PreprintPDF Available

Abstract and Figures

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.
Content may be subject to copyright.
Lack of lockdown, open borders, and no vaccination in sight: is Bosnia and Herzegovina a
control group?
Adnan Fojnica1, Ahmed Osmanovic2, Nermin Đuzic3, Armin Fejzic4, Ensar Mekic3, Zehra
Gromilic5, Imer Muhovic3, and Amina Kurtovic-Kozaric3,6*
1Institute of Biotechnology and Biochemical Engineering, Graz University of Technology, NAWI
Graz, 8010 Graz, Austria.
2Olawell Inc., Manchester, MA 01944, USA
3International Burch University, Francuske revolucije bb, Sarajevo, Bosnia and Herzegovina
4Department of Molecular biology, University of Vienna, Universitätsring 1, 1010 Vienna,
Austria
5Institute of Biochemistry, Graz University of Technology, Petersgasse 10-12/II, 8010 Graz,
Austria.
6Department of Pathology, Cytology and Human Genetics, University Clinical Center Sarajevo,
Sarajevo, Bosnia and Herzegovina,
Correspondence:
Amina Kozaric, PhD
Professor of Genetics
Bolnicka 25, 71 000 Sarajevo, Bosnia and Herzegovina
Phone: +387 62 621 423
Email: amina.kurtovic@gmail.com
. CC-BY-ND 4.0 International licenseIt 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. ; https://doi.org/10.1101/2021.03.01.21252700doi: medRxiv preprint
NOTE: This preprint reports new research that has not been certified by peer review and should not be used to guide clinical practice.
Abstract
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.
2
. CC-BY-ND 4.0 International licenseIt 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. ; https://doi.org/10.1101/2021.03.01.21252700doi: medRxiv preprint
Introduction
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 imperative1. 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 world2. 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
(http://subsites.chinadaily.com.cn/nmpa/2021-02/07/c_588422.htm). Regarding the Balkans,
3
. CC-BY-ND 4.0 International licenseIt 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. ; https://doi.org/10.1101/2021.03.01.21252700doi: medRxiv preprint
vaccination has not started in Albania, Bosnia and Herzegovina (B&H), Kosovo, Montenegro,
and North Macedonia (Figure 1). In B&H, the media have reported that in Republika Srpska, an
entity of Bosnia and Herzegovina, around 2.000 doses of Sputnik V COVID-19 vaccine have
been distributed among healthcare workers.
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.
4
. CC-BY-ND 4.0 International licenseIt 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. ; https://doi.org/10.1101/2021.03.01.21252700doi: medRxiv preprint
Materials and Methods
We conducted a cross-sectional electronic survey study about COVID-19 vaccine acceptance in
Bosnia and Herzegovina from January 26th to February 2nd, 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 licenseIt 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. ; https://doi.org/10.1101/2021.03.01.21252700doi: medRxiv preprint
rationale for or against vaccination having the ability to select multiple options. Furthermore,
participants were asked to state their major source of information about health implications of
COVID-19 vaccines. The respondents willing to be vaccinated were asked to indicate which
vaccine manufacturer(s) would be their personal choice: Pfizer – BioNTech (Germany),
Oxford-AstraZeneca (United Kingdom), Modern (USA), Sputnik V (Russia), or Sinovac
(China), and to choose one or more reasons for the choice.
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 licenseIt 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. ; https://doi.org/10.1101/2021.03.01.21252700doi: medRxiv preprint
Results
Table 1 summarizes the set of demographic data including age, gender, education, monthly
income, and profession. Women were 52.3% respondents of the survey and 53.9% were between
18 and 30 years old. More than half of the participants (53.1%) had monthly income of 450
EUR or more (average salary is about 450 EUR). About half of the respondents (51.9%) had a
university degree. Significant number of healthcare professionals (15%) took part in our study.
Overall, 25.7% (2,695 of 10,461) of respondents indicated they are willing to get a COVID-19
vaccine, while 74.3% of respondents hesitated to get vaccinated (37.4% would not vaccinate,
13.7% respondents would vaccinate only if obliged, and 23.2% will wait for additional clinical
studies to decide). Detailed breakdown of vaccine questions is available in Supplementary Table
1. We treated the three answers: 'No', 'Only if I will have to’ and 'Maybe later' as one group
because they show trends in their answers (Supplementary Table 2 and 3).
