Perception of COVID-19 and Vaccine Acceptance among Healthcare Workers

Background COVID-19 infection is more likely to be acquired and transmitted by healthcare workers (HCWs). Furthermore, they serve as role models for communities in terms of COVID-19 vaccination attitudes. As a result, HCWs' reluctance to vaccinate could have a significant impact on pandemic containment efforts. Aim To characterize the current COVID-19 vaccine approval situation among healthcare workers and to determine the most likely reason for agreement or disagreement with COVID-19 vaccination. Methods This cross-sectional design included 451 HCWs from COVID-19 treatment institutions, with COVID-19 exposure risk changing depending on job function and working location. Results The study recruited 156 physicians and 295 nurses, of whom 58.1% were female and 41.9% were male. Physicians had a significantly higher rate of participation in COVID-19 pandemic prevention and control, with a rate of 69.9% versus 55.3% of nurses. Acceptance of COVID-19 vaccination was reported by 40.8% of HCWs. The rate of acceptance was significantly higher among physicians (55.1%) than among nurses (33.2%) (p < 0.001). Most HCWs (67.8%) believed the vaccine was not effective. Physicians showed more significant trust in the effectiveness of the vaccine than nurses (41% and 27.5, respectively) (p=0.003). Concerning vaccine safety, only 32.8% of HCWs believed it was safe. This was significantly higher in physicians (41.7%) than in nurses (28.1%) (p=0.004). Conclusion Vaccination uncertainty is common among healthcare personnel in Egypt, and this could be a significant barrier to vaccine uptake among the public. Campaigns to raise vaccine knowledge are critically needed.


