Assignment 2: Journal Article Review

Vaccine 39 (2021) 1693–1700

Contents lists available at ScienceDirect

Vaccine

journal homepage: www.elsevier.com/locate/vaccine

Perspectives on the receipt of a COVID-19 vaccine: A survey of employees in two large hospitals in Philadelphia

https://doi.org/10.1016/j.vaccine.2021.02.029 0264-410X/� 2021 Elsevier Ltd. All rights reserved.

⇑ Corresponding author at: Vaccine Education Center, Children’s Hospital of Philadelphia, 3615 Civic Center Boulevard, Philadelphia, PA 19104, United States.

E-mail addresses: [email protected], [email protected] (B.J. Kuter).

Barbara J. Kuter a,⇑, Safa Browne a, Florence M. Momplaisir b, Kristen A. Feemster a, Angela K. Shen a, Judith Green-McKenzie b, Walter Faig c, Paul A. Offit a

a Vaccine Education Center, Children’s Hospital of Philadelphia, United States b Hospital of the University of Pennsylvania, United States c Children’s Hospital of Philadelphia, United States

a r t i c l e i n f o a b s t r a c t

Article history: Received 11 January 2021 Received in revised form 2 February 2021 Accepted 8 February 2021 Available online 16 February 2021

Keywords: COVID-19 Vaccine Health care workers Risk factors Vaccine safety Vaccine acceptance Vaccine hesitancy

Background: Health care personnel have been identified by the ACIP as a priority group for COVID-19 vac- cination. We conducted a survey in November-December 2020 at two large, academic hospitals in Philadelphia to evaluate the intention of hospital employees to be vaccinated. Methods: The survey was sent electronically to all employees (clinical and nonclinical staff) at a chil- dren’s hospital and an adult hospital. The survey was voluntary and confidential. Questions focused on plans to receive a COVID-19 vaccine when available, reasons why employees would/would not get vac- cinated, when employees planned to be vaccinated, vaccine safety and efficacy features that would be acceptable, and past history of receipt of other vaccines by the employee and family. Responses were ana- lyzed using univariate and multiple logistic regression methods. Results: A total of 12,034 hospital employees completed the survey (a 34.5% response rate). Overall, 63.7% of employees reported that they planned to receive a COVID-19 vaccine, 26.3% were unsure, and 10.0% did not plan to be vaccinated. Over 80% of those unsure or unwilling to be vaccinated expressed concerns about vaccine side effects and the vaccines’ newness. In multivariable logistic regression, persons plan- ning to take a COVID-19 vaccine were more likely to be older, male, more educated, Asian or White, up-to-date on vaccinations, without direct patient contact, and tested for COVID-19 in the past. No sig- nificant difference in intention to be vaccinated was found between those with higher versus lower levels of exposure to COVID-19 patients or the number of previous exposures to patients with COVID-19. Conclusions: While the majority of hospital employees are planning to receive a COVID-19 vaccine, many are unsure or not planning to do so. Further education of hospital employees about the safety, efficacy, and value of the currently available COVID-19 vaccines is critical to vaccine acceptance in this population.

� 2021 Elsevier Ltd. All rights reserved.

1. Background

The coronavirus disease 2019 (COVID-19) pandemic continues to aggressively spread throughout the United States with more than 26.1 million cases and 441,831 deaths reported as of February 2, 2021 [1]. COVID-19 is now the leading cause of death in the US [2]. The persistence of the pandemic and its increasing morbidity and mortality, despite current mitigation efforts, underlines the need for COVID-19 vaccines. COVID-19 vaccine development and testing has progressed at rapid speed due to novel vaccine tech- nologies, the unprecedented number of public–private partner-

ships, vaccine manufacturers, and regulatory agencies focused on a solution, and significant funding from both government and pri- vate industry.

A central strategy to mitigating the COVID-19 pandemic is through vaccination. Although vaccination programs are well underway in the US, vaccination can only curtail ongoing transmis- sion of the SARS-CoV-2 virus and reduce the overall severity of the disease if widespread uptake occurs and herd immunity is achieved. Experts estimate that �67% of the population must be immune against the SARS-CoV-2 virus to halt transmission [3–6].

Acceptance of vaccination against COVID-19 by the general population has been reported to be less than optimal. Eight polls conducted between May 2020 and October 2020 showed that the percent of adults who planned to receive a COVID-19 vaccine ranged from 35 to 75% with no clear trend over time [7–13].

B.J. Kuter, S. Browne, F.M. Momplaisir et al. Vaccine 39 (2021) 1693–1700

Acceptance rates varied by race/ethnicity with lower acceptance among Blacks than Whites [8,9].

In anticipation of the imminent Emergency Use Authorization (EUA) of several COVID-19 vaccine candidates, the CDC’s Advisory Committee on Immunization Practices (ACIP) made recommenda- tions for priority groups for vaccination at its December 1, 2020 meeting. Recommendations were made recognizing that supply would be limited when a vaccine was first available. The ACIP rec- ommended that health care personnel should be included in the first group to be offered COVID-19 vaccination as they are on the front lines of pandemic response. Health care settings were recog- nized as high-risk locations for SARS-CoV-2 exposure and trans- mission [14,15].

Health care personnel may not only be some of the first persons to receive a COVID-19 vaccine, they will also play an important role in the acceptance of the vaccine in the general population. Patients turn to health care providers for expert medical advice and care, including vaccine recommendations. It is well established that patients are far more likely to receive an immunization when a provider has recommended it [16–23].

In view of the low vaccine acceptance rate in the general popu- lation and the priority given to vaccination of health care person- nel, we conducted a survey among hospital employees in the weeks prior to imminent COVID-19 vaccine introduction. The pur- pose of the survey was to understand attitudes toward COVID-19 vaccines which will be new to them, their patients, and their fam- ilies. We aimed to obtain a better understanding of how hospital employees, both in clinical and nonclinical positions, perceive the new COVID-19 vaccines and their intention to be vaccinated.

