Characteristics of patients who received Sinopharm BIPB vaccine in Singapore general practice

INTRODUCTION Most bodies of authority recognise messenger RNA (mRNA) vaccines as the most effective coronavirus disease 2019 (COVID-19) vaccines that have met safety standards.[1,2] Singapore, like many countries, encouraged its citizens and residents to receive mRNA vaccines for better protection. Despite the presence of significant evidence that mRNA vaccines reduce the severity of COVID-19 infection and prevent hospitalisation, mRNA vaccine hesitancy persisted due to low confidence and perceived side effects.[3-6] The safety of mRNA vaccines has been questioned due to the accelerated review processes used by authorities such as the US Food and Drug Administration and uncertainty about their long-term adverse events.[7] The public’s concerns were further exacerbated by reports of serious immediate side effects, including allergic reactions and anaphylaxis, myocarditis and pericarditis, and death.[8] However, to slow the infection rate and reduce the severity of COVID-19, vaccination programmes were the only practical and effective public health intervention available. Singapore’s nationwide COVID-19 vaccination programme was the first in Asia and started on 30 December 2020. The Pfizer–BioNTech COVID-19 vaccine, an mRNA vaccine, was granted interim authorisation under the Pandemic Special Access Route (PSAR) by Singapore’s Health Sciences Authority on 14 December 2020, and authorisation of another mRNA vaccine, Moderna, followed on 3 February 2021. After 6 months, 36.8% of Singapore’s population had received two doses of COVID-19 vaccine and 58.1% had received only one dose.[9] It became apparent that providing access to non-mRNA COVID-19 vaccines listed on the Emergency Use Listing of the World Health Organization was necessary to address vaccine hesitancy among those with concerns and worries specifically related to the mRNA technology. In June 2021, the Ministry of Health (MOH) allowed access to six COVID-19 vaccines under the Special Access Route (SAR) — a process to import and supply unregistered medicines and drugs to address unmet medical needs in special circumstances. Late in July, IHH Healthcare Singapore was among the first private healthcare groups in Singapore to obtain approval to import the inactivated Sinopharm BIBP vaccine (BBIBP-CorV), and its administration began on 30 August 2021, in the eighth month of the country’s nationwide vaccine campaign. By this time, 80% of the population had received two doses of COVID-19 vaccines and 83% had received one dose.[10] This paper describes the sociodemographic profile of patients who received the Sinopharm BIBP vaccine in Singapore and their reasons for opting for an inactivated vaccine instead of an mRNA vaccine. These data can inform healthcare providers and policymakers when addressing vaccine hesitancy and concerns about mRNA vaccines. METHODS This cross-sectional study was conducted to explore the demographic characteristics of persons who presented to a three-doctor private general practice clinic in Singapore for vaccination with Sinopharm BIBP vaccine and to elucidate the underlying reasons for choosing this vaccine. Ethical approval was obtained from the institutional ethics committee (Parkway Independent Ethics Committee). Patients who attended the clinic to be vaccinated with Sinopharm BIBP vaccine between 30 August 2021 and 30 October 2021 were invited to complete a questionnaire during their 15-min postvaccination observation period. Patients were informed that their participation was voluntary and would not impact their clinical care. The questionnaire was completed on a clinic desktop computer or on the patients’ smartphone via a QR code. Patients who had difficulty understanding the questionnaire items in English responded with the help of a translator. The self-administered questionnaire included demographic details, respondents’ attitudes and beliefs regarding COVID-19 vaccines, and information-seeking behaviour. Our questionnaire adapted ten items measuring perceived susceptibility to COVID-19, vaccine benefit, vaccine risk, vaccine attitudes, information sourcing and fear of COVID-19 from a survey developed for a comparative study between Ireland and the UK on the causes of vaccination intentions.[11] This questionnaire was selected because it had been developed to specifically explore COVID-19 vaccine hesitancy, rather than generic vaccine hesitancy issues. Although the questions had not been validated for face, content or criterion validity, the questionnaire had undergone testing for scale reliability when it was developed. Descriptive data analysis was conducted to identify the response distribution and sociodemographic differences. Chi-square analysis was used to identify significant relationships between sociodemographic characteristics and vaccine behaviour and intentions. RESULTS Of the 294 patients invited to participate, 212 (72.1%) agreed to complete the questionnaire. The majority of respondents were female (61.8%), aged between 30 and 59 years (64.2%), highly educated (61.2% with university or higher education) and Singapore residents (89.2%) [Table 1]. Almost all respondents (98.6%) reported not having been infected with COVID-19, and over 80% of the respondents were unvaccinated [Table 2].Table 1: Sociodemographic characteristics of participants.Table 2: COVID-19 infection and vaccine history of participants.Reasons for selecting Sinopharm The most common reason for preferring an inactivated COVID-19 vaccine was concerns about the safety of mRNA vaccines (76.9%) [Table 3]. Other reasons included potential allergy to mRNA vaccines, need to get vaccinated with an inactivated vaccine for travel to China, booster after two doses of mRNA vaccines, recommended by a friend, relative or doctor, higher efficacy compared to CoronaVac, lack of access to mRNA vaccines and instructed by employer. Respondents were more likely to report that they would take