Dentistry, Faculty of
DSpace
UBCV
Ejiegbu, Anne Ngozi
Master of Science - MSc
University of British Columbia
Objectives: Immunocompromised individuals face heightened risks from vaccine-preventable diseases, including People Living with HIV (PLHIV), who are further vulnerable due to socio-economic and comorbidity factors, as underscored by the recent COVID-19 pandemic. This study employed a scoping review to identify barriers and facilitators to vaccination in immunocompromised individuals. It also includes a cross-sectional study focused on COVID-19 vaccines in PLHIV to highlight socio-economic and health-related factors influencing vaccine uptake and hesitancy. Methods: The scoping review was guided by the Joanna Briggs Institute’s framework encompassing studies published between January 1974 and July 25, 2022, in academic databases and grey-literature sources. Subsequently, a 34-item anonymous survey was distributed to PLHIV via e-newsletters through HIV/AIDS-related organisations in British Columbia. The survey, conducted between November 2022 and January 2023, collected information on socio-demographics, COVID-19-vulnerability factors, HIV indicators, and vaccine hesitancy scores using the validated adult Vaccine Hesitancy Scale. Descriptive (means and frequencies) and inferential statistics, including ANOVA and Binary logistic regression, were conducted to detect factors associated with COVID-19 vaccine hesitancy and vaccine uptake. Significant level (p<0.05). Results: Seventy-six publications were included in the scoping review, with vaccine uptake ranging from 5.6% to 96.7%. Barriers to vaccine uptake included concerns about adverse effects, lack of physician recommendations, and younger age, while facilitators included older age, perceived disease vulnerability, higher education, prior vaccination history, and longer immunosuppression duration. iv From the cross-sectional study, out of 276 respondents (mean age 29.93±7.548), nearly 40% received three vaccine doses or more, and 82.2% at least one dose. Predictors of COVID-19 vaccine uptake included age [aOR=1.063], bachelor's degree [aOR=0.216], family/friends with COVID-19 [aOR=3.678], HIV viral load >500copies [aOR=0.197], belief in vaccine importance [aOR=0.514], trust in Health Canada's information [aOR=0.494], and concerns about vaccine adverse effects [aOR=0.349]. Conclusions: My study highlights that immunocompromised individuals' vaccination behaviours are influenced by health-related factors, such as concerns about vaccine safety and reliance on physicians’ recommendations due to limited vaccine knowledge. These insights are pivotal in formulating effective public health policies and interventions that address safety concerns and knowledge gaps to support informed vaccination decisions, ultimately fostering vaccine uptake and maintaining an up-to-date vaccination status.
COVID-19 VACCINE HESITANCY AND BEHAVIOURS AMONG PEOPLE LIVING WITH HIV IN BRITISH COLUMBIA by Anne Ngozi Ejiegbu BDS, The University of Lagos, 2019 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE in The Faculty of Graduate and Postdoctoral Studies (Craniofacial Science) THE UNIVERSITY OF BRITISH COLUMBIA (Vancouver) October 2023 © Anne Ngozi Ejiegbu, 2023 ii The following individuals certify that they have read and recommend to the Faculty of Graduate and Postdoctoral Studies for acceptance the thesis entitled: COVID-19 Vaccine Hesitancy and Behaviours Among People Living with HIV In British Columbia Submitted by partial fulfilment of the requirements for the degree of In Examining Committee: Dr Mario Brondani, Professor, Department of Oral Health Sciences, Faculty of Dentistry, UBC Supervisor Dr Batoul Shariati, Clinical Professor, Department of Oral and Biomedical Sciences, Faculty of Dentistry, UBC Supervisory Committee Member Dr Jonathan P. Little, Professor, Centre for Chronic Disease Prevention and Management, Faculty of Health and Social Development, UBC Okanagan Supervisory Committee Member Dr Renata Grazziotin-Soares, Assistant Professor, Department of Oral and Biomedical Sciences, Faculty of Dentistry, UBC Supervisory Committee Member Anne Ngozi Ejiegbu Master of Science Craniofacial Science iii Abstract Objectives: Immunocompromised individuals face heightened risks from vaccine-preventable diseases, including People Living with HIV (PLHIV), who are further vulnerable due to socio-economic and comorbidity factors, as underscored by the recent COVID-19 pandemic. This study employed a scoping review to identify barriers and facilitators to vaccination in immunocompromised individuals. It also includes a cross-sectional study focused on COVID-19 vaccines in PLHIV to highlight socio-economic and health-related factors influencing vaccine uptake and hesitancy. Methods: The scoping review was guided by the Joanna Briggs Institute’s framework encompassing studies published between January 1974 and July 25, 2022, in academic databases and grey-literature sources. Subsequently, a 34-item anonymous survey was distributed to PLHIV via e-newsletters through HIV/AIDS-related organisations in British Columbia. The survey, conducted between November 2022 and January 2023, collected information on socio-demographics, COVID-19-vulnerability factors, HIV indicators, and vaccine hesitancy scores using the validated adult Vaccine Hesitancy Scale. Descriptive (means and frequencies) and inferential statistics, including ANOVA and Binary logistic regression, were conducted to detect factors associated with COVID-19 vaccine hesitancy and vaccine uptake. Significant level (p<0.05). Results: Seventy-six publications were included in the scoping review, with vaccine uptake ranging from 5.6% to 96.7%. Barriers to vaccine uptake included concerns about adverse effects, lack of physician recommendations, and younger age, while facilitators included older age, perceived disease vulnerability, higher education, prior vaccination history, and longer immunosuppression duration. iv From the cross-sectional study, out of 276 respondents (mean age 29.93±7.548), nearly 40% received three vaccine doses or more, and 82.2% at least one dose. Predictors of COVID-19 vaccine uptake included age [aOR=1.063], bachelor's degree [aOR=0.216], family/friends with COVID-19 [aOR=3.678], HIV viral load >500copies [aOR=0.197], belief in vaccine importance [aOR=0.514], trust in Health Canada's information [aOR=0.494], and concerns about vaccine adverse effects [aOR=0.349]. Conclusions: My study highlights that immunocompromised individuals' vaccination behaviours are influenced by health-related factors, such as concerns about vaccine safety and reliance on physicians’ recommendations due to limited vaccine knowledge. These insights are pivotal in formulating effective public health policies and interventions that address safety concerns and knowledge gaps to support informed vaccination decisions, ultimately fostering vaccine uptake and maintaining an up-to-date vaccination status. v Lay Summary The COVID-19 pandemic has further highlighted the necessity to consider the vaccination behaviours of people who are at high risk of contracting the disease and other vaccine-preventable illnesses, particularly those who are immunocompromised. I explored the social, economic, and health-related factors that could either promote or hinder the immunocompromised population from getting vaccinated. I discovered that younger individuals with these conditions are less likely to accept vaccines compared to older people who have been diagnosed with these conditions for a longer period of time. I also found, specifically, that HIV-positive individuals were less likely to be vaccinated with the recommended COVID-19 vaccine doses if they had a high HIV-viral load, did not trust the information from Health Canada and were worried about potential adverse effects of the vaccine. vi Preface This is an original, independently conducted thesis by Anne Ngozi Ejiegbu, which is currently under peer review for publication via two separate manuscripts. The data collection method involved a systematic search of the literature using online academic databases for peer-reviewed journal articles for the scoping review, while the cross-sectional study was conducted among British Columbia’s HIV-positive residents utilising the services of Pacific AIDS network, AIDs Vancouver and Community Based Research Centre. I, being the principal author, was responsible for formulating the scoping review protocol, designing the proposal for the cross-sectional study, developing the survey items, obtaining ethical approval, recruiting participants and data collection, analysis and writing the report of the results, including preparation for manuscript submission. The cross-sectional study presented in Chapter 3 has been granted ethical approval by the University of British Columbia’s Behavioural Research Ethics Board (# H22-02053). vii Table of Contents Abstract ......................................................................................................................................... iii Lay Summary ................................................................................................................................ v Preface ........................................................................................................................................... vi Table of Contents ........................................................................................................................ vii List of Tables ................................................................................................................................. x List of Figures ............................................................................................................................... xi List of Abbreviations .................................................................................................................. xii Acknowledgements .................................................................................................................... xiii Dedication ................................................................................................................................... xiv Chapter 1: Introduction ............................................................................................................... 1 1.1 Impact of COVID-19: Challenges and Vaccine Considerations for People Living with HIV .............................................................................................................................................. 3 1.2 Research Questions and Objectives ................................................................................... 4 1.2.1 Research Questions: ........................................................................................................ 4 1.2.2 Objectives: ....................................................................................................................... 4 Chapter 2: Exploring the Barriers and Facilitators to Vaccination among the Immunocompromised Population: A Scoping Review .............................................................. 6 2.1. Summary ............................................................................................................................. 6 2.2 Background .......................................................................................................................... 8 2.2.1 Review questions: ......................................................................................................... 10 2.3 Methods .............................................................................................................................. 11 2.3.1 Eligibility Criteria ......................................................................................................... 11 viii Participants .......................................................................................................................... 11 Concept ............................................................................................................................... 11 Context ................................................................................................................................ 12 2.3.2 Information Sources and Search Strategy ..................................................................... 12 2.3.3 Screening and Study Selection ...................................................................................... 12 2.3.4 Data Extraction .............................................................................................................. 13 2.3.5 Collating and Summarizing ........................................................................................... 15 2.4 Results ................................................................................................................................. 15 2.4.1 Descriptive Analysis ..................................................................................................... 15 2.4.2 Vaccine Outcomes......................................................................................................... 16 2.4.3 Barriers to Vaccination (Promoters of Vaccine Hesitancy) .......................................... 17 2.4.4 Facilitators of Vaccination ............................................................................................ 18 2.5 Discussion ........................................................................................................................... 38 2.5.1 Contextual Factors......................................................................................................... 38 2.5.2 Individual and Group Factors ........................................................................................ 39 2.5.3 Vaccine and Vaccination Factors .................................................................................. 41 2.5.4 Strengths and Limitations.............................................................................................. 41 2.6 Conclusion .......................................................................................................................... 42 Chapter 3: COVID-19 Vaccination Uptake and Hesitancy among People Living with HIV in British Columbia ......................................................................................................................... 43 3.1. Summary ........................................................................................................................... 43 3.2 Background ........................................................................................................................ 45 3.3 Methods .................................................................................................................................. 50 ix 3.3.1 Study design and population ......................................................................................... 50 Data Collection Tool ........................................................................................................... 50 Sample Size Determination................................................................................................. 51 3.4 Data Analyses ..................................................................................................................... 52 3.5 Results ................................................................................................................................. 53 3.5.1 COVID-19 Vaccine Hesitancy ...................................................................................... 58 3.5.2 COVID-19 Vaccine Uptake .......................................................................................... 60 3.5 Discussion ........................................................................................................................... 63 Chapter 4: Conclusions, Limitations and Future Directions .................................................. 68 4.1 Conclusion .......................................................................................................................... 68 4.2 Limitations ......................................................................................................................... 68 4.3 Future Directions ............................................................................................................... 69 References .................................................................................................................................... 70 Appendices ................................................................................................................................... 87 Appendix A: Search Strategy ................................................................................................. 87 Appendix B: Cross-Sectional Survey Including Informed Consent ................................... 88 x List of Tables Table 2-1: Descriptive Analysis of Objectives, Types of Immunodeficiency, Vaccine Health Outcomes, and Influential Factors in Vaccination ........................................................................ 19 Table 3-1: Sociodemographic Profile of the 276 PLHIV in British Columbia who Participated..54 Table 3-2: Logistic Regression Models Analyzing COVID-19 Vaccine Uptake in PLHIV in British Columbia, January 2023 ............................................................................................................... 62 xi List of Figures Figure 2-1 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Flow Diagram of Studies Included at each Stage of the Review ........................................................... 14 Figure 2-2: Articles about Vaccine Uptake and Hesitancy by Immune Disorder Published between 2011 and 2022 (N =76) ................................................................................................................. 16 Figure 3-1: Reported Motivation for COVID-19 Vaccination ..................................................... 57 Figure 3-2: Reported Concerns for COVID-19 Vaccine Refusal ................................................. 57 Figure 3-3: Reported Factors Underlying Incomplete COVID-19 Vaccination ........................... 58 xii List of Abbreviations AIDS- Acquired Immune Deficiency Syndrome aVHS- Adult Vaccine Hesitancy Scale BREB- Behavioural Research Ethic Board CBRC- Community Based Research Centre CD4- Clusters of differentiation 4 CHODARR- Community Health Online Digital Archive & Research Resource COVID-19- Coronavirus Disease of 2019 HAART- Highly Active Antiretroviral Therapy HIV- Human Immunodeficiency Virus HPV- Human Papilloma Virus MS- Multiple Sclerosis MSM- Men who have sex with Men NACI- National Advisory Committee on Immunization PAN- Pacific AIDS Network PLHIV- People Living with Human Immunodeficiency Virus SAGE- Strategic Advisory Group of Experts on Immunization SARS-CoV-2- Severe Acute Respiratory Syndrome Coronavirus 2 UBC- University of British Columbia USA- United States of America WHO- World Health Organization xiii Acknowledgements I extend my profound gratitude to Dr. Mario Brondani, my esteemed supervisor, for his support, invaluable guidance, and remarkable patience throughout the duration of this project. Your belief in me and the opportunities he provided have been instrumental in my academic journey. Your exceptional work ethic serves as a true source of inspiration. I wish to express my sincere appreciation to my dedicated committee members, Dr. Batoul Shariati and Dr Jonathan Little, for their constant support and mentorship, which have afforded me priceless learning experiences. Special thanks are due to Melody Shayanfar for her vital role as the second reviewer and author in the scoping review project. Additionally, my gratitude extends to Ms. Sae Young Kim and Ms. Ursula Ellis, esteemed consulting librarians at the University of British Columbia, for their unwavering commitment of time and effort. I reserve special recognition for AIDS Vancouver & Dr Peter's Centre for generously funding our pilot study, which paved the way for the cross-sectional study, and for their steadfast support and collaboration throughout. Furthermore, I express my heartfelt thanks to the Pacific AIDS Network for their gracious collaboration in this research endeavour. To the respondents who graciously dedicated their time during the holiday period to complete our surveys, your invaluable contributions are deeply appreciated. Without your participation, this study would not have been possible. Lastly, I extend my gratitude to my family and friends, Adefolawe, Mary, and Chinenye, for their unwavering support in my academic pursuits. xiv Dedication I dedicate this thesis to my husband, Samuel, for his resolute support, motivation, and love, even during the toughest of times over the past two years. To my mother, thank you for your enduring guidance and encouragement throughout my academic journey. To my late father, your heavenly smile remains a constant source of inspiration and strength. James 1:17- Every good gift and every perfect gift is from above, and comes down from the Father of lights, with whom there is no variation or shadow of turning. Chapter 1: Introduction One of the most noteworthy contributions to public health is the reduction of morbidity and mortality through vaccination. Effective vaccination has been validated as an affordable, proactive solution in advancing global welfare as a primary prevention method (1,2). Nonetheless, despite the benefits of vaccination, an increasing number of individuals doubt, question, or outrightly refuse to be vaccinated due to personal, sociocultural and/or political reasons. The efficacy of vaccination in public health hinges on a high proportion of individuals being vaccinated with the recommended doses within their communities (3). This widespread adoption can eliminate and potentially eradicate vaccine-preventable diseases through establishing herd immunity (4,5). Herd immunity refers to the indirect protection conferred on susceptible members of the population when a sufficient percentage of immune individuals exist within the population (6). Over the years, the discourse surrounding vaccine-related behaviours has evolved from a binary "pro-vaccination versus anti-vaccination" stance to encompass the nuanced spectrum of "vaccine acceptance, hesitancy, and refusal." In 2014, the Strategic Advisory Group of Experts on Immunization (SAGE) Working Group produced a report on Vaccine Hesitancy, referring to it as “delay in acceptance or refusal of vaccines despite availability of vaccine services. Vaccine hesitancy is complex and context-specific, varying across time, place, and vaccines.” (3 pg.7) Moreso, the World Health Organization recognised vaccine hesitancy as one of the ten global health threats. While vaccine hesitancy is in the middle of a continuum between vaccine acceptance and refusal, vaccine acceptance is often quantified by vaccine willingness/intention and vaccine uptake (7). 2 Although universal immunisation of children is part of a global healthcare routine which might contribute to uptake, vaccination of adults lags appreciably (8) (9),(10). Nevertheless, there are global and national guidelines targeting adult populations, and vaccine recommendations include vaccines against Influenza, Tetanus, Varicella, Human papillomavirus (HPV)(11) Pneumococcal, Hepatitis (12) and now the SARS-CoV-2 (13). These guidelines also cater to specific populations, notably immunocompromised individuals at heightened risk of vaccine-preventable diseases (9,10) being unable to mount an effective immune response to these illnesses. 1.1 Overview of Vaccination in Immunodeficiency Disorders Individuals with immunodeficiency disorders, often referred to as immunocompromised or immunosuppressed, have conditions that lead to partial or complete impairment of the immune system, and they are broadly categorised into primary immunodeficiencies, which are inherited and encompass deficiencies in B-cell function, T-cell function, complement activity, and immunoglobulin production (e.g., DiGeorge syndrome and X-linked Agammaglobulinemia) and secondary immunodeficiencies, which are acquired and often result from environmental factors, including the human immunodeficiency virus, which may progress into acquired immunodeficiency syndrome. The vaccine uptake rates among these populations vary widely and have been shown to range between 2% to 79% (14), and the low uptake rates have been attributed to insufficient information about vaccine needs, fear of adverse effects and presence of comorbidities, including sociodemographic risks. (15,16) 3 1.1 Impact of COVID-19: Challenges and Vaccine Considerations for People Living with HIV The emergence of Coronavirus disease in 2019 has impacted lives worldwide, having significant medical, psychological and economic implications (17–19), resulting in over 695 million infections and 6.9 million deaths across the globe by September 2023 (17). Over the past three years, multiple waves of COVID-19 infections have occurred globally (20), with multiple and sometimes conflicting policy responses in effect (21), including physical distancing, travel restrictions, lockdowns, and vaccination rollouts (22). During the initial phases of the COVID-19 pandemic, concerns arose regarding the heightened vulnerability of PLHIV to both the incidence and severity of the virus due solely to being immunocompromised (23,24). However, empirical data reveal that while PLHIV did not exhibit an overrepresentation in COVID-19 cases, they did experience more severe outcomes mainly attributable to HIV-related social disparities, medical risks, and comorbidities. Consequently, the need for vaccination in this population was emphasised (25,26). Although limited PLHIV were included in COVID-19 vaccine trials, available data suggests vaccine efficacy and safety among individuals with well-managed HIV, undetectable viral loads, and CD4 cell counts exceeding 200 cells/mm³(27). Therefore, the National Advisory Committee on Immunization (NACI) strongly advocated for the completion of the COVID-19 vaccine regimen in individuals with compromised immune systems, encompassing PLHIV (28). Historical vaccine behaviour among PLHIV has been related to distrust stemming from inequity (29), lack of insurance coverage, sexual orientation and low CD4+ (30,31). Furthermore, several research efforts in Canada have been dedicated to investigating the willingness of PLHIV to receive COVID-19 vaccinations (32,33). However, a gap remains concerning data regarding actual 4 vaccine uptake in this population, particularly pertaining to adherence to the recommended primary vaccine series. To address this gap, my MSc research was conducted with the following research questions and objectives. 