Perception to COVID-19 epidemic and acceptance of vaccination among healthcare workers in Beijing: a survey before the completion of COVID-19 vaccine phase III clinical trials

Background: Covid-19 vaccine research and development is progressing and expected to be put into use in a predictable time, we aimed to learn the awareness and acceptance of the new vaccine by healthcare workers (HCWs) in Beijing, China. Methods: A cross-sectional survey was conducted to investigate HCWs including doctors, nurses and technicians from sixty hospitals in Beijing to obtain the perception of COVID-19 epidemic and the attitudes towards vaccination before before the completion of vaccine phase III clinical trials. Multivariate analysis was applied to evaluate the associated factors with intention to get vaccination. Results: A total of 8040 HCWs was recruited. 67.1% reported they would get vaccination, others said unsure or would not. Half of the HCWs were unsure whether the outbreak in China would come back and the global epidemic would last for a long time. 67.6% agreed the epidemic can be prevented by vaccination. Positive associated factors with willingness to get vaccination were mainly included epidemic situation prognosis, perception of disease severity, self infection risk and disease can be prevented by vaccine, etc. Two positive factors of “wanted the vaccine free of charge” (OR:5.807, 95%CI:5.083-6.635, P<0.001) and “believed vaccine approved for license have been fully evaluated in clinical trials” (OR:4.485, 95%CI:3.849-5.227, P<0.001) were strongly associated with willingness to get vaccination, while two factors of “highest academic degree” (OR:0.840, 95%CI:0.772-0.914, P<0.001) and “professional ranks and titles” (OR:0.930, 95%CI:0.865-1.000, P=0.049) were negative associated . Conclusions: A little above moderate willingness to get COVID-19 vaccination was found among HCWs in Beijing before the vaccine being licensed. Free vaccination strategy should be considered to implement, effective measures should be taken to remove barriers and convey correct information through appropriate ways to enhance the acceptance of COVID-19 vaccination among HCWs in China. COVID-19 the of the disease; c) attitudes towards COVID-19 vaccination; d) past vaccination history and medical history. Five-point likert-scale were used to assessing the attitude and perception responses, and nally classied into three categories: positive answer, negative answer and uncertain answer.

predictable time. What's more, continuous pandemic will generate simultaneous demand for vaccination around the world.
Evidence-based data collection work should certainly be continued, based on experiences of pandemic in uenza A (H1N1) vaccine guidelines, it is highly likely that the healthcare workers (HCWs) will be recommended as a priority population as soon as the vaccine been licensed or has been approved for legal chartered emergency vaccination. Lessons also told us that even if the vaccine is successfully developed, future vaccination acceptance of different population including HCWs may not reach the ideal state [12]. In countries such as China, where Non-Pharmacological interventions (NPI, including early case identi cation and isolation, effectively close contact tracing and management, strictly social distancing, improved hygiene and commonly masks wearing and so on) [13] are strictly implemented and the epidemic was effectively controlled, the awareness and acceptance of the new COVID-19 vaccine by HCWs is still not learn. We conducted a cross-sectional survey in Beijing and hoped to provide references for formulating rational vaccination strategy for China and other counties.

Settings
According to geographical location, in all 16 districts of Beijing, we opted for Chaoyang and Fengtai district located in urban areas, Changping and Daxing district in the suburbs, Miyun and Huairou district in the outer suburbs, a total of 6 districts to participate in the survey. 10 hospitals in each district, including 2 level III general hospitals, 2 level II general hospitals and 6 level I hospitals/community health centers, were randomly selected. During the COVID-19 epidemic in Beijing, Level II and III general hospitals took responsibility for the diagnosis and treatment of cases, and Level I hospitals/community health center were involved in community population screening or nucleic acids sampling. We assumed that HCWs in these hospitals were facing occupational exposure risk.
Two infectious disease hospitals that specialize in treating COVID-19 patients, Beijing Ditan Hospital and Youan Hospital a liated with Capital Medical University, were designated to participate in the survey. Specialist hospitals, including traditional Chinese medical hospitals, children's hospitals, maternity hospitals, dental hospitals, etc., as well as hospitals closed during the epidemic, were excluded in the survey. The investigation began in early May and ended at the middle of June in 2020.

