COVID-19 Vaccine Acceptance Among Cancer Patients at Sindh Institute of Urology and Transplantation

A B S T R A C T

Background: Coronavirus disease (COVID-19) was declared as pandemic by World Health Organization (WHO) on 30th January 2020. Cancer patients are a vulnerable population with increased risk for mortality associated with COVID-19 infection. In this study, we report the impact of education for acceptance of COVID-19 vaccination in our cancer patients.
Methods: This was a cross-sectional study between 1st August 2021 and 31st October 2021. All patients with diagnosis of cancer who presented to the oncology clinic were asked whether they received COVID-19 vaccine or planning to get vaccinated. Patients, who had refused the vaccine, were educated to get vaccinated. Post counseling, they were again asked if they would agree to get vaccinated.
Results: Out of 512 cancer patients, 274 (53.5%) were male. Of total, 456 (89.1%) were diagnosed cases of solid malignancy. Patients who were on active oncological treatment were 406 (79.3%). Of total 512, 396 (77.3%) patients agreed for the COVID-19 vaccine while 116 (22.7%) had refused to get vaccinated. Of those 116, 75 (64.7%) patients accepted to get vaccinated post counseling.
Conclusion: COVID-19 vaccine acceptance is higher among cancer patients at our institute compared to reported data. Oncologists should play a key role in encouraging their patients to get vaccine in order to reduce COVID-19 related mortality.

Keywords

COVID-19, vaccine, cancer

Introduction

Coronavirus disease (COVID-19) was declared a pandemic by World Health Organization (WHO) on 30th January 2020 [1]. By 27th May 2021, 911,302 cases were reported as COVID-19 positive in Pakistan with 20,540 deaths [2]. Sinopharm, Cansino, Sputnik V, Oxford AstraZeneca were approved by Drug Regulatory Authority of Pakistan (DRAP) in February 2021 [3]. To achieve herd immunity, 80% population has to be vaccinated. There is limited information regarding COVID-19 vaccine efficacy in cancer patients. Many trials of vaccine development did not include cancer patients. In BNT162b2 mRNA Pfizer COVID-19 vaccine trial, only 3.7% of 43,540 enrolled persons were cancer patients [4]. Cancer patients are a vulnerable population with increased risk for mortality associated with any infection. This population is at risk of high mortality with new COVID-19 infection. None of approved vaccines are live attenuated virus, therefore can be given to cancer patients [5]. Many studies since the pandemic have shown an increased risk of COVID-19 infection and its related complications in patients with active cancer or history of cancer.

In a study from USA, mortality with COVID-19 infection was higher (14.9%) in patients with cancer as compared to patients without cancer (4.9%) [6]. Cancer patients should get vaccinated along with maintaining other preventive measures like wearing face masks, hand hygiene and social distancing. The professional oncological societies like American Society of Clinical Oncology (ASCO), American Association for Cancer Research (AACR) and European Society of Medical Oncology (ESMO) have strongly recommended to vaccinate cancer patients on priority basis to avoid COVID-19 infection related morbidity and mortality [7-9]. In Pakistan, vaccine related rumors and fears are barriers that prevent people from getting vaccinated against preventable diseases. Vaccine hesitancy is the primary cause of failure of the Polio eradication programme. There is a negative perception and rumors about COVID-19 vaccine among general public of Pakistan [10]. Center for Economic Research in Pakistan (CERP) has done a survey in the general public in Punjab during December 2020/January 2021, which has shown that 30% respondents refused to get vaccinated [11]. COVID-19 vaccine acceptance has been studied among health care professionals in Pakistan [12]. Studies have been published from United States of America (USA) and France regarding vaccine acceptance among cancer patients [13, 14]. There is no published data on vaccine acceptance among cancer patients in Pakistan. In this study, we report the outcome of impact of counseling for acceptance of COVID-19 vaccination in our cancer patients.

Methodology

This was a cross-sectional study done at the Hanifa Suleman Dawood oncology center, Sindh Institute of Urology and Transplantation from 1st August 2021 to 31st October 2021. All patients enrolled in the study were diagnosed of cancer. Based on the previous estimate, 53.7% patients intended to get vaccinated, a total of 512 cancer patients were included in this study, with margin of error 4% and 95% confidence interval [14]. Patient on active treatment (surgery/ chemotherapy/ radiotherapy/ concurrent chemo radiotherapy/ hormonal therapy/ targeted therapy) and surveillance were included. All patients were asked whether they had received COVID-19 vaccine or planning to get vaccine. Patients, who had refused the vaccine, were educated to get the vaccine. Post counseling, patients were asked again if they would agree to get vaccinated. Informed consent was taken before filling structured proforma. Ethical review committee approval was obtained before the initiation of the study.

