To the editor,

We thank the editors for the opportunity to respond and appreciate the thoughtful comments by Daungsupawong and Wiwanitkit regarding our study on coronavirus disease 2019 (COVID-19) vaccine hesitancy among parents of children with systemic lupus erythematosus [1].

While we agree that qualitative research may offer deeper insights, our study employed a validated vaccine hesitancy scale to systematically assess parental concerns. Vaccine hesitancy (VH) was associated with significantly higher scores in domains such as perceived vaccine importance, efficacy, public health benefit, and trust in provider information. In multivariate analysis, skepticism about vaccine efficacy independently predicted lower willingness to vaccinate.

To further explore VH, we examined specific concerns among hesitant parents. Approximately 90% cited fear of side effects. Other concerns included risk of systemic lupus erythematosus (SLE) flares (68%), general safety (56%), uncertain efficacy (32%), vaccine ingredients (24%), lack of long-term data (20%), low perceived COVID-19 risk (20%), and distrust in pharmaceutical companies (8%) (Fig. 1A).

We also identified motivators for vaccine acceptance. The most influential factor was reassurance from treating physicians (72%), followed by availability of a safer vaccine (52%), SLE remission (48%), and practical considerations such as school or travel requirements (28%), improved accessibility (16%), and cost-free vaccination (8%) (Fig. 1B).

We assessed sources of information influencing vaccination decisions (Fig. 1C). Healthcare providers (48%) and pediatricians (40%) were the most cited sources. School or travel requirements (28%), government/public health messaging (20%), and internet or social media (16%), and friends/family (8%) were also noted.

Additionally, we found that children of VH parents had significantly lower rates of previous COVID-19 vaccination and completed immunization schedules, suggesting a broader pattern of healthcare hesitancy that merits further exploration.

We appreciate the correspondents’ insights and strongly support future qualitative and longitudinal research to inform targeted strategies addressing both general and SLE-specific vaccine concerns in this vulnerable pediatric population.