Behavioral Patterns Toward COVID-19 Vaccination Analyzed in Patients With Autoimmune and Inflammatory Diseases

doctor administering vaccine to patient
Doctor gives corona virus vaccine, home care service concept
Researchers aimed to examine behavioral patterns with regard to vaccination against SARS-CoV-2 to identify pragmatic actions to increase vaccine coverage in this population.

In patients with autoimmune and inflammatory rheumatic diseases (AIIRDs), willingness to receive a SARS-CoV-2 vaccine was found to be limited, according to results of an analysis published in Rheumatology (Oxford). Significant behavioral differences were noted between patients who were willing and those who were unwilling to receive the COVID-19 vaccines.

In the study, the researchers examined behavioral patterns with respect to SARS-CoV-2 vaccination in patients with AIIRDs to identify pragmatic actions that might result in increased vaccine coverage in this population.

A hierarchical cluster analysis — the VAXICOV study — was conducted to identify the variables independently associated with readiness to be vaccinated against COVID-19. The investigative tool in VAXICOV was an online questionnaire of 57 questions that addressed sociodemographic, epidemiologic, and therapeutic elements linked to expectations and potential concerns about the SARS-CoV-2 vaccine. The survey was conducted between December 12, 2020, and December 21, 2020, in 56 countries. For native speakers, the questionnaire was translated from English into French and Spanish.

All study participants had a self-reported diagnosis of AIIRDs. The main study outcomes included demographic features (age, prior chronic medical conditions, marital status, children, income, and profession); experiences related to COVID-19; intention to be vaccinated if a COVID-19 vaccine were available; fears and expectations about COVID-19 vaccination; vaccine hesitancy; and history of vaccination against seasonal influenza and pneumococcus. Participants rated their feelings about COVID-19 vaccination on a scale of 0 to 10, with 0 denoting “not at all in agreement” and 10 denoting “fully agree.” An “immunocompromised” status was defined as a participant who was taking 1 or more immunosuppressant agents or glucocorticoids at a dose greater than 10 mg per day of prednisone-equivalent.

A total of 1258 patients with AIIRDs (1138 women) participated in the study. Median participant age was 50 years. The most common inflammatory or autoimmune disorders among the participants were systemic lupus erythematosus (n=492), spondyloarthritis (n=174), rheumatoid arthritis (n=157), and polymyalgia rheumatica/giant cell arteritis (n=144).

Using hierarchical cluster analysis based on 5 questions from the VAXICOV survey that were independently associated with willingness to be vaccinated against SARS-CoV-2, the researchers identified 3 distinct clusters of patients with AIIRDs: cluster 1 (n=180), cluster 2 (n=688), and cluster 3 (n=390). Vaccine willingness differed significantly across the 3 clusters (P <.0001), but no significant differences were reported with respect to fear of getting COVID-19, including severe COVID-19 (P =.11); presence of comorbidities (P =.23); use of glucocorticoids (P =.21); or immunocompromised status (P =.63).

There were 3 predominant patterns of behavior toward COVID-19 vaccination, including “voluntary” (cluster 1), “hesitant” (cluster 2), and “suspicious” (cluster 3). In cluster 1, patients were the most willing to get vaccinated (97.2% were willing, 1.7% were unsure, and 1.1% would decline vaccination). Participants from cluster 2 were more hesitant overall (64.8% willing, 30.1% unsure, and 5.1% would decline vaccination). In cluster 3, participants were the most strongly opposed to receiving a vaccine (15.6% willing, 49.7% unsure, and 34.6% would decline the vaccine).

Reported patterns were similar even if the physicians advised their patients to get vaccinated. The most trusted health care professional across the 3 clusters was the “medical specialist,” trusted by 70.0% of participants from cluster 1, 70.9% from cluster 2, and 68.0% from cluster 3. However, 14.1% of participants from cluster 3 did not trust any health care professional, compared with 0.6% from cluster 1 and 4.9% from cluster 2 (P <.0001). Further, compared with patients from clusters 1 and 2, patients from cluster 3 were significantly more concerned about vaccination in general, use of a new (mRNA) vaccine technology, and potential financial links between governments and pharmaceutical companies (P <.0001).

Researchers concluded, “This study may serve as a basis for improved communication, to increase COVID-19 vaccine coverage in [patients with] AIIRD.”

Disclosures: Multiple study authors declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of disclosures.


Felten R, Dubois M, Ugarte-Gil MF, et al. Cluster analysis reveals 3 main patterns of behavior towards SARS-CoV-2 vaccination in patients with autoimmune and inflammatory diseases. Rheumatology (Oxford). Published online May 13, 2021. doi:10.1093/rheumatology/keab432