Statistical package for social sciences (SPSS) version 22.0 was used to perform data analysis. Demographics and clinical characteristics were reported as frequencies and percentages for qualitative variables. For comparison of clinical characteristics with post counseling acceptance, the chi-square test was used. P-value of ≤0.05 was considered as statistically significant.

Results

Out of 512 cancer patients, there was no significant difference in gender for vaccine acceptance, 274 (53.5%) patients were male, majority of patients were in 41 to 60 years age group 249 (48.6%). Type of malignancy is reported in (Table 1). Patients on active treatment were 406 (79.3%). Of these, 218 (42.6%) were on chemotherapy, 60 (11.7%) were on hormonal therapy. About 51 (10%) were on targeted therapy, 66 (12.9%) patients underwent surgery during this time. Patients on concurrent chemo radiation (CCRT) were 10 (2%), while 8 (1.6%) were on radiotherapy. About three fourth of patients 386 (75.4%) were on curative treatment. A small number of patients 35 (6.8%) had history of COVID-19 infection. Only 58 (11.3%) patients had history of COVID-19 infection in family/friends and history of death due to COVID-19 infection in 16 (3.1%). Of total patients, 396 (77.3%) patients agreed to get the COVID-19 vaccine and 116 (22.7%) patients refused to get vaccinated. Patients who refused to get vaccinated were asked the reasons for refusal (Table 2). These patients were further educated regarding how the vaccine works and that the risk of COVID-19 related mortality is higher in immune suppressed patients. After counseling, they were again asked whether they would now want to get vaccinated. Of these 116 patients, 75 (64.7%) agreed to get vaccinated whereas 41 (35.4%) patients still refused due to some concerns. The two main statistically significant reasons for refusing vaccination in spite of counseling were history of COVID-19 infection in self and concern about vaccine interference with cancer treatment (Table 3).

Table 1: Demographics and Clinical Characteristics.

Parameters

Frequency N=512

Percentages(%)

AGE

 

 

18 to 40

143

27.9

41 to 60

249

48.6

>60

120

23.5

 

GENDER

 

 

Male

274

53.5

Female

238

46.5

 

Cancer Types   

Breast

 

148

 

28.9

GENITO-URINARY 

Prostate (CAP)

 

52

 

10.2

Kidney (RCC)

80

15.6

Bladder (NHC)

52

10.1

Testis (T)

34

6.6

ADRENAL (AD)

9

1.8

GASTROINTESTINAL

Esophagus (ESO)

 

10

 

2.0

Gastric (GAS)

3

0.6

Pancreatic-Biliary (PBC)

8

1.6

Colorectal (CRC)

45

8.8

HAEMATOLOGY  

Hodgkin’s lymphoma (HL)

 

15

 

2.9

Non-Hodgkin’s lymphoma (NHL)

18

3.5

Multiple Myeloma (MM)

22

4.3

MISCELLANEOUS (ONCO)

 

16

3.1

CANCER TYPES

 

 

Solid

456

89.1

Hematological

56

10.9

 

CANCER STATUS

 

 

On Treatment

406

79.3

On Surveillance

106

20.7

 

TREATMENT GOAL

 

 

Curative

386

75.4

Palliative

 

TREATMENT TYPE

126

24.6

 

Surgery

66

12.9

Chemotherapy

218

42.6

Radiotherapy

8

1.6

CCRT

10

2.0

Hormonal Therapy

60

11.7

Targeted therapy

51

10.0

 

DID YOU GET COVID-19 INFECTION?

 

 

YES

36

7.0

NO

476

93.0

 

DID YOU GET COVID-19 INFECTION? IF YES? [15]

 

 

Mild

23

4.5

Moderate

13

2.5

Not applicable (NO infection)

476

93.0

 

HAS SOMEONE IN YOUR FAMILY/FRIENDS CIRCLE SUFFERED FROM COVID-19 INFECTION?

Yes

58

11.3

No

453

88.5

I don’t know

1

0.2

 

HAS SOMEONE IN YOUR FAMILY/FRIENDS CIRCLE DIED OF THIS INFECTION?

Yes

16

3.1

No

495

96.7

I don’t  know

1

0.2

 

WILL YOU AGREE TO GET COVID-19 VACCINE?

 

 

YES

396

77.3

NO

116

22.7


Table 2: Reasons of refusal.