Study participants
For each hospital being sampled, all doctors, nurses, technicians in the high-risk departments/units, including emergency departments, fever clinics, respiratory system disease departments, intensive care unit, medical imaging departments and laboratory testing departments, were required to be investigated. For other departments, we identi ed a lowest limit on the number of participants (if the candidate number does not meet the lowest limit, all staff of the department should be investigated). Prior to the survey, we collected the number of target respondents in each hospital, and implemented quality control measures to ensure the response rate exceeded 95%.

Study instrument
An anonymous questionnaire was developed that assessed the following characteristics of participants: a) demographic characteristics including age, sex, marital status, family situation, job description; b) perception of risk towards COVID-19 epidemic and the severity of the disease; c) attitudes towards COVID-19 vaccination; d) past vaccination history and medical history. Five-point likert-scale were used to assessing the attitude and perception responses, and nally classi ed into three categories: positive answer, negative answer and uncertain answer.
Pilot survey were carried out before the formal use of the questionnaire to ensure that the statement of each question was clear and understandable. We made a mobile phone questionnaire, and the survey was completed by scanning the QR code through WeChat App, which was widely used in China to promote the convenience and compliance of the survey, and helped to avoid missing items.

Data analysis
We use Mapinfo 9.5 to build the database. Univariate analysis includes frequency and constituent ratio calculation as well as Pearson's Chi-squared test for differences was performed using SPSS 19.0.
Multivariate stepwise logistic regression model was applied to evaluate the associated factors with intention to accept COVID-19 vaccination. The odds ratio and 95% con dence interval were calculated. Alpha was set at the 5% level.

Results
General demographic characteristics A total of 8040 HCWs participated in the survey, of them 3844 (47.8%) were nurses, 2836 (35.3%) were doctors and 1360 (16.9%) were technicians. Of the respondents, most were less than 50 years old (90.4%) and female (80.4%), 70.3% stated they had participated in the prevention and control of COVID-19 epidemic, 34.4% admitted coming from departments may directly involve in the diagnosis and treatment of patients, and 35.1% reported having received other vaccines in the past 3 years. Details are summarized in table 1.

Perception to COVID-19 epidemic
The vast majority (95.8%) of the respondents considered that consequences of suffering from SARS-CoV-2 infection were "serious". 80.1% perceived they might be infected with the virus. 57.5% admitted they were at greater risk of SARS-CoV-2 infection than others, the proportion of doctors, nurses and technicians holding the view decreased successively (P<0.001). Nearly half of the respondents were unsure whether the outbreak in China would come back, and thought the global COVID-19 epidemic would last for a long time (59.2% of doctors hold this view, signi cantly higher than nurses and technicians (P<0.001)). 67.6% of the respondents agreed that COVID-19 epidemic can be prevented by vaccination, and a slightly lower proportion believed in the safety and effectiveness of the future vaccine. 73.0% of the respondents reported that their life had been seriously disturbed by the epidemic in the past three months, and 43.6% estimated their life and work would still be disturbed in the next six months. Table 2 shows the differences of perception in doctors, nurses and technicians when answered the same question.

Attitudes to COVID-19 vaccine
Compared with the o cial media's propaganda (80.4%), HCWs investigated believed more in the professional staff' advice (94.1%). 80.0% were convinced of COVID-19 vaccine approved for license have been fully evaluated in clinical trials, and 77.4% wanted the future vaccine free of charge. Most importantly, 67.1% of HCWs surveyed reported that they would get COVID-19 vaccination, 7.9% said they would not, and 25.0% said they were unsure. The proportion of those would advise family members to get vaccination (68.2%) was similar to that of their own willingness to vaccinate, however, the proportion of willingness to take children to get vaccination was signi cantly decreased to 61.9%. For the respondents would be vaccinated, vaccination campaign organized by hospital (75.3%) was obviously more acceptable than vaccination offered by community clinic (24.7%). In general, even if there were statistical differences in the answers of doctors, nurses and technicians on some questions for attitudes to COVID-19 vaccine, the proportion was very similar (table3). and "believed COVID-19 vaccine approved for license have been fully evaluated in clinical trials" (OR:4.485, P<0.001). Two other factors showed negative signi cantly association, which were "highest academic degree" (OR:0.840, P<0.001) and "professional ranks and titles" (OR:0.930, P=0.049).