2. Methods

We conducted a confidential, voluntary survey between November 13, 2020 and December 6, 2020 at two large, academic hospitals in Philadelphia, one serving children and the other serv- ing adults (henceforth referred to as hospital A and hospital B, respectively). The survey was distributed to all hospital employees regardless of clinical role using REDCAP, an electronic survey instrument. The survey was announced by management at each hospital 1–2 days before being distributed, and 3–4 reminders were sent out over the course of the survey period.

The survey was developed based on results from other studies related to COVID-19 vaccine acceptance in the general population with inclusion of specific questions related to role in the hospital and exposure to COVID-19. A pilot survey was conducted prior to dissemination at the two hospitals to test for feasibility, length of time to complete the survey, and clarity. The survey took 10– 15 minutes to complete. The survey questions focused on employee plans to receive a COVID-19 vaccine, timing of vaccine receipt once available, reasons for taking or not taking the vaccine, safety and efficacy features of a vaccine that would or would not be acceptable, who should be vaccinated first, history of exposure to COVID-19 at work, at home or elsewhere, and past history of receipt of other vaccines for the employee or their children. Demo- graphic data collected included hospital of employment, age, gen- der, race/ethnicity, education, position and area employed in the hospital, duration of employment, and residential area. Assump- tions that were communicated to the employees when completing the survey included: 1) The vaccine would be at least 50% effective; 2) The vaccine would be authorized under Emergency Use Autho- rization (EUA) by the Food and Drug Administration (FDA) and would be recommended by the ACIP for health care workers; 3) COVID-19 was expected to continue to circulate in the US for the next few months; and 4) There would be no cost to receive the vaccine.

1694

The protocol and survey were reviewed by the Institutional Review Board at each hospital and determined to be exempt from human subjects’ review.

Analysis included summary statistics (frequencies and percent- ages) of employee characteristics (age, gender, race or ethnicity, level of education, home residence type, and hospital position) for the entire responding population (12,034 individuals). For each survey question, the percent of individuals who responded to each possible answer was tabulated, excluding those who did not respond to the question along with 9 subjects who indicated they had participated in a COVID-19 vaccine trial. Intention to receive a COVID-19 vaccine (based on a response of yes, no, or unsure) was further stratified by the employee characteristics noted above as well as timing of vaccine receipt, self-health assessment, employee/child vaccination status, number of COVID-19 expo- sures, risk of exposure, prior COVID-19 testing status, hospital of employment, and years employed (as categorized in Table 3). Dif- ference in rates were determined by Chi square tests with signifi- cance level 0.05. Variables shown to have significantly different rates of intention to receive a COVID-19 vaccine in this univariate analysis were included in multiple logistic regression analyses [24]. Significance level 0.05 was used to determine a variable’s overall significance in the model when controlling for all other variables as well as a parameter’s odds ratio compared to its refer- ence (as shown in Table 4).

3. Results

3.1. Response rate

The survey was sent to 34,865 health care employees at the two hospitals. A total of 12,034 persons (7427 at hospital A and 4607 at hospital B) responded to the survey. The overall response rate was 34.5% (36.8% at hospital A and 31.3% at hospital B).

3.2. Demographics

The demographics of the 12,034 survey respondents are shown in Table 1. The age distribution and racial/ethnicity of the respon- dents at the two hospitals was comparable. There were more females at hospital A who responded to the survey while there were more employees who lived in an urban setting, more staff in clinical positions, and more employees with postgraduate edu- cation who responded to the survey at hospital B.

3.3. Intention to be vaccinated

A total of 11,760 employees (7271 at hospital A and 4489 at hospital B) responded to the survey question about their plans to be vaccinated. Overall, 63.7% of these employees said they planned to receive a COVID-19 vaccine when available under an EUA in the US. The intention to receive a COVID-19 vaccine was 61.6% at hos- pital A and 67.3% at hospital B. Approximately one quarter (26.3%) of employees (27.6% at hospital A and 24.1% at hospital B) said they were unsure if they would take the vaccine, and 10.0% said that they did not plan to receive the vaccine (10.8% at hospital A and 8.7% at hospital B).

3.4. Vaccine characteristics of importance

Vaccine safety and efficacy were the two COVID-19 vaccine characteristics of most importance to the employees (94.4%% and 82.8%, respectively). Only 28.3% of respondents said they would be willing to receive a vaccine if the side effects they would develop included a high fever, muscle aches, chills, and a headache

Table 1 Demographic Characteristics of 12,034 Hospital Employees who Completed the Survey.

Variable Parameter Hospital A (%) Hospital B (%) Combined (%)

Age <40 years 3732 (50.3) 2404 (52.2) 6136 (51.0) 40–64 years 3020 (40.7) 1692 (36.7) 4612 (39.2) 65 or older 224 (3.0) 208 (4.5) 432 (3.6) Unknown/NR 451 (6.1) 303 (6.6) 754 (6.3)

Gender Female 5658 (76.2) 2969 (64.5) 8627 (71.7) Male 1241 (16.7) 1288 (28.0) 2529 (21.0) Other/Unknown/NR 528 (7.1) 350 (7.6) 878 (7.3)

Race/Ethnicity White 5177 (69.7) 3216 (69.8) 8393 (69.7) Black 607 (8.2) 275 (6.0) 882 (7.3) Hispanic or Latino 209 (2.8) 99 (2.2) 308 (2.6) Asian 440 (5.9) 408 (8.9) 848 (7.1) Other/Unknown/NR 994 (13.4) 609 (13.2) 1603 (13.3)

Education Less than Bachelor’s Degree 1108 (14.9) 404 (8.8) 1512 (12.6) Bachelor’s or Master’s Degree 4471 (60.2) 2324 (50.4) 6795 (56.5) Postgraduate Degree 1489 (20.1) 1621 (35.2) 3110 (25.8) Unknown 359 (4.8) 258 (5.6) 617(5.1)

Home Residence Urban 2729 (36.7) 1971 (42.8) 4700 (39.1) Suburban 4153 (55.9) 2297 (49.9) 6450 (53.6) Rural 184 (2.5) 79 (1.7) 263 (2.2) Unknown 361 (4.9) 260 (5.6) 621 (5.2)

Hospital Position Clinical – Direct patient contact 3365 (45.3) 3115 (67.6) 6480 (53.9) Some patient interaction 723 (9.7) 350 (7.6) 1073 (8.9) Nonclinical - No patient interaction 2371 (31.9) 672 (14.6) 3043 (25.3) Other/Unknown 968 (13.0) 470 (10.2) 1438 (11.9)

NR – No response to this question.

