COVID-19 hospitalisation, mortality, vaccination, and postvaccination trends among people with schizophrenia in Israel: a longitudinal cohort study

Abstract

Background Individuals with schizophrenia have an increased risk of severe COVID-19 outcomes, nonetheless, no previous study has provided a year-long account of this risk, or assessed postvaccination trends in this population. This study assessed temporal trends in COVID-19 hospitalisation and mortality among people with schizophrenia during the first year of the pandemic, the predictors for COVID-19 vaccination, postvaccination infection, admission to hospital, and mortality.Methods In this longitudinal cohort study, people with schizophrenia (n=25 539) and controls (n=25 539) were assessed for COVID-19 outcomes before and after vaccination, up to April 30, 2021. Cox proportional hazard regression models and Kaplan-Meier analyses were done to assess longitudinal trends. The study used the databases of Clalit Health Services, the largest health-care organisation in Israel.Findings The sample included 51 078 participants, of which 31 141 (61•0%) male and 19 937 (39•0%) female participants, with a mean age of 51•94 years (SD 15•62). Most of the sample was from the general Jewish population (75•9%), followed by the Arab (19•1%) and Jewish Ultraorthodox population (5•1%). Overall of 51 078 individuals, 356 (0•7%) people had been hospitalised, 133 (0•3%) had died, and a total of 27 400 (53•6%) had been vaccinated. People with schizophrenia showed a higher risk for COVID-19 hospitalisation (HR 4•81, 95% CI 3•57-6•48, p<0•0001) and mortality (HR 2•52, 95% CI 1•64-3•85, p<0•0001), and showed a sharper decline in survival as time progressed. The control group showed a sharper incline in probability to vaccinate (log-rank=309•88, p<0•0001). Medical comorbidity of diabetes, hypertension, obesity, or ischaemic heart disease played a significant role in predicting vaccination rates in the schizophrenia group (all p<0•0001), but not in the control group. Hospitalisation and mortality disparities remained higher among people with schizophrenia who had not been vaccinated in comparison to controls (incidence rate difference of 6•2 and 3•2, respectively) but substantially declined in fully vaccinated groups (incidence rate difference of 1•1 and -0•9, respectively).Interpretation People with schizophrenia have higher hospitalisation and mortality risk, yet have lower rates of vaccination than in the general population. Disparities in COVID-19 severe outcomes can be substantially reduced by national vaccination plans aimed at actively reaching out to people with schizophrenia.

Attitudes towards vaccines, intent to vaccinate and the relationship with COVID-19 vaccination rates in individuals with schizophrenia

“…As such, promoting vaccination access in people with schizophrenia is a public health priority (5). However, and despite the demonstrated effectiveness of vaccines for reducing the mortality and morbidity of COVID-19 in this population, a cross-sectional and a longitudinal study reported an association between this pathology and lower vaccination rates (6,7). These studies are in line with what has already been observed in other preventive vaccines like the influenza vaccine (8,9).…”

“…Second, a trend was observed in terms of the proportion of vaccinated participants which was lower in patients in comparison to the non-clinical controls (respectively, 64% versus 77.8%, P = .07). Though COVID-19 vaccination rates in people diagnosed with severe mental disorders are to date largely unknown in most countries, a recent study in Israël, which included a large sample of patients, indicated that people with schizophrenia are under-vaccinated for COVID-19 compared to the general population (7). Very importantly, among non-vaccinated participants, a significantly higher proportion of patients had the intention to be vaccinated compared to non-clinical controls.…”

“…poor internet access, shorter life expectancy, geographical distance from vaccination sites, living in more deprived areas) and attitudinal (i.e. beliefs or perceptions that impact the willingness to be vaccinated) (7,10,22,34). Overall our results suggest that structural barriers rather than individual barriers might explain the lower vaccination rates in individuals with schizophrenia.…”

Diminished capacities to make treatment decision for COVID-19 vaccination in schizophrenia

“…Despite accumulating evidence that people with schizophrenia are at high risk for severe forms of COVID-19 and long-term sequelae (including hospitalizations and mortality) a recent longitudinal study indicated that this population remains under-vaccinated against COVID-19 compared to the general population Several factors including costs, accessibility problems, and the absence of medical recommendations have been associated with lower COVID-19 vaccination rates in individuals with schizophrenia [12]. This study indicates that reduced competence to consent to vaccination may constitute a significant barrier to an efficient vaccination program in this population.…”

Physical comorbidity and use of healthcare services in people with schizophrenia: protocol for a systematic review

“…13 Patients with schizophrenia are also less likely to be vaccinated against COVID-19. 14 One of the factors that may be involved in the poorer physical health of patients with schizophrenia are the side effects of secondgeneration antipsychotics. 15 There are also barriers to the provision of adequate healthcare and help-seeking in this population.…”