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 licenseIt 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. ; https://doi.org/10.1101/2021.03.01.21252700doi: medRxiv preprint
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 licenseIt 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. ; https://doi.org/10.1101/2021.03.01.21252700doi: medRxiv preprint
Discussion
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
conducted4.
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 women6. Additionally, we observed
age-related associations with vaccine acceptance. Older people were more likely to report that
9
. CC-BY-ND 4.0 International licenseIt 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. ; https://doi.org/10.1101/2021.03.01.21252700doi: medRxiv preprint
they would take a vaccine, whereas respondents aged 18‒30 years had the highest rate of
vaccination refusal5,7,8.
For the first time in B&H, vaccine acceptance among health care professionals has been
examined and compared to the other professions. Only 39.4 % of healthcare professionals are
willing to accept vaccination, while others are hesitant or strongly refusing vaccination. This
confirms concerns raised by Arapovic et al. in 2019, regarding lower vaccine acceptance among
healthcare workers in B&H, as they directly communicate with patients and shape their
perspective toward vaccination9. Similar vaccine acceptance was reported in a recent study
conducted among health care professionals in the United States10.
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 trials11-15. 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 survey16,17. 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 stories18. 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 licenseIt 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. ; https://doi.org/10.1101/2021.03.01.21252700doi: 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 older19. Since they represent a high-risk
group and are more likely to accept vaccination, the acceptance rate may be larger than
presented4,5. 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 vaccinated20. 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,
11
. CC-BY-ND 4.0 International licenseIt 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. ; https://doi.org/10.1101/2021.03.01.21252700doi: 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
vaccination21.
12
. CC-BY-ND 4.0 International licenseIt 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. ; https://doi.org/10.1101/2021.03.01.21252700doi: medRxiv preprint
Contributions
A.F. and A.O. conceived and designed the study. N.Đ. and A.F. managed and performed data
collection. E.M. and I.M. statistically analyzed and interpreted the data. A.F., A.O., N. Đ., A.F.,
Z.G., and A.K. drafted the manuscript. A.K. edited and approved the final version for
submission.
Competing Interest
The authors declare no competing financial or personal interests that could influence the work
reported in this paper.
Ethical approval
This study was approved by Burch University Ethics Commission and informed consent
obtained from all participants.
13
. CC-BY-ND 4.0 International licenseIt 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. ; https://doi.org/10.1101/2021.03.01.21252700doi: medRxiv preprint
References
1. Graham, B. S. Rapid COVID-19 vaccine development. Science 368, 945–946 (2020).
2. Le, T. T. et al. The COVID-19 vaccine development landscape. Nat. Rev. Drug Discov.
19, 305–306 (2020).
3. Logunov, D. Y. et al. Safety and efficacy of an rAd26 and rAd5 vector-based
heterologous prime-boost COVID-19 vaccine: an interim analysis of a randomised
controlled phase 3 trial in Russia. The Lancet 397, 671-681 (2021).
4. Feleszko, W., Lewulis, P., Czarnecki, A., & Waszkiewicz, P. Flattening the Curve of
COVID-19 Vaccine Rejection—An International Overview. Vaccines 9(1), 44 (2021).
5. Lazarus, J. V. et al. A global survey of potential acceptance of a COVID-19 vaccine. Nat.
Med.,27, 225–228 (2021).
6. Bertakis, K. D., Azari, R., Helms, L. J., Callahan, E. J., & Robbins, J. A. Gender
differences in the utilization of health care services. J. Fam. Prac. 49(2), 147-147 (2000).
7. Harapan, H. et al. Acceptance of a COVID-19 vaccine in southeast Asia: A
cross-sectional study in Indonesia. Front. Public Health 8, 381 (2020).
8. Wong, M. C. et al. Acceptance of the COVID-19 vaccine based on the health belief
model: A population-based survey in Hong Kong. Vaccine 39(7), 1148-1156 (2021).
