Attitudes towards influenza, and COVID-19 vaccines during the COVID-19 pandemic among a representative sample of the Jewish Israeli population

Influenza viruses cause seasonal illness worldwide and are associated with 0.1–0.5% mortality [1]. Complication and mortality increase in patients over 70 years old, in patients with co-morbidities, in infants, pregnant women and in people suffering from obesity [23].

Influenza virus is remarkable for its high rate of mutation [4]. Therefore, new vaccines are produced each year to match circulating viruses. The decision of which influenza antigens to include in the vaccines is made in advance of the influenza season and is based on global surveillance of influenza viruses circulating at the end of the prior influenza season [5]. Mismatches between the vaccine strains and the circulating strains that result in reduced efficacy of the vaccine do occur.

Coronavirus disease 2019 (COVID-19) is a highly infectious pneumonia caused by severe acute respiratory syndrome coronavirus 2 virus (SARS-CoV-2). As of December 2019, it has caused a pandemic outbreak that was first discovered in Wuhan, China [6]. Up to August 30th, 2020, SARS-CoV-2 has infected more than 25 million people and more than 800,000 deaths have been reported. By August 30th, in Israel, 110,863 people were infected, representing 12,808 cases per 1 million population and 885 people have died representing 102 deaths per 1 million population [7].

In the absence of an effective and recommended established therapy, treatment of COVID-19 has mainly been empirical and experimental in addition to supportive care. Recent observational and randomized studies, involving patients with COVID-19 admitted to the hospital demonstrated mixed results regarding the efficacy of various antiviral and antimalarial drugs [811]. Several vaccines have recently received emergency authorizations, but in many countries’ vaccine availability is limited [12].

Vaccines are an important way to control seasonal and pandemic influenza and are thought to be crucial in controlling the COVID-19 pandemic. In recent years, there has been a decline in the willingness to receive various vaccinations, including vaccines against influenza and pneumonia [13]. This is also true for the Israeli population [14]. In response, the World Health Organization (WHO) identified vaccine hesitancy as one of the top ten global health threats in 2019.

Reasons for the declining acceptance of vaccines include the decreased efficacy in some years of the influenza vaccine, concerns about potential side-effects from vaccines, belief that a vaccine can cause the disease it was meant to prevent, thoughts that alternative practices could eliminate the need for vaccines, conspiracy theories promoted in social networks claiming that physicians benefit financially from advocating vaccine use, and that Pharma companies advertise false information regarding vaccines. Also, some religious groups, including some Orthodox Jewish courts reject vaccine use [1315].

Vaccine hesitancy towards influenza vaccine is common worldwide [1617]. Information regarding COVID-19 vaccine hesitancy is emerging both in the general population and in health care workers [1819].

In the winter of 2020–2021 there were no reports of influenza in Israel probably due to COVID-19 lockdowns, wearing masks, social distancing, and limited international travel (personal communications with the Israeli ministry of health). It is reasonable to assume that in the coming winter season (2021–2022) physicians will have to deal with both COVID-19 cases together with influenza, and other winter viral infections, and the rise in pneumonia cases typical to the winter months due to opening of international travel and decrease in social distancing restrictions. Therefore, it is important to understand the effect of the current COVID-19 pandemic on the willingness of people to receive vaccines against influenza, and to assess vaccine barriers for the coming COVID-19 vaccines.

The aim of the study was to assess attitudes towards influenza vaccine, and the upcoming COVID-19 vaccines and to assess whether the current COVID-19 pandemic affects the attitudes towards influenza vaccines in a representative sample of the Jewish Israeli population. We included only Israelis identifying as Jewish and excluded ethnicities that we could not adequately represent and control for selection bias [2021]. While not inclusive of all ethnicities in Israel, our focus on the Jewish Israeli population provides important insights about hesitancy towards vaccines in the largest population in Israel 73.9% of the Israeli population) [22]. Our hypothesis was that hesitancy towards influenza vaccines, or other vaccines, would be associated with hesitancy towards COVID-19 vaccines. We also hypothesized that as there is more information regarding the safety and efficacy of influenza vaccines compared to COVID-19 vaccines, responders would be more inclined to receive influenza vaccines compared to COVID-19 vaccines. 

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