Parameters

Frequency

Percentages

COVID-19 does not exist

2

0.4

Scared of side effects

89

17.4

Don’t know if vaccine will work

6

1.2

Don’t trust due to emergency approval of vaccine

3

0.6

Don’t trust government approved vaccine

3

0.6

Fear of COVID-19 infection with COVID-19 vaccine

6

1.2

Elders in my family are not in favour of vaccination

8

1.6

Someone in my family/friends had a bad reaction after vaccination

10

2.0

I don’t know that I need COVID-19 vaccine

7

1.4

Concern about vaccine interference with fertility/pregnancy

3

0.6

Concern about vaccine interference with cancer treatment

34

6.6

Preference of preventive measures (mask/social distancing

6

1.2

Post Counseling Acceptance

Yes

75

14.6

No

41

8.2


Table 3: Comparison of Post Counseling COVID-19 vaccine acceptance of patients.

 

Parameters

Yes

n =75(%)

NO

n=41 (%)

p-value

Age

 

 

 

18-40

30 (40.0)

14 (34.1)

0.82

41-60

33 (44.0)

20 (48.8)

>60

12 (16.0)

7 (17.1)

Gender

 

 

 

Male

35 (46.7)

16 (39.0)

0.42

Female

40 (53.3)

25 (61.0)

Cancer

 

 

 

Breast

27 (36.0)

14 (34.1)

0.79

Genito-urinary

25 (33.3)

10 (24.4)

Gastro-intestinal

10 (13.3)

8 (19.5)

Hematological

10 (13.3)

7 (17.1)

Others

3 (4.0)

2 (4.9)

Cancer Type

 

 

 

Solid

65 (86.7)

33 (80.5)

0.38

Hematological

10 (13.3)

8 (19.5)

Cancer Status

 

 

 

On Treatment

62 (82.7)

35 (85.4)

0.70

On Surveillance

13 (17.3)

6 (14.6)

Treatment Goal

Curative

 

57 (76.0)

 

32 (78.0)

0.80

Palliative

18 (24.0)

9 (22.0)

Treatment Type

Surgery

 

2 (2.7)

 

2 (4.9)

 

0.53

Chemotherapy

42 (56.0)

23 (56.1)

0.99

Radiotherapy

2 (2.7)

0 (0)

0.29

CCRT

1 (1.3)

3 (7.3)

0.09

Hormonal Therapy

10 (13.3)

6 (14.6)

0.84

Targeted therapy

7 (9.3)

1 (2.4)

0.16

Did you get COVID-19 infection?

2 (2.7)

5 (12.2)

0.03

If YES, then?

 

 

 

Mild

2 (2.7)

3 (7.3)

0.07

Moderate

0 (0)

2 (4.9)

 

Has someone in your family/friends circle suffered from COVID-19 infection

5 (6.7)

5 (12.2)

0.31

Has someone in your family/friends circle dies of this infection

0 (0)

1 (2.4)

0.17

COVID-19 does not exist

0(0)

2 (4.9)

0.05

Scared of side effects

60 (80.0)

29 (70.7)

0.25

Don’t know if vaccine will work

5 (6.7)

1 (2.4)

0.32

Don’t trust due to emergency approval of vaccine

2 (2.7)

1 (2.4)

0.94

Don’t trust government approved vaccine

2 (2.7)

1 (2.4)

0.94

Fear of COVID-19 infection with COVID-19 vaccine

2 (2.7)

4 (9.8)

0.09

Elders in my family are not in favour of vaccination

5 (6.7)

3 (7.3)

0.89

Someone in my family/friends had a bad reaction after vaccination

6 (8.0)

4 (9.8)

0.74

I don’t know that I need COVID-19 vaccine

6 (8.0)

1 (2.4)

0.22

Concern about vaccine interference with fertility/pregnancy

2 (2.7)

1 (2.4)

0.94

Concern about vaccine interference with cancer treatment

29 (38.7)

5 (12.2)

0.03

Preference of preventive measures (mask/social distancing) etc.

3 (4.0)

3 (7.3)

0.44


Discussion

In late February 2020, the first COVID-19 positive case was reported in Pakistan [16]. To end this pandemic, vaccination and preventive measures are the two most important strategies. It is estimated that between 170,000 and 200,000 new cancer cases are diagnosed each year in Pakistan with a population of around 220 million [17]. Cancer patients are known to be immune compromised, either due to cancer or due to its treatment and its related complications. Before this pandemic, cancer patients were advised for infection control measures like hand hygiene, wearing face masks etc. during chemotherapy. Since this pandemic we are advising our patients to maintain these infection control measures and to get vaccinated for COVID-19. The oncologists should evaluate the knowledge as well as efficacy and safety concerns of their patients regarding this vaccine and resolve their concerns.