9. Arapović, J., Sulaver, Ž., Rajič, B., & Pilav, A. The 2019 measles epidemic in Bosnia and
Herzegovina: What is wrong with the mandatory vaccination program? Bosn. J. Basic
Med. Sci. 19(3), 210 (2019).
10. Shekhar, R. et al. COVID-19 vaccine acceptance among health care workers in the
United States Vaccines 9(2), 119 (2021).
14
. CC-BY-ND 4.0 International licenseIt 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. ; https://doi.org/10.1101/2021.03.01.21252700doi: medRxiv preprint
11. Polack, F. P. et al. Safety and efficacy of the BNT162b2 mRNA Covid-19 vaccine. N.
Engl. J. Med.383(27), 2603-2615 (2020).
12. Kim, J. H., Marks, F., & Clemens, J. D. (2021). Looking beyond COVID-19 vaccine
phase 3 trials. Nat. Med. 27, 205–211 (2021).
13. Knoll, M. D., & Wonodi, C. Oxford–AstraZeneca COVID-19 vaccine efficacy. The
Lancet 397(10269), 72-74.(2021).
14. Mahase, E. Covid-19: Moderna vaccine is nearly 95% effective, trial involving high risk
and elderly people shows. B. Med J. 371, (2020).
15. Jones, I., & Roy, P. Sputnik V COVID-19 vaccine candidate appears safe and effective.
The Lancet 397(10275), (2021).
16. Hukic, M. et al. An ongoing measles outbreak in the Federation of Bosnia and
Herzegovina, 2014 to 2015. Eurosurveillance 20(9), 21047 (2015).
17. Čalkić, L., Skomorac, M., Tandir, S., Sivić, S., & Bajramović-Omeragić, L. Public health
significance of immunization and epidemic occurrence of measles. Med Glas (Zenica)
15(1), (2018).
18. Burki, T. Vaccine misinformation and social media. Lancet Digit Health 1(6), e258-e259
(2019).
19. Güleç, D., Işıkhan, S. Y., & Orhaner, E. Social media usage and health promoting
lifestyle in profile related socio-demographic factors in Turkey. Health Promot. Perspect.
10(1), 80 (2020).
20. Randolph, H. E., & Barreiro, L. B. Herd immunity: understanding COVID-19. Immunity
52(5), 737-741 (2020).
15
. CC-BY-ND 4.0 International licenseIt 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. ; https://doi.org/10.1101/2021.03.01.21252700doi: medRxiv preprint
21. Thomson, A., Vallee-Tourangeau, G., & Suggs, L. S. Strategies to increase vaccine
acceptance and uptake: From behavioral insights to context-specific,
culturally-appropriate, evidence-based communications and interventions. Vaccine
36(44), 6457-6458 (2018).
16
. CC-BY-ND 4.0 International licenseIt 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. ; https://doi.org/10.1101/2021.03.01.21252700doi: medRxiv preprint
Figure Legends
Figure 1 The number of vaccine doses given to people, not the number of people fully
vaccinated. Since some vaccines require more than one dose, the number of fully vaccinated
people is likely to be lower. Retrieved from Our World in Data on 2/3/2021.
