Now, today's webinar again entitled influenza and pneumococcal vaccination uptake among Canadian adults. It will be presented by Dr. Nicole Basta, Dr. Georgia Suleys, and Katie Gravani. And Dr. Basta, who is not able to join us in person today, but will be here in another form, is an associate associate professor in the Department of Epidemiology, Biostatistics and Occupational Health at McGill and holds a Canada Research Chair to an infectious disease prevention. As an infectious disease epidemiologist, she specializes in conducting biological clinical and behavioral studies to evaluate the impact of vaccines in immunization programs and also to increase awareness acceptance and uptake and to advance our understanding of the epidemiology and natural history of infectious diseases. Next Dr. Georgia Suleys is an infectious disease epidemiologist with clinical background, with clinical background, and she's also an assistant professor in the School of Epidemiology and Public Health at the University of Ottawa. Her research program focuses on areas of top global health importance, such as vaccine, antimicrobial prescribing practices, and tuberculosis prevention and care. And we also have Katie Gravani, who is an infectious disease epidemiologist completing her PhD in epidemiology at the University of North Carolina at Chapel Hill. And her research areas of interest include vaccine uptake and infection prevention in healthcare settings. Today our webinar will begin with a video presentation by Dr. Nicole Basta. So we'll get started with that and then move on to our other presenters. Well, good afternoon, everyone. And thank you so much, Jen, for that lovely introduction. I'm Nicole Basta and I'm really excited to be here to share with you the research that we've been doing on influenza and pneumococcal vaccination uptake among Canadian adults. We've gained so much insight from the CLSA, and it's really a pleasure to be able to share that with you today. For today's seminar, we're going to divide our talk into three parts. I'm going to start off and give you an overview of the importance of adult vaccination and talk specifically about what kind of insight we can gain from studies like the CLSA. Next, Katie will speak about the CLSA flu vaccine uptake study that she led while she was a master's student working with my group. And then finally, Georgia will share with us the CLSA pneumococcal vaccine uptake study that she did while she was a postdoctoral researcher working with my group as well. So I'm really pleased to be here with this wonderful team of trainees who have moved on to really exciting new adventures and continue to work together on the CLSA studies. None of us have any conflicts of interest to declare either. So influenza and pneumonia are two really significant causes of death among older adults. Both of these infectious diseases really lead to a high number of deaths in Canada and a lot of other countries as well. If we look at the rank of influenza and pneumonia among the leading causes of death in Canada, for all three age groups of those ages 65 to 74, 75 to 84 and older than or equal to 85 years, we see that influenza and pneumonia contributes as one of the top 10 causes of deaths for many of the last few years from 2015 to 2020. This ranking is highest among the oldest age groups shown here, but it is still a significant cause of death even among individuals age 65 to 74 years old and those age 75 to 84 years old as well. And when we think about healthy aging, I really think that the agenda needs to consider more seriously the prevention of infectious diseases to prevent not only mortality, but also morbidity. What we know from many studies is that infectious diseases such as influenza actually lead to quite high hospitalizations in older adults. So if we look at this chart, which shows the influenza associated hospitalization rates per 100,000 population in Canada, we see that Canadian adults age 65 years and older, which are shown here in the orange line, had the highest cumulative rates of influenza associated hospitalizations at 132 per 100,000. Even in the most recent flu season, 2022 to 2023, this is really quite alarming and demonstrates that we really need to be taking steps to prevent influenza from causing such high hospitalizations in this age group. And it's not only hospitalizations and deaths that we need to worry about. Previous research in the US has shown that adults age 65 and older are increased risk of other flu related complications. For instance, the risk of heart attack is increased three to five times in the first two weeks after an influenza infection. And the risk of stroke is increased by two to three times in the first two weeks after an influenza infection. So there are significant severe outcomes that can occur following a case of the flu and individuals age 65 and older are at particular risk of many of these outcomes. So as I was just mentioning, who is most at risk of severe influenza and pneumococcal disease? Well, it's older adults age 65 and older, but not just those individuals. People who have certain chronic health conditions such as heart disease or lung disease or a compromised immune system are also at increased risk of severe influenza and pneumococcal disease. And there's a complete list that you can find from the National Advisory Committee on Immunizations that lists out all of the different chronic health conditions that can put one at increased risk of severe outcomes due to flu or pneumococcal disease. And it is these risk groups for whom vaccination is the most important way to prevent these diseases. Vaccination is truly a cornerstone of prevention that can support healthy aging, especially when it comes to influenza and pneumonia. So let me talk a little bit about influenza and pneumococcal vaccination. Influenza vaccination is designed to protect against multiple flu strains. They change every year as the different flu strains circulate around the globe. Influenza vaccination has been shown to reduce the risk of infection, illness, severe illness, hospitalizations and death. And annual vaccination is required, as I'm sure many of you know, there's an annual flu vaccination campaign that comes up every year, encouraging people to get the flu vaccination at the beginning of the flu season. Similarly for pneumococcal disease, which is a bacterial pathogen, actually, even though influenza is a viral pathogen for pneumococcal disease, we had two vaccines that were available at the time of the study that you're going to hear about today, which was 2015 to 2018. And those two vaccines were called pneumococcal polysaccharide 23 and pneumococcal conjugate 13 vaccine. Both of those vaccines protect against multiple pneumococcal bacterial serotypes, the numbers that are in their name, and they reduce the risk of invasive pneumococcal disease, hospitalization and death caused by these strains of the bacteria. And there's a wealth of evidence that has demonstrated that both influenza and pneumococcal