A survey of Iranian population attitude about vaccination
against COVID-19 and evaluation of its spontaneous reporting of adverse
effects
Abstract
Objectives : The COVID-19 pandemic continues to claim victims
around the world, and Iran is no exception from this ravage. Vaccine
development led to growing optimism regarding control of COVID-19.
Vaccine acceptance by the majority of the population is important for
the success in controlling COVID-19. This study assessed the attitude of
Iranian population toward COVID-19 vaccination. Also, the adverse
effects of the COVID-19 vaccines on vaccinated individuals were
reported.
Method : This cross-sectional study was conducted from May to
July 2021 among Iranian population. The data was collected using the
online researcher-made questionnaire. The questionnaire contained 16
questions in 3 sections.
Results : The questionnaire was filled out by 916 people in
total. The majority of participants had 40-65 years old (N:480, 52.4%).
More than half of participants were from health care team (N:543,
59.3%). The majority of participants trusted the vaccine and said they
would inject it (N:582, 63.5%). However more than 80% of participants
preferred non-domestic vaccines over Iranian ones. Potential adverse
effect following vaccination was the main concern of responders (N:576,
62.9%). The most common adverse effects reported by vaccine recipients
were temporary fatigue and muscle pain (N:313, 71.95%). The level of
education, academic area and area of practice in the health system were
significantly associated with the positive response to COVID-19
vaccination (P-value 0.0001, 0.0001 and 0.004 respectively).
Conclusion : According to the results of this study, Iranian
health authorities should provide clear information about the safety and
efficacy of COVID-19 vaccines, especially domestic types, to increase
public confidence and awareness regarding vaccines.
Keywords : COVID-19, Vaccination, Iranian population, Attitude,
Adverse effect
What is already known about this topic?
As of now, vaccination offers the best chance of controlling COVID-19
disease. It is possible to obtain herd immunity against COVID-19 by
vaccinating 60 to 72 percent of the population. As a result, doubts
about vaccination can hinder the achievement of this goal.
Some factors can lead to uncertainty about vaccinations, for example,
the fear of possible adverse effects is one of them.
What does this article add?
In this study, the majority of participants trusted the vaccine and
said they would inject it (N:582, 63.5%). Although participants were
worried about receiving the vaccine due to fears of negative adverse
effects, fatigue and muscle pain were the most common adverse effects
reported by participants
Introduction
Since the first cases of COVID-19, were identified more than a year ago.
Approximately 220 countries were affected by the COVID-19 outbreak
starting in December 2019. The effects of COVID-19 vary from person to
person. The majority of people who have COVID-19 infection will show
mild to moderate symptoms and recover without hospitalization; however,
some will undergo hospitalization or even die due to their illness
[1]. More than 190 million cases and 4.09 million deaths worldwide
have been attributed to the COVID-19 pandemic as of July 17,2021
[2]. Human health was not the only aspect of human life that was
affected by this disease; economic conditions, and social relationships
were also impacted [3].
It appears that the virus is transmitted mainly through the inhalation
of droplets with a predominance of respiratory symptoms [4]. Several
strategies were implemented to stop the spread of COVID-19, including
social distancing, hand washing, face mask wearing, and reducing
presence in crowded places [5]. Despite the fact that these methods
have slowed disease spread, these methods are challenged by lack of
public support or resilience, noncompliance with national and
international guidelines, and inadequate infrastructure and resources
[6].
As the disease had no specific treatment and many people died daily, the
international community became focused on vaccination and increasing
public immunity against it. Currently, a major public health measure
that can save millions of lives worldwide is the vaccination. To date,
different platforms including inactivated virus, recombinant protein,
RNA based vaccine and deficient adenovirus based, have been used to
manufacture vaccines [7]. As of 17July 2021, human clinical trials
have been conducted on 97 vaccines, and 32 vaccines have reached the
final stages. Also, animal studies are ongoing on 77 preclinical
vaccines [8].
As a result of the development of a vaccine against COVID-19, the human
community gained hope for faster control of the disease. On the other
hand, there are some concerns about safety, efficacy, and availability
of COVID-19 vaccine among many people. Vaccine hesitancy remains a
potential impediment to community uptake [9]. As defined by the WHO
Strategic Advisory Group of Experts (SAGE), vaccine hesitancy is the
refusal or delay of vaccination despite the availability of vaccination
services [10]. The vaccine related adverse effects have a key role
in public confidence in the vaccine. Fear of adverse effects is one of
the reasons for people’s distrust and rejection of the vaccine. The
information on COVID-19 vaccines adverse effects comes from vaccine
manufacturers’ studies; so further observational studies can provide
more information on vaccines adverse effects. Raising knowledge about
different aspects of COVID-19 vaccines can help allay concerns and
improve public confidence [11].