Sinopharm if they were nonresidents of Singapore (χ2 (8) = 41.0, P < 0.001) or if they had a primary school educational level or lower (χ2 (24) = 64.0, P < 0.001).Table 3: Attitudes and beliefs regarding COVID-19 vaccines and information-seeking behaviour of respondents who opted for the Sinopharm vaccine (N=212).Almost half of the respondents would not switch to mRNA vaccines in the future, 33% of the respondents were unsure and a minority (4.3%) would consider an mRNA vaccine [Table 3]. Respondents who were more likely to report a willingness to have an mRNA vaccine in the future had a primary school or lower educational level (χ2 (12) = 21.4, P = 0.045). Most respondents were aware that the Sinopharm vaccine was not as efficacious as an mRNA vaccine (95.8%) and that it was excluded from the National Vaccination Programme and the Vaccine Injury Financial Assistance Programme for COVID-19 Vaccination (VIFAP) (97.2%) [Table 3]. Respondents who were unaware that Sinopharm was not as effective as mRNA vaccines were 4.3 times more likely to be nonresidents of Singapore (χ2 (1) = 5.24, P = 0.022). Information-seeking behaviour Over half of the respondents reported actively seeking information on COVID-19 (61.3%). The main sources of information were traditional media (newspapers or TV) (56.6%) and, to a lesser extent, social media (31.1%), word of mouth (7.6%) and other sources (4.7%) [Table 3]. Further analysis indicated that respondents who were more likely to report that they received information about COVID-19 from word of mouth were nonresidents (χ2 (4) = 18.1, P = 0.001) and those with the lowest educational level (χ2 (12) = 22.8, P = 0.030). Attitudes and beliefs about vaccines and COVID-19 One in four respondents (26.9%) thought other people were more likely to catch COVID-19 than themselves [Figure 1]; male respondents were significantly more likely to strongly agree with this view (χ2 (4) = 12.2, P = 0.016). The two items about vaccine benefits indicated that the majority of respondents believed that vaccines were the best measure to return to a prepandemic way of life (58.9%) and that their likelihood of contracting or suffering significantly from COVID-19 would be lessened if they were vaccinated (67.9%). Concerning vaccine risk, about a third of the respondents did not believe that vaccines in general were safe (30.6%) and a similar number disagreed (32.1%). The majority of respondents (60.4%) believed that if people in their environment were vaccinated, it would not be necessary for them to get vaccinated, a view that was expressed significantly more often in male respondents (χ2 (4) = 13.2, P = 0.010) and among nonresidents (χ2 (4) = 10.5, P = 0.033). Regarding the fear of COVID-19, 39.1% felt uncomfortable thinking about COVID-19 and 40.6% reported feeling nervous and anxious when watching the news and stories about COVID-19 on social media. But only a minority of respondents (6.6%) reported that their sleep was affected by worries about getting infected with COVID-19 [Figure 1]. Male respondents were more likely to strongly disagree with the statement that thinking about COVID-19 made them feel uncomfortable (χ2 (4) = 18.1, P = 0.001).Figure 1: Attitudes and beliefs of the respondents about COVID-19.DISCUSSION This study was conducted at a time when approximately 30% of the Singaporean population was not fully vaccinated.[12] We aimed to describe the characteristics of patients who sought the Sinopharm BIBP vaccine and their reasons for opting for an inactivated vaccine instead of an mRNA vaccine. In our study, most respondents were female, aged between 30 and 59 years, highly educated and residents of Singapore. In our sample, high levels of concern about mRNA technology and potential adverse events contributed to the reticence to use mRNA vaccines. This is a finding consistent with studies conducted in Australia and Japan,[13,14] which found the lowest uptake of COVID-19 vaccines in women, younger individuals and those with higher a level of education. A study of respondents from Bangladesh, India, Sri Lanka, Norway, the UK, Iran, Pakistan, Somalia, the United Arab Emirates, Australia, China, Japan, Malaysia, Singapore and Vietnam reported that respondents from Southeast Asia were more concerned about getting mRNA vaccines.[15] The authors reflected on the challenge of increasing the uptake of new mRNA vaccines despite clearly communicating their effective evaluation in clinical trials. Responses to the questionnaire showed that most of the respondents were concerned about mRNA vaccine safety (76.9%) and a further 4.3% took the Sinopharm BIBP vaccine on the recommendations or instructions of their employer. All these respondents may be amenable to taking an mRNA vaccine in the future and are the target group for future public health interventions. In contrast, there were only 10.8% of respondents who did not have alternatives to the Sinopharm BIBP vaccine for medical reasons (e.g., potential allergy to mRNA vaccines [6.6%]), or due to the need to get vaccinated with an inactivated vaccine to obtain a visa to China (4.2%). Approximately nine out of ten patients surveyed could potentially switch from non-mRNA to mRNA vaccines, so there is a strong justification to consider theories of health behaviour change and maintenance[15] and how mRNA vaccination uptake can be boosted at the four socioecological levels of influence: individual, relationship, community and societal.