National expert consensus recommendations on influenza vaccination in Saudi Arabia (2025)

Abstract

In Saudi Arabia, influenza is considered a primary public health concern. Preventative measures include vaccination, which is reported as suboptimal in terms of uptake by both children and adults. To address this, two multidisciplinary expert workshops brought together, 15 specialists from family medicine, infectious diseases, pediatrics, pulmonology, epidemiology, and public health to Riyadh on 26^th October 2024 and 28^th June 2025 with the aim of developing recommendations on influenza vaccination tailored to the Saudi context. During the two meetings, the experts shared insights and discussions, which were then consolidated into structured, consensus recommendations. To inform the consensus, a narrative literature review was performed. Fifteen comprehensive consensus statements across nine key domains were developed. The domains included disease monitoring and compliance mechanisms, strengthening surveillance and data integration, optimizing vaccination timing, enhancing vaccination coverage rates, enhancing public confidence and acceptance, improving healthcare worker engagement, improving disease severity awareness, decentralizing vaccination responsibilities, and integrating live-attenuated influenza vaccine into public health programs. Implementing these recommendations should help in improving disease prevention and public health in Saudi Arabia.

Introduction

Seasonal influenza remains a global health challenge that causes an estimated 3–5 million cases of serious illness and 290,000–650,000 annual respiratory deaths worldwide.[1,2] While influenza affects all age groups, children under 5 years in developing countries are disproportionately affected, bearing 99% of the influenza-associated lower respiratory tract infection mortality.[1]

Local data from Saudi Arabia mirrors the global trends. Epidemiological evidence reveals a critical and consistent disease burden, with high rates of severe acute respiratory infection (SARI) hospitalization – averaging 294 per 100,000 population across the 2017–2023 seasons.[2] Around 17,678 influenza-associated respiratory cases were reported during the severe 2017–2018 season alone. In addition, hospitalization rates consistently peak in two specific populations: older adults (≥65 years) and young children (0–4 years).[3] Children mainly experience severe symptoms characterized by repeated severe illness, cardiac manifestations, and potential organ failure necessitating mechanical ventilation.[4,5,6] Besides, children are known as the primary drivers of influenza transmission within communities. Consequently, it is important to prioritize the need to optimize pediatric vaccination for community-wide protection.[7,8]

In terms of economic implications of influenza in Saudi Arabia, total economic cost of delayed viral SARI diagnosis is estimated at USD 4.7 billion, compared with USD 3.8 billion linked to early diagnosis.[9] This figure aligns well in developed nations like the United States of America (USA), where influenza is associated with an average annual economic burden of USD 11.2 billion, from which USD 3.2 billion was attributed to direct costs.[10]

Of the most effective preventive measures against influenza, vaccination remains key in reducing infection rates up to 60%. Vaccination was also linked to reduced risk of influenza-related pediatric intensive care unit (ICU) admission by 74%.[11,12] Supportive evidence of pilgrims also demonstrated significant reduction in the incidence of influenza-like illness (5.2% vs. 15.2%) and respiratory conditions.[13] Evidence from Sudanese pilgrims traveling by sea during the same Hajj season further underlines the importance of structured pretravel vaccination strategies.[14]

Live-attenuated influenza vaccine (LAIV) plays a strategic role in enhancing these preventive efforts. Several reasons contribute to its well-known acceptability by children: its noninvasive, injection-free intranasal application directly mitigates needle phobia. In addition, LAIV demonstrated superior immune responses in children along with cost-effective advantages when integrated into pediatric immunization programs.[15,16,17]

To date, coverage of influenza vaccine remains suboptimal in Saudi Arabia despite the evident clinical burden, economic justification, and established infrastructure for mandatory child vaccination.[11,12,18] This disparity suggests that the challenge lies beyond system incapacity, but is rather related to policy prioritization and accessibility. Barriers also reported in voluntary seasonal flu program, contribute to low participation. Such barriers include logistical hurdles and aversion to injectables.[19,20,21]

On account of the above mentioned unmet needs and potential opportunities, a multidisciplinary panel of national experts was convened to reach practical, evidence-based decisions and make recommendations to strengthen immunization strategies in Saudi Arabia.

Materials and Methods

Study design

Two multidisciplinary expert workshops were conducted in Riyadh on October 26, 2024, and June 28, 2025 to establish practical solutions to enhance national immunization strategies. The workshops included structured discussions on local disease burden, vaccination coverage rates, barriers to implementation, and the potential role of preventative measures, including LAIV.

