Trends, Uptake, and Predictors of Influenza Vaccination Among Healthcare Practitioners During the COVID-19 Pandemic Flu Season (2020) and the Following Season (2021) in Saudi Arabia

Adult vaccination in three Eastern Mediterranean countries: current status, challenges and the way forward

INTRODUCTION

Changing population demographics places a premium on optimizing older adult health. Vaccine-preventable diseases represent a substantial clinical and economic burden in older adults (≥65 years).

AREAS COVERED

This narrative review summarizes the adult immunization landscape in three countries; Saudi Arabia, the United Arab Emirates and Türkiye, informed by literature searches; PubMed (23-27 September 2023) supplemented by citation tracking via Google Scholar). Existing vaccination recommendations and published data were reviewed to evaluate vaccine uptake, chiefly focusing on core adult vaccines (seasonal influenza, pneumococcal, and herpes zoster). Barriers to vaccine access and uptake were reviewed, and initiatives to improve recommended vaccine uptake in older (≥65 years) or otherwise high-risk adults are described.

EXPERT OPINION

Uptake of recommended adult vaccines is low in all three countries. Receipt of annual seasonal influenza vaccine is typically below 50% in both older and at-risk younger adults; pneumococcal vaccination rates are even lower in eligible adults (<15% and often far lower), as is herpes zoster vaccine uptake (typically <5%). Low coverage is driven chiefly by low awareness of vaccine benefits, inconsistent recommendations, and vaccine hesitancy, together with often complex adult vaccine access pathways. Initiatives and remedies aimed at augmenting adult vaccination rates are warranted.

Vaccination against influenza viruses reduces infection, not hospitalization or death, from respiratory COVID-19: A systematic review and meta-analysis

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) causes COVID-19 and has brought a huge burden in terms of human lives. Strict social distance and influenza vaccination have been recommended to avoid co-infections between influenza viruses and SARS-CoV-2. Scattered reports suggested a protective effect of influenza vaccine on COVID-19 development and severity. We analyzed 51 studies on the capacity of influenza vaccination to affect infection with SARS-CoV-2, hospitalization, admission to Intensive Care Units (ICU), and mortality. All subjects taken into consideration did not receive any anti-SARS-CoV-2 vaccine, although their status with respect to previous infections with SARS-CoV-2 is not known. Comparison between vaccinated and not-vaccinated subjects for each of the four endpoints was expressed as odds ratio (OR), with 95% confidence intervals (CIs); all analyses were performed by DerSimonian and Laird model, and Hartung-Knapp model when studies were less than 10. In a total of 61 029 936 subjects from 33 studies, influenza vaccination reduced frequency of SARS-CoV-2 infection [OR plus 95% CI = 0.70 (0.65-0.77)]. The effect was significant in all studies together, in health care workers and in the general population; distance from influenza vaccination and the type of vaccine were also of importance. In 98 174 subjects from 11 studies, frequency of ICU admission was reduced with influenza vaccination [OR (95% CI) = 0.71 (0.54-0.94)]; the effect was significant in all studies together, in pregnant women and in hospitalized subjects. In contrast, in 4 737 328 subjects from 14 studies hospitalization was not modified [OR (95% CI) = 1.05 (0.82-1.35)], and in 4 139 660 subjects from 19 studies, mortality was not modified [OR (95% CI) = 0.76 (0.26-2.20)]. Our study emphasizes the importance of influenza vaccination in the protection against SARS-CoV-2 infection.

Motivators for the public to receive the seasonal influenza vaccination and the effect of coronavirus disease 2019 pandemic on the uptake of the seasonal influenza vaccination

BACKGROUND

The coverage of the seasonal influenza vaccine has always been sub-par. Understanding the motivators of receiving vaccines, especially during pandemics, could enhance and increase the coverage rates. The Saudi Ministry of Health launched its annual influenza vaccination campaign during the 2021 influenza season and provided vaccinations in primary healthcare settings. This study aims to explore public motivators to receive influenza vaccination, particularly during the coronavirus disease 2019 global pandemic.

MATERIALS AND METHODS

This cross-sectional study enrolled 783 participants who attended the influenza vaccination campaign. All persons who received the influenza vaccine in the influenza vaccination campaign held in Dammam, Saudi Arabia, from October to November 2021, were interviewed and completed a self-administered questionnaire. Odds ratio with a 95% confidence interval were estimated using the full model fit. The significance level was set as α = 0.05.

