Influenza vaccination coverage and associated factors among medical students in Egypt: A cross-sectional multicenter study

Abstract

Background:

Influenza is a common infectious disease and is responsible for between 290,000 and 650,000 deaths annually. Vaccination is the best preventive strategy for decreasing influenza severity and is highly recommended for medical students. This study aims to estimate influenza vaccination coverage, its associated factors, and future willingness to receive it among medical students.

Design and methods:

This cross-sectional study was conducted among medical students at six Egyptian universities to represent different geographic areas using a self-administered, anonymity-based online questionnaire. Logistic regression analysis was adopted to determine the predictors of previous influenza vaccination and future willingness to get it.

Results:

A total of 1364 students completed the questionnaire. 22.9% of students had received the influenza vaccine at least once in their lives, while 22.4% of the participants had been vaccinated in the index year and 24.7% in the preceding year. Among the ever-vaccinated group, the most frequent motive was to protect themselves and their families (80.8%). The most common reasons for refusing the vaccine were a lack of knowledge about recommended vaccinations (25.7%) and believing that influenza is trivial (25.5%). The willingness to take the vaccine was 55.7% among students, with the majority from the never-been-vaccinated group (70.8%). Students from Alexandria University, having received three COVID-19 vaccine doses and no prior influenza vaccine uptake, were independent predictors for future vaccine willingness (AORs: 0.678, 1.805, and 0.432, respectively).

Conclusion:

Vaccination coverage among medical students in Egypt was low, so a comprehensive awareness program is needed to improve students’ knowledge and enhance vaccine uptake.

Keywords

influenza vaccine coverage willingness medical students Egypt

Introduction

Influenza, a common respiratory tract infection, is caused by one of the influenza viruses, members of the Orthomyxoviridae family.¹ Following an incubation period of 1–4 days, individuals may develop mild to severe symptoms, including fever, headache, aches, cough, chills, and chest discomfort.² Although influenza usually resolves without complications, it can sometimes progress to severe or even fatal illness. According to the World Health Organization (WHO), seasonal influenza epidemics cause between 290,000 and 650,000 deaths and 3–5 million cases of severe illness worldwide each year.³ At the national level, the national burden of influenza-associated respiratory illness was estimated in Egypt between 2016 and 2019, reporting that approximately 17.3% of the population experienced mild to moderate influenza-associated illness seasonally.⁴ The risk of severe disease and complications increases among high-risk groups, including pregnant women, individuals at the extremes of age, patients with chronic medical conditions, immunocompromised patients, and smokers.^3,5

Among influenza preventive measures, vaccination is the most effective measure against infection and its complications.^3,6 Each year, the World Health Organization (WHO) predicts which influenza strains are most likely to spread in the upcoming year, enabling pharmaceutical companies to develop strain-specific vaccines. As a result, the vaccines do not contain all circulating strains, so accurate prediction of prevalent strains is a critical factor in vaccine effectiveness.^3,7,8 Annual vaccination is highly recommended, especially for those at higher risk for severity and complications, as well as all healthcare workers (HCWs) and medical students.^3,9–12 In Egypt, universal recommendations for influenza vaccination are usually implemented; however, pregnant women are excluded. In addition, some specific campaigns were conducted during the most recent 2021–2022 season.¹³

Medical students are not full-time HCWs, but they are in contact with patients, particularly during clinical rotations. Therefore, they can easily catch and transmit the infection within clinical and non-clinical settings, such as their colleagues, other HCWs, and vulnerable patients, thus worsening their condition. Additionally, it has been reported that positive and negative experiences with vaccines before and during medical education can influence how future physicians accept immunization and recommend it to patients.^14,15 Universal vaccination can produce herd immunity, protecting vulnerable individuals who are unable to receive the vaccine and those for whom the vaccine may be ineffective, and subsequently decrease hospital visits and admissions.^16,17 Therefore, medical students’ vaccination is crucial not only for protecting their own health, but also for preventing nosocomial transmission and protecting vulnerable patients.¹⁸

There are, to date, few studies that discuss influenza vaccination among HCWs. To the best of the authors’ knowledge, influenza vaccination among medical students has not been discussed before in previous studies in Egypt. Therefore, this study aims to estimate influenza vaccination coverage among medical students, their willingness to be vaccinated, and their associated factors, assessing the barriers, the motives, and the most influential source of vaccine information among medical students, as well as the vaccine’s common side effects.

Methods

Study settings

A cross-sectional study with an analytical component was conducted during the academic year of 2022–2023 at six universities out of 27 governmental universities in Egypt (Mansoura, Ain Shams, Alexandria, Suhag, Minya, and Aswan). These universities were selected to represent different geographic areas, considering the availability of at least one local collaborator for data collection. The target group was medical students in various grades.

