Attitudes Among Pediatric Gastroenterologists Toward Vaccination Based on an Anonymous Online Survey

Abstract

Background: Children with inflammatory bowel disease (IBD) are at heightened risk for vaccine-preventable infections because of underlying immune dysregulation and long-term immunosuppressive therapy. Despite published guidelines affirming vaccine safety, real-world coverage remains suboptimal. It is a pilot, single-country survey designed to explore baseline knowledge and practices regarding vaccination in paediatric IBD within a specific local healthcare context. Objective: The objective of this study is to evaluate the knowledge, attitudes, and practices of paediatric gastroenterologists (PGs) regarding the immunisation of children with IBD. Methods: We conducted an exploratory pilot, cross-sectional survey of paediatric gastroenterologists in Russia, focusing on immunisation knowledge and practical barriers in routine care. A cross-sectional, anonymous online survey was distributed to PGs nationwide between January 2022 and April 2022. The online questionnaire explored demographic characteristics, awareness of international recommendations, perceptions of vaccine safety at various disease and treatment stages, and routine vaccination practices. Responses were analysed with non-parametric statistics (α = 0.05). In a parallel prospective cohort, the vaccination certificates of 98 paediatric IBD patients (January 2022–April 2023) were audited to quantify real-world coverage. Results: Fifty-one PGs completed the survey. Forty-one per cent agreed that vaccines do not provoke IBD flares, while 17.6% considered live vaccines acceptable during immunosuppressive remission. Nearly one-third (32%) did not personally oversee immunisation, and 18% occasionally discouraged vaccination during therapy. Only 35.3% deemed baseline serology essential before starting immunosuppression; 46.5% supported antibody checks immediately prior to vaccination. The certificate audit revealed a full schedule completion rate of 66.3% for measles–mumps–rubella and 74.2% for hepatitis B, contrasting with parental reports of 82.3% complete coverage. Conclusions: Knowledge gaps, limited guideline awareness, and parental concerns contribute to suboptimal vaccination of paediatric IBD patients. Targeted educational initiatives, clearer shared-care pathways, and routine certificate audits are needed to close the coverage gap and reduce infection-related morbidity. Findings are hypothesis-generating and reflect local practice; as a pilot study, results should be interpreted with caution and may not generalise beyond similar settings.

1. Background

Vaccination is effective for both healthy individuals and those with chronic diseases [1]. Individuals diagnosed with immune-mediated inflammatory disorders (IMIDs)—for example, Crohn’s disease or ulcerative colitis—display an elevated susceptibility to infections attributable to intrinsic immune dysregulation and the immunosuppressive regimens employed in their management [2]. Disease activity, malnutrition, surgery, and comorbidities elevate this risk [3].

Pre-immunosuppressive therapy screening is crucial for paediatric patients with inflammatory bowel disease (IBD). A notable gap remains in clinicians’ knowledge regarding vaccination in paediatric IBD, despite broader improvements in disease management literacy. We therefore underscore the urgent need for structured educational initiatives and subsequent audits to standardise vaccine-related practice across care settings. Recommended tests include hepatitis A, B, and C, Epstein–Barr virus, cytomegalovirus, varicella-zoster virus, rubella, and human papillomavirus (HPV) serologies [2,4,5,6]. When post-vaccination IgG titres are sub-protective, revaccination is advised to achieve protective levels before immunosuppression commences. Vaccination against pneumococcal infection, influenza, Haemophilus influenzae type b, and HPV is also recommended in this population [2,6].

Gastroenterology societies consistently affirm the safety and necessity of vaccinating children and adolescents with IBD [2,4,6]. However, real-world vaccination coverage in this group remains low [7,8]. Key barriers include (1) limited awareness among primary-care and specialist physicians about vaccine options; (2) inadequate coordination between outpatient and inpatient care providers; and (3) concerns among patients and parents about potential adverse events [7,9].

To address these gaps, we combined an anonymous online survey of paediatric gastroenterologists with a systematic audit of vaccination certificates abstracted from the medical records of children with IBD, thereby assessing both provider perspectives and real-world immunisation coverage within this vulnerable cohort. Given heterogeneous access, reimbursement, and care pathways, we undertook a pilot, single-country survey to characterise baseline knowledge and practice around vaccination in paediatric IBD. Accordingly, we pre-specified that inferences would be limited to the local context and not intended for direct international generalisation.

