Attitude and practice towards COVID-19 vaccination among healthcare workers in Kerala

INTRODUCTION

COVID-19/Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) has become a major public health challenge for the whole world. With initial cases reported from Wuhan city in China in December 2019, the pandemic is still raging. WHO Director-General Dr. Tedros, says there must be a ‘new normal’ a world that is healthier, safer and better prepared.¹

Globally, as of 2^nd November 2021, there are 246,951,274 confirmed cases of COVID-19-19, including 5,004,855 deaths, reported to WHO. India reports 34,308,140 confirmed cases and 4,59,191deaths.² There are 49,68,657 confirmed cases in Kerala, of which 1.16% are active cases. The recovery rate is 97.76% and death rate is 0.64%. The test positivity rate is 11%.³

Kerala model of healthcare is known worldwide. The experience and investment made in disaster preparedness and emergency response in the past during Kerala floods in 2018 and Nipah outbreak in 2019 helped the government of Kerala to act promptly in the COVID-19-19 situation. In collaboration with the key stake holders, the state formulated innovative approaches to deploy resources and put up a timely and comprehensive response.⁴ Inspite of all these efforts and praise from international community in the initial phase, the state’s pandemic curve is now defying all predictions. It is one among the top five states in India with the highest number of COVID-19 cases.⁵

With the development of vaccines, there seems to be a new ray of hope for the world to fight the pandemic out. The introduction of various vaccines within a short span of one year is undoubtedly a great achievement. This is welcomed worldwide. But this has also received mistrust and hesitance among public as well as health workers. WHO defines vaccine hesitancy as ‘delay in acceptance or refusal of vaccines despite availability of vaccination services’.⁶ Questions regarding the effectiveness and efficacy of vaccine, adverse effects, worry about commercial gain, concerns regarding clinical trials moving too fast and preference for natural immunity are some of the reasons for hesitance.⁷

India has started vaccination against COVID-19 on 16^th January, 2021. The ministry of health and family welfare has started giving vaccinations for people aged 18 years and above. Healthcare workers (HCW) and frontline workers were vaccinated first. Vaccines administered in India have been cleared for efficacy and safety by the drug regulatory bodies.⁸ Health workers play a major role in influencing the attitude of public regarding vaccination. This is a group particularly entrusted with passing on reliable information to the public, which in turn influences compliance with vaccination campaigns and schedules. Their attitude towards vaccination will decide their own vaccine uptake and likelihood of recommending the same to others including patients, friends and family.

The aim of the study was to find out the attitude and practice towards vaccination among health care workers in Kerala.

Objectives

The objectives of this study were (a) to study the attitude of healthcare workers towards COVID-19 vaccination; and (b) to find out the practice of COVID-19 vaccination among HCW.

METHODS

This was a descriptive study done to assess the attitude and practice towards COVID-19 vaccination among healthcare workers in Kerala. It was done during the period of April 2021-May 2021. Taking 36% as the prevalence of vaccine acceptance among healthcare workers and 10% absolute precision, a sample size of 93 was obtained, which was rounded off to 100.⁹ Convenience sampling was done to recruit the study participants. Data was collected using a semi structured questionnaire which had two parts: part-1 included questions about personal details and socio-demographic information such as age, address, phone number, type of family, religion, education, previous history of COVID-19. Part-2 included questions about determinants, attitude and practice regarding COVID-19 vaccination. It was converted to Google forms which were administered via Whats app or e-mail to all healthcare workers in the personal contacts. All 126 people who responded were included in the study. The data was analyzed using Epi info software.

RESULTS

The age group of the study population varied from 22 to 68 years with a mean age of 31.60±7.8 SD years. Out of the 126 healthcare professionals who took part, majority (51.6%) were Hindus and 61.9% were females. Most of them (81.7%) were modern medicine practitioners and majority (87.3%) had no co morbidities. Baseline characteristics of the study population are shown in Table 1.

