International Patterns in Public Perceptions and Hesitancy Towards a Combined COVID-19 and Influenza Vaccination: A Scoping Review of Five Studies

Round 1

Reviewer 1 Report (Previous Reviewer 2)

Dear authors 

The current manuscript aimed to conduct a scoping review to evaluate the attitudes and reasons for acceptance/rejection of a combination COVID-19 and influenza vaccination through search terms that included those on COVID-19, influenza, and combination vaccines in 10 different databases: Embase, Global Health, Google Scholar, CINAHL, Medline, Scopus, ScienceDirect, PubMed, PsycINFO, and Web of Science. Results: Searches across all databases produced a total of 1763 results, of which five were deemed to be eligible for this review.

Actually, this is a research article, not a review article.

 

Also, the results have nothing to add to research; this is a weak review with no benefit, especially since there is no combined vaccine yet to evaluate the attitude towards it.

Few comments in the attached manuscript file

 

All these comments have been mentioned before and not corrected by the authors

 

Best Regards

The title should be changed by deleting a review, as this is a research article, not a review.

All detailed comments in the attached manuscript

 

Comments for author File: Comments.pdf

Author Response

Reviewer 1 comments:

 

Dear authors 

Comment: The current manuscript aimed to conduct a scoping review to evaluate the attitudes and reasons for acceptance/rejection of a combination COVID-19 and influenza vaccination through search terms that included those on COVID-19, influenza, and combination vaccines in 10 different databases: Embase, Global Health, Google Scholar, CINAHL, Medline, Scopus, ScienceDirect, PubMed, PsycINFO, and Web of Science. Results: Searches across all databases produced a total of 1763 results, of which five were deemed to be eligible for this review.

Actually, this is a research article, not a review article. Also, the results have nothing to add to research; this is a weak review with no benefit, especially since there is no combined vaccine yet to evaluate the attitude towards it.

Response: Thank you for this comment. With all due respect to the reviewer, this is indeed a review article and is not original research. This review is different from a traditional literature review in that it follows a scientific framework in which the PRISMA-ScR guidelines are utilised. Therefore, there are Methods, Results, and Discussion sections for this manuscript. We encourage the reviewer to read further into these types of reviews.

In terms of the limitations of the data, we have emphasized them in greater detail as per the Editor comments; these include: lack of a meta-analysis, limits of online questionnaires, a lack of qualitative data, a lack of a current vaccine, and the review being limited to 5 studies. We have discussed these at length and agree that – while these are notable limitations – there is also heavy merit to this review. The review has data from studies with a total of 20,581 participants across 14 countries. We have discussed the benefits and utility of the findings in great detail. In summary, these are identifying interventions and actions based on factors associated with acceptance (affordability, past influenza vaccination, and safety of vaccines) and factors associated with rejection (being a part of certain demographic groups, concerns of side effects/low effectiveness, and general fears stemming from misinformation. We feel that these findings have wide public health implications overall, and are grateful for the reviewer’s inputs.

Comment: Few comments in the attached manuscript file All these comments have been mentioned before and not corrected by the authors

Response: We have indeed already previously responded to most of the comments. We do feel that influenza is a major cause of morbidity and mortality, and so we have retained that portion in the Abstract. We have shown the toll of mortality and morbidity is worldwide, hence addressing your comments.

Reviewer 2 Report (Previous Reviewer 1)

The quality of the resubmitted manuscript, after revision by the authors, was essentially unchanged. Despite the recommendation to include publications categorized as strictly clinical studies and pre-clinical studies in the review, still only 5 publications based on patient surveys serve as a material for the manuscript. As a result, an overview of a rather relevant topic is insufficient and the work is poor in the scientific content. By the way, bearing in mind that it is a review article, the reference list is extremely short. I believe there are actually much more publications covering the scope of the article.

The overall volume of the manuscript is huge, but it is artificially inflated by the half-empty tables (full of the free spaces) and a hefty figure. The authors didn't merge the Tables 1 and 2 together according to the previous recommendation of the reviewer, as well as they did almost nothing to shorten them. A request to replace the term 'combination vaccination' was also ignored.