Participant selection

The panel comprised 15 key experts, selected according to their academic, clinical, and policy shaping experience in influenza management and immunization across key clinical and public health disciplines in Saudi Arabia. Sampling was decided purposely to first identify the experts’ eligibility to participate in this work. Eligibility was based on relevant experiences and leadership roles in immunization programs, influenza prevention practice, public health, disease burden awareness, and infectious diseases clinical practice. Participants provided professional profiles, including clinical specialization, postgraduate degrees (Master’s or Doctorate), field of the study, publication records, and involvement in academic or university teaching activities, to ensure a diverse representation of clinical and public health perspectives. All experts were requested to declare any conflict of interest before participation. Disclosures were reviewed by the corresponding author and all coauthors, but no conflicts of interest were identified among the panel.

Consensus development and search strategy

Discussions from both workshops were transcribed and analyzed to identify recurring insights and areas of agreement, which were then consolidated into consensus recommendations. We used Modified Nominal Group Technique to refine the statements. Statements were subsequently reviewed and validated by the participating experts. In parallel, a thorough targeted evidence review was conducted to support the consensus using PubMed and Scopus for studies between 2019 and 2025 to assess relevant international and regional experiences. The search strategy utilized a prespecified strategy combining terms for “vaccination,” “recommendation,” “consensus,” “influenza” and “LAIV.” Eligibility criteria included studies relevant to the importance of vaccination, policy shaping, recommendations to address influenza burden. Irrelevant studies, such as those related to infections other than influenza were excluded by screening titles and abstracts.

Draft statements and evidence summaries were circulated to experts for independent review before the meeting. During the session, agreement was assessed anonymously through real-time electronic polling using a predefined threshold of ≥80% acceptance. This threshold aligns with thresholds commonly used in healthcare consensus research.[21] When present, statements with dissenting opinions were refined and re-polled until consensus was achieved during the same meeting. The total number of draft statements was 17; on 13 of these a consensus was reached in the first round, but two statements required further structured discussions and rephrasing (disagreements were mainly related to wording/phrasing) for the 100% agreement to be reached in the second round. During the second round, the panel agreed to exclude two statements deemed vague, redundant and not directional. In brief, two rounds of voting were required to reach final recommendations, which were then reconciled by the steering committee to ensure clarity, consistency, and representation of the panel’s collective judgment.

Ethical considerations

All experts provided informed consent for the inclusion of their professional opinions in this review. Final outcome summarizes consolidated perspectives and key actions recommended by the panel to strengthen coverage of influenza vaccination in Saudi Arabia.

Results

Participant characteristics

The expert panel included 15 national experts representing diverse disciplines from family medicine, preventive medicine, infectious diseases, pediatrics, pulmonology, public health, critical care, epidemiology, and immunization programs in Saudi Arabia.

Consensus recommendations for influenza vaccination

A total of 17 draft recommendations were developed, 15 of which were finalized and confirmed by the expert panel. Recommendations addressed nine key domains: disease monitoring and compliance mechanisms, strengthening surveillance and data integration, optimizing vaccination timing, enhancing vaccination coverage rates, enhancing public confidence and acceptance, improving Healthcare worker (HCW) engagement, improving disease severity awareness, decentralizing vaccination responsibilities, and integrating LAIV into public health programs.

Shared perspective of national experts on feasible and evidence-based strategies to strengthen influenza prevention in Saudi Arabia was established. Experts were keen to include a clear rationale and implementation points within every agreed statement, reflecting the critical importance of influenza prevention in the region. A summary of all recommendations is also presented in Table 1, and their thematic framework is illustrated in Figure 1.

Table 1.

Consensus statements on disease surveillance and influenza vaccination strategies

