|Year : 2021 | Volume
| Issue : 2 | Page : 211-218
COVID-19 vaccine uptake and vaccine hesitancy in Indian patients with cancer: A questionnaire-based survey
Vanita Noronha1, George Abraham1, Suresh Kumar Bondili1, Annu Rajpurohit1, Rakesh P Menon1, Shreya Gattani1, Mehak Trikha1, Rajanigandha Tudu1, Kishore Kumar Kota1, Ajay Kumar Singh1, Prahalad Elamarthi1, Goutam Santosh Panda1, Rahul Kumar Rai1, Madala Ravi Krishna1, Sravan Kumar Chinthala1, Minit Jalan Shah1, Devanshee Shah1, Atul Tiwari1, Deep Nareshbhai Vora1, Arnav Hemant Tongaonkar1, George John1, Akshay Patil2, Nandini Sharrel Menon1, Vijay Maruti Patil1, Amit Joshi1, Shripad Banavali1, Rajendra A Badwe3, Kumar Prabhash1
1 Department of Medical Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
2 Department of Biostatistics, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
3 Department of Surgical Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
|Date of Submission||11-Jun-2021|
|Date of Decision||13-Jun-2021|
|Date of Acceptance||17-Jun-2021|
|Date of Web Publication||30-Jun-2021|
Department of Medical Oncology, Tata Memorial Hospital, Parel, Mumbai - 400 012, Maharashtra
Source of Support: None, Conflict of Interest: None
Background: Patients with cancer are at a higher risk of severe forms of coronavirus disease 2019 (COVID-19) and mortality. Therefore, widespread COVID-19 vaccination is required to attain herd immunity.
Objectives: We aimed to evaluate the uptake of the COVID-19 vaccine in Indian patients with cancer and to collect information regarding vaccine hesitancy and factors that contributed to vaccine hesitancy.
Materials and Methods: This was a questionnaire-based survey conducted between May 7, 2021 and June 10, 2021 in patients aged 45 years and over, with solid tumors. The primary end points of the study were the proportion of Indian patients with cancer aged 45 years and older who had not received the COVID-19 vaccine, and the reasons why these patients had not received the COVID-19 vaccine. Our secondary end points were the proportion of patients with a history of COVID-19 infection, and the proportion of the patients who had vaccine hesitancy. Additionally, we attempted to assess the factors that could impact vaccine hesitancy.
Results: A total of 435 patients were included in the study. Of these, 348 (80%) patients had not received even a single dose of the COVID-19 vaccine; 66 (15.2%) patients had received the first dose, and 21 (4.8%) had received both the doses. Approximately half (47.1%) of the patients reported that they took the COVID-19 vaccine based on the advice from a doctor. The reasons for not taking the COVID-19 vaccine could be considered as vaccine hesitancy in 259 (77%) patients. The two most common reasons were fear in 124 (38%) patients (fear of side-effects and of the impact of the vaccine on the cancer/therapy) and lack of information in 87 (26.7%) patients. On the multivariate analysis, the two factors found to be significantly associated with vaccine hesitancy were a lower educational level (OR, 1.78; 95% CI, 1–3.17; P = 0.048) and a lack of prior advice regarding the COVID-19 vaccine (OR, 2.80; 95% CI, 1.73–4.53; P < 0.001).
Conclusion: Vaccine hesitancy is present in over half of our patients, and the most common reasons are a fear of the vaccine impacting the cancer therapy, fear of side-effects, and lack of information. Widespread vaccination can only be attained if systematic programs for education and dissemination of information regarding the safety and efficacy of the COVID-19 vaccine are given as much importance as fortification of the vaccination supply and distribution system.