1.2 Research Questions and Objectives 1.2.1 Research Questions: 1. What are the facilitators (promoters) and barriers (deterrents) to vaccine uptake among people living with immune deficiency conditions? 2. What are the associated factors of vaccine hesitancy within the immunocompromised population regarding individual and group influences, contextual influences, and vaccine/vaccination influences? 2.1. What are the socio-economic and health-related predicting factors of COVID-19 uptake and hesitancy among PLHIV in British Columbia, Canada? 1.2.2 Objectives: This study has dual objectives: 1. To comprehensively map out evidence on the factors that promote and deter vaccination and shed light on evolving trends in vaccine uptake among individuals with primary and secondary immune disorders. 2. To determine the prevalence of COVID-19 vaccine uptake among PLHIV in British Columbia, Canada; the level of vaccine hesitancy among PLHIV in British Columbia using the adult vaccine hesitancy scale; and the socio-economic and health (COVID-19 and HIV-related) factors associated with COVID-19 vaccine uptake (including predictors) and vaccine hesitancy. 5 To address the research questions and fulfil the objectives, I conducted my research in two phases. The initial phase consisted of a comprehensive scoping review, which explored vaccine behaviours within the immunocompromised population as a whole. The findings of this review are presented in Chapter 2, and a version of this chapter has been prepared for submission to the PLOS One Global Public Health Journal. The second phase of the study was a focused investigation that homed in on a specific immunodeficiency condition and the most recent COVID-19 vaccine. This phase utilised a cross-sectional study design to examine predictive factors influencing COVID-19 vaccine uptake and to identify factors associated with vaccine hesitancy among PLHIV in British Columbia. A version of this chapter has been also prepared for submission to the PLOS One Global Public Health Journal. I then finalize my thesis with a general conclusion, and future directions in Chapter 4. Given the overlap of Chapter 1 and Chapter 4 with the stand-alone manuscripts presented in Chapters 2 and 3, some repetition of content likely occurred. 6 Chapter 2: Exploring the Barriers and Facilitators to Vaccination among the Immunocompromised Population: A Scoping Review 2.1. Summary 2.1.1 Objective: Individuals with immune deficiency are at increased risk of morbidity and mortality caused by vaccine-preventable diseases. Despite the advantages of vaccination, some members of this high-risk population question the use of vaccines. This study aimed to identify the barriers and facilitators to vaccination among people with altered immunocompetence via a scoping review. 2.1.2 Methods: This review was guided by the Joanna Briggs Institute's framework to identify relevant publications examining factors influencing vaccine behaviours in immunocompromised populations. My search encompassed studies published from January 1974 to July 25, 2022, across various databases, including MEDLINE (Ovid), CINAHL, PsycINFO, Web of Science, Cochrane Database of Systematic Reviews, EMBASE, ProQuest, TRIP, CHODARR, OpenGrey, and Google Scholar. Both peer-reviewed and grey literature were incorporated, irrespective of language, in line with predefined criteria. The synthesis specifically addressed vaccine uptake and hesitancy outcomes, along with factors acting as barriers or facilitators. 2.1.3 Results: Seventy-six publications were included, addressing both congenital and acquired immunodeficiencies. Notably, vaccines for COVID-19, Influenza, Pneumococcal disease, and Hepatitis B featured prominently. Vaccine uptake rates exhibited a wide range, spanning from 5.6% to 96.7%. Factors hindering vaccination uptake included concerns about adverse vaccine effects, doubts about vaccine benefits, lack of healthcare professional recommendations, and younger age. Conversely, predictors of higher vaccination uptake comprised older age, perceived 7 vulnerability to vaccine-preventable diseases, higher education attainment, prior vaccination history, and longer immunosuppression duration. 2.1.3 Conclusions: My study highlights that immunocompromised individuals' vaccination behaviours are influenced by unique health-related factors, such as concerns about vaccine safety and reliance on physicians due to limited vaccine knowledge. These insights are pivotal in the formulation of effective public health policies and interventions that address safety concerns and knowledge gaps and enhance understanding to support informed vaccination decisions. 8 2.2 Background Vaccination stands as a cornerstone of public health, curbing morbidity and mortality effectively as a primary preventive measure (1,2). Despite its merits, an increasing number of individuals challenge or decline to get vaccinated due to personal, sociocultural, religious, or political reasons. The concept of vaccine-related behaviours has shifted from the dichotomy of “anti-vaccination and pro-vaccination” to a more nuanced framework of “vaccine acceptance, hesitancy, and refusal.” In 2014, the Strategic Advisory Group of Experts on Immunization (SAGE) produced a report on vaccine hesitancy, defining it as the “delay in acceptance or refusal of vaccines despite the availability of vaccine services [as it] is complex and context-specific, varying across time, place, and vaccines… influenced by factors such as complacency, convenience, and confidence” (3). Notably, vaccine hesitancy ranks among the ten most significant global threats to health (4). Vaccine-hesitant individuals occupy a position in the middle of a spectrum that spans from full acceptance of vaccines to complete refusal (34),(35). Consequently, vaccine hesitancy should be considered “amendable” due to the potential to shift people’s intentions and even behaviour. The associating factors of vaccine hesitancy often manifest as barriers to vaccine uptake, including contextual, individual and group, and vaccine/vaccination-specific factors (3). Contextual factors encompass historical, socio-economic, environmental, institutional/healthcare system, and political influences, while individual and group factors include personal vaccine perceptions and the impact of the social or peer environment. Vaccine and vaccination-specific factors are related directly to the characteristics of the vaccine or the vaccination procedures (36,37). Paradoxically, these same factors can also lead to vaccine refusal altogether (38), likely due to fear of adverse effects or allergies to vaccine components and religious or philosophical objections to vaccination (8–10). Both global and national guidelines exist for vaccine recommendations targeting children 9 and adult populations, particularly for vaccines against Influenza, Tetanus, Varicella, Human papillomavirus (HPV), Pneumococcal infections, Hepatitis (12) and more recently, the SARS-CoV-2 (13). Additionally, guidelines are tailored to specific adult populations, especially immunocompromised individuals who are at high risk for vaccine-preventable diseases (9,10) and are the focus of this study. Immunodeficiency disorders lead to the partial or complete impairment of the immune system, and they can be broadly categorised into two main types: primary immunodeficiencies, which are inherited and encompass deficiencies in B-cell function, T-cell function, complement activity, and immunoglobulin production (e.g., DiGeorge syndrome and X-linked Agammaglobulinemia) (39); and secondary immunodeficiencies, which are acquired and often result from environmental factors, including individuals undergoing immunosuppressive therapies for a number of conditions (40) and those living with the human immunodeficiency virus (HIV), which may lead to acquired immunodeficiency syndrome (AIDS) (39). Individuals with immunodeficiency disorders, often referred to as immunocompromised or immunosuppressed, are unable to generate an effective immune response and are at heightened risk of vaccine-preventable infections. Consequently, vaccination becomes critically important in this population. In General, inactivated (non-viable) vaccines are considered safer for immunocompromised patients compared to live (viable) vaccines that are typically contraindicated in patients with more severe immune disorders. This vaccination approach aims to provide protection while minimising potential risks in individuals with compromised immune functions (18). Perhaps not surprisingly, studies have highlighted low vaccination uptake rates among individuals with various immunocompromising conditions, including those people living with HIV (PLHIV) (30) and those who had received solid organ transplants (43). Factors contributing 10 to low uptake among these groups include fear of adverse effects, insufficient information and misinformation about vaccines, and the presence of comorbidities (43). Vaccine hesitancy also exists among other groups, including travellers and healthcare workers, in which a literature review identified age, information sources, and perceived vaccination risks as important factors contributing to hesitancy as well as uptake (14). All these literature reviews seemed to have examined cognitive determinants of vaccination while neglecting other relevant factors such as health-related determinants, might have not included primary immunodeficiency disorders and were conducted before sufficient data on COVID-19 vaccines were available (44–46). Given these pressing concerns, the imperative of achieving high vaccination uptake among immunocompromised populations has gained renewed emphasis. To address this knowledge gap, I conducted a scoping review aimed at comprehensively mapping out evidence on the factors that promote and deter vaccination against any pathogen, including SARS-CoV-2, and shedding light on evolving trends in vaccine uptake among individuals with primary and secondary immune disorders. The ultimate objective of this review was to provide synthesised evidence that may inform targeted interventions aimed at enhancing vaccination uptake. Following a preliminary search of PROSPERO, MEDLINE, and the Cochrane Database of Systematic Reviews, no identified current or ongoing systematic reviews or scoping reviews were found that addressed the overarching factors impacting vaccination among this population or elicited any trends in vaccination uptake. 2.2.1 Review questions: What are the facilitators (promoters) and barriers (deterrents) to vaccine uptake among people living with immune deficiency conditions? 11 What are the associated factors of vaccine hesitancy within the immunocompromised population in terms of individual and group influences, contextual influences, and vaccine/vaccination influences? 2.3 Methods Due to the extensive and heterogeneous nature of the literature on this topic, a scoping review was considered appropriate to provide a comprehensive and methodical review of the existing evidence. This scoping review was conducted in accordance with the Joanna Briggs Institute’s (JBI) framework for scoping reviews (47). 2.3.1 Eligibility Criteria Participants This scoping review included studies focused on adults aged 18 years and above, based on the legal age of consent in most countries (48), who have immunodeficiencies or immunocompromising conditions, regardless of gender, race, geographical location or socio-economical situations. Concept The core concepts of this scoping review centre on vaccine uptake and hesitancy. Vaccine uptake refers to the number of any specified population vaccinated with a specified dose within a defined timeframe (49,50). Vaccine hesitancy is characterised by the delay in accepting or the outright refusal of vaccines despite their availability (36). As a result, this review encompasses all studies that concentrate on factors associated with these vaccination indicators within immunocompromised populations. 12 Context Peer-reviewed journal articles, as well as grey literature on the topic of vaccine uptake and hesitance among immunocompromised populations from any geographic location or setting, were included. 2.3.2 Information Sources and Search Strategy A systematic search of peer-reviewed literature was conducted to locate relevant documents spanning from January 1974, which marks the commencement of literature indexing by the search engines used, to July 2022 using the strategy and the English keywords shown in Appendix A. Individual searches were performed in Medline, CINAHL, Embase, Cochrane Database, Web of Science, and PsycINFO. Additional records were sought in grey literature sources such as ProQuest Dissertations & Theses Global, CHODARR, and Open Grey. Additional records were identified through grey literature, including ProQuest Dissertations & Theses Global, CHODARR, and Open Grey. I also conducted a supplementary manual search on Google Scholar, reviewing academic literature documents from the first ten pages of the obtained results (51). The final search date across all databases was July 25th, 2022, and Covidence software was utilised to manage all references. 2.3.3 Screening and Study Selection Out of the 4688 articles obtained, 881 duplicates were removed, and 3807 titles and abstracts were included and imported into the Covidence® software. The study selection occurred in two distinct phases. In the first phase, two reviewers (myself and a research assistant) independently screened all titles and abstracts obtained from the databases. This initial screening led to the exclusion of 3,491 irrelevant articles, including those lacking a clear focus on vaccine uptake or hesitancy, those 13 centred on vaccine intervention, guidelines, efficacy, or adverse effects, as well as articles related to vaccine trials and opinion pieces. As a result, 316 articles remained for full-text review. In the second phase, the two reviewers again independently assessed the full text of these 316 articles against the inclusion criteria and excluded 240 of them. Conflicts that arose during the initial screening or full-text review were resolved through discussion between the two reviewers until a consensus was reached. Ultimately, a total of 78 articles were retained (Figure 2-1). 2.3.4 Data Extraction The retained 78 articles were analysed, and relevant information was extracted by curating a pre-hoc data extraction form (Table 2-1). This information encompassed essential details such as the author's information, publication year, country of publication, and study information, including study type, duration/timeframe, study objectives, study population, type of altered immune competence, and study methodology and outcome. Vaccine uptake rate, factors examined, barriers and facilitators identified, and limitations were also appraised. 14 Figure 2-1 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Flow Diagram of Studies Included at each Stage of the Review Database Records of Peer-reviewed literature (N = 4473) Medline- 1101 Embase-1554 CINAHL-710 Web of Science-401 Cochrane Database- 43 PsycINFO-664 Additional records identified through Grey Literature (N = 215) ProQuest Dissertations & Theses Global- 96 Google Scholar- 86 CHODARR- 10 Open Grey- 23 Identification Non-duplicate records (N=3806) Records screened (N=3806) Full-text articles assessed for eligibility (N=316) 882 Duplicates Studies included in scoping review (N=76) 240 were excluded due to: Unavailable full texts (36) No distinct outcome (7) Study population not immunocompromised (86) Focus on vaccine intervention, guidelines, safety, efficacy, or adverse effects (55) Vaccine trials (4) Vaccine uptake rate comparison & scheduling (15) Opinion paper (4) Description of ongoing studies (3) Unavailable full texts (30) 3491 Irrelevant Studies Screening Eligibility Included 15 2.3.5 Collating and Summarizing This is the first comprehensive scoping review describing the barriers, facilitators, and factors associated with any vaccination among the immunocompromised population. My findings have been consolidated into three overarching categories related to vaccine uptake and hesitancy: outcomes, barriers, and facilitators to vaccination, with a specific focus on the immunocompromising conditions found in the study population. They are presented ahead. 2.4 Results 2.4.1 Descriptive Analysis Among the 76 studies examined, sixty-two were cross-sectional studies, one was a case-control study, five were retrospective studies, and two were prospective studies. The highest number of studies were conducted in the United States of America (52–59) (N=13, 17.11%) followed by China (32,60–62) N=8,10.53%, France (63–65) N=6, 7.89%, Germany (66,67) N=4, 5.26%, Australia (68,69) N=4, 5.26%, and Canada (16,70) N=4, 5.26%. The remaining studies were conducted in various countries across Europe, South America, Asia, and Africa, and five studies involved participants in multiple countries internationally (71–75). All studies were published between 2011 and 2022, with 53.9% published in 2021 during the COVID-19 pandemic. Of the total studies, 59.2% focused solely on COVID-19 vaccines, while 18.4% examined both Influenza and Pneumococcal vaccines, 13.2% focused on influenza alone, and 0.01% examined only pneumococcal vaccines. The other vaccines studied included Hepatitis B, Herpes Zoster, Measles, Mumps, and Rubella vaccines, as well as combinations of these. 16 In addition, the type of conditions in the study population were mostly secondary immunodeficiency, including haematological malignancies, solid organ transplantation, autoimmune disorders with immunosuppressive therapy, and HIV (Figure 3-1); only one study focused on Primary immunodeficiency (70). The studied sample size ranged from 82 participants to 21,943 participants. Figure 2-2: Articles about Vaccine Uptake and Hesitancy by Immune Disorder Published between 2011 and 2022 (N =76) 2.4.2 Vaccine Outcomes Within the scope of the 76 studies examined, vaccination indicators were assessed and reported as outcomes in terms of uptake and hesitancy. Among these indicators, vaccine uptake was measured by the majority of the included studies, 40 studies (15,16,43,55–58,62–64,66,68,70,71,74,76–99), while 12 studies had an outcome of vaccine hesitancy (52,55,61,68,74,76,81,99–103). Interestingly, 32 studies explored vaccine intention or willingness (32,54,59–61,66,67,69–024681012Articles Included in the ReviewYear of PublicationMalignancies &Immunosuppressive therapyAutoimmune disorders &Immunosuppressive therapySolid-organ transplant &Immunosuppressive therapyHIVImmunosuppressive therapyfor undefined conditionsPrimary Immunodeficiency 17 72,75,81,82,92,100,103–118), and 6 studies (73,119–123) had an outcome of vaccine coverage- which is defined as the proportion of vaccinated individuals with a specified dose, regardless of the time (or through lifetime). Around 19.74% of the total studies incorporated a combination of these outcomes. Associated factors and positive predictors of vaccine hesitancy were seen to be barriers to vaccination as measured by vaccination uptake or willingness within the study population, as highlighted below; While factors that limited or deterred vaccine hesitancy could potentially encourage vaccination, my review of the literature indicated that this was not consistently the case. Moreover, there was a lack of comparative analysis between the facilitators of vaccine uptake and the factors deterring vaccine hesitancy in the studies I examined. 2.4.3 Barriers to Vaccination (Promoters of Vaccine Hesitancy) Fifteen studies identified positive predictors of vaccine hesitancy, which served as barriers to vaccine uptake and negative predictors of vaccine uptake (15,52,61,64,68,78,81,100,101,103,112–114,116,117), whereas fourteen studies (32,33,40,44,46,53,67,76,89–94) recorded no barriers. The remaining studies reported associated factors that functioned as barriers without utilising regression models. Among these, the most prevalent barrier reported by 26 studies (32,54,55,57,65,67,73,95,106,115,119–121,124) was "fear or concerns about the adverse effects of the vaccines”. These concerns also encompassed potential exacerbation of underlying immune conditions (61) or implications for their treatment (100). Thirteen studies (62,64,69,70,78,79,81,86,88,97,107,109,112) identified a "perceived lack of vaccine benefits" as a barrier, while "a lack of recommendation from healthcare professionals" was underscored in 12 studies (16,56,58,60,78,80,84,89,91,92,96). An additional six studies (72,74,77,81,96,103) reported "younger age" as a barrier, and eight studies (52,72,79,85,86,107,110,113) identified 18 "mistrust of medical systems, pharmaceutical companies, and vaccines in general" as barriers. Other deterrents are identified in Table 2-1, which provides a comprehensive overview of the evidence synthesis across the 76 included publications. 2.4.4 Facilitators of Vaccination Thirty-three studies identified predictors of vaccine uptake (15,32,54–56,61,64,65,67,68,73,74,78,79,84–86,89–91,100,101,103,105,110,112,114,116,119–122,124), which served as promoters of vaccination; 43.4% recorded facilitators that are associated factors of vaccine uptake, while the remaining studies identified no facilitator of vaccination. The highest reported facilitator was "older age, according to 27 studies (15,43,55–57,60,63,65,68,73–75,79,80,84,85,89,91,93,94,106,107,116,119,121,122,124), followed by "perceived risk of serious illness from the vaccine-preventable diseases" reported by 12 studies (54,66,67,82,88,105,106,108,111,114,118,119). Additionally, "recommendation from health professional" (63,69,85,88,91,95–98,103,104,118,122), "higher level of education" (52,54–56,60,67,73,74,105,110,112), "previous vaccination history” (63,79,82,90,95,104,119,122), and “longer duration of immunosuppression" (55,56,59,68,79,92,98,119) were reported by 13, 11, 8, and 8 studies, respectively. Other notable facilitators include "the presence of comorbidities", "better vaccine knowledge", and "the use of biological therapy". Table 2-1: Descriptive Analysis of Objectives, Types of Immunodeficiency, Vaccine Health Outcomes, and Influential Factors in Vaccination Author (Publication Year) Origin & Time frame Study population (Sample size) Study Objectives Primary Immunodeficiency Secondary Immunodeficiency Methodology Vaccine Outcome Vaccine type & Uptake rate (when informed) Barriers /deterrents of vaccination Facilitators/promoters of vaccination Limitations (as stated by the authors) 1 Abbasi et al (2021) Iran Sep - Nov 2021 Patients with Multiple Sclerosis (N=1479) Highlight patient’s concerns on Covid-19 and compliance with vaccination _ Autoimmune Disease & Immunosuppressive therapy Cross-sectional study via electronic survey Vaccine uptake/ Vaccine hesitancy COVID-19 Vaccines •Sinopharm •AstraZeneca •Sputnik, •COVIran Vaccine uptake (93.10%) •Female gender •Unemployment •Past Covid-19 Infection •Less concern about Covid-19 infection •No flu vaccination Hx •High efficacy immunosuppressive treatment __ Vaccine-hesitant patients may not be reached through web-based surveys 2 Aberumand et al (2021) Canada Mar - Apr 2021 Patients with primary immunodeficiency (PID)- (N=449) Understand perceptions regarding uptake in the COVID-19 vaccines by patients with PID & Identify the factors related to vaccine hesitancy. Common Variable Immunodeficiency, Hypogammaglobulinemia, immunoglobulin deficiency Cross-sectional study via electronic survey Vaccine uptake/ Vaccine intention COVID-19 Vaccines •Pfizer-BioNTech •Moderna •AstraZeneca •Janssen Vaccine uptake (21.0%) Vaccine intention (81.6%) • Concerns about long-term adverse effects • Perception of lack of benefit of vaccine • History of allergies • Perception of lack of vaccine benefits • History of allergies __ Under-representation of racial & ethnic populations 3 Bain et al (2022) Australia Jun - Oct 2021 Patients with Solid-organ malignancies (N= 2691) Explore how cancer-specific context impacted vaccine attitudes and behaviour among people with cancer _ Solid Organ malignancies & Immunosuppressive therapy Cross-sectional study via electronic survey Vaccine Uptake Vaccine Hesitancy COVID-19 Vaccine uptake rate – (79.7%) Predictor Variables: •Female gender •English as non-dominant language •Rural location •Head and neck cancer Predictor Variables: •Older age •Higher household income (AUD 50,000 - 100,000) •Longer time since cancer diagnosis •Site: Genitourinary cancer Convenience sampling No evaluation of broader cultural & political factors 4 Boltin et al (2013) Israel Dec 2005- 2012 Patients with Inflammatory Bowel Disease (IBD)- Chron’s disease (N=515) Assess longitudinal trends in influenza vaccine uptake among adults with IBDs _ Autoimmune Disease & Immunosuppressive therapy Retrospective Cohort Study Vaccine uptake Influenza Vaccine uptake rate (16.1%- 38.3%) 2006 -2012 Mean uptake rate (20.0%) • younger age • Male gender • Absence of co-morbidities • Female gender • IBD specific medications, e.g., Oral steroids, biologic therapy • Comorbid conditions e.g., COPD, Asthma, Cerebrovascular Retrospective study design Use of administrative database that has not undergone validation. Use of vaccination codes which may underestimate immunization rate 5 Brocq et al (2016) France Feb - Jul 2013 Patients on biologic therapy for Evaluate influenza and pneumococcal vaccine coverage in patients _ Autoimmune Disease & ImmunosuppRetrospective Cross sectional study Vaccine uptake • Seasonal Influenza Vaccine uptake • Concerns about adverse effects • Male gender • Age >=65years • Previous receipt of influenza vaccine 20 inflammatory joint disease (N=584) taking biological therapy for chronic inflammatory joint disease and to identify factors associated with the decision to administer these two vaccines. ressive therapy rate (44.0%) in patients with RA & (42.0%) patients with Spondylarthritis •Pneumococcal vaccine uptake (60.0%) RA & (65.0%) Spondylarthritis • Absence of co-morbidities • Concerns about adverse effects • Recommendation from primary-care physician/rheumatologist 6 Brodziak et al 2021 Poland Jan -Feb 2021 Patients with a cancer diagnosis and active treatment (N=635) Assess acceptance of COVID-19 vaccine & factors affecting attitudes _ Malignancy & Immunosuppressive therapy Cross-sectional study via e-survey Vaccine acceptance Willingness to vaccinate (Vaccination Intention) • COVID-19 • Vaccine acceptance (6.3%) • Willingness to vaccinate (60.31%) • Female gender • Age >= 65 • Negative/neutral vaccine attitudes to previous vaccines • Previous influenza vaccination • Physician recommendation • Positive