RESULTS

The majority of the participants had more than high school education (81%), were males (66.2%), and married (59.6%), and 50.6% were below 35 years of age. Participants with higher education, health-care workers, and those who had been previously counseled on influenza vaccination were less likely to have started taking the influenza vaccination, whereas smokers and persons who do not have routine checkups were more likely to start influenza vaccination. The main motivator to take the influenza vaccine was the establishment of a vaccination campaign near the participant's workplace (62.2%), followed by advice from their physician (30.3%), and fear of having influenza disease (29.6%).

CONCLUSION

Accessibility to the vaccination campaigns was the main motivator for receiving the vaccine followed by the advice from physician. Advice from physician and increasing mobile vaccination campaigns and mobile clinics would substantially increase influenza vaccine uptake.

The Influence of the COVID-19 Pandemic on Seasonal Influenza Vaccine Uptake Among Patients Visiting a University Hospital in Saudi Arabia

INTRODUCTION

Influenza vaccination is a subject of importance in Saudi Arabia. The study measured the uptake of annual influenza vaccination from 2019 to 2021 among patients attending outpatient clinic of a University Hospital.  Materials and methods: A cross-sectional study design was used, and the questionnaire was administered by trained interviewers. Descriptive and inferential statistics were done using the Statistical Package for the Social Sciences (SPSS) version 21 (IBM, Armonk, New York).  Results: The three-year annual influenza vaccine uptake for 2019-2021 was 19.7%, 11.4%, and 14.2%, respectively. In the year 2022, only 28.2% of the patients were offered influenza vaccines by their physicians, and among those offered, 49.6% showed vaccine acceptance. Higher vaccine acceptance was significantly associated with past episodes of influenza infection (p<0.001) and vaccination history before the COVID-19 pandemic (p<0.001). Lower acceptance of the influenza vaccine was observed during the pandemic (p<0.001) and lower uptake among those who were not offered influenza vaccines (p=0.02). No association was found between influenza vaccine acceptance and smoking status, chronic illness, history of COVID-19 infection, or living with those susceptible to influenza. Reasons for vaccine denial include an assumption of not being at risk, a lack of information about the vaccine, and a fear of side effects.

CONCLUSION

The COVID-19 pandemic has had a detrimental effect on annual influenza vaccination. Efforts must be taken to increase influenza vaccination among vulnerable groups.

The Effect of Combining the COVID-19 Vaccine with the Seasonal Influenza Vaccine on Reducing COVID-19 Vaccine Rejection Among Libyans

BACKGROUND

Coronavirus disease 2019 (COVID-19) vaccine coverage remains low in Libya compared to other countries in the Eastern Mediterranean Region. This study aimed to evaluate the willingness of the general public in Libya to receive COVID-19 and seasonal influenza vaccines. Additionally, the study aimed to investigate the potential effect of combining the two vaccines to reduce COVID-19 vaccine rejection.

METHODS

An anonymous nationwide online cross-sectional survey was carried out from 1st September to 16th October 2022. Libyans aged 18 years or older were recruited using convenience and snowball sampling approaches. The participants were surveyed for sociodemographic information, health status, and vaccination attitude towards COVID-19 and seasonal influenza vaccines.

RESULTS

A total of 2484 participants formed the final study sample: 68.7% were females, 39.4% were aged 18-25 years, 50.4% were single, 32.5% had previous COVID-19 infection, and 47.2% experienced COVID-19 death among relatives. Three-fourths of the respondents showed COVID-19 vaccine rejection: 57.3% did not receive COVID-19 vaccination, 10.1% would not complete the primary vaccination series, and 7.8% refused booster doses. About 55.0% rejected seasonal influenza vaccination, while 1.9% reported influenza vaccine uptake and 21.2% were willing to get the influenza vaccine for the first time. Additionally, 18.8% had already received influenza vaccination in the last year and intended to get the vaccine this season, while 3.3% were unwilling to get influenza vaccination this year despite receiving it in the last influenza season. Age, sex, and occupation were significantly associated with COVID-19 and influenza vaccine rejection. Rejection of COVID-19 vaccination decreased if its combination with influenza vaccine as a single dose was suggested, with 28.2% of the COVID-19 vaccine rejector group accepting the combined vaccine as it would be safer (50.9%), needing fewer injections (24.0%), would be more effective (19.1%), and would be less expensive (3%). Approximately 73.0% of the COVID-19 vaccine rejector group refused this combination due to fear of side effects (48.7%), absence of published studies on this combination (29.8%), and considering this combination as useless (11.2%).

