key: cord-0980781-5i7fp6oi
authors: Perez, Marta J.; Paul, Rachel; Raghuraman, Nandini; Carter, Ebony B.; Odibo, Anthony O.; Kelly, Jeannie C.; Foeller, Megan E.
title: Characterizing initial COVID-19 vaccine attitudes among pregnancy-capable healthcare workers
date: 2021-12-22
journal: Am J Obstet Gynecol MFM
DOI: 10.1016/j.ajogmf.2021.100557
sha: fb60f3df6a5ef5902702ec1eb2a2458a3b89f154
doc_id: 980781
cord_uid: 5i7fp6oi

Background Healthcare workers were prioritized for COVID-19 vaccination roll-out due to high occupational risk. Vaccine trials excluded individuals who were trying to conceive, pregnant, and lactating necessitating vaccine decision-making in the absence of data specific to this population. Objective To determine initial attitudes about COVID-19 vaccination in pregnancy-capable healthcare workers by reproductive status and occupational exposure. Study Design We performed a structured survey distributed via social media of US-based healthcare workers involved in patient care since March 2020 who were pregnancy-capable (biological female sex without history of sterilization or hysterectomy) from January 8th to 31st, 2021. Participants were asked about their desire to receive the COVID-19 vaccine and perceived safety for the COVID-19 vaccine using five-point Likert items with “1” being “I strongly don't want the vaccine”/“very unsafe for me” and “5” being “I strongly want the vaccine”/“very safe for me.” We categorized participants into two groups: 1) reproductive intent (preventing pregnancy vs. attempting pregnancy, currently pregnant, or currently lactating), and 2) perceived COVID-19 occupational risk (high vs. low). We used descriptive statistics to characterize the respondents and their attitudes about the vaccine. Comparisons between reproductive and COVID-19 risk groups were conducted using Mann Whitney U. Results Our survey included 11,405 pregnancy-capable healthcare workers: 51.3% were preventing pregnancy (n=5,846) and 48.7% (n=5,559) were attempting pregnancy, currently pregnant, and/or lactating. Most respondents (n=8,394, 73.6%) had received a vaccine dose at the time of survey completion. Most participants strongly desired vaccination (75.3%) and very few were strongly averse (1.5%). While the distribution of responses was significantly different between respondents attempting conception, pregnant, and/or lactating versus those preventing pregnancy and respondents with high versus lower occupational risk of COVID-19, the effect sizes were small and the distribution was the same for each group (median, interquartile range: 5 [4-5]). Conclusions The majority of healthcare workers desired vaccination. Negative feelings toward vaccination were uncommon but were significantly higher in those attempting pregnancy, pregnant, and lactating and with lower perceived occupational risk of acquiring COVID-19, though the effect size was small. Understanding healthcare workers’ attitudes toward vaccination may help guide interventions to improve vaccine education and uptake in the general population.

Healthcare workers were prioritized for COVID-19 vaccination roll-out due to high occupational risk. Vaccine trials excluded individuals who were trying to conceive, pregnant, and lactating necessitating vaccine decision-making in the absence of data specific to this population.

To determine initial attitudes about COVID-19 vaccination in pregnancy-capable healthcare workers by reproductive status and occupational exposure.

We performed a structured survey distributed via social media of US-based healthcare workers involved in patient care since March 2020 who were pregnancy-capable (biological female sex without history of sterilization or hysterectomy) from January 8 th to 31 st , 2021. Participants were asked about their desire to receive the COVID-19 vaccine and perceived safety for the COVID-19 vaccine using five-point Likert items with "1" being "I strongly don't want the vaccine"/"very unsafe for me" and "5" being "I strongly want the vaccine"/"very safe for me." We categorized participants into two groups: 1) reproductive intent (preventing pregnancy vs. attempting pregnancy, currently pregnant, or currently lactating), and 2) perceived COVID-19 occupational risk (high vs. low). We used descriptive statistics to characterize the respondents and their attitudes about the vaccine. Comparisons between reproductive and COVID-19 risk groups were conducted using Mann Whitney U.