Introduction
Coronavirus disease 2019, also known as COVID-19, is a rapidly spreading pandemic caused by a novel human coronavirus called SARS-CoV-2, an enveloped singlestranded RNA virus that was previously known as 2019-nCov [1][2][3]. It was frst reported in December 2019 among patients with viral pneumonia in Wuhan, China, as the world's most serious health issue [4].
On January 30, 2020, World Health Organization (WHO) proclaimed this extremely contagious virus a "public health emergency of international concern" due to its rapid spread across many countries. COVID-19 was later declared a global pandemic by the WHO on March 11, 2020, due to an increase in the number of afected countries, cases, and deaths [5].
Health Care Workers (HCWs) are on the front lines of COVID-19 pandemic defense, and they are vulnerable to not only COVID-19 infection but also psychological distress, long working hours, fatigue, occupational stigma, and physical violence [6,7]. Te WHO recommends that HCWsand patients' close contacts be protected to prevent the disease from spreading. Overcrowding, a lack of isolation facilities, and a contaminated environment all contribute to disease transmission among HCWs, which is likely aided by HCWs' lack of understanding and awareness of infection control procedures [8]. Inadequate expertise and attitudes among HCWs can have a direct impact on practices, resulting in delayed diagnosis and poor infection control practices [9,10]. Hand washing, social distancing, and respiratory hygiene (covering mouth and nose while coughing or sneezing) are all primary preventive measures [11]. It would be benefcial to protect these healthcare workers from COVID-19 infectious illness, not just for themselves but also for their family members as well as their patients.
As the COVID-19 outbreak poses a serious threat to public health [12], researchers were racing to develop and test COVID-19 vaccines [13]. A COVID-19 vaccine has been considered necessary to end the pandemic, and multiple experimental trials to develop a COVID-19 vaccine are currently being coordinated at a higher level [12]. Following vaccine development, COVID-19 vaccination programs faced the challenge of gaining community acceptance.
Vaccine development took years in the past. Despite its availability, public acceptability of a novel COVID-19 vaccine created in a short period of time remains dubious [14]. Lessons gathered from earlier infuenza pandemics, when the vaccine was frst introduced and acceptance rates were variable in many countries, necessitate a thorough knowledge of the vaccination reluctance problem [15,16].
Te Egyptian Ministry of Health (MOH) gave healthcare personnel top priority when the COVID-19 vaccine became accessible in Egypt [20]. Tey posed the greatest risk of contracting the novel virus of any group. Te frst wave of immunized HCWs received the Oxford-AstraZeneca COVID-19 vaccine until all doses were used up, at which point they switched to the Sinopharm and Sinovac vaccines [21,22]. Te WHO estimates that Egypt has 513,790 confrmed COVID-19 cases up through May 2022, including 24,641 fatalities, and that 82,017,392 vaccine doses were administered in total [23]. Coronavirus vaccinations were found to be well tolerated and safe, with the majority of postvaccination adverse efects being mild to moderate, according to a research study of COVID-19 vaccine side efects among the Egyptian population [24].
Te reasons for vaccine rejection vary, but vaccination hesitancy is a widespread occurrence worldwide [11][12][13]. Perceived hazards vs. advantages and a lack of knowledge and awareness were among the most prevalent causes [25,26]. When it comes to COVID-19 vaccination reluctance, there is a substantial correlation between wanting to receive the vaccine and its perceived safety [27], as well as between having a bad opinion of the vaccine and a desire not to receive it [28].
Due to the complexity of this phenomenon, research on the worldwide efects of vaccination hesitancy, especially readiness to adopt COVID-19 vaccines, may be limited. Tis implies that vaccine reluctance is infuenced by cognitive, psychologic, sociodemographic, and cultural factors [29,30].
Te Advisory Committee on Immunization Practices (ACIP) recommended that HCWs receive immunization priority in December 2020 [31,32]. A study was conducted to describe the potential COVID-19 vaccine acceptance among Egyptian healthcare providers, in which 45.9% accepted to receive the vaccine, while 40.9 percent refused to take the vaccine [33]. Tey concluded that Egyptian HCWs willingness to accept COVID-19 vaccination is lower than in western nations but higher than in African countries. Egyptian HCWs' vaccine apprehension could be a major factor in the COVID-19 approval decision [34]. Te fact that HCWs are exposed to more professional information and subsequently have more concerns about the efcacy and safety of the COVID-19 vaccine may be a contributing factor to this fnding regarding the intention of COVID-19 vaccination among healthcare workers. Tis concern may afect HCWs' decisions to get vaccinated and prevent them from recommending vaccination to patients [32].
In 2019, the World Health Organization (WHO) listed ten global health hazards, including vaccine indecision and the possibility of a pandemic [35]. Both threats actually pose a threat to the world. Te term "vaccine hesitancy" refers to a delay in receiving a vaccine, vaccine acceptance or denial, regardless of accessibility of vaccination programs [36]. Indecisiveness over vaccines is also worrying for public health doctors [37,38] and nurses [39].
Our study aimed to characterize the current COVID-19 vaccine acceptance among HCWs and determine the most likely reasons for agreement or disagreement with COVID-19 vaccination. Also, we aimed at determining healthcare workers' perceptions and attitudes, identifying the elements that infuence their attitudes, and identifying factors that could help enhance vaccine acceptance among healthcare professionals. Tis report serves as guidance for Egyptian health ofcials and public health specialists, highlighting the COVID-19 vaccine's expected problems among HCWs.