Record number		Consensus statement		Agreement level (%)
1		Disease monitoring and compliance mechanism Integrating an influenza monitoring and compliance system across both public and private healthcare sectors is critical to tracking vaccination coverage, disease burden, and overall program compliance		100
2		Strengthening surveillance and data integration The ideal surveillance systems would include weekly testing for influenza integrated with real-time disease monitoring tools, thorough morbidity and mortality reporting to track long-term complications, and comprehensive identification of circulating subtypes		100
3		Optimizing vaccination timing Ideally, influenza vaccine should be delivered one month prior to the flu season, considering the well-defined seasonality in Saudi Arabia from October to March or depending on seasonal patterns shown by surveillance systems		100
4a		Enhancing vaccination coverage rate Influenza vaccination initiatives should be similar to those applied to other mandatory childhood immunization programs		100
4b		Vaccination initiatives must expand beyond children to include adult populations. Such initiatives should be supported by strict monitoring strategies and official tracking systems		100
4c		Vaccines initiatives should include a wider population based on well-defined risk stratifications		100
4d		Availability of influenza vaccines and reliability of vaccine supply chains are critical to optimizing vaccination coverage. Vaccines should be made available well in advance to ensure timely implementation within the national campaign and adequate protection before the season begins		100
4e		To enhance uptake by HCWs, hospitals should provide on-site clinics supported by visual bill-boards that facilitate tracking of coverage rates with strict evaluations for noncompliance		100
5		Enhancing public confidence and acceptance of influenza vaccination Efforts should focus on shaping the community’s mindset and correcting misbeliefs about influenza vaccines. Awareness initiatives should highlight the availability of convenient and noninjectable vaccines		100
6		Improving disease severity awareness It is important to develop emotionally engaging educational messages tailored to raise awareness about disease severity and complications disseminate them through public venues		100
7		Decentralizing vaccination responsibilities The responsibility for vaccination should not be confined to physicians, given their workload and time constraints. Implementation of a standing-order policy incorporating key components, including eligibility checklists and clear guidance for managing potential side effects, was suggested		100
8a		Integrating LAIV into public health vaccination programs LAIV offers an excellent addition to injectable vaccines, making influenza immunization more accessible and acceptable, especially for people with needle phobia		100
8b		LAIV should be incorporated into public health programs to enhance immunization coverage among eligible populations		100
8c		LAIV should be targeted primarily toward high-risk groups, with children aged 2–6 years being the key target group for administration		100
8d		The outcomes of LAIV implementation must be evaluated accurately in addition to ensuring that they are being shared transparently across public health authorities, healthcare providers, and policymakers		100

HCWs=Healthcare worker, LAIV=Live attenuated influenza vaccine

Figure 1.

Methodological flow diagram: Process for synthesizing expert opinion and evidence for the 2025 consensus recommendations

Disease monitoring and compliance mechanisms

Consensus statement: Integrating an influenza monitoring and compliance system across both public and private healthcare sectors is critical to tracking vaccination coverage, disease burden, and overall program compliance.

Rationale: The burden of disease is inconsistently being addressed at the institutional level. For instance, only select institutions monitor influenza-related absenteeism and sick leave as part of vaccination performance indicators. This point was supported by recent findings that highlight the importance of comprehensive surveillance systems and their role in monitoring disease impact.[3]

Implementation: Mandate a comprehensive disease reporting system and incorporate vaccination uptake metrics into centralized institutional databases.

Strengthening surveillance and data integration

Consensus statement: Ideal surveillance systems should include regular testing for influenza integrated with real-time disease monitoring tools, thorough morbidity/mortality reporting to track long-term complications, and identification of circulating subtypes.

Rationale: It is well-known that Saudi Arabia has already established an influenza surveillance infrastructure.[22,23] Current influenza testing practices in Saudi Arabia rely primarily on polymerase chain reaction (PCR)-based methods. While reliable, there are often delays in making results available. Accessibility in primary care, in Saudi Arabia is challenging, and testing is mainly restricted to hospitalized patients. Furthermore, influenza, respiratory syncytial virus, and coronavirus disease 2019 (COVID-19) circulated at the same time, which further complicated disease burden assessment. Rapid tests, including multiplex (quadriplex) PCR assays are not uniformly implemented nationwide despite its widespread use in many hospitals.

Implementation: Establish a real-time influenza surveillance system (ISSA) that integrates data from both public and private sectors to enable continuous monitoring, early detection, and timely response to circulating strains.

Optimizing vaccination timing

Consensus statement: Ideally, the influenza vaccine should be delivered 1 month before the flu season, considering the well-defined seasonality in Saudi Arabia (October to March or depending on seasonality patterns shown by surveillance systems).

Rationale: The complexity of influenza planning is linked to the virus’s continual evolution, differences in circulating strains between the Northern and Southern Hemispheres, and variability in seasonal transmission patterns. Together, these factors have important implications for vaccination planning and public health interventions

Implementation: Careful study of the optimal timing for vaccine distribution to ensure preparedness of healthcare. Timing of vaccination campaigns to be carefully scheduled with other preventive schedules regardless of the specific onset of the flu season, to ensure ICUs and healthcare teams are adequately prepared for potential surges.