Table 2 shows the COVID-19 related information of the study participants. 14.3% had a previous history of confirmed COVID-19 and 17.5% gave a family history of COVID-19. Majority (73.8%) had been involved in dealing with COVID-19 patients. Majority (76.9%) relied on WHO official website for information related to COVID-19.

Table 3 shows the attitude on each aspect related to COVID-19 vaccination among study participants. 118 (93.6%) of the participants agreed that it was fair to vaccinate HCW in the initial phase. The reasons were- they were frontline workers with the highest risk, so they deserved it first (103, 81.7%), vaccinated HCW could treat patients better (5, 3.9%), if HCW fell ill, there would be shortage of staff to look after patients (4, 3.1%), vaccinated HCW could do work without fear of COVID-19 (3, 2.3%), it would build confidence among public regarding vaccination (2, 1.5%) and as it was a government order, we were supposed to obey (1, 0.7%). 2 (1.5%) were neutral and 6 (4.8%) disagreed to vaccinating HCW first. If there were serious adverse effects, it would knock out frontline workers (2, 1.5%), not enough trials had been done on these vaccines (2, 1.5%), experimenting with HCW was not fair (1, 0.7%) and more efficient vaccines would be invented later (1, 0.7%) were the reasons for disagreement.

Concerns regarding COVID-19 vaccine are shown in Table 4. In the present study, 81.7% had taken vaccine and 79.6% had some adverse effects following vaccination. Table 5 shows their preference for other vaccines. Table 6 explains the practice regarding vaccination, Table 7 enlists the adverse effects experienced by vaccines and Table 8 shows the motivating factors for vaccination and Table 9, what vaccines felt after taking COVID-19 vaccination.

Note: #-not mutually exclusive.

Note: #-not mutually exclusive.

Note: #-not mutually exclusive.

Note: #-not mutually exclusive.

DISCUSSION

This is a pioneer study regarding vaccine hesitance among HCW in Kerala. In the present study among 126 HCW, it was interesting to note that majority (76.9%) relied on WHO official website for COVID-19 related information. In a similar study conducted among healthcare professionals of Egypt, colleagues (78.96%) and social media (77.66%) were the main source of information.⁹ It points to the fact that healthcare professionals in Kerala depended on reliable sources of information.

73.8% of the study participants were involved in dealing with COVID-19 patients.14.3% had a previous history of confirmed COVID-19 and 17.5% had a family history of COVID-19. A muti-centric study in Canada showed that occupational COVID-19 exposure was independently associated with acceptance of COVID-19 vaccine.¹⁰ Another study in Egypt also revealed that those who dealt directly with COVID-19 patients were three times more likely to accept COVID-19 vaccine than others.¹¹ Elhadi et al in their study also reported that if they had a family member or friend affected with COVID-19, it was positively associated with vaccine acceptance.¹²

In the present study to see the general attitude and practice of healthcare workers regarding COVID-19 vaccine, it was seen that majority (91.3%) agreed that COVID-19 vaccine is necessary to control the pandemic and 81.7% had already taken and 11.1% were planning to take soon. Only 7.1% had not taken vaccine because they were not eligible for the same. The systematic review conducted by Hajure et al revealed that about two-thirds of the studies among healthcare workers showed a positive attitude (≥50%) towards COVID-19 vaccination. African and Asian studies were observed to have a more negative attitude whereas United Arab Emirates reported highest rate of acceptance.¹³ Another scoping review, by Biswas et al of 35 studies across the world reported that the prevalence of vaccine hesitancy among healthcare workers varied from 4.3 to 72%.¹⁴ Vaccine hesitancy was found among 10.6% of the medical students in India.¹⁵

The results of the present study were in contrast to the studies done in Egypt where only 21% accepted and 51% of the participants were undecided and in Congo where only 27.7% of HCWs were willing to take COVID-19 vaccine.^11,16 But a study done in China revealed 76.98% of the HCW accepted COVID-19-19 vaccine.¹⁷ A similar study done in India showed that 36% were willing to take the vaccine while 56% were not sure or would wait. 8% of them had no plans to get vaccine.⁹ Another study from India done among HCW in a tertiary care centre showed 92.7% had a positive attitude towards vaccine.¹⁸ Even though all the study participants in the present study had a positive attitude, 23% thought that there was still much hesitance and fear regarding COVID-19 vaccination among HCW in Kerala.

