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Background: Preventing COVID-19 in Gaza is crucial due to the devastation of advanced health services infrastructure by war. Despite the high protection offered by COVID-19 vaccines against severe disease, a 2021 survey in Gaza found only half of the population was vaccinated, and one-third was vaccine-hesitant. This follow-up study conducted in March 2023 aimed to re-evaluate vaccination levels, hesitancy, exposure to vaccine promotion efforts, and other risk factors in Gaza. Methods: A community-based cross-sectional survey with multistage stratified sampling was used. Associations of primary exposures and other determinants with vaccine status and hesitancy were quantified using bivariate and multivariable logistic regression. Results: In 2023, 63.5% of adults received at least one vaccine dose compared to 49.1% in 2021 (p < 0.001). Vaccine hesitancy prevalence was 31.7% in 2023 versus 34.1% in 2021 (p = 0.395). Adjusted odds of vaccination were 4.2 times higher among those referred by health workers compared to those not referred. Adjusted odds of vaccine hesitancy among those who received information on the vaccine from health workers were 0.3 times that of people who did not receive information. Conclusions: Results suggest health workers could play a crucial role in future vaccination strategies, as their vaccine promotion efforts were linked to better vaccine outcomes. Investing in the skills development of community health workers to contribute to these efforts is recommended. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]