Attitudes of vaccination service providers to the SARS-CoV-2 intranasal spray vaccine during the SARS-CoV-2 pandemic in China: A cross-sectional study.

To the Editor: Intranasal spray vaccines (ISVs) can produce cellular immunity against severe acute respiratory syndrome virus 2 (SARS-CoV-2) variants and have good safety and protective effects.[1] However, the attitudes of vaccination service providers toward ISVs have rarely been studied. This study investigated the attitudes of service providers towards vaccination processes that require optimization and improvement. The discovery and prevalence of new Omicron variants such as BQ.1 and XBB have increased the risk of infectious outbreaks.[2] The National Health Commission of the People's Republic of China published an implementation plan for the administration of a second booster dose of the corona virus disease (COVID-19) vaccine on December 13, 2022.[3] The booster dose plan, published in April 2023, includes the intranasal spray COVID-19 vaccine as a viable option[4]. Several studies have demonstrated that ISVs are safe and effective in protecting against various SARS-CoV-2 variants.[1,5] Moreover, the first batch of ISVs have completed phase III clinical trials and have been approved worldwide. Therefore, gaining insight into the perspective of vaccination service providers regarding their attitudes and the factors that influence them will furnish fundamental information for the subsequent enhancement of ISVs' vaccination technology and service processes. This study was conducted in December, 2022 in six urban and seven suburban areas of Beijing, China. The respondents comprised a total of 590 participants, all of whom were vaccination service providers responsible for administering ISVs. Staff members who were only responsible for health consultations, signed informed consent forms, as well as other healthcare workers with no direct participatory role in administering ISVs, were excluded from the study. On average, 2–3 vaccination service providers were involved in the survey at each vaccination site. Questionnaires were distributed to the heads of ISV vaccination service organizations and voluntarily completed by the eligible participants at each outpatient clinic. The questionnaire elicited responses from participants regarding their demographic information, vaccination preferences, opinions on recommending ISVs, and areas of the vaccination procedures that required optimization. An open-ended approach was used to gather opinions on the optimization of the vaccination procedure. The data were analyzed independently by two researchers. Continuous variables are presented as mean ± standard deviation (SD). Categorical variables are expressed as frequencies and percentages. Pearson's chi-squared test (χ2) was used to compare different levels of participation (Have preference vs. No preference; willingness to recommend vs. not willing to recommend) between the two groups, and significant items were included in the regression model for statistical analysis. Factors affecting ISV-related personal preferences and recommendations were identified using multiple logistic regression. The final model for personal preference incorporated several covariates: (1) sociodemographic information, (2) comprehension of the vaccination, (3) experiences encountered during vaccination operations, (4) service providers' attitudes towards the vaccination procedure, and (5) the service provider's capacity to address pertinent questions on ISVs. Additional details are provided [Supplementary table 1, https://links.lww.com/CM9/B641]. Data were collected using an online survey tool Wenjuanxing (WJX, https://www.wjx.cn/, in Chinese), stratified in Microsoft Office Excel (version 2021; Microsoft Corp., Washington.D.C, USA), and analyzed using SPSS (version 26.0, SPSS Inc., Chicago, IL, USA). Logistic regression models were constructed to identify factors associated with respondents' preferences for SARS-CoV-2 vaccinations (ISV preference vs. no preference) with a significance level of α = 0.05. Odds ratios (OR) and the corresponding 95% confidence intervals (CI) were calculated. This study was approved by the Ethics Committee of the Chinese Academy of Medical Sciences and Peking Union Medical College (No. CAMS&PUMC-IEC-2022-019). Written informed consent was obtained from all participants. In total, 42.4% (250/590) of the participants demonstrated proficiency in the ISV inoculation technique within 7–14 days. Additionally, 33.4% (197/590) of the respondents expressed a preference for ISV, whereas 32.7% (193/590) indicated a willingness to recommend them to others. However, the majority of respondents (68.0%; 401/590) believed that the vaccination process could be further optimized. [Supplementary Table 2, https://links.lww.com/CM9/B641]. A statistically significant association between personal preference for ISV and suburban provider status was found, with 58.9% (116/197) of suburban providers expressing a high preference for ISV. Among the members of the preferred group, a majority of service providers (75.1% [148/197]) reported possessing sufficient knowledge regarding vaccine production and its mechanism of action, while 91.4% (180/197) believed they were capable of answering questions on ISVs. A notable proportion of respondents 34.5% (68/197) expressed concerns regarding vaccination duration. On average, a large proportion of respondents (58.9% [116/197]) spent less than one minute administering intramuscular injections per person, and 37.6% (74/197) spent less than one minute administering intranasal spray vaccinations per person. Furthermore, 38.1% (75/197) of respondents thought that their vaccination workload increased. Albeit 46.2% (91/197) of respondents who preferred ISVs found the administration of the ISV easy to learn, and 94.9%(187/197) considered that the procedure was not difficult. Additionally, 70.1% (138/197) indicated