key: cord-0752011-v6qcjdc9 authors: Belingheri, Michael; Roncalli, Massimo; Riva, Michele Augusto; Paladino, Maria Emilia; Teruzzi, Carlo Maria title: COVID-19 vaccine hesitancy and reasons for or against adherence among dentists date: 2021-05-06 journal: J Am Dent Assoc DOI: 10.1016/j.adaj.2021.04.020 sha: 54912048a466c418e46dd9c0fcb19a370e3138e3 doc_id: 752011 cord_uid: v6qcjdc9 Background The COVID-19 pandemic has spread widely among health care workers. Oral health care workers have an increased risk of infection due to dental practice characteristics. New effective vaccines against COVID-19 recently began to be inoculated. We aimed to evaluate the intentions to be vaccinated against COVID-19 in a population of dentists, identifying factors associated with their intentions. Methods An anonymous online survey was conducted among 761 dentists enrolled at the Board of Physicians and Dentists of the District of Monza Brianza. It collected data on demographic characteristics, flu vaccine uptake, COVID-19 history, vaccine attitudes, and specific reasons for intending to be vaccinated against COVID-19 or not. Results Overall, 421 dentists completed the survey. More than 82% of the participants declared their intent to be vaccinated against coronavirus. The multivariate logistic regression model reported a positive association with flu vaccine uptake in the current season (OR 5.15, 2.14–12.39) and a negative association with a previous COVID-19 diagnosis (OR 0.32, 0.15–0.66). The participants’ main reason for supporting vaccination was to protect their family and friends (87%), whereas their main reason for opposing vaccination was the lack of information (39%). Conclusions It is fundamental to consider vaccine hesitancy in health care workers and face it properly since they must provide recommendations to patients and promote adherence to vaccination programs. The COVID-19 pandemic has spread widely among health care workers (HCWs). [1] [2] [3] Oral health care workers (OHCWs) have an increased risk of infection due to dental practice characteristics. 4, 5 The potential risk of dental procedure spray emissions-including aerosols and splatters-has contributed to the transmission of SARS-CoV-2 in dental practitioners. 6, 7 While OHCWs are victims of the disease, they are also potential spreaders for their colleagues, relatives, and cohabitants. Even though the systematic use of adequate personal protective equipment and adherence to safety recommendations may prevent infection in dental settings, the risk of infection and transmission to households has contributed to psychological distress in OHCWs. 5, 8 Furthermore, the economic crisis and unemployment related to the COVID-19 pandemic have reduced access to oral health care, with relevant repercussions in dental practice. 9 New effective vaccines against COVID-19 began to be inoculated among HCWs in the UK, the US, and Europe in the last weeks of December 2020. 10 Previous studies investigated HCWs' intentions to be vaccinated against COVID-19; 11-13 however, they generally did not consider OHCWs' opinions. These studies were conducted when vaccines had not been developed and their mechanisms of action were unknown. For the global vaccination campaign to be effective, the reasons for hesitation regarding vaccination must be intercepted as soon as possible, especially among HCWs. Aiming to evaluate the intentions to be vaccinated against COVID-19 in a population of dentists and identify factors associated with their intentions, we focused on dentists living in Lombardy, an Italian region dramatically affected by the disease in its first wave in March and April 2020. J o u r n a l P r e -p r o o f METHODS An anonymous online survey was conducted among 761 dentists enrolled at the Board of Physicians and Dentists of the District of Monza Brianza in Lombardy, Italy, from December 23, 2020, to January 2, 2021. The survey was distributed to OHCWs by e-mail, followed by a second, reminder e-mail after a few days. Data have been originally collected to provide information to the public health authority about the demand of vaccines among healthcare workers. Therefore, data were related to a public health surveillance activity, which does not require IRB. The survey items were developed following a detailed analysis of scientific literature on vaccination hesitancy among HCWs and factors that may affect their vaccine opinions. [14] [15] [16] [17] The survey was used for a pilot study among a small group of HCWs. The survey consisted of four parts: 1) a first part on demographic characteristics (age and gender); 2) a second part on flu vaccine uptake (flu vaccine uptake in past vaccination seasons and the current 2020-21 vaccination season); 3) a third part on COVID-19 and new vaccines (a previous COVID-19 diagnosis, a COVID-19 diagnosis among