attitude to vaccination Majority female patients, higher education living in large cities overrepresentation 7 Chen et al, 2021 China May 2021 Patients with renal & liver transplant (N=813) Assess COVID-19 vaccination willingness among SOT recipients in China _ Solid Organ Transplantation & Immunosuppressive therapy Cross-sectional study via e-survey Willingness to vaccinate (Vaccine Intention) COVID-19 Vaccine Willingness (41.6%) • Fear of existing comorbidities • Concerns about adverse effect of vaccine • Doctors’ negative advice • Last season influenza vaccination • Liver transplant recipients • Main source of information medical doctors, scientific journals • College or higher level of education • Perceived importance of vaccine for Solid organ transplant Non-randomized sample collection causing selection bias We Chat survey underrepresenting those who do not use WeChat 8 Chiganer et al, 2021 Latin America- (Argentina, Mexico, Brazil, Chile, Peru, Columbia, Uruguay) Oct 2018- Nov 2019 Patients with Systemic Lupus Erythematosus (N=1015, N=549) • Assess the degree of influenza and pneumococcal vaccination coverage in SLE patients in Latin America • Identify causes and predictors of non-vaccination. _ Autoimmune disorder & immunosuppressive therapy Cross-sectional study Vaccine uptake • Influenza vaccine uptake (42.7%) • Pneumococcal vaccine (25.0%) • Lack of medical recommendation • Availability and cost Predictor Variables: • Smoking Predictor variables- Influenza Vaccines • Chronic renal disease • Age >50 years • Prior Tetanus coverage • History of Chronic Respiratory disease • Immunosuppressors use Predictor variables- Pneumococcal Vaccines • Chronic renal disease • Age >50 years • Prior Tetanus coverage • History of Chronic Respiratory disease • Immunosuppressors use Self-reported diagnosis of SLE & no medical record verification Non-probability sampling Modified questions that were unvalidated Data collection was restricted to internet-using respondents 9 Chin-Yee et al., 2011 Canada Oct 2009-Mar 2010 Patients with haematological malignancies (N= 129) Determine factors that influence vaccination rates. _ Haematologic malignancies Cross-sectional study Vaccine uptake • H1N1 Influenza • Vaccine uptake- (66.0%) • Seasonal influenza (50.0%) •Reported Vaccine beliefs: Vaccines are dangerous Vaccines are ineffective in patients with their medical condition Belief that vaccines are unnecessary - - 21 • Both Seasonal & H1N1 (50.0%) • Previous bad experience from vaccine • Inconvenient access to vaccine • Physician’s advice against vaccination 10 Chong et al, 2018 Korea Apr - May 2016 Patients who had renal transplant (N=180) •Identify influenza acceptance and vaccine-related health beliefs •Identify correlations among HBM constructs and influenza vaccination •Explore the predictors of influenza vaccination among Korean KT patients. _ Solid organ transplantation & Immunosuppressive therapy Cross-sectional study Vaccine acceptance _ • Age >/=45years • Previous influenza vaccination • Lower perceived barriers, higher benefits, longer duration after renal transplant) - - 11 Chun et al, 2021, Korea Feb - Apr 2021 Patients who have malignancies Immunosuppressive therapy (N=1001) Examine willingness to take the COVID-19 vaccination and comprehensively identify factors associated with the acceptance rate _ Secondary: Malignancies & Immunosuppressive therapy Vaccine acceptance & Vaccine intention Covid-19 vaccine intention (61.2%) • Concerns about COVID-19 safety • Mistrust Covid-19 efficacy • Lack of information about Covid-19 • Underlying malignancy risk for the vaccine • Mistrust of vaccination Predictors • Cancer recurrence • Trust in covid-19 efficacy • Underlying malignancy risks for the dx • Trust in Covid-19 safety • Recommendation from the health authorities • Recommendation from the press Predictors • -Age>/= 50 years • -BMI >/= 23kg/m2 - 12 Clarke et al. 2022 USA Jan - Oct 2021 Oct 2015 - Sep 2016 Adults with Inflammatory Bowel Disease (N=239) Assess COVID-19 vaccine hesitancy and its associated variables. _ Autoimmune disorder & Immunosuppressive therapy Cross-sectional study via e-survey Vaccine hesitancy Covid-19 Vaccine hesitancy (35.6%) Predictors of vaccine hesitancy • Biological therapy use • Past Covid-infection • Social media use • Catholic religion - 13 Constantinou et al, 2021 Greece Oct 2015 - Sep 2016 Patients with autoimmune rheumatic diseases, ARDs (N=395) Explore the patients' awareness regarding vaccination, recognize factors that influence the vaccine uptake _ Autoimmune disorder & Immunosuppressive therapy Cross-sectional study via electronic survey Vaccine uptake Pneumococcal vaccine-PCV13- 40.51% PPSV23 59.49% • Lack of physician recommendation • Lack of trust in vaccines • Fear of adverse reaction • Age >/= 65YEARS • Complete awareness - 14 Cordie et al, 2022 Egypt, Tunisia, Saudi Arabia Mar - Aug 2021 People living with HIV (N=540) Evaluate COVID-19 vaccine acceptance and influencing factors _ HIV Cross-sectional study via e-survey Vaccine acceptance & Vaccine intention COVID-19 Vaccine • Living in rural area • Most recent CD4+ count check >1year • Living in urban area • CD4+ count check <1 year • Less concern about contraction of disease from vaccine - 22 15 Cotte et al, 2021 France Nov 2009 – Jan 2010 People living with HIV (N=1430) Describe the factors associated with acceptability of Influenza A/H1N1 among PLHIV in the hepatology & Aids unit _ HIV Cross-sectional study via survey Vaccine Coverage Influenza A/H1N1 (44.4%) Pneumococcal vaccine-(57.9%) _ Predictor Variables • Age ≥50years • ≥1 seasonal influenza risk factor • Length of diagnosis of HIV • Previous pneumococcal vaccination • >2 visits to the unit • follow-up by a senior physician Convenience sampling Severity of Influenza illness was not examined as a factor A vaccine intervention program preceded the study 16 Day et al, 2022 Australia Jun - Oct 2021 Patients with diabetes, cancer and multiple sclerosis (N=4683) Examined vaccine uptake, hesitancy, and explanatory factors amongst people with serious and/or chronic health conditions, including the impact of underlying disease on attitudes to vaccination. _ Solid Organ & Haematological malignancies, Autoimmune disorder, Chronic disease Cross-sectional study via survey Vaccine uptake, Vaccine hesitancy & Vaccine intention COVID-19 vaccine uptake 81.5% COVID-19 vaccine intention (89.8%) • Younger age • Female sex • Lower education • Lower income, • English as a second language • Residence in regional areas. Predictor variables • Higher total mean scores on the Oxford COVID-19 VHS • More negative attitudes toward COVID-19 vaccines • Higher DIVAS-6 scores • Male gender • ≥1 seasonal influenza risk factor • lower nadir CD4 • recent HIV-RNA < 50 copies/ml • previous pneumococcal vaccination _ Recall and misclassification bias Australia’s high vaccination rate Heterogenic group of secondary immunecompetence 17 de Sousa et al, 2022 Portugal Mar - Apr 2021 Patients with solid-organ malignancies (N=169) Evaluate the COVID-19 vaccine acceptance in cancer patients undergoing immunosuppressive therapy in a Portuguese cancer center by applying a questionnaire adapted from the study by Barrier et al. and understand which factors are associated with COVID-19 vaccine hesitancy _ Solid-organ malignancies & Immunosuppressive therapy Cross-sectional study via survey Vaccine intention COVID-19 vaccine intention (84.0%) • Living in rural areas Predictor factors • High school degree • Reluctance in believing in the vaccine efficacy • Divorced marital status No validated survey at the time of the study Convenience sampling in a single institution 18 Drewes et al, 2021 Germany 2013 -2014 Nation-wide sample of People living with HIV in Describe self-reported vaccination rates in PLHIV in Germany and analyze which _ HIV Cross-sectional study via electronic & paper survey Vaccine Coverage: - Number of • Hepatitis A coverage (69.3%) • Hepatitis B __ Predictor Variables • Non-heterosexual orientation • >10 years education Non-probability sampling Cross-sectional 23 Germany (N=903) sociodemographic, HIV-related, and healthcare-related factors correlate with vaccination coverage. Vaccinations coverage (75.3%) • Pneumococcal vaccine coverage (66.3%) • Tetanus, diphtheria, pertussis (84.6%) • Meningococcal vaccine (51.0%) • Influenza vaccine (77.1%) • Being in a relationship • >200 CD4 count • Last visit to HIV specialist: >3 months • Private practice HIV specialist • >10km distance to HIV specialist study, cannot imply causality 19 Durham et al, 2011 USA Jul 1999 - Jun 2008 Patients living with HIV (N=5365) Describe more recent annual rates of influenza vaccination among HIV- infected persons in care and to identify factors associated with immunization during influenza seasons _ HIV Ongoing prospective observational cohort study Vaccine uptake Annual influenza vaccine uptake 25.8% - 43.3% • Non-Hispanic black race/ethnicity • Log10 HIV viral load ≥ 4 copies/mL • Insurance status at the beginning of a given influenza year. • Male gender • Having ever received ARVs as of the beginning of each given influenza year • Greater numbers of clinical encounters in a given influenza year Recall bias 20 Eder et al, 2021 Austria Jul - Oct 2020 Patients with advanced renal/liver disease & patients with liver/renal transplants (N=516) Evaluate the willingness to receive influenza vaccination _ Chronic liver and kidney disease & Liver & Kidney Transplant Cross-sectional study via survey Vaccine uptake & Vaccine willingness (Intention) Influenza vaccine uptake in 2019/2020 (25.4%), 2016–2018 (27.3%). Influenza vaccine intention (43.9%) • Older age • Self-perceived risks of infection & complications • previously received influenza vaccination. • Self-perceived risks of infection & complications • previously received influenza vaccination. Language barrier in data collection Self-reported vaccination status 21 Ehde et al, January 2021 USA Apr – May 2020 Patients with Multiple Sclerosis (N=486) • Assess willingness to get a COVID-19 vaccine •Determine demographic, MS, psychosocial correlates of vaccine willingness; • Measure the source of COVID-19 information & perceived trustworthiness _ Autoimmune disorder & Immunosuppressive therapy cross-sectional via electronic survey Vaccine willingness (Intention) COVID-19 vaccine willingness (66.0%) ___ Predictors of vaccine willingness • Higher education • Perceiving oneself to be at greater risk of contracting COVID-19 Non-probability sampling Majority white & highly educated sample population Only one vaccine willingness question 22 Ehde et al, September 2021 USA Jan - Feb 2021 Patients with Multiple Sclerosis (N=359) Assess vaccine hesitancy and to guide public health efforts to increase vaccine uptake in the _ Autoimmune disorder & Immunosuppressive therapy cross-sectional via electronic survey Vaccine Intention COVID-19 vaccine intention (73.8% ) COVID-19 • Long-term effects of the vaccine • Vaccine approval • process Predictors of vaccine willingness perceiving oneself to be at greater risk of contracting COVID-19 Non-probability sampling Majority white & highly educated sample population 24 MS population. vaccine hesitancy (20.3%) •Information about the vaccine • Higher education • White race • History of flu vaccination • Greater perceived risk of COVID-19 • Greater trust in the CDC 23 Erdem et al, November, 2021 Turkey May - Jun 2021 Patients with cancer undergoing treatments (N=195) Examine the effect of coronophobia on the attitudes towards COVID-19 vaccine among patients with cancer. _ Solid Organ malignancies & Immunosuppressive therapy Prospective cross-sectional study via questionnaire and telephone survey Vaccine willingness COVID-19 Vaccine willingness- (86.7%) __ • Increased age • Being retired • Being married • Higher COVID-19 phobia scale (C19P-S) scores Non-probability sampling 24 Felten et al, October 2021 UK France Chile USA Spain Mexico Argentina Venezuela December 2020 Patients with autoimmune or inflammatory rheumatic diseases (AIIRDs) undergoing treatment (N=1258) Analyse the different types of attitudes to SARS-CoV-2 vaccination among AIIRD patients, as well as the determinants of those attitudes _ Autoimmune & Immunosuppressive therapy Cross-sectional study via electronic questionnaire Vaccine willingness (Intention) COVID-19 Vaccine Willingness Cluster 1(voluntary): 97.2% Cluster 2 (Hesitant): 64.8% Cluster 3 (suspicious): 15.6% • Younger age • Vaccination concerns • Concerns about use of a new vaccine technology • Concerns about lack of long-term data in relation to COVID-19 vaccination •Concerns about potential financial links with pharmaceutical companies __ Non-probability sampling. Cluster analysis Non validated survey No direct scale for hesitancy 25 Figueroa-Parra et al, September 2021 Mexico Nov 2019 – Feb 2020 Patients with autoimmune rheumatic diseases (N=223) Investigate the knowledge and attitudes about influenza vaccination as factors to vaccine uptake and hesitancy in a population with RD from the north of Mexico. _ Autoimmune & Immunosuppressive therapy Cross-sectional study via electronic questionnaire Vaccine uptake Influenza Vaccine uptake rate: Total (79.8%) Community patients (79.5%) Clinic patients (80.2%). The influenza vaccine uptake by diagnosis was 80.3% in RA, 76.2% in OA, 86.7% in SLE, 73.9% in other AID • Concerns about safety • Concerns of efficacy • Concerns about side effects • Fear of the vaccine • Knowledge of cost __ Non-probability sampling No determination of sample size population No prediction No validated survey 26 Govere-Hwenje et al, June 2022 South Africa Sep2020 - Jan 2021 Patients living with HIV (N=900) •Measure willingness to accept COVID-19 vaccines Among PLHIV • Identify factors associated with willingness to accept COVID-19 Vaccines _ HIV Cross-sectional study conducted through telephone interviews Vaccine willingness (Intention) COVID-19 Vaccine willingness (57%) • Source of information-social media • Medical mistrust score ≥ median score • Fear of side effects · Older age Recall bias 25 27 Haroon et al, July 2011 Ireland Sep 2009 Patients using Immunosuppressive drugs–methotrexate, biologic agents, azathioprine, mycophenolate mofetil, cyclosporine, cyclophosphamide & corticosteroids (N=110) • Assess the influenza and pneumococcal vaccination uptake among rheumatology outpatients who are immunosuppressed • Identify the factors influencing immunisation uptake Autoimmune & Immunosuppressive therapy Cross-sectional study via questionnaire Vaccine uptake Influenza A (H1N1) vaccine (34%), Pneumococcal vaccine (11%,), both Influenza & Pneumococcal vaccine (11%). • Beliefs that the vaccines are unnecessary • Lack of recommendation for the vaccines- “not offered” Predictors of vaccine uptake: • Age > 65 years • Presence of additional risk factors (such as individuals over the age of 65 years and patients with chronic renal failure, chronic heart failure, chronic liver failure, chronic lung disease, and hypersplenism) • Chronic lung disease Non-probability sampling 28 Harrison et al, December 2017 Austria –Jun - Aug 2015 Patients living with HIV (N=455) Evaluate the influenza vaccination coverage among HIV-positive patients and to determine predictors for influenza vaccination. _ HIV Cross-sectional study via questionnaire Vaccine uptake Influenza vaccine (11%) Fear of side effects • Not considering influenza as a severe disease. • HIV related concerns • Concerns about the effect of the vaccine on the compromised immune system Predictors of vaccine uptake: • Older age • Recommendation for vaccination by their family or company physician. • Recommendation by their HIV specialist Non-probability sampling 29 Heyne et al, February 2022 Germany Sep - Nov 2021 Patients with malignancies (N=425) Determine attitudes and vaccination status with a COVID-19 vaccine among cancer patients of different cancer sites. _ Solid-organ malignancies & Immunosuppressive therapy Cross-sectional study via questionnaire Vaccine uptake Vaccine willingness COVID-19 vaccine uptake (95.5%) Vaccine willingness (16.7%) Fear of side effects • Safety concerns • Lack of information • Waiting for more data • General skepticism about vaccines • Rejection of other vaccines • Recovered from COVID-19 • No fear for a severe COVID-19 course • Protection against severe course of COVID-19 • Self-protection • Family protection • Protection of humans • Participation in social life • Safety for everyday business Small sample size Non-probability sampling Sample population attend regular clinics and maybe more integrated into the health system 30 Hmamouchi et al, February, 2015 COMORA Cohort: Argentina Austria, Egypt France, Germany, Hungary Italy Japan, Korea Morocco Spain Taiwan UK Uruguay USA Venezuela 2011-2012 Patients with rheumatoid arthritis undergoing treatments with comorbidities (N=3920) • Describe pneumococcal and influenza vaccine coverage • Evaluate factors associated with their use. _ Autoimmune & Immunosuppressive therapy Cross-sectional study via questionnaire Vaccine Coverage • 17.2% for Pneumococcal vaccination- PPSV-23 (from 0% in Morocco to 56.5% in France) • 25.3% for influenza vaccination (less than 1% in Morocco and Egypt to 66.2% in Japan). __ Predictor variables • Age > 65 years • ≥1 surgery for rheumatoid arthritis • No current smoking status • Lower disease activity • Higher educational level • Use of biotherapy • Absence of corticosteroid therapy • Presence of comorbidities Self-reported vaccination status 31 Hong et al, October 2021 China Jun – Sep 2021 Patients with solid-organ Document this population’s knowledge about and attitude towards the _ Solid-organ malignancies & ImmunosuppCross-sectional study via questionnaire Vaccine acceptance Vaccine willingness • COVID-19 vaccine uptake (35.54%) • COVID-19 Predictors of vaccine hesitancy • Being retired • Undergoing multiple Predictor variables • Alcohol consumption. • Income disruption by the COVID-19 Non-probability sampling 26 malignancies (N=2170) COVID-19 vaccine. • Evaluate the rate of vaccine acceptance, and analyzed parameters that were predictive of a cancer patient’s willingness to receive the COVID-19 vaccine. ressive therapy (Intention) & Vaccine hesitancy vaccine willingness/intention (24.05% ) • COVID-19 vaccine hesitancy (40.41%) treatments for cancer • Worrying that the vaccine might worsen the prognosis of cancer pandemic • Knowledge on how the vaccine was developed. • Belief in the safety of the vaccine • Willingness to pay for the vaccine. • Willingness to recommend vaccination to families and friends 32 Huang et al, June, 2021 China Jan - Feb 2021 People living with HIV (N=2740) Investigate willingness to receive COVID-19 vaccination among a national sample of People living with HIV _ HIV Cross-sectional study via electronic survey Vaccine acceptance Vaccine willingness (Intention) • COVID-19 vaccine uptake (6.20%) • COVID-19 vaccine willingness/intention (57.2% ) __ Predictor variables • Positive COVID-19 vaccine attitudes • perceived support from significant others • Perceived behavioral control. • Receiving advice supportive of COVID-19 vaccination from doctors • Receiving advice supportive of COVID-19 vaccination from friends and/or family members Non-probability sampling 33 Jaiswal et al, 2022 USA Mar - May 2021 People living with HIV (N=496) Describe rates of COVID-19 vaccination intent and uptake and determine demographic, COVID-19-, and HIV-related factors associated with COVID-19 vaccine intent and uptake _ HIV Cross-sectional via electronic survey Vaccine uptake, Vaccine hesitancy & Vaccine intention COVID-19 Vaccine uptake- 64.3% _ Predictor Variables for uptake of at least one dose of vaccine • Age • Black/African American ethnicity • Bachelor degree or higher educational attainment • Sexual minority and cis-gendered males • COVID-19 vaccine hesitancy score • Friend/family diagnosed with COVID-19 • Friend or family member died due to COVID-19 • Number of years since HIV Diagnosis • HIV viral load Predictor variables for vaccine intention • Older Age • Sexual minority and cis-gendered men • COVID-19 Vaccine hesitancy score • Number of years since HIV diagnosis Self-reported vaccine uptake Time-bound to Spring 2021 and does not represent the changing nature of the COVID-19 Pandemic 27 34 Kosaka et al, 2021 Japan Sep - Oct 2020 Patients with cancer (N=163) vaccination intent and uptake and (2) determine demographic, COVID-19-, and HIV-related _ Haematologic & Solid-organ Malignancies & Immunosuppressive therapy Cross-sectional study via electronic survey Vaccine uptake • Influenza vaccine uptake 2019/2020= 61.3%. • COVID-19 vaccine intention (73.6%) • Fear of adverse events • Lack of concern about influenza infection • Lack of trust in vaccine effectiveness Predictor variables • Treatment without chemotherapy • Vaccination history in the 2019/2020 season • Prior experience of influenza infection • Perception that influenza vaccination was more important due to the coronavirus disease pandemic Non-probability sampling Participant recruitment through cancer patient associations who have access to information and resources Small sample population 35 Kourkounti et al, 2014 Greece 2007-2012 Patients living with HIV ( N=569) Evaluate the adherence to HAV vaccination and the factors influencing adherence. _ HIV Retrospective study Vaccine uptake HAV Vaccine acceptance (62.2%) HAV Vaccine hesitancy (37.8%) __ • Older age • Plasma HIV RNA levels of <40 copies/ml, • Lower nadir CD4 T cell counts Predictor variables • Patient’s origin • Higher CD4 T cell count • Lower nadir CD4 T cell counts. Retrospective, performed at a single site Lack of a control group of HIV-negative MSM 36 Krzystanek et al, 2022 Poland Jan - Mar 2021 Patients with Multiple Sclerosis (N=292) Assess the knowledge of patients with MS about SARS-CoV-2, COVID-19 illness, their perception of the possible relationship between MS and COVID-19, their willingness to be vaccinated (and reasons for this decision), and, additionally, gather observations about the possible impact of the pandemic on MS care. _ Autoimmune disease & Immunosuppressive therapy Cross-sectional study via electronic & paper survey Vaccine willingness (Intention) COVID-19 Vaccine Willingness (60.5%) • Belief that the vaccine is not sufficiently studied • Concerns of adverse side-effects • Fear of COVID-19 infection Non-probability sampling Rapidly changing COVID-19 knowledge 37 kumar et al, 2022 India Jul - Oct 2021 Patients diagnosed with systemic lupus erythematosus (418 Participants) Understand the mindset of the SLE patients regarding COVID-19 vaccination and identify factors influencing their choice. _ Autoimmune disease & Immunosuppressive therapy cross-sectional study + telephone-based survey Vaccine uptake COVID-19 Vaccine uptake (48.6% 1 dose, 31.5% 2 doses) • +D24 • Fear of SLE flares, • General vaccine refusal • Limited transport facilities • Doctor/nurse recommendation • Fear of contracting COVID-19 • Fear of death from COVID-19 • Family and Media Telephone data collection No previous pilot study. Non-probability sampling Changing nature of the COVID-19 pandemic and potential change in vaccine behaviour 38 Larsen et al, 2021 Denmark Apr - Sep 2017 Patients living with HIV ( N=203) Investigate influenza and pneumococcal vaccine coverage and _ HIV Cross-sectional study via survey Vaccine uptake Influenza vaccine uptake latest season (31.0%), other • Perception of good health with no need for vaccination • Uninformed about vaccine Predictor variables • Age ≥60 years • any prior influenza vaccination Single-center study with data from a single season 28 patients´ attitudes toward these vaccines season (42.9%). Pneumococcal vaccine (4.4%) recommendation • Concerns about side effects Non-probability sampling Self-reported immunization rate Language limitation to participants speaking Danish & English 39 Larsen et al, 2020 Denmark Aug 2017 - Feb 2019 Patients with chronic kidney disease (CKD), listed for renal transplantation & renal transplant recipients- (N=220) Characterize level and predictors of influenza and pneumococcal vaccine uptake among Danish kidney transplant recipients (KTR) and kidney transplant waiting list patients (WLP) _ Renal transplant & Immunosuppressive therapy Cross-sectional study via survey Vaccine uptake Influenza vaccine uptake in the latest season (41.8%) • Lack of information • Perception of own good health • Fear of adverse reactions. Predictor variable • Recommendations given by other persons (non-physician) Predictor variables • Age ≥65 years • Any prior influenza vaccination Single-center study with data from a single season Non-probability sampling Self-reported immunization rate Language limitation to participants speaking Danish & English 40 Lawson et al, 2015 USA 2009 Individuals with systemic lupus erythematosus (N=485) Understand why immunosuppressed individuals with systemic lupus erythematosus (SLE) fail to receive influenza and pneumococcal vaccines. Autoimmune & Immunosuppressive therapy Cross-sectional study + telephone-based survey Vaccine uptake Vaccine refusal Influenza vaccine uptake in the past year (64.0%) Pneumococcal vaccination rate (67.2%) • Lack of health care worker recommendation • Concerns about vaccine efficacy or safety • Lack of time and motivation • Lack of availability • Cost of vaccine • Allergy to pneumococcal vaccine Predicting variables for Influenza Vaccination • Longer disease duration • 4-year college degree • Immunosuppression with biologic medications & Disease Modifying Antirheumatic drugs (DMARD) • Having seen a rheumatologist in the past year Predicting variables for pneumococcal vaccination • Older age • Caucasian Ethnicity • Immunosuppression with DMARDS & Biologics Assumption of vaccine recommendation from Health care provider Recall bias for multiple vaccination schedule 41 Lejri-ElEuchiet al, 2019 La Reunion Island 2019 Patients with autoimmune/inflammatory disease receiving biologic therapy (N=208) Evaluate seasonal flu and pneumococcal vaccine coverage among patients receiving biological therapy and identify factors associated with vaccine uptake within this population. Autoimmune & Immunosuppressive therapy Retrospective cross-sectional study Vaccine uptake Influenza vaccine uptake latest season (28%), Pneumococcal vaccine (48%) Both Influenza & Pneumococcal Vaccine (22%) • Inflammatory bowel disease group of autoimmune disease • Unfavorable attitude toward vaccines • 40-64years, >65years • Being advised for these vaccine • Having another risk factor for severe flu disease • Use of additional immunosuppressant to biological therapy Predictor Variables • Level of general knowledge about vaccines Recall bias. Potential for reduced accuracy of information retrieved from