Sample size

The sample size was calculated using the Open Epi online program (https://www.openepi.com) based on an immunization rate of 20.7% for seasonal influenza vaccine among medical students recorded from a previous study conducted in Saudi Arabia¹⁹ with an α error of 0.05, β error of 0.10, and confidence limit (precision) of 0.05. The calculated sample size was 178, which was multiplied by 6 due to the design effect. Finally, the estimated sample size was a total of 1068 students. However, 1364 students completed the questionnaire.

Sampling technique and data collection approach

The questionnaire was distributed as an online Google Form. At least one collaborator who was a medical student from one of the targeted universities and a member of the Alpha Research Organization (ARO) team was responsible for distributing the form link to all students through different social media platforms.

Instrument

Based on an extensive literature review, a self-administered English questionnaire was modified from questionnaires used in these studies^20,21 to collect information about the following:

1-Sociodemographic characteristics of the students, such as age, sex, residence, and grade of study.

2-Medical history,

3-Previous history of influenza vaccination,

4-Knowledge related to the influenza vaccine

5-Reasons for vaccination refusal and acceptance: and willingness to take the vaccine in the future

Statistical analysis

The collected data were coded, processed, and analyzed using Statistical Package for Social Studies (SPSS; version 26). The appropriate statistical test was used according to the data analyzed. p Values at 0.05 were considered statistically significant. Associations between categorical variables were evaluated using the chi-square test. Univariate analysis was conducted to estimate Crude Odds Ratios (COR) and 95% Confidence Intervals (CI). To prevent model overfitting, variables yielding a p-value less than 0.2 in the univariate analysis were entered into a multivariate logistic regression model, and adjusted Odds Ratios (AORs) and corresponding 95% CIs were calculated to identify independent associations.

Ethics approval and consent to participate

Ethical approval was provided by the Institutional Research Board of the Faculty of Medicine at Mansoura University (MFM-IRB; code: MD.22.07.666.R1.R2). Participation was voluntary and anonymous, with no compensation provided. Filling out the questionnaire after assurance of the confidentiality of data is considered consent to participate in the study. Participants were informed they could complete the survey at their convenience and withdraw at any point if desired.

STROBE statement

The study followed the SRROBE Checklist of reporting cross-sectional studies (Supplemental File).²²

Results

Characteristics of participants

A total of 1364 students completed the questionnaire with a median age of 20 years (IQR: 19–21). Participants were predominantly females (56.6%), and 21.9% were from Aswan University. Nearly one-third of participants (29.3%) were third-grade students, and over half (56.2%) lived in urban areas. In addition, 166 (12.2%) students reported having one or more long-term medical conditions, with asthma being the most common one (30.1%). Furthermore, 30.7% of participants reported being infected with COVID-19, as presented in Table 1.

Table 1.

Characteristics of the participants, vaccinated group, and those who are willing to receive the vaccine.

Variable		TotalN (%)	Ever been vaccinatedN (%)	p-Value	Positive willingnessN (%)	p-Value
Overall		1364 (100)	312 (22.9)		760 (55.7)
Sex	Male	592 (43.4)	169 (28.5)	<0.001	341 (57.6)	0.220
Sex	Female	772 (56.6)	143 (18.5)	<0.001	419 (54.3)	0.220
Age	16–19	512 (37.5)	129 (25.2)	0.285	286 (55.9)	0.362
	20–22	706 (51.8)	152 (21.5)		385 (54.5)
	23 and more	146 (10.7)	31 (21.2)		89 (61)
University	Mansoura	290 (21.3)	67 (23.1)	0.655	173 (59.7)	0.164
	Ain Shams	196 (14.4)	44 (22.4)		100 (51)
	Alexandria	218 (16)	50 (22.9)		109 (50)
	Suhag	185 (13.6)	51 (27.6)		107 (57.8)
	Minya	176 (12.9)	36 (20.5)		96 (54.5)
	Aswan	299 (21.9)	64 (21.4)		175 (58.5)
Grade	First	285 (20.9)	78 (27.4)	0.007	157 (55.1)	0.118
	Second	277 (20.3)	78 (28.2)		162 (58.5)
	Third	400 (29.3)	82 (20.5)		233 (58.3)
	Fourth	151 (11.1)	25 (16.6)		70 (46.4)
	Fifth or sixth	251 (18.4)	49 (19.5)		138 (55)
Residence	Rural	597 (43.8)	120 (20.1)	0.031	330 (55.3)	0.772
Residence	Urban	767 (56.2)	192 (25)	0.031	430 (56.1)	0.772
Smoker	Ever	53 (3.9)	17 (32.1)	0.104	33 (62.3)	0.328
Smoker	Never	1311 (96.1)	295 (22.5)	0.104	727 (55.5)	0.328
Self-reported with COVID-19	Yes	419 (30.7)	102 (24.3)	0.389	228 (54.4)	0.519
Self-reported with COVID-19	No	945 (69.3)	210 (22.2)	0.389	532 (56.3)	0.519
Received COVID-19 vaccine	Never	164 (12.0)	33 (20.1)	0.015	79 (48.2)	0.031
	Single dose	213 (15.6)	49 (23)		126 (59.2)
	Two doses	821 (60.2)	176 (21.4)		450 (54.8)
	Three doses	166 (12.2)	54 (32.5)		105 (63.3)
Chronic medical condition	Yes^a	166 (12.2)	39 (23.5)	0.839	99 (59.6)	0.278
Chronic medical condition	No	1198 (87.8)	273 (22.8)	0.839	661 (55.2)	0.278
Previous influenza vaccination	Ever	312 (22.9)			222 (71.2)	<0.001
Previous influenza vaccination	Never	1052 (77.1)			538 (51.1)	<0.001
Positive willingness	Yes	760 (55.7)	222 (29.2)	<0.001
Positive willingness	No	604 (44.3)	90 (14.9)	<0.001