Keywords: COVID-19, questionnaire, side effects, vaccine hesitancy
|How to cite this article:|
Noronha V, Abraham G, Bondili SK, Rajpurohit A, Menon RP, Gattani S, Trikha M, Tudu R, Kota KK, Singh AK, Elamarthi P, Panda GS, Rai RK, Krishna MR, Chinthala SK, Shah MJ, Shah D, Tiwari A, Vora DN, Tongaonkar AH, John G, Patil A, Menon NS, Patil VM, Joshi A, Banavali S, Badwe RA, Prabhash K. COVID-19 vaccine uptake and vaccine hesitancy in Indian patients with cancer: A questionnaire-based survey. Cancer Res Stat Treat 2021;4:211-8
|How to cite this URL:|
Noronha V, Abraham G, Bondili SK, Rajpurohit A, Menon RP, Gattani S, Trikha M, Tudu R, Kota KK, Singh AK, Elamarthi P, Panda GS, Rai RK, Krishna MR, Chinthala SK, Shah MJ, Shah D, Tiwari A, Vora DN, Tongaonkar AH, John G, Patil A, Menon NS, Patil VM, Joshi A, Banavali S, Badwe RA, Prabhash K. COVID-19 vaccine uptake and vaccine hesitancy in Indian patients with cancer: A questionnaire-based survey. Cancer Res Stat Treat [serial online] 2021 [cited 2021 Jul 27];4:211-8. Available from: https://www.crstonline.com/text.asp?2021/4/2/211/320134
| Introduction|| |
The coronavirus disease 2019 (COVID-19) pandemic has caused massive disruption and destruction worldwide., As of June 11, 2021, there have been 175,677,082 cases and 3,790,320 deaths due to COVID-19. India has the second largest number of cases worldwide at 29,274,823, with 363,097 deaths. Patients with cancer are at a higher risk of developing severe forms of COVID-19 along with a higher risk of mortality due to various factors like immunosuppression, comorbidities, and advanced age. Given the lack of effective therapeutic options for COVID-19, the strategy that holds the most promise for combating the COVID-19 pandemic is mass vaccination. The Government of India started the national COVID-19 vaccination program in January 2021 and divided the vaccination distribution into phases. In the first phase that started on January 16, 2021, vaccination was provided to the healthcare and other frontline workers, people over the age of 60 years and people between 45 and 59 years with comorbidities. From April 1, 2021 onwards, people aged 45 years or over could receive the vaccine. In these phases, the COVID-19 vaccine was provided free of cost, through registration on a mobile phone application called “CoWin.” Starting May 1, 2021, the vaccination was provided to adults aged 18 years and older. However, there have been issues with vaccine supply,, and at the time of writing this manuscript on June 11, 2021, the vaccine was not widely available to people between the ages of 18 and 44 years.
Globally, there are currently 287 candidate COVID-19 vaccines including 185 in the preclinical stage and 102 in the clinical phase. In India, seven vaccines have been granted Emergency Use Approval including the most widely available Covishield (Oxford-AstraZeneca/Serum Institute of India) and Covaxin (Bharat Biotech/Indian Council of Medical Research), as well as Sputnik-V (Gamaleya Institute, Russia/Dr. Reddy's Lab) NVX-CoV2373 (Novavax/Serum Institute of India), BNT162b2 (Pfizer/BioNTech), mRNA-1273 (Moderna/NIAID), and Ad26.CoV2.S (Johnson and Johnson/Biological E).
Herd immunity or “population immunity” is important to protect the most vulnerable people in a population including the very young, the very sick, and the immunocompromised. Herd immunity against COVID-19 is most appropriately attained by vaccination, rather than by widespread natural infection.,, The proportion of the population that needs to be vaccinated in order to attain herd immunity varies based on the disease. This proportion is 95% of the population for measles, 80% for polio, and 33% to 44% for influenza., The proportion of the population that needs to be vaccinated against COVID-19 to achieve herd immunity is not definitively known. However, it is likely to be between 70% and 85% of the population.
The American Society of Clinical Oncology (ASCO) recommends COVID-19 vaccination be taken by all patients with solid tumor malignancies, unless there is a history of hypersensitivity to any of the components of the vaccine, including those receiving active treatment. ASCO recommends vaccination for patients with hematological malignancies as well; however, vaccination should be administered after an appropriate waiting period to patients who have received a stem cell transplant or immunoglobulins. At the Tata Memorial Hospital in Mumbai, India, the COVID-19 vaccine is freely available for all eligible patients with cancer, with the recommendation of the treating oncologist, after appropriate registration and verification of their identity by a healthcare worker.
