Keywords COVID-19 - vaccination - behavior - oral health
Background
The black swan event of the novel coronavirus disease 2019 (COVID-19) has disrupted
the lives of millions globally. The outbreak was first reported in a seafood wholesale
wet market in Wuhan, Hubei Province, China in December 2019. The disease affected
around 66% of the staff who presented with gastrointestinal symptoms.[1 ] The disease later spread to various nations due to international travelers. The
outbreak was declared as a Public health emergency by the World Health Organization
on January 30, 2020.[1 ]
A per the data available worldwide, the case fatality rate of this pandemic has been
observed to be 4% but may vary from 0 to 20% between countries.[2 ] The variation in the fatality rate may be attributed to the population composition,
gender variations, and presence of co-morbidities. It has been observed that males
had a higher death rate than females. In addition, individuals with diabetes, lung
disease, and hypertension were 3.38 to 3.73 times more prone to witness fatality than
their healthy counterparts.[3 ] As of May 2021, more than 17 crore people have been affected by the disease with
over 35.4 lakh people succumbing to death in over 200 nations globally. India, which
witnessed a major second wave of the disease in mid-February 2021, has reported the
second highest number of cases of the disease.
Apart from rising mortality rates, the morbidity associated with the pandemic cannot
be overlooked. COVID-19 has had a significant impact on the general health of individuals
which affects their day to day functions. Though the disease primarily affects the
lungs, the effects of the virus penetration can be manifested in various parts of
the human body like heart, kidneys and brain due to vascular permeability.[4 ] Studies showed that a significant viral load can be observed in the nasal and oral
cavity. Thus, one cannot flout the effects of COVID-19 on the oral cavity. In addition,
inflammatory markers like C-reaction proteins are also elevated in patients infested
with the disease. These markers have been shown to be significantly associated with
periodontal diseases and other oral problems.[5 ] This multitude of factors necessitates the need for voluminous interventions to
intervene the spread of the disease.
Amongst the various measures taken to combat the spread of the virus, the government
of India imposed stringent lockdown measures with emphasis on personal hygiene measures
like use of mouth mask, frequent hand washing with soap and water, and use of sanitizer.
In addition, India being one of the biggest pharmaceutical manufacturing capacities
in the world was obligated to play a prime role in the vaccination drive against COVID-19.
Thus, with the aim to contain the disease at the earliest, vaccine trials were implemented
in full swing which resulted in the successful discovery of two vaccines that cleared
the phase 1 and 2 trials. The vaccines were then approved for administration in population
groups which led to the initiation of the vaccination drive in India. However, the
acceptance rate of the vaccine among population groups was trivial owing to various
reasons. This review thus aims at assessing the factors that influenced the vaccination
behavior and oral health of individuals.
The Tale of Indian Vaccine Production
The Tale of Indian Vaccine Production
India's vaccination production involved indigenous vaccines and also collaborative
production wherein pharmaceutical and biotech companies tied up with international
vaccine developers. Thus there were eight leading vaccine candidates which were undergoing
clinical trials in India ([Fig. 1 ]). Covishield was produced by the Serum Institute of India which was primarily a
version of the Oxford University—AstraZeneca vaccine consisting of a replication-deficient
chimpanzee adenoviral vector ChAdOx1 having the SARS-CoV-2 structural surface glycoprotein
antigen gene. The phase 1 clinical trials of the original vaccine were initiated in
United Kingdom, Brazil, South Africa, and Kenya that showed to have an efficacy rate
of 70.4%.[6 ] With successful results at phase I and II trials, the vaccine entered the phase
III trials in mid-November. In India, the II/III clinical trials were conducted in
14 centers among 1,600 participants for comparison of the safety of Covishield with
the original Oxford manufactured vaccine. The obtained data were comparable to the
results of the previous trials.[7 ]
Fig. 1 Flowchart indicating the characteristics of different vaccines available in India.
On the other hand, Covaxin is India's first home manufactured vaccine against the
deadly COVID-19. This vaccine was developed by Bharat Biotech in collaboration with
the Indian Council of Medical Research (ICMR) and the National Institute of Virology,
Pune. This vaccine contains inactivated virus, developed in Vero cells. A total of
800 participants were included in the phase I as well as phase II trials wherein a
strong immunological response and protection were observed. The third phase of the
vaccine trials was developed in November 2020 on 25,800 participants in 25 centers
in India which was one of the largest clinical trials in India and showed to have
an interim efficacy of 81%.[7 ]
Among the few domestic vaccines which are still in the phase II trials are the ZyCoV-D
and two unnamed vaccines. ZyCoV-D is developed by Ahmedabad-based Cadila Healthcare.
