Reasons for and Perceptions about the COVID-19 Vaccination among Dental Undergraduate Students in India

A Questionnaire-based Study

Abstract

Background: 

COVID-19 is an infectious disease caused by the newly discovered coronavirus (severe acute respiratory syndrome coronavirus 2). Efforts are being taken to control the spread of this disease, of which the development of vaccine against COVID-19 is a major landmark. However, doubts on the efficacy of the vaccine do exist among the population.

Aim: 

The aim of this study was to know the reasons for, perceptions of, and knowledge about the COVID-19 vaccination among dental undergraduate students.

Materials and Methods: 

The study was conducted using an online survey and distributed among undergraduate dental students throughout India. An online validated and piloted questionnaire was sent to dental colleges throughout India using the Google Forms platform. The responses were downloaded in MS Excel 2019. Descriptive analysis (SPSS IBM, USA version 25) was used.

Results: 

The response rate of the study was 32%. Preventing the spread of COVID-19 infection was the primary reason for getting vaccinated and nonavailability of long-term safety data was the main reason for not getting vaccinated. Majority of the students agree that wearing masks, frequent handwashing, hand sanitation, and social distancing postvaccination are necessary.

Conclusion: 

The study points to a rational wait-and-watch strategy adopted by majority of vaccine-hesitant dental students, though the flaws in reasons for getting vaccinated were observed in the present study. These flaws point to the need for a genuine, consolidated, up-to-date, unified easily available, and succinct source of information on all aspects of the present COVID-19 pandemic.

INTRODUCTION

From a pneumonia in a cluster of patients linked to the seafood market of Wuhan, China, in December 2019[¹] to cause more than 120 million confirmed cases and with more than 2.5 lakh deaths as of March 28, 2021,[²] the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has come a long way. It has virtually bought the entire world to a standstill with far-reaching impact on the physical, mental, and emotional well-being of a vast majority of the world population.[³] Its economic and financial implications on countries, businesses, and individuals have been equally disastrous with many small businesses closing and scores of people losing their livelihoods.[⁴]

India has been the second worst-affected country by the number of cases behind the United States with more than 16 million confirmed cases and more than 18 lakhs deaths.[⁵] Maharashtra is the worst-affected state in the country with nearly 42.3 lakh cases and nearly 64 thousand deaths.[⁶]

The development of a vaccine against the COVID-19 disease is a global effort with several countries and many large and small corporations collaborating to develop effective vaccines. Normally, the development of vaccine takes decades and not months. The other alternative of most population suffering from waves of COVID-19 infection before herd immunity is achieved, which is nonviable in terms of mortality and economic losses, and this has been a major driving force in the rapid development of effective vaccines against the novel coronavirus. The pace of vaccine development can be gauged by the fact that it took 66 days from the publication of the genetic sequencing of the SARS-CoV-2 on January 11, 2020, to the first vaccine entering human clinical trials on March 16, 2020.[⁷] As of March 25, 2021, 13 vaccines had achieved regulatory approval and 58 vaccine candidates are at various stages of development from preclinical phase to phase 3 human clinical trials.[⁸]

India started its vaccination drive on January 16, 2021, with the first phase in which health-care workers (HCWs) and other frontline workers (FLWs) were being vaccinated.[⁹] The second phase started on March 1, 2021, which included general population over 60 years of age and people over 45 years with certain comorbidities.[¹⁰] As of March 28, 2021, over 60 million vaccine doses have been administered in India.[¹¹]

Vaccine hesitation is a phenomenon which refers to refusal or delay in the acceptance of vaccine despite the availability of vaccine services.[¹²] Vaccine hesitancy as a phenomenon has been on a rise, especially in the European Union over the last decade.[¹³] Conventionally, three factors are responsible for vaccine hesitancy, namely confidence (in the vaccine and the companies producing them), complacency (about the perceived disease threat being low), and convenience (easy accessibility, affordability, and health literacy).[¹⁴] COVID-19 vaccine has quite a few unique factors which may play an important role in vaccine hesitancy, such as the short time of its development, the geopolitics involved in vaccine research, development and its distribution, lack of long-term clinical efficacy, and safety data among others.

Dentists and dental students work in the facial region and are routinely exposed to saliva and blood which pose a significant threat of spread of COVID-19 to dental health-care professionals.[¹⁵] This makes the vaccination against COVID-19 even more important for this class of HCWs. The primary objective of this study was to investigate the knowledge, perceptions, and attitudes of undergraduate dental students toward vaccinations against the coronavirus. The secondary objective was to determine postvaccination symptoms in the vaccinated students.