vaccination are safe and that they are the most effective way to prevent severe outcomes from these two pathogens. So what are the current vaccination recommendations for older adults in Canada? Well, first for influenza vaccination, NASI, the National Advisory Committee on Immunizations, particularly recommends that everyone at high risk of severe outcomes be vaccinated annually at the start of the flu season. This includes the two groups that I've already mentioned, adults aged 65 years and older and all adults of any age with chronic medical conditions. For pneumococcal vaccination at the time of our study in 2015 and 2018, NASI recommended that adults aged 65 years and older receive one dose of the pneumococcal polysaccharide 23 vaccine and that all adults with certain chronic medical conditions receive one dose of both the pneumococcal polysaccharide 23 vaccine and the pneumococcal conjugate 13 vaccine. And I do want to note that in 2023, NASI updated their recommendations for pneumococcal vaccine because two new pneumococcal vaccines came on the market. Pneumococcal conjugate 15 and pneumococcal conjugate 20. And this is really important, something really important to talk to your doctor about if you're thinking about getting vaccinated for pneumococcal disease in the near future. So the National Immunization Strategy has set some goals for influenza and pneumococcal vaccination to try to achieve a really high level of uptake. And these goals are 80 percent coverage for flu vaccine uptake in adults aged 65 years and older, 80 percent uptake in adults aged 18 to 64, who have at least one chronic medical condition and 80 percent uptake for pneumococcal vaccine in adults aged 65 years and older. So these are national targets that have been set to try to improve vaccination rates even in a country like Canada where vaccination rates for many routinely recommended vaccines are relatively high. However, when we look at the rates for flu vaccine and pneumococcal vaccines and those three priority groups, we see that efforts to improve vaccination are really urgently needed. So these three graphs show the current uptake of flu vaccine among individuals 65 years and older in the first graph, flu vaccine among individuals 18 to 64 with a chronic condition in the second graph and pneumococcal vaccine uptake in individuals 65 years or older in the third graph. And the red line shows that 80 percent target of 80 percent vaccination coverage. And you can see that even for flu vaccine uptake in older adults where we're at about 70 percent coverage, we still have a ways to go to reach that target. And the situation is even more dire for individuals in the younger age groups with chronic medical conditions and for pneumococcal vaccine as well. So we have a lot of work to do to really reach these targets and ensure that everyone who's at highest risk can be protected. Fortunately, the CLSA is a really unique resource for characterizing vaccine uptake. And I was really fortunate when I came to McGill in 2020 that I got to meet with Tina Wolfson, one of the PIs of the CLSA and talk to her about how we could use the data from the CLSA to try to better understand and create a more comprehensive assessment of patterns of vaccine uptake for influenza and pneumonia vaccines. And it was out of that conversation that grew the studies that you're going to hear about today. So data from follow up one, which happened in 2015 to 2018, can really be used as a baseline to monitor progress towards these national immunization strategy goals. And we can also use the data from the CLSA to identify those who are least likely to be vaccinated among this large cohort, because numerous potential risk factors for non-vaccination have been systematically evaluated and thoroughly assessed, and this understanding that we could gain could help us to develop strategies to support vaccination uptake among those who need that support in order to get vaccinated. So in our CLSA vaccine studies that we're going to be talking about today, our overall aims were to characterize flu vaccine uptake and factors associated with non-vaccination among three groups, adults aged 65 and older, adults aged 46 to 64 with at least one CMC, chronic medical condition. And also we took a look at caregivers of all ages and care recipients who are 65 years and older because caregivers and care recipients are working in such close quarters. We thought it was really important to look at this group to see whether influenza vaccination could be improved among those individuals. And then our second broad aim was to characterize pneumococcal vaccine uptake and factors associated with non-vaccination among adults aged 65 years and older and adults aged 47 to 64 with at least one CMC. And we also looked for pneumococcal disease to try to characterize missed opportunities. Those times where an individual had a health care encounter and received a different vaccine, perhaps, but did not receive pneumococcal vaccine even though they were eligible. So that gives you a very quick overview of what we were aiming to accomplish with these studies. And now I'm going to turn the microphone over to Katie so she can share with you the study that she led on flu vaccine uptake in the CLA. Well, today I will be presenting our findings on our studies of influenza vaccine uptake among Canadian adults. Both of these studies aim to estimate the prevalence of influenza non-vaccination and determine the factors associated with influenza non-vaccination between 2015 to 2018 within two population sets. One, those at high risk of severe outcomes, adults aged 65 years and older and adults aged 46 to 64 years with at least one chronic medical condition or CMC. And two, the second population, those at risk of influenza transmission, as well as potentially at risk of severe outcomes, caregivers age 45 years and older and care recipients age 65 years and older. Now, one of the reasons that the CLA data was so beneficial for these studies is that the CLA provides a uniquely large variety of data on socio-demographic characteristics, health status reports, health services utilization, lifestyle and health behaviors and economic measures that were utilized in these studies. So in order to achieve our goals for these two studies, we conducted a cross-sectional secondary analysis of the follow-up one data. Variables were chosen a priori and only variables that were present in both of the CLA's two cohorts were included in these analyses, although the two cohorts were combined into one data population for analysis. In order to be included in this study, participants needed to have had a valid response, so either yes or no, to the outcome variable of self-reported influenza vaccination status within the past 12 months. A sensitivity analysis was conducted to see if the proportion of participants who reported receiving a flu vaccine by cohort changed if respondents were surveyed during the Canadian flu season, which is generally November through April, or outside of the flu