records Relatively small sample size 29 • Receiving a prescription from physicians in charge or a reminder/recall letter from health authorities. • Patients who received the flu vaccine in previous years 42 Li et al, 2021 China May - Jun 2021 Patients living with HIV (N=350) Establish a theoretical model that explains the mediating effect of vaccination intention regarding the COVID-19 vaccine on the vaccination behavior of PLWH in China HIV Cross-sectional study via electronic survey Vaccine uptake COVID-19 Vaccine uptake (43.71%) Perceived usefulness • Thinking COVID-19 vaccine cannot prevent COVID-19 • Doubting the benefits of vaccination Perceived risks • Concerns about safety of COVID-19 vaccine • Infection with COVID-19 after vaccination • Unaware of impact on people around due to lack of vaccination Subjective norms • People around patients being vaccinated • Family support for vaccination • Acceptance of family’s advice regarding COVID-19 vaccination • Acceptance of friend’s advice concerning COVID-19 vaccination • Acceptance of the government’s advice concerning COVID-19 vaccination • Acceptance of media’s publicity regarding COVID-19 vaccination • Vaccination decision after many people have been vaccinated. Behaviour Intention • Interest in being vaccinated • Supporting vaccination in PLHIV • Willingness to recommend vaccines to others Non-probability sampling Changing nature of the COVID-19 pandemic 43 Loubet et al, 2015 France Summer 2013 Patients receiving care for: rheumatoid arthritis, ankylosing spondylitis, systemic scleroderma, psoriasis, psoriatic arthritis, chronic heart, & kidney failure (Organ transplant recipients), leukemia, chronic myeloid leukemia & Estimate the prevalence and predictors of influenza and pneumococcal vaccine uptake in a large cohort of patients with secondary immune deficiency. _ Autoimmune disorder, Haematologic & Solid-organ Malignancies, Solid organ recipients (& Immunosuppressive therapy) Cross-sectional via electronic survey Vaccine uptake Influenza vaccine uptake (59%), Pneumococcal (49%) Predictor variables • Biological therapy Predictor variables • Age >65 years • Follow-up by a specialist • Belonging to the Malignant blood diseases group • Better knowledge of vaccination • Favorable attitudes toward vaccination Self-reported vaccine uptake Heterogeneity of immunocompromised disorders in the sample population Highly educated sample 30 lymphoma. (N=3653) 44 Loubet et al, 2018 France Dec 2015 - Mar 2016 Patients with inflammatory bowel disease (N=199) Estimate the prevalence and predictors of influenza and pneumococcal vaccination rates in a sample of French IBD adults. _ Autoimmune Disease & Immunosuppressive therapy Cross-sectional via electronic survey Vaccine uptake • Influenza vaccine uptake (34%) • Pneumococcal vaccines (38%) • Not being proposed vaccination • Concerns about vaccine efficacy • Concerns about a possible safety risk to me • No perceived need of the vaccine Predictor variables • Healthcare provider’s (HCP) recommendation for vaccination • Immunosuppressive therapy • Better knowledge of vaccination • Favorable attitudes towards vaccination Non-probability samples Small sample size Self-reported vaccine uptake 45 Marijanović et al, 2021 Bosnia & Herzegovina - Feb 2021 Patients with malignancies (N=364) Evaluate acceptance of COVID-19 vaccination among patients attending the Oncology Clinic of University Clinical Hospital Mostar. _ Solid Organ malignancies & Immunosuppressive therapy Cross-sectional study via survey Vaccine intention COVID-19 vaccine intention (41.8%) • Doubts about the results from clinical trials of COVID-19 vaccines Concerns about adverse effects • Confusion about the various vaccine options • Fear of getting sick • The desire to contribute to herd immunity Trusting the recommendations of health professionals Non-probability sampling 46 Mejri et al, 2022 Tunisia Feb - May 2021 Patients with solid organ Malignancies (N=329) Measure the acceptability towards the COVID-19 vaccination in cancer patients and to investigate determinant factors associated with the patient’s choice _ Solid Organ malignancies & Immunosuppressive therapy Cross-sectional via survey Vaccine Intention Vaccine hesitancy COVID-19 vaccine uptake (50.5%) COVID-19 Vaccine hesitancy (28.3%) Predictor variables • Thinking that the vaccine may interfere with treatment efficacy. • Thinking that the vaccine may impact cancer outcome • Disagreeing that the vaccine is a major weapon against the pandemic • Disagreeing that the vaccine could reduce the virus transmission Predictor variables • Confidence level in the authorities Selection bias since breast cancer is the predominant malignancy in all participating centers Non-probability sampling 47 Monier et al, 2020 France Sep - Oct 2016 Patients with haematologic and solid-organ malignancies (N=671) Assess vaccination coverage and factors associated with appropriate vaccination in oncology and haematology patients. _ Haematologic & Solid-organ Malignancies & Immunosuppressive therapy Cross-sectional via survey Vaccine uptake Influenza vaccine uptake (25.4%), Influenza vaccine intention (43.9%). Pneumococcal Vaccine uptake (7.2%) __ Predictor Variables • age ≥65 years • Information received from family physician • Being treated for a hematological malignancy • Positive opinion about vaccination • Information received from family physician • Up to date dTP vaccination Vaccine-hesitant patients may not be reached through web-based surveys 48 Moujaess et al, 2021 Lebanon Jan - Feb 2021 Patients with solid/haematologic malignancy receiving chemotherapy, targeted therapy, immunotherapy or supportive care (N=111) Assess patients' knowledge about the vaccine, their readiness to be vaccinated and the main determinants that drive their decision _ Haematologic & Solid-organ malignancies & ImmunosuppCross-sectional study via survey Vaccine acceptance Willingness to vaccinate (Vaccination Intention) COVID-19 Vaccine Willingness (55%) • Patient’s belief that vaccine was incompatible treatment • Desire to know more about the consequences of the vaccine in other patients with cancer • Belief that they need for the vaccine was similar to other people according to international recommendations • Belief that they need the vaccine more than other people do • Belief that the vaccine Non-probability sampling Small sample population 31 ressive therapy does not interfere with their treatment 49 Murdaca et al, 2020 Italy Sep 2018- 2019 Patients with Systemic sclerosis (N=91) Analyze the vaccine uptake and the vaccination coverage against both seasonal influenza and S. pneumoniae in a cohort of patients with Systemic sclerosis _ Immune-mediated disease & Immunosuppressive therapy Cross-sectional via survey Vaccine Coverage • Influenza vaccine coverage: 2017-2018 (58.3%), 2018–2019 (69.2%) • Pneumococcal vaccine coverage: 2017-2018 (23.6%), 2018-2019 (74.7%) ___ • Interstitial lung disease Predictor variables • Age over 65 years old • Ongoing immunosuppressive therapy Non-probability sampling Small sample population 50 Nabavi et al, 2022 Iran May - Jun 2021 Patients with Multiple Sclerosis (N=892) Assess the vaccination willingness and acceptability in Iranian MS patients _ Immune-mediated disease & Immunosuppressive therapy Cross-sectional via survey Vaccine willingness COVID-19 Vaccine Willingness (68%) • Fear of reducing the efficacy of disease modifying drugs upon vaccination • Distrusting the vaccines • Overestimation bias in the power of their innate immunity and potential COVID-19 resistance • Lack of belief in the COVID-19 disease Predictor variables • Male gender • University education level • Marital status, married Non-Probability sampling 51 Nguyen et al, 2022 Australia Jun - Aug 2021 Patients with malignancies (N=1073) Evaluate vaccination uptake and hesitancy in people with a history of cancer, we initiated a cross-sectional, multicenter study using a validated COVID-19 vaccine hesitancy scale _ Haematologic & Solid-organ malignancies & Immunosuppressive therapy Cross-sectional study via survey Vaccine uptake Vaccine intention COVID-19 Vaccine uptake (65%) COVID-19 Vaccine Intention (84%) • Concerns regarding vaccine side effects, particularly thrombosis • The desire for clear medical advice • Older age, • Male gender, • English as first language • Longer time since cancer diagnosis • Not being on current anticancer treatment Misclassification bias from self-reported data Bias toward English speaking and technologically adept participants. 52 Ortiz-Martínez et al, 2022 Latin America- Mexico, Ecuador, Chile, Peru, Columbia Feb - May 2021 People living with HIV (N=528) Investigate the willingness to receive a vaccine against COVID-19 within PLHIV and to detect the potential factors influencing their decision to provide evidence for specific recommendations _ HIV Cross-sectional study via survey Vaccine willingness COVID-19 Vaccine Willingness (87.1%) • Concern about potential side effects • Concern about vaccine safety • Low confidence about the vaccine’s effectiveness • Belief that vaccination prevents COVID-19 infection • Having a high occupational risk of becoming infected with COVID-19 • Belief they would be at high risk of death because of COVID-19. Non-Probability sampling Low sample size Restricted in-person data collection due to the pandemic 53 Pham et al, 2018 USA 2010 - 2013 IBD patients on Anti-Tumor Necrosis Factor (anti-TNF) therapy (N=1401) Investigate the rates and predictors of recommended immunizations and screening tests among IBD patients receiving anti-tumor necrosis factor (TNF) therapy _ Autoimmune disorder & Immunosuppressive therapy Retrospective cohort study Vaccine uptake Influenza vaccine uptake latest season (43.5%), Pneumococcal vaccine (24.1%) Older providers (≥50 years) • Older patient age (≥50 years) • Infliximab therapy Retrospective cohort study Limitation to specific type of immunosuppressive therapy (Anti-TNF) & excluding immunomodulator or newer biologic 32 agents for IBD treatment 54 Qendro et al, 2020 Canada May - Sep 2015 Rheumatology patients with rheumatoid arthritis (RA), systemic autoimmune rheumatic diseases (SARD), spondyloarthropathies (SpA), or other diseases (OD)- (N=342) Assess vaccination coverage and predictors of vaccination among a Canadian population of rheumatology patients in routine clinical care (352 Participants) _ Autoimmune & Immunosuppressive therapy Cross-sectional study via survey Vaccine coverage • Influenza (2014–2015 season) • (RA: 48.5%, SARD 42.0%, SpA 31.9%, OD 88.9%) • Pneumococcal Vaccine (RA42.0%, SARD 37.8%, SpA 31.9%, OD 33.3%) • Hepatitis B vaccine (RA 33.6%, SARD 55.6%, SpA 73.5%, OD 36.8%) • Herpes Zoster vaccine (RA 5.6%, SARD 28.6%, SpA 25.0%, OD 16.7%) __ Predictor variables for Influenza and Pneumococcal vaccination • Older age ≥ 65 years • Physician recommendation • Previous pneumococcal vaccination • Previous influenza vaccination Predictor variables for Hepatitis B vaccination • Younger age • Awareness of the protection offered by HBV vaccination • Physician recommendation Small sample size 55 Restivo et al, 2017 Italy 2014 –2015 Solid organ transplant recipients (N=82) Assess compliance to vaccination and analyze factors associated with influenza vaccination of solid organ transplant recipients admitted to the Sicilian solid organ transplant Reference Center _ Solid-organ transplantation & Immunosuppressive therapy Cross-sectional study via survey Vaccine uptake Influenza vaccine uptake (37.8%) Pneumococcal vaccination rate (20.7%) • Fear of adverse reaction • Impaired health status • Low vaccine efficacy • Older age • Retired employment status • Smaller hospital admissions for infectious respiratory diseases • Advice of reference center physicians Small sample size Recall bias 56 Roman et al, 2022 Germany Feb - Apr 2021 Patients with chronic inflammatory rheumatic diseases -CIRD (N=514) Assess the willingness of CIRD patients to be vaccinated against SARS-CoV-2 and to identify the influencing factors compared with non-CIRD patients _ Autoimmune disorder & Immunosuppressive therapy cross-sectional via electronic survey Vaccine willingness COVID-19 Vaccine Willingness (79.6%) __ • Being in a risk group for covid-19 • Hypertension • Information about disease prevention Predictor variables • Age • Higher education Non-Probability sampling 57 Roupa et al, 2021 Cyprus Jan - Feb 2021 Patients with malignancies (N=211) Research the factors affecting the acceptance of new vaccine within the _ Malignancy & Immunosuppressive therapy Cross-sectional via electronic survey Vaccine uptake • Influenza A (H1N1) vaccine uptake • Seasonal flu within the last 5 years vaccine • Source of information from social networks • Increased age • Use of official websites as source of information • Use of mass media information Non-probability sampling Small sample size 33 population of cancer patients. uptake (39.8%) • COVID-19 vaccine intention (37%) • Information from healthcare professionals 58 Sadlier et al, 2015 Ireland Jan - Feb 2014 Dermatology patients prescribed systemic immunosuppressive therapies (N=170) Assess the uptake of the pneumococcal and influenza vaccinations among dermatology patients prescribed systemic immunosuppressive therapies, and to identify factors that influenced vaccination uptake Autoimmune & Immunosuppressive therapy Cross-sectional study via survey Vaccine uptake Seasonal influenza vaccine uptake in previous year (38·2%) Pneumococcal vaccine uptake in the past 5years (21.2%) Both vaccines (18.2%) • Being unaware of immunization recommendations • Forgetfulness • Inconvenience of an additional visit to their general practitioner • Fear of becoming unwell following vaccination • Age ≥65 years • Female gender • Presence of comorbid conditions Non-probability sampling Small sample size 59 Sandler et al, 2016 USA Jul - Sep 2013 Patients with rheumatoid arthritis (RA)- (N=102) Capture patients’ self-report of vaccination status and to better understand vaccination behavior and attitudes of patients with RA. Autoimmune & Immunosuppressive therapy Cross-sectional study conducted through telephone interviews Vaccine uptake Influenza vaccine in 2012 - 2013 (79.4%). Pneumococcal vaccination (53.9%). Herpes zoster vaccination (7.8%) • Lack of physician recommendation • Patient lack of knowledge of vaccinations • Negative attitudes toward vaccinations __ No assessment of predictor variables 60 Serper et al, 2021 USA May 2021 Solid organ transplant recipients (N=103) Assessed vaccine beliefs, concerns, and barriers to vaccination among a cohort of liver and KTRs. Solid-Organ Transplantation & Immunosuppressive therapy Cross-sectional study via survey Vaccine willingness • COVID-19 vaccine willingness (24%) • Older age • White race • lack of long-term data • Inconsistent messaging from providers scheduling inconvenience • Insufficient resources. • Black race • Longer time from transplant Non-Probability sampling 61 Shrestha et al, 2022 USA Dec 2020 - Jan 2021 People living with HIV (N=1030) Investigate vaccine hesitancy among a national sample of PWH in the United States. HIV Cross-sectional study via e-survey Vaccine hesitancy COVID-19 Vaccine hesitancy (90.8%) Predictor variables • Being Black • Politically conservative • concern about side effects • concern about safety • Being worried that the vaccine will not be effective • Concerns about being experimented on Predictor variables • Male gender • White race • University graduates • CD4 count of 200 cells/mm • liberal political orientation • Non-probability sampling Limited to individuals who had access to communication technology (e.g., phones, tablets, and laptops) and the Internet. Exclusion of non-English speakers 62 Su et al, 2022 China May - Jun 2021 People living with HIV (N=903) determine the acceptance rate and factors influencing acceptance of COVID-19 vaccination among people living with HIV in Guangxi, China. HIV Cross-sectional study via e-survey Vaccine willingness COVID-19 Vaccine Willingness (72.9%) • Concerns about vaccine safety • The vaccination’s effect on antiretroviral therapy (ART) Predictor variables • Perception that vaccination is unsafe for HIV-infected people • Perception of poor efficacy in preventing SARS-CoV-2 Predictor variables • Zhuang ethnicity • Highest education level of middle school, high school or above • Vaccination having little effect on ART efficacy __ 34 infection in HIV-infected people 63 Teich et al, 2011 Germany Apr - Sep 2009 Patients with IBD including Crohn’s disease and ulcerative colitis. (N=203) Study vaccination rates among patients with IBD _ Autoimmune & Immunosuppressive therapy cross-sectional via electronic survey (Simple random sampling) Vaccine uptake Tetanus vaccine uptake (67%), Pertussis (21%), Seasonal Influenza vaccine uptake (28%), Pneumococcal vaccine (9%) • Fear of side effects • Perception that their immune system was supposedly “not intact” • Concerns that vaccination would worsen their IBD. __ Fear of side effects Perception that their immune system was supposedly “not intact” Concerns that vaccination would worsen their IBD. Self-reported vaccine status Exclusion of all patients who had been counseled by a physician about vaccinations within the past year 64 Tharmaraj et al, 2021 Australia Mar 2021 Renal transplant recipients (N=473) Identify barriers and enablers to COVID-19 vaccination in renal transplant recipients who are undecided about vaccination _ Secondary: Solid-organ transplantation & Immunosuppressive therapy Cross-sectional study via survey Vaccine intention Covid-19 vaccine intention (73.1%) • Less positive toward vaccination • More concerned about vaccination • Concerns about vaccine safety • Concerns about poor efficacy • Concerns about less rigorous vaccine testing in transplant recipients • Information from transplant specialist and team • Recommendation from transplant specialist Limited to English-speakers Inadequate socio-economic data collection 65 Tsai,et al, 2022 USA, United kingdom,Canada, Australia, Isreal Jan - Feb 2021 Individuals With Cancer, Autoimmune Diseases, or Other Serious Comorbid Conditions (N=21,943) Assess the prevalence and independent predictors of COVID-19 vaccine hesitancy and acceptance among individuals with serious comorbidities and assessed self-reported side effects among those who had been vaccinated. _ Autoimmune disorder, Haematologic & Solid-organ Malignancies, Solid organ transplant (& Immunosuppressive therapy) Cross-sectional via electronic survey Vaccine uptake Vaccine hesitancy COVID-19 Vaccine uptake (25.80%) COVID-19 Vaccine Hesitancy (18.6%) • Younger Age • Conservative political orientation • Residing outside of united states • Concerns about inaccurate report of scientific data by media Predicting variables • Older age • Having received routine influenza vaccine • Having trust that the COVID-19 Vaccine was developed responsibly. • Independent or Liberal political orientation • 4-year College degree • Previous COVID-19 infection Non-probability sampling More female population Low response rate (2.2%) 66 Uhr et al, 2021 USA & other countries Dec 2020 - Feb 2021 Individuals with multiple sclerosis (N=701) Understand COVID-19 and influenza vaccine willingness and its associations among PwMS, following the approval of the first two mRNA COVID-19 vaccines. Autoimmune & Immunosuppresive therapy Cross-sectional study via e-survey Vaccine willingness COVID-19 Vaccine Wilingness (76.6%) • Higher functional disability • Prevalent vaccine-related concerns • concerned about serious side effects of the vaccine • Older age • Agreeing that information received about vaccines from the vaccine program is reliable and trustworthy. Non-probability sampling 35 67 Valerio 2020 Canada Dec 2019 - Jan 2020 Adults with rheumatic diseases-Rheumatoid arthritis, SLE/vasculitis-SARD, spondyloarthropathies-SpA, Osteoarthritis-OA (N=282) Evaluate the frequency and determinants of Inactivated Influenza Vaccine hesitancy among patients with rheumatic diseases Autoimmune Disease & Immunosuppressive therapy ___ Vaccine uptake Influenza Vaccine uptake RA 38.4%, SARD 39.1% SpA 48.2% OA 38.7% • Retired • Biologic therapy use Non-probability sampling 67 Valerio 2020 Canada Dec 2019 - Jan 2020 Adults with rheumatic diseases- SpA, SARDs, vasculitis, SLE, immunoglobulin‐G4‐related disease, Sjögren syndrome, antiphospholipid syndrome, Cogan syndrome, mixed connective tissue disease; osteoarthritis, and fibromyalgia, and other diseases (N=282) Evaluate the frequency and determinants of Inactivated Influenza Vaccine hesitancy among patients with rheumatic diseases Autoimmune Disease & Immunosuppressive therapy ___ Vaccine willingness Influenza vaccine willingness- (58.5) Predictor variables: •No previous Influenza vaccination •Belief that vaccines should not be mandatory •Unwillingness to take time off work to be vaccinated •Distrust in pharmaceutical companies __ Non-probability sampling 68 Vallée et al, 2021 France Jan 2021 People living with HIV (N=237) Understand the possible reasons for refusing a COVID-19 vaccine to better respond to their worries or hesitancies. _ HIV Cross-sectional study via e-survey Vaccine hesitancy Covid-19 Vaccine hesitancy (28.7%) • Concerns about their health • Requirement of mandatory COVID-19 vaccination • Chronic disease status __ Low response rate Selection bias 69 Villarreal-Garza et al, 2021 Mexico Mar 2021 Patients With Breast Cancer (N=612) Assess COVID-19 vaccine hesitancy rates among woman with breast cancer residing in Mexico who visited the social media channels of nongovernmental organizations dedicated to improving breast cancer _ Solid-organ malignancies & Immunosuppressive therapy cross-sectional via electronic survey Vaccine intention. Vaccine hesitancy Covid-19 vaccine intention (66%). COVID-19 Vaccine hesitancy (34%) Predictor variables • age younger than 60 years • low educational attainment • Mistrust in the health care system • misconception that COVID-19 vaccination is contraindicated in patients with breast cancer • not having a close acquaintance already vaccinated against COVID-19 • noncompliance with prior influenza immunization Predictor variables • Vaccine recommendation from their oncologist • More information about vaccine effectiveness Limited sample size, Self-reported data Non-probability sampling 36 • not having a close acquaintance deceased from COVID-19 70 Vinograd et al, 2014 Israel Oct 2010 Apr 2011 Patients with malignancies (N=806) Identify predictive factors for vaccination among cancer patients. _ Malignancies & Immunosuppressive therapy Case–control study Vaccine uptake Seasonal influenza vaccine uptake (48%) __ • Past vaccinations, • Low-risk malignancy, • Country of birth • Recommendations from the oncologist • Recommendations from the primary-care physician Self-reported data Recall bias 71 Wasan 2012 USA Feb - Apr 2012 Patients with Inflammatory Bowel Disease (N=958) Describe vaccine utilization by immunosuppression status, examine reasons for vaccine refusal, and identify characteristics associated with lack of influenza vaccination in IBD patients. Autoimmune & Immunosuppressive therapy Cross-sectional via electronic survey Vaccine uptake • Influenza vaccine uptake (81.5%) • Hepatitis B vaccine uptake (47.7%) • Pneumococcal vaccine (42.6%) • Hepatitis A vaccine (34.1%) • Herpes Zoster vaccine (33.3%) • Younger age • Concerns about adverse effects • Lower level of education • Absence of chronic immunosuppression use • Absence of health care provider recommendation• • Healthcare provider recommendation • Higher rate of immunosuppression • Having a primary health care provider Non-probability sampling Self-reported data 72 Wu et al, 2022 China Apr 2021 People living with HIV (N=556) investigate the willingness to receive the COVID-19 vaccine and associated factors among PLWH HIV Cross-sectional via electronic survey Vaccine intention COVID-19 Vaccine Wilingness (65.5%) • Concerns about potential adverse effects of COVID-19 vaccines • Concerns about COVID-19 vaccine affecting ART efficacy. • Concerns about information leakage • Concerns about ineffectiveness of COVID-19 vaccines Predictors • Higher monthly income • Heterosexual sexual orientation • Considering vaccination as a civil duty • Belief in the safety and efficacy of the vaccine • Convenience • Free cost • Occupational requirement for COVID-19 vaccination Predictors • Concerns about severe illness from COVID-19 • Concerns about ART effectiveness being affected by COVID-19 Non-probability sampling Self-reported data Vaccine intention may not be representative of vaccine uptake 73 Yang et al, 2022 China Jan - Feb 2021 People living with HIV (N=2740) Investigate the prevalence of COVID-19 vaccination uptake among PLHIV in China _ HIV Cross-sectional via electronic survey Vaccine uptake Covid-19 vaccine Uptake ( 6.2%) • COVID-19 vaccine shortage • Negative attitudes towards vaccines • Not having a full-time job • Being a member of priority groups to receive vaccination • Recommendation from health care workers, family and friends • Receiving information from social media • Having positive attitude to vaccination • Being married/cohabiting with opposite sex Non-probability sampling Selection bias Non validated scales Self-reported data 37 74 Yap et al, 2021 Ireland Jan - Mar 2021 People with multiple sclerosis (N=105) Evaluate general vaccination status among pwMS to better inform vaccine practices in this cohort _ Autoimmune & Immunosuppressive therapy Cross-sectional study Vaccine uptake • Pneumococcal vaccine (18.1%) • Influenza vaccine uptake (63.8%) • MMR Vaccine uptake (51.4%) • Perceived lack of necessity • Insufficient knowledge about the vaccine • B-cell therapy • Perceived Safety concerns • Influenza vaccine hesitancy • Longer disease duration • Higher disability • Recommendation from health care workers Self-reported data and recall bias Social-desirability bias 75 Mesfin et al, 2021 Ethiopia Mar - Apr 2021 Patients living with HIV (N=398) Assess the determinant factors of intention to receive the COVID-19 vaccine among HIV-positive patients attending ART clinics in southern Ethiopia _ HIV Cross-sectional study via survey Vaccine intention COVID-19 vaccine intention (34.0%) _ • Diagnosis with chronic disease as comorbidities • Male gender • Good knowledge of COVID-19 practice Self-reported data 76 Zheng et al, 2021 China Feb 2021 Patients living with HIV (N=1295) Understand the uptake of COVID-19 vaccine and factors associated with COVID-19 vaccine hesitancy among HIV-infected MSM in mainland China HIV Cross-sectional via electronic survey Vaccine uptake Vaccine hesitancy Covid-19 vaccine uptake (8.7%) • Concerns about efficacy of COVID-19 vaccine • Concern about side effects • Awaiting workplace vaccination • Lacking knowledge of where to obtain vaccine • High adherence to anti-retroviral medication • Perceived moderate to severe impact of COVID-19 on immunity Non-probability sampling Self-reported data USA – United States of America MSM – Men who have sex with men MS – Multiple Sclerosis 38 2.5 Discussion The determinants of vaccine hesitancy manifest as barriers to vaccine uptake, including individual and group, contextual, and vaccine/vaccination-specific factors (3). As I identified the facilitators and barriers to vaccine uptake and hesitancy among people living with immune deficiency conditions above, I now discuss them in terms of these three factors as per the Sage Working Group Determinants Matrix (3). 