Asthma = 50 (30.1%), Obesity = 46 (27.7%), Rhinitis/sinusitis = 11 (6.6%), Hypertension = 9 (5.4%), Inflammatory bowel disease = 9 (5.4%), Anemia = 7(4.2%), Others = 54 (32.5%).

Influenza vaccination uptake

Three hundred twelve (22.9%) students had received the influenza vaccine at least once in their lives. This included 70 students vaccinated during the index year, 77 the year before, and 193 in preceding years. Of those who had previously been vaccinated, the majority got the vaccine for free 200 (64.1%), and from a community pharmacy 80 (25.6%) (Table 2). Vaccine uptake showed statistically significant differences with sex, grade, residence, COVID-19 vaccination, and willingness to receive the vaccine in the future (Table 1). Furthermore, Logistic regression analysis identified six independent predictors of prior influenza vaccine uptake. These included female sex (AOR = 0.578 (CI: 0.444–0.752), being in the third (AOR = 0.605 (CI: 0.371–0.987)), fourth (AOR = 0.421 (CI: 0.225–0.786)), fifth and sixth academic years (AOR = 0.472 (CI: 0.261–0.856)), urban residence (AOR = 1.337 (CI: 1.026–1.742)), and having received three doses of the COVID-19 vaccine (AOR = 2.035 (CI: 1.213–3.413); Table 3).

Table 2.

Circumstances of vaccination and vaccine uptake in the vaccinated group.

Variable	Categories	N (%)
When did you get the vaccine^a	Index year	70 (22.4)
	The year before	77 (24.7)
	Previous years	193 (61.8)
Where did you get the vaccine from?	Community pharmacy	80 (25.6)
	Student Hospital	59 (18.9)
	Doctor’s office	49 (15.7)
	Microbiology Department	10 (3.2)
	Other	107 (34.3)
	Missing data	7 (2.2)
Free or paid?	Free	200 (64.1)
	Paid	104 (33.3)
	Missing data	8 (2.6)
Reasons for taking the vaccine	Protection of oneself and family members	252 (80.8)
	Protection of colleagues and patients	115 (36.9)
	Vaccination is available for free	71 (22.8)
	The Risk of getting an infection in medical students	67 (21.5)
	Vaccination is available at the university	36(11.5)
	I believe that I am at a higher risk of getting the flu this year due to COVID-19	35 (11.2)
	Having comorbidities (COPD-DM or other diseases)	17 (5.4)
	Missing data	4 (1.3)
Which influences your decision to get the flu vaccine?	Family	224 (71.8)
	Medical websites	86 (27.6)
	Friends	69 (22.1)
	Doctor’s office	60 (19.2)
	Social media	58 (18.6)
	Television	37 (11.9)
	Pharmacist/Pharmacy	35 (11.2)
	News	30 (9.6)
	Non-medical websites	12(3.8)
	Missing data	8 (2.6)
Source of knowledge about the vaccine	Mass media	90 (28.8)
	Health worker	85(27.2)
	Curricula of study	67 (21.5)
	Others	64 (20.5)
	Missing data	6 (1.9)
Did you get any side effects from the vaccine^b	Yes	62 (19.9)
	No	244 (78.2)
	Missing data	6 (1.9)

Ever been vaccinated group (N=312) includes those who received the vaccine during the index year, The year before previous years.

Side effects included fever 26 (41.9%), fatigue 18 (29%), headache 13(20.97%), flu-like symptoms 5 (8%), and others 30 (48.4%).

Table 3.

Predictors of previous influenza vaccination.

