Оценка отношения к вакцинации против COVID-19 среди медицинских работников в Индии
Новая коронавирусная болезнь (COVID-19) была объявлена глобальной пандемией в ноябре 2019 г., и для борьбы с ее разрушительным воздействием исследователи объединились для разработки безопасных и эффективных вакцин.
Цель исследования - оценка отношения медицинских работников (Healthcare Professionals’, HCP) к безопасности, эффективности и приемлемости вакцинации против COVID-19.
Материал и методы. В частном высшем учебном и в исследовательском центре последипломного образования в Ченнаи (Индия) проведено перекрестное веб-исследование среди HCP. Онлайн-опрос осуществлен с помощью форм Google с обменом ссылок между HCP через личные сети, профессиональные ассоциации и социальные сети. Описательный анализ проведен для демографических переменных. При статистической обработке материалов использовали критерий χ² Пирсона. Различия считали статистически достоверными при р<0,05 (двусторонний).
Результаты и обсуждение. В онлайн-опросе приняли участие 393 медицинских работника, среди них почти 60% - женщины. Средний возраст составил 28,11±10,23 года. Почти половина [174 (44%) из 393] респондентов считали, что вакцина против COVID-19 защищает их от болезни. Среди респондентов 80 (50%) из 159 мужчин согласны с защитным действием вакцины против COVID-19, что значимо больше по сравнению с женщинами (40%; р=0,047). Бо́льшая часть мужчин проявила готовность участвовать в клинических испытаниях вакцины (40%; р=0,021) по сравнению с женщинами. Однофакторный анализ показал, что мужчины достоверно чаще были готовы к вакцинации против COVID-19 (p=0,006), особенно респонденты старшего возраста (p=0,029).
Заключение. Исследование выявило неоднозначную реакцию медицинских работников на вакцинацию против COVID-19. Результаты исследования подчеркивают необходимость более широкого распространения национальных и региональных руководств по протоколам вакцинации среди медицинских работников и населения.
Ключевые слова:вакцина против COVID-19; приемлемость вакцины; медицинские работники; гендер
Финансирование. Исследование не имело спонсорской поддержки.
Конфликт интересов. Авторы заявляют об отсутствии конфликта интересов.
Вклад авторов. Разработка дизайна исследования, руководство и контроль сбора данных, написание текста статьи - Сучарита Шри Т. и Премалатха Э.; утверждение протокола исследования в комитете по этике, разработка плана исследования, сбор и анализ данных, отправка рукописи в журнал - Чакрапани Ч.; редактирование текста статьи перед окончательной отправкой - Виджая Лакшми Р.
Для цитирования: Сучарита Шри Т., Премалатха Э., Чакрапани Ч., Сараванан Т.К.В., Виджая Лакшми Р. Оценка отношения к вакцинации против COVID-19 среди медицинских работников в Индии // Инфекционные болезни: новости, мнения, обучение. 2022. Т. 11, № 3. С. 88-94. DOI: https://doi.org/10.33029/2305-3496-2022-11-3-88-94 (англ.)
The novel coronavirus disease (COVID-19) was declared global pandemic in November 2019 which shook-up the world unexpectedly. To combat the devastating impact researchers collectively organized to develop safe and effective vaccines and till date billion doses of vaccine were delivered [1, 2]. Misinformation about vaccination related to COVID-19 results in deleterious outcomes such as ongoing community transmission. Vaccine hesitancy is on the rise globally and World Health Organization (WHO) in February 2020 termed “infodemic” to characterize the massive scale of misinformation in response to the COVID-19 outbreak [3, 4]. Research in the past has established that in times of insecurity anxious people believe in misinformation inconsistent with their views in normal times . Globally observed delays in acceptance or refusal of vaccines despite availability prompted WHO to identify vaccine hesitancy among the top ten threats to global health way back in 2019. Major reasons identified for this hesitancy were lack of confidence of people about vaccines and fearfulness about vaccines etc. [6, 7].