With a population of about 84 million, the COVID-19 infection rate in
Iran is high. As of 17July 2021, more than 3.5 million COVID-19
confirmed cases and over 86966 deaths has been reported in Iran [2].
Several vaccines from different companies have entered the clinical
studies phase. Currently in Iran two domestically made vaccines have
been approved for emergency use from the Ministry of Health of Iran,
there are also a number of vaccines in various stages of development in
different domestic institutions [12]. It is important to examine the
attitudes regarding COVID-19 vaccines among Iranian population as well
as their acceptance of the vaccines. This study was conducted to
evaluate the attitude and acceptance of Iranian population toward
COVID-19 vaccination. A study of the adverse effects of the COVID-19
vaccine on vaccinated individuals was also conducted, in light of the
fact that the occurrence of adverse effects is one of the concerns of
people about the vaccination.
However several studies have examined the tendency to receive vaccines,
preference for domestic versus non-Iranian vaccines [13], priority
groups for vaccination [14], and adverse effects of vaccine [15]
among special groups in Iran. These issues, along with other factors
affecting attitudes, are comprehensively addressed in this study.
Method
This survey is a cross-sectional study in which the attitude and
acceptance of the Iranian population about COVID-19 vaccination were
assessed. Vaccinated individuals were also evaluated for adverse effects
of the vaccine. This study was conducted from May 2021 to July 2021. The
study was reviewed and approved by the Ethics Committee of the Tehran
University of medical sciences (IR.TUMS.TIPS.REC.1400.091). There was no
consent form and completion of the questionnaire by each person was
considered as her/ his satisfaction.
Data collection was conducted using the online researcher-made
questionnaire. The questionnaire contained 16 questions in 3 sections
(Table 1, 2, 3). The first part consisted of 5 questions about
demographic information including age, sex, level of education, and
occupational field. In 6 questions of second part, attitude and
acceptance of general population and healthcare staffs regarding
COVID-19 vaccine were evaluated. The third section of the study focused
on those who had been vaccinated against COVID-19 and asked the
participants about the occurrence of adverse effect after vaccination,
its duration, and measures taken to eliminate it. This questionnaire was
designed and then tested for validity and reliability, and then
converted into an online form. The questionnaire was uploaded to online
social media platforms (WhatsApp, Telegram and Instagram). There are
more than 59 million internet user in Iran [16]. We sent a
questionnaire to various social groups, and members of the groups were
asked to respond to the questions and share the questionnaire with their
contacts or acquaintances. In order to prevent duplicate answers, the
questionnaire was designed to be answered only once by each participant.
The content validity of the Persian-language questionnaire was evaluated
by 9 experts (physicians, pharmacists and university professors).
Content validity index and the content validity ratio calculated 0.96
and 0.82 respectively.
Statistical analysis
All data were analyzed using Statistical Package for the Social Sciences
(SPSS) version 25. Shapiro-Wilk’s test was utilized to assess the
normality distributions of variables. Continuous variables were
expressed as mean ± standard deviation or median [interquartile
range]. Independent sample t-test and Mann–Whitney U-test were
performed to compare normal and non-normal quantitative variables
between the two groups. Categorical variables were presented as numbers
and percentages. Chi-square and Fisher exact test were used to compare
categorical variables. In order to assess the association of acceptance
of the participants and other variables, the answers ” I trust/ I
inject” and ” I do not trust/ I inject ” were considered similar to yes
and the options ” I do not trust/ I do not inject” and ”I trust/ I do
not inject ”and ”Due to catching COVID-19, I do not need a vaccine” were
considered similar to no and were tested by Chi-square/ Fisher exact
test. In all comparisons, P-values less than 0.05 were considered as
significant
The sample size was calculated with the Raosoft sample size calculator.
In order to achieve a confidence level of 99% and margin of error of
5% for this study, a sample size of 664 people with a distribution of
responses of 50% is required. A response rate of 30 to 40% is
estimated for studies based on online questionnaires [17, 18], so
the questionnaire was uploaded in different social groups with a high
number of members.