Vaccine hesitancy, defined as the postponement or refusal by a person for themselves or their dependents (children), of a vaccine that is available, was declared one of the top ten threats to global health by the World Health Organization in 2019. General vaccine hesitancy is often attributed to the 3 C's: lack of confidence, complacency, and inconvenience in terms of easy access to the vaccine. In the context of COVID-19 vaccine hesitancy, two additional Cs have been added to help deal with vaccine hesitancy including communication and context (sociodemographic characteristics). These determinants of vaccine hesitancy vary based on the population being studied, the disease, the vaccine, and various other factors.
There are scant data regarding the uptake of COVID-19 vaccine in Indian patients with cancer, and no information regarding vaccine hesitancy and factors that contribute to vaccine hesitancy. We therefore aimed to study these factors in our patients.
| Materials and Methods|| |
General study details
This was a questionnaire-based survey conducted between May 7, 2021 and June 10, 2021 in the Solid Unit 2 of the Department of Medical Oncology at the Tata Memorial Hospital, a tertiary cancer hospital in Mumbai, India. Given the survey nature of the study and the fact that only de-identified data were captured, approval from the Institutional Ethics Committee was not required. Verbal informed consent was obtained from each patient before administering the questionnaire. The study was conducted according to the ethical guidelines established by the Declaration of Helsinki and Good Clinical Practice guidelines. The study was not registered in a public clinical trials registry, and no funding was utilized for the study.
Patients aged 45 years and over, with thoracic, head and neck, genitourinary malignancies, patients undergoing evaluation in the geriatric oncology clinic, and in the chemotherapy daycare administration area were included in the study. There were no specific exclusion criteria.
The primary end points of our study were the proportion of Indian patients with cancer aged 45 years and above who had not received the COVID-19 vaccine, and the reasons for not receiving the COVID-19 vaccine. The secondary end points were the proportion of patients who had a prior history of COVID-19 infection, and the proportion of the patients who had vaccine hesitancy. Further, we aimed to understand whether there were any differences between patients with vaccine hesitancy and vaccine acceptance, with regard to factors such as age, sex, education, the primary site of malignancy, cancer management, and whether or not someone had spoken to them regarding COVID-19 vaccination.
A questionnaire comprising 23 questions to assess the vaccine uptake was administered to the patients who were willing to participate in the study. The questionnaire was available as a printed form as well as an online Google form [Supplementary Appendix 1]. One separate questionnaire was filled out for each patient who visited the team of doctors in the Solid Unit 2 of the Department of Medical Oncology during the study period.
Vaccine hesitancy was defined as a delay in accepting vaccination or a refusal to take a vaccine that was available.
Statistical analyses were performed using the statistical software R (version 4.0.3-R Core Team (2019); R: A language and environment for statistical computing) and SPSS (the statistical package for social sciences) IBM Corp. Released 2017; IBM SPSS Statistics for Windows, Version 25.0. Armonk, NY, USA: IBM Corp). We did not perform a formal sample size calculation and included all patients who responded to the questionnaire within the timeframe of the study. Demographic data were summarized with descriptive statistics. Continuous data were represented as median (interquartile range [IQR]) and categorical data were reported in absolute numbers and percentages, respectively. The Kolmogorov–Smirnov test was used to determine normality of the test data distribution. We assessed the impact of various factors on vaccine hesitancy, using the Pearson's Chi-square test. The factors tested included age (45–59 years vs. 60 years and over), sex, education (illiterate or primary school education, i.e., up to Standard 4 vs. higher education), primary malignancy (lung vs. esophagus vs. oral cavity/pharynx/larynx, vs. others), active cancer-directed therapy (awaiting the start of therapy and ongoing therapy vs. follow-up), and whether someone has discussed vaccination with the person earlier. We also constructed an adjusted multivariate logistic regression model to evaluate the impact of the same factors on vaccine hesitancy. Backward stepwise deletion based on the Wald test was applied. All P values were two-tailed, and P < 0.05 was considered statistically significant.
| Results|| |
A total of 505 questionnaires were filled out between May 7, 2021, and June 10, 2021. Of these, 70 were excluded and a total of 435 questionnaires were included in the final analysis [Figure 1]. The clinicodemographic details are provided in [Table 1].
