Nearly three in ten Guangzhou parents are hesitant about the voluntary, self-paid vaccine, as infections caused by other enteroviruses make its benefits harder to understand.
Parents in Guangzhou are increasingly questioning whether the EV-A71 vaccine is still worth giving their children, even though the shot has helped drive a sharp fall in severe hand, foot and mouth disease linked to that virus across China. According to a new study in BMC Public Health, that uncertainty has grown as other enteroviruses have taken a larger role in causing the illness, leaving some families unsure why a child can still develop HFMD after vaccination.
The Guangzhou research team surveyed parents of children aged five and under at ten community health centres across the city. In all, 28.95% of respondents showed hesitancy towards the EV-A71 vaccine, which is voluntary and self-paid in China. The study found that mothers were less hesitant than fathers, parents with college or associate degrees were also more accepting, and those working in healthcare were less doubtful. By contrast, parents whose children had never had HFMD were much more likely to hesitate, suggesting that personal experience of the disease may shape how seriously families take the vaccine.
The authors used statistical modelling to look beyond demographics and identify the beliefs driving those attitudes. Their analysis found that confidence in the vaccine, trust in vaccination services and the sense that HFMD poses a real threat all reduced hesitancy. In other words, parents who believed the vaccine works, trusted the health system providing it and saw the illness as dangerous were less likely to refuse or delay vaccination.
Perhaps the most striking finding was that knowledge alone did not directly lower hesitancy. Instead, awareness of EV-A71 and the vaccine influenced parental behaviour indirectly by strengthening confidence, trust and risk perception. The researchers said that simply giving parents facts is unlikely to be enough unless that information also changes how they think and feel about the vaccine and the disease it targets.
That matters because the epidemiological landscape has changed since China introduced the EV-A71 vaccine in 2016. A systematic review published in Vaccines found the two-dose vaccine to be highly effective, with an estimated effectiveness of 84.2% in preventing EV-A71-associated HFMD and severe disease. But the same review also noted the need for a multivalent vaccine to address HFMD caused by other pathogens. Real-world studies have backed up that picture, showing reduced EV-A71 incidence after vaccination but also variation by region, vaccination coverage and population density.
Other surveillance work has shown that the vaccine’s success helped shift the balance of HFMD pathogens. Research on China’s post-vaccine epidemiology found that coxsackievirus A6 overtook EV-A71 as the leading cause in many settings, while a long-term study in Guangdong reported a 41.4% reduction in EV-A71-associated cases between 2017 and 2019, equal to 26,226 cases averted. Public health experts say that kind of shift can be difficult for parents to interpret: if a vaccinated child still develops fever, mouth ulcers and blisters, they may assume the shot has failed, even when the infection is caused by a different virus.
The Guangzhou authors argue that health workers need to respond to that confusion with more careful counselling, not just broader education campaigns. They say providers should explain that the vaccine is designed to prevent the most severe form of EV-A71 disease, that other HFMD infections are often caused by different enteroviruses, and that the danger from EV-A71 has not disappeared. The study also found that physician recommendation may strengthen the effect of vaccine confidence, reinforcing the role of trusted clinicians in shaping parental decisions.
Disclaimer: This content is for informational purposes only and is not intended to be a substitute for professional medical judgment, advice, diagnosis, or treatment.