2.5.1 Contextual Factors These factors have been defined as those arising due to historical, socio-economic, environmental, institutional/health system, and political influences (58). Lower education attainment was found to impede vaccination (96,103,117), whereas higher education beyond high school was consistently shown to predict vaccination uptake, indicating a better understanding of opportunities and indications for vaccination (55,112,120). This association was particularly evident in the context of COVID-19 vaccine uptake and intention (54,67,105). Contrarily, income level has been reported to be both a promoter (114) and a deterrent (68) to vaccine uptake, suggesting that increased income alone is not sufficient to increase uptake in this population cohort. A key predictor of vaccine uptake for immunocompromised populations has been recommendations from healthcare providers. These recommendations consistently promote vaccine uptake or improve willingness across multiple studies, possibly due to the requirement of some vaccines before immunosuppressive treatments, especially in solid-organ transplant patients (125). Conversely, a lack of awareness of vaccine recommendations and the absence of healthcare provider recommendations have proven to hinder interest or acceptance of vaccines (78,80,96). Additionally, a 2015 Canadian study noted hesitancy among patients with haematological malignancies based on their physicians' advice against influenza vaccination (16). Political 39 influences were infrequently examined in the reviewed studies. However, one study conducted in the USA (101) and another involving the USA, Canada, the United Kingdom, Australia and Israel (74) reported that political conservatism was linked to COVID-19 vaccine hesitancy. Additionally, communication and news outlets seem to have lesser influence in this cohort compared to the general population (37). Nonetheless, the overarching response to social media was the promotion of vaccination among the participants, with only one study identifying it as a barrier to vaccine uptake (52,88,93). 2.5.2 Individual and Group Factors Individual factors within immunocompromised populations include age, gender, sexual orientation, health/immune status, experience with past vaccination, beliefs, attitudes, and knowledge. Age significantly influences vaccination, as demonstrated by more than half of the reviewed literature. Generally, older individuals (≥45 years) were shown to be more likely to embrace vaccines against various diseases, including Influenza, Pneumococcal infections, COVID-19, Hepatitis B, and Herpes Zoster, suggesting that they recognise the significance of vaccination in safeguarding their health, especially in the presence of increased vulnerability. Conversely, younger age emerges as a potential barrier to vaccine uptake, as these individuals may perceive themselves to be at lower risk of developing severe disease from vaccine-preventable diseases, especially if they have no additional comorbidity (126). The male gender's impact on vaccination is less clear. Five studies suggest that being male can facilitate vaccination uptake, with three identifying it as a predictor for COVID-19 vaccination. In contrast, lower vaccination uptake was seen in females, and this could be linked to the tendency of females to show more worry than males about vaccine efficacy and safety and the fact that more adverse effects of vaccines have been reported by females (127). Although limited studies reported the impact of 40 sexual orientation on vaccine uptake, being a sexual minority among those living with HIV positively predicted the uptake of Hepatitis and Pneumococcal vaccines and COVID-19 vaccination. This may result from targeted vaccination interventions for this population. However, sexual minorities within the general population also showed reduced vaccine uptake due to historical medical trauma, emotional violence, or discrimination experienced while accessing medical services (128,129). Previous vaccination experience has shown to be a pivotal factor influencing vaccine uptake of newer vaccines and a key predictor of COVID-19 vaccine uptake in particular. Previous vaccination may be a deterrent to vaccination, owing to a bad experience or adverse effects of the previous vaccine, e.g., Seasonal Influenza in patients with haematological malignancies (82). Moving beyond vaccination history, individual preferences and beliefs wield substantial influence over vaccine uptake. Those who perceive vaccines as unnecessary or inadequately studied tend to oppose mandatory vaccination or question vaccine safety with reduced uptake rates. Furthermore, vaccine beliefs are nuanced within the context of immunocompromised individuals, where beliefs such as the incompatibility of COVID-19 vaccines with chemotherapy or their potential to worsen prognosis contribute to decreased willingness to accept vaccines. Over one-third (36%) of the reviewed articles noted concerns about safety and long-term adverse effects of vaccines as a potential barrier to vaccination among the participants, including those with primary (70) and secondary immune disorders (68,91,96,99). Moreover, the influence of knowledge, attitudes and perceptions regarding vaccine-preventable diseases and immunisation were elaborated across most of the reviewed studies. Good knowledge about vaccines consistently predicts higher uptake rates, demonstrated among patients with autoimmune disorders, solid organ transplants, and haematological malignancies (61,64,90,91). Trust is another recurring theme influencing vaccine 41 uptake. Trust in the safety and effectiveness of vaccines, along with trust in healthcare professionals, health authorities, and the vaccine development process, consistently emerge as promoters of vaccination, with a pronounced impact on COVID-19 vaccine uptake in particular. 2.5.3 Vaccine and Vaccination Factors Vaccination is directly related to the scientific-based risk/benefit assessment, mode of administration, vaccine cost, and formulation. While my review underscores the significance of these factors in shaping vaccination decisions, high vaccination costs emerge as a substantial barrier, particularly in non-pandemic situations and for vaccines like seasonal influenza (56,78,79). Additionally, limited vaccine availability and accessibility exert profound effects, resulting in reduced uptake ((56,78). Furthermore, vaccines for Measles, Mumps, and Rubella (MMR) and Herpes Zoster are contraindicated for individuals with severe immunosuppression and are only recommended months before the initiation of immune-altering therapies (130,131). Notably, patients with multiple sclerosis receiving B-cell therapy, which significantly increases immunosuppression, exhibited heightened hesitancy toward MMR vaccines (98). 2.5.4 Strengths and Limitations To the best of my knowledge, this is the first review that offers an exhaustive and up-to-date synthesis of the factors that either encourage or discourage vaccination within both inherited and acquired immunocompromised populations. Through this investigation, I have identified a diverse range of predictors of vaccine uptake and hesitancy. Nevertheless, it is vital to acknowledge the limitations inherent in my study. Firstly, I did not perform a quality assessment of the articles included, as seen in systematic reviews. Moreover, despite my inclusion criteria encompassing studies in all languages, my search terms were formulated exclusively in English, which may have inadvertently excluded relevant 42 studies using non-English keywords. Finally, this review considered both associated factors and expressed concerns in interviews equally when noting barriers and facilitators to vaccination. Additionally, I regarded self-reported vaccine uptake and records-based uptake on an equal footing. While this approach offers a comprehensive perspective, it is crucial to acknowledge that self-reported data may carry a degree of subjectivity and recall bias, which should be considered when interpreting my findings. 2.6 Conclusion I found that while socio-economic, contextual, and vaccination-related factors have long been associated with vaccination behaviours, immunocompromised populations face distinct influences rooted in their health conditions. These influences encompass apprehensions regarding potential adverse vaccine effects, particularly concerns about exacerbating their underlying medical conditions. Furthermore, their reliance on physician recommendations, driven by limited knowledge about vaccine implications for their specific health status and an amplified sense of vulnerability, underscores the multifaceted nature of their vaccination decision-making process. The insights from this scoping review are useful in policy-making and public health intervention strategies. These strategies should be designed not only to alleviate fears surrounding vaccine safety but also to bridge knowledge gaps and enhance understanding, ultimately empowering immunocompromised individuals to make informed vaccination decisions. After reviewing the evidence of vaccine uptake and hesitancy among immune-compromised populations, including PLHIV, I now present a quantitative study I conducted among PLHIV in British Columbia to explore the factors behind COVID-19 vaccine uptake and hesitancy. A version of this chapter has been prepared for submission to the PLOS One Global Public Health Journal. 43 Chapter 3: COVID-19 Vaccination Uptake and Hesitancy among People Living with HIV in British Columbia 3.1. Summary 3.1.1 Objective: COVID-19 vaccination is important for People Living with HIV, given their elevated infection and comorbidity risks. Nevertheless, some PLHIV are hesitant, thereby refusing or delaying to accept vaccination. Hence, I conducted a cross-sectional study in British Columbia, Canada, aimed to identify socio-economic and health-related factors predicting COVID-19 vaccine uptake and contributing to hesitancy among PLHIV. 3.1.2 Methods: A 34-item anonymous self-administered survey was electronically disseminated to PLHIV accessing services through local HIV and AIDS-related organisations’ newsletters between November 2022 and January 2023in British Columbia. It was estimated that in 2022, about 9,800 British Columbians were living with HIV. Questions included sociodemographic information, COVID-19 vulnerability factors, HIV indicators, self-reported vaccination barriers and facilitators, as well as the Vaccine Hesitancy Scale. Descriptive (means and frequencies) and inferential statistics, including odds ratio and ANOVA, were conducted to detect significant associations between sociodemographic characteristics, COVID-19 uptake, HIV indicators, and perceived COVID-19 vulnerability using IBM® SPSS® 28 for Mac software, significance level at p<0.05. 3.1.3 Results: From the 276 respondents (mean age 29.93±7.548), 54.7% were men, 31.6% identified as sexual minorities, and 46.7% were of indigenous origin. Almost 40% of the respondents received three vaccine doses, while 82.2% received at least one dose. Vaccine hesitancy was associated with lower education, age <44, and low income. Predictors of COVID-19 vaccine uptake included age [aOR 1.063 CI=1.010-1.119], bachelor's degree [OR 0.216 44 CI=0.065-0.715], family/friends being infected with COVID-19 [OR 3.678 CI=1.561 – 8.667], detectable HIV viral load >500 copies [OR 0.197 CI=0.064-0.605], beliefs in vaccine importance [OR 0.514 CI=0.281-0.952], trust in Health Canada's information [OR 0.494 CI=0.293-0.834], and concerns about vaccine adverse effects [OR 0.349 CI=0.219-0.556]. Concerns regarding vaccine adverse effects were found to decrease the likelihood of receiving three doses of the COVID-19 vaccine by 65% of the respondents. 3.1.3 Conclusions: Although the estimated sample size was not reached, it remains crucial to consider specific factors that may have an impact on vaccination rates, including information about adverse effects and the importance of vaccines. This insight should guide the development of policies and interventions aimed at promoting additional vaccine doses and encouraging individuals to maintain an up-to-date vaccination status. 45 3.2 Background Since the first reported cases in 1981, the Human Immunodeficiency Virus (HIV) has afflicted over 85.6 million people globally, leading to more than 40.4 million deaths (132,133). The epidemiology of HIV exhibits geographical variations shaped by risk factors, behavioural practices, and healthcare accessibility. This blood-borne virus is associated with severe disease progression, reduced life expectancy, and significant socio-political and economic consequences, especially in high-burden regions (134). HIV impairs the immune system by targeting CD4+T cells, which increases the susceptibility to opportunistic infections and neoplasms (135–137). When it occurs, progression to acquired immunodeficiency syndrome (AIDS) is marked by severe immunocompromise, declining CD4 counts, and rising HIV viral loads, which are critical factors guiding treatment and prognosis (137,138). The introduction of antiretroviral therapy in 1987 and Highly Active Antiretroviral Therapy (HAART) in 1996 has substantially reduced HIV/AIDS-related morbidity and mortality. People Living with HIV (PLHIV) who adhere to therapy now attain life expectancies comparable to those without HIV, albeit mostly in developed countries (139–141). Despite these advancements, marginalised communities, including individuals engaged in commercial sex work, men who have sex with men, people who use illicit substances, and gender minority individuals still account for 65% of global HIV infections (142). In Canada, there are approximately 62,050 PLHIV, with about 9,800 in British Columbia (BC) (143,144). Notably, BC's Indigenous population, comprising just 6% of the provincial population, accounts for 8-17% of new HIV diagnoses, highlighting significant disparities (145). Another global health threat came with the 2019 coronavirus disease (COVID-19) pandemic caused by the airborne SARS-CoV-2, resulting in over 695 million infections and 6.9 million 46 deaths worldwide by September 2023 (17). Over the past three years, multiple waves of COVID-19 infections have occurred globally (20), with policy responses in effect, including physical distancing, travel restrictions, lockdowns, and vaccination rollouts (22). Notably, surges in cases often coincided with the relaxation of preventive measures (146,147). For example, in Canada (148,149), waves occurred in early 2020, late 2020 to early 2021, mid-2021, mid-2021 to late 2021, and early 2022, with the latest emergence of the Omicron EG.5 variant in the fall of 2023 (150). COVID-19, akin to the HIV era, has disproportionately affected marginalised communities grappling with socioeconomic, gender, and racial disparities, as well as individuals with compromised immune systems, healthcare workers, and travellers (150). These vulnerable groups encompass PLHIV, 2SLGBTQQIA+ (Two-spirit, lesbian, gay, bisexual, trans, queer, questioning, intersex and asexual) individuals, people of colour, and Indigenous communities mostly (151–153). Unlike the HIV epidemic's focus on drug treatment, the COVID-19 era witnessed remarkable vaccine development (154), with limited attention on antiviral drug therapies until recently (155). As of June 2022, more than 38 vaccines (156) have been approved globally, with an additional 361 vaccines in various developmental stages, half being in clinical trial stage (157). Canada has authorised the use of a number of vaccines including AstraZeneca (Vaxzevria), Janssen (Johnson & Johnson), Medicago (Covifenz), Moderna (Spikevax), Novavax (Nuvaxovid), and Pfizer-BioNTech (Comirnaty) (158). The NACI prioritised specific populations for initial COVID-19 vaccination in December 2020 based on the risks of severe illness and mortality from COVID-19. These populations included individuals most likely to transmit the virus to vulnerable groups and essential workers. Prioritised groups encompassed older individuals, those with comorbidities, healthcare professionals, long- 47 term care facility caregivers and essential workers outside the healthcare sector, such as police officers, firefighters, and grocery store personnel. Additionally, individuals in environments with increasing susceptibility to COVID-19, including Indigenous communities, were prioritised (28,159). People living with HIV were not prioritised for early vaccination unless they met the priority criteria until June 2021(160). During the initial phases of the COVID-19 pandemic, concerns arose regarding the heightened vulnerability of PLHIV to both the incidence and severity of the virus (23,24). However, empirical data reveal that PLHIV constituted approximately 1.0% of total hospitalised cases, with the prevalence of SARS-CoV-2 infection ranging from 0.88% to 1.8% among them (161,162), a range analogous to that of the general population (163,164). While PLHIV did not exhibit an overrepresentation in COVID-19 cases, they did experience more severe outcomes attributable to HIV-related social disparities, medical risks, and comorbidities (25,26). Although limited PLHIV were included in COVID-19 vaccine trials, available data indicates vaccine efficacy and safety, even among individuals with well-managed HIV, undetectable viral loads, and CD4 cell counts exceeding 200 cells/mm³(27). Hence, NACI strongly advocated for the completion of the COVID-19 vaccine regimen in individuals with compromised immune systems, encompassing PLHIV (28). In alignment with this guidance, the Committee for Drug Evaluation and Therapy at the British Columbia Centre for Excellence in HIV/AIDS recommends that all PLHIV aged 18 years or older should receive the COVID-19 vaccine if they meet the current public health priority criteria, irrespective of their CD4 count (165). Vaccination programmes primarily aim to prevent and control infectious diseases, ultimately striving for herd immunity, a state where a significant portion of the population becomes immune, thus reducing person-to-person transmission (166). Initial studies suggested that 48 achieving herd immunity against COVID-19 might necessitate vaccinating approximately 67% (range from 60 to 70%) of the population using vaccines with 70-90% efficacy (6,167). However, the ongoing mutations in the original SARS-CoV-2 virus have challenged these estimates, as outbreaks persist despite over 80% of Canadians receiving at least one highly effective vaccine dose. In the context of COVID-19 immunisations, "full vaccination" refers to completing at least the recommended primary series of vaccines (168) rather than indicating a state of absolute immunity where antibodies effectively recognise, eliminate, and prevent the infectious agent from causing illness. Conversely, being "up to date" with COVID-19 vaccination implies that an individual has received all the recommended vaccine series doses within a specified time frame plus the boosters (169). This entails three doses of an mRNA vaccine like Pfizer-BioNTech or Moderna, two to three doses of a protein subunit vaccine like Novavax or Medicago, or two doses of a viral vector vaccine such as AstraZeneca or Janssen, followed by one dose of a mRNA vaccine (170). Multiple additional doses, or boosters, have been required with the continued rise in COVID-19 infections due to rapid mutation of the SARS-CoV-2 virus and enhanced transmissibility, reduction in vaccine efficacy following the prevalence of new variants, vaccination inequalities due to social and demographic disparities, and inability to reach herd immunity as the disease progresses (171). Additional boosters are suggested, but not without increasing uncertainties and impacting uptake and vaccine fatigue (172,173). Nonetheless, the success of vaccination programs, hinges on adherence to these public health recommendations to enhance vaccine uptake (36). Vaccine uptake rate signifies the proportion of the population who have received a vaccine during a specific period, and it is influenced by behaviours such as acceptance, hesitancy, and refusal. Vaccine hesitancy, defined by the WHO as delayed approval or outright rejection of vaccines despite availability, can 49 threaten global health (3), and it is influenced by complacency, convenience, and confidence (36). The lingering uncertainties surrounding the required vaccine doses – and their boosters, vaccine fatigue and the persistence of COVID-19 surges have been compounded by historical factors contributing to vaccine hesitancy, including deep-seated mistrust in the medical system and adherence to public health directives (174–176). For individuals living with HIV, additional apprehensions, such as concerns over contracting COVID-19 from the vaccines and the potential effects, loom large (107). Despite a number of researches in Canada dedicated to investigating the willingness of PLHIV to receive COVID-19 vaccinations (32,33), a notable gap remains concerning data regarding actual vaccine uptake and adherence to the recommended primary vaccine series. Furthermore, there is limited research exploring the intricate interplay between vaccine uptake and hesitancy, and health-related factors, including HIV indicators such as CD4+ count, HIV viral load, comorbidities, length of HIV diagnosis, perceived vulnerability, socioeconomic considerations, and prevailing social norms among PLHIV. Given this paucity of literature and the impact of structural marginalisation on health outcomes within HIV communities, this study addressed the following research question: What are the socio-economic and health-related predicting factors of COVID-19 uptake and associated factors of hesitancy among PLHIV in British Columbia, Canada? Our hypothesis was that health-related factors and low socio-demographic factors are predicting factors of vaccine uptake and contribute to vaccine hesitancy among the HIV population in British Columbia, Canada. To address the research question and test the stated hypothesis, this study aimed to determine the prevalence of COVID-19 vaccine uptake among PLHIV in British Columbia, Canada; the level of vaccine hesitancy among PLHIV in British Columbia using the adult vaccine hesitancy scale; and 50 the socio-economic and health (COVID-19 and HIV-related) factors associated with COVID-19 vaccine uptake (including predictors) and vaccine hesitancy. 3.3 Methods 3.3.1 Study design and population Ethical approval for this study was granted by the Behavioral Research Ethics Board at the University of British Columbia (UBC) # H22-02053. Data Collection Tool This study adopted a cross-sectional design via a 34-item survey incorporating the Adult Vaccine Hesitancy Scale (60). The self-administered survey was conducted anonymously via Qualtrics© software (2019, Provo, Utah) (177). Participation was voluntary, with no email or IP linkage to responses. To prevent multiple responses, the first question asked if the participant had completed the survey before, and informed consent was obtained through the introductory page - Appendix B. An earlier version of the survey was piloted among 80 participants attending the AIDS-Vancouver December grocery program in December 2021 in Vancouver, British Columbia, and modifications were made after feedback was gained on the reliability, flow, and overall acceptance of language. The survey consisted of questions about demographics (age, gender, ethnicity, education, income); COVID-19 vaccination status (including the number of doses and motivation and deterrents to vaccination); perceived COVID-19 vulnerability (including previous COVID-19 diagnosis, family & friend diagnosis, and death of family or friend from COVID-19); HIV health indicators (CD4 count, HIV viral load), and Adult Vaccine Hesitancy Scale as validated by Akel et al (178) with 10 Likert scale questions with agreement levels (strongly agree to strongly disagree, 5 options) 51 with statements like ‘Vaccines are important for my health’, and ‘Vaccines are effective’. Scores in each statement range from 1 to 5, totalling 10 (minimum) and 50 (maximum). Participants were given the option to enter a draw to win ten $30 Amazon gift cards as an incentive for responding to the survey. Those who signed up for the draw provided their emails, which were only assessed by me, while the data was de-identified before analysis. Inclusion criteria encompassed adults 19 years of age or older, of any gender or sexual orientation, who self-reported a diagnosis of HIV/AIDS during data collection, who were willing to participate and able to understand English to fill out the survey. Exclusion Criteria included anyone younger than 19 years living or not with HIV. Sample Size Determination Sample size calculation using the Cochran formula set the minimal sample to 384, assuming a normal standard deviation set at 1.96, corresponding to a 95% confidence level, a degree of variability set at maximum 50%= 0.50 and a level of precision/ margin of error set at ±0.05 (5%). In order to accommodate a non-response rate of 10.0% and more substantial statistical power and effect size, the desirable sample size was then set a 407. If an alternative formula was used, the estimated sample size may have been 313 assuming a population proportion of 30% (176). This study employed a convenience sampling method in collaboration with HIV organisations in British Columbia, including the Pacific AIDS Network (PAN), an umbrella organisation comprising 42 member organisations across the five health authorities in BC, that distributed the survey link to their members electronically via Qualtrics©. The surveys were distributed between the 17th of October 2022 and the 7th of January 2023. 