2. Discussion

This survey of paediatric gastroenterologists (PGs) underscores that, even with growing evidence and clear international guidance, vaccination practices in children with inflammatory bowel disease (IBD) remain less than optimal. Although the majority of PGs acknowledge that routine and additional vaccines are safe and beneficial, almost one-fifth still discourage immunisation at specific points during therapy, and sizable gaps persist in real-world coverage.

Non-live (inactivated or recombinant) vaccines can be administered during immunosuppressive therapy in IBD and are not associated with disease exacerbation. Vaccine immunogenicity may be attenuated—particularly with anti-TNF agents and combination regimens—so vaccination should occur at the earliest opportunity, ideally before initiating immunosuppression [9,10]. Importantly, interrupting effective therapy solely to vaccinate is generally discouraged because treatment withdrawal may precipitate flares and, in some cases, loss of response on re-initiation; escalation required to control a flare may further blunt vaccine responses. These principles support a pragmatic approach, namely to proceed with non-live vaccines without stopping therapy while planning live vaccines at least 4 weeks before immunosuppression whenever feasible.

A key finding of this pilot is the discrepancy between parental perception and certificate-documented vaccination records. While parents commonly report complete coverage (82.3%), a certificate audit reveals lower real-world completion rates (66.3% overall), with a pronounced shortfall for hepatitis B (39/87; 44.8%). This gap highlights the importance of systematic verification, proactive catch-up, and clear communication with families.

Multiple factors converge to limit vaccine uptake. Foremost among them are parental fears of triggering an IBD flare, reported by more than 80% of PGs in our study. Similar concerns have been documented in other cohorts of parents of children with chronic immune-mediated diseases [11,12,13,14,15]. Public discourse and sociocultural context can amplify these fears, particularly when misinformation about adverse events is disseminated through mass media and social networks.

System-level issues further compound the problem. Respondents cited insufficient coordination between primary care paediatricians and subspecialists, as well as a tendency for each side to “shift responsibility” for immunisation decisions. Earlier reports from primary care settings describe comparable uncertainties and a lack of clear ownership of vaccination planning for chronically ill children [16]. The absence of an integrated electronic immunisation registry and fragmented communication channels may exacerbate these gaps.

Educational interventions targeting families and healthcare teams have been shown to translate knowledge into action. In a mixed-methods programme that combined online seminars on vaccine safety with on-site availability of the influenza vaccine, uptake among children with chronic immune-mediated diseases increased from 47% to 89.5% [13]. Similar gains have been reported for paediatric IBD after a single specialist consultation: pneumococcal coverage climbed from 16.1% to 85.7%, while completion rates for diphtheria–tetanus–polio, Haemophilus influenzae type b, hepatitis B, and meningococcal C vaccines each increased by 6–35 percentage points (all p < 0.05) [15,17]. These findings underscore that brief, structured educational contact—paired with convenient access to vaccines—can overcome hesitancy.

Coordination across the care continuum remains critical. In our survey, only 23.5% of PGs saw vaccination as primarily the responsibility of primary care physicians, and separate studies have shown that barely one-third of paediatricians are willing to vaccinate children with IBD in the absence of specialist guidance. Comparable data from Greece indicated that 50% of primary care doctors sought explicit approval from a subspecialist before proceeding with immunisation [14]. A clear delineation of roles, coupled with shared protocols, could mitigate these bottlenecks.

Beyond institutional coordination, a personalised strategy anchored in periodic serological surveillance could further strengthen confidence in immunisation. Healthy children follow the National Immunisation Schedule without antibody testing, but those with IBD frequently complete their primary series before disease onset and are subsequently exposed to prolonged immunosuppression. Studies demonstrate that protective antibodies—particularly against measles, rubella, and diphtheria—wane more rapidly under intensive therapy, and titres are lowest in children with severe disease courses.

Practice lagged behind this evidence. In a North American survey of 657 paediatric gastroenterologists, vaccination status was reviewed by 63.5% at the time of diagnosis and 44.4% before starting immunosuppressive therapy. However, 9% ordered pathogen-specific serology to confirm protection [7].