In a study from Pakistan, 70% of general public agreed to get vaccinated whereas 77.3% of our cancer patients agreed to get vaccinated [18]. Of those who had refused initially, when educated, 64.7% of them agreed to get vaccinated. In a French study, 53.7% cancer patients had intent to be vaccinated once vaccine was available [14]. In a study from China, 75.9% cancer patients had vaccine acceptance [19]. In our cancer patients, like the rest of the Pakistani population, fear of side effect was the common reason for vaccine hesitancy. Our 42.6% cancer patients were on chemotherapy and were under going through chemotherapy related adverse effects so their concerns about vaccine related side effects were understandable. In a study from USA, 30% of cancer patients and their caregivers refused to get vaccinated due to fear of side effects [13]. In a French study, 30% patient who refused the vaccine gave fear of side effects as the main reason for refusal [14]. In our study, 17.4%cancer patients were hesitant due to fear of side effects. Of 22.7% patients who had refused the vaccine, 6.6% patients had concern about vaccine interference with cancer treatment. This has also been reported as small in a study from USA [13]. However, that concern of vaccine interference with cancer treatment was significantly reduced with counseling of our patients. The strength of our study is that better communication between oncologists and patients resulted in a high acceptance rate for COVID-19 vaccination. Patients who had agreed to get vaccinated also encouraged other patients to do the same. The limitation of our study is that we did not report vaccine related adverse effects. However, there was no vaccine related mortality noted.

Conclusion

COVID-19 vaccine acceptance is higher among cancer patients at our institute compared to reported data. Oncologists should play a key role in encouraging their patients to get this vaccine in order to reduce COVID-19 related mortality.

Conflicts of Interest

None.

Funding

None.

Article Info

Article Type
Research Article
Publication history
Received: Tue 17, May 2022
Accepted: Mon 30, May 2022
Published: Wed 22, Jun 2022
Copyright
© 2021 Anita Vallacha. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Hosting by Science Repository.
DOI: 10.31487/j.COR.2022.03.01

Author Info

Corresponding Author
Anita Vallacha
Primary Investigator, Senior Lecturer, Department of Medical Oncology, Hanifa Suleman Dawood Cancer Center, Sindh Institute of Urology and Transplantation, Pakistan

Figures & Tables

Table 1: Demographics and Clinical Characteristics.

Parameters

Frequency N=512

Percentages(%)

AGE

 

 

18 to 40

143

27.9

41 to 60

249

48.6

>60

120

23.5

 

GENDER

 

 

Male

274

53.5

Female

238

46.5

 

Cancer Types   

Breast

 

148

 

28.9

GENITO-URINARY 

Prostate (CAP)

 

52

 

10.2

Kidney (RCC)

80

15.6

Bladder (NHC)

52

10.1

Testis (T)

34

6.6

ADRENAL (AD)

9

1.8

GASTROINTESTINAL

Esophagus (ESO)

 

10

 

2.0

Gastric (GAS)

3

0.6

Pancreatic-Biliary (PBC)

8

1.6

Colorectal (CRC)

45

8.8

HAEMATOLOGY  

Hodgkin’s lymphoma (HL)

 

15

 

2.9

Non-Hodgkin’s lymphoma (NHL)

18

3.5

Multiple Myeloma (MM)

22

4.3

MISCELLANEOUS (ONCO)

 

16

3.1

CANCER TYPES

 

 

Solid

456

89.1

Hematological

56

10.9

 

CANCER STATUS

 

 

On Treatment

406

79.3

On Surveillance

106

20.7

 

TREATMENT GOAL

 

 

Curative

386

75.4

Palliative

 

TREATMENT TYPE

126

24.6

 

Surgery

66

12.9

Chemotherapy

218

42.6

Radiotherapy

8

1.6

CCRT

10

2.0

Hormonal Therapy

60

11.7

Targeted therapy

51

10.0

 

DID YOU GET COVID-19 INFECTION?

 

 

YES

36

7.0

NO

476

93.0

 

DID YOU GET COVID-19 INFECTION? IF YES? [15]

 

 

Mild

23

4.5

Moderate

13

2.5

Not applicable (NO infection)

476

93.0

 

HAS SOMEONE IN YOUR FAMILY/FRIENDS CIRCLE SUFFERED FROM COVID-19 INFECTION?