Enhancing vaccination coverage rates

Childhood immunization framework

Consensus statement: Influenza vaccination initiatives should mirror the frameworks applied to other mandatory childhood immunization programs.

Rationale: Influenza vaccination coverage remains suboptimal and fragmented, despite the high coverage rate for mandatory childhood vaccination; ~97%.[22] Vaccine coverage is poor among pediatrics. Despite high national childhood immunization rates overall, influenza vaccination coverage specifically remains unclear. A gap was noted in recent parental knowledge, awareness, and attitude studies.[22]

HCW coverage rates range from roughly 38%–56% in different cities and over various years, with no increase in vaccine uptake post-COVID.[18,23,24,25,26,27,28]

Vaccination coverage for Hajj pilgrims/workers increased over time reaching a coverage of 79% among pilgrims.[13,24,29]

Implementation: Establish targeted outreach campaigns alongside public educational initiatives emphasizing the importance of the influenza vaccine, its safety, and overall protection of eligible population.

Adult versus pediatric populations

Consensus statement: Vaccination initiatives must expand beyond children to include adult population. Such initiatives should be supported by strict monitoring strategies and official tracking systems.

Rationale: The primary focus for current vaccination programs are primarily for children, while adult uptake lags significantly behind (~30%). Figure 2 illustrates the disparity in seasonal influenza vaccination uptake rates across key Saudi Arabian subpopulations in comparison with the World Health Organization (WHO) international target of 75%.[26]

Figure 2.

Disparity in seasonal influenza vaccination uptake rates across key Saudi Arabian subpopulations

Implementation: Expand vaccination strategies beyond children and establish clear schedules and eligibility criteria. Improved uptake is linked to accessibility at public venues (airports, malls, and universities).

Risk-stratification criteria

Consensus statement: Vaccine initiatives should include a wider population based on preset risk stratification criteria.

Rationale: Lack of unified risk-stratification criteria limits coverage of other vulnerable groups.[5,6] Figure 3 illustrates a framework to direct vaccine distribution.

Figure 3.

Proposed three-tier risk stratification for influenza vaccination priority in Saudi Arabia

Implementation: Adhere to standardized risk-stratification guidelines that clearly define priority groups beyond traditional high-risk categories.

Vaccine availability and supply

Consensus statement: Reliability of vaccine supply chains is critical for optimum coverage.

Rationale: Logistical delays in the procurement and distribution of vaccine represents a challenge that compromises the immunization campaign before the onset of the season.

Implementation: Support consistent seasonal delivery by ensuring readiness of the supply-chain in public and private sectors well before the start of the season.

Enhancing public confidence and acceptance

Consensus statement: Efforts should focus on shaping community mindsets and addressing misconceptions on vaccines. Awareness initiatives should highlight the availability of convenient, noninjectable options.

Rationale: Acceptance of vaccines is influenced by public perception and attitudes. Furthermore, the route of administration as an injectable contributes to vaccination hesitancy in certain population groups.[19]

Implementation: Enhance community awareness, mainly concerning the importance of prevention, and the availability of “nasal spray vaccines” (LAIV) as a noninvasive alternative.

Improving healthcare worker engagement

Consensus statement: To enhance vaccine uptake by HCWs, hospitals should provide on-site vaccination clinics supported by visual billboards that track coverage rates, with strict evaluations for noncompliance.

Rationale: Advisors agreed that existing infrastructure often presumes 100% HCW uptake, yet reported rates that vary by profession (85%–90% among nurses vs. 40%–60% among physicians).

Implementation: Incorporate influenza coverage rates into institutional performance indicators and annual quality assessments.

Improving disease severity awareness

Consensus statement: It is vital to develop emotionally engaging educational messaging on disease severity and complications to be disseminated through public venues.

Rationale: The severity of influenza is underestimated by many families, which impacts negatively on uptake rates.[1,4,8]

Implementation: The community should be educated about the potential complications of influenza. It is important to shift the perception from that of a “common cold” with mild illness to a condition that can pose a serious and severe health threat.

Decentralizing vaccination responsibilities

Consensus statement: Vaccination responsibility should not be limited to physicians. The implementation of a standing-order policy incorporating eligibility checklists and safety guidance is recommended.

