• vaccination
• Covid-19
• autoimmune diseases

We read with interest the article by Dejaco et al recently published in Annals of the Rheumatic Disease on the influence of the COVID-19 pandemic on decisions on the management of individuals with rheumatic diseases.1 One issue not touched on in this article is attitudes to vaccination, particularly influenza vaccination, in the COVID-19 era. Seasonal influenza infection is a major cause of morbidity and mortality in selected individuals with altered immune response.2 Influenza vaccination is recommended for the majority of individuals with autoimmune inflammatory rheumatic diseases.3

Previous studies of patients with autoimmune diseases in general and rheumatologic conditions in particular have demonstrated low uptake for influenza vaccine.4 5 The median vaccination coverage rate was 47.1% for 3 seasons in 2015–2018 among older age groups within Europe.5 Various reasons have been suggested for low influenza vaccination uptake, from patient belief that the vaccination is ineffective, perceived financial cost, concerns regarding adverse side effects of vaccination, lack of patient education, to a patient’s own underestimation of their own health risk profile.6–9

In the current context of the COVID-19 global pandemic, public perception of and interest in vaccination programmes has rarely been of a higher concern. Influenza vaccination uptake has emerged as a public health concern of even greater importance in 2020–2021 winter season in order to minimise additional burden on already overstretched healthcare system.

We did a cross-sectional study in St James’s Hospital, Ireland. A questionnaire was given to all patients attending a general rheumatology clinic over the course of 3 months (October–December 2020). This questionnaire consisted of self-reported information regarding socio-demographic characteristics, personal history of chronic illnesses, previous personal uptake of the influenza vaccine in 2019 and personal interest in undergoing vaccination for influenza in 2020/2021. This 14-item questionnaire was self-designed based on variables identified in a literature review. Criteria for inclusion included all adult patients who attended outpatient rheumatology clinic appointments during the specified time period. Those who declined to be part of the study were excluded. The study was approved by the St James’s Hospital’s Research and Innovation Office. The data were summarised using descriptive analyses.

A total of 200 patients completed the survey, 136 (68%) were women and the median age was 59 years, the majority were non-smoker (60%). Eighty-five patients (42.5%) documented actively taking immunosuppressive treatment. The most common comorbidities reported were hypertension: 40/200 (20%), followed by chronic obstructive pulmonary disease (COPD): 18/200 (9%), diabetes: 17/200 (8.5%) and cardiovascular disease: 14/200 (7%). Eighty one (40.5%) of the studied population did not receive influenza vaccination in 2019 due to various reasons, including fear of adverse reaction (n=15), perceived good health (n=15), personal lack of belief in the vaccine effectiveness (n=11), a reported history of side effects (n=10), a lack of recommendation from healthcare workers (n=6), lack of access to the vaccine (n=5), high cost of the vaccine (n=5), needle phobia (n=2) and others provided no reason for their decision (n=12). Among those that did not engage with influenza vaccination in 2019, 39 (48%) opted to receive vaccination in 2020.

The primary aim of this study was to capture patient’s perception of influenza vaccination during the COVID-19 pandemic; in relation to this, the overall percentage of vaccination is comparable to previous studies carried out in Ireland.10 11 A study in Southern Denmark looked at influenza vaccine uptake among 192 rheumatoid arthritis patients. Self-reported uptake was found in 59%. In this study, the most common factor associated with low uptake of vaccination was fear of adverse effects.12 According to our results, the most common factors affecting the level of vaccination were fear of adverse reactions, perceived good health, personal lack of belief in the vaccine and a history of adverse reaction; there were slight differences in ranking compared with prior studies but shared common themes.

The strength of this study was the good sample size and high response rate. There are a number of limitations of this study. These include a selection bias featuring exclusively those attending rheumatology outpatient clinics, a population more likely to receive healthcare recommendations of vaccination uptake compared with the average population. The self-reported nature of the questionnaire introduces some limitations with regards to the comprehensiveness of our data. There was some variability with regards to patient’s response and completion of the questionnaire.

Influenza vaccine is an important step to alleviate global health burden associated with seasonal influenza virus and its negative sequelae during COVID-19 pandemic. The study highlights suboptimal uptake in at risk population seen at our general rheumatology clinic. It indicates the need for a greater emphasis to address concerns surrounding vaccination in our vulnerable patients.