An audit of vaccination records from a prospective cohort of 98 children with IBD highlighted a significant discrepancy between perceived and documented immunisation status. Although structured interviews indicated that more than four-fifths of parents believed their child was fully protected under the National Immunisation Schedule (82%), the certificates told a different story. Fewer than seven in ten patients had received the complete two-dose MMR course, and completion rates for individual components of the vaccine were even lower, seldom exceeding one in two children. A similar gap emerged for hepatitis B, where fewer than half of the children had documentation of all three recommended doses. In short, parental confidence substantially outstripped verified coverage, underscoring the need for systematic record checks rather than relying solely on caregiver recall.

Our findings highlight that many children with newly diagnosed IBD spend an initial period on non-immunosuppressive regimens (EEN for luminal Crohn’s disease; 5-ASA for mild–moderate UC). Clinicians should systematically use this period to optimise preventive care. In practice, this includes (i) a structured vaccine review with documentation, (ii) catch-up of inactivated vaccines without delay, (iii) scheduling live vaccines ≥4 weeks prior to immunosuppression when feasible, and (iv) completing TB screening before anti-TNF or other advanced therapies.

Our findings support an urgent, coordinated programme of education and audit to improve vaccine-related knowledge and practice in paediatric IBD. Clinician-facing education should cover (i) the safety of non-live vaccines during immunosuppression, (ii) the timing of live vaccines (≥4 weeks before immunosuppression when feasible), (iii) HBV serology and boosters, (iv) TB screening prior to biologics, and (v) documentation/communication standards. Parent-facing materials should clearly outline indications, scheduling, and safety information to counter misinformation and support informed shared decisions. Given the observed knowledge gap between ambulatory paediatric gastroenterologists and hospital-based IBD specialists, we recommend shared protocols, joint training sessions, and clear referral pathways to ensure consistent practice.

2.1. Evolving Recommendations for Live Attenuated Vaccines

Guidance on live attenuated vaccines has shifted in recent years—earlier consensus statements limited immunosuppressed patients to inactivated formulations only [17]. In contrast, the latest ECCO guideline permits the administration of live vaccines in children with non-severe IBD who are not receiving intensive immunosuppression and identifies oral poliovirus and Bacillus Calmette–Guérin (BCG) vaccines as the primary contraindications [5]. Emerging data suggest that measles–mumps–rubella (MMR) and varicella vaccines can be given safely under defined conditions, with no requirement to interrupt ongoing therapy.

2.2. Pharmacologic Determinants of Post-Vaccination Immunity

The choice of immunosuppressive agent influences antibody persistence. Systemic corticosteroids and methotrexate have been associated with greater declines in protective titres than most biologic disease-modifying agents [7]. Awareness of this differential impact may guide timely switching to biologics, which offer superior disease control and a more favourable serological profile.

2.3. Parental Perspectives and Information Gaps

An online poll of parents of children with chronic gastrointestinal and rheumatic conditions identified a lack of specialist dialogue and limited access to trustworthy information as major drivers of vaccine hesitancy or refusal [18]. These findings align with our respondents’ observations that improved educational outreach could alleviate parental concerns and increase uptake.

Taken together, our findings support the three following priority actions: (i) targeted education for both clinicians and families, emphasising the proven safety of vaccines in IBD; (ii) formalised shared-care pathways that clarify roles and standardise pre-vaccination screening and scheduling; and (iii) systematic auditing of immunisation certificates to detect and rectify missed doses early. Addressing these areas should help close the immunisation gap and reduce vaccine-preventable morbidity in paediatric IBD.

2.4. Practical Implications

Use a presumptive recommendation (‘Today we will administer…’), address specific concerns succinctly, provide written take-home information, document the discussion, and arrange follow-up when hesitation persists. Non-live vaccines should proceed without interruption of therapy; live vaccines should be planned at least 4 weeks before initiating immunosuppression, whenever feasible. Verify records at diagnosis and before starting immunosuppression; do not rely solely on parental reports. Implement a standardised checklist in clinics (record check → targeted serology where appropriate → catch-up plan). Use brief written materials to align parents’ perceptions with the documented status and timelines.