Rationale: Experts believe that limiting the administration of vaccines to physicians creates unnecessary bottlenecks, given the existing constraints of clinical workload.

Implementation: Empower nurses, pharmacists, and trained technicians to streamline delivery. Adopting a standing-order policy would enable qualified professionals to administer vaccines safely and efficiently.

Integrating live-attenuated influenza vaccine into public health programs

Intranasal route advantages

Consensus statement: LAIV offers an excellent addition to injectable vaccines, which thus increases accessibility for individuals with needle phobia.

Rationale: Both children and adolescents prefer intranasal route given its non-invasiveness.[15,16]

Implementation: Disseminate clear evidence of the effectiveness of LAIV and ease of administration to support the increase of vaccination coverage [Contraindications and special considerations for the LAIV are detailed in the Appendix.

Effectiveness in prevention

Consensus statement: LAIV should be incorporated into public health programs to enhance herd immunity.

Rationale: LAIV effectively reduces influenza-related morbidity when integrated into routine schedules, as supported by evidence.[15]

Implementation: Health authorities should integrate LAIV into existing immunization programs and preventive health campaigns.

Eligibility criteria

Consensus statement: LAIV should be targeted primarily toward appropriate eligible high-risk groups, with children aged 2–6 years being the key demographic.

Rationale: Children aged 2–6 play a central role in influenza transmission, being the drivers of the disease. As such, vaccination of this age group has direct and indirect advantages.[7,8]

Implementation: Outreach efforts should extend to schools, workplaces, and homes to cover healthy individuals aged 2–49 who rarely visit hospitals.

Monitoring and evaluation

Consensus statement: The outcomes of LAIV implementation must be evaluated accurately in addition to ensuring that they are shared transparently across public health authorities, healthcare providers, and policymakers.

Rationale: Evaluation guides future strategies and supports informed policy decision-making.

Implementation: Establish a structured monitoring framework that regularly assesses LAIV coverage, safety, and effectiveness.

Table 1 summarizes the full set of recommendations developed across nine domains. Experts agreed on all statements, which reflected a strong national alignment to the priority actions required to improve influenza vaccination uptake and system-wide preparedness.

In addition to outlining key recommendations, the expert panel also discussed the barriers that continue to limit influenza vaccination uptake in Saudi Arabia. Barriers were grouped into four main domains: patient-level, community-level, physician-related, and healthcare system level. Table 2 summarizes these challenges, highlighting the multi-factorial nature of vaccine hesitancy and delivery gaps that must be addressed to optimize efforts for national influenza prevention.

Table 2.

Level of barriers to influenza vaccination

Category		Key barriers
Patient-level barriers		Low perception of disease risk Misinformation and misconceptions about the importance of vaccination Concerns about vaccine safety Lack of awareness of noninjectable vaccine options among HCPs
Community-level barriers		General hesitancy toward vaccination Limited community engagement and advocacy Peer discouragement Negative social influence
Physician-related barriers		Low motivation to prioritize influenza vaccination during consultations Inconsistent recommendation of influenza vaccines Over-reliance on physicians for vaccine delivery
Healthcare system barriers		Inconsistent vaccine availability and supply chain challenges Insurance coverage gaps for influenza vaccination Fragmented reporting systems and limited coordination across sectors

HCPs=Healthcare professionals

Discussion

This consensus initiative convened leading national experts in Saudi Arabia with the objective of developing actionable recommendations to strengthen influenza prevention, with a focus on integrating the LAIV into the national program. The resulting recommendations encompass several critical domains of influenza control. Recommendations included raising awareness of the public and HCWs on disease severity, implementation strategies and evaluation of vaccine effectiveness.

The advisors agreed that influenza imposed significant public health burden in Saudi Arabia, with comorbidities documented of children and adults. Standardized case reporting and systematic disease tracking were identified by the panel as the first steps towards an optimized national prevention strategy. Experts highlighted the need for robust disease monitoring and compliance mechanisms, including the structural integration of influenza surveillance across both public and private sectors to ensure complete and timely reporting of infection trends.