Table 2 Reasons Why Employees Would Not Receive a COVID-19 Vaccine Among The Subset who Indicated They Were Unsure or Did Not Plan to be Vaccinated.

Reason Hospital A (N = 2791) Hospital B (N = 1470) Combined (N = 4261)

Concern about side effects 2469 (88.5%) 1326 (90.2%) 3795 (89.1%) Vaccine is too new 2363 (84.7%) 1216 (82.7%) 3579 (84.0%) Don’t know enough about the vaccine 2201 (78.9%) 1117 (76.0%) 3318 (77.9%) It may not work 967 (34.6%) 435 (29.6%) 1402 (32.9%) Concern about getting infected with COVID-19 from the vaccine 753 (27.0%) 331 (22.5%) 1084 (25.4%) I do not like vaccines 132 (4.7%) 70 (4.8%) 202 (4.7%) COVID-19 outbreak is not as serious as some people say it is 73 (2.6%) 47 (3.2%) 120 (2.8%) I do not like needles 56 (2.0%) 22 (1.5%) 78 (1.8%) I won’t have time to get vaccinated 10 (0.4%) 10 (0.7%) 20 (0.5%) None of the above 16 (0.6%) 7 (0.5%) 23 (0.5%) Other (specify)1 247 (8.8%) 128 (8.7%) 375 (8.8%)

Reasons listed were prespecified in the survey. Employees could select more than one reason why they would not receive a COVID-19 vaccine. 1 Other includes pregnant, want to get pregnant, breastfeeding, concern about fertility, concern about long term complications, duration of protection unknown, distrust

government and pharma, want more data, underlying medical condition (autoimmune disorder, cancer, allergies, diabetes), vaccine development rushed, concern about fetal cell use, don’t trust the vaccine, too much conflicting information, no other mRNA vaccine on the market, religious reasons, need to see more data, too much political involvement.

B.J. Kuter, S. Browne, F.M. Momplaisir et al. Vaccine 39 (2021) 1693–1700

after vaccination that resulted in loss of 2 days at work, while 33.2% of employees said they were unsure if they would take a vac- cine with this exact safety profile. Intention to be vaccinated increased with increasing vaccine effectiveness (35.8% willing to receive a vaccine with 50% effectiveness, 61.1% willing to receive a vaccine with 70% effectiveness, and 85.6% willing to receive a vaccine with 90% effectiveness). The number of prior persons vac- cinated was an important characteristic of a COVID-19 vaccine for 32.3% of employees.

3.5. Reasons to be vaccinated/reasons not to be vaccinated

The reasons employees most frequently selected for receiving a COVID-19 vaccine included protection of one’s family (86.7%) and protecting themselves (82.9%). Other reasons for receiving a COVID-19 vaccine included protecting one’s community (68.8%), getting life ‘‘back to normal” (59.4%), and a belief that vaccination was the best measure to prevent becoming seriously ill from COVID-19 (58.3%). A desire to travel again was noted by 38.5% of employees.

1695

Table 2 presents the reasons employees selected for not taking a COVID-19 vaccine among those who indicated they were either not planning or unsure about taking the vaccine. The reasons most frequently selected for not wanting to be vaccinated included concern about side effects (89.1%), the vaccine being too new (84.0%), and not knowing enough about the vaccine (77.9%). Other reasons included concerns about the vaccine not working (32.9%) and getting infected with COVID-19 from the vaccine (25.4%).

3.6. Timing of vaccination

Among the 7158 persons who said they planned to be vacci- nated and answered the question about timing of vaccination, 5661 (79.1%) said they would receive the vaccine as soon as it was recommended and made available to them, 1367 (19.1%) said they would take the vaccine after it had been administered to others for 3–6 months, and 130 (1.8%) said they would take the vaccine after it had been administered to others for 12 months.

Table 3 Characteristics of Hospital Employees Planning to Receive a COVID-19 Vaccine (Hospitals A & B Combined)1.

Category Variable Parameter Total Respondents2

N (%) Planning To Receive A COVID-19 Vaccine3

p-value

Demographics Age <40 years 6131 3835 (62.6) <0.0001 40–64 years 4708 3073 (65.3) 65 or older 432 376 (87.0)

Gender Male 2525 2064 (81.7) <0.0001 Female 8622 5181 (60.1) Other/Prefer Not to Answer

253 73 (28.9)

Race/Ethnicity White 8388 5833 (69.5) <0.0001 Black 882 262 (29.7) Hispanic or Latino 307 167 (54.4) Asian 845 626 (74.1) Multiple/Other 449 264 (58.8)

Education Less than Bachelor’s Degree

1511 618 (40.9) <0.0001

Bachelor’s or Master’s Degree

6792 4120 (60.7)

Postgraduate Degree 3105 2583 (83.2) Area of Residence Urban 4696 3163 (67.4) <0.0001

Suburban 6445 4037 (62.6) Rural 263 121 (46.0)

Work Location Hospital A 7271 4480 (61.6) <0.0001 Hospital B 4489 3019 (67.3)

Years Employed at Hospital <1 year 984 670 (68.1) 0.0041 1–4 years 3682 2304 (62.6) 5 or more years 6733 4343 (64.5)

Health of Individual Self-reported health status Excellent 3378 2442 (72.3) <0.0001 Good or Very Good 7753 4729 (61.0) Fair or Poor 393 208 (52.9)

Vaccination History Employee Up-to-date on most or all vaccines

11,193 7220 (64.5) <0.0001

Up-to-date on some vaccines

180 99 (55.0)

Unsure if up-to-date 89 38 (42.7) Not up-to-date 62 22 (35.5)