In India, Healthcare Professionals are designated as the very first priority group to receive COVID-19 vaccines in the first wave of vaccinations rolled out from January 16, 2021. India approved two vaccines, ‘Covishield’ and ‘Covaxin’, for vaccination and healthcare professionals are administered during the first phase. Healthcare professionals serve as major credible source of information regarding vaccines to general public and during novel pandemic like COVID-19 this role is doubly emphasized. Multiple studies reported varying rates of definite uptake of COVID-19 vaccine from 33-70% [7, 8]. The COVID-19 pandemic exacerbated the vaccine hesitancy even in developed world where literature identified that better education attainment and access to credible sources of information such as WHO and CDC could not sway the apprehensions related to COVID-19 vaccination [9, 10].
It is imperative to understand the factors responsible for acceptance of COVID-19 vaccine among healthcare professionals not only to improve uptake among them but also in general population. Vaccine uptake by healthcare professionals and their recommendations will improve the trust among general public on vaccines. If areas of misinformation are identified, vaccine awareness campaigns can be designed and delivered for successful implementation of the vaccine delivery.
Aim of the study - to assess healthcare professionals’ attitudes about vaccine safety, efficacy, and acceptability of a novel SARS CoV-2 vaccine.
Material and methods
A web-based cross sectional study was performed among healthcare professionals i.e., doctors, nurses, laboratory technicians and radio diagnostic personnel who come in contact with patients directly and/or indirectly etc. in a private tertiary post-graduate teaching and research setting at Chennai, India. Non-probability, purposeful sampling technique was deployed to recruit eligible and consenting healthcare professionals. Based on Kabamba Nzaji et al.  study from Republic of Congo, which assessed the acceptability of COVID-19 vaccination among healthcare workers and considering an estimated prevalence of acceptability of COVID-19 vaccine as 50% with a precision of 5% and 95% confidence interval (CI), the sample size was calculated as below:
N = Z² 1 - α / 2 × p × (1 - p) / d²,
Z1 - α/2 = two tailed probability for 95% CI = 1.96, p = prevalence of acceptability of COVID-19 vaccine = 0.5, d = precision or allowable error for acceptability of COVID-19 vaccine = 0.05, N = 1.96² × 0.5 × (1 - 0.5) / 0.05² = 384.15.
Thus the total sample size required for the study was 384.
Study tools and data collection. A google forms survey was distributed by sharing the link among healthcare professionals directly by authors through personal networks, professional associations and social media networks. The survey tool was developed after reviewing peer published literature and suitably adapted to meet the objectives of the study [12, 13]. The survey questionnaire included closed questions and opportunity was provided for submitting additional information as text inputs. Questions collected information broadly in four categories:
2) professional details;
3) levels of confidence in COVID-19 vaccine and
4) perception and attitudes towards COVID-19 vaccine.
Healthcare professionals aged 18 years or older who are willing to submit online survey were eligible to submit this survey. Completion of survey was considered as providing implicit consent. Institutional Ethics Committee approval was obtained (IEC No: 29/Mar/2021) before commencement of the study.
Statistical analysis. Data were analyzed using IBM SPSS v20.0 software. Descriptive analysis was performed for demographic variables. Pearson Chi-square test was applied as appropriate. The level of significance was set to 0.05 (two-tailed).
Demographics. We could get the responses from 393 participants for the online survey of which nearly 60% were women. The mean age of respondents was 28.11 years (95% CI 27.10-29.13) with standard deviation of 10.23 years and ranging between 17 and 71 years. Majority of the respondents (79.4%) were doctors by profession, the other significant group was being from nursing profession (10.9%), the remaining belonged to two categories i.e. professionals with close contact with patients (1.3%) such as lab technicians, physiotherapists etc. and professionals without any direct contact with patients (8.4%) such as researchers, microbiologists etc. Among the doctors, majority was from medical fraternity (188/312; 60%) while others from dental community (124/312; 40%) by stream of education. Mean age of doctors was 28.23 years (Range: 17-71) while that of Nurses, Professionals with patients contact and without contact were 30.12 (Range: 20-56), 31.80 (Range: 20-49) and 27.06 (Range: 17-48) respectively. Three fourths of the respondents were young in experience with <5 years of clinical practice. Female respondents were found to be significantly lesser experience compared to the male respondents (p<0.001). However less than half of them (45.6%) attended a Continued Medical Education (CME) session or webinar or online education programs regarding COVID-19 vaccines in last one year (Table 1).