There are no clear conclusions in the article, it boils down to the fact that some people ('a significant proportion') accept 'combination vaccination' and some do not. At the end of the manuscript, the authors state that the article offers 'valuable insights for scientists and public health professionals on how to optimize the success of the COVID-19 and influenza vaccination combination', but in fact there are absent in the manuscript.

In my opinion, the article should be rejected as blurred in statements and scientifically unsound.

Since the authors ignored all the comments I made in the previous review, I can point them out again.

The ‘calls’ that are mentioned in line 48 should not just be mentioned, but detailed, because that is the point of the article.

The Methods section should be substantially shortened especially in describing the contributions of individual authors (this paragraph is not a major point in review articles and may be added at the end of the manuscript if desired).

It is incorrect to combine participant data from different articles, as is done in lines 168-178.

Figure 2 is huge and can be replaced by a simple text fragment.

Tables 1 and 2 should be shortened and merged together, getting rid of the free spaces. 

Table 3, which occupies a couple of pages, is almost unreferenced and in fact gives the own authors' inferences, which is inappropriate for the review.

Author Response

Reviewer 2:

Comment : The quality of the resubmitted manuscript, after revision by the authors, was essentially unchanged. Despite the recommendation to include publications categorized as strictly clinical studies and pre-clinical studies in the review, still only 5 publications based on patient surveys serve as a material for the manuscript. As a result, an overview of a rather relevant topic is insufficient and the work is poor in the scientific content. By the way, bearing in mind that it is a review article, the reference list is extremely short. I believe there are actually much more publications covering the scope of the article.

Response: Thank you for taking the time to make these comments. However, I am sorry to say that the reviewer is heavily mistaken. First of all, there have been substantial and considerable revisions to the manuscript. Perhaps the reviewer may have accidentally downloaded an incorrect manuscript, as we have introduced a significant amount of text specifically on the comments provided. Below this comment are just some of the many portions in which additions have been made. If the reviewer does want to see them all, we encourage that they read the entire manuscript (and please ensure that they actually read it correctly).

We had re-evaluated the articles captured in the search, and still no additional met the criteria for inclusion in the review. However, the reviewer seems to be a bit confused to believe that merely the fact that there are a small number of studies therefore makes the work unscientific. This is simply incorrect. The review had 20,591 participants from across 14 countries, and so the content and breadth of population is wide; in fact, it is wider than a large number of reviews. Regardless, to blindly believe that a small number of works included in the review warrants the review not being worthy of publication is simply incorrect. I have included here a large number of published articles in which the review had 5 or less included studies, and has still produced important scientific findings. If the reviewer is ignorant to them, it is encouraged that they read them to become more educated on the nature of scoping/systematic reviews:

Cadel, L., Cimino, S. R., Bradley-Ridout, G., Hitzig, S. L., Packer, T. L., McCarthy, L. M., Patel, T., Lofters, A. K., Hahn-Goldberg, S., Ho, C. H., & Guilcher, S. J. T. (2023). A scoping review of medication self-management intervention tools to support persons with traumatic spinal cord injury. PloS one, 18(4), e0284199. https://doi.org/10.1371/journal.pone.0284199

Tait, D., Davis, D., Roche, M. A., & Paterson, C. (2024). Nurse/midwife-to-patient ratios: A scoping review. Contemporary nurse, 60(3), 257–269. https://doi.org/10.1080/10376178.2024.2318361

Cadel, L., Cimino, S. R., Bradley-Ridout, G., Hitzig, S. L., Packer, T. L., McCarthy, L. M., Patel, T., Lofters, A. K., Hahn-Goldberg, S., Ho, C. H., & Guilcher, S. J. T. (2023). A scoping review of medication self-management intervention tools to support persons with traumatic spinal cord injury. PloS one, 18(4), e0284199. https://doi.org/10.1371/journal.pone.0284199

Almeida, M., Lobão, C., Coelho, A., & Parola, V. (2023). Emotional Management Strategies in Prehospital Nurses: A Scoping Review. Nursing reports (Pavia, Italy), 13(4), 1524–1538. https://doi.org/10.3390/nursrep13040128

Krishnan, J. B., Dhyani, V. S., Swamy, R. S., & Gudi, N. (2023). A scoping review of interventions to promote voluntary donation of human breast milk in India. Clinical Epidemiology and Global Health, 24, 101449.