3. Materials and Methods

3.1. Study Design and Population

We conducted a single-centre cross-sectional pilot survey targeting paediatric gastroenterologists (PGs) practising in various regions of the country. The questionnaire was distributed through closed professional online communities between January 2022 and April 2022. Participation was voluntary and anonymous. Prior to enrolment, each candidate reviewed an electronic information sheet outlining the study aims; commencement of the survey constituted informed consent.

3.2. Questionnaire Development

The survey instrument was drafted by the investigators, assessed for face validity by three independent PGs, and piloted on ten PGs. Items considered ambiguous were revised or removed. The final version contained 64 questions arranged in four domains, namely (i) respondent demographics; (ii) knowledge of current vaccine recommendations for children with inflammatory bowel disease (IBD); (iii) attitudes toward live and inactivated vaccines during different disease and treatment stages; and (iv) self-reported vaccination practices.

3.3. Data Collection

Responses were collected with Google Forms and stored in a secure, password-protected database accessible only to the research team. The platform restricted each e-mail address to one submission, preventing duplicate entries.

3.4. Patient Cohort and Vaccination Certificate Audit

In parallel with the physician survey, we conducted a prospective cohort study that enrolled 98 paediatric patients with confirmed inflammatory bowel disease treated at the Department of Paediatric Gastroenterology, Saint Petersburg State Paediatric Medical University, between January 2022 and April 2023. Electronic copies of each patient’s official prophylactic vaccination certificate were retrieved from the medical record. Two investigators independently extracted vaccination dates and dose counts using a standardised abstraction form based on the National Immunisation Schedule [10]; discrepancies were resolved by consensus. The certificate data were then merged with the questionnaire results for the coverage analysis, as described in the Results Section.

For this study, immunosuppressive therapy was defined as the use of systemic corticosteroids, thiopurines, methotrexate, calcineurin inhibitors, biologic agents, or small-molecule agents. 5-aminosalicylates (mesalazine/sulfasalazine) and exclusive enteral nutrition were not considered immunosuppressive.

3.5. Statistical Analysis

A formal sample-size calculation was not carried out in advance. Missing entries were excluded from the dataset (complete-case analysis). The Kolmogorov–Smirnov test was used to assess the normality of quantitative variables; as none conformed to a normal distribution, non-parametric statistics were applied. Continuous data are reported as the median (Me) with interquartile range (Q1; Q3), while categorical data are presented as absolute numbers and percentages. Categorical variables were compared using Pearson’s χ² or Fisher’s exact test (expected frequencies <5). The Mann–Whitney U test was used for comparisons of continuous variables between two independent groups. Two-sided p-values < 0.05 were deemed statistically significant. To account for multiple comparisons, the Bonferroni correction was applied (e.g., p < 0.017 when three comparisons were performed). All analyses were executed in Statistica version 10.0 (StatSoft Corp., Tulsa, OK, USA).

3.6. Participating Physicians

A total of 51 paediatric gastroenterologists (PGs) completed the questionnaire and were included in the analysis. The PG cohort was predominantly female (n = 48; 94%). The median professional experience in paediatric gastroenterology was 13.6 years (IQR 2.7–17.0 years). Twelve (23.5%) respondents had >10 years’ experience specifically as paediatric gastroenterologists, while 29 (56.8%) reported more than a decade of practice in general paediatrics. Most PGs (n = 31; 61%) worked primarily in the outpatient setting, and 12 (23.5%) held an academic degree (PhD or equivalent). Data are in

Table 1. Demographic characteristics of survey respondents.

Questions	Results (n = 51)
Work experience as a specialist, years, Me (25%; 75%)	13.6 (2.7; 17.0)
Gender, female, n (%)	48 (94.0)
Place of employment:
- Outpatient area	31 (61.0)
- Municipal hospital	12 (23.5)
- University hospital	8 (15.5)
Academic degree, n (%)	12 (23.5)

.