17
. CC-BY-ND 4.0 International licenseIt 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. ; https://doi.org/10.1101/2021.03.01.21252700doi: medRxiv preprint
Table 1 Summary of participants’ demographic data
Overall
n
10,471
Gender (%)
Male
4,965 (47.4)
Female
5,476 (52.3)
Other
30 (0.3)
Level of education (%)
Elementary school
159 (1.5)
High school
4,878 (46.6)
Undergraduate degree
3,757 (35.9)
Postgraduate degree (Master or Doctoral degree)
1,677 (16)
Profession (%)
Medical professionals
1,570 (15)
Education sector
936 (8.9)
Economic sector
1,639 (15.7)
Catering and service industry
721 (6.9)
Other
5,605 (53.5)
Age group in years (%)
18-30
5,649 (53.9)
31-50
4,210 (40.2)
51-64
544 (5.2)
65+
68 (0.6)
Total monthly income
250 EUR or less
2,522 (24.1)
250-450 EUR
2,384 (22.8)
450 EUR or more
5,565 (53.1)
18
. CC-BY-ND 4.0 International licenseIt 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. ; https://doi.org/10.1101/2021.03.01.21252700doi: medRxiv preprint
Table 2 Beta coefficients and odds ratios of predictors of attitude towards vaccination when
comparing the answers 'Yes' with 'No / Only if I will have to / Maybe later'
Variable
Level comparison
Beta coefficients (95%
CIs)
Odds ratios (95%
CIs)
Age
31–50 vs 18–30
0.52 (0.42, 0.62)***
1.69 (1.53, 1.87)***
51–64 vs 18–30
1.10 (1.00, 1.30)***
3.15 (2.59, 3.82)***
65 or more vs 18-30
1.50 (1.00, 2.10)***
4.61 (2.74, 7.77)***
Sex
Female vs male
-0.01 (-0.10, 0.09)
0.99 (0.90, 1.10)
Other vs male
-0.71 (-1.70, 0.18)
0.49 (0.17, 1.20)
Education
High school vs primary school
0.68 (0.18, 1.20)*
1.97 (1.20, 3.44)*
Graduate vs primary school
1.50 (1.00, 2.10)***
4.57 (2.78, 8.01)***
Postgraduate vs primary school
1.70 (1.10, 2.20)***
5.21 (3.14, 9.18)***
Profession
Economic sector vs medical
worker
-0.59 (-0.75, -0.44)***
0.55 (0.47, 0.65)***
Service sector vs medical worker
-0.70 (-0.94, -0.47)***
0.50 (0.39, 0.63)***
Educational vs medical worker
-0.93 (-1.10, -0.74)***
0.40 (0.33, 0.48)***
Other vs medical worker
-0.62 (-0.75, -0.49)***
0.54 (0.47, 0.61)***
Income
250-450 EUR vs 250 EUR or less
-0.31 (-0.45, -0.16)***
0.74 (0.63, 0.85)***
450 EUR or more vs 250 EUR or
less
0.17 (0.04, 0.29)**
1.18 (1.04, 1.34)**
*, p < .05; **, p < .01; ***, p < .001
19
. CC-BY-ND 4.0 International licenseIt 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. ; https://doi.org/10.1101/2021.03.01.21252700doi: medRxiv preprint
Supplementary Table 1 Summary of descriptive statistics results
Research Questions
n=10,471
Will most of the people
reject the COVID-19
vaccine?
37.40% does not want to receive COVID-19 vaccine
23.18% will be waiting for additional clinic studies
13.69% will receive only if obliged to
What are the main motives
for vaccination?
30.11% Acquiring collective immunity and preventing spread of virus
29.57% Healthcare and self protection
27.31% Travel possibility and avoidance of „travel ban“
13.00% Employer’s request and preservation of working position
What are the reasons for
vaccination refusal?
30.19% Insufficient clinical trials of vaccination
23.08% Lack of trust to pharmacy
12.23% Vaccines perceived as harmful
9.63% COVID-19 disease is not dangerous for my health
9.63% Vaccines’ compositions are against my ethical and religious
principles
9.19% SARS-CoV-2 does not exist - it is conspiracy theory
6.05% Only most vulnerable categories shall receive the vaccines
What are the main sources
of information about
health-related implication
vaccines have?
27.70% Educational and documentary shows
26.16% Media and information portals
20.10% Social networks (Facebook™, Twitter™ etc.)
15.90% Scientific books and papers
10.14% Recommendations of family physicians
20
. CC-BY-ND 4.0 International licenseIt 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. ; https://doi.org/10.1101/2021.03.01.21252700doi: medRxiv preprint
Which vaccines are more
likely to be accepted by
citizens of Bosnia and
Herzegovina?
No1: Pfizer–BioNTech (Germany), by 50.62%
No2: Oxford-AstraZeneca (United Kingdom), by 16.16%
No3: Moderna (USA), by 15.30%
No4: Sputnik V (Russia), 11.48%
No5: Sinovac (China), by 6.44%
What are the reasons to
choose a specific vaccine
manufacturer?
