COVID-19 Vaccine Uptake among People with Spinal Cord Injury and Dysfunction in Ontario, Canada: A Population-Based Retrospective Cohort Study

Persons with disabilities experience numerous barriers to healthcare access including vaccine accessibility. The purpose of this study was to determine COVID-19 vaccine uptake in the spinal cord injury and disease (SCI/D) population of Ontario and identify potential factors influencing C OVID-19 vaccine uptake. This was a retrospective closed-cohort study using administrative health data on individuals with SCI/D of traumatic and non-traumatic causes to examine the monthly number of COVID-19 vaccine doses received between December 2020 and December 2023. Logistic regression analysis was used to examine the potential association between socio-demographic, clinical, and neighbourhood characteristics with initial COVID-19 vaccine receipt and booster dose uptake. By the end of the observation period in December 2023, 82.9% received the full two-dose coverage and 65.6% received at least one additional booster dose in a cohort of 3574 individuals with SCI/D. SCI/D individuals showed a comparable COVID-19 vaccine uptake percentage to the general population. Sociodemographic, clinical, and neighbourhood characteristics were associated with COVID-19 vaccine uptake in the SCI/D population, including age, type of injury, number of comorbidities, mental health history, and neighbourhood characteristics such as income. Further investigation is necessary to determine the causation effects of these relationships with vaccine uptake to address health equity concerns.


Introduction
As of May 2024, the World Health Organization (WHO) reported over 7 million COVID-19-related deaths globally since the virus onset [1].In Canada, approximately 5 million COVID-19 cases and 59,000 COVID-19 related deaths were reported [2].In addition to mortality, the COVID-19 infection rate contributed to short-term and longterm morbidity, including physical and psychological, on the affected person's health and overall wellbeing [3].Vulnerable populations, such as those with physical disabilities, older adults, females, those with lower income, and racialized groups, were particularly at risk of COVID-19 infection and severe health impacts [4][5][6].
The introduction of COVID-19 vaccines in December 2020 curbed the spread and mitigated further health impacts of the virus [7,8].The COVID-19 virus continued to evolve with new mutations after the introduction of the initial recommended two-dose series of the COVID-19 vaccine [9][10][11][12][13][14].The evolving mutations of the COVID-19 virus caused the failure of full viral protection with the initial vaccine series, and subsequent booster dosages were introduced to mitigate and contain the spread of COVID-19 variants [15,16].The recommended target intervals of various booster dosages were dependent on the individual risk levels for adverse consequences and the regulations of the local public health units in Ontario, Canada [15,16].COVID-19 vaccinations in Ontario were publicly funded and available through mass vaccination clinics, family physician offices, community pharmacies, and community outreach programs such as mobile clinics and home visits for high-risk groups.In the prior Canadian and global literature, the accessibility of the COVID-19 vaccine was not fully equitable across the population, with certain groups such as persons with lower income, those from racialized groups, and those with disabilities being particularly vulnerable to healthcare inequalities and intersectoral barriers to care [17][18][19].
Historically, populations with disabilities experience systemic barriers to accessing healthcare resources, especially during times of stress such as the COVID-19 pandemic [17,18].A 2021 focus group study conducted in Manitoba, Canada, reported that individuals with disabilities were unequally challenged with barriers in receiving COVID-19 vaccine-related information, booking vaccination appointments, and physically accessing the vaccination sites [20].Beyond physical disabilities, research has shown that a history of mental health conditions impacts the uptake of the COVID-19 vaccine as well [21][22][23].Within the disabled population, the spinal cord injury and disease (SCI/D) population was particularly vulnerable to healthcare inequalities and challenges with vaccine access due to mobility barriers, comorbidities, and resource limitations [24][25][26][27].Furthermore, many individuals with SCI/D also face mental health challenges, which were exacerbated during the COVID-19 pandemic and may have impacted their vaccine uptake [28,29].Ensuring the uptake of the COVID-19 vaccine in individuals with SCI/D is important as they are prone to serious respiratory infections, including pneumonia, which is one of the leading causes of mortality in the SCI/D population [28,[30][31][32].A previous cross-sectional survey on community-dwelling individuals with SCI/D displayed lower influenza vaccine uptake compared to the guideline recommendation [33].These factors may disproportionally impact certain subgroups of individuals with SCI/D with increasing vulnerability to healthcare inequalities and severe healthcare consequences.No population-based administrative health data research has been conducted in North America describing the percentage of COVID-19 vaccine uptake in the SCI/D population or other populations with physical disabilities living in the community.This knowledge gap has implications for public health, as individuals with certain specific disabilities are at increased risk for severe COVID-19 outcomes [26,34].Investigating the COVID-19 vaccine uptake in the SCI/D population across different subgroups can provide insight into health service equity and access to guide policy and development.As such, detailed information on factors influencing vaccine uptake within the SCI/D population are needed.The purpose of this study was to investigate the rates of COVID-19 vaccination in the SCI/D population and to identify the impact of sociodemographic, clinical (e.g., sex, age, comorbidities, medications dispensed), and neighbourhood characteristics on vaccine uptake.