season, which would be May through October. And nested multivariable regression models were used to determine the factors associated with influenza non-vaccination. So the first question this research looks to answer was, what's the prevalence of non-vaccination in a population typically considered to be at high risk of severe outcomes from influenza infection? In this case, adults aged 65 years and older and those aged 64 and under with at least one chronic medical condition. Or CMC, within this population, what characteristics do the unvaccinated have? First, about half of the participants from the fall of one population, or about 23,000 people, fell within this first group of interest. Of the adults aged 65 years and older, about a third of them reported not being vaccinated against influenza in the past year. The prevalence of non-vaccination was highest, and those who reported currently smoking daily had higher self-rated health and were residents of the province of Quebec. The next step was to determine which factors were associated with non-vaccination within this group through our regression models. Some of the clearest factors were younger age, in this case, being aged 64 through 74, compared to older ages and identifying as non-white compared to identifying as white. Those who reported visiting a family doctor or medical specialist in the past year had notably lower odds of influenza non-vaccination. Our next population of interest for those at high risk of severe outcomes from influenza infections was adults aged 46 through 64 with at least one CMC. About a quarter of fall of one participants, or about 11,000 people, fell into this category. Within this group, about half reported not being vaccinated against influenza in the past year. The prevalence of non-vaccination did not differ by type of CMC. Those who were younger or current daily smokers and who were Quebec residents had the highest prevalence of non-vaccination within this group. Now, for the factors associated with influenza non-vaccination within this population, as determined by our regression models, we found that the highest odds were associated with the residents in Quebec, living in rural areas compared to living in urban areas and reporting one CMC compared to reporting two or more CMC was also associated with non-vaccination. Again, those who reported visiting a family doctor or visiting a medical specialist in the past year had notably lower odds of influenza non-vaccination. Now, this study allowed us to draw several conclusions about influenza non-vaccination within this population. For one, both of these high risk groups were clearly well below the pre-pandemic target of 80 percent coverage that Nicole discussed. The prevalence of non-vaccination was highly variable by province, which could be due to the confluence of many factors, such as recommendations and practices for influenza vaccination as well as barriers to vaccination, such as where vaccines can be received or administered at the provincial level. This study also highlights the important role that health care encounters may play in getting these high risk groups vaccinated. For example, they may be more exposed to more recommendations for vaccination at a doctor's office than elsewhere. Risk messaging can also be expanded to target groups who may not consider themselves at high risk, such as younger adults with CMC who had high prevalence of non-vaccination in this study. Lastly, future studies may want to look at less studied barriers to influenza vaccination, such as the role that frailty may have in preventing older or chronically ill adults from seeking care that includes vaccination. Now, our next study, which is still undergoing the submission process, looked at the influence of vaccination of caregivers and care recipients. Caregivers were defined as those who answered yes to the question. During the past 12 months, have you provided any of the following types of assistance to another person because of a health condition or limitation for a wide range of care activities such as personal care or health or house maintenance? And care recipients were defined as anyone who answered yes to the question. During the past 12 months, did you receive short term or long term assistance from family, friends or neighbors because of a health condition or limitation that affects your daily life for any of the following activities? And once again, these activities covered a wide range of care activities care recipients could receive either professional, non-professional or both forms of care to fall into this population for the study. Now, about half of the follow up one population or about 24,000 people were in the category of caregiver as defined in this study. About two fifths of caregivers reported influenza non-vaccination. The prevalence of non-vaccination did decrease with age, but was high in residence of Quebec and those who had at least two other members in their household besides the person who was being surveyed. For this group, factors that were associated with non-vaccination included those who identified as non-white compared to those who identified as white and current daily smokers compared to current non-smokers. Once again, individuals who reported visiting a family doctor or a medical specialist in the past year had markedly lower odds of influenza non-vaccination. Now, the next step was to look at non-vaccination for influenza in older individuals who are receiving care due to their high risk of influenza complications as well as transmission. This group was smaller, making up about one tenth of the total follow up one population or about 5,600 people within this group. About one fourth of participants did not receive an influenza vaccine in the past year and the prevalence of non-vaccination was consistent across types of CMC and across levels of self-rated help. However, the prevalence of non-vaccination did increase as reported household income increased. Now, within caregivers in our now, within caregivers in our study, factors associated with influenza non-vaccination were very similar to those seen in high risk groups and included younger ages. Those who identified as non-white and current daily smuggers and we had found in the previous study and for other high risk groups. And as seen before, health care visits were strongly associated with lower odds of non-vaccination. Now, this study identified several important components of influenza vaccination in caregivers and care recipients. First, influenza vaccination prevalence remain notably low among caregivers. This is important not only because of the risk of transmission to the people they care for, but for their own health as well. It may be useful to educate caregivers about these direct and indirect benefits to themselves and the people they care for in order to encourage caregivers to get vaccinated. The importance of health care in county to get vaccinated, the importance of health care encounters is also demonstrated by this study. Getting