Assessment of Knowledge, Perception and Readiness of Nigerians to Participate in the COVID-19 Vaccine Trial

"Sentiment for the anti-vaccine movement will continue to grow if public-health authorities failed to inspire confidence in the vaccine trial process."

As nations around the world struggle with the health, economic, and societal consequences of the COVID-19 pandemic, developing a safe, effective SARS-CoV-2 vaccine is a global public health necessity. However, recruiting volunteers can be challenging in a clinical trial phase because of poor knowledge, negative perceptions (e.g., due to various fears, fake news, and conspiracy theories generated by COVID-19), ethical issues, and safety concerns. Nigeria, with a poor healthcare system and a past history of epidemics and pandemics, has indicated an interest in participating in the World Health Organization (WHO) Access to COVID-19 Tools (ACT) Accelerator, a global collaboration to accelerate development, production, and equitable access to COVID-19 tests, treatments, and vaccines. In that context, these researchers conducted a survey to assess the knowledge, perceptions, and readiness of Nigerians to volunteer for a COVID-19 vaccine trial.

The cross-sectional, web-based study was carried out among 465 Nigerians (aged 18 years and above, with access to the internet) from May 19-22 2020. A 39-item survey instrument (questionnaire), which required about 7 minutes to complete, was developed (using Google forms via Survey Monkey), validated, and the internet link distributed randomly to consenting participants from the 6 geopolitical zones of the country via social media. Descriptive statistics were carried out using Statistical Package for the Social Sciences Software-Version 25 (SPSS-25) to measure frequencies and percentages of the variables. Bivariate analysis was also conducted using chi-square and bivariate logistic regression, and statistical significance was determined by p<0.05 to identify predictors of Nigerians' readiness to participate in COVID-19 vaccine trials.

Central findings:

• The majority of the respondents (96.3%) had a prior knowledge of COVID-19, and 5.4% had at least one family member who had been tested and treated for COVID-19.
• 46.7% confirmed that the nature of their job or lifestyle predisposes them to COVID-19 infection, and 39.4% considered themselves susceptible to COVID-19.
• Most of the participants used social media (80.2%) and the internet (76.3%) as their major source of COVID-19 information.
• Most of them believed that the virus is real (88.6%), highly infectious and deadly (63.4%), with no standard cure or vaccine (53.1%). However, others opined that the virus is a myth (1.1%), a disease only affecting the wealthy (0.9%) or the elderly (1.9%), caused by 5G network (3.0%), or a biological weapon (37.2%), amongst other assumptions.
• 96.0% of respondents had poor knowledge of the disease, with a larger proportion of those of the Islamic faith having a poor knowledge of the disease.
• A significant portion of the respondents saw the need to develop a vaccine to aid in the struggle against the pandemic (75.3%), many of whom (76.8%) were aware that several COVID-19 vaccine candidates are being developed, and 55.5% of whom were aware that Nigeria had indicated interest to participate in the WHO COVID-19 trial. 61.0% had a good perception of the vaccine trial, while the remaining 39.0% had a poor perception of it.
• 39.8% feared that the vaccine may not be affordable for and accessible to the average person. Meanwhile, 80% were afraid of adverse effects/complications that may be associated with the vaccine, 30.8% were afraid of the vaccine been used as a medium for implantation of microchips, 11.8% were afraid of disruption of daily routine, 26.9% feared that the vaccine may be used as a biological weapon, and 50.5% were afraid of vaccine-related death.
• 80% of respondents were unwilling to participate in the COVID-19 vaccine trial. "Even those who indicated support for vaccine trial in Nigeria were unwilling to submit themselves to the trial." 20% were willing, most of whom were 18-25 years of age (12.5%).
• The highest proportion of respondents indicated they would prefer the oral route for vaccine administration. "This may impact on the acceptance and deployment of the vaccine in Nigeria and therefore, should be considered by vaccine developers."
• Respondents' recommendations on the COVID-19 vaccine trial were as follows: be made optional (51.0%); be made mandatory (22.2%); be made available and accessible to all at no cost (68.0%); be made available and accessible to all at a fair cost (23.0%); be made available and accessible on the basis of religion, tribal, and political affiliation (6.5%); and be made available and accessible to all, regardless of religion, tribal, and political affiliation (52.9%).
• 66.5% of the respondents indicated they have no confidence in the Nigeria Centre for Disease Control (NCDC) to coordinate and implement the COVID-19 vaccine trial successfully, while only 1.2% (6/465) were very confident.