Methods
This was a retrospective closed-cohort study using linked health administrative databases from ICES in Ontario, Canada.ICES is an independent, non-profit research institute funded by an annual grant from the Ontario Ministry of Health and the Ministry of Long-Term Care.As a prescribed entity under Ontario's privacy legislation, ICES is authorized to collect and use healthcare data for the purposes of health system analysis, evaluation, and decision support.Secure access to these data is governed by policies and procedures approved by the Information and Privacy Commissioner of Ontario.The use of the data in this project is authorized under section 45 of Ontario's Personal Health Information Protection Act (PHIPA) and is approved by the ICES privacy office; as such, it does not require further review by a research ethics board.

Data Source
Data for this study were obtained from ICES.The Discharge Abstract Database (DAD) and the National Rehabilitation System (NRS) database were both used to identify individuals who would comprise the cohort for this study.The COVID-19 vaccination information system of Ontario (COVaxON) database was used to obtain information related to COVID-19 vaccination.COVID-19 vaccines and boosters are publicly funded in Canada and are available without additional costs to individuals.
Patient characteristics collected included sociodemographics (age, sex, and postal code) from the Registered Persons Database (RPDB).Individuals' postal codes from the RPDB were used to identify neighbourhood characteristics based on rurality and income level stratification.The number of medications dispensed was obtained from the Ontario Drug Benefits Database (ODB).The ODB provides information on medications dispensed for those under the government's public drug programs including persons aged 65 years or older in Ontario, residents of long-term care homes, individuals with no private drug insurances, and recipients of professional home services and social assistances.A history of mental health concerns was identified in the DAD and the Ontario Health Insurance Plan (OHIP) database based on flags in a multimorbidity macro for mood disorders and other mental health conditions [35].The presence of either or both conditions indicated that an individual had a history of mental health conditions or a mental health diagnosis.
The Ontario Marginalization Index (ON-Marg) was used to identify and report the following neighbourhood characteristics as quintiles: households and dwellings, age and labour force, and racialized and newcomer populations.The households and dwellings quintiles measure the types and density of residential accommodations, and certain family structure characteristics, such as number of individuals living alone and number of unowned dwellings in each neighbourhood.Age and labour force quintiles include indicators to describe the dependency ratio (seniors and children within the population from 15 to 64 years old) and the number of individuals not participating in the labour force within a neighbourhood.The racialized and newcomer population quintiles indicate the number of recent immigrants and those who self-identify as a 'visible minority' within a neighbourhood.
The Johns Hopkins ACG ® System Version 10 was used to categorize individuals by resource utilization bands (RUBs).RUBs evaluate the overall morbidity level of the individuals and are indicators of expected health-related resource utilization.The RUB scale ranges from 0 to 5, with higher values associated with higher utilization levels.The SCI/D population has higher comorbidities and RUBs are a useful indicator to address the interactions among the comorbidities [36].