Variable		Univariate analysisCOR (95% CI)	p-Value	Multivariate analysisAOR (95% CI)	p-Value
Sex	Male	Ref.	<0.001	Ref.	<0.001
Sex	Female	0.569 (0.441–0.734)	<0.001	0.578 (0.444–0.752)	<0.001
Age	16–19	Ref.	-	Ref.	-
	20–22	0.815 (0.623–1.065)	0.134	1.313 (0.879–1.961)	0.183
	23 and more	0.8 (0.513–1.248)	0.326	1.481 (0.780–2.811)	0.230
University	Mansoura	Ref.	-
	Ain Shams	0.963 (0.625–1.485)	0.866
	Alexandria	0.991 (0.653–1.504)	0.965
	Suhag	1.267 (0.830–1.933)	0.273
	Minya	0.856 (0.542–1.351)	0.504
	Aswan	0.906 (0.615–1.337)	0.620
Grade	First	Ref.	-	Ref.	-
	Second	1.040 (0.719–1.505)	0.834	1.029 (0.690–1.534)	0.888
	Third	0.684 (0.479–0.977)	0.037	0.605 (0.371–0.987)	0.044
	Fourth	0.527 (0.319–0.870)	0.012	0.421 (0.225–0.786)	0.007
	Fifth or sixth	0.644 (0.429–0.967)	0.034	0.472 (0.261–0.856)	0.013
Residence	Rural	Ref.	0.032	Ref.	0.032
Residence	Urban	1.327 (1.025–1.719)	0.032	1.337 (1.026–1.742)	0.032
Smoker	Ever	Ref.	0.107	Ref	0.531
Smoker	Never	0.615 (0.340–1.111)	0.107	0.821 (0.442–1.524)	0.531
Self-reported with COVID-19	Yes	Ref.	0.390
Self-reported with COVID-19	No	0.888 (0.677–1.164)	0.390
Received COVID-19 vaccine	Never	Ref.	-	Ref.	-
	Single dose	1.186 (0.721–1.951)	0.501	1.346 (0.804–2.253)	0.259
	Two doses	1.083 (0.714–1.643)	0.707	1.261 (0.813–1.955)	0.301
	Three doses	1.914 (1.160–3.159)	0.011	2.035 (1.213–3.413)	0.007
Comorbidities	Yes	Ref.	0.839
Comorbidities	No	0.961 (0.655–1.410)	0.839

Side effects of the vaccine

The side effects from the vaccine were reported among 62 (19.9%) students. Fever (26 (41.9%)), fatigue (18 (29%)), and headache (13 (20.9%)) were the most reported side effects (Table 2).

Motives and barriers to receiving the influenza vaccine

The most frequently reported reason for taking the vaccine was to protect oneself and family members (252 (80.8%)), followed by the protection of colleagues and patients (115 (36.9%)). Most of the vaccinated students received information about influenza vaccination from mass media (90 (28.8%)) and health workers (85 (27.2%)). Family (224 (71.8%)), medical websites (86 (27.6%)), and friends (69 (22.1%)) had the greatest impact on the decision to get the flu vaccine (Table 2).

In contrast, 1052 (77.1%) students had never taken the influenza vaccine. The most frequently reported reasons for not taking the vaccine were lack of knowledge about recommended vaccinations (270 (25.7%)), followed by thinking that seasonal influenza is a trivial health problem, so there is no need for vaccination (268 (25.5%) (Table 4).

Table 4.

Reasons for not taking the vaccine among the never been vaccinated group.

Variable	Categories	N (%)
Why don’t you take the vaccine?	lack of knowledge about recommended vaccinations for healthcare workers & students	270 (25.7)
	Seasonal influenza is a trivial health problem - no need for vaccination	268 (25.5)
	Not aware of its value, administration, and dose	211 (20.1)
	Not sure of its efficiency	198 (18.8)
	Not available vaccine	126 (12.0)
	The possibility of getting influenza is low	118 (11.2)
	Concerns about vaccine safety and side effects	87 (8.3)
	I am afraid of needles	76 (7.2)
	A belief that the vaccine may induce influenza	50 (4.8)
	vaccine high cost	49 (4.7)
	Perception of vaccination ineffectiveness	33 (3.1)
	The vaccine is only for elderly people.	22 (2.1)
	A health problem that makes vaccination contraindicated	11 (1.0)
	Other	242 (23)
	Missing data	72 (6.8)

Willingness to receive influenza vaccination

Notably, 760 (55.7%) students were willing to take the vaccine in the future, with the majority from the never-been-vaccinated group (70.8%). Willingness showed statistically significant differences among students who received COVID-19 and influenza vaccination (Table 1). In addition, Logistic regression analysis identified three independent predictors of positive willingness to receive the vaccine. These included being from Alexandria University (AOR = 0.678 (CI: 0.465–0.989)), having received three COVID-19 vaccine doses (AOR = 1.805 (CI: 1.139–2.861)), and never receiving an influenza vaccine (AOR = 0.432 (CI: 0.328–0.569); Table 5).

Table 5.

Predictors of willingness to receive influenza vaccine in the future.