that they experienced better cooperation from ISV recipients. A proportion of 83.1% (490/590) of the respondents reported have difficulty with ISV administration. Among the no preference group, 31.0% (122/393) of participants reported sneezing, 33.3% (131/393) reported runny noses, 63.1% (248/393) reported resistance during inhalation, and 52.4% (206/393) reported extension of the vaccine solution to the pharynx after administration, which is sometimes accompanied by spitting [Supplementary Table 3, https://links.lww.com/CM9/B641]. Compared with the reference group (preferred ISV), the factors for personal preference included the following: inadequate revision of mechanisms of vaccine production and action (OR = 1.785, 95% CI: 1.079–2.952), easier learning of vaccination techniques of intramuscular injection than ISV techniques (OR = 4.163, 95% CI: 1.991–8.705), better recipient cooperation with intramuscular injection than with the ISV technique (OR = 6.421, 95% CI: 3.237–12.736), and the insufficient ability to answer ISV relevant questions (OR = 2.143, 95% CI:1.147–4.006) [Supplementary Table 3, https://links.lww.com/CM9/B641]. Regarding attitudes towards vaccine recommendations, 193 (32.7%) providers expressed willingness to recommend ISV, 148 (25.1%) preferred intramuscular vaccination, and 249 (42.2%) had no clear recommendations. Vaccine safety (79.1%, 158/193), effectiveness (78.3%, 149/193), and acceptability (72.4%, 148/193) were the three most common reasons for preference for ISV [Supplementary Figure 2, https://links.lww.com/CM9/B641]. Factors affecting willingness to recommend ISV were identified using multiple logistic regression models. Compared with the reference group (willing to recommend ISV), factors for personal preference were no difference between recipient cooperation with intramuscular injection or ISV (OR = 2.891, 95% CI: 1.246–6.706), and ability to answer ISV questions (OR = 3.549, 95% CI: 1.065–11.829) [Supplementary Table 4, https://links.lww.com/CM9/B641]. Service providers reported that the following steps of the vaccination process needed to be optimized: withdrawal of the vaccine (67.6%, 271/401), assembly of the syringe (52.9%, 212/401), assembly of the spray device (32.9%, 132/401), thawing of the vaccines (17.2%, 69/401), and the process of vaccination (8.2%, 33/401). Regarding vaccine withdrawal, 76.8% (208/271) of respondents reported that the plastic needle was not convenient, and 9.6% (26/271) of respondents declared that it should be changed to a pre-filled syringe. Among service providers who thought assembly of the syringe needed optimization, 42.0% (89/212) of respondents reported that the installation processes were complex, and 23.1% (49/212) of respondents indicated that the vaccine device had quality issues. When assembling the spray device, 42.4% (56/132) of the respondents reflected that the procedure was complex, and 20.5% (27/132) of the respondents wanted the device to be changed to a pre-filled syringe. A proportion of 53.6% (37/69) of the respondents reported that they required a long time to thaw, and 24.2% (8/33) of the respondents reported a high risk of viral exposure [Supplementary Figure 2, https://links.lww.com/CM9/B641]. This study validates the influence of three key determinants, namely vaccine safety, effectiveness, and acceptability, on medical workers' recommendations and individuals' decisions to vaccinate. These determinants are associated with the confidence aspect of the 3Cs' (confidence, complacency, and convenience) model of vaccine hesitancy. Add reference: [Supplementary Figure 1, https://links.lww.com/CM9/B641]. In addition, no personal preference of ISV (OR = 211.202, 95%CI: 88.971–501.357) had a stronger influence on the willingness of healthcare providers to recommend ISVs in practice [Supplementary Table 4, https://links.lww.com/CM9/B641]. Based on these findings, two recommendations are proposed for individual learning among vaccination service providers and optimization of the vaccination process. First, vaccination service providers should enhance their understanding of ISVs and their proficiency in administering them, while also addressing the knowledge, beliefs, and behaviors of recipients towards ISVs. Second, vaccination service providers should provide informational videos and photographs at outpatient clinics to familiarize recipients with the vaccination process and encourage their cooperation, thereby increasing their awareness. In general, the simplification of vaccination equipment installation and the promotion of greater collaboration among vaccine recipients have the potential to enhance vaccination efficiency. However, it is important to acknowledge that this study has certain limitations. Despite its extensive geographic coverage in Beijing, the representation of the participants may be constrained. Additionally, as the investigation was conducted during the initial implementation of ISVs, the staff had limited time to fully master the operations, which may have resulted in biased survey results. It is recommended that a comprehensive investigation be conducted in multiple locations to examine the attitudes of healthcare workers towards vaccination using ISVs. In conclusion, the present study reveals that the majority of vaccine service providers perceive ISVs as user-friendly; however, certain limitations remain that necessitate optimization. The distributions of the individual vaccination preferences and recommendations were equal. These findings have the potential to enhance healthcare workers' knowledge of ISVs and serve as a foundation for vaccine-related policies. Funding The present study was supported by grants from the Natural Science Foundation of Beijing Municipality–Haidian Original Innovation Joint Fund Project (No. L222028) and the Beijing Municipal Science & Technology Commission (No. Z221100007922018). Conflicts of interest None.