Cohort
The cohort used for this study was a sub-cohort from a previously developed study investigating healthcare utilization during the pandemic for SCI/D [26].The cohort consisted of individuals with traumatic and non-traumatic causes of SCI/D.Individuals with a traumatic spinal cord injury (TSCI) were identified from the DAD based on first admission and discharge from acute hospitalization between 1 April 2004 and 28 February 2014.The cohort cut-off on 28 February 2014 ensured that individuals were community-dwelling for at least 5 years before the start of the COVID-19 pandemic.Individuals with nontraumatic spinal cord dysfunction (NTSCD) were identified from the NRS database based on first admission and discharge from inpatient rehabilitation between 1 April 2004 and 28 February 2014.Only individuals living in the community per a hospital discharge summary since 2014 and who were alive during the observation window from December 2020 to December 2023 per discharge record were included in the study.The number of monthly COVID-19 vaccine doses were identified from December 2020 to December 2023 in a community-dwelling SCI/D cohort.

Outcomes
The COVaxON database records all COVID-19 vaccines administered in Ontario in its real-time centralized vaccine information system, which also collected information on the date and location of administration, product type, and dose number.We extracted records of vaccination for the SCI/D cohort from December 2020 to December 2023.To evaluate the uptake of the vaccine, we calculated the percent of individuals within the cohort who received 0 to 5 doses by monthly evaluation.Vaccination full coverage was classified as at least 2 doses, with 3+ doses classified as additional booster doses [9- 14,16].Vaccination uptake was stratified and evaluated by the following sociodemographic characteristics: injury type (TSCI vs. NTSCD), sex (males vs. females), and age (under 65 years vs. 65 years and over).

Statistical Analysis
Means, standard deviations, and proportions were used to describe the demographic characteristics for the SCI/D cohort stratified by vaccine doses (0 doses, 1 dose only, 2 doses only, and 3+ doses).Two multivariable logistic regression models were conducted to determine if patient demographic, clinical, and neighbourhood characteristics were associated with COVID-19 vaccination coverage by December 2023.An assessment of multicollinearity was conducted and factors that exhibited multicollinearity were not modeled together in the regression analyses.The first model examined parameters related to the uptake of the initial full vaccination coverage of two doses (zero doses compared to a minimum of two doses) [9- 14,16].The second model examined factors associated with receiving the booster dose in addition to the initial two-dose series (2 doses only compared to 3 or more doses).Missing data were merged with the highest category.The Hosmer-Lemeshow test was conducted for each model to determine goodness of fit.

Results
The final SCI/D cohort included 3574 individuals, with 60.4% diagnosed with NTSCD and 39.6% diagnosed with TSCI.Most of the cohort was male (59.9%) and under 65 years old (54.2%).Table 1 outlines the demographic characteristics stratified by dose uptake.By the end of the observation period in December 2023, 82.9% of individuals reached full vaccine coverage (two doses), with 65.6% receiving additional doses (see Table 2 and Figure 1).Saturation of full coverage was reached by December 2021 and saturation of additional doses was reached by December 2022 (Figure 2).The stratification of COVID-19 vaccine uptake by SCI/D injury type showed a higher percentage of COVID-19 vaccine uptake by individuals with NTSCD compared to TSCI (Figure 3). Figure 4 shows higher COVID-19 vaccine uptake in females compared to males.Stratification by age showed higher COVID-19 vaccine uptake in individuals of 65 years and older compared to under 65 years old (Figure 5).SCI/D individuals 44 years old and under were significantly less likely to receive full coverage compared to individuals 65 years and older (OR: 0.64, 95% CI: 0.46 to 0.90, p-value: 0.01).Individuals with NTSCD were significantly more likely to receive full coverage compared to TSCI individuals (OR: 1.29, 95% CI: 1.02 to 1.64, p-value: 0.03).Individuals with a resource utilization band of zero compared to band five were significantly less likely to receive full coverage (OR: 0.09, 95% CI: 0.06 to 0.13, p-value: <0.01).Individuals with no medications dispensed were significantly less likely to receive full coverage compared to individuals using greater or equal to 20 medications (OR: 0.43, 95% CI: 0.26 to 0.70, p-value: <0.01).Individuals with three to four medical conditions were significantly less likely to receive full coverage compared to individuals with five or more diagnosed health conditions (OR: 0.66, 95% CI: 0.49 to 0.89, p-value: <0.01).Sex and history of mental conditions were not related to the uptake of the COVID-19 vaccine full coverage.

