Covid-19 vaccination among migrants in Rome, Italy | Scientific … – Nature.com

In 2021, among 1,731,832 residents in Rome aged 1864, migrants from HMPCs were 55% less likely to uptake at least one COVID-19 vaccine dose than their Italian counterpart, independently of age and area deprivation index. Past SARS-CoV-2 infection reduced the difference between migrants and Italians to 27%, explained by an increase in vaccination uptake after the infection among migrants and a decrease among Italians. Among migrants from HMPCs, we observed a slight excess of vaccination uptake among females compared to males; while, focusing on geographical areas of origin we did observe that only females from central-western Asia were 9% less likely to uptake vaccination than males. The additional analysis showed comparable results.

Some limitations should be considered. Suppose there were different patterns of vaccination uptake, inside or outside the region, between migrants and Italians. In that case, the observed associations might be biased as we accessed only data from Lazio (the region of Rome). Mobility among migrants may be higher than among non-migrants, which would cause an underestimate of vaccination coverage and bias the observed hazard ratios toward the lower bound. Nevertheless, we studied the resident population, and resident migrants are likely less prone to mobility than non-resident migrants. In addition, due to pandemic restrictions, it is likely that during 2021 mobility was reduced. Another limitation may be related to the record-linkage procedures that could be less efficient among the migrant population than Italians. This would again yield an underestimation of vaccination uptake among migrants. Concerning the adjustment for the deprivation index, based on 2011 Census data, any change in the social tissue that occurred over ten years might imply misclassification. In relation to other sources of confounding, we could adjust only for major factors (age, DI), while other factors, like comorbidities, occupation, or marital status, might also play a role. Finally, contextual factors changing over time, such as fluctuating mobility restrictions, risk of infection, or policies oriented to mandatory vaccination, might directly or indirectly affect the associations. However, the interpretation of models that include calendar time, with cut-offs appropriate for each factor, would be complex. As such, we decided not to adjust or stratify for calendar time in the present study.

The results indicate the vulnerability of migrants residing in Rome concerning COVID-19 vaccination access in 2021 and suggest inequalities in health. Lower vaccination uptake has also been observed in an Italian study conducted in Lazio, the administrative region of Rome, which found that foreign residents have a triple probability of Italians not accessing the vaccine12, and in a study conducted in a Local Health Authority in Rome13. Furthermore, a lower vaccination coverage among foreigners has also been observed in a study conducted in Brescia Province, one of the most dramatically hit by COVID-19 at the beginning of the pandemic15. To interpret the findings, we should consider that COVID cases among migrants might have different characteristics affecting the risk of infection and the need to be vaccinated. Among these, later diagnoses and poorer outcomes in COVID cases among foreigners compared to Italians were reported10,11. In the study conducted by a Local Health Authority in Rome, HMPC citizens were younger than Italians, less likely to be frail and more likely to receive the less effective brand of vaccine (Janssen)13. However, we do not have striking evidence of different risks of infection among immigrants in Italy, though it is possible to argue that the lack of findings is the consequence of the lower access to diagnostic tests16,17. Concerning the young age structure of migrants, in our study, we selected 1864-year-olds, reducing the age gap between Italians and immigrants (mean age 43.8 vs 41.6, Table 1) and, as such, differences in frailty. At the international level, several studies analysed the association between ethnicity and vaccination uptake, using different study designs and measures from our own. For example, in a study conducted over 24 million adults in England, the first dose of COVID-19 vaccination was lower among all ethnic minority groups compared with white British adults18. Another study conducted in Denmark over 4.9 million individuals aged 12 years or more in 2021 found that non-vaccination was most pronounced among migrants or descendants19. In contrast, a study conducted in Switzerland did not find an association between Swiss-born and foreign-born individuals20. We also observed that women from central-western Asia showed lower vaccination coverage than men. In this area, the most prevalent origin countries of subjects living in Rome are Bangladesh, India, Sri Lanka, and Pakistan, and most subjects are males. Most central-western Asian women typically come to Italy for family reunification. They are often unemployed and have few social contacts21. All these aspects may partly explain the lower vaccination coverage among women in this subgroup of migrants.

Various factors in the literature have been identified as possible explanations for low vaccine uptake and hesitancy, for example, the delay in acceptance or refusal of vaccines despite availability of vaccination services22 among migrants. A systematic review exploring barriers and facilitators of vaccine uptake has identified language, literacy, communication, practical, legal, and service barriers in the uptake of vaccines1. In our country, access barriers to health services have been identified for migrants23. These barriers also played a role in the vaccination uptake, especially at the beginning of the vaccination campaign. Later, on 15 October 2021, the vaccine became mandatory for all people over 50 years and for occupied people. Then, the possession of a green pass, a document certifying the vaccination, was imposed at work to demonstrate full vaccination coverage24. According to the 3C model on vaccine hesitancy developed by the SAGE Working Group, three main factors influence vaccine uptake: confidence, complacency, and convenience barriers22. In a recent systematic review performed to synthetise qualitative studies on the reasons for vaccine hesitancy among migrants, the Authors found the confidence dimension of the 3C model, that is, people are vaccine hesitant because they have low confidence in the vaccines effectiveness and safety and distrust scientists, policymakers and health professionals22, represents a disproportionately large barrier to vaccine uptake in ethnic minority groups25. We argue that the confidence dimension may explain vaccine hesitancy among the migrants in Italy because communication during the vaccination campaign was challenging due to linguistic barriers and the different health literacy of migrants compared to Italians, despite some communication strategies adopted in the country26. Health literacy may be associated with vaccination, although evidence is scarce27. In addition, the convenience dimension, that is people are vaccine hesitant because there are a number of barriers (physical, logistical or economical) that hinder them from getting a vaccine22, may have represented another important explanation for the vaccine hesitancy among migrants in Italy. In fact, it is already documented that migrants encounter, in Italy23,28 as in other European countries29, various barriers in accessing health services that during the pandemic may have represented a critical issue for COVID-19 prevention30,31. In addition, we argue that since migrants in Italy are often employed in temporary and precarious jobs32,33, their intention to be vaccinated may be undermined by the fear of possible vaccine collateral effects limiting their chance to work. The ECDC suggests various approaches to strengthening vaccine uptake in migrants. Some of them may be particularly relevant in Italy and adopted, such as the provision of simple, accurate culturally-relevant resources about the COVID-19 vaccine in a range of languages, literacy levels and formats and the provision of cultural mediators in primary care34. In addition, the availability of data stratified by origin country and other relevant factors, such as gender and socioeconomic status, is of paramount relevance as it allows the calculation of immunisation indicators across subgroups of the population35 and highlights the unmet prevention needs of vulnerable groups. For the generalizability of results, although our evaluation covers the population living in a single city only, the findings can, in part, be indicative of differences in vaccination coverage between Italians and migrants in our country, as the study was based on a vast city (2.7 million inhabitants), and a whole population, and access to vaccination was offered to all residents, both Italians and non-Italians, without restrictions in all the Italian regions.

In conclusion, migrants residing in Rome, Italy, showed a lower uptake of COVID-19 vaccination over the first year of the vaccination campaign, independently of socioeconomic factors. Vaccination uptake was lower among migrant women from central-western Asia than migrant males. Health communication strategies oriented to migrants and considering their different languages, cultures, and health literacy, as well as the possible interactions of the provenience country with gender, should be adopted to prevent and reduce inequalities, preferably before emergencies.

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Covid-19 vaccination among migrants in Rome, Italy | Scientific ... - Nature.com