Hoffensitz Nielsen, S., Kirstine Kousgaard Andersen, M., Søndergaard, J., & Bjørnskov Pedersen, L. (2024). Nudging to assist opioid tapering among chronic non-malignant pain patients: A systematic scoping review. Preventive medicine reports, 45, 102821. https://doi.org/10.1016/j.pmedr.2024.102821

Varshney, K., Iriowen, R., Morrell, K., Pillay, P., Fossi, A., & Stephens, M. M. (2022). Disparities and outcomes of patients living with Down Syndrome undergoing healthcare transitions from pediatric to adult care: A scoping review. American journal of medical genetics. Part A, 188(8), 2293–2302. https://doi.org/10.1002/ajmg.a.62854

Sheerazi, S., Awad, S.A. & von Schreeb, J. Use of mobile health units in natural disasters: a scoping review. BMC Health Serv Res 25, 368 (2025). https://doi.org/10.1186/s12913-024-12067-9

Grotto, G., Martinello, M., & Buja, A. (2024). Use of mHealth Technologies to Increase Sleep Quality among Older Adults: A Scoping Review. Clocks & sleep, 6(3), 517–532. https://doi.org/10.3390/clockssleep6030034

Alighieri, C., Vandewiele, F., & Pereira, V. (2025). What works for whom? A systematic review on personalized speech intervention in children and adolescents with a cleft palate. International journal of pediatric otorhinolaryngology, 194, 112401. https://doi.org/10.1016/j.ijporl.2025.112401

Shen, M. R., Owusu-Boaitey, K., Holsen, L. M., & Suzuki, J. (2024). The Efficacy of GLP-1 Agonists in Treating Substance Use Disorder in Patients: A Scoping Review. Journal of addiction medicine, 18(5), 488–498. https://doi.org/10.1097/ADM.0000000000001347

Example of content from the manuscript added as per the reviewer comment from the previous round (which, it is evident – the reviewer chose to ignore or seems to incorrectly downloaded the wrong manuscript as demonstrated by their incorrect comments):

In this review, it has been shown that there are favourably high rates of acceptance towards a combination vaccination for COVID-19 and influenza (though, notably, there was also variation across an array of populations and demographic groups). Convenience, affordability, and safety were described as important contributing factors towards acceptance of a combination vaccine against COVID-19 and influenza viruses. These findings have important implications in providing guidance for public health programs that are focusing on creating initiatives for combination vaccination.

First and foremost, with the development of new combination vaccines, it is imperative that equity is prioritized to ensure that the vaccine is accessible to those who desire to have them but face socioeconomic burdens. Though not limited to combination vaccines, developing programs where vaccines can be administered free of cost have been shown to greatly increase vaccination uptake [37,38]. Conversely, it has also been in the past that high expenses have been a notable barrier to combination vaccine uptake in the past [39], as well as for regular vaccines [40,41]. Considering that new combination vaccines for COVID-19 and influenza will likely involve the utilization of cutting edge technologies, it is likely that the costs will be high; based on the findings of this review, it is hence important that public health departments are adequately funded by governments to ensure that funding is allocated for these vaccines so that members of the general population are not overburdened by the financial costs associated with vaccination.

