key: cord-0751393-0l3bthec authors: Tharmaraj, Dhakshayini; Dendle, Claire; Polkinghorne, Kevan R.; Mulley, William R. title: Kidney transplant recipients’ attitudes toward COVID‐19 vaccination and barriers and enablers to vaccine acceptance date: 2021-11-03 journal: Transpl Infect Dis DOI: 10.1111/tid.13749 sha: c5c5b5e49405a80930318fee7a6acb58dfe77170 doc_id: 751393 cord_uid: 0l3bthec OBJECTIVE: To identify barriers and enablers to COVID‐19 vaccination in renal transplant recipients who are undecided about vaccination. METHODS: An online survey was distributed to 876 adult kidney transplant recipients at a tertiary referral service, who had not been vaccinated against COVID‐19. The survey assessed willingness to be vaccinated, attitudes toward COVID‐19 vaccines, and barriers and enablers to proceeding with vaccination. RESULTS: The survey response rate was 54% (473/876). Three hundred and forty‐six (73.1%) participants planned to receive vaccination (yes group), 105 (22.2%) were undecided, and 22 (4.7%) refused vaccination. The undecided group were younger but were not different in other demographic characteristics to the yes group. The undecided group were less positive toward (34.29% vs. 91.3%, p < .001) and more concerned about (93.3% vs. 25.1%, p < .001) vaccination than the yes group. Their concerns related to vaccine safety (including harm to their transplant), poor efficacy, and a lack of rigorous testing in transplant recipients. Undecided recipients had received less vaccine‐specific information from medical specialists than the yes group. Most undecided participants (95.1%) were willing to proceed with vaccination with appropriate supports. The most desired supports were information and a recommendation to proceed with vaccination from their treating transplant specialist and team. CONCLUSION(S): Concerns about vaccine safety (including harm to transplant), poor vaccine efficacy, and lack of rigorous testing were barriers to vaccine uptake. Most undecided recipients would proceed with vaccination with specific recommendations and vaccine information provided by their transplant specialist/team. These simple interventions can be readily implemented to optimize vaccine uptake. Vaccine hesitancy is defined by the World Health Organization (WHO) as a 'delay in acceptance or refusal of vaccines despite availability of vaccination services,' and was declared by the organization to be one of the top 10 global threats to health in 2019. 1, 2 The current COVID-19 pandemic has amplified the significance of vaccine hesitancy as improving national and global health and economic status relies heavily on high vaccine uptake. The emergence of COVID-19 variants with enhanced transmissibility (such as delta variant) has highlighted the need to vaccinate populations comprehensively and quickly. At the time of this study, the vaccination program in Australia had just commenced, however, by September 29, 2021, 52 .6% of the Australian population aged 16 had been double vaccinated. 3 Solid organ transplant recipients (SOTR) are at risk of severe disease and high mortality from COVID-19 but the data are unfolding and complicated. 4, 5 Earlier observational studies reported a much higher mortality rate in transplant recipients with COVID-19 infection compared to the general population. [6] [7] [8] However, several studies have suggested that short-term mortality in SOTR from COVID-19 is similar to immunocompetent patients, with the postulated reason being protection by blunting of the immune responses due to chronic immunosuppression. 4 There are emerging reports that certain subgroups of SOTR may face worse outcomes in terms of greater morbidity. 4 Responses to COVID-19 vaccination are diminished in SOTR compared with immunocompetent adults. 9 It is possible that vaccination may still offer some protection against severe COVID-19 despite incomplete humoral responses and vaccination is widely recommended for transplant recipients. 4 Vaccine hesitancy needs to be addressed for SOTR for both their own protection from severe COVID-19 but additionally, increased and prolonged viral shedding seen in transplant recipients and other immunosuppressed cohorts increases the risk of viral transmission and development of viral variants. [10] [11] [12] Hesitancy to COVID-19 vaccination in Australia was recently estimated to be 36% of the general population. 13 Complacency about the perceived threat of the vaccine-preventable disease, inconvenience associated with vaccine access, vaccine misinformation, and lack of confidence in the vaccine and public health officials have impacted vaccine uptake in general. 2 Understanding the complex and multifactorial reasons behind vaccine hesitancy in SOTR and channeling resources to address these is crucial to optimize uptake. We sought to assess understanding, attitudes, and hesitancy to COVID-19 vaccination in kidney transplant recipients. We focused on those who were undecided about vaccination in order to identify barriers and enablers of vaccine acceptance that can be addressed to optimize vaccine coverage in this susceptible population. We conducted a cross-sectional survey of kidney and kidney/pancreas The survey was adapted from a survey designed to examine vaccine hesitancy in rheumatic disease. 