3.6.1. Specialists’ Attitudes Towards Vaccination

Twenty-one (41.2%) paediatric gastroenterologists (PGs) (21/51) answered “no” when asked whether vaccines may provoke inflammatory bowel disease (IBD) flares; a further 24 (47.1%) chose “probably no”, so 88% expressed little or no concern about vaccine-associated IBD flare induction. Two-thirds of paediatric gastroenterologists were unconvinced that vaccination could exacerbate ongoing IBD, while 35.3% allowed for such a risk and 2% were unsure. Concerning live attenuated vaccines, nine responders (17.6%) considered them acceptable for patients in clinical remission who remained on immunosuppressive therapy, whereas 20 (39.3%) responders regarded them as safe once immunosuppressants had been discontinued (drug-free remission), with a further 17 (33.3%) respondents answering “probably yes”, resulting in 72.6% combined support. None of the respondents endorsed the administration of live vaccines during active disease; only eight (15.7%) respondents indicated that they might recommend such vaccines outside remission on a case-by-case basis, whereas 80.4% judged such use to be unsafe (

Table 2. The attitude of the physicians towards vaccinating their patients.

Questions	Results (n = 51)
IBD provoked by vaccination, n (%)
- no	21 (41.0)
- probably yes	24 (47.0)
- probably no	3 (5.8)
- yes	2 (3.9)
- I do not know the answer	1 (2.0)
Vaccination can provoke exacerbation of IBD, n (%)
- no	8 (15.7)
- probably no	24 (47.1)
- probably yes	11(21.6)
- yes	7 (13.7)
- I do not know the answer	1 (2.0)
Live vaccines
Vaccination with live vaccines is safe for patients with IBD in an active disease state, n (%)
- No	28 (54.9)
- Probably no	13 (25.5)
- Probably yes	8 (15.7)
- Yes	0 (0.0)
- I do not know the answer	2 (3.9)
Vaccination with live vaccines is safe for IBD patients in remission on therapy, n (%)
- no	11 (21.6)
- probably no	13 (25.5)
- probably yes	16 (31.4)
- yes	9 (17.6)
- I do not know the answer	2 (3.9)
Vaccination with live vaccines is safe for IBD patients in drug-free remission, n (%)
- no	5 (9.8)
- probably no	7 (13.7)
- probably yes	17 (33.3)
- yes	20 (39.3)
- I do not know the answer	2 (3.9)
Do you vaccinate your patients with IBD in remission with live vaccines while on therapy, n (%):
- Yes, I actively recommend and administer live vaccines	15 (29.4)
- I neither promote nor oppose vaccination (neutral stance)	23 (45.1)
- I do not vaccinate.	12 (23.5)
- I consider this the responsibility of primary care	1 (2.0)
- I actively discourage vaccination	0 (0)
Inactivated vaccines
Vaccination with inactivated vaccines is safe for patients with IBD in an active disease state, n (%)
- No	17 (33.3)
- probably no	18 (35.3)
- probably yes	6 (11.8)
- Yes	3 (5.9)
- I do not know the answer	7 (13.7)
Vaccination with inactive vaccines is safe for patients with IBD in drug remission, n (%)
- No	4 (7.8)
- probably no	4 (7.8)
- probably yes	15 (29.4)
- Yes	27 (53.0)
- I do not know the answer	1 (2.0)
Vaccination with inactive vaccines is safe for IBD patients in drug-free remission, n (%)
- no	1 (2.0)
- probably no	4 (7.8)
- probably yes	12 (23.5)
- yes	27 (52.9)
- I do not know the answer	7 (13.7)

Abbreviations: IBD—inflammatory bowel disease.

).

The acceptance of inactivated vaccines has increased progressively with improvement in inflammatory bowel disease (IBD) status. During active disease, 35 (68.6%) paediatric gastroenterologists (PGs) regarded vaccination as unsafe, 9 (17.6%) PGs considered it acceptable, and 7 (13.7%) PGs reported it as uncertain. In clinical remission with ongoing immunosuppressive therapy, the proportion of respondents who judged vaccination safe rose to 42 (82.4%), whereas only 4 (7.8%) opposed the practice; 1 respondent (2%) remained undecided. After withdrawal of immunosuppression (drug-free remission), 39 (76.4%) PGs endorsed vaccination, 5 (9.8%) opposed it, and 7 (13.7%) were unsure. These data demonstrate a transparent gradient of confidence, with the highest approval observed in drug-free remission and the lowest during active disease (Table 2).