52 3.4 Data Analyses The completed surveys were imported from XM Qualtrics© into Microsoft Excel®. Data was analysed using IBM® SPSS® 28 for Mac (SPSS Inc., Chicago, IL, USA, 2021) (180). Descriptive Statistics was employed to summarise socio-demographic characteristics, including age, gender, ethnic origin, education level, employment status, and annual income level. This was achieved through frequency distribution, central tendency, and variability analysis, with results reported as summary frequencies, mean, and standard deviation. Furthermore, this study elicited motivational factors from COVID-19 vaccine recipients, identified primary concerns expressed by vaccine refusers, and examined the rationales behind the partial vaccination status among participants. Inferential Statistics used two outcome variables, including total Vaccine Hesitancy Score (VHS), and COVID-19 Vaccine Uptake (defined as full vaccination, comprising at least three doses ± booster doses). For the Total VHS, a normality test was conducted considering the independent variables. Upon visual inspection, the data distribution, Z-skewness, and Z-Kurtosis all felt within acceptable ranges, approximating normality for total vaccine hesitancy scores for the application of parametric tests. Pearson’s Product-Moment Correlation was carried out after fulfilling the assumption of normality and that of the independent and dependent variables being interval or continuous variables. One-way Analysis of Variance (ANOVA) was conducted to detect significant associations between sociodemographic characteristics, COVID-19 uptake, HIV indicators, and perceived COVID-19 vulnerability. For the COVID-19 Vaccine Uptake, answers were dichotomised into YES and No (<3 recommended primary doses). Bivariate analysis was done using Pearson’s Chi-square test for independence after fulfilling the lowest expected cell frequency assumption. Variables were 53 significant at p<0.05. Multivariate analysis was carried out using Binary logistic regression after the fulfilment of the following assumptions of categorical outcomes; having no linear relationship with the predictors, independence of errors where cases were unrelated and multicollinearity where predictors are not highly correlated. The independent variables included in the model were those with p<0.10 in addition to those with a significant p<0.05 from the Chi-square test. 3.5 Results Out of 477 full responses from British Columbia, 276 self-reported an HIV-positive status, 84 reported being HIV-negative, and 19 did not disclose their status. A response rate of 58.7% (N=276) did not meet the estimated minimal sample size of 407 participants. Participants' mean age at the time of data collection is 29.93 [standard deviation (SD) = 7.55; range, 19–67 years]. Additionally, the sample was characterised by its diverse ethnic and demographic composition, as highlighted in Table 3-1. Specifically, men accounted for slightly over half of the study population, totalling 154 individuals (54.7% of respondents). Furthermore, sexual minorities comprised 31.6% of the study's population. Notably, the Indigenous population was significantly present in the study, with nearly half of the overall population (46.7% of respondents, 129 individuals). Regarding the number of doses received, Completion of the primary series of vaccination without additional boosters included receiving the recommended three doses (181), whereas up-to-date vaccination is the completion of the recommended primary series along with the recommended booster doses as of January 2023, which was total of 5 shots for the immunocompromised population (3 primary doses and 2 booster doses).(182) Partial vaccination is defined as receiving any dose less than the recommended doses and additional boosters. 54 Table 3-1: Sociodemographic Profile of the 276 PLHIV in British Columbia who Participated in the Study Independent Variables N (276) % (100.0) Gender Male 151 54.70 Female 114 41.30 Non-Binary 11 4.00 Sexual Orientation 100.0 Heterosexual 189 68.50 Homosexual 54 19.60 Others (Queer, Pansexual, Asexual) 33 12.00 Ethnicity African/Caribbean 12 4.30 Asian (East, South, South-east, Middle eastern) 32 11.60 White/European 100 36.20 Indigenous 129 46.70 Others (Hispanic) 3 1.10 Level of Education High School or Less 92 33.30 Trade School 16 5.80 Bachelor’s degree 114 41.30 Postgraduate degree (Master’s, PHD/Higher) 54 19.60 Employment Status Part-time employed 51 18.50 Full-time employed 188 68.10 Others (Unemployed/Retired/Welfare/Volunteer/ Full-time Students) 37 13.40 Income Level $0 - $49,020 74 26.80 $49,020 - $98,040 94 34.10 $98,040 - $151,978 47 17.00 > $151,978 49 17.80 Undisclosed 12 4.30 Regional Health Authority Fraser Health 18 6.50 Interior Health 30 10.90 Island Health 31 11.20 55 Northern Health 16 5.80 Vancouver Coastal Health 56 20.30 Unspecified 125 45.30 COVID-19 Vaccine Uptake- 1Dose At Least One Dose 227 82.20 No Uptake 49 17.80 COVID-19 Vaccine Uptake- Primary Series Recommended dose uptake ≥ 3doses 104 37.70 No uptake of recommended dose < 3 doses 172 62.30 AstraZeneca Vaxzevria No 218 79.00 Yes 58 21.00 Janssen (Johnson & Johnson) No 218 79.00 Yes 58 21.00 Pfizer-BioNTech No 182 65.90 Yes 94 34.10 Moderna Spikevax No 248 89.90 Yes 28 10.10 Novavax Nuvaxovid No 255 92.40 Yes 21 7.60 Doses Received 0 49 17.80 1 27 9.80 2 96 34.80 3 84 30.40 4 10 3.60 5 10 3.60 COVID-19 Vulnerability COVID-19 Diagnosis Yes 158 57.20 No 109 39.50 Unsure 9 3.30 Family/friend diagnosed with COVID-19 Yes 177 64.10 56 No 81 29.30 Unsure 18 6.50 Death of family/friend due to COVID-19 Yes 104 37.70 No 147 53.30 Unsure 25 9.10 HIV Health Indicators CD4 count <200 cells/mm 60 21.70 201 - 500cells/mm 134 48.60 >500 cells/mm 46 16.70 Unsure 36 13.00 HIV viral load Undetectable 71 25.70 <500 copies/ml 115 41.70 ≥ 500 copies/ml 60 5.40 Unsure 30 10.90 VHS Score Category Low (≤ 26) 156 56.50 High (> 26) 120 43.50 Continuous Variables Median Mean Std. Deviation Minimum Maximum N Age 250 29.00 29.930 7.548 19.000 67.000 Doses Received 276 2.000 2.0300 4.446 0.000 5.000 Total VHS 276 26.000 26.199 1.260 14.000 38.000 57 Figure 3-1: Reported Motivation for COVID-19 Vaccination Figure 3-2: Reported Concerns for COVID-19 Vaccine Refusal 1681411830108135932760% 20% 40% 60% 80% 100%Self-ProtectionProtection of loved onesProtection of communityPressured into itYES NO11222118382728310% 20% 40% 60% 80% 100%Motives of pharmaceutical companiesInsufficient information about vaccineRapid development of vaccinesNo protection from COVID-19YES NO 58 Figure 3-3: Reported Factors Underlying Incomplete COVID-19 Vaccination 3.5.1 COVID-19 Vaccine Hesitancy The mean vaccine hesitancy score was 26.20± 1.260 and was negatively correlated with age as older participants showed lower vaccine hesitancy scores [r= –.18, n=250, p<.0005]. There was also a negative correlation between the number of doses received and the vaccine hesitancy score value [r= –.245, n=276, p<.001], where participants who received fewer doses had a higher vaccine hesitancy score. The coefficient of determination R2 was only 0.033 and 0.060 for age and number of doses received, respectively. This indicates that only 3.3% and 6.0% of the total variability of VHS could be explained by these factors, and that the line was a poor fit. Therefore, there was only a weak negative correlation between them. The coefficient of determination R2, however, was 0.033, and 0.060, suggesting that only 3.3% and 6.0% of the variability of total VHS was explained by age and number of doses received, suggesting that the line was a poor fit and there was only a small negative correlation. 67879849371501301191681800% 20% 40% 60% 80% 100%Adverse Reaction to the previous COVID-19 doseInsufficient Vaccine InformationBreakthrough COVID-19 Infections Post-VaccinationPerceiving Additional Doses asUnnecessaryObjecting to Vaccine Passport PoliciesYES NO 59 One-way ANOVA revealed a statistically significant difference in the mean VHS scores between those younger than 25 and those between the ages of 26 and 44 years old [F (3, 272) =7.18, p<0.001]. Post-hoc comparisons using the Turkey HSD test indicated the mean score for participants who were 25 years or younger (M=27.04, SD=4.34) was significantly different from those aged 26-44 years (M=25.32, SD=4.28)- (p = 0.019, 95% C.I. = [0.206, 3.219]). Being 45 years or older (M=25.20, SD=5.16) did not differ significantly from either age group < 25 years or 26-44 years. Similarly, there was a significant effect of the level of education on VHS scores [F (3, 272) =6.42, p<0.001]. The mean score for participants who had a bachelor's degree (M=24.86, SD=0.39) was significantly lower than those who had a high school education or less (M=26.92, SD=0.47)- (p = 0.004, 95% C.I. = [-3.629, -0.499]) and those who had a post-graduate degree (M=27.48, SD=4.40)- (p = 0.002, 95% C.I. = [-4.467, -0.777]). Having a trade school education (M=27.25, SD=4.02) did not differ significantly from any other level of education group. Income level was also statistically significant [F (4, 271) =5.00, p<0.001] given that those participants in the lowest federal tax bracket earning ≤CD$49,020 (M=24.68, SD=4.43) had mean VHS scores that were significantly lower than those who earned between CD$98,040-CD$151,978 (M=27.00, SD=3.90)- (p = 0.034, 95% C.I. = [-4.538, -0.110]) and those earning greater than CD$151,978 (M=27.47, SD=4.26)-(p = 0.005, 95% C.I. = [-4.980, -0.608]). Earnings between CD$49,020 and CD$98,020 did not significantly differ from any other income group in terms of mean VHS. Lastly, Although HIV viral load revealed a significant output [F (3, 272) =2.82, p=0.039], the post-hoc comparisons revealed no statistically significant difference between either group of viral loads, i.e., undetectable, <500 Copies or ≥500 copies. 60 3.5.2 COVID-19 Vaccine Uptake Among the surveyed population, approximately 82.2% had received at least one dose of the COVID-19 vaccine, while 17.8% (n=49) remained unvaccinated. On average, participants had received approximately 2 doses (SD ± 4.446, Range 0-5). Of these, 37.6% (n = 104) were vaccinated with a primary series of at least three doses, while 3.6% (n = 10) were up to date as of January 2023, having received all five recommended doses. The Pfizer-BioNTech vaccine was the most prevalent choice among respondents, with ninety-four participants having received it. Following closely were AstraZeneca and Janssen, each administered to fifty-eight participants, while the newer plant-based Novavax vaccine was the least administered. Notably, more than half of the participants had received a COVID-19 diagnosis themselves (n = 158, 59.2%) or were aware of a positive COVID-19 diagnosis among family or friends (n = 177, 64.1%). Additionally, 37.7% of respondents indicated knowledge of the death of a family member or friend due to COVID-19. Pearson’s Chi-square test revealed a statistically significant association between being fully vaccinated and the following factors: Age groups (χ2 = 14.25; df = 3; p = 0.003), education level (χ2 = 16.42; df = 3; p < 0.001), income level (χ2 = 13.22; df = 4; p = 0.010), family or friends diagnosed with COVID-19 (χ2 = 6.65; df = 3; p = 0.003), HIV viral load (χ2 = 12.87; df = 3; p = 0.005), CD4+ count (χ2 = 8.02; df = 3; p = 0.046), and the vaccine hesitancy score (category- ≤ 26- and >26) (χ2 = 7.90; df = 1; p = 0.005). Multi-variable modelling in the form of binary logistic regression analyses was utilised to explain COVID-19 vaccine uptake (Table 3-2); the model was significant using the Omnibus Tests of Model Coefficients (χ2 = 98.36; df = 27; p<0.001; classification fit =76.7%) and non-significant (χ2 = 12.77; df=8; p=.120. The sensitivity percentage of individuals who were vaccinated with the recommended primary series accurately identified by the model was 62.5%, while the specificity, i.e., the 61 percentage of people not vaccinated with the primary series, was 85.6%. Additionally, the positive predictive value was at 73.2%, and the negative predictive value of the model was at 78.4%. The likelihood (odds) of being vaccinated with at least three doses increased by 1.063 [95% CI- 1.010 –1.119, p= 0.019] as the age of the participants increased by one year. In contrast, participants with bachelor’s degrees had 78% lower odds [95% CI- 0.065 - 0.715, p= 0.012] of completing the recommended three doses or more compared to those with high school education. Moreover, participants who had friends or family with a history of COVID-19 diagnosis had 3.678 increased likelihood of completing the recommended three doses or more [95% CI-1.561 – 8.667, p= 0.003]. Additionally, participants who reported a detected viral load of less than 500 copies/ml had 80% lower odds of being vaccinated with at least 3 doses compared with participants with undetectable viral loads [95% CI= 0.095 - 0.809, p= 0.019]. Total vaccine hesitancy score was seen to be a predictor of vaccine uptake; paradoxically, an increase in one unit of the total vaccine hesitancy score was seen to increase the likelihood of receiving the recommended doses by 1.354 [95% CI= 1.061 - 1.728, p= 0.015]. However, a breakdown of the individual scores on the scale revealed that an increase in the score, synonymous with disagreeing that vaccines are important for health, disagreeing about the reliability of the information from Health Canada and agreeing to be concerned about serious adverse vaccines, decreased the odds of being vaccinated with three or more doses of COVID-19 vaccines by 48% [95% CI- 0.281 - 0.952, p= 0.015], 51% [95% CI- 0.293 - 0.843, p= 0.008] and 65% [95% CI- 0.219 - 0.556, p<0.001] respectively. The WALD Test analysis underscores key predictors influencing vaccine uptake. Concerns about potential adverse effects exhibit the most significant impact (WALD = 19.577, p < 0.001), followed by a history of family/friends diagnosed with COVID-19 (8.869, p = 0.003), detectable HIV viral load below 500 copies (8.045, p = 0.005), possessing a Bachelor's degree (6.613, 62 p=0.010), beliefs regarding information from Health Canada (6.976, p=0.008), the Total Vaccine Hesitancy Score (5.945, p=0.015), age (5.513, p=0.019), and beliefs regarding vaccine importance to health (4.479, p=0.034). Table 3-2: Logistic Regression Models Analyzing COVID-19 Vaccine Uptake in PLHIV in British Columbia Received At Least Three Doses Of COVID-19 Vaccine (N=276) B Wald Exp (B) OR 95% CI p Age 0.061 5.513 1.063 1.010 – 1.119 0.019 Level of Education 6.753 0.080 High School or Less -0. 770 0.900 0.463 0.094 - 2.273 0.343 Trade School -0. 354 0.734 0.702 0.312 – 1.578 0.392 Bachelor’s Degree -1.535 6.288 0.216 0.065 - 0.715 0.012 Employment status 2.269 0.322 Part-time employed 0.012 0.000 0.988 0.258 – 3.781 0.986 Full-time employed -0.635 1.027 0.530 0.155 – 1.810 0.311 Income Level 7.085 0.131 $0 - $49,020 -0.249 0.274 0.779 0.307 - 1.982 0.601 $49,020 - $98,040 0.570 0.936 1.768 0.557 - 5.606 0.333 $98,040 - $151,978 -0.876 1.775 0.416 0.115 - 1.511 0.183 > $151,978 0.971 1.012 2.640 0.398 - 17.497 0.314 Family/friend diagnosed of COVID 19 11.602 0.003 Family/friend diagnosed of COVID 19 (Yes) 1.302 8.869 3.678 1.561 – 8.667 0.003 Family/friend diagnosed of COVID 19 (No) -1.124 1.151 0.325 0.042 – 2.534 0.283 HIV Viral Load 14.900 0.002 Undetectable 0.513 0.949 1.670 0.595 - 4.685 0.330 <500 copies/ml -1.625 8.045 0.197 0.064 - 0.605 0.005 ≥ 500 copies/ml -0.756 0.962 0.469 0.104 - 2.218 0.327 CD4+ Count 3.262 0.353 <200 cells/mm 0.457 .757 1.580 0. 564 - 4.426 0.330 201 - 500cells/mm 1.027 3.036 2.792 0.880 – 8.858 0.081 >500 cells/mm 0.798 1.009 2.221 0.468 - 10.538 0.315 Total VHS 0.303 5.945 1.354 1.061 - 1.728 0.015 Vaccines are important for my health -0.659 4.479 0.517 0.281 - 0.952 0.034 Vaccines are effective -0.125 0.199 0.882 0.509 - 1.530 0.655 Being vaccinated is important for the health of others in my community. -0.424 1.880 0.654 0.357 - 1.200 0.170 63 All routine vaccinations recommended by Health Canada are beneficial -0.098 0.104 0.906 0.498 - 1.648 0.747 New vaccines carry more risks than older vaccines. 0.055 0.058 1.057 0.676 - 1.652 0.809 The information I receive about vaccines from Health Canada is reliable and trustworthy -0.705 6.976 0.494 0.293 - 0.834 0.008 Generally, I do what my doctor or healthcare provider recommends about vaccines for me -0.580 3.368 0.560 0.302 - 1.040 0.066 I am concerned about serious adverse effects of vaccines -1.053 19.577 0.349 0.219 – 0.556 <0.001 3.5 Discussion This study was designed to determine the prevalence of COVID-19 vaccine uptake among PLHIV in British Columbia, Canada, the level of vaccine hesitancy among PLHIV in British Columbia using the adult vaccine hesitancy scale, and the socio-economic and health (COVID-19 and HIV-related) factors associated with COVID-19 vaccine uptake and vaccine hesitancy. My findings expand our understanding of COVID-19 vaccine uptake and hesitancy among PLHIV and accept my proposed hypothesis that health-related factors and low socio-demographic factors are predictors of vaccine uptake. While the initial vaccine uptake of at least one dose mirrored the general population at 82.2% vs 83.3%, only 37.4% of PLHIV in my study completed the primary vaccine series—significantly lower than the national average (80.6% as of January 2023) (183). This discrepancy is unsurprising given that earlier studies demonstrated significantly lower rates than the general population, stemming from reduced confidence in vaccination and specific concerns unaddressed by provincial interventions in this demographic (184). A recurring theme among PLHIV who refused or only partially received vaccines was a lack of sufficient information and mistrust in Health Canada's guidance. This underscores the importance of tailored communications catering to the unique 64 social and medical circumstances of this population (185,186). Moreover, limited PLHIV were included in the vaccine trials (27), which might have further influenced any scepticism against the results of those trials for PLHIV. Interestingly, older individuals completed the primary series, while younger ones displayed higher vaccine hesitancy scores—a pattern consistent with the immunocompromised (67,68) and the general population (187), owing to the perception of risk by the aged population versus the younger. This emphasises the need for targeted health promotion strategies to engage younger individuals, many of whom perceive COVID-19 to be of lower risk and severity (188,189). Contrary to the prevailing trend in Canada (190), where higher education is linked to increased vaccine acceptance, my study showed a negative association between having a bachelor's degree and vaccine uptake among PLHIV. This unexpected finding may be attributed to a significant proportion of participants holding bachelor's degrees, suggesting that hesitancy cannot solely be attributed to educational attainment or given the fact that my sample size was below the minimal estimated to be significant. While educational level can serve as a valuable indicator of access to reliable health information sources, it is crucial to recognise the profound impact of misinformation and disinformation on pandemic responses globally (29,191). Additionally, inconsistent vaccination policies - vaccine passport and restrictions (176), and the possibility of re-infection with newer variants of SARS-CoV-2 (192), may contribute to scepticism about the necessity of additional doses, as evidenced by the majority of participants expressing doubts about staying up-to-date with vaccinations. Regarding the income level, participants in the lowest earning bracket were seen to have a higher mean vaccine hesitancy score, corroborating other studies, albeit not with PLHIV (193). Still, income level was not a predicting factor of uptake of three doses. Sexual orientation, gender and 65 ethnicity also did not play a role. This may be due to the small number of participants; likewise, while ethnic minorities have been found to be more hesitant, a large proportion of my study population is of European origin. Considering HIV-related factors, only HIV viral load was seen to be related to uptake, where having a viral load of 500 or less decreased the odds of receiving the recommended three doses compared to those with undetectable viral loads. This finding aligns closely with two recent studies carried out in the United States (29,53), where being undetectable along with longer years of diagnosis was seen to promote vaccine uptake, and this may be due to general trust in health interventions or less perception of adverse effects of vaccine exacerbating underlying immunosuppression (194). Perception of vulnerability to the COVID-19 disease is also worth considering, as my study highlighted participants who had family or friends with a history of positive COVID-19 diagnosis had higher likelihood of completing the recommended three doses plus boosters. This may increase awareness of the disease and the natural inclination to prevent being infected (195). Our study revealed that a high vaccine hesitancy score did not hinder receiving the recommended three doses; in fact, there was a notable increase in vaccine uptake with each unit increase in vaccine hesitancy. Regardless, concerns about potential adverse effects and lack of trust in Health Canada's information, combined with doubts about vaccine benefits on health, exert the most substantial influence on vaccine uptake. These concerns outweigh the overall hesitancy score, indicating that individuals with lower scores can still exhibit pronounced hesitancy if they firmly hold these beliefs; hence, health promotion targeting highly hesitant populations should be well-rounded in their considerations, especially in this population. Despite its findings, my study is not without limitations. The survey I developed was not validated following psychometric assessment (196), although it was piloted and modified accordingly. The 66 number of participants below the projected minimal sample size prevents generalisations to British Columbia’s general population of PLHIV and beyond. Nonetheless, the survey was widely shared through the Pacific AIDS Network, offering access to participants across all five health authorities in British Columbia. The data was self-reported, including the HIV-positive status, COVID-19 vaccine acceptance, and number of vaccine doses. And as with any self-reported data, findings are subject to social desirability bias. Additionally, cross-sectional studies inherently preclude the establishment of causality and confines interpretation to a non-temporal context. Furthermore, most of the data collection was electronic, excluding pertinent members of the population who lack access to digital channels. Lastly, it is vital to acknowledge the temporal limitations of my data. The evolving nature of the COVID-19 pandemic means that my findings are specific to the late 2022 and early 2023 periods. Nevertheless, these findings can serve as a valuable reference point for future investigations into emerging trends related to COVID-19 and vaccine acceptance. Albeit the acknowledged limitations, my research provides a thorough examination of COVID-19 vaccine uptake regarding the recommended three doses, vaccination hesitancy, and the associated factors influencing these outcomes. The insights gleaned from my study underscore the need for a more nationally representative investigation across BC and Canada. Such an expanded study should also involve the continual monitoring of primary vaccine series and up-to-date dose uptake over specific timeframes to discern evolving trends and validate predictive factors. Furthermore, I recommend extending the scope of the investigation to encompass additional HIV-related indicators, such as the presence of comorbidities and the duration of HIV diagnosis, in relation to vaccine uptake. 67 3.6 Conclusion Although the minimal sample size was not reached, my findings reinforce the idea of continuously considering specific factors that may have an impact on vaccination rates, including information about adverse effects and the importance of vaccines among PLHIV. The findings of my study have also revealed that vaccination hesitancy and uptake of one vaccine dose are subject to change and do not necessarily predict the uptake of the necessary additional doses in the case of this highly mutagenic SARS-COv2 virus. Hence, aside from socioeconomic factors, perceptions regarding HIV-related factors should be addressed within this demographic. This insight can further guide the development of policies and interventions aimed at promoting additional vaccine doses and encouraging individuals to maintain an up-to-date vaccination status. In the next chapter, I briefly summarise the main conclusions of both Chapters 2 and 3 and include future directions of these my studies. 68 Chapter 4: Conclusions, Limitations and Future Directions 4.1 Conclusion In this study, the scoping review highlighted unique influences on vaccination behaviour among immunocompromised populations beyond traditional factors. These influences arise from concerns about potential adverse vaccine effects exacerbating their medical conditions. Additionally, their reliance on physician recommendations due to limited knowledge about vaccine implications for their health and an increased sense of vulnerability highlights the complexity of their vaccination decisions. Moreover, the cross-sectional study revealed the inadequacy of a one-size-fits-all approach to vaccination policy within the HIV-positive population. It reveals that existing data on vaccination willingness and receipt of a single COVID-19 vaccine dose are subject to change and do not necessarily predict the uptake of essential additional doses, particularly in light of the highly mutable SARS-CoV-2virus. Instead, factors such as HIV viral load and the level of information available to people living with HIV (PLHIV) regarding adverse effects and the significance of vaccines should be considered alongside socioeconomic factors. Consequently, these findings hold significant implications for policy and public health. They necessitate concerted efforts to address concerns surrounding vaccine safety, bridge knowledge gaps, and empower informed vaccination choices, particularly among immunocompromised individuals, including those living with HIV. 4.2 Limitations The scoping review lacked quality assessment of the reviewed articles, as seen in systematic reviews. Additionally, the use of exclusively English search terms, despite my review's inclusivity of non-English studies, may have excluded relevant studies. The review also treated associated 69 factors and expressed concerns equally when noting barriers and facilitators to vaccination. In the cross-sectional study, data regarding HIV status, COVID-19 vaccine acceptance, and dose count relied solely on self-reports without verification, rendering the findings susceptible to social desirability bias. Additionally, the inherent limitations of cross-sectional studies prevent the establishment of causality. The electronic data collection method used may have excluded individuals lacking digital access, and the adoption of convenience sampling limits the generalizability of my results to the entire PLHIV population in British Columbia. Lastly, the dynamic nature of the COVID-19 pandemic confines my findings to the late 2022 and early 2023 timeframe. Nevertheless, these findings can serve as a valuable reference point for future investigations into emerging trends related to COVID-19 vaccine uptake. 