family members or friends, and the intention to be vaccinated against COVID-19); and 4) a fourth part on specific reasons for intending to be vaccinated against COVID-19 or not. Two separate lists of reasons (for or against vaccination) were formulated, and only one list was presented, according to the participant's intention to be vaccinated or not. The first, second, and third parts included closed-ended questions and single answers, while the fourth part regarding reasons included closed-ended questions and multiple answers. When participants selected "other reason," they could clarify their answer. Data were analyzed using SAS (SAS Institute, Cary, NC, USA) statistical software. Categorical variables were reported as absolute and relative frequencies. Logistic regression was used in J o u r n a l P r e -p r o o f univariable and multivariable models to test the association between the potential adherence to the COVID-19 vaccination program and variables collected (demographic characteristics, flu vaccine uptake, a previous COVID-19 diagnosis, and a COVID-19 diagnosis among family members or friends). The variables included in the multivariable model were age (as a dichotomous variable < 55 or > 55 years), gender, adherence to flu vaccination programs (past and current), and a previous COVID-19 diagnosis (personal and among family members or friends). An odds ratio (OR) and a 95% confidence interval (CI) were reported. Altogether, 421 dentists completed the survey (421/761; response rate = 55%). The main characteristics of the study population are presented in Table 1 . The most representative age group was 56-65 years (32.5%), followed by 46-55 (24.7%) and 36-45 (17.6%). Age groups at the ends were the least numerous: 14.3% and 10.9% in age groups 25-35 and > 65 years, respectively. When age groups were combined in a dichotomous variable, about 56.6% of the participants were < 55, and about 43.4% were > 55. Dentists in the study were largely male (71.5%). Concerning COVID-19, 10.9% of the respondents were diagnosed with coronavirus disease, whereas 55.3% had at least one family member or friend with COVID-19. We also collected data on the adherence to flu vaccination programs with two questions about previous and current vaccination programs. Around 40.6% of dentists were vaccinated in the current 2020-21 season, and 27.8% were vaccinated at least once in the past three flu seasons. Table 1 reports OHCWs' intentions to adhere to the COVID-19 vaccination program. Over 82% of the participants declared their intent to be vaccinated against coronavirus. Specifically, 59.6% answered J o u r n a l P r e -p r o o f "Yes," and 22.6% answered "Probably yes." Conversely, 3.8% and 14.0% of dentists answered "No" and "Probably no," respectively. Table 2 reports the association between demographic characteristics, flu vaccine uptake, a previous COVID-19 diagnosis, a COVID-19 diagnosis among family members or friends, and the potential adherence to the COVID-19 vaccination program. In the univariate analysis, the intention to adhere to the COVID-19 vaccination program was associated with an age > 55 years (OR 2. We also assessed the reasons behind the decision about the novel vaccine. Data are provided in Figure 1a and Figure 1b . Among the 346 dentists who supported the vaccination, the main reasons were to protect family and friends (87%), to protect oneself (85%), and to protect patients (79%). Furthermore, about 32% of OHCWs agreed to the vaccination to return to normal activities (such as travels, concerts, and celebrations), 30% to not miss days of work, and 18% to comply with health ministry recommendations. Finally, around 8% of dentists reported wanting to be vaccinated to avoid wearing masks (Figure 1a) . Conversely, among the 75 participants who opposed the COVID-19 vaccine, the main reasons were the lack of information on the vaccination (39%), the opinion that the vaccine is unsafe (37%), and the fear of adverse events (58%). Moreover, about 20% stated that pharmaceutical companies influence J o u r n a l P r e -p r o o f decisions on vaccination policies, 19% received a previous COVID-19 diagnosis, and 13% believed that the vaccine has a suboptimal protective efficacy. As Figure 1b demonstrates, very few participants provided other reasons: the disagreement to vaccinations in general (5%) and the opinion that COVID-19 is not a threatening disease (1%). Some dentists reported immune disorders and severe allergies as additional reasons to avoid the COVID-19 vaccination (4%). This study aimed to evaluate the intentions to be vaccinated against COVID-19 in a population of dentists and identify associated factors. Until now, no similar studies had been conducted among dental practitioners, despite their increased risk of infection due to the characteristics of their practice. 