Results
Te study included 451 HCWs (156 physicians and 295 nurses); 58.1% of them were female, and 41.9% were male. Most of the HCWs were from urban residences (79.2%), while only 20.8% were from rural ones. Regarding marital status, 59.2% were married, 35% were single, 4% were divorced, and 1.8% were widows. Te number of household members for the studied HCWs ranged from 1 to 10 with a median of 4 persons. Concerning the HCWs' level of education, 30.2% had a bachelor's degree, 27.3% had a diploma, 19.7% had a master's degree, 18.2% had completed a course in a nursing institute, and only 4.7% had a medical doctorate. Te HCWs' duration of work ranged between 1 and 42 years with a mean of 8 ± 6.5 ( Table 1). As shown in Table 2, the most frequently reported chronic illnesses were diabetes and hypertension, which were highly reported among nurses than physicians. Table 3 shows that physicians had a signifcantly higher rate of participation in COVID-19 pandemic prevention and control with a rate of 69.9% versus 55.3% of nurses. Tere was no signifcant diference between physicians and nurses regarding the COVID-19 infection rate 55.1% of physicians and 51.9% of nurses. Concerning the methods of COVID-19 International Journal of Microbiology    International Journal of Microbiology diagnosis among HCWs, clinical presentation was the highest reported method (42.4% of HCWs), and it was more signifcantly reported by physicians than among nurses (p < 0.001). Te least reported method was PCR, although it was signifcantly more reported among physicians than among nurses (p � 0.020). Table 4 shows the knowledge, attitude, and practices of HCWs towards COVID-19 disease. Tere was a signifcantly better knowledge base among physicians than nurses regarding the COVID-19 infection.
As shown in Table 5, 48.8% of HCWs stated that they are at risk of getting COVID-19 infection, but they believe they will get mild symptoms which will not require hospitalization. Only 5.1% of HCWs think they will not get reinfected after recovering from a confrmed infection with COVID-19. Tere was a statistically signifcant diference between nurses' and physicians' responses, where 12.2% of nurses were confdent that they will not get infected, while only 6.4% of physicians had the same response. In addition, 6.8% of nurses believed they would not get reinfected after recovering from a confrmed COVID-19 infection, while only 1.9% of physicians recorded this belief. On the other hand, 57.7% of physicians believed they will have mild symptoms if got COVID-19 infection versus 44.1% of nurses.
Most of the physicians (55.1%) accept to take COVID-19 vaccines than nurses (33.2%) (p < 0.001); also, vaccination campaign organized by the hospital was the preferred place for getting the vaccine (Table 6). Table 7 shows HCWs' beliefs towards the COVID-19 vaccine. Most HCWs (67.8%) believed that the vaccine was not efective. Physicians showed more signifcant trust in the efectiveness of the vaccine than nurses (41% and 27.5%, respectively) (p � 0.003). Concerning vaccine safety, only 32.8% of HCWs believed it was safe. Tis was signifcantly higher in physicians (41.7%) than in nurses (28.1%) (p � 0.004). However, 65.2% of HCWs believed that the vaccine was necessary for them. Tis was slightly higher in physicians (71.8%) than in nurses (61.7%). Tirty-seven percent (37%) of HCWs believe that the COVID-19 vaccine has fatal side efects. Tis was more obvious among nurses (43.7%) than physicians (24.3%) (p < 0.001). Te majority of HCWs (77.6%) stated that they needed more information about the vaccine, especially (86.5% of physicians and 72.9% of nurses) (p � 0.001). Te propaganda of ofcial media was trusted by 32.8% of HCWs, where nurses showed a signifcantly higher percentage than physicians (36.9% and 25%, respectively) (p � 0.010). Concerning the vaccine's clinical trials, only 38.6% of HCWs believed that the vaccine was fully evaluated by clinical trials (46.8% of physicians and 34.2% of nurses) (p � 0.009). 50.8% of HCWs stated that they will get the vaccine in the future (67.9% of physicians and 41.7% of nurses) (p < 0.001). Besides, 47.5% of them will advise their family members to get the vaccine (56.4% of physicians and 42.7% of nurses) (p � 0.006). On the other hand, 59.6% of physicians will take their children to get COVID-19 vaccination versus 35.3% of nurses (p < 0.001).   International Journal of Microbiology As presented in Table 8, medical specialists were the most commonly reported trustworthy source of information about the COVID-19 vaccine.
Healthcare workers' attitudes post-pandemic are presented in Table 9. Periodical administration of the COVID-19 vaccine was reported by 59.4% of HCWs; there was no signifcant diference between nurses and physicians. Similar behavior was detected toward infuenza vaccine (68.1% of HCWs). Nurses reported signifcantly more preference to take pneumococcal vaccine annually than physicians (47.1% and 26.3%, respectively) (p < 0.001).
As presented in Table 10, the mean age of HCWs accepting to take the COVID-19 vaccine was signifcantly higher than those refusing (32.6 ± 7.9 and 30.8 ± 7.2, respectively) (p � 0.011). Males showed a signifcantly higher acceptance for the vaccine than females (53.4% and 31.7%, respectively) (p < 0.001). Regarding the occupational group, 55.1% of physicians accepted to take the vaccine versus 33.2% of nurses (p < 0.001). Concerning the educational level, the highest acceptance of the vaccine was recorded among HCWs having medical doctorate (57.1%) and master's degree (56.2%) (p � 0.001). Besides, HCWs accepting the vaccine had signifcantly larger mean duration of work experience (8.8 ± 6.8) than those refusing the vaccine (7.4 ± 6.3) (p � 0.002).
As shown in Table 11, there was a statistically signifcant relation between vaccine acceptance and medical status of the HCWs.
Tere was no signifcant relation between vaccine acceptance and HCWs' work experience with COVID-19 as shown in Table 12.
Logistic regression analysis was conducted for factors afecting vaccine acceptance. A backward conditional method was used. Factors entered into the model were age, gender, occupation, the level of education, and duration of work experience. Gender and occupation were found to be predictors of COVID-19 vaccine acceptance as presented in Table 13.

