Vaccination is considered the most successful health measure both in human medicine and in veterinary practice. International guidelines of the vaccination of cats and vaccination experts (WSAVA, AAFP, ABCD) recommend that, whenever possible, all cats receive the benefit of vaccination. This not only protects the single subject, but also provides an indispensable ‘herd immunity’ that minimizes the likelihood of infectious disease outbreaks [1, 2, 4].
This study aimed to understand factors influencing the Italian cat owners’ opinion about vaccination.
Sample representativeness linked to the methodology
First of all, in our work we used a web-based questionnaire, as in other similar studies [7, 16]. Indeed, the web-based questionnaire allowed us to include both vaccinated and unvaccinated cats because it was spread online and not among veterinarian practices. Moreover, considering that the majority (65%) of the Italian population uses internet , online survey and social networks approach is a cheap and efficient way for obtaining data across a huge area in a short time: 84% of respondents found out about the questionnaire through the web.
However, considering the nature of internet-based surveys and advertisements conducted via social media networks, there is the possibility that the sample acquired in this study was not truly representative of the general pet owner population and thus our estimates may be biased.
Indeed, it is possible that owners searching information about pets on social media may be more “health conscious” and more prone to vaccination, even if information on health status of cats is obtained online by the majority (68%) of pet owners, regardless of compliance with vaccination of their cats . Therefore, people not interested in pet health would not self-enroll in such a survey. Even though it was clearly written at the beginning of the questionnaire that the survey was aimed at all cat owners, also (and above all) at those who did not vaccinate their animals, it is possible that mainly owners who normally vaccinate cats participated in the study. This could explain the particularly high percentage of vaccinated cats found in our study. Results of phone-based or face-to-face surveys tend to justify this aspect with lower levels of pet health monitoring [19, 20].
Furthermore, the sample of cat owners responding to the survey was based on self-selection and this may have also introduced the age and gender bias observed in our study.
The young age bias probably reflects the common use of the internet by younger owners compared to the elderly. The strong bias towards female pet owners was not reported in previous studies [7, 16], even if females are reportedly more likely to keep pets than males [16, 21,22,23]. Females have been reported to be more incline to answer questionnaires and to use social networks than males in Italy  and this may have accounted for the high prevalence of female respondents (92%) observed in this study. Indeed, our gender bias was in line with a recent study based on a questionnaire disseminated online to English-speaking pet owners regarding pet nutrition . Moreover, females have been reported to have higher empathy towards animals, be more interested in health-related topics and carry the primary responsibility for pets’ healthcare compared to males, and this may have increased the proportion of vaccinated cats compared to previous studies [16, 24].
Finally, questions to confirm recipients understanding of the word “vaccination” were not asked in our study and whether the participants in the survey completely understood what vaccination was and if they could differentiate it from other procedures performed by veterinarians is not known. It is possible that this may represent another limitation of this study .
Finally, our questionnaire was based on owner’s response and was not focused on the households owning the cats. Indeed, management practices of the pets are probably determined at the household level rather than by the single respondents. Comparing demographic characteristics of the sample and available national statistics for the household composition, household income, socio-professional category and living area show us that in some respects our population may not represent general population, and this could change the vaccination status of cats in Italy. For example, in our study respondents older than 50 years old represent only 23% while they represent 45% of the Italian population; Also, the population from north Italy corresponds to 38% of the national data and in our study, they represent 73% of the sample. This could be also correlated with the annual household income that varies a lot from north and south in Italy, being the medium income around 35,000 euros in north regions and 25,000 in south ones . In fact, in this study more than 45% of the respondents indicated an annual income higher than 30,000 euros, and almost 60% of those have an annual income higher than 40,000 euros, clearly representing the impact of the overrepresentation of respondents form north Italy regions that are richer than the south ones.
Therefore, our results should be interpreted taking into consideration all these possible limitations of the study.