influenza vaccination recommendations and reminders to those who may not have annual provider visits may improve influenza vaccination rates, engaging in more positive health behaviors like annual health care provider visits and health care behaviors that are potentially considered to be more negative like smoking emerged as the two clearest modifiable factors linked to non-vaccination in this study. Together, these two studies help clarify the state of influenza non-vaccination and groups at high risk of influenza complications and groups at risk of influenza transmission in Canada. Most notably, despite universal vaccination and attempts to reduce other barriers to vaccination within Canada during this time, influenza non-vaccination remained high during the 2015 to 2018 period. Opportunities for education may have been missed for groups who might not view themselves at risk for influenza complications or transmission, particularly younger adults with CMC and younger caregivers. There are also clear disparities in vaccination within these populations of interest, such as non-vaccination and those who do not identify as white as compared to those who do identify as white that were found in this study that must be addressed. Finally, those without annual health care visits also need to be reached to achieve these national vaccination goals. Now, despite the many benefits that come from using the robust CLSA dataset, the study does have several limitations as do many observational studies. For one, generalizability may be somewhat limited. The CLSA only includes community-dwelling adults, has higher education and socioeconomic status levels than the general population and excludes groups such as those who reside on a federal First Nations reserve. We also use several self-reported variables in our study, including our outcome variable of influenza vaccination. However, the use of self-report for influenza vaccination status has been validated in other studies. Lastly, we were unable to capture information such as the reasons for non-vaccination, whether an individual was a caregiver as part of a formal hate position or was an informal caregiver, and we could not assess trends in vaccination over time. These are topics that future studies could focus on in order to expand on the work that was done in these two studies. However, it is also important to note the strengths of these studies, which include the large sample size of the CLSA and the precision that entails for our vaccination coverage estimates across our groups of interest, the ability to get province-level estimates to potentially identify province-specific barriers in the future, and the ability to analyze the association between influenza non-vaccination and covariates across many vaccine-associated domains simultaneously so that these results can provide additional insight on the findings of previous studies. Overall, these two studies show a high proportion of influenza non-vaccination across multiple groups of interest and demonstrate next steps that could be taken to continue to understand and address these gaps in influenza vaccination coverage. I would like to thank our excellent study team for all of their work on these studies, as well as thank the CLSA for providing their data. Lastly, I would like to share our CLSA acknowledgment and our funding services. And now I will turn it over to Georgia to speak on her studies. Thank you. Thank you, Katie. Just a minute, a second. All right. Hello, everyone. It's a pleasure to be here. I will now talk about another study that we conducted using the CLSA data, which is focused on another vaccine that is recommended to adults to select group of adults, which is pneumococcal vaccination. I will briefly touch only the key elements of our work. So if you're interested in learning more, here is the published article that you might want to look at. You can access the full text through this QR code. And I believe a link will also be shared to participants after the webinar. So as Nicole anticipated at the beginning of this webinar, our aim was to estimate pneumococcal vaccine uptake and differences in uptake among Canadian adults who are eligible to be a vaccinator for pneumococcal disease. And specifically, we focused our attention on two groups, older adults, those aged 65 years and older. And adults younger than 65 will have at least one underlying medical condition that increases the risk of invasive pneumococcal disease. So it's very similar to what Katie presented for her first influenza vaccine study. We also wanted to identify factors associated with pneumococcal non-vaccination and access the frequency and determinants of missed opportunities for vaccination. And I will explain later what constitutes a missed opportunity. For this work, we utilize primarily data collected during the follow up one survey. So collected between 2015 and 2018, although we also utilize some data collected at baseline, mostly socio-demographic variables. As you know, the CLSA originally included more than 50,000 participants, most of whom also contributed to the first follow up survey. And we focused on those because we wanted information regarding pneumococcal vaccine uptake. And the first time CLSA participants were asked this question was during follow up one. Among this group, we selected those who met the eligibility criteria for pneumococcal vaccination based on current guidelines. So essentially older adults, those aged 65 plus and individuals younger than 65 with at least one chronic medical condition. To define this group, we utilized a list of conditions that are known to increase the risk of invasive pneumococcal disease. This is not an exhaustive list. We focused on those conditions that can be defined reasonably well using the CLSA data. We excluded a very small number of individuals who did not respond to the question related to pneumococcal vaccination. We ended up with more than 22,000 participants aged 65 plus and over 10,000 participants younger than 65 with underlying conditions. This constitutes our study population. We considered two outcomes of interest. First of all, lack of pneumococcal vaccination self reported like any other information that comes from the CLSA and missed opportunity for pneumococcal vaccination. I'll get back to that shortly. We considered a number of socio-demographic characteristics like sex at birth, age, income level, education level, province of residence and so forth. We considered various chronic medical conditions. Like I said, we also considered whether participants reported having had a contact with family doctor in the previous 12 months and whether they reported receiving influenza vaccine in the previous 12 months. We analyzed the groups of interest separately. So older adults and adults younger than 65 with chronic conditions because obviously they face different challenges and different factors may may come into play in terms of and may affect vaccine uptake and the scripts. So we first conducted a descriptive