Attitudes regarding vaccines in general. Overall, there was an agreement that vaccines are safe (58%; 226/393). Nearly 80% respondents agreed that vaccines are important for their health (310/393), getting vaccines is a good way to protect themselves from diseases (316/393) and getting vaccinated is important for the health of others in their community (321/393). Majority felt that the information about vaccines from public health authorities/fellow healthcare professionals is reliable and trustworthy (62%; 242/393) which makes them follow the recommendations made by ICMR or WHO etc. (74%; 291/393). However, one third of them feel that the new vaccines carry more risk compared to older vaccines (35%; 137/393) while nearly half have no specific opinion on risk (49%; 191/393) and more than half are thus concerned about side-effects of the vaccines (68%; 267/393) (Table 2).
Attitudes towards COVID-19 vaccines. Nearly half (44%; 174/393) of the respondents felt that COVID-19 vaccine protects them, while 39% (152/393) were neutral and only a minority (17%; 67/393) disagreed about the protective effect of COVID-19 vaccine. However when analyzed by gender, more men (50%; 80/159) agreed about the protective effect of COVID-19 vaccine compared to women (40%; 94/234) (p=0.047). Nearly half (46%; 179/393) of the respondents were confident in the scientific vetting process of the COVID-19 vaccines, while 41% (163/393) and only a minority (13%; 51/393) disagreed about the scientific vetting. However when analyzed by gender, more men (54%; 86/159) agreed about the scientific vetting compared to women (40%; 93/234) (p=0.005). Only a third (34%; 132/393) of the respondents were willing to participate in a vaccine trial for COVID-19 vaccines, while 30% (118/393) and almost similar numbers (36%; 143/393) were not willing to participate in vaccine trials. However when analyzed by gender, more men (40%; 64/159) shown willingness to participate in vaccine trials compared to women (29%; 68/234) (p=0.021) (Figure).
Intentions regarding having COVID-19 vaccines. The univariate analysis yielded that, whenever they are made available, there was significantly higher acceptance of COVID-19 vaccines by men (p=0.006), older respondents (p=0.029). By profession, nurses showed significantly higher acceptance rate (p=0.039). Respondents who understood the benefits of vaccines in general and COVID-19 vaccine specifically have shown significantly higher level intention to receive the vaccine (Table 3).
Among those who were not willing to receive the COVID-19 vaccine, majority felt that they did not yet know enough about the vaccine to make a decision (36.6%; 109/298) followed by 24.2% (72/298) who felt, “the development of the vaccine may be rushed/ the vaccine may not be thoroughly tested prior to approval”. The other reasons for non-acceptance/dilemma in taking vaccine were, “I want to gain natural immunity to the agent that causes COVID-19” (15.8%; 47/298), “I am confident there will be other better treatments soon” (11.4%; 34/298), “I am not sure” (9.1%; 27/298) followed by small subset who expressed, “I believe vaccines may give you the disease they are designed to protect you against” (3.0%; 9/298). “The potential side-effects of the vaccines (30.5%; 91/298)” were the main contributing factor for the negative opinion (non-acceptance/dilemma) about COVID-19 vaccines followed by, “concerns about fast-tracked research regarding vaccine development” (24.5%; 73/298), “frequent evolution of science of SARS CoV” (18.8%; 56/298), “influence of opinion of friends and relative” (14.4%; 43/298) etc.
Healthcare professionals of various cadres are key stakeholders in the health services delivery and their role in accepting novel preventive tools such as vaccines inspires confidence in general public. Multiple roles were played by health workers during this pandemic as frontline workers, and thus were duly recognized as priority recipients of vaccine in the first wave . Vaccination of frontline healthcare professionals yields manifold benefits such as protection of trained health force as well as reduced transmission to treating patients and vulnerable family members .