Saudi Arabia has an established surveillance system spanning more than 100 healthcare facilities; 70 primary care centers and 30 hospitals, with direct data submission to the Inflow system in collaboration with the WHO.[30] Nonetheless, important gaps remain in the assessment of the true burden of influenza. Similar challenges have previously been documented despite the ISSA issued by the Ministry of Health.[3,24,30,31,32,33]

Enhanced surveillance capacity is important during mass gatherings, such as Hajj and Umrah.[22] Epidemiological evidence from the Middle Eastern countries suggests that there are frequent influenza A outbreaks following religious pilgrimages, reinforcing the importance of timely detection and prophylaxis during these periods.[20,30] Embedding regular testing, point-of-care diagnostics, and real-time billboards in national influenza programs enable the deployment of strain-targeted response strategies.

Research concluded that countries lacking climatically-defined winter season often face challenges in identifying the optimal timing for influenza circulation.[34,35,36] In the Saudi Arabia context, seasonal patterns show a primary peak in late November and a secondary rise in March. Current national vaccination strategies may confer suboptimal protection against the latter early summer, mainly because influenza vaccine-induced immunity lasts ~ 6 months,[36,37]

As per the experts, during the 2023–2024 season, the national immunization campaign commenced in October, whereas in 2024–2025, it was changed to September to better align it with observed epidemiological patterns. They also agreed that data from previous seasons can be utilized in anticipation of approaching seasonal trends to refine the timing of immunization campaigns and accordingly improve coverage.

Despite the reported high uptakes of mandatory childhood vaccines in Saudi Arabia, influenza vaccination remains suboptimal. Vulnerable groups, particularly children, experience a disproportionately high burden of influenza-related complications. Vaccine coverage is poor among pediatrics. Despite high national childhood immunization rates overall, influenza vaccination coverage specifically remains unclear, with a gap noted in recent parental knowledge, awareness, and attitude studies.[22] In the USA, the 2023–2024 season recorded 199 influenza-related deaths in children, 80% of whom were not fully vaccinated.[38] Experts agreed that influenza vaccination strategies should be aligned with successful childhood immunization programs.

Vaccination uptake is reported as approximately 30% among adults, significantly lower than the 45% recorded among adults in the USA during 2023–2024.[18,39] Expanding vaccination strategies to adult populations is in accord with international trends.[40] The panel emphasized the need for clear risk stratification and comprehensive eligibility checklists that can be used in community settings to prioritize high-risk groups.

One persistent challenge the experts recognized is the limited window for vaccine availability, influenced by global manufacturing and supply cycles. Ensuring timely access within this restricted period is crucial to improving vaccination coverage, particularly of high-risk groups.

Panel members noted that a number of institutions in Saudi Arabia have successfully embedded influenza vaccination into outpatient visits and inpatient discharge pathways, thereby ensuring that eligible patients are vaccinated during routine healthcare encounters. A similar model in Qatar has demonstrated that integrating antimicrobial resistance surveillance and nationwide electronic medical records across primary and secondary care can significantly improve vaccination delivery.[41]

HCW vaccination remains critical. Although Saudi Arabia reports high overall uptake, coverage varies by cadre – 85%–90% of nurses and 40%–60% of physicians. In the USA, HCW uptake is 75.9%, with physicians demonstrating much higher rates at approximately 95%.[42] According to literature, HCW coverage estimates vary according to sources of data from which figures were extracted. To elaborate, self-reported facility-level surveys have found coverage rates ranging from roughly 38%–56% in different cities and over different years.[18,23,24] Meanwhile, a recent meta-analysis found that no significant time trend was observed among HCWs, unlike the general population, where uptake increased significantly post-COVID.[25] Moreover, findings of a national post-COVID survey indicated overall uptake of 31.8%, with lower uptake specifically of central-region residents.[18] On the other hand, city/province-level studies show a wide spread (e.g., ~55% in Riyadh, ~65% in Makkah region, ~69% in Jazan province).[26,27,28]

Vaccination coverage for Hajj pilgrims/workers represents the most consistently tracked subgroup, with evidence of improvement over time. For instance, surveillance data found that only 13.8% of pilgrims between 2007 and 2012 were vaccinated for both seasonal influenza and pneumonia.[24] A subsequent cohort of Saudi pilgrims showed marked improvement across three consecutive seasons, with vaccination rates of 21.4%, 48.2%, and 58.1% in 2013, 2014, and 2015 respectively.[29] Another surveillance during the 2025 Hajj season recorded influenza vaccination coverage of 79% of pilgrims who sought care, and that vaccinated pilgrims experienced markedly lower rates of influenza-like illness than unvaccinated pilgrims (5.2% vs. 15.2%).[13] The aforementioned findings support the increased coverage rates overtime along with the associated benefits of mass vaccination.