Discussion
This population-based study investigated the rates of COVID-19 vaccination in the Ontario SCI/D population and identified the impact of sociodemographic, clinical (i.e., sex, age, comorbidities, medications dispensed), and neighbourhood characteristics on vaccine uptake.First, over 80% of the community-dwelling SCI/D population received full coverage (minimum of two doses) of the COVID-19 vaccine within one year after vaccine availability, from December 2020 to 2021.Second, over 65% of the community-dwelling SCI/D population also received an additional booster by December 2022.Importantly, certain sociodemographic, clinical, and neighbourhood characteristics impacted the likelihood of receiving full coverage, as well as boosters.
The Ontario SCI/D population's COVID-19 vaccine uptake (84.5% for one dose) is comparable to that of the general population in Canada (84.7%) and slightly higher than in the general population of Ontario (80.9%) [37].Significantly, the Ontario SCI/D population vaccine uptake is higher compared to the internationally reported COVID-19 vaccine uptake.A previous cross-sectional study in Thailand reported the uptake of the COVID-19 vaccine in the SCI/D population comparable to the general population for one (77% vs. 78.2%)and two doses (70% vs. 71.9%),respectively, and a lower uptake of the booster dose (20% vs. 31.3%)[24].A cross-sectional study in Kenya reported a COVID-19 vaccine uptake of 65.7% in persons with disabilities and the vaccination barriers of cost of transportation, lack of mobile clinics, lack of access to reliable vaccine information, the belief in COVID-19 infection, and marital status [25].In Ontario, the presence of mobile clinics, home visits, and community-accessible vaccination possibly supported its higher COVID-19 vaccine uptake compared to Thailand and Kenya.In the Ontario SCI/D population, the decrease in booster dose uptake (65.6%) in comparison with the uptake of initial two-dose series (82.9%) could be due to a decline in vaccine interests and changes in vaccine-service availability in the community setting (i.e., reduced mass vaccination clinics, mobile clinics, etc.), considering these services mostly prevailed during the vaccination initiation phase in 2021 [15,16].Vaccination initiatives at local community sites can better accommodate individuals with disabilities and possibly support the increase in COVID-19 vaccine uptake in Ontario compared to global trends.To compare the COVID-19 vaccine uptake in other populations, a multiple center study in Germany reported comparable COVID-19 vaccine uptake between the multiple sclerosis population with the general population in the uptake of the first (84.5% and 78.0%) and second dose of the COVID-19 vaccine (78.2% vs. 76.4%)[38].These results suggested that the presence of disability alone may not significantly impact the uptake of the COVID-19 vaccine compared to the general population.
The previous literature showed the association between COVID-19 vaccine uptake and various factors including physical barriers, mobility limitations, vaccine hesitancy, societal attitudes, logistical difficulties, information accessibility, and socioeconomic factors [18,24,25,[39][40][41][42].Our study found the younger SCI/D populations were less likely to obtain COVID-19 vaccines compared to the older population of 65 years or older.This finding is consistent with the investigation of COVID-19 vaccine hesitancy in the United States, which reported younger adults had higher vaccine hesitancy compared to the older population [43].Younger populations may be more concerned about the side effects of the vaccine compared to the outcomes of the COVID-19 infection because they have fewer comorbidities causing severe outcomes [44][45][46].Older individuals may be at greater risk of experiencing complications and severe outcomes if infected with the COVID-19 virus [46]; as such, these individuals may have been more diligent with ensuring they are up-to-date with COVID-19 vaccination guidelines.
Surprisingly, sex was not associated with the uptake of full COVID-19 vaccine coverage or the booster dose from the multivariable logistic regression analysis.A previous systematic review and exploratory analysis reported higher vaccine hesitancy rates among females, with vaccine safety being the major concern [43,47].However, a recent scoping review showed that vaccine hesitancy does not necessarily equate with the behaviour of absence of vaccine uptake [48].Canadian national statistics showed higher COVID-19 vaccine uptake of at least one dose and per recommendation in females (84.7% and 21.3%) compared to males (79.7%, and 18.7%) for those of five years and older [37].Our study results showed similar findings of full coverage vaccine uptake in female (85.2%) compared to males (81.4%).The fifth dose of the COVID-19 vaccine is the latest recommended booster dose at the end of the study, with 33.6% uptake in females, and 26.4% in males, showing a slightly higher vaccine uptake compared to the general population.However, after correcting for sociodemographic factors, there were no statistical significance findings between vaccine uptake and sex.This suggests that there are other sociodemographic factors impacting vaccine uptake, which require further investigation.
With respect to injury type, individuals with NTSCD were more likely to obtain the COVID-19 vaccine compared to individuals with TSCI.This finding differs from the previous literature report from Thailand that individuals with NTSCD were less likely to receive a COVID-19 vaccine due to speculated concerns about adverse reactions toward the vaccine [24].Healthcare resource utilization, the number of medications dispensed, the number of health conditions, and mental health status also seemed to impact vaccination uptake at varying levels.Individuals with three to four pre-existing medical conditions were less likely to receive full COVID-19 vaccine coverage compared to those who were diagnosed with five or more health conditions.Interestingly the diagnosis of mental health conditions did not impact the initial COVID-19 vaccine uptake, and the number of health conditions did not impact the uptake of the COVID-19 booster dose.RUB usage, an indicator for overall morbidity and healthcare resource utilization, was associated with both initial vaccine uptake and booster dose uptake and could indicate the potential of those with a higher disease burden to be more inclined for vaccination due to the potential concerns about severe health impacts after COVID-19 infection [49].
Finally, neighbourhood characteristics were found to be important factors associated with the COVID-19 vaccine uptake in this study.Certain neighbourhoods may have barriers to vaccine accessibility and dissemination.Individuals from lower-income neighbourhoods were less likely to receive the full-coverage COVID-19 vaccine or the booster dose.Households and dwellings composition, as well as age and labour factors of a neighbourhood, correlated with receiving full COVID-19 vaccine coverage and booster doses.Lower residency stability decreased the booster dose uptake but did not associate with the uptake of the full COVID-19 vaccine series.A low dependency ratio (age and labour force quintile) suggested that a higher proportion of working adults compared to children and seniors showed decreased COVID-19 vaccine and booster dose uptake.Neighbourhood characteristics were associated with vaccine uptake, but further investigations are needed to understand the implication of these findings.