In this study of 393 healthcare professionals, our study population generally regarded vaccines are important for their health and for communities, which prompt them to follow the recommendations of WHO and ICMR; considerable numbers also expressed that newer vaccines such as novel COVID-19 vaccines carried an element of risk and are thus worried about side-effects. About half of the healthcare professionals felt that COVID-19 vaccines offers protection however less than 25% are willing to accept the vaccine. The findings in the present study are similar to Njazi et al. which reported vaccine acceptance among healthcare providers to be 28% . The vaccine acceptance levels varied from as high as 58% in United States to 39% in Ghana [16, 17]. Misinformation and issues related to vaccine safety, efficacy and potential side effects of vaccines are contributory factors for continued vaccine hesitancy among health providers [18, 19]. In a cross-sectional web-based survey, among 754 care providers across India, it was the belief that vaccines’ usefulness was minimal or slight in infection prevention (OR 7.06; 95% CI 3.98-12.52; p<0.001) during initial phase of vaccination that lead to non-acceptance of vaccine . In the same study endorsement of the vaccine by senior doctors and reputed scientists was observed to yield better acceptance. Hence, efforts have to be undertaken by the health authorities to improve the confidence and trust among healthcare professionals regarding the vaccine development measures.
Our findings revealed, higher acceptance of COVID-19 vaccine by men and older respondents. Also male professionals revealed favourable attitudes about the protective effect of the vaccine and willingness to participate in vaccine trials compared to females. In a scoping review of 35 studies on vaccine hesitancy Biswas N. et al. identified older and male care providers who perceived risk of getting infected with COVID-19, who provide direct care with prior history of influenza vaccination had increased vaccination uptake . In general women expressed higher degrees of vaccine hesitancy and this extends to health care professionals. Factors such as care giving roles for families, infertility, susceptibility to myths and misinformation, history of mistreatment in research etc. contribute to increased vaccine hesitancy among women [22, 23].
In this study, by profession nurses expressed high intention to accept vaccine compared to doctors. This in in contradiction to other studies quoted in literature where doctors were more positively intended to receive COVID-19 vaccine [11, 16, 17, 24, 25]. In a study from Hong Kong during the first pandemic wave intentions among nurses changed from refusal of vaccines to hesitancy or acceptance and reasons identified were suspicious efficacy, effectiveness and safety, lack of time for vaccination .
The study revealed mixed response regarding acceptance of COVID-19 vaccine among healthcare professionals related to efficacy, safety and side-effects of the vaccines. Tailor made educational interventions are to be designed to target healthcare professionals with emerging evidence to gain their trust and build their confidence which is critical for uptake of vaccine at larger scale by general public. The results emphasize the need for wider dissemination of national and regional guidelines about vaccination protocols in clinical and community settings. Personalized continuous medical education (CME) programs can be conducted at regular intervals to share the latest and emerging evidence about public health benefits of vaccines among various cadres of health care providers such as doctors and nurses etc. Showcasing the Testimonials of Champions or Change Agents who are having wider range of positive influence can act as motivation factor for improving vaccination uptake.
Limitations. As this is a web-based study and the sample size is limited with purposive sampling this might have introduced biased participant self-enrolment. But we still believe, to our knowledge, these findings can be used as baseline for further in-depth research on vaccine hesitancy among healthcare professionals especially doctors. It also highly like that there may be attitudinal shifts and thus this survey can capture these emerging changes from hesitancy to acceptance in a cohort study.
Acknowledgements. We sincerely acknowledge the support of all the healthcare professionals who undertook this online survey in a very timely manner and supported our study. We are extremely thankful and submit our sincere gratitude to Dr. I. Kannan, PhD, Co-ordinator, Institutional Research Committee, TMCH, Chennai for the constant encouragement and for expediting the review and approval process. We thank Dr. Kasthuri, Tutor, Department of Biochemistry, TMCH for dissemination the survey link among wider network of potential subjects.
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