analysis to get a sense of how vaccine uptake varies across subgroups defined by covariates of interest. For example, in males versus females or in people living in different provinces and so forth. We utilized multivariable logistic progression analysis to explore associations between the lack of pneumococcal vaccination and a range of covariates. And we did a similar analysis focusing on missed opportunities again more soon. So let's look at some results. If we focus on adults age 65 plus, we see that only 54.2 percent of participants reported having received a pneumococcal vaccine. Perhaps you remember that Nicole in the beginning of this webinar mentioned that the vaccination coverage goal in Canada is 80 percent. So 80 percent of all adults age 65 plus should receive a pneumococcal vaccine. So it's clear that we are well below this target and at least 45 percent of individuals are not getting vaccinated. And this percentage shown here is in line with national vaccination coverage statistics, which speaks to the relevance of the CLSA data and how it is representative of what's happening in the country. But who is more likely to be non-vaccinated for pneumonia among adults age 65 plus? Well, males more than females. Those who identify as other than white versus white participants, those living in rural areas versus those living in urban areas and those residing in the Atlantic, in one of the Atlantic provinces compared to those in Ontario, which was such a reference for convention. There are factors that favor pneumococcal vaccine uptake after controlling for all other sociodemographics and health utilization indicators and so forth. So, for example, vaccine uptake increases with age, increases with income. It is higher among participants residing in Manitoba, Saskatchewan and Quebec versus those in Ontario. It is higher among those who have at least one underlying chronic condition. And but most importantly, the strongest predictor of vaccination, the factor that most strongly affects the likelihood of getting vaccinated, is having received an influenza vaccine in the previous year and also having had a contract with a family doctor, not as much as influenza vaccine received, but it's still an important factor to consider. Now, let's turn the attention to the other group of interests, adults age 47 to 64 years, who had one or more underlying chronic conditions. So here, the situation is a lot more concerning because we see that less than 20 percent of participants reported having received a pneumococcal vaccine. So essentially more than 80 percent are not vaccinated. And there is less variability across subgroups compared to what we've seen for adults older than 65, perhaps because the vast majority here is non-vaccinated. We see something interesting that is that people with higher income are more likely to be non-vaccinated, which seems a bit counterintuitive. I really can't explain this finding. We also found that those residing in New Finland, but not in other Atlantic provinces, were more likely to be non-vaccinated compared to those in Ontario. And factors that favor vaccination are, again, age and most importantly, received of influenza vaccine and contract with family doctors. So these factors continue to be extremely, extremely important. Now, I would like to spend some words about missed opportunities for vaccination. The World Alpha Organization defines a missed opportunity as any contact with health services by an individual who is eligible for vaccination, which does not result in the person receiving one or more vaccine for which they are eligible. Obviously, not all contacts with health services are likely to result in vaccination for a number of reasons. Sometimes that is not even possible if we think of emergency room visits or if you're seeing your doctor because you have a fever. Obviously, even if you don't belong to an eligible group, if you belong to an eligible group, you can't receive the vaccine in that very moment because there are contraindications for that. For the purpose of this study, we consider two types of missed opportunity. The first one is the most important, which is receipt of influenza vaccine. This is the ideal scenario. This is the ideal opportunity for getting another vaccine for which someone is eligible, because obviously, if you're getting one vaccine, like influenza vaccine, there are clearly no contraindications for obtaining another vaccine in that moment and there are no issues at all in getting two vaccines at the same time. So this is the ideal situation. Another type of missed opportunity is related to the contact with a family doctor. At least this can be a chance to schedule a vaccination for some other time if it's not possible to get a vaccine immediately. For both older adults and individuals younger than 65 with underlying conditions, we found that missed opportunities were more frequent among males versus females and among residents in the Atlantic provinces versus those residing in Ontario after controlling for all sociodemographic factors. How frequent is this? It's actually very, very common. If we focus on those who reported having received an influenza vaccine in the previous 12 months, we see that more than 32% of adults aged 65 and older missed an opportunity for pneumococcal vaccination. And this percentage increases to more than 70% among adults aged 47 to 64 with underlying chronic conditions, so a very high number. If we look at those who reported having had a contact with a family doctor in the previous 12 months, we see that approximately 45% of adults aged 65 plus missed an opportunity for pneumococcal vaccination. And this percentage increased to more than 80% for older for individuals younger than 65 who had underlying conditions. So the vast majority missed an opportunity. Now, I would like to just highlight a few strengths and limitations of this work. First of all, I would like to say that the biggest strength is definitely the fact that we could rely on an excellent data source, which is the CLSA, just the largest cohort of adults in Canada. And it is especially important to address this kind of research question because, you know, in Canada, we don't have vaccination registries to record vaccination status, especially for adults. So this is the best way for us to access a vaccine uptake among different subgroups and get a sense of how things are going and who is less likely to to get vaccinated, and it includes participants from 10 provinces. So it's also a chance to look at how different provinces and how different vaccination programs are doing and how people are getting vaccinated and whether there is any difference in vaccine uptake between province. Obviously, this also comes with limitation and particular because for this particular study, we can only use data collected pre-pandemic and, you know, the COVID-19, unfortunately, has had an important impact on health services, including routine immunization services. And it has also impacted attitudes towards vaccination, increasing