Limitations
This is a closed-cohort study focused on a community-dwelling population with SCI/D diagnoses in Ontario for at least 5 years prior to the start of the COVID-19 pandemic and receiving rehabilitation.Individuals with SCI/D living in the community for less than 5 years prior to the start of the COVID-19 pandemic and individuals who passed away before the end of the cohort study at the end of December 2023 were excluded from this study.This study is limited by the extent and type of data available in the databases with the secondary use of health administrative data.It is possible that individuals in the cohort may have received COVID-19 vaccines outside of Ontario, which would not be captured in the COVaxON database.However, due to travel restrictions during this time, as well as limited mobility in our population, this is unlikely.This study assessed COVID-19 vaccine uptake based on the number of dosages received and did not clinically evaluate the type of vaccination and exact interval of vaccination to determine whether the population studied was vaccinated per recommendation of the Public Health Unit.The ODB only captures prescribed medications that are dispensed for individuals 65 years or older and those who receive social assistance.Thus, medications covered by private insurance, dispensed in clinics or hospitals, and prescribed to individuals younger than 65 years old not on the Ontario public drug insurance plan were not captured in this study.Additionally, over-the-counter products, natural health products, and supplements are not captured in this study.Thus, the record of no medications dispensed should be interpreted with caution.Despite this, number of health conditions and the health-related burden are captured with the ICES data and may be a good estimate for the disease burden.Due to limitations in cohort size, parameters of rurality and the first dose were not included in the regression analyses.The results of our study reflected the SCI/D population in Ontario only.As such, inferences about other health systems and regions should be made with caution.

Future Directions
For future pandemic response and preventative-measure planning, further investigations on the reasons for vaccine hesitancy and increased vaccination compliance need to be conducted.Potential concerns include vaccine fatigue (five total doses, and three booster doses introduced as of December 2023), public trust, reduction in mobile clinics, and vaccination sites with booster doses compared to 2021 when vaccines were first introduced.With the increasing number of booster dosages, barriers to vaccinations become more evident with a potential increase in vaccine fatigue within the population.In the future, targeted health policies and strategies need to be implemented with the consideration of the sociodemographic factors driving vaccine hesitancy and reducing barriers to healthcare access for vulnerable populations.For instance, neighbourhood characteristics were found to be correlated with the uptake of the COVID-19 vaccine and booster doses, and further research may be necessary to determine the relationship between the neighbourhood potential for health-resource limitations.Further mixed-method investigations are necessary to understand individual, community, and health-system factors impacting vaccination delivery and uptake.Considering that our study uses existing health administrative data, we did not evaluate marital status or individual perspectives on vaccines or the COVID-19 infection or the education levels of the cohort population.Further studies are needed to investigate these parameters.