52.37% Effectiveness reported through studies
21.69% International politics states’ manufacturers have
19.92% Physician’s or medical staff’s advice
6% Following governmental decisions
21
. CC-BY-ND 4.0 International licenseIt 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. ; https://doi.org/10.1101/2021.03.01.21252700doi: medRxiv preprint
Supplementary Table 2 Beta coefficients and odds ratios of predictors of attitude towards
vaccination when comparing the vaccine answers using multinomial logistic regression
Beta
95% CI
Odds Ratio
95% CI
p-value
0.10
-0.01, 0.21
1.11
0.99, 1.23
0.074
-1.10
-2.10, -0.14
0.32
0.12, 0.87
0.025
2.20
1.60, 2.70
8.72
5.01, 15.2
<0.001
1.90
1.40, 2.50
6.99
4.06, 12.0
<0.001
0.87
0.33, 1.4
2.38
1.38, 4.08
0.002
-0.63
-0.81, -0.44
0.53
0.44, 0.64
<0.001
-0.74
-0.89, -0.59
0.48
0.41, 0.55
<0.001
-0.81
-1.10, -0.55
0.45
0.35, 0.58
<0.001
-1.00
-1.20, -0.73
0.39
0.31, 0.48
<0.001
1.50
0.85, 2.1
4.27
2.33, 7.81
<0.001
1.30
1.10, 1.60
3.81
3.01, 4.82
<0.001
0.59
0.48, 0.70
1.81
1.62, 2.02
<0.001
0.09
-0.05, 0.23
1.10
0.95, 1.26
0.200
-0.43
-0.59, -0.27
0.65
0.55, 0.76
<0.001
22
. CC-BY-ND 4.0 International licenseIt 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. ; https://doi.org/10.1101/2021.03.01.21252700doi: medRxiv preprint
-0.04
-0.17, 0.09
0.96
0.85, 1.10
0.600
-11.00
-11.00,
-11.00
0.00
0.00, 0.00
<0.001
0.39
-0.12, 0.90
1.48
0.89, 2.47
0.130
0.45
-0.03, 0.94
1.57
0.97, 2.56
0.068
0.15
-0.33, 0.63
1.16
0.72, 1.87
0.600
0.00
-0.23, 0.24
1.00
0.79, 1.27
>0.900
-0.24
-0.44, -0.04
0.79
0.65, 0.96
0.018
-0.07
-0.35, 0.21
0.93
0.70, 1.23
0.600
0.31
0.05, 0.58
1.37
1.05, 1.78
0.020
-0.85
-2.10, 0.38
0.43
0.13, 1.46
0.200
-0.06
-0.41, 0.28
0.94
0.67, 1.32
0.700
0.04
-0.09, 0.17
1.04
0.91, 1.18
0.600
0.05
-0.11, 0.22
1.06
0.90, 1.24
0.500
0.01
-0.17, 0.19
1.01
0.85, 1.20
>0.900
0.33
0.22, 0.44
1.39
1.25, 1.56
<0.001
23
. CC-BY-ND 4.0 International licenseIt 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. ; https://doi.org/10.1101/2021.03.01.21252700doi: medRxiv preprint
-0.64
-1.6, 0.31
0.53
0.20, 1.36
0.200
1.50
1.00, 1.90
4.39
2.75, 7.02
<0.001
1.20
0.77, 1.7
3.39
2.15, 5.34
<0.001
0.66
0.21, 1.1
1.94
1.23, 3.03
0.004
-0.08
-0.28, 0.11
0.92
0.75, 1.12
0.400
-0.22
-0.38, -0.05
0.81
0.69, 0.95
0.009
-0.27
-0.51, -0.02
0.77
0.60, 0.98
0.035
-0.26
-0.49, -0.03
0.77
0.61, 0.97
0.028
0.10
-0.65, 0.85
1.10
0.52, 2.34
0.800
0.56
0.31, 0.81
1.75
1.36, 2.25
<0.001
0.19
0.07, 0.30
1.20
1.08, 1.35
0.001
-0.25
-0.39, -0.12
0.78
0.68, 0.89
<0.001
-0.38
-0.53, -0.24
0.68
0.59, 0.79
<0.001
24
. CC-BY-ND 4.0 International licenseIt 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. ; https://doi.org/10.1101/2021.03.01.21252700doi: medRxiv preprint
Supplementary Table 3 Beta coefficients and odds ratios of predictors of attitude towards
vaccination when comparing the answers 'Yes / Only if I will have to' vs. 'No / Maybe later'
Variable
Level comparison
Beta coefficients (95%
CIs)
Odds ratios (95%
CIs)
Age
31–50 vs 18–30
0.31 (0.23, 0.40)***
1.37 (1.25, 1.49)***
51–64 vs 18–30
0.66 (0.48, 0.85)***
1.94 (1.62, 2.33)***
65 or more vs 18-30
0.84 (0.34, 1.30)**
2.31 (1.40, 3.84)***
Sex
Female vs male
-0.08 (-0.17, 0.00)
0.92 (0.84, 1.00)
Other vs male
-1.2 (-2.2, -0.35)*
0.30 (0.11, 0.71)*
Education
High school vs primary school
0.33 (-0.03, 0.72)
1.39 (0.97, 2.05)
Graduate vs primary school
0.91 (0.54, 1.30)***
