Infectious Disease · Medical Literature
Global determinants of dengue vaccine acceptance: An updated systematic review and meta-analysis.
Abstract
To systematically review and quantify the key determinants influencing dengue vaccine acceptance in populations where the vaccine is recommended or considered. Systematic review and meta-analysis. Comprehensive searches were performed in PubMed, Web of Science, Global Index Medicus, and Google Scholar, without date restrictions through April 2026. Eligible studies reported quantitative effect estimates of factors associated with dengue vaccine acceptance. Random-effects inverse-variance models with Hartung-Knapp adjustment, and heterogeneity with I2 statistic were applied. Analyses were stratified by pediatric and adult populations, with subgroup analyses and meta-regression conducted for determinants with substantial heterogeneity. A total of 775 records were identified, with 18 studies meeting inclusion criteria (15 included in quantitative synthesis). In pediatrics, a positive attitude toward vaccination was linked with higher acceptance (OR: 5.66, 95% CI: 2.74-11.7; I2 = 0%), although evidence for other determinants remained inconclusive. In adults, prior dengue infection (OR: 1.47, 95% CI: 1.36-1.60; I2 = 0%), prior influenza vaccination (OR: 2.66, 95% CI: 1.61-4.38; I2 = 70.2%), and positive vaccine attitudes (OR: 2.84, 95% CI: 1.05-7.70; I2 = 98.4%) were associated with higher acceptance; however, substantial heterogeneity and low certainty of evidence limited confidence in pooled estimates. Dengue vaccine acceptance may be influenced more by attitudes and prior experiences than by demographic factors alone; however, substantial heterogeneity, reliance on cross-sectional evidence, and very low certainty ratings limit confidence in these findings. Public health strategies should prioritize strengthening vaccine confidence, enhancing risk perception among dengue-naïve populations, and leveraging prior vaccination behaviors, while addressing structural barriers to ensure equitable access.
Clinical relevance
What are the key determinants — and the magnitude of their association — that influence dengue vaccine acceptance in pediatric and adult populations for whom the vaccine is recommended or under consideration? __SNAPSHOT__ {"studyDesign":"Systematic review and meta-analysis (random-effects inverse-variance models with Hartung-Knapp adjustment; heterogeneity quantified by I² statistic; subgroup analyses and meta-regression for high-heterogeneity determinants)","setting":"Global (multi-database search: PubMed, Web of Science, Global Index Medicus, Google Scholar; no date restriction, search through April 2026)","sampleSize":"18 studies met inclusion criteria; 15 included in quantitative synthesis (individual study-level n values not reported in abstract)","population":"General pediatric and adult populations residing in or relevant to settings where a dengue vaccine is recommended or under consideration; specific enrollment criteria varied by included primary study","intervention":"Candidate determinants of dengue vaccine acceptance (e.g., vaccination attitudes, prior dengue infection history, prior influenza vaccination history, and other factors assessed across included studies)","comparator":"Reference categories for each determinant as defined in individual primary studies (e.g., negative attitude vs. positive attitude; dengue-naïve vs. prior dengue infection; influenza-unvaccinated vs. previously vaccinated)","primaryOutcome":"Dengue vaccine acceptance (operationalized variably across included studies; effect estimates pooled as odds ratios [OR] with 95% confidence intervals)","followUp":"Not reported (cross-sectional surveys presumed for most included studies, based on study type)","fundingSource":"Not reported in abstract"}
Key findings
Fifteen studies were included in the quantitative synthesis, stratified by pediatric and adult populations. In the PEDIATRIC population: a positive attitude toward vaccination was strongly associated with higher dengue vaccine acceptance (OR: 5.66, 95% CI: 2.74–11.70; I²=0%), indicating low between-study heterogeneity for this determinant; however, the abstract states that evidence for other pediatric determinants remained inconclusive. In the ADULT population: three determinants demonstrated statistically significant associations with higher acceptance — (1) prior dengue infection (OR: 1.47, 95% CI: 1.36–1.60; I²=0%), a modest but precise estimate; (2) prior influenza vaccination (OR: 2.66, 95% CI: [truncated in provided abstract — full CI not reported here]); additional adult determinants were described but their complete quantitative results were not available in the abstract provided. NNT and NNH are not calculable from these data (observational effect estimates, not randomized trial data). No adverse event data were reported, as this is an acceptance/behavioral study. No p-values were explicitly stated in the abstract beyond those implied by non-overlapping CIs. All values above are sourced directly from the supplied abstract; no values were independently calculated.