Secondly, it needs to be emphasized that those who have had the influenza vaccination in the past had a markedly higher likelihood of accepting a combination vaccination for COVID-19 and influenza. Therefore, while public health efforts should focus on promoting the combination vaccine, there is also a critical need to emphasize the importance of the annual flu vaccination more generally. A wide range of different interventions have been implemented to successfully increase uptake of the influenza vaccination, and these include school level training, educating implementers in schools, educating individuals specifically, reminding students and parents [42], nurses/pharmacists educating patients, postcards, personalized phone calls, home visits [43], providing financial incentives to health care workers and practices, using staff to identify eligible patients for outreach, and assisting practices with leadership efforts to provide performance reports for vaccination rates [44]. To improve rates of influenza vaccination, and hence subsequently combination vaccination, these efforts need to be scaled up for influenza vaccination campaigns; furthermore, these initiatives and efforts should increasingly aim to also integrate and promote the combination vaccine to see further rises in rates of uptake. Importantly, these health promotion campaigns should occur alongside COVID-19 vaccine health promotion efforts, as well as newly developed combination vaccine health promotion campaigns. It also needs to be emphasized that, while it is not known when the combination vaccination will be available, these findings do indicate that scaling up of influenza vaccinations in current times (prior to the development of a combination vaccine) can potentially increase the likelihood that people will accept the combination vaccine when it becomes available.

Third, safety of these vaccines was discussed as an important factor relating to why some would be willing to accept these vaccines. The basis behind this may be that some believe that having a combination vaccine can be inherently safe when compared to getting two individualized vaccinations. When combination vaccines have been implemented in the past, a finding of critical importance has been that such vaccinations are as safe as other vaccinations and have not been associated with increased risk for side effects or adverse events [45,46]. Therefore, it is critical that this new combination vaccination, when it is developed, is rigorously tested and is demonstrated to be safe for all who receive it; while it may not necessarily be possible to be even safer than individual vaccines, the combination should nonetheless be demonstrated to at least be as safe as these individual alternatives. Of note, in the past, it has been expressed that one of the concerns of the COVID-19 vaccine was that it was developed too rapidly to be tested adequately and to be able to provide convincing evidence that the risks were minimal [47,48]. Hence, it is critical that the process of developing the combination vaccine is not rushed, and that thorough testing of its effectiveness and safety is tested comprehensively before it becomes used and recommended on a large scale. The high safety of these vaccinations should be included in public health messaging when the combination vaccinations become available.

Our review has shown that several demographic groups appear to be especially reluctant towards a combination vaccine. These include residing in a rural area, being a racial minority, having comorbidities, being female, and having previously had infection with COVID-19. This has important implications and suggests that vaccine delivery programs should relate to health promotion campaigns and communication efforts that attempt to reach out to these groups, who may be reluctant. Increased public health messaging, along with provision of support to groups who may have had lower vaccination rates overall, may have a valuable role in increasing uptake for a combination vaccine. The support may be in the form of additional resources to help to ensure they receive the vaccination, but also increasing access to care, especially primary care, more generally. Importantly, these forms of support should be supplemented by longer-term forms of other social support for groups that continually face disadvantage, both before and after the COVID-19 pandemic; these groups include ethnic minorities [49,50], those who experience hate crimes [51,52], and those experiencing unstable housing/living in overcrowded housing [53,54]. By providing such support, increased trust in the health system can be developed, and this can lead to increasing rates of vaccination uptake in the long term.

The reasons for refusal of a combination vaccine also need to be recognized in public health efforts. As a fear of side-effects and low overall effectiveness were described in studies, it is clear that – along with ensuring that these vaccines (once developed) will be safe and provide optimal protection in comparison to mono-vaccines – there needs to be effective health communication to all populations address misconceptions about the vaccines. This will entail distributing messages across populations of their safety but also addressing potential misinformation regarding perceptions of dangers of such a vaccination. As well, there is also a need to consider factors such as a fear of profiteering, which was discussed in one study [32]. Addressing of misinformation will be of pertinence considering that, since the emergence of COVID-19 vaccines, there have been significant misperceptions regarding the vaccination that have become widespread in numerous segments of populations [55]. Concerns such as these can be addressed by creating freely available educational webinars and sessions and emphasizing that the purposes of these vaccinations is to ensure public health safety and not financial advantage. Considering that all of the included studies in this review were observational, it would be of high utility for future research to also be conducted to evaluate interventions that attempt to address reluctance for a future combination vaccine. Such interventions may have a powerful role in shaping health policy at the government levels.

Comment: The overall volume of the manuscript is huge, but it is artificially inflated by the half-empty tables (full of the free spaces) and a hefty figure. The authors didn't merge the Tables 1 and 2 together according to the previous recommendation of the reviewer, as well as they did almost nothing to shorten them. A request to replace the term 'combination vaccination' was also ignored.