The vaccine is based on the technology of plasmid DNA vaccination. However, the vaccine
is still in the phase II trials.[7 ] The first unnamed vaccine is developed by the Biological E. Ltd., together with
Dynavax Technologies Corporation as well as Baylor College of Medicine. This is on
the basis of the Classica Vaccine Technology, which uses a protein antigen, SARS-CoV-2
Spike RBD, which is adsorbed onto an adjuvant called Alhydrogel (Alum), by combining
with one more accepted adjuvant, CpG 1018. This vaccine is also in phase II trials.
The second unnamed vaccine is an mRNA vaccine which has been developed by Gennova
Biopharmaceuticals Ltd., Pune in partnership with HDT Biotech Corporation of the United
States.[7 ]
Yet another vaccine is Gam-COVID-Vac which is developed under the trade name Sputnik
V. This two-vector viral vaccine based on human adenovirus Ad5 and Ad26 is developed
by Gamaleya National Centre of Epidemiology and Microbiology of Moscow in Russia.[7 ] The clinical trials of the vaccine at 25 hospitals in Russia among 21,977 participants
showed to have an efficacy rate of 91.6%.[8 ] The vaccine has been granted approval from the DCGI for testing and production.
Rate of Acceptance of COVID-19 Vaccination
Rate of Acceptance of COVID-19 Vaccination
India's largest vaccination drive against COVID-19 was initiated on January 16, 2021.
Based on the strategy of Central Government, health care workers and frontline health
workers were the first listed out to be vaccinated as they were at high risk of contracting
the disease. Following this, people aged 60 years and above and those with co-morbidities
were included in the vaccination process. From April 1st , people aged 45 years and above were further included.[9 ] A COVID-19 Symptom Survey was conducted by the University of Maryland and Carnegie
Mellon University in partnership with Facebook to assess aspects related to COVID-19.
As per the reports 45% of the population was definitely ready to get vaccinated whereas
12.4% of the population was definitely not ready to get vaccinated.[10 ] The acceptance of COVID-19 vaccination among the Indian population was found to
be good. Various studies have shown that the acceptance rate varied from 41 to 81.3%
among population groups.[11 ]
[12 ] A global survey analyzing the acceptance rate of COVID-19 vaccine among 10 low and
middle income countries have shown that the vaccine acceptance rate was 80.3%.[13 ] However, as of August 2021, only 8.9% of the total population have been vaccinated
in India. 30.9% of the population have received at least one dose of the vaccine.[9 ] According to the A COVID-19 Symptom Survey, Kerala displayed the highest number
of people who were unwilling to get themselves vaccinated.[10 ] The above data are suggestive of the fact that the attitude of people toward COVID-19
vaccination varies which impacts the rate of vaccination.
Factors Affecting the Attitude of People toward COVID Vaccination
Factors Affecting the Attitude of People toward COVID Vaccination
The acceptance level of COVID-19 vaccination by people has been influenced by various
factors like demographic, personal, community, and environmental characteristics.
An array of multifactorial elements with varying effects on different population groups
was observed through individual studies conducted.
Among the demographic factors, age, gender, occupation, and educational status can
be considered as prime factors which have influenced the acceptance rate of COVID-19
vaccination among people. As of August 2021, 175 million people aged 18 to 44 years,
111million people aged >45 years, and 78 million people aged >60 years have received
at least one dose of the vaccination.[14 ] Numerous surveys conducted have shown that age has been significantly associated
with the COVID-19 vaccine acceptance or hesitance rate. It has been found that the
acceptance rate of the people aged >45 years was lower as compared with the younger
age groups.[15 ]
[16 ] However, a global survey conducted has found that people aged 25 years and above
were more likely to accept the vaccine than those aged 18 years and below.[13 ]
[17 ] This could be attributed to the varying degrees of awareness among the people regarding
the vaccine. Another demographic characteristic determining the acceptance rate of
COVID-19 vaccination is gender. Though the differences were small, it was observed
that females were more willing to accept the vaccine as compared with males.[13 ]
[15 ]
[17 ]
[18 ] This could be due to the fact that women are more inclined toward availing preventive
care and bear the responsibility of the health care for the family. In addition, the
ideology of men being stronger and the conservative nature may be the driving force
for this behavior, even amidst the higher rate of men succumbing to death due to COVID-19.[18 ]
The socioeconomic status of the population groups expressed through education, occupation,
and family income were also seen to have an effective role in the COVID-19 vaccine
acceptance behavior. Individuals belonging to higher socio-economic status were significantly
associated with higher vaccine acceptance rate than individuals from the lower socio-economic
status.[10 ]
[15 ]
[17 ]
[19 ] This can be attributed to the fact that individuals with a higher level of education
with a professional job status and income were more inclined to avail the COVID vaccine
due to the ease and affordability of access to health care services.