Results
A total of 1836 people visited this questionnaire, but 916 participants
completed it. The majority of
participants had 40-65 years old (N:480, 52.4%) and more than 74%
(N:679) of them were female. Most participants had high level of
academic education (N: 434, 47.4%) doctoral or post-doctoral
degree). More than half of participants were from health care
team (N:543, 59.3%), whereas pharmacists constituted the majority
(N:231, 25.2%). The sociodemographic characteristics of the
participants were obtained in Table1.
In terms of acceptance of COVID-19 vaccines, among respondents, more
than 80% (N: 758) preferred non-domestic vaccines over Iranian ones.
Nevertheless, the majority of participants trusted the vaccine and said
they would inject it (N:582, 63.5%). Most participants, whether general
population (N: 294, 78%) or health care team (N:505, 93%), tend to
injected vaccine; but the percentage of people who refuse to inject
vaccine was significantly higher for the general population (N:79, 19%)
than for medical staff (N:38, 6.1%). Besides, 86.5% (N: 791) reported
they recommend COVID-19 vaccine administration to others. Potential
adverse effects following vaccination (N:576, 62.9%), as well as the
possibility of inadequate immunization (N:344, 37.6%), were the main
concerns of participants regarding COVID-19 vaccination. Most
participants were well-informed about COVID-19 vaccination; they knew
group priorities for vaccination (N:541, 59.1%) and believed that
vaccination would not eliminate the need for protective measures (e.g.,
face masks) (N:751, 82 %). Compared to the general population, medical
staff had more correct answers to questions dealing with vaccination
priorities (67% vs 47.5%, P-value: 0.004) and need for protective
measures after vaccination (91.5% vs 68.1%, P-value: 0.001). The
comparison between health care providers and the general population is
shown in Table 4.
In this study, almost half of participants (435 participants, 47.4%)
received COVID-19 vaccine, AstraZeneca® vaccine was mostly given to them
(N: 200, 21.8%). Approximately 75.2 percent of participants (N:327)
experienced one or more adverse effects after receiving the vaccine. The
most common adverse effects reported by vaccine recipients were fatigue
and muscle pain (N:313, 71.95%). Most vaccine adverse effects usually
resolved by analgesics or antihistamines (N: 222, 51.1%) within 24 to
72 hours (N: 188, 43.2%), and only 2.8% (N:12) of cases lasted longer
than a week. Majority of respondents (more than 90%, N:345) who had
received the first dose of the vaccine expressed a desire to receive the
next dose.
As shown in Table 5, level of education, academic area and area of
practice in the health system were significantly associated with the
positive response to COVID-19 vaccination (P-value 0.0001, 0.0001 and
0.004 respectively).
Discussion
This study was conducted to investigate the acceptance and attitude of
Iranian population toward COVID-19 vaccines. Additionally, adverse
reactions following the vaccination and how to control them were
investigated in vaccinated individuals.
Many people around the world are concerned about the use of the COVID-19
vaccine because of the lack of global experience with it, doubts about
its effectiveness and potential adverse effects. Among the 916
participants in this study, 87.2% were eager to receive the vaccine.
Surprisingly, 23.7% of respondents (N: 217) said that they still inject
vaccines despite not trusting them. There have been a variety of studies
conducted in different countries to determine the acceptability of the
COVID-19 vaccine. In a global survey, the COVID-19 acceptance of 13426
people from 19 countries was assessed. The highest acceptance rates were
found in China (88.62%), followed by Brazil (85.36%), and the lowest
rates were found in the Russian population (54.85%) [19]. There
were acceptance rates of 53.1% in Kuwait [20], 37.4% in Jordan
[4], and 64.7% in Saudi Arabia [21] among Asian countries. The
present study found that health care providers accept the COVID-19
vaccine more than the general population. It can be attributed to the
higher level of knowledge in the field of COVID-19, possibility of
further COVID-19 infection because of special occupational conditions
among health care providers, as well as the direct observation of
morbidity and mortality of this disease. In the study of Fares et al, in
line with our results, it was observed that factors such as direct
contact with patients with COVID-19 and obtaining sufficient information
about COVID-19 vaccine have a significant effect on increasing the
acceptance of health care workers [22].
This study found that people may be concerned about vaccinations for a
variety of reasons. Participants most commonly cited possible
complications following vaccinations, poor vaccination efficacy, and the
lack of enough scientific backing to make the vaccine. These results are
in line with those reported by Pogue and colleagues. They evaluated the
attitude of Americans toward their vaccination against COVID-19.
