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Agrinier et al. further highlighted inconsistencies between physicians\u0026rsquo; recommendations to patients and the vaccination decisions they make for their own children, underscoring the influence of underlying uncertainty and personal bias (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eImportantly, Sridhar et al. emphasized that missed opportunities for vaccination, often due to false contraindications, remain one of the most frequent and preventable causes of under-immunization globally (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Our data support this conclusion and demonstrate that even in a country with a well-established national immunization program like T\u0026uuml;rkiye, there is a critical need for ongoing education of pediatricians on vaccine safety and contraindications.\u003c/p\u003e\u003cp\u003eOne strength of our study is the use of realistic, case-based scenarios that reflect the complexity of day-to-day pediatric practice. However, our study is not without limitations. The survey was conducted among members of a professional pediatric network, which may include more academically engaged practitioners than the general pediatric population. Therefore, the true prevalence of misinterpretations may be even higher in the broader clinical community. Furthermore, the study did not assess participants' prior training, access to guidelines, or confidence levels in vaccine decision-making, all of which may influence clinical judgment.\u003c/p\u003e\u003cp\u003eIn light of these findings, we recommend that national health authorities and pediatric associations integrate focused, scenario-based training on vaccine contraindications into residency programs and continuing medical education. Developing concise, accessible guidance\u0026mdash;perhaps via mobile apps, flowcharts, or quick-reference tools\u0026mdash;may also improve confidence and reduce the frequency of missed opportunities to vaccinate. This nationwide survey highlights that Turkish pediatricians, while generally knowledgeable and aligned with immunization guidelines in straightforward scenarios, continue to exhibit significant rates of false vaccine contraindications in more complex clinical situations. Similar to findings reported in European studies, conditions such as mild fever, antibiotic use, and recent chemotherapy are frequently misinterpreted as valid reasons to delay or avoid vaccination.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe misconceptions contribute to missed opportunities for immunization, potentially undermining national vaccination coverage and public confidence in vaccines. Of particular concern is the misjudgment surrounding temporary immunosuppressive states, such as post-chemotherapy, where confusion over live vaccine safety persists despite clear international recommendations. To address these gaps, targeted education strategies focusing on practical, scenario-based training in vaccine safety and contraindications should be incorporated into both undergraduate medical curricula and continuing professional development for pediatricians. Strengthening the confidence and consistency of healthcare providers is a critical step toward improving vaccine uptake and combating hesitancy in T\u0026uuml;rkiye and beyond.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e The authors declare that no funds, grants, or other support were received during the preparation of this manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests:\u0026nbsp;\u003c/strong\u003eThe authors have no relevant financial or non-financial interests to disclose.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions:\u003c/strong\u003e All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by Serkan Atıcı, and Ahmet Soysal. The first draft of the manuscript was written by Serkan Atıcı and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval:\u003c/strong\u003e This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Ethics Committee of Memorial Hospital (Decision no: 2025.0616).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to participate:\u003c/strong\u003e Informed consent was obtained from all individual participants included in the study.\u003c/p\u003e\n"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eGentile \u0026Aacute;, Castellano VE, Ju\u0026aacute;rez MDV, Diana Men\u0026eacute;ndez S, Degiuseppe JI, Luci\u0026oacute;n MF, Moreno RP. National survey for pediatricians in Argentina: Vaccination in daily practice, perception of knowledge and barriers. Arch Argent Pediatr. 2024; 1:122(3):e202310204.\u003c/li\u003e\n\u003cli\u003eRivero I, Raguindin PF, Buttler R, Martinon-Torres F. False vaccine contraindications among healthcare providers in Europe: A short survey among members of the European Society of Pediatric Infectious Diseases. Pediatr Infect Dis J. 2019;38(9):974\u0026ndash;6.