Variable		Univariate analysisCOR (95% CI)	p-Value	Multivariate analysisAOR (95% CI)	p-Value
Sex	Male	Ref.	0.220
Sex	Female	0.874 (0.704–1.084)
Age	16–19	Ref.	-
	20–22	0.948 (0.754–1.191)	0.646
	23 and more	1.234 (0.848–1.796)	0.273
University	Mansoura	Ref.	-	Ref.
	Ain Shams	0.704 (0.489–1.015)	0.060	0.697 (0.479–1.015)	0.060
	Alexandria	0.676 (0.475–0.964)	0.030	0.678 (0.465–0.989)	0.044
	Suhag	0.928 (0.638–1.349)	0.695	0.922 (0.613–1.385)	0.694
	Minya	0.812 (0.556–1.185)	0.279	0.868 (0.573–1.315)	0.504
	Aswan	0.954 (0.687–1.326)	0.781	1.009 (0.698–1.459)	0.963
Grade	First	Ref.	-	Ref.	-
	Second	1.148 (0.822–1.604)	0.417	1.016 (0.686–1.506)	0.935
	Third	1.137 (0.837–1.546)	0.410	1.115 (0.789–1.577)	0.536
	Forth	0.705 (0.474–1.047)	0.083	0.760 (0.490–1.180)	0.221
	Fifth or sixth	0.996 (0.708–1.400)	0.980	1.113 (0.761–1.630)	0.581
Residence	Rural	Ref.	0.772
Residence	Urban	1.032 (0.832–1.280)	0.772
Smoker	Ever	Ref.	0.329
Smoker	Never	0.754 (0.428–1.329)	0.329
Self-reported with COVID-19	Yes	Ref.	0.519
Self-reported with COVID-19	No	1.079 (0.856–1.360)	0.519
Received COVID-19 vaccine	Never	Ref.	-	Ref.
	Single dose	1.558 (1.034–2.349)	0.034	1.515 (0.987–2.324)	0.057
	Two doses	1.305 (0.933–1.826)	0.120	1.285 (0.898–1.838)	0.170
	Three doses	1.852 (1.193–2.875)	0.006	1.805 (1.139–2.861)	0.012
Comorbidities	Yes	Ref.	0.278
Comorbidities	No	0.833 (0.599–1.159)	0.278
Previous influenza vaccination	Ever	Ref.	<0.001	Ref.	<0.001
Previous influenza vaccination	Never	0.424 (0.323–0.558)	<0.001	0.433 (0.328–0.571)	<0.001

Discussion

This is the first study in Egypt to estimate influenza vaccination coverage, beliefs, barriers, motives, and willingness among medical students to receive the vaccine. The influenza vaccine uptake was 22.4% during the index year, slightly lower than the uptake reported in the preceding year (24.7%). Additionally, the percentage of students who had ever been vaccinated was 22.9%. This index year is notably lower than in some countries, including Italy (39%),²³ and China in 2021 (25.8%).²⁴ However, it exceeds rates reported in countries such as Saudi Arabia (20.7%),¹⁹ Cyprus (20.1%),²⁵ Poland (16.5%),²⁶ Germany (12.9%),²⁷ and China in 2019 (6.7%).²⁴ These variations may be attributed to differences in public awareness, vaccine availability, affordability, and national vaccination policies. In Egypt, influenza vaccination is not mandatory, which may contribute to the lower coverage rates. In contrast, a study conducted in Egypt among HCWs reported that 46.8% had received the influenza vaccine at least once. This high rate may be due to awareness of influenza-related risks and higher occupational exposure to infection among HCWs. Moreover, the vaccine is mandatory and available for free in certain specialties, such as chest and tropical medicine.²⁸

Lower influenza vaccine uptake was observed among females compared to males, contrary to the findings reported in Germany,²⁷ Saudi Arabia,¹⁹ and China.²⁴ That could be attributed to multiple factors such as misconceptions, fear of side effects or needles, lack of awareness, cultural beliefs, economic barriers, and personal health perceptions. Specifically, this study observed a statistically significant difference between males and females regarding two barriers: fear of needles and uncertainty about vaccine effectiveness. These findings highlight the need for awareness campaigns to address these concerns and enhance vaccine uptake among female medical students. Additionally, vaccine uptake was low among students in their third through sixth academic years. This may be due to vaccine fatigue, apathy, or a perception of lower vulnerability to influenza compared to HCWs. These findings highlight the importance of integrating comprehensive curricula to emphasize vaccine uptake and personal awareness of self-protection during clinical training years. Furthermore, the proportion of vaccinated students was higher among those from urban areas than rural areas, possibly due to differing beliefs, cultures, and socioeconomic status. Notably, vaccination uptake was higher among students who had received three doses of the COVID-19 vaccine. This may reflect a greater trust in vaccines, better health-seeking behaviors, and increased awareness of the importance of vaccination after the COVID-19 pandemic.