Discussion
Te current study investigated whether healthcare workers would accept COVID-19 vaccines since they are on the front lines of pandemic response and are more susceptible to infection.
Te main fndings showed that 40.8% agreed to receive the vaccine and 59.2% disagreed. Te acceptance percentage among physicians (55.1%) was much greater than that of nurses (33.2%). Similar to another study, in which 46% of the participants were either totally agreeing or somewhat agreeing to take the vaccine, despite the fact that a higher percentage of participants intended to accept the vaccine, the overall acceptability of the responses is considered low [34]. Te lack of safety, fear of genetic mutation, and new technology, as well as the belief that the vaccines are inefective, were the main reasons for disagreement. Te existence of comorbidities or chronic conditions, as well as the age of healthcare personnel (older participants tend to approve more), were the key factors infuencing COVID-19 acceptability.
In terms of vaccination acceptance, a survey of 613 Congolese healthcare workers (HCWs) found that only 28% of participants would accept COVID-19 vaccination [41]. A study from France included 3259 people who completed an online questionnaire, and it found that nearly 3/4 of them (77.6%, 95 percent confdence interval 76.2-79 percent) would take the vaccine. Healthcare professionals were 81.5% likely to get vaccinated, compared to 73.7 percent of nonhealthcare workers [42].
Furthermore, research performed in the United States found that only 30% of participants would prefer not to obtain the vaccination as soon as it becomes available [41,43].
Te intention to accept COVID-19 vaccination among Egyptian HCWs is low relative to studies from western countries but higher than African research. Tis could be explained by participants' misconceptions obtained from social media as a source of knowledge [34]. Besides, the variety of professions represented among the respondents in this study may have infuenced our fndings, as a large portion of respondents (39.8%) were medical students, who had a lower degree of expertise than doctors. In addition, since most of the other compared investigations were completed in early 2020, the time efect can be added to the discrepancy between the results of the current study and the other compared research. It was the peak of the pandemic,  International Journal of Microbiology 9 and many people believed that the vaccine was the magical cure to infection control, which infuenced the responses of those who took part in many surveys.
According to the results of this survey, a higher percentage of the participants intended to reject the vaccine, indicating low acceptability among participants. Vaccine apprehension among Egyptian HCWs could be a key stumbling block in the country's vaccine acceptance decision. Along with a global survey of 13,426 participants conducted in 19 countries to investigate the possible acceptability of the COVID-19 vaccination, 71.5% would like to take the vaccine in some way. Despite the fact that they reported a higher percentage of vaccine acceptability, variances in acceptance ranged from 80% in Asian countries to less than 55% in Russia [44]. As a result, it is unsurprising that vaccination acceptability is low in Egypt, given the global prevalence of vaccination hesitancy.  In terms of the vaccination type, it was discovered that 21.9% of participants preferred mRNA-based vaccines (Pfzer/BioNtech) and 21.2% preferred Oxford/Astra Zeneca if available, while the remaining participants were divided among the other vaccine types and refused vaccination. It is uncertain why Pfzer vaccines are more likely to be accepted by participants than other vaccines. It could be related to the participants' trust in the brand and the transparency with which information about their vaccine is presented in public.