According to their study, most people were concerned by the adverse
effects of vaccines, uncertain efficacy, and the short duration of
vaccine studies [23]. In El-Elimat ’s study, vaccine safety concerns
were cited as a significant reason for vaccine rejection in the
Jordanian population [4]. The present study showed that a large
percentage of participants were willing to receive the vaccine, but that
most prefer the non-Iranian vaccine to the Iranian vaccine. Similarly,
73% of Iranian professors and researchers who participated in another
study conducted in August 2020 reported their preference for non-Iranian
vaccines [13]. The distrust may have been caused, in part, by the
idea that domestic products are inferior to foreign counterparts, as
vaccines did as well as many other domestic items. In addition, the
misinformation and worrying rumors about domestic vaccines sparked
public concern. Increased transparency by vaccine manufacturers and
government officials regarding the production and distribution of
locally produced vaccines can lead to greater public confidence in the
field of domestic COVID-19 vaccines.
There is a need to prioritize the population to receive the vaccine in
Iran, in light of the large population and the lack of adequate access
to vaccine for all members at the same time; those involved in the study
were asked to select the priority groups. The results showed that
patients with chronic disease, healthcare providers and elderly
population were reported as prioritized groups for COVID-19 vaccination.
These groups were currently prioritized for vaccination by Iranian
health policymakers. The results were similar to those found by Moradi
et al., who surveyed 878 Iranians about priority groups for vaccination
[14].
This study asked the participants about wearing masks and attention to
protective methods after receiving the vaccine. Most participants,
especially healthcare providers, believed that it was necessary to wear
a mask following vaccination against COVID-19. The center for disease
control and prevention (CDC) now recommends that persons who have been
vaccinated use masks to protect themselves, particularly against the new
variant of COVID-19, and to avoid spread to others [24].
In another part of the study, people who had received the COVID-19
vaccine were asked about the occurrence of adverse effects following
vaccination and how to manage it. During the study period, more
healthcare providers were vaccinated than other populations.
Participants received the AstraZeneca® vaccine at a higher proportion
than other vaccines. This was due to greater imports of AstraZeneca®
vaccine than other brands at the time of this study. Approximately 75%
of participants experienced adverse effects after receiving the COVID-19
vaccine, with fatigue and muscle pain, fever, and headache being the
most common complaints, respectively. The reported adverse effects were
similar to those reported by the CDC, which identified tiredness,
headache, muscle pain and fever as common adverse effects [25].
Fortunately, participants did not report life-threatening complications
or anaphylaxis. A few participants also reported uncommon but important
symptoms such as psychotic symptoms (e.g., restlessness and mood
fluctuations), angina, and arrhythmia although they were temporary
(Figure 1). At this time, these complications are rare and only reported
in some case reports [26, 27]. Most participants reported
improvement in adverse effects after taking analgesics or antipyretics
for 24 to 72 hours. The number of cases that required hospitalization
from vaccination adverse effects was very low in this study.
This study was performed before vaccine was administered to a high
percentage of the Iranian population. Therefore, people’s perceptions
about the vaccine or the pattern of adverse effects coming from the
vaccine may change as the vaccine is distributed further. Additionally,
the study didn’t include all groups of people because those without
access to mobile phones, computers, and the internet were unable to
participate.
Conclusions
This study assessed the attitude of Iranian population toward COVID-19
vaccination. Also, the adverse effects of the COVID-19 vaccine on
vaccinated individuals were evaluated. The majority of participants
trusted the vaccine and said they would inject it. However more than
80% of participants preferred non-domestic vaccines. Although
participants were worried about receiving the vaccine due to fears of
negative adverse effects, fatigue and muscle pain were the most common
adverse effects reported by participants. No life-threatening
complications were reported as well. However, more studies need to be
done with more participants in order to evaluate the adverse effects of
COVID-19 vaccines.
References
1. Nalbandian A, et al. Post-acute COVID-19 syndrome. Nat Med ,
2021; 27(4): 601-615.
2. Reported Cases and Deaths by Country or Territory,
https://www.worldometers.info/coronavirus/.
3. Haleem A, Javaid M, Vaishya R. Effects of COVID-19 pandemic in daily
life. CMRP , 2020; 10(2): 78-79.
4. El-Elimat T, AbuAlSamen MM, Almomani BA, Al-Sawalha NA, Alali FQ.
Acceptance and attitudes toward COVID-19 vaccines: A cross-sectional
study from Jordan. PLoS one . 2021; 16(4): e0250555.
https://doi.org/10.1371/journal.pone.0250555.