The majority of students (64.1%) received the influenza vaccine for free, primarily from community pharmacies (25.6%). Additionally, the free availability of the vaccine was one of the main reasons for vaccination (22.8%). In contrast, among the never-vaccinated group, 12% cited vaccine unavailability and 4.7% mentioned high cost as reasons for not being vaccinated. These findings may be due to a lack of awareness among medical students regarding healthcare centers that offer free influenza vaccines. Moreover, family influence was the most frequent reason for the decision to receive the vaccine, reported by 71.8% of the students who had ever been vaccinated. In contrast, family influence ranked third in Saudi Arabia.¹⁹ This shows the highly influential role of Egyptian families. Social media and television played a minor role in students’ decisions, as they represented 18.6% and 11.9%, respectively, while they were higher in 2019 in China (48.6%).²⁴ This reflects more trust in families and doctors than in the media in Egypt. Moreover, the main source of information about the vaccine came from mass media (28.8%), but this rate is close to other sources of information, such as health workers (27.2%), while healthcare professionals were the main source in China in 2021.²⁴

Data revealed that 19.9% of vaccinated persons had side effects, a higher percentage than reported in a Saudi Arabian study (6.7%).¹⁹ The difference may be due to variations in vaccine dose, manufacturing processes, preparation methods, circulating virus strains, and population genetics.

Important motives for vaccination among students were related to safety concerns. The most frequently reported reasons were protecting themselves and family members (80.8%) and protecting colleagues and patients (36.9%). This finding aligns with results from a study conducted in Germany,²⁷ but patient safety was prioritized over family safety. The perception of a higher risk of infection among medical students (21.5%) also plays a significant role, as medical students are always in close contact with patients during clinical rounds. The COVID-19 pandemic appeared to influence vaccination behavior, including the decision to receive the influenza vaccine, and generally increased awareness of viral infections and the importance of immunization. Among the ever-vaccinated group, 11.2% of students believed they were at a higher risk of getting influenza due to COVID-19. In addition, a study conducted in China found that 96% of students believed the COVID-19 pandemic enhanced their awareness of influenza infection and vaccination.²⁴

This study identified 13 barriers to influenza vaccination. The most prominent barriers included lack of knowledge (25.7%), the misconception that influenza is a trivial disease (25.5%), and insufficient awareness regarding vaccine value, administration, and dosage (20.1%). Doubts about its efficacy (18.8%), unavailability (12%), and low risk of getting the disease (11.2%) came next. On the other hand, A study conducted in Germany reported that the main barriers to influenza vaccination are the perception of not being at risk (43.9%) and the belief that influenza is not a serious disease (21.7%),²⁷ while in Saudi Arabia, the most commonly reported concerns included feeling not at risk 37.9%, fear of side effects 28.9%, and doubts about vaccine effectiveness (14.5%).^19,27 These differences may be attributed to the timing of the studies, as the German one was conducted before the COVID-19 pandemic, or other factors such as social, cultural, or educational factors. In contrast, this study reported that the least frequent reasons for not receiving the vaccine were fear of needle (7.2%), influenza induction (4.8%), and medical contraindication (1.0%), in comparison to the study conducted in Germany, in which they were 0.8%, 4.9%, and 1.9%, respectively.²⁷

The willingness of medical students to receive the influenza vaccine in the future was 55.7%, which is lower than that reported in Saudi Arabia (68%).¹⁹ Students who previously received both the influenza vaccine and the COVID-19 vaccine had a higher intention to receive it in the future, indicating good perception and awareness of its importance. In addition, among the selected universities, students of Alexandria University exhibited lower willingness to receive the influenza vaccine, perhaps due to the vaccine unavailability and inadequate awareness campaigns. Moreover, students who had received three doses of the COVID-19 vaccine were more likely to receive the influenza vaccine, reflecting a broader trend in vaccine acceptance and perception. This may be influenced by the social environment that increased awareness of vaccine importance and encouraged preventive health behaviors during the COVID-19 pandemic. While some individuals may have health concerns that significantly influence their willingness to be vaccinated; it remains unclear whether this willingness will be sustained or is limited to the COVID-19 crisis. This may also be attributed to the increased availability of the influenza vaccine during the COVID-19 pandemic. Notably, it has been reported that the COVID-19 pandemic had a positive impact on the influenza vaccine supply in several Arab countries, including the United Arab Emirates, Qatar, Kuwait, Bahrain, Saudi Arabia, and Oman; however, the impact was mixed in other countries, with Iraq reporting a decrease in supply and Palestine reporting an increase.¹³ In contrast, there is no significant association between prior COVID-19 infection and willingness to receive the influenza vaccine, suggesting that experiencing COVID-19 alone may not be a strong motivator to influence preventive behaviors against similar illnesses like seasonal influenza. In addition, students who had never received the influenza vaccine were less likely to get vaccinated in the future, which may be attributed to a lack of awareness, high cost, or limited accessibility to healthcare services.