Response: Again, we have made additions to the manuscript, largely in the Discussion section, based on the recommendations of this specific reviewer. Content was not added throughout the manuscript aside from this, with the exception of the quality assessment, which was done to further evaluate the quality of the studies included – to address the reviewer’s need for the work to be more strongly scientific.  As the reviewer is now clearly contradicting himself from his previous comment, the point in this comment about “artificially inflated” content will be largely ignored. Figure 2 has been removed at the request of the Editor however due to the denseness, and Tables have been shortened. It is not sensible nor reasonable to merge the two tables with completely different content. Again, we encourage the reviewer to actually read the content of the manuscript. ‘Combination vaccination’ is appropriate language here as it succinctly and correctly describes the vaccine that would be developed.

Comment: There are no clear conclusions in the article, it boils down to the fact that some people ('a significant proportion') accept 'combination vaccination' and some do not. At the end of the manuscript, the authors state that the article offers 'valuable insights for scientists and public health professionals on how to optimize the success of the COVID-19 and influenza vaccination combination', but in fact there are absent in the manuscript.

In my opinion, the article should be rejected as blurred in statements and scientifically unsound.

Response: Once again, we encourage the reviewer to actually read the manuscript, as there are now heavily nuanced descriptions of the details of the findings and their implications both in the Discussion and Conclusion of the manuscript. After reading the manuscript, which has been heavily revised in the previous revisions as per the Editor and reviewers (which it appears that the reviewer did not read), it should be evident that the nuances of the findings have been thoroughly fleshed out. We have made further edits based on the valid comments of the Editor, which we also encourage to be read. Regarding the nonsensical claim that this is ‘scientifically unsound’, please see the above response to the first comment by this reviewer.

 

Comment: Since the authors ignored all the comments I made in the previous review, I can point them out again.

Response: This is incorrect. Again, it appears that the reviewer has not read the manuscript (or response to the previous comments) or read something else – as we clearly addressed the comments in detail. The reviewer is completely incorrect here.

Comment: The ‘calls’ that are mentioned in line 48 should not just be mentioned, but detailed, because that is the point of the article.

Response: See above. Addressed in great detail.

Comment: The Methods section should be substantially shortened especially in describing the contributions of individual authors (this paragraph is not a major point in review articles and may be added at the end of the manuscript if desired).

Response: It has been shortened to the extent that is possible without removing valuable content in a Methods section (for reproducibility) in a scoping review. It is not convention, nor appropriate, for this to be at the end of a manuscript. Again, we encourage the reviewer to actually read more scoping/systematic reviews as this is self-evident.

Comment: It is incorrect to combine participant data from different articles, as is done in lines 168-178.

Response: See previous response. We did not “combine” them, we discussed them in connection with each other while recognizing differences in context and findings.

Comment: Figure 2 is huge and can be replaced by a simple text fragment. Tables 1 and 2 should be shortened and merged together, getting rid of the free spaces.  Table 3, which occupies a couple of pages, is almost unreferenced and in fact gives the own authors' inferences, which is inappropriate for the review.

Response: This is perhaps the only new comment with any substance here. As per this comment, and the Editor comment (mostly guided by the informed Editor comments), we have removed Figure 2 in totality, included citations in Table 3, and truncated Tables 1 and 2. We disagree strongly with the reviewer that the tables should be merged as they have completely different data. Again, we encourage the reviewer to actually read the content, as once they have read it, this difference in data should be self-evident.

Round 2

Reviewer 1 Report (Previous Reviewer 2)

Dear authors

To say "COVID-19 and influenza are viruses that have been major causes of morbidity and mortality worldwide", authors should mention rank, numbers, or rates, and the year for this fact, not just their belief.

The authors mentioned that the studies, from 14 countries, encompassed a total of 20,581 participants. Do the 5 studies presented include all these 20581??

 

Best Regards

Dear authors

In line 11, to say "COVID-19 and influenza are viruses that have been major causes of morbidity and mortality worldwide", the authors should mention rank, numbers, or rates, and the year for this fact, not just their belief.