2.48 (1.72, 3.66)***
Postgraduate vs primary school
0.94 (0.56, 1.30)***
2.56 (1.75, 3.80)***
Profession
Economic sector vs medical
worker
-0.40 (-0.55, -0.26)***
0.67 (0.58, 0.77)***
Service sector vs medical worker
-0.44 (-0.64, -0.25)***
0.64 (0.53, 0.78)***
Educational vs medical worker
-0.42 (-0.59, -0.26)***
0.65 (0.55, 0.77)***
Other vs medical worker
-0.51 (-0.62, -0.39)***
0.60 (0.54, 0.68)***
Income
250-450 EUR vs 250 EUR or less
-0.09 (-0.21, 0.04)
0.92 (0.81, 1.04)
450 EUR or more vs 250 EUR or
less
0.19 (0.08, 0.30)***
1.21 (1.09, 1.35)***
*, p < .05; **, p < .01; ***, p < .001
25
. CC-BY-ND 4.0 International licenseIt 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. ; https://doi.org/10.1101/2021.03.01.21252700doi: medRxiv preprint
ResearchGate has not been able to resolve any citations for this publication.
Article
Full-text available
Background: Acceptance of the COVID-19 vaccine will play a major role in combating the pandemic. Healthcare workers (HCWs) are among the first group to receive vaccination, so it is important to consider their attitudes about COVID-19 vaccination to better address barriers to widespread vaccination acceptance. Methods: We conducted a cross sectional study to assess the attitude of HCWs toward COVID-19 vaccination. Data were collected between 7 October and 9 November 2020. We received 4080 responses out of which 3479 were complete responses and were included in the final analysis. Results: 36% of respondents were willing to take the vaccine as soon as it became available while 56% were not sure or would wait to review more data. Only 8% of HCWs do not plan to get vaccine. Vaccine acceptance increased with increasing age, education, and income level. A smaller percentage of female (31%), Black (19%), Lantinx (30%), and rural (26%) HCWs were willing to take the vaccine as soon as it became available than the overall study population. Direct medical care providers had higher vaccine acceptance (49%). Safety (69%), effectiveness (69%), and speed of development/approval (74%) were noted as the most common concerns regarding COVID-19 vaccination in our survey.
Article
Full-text available
After the recent announcement of COVID-19 vaccine efficacy in clinical trials by several manufacturers for protection against severe disease, a comprehensive post-efficacy strategy for the next steps to ensure vaccination of the global population is now required. These considerations should include how to manufacture billions of doses of high-quality vaccines, support for vaccine purchase, coordination of supply, the equitable distribution of vaccines and the logistics of global vaccine delivery, all of which are a prelude to a massive vaccination campaign targeting people of all ages. Furthermore, additional scientific questions about the vaccines remain that should be answered to improve vaccine efficacy, including questions regarding the optimization of vaccination regimens, booster doses, the correlates of protection, vaccine effectiveness, safety and enhanced surveillance. The timely and coordinated execution of these post-efficacy tasks will bring the pandemic to an effective, and efficient, close. A comprehensive strategy for the next steps to ensure vaccination of the global population against SARS-CoV-2 is now required, and key steps and challenges are detailed in this Perspective.