5 Previous studies on these topics were conducted among general HCWs but only when vaccines were not yet available and their mechanisms of action were still unknown. At the time of this study, COVID-19 vaccines were already available, and in several countriesincluding Italy-the coronavirus vaccination campaign had already begun. A survey based on the general Italian population conducted in September reported that only one of every two Italians wanted to be vaccinated. 18 Lazarus et al. provided a global survey of the potential acceptance of a COVID-19 vaccine among general populations worldwide; about 70% of their participants were very or somewhat likely to take a COVID-19 vaccine. 19 Other studies have reported similar results. 20, 21 We reported an extremely high percentage of dentists favorable to the vaccination (82%). This rate of COVID-19 vaccine acceptance was also higher than percentages reported in several worldwide studies, which focused on HCWs' vaccine hesitancy. [11] [12] [13] 16, 22 We found that the intention to be vaccinated was associated with adherence to the current flu vaccination program. This finding is not surprising since attitudes toward vaccines in general influence J o u r n a l P r e -p r o o f attitudes toward COVID-19 vaccines. 11 However, we did not find an association between being favorable to COVID-19 vaccines and having been vaccinated in a flu vaccination campaign in the past. Although a diagnosis among family members and friends did not influence opinions on COVID-19 vaccines, a previous personal COVID-19 diagnosis seemed to be associated with a low inclination to be vaccinated. Dentists who had fallen sick considered themselves immune. On the one hand, this response is comprehensible; on the other hand, little information on immunity from natural disease and the need for vaccination exists. Despite the high risk of infection in the dental practice, it is essential to note that only one to nine dentists reported a COVID-19 diagnosis, fewer than other practitioners from the same highest-hit Italian region. 23 This result is probably due to proper use of personal protective equipment, adherence to safety recommendations, and, in part, the government restrictions that closed dentists in the first phase of the pandemic. Overall, 17.8% of the participants reported vaccine hesitancy. The main reasons were the lack of information on new vaccines, potential adverse events, and general vaccination safety. These reasons were typical arguments associated with vaccine hesitancy. 17, 24, 25 A lively debate about making vaccination mandatory was recently opened for some professional categories, such as HCWs, and even the general population. While we do not want to take a firm position on this complex and sensitive issue, in our opinion, it is desirable to provide information on vaccines, to manage misinformation and fake news, and raise awareness concerning the extreme importance of widespread vaccination, for example, with educational initiatives. 26 This is a focal point for a successful vaccination campaign to reduce vaccine hesitancy and attain high vaccination coverage. Indeed, the only way toward a rapid return to "normal activities" is to encourage the vaccination of HCWs and the general population. Furthermore, vaccination against COVID-19 among dentists should be prioritized due to particular risks of the dental practice. This study's main limitation is that all its participants were selected from the same territory, the district of Monza Brianza, in the most affected Italian region. The findings may therefore not be representative of the other dental practitioners in Italy. Furthermore, the respondent rate was suboptimal, and the risk of distortion should be considered. Despite these limitations, this study is the first one on attitudes toward COVID-19 vaccines among dentists in Italy and worldwide. It is also the first study on Italian HCWs conducted when vaccines were available. In conclusion, the percentage of dentists who wanted to adhere to the COVID-19 vaccination program was high, demonstrating their awareness of the importance of prevention and the high occupational risk related to their activities. However, it is crucial to consider vaccine hesitancy in HCWs and face it properly since they must provide recommendations to patients and promote adherence to vaccination programs. This study also investigated the reasons for nonadherence to the COVID-19 vaccination program, and the knowledge of specific reasons is important to implementing strategies to address COVID-19 vaccine hesitancy properly. Finally, since dentists are a high-risk population for contracting COVID-19, dental practitioners' vaccination should be prioritized. The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. 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