3.6.2. Assessment of Antibodies to Vaccines

Regarding practical involvement, 12 (23.5%) of PGs stated that they do not personally oversee immunisation, considering it the duty of primary care physicians, and only a single respondent (2%) reported actively discouraging vaccination in remission. Worryingly, 23 (45.1%) PGs chose a neutral stance, neither discouraging nor informing patients about the possibility of vaccination. Only a minority of respondents (n = 18; 35.3%) considered antibody screening mandatory before initiating immunosuppressive therapy. Conversely, nearly half (n = 24, 47%) believed that antibody titres should be verified immediately prior to vaccinating their patients with IBD (

Table 3. The attitude of the physicians towards vaccinating their patients.

Questions	Results (n = 51)
Do you vaccinate your patients with IBD in remission with vaccines while on therapy, n (%):
- Yes, I actively recommend and administer vaccines	15 (29.4)
- I neither promote nor oppose vaccination (neutral stance)	23 (45.1)
- I do not vaccinate; I consider this the responsibility of primary care	12 (23.5)
- I actively discourage vaccination	1 (2.0)
Antibody titres before starting immunosuppressive therapy, n (%):
- no	19 (37.3)
- probably no	12 (23.5)
- probably yes	12 (23.5)
- yes	6 (11.8)
- I do not know the answer	2 (3.9)
Antibody titres before vaccination itself, n (%):
- no	16 (31.4)
- probably no	10 (19.6)
- probably yes	12 (23.5)
- yes	12 (23.5)
- I do not know the answer	1 (2.0)

Abbreviations: IBD—inflammatory bowel disease.

).

3.6.3. Relationship Between Therapy and Vaccination

Before analysing how therapy might be adapted around vaccination, we first asked which agents paediatric gastroenterologists (PGs) themselves classify as immunosuppressive. Methotrexate was named by 40 (78.4%) of respondents, biologic TNF-α inhibitors (e.g., infliximab, adalimumab) by 32 (62.7%) of the PGs, and systemic glucocorticosteroids by 26 (51.0%) of the PGs. Only 8 (15.7%) PG regarded sulfasalazine/mesalazine as meaningfully immunosuppressive.

Opinions on whether to suspend ongoing therapy before vaccination proved highly variable.

• Conventional-agent monotherapy: For methotrexate/azathioprine alone, 7 (13.7%) PGs would interrupt treatment before inactivated vaccines, whereas 17 (33.3%) would do so when live-attenuated vaccines were planned.
• TNF-α-inhibitor monotherapy: The corresponding figures were 7 (13.7%) for inactivated and 9 (17.6%) for live vaccines.
• Combination therapy (TNF-α inhibitor + methotrexate):

○

Inactivated vaccines: Only 1 (1.9%) PG would stop both drugs, and another 12 (23.6%) PGs would stop one of them, whereas 22 (43.4%) would continue with complete treatment and 16 (31.4%) found the scenario difficult to answer.

○

Live vaccines: A total of 4 (7.8%) PGs would withhold both agents, 13 (25.5%) PGs would withhold at least one component, and 13 (25.5%) PGs would proceed without interruption; uncertainty peaked at 21 (42.0%) (

Table 4. Relationship between therapy and vaccination.

