Inuenza Vaccination in Coronavirus Times: Intention to Be Vaccinated by Primary Care Professionals in Central Catalonia (VAGCOVID)

Background Inuenza vaccination is the main measure of prevention against the epidemic u, which annually produces a signicant increase in the pressure on healthcare systems, in addition to inuencing the absenteeism of health workers. Although it is recommended that health professionals be vaccinated, their vaccination coverage is low. The lack of knowledge about the evolution of inuenza in the context of the SARS-CoV-2 coronavirus pandemic led to the continued recommendation of inuenza vaccination to people at risk and to professionals. The aim of the study is to determine the intention to vaccinate against seasonal u of health professionals in the 2020-21 campaign in the context of the SARS-CoV-2 pandemic, and to analyse the factors that inuence it. Methods Cross-sectional study through a structured online survey aimed at Primary Care professionals in the region of central Catalonia. Results A total of 610 participants responded to the survey, 65.7% of whom intended to be vaccinated against the u in this campaign and 11.1% did not yet know or did not answer. The intention to be vaccinated against u is associated with the professional category, the years of professional practice, the fact of making face-to-face guards, and the perception of the risk of suffering from u. It is also related to a history of inuenza vaccination in the previous year and to having been vaccinated on another occasion. The prole of professionals who intend to be vaccinated against u includes professionals with a history of vaccination, who were on duty and perceived that their staff were at risk of becoming ill with u. Conclusions During the SARS-CoV-2 pandemic, many professionals show a clear intention to get vaccinated against the u, but there are still some who doubt it. In order to improve inuenza vaccination coverage among health professionals, it is necessary to design strategies aimed at professionals who are hesitant or reluctant to vaccination. Cross-sectional study on the acceptance of VAG, the perception of risk of seasonal inuenza during the SARS-CoV-2 pandemic, and the inuence of contextual factors related to the hygienic/physical measures implemented during the pandemic, through an online survey to primary care professionals. This survey is based on a one conducted by Apiñániz et al. to study the acceptability of an inuenza A (H1N1) vaccine which used in a recent study on intention to vaccinate among the at-risk population in the same area [22].


Introduction
Flu is estimated to affect between 5% and 20% of the general population each year. It is estimated that approximately 25% of respiratory febrile processes can be caused by in uenza. [1] In uenza is a public health problem that directly affects health care workers due to the increase in consultations resulting from the infection and its complications, leading to an increase in healthcare pressure and hospitalisations. [1,2,3] In addition, professionals who work in healthcare areas are at higher The consensus document on in uenza vaccination in health personnel, published in 2012 by 19 Spanish scienti c societies, makes recommendations based on three basic pillars: necessity, ethics and exemplariness. As to necessity, self-protection is pointed out as the main reason for vaccination, because health professionals are more exposed to circulating viruses and this fact increases the likelihood of leaves. As to ethics (primum non nocere), it should be borne in mind that unvaccinated professionals could be transmitters of the virus to people at risk, who could be more severely affected by the disease, as well as their professional and family environment. As to exemplariness, the fact that professionals are vaccinated, aware and convinced of the usefulness and safety of the u vaccine leads to more con dence in the general population and also among the professionals themselves, and in uences the improvement of vaccine coverage. [18] In the context of the current SARS-CoV-2 pandemic, the VAG 2020-21 campaign was considered to be in uenced by ignorance of in uenza virus behaviour and the risk of coinfection by both viruses. For this reason, health authorities promoted an increase in VAG coverage to reduce the incidence and the impact on healthcare pressure that takes place each year [9,10].
In the 2020-21 in uenza vaccination campaign, Catalonia and Spain set the goal to reach or exceed 75% of vaccination in people over 65 and in health personnel, and 60% in pregnant women and people with high risk of complications [9,10].
In the context of the SARS-CoV-2 pandemic, it is important to know the intention to receive the VAG by health professionals, as intention is a key factor for action [14,19] and therefore can help focus actions that improve vaccine coverage. It is also interesting to explore the pandemic-related reasons that may lead them to decide on the VAG.
The aim of the study is to determine the intention to vaccinate against seasonal u of health professionals in the 2020-21 campaign, in the context of the SARS-CoV-2 pandemic. The speci c objectives are: 1) Assess the perception of risk of seasonal u in the context of the SARS-CoV-2 pandemic. 2) Determine whether the contextual factors related to the physical and hygienic protection measures disseminated and implemented during the pandemic in uence the intention of getting vaccinated against the u.