Te current results demonstrated that medical specialists and medical literature were the most commonly trusted sources of knowledge for the participants; 70.1% and 38.6%, respectively. Fortunately, these sources are preferable to be the source of knowledge owing to the disinformation that can be spread to the public (conspiracy theory) by some social media posts claiming that the use of an mRNA-based COVID-19 vaccination can alter the DNA of the population [34,45]. Tis could contribute to vaccination acceptance hesitancy.
To investigate the factors that can afect the acceptance of the vaccine in the present study, regarding the history of chronic diseases, 20% of HCWs sufered from chronic illnesses (16.7% of physicians and 21.7% of nurses). Te most frequently reported medical conditions were diabetes and hypertension, which were signifcantly reported by nurses than physicians. Tis was similar to another study that demonstrated a signifcant correlation regarding age and the history of chronic diseases using univariate regression analysis [34]. Tis may be explained by the fear of those groups about the impact of COVID-19 on their comorbidities as reported in many studies indicating that diabetes mellitus [46], chronic hepatic and renal diseases [47], and multiple comorbidities, especially neurologic ones, can increase both morbidity and mortality in COVID-19 patients [48].
Regarding vaccine safety, only 32.8% of HCWs believed that it was safe. In another study, concerns regarding the vaccine's safety were expressed by 57 percent of study participants [34]. Similar fndings were observed in many places, and a number of variables linked to vaccine reluctance around the world included plenty of questions regarding the vaccine's safety and efcacy [49], which persisted even after the SARS-CoV-1 pandemic [50]. Fear of such a rapid public release of the vaccine due to a lack of proper research and a lack of research on the Arab population has led to increased doubt about the benefts of receiving newly formed vaccines.
Our study shows that gender and occupation were identifed as predictors of acceptance of the COVID-19 vaccine. Comparable to another study claiming that age, education, and ethnicity were the main determinants of COVID-19 vaccination acceptance and that models based on sociodemographic characteristics could accurately estimate COVID-19 vaccine acceptance [51], Additionally, there are conficting studies on the impact of gender, with some claiming that males were more likely to accept the vaccine than females [52], while others claim that female acceptance was higher [53].

Conclusion
In Egypt, vaccination apprehension is frequent among HCWs, and this could be a serious barrier to vaccine acceptance among the common society. Campaigns to raise awareness on the importance of vaccines are urgently needed.

Recommendation
Tere is a need to clarify the incorrect conceptions and misconceptions that have arisen as a result of the use of social media. Clear communication between national government ofcials and HCWs is helping to build confdence. All of this can be accomplished by explaining how the vaccine works, its level of efectiveness, its safety, and predicted side efects, as well as the vaccine uptake mechanism (doses and site). HCWs should be given lectures prepared by trusted medical leaders who can address any questions they may have.

Limitation of the Study.
A cross-sectional, descriptive study design was used in this study with the advantages that the study has several outcomes, has control over measurements with a short duration, could yield prevalence, and is relatively quick and inexpensive.  From its disadvantages are that it gave a background on the perception and vaccine acceptance of COVID-19 vaccination among healthcare workers in a certain period during this study.

Data Availability
Data are available from the corresponding author upon request.

Conflicts of Interest
Te authors declare that they have no conficts of interest.