Article
Full-text available
Background: If globally implemented, a safe coronavirus disease 2019 (COVID-19) vaccination program will have broad clinical and socioeconomic benefits. However, individuals who anticipate that the coronavirus vaccine will bring life back to normality may be disappointed, due to the emerging antivaccination attitude within the general population. Methods: We surveyed a sample of adult Polish citizens (n = 1066), and compared it with the data on international COVID-19 vaccine reluctance. Results: In 20 national surveys, the vaccine averseness for the anticipated COVID-19 vaccine varied from meager (2-6% China) to very high (43%, Czech Republic, and 44%, Turkey) and in most countries was much higher than regular vaccination reluctance, which varies between 3% (Egypt) and 55% (Russia). Conclusions: These results suggest that a 67% herd immunity may be possible only if mandatory preventive vaccination programs start early and are combined with coordinated education efforts supported by legislative power and social campaigns.
Article
Full-text available
Background Vaccines for COVID-19 are anticipated to be available by 2021. Vaccine uptake rate is a crucial determinant for herd immunity. We examined factors associated with acceptance of vaccine based on (1). constructs of the Health Belief Model (HBM), (2). trust in the healthcare system, new vaccine platforms and manufacturers, and (3). self-reported health outcomes. Methods A population-based, random telephone survey was performed during the peak of the third wave of COVID-19 outbreak (27/07/2020 to 27/08/2020) in Hong Kong. All adults aged ≥18 years were eligible. The survey included sociodemographic details; self-report health conditions; trust scales; and self-reported health outcomes. Multivariable regression analyses were applied to examine independent associations. The primary outcome is the acceptance of the COVID-19 vaccine. Results We conducted 1,200 successful telephone interviews (response rate 55%). The overall vaccine acceptance rate after adjustment for population distribution was 37.2% (95% C.I. 34.5% to 39.9%). The projected acceptance rates exhibited a “J-shaped” pattern with age, with higher rates among young adults (18-24 years), then increased linearly with age. Multivariable regression analyses revealed that perceived severity, perceived benefits of the vaccine, cues to action, self-reported health outcomes, and trust in healthcare system or vaccine manufacturers were positive correlates of acceptance; whilst perceived access barriers and harm were negative correlates. Remarkably, perceived susceptibility to infection carried no significant association, whereas recommendation from Government (aOR=10.2, 95% C.I. 6.54 to 15.9, p<0.001) was as the strongest driving factor for acceptance. Other key obstacles of acceptance included lack of confidence on newer vaccine platforms (43.4%) and manufacturers without track record (52.2%), which are of particular relevance to the current context. Conclusions Governmental recommendation is an important driver, whereas perceived susceptibility is not associated with acceptance of COVID-19 vaccine. These HBM constructs and independent predictors inform evidence-based formulation and implementation of vaccination strategies. (298 words)
Article
Full-text available
Background Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and the resulting coronavirus disease 2019 (Covid-19) have afflicted tens of millions of people in a worldwide pandemic. Safe and effective vaccines are needed urgently. Methods Download a PDF of the Research Summary. In an ongoing multinational, placebo-controlled, observer-blinded, pivotal efficacy trial, we randomly assigned persons 16 years of age or older in a 1:1 ratio to receive two doses, 21 days apart, of either placebo or the BNT162b2 vaccine candidate (30 μg per dose). BNT162b2 is a lipid nanoparticle–formulated, nucleoside-modified RNA vaccine that encodes a prefusion stabilized, membrane-anchored SARS-CoV-2 full-length spike protein. The primary end points were efficacy of the vaccine against laboratory-confirmed Covid-19 and safety. Results A total of 43,548 participants underwent randomization, of whom 43,448 received injections: 21,720 with BNT162b2 and 21,728 with placebo. There were 8 cases of Covid-19 with onset at least 7 days after the second dose among participants assigned to receive BNT162b2 and 162 cases among those assigned to placebo; BNT162b2 was 95% effective in preventing Covid-19 (95% credible interval, 90.3 to 97.6). Similar vaccine efficacy (generally 90 to 100%) was observed across subgroups defined by age, sex, race, ethnicity, baseline body-mass index, and the presence of coexisting conditions. Among 10 cases of severe Covid-19 with onset after the first dose, 9 occurred in placebo recipients and 1 in a BNT162b2 recipient. The safety profile of BNT162b2 was characterized by short-term, mild-to-moderate pain at the injection site, fatigue, and headache. The incidence of serious adverse events was low and was similar in the vaccine and placebo groups. Conclusions A two-dose regimen of BNT162b2 conferred 95% protection against Covid-19 in persons 16 years of age or older. Safety over a median of 2 months was similar to that of other viral vaccines. (Funded by BioNTech and Pfizer; ClinicalTrials.gov number, NCT04368728.)