CONCLUSION

In Libya, the prevalence of COVID-19 vaccine rejection was high, while the rejection of seasonal influenza vaccination was relatively lower. If influenza and COVID-19 vaccines are administered simultaneously as a single injection, this may reduce the rejection of the COVID-19 vaccine due to better-perceived vaccine safety and efficacy besides being more convenient in terms of the number of injections and cost.

Prevalence and Predictors of Seasonal Influenza Vaccine Uptake in Saudi Arabia Post COVID-19: A Web-Based Online Cross-Sectional Study

In the fall of 2022, the number of influenza-like illnesses (ILIs) and severe acute respiratory infections (SARIs) in Saudi Arabia had significantly increased compared with the corresponding period in previous years. Concerns regarding the population's seasonal influenza vaccine (SIV) uptake rates have emerged. In particular, the SIV uptake rates may have dropped post the COVID-19 pandemic compared with rates prior to the COVID-19 era. In this study, we aimed to estimate the prevalence and predictors of SIV uptake in Saudi Arabia post the COVID-19 pandemic. We conducted a cross-sectional study utilizing an online survey platform. We mainly collected sociodemographic information and determined whether the respondent was a healthcare professional or had a chronic disease. The overall SIV uptake prevalence was 31.8%. A lower SIV uptake was observed among those aged 55 years or older, females, residents of the central region, non-health practitioners, and those without chronic diseases. Several factors were associated with SIV uptake. Those aged 35-44 were over three-fold more likely to receive an SIV than those aged 55 years or older (OR: 3.66; 95% CI: 1.33-10.05). In addition, males had 73% higher odds of SIV uptake than females (OR: 1.73; 95% CI: 1.18-2.55). Health practitioners were more likely to receive an SIV than non-health practitioners (OR: 2.11; 95% CI: 1.45-3.06). Similarly, those with chronic diseases had 86% higher odds of SIV uptake than those without chronic diseases (OR: 1.86; 95% CI: 1.18-2.95). These findings can provide insights into the low prevalence and predictors of SIV uptake in Saudi Arabia. Future studies should be conducted to further explore the potential factors associated with such a low prevalence of SIV uptake post COVID-19 in Saudi Arabia.

Influenza and Pneumococcal Vaccination and the Risk of COVID-19: A Systematic Review and Meta-Analysis

A number of studies have investigated the potential on-specific effects of some routinely administered vaccines (e.g., influenza, pneumococcal) on COVID-19 related outcomes, with contrasting results. In order to elucidate this discrepancy, we conducted a systematic review and meta-analysis to assess the association between seasonal influenza vaccination and pneumococcal vaccination with SARS-CoV-2 infection and its clinical outcomes. PubMed and medRxiv databases were searched up to April 2022. A random effects model was used in the meta-analysis to pool odds ratio (OR) and adjusted estimates with 95% confidence intervals (CIs). Heterogeneity was quantitatively assessed using the Cochran's Q and the I2 index. Subgroup analysis, sensitivity analysis and assessment of publication bias were performed for all outcomes. In total, 38 observational studies were included in the meta-analysis and there was substantial heterogeneity. Influenza and pneumococcal vaccination were associated with lower risk of SARS-CoV-2 infection (OR: 0.80, 95% CI: 0.75-0.86 and OR: 0.70, 95% CI: 0.57-0.88, respectively). Regarding influenza vaccination, it seems that the majority of studies did not properly adjust for all potential confounders, so when the analysis was limited to studies that adjusted for age, gender, comorbidities and socioeconomic indices, the association diminished. This is not the case regarding pneumococcal vaccination, for which even after adjustment for such factors the association persisted. Regarding harder endpoints such as ICU admission and death, current data do not support the association. Possible explanations are discussed, including trained immunity, inadequate matching for socioeconomic indices and possible coinfection.

Evaluation of knowledge and barriers of influenza vaccine uptake among university students in Saudi Arabia; a cross-sectional analysis

Background

Influenza vaccine hesitancy is a significant threat to global maneuvers for reducing the burden of seasonal and pandemic influenza. This study estimated the vaccine uptake, barriers, and willingness for influenza vaccines among university students in Saudi Arabia.