20 Participants were categorized into three groups by intention to receive vaccination: yes (planning to have vaccination), undecided (unsure if will have vaccination), and no (planning not to have vaccination). Because our study was interested in contrasts to vaccine uptake in undecided individuals to those in the yes group, those refusing vaccination (no group) were not further considered. Categorical variables were summarized using frequency and percentage. Continuous variables were summarized using mean and standard deviation (SD) or median and interquartile range (IQR) as appropriate. Comparisons of proportions between the yes and undecided groups Of the 876 surveys sent, 473 were returned giving a response rate of 54%. Of the 37 survey questions, 33 had five or less missing responses. While the two groups expressed similar levels of concern about their risk of contracting COVID-19 ( Figure S1 ) there were differences in Agreement with various aspects of vaccine knowledge is presented in Figure 2 . Participants in the yes group were more likely to agree that the vaccines were effective and safe as well as being less concerned about vaccine side effects than the undecided group (p < .001 for all). Despite opting to have vaccination, 127 (36.8%) participants in the yes group agreed that they had concerns that vaccination could cause harm to their transplant. This concern was even more prevalent in the undecided group (n = 78, 75%, p < .001). One-third of the yes group agreed that there had been insufficient vaccine testing (n = 109, 31.5%) compared to 76% (n = 79) of the undecided group (p < .001). Agreement between the two groups was similar regarding prefer- The majority of participants in both groups had received some form of vaccine-specific information (n = 240, 71% vs. n = 69, 65.7% yes versus undecided groups, respectively, p = .30). More than 67% (n = 232) of the yes group agreed that they had received enough vaccine information compared with just 26.2% (n = 27) in the undecided group (p < .001). Kidney/other medical specialist (n = 237, 60.6%), news services (n = 164, 41.9%), and government sources (n = 144, 36.8%) were the most common sources of vaccine information cited by participants ( Figure S2 ). Compared to the undecided group, the yes group were more likely to have received vaccine-specific information from their nephrologist/other medical specialist (n = 189, 54.6% vs. n = 38, 36.2%, p = .007). There were no significant differences in information obtained from other sources. Prior to vaccine availability, most participants from the yes and unde- Participants were asked to rate the efficacy of vaccination and other infection prevention strategies to reduce the risk of contracting and transmitting COVID-19 from 1 (least effective) to 5 (most effective). Results are presented in Figure 3 . Of the total cohort, 318 (68.4%) participants rated vaccination as effective (score of 4 or 5), while hand washing, social distancing, mask wearing, and the combination of these three measures were consistently rated as more effective at 85.4%, 82.8%, 77.9%, and 92.8%, respectively. In general, a significantly lower proportion in the undecided group rated the nonvaccination approaches as effective compared with the yes group (Figure 3 ), all p-values < .05. However, the most marked difference between groups related to vaccination, with only 31% (n = 31) of the undecided group rating it 4 or 5 compared to 81.9% (n = 281) of yes group, p < .001. where to get vaccinated (5.7%), inconvenience of travel (0%), and fear of allergic reactions (1.4%) were not a major concern for most participants. Vaccine-specific information provided by their kidney special- Vaccine hesitancy is a growing concern that undermines national and global efforts to control the COVID-19 pandemic. We present emerging data regarding COVID-19 vaccine attitudes and intentions in a large kidney transplant cohort. The major finding from this study is substantial vaccine hesitancy, primarily comprised of vaccination undecided individuals. Although undecided transplant recipients felt less positive and more concerned about COVID-19 vaccines, more than 95% were open to vaccination given appropriate supports. In international studies in the general population, vaccine hesitancy has ranged from 3% to 41.1%. 21-23 A recent Australian survey found 36% of the population were vaccine hesitant. 13 There is limited data on international COVID-19 vaccine hesitancy in transplant populations. Two studies of US cohorts report vaccine hesitancy rates in SOTR to be 34% and 49%. 24, 25 By comparison, we found 26.9% to be hesitant with 83% of those, undecided rather than outright refusers. While this is lower than the general Australian population and the reported solid organ transplant cohorts in the United States, it remains very concerning considering the substantially increased risk of infection and death in immunosuppressed individuals. Since declaration of the pandemic, the comparatively lower total COVID-19 cases and deaths in Australia has likely contributed significantly to the higher vaccine hesitancy and lower vaccination rates. 26 By contrast countries with higher infection rates such as the United States, United Kingdom, Canada, Israel, Spain, and Italy along with many other countries (predominantly in Europe) have higher total population vaccination rates. 