vaccine hesitancy and so forth. So it is possible that these findings may change a little bit with if we consider data collected more recently as we're planning to do. This is also just a snapshot of a single point in time because we use cross-sectional data, so there are no time trends available here. Another issue that is important to consider is that all data in the CLSA are self-reported, which is not necessarily a problem, but maybe problematic for vaccination status because people may not recall perfectly, especially if they received a vaccine a few years before and especially for something like pneumococcal vaccine, which is something that you receive just once in a lifetime and it's not like an influenza vaccine that is repeated annually. But we conducted sensitivity analysis and considered various scenarios. We simulated scenarios, assuming different levels of sensitivity and specificity of reporting and our findings didn't change much. So this is reassuring. And again, like also Katie mentioned, unfortunately, we can't draw conclusions on the reasons why people did or did not get vaccinated, so other studies will be needed to address this problem. So in summary, the main takeaway is that pneumococcal vaccine uptake remains below expectations of monetary scandals in Canada. And this is something that we need to work more on to improve the levels of uptake. Although we cannot specifically comment on the levels of awareness because they were not specifically investigated and the surveys, we can say that awareness about pneumococcal vaccines is likely law among high risk groups and this may contribute to this scenario. We also found substantial heterogeneity pneumococcal vaccine uptake among Canadian provinces, which likely reflects differences in vaccination programs and how vaccines are deployed and are offered in different provinces. And this contributes to the high frequency of missed opportunities for vaccination. So more efforts need to be made to address this issue. And with this, I want to thank all of the people who contributed to this work at McGill at the University of Calgary at the Laos University under the leadership of Nicole. And I would like to thank all the CLSA participants, without whom none of this would have been possible. So thanks you so much. And thanks also to the CLSA team who make this resource available and accessible to researchers. So this is a great opportunity for all of us. And now I just give me a second because I have some conclusive remarks from Nicole to share with you. Excellent. Well, thank you, Georgia, for sharing your pneumococcal vaccine study as well. Now I'm just going to summarize a little bit of what you've just heard about the two studies that we've been working on and emphasize some of the value that we've found in the CLSA for understanding patterns of vaccine uptake. So I can't emphasize enough how much the CLSA has provided significant insight into these really detailed patterns of vaccine uptake among Canadian adults from the years 2015 to 2018 during follow up one. The comprehensiveness of the CLSA data allowed us to go beyond routine national vaccination coverage surveys, which provide a lot of very valuable information, but the CLSA allowed us to investigate multiple factors simultaneously to better understand who is missing out on flu and pneumococcal vaccination uptake among Canadian adults. There truly is very few resources where we could undertake the same types of studies that we've undertaken with the CLSA data. In these studies, we took the opportunity to focus on two understudies groups who could benefit significantly from flu vaccination as well, caregivers and care recipients. And you heard about this aspect of our studies from Katie. By focusing on caregivers and care recipients, we wanted to look at two groups that really could have a great deal of direct benefits from getting influenza vaccine and also could have a great deal of indirect benefits by protecting one another if they were to be vaccinated. We also assessed in our studies missed opportunities for pneumococcal vaccination. And this concept of missed opportunities, which Georgia spoke about, is really, really critical to the vaccine uptake field because we want to minimize the number of health care encounters that individuals have to have in order to become fully vaccinated for all the recommended vaccines for their age group and characteristics. But we also want to make sure that people are aware in our getting recommendations from the health care providers about which vaccines could really benefit them. So both of these aspects of our analyses, plus the descriptive results, provide much greater insight into who may benefit most from interventions to improve into uptake than previous studies. So for us, I want to outline some of the next steps that we'll be taking. So we're aiming to continue to learn from the CLSA by assessing influenza, pneumococcal, and now shingles vaccine uptake using follow up to data. And we've just begun these analyses. We aim to compare changes over time in vaccine uptake for influenza, pneumococcal vaccine, and to refine hypotheses about factors associated with non-vaccination to better characterize those who are not getting vaccinated. And then we wish to use the evidence from our CLSA analysis to design and to evaluate the impact of potential targeted interventions that can improve vaccine uptake among those with low vaccinate vaccination rates. That's really the goal of all of the research that we do in my group is to try to generate an evidence base that can be used to inform health promotion or health policy in ways that will be most effective in the future. And then we'd like to build on the evidence from our CLSA analysis to better understand reasons for low vaccine uptake and to identify barriers to vaccination in future studies. These were two aspects of vaccine uptake that we weren't able to investigate with the CLSA data simply because these types of questions haven't been asked of CLSA participants, but understanding reasons for uptake and low uptake and identifying barriers to vaccination are really critical aspects of characterizing the vaccination landscape and trying to improve vaccination confidence and also access. So with that, I'll wrap up so we have time for questions and thank you all for your attention today. I also want to take a moment to very sincerely thank all of the CLSA participants who have given so generously of their time and from whom we have truly learned so much. Your time and participation in the CLSA is really a gift to us researchers who are trying to use your data in a way that helps inform evidence for future improvements in public health. I also like to thank everyone who's made the CLSA a success, including the PIs, study coordinators, study staff, data curators, analysts and support staff. As I mentioned, our research team wouldn't be able to gain these insights into interesting questions such as influenza and pneumococcal uptake without the