Dengue vaccine acceptability in Peru: A mixed-methods study in two dengue-endemic Peruvian cities

INTRODUCTION: Dengue poses a major public health challenge in Peru, with Piura and Iquitos experiencing recurrent outbreaks and limited control options. A dengue vaccine could complement current vector control strategies and reduce transmission, yet community perceptions and barriers to uptake in pre-implementation settings remain poorly understood. METHODOLOGY/PRINCIPAL FINDINGS: Our mixed-methods study design was conducted in Piura and Iquitos, guided by the 5C's Framework of Vaccine Hesitancy. Sixteen focus group discussions (n = 147) explored acceptability and concerns regarding a hypothetical future dengue vaccine; a subsequent survey (n = 883) quantified vaccine acceptability. Dengue vaccine acceptability was operationalized using a theory-driven, multi-item outcome contrasting individuals willing to vaccinate ("acceptors") with those unsure about accepting vaccination ("unsure"). Multivariable logistic regression examined factors associated with vaccine uncertainty. RESULTS: Using the multi-item, theory-driven classification, most (81.9%) survey participants were classified as "acceptors", 14.5% were "unsure", and 3.6% would refuse all vaccines ("refusers"). Qualitative findings underscored the need for clear information on efficacy, eligibility, and side effects, provided by trusted health professionals. In multivariable analysis, compared to acceptors, the "unsures" had more negative views towards COVID-19 vaccination (OR 2.17), higher technical or higher education (OR 3.33), and reduced confidence due to the rapid COVID-19 vaccine development (OR 2.17). The "unsures" also expressed less trust in vaccine benefits (OR 0.25), less willingness to pay for a dengue vaccine (OR 0.40), and lower knowledge of dengue transmission (OR 0.45) compared to the acceptors. CONCLUSIONS: Although most participants expressed willingness to receive a future dengue vaccine, vaccine uncertainty was primarily shaped by factors related to confidence, convenience, and communication. Mistrust in vaccines in general or residual mistrust linked to COVID-19 vaccination experiences, and concerns about vaccine development may hinder acceptance. Tailored communication, engaging trusted local leaders, and ensuring easy access are critical for successful dengue vaccination campaigns in these endemic regions.