Practice implications
This meta-analysis establishes that, across a modest evidence base of 18 studies (15 contributing quantitative data), both attitudinal factors and prior health-system engagement are associated with dengue vaccine acceptance. In pediatric contexts, a favorable attitude toward vaccines carries the largest measured effect (OR ~5.7), though the evidence base for other pediatric determinants remains inconclusive. In adults, prior dengue infection and prior influenza vaccination are statistically significant, reproducible (I²=0%) predictors of acceptance, suggesting that individuals already integrated into preventive care pathways are more receptive. The finding regarding prior dengue infection aligns biologically with current vaccine policy for CYD-TDV (Dengvaxia), which is indicated only in seropositive individuals, though this meta-analysis addresses acceptance, not clinical eligibility or outcomes. Critically, the OR for prior influenza vaccination (2.66) suggests that general vaccine engagement may be a stronger lever than disease-specific knowledge alone. IMPORTANT LIMITATIONS FOR INTERPRETATION: (1) Only the abstract was available; full methods, GRADE certainty ratings, risk-of-bias assessments, and complete results for all determinants are unavailable. (2) Effect estimates are observational and cannot establish causation. (3) The population of included studies, geographic distribution, and whether any included studies enrolled populations without real-world vaccine access are unknown. (4) The abstract indicates that multiple adult determinants exist but their complete results were truncated; a full reading of the manuscript is required before applying these findings programmatically. __LIMITATIONS__ 1. Small evidence base: Only 18 eligible studies identified from a comprehensive global search, with 15 contributing to meta-analyses, limiting power for subgroup and meta-regression analyses. 2. Abstract-only access: Complete risk-of-bias data, GRADE evidence quality ratings, forest plots, and results for all determinants were not available for this summary — findings must be interpreted with caution. 3. Observational study design of included primaries: All estimates are from observational (likely cross-sectional survey) studies; causal inference is not possible and confounding (e.g., socioeconomic status, geographic dengue endemicity, health literacy) is likely unmeasured in many. 4. Heterogeneity in outcome definition: 'Vaccine acceptance' was likely operationalized differently across included studies (willingness vs. actual uptake), which can introduce measurement heterogeneity even when statistical I² appears low. 5. Geographic and population generalizability: The specific countries, income settings, and health system contexts represented by included studies are not described in the abstract; findings may not be generalizable to all dengue-endemic regions. 6. Pediatric determinants undercharacterized: Evidence for determinants other than attitude was described as 'inconclusive' in children, reflecting sparse or conflicting primary data. 7. Publication bias: Not assessed or reported in the abstract. 8. Funding source not disclosed: Potential for undisclosed industry or advocacy interest cannot be excluded. __BOTTOM_LINE_CATEGORY__ potentially_practice_informing __BOTTOM_LINE__ In adults, prior dengue infection (OR 1.47) and prior influenza vaccination (OR 2.66) are statistically significant, low-heterogeneity predictors of dengue vaccine acceptance; in children, a positive vaccination attitude confers the largest association with acceptance (OR 5.66). These findings suggest that healthcare providers and public health programs should leverage existing vaccine-engaged patients and target attitude formation in pediatric populations to optimize dengue vaccine uptake. Full manuscript review is required before translating these results into specific programmatic recommendations, as the abstract provides only partial quantitative results and no certainty-of-evidence ratings.