Conclusions
Individuals with physical disabilities, such as SCI/D, frequently experience barriers to healthcare access, and addressing the intersection between disability and other disparities in vaccine uptake is critical to highlighting systemic inequities.This study evaluated the uptake of the COVID-19 vaccine within the SCI/D population and examined the parameters potentially affecting vaccine uptake such as clinical or sociodemographic characteristics (i.e., TSCI and NTSCD, sex, age, and neighbourhood characteristics).Our study found the rate of COVID-19 vaccine uptake in the SCI/D population was comparable to the general population.The comparable initial uptake of the COVID-19 vaccine and the subsequent booster doses between individuals with SCI/D and the general population in Ontario suggested the lack of significant differences with COVID-19 vaccine access associated with the sole diagnosis of SCI/D.The regression analyses showed variability in COVID-19 vaccine uptake amongst the subpopulations of SCI/D.Within the SCI/D subpopulations, individuals diagnosed with NTSCD were statistically more likely to receive the COVID-19 vaccines compared to TSCI.The SCI/D subpopulation analysis also showed that persons less than 44 years old and from neighbourhoods with lower incomes and a low dependency ratio exhibited lower uptake of the initial COVID-19 vaccine series and the booster doses.Community-dwelling SCI/D individuals with the characteristic of lower predicted resource utilization (low RUB quintile) and from neighbourhoods with less residential stability exhibited a lower uptake of the COVID-19 booster dose.The findings from this study provide opportunities for public health policy to modify the vaccination programs with increased awareness and sensitivity to sociodemographic data.This is particularly valuable in situations where multiple vaccination doses or boosters are required to achieve the targeted preventative health goals and the closure of vital community-based access points (i.e., mobile clinics and home visits) may disproportionately impact vulnerable populations.
The immediate threat of the COVID-19 virus has significantly diminished, mainly due to the global efforts of COVID-19 vaccination [7,8].It is important to continue evaluating vaccine uptake in persons with disabilities to inform public health preparedness for future pandemics or infectious disease outbreaks.Ontario offered outreach programs for individuals at high risk for COVID-19 infection complications and living at home, which may increase the percentage of uptake of the COVID-19 vaccine within the community-dwelling SCI/D population [16].Lessons learned from the COVID-19 pandemic can help to develop more effective strategies for reaching and vaccinating vulnerable populations in future health emergencies or seasonal flu outbreaks.The findings of this study can help inform policy, optimize interventions, and ultimately foster better health outcomes for people with disabilities in the context of the ongoing pandemic and future health emergencies.through the Vaccine Surveillance Reference group and the COVID-19 Immunity Task Force.The views expressed herein do not necessarily represent the views of the Public Health Agency of Canada.This study was supported by ICES, which is funded by an annual grant from the Ontario Ministry of Health (MOH) and the Ministry of Long-Term Care (MLTC).This document used data adapted from the Statistics Canada Postal CodeOM Conversion File, which are based on data licensed from the Canada Post Corporation, and/or data adapted from the Ontario Ministry of Health Postal Code Conversion File, which contains data copied under license from ©Canada Post Corporation and Statistics Canada.Parts of this material are based on data and/or information compiled and provided by CIHI and the Ontario Ministry of Health.We thank the Toronto Community Health Profiles Partnership for providing access to the Ontario Marginalization Index.We thank IQVIA Solutions Canada Inc. for use of their Drug Information File.The analyses, conclusions, opinions and statements expressed herein are solely those of the authors and do not reflect those of the funding or data sources; no endorsement is intended or should be inferred.Parts of this material are based on data and information compiled and provided by the Ontario Ministry of Health.The analyses, conclusions, opinions, and statements expressed herein are solely those of the authors and do not reflect those of the funding or data sources; no endorsement is intended or should be inferred.SJTG is currently supported by the University of Toronto Centre for the Study of Pain Scientist Salary Award.K.T. is supported by a Chair in Family and Community Medicine Research in Primary Care

