Vaccination Recommendation Patterns and Associated Factors Among Children with Special Health Care Needs: A Cross-Sectional Study in District-Level Immunization Services in China

<b>Background</b>: Children with special health care needs (CSHCN) are at heightened risk of delayed or missed vaccinations because of clinical complexity and provider uncertainty. Although China has issued expert consensus guidelines and established immunization advisory services, little is known about vaccination decision-making within routine district-level immunization services. This study examined vaccination recommendation patterns and factors associated with deferral or non-recommendation among CSHCN in these settings. <b>Methods</b>: This cross-sectional study was conducted between 1 April 2023, and 31 March 2024, in Changshou District, Chongqing, China, encompassing 18 primary health centers, five general hospitals and one special hospital. Children aged 0-18 years identified by physicians as having conditions potentially affecting vaccination decisions and with at least one documented vaccination-related consultation were included. Clinical characteristics and physician recommendations ("recommended," "temporarily deferred," "not recommended") were recorded via the national Epidemiological Dynamic Data Collection (EDDC) system; subsequent vaccination uptake was verified using the Chongqing Immunization Information Management System. Logistic regression identified factors associated with deferral or non-recommendation. <b>Results</b>: A total of 761 participants were included in the analysis, with a median age of 12 months (IQR: 1-47). Among all vaccine-specific recommendations, 55.2% were classified as "recommended," 43.4% as "temporarily deferred," and 1.5% as "not recommended". Deferral proportions varied markedly, highest in respiratory (73.6%) and immunologic (42.1%) conditions and lowest in neonatal disorders (4.0%). Compared with 0-6-month-olds, children aged 7-12 months (adjusted odds ratio [aOR] = 5.26, 95% CI 2.30-12.33) and >13 months (aOR = 13.48, 95% CI 6.69-28.34) were more likely to receive deferral or non-recommendation; multimorbidity also increased odds (aOR = 20.68, 95% CI 11.26-40.10). Consultations at primary health centers were associated with a lower likelihood of deferral or non-recommendation (aOR = 0.26, 95% CI 0.15-0.45). <b>Conclusion</b>: Vaccination recommendations for CSHCN vary considerably across clinical profiles and facility types in routine immunization settings. Despite national initiatives, many vaccine doses remain deferred or not recommended. Disease-specific guidelines, enhanced provider training, and context-adapted decision-support tools are needed to promote timely and equitable immunization for this medically vulnerable population.