Results obtained through the sample
The very high percentage (86%) of the owners that had taken their cats for vaccination to a veterinarian at least once showed Italian owners trust in cats’ vaccination. This result was higher than previously reported in other similar studies [19, 20], but the differences can be explained by both the considered study area and the different target populations. Indeed, owners living in semirural areas of central Italy and owners of cats living mainly outdoor have been reported to be less careful to cat’s health and this may account for the low percentages of cats that had veterinary consultation in these studies [19, 20].
Italian market studies concerning the pet-owner relationship provide conflicting results in terms of pet vaccination. In a study of 2017  conducted on a sample of 1000 owners, 80% of them find it important that their pets are well cared, but only 46% vaccinate them regularly and 42% take pets to the vet only if they are ill. Data emerging from another market study in 2019  show a completely different output: nearly 90% of the cat owners of the sample analyzed declares to regularly carry out feline vaccinations suggested by their veterinarian. Finally, the results of another survey conducted in the same year  showed that only 30% of cat owners go to the veterinarian once a year for pets’ check-up and vaccination.
The high percentage (80%) of owners that had their cat recently vaccinated within a three-year interval was in line with the 78% of recently vaccinated cats in Germany . Our results were not comparable with the 69% of vaccinated cats in the UK because the interval was set in the preceding 12 months in the English study . The three-year interval was used in this study to differentiate the recently vaccinated and the not recently vaccinated groups of cats. It must be reminded that the general three-year interval recommended by the current guidelines is applicable only to core vaccinations and needs to be considered depending on the vaccine and cats’ lifestyle, as previously observed [1, 3, 4, 7, 28,29,30].
Due to the high percentage of recently vaccinated cats and the low percentage of not adequately vaccinated animals (not recently vaccinated and unvaccinated cats), our results suggest that the cat population of this study may be well protected (considering the aforementioned “herd immunity” concept). However, it has to be reminded that a recent vaccination may not necessarily imply that the cat is well protected [28, 31]. Our results also suggest that the non-vaccination movement that has been reported in Italy in human medicine doesn’t seem to have, at least for now, a big impact in veterinary medicine and among pet owners in which trust in the veterinarian prevails.
Regarding the results from the multinomial logistic regression, the likelihood of recent vaccination being higher in cats between 2 and 4 years was surprising but was in accordance with a previous study .
Our results also showed that young cats (8 weeks-1 year of age) tended to be associated with the unvaccinated status. Therefore, it is of paramount importance to clarify to owners the necessity of vaccination in kittens starting at the age of 6–8 weeks, following the recommendations for a strong immunity.
Our results showing that older cats are more likely grouped within the not recently vaccinated group are in agreement with previous findings . This result may be explained by owners thinking that older cats do not need to be vaccinated, because of a long-lived immunity following vaccination and a higher protection against infectious diseases. However, since old cats are known to have the same risk of infectious disease as younger cats, and ageing is associated with a decline in functional competence of the immune system, regular boosters are recommended for cats, regardless of their age [1, 2, 4, 28, 32].
Our analysis also showed that the annual household income had a significant impact on the vaccination status. Indeed, the likelihood of a recent vaccination status was significantly higher in cats which owners had a higher annual household income, whereas not recently vaccinated cats and unvaccinated cats were significantly associated to a lower household income. The annual household income has not been reported previously as a factor affecting the vaccination status of cats in the UK and in Germany [7, 16]. The difference with foreign countries may be explained by the fact that Italian owners are accustomed to pay for all veterinary services whereas 40% of cats have health insurance in the UK and the insurance covers most of veterinary services . Moreover, the median household income in Italy is lower compared to that of Germany and the UK , and payment of veterinary services, including vaccinations, may be troublesome, especially for owners with lower household income. The economic factor may have also accounted for the significantly higher likelihood of cats being unvaccinated among owners who perceived vaccination cost as an important factor. The importance of vaccination cost has been previously reported to be associated with the unvaccinated status of cats in the UK . Economic data should be carefully considered in the future due to the economic loss linked to the COVID-19 pandemic that may also reduce the likelihood of cats’ vaccination.