Employee’s Children4 Up-to-date on most or all vaccines

6099 3883 (63.7) <0.0001

Up-to-date on some vaccines

110 63 (57.3)

Unsure if up-to-date 108 65 (60.2) Not up-to-date 50 13 (26.0)

Level of Patient Care Position in the Hospital Clinical - direct patient contact5

6473 4270 (66.0) <0.00018

Some patient interaction6 1073 536 (50.0) Nonclinical - no patient interaction7

3041 1995 (65.6)

COVID Exposures & Testing

Area of Employment in the Hospital High Exposure to COVID- 19

3042 2019 (66.4) 0.2642

Moderate Exposure to COVID-19

4883 3156 (64.6)

Low Exposure to COVID- 19

2594 1705 (65.7)

Confirmed COVID-19 exposures at work, home, elsewhere9

0 4142 2687 (64.9) 0.7962 1–4 3047 1954 (64.1) �5 2528 1627 (64.4)

Previous COVID-19 test Yes 4290 2975 (69.4) <0.0001 No 7056 4317 (61.2) Unsure 234 113 (48.3)

p value indicates significant difference among the parameters for each variable and were derived from tests of multiple proportions. 1 Excludes individuals who participated in a COVID-19 vaccine clinical trial. 2 Excludes individuals who did not respond to whether they plan to receive a COVID-19 vaccine. 3 Answered yes to survey question asking whether they planned to receive a COVID-19 vaccine. 4 Limited to those with children in the household. 5 Includes nursing staff, EMT, medical assistant, paramedic, phlebotomist, NP/MD/DO/PA, respiratory therapist, PT/OT/speech therapist. 6 Includes dietician/nutritionist, environmental services, security, radiology technician, visiting nurse, child life services, patient service representative, social worker, unit

clerk, clergy. 7 Includes administrative, management staff, clinical laboratory personnel, IT support, maintenance, dietary staff, pharmacist, research personnel, volunteer. 8 p = 0.7452 when comparing those with direct patient contact to those with no patient interaction. 9 Excludes persons who were unsure of their number of exposures. The rate of persons planning to be vaccinated in this category was 61.0% (1137/1864).

B.J. Kuter, S. Browne, F.M. Momplaisir et al. Vaccine 39 (2021) 1693–1700

1696

Table 4 Multiple Logistic Regression for Intention to Receive a COVID-19 Vaccine (Yes vs. No/Unsure) Across Those Variables Showing Differences in Univariate Analysis (Table 3).

Category Variable Parameter OR (95% CI) P-Value

Demographics Age Group (years) <40 Reference <0.0001 40–64 1.40 (1.26, 1.56) �65 3.50 (2.50, 4.90)

Gender Female Reference <0.0001 Male 2.41 (2.12, 2.75) Other/Prefer Not To Answer 0.73 (0.42, 1.27)

Race/Ethnicity White Reference <0.0001 Black 0.23 (0.19, 0.27) Hispanic or Latino 0.51 (0.39, 0.67) Asian 0.87 (0.73, 1.04) Multiple/Other 0.58 (0.47, 0.73)

Education (Less than Bachelor’s Degree) Less than Bachelor’s Degree Reference <0.0001 Bachelor’s or Master’s Degree 1.84 (1.59, 2.13) Postgraduate Degree 4.59 (3.83, 5.50)

Area of Residence Urban Reference <0.0001 Suburban 0.71 (0.65, 0.79) Rural 0.41 (0.30, 0.54)

Hospital Hospital A Reference 0.7282 Hospital B 0.98 (0.89, 1.08)

Years Employed at Hospital <1 Year Reference 0.2674 1 – 4 Years 0.87 (0.73, 1.03) �5 Years 0.89 (0.74, 1.06)

Health of Individual Self-Reported Health Status Excellent Reference 0.0003 Good – Very Good 0.81 (0.73, 0.90) Poor - Fair 0.73 (0.56, 0.95)

Vaccination History Employee Up-to date on most or all vaccines Reference 0.0023 Up-to-date on some vaccines 0.78 (0.54, 1.13) Not up-to-date 0.36 (0.18, 0.71) Unsure 0.56 (0.32, 0.96)

Level of Patient Care Position in the Hospital Clinical – Direct Contact Reference <0.0001 Some Patient Interaction 1.12 (0.96, 1.31) Non-Clinical – No Patient Interaction 1.44 (1.29, 1.61)

COVID-19 Testing Prior COVID-19 Test Yes Reference <0.0001 No 0.78 (0.71, 0.86) Unsure 0.69 (0.50, 0.95)

The regression analysis was performed on 10,067 individuals who answered the question about their intention to be vaccinated as well as all included variables. Due to the limited number of responses, the category ‘‘Prefer Not to Answer” was excluded from both the race/ethnicity and age variables and the category ‘‘Other” was excluded from the level of patient care variable. Parameters with a significant odds ratio compared to the reference are in bold.

B.J. Kuter, S. Browne, F.M. Momplaisir et al. Vaccine 39 (2021) 1693–1700

3.7. Intention to be vaccinated based on employee characteristics

The difference in the intention of employees to be vaccinated was assessed based on their demographics, hospital of employ- ment, self-reported health status, vaccination history (their own and their children’s), level of patient care, level of exposure to COVID-19, and history of COVID-19 testing. A summary of the results and their corresponding statistical significance is shown in Table 3.

3.7.1. Demographic characteristics There was a significant difference in intention to be vaccinated

by hospital of employment (61.6% at hospital A and 67.3% at hos- pital B) and gender (81.7% of males and 60.1% of females). A higher proportion of older compared with younger employees reported they planned to be vaccinated (87.0% for persons �65 year of age versus 65.3% in 40–64 year olds and 62.6% in those <40 years of age). Those employed <1 year at the hospital were more likely planning to be vaccinated than those employed 5 or more years (68.1% and 64.5%, respectively). A higher proportion of persons with a postgraduate degree were planning on being vaccinated than persons with a bachelor’s or master’s degree or those with less than a bachelor’s degree (83.2%, 60.7%, and 40.9%, respec- tively). Persons reporting that they lived in urban or suburban areas indicated they were more likely to be vaccinated than those living in rural areas (64.6% vs 46.0%).