4.3 Future Directions Despite acknowledging the limitations, my research provides a comprehensive exploration of vaccine hesitancy and uptake within the immunocompromised population. I specifically focused on residents living with HIV in British Columbia, thoroughly examining COVID-19 vaccine uptake, including the recommended three doses, hesitancy factors, and associated influences. However, there remains a pressing need for a nationally representative investigation spanning all of Canada. Such an expanded study should encompass continuous monitoring of the primary vaccine series and ongoing dose uptake trends to track evolving patterns and validate predictive factors. Additionally, I recommend broadening the scope to include additional HIV-related indicators, such as comorbidities and the duration of HIV diagnosis, in relation to vaccine uptake. 70 References 1. Centers for Disease Control and Prevention (CDC). Ten great public health achievements--worldwide, 2001-2010. MMWR Morb Mortal Wkly Rep. 2011;60(24):814–8. 2. Copenhagen Consensus Center. Copenhagen consensus 2008. In 2008 [cited 2021 Oct 15]. Available from: https://www.copenhagenconsensus.com 3. SAGE Working Group. Dealing with Vaccine Hesitancy. [cited 2021 Oct 11]. Available from: http://www.who.int/immunization/sage/sage vaccine hesitancy apr12/en 4. World Health Organization. [cited 2021 Oct 26]. Available from: https://www.who.int/news-room/spotlight/ten-threats-to-global-health-in-2019 5. Metcalf CJE, Ferrari M, Graham AL, Grenfell BT. Understanding Herd Immunity. Trends Immunol. 2015;36(12):753–5. 6. Randolph HE, Barreiro LB. Herd Immunity: Understanding COVID-19. Immunity. 2020;52(5):737–41. 7. Thomson A, Robinson K, Vallée-Tourangeau G. The 5As: A practical taxonomy for the determinants of vaccine uptake. Vaccine. 2016;34(8):1018–24. 8. Williams WW, Lu PJ, O’Halloran A, Bridges CB, Kim DK, Pilishvili T, et al. Vaccination coverage among adults, excluding influenza vaccination - United States, 2013. MMWR Morb Mortal Wkly Rep. 2015;64(4):95–102. 9. Poland GA, Belmin J, Langley J, Michel J pierre, Van Damme P, Wicker S. A global prescription for adult immunization: Time is catching up with us. Vaccine. 2010;28(44):7137–9. 10. Public Health Agency of Canada. [cited 2021 Oct 26]. Available from: http://www.phac-aspc.gc.ca/im/nics-enva/vcac-cvac-eng.php 11. Coyne MTL, Perio D, von Bergmann H, Laronde D, Brondani MAA. British Columbia Dentists’ Perceptions and Practices Regarding HPV Vaccinations: A Cross-sectional Study. J Can Dent Assoc. 2023;89:n6. 12. Center for Disease Control and Prevention. CDC Website. Adult Immunization Schedule. Available from: https://www.cdc.gov/vaccines/schedules/hcp/imz/adult.html#table-age 13. Centers for Disease Control and Prevention. cdc.gov. [cited 2022 Jan 16]. Vaccine Recommendations and Guidelines of the ACIP. Available from: https://www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/covid-19.html 14. Doornekamp L, van Leeuwen L, van Gorp E, Voeten H, Goeijenbier M. Determinants of Vaccination Uptake in Risk Populations: A Comprehensive Literature Review. Vaccines. 2020;8(3):480. 71 15. Larsen L, Bistrup C, Sørensen SS, Boesby L, Nguyen MTT, Johansen IS. The coverage of influenza and pneumococcal vaccination among kidney transplant recipients and waiting list patients: A cross-sectional survey in Denmark. Transpl Infect Dis. 2021;23(3):e13537. 16. Chin-Yee BH, Monkman K, Hussain Z, Minuk LA. Attitudes toward vaccination for pandemic H1N1 and seasonal influenza in patients with hematologic malignancies. J Support Oncol. 2011;9(4):156–60. 17. World Health Organization. WHO Coronavirus (COVID-19) Dashboard [Internet]. [cited 2022 Apr 19]. Available from: https://covid19.who.int/table 18. Pak A, Adegboye OA, Adekunle AI, Rahman KM, McBryde ES, Eisen DP. Economic Consequences of the COVID-19 Outbreak: the Need for Epidemic Preparedness. Front Public Health [Internet]. 2020 [cited 2023 Sep 26];8. Available from: https://www.frontiersin.org/articles/10.3389/fpubh.2020.00241 19. Brondani M, Almeida F, von Bergmann HC, Mathu-Muju K, Maragha T, Cua D, Donnelly L. Uncertainties around COVID-19 and oral health care from the perspective of oral health care providers and administrators. PlosOne 2021;16(4):e0249186. 20. World Health Organization. WHO Director-General’s opening remarks at the media briefing on COVID-19. 2020 Mar 11. World Health Organ Httpswww Who Intdgspeechesdetailwho-Dir-Gen--Open-Remarks-Atthe-Media-Brief--Covid-19---11-March-2020. 2020. 21. Brondani M, Cua D, Maragha T, Shayanfar M, Mathu-Muju K, von Bergmann H, et al. A Pan-Canadian narrative review on the protocols for reopening dental services during the COVID-19 pandemic. BMC Oral Health. 2020;20(1):352. 22. Unruh L, Allin S, Marchildon G, Burke S, Barry S, Siersbaek R, et al. A comparison of 2020 health policy responses to the COVID-19 pandemic in Canada, Ireland, the United Kingdom and the United States of America. Lessons Learn COVID-19 Pandemic. 2022;126(5):427–37. 23. COVID-19 and HIV | HIV Basics | HIV/AIDS | CDC [Internet]. 2022 [cited 2022 Apr 10]. Available from: https://www.cdc.gov/hiv/basics/covid-19.html 24. Brondani M, Donnelly L. The HIV and SARS-CoV-2 parallel in dentistry from the perspectives of the oral health care team. J Dental Res – Clin Translational Res 2021; 6(1):40-46. 25. Brown LB, Spinelli MA, Gandhi M. The interplay between HIV and COVID-19: summary of the data and responses to date. Curr Opin HIV AIDS. 2021;16(1):63–73. 26. Collins LF. Persons with human immunodeficiency virus and the coronavirus disease 2019 pandemic: a viral synergy of biology and sociology. Clin Infect Dis. 2021;73(7):e2106–8. 72 27. aidsmap.com [Internet]. 2023 [cited 2023 Sep 19]. COVID-19 vaccines in people with HIV. Available from: https://www.aidsmap.com/about-hiv/covid-19-vaccines-people-hiv 28. Canada PHA of. Archive 22: Recommendations on the use of COVID-19 vaccines [2021-10-22] [Internet]. 2020 [cited 2022 Apr 10]. Available from: https://www.canada.ca/en/public-health/services/immunization/national-advisory-committee-on-immunization-naci/recommendations-use-covid-19-vaccines.html 29. Jaiswal J, LoSchiavo C, Perlman DC. Disinformation, Misinformation and Inequality-Driven Mistrust in the Time of COVID-19: Lessons Unlearned from AIDS Denialism. AIDS Behav. 2020;24(10):2776–80. 30. Tsachouridou O, Georgiou A, Naoum S, Vasdeki D, Papagianni M, Kotoreni G, et al. Factors associated with poor adherence to vaccination against hepatitis viruses, streptococcus pneumoniae and seasonal influenza in HIV-infected adults. Hum Vaccines Immunother. 2018/11/02 ed. 2019;15(2):295–304. 31. Johnson TM, Klepser DG, Bares SH, Scarsi KK. Predictors of vaccination rates in people living with HIV followed at a specialty care clinic. Hum Vaccines Immunother. 2021;17(3):791–6. 32. Huang X, Yu M, Fu G, Lan G, Li L, Yang J, et al. Willingness to Receive COVID-19 Vaccination Among People Living With HIV and AIDS in China: Nationwide Cross-sectional Online Survey. JMIR Public Health Surveill. 2021;7(10):e31125. 33. Wu S, Ming F, Xing Z, Zhang Z, Zhu S, Guo W, et al. COVID-19 Vaccination Willingness Among People Living With HIV in Wuhan, China. Front Public Health [Internet]. 2022 [cited 2023 Aug 14];10. Available from: https://www.frontiersin.org/articles/10.3389/fpubh.2022.883453 34. Opel DJ, Taylor JA, Mangione-Smith R, Solomon C, Zhao C, Catz S, et al. Validity and reliability of a survey to identify vaccine-hesitant parents. Vaccine. 2011;29(38):6598–605. 35. Benin AL, Wisler-Scher DJ, Colson E, Shapiro ED, Holmboe ES. Qualitative Analysis of Mothers’ Decision-Making About Vaccines for Infants: The Importance of Trust. Pediatrics. 2006;117(5):1532–41. 36. MacDonald NE. Vaccine hesitancy: Definition, scope and determinants. WHO Recomm Vaccine Hesitancy. 2015;33(34):4161–4. 37. Larson HJ, Jarrett C, Eckersberger E, Smith DMD, Paterson P. Understanding vaccine hesitancy around vaccines and vaccination from a global perspective: A systematic review of published literature, 2007–2012. Vaccine. 2014;32(19):2150–9. 38. Gowda C, Dempsey AF. The rise (and fall?) of parental vaccine hesitancy. Hum Vaccines Immunother. 2013;9(8):1755–62. 73 39. British Society for Immunology. Immunodeficiency [Internet]. 2017. Available from: https://www.immunology.org/policy-and-public-affairs/briefings-and-position-statements/immunodeficiency 40. Dropulic LK, Lederman HM. Overview of Infections in the Immunocompromised Host. Microbiol Spectr. 2016 Aug;4(4):10.1128/microbiolspec.DMIH2-0026–2016. 41. Siberry GK, Abzug MJ, Nachman S, on behalf of the Panel on Guidelines for Prevention and Treatment of Opportunistic Infections in HIV-Exposed and HIV-Infected Children—a working group of the Office of AIDS Research (OAR) Advisory Council*. Executive Summary: Guidelines for the Prevention and Treatment of Opportunistic Infections in HIV-Exposed and HIV-Infected Children: Recommendations From the National Institutes of Health, the Centers for Disease Control and Prevention, the HIV Medicine Association of the Infectious Diseases Society of America, the Pediatric Infectious Diseases Society, and the American Academy of Pediatrics. J Pediatr Infect Dis Soc. 2013;2(4):293–308. 42. Rubin LG, Levin MJ, Ljungman P, Davies EG, Avery R, Tomblyn M, et al. Executive Summary: 2013 IDSA Clinical Practice Guideline for Vaccination of the Immunocompromised Host. Clin Infect Dis. 2014;58(3):309–18. 43. Restivo V, Vizzini G, Mularoni A, Di Benedetto C, Gioè SM, Vitale F. Determinants of influenza vaccination among solid organ transplant recipients attending Sicilian reference center. Hum Vaccines Immunother. 2017;13(2):346–50. 44. Sobh A, Bonilla FA. Vaccination in Primary Immunodeficiency Disorders. J Allergy Clin Immunol Pract. 2016;4(6):1066–75. 45. Elias M, Pievani D, Randoux C, Louis K, Denis B, Delion A, et al. COVID-19 Infection in Kidney Transplant Recipients: Disease Incidence and Clinical Outcomes. J Am Soc Nephrol. 2020;31(10):2413. 46. Martínez-Urbistondo M, Gutiérrez-Rojas Á, Andrés A, Gutiérrez I, Escudero G, García S, et al. Severe Lymphopenia as a Predictor of COVID-19 Mortality in Immunosuppressed Patients. J Clin Med. 2021;10(16):3595. 47. Peters MDJ, Godfrey C, McInerney P, Munn Z, Tricco AC, Khalil, H. Chapter 11: Scoping Reviews (2020 version). JBI Manual for Evidence Synthesis, JBI, [Internet]. Available from: https://synthesismanual.jbi.global. 48. World Health Organization. who.int. Mandatory vaccination does not always overrule the need for consent. Available from: https://www.who.int/immunization/programmes_systems/policies_strategies/consent_note_en.pdf 49. Interim Results: State-Specific Influenza Vaccination Coverage --- United States, August 2010--February 2011 [Internet]. [cited 2023 Aug 23]. Available from: https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6022a3.htm 74 50. Crocker-Buque T, Edelstein M, Mounier-Jack S. Interventions to reduce inequalities in vaccine uptake in children and adolescents aged <19 years: a systematic review. J Epidemiol Community Health. 2016/08/17 ed. 2017;71(1):87–97. 51. Haddaway NR, Collins AM, Coughlin D, Kirk S. The Role of Google Scholar in Evidence Reviews and Its Applicability to Grey Literature Searching. PLOS ONE. 2015;10(9):e0138237. 52. Clarke K, Pelton M, Stuart A, Tinsley A, Dalessio S, Bernasko N, et al. COVID-19 Vaccine Hesitancy in Patients with Inflammatory Bowel Disease. Dig Dis Sci. 2022;67(10):4671–7. 53. Durham MD, Buchacz K, Armon C, Patel P, Wood K, Brooks JT. Rates and correlates of influenza vaccination among HIV-infected adults in the HIV Outpatient Study (HOPS), USA, 1999–2008. Prev Med. 2011;53(1):89–94. 54. Ehde DM, Roberts MK, Humbert AT, Herring TE, Alschuler KN. COVID-19 vaccine hesitancy in adults with multiple sclerosis in the United States: A follow up survey during the initial vaccine rollout in 2021. Mult Scler Relat Disord. 2021;54:103163. 55. Jaiswal J, Krause KD, Martino RJ, D’Avanzo PA, Griffin M, Stults CB, et al. SARS-CoV-2 Vaccination Hesitancy and Behaviors in a National Sample of People Living with HIV. AIDS Patient Care STDs. 2022;36(1):34–44. 56. Lawson EF, Trupin L, Yelin EH, Yazdany J. Reasons for failure to receive pneumococcal and influenza vaccinations among immunosuppressed patients with systemic lupus erythematosus. Semin Arthritis Rheum. 2015;44(6):666–71. 57. Pham HV, Hasan I, Udaltsova N, Pham K, Abramson O, Armstrong MA, et al. Rates and Predictors of Vaccinations Among Inflammatory Bowel Disease Patients Receiving Anti-Tumor Necrosis Factor Agents. Dig Dis Sci. 2018;63(1):209–17. 58. Sandler DS, Ruderman EM, Brown T, Lee JY, Mixon A, Liss DT, et al. Understanding Vaccination Rates and Attitudes Among Patients With Rheumatoid Arthritis. Am J Manag CARE. 2016;22(3). 59. Serper M, Liu CH, Blumberg EA, Burdzy AE, Veasey S, Halpern S, et al. A pragmatic outreach pilot to understand and overcome barriers to COVID-19 vaccination in abdominal organ transplant. Transpl Infect Dis. 2021;23(5):e13722. 60. Chen T, Li X, Li Q, Huang L, Cai Q, Wang Y, et al. COVID-19 vaccination hesitancy and associated factors among solid organ transplant recipients in China. Hum Vaccines Immunother. 2021;17(12):4999–5006. 61. Hong J, Xu X wan, Yang J, Zheng J, Dai S mei, Zhou J, et al. Knowledge about, attitude and acceptance towards, and predictors of intention to receive the COVID-19 vaccine among cancer patients in Eastern China: A cross-sectional survey. J Integr Med. 2022;20(1):34–44. 75 62. Qi L, Yang L, Ge J, Yu L, Li X. COVID-19 Vaccination Behavior of People Living with HIV: The Mediating Role of Perceived Risk and Vaccination Intention. Vaccines. 2021;9(11). 63. Brocq O, Acquacalda E, Berthier F, Albert C, Bolla G, Millasseau E, et al. Influenza and pneumococcal vaccine coverage in 584 patients taking biological therapy for chronic inflammatory joint: A retrospective study. Joint Bone Spine. 2016;83(2):155–9. 64. Loubet P, Kernéis S, Groh M, Loulergue P, Blanche P, Verger P, et al. Attitude, knowledge and factors associated with influenza and pneumococcal vaccine uptake in a large cohort of patients with secondary immune deficiency. Vaccine. 2015;33(31):3703–8. 65. Monier A, Puyade M, Hernanz MPG, Bouchaert P, Leleu X, Tourani JM, et al. Observational study of vaccination in cancer patients: How can vaccine coverage be improved? Médecine Mal Infect. 2020;50(3):263–8. 66. Heyne S, Esser P, Werner A, Lehmann-Laue A, Mehnert-Theuerkauf A. Attitudes toward a COVID-19 vaccine and vaccination status in cancer patients: a cross-sectional survey. J Cancer Res Clin Oncol. 2022;148(6):1363–74. 67. Roman I, Andreica I, Baraliakos X, Redeker I, Kiltz U, Braun J. SARS-CoV-2 vaccination willingness and predictors in patients with chronic inflammatory rheumatic diseases (CIRD) and without CIRD. Ther Adv Musculoskelet Dis. 2022 Jan 1;14:1759720X221093760. 68. Bain N, Nguyen M, Grech L, Day D, McCartney A, Webber K, et al. COVID-19 Vaccine Hesitancy in Australian Patients with Solid Organ Cancers. Vaccines. 2022;10(9). 69. Tharmaraj D, Dendle C, Polkinghorne KR, Mulley WR. Kidney transplant recipients’ attitudes toward COVID‐19 vaccination and barriers and enablers to vaccine acceptance. Transpl Infect Dis. 2022;24(1):e13749. 70. Aberumand B, Ayoub Goulstone W, Betschel S. Understanding attitudes and obstacles to vaccination against COVID-19 in patients with primary immunodeficiency. Allergy Asthma Clin Immunol. 2022;18(1):38. 71. Mohamed R, White TM, Lazarus JV, Salem A, Kaki R, Marrakchi W, et al. COVID-19 vaccine acceptance and associated factors among people living with HIV in the Middle East and North Africa region. South Afr J HIV Med. 2022;23(1):1391. 72. Felten R, Dubois M, Ugarte-Gil MF, Chaudier A, Kawka L, Bergier H, et al. Cluster analysis reveals three main patterns of beliefs and intention with respect to SARS-CoV-2 vaccination in patients with autoimmune and inflammatory diseases. Rheumatology. 2021;60(SI):SI68–76. 73. Hmamouchi I, Winthrop K, Launay O, Dougados M. Low rate of influenza and pneumococcal vaccine coverage in rheumatoid arthritis: Data from the international COMORA cohort. Vaccine. 2015;33(12):1446–52. 76 74. Tsai R, Hervey J, Hoffman K, Wood J, Johnson J, Deighton D, et al. COVID-19 Vaccine Hesitancy and Acceptance Among Individuals With Cancer, Autoimmune Diseases, or Other Serious Comorbid Conditions: Cross-sectional, Internet-Based Survey. JMIR Public Health Surveill. 2022;8(1):e29872. 75. Uhr L, Mateen FJ. COVID-19 vaccine hesitancy in multiple sclerosis: A cross-sectional survey. Mult Scler J. 2022;28(7):1072–80. 76. Abbasi N, Ghadiri F, Moghadasi AN, Azimi A, Navardi S, Heidari H, et al. COVID-19 vaccine hesitancy in Iranian patients with multiple sclerosis. Mult Scler Relat Disord. 2022;60:103723. 77. Boltin D, Gingold-Belfer R, Kimchi NA, Ben-Bassat O, Niv Y, Birkenfeld S. Utilization of Influenza Immunization in Adults with Crohn’s Disease—A Longitudinal, Population-Based Study. Inflamm Bowel Dis. 2014;20(2):240–5. 78. Chiganer EH, Ochi BC, Lessa CF. Influenza and pneumococcal vaccination coverage in Latin American patients with systemic lupus erythematosus: a cross-sectional and comparative study. Adv Rheumatol. 2021;61(1):46. 79. Chong HJ, Kim HK, Lee MH, Lee S. Influenza vaccine acceptance and health beliefs among Korean kidney transplant patients. Psychol Health Med. 2018;23(9):1113–24. 80. Constantinou CA, Ziogas DC, Venetsanopoulou A, Gamaletsou MN, Koutsogeorgopoulou L, Barbouni A, et al. A clinical audit of pneumococcal vaccination among patients with autoimmune rheumatic diseases living in Greece: The power of awareness. Vaccine. 2021;39(11):1593–7. 81. Day D, Grech L, Nguyen M, Bain N, Kwok A, Harris S, et al. Serious Underlying Medical Conditions and COVID-19 Vaccine Hesitancy: A Large Cross-Sectional Analysis from Australia. Vaccines. 2022;10(6):851. 82. Eder M, Omic H, Gorges J, Badt F, Kikic Z, Saemann MD, et al. Influenza vaccination uptake and factors influencing vaccination decision among patients with chronic kidney or liver disease. PLOS ONE. 2021;16(4):e0249785. 83. Figueroa-Parra G, Esquivel-Valerio JA, Santoyo-Fexas L, Moreno-Salinas A, Gamboa-Alonso CM, De Leon-Ibarra AL, et al. Knowledge and attitudes about influenza vaccination in rheumatic diseases patients. Hum Vaccines Immunother. 2021;17(5):1420–5. 84. Haroon M, Adeeb F, Eltahir A, Harney S. The uptake of influenza and pneumococcal vaccination among immunocompromised patients attending rheumatology outpatient clinics. Joint Bone Spine. 2011;78(4):374–7. 85. Harrison N, Poeppl W, Herkner H, Tillhof K, Grabmeier-Pfistershammer K, Rieger A, et al. Predictors for and coverage of influenza vaccination among HIV-positive patients: a cross-sectional survey. HIV Med. 2017;18(7):500–6. 77 86. Kosaka M, Kotera Y, Tsuda K, Takahashi K, Hamaki T, Kusumi E, et al. Influenza vaccination uptake and attitudes among adult cancer patients in Japan: a web-based questionnaire survey before the 2020/2021 season. Hum Vaccines Immunother. 2021;17(12):5509–13. 87. Kourkounti S, Paparizos V, Leuow K, Paparizou E, Antoniou C. Adherence to hepatitis A virus vaccination in HIV-infected men who have sex with men. Int J STD AIDS. 2015;26(12):852–6. 88. Kumar R, Manuel S, Elizabeth D, Shobha V. COVID-19 vaccine hesitancy: A telephonic survey in patients with systemic lupus erythematosusxs. Indian J Rheumatol. 2022;S406–13. 89. Larsen L, Nguyen MTT, Johansen IS. The coverage of influenza and pneumococcal vaccinations among people living with HIV in Denmark: A single-center cross-sectional survey. Hum Vaccines Immunother. 2021;17(8):2700–5. 90. Lejri-El Euchi H, Chirpaz E, Foucher A, Sultan-Bichat N, Randrianjohany A, Poubeau P, et al. Vaccination against influenza and pneumococcal infections in patients with autoimmune disorders under biological therapy: Coverage and attitudes in patients and physicians. Eur J Intern Med. 2019;69:25–31. 91. Loubet P, Verger P, Abitbol V, Peyrin-Biroulet L, Launay O. Pneumococcal and influenza vaccine uptake in adults with inflammatory bowel disease in France: Results from a web-based study. Dig Liver Dis. 2018;50(6):563–7. 92. Nguyen M, Bain N, Grech L, Choi T, Harris S, Chau H, et al. COVID-19 vaccination rates, intent, and hesitancy in patients with solid organ and blood cancers: A multicenter study. Asia Pac J Clin Oncol. 2022;18(6):570–7. 93. Roupa Z, Noula M, Nikitara M, Ghobrial S, Latzourakis E, Polychronis G. Acceptance of coronavirus disease 2019 vaccination by cancer patients in Cyprus: A cross-sectional study. J Oncol Pharm Pract. 2022;28(8):1696–703. 94. Sadlier M, Sadlier C, Alani A, Ahmad K, Bergin C, Ramsay B. Poor adherence to vaccination guidelines in dermatology patients on immunosuppressive therapies: an issue that needs addressing. Br J Dermatol. 2015;173(1):288–9. 95. Vinograd I, Baslo R, Eliakim-Raz N, Farbman L, Taha A, Sakhnini A, et al. Factors associated with influenza vaccination among adult cancer patients: a case–control study. Clin Microbiol Infect. 2014;20(9):899–905. 96. Wasan SK, Calderwood AH, Long MD, Kappelman MD, Sandler RS, Farraye FA. Immunization Rates and Vaccine Beliefs Among Patients with Inflammatory Bowel Disease: An Opportunity for Improvement. Inflamm Bowel Dis. 2014;20(2):246–50. 97. Yang J, Yu M, Fu G, Lan G, Li L, Qiao Y, et al. COVID-19 Vaccination Uptake Among a Nationwide Sample of People Living With HIV During the Early Phase of Vaccine Rollout 78 in China. Front Med [Internet]. 2022 [cited 2023 Aug 12];9. Available from: https://www.frontiersin.org/articles/10.3389/fmed.2022.822680 98. Yap SM, Al Hinai M, Gaughan M, Callanan I, Kearney H, Tubridy N, et al. Vaccine hesitancy among people with multiple sclerosis. Mult Scler Relat Disord. 2021 Nov 1;56:103236. 99. Zheng W, Sun Y, Li H, Zhao H, Zhan Y, Gao Y, et al. COVID-19 vaccine uptake and hesitancy among HIV-infected men who have sex with men in mainland China: a cross-sectional survey. Hum Vaccines Immunother. 2021;17(12):4971–81. 100. Mejri N, Berrazega Y, Ouertani E, Rachdi H, Bohli M, Kochbati L, et al. Understanding COVID-19 vaccine hesitancy and resistance: another challenge in cancer patients. Support Care Cancer. 2022;30(1):289–93. 101. Shrestha R, Meyer JP, Shenoi S, Khati A, Altice FL, Mistler C, et al. COVID-19 Vaccine Hesitancy and Associated Factors among People with HIV in the United States: Findings from a National Survey. Vaccines. 2022;10(3):424. 102. Vallée A, Fourn E, Majerholc C, Touche P, Zucman D. COVID-19 Vaccine Hesitancy among French People Living with HIV. Vaccines. 2021;9(4). 103. Villarreal-Garza C, Vaca-Cartagena BF, Becerril-Gaitan A, Ferrigno AS, Mesa-Chavez F, Platas A, et al. Attitudes and Factors Associated With COVID-19 Vaccine Hesitancy Among Patients With Breast Cancer. JAMA Oncol. 2021;7(8):1242–4. 104. Brodziak A, Sigorski D, Osmola M, Wilk M, Gawlik-Urban A, Kiszka J, et al. Attitudes of Patients with Cancer towards Vaccinations—Results of Online Survey with Special Focus on the Vaccination against COVID-19. Vaccines. 2021;9(5). 105. Ehde DM, Roberts MK, Herring TE, Alschuler KN. Willingness to obtain COVID-19 vaccination in adults with multiple sclerosis in the United States. Mult Scler Relat Disord. 2021;49:102788. 106. Erdem D, Karaman I. Impact of corona-phobia on attitudes and acceptance towards COVID-19 vaccine among cancer patients: a single-center study. Future Oncol. 2022;18(4):457–69. 107. Govere-Hwenje S, Jarolimova J, Yan J, Khumalo A, Zondi G, Ngcobo M, et al. Willingness to accept COVID-19 vaccination among people living with HIV in a high HIV prevalence community. BMC Public Health. 2022;22(1):1239. 108. Krzystanek E, Jurczak A, Kocur K, Jurkiewicz J, Kaczmarczyk A. Awareness of COVID-19 Symptoms, Risk Factors, and Vaccinations in Patients with Multiple Sclerosis. Int J Environ Res Public Health. 2022;19(6). 79 109. Moujaess E, Zeid NB, Samaha R, Sawan J, Kourie H, Labaki C, et al. Perceptions of the COVID-19 vaccine among patients with cancer: a single-institution survey. Future Oncol. 2021;17(31):4071–9. 110. Nabavi SM, Mehrabani M, Ghalichi L, Nahayati MA, Ghaffari M, Ashtari F, et al. COVID-19 Vaccination Willingness and Acceptability in Multiple Sclerosis Patients: A Cross Sectional Study in Iran. Vaccines. 2022;10(1). 111. Ortiz-Martínez Y, López-López MÁ, Ruiz-González CE, Turbay-Caballero V, Sacoto DH, Caldera-Caballero M, et al. Willingness to receive COVID-19 vaccination in people living with HIV/AIDS from Latin America. Int J STD AIDS. 2022;33(7):652–9. 112. Su J, Jia Z, Wang X, Qin F, Chen R, Wu Y, et al. Acceptance of COVID-19 vaccination and influencing factors among people living with HIV in Guangxi, China: a cross-sectional survey. BMC Infect Dis. 2022;22(1):471. 113. Valerio V, Hudson M, Wang M, Bernatsky S, Hazel EM, Ward B, et al. Influenza Vaccine Hesitancy and Its Determinants Among Rheumatology Patients. ACR Open Rheumatol. 2022;4(4):352–62. 114. Wu J, Scarabel F, McCarthy Z, Xiao Y, Ogden NH. A window of opportunity for intensifying testing and tracing efforts to prevent new COVID-19 outbreaks due to more transmissible variants. Can Commun Dis Rep. 2021;47(7/8). 115. Mesfin Y, Argaw M, Geze S, Tefera BT. Factors Associated with Intention to Receive COVID-19 Vaccine Among HIV Positive Patients Attending ART Clinic in Southwest Ethiopia. Patient Prefer Adherence. 2021 Dec;Volume 15:2731–8. 116. Chun JY, Kim SI, Park EY, Park SY, Koh SJ, Cha Y, et al. Cancer Patients’ Willingness to Take COVID-19 Vaccination: A Nationwide Multicenter Survey in Korea. Cancers. 2021;13(15). 117. de Sousa MJ, Caramujo C, Júlio N, Magalhães JC, Basto R, Fraga T, et al. Acceptance of SARS-CoV-2 vaccination among cancer patients in Portugal: attitudes and associated factors. Support Care Cancer. 2022;30(5):4565–70. 118. Marijanović I, Kraljević M, Buhovac T, Sokolović E. Acceptance of COVID-19 Vaccination and Its Associated Factors Among Cancer Patients Attending the Oncology Clinic of University Clinical Hospital Mostar, Bosnia and Herzegovina: A Cross-Sectional Study. Med Sci Monit [Internet]. 2021 Nov 13 [cited 2023 Sep 2];27. Available from: https://medscimonit.com/abstract/full/idArt/932788 119. Cotte L, Voirin N, Richard C, Brochier C, Schlienger I, Lack P, et al. Factors associated with pandemic influenza A/H1N1 vaccine coverage in a French cohort of HIV-infected patients. Vaccine. 