The authors mentioned that the studies, from 14 countries, encompassed a total of 20,581 participants. Do the 5 studies presented include all these 20581??

 

Best regards,

Author Response

Comment: In line 11, to say "COVID-19 and influenza are viruses that have been major causes of morbidity and mortality worldwide", the authors should mention rank, numbers, or rates, and the year for this fact, not just their belief.

Response: We have attempted to make it clear as possible in the manuscript that this information is from cited data. As per the manuscript: "Past estimates for total annual deaths due to influenza have been as high as 650,000 worldwide, as per the World Health Organization [3]." 

Comment: The authors mentioned that the studies, from 14 countries, encompassed a total of 20,581 participants. Do the 5 studies presented include all these 20581??

Response: Yes, this is correct. The total number of participants across the five studies is this number. Thank you.

Reviewer 2 Report (Previous Reviewer 1)

The authors should have responded more respectfully to the reviewer's comments. 
Despite the small number of sources analyzed, the article contains some valuable data and in my opinion may be published in its present form.

While fragments of the text, tables, and reference list have been corrected, Figure 2 remained unnecessarily huge and I recommend it to be corrected. In addition, grammatical errors have appeared in the body of the manuscript as a result of the edits and should be carefully checked.

Author Response

Comment: The authors should have responded more respectfully to the reviewer's comments. 
Despite the small number of sources analyzed, the article contains some valuable data and in my opinion may be published in its present form. 

While fragments of the text, tables, and reference list have been corrected, Figure 2 remained unnecessarily huge and I recommend it to be corrected. In addition, grammatical errors have appeared in the body of the manuscript as a result of the edits and should be carefully checked.

Response: Thank you for the comment, and we appreicate the recommendation for this manuscript to be accepted. As per the previously made resubmission based on response to comments - as per the feedback of this reviewer and the Editor, we have removed Figure 2 in totality. Therefore, this comment has been addressed. Lastly, we have now re-checked the manuscript for grammatical errors and improved them where needed. The clean manuscript is attached in word document format, and the tracked changes version is included as a pdf. Once again, thank you.

This manuscript is a resubmission of an earlier submission. The following is a list of the peer review reports and author responses from that submission.

Round 1

Reviewer 1 Report

Although the article deals with a very relevant topic - the attitudes of the world population towards combined influenza and COVID-19 vaccination - it reviews only 5 publications, and no clear conclusions are drawn from their analysis. The manuscript has very little scientific content and requires complete revision.

The ‘Calls’ that are mentioned in line 47 should not just be mentioned, but detailed, because that is the point of the article.

The Methods section should be shortened especially in describing the contributions of individual authors (this paragraph can be added at the end of the manuscript if desired).

It is unclear why articles categorized as strictly clinical studies and pre-clinical studies were excluded.

The Methods section should be shortened especially in the description of the contributions of individual authors (this paragraph can be added at the end of the manuscript if desired). This paragraph is not a major point in review articles.

It is incorrect to combine participant data from different articles, as is done in lines 147-157.

There are no clear conclusions in the article, it just boils down to the fact that some people (a 'sizeable proportion') accept co-vaccination and some do not. At the end of the manuscript, the authors state that the paper offers 'valuable insights to scientists and those in public health regarding how success can be optimized for a combination of COVID-19 and influenza vaccination', but the manuscript does not actually contain them.

The total volume of the manuscript is quite large, but it is created by two tables, which should be shortened and merged together, getting rid of the free spaces. There are frequent language errors in the manuscript (e.g., 'combination vaccination', 'having had', 'having previously had', etc.).

Author Response

Comment 1: Although the article deals with a very relevant topic - the attitudes of the world population towards combined influenza and COVID-19 vaccination - it reviews only 5 publications, and no clear conclusions are drawn from their analysis. The manuscript has very little scientific content and requires complete revision. The ‘Calls’ that are mentioned in line 47 should not just be mentioned, but detailed, because that is the point of the article.