Yes

58

11.3

No

453

88.5

I don’t know

1

0.2

 

HAS SOMEONE IN YOUR FAMILY/FRIENDS CIRCLE DIED OF THIS INFECTION?

Yes

16

3.1

No

495

96.7

I don’t  know

1

0.2

 

WILL YOU AGREE TO GET COVID-19 VACCINE?

 

 

YES

396

77.3

NO

116

22.7


Table 2: Reasons of refusal.

Parameters

Frequency

Percentages

COVID-19 does not exist

2

0.4

Scared of side effects

89

17.4

Don’t know if vaccine will work

6

1.2

Don’t trust due to emergency approval of vaccine

3

0.6

Don’t trust government approved vaccine

3

0.6

Fear of COVID-19 infection with COVID-19 vaccine

6

1.2

Elders in my family are not in favour of vaccination

8

1.6

Someone in my family/friends had a bad reaction after vaccination

10

2.0

I don’t know that I need COVID-19 vaccine

7

1.4

Concern about vaccine interference with fertility/pregnancy

3

0.6

Concern about vaccine interference with cancer treatment

34

6.6

Preference of preventive measures (mask/social distancing

6

1.2

Post Counseling Acceptance

Yes

75

14.6

No

41

8.2


Table 3: Comparison of Post Counseling COVID-19 vaccine acceptance of patients.

 

Parameters

Yes

n =75(%)

NO

n=41 (%)

p-value

Age

 

 

 

18-40

30 (40.0)

14 (34.1)

0.82

41-60

33 (44.0)

20 (48.8)

>60

12 (16.0)

7 (17.1)

Gender

 

 

 

Male

35 (46.7)

16 (39.0)

0.42

Female

40 (53.3)

25 (61.0)

Cancer

 

 

 

Breast

27 (36.0)

14 (34.1)

0.79

Genito-urinary

25 (33.3)

10 (24.4)

Gastro-intestinal

10 (13.3)

8 (19.5)

Hematological

10 (13.3)

7 (17.1)

Others

3 (4.0)

2 (4.9)

Cancer Type

 

 

 

Solid

65 (86.7)

33 (80.5)

0.38

Hematological

10 (13.3)

8 (19.5)

Cancer Status

 

 

 

On Treatment

62 (82.7)

35 (85.4)

0.70

On Surveillance

13 (17.3)

6 (14.6)

Treatment Goal

Curative

 

57 (76.0)

 

32 (78.0)

0.80

Palliative

18 (24.0)

9 (22.0)

Treatment Type

Surgery

 

2 (2.7)

 

2 (4.9)

 

0.53

Chemotherapy

42 (56.0)

23 (56.1)

0.99

Radiotherapy

2 (2.7)

0 (0)

0.29

CCRT

1 (1.3)

3 (7.3)

0.09

Hormonal Therapy

10 (13.3)

6 (14.6)

0.84

Targeted therapy

7 (9.3)

1 (2.4)

0.16

Did you get COVID-19 infection?

2 (2.7)

5 (12.2)

0.03

If YES, then?

 

 

 

Mild

2 (2.7)

3 (7.3)

0.07

Moderate

0 (0)

2 (4.9)

 

Has someone in your family/friends circle suffered from COVID-19 infection

5 (6.7)

5 (12.2)

0.31

Has someone in your family/friends circle dies of this infection

0 (0)

1 (2.4)

0.17

COVID-19 does not exist

0(0)

2 (4.9)

0.05

Scared of side effects

60 (80.0)

29 (70.7)

0.25

Don’t know if vaccine will work

5 (6.7)

1 (2.4)

0.32

Don’t trust due to emergency approval of vaccine

2 (2.7)

1 (2.4)

0.94

Don’t trust government approved vaccine

2 (2.7)

1 (2.4)

0.94

Fear of COVID-19 infection with COVID-19 vaccine

2 (2.7)

4 (9.8)

0.09

Elders in my family are not in favour of vaccination

5 (6.7)

3 (7.3)

0.89

Someone in my family/friends had a bad reaction after vaccination

6 (8.0)

4 (9.8)

0.74

I don’t know that I need COVID-19 vaccine

6 (8.0)

1 (2.4)

0.22

Concern about vaccine interference with fertility/pregnancy

2 (2.7)

1 (2.4)

0.94

Concern about vaccine interference with cancer treatment

29 (38.7)

5 (12.2)

0.03

Preference of preventive measures (mask/social distancing) etc.

3 (4.0)

3 (7.3)

0.44


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