There were 371 (85.1%) patients who were on active therapy. Of the 432 patients in whom the information regarding prior COVID-19 infection was obtained, 35 (8.1%) reported a history of COVID-19 infection. Only 1 of these 35 patients had received the first dose of the COVID-19 vaccine prior to contracting the COVID-19 illness.
Out of 435 patients, 348 (80%) had not received a single dose of the COVID-19 vaccine, 66 (15.2%) had received the first dose, and 21 (4.8%) had received both the doses. A total of 65 (74.7%) patients received the vaccine, Covishield, 11 (12.6%) received Covaxin, and the remaining 11 (12.6%) did not know what brand of COVID-19 vaccine they had received. There were 49 (56.3%) patients who received the vaccine in Mumbai; 35 (40.2%) received it locally in their hometown (outside Mumbai), and in 3 (3.4%) patients, the place of COVID-19 vaccination was not documented. Forty-one (47.1%) patients reported that they took the COVID-19 vaccine based on their doctor's advice, 38 (43.7%) took the vaccine on their own, and 4 (4.6%) took the vaccine based on someone other than the doctor's advice; the reason was not documented in 3 (3.4%) patients.
Of the 348 patients who had not taken the COVID-19 vaccine, the reason why the vaccine was not taken was recorded in 326 patients (93.7%). The reasons provided by the patients, and possible solutions that we envisaged are detailed in [Table 2]. The reasons for not taking the COVID-19 vaccine could be considered as vaccine hesitancy in 259 (77%) patients. The two most common reasons provided for not taking the COVID-19 vaccine were fear in 124 (38%) patients and lack of information in 87 (26.7%) patients. Of the 26 patients who feared side-effect from the COVID-19 vaccine, 8 patients described the specific side-effect that concerned them. These included fever in 4, aggravation of preexisting hypertension in 1, interaction with the pain medications in 1, and fear of death because of the COVID-19 vaccine in 2 patients.
|Table 2: The reasons provided by the patients with cancer for not taking the coronavirus disease-2019 vaccine|
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Of the 406 patients who responded to the question regarding whether anyone had spoken to them about the COVID-19 vaccine, 210 patients (49.5%) responded 'yes'. The person who had advised the COVID-19 vaccine was a healthcare worker in 171 patients (42.1%). Of the 248 patients with vaccine hesitancy, 110 (44.4%) reported that someone had spoken to them earlier about the COVID-19 vaccine, as opposed to 88 (71.5%) of 123 patients without vaccine hesitancy (P < 0.0001, by Chi-square test). On performing a univariate analysis, another factor that was found to be significantly associated with vaccine hesitancy was the primary tumor site, with significantly higher vaccine hesitancy in patients with tumors of the oral cavity/pharynx/larynx-79.2% compared to patients with lung cancer-62.4% and other primaries-64.7%, P=0.014 [Table 3]. On performing a multivariate analysis, the primary tumor site did not retain statistical significance as a factor contributing to vaccine hesitancy. The two factors found to be significantly associated with vaccine hesitancy were a lack of higher education (OR, 1.78; 95% CI, 1.00-3.17; P=0.048) and no prior advice regarding the COVID-19 vaccine (OR, 2.80; 95% CI, 1.73–4.53; P<0.001) [Figure 2].