26 Irrespective of local case numbers and outbreak status, in order to achieve control over the far-reaching health, psychosocial and economic impacts of COVID-19 it is critical that we continue to assess and address vaccine hesitancy, particularly in the low uptake countries and vulnerable subpopulations. Similar to previous studies, younger age was associated with vaccine hesitancy, however we did not find an association with female gender, employment status, or education levels. 21 Vaccine attitudes and uptake intentions are likely to vary over time and place, depending on the perceived risk-benefit ratio following the reporting of side effects and local case rates and outbreaks. The survey was undertaken prior to age restrictions imposed on access to the AstraZeneca vaccine in Australia. While the response rate was very good it is possible that not all subgroups of the target population were represented given it was only delivered in English and a higher response rate might have yielded further themes relating to vaccine hesitancy. As the survey was anonymous, we were unable to define the characteristics of the nonresponder group to examine this. Additionally, while we did assess employment status and level of education, we did not collect additional socioeconomic factors, residential remoteness, or specific health literacy, which may influence vaccine uptake. Vaccine hesitancy is a major public health concern, greatly impacting efforts to achieve herd immunity against COVID-19 and places vulnerable populations at greater risk. Undecided transplant recipients had concerns pertaining to vaccine safety, effectiveness, lack of vaccine information, and inadequate vaccine research. Tailored vaccinespecific information and a recommendation from their specialist or transplant team were identified as key mechanisms to increase vaccine acceptance. The overwhelming majority of the undecided transplant recipients were willing to proceed to vaccination, suggesting that investing in targeted interventions in this vulnerable population would likely be highly effective. WHO's top health threats for 2019 Report of the sage working group on vaccine hesitancy Australian Government; Department of Health. COVID-19 vaccines COVID-19 in solid organ transplant recipients: a review of the current literature Outcomes of COVID-19 in solid organ transplant recipients: a matched cohort study Covid-19 and kidney transplantation COVID-19 infection in kidney transplant recipients: disease incidence and clinical outcomes COVID-19 in solid organ transplant recipients: a single-center case series from Spain Antibody response to 2-dose SARS-CoV-2 mRNA vaccine series in solid organ transplant recipients Shedding of viable SARS-CoV-2 after immunosuppressive therapy for cancer Persistent viral shedding despite seroconversion in a kidney transplant recipient with severe extrapulmonary COVID-19 Viral shedding prolongation in a kidney transplant patient with COVID-19 pneumonia COVID-19 vaccine hesitancy and resistance: correlates in a nationally representative longitudinal survey of the Australian population Group on Vaccine Hesitancy. Vaccine hesitancy: definition, scope and determinants The exclusion of patients with CKD in prospectively registered interventional trials for COVID-19 -a rapid review of international registry data Phase I/II study of COVID-19 RNA vaccine BNT162b1 in adults Safety and immunogenicity of two RNA-based Covid-19 vaccine candidates Vaccine hesitancy, acceptance, and anti-vaccination: trends and future prospects for public health Addressing COVID-19 vaccine hesitancy: is official communication the key? SARS-COV-2 vaccine acceptance in patients with rheumatic diseases: a cross-sectional study. Hum Vaccin Immunother Predictors of COVID-19 vaccine hesitancy in the UK household longitudinal study COVID-19 vaccine hesitancy worldwide: a concise systematic review of vaccine acceptance rates. Vaccines (Basel) How do COVID-19 vaccination and vaccine hesitancy rates vary over time? 2021 Kidney transplant recipient attitudes toward a SARS-CoV-2 vaccine Perspectives on COVID-19 vaccination among kidney and pancreas transplant recipients living in New York City KFF: COVID-19 vaccine monitor. Does the public want to get a COVID-19 vaccine? Covid-19 vaccination hesitancy Confidence and receptivity for COVID-19 vaccines: a rapid systematic review. Vaccines (Basel) COVID-19 vaccine hesitancy in a representative working-age population in France: a survey experiment based on vaccine characteristics Antibody and T cell response to SARS-CoV-2 messenger RNA BNT162b2 vaccine in kidney transplant recipients and hemodialysis patients Humoral and cellular immunity to SARS-CoV-2 vaccination in renal transplant versus dialysis patients: a prospective, multicenter observational study using mRNA-1273 or BNT162b2 mRNA vaccine Antibody response after a third dose of the mRNA-1273 SARS-CoV-2 vaccine in kidney transplant recipients with minimal serologic response to 2 doses Safety of the first dose of SARS-CoV-2 vaccination in solid organ transplant recipients Safety of the first dose of SARS-CoV-2 vaccination in solid organ transplant recipients Does vaccination in solidorgan transplant recipients result in adverse immunologic sequelae? A systematic review and meta-analysis Impact of a physician recommendation and parental immunization attitudes on receipt or intention to receive adolescent vaccines The authors declare no conflict of interest.