Our aim in this study is to increase vaccination rates in rheumatic diseases such as RA and to draw attention to the need in this regard. In recent years, especially in developed countries, there has been a reluctance to get vaccinated all over the world due to skepticism, hesitation and disbelief in the benefits and protection of vaccines. Rheumatologists can inform their patients about the safety and efficacy of vaccines in inflammatory rheumatic diseases and emphasize the importance of the vaccination process in reducing the risk of infection and complications. They can play an important role in reducing vaccine hesitancy and increasing vaccination rates in this group of patients by engaging in patient education initiatives and actively recommending and encouraging vaccinations. In the light of these data, the vaccination rates in the entire patient group was observed to be below the expected level. At the same time, only 40.2% of patients received vaccination education. However, older age (for influenza, pneumococcus, and HBV), urban residence (for influenza, HAV, and HBV), and high frequency of physician visits (for influenza, pneumococcus, and HBV) were determinants of multiple vaccinations. Interestingly, low income (for influenza, pneumococcal, and HBV) was observed at a higher rate in groups with higher vaccination rates. On the other hand, multivariate analysis found that rural area (for Haemophilus influenza and HAV vaccines) and financial income (Pneumococcal vaccine) in specifically were associated with increased vaccination rates. Additionally, the rate of vaccination education was significantly higher in the vaccinated group for all vaccine types, which is noteworthy as a result of the positive effect of education on vaccination.

Currently, a high incidence of influenza-induced infectious diseases is observed in RA patients compared to the normal population. This situation increases the importance of influenza vaccination in the follow-up of RA patients [18]. On the other hand, the current literature emphasizes that influenza vaccination rates are not at an adequate level [19]. In a study by Hmamouchi et al. in which 3920 RA patients from 17 countries were evaluated, the mean influenza vaccination rate was 25.3%. In addition, the vaccination rate varied between countries from 1 to 66%. Furthermore, in countries where vaccination is more common, predictive factors for vaccination were found to be older age, lower disease activity, higher education level, use of biologic agents, absence of corticosteroid treatment, and presence of comorbidities [20]. In another study conducted by Ta et al. in Canada, the vaccination rate of RA patients before diagnosis was 38%, and this rate increased by only 8% after diagnosis to reach 46%. This shows that although the disease is diagnosed, the awareness and practice of vaccination are at a low level [21]. In fact, in the present study, the influenza vaccination rate was 34.3%, which is below the social vaccination target [22]. In addition, advanced age, vaccination education, urban residence, long disease follow-up, and frequent medical check-ups were significantly higher in the vaccinated group, which supports the current literature [20, 23]. Interestingly, the level of low financial income was higher in the vaccinated group in our study, which differs from the classical paradigm, emphasizing that vaccination increases in parallel with income level in the current literature [24]. In conclusion, the variables underlying the variation in influenza vaccination between countries are at different levels in our study.

In studies in the current literature, several factors influence the pneumococcal vaccination rate, and this rate varies between countries. In a study conducted by Schmedt et al. in a large German cohort of approximately 200,000 patients, the vaccination rate was 4.4% in all high-risk conditions, and when disease-based vaccination rates were examined, it was observed that the highest rate was observed in RA patients with a history of immunosuppressive drug use (11.5%). This study also found that the vaccination rate tended to increase with increasing age [25]. In addition, in the analysis of pneumococcal vaccination performed by Matthews I. et al. in a group of approximately 100,000 patients in the United Kingdom, it was found that 13.6% of all patients were vaccinated during the one-year follow-up period and 32.0% during the four-year follow-up period. In addition, this study found that the average time from diagnosis to vaccination was five months [26]. Considering all this information, the pneumococcal vaccination rate in the present study was 21.8%, which was found to be low in accordance with the literature. Additionally, older people who had received vaccination education and had a higher frequency of physician visits were observed at a higher rate in the vaccinated group. Futhermore, similar to influenza vaccination, low financial income levels were observed at a higher rate in the pneumococcal vaccination group, which was found to be different from the literature.

Although HAV and HBV vaccination is important in chronic inflammatory diseases, there is limited information in the current literature on patients who have received these vaccines in RA patients. In a study conducted by Qendro T. et al. in the Canadian population, 136 RA patients were evaluated, and the HBV vaccination rate was 33.6%. In this study, physician recommendation was found to be the most effective predictor of positive vaccination [27]. Furthermore, in another study conducted by Krasselt M. et al. in Germany, the HAV and HBV vaccination rates in RA patients were 8.5% and 11.8%, respectively [14]. In the present study, HAV (12.3%) and HBV (28.5%) vaccination rates were low, which is consistent with the current literature. As expected, receiving vaccination education and living in urban areas were significantly higher in the vaccination group for both vaccine types. In addition, the frequency of physician visits was higher in the HBV vaccinated group than in the unvaccinated group. On the other hand, the duration of disease follow-up was higher in the vaccinated group for HAV but not for HBV. It is important to show that one variable may have different effects on different vaccine types. In addition, the low financial income level in HBV vaccination was higher in the vaccinated group, and this result is different from that of the literature [27].

To our knowledge, there is no multicenter awareness study designed on vaccination in RA patients in Türkiye in the current literature. The study presented here is the first national multicenter vaccination awareness study conducted in Türkiye in a large cohort of RA patients. The strength of our study is that it is the first multicenter study in RA patients conducted in regions with different geographical and cultural characteristics, and it evaluates four types of vaccines (pneumococcal, influenza, HBV, and HCV vaccines) together. Additionally, this study analyzed the vaccination rates of patients as well as their vaccine awareness levels and education status. However, this study has several limitations. First, our study is a cross-sectional survey study, and health system registration data of patients could not be accessed. Second, patient self-reported data were used in the study, which could not prevent possible patient misreporting. Third, although our study was designed as a multicenter study, the data obtained do not reflect the whole country. Finally, with the data obtained in this study, it was not possible to investigate the extent to which correct interventions with patients could influence the vaccination rate.