|Table 3: Univariate analysis to evaluate the impact of various factors on vaccine hesitancy|
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|Figure 2: Forest plot showing the odds ratio for the various parameters used in the analysis of vaccine hesitancy. An odds ratio of more than one favors vaccine hesitancy and less than one favors vaccine acceptance. Lower level of education attained and lack of prior advice regarding coronavirus disease 2019 vaccination were significantly associated with vaccine hesitancy, with P-values of 0.048 and <0.001, respectively.|
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Starting May 28, 2021, we asked patients regarding whether they would be willing to take the COVID-19 vaccine at the end of the questionnaire session. Of a total of 109 patients, 20 (18.3%) had already taken the vaccine. Of the remaining 89 patients, 3 (3.4%) were undecided, 5 (5.6%) refused, and 81 (91%) said that they were willing to take the COVID-19 vaccine. Of the 8 patients who refused or were undecided, 3 reported that they were still worried that the COVID-19 vaccine would affect the cancer treatment, 2 were worried that it would increase their weakness, 2 refused to give a reason, and 1 was scared of death after the vaccine. A total of 76 patients responded to the question, “What will convince you to take the COVID-19 vaccine?” The responses were, information/education in 23 (30.3%), advice from the treating physician in 20 (26.3%), a visit to the COVID-19 vaccination center in 2 (2.6%), improvement in general well-being (decrease of cancer-related or therapy-related fatigue) or a return to hometown in 2 (2.6%); 22 (28.9%) patients reported that they had become convinced by the end of the brief discussion with the physician administering the questionnaire, whereas 3 (3.9%) stated that nothing could convince them.
| Discussion|| |
In our study in 435 Indian patients with solid tumors, aged 45 years and above, we observed that 80% of the patients had not taken the COVID-19 vaccine, despite the fact that the Government of India was widely providing the COVID-19 vaccine free of cost at the time of the study (May 2021 to early June 2021). Although approximately 18% of the patients reported that they wanted to receive the COVID-19 vaccine but were unable to due to unavailability of the vaccine, the vast majority, (77%) of the patients were hesitant to receive the COVID-19 vaccine. Overall, the vaccine hesitancy in our study was 59.4%. In order to effectively control the pandemic, a significant proportion of the population (approximately 70%–85% of the population) needs to be vaccinated to attain herd immunity. [13, 17, 24] Our study suggests that merely increasing vaccine supply and strengthening the vaccine distribution system is unlikely to automatically translate to widespread vaccination. Therefore, aggressively tackling vaccine hesitancy is equally or perhaps more important.
The uptake of COVID-19 vaccine in our patients with cancer was approximately 20% for one dose; approximately 5% of patients had received both doses of the vaccine. As of June 9, 2021, 12.1% of the world's population and 13.9% of Indians had received at least one dose of the COVID-19 vaccine; 6.2% of the world's population and 3.3% of Indians were fully vaccinated, i.e., had received both doses of the COVID-19 vaccine. In our study, we included only adults aged 45 years and over, rather than including all patients, hence our denominator included the group of people most likely to have received the vaccination, which is perhaps what led to the slightly higher proportion of vaccinated individuals in our study. There were 49 patients who were younger than 45 years old, and for whom the vaccine questionnaires were filled out. These patients were excluded from the study and from the analysis. Only two patients from this cohort (4.1%) had received at least 1 dose of the COVID-19 vaccine, and one patient (2%) had received both doses. This illustrates the fact that the vaccine uptake in Indians younger than age 45 years is still poor. Batra et al. have reported a higher uptake of the COVID-19 vaccine, i.e., 29% of their patients with cancer had received at least one vaccine dose. Patients with cancer are a higher risk for developing severe COVID-19 infection and should be prioritized as a high-risk group, for vaccination, regardless of their age.
COVID-19 vaccine hesitancy has been characterized in various studies. A survey of over 36,000 Arabs showed a vaccine hesitancy rate of over 80%, with the common reasons being fear of side-effects, lack of trust in the healthcare system, the companies producing the vaccine, and the rapid rate of vaccine approval and production. The vaccine hesitancy rate in adult Americans is 26.3% (95% CI, 17.3–36.4), while that in ethnic minorities has been reported to be higher at 30.2% (95% CI, 23.2–37.7) in Hispanics and 41.6% (95% CI, 34.4–48.9) in African-Americans. A study of 428 hospital employees in inner-city New York revealed that only 64% had planned to receive the COVID-19 vaccine within 1 month; an additional 9% planned on getting vaccinated over the following 6 months. A survey in 505 Chinese healthcare workers revealed that vaccine hesitancy existed in 23.4%. Far more alarmingly, 61.7% of Nepalese healthcare workers had vaccine hesitancy. The most significant factor that lowered the vaccine hesitancy in our cohort of patients was advice from someone regarding the COVID-19 vaccine. A nationwide survey in 1068 Indian medical students revealed that their vaccine hesitancy was 10.6%. Healthcare workers play a pivotal role in allaying patients' fears and mitigating vaccine hesitancy. For the patients in our study, the mere process of asking them questions about COVID-19 vaccination as part of the survey led to a discussion with them about the pros and cons of taking the COVID-19 vaccine. At the end of this brief counseling, 91% of the patients reported that they were convinced regarding the need for vaccination. Thus, merely advising our patients with cancer to take the COVID-19 vaccine and solving their doubts appears to be a powerful tool to improve vaccination rates.
