key: cord-0325325-w2lcncd5
authors: Anthony Elia, Nedal Taha; Tokajian, Sima
title: COVID-19 and Influenza: Vaccination Before and During the Pandemic among the Lebanese Adult Population
date: 2021-02-12
journal: nan
DOI: 10.1101/2021.02.10.21251392
sha: 557425179d49e1fc7b598431439d9162b964fca0
doc_id: 325325
cord_uid: w2lcncd5

nan

Until the 6 th of February 2021, we had more than 104 million confirmed cases worldwide with an increased fatality rate in high-risk groups (World Health Organization 2021). The first documented case in Lebanon was on February 21 st , 2020 and since then we had almost 300,000 confirmed COVID-19 cases and more than 2,500 reported deaths (Ministry of Public Health 2021) . Unfortunately, in January 2021, the healthcare system reached its full capacity with complete occupancy in intensive care units. Although all countries worldwide were feeling the strain, Lebanon's experience was exceptional as this pandemic piled on top of a financial collapse and a huge port blast which already brought the health system to its knees.

There is no national seasonal influenza vaccination program in Lebanon , therefore, the vaccine is paid out-of-pocket. It costs between 8.04 $ and 17.41$ (12, 234 Lebanese Pounds) considering the official exchange rate (Ministry of Public Health 2021) . The only report evaluating vaccine acceptance in the adult population in Lebanon was that conducted by El . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted February 12, 2021. ; https://doi.org/10.1101 https://doi.org/10. /2021 Khoury and Salameh (2015) . Their results revealed an alarmingly low (27.6%) regular uptake of the influenza vaccine even in the high-risk groups.

The objective of this study was to assess the knowledge, attitudes, and practices of the Lebanese population towards the seasonal influenza and its vaccine, and to evaluate the effect of the COVID-19 pandemic on the influenza vaccination in the general Lebanese adult population.

Data generated from this study will help to formulate strategies and campaigns to increase acceptance of the influenza and SARS-CoV-2 vaccines in Lebanon.

The presented cross-sectional study was revised and approved by the Institutional Review Board (IRB) at the Lebanese American University (approval number LAU.SAS.ST3.4/Nov/2020).

Informed consents were obtained electronically from participants after presenting the purpose of the study through a written text prior to the start of the survey questionnaire.

A 30-item structured, self-established questionnaire was designed and developed in English and Arabic languages (see appendix 1). The questionnaire included 4 sections: (1) general information, (2) influenza and influenza vaccine, (3) COVID-19, and (4) influenza-COVID-19 intersection.

Preceding data collection, a pilot study was carried out on 12 volunteers to evaluate the clarity of the questionnaire after which minor modifications were introduced according to their collective feedback.

. CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)

The copyright holder for this preprint this version posted February 12, 2021. ; https://doi.org/10.1101 https://doi.org/10. /2021 

The survey was disseminated from November 2020 to December 2020 as an electronic link to a Google form entitled "FLUVACO" using social media applications, namely WhatsApp, Instagram, and Facebook. A total of 1055 participants from all adult age groups and residing in all 8 governorates of Lebanon gave their consent to participate.

Statistical analysis was performed using Statistical Package for Social Sciences (SPSS), version 26.0 (IBM Corp, Armonk, NY, USA). The data was analyzed using univariate (descriptive), bivariate (Pearson chi-square test for association and McNemar's test) as well as multivariate (logistic regression) techniques. p-values in the figures are represented as follows: * (p≤0.05), ** (p≤0.01), *** (p≤0.001). Confidence intervals mentioned in the text are at the 95% level.

The sample included 1055 participants with 66.2% being females. The most represented age group was 25-34 years old (30.2%), which was in line with the prevalent age group in the Lebanese population (Central Administration of Statistics 2019), while the older age group (45 and above) was among the least represented (15.9%). The geographical distribution over the 8 governorates showed that the majority (49.3%) of the participants resided in Mount Lebanon followed by the capital Beirut (14.6%), Northern Lebanon (10.9%), Southern Lebanon (7.4%), Nabatiyeh (5.1%), Akkar (4.4%), Baalbeck-Hermel (4.2%), and Beqaa (4.0%). The highest percentage (74.2%) was for those having a university degree, and 24.2% of the participants were in health-related fields. Regarding occupation, 55.8% were employed, 19.2% were unemployed, . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted February 12, 2021. ; https://doi.org/10.1101/2021.02.10.21251392 doi: medRxiv preprint 20.8% were university students, and the rest had other occupations (school students, volunteers or retired). The highest response (63%) came from participants with a low financial standing.