Figure 1 .
Figure 1.The cumulative percentage of COVID-19 vaccine uptake among individuals with spinal cord injury and disease in Ontario: December 2020 to December 2023.Graphical representation of the cumulative percentage of COVID-19 uptake (1 dose, 2 doses, and 3 or more doses) at the timepoints of December 2021, December 2022, and December 2023, stratified by sex, age and type of spinal cord injury and disease (traumatic spinal cord injury (TSCI) and non-traumatic spinal cord dysfunction (NTSCD)).Individuals of 65 years or older or with NTSCD have a higher percentage of COVID-19 vaccine uptake.See Table2for specific percentage values.

Figure 2 .
Figure 2. Full cohort of COVID-19 vaccine uptake among individuals with spinal cord injury and dysfunction (SCI/D) living in the community setting of Ontario.The graph displays the percentage of COVID-19 vaccine uptake from December 2020 to December 2023 for the Ontario spinal cord injury and disease population living in the community setting.At the end of the retrospective cohort study, individuals can receive up to a maximum of five doses of the COVID-19 vaccine according to local public health guidelines.Total number of individuals in the cohort is 3574.At the end of

Figure 2 .
Figure 2. Full cohort of COVID-19 vaccine uptake among individuals with spinal cord injury and dysfunction (SCI/D) living in the community setting of Ontario.The graph displays the percentage of COVID-19 vaccine uptake from December 2020 to December 2023 for the Ontario spinal cord injury and disease population living in the community setting.At the end of the retrospective cohort study, individuals can receive up to a maximum of five doses of the COVID-19 vaccine according to local public health guidelines.Total number of individuals in the cohort is 3574.At the end of

Figure 3 .
Figure 3.The percentage of COVID-19 vaccine uptake from December 2020 to December 2023 for people with traumatic and non-traumatic spinal cord-injuries and dysfunction living in the community setting.(A)The percentage of COVID-19 vaccine uptake for people with traumatic spinal cord-injuries (TSCI).Total population in the TSCI group is 1414.At the end of December 2023, percentage of COVID-19 vaccine uptake is 80.3% for first dose, 78.1% for second dose, 53.9% for third dose, 32.3% for fourth dose, and 19.6% for fifth dose.(B) The percentage of COVID-19 vaccine uptake for people with non-traumatic spinal cord dysfunction(NTSCD).Total population in the NTSCD group is 2142.At the end of December 2023, percentage of COVID-19 vaccine uptake is 87.3% for first dose, 86.1% for second dose, 73.3% for third dose, 49.8% for fourth dose, and 35.7% for fifth dose.

Figure 4 .
Figure 4.The percentage of COVID-19 vaccine uptake from December 2020 to December 2023 based on gender for people with traumatic and non-traumatic spinal cord-injuries and dysfunction living in the community setting.(A) The percentage of COVID-19 vaccine uptake for males.Total male population is 2142.At the end of December 2023, percentage of COVID-19 vaccine uptake is 83.1% for first dose, 81.4% for second dose, 62.3% for third dose, 40.1% for fourth dose, and 26.4% for fifth dose.(B) The percentage of COVID-19 vaccine uptake for females.Total female population is 1432.At the end of December 2023, percentage of COVID-19 vaccine uptake is 86.7% for first dose, 85.2% for second dose, 70.5% for third dose, 47.0% for fourth dose, and 33.6% for fifth dose.

Figure 4 .
Figure 4.The percentage of COVID-19 vaccine uptake from December 2020 to December 2023 based on gender for people with traumatic and non-traumatic spinal cord-injuries and dysfunction living in the community setting.(A) The percentage of COVID-19 vaccine uptake for males.Total male population is 2142.At the end of December 2023, percentage of COVID-19 vaccine uptake is 83.1% for first dose, 81.4% for second dose, 62.3% for third dose, 40.1% for fourth dose, and 26.4% for fifth dose.(B) The percentage of COVID-19 vaccine uptake for females.Total female population is 1432.At the end of December 2023, percentage of COVID-19 vaccine uptake is 86.7% for first dose, 85.2% for second dose, 70.5% for third dose, 47.0% for fourth dose, and 33.6% for fifth dose.