Questions	Results (n = 51)
IBD medications regarded as immunosuppressive, n (%):
- Methotrexate	40 (78.4)
- Biologic therapy (e.g., infliximab, adalimumab)	32 (62.7)
- Systemic glucocorticosteroids (e.g., prednisolone)	26 (51.0)
- Sulfasalazine/mesalazine	8 (15.7)
Discontinue methotrexate/azathioprine monotherapy before vaccination with
- Inactivated vaccines, n (%):	7 (13.7)
- Live vaccines, n (%):	17 (33.3)
Discontinue TNF-α inhibitor monotherapy before vaccination with
- Inactivated vaccines, n (%):	7 (13.7)
- Live vaccines, n (%):	9 (17.6)
Temporary discontinuation of methotrexate and/or biologic therapy is necessary when vaccinating a patient with IBD with inactivated vaccines in case of combined therapy with both classes of drugs, n (%):
- I will discontinue both methotrexate and biologic therapy	1 (1.9)
- I will discontinue biologic therapy but continue methotrexate	6 (11.8)
- I will discontinue methotrexate but continue biological therapy	6 (11.8)
- I will not discontinue either methotrexate or biologic therapy	22 (43.4)
- Difficult to answer	16 (31.4)
Temporary discontinuation of methotrexate and/or biologic therapy is necessary when vaccinating a patient with IBD with live vaccines in case of combined therapy with both classes of drugs, n (%):
- I will discontinue both methotrexate and biologic therapy	4 (7.8)
- I will discontinue biologic therapy but continue methotrexate	5 (9.8)
- I will discontinue methotrexate but continue biological therapy	8 (15.7)
- I will not discontinue either methotrexate or biologic therapy	13 (25.5)
- Difficult to answer	21 (42.0)

Abbreviations: IBD—inflammatory bowel disease.

).

Thus, up to two in five PGs selected “difficult to answer” in at least one setting, underscoring a persistent need for clear, evidence-based guidance. Current international recommendations permit the administration of inactivated vaccines during immunosuppressive therapy but strictly contraindicate the use of live-attenuated vaccines until immunosuppression is withdrawn. The dispersion of responses observed here, therefore, signals a partial divergence from guideline-concordant practice.

Vaccination Coverage

An audit of the official vaccination certificates collected from the prospective cohort of 98 children with IBD revealed substantial gaps in immunisation. Parental interviews suggested that 82.3% of patients were fully vaccinated according to the National Immunisation Schedule—vaccination coverage (parent-reported vs. certificate audit). Parent-reported complete coverage was 82.3%, whereas a certificate review demonstrated lower documented coverage (66.3% overall). For hepatitis B, a complete schedule was documented in 39/87 (44.8%). These findings indicate a meaningful perception–documentation gap.

Only 65 (66.3%) had completed the two-dose measles–mumps–rubella (MMR) series by the specified age, and 41 (47.7%) children received individual MMR components: 21 (24.4%) received vaccinations against measles and mumps and 20 (22.7%) against rubella. Only a little more than half of the patients (39/87; 44.8%) received the complete three doses of hepatitis B.

These findings highlight a discrepancy between parental perception and documented vaccine uptake, underscoring the importance of systematic certificate verification in routine paediatric IBD care.

3.7. Factors Associated with Low Vaccination Coverage

Parental concern over potential disease exacerbation was identified as the leading barrier to immunisation, reported by 82.4% of PGs (Table 4). Additional obstacles cited by PGs included media-driven misinformation about vaccine side effects, occasional reluctance among primary care physicians to vaccinate children with IBD, and limited awareness among both clinicians and families regarding the importance of timely vaccination. A subset of respondents reported that perceived parental concerns may influence their vaccination recommendations. This item reflects self-reported perceptions and does not indicate endorsed practice. We note with concern that some clinicians perceive social pressure from parents during vaccine counselling in paediatric IBD (

Table 5. Factors contributing to low vaccination coverage in IBD patients.

Factors Hindering the Vaccination of Patients with IBD	Results (n = 51)
Parents’ fear of possible worsening of IBD course, n (%):	42 (82.4)
Spread of information about the ‘side effects’ of vaccines in the media, n (%)	26 (51.0)
Primary care physicians’ fear of worsening IBD course, n (%):	19 (37.2)
Practicing specialists’ fear of worsening IBD course, n (%):	40 (78.4)
Lack or insufficient awareness of parents/physicians about the necessity of vaccination for patients with IBD, n (%):	30 (58.8)
Lack or insufficient awareness of parents/doctors about the safety of vaccination for patients with IBD, n (%):	36 (70.6)

).

3.8. Opinion on Pneumococcal and Haemophilus Influenzae Type B Vaccination

Because respiratory infections are among the most frequent complications during immunosuppressive therapy, PGs were asked about the preventive value of pneumococcal and Haemophilus influenzae type b (Hib) vaccines. The majority (84.2%) believed that these vaccines do not provoke IBD flares and can help reduce the number of infectious episodes; 68.6% regarded them as effective prophylaxis. Nevertheless, roughly half of the respondents reported that they seldom implement this preventive measure in routine practice, and about one-third actively promote these vaccinations to their patients.