1697

Significant differences in vaccine acceptance also were noted by race/ethnicity. The reported intention to receive a COVID-19 vac- cine was 74.1% in Asians, 69.5% in Whites, 54.4% in Hispanics, 29.7% in Blacks, and 58.8% in multiple/other races.

3.7.2. Personal health status/vaccination history Those who planned to be vaccinated were more likely to report

being in excellent health. The intention to be vaccinated was 72.3% among employees who said their health was excellent versus 52.9% among those who said their health was poor or fair.

History of vaccination among the employees and their children was assessed. Employees who reported that they were up-to-date on most or all routinely recommended vaccines for their age were more likely planning to be vaccinated compared with those employees who reported that they were up-to-date on some or no vaccines (64.5%, 55.0%, and 35.5%, respectively). Employees who intended to be vaccinated were also more likely to report hav- ing children who were up-to-date on most or all routinely recom- mended vaccines for their age compared to those who reported their children were up-to-date on some or no vaccines (63.7%, 57.3%, and 26.0%, respectively).

3.7.3. Exposure to COVID-19 Level of exposure to COVID-19 was assessed using three proxy

measures – role in the hospital, area of employment within the hospital, and number of confirmed COVID-19 exposures at work,

B.J. Kuter, S. Browne, F.M. Momplaisir et al. Vaccine 39 (2021) 1693–1700

home, and/or elsewhere. First, clinical roles involving direct patient care (including, but not limited to physicians, nurses, paramedics, phlebotomists, and emergency medical technicians) were com- pared to those with some patient interaction (such as dieticians, social workers, and environmental services) and nonclinical roles with no direct patient interaction (such as pharmacists, research staff, or administrative staff). Vaccine acceptance was similar for those in hospital roles with direct patient interaction and those in nonclinical roles with no patient interaction (66.0% and 65.6%, respectively), but declined significantly for those with some patient interactions (50.0%). Second, the area of employment within the hospital was assessed with those having a high level of exposure to COVID-19 (including persons working in a COVID- 19 unit, emergency room [ER], or intensive care unit [ICU]) com- pared with persons with a moderate or low level of exposure to COVID-19 in their daily work. The level of exposure to COVID-19 based on area of employment in the hospital played no role in intention to be vaccinated (66.4% of those with high level of expo- sure, 64.6% with moderate exposure, and 65.7% with low expo- sure). Third, there were no differences in the proportion of respondents intending to be vaccinated by number of reported exposures to persons with COVID-19 at work, home, or elsewhere (64.4% for those who reported �5 exposures, 64.1% for those reporting 1–4 exposures, and 64.9% for those who reported no exposures). A lower proportion (61.0%) of those who were unsure of their exposures planned to be vaccinated.

Employees were also asked if they had ever been tested to see if they had an ongoing COVID-19 infection. Those who had been tested for COVID-19 were more likely planning on being vacci- nated compared to those who had never been tested (69.4% vs 61.2%, respectively).

3.8. Multiple logistic regression analysis - intention to be vaccinated

Table 4 presents the results of the multiple logistic regression analysis that includes the 11 variables that were found to be signif- icantly associated with employee intention to be vaccinated in uni- variate analysis (as shown in Table 3). Several demographic characteristics (race/ethnicity, gender, age, education, and area of residence) as well as self-health assessment, vaccination history, level of patient care, and prior COVID-19 testing remained inde- pendently associated with an employee’s intention to be vacci- nated when controlling for all other variables. The likelihood of intending to be vaccinated was lower among Blacks (OR: 0.23, 95% CI 0.19, 0.27), Hispanics (OR: 0.51, 95% CI 0.39, 0.67), and those reporting multiple/other races (OR: 0.58, 95% CI 0.47, 0.73) com- pared to Whites. The likelihood of intending to be vaccinated was twice as high among males compared to females (OR: 2.41, 95% CI 2.12, 2.75). Adults � 65 years of age were 3.5 times more likely planning to be vaccinated compared with those <40 years of age (OR: 3.50, 95% CI 2.50, 4.90). Employees with a postgraduate degree were > 4 times more likely planning to be vaccinated than persons with less than a bachelor’s degree (OR: 4.59, 95% CI 3.83, 5.50). The likelihood of intending to be vaccinated was lower among persons in poor or fair health compared with those in excel- lent health (OR: 0.73, 95% CI 0.56, 0.95). The likelihood of intending to be vaccinated also was lower among those who were not up-to- date on their vaccinations compared with those who were up-to- date on most or all vaccinations (OR: 0.36, 95% CI 0.18, 0.71). Employees who had no direct contact with patients were 1.4 times more likely planning to be vaccinated compared with those with direct patient care (OR: 1.44, 95% CI 1.29, 1.61). Although the uni- variate analysis (Table 3) found a difference in those planning to be vaccinated by hospital of employment and years of employment, these two variables were no longer significant in the multiple regression analysis.

1698

4. Discussion

In this study, we aimed to understand how hospital employees view a COVID-19 vaccine, especially in light of the rapidity of vac- cine development, the ongoing pandemic, and our evolving knowl- edge about the disease. To the best of our knowledge, this survey of more than 12,000 employees at two hospitals in Philadelphia is the largest study conducted to assess intent to receive a COVID-19 vac- cine in healthcare workers to date. Our results demonstrate that while the majority of respondents intend to receive a COVID-19 vaccine, one third are unsure or do not intend to be vaccinated despite their role as hospital employees, including many frontline care providers.

The overall rate of acceptance of a COVID-19 vaccine in our sur- vey was 64%, similar to the results of earlier studies in healthcare personnel. Vaccine acceptance rates were assessed among 829 healthcare staff in Israel, 609 healthcare workers in Los Angeles, and 168 medical students in Southeast Michigan [25–27]. These surveys showed that willingness among health care providers and medical students to receive a COVID-19 vaccine varied widely (61–78%, 32.3%, and 77%, respectively).