Concerning the likelihood of recent vaccination status, the significantly higher recent vaccination status among cats from breeders or pet shops compared to other cats was not surprising. High purchase price could lead owners to be more prompt to vaccination. Our results did not confirm the likelihood of a vaccination status higher in cats that had traveled abroad, visited a cat show or a cattery, probably due to the low number of cats belonging to these categories. These factors have been associated with the requirement of up-to-date vaccinations and European Pet Passport with vaccination against rabies to travel within Europe and are usually more common in purebred cats [7, 16]. The lower importance of cat’s stress and the higher perception of vaccination effectiveness reported by owners of recently vaccinated cats, even if not statistically significant, may also explain their willingness to vaccinate their cats.
The likelihood of not recent vaccination status was significantly higher in owners that perceived the lifestyle of cats as an important factor. This result is likely linked to the higher frequency of indoor lifestyle only in cats belonging to the not recently vaccinated group. This result suggests that owners of these cats might have assumed that animals living for prolonged periods in closed environments with no contact with other cats were not at risk and did not need revaccination. However, global guidelines recommend vaccination booster every 3 years also for cats living indoors only, except for FPV that may be administered every 3 years or more [1, 2, 4, 28, 29]. Veterinarians should consider this result and, to improve the vaccination status of cats, educate owners on the importance of adequate vaccination protocols and boosters also for cats living indoors only.
The likelihood of vaccinated status was higher in owners with health related jobs, such as doctors, nurses, or pharmacists, and that was not surprising. This result may also be linked to the lower level of education that was observed in the owners of the unvaccinated cats. Our results suggest that jobs not related to health aspects and lower education levels may be associated with little knowledge on scientific aspects, including the importance of vaccination, and therefore the higher unvaccinated status of cats is more likely.
The unvaccinated status tended to be associated with owners being 21–49 years old. Despite this was not a significant result, it is interesting to keep on monitoring this age category of owners because non-vaccination movements in Italy tended to be more frequently reported among people aged 25–44 .
The importance of factors preventing owners from having their cats vaccinated, such as cats’ capture, travel to the veterinarian and inappropriate waiting times, may be related to the lower perception of infectious risk and knowledge of importance of vaccination. Therefore, it is likely that owners of unvaccinated cats consider taking the cat to the veterinarian not necessary for their cat’s health. Indeed, such factors have been considered not important by a high percentage of owners of recently vaccinated cats. Moreover, the lower compliance of owners of unvaccinated cats with veterinary advice for vaccination and the lower importance for cats’ susceptibility to infectious disease compared to the owners of vaccinated cats, even if not statistically significant, may also explain why owners of unvaccinated cats do not understand the need of vaccination in cats. It should also be taken into consideration that both “unvaccinated” and “not recently vaccinated” categories could be at risk for infectious diseases, since vaccination is not up-to-date.
This study showed that Italian cats’ owners have a good level of confidence in veterinarians. Most owners reported the importance of veterinary advice and considered veterinarians as the main source of information for their cats’ health. More than half of respondents (59%) followed their veterinarian recommendation for annual vaccinations, which was surprising, as not in line with guidelines. Annual vaccination is recommended for some of the non-core vaccines, such as feline leukemia virus (FeLV) only in high-risk cats, Chlamydophila (Chlamydia) felis, feline immunodeficiency virus (FIV) and B. bronchiseptica (the last two vaccines are not available in Italy) and might also apply for feline herpesvirus (FHV-1) and feline calicivirus (FCV) in some high-risk situations [1, 2, 4, 28]. However, most cats of this study lived indoors (63%) and several lived in a single-cat household (31%), situations in which annual booster is not necessary. The only exception is for cats travelling abroad that, depending on the vaccine used, may require annual boosters of vaccination against rabies. Recommendation of annual vaccination was recently reported in German cats  and was suggested to be associated with lack of knowledge of feline vaccination guidelines or due to the old habit of veterinarians to vaccinate annually regardless of the type of vaccine used.
Results on the knowledge of antibody test to evaluate vaccination status and avoid unnecessary boosters showed that respondents who had vaccinated their cats were more aware of it and owners of recently vaccinated cats were more inclined to use it in the future.