\u003c/li\u003e\n\u003cli\u003eKroger AT, Duchin J, V\u0026aacute;zquez M. General Best Practice Guidelines for Immunization: Best Practices Guidance of the Advisory Committee on Immunization Practices (ACIP). Centers for Disease Control and Prevention; 2018. Available from: https://www.cdc.gov/vaccines/hcp/acip-recs/general-recs/index.html\u003c/li\u003e\n\u003cli\u003eLopez AL, Harris JB, Raguindin PF, et al. Introduction of inactivated poliovirus vaccine in the Philippines: effect on healthcare provider and infant caregiver attitudes and practices. Vaccine. 2018;36(52):7399\u0026ndash;7407. doi:10.1016/j.vaccine.2018.10.090\u003c/li\u003e\n\u003cli\u003eMartinon-Torres F, Rivero-Calle I. Vaccine Safety and False Contraindication to Vaccination: Training Manual. Copenhagen: WHO Regional Office for Europe; 2017.\u003c/li\u003e\n\u003cli\u003eEinarsson J, Wilkinson AN. Vaccination considerations for patients receiving cancer therapy. Can Fam Physician. 2022;68(10):751-2.\u003c/li\u003e\n\u003cli\u003eSridhar S, Maleq N, Guillermet E, Colombini A, Gessner BD. A systematic literature review of missed opportunities for immunization in low- and middle-income countries. Vaccine. 2014;32(51):6870\u0026ndash;9. doi:10.1016/j.vaccine.2014.10.063\u003c/li\u003e\n\u003cli\u003eVerger P, Fressard L, Collange F, Gautier A, Jestin C, Launay O, et al. Vaccine hesitancy among general practitioners and its determinants during controversies: a National Cross-Sectional Survey in France. EBioMedicine. 2015;2(8):891\u0026ndash;7. doi:10.1016/j.ebiom.2015.06.018\u003c/li\u003e\n\u003cli\u003eAgrinier N, Le Mar\u0026eacute;chal M, Fressard L, Verger P, Pulcini C. Discrepancies between general practitioners\u0026rsquo; vaccination recommendations for their patients and practices for their own children. Clin Microbiol Infect. 2017;23(5):311\u0026ndash;7. doi:10.1016/j.cmi.2016.12.006\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"False contraindications, immunization, pediatrics, vaccine hesitancy","lastPublishedDoi":"10.21203/rs.3.rs-7030020/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7030020/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e\u003cp\u003eFalse vaccine contraindications among healthcare providers contribute to preventable under-immunization. Although there are European data on the practices of false known vaccine contraindications that may contribute to increasing vaccine hesitancy and refusal in recent years, there is no comprehensive study in this area in T\u0026uuml;rkiye and similar countries.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eA survey study with the participation of the members of the European Society of Pediatric Infectious Diseases was taken as an example and an attempt was made to determine the practical practices of pediatricians regarding vaccine contraindications and precautions with more expanded themes of vaccine practices. The study was conducted as a survey study with the members of the National Pediatric Workshop called Pediatric Atelier.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eA total of 126 pediatricians completed the survey, yielding 1,638 responses across 13 clinical scenarios. In scenarios where there were no real precautions or contraindications to vaccination, 96.4% (1060/1100) of pediatricians made the correct decision to vaccinate. In the chemotherapy scenario requiring postpone, only 44.4% (56/126) pediatricians appropriately postponed live attenuated vaccine. 93.6% (118/126) of pediatricians correctly contraindicated vaccines in anaphylaxis scenario. For the other total scenarios, 33.3% (59/177) of pediatricians\u0026rsquo; responses demonstrated false contraindication tendencies.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eFalse contraindication patterns in T\u0026uuml;rkiye mirror Europe but reveal country-specific gaps, particularly in critical conditions such as chemotherapy scenario and false anaphylaxis indications. These findings highlight the need for targeted education on vaccine contraindications in pediatric training programs.\u003c/p\u003e","manuscriptTitle":"False Vaccine Contraindications in Pediatric Practice: A Nationwide Survey and European Comparison","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-11 11:54:27","doi":"10.21203/rs.3.rs-7030020/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"b2d97c01-76bb-4794-b7f7-8046ac9c8ab4","owner":[],"postedDate":"July 11th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-10-22T20:08:16+00:00","versionOfRecord":[],"versionCreatedAt":"2025-07-11 11:54:27","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7030020","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7030020","identity":"rs-7030020","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}