3.9. Awareness of International Vaccination Guidelines

Awareness of the European Crohn’s and Colitis Organisation (ECCO) recommendations on vaccination in IBD varied within the PG group. Overall, 47.1% had at least partial knowledge of these guidelines; only 1.9% reported complete familiarity, while 45.2% possessed limited knowledge. Holding an academic degree significantly increased awareness: physicians with higher academic qualifications were more likely to be fully (25.0%) or partially (46.9%) informed compared with those without a degree (3.1% and 24.6%, respectively; p = 0.0001) (

Table 6. Awareness of physicians regarding international vaccination guidelines for patients.

Parameter	Results (n = 51)
Are you familiar with the main recommendations of ECCO (European Crohn’s and Colitis Organisation) regarding the vaccination of patients with IBD, n (%):
- Fully familiar	1 (1.9)
- Somewhat familiar, have a general understanding	10 (19.6)
- Somewhat familiar, have a limited understanding	13 (25.5)
- Not familiar/have not heard of such guidelines	27 (52.9)

).

4. Conclusions

Our goal is to draw attention to this problem and to the need for targeted education and organisational support to strengthen vaccine counselling in paediatric IBD. Addressing misinformation and supporting physicians in confident, guideline-consistent communication are essential to improving vaccination uptake. Emphasising the parent–certificate discrepancy as a measurable target for improvement can guide education, record verification, and catch-up strategies in paediatric IBD care. Targeted education for clinicians and families, paired with systematic audit and feedback, is essential for raising vaccination standards in paediatric IBD and closing the practice gap between ambulatory and specialist care.

5. Study Limitations

The study’s main limitations are related to the relatively small number of respondents in both groups, as well as differences in education and work experience levels. Differences in the knowledge of current recommendations could have influenced attitudes towards vaccination. The relatively large number of non-responders introduced bias, which is particularly problematic given the sensitive nature of vaccination attitudes. The significant gender skew, with a majority of female respondents, distorts the findings regarding practice patterns and attitudes. The additional analysis, which includes females as a confounding variable, may alter the study results. Male and female healthcare professionals assess risks and adhere to guidelines differently, making this imbalance particularly concerning. Smaller groups and minor variations in participant numbers can lead to inflated or misleading statistical significance. These questionable, both methodological and statistical choices, weaken the credibility of the findings. An insufficient sample size, combined with the absence of an initial calculation of the sample size, elevates the risk of Type I errors (false positives) and leads to exaggerated claims of effect. We collected the responses from the participants but were unable to examine them to determine their actual knowledge of contemporary vaccination recommendations. The survey was only validated by the manuscript’s authors, without rigorous psychometric standards. The pilot validation would increase the reliability and construct validity of the questionnaire. Pilot testing, whether the questionnaire effectively captures the constructs it purports to measure (e.g., “safety perceptions”), remains unclear. High rates of “difficult to answer” responses indicate potential flaws in the clarity or design of the questions. This lack of transparency in survey methodology and validation fundamentally undermines confidence that the reported attitudes genuinely reflect the physicians’ perspectives on vaccination. In our study, we did not evaluate the confounding variables or conduct post hoc analysis. These factors could skew the results and interpretations. A more comprehensive analysis that accounts for these confounders would provide more robust and reliable findings. The above-mentioned methodological and statistical shortcomings severely undermine its validity and generalizability.

In conclusion, regular surveys of specialists will enable a better understanding of their attitudes toward vaccination issues and outline goals to optimise the vaccination process, thereby increasing doctors’ trust in vaccination. Studying the problem of incomplete vaccination will enable the personalization of the educational process for specialist doctors and parents. Additional education, in the form of a scientific degree, is associated with a better understanding of specialist doctors regarding modern recommendations for vaccinating patients with immune-mediated diseases. The study showed that the knowledge of international recommendations increases the degree of trust of specialist doctors in vaccination. The experience of educational events among parents contributes to increasing parents’ trust in vaccination.