In 2019, the World Health Organization identified vaccine hesitancy (defined as the reluctance or refusal to vaccinate despite the availability of vaccines) as one of the top 10 threats to global health [28]. More recently, vaccine hesitancy has been described as one of the biggest challenges in the fight against COVID-19 [25]. The results of this survey suggest that hospital employees share some of the same concerns about COVID-19 vaccines as the general public including their newness and a gen- eral lack of knowledge about the vaccines, particularly their safety profiles. The rate (64%) of intention to be vaccinated in this population of healthcare employees was fairly similar to the range of 42–75% reported in other studies in the general popula- tion [7–13]. This suggests that a substantial number of healthcare employees, like the general population, may have reservations about a new vaccine. Healthcare professionals, as the first persons to be vaccinated, need to be viewed as vaccine consumers first and then as healthcare professionals and vaccine recommenders. Health care providers will not only need to vaccinate their patients, but vaccinate them with confidence based on personal experience and full knowledge of the risks and benefits of the available vaccines.

We expected that hospital employees with direct patient con- tact, those working in an area with high exposure to COVID-19 (such as the COVID-19 unit, ER, or ICU), and/or those reporting more confirmed exposures to COVID-19 patients (at work, home, or elsewhere) would be more interested in vaccination in view of their increased exposure to the SARS-CoV-2 virus. While 66% of employees engaged in clinical roles with direct patient contact expressed an intention to be vaccinated, the rate was equally high (65.6%) in employees with nonclinical responsibilities and no patient contact. However, when controlling for other employee characteristics, those with no patient contact were significantly (OR: 1.44, 95% CI 1.29, 1.61) more likely to be planning to be vac- cinated compared with those with direct patient contact. This sug- gests that initial efforts to increase vaccination rates in these two academic hospitals may require more focus on health care person- nel with clinical facing roles despite their higher probability of exposure to SARS-CoV-2. An employee’s role in the hospital was significantly associated with characteristics such as race/ethnicity and education level (Chi square p values < 0.00001), These associ- ations warrant further examination as they may result in modifica- tion of our measured associations between employee role and intention to be vaccinated.

We did not expect to find that intention to be vaccinated would not differ based on the employee’s level of exposure to COVID-19

B.J. Kuter, S. Browne, F.M. Momplaisir et al. Vaccine 39 (2021) 1693–1700

in their work area or number of reported exposures to COVID-19 patients. We also expected that employees working in a hospital treating a significant number of adults with COVID-19 would be more interested in vaccination than those working in a children’s hospital with a lower COVID-19 case load, and this is supported by our results. The finding that hospital of employment was not significant in the multiple logistic regression analysis suggests that both the employee demographics and characteristics of the employee’s work dictate the intention to be vaccinated and not necessarily the location of employment.

An earlier study in Israel reported that healthcare staff involved in the care of COVID-19 positive patients were more likely to report interest in vaccination, while our study showed little difference in intent to vaccinate among employees working in a COVID-19 unit, the ER or ICU with a high level of exposure to COVID-19 patients com- pared with those with a low level of exposure to COVID-19 patients [25]. Furthermore, our results suggested no difference in the per- ceived risk of COVID-19 versus benefit of vaccination between staff with direct patient care and those with no patient interactions or those who reported a higher compared to a lower number of expo- sures to persons with COVID-19. One possible explanation for these findings is that staff with no direct patient interactions or those with a low risk of exposure to the SARS-CoV-2 virus in both hospitals, although not in direct contact with COVID-19 patients, consider themselves to be at equally high risk of COVID-19 simply because theyworkinhospitals ina large city with a high COVID-19 attack rate. Another possibility is that persons in nonclinical roles may live in neighborhoodswhere communityexposureismorelikely(i.e.crowd- ing, multigenerational homes, or fewer persons working from home). Nonclinical staff could also see themselves as high risk because they may not have access to the same level of personal protective equip- ment (PPE) as their clinical colleagues, and therefore, could feel less protected against the SARS-CoV-2 virus. Some healthcare workers who have not been exposedorpreviously infected may feel morecon- fident in and comfortable with PPE and other preventive measures other than a new vaccine. There may also be other factors contribut- ing to risk perception and acceptance of a COVID-19 vaccine that we did not measure in this survey.

Our study showed that of the hospital employees who planned to be vaccinated, nearly four out of five (79%) intended to do so as soon as the vaccine was made available to them. While the remain- ing employees (21%) planned to wait 3–12 months before being vaccinated, this was considerably lower than the rate reported in the survey of healthcare workers in Los Angeles (conducted almost two months before our survey) in which 66.5% intended to delay vaccination [26]. The rapid desire to be vaccinated in our study only a few months later may be the result of the availability of more clinical data on the vaccines proposed for EUA, more data on the disease and its transmission, and/or the continued surge of COVID-19 across the US.

Intention to receive a COVID-19 vaccine was lower in Black and Hispanic employees in our survey compared to Asians and Whites. These results were not unexpected in view of the lower COVID-19 vaccine acceptance rates reported in Blacks in the general adult population and lower rates of vaccine acceptance for influenza vac- cine among Blacks and Hispanics as reported by the CDC in the 2018–19 influenza season [8,9,29]. These results are particularly concerning considering that Blacks and Hispanics/Latinos are dis- proportionately affected by COVID-19 both in terms of infection rates and mortality [30]. These results highlight the need for edu- cational efforts targeted at addressing prevalent concerns about COVID-19 vaccines among Blacks and Hispanics and using trusted sources to deliver these messages.

We found that the intention to be vaccinated was significantly higher among males than females. A study in healthcare staff in Israel reported a similar finding as did a study of acceptance rates

1699

in the general US population [25]. A systematic review and meta- analysis of COVID-19 clinical outcomes found that males consti- tuted a significantly higher proportion of those who had adverse clinical outcomes and died from COVID-19 [31]. The increased morbidity and mortality associated with COVID-19 in males may explain why men in our survey were more likely to accept a COVID-19 vaccine.