incredibly dedicated and hard work that all of you do to make the CLSA possible. So thank you. And finally, I want to thank all of our collaborators with whom it's been a really pleasure to conduct this research and Georgia and Katie noted all of our collaborators for each of the two studies that they presented. So you have a sense of who's been contributing to this work. And finally, I want to thank my research group, which is the vaccines infectious disease prevention and epidemiology research group at McGill. We are a group that is really dynamic and always thinking about how we can improve vaccine uptake and how we can learn more about vaccines and vaccination. This has become a very hot topic over the last few years with COVID vaccines, but we work more broadly on a wide range of vaccines in both children and adults. So if you're ever interested in these topics or in collaborating, please feel free to get in touch. OK, thank you. I think we can go on to questions. The first question and I'll let either Katie or Jordan decide who to answer. It is about the difference in vaccine uptake in the in the data that you presented versus the stats can data. And if you have any comment on why it may be different. Yes, so I can go ahead and take this question. So the the question of why are flu uptake prevalence seem different than the second data is a very interesting question. Well, for one, it is difficult for us to compare our influence of vaccination results as on an annual basis since we weren't able to look at flu vaccine uptake trends over time. So the study covered the 2015 to 2018 period, but we weren't really able to break it down. There could be a variety of potential reasons, which is a bit outside of the scope of this specific study. But for example, it could be related to the different number of participants. And as I believe another person participant mentioned, the CLS A and the CCHS do have different recruitment strategies that could lead to potentially different participant characteristics between these two data sources. So it's an interesting question that we can't quite answer right now, but it's definitely worth thinking about. And then the next question is more of a statement. And Jeff says the CLS A doesn't include long term care nursing home residents who typically may receive higher rates of vaccination. So could this be a factor in the observation that a land a land make? And I will just I can interject on this one. The CLS A does willing collect data from participants who are in long term care nursing home participants at baseline needed to be within the community. But we do have a proxy questionnaire process so that if a participant does require the aid of somebody that can be done and also our interviewers as long as able will visit and complete interviews within long term care facilities or so. So I will. But is there any other comment on that from our panelists? No, I think that that's a good explanation of sort of the difference there. I think you you cover that very thoroughly. And definitely, you know, the different recruitment frames are something to take into mind when comparing different sort of survey influenza vaccine data. And so the next question says, of course, thank you. I'm wondering if you observe in either of the studies a trend in the onset of progression of age related diseases, either neurodegenerative or metabolic when vaccinated individuals are compared with non-vaccinated. So I think that we didn't specifically focus on individuals with neurodegenerative or metabolic diseases or specific conditions. We mostly considered participants as a broader group with one or more conditions. So we couldn't actually look into subgroups mostly due to small numbers. I think the same applies to the influenza vaccine studies that Katie led. So we could only look at overall uptake in subgroups with certain diseases like cardiovascular disease, like chronic pulmonary disease. We did have something related to neurodegenerative. I think Alzheimer and Parkinson and other conditions that are all known to increase the risk of severe outcomes from both influenza and pneumonia. But again, we didn't specifically investigate these groups. So I'm not sure we can comment much on that. I mean, we also have a question about the wording of the one question. Yeah, yeah, I'm not to Gloria if she wanted to email you. So I don't have the exact wording, but it was something like, have you ever received a pneumonia shot? So it's not called pneumococcal vaccination, but it was like pneumonia shot in your lifetime, because again, pneumococcal vaccination is something at least in adults, it's something that is given only once or maximum twice, especially for individuals younger than 65 who have underlying condition or it's particularly increased risk of severe outcomes. So in that case, it typically used a conjugate vaccine first, followed by no polysaccharide vaccine for older adults who don't have additional risk factors. There's just one dose of polysaccharide vaccines. But as Nicole mentioned at the beginning, there was a recent change in the recommendations due to the recent approval of two new conjugate vaccines. So this is going to change as well. So, yeah, the question was was framed in using a language that could be understood by anyone because it was like pneumonia shot, which was how most people know about this vaccine if at all. OK, well, I think that's all of our questions. So I'm just going to go on to a few last things. Again, firstly, a big thank you to our presenters who are both here and not here for your participation today. I'd also like to remind everyone if you're interested in CLSA data, the next application deadline is July 12th and you can visit the CLSA website under data access to review the available data and details on how to apply. This is the last webinar I forgot of this session and we're actually looking at identifying topics for next winter and spring. And so your feedback that you're hopefully going to submit is going to be very valuable and will help us organize those webinars. So check on the CLSA website under the webinars tab for details on what those are. And lastly, remember the CLSA promote this webinar series and will also promote this one using the hashtag CLSA webinar and we do invite you to follow us on Twitter at CLSA underscore ELCB. And with that, I wish everyone a great summer and depending on where you are today, good air quality, lots of environmental warnings today. But I'm sure within a day or two of some rain will all be breathing good. Thanks, everyone.


