Abstract
BACKGROUND: The Gaza Strip, like other settings of complex humanitarian emergencies, faces immense challenges in vaccinating its population against COVID-19. This study was conducted in October 2021 among Gaza's adult population and healthcare workers (HCWs). The primary aim was to estimate two indicators, coverage of COVID-19 vaccination and the prevalence of vaccine hesitancy. The secondary aim was to evaluate the two indicators' associations with globally identified risk factors. METHODS: A cross-sectional study was conducted using a population-based survey of adults and a purposive survey of HCWs in Gaza. A multi-stage sampling design was used for the population survey component. For the HCW component, five health facilities were purposively selected as entry points; HCWs in the facilities holding clinical or other specialized positions were approached to participate in the survey. Data were summarized as univariable descriptive statistics with unweighted and weighted point estimates. Logistic regression was used to evaluate associations of risk factors with vaccination status and vaccine hesitancy. RESULTS: A total of 1075 individuals were surveyed, of whom 906 were community members and 169 were HCWs. Population-weighted vaccine coverage was estimated to be 49.08% (95% CI 43.10-55.08). 89.35% of HCWs were vaccinated. Population-weighted vaccine hesitancy was estimated to be 34.08% (95% CI 28.14-40.56) in the overall population and 67.24% (95% CI 49.04-81.41) among the unvaccinated sub-group. In logistic regression vaccination was independently associated with male sex (aOR 1.88, p = 0.006, 95% CI 1.20-2.95), older age (40+ vs. 18-39 age group) (aOR 1.92, p < 0.001, 95% CI 1.73-2.13), higher education (aOR 2.19, p < 0.001, 95% CI 1.51-3.17), and confidence in the safety of the vaccine (aOR 13.8, p < 0.001, 95% CI 10.1-18.8). Risk factors for hesitancy were similar to those identified for vaccination status, however hesitant individuals were somewhat more likely to obtain vaccine information from family members (aOR 1.29, p = 0.051, 95% CI 1.00-1.67) and less likely to trust healthcare providers (aOR 0.58, p < 0.001, 95% CI 0.49-0.68). CONCLUSIONS: The continued emergence of SARS-CoV-2 variants reinforces the importance of achieving high levels of vaccination coverage globally-a difficult undertaking in Gaza. This study estimated half of Gaza's adult population received at least one dose of any COVID-19 vaccine by October 2021, and the majority of unvaccinated individuals were hesitant. Disparities in vaccination across the territory's demographic groups underscore the need for targeted outreach to these populations and messaging through community-based channels to permeate social networks of the unvaccinated.