MATERIALS AND METHODS

A validated questionnaire was used for the study and distributed through Google Forms^®. A pilot study was done on ten randomly selected students, the results of which were not included in the final study. Participation in the study was voluntary and anonymous. The institutional ethical committee permission was taken for the same. The link to the Google Forms questionnaire was sent to around 50 dental institutes across India through an Email to the deans/principals of the institutes and was also shared through social media with undergraduate dental students (individually and in dental groups). The link was live from April 5, 2021, to April 30, 2021. The survey consisted of 13 closed-ended questions comprising participant characteristics (one item), COVID-19 vaccination status (one item), reasons for the same (two items), source of information about vaccination (two items), postvaccination symptoms within 48 h (one item), and vaccination knowledge (five items). Twelve hundred and fifty-six (1261) responses were received during the above-mentioned period. After the abovementioned date, the responses were downloaded in Excel format and were analyzed using descriptive statistics.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards with approval sanction project no.: EC-153/Cons/99ND/2021.

Informed consent

Informed consent was obtained from all individual participants included in the study.

Statistics

Descriptive Analysis (SPSS IBM, USA version 25) was used to tabulate the results using MS Excel 2019.

RESULTS

Out of 3940 undergraduate dental students in 50 dental colleges across India, 1261 undergraduate dental students filled the survey with a response rate of 32% (n = 1261).

Of the 1261 students, 962 students have been vaccinated (76.28%) and the remaining 299 were not vaccinated (23.71%). Preventing the spread of COVID-19 infection was the primary reason for getting vaccinated (53.64%) followed by their own protection against the virus (37.11%). Nonavailability of long-term safety data (66.22%) and wanting to see how others react to the vaccine (15.72%) were the main reasons for not getting vaccinated. Of the 299 students who had not been vaccinated, 170 (57%) students were positive about getting vaccinated in the next 6–12 months, while 40 (13.37%) did not plan to get vaccinated and 89 (29.76%) were not sure about getting vaccinated (low intention to get vaccinated).

A higher proportion of students (72.30%) had done some inquiries before deciding to take COVID-19 vaccine, whereas the remaining 27.70% had done none. News (580) and scholarly articles (556) were the primary sources of research followed by social media (427) and colleagues and family (244).

According to 585 students (46.39%), they can still be the carrier of the disease even after getting vaccinated; however, 385 (30.53%) were not sure and 291 (23.07%) said that they would not be a carrier. About 590 (46.78%) knew that they can still get infected by the virus even after getting vaccinated, whereas 389 (30.84%) were not sure and 282 (22.36%) believed that they will not get infected postvaccination. Majority of the students (91.43%) said that wearing a mask is necessary even after getting vaccinated, 5.15% of students were not sure, and 3.40% of students felt that there is no need of wearing a mask postvaccination. When asked about frequent handwashing, hand sanitation, and social distancing postvaccination, 1160 (92%) students agreed it to be true, whereas 65 (5.15%) students were not sure, and 36 (2.85%) students disagreed to the same.

The most common postvaccination symptom within the first 48 h was fever (58.04%) followed by body ache (54.87%), soreness in the injected arm (44.48%), and chills (33.54%) [Figure 1].

Figure 1: Postvaccination symptoms

DISCUSSION

To the best of the authors' knowledge, this is probably the first study of its kind to be undertaken on dental undergraduates after the vaccine was actually available. In the present study, vaccine hesitancy was 23.71% (299) which is significantly higher than the 10.6% found among medical students in India as reported by Jain et al.[¹⁶] It is noteworthy that both the studies were conducted after the actual vaccination drive opened for HCWs. In previous studies related to COVID-19 vaccine hesitancy conducted before the actual vaccination drive, higher vaccine hesitancy rates were observed in the general population and HCWs including dentists.[¹⁷¹⁸¹⁹] The present study has assessed two important questions related to vaccine hesitancy, the first one enquired about the vaccine hesitancy at the time of participation of the students. The second question was a follow-up question for students who had responded with a “no” to the first question inquiring if the students plan to take the vaccine in the next 6–12 months and responses of 57% of students were “yes” while 29.90% were “not sure” about it. Only 13.90% said a categorical no to getting vaccinated. The reason for most of the students not getting vaccinated at present was either the lack of long-term safety data (66.22%) or they were skeptical of taking the vaccine early in its life cycle (10.36%). Looking at the responses, most of the hesitant students adopted a “wait-and-watch strategy” for more data to be available and were positively convinced of getting vaccinated in the next 6–12 months. This is a scientific reason for the delay and cannot be considered typical vaccine hesitancy. Similar reason for vaccine hesitancy was reported by a review of studies by Troiano and Nardi, in which the main reason for vaccine refusal was the haste of its production and lack of adequate testing of the same.[²⁰] In India, like in most countries, HCWs and FLWs were the first to get vaccinated much before vaccination opened for the general population. This is a situation unlike any the world has faced before, where the HCWs have become the first recipient of a new vaccine candidate instead of very large-scale general population trials which span over years. In a commentary by Goetz et al. in 2010[²¹] titled “First-in-human clinical trials with vaccines—what regulators want. Nature biotechnology,” it was highlighted that though adverse reactions are common, they are minor and manageable in most cases apart from some incidences of large magnitude which have occurred during initial trials including what has come to be known as the Cutter incident[²²] of 1955 in which around 40,000 children developed mild polio because of insufficiently inactivated polio vaccine. These kinds of incidences can instill a sense of fear in the first recipients of the vaccine which in the case of COVID-19 are the HCW and FLW. The commentary further states that for novel vaccines and new vaccine formats, safety must be put on a much broader scale than what has been done for previous incidences like the Cutter incidence.