Financial standing is based on the household total income partitioned equally among the household individuals (see note 1). The vast majority (79.1%) implicated in their responses a decrease in the purchasing power following the economic crisis in Lebanon (in 2019). The studied population mainly (37.8%) belonged to families of 5 members or more. The majority (79%) consulted physicians only when needed. Concerning vaccines in general, a notable 5.1% considered themselves anti-vaxxers while the majority (51.3%) indicated that it would be dependent on the vaccine and/or production company and the disease.

Prior to the COVID-19 pandemic, 718 (69.7%, CI=66.8-72.5%) of the study participants never received the influenza vaccine within the last 5 years. The remaining 312 (30.3%, CI=27.5-33.2%) were vaccinated at least once: 206 (20.0%, CI=17.6-22.6%) vaccinated occasionally and only 106 (10.3%, CI=8.5-12.3%) were yearly vaccinated. Regarding winter 2020-2021, 696 (66.4%, CI=63.5-69.3%) implied that they will probably or surely not vaccinate, whereas 352 (33.6%, CI=30.7-36.5%) will probably or surely vaccinate. Interestingly, 20.7% of those who never vaccinated reported their willingness to vaccinate this winter. An exact McNemar test showed a significant increase in the percentage of participants intending to vaccinate this winter, p<0.001.

pandemic . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted February 12, 2021. ; https://doi.org/10.1101 https://doi.org/10. /2021 According to our results presented in figure 1, in the last five years, vaccination was significantly influenced by age, occupation, education level, the field of study, frequency of medical visits, and attitudes towards vaccination.

As for the potential to get the influenza vaccine this winter 2020-2021, it was significantly correlated with age, education level, field of study, financial standing, frequency of medical visits, and general opinion on vaccines. Gender, governorate of residency, and household population; however, did not significantly affect participants' willingness to get the influenza vaccine. All the assessed KAP variables have the same relation with influenza vaccination before and during COVID-19. For instance, the more the participants were worried about an influenza infection, the more the participants were familiar with the influenza vaccine (subjective evaluation), and the more general knowledge the participants knew about influenza (objective assessment, see note 2), the significantly higher the percentage of participants vaccinating against influenza. Figure 3 summarizes the results of the multivariate analysis performed to ascertain the effects of the variables on the likelihood of influenza vaccination . Only the variables that can be targeted were included in the analysis.

. CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted February 12, 2021. ; https://doi.org/10.1101/2021.02.10.21251392 doi: medRxiv preprint Model 1 shows that participants in all age categories except above 65 were significantly less vaccinated compared to those aged 18-24. Furthermore, individuals with a secondary education had a lower vaccine uptake relative to those with tertiary education (OR=0.61, CI=0.41-0.91, p=0.016). Also, an increased influenza vaccine familiarity was associated with a significant increase in vaccination rate (OR=1.57, CI=1.38-1.78, p < 0.001).

Model 2 generated for the predicted rate of influenza vaccination this winter 2020-2021 indicates that participants aged 55-64 vs 18-24 (OR=2.35, CI=1.18-4.69, p=0.015), who answered correctly that influenza can cause fever vs not sure (OR=1.89, CI=1.18-3.04, p=0.008), and are more familiar with the influenza vaccine (OR=1.32, CI=1.17-1.47, p< 0.001) intend to vaccinate more than others this winter. Contrariwise, participants living in households where the purchasing power decreased between 2019 and 2020 are 30% less willing to vaccinate (CI=0.51-0.98, p=0.036) when compared with those living in households where the purchasing power did not decrease.

Participants who were more likely to vaccinate this winter were also more likely to agree that the influenza vaccine should be obligatory, free of charge, and available to everyone (supplementary Figure 1 ). Models 1, 2, and 3 presented in Figure 4 were created to assess the effect of the COVID-19 pandemic on the willingness of participants who never, occasionally, or yearly vaccinated, respectively, to get the influenza shot this winter.