2011;29(34):5638–44. 120. Drewes J, Langer PC, Ebert J, Kleiber D, Gusy B. Sociodemographic, HIV-Related Characteristics, and Health Care Factors as Predictors of Self-Reported Vaccination 80 Coverage in a Nationwide Sample of People Aging with HIV in Germany. Int J Environ Res Public Health. 2021;18(9). 121. Murdaca G, Noberasco G, Battaglini A, Vassallo C, Giusti F, Greco M, et al. Systemic Sclerosis and Vaccinations: A Register-Based Cohort Study about Seasonal Influenza and Streptococcus pneumoniae Vaccination Rate and Uptake from Liguria Regional Center, Northwest Italy. Vaccines. 2020;8(2). 122. Qendro T, Torre ML de la, Panopalis P, Hazel E, Ward BJ, Colmegna I, et al. Suboptimal Immunization Coverage among Canadian Rheumatology Patients in Routine Clinical Care. J Rheumatol. 2020;47(5):770–8. 123. Teich N, Klugmann T, Tiedemann A, Holler B, Mössner J, Liebetrau A, et al. Vaccination Coverage in Immunosuppressed Patients. Dtsch Ärztebl Int. 2011;108(7):105–11. 124. Kourkounti S, Paparizos V, Leuow K, Paparizou E, Antoniou C. Adherence to hepatitis A virus vaccination in HIV-infected men who have sex with men. Int J STD AIDS. 2015;26(12):852–6. 125. Feldman AG, Hsu EK, Mack CL. The Importance of Prioritizing Pre and Post Transplant Immunizations in An Era of Vaccine Refusal and Epidemic Outbreaks. Transplantation. 2020;104(1):33–8. 126. Adams J, Hillier-Brown FC, Moore HJ, Lake AA, Araujo-Soares V, White M, et al. Searching and synthesising ‘grey literature’ and ‘grey information’ in public health: critical reflections on three case studies. Syst Rev. 2016;5(1):164. 127. Flanagan KL, Fink AL, Plebanski M, Klein SL. Sex and gender differences in the outcomes of vaccination over the life course. Annu Rev Cell Dev Biol. 2017;33:577–99. 128. Azucar D, Slay L, Valerio DG, Kipke MD. Barriers to COVID-19 Vaccine Uptake in the LGBTQIA Community. Am J Public Health. 2022;112(3):405–7. 129. Balaji JN, Prakash S, Joshi A, Surapaneni KM. A Scoping Review on COVID-19 Vaccine Hesitancy among the Lesbian, Gay, Bisexual, Transgender, Queer, Intersex and Asexual (LGBTQIA+) Community and Factors Fostering Its Refusal. Healthcare. 2023;11(2):245. 130. Canada PHA of. Measles vaccines: Canadian immunization guide [Internet]. 2007 [cited 2023 Sep 10]. Available from: https://www.canada.ca/en/public-health/services/publications/healthy-living/canadian-immunization-guide-part-4-active-vaccines/page-12-measles-vaccine.html 131. Reich J, Wasan S, Farraye FA. Vaccinating Patients With Inflammatory Bowel Disease. Gastroenterol Hepatol. 2016;12(9):540–6. 132. Organization WH. HIV/AIDS: the global epidemic. Wkly Epidemiol Rec Relevé Épidémiologique Hebd. 1997;72(04):17–21. 81 133. HIV.gov [Internet]. 2016 [cited 2022 Apr 5]. A Timeline of HIV and AIDS. Available from: https://www.hiv.gov/hiv-basics/overview/history/hiv-and-aids-timeline 134. European Centre for Disease Prevention and Control [Internet]. [cited 2022 Apr 6]. Facts about HIV/AIDS. Available from: https://www.ecdc.europa.eu/en/all-topics-zhiv-infection-and-aids/facts-about-hivaids 135. Human Immunodeficiency Virus (HIV) | British Society for Immunology [Internet]. [cited 2022 Apr 7]. Available from: https://www.immunology.org/public-information/bitesized-immunology/pathogens-and-disease/human-immunodeficiency-virus-hiv 136. Dalgleish AG, Beverley PCL, Clapham PR, Crawford DH, Greaves MF, Weiss RA. The CD4 (T4) antigen is an essential component of the receptor for the AIDS retrovirus. Nature. 1984;312(5996):763–7. 137. Nwankwo N, Seker H. HIV progression to AIDS: bioinformatics approach to determining the mechanism of action. Curr HIV Res. 2013;11(1):30–42. 138. Pantaleo G, Graziosi C, Fauci A. New concepts in the immunopathogenesis of human immunodeficiency. N Engl J Med. 1993;328:327–35. 139. Samji H, Cescon A, Hogg RS, Modur SP, Althoff KN, Buchacz K, et al. Closing the gap: increases in life expectancy among treated HIV-positive individuals in the United States and Canada. PloS One. 2013;8(12):e81355. 140. Lohse N, Obel N. Update of survival for persons with HIV infection in Denmark. Ann Intern Med. 2016;165(10):749–50. 141. Johnson LF, Mossong J, Dorrington RE, Schomaker M, Hoffmann CJ, Keiser O, et al. Life expectancies of South African adults starting antiretroviral treatment: collaborative analysis of cohort studies. PLoS Med. 2013;10(4):e1001418. 142. Global HIV & AIDS statistics — Fact sheet [Internet]. [cited 2022 Apr 7]. Available from: https://www.unaids.org/en/resources/fact-sheet 143. CATIE - Canada’s source for HIV and hepatitis C information [Internet]. 2021 [cited 2022 Apr 13]. The Epidemiology of HIV in Canada. Available from: https://www.catie.ca/the-epidemiology-of-hiv-in-canada 144. HIV incidence and prevalence estimates for British Columbia and Canada in 2018 | SmartSexResource [Internet]. [cited 2022 Apr 10]. Available from: https://smartsexresource.com/health-providers/blog/202111/hiv-incidence-and-prevalence-estimates-british-columbia-and-canada-2018 145. BC CDC. BC Centre for Disease Control. Available from: http://www.bccdc.ca/health-professionals/clinical-resources/communicable-disease-control-manual/immunization/immunization-of-special-populations 82 146. Coronavirus Second Wave, Third Wave and Beyond: What Causes a COVID Surge [Internet]. 2022 [cited 2022 Jun 8]. Available from: https://www.hopkinsmedicine.org/health/conditions-and-diseases/coronavirus/first-and-second-waves-of-coronavirus 147. Chung HW, Apio C, Goo T, Heo G, Han K, Kim T, et al. Effects of government policies on the spread of COVID-19 worldwide. Sci Rep. 2021;11(1):20495. 148. Canada PHA of. aem. 2020 [cited 2022 Jun 8]. COVID-19 daily epidemiology update. Available from: https://health-infobase.canada.ca/covid-19/epidemiological-summary-covid-19-cases.html#a4 149. COVID’s “fifth wave” exceeds all previous waves combined. The Toronto Star [Internet]. 2022 Feb 24 [cited 2022 Jun 8]; Available from: https://www.thestar.com/news/canada/2022/02/24/covids-fifth-wave-exceeds-all-previous-waves-combined.html 150. GOV.UK [Internet]. [cited 2023 Sep 19]. SARS-CoV-2 genome sequence prevalence and growth rate update: 2 August 2023. Available from: https://www.gov.uk/government/publications/sars-cov-2-genome-sequence-prevalence-and-growth-rate/sars-cov-2-genome-sequence-prevalence-and-growth-rate-update-2-august-2023 151. Centers for Disease Control and Prevention. Centers for Disease Control and Prevention. Risk for COVID-19 Infection, Hospitalization, and Death by Race/ Ethnicity. Available from: https://stacks.cdc.gov/view/cdc/105453 152. Sundaram ME, Calzavara A, Mishra S, Kustra R, Chan AK, Hamilton MA, et al. Individual and social determinants of SARS-CoV-2 testing and positivity in Ontario, Canada: a population-wide study. Cmaj. 2021;193(20):E723–34. 153. Morgan R, Baker P, Griffith DM, Klein SL, Logie CH, Mwiine AA, et al. Beyond a zero-sum game: how does the impact of COVID-19 vary by gender? Front Sociol. 2021;126. 154. https://connect.uclahealth.org/ [Internet]. [cited 2022 Jun 8]. The fastest vaccine in history. Available from: https://connect.uclahealth.org/2020/12/10/the-fastest-vaccine-in-history/ 155. Canada H. COVID-19 treatments [Internet]. 2020 [cited 2022 Jun 8]. Available from: https://www.canada.ca/en/health-canada/services/drugs-health-products/covid19-industry/drugs-vaccines-treatments/treatments.html 156. Vaccines – COVID19 Vaccine Tracker [Internet]. [cited 2022 Jun 8]. Available from: https://covid19.trackvaccines.org/vaccines/approved/ 157. COVID-19 vaccine tracker and landscape [Internet]. [cited 2022 Jun 8]. Available from: https://www.who.int/publications/m/item/draft-landscape-of-covid-19-candidate-vaccines 83 158. Canada PHA of. Vaccines for COVID-19 [Internet]. 2020 [cited 2022 Jun 8]. Available from: https://www.canada.ca/en/public-health/services/diseases/coronavirus-disease-covid-19/vaccines.html 159. Ismail SJ, Zhao L, Tunis MC, Deeks SL, Quach C. Key populations for early COVID-19 immunization: preliminary guidance for policy. CMAJ. 2020;192(48):E1620–32. 160. canadas-covid-19-immunization-plan-en.pdf [Internet]. [cited 2022 Apr 12]. Available from: https://www.canada.ca/content/dam/phac-aspc/documents/services/diseases/2019-novel-coronavirus-infection/canadas-reponse/canadas-covid-19-immunization-plan-en.pdf 161. Bhaskaran K, Rentsch CT, MacKenna B, Schultze A, Mehrkar A, Bates CJ, et al. HIV infection and COVID-19 death: a population-based cohort analysis of UK primary care data and linked national death registrations within the OpenSAFELY platform. Lancet HIV. 2021;8(1):e24–32. 162. Lesko CR, Bengtson AM. HIV and COVID-19: Intersecting Epidemics With Many Unknowns. Am J Epidemiol. 2021;190(1):10–6. 163. Cooper TJ, Woodward B, Alom S, Harky A. Coronavirus disease 2019 (COVID‐19) outcomes in HIV/AIDS patients: a systematic review. HIV Med. 2020;21(9):567–77. 164. Mirzaei H, McFarland W, Karamouzian M, Sharifi H. COVID-19 among people living with HIV: a systematic review. AIDS Behav. 2021;25(1):85–92. 165. BC Centre for Excellence in HIV/AIDS CDET Committee Statement on the use of COVID-19 mRNA vaccines (Pfizer and Moderna) in Persons living with HIV | BC Centre for Excellence in HIV/AIDS [Internet]. [cited 2023 Sep 19]. Available from: https://www.bccfe.ca/therapeutic-guidelines/healthcare-providers/therapeutic-guidelines/bc-centre-excellence-hivaids-cdet-committee-statement 166. Smith DR. Herd Immunity. Rumin Immunol. 2019;35(3):593–604. 167. Fontanet A, Cauchemez S. COVID-19 herd immunity: where are we? Nat Rev Immunol. 2020;20(10):583–4. 168. CDC. Centers for Disease Control and Prevention. 2023 [cited 2023 Sep 19]. Frequently Asked Questions about COVID-19 Vaccination. Available from: https://www.cdc.gov/coronavirus/2019-ncov/vaccines/faq.html 169. CDC. Centers for Disease Control and Prevention. 2023 [cited 2023 Sep 19]. COVID-19 Vaccination. Available from: https://www.cdc.gov/coronavirus/2019-ncov/vaccines/stay-up-to-date.html 170. Canada PHA of. COVID-19 vaccine: Canadian Immunization Guide [Internet]. 2021 [cited 2022 Apr 12]. Available from: https://www.canada.ca/en/public-health/services/publications/healthy-living/canadian-immunization-guide-part-4-active-vaccines/page-26-covid-19-vaccine.html 84 171. Giurgea Luca T., Morens David M., Yount Jacob. Great Expectations of COVID-19 Herd Immunity. mBio. 13(1):e03495-21. 172. Su Z, Cheshmehzangi A, McDonnell D, da Veiga CP, Xiang YT. Mind the “Vaccine Fatigue.” Front Immunol [Internet]. 2022 [cited 2023 Sep 23];13. Available from: https://www.frontiersin.org/articles/10.3389/fimmu.2022.839433 173. Paul E, Fancourt D. Predictors of uncertainty and unwillingness to receive the COVID-19 booster vaccine: An observational study of 22,139 fully vaccinated adults in the UK. Lancet Reg Health – Eur [Internet]. 2022 Mar 1 [cited 2023 Sep 23];14. Available from: https://www.thelancet.com/journals/lanepe/article/PIIS2666-7762(22)00010-2/fulltext 174. Lemmens T. Pharmaceutical Knowledge Governance: A Human Rights Perspective. J Law Med Ethics. 2013;41(1):163–84. 175. Lawrence HY. Vaccine Hesitancy: Public Trust, Expertise, and the War on Science, by Maya J. Goldenberg. Pittsburgh, PA: University of Pittsburgh Press, 2021. J Med Humanit.;44(3):413–5. 176. Bardosh K, Figueiredo A de, Gur-Arie R, Jamrozik E, Doidge J, Lemmens T, et al. The unintended consequences of COVID-19 vaccine policy: why mandates, passports and restrictions may cause more harm than good. BMJ Glob Health. 2022 May 1;7(5):e008684. 177. Home | Qualtrics Experience Management [Internet]. [cited 2022 Apr 13]. Available from: https://ubc.ca1.qualtrics.com/homepage/ui 178. Akel KB, Masters NB, Shih SF, Lu Y, Wagner AL. Modification of a vaccine hesitancy scale for use in adult vaccinations in the United States and China. Hum Vaccines Immunother. 2021;17(8):2639–46. 179. Sample Size Calculation. 2008 [cited 2023 Oct 18]Available from: https://www.calculator.net/sample-size-calculator.html?type=1&cl=95&ci=5&pp=50&ps=9800&x=59&y=22 180. IBM SPSS Statistics for Macintosh [Internet]. Armonk, NY: IBM Corp.; 2020. Available from: https://www.ibm.com/support/pages/downloading-ibm-spss-statistics-280 181. Canada PHA of. COVID-19 vaccines: Canadian Immunization Guide [Internet]. 2021 [cited 2023 Oct 18]. Available from: https://www.canada.ca/en/public-health/services/publications/healthy-living/canadian-immunization-guide-part-4-active-vaccines/page-26-covid-19-vaccine.html 182. CDC. Centers for Disease Control and Prevention. 2020 [cited 2022 Apr 19]. COVID-19 Vaccination. Available from: https://www.cdc.gov/coronavirus/2019-ncov/vaccines/recommendations/immuno.html 85 183. Public Health Agency of Canada. aem. 2023 [cited 2023 Sep 18]. Canadian COVID-19 vaccination coverage report. Ottawa: Available from: https://health-infobase.canada.ca/covid-19/vaccination-coverage/ 184. Kaida A, Brotto LA, Murray MCM, Côté HCF, Albert AY, Nicholson V, et al. Intention to Receive a COVID-19 Vaccine by HIV Status Among a Population-Based Sample of Women and Gender Diverse Individuals in British Columbia, Canada. AIDS Behav. 2022;26(7):2242–55. 185. Dubé E, Gagnon D, MacDonald NE. Strategies intended to address vaccine hesitancy: Review of published reviews. Vaccine. 2015;33(34):4191–203. 186. Attwell K, Dube E, Gagneur A, Omer SB, Suggs LS, Thomson A. Vaccine acceptance: Science, policy, and practice in a ‘post-fact’ world. Vaccine. 2019;37(5):677–82. 187. Malik AA, McFadden SM, Elharake J, Omer SB. Determinants of COVID-19 vaccine acceptance in the US. EClinicalMedicine. 2020;26:100495. 188. Kabito GG, Alemayehu M, Mekonnen TH, Daba Wami S, Azanaw J, Adane T, et al. Community’s perceived high risk of coronavirus infections during early phase of epidemics are significantly influenced by socio-demographic background, in Gondar City, Northwest Ethiopia: A cross-sectional-study. Plos One. 2020;15(11):e0242654. 189. Niepel C, Kranz D, Borgonovi F, Emslander V, Greiff S. The coronavirus (COVID-19) fatality risk perception of US adult residents in March and April 2020. Br J Health Psychol. 2020;25(4):883–8. 190. Canada PHA of. COVID-19 vaccine uptake and intent: Canadian Community Health Survey (CCHS) insight [Internet]. 2021 [cited 2023 Sep 19]. Available from: https://www.canada.ca/en/public-health/services/publications/vaccines-immunization/covid-19-vaccine-uptake-intent-canadian-community-health-survey.html 191. Zimmerman T, Shiroma K, Fleischmann KR, Xie B, Jia C, Verma N, et al. Misinformation and COVID-19 vaccine hesitancy. Vaccine. 2023;41(1):136–44. 192. Ye C, Zhang G, Zhang A, Xin H, Wu K, Li Z, et al. The Omicron Variant Reinfection Risk among Individuals with a Previous SARS-CoV-2 Infection within One Year in Shanghai, China: A Cross-Sectional Study. Vaccines. 2023;11(7):1146. 193. Jantzen R, Maltais M, Broët P. Socio-Demographic Factors Associated With COVID-19 Vaccine Hesitancy Among Middle-Aged Adults During the Quebec’s Vaccination Campaign. Front Public Health. 2022;10:756037. 194. Hong J, Xu XW, Yang J, Zheng J, Dai SM, Zhou J, et al. Knowledge about, attitude and acceptance towards, and predictors of intention to receive the COVID-19 vaccine among cancer patients in Eastern China: A cross-sectional survey. J Integr Med. 2022;20(1):34–44. 86 195. Elgendy MO, Abdelrahim MEA. Public awareness about coronavirus vaccine, vaccine acceptance, and hesitancy. J Med Virol. 2021;93(12):6535–43. 196. Brondani M, MacEntee M. The concept of validity in sociodental indicators and oral health‐related quality‐of‐life measures. Community Dent Oral Epidemiol. 2007;35(6):472–8. 87 Appendices Appendix A: Search Strategy Preliminary Search from MEDLINE (OVID) and CINAHL, Adapted to All Databases Date Database Search # Keywords/ MeSH terms Results July 25, 2022 MEDLINE (Ovid) S1 (Vaccin* or immuni?ation*) adj3 (hesita* or uptake or willingness or confidence or refusal)).mp 9513 S2 vaccination refusal/ or vaccination hesitancy/ 1005 S3 S1 OR S2 9513 S4 Immunosuppress* or Immunodeficien* or Immunocompromised or immune compromised or HIV or PLHIV or Cancer or Transplant* or High risk).mp. 3558113 S5 Immunosuppression Therapy/ or Immunocompromised Host/ 55577 S6 S4 OR S5 3558113 S7 (Determinant* or Barrier* or Facilitator* or Factor* or Socioeconomic or Behavio?r*).mp. 7943808 S8 S3 AND S6 AND S7 1101 July 25, 2022 CINAHL S1 (MM"Immunization") OR "(Vaccin* or immuni?ation*) adj3 (hesita* or uptake or willingness or confidence or refusal) 16,038 S2 Immunosuppress* or Immunodeficien* or Immunocompromised or immune compromised or HIV or PLHIV or Cancer or Transplant* or High risk 826,084 S3 (Determinant* or Barrier* or Facilitator* or Factor* or Socioeconomic or Behavio?r*) 1,881,887 S4 S1 AND S2 AND S3 710 88 Appendix B: Cross-Sectional Survey Including Informed Consent COVID-19 Vaccine Hesitancy Among People Living with HIV in British Columbia, Canada You are invited to participate in this research study about the factors determining COVID-19 vaccine hesitancy among British Columbia residents living with HIV. We are evaluating health behaviours towards COVID-19 vaccines in Canada, including AstraZeneca, Janssen, Medicago, Moderna, Pfizer-BioNTech and others. For this study, COVID-19 vaccine hesitancy is defined as the delay in acceptance or refusal of vaccines despite their availability. Anne Ejiegbu is conducting this study as a graduate student in the MSc Craniofacial Sciences program at the Faculty of Dentistry, University of British Columbia and supervised by Dr. Mario Brondani, an associate professor at the Faculty of Dentistry at the University of British Columbia (UBC). Surveys will be disseminated to members of HIV Organizations in British Columbia via the Qualtrics® platform. In order to participate in this study, please complete the attached survey. Your participation is entirely voluntary, and you may withdraw from the study at any point before submitting the survey. However, your answers cannot be withdrawn after submission of the completed survey due to data anonymity. The survey will take approximately 10 minutes to complete. Your response will be collected anonymously, and your email and IP address will not be linked to your response. UBC collects the information in the survey under the authority of sections 26(c) and 26(e) of the BC Freedom of Information and Protection of Privacy Act (BC FIPPA). There are no anticipated risks to you while participating in this research. Still, the study may provoke your thoughts about the Covid-19 vaccines. At the end of the survey, you will have the option to be entered into a draw for ten $30 Amazon gift cards. To enter the draw, you will be asked for your contact information at the end of the survey. This will not be shared with anyone other than the graduate student. However, if you provide your contact information, the data will no longer be anonymous, although they will be de-identified before analyzing. You can also withdraw your information if you change your mind about participating in the study after you have inserted your contact information. If you decide not to participate in our draw, in that case, you can submit your answers without providing your contact information, but you cannot withdraw after submission because your submitted survey will be anonymous and untraceable. The results from this study will be available in the form of a graduate thesis and peer-reviewed manuscripts, which may be in an open-access format. They will also be presented at academic conferences without your name or identity. You will also have the option to receive an update about the study results once published through your member organization If you have any other questions about your rights as a participant in this research, please do not hesitate to contact us: Dr. Mario Brondani (The Principal investigator): brondani@dentistry.ubc.ca Anne Ejiegbu (The researcher): aejiegbu@student.ubc.ca By completing this survey, you are consenting to participate in this study. Thank you in advance for your thoughtful input. Who can you contact if you have complaints or concerns about the study? If you have any concerns or complaints about your rights as a research participant and/or your experiences while participating in this study, contact the Research Participant Complaint Line in the UBC Office of Research Ethics at 604-822-8598 or if long-distance e-mail RSIL@ors.ubc.ca or call toll free 1-877-822-8598. Ethics ID Number: H22-02053 89 Q1 Have you filled out this survey before?  Yes  No (If “Yes” kindly return the survey as you do not need to fill it again)Q2 Are you aware of your HIV status?  Yes, I am HIV positive  I am HIV negative  I am not aware of my HIV status  Prefer not to disclose Section A: Demographic Characteristics Q3 What is your age as at your last birthday? (Years)_____ Q4 Please identify your gender: _____________________ Q5 Please identify your sexual orientation: ____________ Q6 What is your ethnicity? _________________________ Q7 What is the highest degree or level of education you have completed? _________________________________ Q8 What is your current employment status? ___________ Q9 Which of these describes your income last year?  Less than $49,020  $49,020-$98,040  $98,040-$151,978  $151,978 to $216,511  More than $216,511  Prefer not to say Q10 Which province do you currently reside in?_________ Q11 Which city do you currently reside in? _____________ Q12 Have you received any of the COVID-19 vaccines? (IF “NO” please, move to Q16-17)  Yes  No Q13 Which COVID-19 vaccine did you receive? (Select all that apply)  None  AstraZeneca  Moderna  Janssen  Pfizer-BioNTech  Novavax  Medicago  Others (Please specify) _____________ Q14 How many doses of the vaccine, including boosters, have you received so far? __________________________ Q15 What factors encouraged you to get vaccinated against COVID- 19? (Select all that apply)  I want to protect myself  I wanted to protect people I love  I wanted to protect my community  Other (please specify) ____________________ Section B: COVID-19 Vaccine Uptake Q16 If you have NOT taken any of the vaccines, what factors discouraged you from getting vaccinated against COVID- 19? (Select all that apply)  I don't trust the vaccine is safe  I have had bad experiences with other vaccines  I don't trust the government  I don't trust the medical community  I don't think the vaccine would protect me from getting sick with COVID-19  Other reason (please specify) _________________ Q17 If you have NOT taken any of the vaccines, what are your main concerns? (Select all that apply)  Motives of the pharmaceutical companies  Insufficient information about the vaccine  The rapid development of the vaccine  The uncertainties about when/how I can receive the vaccine  Other concern (please specify)____________________ Q18 If you are partially vaccinated and have not taken the recommended dose, what factors prevented you from getting the additional doses and boosters? (Select all that apply)  I do not trust that the vaccine is safe  I had a bad experience with the previous dose of the COVID-19 Vaccine  I don't trust the government  I don't trust the medical community  I got infected even after being vaccinated  I don't think other doses are necessary  Not applicable to me  Other reason (please specify): __________________ Q19 If you are partially vaccinated and have not taken the recommended dose, what are your main concerns? (Select all that apply)  Motives of the pharmaceutical companies  Insufficient information about the vaccine  Possible adverse effects  Vaccine passport policies  Not applicable to me  Other (please specify): ______________________ 90 Section C: Perceived COVID-19 Vulnerability Q20 Have you been diagnosed with COVID-19 since the start of the pandemic?  Yes  No  Unsure Q21 Has any of your friends or family members been diagnosed with Covid-19 since the start of the pandemic?  Yes  No  Unsure Q22 Has any of your friends, or family members died from Covid-19 since the start of the pandemic?  Yes  No  Unsure Section D: HIV Health indicators Q23 What was the value of your last CD4 count?  Less than 200 cells/mm3  201- 500 cells/mm3  Greater than 500 cells/mm3  Unsure Q24 What was the value of your last HIV viral load count?  Undetectable  Less than 500  500 – 5000  Greater than 5000  Unsure Section E: Vaccine Hesitancy Scale – aVHS How well do you agree with the statements regarding COVID-19 vaccines? Q25 Vaccines are important for my health  Strongly disagree  Somewhat disagree  Neither agree nor disagree  Somewhat agree  Strongly agree Q26 Vaccines are effective  Strongly disagree  Somewhat disagree  Neither agree nor disagree  Somewhat agree  Strongly agree Q27 Being vaccinated is important for the health of others in my community.  Strongly disagree  Somewhat disagree  Neither agree nor disagree  Somewhat agree  Strongly agree Q28 All routine vaccinations recommended by Health Canada are beneficial  Strongly disagree  Somewhat disagree  Neither agree nor disagree  Somewhat agree  Strongly agree Q29 New vaccines carry more risks than older vaccines.  Strongly disagree  Somewhat disagree  Neither agree nor disagree  Somewhat agree  Strongly agree Q30 The information I receive about vaccines from Health Canada is reliable and trustworthy.  Strongly disagree  Somewhat disagree  Neither agree nor disagree  Somewhat agree  Strongly agree Q31 Getting vaccines is a good way to protect me from disease.  Strongly disagree  Somewhat disagree  Neither agree nor disagree  Somewhat agree  Strongly agree Q32 Generally, I do what my doctor or healthcare provider recommends about vaccines for me.  Strongly disagree  Somewhat disagree  Neither agree nor disagree  Somewhat agree  Strongly agree Q33 I am concerned about serious adverse effects of vaccines.  Strongly disagree  Somewhat disagree  Neither agree nor disagree  Somewhat agree  Strongly agree Q34 I do not need vaccines for diseases that are not common anymore.  Strongly disagree  Somewhat disagree  Neither agree nor disagree  Somewhat agree  Strongly agree Q35 Would you like to participate in our raffle draw? (If “Yes”, please answer “Q36”, If “No”, this is the end of the survey. Thank you for participating in our survey) Q36 Thank you for agreeing to participate in the raffle draw. If you win this draw, you will get an electronic or physical Amazon gift card worth $30 CAD. Please enter your preferred contact information, E-mail, Phone number and/or Mailing address. (Note that your information will be kept confidential) _______________
Thesis/Dissertation
eng
Craniofacial Science
Vancouver : University of British Columbia Library
Attribution-NonCommercial-NoDerivatives 4.0 International
Graduate
Brondani, Mario
COVID-19 vaccine hesitancy and behaviours among people living with HIV in British Columbia
Text