Discussion
China's COVID-19 epidemic has experienced the following stages by the time axis to the end of August 2020: prevention and control outbreaks in Wuhan city and Hubei province (from 2019 to March 2020), prevention and control overseas imported and associated cases (since April 2020 to date), and control local outbreaks in Beijing, Dalian and Urumqi city (since early June 2020 to date) [14][15][16]. During the time of our investigation, the outbreak in Wuhan city has been already controlled, and the outbreak of Xinfadi wholesale market in Beijing have not yet begun. We did the investigation in this context and found out that the HCWs in Beijing only have a little more above moderate willingness to get the future COVID-19 vaccination, nearly one third of the respondents stated they would not or unsure. This is particularly surprising in a city where facing COVID-19 continuously attacking and even occurred local outbreaks in the past months, as well as historical suffering from huge SARS impact [17].
Two factors were found with strongly associated with intention to accept vaccine, which were "wanted the vaccine free of charge" and "believed vaccine approved for license have been fully evaluated in clinical trials". Other positive associated factors were mainly about perception of the disease, including epidemic situation prognosis, disease severity, self infection risk, disease can be prevented by vaccine, etc., which were consistent with the common sense and logic of willingness to vaccinate. Concerns about the safety and effectiveness of vaccines were similar with in uential factors previously reported in pandemic in uenza A (H1N1) vaccine studies [12,[18][19][20]. Our study also found only slightly more than 60% of the respondents agreed that the vaccine was safe and effective during the investigation. What's more, more than half of the respondents' judges of epidemic trend were apparently not consistent with the real situation. This means rooms still leaved for effective interventions to change the HCWs' perception to improve the acceptance of the COVID-19 vaccine.
Negative associated factors including "highest academic degree" and "professional ranks and titles" were not strong but worthy of attention. This may be due to higher correct cognition of the disease and vaccine, or be more con dent with the effect of Non-Pharmacological control interventions, so they tended to hold more cautious attitudes to accept a new vaccine. HCWs are the high-risk group of infection, the bridge group of hospital infection transmission, and also the professional playing key roles to recommend vaccine to the general population. The reason may need to further study to avoid the negative of authority effect on vaccination.
Reviewing the pandemic in uenza A (H1N1) vaccination process in 2009, the reported willingness of HCWs were usually 13-89% in different studies while the actual vaccination rate is slightly lower [12]. In China, willingness of the HCWs were about 50-80% to get vaccination in the early and rapid rising period and dropped to 20-30% at the peak of the in uenza A (H1N1) epidemic. One main reason is the public thought the disease was not serious as expected [21]. Under the implementation of a free and voluntary in uenza A (H1N1) vaccination strategy, the coverage rate of HCWs in Beijing were nally achieved 71% which were much higher than that of the general population 12.6% [22].
A successful vaccination strategy does not just protect the health of HCWs, but also limit the transmission between the health sector and the community. Measures may be recommended to improve HCWs' vaccination acceptance and encourage them play an exemplary role for the public: results of phase III clinical trials and post-licensed studies should continue to be published in peer-reviewed journals to maintain openness and transparency; evidence-based evaluation should be started, National Immunization Advisory Committee(NIAC), technical guidelines of Physicians Association and other ways should be made full use to provide authoritative information to HCWs; correct information should be ensure to transmit to the leaders and members of medical professional associations to mobilize them to participate in vaccination.

Conclusions
In summary, our study found that the HCWs in Beijing have a little more above moderate willingness to get the future COVID-19 vaccination before the completion of phase III vaccineclinical trials, and the willingness were strongly associated with the perception of whether the vaccine is free and safe. It suggested that free vaccination strategy should be considered to be implemented, hard work and effective measures should be taken immediately to remove barriers and convey correct information through appropriate ways to further enhance the awareness and improve acceptance of COVID-19 vaccination among HCWs in China.

Declarations Ethics approval and consent to participate
The method of this study was performed in accordance with the Declaration of Helsinki. Ethical approval was sought and granted from the Institutional Review Board and Human Research Ethics Committee of the Beijing Center for Disease Prevention and Control (Ethical approval No. 2020 (25)). The research was carried out in strict accordance with the research plan approved by the ethics committee. We obtained subjects' informed consent before the start of the interviews.

Consent for publication
Written informed consent for publication was obtained from all participants.

Data availability statements
The datasets used and/or analysed during the current study available from the corresponding author on reasonable request.     For the dependent variable "accept covid-19 vacciation", answer "Yes" is assigned as 1, answer "No" or "Unsure" is assigned as 0; if the independent variable is an ordered classi cation variable, it is set as dumb variables. All variables signi cant at p<0.1 in univariate logistic regression could be selected in the nal multivariable stepwise logistic regression analysis.