Previous vaccine history for either the hospital employee or their children was found to be a good indicator of whether an employee was planning to receive the COVID-19 vaccine. This find- ing suggests that persons who generally believe in the value of vac- cines and/or follow the routine recommendations for vaccination are planning on being vaccinated. Our results are supported by the study in Israel in which the most significant predictor for acceptance of a potential COVID-19 vaccine among healthcare staff was current influenza vaccination [25].

Our survey showed that the intention to be vaccinated was lower among persons whose self-assessment of their health was poor-fair or good-very good compared to those reporting excellent health. These results suggest that additional efforts are needed to better educate employees about their individual risk for COVID- 19, especially among those in fair or poor health. It will also be important to assess whether employees believe that their underly- ing health condition(s) may increase the risk of adverse events after vaccination and to provide appropriate vaccine safety information.

We were encouraged to see that intention to be vaccinated directly correlated with vaccine efficacy. Now that we know that the efficacy of the two vaccines approved for use in the US under an EUA is 94–95%, we are optimistic that vaccine acceptance may be higher than reported here [32,33].

According to the WHO, ‘‘health workers, especially those in communities, remain the most trusted advisor and influencer of vaccination decisions, and they must be supported to provide trusted, credible information on vaccines" [28]. The recommenda- tion of a health care provider is the single most important predictor of vaccination [16–23]. Therefore, vaccine acceptance among health care professionals will be important in establishing confi- dence in the general public in these new vaccines. Sharing their own vaccination experience is an excellent way for health care pro- viders to encourage their patients to receive a vaccine.

This study has several limitations. With a response rate of ~35%, the results may not be fully representative of the population at the two hospitals and may not be easily extrapolated to other hospital settings. We had no ability to compare the demographics of the survey respondents to the nonrespondents. However, our response rate was within the range (34–56%) of other surveys conducted on this topic [26,27]. In addition, acceptance of COVID-19 vaccines may have changed since this survey was conducted, as more clin- ical data on vaccine safety and efficacy became available in Decem- ber 2020, when two COVID-19 vaccines were approved for use in the US under an EUA [32,33]. We also did not explore other factors that could explain some of our results including access to PPE and healthcare-related attitudes, beliefs, and risk perception in this population. Lastly, while our survey reports the intention of healthcare employees to be vaccinated, this may not translate into actual vaccine acceptance.

The strengths of the survey are several fold. To our knowledge, the sample size (more than 12,000 hospital employees) is the lar- gest of any survey conducted in the United States on this topic to date. Inclusion of two hospitals with different patient populations allowed for comparison of responses in different settings. Inclusion of both clinical and nonclinical staff allowed for comparisons based on likely exposure to the SARS-CoV-2 virus.

The prospect for control of the ongoing COVID-19 pandemic can best be addressed through vaccination, and healthcare employees

B.J. Kuter, S. Browne, F.M. Momplaisir et al. Vaccine 39 (2021) 1693–1700

will be a key priority group for COVID-19 vaccination to ensure that we can maintain a healthy and robust healthcare workforce. Healthcare employees may also play an important role in increas- ing vaccine acceptance in the community through endorsement of COVID-19 vaccination and the provision of education about COVID-19 vaccine to others. However, even among a group at high risk of exposure, vaccine hesitancy is an important barrier. Our results highlight prevalent concerns that can be addressed as well as beliefs that can be leveraged through educational initiatives about the safety, efficacy, and value of COVID-19 vaccination. In particular, efforts also should be focused on promoting vaccine acceptance across all racial and ethnic groups through tailored strategies that target specific concerns and questions among those who are most hesitant. Only then will we achieve optimal protec- tion for healthcare workers who are critical in this pandemic response, as well as ensure that health care employees can serve as role models for their patients, families and friends and effec- tively communicate about the value of COVID-19 vaccination.

Declaration of Competing Interest

The authors declare that they have no known competing finan- cial interests or personal relationships that could have appeared to influence the work reported in this paper.

Acknowledgements

We would like to thank the employees at both hospitals who took the time to complete this survey, the management and inter- nal communications teams at each hospital for their support of this survey, and the health care personnel who helped with the pilot of the survey.

References

[1] Centers for Disease Control and Prevention. CDC COVID-19 data tracker. Accessed 1/11/21. https://www.cdc.gov/coronavirus/2019-ncov/cases- updates/cases-in-us.html.

[2] Woolf SH, Chapman DA, Lee JH. COVID-19 as the leading cause of death in the United States. JAMA Published online December 17, 2020. https://doi:10. 1001/jama.2020.24865.

[3] Randolph HE, Barreiro LB. Herd immunity: understanding COVID-19. Immunity 2020;52(3):737–41. https://doi.org/10.1016/j.immuni.2020.04.012.

[4] Salje H, Tran Kiem C, Lefrancq N, Courtejoie N, Bosetti P, Paireau J. Estimating the burden of SARS-CoV-2 in France. Science 2020;369:208–11.

[5] Kwok KO, Lai F, Wei WI, Wong SYS, Tang JWT. Herd immunity - estimating the level required to halt the COVID-19 epidemics in affected countries. J Infect. 2020;80(6):e32–3.

[6] McNeil DJ. How much herd immunity is enough? NY Times Dec 24, 2020. [7] Neergaard L, Fingerhut H. AP-NORC poll: Half of Americans would get a COVID-

19 vaccine. Associated Press NORC; 2020. https:// apnews.com/dacdc8bc428dd4df6511bfa259cfec44.

[8] Reiter PL, Pennell ML, Kath ML. Acceptability of a COVID-19 vaccine among adults in the United States: how many people would get vaccinated?. Vaccine 2020;38:6500–7.

[9] Malik AA, McFadden SAM, Ekharake J, Omer SB. Determinants of COVID-19 Vaccine acceptance in the US. EClinical Med 2020;20(100495). https://doi.org/ 10.1016/j.eclinm.2020.100495.

[10] Lazarus JV, Ratzan SC, Palayew A, Gostin LO, Larson HJ, Rabin K, et al. A global survey of potential acceptance of a COVID-19 vaccine. Nat Med. 2020. https:// doi.org/10.1038/s41591-020-1124-9.

