key: cord-1007216-ru4q9sjy authors: Fojnica, A.; Osmanovic, A.; Duzic, N.; Fejzic, A.; Mekic, E.; Gromilic, Z.; Muhovic, I.; Kurtovic-Kozaric, A. title: Lack of lockdown, open borders, and no vaccination in sight: is Bosnia and Herzegovina a control group? date: 2021-03-03 journal: nan DOI: 10.1101/2021.03.01.21252700 sha: 8767b13bd13b98f634b74b12ae080483c0f2a9c0 doc_id: 1007216 cord_uid: ru4q9sjy Bosnia and Herzegovina is among ten countries in the world with the highest mortality rate due to COVID-19 infection. Lack of lockdown, open borders, high mortality rate, no herd immunity, no vaccination plan, and strong domestic anti-vaccination movement present serious COVID-19 concerns in Bosnia and Herzegovina. In such circumstances, we set out to study if the population is willing to receive the vaccine. A cross-sectional study was conducted among 10,471 adults in Bosnia and Herzegovina to assess the attitude of participants toward COVID-19 vaccination. Using a logistic regression model, we assessed the associations of sociodemographic characteristics with vaccine rejection, reasons for vaccine hesitancy, preferred vaccine manufacturer, and information sources. Surprisingly, only 25.7% of respondents indicated they would like to get a COVID-19 vaccine, while 74.3% of respondents were either hesitant or completely rejected vaccination. The vaccine acceptance increased with increasing age, education, and income level. Major motivation of pro-vaccination behaviour was intention to achieve collective immunity (30.1%), while the leading incentive for vaccine refusal was deficiency of clinical data (30.2%). The Pfizer-BioNTech vaccine is shown to be eightfold more preferred vaccine compared to the other manufacturers. For the first time, vaccine acceptance among health care professionals has been reported, where only 39.4% of healthcare professionals expressed willingness to get vaccinated. With the high share of the population unwilling to vaccinate, governmental impotence in securing the vaccines supplies, combined with the lack of any lockdown measures suggests that Bosnia and Herzegovina is unlikely to put COVID-19 pandemic under control in near future. On 1st March 2020, the World Health Organization (WHO) characterized the coronavirus disease 2019 (COVID-19) as a pandemic (https://www.who.int/director-general/speeches/detail/who-director-general-s-opening-remarks-a t-the-media-briefing-on-covid-19---11-march-2020). Since the first registered case of COVID-19 until now there were more than 100 million officially registered cases of COVID-19 and more than 2 million persons have passed away due to COVID-19 infection (https://www.worldometers.info/coronavirus/). Consequently, the rapid development of a COVID-19 vaccine was a global imperative 1 . Now in 2021, there are currently a few vaccines that passed the third phase of clinical trial and they are being distributed all over the world 2 . In the majority of developed countries, the vaccination has already started, whereas in most developing and less developed countries the vaccination has not yet started (https://ourworldindata.org/covid-vaccinations). Vaccination has already started in the United States (US) and the European Union (EU). In the US and EU, Pfizer-BioNTech and Moderna vaccines have been approved (https://www.pfizer.com/news/press-release/press-release-detail/pfizer-and-biontech-receive-auth orization-european-union),while European Medicines Agency (EMA) has recommended the approval of the AstraZeneca COVID-19 vaccine (https://www.ema.europa.eu/en/news/ema-recommends-first-covid-19-vaccine-authorisation-eu). Safety and efficiency of the COVID-19 vaccine has been also confirmed for the Sputnik V. 3 Additionally, the National Medical Products Administration in China has given approval for the COVID-19 vaccine made by Sinovac Biotech In Bosnia and Herzegovina, ~120.000 cases of COVID- 19 have been officially been registered until February 2021 (3.4% of the whole population) and almost 5.000 deaths (4.16% of all COVID-19 cases). The peak of infection was in October and November. Currently, in B&H there are around 400 active cases, with ~93 new confirmed cases daily per million people and ~4 deaths daily per million people (https://ourworldindata.org/coronavirus-data-explorer). In January 2021, B&H was 4th among the countries with the highest mortality rate due to COVID-19 infection with 123 deaths reported per 100,000 people (https://worldmapper.org/maps/coronavirus-cases-casemortality/). Even though some COVID-19 measures are present (the curfew from 23:00 to 5:00 h, the ban of public gatherings for >50 persons indoors and 100 persons outdoors), they are not enforced. There is no lock-down, borders are open, schools and universities are partially opened, while shopping centers, restaurants, ski centers, and bars are working as usual (https://www.dw.com/bs/njema%C4%8Dki-mediji-gra%C4%91ani-bih-se-ne-pridr%C5%BEavaj u-pravila/a-54047892). The aim of this study was to collect data about the willingness of the adult population in Bosnia and Herzegovina to be vaccinated and to examine the factors that affect vaccine rejection. Additionally, we examined if vaccine rejection was correlated with education, income, profession, and age. We conducted a cross-sectional electronic survey study about COVID-19 vaccine acceptance in Bosnia and Herzegovina from January 26 th to February 2 nd , 2021 gathering answers from a total of 10,471 participants. The study was approved by the Ethics Committee of the Faculty of Engineering and Natural Sciences, International Burch University. Eligibility criteria included being age 18 or older and currently living