Disagreeing to or being neutral about the statement "the influenza vaccine will decrease influenza hospitalization, and spare hospital beds for urgent COVID-19 cases" was the only inverse correlate shared between the 3 groups.

. CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted February 12, 2021. ; https://doi.org/10. 1101 /2021 Besides, being afraid of catching the influenza and the COVID-19 together and believing that the influenza vaccine will be effective against COVID-19 significantly influenced the willingness of those who never vaccinated prior to the COVID-19 to vaccinate this winter. Figure 5A and 5B depict the correlations between general characteristics, KAP regarding COVID-19, and participants' views, on one side, and COVID-19 vaccination (after the vaccine is endorsed in Lebanon) on the other side.

It is obvious that males, old age groups, and individuals with a health-related background are considerably more willing to vaccinate.

Individuals agreeing that the COVID-19 vaccine should be obligatory, are extremely more willing to vaccinate (93.5%) vs only 18% and 43.6% of those disagreeing or having no opinion (p<0.001). Comparably, individuals agreeing that they are afraid of catching the influenza and the COVID-19 at the same time are significantly more willing to be vaccinated (p=0.025).

The emergence and spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and the resulting coronavirus disease 2019 (COVID-19) led to a global health crisis.

Governments worldwide endorsed quarantine measures to slow the spread, protect the most vulnerable, and cope with the tremendous demand on health care services. To stalk the COVID-19 pandemic, regulatory agencies need to support rapid testing and progression of vaccine candidates while in parallel efforts should be directed towards identifying and understanding COVID-19 vaccine hesitancy within distinct populations. Accordingly, we conducted a quantitative cross-sectional study by designing and disseminating a 30-item structured questionnaire. Our study aimed at determining whether the COVID-19 pandemic affected . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted February 12, 2021. ; https://doi.org/10.1101/2021.02.10.21251392 doi: medRxiv preprint influenza vaccination rate in the general Lebanese adult population with the ultimate goal being to understand the factors behind vaccine hesitancy to shape public health campaigns that could help in increasing the uptake of the influenza and COVID-19 vaccines. To our knowledge, this is the largest study of vaccine confidence in Lebanon, with cross-country comparisons that helped elucidate the public's vaccination willingness, investigate vaccination confidence, and determine factors behind hesitancy. The sample included 1055 participants with 66.2% being females, and the prevalent age group being 25-34 years old (30.2%). Our results revealed that 5.1% of the participants were anti-vaxxers while the majority (51.3%) could be considered as being hesitant and their willingness was linked to the vaccine and/or production company and the disease. A recent study conducted in Ireland and UK revealed that vaccine resistance/hesitance was evident in 35% and 31% of the respondents, respectively (Murphy et al. 2021) . It is noteworthy that prior to the COVID-19 pandemic almost 70% of our study participants never received the flu vaccine within the last five years, with a significant increase in the percentage of participants intending to vaccinate this winter and which our results showed that it was directly linked to the fear of getting a serious COVID-19 infection (results not shown). Perceived risk was previously linked to a change in vaccine hesitancy with at least 30% in proportion willing to vaccinate as risk of infection increases (Baumgaertner et al. 2020 ).

On the other hand, the education level, the field of study, frequency of medical visits, and attitudes towards vaccination were among the factors in this study with significant impact on the tendency to vaccinate. Tendency to vaccinate was significantly lower in old age brackets compared to the younger participants (p < 0.001), and those having tertiary education representing the dominant within the pro-vaccine group. This was in contrast to the results . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted February 12, 2021. There are many other causes given for not getting vaccinated by adults and that are linked to ignorance of the true facts, lack of support and follow up from the healthcare system or baseless fears (Baeyens 2014). Our results came to confirm the aforementioned reasons, where the more the participants were worried about an influenza infection, the more familiar they were with the vaccine and consequently the higher was their tendency to vaccinate. Additionally, suboptimal vaccination was previously linked to affordability and the lack of funding for adult vaccines (Swanson et al. 2015) . This agreed with our results, with participants living in households where the purchasing power decreased between 2019 and 2020 were 30% less willing to vaccinate. As the combination of flu and COVID-19 could further overwhelm healthcare settings this winter, there is an urgent need to reform and strengthen public health systems in Lebanon to maximize vaccine availability and affordability and be free and available to the rich and poor alike.