Figure 5 .
Figure 5.The percentage of COVID-19 vaccine uptake from December 2020 to December 2023 based on age for people with traumatic and non-traumatic spinal cord-injuries and dysfunction living in the community setting.(A) The percentage of COVID-19 vaccine uptake for 65 years old and over.Total 65 years old and over population is 1637.At the end of December 2023, percentage of COVID-19 vaccine uptake is 88.6% for first dose, 88.2% for second dose, 80.6% for third dose, 63.2% for

Table 1 .
Demographic table for the spinal cord injury and disease (SCI/D) population living in the community setting from December 2020 to December 2023 in Ontario, Canada.

PERCENTAGE % TIME (MONTH, YEAR) PERCENTAGE OF COVID-19 VACCINE UPTAKE AMONG INDIVIDUALS WITH SPINAL CORD INJURY AND DISEASE OF ONTARIO
Full cohort of COVID-19 vaccine uptake among individuals with spinal cord injury and dysfunction (SCI/D) living in the community setting of Ontario.The graph displays the percentage of COVID-19 vaccine uptake from December 2020 to December 2023 for the Ontario spinal cord injury and disease population living in the community setting.At the end of the retrospective cohort study, individuals can receive up to a maximum of five doses of the COVID-19 vaccine according to local public health guidelines.Total number of individuals in the cohort is 3574.At the end of December 2023, total percentage of COVID-19 vaccine is 84.5% for first dose, 82.9% for second dose, 65.6% for third dose, 42.9% for fourth dose, and 29.3% for fifth dose.
Total population in the TSCI group is 1414.At the end of December 2023, with traumatic and non-traumatic spinal cord-injuries and dysfunction living in the community setting.(A) The percentage of COVID-19 vaccine uptake for people with traumatic spinal cordinjuries (TSCI).Total population in the TSCI group is 1414.At the end of December 2023, percentage of COVID-19 vaccine uptake is 80.3% for first dose, 78.1% for second dose, 53.9% for third dose, 32.3% for fourth dose, and 19.6% for fifth dose.(B) The percentage of COVID-19 vaccine uptake for people with non-traumatic spinal cord dysfunction(NTSCD).Total population in the NTSCD group is 2142.At the end of December 2023, percentage of COVID-19 vaccine uptake is 87.3% for first dose, 86.1% for second dose, 73.3% for third dose, 49.8% for fourth dose, and 35.7% for fifth dose.
percentage of COVID-19 vaccine uptake is 80.3% for first dose, 78.1% for second dose, 53.9% for third dose, 32.3% for fourth dose, and 19.6% for fifth dose.(B) The percentage of COVID-19 vaccine uptake for people with non-traumatic spinal cord dysfunction(NTSCD).Total population in the NTSCD group is 2142.At the end of December 2023, percentage of COVID-19 vaccine uptake is 87.3% for first dose, 86.1% for second dose, 73.3% for third dose, 49.8% for fourth dose, and 35.7% for fifth dose.people Total male population is 2142.At the end of December 2023, percentage of COVID-19 vaccine uptake is 83.1% for first dose, 81.4% for second dose, 62.3% for third dose, 40.1% for fourth dose, and 26.4% for fifth dose.
(B)The percentage of COVID-19 vaccine uptake for females.Total female population is 1432.At the end of December 2023, percentage of COVID-19 vaccine uptake is 86.7% for first dose, 85.2% for second dose, 70.5% for third dose, 47.0% for fourth dose, and 33.6% for fifth dose.
Total male population is 2142.At the end of December 2023, percentage of COVID-19 vaccine uptake is 83.1% for first dose, 81.4% for second dose, 62.3% for third dose, 40.1% for fourth dose, and 26.4% for fifth dose.(B) The percentage of COVID-19 vaccine uptake for females.Total female population is 1432.At the end of December 2023, percentage of COVID-19 vaccine uptake is 86.7% for first dose, 85.2% for second dose, 70.5% for third dose, 47.0% for fourth dose, and 33.6% for fifth dose.