in Bosnia and Herzegovina. The survey was developed in the local language and created using Google's online survey platform. All the study participants were informed that the data would be used only for research purposes and not available to the public. According to Google's privacy policy, all survey responses were anonymous and confidential. It was delivered to respondents via e-mails, research and employment-oriented online services (ResearchGate™ and LinkedIn™), and other social media platforms such as Facebook™, Skype™, and Viber™). The participants responded to a total of 11 items. The first part of the survey covered demographic questions including gender, level of education, profession, age, and monthly income. Gender was categorized as male, female or other. The level of education was defined as elementary school, high school, undergraduate degree, and postgraduate degree (master or doctorate). The profession was classified into five categories including medical professionals, teachers, business sector, catering and service industry, and others. The age was categorized into four different groups: 18-30, 31-50, 51-64, and 65 years or older. Monthly income was defined as 250 EUR or less, 250-450 EUR, and 450 EUR or more. The second part of the survey assessed a range of vaccine-related questions. Respondents were asked to claim whether they will choose to vaccinate or not, and to corroborate their choice with 5 . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. Statistical analysis included descriptive statistics data regarding the frequencies calculated for each category of demographic set of questions. Also, a univariate and multinomial logistic regressions in R were employed to examine correlation between vaccine acceptability and a set of demographics and variables of interest. 6 . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted March 3, 2021. Table 2 summarizes 5 univariate regressions regarding vaccine acceptability against demographics (age, gender, monthly income, education, and profession). Accordingly, age, education, occupation and income significantly affected attitudes towards vaccination (p <.05), while sex of the participant did not (p > .05). People aged 31-50, 51-64 and 65+ were more likely to accept the vaccine than those who were aged 18-30. This difference was strongest (odds ratio (OR) = 4.61; 95% confidence interval (CI) (2.74, 7.77)) when respondents aged 65+ were compared to the youngest age cohort. The univariate regression suggests no significant distinction in the response to vaccine acceptance based on the gender. Higher income was positively associated with vaccine acceptance. People earning 450+ EUR per month were 1.18 (95 CI% (1.04, 1.34)) times more likely to respond positively to the vaccine 7 . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted March 3, 2021. acceptance question than people earning 250 EUR and less. Higher levels of education were also associated positively with vaccine acceptance. Respondents from the postgraduate group were 5.21 (95 CI% (3.14, 9.18)) times more likely to respond positively compared to participants having only primary school education. Medical health professionals were more likely to get vaccinated compared to other professions. In fact, educational workers had 60% lower odds of vaccine acceptance compared to the health professionals. Major determinants behind vaccination were achieving collective immunity (30.11%) and concern regarding personal health (29.57%), following avoidance of "travel ban" (27.31%) and employer request (13.00%). The Pfizer-BioNTech would be chosen by 50.62 % participants willing to vaccinate, while Sinovac vaccines would be preferred for only 6.44 % of them. Effectiveness shown in clinical trials is the main motive for Pfizer's vaccine choice. Most objections to vaccination are due to insufficient clinical trials (30.11 %), 23.08 % respondents perceive pharmaceutical companies as self-serving enterprises. Significant numbers recognize vaccines as harmful (12.23%), 9.63% participants identify COVID-19 disease as harmless to their health, while an identical portion of respondents reject vaccines due to religious motives. For 9.19% participants SARS-CoV-2 virus is just a conspiracy theory, while 6.05% individuals assessed vaccines as necessary only for clinically vulnerable citizens. 8 . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted March 3, 2021. ; https://doi.org/10.1101/2021.03.01.21252700 doi: medRxiv preprint In this study, we report the lowest COVID-19 vaccine acceptance in the world, where only 25.7% participants demonstrated willingness to receive vaccination against SARS-CoV-2. Lowest COVID-19 vaccination acceptance levels prior reported was in Poland (37 %), following Slovakia (41 %), Romania (44 %) and Czech Republic (49 %) [4] [5] . Understanding of vaccination refusal and reasons for rejection among citizens in B&H is of great importance as reports from the January 2021 list Bosnia and Herzegovina as fourth in the world in terms of deaths per 100,000 inhabitants, right after Slovenia, Belgium and San Marino (https://worldmapper.org/maps/coronavirus-cases-casemortality/). Observed data should be used to raise awareness among the population and reach those strongly advocating against COVID-19 vaccination programs. Univariate regression outputs for vaccine acceptability demonstrate important discrepancies across diverse categories in the survey. Participants with above average income were more likely to accept vaccination compared to those having minimum wage. Findings suggest participants with primary school education were more prone to reject vaccination compared to participants having higher levels of education. Observed data are in accordance with studies previously conducted 4 . The univariate regression suggests no significant distinction in the response to vaccine acceptance based on the gender. However, we see a trend where women seem to be more hesitant regarding COVID-19 vaccines, while men are slightly more prone to vaccination, diverting from the trend of higher medical care service utilization among women 6 . Additionally, we observed age-related associations with vaccine acceptance. Older people were more likely to report that 9 . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted March 3, 2021. ; https://doi.org/10.1101/2021.03.01.21252700 doi: medRxiv preprint they would take a vaccine, whereas respondents aged 18-30 years had the highest rate of vaccination refusal 5, 7, 8 . Major driver of pro-vaccination behaviour was intention to achieve collective immunity, following health care and personal protection. Also, data clearly shows employer's vaccination requests would be insufficient incentive for vaccine acceptance among employees. The participants willing to vaccinate prefer Pfizer-BioNTech vaccines up to eightfold more compared to the other vaccine manufacturers, acknowledging high vaccine effectiveness reported in clinical trials [11] [12] [13] [14] [15] . Confidence in system and governmental decisions is evidently low, as the population witnesses various political and socio-economic crises in the post-war period. Strong domestic anti-vaccination movement noticed in the last several years finally got better understanding through cross-examination and common objections anti-vaccine advocates expressed over the years are reported in our survey 16, 17 . Anti-vaccination groups target local media and online platforms to spread misleading health information and address controversial arguments such as the economic benefit of pharmacies and tragic personal stories 18 . Reporting educational programs, media platforms and social networks as main sources of information during pandemic, high COVID-19 vaccine rejection among participants becomes utterly 10 . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted March 3, 2021. ; https://doi.org/10.1101/2021.03.01.21252700 doi: medRxiv preprint understandable. As the second major motivation for vaccine rejection, participants listed mistrust in pharmaceutical companies, followed by assessment of vaccines as harmful. Scientific community and health care professionals advocating vaccines, must be more presented on those platforms to raise awareness and reach citizens looking for reliable information. Most of the data used in this survey have been collected using online social networks, which often excludes citizens in the category of age 65 and older 19 . Since they represent a high-risk group and are more likely to accept vaccination, the acceptance rate may be larger than presented 4, 5 . Another limitation represents absence of information in case participants were infected with SARS-CoV-2 virus and whether they consider acquired immunity to be sufficient protection and adequate replacement for the vaccination. 23.2 % participants indicated hesitance to the vaccination due to insufficient clinical trials conducted, therefore safe and effective mass immunization around the globe could increase acceptance rate as time passes. Finally, rejection was assessed using a hypothetical vaccine, which may differ from the respondents' preferences encountering real life situations once COVID 19 vaccines become widely available. According to current studies, herd immunity benefits are achievable if 65%-70% of the population is vaccinated 20 . With the high share of the population unwilling to vaccinate, governmental impotence in securing the vaccines' supplies, combined with the number of people unable to receive the COVID-19 vaccine (e.g., allergies), herd immunity is out of reach for the B&H population in the near future. In order to increase awareness regarding health benefits of vaccination and the historical role immunization had in eradication of many deadly diseases, people must be reached through main informing sources -educational programs and media. Additional efforts must be made to organize scientific panels and conferences for healthcare workers and physicians, as only 39,4% of them are willing to accept vaccination. Ideally, . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted March 3, 2021. ; https://doi.org/10.1101/2021.03.01.21252700 doi: medRxiv preprint frontline medical professionals should make strong recommendations for vaccination, as well as share their personal experiences with COVID-19 vaccines. Finally, preparation for public acceptance of a COVID-19 vaccine must be carefully conducted before a vaccine becomes widely available. Based on this study, we urge the Bosnian government to develop strategies and COVID-19 vaccination implementation plans that would encourage citizens to accept a vaccination 21 . 12 . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The authors declare no competing financial or personal interests that could influence the work reported in this paper. This study was approved by Burch University Ethics Commission and informed consent obtained from all participants. . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted March 3, 2021. ; https://doi.org/10.1101/2021.03.01.21252700 doi: medRxiv preprint . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. 19 . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted March 3, 2021. 24 . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. 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