Studying the correlations between knowledge, attitude, and practices regarding COVID-19, and participants' tendency to vaccinate after introducing COVID-19 vaccine in Lebanon, revealed that males, old age, and having a health-related background demarked those that were more willing to vaccinate. Sex, age, and income level was according to Murphy et al. (2021) the demographic factors that were most significantly associated with vaccine hesitance or resistance.

Moreover, 70% of the study participants never received the influenza vaccine within the last 5 years. We think, and according to the received responses, that this hesitancy and resistance could . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted February 12, 2021. ; https://doi.org/10.1101 https://doi.org/10. /2021 be correlated to knowledge gap and low perceived importance on the impact vaccination that goes beyond the vaccinated individual.

All the aforementioned factors affecting the population's decision to vaccinate culminated in a worrisome sub-optimal influenza and COVID-19 vaccination rates. Continuing with such rates over the next years will result in a higher burden and mortalities caused by infectious agents against which we have a very affordable and effective prevention measure -vaccination.

Combatting the "ideology" of vaccine hesitancy starts with campaigns that stress the success of vaccines on a societal rather than on an individualistic level, highlighting the success of vaccination in eradicating smallpox. We need to promote the integration of health education within all scholastic programs, use technology and media platforms to fight vaccine hesitancy.

The present study has a few limitations. Since the survey was propagated solely in an electronic version, the elderly in our sample were less represented than younger age groups. Moreover, participants were required to self-report their previous vaccination records thus we were unable to double check their accuracy. These rates might not accurately translate in reality for this winter because of the possible lack of influenza vaccines in Lebanon or simply because the participants changed their mind after completing the survey. In spite of all these mentioned limitations, our sample included a considerable number of individuals, of different adult ages, with different educational backgrounds, and most importantly from all 8 governorates in Lebanon to represent as close as possible the general population.

. CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted February 12, 2021. ; https://doi.org/10.1101 https://doi.org/10. /2021 To our knowledge, this study is the largest to evaluate vaccination willingness among the general adult population in Lebanon emphasizing on influenza and endorsing COVID-19 programs. We observed a significant increase in the predicted tendency to be vaccinated against influenza for this winter relative to the rate prior to the COVID-19 pandemic but is still alarmingly suboptimal. We believe that maximizing the availability and affordability of vaccines, providing public educational campaigns, involving healthcare workers to educate the public, and implementing immunization reminder-recall systems are much needed in the time of the COVID-19 pandemic.

Participants were asked about their family income as well as the number of people living in their household. Consequently, the family incomes were divided by the number of people living in the household to determine the income per person per month in Lebanese pounds (LBP) which was categorized into either low (less than 1 000 000 LBP) , moderate (between 1 000 000 and 3 000 000 LBP), or high financial standing (above 3 000 000 LBP).

were scored either 0 for a wrong answer or 1 for a correct answer. The scores were added up to 5 possible points for each disease which were consequently grouped into 4 categories: unsatisfactory (0/5, 1/5, or 2/5), satisfactory (3/5), good (4/5), and very good (5/5).

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The copyright holder for this preprint this version posted February 12, 2021. in Lebanon). The scores were then averaged for each individual for analytic purposes and classified into low (2.5/5 and below), average (between 2.5/4 and 4/5), high (4/5 and above).

. CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted February 12, 2021. . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted February 12, 2021. ; https://doi.org/10.1101 https://doi.org/10. /2021 . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted February 12, 2021. ; https://doi.org/10.1101 https://doi.org/10. /2021 . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted February 12, 2021. ; https://doi.org/10.1101/2021.02.10.21251392 doi: medRxiv preprint . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted February 12, 2021. ; https://doi.org/10.1101/2021.02.10.21251392 doi: medRxiv preprint . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)

The copyright holder for this preprint this version posted February 12, 2021. ; https://doi.org/10.1101/2021.02.10.21251392 doi: medRxiv preprint . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)

The copyright holder for this preprint this version posted February 12, 2021. . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)

The copyright holder for this preprint this version posted February 12, 2021. ; https://doi.org/10.1101/2021.02.10.21251392 doi: medRxiv preprint

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three logistic regressions were statistically significant (p < 0.05) and explained 18.3%, 23.5% and 5.7% (Nagelkerke R 2 ) of the variance in influenza vaccination