Article
Full-text available
Several coronavirus disease 2019 (COVID-19) vaccines are currently in human trials. In June 2020, we surveyed 13,426 people in 19 countries to determine potential acceptance rates and factors influencing acceptance of a COVID-19 vaccine. Of these, 71.5% of participants reported that they would be very or somewhat likely to take a COVID-19 vaccine, and 61.4% reported that they would accept their employer’s recommendation to do so. Differences in acceptance rates ranged from almost 90% (in China) to less than 55% (in Russia). Respondents reporting higher levels of trust in information from government sources were more likely to accept a vaccine and take their employer’s advice to do so.
Article
Background A heterologous recombinant adenovirus (rAd)-based vaccine, Gam-COVID-Vac (Sputnik V), showed a good safety profile and induced strong humoral and cellular immune responses in participants in phase 1/2 clinical trials. Here, we report preliminary results on the efficacy and safety of Gam-COVID-Vac from the interim analysis of this phase 3 trial. Methods We did a randomised, double-blind, placebo-controlled, phase 3 trial at 25 hospitals and polyclinics in Moscow, Russia. We included participants aged at least 18 years, with negative SARS-CoV-2 PCR and IgG and IgM tests, no infectious diseases in the 14 days before enrolment, and no other vaccinations in the 30 days before enrolment. Participants were randomly assigned (3:1) to receive vaccine or placebo, with stratification by age group. Investigators, participants, and all study staff were masked to group assignment. The vaccine was administered (0·5 mL/dose) intramuscularly in a prime-boost regimen: a 21-day interval between the first dose (rAd26) and the second dose (rAd5), both vectors carrying the gene for the full-length SARS-CoV-2 glycoprotein S. The primary outcome was the proportion of participants with PCR-confirmed COVID-19 from day 21 after receiving the first dose. All analyses excluded participants with protocol violations: the primary outcome was assessed in participants who had received two doses of vaccine or placebo, serious adverse events were assessed in all participants who had received at least one dose at the time of database lock, and rare adverse events were assessed in all participants who had received two doses and for whom all available data were verified in the case report form at the time of database lock. The trial is registered at ClinicalTrials.gov (NCT04530396). Findings Between Sept 7 and Nov 24, 2020, 21 977 adults were randomly assigned to the vaccine group (n=16 501) or the placebo group (n=5476). 19 866 received two doses of vaccine or placebo and were included in the primary outcome analysis. From 21 days after the first dose of vaccine (the day of dose 2), 16 (0·1%) of 14 964 participants in the vaccine group and 62 (1·3%) of 4902 in the placebo group were confirmed to have COVID-19; vaccine efficacy was 91·6% (95% CI 85·6–95·2). Most reported adverse events were grade 1 (7485 [94·0%] of 7966 total events). 45 (0·3%) of 16 427 participants in the vaccine group and 23 (0·4%) of 5435 participants in the placebo group had serious adverse events; none were considered associated with vaccination, with confirmation from the independent data monitoring committee. Four deaths were reported during the study (three [<0·1%] of 16 427 participants in the vaccine group and one [<0·1%] of 5435 participants in the placebo group), none of which were considered related to the vaccine. Interpretation This interim analysis of the phase 3 trial of Gam-COVID-Vac showed 91·6% efficacy against COVID-19 and was well tolerated in a large cohort. Funding Moscow City Health Department, Russian Direct Investment Fund, Sberbank, and RUSAL.