On the other hand, personal or individual factors also seem to bear a prime role in
vaccine acceptance rates of people. Various descriptive studies conducted across population
groups have suggested that fear of health due to vaccine allergic reactions, incredulity
over vaccine trails, nationality of the vaccine produce, rush in vaccine production,
exaggeration of COVID-19 prevalence, and incidence data may be cited as the few reasons
affecting the uptake of COVID vaccine by people.[19 ] Studies have shown that around 44% of the population were apprehensive about the
possible side effects and 29% of the population showed concerns regarding the clinical
trials of the vaccine since the vaccine for COVID-19 was delivered at a faster pace
amid various speculations that enhance the fear among people regarding the vaccine.[20 ]
The efficacy rate of the Indian manufactured vaccine as compared with the foreign
manufactured vaccines could also be a contributing factor. The efficacy rate of 94%
of foreign vaccines as compared with the 74% efficacy of Indian vaccines could produce
a lag in the minds of people to vaccinate themselves with the available vaccine or
wait for the best to be available in the market. Around 67% of the participants in
surveys conducted have shown that people wish to get themselves vaccinated with a
vaccine which has a higher efficacy rate.[21 ] However, around 33% of the population preferred vaccines developed by Indian pharmaceutical
companies.[18 ]
Another important factor is the cost of the vaccines. At present, vaccine is available
at private and government health care sectors. While the government-based health sectors
are providing vaccine free of cost, the private health care sectors are charging rupees
750 to 1,300 per dose of the vaccine, based on the vaccine type.[9 ] Thus, 20% of the population comprehend cost of the vaccine as a barrier in availing
vaccine, as it is an out of pocket expense and a burden to the family disbursements.[18 ] On the personal front, the time can also be perceived as a significant barrier in
availing vaccine. COVID-19 vaccine demand and supply faced an inverse relationship
wherein the demand for the vaccine upsurged the supply of the vaccine, even though
the production was carried on a large phase. This eventually steered a situation wherein
people are forced to wait for long hours outside the health centers to avoid missed
vaccine schedules. This brunt cannot be faced by working individuals and thus can
affect the vaccine acceptance behavior of individuals.[12 ]
[18 ]
The vaccine behavior, though not limited to COVID vaccine alone can largely be attributed
to the individual's phobia of needles and fear of adverse effects. Needle phobia/trypanophobia
affects around 10 to 25% of individuals across all age groups.[22 ]
[23 ] The drive for COVID vaccination in the country can be hindered by needle phobics
who are likely to refuse the vaccination, as it involves not one but two jabs. In
addition, around 73% of people expressed their concerns regarding the risks or adverse
effects associated with the COVID vaccine.[18 ] The common effects seen after the vaccination range from mild symptoms like fever,
muscle pain to severe symptoms like breathlessness. Thus, the response of peers, family,
friends. and relatives who are already vaccinated could endure a significant influence
on the minds of people who are unwilling to take vaccine.[20 ]
The perceived risk of COVID infection and the belief in self-immunity can also be
the other driving factors in this vaccination initiative. Around 22 to 30% of the
population perceived to be at lesser risk of COVID infection.[12 ]
[18 ]
[19 ] This could be due to the self-perceived immunity of people which renders them the
thought of being resistant to COVD-19 infection. The information in social media and
through peers on a large basis, initiated the belief that increasing the immunity
of an individual through household remedies can help them combat the infection on
a large basis rather than depending on a vaccine.
In addition, trust on public authorities was also perceived as a reason of hesitancy
toward availing COVID vaccine. Surveys conducted have demonstrated that individuals
who trusted the government were 1.6 times more willing to avail the vaccine as compared
with the individuals who had no faith in the government.[17 ]
[18 ] Trust plays a key role in shaping the public opinion regarding vaccines. However,
the seeming reluctance among individuals may arise above science of the vaccines and
may be determined by the politics driving the production and availability of the vaccine.
This could be due to the known facts like political differences and statements passed
by oppositions to demean the reigning party, consistent changes in vaccine schedules
which could create a restraint in the minds of people regarding the vaccination process.
Will COVID-19 Vaccination Ace Oral Health and Access to Oral Health Care Services?
Will COVID-19 Vaccination Ace Oral Health and Access to Oral Health Care Services?