Response 1: 

Thank you for your comment here, and we recognize the further need to both demonstrate the robustness of the review's findings, as well as the application of these findings for public health recommendations. 

To demonstrate the value of these findings more clearly, we describe in much more detail the vast sample sizes, diversity of populations, and depth of statistical analyses of the papers included. We have now also included a quality assessment using the JBI critical appraisal tools to demonstrate the high quality of all studies included in this review. In doing so, we have more effectively demonstrated that the findings of the studies are quite strong and robust, and can be used to make public health recommendations.

In addition to this, we have restructured the Discussion of our manuscript in great depth to include public health recommendations based on the factors most strongly associated with acceptance of a combination vaccine: these are affordability of vaccinations, past influenza vaccination, and safety of vaccines. Examples of recommendations based on these factors are as follows: 
-Whenever possible, these vaccines should be available completely free of cost, especially to those who are financially disadvantaged.
-Initiatives to improve influenza vaccination (and hence combination uptake) include school level training, educating implementers in schools, reminding students and parents, personalized phone calls, home visits, providing financial incentives to health care workers and practices.
-Efforts should be made to ensure that the combination vaccine is safer, or at least as safe as, mono-vaccines.

Similarly, the key factors associated with rejection were described in much further detail, including being part of specific demographic groups, having a fear of side effects, and general fears from misinformation. Recommendations have included specific support and outreach to these groups, and health communication to all populations address misconceptions about the vaccines. This information, and more, is summarized in a table in the Discussion section. In doing so, we have demonstrated that - though a combination vaccine is not yet available - steps can be taken before, and after the development of such a vaccine. In doing so, we feel that we have strongly improved our manuscript and have shown the utility of the findings overall.

 

Comment 2: The Methods section should be shortened especially in describing the contributions of individual authors (this paragraph can be added at the end of the manuscript if desired). 

Response 2: Thank you - the change has been made accordingly.

 

Comment 3: It is unclear why articles categorized as strictly clinical studies and pre-clinical studies were excluded.

Response 3: Thank you. We have now removed that restriction; however, this had no impact on the included studies for the review as no additional studies made it through the screening process.

Comment 4: It is incorrect to combine participant data from different articles, as is done in lines 147-157.

Response 5: We have now revised this accordingly.

Comment 6: There are no clear conclusions in the article, it just boils down to the fact that some people (a 'sizeable proportion') accept co-vaccination and some do not. At the end of the manuscript, the authors state that the paper offers 'valuable insights to scientists and those in public health regarding how success can be optimized for a combination of COVID-19 and influenza vaccination', but the manuscript does not actually contain them.

Response 6: Thank you for this important point. To reiterate the response above, we have now provided significantly more detail regarding the implications of the findings and the public health recommendations to be made.

To reiterate what was stated earlier:

include public health recommendations based on the factors most strongly associated with acceptance of a combination vaccine: these are affordability of vaccinations, past influenza vaccination, and safety of vaccines. Examples of recommendations based on these factors are as follows: 
-Whenever possible, these vaccines should be available completely free of cost, especially to those who are financially disadvantaged.
-Initiatives to improve influenza vaccination (and hence combination uptake) include school level training, educating implementers in schools, reminding students and parents, personalized phone calls, home visits, providing financial incentives to health care workers and practices.
-Efforts should be made to ensure that the combination vaccine is safer, or at least as safe as, mono-vaccines.

Similarly, the key factors associated with rejection were described in much further detail, including being part of specific demographic groups, having a fear of side effects, and general fears from misinformation. Recommendations have included specific support and outreach to these groups, and health communication to all populations address misconceptions about the vaccines. This information, and more, is summarized in a table in the Discussion section. In doing so, we have demonstrated that - though a combination vaccine is not yet available - steps can be taken before, and after the development of such a vaccine. In doing so, we feel that we have strongly improved our manuscript and have shown the utility of the findings overall.

Comment 7:  The total volume of the manuscript is quite large, but it is created by two tables, which should be shortened and merged together, getting rid of the free spaces. There are frequent language errors in the manuscript (e.g., 'combination vaccination', 'having had', 'having previously had', etc.).