5. How to Protect Yourself & Others, Content source: National Center
for Immunization and Respiratory Diseases, June 11, 2021.
6. Maqbool A, Khan NZ. Analyzing barriers for implementation of public
health and social measures to prevent the transmission of COVID-19
disease using DEMATEL method. Diabetes Metab Syndr . 2020; 14(5):
887-892.
7. Nagy A, Alhatlani B. An overview of current COVID-19 vaccine
platforms. Comput. Struct. Biotechnol. J. 2021; 19: 2508-2517.
8. Zimmer C, Corum J, Wee S-L. Coronavirus vaccine tracker US: The New
York Times. 2010 [cited 2021 July 15]. Available from:
https://www.nytimes.com/interactive/2020/science/coronavirusvaccine-tracker.html.
9. Cordina M, Lauri MA, Lauri J. Attitudes towards COVID-19 vaccination,
vaccine hesitancy and intention to take the vaccine. Pharmacy
practice . 2021; 19(1): 2317-2317.
10. Butler R, MacDonald NE. Diagnosing the determinants of vaccine
hesitancy in specific subgroups: The Guide to Tailoring Immunization
Programmes (TIP). Vaccine . 2015; 33(34): 4176-4179.
11. Riad A, et al. Prevalence of COVID-19 Vaccine Side Effects among
Healthcare Workers in the Czech Republic. J. Clin. Med. 2021;
10(7): 1428.
12. Islamic republic of Iran ministry of health and medical education,
https://behdasht.gov.ir/.
13. Abouee-Mehrizi A. A National Survey of Iranian
Academicians’Attitudes Towards COVID-19 Vaccinationn. CJHR . 2021;
6(1):21-28. https://doi.org/10.32598/CJHR.6.1.334.1.
14. Moradi N, et al, Public Views on Priority Groups for COVID-19
Vaccination: A Survey from Iran. SEMJ . 2021; 22(7).
15. Babamahmoodi F, et al. Side Effects and Immunogenicity Following
Administration of The Sputnik V COVID-19 Vaccine Among Health Care
Workers; An Observational Study in Iran. 2021. Preprint.
16. Digital 2021: Iran,
https://datareportal.com/reports/digital-2021-iran.
17. Fincham J.E. Response rates and responsiveness for surveys,
standards, and the Journal. Am. J. Pharm. Educ . 2008; 72(2):
43-43.
18. Regmi PR, et al. Guide to the design and application of online
questionnaire surveys. Nepal J Epidemiol . 2016; 6(4): 640.
19. Lazarus JV, et al. A global survey of potential acceptance of a
COVID-19 vaccine. Nat med . 2021; 27(2):225-228.
20. Alqudeimat Y, et al. Acceptance of a COVID-19 Vaccine and Its
Related Determinants among the General Adult Population in Kuwait.Med Princ Pract . 2021; 30(3): 262-271.
21. Al-Mohaithef M, Padhi BK. Determinants of COVID-19 Vaccine
Acceptance in Saudi Arabia: A Web-Based National Survey. J
Multidiscip Healthc . 2020; 13:1657-1663.
22. Fares S, et al. COVID-19 Vaccination Perception and Attitude among
Healthcare Workers in Egypt. J Prim Care Community Health . 2021;
12.
23. Pogue K, et al. Influences on Attitudes Regarding Potential COVID-19
Vaccination in the United States. Vaccines . 2020; 8(4): 582.
24. When You’ve Been Fully Vaccinated. center for disease control and
prevention. July 27, 2021.
https://www.cdc.gov/coronavirus/2019-ncov/vaccines/fully-vaccinated.html.
25. Possible Side Effects After Getting a COVID-19 Vaccine. center for
disease control and prevention. June 24, 2021.
https://www.cdc.gov/coronavirus/2019-ncov/vaccines/expect/after.html.
26. Jeet Kaur R, et al. Cardiovascular Adverse Events Reported from
COVID-19 Vaccines: A Study Based on WHO Database. Int J Gen Med .
2021; 14: 3909-3927.
27. Srinivasan KN, Sathyamurthy I, Neelagandan M. Relation between
COVID-19 vaccination and myocardial infarction - Casual or
coincidental?. IHJ CVCR . 2021; 5(2): 71-74.
Table 1. The demographic characteristics of the study participants
(N=916)