The primary reason for the students who got vaccinated was the concern regarding the protection of their family as they were HCWs (53.64%) followed by themselves getting protected against COVID-19 (37.11%). There seems to be an inverse correlation between the two questions as the year of study progresses as can be observed in Figure 2 with the interns being most concern about the spread of infection to their families from them and the 1^st years being most concern about getting protection against COVID-19. This can be explained by the fact the interns handle the bulk of clinical patients and are most exposed to patients and are at a higher risk of contracting COVID-19 in contrast to the 1^st and 2^nd years who are restricted to the classrooms and laboratories. The reason for majority of senior year students getting vaccinated to protect their family is a serious reason of concern as it represents flawed logic leading to a good outcome. As of today, there is no concrete evidence that individual vaccination reduces the transmission rates of the coronavirus infection but reduces the severity of the disease if the vaccinated person gets infected. It is even more worrisome that higher year students who were treating patients had this flawed logic as this may pass on to the patients who look up to HCWs for advice on vaccination It is also worrisome because the vaccinated individuals may become confident about their own noninfectivity and may not take the mandatory precautions after vaccinations leading to higher spread of infection. In the present study, most students had multiple sources of information on which they relied on for making their decision about getting vaccinated. News (60.29%), scientific material from sites such as PubMed and Google Scholar (57.79%), and social media (44.38%) were the key information sources which the participants referred to. Only 25.36% had gathered the information from their family and colleagues. This fact reiterates the importance of proper, genuine, consolidated, and structured knowledge being presented to the medical and allied field students rather than piecemeal misinformation which is circulating on social media or the sensationalized news in print and other media. Even when trying to find information of scientific websites such as PubMed and Google Scholar, it can be difficult for undergraduate students to gather and assimilate the facts from different scientific articles and form an opinion on a topic like vaccination against COVID-19. Based on all findings, we suggest that it is important to hold counseling sessions for undergraduate students where coherent, collective, and genuine information can be provided to them.

Figure 2: Primary reasons for getting vaccinated among undergraduate dental students

The confusion about being a carrier of COVID-19 and getting infected from it as illustrated in Figures 3 and 4 was observed in the senior year students, which correlates well with the flawed assumption that by getting vaccinated, they will be protecting their family members from the spread of infection. Around 60% of interns and 59% of final-year students responded with a “no” or “not sure” to the questions about being a carrier of COVID-19 disease or getting infected by it after getting vaccinated. Nearly, similar percentage of interns (about 58%) and final-year students (about 60%) responded with a “no” or “not sure” to the question about getting infected with coronavirus even after being vaccinated. It is noteworthy that in both the questions, the percentage of people responding with a “not sure” response was almost double of the people responding with a “no.” This clearly indicates a gap in knowledge and confusion about the topic pertaining to COVID-19 in general and vaccination in particular. One reason for the confusion in this regard can be attributed to the fact that for the first time in human history, medical advances are translating into actual treatment and vaccination protocols that the information is just not available. There is also considerable confusion about the characteristic of this disease that is adding to the confusion about the COVID-19 vaccine, for example, the question of COVID-19 being an airborne disease or the efficacy of the current vaccine against the new mutant strains of coronavirus are much- debated topic and a lot of conflicting data has been presented for and against the same.[²³²⁴²⁵] Majority of the vaccinated students had three or more symptoms with the most common being fever, malaise, and soreness of the vaccinated arm in descending order. Other symptoms included chills, numbness in the vaccinated hand, nausea, blurred vision, and syncope in descending order of occurrence. Only 81 students (8.41%) had no symptoms at all. This is illustrated in Figure 1. Similar postvaccination adverse effects have been noted in some studies from Nepal.[²⁶]

Figure 3: Can you be a carrier after getting vaccinated

Figure 4: Can you still get infected after being vaccinated

CONCLUSION

The present study has clear messages for the scientific community, though there is considerable vaccine hesitancy in dental students, but they have a rational wait-and-watch approach toward COVID-19 vaccination and majority are positive that they will take the vaccine in the coming year.

The study also points to the need for a consolidated, up-to-date, available to all, single portal of information for medical fraternity on all aspects of COVID-19 including vaccination. This will prevent misinformation and conflicting information which leads to confusion.

We would further like to suggest that the curriculum, especially in public health dentistry, should be modified to address the issues of pandemics and vaccinations.

The limitations of the study are that it was conducted in the initial phase of vaccination and there has been a rapid progress in evolution of the vaccine which may affect results in future.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.