Our survey included 11,405 pregnancy-capable healthcare workers: 51.3% were preventing pregnancy (n=5,846) and 48.7% (n=5,559) were attempting pregnancy, currently pregnant, and/or lactating. Most respondents (n=8,394, 73.6%) had received a vaccine dose at the time of survey completion. Most participants strongly desired vaccination (75.3%) and very few were strongly averse (1.5%). While the distribution of responses was significantly different between respondents attempting conception, pregnant, and/or lactating versus those preventing pregnancy and respondents with high versus lower occupational risk of COVID-19, the effect sizes were small and the distribution was the same for each group (median, interquartile range: 5 [4] [5] ).

The SARS-CoV-2 pandemic created a strain on the healthcare system and healthcare workers faced unique burdens of occupational exposures. 1 The FDA granted emergency use authorization (EUA) for the Pfizer/BioNTech (BNT162b2) based on phase 3 clinical trial data in December 2020, 2 and healthcare workers were prioritized for vaccine administration. 3 Pregnancy and lactation were exclusion criteria in clinical trial participants, 4 and misperceptions that the COVID vaccines could negatively affect fertility spread on social media. 5 Because pregnancy is a risk factor for severe disease and increased mortality, 6-8 and theoretical risks of vaccination are low regardless of reproductive status, the CDC Advisory Committee on Immunization Practices recommended pregnant and lactating healthcare workers be offered the vaccination shortly after EUA. 9 The American College of Obstetrics & Gynecology, Society for Maternal Fetal Medicine, and American Society for Reproductive Medicine published guidance on theoretical risks and benefits of vaccination in pregnant and lactating individuals, encouraged shared decision-making, patient autonomy, and access to vaccination, and stated there was no data to support a negative impact on fertility. [10] [11] [12] [13] We aimed to assess the attitudes towards COVID-19 vaccination in pregnancy-capable healthcare workers shortly following emergency authorization when limited pregnancy-specific data was available. We hypothesized the attitudes of healthcare workers preventing pregnancy would differ from those planning to conceive, currently pregnant or lactating due to lack of data in this population. We also hypothesized that attitudes toward vaccination would be influenced by of the perceived risk of occupational exposure to COVID-19.

We designed a cross-sectional, structured, web-based survey. The survey was written by the research team and piloted by research staff that met inclusion and exclusion criteria.

Individuals were eligible if they were pregnancy-capable, a healthcare worker in the United States, had interacted with patients in any capacity since March 2020, and 18 years or older. We defined healthcare workers as anyone employed in a healthcare field who participated in patient contact. Pregnancy-capable was defined as an individual of biological female sex who had not undergone sterilization procedure or hysterectomy. Individuals who reported biological male sex or intersex, age over 50, no work in healthcare, no patient interaction since March 2020, or practice outside the United States were excluded.

Following the screening questions, respondents provided brief demographic and reproductive characteristics and information about their role in healthcare including the area(s) they worked in (inpatient, outpatient, ICU, Emergency Department, Urgent Care, Labor and Delivery, etc.) and the proportion of time spent working with patients both in-person and using telemedicine. Using five-point Likert item questions, we asked respondents "What best describes your feelings about receiving the vaccine?" with responses ranging to "strongly don't want it"

(1) to "strongly want it" (5), and "When considering how safe the vaccine is for you, do you feel it is…" with responses ranging from "very unsafe" (1) to "very safe" (5) . For the vaccine safety question, we included an option for "I am unsure about the vaccine's safety" in addition to the five-point Likert item responses, which we collapsed with the middle response, "neither safe nor unsafe" (3) for analysis. We also asked respondents "When considering your risk of contracting COVID-19 at work, do you consider your risk to be…" with response options ranging from "very high risk" (1) to "very low risk" (5) . At the end of the survey, respondents were asked to enter a unique, anonymous ID so that duplicate responses could be removed prior to analysis.

Respondent recruitment was conducted via social media channels (Twitter, Instagram, and Facebook) to obtain a diverse sample of healthcare worker roles, geographies, practice settings, and ages. The original posting with a link to the survey was shared through the department social media accounts; respondents were encouraged to share the link with their colleagues and repost the original recruitment post (i.e. snowball sampling). Individuals reviewed a consent information sheet prior to beginning the survey. Our institution's Human

Research Protection Office deemed this study exempt (IRB ID#: 202012141) prior to any recruitment activities.