Our parents form a big part of our personality during the time when we completely depend on their care. This happens because as young children, we perceive them as almighty, endlessly wise, and flawless. We also believe that whatever they do, literally whatever they do, they do out of unconditional love. And because we think they are infallible and full of love, we consequently think that we are at fault whenever a conflict arises. In order to reduce any kind of conflict, we develop patterns of behavior, feelings and thinking designed to please our parents and minimize any friction. Unfortunately, these patterns can lead to the development of a personality that is misaligned with its true spiritual self. And so, we grow into adults that behave in ways that make us sad. The Hoffman process was designed to help us recognize negative behavioral patterns, break them and to become the person we really are. To condense a lifetime of analysis into seven days, the process is highly structured, very intense and applies a multitude of techniques. Afterwards, participants often understand why they are the way they are and learn to let go of the negative sides of their personality. To understand how the process works, let us look at three types of people who on the outside look just fine, but on the inside, deeply struggle. Eva is 27, a university graduate, and she has just started her first job. She's unable to trust men and is at a loss when it comes to forming healthy relationships. Jay is 51, an overachiever and a respected CEO. However, his marriage is broken and his two adult children hardly ever call. He asks himself if that's really all that life has to offer. Tom is 45, married with one child, but he's got no friends. He lives with his family far outside town and signs up for the process when he realizes that his daughter also has problems making friends. Through the process, Eva will realize that when her dad left when she was four and her mother then struggled as a single mom and a lonely woman, it had a big impact on her. Over the years, her own relationship with her father became broken and she learned that men couldn't be trusted. Jay will learn that his life was going great up until his little brother was born, a funny, extroverted and bright boy. Afterwards, Jay was hardly ever noticed. Jay soon realizes that his parents would only pay attention to him if he excelled in school or sports, causing him to grow into an adult who tries to be the best in everything in order to get the love he seeks. Tom will realize that he was an accident, born to a young couple who had just begun dating. As a young boy, he was often neglected because their life was difficult. His parents, who were overwhelmed by the situation, would often snap at him over the smallest thing. Little Tom began to think that he was the cause of all misery he should never have been born. The process begins with a phone call from a designated therapist. This is followed by a 50-page questionnaire that helps their client to reflect on their lives. Going through the questions, the participants identify particular patterns in behavior and link them to their parents. Once returned, the therapist uses the questionnaire to understand the underlying issues. On day one, all three arrive at the retreat, a place isolated from the outside world. They hand over their phones and any books to ensure there are no distractions. Tom then meets his therapist for an in-depth conversation. Afterwards, he gets to know the other 17 participants and learns that everyone carries within them an inner child that manages their expectations, thoughts and feelings. On day two, Jay and the others learn more about their parents and how their behavioral patterns have formed out of love for their father and mother. Jay, who only got real attention when he impressed his parents, could never be good enough to get all the love he needed. Such conditional love is negative because subconsciously, Jay takes on the blame for this disjunction and develops a core shame belief. He begins to think something is inherently wrong with himself.  On day three, Eva realizes how the pattern she established as a young girl subconsciously project into her adult relationships. Anyone who reminds Eva of her father can't be trusted. Through a group game later that day, she experiences that there are men she can rely on. Eva then accuses her parents of making her the victim of their broken relationship. This is important because this way she can retrace her negative pattern back to her parents. Afterwards, she learns to understand their story, because they too were once children, with parents who had their own issues. This is important because then she can understand their situation and realizes that the way she was brought up was all her parents were able to provide. Now, she can make peace with her past, and her mistrust of men begins to wither. On day four, participants say goodbye to their parents and their childhood, and ask themselves where am I from? What injuries do I bring along from my mother and father? How have these injuries impacted my life? What strategies have I developed to compensate for these injuries so far? Jay, who didn't want to be reminded of the painful thought that he's not worthy of his parents' unconditional love, compensated by only contacting them when he had outstanding news, such as another promotion. Knowing that they would then surely listen and act predictably, he reduces the risk of feeling hurt. After this realization, Jay creates a development plan to follow his vision for life after the process. Day five is about our vindictiveness. Tom, who didn't want to be reminded that he is the root of all problems, compensated for the pain he experienced by hiding himself. At a young age, children keep their honor by thinking of how to, one day, pay their parents back for the misery they caused them. As we mature, such vindictive thoughts move into the subconscious, and by the time he is a teenager, Tom begins to pay back, first by breaking the law, then by breaking all contacts with his friends and family. On this day, Tom stops feeling vindictive and makes peace with his parents. His inner child regains his honor and grows in strength. Grown-up Tom can now leave his hiding place and finally enjoy meeting other people. On day six, the participants get to know the saboteur, the inner voice that warns us of any change in order to keep us in the safe old world we know so well. Eva hears the voice whenever she opens up to the opposite sex. It whispers, remember, you can't trust man. Tom hears it when he enters a group of people. You are not welcome here. But Jay tries to relax and be himself, the saboteur says, don't just do nothing. You are better than this. After getting to know this evil agent, they learn how to deal with this enemy of our progress. Then the group recaps the entire process and celebrates their new found selves. On day seven, they learn practical tools on how to cope with the change they will face when they go back into their lives. Finally, they go home to their parents to complete what they have started, end their old lives and begin afresh. To learn more about the Hoffman process or to read the research on it by the Harvard Center for Public Leadership, check out the descriptions below. Prior to creating this channel, our founder went through the Hoffman process and it had a profound effect on his life. 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