Comparative GCC data reveal that Saudi Arabia’s position relative to its regional neighbors depends heavily on which population and data source are examined. Data from 2018 to 2024 across six GCC countries revealed that Saudi Arabia attained the highest median HCW coverage rate (93.2%, IQR: 84.0%–100.0%) of any Gulf state, well above Qatar (65.6%), Bahrain (43.7%), and Oman (31.2%), while uptake among children and people with chronic disease remained low in all six countries.[13] It's worth mentioning that previous population survey data revealed contradictory findings in which Saudi Arabia recorded the lowest self-reported influenza vaccine uptake in the region (15%) compared to Qatar (24%), out of an overall GCC average of 17%.[31]

The panel recommended structured evaluation frameworks and transparent reporting to strengthen uptake among HCWs and ensure consistent implementation across institutions.

Vaccine uptake is influenced by multiple patient, community, physician, and healthcare system levels barriers. These barriers, summarized in Table 2, must be comprehensively assessed to inform a targeted and prioritized action plan.

Vaccine hesitancy has increased since the COVID-19 pandemic, with more individuals expressing reluctance toward routine immunization.[43] The true burden of influenza is often underestimated, as many people perceive the disease as a mild seasonal illness. A 2021 Saudi survey found that only 12.65% of respondents regularly received the influenza vaccine despite having reasonable knowledge about influenza.[44]

Addressing misconceptions and promoting preventive healthcare are essential. Concerns about side effects remain a major driver of refusal.[45] In the USA, 18.6% of adults reported worries about the side effects of the vaccine, and 35.6% did not view their healthcare provider as their most trusted information source.[46] These findings underscore the need for stronger communication strategies that reinforce the safety and benefits of influenza vaccination.

Experts believe that the growing number of available vaccines with no clear instructions and appropriate guidance may also contribute to public confusion and fatigue. Clear epidemiological messaging, for example, highlighting that one in ten children with influenza may develop pneumonia, can reshape perceptions and encourage better vaccine uptake.

The panel agreed that physician engagement contributes to vaccine acceptance. Despite this, a considerable number of physicians do not consistently recommend the vaccine. As such, valuable opportunities for health promotion are missed. Family physicians, primary care providers, and preventive health professionals occupy a uniquely influential role in shifting public attitudes. Structured and targeted educational initiatives are, therefore, essential for communicating effectively with patients.

The incorporation of real-life clinical cases, such as ICU admissions as a result of influenza complications, can help motivate HCWs to prioritize influenza prevention. Communicating vaccine’s importance is perceived as the most effective strategy in mandating vaccination.

Experts also believe that engaging public figures and leveraging trusted communication platforms, including national television channels, can further enhance community acceptance. Parental engagement is also crucial, as immunizing children has a direct protective effect on households and communities.

Expanding the immunization workforce beyond physicians has demonstrated promising results in practice. Positive experiences with nurse-led vaccination programs have been reported across various institutions. Pharmacist empowerment is also gaining traction, supported by a forthcoming certification program developed with the Saudi Commission for Health Specialties to allow independent vaccine administration.

International evidence shows that extending vaccination authority to pharmacists improves coverage, including pediatric populations.[47] Experts argued that other allied health professionals could also be trained under competency-based frameworks to strengthen immunization capacity.

Successful examples from several institutions in Saudi Arabia, including the Ministry of National Guard Health Affairs, as well as examples from other Gulf countries such as Qatar, provide a guide for standing-order policies, in which trained nurses follow a structured checklist to guide safe vaccination. Only patients with specific concerns, including those with a history of allergies or comorbidities are referred to physicians, while most are vaccinated immediately, thereby reducing waiting times and easing the burden on physicians.

Experts agreed that implementing LAIV could significantly increase vaccine uptake, particularly of individuals with needle phobia or challenges in accessing vaccination. Studies from Switzerland and the USA consistently demonstrate a strong preference for the intranasal route, 97% and 69% in two separate studies.[48,49]

The panel recommended introducing LAIV into the national influenza program, and prioritizing children aged 2–6 years. LAIV is currently used in national programs in France, the United Kingdom, Finland, Ireland, and the USA,[50,51,52,53,54,55,56,57,58,59] where it has shown strong effectiveness in preventing infection and reducing community transmission.

The panel emphasized integrating LAIV administration into platforms such as the National Vaccination Registry to ensure accurate documentation and facilitate data-driven evaluations of vaccine performance.