Data collection and management were conducted using Research Electronic Data Capture (REDCap). 14, 15 We categorized respondents into two reproductive groups: 1) preventing pregnancy and 2) attempting pregnancy, currently pregnant, and/or currently lactating.

Additionally, we categorized respondents into two contracting COVID-19 risk groups based on their perception of contracting COVID-19 at work: 1) high risk (those who answered "very high risk" or "somewhat high risk") and 2) low risk (those who answered "neither high or low risk," "somewhat low risk," or "very low risk"). We used descriptive statistics to characterize the respondents and their attitudes about the vaccine. Due to the non-normal distribution of responses, comparisons between reproductive groups and contracting COVID-19 risk groups were conducted using Mann Whitney U and η 2 was calculated to determine effect size. Data analysis was conducted using SPSS Version 27 (IBM Corp., Armonk, NY).

The survey was active from January 8, 2021 to January 31, 2021, the full enrollment flow is shown in Figure 1 . A total of 11,405 unique respondents were included in our analysis: 51.3%

were preventing pregnancy (n=5,846) and the remaining 48.7% (n=5,559) were attempting pregnancy, currently pregnant, and/or lactating. In the latter group, 955 (17.2%) were attempting pregnancy, 2,196 (39.5%) were currently pregnant, 2,250 (40.5%) were lactating, 67 (1.2%) were attempting pregnancy and lactating, and 91 (1.6%) were currently pregnant and lactating.

The median age of respondents was 32, 81.9% were White, and approximately one-third (34.8%) were nurses (Table 1) . Most (91.8%) respondents said their workplace was offering the COVID-19 vaccine, and 73.6% had received it at the time of completing the survey. Among respondents who felt neutral or negatively about desiring the vaccine, individuals who were Black, multiracial, or declined to provide their race were overrepresented, reflecting the trends seen in the general population (data not shown). We observed similar patterns among respondents who had neutral or negative feelings regarding the vaccine's safety; Hispanic patients were also overrepresented among respondents in this group (data not shown).

Most participants strongly desired vaccination (75.3%) and very few were strongly averse (1.5%). While the distribution was significantly different between reproductive groups ( Figure   2A ), the effect size was small, and the median and interquartile range were the same (p<0.001, η 2 =0.005, 5 [4] [5] ). When we asked respondents about the safety of the vaccine ( Figure 2B ), we observed similar results (p<0.001, η 2 =0.018, 5 [4] [5] ).

Three-quarters of the respondents (74.6%) believed they were at high risk of contracting COVID-19 at work. When we examined the responses for desiring vaccination stratified by high versus lower occupational risk of contracting COVID-19 ( Figure 3A) , there was a significant difference in the distribution, but the effect size was small (p<0.001, η 2 =0.009). The same pattern was true for perceived safety of vaccination stratified by occupational risk (p<0.001, η 2 =0.002, Figure 3B ). For each group, the median (interquartile range) of the distribution was 5 (4) (5) .

Among the participants who were unvaccinated at the time of the survey (n=2,075), 68.1% were attempting conception, pregnant, or lactating, 39.3% strongly desired vaccination and 28.4% thought the vaccination was very safe.

The majority of pregnancy-capable healthcare workers in our January 2021 survey strongly desired vaccination. Negative feelings toward vaccination were not common, but were higher in healthcare workers attempting conception, pregnant, or lactating compared to those preventing pregnancy. Participants with higher perceived occupational exposure risk to COVID-19 more strongly desired vaccination than those at lower perceived occupational risk.