Methodology
Cross-sectional study on the acceptance of VAG, the perception of risk of seasonal in uenza during the SARS-CoV-2 pandemic, and the in uence of contextual factors related to the hygienic/physical measures implemented during the pandemic, through an online survey to primary care professionals. This survey (Annex I) is based on a previous one conducted by Apiñániz et al. to study the acceptability of an in uenza A (H1N1) vaccine [21], which has already been used in a recent study on the intention to vaccinate among the at-risk population in the same area [22].
The eld of the study was the Health Region of Central Catalonia, which includes the counties of Anoia, Bages, Berguedà, Moianès and Osona. The research period ranged from 15 days before the start of the in uenza vaccination campaign until the month after its completion (October 5, 2020 -January 31, 2021). The population included was that of health professionals from the Catalan Institute of Health at Primary Care Teams (EAP) in Central Catalonia; approximately 1,500 professionals. The different professional categories included were: Group A1 (family doctors, paediatricians, dentists, pharmacists, senior technicians), Group A2 (nurses, midwives, social workers, management technicians), Group C1 (administrators, specialist technicians), Group C2 (pharmacy assistants, nursing assistants, nurses, administrative assistants, drivers, maintenance staff) and GP Group (caretakers, or others) The inclusion criteria were: 1) Being a Primary Care Professional at the Catalan Institute of Health. 2) Having an indication for in uenza vaccination due to belonging to the group of health professionals [6]. 3) Agreeing to participate in the study voluntarily, with informed consent and by answering the selfadministered online questionnaire, which the professionals received via the corporate e-mail address.
People who were unable to understand the nature of the study were excluded from it.
The sample size was calculated with the GRANMO calculator [23]. It was calculated that a random sample of 290 individuals would be su cient to estimate, with 95% con dence and an accuracy of +/-5 percentage units, a population percentage that was predicted to be around 30%. The expected percentage of replacements was 10%.
A descriptive statistical analysis was performed with the data derived from the responses to the surveys. Categorical variables have been described using frequencies and percentages. Continuous variables have been described with mean and standard deviation. The proportions of categorical variables have been compared using Fisher's exact test and the t test for continuous variables.
The statistical programme R for Windows (version 3.6.3) has been used for statistical analysis. The results were considered signi cant with p < 0.05.
The study protocol was approved by the University Institute for Primary Care Research (IDIAP), Jordi Gol Health Care Ethics Committee (Code 20/177-PCV).

Results
The online survey was sent to 1,747 primary care professionals, 610 of whom (34.9%) responded to the entire survey. 83.6% of respondents were women and the average age was 50, with an age range of 20 to 60 years. 70.8% lived as a couple and 46.2% had one or more dependants.
24.1% of participants belonged to the professional category A1 and 38.5% to A2. 20.3% had a temporary contract and 42.8% were interim workers. 25.9% had a professional experience of more than 21 years and 22.1% of less than 5 years. 44.6% of participants performed physical presence guards. All this data is detailed in table number 1.
65.7% of participants reported intending to get vaccinated against the u in this campaign and 11.1% did not yet know or did not answer as you can see in table number 3. When asked if they intended to be vaccinated in the pandemic situation due to SARS-CoV-2, 60% answered that they would do so regardless of the situation, 6.7% would do so because of it, and 12.6% did not yet know or did not answer.
Regarding the intention to vaccinate and the relationship with the recommended protection measures during the pandemic, 52.8% would get vaccinated despite thinking that the mask already protects them, and 13.9% would not do so despite knowing that the mask does not protect them totally. Regarding hand washing and physical distancing, 52.1% and 51.1% of respondents respectively stated that they would get vaccinated despite applying these measures; and 15.2% and 15.4%, respectively, had no intention of getting vaccinated despite knowing that these measures do not protect them totally either. In the questions related to the three contextual variables, the answer Don't Know/No Answer was chosen by 14% of the participants.