The impact of COVID-19 on oral health can be viewed in a bidirectional manner. On
one hand, COVID-19 can affect the oral tissues and instigate several oral diseases
and on the other hand, the rising cases and evolving strains of the virus can impede
the oral health care availing behavior of individual, due to the fear of contracting
the disease. As per numerous research, the neurotropic and mucotropic properties of
the SARS-CoV-2 virus can significantly affect the salivary gland functions, alter
the taste sensations, integrity of the oral mucosa causing an imbalance in the oral
environment dynamics.[24 ] Individuals can thus be predisposed to a variety of oral problems like xerostomia,
opportunistic fungal infections, ulcerations, and gingival infections.[5 ]
[24 ] The cytokine storm that is caused by the impaired humoral mechanism and cellular
mechanism can magnify the autoimmune disorders well within the oropharyngeal region,
which can be of great concern.[24 ] Apart from the virus impingement, the after effects of the treatment can also predispose
the individuals to various infections. Uncontrolled diabetes mellitus or systemic
illness and rampant use of corticosteroids during the treatment of COVID-19, extensive
use of ventilation and oxygen therapies in the background appear to be silent triggers
in the rising cases of mucormycosis.[24 ] India appears to account for around 81% of the total cases of mucormycosis, wherein
88.9% of the cases are seen involving the nose and sinus area and 56.7% cases involve
the rhino-orbital region.[25 ]
However, with the increasing rates of COVID-19 cases, the decrease in patients availing
dental care is also alarming. Studies have reported that around 97% of dentists have
reported the decline in patient attendance for availing oral care procedures. An inverse
trend was noted between the COVID-19 pandemic prevalence and oral health care admissions,
which further increased during the second wave of the pandemic.[26 ]
[27 ] Research suggests that in view of the pandemic, 32.5% of the patients seeking dental
care for routine dental treatments preferred teleconsultation in the present situation.
However, only 18% of individuals were ready to avail dental treatment owing to the
pandemic distress, since oral treatments involve aerosol procedures that can increase
their risk of contracting the disease.[28 ]
[29 ]
Thus the vaccination drive can accentuate the current oral disease distress to a large
extent. This can be owed to the fact that vaccinated individuals are less prone to
face the serious illness or effects of the disease and thereby avoid hospitalization
and death. Reports suggest that the attack rate of the disease sharply decreased from
9 to 4% post vaccination.[30 ] In addition, the immunity boost acquired by the vaccination process, be it natural
or psychological, can enhance the individual's impetus to attain oral health care
on a regular basis.
Recommendations
Amidst the panic of the third wave of the COVID-19 pandemic, the COVID vaccine is
definitely a ray of silver lining for a prospective future. The vaccination drive
in India is a multifactorial enterprise which is largely dependent on the attitude
of individuals to the vaccine. Individuals with different ideological objections,
the accessibility, affordability and political factors largely affect the acceptance
rate of people. The safety concerns and the costs associated with the vaccine are
highly associated with the refusal tendencies of individuals. Thus, it is the need
of the hour to enhance the grass root strategies to influence all sections of the
society. New advances in technology utilized for vaccine production should be highlighted,
to boost the vaccine acceptance among people. Government officials and advocacy assemblies
must address the vaccine hesitancy by building vaccine literacy to fasten the vaccine
acceptance rates. Utilizing the health professionals who are considered as sources
of trustworthy information by people, interventions like awareness campaigns via social
media and other multimedia campaigns should be designed with the objective to spread
transparent and trustworthy information about the safety, efficacy, and effects of
the vaccine. Strategies should also involve addressing the affordability and accessibility
aspects of the vaccine, by making the free vaccines available at a larger scale. Enhancement
of the vaccine booking strategies, house-to-house vaccination campaigns majorly addressing
the vulnerable and geriatric population groups will also go a long way in this regard.
Conclusion
An approach based on increasing internal motivation and imbibing attitudinal changes
in an individual can pave the way for a healthy vaccinated nation in our fight against
this deadly COVID-19 pandemic. Dentists can play a crucial role by thus being a part
of the multidisciplinary team approach and bridge the gap by reducing oral health
disparities, identifying risk factors and early lesions, creating awareness and promoting
COVID-appropriate behavior especially among the immunocompromised, elderly, and vulnerable
populations. Utilization of dental health professionals in vaccination campaigns is
vital for the enforcement of common risk factor approach wherein focus can be shed
on both general and oral health wellness. Scaling up awareness campaigns and use of
social media in this regard will play a major role in the success of vaccination campaigns.