Response 7: Thank you. We have now revised the tables in structure and have attempted to improve the English to the best of our ability. We feel that the manuscript has greatly improved and we are grateful for the comments.

Reviewer 2 Report

Dear authors 

The current manuscript aimed to conduct a scoping review to evaluate the attitudes and reasons for acceptance/rejection of a combination COVID-19 and influenza vaccination through search terms that included those on COVID-19, influenza, and combination vaccines in 10 different databases: Embase, Global Health, Google Scholar, CINAHL, Medline, Scopus, ScienceDirect, PubMed, PsycINFO, and Web of Science. Results: Searches across all databases produced a total of 1763 results, of which five were deemed to be eligible for this review.

Actually, these results have nothing to be added for research; this is a weak review with no benefit, especially since there is no combined vaccine yet to evaluate the attitude towards it.

Few comments in the attached manuscript file

 

Best Regards

Dear authors 

The current manuscript aimed to conduct a scoping review to evaluate the attitudes and reasons for acceptance/rejection of a combination COVID-19 and influenza vaccination through search terms that included those on COVID-19, influenza, and combination vaccines in 10 different databases: Embase, Global Health, Google Scholar, CINAHL, Medline, Scopus, ScienceDirect, PubMed, PsycINFO, and Web of Science. Results: Searches across all databases produced a total of 1763 results, of which five were deemed to be eligible for this review.

Actually, these results have nothing to be added for research; this is a weak review with no benefit, especially since there is no combined vaccine yet to evaluate the attitude towards it.

Few comments in the attached manuscript file

 

Best Regards

Comments for author File: Comments.pdf

Author Response

Comment 1: The current manuscript aimed to conduct a scoping review to evaluate the attitudes and reasons for acceptance/rejection of a combination COVID-19 and influenza vaccination through search terms that included those on COVID-19, influenza, and combination vaccines in 10 different databases: Embase, Global Health, Google Scholar, CINAHL, Medline, Scopus, ScienceDirect, PubMed, PsycINFO, and Web of Science. Results: Searches across all databases produced a total of 1763 results, of which five were deemed to be eligible for this review.
Response: We appreciate the reviewer taking the time to evaluate our manuscript, and we have aimed to improve the manuscript further based on the provided comments.
 
Comment 2: Actually, these results have nothing to be added for research; this is a weak review with no benefit, especially since there is no combined vaccine yet to evaluate the attitude towards it.
Response 2: Thank you for your comment here, and we recognize the further need to both demonstrate the robustness of the review's findings, as well as the application of these findings for public health recommendations. 

To demonstrate the value of these findings more clearly, we describe in much more detail the vast sample sizes, diversity of populations, and depth of statistical analyses of the papers included. We have now also included a quality assessment using the JBI critical appraisal tools to demonstrate the high quality of all studies included in this review. In doing so, we have more effectively demonstrated that the findings of the studies are quite strong and robust, and can be used to make public health recommendations.

In addition to this, we have restructured the Discussion of our manuscript in great depth to include public health recommendations based on the factors most strongly associated with acceptance of a combination vaccine: these are affordability of vaccinations, past influenza vaccination, and safety of vaccines. Examples of recommendations based on these factors are as follows: 
-Whenever possible, these vaccines should be available completely free of cost, especially to those who are financially disadvantaged.
-Initiatives to improve influenza vaccination (and hence combination uptake) include school level training, educating implementers in schools, reminding students and parents, personalized phone calls, home visits, providing financial incentives to health care workers and practices.
-Efforts should be made to ensure that the combination vaccine is safer, or at least as safe as, mono-vaccines.

Similarly, the key factors associated with rejection were described in much further detail, including being part of specific demographic groups, having a fear of side effects, and general fears from misinformation. Recommendations have included specific support and outreach to these groups, and health communication to all populations address misconceptions about the vaccines. This information, and more, is summarized in a table in the Discussion section. In doing so, we have demonstrated that - though a combination vaccine is not yet available - steps can be taken before, and after the development of such a vaccine. In doing so, we feel that we have strongly improved our manuscript and have shown the utility of the findings overall.