The present study stands out in the sense that it took into consideration different dimensions of attitude among HCW towards COVID-19 vaccination which other studies had not looked into. 93.7% of the study participants agreed that vaccines provided in India were safe and 82.5% thought they were effective. 58.7% disagreed that even without vaccination, the pandemic would subside on its own by developing herd immunity. 94.5% believed that since HCW deal more closely with COVID-19 patients, they should be vaccinated and 93.6% agreed that it was only fair to vaccinate them in the initial phase of the pandemic before the general population. Majority (81.7%) said as they were frontline workers with the highest risk, they deserved vaccination first. 96.9% had positive attitude towards practicing infection control measures even after vaccination.

Majority (56.3%) thought the protection of vaccine would last for 3months to 1 year. All the study participants would recommend vaccination for others. This was in contrast to the study done by Fares et al where only 42.08% of the HCW were willing to do the same.¹¹ This again points to the strong positive attitude among HCW in Kerala. This attitude also reflected on the good practice. This was again in line with the findings of the Egyptian study where HCW who recommended vaccination for others had 17 times higher odds of acceptance.¹¹ 55.5% preferred other vaccines to the two vaccines given in India and Pfizer was the most preferred vaccine (43.6%). This was similar to the study done by Metwali et al where HCW preferred vaccines of US origin (55.3%).¹⁹ But in a study done in India, 26.9% preferred a foreign or imported vaccine, 36.9% preferred a domestic (Indian) vaccine and 36.2% agreed on either.²⁰

Duration of protection (61.1%), protection against new strains (57.1%), inadequate studies on long term effects (47.6%) and inadequate clinical trials (26.9%) were the most common concerns among the study participants. This was similar to many studies done across the world.^{10,11,12,17,21} Concerns for safety, efficacy and effectiveness and distrust of the government were barriers to vaccination according to a systematic review done by Li et al.¹⁷ Fares et al in their study showed that the reasons for vaccine hesitancy and refusal were inadequate clinical trials (92.4%) and fear of vaccine’s side effects (91.4%).¹¹ Another study reported lack of trust in vaccine safety (85%) and receiving little (78%) or conflicting (69%) information about vaccines as reasons for the same.²² A concern with proper storage was the biggest barrier to acceptance of vaccine in another study.¹⁹ It should be noted that 3.9% of the HCW in this study had concerns regarding fertility following vaccination. Even though a small percentage, they could spread wrong information and negative attitude in the community. Hence it is utmost important to address these concerns with supporting scientific evidence. Li et al in their study, also suggested tailored communication strategies and more transparency on safety and efficacy of vaccines to increase the vaccine acceptance of HCWs.¹⁷

Among the vaccines (N=103), 79.6% had experienced adverse effects following vaccination. Fever (51.4%), injection site pain (45.6%) and myalgia (41.7%) were the most common adverse effects in this study. This was in line with the reported side effects of covishield.²³ None had serious adverse effects requiring hospitalization. Pain at injection site (89.8%), fatigue (62.2%), headache (45.6%) and myalgia (37.1%) were the most commonly reported side effects among HCW in Czech Republic.²⁴ Similar findings were reported in a study done in Kathmandu.²⁵ 50.88% of the participants reported AEFI after taking Covishield, in a study done in Bangladesh, of which swelling and pain at the injection site (37.07%) and fever (25.84%) were the most common.²⁶

Protection of self and family was the strongest motivation for vaccination among 82% of the vaccines, followed by protection of patients (6.8%). Singhania et al in their study also reported protection of self (66.0%), family (65.1%), the patients (40.5%), and the entire community through herd immunity (54.7%) as the reasons for taking vaccination.²⁰ 80.7% of the vaccines in this study had a positive feeling after vaccination. They felt confident/ happy/grateful/safe from complications, whereas 15.5% were still in fear of long-term side effects of the vaccine.