The panel recognizes that LAIV is not indicated for all populations and is contraindicated in some patients [Appendix]. As such, careful patient selection is needed to ensure safe implementation. Robust monitoring and transparent reporting are essential for assessing LAIV implementation and ensuring accountability. Cost, including direct vaccine costs, operational costs, administration procedures and required trainings for healthcare professionals, is another important consideration. To conclude, transparent data sharing across public health authorities, HCWs, and policymakers supports program evaluation, guides policy refinement, and strengthens public trust.

Limitations

This work provides valuable, context-specific guidance to inform influenza prevention strategies in Saudi Arabia, yet, several limitations should be considered when interpreting these consensus recommendations. First, although expert consensus is a valuable approach to informing policy and practice in areas where evidence may be limited, the recommendations reflect the experiences and perspectives of the participating experts, without the diversity of healthcare settings across Saudi Arabia, particularly in remote regions where resource availability and operational challenges may differ.

Second, despite efforts to assemble the panel, the number of participants was relatively low. As a result, some practice perspectives may not have been fully captured, including those of frontline healthcare workers such as allied health professionals, community pharmacists, and primary care providers.

Third, the recommendations developed were based on the evidence and clinical experience available at the time of the consensus process. As influenza epidemiology evolves and new vaccine technologies emerge, including next-generation mucosal and mRNA-based influenza vaccines, some recommendations may require future refinement. In addition, the practical feasibility of implementing certain recommendations, particularly those requiring expanded digital infrastructure, workforce capacity, or policy-level changes, was not formally assessed.

Finally, although a targeted literature review was conducted to support and contextualize the expert discussions, it was not performed as a systematic review. Therefore, some relevant evidence may have been missed, and the level of evidence supporting individual recommendations may vary. In addition, no evidence grading of the recommendations was applied. The objective of literature review was mainly to inform and support the consensus process. Despite these limitations, this work highlighted priority areas for future research, implementation evaluation, and policy development.

Conclusion

A central conclusion of the panel is the strong potential value of integrating the LAIV into the national program.

Implementing these consensus-based recommendations within national policy frameworks could improve vaccination uptake, reduce influenza-related morbidity, and enhance preparedness for seasonal and pandemic respiratory threats. Moreover, the strategies outlined in this report can serve as a model for strengthening prevention of other respiratory viruses in both Saudi Arabia and the wider region. Continued evaluation, transparent reporting, and sustained investment in public health infrastructure will be essential to achieving long-term success in influenza control.

Conflicts of interest

There are no conflicts of interest.

Appendix

Pre-vaccination screening checklist for Live Attenuated Influenza Vaccine (LAIV): Contraindications and special considerations prior to vaccine administration

Do not administer LAIV if your patient answers yes to the following:

Contraindication		Yes		No
Your patient had a severe allergic reaction (anaphylaxis) requiring intensive care admission to:     Egg protein     A previous dose of influenza vaccine		Yes		No
Your patient is currently receiving salicylate therapy (i.e., aspirin) and under the age of 17 years		Yes		No
Your Patient has been diagnosed with severe asthma OR admitted with acute asthma to ICU OR recurrent ED visits with acute asthma OR had an acute exacerbation in the last 72 h		Yes		No

ICU=Intensive Care Unit, OR=Odds ratio, LAIV=Live attenuated influenza vaccine

Special considerations

Assess your patient before administering LAIV if your patient answers yes to any of the following:

Contraindication		Yes		No
Your patient is currently in a severely immunocompromised state*		Yes		No
Anyone in your patient’s family currently having treatment that very severely affects their immune system (patients in need of isolation including bone marrow transplant recipients)		Yes		No
Your patient had GBS within 6 weeks of a previous influenza vaccination		Yes		No
Your patient is currently suffering from a febrile illness		Yes		No

*Acute and chronic leukemias; lymphoma; cellular immune deficiencies; and HIV infection not suppressed by antiretroviral therapy; and high dose corticosteroids (>40 mg prednisolone per day or 2 mg/kg/day in children under 20 kg for more than 1 week). GBS=Guillain–Barré syndrome, LAIV=Live-attenuated influenza vaccine

Funding Statement

The two expert workshops were organized and financially supported by AstraZeneca. The funder had no role in the interpretation of the data; or manuscript drafting or the decision to submit the manuscript for publication. None of the authors received any honorarium.