Recommendations

Raising awareness about vaccines among medical students through scientific days and seminars that focus on correcting incorrect beliefs regarding vaccine effectiveness and safety is highly recommended. Using the power of social media and adding more knowledge about the influenza vaccine and its importance in medical students’ curricula are necessary. University administrators could have a major role in reminding students during influenza seasons to take the vaccine, making the vaccine more available, and highlighting the places free of charge to all students. Additionally, future studies should consider the acceptance and feasibility of seasonal influenza vaccination policies among this high-risk group. Moreover, policymakers may play a crucial role in raising influenza vaccination uptake by implementing mandatory vaccination programs, securing adequate resources and funding for the production, storage, distribution, and administration of vaccines, to ensure greater access and higher acceptance of the influenza vaccine.

Strengths

This study is the first of its kind to assess influenza vaccine uptake, acceptance, refusal, main side effects, and willingness to receive the vaccine in the future among medical students in Egypt. The study included a large sample of students from six universities that were geographically selected to enhance the generalizability and precision of the study’s results.

Limitations

The study used a self-reporting questionnaire that had the possibility of under- or over-estimation. Recall bias may affect the responses. Additionally, the questionnaire was online, so there may be survey fatigue or an inability to interpret the Sentiment behind the answers, and it might even exclude some student populations due to poor or unstable internet connection, digital literacy, or even limited devices. Moreover, given the cross-sectional nature of the study, it was not feasible to establish causal relationships, despite the potential existence of associations between the variables.

Conclusion

This study found that influenza vaccine uptake among Egyptian medical students in the academic year 2022–2023 was low, but promisingly, there is a slightly higher intention to have it in the future. Protecting themselves, their families, colleagues, and patients is the most common motive to receive the influenza vaccine. Comprehensive awareness programs are needed to improve students’ knowledge and enhance vaccine uptake, and it is recommended to make vaccines available for free at the university level.

Supplemental Material

sj-docx-1-phj-10.1177_22799036251362296 – Supplemental material for Influenza vaccination coverage and associated factors among medical students in Egypt: A cross-sectional multicenter study

Supplemental material, sj-docx-1-phj-10.1177_22799036251362296 for Influenza vaccination coverage and associated factors among medical students in Egypt: A cross-sectional multicenter study by Mohamed A. Elzayat, Shorouq A. Kassab, Gehad Gamal Mohamed, Alyaa S. Moselhy and Abdel-Hady El-Gilany in Journal of Public Health Research

Footnotes

Acknowledgements

Alpha Research Organization (ARO) team of collaborators: Aya F. Abo Eissa, Amira E. El-Shreef, Mohamed N. Abdelsabour, and Ahmed A. Elkeshky. We would like to thank Mahmoud Ahmed for his minor role in data collection.

List of abbreviations

ARO: Alpha Research Organization.

COVID-19: coronavirus disease of 2019.

AOR: Adjusted odds ratio.

WHO: World Health Organization.

HCWs: healthcare workers.

MFM-IRB: Mansoura Faculty of Medicine Institutional Research Board.

SPSS: Statistical Package for Social Studies.

COR: Crude odds ratio.

CI: Confidence intervals.

USA: United States of America.

ORCID iDs

Mohamed A. Elzayat

Shorouq A. Kassab

Gehad Gamal Mohamed

Alyaa S. Moselhy

Abdel-Hady El-Gilany

Ethical considerations

Ethical approval was provided by the Institutional Research Board of the Faculty of Medicine at Mansoura University (MFM-IRB; code: MD.22.07.666.R1.R2).

Consent to participate

Participants voluntarily took part in the online anonymity-based questionnaire without receiving any compensation. They provided electronic informed consent and had the flexibility to complete the questionnaire at their convenience. They were informed that they had the option to discontinue the survey at any point if desired.

Author contributions

Conception and design of the study were done by ME, SK, GM, AM, and AE. Acquisition of data was done by ME, SK, and GM. Analysis and interpretation of data were done by ME and AE. Drafting the manuscript was done by ME, SK, and GM. Revising the manuscript critically for important intellectual content was done by ME, SK, AM, and AE. Approval of the version of the manuscript to be published was done by ME, SK, GM, AM, and AE.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data availability statement

The datasets generated and/or analyzed during the current study are available from the corresponding author upon reasonable request.

Supplemental material

Supplemental material for this article is available online.

References

Nuwarda

Alharbi

Kayser

. An overview of influenza viruses and vaccines. Vaccines 2021; 9(9): 1032.

CDC. Flu symptoms & complications. CDC, https://www.cdc.gov/flu/symptoms/symptoms.htm (3 October 2022, accessed 29 July 2023).

WHO. Influenza (Seasonal), https://www.who.int/news-room/fact-sheets/detail/influenza-(seasonal) (12 January 2023, accessed 29 July 2023).

Fahim

Deghedy

Alim

, et al. The national burden of influenza-associated respiratory illness across levels of severity in Egypt, 2016-2019. Influenza Other Respi Viruses 2024; 18(12): e70061.