CONCLUSION

From the present study, it could be concluded that most of the HCW had positive attitude and practice towards COVID-19 vaccination. This would in turn help to prevent vaccine hesitance among the public as HCW influence their decision on vaccine acceptance. However, there were still concerns regarding the same which should be addressed.

The major limitation of our study was that it had a small sample size and the study population consisted mainly of modern medicine practitioners, so results might not be generalized to the entire HCW community. Further, the adverse effects were self-reported, hence there could be bias and misrepresentation.

ACKNOWLEDGEMENTS

We would like to thank all the HCW who participated in this study.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: Not required

REFERENCES

1. 1. WHO. Coronavirus disease 2019 (COVID-19) Situation Report-94 highlights, 2020. Available at: https://www.who.int/docs/defaultsource/coronaviruse/situation-reports/20200423-sitcovid-19. Accessed on 20 November 2021.
2. 2. WHO. WHO Coronavirus Disease (COVID-19) Dashboard, 2021. Available at: https://covid19.who.int/. Accessed on 20 November 2021.
3. 3. Government of Kerala. Dashboard Official Kerala COVID-19 Statistics, 2021. Available at: https://dashboard.kerala.gov.in/covid/. Accessed on 20 November 2021.
4. 4. WHO. Responding to COVID-19 - Learnings from Kerala, 2020. Available at: https://www.who.int/india/news/featurestories/detail/responding-to-c-learnings-from-kerala. Accessed on 20 November 2021.
5. 5. Mongabay. After early success, Kerala stumbles in containing the COVID-19 pandemic, 2020. Available at: https://india.mongabay.com/2020/10/afterearlysuccess-kerala-stumntaining-the19pandemic/. Accessed on 20 November 2021.
6. 6. WHO. Summary WHO SAGE conclusions and recommendations on Vaccine Hesitancy-Guide-to-Tailoring-Immunization-Programmes-TIP, 2015. Available at: http://www.who.int/immunization/sage/meetings/2014/october/2_SAGE_Appendicies_Background_final.pdf?ua=12http://www.euro.who.int/__data/assets/pdf_file/0003/187347/T. Accessed on 20 November 2021.
7. 7. Ipsos. Global attitudes on a COVID-19 vaccine, 2020. Available at: https://www.ipsos.com/en/global-attitudes-covid-19-vaccine-december-2020. Accessed on 20 November 2021.
8. 8. MoHFW. Information Regarding COVID-19 Vaccine, 2021. Available at: https://www.mohfw.gov.in/covid_vaccination/vaccination/index.html. Accessed on 20 November 2021.
9. 9. Shekhar R, Sheikh AB, Upadhyay S, Singh M, Kottewar S, Mir H, et al. COVID-19 Vaccine Acceptance among Health Care Workers in the United States. Vaccines (Basel). 2021;9(2):119.
10. 10. Dzieciolowska S, Hamel D, Gadio S, Dionne M, Gagnon D, Robitaille L, et al. Covid-19 vaccine acceptance, hesitancy, and refusal among Canadian healthcare workers: A multicenter survey. Am J Infect Control. 2021;49(9):1152-7.
11. 11. Fares S, Elmnyer MM, Mohamed SS, Elsayed R. COVID-19 Vaccination Perception and Attitude among Healthcare Workers in Egypt. J Prim Care Community Health. 2021;12:21501327211013303.