A key take-away from this survey is that most respondents were unwilling to take the COVID-19 vaccine. High incidence of infectious diseases has been recorded in places where people declined or resisted vaccination. For instance, the Northeast of Nigeria was plagued with poliovirus until recently due to public resistance and outright rejection of the polio vaccine by the people. The anti-vaccine movement in Nigeria has been driven by tribal, religious, and political sentiments, while protests against vaccination in most developed countries hinge on advocacy for respect for human rights and individual liberty. The researchers suggest: "To make COVID-19 vaccine mandatory or compulsory with the current anti-vaccine trends in Nigeria, without adequate public awareness, will not only be considered a violation of fundamental human rights, but will also fuel the anti-vaccine movement and undermine efforts in curbing the pandemic....A balance is therefore needed between respect for individual liberty and the need for medical interventions like vaccination to curb a deadly pandemic..."

Another notable finding is that over 80% of the respondents had social media as their major source of information on COVID-19. As the researchers detailed, at the onset of the pandemic, "wild conspiracy theories about the new coronavirus emerged online....Rumour-mongers who might once have been isolated in their local communities can connect with like-minded sceptics anywhere in the world via several social-media platforms....Groups that spread vaccine misinformation on social media appear to have more impact than government health agencies and other expert organizations on undecided people....They are capitalizing on both the many unknowns about the COVID-19 virus and the disease it causes, as well as the many legitimate questions about safety and efficacy as vaccines are being developed at unprecedented speed. The spread of false information could have significant public health consequences if an effective COVID-19 vaccine is developed....While vaccine supporters outnumber users with anti-vaccine views on social media (Facebook), the platform has nearly three times as many anti-vaccination communities, according to a recent study....That makes it far more likely that their views will reach people who are undecided."

The survey's finding about the lack of confidence in the NCDC to coordinate the vaccine trial successfully is also another concern of the researchers, who say that further study would be need to assess whether this is an issue of competence or trust. This situation is reminiscent of research on the Ebola vaccine trial in Guinea, where trust was identified as a major confounding factor in the recruitment of volunteers. The researchers point to the history of racism, as well as several conspiracy theories including alleged plans to use black people as experimental guinea pigs and plans to use vaccines as a medium to implant microchips to manipulate or monitor them. They are also reportedly asking questions such as why the healthcare workers who are trying to convince them to take the vaccine are not also participating in the trials. This may explain why vaccine developers are now prioritising the recruitment of local healthcare workers into the trial, as they are more likely than others to be exposed to the virus. Inclusion of healthcare workers in vaccine trial has the potential to stimulate the support and confidence of the public in the scientific process.

To this end, say the researchers, deliberate efforts must be made to restore vaccine confidence among the Nigerian populace. They stressed that individuals who are hesitant to vaccinate should not be demonised; instead, their worries and fears should be addressed. All stakeholders involved in vaccine development, evaluation, and licensure "must be transparent as much as possible throughout the entire process (including disclosing potential risks and associated side effects) to inspire confidence in the public...".

In conclusion, misinformation and disinformation strengthen vaccine skepticism and could undermine efforts to end the coronavirus pandemic as the quest for a SARS-CoV-2 vaccine is underway. The outcomes of this study further underscore "the need for adequate public health enlightenment on the role of vaccine in curbing the COVID-19 pandemic. This will ensure adequate deployment and acceptance of the vaccine when it finally arrives."