Han

Ran

Mak

, et al. Smoking and influenza-associated morbidity and mortality: a systematic review and meta-analysis. Epidemiology 2019; 30(3): 405–417.

Buchman

Simpson

Sciarretta

, et al. Seasonal influenza vaccination is associated with reduced risk of death among Medicare beneficiaries☆. Vaccine 2021; 39(52): 7569–7577.

Paules

Sullivan

Subbarao

, et al. Chasing seasonal Influenza - the need for a universal influenza vaccine. N Engl J Med 2018; 378(1): 7–9.

Tregoning

Russell

Kinnear

. Adjuvanted influenza vaccines. Hum Vaccin Immunother 2018; 14(3): 550–564.

Kim

Webster

Webby

. Influenza virus: dealing with a drifting and shifting pathogen. Viral Immunol 2018; 31(2): 174–183.

10.

Rodríguez-Blanco

Tuells

. Knowledge and attitudes about the flu vaccine among pregnant women in the Valencian Community (Spain). Medicinar 2019; 55(8): 467.

11.

CDC. Who needs a flu vaccine. CDC. https://www.cdc.gov/flu/prevent/vaccinations.htm (13 September 2022, accessed 29 July 2023).

12.

Grohskopf

Blanton

Ferdinands

, et al. Prevention and control of seasonal Influenza with vaccines: recommendations of the advisory committee on immunization practices — United States, 2022–23 Influenza season. MMWR Recomm Rep 2022; 71(1): 1–28.

13.

Attia

Abubakar

Bresee

, et al. A review of policies and coverage of seasonal influenza vaccination programs in the WHO Eastern Mediterranean Region. Influenza Other Respi Viruses 2023; 17(3): e13126.

14.

Betsch

Wicker

. E-health use, vaccination knowledge and perception of own risk: Drivers of vaccination uptake in medical students. Vaccine 2012; 30(6): 1143–1148.

15.

Pelly

Pierrynowski MacDougall

Halperin

, et al. THE VAXED PROJECT: an assessment of immunization education in Canadian health professional programs. BMC Med Educ 2010; 10(1): 1–9.

16.

Plans-Rubió

. The vaccination coverage required to establish herd immunity against influenza viruses. Prev Med 2012; 55(1): 72–77.

17.

Kim

. Seasonal influenza and vaccine herd effect. Clin Exp Vaccine Res 2014; 3(2): 128–132.

18.

Sanftenberg

Roggendorf

Babucke

, et al. Medical students’ knowledge and attitudes regarding vaccination against measles, influenza and HPV. An international multicenter study. J Prev Med Hyg 2020; 61(2): E181–E185.

19.

Abalkhail

Alzahrany

Alghamdi

, et al. Uptake of influenza vaccination, awareness and its associated barriers among medical students of a University Hospital in central Saudi Arabia. J Infect Public Health 2017; 10(5): 644–648.

20.

Lee

Aung

Chin

, et al. Factors affecting medical students’ uptake of the 2009 Pandemic Influenza A (H1N1) vaccine. Influenza Res Treat 2012; 2012(1): 753164.

21.

Zhang

Harapan

Rajamoorthy

, et al. The relationship between influenza and COVID-19 vaccine uptake in a cross-sectional study in China, Indonesia, Malaysia, and the United States. Asia Pac J Public Health 2023; 35(4): 308–310.

22.

von Elm

Altman

Egger

, et al. The strengthening the reporting of observational studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. PLoS Med 2007; 4: e296.

23.

Gallone

Cappelli

, et al. Medical students’ attitude toward influenza vaccination: results of a survey in the University of Bari (Italy). Hum Vaccin Immunother 2017; 13(8): 1937–1941.

24.

Wang

Jiang

, et al. Does COVID-19 have an impact on influenza vaccine knowledge, attitude and practice among medical students: a 2-year prospective cohort study. BMJ Open 2022; 12(9): e055945.

25.

Strouthou

Karageorgos

Christaki

, et al. Medical students’ attitudes and perceptions of influenza and SARS-CoV-2 vaccination in Cyprus. Germs 2022; 12(2): 180–194.

26.

Banaszkiewicz

Talarek

Śliwka

, et al. Awareness of influenza and attitude toward Influenza vaccination among medical students. Adv Exp Med Biol 2016; 934: 83–88.

27.

Lehmann

Ruiter

Wicker

, et al. Medical students’ attitude towards influenza vaccination. BMC Infect Dis 2015; 15(1): 185–187.

28.

Hakim

Amin

Allam

, et al. Attitudes, beliefs and practice of Egyptian healthcare workers towards seasonal influenza vaccination. Influenza Other Respi Viruses 2021; 15(6): 778–788.

Supplementary Material

Please find the following supplemental material available below.

For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.

For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.

0.00 MB

0.03 MB