12. 12. Elhadi M, Alsoufi A, Alhadi A, Hmeida A, Alshareea E, Dokali M, et al. Knowledge, attitude, and acceptance of healthcare workers and the public regarding the COVID-19 vaccine: a cross-sectional study. BMC Public Health. 2021;21(1):955.
13. 13. Hajure M, Tariku M, Bekele F, Abdu Z, Dule A, Mohammedhussein M, et al. Attitude Towards COVID-19 Vaccination Among Healthcare Workers: A Systematic Review. Infect Drug Resist. 2021;14:3883-97.
14. 14. Biswas N, Mustapha T, Khubchandani J, Price JH. The Nature and Extent of COVID-19 Vaccination Hesitancy in Healthcare Workers. J Community Health. 2021;46(6):1244-51.
15. 15. Jain J, Saurabh S, Kumar P, Verma MK, Goel AD, Gupta MK, et al. COVID-19 vaccine hesitancy among medical students in India. Epidemiol Infect. 2021;149:132.
16. 16. Kabamba NM, Kabamba NL, Ngoie MG, Banza NDB, Mbidi MJ, Luhata LC, et al. Acceptability of Vaccination Against COVID-19 Among Healthcare Workers in the Democratic Republic of the Congo. Pragmat Obs Res. 2020;11:103-9.
17. 17. Li M, Luo Y, Watson R, Zheng Y, Ren J, Tang J, Chen Y. Healthcare workers' (HCWs) attitudes and related factors towards COVID-19 vaccination: a rapid systematic review. Postgrad Med J. 2021;140195.
18. 18. Joshi A, Sridhar M, Tenneti VJD, Devi V, Nallaperumal AB. COVID-19 Vaccine Hesitancy in Healthcare Workers Amidst the Second Wave of the Pandemic in India: A Single Centre Study. Cureus. 2021;13(8):17370.
19. 19. Metwali BZ, Jumaili AA, Alag ZA, Sorofman B. Exploring the acceptance of COVID-19 vaccine among healthcare workers and general population using health belief model. J Eval Clin Pract. 2021;27(5):1112-2.
20. 20. Singhania N, Kathiravan S, Pannu AK. Acceptance of coronavirus disease 2019 vaccine among healthcare personnel in India: a cross-sectional survey during the initial phase of vaccination. Clin Microbiol Infect. 2021;27(7):1064-6.
21. 21. Malik AA, Fadden SM, Elharake J, Omer SB. Determinants of COVID-19 vaccine acceptance in the US. E Clin Med. 2020;26:100495.
22. 22. Gennaro F, Murri R, Segala FV, Cerruti L, Abdulle A, Saracino A, et al. Attitudes towards Anti-SARS-CoV2 Vaccination among Healthcare Workers: Results from a National Survey in Italy. Viruses. 2021;13(3):371.
23. 23. MOHFW. Common Side Effects (AEFI) of COVID-19 Vaccine, 2019. Available at: https://www.mohfw.gov.in/covid_vaccination/vaccination/common-side-effects-aefi.html. Accessed on 20 November 2021.
24. 24. Riad A, Pokorná A, Attia S, Klugarová J, Koščík M, Klugar M. Prevalence of COVID-19 Vaccine Side Effects among Healthcare Workers in the Czech Republic. J Clin Med. 2021;10(7):1428.
25. 25. Pokharel K, Dawadi BR, Karki A. Side Effects after Second Dose of Covishield Vaccine among Health Care Workers: A Descriptive Cross Sectional Study. JNMA J Nepal Med Assoc. 2021;59(238):577-9.
26. 26. Sultana A, Shahriar S, Tahsin MR, Mim SR, Fatema KR, Saha A, et al. A Retrospective Cross-Sectional Study Assessing Self-Reported Adverse Events following Immunization (AEFI) of the COVID-19 Vaccine in Bangladesh. Vaccines (Basel). 2021;9(10):1090.