The general uptake of adult vaccination like the influenza and pneumococcal vaccine is very low in India. Geneev et al. reported that only 2% and 0.7% of their patients had received influenza and pneumococcal vaccination, respectively. In the initial analysis from our geriatric oncology clinic in June 2020, we found that none of the 30 patients who were asked about vaccination status had been advised or received any vaccination by their primary care physician. In an updated evaluation of the 341 patients seen in the geriatric oncology clinic between February 2020 and June 2021, only 4 (1.2%) and 3 (0.9%) patients had received pneumococcal and influenza vaccines, respectively, before the geriatric assessment (unpublished data). The major barrier to widespread adult vaccination in India is financial constraints. This issue has been eliminated for the COVID-19 vaccine, as it is being provided free through the government. Vaccine centers are also widely available, thus eliminating one “C” from the list of determinants of vaccine hesitancy, i.e., convenience. As per the Delhi National Capital Region Coronavirus Telephone Survey ( (DCVTS)-round 4, that was performed from December 23, 2020, to January 4, 2021, approximately 39% of people from Delhi had vaccine hesitancy, including 20% who said that they would definitely refuse the vaccine. According to the online, “COVID-19 Symptom Survey,” conducted among Facebook users since April 2020, 29% of Indians had vaccine hesitancy, including 16.3% who said that they would probably not take the vaccine and 12.4% who said that they would definitely not take it. The common reasons for vaccine hesitancy provided were the need to further evaluate the spectrum of side-effects of the vaccine (confidence), the feeling that the vaccine was needed more by others than the person surveyed (complacency), and the fear of side-effects (confidence).
In Barriere et al.'s study, 46.3% of the French patients with cancer reported vaccine hesitancy. Villarreal-Garza et al. evaluated 610 Mexican women with breast cancer and reported a 34% rate of vaccine hesitancy. In our study, the rate of vaccine hesitancy was much higher at 59.4%. We found that in addition to the common reasons for vaccine hesitancy, a major concern for our patients with cancer was a fear that the COVID-19 vaccine or the side-effects of the COVID-19 vaccine would affect the cancer therapy or the cancer itself (confidence). Advice or a simple discussion with the patient regarding the COVID-19 vaccine (communication and context) was associated with a significantly lower rate of vaccine hesitancy. Of the patients who had taken the COVID-19 vaccine, approximately half the patients said that the reason they took the vaccine was the advice of their doctor. Thus, an aggressive information, education, and communication campaign is likely to be the key mechanism of tackling the issue of COVID-19 vaccine hesitancy.
The limitations of our study were that we did not collect detailed information from the participants about factors that may have impacted vaccine hesitancy including income level, employment status, the place of residence, number of household inhabitants, the time from diagnosis of cancer, and whether the patient had received any other vaccination such as influenza or pneumococcal vaccine. We did not record whether a friend, relative, or acquaintance of the patient had developed COVID-19 infection or had died as a result of COVID-19 infection or had taken the COVID-19 vaccine. We also do not have follow-up data regarding whether the patients who said that they were willing to take the COVID-19 vaccine actually went on to get vaccinated.
| Conclusion|| |
In conclusion, 20% of the Indian patients with cancer aged 45 years and above have received at least one dose of the COVID-19 vaccine. Vaccine hesitancy is present in almost 60% of our patients, and the most common reasons are the fear of the vaccine impacting the cancer therapy, fear of side-effects, and lack of information. In the vaccine policy of the Government of India, systematic programs for education and dissemination of information regarding the safety and efficacy of the COVID-19 vaccine should be considered as important as fortification of the vaccination supply and distribution programs.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3]