Our findings describing reproductive status and occupational risk of healthcare workers on vaccine attitudes adds to data on vaccine attitudes in both general and healthcare worker populations. Surveys assessing attitudes about receiving a COVID-19 vaccine report increased hesitancy among women compared to men, including in healthcare workers. [16] [17] [18] Differences in reproductive status may account for some of this sex difference: several recently published surveys of reproductive-age females, including healthcare workers, show that individuals trying to conceive, pregnant, or lactating are less likely to accept vaccination and be more likely to delay or decline vaccination. [19] [20] [21] Our findings demonstrate that healthcare workers experience these documented differences in vaccine attitudes depending on their reproductive status, suggesting that medical knowledge does not fully combat vaccine hesitancy. Sutton et al found that women who accepted vaccination reported seeing healthcare workers receiving COVID-19 vaccines factored into their decision to accept vaccination. 19 While vaccine attitudes may be similar between healthcare workers and non-healthcare workers, the general population may be guided by the decisions of healthcare workers. Overall, our population of pregnancy-capable healthcare workers had positive feelings toward vaccination and considered it safe. While participants attempting conception, pregnant, and/or lactating were not as strongly assured of safety, possibly because these reproductive statuses were not included in clinical trial participants, the effect sizes were small. Occupational exposure risk also showed a relationship with desiring the vaccine and perceived safety, but the small effect sizes indicate the finding may not be clinically relevant.

Exclusion of pregnant and lactating individuals from vaccine clinical trials attempts to protect the pregnant or lactating person and fetus or infant from unanticipated adverse events.

However, during a pandemic in which pregnant individuals are a high-risk group for severe disease, these exclusions have the opposite effect. Exclusion leaves pregnancy-capable populations without data to make informed decisions, delaying important data pertaining to efficacy and safety. At the time of manuscript writing, less than 1 in 4 pregnant people are vaccinated against COVID-19 despite retrospective data showing safety, efficacy, and vaccinegenerated antibody passage through umbilical cord blood and breastmilk. [22] [23] [24] [25] While the data is reassuring, had it been available when the vaccines were first released its impact would have been more substantial. Targeted education to reproductive aged populations is needed to battle vaccine misinformation related to fertility. Vaccine hesitancy and declination leaves patients at risk of COVID-19 infection and lack of data creates opportunities for anti-vaccine misinformation.

We identified reproductive status as a possible driver behind established differences in vaccine attitudes in female sex individuals, even in healthcare workers who may have higher health literacy. Further investigation should focus on understanding vaccine hesitancy, countering vaccine misinformation, and strategies for education and counseling to address vaccine attitudes among those trying to conceive, pregnant, and lactating.

The strengths of our study include a large sample size, particularly in the context of survey studies about COVID vaccine hesitancy. [17] [18] [19] 21, 26, 27 Our respondents represented varied geographies and roles in healthcare. We included respondents with a wide range of reproductive statuses, including those trying to conceive and lactating in addition to a large comparison group that were preventing pregnancy. Furthermore, the respondents captured a group at high risk for occupational exposure, and elicited responses during a time point when data regarding vaccination safety in pregnancy was lacking, but pregnancy had been clearly linked to severe COVID-19 infection.

There are limitations to our study. The nature of a web-based, social-media recruitment strategy leaves us unable to calculate a response rate. However, our completion rate among eligible respondents was over 90%. A web-based recruitment and survey strategy requires internet access, and social media snowball recruitment may increase responsiveness within particular social networks and online communities, limiting generalizability of our results.

White, non-Hispanic respondents were overrepresented in our sample, and our recruitment strategies did not have the same reach in communities of color. This may bias our results, as communities of color have higher rates of COVID-19 cases and mortality 28 and typically report lower vaccine acceptance in surveys. 17, 18 Individuals with strong feelings about vaccination could be more likely to participate and most of our respondents had already been vaccinated at the time of the survey, leading to selection bias. Our survey was created during a novel pandemic and vaccination roll-out, therefore it is not a validated survey instrument.

Our results show that the reproductive status of pregnancy-capable healthcare providers has a small but significant effect on desire for vaccination and the perceived safety of the vaccination. Healthcare workers who believed themselves to have a higher occupational risk of COVID-19 also had a small but significant effect on desire for vaccination. Given that vaccine attitudes significantly differ even in a medically-literate, high-risk group of people, further exploration of vaccine attitudes and acceptance in this population is needed.

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Table 1: Respondent characteristics of pregnancy-capable healthcare workers who worked with patients during the COVID-19 pandemic