[16] At the individual level, interventions need to focus on education to address knowledge gaps or modify attitudes and beliefs. The health belief model is among the most commonly utilised theories of health behaviour and proposes several constructs that influence the ‘likelihood of taking action’. These are perceived susceptibility, perceived severity, perceived threat, cues to action, perceived benefits, perceived barriers and self-efficacy. The majority of respondents exhibited low perceived susceptibility but high perceived benefits (i.e., the resumption of the prepandemic way of life). Education should focus on raising risk perception through regular updating of COVID-19 cases in the community; providing cues to action by personalised reminders of the need for mRNA boosters; reducing perceived barriers with assistance such as subsidised transport to get to vaccination centres, and reassurance via frequent sharing of safety data. Most respondents were actively seeking information on COVID-19 via paper-based news or social media, so these media channels will reach over two-thirds of the target population. There were differences between males and females in their assessment of perceived susceptibility risk and attitudes to vaccine, with males feeling that the people around them were more likely to get infected by COVID-19. Male respondents also reported that they believed they would not need to be vaccinated if people in their environment were vaccinated, a view also echoed by respondents who were nonresidents of Singapore. This suggests that there may be benefit in exploring some gender-specific interventions. In this context, the social marketing framework may be appropriate, combining social sciences and commercial marketing to change an individual’s behaviour for the benefit of society.[17] Social marketing uses four constructs: product, price, place and promotion. Product refers to benefits that the target audience will experience or expect from performing the target behaviour. These include increased protection from infection and reduced morbidity and mortality upon infection. For example, the MOH can mandate that individuals who opt for non-mRNA vaccines be counselled by the administering physician about the differing vaccine efficacies. Price refers to the cost of adopting the desired behaviour, and in this context, it includes cost of the vaccine, time spent to receive the vaccine, cost of transportation and side effects resulting in time-off from work. The Singapore government can regulate pricing of the Sinopharm BIBP vaccine at clinics to reduce its accessibility and affordability and to enhance the selection of mRNA vaccines for economic reasons. Place is the distribution channel or place of delivery. Promotion includes communication channels and activities to promote the benefits of the desired behaviour. Advocates can combine promotion and placement elements to maximise outreach to the target audience. They can utilise the mass media and spokespersons at schools, workplaces and healthcare institutions [Figure 1]. For example, the MOH can mandate that posters and pamphlets showing the location and opening hours of vaccination centres offering free mRNA vaccines be displayed in clinics administering the Sinopharm BIBP vaccine. At the community level, influencers can be recruited to set social norms and influence behaviour. They can be individuals at home, workplace, faith-based organisations or healthcare institutions. For example, teachers and doctors can share data on the efficacy of different COVID-19 vaccines with students and patients, respectively. These are persons of authority and are responsible for encouraging and promoting mRNA vaccines by word of mouth. Studies show that when the messages come from community leaders — persons who are credible and trusted — there is better retention of long-term knowledge.[18] As indicated in our data, this may be a helpful strategy to engage nonresidents who are not likely to have sufficient knowledge (e.g., about the efficacy of different vaccines). Clear and assertive evidence-based recommendations from healthcare professionals such as doctors and nurses can also alleviate safety concerns and further enhance vaccine adoption.[19] Finally, at the societal level, policies can be implemented to nudge individuals to adopt mRNA vaccines. As of 12 January 2022, the MOH has put in place some vaccine-differentiated measures. First, only medically ineligible persons qualify for free inactivated COVID-19 vaccines. Those without clinical contraindications are forced to pay for inactivated vaccines out of their own pocket. Second, persons who had received inactivated vaccines as their third vaccine dose are required to receive a booster dose 3 months after the third dose of the vaccine (compared to 5 months for those who took mRNA vaccines). Third, VIFAP is a goodwill financial assistance provided by the government only to those who experience serious side effects after receiving COVID-19 vaccines within the national programme. Better awareness of VIFAP may mitigate concerns about exorbitant medical bills due to an adverse event. Interventions to further promote mRNA vaccination might include subsidised travel and protected time off work. This study is limited by being a single-centred study from a practice based in the central business district. Everyone attending for vaccination had the opportunity to complete the questionnaire, and the response rate was high for a community-based survey. Unfortunately, we do not have data on the nonresponders, making it impossible to assess response bias. We recognise that our findings may not be generalisable to all settings, including public housing estates, but it does provide a deeper understanding of vaccine intention in Singapore and can inform the promotion of vaccine uptake in the future. In conclusion, with the extensive evidence demonstrating the superior efficacy of mRNA vaccines over inactivated COVID-19 vaccines, there is increasing pressure to improve community uptake. A better understanding of the characteristics of members of the public who avoided mRNA vaccination and the application of health behaviour theories, such as the Health Belief Model, will allow those leading public health and health education interventions to design and implement interventions tailored to facilitate successful behaviour change within the target audience. Acknowledgement We thank Dr Hoe Wan Sin and Dr Liew Su Lyn for helping to recruit patients for the study. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.