[11] Poll: Most Americans worry political pressure will lead to premature approval of a COVID-19 vaccine; half say they would not get a free vaccine approved before election day. September 20, 2020. https://www.kff.org/coronavirus-

1700

covid-19/press-release/poll-most-americans-worry-political-pressure-will- lead-to-premature-approval-of-a-covid-19-vaccine-half-say-they-would-not- get-a-free-vaccine-approved-before-election-day/.

[12] COVID Collaborative. Americans’ views on a COVID-19 vaccine. Sept 2020. https://static1.squarespace.com/static/5f85f5a156091e113f96e4d3/t/ 5fa58c2fa5528f729b2690ba/1604684849352/Vaccine+Poll_ ExecutiveSummary_FINAL.pdf.

[13] Hamel L. Kirzinger A, Munana C, Brodie M. KFF COVID-19 Vaccine Monitor: December 2020. https://www.kff.org/coronavirus-covid-19/report/kff-covid- 19-vaccine-monitor-december-2020/.

[14] Cohen J. The line is forming for a COVID-19 vaccine. Who should be at the front?. Science 2020.

[15] Dooling K, Marin M, Wallace M, McClung N, Chamberland M, Lee G, et al. The advisory committee on immunization practices’ updated interim recommendation for allocation of COVID-19 vaccine — United States, December 2020. Morb Mortal Wkly Rep 2021;69:1657–60. , https://doi.org/ 10.15585/mmwr.mm695152e2.

[16] Gargano LM, Herbert NL, Painter JE, Sale JM, Morfaw C, Rask K, et al. Impact of a physician recommendation and parental immunization attitudes on receipt or intention to receive adolescent vaccines. Hum Vaccin Immunother. 2013;9 (12):2627–33.

[17] Brewer NT, Gottlieb SL, Reiter PL, McRee AL, Liddon N, Markowitz L, et al. Longitudinal predictors of human papillomavirus vaccine initiation among adolescent girls in a high-risk geographic area. Sex Transm Dis. 2011;38:197–204.

[18] Guerry SL, De Rosa CJ, Markowitz LE, Walker S, Liddon N, Kerndt PR, et al. Human papillomavirus vaccine initiation among adolescent girls in high-risk communities. Vaccine. 2011;29:2235–41.

[19] Winston CA, Wortley PM, Lees KA. Factors associated with vaccination of Medicare beneficiaries in five U.S. communities: Results from the racial and ethnic adult disparities in immunization initiative survey, 2003. J Am Geriatr Soc. 2006;54:303–10.

[20] Rosenthal SL, Weiss TW, Zimet GD, Ma L, Good MB, Vichnin MD. Predictors of HPV vaccine uptake among women aged 19–26: importance of a physician’s recommendation. Vaccine 2011;29:890–5.

[21] Hofstetter AM, Robinson JD, Lepere K, Cunningham M, Etsekson N, Opel DJ. Clinician-parent discussions about influenza vaccination of children and their association with vaccine acceptance. Vaccine 2017;35(20):2709–15. https:// doi.org/10.1016/j.vaccine.2017.03.077.

[22] Larson HJ, Clarke RM, Jarrett C, Eckersberger E, Levine Z, Schultz WS, et al. Measuring trust in vaccination: a systematic review. Hum Vaccines Immuno 2018;14(7):1599–609. https://doi.org/10.1080/21645515.2018.1459252.

[23] Freimuth VS, Jamison AM, An J, Hancock GR, Quinn SC. Determinants of trust in the flu vaccine for African Americans and Whites. Soc Sci Med. 2017;1 (193):70–9. https://doi.org/10.1016/j.socscimed.2017.10.001.

[24] Nick TG, Campbell KM. Logistic regression. In: Ambrosius WT, editor. Topics in Biostatistics. Methods in Molecular BiologyTM, vol 404. Humana Press. https://doi.org/10.1007/978-1-59745-530-5_14.

[25] Dror AA, Eisenback N, Talber S, Morozov NG, Mizrachi M, Zigron A, et al. Vaccine hesitancy: the next challenge in the fight against COVID-19. Eur J Epi 2020;35:775–9.

[26] Gadoth A, Halbrook M, Martin-Blais R, Gray A, Tobin NH, Ferbas KG et al. Assessment of COVID-19 vaccine acceptance among healthcare workers in Los Angeles. MedRxiv https://doi.org/10.1101/2020.11.18.20234468.

[27] Lucia VC, Kelekar A, Afonso N. COVID-19 vaccine hesitancy among medical students. J Pub Health fdaa230, https://doi.org/10.1093/pubmed/fdaa230.

[28] World Health Organization. Ten threats to global health in 2019. 10 January 2019. https://www.who.int/news-room/spotlight/ten-threats-to-global- health-in-2019.

[29] Centers for Disease Control and Prevention, Flu Vaccination Coverage, United States 2018–2019 Season. https://www.cdc.gov/flu/fluvaxview/coverage- 1819estimateshtm.

[30] Owen WF, Carmona R, Pomeroy C. Failing another national stress test on health disparities. JAMA 2020;323(10):1905–6.

[31] Galbadate T, Peterson B, Awada J, Buck AS, Ramizez DA, Wilson J, et al. Systematic review and meta-analysis of sex-specific COVID-19 clinical outcomes Front Med. 2020. https://doi.org/10.3389/fmed.2020.00348.

[32] Polack FP, Thomas SJ, Kitchin N, Absalon J, Gurtman A, Lockhart S, et al. Safety and efficacy of the BNT162b2 mRNA Covid-19 vaccine. New Engl J Med 2020;383:2603–15. https://doi.org/10.1056/NEJM0a2034577.

[33] Baden LR, El Sahly HM, Essink B, Kotloff K, Frey S, Novak R, et al. Efficacy and safety of the mRNA-1273 SARS-CoV-2 vaccine. New Engl J Med 2020. https:// doi.org/10.1056/NEJMoa2035389.