Methods

A cross-sectional survey was conducted among health science (HS) and non-health science (NHS) university students. A 31-item questionnaire was used to ascertain the vaccination rate, barriers, and willingness for the flu vaccine.

Results

This study included 790 students (mean age: 21.40 ± 1.94 years), 246 (31.1%) from HS and 544 (68.9%) from NHS disciplines. About 70% did not take flu shots before the arrival of the winter. The mean knowledge score was 7.81 ± 1.96, where 20.4%, 67.6%, and 12% of respondents had good, moderate, and poor knowledge regarding flu vaccines. The relative importance index (RII) analysis showed a lack of recommendation from physicians (51.5%, RI ranked: 1) was a top-ranked barrier to vaccine uptake, followed by negative perceptions and accessibility issues. Only 36.6% of the participants were willing to get vaccinated every year, 70% were willing to receive a vaccine on their doctor's recommendations, and 46% agreed to vaccinate if vaccines were freely available in the university. The knowledge, barriers, and willingness widely varied across students from two disciplines.

Conclusions

Our analysis underscored low flu vaccine uptake among university students. In addition, the study participants' knowledge was unsatisfactory, and they were less inclined to receive the flu vaccine in the future. Lack of recommendation from the physicians, negative perceptions towards the flu vaccine, and difficult accessibility were found as significant barriers to the vaccine uptake. A multidimensional approach at educational institutes to cover the knowledge gap and address the barriers curtailing the vaccination rate among students is recommended.

Influenza Vaccination Uptake and Hesitancy among Healthcare Workers in Early 2021 at the Start of the COVID-19 Vaccine Rollout in Cape Town, South Africa

Vaccination attitudes among healthcare workers (HCWs) predict their level of vaccination uptake and intention to recommend vaccinations to their patients. To our knowledge, no study has been conducted in South Africa to assess hesitancy toward influenza vaccines among HCWs. We adapted a questionnaire developed and validated by Betsch and colleagues and used it to conduct online and face-to-face interviews among HCWs at the start of the COVID-19 vaccine rollout. Multivariate logistic regression was used to assess predictors of influenza vaccine hesitancy. Of 401 participants, 64.5% were women, 49.2% were nurses, and 12.5% were physicians. A total of 54.9% were willing to accept, 20.4% were undecided, and 24.7% intended to refuse influenza vaccination. Participants who were above 25 years of age and physicians were more likely to accept the vaccine. Key predictors of vaccine acceptance were confidence in the effectiveness, consideration of benefits and risks, and willingness to be vaccinated to protect others. Influenza vaccine hesitancy was highest in those who did not trust that influenza vaccines are safe. For future flu seasons, tailored education programs on the safety and effectiveness of flu vaccines targeting younger HCWs, could be vital to improving vaccine uptake.

Flu Vaccination Coverage and Predictors of Non-Vaccination in Military Health Corps Personnel 2016-2017 and 2019-2021

(1) Background: Vaccination is the most effective intervention to control seasonal influenza morbidity and mortality. The present study aimed to determine the influenza vaccination coverage in the Military Health Corps personnel in the 2020−2021 season, as well as the time trend and the possible influence of the pandemic on coverage, in order to study the reasons that led to the non-vaccination of health professionals and to analyze adverse drug reactions (ADRs). (2) Methods: A descriptive, cross-sectional study was conducted from February to May 2021. All FAS CMS personnel were included. A self-administered questionnaire was sent by e-mail to the selected personnel. (3) Results: Vaccination coverage in the 2016−2017 season was 15.8% (n = 276), in the 2019−2020 season it was 17.41% (n = 424), and in the 2020−2021 season it was 24.22% (n = 590). The percentage of vaccinated men was higher than the percentage of women. In 2019 and 2020 the most vaccinated group was 31−40 years old. Lieutenants had the highest vaccination uptake in 2019 and 2020. The personnel with the highest uptake of vaccines were those in the specialty of nursing in each of 2016, 2019 and 2020, with >30 years of time worked in 2016. In terms of factors leading to refusal of vaccination, the most reported was “not considered a risk group” (23.0%), and the least reported was “avoidance of vaccine administration” (2.2%). Eighty individuals presented adverse reactions after vaccine administration (9.6%). (4) Conclusions: The rate of influenza vaccination among healthcare professionals was lower during the 2020 season compared to the previous season, but was expected to increase in the upcoming 2021 season.